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Physical Design of Integrated Circuits. ------------------------------------ Teacher: Prof. Dr.-Ing. Manfred Berroth University of Stuttgart
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Physical Therapy Notes
1 The Institute of Physical Therapy 2000 - 2005
The Elbow – Deformities
RA and Sprain
Fractures and Ulnar Neuritis
TB of Bones and Joints
OA Wrist, Hand and Fingers
Tenosynovitis, De Quervain's
PID, Lumbar Disc, Intervertebral Disc
Cervical Disc, Spondylolysis
Nerve Injuries to the Hand
Osteoarthritis of the Hip
Snapping Hip, Bursitis
Hip and Pelvic Examination
The Knee -- Screw home principle
Physical Examination of the Spine
Osgood Schlatters Disease
Patella OA, Tendinitis
Coronary Ligament Sprain
Foot and Ankle Conditions
Application of Cold
Application of Heat
Adhesions and Limited ROM
Inspection of Shoulder Joint
Painful Arc Syndrome
Surface Markings of the Foot and Ankle
Foot and Ankle – Resisted Movements
Rupture of Long Tendon of Biceps
Soft Tissue Injuries
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OSTEOARTHRITIS. (O.A.) Osteo Arthritis, Degenerative Arthritis, Wear and Tear. Definition: A degenerative joint disease giving rise to painful impairment of function and deformity and building later to displacement. Causes. Wear and tear due to micro trauma and age. Age changes in cartilage can be seen:young cartilage is red and shiny, old cartilage is brownish in colour. There is an impaired capacity for tissue repair inherent in the process of ageing. Micro - trauma. Due to sports injuries, especially rugby or golf players (heavy contact sports) General day to day trauma. Occupational factors. Obesity and Stress. O.A. occurs in weight bearing joints, hence the relatively lightly stressed joints of the upper limb are in general, less prone to O.A. than the heavily stressed joints of the lower limb. Post Traumatic O.A. After mass trauma. Internal derangement such as loose bodies or a torn meniscus. Any congenital abnormality ie congenital dislocation of the hip and inflammatory joint disease and leading on to O.A. ie secondary O.A. Joint mal-alignment from any cause ie bow leg. Climate. High or low pressure which causes joints to expand or contract. They feel worse at different times of the year. Climate can aggravate the symptoms. Diet. As a causative factor there is no scientific back up. It is not proven that it affects joints. However we try to keep patients away from acid forming foods. Pathology. Any joint in the body may be affected. The moving part of the joints are primarily affected, so that the first change is in the articular cartilage. The cartilage begins to wear, it becomes roughened and little cracks begin to appear along the surface. Eventually this leads to erosion of the cartilage. As it wears the underlying bone becomes visible, eventually leading to bare bone as it becomes weight bearing. Bone surface changes. As the above process is going on the exposed bone becomes sclerosed (hardened) and surface grooves develop. This sub-chondral (sub cartilage) bone is then known as eburnation. The main changes occur at the points of greatest pressure ie points that undergo the weight. What happens is that the body tries to lay down new layers of bone due to the absence of cartilage. The bone hypertrophies (increases in size according to demand) at the edges to form outgrowths of bone known as osteophyte or spurs. Beneath the sub chondral bone cysts can develop (subchondral cysts). If they increase in size it can lead to collapse. No major changes in the capsule or synovial membrane, but some thickening/fibrosis may develop later. As the process continues the joint spaces approximates.
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Joints affected by O.A. Major weight bearing joints are most effected, especially the hips and knees. The spine is also commonly effected, especially the lower lumbar and cervicals. It is not as common in the S.I. joints. Note: Ankle joint is not affected as much as other joints as weight is distributed as much through the M.T. joints as it is through the ankle joint. Clinical Features. There are 5 sets:- Pain, Stiffness, Swelling, Deformity, Loss of function Pain. It is described as a deep ache. The onset is gradual, but severity increases as disease progresses. Pain increases with exertion and disappears with rest. Pain increase during the day. Joint Stiffness. 2 Types a) due to a reduction in the range of movement as a result of thickening of capsule and osteophyte. b) due to articular swelling. Mainly morning stiffness which disappears after half an hour with movement. There is usually stiffness after prolonged sitting. Swelling. There is a lot of swelling around the joint for two reasons a) accumulation of fluid within synovial capsule, which after rest becomes viscous or sticky. b) infiltration of fluid into surrounding tissue. Deformity. This occurs if the joint is destroyed. Loss of function. Due to osteophyte encroachment, thickening of capsule, pain, erosion of bone and cartilage.
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RHEUMATOID ARTHRITIS Definition: This is an inflammatory joint disease which affects the synovial joints. Causes. Difficult to understand. Causes are unknown. There is a genetic predisposition. Immunological fault is the major theory now. Virus theory, but this is not proven An allergic response. Pathology of R.A. is very involved. Resentment, tension and anger are sometimes associated. R.A. factor in blood found in patients who have not got R.A. Clinical Features. Generally it is polyarticular but it can be monoarticular. Onset is usually insidious and there are no major signs. May be history of mild attack of pain months before. Vague joint pains. Main Signs and Symptoms Pain especially with movement Local heat around joint and warmer than normal Redness Swelling from synovial thickening Deformity Affects females more. 25 to 55 years are the commonest ages. It usually starts in the smaller joints of the hands and toes, spreading later to the wrists, knees, shoulders, hips. It can however start in any joint.
• • • • • • •
Non Articular disorders of R.A. Anaemia, tiredness, lethargy, loss of weight and appetite, muscle wasting around affected joint. They can precede joint symptoms by up to a year. Skin can become tight and wasted. Prone to leg ulcers especially of the lower tibial shaft (may start 6 to 9 months before the joint is affected). Sub-cutaneous nodules which are firm, non tender and mobile are present in 20% of patients with R.A. especially around prominences egg elbow, knees, wrist. Muscles tend to be weak. Other Systemic Manifestations. These are many and varied. There may be eye and cardiac involvement e.g.: Rheumatic Fever, Pericarditis, Pleurisy ( may precede R.A.), Rheumatoid nodule in lung. Pathology Mainly affects the synovial membrane of joints. There is a lot of inflammation and thickening around the affected joints. Severity can vary from moderate to intermediate, to total joint destruction.
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STILL'S DISEASE. Juvenile Rheumatoid Arthritis. (J.R.A.) Definition: A form of R.A. occurring in patients under 16 years. J.R.A. in children is similar in most respects to that occurring in adults. It is thought that the disease is not a single entity, but that it comprises a number of conditions that are more or less distinct, though features common to all are pain, swelling and stiffness of the joints. The disease is modified in that it tends to affect the larger joints with resultant changes in growth and development. General signs and symptoms. It is not very common. It may be mono or poly arthritis and the prognosis can vary a lot. It may start with a fever, swollen lymph glands and tiredness. Within a few weeks may get marked joint symptoms such as mild aches and pains. Children tend to lose weight rapidly. Often there is a marked rash - raised mapula, papula on the face and trunk. N.B. Must distinguish between growing pains. In children it tends to affect the elbows, knees and wrists whereas in adults it tends to be polyarthritis. There may be a family history of R.A. In 20% there is liver enlargement, spleen enlargement, generalised lymph problems and pericarditis occurring. Often an anaemia will be present. 10% get eye problems such as scleritis or Iritis. There may be a growth retardation, shortness of stature, and a deformity leading to varying degrees of disability. Types. Sero - positive J.R.A. Very similar to R.A. Begins late in childhood, and effects girls more than boys. Classical Still's disease. Begins in early childhood, with liver and spleen involvement (hence classical). Sero negative disease with sacro - iliactis is common in boys and begins in late childhood. It tends to lead to ankylosing spondylitis. Treatment. Aspirin. Anti inflammatory drugs. Gold injections. Corticosteroid if eye involvement Rest Physio/Massage Operation - if fixed flexion deformity Passive exercises and splints usually prevents fixed flexion contractures.
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Definition: A chronic yet actively progressive condition that affects not only the spine but other joints also, in which destruction of the joint space occurs and is followed by sclerosis and calcification. Causes. Unknown. Tends to be familial. Commonest age group affected 15 - 20 years. Begins with lower back and Sciatic pains and then progresses up the spine over a number of years. Pain is episodic at first and then becomes constant. More stiffness develops as the condition progresses, and the degree of stiffness depends on the degree of inflammation. Rest seems to make the condition worse, while movement seems to ease it. There are 5 important sets of factors for diagnosis:Onset of back discomfort before the age of 40 An insidious as opposed to sudden onset. Persistence for more than 3 months. Association with early morning stiffness. Improves with exercise.
• • • • •
May commence with heel pain, rather than S.I. pain. Difficult to diagnose early on, but mobility testing reveals loss of movement. Test. Measure chest expansion if the thoracics are involved. Ask patient to reach toes. Stand patient against wall and see if head touches wall easily. If fixed flexion deformity of neck, record distance from wall. Later develops in the cervicals. Note:- May commence in the cervicals. In some cases the hips and shoulders are involved. Classic C-shaped spine in later life. Pathology. This is an inflammatory process which primarily affects the spine and involves cartilage, sub-chondral bone and the ligamentous and tendinous insertions into bone and periosteum. Eventually the ligaments around the spine calcify and give the spine a "bamboo look". It usually begins in the S.I.J's. and pubis, next the lumbars, then the thoracics and ribs and then the cervicals. Or it may develop in one area only. Sometimes the hips, shoulders and heels may be involved. It usually commences with lower back pain and stiffness. After a certain period of time the inflammation becomes dormant, having varying degrees of stiffness, flexion deformity of the spine, respiratory infection and ileitis.
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Diagnosis. X-ray Increased E.S.R. (rate at which red blood cells stick together) H.L.B. 27 Antigen. Medical Treatment. Anti inflammatory drugs Corticosteroids if systemic e.g. eye involvement. Wedged osteotomy if very bad. Treatment. Flat firm mattress, single pillow to prevent flexion deformity of spine. Postural correction instruction to avoid bending and stooping. Isometric exercise especially for extensor groups of the spine and legs. Breathing exercises for the chest to keep mobility. Light sports, particularly swimming and stretching. Massage.
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GOUT Definition: An abnormality of the purine metabolism whereby the blood uric acid levels is raised and sodium Biurate crystals are deposited on soft tissues, particularly near the smaller joints. Causes. Inadequate excretion of uric acid. Over production of uric acid. Inherited predisposition to the disease. Clinical Findings. Patient is usually middle aged. It affects men more than women by a ratio of 20:1 60% of U.K. sufferers have a familial history. There is a sudden onset of pain in the joints especially meta-tarsal phalangeal joints. Or the hallux. Pain may start at night. Patient may have gout for a long time and it is escalated by trauma, e.g. hitting the foot of a wall may cause a flare up in symptoms. On examination - heat, redness, swelling, throbbing pain, tender and very shiny. After a few days the symptoms subside, only to recur, sometimes in a different joint. The main joints affected are the toes, ankles, small joints of the hands. May also occur in the ear lobe, which is known as tophi. Or can occur on other sites. Pathology. Due to an impaired excretion of uric acid by the kidneys you get a build up of urates in the blood stream. This in turn can lead to the formation of crystals which may be deposited in various tissues. Diagnosis. Sudden onset History of previous attack with symptom free intervals Raised plasma urate level. Detection of crystals; synovial fluid. Treatment. Drugs to reduce urate level Increase high content purine foods Organ meats/meats/shellfish Alcohol as it decreases uric acid secretion.
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OSTEOPOROSIS. Definition: Fragility of bone due to reabsorption of calcium or A reduction in the amount of bone tissue; the tissue remaining is normally calcified. Rarefaction of the bone. Pathology. Osteoporosis should be regarded as a multifactorial process of diverse etiology and it should be considered as a disease and not solely as part of the ageing process. The term osteoporosis indicates porosity, brittleness and rarefaction of bone. There is loss of bone mass accompanied by rarefaction of the skeleton. The major pathology is that there is a greater proportional loss of trabecular than of compact bone which accounts for the primary complication of the disease, i.e. compression fractures of one or more of the vertebral bodies. The spine generally tends towards Kyphosis and the long bones are also prone to fracture. Types. Disuse Post - menopausal Steroid Juvenile Hyperthyroidism Idiopathic (senile)
The first 3 are the most common.
Causes. Age. When the rate of cell death outstrips that of repair, therefore more common in older people. Lack of exercise. Gravity. Individual must be upright and mobile for at least 2 hours a day, otherwise become osteoporotic. Age types. Senile osteoporosis; old and osteoporotic. Recumbent; bedridden. Climacteric; post-menopausal osteoporosis Post traumatic. A damaged joint may develop osteoporosis. Malabsorption or malnutrition. Drug - induced; Steroidal osteoporosis, especially if intravenous and can happen within six months. Greater frequency in white than in blacks. Defective intestinal calcium absorption and Vitamin D deficiency Hormonal, Lifestyle, Nutritional and Environmental Endocrine disorders, such as Cushing's syndrome, Hyperparathyroidism, Thyrotoxicosis. Clinical Findings May be asymptomatic for long periods. Pain in the back. May be due to vertebral collapse. It can come on suddenly after moving furniture or similar minor trauma. Patient may notice loss of height. Increase in Kyphosis. Disc compressions leading to neural complications. Increased in the over 55 age group. 10 The Institute of Physical Therapy 2000 - 2005
Weight bearing affects below T8 area of spine. Treatment. Isometric Extensions Activity. Vegetarian Diet Physical Therapy. A high protein diet or high in phosphates is associated with an increase in the excretion of Ca in the urine. High sugar intake also leads to an increases of Ca excretion in the urine.
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ACUTE OSTEOMYELITIS. Definition: A.O. is basically an infection of bone and bone marrow. It affects children in the 4 to 16 age group predominantly, and mostly boys in a 3:1 ratio. Tibia, fibula and humerus are most commonly affected, but it can occur in any long bone. Cause. It's a pyogenic (pus forming) infection of bone. The most common organisms are:a) Staphylococcus Orus in 86% to 90% of cases b) Streptococcus Pyogenic .4% to 6% c) Pneumococcus Pathology. There are 2 modes of infection:Haematogenous is the most common. Via open fracture. Haematogenous. Usually it begins at the end of a long bone near the metaphysis. The symptoms often begin after a minor trauma, as the trauma can create a haematoma near the epiphyseal plate. The haematoma provides an ideal breeding ground for the bacteria reaching it from the blood stream. Clinical Findings. Patient gives recent history of a contusion, skin abrasion, bruise, bone injury, skin lesion or recent history of sore throat. There is a rapid onset especially in children. The child feels ill and there is pain on the affected joint. There may be a constitutional illness and a high temperature. Initially, as the lesion is within the medullary cavity, while tenderness is marked, local heat and swelling are not obvious. These rapidly follow as the sub-periosteal abscess forms. 40% give reliable history of previous trauma. Pain increases and is not relieved by rest. Marked redness and swelling, stretching and tension in overlying skin. Touching the skin can cause the child to "freak". Child will hold the limb still. Biggest confusion is a fracture. Marked tenderness is over a bone, whereas in Still's disease it is over a joint. Treatment. Rest Broad spectrum antibiotics Surgery to expose bone Open areas/ strip periosteum/ clear pus/ remove sequestrum. Drill bone/ drill holes.
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CHRONIC OSTEOMYELITIS. This comes in 2 ways:• Neglected acute which has been left untreated, get retardation of growth in that limb. Totally pus-filled cavity in bone changing to honeycombed granulation tissue. • Acute which falls into chronic. Purulent discharge from sinus, either continuous or intermittent or get a flare up ie. reappearance of a previously healed sinus, or the formation of a sub-periosteal sinus. Cause. This occurs after irreversible changes have taken place in a bone and is due to the fact that the causative organism can lie dormant in avascular necrotic areas, occasionally becoming reactivated, resulting in a flare up. Clinical Features. Quiescent Phase which may last for years with no symptoms Scars from past sinuses are visible. Intermittent flare ups, especially after minor trauma or may come spontaneously immediate pain and constitutional illness, heat, swelling, redness, fever, sinuses, leading to pus. Treatment. Drain Abscess Clear dead bone replacing bone chips. Antibiotics.
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TUBERCULOSIS OF BONE AND JOINTS Myobacterium tuberculosis. T.B. of spine = Pott's Disease. Tubercle bacillus. Rare in western countries due to hygiene and living standards. Still very common in developing countries, was known as galloping consumption. Definition. Infection of a joint with tubercle bacilli. Transmitted. Via droplet infection (usually human) Ingestion of bovine material. More prominent before herd testing. Pathology. • It enters via droplet infection coming in contact with sputum, drinking infected milk or via skin wound. • Usually the main focus of infection is dormant in the lungs or the Alimentary tract. • No joint is immune for infection, but intervertebral lumbars or thoracics are most often infected followed by the hip and knee joint. • Tubercles bacilli may primarily infect bone or the synovial membrane, but in the majority of cases eventually both the joint and neighbouring bones are infected together. • The tubercle bacilli at first causes an inflammatory secretion, in which are found the typical tubercles giant cell and sound cell infiltration. (They basically multiply rapidly and form giant cell systems which actually melt away the normal joint cell tissues). • NOTE: unless the disease is halted at this stage you will normally get destruction of a joint. • Soon this is followed by tissue necrosis and the formation of a tubercular abscess known as ?. The abscess may reach the skin surface and rupture giving rise to tuberculous sinus. This may provide a route of entry for the secondary infecting organisms. There are 3 phases in joint T.B.:• Active infiltration of synocium and muscle wasting. If caught can be restored to normal. • Beginning of cartilage destruction. If caught before articular cartilage affected can return to normal. If caught after articular cartilage affected, you can get healing with fibrosis. • Aftermath. Cartilage erosion. • Fibrosis. • Unsteady joint. • Bacilli liberated -- reinfection -- joint destruction. Clinical Features. • Gradual onset of general illness. • Patient looks ill and wasted. • Looks pale and thin, suffers from loss of appetite, anorexia, weight loss, night sweats. • Predominant symptoms are pain, swelling, and impairment of swelling of the affected joint. 14 The Institute of Physical Therapy 2000 - 2005
• • • • •
On examination get warmth of overlying skin and swelling from synovial thickening and limitations of movement in all directions. Forced movement induces sharp pain and protective muscle spasm. Muscles controlling the joint are usually wasted. Abscesses or sinuses of the ? A tuberculous lesion may be found elsewhere. Often a history of contact with a patient having a history of active pulmonary tuberculosis.
Diagnosis. • is raised. • White blood cell count shows some lymphocytosis. • Sputum -- tubercle bacilli. • Montour test. • X - Ray. Treatment. Rest Fresh air. Immobilisation of joint. Splints Aspirate abscess Streptomycin Isoniazid Para-aminosalicylic acid Chemotherapy.
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COCCYDYNIA. Description. Any painful condition in the region of the coccyx. Cause. Usually a history of trauma such as a kick in the posterior, or fall from height on to the buttocks, giving birth. Due to P.I.D. or pelvic disorders ( e.g. cancer of rectum). Referred pain due to hypomobility lesion of the L/S spine Signs and Symptoms. It's very sensitive to injury and difficult to eradicate. Common in women because of the increased width of the pelvic outlet. Severe pain on sitting or can only sit for a few minutes. (difficulty in rising from a sitting position), or there may be pain during defecation. No pain experienced on standing or walking. Pathology. May just be strain from the sacro coccygeal joint. May be a contusion of the periosteum over the inferior aspect of the sacrum or coccyx. Usually there is a deviation, either anteriorly or laterally of the coccyx, especially after trauma. Sometimes the problem can resolve spontaneously. Treatment. Hydrocortisone injection. Coccygectomy but with limited success, ie coccyx may be excised. Inhibition techniques either side of the coccyx.
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P.I.D. Prolapse Herniation, Grades 1, 2, 3, 4. Anatomy. Intervertebral discs are more liable to give trouble in those parts of the spine which are mobile and which are also subject to the greatest strains, such as the lower cervicals and the lower lumbar regions. They are least commonly involved in the thoracic spine where the rib - cage gives support and limits movement. When a disc prolapse occurs there is initially rupture to the Annulus Fibrosis, which causes acute pain and muscle spasm in the neck or back. Then through the rupture, a protrusion of the nucleus pulposus takes place and enters the spinal canal. The central part of the disc posteriorly is protected by the strong posterior longitudinal ligament, so that a prolapse much more commonly occurs to one side. This, therefore, is very likely to impinge against a nerve root, causing pain, sensory impairment, and muscle weakness in the area supplied by that segment. Central prolapse is fortunately rare, clinical patterns differ somewhat in the 2 areas most commonly affected. LUMBAR DISC LESION. Causes. Many and varied Disc Degeneration due to age. Injury trauma Bad usage/posture over the years Occupational, from prolonged bending/lifting
INTERVERTEBRAL DISC A flexible mechanism to maintain proper alignment. They are primarily responsible for the curves. The IVD forms the anterior boundary of the intervertebral foramen and anterior wall of the vertebral canal. Structure Nucleus Pulposus Annulus Fibrosus Cartilage end plate The disc is anchored by number 2 and 3 to vertebral body.
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Nucleus Pulposus Soft highly hydrophillic substance contained within the centre of the disc. There is no clear division between nucleus and annulus, the main difference being in the intensity of the fibres. The position of the nucleus within the disc varies regionally; centrally located in the cervical and thoracic, more posterior in lumbar discs. In early life a water content of 80 to 88% is usual. In the forties this decreases to 70%. This changes the mechanical behaviour of the disc. Annulus Fibrosus This consists of a series of annular bands. With ageing the annulus becomes weakest in the posterio-lateral region and predisposes to PID. The attachment of the annulus to the vertebrae is complex. Fibres pass over the edge of the cartilage end plate and anchor themselves to and beyond the compact bony zone that forms outside of the vertebral rim and margins of adjacent vertebral body and it's periosteum. These fibres become interwoven with the bony trabeculae. Cartilage end plate Found on each surface of vertebral body and represents the anatomical limit of the disc. It is 1 mm in thickness and decreases towards the centre. After 30 years of age it begins to show signs of ossification with increased calcification. It becomes more brittle and ranges from thinning to complete destruction of central end plate. Pathology The most frequent level for a disc prolapse is the lumbo-sacral, because here the mobile lumbar spine joins the rigid sacrum and pelvis. Next in frequency is the L4/5 and the L3/4. Rare at L1/2. Part of the nucleus pulposus protrudes through a rent in the annulus fibrosus at it's weakest part, which is postero - lateral. If it is small, pain is confined to the lower back. If it is large the protrusion herniates through the posterior ligament and may impinge upon an issuing nerve and cause sciatic pain. The nerve affected will be that below the disc lesion. Signs and Symptoms Usually youngish, often from 18 to 50 years. Complaints of sudden, very severe lower back pain which may immobilise. May commence in the lower back and move into the leg after a few days. May just be in the lower back or in the leg, it varies a lot. Pain is made worse by flexion, coughing, sneezing, defecation. Spine tilted (sciatic scoliosis) and or lordosis obliterated. Tenderness over area of prolapse. Muscle spasm Tingling numbness in calf or foot. Area of pain depends on where prolapse is. Severity varies from patient to patient. Test Flexion decreased. Ask patient to touch toes keeping knees straight. Side bending to affected side decreased S.L.R.T. decreased Press on relevant spinal level will cause pain. Diagnosis 18 The Institute of Physical Therapy 2000 - 2005
Myelogram Cat scan Medical Treatment Rest Corset Pain killers Hospital with 1 to 4 weeks in traction. Physical Treatment. Rest Massage Traction Mobilisations
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CERVICAL DISC LESION. Commonest at C5/6 and C6/7, where mobile spine meets relatively immobile spine. Presents: with acute neck pain which is held rigid, (acute stiff neck). May be tilted. This is torticollis. Pain down the arm or to fingers. C5/6 leads to pain in thumb and forefinger, below shoulder, outer arm. C6/7 leads to pain in back of arm to middle fingers. C7 T1 leads to pain in little finger and ulnar side of forearm Worse at night when the neck extends and the muscle relaxes out of protective spasm, the nerve root irritation increases.
SPONDYLOLYSIS. A defect in the pars-interarticularis (or neural arch) of L5. There is a loss of bony continuity between the superior and inferior articular processes, where fibrous tissue replaces bone. Causes May be:Congenital Due to trauma Stress Fracture, this is most likely. Clinical Features. Common in some sports e.g. weight lifting, rowers. fast bowlers. May present with L.B.P. or unilateral pain. May radiate to buttocks Rare to get referred neurological pain May be no symptoms Racial Inheritance, it is common in Eskimos, _ of over 40's have it, less common in Negroes (2%). Treatment. Corset Spinal fusion to close defect
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SPONDYLOLISTHESIS. Definition: Vertebral slipping, where there is forward subluxation of one vertebra on another, though this can sometimes be backwards. Causes Spondylolysis O.A. of posterior facets of joints. Congenital malformation of articular process Signs and Symptoms. Varies a lot Depends on the type Present with chronic low back ache with or without sciatica Worse on standing May or may not be restriction of movement Often a visible step at L5/S1 gap. Neurological disturbance is minimal usually. Treatment. None if no symptoms Corset Operation to link the 2 separate halves of the vertebrae Diagnosis. X-Ray.
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POSTURE By posture we mean the alignment of the head, neck, shoulders, trunk, pelvis and limbs. If this is correct, an imaginary plumb-line dropped from the side of the head should pass through the middle of the ear, shoulder, hip, knee, and lateral malleolus. The line of gravity of the human body is an imaginary line, drawn vertically through the centre of the body, from the crown of the head to a point between the two feet , on either side of which line, the weight is equal. The weight is also equal in front of and behind it. The line represents the direction of the pull of gravity. If the body is to balance properly and without effort, the line of gravity must fall well within the base, or supporting area-that is, the space occupied by the two feet on the floor. For perfect balance in the erect position, the line should fall right through the centre of the base. A good posture must be that from which all activities of the body can take place, with the minimum of effort, and from which the systems of the body (respiratory, circulatory, digestive etc) can function normally. Maintenance of Posture. Normally the body is kept in the correct posture by the beautifully balanced action of opposing muscle groups and by the efficient working of the nerves which control this type of muscular activity. Such activity is, in effect, an anti-gravity reaction. It is known as postural tone and exists throughout the body. This form of work, does not, however, produce fatigue in the same way as do voluntary contractions of the same muscles. If a man is asked to extend his spine or even his knee repeatedly, the muscles will soon tire; yet he can remain in a standing or sitting position for a very long time. Although the muscles are in a state of contraction, and although the impulses producing this condition are carried by the same nerves which initiate voluntary movement, the contraction is a static (isometric) one, and the small stimuli reach the muscle fibres at a much slower rate-only about 8 or 9 per second, instead of the 50 or so per second required to bring about a tetanic (isotonic) contraction. Moreover, each stimulus reaches only a small number of muscle fibres, one set contracting then relaxing as another set contracts so that no single fibre is in action for long at a time. POSTURAL DEFORMITIES Even though we have the means of maintaining balance in any position, to stand with the body bent, even slightly, in any direction, imposes a strain on the muscles on the side from which the bending takes place. This is because, the force of gravity instead of falling through the centre of the body, pulls at an angle on the flexed upper part. The more the body is bent, the greater the angle of it's pull, and the greater the strain on the muscles. If this bend is fixed for any reason, the patient will tend to relieve the strain by bending the spine in the opposite direction at a higher or a lower level. In other words, the patient compensates. These facts have to be borne in mind when considering the causation and development of all postural deformities. Types of Deformity. Alteration in posture may occur in an anteroposterior or lateral direction, but it is important to realise the reason for either is the alteration of angle in pelvic tilt away from the normal, also that the fault does not necessarily lie in the spine.
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Bodily Types and Postures There is really no normal type of posture, since no two human beings are alike in skeletal, muscular or neurological make-up, nor do any two people use their bodies in the same way. Generally speaking, individuals may be divided into three main types; the slender, the heavy and the so-called normal or intermediate, each having it's own characteristic make-up. The Slender Type is most inclined to faulty posture, especially to lordosis. The spine of such a patient has a tendency to bend back from it's lowest part, the pelvis being tilted forward at the same time, thus forming a forward curve, with the maximum convexity in the mid-lumbar region. Following this, the compensatory kyphosis develops, the chest droops, the ribs become more vertical, the costal angle is increased, the head is carried forward, and the cervical fascia loses it's tension. This may ultimately lead to cramping, and possibly even to displacement of organs, producing visceral disturbances, or aggravating any such troubles if they already exist. The Heavy Type also tends to bend backwards, but at the lumbodorsal junction, the pelvis thus being tilted backwards. People of this kind tend to develop kyphosis and rigidity of the thorax. Lordosis is uncommon in this type. The Intermediate Type varies according to which of the others it most nearly approaches. The spine may bend back at a point between those characteristics of the other two types. Because of these varieties in postural types, the characteristic physical make-up of each patient should be taken into consideration when assessing his or her special disability. Degrees of Deformity. There may be postural or structural. In the postural curves, occurring in children and young people, there is no bony change; there may not even be muscular weakness. There is a postural reflex, and in many cases there is also a psychological or nervous factor. Any form of nervous disturbance or imbalance, in greater or less degree, may cause faulty posture in children, adolescents and adults, and in such cases unless the psychological is set right it is unlikely that we will fully correct the postural defect. This only applies, however, to defects complicated by psychological factors. The Structural Curves. It used, at one time be assumed that all, or almost all, postural defects if neglected would develop into structural ones. It is, however, probably only very rarely that this occurs, but this is no reason for neglecting such postural cases, or failing to keep them under supervision. In such postural curves as do become structural, there would appear to be a transition stage between the two, when some degree of alteration has only taken place in the length of soft structures (muscles and ligaments), the bones not yet being affected. At this stage, treatment can be of great value. Serious structural curves have other causes than mere faulty posture or nervous upset. This may be due to unilateral lung disease, tuberculosis, paralysis etc. ,or the causes may be unknown as in idiopathic scoliosis. In structural cases, the body changes may be slight or serious. To differentiate between postural, and structural scoliosis, ask patient to flex forward. If postural scoliosis is present the curvature will disappear. If structural curvature is present, the curve will remain or even be exaggerated.
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SCOLIOSIS Definition. A lateral curvature of the spine, or a rotational deformity of the spine. It is assessed by noting any lateral deviation from a line drawn, between the S.P.'s from T1 to the mid-line of the sacrum. Varieties. Simple C-shaped curve in any one area. Compound curves, that is 2 or more curves. Lumbar scoliosis Thoraco-lumbar scoliosis Thoracic scoliosis Types. Compensatory, is due to a cause that is usually obvious, e.g. Torticollis, short leg syndrome, hip deformity, etc Non-structural curves - also known as postural or secondary curves. These curves have no rotation of the vertebrae. Usually a single curve and disappears on flexion, or hanging from rafter. Structural or Primary curve is due to some underlying pathology of the spine. It is always accompanied by vertebral rotation towards the convexity and both rotation and the curve become more accentuated on forward flexion. Pathology. .....of structural scoliosis. May affect only part of the thoraco lumbar spine May be a primary curve with secondary compensatory curves. The lateral curvature is accompanied by rotation of the vertebra towards the convexity of the curve and the S.P.'s away from the convexity into the concavity. This causes the ribs to be thrust backwards on the convex side. It is more notable in the thoracics than in the lumbar region. Onset - any time from infancy to adolescence, especially between 10 and 12 years. Deformity is the main symptom in children. Structural Types. Idiopathic Congenital/Osteogenic Neuromuscular or myogenic Paralytic or Neurogenic Idiopathic:a) Infantile -- 0 to 3 years b) Juvenile -- 3 to 10 years c) Adolescent -- 10 to maturity d) Adult -- maturity +. Adolescent idiopathic is the most common. Developed during adolescent growth spurt Commoner in females by a 4:1 ratio. Thoracic curves are usually convex to the right! Cause is unknown The curve may be mild, moderate, or severe. A mild curve may pass completely unnoticed In severe form the spine can become grossly deformed if not treated to produce the classical hunchback of history. 24 The Institute of Physical Therapy 2000 - 2005
The curvature tends to increase until the end of the period of spinal growth, but not significantly thereafter. In general, the earlier in life the curve appears, the greater the potential for the deformity to become severe. Therefore it is important to determine when it first appeared and if there is pain. The thoracic spine is most involved and has the most serious consequences. Also can get deformity of the lumbar, thoraco lumbar, and cervical spines. Congenital. e.g.. due to the absence of half a vertebra (hemi-vertebrae) or fusion of several ribs on one side obvious at birth. Neuromuscular/Paralytic. Imbalance of spinal muscles due to muscle disorders. If muscles of one side are paralysed it can lead to a curve e.g.. due to poliomyelitis. Clinical finding – Observation 1.
Detailed History • • • • • • • •
Family history of scoliosis, injuries, previous history of back pain. When the deviation was first noticed? By Whom? When it was first assessed and by whom? How was it assessed, X-rays, Results? Treatment and response Any history of chest infections or other respiratory problems? General state of health
Head position, Ear levels, Rotation of head, Angle of neck, Shoulder levels, Inferior angle of scapula, Waist line, Arm gaps, Arm length, Iliac crest levels, PSIS levels, Gluteal fold, Gluteal mass, Popliteal levels, Achilles tendon angle, Arches, Foot position, Varicosities? Spine? Any lateral deviation? Draw and describe shape, 25
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• • • • • • •
Indicate where greatest curve is, Any rotation of body of vertebrae? Where? Is it into concavity or convexity? Does sacral base slope to low or high side? Does pelvis shift to low or high side? Is lumbo dorsal junction directly over mid-point of sacrum? Is compensation normal?
Lateral View General impression e.g. Forward head posture, abdomen protracting, etc.
Clavicular position Symmetry of chest Arm gap Shoulder positions, e.g. internally rotated Arm length Position of umbilicus Iliac crest levels ASIS Position of pelvis e.g. rotated Leg position Knee position Foot position
Examination Active ROM • • • • • Passive ROM: • • • • •
Resisted movements if indicated Full MET assessment Palpation of each muscle, particularly SCM, upper trapezius, levator scapula, pectoralis major, pectoralis minor, subscapularis, infraspinatus, latissimus dorsi, psoas, quadratus lumborum, TFL, gluteus medius, gluteus maximus, piriformis
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Note: Whether single C-shaped or S-shaped or more complex, record the findings diagrammatically. Endeavour to determine which type of scoliosis is present. Orthodox Treatment. Conservative. Assessing the degree of curve Measuring the cardio-pulmonary function Exercises Spinal supports e.g. Milwaukee brace Casts/Braces Operation fusion.
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KYPHOSIS ARCUATA Kyphosis Arcuata:- Round Back. This deformity may appear at any period of life, but is more common at childhood, adolescence or old age. The back is rounded, the chest flattened and the head carried forward. The shoulders are round with the scapula protracted. Kyphosis is more common in girls than in boys, and a primary kyphosis is more common in the heavier types of individual. Causes; In childhood: • Habitual poor posture, often acquired at school • Undetected sight or hearing defects • Severe childhood respiratory conditions leading to pigeon chest • Emotional factor • Mental or physical fatigue • Predisposition to kyphosis due to muscular weakness or reflex deficiency • Failure of development of secondary curves. In adolescence and adult life • Poor posture • Occupation • Arthritis • Lung conditions • Scheurmanns disease In old age Habitual poor posture • Muscle weakness • Degeneration of intervertebral discs or bodies of the vertebra •
Pathological Changes. This deformity like any other may be divided into three degrees. In the early stages no change is present except laxity and poor tone in the muscles. In time the pectoral muscles become shortened . This interferes with the mobility of the thorax and hence with respiration. The erector spinae are stretched and weakened in their upper parts, and the rhomboids and middle trapezius suffer in a similar fashion. The posterior ligaments of the vertebral column are lengthened and those on the anterior aspect are shortened. In the latter stages the vertebra may become wedge-shaped, being much narrower anteriorly. This is uncommon except in adolescent Kyphosis. KYPHOSIS; An exaggerated posterior curve of the thoracic area ARCUATA ; Inclusive of round-shoulderedness SECONDARY KYPHOSIS: An exaggerated cervical curve Involved muscles: • Pectoralis Major Origin: Clavicular head -- Medial Clavicle, Sternal Head, Cartilages of Upper 6 ribs Insertion: Lateral lip of the bicipital groove of humerus • Pectoralis Minor Origin: Anterior 3, 4, 5 ribs Insertion: Coracoid Process of scapula 28 The Institute of Physical Therapy 2000 - 2005
• Trapezius Origin: Occiput, nuchal ligament C7 to T12 spinous processes Insertion: Lateral Clavicle -- Acromion; Spine -- root of scapula • Levator Scapula Origin: C1 to C4 Transverse processes Insertion: Superior Angle -- Root of scapular spine • Rhomboids Origin: C7 to T1/T2 to T5 Spinous processes Insertion: Vertebral Border of Scapula -- root of spine to inferior angle • Erector Spinae see Lordosis • Posterior neck Splenius Capitus, Splenius Cervicis, Semispinalis/Multifidus Goals of Treatment. To re-educate patients' postural sense To lengthen the muscles of the chest and posterior neck To strengthen erector spinae, rhomboids and middle trapezius To improve chest breathing EXERCISES FOR PATIENT --Goal. Flatten the thoracic area Open the chest Improve chest breathing By: Increasing range of movement of shoulder joint. Encouraging patient to bring the vertebral borders of the scapula together, Combining with above, deep inhalation. Tuck chin in towards the neck.
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LORDOSIS Exaggerated anterior curvature of the lumbar spine. Also called saddleback (!) or hollowback. Basically a postural condition. Causes. The causes are similar to those leading to kyphosis, namely: Habitually incorrect posture or defective postural sense (the pelvis is tilted forward and the patient compensates for this by hollowing the lumbar spine). It may be a compensatory mechanism, the lordosis being a compensatory deformity to a high kyphosis or to conditions involving the hip joint, e.g. bilateral congenital dislocation of the hip, or TB of the hip involving the fixation of the joint in flexion, foot problems, etc Weakness or paralysis of the abdominal muscles, the flexors of the lumbar spine Careless treatment of kyphosis Pathological Changes. The abdominal muscles are stretched, the lumbar muscles contracted and the ligaments on the front of the spine are lengthened, while those on the back are shortened. The glutei are weakened, the rectus femoris is shortened, and the hamstrings may be lengthened. The psoas is contracted and so likewise may be the adductor longus and brevis. Bony change is uncommon. Note: Contraction of abdominals / hip extensors decreases the pelvic tilt. Contraction of the back extensors / hip flexors increases the pelvic tilt. Pelvic Tilt is approx 30° Muscles Involved. Erector Spinae: Spinalis, Capitis, Cervicus, Thoracis Longissimus: Capitis, Cervicis, Thoracis Iliocostalis: Cervicis, Thoracis, Lumborum, Rectus Femoris Hamstrings: Semitendinosus, Semimembranosus, Biceps Femorus, Psoas Abdominals: External Obliques, Internal Obliques, Transversus Abdominis, Rectus Abdominis, Adductors: Adductor Magnus, Adductor Brevis, Adductor Longus. Goals of Treatment. Postural re-education Mobilise and stretch the lumbar spine To strengthen the lengthened muscles To lengthen the shortened muscles The patient should be taught to correct the position of the pelvis and shown how to tilt it backward by contracting the lower part of the abdominals and glutei. This should be done successively in a lying, sitting and standing position. The position of the thorax is then corrected. The chest is raised and the shoulders pressed back, the head held well up, and the chin in (not drawn in to an unnatural position). The correct position of the pelvis must be maintained. When standing the patients are told to make themselves as tall as possible.
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PHYSICAL EXAMINATION OF THE SPINE Standing Observation. Posterior:Neck, straight/lordotic/side-bent or retracted Shoulder levels. Scapula levels -- spine at T3 -- inferior angle at T7 - T8 Thorax kyphotic or straight. Shoulder protracted or retracted Spine. Scoliosis C-shaped, S-shaped, poker spine Lumbar, lordotic/straight/retro-lordosis. Iliac crest levels L5 P.S.I.S. Gluteal folds levels. Sacrum/Coccyx deviations, (gluteal crease). Lateral:Angle of head; protruding, straight, side-bent or rotated, lordotic. Shoulders; protracted or retracted Abdomen - protrusion. Anterior:Shoulder levels. Clavicles Chest - deformities. Abdomen - abnormalities/ umbilicus at L3 Crest levels. Anterior iliac spines. Hip levels trochanter. Pelvic Examination. Hands on superior border of iliac crest. Thumbs on P.S.I.S. Get patient to touch toes by curling spine -- observe movement (forward flexion test) Leg thigh extension - observe P.S.I.S. Lumbar Examination. Touch toes, observe if lumbar spine flex or not. Extension. Lateral flexion. Rotation. Thoracic Examination. Flexion. Extension. Rotation. Lateral flexion.
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Cervical Examination. Flexion. Extension. Rotation. Lateral flexion. Sitting Examination. Pelvis. Iliac crests height. P.S.I.S. heights/levels. I.L.A. levels, seated forward-flexion test. Lumbar spine. Flexion Extension. Rotation. Lateral flexion. Thoracic Spine. How to palpate the inter spinous processes for movement. Flexion Extension. Rotation. Lateral flexion. Cervical Spine. Flexion Extension. Rotation. Lateral flexion.
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FRACTURES A fracture is any sudden break in a bone. Symptoms: There are different symptoms in different cases of broken bones, but some will present the following: Pain Deformity Abnormal motion Crepitus -due to grating of the fragments against each other Muscular spasm -caused by the irritation of nerves and muscles by the irregular fragments of bone followed by pain. Ecchymosis Swelling. Types Fractures may be complete or incomplete. Complete - when the bone is broken entirely through Incomplete - when the bone is broken partially through A fracture may be simple or compound. Simple -when the fragments of bone do not communicate with the air through an open wound, ie the skin is intact. Simple fractures are also called closed fractures. Compound -when fragments of bone are forced through the skin. Compound fractures are also called open fractures. Specific types of fracture. Comminuted -when a bone is splintered and broken into several or many pieces. Multiple -more than one fracture. Complicated -in addition to the broken bone surrounding important structures such as blood vessels or nerves are injured. Greenstick -an incomplete fracture with bending of the bone (occurs in children). Impacted -when one end of the broken bone has been driven into the other at the time of injury; most frequent in the femur, the neck being driven into the shaft. Pathological when a bone breaks due to a disease such as osteomyelitis, osteomalacia, or tuberculosis. Also called a spontaneous fracture. Bone Healing. Almost immediately after the injury a blood clot is formed at the fracture site. The clot is gradually changed into a callus by the depositing of lime salts. The callus is a bone like substance forming around the ends of a fractured bone, which then turns into mature bone. • •
Treatment. X-rays should be taken as soon as possible. The broken part is kept at rest and elevated. Ice or cold water should be applied to help relieve pain and control haemorrhage. In the majority of fractures local massage treatment should not be applied until the bone is healed and union of the fragment is fully established. Although the plaster of Paris casts give assurance of healing in a normal position, they nevertheless have an impeding influence upon the circulation and nutrition, causing stasis (stagnation of blood) and passive inflammation, atrophies of various 33
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kinds, and, worst of all, muscular contractures. At the present time there is a marked tendency to limit the use of casting to the shortest time necessary, and the heavy plaster of Paris casts are commonly replaced by soft casts which can be removed while the joint is being massaged, and then reapplied. Important: Massage is given above and below the site of a fracture, not over the site. This ensures that the healing process will not be disturbed. The first object of massage is to remove the detrimental effects of immobilisation. Effleurage promotes the blood and lymph circulation and increases nutrition to aid healing. In addition, effleurage and friction stimulate the absorption of the products of stasis. The massage movements must be regulated to suit the individual case. Immoderate movements would surely prove to be disadvantageous and injurious. The particular movements and procedures to be applied in treating fractures before union is complete are matters of the most careful discrimination. No one who is not thoroughly familiar with the treatment of these cases should undertake to treat them. General massage treatment of the whole body is of great benefit to the circulation and stimulates the repair of the injury during the period of immobilization. Local treatment to the injured part after the cast is removed should consist of Effleurage, Friction - used with care; alternate with effleurage, Kneading - used with care; alternate with effleurage. Each treatment lasts for twenty to thirty minutes and should be given every day. The patient should continue to receive treatment until full mobility is achieved. Local treatment directly over the site of the break may be employed after the fracture is known to be completely united and all the tenderness is disappeared.
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COLLE'S FRACTURE A fracture of the distal radius. There may be secondary shoulder problems. Patient usually presents in a cast, from below the elbow to the hand. The hand is supinated. There is swelling of the hand, wrist and maybe the shoulder. Involved muscles. Flexors and extensors of the wrist and fingers. Brachioradialis. Brachialis. Palmer fascia. In cast treatment. • Elevate (support) the elbow on a pillow. • Proximal to distal draining. Start at the shoulder area with short strokes towards the heart, and work down the arm. Drain above and below the fracture site. • NOTE: draining helps to prevent or minimise adhesions. • Passive movements, all possible movements of the fingers. • Full intermediate massage to shoulder area. If there is injury to the shoulder, treat accordingly. • NOTE: Patient must be encouraged to do any possible finger movements while in the cast. Muscle action under the cast, must also be maintained so isometric contractions of the forearm must be included. These exercises will aid circulation and limit muscle atrophy. Shoulder movements and exercises are prescribed, as early as possible Out of cast treatment. Clinical union (no bony union). NO MOVEMENTS AT THE BREAK SITE. Work superficially, no deep work. Support site of break with one hand, work with the other. Very light effleurage and drainage work up forearm to the shoulder. Stretch (lengthen) the biceps. Bony union Now there is the potential for movement. At the beginning patient has limited R.O.M. and poor muscle tone. Goals Restore R.O.M. Resisted exercises to rebuild atrophied muscles. Light effleurage and draining. Trace the brachioradialis and move muscle off the bone. Use inhibition where necessary. Trace and "strip out" each flexor individually. Transverse friction to insertion. Tracing and "stripping" of individual extensors. Slowly introduce passive flexor and extensor movements. Slowly introduce resisted flexor/extensor movements when muscle tone starts to return Introduce passive and resisted pronation. M.E.T. can be introduced at this point. Full muscle tone and R.O.M. has returned. Note: A similar treatment as for Carpal Tunnel Syndrome - an impingement of the median nerve, generally due to the overuse of the wrist and hands involving fine motor movements. Can cause pain, but more likely numbness and tingling to radiate in the wrist hand area. 35 The Institute of Physical Therapy 2000 - 2005
Goals. Lengthen the tissue Break up adhesions. Eliminate debris. NOTE: With carpal tunnel syndrome the patient has full R.O.M. Clean out the heel of the hand. Using the thumbs, work up the metacarpal spaces. Work as deeply as possible. Don't work over the carpals. Stretch thenar /hypothenar apart. Intermediate massage to forearm wrist and elbow. Mobilisation techniques are introduced slowly and with care. Exercises for Colle's Fracture. Strengthen radial and ulnar deviation. Twist cap on/ off a bottle. Pronation / Supination. Screw and unscrew using a screwdriver, or open and close using a doorknob. For carpal tunnel syndrome. Rest arm initially. Wrist curls, starting with very light weights. Movements should include flexion and extension of the fingers. Light stretches of the wrist and fingers. Intrinsic hand muscles. Place the palmar surface of the hand and fingers flat against a soft and firm surface. Press down on the fingertips without lifting the palm.
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Soft Tissue Injuries The soft tissues include muscles, ligaments, tendons, fascia, bursa, joint capsule, and cartilage.
Muscle Injury Strain refers to a muscle injury Damaged muscle can heal quickly, with fibres reformed in about three weeks. When injury occurs however, there is almost inevitably some degree of bleeding and this can effect the healing process mechanically by reducing contact between the ruptured ends of the muscle fibres. If bleeding can be controlled healing is more likely to be quick and complete. There are two distinct types of muscle rupture: Distraction and Compression.
Distraction Ruptures These are caused by overstretching or overload and are often located in the superficial parts of the muscles or their insertions or origins
Compression Ruptures These occur as a result of direct trauma or impact. The muscle is pressed against the underlying bone for example when a player’s knee hits another’s thigh during contact sport and heavy bleeding deep within the muscle may occur.
Factors which contribute to muscle ruptures • • • • • • •
A number of factors are important in contributing towards the occurrence of muscle ruptures: The muscle may have been poorly prepared because of inadequate training or lack of warm-up The muscle may have been weakened by previous injury followed by faulty rehabilitation The muscle may previously have been extensively injured with resultant scar tissue formation. (Scar tissue is less elastic than muscle and therefore more liable to recurrent injury) A muscle which is overstrained or fatigued is injured more easily Tense muscles which do not allow a full range of joint movement may be injured in sports demanding flexibility Muscles subjected to prolonged exposure to cold are less contractile than normal
Distraction Ruptures Distraction ruptures frequently occurs in sports that require explosive muscular effort over a short period of time, for example in sprinting, jumping and football. When the demand made on a muscle exceeds its innate strength, rupture may occur. Other examples in sport include sudden stopping, deceleration, rapid acceleration or a combination of deceleration and acceleration when turning, cutting, jumping and so on.
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Distraction ruptures often occur in muscles that move two joints, for example the hamstrings. The symptoms of muscle rupture depend on it’s severity. Ruptures are classified as partial or total. Another form of rupture classification describes different degrees of strains; so first and second degree strains are partial ruptures and third degree strains are total ruptures or disruptions.
Partial Ruptures A first degree or mild strain describes an overstretching of the muscle with a rupture of less than 5% of the muscle fibres. There is no great loss of strength or restriction of movement. Active movement or passive stretching will however cause pain around the area of damage and there will be some discomfort. It should be remembered that a small rupture or mild strain could be just as distressing to the athlete as a more serious injury. A second degree or moderate strain involves a more significant or less than total tear to the muscle. The pain will be aggravated by any attempt to contract the muscle. A total rupture (or third degree / severe strain) involves total disruption of the muscle.
Symptoms and diagnosis The following features suggest that a distraction rupture has occurred; A sharp or stabbing pain is felt at the moment of injury and reproduced by contracting the muscle concerned. Usually there is little pain if the muscle is rested • In a partial rupture the resulting pain can inhibit muscle contraction. In total ruptures the muscles are unable to contract for mechanical reasons • In partial ruptures it is sometimes possible to feel a defect in part of the muscle under examination. In a totally ruptured muscle the defect can be felt across the entire muscle belly. The muscle may ‘bunch up’ and form a lump resembling a tumour. • There is often localised tenderness and swelling over the damaged area • After about 24 hours bruising and discoloration may be seen, often below the site of the injury. These are signs of bleeding within the damaged muscle. Muscle spasm may occur The most effective diagnostic test is often a test of function, with or without resistance.
Healing When a muscle is overstretched the muscle fibres and blood vessels will tear. The torn ends will retract from the injured area leaving it filled with blood. Initially there will inflammation and thereafter reabsorption of the bleeding. The repair of a muscle injury involves two ‘competitive’ events; formation of new muscle fibres (regeneration) and the simultaneous production of scar tissue (granulation tissue). Skeletal muscle possesses a high capacity to regenerate, but the new muscle fibres will be shorter an incorporate inelastic scar tissue. If the scar covers a large area functions will be impaired because contraction will be restricted. Areas of different elasticity may be formed in the muscle which increase the risk of recurrence of rupture. It is therefore important to follow a muscle injury with a long-lasting rehabilitation programme.
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Compression Ruptures When direct impact is the cause of injury, deep rupture and bleeding can occur as the contracted muscle is compressed against the underlying bone. Compression ruptures can also occur in superficial muscles.
Muscular Haematoma During physical activity there is substantial redistribution of blood flow. In the muscles it increases from about 1.5 pints/min (15% of cardiac output) at rest, to 32 pints/min (72% of cardiac output) during strenuous effort. It follows that blood supply to the muscles during sporting injury is enormous; the extent of bleeding when the muscle is damaged is directly proportional to muscle blood flow and inversely proportional to muscle tension at the time of injury. The effect of an injury depends on it’s location and extent rather than upon it’s cause, and in the following paragraphs, no distinction will be made between compression and distraction ruptures. Treatment, healing and rehabilitation will also vary on the type, location and extent of hemorrhage and ruptured tissue.
Intramuscular Haematoma Bleeding within a muscle may be caused by rupture or impact. It begins within the muscle sheath (fascia), and cause an increase intramuscular pressure which counteracts any tendency to further bleeding by compressing the blood vessels. The resultant swelling persists beyond the first 48 hours and is accompanied by tenderness, pain and impaired mobility. Swelling may increase as the bleeding draws fluid from the surrounding tissue (osmosis) and muscle function may be completely absent. If the muscle sheath is damaged, blood may spread into the space between the muscles (see below) or out into the surrounding tissues. Intramuscular haematoma may create an acute compartment syndrome due to increased intracompartmental pressure.
Intermuscular Haematoma Bleeding may occur between muscle when a muscle sheath (fascia) and it’s adjacent blood vessels are damaged. After an initial increase causing the bleeding to spread, the pressure falls quickly. Typically, bruising and swelling caused by a collection of blood, occur at some distance to the damaged area 24 to 48 hours after the injury due to gravity. Because there is no sustained increase in pressure the swelling is temporary and muscle function returns rapidly. Provided immediate treatment is available, recovery can be expected to be speedy and complete.
Treatment of Muscle Rupture and Haematoma The athlete or trainer should stop or control muscle bleeding irrespective of its cause by use of the following measures; Rest, Ice, Compression, Elevation. The body’s defense against bleeding (coagulation or clotting) comes into action as soon as the injury occurs and continues to function for several hours. The repair mechanism, however, is unstable for the first 24 to 36 hours, so that further bleeding may occur as the result of another impact, vigourous muscle contraction or unprotected weightbearing. Massage, which is, in effect, repeated minor trauma, should not be used within 48 to 72 hours of the injury. Wherever there is any suspicion of major muscle rupture or significant bleeding, a doctor should be consulted as soon as possible. The doctor’s action will depend on the 39 The Institute of Physical Therapy 2000 - 2005
extent of the injury. If it is severe, admission to hospital for observation is usual as the bleeding and swelling may increase, impairing the blood supply and raising the intramuscular pressure. This can be dangerous if left unmonitored. If the bleeding is not extensive, or if there is any uncertainty about the nature or extent of the injury, 48 to 72 hours rest may be prescribed. Precise diagnosis can be difficult in the acute phase and for the first 2 to 3 days an injury should be considered as potentially serious. Constant re-examination of the injured area is necessary in order to distinguish between intermuscular and intramuscular bleeding. Decreased swelling and rapid recovery of function would suggest the former. And persistent or increased swelling with poor function, the latter. After 48 to 72 hours the following questions should be answered Has the swelling resolved? If not, intramuscular haematoma is probably present Has the bleeding spread and caused some bruising at some distance from the injury? If not, the injury probably involves intramuscular haematoma Is the haematoma a symptom of a total or partial muscle rupture? It is important that an accurate diagnosis is made; premature exercise of a muscle effected by extensive intramuscular haematoma or a complete rupture can cause complications in the form of further bleeding and sometimes increased scar tissue formation. This, in turn, is likely to lead to a more protracted healing process and possibly even permanent disability. Treatment beyond the first 72 hours depends on the diagnosis which has been made. If the symptoms caused by the injured muscle fail to improve, it is important to reconsider intramuscular haematoma and tissue damage.
Complications of Muscle Injury 1. Scar tissue formation Muscle fibres which have been overloaded with resultant bleeding and rupture become less contractile. The space between ruptured muscle fibres fills with blood which clots and is gradually converted into connective tissue. This, in turn, is gradually converted into scar tissue. This healing process leaves the muscles with areas of varying elasticity, and further injury (rupture or haematoma) may then occur if the muscle is exercised too hard, too soon. If scar tissue causes persistent problems it may be necessary to remove it surgically. Prognosis With early recognition of onset and good management the bone may be re-absorbed. If not the bone tissue matures and may cause problems by pressing on blood vessels, nerves and muscle tissue. Clinical features Loss of range of movement Pain on muscle activity Firmness of tissue on palpation On x-ray there is a faint outline of bone tissue The commonest sites are; 40 The Institute of Physical Therapy 2000 - 2005
Thigh – quadriceps Biceps brachii Supraspinatus Anterior tibialis 2. Myositis Ossificans ‘Charley-horse’ Direct impact causes intramuscular and/or intermuscular bleeding. If immediate treatment is inadequate, deep located intramuscular haematoma may gradually become calcified and ossified. Ossification continues as long as healing is disrupted by repeat impact or contraction. This will result in areas of varying strength and elasticity in the affected muscle, with a correspondingly increased risk of further injury. Ossification is a lengthy inflammatory process for which doctors hesitate to recommend active treatment for a long period of time. If muscle function and flexibility are significantly impaired for more than 6 to 10 weeks and x-ray reveals signs of ossification, then surgical removal of the ossification should be considered. 3. Infection This is not common in an intramuscular haematoma but may occur in a subcutaneous area, e.g. Anterior aspect of the tibia. It is treated with rest and antibiotics until clear and then rehabilitation is as for an acute injury. 4. Cyst formation A serous filled cavity forms owing to partial but not complete absorption of the haematoma. Treatment is by incision to remove the fluid. A firm pressure bandage is applied for two to three days. The rehabilitation follows the acute injury programme.
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Ligamentous Injury Sprain refers to injury to a ligament. The primary function of ligamentous tissue is to create stability around the joints. Ligaments are comprised of white connective tissue which forms bands either inside or outside the capsule of a synovial joint. The are attached to and blend with the periosteum of the bone. All ligaments are taut at the normal limit of a particular movement. They are however slightly elastic and protected from excessive tension by reflex contraction of appropriate muscles. There are more transverse fibres in a ligamentous tissue than in tendon tissue. This allows the ligament to be more resistant to stress in multiple directions. The tendon only encounters tensile strength along it’s length from muscle contraction. The ligament is designed to be strong in one predominant direction (the line of tensile strength along it’s length) but also must be resistant multi-directional stresses that the joint may encounter during movement. Ligament also has a greater concentration of elastin than the tendon does. This will allow the ligament a small degree of ‘give’ before it pulls taut at that particular joint. This small amount of ‘give’ is important. If the ligament were as rigid and ‘ungiving’ to tensile stress as a tendon, the frequency of ligament injuries would be much greater. Prolonged tension results in pain. Acute sprain is caused by sudden twisting or wrenching of a joint which results in overstretching of a ligament. It is associated with the muscles controlling a joint being momentarily off guard so that the ligament is subject to the full force of the movement. The severity of the injury depends on the number of fibres injured, the quality of the stability depends on the number of fibres remaining intact. Chronic sprain is caused by repetitive stretching from a minor force which may be due to faulty posture or poor quality of movement. Complete rupture is disruption of all fibres of the ligaments caused by a sudden violent force such that the joint is unstable.
Healing of Ligaments Ligaments, having only fair vascularity, heal slowly. Since they have no specialised cells repair is always by fibrous tissue. Completely ruptured ligaments must be sutured and protected for lengthy periods. Otherwise the fibrous tissue forms a weak union between the ends of the fibres. The danger then is that the ligament lengthens and does not perform its stabilising and controlling functions. Sprained ligaments also heal by fibrous tissue. The degree of protection required during healing depends upon the severity of the injury. It is important to gauge the point at which mobility must be rehabilitated because the healing fibrous tissue may cause adhesions. The danger then, is that the ligament, being bound to neighbouring structures, is prone to further injury and the movement controlled by the ligament is painful and limited. (Evans, 1980).
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Acute Sprains, Clinical Features
History: There is a history of injury which the patient can usually describe. Pain – There is a sudden pain and feeling of nausea at the time of injury. The intensity of pain reduces but can be reproduced if the causative movement is repeated. As healing occurs, the pain becomes less constant and is reproduced only if the ligament is stretched. Swelling – This occurs rapidly and is due to the escaping of fluid into the fascial space around the ligament. Later, inflammatory exudate is a component of the swelling. If the joint capsule is injured, synovial fluid may be present in the swollen area. Bruising – Blood escapes from injured blood vessels into neighbouring tissues. The red blood cells break down releasing constituent pigments which produce the various colours of bruising. The presence of plasmaprotein fibrinogen in tissue fluid is a disadvantage because fibrin is formed producing consolidation of the tissue fluid. Chronic swelling can result if the treatment is ineffective. If blood goes into a joint space there is haemarthrosis which limits joint movement. Loss of movement – A lower limb ligament injury will prevent use of the limb especially in walking and running. An upper limb ligament injury makes many activities of daily living difficult, e.g. dressing, eating, writing, etc. Chronic Sprains; Clinical features History – There is recurrent minor injury which may or may not be known to the patient. It may be necessary for the therapist to analyse activities or sport techniques to identify the cause. Pain – This is a dull aching around the area of the injured ligament. It may be constant or intermittent, tends to increase with activities which move the joint controlled by the ligament and may be superimposed occasionally by sharp stabbing pain. Swelling – There is often an area over the ligament which feels like thickened jelly and cannot be moved, like the fluid swelling of acute injuries. Loss of movement – The movement controlled by the injury is equally limited both actively and passively Instability – if the ligament is subjected to frequently prolonged stretching it becomes weakened and the joint becomes unstable. Instability may also be due to loss of proprioceptive input due to damage of the mechano-receptors. Loss of function – Activities are impaired and the movements producing the movements of the affected joints tire more easily. Following activity, the patient may feel stiff and sore in the affected part. 43 The Institute of Physical Therapy 2000 - 2005
Complete Ruptures History – The patient reports a definite injury, often with an audible snap. Sometimes it is described as being like a kick or blow over the site of the rupture. Pain – sometimes there is little or no pain immediately after the injury but usually there is severe sickening pain. The intensity reduces over the first few days with treatment. Swelling – A large amount of swelling forms rapidly indicating gross tissue damage. Bruising – This occurs as in acute sprains Loss of function – there is severe loss of function of the affected limb, e.g. weightbearing is impossible with a lower limb injury.
Treatment of Ligaments -- Acute injuries. Early management of an acute injury is very important in relation to the long term outcome. The main aims as soon as the injury has occurred are as follows: •
To enable healing to take place
To reduce the risk of further injury
To minimise swelling
The important themes are, therefore, rest, ice, compression, elevation and controlled exercise. The main aims as healing takes place are; •
To prevent adhesion formation
To strengthen the muscle related to the ligament
To re-educate proprioception
To restore full mobility of the ligament and corresponding joint
To restore the patient’s confidence
To restore the patient to full functional activity
Chronic Injuries The important aspects of the management of chronic injuries are: •
To identify the cause of the repeated trauma to which the ligament is subjected
To treat the ligament
To prevent recurrence
Identifying the cause demands careful, logical analysis of the patient’s lifestyle. It is important to include positions that may cause long term stress, e.g. sitting with the feet held in inversion stretches the lateral ligament of the ankle joint; always running clockwise around an athletics track stretches the right lateral and left medial ankle ligaments with shortening of the opposite ligaments. Poor posture tends to put long 44 The Institute of Physical Therapy 2000 - 2005
term stress on ligaments. Changing the grip on a racquet or golf club can stress the ligaments of the hand and wrist, The patient can often trace the onset of pain in a ligament to a change in technique or equipment at work or at play but may have to be prompted by the therapist to remember this. Treatment is directed at achieving the following aims: •
To mobilise the ligament from underlying structures
To restore flexibility to the ligament
To strengthen the muscles related to the ligament
To re-educate proprioception
To re-educate function and the patient’s confidence
Mobility of the joint is regained by soft tissue manipulation to reduce swelling and to restore mobility to all soft tissues within their fascial planes. Active exercises are essential. Mobilisations are usually required and are generally essential to restore accessory movements especially where there is a complexity of joint involved, e.g. tarsal, carpal, elbow, intervertebral joints. Flexibility of the elbow can be regained by using transverse frictions, passive stretching and active exercise. Strengthening of the muscles is achieved by active exercise resisted manually or mechanically. Proprioception can be re-educated by proprioceptive neuromuscular facilitation techniques, weight bearing activities, co-ordination exercises and, for lower limb injuries, balance (wobble) boards.
Prevention of recurrence This starts by eliminating, where possible, the causative factors or repeated stress. General fitness is important with an exercise programme designed to increase the flexibility of the ligaments. Before activity, which may be high level competitive sport or the occasional weekend gardening, warm up is essential. This includes stretching and jogging for anything from 5 to 20 minute beforehand, depending on the intended activity. Clothing needs to provide warmth and protection together with freedom of movement. Equipment must be reliable and appropriate to the activity as well as to the individual.
Complete Rupture As with acute injuries, early management is vital to enable good long-term outcome, The two principal methods are: Surgical repair followed by immobilisation Immobilisation in a shortened position In both instances the joint is fixed so that the ligament is in a shortened position. During the period of fixation the main aims are: 45 The Institute of Physical Therapy 2000 - 2005
• • • •
To encourage healing To minimise adhesion formation To maintain the strength of the muscles related to the ligament To maintain function
The main themes are, therefore, active exercises, functional use of the limb and specific exercises to work the muscles isometrically over the fixed joints. After the fixation is removed the principles of treatment are similar to those for chronic ligament injuries. Principles Applied – Ankle ligaments The ligaments of the ankle are injured when the plantar flexed foot is forced suddenly into inversion (lateral ligament) or eversion (medial ligament). Injury to the lateral ligament is most common.
Acute Sprain to Lateral Ligament Aetiology This injury is common in sports activities such as pole vaulting, cross-country running and hiking. It is also quite common in general terms when a person slips off a pavement or walks on uneven surfaces. The mechanism is for the foot to be forced into inversion and plantar flexion. The site of the injury is generally between the centre and distal attachments of the middle and anterior bands of the ligament. Clinical Features History – The patient describes ‘going over’ on an ankle Pain – There is sharp pain just below and anterior to the lateral malleolus at the time of injury. Passive stretching and weight bearing increases the pain. Swelling – This is present from the lateral border of the tendo Achillis, over the lateral malleolus along the dorsum of the foot. In severe injuries the swelling may spread to the dorsum of the toes and up the leg. Bruising – This appears under the lateral malleolus and over the dorsum of the foot. Loss of function – All weight bearing is painful so that the patient cannot run and has a gait with a very short stance phase on the affected foot.
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Chronic Sprain to Lateral ligament Identifying the cause Causes may be: • • • •
Poor reflex co-ordination of peronei to prevent twisting while walking over uneven ground Improper support from footwear; worn heels or old shoes which have become too large Prolonged sitting with feet turned in causes lengthening Poor foot posture with feet everted
Clinical Features Pain – Dull ache over ligament which may become more sharp during prolonged walking or running. Swelling – Thickened swelling is often present under the lateral malleolus and along the Achilles tendon Loss of movement – plantar flexion with inversion is limited and feels tight Instability – balancing on the affected leg is more difficult than on the other leg even though muscle power may not be markedly diminished. Complete Rupture – Lateral ligament This is caused by a violent force which produces plantar flexion, inversion and adduction of the foot; often the patient falls with the foot twisted under the body weight. Clinical Features Pain – severe pain over the ligament area Swelling – immediate swelling denoting severe injury occurs on the lateral side of the ankle and over the dorsum of the foot. Instability – There is excessive range of inversion and adduction Loss of function – The patient is unable to walk or to take any weight at all on the foot. Radiograph – Abnormal sideways tilt of the talus demonstrated on x-ray
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Tendons These are tough white cords of fibrous tissue. The primary role of tendon tissue is to transmit the contractile force of the muscle to the bone in order to move the bone. For this reason tendons are relatively inflexible structures which are designed to be strongest in the direction of tensile stress. Most of the fibres of a tendon will run in a longitudinal direction in the tendon. This will give it the greatest amount of tensile strength. Tendons do not contract but they are considered part of the group of tissue known as contractile tissues because they function so interdependently with muscle. They vary in length and thickness according to the site within the body. Most muscles have tendons at one end. A tendon may be enclosed in a synovial sheath to prevent friction and may be separated from neighbouring structures by a bursa. The tensile strength of tendons is similar to that of the bone i.e. half that of steel. However, tendons are often ruptured, with injuries occurring at the musculotendinous and tendoperiosteal junction. Blood supply is scant. The metabolic rate of tendon is very low but increases in reaction to infection or injury.
Types of Injuries Partial Rupture Complete Rupture Tenosynovitis
Cause of Injury These may be traumatic or spontaneous
Traumatic Direct cuts; window glass, road traffic accidents, knife accidents (butcher’s shop or a kitchen). Complete rupture is most likely. A sudden stretch when the muscle is contracting; sometimes the tendon gives, sometimes it’s the muscle. The injury may be a partial complete. Spontaneous Degenerative changes may weaken a muscle which then ruptures without apparent trauma. For example; long head of biceps brachii, extensor pollices longus (particularly after a Colles' fracture has healed and the radius is roughened, producing friction on the tendon).
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Tendons Commonly Affected •
Rotator cuff, especially supraspinatus
Long head of biceps brachii
Common extensor tendon (tennis elbow)
Common flexor tendon (Golfer’s elbow)
Extensor pollicis longus
Abductor pollicis longus and extensor pollicis brevis
Finger flexor or extensor tendons
Partial Rupture – Pathology •
Some of the tendon fibres tear and others are intact
Tendon is a poorly vascualrised tissue and only a small amount of blood may be released from damaged blood vessels
Low-grade inflammatory changes take place.
Granulation tissue forms at the site of injury
Tendon cells invade the area and tendon fibres are laid down so that healing takes place
If there is extensive damage the fibrous (non tendon type) scar tissue may form as well and this can bind the tendon to surrounding tissues
Repair can take from 3 to 6 weeks depending on the degree of injury
Clinical Features History – a sharp stabbing pain or tearing may be heard or felt Loss of function – The patient is unable to produce the action of the muscle Swelling and bruising may appear 2 to 3 days after injury
Complete Rupture – Pathology Spasm of the muscle causes retraction of the free end of the tendon so that a gap forms. Haematoma fills the gap. Granulation tissue forms in the haematoma. Tendon cells may lay down tendon fibres but generally fibrous tissue fills the gap. This renders the tissues virtually useless because the fibrous tissue stretches. Suturing is therefore essential to enable tendon fibres to reunite the tendon. Where the rupture is spontaneous, the poor blood supply and frayed ends of the tendon make spontaneous healing impossible and suturing is difficult. Repair may require a graft. 49 The Institute of Physical Therapy 2000 - 2005
Clinical Features -- History •
Knife injury (fingers)
Hand going through window (wrist)
Snap on sudden activity (tendo Achillis)
Sudden stretch with muscle contracting(quadriceps tendon)
Tenosynovitis This is inflammation of the synovial sheath of a tendon. Tendinitis is inflammation of a tendon which does not have a sheath.
Cause The commonest cause is over-use, but pressure may also cause the condition
Pathology Inflammatory changes occur within the tissues of the sheath resulting in excess synovium production and inflammatory exudate. Over 1 to 2 weeks fibrin forms and can consolidate into adhesions which can impair tendon movement. With correct treatment, the inflammation subsides, the excess fluid is absorbed and the tendon plus sheath return to normal within 2 to 3 weeks. Overuse and abuse can cause chronic inflammation.
Clinical Features Sharp pain is felt at the site of the inflammation and spreads in line with the tendon both distally and proximally Redness - This appears over the line of the tendon Swelling - There is swelling, sometimes sausage shaped, along the length of the sheath Crepitus – ‘Grating’ can be felt over the sheath as the tendon moves with it Loss of function – This is a disabling condition, the patient being unable to perform any of the movements involving the tendon
Common Sites • • • •
Wrist tendons; caused by overuse, e.g. at a keyboard, prolonged knitting or writing, change of grip (technique or handle) in sport Extensor pollicis longus; caused for example by using scissors excessively Tibialis anterior; caused for example by sudden extra fast walking Extensor tendons (toes); caused for example by pressure from an ill-fitting shoe or extra walking in tight shoes
Fascia 50 The Institute of Physical Therapy 2000 - 2005
Fascia is the complex soft tissue webbing which holds us all together. It is wrapped around muscles, around individual muscle fibres, used in suspending organs, a necessary matrix of vascular structures, nerves, and lymphatic vessels and instrumental in creating our body shape. Fascia is a connective tissue. It is quite pliable and malleable so it is rarely subjected to compressive force injuries. The main problem with fascia are tensile stress injuries and the problematic results created from periods of prolonged shortening. When soft tissue structures of the body are over-stretched, the fascia that binds or connects then will also be over-stretched. The fascia has multidirectional fibres in order to resist stress from different directions. However, if that stress overcomes the tensile strength of the fascia, it will tear. When it does, it is likely to create scar tissue which may bind the fascia to adjacent structures. This scar tissue is most easily managed through the rehabilitation process by multidirectional stress (massage strokes, stretching, etc) being applied to it within it’s comfortable and normal range of motion. One of the most problematic features of fascia is it’s response to prolonged immobilisation. If the body is held in one position for prolonged periods of time the fascia has a tendency to adapt to the position. The is especially problematic when the fascia is held in a shortened position. When it is kept in this shortened position it will structurally adapt to that position and resist an attempt to return to it’s normal length. The longer it is subjected to this shortening the harder it will be to return to it’s normal length. Common conditions include: Iliotibial tract syndrome Shin soreness Interscapular pain
Iliotibial Tract Syndrome The iliotibial tract is a thickened band of fascia on the lateral aspect of the thigh. Proximally, the gluteus maximus and tensor fascia latae are inserted into it. Distally, it is attached to the lateral condyle of the tibia.
Pathology The tract can become thickened and tight. The deep surface can become inflamed
Cause Excessive use in patients who participate in long distance sport (running, walking) gives rise to this syndrome. It can also occur in people who habitually stand on one leg more than the other, e.g. a person who favours the left leg has a lengthened left tract and a lightened right tract.
Clinical Features Pain – usually come on gradually over the lateral side of the thigh. It increases in intensity until the patient decides to seek help. 51 The Institute of Physical Therapy 2000 - 2005
Tenderness – The tract is tender on palpation especially in the lower third.
Movements – Hip adduction is slightly limited
Shin Soreness This is related to a tight fascial compartment in which the anterior tibial muscles are contained. Exercise – especially long distance walking or unaccustomed running or walking – bring on the pain over the anterior aspect of the shin. As the muscle exercises, fluid collects and the tightness of the fascia causes compression which brings on the pain.
Interscapular Pain Long-standing tension in the interscapular muscles is associated with tethering of the fascia. This is a component in a viscous circle: tension in the muscle causes accumulation of fluid, causing discomfort, leading to further tension and pressure within fascial compartments causing more stretching of the fascia with a reaction of thickening and tethering, causing more pain and more tension.
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Bursitis Definition Bursitis is inflammation of a bursa. A bursa is a membrane sac lined with endothelial cells. It may or may not communicate with the synovial membrane of the joints. The function of a bursa is to prevent friction between two structures (e.g. tendon and bone or tendon and muscle) or to protect bony points.
Common Sites •
Prepatellar bursitis (Housemaid’s knee)
Miner’s or student’s elbow (olecranon bursitis)
Achilloydina (inflammation of one of the bursa around the tendo Achillis
Causes Trauma – one episode or, more often, repeated minor episodes Associated diseases e.g. rheumatoid arthritis, gout
Pathology Acute inflammatory changes occur. Chronic inflammation may arise with repeated minor trauma
Clinical Features Pain – Over the bursa especially on compression Swelling – a large fluctuating swelling may be present
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The composition of joint capsule tissue is similar to that of ligament tissue. It’s primary function is to maintain integrity of the joint, guide specific joint motions, prevent excessive motion and house the lubricating synovial fluid which reduces friction and wear on the joints. Portions of the joint capsule are highly innervated with proprioceptors and noiceptors. Proprioceptors are specialised cells that give a great deal of feedback information to the central nervous system about movement and position in space.
Nociceptors are pain receptors. Injuries to the joint capsules may be quite painful. The most common types of injuries sustained by the joint capsule are tensile stress tearing injuries such as those sustained by ligaments.
The joint capsule may also be involved in various conditions of adhesion that will limit functional range of motion. For numerous reasons, some of them unknown, a joint capsule will begin to develop adhesions and restrictions to movement in certain planes of motion. This may involve muscle spasm and tightness, prolonged immobilisation, repetitive misuse or emotional factors. The condition of adhesive capsulitis, also known as ‘frozen shoulder’ is an example of this.
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There are two types of cartilage that will be of primary concern, hyaline cartilage and fibrocartilage. This cartilage does not have vascular or nerve supply. This is important because injury of the actual cartilage tissue may not feel painful to the individual. Many times it is only when the injured cartilage interferes with other types of tissue that pain or discomfort will be felt.
Hyaline cartilage is prominent at the ends of bones in joints where it is called articular cartilage. It is a hard shiny substance which greatly reduces friction of the bones and help to create a smooth gliding substance for the two ends of the bone that are meeting. Fibrocartilage is also present between the bones but it plays a different role. Fibrocartilage can be found in regions such as the menisci of the knee or the intervertebral discs in the spine. These fibrocartilagenous discs in both the knee and the spine help to provide additional cushioning from compressive forces. The intervertebral discs also help to angle the spine and the menisci in the knee help to provide the optimum contact surfaces required for functional joint mechanics.
Cartilage is susceptible to several types of injures. Compressive force injuries to cartilage are the most frequent. Disc herniations and ruptures of the intervertebral discs in the spine are the result of cumulative compressive forces over time. They made be made suddenly worse by an acute injury but there is usually a history of chronic compression needed to fully herniate or rupture a disc.
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Blood Supply and Healing Times of Various Body Tissues
3 to 14 days
Upper Limb 3 to12 weeks
Lower Limb 12 to 18 weeks Femur 4 to 5 months Young Children 4 to 6 weeks
No Healing process
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HISTORY TAKING When did the present problem arise? Was the onset gradual or sudden? Was an injury or unusual activity involved? An insidious onset unrelated to injury or unusual activity should always be viewed with suspicion since this history is typical of a neoplasm. However degenerative lesions or lesions due to tissue fatigue are common and may also arise in this manner. If the patient blames some injury or activity, keep in mind that he may or may not be correct. The exact nature of the event or mechanism of injury should be determined so that correlation can be made to symptoms and signs for interpretation. Determining the direction and nature of forces producing the injury may give some clues as to which tissues may have been stressed. What aggravates the pain? What relieves it? Is it any better or worse in the morning or evening? When do you typically feel pain? Bilateral referred pain is generally associated with a lesion in the vertebral canal therefore immediate medical attention is warranted. Pain not aggravated by activity or relieved by rest should be suspected as arising from a pathological process other than a musculoskeletal disorder. The exception is a disc problem that may be aggravated by sitting and relieved by getting up and walking. Morning pain is suggestive of arthritis, especially the inflammatory varieties. Morning stiffness is suggestive of degenerative joint disease or chronic arthritis. Pain awakening the patient at night is typical of shoulder or hip problems that may be aggravated by lying on an affected side. Otherwise a more serious problem should be suspected, particularly if the patient is kept awake and particularly if he must get up and walk about. Arthritis in weight bearing joints leads to pain on fatigue (long walks etc) in it's early stages. In later stages the pain is felt when beginning a walk, somewhat relieved once going, and returns after walking too far. Have you had this problem in the past? If so, how was it resolved? Did you seek help? Was there any treatment? Is the pain the same this time? Should the examiner elicit a history of recurrence, the patient should be asked in depth about the first episode and the most recent episode, with an estimate of the number of intervening episodes. Recurrences are typical of spinal cord lesions, but many common extremity lesions such as ankle sprains, minor meniscus lesions, or other internal derangements, minor degenerative joint problems, tendinitis, and frozen shoulder may also tend to recur. By enquiring about previous management, some helpful information may also be obtained for treatment planning. However, the patients judgement of the effectiveness or value of previous treatment must not be weighted too heavily. If an injection helped before, for example in the case of supraspinatus tendinitis, it does not necessarily follow that another injection is necessary or indicated. If physical therapy (perhaps inadequately instituted) was unsuccessful in the past, do not assume that it will not be helpful on this occasion.
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Are there other symptoms that you have or have had that you associate with the problem, such as grinding, popping, giving way, numbness, tingling, weakness, dizziness or nausea? By concentrating on the patient's account of pain, the examiner may well overlook some other important symptoms. A wide variety of responses may be elicited with this question, each of which must be carefully weighed and considered. A patient's description of numbness is very often not true hypesthesia but is actually referred pain. In most cases, considerable weakness must be present before the patient can accurately perceive it as such, and very often, what the patient describes as "weakness" is actually instability or giving way. Symptoms inconsistent with musculoskeletal dysfunction must be viewed with some suspicion and medical consultation sought for interpretation. What treatment are you having, or have you had for the present problem? Are you taking any medication for this problem or for any other reason? Here again, it may or may not be helpful to determine whether certain attempts at treatment have had any good or bad effects especially treatments involving physical agents. The examiner must determine whether pain medications, anti-inflammatory agents, or muscle relaxants are being taken. Symptoms or signs may be masked accordingly. Certain medications may produce rather marked musculoskeletal changes (in addition to effects on other tissues and functions). Most important perhaps is the long term use of corticosteroids, which produces osteoporosis, proximal muscle weakness, generalised tissue oedema, thin fragile skin, collagen tissue weakening, and increased pain threshold. These factors of course, will affect findings on examination. More importantly however, they must be considered when planning treatment. How is your general health? It is necessary to determine whether the patient has, or has had any disease process or health problem that may have contributed to the present problem, or that may influence the choice of treatment procedures. Do you have any ideas of your own as to what the problem is? Some useful information may be elicited as to what the patient has learned from others, what his insight is into the problem, and so on. If nothing else, the patient can be reassured that the examiner is interested in him and his opinions and that he is to be involved in the therapeutic programme.
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APPLICATION OF COLD The application of cold, including ice, is a frequently used modality in Physical Therapy. Muscles constantly produce heat. When muscles are exposed to cold, there is need for increased production of heat, and subsequently, muscle tone is increased. Brief exposure to cold therefore, causes an increase in work output. It also raises the stimulus threshold of muscle spindles and prolongs relaxation. In other words, cooling the tissues causes vaso-constriction, decreased tissue metabolism, and blocks the release of histamine which is responsible for vaso-dilation and exudate formation. Physiological effects. Reduces oedema and facilitates it's reabsorption, therefore aiding in the repair of injured tissue. Ice provides a quick and effective way by which nerve impulses can be suppressed to a considerable extent, thus inducing pain relief. Reduces muscle spasm by lowering nerve conduction and directly inhibiting the muscle spindles or tone regulators. There is an increased output of adrenalin and generally prepares the muscle for activity. Ice is an excellent modality in acute, traumatic or inflammatory conditions. Indications for use. Acute traumatic conditions, low - back sprains, whiplash, injuries etc. Sometimes used for chronic traumatic injuries. In reduction of pain and inflammatory processes in rheumatoid arthritis. In preventing bleeding and swelling in sport injuries. In re-education of weak muscles as part of the neuromuscular facilitation or muscle energy techniques. Used in temporarily decreasing spasticity in neurological disabilities. When ice is applied to the skin, heat is conducted away in order to melt it. To change it's state ice requires considerable energy, therefore it is important to use ice and not cold water compress. The initial response to cooling is vaso-constriction in order to preserve heat. This means the part becomes very cold. After a short period there is vaso-dilation and then alternate periods of vaso-constriction and vaso-dilation. This hunting for a mean circulation is called "Lewis' hunting reaction". It is thought that there is an increased flow of blood through the capillaries thus aiding the treatment of swelling and tissue damage. Neural Response There are several more cold receptors in the skin than warm receptors, therefore a rapid response to cooling. The first fibres affected by cooling are A, B, then C. The main function of ice is to reduce pain. The probable mechanism is as follows:- cold receptors send neural signals to the posterior horn of the spinal cord via large diameter neurons and close the gate. The cold stimulus could be classed as an irritant and stimulate the release of opiates into the posterior horn. Physiotherapeutic uses of circulatory effect. • The initial vasoconstriction limits the invasion of blood into tissue following injury. Then follow with compression bandage. 59 The Institute of Physical Therapy 2000 - 2005
Lewis' hunting reaction takes place at the capillary level and because it is across capillary membrane that tissue fluid exchange takes place, an effect at a local level can reduce swelling. Excess tissue fluid is returned to general circulation, therefore there are more nutrients and repair substances. Note: Ice cube massage accelerates repair of bed sores. Cooled muscle have a lower metabolic rate and muscles can contract more times before fatigue. Possible increased circulation vents chemical substances and prevents them stimulation nociceptors and producing pain.
Methods of application Ice packs Ice towels Ice cube-massage Immersion Ice towels Crushed or flaked ice in a container with water added in the proportion of 1 : 2 part of ice. If the container is covered with a waterproof material the ice will remain at the correct consistency all day. Terry towels (hold the chips better) can be kept in the ice, ready to wring out and use when required. This form of cold therapy sometimes produces a skin reaction, ie patches of erythema with indurations and some hyperaesthesia appear. This reaction may last 24 - 48 hours but the sensitivity may last some time longer. Treatment:- calamine lotion. It can be avoided by applying oil to the skin prior to cold therapy. The areas most susceptible are, - over the anterior aspect of the shoulder, and the medial and posterior aspect of the knee. When the ice-pack is required it is wrung out, but still containing the ice chips. The towel is laid on the part to be treated to cover as much of the painful area as possible, including the O & I of the muscles involved. The towel is renewed every minute and treatment continued for 5 - 15 minutes. Treatment is enhanced if isometric or isotonic contractions are given while ice packs are in place. Ice packs. Oil skin first. It is a most effective form of treatment. Frozen peas - cryogen. Contraindications. There is general disagreement about contraindications but we list all the possibilities:- Circulatory problems such as Raynaud's disease. - Cancer. - Sickle - cell anaemia. - Cardiac conditions - avoid the thoracic area. - Hydrocortisone injections. - Area behind the ear where the vagus nerve lies superficially because of the possible effect on blood pressure. - Very young or very elderly people. - Highly sensitive individuals. - Recent skin grafts. - Loss of sensation. Effects of Ice During Immediate Care 60 The Institute of Physical Therapy 2000 - 2005
Treatment Schedule— Moderate Sprains
Age of patients
Day on which patients were able, without pain, to… Stand
Run and Jump
Moderate Plus Sprains
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APPLICATION OF HEAT The physiological effects of heat are, analgesic, antispasmodic, decongestive and sedative. Heat increases the exchange of oxygen and hastens the absorption of exudates. It is a vaso-dilator that increases the amount of blood brought to a region; it also increases metabolism locally. When vaso-dilation, relief of pain, or muscular relaxation is required, heat may be prescribed as a therapeutic agent. It is often used before massage and exercise is given. Contraindications Areas of loss of sensation. Decompensated heart disease. Peripheral vascular disease Metallic or thermoplastic implants in underlying area. Malignant tumour except in the terminal stage Certain acute arthritic conditions, for example RA. ADHESIONS AND LIMITED RANGE OF MOTIONS OF JOINTS.
Limitation of range of motion. A goal of treatment is to regain range of motion. Voluntary motion or active exercise (when the patient performs the movement) helps rebuild muscle strength and coordination. The movement limitation is sometimes due to muscle spasms; severed tendons, muscles or nerves; scarring or adhesions. The cause of the limitation must be carefully considered before starting treatment. Adhesions. An adhesion is the holding together of two tissues which are normally separate structures. Adhesions may be either inside or outside of a joint, but those inside are harder to deal with since massage cannot reach this area. Therefore passive movements are essential in treating intra articular adhesions. Adhesions are physical in nature and may vary from a mere film to a firm band, producing general stiffness to complete immobility of a joint. The breakdown of adhesions is a gradual process and attempts to hasten progress may result in repeated irritation or re-injury of the area. Adhesions which do not yield to a fair trial may need to be stretched under an anaesthetic by a physician, or surgically treated. Adhesions are not limited to joints but may be found in any tissue where injury and inflammation have occurred. TRANSVERSE FRICTION. Goading. Many of the chronic musculoskeletal disorders, e.g.. tennis elbow, tendinitis, frozen shoulder are manifestations of the body's response to fatigue, stresses, (overuse from repetitive movements or sustained contractions). Tissues tend to respond to fatigue stress by increasing the rate of tissue production. Thus, prolonged abnormal stresses to a tissue will lead to tissue hypertrophy, provided that the nutritional status of the tissue is not compromised and that the rate of tissue breakdown does not exceed the rate at which the tissue can repair the micro damage.
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Under continuing stress, if nutrition to the tissue is effected, or if the rate of tissue breakdown is excessive, the tissue will gradually weaken and atrophy to the point of eventual failure. Tissues that normally have a low metabolic rate are most susceptible to such degeneration are articular cartilage, intra-articular fibro-cartilage, tendons and some ligaments. Likewise, if the new tissue that is produced does not have sufficient time or proper inducement to mature, pain and inflammation are likely to result if stresses continue. Correction of such conditions requires that stress levels be reduced, whilst stresses sufficient to stimulate normal tissue modelling are maintained. In addition, normal extensibility of the structure must be restored. This requires that inter-fibre mobility be increased. The nutritional states of the tissue must also be considered. In situations in which significant reduction of activities is necessary in order to allow healing to occur, there are measures which the therapist can and should take. The therapist must help prevent undue dysfunction that may result from a mass of tissue being laid down causing adhesions and atrophy of related muscle groups. There are few conditions, even of an acute inflammatory nature, in which some gentle ROM and isometric muscle exercises cannot be performed during the healing process without detrimental effects. Some of the chronic disorders that tend to be most persistent are minor lesions of tendons and ligaments. They often respond poorly to rest and anti-inflammatories because they are not chronic inflammatory lesions per se, but pathological processes resulting from abnormal modelling of tissues in response to fatigue stresses. Therefore, while rest allows new tissue to be produced, that which is produced, is not of normal extensibility. Therefore the structure becomes more susceptible to internal strain when stresses are resumed. The result is recurrence of a low-grade inflammatory process each time use of the part is resumed. The most common of these disorders are supraspinatus tendonitis, tendonitis of the extensor carpi radialis brevis (tennis elbow), Tendonitis of the abductor pollicis longus or extensor pollicis brevis tendons at the wrist (de Quervain's Disease), coronary ligament sprain at the knee, and anterior talo-fibular ligament sprain. A very effective method of promoting increased extensibility and mobility of the damaged structure while reducing stress levels and allowing healing to take place is the use of deep transverse friction. This is a form of treatment advocated by Cyriax. It involves applying a deep massage directly to the site of the lesion in a direction perpendicular to the normal orientation of fibrous elements. This maintains mobility of the structure, with respect to adjacent tissues, and probably helps to promote increased interfibre mobility of the structures itself without longitudinally stressing it. It may also produce normal orientation of the fibres as they are produced. In some pathological processes such as rotator cuff tendinitis, in which the etiology may be related to a nutritional deficit arising from hypovascularity, the hyperaemia induced by the deep friction massage may also contribute to the healing response. In addition to the various tendinitis conditions, deep transverse friction is also very effective in sub-acute or chronic ligamentous sprains, e.g.. intercarpal ligament sprains (wrist), minor medial collateral ligament sprains (knee), minor anterior talofibular or calcaneocuboid ligament sprains (ankle). Acute signs and symptoms should be resolved at the time at which friction is used.
Technique. 63 The Institute of Physical Therapy 2000 - 2005
• • • • • • • •
Fingernails should be cut short. The part should be well exposed and supported. Structure to be treated is usually put in a position of neutral tension. Position for easy accessibility. Therapist should be comfortably seated (standing). Use pad of index, middle finger or thumb directly over the involved site. No lubrication is used. The patients' skin must not move with the therapists finger. Begin with light pressure, patient may feel light to moderate tenderness, which should have subsided considerably after 1 to 2 minutes. Increase pressure some more for 1 to 2 minutes. During the first treatment, the massage should be stopped after 5 to 6 minutes and the key signs reassessed (stretching the tendon or resisted movements). With successive treatments, the depth of massage is always gradually increased, and the length of treatment is increased to 12 or 15 minutes per session. Some authorities feel that treatment should not be continued during a particular session, nor should the depth of treatment be increased if the tenderness to massage increases or does not subside during treatment. It is not unusual for a patient to feel some increased soreness following the first or second session, but this must be distinguished from exacerbation of symptoms. Deep friction should be avoided on patients with long term, high dose, steroid drug therapy and patients with known peripheral vascular disease.
IS IT A MUSCLE OR IS IT A JOINT? Is the patients problem mainly in the soft tissues? Traction or stretching of the painful area increases pain in soft tissue dysfunction Compression of a painful area usually decreases pain in soft tissue dysfunction. Patient controlled (ACTIVE) movement in one direction which produces pain or which is restricted, and operator controlled movement (PASSIVE) in the opposite direction which is painful or restricted indicates contractile tissue as being implicated. Active and passive movement in the same direction both producing pain and or restriction indicates a joint (INTRA-ARTICULAR) dysfunction.
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SHOULDER The Scapulo - Humeral Rhythm. This denotes the combined movement of the humerus upon the scapula at the gleno - humeral joint and the scapula on the thorax. This is best seen in abduction. Abduction of the arm occurs in the gleno - humeral joint and scapulothoracic articulation in a two to one ratio (2:1), for every 3° of abduction, 2° occur in the gleno-humeral joint and 1° occurs at the scapulothoracic articulation. Full abduction = 180° Gleno-humeral movement = 120° Scapulo-thoracic movement = 60° The first 15° - 30° of abduction takes place at the gleno-humeral joint and is initiated by the supraspinatus. The scapular muscles contract and stabilise the scapula. At approximately 15° - 30° Deltoid takes over. The scapula moves forward, elevates and rotates around the chest wall, with the aid of the sternoclavicular and acromioclavicular joints. As the arm is being abducted there is a medial twist developing in the capsule. At approximately 90° - 110° the humerus has to rotate laterally so that the greater tuberosity does not impinge upon the coraco-acromial arch. The sub-deltoid bursa moves proximally beneath the acromina. Note. As the Deltoid is abducting the arm, the humerus is pulled upwards and outwards. To counteract this action there is a downward pull by the Infraspinatus, Teres Minor and subscapularis. If the subdeltoid Bursa is distended or a decrease in lateral rotation or the Humerus rides too high, there is inevitably an impingement. To be more precise, the combined range of movement of the gleno-humeral joint and scapulo thoracic articulation is 160°. Unilateral abduction - cervicals side bend to opposite side. Bilateral Abduction - lower cervicals and upper thoracics extend. Fixed Thoracic Kyphosis - Abduction cannot be full. NB. In paralysis - Inferior glide of humerus is essential in conducting Abduction and flexion. Sternoclavicular joint. At 90° of abduction the clavicle will have elevated 30°. When the arm is abducted beyond 90° , the clavicle rotates. Acromio-clavicular joint. This allows a gliding movement of the scapula when the scapula rotates in such movements as thrusting the arm forward or raising it over the head.
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INSPECTION OF SHOULDER JOINT Observation. How patient carries arm How patient undresses; look for asymmetry of movement Scars, discolourations, obvious deformity or dislocation Bilateral comparison of the following:Posteriorly Height of shoulders Scapula levels Distance from spine Anteriorly Shape and angle of clavicles Round shoulders Are arms internally or externally rotated Check the spine for excessive lordosis or kyphosis. Note any scoliosis. Head position asymmetrical side-bending or rotation. Bony palpation. Suprasternal notch Sternoclavicular joint Clavicle Coracoid process Lateral border of scapula Inferior angle Vertebral border Superior angle Spine of scapula Acromion process Acromioclavicular joint Greater tuberosity Bicipital groove (intertuberculus sulcus) Lesser Tuberosity Shoulder Pain Shoulder pain may result from any of the following:Local, Soft tissue lesions, for example frozen shoulder, tendinitis, secondary bursitis, acromioclavicular sprain, rotator cuff strains. Joint lesion, e.g.. O.A., R.A. of the glenohumeral joint. O.A. of the acromioclavicular joint. Dislocation of the sternoclavicular joint, A/c Joint or G/H joint, fractures. Referred pain:Radicular (nerve root) Active Trigger point Visceral Note: There could be local pathology and referral of pain at the same time. If the degree of pain is excessive in comparison to the amount of pressure applied, you may assume that the problem is local. If there is no local tenderness or only mild tenderness where patient complains of pain, then pain is very likely to be referred from elsewhere.
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Painful Arc Syndrome Characterised by pain in the shoulder and upper arm during the mid-range of glenohumeral abduction (45° to 160°) with freedom from the pain at the extremities of range. Adduction in middle range can also cause pain and the arm to wobble. Causes: Overstrain Accident/Trauma Pathology Decreased blood supply to area in over 50 year age group. Pain is produced mechanically by nipping of a tender structure between the tuberosity of the humerus and the acromium process whilst the arm is being abducted. 5 different and distinct lesions are involved: Minor tear of supraspinatus tendon. Supraspinatus tendinitis. Injury of greater tuberosity, contusion due to fall or injury. Sub-acromial bursa (over the supraspinatus). Calcified deposit in the supraspinatus tendon. Diagnosis: Types 1 + 2 + 3 Lateral arm pain Difficulty in abducting arm Active and resisted abduction elicits pain between 60° and 120° as the tendon is compressed between the tuberosity of the humerus and acromion. Type 4 Elevation from 30° to 60° produces maximum compression of the bursa, which, if inflamed, gives pain. Type 5 Calcification develops in an area of the degenerated tendon near the tender insertion. Cause: associated with supraspinatus tendinitis and can lead to calcific bursitis, which is very tender.
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Partial Rupture Of Supraspinatus Signs & Symptoms Sharp pain at shoulder (may have felt a tear). Pain referred to elbow. Painful Arc. Passive abduction pain-free. Resisted abduction painful and weak. Treatment See treatment of Tendinitis. Progress is slower. Tendinitis -- Bursitis Tendinitis at the shoulder is a very common disorder. It occurs in the young and active as well as in older people. In the case of a younger person it may be caused by activities such as tennis, racquetball, baseball, basketball, all of which increase the stress levels to the rotator cuff tendons. In the older person it is more likely to be degenerative lesion. Because of the relatively poor blood supply near the insertion of the rotator cuff muscles, nutrition to the area may not meet the metabolic demands of the tendon tissue. The resultant cell death sets up an inflammatory response, probably due to the release of irritating enzymes and dead tissue acting as a foreign body. The body may react by laying down scar tissue or calcific deposits. Such calcific deposits may be visible on radiographs; however they are often seen in the absence of symptoms, and conversely they are not always present in known cases of tendinitis. There is nagging pain at rest but made worse by certain movements, depending on the tendon involved. Infraspinatus and Teres Minor -- pain is localised on the greater tuberosity. Resisted external rotation makes it worse. Subscapularis -- pain over lesser tuberosity and aggravated by resisted internal rotation. Supraspinatus -- active abduction is painful through 60 to 120 degrees, possibly due to the inflamed tendon rubbing against the acromion and is abolished by externally rotating the arm. Pain is aggravated by resisted abduction. Tenderness is greatest over the tendon where it blends with the capsule. Superficial migration of these deposits with rupture into the underside of subdeltoid bursa is thought to be a major cause of acute bursitis of the shoulder, with patient complaining of severe pain on abduction and external rotation. Pain may be throbbing in nature and patient may hesitate on performing full contraction under resistance. Because of the poor blood supply to the region adequate repair may not take place and the lesion may develop into an actual tear in the tendon in which case there will be sudden severe pain associated with the tear. The degenerative lesions tend to be persistent with little likelihood of spontaneous resolution. The combined effects of poor blood-flow and continued stress to the tendon do not allow for adequate maturation of the healing tissue.
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It is not unusual for a patient to describe a history of several years of constant or intermittent problems with the shoulder. This by no means should suggest that these patients cannot be helped, since they do respond well, and often dramatically to treatment. Transverse Friction. This is an essential component of the treatment programme in chronic cases. The beneficial effects of friction in such cases is not well understood. However it is proposed that an increase in the mobility of the developing or developed scar tissue takes place without stressing the tendon longitudinally. This prevents the healing tissue from being continually re-torn during daily activities. A factor which may contribute to chronicity and recurrence is weakening of the rotator cuff muscles from reflex inhibition or from actual disuse. Such weakening would predispose to subacromial impingement during elevation of the arm and further mechanical irritation at the site of the lesion. Light to deep transverse friction are given over the tendon. Therapist at the patients' side and identifies the site of the supraspinatus tendon lying between the greater tubercle of the humerus and the acromion process. It is essential that the tendon be accurately located by knowledge of anatomy, it can not be distinguished by palpation. The pad of the therapists' finger (reinforced) is placed directly over the site of the lesion, which is always just proximal to the tendon insertion of the greater tubercle. Friction is applied transversely in a direction perpendicular to the normal orientation of the tendon. This is a most valuable treatment in the management of supraspinatus tendinitis. A similar technique is used for the other tendons of the rotator cuff. Two treatments per week are required if satisfactory progress is to be achieved. Cryotherapy immediately after friction helps ease inflammation. Rotator cuff strengthening. This is also an important part of the treatment programme, however if recent or repeated steroid injections to the tendon have been performed it is necessary to proceed gradually with the strengthening programme. Although local steroids do relieve the pain through inhibiting local inflammatory response, they have an anabolic effect on connective tissue, which may result in structural weakening of the injected tendon. Supraspinatus strengthening. The patient should stand with the arm at the side and rotate the shoulder internally to pronate the forearm. Then, moving the arm in a diagonal direction of abduction the patient should aim to achieve 90° abduction at 30° to 40° in front of the coronal position. This position aligns the muscle parallel to arm movement (in the plane of the scapula) and in this position maximum contraction of the supraspinatus is achieved. NOTE: There will always be tenderness over the involved tendon insertion point. There will probably be pain on stretching the involved tendon e.g. on full internal rotation in the case of infraspinatus tendinitis. As regards resisted movements in the case of simple tendinitis the contraction will be fairly strong, if a tear exists it will be fairly weak. 69 The Institute of Physical Therapy 2000 - 2005
Advice to patient: Strict avoidance of activities that may cause impingement or tension stress at the site of involvement while formation of painless scar takes place. Gradual return to normal use as healing progresses. Supraspinatus Tendinitis Causes Prolonged and repeated use of the shoulder with the arm at or above shoulder level. Repeated external rotation of the upper arm Trauma, for example a fall on the shoulder Repeated minor trauma. Physical Therapy Assessment & Treatment -- Clinical Features There may be nagging pain at rest. Active movement - painful arc between 60° - 120° abduction. Pain on lowering arm from abducted position. Pain eases if this movement is resisted. Passive movement that stretches the tendon is painful i.e. full adduction, and full internal rotation. Resisted abduction is painful (the degree varies according to severity of lesion). In the case of a simple tendinitis, contraction against resistance will be fairly strong. If an actual tear exists it will be weak. Treatment Goals. To relieve pain. To encourage adequate maturation of the healing tissue. To normalise surrounding soft tissue. To develop postural awareness. Treatment Plan Rest to injured area. Cryotherapy (ice). Myofascial work to shoulder girdle muscles. Transverse friction to tendon. Encourage active depression of humerus hourly. Gentle painless stretching of supraspinatus. Strengthening of supraspinatus. Look closely at daily activities - avoid elevation of arm to shoulder level. Ruta grav application three times daily. Infraspinatus Tendinitis Cause Repeated minor trauma resulting generally in chronic inflammation Clinical Features Pain at night on both lying on the affected side and lying on the opposite side. Tenderness on palpation of attachment. Specific Test Pain and weakness on resisted lateral rotation 70 The Institute of Physical Therapy 2000 - 2005
Treatment Same as for all tendinitis with specific stretching and strengthening techniques to Infraspinatus. NOTE: Encourage client to lie on unaffected side with pillow supporting affected arm. This prevents prolonged overstretching of tendon. Tendinitis of the Long Head of the Biceps Cause It is generally sports related for example among canoeists, oarsmen, weightlifters, swimmers, javelin throwers, wrestlers and racquet sports. Clinical Features Pain over anterior aspect of the shoulder particularly when the shoulder is externally rotated against resistance while the elbow is held flexed at a 90 degree angle. Test Pain on resisted elbow flexion and supination. Yergason Test. This determines whether or not the biceps tendon is stable, ie a tear to the transverse ligament. Treatment Same as for all tendinitis with specific stretching and strengthening techniques to Biceps.
Subacromial Bursitis. The shoulder tendons are wide bands of collagen fibres. If stress roughens a tendon its' tensile strength decreases. This leads to fibrinoid degeneration in and between collagen fibres and later fibrosis. With necrosis, the local tissues become alkaline which induces precipitation of calcium salts. Of the 140 bursae in the body, none receive the attention in sports as much as the subdeltoid bursae. Causes: Remember it is usually not a primary cause. Usually it is secondary to lesions in the rotator cuff. Strain or injury of the supraspinatus muscle. Direct trauma, for example a fall or blow to the shoulder. Clinical Features Most shoulder movements will be painful especially abduction. Pain on resisted adduction from abducted position The bursa may be swollen and palpable. Weakness of all shoulder movements. To find, extend the arm and exert traction to palpate portions of the subdeltoid and subacromial bursae Treatment: Rest and sling for the first three days. (in some cases strapping may be necessary). 71 The Institute of Physical Therapy 2000 - 2005
Cryotherapy When swelling begins to subside, a most gradual programme of active exercise can usually begin in 4 to 7 days. DO NOT OVERTREAT. NO DIRECT WORK TO BURSA Stubborn cases, aspiration and steroid injections.
RUPTURE OF THE SUPRASPINATUS. Causes: Fall with outstretched hand. Blow to the shoulders. Throwing or heavy lifting. May be asymptomatic. Usually due to attrition. Previous history of tendinitis/bursitis Clinical Features. Inability to intitiate glenohumeral abduction Commoner in older people especially in over 60 years May say they heard a snap. Pain on lateral aspect of shoulder. Hunches shoulder to raise arm. Loss of abduction. Scapular abduction to maybe 20° May be a gap between acromium and greater tuberosity. May be supraspinatus atrophy (gap in fossa) Supraspinatus pulls the humerus into the glenoid fossas and abducts the humerus, initially 10° to 15° before deltoid becomes effective. Tear near insertion. Full range of passive movement. If arm is abducted to 90° patient can hold it by deltoid action. Test Drop arm test. Diagnosis: Artrography. Treatment: Older - conservative¨ Younger - suture
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RUPTURE OF LONG TENDON OF BICEPS. Causes Usually it is the long head of the biceps that ruptures due to forceful contracture of biceps ie. lifting. May avulse from origin or along course of muscle (Rupture of belly of muscle). Age / old friction injuries. History of tendinitis. Clinical Findings: Usually male over 45 years. Not much pain usually, may be a little shoulder pain. Bulging in biceps as long head bunches up - Popeye sign. Little weakness in flexion/Supination. Treatment: Usually none.
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FROZEN SHOULDER. -- Adhesive Capsulitis, Periarticular Capsulitis A condition in which all shoulder movements are very restricted and very painful. Clinical Features. The patient is usually middle-aged. Usually the onset is gradual but it can occur overnight. On examination there is little gleno-humeral movement. Both active and passive movements are reduced. Mainly it is scapular movement. The patient presents with severe shoulder and upper arm pain, which is worse at night and very difficult to sleep on. Loss of 25% to 50% of movement is common, or more in severe cases. External rotation is the most severely affected. Etiology. Unknown. Postulated that it may occur after injury to the shoulder or due to repeated minor injuries. Possibly as a complication of tendinitis. Possibly due to long periods of immobility. e.g. hand in sling or in hemiplegia etc. Pathology: This is not very well understood. There is a widespread, acute, inflammatory reaction involving the capsule. There is thickening of the shoulder capsule and contracture which leads to loss of joint space. The term frozen shoulder should be reserved for the shoulder in which synovial inflammation has produced adhesions between the two layers of dependent, inferior, folds of capsule. When these two layers become effectively stuck together then the shoulder is truly frozen and relatively immobile. The capsule can no longer expand and allow the head of the humerus it's normal range of movement. There may be complete resolution within two years, but up to 20% may be left with varying degrees of restriction. Medical Treatment: Hydrocortisone. Hydrocortisone and forced manipulation under anaesthesia and active movements. Weekly or bi-weekly injections of hydrocortisone. Rest and sling in early stages and mild exercises. Analgesics and anti-inflammatories. Course: Initial Stage: PAIN May last 2 to 4 months approx. May be very painful. Movement may make pain worse. Patient can wake up at night if he lies on it. Lateral deltoid and arm pain to elbow is possible. Later Stage: STIFFNESS Now stiffness takes over as pain decreases (except on sudden movement). Some shoulder muscles may become atrophic. N.B. It may just start with symptoms of the later stage. Final Stage: Resolution. 74 The Institute of Physical Therapy 2000 - 2005
The so called idiopathic cases of adhesive capsulitis are probably due to alteration in scapulohumeral alignment. It is debatable as to which starts first - pain or stiffness. Generally patient is unable to fasten bra or comb hair. There is pain at night on rolling onto affected side. The older age group generally don't come for treatment until all range of movement is greatly reduced. Conditions which may result in capsular tightness at the glenohumoral joint include : • Degenerative joint disease (rare). (Hands and feet are affected first). • Immobilisation due to dislocation or fracture. • Reflex sympathetic dystrophy - this condition may be associated with certain visceral disorders e.g. myocardial infarction or trauma e.g. Colles fracture. Stiffness at the wrist and hand is a common component of this syndrome. History Site of Pain Lateral brachial region, possibly referred distally into C5 or C6 segment. Nature of Pain Varies from constant dull ache to pain felt only on activities involving the movement into the restricted ranges. Patient is often awakened at night when rolling onto painful shoulder. Onset of Pain Usually very gradual. Physical Examination Active movements:- external rotation and abduction are severely limited, followed by flexion, extension, adduction and internal rotation. Passive movements:- external rotation and abduction are severly limited. All other movements somewhat limited. Resisted isometric movements - Strong and painless unless Tendinitis present. Palpation - Often referred Tenderness over lateral brachial area. Feeling of increased muscle tone. Inspection - negative. Look for surgical scar. Acute Vs Chronic Acute Pain radiates to below elbow. Patient is awakened by pain at night. Passive movements are limited due to pain and muscle guarding rather than stiffness per se. Chronic Pain is localised to lateral brachial region. No night pain. Passive movements are limited by capsular tightness and painful only when the capsule is stretched. Sub-Acute Some combination of above findings. Management 75 The Institute of Physical Therapy 2000 - 2005
Overall Goal :- Restoration of painless functional R.O.M. Acute Stage Goals Relief of pain and muscle guarding to allow early, gentle mobilisation. Maintenance of existing range of motion. To commence gentle increase in range of motion. Prevention of excessive kyphoses and shoulder girdle protraction. Postural re-education - look at possible cause of condition. Treatment Plan Use ice to relieve pain and inflammation. Commence gentle mobilisation of joint i.e. inferior glide to counteract superior position of humerus due to spasm. Initiate active range of motion exercises at home -- pendulum, and isometric strengthening exercises for rotator cuff muscles. Remedial massage work to all muscles of shoulder girdle. Initial treatments should always be gentle. Precise treatment depends on individual findings, e.g. detailed work to Pectoralis if shortened etc. Gentle passive movements to joint. Help patient correct postural faults e.g. round shoulders, head forward position, by instigating a routine of regular postural checks in daily activities. Chronic Stage Goals Restoration of painless functional R.O.M. within limits. To promote independence in mobilisation procedures. To encourage patient to use arm as much as is tolerable to minimise habitual disuse. Once approx. 120° abduction, 140° flexion, and 60° ext. rotation are achieved ® commence supervised home exercise programme. Improvement is characterised by peaks & valleys. Easy to get frustrated. Physical Therapy Treatment. Treat all the involved muscles as appropriate, particularly all the rotator cuff muscles. The therapist can combine joint play movements with certain movements of the arm to reduce cartilaginous or bony impingement at the extreme of movement. For example, while moving the arm into abduction, the therapist can passively move the head of the humerus inferiorly to prevent impingement of the greater tubercle against the acromial arch which would tend to occur from the loss of external rotation and from the loss of inferior glide of the joint. By doing so, muscle spasm is reduced and a more effective stretch to the inferior capsule is effected. In fact until significant gains in external rotation are made, the patient should not be instructed to stretch into abduction on his own, because attempts to do so may traumatise the subacromial tissues more than stretching the inferior aspect of the joint capsule. It must be emphasised that the primary goal of treatment is restoration of painless, functional R.O.M. and that regaining full movement of the arm is not always realistic. R.O.M. of the uninvolved side should serve as a guide for setting treatment goals. While certain stress (to the joint) related activities may need to be curtailed, it is important to encourage use of the arm as much as possible to minimise habitual disuse which can perpetuate the disorder.
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Use of pulley and traction pendulum are very effective. Clockwise and anti-clockwise movements with traction to improve internal and external rotation. Later walking up the wall with fingers to encourage flexion and abduction. Satisfactory results can be expected within 3 to 4 months except if the frozen shoulder results as part of a reflex sympathetic dystrophy. These causes may require additional measures such as sympathetic blocks or manipulations under anaesthetic. Improvement tends to be characterised by spurts and plateaus. Both patient and therapist should be cognisant of this to avoid undue frustration during periods of limited progress. NOTE: Nocturnal pain results in fatigue which adds to the patients general debilitation. Fortunately, with appropriate management, this is the first aspect of the problem to resolve and should do so in 2 to 3 treatments. Massage gentle joint-play oscillations, especially into inferior glide proceeded by heat or ice are generally the techniques of choice.
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Acromioclavicular Strain Pain on the shoulder tip aggravated by full passive adduction. REFERRED NEUROLOGICAL PAIN Shoulder movement is normal. Neck movements may be restricted and painful. This can vary from patient to patient. C6 nerve root lesions:- There is usually pain and stiffness in the neck and pain in the outer part of the shoulder. Pain may radiate down the arm to the thumb and index finger. There is weakness and possibly wasting in the biceps and wrist extensors. C7 lesion:- pain in the upper scapular region and outer side of the shoulder. Pain may refer to middle and index fingers. Weakness and wasting in triceps, wrist flexors and finger extensors. C8 :- Pain in the outer part of shoulder and mid-scapular region. Weakness in finger flexors. ** Referred pain from nerve root source may cause secondary activation of trigger points. **
Tennis Elbow Lateral Epicondilitis. Definition: Pain in the region of the lateral epicondyle, generally due to repetitive strain Causes. • Macro or microscopic tears at the origin of the common extensor tendon. The tear may cause inflammation. • Trauma due to direct injury to the lateral epicondyle. • Degeneration due to ageing. • Over use, over extension leading to inflammation, e.g. sudden wrenching of the elbow (extension, supination, pronation against resistance) • Inadequate conditioning for racket sport • Improper technique such as faulty backhand Other factors : • Racket - the heavier the racket the smaller the grip, and the tighter the string tension, the more stress on the arm. • Court surface - hard, fast surfaces. Grass and concrete especially increase the speed at which the ball hits the racket strings and increases the amount of stress transmitted to the elbow. • Balls - older and heavier balls increase the amount of stress absorbed by the arm. • The risk factor in tennis elbow that is most often overlooked is conditioning, specifically lack of strength and flexibility in the shoulders. • A weak shoulder is often the first stage in a sequence of ailments that culminates in tennis elbow. • This often start with rotator cuff problems, weakness will affect technique and in time tennis elbow forms. Pathology. • Lateral epicondyle is affected 7 times more than the medial epicondyle • The term "tennis elbow" is a misnomer in that it has a higher incidence in golf, squash, rowing, manual labour, and even violin playing than in tennis. Clinical Features. • Common after middle age in the dominant arm. • Occasionally it is bilateral, saving one arm and over using the other. Common in females. • Onset may be sudden or gradual. • Pain over lateral epicondyle or just distal to it. • Pain may radiate down to hand, seldom up. • Pain is usually sharp on exertion, but it may be dull, aching and constant. • Squeezing with fingertips can be painful. • Tenderness, heat, swelling are found over the affected epicondyle if acute. Generally swelling is not a feature • Grip strength as well as supination, pronation strength are affected. • Pain on passive stretching i.e. wrist flexion • Pain and weakness on resisted wrist extension • Poor blood supply to this area therefore there is a slow healing process. 80 The Institute of Physical Therapy 2000 - 2005
Tests. • Stretch the extensors by passively flexing the wrist. • Contract the extensors by extending the wrist against resistance. Medical Treatment. • Cortisone injections, on which there are conflicting views. Repeated injection can lead to tissue damage. • Surgically release the extensor muscles. Spontaneous remission in 8 to 10 to 24 months approx. • Rest with sling immobilisation of wrist and elbow • Physiotherapy Physical Therapy Treatment Patient supine with elbow extended, pronated forearm and flexed wrist Tx 1
Myofascial work to flexors, extensors, supinators and pronators. Check for trigger points particularly in supinator, brachioradialis, extensor carpii radialis longus. Transverse friction for approx. 3 minutes to tendon attachment. Check for most tender point. Use ice if it is very painful i.e. ice x 1 minute, friction x 1 minute, ice etc. Myofascial work can also be interspersed between friction. Work into hand. Treatment time approx. 20- 30 minutes. Use Likon if available Home Advice Ice x 20 minutes later that evening and again before bed. Use approximately 3 to 4 times a day, until next treatment. Avoid activity that aggravates the pain i.e. lifting shopping bags, kettle or saucepans, playing golf etc. See Client in 3 to 4 days.
Re-Evaluate. Same as Tx 1. Work deeper into muscles, particularly the extensors. Tease out matted fibres. Increase transverse friction to 5 minutes. Once again alternate with ice and myofascial work. Use Likon for 20 minutes after soft tissue treatment. Home advice as per first treatment. See in 3 to 4 days.
Re-Evaluate. Same as above. Increase friction to 8 minutes. Introduce gentle stretch to extensor tendon. Take care not to strain wrist. Hold stretch for 3 to 5 sec., relax, stretch, relax for approximately 1 to 2 minutes. This could be introduced in Tx x 2 if condition allowed. Likon. See in 3 to 4 days. 81
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Home Advice. Gentle home stretch to extensors. Care must be taken to position arm so that the stretch is felt in the target tissues. Generally elbow is extended Ice may be continued if there is discomfort after treatment or home stretching. See in 3 to 4 days. Tx 4
Re-Evaluate. Same as above. If stretch is being achieved with no ill effects, strengthening may be introduced. Commence with appropriate strength theraband, i.e. 3 x 3, 3 times a day. Allow 2 days after treatment before commencing these home exercises. After 3 days increase to 5 x 5 x 5. After 6 days increase to 8 x 8 x 8. Continue with stretching. See in one week.
Re-Evaluate. Increase strength of theraband and continue stretching programme in addition to strengthening.
Technique Advise to client. • Your forearm muscles should be used for control not power. Most of the power should come from your shoulder, torso, and leg muscles, coordinated with rotation of your hips. • Focus on hitting the "sweet spot" (centre) as often as possible. • Follow through on your stroke, don't "brake" after hitting the ball. • Learn proper footwork so you approach the ball correctly. Equipment : • Use a light racket (12-12.5 oz.) made of graphite which provides good impact absorption. • Use the largest grip that is comfortable. The optimal grip size is the distance from the tip of your ring finger to the bottom horizontal palm crease at the point between your ring and middle fingers. • To minimize impact, your racket should have an approximate string tension of 52 - 55 lbs on 16 gauge nylon. • Do not use old or wet balls. Court Surface: Play on a court with a slower surface, thus reducing the impact of the ball on your racket. Conditions • Develop strength and flexibility in the arm, shoulder and back muscles. Tennis elbow straps may provide relief from tennis elbow, while at the same time allowing the injury to recover. • However never use a tennis elbow strap unless you are positive your injury is tennis elbow. • Straps may worsen conditions such as medial elbow instability in adults.
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Definition: A strain of the common flexor tendon at the medial humeral epicondyle. Cause: • Repeated over-strain. • Strong forehand drive in tennis. • Poor warm-up before sport. • Hitting ground by mistake in golf. • Overstrain of wrist by repetitive bending, twisting or faulty technique. Pathology: • Pain over the medial epicondyle which is the site of the origin of the wrist flexors and pronator of the forearm. • Less common than lateral epicondylitis. • More common in the 40 - 60 year bracket or in older people involved in sport or an occupation involving a strong hand grip and an adduction movement of the elbow. • Pain over the medial elbow and may radiate distally. • Pain is made worse by gripping or repeated wrist flexion. • Subperiosteal haematoma and periostitis are often involved. • The musculo-tendinous junction may also be involved. (Level with the inferior edge of the medial epicondyle). Tests • Resisted wrist flexion with extended wrist hurts. • Resisted pronation hurts. Treatment: Similar to tennis elbow except for positioning, that is, the wrist and fingers are extended and the forearm supinated while the elbow is fully extended. Can be done with patient sitting up or in supine position. If sitting up, support the extended elbow. N.B. Stretching is to the flexors, whereas in tennis elbow stretching is to the extensors.
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Olecranon Bursitis. Dart Thrower's Elbow, Miner's Elbow, Student's Elbow. Types Traumatic. Septic bursitis. Gout/Rheumatoid bursitis (may be associated with oleccranon-bursitis. Swelling occurs as part of the acute inflammatory synovitis in both of these conditions, may be rheumatoid nodules, gouty deposits). Traumatic: Pathology: The olecranon bursa is subject to direct impact, haemorrhage, abrasion, contusion, laceration and puncture which may cause chronic inflammation, thickening of synovium and formation of excessive fluid. The mechanism of injury is one of repetitive direct injury, constant friction of extensor tendons as in tennis elbow and/or repetitious local injuries with synovial irritation. Local pain tenderness, swelling, and movement restrictions are exhibited. Dart throwers are prone to it due to repeated elbow flexing. N.B. The bursa is exposed when fixed on a firm surface therefore the term student's elbow from leaning on it. Treatment: Cold compress. There may be a need for aspiration. Taping Elbow, In moderate cases an elbow support with an opening for tip of elbow. Excision if recurrent. Avoid pressure on elbow. Protective padding long after swelling subsides. Recurrent swelling is common. May be a need for cortisone and anti-inflammatories. If infected antibiotics are required
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Deformities of the Elbow. Cubitus Valgus. This is an increase in the normal carrying angle of the elbow. In the male it is 10 degrees. In the female it is 15 degrees. It is usually caused by a previous fracture of the elbow and is usually symptomless. It may cause an entrapment neuropathy of the ulnar nerve later on or it may not. Cubitus Varus. This a decrease in the carrying angle of the elbow. Usually caused by an old fracture. Usually there are no symptoms. It may lead to O.A. later on. Cubitus Recurvatus. A hyperextension deformity of the elbow and is due to hypermobility of the elbow. Flexion Deformity. As in O.A. of the elbow the patient is unable to fully extend the elbow. It is usually painless. Stiff Elbow -- O.A. Of The Elbow. This is not very common. Usually there is a predisposing factor such as an old fracture or osteochondritis dissecans. Signs and symptoms. Restriction of flexion/extension. Rotation is often normal. Slow increase in pain made worse by heavy use of the limb. Thickening of the joint due to osteophytes and crepitations on movement. Medical Treatment. Anti-inflammatories. Debridement / not much use as the osteophytes grow back. If there is a loose body (which can cause locking of the elbow) it is removed. Physical Treatment. Heat. Remedial massage technique Mobilisation. Traction.
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R.A. Of Elbow In R.A. the main symptom is pain and the joint may become unstable. Treatment is anti-inflammatory or arthroplasty i.e. total joint replacement (is not very successful as it can loosen). Elbow Sprain. Cause: Forced joint movement beyond full extension, abduction, adduction can cause sprain of elbow ligaments. Movement in the direction of the injury aggravates the pain and there is some restriction at extremes of range. Sport commonly involves strains e.g. twisting, stretching, hard strain of medial ligaments. Also wrenching the elbow i.e. wrestling. Incorrect javelin throwing, where the inner elbow is pulled apart at each throw. Types: Hyperextension sprain. Pain increases on extension and relieved on flexion. Swelling and tenderness around the joint. Hyperabduction Sprain. Tenderness is found below the medial epicondyle indicating sprain of the ulnar collateral ligament. Hyperadduction sprain. Tenderness below the lateral epicondyle indicating sprain of the radial collateral ligaments. Treatment. Rest arm for 10 to 14 days Ice for the first two days or until swelling subsides. Sling for arm if bad sprain. From day 3 or four onwards -Hot and Cold Light Massage Gentle Mobilisation Mild range-of-motion exercises Increase the above to heavier neuromuscular and stronger mobilisation after 2 to 3 treatments.
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Elbow Fractures There are many types, combinations and variations. Fracture in the area of the elbow usually involves the joint itself. Most common are the supracondylar, fracture of the humerus, olecranon, head of radius and coronoid process.
Ulnar Neuritis. The ulnar nerve is located behind the medial epicondyle. Causes. Due to recurrent friction whilst under tension, e.g. in cubitus valgus, i.e. when the carrying angle is increased (as the deformity and symptoms takes some time to develop this has been called a tardy ulnar palsy). Due to constriction for example in O.A. where you get osteophytic encroachment in the ulnar groove which can cause pressure on the ulnar nerve. Trauma e.g. single blow on the elbow. Repeated trauma occupations that involve leaning on the elbow. Signs and Symptoms. May be pain and or numbness/tingling in the 4th and 5th fingers, (ulnar distribution area). Pain may radiate up the elbow. Wasting or weakness of the ulnar innervated muscles which can cause clumsiness of hand movements. ***The Nerve Gets Thickened And Fibrosed.*** Diagnosis Pressure over ulnar nerve behind medial epicondyle reproduces the symptoms. Tinel test is positive. Full flexion may cause symptoms. Treatment: Rest Padded protection for elbows to avoid trauma Cortisone Surgery to relieve the mechanical fault by anterior transposition of the nerve.
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O.A. Wrist. Not common in the wrist. Usually is as a sequel to fractures or other injuries. The pathology and clinical findings are as usual: stiffness, thickening, decrease in mobility &c.
O.A. Hand And Fingers. Common in the elderly. Pain on gripping and twisting when in the hand. There may be large osteophytic lumps in the fingers. The thumb joint is commonly affected (trapezio-metacarpal joint). Massage and joint mobilisation is very effective.
R.A. Wrist And Fingers. The disease follows the usual pattern. The wrist radically deviates and supinates. Many complications can arise such as tendon rupture, mass synovial thickening, fixed muscle contracture, &c.
Hand / Finger / Thumb Sprain Can sprain hand/finger again by wrenching or twisting forces. Commonly injured in ball games and contact sports. Again there is local pain, tenderness, swelling, motion restriction. The thumb is especially prone to sprain injuries and may take two to three months to fully recuperate (if bad sprain).
Ganglions These are very common about the wrist and hand, especially on the back of the wrist and in the palm. A ganglion is composed of thick fluid surrounded by a layer of synovium in the soft tissue around joints and tendons. It is caused by the secretion of synovial fluid into soft tissue instead of into the joint cavity. If it interferes with the function of a joint it is excised, if not it is best left alone ie neurological interference with the ulnar or median nerve.
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Tenosynovitis The term tenosynovitis implies inflammation of the thin synovial lining of a tendon sheath as distinct from its outer fibrous sheath. It may be caused by mechanical irritation or less commonly by bacterial infection. Irritative (Frictional) Tenosynovitis is caused by excessive friction from over-use. The synovial sheath is mildly inflamed and there is an exudate of watery fluid within it. Tenosynovitis of the wrist is a common complaint among Physical Therapists.
De Quervain's Disease. This is a relatively common condition. It is generally believed to be an inflammation and swelling of the common sheath of the abductor pollicis longus and the extensor pollicis brevis tendons where they pass along the distal radial aspect of the radius. The tendons themselves are normal. History. Pain is felt over the distal radial aspect of the radius, sometimes radiating distally into the thumb or even proximally up the forearm. The onset is usually insidious. The patient complains of pain, primarily with activities involving thumb movements such as wringing or grasping activities. Examination. Pain on resisted thumb extension and abduction. Pain on ulnar deviation of the wrist with the thumb held fixed in flexion. On this movement the tendons and the sheath are placed on the stretch . Tenderness on palpation of the tendon sheath in the region of the radial styloid process, the thickened sheaths are usually palpable as a firm nodule. Treatment. Rest, discontinue activities that have caused or aggravate the condition. Ice. After acute stage begin with gentle massage and very gentle passive movements. Later deep strokes especially transverse friction. Gentle passive and active movements. NOTE: synovectomy is very successful.
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Wrist Sprain This is very common in many sports and may be associated with fractures and dislocations of the carpals. Therefore, it is sometimes important to X-ray if very painful. You can sprain the wrist by falling on it or wrenching it, or it may be due to repetitive stress e.g.. racquet sports like tennis and squash. May get pain in all movement or just in one direction. There may be swelling, bruising and various degrees of pain. Examination. If the wrist has been sprained through direct trauma it is essential that the patient has an X-ray before any movements are carried out. Assuming that there are no fractures proceed to examine joint as follows: Observe the joint and note the degree of bruising. Ask patient to perform active flexion and extension, supination, pronation, ulnar and radial deviation. Record findings. Very gently, apply passive movements to determine the extent of limitation of movement. Examine finger movement, as it may be limited due to oedema. History taking. First Treatment from time of injury. First Aid. Rest. Ice. Compression. Elevation. The sprained wrist needs to be rested, so use pillows to prop in an elevated position. Apply an ice-pack having protected the skin with oil or a damp cloth, for 10 to 15 minutes. Advise patient to continue this treatment every 2 to 4 hours for the first one or two days. Generally a firm bandage or strapping gives adequate support, but occasionally a splint of some kind can be used if it is felt that the patient is likely to do, too much with the wrist and hand. This is removed as soon as possible. No massage for the first 24 to 48 hours as the condition is generally too painful. See patient one or two days later. Second Treatment. Make patient as comfortable as possible -- rest arm on a pillow. Reassure your patient. Effleurage proximal to the site of injury -- flexors and extensors -- as far as the elbow. If condition allows do some light effleurage over the site of the injury to help decrease the oedema. Petrissage and friction to flexors and extensors, paying particular attention to tender areas. It is important to work on the fingers and hand. Finger kneading and friction are used. Clear out between metacarpals &c. Encourage patient to perform active finger movements as this assists in the dispersion of fluid. Gentle passive movements to the joint if condition allows. No mobilisation of the joint at this point.
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Home Treatment. Commence contrast bathing. Encourage light active movement of the joint where possible. See patient in two to three days. Third Treatment. Always evaluate condition at the beginning of treatment. Treat as for Second treatment. Gradually increase the depth of pressure. Work into the carpals and joint line using friction and passive movements. Continue home treatment of contrast bathing and active movements (full range) of finger and wrist. Fourth to Fifth Treatments. Treat as above. Introduce resisted movements of M.E.T. always following with a stretch. Gentle mobilisation techniques may be introduced. Wrist movements should be full and pain free in 7 - 14 days.
Carpal Tunnel Syndrome There is compression of the median nerve as it passes beneath the flexor retinaculum. It is a common cause of discomfort of the hand, especially in middle-aged, or elderly women. Causes Any space-occupying lesion within the carpal tunnel may be responsible e.g. Rheumatoid arthritis, osteoarthritis of the wrist, thickening following Colles' fracture, myxoedema, pregnancy. In many cases no primary cause can be discovered. Symptoms. These are both motor and sensory. There is tingling, numbness or discomfort in the radial three and a half digits and there is a feeling of clumsiness in carrying out fine movements such as those concerned in sewing. Tingling is often prominent during the night. Diagnosis. Clinical examination in history taking. Care must be taken to exclude other causes of neurological disturbances in the hand. Be sure that your patient has been investigated medically.
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Nerve Injuries To The Hand These conditions, although within the province of the surgeon, often seek help from a physical therapist while awaiting surgery. Massage and movements are given to improve nutrition to the area. Nerve injuries which produce deformities are easily diagnosed but not easily treated, Median Nerve injury. This type of injury usually occurs due to deep lacerations at the wrist. The thenar muscles, and the radial two lumbricals become paralysed, and this results in rapid wasting of the thenar muscles. Opposition of thumb to finger is lost, and there is loss of sensation over the cutaneous distribution of the medial nerve. Ulnar Nerve Injury. The ulnar nerve lies superficially at the medial epicondyle of the humerus, therefore fracture or dislocation of the elbow may cause injury to the nerve. The hand becomes clawed, and there is loss of sensation over the ulnar distribution to the little finger and medial side of the ring finger. Radial Nerve Injury. The type of injury may be due to either sustained pressure in the axilla (as in using a crutch) or fracture of the humeral head. Wrist drop due to injury of the main trunk of the radial is fairly common and is due to the fact that all the extensors of the wrist have been paralysed. There is a marked disability to grip strongly with the hand, unless the wrist is raised to an extended position.
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Sample questions – Elbow Joint
Classify and list the possible causes of elbow pain
Describe the process of inflammation and tissue healing
Describe the effects of transverse friction
List the indications and contraindications to transverse friction
List the possible causes of lateral epicondylar pain
List the possible causes of medial epicondylar pain
List the possible causes and clinical features of medial epicondylitis
List the possible causes and clinical features of lateral epicondylitis
List the possible causes and clinical features of olecranon bursitis
Describe you examination of a client who presents with elbow pain
Describe your management of a client who presents with lateral epicondylar pain through to full recovery
Give a detailed description of your treatment of medial epicondylitis to include possible advice and home exercises
A client presents with a history of having fallen in the last 24 hours and twisted her arm. Within a short period the elbow had become very swollen and painful: Describe your initial consultation Describe your treatment plan for the acute phase Describe your treatment plan for the sub-acute phase
Classify tendon injuries Discuss the common sites where each injury is likely to occur and List the clinical features.
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Osteoarthritis of The Hip Definition: This is a degenerative, non-inflammatory disease. Osteoarthrosis is the more appropriate name but is less commonly used. Articular cartilage gradually becomes thinner because its' replacement does not keep pace with its' removal. Eventually the bony articular surfaces come in contact, and the bones begin to degenerate. There is abnormal bone repair, and the articular surfaces become misshapen. Chronic inflammation develops with effusion into the joint possibly due to irritation caused by tissue debris not removed by phagocytes. Sometimes, there is abnormal outgrowth of cartilage at the edges of bones which becomes ossified forming osteophytes. Causes. There are two types; Primary and Secondary. In primary, the cause is unknown. In secondary the causes are as follows: • Trauma: Intercapsular fracture to a bone, injury to intercapsular structures. • Age; common from age 50 onwards due to wear and tear. • Congenital dislocation of the hip, there are unusual stresses in the joint. • Obesity. • Stress • Disease: Inflammatory diseases -- R.A. • Haemophilia, slight injury may lead to haemorrhage into a joint. Repeated bleeding may damage an articular cartilage and lead to O.A. Peripheral nerve lesions, Diabetes mellitus, T.B. • Climate. Dampness and cold exaggerates O.A. and causes pain. • Hereditary. • Acromegaly. Abnormal enlargement of the extremities of the skeleton caused by hypersecretion of the pituitary growth hormone after maturity. • Hyperthyroidism -- excessive thyroid gland activity. • Diet. • Poor posture causing muscle imbalance. Pathology. The main changes are in the articular cartilage and underlying bone. The cartilage is gradually worn away, disappearing first at the points of greatest pressure. The subchondral bone becomes sclerotic and at the joint margins it hypertrophies (outgrowth of a part due to an increase in size) to form osteophytes. There is no primary change in the capsule or synovial membrane, but the recurrent strains to which an osteoarthritic joint is subject, often lead to slight thickening and fibrosis. Muscles atrophy related to disuse because pain limits movement and function. Exercise is very important to keep muscles healthy. Signs and Symptoms of O.A. of the hip. Pain in the groin and front of the thigh, often also in the knee (medial aspect). Pain is made worse by walking and eases by rest. Pain or weakness going up stairs (psoas muscle) unable to step up with the involved leg. Later there may be a complaint of stiffness which manifests itself in everyday life by inability to reach the foot to tie the shoe laces or to cut the toe nails. Pain at night when changing positions during sleep. 94 The Institute of Physical Therapy 2000 - 2005
The symptoms tend to increase progressively, month by month, and year by year, until they eventually cause severe painful limp and incapacity for normal activities. Examination. On examination all hip movements are impaired. Limitation of abduction, adduction and rotation is marked, but a good range of flexion is often preserved. Forced movements are painful. In advanced O.A. fixed deformity (flexion, adduction, or lateral rotation, or a combination of these) is common. Treatmen--.Physical Therapy. Deep massage, passive movements, traction, M.E.T. , home exercise including swimming. Diet. Homeopathy Acupuncture Conservative treatment -- drugs (anti-inflammatory), Joint injection (hydrocortisone) but not recommended, surgery. Muscles Involved. Flexion. Psoas and iliacus, sartorius and rectus femoris. The iliopsoas will have shortened and can lead to a flexion deformity of the hip. Adduction. Adductor longus, brevis and magnus, gracilis and pectineus will also have shortened and maybe hold the hip in adduction. Abduction Mainly gluteus medius with assistance from gluteus minimus and tensor fascia latae -the gluteus medius will have weakened (Trandenburg test). Extension Gluteus maximus and hamstrings, -- these will be weak. Internal Rotation. Psoas, iliacus, gracilis, TFL and anterior fibres of gluteus medius and minimus movement is limited by tension of the lateral rotators. External Rotation Piriformis, obturator internus and externus, quadratus femoris, gemellus superior and inferior and the adductors. Diet. The chief forms of arthritis are osteoarthritis and Rheumatoid arthritis the underlying cause of both with regard to diet is too much acid in the body. Acid is taken in over the years in the food we eat and the liquids we drink. If our bodies contain the required nutrients to burn up the acid that we take in, then there is no problem. The food we eat today is lacking in these nutrients, so we are left with an undernourished body full of acid. This acid is carried around in the blood until it eventually deposits itself between joints, on the bones or in the muscles. When acid is deposited in the muscles, we call the effect muscular rheumatism. If both arthritis and muscular rheumatism are not treated, excruciating pain with every movement results. Depending on how advanced the O.A., you may not reverse the condition, but by dissolving the acid deposits the pain can be alleviated and the condition eased. The muscular condition will respond much quicker than will O.A. to faulty diet treatment.
Conditions Related to Arthritis. 95 The Institute of Physical Therapy 2000 - 2005
The spine is often the site of arthritis, and as a result there may be some mis-alignment of the vertebrae. As you know, every area of the body is controlled by nerves that run down the spinal column and exit at various levels of the spine. In the cervical area acid deposits (OA) may effect:- blood supply to the head - pituitary gland - neck muscles - tonsils - thyroid gland..... and many more. Interference in the cervical area may bring about conditions like, headaches, migraine, insomnia, dizziness, chronic neuralgia, stiff neck, vertigo, hay fever, catarrh, etc. In the thoracic area may affect, chest, lungs, bronchial tubes, causing conditions like pleurisy, bronchitis, pneumonia, shortness of breath, chest pain etc. The liver and solar plexus get their nerve supply from the thoracic area, could cause indigestion and related conditions. Lumbar area. Most commonly effected here is OA of the spine. It can also effect constipation, colitis, diarrhoea, etc, etc. There are many conditions that OA of the spine can effect due to mis-alignment, and it is well worth advising patients on the foods to avoid, what to cut down on, and the foods that will not aggravate O.A. To help arrest or halt O.A. and possibly cure it:Eliminate toxic acids from the body (a) On arising take one dessert spoon of cider vinegar with one teaspoon of clear honey in a tumbler of hot water, if possible, 1 hour before breakfast. This can be taken three times a day. (b) One teaspoon of black molasses three times a day. (c) Epsom salts bath (3 per week) Dissolve three cups of epsom salts in a bath of hot water. Do not add soaps, bath cubes, salts or oils as the alkalinity of these will fight the acidity of the epsom salts. Keep the water hot, by adding more hot water. Exercise in the water as much as possible by moving the fingers, feet, etc. The heat of the water will open the pores of the skin, enabling the epsom salts to draw out the acid poisons. After 15 minutes, get out of the bath and get into a warm bed. This will keep the pores open to draw out more acid. On rising take a shower to wash away the accumulated acids. Cider Vinegar. This is made from mature cider apples and is a combination of minerals, organic matter and acetic acid. It regulates the bodies metabolism through the quantities of minerals that it contains. Cider vinegar dissolves the acid deposits so that they pass out naturally via the kidneys. It saturates the bloodstream, getting in between the joints, dissolving the acid deposits. It contains malic acid. Cider vinegar is a natural diuretic and acts as a slimming agent, as overweight effects an arthritic hip. Cider vinegar is known to be a blood normaliser, will help reduce high blood pressure, and raise low blood pressure.
Honey. 96 The Institute of Physical Therapy 2000 - 2005
Honey contains vitamins and minerals. Darker honey contains more than lighter honey, arthritis patients can suffer from iron deficiency. Lack of ROM can lead to blood disorders, particularly anaemia. Most "Complex B" range of Vitamins can be found in honey, they feed the nerves. Honey is also rich in Vitamin C. Black Molasses. Molasses is made from raw unsulphured cane sugar packed with nutrients, it may be taken undiluted but should be followed by a drink of water as it can discolour the teeth. It may upset the stomach, in which case it can be taken on toast, wholemeal or even in porridge. Molasses is also a laxative, and rich in iron and Vitamin B. Food To Avoid. An acid-free diet is of the utmost importance. • Red Meat:- Beef, lamb, pork, pork products, sausages, patés, corned beef. • Citrus Fruits:- Oranges, Lemons, Grapefruit, Pineapples, Tomatoes, Strawberries, Gooseberries, Rhubarb, Blackcurrants, Red currants, Blackberries and Damsons. • Coffee:-Instant, decaffeinated and ground. • White sugar including sweets. • White flour and white flour products; cakes, biscuits and pastries • Processed and tinned food. • Red wine, sherry, port • Artificial additives such as colouring flavouring and preservatives. • Fizzy drinks. Foods to Reduce • Dairy products and eggs. • Salt • Alcohol • Tea Foods for a Healthy Diet. Fish, Poultry, Green and all other vegetables Salads except tomatoes Sunflower oil Fruit except citrus Herb tea, Mineral/Distilled water. SNAPPING HIP. This is a harmless condition in which a snap is heard in certain hip movements. It is commonly caused by a snapping of the iliotibial tract, snapping over the greater trochanter when the patient actively flexes the hip. (Sometimes fibres of the gluteus maximus may be involved). BURSITIS OF THE HIP Between the greater trochanter and the tensor fascia lata lies a superficial bursa which is prone to injury due to falls or blows. Possibly due to friction or overuse, the bursa can become inflamed and swollen. (Another small bursa, the deep trochanter bursa, lies between the gluteus medius tendon and the gluteus minimus tendon. This is not as prone to injury as the superficial bursa). Clinical Findings. 97 The Institute of Physical Therapy 2000 - 2005
Localised pain over the greater trochanter and the bursa is tender. When severe pain can radiate down the posterior and lateral aspect of the thigh. Activity makes it worse, especially climbing stairs. Active and resisted abduction leads to pain as this causes compression of the bursa. Treatment. Medical. Anti-inflammatories Rest Cortisone injection Aspiration if bleeding has occurred
HIP AND PELVIC EXAMINATION The patient should be undressed to underwear The patient should adopt a comfortable posture in front of you The lighting should be good and you should not stand too close to the patient Look for swellings, scars, bruising, dry flaky skin, or areas of redness Is one foot rotated more than the other? -- Probably tight piriformis Check the levels of the iliac crests Are the ASIS even? Check the levels of the greater trochanter From the side, check the lumbar spine for increased or decreased lordosis Moving to the back again,, check the levels of the iliac crests Are the ischial tuberosities level? Are the gluteal creases level? Check the gluteal mass and compare Ask the patient to walk across the room. Observe for signs of stiffness, pain, compensatory movement, gluteus medius or gluteus maximus lurch
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THE KNEE -- THE SCREW HOME PRINCIPLE Flexion and extension are complex movements involving a rolling of the femur over the top of the tibia or vice versa combined with a gliding movement in which the femur moves forward over the tibia and the menisci during flexion and backwards during extension. In the final stages of extension (the last 20 to 30 degrees) the femur rotates medially on the tibia causing a screwing home or locking effect which allows the quadriceps to relax and brings the knee into it's most stable position. In the first stage of flexion from this fully extended position, the femur has to rotate laterally to unlock the joint. This applies when the tibia is weight bearing and stationary on the ground. The opposite occurs when the foot is off the ground, ie the tibia rotates laterally to lock the knee and rotates medially to unlock it. Bony structure of the knee. The distal end of the femur has two convex condyles separated inferiorly by a deep V shaped notch and anteriorly by a concave depression into which fits the patella. The medial femoral condyle is approx a half an inch longer than the left. It is more elongated or oval in shape and has a larger articulating surface than the left. The lateral femoral condyle is circular in shape and it's anterior lateral border protrudes further anteriorly than does the medial condyle. The latter point is important in preventing lateral dislocation of the patella. The tibial surfaces are reciprocally curved and comprise two curved and concave areas called the medial and lateral tibial condyles. As with the femoral condyles the lateral facet is circular and the medial is oval. Between the two facets is a roughened intercondylar area called the intercondylar eminences which fits into the intercondylar fossa of the femur. Mechanism of movement. The femoral condyle rolls and slides simultaneously over the tibial condyles. The femur slides anteriorly as it moves into flexion and posteriorly into extension. The lateral condyle rolls far more than the medial. Therefore the distance covered by the lateral femoral condyle over the corresponding tibial condyle is greater than that covered by the medial condyle. In moving from flexion into extension due to the fact that the lateral femoral condyle is shorter than the medial femoral condyle it reaches it's end point before the medial side. The lateral femoral condyle moves forward over the lateral tibial condyle while the medial femoral condyle moves backwards over the medial tibial condyle, which brings about medial rotation of the femur on the tibia, thus locking the joint in extension. In moving from extension into flexion the opposite takes place. The lateral femoral condyle moves posteriorly and the medial femoral condyle moves anteriorly, thus causing lateral rotation. The Knee 99 The Institute of Physical Therapy 2000 - 2005
As the knee is such a complex joint and is prone to various injuries and pathologies, there are two useful methods to bear in mind during diagnosis:From an age view point and the corresponding pathologies From a positional and anatomical view point. Age Group. 7 to 25 years Chondramalacia Patella is greater in female 8 to 12 years Osteochondritis Dissicans is greater in male 10 to 16 years Osgood-Schlatters greater in male 30 to 50 years Rheumatoid Arthritis 45+ Osteoarthritis. Positional/Anatomical Anterior Knee. Chondramalacia Patella Osteochondritis Dissicans Osgood-Schlatters Patella O.A. Tendinitis and Insertional Tendinitis Prepatellar Bursitis Infrapatellar Bursitis Posterior Knee. Baker Cyst. Medial Knee. Meniscus Injury Tear Medial Ligament Strain or Sprain Lateral Knee. Meniscus Injury Tear Lateral Ligament Strain or Sprain Runners' Knee General. O.A. R.A.
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CHONDRAMALACIA PATELLA This occurs due to damage to the articular surface of the patella. The cartilage becomes soft and swollen, cracks and fissures appear and the cartilage becomes thinned. Causes. Increased compression forces between patella and femur Trauma is associated in 66% of cases. Recurrent subluxation - dislocating patella Quadriceps wasting Pronated or flat feet Mortons' syndrome Postural instability Short leg syndrome Abnormal patella development Extreme flexion as in deep knee bends (subpatellar flexion may rise to twenty times that of body weight) Alteration of "Q" angle. Signs and symptoms. Age group 7 to 25 years More common in females Pain behind the patella which is made worse by compression and exertion Tenderness in posteromedial/lateral aspects of patella Worse on hilly ground and up and down stairs Stiffness after sitting for long periods with knee flexed and relieved by activity Grating and cracking May be slight effusion Treatment. In most patients the symptoms settle within a year of growth ceasing. Pain can disappear spontaneously though this can take up to 1 or 2 years. An affected athlete may have to dramatically change a training programme. Chondramalacia can in some cases predispose to the later development of O.A. General Treatment. Rest Heat Supportive brace / Heat retainer Static exercises to quads, (especially to build up the vastus medialis) and hamstrings. Internal and external rotation exercises for tibia. Medical. Anti-inflammatories Operation to remove degenerative cartilage in cases that don't respond.
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OSGOOD SCHLATTERS DISEASE This is a condition in which the tibial attachment of the patella tendon becomes inflamed. It is thought to be a strain of the developing tibial tubercle from the pull of the patellar tendon. Signs and symptoms. More common in boys Age group 10 to 16 years Pain in front of and below the knee Worse during or after activity May be swelling or tenderness over attachment Tibial tubercle is prominent and tender Pain made worse on tensing quads Sometimes plaster cast for a few weeks Osgoods Schlatters disease, usually heals spontaneously.
OSTEOCHONDRITIS DISSICANS. This affects the medial femoral condyle where fragment of bone and cartilage are released into the knee joint (forming a loose body) and can cause permanent damage to the articular surface of the femur. Causes. Unknown May be impairment of blood supply to that particular area of the knee Injury may be involved Signs and symptoms. More common in boys Age group 8 to 12 years Pain during and after exercise Knee may lock Recurrent effusions in knee joint Treatment. With time the separated loose fragment (which is usually the size of a hazelnut) may reattach spontaneously. If not it may be surgically reattached or removed.
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PATELLA O.A. This is not uncommon and may be due to occupation, direct trauma, or previous pathology e.g. Chondramalacia Patella. The cartilaginous surface will become roughened and bending the knee under load will cause pain. Crepitus and grating is usually present. Treatment. Rest from strenuous activity Reduce weight if overweight Heat Massage Analgesics and anti-inflammatories In severe cases a patellectomy may be needed Patellofemoral O.A. can exist separate from Tibiofemoral O.A.
TENDINITIS AND INSERTIONAL TENDINITIS This may occur at any point along the quadriceps mechanism at the knee. Inflammation may occur at any point along this mechanism and is usually initiated by a small tear in the tendon. The inflammation is usually localised to either the tendon itself (a simple tendinitis) or to the insertion of the tendon into the bone (an insertional tendinitis), e.g. quadriceps tendon with patella, patellar tendon with patella, patellar tendon with tibia. An insertional tendinitis known as "Jumpers' Knee" is found where the patellar tendon inserts at the patella. The tendinitides are most frequency seen in sportsmen and women. The tenderness is usually localised and there may be some local oedema. Signs and symptoms. Localised pain over part of the tendon Pain / aching after exertion May be swelling Quad contractions causes pain Treatment.--Acute Phase. Rest Ice Ice massage After acute phase is over use heat and a heat retainer strap. THE KNEE In discussing soft tissue damage of the knee joint, structures most usually damaged are:The Collateral ligaments The Cruciate ligaments The Menisci. 103 The Institute of Physical Therapy 2000 - 2005
The Collateral Ligaments. These are fully stressed when the knee is in full extension and will only become injured in this position. The medial collateral ligament will be strained or torn if the extended knee is forcibly abducted whilst the lateral collateral ligament is damaged when the extended knee is forcibly adducted. In full extension of the knee, adduction and abduction are negligible, but if torn, the extended leg can be moved away from the affected side. Clinical Features of Acute Sprain. The patient is clear as to how the injury occurred. Pain. There is sharp, sudden pain over the medial or lateral side of the knee. In minor sprain the pain is momentary, but in more severe injuries it arrests movements. Swellings. This only tends to occur when there is severe injury. There is visible swelling over the injured side of the joint. There may also be effusion in the medial or lateral compartment of the tibio-femoral joint. Loss of Function. The joint may feel unstable and walking is impaired because the joint will not extend to bear weight during the stance phase. Palpation. The damaged ligament is tender especially over the joint line or at the femoral attachment. Specific Tests. • Valgus Stress Test (Medial Collateral Ligament). • Varus Stress Test (Lateral Collateral Ligament) • X-rays:- Joint opening can be seen if valgus/varus strain is applied. • Orthography:- If the dye remains within the joint the ligament is intact. The Valgus Stress Test; Principles. The principle is to attempt to open up the medial side of the joint by an abduction force to the lower leg, while pressing medially on the lateral side (the knee should be slightly flexed). During the test, the therapist looks for excessive angulation, either by sight or by feeling for gapping in the joint line. During the return movement, one feels for the clunk. Results. A positive valgus stress test indicates damage to the medial structures including the medial ligament. A strongly positive test indicates additional damage to structures in the sagittal mid-line of the joint, e.g. the anterior cruciate ligament. If the test is grossly positive, there could be damage to both the cruciates and the posterior capsule, as well as to the medial structures. If the V. S. T. is at all positive in full extension, when all the ligaments should be taut and resisting any movement, this indicates considerable damage to mid line structures as well as medial structures. The Varus Stress Test. The same as for valgus stress test. There is normally some "give" more than on the medial side, but it should diminish to nothing when the extension is closed. Treatment First Aid R.I.C.E. No weight bearing allowed. Follow-up Treatment. 104 The Institute of Physical Therapy 2000 - 2005
• • • •
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For minor injuries the compression bandage will be retained for approx. 1 week. For severe injuries back splint and bandage for 2 weeks For very severe injuries, 6 to 8 weeks in plaster. The quadriceps atrophy very quickly in knee injury, therefore static exercises must be practised (approx. 5 contractions every hour). Depending on severity, partial weight bearing should be practised slowly. Ice massage for 15 to 20 minutes to relieve oedema every 3 to 4 hours. Massage above and below the injury initially to relieve swelling and promote healing. Deep work to the quads and hamstrings. Transverse friction to the damaged structure/structures. Non weight-bearing free active flexion/extension of the knee to be practised repeatedly. Mobilisation of the patella, superiorly/inferiorly. anterior/posterior mobilisation of tibia etc. make sure that all movements have been fully restored. Compare the relative strength of quads and hamstrings with the non-injured knee and work towards full muscle balance.
Chronic Ligamentous Sprain, Collaterals. This is usually associated with repeated minor injuries or poor foot or hip posture. It is also present in patients who did not have full pliability or mobility restored after an acute injury, fail to warm up and stretch before activities, or have excessive valgus stress during push-off in walking. History. Sharp, niggling, stabbing, intermittent pain over the ligament which is generally absent at rest. Full extension of the knee is sometimes limited. The knee may, at times "give way" on going down a step. Treatment. Deep massage including transverse friction (excellent when correctly applied) Look at patients over-all posture and deal with findings. The Cruciate Ligaments. These tear through similar abduction and adduction strains which damage the collaterals and anterior cruciate is often torn due to forced hyperextension of the knee. In testing for cruciate ligament tears, if forward movement is greater than normal, the anterior cruciate has been badly strained or torn. If backward movement is excessive, then a strain or tear of the posterior cruciate ligaments is indicated. Clinical Features. History. Patient often feels something "go" inside the joint. Swelling At the time of injury there is haemarthrosis, a jelly-like swelling which makes walking impossible. Treatment. A complete rupture requires surgical repair. Partial tears may also be surgically treated. Physical Therapy is very important as after care. Meniscus. 105 The Institute of Physical Therapy 2000 - 2005
Meniscus lesions affecting the knee are common injuries especially in athletes. The medial meniscus being less mobile than the lateral meniscus is more susceptible to injury. The menisci move with the tibia in flexion - extension and with the femur in rotation. If during flexion, external tibial rotation is forced instead of the internal rotation that should normally occur, abnormal stresses are applied to the menisci with the possibility of a tear occurring. The same applies to the case of a forced internal tibial rotation during knee extension. Similarly, flexion or extension taking place in the absence of normal rotary movements that should accompany it may result in a meniscus tear. History. The cartilage will only be injured while the knee is in flexion. The foot was on the ground at the time of injury. The knee was flexed. There was internal rotation of the femur on the flexed and abducted externally rotated tibia. This was followed by sudden extension of the knee. Meniscus tears may also occur with hyperflexion of the knee, especially during weight bearing. In this position the femoral condyles have rolled back to articulate with the posterior aspects of the tibial articular surfaces. The menisci then must recede backwards during flexion, but can only recede to a certain point before capsuloligamentous attachments restrict further movements of the menisci. If further flexion is forced once the menisci have reached their limit of backward movement, the menisci are susceptible to being ground between the femoral and tibial joint surfaces. This is especially true if rotation is forced in hyperflexion, because a rotary movement entails further backward movement of one condyle. Certain occupations, such as mining, in which one must move about in a squatting position may predispose to development of minuscule tears from this mechanism. Among athletes, the wrestler is prone to this type of injury. Signs. The knee will usually be locked in flexion. Synovial effusion causing a generalised pressure sensation may arise within hours following injury. Effusion nearly always accompanies a medial meniscus. It does not always accompany a lateral tear. As patient is unable to fully extend the knee, weight will be taken on the forefoot and patient will walk with knee partly flexed. Patient may have difficulty in removing clothes (shoes, socks etc). Symptoms. Patient will usually feel something "give" in the joint, often with an accompanying deep, sickening type of pain. If haemarthrosis occurs, the typical severe generalised pain arising within minutes of the injury is reported. If not masked by other injuries or extensive effusion, the patient will often be able to point to the spot of the joint line corresponding to the site of the tear where the coronary ligament has been sprained. The person sustaining a meniscus tear is very hesitant to resume activity immediately following the injury, unlike a person suffering from a ligamentous sprain.
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A straight-forward displacement may be reduced my manipulation. If there is a "Bucket-handle-tear" of the meniscus, that is, a tear which resembles a bucket handle in shape, with the outer part lifted upwards and pulled inwards, then surgery is indicated. Similarly, if the meniscus is fractured or fragmented, surgery is the only possible treatment. To Test for Fracture Patient seated on plinth, with the injured leg at about 45 degrees flexion. A thumb should be placed over the injured area and the lower leg lifted upwards to extension. If there is a fracture of the cartilage, crepitus will be readily felt under the thumb.
CORONARY LIGAMENT SPRAIN. History. The patient usually describes a twisting injury followed by some minor swelling and pain over the anteriomedial knee region. Rarely is the victim significantly disabled immediately following the injury and he or she will rarely seek attention in the acute stage. The acute symptoms usually subside within a few days. If the meniscus maintains good mobility during healing, the patient should have no further problems. However, often the coronary ligament becomes adhered to the anteriomedial margin of the medial tibial condyle as it heals, resulting in reduced mobility of this part of the meniscus. In such cases the individual develops a more chronic problem characterised by intermittent twinging of the pain, when the adhered tissue is stressed, usually by activities involving external rotation of the tibia on the femur. It is the persistent nature of the problem that eventually prompts the individual to seek assistance. Findings. • Tenderness over the anteriomedial joint line. • Pain on external rotation of the tibia on the femur, but no pain on valgus stress. • Occasionally forced extension causes discomfort. • Effusion is rarely present. • There may be some minimal quadriceps atrophy if the problem has been longstanding. Treatment. Chronic Stage. The objective of treatment is to gradually restore mobility to this part of the meniscus. Therefore massage, particularly deep friction applied directly to the site of the lesion, followed by passive movements is recommended.
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EFFUSION Articular effusion commonly follows traumatic injury to the knee. This may be the result of blood filling the joint or of over production of synovial fluid. The time frame of the onset of effusion often provides an important insight into the nature of effusion. Haemarthrosis tends to develop over a relatively short period following injury, from several minutes to a few hours. Synovial effusion occurs over a longer period of time, perhaps 6 to 12 hours before it is noticed. Synovial effusion causes a dull aching type of pain from the distension of the joint capsule. Haemarthrosis may be associated with more severe discomfort caused by chemical stimulation of nociceptors. Clinically it is important to attempt to differentiate the nature of the effusion, since the cause of haemathrosis, an intra articular fracture must be ruled out. Some relatively severe joint injuries, such as a complete rupture of the medial ligament, may not be followed by significant effusion because of leakage of fluid through the defect out from the confines of the joint capsule. More subtle joint effusion may accompany chronic, non traumatic knee disorders. The patient often describes posterior knee discomfort from posterior capsular distension. It is desirable that excess effusion be removed from an injured part as soon as possible in order to prevent adhesions and excess formations of fibrous tissue which forms whenever a structure is damaged. Massage reduces swelling, improves circulation and removes static lymph. It also enables blood clots to be broken down and removed from the site of injury. If we use passive movements after massage, fibrous tissue will be prevented from adhering across the striations of injured muscles and active movements then improve nutrition to the area. While the presence of effusion at the knee is usually visible, this is not always the case, but careful palpation should reveal it's presence at such times. A gentle hand pressure over the suprapatellar bursa would have the effect of squeezing any fluid downwards into the joint, where its' presence might be more easily detected by pressing the patella to float it against the fluid at this point (patella tap). "Nipping at the edge of the infra-patellar pad". Sometimes a patient complains of pain at the knee, particularly when going up and down the stairs. Pain is usually just a brief stab, but repeated often and getting steadily worse. A portion of the pad of fat gets caught between the bone ends and causes limitation of extension. Inflammation results and causes frequent stabs of pain. Treatment. Prescribing heel elevators to avoid further nipping and electrical therapy for the inflammation.
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CHRONIC KNEE SPRAIN "GAMMY KNEE" Usually described as the knee that lets one down from time to time and is always having to be "taken care of". The patient may not be able to recall any particular injury to the knee and often the initial injury may have been so slight as to have passed unnoticed at the time, perhaps from minor swelling, long forgotten. Therefore it is likely that adhesions are present somewhere within the joint tissue, most probably within the fibrous tissue of the tendon attachments of muscles acting on the knee. Palpation may not reveal anything significant. The joint should be move passively through it's normal R.O.M. and compared with that of the unaffected leg. Active and forceful resisted movement, against resistance applied by the therapist, should then be carried out by the patient, and it should be carefully noted whether pain occurs at any stage of the movement or whether there is spasmodic pain at full flexion or extension. Check for possible adhesions around the patella itself, and it is essential that the patella is first seen to be freely moveable in its' tendon, before any flexion of the knee is attempted, to avoid any possibility of hairline fractures.
POPLITEAL AND SEMIMEMBRANOSUS TENDINITIS. Tendinitis of the popliteal or the semimembranosus tendons follows overuse injuries, usually from long-distance running. Hyperpronation of the foot may result in either popliteal or bicipital tendinitis at the knee secondary to overuse. In popliteal tendinitis the patient complains of localised pain over the lateral aspect of the knee. Joint tenderness is noticed at it's insertion on the femur anterior to the lateral condyle. Tendinitis of the semimembranosus can mimic a meniscus injury because of it's proximity to the joint line. The semimembranosus functions synergistically with the popliteus to prevent excessive external rotation of the tibia. Therefore, hyperpronating problems of the foot can stress the insertion of the semimembranosus. Treatment. Rest and ice for the first 48 to 72 hours. Usual massage treatment of tendinitis including friction and strengthening exercises. Proper training techniques (see coach) and appropriate footwear should be addressed. Adhesions It is common to find adhesions at the mid-point of the medial collateral ligament. Clinical Signs. Full extension hurts at the medial ligament. Flexion is limited by about 10°. Full lateral rotation of tibia is painful. Full medial rotation is painless. Quiet use of an adhesion does not pull on an adhesion. Vigourous exercise does.
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PAINFUL ARC. Painful Arc may suggest :Impacted loose body Fragment of cartilage Post traumatic irregularity of edge of patella. Torn meniscus.
CYSTIC SWELLINGS ABOUT THE KNEE If the swelling is suspected of being a bursa, it has one characteristic. If it is connected to the joint cavity (popliteus bursa, medial gastroc bursa, suprapatellar bursa) it should be soft in flexion but become tense and hard in extension. A popliteal cyst is a cystic swelling behind the knee. It may be an enlarged semimebranosus bursa or a simple herniation of synovium via the posterior capsule. If herniation, it is secondary to whatever is causing the persistent effusion. Note: Exercise on a joint with an effusion damages its articular cartilage. Anterior Knee Pain. This may be caused by disease in the hip. The characteristic gesture is a rubbing of the front of the distal thigh, with the fingers over the knee cap. Giving Way. This may be due to chronic meniscal injuries or lax ligaments. In the case of meniscus injury the dislodged meniscus may get jammed. It deforms the subchondral bone and stretches the capsule thus causing pain. Pain produces inhibitory impulses, the muscles "switch off" and the knee "gives way". Note: Pain comes before the giving way. When the ligaments and capsules are damaged they are often lax. Sudden stress is likely to occur stimulating the golgi tendon organs. Their efferent stimulus acts on the segmental motor neurons inhibiting nearly all muscular activity at the joint. The knee gives way without warning. This is usually painless. Patello Femoral Joint. Symptoms appear especially with anti-gravity efforts:- stairs and chairs, baths and cars. Chondromalacia Patella. There is wearing away of cartilage on posterior surface of the patella. If either the vastus medialis or lateralis is not equally toned the muscle balance is uneven thus causing the patella to go off track. Generally the vastus medialis is weakened and the inferior angle points medially. (If the condition exists bilaterally this is known as kissing or squinting patella). This condition is often associated with tibial torsion or pronated feet. The muscles will adhere to try to limit movement and pain. There is a low grade inflammation in progress, thus adhesions are formed.
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Liberate adherent tissues. Allow individual muscles to function independently. Increase vatus medialis muscle tone only if this is the cause. Test. Patella femoral grinding test. Treatment. Always place a pillow under the knee to prevent extension. Use plenty of warm-up strokes initially. Trace all muscles and discover where adhesions have formed. Attempt to separate the vasti from each other by lifting and separating the fibres. Work very slowly and go as close to the bone as possible -- monitor patients' reaction. Tease out any adherent fibres paying particular attention to Vastus Medialis. Friction to tendons and fascia around patella. Move patella medially/laterally and work on undersurface. Clear off condyles. MET to quads and hamstrings. Quads Strengthening. The patient sits with the knees flexed over the edge of the plinth. The foot is dorsiflexed and inverted. The therapist applies resistance to the foot as the patient attempts to extend the knee. The patient can apply his own resistance using the crossed ankle position. The vastus medialis has to contract most strongly in the final 30° of flexion into extension, therefore this is a good position to work from. Patella -- Pain. This is localised pain at the lower pole of the patella where the patella tendon joins the patella. It can be due to repeated small avulsion of collagen from bone. This is "Jumper's Knee" similar to "Tennis Elbow".
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FOOT AND ANKLE CONDITIONS In discussing foot problems it is important to look at the overall construction and shape. Although faultless in it's architectural design as regards its' weight-bearing function and ease of movement in propelling the body forward on ambulation, its' complexity makes it vulnerable to distortion. The foot is best described as having four arches, medial longitudinal, lateral longitudinal, anterior transverse, and posterior transverse arch. The only weightbearing areas are the calcaneus, 5th metatarsal head and 1st metatarsal head. The factors which maintain the arch are:The shape of the bones, e.g.. the 3 cuniforms are wedge-shaped inferiorly. The talus rests on the sustentaculum tali of the calcaneus and so helps maintain the medial arch. The ligaments on the plantar surface of the foot, e.g.. long and short plantar ligaments, spring ligaments by virtue of their tautness help maintain the longitudinal arches and are very strong. The plantar aponeuroses which attaches the medial tubercle of the calcaneus to the distal heads of the metatarsals. The intrinsic muscles, e.g.. lumbricals and interossei in which muscle tone is vital. The long muscles which have their origin in the leg and insert into the bones of the foot e.g.. the anterior tibialis exerts an upward pull on the medial longitudinal arch. Flexor digitorum longus and flexor hallucis longus exert an anterio-posterior pull which again helps maintain the medial longitudinal arch. The peroneus longus and the posterior tibialis act as a stirrup and also give support to the medial longitudinal arch. The muscles provide the most important support to the arch. The ligament alone would give way under strain imposed by the weight of the body if the muscles fail to work due to weakness or disease. Muscles need adequate nourishment which is only made possible through proper exercise. Lack of such exercise leads to decreased tone and atrophy. In walking, the heel first strikes the ground, then the lateral and finally the medial side of the forefoot is placed firmly on the ground. As the weight falls on the foot, the arches, especially the medial longitudinal and the anterior transverse arches are flattened a little with a tendency towards pronation (abduction, eversion and dorsiflexion). Normally, once the body weight is removed, the muscles, particularly the anterior and posterior tibialis act as invertors and restore the arch. If however, we habitually walk with an exaggerated pronation of the foot, the muscles lose their tonicity and more strain is placed on the medial ligaments, especially the spring ligament. The medial arch is decreased, there is splaying of the forefoot (widening), the big toe is abducted and the patient pushes off the inner border of the undersurface of the big toe instead of all the toes. With this, two serious pathological conditions have arisen, namely Pes Planus (flat foot) and Hallux Valgus. The most common foot conditions are: Metatarsalgia Pes Planus Pes Cavus Hallux Valgus Hallux Rigidus. 112 The Institute of Physical Therapy 2000 - 2005
METATARSALGIA Morton's Neuroma. The patient complains of pain under the metatarsal heads, or in the region of the fourth toe. It is due either to a collapse of the anterior transverse arch, or a displacement of one of the metatarsals. Collapse of the arch leads to splaying out of the metatarsal heads stretching the transverse ligaments and thus causing pain. Causes. High heeled shoes, causing the foot to slide forward and the weight to be taken on the metatarsal heads. Increased weight. Changing from a sedentary lifestyle to an occupation which requires hours of standing. Carrying heavy loads e.g. builder. Pathology. Depression of the transverse metatarsal arch causes overstretching of ligaments and weakening of the muscles. There is pressure on the nerve endings causing pain. Treatment Goals. Ease pain Re-tone muscles Ease pressure on ligament and nerves Education Treatment Plan. • Suitable footwear should be worn. • Corns or callosities should be dealt with, so refer patient to see a Chiropodist. It is important to try to regain the transverse arch, taking the weight off the 2nd 3rd and 4th metatarsal heads. To this end a padding is applied behind the metatarsal heads and strapping applied in such a way as to maintain and encourage reformation of the arch on walking. 7 to 10 days before next visit. • Deep massage to the feet, paying particular attention to the plantar aspect. • Petrissage and deep goading are given to the patient’s tolerance. • Bone-shaking between the metatarsals. Vigourous passive movements to the metatarsophalangeal joints, mid-tarsal joints, ankle etc. • Deep stripping and friction to the anterior and posterior leg muscles. Padding and strapping is reapplied. Follow up treatment consists of three treatments per week where deep massage and passive movement are given. • When condition improves significantly -- weekly treatments. • Home exercise:- picking up pencils or a towel off the floor with a bare foot. Walking on a stony beach is very beneficial. • Regular checks are made to determine that the metatarsal arch is improving.
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FLAT FOOT. This condition is generally bilateral, more common in women, and as already mentioned there is a natural tendency in walking to pronate the foot. If this is even slightly exaggerated over a long period of time, the tibialis anterior and posterior become over-strained and lose their tone, thus becoming almost ineffective. As the foot goes further into pronation, the lateral evertors (peroneus longus and brevis) shorten. The toe extensors change their alignment and become evertors of the foot. The calcaneus everts, placing increased strain on the deltoid ligament which produces pain. The talus glides forwards on the calcaneus, depressing the navicular bone and thus decreasing the longitudinal arch. The plantar fascia is stretched and tenderness results. Causes. Poor footwear Badly fitting stockings Bad posture Increased weight Occupation; standing for long periods General ill-health Injury to the extremity Paralysis of any of the muscles involved in maintaining the arch. There are various stages in the progression of this condition and as usual, the earlier treatment is implemented, the more successful the outcome. Symptoms commence with a vague discomfort under the medical long arch. Pain will be greater in the vicinity of the ligaments and the joints. Corns and callouses begin to form along the inner border of the foot. Treatment Goals To encourage the normal restoration of the longitudinal arch Retensioning of muscles Tightening of ligaments Education re posture and correct walking Treatment Change occupation if necessary, otherwise rest feet when possible Proper footwear is essential, and even your best efforts are wasted if this isn't seen to. If patients health is generally poor, ask about diet etc. Suggest that patient see a G.P. Maybe a course of iron or Vitamin tablets are needed. If over-weight, suggest joining some weight watchers association. The arch needs support initially, therefore an arch support is required, preferably those made by plaster cast of the patients own feet. Massage treatment is similar to that for metatarsalgia. Deep friction, particularly to any ligaments that are in trouble. Strong passive movements. Exercises to strengthen plantar aspect of the foot. Treatment should be 3 times weekly initially, until substantial improvement can be seen. Check arch support regularly, and they will need modification as the condition improves. Always inspect for corns and callouses. Ask patient to see a chiropodist if necessary. This condition, if treated early, responds well. You could save your patient from a life of discomfort which inevitably occurs as the condition progresses. Knee, hip, and lower-back problems often result. 114 The Institute of Physical Therapy 2000 - 2005
PES CAVUS -- HIGH ARCH There is an increase in the height of the medial longitudinal arch. The plantar fascia and short plantar muscles are shortened. The forefoot and hindfoot are drawn closer together. There is over stretching of the anterior musculature. An imbalance sets up between plantar muscles and those that support the arch. Causes-. Pes Cavus can be inherited or acquired. It may be due to acute anterior poliomyelitis (unilateral) Infectious diseases. Chemical poisoning Gout Diabetes The following is a list of causes most likely to prompt the patient to contact a Physical Therapist. • Prolonged Bed Rest • Years of wearing high heels with a recent change to a low-heeled shoe • Ballet dancing or any toe dancing. Symptoms. Pain in the area of mid-plantar aponeurosis Ache in the anterior tibialis Discomfort over the dorsal arch Corns under the metatarsophalangeal joints, dorsum of toes and tips of toes. Treatment Goal Alleviate pain Stretch the plantar surface Strengthen the anterior leg muscles Improve mobility Treatment Plan. Arch support to help redistribute body weight. Well-fitting shoes; low-heeled shoes or sandals with slots to enable the toes to be strapped down. Forefoot may be rigid -- bone shaking. Deep massage and stretching to plantar surface and gastrocnemius. Friction to O. and I. of anterior tibialis This condition is not as successfully treated as Pes Planus. Surgery is avoided if possible, again due to the poor outcome. The surgical procedure is to divide the plantar fascia, lengthen the achilles tendon, and place the foot in a plaster cast in an over corrected position for several weeks. Scar tissue on the plantar surface will always give trouble. Corns will also develop and cause pain. HALLUX VALGUS The big toe deviates laterally at the metatarsophalangeal joint, while the metatarsal splays out medially. Consequently, there is a projection which rubs off the shoe, causing tenderness, inflammation, callous formation, bursitis, corn development and bunion. There is chronic muscular imbalance whereby the abductor hallucis is lengthened, while the remaining muscles that act in balancing the big toe are shortened. Causes. 115 The Institute of Physical Therapy 2000 - 2005
Tight shoes with pointed toes. Ill-fitting stockings or tights. Flat foot. Hereditary. If treatment is instigated at an early stage, a good degree of success is expected. This decreases with the severity of the condition. Pre or post-operative deep massage and strong passive movements are very beneficial. Treatment. Correct shoes of sufficient size must be worn. The inner border must be straight rather than curved, and the heels must not be too high. Treat inflammation with rest and a poultice. Treat Pes Planus if this condition is present. Slight cases may respond to physical treatment. Passive movements should be given at least twice a day, and patients should be instructed in the method of doing these for themselves. Particular attention must be paid to abduction of the toe. Strapping is applied to the medial aspect of the foot to prevent further deviation. Massage treatment to stretch shortened structures and to strengthen lengthened ones. Surgery, if Physical Therapy is unsuccessful, or if condition is advanced. HALLUX RIGIDUS There is partial or complete limitation of range of movement of the big toe at the metatarsophalangeal joint. Causes. These are not fully understood. It may be due to:Injury, as in kicking the toe against a stone. Tight-fitting shoes. Pathology. This is variable. The head of the metatarsal bone may be enlarged, though not to a great extent, and the cartilage bruised or even eroded. The synovial membrane and periarticular structures may be acutely inflamed and the cause of much pain. There may be tenosynovitis of the tendon hallucis longus. In its' early stages, the muscles are in protective spasm. Later, permanent shortening of soft structures may occur, and finally osteo-arthritic changes may take place. The toe may become partially or completely rigid, all extension being lost. Movement at the interphalangeal joint is usually unimpaired. Signs and Symptoms. There is severe pain on using the foot, walking is difficult. The metatarsophalangeal joint is tender, pressure increasing pain. There is spasm and rigidity of the toe. Treatment. This is a very painful condition and treatment should commence as early as possible before the cartilage erodes and the joint becomes fixed. Otherwise, Physical Therapy is ineffective. Special shoes may be prescribed, designed to relieve the feet of all pressure. Re-education of the intrinsic muscles of the foot and of walking. 116 The Institute of Physical Therapy 2000 - 2005
Treatment is similar to that for Hallux Valgus. Deep massage and strong passive movements. Sprained Ankle. This is really a sprain of the mid tarsal and talocalcaneal (subtaloid) joints as well as the ankle joints. it is generally caused by turning over the ankle, that is a violent eversion or inversion of the foot. Inversion sprain is the most common. The patient generally falls down when the accident occurs and in severe sprains is unable to walk without pain. The lateral ligament is partially or completely ruptured and there may be damage to the small ligaments on the outer side of the foot. The peronei and extensor brevis digitorum are wrenched. The swelling may be considerable over the foot and round the ankle and may extend some way up the leg. Treatment. As a result of the very large amount of exudation, adhesions are very liable to form, and unless properly treated the patients foot may remain stiff and painful for a long time. It is essential therefore to check effusion as soon as possible and to keep the foot mobile. The foot should be bandaged in dorsiflexion and eversion. Zinc oxide strapping or elastoplast provide the best support but a crepe or elastonet bandage can be used. The bandage should start behind the metatarsal heads and extend well above the ankle joints to avoid an oedematous pouching over the bandage. It is also very important to see that support is given over the lateral malleolus to avoid a pocket of oedema there. If the bandage is started in the medial side, the foot is pulled into eversion by the turns of the bandage. Before doing any work, ask if patient has had an X-ray. If not, don't do any work, if there are no fractures proceed. Physical Treatment. Treatment follows the same lines as the wrist joint. This type of injury is severely painful, so take good care while working to avoid direct contact with the ankle area during the acute phase. Work above and below the site of injury. Use short strokes towards the heart to help drain the area, working as close as possible to the injury without causing undue pain. After the acute phase have patient contrast bathe the area. Introduce some small active movements in the joint. In terms of massage the two muscle groups mainly affected are: The Tibialis Anterior which needs to be lengthened (deep stripping). The peroneals which need to be strengthened or made to contract (circular or transverse friction to belly). Full Intermediate Massage Treatment. Pay particular attention to the dorsum of the foot and around the malleoli and tendo achillis, when using friction to, the lateral ligament, the foot should be slightly inverted and plantar flexed. Exercise. Encourage gentle active movements from the onset of injury, avoiding inversion. Passive R.O.M. to be commenced - again inversion the last movement to be introduced. Resisted eversion. 117 The Institute of Physical Therapy 2000 - 2005
At home -- as soon as patient is able: In a bucket of cold water, "write sentences" with the foot. Note: If the ankle condition is a chronic one, then use hot water. Pull/Push towel on floor with the toes. Stand on one (the affected foot) and balance for as long as possible. Push up on toes, down 2/3 of the way, and remain there. Re-education of walking is essential and should begin as soon as possible. You must ensure that the weight of the body is taken correctly on the foot in walking and in standing, that is, through the calcaneum, to the base of the 5th metatarsal and across to the head of the 1st metatarsal. The hip, knee, ankle and toes must be used correctly when steps are taken. SURFACE MARKINGS OF FOOT AND ANKLE Medial malleolus Situated at the distal end of the tibia. Lateral malleolus Situated at the distal end of the fibula. It extends further distally than the medial malleolus, therefore it enjoys a mechanical advantage in that eversion sprains are less likely to occur. Ankle joint proper Formed by the articulation of the talus with the tibia and fibula. It can be located by measuring about a half inch above the medial malleolus and about one inch above the lip of the lateral malleolus. Talus Is palpable immediately in front of the malleoli. No muscle attachments. Spring ligament. Sustentaculum tali Palpate one inch below the medial malleolus. This is a projection of the calcaneus on which the talus lies. Attachment point for the spring ligament and the flexor hallucis longus. Tubercle of the navicular Palpate one inch in front and one inch below the medial malleolus. Point of insertion of the tibialis posterior. 1st cuneiform Palpable distally from the navicular. 1st metatarsal & metatarsophalangeal joint Ball of foot, weight bearing. Calcaneus Heel and is subcutaneous. Insertion point for the achilles tendon. Peroneal tubercle Lies on the calcaneus and is distal to the lateral malleolus. It separates the peroneus brevis and longus. Styloid process 118 The Institute of Physical Therapy 2000 - 2005
Proximal end of the 5th metatarsal. Insertion point for the peroneus brevis. 5th metatarsal head and metatarsophalangeal joint Weight bearing. Soft tissue palpation Medial aspect Spring ligament Deltoid ligament / medial collateral ligament Structures between medial malleolus and achilles tendon. Lateral aspect Structures between lateral malleolus and achilles tendon. Anterior aspect Structure between medial and lateral malleolus. pages 212 - 216 Hoppenfeld.
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FOOT AND ANKLE Resisted movements to assess individual muscle strength. Anterior tibialis Foot position: Patient dorsiflexes and inverts foot. Therapist: Try to plantarflex and evert. Extensor hallucis longus. Foot position: Patient extends big toe. Therapist: Thumb on nail bed of big toe, try to push toe into flexion. Extensor hallucis brevis. Foot position: Same as E.H.L.(above). Therapist: Thumb on first interphalangeal joint and try to push toe into flexion. Extensor digitorum longus. Foot position: Patient extends 2nd to 5th toes. Therapist: Attempts to force toes into flexion. Flexor hallucis longus. Foot position: Patient curls (flexes) big toe. Therapist: Attempts to extend toe. Flexus digitorum longus. Foot position: Patient curls 2nd to 5th toe. Therapist: Attempts to extend toes collectively. Peroneus longus and brevis. Foot position: Patient plantarflexes and everts foot. Therapist: Attempts to force foot into inversion and plantar flexion applying pressure with the thenar eminence on the dorsal aspect of the 5th metatarsal. Gastronemius. Position: Therapist:
Knee extended. Foot dorsiflexed to 90 degrees. Resists patient attempts to plantarflex foot.
Knee flexed, same as gastronemius.
Posterior tibialis. Position: Therapist:
Patient's foot in neutral position. Instruct patient to plantar flex and invert foot while you resist his movement. **** Always compare sides right and left ****
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Supine Knees flexed Shoulder 0° Forearm 0° Supination and pronation, i.e. palm facing body
Supine Shoulders 0° and full external rotation Elbow extended
Supine Shoulders 90° abduction Forearm perpendicular to ground 0° supination and pronation Towel
GH: Stabilise scapula S. Complex: Stabilise Thorax
GH: Stabilise scapula S. Complex: Stabilise thorax
GH: Scapula S. Complex: Thorax
G.H.: Firm – tension in posterior band of coracohumeral ligament, posterior joint capsule, teres minor, teres major, infraspinatus.
GH: Firm Tension in anterior band of coracohumeral ligament and anterior joint capsule S. Complex: firm Clavicular fibres of pectoralis major, serratus anterior
GH: Firm Middle and inferior bands of glenohumeral ligament, inferior joint capsule, latissimus dorsi and pectoralis major S. Complex - Firm Rhomboid major and minor
Firm – Intertransverse ligaments, tension in annulus firbrosus on opposite side, Scalenus anterior medius and posterior, splenius cervicis, splenius capitus, levator scapulae, SCM, rectus capitus lateralis, Upper trapezius
Fulcrum – External audiatory meatus Proximal arm – Perpendicular to ground Distal arm – Base of nares Mouth closed
Fulcrum – Centre of cranium Proximal arm – parallel Imaginary line between two acromial processes Distal arm – Tip of nose
45° -- 60°
60° -- 80°
60° -- 80°
Fulcrum – SP of C7 Proximal arm -- perpendicular with ground Distal arm – midline of head with occipital protuberance for reference 35° -- 45°
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Seated at side of plinth
Prone – foot over edge of couch
Tibia and fibula
Firm – Lateral joint capsule, anterior and posterior talofibular ligament, calcaneofibular ligament, lateral, posterior and anterior talocalcaneal ligament
Hard – calcaneus and floor of sinus tarsi
Firm – tension in posterior joint capsule, Achilles tendon, posterior portion of deltoid ligament, posterior talofibular ligament, calcaneofibular ligament, soleus
Firm – Tension in anterior joint capsule, anterior portion of deltoid ligament, anterior talofibular ligament, tibialis anterior, extensor hallucis longus, extensor digitorum longus, or Hard – Talus and tibia
Firm – Anterior and posterior talofibiular ligament, calcaneofibular ligament, anterior posterior and lateral talocalcaneal ligament, dorsal calcaneal ligament, peroneus longus and brevis
Hard – Calcaneus and floor of sinus tarsi or Firm – Joint capsule, deltoid ligament, medial talocalcaneal ligament, posterior calcaneonavicular. Posterior tibialis muscle,
or Firm – Deltoid ligament, medial talocalcaneal ligament, tibialis posterior
Fulcrum – Lateral malleolus Proximal arm – Midline of fibula Distal arm – parallel to 5th metatarsal
Fulcrum – Anterior ankle midway between malleoli Proximal arm – midline of tibia with tibial tubercle as reference Distal arm – midline of 2nd metatarsal
Fulcrum – Midway between malleoli Proximal arm – Posterior midline of lower leg Distal arm – Posterior midline of calcaneus
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The Piriformis Muscle Anatomical Attachments Medially to the inner surface of the sacrum, the piriformis exits the pelvis through the greater sciatic foramen. Laterally, its tendon with those of the other short lateral rotators, attaches to the greater trochanter of the femur. Function The function of the piriformis in the non-weight bearing limb is primarily lateral rotation of the thigh with the hip extended. It also acts in abduction when the hip is flexed at 90o. Of greater importance to understand the piriformis entrapment syndrome is knowledge of the distribution of the neurovascular structures that exit the pelvis with the muscle through the unyielding greater sciatic foramen. The superior gluteal nerve and blood vessels pass between the superior border of the piriformis and the upper rim of the foramen. This nerve supplies the gluteus medius, gluteus minimus, and tensor fascia latae muscle. The sciatic nerve usually exits between the piriformis muscle and the rim of the greater sciatic foramen. It supplies the skin and muscles of the posterior thigh and most of the leg and foot. Also exiting the pelvis along the lower border of the piriformis are the pudenal nerve and vessels. The pudenal nerve the crosses the spine of the ischium and re-enters the pelvis through the lesser sciatic foramen. It supplies the external and sphincter muscle and helps supply the skin of the posterior thigh and scrotum. The inferior gluteal nerve, which exclusively supplies the gluteus maximus muscle, the posterior femoral cutaneous nerve, and the nerves to the gemelli, obturator interimus and quadratus femoris muscles also pass through the greater sciatic foramen with the piriformis muscle. Collectively, these nerves are responsible for all Gluteal muscle sensation and function and nearly all of the sensation and motor function in the posterior thigh and calf. It is apparent that chronic compression of these nerves would cause buttock, inguinal and posterior thigh pain as well as pain in the lower limb.
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Symptoms of Piriformis Syndrome Pain in: • Low back • Groin • Perineum • Buttock • Hip • Posterior thigh and leg Symptoms are aggravated by sitting, by a prolonged combination of hip flexion, adduction and medial rotation. In addition the patient may complain of swelling in the painful limb or of sexual dysfunction. Three specific conditions may contribute to Piriformis syndrome:• • •
Myofascial pain referred from TP in the piriformis muscle Nerve and vascular entrapment by the piriformis muscle at the greater sciatic foramen Dysfunction of the sacro-iliac joint
Differential Diagnosis The piriformis Myofascial Pain syndrome is recognised by the characteristic pain pattern projected by trigger points:0 • Pain and weakness on resisted abduction of the thigh with the hip flexed at 90 . • On palpation the piriformis muscle is very painful • Nerve entrapment is suggested by paraesthesia into mid-thigh Symptoms of the piriformis syndrome are easily confused with those of a herniated intervertebral disc. Absence of or marked weakness of the achilles tendon reflex suggest a disc lesion. Activation of Trigger Points • • • • • •
Catching oneself in a fall can overload muscles including the piriformis Other movements producing overload are twisting sideways while bending and lifting a heavy weight or forceful rotation of the bodyweight on one leg. The piriformis can become overloaded when it restrains vigorous medial rotation of the weight-bearing limb which may occur during running Direct trauma on to the muscle will activate trigger points Driving a car with the foot in place on the accelerator , or sitting on one foot can cause trigger points The Morton foot structure also tends to cause problems in piriformis muscle as it increases medial rotation and adduction of the thigh during walking.
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