10b - MSK and other conditions during childbearing year

Question 1

Hand Conditions in Pregnancy / Postpartum

Answer 1

1 Carpal Tunnel Syndrome
• Pregnancy
• Postpartum

2 De Quervain’s Tenosynovitis
• Postpartum

Question 2

Carpal Tunnel related to Pregnancy causes

Answer 2

Carpal Tunnel of Pregnancy
• Predominantly related to increase in UL fluid retention in late pregnancy

Carpal Tunnel in the Puerperium
• Predominantly related to prolonged wrist flexion posture during breastfeeding

Question 3

Tests for carpal tunnel

Answer 3

phalen’s

tinel’s

Question 4

Carpal Tunnel – Treatment

Answer 4

Night splints

Oedema management (circulatory exercises, heat > massage > cold)

Question 5

Carpal tunnel prognosis

Answer 5

Prognosis
– May worsen temporarily post birth if had IV fluids
– Tends to resolve within 2/52 of delivery
– Ave. Total duration = 2.36 months

Question 6

Biggest concern carpal tunnel puerperium

Answer 6

Weakness and numbness > risk of dropping the baby

Question 7

De Quervains Tenosynovitis – “BABY WRIST” caused by

Answer 7

Caused by impaired gliding of:
– Abductor pollicus longus (APL)
– Extensor pollicus brevis (EPB)
- repetitive lifting movements

Question 8

Assessment of DeQuervain’s Tendonitis

Answer 8

Finkelstein Test

Question 9

Conservative Management of DeQuervain’s

Answer 9

Ice Massage to Decrease Inflammation

• Splinting to immobilise thumb
• Taping to minimise wrist deviation movements

Question 10

Abdominal Conditions in the Childbearing Year

Answer 10

1 Rectus Diastasis

2 Round Ligament Pain

Question 11

Rectus Diastasis

Answer 11

Increased distance between bellies of rectus abdominus to allow for enlarging uterus

Question 12

When does rectus siastasis occur?

Answer 12

2nd and 3rd trimester

Question 13

Rectus Diastasis during pregnancy Is there anything we can do to minimise??

Answer 13

• No research to guide us!!
• The higher the tone / shorter mm length of
rectus abdominus the greater the linea
alba will need to stretch
• Sit-Ups during pregnancy are NOT advised
– Advice re in/out of bed via side-lying
• ??Tubigrip / Maternity belt to hold uterus in
toward spine rather than pull forward

Question 14

Location of Round Ligament

Answer 14

– Extends from the lateral uterus to the labia majora

Question 15

Round Ligament Structure

Answer 15

– Not true ligament
– Fibromuscular band with mm fibres
– Contains
• Veins
• Arteries
• Lymphatics
• Nerves

Question 16

Round Ligament Function

Answer 16

– Supports growing uterus

– Maintains position of uterus during movement

Question 17

Round Ligament Varicosities

Answer 17

• RLV are prominent veins within the round ligament.
• Often presents similarly to inguinal hernia
• Presents as an inguinal mass or “groin bulge” and mild discomfort.

nb If pain is predominant symptom thrombosis of RL vein or rupture
should be excluded.

Question 18

Round Ligament Varicosities cause

Answer 18

– Progesterone dilatation of veins within the RL
– Increased blood volume of pregnancy
– Gravid uterus impingement of pelvic veins

Question 19

Lower Limb Varicose Veins (LLVV) • Associated symptoms

Answer 19

– Pain+++
– Night cramps+++
– Numbness
– Tingling
– Legs feel heavy, ‘achy’ and “unsightly”

Question 20

Lower Limb Varicose Veins (LLVV) Treatments during pregnancy…….

Answer 20

– Circulatory exercises,
– avoid prolonged standing,
– Leg elevation during the day.
– Rest
• Sleep on left side
Inferior vena cava is on the right
less pressure on IVC less pressure on saphenous
Les venous congestio

Compression Stockings

Question 21

Meralgia Paraesthetica

Answer 21

Painful, mononeuropathy of the Lateral Femoral Cutaneous nerve of the thigh (sensory)

Question 22

Meralgia Paraesthetica

Symptoms

Answer 22

Presents as early as 25/40
• Purely sensory, very distinct cutaneous distribution
• Burning Paraesthesia
• Pain, pins and needles and
• Mild sensory loss to light touch and pin-prick
• In intense forms can be very debilitating

Question 23

Treatmet Meralgia Paraesthetica

Answer 23

Fisher & Hanna (1987) found TENS along the course of the nn

to be highly successful, non-invasive and to carry no foetal risk

Question 24

Posterior Tibial Nn Compression cause

Answer 24

• Oedema and swelling compression behind medial malleolus

Question 25

Posterior Tibial Nn Compression • Symptoms:

Answer 25

• Symptoms:
– Paraesthesia over the sole of the foot
– Paraesthesia over the plantar aspect of the toes.

Question 26

Posterior Tibial Nn Compression treatment

Answer 26

– Resting with legs in elevation
– Foot and ankle exercises
– Ice packs

Question 27

Transient osteoporosis of Hip in Pregnancy symptoms

Answer 27

• Sudden, spontaneous onset of severe pain usually in unilateral groin, but can also be in
front of thigh, side of hip, or buttock.
• No history of accident / injury that would trigger pain
• Difficulty WB - Pt may have difficulty WB even with minimal pressure.
• Pain worsens with prolonged WB
– Patient often prefers to walk than stand still (good differential diagnosis tool for
comparing standard SIJ problems in pregnancy).
• Altered gait - Gradually worsening pain eventually preventing mobilisation completely

Question 28

• Three phases of Transient Osteoporosis of the Hip in Pregnancy :

Answer 28

• Three phases of Transient Osteoporosis of the Hip in Pregnancy :
– 1- increasing pain with normal x rays
– 2- maximal pain with osteopaenia
– 3- regression of the symptoms and radiologic changes.

Question 29

Meant duration of Transient Osteoporosis of the Hip in Pregnancy :

Answer 29

The mean duration is typically 6 to 8 months but can last up to & beyond 1 yr

Question 30

If Hip Fractures due to ransient Osteoporosis of the Hip in Pregnancy :

Answer 30

will commonly need bilateral hip replacements.

Question 31

When does Transient Osteoporosis of the Hip in Pregnancy present?

Answer 31

Usually presents in 3rd trimester (possibly earlier in multiple pregnancies

Question 32

At risk: (however, may not have risk factors) transient osteoporosis of the hip

Answer 32

– Lean women

– 30-53 tears

Question 33

Cause of transient osteoporosis of hip in pregnancy

Answer 33

• Unknown..... However:
– Oestrogen associated with bone loss
– Negative calcium balance in favour of the fetus
• Suggested causes:
– Viral infections
– Marrow hypertrophy
– Low bone density prior to pregnancy

Question 34

Diagnosis transient osteoporosis hip

Answer 34

• Via bone scan or MRI (not usually performed until after pregnancy)

• During pregnancy:
– “Gut feeling” based on history / symptoms during pregnancy
– Pain on most ROM: in particular
• Quadrant
• Ends of range
– Rule out other options of pain
– Patients risk

Question 35

Treatment of Transient Osteop of Hip

Answer 35

• Condition usually spontaneously resolves within 3 – 12 months of birth
• Management aims to
– Minimise loss of strength, ROM, etc
– Prevent stress facture and necrosis during period of osteoporosis.

Question 36

Physiotherapy aims transient osteoporosis hip

Answer 36

BEST OPTION: Water based exercise to
• Maintain general strength
• Maintain ROM

• Maintain general health
• Improve circulation
• Minimise WB strain on hips

Progressively increase walking aids as needed to decrease strain on
bones
– Walking stick
– Crutches
– Frame
– Wheelchair
• Upper limb exercises for general health