Assessment and Management

Question 1

Symptoms of sprains

Answer 1

1. MOI that fits overstretching of particular structure
2. Any age group, but often in early adulthood
3. Focal joint pain
4. +/- h/o clicking, popping, giving way, locking
5. Swelling developing > 24 hours for extra-articular ligs <24hrs for intra-articular ligs or intra-articular damage
6. TOP of lig
7. Positive on appropriate stress test(laxity +/-pain)
8. In Grade III injuries will have laxity at neutral

Question 2

Tendons Management

Answer 2

Tendons - Modify load, strengthen (loading), progress to plyometrics if applicable, RTP

Question 3

General Management

Answer 3

Load Management for most conditions, esp overuse injuries (POLICE)
Increase muscle strength/co-ordination
Restore ROM (soft tissue or Joint)
Progressive rehab
Graded exposure for central and peripheral sensitization (pain)
Treat the person not the tissue
Continue Maintenance regime (overuse conditions)

Question 4

Joint/OA management

Answer 4

Joint/OA – Modify load, ROM (improve shock absorption prior to strength), Strengthen, Progress function back to normal

Passive Physiological movements to encourage arthrokinematics of joint

Question 5

Ligament management

Answer 5

Ligaments- Modify load (POLICE), ROM (sprains involve joint injuries), balance (LL and shoulder dislocations), strength (around joint), Neuromuscular control (MOI: start in neutral, progress to activities requiring more control than MOI)

Unlikely to be isolated - Consider Rx of other structures
Rehab +/- reconstruction
Functional bracing - early stages to aid recovery
Restoration of function - ROM, strengthening exercises (isometric -> isotonic), progression into high-speed exercises (proprioception)

Joint mobs/MWM for pain modulation

Question 6

Fractures and Joint replacement management

Answer 6

Fractures and joint replacements – ROM, strengthen (close chain), rehab function

Joint mobs to encourage arthrokinematics + pain modulation

Question 7

What other thing to include in management

Answer 7

Always remember the person

Question 8

Soft tissue Assessment includes:

Answer 8

Length
Strength
Isometric - pain provocation
Palp for tenderness (Inc TrP searching)

If tendon:
Plyometrics (SSC) - energy recoil capacity

If ligaments, sports specific or functional goal involved: 
Endurance
Power - often relevant to tendons
Proprioception and balance
Motor control/patterning

Question 9

Overuse injuries, stress #, tendinopathies all occur by:

Answer 9

An active degenerative process involving inflammatory pathways.

Correct amount of activity/load will trigger tissue adaptation which in turns will make tissue stronger increasing level of stress tissue can withstand.
Too much activity will lead to loss of homoeostasis and tissue changes with pain occurring when the tissue has to rapidly adapt. Rested tissue (too little activity) causes tissue to become unloaded causing tissue to become structurally weaker and if then normal or excessive load is suddenly applied tissue failure occurs through an active inflammatory process and degrades. If tissue degradation is allowed to continue for an excessive length of time with excessive loading this leads to significant alteration to tissue structure

Question 10

Ligament Assessment

Answer 10

PROM
ACC movements (special tests)
Proprioception
Muscles tests (to check if muscles are injured)

Question 11

How does strengthening exercises help tendinopathy

Answer 11

Strengthening muscles causes neuromuscular adaption to increase neuromuscular capacity in turn increasing shock absorption capability of muscles which reduces load through tendon

Question 12

Muscle strain management

Answer 12

Activity modification (POLICE), Stretching/lengthening to maintain length and prevent contracture, strengthening, neuromuscular control (MOI), RTS if applicable

Question 13

How is tissue capacity/tolerance improved

Answer 13

Mechanotherapy:
Load tissue, stimulate cellular activity for tissue adaptation which overtime improves tissue resilience or robustness so tissue can maintain homeostasis

Question 14

How does length of MTU occur

Answer 14

Creep - uncrimping of collagen by providing sustained low load to tissue. Effect is transient thus stretching needs to be done regularly

Hysteresis - heat produced from energy loss of lengthened tissue returning back to normal length. Reduces tissue stiffness

Question 15

How does ROM improve

Answer 15

Improved glide, roll and slide (arthrokinematic motion) and increased synovial fluid production

Question 16

How does pain relief occur

Answer 16

Neuromodulation - altering neural input that modulated pain perception at a central or peripheral level, reducing pain for person

Descending pain modulatory pathway
Pain gate theory

Question 17

General health conditions affecting assessment:

Answer 17

• Age (not a health condition but gives a big clue!)
• Diabetes – peripheral neuropathies. High risk of capsulitis in shoulder. Poor healing. Tendinopathies. Type 1 vs type 2
• Inflammatory arthropathies – joint pain and tendinopathies
• Smokers – poor healing / circulation. Tendinopathies
• HTN, High cholesterol, obesity, general deconditioning
• Steroid use - tendinopathies
• HIV, IVDU, recent surgery – infection risk
• Anxiety / stress / psychosocial factors - chronicity
• History of Ca – risk of secondary metastases

Question 18

Peripheral nerve entrapment conditions:

Answer 18

• Thoracic outlet syndrome
• Radial tunnel
• Pronator syndrome
• Cubital tunnel
• Carpal tunnel
• Guyons canal
• Piriformis syndrome
• Fibular head
• Tarsal tunnel

Question 19

Routine Assessment

Answer 19

Observation
•AROM
•PROM
•MMT
•Palpation – tissue tenderness
•Accessory movements
•“Special” tests
•Functional tests - relate to AGGs

Question 20

Explain Pain Gate Theory

Answer 20

Low threshold, large diameter, myelinated Aβ fibres (mechanoreceptors) are stimulated by innocuous stimuli (touch)
Mechanoreceptors enter into spinal cord stimulate inhibitory interneuron within spinal cord, stopping transmission of nociceptive fibres A delta and C fibres.
There are multiple gates in the dorsal horn of the spinal cord. Closing one gate reduces some pain transmission. Relatively impossible to close all the gates

Question 21

Explain descending pain modulatory pathway

Answer 21

Manual techniques, i.e. joint mobilisations, SSTMS, nerve flossing that elicit some pain (noxious stimuli) is thought to activate the descending pain modulatory pathway. Peri-aquaductal grey matter (PAG) receives input from the frontal lobe, amygdala and the hypothalamus. Neurones either project to the dorsal horn, having a descending control of nociception and/or neurones project upwards to the medial thalamus and orbital frontal cortex, having an ascending control of nociception. The PAG has two distinct regions, the dPAG and vPAG. Stimulation of the dPAG (noradrenergic system) causes the release of the neurotransmitter nor-adrenaline at the spinal cord level causing inhibition of substance P in response to noxious mechanical stimuli. Stimulation of the vPAG (serotonergic system) causes the release of neurotransmitter serotonin at the dorsal horn inhibiting the release of somatostatin, produced by noxious thermal stimuli.

It is suggested that nerve mobilisations almost immediately stimulate the dPAG to cause hypoalgesia and a few minutes later vPAG is stimulated