Inert Tissue Structures Flashcards
What are inert tissues?
Ligaments joints and joint capsules
What is femoralacetabular impingement (FAI)?
Name the three types -
Pathological mechanical process by which morphological abnormalities of the acetabulum and or femur combined with vigorous hip motion can damage the soft tissue structures within the hip itself
Types - cam, pincer and combined impingement
FAI
Cam impingement -
On the femoral side
Extra bone formation at anterior-lateral aspect of head neck junction of femur therefore it is non-spherical
Flexion and internal rotation affected most as cam is forced into acetabulum
The cartilage will be displaced centrally
FAI
Pincer impingement -
Abnormality of the acetabulum which leads to over coverage of femoral head
Can be deep or retroverted acetabulum
Can lead to labrum and cartilage damage
Flexion and internal rotation affected the most
FAI
What is a combined impingement ?
Both cam and pincer impingements existing together
FAI
Are men or woman more commonly affected?
Cam occurs more in men
Pincer occurs more in women
What factors influence the development of FAI ?
Repetitive exposure to hip rotation and flexion during development in childhood and adolescence e.g hockey, basketball or football
Repeated stress of this type can trigger adaptive remodelling and eventually develop FAI associated morphologies and symptoms
History childhood hip disease following femoral neck fractures - may have altered contour of femoral neck/head
Surgical over-correction of conditions like hip dysplasia may lead to pincer morphology
Ligament
What are they, and how can they get injured?
Ligament - connects two or more bones to a joint
Primary function is to provide passive stabilisation of a joint and it also plays an important role in proprioception
- therefore in lig recovery and management, so important to work on proprioception
Sprain - injury to the band of collagen tissue eg ligament
Sprains are usually caused by the joint being forced suddenly outside of its usual ROM and the inelastic fibres are stretched through to a great range
Classification sprains and strains
Grade I -
Ligament, tendon or muscle is overstretched with only micro tears
Localised pain/tenderness
No visible bruising
Minimal swelling and loss of function
Muscle - no loss of muscle strength or ROM (<10 degrees)
ligament - no ligament laxity
Classification sprains and strains
Grade II -
Partial tear or ligament, tendon or muscle with immediate onset of all inflammatory signs
Moderate swelling
Bruising
Poorly localised pain
Impairment and painful ROM ( with deficit)
Muscle - decrease in strength and pain on contraction
Ligament - joint may be unstable
Sprains and strains
Grade III-
Complete rupture of ligament, tendon or muscle
Sprain, ligament - joint instability increase
Strain, muscle/tendon - inability to contract muscle, separation may be evident
Both - immediate a true pain, often audible ‘pop’ ‘crack ‘click’ all other cardinal signs
Later - symptoms may be less than grade II
May require immobilisation and/or surgery
What are the common sites of ligament injuries ?
ACL - normally non contact cause eg twisting movement
PCL
LCL
MCL
ATFL - ankle
CTFL -ankle
ACJ ligaments - can come from eg falling on outstretched hand
*more common in lower limb
Frozen shoulder
Classification -
Also known as adhesive capsulitis
Characterised by initially painful and later progressively restricted active and passive GHJ ROM with spontaneous complete or nearly-complete recovery over a varied period of time.
Inflammatory condition causes fibrosis of GH joint capsule, and accompanied by gradually progressive stiffness and significant ROM restriction (esp. ext. rotation)
Frozen shoulder
Pathology -
Disease process affects anterior-superior joint capsule, axial recess and coacohumeral ligament
Synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid down
Elevated levels of serum cytokines facilitate tissue repair and remodelling during inflammatory process
Normally will have loss of axially fold, tight anterior capsule, but not necessarily adhesions.
Proposed that there is an imbalance between aggressive fibrosis and loss of normal collagenous remodelling - leads to stiffening of capsule and ligamentous structures.
Frozen shoulder
Prevalence -
70% people who have it are female
Generally between 35-65 and occur between 2-5% of population
More common if diabetic (20%)
More likely to develop in opposite shoulder if they have had frozen shoulder before
Simultaneous bilateral involvement has been found to occur in approx 14% of cases
No mechanism of injury, gradual decrease in ROM and symptoms getting progressively worse are all signs of frozen shoulder.
Phases of frozen shoulder
1=
Acute/freezing/painful phase - gradual onset of shoulder pain at rest with sharp pain at extremes of motion and pain at night with sleep interruption
May last anywhere between from 2-9 months
This is the most painful phase!
Phases frozen shoulder
2=
Adhesive/frozen/stiffening phase -
Pain begins to subside, progressive loss of GH motion in capsular pattern
Pain is apparent only at extremes of movement
Phase may occur at around 4months and last till about 12 months
Phases of frozen shoulder
3=
Resolution/thawing phase -
Spontaneous progressive improvement in functional ROM, last anywhere from 5-24 months
Some studies suggest its a self limiting condition and may last up to 3 years
Estimated that 15% may have persistent pain and long term disability
Management of frozen shoulder in the different phases -
Initial phase: painful, freezing
- steroid injections can help ROM based exercises
Second phase: decreased ROM
- stretches from ant/post capsule
Eccentric loading can help
Third phase: resolution
- recondition shoulder, re-gain strength
*this condition is a tricky one for physios!!
Osteoarthritis information -
- how does the articular cartilage degenerate?
Most common chronic condition of joints!
Mostly occurs in knees, hips, lower back and neck, small joints of fingers and bases of thumb and big toe.
Disease process affects articulation cartilage, subchondral bone, ligaments, capsule, synovial membrane and periarticular muscles
Articular cartilage degenerates with fibrillation, fissures, ulceration and full thickness loss of the joint surface.
Osteoarthritis
Prevalence -
Affects about 3.3-3.6% of population globally
11th most debilitating disease around the world, causing moderate to severe disability in 43 million people
Osteoarthritis
Risk factors -
Age, female gender
Obesity - more load on joints
Anatomical factors - genetic link
Muscle weakness
Joint injury - eg tibial plateau fracture may mean you are more susceptible to developing OA
Osteoarthritis
Primary -
Secondary -
Primary - no known cause
Often attributed to aging and general wear and tear
Environmental and genetic factors may influence
Secondary - caused by pre existing conditions eg Joint injury, infection
May develop more rapidly than primary
Can also be related to congenital joint abnormalities
Osteoarthritis
Clinal sings and symptoms -
Pain, more on weight bearing activities e walking, stairs etc.
pain that increases with fatigue and decreases with rest
Reduced ROM active and passively
Can cause slight swelling over the joint
Clicking/grinding
Can worsen in cold weather
Osteoarthritis management -
OA is very common!
Education and self-management
Non pharmacological management - physio, strength and mobility exercises
Pharmacological management - eg steroid injections for pain
Referral for joint surgery
Look at NICE guidelines!!!
What is the most common way to injure the meniscus (mechanism of injury) -
Twisting injury on a semi flexed limb through a weight bearing knee
Mensical issues
Signs and symptoms -
Pain in knee joint, usually on medial, lateral or back of the knee.
Swelling, catching or locking of the knee joint
Inability to fully extend or bend the knee joint
Difficulty weight bearing
Giving way indicates ligament injury involvement!
Meniscal tear types:
Acute tears -
Commonly result of a trauma or sports injury (tennis, jogging, football…)
Acute tears have different shapes (horizontal, vertical, radial, oblique, complex and bucket handle)
If not responding to conservative management, surgical management may be indicated
Similar to OA - manipulate structures around joint to aid eg. Increase muscle strength to aid movements and manage pain
Meniscal tear types
Degenerative tears -
Most often occur in elderly people and are meniscal tears that occur after minimal trauma or stress on the knee
They are often treated with physical therapy and anti inflammatory medication
What is patellafemoral pain syndrome?
Umbrella term used for pain arising from the patella femoral joint itself or adjacent soft tissues
It can be acute or chronic that is characterised by overload
Tends to worsen with activities such as squatting, sitting, climbing stairs and running
Patellafemoral pain syndrome PFPS)
Causes-
Most often combination of serval factors
Overuse and overload of patellafemoral joint, anatomical or biomechanical abnormalities, muscle weakness, imbalance and dysfunction
Can occur secondary to a trauma or surgery
One of main causes - patella orientation and alignment - may cause gliding more to one side of femur, therefore causing overus/overload on that parent of femur which can result in pain, discomfort and irritation.
Patellafemoral pain syndrome (PFPS)
Risk factors -
Knee hyperextnsion
Lateral tibial torsion
Genu valgum or varus
Increased Q angle (women)
Tightness in iliotibaial band, hamstring or gastroc.
Pes plants (pronation) or pes cavus (supination) can provoke it.
Patellafemoral pain syndrome
Management -
Education
Open (external weight eg. Machine at gym) vs closed (squat, press up etc) chain exercises
Quads, hams, glutes and calf strengthening
Patella taping - shown to reduce irritation
Orthotics
Modalities
Manual therapy
Shoulder instability -
Naturally unstable
Stabilised by labrum and capsule and surrounding muscles
When labrum and/or ligaments stretch/tear, shoulder has greater tendency to dislocate
Known as instability - can lead to greater and more painful shoulder conditions, especially dislocation and subluxation
These are the tell tale signs of instability
Can dislocate out the front, back or bottom (inf. subluxio erecta)
Shoulder instability
Bankart lesions -
High force can result in the labrum being torn from the bone = bankart lesion
Results in unstable shoulder which may lad to further episodes of dislocation
Indication for surgical procedure called anterior stabilisation
Shoulder instability
Dislocation types:
ALPSA lesion -
HAGL tear -
Anterior Labrador periosteal sleeve avulsion - displaced bankart tear where labrum displaced around glenoid neck. Associated with higher risk of reacurrent instability than an undisplaced bankart tear
HAGL - humeral avulsion of GH ligament
Shoulder instability
Types of dislocation:
Bony bankart -
Hill-sachs lesion -
SLAP tear -
Bony - a fragment of Bon breaks off with the bankart tear
Hill-Sachs - dent in the back on the humeral head which occurs during the dislocation as the humeral head impacts against the front of the glenoid
SLAP - tear at the bottom of the labrum
Shoulder instability
Management - physio and surgery -
Physio - train the shoulder muscles to control the shoulder correctly and prevent further instability
Surgery - number of procedures available depending on causes and findings :
Arthroscopic - keyhole surgery
Open shoulder procedures - depending on problems found, eg latarjet procedure for glenoid bone loss or open capsular repair for HAGL lesions.
