Ligament sprains/tears & Tendinopathies Flashcards
Ligament sprain grades
I: minor rupture few fibers torn, stability maintained
II: partial rupture increased laxity, NO gross instability
III: complete rupture gross instability
Ligament sprain Ax
- Stability testing - laxity + end feel
- Pain
Ligament sprain Rx
Acute: PRICE, structural support, offload area -> orthotics, braces
Repair:
- Stability w/ muscle strength (especially if chronic sprain)
- DTFM, modalities
- Progressive loading (strength/stretch) linear movement
Remodelling
- DTFM
- Progressive loads + dynamic movement (multidirectional)
- Sport/function specific
Syndesmotic ankle sprain MOI
- Planted foot + IR of leg (ER of talus in mortise)
- Also hyper DF (splays mortise), inversion, PF
- Falls, twisting, MVA (slamming foot onto brake pedal)
Syndesmotic ankle sprain ligaments affected:
- AITFL, PITFL, Interosseous
- Possible tearing of other ligaments depending MOI
Syndesmotic ankle sprain S&S
- Limited swelling, antalgic gait (pain with WB/push-off, short stance phase, toe walking to limit DF)
- TOP @ injury site AITFL, PTFL, anterior distal tib-fib area (length of tenderness indicates severity
Syndesmotic ankle sprain Dx
- ER stress test (foot), squeeze test (proximal tib-fib), crossed-leg test, ant/post translation of fibula
- squat test - DF reproduces pain, decreased with compression/stabilization of malleoli
- heel thump test, one-legged hop test
Syndesmotic ankle sprain Rx
Phase 1 (0-2wks) - PROTECTION PHASE
- inflammation with PRICE, modalities for edema/ROM, immobilization (cast, boot, tape)
- Light ROM exercises (ankle pumps/circles/alphabets, toe curls, bike arcs)
- NWB with crutches
Phase 2 (2-4wks) - MANAGEMENT PHASE
- Regain normal mobility
- Inc. strength & fx (resistance bands in all 4 directions, aquatic therapy, low tension cycling)
- Joint mobs to restore DF
- PWB ambulation (must be pain free, can use heel lift), bilateral balance training
Phase 3 - MANAGEMENT
- inc. function
- unilateral balance & strength (stable to unstable surface, double to single heel raise)
Phase 4 - RETURN TO SPORT
- cutting, jumping, more aggressive strengthening, increase walking speed (w/o heel lift)
Syndesmotic ankle sprain recovery = ___x longer than regular ankle sprain
2x
What is tendon composed of
- tenocytes
- ECM (Collagen, glycosaminoglycan)
Tenocytes crave ___
Mechanical load
What is the result of loading tendons
Increased collagen synthesis, Cellular proliferation, alignment
Too much = fiber disruption
What is tendinopathy/tendinosis
Chronic microtrauma leading to loss of collagen organization (lose alignment)
- Presence of glycosaminoglucan, variable tenocyte density, increase vessels and nerves
- NOT Tendinitis - No evidence of inflammation - NSAIDS dont work
Tendinopathy Rx
Proper loading/resting of tissue
Achilles tendinopathy Risk factors
- Age, BMI, Diabetes, Male
- Sport (running), training errors, footwear
- Pronation, decrease DF, decrease LE strength, tight/weak calf mm
Achilles tendinopathy S&S
- Thickened tendon, TOP
Achilles tendinopathy Rx
- Nsaids if acute
- Alter contributing factors- pronation, muscle imbalance, myofascial restrictions, core
- Progressive ex program ECCENTRIC LOADING NECESSARY
- Only drop to neutral foot
- Pain level <5/10
- Don’t want pain next day or loss of function
- Footwear w/ heel lift, orthotics/brace
- Stretching, manual therapy
What is De Quervain’s tenosynovitis
Tendinosis or inflammation of the sheath surrounding the extensor pollicis brevis and abductor pollicis longus
Extensor pollicis brevis O, I, and function
O - Poster lower 1/3 of radius
I - Base of proximal thumb phalanx
F - Ext + abd thumb
Abductor pollici longus O, I, and function
O - Ulna, radius, interosseous membrane
I - Base of 1st Metacarpal
F - Abd thumb
Who is most likely to get de quervains tenosynovitis
Women age 30-40 years who use the wrist repetitively
What is the pathophysiology leading to de quervains tenosynovitis
Inflammation caused by constant friction -> microtrauma -> leads to scarring/fibrosis
De quervains S&S
Pain (over anatomical snuffbox) worse with repetitive hand/wrist movement
Tendon thickening
Swelling
Decreased grip and/or pinch strength
De Quervains Ax/Dx
Finkelstein test
- Tuck thumb in fist -> ulnar wrist deviation -> +ve if pain along distal radius
De Quervains Rx
- Acute: off load tissue, PRICE, risk factor education
- Corticosteroid injection (50% effective)
Tennis elbow = medial or lateral elbow pain?
Lateral
Tennis elbow must common in what age group?
35-55 years
Tennis elbow is a tendinosis ___% of the time and a partial tear ___% of the time
80%
20%
90% of cases of tennis elbow involve:
Extensor carpi radialis brevis
10% of tennis elbow cases involve:
Common extensor tendon & origin of extensor carpi radialis longus
EXT CARPI RADIALIS BREVIS O, I, F, N
O - Lateral epicondyle
I - Posterior base of 3rd metacarpal
F - Extension and radial dev of hand
N - Radial (deep branch)
EXT CARPI RADIALIS LONGUS O, I, F, N
o - Lateral supracondylar ridge
I - 2nd metacarpal base (radial side)
F - Extension and radial dev of hand
N - Radial nerve
Tennis elbow S&S
Worse with
- Gripping
- Repetitive reach/grasp
- Repetitive overload (typing)
Tennis elbow Ax
+ve is pain over lateral epicondyle
- Maudsley’s Resist 3rd finger PIP extension (w/ elbow extended, shoulder at 90)
- Cozen’s test Resist active wrist ext +radial dev (elbow at 90)
- Passively pronate forearm, flex wrist + ext elbow
TOP common origin, trigger points in muscle belly
- NO nerve s&s - check with radial bias ULTT
Tennis elbow DDs
- Cspine referred (c5-7), shoulder referred, nerve entrapment
- Bursitis, LCL sprain, proximal radioulnar joint affected
Tennis elbow Rx
Acute
- PRICE - control pain & inflammation
- Modalities (US, TENS)
- Maintain muscle length/mobility (AROM @ elbow, wrist, hand)
- Offload tissue – tennis strap
- Education: avoid NSAIDs, posture, rest breaks
Repair
- Gentle stressing of collagen - DTFM + stretching
- Eccentric strength training
- Manual therapy as indicated
- Needling/Mulligans
Outcome measure
Hand grip dynamometer
Which structures are normally involved in rotator cuff tendinopathy
long head of biceps tendon & supraspinatus
What are the 2 types of rotator cuff tendinopathy
1° impingement NARROWED SUBACROMIAL SPACE (older patient)
- Intrinsic factors: anatomical abnormalities, degenerative change
- Extrinsic factors: muscle imbalances, postural faults
2° impingement - INSTABILITY (patient <35)
- Microtrauma -> instability -> subluxation of humeral head -> impingement
• Overhead activities/sports -> microtrauma of stabilizers
• Ant capsule lax, Post capsule tight -> ant humeral head subluxation
Rotator cuff tendinopathy S&S
Pain with overhead activity, repetitive shoulder motion, longstanding
Rotator cuff Ax
- Neers
- Speeds
- Empty can
Rotator cuff Rx
o Correct biomechanical faults, muscle imbalances
o Modalities
o DTFM
o Manual therapy
o Education (training errors, position, self-management, stretches)
Patellar tendinopathy is caused by…
Repetitive loading in extensor mechanism of knee
What is another name for patellar tendinopathy
jumper’s knee
Risk factors for patellar tendinopathy
Male Jumping athletes Jump height Reduced DF Age BMI
Patellar tendinopathy Rx
- Slow heavy load (eccentric + concentric)
- Scan to find muscle imbalances and faults
- Knee may be in valgus position
What is another name for gluteal tendinopathy
Greater trochanteric pain syndrome
What is the key feature of myofascial pain syndrome
TOP – trigger point (focal irritation) found within a muscle
What is the onset for myofascial
Sudden overload, over-stretching &/or repetitive strain, sustained mm activities
Myofascial pain syndrom Rx
- Dry needling, injections
- Flexibility, ROM, mm length
- Soft tissue massage
- modalities, cryotherapy
- manual therapy if poor joint mechanics
