MS Disorders Flashcards
Arthrogryposis
nonprogressive, nongenetic, congenital disorder
characterized by rigid joints of the extremities (usually symmetrical), sausage-like shapeless limbs and weak or nonfunctioning muscles
hip dislocations and contractures (flex, abd, ER), shoulder contractures (add, and IR) and club feet can result
tx: surgery, ROM, splinting, positioning, ADL training, use of ADs
complex regional pain syndrome
abnormal sympathetic reflex resulting from a persistent painful lesion
results in dysfunction of SNS to include pain, circulation and vasomotor disturbances
clinical signs: pain, edema, decreased circulation, osteoporosis, skin dryness, decreased proprioception and atrophy of muscles in close proximity to the involved area
type I: frequently triggered by tissue injury;term describes all patients with the above symptoms but no underlying nerve injury
typeII: experience the same symptoms but clearly associated with nerve injury
tx: modalities to decrease pain, joint mob, WB or closed chain exercises, massage, manual lymphatic drainage, splinting
meds: sympathetic nerve block, surgical sympathectomy, SC stimulation, intrathecal drug pumps
Tx: education for injury prevention, desensitization activities that focus on return to normal activities, flexibility exercises, TENS for pain relief
Colles’ fracture
most common wrist fracture resulting from FOSH
the distal fragment of the radius has a dorsal displacement with a radial shift of the wrist and hand.
tx: casting, early AROM and PROM are essential for ultimate functional recovery, progressive resistance exercises, mobs, closed chain stabilization exercises
Degenerative joint disease (osteoarthritis)
a nonrheumatoid, nonsystemic disease
often affects WB joints by the degeneration of the articular cartilage
any stiffness may be improved with exercise
the onset is usually gradual, initially involving one or a few joints
as the disease progresses, joint motion becomes diminished, flexion contractures occur, tenderness and crepitus or grating sensations appear.
differential dx: normal ESR, abnormal joint radiographs , problems in WB joints
tx:
- NSAIDS
- functional training and education
- ROM exercises
- isometric, isotonic, isokinetic and postural exercises
- ADL training
- continue physical activity
- surgery or joint replacement
- joint protection strategies
fibromyalgia
classified as an immune system disorder of unknown origin that causes tenderness, pain and stiffness in the muscles
often relates to stress, anxiety, fatigue and sleeplessness in women>men
characterized by aching burning in the muscles, “a migraine headache of the muscles,” diffuse pain, or tender points on both sides of the body
differential dx:
- widespread pain in at least 11/18 tender points
- recognition of typical pattern of non rheumatic symptoms and sleep deprivation
- exclusion of other systemic diseases
tx:
- holistic and multidisciplinary approaches are necessary
- ADL education and training
- stress managemet
- meds: analygesics and antidepressants
- local modalities and techniques for muscle pain relief
- aerobic/conditioning exercises
- improve sleeping patterns
Gout or gouty arthritis
metabolic disease marked by elevated level of serum uric acid and deposition of rate crystals in the joints, soft tissues and kidneys
most often affects the feet (* great toe, ankle and mid foot)
severe joint pain commonly at night with warmth, erythema, and extreme tenderness/hypersensitivity
tx:
- anti-inflammatory meds
- daily use of colchicine
- lowering of rate concentration in body fluids with diet, weight loss, and moderation of alcohol
- allopurinol to reduce hyperuricemia
- rest, elevation and joint protection during acute phase
hemophilia
hemorrhagic disorder that is hereditary
results from a deficiency of specific clotting factors
PT concerns:
- hemiarthrosis
- muscle bleeds: can cause pain, swelling, extreme tenderness and possibly permanent deformity. bleeding near peripheral nerves can cause peripheral neuropathies, pain, paresthesia and muscle atrophy. f bleeding impairs a major vessel, ischemia and gangrene can occur.
Tx:
- splinting
- ice, rest and elevation in acute phase
- chronic- joint protection, maintaining joint function, daily ROM, endurance and strength, ADL training and use of appropriate splints and AD
ITB friction syndrome
an irritation caused by the rubbing of the ITB over the lateral epicondyle of the femur
often occurs in runners from an overuse syndrome
differential dx:
- positive ober’s test
- excessive hip IR in stance
- palpation over ITB insertion
- positive noble compression test
tx:
- stretching
- modalities for pain and inflammation
- STM
- shoe orthosis
myositis ossificans
often caused by trauma to a muscle resulting in hematoma that may calcify or ossify - painful
can be induced by early mobilization and stretching with aggressive PT following trauma to the muscle
frequent locations: quads, brachialis, biceps
dx: radiographs will show calcium deposits
tx:
- conservative with gentle active and AA ROM
- passive stretching or manual overpressure is NOT indicated
osteochondritis dissecans
separation of the articular cartilage from the underlying bone (osteochondral fracture)
usually involving the medial femoral condyle near the intercondylar notch and humeral capitulum and observed less frequently at the femoral head and talar dome
tx:
- if displaced surgery is indicated
- gait training
- functional strengthening
- conditioning
osteomalacia
decalcification of bones
results from vitamin D deficiency, which may cause deformities, fractures and severe pain
tx: pain control and functional mobility training
maintain/improve joint mechanics and CT functions
implement aerobic capacity/endurance conditioning (aquatics)
meds: calcium, vit D, vit D injections
osteomyelitis
acute or chronic bone infection
commonly the result of combined traumatic injury and acute infection
in adults, the disease commonly localizes in the pelvis and vertebrae and is usually a result of contamination related to surgery or trauma
more common in children and immunosuppresed adults
treatment:
- high doses of antibiotics
- infected limb is immobilized by cast
- traction or best rest
- sometimes surgical intervention to drain infection
- chronic infection may require amputation
osteoporosis
the most common metabolic bone disease
affects white females most commonly
depletes bone mineral density, which may predispose the individual to fracture
common sites of fracture include thoracic and lumbar spine, femoral neck, proximal humerus, proximal tibia, pelvis and distal radius
primary postmenopausal osteoporosis is directly related to a decrease in the production of estrogen
treatment: pain management postural education breathing exercises general conditioning pec stretching WB exercises abdominal strengthening (with caution- don't want excessive and repeated flexion of spine as can lead to wedge fractures)
Paget’s disease (osteitis deformans)
a slowly progressive metabolic bone disease
characterized by an initial phase of excessive bone reabsorption followed by a reactive phase of excessive abnormal bone formation. The new bone structure is fragile and weak and causes painful deformities of the external contour and the internal structures.
abnormal osteoclastic and osteoblastic activity
Usually affects several skeletal areas- spine, pelvis, femur and skull
-can result in spinal stenosis, facet arthropathy,
involved sites can fracture easily and heal slowly and usually incompletely
vertebral collapse or vascular changes can lead to paraplegia
treatment
-if asymptomatic: no tx
-symptomatic: drug therapy for pain
joint protection, joint mechanics and CT function, aerobics- aquatic
patellofemoral dysfunction
the patella fails to track properly in the trochlear groove of the femur
instability or pain usually occurs at the first 30 deg of knee flexion
stair climbing, prolonged sitting (moviegoer’s sign), squatting, or jumping may aggravate the condition
differential dx:
- Q angle >18 deg
- positive chondromalacia test: pain under patella with compression of patella and quad contraction
- abnormal tracking of patella during knee flex/ext
tx:
- McConnell’s taping
- VMO strengthening
- ITB and TFL stretching
- shoe inserts to decrease genu valgum and pes planus
- on track brace to reposition patella
- transverse friction massage over lateral retinaculum
- patellar mobs: medial patellar glide and stretching deep fibers of lateral reticulum to decrease patellar tilt
patella positions
normal: patella articular surface is evenly against anterior femur
Patella baja = lower placement
Patella alta = higher placement
a “camel sign” ma be present from a high patella (one hump) and the infrapatella fat pad (second hump)
-less efficient in exerting forces for knee extension
- mob techniques:
- inferior glide for patella alta
- superior glide for patella baja
progressive systemic sclerosis (scleroderma)
a chronic disorder characterized by fibrosis and changes in the internal organs and skin
frequently, accompanied by Raynauds
polyarthralgia is a common early symptom-
heartburn and dyspnea occasionally are the first manifestations
differential dx:
- positive rheumatoid factor test
- multiple system problems in the skin, GI tract, cardiorespiratory system and kidneys
tx:
- maintain joint ROM
- meds
- strengthening
pronator teres syndrome
median nerve entrapment in the pronator teres muscle
pronator teres syndrome test: PT strongly resists pronation of the elbow as it extends from 90 deg flexion
+ test = tingling/paresthesia provoked in the forearm and hand in a median nerve distribution
tx:
- manual nerve glides
- stretching
- AROM
- US
- NMES for nerve healing
Rheumatoid arthritis (RA)
chronic, systemic inflammatory disease
unknown etiology, although an immunological mechanism appears to play an important role
more often in women- peak onset 30-40 y/o
usually involves a symmetrical pattern of dysfunction in the synovial tissues and articular cartilage of the joints of the hands, wrists, elbow, shoulders, knees, ankles and feet
joints of the cspine are commonly involved, potentially leading to subluxation and SC compression
extra articular systems may be involved- cardiovascular, pulmonary, and GI
additional manifestations: eye lesions, infection and osteoporosis
Juvenile RA: onset prior to 16 y/o with complete remission in 75% of children. may affect any number of joints but is characterized chiefly by fever and rash.
differential dx:
- blood test for a rheumatoid factor
- symptoms usually begin insidiously and progress slowly
- complaints of fatigue, weight loss, weakness and general diffuse MS pain are often initial presentations
- pain is localized to specific joints with symmetrical bilateral presentation
- after periods of rest, intense joint pain and stiffness can last 30 minutes to several hours with the initiation of activities
- deformities of the fingers are common and can include ulnar deviation and swan neck or boutonniere deformities
- MCP and PIP joints are mainly affected, with characteristic pannus formation (inflammatory granulation tissue that covers joint surface), ulnar drift and solar subluxation of MCP joints.
treatment:
- reduce pain
- maintain mobility
- minimize joint stiffness, edema and destruction
- prevent deformities with orthoses
- patient education and continual adherence to tx program; energy conservation is stressed
- meds, rest, ADs, and ice in acute phases
scoliosis
unknown etiology for most cases
can also be caused by structural abnormalities (LLD or herniated lumbar disc)
structural scoliosis is an irreversible curvature with a rotational component demonstrated upon forward flexion of the spine
nonstructural scoliosis is a reversible lateral curve without rotation that straightens as the individual flexes the spine
diff dx:
- xray
- postural analysis
- forward flexion test
tx:
- structural: bracing and/or surgery for placement of Harrington rods along the spine; conservative tx for 45 deg
- nonstructural can be managed with stretching, shoe lifts and postural re-education
- respiratory care may be needed if Cobb’s angle >40 deg
-flexibility, strengthening, estim to improve muscle performance, education for spinal orthoses
Sjogren’s syndrome
a rheumatoid like disorder characterized by dryness of the mucous membranes, joint inflammation and anemia
more common than systemic lupus erythematous (SLE) and less common than RA
differential dx:
- dryness of the eyes and mouth along with joint inflammation
- arthritis occurs in ~33% of the patients and is similar in distribution to RA, but milder and without joint destruction
tx:
- sipping fluids t/o the day
- chewing sugarless hum
- using a mouthwash for dryness
- meds for pain and inflammation
- maintain mobility and function through a regular exercise program
sprain:
degrees?
an injury to a ligament or joint capsules from over stress that damages the fibers either partially or completely
1st degree: some fibers are torn; a small amount of hemorrhaging is present and joint remains stable
Tx:
-prevent joint hypo mobility and disuse atrophy with movements within pain free AROM
-modalities to decrease pain, reduce edema and promote healing
-gradual return to normal functional level
2nd degree: a portion of the ligament or joint capsule is torn, moderate amount of hemorrhaging, some functional loss is present and joint stability remains intact
TX:
-guard against rein jury with limited WB and bracing as needed
-pain free AROM and joint mob should be integrated into the treatment, which includes physical agents to reduce pain and edema
3rd degree: complete disruption or avulsion of the ligament or joint capsule with loss of function, joint instability and pronounced hemorrhaging and swelling in the area. WB is undesirable
TX:
-After 2-3 weeks, the joint has usually healed (is pain free and has normal mobility) and strengthening exercises are used to reduce chance of re-injury
-may require surgical repair to avoid permanent joint instability
-bracing or splinting used to immobilize the joint and allow healing
-proprioception exercises and controlled motion exercises followed by gradual return to functional activities
-strength and mobility exercises used to complete rehab process- can take up to 5-6 months following
differential dx:
- joint palpation
- joint stability tests specific for injured area
- amount of swelling and ecchymosis
- functional/strength tests
systemic lupus erythematosus (SLE)
a chronic, systemic, rheumatic, inflammatory disorder of the CTs
affects multiple organs including skin, joints, kidneys, heart, blood-forming organ, nervous system, and serous membrane. also may affect membranes lining the walls of the body cavities and enclosing contained organs.
unknown etiology
differential dx:
- symptoms include malaise, overwhelming fatigue, arthralgia, fever, arthritis, skin rashes (butterfly rash over nose and cheeks), photosensitivity, anemia, hair loss, raynaud’s, kidney involvement
- other skin manifestations can indicate vasculitis, resulting in lesions in the digits, necrotic leg ulcers, or digital gangrene
tx:
- topical corticosteroid creams for skin lesions
- patient education for energy conservation, good nutrition, and skin care
- ROM
- ergonomic and postural training
TMJ syndromes
dysfunctions of this joint can be divided into 3 diagnostic categories
1- joint abnormalities that result from trauma, arthritis, disease or neoplasm
2- congenital structural defects. may include- meniscus, ligaments that control movement of the disc, the condyles, the fossa or the articular tubercles
3- loss of functional mobility of unknown etiology. may result from increased activity in the muscles of mastication as the result of stress and anxiety
differential dx: exam for joint noise, joint locking, AROM of the jaw, lateral deviation of the mandible during depression or elevation, decreased strength, tinnitus, headaches, FHP, and pain with movement
SPECIFIC CONDITIONS
1-Synovitis and capsulitis:
- pain located in pre auricular (anterior to ear) area
- unable to fully close back teeth together
- opening 40 mm and deviates toward the noninvolved side
3-Disc displacement with reduction
- patient reports joint noises with opening and closing equal to “pops” or “clicks”
- palpation over lateral poles reveals an opening click (the reduction of the disc) and a closing click (the disc displacing anterior to the condyle). these noises = the “reciprocal click”
4- disc displacement without reduction
- patient reports intermittent locking without joint noises
- opening of mandible is limited to 20-25mm with deflection toward involved side
- limited lateral excursion toward the opposite side of the involved joint
TX:
- postural re-ed
- modalities for pain
- inflammation reduction
- biofeedback
- joint mob
- AROM and muscle strengthening exercises
- patient education for eating soft foods and decreasing habits that stress TMG (biting nails or pencils)
- instruct patient in maintaining the rest position of the tongue (upright postural position of the tongue on the hard palate
tibial fracture
TYPES:
- march fractures of the inferior 1/3 of the tibia, common in persons who take long walks when they aren’t used to this activity
- spiral factures occur at the junction of the middle and inferior thirds resulting from severe tibial torsion during skiing
- compound fractures can occur from a direct blow to the tibia
*most common long bone to be fractured and suffer compound injury
TX:
- casting
- possible ORIF with hardware
- poor blood supply- even stable fractures may take up to 6 months to heal
- after healing is complete, early AROM and PROM are essential for ultimate functional recovery.
- progressive resistance exercises, mobs and closed chain stabilization exercises are needed to complete the rehab process
torticollis (wryneck)
occurs when the SCM continuously contracts (spasm and/or tightness). Results in the lateral bending of the head to the affected side with rotation of the chin to the opposite side
usually develops in utero and is considered congenital. May also be acquired by pressure on the spinal accessory nerve, inflammation of the glands of the neck or muscle spasm
TX:
- modalities to reduce spasm
- stretching
- biofeedback
- postural education and training
Total hip replacement precautions
avoid excessive hip flexion and adduction past neutral
avoid ER with an ant/lat approach and IR with a post/lat approach
avoid low chairs and crossing involved leg
WB orders and precautions determined by surgeon
-cemented,- exercise and WB usually can proceed more rapidly than if cements
sleep with abduction pillow and avoid vigorous stretching
need to increase extensor and abductor strength for efficient gait pattern
Rheumatoid conditions
ankylosing spondylitis
Gout
psoriatic arthritis
RA
ankylosing spondylitis
“Marie-Strumpell disease, Bechterew’s disease, rheumatoid spondylitis”
progressive inflammatory disorder of unknown etiology that initially affects the axial skeleton
initial onset (usually mid and LBP >3 months) before 40 y/o
1st symptoms include back pain, morning stiffness and sacroiilitis
results in kyphotic deformity of the cervical and thoracic spine and a decrease in lumbar lordosis
degeneration of peripheral and costovertebral joints may be observed in advanced stages
affects men 3x more than women
Gout
genetic disorder of purine metabolism, characterized by elevated serum uric acid (hyperuricemia). Uric acid changes into crystals and deposits into peripheral joints and other tissues (kidneys).
most frequently at knee and great toe
dx tests identify monosodium rate crystals in synovial fluid and/or CT samples
psoriatic arthritis
chronic, erosive inflammatory disorder of unknown etiology, associated with psoriasis
erosive degeneration usually occurs in joints of digits as well as axial skeleton
coxa vara
femoral neck shaft angled inward
coxa valga
femoral neck shaft angled outward
>125 deg
(normal 115-125)
may result from necrosis of femoral head occurring with septic arthritis
femoral antetorsion/anteversion
femoral neck angles anteriorly 10-15 deg from frontal plane to form anterior anteversion angle
excessive anteversion >25-30 deg
femoral neck rotated forward –> execessive IR “toe in”
femoral retroversion
femoral neck angles anteriorly 10-15 deg from frontal plane to form anterior ante version angle
excessive retroversion= excessive ER “toe out”
Internal tibial torsion:
distal aspect of tibia rotated or twisted medially as compared to its proximal end
Genu varum
knees are lateral in relation to the ankle
“bowlegged”
Genu valgum
knees come together or almost touch
“knock kneed”
Talipes Equinus
DF limitation, the toe is in a down position
Talipes Calcaneous
the heel down position
PF is limited
talipes equinovarus
ankle and foot are down and in “club foot”
Pes cavus
high arched or supinated foot
Pes planus
low arched foot, pronated “flat foot”
valgus heel
the rearfoot is deviated toward the outside resulting in a pronated heel
hallux valgus
the 1st MT has an abduction deformity “bunion”
osteogenesis imperfecta
inherited disorder transmitted by an autosomal dominant gene
characterized by abnormal collagen synthesis, leading to an imbalance between bone deposition and reabsorption
cortical and cancellous bones become very thin, leading to fractures and deformity of WB bones
tx: bone/joint protection, joint mechanics and CT functions, aerobic apacity/endurance- aquatics
osteochondritis dissecans
a separation of articular cartilage from underlying bone (osteochondral fracture)
usually involves medial femoral condyle near intercondylar notch or humeral capitulum; less observed at femoral head and talar dome.
surgical intervention if fracture is displaced
tx: joint/bone protection, flexibility exercises, aerobic endurance, strengthing
myofascial pain syndrome
“trigger point” = focal point of irritability within a muscle
=taut, palpable band within a muscle
Active: tender to palpation and have a characteristic referral pattern of pain when provoked
Latent: palpable taut bands that are not tender but can be converted into an active TP
onset: sudden overload, overstretching and/or repetitive/sustained muscle activities
tx: flexibility exercises, manual therapy (STM, joint mobs), spray and stretch, dry needling, hot, cold, TENS, desensitization with manual pressure, strengthening
tendonosis/tendonopathy
common tendon dysfunction whose cause and pathogenesis are poorly understood
-often referred to as tendonitis although no inflammatory response noted
histological characeristics: hypercellularity, hypervascularity, no indication of inflammatory infiltrates, and poor organization and loosening of collagen fibrils
meds: acetaminophen, NSAIDS, steroid injection
tx: flexibility, manual therapy (STM, joint mobs), endurance, strengthening with emphasis on eccentrics, aerobic capacity, thermal agents for pain, education
bursitis
inflammation of ursa secondary to overuse, trauma, gout or infection
S&S: pain with rest, limited A&P ROM due to pain but not in capsular pattern
meds: acetaminophen, NSAIDS, steroid injection
tx: flexibility, manual therapy, aerobic capacity, thermal agents, education
muscle strains
inflammatory response within a muscle following a traumatic event that caused micro tearing of the musculotendinous fibers
pain and tenderness
meds: acetometophen and NSAIDs
tx: flexibility, manual therapy, aerobics, thermal agents for pain, education
List of shoulder conditions
glenohumeral subluxation and dislocation
instability
labral tears
thoracic outlet syndrome
acromioclavicular and sternoclavicular joint disorders
subacromial/subdeltoid bursitis
rotator cuff tendonosis/tendonopathy
internal (posterior) impingement
bicipital tenonosis/tendonopathy
proximal humeral fractures
adhesive capsulitis
glenohumeral subluxation and dislocations
95% occur in anterior-inferior direction
-occurs when abducted UE is forcefully ER, causing tearing of inferior GH ligament, anterior capsule and occasionally gleaned labrum
posterior dislocations are rare- occur with multidirectional laxity of GH joint
-occurs with horizontal adduction and IR
complications include:
- compression fracture of posterior humeral head- Hill sachs lesion
- tearing of superior gleaned labrum from anterior to posterior- SLAP lesion
- avulsion of anterior inferior capsule and ligaments associated with glenoid rim- Bankart’s lesion
- bruising of axillary nerve
following surgical repair avoid apprehension position
shoulder instability
1- traumatic- common in young throwing athletes
2- atraumatic- congenitally loose CT
characterized by popping/clicking and repeated dislocation/sublux of GHJ
unstable injuries require surgery to reattach the labrum to glenoid (bankart)
tx:
- restore function without pain
- functional training- restore strength, endurance, coordination, flexibility
- joint mobs
- surgery- sling 3-4 weeks, after 6 weeks more specific training; full fitness 3-4 months
GH labral tears
classified as superior, inferior, SLAP or bankart
- SLAP- tear of the rim above the middle of the socket that may also involve the biceps tendon
- Bankart- tear of the rim below the middle, also involves the inferior GH ligament
S&S:
- shoulder pain can’t be localized to a specific point
- pain made worse by OH activities when arm is behind the back
- weakness
- instability
- pain on resisted flexion of biceps
- tenderness over front of shoulder
unstable injuries require surgery to reattach labrum to glenoid; bankart requires sx
dx: exam, MRI or arthroscopic surgery (gold standard)
tx:
- return of function without pain
- functional training- strength, endurance, coordination, flexibility
- underlying causes addressed- instability
- joint mobs
- following surgery: sling 3-4 weeks, after 6 weeks more sports specific training, full fitness 3-4 months
Thoracic outlet syndrome
compression of neuromuscular bundle (brachial plexus, subclavian A and V, vagus and phrenic nerves and the sympathetic trunk) in thoracic outlet between bony and soft tissue structures
common areas of compression:
- superior TO
- scalene triangle
- between clavicle and 1st rib
- between pec minor and thoracic wall
surgery may be performed to remove a cervical rib or release ant/middle scalene
special tests: adson’s, roos, wright, costoclavicular
PT:
- depends on cause of compression
- postural re-ed
- functional training
- correct biomechanical faults
- manipulations- 1st rib to diminsh pain and soft tissue guarding
acromioclavicular and sternocalvicular joint disorders
MOI: fall onto shoulder with UE adducted or collision with another individual during sport
3 grades
UE is positioned in neutral with use of sling in acute phase to avoid shoulder elevation
surgery is rare due to tendency of AC joint degeneration following repair
PT:
- return of function without pain
- functional training
- manual therapy to AC and SC joints and surrounding tissues : STM, joint mobs
rotator cuff tendonosis/tendonopathy
tendons of RC are susceptible to tendonitis, due to relatively poor blood supply near insertion of muscles
results from mechanical impingement of the distal attachment of the RC on the anterior accordion and/or coracoacromial ligament with repetitive OH activities
special tests: supraspinatus test, Neer’s impingement test
Impingement syndrome- shoulder
characterized by soft tissue inflammation of the shoulder from impingement against the accordion with repetitive OH AROM
special tests: Neer’s impingement, supraspinatus, drop arm
surgical repair: avoid shoulder elevation >90
PT:
- restore posture
- correct muscle imbalances and biomechanical faults
Internal (posterior) impingement -shoulder
characterized by an irritation between the RC and greater tuberosity or posterior glenoid and labrum
OH athletes
special tests: posterior internal impingement test
Bicipital tendonosis/tendonopathy
most commonly an inflammation of the long head of biceps
results from mechanical impingement of proximal tendon, between anterior accordion and bicipital groove of humerus
special test: speed’s test
proximal humeral fractures
Humeral neck fractures:
frequently occur with a fall onto outstretched UE among older osteoporotic women. Generally doesn’t require immobilization or surgical repair; fairly stable fracture
Greater tuberosity fractures
more common in middle aged and elder adults. usually related to a fall onto the shoulder, doesn’t require immobilization
PT:
- early PROM important in preventing capsular adhesions
- functional training without pain
Adhesive capsulitis
“frozen shoulder”
characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule, usually due to disuse following injury or repetitive micro trauma
restriction follows capsular pattern of limitation:
-greatest limitation in ER, following by abduction and flexion and least restricted in IR
commonly seen in associated with DM
PT:
- return of function w/out pain
- functional training
- biomechanical faults
List of elbow conditions
elbow contractures
lateral epicondylosis/epicondylopathy
“tennis elbow”
medial epicondylosis/epicondyylopathy
“golfer’s elbow”
Distal humeral fractures
osteochondrosis of humeral capitulum
Ulnar collateral ligament injury
Nerve entrapments
elbow dislocations
elbow contractures
loss of motion in capsular pattern (flexion>extension)
los of motion in non capsular pattern as the result of a loose body in the joint, ligamentous sprain, and/or complex regional pain syndrome
PT:
- joint mobs
- STM, modalities, flexibility, functional exercises
- splinting
lateral epicondylosis/epicondylopathy
“tennis elbow”
most often a chronic degenerative condition of the ECRB tendon at its proximal attachment to the lateral epicondyle of the humerus
gradual onset, usually the result of sports or occupations that require repetitive wrist extension or strong grip without the wrist extended- overloading the ECRB
special tests: lateral epicondylitis test
PT:
- correct muscle imbalances & biomechanical faults
- endurance and strengthening with emphasis on eccentrics
- prevention education
- thermal agents and TENS
medial epicondylosis/epicondylopathy
“golfer’s elbow”
usually a degenerative condition of the pronator teres and FCR tendons at their attachment to the medial epicondyle of the humerus
occurs with overuse in sports- baseball, pitching, golf swings, swimming or occupations that require a strong hand grip and excessive pronation of the forearm
special tests: medial epicondylitis test
PT:
- correct muscle imbalances & biomechanical faults
- endurance and strengthening with emphasis on eccentrics
- prevention education
- thermal agents and TENS
distal humeral fractures
complications can include: loss of motion, myositis ossificans, malalignment, neurovascular compromise, ligamentous injury and CRPS
supracondylar fractures:
- must be examined quickly for neuromuscular status due to high # of neurological (typically radial nerve involvement) and vascular structures that pass through this region (may lead to Volkmann’s ischemia).
- in youth- important to assess growth plate as well
- high incidence of melanin
Lateral epicondyle fractures:
-fairly common in young people and typically require ORIF to ensure absolute alignment
PT:
- pain reduction and limiting inflammatory response following trauma/surgery
- improve flexibility of shortened structures, strengthening and training to restore functional use of UE
osteochondrosis of humeral capitulum
osteochondritis dissecans affects central and/or lateral aspect of capitulum or radial head. An osteochondral bone fragment becomes detached from articular surface, forming a loose body in the joint.
Caused by repetitive compressive forces between radial head and humeral capitulum.
occurs in adolescents 12-15 y/o
Panner’s disease= a localized avascular necrosis of capitulum leading to loss of subchondral bone, with fissuring and softening of articular surfaces of radiocapitellar joint. children >10 y/o
PT
- rest with avoidance of throwing or UE loading activities (gymnastics)
- when painfree, initiate flexibility and strengthening/endurance/coordination exercises
- during late phases of rehab: program to slowly increase load on joint is initiated. If symptoms persist, surgical intervention is necessary
- after surgery: initial focus of rehab is to minimize pain and swelling using modalities. Flexibility exercises begun immediately after surgery. progressive strengthening.
- biomechanical faults- joint mobs
Ulnar collateral ligament injuries- elbow
occurs as a result of repetitive values stresses to medial elbow with OH throwing
clinical signs: pain along medial elbow at distal insertion of ligament. In some cases- paresthesias in ulnar nerve distribution with + Tinel’s sign
special tests: MCL instability test
PT:
- initially rest and pain management
- after resolution of pain and inflammation- strengthening exercises that focus on elbow flexors are initiated. Taping can also be used for protection during return to activities.
Nerve entrapments- elbow
Ulnar nerve
Radial nerve
Median nerve
meds:
- acetomenophen
- NSAIDs
- neurontin for neuropathic pain
PT
- early intervention: rest, avoiding exacerbating activities, NSAIDs, modalities and STM to reduce inflammation and pain
- if abnormal neurotension is present, neurodynamic mobs may be indicated
- protective padding and night splints to maintain slackened position of involved nerves
- with reduction in pain and paresthesias- rehab program should focus on strengthening, endurance, coordination exercise of involved muscles to achieve muscle balance, normal flexibility of shortened structures and normalizations of strength, etc.
- functional training, patient education and self management techniques
Ulnar nerve entrapment
Various cases:
- direct trauma at cubital tunnel
- traction due to laxity at medial aspect of elbow
- compression due to a thickened retinaculum or hypertrophy of FCU
- recurrent subluxation or dislocation
- DJD that affects cubital tunnel
Clinical findings:
- medial elbow pain
- paresthesias in ulnar distribution
- positive Tinel’s sign
Median nerve entrapment
occurs within pronator teres muscle and under superficial head of FDS with repetitive gripping activities required in occupations (electricians) and with leisure time activities (tennis)
Clinical signs
- aching pain with weakness of forearm muscles
- positive Tinel’s sign with paresthesias in median nerve distribution
Radial nerve entrapment
entrapment of distal braces (posterior interosseous nerve) occurs within radial tunnel (radial tunnel syndrome) as result of OH activities and throwing
Clinical signs:
- lateral elbow pain that can be confused with lateral epicondylitis
- pain over supinator muscle
- paresthesias in a radial nerve distribution
- Tinel’s sign may be positive
elbow dislocations
posterior dislocations account for most elbow dislocations
- defined by position of olecranon relative to humerus
- posterolateral dislocations are most common and occur as the result of elbow hyperextension from a fall on outstretched UE
- frequently cause avulsion fractures of medial epicondyle secondary to traction pull of MCL
anterior and radial head dislocations account for only 1-2%
with a complete dislocation, UCL will rupture, with possible rupture of anterior capsule, RCL, brachialis muscle, and/or wrist flexor and extensor muscles
Clinical signs:
- rapid swelling
- severe pain at elbow
- deformity with the olecranon pushed posteriorly
PT
- initial intervention: reduction of dislocation
- once stable, there is an initial phase of immobilization, followed by rehab focusing on regaining flexibility within limits of stability and strengthening
- surgery indicated if unstable dislocation
List of wrist and hand conditions
carpal tunnel syndrome
De Quervain’s tenosynovitis
Colles’ fracture
Smith’s fracture
Scaphoid fracture
Dupuytren’s contracture
Boutonniere deformity
Swan neck deformity
Ape hand deformity
Mallet finger
Gamekeeper’s thumb
Boxer’s fracture
Carpal tunnel syndrome
“repetitive stress syndrome”
compression of median nerve at the carpal tunnel due to inflammation of the flexor tendons and/or median nerve
commonly occurs as result of repetitive wrist motions or gripping, with pregnancy, diabetes and RA
must rule out potential of cervical spine dysfunction, TOS, or peripheral nerve entrapment that mimics condition
Common clinical findings:
- exacerbation of burning, tingling, pins and needles and numbness into medial nerve distribution at night
- positive Tinel’s sign and/or Phalen’s test
- long term compression causes atrophy and weakness of thinner muscles and lateral two lumbricals
PT
- -correct biomechanical faults
- STM, modalities, flexibility, functional exercises
De Quervain’s tenosynovitis
inflammation of extensor policies brevis and abductor pollicis longus tendons at first dorsal compartment
results from repetitive micro trauma or as a complication of swelling during pregnancy
clinical signs:
- pain at anatomical snuffbox
- swelling
- decreased grip and pinch strength
- positive Finkelstein’s test - places tendons on stretch
PT
- correct biomechanical faults
- STM, modalities, flexibility, functional exercises
Colles’ fracture
most common wrist fracture
FOSH
immobilized for 5-8 weeks
characteristive “dinner fork” deformity of wrist and hand results from dorsal or posterior displacement of distal fragment of radius, with a radial shift of wrist and hand
Complications:
- median nerve compression can occur with excessive edema
- loss of motion
- decreased grip strength
- CRPS
- carpal tunnel syndrome
PT:
- early PT focuses on normalizing flexibility is paramount to functional recovery of wrist and hand
- correct biomechanical faults
- STM, modalities, flexibility, functional exercises
Smith’s fracture
similar to Colles’ except distal fragment if radius dislocates in a polar direction, causing a characteristic “garden spade” deformity
results from a fall onto a flexed wrist
scaphoid fracture
results from FOSH in a younger person
most commonly fractured carpal bone.
because of poor vascular supply to this bone, there is high risk of avascular necrosis of proximal fragment of the scaphoid
tx:
- immobilized 4-8 weeks
- early maintenance of AROM of the distal and proximal joints while the UE is casted
- later tx emphasis is on regaining full functional use of the wrist and hand
Dupuytren’s contracture
observed as banding on palm and digit flexion contracture of palmar fascia that adheres to skin
men>women
contracture usually affects the MCP and PIP joints of digits 4 and 5 in non diabetic individuals and digits 3&4 most often in people with diabetes
PT
- flexibility exercises to prevent further contracture and splint fabrication/application
- once contracture is under control, promote restoration of normal hand function through functional exercises
- PT after surgery includes wound management, edema control and progression of functional exercise
Boutonniere deformity
results from rupture of central tendon slip of extensor hood
observed deformity is extension of MCP and DIP with flexion of PIP
commonly occurs following trauma, or in RA with degeneration of central extensor tendon
PT
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening
Swan neck deformity
results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
observed deformity is flexion of MCP and DIP with extension of PIP
commonly occurs following trauma or with RA following degeneration of lateral extensor tendons
PT
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening
Ape hand deformity
observed as thenar muscle wasting, with 1st digit moving dorsally until it is in line with 2nd digit
unable to flex digits 1-3, and oppose thumb
results from median nerve dysfunction
PT
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening
mallet finger
rupture of avulsion of extensor tendon at its insertion into distal phalanx of digit
observed deformity is flexion of DIP
PT
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening
Gamekeeper’s thumb
a sprain/rupture of UCL of MCP joint of thumb resulting in medial instability
frequently occurs during a fall while skiing, when increasing forces are placed on the thumb through ski pole
immobilized 6 weeks
PT:
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening
Boxer’s fracture
fracture of the 5th metacarpal
frequently sustained during a fight, or punching a wall
casted 2-4 weeks
PT:
- edema management
- flexibility exercises
- splinting/taping
- functional strengthening when flexibility is restored
List of hip conditions
avascular necrosis of the hip (osteonecrosis)
Legg calve perches disease (osteochondrosis)
slipped capital femoral epiphysis
femoral anteversion
coxa vara or valga
trochanteric bursitis
ITB tightness/friction disorder
piriformis syndrome
avascular necrosis of the hip (osteonecrosis)
impaired blood supply to femoral head
hip ROM is decreased in flexion, IR and abduction
Symptoms:
- pain in the groin and/or thigh
- tenderness with palpation at hip joint
- coxalgic gait
meds:
- acetomenophens
- NSAIDs
- corticosteroids contraindicated since that may be causative factor- if already taking, decrease dosage needed
PT:
- joint/bone protection strategies
- maintain/improve joint mechanics
- implement aerobic capacity/endurance (aquatics)
- postsurgical intervention includes regaining functional flexibility, improving strength/endurance/coordination and gait training
Legg-Calve-Perthes disease (osteochondrosis)
age of onset: 2-13 y/o (average=6)
males 4x> females
characteristic psoatic limb due to weakness of posts major; affected LE moves in ER, flexion and adduction
gradual onset of “Aching” pain at high, thigh and knee
AROM limited in abduction and extension
Dx: MRI;
-positive bony crescent sign (collapse of subchondral bone at femoral neck/head)
PT:
- joint/bone protection strategies
- maintain/improve joint mechanics and CT functions
- implement aerobic capacity/endurance
- postsurgical interventions: regain functional flexibility, improve strength/endurance
slipped capital femoral epiphysis
most common hip disorder observed in adolescents
unknown etiology
onset in males: 10-17 y/o (avg=13)
onset in females: 8-15 y/o (avg=11)
males 2x >females
AROM is restricted in abduction, flexion and IR
patient describes pain as vague at knee, thigh and hip
chronic conditions- patient may demo Trendelenburg gait
dx: plain film shows a + displacement of upper femoral epiphysis
PT:
- joint/bone protection strategies
- maintain/improve joint mechanics
- implement aerobic capacity/endurance (aquatics)
- postsurgical intervention includes regaining functional flexibility, improving strength/endurance/coordination and gait training
trochanteric bursitis
an inflammation of deep trochanteric bursa from a direct blow, irritation by ITB and biomechanical/gait abnormalities causing repetitive micro trauma
common in patients with RA
differentiate from contractile condition by comparing A&P ROM and resistive tests
ITB tightness/friction disorder
tight ITB/abnormal gait patterns
results in inflammation of trochanteric bursa
Special tests:
- noble compression test is positive when friction is introduced over the lateral femoral condyle during knee extension
- Ober’s test
PT:
- reduce pain and inflammation with modalities, STM and manual therapy
- correct muscle imbalance and biomechanical faults
- flexibility: ITB, hamstrings, quads, and hip flexors
- joints mobs
- gait training and patient education regarding running shoes and surfaces, orthoses
piriformis syndrome
piriformis: ER of the hip- can become overworked with excessive pronation of the foot, causing abnormal femoral IR. considered a tonic muscle that is active with motion of SI joint, particularly sacrum.
tightness or spasm of performs muscle can result in sciatic nerve compression and/or SI dysfunction
S&S:
- restriction in IR
- pain with performs palpation
- referral of pain to posterior thigh
- weakness in ER, positive piriformis test
- uneven sacral base
perform LE biomechanical exam to determine if abnormal biomechanics are the cause. must rule out involvement of lumbar spine and/or SIJ
PT:
- reduce pain- modalities, STM
- joint oscillations to hip or pelvis to inhibit pain
- correct muscle imbalances and biomechanical faults
- restore muscle balance and patient education to protect SIJ (not to step off curb onto bad LE)
- orthoses
List of knee conditions
Ligament sprains
meniscal injuries
abnormal patella positions
- alta
- baka
- lateral tracking
patellofemoral pain syndrome (PFPS)
patellar tenonosis/tendonopathy
“jumper’s knee”
pes anserine bursitis
Osgood-Schlatter disease
Genu varum and valgum
knee joint fractures
- femoral condyle
- tibial plateau
- epiphyseal plate
- patella
Knee ligament sprains
injury to the ligaments may result in a single plain or rotary instability
ant, post, med, lat, ant/med, ant/lat, post/med, post/lat
“Unhappy triad” includes injury to MCL, ACL and medial meniscus– results from a combo of valgum, flexion and ER forces applied to knee when the foot is planted
MRI difficult to visualize complete ACL; often misdiagnosed
reconstruction frequently involves combo of intra-articular and extra-articular procedures
Special tests:
- ACL: lachman’s, pivot shift,
- PCL: posterior sag, posterior drawer, reverse lachman’s
PT:
- varied based on need for surgery
- reduce pain and inflammation- modalities, STM, oscillations
- post-op: CPM to maintain flexibility
- correct muscle imbalances and biomechanical faults, joint mobs
- progress to functional training
ACL rehab:
- immediately following surgery a CPM is used with PROM 0-70 flexion; increased to 120 by week 6
- protected with a hinge brace set at 20-70 flexion initially; weaned from brace weeks 2-4
- NWB ~1 week
PCL rehab:
-same as ACL except hinge brace at 0 during ambulation
6 phases of rehab: preoperative, max protection, controlled motion, moderate protection, min protection and return to activity
interventions:
- STM to quads and hamstrings to reduce guarding
- joint oscillations to inhibit joint pain and muscle guarding
- correct muscle imbalances
- joint mobs
- progress to functional training
classification of ligament injury
1st degree: little or no instability
2nd degree: minimal-moderate instability
3rd degree: extreme instability
Meniscal injuries
result from a combo of forces to include tibiofemoral joint flexion, compression and rotation, which places abnormal sear stresses on the meniscus
symptoms:
- lateral and/pr medial joint pain
- effusion (swelling w/in a joint)
- joint popping
- knee giving way
- loss of ROM
- joint locking
special tests:
-mcmurrary’s, apleys
PT
- reduce pain and inflammation
- correct muscle imbalances and biomechanical faults
- progress to functional training
Partial meniscectomy: PWB as tolerated when full knee ext is obtained
- initial focus on edema/effusion control
- AROM urged surgical day 1
- isotonic and isokinetic strengthening by day 3
- jogging on ball of the foot or ties is recommended to decrease loading of knee joint
Meniscal repair:
- NWB 3-6 weeks
- rehab beings 7-10 days
abnormal patella positions
Patella alta:
- patella tracks superiorly in femoral intercondylar notch
- may result in chronic patellar subluxation
- positive camel back sign (2 bumps over anterior knee region instead of 1- patella superiorly and tibial tuberosity)
Patella baja:
- patella tracks inferiorly in femoral intercondylar notch
- results in restricted knee extension with abnormal cartilaginous wearing, resulting in DJD
Lateral patellar tracking:
-could result if there is an increase in Q angle with a tendency for lateral subluxation or dislocation
PT:
-regain functional strength of structures surrounding knee, particularly VMO, regain normal flexibility of ITB and hamstrings, orthoses (if appropriate) and patellar bracing/taping
lateral reticular release to restore tacking of patella during contraction of quads
PT: emphasize closed chain exercise to strengthen quads and regain dynamic balance of all structures surrounding knee; normalize flexibility of hamstrings, triceps sure and ITB ; mob patella to maintain nutrition and decreased adhesion
Patellofemoral pain syndrome (PFPS)
common dysfunction that may occur on its own or in conjunction with other entities. May have been caused by trauma or by congenital/developmental dysfunction
may be interrelated with chondromalacia patellae and/or patella tendonitis
common result is an abnormal patellofemoral tracking leading to abnormal patellofemoral stress
occasionally, surgery is indicated
PT:
- patellofemoral (McConnell) taping is helpful to inhibit pain during rehab
- patella mobs
- correct muscle imbalances and biomechnaical faults
patellar tendonosis/tendonopathy
“Jumper’s knee”
degenerative condition of the patellar tendon, typically of the deep aspect
may be related to overload and/or jumping related activities
may also be interrelated to patellofemoral dysfunction
corticosteroids
Pes anserine bursitis
typically caused by overuse or a contusion
must be differentiated from tendonitis
corticosteroids
PT: general bursitis treatment
Osgood-Schlatter disease
mechanical dysfunction resulting in traction apophysitis of the tibial tubercle at the patellar tendon insertion
often surgery
*early flexibility is important in preventing
PT:
-modify activities to prevent excessive stress to irritated site
Genu varum and valgum
normal tibiofemoral shaft angle= 6 deg of valgum
Genu varum= excessive medial tibial torsion
“bowlegs”
-results in excessive medial patellar positioning and the pigeon-toed orientation of the feet
Genu valgum= excessive lateral tibial torsion
“knock knees”
-results in excessive lateral patellar positioning
PT: decreased loading of knee while maintaining strength and endurance
Femoral condyle fractures
medial femoral most often involved d/t anatomical design
numerous etiology factors: trauma, shearing, impacting, and avulsion forces
common MOI = fall with knee subjected to a shearing force
tibial plateau fractures
common MOI= combo of valgum and compression forces to knee when flexed
occurs in conjunction with MCL injury
epiphyseal plate fractures
MOI frequently WB torsional stress
presents more frequently in adolescents where an ACL injury would occur in an adult
Patella fractures
common MOI- direct blow to patella due to fall
List of conditions to the lower leg
Anterior compartment syndrome (ACS)
anterior tibial periostitis (shin splints)
medial tibial stress syndrome
stress fractures
Anterior compartment syndrome (ACS)
increased compartmental pressure resulting in a local ischemic condition
-resulting from direct trauma, fracture, overuse, and/or muscle hypertrophy
symptoms of chronic or exertion compartment syndrome are produced by exercise or exertion and described as a “deep, cramping feeling”
symptoms of acute ACS are produced by sudden trauma causing swelling within the compartment
* considered a medical emergency and requires immediate surgical intervention with fasciotomy
Anterior tibial periostitis
“shin splints”
musculotendinous overuse condition
3 common etiologies:
1-abnormal biomechanical alignment
2-poor conditioning
3-improper training methods
muscles involved: anterior tibialis and extensor hallucis longus
pain elicited with palpation of lateral tibia and anterior compartment
PT:
- correct muscle imbalances and biomechanical faults
- flexibility for anterior compartment muscles as well as triceps surae
medial tibial stress syndrome
overuse injury of the posterior tibias and/or the medial soleus, resulting in periosteal inflammation at the muscular attachments
thought to result from excess pronation
pain elicited with palpation of the distal posteromedial border of the tibia
PT:
- correct muscle imbalances and biomechanical faults
- flexibility exercises for anterior compartment muscles as well as triceps sure to gain restoration of normal function
lower leg stress fractures
overuse injury resulting most often in micro fracture of the tibia or fibula
49% involve tibia, 10% involve fibula
common etiologies:
1-abnormal biomechanical alignment,
2- poor conditioning
3-improper training methods
PT:
- correct muscle imbalances and biomechanical faults
- flexibility exercises for anterior compartment muscles as well as triceps sure to gain restoration of normal function
List of foot and ankle conditions
Ligament sprains
Achilles’ tendonosis/tendonopathy
fractures of the foot/ankle
Tarsal tunnel syndrome
flexor hallucis tendonopathy
pes cavus -“hollow foot”
pes planas -“flat foot”
talipes equinovarus - “clubfoot”
equinus
hallux valgus
metatarsalgia
metatarsus adductus
Charcot-Marie-Tooth disease
Plantar fasciitis
forefoot/rearfoot deformities
-varus/valgus
ligament sprains- foot and ankle
95% of all ankle sprains involve lateral ligaments
-foot is PF and inverted at time of injury
instability evaluated with anterior drawer and talar tilt special tests
PT:
- varied depending whether surgery is needed
- reduce pain and inflammation
- correct muscle imbalances and biomechanical faults
- progress to functional training
Ankle ligament sprain grading
Grade I:
- no loss of function
- minimal tearing of ant talofibular ligament
Grade II:
- some loss of function
- partial disruption of anterior talofibular and calcaneofibular ligaments
Grade III:
- complete loss of function
- complete tearing of the anterior talofibular and calcaneofibular ligaments and partial tear of posterior talofibular ligament
Achilles’ tendonosis/tendonopathy
degenerative condition
special test: Thompson’s test
corticosteroid
general tx for tendonopathy
fractures of foot and ankle
unimalleolar
bimalleolar
trimalleolar: medial, lateral and posterior tubercle of distal tibia
concern for growth plate fractures
PT:
- return of function w/out pain
- functional training and restoration of muscle imbalances
- early PROM to prevent capsular adhesions
tarsal tunnel syndrome
entrapment of the posterior tibial nerve or one of its branches within the tarsal tunnel
excessive pronation, overuse problems resulting in tendonitis of the long flexor and posterior tibialis tendon, and trauma may compromise space in the tunnel
special test: Tinel’s
PT:
- orthoses to maintain neutral alignment
- if abnormal neurotension is present, neurodynamic mobilization may be indicated
flexor hallucis tendonopathy
identified as tendonitis in the acute stage, or can present as chronic
commonly seen in ballet performers
corticosteroid
Pes cavus
“hollow foot”
results from:
- genetics
- neurological disorders resulting in muscle imbalances and contracture of soft tissues
deformity observed includes:
- an increased height of longitudinal arches
- dropping of anterior arch
- MT heads lower than handoff
- plantar flexion
- splaying of forefoot and claw toes
function is limited due to altered arthrokinematics, reducing ability to absorb forces through foot
PT education: limit high impact sports, use of proper footwear and fitting orthoses
Pes planus
“flat foot”
etiologies: genetics, muscle weakness, ligamentous laxity, paralysis, excessive pronation, trauma or disease (RA)
normal in infant and toddlers
deformity observed: reduction in height of medial longitudinal arch
decreased ability of foot to provide a rigid lever for push off due to altered arthrokinematics
PT education: proper footwear, orthoses
Talipes equinovarus
“clubfoot”
types:
1-postural- results from intrauterine malposition
2- talipes equinovarus is an abnormal development of the head and neck of the talus, due to heredity or neuromuscular disorders (myelomeningocele)
deformity observed:
- postural: PF, adducted, inverted foot
- TE: 3 components- PF at talocrural joint; inversion at subtler, talocalcaneal, talonavicular and calcaneocuboid joints; and supination at mid tarsal joints
PT:
- manipulation followed by casting or splinting for postural condition
- TW requires surgery to correct deformity followed by casting/splinting
talipes equinus
etiology: congenital bone deformity, neurological disorders (CP, contracture of calf, trauma, or inflammatory disease)
deformity observed: PF foot
compensation secondary to limited DR includes subtler or mid tarsal pronation
PT: flexibility, joint mobs, strengthening to foot muscles and orthotic mgmt
hallux valgus
etiology:
- biomechanical malalignment (excessive pronation)
- ligamentous laxity
- heredity
- weak muscles
- tight footwear
deformity observed:
- medial deviation of 1st MT head
- MT and base of proximal phalanx move medially
- distal phalanx then moves laterally
normal MTP angle= 8-20 deg
PT
- early orthotic fitting and patient education
- lateral management- surgery followed by flexibility and strengthening
Metatarsalgia
etiologies:
- mechanical: tight triceps sure group and/or achilles tendon, collapse of transverse arch, short 1st ray, pronation of forefoot
- structural changes in transverse arch, possibly leading to vascular and/or neural compromise in tissues of forefoot
complaint frequently heard is pain at 1st and 2nd MT heads after long periods of WB
PT:
- correct biomechanical abnormalities- improve flexibility of triceps surae, modalities to decrease pain
- orthoses
- footwear education
metatarsus adductus
etiology: congenital, muscle imbalance, or neuromuscular diseases (polio)
types:
1- rigid: results in a medial subluxation of tarsometatarsal joints. Hindfoot is slightly in values with navicular lateral to head of talus.
2- flexible: observed as adduction of all 5 MT at the tarsometatarsal joints.
PT:
-strengthening and regaining proper alignment of foot, orthoses
Charcot-Marie-Tooth disease
peroneal muscular atrophy that affects motor and sensory nerves
child or adulthood
initially affects muscles in lower leg and foot, but eventually progresses to muscles of hands and forearm
slowly progressive disorder with varying degrees of involvement, depending on degree of genetic dominance
neurontin for neuropathic pain
PT:
- no specific tx to prevent, inherited disorder
- intervention centers on preventing contractures/skin breakdown and maximizing patient’s functional capacity to perform activities
- education/training for braces and ADs
plantar fasciitis
mechanical etiology:
- chornic irritation of plantar fascia from excessive pronation
- limited ROM of 1st MTP and talocrural joint
- tight triceps surae
- acute injury from excessive loading of foot
- rigid caves foot
results in microtears at attachment of plantar fascia
differentiate from tarsal tunnel by (-) tinel’s
PT
- regain proper mechanical alignment
- modalities for pain and inflammation
- flexibility of plantar fascia for pes cavus foot
- careful flexibility for triceps sure
- joint mobs
- night splints
- strengthen inverters
- patient education of footwear and orthotic fitting
Rearfoot varus
etiology:
- abnormal mechanical alignment of tibia
- shortened rearfoot soft tissues
- malunion of calcaneus
deformity observed: rigid inversion of calcaneus (medial side elevated) when subtalar joint is neutral
compensated-subtalar pronation
PT
- regain alignment
- improve flexibility
- orthotics and footwear
Rearfoot valgus
etiology:
-abnormal mechanical alignment of the knee (genu valgum) or tibial valgus
deformity observed: eversion of calcaneus with a neutral subtalar joint
due to increased mobility of hindfoot, fewer MS problems develop from this than with rearfoot varus
PT
- regain alignment
- improve flexibility
- orthotics and footwear
forefoot varus
etiology:
-congenital abnormal deviation of head and neck of talus
deformity observed: medial forefoot elevated/inverted when subtalar joint is neutral
PT
- regain alignment
- improve flexibility
- orthotics and footwear
forefoot valgus
etiology:
-congenital abnormal development of head and neck of talus
deformity observed: eversion of forefoot when the subtalar joint is in neutral
PT
- regain alignment
- improve flexibility
- orthotics and footwear
List of spinal conditions
muscle strains
spondylolysis/spondylolisthesis
spinal or intervertebral stenosis
disc conditions
- internal disc disruption
- posterolateral bulge/herniation
- central posterior bulge/herniation
- anterior bulge/herniation
facet joint conditions
- DJD
- facet entrapment- acute locked back
acceleration/deceleration injuries or cervical spine- “whiplash”
hypermobile spinal segments
SI joint conditions
repetitive/cumulative trauma to back
bone tumors
visceral tumors
GI conditions
cardiovascular and pulmonary conditions
muscle strain- spine
may be related to sudden trauma, chronic or sustained overload, or abnormal muscle biomechanics secondary to faulty function
meds:
- acetomenophen
- NSAIDS
- corticosteroid
- muscle relaxants- flexeril, valium
- trigger point injections
PT:
- correct biomechanical faults- joint mobs
- patient education- harmful positions and postural re-ed
- spinal manipulation for pain inhibition
spondylosis
ankylosing of a vertebral
degenerative changes >stiffness>immobility
spondylolysis and spondylolisthesis
etiology: thought to be congenitally defective pars interarticularis
Spondylolysis= a fracture of the pars interarticularis with positive “Scotty dog” sign on oblique radiographic view of spine
Spondylolisthesis= the actual anterior or posterior slippage of 1 vertebra on another, following bilateral fracture of pars interarticularis
-can be graded according to amount of slippage from 1 (25% slip) to 4 (100% slip)
dx: plain films (oblique and lateral)
special tests:
-stork test
PT
- correct mechanical faults
- exercise focused on dynamic stabilization of trunk with particular emphasis on abdominals
- avoid extension and/or other positions that add stress to defect (extension, ipsilateral side bend, contralateral rotation)
- patient education- eliminate positions of ext and postural education
- braces- boston brace and TLSO (thoracolumbarsacral orthosis)
- spinal mani may be contraindicated particularly at level of defect
spinal or intervertebral stenosis
etiology: congenital narrow spinal canal or intervertebral foramen, coupled with hypertrophy of the spinal lamina and ligamentum flavor or facets, as the result of age related degenerative processes or disease
results in vascular and/or neural compromise
S&S:
- bilateral pain and paresthesia in back, buttocks, thighs, calves and feet
- pain decreases in spinal flexion, increases in extension
- pain increases with walking
- pain relieved with prolonged rest
Dx: plain films, MRI, CT, myelography
special tests: bicycle/Van gelderen’s test helps differentiate from intermittent claudication
*if stenosis pain will alleviate with slouched/flexion position
PT
- correct biomechanical faults
- perform flexion-based exercise and exercise that promotes dynamic stability t/out trunk and pelvis
- avoid extension and/or other positions that narrow spinal canal or intervertebral foramen (ext, ipsilateral SB, ipsilateral rotation)
- manual/mechanical traction
- –c-spine positioned to 15 deg of flexion to provide optimum intervertebral foraminal opening
- –contraindications include joint hyper mobility, pregnancy, RA, down syndrome, or any other systemic disease that affects ligamentous integrity
internal disc disruption
internal structure of disc annulus is disrupted; however external structures remain normal
* most common in lumbar region
symtoms:
- constant deep, achy pain
- increased pain with movement
- no objective physical findings although patient may have referred pain in LE
dx: CT discogram or MRI
PT
-correct biomechanical faults
spinal manipulation may be contraindicated
-patient education - proper body mechanics, positions to avoid limiting repetitive bending and twisting, limiting UE OH and sitting activities and carrying heavy loads
Posterolateral bulge/herniation
most commonly observed disc disorder of lumbar spine due to 3 structural deficiencies:
1- posterior disc is narrower in height than anterior disc
2- posterior longitudinal ligament is not as strong and only centrally located in lumbar spine
3-posterior lamellae of annulus are thinner
etiology: overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures, from high compressive forces or repetitive micro trauma
results in loss of strength, radicular pain, paresthesia and inability to perform ADLs
dx: MRI
PT
- exercise program to promote dynamic stability t/out trunk and pelvis and to provide optimal stimulus for regeneration of disc
- positional gapping for 10 min to increase space within region of space occupying lesion
- -If L posterolateral lumbar is herniated:
- —have pt. SL on R side, with pillow under R trunk (accentuating trunk SB R)
- —flex both hips and knees
- —rotate trunk to left (or pelvis to R)
- spinal manipulation may be contraindicated
- patient education- body mechanics, positions to avoid, limiting repetitive bending and twisting movements, limiting UE OH and sitting activities, and carrying heavy loads
- manual/mechanical traction
Central posterior bulge/herniation
more commonly observed in cervical spine but also seen in lumbar
etiology: overstretching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (posterior longitudinal log) from high compressive forces and/or long term postural malalignment
results in loss of strength, radicular pain, paresthesia, inability to perform ADLs, and possible compression of SC. Patients exhibit CNS symptoms (hyperreflexia, +babinski)
dx: MRI
PT
- exercise program to promote dynamic stability t/out trunk and pelvis and to provide optimal stimulus for regeneration of disc
- positional gapping for 10 min to increase space within region of space occupying lesion
- spinal manipulation may be contraindicated
- patient education- body mechanics, positions to avoid, limiting repetitive bending and twisting movements, limiting UE OH and sitting activities, and carrying heavy loads
- manual/mechanical traction
anterior bulge/herniation
very rare due to structural integrity of anterior intervertebral disc
Degenerative joint disease- spine
etiology: normal aging process due to WB properties of facets and intervertebral joints
results in bone hypertrophy, capsular fibrosis, hyper/hypo mobility and proliferation of synovium
symptoms:
- reduction in mobility of spine
- pain
- possible impingement of associated nerve root resulting in loss of strength and paresthesias
special test: quadrant
PT
- exercise program to promote dynamic stability t/o trunk and pelvis and to provide optimal stimulus for regeneration of facet cartilage and/or capsule
- correct biomechanical faults
- spinal mani may be useful
facet entrapment (acute locked back)
caused by abnormal movement of fibroadipose meniscoidal in facet during extension (from flexion). Meniscoidal doesn’t properly reenter joint cavity and bunches up, becoming a space occupying lesion, which distends capsule and causes pain
flexion is most comfortable, extension increases pain
special test: lumbar quadrant
PT
-positional facet joint gapping and or manipulation
acceleration/deceleration injuries of cervical spine
“whiplash”
occurs when excess shear and tensile forces are exerted on cervical structures
- facets/articular processes
- facet joint capsules
- ligaments
- disc
- ant/post muscles
- fracture to odontoid process and SP
- TMJ
- sympathetic chain ganglia
- spinal and cranial nerves
S&S
- Early: headaches, neck pain, limited flexibility, reversal of lower cervical lordosis and decrease in upper cervical kyphosis, vertigo, change in vision and hearing, irritability to noise and light, dysesthesias of face and bilateral UEs, nausea, difficulty swallowing and emotional lability
- Late: chronic head and neck pain, limitation in flexibility, TMJ dysfunction, limited tolerance to ADLs, disequilibrium, anxiety and depression
common clinical findings:
-postural changes, excessive muscle guarding with soft tissue fibrosis, segmental hyper mobility, and gradual development of restricted segmental motion, cranial and caudal to the injury (segmental hypo mobility)
PT:
- spinal manipulation generally indicated
- correct muscle imbalances and biomechanical faults
- progress to functional training
- patient education-eliminate harmful positions and postural re-ed
- traction
hypermobile spinal segments
=abnormal increase in ROM at a joint due to insufficient soft tissue control (ligamentous, distal, muscle or a combo)
PT:
- pain reduction modalities to reduce structural irritation
- PROM within normal ROM
- passive stabilization with corsets, splints, casts, tape, collars
- increase strength, endurance, coordination, especially in multifidus, abdominals, extensors and gluteals which control posture
- regain muscle balance
- education- postural education, limit excessive overloading and sustained activities and end range postures
SI joint conditions
cause and specific pathology unknown
-joint ma become inflamed, develop degenerative changes or develop abnormal movement patterns
anatomically and functionally, SIJ is closely related to lumbar spine, so a thorough exam of both regions is indicated
special tests:
- gillet’s
- ipsilateral anterior rotation
- gaenslen’s
- long sitting
- goldthwait’s
PT:
- spinal manipulations- SIJ gapping generally indicated to inhibit pain, reduce muscle guarding and restore normal joint motion
- correct muscle imbalance t/o pelvis- strengthen, endurance, coordination, flexibility
- joint mobs
- education- harmful positions and postural re-ed
- SI belts
repetitive/cumulative trauma to back
disorders of the nerves, soft tissues and bones precipitated or aggravated by repeated exertions or movements of the back
repetitive trauma- 48% of all occupational diseases
difficult dx - 85% of back pain undx
chronic disability may be reduced by enrollment in a work-conditioning program, patient education, aerobic exercise, general strengthening and functional stability exercises that promote endurance for work related activities
intervention should focus on prevention with education.
bone tumors - spine
primary tumors:
- multiple myeloma (most common primary bone tumor)
- Ewing’s sarcoma
- malignant lymphoma
- chondrosarcoma
- osteosarcoma
- chondromas
metastatic bone caner has primary sites in lung, prostate, breast, kidney and thyroid
S&S: pain that is unvarying and progressive, not relieved with rest or analgesics, more pronounced at night
visceral tumors related to the spine
esophageal cancer symptoms may include pain radiating to the back, pain with swallowing, dysphagia and weight loss
pancreatic caner symptoms include a deep, gnawing pain that may radiate from chest to back
GI conditions related to the spine
acute pancreatitis may manifest as mid-epigastric pain radiating through to the back
cholecystitis may present with abrupt, severe abdominal pain and R upper quadrant tenderness, nausea, vomiting and fever
cardiovascular and pulmonary conditions related to the spine
heart and lung disorders can refer pain to chest, back, neck, jaw and UE
abdominal aortic aneurysm (AAA) usually appears as nonspecific lumbar pain
urological and gynecological conditions related to the spine
kidney, bladder, ovary and uterus disorders can refer pain to the trunk, pelvis and thighs
TMJ conditions
common S&S
- joint noise
- joint locking
- limited flexibility of jaw
- lateral deviation of mandible during depression or elevation
- decreased strength/endurance of muscles of mastication
- tinnitus
- headaches
- FHP
- pain with mandible movement
many patients with TMJ conditions have a component of cervical dysfunction
dysfunction categories:
1- DJD (OA or RA)
2- myofascial pain (*most common TMD)- discomfort or pain in muscles controlling jaw function, as well as neck and shoulder muscles.
3- internal derangement of joint, meaning a dislocated jaw, displaced articular disc, or injury to condyle
-loss of functional mobility may result from increased activity in muscles of mastication due to stress and anxiety
-causes::
—trauma: leading to joint edema, capsulitis, hypo/hypermobility, abnormal function of ligaments, capsule and muscles
—congenital anatomical anomalies- change in shape of palate
—abnormal function- repeated chewing hard/chewy, mouth breather, FHP
PT:
- postural re-ed
- modalities to reduce pain/inflammation
- biofeedback to minimize effects of stress/anxiety
- joint mob is TMJ restriction present (primary glide is inferior which gaps joint, stretches capsule and allows relocation of anteriorly displaced disc
- flexibility and muscle strengthening exercises (rocabado’s jaw opening while maintaining the tongue in contact with the palate and isometric mandibular exercises)
- patient education- foots, posture
- night splints
- resting tongue position on hard palate
- critical to normalize the cervical spine posture before patient receives any permanent dental procedures and/or appliances
surgical repairs of the spine
back protection program and early mobilization should be initiated prior to surgery
avoid prolonged sitting, heavy lifting, and long car trips ~3months
repetitive bending with twisting always avoided
microdiscectomies: rehab time is decreased bc the fibers of the annulus fibrosis are not damaged
laminectomy/discectomy: early movement and activation of paraspinal musculature (especially multifidi) is necessary
multilevel vertebra fusion:
- ~6weeks of trunk immobility with bracing
- after bracing, important to regain as much normal/functional movement as possible, while restoring functional activation of muscles
- with combined ant/post surgical approach, bracing seldom used
Harrington rod placement for idiopathic scoliosis:
- rehab goals focus on early mobilization in bed and effective coughing
- begin ambulation between days 4-7
- avoid heavy lifting and excessive twisting/bending
