MSK Pathologies Flashcards
Give the background Pathology of Lateral Epicondylitis ( Tennis Elbow)
- Impacting the extensor muscles of the forearm
- Age range 40/50s
- Extensor Carpi Radialis Brevis most commonly affected
- SUP , ECRL,ED,EDM,ECU
- Caused by excessive/repetitive use
How does pain present in Tennis Elbow?
- Pain @ lateral epicondyle in line with extensors ( common extensor origin)
- Varying in pain and severity
- Aggs = Resisted wrist/finger extension/Supination
How is Tennis Elbow managed?( not meds)
- Load management
- Exercise
- Brace/taping
- Eduction
How is Tennis Elbow managed? ( Medication)
- NSAIDS
- Corticosteroids
- Shockwave Therapy
- Surgery
Give the background pathology of Medial Epicondylitis ( Golfers elbow)
- Pronator teres and Flexor Carpi Radialis
- Pinching of the ulnar nerve
- Females>Males
- Less common
- Aggs - Throwing and Gripping
How is Golfers Elbow managed?( Not meds)
- Load Mangement
- Exercise
- Brace and Trapping
- Education
Hows is Golfers Elbow managed?( Meds)
- NSAIDS
- Corticosteroids
- Shockwave Therapy
- Surgery
Give the background Pathology of De Quervains Tenosynovitis
- Thickening of the tendon sheath around EPB and APL
- May be spontaneous or initiated by overuse of the thumb( eccentric lowering of wrist into ulnar deviation)
- Adhesions may develop
- Pain on radial aspect
How is De Quervains Tenosynovitis managed?
not meds
- Finkelstein Test and Palpation
- Load management
- Exercise
- Brace and Tapping
- Education
How is De Quervains managed medically?
- NSAIDS
- Corticosteroids
- Shockwave therapy
- Surgery
Using POLICE /PRICE give the management strategies for Strains/Sprains
- Mobilising
- Strength/Loading
- Proprioception
- Endurance training
- Surgery
Give the background Pathology of Carpal Tunnel
- Compression of the Medial nerve
- 1/10
- Common in females
- Oedema , tendon inflammation , hormonal changes
How does Carpal Tunnel present?
- Nocturnal Paraesthesia
- Loss of sensation
- Weakness of the muscles supplied by the median nerve
- Pain
How is Carpal Tunnel Managed?
- Education
- Load management
- Splinting
- Exercise
- Corticosteroid injection
- Surgery
What is An Avulsion Injury?
- Attachment site pulled away usually taking away a portion of the bone
- For example- ASISw/Sartorius , AIISw/Rectus Femoris
Give the background pathology of REDS and its meaning
REDS = Reduces Energy Deficiency Syndrome
- Common in Teens/20s
- Young Athletes
- Resulting in Decreased body fat and can result in the loss of menstrual cycle in young women.
What is Avascular Necrosis?
- Loss of Blood Supply to the Bone
- Bone death=Bone Collapse.
What Causes Avascular Necrosis?
- Trauma
- Surgery
- Steroid
- Excessive Alcohol
What is Hip Dysplasia?
- Hip socket not covering full ball portion of the ball
head of femur
Give the Background Pathology of Hip Dysplasia
- Unstable , Shallow socket
- Most common in females
- Presents complications with age
- Normal centre edge angle
Give the background pathology of a Labral Tear
- Labrum
- Common amongst athletes
-End range position =Hyperextension , Hyperabduction and Hyper-flexion + External rotation - Injection to detect tear using MRI
( Gadolinium dye)
Give the background pathology of Greater Trochanteric pain Syndrome
- Lateral Hip pain
- Tendinopathy of Gluteus Medius and Minimus
- Pressure of Illiotibial band
- 40-60 yr old females
- Post Menstrual
- Lowering of Femoral Neck Angle
What is Tendinopathy?
Active Process of Degeneration that involves Inflammatory Pathways
Give the name tendons where tendinopathy occurs
-Achilles Tendon
-Patella Tendon
-Gluteal Tendon
-Hamstring Tendon
+ Upper Limb = Rotator Cuff , Long head Biceps , Lat and met Epicondylagia
Give the 3 stages of the Tendon Continuum
The reactive tendinopathy, tendon disrepair and the degenerative tendinopathy
Describe the changes to tendon cell population in Tendinopathy
Increased number of Tenocytes, Increased tenocytes metabolism , Increased immature Tenocytes, increased rate of apoptosis, immunoactive cells.
Describe the changes in collagen structure in tendinopathy
- Reduction in Type I collagen
- Organised areas with higher concentrations of immature collagen bundles (Type III)
- linear fibres - unorganised smaller and irregular structure
Describe the Ground substance changes in Tendinopathy
PG and GAG ( Natural Lubricants) content alters , Increased H20 , Chemical Alterations , Substance P , Glutamate and Lactate.
Describe Neurovascularization in Tendinopathy
Influx of blood vessels into the anterior surface and mid substances , this is associated with various nerve fibres ingrowing into the Tendon.
Who gets tendinopathy?
- Endurance runners
- Older athletes
- Active/athletic 40+
- Changes in Loading
- +60 yrs , adiposity, diabetes, inactive lifestyle
Give the background pathology of Adhesive Capsulitis ( Frozen Shoulder)
- Excessive scar tissue or adhesions across GHJ - fibrosis
- 3-5% general population
- 20% obese/diabetes patients.
- Resolution 1-3 years
- Resulting in Stiffness, pain and Dysfunction
Give the two types of Adhesive Capsulitis ( Frozen Shoulder)
Primary - Spontaneous
Secondary-Trauma
State the risk factors associated with Adhesive Capsulitis
- Female>Male
- > 40
- Trauma
- Diabetes
- Hyperthyroidism
- Cerebrovascular /Coronary artery disease
Give the First Stage of Adhesive Capsulitis
- Shoulder pain@night
- Synovitis
- Inflammatory cell infiltration
Give the second stage of Adhesive Capsulitis
- Stiffness and pain
- Synovitis
- Loss of Axillary fold
- Synovial Proliferation - dense fibrous tissue
Give the Third stage of Adhesive Capsulitis
Global loss of ROM , with pain at End range
- Synovitis resolved , however replaces by significant adhesions
- Dense collagenous tissue
Give the Fourth stage of Adhesive Capsulitis
- Persistent stiffness w/minimal pain
- Advances adhesions
Give the Management for Adhesive Capsulitis
- Physiotherapy with early mobilisation and education
- NSAIDS
- Corticosteroid injections - Being careful of when in the disease process this is administered
- Hydrodilation
- Surgery (MUA , joint distension H20 and open surgical release)
Give the Background Pathology of Osteoarthritis
- Most common form of Arthritis
- Can occur at any synovial joint
- The pathogenesis of OA involves a degradation of cartilage and remodelling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells in the surrounding tissues.
State the management strategies for osteoarthritis
- Physio - mobilisations for pain and stiffness, ROM and strengthening exercises, lifestyle and weight loss
- Corticosteroid injection
- Surgery
Give the Background pathology of Rheumatoid Arthritis
- Systemic autoimmune disease
- Synovium infiltration by immune cells
- Osteoclast generation = bone erosion and loss of joint integrity
- RA begins long before the onset of joint inflammation
Give the risk factors associated with RA
-North America and Northern Europe
- Increase prevalence in females
-Increases with age
Pediatic = Juvenile idiopathic Arthritis.
-Smoking
-Air pollution
-Obesity
- Lack of Vit D
Describe the Clinical presentation of Rheumatoid Arthritis
- Polyarthritis of small joints of the hand
- Joint stiffness in the morning
- Fatigue
- Deformity pain, weakness and restricted mobility in affected joints
- If CX spine affected = cervical instability between C1 and C2
State the management strategies of RA
- Symptom management
- Pharmacological management
- nutrition
- physiotherapy
Give the background pathology of an Anterior shoulder dislocation
- Arm positioned in abduction and external rotation
- Humeral head displaces antero-inferiorly.
- Can lead to Hill-sachs lesion/Bankart lesion
- Concurrent rotator cuff injuries can also occur
- Vascular and neuro structures at risk
- Males
- Younger patients
Give the background pathology of an Posterior shoulder dislocation
- 5% incidence rate
- Blow to the front of the shoulder
- Can also occur during seizures
- Concurrent injuries to rotator cuff , ex-post labrum
- Males
- Younger patients
- FOOSH
Give the background pathology of Shoulder Instability
- Disruption of dynamic/static stabiliser of the GHJ leading to dislocation, subluxation or apprehension
- Traumatic or atraumatic
- Ant, Post, inferior or Multidirectional
State the clinical presentation of shoulder instability
- Clicking /Pain
- Sub-acromial signs
- Rotator cuff signs
- Positive apprehension test
- Increased accessory movement at the GHJ
Give the management strategies of Shoulder instability-
- physiotherapy
- Education
- Motor control
- Strength training
- Proprioception training
- surgery
Give the Background Pathology of Dupuytrens Disease.
- Nodular hypertrophy and contracture of the superficial palmar fascia ( Palmar aponeurosis)
- Contracture of MCP and PIP = Loss of function
- Slow occurrence
- Thickening of the skin- Bands of fibrotic tissue - fingers impacted and pulling into flexion
- Bilaterally
State the risk factors associated with Dupuytrens Disease
- Higher in males
- Elderly
- Strong genetic component
- Alcohol ,smoking, manual labour
- Associated with diabetes.
State the management strategies for Dupuytrens Disease
- Surgery
- Fasciotomy - Least invasive - cut
- Fasciectomy - removal
- Dermofasciectomy - includes overlying skin ( Fat )
- Amputation
- Physiotherapy( post-op)
- Splinting exercise
- Education/advice
- Oedema and Scar Management
What are the two types of Meniscal Vascularisation?
- Red-red region - Vascular
- White-white region - avascular , poor healing quality
Give the types of Meniscal injury classification
- Vertical longitudinal
- Vertical horizontal
- Horizontal
- Oblique
- Complex and degeneration
- Bucket handle tear
Give the background pathology of an ACL
- More common
- 15-25 sports
- more common in women
- Intra-articular
- Knee is in flexion with valgus positioning , often causing trauma with rapid changes in direction.
- Proximal = increased vascularity
Give the Background pathology of an PCL
- Less Common
- Posterior force on proximal tibia.
- Swelling , pain on kneeling , positive posterior drawer test
What is Osgood Schlatter disease?
Irritation of occurring at the growth plate of the knee caused by too much tension on the patella tendon.
Common in young athletes
Give the background pathology of patellofemoral joint pain
- AKP
- Tightening
- Altered mechanics
Give the symptoms of damage to lateral ligaments-
- usually after traumatic event
- pain =/tenderness
- swelling/bruising
- Muscle spasm
- Inability bear weight
Osgood- Schlatter Disease
Swelling and irritation of the growth plate tibial tubercle
Over use injury
Sinding Larsen- Johansson Syndrome
Inferior pole of the patella - swelling and irritation of the growth plate
Perthes Disease
Avascular necrosis of the femoral head - adolescence
Self limiting with revascularisation occurring within 2-4 years
2-12 years old , most common 6
Male:female , 4:1
- reduce weight bearing
Slipped Femoral epiphysis
Growth plate slipping at the hip.
Altering biomechanics
Can result in OA
Realignment with pins.
Severs disease
Traction Apophysitis of the calcaneal insertion of the Achilles’ tendon
Activity modification
Pain monitoring model 0-10
4-5 Caution - reduce exercise
6-10 stop - stop exercise allow to settle
Why do weak muscles influence tendinopathy?
Good muscle contraction - increased energy efficiency, greater elastic recoil, less heat production , potential to improve and protection from tendinopathy
Poor muscle contraction / coordination - reduced energy efficiency, greater heat absorption , potential to trigger cellular response and tendinopathy, greater amplitude of tendon strain and accumulative load.
Give 5 elements of a neuromuscular Achilles rehab program
1 - ensure full dorsiflexion 2- stop start movements at different positions 3- make patient aware of any tremors 4- add external load early in rehab 5- different knee flexion angles
Features of rehab post fracture
1- restore function 2- gait re-Ed 3- ROM 4- strength training 5-Pain relief
Management of Hamstring Strain
- POLICE
- early load
- length of muscle ROM and stretch
- strengthen
- pain relief
Posters-lateral complex injury
Rare but disabling
Poor outcome
Associated with PCL/ACL Injuries
Mechanism
Direct blow to anterior medial tibia in the extended knee
Fall into a flexed knee
Non contract hyper extension injuries
Some structures involved - ITB ,LCL, popliteus, ACL,lateral meniscus, biceps fem tendon etc
Signs and symptoms of méniscal tears
- catching
- H/O loading and twisting
- locking
- effusion developing over 24hours
- joint line tenderness
- +ve clinical tests ( apley’s, mcmurrays)
Overview of tissue rehab
Tendons - modify tissue , strengthen, progress , RTP
Joint/OA - Modify load , ROM, balance, strength, neuromuscular control MOI
Ligaments - Modify load, ROM, balance, strength , neuromuscular control MOI
Fractures and Joint replacements - ROM, strengthen, rehab function
Always remembering the wants and needs of the patient.
POLICE
Give the diagnostic criteria of a frozen shoulder
- Pain that comes on slowly and is felt at the deltoid region
- Painful restriction of AROM and PROM in capsular pattern - LR-AB>MR + decreased ER
- Inability to sleep on affected side
- x-ray
Signs and symptoms of rotator cuff tendinopathy-
- Shoulder weakness
- catching
- full ROM - no limited end feel
- Weakness and pain response on isometric resisted testing
What is tendinitis?
- Acute tendon overuse
- Often seen in young adults
What is tendinosis?
Overloaded tendon condition with a degenerative, non-inflammatory pathology
What is calcification?
Calcific deposits within tendon
When referencing shoulder instability classification what is TAUBS
Primary classification - dislocation
T-raumatic
U-nidirectional - anterior most common 98%
B-ankhart lesion - Bankhurt reconstruction
S-urgery
- positive apprehension test
When referencing shoulder instability what is AMBRI?
Secondary - Poor neuromuscular control A-traumatic M-ulti-directional B-ilateral R-ehabilitation I-Inferior capsular shift
Positive Sulcus test
What causes fall under the congenital classification of shoulder instability?
- Osseous/labral defect
- Soft tissue abnormality
S&S of Acromio-clavicular dislocation/subluxation
Common causes -
FOOSH
Contact sports
Fall onto point of shoulder
Signs and symptoms
- Step deformity
- Decreased HF/Elevation above 90 degrees
State the management strategies of AC joint dislocation
conservation- -POLICE -Mobilisation -Active exs Surgical -A/C joint stabilisation using coracohumeral ligament
What management strategies would you recommend post fracture?
Soft tissue massage, particularly to manage Edema and swelling
Ice therapy
Stretching exercises to regain joint range of movement
Joint manual therapy and mobilisations to assist in regaining joint mobility
Structured and progressive strengthening regime
Balance and control work and gait (walking) re-education where appropriate
Taping to support the injured area/help with swelling management
Return to sport preparatory work and advice where required
What are SLAP lesions?
SLAP lesion is mostly combined with a lesion of the proximal head of the biceps because it attaches on the superior part of the labrum glenoidalis. It is associated with pain and instability and an inability of the patient to perform overhead movements.
What are Bankart lesions?
A Bankart lesion is a lesion of the anterior part of the glenoid labrum of the shoulder. This injury is caused by repeated anterior shoulder subluxations. The dislocation of the shoulder joint (anterior) can damage the connective tissue ring around the glenoid labrum.
What is the background pathology of non-specific back pain?
