Musc case Flashcards
Objective and subjective assessment for Damon
Objective:
Static Observation:
-Sitting: symmetry of limbs, postural abnormalities, sitting balance.
-Standing: symmetry of limbs, postural abnormalities, standing balance.
Functional:
-Walking.
-Running.
-Jumping/hopping.
-Getting on/off the floor.
-Sit to stand.
-Impairment based assessment:
-PROM.
-AROM.
-Strength (MMT, hand held dynamometry).
-Coordination/ataxia tests (step test or heel-shin test).
-Special musculoskeletal tests: Mcconnells, MWM, Hip and lumbar quadrant tests, tibiofemoral/patellofemoral/tibiofibular glides, ligament stress tests, McMurrays.
Neuro (if indicated in subjective):
-Neurological testing.
-Neurodynamic testing.
-Tactile sensation.
-Proprioception.
Subjective:
Current history:
-Limping came about 12 months, with onset of increased activity (AFL, running)
-Pain started 6 months ago (sitting crossed legged, running, AFL, stairs - up and down, progressive)
-Pain comes on with 10 mins of activity (high irritability)
-Area; front of knee and lower ⅓ of thigh
-Wong-baker scale = 4
-Ankle✔️✔️, hip✔️✔️, back ✔️✔️
-Nil numbness, locking, p/ns
Aggravating factors;
-Walking >100m
-Unable to run without p
-Sitting cross legged
-AFL
-basketball
-Trampoline
-Stairs - step to pattern
Pain relief
-~ 1 rest
-Analgesia
Night
-Difficulty to getting asleep, but doesn’t wake
Social history
-Has to stop running with friends
-Stopped AFL,
-Discuss about his culture and how he interacts in his community/mob (Wurundjeri people)
Past/birth history
General health questions
Investigations
-Saw an Osteopath 8/12 (limb due to growing pains)
Yellow and red flags
Previous treatment
-Saw an osteopath 8 months who felt that Damon’s limp was due to ‘growing pains’
Musculoskeletal conditions potentially related to Damon
-Long bone fracture
-Growth plate fracture
-Stress fracture
-Osteogenesis imperfecta (brittle bone disease)
-Leg length discrepancy
-Osteomyelitis
-Knee valgus/varus
-Knee ligament tear/sprain (ACL, PCL, LCL, MCL)
-Meniscus tear
-PFPS
-Patellar tendinopathy
-Generalised joint hypermobility
-ITB syndrome
-Pre-patellar bursitis
-Fat pad impingement
-Osteochondrosis (osgood-schallaters, sinding-larsen johanassons)
-Osteochondritis dissecans
-Blount’s disease
-Juvenile idiopathic arthritis
-Compartment syndrome of quadriceps
-Non-accidental injury
-Appendicitis
-Growing pains
-Sickle cell disease
-CP
-Testicular torsion
-Lumbar radiculopathy
-Spondylolisthesis
-Spondyloarthropy
-Perthes disease
-Slipped capital femoral epiphysis (SCFE/SUFE)
-Hip dysplasia
-Transient synovitis
-Severs disease
-Kohler’s disease
-Freiberg’s disease
-Club foot
-Iselin’s
-Scoliosis/Scheuermann’s disease
-Stress fracture of pelvis
-Shingles
Key differential diagnoses: hip dysplasia
The head of femur is not fully articulated within the acetabulum, leading to increased risk of displacement. This can further cause abnormal alignment of the joint, resulting in hypertrophy of the capsule, neolimbus, and deteriorating the joint cartilage.
Aetiology:
●Unknown, however, more commonly seen in females, those with family history of the condition, breech babies and those with structural hip abnormalities.
S and Sx:
●Hip instability.
●Gait deviations.
●Hip Pain.
●Catching, locking.
●Reduced ROM (limited abduction).
●Dislocations.
Diagnosis
●Dependent on clinical findings (see signs and symptoms).
●May present with a Galeazzi sign.
●Ortolani and Barlow tests in neonates.
●Imaging: XRAY, US, MRI.
Key differential diagnoses: SUFE/SCFE
Epiphyseal head displaced. This occurs through reduced integrity of the perichondrial ring, allowing the epiphysis and metaphysis to gradually slip from each other.
Aetiology:
●Unknown but is commonly seen in adolescence.
●Those who are at greater risk are patients who are young, male, skeletally immature and obese.
S and Sx:
●Medial thigh and leg pain
●Referred knee pain
●Limited hip internal rotation
●Reduced physical activity
●Abnormal gait limp
●Stiffness
Dx:
●Subjective examination- history, pain, ADL, etc
●Physical- muscle length, strength, AROM, PROM, hip quadrant, internal/external rot, functional, etc.
●Ultrasound/MRI/XRAY
Perthes disease (definition and stages)
Definition:
-Legg-Calve Perthes disease is a condition in which the blood supply to the femoral head is disrupted caused by idiopathic osteonecrosis.
Signs and symptoms
- Pain with aggravating activities and relieved with rest
- Insidious of limp (adductor limp)
- Pain in lateral/anterior hip
- Referred pain from thigh, knee is common
- Decreased hip MMT +/- pain
- Decreased/painful ROMs (decreased IR and adduction)
Diagnosed with Xray and MRI
Initial stage (mean duration = 6 months):
-The capital epiphysis of the head of femur ceases growing, resulting in a smaller ossific nucleus.
-This causes the hip to become quite painful and inflamed due to lack of blood supply and bone necrosis.
The Fragmentation stage (mean duration = 8 months)
-In this stage, the body attempts to repair itself by absorbing the necrosed/dissolved bone in the hip, allowing new bone to grow.
-However, this is the stage in which the bone is at its most fragile and the acetabulum becomes more irregular. Therefore, there is a risk that the head of femur will collapse.
The Reossification stage (mean duration = 4 years (approximately)):
-Now that the dead bone has been absorbed, new bone starts to form. This process starts from the centre of the femur and fans out.
-Eventually the head of femur is replaced with woven bone which will then be remodelled with trabecular bone.
-The head of femur is shown to become less flat in this stage as the entire femoral head has reossified.
-Extra care should be taken during this stage to allow the new bone to form into a correct shape.
The Remodelling stage (lasts for 2 to 3 years post reossification)
-In this stage, the bone has fully regrown but continues to shape and develop until the skeletal development of the child is complete.
The Herring classification
-Prognostic tool to predict Perthes’ disease patient’s future outcomes.
-The Herring Classification categorises hip x-rays into three groups, depending on the height of the lateral pillar of the head of femur. -These x-rays are taken during the fragmentation stage and are classified as either A, B, C and B/C.
-The Herring Classification is effective in predicting the final outcome of the patient’s disease because of its high prognostic value, its validity to children under 8 and its commendable inter and intra reproducibility
A = excellent prognosis
B = fair prognosis
C = poor/uncertain prognosis
B/C = dependent on Stulburg classification but often uncertain
Stulberg classification
-The Stulberg classification describes the different patterns of deterioration of the head of femur in Legg-Calve Perthes disease. This classification uses these patterns to give a predicted prognosis.
-Stulberg classification categories x-rays into five groups
-X-rays that show a more spherical femoral head with an elongated neck of femur are associated with a better prognosis. However, x-rays with an aspherical or flat head of femur with an flat, irregularly-shaped acetabulum are associated with poorer prognosis’.
-Using this classification and Damon’s x-ray, the therapist can explain to Damon and his mother his likely prognosis
Classification instrument (CLIPer)
-The CLIPer is used to give more specific rehabilitation to a patient by classifying them into one of three stages; Mild Involvement, Moderate Involvement and Severe involvement.
-A patient is categorised into a stage based on their CLIPeR score that is deduced based on the patient’s pain, hip ROM, hip Strength, gait and balance (see Appendix2). These stages allow the patient to receive rehabilitation that is more tailored to their symptoms, ICF and disease prognosis.
-Moderate involvement stage = Damon
Discussing with Damon and his mother
-Using gentle language
-Build rapport and address how health-care can be scary and address any apprehensions
-Discuss treatment modalities (conservative and surgical)
-Discuss prognosis for Damon: male, aged 5-7, within normal weight limits and does not possess any general health comorbidities = positive prognosis
-Risk factors of Perthes
-Discuss ways to integrate cultural influences/interests into his treatment: working with social worker, discuss role models in their community who can assist in his management, suggest other interests he can do whilst non-weightbearing (UL strengthening)
Short term management of Damon
Decrease pain
-Hot pack with gentle hip stretching
-Cryotherapy
-NSAIDs and acetylsalicylic acid to improve blood supply to femoral head
Improve ROM
-static stretching with/without heat pack: IR< ER< abduction, flexors and extensors
-HEP: 30s, 4x/day per muscle group
-AAROM and dynamic ROM focusing on ER< IR< flexion, extension and abduction
-HEP: 24 repetitions with 5s holds, 1x/day, per muscle group
Improve strength:
-Damon starts with gentle isotonic (eccentric and concentric) exercises in gravity eliminated positions focusing on abduction, IR, ER, flexion and extension.
-Start in non-weightbearing and progress to weightbearing
-Side steps and step ups = progression
Improve gait functionality/efficiency:
-Can start once medically cleared for full weightbearing
-Focusing on improving gait speed, shorter step length on affected side and increasing hip extension in stance
-Focus on Trendelenburg
-reassess periodically
Improve balance:
-should start balancing with double-limb stance with narrowed BOS on stable and unstable surfaces
-Practise his balance 30s, 3x/day
-Make into a game format
CV training:
-Low load activities
-Swimming and/or cycling
Short term goals for Damon
Clinical goals: The following is intended to be achieved in 3 weeks.
● To reduce Damon’s pain to a 4/10 at rest.
● To regain 75% of Damon’s hip ROM and strength compared to unaffected side.
● For Damon to be able to climb stairs with a step-to pattern without any UL support.
● To improve his walking efficiency and to stop his limp.
SMART goal for Damon:
For Damon to be able stand/balance on affected leg so he can kick his AFL ball with his unaffected leg without any pain, trendelenburg or feeling of unsteadiness in 3 weeks time.
Damon’s discharge criteria
-Damon should not have any pain higher than a 1/10 VAS or 2 Wong-Baker scale.
-His ROM should match or be at 90% compared to his unaffected side.
-His strength should match or be at 90% compared to his unaffected side.
-His single-leg balance on the Paediatric Balance Scale should match or be at 90% compared to his unaffected side.
-He should be walking and climbing stairs without pain, any limping or kinematic deviations.
Long term management for Damon
Increase his walking endurance:
-Can increase distances once no kinematic deviations or limp is present
-Walking training on a treadmill
-Incorporate into HEP: walking around the block with friends every afternoon.
Improve his running:
-Commence training in clinic over short distance to analyse any deviations and monitor for pain.
-Keep activity within limits of pain and correct an deviations
-Once safe to, can incorporate into HEP
Muscle strength, power and endurance:
-Ensure medical clearance
-Can commence resistance training with weights, squats, wall sits, leg press, lunges
-Incorporate into HEP
Core stability
-Strong core = lower risk of reinjury
-Athletes shown that have deficiencies in hip abduction and external rotation (which Damon is currently exhibiting and is very common in perthes) are shown to have an increased risk in back and lower extremity injuries.
-Improving Damon’s core stability will help prevent any lower limb injuries as well as help him with his return to sport.
Balancing:
-If medically cleared, commence single leg balance exercises.
-Can be done on flat and unstable surfaces which will further challenge Damon’s proprioception. Improving Damon’s proprioception will decrease his risk of injury whilst also giving him the skill of ‘self-correcting.
Return to sport:
-Damon needs to be able to perform dynamic activities and AFL skills in practice before combining them in a game setting.
-Damon should commence plyometric exercises such as side-to-side ankle hops, lateral jumping and standing long jump.
-Damon should also be completing ball skills (e.g. passing) to improve his coordination.
Long term goals for Damon
The following is intended to be achieved over the course of a year.
-For Damon to have minimal to no pain (max. 2 Wong-Baker scale) at rest and with activity.
-For Damon to be able to walk, run, climb stairs and perform his other ADL’s efficiently with no kinematic deviations or pain.
-For Damon to get back to lunchtime play and PE classes without any pain or limitations
SMART: for Damon to be able to play AFL in the next season without any pain, limping or kinematic deviations.
People involved in Damon’s management
-GP
-Social worker
-Indigenous liaison officer
-Family
-School/staff
-Coach
-OT
-Surgeon/specialist
