OCS Flashcards
1
Q
Risk factors for knee articular cartilage lesion
A
following ACL injury, increased age, medial meniscus tear increases odds of having chondral lesion.
2 factors for severity of chondral lesions:
increased age
longer time since initial ACL injury
increased # chondral lesions is associated with increased time since initial ACL injury
2
Q
Patient outcome for knee articular cartilage lesion
A
B level: IKDC 2000, KOOS (MCID 7.4-12.1 or about 10 for cartilage injuries only)
3
Q
Timeline for knee injury
A
meniscus- delayed 6-24 hrs.
ACL- 0-2 hours
PCL/MCL: 0-12
Osteochondral fracture 0-2 hours (rule out ACL and ligaments first)
order of suspect within first 2 hours: ACL > PCL/MCL >osteochondral fracture> meniscus
4
Q
Articular cartilage lesion surgeries
A
- arthroscopic lavage and debridement
- microfracture (aka best in young patients who have small lesions that want to return to low load activities)
- autologous chondrocyte implantation (ACI) (return to activities rates is good even with high level demands, but timeline for return to activity is much longer and much higher failure rate compared to OAT/OCT )
- osteochondral autograft transplantation (OAT) or OCT (osteochondral transplant) athletes who want to return to high demand activities
higher rate of self reported knee function, return to sports, and maintenance of level of activity compared to the other surgery options
5
Q
risk factors for cartilage lesion failing
A
female sex
older age
higher BMI
longer symptom duration
previous surgeries and procedure
lower self reported knee function
6
Q
cartilage lesion post op eval+ treat
A
PT post op evaluation and treatment
early rehab (similar to post op meniscus lesion management)
30 sec chair stand test
stair climb test
TUG
6 min walk test
- return to sports
single leg hop test
- physical impairment measures
modified stroke test for effusion
knee AROM
quad strength testing
joint line tenderness
7
Q
cartilage lesion treatment
A
B level: progression AROM and PROM
B level: accelerated progressive weight bearing (research mostly done with ACI procedures) in 6-8 weeks after surgery
E level: delay to return to sports depending on type of surgery.
B level: therex, focusing on ROM, neuromuscular, and hip/knee strength muscles to patients with knee meniscus tear and knee articular cartilage lesions (non op) and after meniscus or articular cartilage surgery.
8
Q
Ottawa knee rules for imaging
A
Age 55 years or older
Isolated tenderness of the patella (no other bone tenderness in the knee)
Tenderness at the head of the fibula
Inability to flex the knee to 90 degrees
Inability to bear weight for four steps immediately after the injury
9
Q
kellgren-lawrence classification system
A
0- no OA with definite absence of x-ray changes of OA
1- doubtful OA with doubt joint space narrowing and possible small osteophytes
2 (first signs of actual OA)- minimal OA with definite osteophyte and possible joint space narrowing
3- moderate OA, with moderate multiple osteophytes, definite joint space narrowing, and some sclerosis and possible deformity of the bone ends
4- severe OA, large osteophytes, marked narrow of joint space, severe sclerosis, and definite deformity of bone ends
10
Q
tibiofemoral OA,
A
criteria: pain in the knee and any three of the following
1.) age >50
2.) <30 min of morning stiffness
3.) crepitus on active motion
4.) bony tenderness
5.) boney enlargement
6.) no palpable warmth of synovium
11
Q
knee OA treatment
A
moderate support for bracing for valgus unloading braces that offloads medial compartment for medial knee OA
lateral heel wedge- strong recommendation AGAINST
high tibial osteotomy- limited recommendation in those with medial OA. the surgeon will go in to fracture one side of the superior portion of tibia and then do an ORIF to reshape the tibial plateau to change the joint space shape. uni TKA is better than this option, but osteotomy is better for patients who are more active
12
Q
conservative treatment for general knee OA
A
any form of exercise yields good results- doesn’t matter water, resistated, hip involvement or not, supervised or not.
neuromuscular training only has a moderate level of recommendation.
study: traditional exercise + neuromuscular training was not superior to traditional exercise alone.
manual: recommendation ranges from limited to recommended against. manual effects don’t last at a 1 year follow up (not long term solution), but has short term benefits during treatment course
massage: recommendation ranges from limited to recommended against. improvement at 8 weeks, but did not maintain improvement for the rest of the year
13
Q
modalities for knee OA
A
high level laser therapy - significant improvement compared to placebo or no treatment
no difference between high level and low level
TENS: recommendation ranges from limited to recommended against
extracorporeal shock therapy: limited recommendation
dry needling: no recommendation
NSAIDs are best
14
Q
medical procedures for knee OA
A
hyaluronic injections (viscosupplementation): recommended AGAINST
corticosteroid: effective for up to 3 months, short term relief
PRP injections: single or series of 2 have inconsistent results. limited recommendation by AAOS, strongly against by ACR
15
Q
Risk factors for medial meniscus tears only
A
female sex, older age, BMI, lower physical activities, delayed ACL reconstruction
16
Q
Risk factor for both medial and lateral meniscus tears
A
cutting and pivoting are risk factors for acute tears
increased age and delayed ACL reconstructions
17
Q
meniscus pathology composite score greater than 3+ findings (90% specific)
A
clinical prediction rule with 5 parts
history of catching and locking
pain with forced hyperextension
pain with max knee flexion
joint line tenderness
pain or audible click with mcmurry’s
18
Q
meniscus surgery recommendations
A
meniscus injury leads to lower function years after knee injury whether or not they decide to get an partial meniscectomy
nonoperative management have similar to better outcome in terms of strength and perceived knee function in short and intermediate term compared to those who had arthroscopic meniscectomy - this is especially true for degenerative tears
Study show strong recommendation against arthroscopic knee surgery compared to conservative treatment when dealing with degenerative meniscus tears
with or without imagine evidence of osteoarthritis
mechanical symptoms
sudden symptom onset
young patients do better with meniscus REPAIR compared to partial meniscectomy, typically <30 y.o
return to sports
<30 y.o or competitive/elite athletes can return to sports less than 2 months after partial meniscectomy
>30 y.o return by 3 months after partial meniscectomy
19
Q
knee effusion test scale
A
0 = no wave with down stroke.
trace = if there’s small wave
1+ = milk out swelling, doesn’t refill on its own, but returns with lateral sweeps. large bulge with downstroke
2+ = milk out, returns on its own. returns spontaneously without downstroke
3+ = can’t milk out. upstroke cannot move effusion out of medial knee
20
Q
meniscus interventions
A
Interventions
non op management
B level: supervised progressive knee ROM exercises, progressive strength of knee and hip muscles, neuromuscular training. applies to post op as well
Post op management
B level: early progressive AROM and PROM after arthroscopic knee surgery
B level: in clinic program in addition to HEP compared to HEP only. vertical jump and hop test favor in clinic rehab
B level: neuromuscular e-stim for quad strength, functional performance, knee function symptoms
C level for meniscus repair: early progressive WB, early progressive return to activity
21
Q
Paget Schroetter Syndrome
A
venous thoracic outlet
aka thrombosis
axillosubclavian vein thrombosis at costcoclavicular junction
“blue, swollen, heavy, painful”
“heaviness, swelling, reddish-blue”
80% related to vigorous exercise
symptoms within 24 hrs
22
Q
Parsonage Turner Syndrome
A
brachial plexopathy related to illness/vaccinations
>50 y.o
23
Q
T4 syndome
A
a clinical entity characterized by symptoms in the upper extremities, including pain, numbness, tingling, and weakness. It is believed to be caused by irritation or compression of the nerves and spinal cord at the level of the fourth thoracic vertebra (T4)
bilateral
24
Q
Reiter’s syndrome
A
reactive arthritis that develops after infection of another part of the body
“can’t see, can’t pee, arthritis”
HLA-B27
25
NDI MCID
14-16
26
Neck movement for classifications (eg. CCFT)
neck pain w/ mobility deficits- CRLF (cervical rotation lateral flexion), 1st rib mobility/CT junction
Neck pain w/ coordination: whiplash/trauma. CCFT (craniocervical flexion test)
neck pain w/ headache- cervicogenic CFRT (cerfical flexion rotation test). Ram's horn symptom pattern
Neck pain w/ radic pain- cervical rotation <60 deg. valsalva test
27
odontoid process fracture
Type I:
This fracture occurs at the very top of the odontoid process, where the alar ligaments attach, and is usually considered stable.
Type II:
This is the most common type of odontoid fracture and is considered unstable due to its location at the base of the dens, often requiring surgical intervention.
Type III:
This fracture extends into the body of the C2 vertebra and can be stable or unstable depending on the displacement of the fracture fragments.
28
Canadian c-spine rules for imaging
Age ≥65 years, extremity paresthesias, or dangerous mechanism
Fall from ≥3 ft (0.9 m) / 5 stairs
axial load injury
high speed MVC/rollover/ejection,
bicycle collision,
motorized recreational vehicle
29
most common ankle sprain ligaments
Anterior talofibular and calcaneofibular ankles
30
os trigonum
Os trigonum is a small, accessory bone located behind the ankle joint (talus). It is typically triangular in shape
Os trigonum is present in about 10-15% of the population. It is more common in women and athletes who participate in activities that involve repetitive plantar flexion (pointing the toes down
31
chronic ankle sprain developement
not associated with how many ligaments are torn
abnormal timing of muscle activation
decreased force output or strength
impaired proprio
decreased ankle DF
increased subtalar and midfoot motion
impaired spinal level sensorimotor control and reflex inhibition and supraspinal corticomotor abnormalities (CNS)
deficits at knee and hip as well
32
risk factors for acute ankle sprain
female sex, weakness of hip abduction and extension, poor performance on balance and hop test, participation in court sport
33
risk factor of chornic ankle sprain
not using prophylactic bracing, not participating in exercise balance program, poor functional performance after acute sprain, participation in sports in general, higher BMI
34
clinical course of post acute ankle sprain
up to 12 months
B level recommendation in IE that will help determine and influence clinical course and recovery time: age, BMI, pain coping strat, report of instability, history of sprain, ability to WB, pain with WB, DF ROM, medial joint line tenderness, balance, ability to jump and land once safe
35
clinical course for chronic instability after ankle sprain
these are NON copers because they still have instability- 40% will become noncopers
C level recommendation in IE to determine clinical course and recovery time: previous treatment, # of sprains, pain level, self report of function, assessment of sensorimotor systems during dynamic control and functional control (eg balance/prop testing, y-balance, star balance, etc etc)
36
ankle sprain "copers"
Copers: return to full function and return to activity within a year
37
diagnosis of acute lateral ankle sprain
B level:
history of sudden onset of ankle inversion injury, negative ottawa ankle rules, + reverse anterolateral drawer test (10-15 deg PF and IR, posterior drive of tibia/fibula. one hand palpates movement of talus), + anterolateral talar palpation test, + anterior drawer test (poor sensitivity and perfect specificity)
38
diagnosis of chronic lateral ankle sprain (instability?)
B level:
history of at least 1 significant ankle sprain, reports of giving away or instability, episode of subsequent ankle sprain, perception of ankle instability, decreased performance on functional performance test
scores on the following discriminant instruments: >11 FAID (functional ankle instability scale), <25 cumberland ankle instability tool score, >4 yes on AII (ankle instability instrument)
functional performance measures used: side hop, timed hop, multiple hop, foot lift test, star excursion (medial, posterior medial, and anterior medial directions)
39
ottawa ankle rules
any of the follow will warrant referral for radiograph
inability to bear weight and take 4 steps immediately after injury OR in ER
tenderness to palpation along posterior edge or tip of the medial or lateral malleolus
tenderness to pal of navicular and at the base of 5th metatarsal
40
syndesmotic (high) vs lateral
high ankle: commonly happen with hyper DF and ER of the foot , spreading the mortus apart. planted foot and leg is IR and forced forward. 1cm higher at distal tibiofibular joint
squeeze test, reproduce pain
41
outcome measure for ankle sprain
A level recommendation: foot and ankle ability measure (FAAM, ability measure, high = better. MCID is 8%), LEFS (function scale, high = good function. MCID 9 points), PROMISE aka PF scale (high = better function), pain interface scale. use with both acute and chronic.
C level recommendation: psychological status for fear avoidance, anxiety and fear for reinjury, kinesiophobia. acute and post acute, use pain efficacy questionnaires. Tampa scale for kinesiophobia (TKS 11) or FABQ. Hgh score = worse fear of movement
42
preventing first time ankle sprain
use taping, prophylactic bracing. especially with those engaging in high risk activity and intrinsic factors (female, poor hip abd and extension strength, poor balance and hop testing)
C level recommendation: prophylactic balance training
43
prevent secondary ankle sprain
A level: use of prophylactic bracing and taping, proprioceptive and balance program directed at specific impairments to prevent further injury
orthotics and footwear modifications are not helpful at preventing second ankle sprain
44
A level acute/subacute phase for ankle sprain
A level: early progressive weight bearing, use external support, even AD.
A level: more severe injury, immobilization may be indicated for up to 10 days.
A level therex: neuromuscular training, balance training, postural re-education to improve talocrural stability and return to preinjury level. protected AROM, stretching
A level: manual therapy in acute period to improve DF, decrease pain. in addition to exercise. MLD, joint and soft tissue mobe, AROM, anterior to posterior talo mobilization within pain free range, therex to reduce swelling.
A level: should NOT use ultrasound
45
B level acute/subacute ankle sprain
B level: use a return to work, sport schedule- use a brace early in rehab, work hardening, sports related training, occupational training program to mitigate activity limitation and participation restriction.
3 timelines
distortion injury (mild, grade I sprain): return to sedentary work and activities by 2 weeks, mostly sitting, no more than 10kg of lifting, limiting standing/walking on uneven surface. full return 3-4 week range
partial/total rupture: sedentary work and activity to 3-6 weeks, sitting and no more than 10kg and lifting and avoiding walking/standing on uneven surfaces. full return to work and sport 6-8 weeks.
surgery: 2 weeks of nonWB, 3-6 weeks WBAT resuming sedentary work in boot/cast, 6 weeks can go into brace, 12-16 weeks projected return to physically demanding jobs and sports.
46
C level acute/subacute ankle sprain
C level: ice only in association with exercise program. RICE itself is not enough to decrease swelling and improve function
C level: low level laser therapy to decrease pain during initial phase of acute sprain
C level: diathermy
C level: NSAIDs to reduce pain and swelling in acute, only in the first 14 days
47
D level acute/subacute ankle sprain
D level (neither recommend nor not recommend): e-stim
D level: acupuncture
48
chronic ankle instability treatment
A level: proprio, neuro therex, improve dynamic postural stability and perceived stability
A level: manual therapy, graded joint mobe, WB and non WB mobilization with movement to improve WB DF and dynamic balance
B level: bracing, taping, insoles. must be in addition with exercise program
B level: combined treatment of therex + balance training guided by pt value and goals, clinical judgment- combination of everything from vestibular and dry needling and exercise. pt value is the most important component here and individualization approach
C level: dry needling of fibularis muscle group in addition to proprioception program
49
risk factors of planter fascitis
limitated DF
high BMI
running
work related WB activities with poor shock absorption
50
FP1-6
0 to 5 = Normal · 6 to 9 = Pronated · 10+ = Highly pronated · -1 to -4 = Supinated · -5 to -12 = Highly
51
- tarsal tunnel test (must to be done to rule out)
DF eversion test, max DF and everts while toes are extended, hold 5-10sec while tapping over tarsal tunnel. + with heel pain, numbness, tenderness to tarsal tunnel
must be used to rule out tarsal tunnel syndrome vs plantar fascitis
52
outcome measure for plantar fascitis
A level: FAAM (>high = high function), FAHSQ, FFI (high = higher disability), LEFS (higher= higher function. MCID is 9)
53
A level recommendation for plantar fascitis treatment
A level
manual therapy in combination with exercise
stretching- PF, soleus and gastroc, provide 1 week-4 month pain relief. heel pad can be used to maintain the benefit of stretching. 2-3x a day sustained or intermittent holds
taping- anti pronation taping up to 3 weeks for pain reduction and improve function. PF and gastroc for 1 week for pain reduction
foot orthosis, custom or prefabricated. support medial long arch and cushion heel. can be used short and long term
night splints 1-3 months, should be only prescribed for patients who have pain first thing in the morning
avoid corticosteroid injection
54
C level treatment for plantar F
low level laser
phonophoresis
AGAINST ultrasound use
rocker bottom shoe with orthosis and shoe rotation for those who stand for long periods
55
D, E, F level for PF treatment
D level
iontophoresis
electrotherapy
E level (theoretical or foundation support)
education and counseling for weight loss
F level (expert opinion)
therex and neuro re-ed to control pronation and attenuation of forces during weightbearing
eg. short arch, hip ER and abd, balance, etc
heavy slow resistance training
dry needling cannot be recommended
56
Beiring-Sorenson
measuring how many seconds the subject is able to keep the unsupported upper body (from the upper border of the iliac crest) horizontal, while placed prone with the buttocks and legs fixed to the couch by three wide canvas straps and the arms folded across the chest.”
In subjects with low back pain, the mean endurance time ranges from 39.55 to 54.5 seconds in mixed-gender groups (compared with 80 to 194 seconds for men and 146 to 227 seconds for women without pain)
57
Which muscles are responsible for lateral movement of the mandible
Medial and lateral pterygoids
58
Nexus low-risk criteria for neck imaging
Cervical-spine radiography is indicated for patients with trauma unless they meet all of the following criteria
No posterior midline cervical-spine tenderness
No evidence of intoxication
A normal level of alertness
No focal neurologic deficit, and
No painful distracting injuries
59
Klumpke's palsy
Lower brachial plexus, usually the eighth cervical and first thoracic nerves are inured before or
after they have jointed to form the lower trunk. Patients will have a "claw hand" where the forearm
is supinated and the wrist and fingers are flexed, along with C8/T1 dermatome/myotome
impairments
60
Laslett Cluster for SIG pathology
Distraction test: The patient lies supine with the legs extended. You are going to stand on the symptomatic side and place your hands on the patient’s anterior superior iliac spines. Then apply 3-6 moderate velocity thrusts and gradually increase pressure in a dorsolateral direction.
Thigh Thrust test: Your patient lies supine and you are going to stand on the asymptomatic side. Flex the leg on the symptomatic side to 90° of hip flexion. Place one hand over the sacrum and then apply longitudinal pressure through the patient’s femur creating a shear force in the SI joint. Apply 3-6 higher velocity thrusts with gradually increasing pressure
Compression test: Ask your patient to lie on the asymptomatic side with the hips flexed to 45° and knees bent to 90°. You are going to position yourself behind the patient and place your hands on the anterior rim of the ilium. They apply 3-6 vertical thrusts with moderate velocity and gradually increasing pressure.
Sacral thrust test: For the sacral thrust test, your patient is going to lie in prone position. You are going to stand next to the bench and place the palm of your hand over spinal level S2. The direction of pressure is going to be vertically downwards. Apply 3-6 higher velocity thrusts and gradually increase pressure.
Overall, the rule of thumb is 2/4 positive tests are needed to diagnose a symptomatic SI joint. If the first two tests are positive, the SI joint is likely the source of pain, and no further testing is needed.
If you fail to provoke pain during the first two tests, continue with the third test. If this test is positive and you now have 2 positive tests, the SI joint is likely the source of pain.
gaenslen test is most useless
61
Meralgia Paresthetica
Meralgia paresthetica is a condition that causes burning, tingling, or numbness in the outer thigh. It results from compression of the lateral femoral cutaneous nerve, which supplies sensation to this area
palpate just medial to ASIS
62
Well's DVT criteria
Active cancer (patient either receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment) 1
Paralysis, paresis, or recent cast immobilization of the lower extremities 1
Recently bedridden for ≥ 3 days, or major surgery within the previous 12 weeks requiring general or regional anesthesia 1
Localized tenderness along the distribution of the deep venous system 1
Entire leg swelling 1
Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tibial tuberosity) 1
Pitting edema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented deep vein thrombosis 1
Alternative diagnosis at least as likely as deep vein thrombosis
-2- to 0= low. 1-2 moderate. 3-8 high
63
RTC tear diameter scale
A small tear will be <1cm, medium 1-3 cm, large 3-5 cm, and
massive >5 cm in it's greatest diameter
64
P value
P-Values: Probability differences are due to chance
Example: P-value of 0.09 means a 9% chance differences are due to chance
65
alpha level
Alpha level - determines the level of statistical significance (commonly 0.05, so my p-value must be less than 0.05 to be significant)
Alpha level at 0.03 and p-value of 0.04 means the info is not statistically significant (p-value must be lower than the alpha level)
66
2 types of errors
type I: "False positive" - You wrongly conclude there is a significant effect when there isn't
type II: "False negative" - You fail to identify a significant effect when it actually exists
67
effect size
Large: 0.8 and up
Moderate: 0.5 to 0.7999
Small: 0.2 to 0.4999
Trivial: Less than 0.2
A large effect size means that a research finding has practical significance, while a small effect size indicates limited practical applications.
68
Cohen's kappa scale
(0 to 1) – most common measure of test reliability
No better than chance: 0
Poor: Less than 0.4
Fair: 0.4 to 0.6
Good: 0.6 to 0.75
Excellent: Greater than 0.75
Perfect: 1
69
Positive Likelihood Ratios
a statistical measurement that compares the probability of a positive test result in people with a disease to the probability of a positive test result in people without the disease
Large shift: Greater than 10
Moderate shift: 5 to 10
Small shift: Less than 5
No change: 1
70
Negative Likelihood Ratios
a statistical measurement that compares the likelihood of a negative test result in people with a disease to the likelihood in people without the disease
Large shift away: Less than 0.1
Moderate shift away: 0.1 to 0.2
Small shift away: Larger than 0.2
71
Nocebo Effect
Opposite to placebo effect where they think they’re getting the real treatment and the side-effects that come with it (nausea, dizziness, etc.)
72
Hawthorne Effect
Definition: Subjects try harder when observed
73
John Henry Effect
Definition: Control group works harder when feeling disadvantaged
Prevention: Blinding subjects to their group
74
Pygmalion Effect
Definition: Authority's expectations influence subjects' outcomes
AKA Rosenthal effect: told teacher which randomly selected kids had the highest IQ and at the end of the study, they did
Impact on research outcomes (e.g., surgeon and physical therapist biases)
Prevention: Blinding clinicians administering treatment and assessments
75
radial nerve
C5-T1
Course: radial groove in humerus
Motor: triceps, brachioradialis, wrist extensors
Sensory: posterior arm and forearm, below fingertips of the medial three and ½ fingers
Injury:
fracture of body of humerus
Saturday night palsy: compression of nerve in the axilla
Improper use of crutches
Wrist drop
76
Ulnar nerve
Nerve roots: C8, T1
Course: posterior to medial epicondyle, superficial to flexor retinaculum
Motor:
Forearm
Medial flexors of wrist
Hand
Hypothenar eminence
Medial lumbrical muscles
All interossceos muscles of the hand
Sensory: dorsal and palmar aspect of hand for medial 1 ½ fingers, medial forearm
Injury:
medial epicondyle fracture, fracture of hook of hamate.
Results in:
Inability to abduct or adduct fingers
Hypothenar atrophy
Ulnar claw hand
Loss of medial lumbricals
Patient tries to open hand, cannot extend 4th and 5th digits
77
Median
Nerve roots: C6, C7, C8, T1
Course: anterior to the elbow. Supplies and passes 2 heads of pronator teres
Motor: lateral flexor of wrist. Hand- 2 lateral lumbricals, thenar eminence via the recurrent branch
Sensory: lateral three and one-half fingers. Palmer surface. Superior dorsal aspect (finger tips)
Injury:
carpal tunnel
Tendonitis of flexor retinaculum. Numbness, tingling/sensory loss, atrophy of thenar eminence (recurrent branch)
supracondylar fracture of humerus, lunate dislocation
Thenal atrophy, loss of thumb opposition
Distal media n claw hand: loss of two lateral lumbricals. Patient asked to open (2 and 3 stay flexed)
Proximal median claw hand: loss of 2 lateral lumbricals. Loss of muscles of thumb opposition. Lateral lumbricals stay extended as well as thumb (scissors and thumb up)
78
Musculocutaneous nerve
Nerve roots: C5, C6, C7
Course: anterior arm and exits lateral in forearm
Motor: anterior flexor compartment of arm
Sensory: arm and lateral forearm
Injury: cannot flex elbow
79
Axillary nerve
Nerve roots: C5, C6
Course: posterior to the surgical neck of humerus
Motor: deltoid and teres minor
Sensory: shoulder
Injury: common is surgical neck fracture (loss of abduction from 15-90 deg)
80
Carpal Tunnel Syndrome (Median Nerve Entrapment)
Location: Compression of the median nerve at the wrist within the carpal tunnel.
Symptoms:
Numbness, tingling, or pain in the thumb, index, middle, and half of the ring finger.
Weakness in thumb opposition and abduction.
Worsening symptoms at night.
Differential from C6-C7 Radiculopathy:
C6-C7 radiculopathy may cause similar sensory changes but typically involves forearm pain and weakness in elbow extension or wrist extension.
Special Tests:
Phalen’s Test: Wrist flexion reproducing symptoms.
Tinel’s Sign: Tapping over the carpal tunnel elicits tingling.
81
Cubital Tunnel Syndrome (Ulnar Nerve Entrapment):
Location: Compression of the ulnar nerve at the elbow.
Symptoms:
Numbness and tingling in the ring and little finger.
Weakness in grip strength and difficulty with finger abduction/adduction.
Clawing of the fourth and fifth fingers in severe cases.
Differential from C8-T1 Radiculopathy:
C8-T1 radiculopathy would include more diffuse hand weakness and possibly forearm pain.
Special Tests:
Tinel’s Sign at the elbow.
Elbow Flexion Test: Holding elbow in flexion reproduces symptoms.
82
Pronator Teres Syndrome (Median Nerve Entrapment):
Location: Compression of the median nerve at the pronator teres muscle in the forearm.
Symptoms:
Pain and tenderness in the proximal forearm.
Numbness in the palm and first three fingers (unlike carpal tunnel syndrome which spares the palm).
Weakness in forearm pronation and wrist flexion.
Differential from C6-C7 Radiculopathy:
C6-C7 would include weakness in elbow flexion or wrist extension.
Special Tests:
Resisted Pronation Test: Reproduces pain and tingling.
83
Radial Tunnel Syndrome (Radial Nerve Entrapment):
Location: Compression of the radial nerve near the supinator muscle.
Symptoms:
Pain in the lateral elbow and forearm (similar to tennis elbow).
Tenderness over the radial tunnel.
No significant muscle weakness (unlike posterior interosseous nerve syndrome).
Differential from C5-C6 Radiculopathy:
C5-C6 radiculopathy would cause more diffuse weakness in shoulder abduction or elbow flexion.
Special Tests:
Middle Finger Test: Pain with resisted middle finger extension.
84
Posterior Interosseous Nerve Syndrome (Radial Nerve Entrapment):
Location: Compression of the posterior interosseous nerve (a branch of the radial nerve) at the supinator muscle.
Symptoms:
Weakness in finger extension and wrist extension (wrist drop).
No sensory loss (only motor involvement).
Differential from C7 Radiculopathy:
C7 would include triceps weakness and sensory changes in the middle finger.
Special Tests:
Resisted Supination Test: Pain and weakness with supination.
85
Thoracic Outlet Syndrome (Brachial Plexus Compression):
Location: Compression of the brachial plexus or subclavian vessels at the thoracic outlet.
Symptoms:
Diffuse arm pain, tingling, numbness, and weakness.
Can affect any or all parts of the arm and hand.
Symptoms worsen with overhead activities.
Differential from Cervical Radiculopathy:
More diffuse and inconsistent sensory and motor findings compared to specific dermatomal or myotomal patterns.
Special Tests:
Adson’s Test, Roos Test, and Wright’s Test for vascular and neurological symptoms.
86
Suprascapular Nerve Entrapment:
Location: Compression of the suprascapular nerve at the suprascapular notch or spinoglenoid notch.
Symptoms:
Shoulder pain and weakness in external rotation and abduction.
Muscle atrophy in the supraspinatus and infraspinatus.
Differential from C5-C6 Radiculopathy:
C5-C6 would also include weakness in elbow flexion or wrist extension.
Special Tests:
Suprascapular Notch Tenderness and Weak External Rotation Test.
87
OA
pain and stiffness in the morning <30 minutes, improved with movement
pain with activities in weight bearing, aggravated with activities
crepitus and joint effusion that's “cool”, not “boggy”
bone spur are most common findings on radiographs, subcondryal cytes, joint narrowing are common too
OA in hands- most common in first CMC joint, DIP and PIP, but spares MCP joints
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RA
20-50 y.o onset, women 2-3x more often than men
RA most common affect small joints (can be all joints), frequently affecting PIP, MCP of hands, DIP are typically spared
wrist, shoulders, elbows, knees, cervical spine (AA joint), ankles. rest of the spine is often spared
AA joint
RA with associated with upper cervical spine instability
watch for cervical myelopathy
morning stiffness >1 hour - several hours or after many prolonged time of being sedentary
early on in the disease- complaints may be isolated to one joint, but will always progress to >5 joints
progression is often to symmetrical presentation
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RA flare up
low grade fever 99-100F
synovitis of affected joints with swelling and heat
palpation will reveal spongy or doughy, unlike bony enlargement with OA
90
systemic symptoms of RA
fatigue, malaise, and depression
weight loss
subcutaneous nodules in 20-30% of cases on extensor surfaces of arms and elbows
cardiac problems include pericarditis and myocarditis
atherosclerosis is common of cardiac manifestation of RA, it's the leading cause of death
pulmonary, pulmonary fibrosis
dry eyes
10-15% also have sjogren's syndrome- autoimmune disorder of exocrine glands that lead to decreased tear and saliva production
felty syndrome- leukopenia and splenomegaly that lead to recurrent infections
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ankylosing spondylitis
chronic inflammation disease that affect axial spine
teens-20s when first diagnosed
2x more in men
most common first symptom is complaints of symptoms that mimic insertional achilles tendonitis or plantar fasciitis
affects thoracic spine most common, but can be lumbar, cervical, and SI joint
SI is usually symmetrical
less common, but can progress to extremity joints- can be asymmetrical- if arthritis occurs in peripheral joints early in the joint progression the prognosis is poor
AS can cause UVeitis, cardiac arrhythmias, aortitis
AS and human leukocyte antigen B27 gene (HLA B 27)
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S&S of Ankylosing S
inflammatory pattern, worse at rest and improves with activities
will wake up secondary half of the night due to back pain
morning stiffness >30 min and improve with movement
symptoms start at thoracic and progress at cervical and lumbar
vertebra slowly fuse together
can affect ribs at thoracic spine and sternum, so chest excursion is limited. when taking a deep breath, chest excursion (measured at 4th intercostal space) should be at least 5 cm. <2.5 cm is highly specific for AS
decreased lumbar lordosis and increased excessive thoracic kyphosis
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PT treatment of Ankylosing S
PT focused on maintaining mobility, especially thoracic extension
as disease progresses, PT focus on max ADLs and function rather than extension or ROM
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diagnostic criteria of Ankylosing S
back pain >3 months
<45 y.o
HLA B 27 positive
one feature of spondyloarthropathy, such as inflammatory back pain, enthesitis (insertional heel pain/plantar fasciitis pain), family history
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2 clinical prediction rules of Anky S
1.) 4 criteria
morning stiffness >30 min
improved with back pain with exercise, but not with rest
wakening during second half of the night
alternating buttock pain
2.) 5 criteria (⅘ rules met)
age of onset <45 y.o
insidious onset
improvement with exercises
no improvement at rest
pain at night, improvement when getting up
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Psoriatic arthritis
autoimmune disease associated with skin disease psoriasis
HLA B27 is in 60% of people with PA
distal joint disease, DIP, PIP
asymmetric oligoarthritis affecting several peripheral joints affecting many joints in a asymmetric pattern
polyarthritis- affecting many joints in an asymmetrical pattern 50%
radiographs
pencil in cup deformity where the eroded and collapsing IP joint looks like a pencil going into a cup
telescoping recession of the fingers called telescoping fingers or opera glass hands
SI joint- asymmetric (AS is symmetrical)
nail lesions
swelling of fingers and toes
tenosynovitis
enthesitis (heel and plantar fascia pain)
iritis - inflammation of the iris can lead to vision loss
urethritis- inflammation of the urethra causing painful urination
cardiac arrhythmias
GI problems, including inflammatory bowel disease
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reactive arthritis aka riter's syndrome
inflammatory arthritis following a bacteria infection, most often GI or urigenital- usually from tainted food like salmonella or STI
inflammatory reaction happens 2-4 weeks after infection that can affect 1 or a few joints
asymmetric, most common is knees, ankles, and feet- occasionally fingers and wrists. usually does not involve thoracic or rib stiffness, doesn't involve psoriasis or nail lesions like PA
Riter's syndrome- a triad of arthritis, conjunctivitis, and urethritis
“Can't see, can't pee, sore knee”
Often + for HLA B27
often have enthesitis pain (heel pain, PF pain)
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ACL injury + return to sports
70% are non-contact, usually with accelerating or decelerating motions with excessive quad contraction and reduced hamstring co-contraction at or near full extension combined with
knee IR
or valgus load with knee IR
or valgus load during WB acceleration
study: athletes who returned to sport under 9 months since surgery were 7x more likely to re-injure. no correlation between symmetrical muscle function or quad strength in secondary ACL injury
reasonable timeline to return to sport >9 months
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ACL prevention programs
ACL preventions programs need the following:
more than 1 exercise component
more proximal control exercises, trunk or core strength exercises
plyometric and strengthening components
balance exercises are NOT necessary
dosage
longer 20 min, multiple times per week
in season or preseason + in season are effective. just off pre-season is not enough
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ACL copers
East et al identified a screening to identify copers. the following is a list of criteria someone must meet before even going through the screening:
injury has to be isolated ACL tear without comorbid injury
full painfree ROM, no joint effusion
MVIC (max voluntary isometric contraction) of quad on involved side need to be >75% strong compared to uninvolved side
The Screening for identifying Copers
1.) report no more than 1 episode of the knee giving way
2.) >80% symmetry in timed 6 meter hop test
3.) >80% knee outcome surgery of ADL
4.) >60% on global rating of knee function
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WOMAC MCID
12-22%. disability measure, lower = better
102
risk factor for hip OA
age
history of developmental disorders, such as hip dysplasia, previous hip joint injury,reduced hip ROM (especially IR), osteophytes, higher bone mass, higher BMI
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hip OA diagnostic critera
>50 y.o
anterior or lateral hip pain during WB
morning stiffness <1 hour
hip IR <24 deg or hip IR and flexion 15 deg less than nonpainful sign. or hip pain provoked with passive hip IR
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outcome measures for hip OA
WOMAC is best as a measure of disability, high = worse. MCID is 12-22%, decrease % = improvement has been made
Brief pain inventory
pain pressure threshold
VAS
HOOS, LEFS (MCID is 9), harris hip score
high = better
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physical exam for hip OA
physical examination
A level: 6 min walk test, 30 sec sit to stand, stair measure, TUG, self paced walking, timed SL stance, 4 square step test, step test (timing to perform 9 steps)
A level: balance measure specific for fall risk, including BERG (<50% fall risk, <40% is significant fall risk and need AD), 4 square step test, SL balance
objective examination
FABER and FADIR
MMT and ROM in all planes of the hip
the minimum to include in an OA examination:
WOMAC for self report measure
physical performance: 6min walk, 30 sit to stand, stair measure, TUG
MMT and ROM for all planes of the hip
NPRS for pain
joint irritability with FABER test
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A level treatment for hip OA
A level: manual for mild-moderate OA, thrust and non thrust, STM. 1-3x per week over 6-12 weeks
A level: flexibility, strengthening, and endurance exercise to address impairments in hip ROM, specific muscle weakness, limited hip or thigh flexibility. 1-5x per week for 6-12 weeks
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B level treatment for hip OA
B level: education combined with exercise and manual. activity modification, exercise, weight loss, unloading hip.
B level: ultrasound. 1mHz, 1watt per cm2- but have to do 5min each on anterior, lateral, posterior hip. in addition to exercise and hot pack and only for short term management of pain and activity limitation.
study: dosage is given 10 session over 2 week period
108
C level treatment for hip OA
C level: functional gait and balance training.
C level: prescription of theract should be based on pt's individual values, activity participation, daily function (eg. playing golf)
C level: weight loss
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Arthrocentesis
a medical procedure that involves aspirating (removing) fluid from a joint space
110
rule of 3 thoracic spine
the spinous processes of T1 through T3 are at
the same level as the transverse processes, the spinous processes
of T4 through T6 are 0.5 vertebral level below the transverse
processes, the spinous processes of T7 through T9 are 1 full
vertebral level below the transverse processes, and the spinous
processes of T10 through T12 are at the same vertebral level to
which they are attached
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nociplastic pain
a type of chronic pain that arises from altered pain processing in the central nervous system (CNS), without evidence of tissue damage or neuropathy
Central sensitization: Increased responsiveness of pain pathways in the brain and spinal cord.
Dysregulation of pain modulation: Alterations in the body's natural mechanisms for inhibiting pain.
Psychological factors: Stress, anxiety, and depression can contribute to the development and maintenance of nociplastic pain.
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Nociceptive pain
a type of pain that arises from the activation of sensory neurons called nociceptors. These neurons are responsible for detecting and transmitting signals of potential or actual tissue damage
When tissue is damaged or threatened, chemicals are released that activate nociceptors. These neurons send signals along sensory nerves to the spinal cord and then to the brain. In the brain, the signals are processed and interpreted as pain
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neuropathic pain
a type of chronic pain that arises from damage or dysfunction in the nervous system. It is characterized by abnormal sensations, such as burning, tingling, shooting, or electric shock-like pain.
Neuropathic pain can be caused by various factors, including:
Trauma (e.g., nerve injury)
Infections (e.g., shingles)
Autoimmune disorders (e.g., multiple sclerosis)
Metabolic disorders (e.g., diabetes)
Certain medications (e.g., chemotherapy drugs
114
painDETECT
questionnaire used to detect neuropathic pain vs others
115
A level treatment lumbar pain
manual therapy
trust manipulation to reduce pain and disability in acute low back pain
some evidence, but weaker, in subacute and chronic low back pain
trunk coordination and strengthening and endurance exercises (stabilization)
subacute and chronic low back pain with movement coordination impairments
patients post lumbar microdiscectomy
directional preference
centralization or reduction of symptoms of symptoms with acute low back with with referred LE pain
acute, subacute, chronic LBP with mobility deficits- used to improve mobility in specific directions
flexion for stenosis only gets C level recommendation- it's different than directional preference
progressive endurance exercise and fitness exercises
chronic back pain without generalized pain
A level for moderate to high intensity exercises
chronic back pain with generalized pain
may have centralization
progressive, low intensity, submax fitness and endurance activities
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B level treatment for low back pain
patient education
don't talk about using bed mobility for rest or talk in depth about pathoanatomical reasons for low back pain
SHOULD talk about:
1.) talk about anatomical and strength of spine
2.) neuroscience that talks about pain perception
3.) overall favorable outcomes of LBP
4.) active pain coping strategies that decrease fear and catastrophizing
5.) early resumption or vocational activities even when still having pain
6.) importance of improvement of activity levels, not just pain relief
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C level treatment low back pain
flexion exercises for specifically stenosis
flexion exercises combined with manual, exercises, nerve mobilization, progressive walking
2006 whitman study:
compare flexion exercise + treadmill walking to group that received manual + exercise +body weight treadmill walking
manual+ exercise + bodyweight treadmill walking were much more successful than the group that didn't
multimodal approach with manual and exercises is best
bodyweight treadmill walking is good for lumbar stenosis
nerve mobilization
nerve glide and glossing
new studies since 2012 CPG are in favor of nerve flossing, so they may be more A or B level recommended now
subacute and chronic LBP and radiating pain
nerve tension testing - SLR+ all have hip flexion and knee extension:
sciatic nerve: add hip adduction and/or IR + ankle DF
posterior tibial nerve: ankle DF and eversion
sural nerve: ankle DF and IV
common peroneal nerve: hip IR, ankle PF + IV
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D level lumbar treatment
D level
traction
conflicting evidence
some preliminary evidence showing that a subgroup of patients that may benefit from lumbar traction
nerve root compression with peripheralization of symptoms or + cross straight leg raise test may benefit from lumbar traction in prone position
should not use intermittent or static traction acute or subacute nonradicular low back pain
should not use in patients with chronic low back pain
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cervical myelopathy clinical prediction rule
MRI is most useful
clinical prediction rule by cook et al. 5 criteria:
gait disturbance
positive hoffman
positive inverted supinator sign
+ babinski test
age >45
1 out of 5 is sensitive to indicate potential cervical myelopathy
⅗ = + 90% change of myelopathy
⅘ = 99% change of myelopathy
120
5 D's, 3 N's
dizziness
diplopia
dysarthria
drop attack
dysphasia
nausea
nystagmus
facial numbness
121
low risk factors for cervical trauma
low risk factors that will allow you to assess patient's ROM
can sit in ER
had simple rear end MVA
ambulatory at any time
delayed onset of neck pain
no midline cervical tenderness
if they don't have any of these low risk factors, you cannot safely assess for ROM
if they have any ONE of these factors you can precede with assessing ROM
if they can rotate their head 45 deg in each direction, they're considered to be low risk and no imaging is required
122
NDI score
0-4 points, 0-8% = no disability
5-14 points, 10-28% = mild
5-24 points, 30-48%= moderate
25-34 points, 50-64% = severe
35-50 points, 60-100% = complete disability
MCID, 5 points or 10%
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cervical manipulation CPR
cervical manipulation CPR (not in CPG?)
symptom duration <38 days
+ expectation that manipulation will help
side to side difference in cervical ROM of 10 deg or more
pain with PA spring testing of middle cervical spine
¾ factors was highly predictive of positive response to cervical manipulation
124
treating whiplash
acute stage with patients fitting into any of the prognosis categories
B level: educate to return to normal non provocative pre-accident activity level ASAP. minimize use of cervical collar. start doing postural and mobility exercises to decrease pain and improve ROM. reassure that recovery is expected to occur during the first 2-3 months
low risk of chronicity:
C level: one session of early advice, exercise instruction, education. one follow up session for strength and endurance with/without coordination exercises, use of TENS
moderate- slow recovery
B level: multimodal recovery using manual mobes/mani + exercise including strength/endurance/postural/coordination/aerobic/functional + modalities (heat/ice/TENS)
125
testing for neck pain with radiating pain
neck and UE symptoms provoked with relieved with radiculopathy cluster testing
+ upper limb neural mobility testing (A = median nerve)
pain reproduced with spurling
symptoms relieved with cervical distraction test
pain produced or relieved with cervical ROM
UE sensory, strength, and reflex deficits
126
neck pain with radiating pain- clinical prediction rule for intermittent traction and exercise
5 criteria
>55 y.o
+ shoulder abduction test , alleviation of symptoms when patient rests hand on head that relieves tension on cervical nerve roots
+ upper limb nerve tension test A
+ distraction test
symptom peripheralizing with PA testing of lower cervical spine
⅗ = ?
⅘ = 95%
