Pathalogy

Question 1

The student is able to name the causes of primary impingement.

Answer 1

Impingement means entrapment of soft tissues in the subacromial space. A distinction is made between primary and secondary impingement:

→ Primary (physio can usually not do a lot)
Structural narrowing of subacromial space

• Osteoarthritis: Acosteophyte ‘extra bone growth’
• Angular acromion (X-ray)
• Swollen soft tissues (tendon/bursa)

Question 2

The student is able to name the causes of secondary impingement.

Answer 2

Secondary (physiotherapy can help)
Constriction during specific postures and/or movements

• Rotator cuff dysfunction (e.g. the supraspintus muscle pulls the humeral head at abduction not sufficiently caudal)
• GH instability
• Scapular dyskinesia
• Biceps/SLAP injury (superior labrum anterior posterior lesion. The tendon of the biceps brachii caput longum pushes the humeral head downward in flexion.
  If the tendon does not do this properly, there is not enough space under the acromion during flexion)
• GIRD glenohumeral internal rotation deficit
• Overload (surmenage)
• Trauma

Question 3

The student is able to name the symptomatology of a shoulder impingement.

Answer 3

• Pain (anterolateral)→deltoid region
• Painful arc: pain on abduction of the arm
• Pain on elevation
• Pain/weakness on resistance: external rotation and abduction

Question 4

The student is able to name different pathologies that could cause impingement complaints.

Answer 4

• Tendinopathy
• Calcification of the tendon
• Bursitis
• Central and peripheral sensitization
• Tendon ruptures of the RC or biceps caput longum (complete rupture or wholly or partially perforated)

Question 5

The student is able to explain what an impingement is.

Answer 5

SAPS: subacromial pain syndrome: space under the acromion. In the past this was called impingement, but now there is doubt whether impingement is a correct term.

Below the acromion is the subacromial space. In the subacromial space there are several structures: ligaments, tendons, capsule, bursa.

Impingement is an entrapment of the soft tissues in the subacromial space

Question 6

The student knows the aetiology of impingement complaints of the shoulder.

Answer 6

There is no apparent cause for impingement/SAPS (idiopathic). The abnormalities that can be considered a possible cause of shoulder complaints are described below:

• Abnormalities of structures in the subacromial space: ligaments, tendons, capsule, bursa
• Abnormalities of the glenohumeral joint (osteoarthritis and frozen shoulder)
• Glenohumeral Instability
• Abnormalities of the AC or SC joint (eg osteoarthritis)
• Functional disorders of the cervical spine or the cervicothoracic spine

Question 7

The student is able to explain what a frozen shoulder is.

Answer 7

Frozen shoulder is an idiopathic condition in the shoulder, in which there is an increasing limitation of movement.

MMP2 and MMP9 are matrix protein proteolytic enzymes. These substances break down elastin. Somehow, these substances are produced more in someone with a frozen shoulder. These substances therefore ensure that holes are made in the haircut, because the elastin in the haircut is broken down.

• Fibroblasts: want to fill in the gap (repair)
• Myofibroblasts: want to bring the wound edges (holes) back together

This causes the capsel to contract and become stiff, reducing in size and thereby decreasing the range of motion.

Question 8

The student is able to describe the different stages of a frozen shoulder.

Answer 8

Average duration is 30 months

• Freezing (2-9 months): pain + start ROM decrease (suddenly the shoulder starts to hurt more, movement restriction increases)
• Frozen (4-12 months): ROM limited, pain decreases. Mainly movement restriction
• Thawing (5-26 months): ROM increases pain and decreases range of motion

Question 9

The student is able to describe different stages of an AC dislocation.

Answer 9

• Tossy 1: all 3 ligaments are stretched (lig. accromioclavicular and lig. coracoclavicular (consists of 2))
• Tossy 2: lig accromioclavicular is torn, lig. coracoclavicular is stretched
• Tossy 3: all 3 ligaments are torn

Rockwood is described at the time of surgery:

• Rockwood 1, 2 and 3: are the tossy’s
• Rockwood 4: clavicle shoots posterior
• Rockwood 5: clavicle shoots cranial
• Rockwood 6: clavicle shoots forward and below coracoid process

Type 4, 5, and 6 are the types that require surgery.
Rockwood 4, 5 and 6 are all Tossy type 3, but here the clavicle did not stay in the same place, but shot in a certain direction.

Question 10

The student is able to name the characteristics of nonspecific complaints of the lower back.

Answer 10

• These back complaints have no clear cause (non-specific), this is in about 90% of all PTs with low back pain
• The course is abnormal if there is no clear increase in activities and participation after 3 weeks
• Pain in the lumbosacral region
• The pt can radiate to the buttock and thigh
• The pain may be made worse by certain postures, movements and lifting or moving loads

Question 11

The student is able to name the characteristics of a cervical radicular syndrome.

Answer 11

• Neck pain
• Radicular pain: shooting pain
• Paresthesia: tingling, burning sensation
• Loss of strength: of arm and hand muscles
• Pain in arm or hand
• Sometimes there are also atypical symptoms such as: weakness of the deltoid muscle,
weakness of scapula musculature (*with scapula alata), chest pain and headache

Question 12

The student can name the cause of cervical radicular syndrome.

Answer 12

Cervical radiculopathy is caused by compression of one or more cervical nerve roots (spinal nerves). Compression can be caused by various factors: soft neck hernia, hard neck hernia or a combination of both

Question 13

The student can explain scapula alata

Answer 13

Scapula alata: abnormal position of the scapula

• winging: protrusion of the medial margo
• scutching: protrusion of the superior margin
• tipping: protrusion of the inferior angulus.

This occurs when the muscles of the shoulder girdle no longer function properly. In most cases in a reduced control by the nerve the cause of the abnormal position The nerve can be damaged by trauma or a bacterial infection A reduced muscle function can also be caused locally by a bursa inflammation or SAPS

Question 14

The student is able to name the red flags of the CS.

Answer 14

• Under 20 years old or over 50 years old
• Trauma
• Long-term use of corticosteroids
• Neurological failure
• Neurological complaints in legs / cotton wool feeling under feet
• Problems with bowel movements/incontinence
• Hoarseness/swallowing problems
• Structural deviations

Question 15

The student is able to name the red flags for the head.

Answer 15

• First headache > 40 years
• New headache > 50 years
• Temporal headache > 50 years (temporal arteritis)
• Sudden severe headache
• Headache after (recent) trauma.
• Headache in combination with neurological symptoms
• “Sentinel headache” (occipital unilateral headache as a “warning” for an aneurysm a. vertebralis, a. carotid int.)
• Increasing headache despite treatments
• Focal neurological signs and symptoms: glare, colored or dark
spots, sometimes even facial loss. Also, tingling in one hand or around the mouth may occur.
• Changes in mental status such as: memory disorders, confusion,
loss of consciousness, drowsiness, increased irritability

Question 16

The student is able to name the different types of neck complaints/headache.

Answer 16

→ Neck complaints
• Specific complaints
• Non specific complaints
• Cervical radiculopathy
Following headaches are also neck related:
- Migraine
- Tension type headache
- Cervicogenic headache

→ Headaches
• Primary headaches
- Migraine
- Tension-type headaches 
- Clusterheadache
- Other primary headaches: caused by movement, coughing, sexual activity.

• Secundary headaches

• Trauma related
• Medication related
• Cervicogenic headache
• Temperomandibular headache

Question 17

The student is able to name the signs and symptoms corresponding to cervicogenic headache

Answer 17

• Unilateral “side locked”
• Starts occipital
• Not pulsating
• Can be provoked
• (often) Cerv. mov. limitation
• Possible arm/shoulder pain (ipsilateral)
• Hours up to weeks

Question 18

The student is able to name the signs and symptoms corresponding to a migraine.

Answer 18

• Unilateral “side shift”
• Starts front-temporal
• Pulsating
• Cannot be provoked
• (often) no cerv. mov. limitation
• No arm shoulder/pain
• Max 72 hours

Question 19

The student is able to name the signs and symptoms corresponding to Tension Type Headache

Answer 19

• Pressing pain around skull
• Minutes to days
• Hypersensitive for sound OR light
• Not provokable

Question 20

The student is able to name the signs and symptoms corresponding to cluster headache

Answer 20

• Attacks of pulsating stabbing pain
• One side around eye or temporal
• 15 to 180 minutes
• Clusters of weeks to months
• 1 to 8 attacks a day
• Additional symptoms:
- ipsilateral red eye
- tearing eye
- a cold

Question 21

The student is able to name the signs and symptoms corresponding to temperomandibular headache

Answer 21

• Dysfunction of the jaw joint

Question 22

The student is able to name the signs and symptoms corresponding to a cervical radiculopathy.

Answer 22

• Neck pain
• Radicular pain: shooting pain
• Tingling, burning sensation
• Loss of strength: arm / hand
• Pain arm / hand
• Atypical symptoms as, weakened deltoid/rotator cuff, , headaches

Question 23

The student can name the directions of scapular diskynesia.

Answer 23

→ Winging: protrusion margo medialis
→ Shrugging: protrusion margo superior
→ Tipping: protrusion angulus inferior

Question 24

The student is able to name the consequences of spondylosis in the long term (spondylolysis, spondylolisthesis, spondylodesis)

Answer 24

→ Spondylosis: umbrella term for degenerative defects of the spine. Often occurs at the disc or facet joints. The symptoms are diverse and develop gradually.

• Spondylolysis: vertebral fracture → interruption of the connection between the vertebral body and the vertebral arch (arcus).
• Spondylolisthesis: displacement of one vertebra relative to the other vertebra. Usually L4, L5 and S1 are affected, the lower in the back the more pressure
• Spondylodesis: fixation of the vertebra

Long-term consequences of spondylosis: when there is degeneration in the spinal column, all kinds of complaints and disorders can arise. Including specific back conditions.

The most common symptoms of spondylosis are:
• Instability spinal column
• Syndesmophytes (extra bone formation around the edges of the vertebra)
• Sclerosis of the cover and closing plates (due to increased pressure load on the bone of the vertebral body)
• Spinal column stiffness

Question 25

The student is able to name the characteristics of lumbar radicular syndrome.

Answer 25

A problem in the lumbosacral region. Radicular means that it has something to do with the radix (nerve root).

Symptoms:
→ The radiating pain in the buttock/leg is more intense than pain in the back

→ There is neuropathic pain:
• Numbness
• Stabbing pain
• Paresthesias (tingling)
• Decreased reflexes
• Hypoaesthesia (decreased sensitivity)

Question 26

The student is able to name the aetiology of osteoporosis.

Answer 26

Etiology (cause)

Between the twentieth and thirtieth years of life, the bones reach their maximum mass (peak bone mass). High-quality food (not too much fat and sugar) with sufficient vitamin D, magnesium and calcium, exercise/sports and preferably at least fifteen minutes a day exposure to sunlight are important for good bone formation.

Between the ages of 40 and 60, bone mass begins to decline. This is due to increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts. Age-related changes in the bones are the main cause of osteoporosis.

• Too little exercise
• Calcium deficiency
• Vitamin D deficiency
• Postmenopausal women, less estrogen production
• Smoking and excessive alcohol use (speeds up the process of bone decalcification)
• Use of drugs: prednisone, corticosteroids
• Malnutrition/poor eating habit

Question 27

The student is able to name the pathogenesis of osteoporosis.

Answer 27

Pathogenesis (origin, development and course):

• Primary osteoporosis: loss of bone mass density due to aging process. There is no specific cause
• Secondary osteoporosis: the cause is identifiable. E.g. by using certain drugs or conditions that increase the risk of osteoporosis: underweight, osteoporosis in families

Question 28

The student is able to name the symptoms of osteoporosis.

Answer 28

Symptoms

• (Low) back pain without an identifiable cause
• Local knock, pressure and shaft pressure pain from the spinal column
• Noticeable length reduction
• Enhanced thoracic kyphosis

Question 29

The student is able to has knowledge of primary deforming osteoarthritis of the hip.

Answer 29

→ Primary arthrosis (without detectable provoking factor); is based on cartilage degeneration. The surface becomes frayed and pieces can break off.

→Secondary arthrosis deformans; is caused by:
• Anatomical abnormalities that put extra stress on the joint (such as a shorter leg)
• Joint inflammation
• Prior trauma (injuries)
• Endocrine* abnormalities
• Neurological disorders
• Metabolic Disorders

Question 30

The student is able to name the differences between primary gonarthrosis and secondary gonarthrosis.

Answer 30

→ Primary gonarthrosis
The cause of gonarthrosis is unknown

→ Secondary gonarthrosis
The cause is a previous condition:
• Meniscus injury
• Cruciate Ligament Problems
• Damage to cartilage
• Lower extremity misalignment
• Overweight

Question 31

The student is able to name the different possibilities for the surgical treatment of gonarthrosis.

Answer 31

→ Cartilage repair operations
Because hyaline cartilage has poor blood circulation, it can hardly repair itself.
however, there are cartilage repair surgeries:
• Artificial hyaline-like cartilage (still in development)
• Transplantation of hyaline cartilage
• Tap into fibrocartilage

→ Prostheses
• Unicompartmental knee endoprostheses, a prosthesis on one side/condyle
• Total knee replacement. In most pts, the ACL and sometimes the PCL must be removed,
flexion should be possible up to 100 degrees. The greatest danger is the infections that can affect the prosthesis

→ Arthrodesis
Securing the joint, this is almost never done because it does the mobility of the knee no good. The leg can no longer flex.

→ Osteotomy Posture Correction
The knee can be divided into 3 compartments: lateral compartment (lateral femoral condyle and the lateral part of the tibial plateau), medial compartment (medial femoral condyle and the medial part of the tibial plateau) and the patellofemoral compartment. The goal of osteotomy is to transfer the load to the correct compartment, thereby reducing the symptoms.

Question 32

The student is able to name the different causes that could impede tendon recovery (risk factors).

Answer 32

• Under/overload
• Hormonal influence, eg through stress
• Medication: for example, antibiotics can cause collagenolysis (breakdown of collagen)