PPAC Test Shoulder, hip & lumbar spine Flashcards
Shoulder and hip
What does the clinical pattern & presentation look like for rotator cuff tendinopathy (supraspinatus)
• Local pain +/- referral - Over head pain • Hx overload/overuse • PMx instability or subluxation - compromised healing e.g. diabetes o Usually young adults (25-45 years old) o Dull ache sometimes the following overuse o Pain can be severe at rest o Acute stage - guarding of movement
Presentation:
TOP, Pain and weakness on RSC, Painful arc, Superior translation due to SS failure, impingement test (empty can +ve)
What does the management look like of someone with a rotator cuff tendinopathy.
Treatment depends on continuum (reactive-disrepair-degenerative)e.g. reactive- reduce ex and avoid high load,
Disrepair/degenerative- exercise and gradual increase of load to stimulate cellular activity
Treat the tendinopathy o Education o NSAIDs o US, interferential, laser o Local massage o Frictions o Trigger points
Address the cause or contributors o Soft tissue tightness o Poor posture/dynamics o Impaired scapulo-humeral rhythm o Reduced RC strength o Capsular tightness o GH instability o Poor technique e.g. sport or work etc.
Calcific o Manage pain- Ice, IFT, NSAIDs o Refer for medical management Aspiration Steroid injections Surgical excision
What does the clinical pattern & presentation look like for Adhesive capsulitis/Frozen shoulder?
4 stages stage 1 (< 3/12) - Referred pain to deltoid - Aching at rest, sharp with movement - Night pain - Minimal/no loss ROM stage 2 (3-9/12) - Progressive ↑ pain → ↓ ROM - Resting and night pain stage 3 (9-15/12) - Symptoms 9-15/12 - ↓ ROM++ - Minimal /no Resting and night pain Stage 4 (15-19+/12) ↑ ROM+++
PRESENTATION Stage 1 Pain AROM and PROM Pain is biggest characteristic No particular direction that hurts the most, and no loss of ROM Stage 2 Freezing stage significant capsular reactions (scar formation, fibroplasia) evident AROM ↓ ROM capsular pattern (ER>abd>IR/flex) PROM capsular pattern (pain limit or stiffness) Muscle strength – strong and pain free (? pathology) Tender on palpation Range changes Still painful, may decrease slightly End range will be VERY painful stage 3 AROM ↓ ROM capsular pattern ++PROM capsular pattern (pain limit or stiffness) PROM rigid end feel Almost no pain Range minimal stage 4 Thawing stage capsule remodels ↑ AROM+++ and PROM Range slowly starts to come back No pain May never recover full AROM Stage we can help the most with
What does the management look like of someone with adhesive capsulitis?
Stage I - ↓ pain
o Maintain ROM
o Activity modification
• Stage II - ↓ pain and maintain ROM
o Stretch more
• Stage III – IV
o ↑ capsule extensibility
o Address weakness, dysfunction
• Surgical – hydro-dilation, MUA, capsular release
What does the clinical pattern & presentation look like for someone with shoulder Instability?
- Clicking
- Pain
- Possible signs of impingement
- May have history of dislocation
- ADLs may be hard to complete
PRESENTATION • Increased accessory movement • May have GIRD (reduced internal rotation) • Screen cervical and thoracic spine • May show apprehension in AROM • Pain/stiffness in PROM
management of shoulder instability ?
Management
• Education
• Postural re-education
• Strengthening
o Deltoid
o RC
o Scapular stabilisers
• Stretching
o Pec major and minor
o Tight muscles
o Posterior shoulder structures
• May require surgery
o Post-surgery rehab
Clinical pattern and presentation for hip OA?
- Hip pain –> Gradually worsening
- Insidious onset
- May be history of trauma
- May be genetic/ FHx
- Aggravated when hip is loaded for too long
- Eased with continuous movement
- Morning stiffness, eased with movement
- May report ‘locking’
Presentation • Reduced ROM o Pain/ reduction of IR o Reduced hip flexion • Crepitus • May have atrophy • Antalgic gait • Local inflammation • TOP at hip
Management of hip OA
• Pain management –> May require referral for this
• Patient-specific exercise program
• Focus on function
• Adaptive equipment or gait aids
• Self-management
o Education on pain e.g. use heat/ice, gentle exercises, relaxation techniques
• hydrotherapy
clincal pattern and presentation of gluteal tendinopathy/ lat hip pain?
Subjective • Lateral hip pain (over greater trochanter) o Often insidious o Gradually worsening • Reported pain in walking and stairs • Night pain PRESENTATION • May have antalgic gait • TOP of GT • Hip examination o FADER test (flex, add, ER) +ve (elicits pain over lateral hip) o FABER test (flex, abd, ER) +ve (elicits pain over lateral hip) • MRI is gold standard for diagnosis
management for gluteal tendinopathy/ lat hip pain?
• Load management • Modifications • Avoiding aggravating activities • Correcting movement abnormalities • STRETCHING TO BE AVOIDED • Massage may be implicated for pain management • Hip strengthening (focus on abductors) o Bridging o Squatting o Lunges o Pelvic control training
Address the cause or contributors
clinical pattern and presentation of lumbar disc?
Back pain with potential progression of symptoms into leg
Worse with activities that increase intradiscal pressure
Eased by positions of decreased intadiscal pressure
History – minor incident leading to LBP.
Worse over night
Repeated episodes of LBP – may be Progressive- not 100% between episodes
Common in tradies/plumbers/mechanics due to extended periods in flexion (increased interdiscal pressure)
Central lower back pain
objective
• Commonly present with contralateral list away from symptomatic side
• May be limited in lateral flexion and rotation but these are not key features
• Protective deformity
• Limited flexion
• Limited extension
• PAIVM – central pa’s stiff and painful
management of lumbar disc?
Management Acute o Advice & reassurance o Early return to activities o Bed rest (very short term) o Traction o Passive mobilisation
•Chronic o Education o exercise o McKenzie o Passive mob o Neural mobilisation o Treat secondary causes
what is the clinical patten and presentation of lumbar PIV joint?
Acute
o Sharp local unilateral pain
o Worse with activities that stretch the joint
o Worse with activities that compress the joint
o May be irritable
o History – usually of a quick unguarded movt or trauma – immediate pain
o Usually improves over a number of days
• Chronic
o Unilateral pain- may refer around the abdomen, refer down leg
o Type – may be sharp catching on stretching activities (peri-articular) or deep ache with intra-articular
o History- insidious onset – “always something there”
Objective
Acute
o If pn from stretching then Flex, rot away and LF away will be limited
o If pn from compression then Extension, rot towards and LF towards will be painful
o Caution as may be irritable
o PAIVM’s – unilateral pa’s pain & stiff
o Flexion, lateral flexion away, rotation away- any activities stretching the joint will be painful
o Pain itself usually worse immediately and then settles down
o Can be quite irritable
Management of PIV?
Management • Acute oPassive mobilisation Unilateral pa’s Rotations o Traction (this is rarely used for this anymore) o Electrotherapy
• Chronic o Depends on signs Treatment done accordingly o Large amplitude passive mobilisation techniques o Manipulation techniques o Exercise o Advice reassurance and education o May not get to 100% o Treatment to manage muscle imbalance –muscle control & muscle length
clinical pattern and presentation for lumbar postural deformity ?
- General local ache.
- Aggravated by sustained activities (certain postures) and worse at the end of the day.
- Eased by movement and rest.
- Symptom free on days which do not involve poor posture (eg weekends)
Objective
• Observation may reveal poor sitting or standing posture.
• Physiological movements may be full and symptom free.
• Sustained positions may elicit symptoms.
• No neurological signs, +/- neural tension signs.
• Minimal palpation signs,
• not enough to substantiate the symptoms described.
o Findings can be vague and inconclusive, or seem too extreme for problems found
• Poor muscle control and strength, muscle tightness.
Management for lumbar postural deformity?
Management • Need lots of advice on positioning • Treat muscle imbalance/weakness • Treat joint signs if present • Treat neural tensions if present
clincal pattern and presentation for lumbar Instability?
- Arcs/twinges of pain on movement and on return to neutral position
- Trivial mechanical stress causes pain
- Persistent back or neck aching, recurrent episodes
- only short term relief from physiotherapy, chiropractic (mechanical Rx)
- Ease by lying
Objective • Excessive ROM • Full painless mobility • Extension – excessive movt at 1 level • Use hands to return to neutral • Muscle weakness • Bilat SLR pain at 40 degrees • +/- neurological signs • PAIVM’s – feel step- pain and altered end feel at level
management of lumbar instability?
Management • Harder to treat • Treat pain • Gentle mobilising • Exercises to improve core control • Some are too unstable to improve and will need spinal fusion • Advice , reassurance & education • Pain relief • Restore normal movt • Passive mob with caution • Traction • Improve Stability • Specific muscle exs • Fusion
clinical pattern and presentation for spinal canal stenosis?
Subjective • Usually in the over 60 age group • Long history of LBP • LBP common • Pain, paraesthesia numbness & weakness in the lower extremities • Symptoms usually brought on by walking • Relieved by rest Objective • Increase symptoms with extension. • Decrease symptoms with flexion • Often walk flexed • Able to ride bike / differentiate from arterial claudication
management of spinal canal stenosis
• Advise • Exercise for core and to limit lumbar lordosis o Role for biofeedback? • Passive mobilisation • Muscle control
cinical presentation and pattern of shoulder labral injury
Subjective:
• C/o Poorly localised deep shoulder pain
• May also report feeling of ‘weakness’ during
throwing*
• May report grinding or clunking
• HPC: acute or chronic shoulder traction,
compression or dislocation injury
• Agg: Overhead and behind back activities,
throwing (feels weak)
Objective
• +ve on Labral and resisted biceps testing (O’Briens
test, Biceps Load II + others)*
Objective (cont)
• May present with grossly full AROM
• Weakness of rotator cuff mm
management of shoulder labral injury ?
Treatment
• Non-operative Mx
• Strengthening shoulder girdle, RC and scapular mm
• Surgical management - arthroscopy If fail conservative management
What is the clinical pattern and presentation of deep gluteal (piriformis syndrome)
Subjective
• Pain around buttock region (sciatic notch) +/-
cramping or burning in posterior thigh
• May also report tingling sensation and motor
weakness
• Agg: sitting for prolonged periods, activities
which stretch sciatic nerve
• Common cause: direct contusion and overuse
Objective
• Neurological may be +ve in area of sciatic nerve if
compressive
• Neurodynamic SLR +/- Slump may be +ve
• May have weak hip abductors
• P+ on piriformis stretch and contraction
• Palp: tenderness + spasm over posterior buttock muscles
management of deep gluteal syndrome ?
- Load management/education
- Exercise therapy
- Neurodynamic mobilisations
- Manual therapy as adjunct
- Medical management
- Pharmacology
- Surgery (decompression, piriformis release)
clinical pattern and presentation of Femoroacetabular impingement (FAI)
• Patient c/o pain in anterior hip and groin region
• May report: locking, clicking, catching
• Usually deep dull i/m
• Agg: activities which place in impingement
(combined F/Add), sitting cross legged, stairs and
steps, kicking ball across body
• Common in those with repetitive twisting and
pivoting of hip (soccer, AFL)
Objective
• May have antalgic gait pattern
• May have limitation in AROM (Flexion, abduction)
• Painful on Flexion + IR overpressure
• FADIR +ve (not –ve: high sensitivity test)
• ↓ muscle strength (hip abductors, add, extensors, ER)
• Poor trunk and pelvis control on balance tasks
management of Femoroacetabular impingement (FAI)
Treatment • Exercises targeting muscle strength • Gluteals - hip abductors, add, extensors, ER • Trunk stability • Progress to functional tasks • Soft tissue release • Joint mobilisations, Mulligans MWM mobilisation • Stretching
clinical pattern and presentation of hip OA
Subjective:
• Patient c/o anterior hip +/- groin pain
• Gradual insidious onset
• Usually deep dull ache but can be sharp stabbing p+
• May report catching pain ± clicking/crepitus
• Difficulty walking prolonged distances, getting in/out of
car, reaching down to feet
• Reports of gradual progressive ROM restriction and
stiffness*
• Pain that may occur on rising to stand and walk, but
eases with continued walking
• Ease: changing hip loads, reducing hip flexion positions
• Older age group
Objective
• Antalgic gait (glute med gait/Trendelenberg)
• Limited AROM (esp in Flexion, F/IR)
• Loss of PROM (esp Flexion, F/IR)
• Visible wasting of muscles esp gluteals
• ↓ mm strength in gluteals (hip abd, add, ext, ER)
• Passive Accessory movements stiff
Management of hip OA
Treatment
• Pain relief: joint mobilisation, soft tissue massage, stretching
• Gait retraining + gait aid prescription if need
• Activity modification
• Active exercises
• Land based strengthening program
• Target: lower limb muscles esp. gluteals
• Hydrotherapy
• Balance exercises
CLinical pattern and presentation of lumbar radicuolpathy?
MP: LBP + leg pain (dermatomal)
Nature: constant, severe
Behaviour: Agg: any WB position (sitting*)
Ease: often a specific easing position
SQs: radiating pain +/- sensation change, loss of power
Inv: MRI
HPC: usually relatively quick onset but nil incident
Obs: look uncomfortable, fidgety, sick (acute)
Functional: won’t want to sit in the chair for S/E, will struggle to get onto plinth
AROM: often limited esp F
Palpation: protective muscle spasm
PAIVMs: would find impairments but probably won’t assess
Neurodynamic: would find impairments but probably won’t assess
Neurological: +ve
mangagement for lumbar radiculopathy?
ACUTE Advice and reassurance Find a pain-relieving position GENTLE traction GENTLE mobilisations
CHRONIC Advice and reassurance Traction Mobilisations – at, above/below the affected segment Neural mobilisations (gentle)
