Soft Tissue Injury Flashcards
What are ligaments?
fibrous tissues that connect bone to bone and provide joint stability => very elastic and have a better blood supply than tendons so are less prone to chronic injury
What are tendons?
fibrous tissues that connect muscles with bone and allow for joint movement
What are bursae and menisci?
soft tissues that reduce friction between moving parts in a joint => bursae are fluid filled sacs while menisci are soft cartilaginous tissues
What are the common types of acute soft tissue injuries?
sprains (ligaments) and strains (tendons) - due to acute trauma (can be partial or full tears)
What are the common types of chronic soft tissue injuries?
tendonitis/tendinopathy (there is no inflammatory component in the pathophysiological process) and bursitis - due to overuse (usually an insidious onset)
What is tendinopathy?
injury to tendons due to repetitive mechanical load that does not provide sufficient time for healing => leads to micro-tears, improper healing, degenerative changes (e.g., loss of collagen), and tears
How do acute soft tissue injuries present?
clearly defined cause/onset, localized pain with activities and at rest, “popping” sensation (if a tear), edema, ecchymosis
How do chronic/overuse soft tissue injuries present?
gradual onset/no clearly defined cause/trauma, localized pain only with specific movements (at rest in late stages), no edema
What is the approach to diagnosing soft tissue injuries?
diagnosed clinically, x-ray is the best initial test when diagnostic tests are needed (some acute injuries, no improvement after 6 weeks, r/o fracture/tumor/arthritis => NOT used to diagnose a problem), MRI is the most accurate diagnostic test for soft tissue injuries, nerve conduction tests are most accurate tests for peripheral mono-neuropathy
What is the treatment for acute soft tissue injuries?
RICE (rest, ice for 20 minutes at a time, compression bandage, elevation) for the first 2-3 days, physical therapy when pain/swelling subside (usually after 1 week) to prevent chronic instability and recurrent injury, surgical repair is last resort
What is the treatment for chronic soft tissue injuries?
#1 relative rest (not absolute rest) - rest from activities that reproduce the pain (need to move to build muscles/stretch and rebuild collagen) #2 pain control - short course of NSAIDs (despite the fact that there is no inflammation) #3 physical therapy - strength and muscle training #4 corticosteroid injections - if no response to pain control and relative rest for 6 weeks #5 surgery (debridement of degenerative tissues) - if no response to conservative therapy for 6 months (surgery is a last resort)
What is unique about the shoulder joint?
it lacks ligaments so its stability comes from muscles
How is rotator cuff tendonitis diagnosed?
gradual onset, pain with overhead activities (painful arc - lifting arm laterally causes pain when arm is at around 90 degrees), pain on lateral shoulder, night pain, + impingement sign, + Neer’s test, + Hawkins’ test => ROM and strength usually normal
What is Neer’s test?
press on PT’s scapula to prevent motion and raise PT’s arm with the other - compresses the head of the humerus against the acromion process => pain = + (rotator cuff tendonitis)
What is Hawkins’ test?
flex PTs shoulder and elbow to 90 degrees with palm down and rotate forearm internally - compresses the greater tuberosity against the acromion process => pain = + (rotator cuff tendonitis)
How is a rotator cuff tear diagnosed?
follows acute trauma or chronic overuse, pain and weakness on abduction, + open can test, + drop arm test => ROM and strength decreased
What is the open can test?
elevate arm to 90 degrees and rotate internally (thumb down) and ask PT to resist as you place downward pressure on the arm => inability to hold arm at 90 degrees (shoulder level) = + (rotator cuff/tendon tear)
What is the drop arm test?
ask PT to fully abduct arm to shoulder level and slowly lower it or hold arm up against resistance => PT cannot hold arm fully abducted at shoulder level = + (rotator cuff/tendon tear)
How does adhesive capsulitis of the shoulder present?
stiffness, pain and extreme limitation of ROM (both active and passive - true joint injury)
How does osteoarthritis present?
pain in anterior shoulder with activity relieved by rest, crepitus, limited ROM (active and passive - true joint injury)
How does cervical radiculopathy present?
pain in posterior shoulder radiating to neck/forearm (poorly localized), sensory deficits (numbness/parasthesia), motor deficits (very rarely), reduced deep tendon reflexes (biceps C5-6 and triceps C7-8) => peripheral neuropathy causes diminished reflexes (hyporeflexes) because problem is in the spinal nerve
How does central neuropathy present?
increased (hyper) reflexes and weakness below the lesion - problem is in the spinal cord itself
What are the signs and symptoms of spinal cord compression?
hyperreflexia, weakness, urinary incontinence - requires emergency MRI
Which patients are at risk for spinal cord compression?
those at risk for metastatic cancer or epidural abscess (cancer, HIV, IDU)
What effect does injury to bursae and menisci have on ROM?
none - they are outside the joint itself
How does olecranon bursitis present?
swollen elbow (“ball hanging out”), minimal tenderness, full ROM
How does septic olecranon bursitis present?
swollen elbow, tenderness, redness, warmth, full ROM (active and passive)
How does lateral epicondylitis (Tennis elbow) present?
pain over the lateral aspect of the elbow (lateral epicondyle/funny bone) with wrist extension (gripping), pain with hyperextension of wrist (arm extended with hand up “STOP”) against resistance
How does median epicondylitis (Golfer’s elbow) present?
pain over the median (inner) aspect of the elbow with wrist flexion (lifting), pain with flexion of wrist against resistance
How does septic arthritis present?
swollen joint, redness, fever, limited ROM (active and passive)
What are the tests for hand motor function?
rock (median nerve) - paper (radial) - scissors (ulnar)
What is carpal tunnel syndrome?
compression of the median nerve - numbness/pain in first 3 fingers (never 4th or 5th), + Tinel sign, + Phalen sign, atrophy of thenar prominence (pad on palm at base of thumb)
What is Tinel’s sign?
tapping lightly over the course of the median nerve in the carpal tunnel => numbness/pain in median nerve distribution (1st 3 fingers) = + carpal tunnel
What is Phalen’s sign?
ask PT to hold wrists in flexion (folded in and down) for 60 seconds => numbness/pain in median nerve distribution (1st 3 fingers) = + carpal tunnel
What are the risk factors for carpal tunnel syndrome?
uncontrolled DM, uncontrolled hypothyroidism, poorly controlled RA, pregnancy
What is the most accurate diagnostic test for carpal tunnel syndrome?
nerve conduction test
What is the treatment for carpal tunnel syndrome?
wrist splint with wrist in neutral position, with slight extension
What is De Quiervain’s tendinitis (washerwoman’s thumb)?
pain over the radial side of the hand exacerbated by thumb movements, + Finkelstein’s test
What is Finkelstein’s test?
ask PT to grasp thumb against palm and move wrist toward midline in ulnar deviation => pain over thumb extensor = + De Queirvain’s tensosynovitis
What is acute infectious tenosynovitis?
symmetric swelling of a digit (“sausage-like”) following a puncture wound, pain with passive extension and slightly flexed digit at rest => surgical emergency requiring IV Abx (can lead to adhesions/necrosis of all tendons in hand)
What is a scaphoid fracture?
+ snuff box tenderness after fall on outstretched hand => assume scaphoid fracture with any snuff box tenderness (put into spica cast/thumb up and send to orthopedist) - x-rays will be negative initially
How does ulnar nerve compression present?
pain and numbness over 4th and 5th digits, night symptoms, + Tinel’s sign, + Phalen’s sign, atrophy of hypothenar eminance
What is trochanteric bursitis?
lateral hip pain worse with direct pressure, unaffected by weight bearing, no limitations in ROM, + trochanteric tenderness
How does hip osteoarthritis present?
insidious onset of anterior hip/groin pain, worse with weight bearing, pain relieved by rest, + crepitus, + limited ROM
What is avascular necrosis of the hip?
compromised vascular supply causes necrosis of proximal femur and bone collapse, anterior hip/groin pain worse with weight bearing, pain relieved by rest, + limited ROM => presents same as hip osteoarthritis - have to assess risk factors (chronic alcoholics, chronic steroid use, sickle cell disease) - requires surgery (most accurate Dx with MRI - perform x-ray first)
How does lumbosacral radiculopathy present?
posterior hip/buttocks pain extending to knee, normal hip ROM, + straight leg test, + motor/sensory deficits, reduced reflexes => spinal cord terminates at L1 (below L1 is only spinal nerves) - lower back pain is not due to spinal cord compression
How does a ligamentous knee injury (sprain) present?
history of trauma, “popping” sound in the knee, pain and swelling, laxity (no end point - joint lacks stability)
What is McMurray’s test?
PT supine with knee flexed - stabilize knee and twist knee in rotational movement => pain and clicking = + test (meniscal tear)
How does a meniscal tear present?
follows vigorous sport activity, lateral or medial knee pan exacerbated by twisting movements, knee “gives way” or locks, + McMurray test
What are the tests for an ACL injury?
anterior drawer test and Lachman’s test
What is the test for a PCL injury?
posterior drawer test
What is Lachman’s test?
place knee in 15 degrees of flexion, stabilize femur, pull tibia forward to assess amount of anterior motion (intact ACL has a firm endpoint) => laxity/lack of endpoint = + (ACL tear)
What is patellar bursitis?
anterior knee pain exacerbated by activity (repetitive knee flexion) - no history of injury, no limitation in passive ROM
What is Osgood-Schlatter disease?
pain and swelling in the tibial tubercle exacerbated by activity and relieved by rest - common in young athletes who have undergone rapid growth spurt
How does slipped capital femoral epiphysis (SCFE) present?
chronic or intermittent pain in the hip or knee exacerbated with activity, painful limp, no history of trauma, limited ROM, leg may be externally rotated - common in obese children 12-14 years old
What is the treatment for SCFE?
avoid weight bearing until seen by orthopedist - 50% of time affects both hips (best x-ray view is lateral/frog leg) => only treatment is surgery
How does an ankle sprain present?
pain, swelling, instability, maybe a popping sensation following acute inversion (sole turns in) or eversion (sole turns out) of ankle, laxity on stretch test and anterior drawer test => avulsion fracture likely with an inversion injury
What are the Ottawa rules for ankle x-ray?
only perform an ankle x-ray if there is pain in the malleolar zone (ankle) and one of the following findings hold:
=> bone tenderness in posterior part of the lateral malleolus (distal fibula)
=> bone tenderness in posterior part of the medial malleolus (distal tibia)
=> inability to bear weight immediately and in ED
What are the Ottawa rules for foot x-ray?
only perform a foot x-ray if there is pain in the mid-foot zone and one of the following findings hold:
=> bone tenderness at base of the 5th metatarsal (pinky toe)
=> bone tenderness on the top of the foot near the base of the ankle (navicular zone)
=> inability to bear weight immediately and in ED
How does Achilles tendon tear present?
pain in the back of the ankle/popping sensation following forceful ankle dorsiflexion, + Thompson test
What is Thompson’s test?
PT lies prone on table with foot extended off the edge, squeeze base of calf muscle => no flexion of foot = + test (Achilles tendon rupture)
How does plantar fasciitis present?
chronic heel pain with first few steps in the morning or following periods of inactivity, pain improves with walking, common in runners and PTs with inappropriate footwear
How does Morton neuroma present?
burning pain (“walking on pebbles”) in the ball of the foot/sole, numbness between 3rd and 4th toes, + squeeze metatarsal joints test - common in women who wear high heels with a narrow toe box
