THORACIC Flashcards
Clinical pattern and presentation for - Ankylosing Spondylitis?
• Pain increases with rest, early am p &stiff+, reduces with exercise, walking
• May have had systemic illness
• Deep throb/ache lower back
• Stiff whole lumbar area
• Tend to be male and 40yrs+
Objective
• Reduced Lx lordosis-’ironed out’, flat, Tx kyphos
• Reduced range Lx E, LF, F; chest expansion
• +SIJ testslow back/buttock p
• Palp-spinous process tender,
• sharp local p on SIJ mobs
• Tender: enthesitis-iliac crest, ischial tub, PS, achilles, manubriosternal jt, heel, st/clav jt
• Differential diag-RA instability not stiff
management of ankylosing spondylitis ??
- Patient education
- NSAID/asprin
- rest, modalities, pain techs
- mob/ROM exs-LF, deep inspiration
- strengthen back E, deep Cx F, low Cx E, scapula retractors
- Hydro/swimming-E++
- Postural work, stretches
Clinical Pattern and presentation for Thoracic outlet syndrome?
• Diffuse and unlocalised dull ache
- Medial arm/hand, supraclavicular fossa
• Pins and needles/numbness C8/T1
• Cold hands and colour changes
• Heaviness, fatigue
• Aggravated by activities reducing costoclavicular space
Retract arms
Military position
Hyperabduct
• Eased
Activities that reduce pressure on A, V, N
Objective
• Elevation of arms may cause symptoms
• Weakness in hand muscles
• Tight scalenes/ pec min
• Adsons test
Cx rot, E, sh abd, deep insp
Will lead to reduced radial pulse or elicit symptoms
management of thoracic outlet syndrome?
- Stretch tight mm eg scaleni, pect minor
- Postural re-ed and mm strength eg retractors
- mob Cx, Tx, 1st rib/neural techs-restore painfree movt at site of compression
- advice re-support arms on chair before bedrelease phenomena.
- ?more supportive bra
- surgery-?remove 1st rib, ?scalenectomy
- treat the things found, don’t try to treat the whole condition- this will not work
Clinical pattern and presentation of - Scheuermann’s ?
Subjective
• 22 yr deep ache i/m-const+/-sharp p mid/low Tx EOR
• prolonged EOR F/E
• rest, am stiff
• X-ray-wedge body (front section grows slower than back section), endplate irreg, Schmorls nodes
• insid,. growing p, self limit at ossification
Objective
• Tx kyphosis
• All movts-dull ache, stiff
• Stiff 1-2 segmts Tx/Lx
• Rigid between stiff and non-stiff segments
• Stiff central cf unilat PAs bilat.
• Neurolog/Neural is fine
management of scheuermanns?
- Advice re-posture/ mobilising exs into E
- Strength/endurance exs
- Mob stiff (hypomobile) segments
- Brace if moderately severe deformity (55-80 degrees)
- Surgery if severe deformity (>80 degrees)
- Sports involving extension encouraged e.g. swimming
clinical pattern and presentation for cervical disc ?
Subjective
• Central/bilateral, suprascapular fossa, medial scapular
• pain sustained Flexion
• Pain reduced when non weight bearing (lying on back)
• unusual, sustained activity of neck, strain with arms eg lifting
• Symptoms not immediate; more next day
Objective
• Extension often quite stiff
All movements may be limited by pain
• Posterior glide also stiff (accessory passive movement)
• A lot of central soft tissue changes
Central thickening
• C4 depressed and C5 more prominent
• Neurological should be negative, but often issues occur together so nerve may be affected as well as disc
• No findings with PAIVMs
o However, C5 may be stiff while C4 is mobile
management of cervical disc?
Management • PAIVMs • If irritable: o Collar o Analgesics o NSAIDs o Bed rest o Cervical traction o Electrotherapy • Non-irritable o Central PAs into resistance o Posture correction o Muscle balance o Self-treatment o Stretches at home o Correct own posture o Muscle length and strength
clinical pattern and presentation of cervical PIV joint?
Subjective
• Pain may be referred to supraspinous fossa and scapula
• Local, bilateral not central
Med. Scapula may hurt
• INCREASE PAIN on stretch movements eg F, LF, rot away OR compression movements eg E, LF, rot toward
• Quick unguarded movement cause immediate symptoms and then improve rapidly
Objective
• Nil deformity
• Peri-articular-symptoms F, LF away, rot away, from side of symptoms
• Intra-articular- symptoms E, LF toward, rot toward side of symptoms
• Lateral interlaminar thickening
• Unilateral PA’s stiff
• Neurological not expected but may be present if other issue also
management of cervical PIV?
Management • Acute o Gentle passive mobs o unilat PA’s, lateral glide, rot away o Cx traction o Electrotherapy, collar o ROM exs • Chronic o strong EOR mobs (grade 3/4) o self Rx
clinical pattern and presentation of cervical postural pain ?
Subjective
• widespread diffuse ache with uni-bilat spread
• increase withsustained posture
decreases with movts, non weightbearing
• pre-disposing illness = rest and reduced mm control
Increase pace, hrs, activities
Objective • Forward head posture, Tx kyphosis • Full ROM, painfree • Mm imbalance tight-suboccipital E, upper traps, levator scapulae weak-short neck Fx/long neck Ex • Palp-tender over area • PAIVM’s = good • Neural= good
management of cervical postural pain?
Management
• Explain-mechanism, active role
• Advice-rest, regular curve reversal
• Home exs:
o endurance exs. for weak mm
o stretches for tight mm;
• Passive mobs for joint/neural signsclinical pattern and presentation of cervicogenic headache ?
0/C1 o Vice-like “ache” o TMJ pain o Ear pain/blocked o Patchy o Uni/bi-lateral o No neck pain below occiput C1/C2 o Uni/bi-lateral o Immediate SO pain o May describe a ‘head-band’ of pain o Rare and most difficult to treat o Commonly associated with trauma C2/C3 o Uni/bi-lateral, “face ache”+/- nuchal line pain o Nausea, dizziness, throbbing,“migraine-type” o Most common & often associated with O/C1 dysfunction
objective
• Forward head posture, poking chin
• Movements-no set pattern of restriction, may need combined upper Cx
• Reproduce H/A=diagnostic of Cx H/A
• VBI may be +ive
• Mm-tight suboccipital E, upper traps, loss endurance-deep Cx F
• Palp/PAIVM’s findings in upper Cx region O-C3
management of cervicogenic headache?
• Strong sustained mobs IV+ >oscillations stiff Cx
Home exs:
o Stretch tight mm-suboccip E, upper traps
o Posture: generalised/localised upper Cx retraction
o Increase endurance of deep Cx Fors +isometric strengthening other neck mm
o Ergonomics: desk, pillow, sleep position
• Check thoracic spine-mobilise if stiff
clinical pattern and presentation of carpel tunnel syndrome?
Subjective
• Common
• Numbness and tingling
• Aggravated by gripping
• Worse at night or AM
• May be eased by shaking/ flicking wrist
• “dropping things”
Objective
• Weakness or atrophy of wrist
• Reduced grip strength
• Boston Carpal Tunnel Questionnaire (potential OM)
• Phalen’s test (dorsum of hands held together, do for 1 minute)
o Will be +ve in CTS (Symptoms, tingling in thumb, index, middle or ring finger, pain)
management of carpal tunnel syndrome?
Management • Night splints can help provide relief • Surgical intervention commonly effective, as is steroids --> refer • Modifications of activities • Neural mobilisation
clinical pattern and presentation of dequervains tensosynovitis?
Subjective
• Localised swelling and tenderness which may radiate distally or proximally
• Radial sided wrist pain
Aggravated by:
o Activities with wide grip and resisted ulnar deviation
o Wearing watches/ bracelets
o Repeated thumb extension, and abduction and/or radial deviation
o Activity-dependent BUT may be worse at night with less distractions
Eased by:
o Rest, ice, splinting
o If chronic, heat
Objective
Observation:
o Local oedema
o Swelling in anatomical snuffbox
• Palpation:
o Local tenderness and oedema
o Tender radial styloid process
o Palpable thickening of extensor sheaths and crepitus of tendons
• Resisted static contractions of APL & EPB painful
• Finkelstein’s test positive: (thumb in palm, make a fist, ulnar deviation)
management of dequervains?
Management • Corticosteroid injection into synovial sheath • Rest (may include splinting/ taping) • Ice or heat (chronic) • Ultrasound • Massage • Activity modification • Strengthening APL and EPB • Mobilisation
what is the clinical pattern and management of depuytens contracture?
Nodules in the hand Generally not painful Flexion contractures Difficulties with functional tasks such as ... Washing Dressing Shaking hands
objective
Firm nodules on palpation or observation
Nodules may be tender to palpate
Active finger extension –. in skin blanching
Contractures of the PIP (proximal interphalangeal ) or MCP
Management of depuytens contrature ?
Massage (deep) Stretches Splinting Surgery: Fasciectomy Relatively new treatment: Collagenase injections
clinical pattern and presentation of lateral elbow tendinopathy ? tennis elbow
1-2cm below origin of ECRB, +/- radiating down forearm (mid-substance) or insertional (on Common Extsensor Origin )
Agg: gripping activities especially with load, activities with arm pronated & extended (hammer, computer etc)
Ease: rest, splint, NSAID’s
Hx: Insidious usually with new activity (rarely – trauma)
obective
AROM: NAD unless acute
PROM: pain with elbow E/PRON + wrist F/UD
Special tests: Mill’s test +ve (same as above)
Pass acc glides: NAD
RSC: painful wrist E with EE (especially 3rd MC)
Palp: tender 1-2cm distal to epicondyle or at insertion
management of lateral elbow tendiopathy
EPAs DTF (deep friction massage) & Myofascial release Stretches Strengthening - eccentric Activity modification Bracing/taping
clinical pattern and presentation of cervical instability ?
Arcs, twinges on movement and especially onreturn
Increased trivial mech. stress; sustained postures
decreased nwb-but too long will aggravate
Persistent neck ache, recurrent
Gain short term relief with Rx-often directed at joints, muscle length etc
objective
Forward head posture
E: excess mid Cx movement –> p++ and p on return
Other Cx ROM = good
Generalised mobile jts
Mm-all groups weak esp deep Cx Flexors
Palp-thickened C4/5, depressed C4, prominent C5
PAIVM’s reduced C4 mobile, soft endfeel, deep p+ reduced C567=stiff
management of cervical instability ?
Early: pain relief with gentle mobs for mobile C4 and/or collar
Stronger mobilisation to reduce stiff levels
Later: Stability-endurance ex eg deep Cx flexors, intersegmental mm control
Fusion surgery, inject joints
Prophylaxis-modify work/recreation to limit strain on unstable jt
clinical pattern and presentation of cervical radiculopathy?
Acute
MP: Severe, sharp neck pain + referral into the arm +/- P+N and numbness, weakness
Area: Dermatome for n. root (distal worse)
Nature: severe, lancinating, stabbing, constant
HPC: Heavy, sustained, repetitive activity/ lifting, prolonged looking down/computer work, prolonged E activity,
Starts centrally & spreads /worsens
Chronic
MP: “Nuisance” pain
Area: Patchy within dermatome +/- P&N’s
Nature: Deep, residual, recurrent
Behaviour: Needs considerable activity to agg.
HPC: Not necessarily associated with particular incident
objective
Acute (BE CAREFUL)
Obs: Look very uncomfortable +/- list in anti-tension
Functional: Correct list to P1 (may increase symptoms later)
AROM: increased symptoms with E, LF, rot toward (i.e. compression) OR F/LF/Rotation away (stretch)
Neurodynamic: +ve (often latent change in symptoms)
Neurological: +ve
Chronic (need to be more aggressive with P/E)
Obs: Nil significant
AROM: often full or minor impairments
Palpation: thickening at the segment (unilateral)
PAIVMs: stiff around the segment (maybe worse above/below)
Neurodynamic: +ve++
Neurological: mildly +ve
management of cervical radiculopathy?
Multimodal (combination) approach best
Manual Therapy – PAIVMs, PPIVMs, Mulligan’s Apophyseal Glides techniques, (?short term alone)
Cervical traction - low kg, ↑ time
Neurodynamics - slider/tension-short term ↑function ↓pain
*Exercise Therapy: ROM, stretching and strengthening (isotonic, endurance), DNF retraining shoulder girdle muscle strengthening, increased general exercise)
Postural re-education, Advice and education - ↓ smoking, ↑activity, change ergonomics if aggravating
clinical pattern and presentation of UCL ligament injury of elbow
• Patient c/o pain medial (ulnar side) elbow
• HPC: traumatic – Hx of valgus force (on extended arm). Overuse – Hx of
repetitive throwing (baseball pitch)
• Agg: repeated throwing, elbow extension
objective • May have reduced grip strength • Limited AROM into elbow extension • Palpation tenderness over UCL/MCL • Valgus stress test +ve
management of UCL ligament injury to the elbow
Treatment • Strapping • Graduated exercise program • Electrotherapy (?) • If severe – surgical Mx
clinical pattern and presentation of golfers elbow? medial tendiopathy
• Body Chart: pain over medial epicondyle
region. May extend along medial forearm
• HPC: Gradual insidious onset. May report Hx of
chronic overload.
• No acute trauma. May occur 24-72 hours post
excessive activity ( sharp ↑ load)
• Agg: activities which involve
excessive/repetitive gripping/wrist
flexion/pronation,
• Ease: rest
Objective
• Reduced grip strength
• Pain with resisted wrist and finger flexion
• Palpation tenderness 1-2cm distal to medial epicondyle
• May have sensitivity with ULTT3 neurodynamic (ulnar nerve bias)
• May have cervical spine involvement (C7/T1 level)
management of golfers elbow ?
• No single treatment effective
• Combination of different treatments selected based on clinical presentation and
informed by current best evidence
Aims:
• Improve grip strength
• Treat impairments of UL, elbow and wrist
• Pain relief (Electrotherapy? Ice, bracing)
• Education
• Diagnosis, prognosis, correction of predisposing factors, activity modification
• Graduated Exercise program
• Gradual return to activity
• Manual therapy
• Mobilisation with Movement
• Soft tissue release
• Transverse frictions has little evidence
• Cervical mobilisation
• Bracing/taping
• Exercise – Tendon pathology principles
• Isometric, concentric, eccentric
• Electrotherapeutic modalities (ESWT, Laser, TENS, US)
• Mixed evidence on their effectiveness
• Therapeutic US has little evidence to support its use in LE
clinical pattern and presentation of scapholunate ligament injury
Common radial-side wrist presentation(tear/sprain)
• S-L ligament most important wrist stabiliser
• Rarely recognised acutely; imaging useful
• Need to consider Scaphoid fracture as differential
diagnosis**
• Scaphoid # should be considered with any contactsport athlete with radial wrist pain or patient with
FOOSH and c/o radial wrist pain
• Concern is long term scaphoid non-union
• Usually caused by hyperextension + radial deviation
force (FOOSH)
Patient c/o radial side wrist pain +/- clicking
• Agg: WB thru extended wrist, gripping, pushing up from sitting
• MOI: usually traumatic onset – excessive wrist ext i.e. FOOsh
Objectively • Obs: possible swelling S-L interval • Decreased ROM, esp into ext/UD • Decreased Grip strength • Watsons Test +ve • Tenderness on palpation
management of scapholunate ligament injury
Treatment
• Taping/Bracing/splinting
• Surgical management ?
clilnical pattern and presentation of thumb CMC OA
• Typically c/o pain + stiffness at base of thumb +/-
swelling, weakness
• Difficulty with fine motor tasks involving thumb,
reduced grip and pinch strength
Thumb CMC OA
• May have reduced AROM of thumb
• Reduced pinch strength
management of thumb CMC OA
- Treatment:
- Local symptomatic relief: heat, STM, distraction
- Education in thumb postures, ADL, relative rest
- Strengthen stabilising muscles: APB, APL
- Splint to facilitate stabilisation
- Medical Mx - CSI
