Week 4 Lecture 2

Question 1

• Describe the common causes of pain and tissue injury in the musculoskeletal system, and the relative place of physiotherapy treatment in each case

Answer 1

Acute:
Soft tissue
-Muscle tears
-Capsulo/ligamentous sprains
-Contusions
Articular
-Osteochondral lesions/fractures
Bone
-Fractures

Chronic/non-acute:
Lower limb overuse tendinopathies
Achilles
Patella
Tibialis posterior
Upper hamstring
Upper limb overuse tendinopathies
-Rotator cuff
-Lateral epicondylagia
-Medial epicondylagia

Fasciopathies/other non-contractile tissue disorders

                            	- Plantar fasciopathy
               - Retinacular and ligamentous stress reactions

Chronic exertional (exercise =-related) syndroms
Bony disorders
Bony stress reactions
OCDosteochondritisdissecans)
Bone stress injuries
Stress fractures
Joint disorders
Articular stress reactions
Degenerative joint disorders
Inflammatory diseases
RA, spondylopathies
Infections
Congenital lesions, deformities

Question 2

Outline the mechanisms of injury for muscles, ligaments, joint surfaces (including bone & cartilage), tendon and fascia, and the clinical classification systems used in each case

GO INTO MORE DETAIL?

Answer 2

Muscles:
Functional muscle injury – acute indirect muscle disorder, no macroscopic evidence (in MRI) of muscular tear. Associated with increase of muscle tone

Structural muscle injury – any acute indirect muscle injury with macroscopic evidence
Classically labeled as a ‘strain’ injury

Ligaments:
Grade I, II, III, IV (III plus avulsion)
Indicates severity

Joint surfaces:
Isolated OC lesion
Associated lesion

Classfication:
Matrix and AC cell injuries (micro-trauma to joint surface)

Chondral injury- Cartilage disruption
(macroscopitc injury, variable patterns: fissure, flap, tear)

osteochondral injury (Cartilage + bone disruption)

• also classified with grades 1-4

Tendon:
Reactive/proliferative
Hx of acute overload
De-trained athlete returning to training
Tendon disrepair
Hx of repeated or chronic overload
Degenerative tendinopathy
Long term (mal)adaptive changes

Fascia:

Question 3

Classification of musculoskeletal disorders

Answer 3

INDIRECT vs DIRECT

Indirect: Structural vs Functional

Stage: (acute, subacute, chronic)

Grade: severity of injury

Associated injuries

Question 4

Define indirect and direct injuries

Answer 4

Indirect:
Inability to tolerate forces transferred to or generated within a tissue structure

Direct injury:
Contusion or impact injury

Question 5

List all the types of musculoskeletal injury

Answer 5

INDIRECT
Type 1 overexertion related (functional)
-Ia Fatigue induced
-Ib DOMS

Type II Neuromuscular disorder( functional)

• IIa Spine related muscle disorder
• IIB Muscle related muscle disorder

Type III Partial muscle tear (Structural)

• IIa minor partial tear
• IIb moderate partial tear

Type IV (sub) total muscle tear(Structural)

DIRECT- contusion
-laceration

Question 6

What is a type Ia neuromuscular injury?

*Focal involvement up entire length of muscle

Answer 6

Over exertion related disorder
IA Fatigue induced mms disorder

Circumscribed longitudinal increase in mms tone due to overexertion (change of playing surface, change in training patterns)

Aching mms firmness, can provoke pain at rest, during or after activity

Dull diffuse tolerabel pain in involved mms
Circumscribed increase in tone, mms tightness

MRI: neg

Question 7

What is a type Ib neuromuscular injury?

• mostly entire muscle or muscle group

Answer 7

OVEREXERTION RELATED DISORDER
DOMS

Generalised muscle pain following unaccustomed eccentric deceleration movements

Acute inflammatory pain. Pain at rest hours after activity

Odematous swelling, stiff mms, limited ROM, pain on isometric contraction
Stretching leads to releif

MRI: Neg or odema only

Question 8

What is a type 2a neuromuscular injury?

• muscle bundle or larger muscle group along entire length of muscle

Answer 8

NEUROMUSCULAR DISORDER
Spine related neuromuscular disorder

Circumscribed longitudinal increase in mms tone
due to functional or structural disorder

Aching mms firmness. Increases with continued activity
No pain at rest

Discreet odema b/n mms & fascia occasional skin sensitivity. Defensiver reaction on muscle stretching. Pressure pain.

MRI: neg or odema

Question 9

What is a type 2b neuromuscular injury?

*Mostly along entire length of muscle belly

Answer 9

NEUROMUSCULAR DISORDER
Muscle related neuromuscular disorder

Circumscribed (spindle shaped) area of mms tone
Results from dysfunctional neuromuscular control

aching gradually increases mms firmness
Cramp like pain

Odematous swelling, theraputic stretching> releif
Pressure pain

MRI: neg or odema

Question 10

What is a type 3a neuromuscular injury?

• primarily muscle-tendon junction

Answer 10

PARTIAL MUSCLE TEAR
Minor partial muscle tear

Tear with max diameter less than muscle fascicle/bundle

Sharp needle like stabbing pain at time of injury

Well defined localised pain
Palpable defect in fibre structure within a firm muscle band

Stretch induced pain aggravation

MRI: pos for fibre disruption. intramuscular hematoma

Question 11

What is a type 3b neuromuscular injury?

• primarily muscle-tendon junction

Answer 11

PARTIAL MUSCLE TEAR
Moderate partial muscle tear

Tear with diameter greater than fasicle/bundle

Sharp stabbing pain @ time of injury

Well defined localised pain
Palpable defect in muscle structure
often hematoma fascial injury
Stretch induced pain aggragation

MRI: pos for sig fibres disruption & retraction
Intramuscular hematoma
Fascial injury

Question 12

What is a type IV neuromuscular injury?

• primarily muscle- tendon junction

Answer 12

Sub total muscle tear/tendinous avulsion

Tear involving subtotal/complete muscle diameter
Tendinous injury involving bone tendon junction

Dull pain @ time of injury
Noticable tearing
‘snap’ followed by sudden onset of localised pain

Large defectin in muscle 
Hematoma 
Muscle retraction 
Pain with movement
Loss of function

MRI: subtotal/complete discontinuity of muscle

Question 13

Direct muscle injury

Answer 13

Direct mms trauma caused by blunt external force
Leads to diffuse or circumscribed hematoma within muscle causing pain and loss of motion

Dull pain @ time of injury
Increased due to hematoma

Dull diffuse pain
Hematoma
Pain on mvmnt
Swelling
Decreased ROM, TOP

Question 14

Discuss the methods of diagnosis and clinical features of various injuries to muscles, ligaments, joint surfaces (including bone & cartilage), tendon and fascia

Answer 14

Muscle:
              	Ultrasound
              	MRI
              	Clinical diagnosis usually adequate
Ligaments:
              	Abnormal end-feel

Joint surfaces:
CT scan
MRI

HORRIBLE ANSWER

Question 15

Discuss the role of immobilisation and early mobilisation for common injuries to the musculoskeletal system

Answer 15

Challenged wisdom to mobilise aggressively post ankle-sprain:
Resulted to severe, acute ankle sprain injuries
Found superior results with a period of immediate complete immovilisation versus early, aggressive mobilization at 10 days post
But same outcomes at 6/12

CLINICAL BOTTOM LINE:
Limited period of joint protection with a graduated return to FWB is indicated – including some relatively mild cases

Question 16

Ligament Injury

Describe the grades

Answer 16

GRADE 1
4-10% deformation 
A few fibres torn, capsule intact, joint stable
Painful on stress testing
Increased range/laxity on testing
End feel may be slightly softer

GRADE 2
10-20 % deformation
<50% fibres torn +- capsule tear, joint stable
Painfull on stress testing
Significantly increased range/laxity on testing
End feel markedly soft

GRADE 3
>20% deformation
\+- capsule tear, joint unstable
may or may not be painful if complete rupture
marked abnormal laxity on testing
Hollow end feel

GRADE 4
Grade 3 + avulsion

Question 17

Classification of Cartilage injuries

The 3 stages

Answer 17

MATRIX INJURIES

• variable pain response
• low grade effusion & synovitis
• undetectable on imaging
• some cell proliferation, generally reversible

CHONDRAL INJURIES( cartilage destruction)
Pain & intolerance of joint loading
Synovitis & effusion more marked
Mechanical symptoms more common
*synovial macrophages ingest particles & release catabolic substances
* some attempt to repair at margins(chondrocytes unable to migrate to to lack of inflam response)
* increased matrix synthesis at margins but deficit not repaired

OSTOCHONDRAL INJURIES(cartilage+subchondral bone
Grade 4 or greater
-Hemmorage clotting with associated inflam response
-Clot fills bone defect
-Platelets release growth factors
-Chondrocytes produce hyaline cartilage in defect
(2 weeks post)
-Immature bone & fibrous osseous tissue fills osseous defect
-Chondral repair (6-8) weeks repair breaks down within (1-2) years
Defect leaves subchondral bone exposed

Question 18

Classification of Chondral injuries

Answer 18

Grade 0 = normal
1 Chondral softening & blistering
2 Partial thickness AC injury less than 50% depth
3 Deeper partial thickness AC injury > 50% depth
4 Full thickness cartilage loss with exposure of subchondral bone

Clinical features
Effusion on MRI
Bone scan. Increased BF in synovial lining
XRay only detects ostochondral lesions