Week 4: Multifactorial/Multicomponent MSK conditions

Question 1

What aggravates PFP

Answer 1

tasks that increase patellofemoral joint loading
such as
- jumping, running, squatting, stairs, prolonged sitting

Question 2

Differentials for PFP

Answer 2

chrondomallacia patella 
patellar tendinopathy 
osgood schlatters
sinding larsen-johansson's disease 
bursitis 
pleural of neuromas 
intra-articular pathology
plica syndrome

Question 3

What is the most common alternative diagnosis to PFP

Answer 3

patellar tendinopathy

Question 4

How to differentiate between PFP and patellar tendinopathy

Answer 4

Onset
running, stairs, WB knee flexion vs jumping, change direction, stairs

pain
nonspecific, vague vs patella inferior pole

Aggrav
activities that load PFJ vs jumping, early to mid squat

Inspection
normal or VMO wasting vs general quads wasting

TOP
medial, lateral patella facets, inf patella or non vs inferior pole and possibly tibial tuberosity, rare mid tendon

Swelling
occasional vs tendon thickening

Question 5

Differentiation #2

Answer 5

click, clunks and crepitus
give way = occasionally
knee ROM = normal, reduced in severe cases vs normal with OP

Quads concentric contraction = normally no pain but not quality vs possibly painful

PFJ= potential restriction any direction but commonly medial vs normal unless combined with PFPS

VMO =potential for weakness & deficits in tone and timing vs general quads weakness

function = stairs & squats may aggrav, PFJ taping decreases pain vs decline squat aggravtes, PFJ tape less effect

Question 6

Extrinsic factors that lead to PFP

Answer 6

excess training load
altered training surface
incorrect footwear

Question 7

intrinsic factors that lead to PFP

Answer 7

gender
weak medial
tight lateral
torsion of the femur /tibia 
eversion of the foot
 larger Q angle 
sulcus sign 
patella tilt 
decreased abduction strength of the hip and decreased ER strength of the hip lead to lower knee peak extension torque

Question 8

Proximal treatments of PFP

Answer 8

hip abductor and ER strengthening

Question 9

Distal treatment for PFP

Answer 9

orthoses

Question 10

Local treatment for PFP

Answer 10

taping
PF mobes
vasti retraining

Question 11

what is considered gold standard approach to treatment for PFP

Answer 11

multimodal approach 
including taping
vasti retraining
gluteal strength 
patella mobes and stretches

Question 12

Sum up conservative treatment success for PFP

Answer 12

high success rate short term but long term is questionable

Question 13

what is the role of supraspinatus

Answer 13

superior role of HOH
compresses HOH into glenoid fossa
restricts excessive superior translation of humerus

Question 14

role of infraspinatus, teres minor and subscap

Answer 14

depression force on HOH

Question 15

Role of infraspinatus and teres minor together

Answer 15

externally rotate humerus

Question 16

Primary external impingement is

Answer 16

abnormalities of superior structures encroach into subacromial space
undersurface of the acromion may be beaked, curved, hooked
thickening of the coracoacromial arch or osteophytes on inf AC joint in older populations

Question 17

Secondary external impingement includes

Answer 17

excessive angulation (anterior tilt and IR) of acromion due to inadequate muscular stabilisation of scapula in younger athletes 
- altered activation patterns or strength imbalances (eg. deltoid vs RC)

RC tendons weakened by large volumes of activity

Question 18

Internal impingement is

Answer 18

occurs mainly in overhead sportspeople during late cocking stage of throwing (ext, abd+ER)
RC undersurface impinged against posterosuperior glenoid surface

may become pathologic due to repetitive trauma/overuse and injury to superior labrum

Question 19

Tendinopathy development involves

Answer 19

tendon becoming swollen and hypercellular
collagen matrix disorganised and tendon is weaker
increased vascularity and nerve density

volume is major determinant

Question 20

3 stages of tendon pathology

tendon pathology continuum

Answer 20

reactive tendinopathy

• non-inflammatory proliferative response
• acute overload

tendon dysrepair

• similar, but greater matrix breakdown
• chronic overload

degenerative
-progression of both matrix and cell changes/breakdown
areas of cell death
Ageing or chronic overload

Question 21

clinical presentation of supraspinatus tendinopathy

Answer 21

complaints of pain with overhead activities
activities <90 degrees may be pain free
ER can be a problem
possible Hx of associated symptoms of instability including recurrent subluxation
Episodes of dead arm
night pain is extremely common
difficulty sleeping
symptoms may be reproduced with impingement tests
EOR passive flexion - symptomatic
Resisted supraspinatus contraction
- resisted upward movement in 90 degrees abduction, 30 degrees horizontal flexion +IR
MRI = investigation of choice to determine presence of partial tears

Question 22

treatment of supraspinatus tendinopathy #1

Answer 22

avoid aggrav activities
Ice
single corticosteroid injection

Question 23

treatment of supraspinatus tendinopathy #2

Answer 23

correction of abnormalities 
GH instability 
Muscle weakness or imbalance 
ST tightness
Impaired scapulohumeral rhythm 
Training errors

Question 24

Exercise therapy for the shoulder

Answer 24

the shoulder is highly muscular dependant
muscle recruitment patterns, coactivation and force couples are vital for normal function
minimise pain to avoid pain inhibition
- pain relief is a key to success

Question 25

Exercise rehab for supraspinatus tendinopathy can include

Answer 25

addressing decreased rotator cuff strength or imbalance
- target ERs
Restore correct SH rhythm
Stretching of the posterior capsule + Tx spine mobilisation

Question 26

Closed chain exercises can be used in supraspinatus rehabilitation, what are the suggested parameters

Answer 26

proximal to distal sequencing allows optimum force generation
safe muscle loads and activation levels
decreases tensile stresses on ligament and tendons
enhances proprioceptive function
provides stability to the ST joint
force closure to the GH joint

abnormalities along the kinetic chain must be identified and corrected
- training errors such as technique and overuse should be corrected-

Question 27

Plyometrics for supraspinatus rehabilitation

Answer 27

development of power
utilise stretch-shortening cycle
heightens excitability of nervous system

goal is to decrease amortization time phase

Question 28

What is a SLAP lesion

Answer 28

due to excessive traction through labrum via LH biceps
extend from ant to biceps tendon to posterior to tendon
stable or unstable depending on amount of superior labrum and LH biceps tendon firmly attached to glenoid margin
4 types - classification

Non-Slap
- degenerative, flap and vertical labral tears, Bankart lesions, Hill-Sachs

Question 29

the 4 types of SLAP lesions are

Answer 29

Type 1: attachment of the labrum to glenoid attached but fraying and degeneration present
Type 2: lesions with detachment of Sup labrum and LH biceps tendon from glenoid rim
Type 3: meniscoid superior labrum torn away & displaced into joint but tendon & its labral rim attachment intact
Type 4 : tear of sup labrum extends into tendon and these are displaced into joint

Question 30

Clinical presentation of glenoid labrum injuries

Answer 30

Hx - often MOI or excessive traction on labrum via LH biceps

Pain in posterior or posterosuperior joint line esp in abduction
pain increased by overhead and HBB positions
popping, catching, grinding
TOP ant shoulder
pain on resisted biceps contraction
dynamic labral shear test +ve
MRI often unnecessary with combination of clinical tests more sensitive

Question 31

Treatment of glenoid labrum injuries

Answer 31

conservative Mx is generally unsuccessful except in extremely minor cases (always SLAP type 1)
-if so, avoid heavy weights

surgical repair generally indicated
-arthroscopic SL repair +/- debridement

Post surgery - exercise program - no gold standard
Evidence on rate of return to participation post surgery is in consistent
- return to pre injury levels of participation in athletes that perform overhead activities consistently lower than non-throwing/non overhead athletes