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nd

2 Year
Physical Therapy Notes

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CONTENTS

Osteoarthritis 2 Frozen Shoulder 73


Rheumatoid Arthritis 4 Acromioclavicular Strain 77
Still's Disease 5 Tennis Elbow 79
Ankylosing Spondylitis 6 Golfer's Elbow 82
Gout 8 Olecranon Bursitis 83
Osteoporosis 9 The Elbow – Deformities 84
Acute Osteomyelitis 11 RA and Sprain 85
Chronic Osteomyelitis 12 Fractures and Ulnar Neuritis 86
TB of Bones and Joints 13 OA Wrist, Hand and Fingers 87
Coccydynia 15 Tenosynovitis, De Quervain's 88
PID, Lumbar Disc, Intervertebral Disc 16 Wrist Sprain 89
Cervical Disc, Spondylolysis 19 Nerve Injuries to the Hand 91
Posture 21 Osteoarthritis of the Hip 93
Scoliosis 23 Snapping Hip, Bursitis 96
Kyphosis Arcuata 27 Hip and Pelvic Examination 97
Lordosis 29 The Knee -- Screw home principle 98
Physical Examination of the Spine 30 Chondromalacia Patella 100
Fractures 32 Osgood Schlatters Disease 101
Colle's Fracture 34 Patella OA, Tendinitis 102
Soft Tissue Injuries …Muscles 36 Coronary Ligament Sprain 106
…Ligamentous 41 Effusion 107
…Tendons 47 Knee Sprain 108
…Fascia 50 Popliteal Tendinitis 108
Bursitis 52 Foot and Ankle Conditions 111
History Taking 56 Metatarsalgia 112
Application of Cold 58 Flat Foot 113
Application of Heat 61 Pes Cavus 114
Adhesions and Limited ROM 61 Hallux Valgus 114
Shoulder 64 Hallux Rigidus 115
Inspection of Shoulder Joint 65 Sprained Ankle 116
Painful Arc Syndrome 66 Surface Markings of the Foot and Ankle 117
Supraspinatus Tendinitis 69 Foot and Ankle – Resisted Movements 119
Subacromial Bursitis 70 Goniometry Notes 121
Rupture of Long Tendon of Biceps 72 Piriformis Syndrome 128

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OSTEOARTHRITIS. (O.A.)

Osteo Arthritis, Degenerative Arthritis, Wear and Tear.

Definition:
A degenerative joint disease giving rise to painful impairment of function and deformity
and building later to displacement.

Causes.
Wear and tear due to micro trauma and age. Age changes in cartilage can be seen:-
young cartilage is red and shiny, old cartilage is brownish in colour. There is an
impaired capacity for tissue repair inherent in the process of ageing.
Micro - trauma. Due to sports injuries, especially rugby or golf players (heavy
contact sports) General day to day trauma. Occupational factors.
Obesity and Stress. O.A. occurs in weight bearing joints, hence the relatively
lightly stressed joints of the upper limb are in general, less prone to O.A. than the
heavily stressed joints of the lower limb.
Post Traumatic O.A. After mass trauma.
Internal derangement such as loose bodies or a torn meniscus.
Any congenital abnormality ie congenital dislocation of the hip and inflammatory
joint disease and leading on to O.A. ie secondary O.A.
Joint mal-alignment from any cause ie bow leg.
Climate. High or low pressure which causes joints to expand or contract. They feel
worse at different times of the year. Climate can aggravate the symptoms.
Diet. As a causative factor there is no scientific back up. It is not proven that it
affects joints. However we try to keep patients away from acid forming foods.

Pathology.
Any joint in the body may be affected. The moving part of the joints are primarily
affected, so that the first change is in the articular cartilage. The cartilage begins to
wear, it becomes roughened and little cracks begin to appear along the surface.
Eventually this leads to erosion of the cartilage. As it wears the underlying bone
becomes visible, eventually leading to bare bone as it becomes weight bearing.

Bone surface changes.


As the above process is going on the exposed bone becomes sclerosed (hardened) and
surface grooves develop. This sub-chondral (sub cartilage) bone is then known as
eburnation.
The main changes occur at the points of greatest pressure ie points that undergo the
weight. What happens is that the body tries to lay down new layers of bone due to the
absence of cartilage.
The bone hypertrophies (increases in size according to demand) at the edges to form
outgrowths of bone known as osteophyte or spurs. Beneath the sub chondral bone cysts
can develop (subchondral cysts).
If they increase in size it can lead to collapse. No major changes in the capsule or
synovial membrane, but some thickening/fibrosis may develop later. As the process
continues the joint spaces approximates.

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Joints affected by O.A.
Major weight bearing joints are most effected, especially the hips and knees. The spine
is also commonly effected, especially the lower lumbar and cervicals. It is not as
common in the S.I. joints.
Note: Ankle joint is not affected as much as other joints as weight is distributed as much
through the M.T. joints as it is through the ankle joint.

Clinical Features.
There are 5 sets:- Pain, Stiffness, Swelling, Deformity, Loss of function

Pain.
It is described as a deep ache. The onset is gradual, but severity increases as disease
progresses. Pain increases with exertion and disappears with rest. Pain increase during
the day.

Joint Stiffness. 2 Types


a) due to a reduction in the range of movement as a result of thickening of capsule and
osteophyte.
b) due to articular swelling.
Mainly morning stiffness which disappears after half an hour with movement. There is
usually stiffness after prolonged sitting.

Swelling.
There is a lot of swelling around the joint for two reasons
a) accumulation of fluid within synovial capsule, which after rest becomes viscous or
sticky.
b) infiltration of fluid into surrounding tissue.

Deformity.
This occurs if the joint is destroyed.

Loss of function.
Due to osteophyte encroachment, thickening of capsule, pain, erosion of bone and
cartilage.

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RHEUMATOID ARTHRITIS

Definition: This is an inflammatory joint disease which affects the synovial joints.

Causes.
Difficult to understand. Causes are unknown.
There is a genetic predisposition.
Immunological fault is the major theory now.
Virus theory, but this is not proven
An allergic response.
Pathology of R.A. is very involved. Resentment, tension and anger are sometimes
associated.
R.A. factor in blood found in patients who have not got R.A.

Clinical Features.
Generally it is polyarticular but it can be monoarticular.
Onset is usually insidious and there are no major signs.
May be history of mild attack of pain months before.
Vague joint pains.

Main Signs and Symptoms


• Pain especially with movement
• Local heat around joint and warmer than normal
• Redness
• Swelling from synovial thickening
• Deformity
• Affects females more. 25 to 55 years are the commonest ages.
• It usually starts in the smaller joints of the hands and toes, spreading later to the
wrists, knees, shoulders, hips. It can however start in any joint.

Non Articular disorders of R.A.


Anaemia, tiredness, lethargy, loss of weight and appetite, muscle wasting around
affected joint. They can precede joint symptoms by up to a year. Skin can become tight
and wasted.
Prone to leg ulcers especially of the lower tibial shaft (may start 6 to 9 months before
the joint is affected). Sub-cutaneous nodules which are firm, non tender and mobile are
present in 20% of patients with R.A. especially around prominences egg elbow, knees,
wrist. Muscles tend to be weak.

Other Systemic Manifestations.


These are many and varied.
There may be eye and cardiac involvement e.g.: Rheumatic Fever, Pericarditis, Pleurisy
( may precede R.A.), Rheumatoid nodule in lung.

Pathology
Mainly affects the synovial membrane of joints. There is a lot of inflammation and
thickening around the affected joints. Severity can vary from moderate to intermediate,
to total joint destruction.

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STILL'S DISEASE.

Juvenile Rheumatoid Arthritis. (J.R.A.)

Definition: A form of R.A. occurring in patients under 16 years. J.R.A. in children is


similar in most respects to that occurring in adults.
It is thought that the disease is not a single entity, but that it comprises a number of
conditions that are more or less distinct, though features common to all are pain,
swelling and stiffness of the joints. The disease is modified in that it tends to affect the
larger joints with resultant changes in growth and development.

General signs and symptoms.


It is not very common.
It may be mono or poly arthritis and the prognosis can vary a lot.
It may start with a fever, swollen lymph glands and tiredness. Within a few weeks may
get marked joint symptoms such as mild aches and pains.
Children tend to lose weight rapidly. Often there is a marked rash - raised mapula,
papula on the face and trunk.
N.B. Must distinguish between growing pains.
In children it tends to affect the elbows, knees and wrists whereas in adults it tends to
be polyarthritis.
There may be a family history of R.A.
In 20% there is liver enlargement, spleen enlargement, generalised lymph problems and
pericarditis occurring.
Often an anaemia will be present.
10% get eye problems such as scleritis or Iritis.
There may be a growth retardation, shortness of stature, and a deformity leading to
varying degrees of disability.

Types.
Sero - positive J.R.A. Very similar to R.A. Begins late in childhood, and effects girls
more than boys.
Classical Still's disease. Begins in early childhood, with liver and spleen involvement
(hence classical).
Sero negative disease with sacro - iliactis is common in boys and begins in late
childhood. It tends to lead to ankylosing spondylitis.

Treatment.
Aspirin.
Anti inflammatory drugs.
Gold injections.
Corticosteroid if eye involvement
Rest
Physio/Massage
Operation - if fixed flexion deformity
Passive exercises and splints usually prevents fixed flexion contractures.

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ANKYLOSING SPONDYLITIS.

Definition: A chronic yet actively progressive condition that affects not only the spine
but other joints also, in which destruction of the joint space occurs and is followed by
sclerosis and calcification.

Causes.
Unknown.
Tends to be familial.
Commonest age group affected 15 - 20 years.
Begins with lower back and Sciatic pains and then progresses up the spine over a
number of years.
Pain is episodic at first and then becomes constant.
More stiffness develops as the condition progresses, and the degree of stiffness depends
on the degree of inflammation. Rest seems to make the condition worse, while
movement seems to ease it.

There are 5 important sets of factors for diagnosis:-


• Onset of back discomfort before the age of 40
• An insidious as opposed to sudden onset.
• Persistence for more than 3 months.
• Association with early morning stiffness.
• Improves with exercise.

May commence with heel pain, rather than S.I. pain.


Difficult to diagnose early on, but mobility testing reveals loss of movement.

Test.
Measure chest expansion if the thoracics are involved.
Ask patient to reach toes.
Stand patient against wall and see if head touches wall easily. If fixed flexion deformity
of neck, record distance from wall.
Later develops in the cervicals. Note:- May commence in the cervicals.
In some cases the hips and shoulders are involved.
Classic C-shaped spine in later life.

Pathology.
This is an inflammatory process which primarily affects the spine and involves
cartilage, sub-chondral bone and the ligamentous and tendinous insertions into bone and
periosteum. Eventually the ligaments around the spine calcify and give the spine a
"bamboo look".
It usually begins in the S.I.J's. and pubis, next the lumbars, then the thoracics and ribs
and then the cervicals. Or it may develop in one area only. Sometimes the hips,
shoulders and heels may be involved. It usually commences with lower back pain and
stiffness. After a certain period of time the inflammation becomes dormant, having
varying degrees of stiffness, flexion deformity of the spine, respiratory infection and
ileitis.

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Diagnosis.
X-ray
Increased E.S.R. (rate at which red blood cells stick together)
H.L.B. 27 Antigen.

Medical Treatment.
Anti inflammatory drugs
Corticosteroids if systemic e.g. eye involvement.
Wedged osteotomy if very bad.

Treatment.
Flat firm mattress, single pillow to prevent flexion deformity of spine.
Postural correction instruction to avoid bending and stooping.
Isometric exercise especially for extensor groups of the spine and legs.
Breathing exercises for the chest to keep mobility.
Light sports, particularly swimming and stretching.
Massage.

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GOUT

Definition: An abnormality of the purine metabolism whereby the blood uric acid
levels is raised and sodium Biurate crystals are deposited on soft tissues, particularly
near the smaller joints.

Causes.
Inadequate excretion of uric acid.
Over production of uric acid.
Inherited predisposition to the disease.

Clinical Findings.
Patient is usually middle aged.
It affects men more than women by a ratio of 20:1
60% of U.K. sufferers have a familial history.
There is a sudden onset of pain in the joints especially meta-tarsal phalangeal joints.
Or the hallux.
Pain may start at night.
Patient may have gout for a long time and it is escalated by trauma, e.g. hitting the foot
of a wall may cause a flare up in symptoms.
On examination - heat, redness, swelling, throbbing pain, tender and very shiny.
After a few days the symptoms subside, only to recur, sometimes in a different joint.
The main joints affected are the toes, ankles, small joints of the hands.
May also occur in the ear lobe, which is known as tophi. Or can occur on other sites.

Pathology.
Due to an impaired excretion of uric acid by the kidneys you get a build up of urates in
the blood stream. This in turn can lead to the formation of crystals which may be
deposited in various tissues.

Diagnosis.
Sudden onset
History of previous attack with symptom free intervals
Raised plasma urate level.
Detection of crystals; synovial fluid.

Treatment.
Drugs to reduce urate level
Increase high content purine foods
Organ meats/meats/shellfish
Alcohol as it decreases uric acid secretion.

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OSTEOPOROSIS.

Definition: Fragility of bone due to reabsorption of calcium or


A reduction in the amount of bone tissue; the tissue remaining is normally calcified.
Rarefaction of the bone.

Pathology.
Osteoporosis should be regarded as a multifactorial process of diverse etiology and it
should be considered as a disease and not solely as part of the ageing process. The term
osteoporosis indicates porosity, brittleness and rarefaction of bone. There is loss of
bone mass accompanied by rarefaction of the skeleton. The major pathology is that
there is a greater proportional loss of trabecular than of compact bone which accounts
for the primary complication of the disease, i.e. compression fractures of one or more of
the vertebral bodies. The spine generally tends towards Kyphosis and the long bones
are also prone to fracture.

Types.
Disuse
Post - menopausal
Steroid
Juvenile
Hyperthyroidism
Idiopathic (senile) The first 3 are the most common.

Causes.
Age. When the rate of cell death outstrips that of repair, therefore more common in
older people.
Lack of exercise.
Gravity. Individual must be upright and mobile for at least 2 hours a day, otherwise
become osteoporotic.
Age types. Senile osteoporosis; old and osteoporotic.
Recumbent; bedridden.
Climacteric; post-menopausal osteoporosis
Post traumatic. A damaged joint may develop osteoporosis.
Malabsorption or malnutrition.
Drug - induced; Steroidal osteoporosis, especially if intravenous and can happen within
six months.
Greater frequency in white than in blacks.
Defective intestinal calcium absorption and Vitamin D deficiency
Hormonal, Lifestyle, Nutritional and Environmental
Endocrine disorders, such as Cushing's syndrome, Hyperparathyroidism,
Thyrotoxicosis.

Clinical Findings
May be asymptomatic for long periods.
Pain in the back.
May be due to vertebral collapse. It can come on suddenly after moving furniture or
similar minor trauma.
Patient may notice loss of height.
Increase in Kyphosis.
Disc compressions leading to neural complications.
Increased in the over 55 age group.
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Weight bearing affects below T8 area of spine.

Treatment.
Isometric Extensions
Activity.
Vegetarian Diet
Physical Therapy.
A high protein diet or high in phosphates is associated with an increase in the excretion
of Ca in the urine. High sugar intake also leads to an increases of Ca excretion in the
urine.

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ACUTE OSTEOMYELITIS.

Definition: A.O. is basically an infection of bone and bone marrow. It affects children
in the 4 to 16 age group predominantly, and mostly boys in a 3:1 ratio. Tibia, fibula and
humerus are most commonly affected, but it can occur in any long bone.

Cause.
It's a pyogenic (pus forming) infection of bone. The most common organisms are:-
a) Staphylococcus Orus in 86% to 90% of cases
b) Streptococcus Pyogenic .4% to 6%
c) Pneumococcus

Pathology.
There are 2 modes of infection:-
Haematogenous is the most common.
Via open fracture.

Haematogenous.
Usually it begins at the end of a long bone near the metaphysis. The symptoms often
begin after a minor trauma, as the trauma can create a haematoma near the epiphyseal
plate. The haematoma provides an ideal breeding ground for the bacteria reaching it
from the blood stream.

Clinical Findings.
Patient gives recent history of a contusion, skin abrasion, bruise, bone injury, skin
lesion or recent history of sore throat.
There is a rapid onset especially in children. The child feels ill and there is pain on the
affected joint.
There may be a constitutional illness and a high temperature.
Initially, as the lesion is within the medullary cavity, while tenderness is marked, local
heat and swelling are not obvious.
These rapidly follow as the sub-periosteal abscess forms.
40% give reliable history of previous trauma.
Pain increases and is not relieved by rest.
Marked redness and swelling, stretching and tension in overlying skin.
Touching the skin can cause the child to "freak".
Child will hold the limb still.
Biggest confusion is a fracture.
Marked tenderness is over a bone, whereas in Still's disease it is over a joint.

Treatment.
Rest
Broad spectrum antibiotics
Surgery to expose bone
Open areas/ strip periosteum/ clear pus/ remove sequestrum.
Drill bone/ drill holes.

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CHRONIC OSTEOMYELITIS.

This comes in 2 ways:-


• Neglected acute which has been left untreated, get retardation of growth in that limb.
Totally pus-filled cavity in bone changing to honeycombed granulation tissue.
• Acute which falls into chronic. Purulent discharge from sinus, either continuous or
intermittent or get a flare up ie. reappearance of a previously healed sinus, or the
formation of a sub-periosteal sinus.

Cause.
This occurs after irreversible changes have taken place in a bone and is due to the fact
that the causative organism can lie dormant in avascular necrotic areas, occasionally
becoming reactivated, resulting in a flare up.

Clinical Features.
Quiescent Phase which may last for years with no symptoms
Scars from past sinuses are visible.
Intermittent flare ups, especially after minor trauma or may come spontaneously
immediate pain and constitutional illness, heat, swelling, redness, fever, sinuses, leading
to pus.

Treatment.
Drain Abscess
Clear dead bone replacing bone chips.
Antibiotics.

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TUBERCULOSIS OF BONE AND JOINTS

Myobacterium tuberculosis.
T.B. of spine = Pott's Disease.
Tubercle bacillus.
Rare in western countries due to hygiene and living standards. Still very common in
developing countries, was known as galloping consumption.

Definition.
Infection of a joint with tubercle bacilli.

Transmitted.
Via droplet infection (usually human)
Ingestion of bovine material. More prominent before herd testing.

Pathology.
• It enters via droplet infection coming in contact with sputum, drinking infected milk
or via skin wound.
• Usually the main focus of infection is dormant in the lungs or the Alimentary tract.
• No joint is immune for infection, but intervertebral lumbars or thoracics are most
often infected followed by the hip and knee joint.
• Tubercles bacilli may primarily infect bone or the synovial membrane, but in the
majority of cases eventually both the joint and neighbouring bones are infected
together.
• The tubercle bacilli at first causes an inflammatory secretion, in which are found the
typical tubercles giant cell and sound cell infiltration. (They basically multiply
rapidly and form giant cell systems which actually melt away the normal joint cell
tissues).
• NOTE: unless the disease is halted at this stage you will normally get destruction of
a joint.
• Soon this is followed by tissue necrosis and the formation of a tubercular abscess
known as ?. The abscess may reach the skin surface and rupture giving rise to
tuberculous sinus. This may provide a route of entry for the secondary infecting
organisms.
There are 3 phases in joint T.B.:-
• Active infiltration of synocium and muscle wasting. If caught can be restored to
normal.
• Beginning of cartilage destruction. If caught before articular cartilage affected can
return to normal. If caught after articular cartilage affected, you can get healing with
fibrosis.
• Aftermath. Cartilage erosion.
• Fibrosis.
• Unsteady joint.
• Bacilli liberated -- reinfection -- joint destruction.

Clinical Features.
• Gradual onset of general illness.
• Patient looks ill and wasted.
• Looks pale and thin, suffers from loss of appetite, anorexia, weight loss, night
sweats.
• Predominant symptoms are pain, swelling, and impairment of swelling of the
affected joint.
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• On examination get warmth of overlying skin and swelling from synovial thickening
and limitations of movement in all directions.
• Forced movement induces sharp pain and protective muscle spasm.
• Muscles controlling the joint are usually wasted.
• Abscesses or sinuses of the ?
• A tuberculous lesion may be found elsewhere.
• Often a history of contact with a patient having a history of active pulmonary
tuberculosis.

Diagnosis.
• is raised.
• White blood cell count shows some lymphocytosis.
• Sputum -- tubercle bacilli.
• Montour test.
• X - Ray.

Treatment.
Rest
Fresh air.
Immobilisation of joint.
Splints
Aspirate abscess
Streptomycin
Isoniazid
Para-aminosalicylic acid
Chemotherapy.

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COCCYDYNIA.

Description.
Any painful condition in the region of the coccyx.

Cause.
Usually a history of trauma such as a kick in the posterior, or fall from height on to the
buttocks, giving birth.
Due to P.I.D. or pelvic disorders ( e.g. cancer of rectum). Referred pain due to hypo-
mobility lesion of the L/S spine

Signs and Symptoms.


It's very sensitive to injury and difficult to eradicate.
Common in women because of the increased width of the pelvic outlet.
Severe pain on sitting or can only sit for a few minutes. (difficulty in rising from a
sitting position), or there may be pain during defecation.
No pain experienced on standing or walking.

Pathology.
May just be strain from the sacro coccygeal joint.
May be a contusion of the periosteum over the inferior aspect of the sacrum or coccyx.

Usually there is a deviation, either anteriorly or laterally of the coccyx, especially after
trauma.
Sometimes the problem can resolve spontaneously.

Treatment.
Hydrocortisone injection.
Coccygectomy but with limited success, ie coccyx may be excised.
Inhibition techniques either side of the coccyx.

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P.I.D.

Prolapse
Herniation, Grades 1, 2, 3, 4.

Anatomy.
Intervertebral discs are more liable to give trouble in those parts of the spine which are
mobile and which are also subject to the greatest strains, such as the lower cervicals and
the lower lumbar regions. They are least commonly involved in the thoracic spine
where the rib - cage gives support and limits movement.

When a disc prolapse occurs there is initially rupture to the Annulus Fibrosis, which
causes acute pain and muscle spasm in the neck or back. Then through the rupture, a
protrusion of the nucleus pulposus takes place and enters the spinal canal. The central
part of the disc posteriorly is protected by the strong posterior longitudinal ligament, so
that a prolapse much more commonly occurs to one side.

This, therefore, is very likely to impinge against a nerve root, causing pain, sensory
impairment, and muscle weakness in the area supplied by that segment.
Central prolapse is fortunately rare, clinical patterns differ somewhat in the 2 areas
most commonly affected.

LUMBAR DISC LESION.

Causes.
Many and varied
Disc Degeneration due to age.
Injury trauma
Bad usage/posture over the years
Occupational, from prolonged bending/lifting

INTERVERTEBRAL DISC

A flexible mechanism to maintain proper alignment. They are primarily responsible for
the curves. The IVD forms the anterior boundary of the intervertebral foramen and
anterior wall of the vertebral canal.

Structure
Nucleus Pulposus
Annulus Fibrosus
Cartilage end plate
The disc is anchored by number 2 and 3 to vertebral body.

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Nucleus Pulposus
Soft highly hydrophillic substance contained within the centre of the disc. There is no
clear division between nucleus and annulus, the main difference being in the intensity of
the fibres. The position of the nucleus within the disc varies regionally; centrally
located in the cervical and thoracic, more posterior in lumbar discs. In early life a water
content of 80 to 88% is usual. In the forties this decreases to 70%. This changes the
mechanical behaviour of the disc.

Annulus Fibrosus
This consists of a series of annular bands. With ageing the annulus becomes weakest in
the posterio-lateral region and predisposes to PID. The attachment of the annulus to the
vertebrae is complex. Fibres pass over the edge of the cartilage end plate and anchor
themselves to and beyond the compact bony zone that forms outside of the vertebral rim
and margins of adjacent vertebral body and it's periosteum. These fibres become
interwoven with the bony trabeculae.

Cartilage end plate


Found on each surface of vertebral body and represents the anatomical limit of the disc.
It is 1 mm in thickness and decreases towards the centre. After 30 years of age it
begins to show signs of ossification with increased calcification. It becomes more
brittle and ranges from thinning to complete destruction of central end plate.

Pathology
The most frequent level for a disc prolapse is the lumbo-sacral, because here the mobile
lumbar spine joins the rigid sacrum and pelvis. Next in frequency is the L4/5 and the
L3/4.

Rare at L1/2. Part of the nucleus pulposus protrudes through a rent in the annulus
fibrosus at it's weakest part, which is postero - lateral. If it is small, pain is confined to
the lower back. If it is large the protrusion herniates through the posterior ligament and
may impinge upon an issuing nerve and cause sciatic pain. The nerve affected will be
that below the disc lesion.

Signs and Symptoms


Usually youngish, often from 18 to 50 years.
Complaints of sudden, very severe lower back pain which may immobilise.
May commence in the lower back and move into the leg after a few days.
May just be in the lower back or in the leg, it varies a lot.
Pain is made worse by flexion, coughing, sneezing, defecation.
Spine tilted (sciatic scoliosis) and or lordosis obliterated.
Tenderness over area of prolapse.
Muscle spasm
Tingling numbness in calf or foot.
Area of pain depends on where prolapse is.
Severity varies from patient to patient.

Test
Flexion decreased. Ask patient to touch toes keeping knees straight.
Side bending to affected side decreased
S.L.R.T. decreased
Press on relevant spinal level will cause pain.

Diagnosis
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Myelogram
Cat scan

Medical Treatment
Rest
Corset
Pain killers
Hospital with 1 to 4 weeks in traction.

Physical Treatment.
Rest
Massage
Traction
Mobilisations

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CERVICAL DISC LESION.

Commonest at C5/6 and C6/7, where mobile spine meets relatively immobile spine.
Presents: with acute neck pain which is held rigid, (acute stiff neck). May be tilted.
This is torticollis.
Pain down the arm or to fingers.
C5/6 leads to pain in thumb and forefinger, below shoulder, outer arm.
C6/7 leads to pain in back of arm to middle fingers.
C7 T1 leads to pain in little finger and ulnar side of forearm
Worse at night when the neck extends and the muscle relaxes out of protective spasm,
the nerve root irritation increases.

SPONDYLOLYSIS.

A defect in the pars-interarticularis (or neural arch) of L5. There is a loss of bony
continuity between the superior and inferior articular processes, where fibrous tissue
replaces bone.

Causes May be:-


Congenital
Due to trauma
Stress Fracture, this is most likely.

Clinical Features.
Common in some sports e.g. weight lifting, rowers. fast bowlers.
May present with L.B.P. or unilateral pain.
May radiate to buttocks
Rare to get referred neurological pain
May be no symptoms
Racial Inheritance, it is common in Eskimos, _ of over 40's have it, less common in
Negroes (2%).

Treatment.
Corset
Spinal fusion to close defect

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SPONDYLOLISTHESIS.

Definition: Vertebral slipping, where there is forward subluxation of one vertebra on


another, though this can sometimes be backwards.

Causes
Spondylolysis
O.A. of posterior facets of joints.
Congenital malformation of articular process

Signs and Symptoms.


Varies a lot
Depends on the type
Present with chronic low back ache with or without sciatica
Worse on standing
May or may not be restriction of movement
Often a visible step at L5/S1 gap.
Neurological disturbance is minimal usually.

Treatment.
None if no symptoms
Corset
Operation to link the 2 separate halves of the vertebrae

Diagnosis.
X-Ray.

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POSTURE

By posture we mean the alignment of the head, neck, shoulders, trunk, pelvis and limbs.
If this is correct, an imaginary plumb-line dropped from the side of the head should
pass through the middle of the ear, shoulder, hip, knee, and lateral malleolus.
The line of gravity of the human body is an imaginary line, drawn vertically through the
centre of the body, from the crown of the head to a point between the two feet , on
either side of which line, the weight is equal. The weight is also equal in front of and
behind it. The line represents the direction of the pull of gravity.
If the body is to balance properly and without effort, the line of gravity must fall well
within the base, or supporting area-that is, the space occupied by the two feet on the
floor. For perfect balance in the erect position, the line should fall right through the
centre of the base.
A good posture must be that from which all activities of the body can take place, with
the minimum of effort, and from which the systems of the body (respiratory,
circulatory, digestive etc) can function normally.

Maintenance of Posture.
Normally the body is kept in the correct posture by the beautifully balanced action of
opposing muscle groups and by the efficient working of the nerves which control this
type of muscular activity. Such activity is, in effect, an anti-gravity reaction. It is
known as postural tone and exists throughout the body. This form of work, does not,
however, produce fatigue in the same way as do voluntary contractions of the same
muscles. If a man is asked to extend his spine or even his knee repeatedly, the muscles
will soon tire; yet he can remain in a standing or sitting position for a very long time.
Although the muscles are in a state of contraction, and although the impulses producing
this condition are carried by the same nerves which initiate voluntary movement, the
contraction is a static (isometric) one, and the small stimuli reach the muscle fibres at a
much slower rate-only about 8 or 9 per second, instead of the 50 or so per second
required to bring about a tetanic (isotonic) contraction. Moreover, each stimulus
reaches only a small number of muscle fibres, one set contracting then relaxing as
another set contracts so that no single fibre is in action for long at a time.

POSTURAL DEFORMITIES
Even though we have the means of maintaining balance in any position, to stand with
the body bent, even slightly, in any direction, imposes a strain on the muscles on the
side from which the bending takes place.
This is because, the force of gravity instead of falling through the centre of the body,
pulls at an angle on the flexed upper part. The more the body is bent, the greater the
angle of it's pull, and the greater the strain on the muscles. If this bend is fixed for any
reason, the patient will tend to relieve the strain by bending the spine in the opposite
direction at a higher or a lower level. In other words, the patient compensates.
These facts have to be borne in mind when considering the causation and development
of all postural deformities.

Types of Deformity.
Alteration in posture may occur in an anteroposterior or lateral direction, but it is
important to realise the reason for either is the alteration of angle in pelvic tilt away
from the normal, also that the fault does not necessarily lie in the spine.

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Bodily Types and Postures
There is really no normal type of posture, since no two human beings are alike in
skeletal, muscular or neurological make-up, nor do any two people use their bodies in
the same way. Generally speaking, individuals may be divided into three main types;
the slender, the heavy and the so-called normal or intermediate, each having it's own
characteristic make-up.

The Slender Type is most inclined to faulty posture, especially to lordosis. The spine of
such a patient has a tendency to bend back from it's lowest part, the pelvis being tilted
forward at the same time, thus forming a forward curve, with the maximum convexity in
the mid-lumbar region. Following this, the compensatory kyphosis develops, the chest
droops, the ribs become more vertical, the costal angle is increased, the head is carried
forward, and the cervical fascia loses it's tension. This may ultimately lead to cramping,
and possibly even to displacement of organs, producing visceral disturbances, or
aggravating any such troubles if they already exist.

The Heavy Type also tends to bend backwards, but at the lumbodorsal junction, the
pelvis thus being tilted backwards. People of this kind tend to develop kyphosis and
rigidity of the thorax. Lordosis is uncommon in this type.

The Intermediate Type varies according to which of the others it most nearly
approaches. The spine may bend back at a point between those characteristics of the
other two types.
Because of these varieties in postural types, the characteristic physical make-up of each
patient should be taken into consideration when assessing his or her special disability.

Degrees of Deformity.
There may be postural or structural. In the postural curves, occurring in children and
young people, there is no bony change; there may not even be muscular weakness.
There is a postural reflex, and in many cases there is also a psychological or nervous
factor. Any form of nervous disturbance or imbalance, in greater or less degree, may
cause faulty posture in children, adolescents and adults, and in such cases unless the
psychological is set right it is unlikely that we will fully correct the postural defect.
This only applies, however, to defects complicated by psychological factors.

The Structural Curves. It used, at one time be assumed that all, or almost all, postural
defects if neglected would develop into structural ones. It is, however, probably only
very rarely that this occurs, but this is no reason for neglecting such postural cases, or
failing to keep them under supervision. In such postural curves as do become structural,
there would appear to be a transition stage between the two, when some degree of
alteration has only taken place in the length of soft structures (muscles and ligaments),
the bones not yet being affected. At this stage, treatment can be of great value.

Serious structural curves have other causes than mere faulty posture or nervous upset.
This may be due to unilateral lung disease, tuberculosis, paralysis etc. ,or the causes
may be unknown as in idiopathic scoliosis. In structural cases, the body changes may
be slight or serious. To differentiate between postural, and structural scoliosis, ask
patient to flex forward. If postural scoliosis is present the curvature will disappear. If
structural curvature is present, the curve will remain or even be exaggerated.

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SCOLIOSIS

Definition. A lateral curvature of the spine, or a rotational deformity of the spine. It is


assessed by noting any lateral deviation from a line drawn, between the S.P.'s from T1 to
the mid-line of the sacrum.

Varieties.
Simple C-shaped curve in any one area.
Compound curves, that is 2 or more curves.
Lumbar scoliosis
Thoraco-lumbar scoliosis
Thoracic scoliosis

Types.
Compensatory, is due to a cause that is usually obvious, e.g. Torticollis, short leg
syndrome, hip deformity, etc
Non-structural curves - also known as postural or secondary curves. These curves have
no rotation of the vertebrae. Usually a single curve and disappears on flexion, or
hanging from rafter.
Structural or Primary curve is due to some underlying pathology of the spine. It is
always accompanied by vertebral rotation towards the convexity and both rotation and
the curve become more accentuated on forward flexion.

Pathology. .....of structural scoliosis.


May affect only part of the thoraco lumbar spine
May be a primary curve with secondary compensatory curves.
The lateral curvature is accompanied by rotation of the vertebra towards the convexity
of the curve and the S.P.'s away from the convexity into the concavity. This causes the
ribs to be thrust backwards on the convex side. It is more notable in the thoracics than
in the lumbar region.
Onset - any time from infancy to adolescence, especially between 10 and 12 years.
Deformity is the main symptom in children.

Structural Types.
Idiopathic
Congenital/Osteogenic
Neuromuscular or myogenic
Paralytic or Neurogenic
Idiopathic:-
a) Infantile -- 0 to 3 years
b) Juvenile -- 3 to 10 years
c) Adolescent -- 10 to maturity
d) Adult -- maturity +.
Adolescent idiopathic is the most common.
Developed during adolescent growth spurt
Commoner in females by a 4:1 ratio.
Thoracic curves are usually convex to the right!
Cause is unknown
The curve may be mild, moderate, or severe.
A mild curve may pass completely unnoticed
In severe form the spine can become grossly deformed if not treated to produce the
classical hunchback of history.

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The curvature tends to increase until the end of the period of spinal growth, but not
significantly thereafter.
In general, the earlier in life the curve appears, the greater the potential for the
deformity to become severe.
Therefore it is important to determine when it first appeared and if there is pain. The
thoracic spine is most involved and has the most serious consequences.
Also can get deformity of the lumbar, thoraco lumbar, and cervical spines.

Congenital.
e.g.. due to the absence of half a vertebra (hemi-vertebrae) or fusion of several ribs on
one side obvious at birth.

Neuromuscular/Paralytic.
Imbalance of spinal muscles due to muscle disorders. If muscles of one side are
paralysed it can lead to a curve e.g.. due to poliomyelitis.

Clinical finding – Observation


1. Detailed History
• Family history of scoliosis, injuries, previous history of back pain.
• When the deviation was first noticed?
• By Whom?
• When it was first assessed and by whom?
• How was it assessed, X-rays, Results?
• Treatment and response
• Any history of chest infections or other respiratory problems?
• General state of health

2. Visual Examination
• Initial general impression

Posterior view:
• Head position,
• Ear levels,
• Rotation of head,
• Angle of neck,
• Shoulder levels,
• Inferior angle of scapula,
• Waist line, Arm gaps,
• Arm length,
• Iliac crest levels,
• PSIS levels,
• Gluteal fold,
• Gluteal mass,
• Popliteal levels,
• Achilles tendon angle,
• Arches,
• Foot position,
• Varicosities?
• Spine?
• Any lateral deviation?
• Draw and describe shape,
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• Indicate where greatest curve is,
• Any rotation of body of vertebrae? Where?
• Is it into concavity or convexity?
• Does sacral base slope to low or high side?
• Does pelvis shift to low or high side?
• Is lumbo dorsal junction directly over mid-point of sacrum?
• Is compensation normal?

Lateral View
General impression e.g. Forward head posture, abdomen protracting, etc.

Anterior View
General impression
• Clavicular position
• Symmetry of chest
• Arm gap
• Shoulder positions, e.g. internally rotated
• Arm length
• Position of umbilicus
• Iliac crest levels
• ASIS
• Position of pelvis e.g. rotated
• Leg position
• Knee position
• Foot position

Examination
Active ROM
• Cervical
• Thoracic
• Lumbar
• Shoulders
• Hips
Passive ROM:
• Cervical
• Thoracic
• Lumbar
• Shoulder
• Hips

Resisted movements if indicated


Full MET assessment
Palpation of each muscle, particularly SCM, upper trapezius, levator scapula, pectoralis
major, pectoralis minor, subscapularis, infraspinatus, latissimus dorsi, psoas, quadratus
lumborum, TFL, gluteus medius, gluteus maximus, piriformis

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Note:
Whether single C-shaped or S-shaped or more complex, record the findings
diagrammatically.
Endeavour to determine which type of scoliosis is present.

Orthodox Treatment.
Conservative.
Assessing the degree of curve
Measuring the cardio-pulmonary function
Exercises
Spinal supports e.g. Milwaukee brace
Casts/Braces
Operation fusion.

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KYPHOSIS ARCUATA

Kyphosis Arcuata:- Round Back.


This deformity may appear at any period of life, but is more common at childhood,
adolescence or old age. The back is rounded, the chest flattened and the head carried
forward. The shoulders are round with the scapula protracted. Kyphosis is more
common in girls than in boys, and a primary kyphosis is more common in the heavier
types of individual.

Causes; In childhood:
• Habitual poor posture, often acquired at school
• Undetected sight or hearing defects
• Severe childhood respiratory conditions leading to pigeon chest
• Emotional factor
• Mental or physical fatigue
• Predisposition to kyphosis due to muscular weakness or reflex deficiency
• Failure of development of secondary curves.

In adolescence and adult life


• Poor posture
• Occupation
• Arthritis
• Lung conditions
• Scheurmanns disease

In old age
• Habitual poor posture
• Muscle weakness
• Degeneration of intervertebral discs or bodies of the vertebra

Pathological Changes.
This deformity like any other may be divided into three degrees. In the early stages no
change is present except laxity and poor tone in the muscles. In time the pectoral
muscles become shortened . This interferes with the mobility of the thorax and hence
with respiration. The erector spinae are stretched and weakened in their upper parts,
and the rhomboids and middle trapezius suffer in a similar fashion. The posterior
ligaments of the vertebral column are lengthened and those on the anterior aspect are
shortened. In the latter stages the vertebra may become wedge-shaped, being much
narrower anteriorly. This is uncommon except in adolescent Kyphosis.

KYPHOSIS; An exaggerated posterior curve of the thoracic area


ARCUATA ; Inclusive of round-shoulderedness

SECONDARY KYPHOSIS: An exaggerated cervical curve


Involved muscles:
• Pectoralis Major
Origin: Clavicular head -- Medial Clavicle, Sternal Head, Cartilages of Upper 6 ribs
Insertion: Lateral lip of the bicipital groove of humerus

• Pectoralis Minor
Origin: Anterior 3, 4, 5 ribs
Insertion: Coracoid Process of scapula

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• Trapezius
Origin: Occiput, nuchal ligament C7 to T12 spinous processes
Insertion: Lateral Clavicle -- Acromion; Spine -- root of scapula

• Levator Scapula
Origin: C1 to C4 Transverse processes
Insertion: Superior Angle -- Root of scapular spine

• Rhomboids
Origin: C7 to T1/T2 to T5 Spinous processes
Insertion: Vertebral Border of Scapula -- root of spine to inferior angle

• Erector Spinae see Lordosis


• Posterior neck Splenius Capitus, Splenius Cervicis, Semispinalis/Multifidus

Goals of Treatment.
To re-educate patients' postural sense
To lengthen the muscles of the chest and posterior neck
To strengthen erector spinae, rhomboids and middle trapezius
To improve chest breathing

EXERCISES FOR PATIENT --Goal.


Flatten the thoracic area
Open the chest
Improve chest breathing

By:
Increasing range of movement of shoulder joint.
Encouraging patient to bring the vertebral borders of the scapula together,
Combining with above, deep inhalation. Tuck chin in towards the neck.

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LORDOSIS

Exaggerated anterior curvature of the lumbar spine.


Also called saddleback (!) or hollowback. Basically a postural condition.

Causes.
The causes are similar to those leading to kyphosis, namely:
Habitually incorrect posture or defective postural sense (the pelvis is tilted forward and
the patient compensates for this by hollowing the lumbar spine).
It may be a compensatory mechanism, the lordosis being a compensatory deformity to
a high kyphosis or to conditions involving the hip joint, e.g. bilateral congenital
dislocation of the hip, or TB of the hip involving the fixation of the joint in flexion,
foot problems, etc
Weakness or paralysis of the abdominal muscles, the flexors of the lumbar spine
Careless treatment of kyphosis

Pathological Changes.
The abdominal muscles are stretched, the lumbar muscles contracted and the ligaments
on the front of the spine are lengthened, while those on the back are shortened. The
glutei are weakened, the rectus femoris is shortened, and the hamstrings may be
lengthened. The psoas is contracted and so likewise may be the adductor longus and
brevis. Bony change is uncommon.
Note: Contraction of abdominals / hip extensors decreases the pelvic tilt. Contraction of
the back extensors / hip flexors increases the pelvic tilt. Pelvic Tilt is approx 30°

Muscles Involved.
Erector Spinae: Spinalis, Capitis, Cervicus, Thoracis
Longissimus: Capitis, Cervicis, Thoracis
Iliocostalis: Cervicis, Thoracis, Lumborum,
Rectus Femoris
Hamstrings: Semitendinosus, Semimembranosus, Biceps Femorus,
Psoas
Abdominals: External Obliques, Internal Obliques, Transversus Abdominis, Rectus
Abdominis,
Adductors: Adductor Magnus, Adductor Brevis, Adductor Longus.

Goals of Treatment.
Postural re-education
Mobilise and stretch the lumbar spine
To strengthen the lengthened muscles
To lengthen the shortened muscles
The patient should be taught to correct the position of the pelvis and shown how to tilt it
backward by contracting the lower part of the abdominals and glutei. This should be
done successively in a lying, sitting and standing position. The position of the thorax is
then corrected. The chest is raised and the shoulders pressed back, the head held well
up, and the chin in (not drawn in to an unnatural position). The correct position of the
pelvis must be maintained. When standing the patients are told to make themselves as
tall as possible.

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PHYSICAL EXAMINATION OF THE SPINE

Standing Observation.
Posterior:-
Neck, straight/lordotic/side-bent or retracted
Shoulder levels.
Scapula levels -- spine at T3 -- inferior angle at T7 - T8
Thorax kyphotic or straight.
Shoulder protracted or retracted
Spine. Scoliosis C-shaped, S-shaped, poker spine
Lumbar, lordotic/straight/retro-lordosis.
Iliac crest levels L5
P.S.I.S.
Gluteal folds levels.
Sacrum/Coccyx deviations, (gluteal crease).

Lateral:-
Angle of head; protruding, straight, side-bent or rotated, lordotic.
Shoulders; protracted or retracted
Abdomen - protrusion.

Anterior:-
Shoulder levels.
Clavicles
Chest - deformities.
Abdomen - abnormalities/ umbilicus at L3
Crest levels.
Anterior iliac spines.
Hip levels trochanter.

Pelvic Examination.
Hands on superior border of iliac crest.
Thumbs on P.S.I.S. Get patient to touch toes by curling spine -- observe movement
(forward flexion test)
Leg thigh extension - observe P.S.I.S.

Lumbar Examination.
Touch toes, observe if lumbar spine flex or not.
Extension.
Lateral flexion.
Rotation.

Thoracic Examination.
Flexion.
Extension.
Rotation.
Lateral flexion.

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Cervical Examination.
Flexion.
Extension.
Rotation.
Lateral flexion.

Sitting Examination. Pelvis.


Iliac crests height.
P.S.I.S. heights/levels.
I.L.A. levels, seated forward-flexion test.

Lumbar spine.
Flexion
Extension.
Rotation.
Lateral flexion.

Thoracic Spine.
How to palpate the inter spinous processes for movement.
Flexion
Extension.
Rotation.
Lateral flexion.

Cervical Spine.
Flexion
Extension.
Rotation.
Lateral flexion.

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FRACTURES

A fracture is any sudden break in a bone.

Symptoms:
There are different symptoms in different cases of broken bones, but some will present
the following:
Pain
Deformity
Abnormal motion
Crepitus -due to grating of the fragments against each other
Muscular spasm -caused by the irritation of nerves and muscles by the irregular
fragments of bone followed by pain.
Ecchymosis
Swelling.

Types
Fractures may be complete or incomplete.
Complete - when the bone is broken entirely through
Incomplete - when the bone is broken partially through
A fracture may be simple or compound.
Simple -when the fragments of bone do not communicate with the air through an open
wound, ie the skin is intact. Simple fractures are also called closed fractures.
Compound -when fragments of bone are forced through the skin. Compound fractures
are also called open fractures.

Specific types of fracture.


Comminuted -when a bone is splintered and broken into several or many pieces.
Multiple -more than one fracture.
Complicated -in addition to the broken bone surrounding important structures such as
blood vessels or nerves are injured.
Greenstick -an incomplete fracture with bending of the bone (occurs in children).
Impacted -when one end of the broken bone has been driven into the other at the time
of injury; most frequent in the femur, the neck being driven into the shaft.
Pathological when a bone breaks due to a disease such as osteomyelitis, osteomalacia,
or tuberculosis. Also called a spontaneous fracture.

Bone Healing.
Almost immediately after the injury a blood clot is formed at the fracture site. The clot
is gradually changed into a callus by the depositing of lime salts. The callus is a bone
like substance forming around the ends of a fractured bone, which then turns into
mature bone.

• Treatment.
• X-rays should be taken as soon as possible. The broken part is kept at rest and
elevated. Ice or cold water should be applied to help relieve pain and control
haemorrhage. In the majority of fractures local massage treatment should not be
applied until the bone is healed and union of the fragment is fully established.
• Although the plaster of Paris casts give assurance of healing in a normal position,
they nevertheless have an impeding influence upon the circulation and nutrition,
causing stasis (stagnation of blood) and passive inflammation, atrophies of various

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kinds, and, worst of all, muscular contractures. At the present time there is a marked
tendency to limit the use of casting to the shortest time necessary, and the heavy
plaster of Paris casts are commonly replaced by soft casts which can be removed
while the joint is being massaged, and then reapplied.
• Important: Massage is given above and below the site of a fracture, not over the site.
This ensures that the healing process will not be disturbed. The first object of
massage is to remove the detrimental effects of immobilisation. Effleurage promotes
the blood and lymph circulation and increases nutrition to aid healing. In addition,
effleurage and friction stimulate the absorption of the products of stasis. The
massage movements must be regulated to suit the individual case. Immoderate
movements would surely prove to be disadvantageous and injurious.
• The particular movements and procedures to be applied in treating fractures before
union is complete are matters of the most careful discrimination. No one who is not
thoroughly familiar with the treatment of these cases should undertake to treat them.
• General massage treatment of the whole body is of great benefit to the circulation
and stimulates the repair of the injury during the period of immobilization.
• Local treatment to the injured part after the cast is removed should consist of
Effleurage, Friction - used with care; alternate with effleurage, Kneading - used
with care; alternate with effleurage.
• Each treatment lasts for twenty to thirty minutes and should be given every day. The
patient should continue to receive treatment until full mobility is achieved.
• Local treatment directly over the site of the break may be employed after the fracture
is known to be completely united and all the tenderness is disappeared.

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COLLE'S FRACTURE

A fracture of the distal radius. There may be secondary shoulder problems. Patient
usually presents in a cast, from below the elbow to the hand. The hand is supinated.
There is swelling of the hand, wrist and maybe the shoulder.

Involved muscles.
Flexors and extensors of the wrist and fingers.
Brachioradialis.
Brachialis.
Palmer fascia.

In cast treatment.
• Elevate (support) the elbow on a pillow.
• Proximal to distal draining. Start at the shoulder area with short strokes towards the
heart, and work down the arm. Drain above and below the fracture site.
• NOTE: draining helps to prevent or minimise adhesions.
• Passive movements, all possible movements of the fingers.
• Full intermediate massage to shoulder area. If there is injury to the shoulder, treat
accordingly.
• NOTE: Patient must be encouraged to do any possible finger movements while in the
cast. Muscle action under the cast, must also be maintained so isometric contractions
of the forearm must be included. These exercises will aid circulation and limit
muscle atrophy. Shoulder movements and exercises are prescribed, as early as
possible

Out of cast treatment.


Clinical union (no bony union). NO MOVEMENTS AT THE BREAK SITE. Work
superficially, no deep work. Support site of break with one hand, work with the other.
Very light effleurage and drainage work up forearm to the shoulder.
Stretch (lengthen) the biceps.
Bony union Now there is the potential for movement. At the beginning patient has
limited R.O.M. and poor muscle tone.

Goals
Restore R.O.M.
Resisted exercises to rebuild atrophied muscles.
Light effleurage and draining.
Trace the brachioradialis and move muscle off the bone. Use inhibition where
necessary.
Trace and "strip out" each flexor individually. Transverse friction to insertion.
Tracing and "stripping" of individual extensors.
Slowly introduce passive flexor and extensor movements.
Slowly introduce resisted flexor/extensor movements when muscle tone starts to return
Introduce passive and resisted pronation. M.E.T. can be introduced at this point.

Full muscle tone and R.O.M. has returned.


Note: A similar treatment as for Carpal Tunnel Syndrome - an impingement of the median
nerve, generally due to the overuse of the wrist and hands involving fine motor
movements. Can cause pain, but more likely numbness and tingling to radiate in the wrist
hand area.

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Goals.
Lengthen the tissue
Break up adhesions.
Eliminate debris.
NOTE: With carpal tunnel syndrome the patient has full R.O.M.
Clean out the heel of the hand. Using the thumbs, work up the metacarpal spaces.
Work as deeply as possible. Don't work over the carpals.
Stretch thenar /hypothenar apart.
Intermediate massage to forearm wrist and elbow. Mobilisation techniques are
introduced slowly and with care.

Exercises for Colle's Fracture.


Strengthen radial and ulnar deviation. Twist cap on/ off a bottle.
Pronation / Supination. Screw and unscrew using a screwdriver, or open and close
using a doorknob.

For carpal tunnel syndrome.


Rest arm initially.
Wrist curls, starting with very light weights. Movements should include flexion and
extension of the fingers.
Light stretches of the wrist and fingers.
Intrinsic hand muscles. Place the palmar surface of the hand and fingers flat against a
soft and firm surface. Press down on the fingertips without lifting the palm.

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Soft Tissue Injuries

The soft tissues include muscles, ligaments, tendons, fascia, bursa, joint capsule, and
cartilage.
Muscle Injury
Strain refers to a muscle injury
Damaged muscle can heal quickly, with fibres reformed in about three weeks. When
injury occurs however, there is almost inevitably some degree of bleeding and this can
effect the healing process mechanically by reducing contact between the ruptured ends
of the muscle fibres. If bleeding can be controlled healing is more likely to be quick
and complete. There are two distinct types of muscle rupture: Distraction and
Compression.

Distraction Ruptures
These are caused by overstretching or overload and are often located in the superficial
parts of the muscles or their insertions or origins

Compression Ruptures
These occur as a result of direct trauma or impact. The muscle is pressed against the
underlying bone for example when a player’s knee hits another’s thigh during contact
sport and heavy bleeding deep within the muscle may occur.

Factors which contribute to muscle ruptures


• A number of factors are important in contributing towards the occurrence of muscle
ruptures:
• The muscle may have been poorly prepared because of inadequate training or lack
of warm-up
• The muscle may have been weakened by previous injury followed by faulty
rehabilitation
• The muscle may previously have been extensively injured with resultant scar tissue
formation. (Scar tissue is less elastic than muscle and therefore more liable to
recurrent injury)
• A muscle which is overstrained or fatigued is injured more easily
• Tense muscles which do not allow a full range of joint movement may be injured in
sports demanding flexibility
• Muscles subjected to prolonged exposure to cold are less contractile than normal

Distraction Ruptures
Distraction ruptures frequently occurs in sports that require explosive muscular effort
over a short period of time, for example in sprinting, jumping and football. When the
demand made on a muscle exceeds its innate strength, rupture may occur. Other
examples in sport include sudden stopping, deceleration, rapid acceleration or a
combination of deceleration and acceleration when turning, cutting, jumping and so on.

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Distraction ruptures often occur in muscles that move two joints, for example the
hamstrings.
The symptoms of muscle rupture depend on it’s severity. Ruptures are classified as
partial or total. Another form of rupture classification describes different degrees of
strains; so first and second degree strains are partial ruptures and third degree strains are
total ruptures or disruptions.

Partial Ruptures
A first degree or mild strain describes an overstretching of the muscle with a rupture of
less than 5% of the muscle fibres. There is no great loss of strength or restriction of
movement. Active movement or passive stretching will however cause pain around the
area of damage and there will be some discomfort. It should be remembered that a
small rupture or mild strain could be just as distressing to the athlete as a more serious
injury.
A second degree or moderate strain involves a more significant or less than total tear to
the muscle. The pain will be aggravated by any attempt to contract the muscle.

A total rupture (or third degree / severe strain) involves total disruption of the muscle.
Symptoms and diagnosis

The following features suggest that a distraction rupture has occurred;


A sharp or stabbing pain is felt at the moment of injury and reproduced by contracting
the muscle concerned. Usually there is little pain if the muscle is rested
• In a partial rupture the resulting pain can inhibit muscle contraction. In total
ruptures the muscles are unable to contract for mechanical reasons
• In partial ruptures it is sometimes possible to feel a defect in part of the muscle
under examination. In a totally ruptured muscle the defect can be felt across the
entire muscle belly. The muscle may ‘bunch up’ and form a lump resembling a
tumour.
• There is often localised tenderness and swelling over the damaged area
• After about 24 hours bruising and discoloration may be seen, often below the site of
the injury. These are signs of bleeding within the damaged muscle. Muscle spasm
may occur

The most effective diagnostic test is often a test of function, with or without resistance.
Healing
When a muscle is overstretched the muscle fibres and blood vessels will tear. The torn
ends will retract from the injured area leaving it filled with blood. Initially there will
inflammation and thereafter reabsorption of the bleeding. The repair of a muscle injury
involves two ‘competitive’ events; formation of new muscle fibres (regeneration) and
the simultaneous production of scar tissue (granulation tissue).

Skeletal muscle possesses a high capacity to regenerate, but the new muscle fibres will
be shorter an incorporate inelastic scar tissue. If the scar covers a large area functions
will be impaired because contraction will be restricted. Areas of different elasticity may
be formed in the muscle which increase the risk of recurrence of rupture. It is therefore
important to follow a muscle injury with a long-lasting rehabilitation programme.

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Compression Ruptures
When direct impact is the cause of injury, deep rupture and bleeding can occur as the
contracted muscle is compressed against the underlying bone. Compression ruptures
can also occur in superficial muscles.

Muscular Haematoma
During physical activity there is substantial redistribution of blood flow. In the muscles
it increases from about 1.5 pints/min (15% of cardiac output) at rest, to 32 pints/min
(72% of cardiac output) during strenuous effort. It follows that blood supply to the
muscles during sporting injury is enormous; the extent of bleeding when the muscle is
damaged is directly proportional to muscle blood flow and inversely proportional to
muscle tension at the time of injury. The effect of an injury depends on it’s location and
extent rather than upon it’s cause, and in the following paragraphs, no distinction will
be made between compression and distraction ruptures. Treatment, healing and
rehabilitation will also vary on the type, location and extent of hemorrhage and ruptured
tissue.
Intramuscular Haematoma
Bleeding within a muscle may be caused by rupture or impact. It begins within the
muscle sheath (fascia), and cause an increase intramuscular pressure which counteracts
any tendency to further bleeding by compressing the blood vessels. The resultant
swelling persists beyond the first 48 hours and is accompanied by tenderness, pain and
impaired mobility. Swelling may increase as the bleeding draws fluid from the
surrounding tissue (osmosis) and muscle function may be completely absent. If the
muscle sheath is damaged, blood may spread into the space between the muscles (see
below) or out into the surrounding tissues. Intramuscular haematoma may create an
acute compartment syndrome due to increased intracompartmental pressure.
Intermuscular Haematoma
Bleeding may occur between muscle when a muscle sheath (fascia) and it’s adjacent
blood vessels are damaged. After an initial increase causing the bleeding to spread, the
pressure falls quickly. Typically, bruising and swelling caused by a collection of blood,
occur at some distance to the damaged area 24 to 48 hours after the injury due to
gravity. Because there is no sustained increase in pressure the swelling is temporary
and muscle function returns rapidly. Provided immediate treatment is available,
recovery can be expected to be speedy and complete.

Treatment of Muscle Rupture and Haematoma


The athlete or trainer should stop or control muscle bleeding irrespective of its cause by
use of the following measures; Rest, Ice, Compression, Elevation.

The body’s defense against bleeding (coagulation or clotting) comes into action as soon
as the injury occurs and continues to function for several hours. The repair mechanism,
however, is unstable for the first 24 to 36 hours, so that further bleeding may occur as
the result of another impact, vigourous muscle contraction or unprotected weight-
bearing. Massage, which is, in effect, repeated minor trauma, should not be used within
48 to 72 hours of the injury.

Wherever there is any suspicion of major muscle rupture or significant bleeding, a


doctor should be consulted as soon as possible. The doctor’s action will depend on the

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extent of the injury. If it is severe, admission to hospital for observation is usual as the
bleeding and swelling may increase, impairing the blood supply and raising the
intramuscular pressure. This can be dangerous if left unmonitored. If the bleeding is
not extensive, or if there is any uncertainty about the nature or extent of the injury, 48 to
72 hours rest may be prescribed. Precise diagnosis can be difficult in the acute phase
and for the first 2 to 3 days an injury should be considered as potentially serious.

Constant re-examination of the injured area is necessary in order to distinguish between


intermuscular and intramuscular bleeding. Decreased swelling and rapid recovery of
function would suggest the former. And persistent or increased swelling with poor
function, the latter.

After 48 to 72 hours the following questions should be answered


Has the swelling resolved? If not, intramuscular haematoma is probably present
Has the bleeding spread and caused some bruising at some distance from the injury?
If not, the injury probably involves intramuscular haematoma
Is the haematoma a symptom of a total or partial muscle rupture?

It is important that an accurate diagnosis is made; premature exercise of a muscle


effected by extensive intramuscular haematoma or a complete rupture can cause
complications in the form of further bleeding and sometimes increased scar tissue
formation. This, in turn, is likely to lead to a more protracted healing process and
possibly even permanent disability.

Treatment beyond the first 72 hours depends on the diagnosis which has been made. If
the symptoms caused by the injured muscle fail to improve, it is important to reconsider
intramuscular haematoma and tissue damage.
Complications of Muscle Injury

1. Scar tissue formation


Muscle fibres which have been overloaded with resultant bleeding and rupture become
less contractile. The space between ruptured muscle fibres fills with blood which clots
and is gradually converted into connective tissue. This, in turn, is gradually converted
into scar tissue. This healing process leaves the muscles with areas of varying
elasticity, and further injury (rupture or haematoma) may then occur if the muscle is
exercised too hard, too soon. If scar tissue causes persistent problems it may be
necessary to remove it surgically.

Prognosis
With early recognition of onset and good management the bone may be re-absorbed. If
not the bone tissue matures and may cause problems by pressing on blood vessels,
nerves and muscle tissue.

Clinical features
Loss of range of movement
Pain on muscle activity
Firmness of tissue on palpation
On x-ray there is a faint outline of bone tissue

The commonest sites are;


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Thigh – quadriceps
Biceps brachii
Supraspinatus
Anterior tibialis

2. Myositis Ossificans ‘Charley-horse’


Direct impact causes intramuscular and/or intermuscular bleeding. If immediate
treatment is inadequate, deep located intramuscular haematoma may gradually become
calcified and ossified. Ossification continues as long as healing is disrupted by repeat
impact or contraction. This will result in areas of varying strength and elasticity in the
affected muscle, with a correspondingly increased risk of further injury. Ossification is
a lengthy inflammatory process for which doctors hesitate to recommend active
treatment for a long period of time. If muscle function and flexibility are significantly
impaired for more than 6 to 10 weeks and x-ray reveals signs of ossification, then
surgical removal of the ossification should be considered.

3. Infection
This is not common in an intramuscular haematoma but may occur in a subcutaneous
area, e.g. Anterior aspect of the tibia.
It is treated with rest and antibiotics until clear and then rehabilitation is as for an acute
injury.

4. Cyst formation
A serous filled cavity forms owing to partial but not complete absorption of the
haematoma.
Treatment is by incision to remove the fluid. A firm pressure bandage is applied for
two to three days. The rehabilitation follows the acute injury programme.

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Ligamentous Injury

Sprain refers to injury to a ligament. The primary function of ligamentous tissue is to


create stability around the joints. Ligaments are comprised of white connective tissue
which forms bands either inside or outside the capsule of a synovial joint. The are
attached to and blend with the periosteum of the bone.

All ligaments are taut at the normal limit of a particular movement. They are however
slightly elastic and protected from excessive tension by reflex contraction of appropriate
muscles. There are more transverse fibres in a ligamentous tissue than in tendon tissue.
This allows the ligament to be more resistant to stress in multiple directions. The
tendon only encounters tensile strength along it’s length from muscle contraction. The
ligament is designed to be strong in one predominant direction (the line of tensile
strength along it’s length) but also must be resistant multi-directional stresses that the
joint may encounter during movement. Ligament also has a greater concentration of
elastin than the tendon does. This will allow the ligament a small degree of ‘give’
before it pulls taut at that particular joint. This small amount of ‘give’ is important. If
the ligament were as rigid and ‘ungiving’ to tensile stress as a tendon, the frequency of
ligament injuries would be much greater. Prolonged tension results in pain.

Acute sprain is caused by sudden twisting or wrenching of a joint which results in


overstretching of a ligament. It is associated with the muscles controlling a joint being
momentarily off guard so that the ligament is subject to the full force of the movement.
The severity of the injury depends on the number of fibres injured, the quality of the
stability depends on the number of fibres remaining intact.

Chronic sprain is caused by repetitive stretching from a minor force which may be due
to faulty posture or poor quality of movement.

Complete rupture is disruption of all fibres of the ligaments caused by a sudden violent
force such that the joint is unstable.

Healing of Ligaments
Ligaments, having only fair vascularity, heal slowly. Since they have no specialised
cells repair is always by fibrous tissue. Completely ruptured ligaments must be sutured
and protected for lengthy periods. Otherwise the fibrous tissue forms a weak union
between the ends of the fibres. The danger then is that the ligament lengthens and does
not perform its stabilising and controlling functions. Sprained ligaments also heal by
fibrous tissue. The degree of protection required during healing depends upon the
severity of the injury. It is important to gauge the point at which mobility must be
rehabilitated because the healing fibrous tissue may cause adhesions. The danger then,
is that the ligament, being bound to neighbouring structures, is prone to further injury
and the movement controlled by the ligament is painful and limited. (Evans, 1980).

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Acute Sprains, Clinical Features

History: There is a history of injury which the patient can usually describe.

Pain – There is a sudden pain and feeling of nausea at the time of injury. The intensity
of pain reduces but can be reproduced if the causative movement is repeated. As
healing occurs, the pain becomes less constant and is reproduced only if the ligament is
stretched.

Swelling – This occurs rapidly and is due to the escaping of fluid into the fascial space
around the ligament. Later, inflammatory exudate is a component of the swelling. If
the joint capsule is injured, synovial fluid may be present in the swollen area.

Bruising – Blood escapes from injured blood vessels into neighbouring tissues. The red
blood cells break down releasing constituent pigments which produce the various
colours of bruising. The presence of plasmaprotein fibrinogen in tissue fluid is a
disadvantage because fibrin is formed producing consolidation of the tissue fluid.
Chronic swelling can result if the treatment is ineffective. If blood goes into a joint
space there is haemarthrosis which limits joint movement.

Loss of movement – A lower limb ligament injury will prevent use of the limb
especially in walking and running. An upper limb ligament injury makes many
activities of daily living difficult, e.g. dressing, eating, writing, etc.

Chronic Sprains; Clinical features


History – There is recurrent minor injury which may or may not be known to the
patient. It may be necessary for the therapist to analyse activities or sport techniques to
identify the cause.

Pain – This is a dull aching around the area of the injured ligament. It may be constant
or intermittent, tends to increase with activities which move the joint controlled by the
ligament and may be superimposed occasionally by sharp stabbing pain.

Swelling – There is often an area over the ligament which feels like thickened jelly and
cannot be moved, like the fluid swelling of acute injuries.

Loss of movement – The movement controlled by the injury is equally limited both
actively and passively

Instability – if the ligament is subjected to frequently prolonged stretching it becomes


weakened and the joint becomes unstable. Instability may also be due to loss of
proprioceptive input due to damage of the mechano-receptors.

Loss of function – Activities are impaired and the movements producing the
movements of the affected joints tire more easily. Following activity, the patient may
feel stiff and sore in the affected part.

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Complete Ruptures

History – The patient reports a definite injury, often with an audible snap. Sometimes it
is described as being like a kick or blow over the site of the rupture.

Pain – sometimes there is little or no pain immediately after the injury but usually there
is severe sickening pain. The intensity reduces over the first few days with treatment.
Swelling – A large amount of swelling forms rapidly indicating gross tissue damage.
Bruising – This occurs as in acute sprains
Loss of function – there is severe loss of function of the affected limb, e.g. weight-
bearing is impossible with a lower limb injury.

Treatment of Ligaments -- Acute injuries.


Early management of an acute injury is very important in relation to the long term
outcome. The main aims as soon as the injury has occurred are as follows:
• To enable healing to take place
• To reduce the risk of further injury
• To minimise swelling
The important themes are, therefore, rest, ice, compression, elevation and controlled
exercise.
The main aims as healing takes place are;
• To prevent adhesion formation
• To strengthen the muscle related to the ligament
• To re-educate proprioception
• To restore full mobility of the ligament and corresponding joint
• To restore the patient’s confidence
• To restore the patient to full functional activity

Chronic Injuries
The important aspects of the management of chronic injuries are:
• To identify the cause of the repeated trauma to which the ligament is subjected
• To treat the ligament
• To prevent recurrence
Identifying the cause demands careful, logical analysis of the patient’s lifestyle. It is
important to include positions that may cause long term stress, e.g. sitting with the feet
held in inversion stretches the lateral ligament of the ankle joint; always running
clockwise around an athletics track stretches the right lateral and left medial ankle
ligaments with shortening of the opposite ligaments. Poor posture tends to put long
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term stress on ligaments. Changing the grip on a racquet or golf club can stress the
ligaments of the hand and wrist, The patient can often trace the onset of pain in a
ligament to a change in technique or equipment at work or at play but may have to be
prompted by the therapist to remember this. Treatment is directed at achieving the
following aims:
• To mobilise the ligament from underlying structures
• To restore flexibility to the ligament
• To strengthen the muscles related to the ligament
• To re-educate proprioception
• To re-educate function and the patient’s confidence

Mobility of the joint is regained by soft tissue manipulation to reduce swelling and to
restore mobility to all soft tissues within their fascial planes. Active exercises are
essential. Mobilisations are usually required and are generally essential to restore
accessory movements especially where there is a complexity of joint involved, e.g.
tarsal, carpal, elbow, intervertebral joints.
Flexibility of the elbow can be regained by using transverse frictions, passive stretching
and active exercise.
Strengthening of the muscles is achieved by active exercise resisted manually or
mechanically.
Proprioception can be re-educated by proprioceptive neuromuscular facilitation
techniques, weight bearing activities, co-ordination exercises and, for lower limb
injuries, balance (wobble) boards.

Prevention of recurrence
This starts by eliminating, where possible, the causative factors or repeated stress.
General fitness is important with an exercise programme designed to increase the
flexibility of the ligaments. Before activity, which may be high level competitive sport
or the occasional weekend gardening, warm up is essential. This includes stretching
and jogging for anything from 5 to 20 minute beforehand, depending on the intended
activity.
Clothing needs to provide warmth and protection together with freedom of movement.
Equipment must be reliable and appropriate to the activity as well as to the individual.

Complete Rupture
As with acute injuries, early management is vital to enable good long-term outcome,
The two principal methods are:
Surgical repair followed by immobilisation
Immobilisation in a shortened position
In both instances the joint is fixed so that the ligament is in a shortened position.

During the period of fixation the main aims are:

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• To encourage healing
• To minimise adhesion formation
• To maintain the strength of the muscles related to the ligament
• To maintain function

The main themes are, therefore, active exercises, functional use of the limb and specific
exercises to work the muscles isometrically over the fixed joints.
After the fixation is removed the principles of treatment are similar to those for chronic
ligament injuries.
Principles Applied – Ankle ligaments
The ligaments of the ankle are injured when the plantar flexed foot is forced suddenly
into inversion (lateral ligament) or eversion (medial ligament). Injury to the lateral
ligament is most common.

Acute Sprain to Lateral Ligament

Aetiology
This injury is common in sports activities such as pole vaulting, cross-country
running and hiking. It is also quite common in general terms when a person slips off
a pavement or walks on uneven surfaces. The mechanism is for the foot to be forced
into inversion and plantar flexion. The site of the injury is generally between the
centre and distal attachments of the middle and anterior bands of the ligament.

Clinical Features

History – The patient describes ‘going over’ on an ankle

Pain – There is sharp pain just below and anterior to the lateral malleolus at the time of
injury. Passive stretching and weight bearing increases the pain.

Swelling – This is present from the lateral border of the tendo Achillis, over the lateral
malleolus along the dorsum of the foot. In severe injuries the swelling may spread to
the dorsum of the toes and up the leg.

Bruising – This appears under the lateral malleolus and over the dorsum of the foot.

Loss of function – All weight bearing is painful so that the patient cannot run and has a
gait with a very short stance phase on the affected foot.

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Chronic Sprain to Lateral ligament

Identifying the cause

Causes may be:


• Poor reflex co-ordination of peronei to prevent twisting while walking over uneven
ground
• Improper support from footwear; worn heels or old shoes which have become too
large
• Prolonged sitting with feet turned in causes lengthening
• Poor foot posture with feet everted

Clinical Features
Pain – Dull ache over ligament which may become more sharp during prolonged
walking or running.

Swelling – Thickened swelling is often present under the lateral malleolus and along the
Achilles tendon

Loss of movement – plantar flexion with inversion is limited and feels tight

Instability – balancing on the affected leg is more difficult than on the other leg even
though muscle power may not be markedly diminished.

Complete Rupture – Lateral ligament


This is caused by a violent force which produces plantar flexion, inversion and
adduction of the foot; often the patient falls with the foot twisted under the body weight.

Clinical Features
Pain – severe pain over the ligament area

Swelling – immediate swelling denoting severe injury occurs on the lateral side of the
ankle and over the dorsum of the foot.

Instability – There is excessive range of inversion and adduction

Loss of function – The patient is unable to walk or to take any weight at all on the foot.

Radiograph – Abnormal sideways tilt of the talus demonstrated on x-ray

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Tendons

These are tough white cords of fibrous tissue. The primary role of tendon tissue is to
transmit the contractile force of the muscle to the bone in order to move the bone. For
this reason tendons are relatively inflexible structures which are designed to be
strongest in the direction of tensile stress. Most of the fibres of a tendon will run in a
longitudinal direction in the tendon. This will give it the greatest amount of tensile
strength.

Tendons do not contract but they are considered part of the group of tissue known as
contractile tissues because they function so interdependently with muscle. They vary in
length and thickness according to the site within the body. Most muscles have tendons
at one end. A tendon may be enclosed in a synovial sheath to prevent friction and may
be separated from neighbouring structures by a bursa. The tensile strength of tendons is
similar to that of the bone i.e. half that of steel. However, tendons are often ruptured,
with injuries occurring at the musculotendinous and tendoperiosteal junction. Blood
supply is scant. The metabolic rate of tendon is very low but increases in reaction to
infection or injury.

Types of Injuries
Partial Rupture
Complete Rupture
Tenosynovitis

Cause of Injury
These may be traumatic or spontaneous

Traumatic
Direct cuts; window glass, road traffic accidents, knife accidents (butcher’s shop or a
kitchen). Complete rupture is most likely.
A sudden stretch when the muscle is contracting; sometimes the tendon gives,
sometimes it’s the muscle.
The injury may be a partial complete.

Spontaneous
Degenerative changes may weaken a muscle which then ruptures without apparent
trauma. For example; long head of biceps brachii, extensor pollices longus (particularly
after a Colles' fracture has healed and the radius is roughened, producing friction on the
tendon).

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Tendons Commonly Affected
• Tendo calcaneus
• Ligamentum patellae
• Hamstrings
• Rotator cuff, especially supraspinatus
• Long head of biceps brachii
• Common extensor tendon (tennis elbow)
• Common flexor tendon (Golfer’s elbow)
• Extensor pollicis longus
• Abductor pollicis longus and extensor pollicis brevis
• Finger flexor or extensor tendons

Partial Rupture – Pathology


• Some of the tendon fibres tear and others are intact
• Tendon is a poorly vascualrised tissue and only a small amount of blood may be
released from damaged blood vessels
• Low-grade inflammatory changes take place.
• Granulation tissue forms at the site of injury
• Tendon cells invade the area and tendon fibres are laid down so that healing takes
place
• If there is extensive damage the fibrous (non tendon type) scar tissue may form as
well and this can bind the tendon to surrounding tissues
• Repair can take from 3 to 6 weeks depending on the degree of injury
Clinical Features
History – a sharp stabbing pain or tearing may be heard or felt
Loss of function – The patient is unable to produce the action of the muscle
Swelling and bruising may appear 2 to 3 days after injury

Complete Rupture – Pathology


Spasm of the muscle causes retraction of the free end of the tendon so that a gap forms.
Haematoma fills the gap. Granulation tissue forms in the haematoma. Tendon cells
may lay down tendon fibres but generally fibrous tissue fills the gap. This renders the
tissues virtually useless because the fibrous tissue stretches. Suturing is therefore
essential to enable tendon fibres to reunite the tendon.
Where the rupture is spontaneous, the poor blood supply and frayed ends of the tendon
make spontaneous healing impossible and suturing is difficult. Repair may require a
graft.
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Clinical Features -- History
• Knife injury (fingers)
• Hand going through window (wrist)
• Snap on sudden activity (tendo Achillis)
• Sudden stretch with muscle contracting(quadriceps tendon)
Tenosynovitis
This is inflammation of the synovial sheath of a tendon. Tendinitis is inflammation of a
tendon which does not have a sheath.

Cause
The commonest cause is over-use, but pressure may also cause the condition

Pathology
Inflammatory changes occur within the tissues of the sheath resulting in excess
synovium production and inflammatory exudate. Over 1 to 2 weeks fibrin forms and
can consolidate into adhesions which can impair tendon movement. With correct
treatment, the inflammation subsides, the excess fluid is absorbed and the tendon plus
sheath return to normal within 2 to 3 weeks. Overuse and abuse can cause chronic
inflammation.

Clinical Features
Sharp pain is felt at the site of the inflammation and spreads in line with the tendon both
distally and proximally
Redness - This appears over the line of the tendon
Swelling - There is swelling, sometimes sausage shaped, along the length of the sheath
Crepitus – ‘Grating’ can be felt over the sheath as the tendon moves with it
Loss of function – This is a disabling condition, the patient being unable to perform any
of the movements involving the tendon
Common Sites
• Wrist tendons; caused by overuse, e.g. at a keyboard, prolonged knitting or writing,
change of grip (technique or handle) in sport
• Extensor pollicis longus; caused for example by using scissors excessively
• Tibialis anterior; caused for example by sudden extra fast walking
• Extensor tendons (toes); caused for example by pressure from an ill-fitting shoe or
extra walking in tight shoes

Fascia

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Fascia is the complex soft tissue webbing which holds us all together. It is wrapped
around muscles, around individual muscle fibres, used in suspending organs, a
necessary matrix of vascular structures, nerves, and lymphatic vessels and instrumental
in creating our body shape.
Fascia is a connective tissue. It is quite pliable and malleable so it is rarely subjected to
compressive force injuries. The main problem with fascia are tensile stress injuries and
the problematic results created from periods of prolonged shortening.
When soft tissue structures of the body are over-stretched, the fascia that binds or
connects then will also be over-stretched. The fascia has multidirectional fibres in order
to resist stress from different directions. However, if that stress overcomes the tensile
strength of the fascia, it will tear. When it does, it is likely to create scar tissue which
may bind the fascia to adjacent structures. This scar tissue is most easily managed
through the rehabilitation process by multidirectional stress (massage strokes,
stretching, etc) being applied to it within it’s comfortable and normal range of motion.
One of the most problematic features of fascia is it’s response to prolonged
immobilisation. If the body is held in one position for prolonged periods of time the
fascia has a tendency to adapt to the position. The is especially problematic when the
fascia is held in a shortened position. When it is kept in this shortened position it will
structurally adapt to that position and resist an attempt to return to it’s normal length.
The longer it is subjected to this shortening the harder it will be to return to it’s normal
length.
Common conditions include:
Iliotibial tract syndrome
Shin soreness
Interscapular pain

Iliotibial Tract Syndrome


The iliotibial tract is a thickened band of fascia on the lateral aspect of the thigh.
Proximally, the gluteus maximus and tensor fascia latae are inserted into it. Distally, it
is attached to the lateral condyle of the tibia.

Pathology
The tract can become thickened and tight. The deep surface can become inflamed

Cause
Excessive use in patients who participate in long distance sport (running, walking) gives
rise to this syndrome. It can also occur in people who habitually stand on one leg more
than the other, e.g. a person who favours the left leg has a lengthened left tract and a
lightened right tract.
Clinical Features
Pain – usually come on gradually over the lateral side of the thigh. It increases in
intensity until the patient decides to seek help.

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Tenderness – The tract is tender on palpation especially in the lower third.

Movements – Hip adduction is slightly limited

Shin Soreness
This is related to a tight fascial compartment in which the anterior tibial muscles are
contained. Exercise – especially long distance walking or unaccustomed running or
walking – bring on the pain over the anterior aspect of the shin. As the muscle
exercises, fluid collects and the tightness of the fascia causes compression which brings
on the pain.

Interscapular Pain
Long-standing tension in the interscapular muscles is associated with tethering of the
fascia. This is a component in a viscous circle: tension in the muscle causes
accumulation of fluid, causing discomfort, leading to further tension and pressure
within fascial compartments causing more stretching of the fascia with a reaction of
thickening and tethering, causing more pain and more tension.

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Bursitis

Definition
Bursitis is inflammation of a bursa. A bursa is a membrane sac lined with endothelial
cells. It may or may not communicate with the synovial membrane of the joints. The
function of a bursa is to prevent friction between two structures (e.g. tendon and bone or
tendon and muscle) or to protect bony points.

Common Sites
• Prepatellar bursitis (Housemaid’s knee)
• Suprapatellar bursitis
• Subdeltoid bursitis
• Miner’s or student’s elbow (olecranon bursitis)
• Achilloydina (inflammation of one of the bursa around the tendo Achillis

Causes
Trauma – one episode or, more often, repeated minor episodes
Associated diseases e.g. rheumatoid arthritis, gout

Pathology
Acute inflammatory changes occur. Chronic inflammation may arise with repeated
minor trauma

Clinical Features
Pain – Over the bursa especially on compression
Swelling – a large fluctuating swelling may be present

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Joint Capsule

The composition of joint capsule tissue is similar to that of ligament tissue. It’s primary
function is to maintain integrity of the joint, guide specific joint motions, prevent
excessive motion and house the lubricating synovial fluid which reduces friction and
wear on the joints.
Portions of the joint capsule are highly innervated with proprioceptors and noiceptors.
Proprioceptors are specialised cells that give a great deal of feedback information to the
central nervous system about movement and position in space.

Nociceptors are pain receptors. Injuries to the joint capsules may be quite painful. The
most common types of injuries sustained by the joint capsule are tensile stress tearing
injuries such as those sustained by ligaments.

The joint capsule may also be involved in various conditions of adhesion that will limit
functional range of motion. For numerous reasons, some of them unknown, a joint
capsule will begin to develop adhesions and restrictions to movement in certain planes
of motion. This may involve muscle spasm and tightness, prolonged immobilisation,
repetitive misuse or emotional factors. The condition of adhesive capsulitis, also known
as ‘frozen shoulder’ is an example of this.

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Cartilage

There are two types of cartilage that will be of primary concern, hyaline cartilage and
fibrocartilage. This cartilage does not have vascular or nerve supply. This is important
because injury of the actual cartilage tissue may not feel painful to the individual.
Many times it is only when the injured cartilage interferes with other types of tissue that
pain or discomfort will be felt.

Hyaline cartilage is prominent at the ends of bones in joints where it is called articular
cartilage. It is a hard shiny substance which greatly reduces friction of the bones and
help to create a smooth gliding substance for the two ends of the bone that are meeting.
Fibrocartilage is also present between the bones but it plays a different role.
Fibrocartilage can be found in regions such as the menisci of the knee or the
intervertebral discs in the spine. These fibrocartilagenous discs in both the knee and the
spine help to provide additional cushioning from compressive forces. The intervertebral
discs also help to angle the spine and the menisci in the knee help to provide the
optimum contact surfaces required for functional joint mechanics.

Cartilage is susceptible to several types of injures. Compressive force injuries to


cartilage are the most frequent. Disc herniations and ruptures of the intervertebral discs
in the spine are the result of cumulative compressive forces over time. They made be
made suddenly worse by an acute injury but there is usually a history of chronic
compression needed to fully herniate or rupture a disc.

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Blood Supply and Healing Times of Various Body Tissues

Tissue Type Blood Supply Healing Time

Skin Good 3 to 14 days

Muscle Average 3 weeks

Tendon/Ligament Poor 6 weeks

Bone Good Upper Limb 3 to12 weeks


Lower Limb 12 to 18 weeks
Femur 4 to 5 months
Young Children 4 to 6 weeks

Cartilage None No Healing process

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HISTORY TAKING

When did the present problem arise?


Was the onset gradual or sudden?
Was an injury or unusual activity involved?

An insidious onset unrelated to injury or unusual activity should always be viewed with
suspicion since this history is typical of a neoplasm. However degenerative lesions or
lesions due to tissue fatigue are common and may also arise in this manner.
If the patient blames some injury or activity, keep in mind that he may or may not be
correct. The exact nature of the event or mechanism of injury should be determined so
that correlation can be made to symptoms and signs for interpretation.
Determining the direction and nature of forces producing the injury may give some
clues as to which tissues may have been stressed.

What aggravates the pain?


What relieves it? Is it any better or worse in the morning or evening?
When do you typically feel pain?
Bilateral referred pain is generally associated with a lesion in the vertebral canal
therefore immediate medical attention is warranted.
Pain not aggravated by activity or relieved by rest should be suspected as arising from a
pathological process other than a musculoskeletal disorder. The exception is a disc
problem that may be aggravated by sitting and relieved by getting up and walking.
Morning pain is suggestive of arthritis, especially the inflammatory varieties.
Morning stiffness is suggestive of degenerative joint disease or chronic arthritis.
Pain awakening the patient at night is typical of shoulder or hip problems that may be
aggravated by lying on an affected side. Otherwise a more serious problem should be
suspected, particularly if the patient is kept awake and particularly if he must get up and
walk about.
Arthritis in weight bearing joints leads to pain on fatigue (long walks etc) in it's early
stages. In later stages the pain is felt when beginning a walk, somewhat relieved once
going, and returns after walking too far.

Have you had this problem in the past?


If so, how was it resolved? Did you seek help?
Was there any treatment? Is the pain the same this time?
Should the examiner elicit a history of recurrence, the patient should be asked in depth
about the first episode and the most recent episode, with an estimate of the number of
intervening episodes. Recurrences are typical of spinal cord lesions, but many common
extremity lesions such as ankle sprains, minor meniscus lesions, or other internal
derangements, minor degenerative joint problems, tendinitis, and frozen shoulder may
also tend to recur.
By enquiring about previous management, some helpful information may also be
obtained for treatment planning. However, the patients judgement of the effectiveness
or value of previous treatment must not be weighted too heavily. If an injection helped
before, for example in the case of supraspinatus tendinitis, it does not necessarily follow
that another injection is necessary or indicated. If physical therapy (perhaps
inadequately instituted) was unsuccessful in the past, do not assume that it will not be
helpful on this occasion.

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Are there other symptoms that you have or have had that you associate with the problem,
such as grinding, popping, giving way, numbness, tingling, weakness, dizziness or
nausea?

By concentrating on the patient's account of pain, the examiner may well overlook some
other important symptoms. A wide variety of responses may be elicited with this
question, each of which must be carefully weighed and considered.
A patient's description of numbness is very often not true hypesthesia but is actually
referred pain. In most cases, considerable weakness must be present before the patient
can accurately perceive it as such, and very often, what the patient describes as
"weakness" is actually instability or giving way. Symptoms inconsistent with
musculoskeletal dysfunction must be viewed with some suspicion and medical
consultation sought for interpretation.

What treatment are you having, or have you had for the present problem?
Are you taking any medication for this problem or for any other reason?
Here again, it may or may not be helpful to determine whether certain attempts at
treatment have had any good or bad effects especially treatments involving physical
agents.
The examiner must determine whether pain medications, anti-inflammatory agents, or
muscle relaxants are being taken. Symptoms or signs may be masked accordingly.
Certain medications may produce rather marked musculoskeletal changes (in addition to
effects on other tissues and functions). Most important perhaps is the long term use of
corticosteroids, which produces osteoporosis, proximal muscle weakness, generalised
tissue oedema, thin fragile skin, collagen tissue weakening, and increased pain
threshold. These factors of course, will affect findings on examination. More
importantly however, they must be considered when planning treatment.

How is your general health?


It is necessary to determine whether the patient has, or has had any disease process or
health problem that may have contributed to the present problem, or that may influence
the choice of treatment procedures.

Do you have any ideas of your own as to what the problem is?
Some useful information may be elicited as to what the patient has learned from others,
what his insight is into the problem, and so on. If nothing else, the patient can be
reassured that the examiner is interested in him and his opinions and that he is to be
involved in the therapeutic programme.

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APPLICATION OF COLD

The application of cold, including ice, is a frequently used modality in Physical


Therapy. Muscles constantly produce heat. When muscles are exposed to cold, there is
need for increased production of heat, and subsequently, muscle tone is increased. Brief
exposure to cold therefore, causes an increase in work output. It also raises the stimulus
threshold of muscle spindles and prolongs relaxation. In other words, cooling the
tissues causes vaso-constriction, decreased tissue metabolism, and blocks the release of
histamine which is responsible for vaso-dilation and exudate formation.

Physiological effects.
Reduces oedema and facilitates it's reabsorption, therefore aiding in the repair of injured
tissue.
Ice provides a quick and effective way by which nerve impulses can be suppressed to a
considerable extent, thus inducing pain relief.
Reduces muscle spasm by lowering nerve conduction and directly inhibiting the muscle
spindles or tone regulators.
There is an increased output of adrenalin and generally prepares the muscle for activity.
Ice is an excellent modality in acute, traumatic or inflammatory conditions.

Indications for use.


Acute traumatic conditions, low - back sprains, whiplash, injuries etc.
Sometimes used for chronic traumatic injuries.
In reduction of pain and inflammatory processes in rheumatoid arthritis.
In preventing bleeding and swelling in sport injuries.
In re-education of weak muscles as part of the neuromuscular facilitation or muscle
energy techniques.
Used in temporarily decreasing spasticity in neurological disabilities.
When ice is applied to the skin, heat is conducted away in order to melt it. To change
it's state ice requires considerable energy, therefore it is important to use ice and not
cold water compress.

The initial response to cooling is vaso-constriction in order to preserve heat. This


means the part becomes very cold. After a short period there is vaso-dilation and then
alternate periods of vaso-constriction and vaso-dilation. This hunting for a mean
circulation is called "Lewis' hunting reaction". It is thought that there is an increased
flow of blood through the capillaries thus aiding the treatment of swelling and tissue
damage.

Neural Response
There are several more cold receptors in the skin than warm receptors, therefore a rapid
response to cooling. The first fibres affected by cooling are A, B, then C. The main
function of ice is to reduce pain. The probable mechanism is as follows:- cold receptors
send neural signals to the posterior horn of the spinal cord via large diameter neurons
and close the gate. The cold stimulus could be classed as an irritant and stimulate the
release of opiates into the posterior horn.

Physiotherapeutic uses of circulatory effect.


• The initial vasoconstriction limits the invasion of blood into tissue following injury.
Then follow with compression bandage.

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• Lewis' hunting reaction takes place at the capillary level and because it is across
capillary membrane that tissue fluid exchange takes place, an effect at a local level
can reduce swelling. Excess tissue fluid is returned to general circulation, therefore
there are more nutrients and repair substances. Note: Ice cube massage accelerates
repair of bed sores.
• Cooled muscle have a lower metabolic rate and muscles can contract more times
before fatigue.
• Possible increased circulation vents chemical substances and prevents them
stimulation nociceptors and producing pain.

Methods of application
Ice packs
Ice towels
Ice cube-massage
Immersion

Ice towels
Crushed or flaked ice in a container with water added in the proportion of 1 : 2 part of
ice. If the container is covered with a waterproof material the ice will remain at the
correct consistency all day. Terry towels (hold the chips better) can be kept in the ice,
ready to wring out and use when required. This form of cold therapy sometimes
produces a skin reaction, ie patches of erythema with indurations and some
hyperaesthesia appear. This reaction may last 24 - 48 hours but the sensitivity may last
some time longer.
Treatment:- calamine lotion. It can be avoided by applying oil to the skin prior to cold
therapy. The areas most susceptible are, - over the anterior aspect of the shoulder, and
the medial and posterior aspect of the knee.
When the ice-pack is required it is wrung out, but still containing the ice chips. The
towel is laid on the part to be treated to cover as much of the painful area as possible,
including the O & I of the muscles involved. The towel is renewed every minute and
treatment continued for 5 - 15 minutes. Treatment is enhanced if isometric or isotonic
contractions are given while ice packs are in place.

Ice packs.
Oil skin first. It is a most effective form of treatment. Frozen peas - cryogen.

Contraindications.
There is general disagreement about contraindications but we list all the possibilities:-
- Circulatory problems such as Raynaud's disease.
- Cancer.
- Sickle - cell anaemia.
- Cardiac conditions - avoid the thoracic area.
- Hydrocortisone injections.
- Area behind the ear where the vagus nerve lies superficially because of the possible
effect on blood pressure.
- Very young or very elderly people.
- Highly sensitive individuals.
- Recent skin grafts.
- Loss of sensation.

Effects of Ice During Immediate Care


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Treatment Schedule— Age of Day on which patients were able, without pain, to…
patients
Moderate Sprains Stand Walk Climb Stairs Run and Jump

Early Cryotherapy 28 0 2.6 3.7 6.0

Delayed Cryotherapy 24.7 0 5.2 +6.8 11.0

Early Thermotherapy 24.0 0 7.8 9.0 14.8

Moderate Plus Sprains

Early Cryotherapy 25.3 2.7 4.2 5.7 13.2

Delayed Cryotherapy 23.2 6.2 12.0 13.6 30.4

Early Thermotherapy 23.7 5.7 9.7 9.7 33.3

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APPLICATION OF HEAT

The physiological effects of heat are, analgesic, antispasmodic, decongestive and


sedative. Heat increases the exchange of oxygen and hastens the absorption of
exudates. It is a vaso-dilator that increases the amount of blood brought to a region; it
also increases metabolism locally. When vaso-dilation, relief of pain, or muscular
relaxation is required, heat may be prescribed as a therapeutic agent. It is often used
before massage and exercise is given.

Contraindications
Areas of loss of sensation.
Decompensated heart disease.
Peripheral vascular disease
Metallic or thermoplastic implants in underlying area.
Malignant tumour except in the terminal stage
Certain acute arthritic conditions, for example RA.

ADHESIONS AND LIMITED RANGE OF MOTIONS OF JOINTS.

Limitation of range of motion.


A goal of treatment is to regain range of motion. Voluntary motion or active exercise
(when the patient performs the movement) helps rebuild muscle strength and
coordination. The movement limitation is sometimes due to muscle spasms; severed
tendons, muscles or nerves; scarring or adhesions. The cause of the limitation must be
carefully considered before starting treatment.

Adhesions.
An adhesion is the holding together of two tissues which are normally separate
structures.
Adhesions may be either inside or outside of a joint, but those inside are harder to deal
with since massage cannot reach this area. Therefore passive movements are essential in
treating intra articular adhesions. Adhesions are physical in nature and may vary from a
mere film to a firm band, producing general stiffness to complete immobility of a joint.
The breakdown of adhesions is a gradual process and attempts to hasten progress may
result in repeated irritation or re-injury of the area.
Adhesions which do not yield to a fair trial may need to be stretched under an
anaesthetic by a physician, or surgically treated. Adhesions are not limited to joints but
may be found in any tissue where injury and inflammation have occurred.

TRANSVERSE FRICTION. Goading.


Many of the chronic musculoskeletal disorders, e.g.. tennis elbow, tendinitis, frozen
shoulder are manifestations of the body's response to fatigue, stresses, (overuse from
repetitive movements or sustained contractions). Tissues tend to respond to fatigue
stress by increasing the rate of tissue production. Thus, prolonged abnormal stresses to
a tissue will lead to tissue hypertrophy, provided that the nutritional status of the tissue
is not compromised and that the rate of tissue breakdown does not exceed the rate at
which the tissue can repair the micro damage.

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Under continuing stress, if nutrition to the tissue is effected, or if the rate of tissue
breakdown is excessive, the tissue will gradually weaken and atrophy to the point of
eventual failure. Tissues that normally have a low metabolic rate are most susceptible
to such degeneration are articular cartilage, intra-articular fibro-cartilage, tendons and
some ligaments.
Likewise, if the new tissue that is produced does not have sufficient time or proper
inducement to mature, pain and inflammation are likely to result if stresses continue.
Correction of such conditions requires that stress levels be reduced, whilst stresses
sufficient to stimulate normal tissue modelling are maintained. In addition, normal
extensibility of the structure must be restored. This requires that inter-fibre mobility be
increased. The nutritional states of the tissue must also be considered.
In situations in which significant reduction of activities is necessary in order to allow
healing to occur, there are measures which the therapist can and should take. The
therapist must help prevent undue dysfunction that may result from a mass of tissue
being laid down causing adhesions and atrophy of related muscle groups. There are few
conditions, even of an acute inflammatory nature, in which some gentle ROM and
isometric muscle exercises cannot be performed during the healing process without
detrimental effects.
Some of the chronic disorders that tend to be most persistent are minor lesions of
tendons and ligaments. They often respond poorly to rest and anti-inflammatories
because they are not chronic inflammatory lesions per se, but pathological processes
resulting from abnormal modelling of tissues in response to fatigue stresses. Therefore,
while rest allows new tissue to be produced, that which is produced, is not of normal
extensibility.
Therefore the structure becomes more susceptible to internal strain when stresses are
resumed. The result is recurrence of a low-grade inflammatory process each time use of
the part is resumed.
The most common of these disorders are supraspinatus tendonitis, tendonitis of the
extensor carpi radialis brevis (tennis elbow), Tendonitis of the abductor pollicis longus
or extensor pollicis brevis tendons at the wrist (de Quervain's Disease), coronary
ligament sprain at the knee, and anterior talo-fibular ligament sprain.

A very effective method of promoting increased extensibility and mobility of the


damaged structure while reducing stress levels and allowing healing to take place is the
use of deep transverse friction. This is a form of treatment advocated by Cyriax. It
involves applying a deep massage directly to the site of the lesion in a direction
perpendicular to the normal orientation of fibrous elements.
This maintains mobility of the structure, with respect to adjacent tissues, and probably
helps to promote increased interfibre mobility of the structures itself without
longitudinally stressing it. It may also produce normal orientation of the fibres as they
are produced. In some pathological processes such as rotator cuff tendinitis, in which
the etiology may be related to a nutritional deficit arising from hypovascularity, the
hyperaemia induced by the deep friction massage may also contribute to the healing
response.
In addition to the various tendinitis conditions, deep transverse friction is also very
effective in sub-acute or chronic ligamentous sprains, e.g.. intercarpal ligament sprains
(wrist), minor medial collateral ligament sprains (knee), minor anterior talofibular or
calcaneocuboid ligament sprains (ankle). Acute signs and symptoms should be resolved
at the time at which friction is used.

Technique.
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• Fingernails should be cut short.
• The part should be well exposed and supported.
• Structure to be treated is usually put in a position of neutral tension.
• Position for easy accessibility.
• Therapist should be comfortably seated (standing).
• Use pad of index, middle finger or thumb directly over the involved site.
• No lubrication is used. The patients' skin must not move with the therapists finger.
• Begin with light pressure, patient may feel light to moderate tenderness, which
should have subsided considerably after 1 to 2 minutes. Increase pressure some
more for 1 to 2 minutes.
• During the first treatment, the massage should be stopped after 5 to 6 minutes and the
key signs reassessed (stretching the tendon or resisted movements). With successive
treatments, the depth of massage is always gradually increased, and the length of
treatment is increased to 12 or 15 minutes per session. Some authorities feel that
treatment should not be continued during a particular session, nor should the depth of
treatment be increased if the tenderness to massage increases or does not subside
during treatment. It is not unusual for a patient to feel some increased soreness
following the first or second session, but this must be distinguished from
exacerbation of symptoms.
• Deep friction should be avoided on patients with long term, high dose, steroid drug
therapy and patients with known peripheral vascular disease.

IS IT A MUSCLE OR IS IT A JOINT?
Is the patients problem mainly in the soft tissues?
Traction or stretching of the painful area increases pain in soft tissue dysfunction
Compression of a painful area usually decreases pain in soft tissue dysfunction.
Patient controlled (ACTIVE) movement in one direction which produces pain or which
is restricted, and operator controlled movement (PASSIVE) in the opposite direction
which is painful or restricted indicates contractile tissue as being implicated.
Active and passive movement in the same direction both producing pain and or
restriction indicates a joint (INTRA-ARTICULAR) dysfunction.

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SHOULDER

The Scapulo - Humeral Rhythm. This denotes the combined movement of the humerus
upon the scapula at the gleno - humeral joint and the scapula on the thorax. This is best
seen in abduction. Abduction of the arm occurs in the gleno - humeral joint and
scapulothoracic articulation in a two to one ratio (2:1), for every 3° of abduction, 2°
occur in the gleno-humeral joint and 1° occurs at the scapulothoracic articulation.
Full abduction = 180°
Gleno-humeral movement = 120°
Scapulo-thoracic movement = 60°

The first 15° - 30° of abduction takes place at the gleno-humeral joint and is initiated by
the supraspinatus. The scapular muscles contract and stabilise the scapula. At
approximately 15° - 30° Deltoid takes over. The scapula moves forward, elevates and
rotates around the chest wall, with the aid of the sternoclavicular and acromioclavicular
joints.

As the arm is being abducted there is a medial twist developing in the capsule. At
approximately 90° - 110° the humerus has to rotate laterally so that the greater
tuberosity does not impinge upon the coraco-acromial arch. The sub-deltoid bursa
moves proximally beneath the acromina.

Note. As the Deltoid is abducting the arm, the humerus is pulled upwards and
outwards. To counteract this action there is a downward pull by the Infraspinatus, Teres
Minor and subscapularis. If the subdeltoid Bursa is distended or a decrease in lateral
rotation or the Humerus rides too high, there is inevitably an impingement.
To be more precise, the combined range of movement of the gleno-humeral joint and
scapulo thoracic articulation is 160°.
Unilateral abduction - cervicals side bend to opposite side.
Bilateral Abduction - lower cervicals and upper thoracics extend.
Fixed Thoracic Kyphosis - Abduction cannot be full.
NB. In paralysis - Inferior glide of humerus is essential in conducting Abduction and
flexion.

Sternoclavicular joint.
At 90° of abduction the clavicle will have elevated 30°. When the arm is abducted
beyond 90° , the clavicle rotates.

Acromio-clavicular joint.
This allows a gliding movement of the scapula when the scapula rotates in such
movements as thrusting the arm forward or raising it over the head.

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INSPECTION OF SHOULDER JOINT

Observation.
How patient carries arm
How patient undresses; look for asymmetry of movement
Scars, discolourations, obvious deformity or dislocation
Bilateral comparison of the following:-
Posteriorly Height of shoulders
Scapula levels
Distance from spine
Anteriorly Shape and angle of clavicles
Round shoulders
Are arms internally or externally rotated
Check the spine for excessive lordosis or kyphosis. Note any scoliosis.
Head position asymmetrical side-bending or rotation.

Bony palpation.
Suprasternal notch
Sternoclavicular joint
Clavicle
Coracoid process
Lateral border of scapula
Inferior angle
Vertebral border
Superior angle
Spine of scapula
Acromion process
Acromioclavicular joint
Greater tuberosity
Bicipital groove (intertuberculus sulcus)
Lesser Tuberosity

Shoulder Pain
Shoulder pain may result from any of the following:-
Local, Soft tissue lesions, for example frozen shoulder, tendinitis, secondary bursitis,
acromioclavicular sprain, rotator cuff strains.
Joint lesion, e.g.. O.A., R.A. of the glenohumeral joint. O.A. of the acromioclavicular
joint. Dislocation of the sternoclavicular joint, A/c Joint or G/H joint, fractures.
Referred pain:-
Radicular (nerve root)
Active Trigger point
Visceral
Note: There could be local pathology and referral of pain at the same time. If the
degree of pain is excessive in comparison to the amount of pressure applied, you may
assume that the problem is local. If there is no local tenderness or only mild tenderness
where patient complains of pain, then pain is very likely to be referred from elsewhere.

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Painful Arc Syndrome

Characterised by pain in the shoulder and upper arm during the mid-range of gleno-
humeral abduction (45° to 160°) with freedom from the pain at the extremities of range.
Adduction in middle range can also cause pain and the arm to wobble.

Causes:
Overstrain
Accident/Trauma

Pathology
Decreased blood supply to area in over 50 year age group.
Pain is produced mechanically by nipping of a tender structure between the tuberosity
of the humerus and the acromium process whilst the arm is being abducted.
5 different and distinct lesions are involved:
Minor tear of supraspinatus tendon.
Supraspinatus tendinitis.
Injury of greater tuberosity, contusion due to fall or injury.
Sub-acromial bursa (over the supraspinatus).
Calcified deposit in the supraspinatus tendon.

Diagnosis: Types 1 + 2 + 3
Lateral arm pain
Difficulty in abducting arm
Active and resisted abduction elicits pain between 60° and 120° as the tendon is
compressed between the tuberosity of the humerus and acromion.

Type 4
Elevation from 30° to 60° produces maximum compression of the bursa, which, if
inflamed, gives pain.

Type 5
Calcification develops in an area of the degenerated tendon near the tender insertion.
Cause: associated with supraspinatus tendinitis and can lead to calcific bursitis, which
is very tender.

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Partial Rupture Of Supraspinatus

Signs & Symptoms


Sharp pain at shoulder (may have felt a tear).
Pain referred to elbow.
Painful Arc.
Passive abduction pain-free.
Resisted abduction painful and weak.

Treatment
See treatment of Tendinitis.
Progress is slower.

Tendinitis -- Bursitis
Tendinitis at the shoulder is a very common disorder. It occurs in the young and active
as well as in older people. In the case of a younger person it may be caused by
activities such as tennis, racquetball, baseball, basketball, all of which increase the
stress levels to the rotator cuff tendons.

In the older person it is more likely to be degenerative lesion. Because of the relatively
poor blood supply near the insertion of the rotator cuff muscles, nutrition to the area
may not meet the metabolic demands of the tendon tissue. The resultant cell death sets
up an inflammatory response, probably due to the release of irritating enzymes and dead
tissue acting as a foreign body. The body may react by laying down scar tissue or
calcific deposits. Such calcific deposits may be visible on radiographs; however they
are often seen in the absence of symptoms, and conversely they are not always present
in known cases of tendinitis.

There is nagging pain at rest but made worse by certain movements, depending on the
tendon involved. Infraspinatus and Teres Minor -- pain is localised on the greater
tuberosity. Resisted external rotation makes it worse.

Subscapularis -- pain over lesser tuberosity and aggravated by resisted internal rotation.

Supraspinatus -- active abduction is painful through 60 to 120 degrees, possibly due to


the inflamed tendon rubbing against the acromion and is abolished by externally
rotating the arm. Pain is aggravated by resisted abduction. Tenderness is greatest over
the tendon where it blends with the capsule.

Superficial migration of these deposits with rupture into the underside of subdeltoid
bursa is thought to be a major cause of acute bursitis of the shoulder, with patient
complaining of severe pain on abduction and external rotation. Pain may be throbbing
in nature and patient may hesitate on performing full contraction under resistance.
Because of the poor blood supply to the region adequate repair may not take place and
the lesion may develop into an actual tear in the tendon in which case there will be
sudden severe pain associated with the tear.

The degenerative lesions tend to be persistent with little likelihood of spontaneous


resolution. The combined effects of poor blood-flow and continued stress to the tendon
do not allow for adequate maturation of the healing tissue.

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It is not unusual for a patient to describe a history of several years of constant or
intermittent problems with the shoulder. This by no means should suggest that these
patients cannot be helped, since they do respond well, and often dramatically to
treatment.

Transverse Friction.
This is an essential component of the treatment programme in chronic cases. The
beneficial effects of friction in such cases is not well understood. However it is
proposed that an increase in the mobility of the developing or developed scar tissue
takes place without stressing the tendon longitudinally.

This prevents the healing tissue from being continually re-torn during daily activities.
A factor which may contribute to chronicity and recurrence is weakening of the rotator
cuff muscles from reflex inhibition or from actual disuse.

Such weakening would predispose to subacromial impingement during elevation of the


arm and further mechanical irritation at the site of the lesion. Light to deep transverse
friction are given over the tendon. Therapist at the patients' side and identifies the site of
the supraspinatus tendon lying between the greater tubercle of the humerus and the
acromion process. It is essential that the tendon be accurately located by knowledge of
anatomy, it can not be distinguished by palpation. The pad of the therapists' finger
(reinforced) is placed directly over the site of the lesion, which is always just proximal
to the tendon insertion of the greater tubercle.

Friction is applied transversely in a direction perpendicular to the normal orientation of


the tendon. This is a most valuable treatment in the management of supraspinatus
tendinitis. A similar technique is used for the other tendons of the rotator cuff. Two
treatments per week are required if satisfactory progress is to be achieved. Cryotherapy
immediately after friction helps ease inflammation.

Rotator cuff strengthening.


This is also an important part of the treatment programme, however if recent or repeated
steroid injections to the tendon have been performed it is necessary to proceed gradually
with the strengthening programme.

Although local steroids do relieve the pain through inhibiting local inflammatory
response, they have an anabolic effect on connective tissue, which may result in
structural weakening of the injected tendon.

Supraspinatus strengthening.
The patient should stand with the arm at the side and rotate the shoulder internally to
pronate the forearm. Then, moving the arm in a diagonal direction of abduction the
patient should aim to achieve 90° abduction at 30° to 40° in front of the coronal
position. This position aligns the muscle parallel to arm movement (in the plane of the
scapula) and in this position maximum contraction of the supraspinatus is achieved.
NOTE: There will always be tenderness over the involved tendon insertion point.

There will probably be pain on stretching the involved tendon e.g. on full internal
rotation in the case of infraspinatus tendinitis.
As regards resisted movements in the case of simple tendinitis the contraction will be
fairly strong, if a tear exists it will be fairly weak.

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Advice to patient:
Strict avoidance of activities that may cause impingement or tension stress at the site of
involvement while formation of painless scar takes place.
Gradual return to normal use as healing progresses.

Supraspinatus Tendinitis

Causes
Prolonged and repeated use of the shoulder with the arm at or above shoulder level.
Repeated external rotation of the upper arm
Trauma, for example a fall on the shoulder
Repeated minor trauma.

Physical Therapy Assessment & Treatment -- Clinical Features


There may be nagging pain at rest.
Active movement - painful arc between 60° - 120° abduction.
Pain on lowering arm from abducted position. Pain eases if this movement is resisted.
Passive movement that stretches the tendon is painful i.e. full adduction, and full
internal rotation.
Resisted abduction is painful (the degree varies according to severity of lesion).
In the case of a simple tendinitis, contraction against resistance will be fairly strong. If
an actual tear exists it will be weak.

Treatment Goals.
To relieve pain.
To encourage adequate maturation of the healing tissue.
To normalise surrounding soft tissue.
To develop postural awareness.

Treatment Plan
Rest to injured area.
Cryotherapy (ice).
Myofascial work to shoulder girdle muscles.
Transverse friction to tendon.
Encourage active depression of humerus hourly.
Gentle painless stretching of supraspinatus.
Strengthening of supraspinatus.
Look closely at daily activities - avoid elevation of arm to shoulder level.
Ruta grav application three times daily.

Infraspinatus Tendinitis

Cause
Repeated minor trauma resulting generally in chronic inflammation

Clinical Features
Pain at night on both lying on the affected side and lying on the opposite side.
Tenderness on palpation of attachment.

Specific Test
Pain and weakness on resisted lateral rotation
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Treatment
Same as for all tendinitis with specific stretching and strengthening techniques to
Infraspinatus.

NOTE: Encourage client to lie on unaffected side with pillow supporting affected arm.
This prevents prolonged overstretching of tendon.

Tendinitis of the Long Head of the Biceps

Cause
It is generally sports related for example among canoeists, oarsmen, weightlifters,
swimmers, javelin throwers, wrestlers and racquet sports.

Clinical Features
Pain over anterior aspect of the shoulder particularly when the shoulder is externally
rotated against resistance while the elbow is held flexed at a 90 degree angle.

Test
Pain on resisted elbow flexion and supination.
Yergason Test. This determines whether or not the biceps tendon is stable, ie a tear to
the transverse ligament.

Treatment
Same as for all tendinitis with specific stretching and strengthening techniques to
Biceps.

Subacromial Bursitis.
The shoulder tendons are wide bands of collagen fibres. If stress roughens a tendon its'
tensile strength decreases. This leads to fibrinoid degeneration in and between collagen
fibres and later fibrosis. With necrosis, the local tissues become alkaline which induces
precipitation of calcium salts. Of the 140 bursae in the body, none receive the attention
in sports as much as the subdeltoid bursae.

Causes:
Remember it is usually not a primary cause.
Usually it is secondary to lesions in the rotator cuff.
Strain or injury of the supraspinatus muscle.
Direct trauma, for example a fall or blow to the shoulder.

Clinical Features
Most shoulder movements will be painful especially abduction.
Pain on resisted adduction from abducted position
The bursa may be swollen and palpable.
Weakness of all shoulder movements.
To find, extend the arm and exert traction to palpate portions of the subdeltoid and
subacromial bursae
Treatment:
Rest and sling for the first three days. (in some cases strapping may be necessary).

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Cryotherapy
When swelling begins to subside, a most gradual programme of active exercise can
usually begin in 4 to 7 days.
DO NOT OVERTREAT. NO DIRECT WORK TO BURSA
Stubborn cases, aspiration and steroid injections.

RUPTURE OF THE SUPRASPINATUS.

Causes:
Fall with outstretched hand.
Blow to the shoulders.
Throwing or heavy lifting.
May be asymptomatic.
Usually due to attrition.
Previous history of tendinitis/bursitis

Clinical Features.
Inability to intitiate glenohumeral abduction
Commoner in older people especially in over 60 years
May say they heard a snap.
Pain on lateral aspect of shoulder.
Hunches shoulder to raise arm.
Loss of abduction.
Scapular abduction to maybe 20°
May be a gap between acromium and greater tuberosity.
May be supraspinatus atrophy (gap in fossa)
Supraspinatus pulls the humerus into the glenoid fossas and abducts the humerus,
initially 10° to 15° before deltoid becomes effective.
Tear near insertion.
Full range of passive movement.
If arm is abducted to 90° patient can hold it by deltoid action.

Test
Drop arm test.

Diagnosis:
Artrography.

Treatment:
Older - conservative¨ Younger - suture

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RUPTURE OF LONG TENDON OF BICEPS.

Causes
Usually it is the long head of the biceps that ruptures due to forceful contracture of
biceps ie. lifting.
May avulse from origin or along course of muscle (Rupture of belly of muscle).
Age / old friction injuries.
History of tendinitis.

Clinical Findings:
Usually male over 45 years.
Not much pain usually, may be a little shoulder pain.
Bulging in biceps as long head bunches up - Popeye sign.
Little weakness in flexion/Supination.

Treatment:
Usually none.

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FROZEN SHOULDER.

-- Adhesive Capsulitis, Periarticular Capsulitis


A condition in which all shoulder movements are very restricted and very painful.

Clinical Features.
The patient is usually middle-aged.
Usually the onset is gradual but it can occur overnight.
On examination there is little gleno-humeral movement.
Both active and passive movements are reduced. Mainly it is scapular movement. The
patient presents with severe shoulder and upper arm pain, which is worse at night and
very difficult to sleep on.
Loss of 25% to 50% of movement is common, or more in severe cases. External
rotation is the most severely affected.

Etiology.
Unknown.
Postulated that it may occur after injury to the shoulder or due to repeated minor
injuries.
Possibly as a complication of tendinitis.
Possibly due to long periods of immobility. e.g. hand in sling or in hemiplegia etc.

Pathology:
This is not very well understood.
There is a widespread, acute, inflammatory reaction involving the capsule.
There is thickening of the shoulder capsule and contracture which leads to loss of joint
space.
The term frozen shoulder should be reserved for the shoulder in which synovial
inflammation has produced adhesions between the two layers of dependent, inferior,
folds of capsule. When these two layers become effectively stuck together then the
shoulder is truly frozen and relatively immobile.
The capsule can no longer expand and allow the head of the humerus it's normal range
of movement. There may be complete resolution within two years, but up to 20% may
be left with varying degrees of restriction.

Medical Treatment:
Hydrocortisone.
Hydrocortisone and forced manipulation under anaesthesia and active movements.
Weekly or bi-weekly injections of hydrocortisone.
Rest and sling in early stages and mild exercises.
Analgesics and anti-inflammatories.

Course:
Initial Stage: PAIN May last 2 to 4 months approx. May be very painful. Movement
may make pain worse. Patient can wake up at night if he lies on it. Lateral deltoid and
arm pain to elbow is possible.

Later Stage: STIFFNESS Now stiffness takes over as pain decreases (except on
sudden movement). Some shoulder muscles may become atrophic. N.B. It may just
start with symptoms of the later stage.

Final Stage: Resolution.


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The so called idiopathic cases of adhesive capsulitis are probably due to alteration in
scapulohumeral alignment. It is debatable as to which starts first - pain or stiffness.
Generally patient is unable to fasten bra or comb hair. There is pain at night on rolling
onto affected side. The older age group generally don't come for treatment until all
range of movement is greatly reduced.

Conditions which may result in capsular tightness at the glenohumoral joint include :
• Degenerative joint disease (rare). (Hands and feet are affected first).
• Immobilisation due to dislocation or fracture.
• Reflex sympathetic dystrophy - this condition may be associated with certain visceral
disorders e.g. myocardial infarction or trauma e.g. Colles fracture. Stiffness at the
wrist and hand is a common component of this syndrome.

History
Site of Pain
Lateral brachial region, possibly referred distally into C5 or C6 segment.

Nature of Pain
Varies from constant dull ache to pain felt only on activities involving the movement
into the restricted ranges. Patient is often awakened at night when rolling onto painful
shoulder.

Onset of Pain
Usually very gradual.

Physical Examination
Active movements:- external rotation and abduction are severely limited, followed by
flexion, extension, adduction and internal rotation.
Passive movements:- external rotation and abduction are severly limited. All other
movements somewhat limited.
Resisted isometric movements - Strong and painless unless Tendinitis present.
Palpation - Often referred Tenderness over lateral brachial area. Feeling of increased
muscle tone.
Inspection - negative. Look for surgical scar.

Acute Vs Chronic
Acute
Pain radiates to below elbow.
Patient is awakened by pain at night.
Passive movements are limited due to pain and muscle guarding rather than stiffness per
se.

Chronic
Pain is localised to lateral brachial region.
No night pain.
Passive movements are limited by capsular tightness and painful only when the capsule
is stretched.

Sub-Acute
Some combination of above findings.

Management
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Overall Goal :- Restoration of painless functional R.O.M.

Acute Stage
Goals -
Relief of pain and muscle guarding to allow early, gentle mobilisation.
Maintenance of existing range of motion.
To commence gentle increase in range of motion.
Prevention of excessive kyphoses and shoulder girdle protraction.
Postural re-education - look at possible cause of condition.

Treatment Plan
Use ice to relieve pain and inflammation.
Commence gentle mobilisation of joint i.e. inferior glide to counteract superior position
of humerus due to spasm.
Initiate active range of motion exercises at home -- pendulum, and isometric
strengthening exercises for rotator cuff muscles.
Remedial massage work to all muscles of shoulder girdle. Initial treatments should
always be gentle. Precise treatment depends on individual findings, e.g. detailed work
to Pectoralis if shortened etc.
Gentle passive movements to joint.
Help patient correct postural faults e.g. round shoulders, head forward position, by
instigating a routine of regular postural checks in daily activities.

Chronic Stage
Goals -
Restoration of painless functional R.O.M. within limits.
To promote independence in mobilisation procedures.
To encourage patient to use arm as much as is tolerable to minimise habitual disuse.
Once approx. 120° abduction, 140° flexion, and 60° ext. rotation are achieved ®
commence supervised home exercise programme.
Improvement is characterised by peaks & valleys. Easy to get frustrated.

Physical Therapy Treatment.


Treat all the involved muscles as appropriate, particularly all the rotator cuff muscles.
The therapist can combine joint play movements with certain movements of the arm to
reduce cartilaginous or bony impingement at the extreme of movement. For example,
while moving the arm into abduction, the therapist can passively move the head of the
humerus inferiorly to prevent impingement of the greater tubercle against the acromial
arch which would tend to occur from the loss of external rotation and from the loss of
inferior glide of the joint.
By doing so, muscle spasm is reduced and a more effective stretch to the inferior
capsule is effected. In fact until significant gains in external rotation are made, the
patient should not be instructed to stretch into abduction on his own, because attempts to
do so may traumatise the subacromial tissues more than stretching the inferior aspect of
the joint capsule.
It must be emphasised that the primary goal of treatment is restoration of painless,
functional R.O.M. and that regaining full movement of the arm is not always realistic.
R.O.M. of the uninvolved side should serve as a guide for setting treatment goals.
While certain stress (to the joint) related activities may need to be curtailed, it is
important to encourage use of the arm as much as possible to minimise habitual disuse
which can perpetuate the disorder.

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Use of pulley and traction pendulum are very effective. Clockwise and anti-clockwise
movements with traction to improve internal and external rotation. Later walking up
the wall with fingers to encourage flexion and abduction.
Satisfactory results can be expected within 3 to 4 months except if the frozen shoulder
results as part of a reflex sympathetic dystrophy. These causes may require additional
measures such as sympathetic blocks or manipulations under anaesthetic.

Improvement tends to be characterised by spurts and plateaus. Both patient and


therapist should be cognisant of this to avoid undue frustration during periods of limited
progress.
NOTE: Nocturnal pain results in fatigue which adds to the patients general debilitation.
Fortunately, with appropriate management, this is the first aspect of the problem to
resolve and should do so in 2 to 3 treatments. Massage gentle joint-play oscillations,
especially into inferior glide proceeded by heat or ice are generally the techniques of
choice.

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Acromioclavicular Strain

Pain on the shoulder tip aggravated by full passive adduction.

REFERRED NEUROLOGICAL PAIN


Shoulder movement is normal. Neck movements may be restricted and painful. This
can vary from patient to patient.
C6 nerve root lesions:- There is usually pain and stiffness in the neck and pain in the
outer part of the shoulder. Pain may radiate down the arm to the thumb and index
finger. There is weakness and possibly wasting in the biceps and wrist extensors.
C7 lesion:- pain in the upper scapular region and outer side of the shoulder. Pain may
refer to middle and index fingers. Weakness and wasting in triceps, wrist flexors and
finger extensors.
C8 :- Pain in the outer part of shoulder and mid-scapular region. Weakness in finger
flexors.

** Referred pain from nerve root source may cause secondary activation of trigger points.
**

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POSSIBLE CAUSES OF ELBOW PAIN

Bone Infection • Acute osteomyelitis


• Chronic osteomyelitis

Tumours • Benign
• Malignant

Bone Cyst

Fracture • Supracondylar

Arthritis • Osteoarthritis
Joint
• Rheumatoid arthritis
• Pyogenic arthritis
• Tuberculous arthritis
• Neuropathic arthritis
• Haemophiliac arthritis

Deformity • Cubitus valgus


• Cubitus varus

Sprain • Acute
• Chronic
Osteochondritis dissicans
Loose bodies in the elbow

Soft tissue conditions • Lateral epicondylitis


• Medial epicondylitis
• Olecranon bursitis

Referred pain • Entrapment syndrome


• Myofascial trigger point pain Supinator
Extensor carpi radialis longus
Extensor digitorum
Supraspinatus

• Cervical Pathology Tumour


Disc lesion
Subluxation
Cervical rib syndrome
Scalenes syndrome
Clavicular lesion

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Tennis Elbow

Lateral Epicondilitis.

Definition: Pain in the region of the lateral epicondyle, generally due to repetitive strain

Causes.
• Macro or microscopic tears at the origin of the common extensor tendon. The tear
may cause inflammation.
• Trauma due to direct injury to the lateral epicondyle.
• Degeneration due to ageing.
• Over use, over extension leading to inflammation, e.g. sudden wrenching of the elbow
(extension, supination, pronation against resistance)
• Inadequate conditioning for racket sport
• Improper technique such as faulty backhand

Other factors :
• Racket - the heavier the racket the smaller the grip, and the tighter the string tension,
the more stress on the arm.
• Court surface - hard, fast surfaces. Grass and concrete especially increase the speed at
which the ball hits the racket strings and increases the amount of stress transmitted to
the elbow.
• Balls - older and heavier balls increase the amount of stress absorbed by the arm.
• The risk factor in tennis elbow that is most often overlooked is conditioning,
specifically lack of strength and flexibility in the shoulders.
• A weak shoulder is often the first stage in a sequence of ailments that culminates in
tennis elbow.
• This often start with rotator cuff problems, weakness will affect technique and in time
tennis elbow forms.

Pathology.
• Lateral epicondyle is affected 7 times more than the medial epicondyle
• The term "tennis elbow" is a misnomer in that it has a higher incidence in golf, squash,
rowing, manual labour, and even violin playing than in tennis.

Clinical Features.
• Common after middle age in the dominant arm.
• Occasionally it is bilateral, saving one arm and over using the other. Common in
females.
• Onset may be sudden or gradual.
• Pain over lateral epicondyle or just distal to it.
• Pain may radiate down to hand, seldom up.
• Pain is usually sharp on exertion, but it may be dull, aching and constant.
• Squeezing with fingertips can be painful.
• Tenderness, heat, swelling are found over the affected epicondyle if acute. Generally
swelling is not a feature
• Grip strength as well as supination, pronation strength are affected.
• Pain on passive stretching i.e. wrist flexion
• Pain and weakness on resisted wrist extension
• Poor blood supply to this area therefore there is a slow healing process.
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Tests.
• Stretch the extensors by passively flexing the wrist.
• Contract the extensors by extending the wrist against resistance.

Medical Treatment.
• Cortisone injections, on which there are conflicting views. Repeated injection can
lead to tissue damage.
• Surgically release the extensor muscles. Spontaneous remission in 8 to 10 to 24
months approx.
• Rest with sling immobilisation of wrist and elbow
• Physiotherapy

Physical Therapy Treatment


Patient supine with elbow extended, pronated forearm and flexed wrist

Tx 1 Myofascial work to flexors, extensors, supinators and pronators. Check for trigger
points particularly in supinator, brachioradialis, extensor carpii radialis longus.
Transverse friction for approx. 3 minutes to tendon attachment. Check for most
tender point. Use ice if it is very painful i.e. ice x 1 minute, friction x 1 minute,
ice etc.
Myofascial work can also be interspersed between friction.
Work into hand.
Treatment time approx. 20- 30 minutes.
Use Likon if available

Home Advice
Ice x 20 minutes later that evening and again before bed. Use approximately 3
to 4 times a day, until next treatment.
Avoid activity that aggravates the pain i.e. lifting shopping bags, kettle or
saucepans, playing golf etc.
See Client in 3 to 4 days.

Tx 2 Re-Evaluate.
Same as Tx 1.
Work deeper into muscles, particularly the extensors. Tease out matted fibres.
Increase transverse friction to 5 minutes.
Once again alternate with ice and myofascial work.
Use Likon for 20 minutes after soft tissue treatment.
Home advice as per first treatment.
See in 3 to 4 days.

Tx 3 Re-Evaluate.
Same as above.
Increase friction to 8 minutes.
Introduce gentle stretch to extensor tendon. Take care not to strain wrist.
Hold stretch for 3 to 5 sec., relax, stretch, relax for approximately 1 to 2 minutes.
This could be introduced in Tx x 2 if condition allowed.
Likon.
See in 3 to 4 days.

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Home Advice.
Gentle home stretch to extensors. Care must be taken to position arm so that the stretch
is felt in the target tissues. Generally elbow is extended
Ice may be continued if there is discomfort after treatment or home stretching.
See in 3 to 4 days.

Tx 4 Re-Evaluate.
Same as above.
If stretch is being achieved with no ill effects, strengthening may be introduced.
Commence with appropriate strength theraband, i.e. 3 x 3,
3 times a day. Allow 2 days after treatment before commencing these home
exercises.
After 3 days increase to 5 x 5 x 5.
After 6 days increase to 8 x 8 x 8.
Continue with stretching.
See in one week.

Tx 5 Re-Evaluate.
Increase strength of theraband and continue stretching programme in addition to
strengthening.

Technique Advise to client.


• Your forearm muscles should be used for control not power. Most of the power should
come from your shoulder, torso, and leg muscles, coordinated with rotation of your
hips.
• Focus on hitting the "sweet spot" (centre) as often as possible.
• Follow through on your stroke, don't "brake" after hitting the ball.
• Learn proper footwork so you approach the ball correctly.

Equipment :
• Use a light racket (12-12.5 oz.) made of graphite which provides good impact
absorption.
• Use the largest grip that is comfortable. The optimal grip size is the distance from the
tip of your ring finger to the bottom horizontal palm crease at the point between your
ring and middle fingers.
• To minimize impact, your racket should have an approximate string tension of 52 - 55
lbs on 16 gauge nylon.
• Do not use old or wet balls.

Court Surface:
Play on a court with a slower surface, thus reducing the impact of the ball on your racket.

Conditions
• Develop strength and flexibility in the arm, shoulder and back muscles. Tennis elbow
straps may provide relief from tennis elbow, while at the same time allowing the injury
to recover.
• However never use a tennis elbow strap unless you are positive your injury is tennis
elbow.
• Straps may worsen conditions such as medial elbow instability in adults.

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Golfer's Elbow Medial Epicondylitis.

Definition: A strain of the common flexor tendon at the medial humeral epicondyle.

Cause:
• Repeated over-strain.
• Strong forehand drive in tennis.
• Poor warm-up before sport.
• Hitting ground by mistake in golf.
• Overstrain of wrist by repetitive bending, twisting or faulty technique.

Pathology:
• Pain over the medial epicondyle which is the site of the origin of the wrist flexors and
pronator of the forearm.
• Less common than lateral epicondylitis.
• More common in the 40 - 60 year bracket or in older people involved in sport or an
occupation involving a strong hand grip and an adduction movement of the elbow.
• Pain over the medial elbow and may radiate distally.
• Pain is made worse by gripping or repeated wrist flexion.
• Subperiosteal haematoma and periostitis are often involved.
• The musculo-tendinous junction may also be involved. (Level with the inferior edge
of the medial epicondyle).

Tests
• Resisted wrist flexion with extended wrist hurts.
• Resisted pronation hurts.

Treatment:
Similar to tennis elbow except for positioning, that is, the wrist and fingers are extended
and the forearm supinated while the elbow is fully extended.
Can be done with patient sitting up or in supine position. If sitting up, support the
extended elbow.
N.B. Stretching is to the flexors, whereas in tennis elbow stretching is to the extensors.

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Olecranon Bursitis.

Dart Thrower's Elbow, Miner's Elbow, Student's Elbow.

Types
Traumatic.
Septic bursitis.
Gout/Rheumatoid bursitis (may be associated with oleccranon-bursitis. Swelling occurs as
part of the acute inflammatory synovitis in both of these conditions, may be rheumatoid
nodules, gouty deposits).

Traumatic: Pathology:
The olecranon bursa is subject to direct impact, haemorrhage, abrasion, contusion,
laceration and puncture which may cause chronic inflammation, thickening of synovium
and formation of excessive fluid.
The mechanism of injury is one of repetitive direct injury, constant friction of extensor
tendons as in tennis elbow and/or repetitious local injuries with synovial irritation.
Local pain tenderness, swelling, and movement restrictions are exhibited.
Dart throwers are prone to it due to repeated elbow flexing.
N.B. The bursa is exposed when fixed on a firm surface therefore the term student's
elbow from leaning on it.

Treatment:
Cold compress.
There may be a need for aspiration.
Taping Elbow, In moderate cases an elbow support with an opening for tip of elbow.
Excision if recurrent.
Avoid pressure on elbow.
Protective padding long after swelling subsides.
Recurrent swelling is common.
May be a need for cortisone and anti-inflammatories.
If infected antibiotics are required

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Deformities of the Elbow.

Cubitus Valgus.
This is an increase in the normal carrying angle of the elbow.
In the male it is 10 degrees.
In the female it is 15 degrees.
It is usually caused by a previous fracture of the elbow and is usually symptomless.
It may cause an entrapment neuropathy of the ulnar nerve later on or it may not.

Cubitus Varus.
This a decrease in the carrying angle of the elbow.
Usually caused by an old fracture.
Usually there are no symptoms.
It may lead to O.A. later on.

Cubitus Recurvatus.
A hyperextension deformity of the elbow and is due to hypermobility of the elbow.

Flexion Deformity.
As in O.A. of the elbow the patient is unable to fully extend the elbow. It is usually
painless.

Stiff Elbow -- O.A. Of The Elbow.

This is not very common. Usually there is a predisposing factor such as an old fracture or
osteochondritis dissecans.

Signs and symptoms.


Restriction of flexion/extension. Rotation is often normal.
Slow increase in pain made worse by heavy use of the limb.
Thickening of the joint due to osteophytes and crepitations on movement.

Medical Treatment.
Anti-inflammatories.
Debridement / not much use as the osteophytes grow back.
If there is a loose body (which can cause locking of the elbow) it is removed.

Physical Treatment.
Heat.
Remedial massage technique
Mobilisation.
Traction.

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R.A. Of Elbow

In R.A. the main symptom is pain and the joint may become unstable.
Treatment is anti-inflammatory or arthroplasty i.e. total joint replacement (is not very
successful as it can loosen).

Elbow Sprain.

Cause:
Forced joint movement beyond full extension, abduction, adduction can cause sprain of
elbow ligaments. Movement in the direction of the injury aggravates the pain and there is
some restriction at extremes of range.
Sport commonly involves strains e.g. twisting, stretching, hard strain of medial ligaments.
Also wrenching the elbow i.e. wrestling.
Incorrect javelin throwing, where the inner elbow is pulled apart at each throw.

Types:
Hyperextension sprain. Pain increases on extension and relieved on flexion. Swelling
and tenderness around the joint.
Hyperabduction Sprain. Tenderness is found below the medial epicondyle indicating
sprain of the ulnar collateral ligament.
Hyperadduction sprain. Tenderness below the lateral epicondyle indicating sprain of the
radial collateral ligaments.

Treatment.
Rest arm for 10 to 14 days
Ice for the first two days or until swelling subsides.
Sling for arm if bad sprain.
From day 3 or four onwards --
Hot and Cold
Light Massage
Gentle Mobilisation
Mild range-of-motion exercises
Increase the above to heavier neuromuscular and stronger mobilisation after 2 to 3
treatments.

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Elbow Fractures

There are many types, combinations and variations. Fracture in the area of the elbow
usually involves the joint itself. Most common are the supracondylar, fracture of the
humerus, olecranon, head of radius and coronoid process.

Ulnar Neuritis.

The ulnar nerve is located behind the medial epicondyle.

Causes.
Due to recurrent friction whilst under tension, e.g. in cubitus valgus, i.e. when the carrying
angle is increased (as the deformity and symptoms takes some time to develop this has
been called a tardy ulnar palsy).
Due to constriction for example in O.A. where you get osteophytic encroachment in the
ulnar groove which can cause pressure on the ulnar nerve.
Trauma e.g. single blow on the elbow.
Repeated trauma occupations that involve leaning on the elbow.

Signs and Symptoms.


May be pain and or numbness/tingling in the 4th and 5th fingers, (ulnar distribution area).

Pain may radiate up the elbow.


Wasting or weakness of the ulnar innervated muscles which can cause clumsiness of hand
movements.
***The Nerve Gets Thickened And Fibrosed.***

Diagnosis
Pressure over ulnar nerve behind medial epicondyle reproduces the symptoms.
Tinel test is positive.
Full flexion may cause symptoms.

Treatment:
Rest
Padded protection for elbows to avoid trauma
Cortisone
Surgery to relieve the mechanical fault by anterior transposition of the nerve.

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O.A. Wrist.

Not common in the wrist.


Usually is as a sequel to fractures or other injuries.
The pathology and clinical findings are as usual: stiffness, thickening, decrease in
mobility &c.

O.A. Hand And Fingers.

Common in the elderly.


Pain on gripping and twisting when in the hand.
There may be large osteophytic lumps in the fingers.
The thumb joint is commonly affected (trapezio-metacarpal joint).
Massage and joint mobilisation is very effective.

R.A. Wrist And Fingers.

The disease follows the usual pattern.


The wrist radically deviates and supinates.
Many complications can arise such as tendon rupture, mass synovial thickening, fixed
muscle contracture, &c.

Hand / Finger / Thumb Sprain

Can sprain hand/finger again by wrenching or twisting forces.


Commonly injured in ball games and contact sports.
Again there is local pain, tenderness, swelling, motion restriction.
The thumb is especially prone to sprain injuries and may take two to three months to fully
recuperate (if bad sprain).

Ganglions

These are very common about the wrist and hand, especially on the back of the wrist and
in the palm.
A ganglion is composed of thick fluid surrounded by a layer of synovium in the soft tissue
around joints and tendons.
It is caused by the secretion of synovial fluid into soft tissue instead of into the joint
cavity.
If it interferes with the function of a joint it is excised, if not it is best left alone
ie neurological interference with the ulnar or median nerve.

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Tenosynovitis

The term tenosynovitis implies inflammation of the thin synovial lining of a tendon
sheath as distinct from its outer fibrous sheath. It may be caused by mechanical
irritation or less commonly by bacterial infection.

Irritative (Frictional) Tenosynovitis is caused by excessive friction from over-use. The


synovial sheath is mildly inflamed and there is an exudate of watery fluid within it.
Tenosynovitis of the wrist is a common complaint among Physical Therapists.

De Quervain's Disease.

This is a relatively common condition. It is generally believed to be an inflammation


and swelling of the common sheath of the abductor pollicis longus and the extensor
pollicis brevis tendons where they pass along the distal radial aspect of the radius. The
tendons themselves are normal.

History.
Pain is felt over the distal radial aspect of the radius, sometimes radiating distally into
the thumb or even proximally up the forearm. The onset is usually insidious. The
patient complains of pain, primarily with activities involving thumb movements such as
wringing or grasping activities.

Examination.
Pain on resisted thumb extension and abduction.
Pain on ulnar deviation of the wrist with the thumb held fixed in flexion. On this
movement the tendons and the sheath are placed on the stretch .
Tenderness on palpation of the tendon sheath in the region of the radial styloid process,
the thickened sheaths are usually palpable as a firm nodule.

Treatment.
Rest, discontinue activities that have caused or aggravate the condition.
Ice.
After acute stage begin with gentle massage and very gentle passive movements.
Later deep strokes especially transverse friction.
Gentle passive and active movements.
NOTE: synovectomy is very successful.

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Wrist Sprain

This is very common in many sports and may be associated with fractures and
dislocations of the carpals. Therefore, it is sometimes important to X-ray if very painful.
You can sprain the wrist by falling on it or wrenching it, or it may be due to repetitive
stress e.g.. racquet sports like tennis and squash.
May get pain in all movement or just in one direction.
There may be swelling, bruising and various degrees of pain.
Examination.
If the wrist has been sprained through direct trauma it is essential that the patient has an
X-ray before any movements are carried out.
Assuming that there are no fractures proceed to examine joint as follows:
Observe the joint and note the degree of bruising.
Ask patient to perform active flexion and extension, supination, pronation, ulnar and
radial deviation. Record findings.
Very gently, apply passive movements to determine the extent of limitation of movement.
Examine finger movement, as it may be limited due to oedema.
History taking.

First Treatment from time of injury.


First Aid.
Rest.
Ice.
Compression.
Elevation.
The sprained wrist needs to be rested, so use pillows to prop in an elevated position.
Apply an ice-pack having protected the skin with oil or a damp cloth, for 10 to 15
minutes. Advise patient to continue this treatment every 2 to 4 hours for the first one or
two days.
Generally a firm bandage or strapping gives adequate support, but occasionally a splint of
some kind can be used if it is felt that the patient is likely to do, too much with the wrist
and hand. This is removed as soon as possible.
No massage for the first 24 to 48 hours as the condition is generally too painful. See
patient one or two days later.

Second Treatment.
Make patient as comfortable as possible -- rest arm on a pillow. Reassure your patient.
Effleurage proximal to the site of injury -- flexors and extensors -- as far as the elbow.
If condition allows do some light effleurage over the site of the injury to help decrease the
oedema.
Petrissage and friction to flexors and extensors, paying particular attention to tender areas.
It is important to work on the fingers and hand. Finger kneading and friction are used.
Clear out between metacarpals &c.
Encourage patient to perform active finger movements as this assists in the dispersion of
fluid.
Gentle passive movements to the joint if condition allows.

No mobilisation of the joint at this point.

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Home Treatment.
Commence contrast bathing.
Encourage light active movement of the joint where possible.
See patient in two to three days.

Third Treatment.
Always evaluate condition at the beginning of treatment.
Treat as for Second treatment.
Gradually increase the depth of pressure. Work into the carpals and joint line using
friction and passive movements.
Continue home treatment of contrast bathing and active movements (full range) of
finger and wrist.

Fourth to Fifth Treatments.


Treat as above.
Introduce resisted movements of M.E.T. always following with a stretch.
Gentle mobilisation techniques may be introduced.
Wrist movements should be full and pain free in 7 - 14 days.

Carpal Tunnel Syndrome

There is compression of the median nerve as it passes beneath the flexor retinaculum. It
is a common cause of discomfort of the hand, especially in middle-aged, or elderly
women.

Causes
Any space-occupying lesion within the carpal tunnel may be responsible e.g.
Rheumatoid arthritis, osteoarthritis of the wrist, thickening following Colles' fracture,
myxoedema, pregnancy. In many cases no primary cause can be discovered.

Symptoms.
These are both motor and sensory. There is tingling, numbness or discomfort in the
radial three and a half digits and there is a feeling of clumsiness in carrying out fine
movements such as those concerned in sewing. Tingling is often prominent during the
night.

Diagnosis.
Clinical examination in history taking. Care must be taken to exclude other causes of
neurological disturbances in the hand. Be sure that your patient has been investigated
medically.

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Nerve Injuries To The Hand

These conditions, although within the province of the surgeon, often seek help from a
physical therapist while awaiting surgery. Massage and movements are given to
improve nutrition to the area. Nerve injuries which produce deformities are easily
diagnosed but not easily treated,

Median Nerve injury.


This type of injury usually occurs due to deep lacerations at the wrist. The thenar
muscles, and the radial two lumbricals become paralysed, and this results in rapid
wasting of the thenar muscles. Opposition of thumb to finger is lost, and there is loss of
sensation over the cutaneous distribution of the medial nerve.

Ulnar Nerve Injury.


The ulnar nerve lies superficially at the medial epicondyle of the humerus, therefore
fracture or dislocation of the elbow may cause injury to the nerve. The hand becomes
clawed, and there is loss of sensation over the ulnar distribution to the little finger and
medial side of the ring finger.

Radial Nerve Injury.


The type of injury may be due to either sustained pressure in the axilla (as in using a
crutch) or fracture of the humeral head. Wrist drop due to injury of the main trunk of
the radial is fairly common and is due to the fact that all the extensors of the wrist have
been paralysed. There is a marked disability to grip strongly with the hand, unless the
wrist is raised to an extended position.

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Sample questions – Elbow Joint

1. Classify and list the possible causes of elbow pain

2. Describe the process of inflammation and tissue healing

3. Describe the effects of transverse friction

4. List the indications and contraindications to transverse friction

5. List the possible causes of lateral epicondylar pain

6. List the possible causes of medial epicondylar pain

7. List the possible causes and clinical features of medial epicondylitis

8. List the possible causes and clinical features of lateral epicondylitis

9. List the possible causes and clinical features of olecranon bursitis

10. Describe you examination of a client who presents with elbow pain

11. Describe your management of a client who presents with lateral epicondylar
pain through to full recovery

12. Give a detailed description of your treatment of medial epicondylitis to include


possible advice and home exercises

13. A client presents with a history of having fallen in the last 24 hours and twisted
her arm. Within a short period the elbow had become very swollen and painful:
Describe your initial consultation
Describe your treatment plan for the acute phase
Describe your treatment plan for the sub-acute phase

14. Classify tendon injuries


Discuss the common sites where each injury is likely to occur and
List the clinical features.

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Osteoarthritis of The Hip

Definition: This is a degenerative, non-inflammatory disease. Osteoarthrosis is the


more appropriate name but is less commonly used. Articular cartilage gradually
becomes thinner because its' replacement does not keep pace with its' removal.
Eventually the bony articular surfaces come in contact, and the bones begin to
degenerate. There is abnormal bone repair, and the articular surfaces become mis-
shapen.
Chronic inflammation develops with effusion into the joint possibly due to irritation
caused by tissue debris not removed by phagocytes. Sometimes, there is abnormal
outgrowth of cartilage at the edges of bones which becomes ossified forming
osteophytes.

Causes.
There are two types; Primary and Secondary. In primary, the cause is unknown. In
secondary the causes are as follows:
• Trauma: Intercapsular fracture to a bone, injury to intercapsular structures.
• Age; common from age 50 onwards due to wear and tear.
• Congenital dislocation of the hip, there are unusual stresses in the joint.
• Obesity.
• Stress
• Disease: Inflammatory diseases -- R.A.
• Haemophilia, slight injury may lead to haemorrhage into a joint. Repeated bleeding
may damage an articular cartilage and lead to O.A. Peripheral nerve lesions,
Diabetes mellitus, T.B.
• Climate. Dampness and cold exaggerates O.A. and causes pain.
• Hereditary.
• Acromegaly. Abnormal enlargement of the extremities of the skeleton caused by
hypersecretion of the pituitary growth hormone after maturity.
• Hyperthyroidism -- excessive thyroid gland activity.
• Diet.
• Poor posture causing muscle imbalance.

Pathology.
The main changes are in the articular cartilage and underlying bone. The cartilage is
gradually worn away, disappearing first at the points of greatest pressure. The
subchondral bone becomes sclerotic and at the joint margins it hypertrophies
(outgrowth of a part due to an increase in size) to form osteophytes.

There is no primary change in the capsule or synovial membrane, but the recurrent
strains to which an osteoarthritic joint is subject, often lead to slight thickening and
fibrosis. Muscles atrophy related to disuse because pain limits movement and function.
Exercise is very important to keep muscles healthy.

Signs and Symptoms of O.A. of the hip.


Pain in the groin and front of the thigh, often also in the knee (medial aspect). Pain is
made worse by walking and eases by rest. Pain or weakness going up stairs (psoas
muscle) unable to step up with the involved leg. Later there may be a complaint of
stiffness which manifests itself in everyday life by inability to reach the foot to tie the
shoe laces or to cut the toe nails. Pain at night when changing positions during sleep.

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The symptoms tend to increase progressively, month by month, and year by year, until
they eventually cause severe painful limp and incapacity for normal activities.

Examination.
On examination all hip movements are impaired. Limitation of abduction, adduction
and rotation is marked, but a good range of flexion is often preserved. Forced
movements are painful. In advanced O.A. fixed deformity (flexion, adduction, or lateral
rotation, or a combination of these) is common.

Treatmen--.Physical Therapy. Deep massage, passive movements, traction, M.E.T. ,


home exercise including swimming.
Diet.
Homeopathy
Acupuncture
Conservative treatment -- drugs (anti-inflammatory), Joint injection (hydrocortisone)
but not recommended, surgery.

Muscles Involved.
Flexion.
Psoas and iliacus, sartorius and rectus femoris. The iliopsoas will have shortened and
can lead to a flexion deformity of the hip.
Adduction.
Adductor longus, brevis and magnus, gracilis and pectineus will also have shortened
and maybe hold the hip in adduction.
Abduction
Mainly gluteus medius with assistance from gluteus minimus and tensor fascia latae --
the gluteus medius will have weakened (Trandenburg test).
Extension
Gluteus maximus and hamstrings, -- these will be weak.
Internal Rotation.
Psoas, iliacus, gracilis, TFL and anterior fibres of gluteus medius and minimus
movement is limited by tension of the lateral rotators.
External Rotation
Piriformis, obturator internus and externus, quadratus femoris, gemellus superior and
inferior and the adductors.

Diet.
The chief forms of arthritis are osteoarthritis and Rheumatoid arthritis the underlying
cause of both with regard to diet is too much acid in the body.
Acid is taken in over the years in the food we eat and the liquids we drink. If our bodies
contain the required nutrients to burn up the acid that we take in, then there is no
problem. The food we eat today is lacking in these nutrients, so we are left with an
undernourished body full of acid. This acid is carried around in the blood until it
eventually deposits itself between joints, on the bones or in the muscles. When acid is
deposited in the muscles, we call the effect muscular rheumatism. If both arthritis and
muscular rheumatism are not treated, excruciating pain with every movement results.
Depending on how advanced the O.A., you may not reverse the condition, but by
dissolving the acid deposits the pain can be alleviated and the condition eased. The
muscular condition will respond much quicker than will O.A. to faulty diet treatment.

Conditions Related to Arthritis.


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The spine is often the site of arthritis, and as a result there may be some mis-alignment
of the vertebrae. As you know, every area of the body is controlled by nerves that run
down the spinal column and exit at various levels of the spine.
In the cervical area acid deposits (OA) may effect:-
- blood supply to the head
- pituitary gland
- neck muscles
- tonsils
- thyroid gland..... and many more.

Interference in the cervical area may bring about conditions like, headaches, migraine,
insomnia, dizziness, chronic neuralgia, stiff neck, vertigo, hay fever, catarrh, etc.

In the thoracic area may affect, chest, lungs, bronchial tubes, causing conditions like
pleurisy, bronchitis, pneumonia, shortness of breath, chest pain etc.
The liver and solar plexus get their nerve supply from the thoracic area, could cause
indigestion and related conditions.

Lumbar area.
Most commonly effected here is OA of the spine. It can also effect constipation, colitis,
diarrhoea, etc, etc.
There are many conditions that OA of the spine can effect due to mis-alignment, and it
is well worth advising patients on the foods to avoid, what to cut down on, and the
foods that will not aggravate O.A.
To help arrest or halt O.A. and possibly cure it:-
Eliminate toxic acids from the body
(a) On arising take one dessert spoon of cider vinegar with one teaspoon of clear
honey in a tumbler of hot water, if possible, 1 hour before breakfast. This can be
taken three times a day.
(b) One teaspoon of black molasses three times a day.
(c) Epsom salts bath (3 per week) Dissolve three cups of epsom salts in a bath of
hot water. Do not add soaps, bath cubes, salts or oils as the alkalinity of these
will fight the acidity of the epsom salts. Keep the water hot, by adding more hot
water. Exercise in the water as much as possible by moving the fingers, feet,
etc. The heat of the water will open the pores of the skin, enabling the epsom
salts to draw out the acid poisons.
After 15 minutes, get out of the bath and get into a warm bed. This will keep the pores
open to draw out more acid. On rising take a shower to wash away the accumulated
acids.

Cider Vinegar.
This is made from mature cider apples and is a combination of minerals, organic matter
and acetic acid. It regulates the bodies metabolism through the quantities of minerals
that it contains. Cider vinegar dissolves the acid deposits so that they pass out naturally
via the kidneys. It saturates the bloodstream, getting in between the joints, dissolving
the acid deposits. It contains malic acid. Cider vinegar is a natural diuretic and acts as
a slimming agent, as overweight effects an arthritic hip. Cider vinegar is known to be a
blood normaliser, will help reduce high blood pressure, and raise low blood pressure.

Honey.

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Honey contains vitamins and minerals. Darker honey contains more than lighter honey,
arthritis patients can suffer from iron deficiency. Lack of ROM can lead to blood
disorders, particularly anaemia. Most "Complex B" range of Vitamins can be found in
honey, they feed the nerves. Honey is also rich in Vitamin C.

Black Molasses.
Molasses is made from raw unsulphured cane sugar packed with nutrients, it may be
taken undiluted but should be followed by a drink of water as it can discolour the teeth.
It may upset the stomach, in which case it can be taken on toast, wholemeal or even in
porridge. Molasses is also a laxative, and rich in iron and Vitamin B.

Food To Avoid.
An acid-free diet is of the utmost importance.
• Red Meat:- Beef, lamb, pork, pork products, sausages, patés, corned beef.
• Citrus Fruits:- Oranges, Lemons, Grapefruit, Pineapples, Tomatoes, Strawberries,
Gooseberries, Rhubarb, Blackcurrants, Red currants, Blackberries and Damsons.
• Coffee:-Instant, decaffeinated and ground.
• White sugar including sweets.
• White flour and white flour products; cakes, biscuits and pastries
• Processed and tinned food.
• Red wine, sherry, port
• Artificial additives such as colouring flavouring and preservatives.
• Fizzy drinks.

Foods to Reduce
• Dairy products and eggs.
• Salt
• Alcohol
• Tea

Foods for a Healthy Diet.


Fish, Poultry, Green and all other vegetables
Salads except tomatoes
Sunflower oil
Fruit except citrus
Herb tea, Mineral/Distilled water.

SNAPPING HIP.
This is a harmless condition in which a snap is heard in certain hip movements. It is
commonly caused by a snapping of the iliotibial tract, snapping over the greater
trochanter when the patient actively flexes the hip. (Sometimes fibres of the gluteus
maximus may be involved).

BURSITIS OF THE HIP


Between the greater trochanter and the tensor fascia lata lies a superficial bursa which is
prone to injury due to falls or blows. Possibly due to friction or overuse, the bursa can
become inflamed and swollen. (Another small bursa, the deep trochanter bursa, lies
between the gluteus medius tendon and the gluteus minimus tendon. This is not as
prone to injury as the superficial bursa).

Clinical Findings.
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Localised pain over the greater trochanter and the bursa is tender. When severe pain
can radiate down the posterior and lateral aspect of the thigh.
Activity makes it worse, especially climbing stairs.
Active and resisted abduction leads to pain as this causes compression of the bursa.

Treatment.
Medical.
Anti-inflammatories
Rest
Cortisone injection
Aspiration if bleeding has occurred

HIP AND PELVIC EXAMINATION

The patient should be undressed to underwear


The patient should adopt a comfortable posture in front of you
The lighting should be good and you should not stand too close to the patient
Look for swellings, scars, bruising, dry flaky skin, or areas of redness
Is one foot rotated more than the other? -- Probably tight piriformis
Check the levels of the iliac crests
Are the ASIS even?
Check the levels of the greater trochanter
From the side, check the lumbar spine for increased or decreased lordosis
Moving to the back again,, check the levels of the iliac crests
Are the ischial tuberosities level?
Are the gluteal creases level?
Check the gluteal mass and compare
Ask the patient to walk across the room. Observe for signs of stiffness, pain,
compensatory movement, gluteus medius or gluteus maximus lurch

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THE KNEE -- THE SCREW HOME PRINCIPLE

Flexion and extension are complex movements involving a rolling of the femur over the
top of the tibia or vice versa combined with a gliding movement in which the femur
moves forward over the tibia and the menisci during flexion and backwards during
extension.

In the final stages of extension (the last 20 to 30 degrees) the femur rotates medially on
the tibia causing a screwing home or locking effect which allows the quadriceps to relax
and brings the knee into it's most stable position.

In the first stage of flexion from this fully extended position, the femur has to rotate
laterally to unlock the joint. This applies when the tibia is weight bearing and
stationary on the ground. The opposite occurs when the foot is off the ground, ie the
tibia rotates laterally to lock the knee and rotates medially to unlock it.

Bony structure of the knee.


The distal end of the femur has two convex condyles separated inferiorly by a deep V
shaped notch and anteriorly by a concave depression into which fits the patella.

The medial femoral condyle is approx a half an inch longer than the left. It is more
elongated or oval in shape and has a larger articulating surface than the left.

The lateral femoral condyle is circular in shape and it's anterior lateral border protrudes
further anteriorly than does the medial condyle. The latter point is important in
preventing lateral dislocation of the patella.

The tibial surfaces are reciprocally curved and comprise two curved and concave areas
called the medial and lateral tibial condyles. As with the femoral condyles the lateral
facet is circular and the medial is oval. Between the two facets is a roughened
intercondylar area called the intercondylar eminences which fits into the intercondylar
fossa of the femur.

Mechanism of movement.
The femoral condyle rolls and slides simultaneously over the tibial condyles. The
femur slides anteriorly as it moves into flexion and posteriorly into extension.

The lateral condyle rolls far more than the medial. Therefore the distance covered by
the lateral femoral condyle over the corresponding tibial condyle is greater than that
covered by the medial condyle.
In moving from flexion into extension due to the fact that the lateral femoral condyle is
shorter than the medial femoral condyle it reaches it's end point before the medial side.
The lateral femoral condyle moves forward over the lateral tibial condyle while the
medial femoral condyle moves backwards over the medial tibial condyle, which brings
about medial rotation of the femur on the tibia, thus locking the joint in extension.

In moving from extension into flexion the opposite takes place. The lateral femoral
condyle moves posteriorly and the medial femoral condyle moves anteriorly, thus
causing lateral rotation.

The Knee
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As the knee is such a complex joint and is prone to various injuries and pathologies,
there are two useful methods to bear in mind during diagnosis:-
From an age view point and the corresponding pathologies
From a positional and anatomical view point.

Age Group.
7 to 25 years Chondramalacia Patella is greater in female
8 to 12 years Osteochondritis Dissicans is greater in male
10 to 16 years Osgood-Schlatters greater in male
30 to 50 years Rheumatoid Arthritis
45+ Osteoarthritis.

Positional/Anatomical Anterior Knee.


Chondramalacia Patella
Osteochondritis Dissicans
Osgood-Schlatters
Patella O.A.
Tendinitis and Insertional Tendinitis
Prepatellar Bursitis
Infrapatellar Bursitis
Posterior Knee.
Baker Cyst.

Medial Knee.
Meniscus Injury Tear
Medial Ligament Strain or Sprain

Lateral Knee.
Meniscus Injury Tear
Lateral Ligament Strain or Sprain
Runners' Knee

General.
O.A.
R.A.

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CHONDRAMALACIA PATELLA

This occurs due to damage to the articular surface of the patella. The cartilage becomes
soft and swollen, cracks and fissures appear and the cartilage becomes thinned.

Causes.
Increased compression forces between patella and femur
Trauma is associated in 66% of cases.
Recurrent subluxation - dislocating patella
Quadriceps wasting
Pronated or flat feet
Mortons' syndrome
Postural instability
Short leg syndrome
Abnormal patella development
Extreme flexion as in deep knee bends (subpatellar flexion may rise to twenty times that
of body weight)
Alteration of "Q" angle.

Signs and symptoms.


Age group 7 to 25 years
More common in females
Pain behind the patella which is made worse by compression and exertion
Tenderness in posteromedial/lateral aspects of patella
Worse on hilly ground and up and down stairs
Stiffness after sitting for long periods with knee flexed and relieved by activity
Grating and cracking
May be slight effusion

Treatment.
In most patients the symptoms settle within a year of growth ceasing. Pain can
disappear spontaneously though this can take up to 1 or 2 years. An affected athlete
may have to dramatically change a training programme. Chondramalacia can in some
cases predispose to the later development of O.A.

General Treatment.
Rest
Heat
Supportive brace / Heat retainer
Static exercises to quads, (especially to build up the vastus medialis) and hamstrings.
Internal and external rotation exercises for tibia.

Medical.
Anti-inflammatories
Operation to remove degenerative cartilage in cases that don't respond.

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OSGOOD SCHLATTERS DISEASE

This is a condition in which the tibial attachment of the patella tendon becomes
inflamed. It is thought to be a strain of the developing tibial tubercle from the pull of
the patellar tendon.

Signs and symptoms.


More common in boys
Age group 10 to 16 years
Pain in front of and below the knee
Worse during or after activity
May be swelling or tenderness over attachment
Tibial tubercle is prominent and tender
Pain made worse on tensing quads
Sometimes plaster cast for a few weeks
Osgoods Schlatters disease, usually heals spontaneously.

OSTEOCHONDRITIS DISSICANS.

This affects the medial femoral condyle where fragment of bone and cartilage are
released into the knee joint (forming a loose body) and can cause permanent damage to
the articular surface of the femur.

Causes.
Unknown
May be impairment of blood supply to that particular area of the knee
Injury may be involved

Signs and symptoms.


More common in boys
Age group 8 to 12 years
Pain during and after exercise
Knee may lock
Recurrent effusions in knee joint

Treatment.
With time the separated loose fragment (which is usually the size of a hazelnut) may
reattach spontaneously. If not it may be surgically reattached or removed.

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PATELLA O.A.

This is not uncommon and may be due to occupation, direct trauma, or previous
pathology e.g. Chondramalacia Patella. The cartilaginous surface will become
roughened and bending the knee under load will cause pain. Crepitus and grating is
usually present.

Treatment.
Rest from strenuous activity
Reduce weight if overweight
Heat
Massage
Analgesics and anti-inflammatories
In severe cases a patellectomy may be needed
Patellofemoral O.A. can exist separate from Tibiofemoral O.A.

TENDINITIS AND INSERTIONAL TENDINITIS

This may occur at any point along the quadriceps mechanism at the knee.
Inflammation may occur at any point along this mechanism and is usually initiated by a
small tear in the tendon.
The inflammation is usually localised to either the tendon itself (a simple tendinitis) or
to the insertion of the tendon into the bone (an insertional tendinitis), e.g. quadriceps
tendon with patella, patellar tendon with patella, patellar tendon with tibia.
An insertional tendinitis known as "Jumpers' Knee" is found where the patellar tendon
inserts at the patella.
The tendinitides are most frequency seen in sportsmen and women. The tenderness is
usually localised and there may be some local oedema.

Signs and symptoms.


Localised pain over part of the tendon
Pain / aching after exertion
May be swelling
Quad contractions causes pain

Treatment.--Acute Phase.
Rest
Ice
Ice massage
After acute phase is over use heat and a heat retainer strap.

THE KNEE
In discussing soft tissue damage of the knee joint, structures most usually damaged are:-
The Collateral ligaments
The Cruciate ligaments
The Menisci.

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The Collateral Ligaments.
These are fully stressed when the knee is in full extension and will only become injured
in this position. The medial collateral ligament will be strained or torn if the extended
knee is forcibly abducted whilst the lateral collateral ligament is damaged when the
extended knee is forcibly adducted. In full extension of the knee, adduction and
abduction are negligible, but if torn, the extended leg can be moved away from the
affected side.

Clinical Features of Acute Sprain.


The patient is clear as to how the injury occurred.

Pain. There is sharp, sudden pain over the medial or lateral side of the knee. In minor
sprain the pain is momentary, but in more severe injuries it arrests movements.
Swellings.
This only tends to occur when there is severe injury. There is visible swelling
over the injured side of the joint. There may also be effusion in the medial or
lateral compartment of the tibio-femoral joint.
Loss of Function.
The joint may feel unstable and walking is impaired because the joint will not
extend to bear weight during the stance phase.
Palpation.
The damaged ligament is tender especially over the joint line or at the femoral
attachment.
Specific Tests.
• Valgus Stress Test (Medial Collateral Ligament).
• Varus Stress Test (Lateral Collateral Ligament)
• X-rays:- Joint opening can be seen if valgus/varus strain is applied.
• Orthography:- If the dye remains within the joint the ligament is intact.

The Valgus Stress Test; Principles.


The principle is to attempt to open up the medial side of the joint by an abduction force
to the lower leg, while pressing medially on the lateral side (the knee should be slightly
flexed). During the test, the therapist looks for excessive angulation, either by sight or
by feeling for gapping in the joint line. During the return movement, one feels for the
clunk.

Results.
A positive valgus stress test indicates damage to the medial structures including the
medial ligament. A strongly positive test indicates additional damage to structures in
the sagittal mid-line of the joint, e.g. the anterior cruciate ligament. If the test is grossly
positive, there could be damage to both the cruciates and the posterior capsule, as well
as to the medial structures. If the V. S. T. is at all positive in full extension, when all
the ligaments should be taut and resisting any movement, this indicates considerable
damage to mid line structures as well as medial structures.
The Varus Stress Test.
The same as for valgus stress test. There is normally some "give" more than on the
medial side, but it should diminish to nothing when the extension is closed.

Treatment
First Aid
R.I.C.E.
No weight bearing allowed.
Follow-up Treatment.
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• For minor injuries the compression bandage will be retained for approx. 1 week.
• For severe injuries back splint and bandage for 2 weeks
• For very severe injuries, 6 to 8 weeks in plaster.
• The quadriceps atrophy very quickly in knee injury, therefore static exercises must
be practised (approx. 5 contractions every hour).
• Depending on severity, partial weight bearing should be practised slowly.
• Ice massage for 15 to 20 minutes to relieve oedema every 3 to 4 hours.
• Massage above and below the injury initially to relieve swelling and promote
healing.
• Deep work to the quads and hamstrings.
• Transverse friction to the damaged structure/structures.
• Non weight-bearing free active flexion/extension of the knee to be practised
repeatedly.
• Mobilisation of the patella, superiorly/inferiorly.
• anterior/posterior mobilisation of tibia etc.
• make sure that all movements have been fully restored.
• Compare the relative strength of quads and hamstrings with the non-injured knee and
work towards full muscle balance.

Chronic Ligamentous Sprain, Collaterals.


This is usually associated with repeated minor injuries or poor foot or hip posture. It is
also present in patients who did not have full pliability or mobility restored after an
acute injury, fail to warm up and stretch before activities, or have excessive valgus
stress during push-off in walking.

History.
Sharp, niggling, stabbing, intermittent pain over the ligament which is generally absent
at rest. Full extension of the knee is sometimes limited. The knee may, at times "give
way" on going down a step.

Treatment.
Deep massage including transverse friction (excellent when correctly applied)
Look at patients over-all posture and deal with findings.

The Cruciate Ligaments.


These tear through similar abduction and adduction strains which damage the collaterals
and anterior cruciate is often torn due to forced hyperextension of the knee. In testing
for cruciate ligament tears, if forward movement is greater than normal, the anterior
cruciate has been badly strained or torn. If backward movement is excessive, then a
strain or tear of the posterior cruciate ligaments is indicated.

Clinical Features. History.


Patient often feels something "go" inside the joint.

Swelling
At the time of injury there is haemarthrosis, a jelly-like swelling which makes walking
impossible.

Treatment.
A complete rupture requires surgical repair.
Partial tears may also be surgically treated.
Physical Therapy is very important as after care.
Meniscus.
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Meniscus lesions affecting the knee are common injuries especially in athletes. The
medial meniscus being less mobile than the lateral meniscus is more susceptible to
injury.
The menisci move with the tibia in flexion - extension and with the femur in rotation. If
during flexion, external tibial rotation is forced instead of the internal rotation that
should normally occur, abnormal stresses are applied to the menisci with the possibility
of a tear occurring. The same applies to the case of a forced internal tibial rotation
during knee extension. Similarly, flexion or extension taking place in the absence of
normal rotary movements that should accompany it may result in a meniscus tear.

History.
The cartilage will only be injured while the knee is in flexion.
The foot was on the ground at the time of injury.
The knee was flexed.
There was internal rotation of the femur on the flexed and abducted externally rotated
tibia. This was followed by sudden extension of the knee.
Meniscus tears may also occur with hyperflexion of the knee, especially during weight
bearing. In this position the femoral condyles have rolled back to articulate with the
posterior aspects of the tibial articular surfaces. The menisci then must recede
backwards during flexion, but can only recede to a certain point before capsulo-
ligamentous attachments restrict further movements of the menisci. If further flexion is
forced once the menisci have reached their limit of backward movement, the menisci
are susceptible to being ground between the femoral and tibial joint surfaces. This is
especially true if rotation is forced in hyperflexion, because a rotary movement entails
further backward movement of one condyle. Certain occupations, such as mining, in
which one must move about in a squatting position may predispose to development of
minuscule tears from this mechanism. Among athletes, the wrestler is prone to this type
of injury.

Signs.
The knee will usually be locked in flexion.
Synovial effusion causing a generalised pressure sensation may arise within hours
following injury. Effusion nearly always accompanies a medial meniscus. It does not
always accompany a lateral tear.
As patient is unable to fully extend the knee, weight will be taken on the forefoot and
patient will walk with knee partly flexed.
Patient may have difficulty in removing clothes (shoes, socks etc).

Symptoms.
Patient will usually feel something "give" in the joint, often with an accompanying
deep, sickening type of pain.
If haemarthrosis occurs, the typical severe generalised pain arising within minutes of
the injury is reported.
If not masked by other injuries or extensive effusion, the patient will often be able to
point to the spot of the joint line corresponding to the site of the tear where the coronary
ligament has been sprained.
The person sustaining a meniscus tear is very hesitant to resume activity immediately
following the injury, unlike a person suffering from a ligamentous sprain.

Treatment.

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A straight-forward displacement may be reduced my manipulation. If there is a
"Bucket-handle-tear" of the meniscus, that is, a tear which resembles a bucket handle in
shape, with the outer part lifted upwards and pulled inwards, then surgery is indicated.
Similarly, if the meniscus is fractured or fragmented, surgery is the only possible
treatment.

To Test for Fracture


Patient seated on plinth, with the injured leg at about 45 degrees flexion. A thumb
should be placed over the injured area and the lower leg lifted upwards to extension. If
there is a fracture of the cartilage, crepitus will be readily felt under the thumb.

CORONARY LIGAMENT SPRAIN.

History.
The patient usually describes a twisting injury followed by some minor swelling and
pain over the anteriomedial knee region. Rarely is the victim significantly disabled
immediately following the injury and he or she will rarely seek attention in the acute
stage.
The acute symptoms usually subside within a few days. If the meniscus maintains good
mobility during healing, the patient should have no further problems. However, often
the coronary ligament becomes adhered to the anteriomedial margin of the medial tibial
condyle as it heals, resulting in reduced mobility of this part of the meniscus. In such
cases the individual develops a more chronic problem characterised by intermittent
twinging of the pain, when the adhered tissue is stressed, usually by activities involving
external rotation of the tibia on the femur. It is the persistent nature of the problem that
eventually prompts the individual to seek assistance.

Findings.
• Tenderness over the anteriomedial joint line.
• Pain on external rotation of the tibia on the femur, but no pain on valgus stress.
• Occasionally forced extension causes discomfort.
• Effusion is rarely present.
• There may be some minimal quadriceps atrophy if the problem has been long-
standing.

Treatment. Chronic Stage.


The objective of treatment is to gradually restore mobility to this part of the meniscus.
Therefore massage, particularly deep friction applied directly to the site of the lesion,
followed by passive movements is recommended.

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EFFUSION

Articular effusion commonly follows traumatic injury to the knee. This may be the
result of blood filling the joint or of over production of synovial fluid. The time frame
of the onset of effusion often provides an important insight into the nature of effusion.
Haemarthrosis tends to develop over a relatively short period following injury, from
several minutes to a few hours. Synovial effusion occurs over a longer period of time,
perhaps 6 to 12 hours before it is noticed.

Synovial effusion causes a dull aching type of pain from the distension of the joint
capsule. Haemarthrosis may be associated with more severe discomfort caused by
chemical stimulation of nociceptors.
Clinically it is important to attempt to differentiate the nature of the effusion, since the
cause of haemathrosis, an intra articular fracture must be ruled out. Some relatively
severe joint injuries, such as a complete rupture of the medial ligament, may not be
followed by significant effusion because of leakage of fluid through the defect out from
the confines of the joint capsule.

More subtle joint effusion may accompany chronic, non traumatic knee disorders. The
patient often describes posterior knee discomfort from posterior capsular distension.

It is desirable that excess effusion be removed from an injured part as soon as possible
in order to prevent adhesions and excess formations of fibrous tissue which forms
whenever a structure is damaged. Massage reduces swelling, improves circulation and
removes static lymph. It also enables blood clots to be broken down and removed from
the site of injury. If we use passive movements after massage, fibrous tissue will be
prevented from adhering across the striations of injured muscles and active movements
then improve nutrition to the area.
While the presence of effusion at the knee is usually visible, this is not always the case,
but careful palpation should reveal it's presence at such times. A gentle hand pressure
over the suprapatellar bursa would have the effect of squeezing any fluid downwards
into the joint, where its' presence might be more easily detected by pressing the patella
to float it against the fluid at this point (patella tap).

"Nipping at the edge of the infra-patellar pad".


Sometimes a patient complains of pain at the knee, particularly when going up and
down the stairs. Pain is usually just a brief stab, but repeated often and getting steadily
worse. A portion of the pad of fat gets caught between the bone ends and causes
limitation of extension. Inflammation results and causes frequent stabs of pain.

Treatment.
Prescribing heel elevators to avoid further nipping and electrical therapy for the
inflammation.

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CHRONIC KNEE SPRAIN "GAMMY KNEE"

Usually described as the knee that lets one down from time to time and is always having
to be "taken care of". The patient may not be able to recall any particular injury to the
knee and often the initial injury may have been so slight as to have passed unnoticed at
the time, perhaps from minor swelling, long forgotten.
Therefore it is likely that adhesions are present somewhere within the joint tissue, most
probably within the fibrous tissue of the tendon attachments of muscles acting on the
knee.
Palpation may not reveal anything significant. The joint should be move passively
through it's normal R.O.M. and compared with that of the unaffected leg. Active and
forceful resisted movement, against resistance applied by the therapist, should then be
carried out by the patient, and it should be carefully noted whether pain occurs at any
stage of the movement or whether there is spasmodic pain at full flexion or extension.
Check for possible adhesions around the patella itself, and it is essential that the patella
is first seen to be freely moveable in its' tendon, before any flexion of the knee is
attempted, to avoid any possibility of hairline fractures.

POPLITEAL AND SEMIMEMBRANOSUS TENDINITIS.

Tendinitis of the popliteal or the semimembranosus tendons follows overuse injuries,


usually from long-distance running. Hyperpronation of the foot may result in either
popliteal or bicipital tendinitis at the knee secondary to overuse.
In popliteal tendinitis the patient complains of localised pain over the lateral aspect of
the knee. Joint tenderness is noticed at it's insertion on the femur anterior to the lateral
condyle.
Tendinitis of the semimembranosus can mimic a meniscus injury because of it's
proximity to the joint line. The semimembranosus functions synergistically with the
popliteus to prevent excessive external rotation of the tibia. Therefore, hyperpronating
problems of the foot can stress the insertion of the semimembranosus.

Treatment.
Rest and ice for the first 48 to 72 hours.
Usual massage treatment of tendinitis including friction and strengthening exercises.
Proper training techniques (see coach) and appropriate footwear should be addressed.

Adhesions
It is common to find adhesions at the mid-point of the medial collateral ligament.

Clinical Signs.
Full extension hurts at the medial ligament.
Flexion is limited by about 10°.
Full lateral rotation of tibia is painful.
Full medial rotation is painless.
Quiet use of an adhesion does not pull on an adhesion. Vigourous exercise does.

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PAINFUL ARC.

Painful Arc may suggest :-


Impacted loose body
Fragment of cartilage
Post traumatic irregularity of edge of patella.
Torn meniscus.

CYSTIC SWELLINGS ABOUT THE KNEE

If the swelling is suspected of being a bursa, it has one characteristic. If it is connected


to the joint cavity (popliteus bursa, medial gastroc bursa, suprapatellar bursa) it should
be soft in flexion but become tense and hard in extension. A popliteal cyst is a cystic
swelling behind the knee. It may be an enlarged semimebranosus bursa or a simple
herniation of synovium via the posterior capsule. If herniation, it is secondary to
whatever is causing the persistent effusion.
Note: Exercise on a joint with an effusion damages its articular cartilage.

Anterior Knee Pain.


This may be caused by disease in the hip. The characteristic gesture is a rubbing of the
front of the distal thigh, with the fingers over the knee cap.

Giving Way.
This may be due to chronic meniscal injuries or lax ligaments. In the case of meniscus
injury the dislodged meniscus may get jammed. It deforms the subchondral bone and
stretches the capsule thus causing pain. Pain produces inhibitory impulses, the muscles
"switch off" and the knee "gives way".
Note: Pain comes before the giving way.
When the ligaments and capsules are damaged they are often lax. Sudden stress is
likely to occur stimulating the golgi tendon organs. Their efferent stimulus acts on the
segmental motor neurons inhibiting nearly all muscular activity at the joint. The knee
gives way without warning. This is usually painless.

Patello Femoral Joint.


Symptoms appear especially with anti-gravity efforts:- stairs and chairs, baths and cars.

Chondromalacia Patella.
There is wearing away of cartilage on posterior surface of the patella. If either the
vastus medialis or lateralis is not equally toned the muscle balance is uneven thus
causing the patella to go off track. Generally the vastus medialis is weakened and the
inferior angle points medially. (If the condition exists bilaterally this is known as
kissing or squinting patella). This condition is often associated with tibial torsion or
pronated feet. The muscles will adhere to try to limit movement and pain. There is a
low grade inflammation in progress, thus adhesions are formed.

Goal of Treatment.
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Liberate adherent tissues.
Allow individual muscles to function independently.
Increase vatus medialis muscle tone only if this is the cause.

Test.
Patella femoral grinding test.

Treatment.
Always place a pillow under the knee to prevent extension. Use plenty of warm-up
strokes initially. Trace all muscles and discover where adhesions have formed.
Attempt to separate the vasti from each other by lifting and separating the fibres. Work
very slowly and go as close to the bone as possible -- monitor patients' reaction. Tease
out any adherent fibres paying particular attention to Vastus Medialis.
Friction to tendons and fascia around patella. Move patella medially/laterally and work
on undersurface. Clear off condyles.
MET to quads and hamstrings.

Quads Strengthening.
The patient sits with the knees flexed over the edge of the plinth. The foot is
dorsiflexed and inverted. The therapist applies resistance to the foot as the patient
attempts to extend the knee. The patient can apply his own resistance using the crossed
ankle position. The vastus medialis has to contract most strongly in the final 30° of
flexion into extension, therefore this is a good position to work from.

Patella -- Pain.
This is localised pain at the lower pole of the patella where the patella tendon joins the
patella. It can be due to repeated small avulsion of collagen from bone. This is
"Jumper's Knee" similar to "Tennis Elbow".

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FOOT AND ANKLE CONDITIONS

In discussing foot problems it is important to look at the overall construction and shape.
Although faultless in it's architectural design as regards its' weight-bearing function and
ease of movement in propelling the body forward on ambulation, its' complexity makes
it vulnerable to distortion.
The foot is best described as having four arches, medial longitudinal, lateral
longitudinal, anterior transverse, and posterior transverse arch. The only weight-
bearing areas are the calcaneus, 5th metatarsal head and 1st metatarsal head. The
factors which maintain the arch are:-
The shape of the bones, e.g.. the 3 cuniforms are wedge-shaped inferiorly. The talus
rests on the sustentaculum tali of the calcaneus and so helps maintain the medial
arch.
The ligaments on the plantar surface of the foot, e.g.. long and short plantar
ligaments, spring ligaments by virtue of their tautness help maintain the longitudinal
arches and are very strong.
The plantar aponeuroses which attaches the medial tubercle of the calcaneus to the
distal heads of the metatarsals.
The intrinsic muscles, e.g.. lumbricals and interossei in which muscle tone is vital.
The long muscles which have their origin in the leg and insert into the bones of the
foot e.g.. the anterior tibialis exerts an upward pull on the medial longitudinal arch.
Flexor digitorum longus and flexor hallucis longus exert an anterio-posterior pull
which again helps maintain the medial longitudinal arch.
The peroneus longus and the posterior tibialis act as a stirrup and also give support
to the medial longitudinal arch.
The muscles provide the most important support to the arch. The ligament alone
would give way under strain imposed by the weight of the body if the muscles fail
to work due to weakness or disease. Muscles need adequate nourishment which is
only made possible through proper exercise. Lack of such exercise leads to
decreased tone and atrophy.

In walking, the heel first strikes the ground, then the lateral and finally the medial side
of the forefoot is placed firmly on the ground. As the weight falls on the foot, the
arches, especially the medial longitudinal and the anterior transverse arches are
flattened a little with a tendency towards pronation (abduction, eversion and
dorsiflexion).
Normally, once the body weight is removed, the muscles, particularly the anterior and
posterior tibialis act as invertors and restore the arch. If however, we habitually walk
with an exaggerated pronation of the foot, the muscles lose their tonicity and more
strain is placed on the medial ligaments, especially the spring ligament.
The medial arch is decreased, there is splaying of the forefoot (widening), the big toe is
abducted and the patient pushes off the inner border of the undersurface of the big toe
instead of all the toes. With this, two serious pathological conditions have arisen,
namely Pes Planus (flat foot) and Hallux Valgus.
The most common foot conditions are:
Metatarsalgia
Pes Planus
Pes Cavus
Hallux Valgus
Hallux Rigidus.

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METATARSALGIA Morton's Neuroma.

The patient complains of pain under the metatarsal heads, or in the region of the fourth
toe. It is due either to a collapse of the anterior transverse arch, or a displacement of
one of the metatarsals. Collapse of the arch leads to splaying out of the metatarsal
heads stretching the transverse ligaments and thus causing pain.

Causes.
High heeled shoes, causing the foot to slide forward and the weight to be taken on the
metatarsal heads.
Increased weight.
Changing from a sedentary lifestyle to an occupation which requires hours of standing.
Carrying heavy loads e.g. builder.

Pathology.
Depression of the transverse metatarsal arch causes overstretching of ligaments and
weakening of the muscles. There is pressure on the nerve endings causing pain.

Treatment Goals.
Ease pain
Re-tone muscles
Ease pressure on ligament and nerves
Education

Treatment Plan.
• Suitable footwear should be worn.
• Corns or callosities should be dealt with, so refer patient to see a Chiropodist. It is
important to try to regain the transverse arch, taking the weight off the 2nd 3rd and
4th metatarsal heads. To this end a padding is applied behind the metatarsal heads
and strapping applied in such a way as to maintain and encourage reformation of the
arch on walking. 7 to 10 days before next visit.
• Deep massage to the feet, paying particular attention to the plantar aspect.
• Petrissage and deep goading are given to the patient’s tolerance.
• Bone-shaking between the metatarsals. Vigourous passive movements to the
metatarsophalangeal joints, mid-tarsal joints, ankle etc.
• Deep stripping and friction to the anterior and posterior leg muscles. Padding and
strapping is reapplied. Follow up treatment consists of three treatments per week
where deep massage and passive movement are given.
• When condition improves significantly -- weekly treatments.
• Home exercise:- picking up pencils or a towel off the floor with a bare foot.
Walking on a stony beach is very beneficial.
• Regular checks are made to determine that the metatarsal arch is improving.

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FLAT FOOT.

This condition is generally bilateral, more common in women, and as already


mentioned there is a natural tendency in walking to pronate the foot. If this is even
slightly exaggerated over a long period of time, the tibialis anterior and posterior
become over-strained and lose their tone, thus becoming almost ineffective. As the foot
goes further into pronation, the lateral evertors (peroneus longus and brevis) shorten.
The toe extensors change their alignment and become evertors of the foot.

The calcaneus everts, placing increased strain on the deltoid ligament which produces
pain. The talus glides forwards on the calcaneus, depressing the navicular bone and
thus decreasing the longitudinal arch. The plantar fascia is stretched and tenderness
results.

Causes.
Poor footwear
Badly fitting stockings
Bad posture
Increased weight
Occupation; standing for long periods
General ill-health
Injury to the extremity
Paralysis of any of the muscles involved in maintaining the arch.
There are various stages in the progression of this condition and as usual, the earlier
treatment is implemented, the more successful the outcome.
Symptoms commence with a vague discomfort under the medical long arch. Pain will
be greater in the vicinity of the ligaments and the joints. Corns and callouses begin to
form along the inner border of the foot.

Treatment Goals
To encourage the normal restoration of the longitudinal arch
Retensioning of muscles
Tightening of ligaments
Education re posture and correct walking

Treatment
Change occupation if necessary, otherwise rest feet when possible
Proper footwear is essential, and even your best efforts are wasted if this isn't seen to.
If patients health is generally poor, ask about diet etc. Suggest that patient see a G.P.
Maybe a course of iron or Vitamin tablets are needed.
If over-weight, suggest joining some weight watchers association.
The arch needs support initially, therefore an arch support is required, preferably those
made by plaster cast of the patients own feet.
Massage treatment is similar to that for metatarsalgia. Deep friction, particularly to any
ligaments that are in trouble. Strong passive movements. Exercises to strengthen
plantar aspect of the foot. Treatment should be 3 times weekly initially, until
substantial improvement can be seen. Check arch support regularly, and they will need
modification as the condition improves.
Always inspect for corns and callouses. Ask patient to see a chiropodist if necessary.
This condition, if treated early, responds well. You could save your patient from a life
of discomfort which inevitably occurs as the condition progresses. Knee, hip, and
lower-back problems often result.
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PES CAVUS -- HIGH ARCH
There is an increase in the height of the medial longitudinal arch. The plantar fascia
and short plantar muscles are shortened. The forefoot and hindfoot are drawn closer
together. There is over stretching of the anterior musculature. An imbalance sets up
between plantar muscles and those that support the arch.

Causes-.
Pes Cavus can be inherited or acquired.
It may be due to acute anterior poliomyelitis (unilateral)
Infectious diseases.
Chemical poisoning
Gout
Diabetes

The following is a list of causes most likely to prompt the patient to contact a Physical
Therapist.
• Prolonged Bed Rest
• Years of wearing high heels with a recent change to a low-heeled shoe
• Ballet dancing or any toe dancing.

Symptoms.
Pain in the area of mid-plantar aponeurosis
Ache in the anterior tibialis
Discomfort over the dorsal arch
Corns under the metatarsophalangeal joints, dorsum of toes and tips of toes.

Treatment Goal
Alleviate pain
Stretch the plantar surface
Strengthen the anterior leg muscles
Improve mobility

Treatment Plan.
Arch support to help redistribute body weight.
Well-fitting shoes; low-heeled shoes or sandals with slots to enable the toes to be
strapped down.
Forefoot may be rigid -- bone shaking.
Deep massage and stretching to plantar surface and gastrocnemius.
Friction to O. and I. of anterior tibialis
This condition is not as successfully treated as Pes Planus. Surgery is avoided if
possible, again due to the poor outcome. The surgical procedure is to divide the plantar
fascia, lengthen the achilles tendon, and place the foot in a plaster cast in an over
corrected position for several weeks. Scar tissue on the plantar surface will always give
trouble. Corns will also develop and cause pain.

HALLUX VALGUS
The big toe deviates laterally at the metatarsophalangeal joint, while the metatarsal
splays out medially. Consequently, there is a projection which rubs off the shoe,
causing tenderness, inflammation, callous formation, bursitis, corn development and
bunion.
There is chronic muscular imbalance whereby the abductor hallucis is lengthened, while
the remaining muscles that act in balancing the big toe are shortened.
Causes.
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Tight shoes with pointed toes.
Ill-fitting stockings or tights.
Flat foot.
Hereditary.
If treatment is instigated at an early stage, a good degree of success is expected. This
decreases with the severity of the condition. Pre or post-operative deep massage and
strong passive movements are very beneficial.

Treatment.
Correct shoes of sufficient size must be worn. The inner border must be straight rather
than curved, and the heels must not be too high.
Treat inflammation with rest and a poultice.
Treat Pes Planus if this condition is present.
Slight cases may respond to physical treatment.
Passive movements should be given at least twice a day, and patients should be
instructed in the method of doing these for themselves. Particular attention must be
paid to abduction of the toe.
Strapping is applied to the medial aspect of the foot to prevent further deviation.
Massage treatment to stretch shortened structures and to strengthen lengthened ones.
Surgery, if Physical Therapy is unsuccessful, or if condition is advanced.

HALLUX RIGIDUS
There is partial or complete limitation of range of movement of the big toe at the
metatarsophalangeal joint.

Causes.
These are not fully understood. It may be due to:-
Injury, as in kicking the toe against a stone.
Tight-fitting shoes.

Pathology.
This is variable. The head of the metatarsal bone may be enlarged, though not to a great
extent, and the cartilage bruised or even eroded. The synovial membrane and
periarticular structures may be acutely inflamed and the cause of much pain. There may
be tenosynovitis of the tendon hallucis longus. In its' early stages, the muscles are in
protective spasm. Later, permanent shortening of soft structures may occur, and finally
osteo-arthritic changes may take place. The toe may become partially or completely
rigid, all extension being lost. Movement at the interphalangeal joint is usually
unimpaired.

Signs and Symptoms.


There is severe pain on using the foot, walking is difficult.
The metatarsophalangeal joint is tender, pressure increasing pain.
There is spasm and rigidity of the toe.

Treatment.
This is a very painful condition and treatment should commence as early as possible
before the cartilage erodes and the joint becomes fixed. Otherwise, Physical Therapy is
ineffective.
Special shoes may be prescribed, designed to relieve the feet of all pressure.
Re-education of the intrinsic muscles of the foot and of walking.

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Treatment is similar to that for Hallux Valgus. Deep massage and strong passive
movements.

Sprained Ankle.
This is really a sprain of the mid tarsal and talocalcaneal (subtaloid) joints as well as the
ankle joints. it is generally caused by turning over the ankle, that is a violent eversion
or inversion of the foot. Inversion sprain is the most common. The patient generally
falls down when the accident occurs and in severe sprains is unable to walk without
pain.

The lateral ligament is partially or completely ruptured and there may be damage to the
small ligaments on the outer side of the foot. The peronei and extensor brevis digitorum
are wrenched. The swelling may be considerable over the foot and round the ankle and
may extend some way up the leg.

Treatment.
As a result of the very large amount of exudation, adhesions are very liable to form, and
unless properly treated the patients foot may remain stiff and painful for a long time. It
is essential therefore to check effusion as soon as possible and to keep the foot mobile.
The foot should be bandaged in dorsiflexion and eversion. Zinc oxide strapping or
elastoplast provide the best support but a crepe or elastonet bandage can be used. The
bandage should start behind the metatarsal heads and extend well above the ankle joints
to avoid an oedematous pouching over the bandage. It is also very important to see that
support is given over the lateral malleolus to avoid a pocket of oedema there.

If the bandage is started in the medial side, the foot is pulled into eversion by the turns
of the bandage.
Before doing any work, ask if patient has had an X-ray. If not, don't do any work, if there
are no fractures proceed.

Physical Treatment.
Treatment follows the same lines as the wrist joint. This type of injury is severely
painful, so take good care while working to avoid direct contact with the ankle area
during the acute phase. Work above and below the site of injury. Use short strokes
towards the heart to help drain the area, working as close as possible to the injury
without causing undue pain.
After the acute phase have patient contrast bathe the area.
Introduce some small active movements in the joint.
In terms of massage the two muscle groups mainly affected are:
The Tibialis Anterior which needs to be lengthened (deep stripping).
The peroneals which need to be strengthened or made to contract (circular or transverse
friction to belly).
Full Intermediate Massage Treatment.
Pay particular attention to the dorsum of the foot and around the malleoli and tendo
achillis, when using friction to, the lateral ligament, the foot should be slightly inverted
and plantar flexed.

Exercise.
Encourage gentle active movements from the onset of injury, avoiding inversion.
Passive R.O.M. to be commenced - again inversion the last movement to be introduced.
Resisted eversion.

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At home -- as soon as patient is able:
In a bucket of cold water, "write sentences" with the foot.
Note: If the ankle condition is a chronic one, then use hot water.
Pull/Push towel on floor with the toes.
Stand on one (the affected foot) and balance for as long as possible.
Push up on toes, down 2/3 of the way, and remain there.
Re-education of walking is essential and should begin as soon as possible. You must
ensure that the weight of the body is taken correctly on the foot in walking and in
standing, that is, through the calcaneum, to the base of the 5th metatarsal and across to
the head of the 1st metatarsal. The hip, knee, ankle and toes must be used correctly
when steps are taken.

SURFACE MARKINGS OF FOOT AND ANKLE

Medial malleolus
Situated at the distal end of the tibia.

Lateral malleolus
Situated at the distal end of the fibula. It extends further distally than the medial
malleolus, therefore it enjoys a mechanical advantage in that eversion sprains
are less likely to occur.

Ankle joint proper


Formed by the articulation of the talus with the tibia and fibula. It can be
located by measuring about a half inch above the medial malleolus and about
one inch above the lip of the lateral malleolus.
Talus
Is palpable immediately in front of the malleoli. No muscle attachments. Spring
ligament.

Sustentaculum tali
Palpate one inch below the medial malleolus. This is a projection of the
calcaneus on which the talus lies. Attachment point for the spring ligament and
the flexor hallucis longus.

Tubercle of the navicular


Palpate one inch in front and one inch below the medial malleolus. Point of
insertion of the tibialis posterior.

1st cuneiform
Palpable distally from the navicular.

1st metatarsal & metatarsophalangeal joint


Ball of foot, weight bearing.
Calcaneus
Heel and is subcutaneous. Insertion point for the achilles tendon.

Peroneal tubercle
Lies on the calcaneus and is distal to the lateral malleolus. It separates the
peroneus brevis and longus.

Styloid process
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Proximal end of the 5th metatarsal. Insertion point for the peroneus brevis.

5th metatarsal head and metatarsophalangeal joint


Weight bearing.

Soft tissue palpation


Medial aspect
Spring ligament
Deltoid ligament / medial collateral ligament
Structures between medial malleolus and achilles tendon.

Lateral aspect
Structures between lateral malleolus and achilles tendon.

Anterior aspect
Structure between medial and lateral malleolus.
pages 212 - 216 Hoppenfeld.

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FOOT AND ANKLE

Resisted movements
to assess individual muscle strength.

Anterior tibialis
Foot position: Patient dorsiflexes and inverts foot.
Therapist: Try to plantarflex and evert.

Extensor hallucis longus.


Foot position: Patient extends big toe.
Therapist: Thumb on nail bed of big toe, try to push toe into flexion.

Extensor hallucis brevis.


Foot position: Same as E.H.L.(above).
Therapist: Thumb on first interphalangeal joint and try to push toe into
flexion.
Extensor digitorum longus.
Foot position: Patient extends 2nd to 5th toes.
Therapist: Attempts to force toes into flexion.

Flexor hallucis longus.


Foot position: Patient curls (flexes) big toe.
Therapist: Attempts to extend toe.

Flexus digitorum longus.


Foot position: Patient curls 2nd to 5th toe.
Therapist: Attempts to extend toes collectively.

Peroneus longus and brevis.


Foot position: Patient plantarflexes and everts foot.
Therapist: Attempts to force foot into inversion and plantar flexion applying
pressure with the thenar eminence on the dorsal aspect of
the 5th metatarsal.

Gastronemius.
Position: Knee extended. Foot dorsiflexed to 90 degrees.
Therapist: Resists patient attempts to plantarflex foot.

Soleus.
Position: Knee flexed, same as gastronemius.

Posterior tibialis.
Position: Patient's foot in neutral position.
Therapist: Instruct patient to plantar flex and invert foot while you
resist his movement.

**** Always compare sides right and left ****

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Shoulder
Extension Abduction Adduction External Rotation
Flexion Internal
Rotation
Supine Same Supine Same Supine Same
Test Position Knees flexed Shoulders 0° and full external Shoulders 90° abduction
Shoulder 0° rotation Forearm perpendicular to ground
Forearm 0° Supination and Elbow extended 0° supination and pronation
pronation, i.e. palm facing body Towel

GH: Stabilise scapula Same GH: Stabilise scapula Same GH: Scapula Same
Stabilisation S. Complex: Stabilise Thorax S. Complex: Stabilise thorax S. Complex: Thorax

G.H.: Firm – tension in posterior GH: Firm GH: Firm GH: Firm GH: Firm GH; Firm
Normal end-feel band of coracohumeral ligament, Tension in anterior band of Middle and inferior bands of Posterior joint capsules, Posterior joint capsule, Three bands of glenohumeral
posterior joint capsule, teres coracohumeral ligament and glenohumeral ligament, inferior supraspinatus, infraspinatus, infraspinatus, teres minor ligament, coracohumeral ligament,
minor, teres major, infraspinatus. anterior joint capsule joint capsule, latissimus dorsi and posterior deltoid anterior joint capsule,
S. Complex: firm pectoralis major S. Complex: Firm subscapularis, pectoralis major,
S. Complex: Firm, latissimus Clavicular fibres of pectoralis S. Complex - Firm S. Complex: Firm Rhomboid major, and minor, mid latissimus dorsi, teres major,
dorsi and costosternal fibres of major, serratus anterior Rhomboid major and minor Rhomboid major and minor, lower fibres of trapezius S. Complex: Firm
pectoralis major Latissimus dorsi Serratus anterior and pectoralis
minor

Fulcrum: Close to lateral acromial Same Fulcrum: Close to anterior aspect Same Fulcrum: Olecranon process
Goniometry alignment process of acromial process
Proximal arm: Midaxillary line of Proximal arm: Perpendicular to
thorax Proximal arm: Middle of anterior floor
Distal arm: Lateral epicondyle sternum
Distal arm: Middle of humerus Distal arm: ulna styloid process
° ° ° ° °
180 45 -- 55 180 45 55° 40° -- 45°
Range

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Elbow
Extension Supination Pronation
Flexion
Supine Same Standing Same
Test Position Forearm fully supinated Shoulder 0°
Towel under distal humerus Elbow 90°

Distal end of humerus Same Distal end of humerus Same


Stabilisation
Soft: Muscle bulk Hard – olecranon process of ulna with Firm – Tension in palmar radioulnar ligament of Hard – Ulna and radius
Normal end-feel Or olecranon fossa of humerus inferior radioulnar joint , oblique cord, interosseus Firm – tension in dorsal radioulnar ligaments of
Firm: Due to tension in posterior joint capsule or tension in membrane, pronator teres and pronator quadratus inferior radioulnar joint, interosseus membrane,
posterior triceps supinator, biceps

Fulcrum – lateral epicondyle Same Pencil parallel with floor Same


Goniometry alignment Proximal arm: Middle of lateral humerus with acromial
process for reference

Distal arm: Middle of radius with styloid process for


reference

140° -- 150° 0° -- 50° 80° -- 90° 80° -- 90°


Range

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Wrist
Extension Radial Deviation Ulnar Deviation
Flexion
Seated Same Same Same
Test Position Avoid extension of fingers
Shoulder abducted to 90°
Forearm semi-supinated, semi pronated
Fingers relaxed

Radius and Ulna Same Same Same


Stabilisation
Firm – Tension in dorsal radiocarpal ligament and Firm – Tension in palmar radiocarpal ligament and Hard – radial styloid process and scaphoid Firm – Tension in radial collateral ligament and
Normal end-feel dorsal joint capsule palmar joint capsule Or radial portion of joint capsule
Or Firm – Tension in ulnar collateral ligaments,
Hard – radius and carpals ulnocarpal ligament and capsule

Fulcrum – triquetrum on lateral aspect of wrist Same Fulcrum – capitate, middle of dorsal aspect with Same
Goniometry alignment wrist
Proximal arm – olecranon process and ulnar Proximal arm – midline of forearm with lateral
styloid epicondyle for reference
Distal arm – midline of 3rd metacarpal
Distal arm – 5th metacarpal

80° 70° 20° 30°


Range

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Hip
Extension Abduction Adduction External Rotation
Flexion Internal Rotation
Same but
Supine Prone Supine contralateral leg is Seated Same
Test Position Knee is flexed Knee extended Hip neutral abducted Knee flexed to 90° Contralateral knee flexed beyond 90°
No back extension Knee extended Towel under distal end of femur

Pelvis to prevent rotation Pelvis Pelvis Pelvis Distal end of femur Distal end of femur
Stabilisation

Firm – Lateral Firm – Posterior joint capsule, ischiofemoral


Soft – muscle bulk or, Firm – Anterior joint capsule, Firm – medial joint capsule, joint capsule, ligament, piriformis obturator internus and Firm – Anterior joint capsule,
Normal end-feel Firm – due to tension in posterior iliofemoral ligament, tension in pubofemoral, ischiofemoral iliofemoral externus, gemelli, quadratus femoris, posterior iliofemoral and pubofemoral ligament,
joint capsule, gluteus maximus iliopsoas, Sartorius, TFL, ligament, adductor magnus, ligament, gluteus fibres of gluteus maximus and medius anterior portion of gluteus medius and
gracillis, adductor longus longus, brevis, pectineus, medius, gluteus minimus, adductor magnus and longus,
gracillis minimus, TFL pectineus and piriformis

Fulcrum – Greater trochanter Same Fulcrum – ASIS Same Fulcrum – Anterior patella Same
Goniometry alignment Proximal arm – lateral midline of Proximal arm – horizontal line Proximal arm – perpendicular to floor
pelvis extending from one ASIS to the Distal arm – crest of tibia with mid-point
Distal arm – lateral midline of other ASIS between two malleoli for reference
femur with lateral epicondyle for Distal arm – anterior midline of
reference femur with patella for reference

120° 30° 45° -- 50° 20° -- 30° 35° 45°


Range

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Knee
Extension
Flexion
Supine Prone – Hip in neutral position
Test Position Foot over edge of couch
Towel under femur

Femur Femur
Stabilisation
Soft – Muscle bulk or Soft – Muscle bulk or
Normal end-feel Firm – Vastus medialis, vastus lateralis and vastus intermedius Tension in rectus femoris

Fulcrum – Lateral epicondyle


Goniometry alignment Proximal arm – midline of femur with greater trochanter for
reference
Distal arm – Fibula with lateral malleolus and fibular head for
reference

135° 0°
Range

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Cervical
Extension Rotation Lateral Flexion
Flexion
Seated on chair with good support Same Same Same
Test Position A tongue depressor may be used in mouth

Shoulder girdle by good back support and patient’s Same Same Same
Stabilisation effort

Firm – Supraspinous and interspinous ligaments, Hard – Spinous process Firm – joint capsules, intertransverse ligaments, Firm – Intertransverse ligaments, tension in annulus
Normal end-feel zygapophysical joint capsules, ligamentum flavum, Firm – joint capsules, anterior fibres of annulus SCM, splenius capitis, splenius cervicis, multifidus, firbrosus on opposite side, Scalenus anterior
posterior longitudinal ligament, posterior fibres of fibrosus, anterior longitudinal ligament, longus scalenes anterior, semispinalis, cervicis, RCPM, medius and posterior, splenius cervicis, splenius
annulus fibrosus and levator scapula, splenius colli, SCM, scalenus anterior, longus capitus, rectus obliquus capitis, posterior major capitus, levator scapulae, SCM, rectus capitus
cervicus, splenius capitus, upper trapezius, rectus capitus lateralis, Upper trapezius
capitus posterior minor and major, obliquus capitis
superior
Fulcrum – SP of C7
Fulcrum – External audiatory meatus Same Fulcrum – Centre of cranium Proximal arm -- perpendicular with ground
Goniometry alignment Proximal arm – Perpendicular to ground Proximal arm – parallel Imaginary line between two Distal arm – midline of head with occipital
Distal arm – Base of nares acromial processes protuberance for reference
Mouth closed Distal arm – Tip of nose

45° -- 60° 60° -- 80° 60° -- 80° 35° -- 45°


Range

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Ankle
Plantarflexion Inversion Eversion Hindfoot Eversion
Dorsiflexion Hindfoot
Inversion
Seated at side of plinth Same Same Same Prone – foot over edge of couch Same
Test Position
Tibia and fibula Same Same Same Same Same
Stabilisation
Firm – Lateral joint capsule,
Firm – tension in posterior joint Firm – Tension in anterior joint Firm – Anterior and posterior Hard – Calcaneus and floor of anterior and posterior talofibular Hard – calcaneus and
Normal end-feel capsule, Achilles tendon, posterior capsule, anterior portion of deltoid talofibiular ligament, sinus tarsi or ligament, calcaneofibular
portion of deltoid ligament, ligament, anterior talofibular calcaneofibular ligament, anterior Firm – Joint capsule, deltoid ligament, lateral, posterior and floor of sinus tarsi
posterior talofibular ligament, ligament, tibialis anterior, posterior and lateral talocalcaneal ligament, medial talocalcaneal anterior talocalcaneal ligament
calcaneofibular ligament, soleus extensor hallucis longus, extensor ligament, dorsal calcaneal ligament, posterior or
digitorum longus, or ligament, peroneus longus and calcaneonavicular. Posterior
Hard – Talus and tibia brevis tibialis muscle, Firm – Deltoid ligament, medial
talocalcaneal ligament, tibialis
posterior

Fulcrum – Lateral malleolus Same Fulcrum – Anterior ankle midway Same Fulcrum – Midway between Same
Goniometry alignment Proximal arm – Midline of fibula between malleoli malleoli
Distal arm – parallel to 5th Proximal arm – midline of tibia Proximal arm – Posterior midline
metatarsal with tibial tubercle as reference of lower leg
Distal arm – midline of 2nd Distal arm – Posterior midline of
metatarsal calcaneus

20° 50° 5° 5° 20° 10°


Range

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The Piriformis Muscle

Anatomical Attachments
Medially to the inner surface of the sacrum, the piriformis exits the pelvis through the
greater sciatic foramen.
Laterally, its tendon with those of the other short lateral rotators, attaches to the
greater trochanter of the femur.

Function
The function of the piriformis in the non-weight bearing limb is primarily lateral
rotation of the thigh with the hip extended. It also acts in abduction when the hip is
flexed at 90o.

Of greater importance to understand the piriformis entrapment syndrome is


knowledge of the distribution of the neurovascular structures that exit the pelvis with
the muscle through the unyielding greater sciatic foramen.

The superior gluteal nerve and blood vessels pass between the superior border of the
piriformis and the upper rim of the foramen. This nerve supplies the gluteus medius,
gluteus minimus, and tensor fascia latae muscle.
The sciatic nerve usually exits between the piriformis muscle and the rim of the
greater sciatic foramen. It supplies the skin and muscles of the posterior thigh and
most of the leg and foot. Also exiting the pelvis along the lower border of the
piriformis are the pudenal nerve and vessels. The pudenal nerve the crosses the spine
of the ischium and re-enters the pelvis through the lesser sciatic foramen. It supplies
the external and sphincter muscle and helps supply the skin of the posterior thigh and
scrotum.

The inferior gluteal nerve, which exclusively supplies the gluteus maximus muscle,
the posterior femoral cutaneous nerve, and the nerves to the gemelli, obturator
interimus and quadratus femoris muscles also pass through the greater sciatic foramen
with the piriformis muscle.
Collectively, these nerves are responsible for all Gluteal muscle sensation and
function and nearly all of the sensation and motor function in the posterior thigh and
calf.
It is apparent that chronic compression of these nerves would cause buttock, inguinal
and posterior thigh pain as well as pain in the lower limb.

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Symptoms of Piriformis Syndrome
Pain in:
• Low back
• Groin
• Perineum
• Buttock
• Hip
• Posterior thigh and leg

Symptoms are aggravated by sitting, by a prolonged combination of hip flexion,


adduction and medial rotation. In addition the patient may complain of swelling in
the painful limb or of sexual dysfunction.

Three specific conditions may contribute to Piriformis syndrome:-


• Myofascial pain referred from TP in the piriformis muscle
• Nerve and vascular entrapment by the piriformis muscle at the greater sciatic
foramen
• Dysfunction of the sacro-iliac joint

Differential Diagnosis
The piriformis Myofascial Pain syndrome is recognised by the characteristic pain
pattern projected by trigger points:-
0
• Pain and weakness on resisted abduction of the thigh with the hip flexed at 90 .
• On palpation the piriformis muscle is very painful
• Nerve entrapment is suggested by paraesthesia into mid-thigh

Symptoms of the piriformis syndrome are easily confused with those of a herniated
intervertebral disc. Absence of or marked weakness of the achilles tendon reflex
suggest a disc lesion.

Activation of Trigger Points


• Catching oneself in a fall can overload muscles including the piriformis
• Other movements producing overload are twisting sideways while bending and
lifting a heavy weight or forceful rotation of the bodyweight on one leg.
• The piriformis can become overloaded when it restrains vigorous medial rotation
of the weight-bearing limb which may occur during running
• Direct trauma on to the muscle will activate trigger points
• Driving a car with the foot in place on the accelerator , or sitting on one foot can
cause trigger points
• The Morton foot structure also tends to cause problems in piriformis muscle as it
increases medial rotation and adduction of the thigh during walking.

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