Musculoskeletal 2

The Stomatognathic System is made up of….

Bones (skull, mandible, hyoid, teeth, clavicle, sternum), joints (dentoalveolar, TMJs, ligs/discs), muscles, vascular system, lymphatics, palate/gums/glands

Integrated functional unit of the mouth, jaws, and associated structures

What are the 2 cavities of the articular disc of the TMJ?

• Upper cavity - mandibular translation

• Lower cavity - mandibular rotation

  • Ant. - Lateral pterygoid muscle

  • Post. - Retrodiscal pad

What is the Retro discal Pad?

Bilaminar

• positioned posterior to the articular disc

• Superior portion - Elastic

• Inferior portion - Non-elastic

• Vascular, richly innervated and potential source of pain

• Located between the posterior border of the articular disc and the posterior capsule of the TMJ

Nerve Supply of the TMJ area?

• Primary trigeminal nerve (particularly mandibular V3)

• Upper 3 cervical nerve roots (Opthalmic, maxillary, mandibular)

Muscles of Mastication - Temporalis & Masseter

• Primary function = elevate mandible (close mouth)

• Innervation: V3

Muscle of Mastication - Lateral Pterygoid

• 2 distinct portions - superior & inferior bellies

• Action

  • bilateral contraction = protrusion

  • unilateral contraction = contralateral laterotrusion

• Innervation V3

Muscle of Mastication - Medial Pterygoid

• Attach onto ramus of mandible

• Action

  • bilateral contraction = elevate mandible

  • unilateral contraction = laterotrusion

• Innervation V3

Is this the Open or Closed position of the TMJ?

Closed Position

• ant translation, ant rotation

• disc pulled back by elastic fibers of retro discal pad, controlled eccentrically by lateral pterygoid

Is this the Open or Closed position of the TMJ?

Open position

• 40-55mm

• Ant rotation, ant translation

What are some red flags for TMJ disorders?

• Worsening pain

• fever, weight loss, aches, pains

• night pain

• facial/neck masses

• unilateral hearing loss

• pain with exertion

How many cervical nerves are there?

8 nerves

• 1st 7 exit above the corresponding vertebrae

• C8 exits below the 7th Cervical vertebrae

What are the 5D’s and 3N’s for VBI symptoms?

1. Dizziness (vertigo or lightheadedness)

2. Diplopia (double vision)

3. Dysarthria (slurred or impaired speech)

4. Dysphagia (difficulty swallowing)

5. Drop attacks (sudden loss of postural control without loss of consciousness)

1. Nausea (or vomiting)

2. Nystagmus (involuntary eye movements)

3. Numbness (especially facial or perioral paresthesia)

______: Grade 1 → compression, traction, ischemia

______: Grade 2, 3, 4 → Nerve crush

______: Grade 5 → Nerve laceration, Grade 6 → gunshot, stab etc

Neuropraxia

Axonotmesis

Neurotmesis

5 nerves and their roots of the Brachial Plexus

• Musculocutaneous (C5-7)

• Axillary (C5-6)

• Radial (C5-T1)

• Median (C5-T1)

• Ulnar (C7-T1)

Compression injury to the nervous system

• disruption of blood supply and axonal transport

• reversible after short duration

• total conduction loss within 60-90mins

• rapid recovery still occurs if duration <6hrs

Tension injury to the nervous system

• conduction impaired if held >1 hour

• complete loss of conduction at ~15% elongation

What is Myelopathy?

Compression of the spinal cord

4 Diagnostic Criteria of Neuropathic Pain

Criterion 1: pain descriptors

Criterion 2: pain distribution

Criterion 3: pain with signs/ sensation

Criterion 4: objective diagnostic tests

Indications for Neurodynamic Tests

• minor neurological symptoms

• stable and not rapidly deteriorating

• pain isn’t severe at time of examination

Contraindications for Neurodynamic Tests

• physical exam is inappropriate

• severe pain could be provoked

• unstable, irritable, hypertensive

Mobility depends on the relationship between _____ and cross-sectional area of _____ and ____ ____ _________.

Mobility depends on the relationship between height and cross-sectional area of discs and facet joint orientation.

Global Normal ROM for Thoracic Spine (Flx, Ext, LatFlx, Rot)

Flexion = 30-40deg

Extension = 15-20deg

Lateral Flexion + rotation = both 25-30deg

Subjective Exam for Thoracic

Innervation:

Pain Sources:

Referral Patterns:

Cervical into Thoracic pain:

Innervation: Dorsal rami or sinuvertebral nerve

Pain Sources: IVD, facet, muscles (traps/scalenes), ganglion

Referral Patterns: inconsistent location (intersegmental stimulation), visceral (esophagus, pancreas, spleen, heart), dermatomes (T5, T7-8, T10-11, T12)

Cervical into Thoracic pain: C 6/7 referral

Thoracic Objective Exam - 3 functional regions to test

1. Upper Thoracic - cervical AROM + shoulder elevation

2. Middle Thoracic - Flexion, Extension, Rotation, Lateral flexion

3. Lower Thoracic -Lumbar AROM

4 General Managements of Thoracic Spine Pain Disorders

1. Improve Posture

2. Improve spinal mobility

3. Optimise muscle function

4. Address contributing impairments

Manual therapy: PAIVMs, SNAGs, neutral mobilisations and manipulations

Upper cervical referral area →

Lower Cervical referral area →

Mid thoracic referral area →

Lower thoracic a& thoracolumbar referral area →

Upper cervical referral area → upper thoracic region

Lower Cervical referral area → anterior chest wall

Mid thoracic referral area → mimics visceral pain

Lower thoracic a& thoracolumbar referral area → lumbar region (iliac crest)

Shoulder Pain Subjective Assessment Findings

Body Chart:

• Dull, aching, poorly localized, less traumatic, impingements, instability

History

• Atraumatic: insidious, progressive worsening of pain

• Traumatic: Sudden, intense sharp pain, major loss of ROM

Agg Factors

• Reaching hand behind back/head, should elevation, reaching across body

Easing Factors

• rest, unloading, support

Night Symptoms

• Visceral, red flags, agg by ipsilateral side lying

Patient Reported Outcome Measures

• Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH)

• Simple shoulder test

• Shoulder Pain and Disability Index (SPADI)

Quiz: Does Physiotherapy have a large role to play in the management of cluster headaches?

No

Quiz: At what degree can operative intervention for scoliosis be indicated?

More than 60 degrees of curvature

Quiz: Features of craniovertebral instability

• Excessive movement at C1-2

• Neurological symptoms

• wry neck posture

• acute trauma/ degeneration/ congenital conditions

Quiz: Symptoms of Ankylosing Spondylitis

• Positive HLA-B27

• age 16-25

• hip and buttock pain

• worse after activity

• AM stiffness

• limited chest wall excursion

Quiz: What are some questions to ask about TMJ “clicking”

• Hard vs soft

• timing of clicking

• consistency of clicking

• is there locking and/or catching present

• associated pain

Quiz: What is not considered a “high risk feature” in the Canadian c-spine rule?

Delayed onset of neck pain

Quiz: What is the most specific orthopedic test for a tear in the infraspinatus tendon?

External rotation lag sign

Quiz: Common clinical feature of cervicogenic headache?

Tenderness in the region of C1-3

Quiz: What is not a sign of Cervical myelopathy?

Upper limb HYPOreflexia

Quiz: What 3 tests make up the Cluster of Wainner?

1. Upper limb tension test (ULNTT1)

2. Spurlings test

3. Cervical axial distraction

Quiz: Percentage of scoliosis patients report back pain present?

25%

Quiz: What is not a source of subacromial impingement syndrome?

Subscapularis tendon

Quiz: Thoracic spine is the most common site of metastases for which type of cancer?

Breast cancer

Quiz: 3 Upper motor neuron integrity tests

Babinski sign, inverted supinator sign and Hoffmans sign

Quiz: List 4 clinical features of cervicogenic headache you could use to differentiate it from migraine?

Uni

head mov

restr

tender

- unilateral headache

- pain provoked by certain head movements 

- restricted ROM

- tenderness over cervical region

Quiz: What are the 4 key features of the Canadian C-spine rules?

UEP

AL

Age

RH45LR

• Upper extremity paresthesia

• Axial loading to the head

• Age >65

• can rotate head 45deg left and right

What are some symptoms of Trigeminal Autonomic Cephalgias?

• Ipsilateral pain

• lacrimation

• rhinorrhea

• nasal congestion

• sweating

• restlessness

What are some symptoms of Cervical Arterial Dissection?

• Horners syndrome

  • constricted pupils

  • droopy eyelids

  • inability to sweat)

• Neuro exam findings

What are the 4 sub-SLAP types

1. Degeneration

2. SL + LHB detachment

3. SL detached, LHB intact

4. SL + LHB teat + displacement

4 stages of Migraine

1. Prodrome

2. Aura

3. Migraine

4. Postdrome

What 6 pathologies are considered in the “Big 6?”

1. Rotator cuff pathology

2. Biceps tendon pathology

3. Glenohumeral instability

4. Scapular dyskinesia

5. Glenohumeral rotation deficit (GIRD)

6. Impingemenet-related shoulder pain

Grading System of Shoulder Pathologies

Grade 1: Tear of capsule & AC ligaments (‘Sprain’)

Grade 2: Rupture AC ligaments & tear to the CC ligament (‘sprain’)

Grade 3: Rupture AC ligament & CC ligament (‘dislocation’)

Grade 4: Post-displacement of clavicle (‘dislocation’)

Grade 5: Similar to Grade 3 + greater ST damage (‘dislocation’)

Grade 6: Inferior displacement to subacromial/sub coracoid space (‘dislocation’)

Dynatome vs Dermatome

Dynatome: resemble dermatome maps, but frequently fell outside the classic distribution

Dermatome: area off skin innervated by a single nerve root

Cervical Red Flags and Categories

Category 1: immediate medical attention

• head injury, cervical spine #, UCx spine instability

Category 2: Further Q’s and precautions

• VBI, congenital/hereditary (RA, Down Syndrome, Marfans Syndrome), gait dysfunction/balance

Category 3: Further testing and differentiation

• Myelopathy or visceral pain

Thoracic Red Flags and Categories

Category 1: Immediate medical attention

• viscerosomatic pain, tumours, fractures

Category 2: Further Q’s and precautions

• metabolic disorders, corticosteroid use, age over 50, spondylodiscitis

Category 3: further testing and differentiation

• thoracic disc lesions (T6), Spinal cord compression disorders

Objective Assessment for Shoulder, Cx and Tx → Look for….?

Muscle Bulk

• SS atrophy in chronic RC tendinopathy, atrophy of infraspinatus & lwoer traps, biceps atrophy, muscle bulging over distal humerus may be LHBB rupture

Posture

• Cervical posture away from painful side, arms supported/held overhead, shoulder supported in 30deg scaption for comfort

• Slumped posture, scapular protraction + down rotation, elevated medial scap border indicated pec minor shortening

AROM

• Cx→ large loss of AROM in multiple planes, loss of EOR motion an low Cx pain

• Tx → upper Tx pain requires strucutual differentiation, Mid Tx pain best reproduced with combined AROM

• Shoulder → loss of ER, defined painful arc

PROM

• Cx→ hypomobility, pain with Ext+Rot and PAIVMs

• Tx→ reproduction of pain & hypermobility of PAIVMs

• Shoulder → global ross of ROM, pain preproduced with ACJ PAMs

Special Tests

Key Indication Cx as the Primary Source

Subjective Examination

• Pain in upper Cx and head most likely Cx (or TMJ or non-MSK)

• Neck-spinal pain extending below elbow

• Pain and sensory changes (p&n/n) in roughly dermatomal distribution

• Other symptoms (dizziness, lightheaded etc) common in Cx headaches, WAD etc

• MOIandaggs/ease can be useful– but break them down!

• C5-6 commonly presents as pain into shoulder girdle, esp discogenic and CR

  Objective Examination

• * Forward head posture

• Abnormal CxAROM, esp. loss of flexion and rotation

• +vesegmental signs (palpation, PAIVMs, PPIVMs) and quadrant (Ext+ROT) test •-ve shoulder impingement tests

• -ve segmental signs in Tx

• +veneurological exam (high spec) and Spurlings test (high spec) = CxR

Key indication Tx as the Primary Source

Subjective Examination

• Pain inferior to scapula, along ribs, anterior chest or iliac crest most likely Tx

• Pain often well defined (+/- 1-2 segments) and more sharp than Cx referral

• Rarely extends past shoulder point and into neck

• Pain with inspiration or coughing

• Hx of prolonged slumped sitting

• Twisting/lifting MOI that triggers immediate onset Tx pain

  Objective Examination

• * Pain with combined Tx movements - often requires structural differentiation

• +vesegmental signs (palpation, PAIVMs, PPIVMs)

• -ve Sh impingement tests •-ve Cx segmental findings

Key Indications Shoulder as the Primary Source

Subjective Examination

• Location of pain most commonly antero-supero-lateral shoulder region

• Rarely into neck or below elbow

• Usually recall some MOI – either overuse or sudden lifting related pain

• Unable to sleep on affected side

• Joint signs (clicking, catching, unstable, weak) common

  Objective Examination •

• SS atrophy and abnormal scapular positioning – protracted+down-rotated

• +ve impingement tests – H-K, Neers and quadrant

• Limited active-passive ER and pure GHJ abduction • TOP over AC

Normal Elbow Carrying Angle

Normal – approx 15o

Males = 5-10 deg

Females = 10-15deg

Cubitus Valgus vs Cubitus Varus

3 Ligaments of the Elbow

1. Medial (Ulnar) collateral ligament (ant, post, transverse)

2. Lateral (Radial) collateral ligament

3. Annular ligament

4 Criterions for the Pathologies of Neuropathic pain diagnosis

Criterion 1 & 2: Subjective Examination

Criterion 3: physical tests (sensation, motor as required)

Criterion 4: Objective tests (nerve conduction)

Peripheral Neuropathies Common Area

Entrapment/compression or tension/elongation of:

• Median nerve

• Ulnar Nerve

• Radial nerve

• Stingers and Burners (Cx)