Musculoskeletal Upper Limb

Craniovertebral Instability

“Excessive movement at C1-C2 vertebrae as a result of bony or ligamentous abnormality”

Symptoms: Neck pain, wry neck posture, headache, myelopathy bowel/bladder dysfunction, ataxia

Diagnosis: Sharp-Purer test, neurological exam, Imaging, UMNL signs

Risk Factors: acute trauma, degeneration, congenital conditions

Cervical Arterial Dissection (CAD)

“Tear in the wall of the vertebral artery which may result in a cerebrovascular accident/stroke”

Symptoms: acute onset neck pain, headache,

Diagnosis: Horners syndrome (constricted pupils, droopy eyelids, inability to sweat), neuro exam

Treatment: refer to ED immediately!

Risk Factors: minor trauma, infection, genetics, younger population

Vertebro-basilar Insufficiency (VBI)

“Decrease blood flow to the posterior portion of the brain via the basilar artery”

Symptoms: 5 D’s and 3 N’s, lightheadedness, blurriness of vision, vomiting, P&N, pallor

Diagnosis: VBI positional tests, Positive test → dizziness, nystagmus, unwell feeling

Treatment: refer to ED immediately!

Risk Factors: older patients, chronic neck pain/stiffness, atherosclerosis, spondylolysis, trauma

Cervical Myelopathy

“Compression to the spinal cord from trauma or stenosis”

Symptoms: bilateral neuro symptoms, weakness, bladder/bowel dysfunction, saddle anesthesia.

Treatment: ED or specialist, diagnostic imaging, surgery

Risk Factors: older age

Whiplash Syndrome (Whiplash Associated Disorders= WAD)

“Acceleration-deceleration injuries to cervical spine“

Symptoms: neck pain, headache, decrease neck mobility, arm pain, 5Ds/3Ns,

Diagnosis: history taking, MOI in detail, palpation, ROM, neuro exam

Treatment: stay active, pharmacology, manual therapy

Acute Wry Neck (Zygapophyseal/Discogenic)

“Sudden onset of sharp neck pain with protective deformity and limitation of movement”

Symptoms of Zygopophyseal:

• young children/adults, Upper Cx, locking of C0-C2, limited ROM, sudden movement = sharp pain, trauma

  Treatment

• joint mobilization, AROM/PROM, posture, traction

Symptoms of Discogenic:

• gradual onset, older generation, lower Cx, refer to scapular region

Treatment:

• gentle traction, heat, posture, collar, soft tissue mobilisations

Risk Factors: sudden quick movement or waking from sleep

Non-specific Cervical Spine Pain - Spondylosis

“degeneration of the spine”

Symptoms: neck pain, stiff neck, headaches, radiculopathy

Diagnosis: patient Hx, imaging

Treatment: soft tissue, strengthening, medication, ROM, surgery

Risk Factors: age

Disc Prolapse

Symptoms: neck pain, painful AROM/PROM, arm pain

Diagnosis: imaging, patient Hx

Treatment:

Risk Factors: acute trauma, insidious→ degeneration, 51-60yrs, females

Cervical Radiculopathy

Symptoms: neck pain, arm pain, neurological symptoms, tingling/P&N, reflex changes

Diagnosis: patient Hx, Neuro exam, diagnostic imaging, Spurlings test

Treatment: traction, immobilization, soft tissue, manual therapy, steroids, ROM

“Nerve root compression”

Stinger and Burner Syndrome

“brachial plexus traction injury → pulling arm and neck away”

Symptoms: radicular type burning, shooting, stinging, numbness, weakness

Diagnosis: neuro exam, AROM/PROM, MMT

Treatment: treat the deficits, stretching, postural restraining, strength training

Risk Factors: rugby league, contact sports

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)

Migraine without Aura

Sudden onset - recurrent headache disorder lasting 4-72 hours

Management: Sleep, hydrate, drugs, exercise, diet, lifestyle

Migraine with Aura

Buildup for the migraine - recurrent attacks, symptoms build up followed by headache/migraine

Management: Sleep, hydrate, drugs, exercise, diet, lifestyle

Tension-type Headache - Episodic and Chronic

Symptoms: bilateral, pressing/tightening, mild-moderate, not agg by physical activity

Cause: stress, poor posture, muscular, nutrition, concentration, environmental

Management: Pharmacology, NSIADS< physical activity, CBT, treatment of the cranio-cervical-mandibular region

Trigeminal Autonomic Cephalagias - Cluster or Episodic

Symptoms: intense one-sided pain centered by the eye/temple

• Ipsilateral pain, lacrimation, rhinorrhea, nasal congestion, sweating, restlessness, miosis

• Lasts 15-180 minutes

Management: Triptans, oxygen, pharmacology, physiotherapy, electrostimulation

Primary Cough Headache

Cause: coughing or other Valsalva/straining maneuver

Primary Exercise Headache

Cause: exercise in the absence of any intercranial disorder, hot weather, short duration

HA due to Trauma - Persistent

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time frame: HA more than 3 months caused by trauma to the head

HA due to Trauma - Acute

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: less than 3 months caused by trauma to head

Acute HA due to Whiplash

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: Less than 3 months due to whiplash

Persistent HA due to Whiplash

Symptoms: Dizziness, fatigue, reduced concentration, memory loss, insomnia, anxiety, personality changes

Time Frame: HA more than 3 months due to whiplash

Cervicogenic Headache

“C1-C3 nerve roots converge in same brain region”

Symptoms: Unilateral headache, ipsilateral neck/shoulder/arm pain, migraine-like features

Physical Signs: Anesthetic blockades (gold standard), reduced cervical AROM/PROM, dysfunction, impaired muscle function

Treatment: sleep, drugs, exercise, posture, psych, mobilization

Headache attributed to TMJ disorder

“Referral between Cervical and TMJ - anatomical, neurophysiological, biomechanical, function

Symptoms: Muscle pain, headaches, joint related issues

Headache Differentiation

Myalgia (TMJ)

Muscle as the primary source of pain and/or dysfunction

Symptoms: pain in the jaw, temple, in ear or front of ear AND pain modified with jaw movement, function or parafunction, headaches, difficult to localise, dull pressure, multifactorial

Diagnosis: confirmation of pain in temporalis or masseter on palpation, maximal unassisted/assisted opening

Risk Factor: dental occlusion, molar removals, genetics, depression

Disc Displacements - Ant. displacement without reduction (ADDwoR)

• “Closed lock” limited opening + absence of click

• traumatic onset, sudden crack, clicking

• painful limited protrusion + deflection to affected side

• restricted lateral deviation to contralateral side

Disc Displacement - Ant. displacement with reduction (ADDwR)

• click, no lock

• deviation to unaffected side during early opening

• may achieve full rom

Disc Displacement - Post. disc displacement without reduction

• “Open lock” “subluxation”

• much less common

Non-specific Thoracic Spine Pain (x3) (mechanical)

Conditions: joint dysfunction, paraspinal muscle sprain. posture related, structural pathologies

Facet Joint:

• unilateral/post pain, acute onset, dull pain at rest

• reduced AROM, hypomibility of involved facet, muscle spasm guarding

• management: manual therapy, gentle ROM

IVD:

• central/post/ant pain felt through chest, postural loading, dull and diffuse pain

• limited AROM, hypomobility of involved segments

• management: manual therapy, gentle ROM, exercises

CVJ/CTJ:

• unilateral pain along rib line, conjunction with facet joint injury, respiratory signs,

• limited trunk motion, multiple segments involved

• Management: manual therapy, gentle ROM

Specific Thoracic Spine Pain - Scheuremann’s Disease (Kyphosis)

Type 1: Thoracic, produces more deformity than pain

Type 2: more pain than deformity in thoracolumbar

Presentation on Imaging: irregularity of end plates, Schmorls nodes, wedge-shaped VB’s, hyperkyphosis

Diagnosis: after long posture, tight hamstrings, respiratory limitation, curvatures,

Risk Factors: adolescents, males, taller/skeletally mature, 13-16 yrs

Management: Education, braces, Tx-Lx-pelvic-hip mobility

Conditions: rib fracture, central canal stenosis, disc prolapse, syndromes

Serious Pathologies of the Thoracic Spine (x4) (PVoPT)

Pyrogenic Spinal Infections

• septic discitis, vertebral osteomyelitis, epidural abscess, occurs more in males over 50

Vertebral Osteomyelitis (an infection)

• triad of pain, fever and local tenderness, paraspinal abcesses, jaggered N plates

• Risks involve malnutrition, IV use, infection, renal failure, spinal surgery

Pyrogenic Discitis

• can occur with vertebral osteomyelitis, antibiotics can fix, surgical intervention

Tumors

• primary, benign or metastatic, (metastatic spinal disease common)

Specific Thoracic Spine Pain - Scoliosis

Type: Structural: idiopathic (known cause)

• usually painless, respiratory issues can be present, lateral curvature

• Managment: exercise, bracing, operation

Type: Non-structural (adaptive/maladaptive posture)

• leg length differences, hip add/abd deformity, poor lumbar-hip control, muscle asymmetry

Risk Factors: females

Specific Thoracic Spine Pain - Spondyloarthropathies

Inflammatory spinal pain with ONE or more of:

• Positive family history in first- or second-degree relatives of patients with ankylosing spondylitis, psoriatic arthropathy, acute iritis, reactive arthritis or IBD.

• Psoriasis

• Inflammatory bowel disease

• Alternating buttock pain

• Enthesitis

• Acute diarrhoea

• Urethritis

• Sacro-iliitis: bilateral grade 2-4 changes or unilateral 3-4 changes.

Symptoms: LBP, IT aching, sharp, worse after activity, AM stiffness, limited chest wall excursion

Management: aerobic exercises, manual therapy

Risk Factors: Males, 16-25 years

Specific Thoracic Spine Pain - Central Canal Stenosis

Signs: intermittent aching and clumsiness of both legs, worse with walking, neurogenic intermittent claudication, ataxia, incoordination of LL, cauda equina symptoms, “shopping trolley” sign

Risk factors: older age

Specific Thoracic Spine Pain - IVD protrusion -/+ radiculopathy

Symptoms: localized back pain, radiates around chest wall, myelopathy, +/- cord compression, bladder/bowel changes → UMN

Management: Physio, education, activity, manual therapy, postural control, trunk strengthening

Risk Factors: disc degeneration, disc calcification, below T7

Specific Thoracic Spine Pain - Fractures (x3)

Vertebral body compression #

• trauma, high compression

Rib #

• blunt trauma (pneumo/hemothorax), ribs 5-10 most common, symptomatic, >3-week recovery

Rib stress injury

• shear forces created by muscle contraction, activity related chest wall pain, confirmed by MRI or bone scan

Specific Thoracic Spine Pain - T4 Syndrome

Upper extremity paresthesia and pain +/- symptoms into the neck and/or head

• Autonomic nervous system role → dysfunctions expressed over lower Cx spine and down the UL

• Hypomobility upper Tx region (esp. T4) common = responds to joint mobilizations

Specific Thoracic Spine Pain - Thoracic Outlet Syndrome

Mechanical compression/entrapment of the cords of the brachial plexus +/ subclavian artery + vein

Symptoms: hand weakness, swelling, atrophy, C8/T1 radiculopathy

Management: Roo’s test, Adson’s maneuver, costoclavicular maneuverer

Specific Thoracic Spine Pain - Costochondritis and Tietze Syndrome

Costochondritis:

• systemic cause, no local swelling, multi-joint, usually chronic, swelling of costochondral joint

Tietze Syndrome

• swelling of costochondral junction, idiopathic, local pain and swelling, may occur after chronic coughing, vomiting, viral or trauma

Specific Thoracic Spine Pain - Ankylosing Spondylitis

Symptoms: Hereditary link to HLA-B27, Insidious onset of hip/buttock to LBP, IT aching +/- sharp, Worse after activity, AM stiffness, Limited chest wall excursion, Global limitation of trunk/Tx ROM •

Radiographic changes– Sacroiliitis; bamboo spine

Management:

Risk factors: 16-25 years, males

What is Shoulder Impingement?

• Influenced by thoracic posture and mobility

External (Subacromial)- mechanical encroachment of the soft tissue in the subacromial space between the humeral head and subacromial space, occurs mid-range (60-120 deg “painful arc”)

Internal (post/sup)- Encroachment of the RC tendons in the glenohumeral joint

Primary cause- Structural narrowing of subacromial space (arthritis, AC enlargement, soft-tissue swelling)

Secondary cause- functional problems in shoulder positions (RC weakness, instability)

• A cluster of symptoms, NOT a pathology

Shoulder Impingement: Rotator Cuff Related Shoulder Pain (SCRSP)

Supra > Infra > Subscap

• Tears: can’t sleep on affected side, pain/weakness with RC testing,

• Tendinopathy: multifactorial etiology, chronic pain, pain free past 90deg elevation

Diagnosis:

• Tears: MRI, Ultrasound

• Tendinopathy: MRI arthorgram

Treatment:

• Tears: Conservative treatment surgery, strength, balance/control

• Pain relief, RC rehab

Risk Factors: athletes, overhead workers, traumatic event

Shoulder Impingement: Scapular Dyskinesia

Clinical Manifestations: reduced scap upward rotation, post tilt, ER, increased clavicle elevation, decreased strength, Pec minor/post capsule reduced length

Treatment: pain relief, flexibility, muscle training, thoracic spine and STJ mobility, muscle control

Shoulder Impingement: Shoulder Instability - TUBS

(Traumatic Unidirectional (+/‐ Bankart lesion) instability +/‐ Surgery (TUBS)

1. Anterior dislocation

   • forced shoulder abd + ER, usually a traumatic injury

2. Recurrent dislocation

   • chronic shoulder instability

3. Posterior dislocation

   • Fall on outstretched hand (FOOSH)

   • pain, tightening, clicking, decreased ER

Treatment: Scapular rehab, RC control/strengthening, open/closed chain exercises, kinetic chain exercises

Shoulder Impingement: Shoulder Instability - AIOS

(Acquired sport‐specific instability (AIOS))

Symptoms: laxity of ant capsule caused by excessive anterior translation of humeral head

Clinical Manifestations: excessive PROM ER vs IR, recurrent shoulder pain during overhead activity

Diagnosis: “dead arm syndrome,” apprehension/relocation tests positive

Treatment: Scapular rehab, RC control/strengthening, open/closed chain exercises, posterior shoulder stretching, kinetic chain exercises

Risk Factors: overhead athletes, laxity

Shoulder Impingement: Shoulder Instability - AMBRI

(Atraumatic multidirectional instability with bilateral laxity (AMBRI)

Symptoms: pain, repeated subluxation or full dislocation

Clinical Manifestations: dynamic/muscle patterning instability, congenital joint hyperlaxity, repetitive overuse,

Diagnosis: laxity tests positive, altered muscle activation

Treatment: therapeutic exercises ongoing, surgery may be needed, closed/open chain exercises,

Risk Factors: 2-3 atraumatic instabilities

Shoulder Impingement: Biceps-related

Symptoms: All present with shoulder pain

Risk factors: Repetitive overhead activities

1. Inflammatory/degenerative/partial tears long thhead of biceps brachii (LHBB)

2. Instability of the bicep tendon in the bicipital groove

3. Superio Labrum Anterior to Posterior (SLAP)

^ Stable/unstable - 4 SLAP sub-types

• Intact, fraying, degeneration

• Detachment Superior Labrum and LHB

• SL detached, LHB intact

• Tear SL and LHB, displaced in the GHJ

Caused By: carrying, dropping, throwing

Symptoms: popping, catching, grinding

Treatment: Conservative treatment for most clients, surgery for traumatic injuries