9.7 - Gold Level Clinical Application Questions (pgs 142 -?)

This is an extension of the basic info covered on the Gold-Level pathologies in the musculoskeletal pathos set

How is adhesive capsulitis diagnosed? What imaging can be used?

Inflammation and fibrotic thickening of the anterior joint capsule of the shoulder resulting in an adherent humeral head and contracture -

• Characterized by GH limitation and pain

• Decrease space in joint capsule results in decrease synovia fluid and further GH irritation

Arthrogram (MRI, CT, or X-ray ) can be used to detect dec fluid

Primary adhesive capsulitis

Frozen shoulder that occurs spontaneously

Secondary adhesive capsulitis

Frozen shoulder that results from an underlying condition such as:

• Ortho-related:

  • RA

  • Immobilization

  • Trauma to the joint

  • Supraspinatus tendonitis

  • Partial rotator cuff tear

  • Bicipital tendonitis

• Other:

  • Diabetes mellitus

  • Thyroid abnormalities

  • Cardiopulmonary conditions

  • Abdominal disorders

  • Psychogenic disorders

What motions are primarily lost? How does adhesive capsulitis present clinically at the acute and chronic stages?

Motions lost: general GH motion (main lat rotation, abduction, med rotation) and scapular elevation

Looks like:

• Acute stage = pain that radiates to the elbow and wakes patient at night, PROM limited

• Chronic = localized pain at lateral brachial region, pain doesn’t wake patient at night, ROM limited due to stiffness

How can adhesive capsulitis be managed by physical therapy?

Acute phase:

• Cryo/thermo therapy

• Joint mob (gentle)

• Strengthening

• Pendulums

• Isometric strengthening

Chronic phase:

• US

• Grade 3 and 4 joint mobs (to inc jt capsule extensibility)

• PNF

*HEP can be implemented at both stages but care needs to be taken at the acute phase

*Rx can range from 3 to 24 months

What other medical treatment (besides PT) are used to treat adhesive capsulitis?

• Pharmacological (acetaminophen, long-lasting analgesics, NSAIDs, narcotics)

• Injection of corticosteroid

• Surgery to break up adhesions or release muscles (last resort)

What is the prognosis for adhesive capsulitis?

Most people recover but some experience permanent loss of motion with little to no functional ability impairment

How is adhesive capsulitis different than acute bursitis?

Acute bursitis:

• Intense pain at brachial region

• Usually secondary to calcific tendonitis

• AROM/PROM limited in all directions with flex and abduction producing severe pain

• Lasts a few days

Adhesive capsulitis:

• Lasts weeks

Which direction are ankles usually sprained and why?

Usually cause by excess inversion because:

• The deltoid ligament (medial) is stronger than the lateral ligaments (Ant/post talofibular and calcaneofibular)

When an ankle is sprained, which ligament is most likely damaged?

Anterior talofibular (ATFL)

Which motions do the ATFL, PTFL, CF and deltoid ligaments resist?

• ATFL - inversion (ankle varus) and PF

• PTFL - posterior translation of the talus

• CF - inversion (ankle varus)

• Deltoid - eversion (ankle valgus)

Who is most likely to sustain a grade 2 lateral ankle sprain?

Soccer player

How does a grade 2 lateral ankle sprain present itself?

• Tenderness and pain along the lateral ankle - especially with passive inversion and PF

• Limited strength

• Ecchymosis (bruising) and mod to sever edema

How can an ankle sprain be diagnosed and examined?

• Anterior drawer test for the ATFL

• Talar tilt test for the CF

• Edema measurements

• Muscle tests

• ROM

How are grade 2 ankle sprains treated?

• RICE, NSAIDS

• Crutches until FWB

• Surgery if there is a fx or vascular disruption

• PT:

  • ROM,

  • Proprioceptive/ balance training

  • Jt mobs,

  • Resistive ex.

  • Gt training

  • Sport-specific agility training

  • ESTIM

  • Friction massage

What is the likely outcome of a grade 2 ankle sprain being treated with physical therapy?

A return to normal activities (with bracing or taping) in 2-6 weeks; this is indicated when ROM and palpation are pain-free and proprioception and gait are normal

How is a “high ankle sprain” different from typical ankle sprain?

• Involves excessive force resulting in injury to the syndesmotic ligaments that attach the tibia and fibula

• Often occur with an ankle FX

• Significant tear will require surgery

• Can cause sever post-traumatic arthritis if not treated

Grade 3 Anterior Cruciate Ligament Sprain

Tear of the ligament that runs from the anterior tibia to the medial aspect of the lateral femoral condyle; this ligament prevents anterior translation of the tibia on the femur

Etiology:

• Excessive force (>500lbs) during hyperflexion, rapid deceleration, hyperflexion, or an unbalanced landing

• Athletics requiring high levels of agility

• 14-29 yrs old

• Females > males

Dx: MRI and X-ray, special tests (Lachman, anterior drawer, picot shift), patient reporting loud pop or knee buckle

S/S:

• Grade 1 = microscopic tear, grade 2 = partial tear, grade 3 - complete tear

• Anterolateral/medial laxity

• Pain, effusion, edema, and limited ROM

• Meniscal and MCL tears

Treatment:

• Initially: surgery (patellar tendon graft) the controlling edema, ROM, pain modulation

• Later: CC strength ex (which minimizes ant mvmt of tibia) and functional activities

Prognosis: 6+ months (or longer if returning to athletic activities)

Why are younger people, and females specifically, more likely to have ACL tears?

• Younger people are more active

• Females have an increased Q angle and at times supporting muscles

How is a grade 3 PCL different than a grade 3 ACL tear?

• Less commonly torn

• Dashboard injury (knee hyperflexion) is most common cause

• Posterior tenderness and positive posterior drawer test

• Surgical intervention is less common

• More commonly causes arthritis due to effect on arthrokinematics

Bicipital tendonitis

An inflammatory response almost always to the long head of the biceps tendon

Etiology: repetitive overhead movements such as in swimming, racquet sports, and throwing motions, causing microscopic tears, edema, and degeneration

Dx: Yergason’s and Speed’s test, sometimes MRI

S/S: Deep ache anterior and superiorly on the shoulder

Treatment: RICE, activity modification (reduce overhead movement, no PT or only TENS or Iontophoresis until inflammation is reduced, then stretching and strengthening

Prognosis: 6-8 weeks of PT, then return to normal activity is expected unless severe, then surgery to fully restore

What is the difference between edema and inflammation?

Inflammation is an immune response by the body to injury or irritation (which can cause swelling), while edema is the build up a fluid causing swelling

What is the primary mechanism of injury of bicipital tendonitis?

Repetitive shoulder motions, where the cells within the tendon are damaged and do not have time to heal

• Primary causes include especially overhead movements, such as in athletes who throw, swim, or swing a racquet

• Secondary causes include \other shoulder pathologies (rotator cuff disease, impingement syndrome, labral tears, etc.)

What is considered the gold standard for imaging tendonous or ligamentous injuries?

MRI

Lateral/medial epicondylalgia/tendinopathy

Inflammation and degeneration of the common extensor (usually specifically the ECR) or flexor (FCR) tendons

Etiology: repetitive movements including wrist extension, flexion, and gripping

Dx: Cozen’s (lateral epi), medial/lateral epicondylitis test

S/S: pain and weakness with gripping exercises and resisted wrist extension

Treatment: RICE, activity modification (reduce ext/flex and gripping movements), nerve glides, ionto or TENS, stretching and strengthening, sometimes a brace

Prognosis: likely good outcome with 2-3 months of PT typically then surgery if no progress

MCL sprain - Grade 2

• Etiology: usually a blow/force to the lateral surface of the knee; often occurs alongside ACL or meniscal damage

• Dx: valgus stress test or MRI

• S/S: inability to extend and flex the knee, laxity, and a possible decrease in strength

• Rx: RICE, NSAIDS, PT ROM, strengthening (isometrics and closed-chain ex.), then functional activities

• Prog: Good progress in 4-8 weeks unless ACL and meniscus are involved, then surgery might be needed

What are the connection points of the medial collateral ligament?

The medial epicondyle of the femur to the medial tibia (resists a valgus forces)

Osteoarthritis

A chronic degenerative disorder resulting from the biochemical breakdown of particular cartilage

• Etiology: idiopathic, excess loading of a healthy joint or normal loading to a normal joint, primary is from aging and secondary is from a predisposing condition such as trauma, obesity, or infection, women > men

• Dx:

• S/S: can be diagnosed by X-ray or a clinical exam

  • Includes: potential osteophytes and crepitus (in the hands), pain that is relieved with rest, effusion

• Rx: NSAIDS, nutritional ed., strength, gait, and balance training, aquatic therapy, ice/heat for pain,

• Prog: Therapy can assist but not stop it (it is chronic and progressive)

How is OA different than RA?

OA is caused by wear and tear and affects large, weight-bearing joints while RA is auto-immune and usually affects smaller non-weight-bearing joints and causes systemic inflammation

Patellofemoral Syndrome

• Etiology: abnormal tracking of the patella between the femoral condyles; usually occurs laterally and is more common in adolescents and females

• Dx:

• S/S: gradual onset of ant (or retropateller) knee pain with inc physical activity, especially compressive activities such as jumoing or climbing stairs

• Rx:

• Prog:

What adjacent conditions are associated with patellofemoral syndrome?

• Patella alter (high patella)

• Weak VMO

• Excess pronation or knee valgus

• General muscle tightness in the lower extremity