Approach To Soft Tissue Approach To Soft Tissue Musculoskeletal DisordersMusculoskeletal Disorders

Gerald Wolff MD FRCPGerald Wolff MD FRCPPhysical Medicine and RehabilitationPhysical Medicine and Rehabilitation

Nov 11, 2015Nov 11, 2015

DisclosureDisclosure

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ObjectivesObjectives Describe the pathology and list the physical findings of Describe the pathology and list the physical findings of

carpal tunnel syndromecarpal tunnel syndrome Describe an approach to the assessment and diagnosis of Describe an approach to the assessment and diagnosis of

common upper extremity soft tissue disorders and injuries: common upper extremity soft tissue disorders and injuries: 1) Rotator cuff1) Rotator cuff 2) Biceps tendon rupture2) Biceps tendon rupture 3) AC joint injuries3) AC joint injuries 4) Medial and lateral epicondylitis4) Medial and lateral epicondylitis 5) De Quervain’s tenosynovitis5) De Quervain’s tenosynovitis

Describe an approach to the assessment and diagnosis of Describe an approach to the assessment and diagnosis of common lower extremity soft tissue disorders and injuries:common lower extremity soft tissue disorders and injuries: 1) ankle sprains1) ankle sprains 2) plantar fasciitis2) plantar fasciitis 3) meniscal tears3) meniscal tears 4) cruciate (ACL) tears4) cruciate (ACL) tears 5) collateral ligament (LCL, MCL) tears5) collateral ligament (LCL, MCL) tears 6) patelofemoral syndrome6) patelofemoral syndrome 7) trochanteric bursitis7) trochanteric bursitis 8) iliotibial band syndrome 8) iliotibial band syndrome

Why do I need to know sports Why do I need to know sports medicine?medicine?

All of these disorders can occur in the athlete, but All of these disorders can occur in the athlete, but more commonly occur from daily activities:more commonly occur from daily activities: Doing overhead work (eg. Lights or duct work)Doing overhead work (eg. Lights or duct work) Screwdriver useScrewdriver use TypingTyping Dog walkingDog walking Changing newborn babyChanging newborn baby Texting & playing video gamesTexting & playing video games PregnancyPregnancy Walking on uneven ground (eg. Ice & snow)Walking on uneven ground (eg. Ice & snow) Climbing stairsClimbing stairs

Overuse Injury Medicine!!

Factors leading to MSK injuryFactors leading to MSK injury

Intrinsic Intrinsic TissueTissue

WeaknessWeakness InflexibilityInflexibility OverloadOverload

Biomechanical factorsBiomechanical factors DeconditioningDeconditioning Body sizeBody size Performance abilityPerformance ability Playing stylePlaying style

ExtrinsicExtrinsic Faulty equipmentFaulty equipment Other peopleOther people Training/playing/work Training/playing/work

surfacessurfaces Training/work scheduleTraining/work schedule CoachingCoaching WeatherWeather

Approach to a MSK problemApproach to a MSK problem

History: in addition to the usual questions…History: in addition to the usual questions… Sudden onset or gradual onsetSudden onset or gradual onset

Recurrent or new problemRecurrent or new problem

Injury replay/mechanism of injuryInjury replay/mechanism of injury

Specific activitiesSpecific activities

Training regime – frequency, duration, recent changesTraining regime – frequency, duration, recent changes

Upcoming “competitions”/eventsUpcoming “competitions”/events

Impact on function – Activities of Daily Living (ADL)Impact on function – Activities of Daily Living (ADL)

EquipmentEquipment

EnvironmentEnvironment

Approach to a MSK problemApproach to a MSK problem

Don’t forget to ask:Don’t forget to ask: HandednessHandedness

OccupationOccupation Physical or sedentaryPhysical or sedentary

Computer use (time) and setupComputer use (time) and setup

Increase/change of activitiesIncrease/change of activities

Other hobbiesOther hobbies RenovationsRenovations

LandscapingLandscaping

Approach to a MSK problemApproach to a MSK problem

Physical Exam:Physical Exam: Know your anatomy!!Know your anatomy!!

Inspection, ROM, PalpationInspection, ROM, Palpation Examine suspected most painful structure lastExamine suspected most painful structure last

Special testsSpecial tests

Joint above and belowJoint above and below

Neurologic screenNeurologic screen

Compare to the other limbCompare to the other limb

TerminologyTerminology

Tendon – muscle to boneTendon – muscle to bone

Ligament – bone to boneLigament – bone to bone

Muscles are “strained”Muscles are “strained”

Ligaments are “sprained”Ligaments are “sprained”

Tendon termsTendon terms TendonitisTendonitis

Inflammation – tendon properInflammation – tendon proper

TendinosisTendinosis Degeneration – tendon properDegeneration – tendon proper

Collagen disarrayCollagen disarray

Increased poor quality blood vessels (neovascularization)Increased poor quality blood vessels (neovascularization)

No inflammatory cellsNo inflammatory cells

TenosynovitisTenosynovitis Inflammation – lining of tendonInflammation – lining of tendon

TendonopathyTendonopathy A problem with the tendon A problem with the tendon

EnthesitisEnthesitis Inflammation of tendon at its insertion point to the boneInflammation of tendon at its insertion point to the bone

Associated with seronegative arthropathies (ankylosing spondylitis, Reiter’s)Associated with seronegative arthropathies (ankylosing spondylitis, Reiter’s)

Classification of Ligament Injuries Classification of Ligament Injuries (sprains)(sprains)

11stst degree degree Pain on stressing ligamentPain on stressing ligament NoNo ↑ laxity (compared to contralateral side) on stressing ↑ laxity (compared to contralateral side) on stressing

ligamentligament

22ndnd degree degree PainPain ↑ ↑ laxity, but firm endpointlaxity, but firm endpoint

33rdrd degree degree ↑ ↑ laxitylaxity No firm endpoint (complete tear)No firm endpoint (complete tear)

BursaBursa

Synovial sac of fluidSynovial sac of fluid

Reduces friction by motion of tissueReduces friction by motion of tissue

Between tendons, skin and boneBetween tendons, skin and bone

BursitisBursitis Inflammation of bursaInflammation of bursa

Trauma or repetitionTrauma or repetition

Common locationsCommon locations HipHip

KneeKnee

HeelHeel

ElbowElbow

ShoulderShoulder

Prepatellar bursitisPrepatellar bursitisa.k.a. “Housemaid’s knee”a.k.a. “Housemaid’s knee”

MSK Treatment OptionsMSK Treatment Options

ConservativeConservative

Activity modification!!Activity modification!!

MedicationsMedications

PhysiotherapyPhysiotherapy

Massage TherapyMassage Therapy

Local steroid injectionsLocal steroid injections

Platelet-rich plasma injection??Platelet-rich plasma injection??

Orthoses (bracing)Orthoses (bracing)

Extracorporeal Shock Wave TherapyExtracorporeal Shock Wave Therapy

SurgerySurgery ArthroscopicArthroscopic

OpenOpen

DebridementDebridement

RepairRepair

ReconstructionReconstruction

MSK treatment principlesMSK treatment principles

Control inflammation – PRICEMControl inflammation – PRICEM ProtectProtect

Relative restRelative rest

IceIce

CompressionCompression

ElevationElevation

Medication Medication Anti-inflammatory: oral NSAIDs, topical pennsaid, cortisone Anti-inflammatory: oral NSAIDs, topical pennsaid, cortisone

injectioninjection

Analgesic: tylenol, narcoticsAnalgesic: tylenol, narcotics

MSK treatment principlesMSK treatment principles

Restoration of joint ROMRestoration of joint ROM

Restoration of soft tissue extensibility / flexibilityRestoration of soft tissue extensibility / flexibility

Restoration of muscle strengthRestoration of muscle strength

Restoration of muscle enduranceRestoration of muscle endurance

Retraining in biomechanicsRetraining in biomechanics

Restoration of proprioceptionRestoration of proprioception

Maintenance programMaintenance program

Rehab PathwayRehab Pathway

Passive Range of Motion (PROM)Passive Range of Motion (PROM)

Active Assisted ROMActive Assisted ROM

Active ROMActive ROM

Concentric strengtheningConcentric strengthening

EnduranceEndurance

Biomechanics / proprioceptionBiomechanics / proprioception

Eccentric strengtheningEccentric strengthening

Restoration of muscle strengthRestoration of muscle strength

Concentric exercisesConcentric exercises

Muscle contraction while shorteningMuscle contraction while shortening

Eg. Flexing elbow during biceps curlEg. Flexing elbow during biceps curl

Eccentric exercisesEccentric exercises

Muscle contraction while lengtheningMuscle contraction while lengthening

Eg. Slowly lowering weight during biceps curlEg. Slowly lowering weight during biceps curl

Gravity is pulling weight down, triceps is fully relaxedGravity is pulling weight down, triceps is fully relaxed

Greater force generated (potential for more damage)Greater force generated (potential for more damage)

Best way to strengthen tendinous insertions & prevent further injuriesBest way to strengthen tendinous insertions & prevent further injuries

Maintenance programMaintenance program

Patient education re: maintenancePatient education re: maintenance

Injury preventionInjury prevention

Incorporate:Incorporate: Aerobic trainingAerobic training

Muscle Strength & endurance exercisesMuscle Strength & endurance exercises

Flexibility trainingFlexibility training

Cross trainingCross training

Patient ownership!Patient ownership!

Questions so far…Questions so far…

Part Two: Common Soft Tissue Part Two: Common Soft Tissue Injuries in the ExtremitiesInjuries in the Extremities

NOT a complete review of all MSK NOT a complete review of all MSK conditionsconditions

SHOULDERSHOULDER

CaseCase

Sara is a 27 year old Sara is a 27 year old wheelchair athlete for Team wheelchair athlete for Team Canada and an events planner Canada and an events planner for the city.for the city.

She’s had gradual onset She’s had gradual onset bilateral shoulder pain for 1 bilateral shoulder pain for 1 year.year.

She has a competition in 3/52 She has a competition in 3/52 and wants to be in top shape and wants to be in top shape for the race.for the race.

Can you help?Can you help?

Rotator cuff – AnatomyRotator cuff – Anatomy

Rotator cuff tendinopathyRotator cuff tendinopathy

Combination of tendonitis, tendinosis, tendon rupture Combination of tendonitis, tendinosis, tendon rupture Most common cause of shoulder painMost common cause of shoulder pain

PresentationPresentation Due to repetition/overuse (swimmers, pitchers, wheelchair)Due to repetition/overuse (swimmers, pitchers, wheelchair)

Especially overhead activityEspecially overhead activity Occasionally due to a single eventOccasionally due to a single event May be associated with laxity or instabilityMay be associated with laxity or instability Pain with overhead activityPain with overhead activity Pain to sleep onPain to sleep on Inability to lift arm (complete tear)Inability to lift arm (complete tear)

Rotator cuff tendinopathyRotator cuff tendinopathy Concept – ImpingementConcept – Impingement

Rotator cuff tendons (usually supraspinatus) are impinged as Rotator cuff tendons (usually supraspinatus) are impinged as they pass through the subacromial spacethey pass through the subacromial space

Boundaries: acromion, coracoarcromial arch, acromioclavicular Boundaries: acromion, coracoarcromial arch, acromioclavicular (AC) joint above and the glenohumeral (GH) joint below(AC) joint above and the glenohumeral (GH) joint below

Mechanical irritation of rotator cuff tendonsMechanical irritation of rotator cuff tendons

Swelling and damageSwelling and damage

ImpingementImpingement

Subacromial space is reduced if lateral Subacromial space is reduced if lateral scapula is translated anteriorly or humerus scapula is translated anteriorly or humerus internally rotatedinternally rotated Common culprits:Common culprits:

Weak posterior musculature (scapular stabilizers: Weak posterior musculature (scapular stabilizers: rhomboids, traps)rhomboids, traps)

Tight internal rotators (pecs, lats)Tight internal rotators (pecs, lats) Weak external rotators (infraspinatus, teres minor)Weak external rotators (infraspinatus, teres minor)

Do you think this guy is more likely to hit the gym for a hardchest (pec) & back (lats) workout,or a killer infraspinatus workout??

Rotator cuff tendinopathyRotator cuff tendinopathy

SignsSigns

Painful arc (60-120 degrees)Painful arc (60-120 degrees)

Mild reduction in ROM (pain)Mild reduction in ROM (pain)

Pain with combined abduction & internal rotationPain with combined abduction & internal rotation

Painful subacromial space and bursaPainful subacromial space and bursa

Positive impingement signsPositive impingement signs

Wasting & weakness of rotator cuff musclesWasting & weakness of rotator cuff muscles

Pain with resisted rotator cuff muscle testingPain with resisted rotator cuff muscle testing

Painful arcPainful arc

• Occurs because there is not enough space for the soft tissue structures to fit as the greater tuberosity of the humerus passes under the acromion

Rotator cuff tendinopathyRotator cuff tendinopathy

InvestigationsInvestigations NothingNothing X-rayX-ray USUS MRIMRI

Rotator cuff tendinopathyRotator cuff tendinopathy

ManagementManagement PRPRICEICEMM

Physio:Physio:

ModalitiesModalities

Strengthen scapular and glenohumeral stabilizersStrengthen scapular and glenohumeral stabilizers

Stretching pecsStretching pecs

Corticosteroid injectionCorticosteroid injection

Surgery if Surgery if traumatictraumatic full thickness tear full thickness tear Degenerative tears (usually elderly) are poor surgical candidatesDegenerative tears (usually elderly) are poor surgical candidates

SLAP lesionSLAP lesion Superior Labral Anterior to PosteriorSuperior Labral Anterior to Posterior

Labral tear where long head of biceps insertsLabral tear where long head of biceps inserts Injured with repetitive overhead throwing or excessive Injured with repetitive overhead throwing or excessive

inferior tractioninferior traction Eg. Carrying or dropping and catching a heavy objectEg. Carrying or dropping and catching a heavy object

Complain of poorly localized shoulder pain, worse with Complain of poorly localized shoulder pain, worse with overhead activitiesoverhead activities

+ve O’Brien’s test+ve O’Brien’s test MR arthrogram to image lesionMR arthrogram to image lesion Definitive diagnosis & treatment isDefinitive diagnosis & treatment is via surgical explorationvia surgical exploration

Biceps tendon ruptureBiceps tendon rupture

Biceps – Anatomy Biceps – Anatomy

• Long head•Supraglenoid tuberosity of scapula

• Short head•Coracoid process

Biceps ruptureBiceps rupture

Rupture is usually of long head of bicepsRupture is usually of long head of biceps

PresentationPresentation

Usually older athlete or older personUsually older athlete or older person

Often accompanied by sharp painOften accompanied by sharp pain

Obvious deformity – “Popeye sign”Obvious deformity – “Popeye sign”

Later little painLater little pain

Little loss of strengthLittle loss of strength

Popeye signPopeye sign

Biceps ruptureBiceps rupture

InvestigationInvestigation US / MRI (if needed)US / MRI (if needed)

TreatmentTreatment Usually conservative (ROM & strengthening)Usually conservative (ROM & strengthening) SurgerySurgery

Indicated if distal tear (at insertion into radius)Indicated if distal tear (at insertion into radius) Prefer to repair relatively acutely (< 6 wks)Prefer to repair relatively acutely (< 6 wks)

Proximal tear – little loss of strength, surgery only in those who Proximal tear – little loss of strength, surgery only in those who perform power sportsperform power sports

AC jt Separation AC jt Separation

AC joint injuriesAC joint injuries

PresentationPresentation ““Separated shoulder”Separated shoulder”

Usually caused by a fall onto point of shoulder or Usually caused by a fall onto point of shoulder or

check into boardscheck into boards

Collision sports at high risk (hockey, football, skiing)Collision sports at high risk (hockey, football, skiing)

Pain in area of jointPain in area of joint

Pain with combined flexion and adductionPain with combined flexion and adduction

AC joint injury physical examAC joint injury physical exam SignsSigns

Point tendernessPoint tenderness

May see step deformityMay see step deformity

Painful at extreme abduction or flexionPainful at extreme abduction or flexion

Horizontal adduction test (scarf test)Horizontal adduction test (scarf test)

O’Brien’s test (internal rotation, flexion, O’Brien’s test (internal rotation, flexion, 15° of adduction » resisted flexion » 15° of adduction » resisted flexion » superficial superior shoulder pain)superficial superior shoulder pain)

InvestigationsInvestigations X-ray with AC jt views (15X-ray with AC jt views (15° cephlad ° cephlad

tilt)tilt)

ManagementManagement

Type I

– localized tenderness / pain

- sling for 2-3 days

Type II

- ↑ 25 – 50% ofcoracoclavicular distance(step deformity)

-Sling for a few weeks, until pain improved

-Return to sport when full,pain free ROM & no localtenderness

Type III

- ↑ 50 – 100% ofcoracolavicular distance

-Treatment controversial

-Generally treat as bad Type II

-If fail conservative Rx,may try surgery

ManagementManagement

Type IV

- Posterior displacement of clavicle

- Surgery

Type V

- Bad Type III

- More damage to muscle fascia

- Surgery

Type VI

- Inferiorly displaced clavicle

- Surgery

Adhesive capsulitisAdhesive capsulitis

aka “frozen shoulder” aka “frozen shoulder”

PathophysiologyPathophysiology Fibrosis of GH joint capsule & profound loss of capsular volume Fibrosis of GH joint capsule & profound loss of capsular volume

PresentationPresentation Early - pain with active and passive ROMEarly - pain with active and passive ROM

Pain often radiates to deltoid insertionPain often radiates to deltoid insertion Pain at nightPain at night

Late – Loss of active & Late – Loss of active & passivepassive ROM ROM ROM is lost in glenohumeral (GH) jointROM is lost in glenohumeral (GH) joint

PrimaryPrimary Associated with: diabetes, hypothyroid, dupytren’s, parkinson’sAssociated with: diabetes, hypothyroid, dupytren’s, parkinson’s

Secondary (post traumatic or immobilization)Secondary (post traumatic or immobilization) Eg. Post surgery, rotator cuff tear, fracture, or strokeEg. Post surgery, rotator cuff tear, fracture, or stroke

Adhesive capsulitisAdhesive capsulitis Natural courseNatural course

4 stages:4 stages: ““Inflammatory”Inflammatory” FreezingFreezing FrozenFrozen ThawingThawing

Majority progress through stages with good resolutionMajority progress through stages with good resolution Diabetes, hypothyroid & male gender have worse prognosisDiabetes, hypothyroid & male gender have worse prognosis

Takes 6 months – 3 years to get through stagesTakes 6 months – 3 years to get through stages

Adhesive CapsulitisAdhesive Capsulitis

Treatment optionsTreatment options Steroid injection (best efficacy in earlier stages)Steroid injection (best efficacy in earlier stages) ROM exercises ROM exercises

Patient does on own (no benefit of physio)Patient does on own (no benefit of physio)

Aggressive ROM (pushing through pain at end range) Aggressive ROM (pushing through pain at end range) makes patient worsemakes patient worse

Physio beneficial once thawing phase starts (retrain Physio beneficial once thawing phase starts (retrain scapular stabilizers that became lax to compensate for scapular stabilizers that became lax to compensate for ↓ ↓ ROM)ROM)

Arthrographic GH hydrodilatationArthrographic GH hydrodilatation Manipulation under anesthesiaeManipulation under anesthesiae Surgical releaseSurgical release

Questions?Questions?

ELBOWELBOW

Palmar surface

Dorsum of hand

Lateralepicondyle

Medial epicondyle

Wrist flexors &Finger flexors

Wrist extensors& finger extensors

CaseCase

Chris is a 30 year old Chris is a 30 year old tennis playertennis player

He’s developed medial He’s developed medial elbow pain over the last elbow pain over the last month, worse when month, worse when servingserving

It’s affecting his game.It’s affecting his game.

What’s going on?What’s going on?

       

                                                                

Medial epicondylitisMedial epicondylitis Often not acute inflammation but rather degenerative Often not acute inflammation but rather degenerative

(tendinosis) (tendinosis)

““Golfer’s elbow”Golfer’s elbow” Note case involves tennis player with “golfer’s elbow” Note case involves tennis player with “golfer’s elbow”

Overuse of muscles attaching to medial epicondyle (wrist Overuse of muscles attaching to medial epicondyle (wrist flexors, finger flexors, forearm pronators) flexors, finger flexors, forearm pronators) Seen in throwing sports, golfing, tennis, occupational / Seen in throwing sports, golfing, tennis, occupational /

recreational (snow shovelling, grocery bagging)recreational (snow shovelling, grocery bagging)

PresentationPresentation Pain along medial elbowPain along medial elbow Aching along volar forearmAching along volar forearm Impact on ADL if continualImpact on ADL if continual

Medial epicondylitisMedial epicondylitis

Physical examPhysical exam Pain on palpation common tendon & medial epicondylePain on palpation common tendon & medial epicondyle

Pain with resisted wrist flexion and forearm pronationPain with resisted wrist flexion and forearm pronation

Pain with passive wrist extension (stretch of wrist Pain with passive wrist extension (stretch of wrist

flexors)flexors)

InvestigationsInvestigations Usually not necessaryUsually not necessary

Medial epicondylitisMedial epicondylitis

ManagementManagement

NSAIDsNSAIDs

Corticosteroid injection if acute flareCorticosteroid injection if acute flare

Relative restRelative rest Identify & modify causitive actionsIdentify & modify causitive actions Eg. Change in playing style, change in work Eg. Change in playing style, change in work

ergonomicsergonomics

IceIce StretchingStretching StrengtheningStrengthening Band (changes point of tension when Band (changes point of tension when

muscles contracts)muscles contracts)

Lateral epicondylitisLateral epicondylitis ““Tennis elbow”Tennis elbow”

Overuse of muscles attaching to lateral Overuse of muscles attaching to lateral epicondyle (wrist extensors, finger extensors, epicondyle (wrist extensors, finger extensors, forearm supinators) forearm supinators)

Seen in racquet sports, screwdriver use, knitting, brick Seen in racquet sports, screwdriver use, knitting, brick laying, typistslaying, typists

PresentationPresentation Pain along lateral elbowPain along lateral elbow Aching along dorsal forearmAching along dorsal forearm Impact on ADL if continualImpact on ADL if continual

Lateral epicondylitisLateral epicondylitis Physical examPhysical exam

Pain on palpation common tendon & lateral epicondylePain on palpation common tendon & lateral epicondyle

Pain with resisted wrist extension and forearm supinationPain with resisted wrist extension and forearm supination

Pain with resisted extension of 3Pain with resisted extension of 3rdrd digit digit

Pain with passive wrist flexion (stretch of wrist extensors)Pain with passive wrist flexion (stretch of wrist extensors)

InvestigationsInvestigations Usually not necessaryUsually not necessary

ManagementManagement Same as per medial epicondylitisSame as per medial epicondylitis

Except Except eccentriceccentric contractions are of benefit in strengthening contractions are of benefit in strengthening

extensor origin & preventing recurrenceextensor origin & preventing recurrence

Questions?Questions?

WRIST & HANDWRIST & HAND

CaseCase

26 yr old John just 26 yr old John just invested in a new cell invested in a new cell phone plan with unlimited phone plan with unlimited txt messages. txt messages.

He has pain in his right > He has pain in his right > left wrist on the thumb left wrist on the thumb side.side.

What is it?What is it?

Wrist – AnatomyWrist – Anatomy

Extensor Pollicus Brevis

Abductor PollicusLongus

De Quervain’s tenosynovitisDe Quervain’s tenosynovitis Inflammation of the first extensor compartment tendons (APL & Inflammation of the first extensor compartment tendons (APL &

EPB)EPB)

Seen with repetitive wrist deviation, forceful gripping with radial Seen with repetitive wrist deviation, forceful gripping with radial wrist deviation, video games (repetitive use of thumb)wrist deviation, video games (repetitive use of thumb)

PresentationPresentation

Pain with palpation of tendons along radial distal wrist Pain with palpation of tendons along radial distal wrist

Pain over radial styloidPain over radial styloid

May have swellingMay have swelling

CrepitusCrepitus

Pain with thumb movements (abduction & extension)Pain with thumb movements (abduction & extension)

Positive Finkelstein’s maneuver Positive Finkelstein’s maneuver

Finkelstein’s testFinkelstein’s testPassive ulnar deviation, while thumb is in palm

DeQuervain’s tenosynovitisDeQuervain’s tenosynovitis

ManagementManagement Clinical diagnosisClinical diagnosis Mild casesMild cases

IceIce NSAIDNSAID Modification of activitiesModification of activities

Intense or prolonged symptomsIntense or prolonged symptoms Corticosteroid injection along tendon sheathCorticosteroid injection along tendon sheath Thumb spica orthosisThumb spica orthosis

SplintsSplints

Carpal tunnel

Thumb spicaImmobilizes 1st MCP!!

Carpal tunnel – Anatomy Carpal tunnel – Anatomy

Confined space with median nerve + 9 tendons:Flexor digitorum profundus x 4Flexor digitorum superficialis x 4Flexor pollicus longus

Carpal tunnel syndromeCarpal tunnel syndrome

PresentationPresentation Median nerve compression at the wristMedian nerve compression at the wrist

Sensory changes in lateral 3.5 digits (burning, pins & needles, Sensory changes in lateral 3.5 digits (burning, pins & needles,

numb)numb) Pain may radiate up forearmPain may radiate up forearm

Symptoms often occur at nightSymptoms often occur at night

Symptoms positionalSymptoms positional

Relief with shaking hands (+ve “flick” sign)Relief with shaking hands (+ve “flick” sign)

Loss of strength, dropping objectsLoss of strength, dropping objects

Carpal tunnel syndromeCarpal tunnel syndrome

SignsSigns Sensory abnormalities in median nerve territorySensory abnormalities in median nerve territory

44thth digit split digit split

Phalen’s maneuverPhalen’s maneuver

Tinel’s signTinel’s sign

Loss of strength of thumb abductionLoss of strength of thumb abduction

Wasting of thenar eminence (later, more severe Wasting of thenar eminence (later, more severe

compression)compression)

Carpal tunnel signsCarpal tunnel signs

Phalen’s maneuver Median nerve territory

Carpal tunnel etiologyCarpal tunnel etiology

Repetitive use of hands (manual labour)Repetitive use of hands (manual labour) Swelling of tendons passing through tunnelSwelling of tendons passing through tunnel

Abnormal finger / wrist postures (painter carrying Abnormal finger / wrist postures (painter carrying can & painting)can & painting) Space in tunnel is maximal with wrist in neutralSpace in tunnel is maximal with wrist in neutral

Use of vibrating tools (jackhammer)Use of vibrating tools (jackhammer)

Rheumatoid arthritisRheumatoid arthritis

ObesityObesity

PregnancyPregnancy

Carpal tunnel syndromeCarpal tunnel syndrome InvestigationsInvestigations

Nerve conduction studies & electromyographyNerve conduction studies & electromyography

ManagementManagement

Activity modification / ergonomicsActivity modification / ergonomics

Night splints (place wrist in neutral position)Night splints (place wrist in neutral position)

Relative rest (breaks when involved in repetitive Relative rest (breaks when involved in repetitive

activity)activity)

Stretching (nerve and tendon gliding exercises)Stretching (nerve and tendon gliding exercises)

Steroid injection Steroid injection

SurgerySurgery

Questions?Questions?

BREAK!!!BREAK!!!

HIPHIP

Trochanteric bursitis – AnatomyTrochanteric bursitis – Anatomy

Greater TrochanterBursa

Trochanteric bursitisTrochanteric bursitis Bursa irritated by:Bursa irritated by:

Direct impact (fall, contact sport)Direct impact (fall, contact sport) Repetitive use of tensor fascia lata (prox IT band) or Repetitive use of tensor fascia lata (prox IT band) or

gluteus mediusgluteus medius Walking (esp uneven ground), runners, XC skiers, ballet Walking (esp uneven ground), runners, XC skiers, ballet

dancersdancers

Signs & symptomsSigns & symptoms Burning, ache, or sharp pain in buttock / lateral hip, often Burning, ache, or sharp pain in buttock / lateral hip, often

radiates down lateral thighradiates down lateral thigh Pain on palpation over greater trochanterPain on palpation over greater trochanter Often unable to sleep on affected sideOften unable to sleep on affected side May have “snapping hip” TFL as moves over greater May have “snapping hip” TFL as moves over greater

trochantertrochanter

Trochanteric bursitisTrochanteric bursitis InvestigationsInvestigations

Usually noneUsually none

TreatmentTreatment Initial rest from aggravating activitiesInitial rest from aggravating activities

Ambulation with cane / walking pole in CONTRALATERAL handAmbulation with cane / walking pole in CONTRALATERAL hand

Stretching ITBStretching ITB

Strengthening of gluteus mediusStrengthening of gluteus medius

Corticosteroid injectionCorticosteroid injection

Iliotibial band syndromeIliotibial band syndrome Overuse injury common in runners or Overuse injury common in runners or

those who use step machines at the gymthose who use step machines at the gym

ITB lies infront of lateral epicondyleof femur when knee fully extended

Moves behind lateral epicondylewhen knee flexed

ITB is irritated by repetitive rubbingover lateral epicondyle (repetitive knee flexion / extension)

Iliotibial band syndromeIliotibial band syndrome Patient complains of lateral knee painPatient complains of lateral knee pain

May radiate up lateral legMay radiate up lateral leg

Worse with repetitive knee flex / extWorse with repetitive knee flex / ext

May feel snapping of ITB over lateral May feel snapping of ITB over lateral epicondyleepicondyle

++ pain on palpation over lateral epicondyle++ pain on palpation over lateral epicondyle ITB often diffusely tender to palpationITB often diffusely tender to palpation

+ve Ober’s test (tight ITB)+ve Ober’s test (tight ITB)

Iliotibial band syndromeIliotibial band syndrome Precipitating biomechanical factors:Precipitating biomechanical factors:

Weak hip abductors, excessive pronationWeak hip abductors, excessive pronation

Treatment:Treatment: Relative restRelative rest Stretch ITB!!Stretch ITB!! ITB friction / myofascial release / massageITB friction / myofascial release / massage Strengthen hip abductorsStrengthen hip abductors Correct excessive pronation with footwear +/- orthoticsCorrect excessive pronation with footwear +/- orthotics IceIce Steroid injection (if + acute flare)Steroid injection (if + acute flare)

KNEEKNEE

Ligament injuries - ACLLigament injuries - ACL

Mechanisms of Injury:Mechanisms of Injury: Landing from jumpLanding from jump

PivotingPivoting

Sudden deceleration (cutting)Sudden deceleration (cutting)

Valgus force to kneeValgus force to knee

““Terrible triad”Terrible triad” MCL, medial meniscus & ACL MCL, medial meniscus & ACL

often injured togetheroften injured together

ACL injury

Ligament injuries - ACLLigament injuries - ACL

Presentation:Presentation: Feel or hear a “pop”Feel or hear a “pop”

Acutely painfulAcutely painful Usually unable to return to playUsually unable to return to play Rapid knee Rapid knee hemarthrohemarthrosis (large swellingsis (large swelling within an hour)**within an hour)** Complain of knee giving wayComplain of knee giving way

Partial tear has less dramatic presentationPartial tear has less dramatic presentation

Ligament injuries - ACLLigament injuries - ACL

Physical exam:Physical exam: Knee effusionKnee effusion

Limited ROMLimited ROM

Limited weightbearingLimited weightbearing

Special tests:Special tests: Aim: demonstrate anterior tibial translation on femurAim: demonstrate anterior tibial translation on femur

Lachman, pivot shift, anterior drawerLachman, pivot shift, anterior drawer

ACL – Physical ExamACL – Physical Exam Problem:Problem:

Actue swollen, painful knee – patient won’t let you Actue swollen, painful knee – patient won’t let you examine / perform ACL testsexamine / perform ACL tests

How does one make a diagnosis?How does one make a diagnosis?

Solution:Solution: Only 3 knee structures cause large, rapid knee swelling Only 3 knee structures cause large, rapid knee swelling

(hemarthrosis)(hemarthrosis) Tibial plateau fracture – r/o based on Hx +/- x-rayTibial plateau fracture – r/o based on Hx +/- x-ray

Lateral patellar dislocation – r/o with patellar apprehension Lateral patellar dislocation – r/o with patellar apprehension test (can do even if ++ swollen & painful knee)test (can do even if ++ swollen & painful knee)

ACL tearACL tear

Ligament injuries - ACLLigament injuries - ACL InvestigationsInvestigations

X-rayX-ray Avulsion fracture from tibia pathognomonic of ACL ruptureAvulsion fracture from tibia pathognomonic of ACL rupture

MRIMRI

ManagementManagement Prevent injury – Prevent injury – www.aclprevent.com Physio for pain control, restore ROM, strengthen hamstrings, Physio for pain control, restore ROM, strengthen hamstrings,

proprioceptionproprioception ?ACL brace ?ACL brace Operative & non-operative treatmentOperative & non-operative treatment

Decision made based on presence of instability, activity level (work Decision made based on presence of instability, activity level (work & sport), patient age, associated knee injuries& sport), patient age, associated knee injuries

Significant rehab program with either treatment planSignificant rehab program with either treatment plan Typically out of pivoting sport Typically out of pivoting sport ~ 9 months (vs 3 - 6 weeks with MCL ~ 9 months (vs 3 - 6 weeks with MCL

tear)tear)

Ligament injuries - PCLLigament injuries - PCL

Mechanisms of Injury:Mechanisms of Injury: Knee in flexion & posterior force applied to tibiaKnee in flexion & posterior force applied to tibia

Ex. Dashboard or fall onto flexed kneeEx. Dashboard or fall onto flexed knee

Hyperextension with rotation on planted footHyperextension with rotation on planted foot

Often associated with other knee injuries (meniscus)Often associated with other knee injuries (meniscus)

Management usually non-operative (unless other injuries dictate Management usually non-operative (unless other injuries dictate

surgery)surgery)

Ligament injuries - MCLLigament injuries - MCL

Mechanism of injury:Mechanism of injury: Valgus stress to the kneeValgus stress to the knee

Usually when knee is partially flexedUsually when knee is partially flexed

May complain of instability or “giving way”May complain of instability or “giving way”

O/E:O/E: Medial joint line tenderness (along ligament)Medial joint line tenderness (along ligament)

No swelling (grd 1) to mod swelling (grd 3)No swelling (grd 1) to mod swelling (grd 3)

Valgus stress @ 30Valgus stress @ 30°° – pain +/- – pain +/- ↑ laxity↑ laxity

Ligament injuries - MCLLigament injuries - MCL

InvestigationsInvestigations Usually clinical diagnosisUsually clinical diagnosis

ManagementManagement Non-operative for all gradesNon-operative for all grades

Rehab focuses on ROM, quad & hamstring Rehab focuses on ROM, quad & hamstring strengthening, and joint proprioceptionstrengthening, and joint proprioception

May benefit from hinged knee brace (with medial May benefit from hinged knee brace (with medial support) to facilitate early return to sportsupport) to facilitate early return to sport

Ligament injuries - LCLLigament injuries - LCL

UncommonUncommon

Mechanism of injury:Mechanism of injury: Varus stress to the kneeVarus stress to the knee

O/E:O/E:

Lateral joint line tenderness (along ligament)Lateral joint line tenderness (along ligament) Tenderness posterolateral jt can also occur with ACL tearsTenderness posterolateral jt can also occur with ACL tears

Rare swellingRare swelling

Pain +/- laxity with vaPain +/- laxity with varrus stress @ 30us stress @ 30°°

Ligament injuries - LCLLigament injuries - LCL

InvestigationsInvestigations Usually clinical diagnosisUsually clinical diagnosis

ManagementManagement Non-operative - grades 1 & 2Non-operative - grades 1 & 2 Operative for grade 3 (usually associated with other Operative for grade 3 (usually associated with other

instabilities such as PCL rupture)instabilities such as PCL rupture)

Meniscus injuries – Anatomy Meniscus injuries – Anatomy

Medial & lateral meniscus injuriesMedial & lateral meniscus injuries

Lateral meniscus more mobile – rarely injuredLateral meniscus more mobile – rarely injured

MechanismMechanismss of injury: of injury: Twisting injuryTwisting injury

Repetitive squatting activitiesRepetitive squatting activities Eg. Hockey goalieEg. Hockey goalie

Menisci most stressed when knee is near full flexion!!Menisci most stressed when knee is near full flexion!!

Can be seenCan be seen with ACL / PCL injuries with ACL / PCL injuries

DDegenerationegeneration

AgingAging

Repeated traumaRepeated trauma

Medial & lateral meniscus injuriesMedial & lateral meniscus injuries

Presentation:Presentation:

PainPain Worse with squattingWorse with squatting

LockingLocking

ClickingClicking

GiveGive--way sensation (knee buckling)way sensation (knee buckling)

Swelling after activitySwelling after activity

Medial & lateral meniscus injuriesMedial & lateral meniscus injuries

O/E:O/E: Possible effusionPossible effusion

Loss of ROMLoss of ROM

Joint line tendernessJoint line tenderness

+ve McMurray’s+ve McMurray’s

InvestigationsInvestigations X-rayX-ray

Degenerative changesDegenerative changes

MRIMRI

Medial & lateral meniscus injuriesMedial & lateral meniscus injuries

ManagementManagement Analgesics Analgesics

Physio for ROM & strengtheningPhysio for ROM & strengthening

Degenerative tears usually managed conservativelyDegenerative tears usually managed conservatively

Outer 1/3 of meniscus is vascular – tears can healOuter 1/3 of meniscus is vascular – tears can heal

Surgery (arthroscopic) if: Surgery (arthroscopic) if: Mechanical symptoms (locking, instability, sig Mechanical symptoms (locking, instability, sig ↓ ROM)↓ ROM) Persistent pain after 6 wks of conservative RxPersistent pain after 6 wks of conservative Rx

Patellofemoral pain syndromePatellofemoral pain syndrome A.k.a. chondromalacia patellaA.k.a. chondromalacia patella

Presentation:Presentation: Pain Pain in andin and around around patellapatella

Worse with prolonged sittingWorse with prolonged sitting ““Movie-goers knee”Movie-goers knee”

Worse with squats and stairsWorse with squats and stairs

Women > menWomen > men

““Crunchy” kneesCrunchy” knees

Etiology not Etiology not always always clearclear

Patellofemoral pain syndromePatellofemoral pain syndrome

Common in runnersCommon in runners

Usually linked to altered patellar tracking (too far Usually linked to altered patellar tracking (too far lateral as moved along femur during knee flexion)lateral as moved along femur during knee flexion)

Biomechanical causes:Biomechanical causes: Weak vastus medialis oblique (VMO)Weak vastus medialis oblique (VMO) Excessive pronationExcessive pronation Weak hip abductorsWeak hip abductors Tight IT bandTight IT band Poor proprioceptionPoor proprioception ↑ ↑ Q angleQ angle

Q angleQ angle

Difference in line of pull of quads Difference in line of pull of quads

vs patellar tendonvs patellar tendon

Bigger > = more lateral pull on Bigger > = more lateral pull on

patellapatella

Normal Q angle:Normal Q angle:

10-18 degrees10-18 degrees

Women – 15-18 (wider hips)Women – 15-18 (wider hips)

Men – 10-15Men – 10-15

Patellofemoral painPatellofemoral pain

Signs:Signs:

CrepitusCrepitus

Usually no or minimal effusionUsually no or minimal effusion

Pain on palpation under patellaPain on palpation under patella

Pain with patellar stressing (patellar grind)Pain with patellar stressing (patellar grind)

Investigations:Investigations:

Usually clinical DxUsually clinical Dx

May get x-ray to assess for patellofemoral OAMay get x-ray to assess for patellofemoral OA

Patellofemoral painPatellofemoral pain

ManagementManagement AnalgesicsAnalgesics

Correct contributing factors!!Correct contributing factors!!

Modify activity pattern (eg. Eliptical Modify activity pattern (eg. Eliptical instead of treadmill)instead of treadmill)

Patellar stabilizing bracePatellar stabilizing brace

Lateral patellar bar

Questions?Questions?

ANKLE & FOOTANKLE & FOOT

Plantar fasciitis - AnatomyPlantar fasciitis - Anatomy

Plantar surface of foot

Plantar aponeurosis

Inserts onto medialtuberosity of calcaneus

Plantar fasciitisPlantar fasciitis

Presentation:Presentation: Pain along course of plantar fascia, particularly at insertion Pain along course of plantar fascia, particularly at insertion

on calcaneuson calcaneus

Pain worse with first few steps in morning (tightens up over Pain worse with first few steps in morning (tightens up over

night)night) Some relief after a couple minutes Some relief after a couple minutes

Worsens as weight bearing throughout day continuesWorsens as weight bearing throughout day continues

Prefer to bear weight on lateral heel/footPrefer to bear weight on lateral heel/foot

Pain with toe dorsiflexionPain with toe dorsiflexion

Plantar fasciitisPlantar fasciitis EpidemiologyEpidemiology

Very common overuse injuryVery common overuse injury

Atheltes requiring push-off (eg. Running, dancing)Atheltes requiring push-off (eg. Running, dancing)

Non – athletesNon – athletes Increased load bearing (eg. Obesity, pregnancy, firefighter / Increased load bearing (eg. Obesity, pregnancy, firefighter /

army carrying equipment)army carrying equipment)

Those with pes planus or cavus are at Those with pes planus or cavus are at ↑ risk↑ risk

InvestigationsInvestigations Clinical diagnosisClinical diagnosis

Plantar fasciitisPlantar fasciitis

Treatment:Treatment: Modify activityModify activity Proper foot wear + / - custom orthoticsProper foot wear + / - custom orthotics Stretching!!Stretching!!

Night splint to keep foot in neutralNight splint to keep foot in neutral IceIce Massage with golf ballMassage with golf ball NSAIDsNSAIDs

Corticosteroid injectionCorticosteroid injection Extracorporeal shock wave therapy Extracorporeal shock wave therapy

Ankle Ankle ssprains – prains – AAnatomynatomy

Lateral ankleMedial ankle

Deltoid Ligament

Ankle Ankle sprainssprains – Mechanism of – Mechanism of injuryinjury

Lateral ligamentsLateral ligaments More commonMore common

Excessive inversionExcessive inversion

Associated plantarflexionAssociated plantarflexion

Landing from a jumpLanding from a jump

Eg. BasketballEg. Basketball

Walking on uneven groundWalking on uneven ground

Medial ligamentsMedial ligaments Excessive eversionExcessive eversion

Quick change of directionQuick change of direction

Rare to occur in isolationRare to occur in isolation

Associated with:Associated with:

Proximal fibular fractures Proximal fibular fractures

(Maisonneuve fracture)(Maisonneuve fracture)

Disrupted interroseus Disrupted interroseus

membranemembrane

Disrupted tibiofibular ligamentsDisrupted tibiofibular ligaments

Ankle Ankle ssprainsprains

Signs:Signs: Depends on the degreeDepends on the degree

SwellingSwelling

Point tenderness over ligamentsPoint tenderness over ligaments

Rule out fracturesRule out fractures

Reduced ROMReduced ROM

Stability testingStability testing

Anterior drawerAnterior drawer

Lateral tiltLateral tilt

Ankle Sprains – When to x-rayAnkle Sprains – When to x-ray

Ankle sprain – When to x-rayAnkle sprain – When to x-ray

AnkleAnkle Pain in malleolar zone + one of:Pain in malleolar zone + one of:

Bone tenderness at A (post lat malleolus)Bone tenderness at A (post lat malleolus) Bone tenderness at B (post med malleolus)Bone tenderness at B (post med malleolus) Unable to weight-bear (4 steps at time of injury or time of Unable to weight-bear (4 steps at time of injury or time of

assessment)assessment)

FootFoot Pain in midfoot zone + one of:Pain in midfoot zone + one of:

Bone tenderness at C (base of 5Bone tenderness at C (base of 5thth metatarsal) metatarsal) Bone tenderness at D (navicular)Bone tenderness at D (navicular) Unable to weight-bearUnable to weight-bear

Ankle sprainsAnkle sprains

ManagementManagement

Reduction of pain & swelling (PRICEM)Reduction of pain & swelling (PRICEM)

Restore ROMRestore ROM

Muscle conditioningMuscle conditioning

ProprioceptionProprioception training training

Functional exercisesFunctional exercises

Ankle bracesAnkle braces temporary bridge to allow sporting activity while working on rehab temporary bridge to allow sporting activity while working on rehab

QuestionsQuestions

ReferencesReferences

Sports Injury Assessment and Rehabilitation. Reid, 1992.Sports Injury Assessment and Rehabilitation. Reid, 1992.

Physical Medicine and Rehabilitation. Braddom, 2010.Physical Medicine and Rehabilitation. Braddom, 2010.

Clinical Sports Medicine. Brukner & Khan, 2012.Clinical Sports Medicine. Brukner & Khan, 2012.

Essentials of Physical Medicine & Rehabilitation. Essentials of Physical Medicine & Rehabilitation. Frontera, 2014.Frontera, 2014.

Clinical Sports Medicine, Frontera, 2007.Clinical Sports Medicine, Frontera, 2007.

www.emedicine.com – Sports Medicine – Sports Medicine