Physio, Medico or Let It Go

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Physio, Medico or Let It Go?

ABOUT THE AUTHOR

Karen FinninMusculoskeletal PhysiotherapistBAppSc(Physio), MMuscPhys,

Karen graduated as a Physiotherapist from LaTrobe University in Melbourne, Australia in 1998, and subsequently completed a Masters in Musculoskeletal Physiotherapy. With over a decade working in Private Practice and with Defence populations, Karen has extensive experience in managing spinal injuries, general sporting injuries and work related conditions. She has travelled interstate and overseas with sporting teams, and has developed a number of education programs in fields such as core stability retraining, fit ball use, and injury management.

Karen is the Director of Physios Online, an online Physiotherapy Practice that specializes in providing long distance consultations to people who are injured, but live or work in a remote location.

You can contact Karen at [email protected], or visit the Physios Online website at www.physios-online.com.

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ACKNOWLEDGEMENTS

The author wishes to acknowledge the following sources:

Dan UdenSports PhysiotherapistBExSc, BPhysio, MSportsPhys

Greg DeaAPA Sports PhysiotherapistMPhysio(Sports), BPhysio(Hons), BSc

Clinical Sports MedicineBy Peter Brukner and Karim KhanPublished 2007 by McGraw Hill Australia Pty Ltd in North Ryde, NSW

Referenced Journal Articles:

1. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 2011. 93-A(2): p. 113-20.

2. Russell, T.G., Blumke, R., Richardson, B., Truter, P., Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother.Res. Int., 2010. 15: p. 167-175.

3. Kairy, D., Lehoux, P., Vincent, C., Visintin, M., A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation, 2009. 31(6): p. 427-447.

4. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Rehabilitation after total knee replacement via low-bandwidth telemedicine:The patient and therapist experience. J Telemed Telecare, 2004. 10(Suppl 1): p. 85-87.

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1084

CONTENTS

Introduction Common Injury One: Neck Pain

Common Injury Two: Shoulder Pain - Insidious Onset

Common Injury Three: Shoulder Pain - Acute Onset

Common Injury Four: Elbow Pain

Common Injury Five: Low Back Pain

Common Injury Six: Knee Pain - Insidious Onset

Common Injury Nine: Ankle Injury

Common Injury Ten: Foot Arch Pain

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Common Injury Seven: Knee Pain - Acute Onset

Common Injury Eight: Shin Pain

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Efficient Referring…One of the most powerful skills for any Medic to have is to know when and where to refer a patient when assistance is required beyond their own circle of expertise. This is especially true for health professionals servicing remote locations, where the desire to act fast often competes with the upheaval and cost of increased travel for specialized services.

Referral to health services, particularly in remote areas, is becoming easier and more efficient than ever before. This is largely due to the development of ‘eHealth’ initiatives.

‘eHealth’ refers to the progression of healthcare into the use of digital and online technologies. It is a broad term, and can include the digitizing of patient records, transmission of test results, and performance of health related consultations online.

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Research has proven that online consultation is as effective as ‘on site’ consultation in many areas of health. This certainly is true for online Physiotherapy consultation [1-4], meaning that quality diagnosis and management of musculoskeletal injuries is now increasingly accessible to people living and working in remote locations, such as on board Navy vessels, or on remote deployment.

When dealing with musculoskeletal injuries, Medics are generally deciding between three main referral points:

Do I refer the patient for rehabilitation, such as Physiotherapy?

Do I refer the patient to a medical doctor?

or

Do I administer basic medical advice and management, and leave the patient to self-monitor, with the recommendation to present for review, if symptoms do not progress as expected.

In this book, we have simplified these three options with the following terms:

* * *

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Physio? ie, when is referral to Physiotherapy warranted?

Referral is generally made to an ‘on site’ Physiotherapist, if there is one readily available. This can include Physiotherapy services through a Defence Health Centre, or publicly accessible private Physiotherapy services.

If an on site Physiotherapist is not readily accessible for the patient, referral can be made to an online Physiotherapy service. In many cases, the online service is as reliable as the ‘on site’ equivalent [Refs 1-4], and, if an online Physiotherapist feels that the patient requires an ‘on site’ health consultation, they will not hesitate to refer.

* * *

Medico? Ie, when is referral to a Medical Doctor required?

Referral to a Medical Doctor is a simple action when a Doctor is available in close proximity, eg within a Health Centre. In more remote situations, however, a Doctor may not be easy to access. In these situations, correct decision making regarding referral is extremely important.

Referral to a Medical Doctor, is always required if ‘red flags’ are present, eg •nightsweats •wakinginthenight •unexplainedweightloss •changeinbladderorbowelfunction

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•severeandescalatingpain •historyoftumor

There is a decreased threshold to refer the injuries of patients under 18 and over 55 years of age. The immature and ‘over mature’ musculoskeletal systems of these populations can have a higher propensity for structural damage.

* * *

Let It Go? ie, when is it OK to perform basic medical management

and just ‘see how they go’?

Sometimes patients simply require basic management, medication and reassurance, but it is important to identify these patients correctly. Medics can provide an excellent screening process to ensure that only relevant cases progress to the valuable resources of Physiotherapy and General Medical Practice.

Physio, Medico or Let It Go? outlines referral guidelines for the ten most common musculoskeletal injuries. It is designed to assist the decision making process performed by Medics, and should only be used in conjunction with a thorough clinical assessment, and consideration of both musculoskeletal and medical differential diagnoses.

To ask questions, give feedback or obtain further copies of this book, please contact [email protected].

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COMMON INJURY ONE:

Neck Pain

SummaryNeck pain is often triggered by damage to a cervical disc, facet joint or muscle. The longer the duration of the neck pain, the more factors tend to contribute, such as stress, posture, central sensitization, and weakness of the deep neck flexor muscles. Neck pain that includes persisting pins and needles, numbness and/or weakness in the arm must be investigated, and may require surgery in severe circumstances.

PhysioRefer to a Physiotherapist if there is:•Neck pain, that is not improving, lasting more than 3 days

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MedicoRefer to a Medical Doctor if there is:•A history of trauma to the neck•A history of acceleration/deceleration injury•General neck pain lasting more than 3 months•Upper limb pins and needles and/or numbness and/ or weakness lasting more than 2 weeks•Severe Sharp shooting pain (bad enough to interrupt sleep)

Let It GoIf a patient experiences a sudden onset of neck pain with no specific event or trauma (eg waking with it in the morning) and there are no neural signs present (as listed in ‘Medico’ section), it is possible that it may settle in 2 to 3 days with relative rest, heat and gentle movement. If it does not resolve, consult the ‘Physio’ and ‘Medico’ guidelines above.

* * *

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COMMON INJURY TWO:

Shoulder Pain- Insidious Onset

SummaryInsidious onset shoulder pain is often caused by the rotator cuff tendons, and generally results in issues with tendon impingement. Unless the tear is full thickness, conservative management is often adequate.

PhysioRefer to a Physiotherapist if there is:•Shoulder pain lasting more than 1 week

MedicoRefer to a Medical Doctor if there is: •Unsatisfactory improvement following a 6 week rehabilitation program (ie continued impairment of ADLs or sport)

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•Marked weakness with arm elevation past shoulder height, lasting more than 6 weeks•Pain interrupting sleep for more than 2 weeks

Let It GoIf a shoulder develops pain related to a particular activity, and there is no significant weakness, and the duration has been less than a week, advise avoidance of the aggravating activity/ies, and see if it settles. If pain persists, use the ‘Physio’ and ‘Medico’ guidelines.

* * *

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SummaryShoulder trauma can range from reaching quickly to grab a falling

object, to forceful dislocation from body contact. Dislocation can

sometimes cause a Bankart lesion to the anterior glenoid, or a Hill-

Sachs compression fracture to the posterior humeral head – these often

require surgical reivew. Despite this, dislocations can often be managed

conservatively, unless they become recurrent. Forcefully resisted muscle

contraction around the shoulder can cause labral injuries (eg SLAP or

non-SLAP), or a rotator cuff tear. A fall onto the shoulder can cause

acromio-clavicular joint separation, or clavicle fracture.

COMMON INJURY THREE:

Shoulder Pain- Acute Onset

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PhysioRefer to a Physiotherapist if there is:•Shoulder pain lasting more than 1 week

MedicoRefer to a Medical Doctor if there is:•History of a full dislocation•Marked weakness with arm elevation•Unsatisfactory improvement with 6 weeks of a rehabilitation program

Let It GoA fall or ‘yank’ on the shoulder can cause some tendon inflammation that feels painful the day after, but settles over the course of a week. If symptoms persist, it is important to refer as recommended above, to get the shoulder structures assessed.

Mild injuries to the ac joint require minimal management, except for advising avoidance of painful activities. Taping may help to relieve pain.

* * *

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SummaryElbow pain is most commonly an insidious onset of pain through overuse, but a direct blow, forced movement, or fall onto the outstretched arm can also cause issues. Lateral epicondylalgia (‘tennis elbow’) is the most common cause of pain in the elbow, with irritation at the common wrist and finger extensor bone/tendon junction caused by repeated use. Trauma related bony tenderness generally requires investigation.

PhysioRefer to a Physiotherapist if there is:•Elbow pain lasting more than 2 weeks

COMMON INJURY FOUR:

Elbow Pain

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MedicoRefer to a Medical Doctor if there is:•Significant trauma, particularly in the presence of bony tenderness and swelling•Unresolving pain lasting 3 to 6 months

Let It GoIf elbow pain flares up due to a specific incident (like a weekend of pruning, first squash game in a while, or intensive use of a hammer), then advise rest from the painful activity until pain settles. If the activity is to be returned to, insist it is done with frequent breaks at first, and gradual progression of load.

* * *

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SummaryLow back pain is often triggered by damage to a lumbar disc, facet joint or muscle. Defects in the bony structure of the vertebrae, such as spondylolysis (pars defect or stress fracture) or spondylolisthesis (vertebral slip) are also possible, particularly in adolescents. The longer the duration of the back pain, the more factors tend to contribute, such as stress, central sensitization, and weakness of the core stabilizing muscles. Back pain that includes persisting pins and needles, numbness and/or weakness in the leg must be investigated, and may require surgery in severe circumstances.

PhysioRefer to a Physiotherapist if there is:•Back pain, that is not improving, lasting more than 3 days

COMMON INJURY FIVE: Low Back Pain

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MedicoRefer to a Medical Doctor if there is:•History of trauma to the back•Noted change in bladder or bowel function•General back pain lasting more than 3 months•Pain with spinal extension and/or rotation, linked with a history of repeated extension/rotation load eg gymnastics, fast bowling•Lower limb pins and needles and/or numbness and/or weakness •Severe, or sharp, shooting pain bad enough to interrupt sleep

Let It GoIt is generally important to refer all episodes of back pain, lasting more then 3 days, to a Physio or Doctor. The main time when it is left to settle on its own, is if back soreness simply results from delayed onset muscle soreness (DOMS) following a weights/gym workout.

* * *

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SummaryKnee pain that develops gradually is often due to tracking issues with the patello-femoral joint, but can also be due to degenerative changes of the articular surfaces, meniscal bruising or various tendinopathies. Persistent locking, catching or giving way can be indicators of structural damage requiring medical review, as can persisting effusion.

PhysioRefer to a Physiotherapist if there is:•Knee pain lasting more than 2 weeks

COMMON INJURY SIX: Knee Pain - Insidious Onset

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MedicoRefer to a Medical Doctor if there is:•Inability to flex knee past 90 degrees•Inability to weight bear for more than 4 steps•Locking, catching or giving way persisting despite rehabilitation •Significant intracapsular effusion•Pain unresolved/ unchanging after 12 weeks

Let It GoIf a patient develops knee pain, but can walk around OK and has no swelling, it can often be good to leave it for a week or two to see if it settles down. Advise avoidance of impact (or aggravating activity). If pain persists, refer.

* * *

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SummaryAcute knee trauma often occurs on the sports field, but can also occur through motor vehicle accidents, slips and falls. A knee with a history of twisting mechanism, click or pop at that time, and instant swelling, must be assumed to have an ACL rupture until proven otherwise through MRI. Most other knee ligament injuries are managed conservatively, particularly if no other accompanying damage is found. Persisting mechanical failure must be investigated.

PhysioRefer to a Physiotherapist if there is:•Knee pain lasting more than 1 week•Twisting episode with an audible snap and swelling

COMMON INJURY SEVEN: Knee Pain - Acute Onset

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MedicoRefer to a Medical Doctor if there is:•History of a traumatic incident, particularly in the presence of bony tenderness•Inability to flex knee past 90 degrees•Inability to weight bear for more than 4 steps•Locking, catching or giving way persisting despite rehabilitation •Significant intracapsular effusion•Pain unresolved/ unchanging after 6 week rehabilitation program

Let It GoIf a patient develops knee pain, but can walk around OK and has no swelling, it can often be good to leave it for a week or two to see if it settles down. Advise avoidance of impact (or aggravating activity). If pain persists, refer.

* * *

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SummaryThe most common cause of shin pain is medial or anterior tibial periostalgia, commonly known as ‘shin splints’. There is usually a history of commencing or increasing impact activity, which results in overload to the tibia. In severe situations, this can result in tibial stress fracture, in which the pain is more severe and point specific. In non-responding shin pain, a differential diagnosis of compartment syndrome must be considered, particularly if the area of pain corresponds to the anterior, or deep posterior muscle compartments.

PhysioRefer to a Physiotherapist if there is:•Shin pain lasting more than 2 weeks

COMMON INJURY EIGHT: Shin Pain

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MedicoRefer to a Medical Doctor if there is:•History of a traumatic incident, particularly in the presence of bony tenderness•Site specific pain with impact and focal bony tenderness•Failed rehabilitation program, pain in the distribution of the deep posterior compartment (medially), or anterior compartment (antero-laterally)

Let It GoIf pain develops quickly with a new impact activity or a dramatic increase in impact activity, advise rest from the activity until pain settles. On return to the activity, advise alternate days to begin with, and increase volume by only 10 to 15% each week. For persisting, or long duration pain, refer.

* * *

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SummaryThe most common acute ankle injury is the inversion sprain, with damage to the anterior talo-fibular ligament and, in more severe cases, the calcaneo-fibular ligament. The same general mechanism of injury can cause a malleolar fracture, which may or may not require surgical fixation, so bony tenderness needs to be investigated. Inversion injury with peroneal contraction can sometimes cause an avulsion fracture of the base of the 5th metatarsal, so bony tenderness in this area should also be investigated. An ankle sprain that is not recovering should be checked for damage to the cartilage surface of the talar dome with an MRI.

COMMON INJURY NINE: Ankle Injury

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PhysioRefer to a Physiotherapist if there is:•Any acute ankle injury

MedicoRefer to a Medical Doctor if there is:•Bony tenderness over the lateral or medial malleolus, navicular, or the base of the 5th metatarsal•Bony tenderness along the posterior border of the tibia or fibula, in the distal 6cm segment•Inability to weight bear for more than 4 steps at time of injury, and at time of assessment•Significant pain and disability persisting 6 weeks post ankle injury, despite rehabilitation •History of recurrent instability (ie ankle ‘rolls’ repeatedly with minimal provocation)

Let It GoAnkle injuries have a very high recurrence rate, so all injuries should be referred for rehabilitation, unless they are completely symptom free in a day or so.

* * *

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SummaryThe predominant cause of insidious onset arch of foot pain is Plantar Fasciitis, with peak tenderness at the back of the arch next to the heel. It is often mistakenly referred to as a ‘heel spur’, however the finding of a heel spur on xray has proven to be unrelated to the condition. It can be stubborn to treat, but will usually resolve with time and persistent rehabilitation. Taping of the arch by a Physiotherapist or Podiatrist can be very effective for shorter term pain relief.

PhysioRefer to a Physiotherapist or Podiatrist if there is:•Foot arch pain lasting more than 2 weeks

COMMON INJURY TEN: Foot Arch Pain

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Medico• 3 months of non improving pain, including failed rehabilitation program, for possible injection therapy

Let It GoIf foot arch pain, of less than 2 weeks duration, can be attributed to a change in activity or footwear, advice cessation of the aggravating activity. Once pain settles, return to the activity gently and progress gradually. For persisting pain, refer to a Physio or Podiatrist.

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ABOUT PHYSIOS ONLINEwww.physios-online.com

Physios Online is an online Physiotherapy Clinic, specializing in distance injury management through the use of digital technologies. Physios Online is great at helping people who are injured, but live or work in

a remote location.

At Physios Online, Physiotherapists trained in distance injury management, can assess, diagnose and treat

musculoskeletal injuries, using a combination of digital media, such as online assessment forms, video and

audio communication, and email.

For more information:[email protected]

www.physios-online.com

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Physio, Medico or Let It Go

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