Thoracic Outlet Syndrome Quiz

Achilles Tendinopathy/Tendinosis/Tendinopathy

• Refers to a combination of pathological changes affecting the Achilles tendon, usually due to overuse and chronic stress.
• Can occur in athletes and non-athletes.
• May or may not be associated with an Achilles tendon tear.
• Lack of flexibility or a stiff Achilles tendon increases the risk of injury.
• The thickest and strongest tendon in the body.
• Originates from the gastrocnemius and soleus muscles, inserting on the calcaneal tuberosity.
• Approximately 15 cm (6 inches) long.
• Experiences stress of 3.9 times body weight during walking and 7.7 times body weight during running.
• Surrounded by a paratenon (connective tissue sheath) instead of a synovial sheath.
• Paratenon provides the major blood supply to the tendon.
• Blood supply comes distally from intraosseous vessels (calcaneus) and proximally from intramuscular branches.
• A relative avascular zone exists 2-6 cm from the calcaneal insertion, making it vulnerable to degeneration and injury.
• Blood supply is evident at the muscle-tendon junction and tendon-bone insertion.
• Vascular density is greatest proximally and least in the midportion of the tendon.
• Tendon injuries are commonly associated with repetitive impact loading from running and jumping.
• Either the tendon or paratenon (or both) can become inflamed, resulting in tendonitis or peritendinitis.
• Tendinopathy is a common overuse injury caused by repetitive energy storage and release with excessive compression. This can lead to a sudden injury or a rupture.
• Commonly called Achilles tendonitis, but more accurately described as tendinosis (not inflammation).
• Classified into insertional (within 2 cm of insertion) and mid-substance/noninsertional (2-6 cm proximal to insertion).

Causes of Achilles Tendonitis

• Overuse injury with forces within the physiological range, but repeated with poor recovery time, causing fatigue and increasing susceptibility to micro-tearing.
• Sudden loading of excessive force, especially with eccentric motion, causing damage.
• Insufficient flexibility in the gastrocnemius and soleus muscles, increasing strain on the tendon and causing micro-tears.
• Muscle weakness in the gastrocnemius and soleus which results in micro-tears and inflammation of the Achilles tendon.
• Joint restrictions (e.g., pes cavus) in the talocrural or subtalar joints decrease shock absorption and adaptability to uneven terrain.
• Excessive pronation leads to internal tibial rotation, drawing the Achilles tendon medially (whipping action) and contributing to overuse degeneration and inflammation or small tears, particularly in the medial aspect.
• Systemic diseases such as diabetes, lupus, and gout are associated with tendon weakness.
• Corticosteroid injections can cause tendon rupture and are controversial.
• Poor footwear (too small, worn-out, poor heel counter) reduces rear foot stability and shock absorption.
• Running on unyielding or uneven surfaces.

Physical Examination and Findings

• Morning pain is a hallmark symptom.
• Diffuse pain in or around the back of the ankle and heel, aggravated by activity (especially uphill running or stair climbing).
• Pain is relieved somewhat by wearing higher-heeled shoes or boots.
• Recent increase in activity levels or changes in footwear is often reported by patients.
• Observable, palpable edema and thickening of the Achilles tendon (A-P and M-L).
• Painful and prominent lumps or nodules within the tendon.
• Crepitus during plantar and dorsiflexion, detected through arc sign.

Diagnosis

• Diagnosis uses history, symptom behavior, clinical tests, ultrasound (for tendons, water content, collagen integrity and bursal swelling), X-rays (for bone changes, calcification), and MRI (for surgery planning).
• X-rays visualize calcification in the tendon (insertional) or midportion (severe noninsertional) tendinopathy.

Differential Diagnosis

• Plantar fasciitis
• Calcaneal fracture stress
• Heel pad syndrome
• Haglund deformity
• Sever's disease
• Posterior Ankle Impingement
• Medial Tendinopathy
• Retrocalcaneal Bursitis
• Sural Nerve
• Lumbar Radiculopathy
• Ankle OA
• Deep vein thrombosis
• Partial Achilles Tendon Rupture

Treatment and Management

• Aims for optimizing foot biomechanics, controlling symptoms (pain, swelling, inflammation), protecting the inflamed tendon, and enhancing tendon healing and muscle activity balance.
• Conservative management:
  • Medication (NSAIDs)
  • Physical therapy (RICE, cross-training, and specific exercises)
  • Corticosteroid injections (use cautiously, risk of rupture)
  • Platelet-Rich Plasma (PRP) injections
• Surgical management is considered if conservative approaches fail.
• Physical therapy includes:
  • Implementing RICE (Rest, Ice, Compression, Elevation)
  • Orthotics (heel lifts, specialized braces)
  • Taping
  • Gentle stretching of tight gastrocnemius/soleus complex.
  • Isometric-loaded exercises (e.g., heel raises) to strengthen tendons, progressing to more challenging exercises with weight.
  • Cross-training on opposite ankle
  • Specific positions to reduce pressure on the affected area
  • Physiotherapy treatments (e.g soft tissue mobilization)
• The physician may recommend using a walking boot for a short period in case of severe pain.

Thoracic Outlet Syndrome (TOS)

• Compression of neurovascular structures (nerves, blood vessels) exiting the thoracic outlet.
• Outlet is bordered by the first rib, clavicle, upper border of the scapula, and sternum.
• Marked by the anterior scalene, middle scalene, and subclavian vasculature/neurovascular bundle.
• The thoracic outlet is both confined and dynamic.
• Symptoms are often controversial and depend on whether the nerves, blood vessels, or both are compressed.
  • Typical findings include:
    • Numbness or tingling in the arm or fingers.
    • Pain or aches in neck, shoulder, arm, or hand.
    • Arm fatigue with activity.
    • Weakening grip.
• Causes of TOS often are anatomical defects:
  • Extra rib located above first rib.
  • Cervical ribs (0.5-0.6% pop., 50-80% bilateral)
  • Fibromuscular bands connected to cervical ribs (most neural compression cause).
  • Poor posture, causing shortening of the sternocleidomastoid muscle, thereby creating a shortened scalene and pectoralis muscle grouping, which leads to improper head-neck alignment.
  • Injuries or repetitive activities (e.g., typing, heavy lifting).
• Classifications:
  • Vascular (vTOS):
    • Color changes in hands, or fingers (cyanosis)
    • Hand or arm pain and swelling
    • Pulsating lump near collarbone.
    • Cold hands or fingers.
    • Hand and arm pain (claudication pain)
  • Neurological (nTOS): (includes true and disputed types of nTOS)
• Diagnostic procedures include electrophysiological studies and imaging.
• Treatment involves physical therapy (mobilization, stretching), activity modification, and potentially surgery if conservative measures are unsuccessful.

Rehabilitation After Knee Arthroplasty

. Preoperative rehab includes measuring pain, swelling, functional ability, range of motion, and muscle strength. Patients are trained to use assistive devices like walkers or crutches, along with practicing isometric exercises, like quadriceps.

. Postoperative rehab includes deep breathing, ankle pumps, upper extremity exercises(e.g., moving the patella up and down), frequent quadriceps exercises, and attempts at SLR (straight leg raises) after the first two days if not contraindicated.

. Two main forms of management are used: No CPM or CPM. No CPM includes maintaining the knee in an extended position, using pressure bandages, and splints. CPM uses a continuous passive motion machine to actively exercise the knee post-surgery.

. The types of exercises used to rehabilitate the knee after surgery include isometric, active, and resisted exercises and are tailored to each patient's needs and determined by the surgeon.

. The rehabilitation process after knee arthroplasty varies based on the specific type of prosthesis (cemented or cemented-less, and the specific situation of each patient.

. Proprioception training, walking/stair climbing, and avoidance of twisting, jumping and running are crucial to consider in patient rehabilitation programs.