AMP Clinical Patterns Revision Sheet.docx

**AMP Clinical Patterns Revision Sheet** *Each CP:* - Pathophysiology - Body Chart (detailed) - HPC - \(3) SE - \(4) OE **Condition** +-----------------------------------+-----------------------------------+ | Clinical Pattern | |...

**AMP Clinical Patterns Revision Sheet** *Each CP:* - Pathophysiology - Body Chart (detailed) - HPC - \(3) SE - \(4) OE **Condition** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: | | +-----------------------------------+-----------------------------------+ | HPC | | +-----------------------------------+-----------------------------------+ | SE | | | | | | 1. ? | | | | | | 2. ? | | | | | | 3. ? | | +-----------------------------------+-----------------------------------+ | OE | | | | | | 1. ? | | | | | | 2. ? | | | | | | 3. ? | | | | | | 4. ? | | +-----------------------------------+-----------------------------------+ *Shoulder* **Rotator Cuff Related Shoulder Pain** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Sudden tendon | - Dull | | overload, tendon designed to | c/o ache at rest | | withstand load, excessive | | | movement (likely 30 degrees | - Can be sharp, burning pain | | abduction) means tendon is unable | with movement. | | to withstand abrupt load, results | | | in tendon disrepair. | | | | | | Includes - Impingement: Rotator | | | cuff tendinopathy, supraspinatus | | | bursa or RC tear. | | +-----------------------------------+-----------------------------------+ | HPC: | | | | | | - Overuse -- gradual onset. | | | | | | - Excessive abduction injury-- | | | supraspinatus -- overload of | | | tendon. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Difficulty with OH, HBB | | | (carrying kids, lifting, | | | reaching) | | | | | | - Occupation may involve heavy | | | lifting. | | | | | | - DOA throughout day. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - +ve in Empty can / full can. | | | | | | - +ve Neers / Hawkins Kennedy. | | | | | | - Decreased MMT -- Shoulder ER | | | / IR | | | | | | - Decreased AROM -- Painful arc | | | in (70-120) through flexion | | | and abduction, limited HBB / | | | IR | | +-----------------------------------+-----------------------------------+ **Adhesive Capsulitis** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Contracture of | - Over ant-post capsule- to | | GHJ capsule, gradual insidious | deltoid insertion -- can | | onset and generally unknown | radiate distally into bicep | | cause. Associated w/ diabetes and | or proximally into scapular | | hypothyroidism. | region | | | | | | - Diffuse deep ache, w/ | | | movement can be sharp | | | | | | - Can get P+N in hands | +-----------------------------------+-----------------------------------+ | HPC: Gradual insidious onset- | | | reduction in ROM overtime. | | | | | | - Freezing -- (PAIN \> | | | STIFFNESS) | | | | | | - Frozen -- (STIFFNESS \> PAIN) | | | | | | - Thawing- (RESOLUTION OF ROM) | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Severe night pain ++ | | | | | | - Shoulder - Reduced ROM and | | | pain. | | | | | | - Agg: Movements, particularly | | | HBB (reaching into back | | | pocket) | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Reduced and painful AROM | | | (flexion, abduction and ER) | | | | | | - Poor scap humeral rhythm -- | | | Hitch in Ext | | | | | | - Reduced PROM (Passive ER | | | most + indicator) | | | | | | - Reduced MMT -- SCAP AND ER | | | | | | - LIMITATION IN HBB | | +-----------------------------------+-----------------------------------+ **Instability** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Glenohumeral | | | joint- flexibility \> intrinsic | | | stability. Makes it a commonly | | | dislocated joint. | | | | | | *Associated w/ instability.* | | | | | | - Hill-sach: Compression | | | fracture- posteriorly, | | | resulting in fracture of HoH. | | | | | | - Bankart: Fracture of anterior | | | rim of GHJ | | +-----------------------------------+-----------------------------------+ | HPC: Sudden onset following | | | direct or indirect trauma- | | | Dislocation- FOOSH (excessive ER | | | and abduction) | | | | | | - Subluxation: Where articular | | | surface of joint remains with | | | some sort of contact. \-- | | | Dislocation: Articular | | | surfaces of joint have lost | | | contact- anterior most | | | common. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Hx of dislocations. | | | | | | - OH activities? | | | | | | - Feeling of 'popping out' | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Apprehension test +ve | | | | | | - +ve on instability -- | | | anterior / inferior draw. | | | | | | - Shoulder MMT -- reduction of | | | ER / IR. | | | | | | - Hollow below acromion | | +-----------------------------------+-----------------------------------+ **Labral Injury** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: SLAP: Superior | - Deep, | | Labrum Anterior-Posterior tear. | poorly localised c/o pain | | | over anterior shoulder | | Overuse (OH athletes, baseball | | | etc.)- repetitive ER / IR | | | | | | Peel back mechanism: torsion | | | force into base of biceps tendon | | | (attached to superior labrum) | | | | | | Pinching MOA and traumatic (more | | | likely in elderly) FOOSH and MVA. | | +-----------------------------------+-----------------------------------+ | HPC: Acute / Chronic shoulder | | | traction + compression / | | | dislocation injury. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Click and clunk | | | | | | - OH activities + HBB | | | | | | - Weakness in throwing | | | activities. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Cluster: O'briens, crank and | | | biceps load II | | | | | | - Mainly intact AROM | | | | | | - Tender on palpation | | +-----------------------------------+-----------------------------------+ *Hip* **Femoro-Acetabular Impingement (FAI)** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Symptomatic | - Dull deep pain -- c/o or i/m | | pre-mature contact of acetabulum | in anterior hip / groin area. | | and proximal femur. | | | | | | - Movement disorder- hip | | | morphology results in bunt | | | contact of proximal femur | | | with acetabulum- results in | | | pain (unsure if from contact | | | or soft tissue changes) | | | | | | Cam morphology vs pincer | | | morphology vs mixed (cam + | | | pincer) | | | | | | - Cam -Bony bump at femoral | | | head-neck junction | | | | | | - Pincer --acetabular | | | over-coverage or retroversion | | +-----------------------------------+-----------------------------------+ | HPC: ? | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - May report locking, clicking | | | or catching. | | | | | | - Activities that put in | | | impingement -- e.g. flexion, | | | adduction -- cross legged, | | | stairs, kicking ball across. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - FADIR +ve | | | | | | - Limited AROM w/ flexion, | | | abduction- Pain on IR / | | | flexion | | | | | | - Decreased MMT -- flexion, | | | abduction, ER and extension. | | | | | | - Antalgic gait. | | | | | | - Poor balance / trunk control. | | +-----------------------------------+-----------------------------------+ **Hip OA** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Inflammatory | -  c/o in | | joint condition. Loss of | anterior hip / groin area. | | articular cartilage, results in | | | inflammation of synovium. | - Deep dull ache, can be | | Thinning of acetabular head, | sharp + stabbing P | | results in more joint narrowing. | | +-----------------------------------+-----------------------------------+ | HPC: Insidious onset, gradual. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - AM: Stiffness, Nocte: Pain | | | | | | - Agg: Difficulty -- prolonged | | | walking, getting out of car, | | | reaching down to feet. Pain | | | on standing, ease with | | | walking. | | | | | | - Ease: Reduce hip load, | | | sitting on high stool. | | | | | | - +/- crepitus / clicking. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limited AROM / Loss of PROM: | | | Hip flexion, F/ IR | | | | | | - Gait (Trendelenburg, glute | | | medias gait) | | | | | | - MMT -- decreased hip flexion, | | | abduction | | | | | | - Visible wasting of glutes. | | | | | | - Passive Accessory -- | | | stiffness. | | +-----------------------------------+-----------------------------------+ **Deep Gluteal Syndrome (Piriformis Syndrome)** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Tightness of | - Pain around buttock region | | piriformis, results in entrapment | (sciatic notch) +/- cramp / | | or irritation of sciatic nerve. | burn on posterior thigh. | | | | | | - Sharp, shooting pain | +-----------------------------------+-----------------------------------+ | HPC: Direct contusion or overuse. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Symptoms radiating down legs. | | | | | | - Agg: Sitting for prolonged | | | periods, activities w/ | | | sciatic nerve stretch. | | | | | | - Tingling sensation or motor | | | weakness. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Palpation: Tightness in | | | gluteal, piriformis | | | | | | - SLR / Slump +ve. | | | | | | - Weak hip abductors. | | | | | | - P+ on piriformis stretch or | | | contraction i.e. Prone IR. | | +-----------------------------------+-----------------------------------+ **Gluteal Tendinopathy** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Pathology of | - Postero | | gluteus minimus and medias | -lateral | | tendon. Progressive overload of | hip pain -- GT insertion. | | tendon, unable to withstand | Radiates down lateral thigh | | loading, tendon disrepair and | -- does not pass the knee! | | loss of tendon integrity. | | +-----------------------------------+-----------------------------------+ | HPC: Gradual onset following | | | sudden increase in load. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Agg: Stairs, steps, lunges, | | | low chairs, standing. | | | | | | - Sleep- struggle to sleep on | | | affected side, may wake. | | | | | | - Ease: rest (reduce | | | compressive loading on | | | tendon) | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Excessive lateral pelvic | | | tilt, may have tredelenburg. | | | | | | - Functional- STS, Steps + | | | Squat + single leg balance. | | | | | | - RSC: FADER-R- Pain, Flexion, | | | adduction, ER/IR | | | | | | - Palp: Tenderness over MMT / | | | MLT. | | | | | | - AROM: Adduction -- may be | | | tender. | | | | | | - Pain w/ FABER + Obers- | | | abduction | | +-----------------------------------+-----------------------------------+ **Groin Pain** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Adductor-related: | | | | | | - Adductor tenderness AND pain | | | on RSC | | | | | | - | | | | | | Iliopsoas-related: pain on hip F | | | RSC and/or on hip F in Thomas | | | Test Inguinal-related: pain | | | located in inguinal canal region | | | AND tenderness here but nil | | | palpable inguinal hernia. Likely | | | if pain agg w/ resistance testing | | | of abdominal muscles OR on | | | cough/sneeze | | | | | | Pubic-related: local tenderness | | | of pubic symphysis and | | | immediately adjacent bone. Nil | | | RSC agg. | | +-----------------------------------+-----------------------------------+ | HPC: acute groin injuries have a | | | sudden onset from a specific | | | inciting event | | +-----------------------------------+-----------------------------------+ | SE: Hip related +/- catching, | | | giving way or locking. | | +-----------------------------------+-----------------------------------+ **Pelvic Pain** +-----------------------------------------------------------------------+ | Clinical Pattern | +=======================================================================+ | Pathological: Pathologies such as endometriosis, chronic prostatitis, | | painful bladder syndrome etc. | +-----------------------------------------------------------------------+ | SE: | | | | - Sx suggestive of lower urinary tract, sexual, bowel, pelvic floor | | or gynaecological dysfunction | | | | - -ve cognitive, behav, sexual and emotional consequences | +-----------------------------------------------------------------------+ | OE: 5 P's | | | | - Peeing: starting/holding flow | | | | - Pooing: pain/strain, incontinence | | | | - Penetration: pain, arousal, function | | | | - Periods: pain, length, consistency | | | | - 5\. Psychological wellbeing | +-----------------------------------------------------------------------+ **Transient Synovitis** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: An acute, | - Acute | | non-specific inflammatory process | hip pain +/- associated limp. | | which targets synovial lining. | | | Causes hypertrophic changes. | - Can be bilat in some cases. | | Non-traumatic. | | +-----------------------------------+-----------------------------------+ | HPC: Self-limiting acute | | | inflammatory phase. -1-2 weeks. | | | If longer, consider Dx diagnosis. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Recent viral infection | | | | | | - Possible related back / knee | | | pain | | | | | | - Unable to complete normal | | | child activities. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Associated limp / inability | | | to WB | | | | | | - Decreased ADD / IR | | | | | | - Hold in FABER position, | | | decrease intraarticular | | | pressure. | | +-----------------------------------+-----------------------------------+ **Slipped Upper Femoral Epiphysis (SUFE)** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: | +/- anterior groin pain -- can | | | refer to knee and abdomen- | | Occurs when capital femoral | | | physis displaced from metaphysis. | - Poorly localised. | | Appears as CFE has fallen off- | | | ice-cream off cone. However, | | | remains in acetabulum but | | | retroverted. | | +-----------------------------------+-----------------------------------+ | HPC | | | | | | - Adolescents, growth spurt. | | | | | | - Traumatic event. | | | | | | - Can refer to knee, result in | | | late Dx of SUFE | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Sudden onset, inability to WB | | | | | | - Previous slips. | | | | | | - May be very vague- knee pain | | | may be any symptom. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limitation of Abduction / IR | | | | | | - Fall into ER / Abd in passive | | | hip flexion. | | | | | | - Frog leg position. | | | | | | - Antalgic gait | | +-----------------------------------+-----------------------------------+ **Perthes Disease** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Necrosis of part | - Unilate | | of the femoral head. | ral- | | | can be bilateral. | | - Interrupts blood supply to | | | CFE -- ossification | - (Pain, if present) | | temporarily ceases. | | | | | | - Femoral head- flattened and | | | mis-shapen | | | | | | - Fragmentation of femoral | | | head. | | +-----------------------------------+-----------------------------------+ | HPC: Insidious onset, often | | | painless 1-3/12. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Difficulty w/ walking -- | | | limping. | | | | | | - Hyperactive child | | | | | | - Worsens with activity | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limp + worsens with activity | | | | | | - Limited Abd and IR | | | | | | - Limited in Flexion | | | | | | - Muscle wasting in glutes. | | +-----------------------------------+-----------------------------------+ *Lumbar Conditions* **Lx Instability** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Clinical | - c/o poorly localised deep | | hypermobility causing structural | ache. | | dysfunction -\> spondylithesis- | | | Slip of one vertebra in | - Painful twinge and arc with | | association to adjunct vertebra | movement- relaxes with back | | resulting in pain. | to normal positions. | +-----------------------------------+-----------------------------------+ | HPC: Congenital vs. acquired. | | | Insidious onset, persistent | | | episodes. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Getting up from low chairs / | | | cars. Prolonged flexed | | | positions | | | | | | - ?Previously had STR from | | | chiro / physio | | | | | | - Lying down eases pain | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Hypermobility at one segment- | | | excessive mobility on | | | Central \> Unilateral PAIVMs | | | | | | - May have excessive Ext + may | | | walk hands up from flexion. | | | | | | - Poor motor control and | | | timing- core control | | | assessment. | | | | | | - Bilateral SLR at 40 degrees | | | hip flexion. | | +-----------------------------------+-----------------------------------+ **Lx Discogenic** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Overtime, loss | - c/o | | of water and proteoglycans in | widespread deep ache. | | nucleus. Loss of disc height | | | results in annular prolapse. | - May have sharp ache with | | | movement -- mainly flexion. | +-----------------------------------+-----------------------------------+ | HPC: Onset, from unusual | | | activity, carrying heavy loads. | | | Usually worse following day. Can | | | also be insidious onset. Can | | | become episodic | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Agg: Flexion activities, | | | tying shoes, | | | | | | - Prolonged sitting / standing | | | activities | | | | | | - Back feels locked up | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limited AROM F/E \> LF/Rot | | | | | | - Central \> Unilateral PAIVMs | | | (Pain + Stiffness) | | | | | | - Tight Lx Paraspinals | | | | | | - Protective behaviours -- | | | list, stiff / upright | | | position. | | +-----------------------------------+-----------------------------------+ **Lx PIV / Facet Joint** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Degeneration of | Acute: Deep, sharp localised pain | | joint and inflammation of capsule | with movement + severe and | | results in pain. | irritable | | | | | - | Chronic: | | | | | | - Deep ache: Intra-articular | | | | | | - Sharp catching: | | | Peri-articular | +-----------------------------------+-----------------------------------+ | HPC: Acute: Quick, unguarded | | | movement or gradual insidious | | | onset. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Struggle with lateral | | | rotation and flexion, putting | | | on seatbelt, looking in blind | | | spot. | | | | | | - Feeling of stiffness / | | | restriction. | | | | | | - Sports w/ repetitive rotation | | | e.g. golf etc. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Unilateral \> Central PAIVMs | | | -- pain+ and stiffness. | | | | | | - AROM: | | | | | | - Peri-articular: Limited | | | Flexion: Lat Flexion, | | | rotation away from | | | affected side. | | | | | | - Intra-articular: Limited | | | Extension: Lat Flexion, | | | rotation towards affected | | | side. | | | | | | - Tight Paraspinals + | | | | | | - Protective behaviour -- list, | | | stiff movement and avoid | | | sitting. | | +-----------------------------------+-----------------------------------+ **Lx Postural Pain** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: No relationship | - Deep | | between poor posture and pain. | dull ache over central lower | | However, theorised relationship | back. | | between sustained posture and | | | pain. Sustained posture, | - Poorly localised. | | increased muscle activity, | | | overtime- ischemia, increased | | | substance P, leads to increased | | | pain sensitivity. | | +-----------------------------------+-----------------------------------+ | HPC: Sustained postures for | | | extended periods. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Agg: Sustained sitting or | | | standing. | | | | | | - Gets better over weekends- if | | | work is contributor. | | | | | | - Office job or working at | | | computer with poor posture. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Obs: Poor standing or sitting | | | posture. In Lx may have | | | lordosis. | | | | | | - AROM, PAIVMs and palp | | | findings all cannot account | | | for symptoms. | | | | | | - MMT / MLT -- imbalance if | | | biomechanical contribution. | | | | | | - Poor motor control. | | +-----------------------------------+-----------------------------------+ **Lx Radiculopathy** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Compression of | - Sharp c/o severe lower back | | nerve root from spinal canal due | pain which radiates down | | to disc herniation or spondylosis | dermatomal pattern. | | (degenerative changes). Lx | | | radiculopathy is often due to | | | compression of sciatic nerve. | | +-----------------------------------+-----------------------------------+ | HPC: Nil event. Sudden onset. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Reported muscle weakness, | | | loss of sensation, P+Ns or | | | numbness. | | | | | | - Radiates from back, down | | | posterior leg to feet. | | | | | | - WB and sitting produces | | | symptoms. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - +ve SLR and / or Slump | | | | | | - +ve Neurological findings- | | | associated reflex, power and | | | sensation to nerve affected. | | | | | | - Palpation: tenderness + | | | protective muscle spasm | | | | | | - May look uncomfortable, | | | doesn't want to sit for | | | prolonged periods and | | | fidgety. | | +-----------------------------------+-----------------------------------+ **Spinal Canal Stenosis** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Compression of | - Bilater | | the spinal nerve in the canal due | al, | | to narrowing (congenital vs. | can be unilateral. Severe, | | acquired). Often with associated | sharp LB pain with | | PIV / disc degeneration. | paraesthesia, numbness and | | | weakness in lower limbs. | +-----------------------------------+-----------------------------------+ | HPC: Onset is gradual, insidious. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - May report P+Ns, numbness- | | | bilaterally. | | | | | | - Walking and Lx extension -- | | | Agg | | | | | | - Have long-standing back | | | pain \> 60 | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - +ve neurological and | | | neurodynamic findings | | | | | | - Differential from arterial | | | claudication w/ riding on | | | bike- due to oxygen demand. | | | | | | - Reduced Sx with flexion, | | | Increased with Ext | | | | | | - Often walk flexed. | | +-----------------------------------+-----------------------------------+ Thoracic Conditions **Facet or CTJ** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Degeneration of | - Unilateral pain, deep sharp | | joint and inflammation of capsule | over affected joint. | | results in pain. | | | | - Occasional radiating ache. | +-----------------------------------+-----------------------------------+ | HPC: Gradual or sudden onset. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - May report difficulty with | | | breathing, coughing or | | | laughing (CTJ) | | | | | | - Difficulty sleeping -- | | | finding position of comfort. | | | | | | - DD: Activity dependent, rest | | | relieves. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Unilateral \> Central PAIVMs | | | | | | - Increased Tx paraspinals + | | | | | | - Limited AROM, lateral | | | flexion, rotation. | | | | | | - Thoracic kyphosis -- obs. | | | Antalgic posture. | | +-----------------------------------+-----------------------------------+ **Ankylosing Spondylitis** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Auto-Immune | - Deep | | disorder. Involving inflammation | ache and stiffness in spine. | | of joints and ligaments in body. | Hips, SIJ and ankles. | | Can effect enthesis in spine. | | | End-stage can result in fusion of | - In tendons- achilles, | | vertebra. | sternum. | | | | | | - In fascia- PF, or alternating | | | gluteal / posterior thigh | | | pain. | +-----------------------------------+-----------------------------------+ | HPC: Gradual insidious onset. | | | Likely from younger age \ 40 years | | | | | | - AM: Stiffness, Night pain+ | | | | | | - Eases with movement, worse w/ | | | immobility. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limited and painful AROM -- | | | Tx | | | | | | - Swollen / red around area | | | | | | - Limited chest expansion / Tx | | | kyphosis | | | | | | - TOP over peripheral joints | | | and tendonous insertions. | | +-----------------------------------+-----------------------------------+ **Scheuermann's Disease** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Rigid kyphotic | - Pain, deep ache in upper back | | deformity. Anterior wedging of | region over kyphotic. | | vertebra \> 5 degrees from | | | adjacent vertebra. Possible | | | irregular vertebral end-plate or | | | decreased disc height. | | +-----------------------------------+-----------------------------------+ | HPC: Often develops from a | | | younger age. Parents notice poor | | | posture / kid can be | | | self-conscious. Gradual insidious | | | onset. Pain resolves w/ skeletal | | | maturity- deformity does not. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Worse w/ **EOR** F/E | | | activities- Prolonged | | | standing / sitting | | | | | | - Agg: work / sport and Ease: | | | w/ relative rest. | | | | | | - Parent concerned for posture. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Obs: Excessive Tx kyphosis | | | +/- excessive lordosis of Cx | | | / Lx | | | | | | - AROM: Limited and painful. | | | | | | - Central \> Unilateral | | | stiffness++ over kyphotic | | | levels | | | | | | - Cobb angle and schmorl nodes | | | on X-Ray | | +-----------------------------------+-----------------------------------+ **Thoracic Outlet Syndrome** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Irritation or | 1. Deep, | | compression at the thoracic | dull radiating ache from | | outlet. Can be neurogenic (often) | supraclavicular fossa, | | or vascular (less common). Can be | radiating down ant shoulder | | due to anatomical variants (wide | into med forearm to hand. | | C7 Transverse process, first rib | Poorly localisable. | | or clavicular alignment following | | | \#) or soft tissue. | 2. Weakness, P+N and numbness | | | into arm. | +-----------------------------------+-----------------------------------+ | HPC: Gradual onset (repeated | | | stress) or sudden (trauma) | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Weakness / heaviness in UL. | | | | | | - Agg: Worse with OH activities | | | or carrying heavy loads- | | | decreases costoclavicular | | | space. | | | | | | - Worse at EOD- muscle activity | | | increased. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Neurodynamic +ve | | | | | | - MLT: Tight scalenes and pect | | | minor with scap elevator | | | weakness. | | | | | | - +ve Wrights, Roos or Adsons. | | | | | | - Obs: dropped shoulders, | | | vascular changes in hands | | +-----------------------------------+-----------------------------------+ Cervical Conditions **Cx Instability** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Clinical | - Deep ache, around affected | | hypermobility with/ out | level. | | structural dysfunction resulting | | | in spondylolisthesis, slip of one | - Persistent neck | | vertebra in association to | | | another adjacent vertebra. Can be | - Arc and twinge with movement. | | congenital or acquired. | | +-----------------------------------+-----------------------------------+ | HPC: Insidious onset -- | | | persistent neck ache, recurrent | | | episodes, ofrten associated with | | | PIV etc. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Lying down- eases, w/ non-WB | | | but agg if too long. | | | | | | - Arc and twinge with movement. | | | | | | - Increased response to trivial | | | mechanical stress. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Excessive mid-Cx movement | | | with pain -- on return, | | | tentative- to look at | | | ceiling, pain on return from | | | Ext. | | | | | | - Strong hinge point. | | | | | | - Obs: Forward head posture. | | | | | | - Palpation: One noticeable | | | drop off and elevation on | | | vertebra. | | +-----------------------------------+-----------------------------------+ **Cx Discogenic** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Degenerative, | - Central | | loss of water and proteoglycans | neck pain, deep c/o ache, can | | in nucleus. This results in loss | be sharp with movement | | of disc height and subsequent | | | annulus prolapse. | | +-----------------------------------+-----------------------------------+ | HPC: Degenerative process, often | | | associated with quick unguarded | | | movement which was worse next | | | day. | | | | | | - Can become episodic. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Worse with F/ E activities. | | | Washing dishes, working at | | | computer. | | | | | | - Ease: Lying down / non-WB. | | | | | | - Looking down at feet- agg. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limited and painful AROM -- | | | **Flexion** / Extension \> | | | LF/Rot | | | | | | - Limited on Ext, posterior | | | glide causing + mid Cx pain | | | | | | - Central \> Unilateral PAIVMs, | | | pain + stiffness. | | | | | | - Palp: Inconsistent -- | | | prominent and depressed. | | | | | | - Thickening centrally over | | | paraspinals- producing | | | restriction. | | +-----------------------------------+-----------------------------------+ **Cx Radiculopathy** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Compression of | - Sharp shooting pain radiating | | nerve root- can be herniation of | from posterior neck, down | | disc (reduced disc height -- | anterior shoulder, forearm | | narrow exit foramina) or | into hand. | | degeneration of facet joint / | | | disc body. | - +/- P+Ns, numbness. | | | | | Can also be non-degenerative e.g. | | | diabetes, guillan barre, | | | carcinoma etc. | | +-----------------------------------+-----------------------------------+ | HPC: Acute (Heavy sustained | | | repetitive stress / activity, | | | computer for extended periods- | | | prolonged extension / starts | | | centrally and radiates. Chronic | | | (not-associated with any event). | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Recent Hx of sustained neck | | | postures. | | | | | | - Radiating pain in dermatomal | | | position | | | | | | - Pt is visibly uncomfortable, | | | unable to relax, fidgety | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - +ve neurological examination. | | | | | | - (neurodynamic -- latent | | | mild +ve) | | | | | | - Limited AROM -- flexion / | | | lateral flexion / rotation | | | (away- stretch) + extension, | | | rotation and lateral flexion | | | towards (compression) | | | | | | - Pt is visibly uncomfortable, | | | looks sick. | | | | | | - +/- list in anti-tension. | | +-----------------------------------+-----------------------------------+ **Cx Postural** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Sustained |  | | postures -\> increased muscle | | | tension -\> abnormal | - Posterior- Poorly localised. | | relax-contract -\> ischemia -\> | Neck stiffness + dull ache | | increased substance P and thus, | | | increased pain sensitivity. | | +-----------------------------------+-----------------------------------+ | HPC: Gradual onset- often | | | associated with sustained | | | postures e.g. looking down at | | | computer etc. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Agg: Prolonged postural | | | positions, washing dishes, | | | working at computer. | | | | | | - Ease: Rest (out of postures) | | | or weekends- if work | | | contributing. | | | | | | - Increase in activity or work | | | contribution of ergonomic | | | factors. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - AROM, PAIVMs do not account | | | for symptoms | | | | | | - Tight upper traps, levator | | | scap, tight suboccipital | | | extensors--if contributing | | | factor. Weak short neck | | | flexors. | | | | | | - Obs: FHP, Tx kyphosis | | | | | | - Tender over area, nothing | | | localised. | | +-----------------------------------+-----------------------------------+ **Cx PIV / Facet** +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: Degeneration -- | - Unilateral vs. bilateral (can | | often associated with joint | -- but does not cross midline | | arthropathy, where loss of | unlike discogenic) | | articular cartilage, synovitis | | | and associated joint space | - Sharp: Acute +/- sharp if | | narrowing results in degeneration | chronic | | and pain. | | +-----------------------------------+-----------------------------------+ | HPC: Quick, unguarded movement- | | | LF + Rot. Can be more gradual | | | onset for degenerative picture. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Difficulty with LF/Rot -- | | | e.g. turning for blind-spot, | | | looking each way on the road | | | etc. Stretch or compression | | | movements. | | | | | | - Unilateral? | | | | | | - Report HPC | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - Limited AROM -- Pain -- LF | | | and Rot (F + away = peri, E + | | | towards = intra) | | | | | | - Unilateral \> Central PAIVMs. | | | | | | - +ve neurological (if NR | | | compressed), +ve neurodynamic | | | if chronic | | | | | | - Mm. imbalance may be present | | | if chronic. | | | | | | - Tightness of Cx paraspinals | | | -- interlaminal | | +-----------------------------------+-----------------------------------+ **Cx Headaches** *Cervico-Genic* +-----------------------------------+-----------------------------------+ | Clinical Pattern | | +===================================+===================================+ | Pathophysiology: A lot of | - Area of | | information (C0, 1, 2, 3) | which trigeminal and cervical | | diverges into trigeminal and | nerves distribute in face / | | occipital in brainstem, brain | head region. Esp. | | becomes confused. | suboccipital region. | | | | | Headache or facial pain from | | | disorders of cranium, neck, eyes, | | | ears, nose, sinuses, teeth, mouth | | | or other facial or cervical | | | structure (C0-1) | | +-----------------------------------+-----------------------------------+ | HPC: 50% relating to previous | | | neck trauma e.g. Whiplash or | | | degenerative joint disease. | | +-----------------------------------+-----------------------------------+ | SE | | | | | | - Associated tinnitus, | | | light-headed, dizziness and | | | visual. | | | | | | - Agg: mechanical Cx movements, | | | sustained postures. | | | | | | - Ease: Supine, non-WB. | | +-----------------------------------+-----------------------------------+ | OE | | | | | | - FHP, poking chin. | | | | | | - +ve on vestibular tests | | | | | | - No big AROM/PROM but more | | | symptom reproduction in PROM | | | | | | - Mm. tight suboccipitals, | | | upper traps, upper Cx flexors | | | lost endurance. | | | | | | - PAIVMs- stiffness+ tender in | | | upper Cx | | +-----------------------------------+-----------------------------------+ *Tension-Type, Cluster and Migraine* +-----------------------+-----------------------+-----------------------+ | Clinical Pattern | | | +=======================+=======================+=======================+ | **Tension-Type** | **Cluster** | **Migraine** | +-----------------------+-----------------------+-----------------------+ | A. 20 mins-7 days | A. 5 attacks of B-D | A. 5 attacks of B-D | | | | | | B. 2 or more of: | B. severe | B. H/A 4-72 hrs | | | unilateral, | | | - bilateral | orbital, | C. At least 2 of | | pressing/tighteni | supraorbital | following:-unilat | | ng | and/or temporal | eral | | (non-pulsating) | pain, 15min-2 hrs | -pulsating | | | if untreated | -moderate/severe | | - mild-moderate | | -aggravation by | | | C. **one or more of: | or causing | | - not aggravated by | Autonomic NS | avoidance of | | routine physical | component** | routine physical | | activity eg | | activity e.g. | | walking, stairs | - ipsilateral | walking | | | lacrimation | | | C. both of | | D. At least 1 of: | | following: | - ipsilateral | -nausea/vomiting | | | nasal | (dizziness or | | - no nausea or | congestion | funny taste etc.) | | vomiting | | | | | - ipsilateral | **Photophobia/phonoph | | **no more than 1 of | eyelid oedema | obia** | | photophobia or | | | | phonophobia** | - ipsilateral | | | | forehead and | | | | facial | | | | sweating | | | | | | | | - ipsilateral | | | | miosis | | | | (↓pupil) | | | | and/or ptosis | | | | (↓eyelid) | | | | | | | | - a sense of | | | | restlessness | | | | or agitation | | | | | | | | Attacks from [1 every | | | | other day to | | | | 8/day] | | +-----------------------+-----------------------+-----------------------+ | - No Nausea / | Variable presentation | ±aura develops over | | Vomiting - no | & Most painful MSK | 5-20 mins, lasts \