Achilles Tendonitis/Tendinosis/Tendonopathy PDF

Achilles Tendinitis/Tendinosis/tendinopathy Presented by Dina Othman Shokri Achilles tendinopathy (common overuse injury) refers to a combination of pathological changes affecting the Achilles tendon usually due to overuse and excessive chronic stress upon the tendon. It can be...

Achilles Tendinitis/Tendinosis/tendinopathy Presented by Dina Othman Shokri Achilles tendinopathy (common overuse injury) refers to a combination of pathological changes affecting the Achilles tendon usually due to overuse and excessive chronic stress upon the tendon. It can be seen both in athletes and non-athletes. It may or may not be associated with an Achilles tendon tear. A lack of flexibility or a stiff Achilles tendon can increase the risk of these injuries. Achilles tendon is the thickest and strongest tendon in the body. Origin from gastrocnemius and soleus muscles and Insertion on calcaneal tuberosity, about 15 cm (6in) long. The tendon can receive a load stress 3.9 times body weight during walking And 7.7 times body weight during running. The tendon is surrounded by a connective tissue sheath (Paratenon) rather than a true synovial sheath, which function like an elastic sleeve and increase freedom of movement against surrounding tissues. The paratenon also provides the major blood supply to the Achilles tendon. The vascular supply to the tendon comes distally from intraosseous vessels from the calcaneus and proximally from intramuscular branches. There is a relative area of avascularity 2 to 6 cm from the calcaneal insertion that is more vulnerable to degeneration and injury. Blood supply to the achilles tendon is evident at the muscle tendon junction and at the tendon bone insertion. Vascular density is greatest proximally and least in the midportion of the tendon. Achilles tendon injuries are commonly associated with repetitive impact loading resulting from running and jumping. Either the tendon or paratenon (or both) can become inflamed and symptomatic, resulting in tendonitis or peritendinitis. Achilles tendinopathy is a common overuse injury caused by repetitive energy storage and release with excessive compression. This can lead to a sudden injury, or in the worst case, can cause a rupture of the Achilles tendon. Achilles tendinopathy characterized by pain in the posterior part of the heel it can be both acute and chronic in nature. A common term for this posterior heel pain is Achilles tendonitis, but this term may be misleading as it implies acute inflammation within the tendon, whereas it has been shown that other pathological processes may also be the cause of pain. It is better to call it as "tendinosis. These are "overuse" or "misuse" conditions caused by excessive and/or repetitive motion, often associated with poor biomechanics. The end result is a microtrauma injury. The over-stretching or over-use of the achilles tendon causes achilles tendonitis. Achilles Tendinitis/Tendinosis/ tendinopathy classified into Insertional: within 2 cm of its insertion. Mid-substance or noninsertional – 2-6 cm proximal to its insertion. Causes of achilles tendonitis 1) Overuse injury occurs with forces within the physiological range, but when repeated with poor recovery time, therefore, causing fatigue to the tendon, making it susceptible to micro tearing. 2) Sudden loading of excessive force, especially with eccentric motion, can cause damage. 3) Poor flexibility to gastrocnemius and soleus increase the strain to the tendon and can result in micro tearing. 4) Muscle weakness of the gastrocnemius and soleus will result in micro tears and inflammation to the Achilles tendon. 5) Joint restriction of the talocrural or subtalar joints, pes cavus lead to decreased shock absorption or poor ability to adapt to uneven terrain. 6) Excessive pronation, pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially, creating a whipping action. The whipping action, when exaggerated, may contribute to overuse degeneration and inflammation or microtears in the tendon, particularly in its medial aspect. 7) Systemic disease, such as diabetes, lupus, gout, are all related to weakness within the tendon structure. 8) Corticosteriod injections may be a cause of rupture and there is controversy with its use. 9) Training errors 10) Poor footwear-too small, worn-out, poor heel counter for rear foot stability and poor shock absorption 11) Running on unyielding or uneven surfaces Physical examination and finding -Morning pain is a hallmark symptom because the Achilles tendon must tolerate a full range of movement including stretch immediately after getting up in the morning. -Diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or stairclimbing, and relieved somewhat by wearing higher-heeled shoes or boots. -Often, a recent increase in activity levels (such as more stair climbing) or a change in footwear is reported by the patient. -Observable, palpable edema and thickening of the achilles tendon (The tendon can appear to have subtle changes in outline, becoming thicker in the A-P and M-L planes). -Achilles tendons will often have a painful and prominent lump or nodules within the tendon. -There may be crepitus during plantar and dorsiflexion. -A positive arc sign The patient lie on the examination table in prone position with the ankles clear of the table. First, the clinician palpates the Achilles tendon in a distal to proximal direction, between 2 and 6 cm above the insertion into the calcaneus, gently squeezing the tendon between the index finger and the thumb feeling for localized thickening of the tendon. Afterward, the palpating fingers stay on the area of swelling and the patient is asked to dorsiflex and plantarflex the ankle. In tendinopathy of the main body of the tendon, the area of swelling moves with dorsiflexion and plantarflexion. If the palpable thickening does not move but stays relatively still with palpable crepitation, the tendon sheath might be suspected as the area of injury. The use of a stethoscope might be a helpful addition in case crepitation cannot be felt. If an area of swelling cannot be identified, an area in the tendon 3 cm proximal to the calcaneal insertion is palpated during the movement. -Positive Royal London Hospital test (RLH) for Achilles tendinitis The patient can be in prone or sitting position with the foot over the edge of the bench. The ankle is in neutral or slight plantar flexion while you palpate the achilles tendon for tenderness. In midportion tendinopathy, this is commonly the case 2-5cm from the calcaneal insertion or right at the calcaneus in insertional tendinopathy. The patient is then asked to move the ankle into maximum dorsiflexion. The tendon is then again palpated at the previously found tender spot. Then the patient moves the foot into maximum plantarflexion and the tender spot is again palpated. The test is considered positive for achilles tendinopathy if the pain on the tender spot initially found is absent in the maximally dorsiflexion. The authors have no explanation as to why the pain disappears on maximal tension on the tendon. -Decreased ankle dorsiflexion (from tightness in the gastrocnemius– soleus tendon complex) and hamstring tightness are commonly found in patients with Achilles tendon pathology. -Calf atrophy is common in any Achilles tendon dysfunction (Atrophy is an important clue to the duration of the tendinopathy and it is often present with chronic conditions). -There is usually pain with passive dorsiflexion and on active or resisted planterflexion. -In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify. Bone spurs (extra bone growth) often form. it can rub against the tendon and cause pain.  Diagnosis Diagnosis depends on history, symptom behavior and clinical tests. X-ray: provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional achilles tendinitis. In cases of severe noninsertional achilles tendinitis, there can be calcification in the middle portion of the tendon. Insertional achilles tendinopathy with calcific enthesopathy -Ultrasound is the imaging modality of first choice as it provides a clear indication of the tendons width, changes of water content within the tendon and collagen integrity, as well as bursal swelling. -Magnetic Resonance Imaging (MRI): Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. Differential Diagnosis Plantar fasciitis Calcaneal fracture stress Heel pad syndrome (deep, bruises and pain in the center of the heel) Haglund deformity - this is a prominence of the calcaneus that can cause bursitis between the calcaneus and the Achilles tendon Sever's Disease - Irritation of the back of the calcaneus at the growth plate. Occurs in young children and adolescents, particularly around puberty and during growth spurts. Posterior Ankle Impingement Medial Tendinopathy Retrocalcaneal Bursitis Sural Nerve Lumbar Radiculopathy Ankle OA Deep vein thrombosis Management ❖ Medication ❖ Physical therapy ❖ Corticosteroid Injections ❖ Platelet-Rich Plasma Injections ❖ Operative Surgery Aims of treatment of physical therapy treatment ▪ Optimize foot biomechanics. ▪ Control the symptoms, decrease pain, edema and inflammation. ▪ Protected the inflamed tendon and enhance tendon healing ▪ Optimize the muscle activity balance.  Physical therapy To Control the symptoms (pain, edema and inflammation) using RICE +using physical agents to control symptoms and promote healing. Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Activities such as biking and swimming are low-impact options to help you stay active. For patients with nonacute Achilles tendinopathy, clinicians should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation. Cross-training activities: Exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (the "crossover effect"), and helps to prevent atrophy. Ice. Placing ice on the most painful area of the achilles tendon is helpful and can be done as needed throughout the day. Electrotherapy Modalities: Ultrasound and low level laser therapy may be used. Iontophoresis using dexamethasone in the acute stage. Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged area. Protected the inflamed tendon by using taping, Ant pronation taping is supported, many consider using taping, possibly prior to orthotics in the acute stage, then using orthotics (Air Heel Brace and Night Splints). Ant pronation taping taping If the pain is severe, you may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken the calf muscle. Foot orthotics may be needed if abnormal mechanics at the foot and ankle contribute to the onset or recurrence. Shoe wear: Firm, closed fitting heel counters. Heel pads and wide heel base for rear foot stability. Avoid stiff soled shoes: this increases the work of the muscle tendon complex. Figure 2. Heel Pads Air Heel Brace Heel lift can decrease stress on the tendon by effectively shortening it during weight bearing. As elevation of heel with small heel lift (1/4to3/8 inch) to decrease excursion of tendon. Transverse friction massage may to improve circulation and promote healing. Optimize the muscle activity balance by increase the flexibility of shorted muscle (calf muscle) and increase the strength of weak muscle (planter flexor muscle) at first unloaded isometric then concentric then eccentric then loaded exercises. Stretching of the tight and shortened gastrocnemius/soleus muscle complex. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. Strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation. These exercises should be progressed to closed-chain, heavily loaded eccentric exercises by carrying weight while doing heel raise to stimulate collagen fiber re-orientation and strengthening. The patient is instructed to sit then stand on the edge of a stair, do a toe raise up, then rapidly drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg. Isometric Loading- Achilles tendon holds: Isometric tendon loading act as a mainstay of tendinopathy treatment. Isometric tendon loading has been found to have pain-relieving effects on tendons, while simultaneously maintaining some baseline strength. Isotonic Loading- Calf raises These exercises are often commenced once the athlete's pain level and the tendon’s irritability reduces. There are no ‘hard and fast’ rules for when to start an athlete on isotonic loading for the rehabilitation of Achilles tendinopathy. Graduated isotonic loading is initiated once they have less than 5/10 pain on NRS or tolerable and acceptable pain on repeated single leg calf raises, and their morning tendon stiffness has been reduced significantly. The ultimate goal of the isotonic exercise is to develop strength in the tendon and the surrounding muscles. Isotonic seated calf raises Isotonic standing calf raises should be performed at the mid-range of the muscle’s movement. The benefit of performing Heavy slow resistance (HSR) exercise in the mid-range is that it will avoid the compression of the tendon at end of the range Energy Storage Loading- Plyometric Exercises: The crucial last stage of rehabilitation is the initiation and execution of ‘energy storage’ tendon exercises. These exercises include deformation of the tendon with jumping and hopping based exercises. These exercises help the tendon to regain its capacity to absorb and then release energy via the stretch- shortening cycle, The ankle mobilizations can be used for dorsiflexion limitation of the talocrural joint and varus- or valgus limitation of the subtalar joint. Balance exercises; Balance boards can introduce activities on uneven surfaces and add stress to mimic function in WB. Pool exercises can be appropriate to promote progression in weight bearing activities. N.B: The patients should ice the tendon area after activities until he has returned to normal activities. Prevention Prevention can be facilitated with -Proper foot wear -Maintaince of strength and flexibility for calf muscles -Monitoring activities and balancing any mechanical abnormalities at the foot and ankle. -Counterforce straps may decrease symptoms and tension to the achilles tendon. -Proper conditioning and warm-up, Almost all sport injuries can be avoided when proper warm-up and cool downs are used during and after practice. -Heel raises is a good warm-up. Thoracic outlet syndrome By Dina Othman Shokri  Objectives At the end of this lecture, the student will be able to: I. Overview ❖ Definition of TOS ❖ Etiology , Classification of TOS II. Identify how to diagnosis TOS III. Know what are the physical examination for TOS IV. What are the signs and symptoms for different types of TOS V. Know how to apply a successful patient management.  Thoracic outlet syndrome Thoracic outlet syndrome’ describes compression of the neurovascular structures as they exit through the thoracic outlet. The thoracic outlet is the anatomic space bordered by the first thoracic rib, the clavicle, and the superior border of the scapula (the clavicle anteriorly, the first thoracic rib posteriorly, the insertion of the pectoralis minor muscle onto the coracoid process of the scapula laterally, and the sternum medially). The thoracic outlet is marked by the anterior scalene muscle anteriorly, the middle scalene posteriorly, and The subclavian vasculature and brachial plexus—together termed the neurovascular bundle—pass from the scalene triangle into the costoclavicular space before exiting through the subcoracoid space. The thoracic outlet is both a confined and a dynamic space: compression of the neurovascular bundle resulting in the clinical syndrome generally termed thoracic outlet syndrome (TOS) may occur constantly or intermittently with movement of the neck, thorax, and arm This condition has emerged as one of the most controversial topics in musculoskeletal medicine and rehabilitation. This controversy extends to almost every aspect of the pathology including the definition, incidence, pathoanatomical contributions, diagnosis, and treatment. The pain and discomfort of TOS are generally attributed to the compression of the Subclavian vein, Subclavian artery, brachial plexus. The lowest trunk of the brachial plexus, which is made up of rami from the C8 and T1 nerve roots, is the most commonly compressed neural structure in TOS. These nerve roots provide sensation to the fourth and fifth fingers of the hand and motor innervation to the hand intrinsic muscles. TOS affects approximately 8% of the population and is 3-4 times as frequent in woman as in men between the age of 20 and 50 years (The mean age of people effected with TOS is 30s-40s; it is rarely seen in children). Females have less-developed muscles, a greater tendency for drooping shoulders owing to additional breast tissue, a narrowed thoracic outlet and an anatomical lower sternum, these factors change the angle between the scalene muscles and consequently cause a higher prevalence in women. Almost all cases of TOS (95-98%) affect the brachial plexus; the other 2-5% affecting vascular structures, such as the subclavian artery and vein. Possible 3 sites of compression of the vessels and nerves. Interscalene triangle Costoclavicular space Sub-coracoid tunnel or sub-pectoralis minor space Three spaces of the thoracic outlet.  Classification of thoracic outlet syndrome Vascular Thoracic Outlet Syndrome (vTOS): which represents approximately 3% of cases and compression is of the vascular structures (may be arterial or venous)) Neurological Thoracic Outlet Syndrome (nTOS): represents approximately 97% of cases and compression is of the neural structures of the brachial plexus. It may be divided into: True Neurological TOS (tTOS): is associated with true neurological deficits (mostly muscular atrophy). Disputed / non-specific / Symptomatic TOS (sTOS): is associated with symptoms of TOS, however, there are no objective neurological, electro- physical or radiological abnormalities. Causes Anatomical defects. Congenital may include an extra rib located above the first rib. Cervical ribs are present in approximately 0.5-0.6% of the population, 50-80% of which are bilateral, and 10-20% produce symptoms; the female to male ratio is 2:1. Cervical ribs and the fibromuscular bands connected to them are the cause of most neural compression. Fibrous bands are a more common cause of TOS than rib anomalies. Poor posture Dysfunctions or imbalances of the musculature of the neck and shoulder region. A common feature exhibited by individuals with TOS is a flexed head position, depressed and anteriorly shifted shoulder, and protracted scapula. This abnormal shoulder position, combined with 90° of abduction or flexion (as is commonly observed with those whose occupations require reaching, especially overhead, and repeated loading), could lead to a decrease in the costoclavicular space, increased friction of the neurovascular bundle in the subpectoral area. and a shortening of the sternocleidomastoid. The shortened sternocleidomastoid may cause the scalenes and pectoralis muscle groups to shorten, leading to improper head and neck alignment and postural dysfunction. The most commonly affected muscles in TOS Scalenes: When these muscles tighten, they pull on the first rib. These are accessory respiratory muscles, meaning they should help the diaphragm expand the rib cage while we breathe. If you have a bad habit of not efficiently using the diaphragm, then these muscles get overworked and will hypertrophy. Compression with movement of the scalene muscle. As the anterior scalene muscle goes from rest (A) to contracted (B), it pulls the first thoracic rib cranially and compresses the brachial plexus and subclavian within the costoclavicular space. Presence of a supernumerary cervical rib, as demonstrated in this figure, may constrict this space further. Pectoralis Minor. If this muscle is tight or shortened, it tilts the scapula forward, makes the scapula rotate downward, and promotes adduction of the shoulder which is a BIG problem for an overhead activity. Scapular stability. If the scapular muscle is weak as the Serratus Anterior and the Lower Trapezius. These muscles help posteriorly tilt the scapula while providing an upward rotational force to allow for appropriate positioning of the humeral head. If they are weak and the scapula is allowed to tip forward and rotate downward. Abnormal muscle mechanics at the pelvis. Pelvic alignment has been shown to affect posture, gait, and alignment of the axial skeleton (particularly the head and neck). If the axial skeleton is not aligned properly, stresses exerted on the body from exercise, occupational demands, or even from daily activities, may be distributed to other body segments and tissues that are not accustomed to adapting to these loads. For example, if the hip flexors (particularly the iliopsoas) are tight and the hip extensors are weak (particularly the glutes and hamstrings), the individual may exhibit an anterior pelvic tilt. In addition, abdominal muscles (e.g., Transverse abdominus) which normally generate a torque couple to resist the hip flexors, may be weak, thus causing lumbar vertebrae lordosis. This lordosis may induce thoracic vertebrae kyphosis, a common condition in those diagnosed with TOS. Trauma. This may involve macro-trauma, as in the case of an MVA (The scalene muscle could have been injured and scarred from a previous injury (whiplash), or microtrauma, as in the case of a muscle strain of the scapular stabilizers, resulting from repetitive overhead activities. The onset of symptoms related to a traumatic accident often is delayed. Trauma to the first rib or clavicle, and structural changes in the subclavian muscle or the costocoracoid ligament. Repetitive activity, such as typing on a computer, lifting things above head, as you would if you were stocking shelves. Athletes, such as baseball pitchers and swimmers, also can develop thoracic outlet syndrome from years of repetitive movements.  Diagnosis The diagnosis of TOS is essentially based on history, physical examination, provocative tests, and if needed ultrasound, radiological evaluation and electrodiagnostic evaluation. It must always kept in mind that TOS diagnosis is usually confirmed by elimination of other causes with similar clinical presentation. Especially differential diagnosis of cervical radiculopathies and upper extremity entrapment neuropathies. In order to diagnose accurately, the clinical presentation must be evaluated as either neurogenic (compression of the brachial plexus) or vascular (compression of the subclavian vessels).TOS manifestations are varied and there is no single definitive test, which makes it difficult to diagnose. Electrodiagnostic evaluation and imaging Nerve conduction studies and electromyography are often helpful as components of the diagnostic evaluation of patients with suspected TOS. Nerve conduction studies usually reveal decreased ulnar sensorial potentials, decreased median action potentials, normal or close to normal ulnar motor and median sensorial potentials. Typically TOS does not follow a dermatomal or myotomal pattern unless there is nerve root involvement. Vascular TOS can be identified with venography and arteriography. Imaging studies can provide useful information in the diagnosis of TOS. Cervical spine and chest x-rays are important in the identification of bony abnormalities (such as cervical ribs or a “peaked C7 transverse processes)  The physical examination Physical examination should include the following: Assessment of respiration to ensure patient is using correct abdominodiaphragmatic breathing. Assessment of the thoracic outlet closers muscles: The anterior and middle scalenes, subclavius, pectoralis minor and major These muscles typically are found to be adaptively shortened. Assessment of first rib position and mobility. Rib elevation caused by scalene hypertonicity, A post fracture callus formation of the first rib or presence of cervical rib. To detect the presence of first rib hypomobility. Cervical rotation–side bending test was used. The patient is seated and the clinician stands behind the patient. The test is in two parts. In the first part, the patient’s head is rotated to one side. From this position the patient’s head is flexed forward, and an end-feel assessment is made. The test is then repeated by first rotating the patient’s head to the other side and then flexing the head forward. A hard end-feel at the position of forward flexion indicates an elevated hypomobile first rib on the side opposite to the rotation. Assessment of Clavicle position: Clavicle depression and history of prior fracture, producing abnormal callous formation or malalignment. Assessment of Scapula position. Assessment of scapular muscle strength. Assessment of acromioclavicular and sternoclavicular joint mobility.  Signs and symptoms Patients with thoracic outlet syndrome will most likely present pain anywhere between the neck, face and occipital region or into the chest, shoulder and upper extremity. Signs and symptoms are typically worse when the arm is abducted overhead and externally rotated with the head rotated to the same or the opposite side. Symptoms depend on whether the nerves, the blood vessels, or both are compressed. When nerves are compressed, symptoms of neurogenic thoracic outlet syndrome include: Numbness or tingling in the arm or fingers. Pain or aches in the neck, shoulder, arm or hand. Arm fatigue with activity. A weakening grip. When the upper plexus (C5,6,7) is involved there is pain in the side of the neck and this pain may radiate to the ear and face. Often the pain radiates from the ear posteriorly to the rhomboids and anteriorly over the clavicle and pectoralis regions. The pain may move laterally down the radial nerve area. Headaches are not uncommon when the upper plexus is involved. Patients with lower plexus (C8,T1) involvement typically have symptoms which are present in the anterior and posterior shoulder region and radiate down the ulnar side of the forearm into the hand, the ring and small fingers. True TOS: Pain, paresthesia, numbness, and/or weakness (Objective weakness), S/s present day and/or night (Compressors*: s/s day>night) , loss of fine motor skills. Disputed Neurogenic TOS: Pain, paresthesia, and Subjective weakness "feeling" of weakness. Nocturnal paresthesias that often wake patient (Releasers*: s/s night>day) Occipital headaches Compressors - a patient that experiences symptoms throughout the daytime while using prolonged postures resulting in increased tension or compression of the thoracic outlet. These positions cause an increase in tension or compression of the neurovascular bundle of the brachial plexus. Releasers- Describes patients that often experience parasthesia at night that often wakes them up. It is caused by a release of tension or compression to thoracic outlet, that restores the perineural blood supply to the brachial plexus, signalling a return of normal sensation. This is used an indicator of a favourable outcome and resolution of symptoms. Symptoms of venous thoracic outlet syndrome can include: A change in the color of the hand or one or more fingers (Cyanosis) Hand or arm pain and swelling. Symptoms of arterial thoracic outlet syndrome can include: A pulsating lump near the collarbone. Cold fingers, hands or arms (Cold intolerance). Hand and arm pain (Claudication pain in arms that occurs while using the arms, the pain is caused by too little blood flow to arms). A change in color in one or more of the fingers or the entire hand (Pallor) Weak or no pulse in the affected arm. Special Provocative Testing: Roos Stress Test: It triggers the symptoms spontaneously experienced by the patient in less than one minute In order to determine if the scalene muscle is responsible, the roos test should be followed by the scalene cramp test and the scalene relief test. scalene cramp test: The patient is positioned in sitting and is asked to turn the head toward the painful side and pull the chin down into the supraclavicular fossa. This position causes contraction of the scalenes and should reproduce distal radiation of pain if the scalenes are involved. Scalene relief test: Is performed by asking the patient to actively place the forearm against the forehead on the involved side. This position increases the space between the clavicle and the scalenes and is positive for scalene dysfunction if it relieves the patients pain. The upper limb tension tests (ULTTs) are also known as Brachial Plexus Tension or Elvey Test. Morley’s Sign: Tenderness in the supra-clavicular fossa may have a diagnostic value when it is clearly asymmetrical and triggers distal pain. Supraclavicular pressure test: Tenderness at the root of the neck with pressure over the plexus in the interscalene groove causing neurological symptom. Special Vascular Tests: These include Adson’s Maneuver and Wright’s Test. The aim of these tests is to obliterate distal pulses by causing a dynamic compression of the vascular vessels.  Wright’s test (hyper abduction test): This test is considered by many to be the best provocative test for thoracic outlet compression caused by compression in the costoclavicular space. The test can be performed unilaterally or bilaterally. The patient is seated with his elbows extended. The shoulders are externally rotated and the examiner palpates the radial artery pulse. The examiner then passively abducts the patient’s upper extremities up to 180 degrees, keeping them posterior to the coronal plane. An option is to have the patient take and hold a deep breath. The examiner instructs patient to “tell me if you feel any changes in your arms.” Symptom production and pulse changes are noted.  Treatment Conservative management (medical, physical therapy Medical Management: Nonsteroidal anti-inflammatory drugs have been prescribed to reduce pain and inflammation. Botulinum injections to the anterior and middle scalenes have also found to temporarily reduce pain and spasm from neurovascular compression. Surgical management of TOS should only be considered after conservative treatment has been proven ineffective  Physiotherapy treatment ❑ First rib mobilization and 1st Rib manipulation ❑ MWM for First rib MWM for First rib First rib self-mobilization. The patient is positioned in sitting with spine supported. The cervical spine is retracted, laterally flexed away and rotated towards the treatment side. A thin sheet strap is positioned to contact the first rib on the cranial surface 1 inch lateral to the transverse process of T1. The patient uses her own hands to pull on the sheet loop and produce a mobilization force directed caudal and contralateral (towards the opposite hip). ❑ Cervical, thoracic mobilization ❑ Mobilization of the sternoclavicular and acromioclavicular joints is necessary to restore normal end-range arthrokinematics of the clavicle during elevation activities. ❑ Glenohumeral mobilizations in end-range elevation ❑ Cervical traction in combination with a hot pack and light exercise may reduce pain and irritable symptoms for some acute patients ❑ Massage or myofascial techniques and stretching to scalenes/pectoral muscles/scapular depressors,subclavius. N.B. Stretching of the pectoralis, lower trapezius and scalene muscles (These muscles close the thoracic outlet)  Subclavius stretch Lower trapezius stretch Glenohumeral mobilizations in end-range elevation with the elbow supported in extension ❑Strengthening to the commonly weakened muscles in TOS are scapular stabilizer ,rotator cuff (Facilitate co-contraction of the rotator cuff to help stabilize and centralize the humeral head). Deep cervical flexor and thoracic extensors Scapular depression. Scapular retraction Trapezius (lower)- Rhomboids - Trapezius Latissimus dorsi- Rhomboids Standing external rotation Trapezius (lower)- Infraspinatus- Teres minor-  banded straight arm extension Latissimus dorsi- Teres major- Triceps brachii banded high pull (Row) Latissimus dorsi- Trapezius* Rhomboids- Teres major/minor Prone shoulder extension, abduction, and horizontal abduction Trapezius- Supraspinatus- Infraspinatus- Deltoid -Latissimus dorsi- Teres major (I-Y-T exercices) frontal raise (deltoid) and lateral raise ( Deltoid- Supraspinatus- Trapezius Serratus push (Serratus anterior) chin tuck ❑Abdominal core transverse abdominis and rectus abdominis recruitment. ❑Breathing exercises (diaphragmatic) as TOS characterizes by shallow respiratory pattern (upper thoracic breathing). ❑ Supportive taping ❑ Neural mobilization ❑ Patient education and activity modification ❑ Postural re-education Disturbed sleep patterns are common in many people suffering from TOS, often as a result of either sleeping with the arms in an abducted, overhead position, or the consequence of the ‘release phenomenon’. If position dependent, then patients who cannot avoid the provocative position during the night may benefit from pinning the sleeve of the pajama arm to the pajama leg. Avoid sleeping on the affected side and on your stomach. The patient should sleep on the uninvolved side. Pillows may be placed under each arm when lying supine or between the body and the involved upper extremity when on lying on the side. These patients are instructed in the Cyriax release technique. The goal of this technique is to fully unload the neurovascular structures in the thoracic outlet prior to going to sleep at night, which will allow the patient to sleep through the night without waking. Before going to bed, the patient sits in a chair with adequate arm rests to place the shoulder girdle in a passively elevated position. As the load on the brachial plexus is released, the person’s symptoms begin and then gradually increase. Subsequently, as nerve function is normalized, the paresthesias begin to wane and eventually disappear. As a result of performing this technique, the patient will sleep longer into the night without waking. After one to two weeks of consistent use of this technique, it may be possible for the patient to sleep through the night without waking. Cyriax release maneuver.  Surgery ▪ Supraclavicular Scalenectomy. ▪ Transaxillary resection of the first rib: an effective procedure provided all nervous and vascular structures are completely released. ▪ Some larger-chested women have sagging shoulders that increase pressure on the neurovascular structures in the thoracic outlet. A supportive bra with wide and posterior-crossing straps can help reduce tension. Extreme cases may resort to breast-reduction surgery to relieve TOS and other biomechanical problems Postoperative physical therapy Rehabilitation begins with shoulder and cervical range of motion exercises and gentle neural mobilization techniques. Overhead activities and lifting are avoided for 2–4 weeks. If postural abnormalities or muscle imbalances are found, an exercise program that addresses these issues must be implemented to help prevent a reoccurrence of the patient’s symptoms. Rehabilitation After Knee Arthroplasty Mona Selim  Classifications Knee Arthroplasty is : Surgical construction of newly artificial, painless, movable and stable knee joint According to the replaced portion of the knee: Uni-compartmental Bi-compartmental Tri-compartmental According to mechanical constrain: Un-constraint Semi-constraint Fully -constraint According to type of fixation: Mona Selim Cemented Cemented-less Indications Knee arthroplasty was designed to relieve pain, provide motion, stability and correct deformity. So the indications are sever painful joint with or without deformity SECONDARY TO 1. Rheumatoid arthritis 2. Osteoarthritis 3. Traumatic arthritis Contraindications 1. Bone infection 2. Severe osteoporosis 3. Recent joint sepsis 4. Malignant tumours. Mona Selim  Mona Selim Classification According to the replaced portion of the knee: 1. Uni-compartmental: Replace opposing articular surfaces of femur and tibia of either medial or lateral compartment of knee, has Poor results 2-Bi-compartmental: provides for the replacement of the opposing articular surfaces of the femur and tibia of both medial and lateral compartments of knee 3.Tri-compartmental: Same as Bi-compartmental + resurfacing the patellofemoral articulation  Preoperative rehabilitation One purpose of the preoperative visit is to record a baseline of information. This includes measurements of : 1. Pain & Swelling 2. Functional abilities & ROM 3. Muscle strength A second purpose to prepare patient for postoperative program: 1. You will practice some of the exercises used just after surgery, e.g. isometric quadriceps. 2. Walking aids should be trained either the use of a walker or crutches. 3. If a CPM machine is to be used the patient should try this before surgery for easy post-surgery Mona Selim  Early postoperative stage Day one post operation. 1. Deep breathing exercises and coughing several times per hour 2. Minimize the chance of pressure sores. 3. ankle pumps 10 times every 2 hours to encourage circulation and minimize DVT 4. gluteal sets 5. upper extremity exercises. 6. Move patella up and down. gluteal sets 7. Quadriceps sets: 10 times repeated hourly throughout the day (why?) To reduce joint effusion To overcome muscle inhibition produced by pain Help to achieve the inner range strength Prepare to do the SLR exercises. (SLR should be attempted after the first two days ) Mona Selim  Two main forms of management 1-No CPM - Knee will be maintained in extended position for 4 days by - pressure bandage & splint. A large compression bandage is applied. A back splint holds the leg in the straightened position to prevent movement and reduce pain. No active exercise to the knee can begin until this is removed. SLR will not be possible at this early stage Assisted weight bearing begins from Day 2. Mona Selim  As soon as this is removed (after 4 days) Passive mobilization of the patella and the scar.(reduce pain and increase flexion) Active assisted knee flexion should begin twice per day for at least 20 minutes Patients discharged home at 5 -6 days (no complications) By the 7th postoperative day the patient must normally have 50-70o of active knee flexion Mona Selim Return of knee flexion should be undertaken at home. Flexion range should be increased by at least 10 degrees per day. If has not reached 50-70 degrees knee flexion by day 7; start CPM taking knee flexion up to its maximum and keeping 6 hours a day. The knee should reach 80 -90 degrees by day 14 If a CPM machine is not available the manipulation under anaesthesia may be indicated Water therapy, if available can be valuable. Mona Selim  2- CPM Use of CPM machine: - Immediately post-operative (in the surgical recovery room)up to 4 days, 6 hours per day - Range of flexion is controlled to 40 over the first 24 hours and increased by 10 per day until 80-90 flexion By day 7. -Active knee flexion will always return much more quickly than with the non- CPM group -Weight bearing with splint can start on postoperative day 2 and without the splint only after quadriceps control. Mona Selim -Unsupported weight bearing is often a day or two later in the CPM group due to greater quadriceps lag. Don’t use CPM for postoperative management of patients following uncomplicated total knee replacement (White n,etal.2015) Mona Selim  Disadvantages of CPM in the early stage: 1. Increased time in bed 2. Loss of independence if on CPM for long periods 3. Discomfort 4. Incidence of common peroneal nerve palsy 5. Patients on CPM have a greater quadriceps lag (what?) and should wear a splint at night or when off the CPM to reduce the possibility of holding the knee in flexion. Mona Selim  Extensor lag or fixed flexion deformity This can be a particular problem for the CPM group and occurs if there is an imbalance between the gain of flexion and of extension. How to solve this problem Mona Selim 1. Progression of passive flexion should be stopped until there is reduction of the extensor lag. 2. Gentle manual mobilization techniques Gd I or II Maitland mobilization can be used to help increase extension (avoid forceful mobilization or PROM>90◦ 3. Inner range quadriceps strengthening exercise 4. Hamstring and posterior knee stretching Mona Selim Mona Selim How to stretch the posterior aspect of a prosthetic knee replacement ? 1. POP, knee extension splint 2. passive knee extension stretch 3. isometric exercises and inner range quadriceps exercise 4. SLR Mona Selim  Functional rehabilitation Starts on week 3 Closed chain exercises e.g. 1. sitting to standing from various heights 2. step ups 3. small arch cycling. Mona Selim Mona Selim Mona Selim Proprioception training Loss of proprioception is normal with any joint replacement but removal of the ACL and joint capsule, exaggerates this loss following a knee replacement. Mona Selim  Walking For cemented prosthesis we recommend that crutches or a walker be used for 6 weeks and then a cane for 4 -6 months For cement-less prosthesis we keep crutches or a walker for 12 weeks. Walking instructions 1. Walk as rhythmically and smooth as you can. 2. Don't hurry. 3. Adjust the length of your step and speed. 4. gradually put more weight on your leg. 5. Use a single crutch or cane in the contralateral hand 6. You should not limp or lean away from your operated knee. Mona Selim  Stairs At first, you will need a handrail for support and will be able to go only one step at a time. Remember, "up with the good" and "down with the bad.". Stair climbing is an excellent strengthening and endurance activity. As you become stronger and more mobile, you can begin to climb stairs foot over foot. Mona Selim  Driving: Knee joint proprioception is definitely needed for driving, along with inner range quadriceps strength and ROM. Not before 6 weeks Avoidance of twisting and turning, jumping and running is essential for at least 3 months post operation some surgeons extend this to 6 months. The best knee replacements are offering about 80-85% of normal function, this is to be contrasted the total hip replacement, which being a simple universal ball and socket joint is much simpler mechanically and probably gives 90- 95% of normal function Mona Selim Total knee replacement Guidelines and Precautions Mona Selim Activity Cemented Cemented-less Range of motion 0-90◦ within 2 weeks 0-90◦ within 2 weeks 0-120◦ within 3-4 weeks 0-120◦ within 3-4 weeks Isometric exercise & Immediately postop. Immediately postop. active exercises Resisted exercises Begin at week 2-3 Begin at week 2-3 Mona Selim Ambulation Cemented Cemented-less Partial weight bearing as tolerated Varies from weight bearing as with walker immediately postop. tolerated (WBAT) to touch- down weight bearing (TDWB) Begin ambulation with cane at based on the surgeon’s week 3 postoperative. philosophy and the surgical approach. Begin transition to full weight bearing at week 4. Mona Selim  Cemented-less Ambulation TDWB: WBAT: Touch down weight bearing with walker weight bearing as tolerated with walker immediately immediately postop. postop. Weight bearing as tolerated with walker at week 6. Begin ambulation with cane at week 5-6. Ambulate with cane at week 8-10. Begin translation to full weight bearing at week 6. Begin transition to full weight bearing at week 10-12. *25% of body weight at 1-7 weeks. 50% by week 8. 75% by week 10. 100% without assistive device by week 12. Mona Selim Mona Selim  Problem-solving exercises A patient with a 3 day old new knee joint is complaining of a hot painful knee joint following exercise. On inspection the knee is slightly more swollen than prior to treatment. Why do you think this has occurred and what would you do about it? Mona Selim  Answer Possible causes are 1. Infection, (patient’s body temperature need to be checked) 2. DVT, (check to see if there are any signs of DVT in the calf e.g. swelling, pain and discomfort) 3. Too much exercise too soon (if flexion is pushed too much in the non-CPM group because they are not moving into flexion as regularly as the CPM group). Ice may be applied to the knee if sensation is intact and the leg elevated to help reduce the signs Mona Selim  Thank you Mona Selim