ortho-summary-notes.pdf

lOMoARcPSD|9328766 Ortho Summary Notes Orthopaedic Physical Assessment (Macquarie University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloade...

lOMoARcPSD|9328766 Ortho Summary Notes Orthopaedic Physical Assessment (Macquarie University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Ortho Summary Notes; Neck Pain: Grading Definition Associations Prognosis/Management Grade 1 No signs of serious - Stiffness, tenderness but no Reassurance and self-care, pathology and 0 or minimal significant neuro signs active rest interference with daily - Do not require further activities imaging or lab investigations Grade 2 Neck pain that interferes Can be quantified using self- Personal and environmental with activities of daily living report questionnaires assessment but no signs of serious - Neck Disability Index (NDI) Reassurance and self-care, pathology - Neck Pain and Disability active rest Questionnaire (NPDQ) A course of therapy may be - Visual Analogue Scale (VAS) trialed, however this unlikely to offer significant benefit Grade 3 Neck pain with neurogenic - Altered DTR’s Short term conservative care signs of nerve compression - Muscle weakness Referral in cases that are not - Sensory deficits responding - Other sign and symptoms indicating LMNL - Suggestive of malfunction of spinal nerves Grade 4 Neck pain with signs of - Neck pain and/or Require immediate referral if major structural pathology associated symptoms grade 4 neck pain. Cannot be suggestive of major handled with conservative e.g. fracture/dislocations structural pathology care Investigations = specific testing to rule out pathology Neck pain red flags: Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Fractures and Dislocations: The most commonly affected upper cervical segment is C2 The most commonly affected lower cervical segments are C5-7 Fractures and dislocations of the cervical spine most commonly occur in the 3 rd decade of life 56% of cervical spine fx will present with associated neurological symptoms Risk factors of fx/dislocation Age Commonly in ages 15-30 and then again 55+ Sex Men > women Congenital abnormalities e.g. agenesis of the dens Osteoporosis Must be considered in the 55+ age group Inflammatory arthridities e.g. RA or psoriatic Clinical presentation: Usually result of high energy trauma (car accidents, diving into shallow water, sporting injuries) Wide range of signs and symptoms depending on extent of neurological damage or compromise; o Severe neck pain o Major reduction in cervical ROM o Lump in the throat or difficulty swallowing o Difficulty breathing o Weakness and sensory changes Atlas Fractures: Account for 15% of all fractures of the C spine Usually at odontoid process Usually result from axial compression and/or hyperextension o Type 1 - oblique upper odontoid o Type 2 – base of odontoid process o Type 3 – odontoid into body Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Management of atlas fractures: Type 1 Managed with cervical orthoses ~ 8 wks Type 2 Treatment depends on stability of fx and the condition of the transverse ligament and degree of damage to the anterior arch Type 3 Treatment is based on the degree of fragment displacement – 2-7mm of displacement → halo-tarction and halo-vest 6-8 wks Dislocations Commonly surgical fixation + immobilization in less severe cases Traumatic spondylolisthesis (Hangman’s fx) B/L pedicle fx Radiculopathy: Grade 3 type neck pain Syndrome of pain and/or sensorimotor deficits due to compression of cervical nerve roots Commonly occurs in the following conditions; o Spondylosis o Instability o Disc herniation o Trauma o Other causes such as cysts, tumours, infection Clinical manifestations; Neck pain, although pain may not be present Altered DTR’s Numbness/tingling in upper quarter Electric or shooting quality pain in upper quarter Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Weakness in the upper quarter and alterations in neck muscle function Radicular pain VS radiculopathy: Radicular pain Radiculopathy - Pain perceived as arising in the upper limb - Includes neurological signs such as sensory cause by ectopic activation of nociceptive and/or motor deficits and altered DTR’s afferents in a spinal nerve or its roots - Motor weakness usually presents as the last - Radicular pain is not limited to a particular symptoms in cervical radiculopathy or dermatome, in fact it can be perceived in all stenosis structures that are innervated by the affected nerve root (mm, ligs, joints, bone and the skin) Radicular pain and radiculopathy are not the same thing, but can occur simultaneously and are likely caused by the same clinical entities Assessment for cervical radiculopathy: Upper limb neurodynamic tests Kemp’s test Maximal foraminal compression test Spurling’s test Valsalva maneuvre Jackson’s compression test Cervical compression test Shoulder depression test Neuro examination: DTR’s Dermatomes Myotomes Gait assessment Babinski reflex Hoffman’s reflex Test for clonus Tone assessment Inflammatory Arthridities Rheumatoid - C spine involvement in 25-80% of patients - Weakens or obliterates ligs, arthritis - Atlanto-occipital and C1-C1 region most tendons, muscular or capsular commonly affected attachments - Pannus formation or mechanical impingement can compress neural and vascular structures due to their close relationship to bony structures in the cervical spine Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Atlantoaxial instability - Subluxation - Basilar impression (can cause vomiting, nausea, dysphagia and cerebellar symptoms) Ankylosing May induce structural deformity on C spine - Instability (but rarer) Spondylitis Male: females 2:1 - Predisposed to fx due to vertebral 2-4th decades usually diagnosed fusion (C5-T1 most common) Systemic involvement – vision, respiration, digestion Psoriatic Arthritis Usually associated with psoriasis - Neck pain, reduced C ROM, Males: females 1:1 neurological symptoms, pain Between 25-40% of report C symptoms preceding lengthy periods of sitting and stiffness, (worse in mornings) - Subluxation of C1-2 (but less common than RA) - Erosive bony change Myelopathy: Grade 4 neck pain Spinal cord pathology - usually due to compression of spinal cord by osteophytes, disc material, hypertrophied/ossified ligs, inflammation Other causes; o Extradural masses o Infection o Neoplasm o Inflammation o Ossified ligaments o Nutritional causes o Penetrating trauma Nature and character of the symptomatology is determined by; o Level of compression o Rate of compression o Origin of compression o Duration of compression Clinical presentation; Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Vascular causes of neck pain: Grade 4 neck pain Vertebral and carotid artery dissection and arterial conditions can sometimes present as neck pain Can mimic MSK disorders CAD: General term for a range of pathologies that may produce cervico-cranial ischaemia Tearing of one or more layers of the vertebral or carotid arteries or part of the vasa vasorum: o Tunica media o Tunica intima o Tunica adventitia Most commonly internal carotid artery 4th and 5th decade of life Accounts for 10-25 of stroke in these ages groups Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Aetiology ,Risk factors and SS’s for CAD Aetiology - Mechanism not fully understood - Spontaneous or traumatic - Genetic predisposition - Minor trauma - Migraine headaches Risk factors - Pregnancy and postpartum - Previous infection or inflammation - Connective tissue disease - Strangulation and hypertension Signs and symptoms - Dizziness/vertigo - Dysphagia - Drop attacks - Malaise and nausea - Vomiting - Unsteadiness in walking, poor coordination - Visual disturbances - Severe headaches - Weakness in extremities - Sensory changes in the face or body - Dysarthria - Loss of consciousness, disorientation, lightheadedness - Facial paralysis - Hearing difficulties Imaging = doppler ultrasound Digital subtraction angiography (gold standard for diagnosing and excluding cervical dissections) Cervical Instability: Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Loss of ability of the spine under physiologic loads to maintain its patterns of displacement Types; o Atlanto-axial instability o Subaxial instability o Cranial instability Aetiology, clinical presentation and exam findings Aetiology Trauma - major or repetitive trauma Advanced spondylosis Genetic predisposition Inflammatory arthropathies (RA) Surgery Clinical presentation - Reluctant to move head into flexion - ‘Lump in throat’ sensation - Lip or facial paraesthesia - Severe headaches - Dizziness - Nystagmus - Nausea - C=vomiting - Pupillary changes - Cervical pain - Nystagmus - Paraspinal muscle spasm - Pain during sustained postures - Complaints of ‘locking’ or ‘catching’ - Radiculopathy, myelopathy, or death in extreme cases Physical examination Diagnosis made using info form neuro and imaging findings Neuro; - Motor exam → upper and lower limb myotomes - Sensory exam → dermatomes from C2-S4/5 (light touch and pin prick - Soft or empty end feel Cervical sprain/strain injuries; Damage to facet capsules, ligaments, and/or musculotendinuos structures in the C spine Aetiology, clinical presentation Aetiology Overload injury due to excessive forces (whiplash or hyperextension event) Other causes; - Over exertion - Awkward or prolonged postures - Psychosocial factors - Overhead, repetitive or unusual upper extremity work Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Clinical presentation - Axial neck pain that is dull or achy in quality - Decreased and painful neck movement - Headache (originating from occipital region and radiating to frontal region) - Sensation of a heavy head, neck fatigue, and pain with static postures Physical examination - Reduced ROM findings - Diffuse tenderness along paraspinal musculature - Myofascial trigger points may be present - Pain with AROM and resisted isometric movements Paraclinical studies Only required if red flags present Discogenic Neck Pain: Neck pain being generated from damage or degeneration of the IVD o Compression of nervous tissue by herniated IVD’s o Ingrowth of free nerve endings into damaged IVD’s Aetiology, risk factors and clinical presentation Aetiology Patients develop neck pain after some inciting event; - Whiplash injury - Post-traumatic arthropathy - Post-surgical pain - Aging and/or advanced spondylosis Risk factors - Smoking - Advancing age - Repetitive neck motions - Trauma Note: disc degeneration increases risk of disc herniation Clinical presentation - Insidious onset neck pain - Pain local or referred - Pain location (axial, shoulder pain, non-radicular arm pain, anterior chest wall, vestibular dysfunction, ocular dysfunction - Headaches - Neck stiffness Physical examination finding Highly dependent upon severity and local of the disc damage/degeneration - Reduced ROM - Midline tenderness Facet Mediated Neck Pain: Neck pain being generated form: o Facet joint impingement Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 o Synovial fold pinching o Facet joint capsule sprain Aetiology, Clinical presentation and Physical exam findings Aetiology - Whiplash or similar hyperextension injury - Post-traumatic arthropathy - Post-surgical pain - Advanced spondylosis Types of receptors (that are capable - Silent nociceptors of generating pain) - Low-threshold mechanoreceptors - Mechanically sensitive nociceptors Clinical presentation Pain; U/L or B/L - Dull and achy - Continual - Located in the suboccipital and/or posterior neck regions or shoulders - Moderate-severe in intensity Neck stiffness and reduced cervical ROM Cervicogenic headaches Physical examination findings Reduced ROM Capsular pattern; - Lateral flexion and rotation equally limited - Limited extension - End feel alterations - Abnormal joint motion, tenderness and abnormal tone in C spine paraspinals - Abberant function in the C spine (weakness on muscle testing due to arthrogenic muscle inhibition) Paraclinical studies Fluoroscopy guided medial branch blocks (gold standard) for assessing cervical facet joint involvement Tumours: Two general categories; Tumours that affect the vertebrae Tumours that affect the tissues adjacent to the vertebrae SS’s and Assessment Signs and symptoms - Mild neck pain through to severe night pain and continuing pain at rest - Pain not relieved by analgesics - Referred pain - U/L or B/L symptoms - Neck stiffness Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Associated torticollis - Presence or mass - Neurological deficit - Deformity - Decreased ROM Assessment Observation Vitals Normal ortho examination Full neuro exam Imaging; - MRI gold standard - Bone scan can be used to search for additional metastatic spread - Blood workup - Biopsy Infection: Referred to as ‘spondylitis’ Comprise of fungal, bacterial, myco-bacterial and parasitic infections that occupy various anatomical locations in or around the spine Arise from various sources; o Direct insult o Extension from a nearby infection o Haematogenous spread Patients with greater risk; o Involved in high risk behaviours o High risk environment o Immune-compromised o Previous spinal surgeries Risk factors for pyogenic vertebral osteomyelitis (PVO): Intravenous drug use Immune-compromised Diabetes mellitus Malnutrition Oncology hx Renal failure Alcoholism Obesity Congenital immune-deficiencies Symptoms and assessment Symptoms - Often insidious onset Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Neck pain - Severe, unremitting pain that can wake them from sleep - Pain not proceeded by trauma or exertion - Pain accompanied by a hx of fever - Night sweats and anorexia may present - Neurological compromise Assessment Observation (signs of infection) Vitals Normal oartho exam full neuro exam blood work up Imaging - May start with plain film radiography and CT - Gold standard = MRI and radionuclide imaging Biopsy Whiplash-Associated Disorders (WAD): Acceleration-deceleration injury of energy transfer to the neck The transfer of energy to the neck can result in injury to the soft tissue or bony structures and may lead to a variety of clinical manifestations Mechanism of injury. Involved two factors; o Force vector o Change in velocity ▪ Usually occur in very small period of time (450ms) ▪ In MVAs, the injury is thought to occur between 60-100ms Reflex protective mechanisms occur too late (postural reflex and voluntary responses) The threshold for injury is a change in velocity of >8km/hr in rear end collisions Startle Response - Elicited by a multi-sensory stimulus - Paraspinal and appendicular muscle activation (generalized flexion response in body) - Increases neck muscle activity and increased activity in the posterior neck muscles, in particular the cervical multifidus muscles Epidemiology and Signs and Symptoms Epidemiology Affects 83% of individuals involved in a MVA Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Women are more badly affected compared to men (increased tendency to chronicity also) SS’s - Neck pain - Upper and mid-thoracic pain - Shoulder pain - Arm pain/paraesthestia/weakness - Headache - Decreased ROM and mobility - Hard neurological signs - Cervical spine fracture - Blurred vision - Memory and concentration problems - Insomnia - Vertebral artery disturbance - Palpitations - Dyspnoea - GI disturbances - Motor dysfunction Note: myofascial pain syndrome eis common following a WAD injury WAD classification Imaging - Plain films - CT and MRI - Nerve conduction studies for radiculopathy and peripheral neuropathy Diagnosis - Diagnosed clinically Cervical Spondylosis: Degeneration of the various components of the spine (vertebrae, joints, discs, ligs, entheses) Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Risk factors, clinical presentation, Risk factors - Age (degeneration changes starts from age 20) - Smoking - Axial load bearing - Certain occupations (meat carriers, dentists, race car drivers, aviators, astronauts) - Previous lumbar radiculopathy Clinical presentation - Insidious or traumatic event - Pain aggravated by movement (referred pain, retro- orbital or temporal pain) - Cervical stiffness - Vague numbness, tingling or weakness in upper limbs - Dizziness or vertigo - Poor balance Physical examination findings Reduction in ROM of C spine - Capsular pattern = lateral flexion and rotation equally limited, limited extension - Alterations to normal end feel, tenderness and abnormal tone in C spine paraspinals - Weakness on manual muscle testing Paraclinical studies - Electromyography and nerve conduction studies (gold standard) Costochondritis and Tietze Syndrome: Inflammation, typically without associated swelling, of one or more of costal cartilage structures causing pain and discomfort in the anterior chest wall Aetiology and clinical features Aetiology - Often insidious onset - Trauma - Recent strenuous exercise especially movements that stress upper trunk and upper extremity - Often preceded by recent illness that involved coughing/vomiting - Can be associated with seronegative spondyloarthropathy - Can be associated with vit D deficiency Clinical features - Anterior chest pain (sharp, aching, pressure-like) - Exacerbated by upper trunk movement, deep breathing, exertional activities, and can be present at rest - 2nd-5th costochondral cartilages most commonly affected Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Commonly U/L - Swelling is uncommon Diagnosis Made clinically Often imaging in unremarkable CT – can delineate between cartilage structures and other pathology (e.g. tumours) Tietze Syndrome: Presence of painful, benign swelling of the costal cartilages Diagnosis of exclusion Aetiolgy and physical examination findings Aetiology - Not well understood - Can follow minor trauma or periods of physical strain - May present after excessive coughing or vomiting - Suspected association with viral infections Physical examination findings - Pain in anterior chest during AROM and PROM - Pain during respiration - Pain on palpation - Swelling over costosternal or costochondral joints Diagnosis Made clinically Imaging studies are usually unremarkable CT – delineates between cartilage structures and other pathology (e.g. tumours) Hyperkyphosis: An increase (>40 degrees) in the physiological thoracic kyphosis (T1-T12) Aetiology and clinical presentation Aetiology - Vertebral fx - Degenerative disc disease - Muscle weakness (spinal extensors, sarcopenia) - Reduced spoinal extension mobility - Heritable diseases - Neurological conditions - Osteochondrosis (e.g. scheuermann’s disease) - Idiopathic Clinical presentation - Pain around apex of deformity - Rounded shoulder, hyperlordosis and FHC Physical examination findings - Tenderness of palpation at site - Angulation notes on sideview of the Adamas Forward Bending Test - Reduced thoracic spinal extension Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Tightness of the hamstrings and iliopsoas - Neurological compromise - May have scoliosis and lower lumbar spondylolisthesis Imaging - X rays (gold standard) Scoliosis: Deviation of the spine in the coronal plane that includes vertebral rotation Types; o Structural o Non-structural (functional) Classification Types Non-idiopathic scoliosis Idiopathic Types; 1. Infantile idiopathic scoliosis (0-2 yrs) 2. Juvenile idiopathic scoliosis (3-9 yrs) 3. Adolescent idiopathic scoliosis (10-17 yrs) 4. Progressive idiopathic scoliosis Aetiolgy and Heuter-Volkmann Principle Aetiology - Genetic abnormalities - Vestibular abnormalities - Mechanical abnormalities - Metabolic abnormalities - Hormonal imbalances - Neuromuscular changes - Growth abnormalities Heuter-Volkmann Principle - Bone growth is retarded in areas where pressure is increased and Scoliosis - Bone growth is accelerated in areas where pressure is decreased - Uneven pressure is created when weight-bearing joint surfaces are not parallel, as seen in the convexity of the scoliotic spine Grading Mild = 56 Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 T4 Syndrome: A vague constellation of symptoms in the upper thoracic spine and shoulder girdle. Rare condition. Aetiology, clinical features and Aetiology Thought to be a result of intervertebral joint problems in the upper thoracic spine (T2-T7) Hypothesizes entrapment ischaemia of sympathetic nerves → sympathetic ganglion → altered vasoconstriction in arterioles and capillaries Clinical features - Aching in mid-upper T spine - Diffuse arm pain (non-dermatomal) - Usually begins with U/L presentation with a glove distribution of pareasthesia and may progress to B/L paraesthesia in the hands - Hands may feel hot or cold or swollen - Arms may feel heavy - Generalized headache - Inter-scapular tightness Physical examination findings - Limited cervical mobility - Mid-thoracic hypomobility - Neurological and vascular testing typically unremarkable Imaging - To rule out other potential causes of the patient’s symptoms Thoracic Spine Disc and Joint Dysfunction: Thoracic disc disease; Progressive, gradual wear and tear of the intervertebral disc affecting the outer annulus fibrosis and nucleus pulposus Degeneration of the disc is associated with normal aging but can be accelerated as a result of trauma, repetitive strain or injury Less common when compared to lumbar and cervical regions Aetiology and clinical presentation Aetiology - Age related degeneration - Trauma - Sport specific biomechanics - Other factors – smoking, obesity, sedentary lifestyle Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Clinical presentation - Back pain (often insidious, intermittent or constant and maybe radicular) - Pain can be retrogastric, retrosternal or inguinal regions - Associated osteophytic formation - Bowel or bladder changes motor and sensory disturbances - Spasticity - Long tract signs Imaging - X-rays – reduced disc height, disc calcification, osteophyte formation, hyperkyphosis, schmorl’s nodes, endplate irregularities - MRI – disc herniation, nerve root, thecal sac/spinal cord compression Thoracic Facet Pain: Can be sudden or gradual onset Pain and stiffness in and around the thoracic spine and rib cage Referred pain is common Pain can be B/L Pain is aggravated by; o Prolonged standing o Hyper-extension o Torsional movements Paraclinical studies; o X ray – generally unremarkable o Medial branch blocks o MRI – to rule out other pathology Thoracic Spine Fractures: Fracture to one or more of the components of a thoracic vertebrae Can be stable or unstable Fractures can be combined with dislocations Mechansim of injury, aetiology, clinical presentation of thoracic spine fx Mechanism of Injury - Axial compression - Flexion - Lateral compression - Flexion-rotation - Shear - Flexion distraction - Extension Aetiology - Majority due to MVA’s - Other causes = falls, sporting injuries, acts of violence Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Epidemiology Males > females 4:1 Fx incidence increases in elderly over 65 yrs Clinical presentation - Pain - Muscle spasm and guarding at the level of fx site - Reduced and painful ROM - Increased kyphosis or other deformity - May be associated with pain on respiration - May be associated with neurological deficit - Alteration in height in eldery patient Imaging X-rays; - Loss of vertebral body height - Widened paraspinal line - Widened mediastinum CT; preferred modality for suspected spinal fx’s Rib Fractures: Rib fractures occur when a significant force is dreicted to a rib causing fracture Can be pathological Epidemiology, clinical presentation and physical examination Epidemiology - Grossly under reported - More common in adults - Stress fx’s in certain athletes (baseball pitchers, discus throwers) - Ribs 4-9 most commonly fx’d Clinical presentation - Pain over fx site - Pain on inspiration - Dyspnoea - Hypoventilation Physical examination - Chest wall deformity - Tenderness on palpation - Muscle spasm and reduced thoracic spine and rib cage mption - Crepitus during inspiration or palpation - Check for signs of ventilatory insufficiency (cyanosis, tachypnoea, activation of accessory breathing mm., anxiety and agitation) Imaging - Often difficult to visualize - AP and lateral chest x rays (but have poor sensitivity) - Diagnostic ultrasound - CT - Bone scan Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Sternal Fractures: Fracture of the sternal body or the manubrium. Very painful Epidemiology, clinical features and physical examination findings Epidemiology - Usually result from direct blow to anterior chest or acceleration/deceleration injuries (MV’s) - Direct impact sports - More common in males and patients >50 yrs Clinical features - Severe localized pain over anterior chest wall - Pt reluctant to inspire fully Physical examination findings - Anterior chest deformity - Crepitus may be felt during inhalation and/or exhalation in cases of significant displacement - Reduced chest expansion and muscle splinting and spasm - 50% present with overlying soft tissue oedema or ecchymosis Imaging - Plain films (AP, lateral) - Ultrasound - CT (gold standard) Xiphodynia: Pain in the region of the xiphoid cartilage Inflammation of the xiphosternal joint Rare condition – but likely under reported Aetiology and clinical features Aetiology - Acceleration/deceleration injuries - Blunt trauma - Heavy lifting (due to mm that attach to xipoid – abdominals) Clinical features - Epigastric or substernal pain - Pain may refer to precordium, abdomen or even throat or arms - Difficulty with deep breathing or lying prone - Pain may be aggravated by heavy meals, bending or twisting Physical - Xiphoid cartilage is tender examination findings - The pt’s pain is usually replicated via palpation over xiphoid - May be associated with palpable swelling over xiphisternal joint Imaging - Only necessary to rule out other potential causes of pt’s symptoms - X-ray/CT - Is a diagnosis of exclusion Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Temporomandibular Disorders: The TMJ can be affected by trauma as well as inflammatory, infectious, congenital or developmental abnormalities and neoplastic diseases. Epidemiology, aetiology, clinical presentation Epidemiology - Most common cause of non-dental orofascial pain and very prone to chronicity - Affects 10-15% of adults and 4-7% of adolescents - Mean age = 30-40 yrs - Women > men 2:1 Aetiology - Physical SS’s with accompanying changes in behaviours, emotional status, and social interactions as manifestations of general central nervous system dysregulation - Biological factors - Co-morbid pain conditions - Psychosocial factors - Trauma - Dental procedures - Anatomical differences - Smoking Symptoms Cardinal features of TMJ dysfunction; - U/L orofascial pain +/- referral, aggravated by jaw movement, function or parafunction - Restricted, asymmetrical jaw movements - Joint noises - Joint locking Other symptoms; - Tinnitus, impaired hearing, and dizziness - Tension type headache - Neck and lower back pain - Psychosocial distress Subtypes of TMD Muscle dysfunction; - Myalgias - Myofascial pain syndromes Joint dysfunction; - Internal disc derangement - Temporomandibular arthralgia - Temporomandibular joint degeneration - Hypermobility Headaches associated with TMD Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Imaging MRI = gold standard Note: Imaging for myalgia is rarely indicated. Indications for imaging include; - Suspected advanced internal derangement - Arthritis - Non-responsive to treatment - Atypical pain - Sensory or motor dysfunction - Palpaale mass Orthopantomogram (special type of x-ray) for myalgia Myalgia, intra-articular disc derangement disorder and anterior disc displacement: What is it? Clinical presentation Myalgia Myofascial pain disorders are classified - Facial pain under ‘myalgia’ - Limitation of jaw motion - Muscle tenderness and/or stiffness (masseter, temporalis, SCM, trapezius, cervical musculature) - Head, neck, and facial symptoms Intra-articular Disc Defined as TMJ resulting from - Pain Derangement Disorder displacement of the TMJ disc from its - ‘clicking’ noise (reduction of normal position and/or deformation of disc) the disc. - Synovitis Types; - Altered joint mechanics 1. Anterior disc displacement with - Limitations in joint motion reduction 2. ADD with reduction with intermittent locking 3. ADD without reduction with limited opening 4. ADD without reduction without limited opening Types of Anterior Disc Displacement; Type What is it? ADD with reduction with - Disc returns to the normal position at some point during opening intermittent locking - The disc returning to normal is associated with ‘clicking’ sound (reciprocal click) - Click is not necessarily painful Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Reduction implies that the disc is moving normally, but is mispositioned - The jaw often deviates to the affected side then returns to the midline after the click has occurred - Displacement may result in intermittent locking which can progress to joint locking ADD without reduction with - Also referred to as a ‘closed lock’ limited opening - The displaced disc acts as a mechanical barrier to the rotation and translation observed in normal TMJ gait - Patients with a closed lock have reduced TMJ motion and pain on the involved side - Active opening usually 35mm - Joint sounds may be present but do not represent disc displacement with reduction - Imaging studies reveal disc displacement without reduction TMJ Arthralgia: Familiar pain in the masticatory structure. Clinical features; Pain in one or both joint sites during palpation Pain in the joint during maximum unassisted opening Pain in the joint during assisted opening Pain in the joint during lateral excursion Coarse crepitus is absent in cases of simple arthralgia Osteoarthritis of the temporomandibular joint: Aetiology - Trauma - Infection - Metabolic disturbance - Iatrogenic (previous surgery) Clinical features - Pain with movement - Limitations in joint motion - Deviation to the affected side - Joint sounds (no clicking/popping but grating, grinding and crunching) TMJ hypermobility/dislocation/subluxation Definition Movement of the mandibular condyles past the articular eminence and into the infratemporal fossa Excessive movement available in the joint can lead to dislocation or subluxation. Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Often associated with internal derangement of the TMJ Aetiology - Trauma - Developmental disorder - Connective tissue disorder - Idiopathic Headache attributed to TMD Definition Headache that occurs in the temple region secondary to a pain-related TMD Headache is affected by jaw movement, jaw function or parafunction The headache sis reproducible upon provocation of the masticatory system Shoulder: Most mobile joint in the body Static glenohumeral stability o Dependent on the integrity of soft tissue and bony structures such as labrum, GH ligs, capsular ligs and bony glenoid. Dynamic stability; o Shoulder girdle musculature Stability structures of the GH joint Static GH stability - Glenoid shallow socket on scapula – faces slightly anterior - Glenoid labrum – rim of fibrocartilage - Joint capsule - Ligamentous – anterior GH ligs Ligamentous function; - Coracohumeral lig – reinforces rotator cuff internal, limits ER/abd of humerus, inferior stabilizer - SGHL – reinforces rotator cuff interval, limits ER/abd of humerus, inferior stabilizer - MGHL – taut at 45 abd, ext 10 degrees and ER, anterior stability between 45-60 degrees of abduction Dynamic GH stability - Prime stabilisers – rotator cuff (pulls humeral head into glenoid fossa) - Deltoid – large stabilizing component - Long head of biceps – most effected when shoulder is extended - Long head of triceps – most effective when shoulder is flexed Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Prime Movers of the Shoulder Sternoclavicular joint: Resting position = arm by side Closed packed position = full rotation of the clavicle which occurs with maximum abduction of the humerus Capsular pattern = horizontal adduction and full abduction of humerus Acromioclavicuarl joint: Resting position = arm by side Closed packed position = 90 abduction Capsular pattern = horizontal adduction and full abduction Sources of Shoulder Pain: Intrinsic (local) Extrinsic (referred) o Myofascial o Articular o Radicular o Visceral Causes of referral pain to shoulder Visceral - Shoulder pain not aggravated by Heart – refers to anterior/superior movement shoulder and neck - Deep, poorly localized, no neuro Liver – right shoulder signs Gallbladder – right shoulder, scapular area Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Diaphragm - refers to C4/5 dermatome Lymph nodes – in axilla Lungs – refers to shoulder Pancoast Tumour - Uncommon lung tumour - Chdonric C8/T1 - Presents with cough, dyspnoea, radiculopathy haemoptysis - Medial arm and hand pain - Weakness ulna nerve distribution - Atrophy of intrinsic hand mm - +/- Horner’s syndrome - Supraclavicular swelling Imaging = CT, MRI, MRA, chest x-ray Death within 10.5 mths if left untreated Neck muscles Myofascial trigger points Scalenes and RC mm are the only neck mm that refer pain to shoulder girdle Myofascial Pain See lecture slides to see referral pattern Syndrome Shoulder Muscle Referral: 3 muscles of pseudoarticular pain o Anterior scalene o Infraspinatus o Supraspinatus Transient Brachial Plexopathy What is it? Transient, U/L injury to cervical nerve root/s or the brachial plexus Epidemiology Commonly occur in contact sports; - NFL, rugby, wrestling, hockey, basketball, boxing, weight lifting - Occurs in up to 50% of athletes Mechanism 1. Stretch or traction (increased acromio-mastoid distance) 2. Compression within the IVF; decreased acromio-mastoid distance 3. Contusion – direct low to Erb’s point Clinical presentation - Cradling or elevating the arm for anti-tension purposes - Bakody’s sign - Slightly flexed C posture - Most commonly occurs at C5 or C6 level Sensory and motor abnormalities; - U/L electrical or burning type pain - Pain/paraesthesia - Weakness Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Symptoms may develop hours to days after the injury Scapula Dyskinesis: Alteration of the scapula resting position and/or movement Altered activation, mobilization and stabilization of the scapula Abnormal scapula positioning and/or movement place under stress on the shoulder Aetiology, clinical presentation and clinical features Aetiology - Proximal mm weakness - Local muscle imbalance - Nerve injury - AC joint injury - Superior labral tears - RC injury - Fatigue - Altered activation patterns - Previous fx - Hyperkyphosis - Flexibility Clinical presentation SICK syndrome; - Scapula malposition - Inferior medial border prominence - Coracoid pain and malposition - Dyskinesis Clinical features - Dropped shoulder - Pain in medial border of scapula - Pain at or around coracoid Physical examination findings - Prominence of medial border of scapula - Excessive protraction during movement - Premature, limited or excessive movements or abnormal stuttering or jogging motions of the scapula during abduction of flexion - Asymmetry of movement and quality of movement Types; Tye 1 = inferior medial scapula border prominence Type 2 = medial scapular border prominence Type 3 = prominence of the superomedial border of scap Type 4 = normal Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Entrapment Neuropathies of the Shoulder: Clinically challenging to diagnose Typically caused by extrinsic compression or by stretching during repetitive movements Common entrapment neuropathies; o Suprascapular nerve o Axillary nerve o Long thoracic nerve o Accessory nerve o Dorsal scapular nerve Epidemiology and mechanism of Entrapment Neuropathies Epidemiology 2% of shoulder pain or painful instability Mechanism Direct; - Compression/tethering - Abnormal joint mechanics - Pincer action - Mechanically disadvantaged nervous system Indirect; - Immune - Chemicals - Temperature - Hormones - Poor circulation Cutaneous distribution Common Entrapment Neuropathies: Nerve Mechanism Clinical presentation Physical assessment Long thoracic Nerve Non-traumatic; Pain after injury - Reduced active arm Injury - Viral or toxic - Radiating from elevation agents neck into arm - MMT of serratus anterior Traumatic; Weakness; (weak and no pain) Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Motor innervation to - Repetitive - Not apparent - Wall push = +ve scapular serratus anterior) movements until several winging - Blunt force weeks after Functional alteration; trauma injury - Abnormal scapulohumeral - Idiopathic - Loss of shoulder rhythm protraction - Subnormal scapulothoracic - Prominent movement inferior scap - Scapular dyskinesis Suprascapular nerve Trauma – common - May be injured Pain on extremes of C/L neck Non-traumatic – at several points rotation (stretches Innervates; rare 2 common points of suprascapular nerve) - Supraspinatus compromise; Painful arc – 90-160 d - Infraspinatus - Suprascapular Increased pain on horizontal notch abduction - Spinoglenoid Tenderness on pressure notch Isometric resisted testing is Wasting; supra/infra = weakness without - Supraspinatus fossa pain - Infraspinatus fossa Pain; - Poorly localized over posterior shoulder - Aggravated by arm use - Occasional radiation to neck and lateral arm Weakness; - Shoulder abduction Shoulder ER Axillary nerve Usually GH - Gradual atrophy of - Deltoid atrophy dislocation deltoid - Sensory loss – light touch/pin Sensory distribution - Flattened shoulder prick) – military patch (after 3 months of - Weakness and no pain Motor; injury) - +ve extension lag sign - Deltoid - Pareasthesia, pain - Teres minor over lateral deltoid - Weakness – shoulder abd/ext Quadrilateral Space Syndrome: Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Neurovascular compression of the posterior humeral circumflex artery and/or axillary nerve or one of its major branches in the quadrilateral space Triceps Teres minor Teres major Aetiology, clinical presentation and examination of Quadrilateral Space Syndrome Aetiology Trauma; - Association with humeral fx or dislocation - Cases of repetitive trauma in throwing athletes, tennis players and volleyball players Fibrotic band compressing neurovascular bundle Hypertrophied muscular boundaries Other – glenoid osteophytes, ganglion cysts Clinical presentation - Deltoid injury - Pain and paraesthesia (military patch) - Non-dermatomal referral to forearm and hand - Localized tenderness in quadrilateral space - Pain in anterior shoulder with abd, lateral rotation and extension Physical examination - Point tenderness on palpation of QS - Pain on active or passive shoulder; abd at 90, ER, extension (after 1 min) Management - Physical therapy - NSAIDs - Active rest - Surgery – decompression of nerves and treatment of any shoulder abnormalities e.g. ganglion cysts Shoulder Girdle Trauma: Acromioclavicular joint sprain: Disruption to the AC complex +/- coracoclavicular complex Mechanism and Types of AC Joint Sprains Mechanism Trauma; - Fall onto tip of shoulder - Direct blow to adducted shoulder - FOOSH Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Types Clinical presentation - Localized pain in the AC region (tip of shoulder) - Painful motion particularly at end stages Physical assessment - AC joint tender on palpation - Pain on passive abduction from 90-180 degrees - Pain on passive horizontal adduction - Resisted tests negative in chornic AC problem - +ve O’Briens test Management - RICED - Early mobilization (type 1 = 1-3 days, Type 2-3 = up to 6 wks) - NSAIDs - Active rest - Strengthening regimens post-immobilisations period - Taping for sport or recreational activities - Orthopaedic consults recommended for type 4- 6 injuries Rotator Cuff Pathology and Subacromial Impingement: Subscapularis Supraspinatus Infraspinatus Teres minor Rotator Cuff Pathology Definition Involves pathological alterations in the rotator cuff tendons within a clinical, histological and imaging framework Epidemiology Most common cause of shoulder pain Increasing incidence with age Prevalent in occupations and athletic pursuits that involve overhead activities Mechanism - Eccentric overload - Repetitive micro trauma - Muscular weakness or tightness Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Age Risk factors - Lateral epicondylitis - Trigger finger - Carpal tunnel syndrome - Achilles tendonitis - Insulin use - Oral anti-diabetic medication use - Oral steroid use - Obesity (high BMI) Subacromial Impingement: High prevalence - Oedema and haemorrhage - Usually up to age 25 Stage 1 - Mechanical irritation of tendon occurs with overhead activities - Reversible, manages conservatively - Symptoms include +ve impingement sign, painful arc and varying degrees of muscular weakness - Fibrosis and tendonitis - 25-40 age group Stage 2 - Repeated episodes of mechanical inflammation, can include thickening or fibrosis of the subacromial bursae - +ve impingement sign, painful arc, varying degrees of muscular weakness - Severe degeneration - >40 yrs Stage 3 - Result of continues mechanical compression fo the RC tendon - Full thickness, partial thickness tears, biceps lesions and bony alteration of the AC and acromion can be associated with this stage due to repetitive stress to the shoulder Extrinsic VS intrinsic causes of Rotator Cuff Pathology: Extrinsic Intrinsic - Scapula and GH muscle imbalances - Age related degenerative changes - Postural changes - Insertional tendonitis may occur in the - Precipitating factors, relates to repetitive chronic degeneration phase leading to spur overuse formation, fibrosis, scarring and bursal - Posterior capsular tightness hypertrophy - Calcium deposits in the tendon in older patients Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Anatomic Anomalies: Bony narrowing of supraspinatus canal from bone spurs involved with arthritis of AC AC joint enlargement GT prominence Coracoacromial ligament thickening Morphology of the acromion; o Type 1 – flat o Type 2 – curved under o Type 3 – hooked 2 Impingement Syndrome: Mainly seen in younger athletes (30 - Heavy lifting, overhead work/sports, vibration - Can occur in children and adolescent Types Type 1; - Often crescent shaped - Longer in PA dimensions - Shorter on medial to lateral dimension Type 2; - Usually ‘L’ or ‘U’ shaped - Longer in medial-lateral dimensions - Shorter in posterior to anterior dimensions - Type 3; - - massive contracted tears - Proximal muscle bunching Imaging Plain radiographs Ultrasound MRI Management Conservative treatment should be trialed for 6-8 weeks Impingement and Tendinopathy: Pathology of subacromial impingement syndrome (SIS); With progression of the condition = swelling, fibrosis, and thickening of cuff tissue, possible hypertrophy and decrease of subacromial space May cause subacromial bursitis, rotator and biceps tendinosis, and eventual tearing Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Subacromial Impingement Syndrome Mechanism Overuse/repetitive micro trauma Common in throwing athletes SS’s - Sudden onset pain with tearing sensation, possible tear - Gradual increase of pain with overhead activities, possible SIS - Location lateral, superior or anterior, can refer to deltoid - Posterior pain-instability - Pain can be sharp, dull, catching, burning or throbbing - Relieved by rest or position change - Functional symptoms, sports or occupation specific Physical assessment - Stiffness, decreased IR/ER or abduction - +ve PA - +ve SIS tests - +ve manual muscle testing dependent upon muscle involved Imaging Radiographs MRI – specific for inflammation, oedema, haemorrhage, intrasubstance tendon degeneration and PRCT Tendinopathy Supraspinatus tendinopathy - Pain in A/PROM or weakness especially in abd/ER - Possible PA - Probable +ve impingement tests - Pain with stretching Infraspinatus and teres minor - Possible pain with restricted external rotation - Possible PA - May be pain on passive internal rotation - Soft tissue palpation may demonstrate inflammation, pain and boggy texture - Pain on isometric ER, add, and ER Subscapularis - Pain with resisted IR but strong - Possible pain in stretching (horizontal adduction) - Possible pain on active and passive ER Bursitis/Bursopathy: Bursa allows free and well lubricated movement of the greater tuberosity beneath the acromion in abduction of 60-130. Non specific unlocalized ache after overhead activities +ve PA signs Passive tests may or may not aggravate pain Resisted muscle tests likely to be +ve Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Resisted muscle tests do not specifically identify particular problem Biceps Pathology: Proximal biceps tendon is supported by; SGHL CH lig TH lig Supraspinatus, subscapularis tendon Long head of biceps tendinopathy Mechanism - Repetitive overload and friction (overuse - throwing sports) - Anatomic reasons - Direct trauma - Associated with → impingement syndromes, GH instability, tears to supraspinatus and/or infraspinatus Clinical presentation Diffuse anterior shoulder pain Pain; - On stretching bicep tendon - On resisted contraction of biceps - Throwing motion Physical examination - Point tenderness (biciptial groove, proximal tendon) - Pain on active straight arm flexion - Pain on ER at 90 abduction - Pain resisted forearm supination - +ve Speed’s and Yergason’s tests Shoulder Instability: Laxity VS instability; Laxity Instability Is the measured translation (linear displacement) of Instability is the symptomatic manifestation of one articular surface in relation to the other. Laxity pathological movement of one joint surface in is not a pathological state unless it is qualified as relation to the other. Inability to maintain the such. May predispose to instability humeral head in the instantaneous centre of motion, therefore it symptom generating. Types of Instability: 1. Atraumatic 2. Traumatic 3. Acquired - Typically multidirectional Diagnosis predominantly based on Atraumatic combination of 2 or 3 instabilities, clinical exam anterior, posterior and inferior - 3mm “Terry Thomas sign - Alteration in the normal angulation of the carpal bones MRI; - Combined with arthography CT; - Used when MRI is C/I’d Lunotriquetral Ligament Injury Definition A tear of the interosseous ligaments between the lunate and the triquetrum Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Epidemiology Less common than scapholunate ligament tears Mechanism of injury - Abnormal excessive loading with wrist in maximal extension - Abnormal or excessive loading with radial deviation of wrist with/without pronation - Tearing may be associated wit end-stage perilunate instability - Tearing may be associated with ulnocarpal abutment syndrome Clinical presentation - Dorsal wrist pain - Swelling - ‘popping’ or ‘clicking’ sounds during wrist motion - Decreased grip strength Physical examination - Localized pain of the lunotriquetral ligament - Clunking and crepitus during the wrist/hand AROM and PROM - Weakness during provocative wrist maneuvres - Decreased grip strength - +ve lunotriquetral balottment test - +ve finger extension “shuck” test Paraclinical findings - Don’t usually result in joint space widening Plain films; - Overlapping of the lunate and capitate - Alteration in the normal angulation of the carpal bones Perilunate Instability Definition - Form of carpal instability complex (CIC) - Dissociation of the capitate form lunate - 95-97% involves dorsal (posterior) dislocations - Deformity is subtle and spontaneous reduction can occur which can result in these injuries being missed - Can be acute or progressive - Can be purely ligamentous, or result of fracture Clinical presentation - Frequently follow high energy trauma - Swollen and painful wrist - If the carpus are dislocated, it is usually posterior Physical examination findings - High index of suspicion required - Swelling may be obscure bone landmarks - Often a prominent, palpable capitate dorsally - Dislocated lunate ca encroach on the carpal tunnel provoking symptoms of medial neuropathy Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Paraclinical findings Extrinsic Wrist/Hand Ligament Injury: A tear of one or more of the extrinsic ligaments listed below; o Radioscaphocapitate ligament o Radiotriquetral ligament o Ulnolunate ligament o Ulnotriquetral ligament Dorsal radiocarpal ligament Paraclinical findings - Extrinsic ligament tears best detected with MRI Scaphoid fracture: Break in the scaphoid carpal bone. Epidemiology - Male > female - 2.4% of all wrist fx’s - Most commonly fractured carpal bone - 20-30 yrs most common age - High in athletes and military personnel Mechanism of injury - FOOSH injury most commonly (with wrist extension and radial deviation) - Occur concomitantly with other fractures (perilunate fractures, distal radius fx) Types Clinical presentation - Hx of fall, MVA, punch or sporting injury - Wrist pain Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Tenderness over scaphoid (anatomical snuffbox) Physical examination - Palpable swelling over anatomical snuff box - Pain in anatomical snuff box on ulna and radial deviation - Pain on longitudinal/axial thumb compression - Scaphoid tubercle tenderness Paraclinical findings X-ray; - May not see in 15-20% of cases MRI; - Sensitivity 97.7% - Specificity 99.8% CT and bone scintigraphy as alternatives TFCC Complex Tears The TFCC is made up of several structures; Relatively avascular central disc Dorsal radioulna ligaments Volar radioulna ligaments Subsheath of ECU Ulna collateral ligament Mechanism of injury Acute trauma; - Axial loading through the wrist (with ulnar deviation plus wrist extension, OR with wrist rotation) - Individuals with +ve ulna variance are more prone to injury - Acute distraction Degenerative/overuse; - Common in sports involving forceful wrist flexion and rotation - Chronic loading of the ulnocarpal joint Clinical presentation - Ulna sided wrist pain in the location of the TFCC - Popping or clicking with wrist motion - Pain during powerful rotational hand movements Physical examination - Surgical tears - Pain with direct pressure over the palmar aspect of the ulna styloid - Axial loading with ulna deviation will reproduce patient symptoms - +ve Fovea sign - Possible instability at the DRUJ or carpals Paraclinical findings - Arthroscopy = gold standard for diagnosing TFCC pathology X-ray MRI with arthography Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 Forearm Compartment Syndrome Increase in forearm compartment pressure >30mmHg caused by an acute or chronic insult Results in a lack of blood flow to the forearm Acute Chronic exertional Epidemiology CECS in upper extremity is rare (more common in lower extremity) Higher in athletes; - Gymnasts - Rock climbers - Tennis players - Weightlifters - Rowers - Professional motorbike riders Pathopshyiology Aetiology Acute; - Fractures (distal radius) - Burns - Infections (bites) - Surgical trauma - Intravenous trauma - Bleeding disorders - External compression Chronic; - Excessive exercise of hypertrophy of forearm musculature - Exertion Clinical presentation Five ‘P’s - Pain (aching, squeezing and tightness) - Pallor - Pulselessness - Pain with passive stretch of muscles - Paraesthesia Skin manifestation including blistering SS’s in the chronic exertional type are transient and relived by rest Physical examination - Tense, swollen compartment Downloaded by min kyo kim ([email protected])  lOMoARcPSD|9328766 - Progressive neurological dysfunction - Pallor - Pain that is out of proportion to the injury during passive stretching - In chronic exertion al compartment syndrome physical assessment is often unremarkable if the patient is not engaged in the provoking activity - Normal intra-compartmental pressure is 0-15mmHg Paraclinical findings - Diagnosis of CECS can be made from hx and physical exam Finger Deformities: Swan Neck Deformity Definition Weakness of the PIP joint statis stabilisers combined with increased power of the long extensors and intrinsic hand mm. - Flexion of DIP and hyperextension of PIP Dislocation of the lateral bands of the extensor tendons Aetiology - Inflammatory conditions – most often RA - Chornic mallet finger - Injury - Hypertonia