Orthopedic Conditions & Assessment Week 14 PDF

Orthopedic Conditions & Assessment We e k 1 4 Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Screen and identify pertinent red flags Screen and identify pertinent yellow flags Discuss pain sensation and specific tissues Describe stages of injury and healing and the treatment goals at...

Orthopedic Conditions & Assessment We e k 1 4 Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Screen and identify pertinent red flags Screen and identify pertinent yellow flags Discuss pain sensation and specific tissues Describe stages of injury and healing and the treatment goals at each stage Compare and contrast normal end feels to pathologic end feels Define muscle spasm and guarding Red Flags Fractures Dislocations Infections Compartment syndrome You will learn about many more when we start discussing orthopedic adjustments Red Flags Fractures Hx of significant trauma? Older than 55? Dark black bruising? Four step test (4 steps without pain or altered gait?) Resisted isometric contraction Percussion – light palpation Pain with squeezing of the bone 128 Hz tuning fork or set your phone to vibrate and place on bone Inability to move damaged area? Dislocations *Neurovascular screen, ER Red Flags Compartment Syndrome Neurovascular screen, ER *5Ps pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements) *Vitals Labs: CBC, ESR, CRP I: erythema, streaking P: disproportional tenderness, increased warmth, spinal percussion Hx: IV drug use, steroid use, dental abscess, recent infection etc. Tissue Sensitivity to Pain Skin Most Sensitive Periosteum Fibrous Capsule Tendons ↓ Ligaments Subchondral Bone Cortical Bone ↓ Muscle Fascia Synovium Least Sensitive Fibrocartilage Articular Cartilage Pain & Specific Tissues Condition AROM PROM RROM Pain Muscle Injury ↓AROM WNL Pain Dull ache- sharp pain when (Strain or (Painful) (Pain at challenged tendinopathy) end ROM) Pain with palpation, stretching or contraction of damaged muscle (possible) weakness) Unidirectional pain with motion in muscle fibre direction Fascial Strain ↓AROM ↓PROM WNL May have palpatory (Painful) (Painful) (no subcutaneous adhesions, limited pain) ROM or non-dermatomal pain and posture changes Pain & Specific Tissues Condition AROM PROM RROM Pain Ligament Injury ↓AROM ↓PROM WNL Injured at full end ROM with (Sprain) (Painful) (Painful) (no tearing pain) Pain with palpation or stretching of ligament (passive over pressure) Instability due to full ligament rupture may show empty end feel, increase PROM or ‘clunk’ Capsulitis ↓AROM ↓PROM WNL Pain with direct capsule palpation (Painful) (Painful) (no or multidirectional pain with pain) motion – pain in a single direction indicates muscles or tendon damage Pain & Specific Tissues Condition AROM PROM RROM Pain Joint Injury ↓AROM ↓PROM WNL Mild loss of ROM or pain (arthropathy) (Painful) (Painful) (no Crepitus with scour test pain) AROM may show repeatable ‘snapping’ or ‘popping’ Pain may change with weather Joint WNL or Limited in WNL or Pain or point tenderness dysfunction limited specific weak Asymmetry/misalignment (subluxation) segmental ROM PROM abnormality or restriction ROM –joint ‘feels stuck’ Pain & Specific Tissues Condition AROM PROM RROM Pain Bone Injury ↓AROM ↓PROM ↓PROM Hx of trauma - perform fracture (fracture) (Painful) (Painful) (Painful) screen Pinpoint tenderness, dull ache but very sharp when challenged Nerve Injury ↓ or ↓ or ↓ or Numbness, tingling, or muscle WNL WNL WNL weakness & shooting electrical pain with compression of the nerve Tissue Stages of Healing Stages of Healing GOOD PAIN VS ACUTE PHASE (1-5 days) Main goals: BAD PAIN? Relieve pain Prevent muscle atrophy Re-establish pain-free ROM & normalize biomechanical function – support inflammation and the normal process of healing Low pain motion is key – the sooner you move the better the outcome will be Stages of Healing ACUTE PHASE (1-5 days) Treatment principles: METH – CI in compartment syndrome Protect – DO NOT re-injure damaged tissue (develop chronicity & delay healing) Relative Rest – short term cessation of use (1-2 days max)- continued excessive activity may cause further injury and delay healing Relaxation massage & breathing Stages of Healing POST-ACUTE PHASE (~2 days-6 weeks) Main goals: Normalize ROM & biomechanics, perform symptom free daily activities & improve neuromuscular control & muscle strength Prevent muscle atrophy Re-establish pain-free ROM & normalize biomechanical function – support inflammation and the normal process of healing Stages of Healing POST-ACUTE PHASE (~2 days-6 weeks) Treatment principles: Warm up prior to activity: key goal is restoring integrity & strength of dynamic & static stabilizers Isometrics progress to concentric exercises and then to eccentric exercises & finally to active/sport-specific exercises. AROM & mild strengthening activates: Massage Aquatic therapy **Pain free, submaximal exercise Stages of Healing FUNCTIONAL STAGE (2 week-6 months) Main Goals: Maintain a high level of ability Prevent tissue contracture & recurrence of injury Maintain normal biomechanical function Stages of Healing FUNCTIONAL STAGE (2 week-6 months) Treatment Principles: Normal gait pattern & fast walking If they can walk 20-30 minutes at a fast speed without pain or stiffness, short periods of jogging can be added to fast walking During later stages: sport massage and plyometric exercises to increase speed and power Importance of mental training/toughness, self talk & visualization cannot be overstated Stages of Healing REMODELING PHASE (3 weeks-12+months) Main goals: Maintain a high level of ability Prevent tissue contracture & recurrence of injury Maintain normal biomechanical function Stages of Healing REMODELING PHASE (3 weeks-12+months) Treatment Principles: Massage and IASTM – reduce scar tissue & promote healing Begin unilaterally with weights, using low weight and higher repetitions to monitor form & technique; slowly increase the weight as tolerated as long as pain/inflammation is not increased afterwards DO NOT increase weight or intensity too rapidly, can cause chronic injury (10% per week max) Warm up and post activity stretching are essential; address other compensations (posture, activations, imbalance, ergonomics)  Treatment Guideline Summary Phase Time Clinical Objective Course Acute 2-3 d (up Reduce pain: PRICE or METH as indicated to 7d) Emergency referral if required, prevent excess swelling/ ischemia Basic PFROM, activity as tolerated and relaxation massage Address psychosocial concerns (anxiety) Post- 2d – 6wk Pain reduction, prevent early scar tissue adhesion Acute Begin orienting repair tissue along line of tension Maintain normal muscle tone, ROM & functional capacity Basic stretch, strength, functional & proprioceptive training Chronic 2wks – Proper loading of repair collagen & myofascial tissue 12+mos Increase elasticity of scar tissue (increase ROM & strength Reduce fibrotic adhesion, relieve muscle spasms Advanced stretch, strength, functional & proprioceptive training Address psychosocial concerns (yellow flags) Yellow Flags – look familiar?! If the patient is not progressing as expected after 4-6 weeks (e.g. severe pain, pain is increasingly complex, multiple pain sites) Assess for biopsychosocial factors (Yellow Flags) that may indicate risk for developing persistent pain and disability Consider asking “How is the pain affecting the rest of your life?”  Yellow Flags Physical Factors Psychological Factors Social Context Lack of activity/prior Depression Injured at work; low job deconditioning Anxiety satisfaction; challenging Increasing age (levels out at Post-Traumatic Stress work relationships; age 60) Disorder (PTSD) awareness of work safety Early and high levels of Adverse Childhood issues disability Experiences On-going litigation or Duration or intensity of History of sexual abuse compensation issues pain, disproportional to Anger, fear, hypervigilance Poor support structure mechanism of injury Past/present history of (family and social) Family Multiple somatic substance use history of chronic pain complaints such as fatigue, Motor Vehicle Accident insomnia, anorexia Vulnerable populations Poor sleep (e.g., social determinants of Previous injury and/or health such as poverty, lack comorbid conditions, of stable housing, physical particularly if prolonged or mental/ cognitive recovery challenges, language and cultural barriers, frail  End Play (End Feel Types) NO End Play Definition (Example) RM Tissue Stretch Near end ROM hard/firm type of movement limited by AL tension in muscle & fascia i.e. cervical lateral flexion Soft Tissue Squeezing quality, near end ROM where soft tissue Approximation compression prevent further motion i.e. elbow flexion Ligamentous Hard, firm, painless ROM, limited by tension in ligament i.e. normal knee extension Bone to Bone Hard, non-giving, painless end ROM i.e. elbow extension  End Play (End Feel Types) AB End Play Definition (Example) NO Bone to Bone Painful, hard end feel RM i.e. osteophyte formation, ankylosis (fusion) AL Muscle Spasm Guarding or splinting feel caused by movement reduction secondary to reactive myoplasm to protect the injured tissues i.e. instability, trauma Capsular Firm, decreased ROM accompanied with pain, but not myospasm; synonym: boggy end feel i.e. edema, adhesions, synovitis, adhesive capsulitis Springy block Bouncing or springy, seen in joints with menisci (knee mainly), associated rebound effect i.e. internal derangement, meniscal lesion Empty Lack of normal end ROM resistance, usually associate with an increase ROM i.e. instability, hypermobility, ligament rupture Muscle Spasm and Guarding Following injury muscle within an affected area will contract to splint the area in an effort to minimize pain through limitation of motion. Involuntary muscle contraction in response to pain following an injury Spasm usually indicates increased tone due to upper motor neuron lesion in the brain