Stages of Healing
Types of Injuries
Joint Accessory Motions
This is new.
In the past we have had a paper based textbook to accompany the course. The feedback from former students, and the trend in general, has been to move away from paper based texts and adopt more electronic content. I have discovered over time, both as a student and from student feedback, that observing, feeling and participating in the evaluation process of orthopedic injuries, ingrains the information more effectively than reading or lecturing alone. My hope is that you will remember the content from this class and not simply 'learn' it to do well on the quizzes and tests.
We all learn differently; some are better at memorizing, some better with hands-on learning while others are visual learners. I try, as much as possible, to cater to all types of learners, both when I lecture, and hopefully in this new endeavour, a text.
People frequently ask me in this course and others I teach, "What should I memorize?". I am not a huge fan of this type of 'learning' as it has been shown to be ineffective in developing 'deeper learning'. Although deeper learning may not be important to you, if you plan on working in a health care setting, you may find many sections applicable for your future careers. My typical answer to the memorization question is that you have to memorize or ingrain some aspects, especially anatomy. Origins, insertions, innervations, etc. are all things that must be embedded in the brain to make sense or figure out how a muscle acts. But understanding how all tissues function in the healthy and injured states as a part of the whole body is also critical. Looking at static postures and states is an important part of the assessment process but it is only a snapshot of the overall person's function.
The anatomy sections in this text will aim to provide you with the most pertinent information for the course; it will not delve into the origin, insertion, action, function, innervations like other texts. I will direct you on to other sources for that or a review of your other previous anatomy classes. To understand the human body though, we must consider a number of different areas beyond anatomy alone; pathology, pathophysiology, biomechanics and physics, motor control, and others. This is critical in making connections between areas but, having said that, it also takes a keen eye and ear during your evaluation process. You must observe your client and, at times more importantly, listen to what they have to say after you ask some key questions. It doesn't end there though. You must also learn to integrate your sense of touch and feel when applying forces or tests to your client. Constant research is required to prove the efficacy of the testing processes we use. Is the test sensitive, specific, valid and reliable?
So I hope you can see that this is not a perfect process, nor is it an easy one. You must do more than simply memorize.
This 'text' will be broken into sections or chapters by body part. This will follow along with the format of the course. The plan is to use some text based pieces, some content quizzes, links, video and picture content. All of this is in an effort to cater to the various different learning styles and take advantage of the accessible content available online. Many of the video sections were filmed during my other classes and demonstrate the way, rationale and techniques I have learned to be the most effective way to perform each test. These are not the only way to perform the test, nor are they the only tests to perform. They are merely my interpretation of each test and the tests I consider to be the most important to perform for each structure we discuss. This is a work in progress so if you have input on the content or ideas for future content, please pass them along to me.
The first thing we need to address in learning about the various musculoskeletal (MSK) conditions is the process the human body uses to repair itself and the phases of healing. This knowledge is essential in understanding and rationalizing how we evaluate MSK injuries. In the future, after you have learned about the conditions and the evaluation process, you can also use this knowledge to design a rehabilitation program to assist your clients in reducing pain, increasing range of motion, strength, balance, motor control, etc. required to improve their condition.
We also need to review, on a cellular level, what takes place when and after an injury occurs. This is important in understanding the pathophysiology occurring at the site, as well as to systemically determine when it is safe to commence some forms of treatments we may provide for our clients.
You will be familiar with some of the terms below, but many are new and novel to this area. Just to make sure that we are all on the same page, please review the terms.
Anatomical Position: see picture
Medial: towards the mid-line of the body
Lateral: away from the mid-line of the body
Cephalo: towards the head
Caudal: away from the head
Superficial: close to the skin surface
Deep: not close to the skin surface
Proximal: closer to the trunk (referring to limbs)
Distal: further from the trunk
Supine: face up
Prone: face down
Valgus: angulation of distal part outwards, distal aspect of the distal bone moving away from the midline
Varus: angulation of distal part inwards, distal aspect of the distal bone moving toward the midline
Dorsal: posterior; pertaining to the back
Plantar: pertaining to the sole of the foot
Volar: pertaining to the sole or palm
- Horizontal • Vertical/Craniocaudal
- Sagittal • Medial/Lateral
- Frontal • Anterior/Posterior
- Flexion/extension: movement in the sagittal plane
- Abduction/adduction: movement in the frontal plane
- Internal rotation/External rotation: movement in the horizontal plane (vertical axis)
- Circumduction: combination of 4 primary movements: flexion, abduction, extension and adduction succeed each other. (eg swinging the arm in a circular fashion)- we do not test for this in our MSK assessment
Supination: palms up; occurs along the length of the forearm
Pronation: palms down;
*these can also refer to the sole of the foot; is purely a foot/ankle motion
Dorsiflexion: ankle movement that brings the top of the foot up
Plantarflexion: ankle movement that points foot down
Atrophy: shrinkage due to disuse (eg muscle)
Hypertrophy: enlargement due to training, excessive use (eg muscle, heart)
Side flexion: = side bending (usually used to describe neck/spine movements)
Proprioception: the sense of static position of the limbs and body, joint position sense
Talo-crural joint: the true ankle joint, which takes place between the talus and the “crura”, or socket formed by the inferior tibia and fibula
Subtalar Joint: the junction of the inferior aspect of the talus with the superior aspect of the calcaneus which permits inversion and eversion of the ankle.
# = fracture
ORIF: open reduction, internal fixation. This refers to a method of fixating a fracture that involves opening up the tissue, reducing the fracture to approximate the bony ends, and fixating the bones in place with some sort of metal (screws, plates, rods). This is a surgical procedure. Not all fractures require ORIF: some can be managed with closed reduction, (no surgery) and immobilization.
Contralateral: Opposite side
Ipsilateral: Same side
Isometric: Muscle contraction where the muscle develops force against a resistance but does not change it's length
Isotonic: Muscle contraction against resistance while moving through a range of motion
Concentric: Muscle shortening while contracting against resistance
Eccentric: Muscle lengthening while contracting against resistance
Plyometric: Muscle action where there is an eccentric contraction then a rapid concentric contraction
Subluxation: An injury to any joint where one bone moves out of position in relation to the the bone it connects to in the joint and then spontaneously 'reduces' or moves back into position
Dislocation: A joint injury where one bone moves out of position in relation to the connecting bone in the joint but does not slide back into position spontaneously
Mechanism of Injury (MOI): The specific mechanical method by which specific tissues are injured or damaged.
The knee, as it relates to the hip, is more:
There are specific phases that occur in the body during the healing process. These phases overlap; they are not black and white in terms of timing. Each phase has general timelines but some of the processes involved in each phase can occur simultaneously.
Stages of Healing
Inflammatory- 0-72 hours
Demolition- 48- 96 hours
Early Healing- 7-10 days- 4-6 weeks
Late Healing- 4-6 weeks onward
Cardinal Signs of Inflammation (SHARP)
• Color (Heat)
• Altered function
• Rubor (Redness)
• Dolor (Pain)
Muscles in the body can be divided into three main types:
Muscle fibre is composed of myofibrils: (hundreds per fibre)
- Responsible for contraction/relaxation
- Protected by connective tissue:
- Epimysium- surrounds entire muscle
- Perimysium- surrounds bundles
- Endomysium- surrounds myofibril
- Large numbers: Medial head gastrocs: 1,033,000 fibres
- Cross-bridges: actin/myosin
Fascia is collagenous connective tissue that surrounds muscles. The largest example is the Iliotibial Band or Tract that runs along the lateral portion of the thigh. There are superficial and deep layers. The videos below go into great depth in visualizing and describing the fascia.
- Collagenous tissue, mostly Type I, connecting bone to bone
- Rope-like structure, inert tissue with no inherent capacity to contract
- Contain blood vessels, nerves, proprioceptive structures, water, elastin
- Less collagen content than tendons
- Collagenous structures,primarily Type I and III, that connect muscles to bones
- Weakness at the junction between muscle and tendon
- Integral in allowing the muscles to which they are connected to impart forces to move and or stabilize joints
- Flat bones - skull, ribs, scapulae
- Irregular bones - vertebrae and skull
- Short bones- wrist and ankle
- Long bones (humerus, ulna, tibia, radius, fibula, femur) - bones most commonly injured
- Sesamoid bones- e.g. patella, 1st metatarsal, protect tendons, provide leverage
- Fluid-filled sac between the tendon and bony prominence
- Provides friction-less surface for the tendon to glide
- When irritated fills with fluid to cause reduction in motion and pain to protect the area
Nerve tissue conduct impulses from the brain to the muscles and organs and vice versa. Our main focus will be injury to the nerves and the impact that other injuries have upon nerve conduction and function.
Types of Injuries
Sprains occur to ligaments.
MECHANISM OF INJURY:
a) Excessive use or stretch of a ligament
c) Fatigue of supporting muscles
Minor to complete tearing of a ligament which may include an avulsion of the bone at the ligaments’ attachment
SIGNS AND SYMPTOMS:
1st DEGREE= MILD
Minor tear of the ligaments, pain on stretching of the ligament, minimal/no swelling, mild point tenderness, disability, minimal loss of function and range of motion, lower extremity - able to fully weight bear -limps but able to continue to play
2nd DEGREE= MODERATE
Partial tear of the ligaments, pain on stretching of the ligament, "golf ball" swelling, may have slight discoloration point tenderness, disability: moderate loss of function and increased range of motion initially then decreases with swelling, lower extremity- partial weight bearing, limps and is unable to continue to play
3RD DEGREE= SEVERE
- Complete tear of ligaments, no pain on stretching of the ligament, immediate and
- Gross amount of swelling and discoloration
- Very point tender, disability: maximum total loss of function and abnormal range of motion
- May lead to a dislocation - initially it will be increased, but as blood fills the joint it will decrease, lower extremity- unable to weight bear
This structure is a fluid filled sac, which prevents friction between a bony prominence a soft tissue structure
Strains occur to muscles or the musculotendious unit.
MECHANISM OF INJURY:
a) Trauma from excessive use or stretch to a muscle or its tendon
b) Poor reciprocal muscle strength
Disruption of muscle, muscle-tendon or tendon tissue amount of hemorrhage will depend on the amount of tearing inflammation will result from tearing
SIGNS AND SYMPTOMS:
1st DEGREE= (mild)
- Slight pain on active and resisted movements, stretching muscle
- Full strength on resisted tests, minor disability and loss of function
- Lower extremity- full weight bearing, no limp mild if any swelling and muscle spasm
2nd DEGREE= (moderate)
Pain especially on resisted movement and passive stretching, good to average strength on resisted tests, moderate disability and impaired muscle function, increased muscle spasm with swelling, bruising
- Increased warmth in injured area
- Muscle fibers are over stretched
- Tearing of fibers without complete disruption
3rd DEGREE= (severe)
- Severe pain at time of injury then usually painless- tearing of nerve endings
- Weak or no strength on resisted tests and painless
- Total disability and loss of muscle function
- Gross muscle spasm and visible swelling and massive discoloration
- Possible palpable defect (visual deformity in the muscle belly)
- Possibility of avulsion fracture
Inflammation or alterations of a tendon within the musculotendinous unit
- Tendinopathy is probably a more accurate term that tendonitis based upon the physiological damage observed under microscope
- Tenosynovitis (Tenovaginitis): inflammation of the tendon in the sheath. Thickening of the synovial fluid and may include small tethers of collagen connecting the tendon to the sheath.
- Tendinosis: irriation of the tendon resulting in microscopic changes in the tendon unit including disorganization of fibers, decreased blood flow and pain. Typically it does not include swelling and is one of the most common
MECHANISM OF INJURY:
b) Excessive friction
c) Trauma (compression)
a) POOR BLOOD SUPPLY
The blood vessels pass through the tendon in a longitudinal direction and therefore are susceptible to traction and pressure. This leads to decrease in circulation.
Results in loss of smooth gliding action of the tendon
Tendon becomes thicker, softer and loses its normal luster and becomes yellowish
May thicken resulting in resisted movement of the tendon in its sheath due to stenosis (tendon sticking). The tendon's sheath is the vascular structure therefore the nutrition to the tendon will be affected.
SIGNS AND SYMPTOMS
a) Localized pain on active and resisted movements subsides with rest
b) Tender on palpation
c) Crepitus (squeaking lump), especially tenosynovitis
d) Swelling- tendonitis
e) Thickening of the tendon
DEFINITION; inflammation of the bursa sac leading to pain and swelling which, if not allowed to resolve, will progress to a chronic condition with secondary thickening in the bursal walls and a tendency to recurrence.
MECHANISM OF INJURY:
b) Chronic irritation (overuse)
d) Calcium deposits
a) Onset may be slow or fast
b) Thickening of the bursal wall; enlarges bursa
c) Increase of synovial fluid; enlarges bursa
d) Degeneration of epithelial lining
e) Adhesions may form
f) May recur
g) Loss of mobility without injury (unless trauma involved)
h) May be chronic or acute
SIGNS AND SYMPTOMS:
a) Pain in region of the bursa especially if squeezed may be burning and/or referred
b) Varying disability
f) Palpable granules in bursa
g) No muscle spasm
i) Painful arc (subacromial) with GH abduction
j) Range of motion may be limited
k) Usually subsides in 6 weeks but may remain tender for longer periods
Which of the following terms best describes inflammation of the synovium of the tendon?
None of the above
- Abnormal nerve responses can be attributed to injury
- The most frequent injury is neuropraxia produced by direct trauma
- Lacerations of nerves as well as compression of nerves as a result of fractures and dislocations can impact nerve function
- Compression and tension/distraction are primary mechanisms
- May be acute or chronic
- Physical trauma causes pain and can result in a host of sensory responses (pinch, burn, tingle, muscle weakness, radiating pain)
- Long term problems can go from minor nerve problems to paralysis
- Interruption in conduction through nerve fiber
- Brought about via compression or blunt trauma
- Impact motor more than sensory function
- Temporary loss of function
- Pain can be referred as well
• Area of skin supplied by the dorsal or sensory fibres of a single spinal nerve root
- Muscle or group of muscles supplied by the ventral or motor fibres from a single spinal nerve root
- Overlap; distribution not exclusive
- C1 Cervical flexion
- C2 Cervical rotn
- C3 Cervical SB
- C4 shoulder elevation
- C5 shoulder abduction
- C6 elbow flexion or wrist extension
- C7 elbow extension or wrist flexion
- C8 thumb extension
- T1 finger abduction
- L2 hip flexion
- L3 knee extension
- L4 dorsiflexion
- L5 big toe extension
- S1 plantarflexion
- S2 knee flexion
Scar tissue in a ligament has the capacity to attain this percentage of the original tensile strength of the tissue
Compression- depending upon the type of tissue, some types of tissue- bone, are more amenable to compressive loads. That would be the case in some types of bones, long bones, with a compressive load along the long axis of the bone. Compression describes load through tissue which is applied along the length of the tissue.
Distraction- this force is directed along the tissue in a pulling force and is opposite to a compressive load.
Torque- rotational twisting force applied to tissue
Shearing- forces directed directly opposite one another across the tissue plane
There are different approaches to assessing musculoskeletal injuries. Some health care providers rely on a combination of hands on, history and special tests such as radiographs or xrays. We will learn about a method first described by Cyriax.
His method is helpful for new evaluators as it provides a very structured approach to assessment. There is a framework from which you can assess all MSK injuries. If you get stuck along the way you can 'right' yourself by getting back on the path. It is not perfect but relies upon the examiner to listen, observe movements and patterns both statically and dynamically as well as use hands on assessment skills.
The framework is:
- Functional movements
- Rule outs
- Special Tests
- Neurological Testing
- Accessory Joint Movements
Oftentimes you may develop an immediate index of suspicion as to the injury relatively soon after beginning to take a history from the client. Tempting as it is to simply direct all of your testing toward this injury, it is incumbent upon you to follow the process, not skip steps in haste, and both rule in, but also rule out injuries or conditions.
As you move through the assessment process you will be able to siphon the information you glean and direct your assessment and further testing. You begin with a huge range and quantity of information. As you move through each step, you gain more information which helps you to rule in or rule out certain injuries or conditions. Knowing which questions to ask and following along in a flowchart sort of manner is helpful but takes time, knowledge and lots of practice. This is the art of evaluation.
It is important to keep in mind though that oftentimes clients may present with multiple injuries, rather than simply having one tissue at fault. Sometimes clients are unable to move enough, have too much pain or are too unsure of their movements to perform a complete assessment in the first visit. Pushing them too far through range or trying to fully assess in those instances gains you very little information and may in fact, strain your future interactions with the client. They may be too sore after, unwilling to continue with you, etc. Working on their limitations- pain, range of motion, etc. may be more helpful at first and help you further evaluate their injury in subsequent visits.
- Chance to gain subjective info from client
- Should take no longer than 5-10 minutes depending upon the injury/circumstances, though may take longer with more in depth issues
- Thorough but direct
- Important to listen carefully to what the client tells you
- Builds from broad/general to specific
- General demographic info
- Name, age, sport/activity, occupation
- Any medications taken
- Previous injuries or episodes in the region, above/below
- Injury site- side, joint(s)
- Injury timing- when did it occur or commence
- Chief complaint
- Location of pain- radiation of symptoms
- MOI- Mechanism of Injury
- Sudden or gradual onset (insidious)
- If gradual when did pain begin
- If insidious you must ask more questions such as:
- Correlating factors- changes in training, surface, equipment
- Other injuries in the area
- Biomechanical/neuromuscular impact
You must ask about pain. The easiest method, which covers a number of items is following OPQRST. This includes:
- O- Onset- When does it occur
- P- Provokes- Aggravates
- Q- Quality- Description of pain- sharp, dull
- R- Resolves- Alleviates
- S- Severity- Scale of 1-10
- T- Timing- When during the day
- Once completed history should have a couple of indices of suspicion
- These will guide the rest of your assessment
- Starts as soon as the client steps into the clinic
- Can they weight-bear, on crutches, limp
- How do they sit, stand
- How are they holding their upper limb, head
- Do they have a sling, brace
- Once the person enters the clinic monitor how they walk
- Antalgic, normal, abnormal biomechanics
- How do they sit, stand, get onto the table
- Can they remove clothing effectively
- Once on the table can have a closer look at the area
- Facial expressions are important during movement or palpation
- Contour, discolouration
- Compare right versus left
- Bony or soft tissue abnormalities
- Any alignment abnormalities
- Postural observations
- Lateral- both
- Each direction gives you specific info about the client
Check the equipment they use:
- Shoes, skates
- Wear patterns of shoes, equipment
- Heel counter
- EVA form- creasing
- Rearfoot wear
- Forefoot wear
- Type- appropriate for activity?
Other equipment to check:
- Padding- Wrong type, worn
- Skates- tongue
For a lower limb injury must see the person walk in the clinic. If pain only with running then have them run.
- You can use a treadmill or simply in your clinic space
- Be cautious with the treadmill as gait is modified
- Monitor any major abnormalities you see in the pattern
- Remember shoes off, socks off to view when walking and running
- This factor will also alter running gait so keep that in mind
It is important to see the person move through functional actions
- The squat is a very effective tool both bilaterally and unilaterally
- Also toe raise and calf raise, toe/heel walk forward and back
- Can also use overhead squat to incorporate upper body influence
- Stairs both up and down are important if they describe pain during that activity
- Functional movements that cause the person's pain
Shoulder abduction is governed by which myotome
E.g. if suspect shoulder injury must rule out the cervical spine and elbow
- Quick assessment of active plus overpressure for primary movements
- Monitor to see if pain reproduced in the area in question, if pain determine why there is pain, which may include evaluating that joint
- Tests both the contractile and inert tissue
- Quality of movement
- Willingness to move
- Any ‘trick’ movements
- Must move onto passive to narrow focus and evaluate inert tissue
- Should assess more of the inert tissue, but will also elongate contractile tissue in the area
- No assistance from client, therapist moves only, the limb will be heavy if passive
- Client must relax
- At end range will get some stretch of antagonists
- Assess full ROM
- Monitor end feels
- Soft-tissue approximation- biceps
- Capsular- external rotation at the hip
- Bone on bone- elbow extension
- Muscular- springy- end range abduction
- Empty- move beyond normal ROM and pain before end ROM
- Spasm- involuntary muscle contraction, guarding
- Loose- extreme hypermobility
- Spring block- rebound at end ROM, meniscal
- Isometric contraction- no movement
- Build gradually to max contraction
- Hold for 3-5 seconds
- Grade scales vary
- Assesses contractile as no movement so inert should not be affected
- Place in mid range to test initially
- Can move to different ranges if pain in certain specific ranges
The chart below breaks down the theory and rationale as to when clients will feel pain with the Cyriax method of MSK evaluation.
Manual Muscle Tests
- Specific to each individual muscle and it’s known actions
- E.g. Tibialis anterior
- DF plus inversion
- Can use to identify muscle, pain, strength
- Assessment gradually filters down to a specific region, more so when it is an acute injury
- Must have some indices of suspicion
- Tests must rule out other possible structures at fault
- Remember rarely is an injury isolated to one structure
- There are lots of tests per structure; we will review the most common
Reflexes- involuntary contraction due to a stimulus
- Various upper and lower, looking for bilateral comparison, look for:
- Biceps (C5), Triceps- (C7)
- Patellar (L4), Achilles- (S1)
For more info see http://www.neuroexam.com/neuroexam/content.php?p=31
• 2 of 3 positives in the tests above indicates injury at that nerve root level
Joint Accessory Movements
- Movements which must occur but are not controlled by client consciously for physiological motion to occur
- Leave palpation to the end as it may cause more pain, if completed early it may make all other tests positive due to pain
- Careful palpation from general to specific, global to local
- Monitor temperature, skin changes, skin wounds, colour
- Must have intimate knowledge of anatomy of the area injured
- Light to deep pressure
In a perfect world, when doing an assessment, which movements would you expect to be positive with an injury to a ligament.
Passive and resisted
Active and passive
This is the basic framework we will follow for each of the joints we discuss and start to evaluate. There will be branches in the decision tree based upon the questions you ask, the results you get from your tests and your observations. Try to be as objective as possible when completing your testing, listen carefully to the answers your client gives you and ask good questions. It appears to be a relatively simple process; it is not. It takes years to hone your skills, but you will be able to, if you follow the framework, narrow down your index of suspicion. Another things to keep in mind is that, oftentimes, more than one structure is at fault or injured. You must look beyond the structure where the client indicates they have pain and consider their movement, neuromuscular control, joint position sense, etc. globally AND locally. Many times we can come to a conclusion as to the structure at fault as soon as the client answers a few key questions. The danger in cheating the process is that you miss a great deal of other information by getting tunnel vision. Follow the system when you are beginning in this process. You may eventually modify or change the process as you become more proficient, but having a system at first is important in gaining confidence in your skills.
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