Rehabilitation Guideline after meniscus repair surgery

Meniscus injuries within the knee are a common occurrence.  In spite of this high event, numerous irregularities keep on existing in the restoration of a patient after meniscus repair surgery, especially including the rate of weight bearing and range of movement.

Rehabilitation Follow Meniscus Repair

Restoration after surgical debridement of the meniscus is entirely clear. We restore the patient’s range  of movement, quality and function,  their manifestations and let pain and swelling guide the recovery procedure (an exceptionally broad guide yet one frequently utilized by numerous rehabilitation specialists).

In any case, when the meniscus is really repaired and not only debrided, there are different variables to consider. At the point when a meniscus is repaired, the tear is approximated utilizing stitches to enable the tear to heal.

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

So if we’re going to talk some  protocols, take a look at these studies from way back when from Shelbourne et al  and Barber et al   that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave et al  and Lind et al on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

Again, these studies show meniscal repair outcomes are no different while using restricted weight bearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

 Weightbearing After Meniscus Repair : 

Things being what they are, if immobilized in extension, for what reason do we restrict weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are believed to help the healing procedure in many tears by approximating the tissue.

Besides, the compressive loads connected while weightbearing in full expansion following a vertical, longitudinal repair or container handle repair have been appeared to lessen the meniscus and settle the tear, as noted by Rodeo et al.  and all the more as of late by McCulloch et al.

There are studies said “A repaired longitudinal medial meniscal tear undergo compression, not gapping, during simulated gait ”

What about early range of motion? 

 

 

 

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Questions and Answers

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Our expert team will analyse and will give you answer in 24 hours. We don’t provide exact protocol for any pathology. We will publish relevant questions and its answers under this section.

netter anatomy , pectoralis minor , physiotherapy

PECTORALIS MINOR- THE NEGLECTED MUSCLE

Pectoralis minor ,proactive physiotherapy, kinetic chain

Coutsey : Wikipedia.com

Human body is designed in such an intricate manner that upper limbs are for manipulative activities and lower limbs are for mobility. When each of the body segments is aligned properly it gives a pleasant appearance as well as a disorder free body. While poor posture and muscular imbalance often results into pain and loss of function.

Physiotherapy musculoskeletal assessment format consists of many points in observation, palpation and examination which are extremely important for proper diagnosis, treatment planning and knowing the prognosis. However, many a times while assessing shoulder and cervical region; one of the important muscle- Pectoralis Minor is often neglected. A shortened pectoralis minor muscle commonly contributes to muscular imbalance and pain in shoulder and cervical region.

Poor upper body posture is many a times referred to as a ‘forward head posture’, ‘slouched posture’, ‘poking chin posture’, or ’rounded shoulder posture’ and is considered to be a potential etiological factor in the pathogenesis and perpetuation of many clinical syndromes like Thoracic outlet syndrome, Scapular downward rotation syndrome, Scapular winging & tilting syndrome, shoulder impingement syndrome and also upper cross syndrome involving the neck and shoulder.1, 2

origin insertion of pectoralis minor , neurokinetic

The pectoralis minor attaches at the coracoid process of the scapula and at the third, fourth, and fifth ribs near their sternocostal junctions. A short pectoralis minor muscle increases the muscles passive tension with arm elevation resulting in restriction of normal scapular movements such as external rotation, upward rotation and posterior tipping and this in turn will affect glenohumeral and cervical motion.1, 3

 

Few Clinical tests have been recommended to test for shortening of this muscle.

AT Distance: 1, 4, 5

Pectoralis length test

Courtsey:www.musculoskeletalkey.com

The patient in supine lying, arms by side or resting on abdomen and instructed to relax. With the help of rigid standard plastic transparent right angle, measure the linear distance in millimeters between the posterior border of the acromion and the table. Take care not to exert any downward pressure into the table and place the base on the treatment table and the vertical side adjacent to the lateral aspect of the acromion. A distance greater than 2.54 cm (1 inch) suggests short pectoralis minor.

Pectoralis Minor Length Index (PMI): 1, 4, 5, 6

The PMI is calculated by dividing the resting muscle length measurement by the subject height and multiplying by 100.The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a measuring tape or sliding caliper. PMI is suggested to reflect a shortened pectoralis minor when 7.65 or lower.

 

Referances :

  1. Jain S, Shukla Y. “To find the intra-rater reliability & concurrent validity of two methods of measuring Pectoralis Minor tightness in Periarthritic Shoulder patients.” Indian Journal Of Physical Therapy 2013;1(2):34-38
  2. Lewis J.S., Valentine R.E. “The Pectoralis minor length test: a study of the intra-rater reliability & diagnostic accuracy in subjects with & without shoulder symptoms.” BMC Musculoskeletal Disorders. 2007; 8:64.
  3. Borstad J.D. “Resting position variables at the shoulder: Evidence to support a posture-impairment association.” Journal of the American Physical Therapy Association. 2006; 86(4):549-557.
  4. Borstad J.D. “Measurement of Pectoralis Minor Muscle Length: Validation and Clinical Application.” Journal of Orthopaedic and Sports Physical Therapy. 2008; 38(4):169-174.
  5. Struyf F., Nijs J., Mottram S., Roussel N., Ann M J Cools, Meeusen R. “Clinical assessment of the scapula: a review of the literature.” Br J Sports Med 2012;0:1–8.
  6. Muraki T, Aoki M., Izu.mi T, Fujii M., Hidaka E., Miyamoto H. “Lengthening of the pectoralis minor muscle during passive shoulder motions & stretching techniques: a cadaveric biomechanical study.” Phys Ther. 2009; 89(4).
  7. Pic : Netter`s Anatomy

 

Gluteal Amnesia and selecting the most effective interventions

Most people spend a huge proportion of their time in a position of hip flexion (sitting down). An inactive lifestyle is a Janda approachsure-fire way to create glute dysfunction. Extended periods of time in this posture over the long term will lead to negative adaptations in the hip flexor muscles.

Shortened hip flexors don’t allow for full hip extension, which is where your glutes are able to contract with the most force. Additionally, being an antagonistic pair, short and tight hip flexors will actually inhibit your glutes. The actual physical compression associated with sitting on your gluteus maximus will also impair blood flow and neuromuscular function.

Gluteal amnesia is a condition where your body can’t or forgets how to properly activate the gluteal muscles, whether it’s due to postural flaws or lack of use. As a result, you may lose the ability to move your hips through a full range of motion which adds stress to your knee, lower back, and even your shoulder joints! Common injuries associated with gluteal amnesia are patellofemoral pain syndrome, Iliotibial Band Syndrome, Disc Herniation, and Piriformis Syndrome. Fortunately, you can reverse this condition with the right corrective exercises.

A postural flaw that can lead to gluteal amnesia is known as anterior pelvic tilt. This occurs when the pelvis tilts forward and the stomach protrudes. The forward tilt of the pelvis stretches your gluteals into a relaxed state which decreases your ability to properly activate them. Other causes of gluteal amnesia are as follows:

• Too many quadriceps dominant exercises.
• Poor sitting or static posture.
• Improper abdominal training.
• Soft tissue contractures (i.e., tight hip flexors and low back extensors).
• Articular (joint) fixations.
• Not landing properly from jumps (i.e., landing from a rebound in basketball).
• Knee or back pain sufferer.

The gluteus maximus and lower back stability
Activating and strengthening the glutes needs to form an important part of your core routine.

Co-contraction of the gluteus maximus with the psoas major contributes to lumbo-sacral stabilisation The gluteus maximus provides stability to the sacroiliac joint (SI joint) by bracing and compression. Excess movement at the SI joint would compromise the L5-S1 intervertebral joints and disc and could lead to SI joint dysfunction and low back pain.

kinetic chain, gluteus maximmus, eric dalton

Coutrsey : Ericdalton

The gluteus maximus also provides lower back stability through its connection with the erector spinae and thoraco-lumbar fascia. Some of its fibres are continuous with the fibres of the erector spinae. A contraction of the gluteus maximus will generate tension in the erector spinae muscle on the same side, providing stiffness to the spinal column.

Gluteus maximus contraction also exerts a pull on the lower end of the thoraco-lumbar fascia, which is a thick layer of ligamentous connective tissue. Tightening of this fascia stabilises the vertebras. People with low back pain often have weak and deconditioned glutes.

Here are some simple but superbly effective exercises to tone up glutes muscles.

Gluteal Squeeze :

Purpose: Strengthen the hips (especially for the gluteus maximus).
Start in a standing position with your feet shoulder-width apart.
Squeeze the gluteal muscles for two seconds, then relax for two seconds. Count the two seconds out loud to avoid holding your breath.
Sets/Reps: 1-2 x 10, with 5-10-second holds and 5-10 seconds rest.

Bird Dog :Core stability, proactive physio

Purpose: Strengthen the hips (especially for the gluteus maximus).

Start on your hands and knees. Slowly raise your right arm and left leg so they are level to the floor. Turn your left foot slightly outward so you feel your gluteus maximus tightening. Hold this position for 10 seconds. Repeat with the opposite arm and leg.
Suggested Sets/Reps: 1-2 x 10 of 10-second holds.

Double-Leg Squat Series :

 

Purpose: Strengthen the hips and legs.

Stand with your feet shoulder-width apart. Looking straight ahead, slowly squat down until your thighs are parallel to the floor while simultaneously raising both arms out in front of you like you are guarding an opponent in basketball or skiing down a hill.
Try to keep your knees behind your toes, maintain a normal arch in your lower back and keep your core tight. Once you master perfect technique using your body weight with this simple exercise (feet side by side)

Single-Leg Squats :

Purpose: Strengthen the hips and legs.

Stand facing a step and hold on to a rail. Slowly step up and down on one side. Repeat with the opposite leg. Alternate version: perform the Step-Ups from the side, and progress by varying the step height from 4 or 6 inches to 8 inches.
Suggested Sets/Reps: 1-2 x 10-15

Side-Step Walking :

Purpose: Strengthen the hips and legs.

Start in a squatting position with your feet slightly wider than hip-width as if you were guarding an opponent in basketball.
Take five to 10 steps to the right. Your step lengths should be approximately 50 percent of the starting position distance between your feet.
Keep your knees aligned with the second toe. Repeat five to 10 steps to the left.
Once you master perfect technique using your own body weight.

Side-Lying Straight-Leg Abduction :

Hip abduction, core and posture st

Courtsey:Dr. Alex Jimenez D.C.,C.C.S.T

Purpose: Strengthen the hips and core.

Start by lying on your right side with your top leg straight and bottom leg bent. Place your top hand on the floor or mat in front of you for good support. Slowly raise your top leg up to approximately 40 degrees for the designated sets/reps.
Keep your hips level and don’t over-arch your back.
Repeat on the other side.
To increase the difficulty, place an elastic band around your thighs (just above the knees) or an ankle weight just above your ankle.
Sets/Reps: 2-3x 0-15

Side-Lying Bent-Leg Abductions: gluteus strengthning, gluteus activation

Purpose: Strengthen the hips and core

Start by lying on your right side with both knees bent 90 degrees and hips bent 45 degrees. Place your right arm under your head and your left arm on the floor in front of you for stability. Slowly raise your top leg up to 30 degrees of abduction, then lower slowly for the designated sets/reps. To increase the difficulty, hold the 30-degree hip-abducted position for five to 30 seconds as a single repetition.
Sets/Reps: 2-3×10-15

Supine Bridge:proactive physiotherapy

Purpose: Strengthen the hips and core

Start by lying on your back with your knees bent 90 degrees and feet hip-width apart. Place a small, soft ball between your knees and squeeze with no more than 50 percent effort.
Lift your hips off the floor approximately 4 inches, then slowly lower them while relaxing the squeeze between your knees.
To increase the difficulty, hold for five to 10 seconds as a single set.
Sets/Reps: 2-3×10-15

 

Referances :

  1. Distefano LJ, Blackburn JT, Marshall SW, Padua DA, Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. Jul;39(7):532-40, 2009.
  2. Vleeming A, Van Wingerden JP, Snijders CJ, Stoeckart R and Stijnen T (1989): Load application to the sacrotuberous ligament; influences on sacroiliac joint mechanics. Clinical Biomechanics, 4(4), 204-209.
  3. Snijders CJ, Vleeming A and Stoeckart R (1993): Transfer of lumbosacral load to iliac bones and legs. Clinical Biomechanics 8, 285-294.
  4. Sean GT Gibbons and Mark J Comerford (2001) Strength versus stability: Part 1: Concept and terms. Orthopaedic Division Review. March / April: 21-27
  5. Gibbons SGT 2005 Integrating the psoas major and deep sacral guteus maximus muscles into the lumbar cylinder model. Proceedings of: “The Spine”: World Congress on Manual Therapy. October 7th – 9th, 2005, Rome, Italy.
  6.  Kankaanpää M, Taimela S, Laaksonen D, Hanninen O and Airaksinen O (1998): Back and hip extensor fatigability in chronic low back pain patients and controls. Archives of 100 NZ Journal of Physiotherapy – November 2005. Vol. 33, 3 Physical Medical Rehabilitation 79, 412-417.

 

Shoulder joint

Clinical assessment of scapula

Upper limb is designed in such a way that there is ample amount of mobility which is required for manipulative activities that are a part of daily functional activities. In recent days there is increased interest on the role of scapula, its related pathologies and how entire upper extremity function is dependent on the controlled movement of scapula.

For a full, efficient as well as atleast functional range of motion of entire upper limb, scapula plays many roles in facilitating optimal shoulder function by glenohumeral integration, motion on thoracic wall and as a part of scapula-humeral rhythm. With good proximal control there is good distal mobility. Any alterations in the activity of scapula hamper the control over all upper limb activities leading to pain, impingement and other clinical syndromes which gradually causes disability.

 

Observable alterations in the position of the scapula & the pattern of scapular motion in relation to thoracic cage are called scapular dyskinesis. It causes many clinical dysfunction of the shoulder leading to disabilities.

 

Causes of Scapular Dyskinesia:

 

  1. Bony injuries or abnormalities- Types of acromion process or postural alteration 
  2. .Alteration of muscle function- upper cross syndrome, inhibited muscle- serratus anterior, lower fibres of trapezius, rhomboids, deep neck flexors, force couples.

 

  1. Contracture & other flexibility problems- pectoralis minor & major, joint capsule, upper fibres of trapezius, levator scapula

 

  1. Nerve injury/ proprioceptive dysfunction- long thoracic nerve, spinal accessory nerve

 

 

Classification of Scapular Dyskinesia:

 

               (Slideshare.net)

  • Type I – Abnormal rotation around transverse axis: commonly found secondary after rotator cuff dysfunction- inferior angle becomes prominent
  • Type II – Abnormal rotation around vertical axis: commonly seen in patients with glenohumeral joint instability- medial border becomes prominent
  • Type III – Abnormal superior translation of entire scapula: commonly seen in rotator cuff dysfunction and deltoid-rotator cuff force imbalances- superior border becomes prominent
  • Type IV- both scapula are symmetrical at rest & during motion; they rotate symmetrically upward with inferior angles rotating laterally away from midline. This indicates scapular control muscles are not stabilizing the scapula.

 

 

Types of Winging:

  1. Static winging- winging happens at rest, usually caused by structural deformity of scapula, ribs, clavicle or spine.
  2. Dynamic winging- winging happens with shoulder motion. It can be cause of trapezius weakness or serratus anterior weakness. In case of trapezius weakness, scapula depresses and moves move laterally with inferior angle rotated laterally. In case of serratus anterior weakness, scapula elevates amd move medially with inferior angle rotated medially.

 

One more clinical syndrome exists which is coined as S.I.C.K scapula

S- Scapular mal-position

I- Inferior angle prominent

C- Coracoid pain

K- Dyskinesia

 

Clinical assessment of scapula includes evaluating posture, motion, muscular activation and control and corrective maneuvers. Steps for assessment

  1. History taking
  2. Thoracic and cervical posture – trigger points and flexibility
  3. Check for the shoulder posture- trigger points and flexibility
  4. Shoulder strength – especially supraspinatus, infraspinatus, and subscapularis, Serratus anterior, lower trapezius
  5. Shoulder ROM @ 0 and 90 degrees – GIRD
  6. Scapula position @ rest
  7. Scapula position during active abduction and flexion – especially watch descending phase
  8. Scapulothoracic bursitis

 

 

Few important tests include Lennie test, Lateral scapular slide test, Scapular assistance test, scapular isometric pinch test, wall push test, Labral tests, impingement tests, tendinitis tests, etc.

 

References

  • Kibler B, McMullen J. “Scapular dyskinesis and its relation to shoulder pain”. J Am Acad Orthop Surg. 2003;11:142-151.
  • Magee DJ. “Shoulder. Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012; 231-360.

 

What is Resisted isometric movements?

Working with the patients in the clinic and assessing their structural affection has always been a mind scratching job. Multiple tests are performed but there remains a doubt that which structure/ tissue is involved – contractile or non- contractile/ inert tissue. Contractile tissue refers to Muscle, Tendon, Musculo – Tendinous junction, Teno – Periosteal junction, Nerves, etc.  

Contractile tissue assessment involves voluntary contraction of muscles. These contractions include strong isometric contraction, multiple angle isometrics or concentric/ eccentric contraction. During this testing, it is checked if there is any pain or not and if it is then what is the intensity and quality of pain. Along with the pain it is also assessed what is the strength of contraction and which type of contraction is painful as well as weak.

For solving the above queries, the testing is done by Resisted Isometric Movements. However these movements are always tested last in the examination of the joints. This type of movement consists of a strong, isometric voluntary contraction of muscles and primarily detects muscles as well as nerves supplying the tested muscles.

  • If the muscle, its tendon or the bone into which they insert is at fault, pain & weakness result; the severity of pain and weakness helps to judge the degree of injury and patient’s pain threshold.

Some of the important points to be taken care of while assessing:

  1. There should not be any movement while performing the test because if movement occurs then inert tissue will also move and it will be difficult to find out which is the offending structure- contractile or inert.
  2. The test joint should be put in neutral or resting position in order to minimize tension on inert tissue.
  3. The movements should be done in resting position of the joint as in this position muscle is in its optimal length so that maximum force can be elicited.
  4. Moreover this position can be modified if required when assessing for tight or lengthened structures as well performing multiple angle isometric testing.
  5. This test involves isometric hold so it is essential to have the muscle strength of grade 3 to 5 on the muscle test grading scale.
  6. If there is difficulty in differentiating between grades 4 and 5, eccentric break test can be used. The test starts as an isometric contraction, but then assessor applies sufficient force to cause eccentric contraction or break in the isometric contraction.
  7. Post testing isometrics, other types of contraction can also be checked for according to patient’s complain.

Steps to perform Resisted Isometric Movements:

  1. The joint is placed in neutral or resting position. Every joint has a specific resting position.
  2. The patient is asked to perform strong isometric contraction, not to move the part and the assessor will resist with almost equal amount of force to prevent any movement from occurring and also to ensure that patient exerts maximum effort.
  3. However movement cannot be completely eliminated, but this will minimize it.

After these movements are performed, the assessor determines the contractile tissue affected by judging the degree of pain & strength of contraction. Along with these movements, functional testing, myotomes assessment, manual muscle testing, palpation and special tests are also equally important.

Active movements as well as passive movements can also be performed. And it has been observed that if contractile tissue is injured, active movement is painful in one direction (contraction) and passive movement is painful in opposite direction (stretch). Resisted isometric movement is painful in the direction of active movement.

There are 4 classic Patterns of contractile tissue lesions, according to pain & strength. They are as follows:

  • Strong & Pain free: – There is no lesion of the contractile tissue (muscles as well as nerves supplying) which is being tested regardless of being tender on touch.

 

  • Strong & Painful – In this there is local lesion of muscle or tendon. 1st or 2nd degree muscle strain. 2nd degree strain produces more muscle weakness and pain than 1st degree strain.

There can be tendinitis, tendinosis, paratenonitis or paratenonitis with tendinosis or partial avulsion fracture, but in this contraction will be strong (not as good side) and painful, pain will be around the tendon and not the muscle.

 

  • Weak & Painful: – This is seen in cases of severe lesion around of joint such as fracture. Weakness is usually caused by reflex inhibition of muscles around the joint secondary to pain.

 

  • Weak & Pain free: – This indicates complete rupture of muscle or tendon (3rd degree) or involvement of peripheral nerve or nerve root supplying that muscle. With neurological involvement, assessor must differentiate between affection of (a) peripheral nerve by checking muscles & (b) nerve root by checking myotomes and dermatomes. Differentiate between UMN & LMN lesions.

3rd degree strains usually are painless, but many a times along with this there is 1st or 2nd degree strain of surrounding muscles resulting into pain. To find out 3rd degree strain, one must check for presence of hole or gap in muscle by palpation or check the muscle bulk when contraction is attempted and how it gives appearance of obvious deformity.

 

Reference

  • Magee DJ. “Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012.
  • Image : http://www.ptonthenet.com

 

Soft endfeel

How to check End feel during examination?

Soft endfeel

It has always been a query regarding the end feel for a particular joint and its movement. In order to solve this query here is a bit of overview on it. Hope it clarifies the doubts and solves the issue with better ease for judging the particular type of end feel.

Defining the End Feel in easier terms is the feel that is perceived by the assessor at the end of any movement. The movement that the patient performs actively is repeated passively and when the end of the available range is reached over pressure is applied to get a feel of resistance of tissue. This feel of barrier at the end of a passive range of motion is called end feel.

Steps to be noted while assessing End Feel

  1. Movement & end pressure should be done slowly and carefully
  2. Detect the end of available range of motion
  3. Distinguish between normal & abnormal end feel
  4. Caution to be taken not to be too forceful and injure the tissue
  5. Always compare it with the contra lateral side

Significance of taking End feel

  • It helps the assessor to differentiate between limiting structures
  • It guides in measuring range of motion and compare with the contra lateral side and thereby detect the pathology
  • It determines if the limitation is due to articular or peri-articular problem
  • Proper evaluations of end feel help determine a prognosis for the condition & learn severity or stage of problem.
  • The quality of resistance at end range
  • Each joint has a normal end feel at a normal point in Range of Motion (ROM)
  • Incorrect end feel, or correct end feel at incorrect ROM indicate pathology

 

 

 

 

 

NORMAL OR PHYSIOLOGICAL END FEEL

1. Soft tissue approximation Subcutaneous tissues (muscle bulk, fat) are pushing against each other

e.g.- Knee Flexion, Elbow Flexion

2. Tissue stretch (Muscle stretch) Passive elastic stretch (Tension)

Feels like stretching a bicycle tire inner tube

e.g.- Hip Flexion with Knee Extension

 

3. Tissue stretch (Capsular stretch) Tension in joint capsule

Feels like stretching a leather belt; more resistance than ligament

e.g.- Extension of MCP Joint of Fingers

4. Tissue stretch (Ligamentous stretch) Tension in ligaments surrounding the joint

Feels like stretching a leather belt

e.g.- Forearm Supination

5. Hard (Bony) Bone contacting bone (painless)

Feels like pushing 2 wooden surfaces together

e.g.- Elbow Extension

 

 

ABNORMAL OR PATHOLOGICAL END FEEL

1. Soft Capsular Related to compressing & stretching of soft tissues

Similar to Normal but with restricted ROM. Is often found in acute conditions with stiffness occurring early in range & increases until end of range

Soft boggy end feel

e.g.- Synovitis, Soft Tissue Oedema

2. Hard Capsular Similar limitation comes abruptly after smooth, friction free movement

e.g.- Frozen Shoulder, Chronic Conditions

3. Early Muscle Spasm Invoked with movement, with a sudden arrest of movement often accompanied by pain

End feel is sudden

e.g.– Acute protective spasm associated with Inflammation

4. Late Muscle Spasm Restriction occurs at or near end of ROM

Caused by instability & the resulting irritability caused by movement

e.g.- Chronic condition, spasm caused by instability

5. Springy When passive movement performed rebound phenomenon occurs

e.g.- Meniscal Tear or spasm

6. Empty Sensation is painful at certain limit.

Range is not restricted but patient is not willing to allow motion to end of range because of anticipated pain and so assessor did not reach end feel

Feels like the joint has more range available, but patient is purposefully preventing movement through full ROM.

e.g.- Acute Joint Inflammation, Bursitis, Abscess, Fractures, Psychogenic disorders

7. Bone to Bone Similar to normal end feel but range is not complete

e.g.- Osteophyte formation, Myositis Ossificans

 

 

References

  • Magee DJ. “Orthopaedic Physical Assessment.” 5th Philadelphia: WB Saunders. 2012.
  • Image courtsey : bostonbodyworker.com

 

Hunh back, Rounded shoulder

How to fix Poor Posture?

We hear it all the time…”Keep your shoulders back! Stand straight!  Posture has become an ever present issue within healthcare circles but why exactly is posture so important? As renowned Doctor of Science Vladimir Janda explains,

“Human movement and function requires a balance of muscle length and strength between opposing muscles surrounding a joint.”

 

Poor posture results in  muscle imbalance at a joint, in which opposing muscles (the agonist and the antagonist) on opposite sides of a joint provide differing amounts of tension, due to muscle weakness or tightness. Muscle imbalances can then result in abnormal stresses applied to the joint.

 

While a muscle imbalance might not directly be a source of pain, many musculoskeletal pain syndromes are a result of chronic muscle imbalances. One musculoskeletal pain syndrome often diagnosed within the medical community is called upper cross syndrome.

Upper cross syndrome is characterized by forward head posture, increased thoracic kyphosis (rounded back), excessive mid-upper cervical spine extension, and scapular protraction (forward shoulders).

This results in tight upper cervical extensors and anterior thoracic muscles, as well as weakened (elongated) deep neck flexors and scapular muscles.
Tight muscles can impact joint movements in a variety of ways. Moreover, tight muscles tend to adapt  a consistently shortened position. Conversely, elongated muscles become weak when they are lengthened  their optimal length. Every muscle has an optimal length in which it can produce the most tension (force). The amount of crossbridging between the myosin (thick) and actin (thin) filaments is directly correlated with the amount of tension the muscle can produce. Therefore, an elongated muscle does not have as much overlap between myosin and actin filaments so it cannot produce as much active muscle force. Overtime period of time, these muscle imbalances of tight and weak muscles can lead to abnormal movement patterns, movement dysfunctions, and ultimately predispose your body to a host of other potential issues.

We found that when patient came with neck pain or shoulder you should check out the below muscles box which can help you in your assessment.

Via Dr. Dan Kirages

References :

  • Biondi, David M. “Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies.” Current Science Inc Current Pain and Headache Reports 5.4 (2001): 361-68.
  • Bullock, Michael P., Nadine E. Foster, and Chris C. Wright. “Shoulder Impingement: The Effect of Sitting Posture on Shoulder Pain and Range of Motion.” Manual Therapy 10.1 (2005): 28-37.
  • Chiu, Tai-Wing. “The Efficacy of Exercise for Patients with Chronic Neck Pain.” Spine 30.1 (2005): 1-7.
  • “What Is Muscle Imbalance.” Muscle Imbalance Syndromes RSS. N.p., n.d. Web. 19 Aug. 2015.

Static Postural Assessments

Static posture define as how individuals physically present themselves in stance. It is reflected in the alignment of the body.

Posture can be thought of as static or dynamic. Static posture means how individuals physically present themselves in stance which  could be considered the base from which an individual moves. It provides the foundation or the platform from which the extremity moves.

Dynamic posture is reflective of how an individual is able to maintain posture while performing functional tasks.

We will only discuss static posture here.

Systemic approach to assess static posture.

Static postural assessments require a strong visual observation skill from the clinicians. This can be developed with time and practice. Generally, and  static postural assessments begin at the feet and travel upward toward the head. Clinicians should observe from anterior, posterior and Lateral view.

Basic check point of body region that needs to consider while assessment.

  1. Foot and ankle
  2. Knee
  3. Lumbo-pelvic-hip complex (LPHC)
  4. Shoulders
  5. Head/cervical spine

A static postural assessment is a simple yet effective tool to quickly “size up” your client. Consider yourself a detective looking for structural deviations within a kinetic chain. Many muscle imbalances can be easily identify from the deviations noted in the static postural assessment.

Using a static postural assessment on an initial evaluation of your client will give you a “big picture” view of how that individual uses his or her body day in and day out. Consider the body as a road map.

There are several questions in our mind that

  1.  How have these alterations distorted the feedback from the proprioceptors?
  2.  How has the altered alignment affected the function of the soft tissue?
  3. Has the fascia been overloaded?
  4. Have compensatory muscle imbalances been generated creating altered length-tension relationships, altered force production, synergistic dominance, and altered reciprocal inhibition relationships?
  5. How have these changes affected the entire kinetic chain and overall coordination of movement within the limbs and between the limbs and the trunk?

The static postural assessment is the first step in assessing the biomechanical and neuromuscular pieces of the puzzle necessary to create a program for functional re balancing for your client.

By looking on patient’s posture clinicians have easy to identify on Which muscle they have to work regarding condition.  By looking from different view of standing position one should easly identify the over active and under active muscle group. These will help in clinicians to reach functional goal.

Coutrsey : corrective exercise essential  : NASM

Overhead squat assessment

The over head squat is one of the most valuable assessment you can do with your patient. Before starting assessment one should check rang of motion of all joints.

Rationale:

This test for bilateral symmetrical mobility and stability of hip, knee and ankle joint .In addition to check shoulder as well as thoracic mobility.

Red flag must be address before assessment.

How to perform?

  • Instruct the patient for 5 repetitions of squat as per his comforts zone.
  • Heel should not off the ground while performing task.
  • You must address in your document regarding pain or discomfort during squatting.
  • Do not let the patient know what you are looking for otherwise patient might adjust him self and we may get false result.
  • We should consider different view motion from different angles.

Courtsey:prezi

Observation check list:

1). Feet pronate and externally rotate:

This may indicate tightness in the soleus, gastrocnemius, peroneals, hamstring and piriformis and/or weakness in the gluteus medius. There may also be a restriction in ankle joint dorsiflexion, since the body will pronate the foot to gain more motion in the ankle mortise. If dorsiflexion is limited, there is a posterior chain extensibility dysfunction or ankle joint extensibility problem, or both.

2). Knees buckle / hip internal rotation:

May indicate weak/inhibited gluteus maximus/medius, tight adductor complex and iliotibial band. May be an inability to control hip movements, pointing to an underlying motor control stability problem.

3). Low back arches:

There might be tight iliopsoas and/or other hip flexors and latissimus dorsi,
compensating for a weak core.

4). Low back rounds:
It may reflects the overactive external obliques, compensating for a weak core. Observe if there is a rotational component to the movement when the low back rounds due to the fascial attachment of the spiral line of myofascial from the external oblique to the opposite shoulder.
5). Arms fall forward:
It may indicate tight latissimus dorsi and /or pectoralis major/minor and weak lower trapezius, rhomboids, teres minor and infraspinatus.
6). Lateral shift:
A shift to either the right or left side during any part of the movement may indicate a motor control stability problem or an underlying self-protective mechanism to deviate away from pain.
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  2. Liebenson C. Integrated Rehabilitation Into Chiropractic Practice (blending active and passive care). In: Liebenson C, ed. Rehabilitation of the Spine. Baltimore, MD: Williams & Wilkins; 1996:13–43.
  3. Comerford MJ, Mottram SL. Movement and stability dysfunction—contemporary developments. Man Ther 2001;6(1):15–26.
  4. Janda V. Evaluation of Muscle Imbalances. In: Liebenson C, ed. Rehabilitation of the Spine.
  5. Baltimore, MD: Williams & Wilkins; 1996:97–112.
  6. Sahrmann SA. Posture and muscle imbalance. Faulty lumbar pelvic alignments. Phys Ther 1987;67:1840–4.
  7. Janda V. Muscles and Motor Control in Low Back Pain: Assessment and Management. In: Twomey LT, ed. Physical Therapy of the Low Back. Edinburgh: Churchill Livingstone; 1987:253–78
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