The Everyday Physiotherapist

[everydayphysio-blog]

Myelomalacia

Myelomalacia refers to softening of the spinal cord.  This can occur when there is post traumatic or operative bleeding or oedema into the spinal canal. It can also occur when there is a disc protrusion which compromises the spinal cord. Furthermore, Myelomalacia can occur when there is a limit of blood supply to the spinal cord itself (for example in patients with canal stenosis). This can make the spinal cord “weak” and susceptible to further damage.

Causes

- Trauma

-  Disc Protrusion

-  Post operative

-  Spinal canal stenosis 

Signs and Symptoms

Often the signs and symptoms can be quite subtle and easily overlooked. These can include;

-  Flacid Paraplegia

-  Total areflexia

-  Loss of deep pain perception 

-  Muscle atrophy

-  Low mood and depression

-  Issues with diaphragmatic breathing.

-  Death can occur if the lesion reaches the motor nuclei of the phrenic nerves in the neck region.

Treatment

There is currently no treatment for myelomalacia once nerve damage has occurred. Steroids may help with relieving any swelling in the area and sometimes can assist with spasticity. Baclofen can also be prescribed to help manage spasticity. 

Physiotherapy can assist in prescribing appropriate exercises to increase strength to manage the ongoing symptoms and allow for better everyday function. 

For further information please refer to the below references.

Holly

References

Langdon, F. W. (1994). "Myelomalacia, With Especial Reference To Diagnosis and Treatment". The Journal of Nervous and Mental Disease. 32 (5): 233–44.

K. Tsuchiya, S. Katase, A. Fujikawa. (2003). Diffusion-weighted MRI of the cervical spinal cord using a single-shot fast spin-echo technique: findings in normal subjects and in myelomalacia.  Neuroradiology, Volume 45, Number 2, Page 90

[everydayphysio-blog]

Segond Fracture

-  Is an avulsion fracture of the lateral aspect of the tibial plateau.

-  Recognized marker of ACL rupture on plain X-Ray

-  Is associated with ACL injury 75-100% of the time

- If in doubt get it checked out. An X-Ray is cheaper and more readily available at times.

[everydayphysio-blog]

Cyclops Lesions

What?

-  Nodulous fiborous tissue composed of a reddish colour resembling a cyclops eye.  Is located in the intercondylar notch of the knee

-  90% are just anterior to the distal ACL graft (Runyan et al, 2007).

-  As the lesion sits anterior to the distal ACL graft and in the intercondylar notch, it can become ipinged between the tibia and the femur in extension (Bradley et al, 2000)

-  Is the second most common cause for loss of extension following ACL reconstruction (the most common being graft impingement) (Recht et al, 1995)

Who?

- Occur in an estimated 5% of those who have undergone an ACL reconstruction (Runyan et al, 2007).

Why?

-  Multi factorial

-  The following may have a part to play however;

*  Drilling debris

*  Stump remnants

*  Broken graft fibers

*  Poor surgical technique

*  Poor graft positioning

( Delince et al., 1998)

Clinical Presentation

-  Loss of knee extension with or without anterior knee pain (generally at 10 degrees)

-  Audible clunk with knee extension

-  Swelling (sometimes)

-  These generally come on or persist at 2-3/12 (Tonin et al., 2001)

Treatment

- Surgical resection and continue with rehabilitation.

-  Excellent outcomes with 85.7% of patients had restoration of full ROM and 78.5% were graded A on the IKDC objective evaluation (Sonnery-Cottet et al. 2010 from the sports physiotherapist website)

  References

Bradley DM, Bergman AG, Dillingham MF. MR Imaging of Cyclops Lesions. AJR 2000; 174:719-726

Delince P, Descamps PY, Fabeck L, Hardy D. Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998 14(8): 869-876

Runyan BR, Bancroft LW, Peterson JJ et-al. Cyclops lesions that occur in the absence of prior anterior ligament reconstruction. Radiographics. 27 (6)

Recht MP, Piraino DW, Cohen MA, Parker RD, Bergfeld JA. Localized anterior arthrofibrosis (cyclops lesion) after reconstruction of the anterior cruciate ligament: MR imaging findings. AJR Am J Roentgenol 1995;165:383-5.

Sonnery-Cottet B, Lavoie F, Ogassawara R, Kasmaoui H, Scussiato RG, Kidder JF, Chambat P. Clinical and operative characteristics of cyclops syndrome after double-bundle anterior cruciate ligament reconstruction. Arthroscopy 2010 26(11):1483-8

Tonin M, Saciri V, Veselko M, Rotter A. Loss of Knee Extension after Injury : Cyclops Syndrome due to a Lesion of the Anterior Cruciate Ligament. Am J Sports Med 2001 29: 545

[everydayphysio-blog]

[everydayphysio-blog]

The Trigeminal Cervical Nucleus

-  Region of the upper cervical spinal cord where sensory fibers from the descending tract of the Trigeminal nerve are believed to interact with the sensory fibers of the upper cervical nerve roots.

-  This region allows convergence of painful sensation from the upper cervical region to the face/head via the Trigeminal nerve and vice versa.

-  Important as clinicians to understand the role of the TSN and the element of central sensitisation that exists in those suffering from chronic cervicogenic headache.

[everydayphysio-blog]

Cervicogenic Headache

The Facts

-       Headaches affect 47% of the global population

-       Of this 15-20% of these are CG headache (Nilsson, 1995).

-       Females 4 X more likely to suffer CG headache than men (Page, 2011)

-       Up to 44% of those with CG headache have TMJ issues also (Von Piekartz & Ludtke, 2011)

Cervicogenic Headache

-       Unilateral without sideshift

-       Often base of neck , can migrate to the front of the neck and at times associated with ipsilateral arm pain (Page, 2011).

-       May occur with TrP Palpation in the head or neck (Page, 2011)

-       Aching pain- mild to severe

-       Triggers are often mechanical or postural. Different things can feed into this such as stress and workplace posture.

-       CGH origin lies predominantly peripherally (ie it is a MSK dysfunction not so much coming from central factors such as biochemical imbalances, hormonal triggers etc)

-       However, research has concluded that there is a large element of central sensitization of pain (input to the Trigeminal Spinal Nucleus) (Page, 2011)

Migraine

-       Alternating unilateral

-       Throbbing-Severe

-       Often people will know their triggers such as foods (Chocolate, cheese, red wine, citrus etc), light, noise, stress.

-       Central. Although peripheral MSK factors such as posture, tension etc can feed into migraine slightly.

-       Best managed with Triptans and Beta Blockers

Tension Type Headache

-       Bilateral

-       Tight/pressure type pain. Moderate to severe

-       Central origin (Stress)= TCN sensitivity

-       Best treated utilising and recognizing stress management techniques, biofeedback, TCA’s (meds). Jury is out weather Physio can help although physio can definitely help with any MSK/postural issues the patient may likely have.

References

Page, P. (2011). Cervicogenic headaches: An evidence led approach to clinical management. IJSPT. 6(3).

Nilsson, N. (1995).  The prevalence of cervicogenic headache in a random population sample of 20-59 year olds.  Spine.  20(17): p. 1884-8

Von Piekartz, H. and K. Ludtke (2011).  Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study.  Cranio, 2011. 29(1): p. 43-56.

Jull, G., et al. (1999), Further clinical clarification of the muscle dysfunction in cervical headache.  Cephalalgia, 19(3): p. 179-85

[everydayphysio-blog]

Br J Sports Med. 2011 Apr;45(5):437-40. doi: 10.1136/bjsm.2009.060731. Epub 2009 Jun 23. Research Support, Non-U.S. Gov't

A great insight into chronic non specific low back pain.  Something to consider for future treatment implications.

[everydayphysio-blog]

Acute Wry Neck

Acute wry neck is a common injury that presents in the physiotherapy clinic. It can be quite disabling yet the good news is there is a good prognosis. Almost always symptoms are unilateral and asymmetrical.   It is important when assessing the patient with wry neck that we get the diagnosis correct as treatment methods are significantly different.

Epidemiology

-  Women>men

-  Younger adults

-  Sudden onset, trivial incident or can be post viral.

Differential diagnosis

This is important as it will dramatically alter the way you treat.

-  discogenic wry neck

-  Atlanto-Axial subluxation.

- Spasmocid torticollis

-  Hysterical wry neck.

Assessment

-  Acute onset of neck pain. Often sharp pain.

-  Patients will generally be pain free at rest and can find a comfortable position.

-  Often will come in and will be unable to rotate or laterally flex the neck to or past midline.

-  Painful + into controlateral rotation and lateral flexion.

Treatment

-  Generally the acute wry neck will respond well and quickly to treatment.

-  Best response is generally to PPIVMS (pain free) using rotation and lateral flexion movements in the pain free direction.

-  PAIVMS and manipulation are not recommended as the first line of treatment.

This blog has been adapted from clinical edge. Checkout their amazing website here

Holly

[everydayphysio-blog]

This blog is a reflection on my recent trip to Aspen, Colorado as the travelling physiotherapist for the Australian and New Zealand Para Alpine teams in the Winter World Cup Finals. I learnt so much about ski racing from these inspiring athletes (who discuss their experience with us) and got a taste for working in an adaptive program, which was more rewarding and enjoyable than I ever could've imagined.

[everydayphysio-blog]

37% of patients with knee hemarthroses have an asociated PCL injury

Wind et al., 2004

#knee  #injury #physio #PCL

[everydayphysio-blog]

Assessment of acute knee injuries with snow-specific skills

This week we welcome Holly Lipson to Rayner & Smale. Holly is a passionate and vibrant Physiotherapist who loves the sun, surf, snow and of course physiotherapy. Holly is going to share her clinical tips for the assessment of acute knee injuries with some specific attention to the snow environment.

#knee #injury #sport #winter #ACL #snow #rehab #physio

[everydayphysio-blog]

Primary Lateral Sclerosis

I have recently had a bit to do with a disease known as Primary Lateral Sclerosis (PLS).  It has been a very re-warding and educational experience.  The below is a summary of the rare disease and what physiotherapy input can do to help those suffering from PLS.

What is PLS?

Primary Lateral Schlerosis is a rare degenerative disease of the upper motor neurons.  It is a hard disease to diagnose as several other disease can easily present with similar presentations with one of these being Amytrophic Lateral Sclerosis (ALS). There is no diagnostic tests to confirm PLS, it is more a process of eliminating other neurological conditions first.

PLS affects the upper motor neurons of the legs, arms and the the bulbar muscles of the face.  Often the legs are affected first.   Symptoms include;

-  Balance disturbances,

-  Stiffness and rigidity of the limbs,

-  Weakness (as a secondary symptom)  

-  Spasticity in the legs and arms.  

As the bulbar muscles are affected, speech and swallowing is also impaired.  The first symptom to appear is generally progressive lower limb spasticity without a loss of strength (Rollins, Oskarsson & Ringle, 2010).

PLS is not believed to affect cognitive or mental functioning yet one trial showed mild deficits in frontal lobe function and memory in 8/9 patients studied (Rollins, Oskarsson & Pringle, 2010).  

The disease is a slow progressing one yet it is not fatal.  Disease progression takes an average of 15-20 years and is quite slow.  Average age of onset is approximately 50 years (Pringle et al, 1992) and is more common in men than women.

Treatment

Medications

-  Muscle relaxants such as Baclofen, Tizanidine or Benzodiazepines are often administered to try reduce spasticity.

-  Quinine and Phenytoin can help to alleviate cramp symptoms.

Physiotherapy

 There is limited evidence out ther on the effects of exercise for those suffering from PLS as well as other motor neurone diseases.  An updated systematic review published in 2012 looked into what evidence is out there for the effects of exercise in the Amytrophic Lateral Sclerosis or motor neurone disease. They found there was minimal evidenceinvestigating the effects of exercise on this population.  The review found two trials which met their criteria yet each were quite small in size.  From these two trials the following was shown

1.  A moderate intesnity and load exercise program three times a week versus regular care (stretching etc) improved function on the Amyotrophic Lateral Sclerosis functional rating scale (ALSFRS) at three months (Dal Bello-Haas & Florence, 2012).

2.  There were no reported adverse affects to exercise such as increased spasticity and cramps in the exercise group of the above study (Dal Bello-Haas & Florence, 2012).

 -  Spasticity: Spasticity is usually treated with a combination of  pharmacological treatment and stretching exercises.  Sometimes splinting is required.   Remember to be careful with giving out stretches in a HEP as spasticity and cramps can often come on when the muscle on stretch.  Be sure that if providing stretches the effects are monitored closely and that they are not done at a high speed (Which will can bring on spasticity). Massage can also be used to help alleviate tight muscles.

-  Strength work: There are many options for maintaining and improving strength in those with PLS.  Hydrotherapy is a great option as the heat of the pool provides great therapeutic effect for the muscles.  For some, a home based exercise program is more suitable.  Whatever shape or form, it is important to target the stabilising muscles of the trunk and pelvis as well as the muscles of the lower (and upper) limbs as balance can often be affected due to rigidity and spasticity.  

Falls risk is high in this small population, thus monitoring balance deficits is important.  Balance type exercises can also be given specific to the individuals needs.

- Multidisciplinary Involvement: Getting a person with PLS involved with a multidisciplinary team is crucial for quality care.  Often there are clinics where the client can access physiotherapy, speech therapy, medical practitioners, occupational therapists and dieticians.  

References

Pringle et al. (1992). PRIMARY LATERAL SCLEROSIS: CLINICAL FEATURES, NEUROPATHOLOGY AND DIAGNOSTIC CRITERIA

Rollins, Oskarsson & Ringle.  International Neurology: A clinical approach.  Blackwell Publishing. 2010.  

Primary Lateral Sclerosis and Physical Therapy

NINDS Primary Lateral Sclerosis Information Page

Primary Lateral Sclerosis Treatment & Management

Dal bello-Haas, V. & Florence, J. (2012). Therapeutic exercise for people with amyotrophic lateral sclerosis or motor neuron disease.  Cochrane database of systematic reviews. DOI: 10.1002/14651858

[everydayphysio-blog]

Meniscus Injury

The knee joint is one of the most complex joints in the human body.  It is also one of the most commonly injured joints amongst the sporting population.  

One of the most common knee injuries is injury to the meniscus.  The meniscus are tough C shaped fibrocartilage structures which sit on the tibial plateau.  The meniscus are important as they distribute load and help absorbing shock.

Assessment

One of the most important things you can do assessing someone with an acute knee injury is make sure yet get the entire subjective history from the client.  Key things to consider are;

-       Mechanism of Injury.  Meniscus injuries usually occur when the knee is flexed and the person twists.  Injury can be degenerative as well as traumatic.

-       Degree and onset of any swelling.  This will let you know if the injury is intra- articular are extra-articular (or both). Meniscus damage will usually swell immediately.

-       The location of the pain (get the client to point this out).  Pain from the collateral ligaments is generally well localised, Cruciate ligament injury is generally more diffuse.

-       Severity of pain. With large Meniscus tears, severe sharp pain can occur as the cartilage gets stuck and “locks” the joint.

-       If the patient could walk post injury.

-       If they heard a noise or felt a “giving away”.

-       If there are any symptoms of catching and locking.

Objective assessment

The McMurrays test.

o   Sensitivity: 71%

o   Specificity: 71%

Hegedus et al (2007)

Note:  the hyperflexion of the Mcmurrays test is usually enough to evoke a pain response.

Appleys Grind test

o   Sensitivity: 61%

o   Specificity:  70%

Hegedus et al (2007)

Joint Line tenderness

o   Sensitivity: 63%

o   Specificity:  77%

Hegedus et al (2007)

Thessaly Test in 20 degrees flexion

o   Sensitivity: 89%

o   Specificity: 97%

Hegedus et al (2007)

Objective findings that indicate a Meniscus tear include:

·       Joint line tenderness at 45-90 degrees flexion

·      Joint effusion

·      Pain with hyperflexion (and at rest).

·      Restricted ROM and catching or locking.

For a concise and complete objective examination for acute knee injuries, the below video is a good watch.

Imaging

MRI

MRI is the image of choice as it can aid in management by showing if the tear is a complex tear. If the tear is minimal and non-displaced, conservative management is advised.  If the tear is peripheral and displaced, depending on the length and severity, it can be fixed surgically (Brukner & Khan, 2012).

o   Sensitivity: 93%

o   Specificity: 84%

Hegedus et al (2007)

Where to next?

Most Meniscus injuries will fall between major bucket handle tears and a small tear which presents with pain yet with no mechanical locking or restrictive ROM symptoms.  This is where it can become tricky to decide whether or not to proceed with conservative or surgical management.  When this is the case, the decision needs to be made on the basis of how severe the symptoms are, and what the patient wants to get back to (ie the sportsman versus the older more sedentary patient).

In terms of guidelines as when to opt for surgical treatment the following generally applies (Brukner & Khan, 2012).

-        Increasing pain (as opposed to stable pain).

-       Locking and catching

-       Correlating MRI findings with a displaced tear.

Surgery

Meniscus Repair or Meniscectomy?

There has been much debate over meniscus repair or meniscectomy over the years but emerging evidence is now pushing for meniscus repair over meniscectomy.  Maintaining the meniscus by means of repair versus removal obviously means that the joint has a greater ability to absorb shock and disperse load.  The results of a study by Stein et al showed that at 8 years follow up there were no signs of osteoarthritic changes in 80.8% of those who underwent Mensical repair, versus only 40% of those who underwent Meniscectomy.(2010).

For a great summary of the pros/cons and evidence for meniscus repair over meniscectomy click here.

Conservative treatment

The following is a general guide only taken from Brukner and Khan’s Clinical Sports Medicine.  Each person will respond differently to rehabilitation and at different rates.

1.   Week 0-1

a.   Control swelling, maintain knee extension, knee flexion to 100 degrees +, quads and hamstring strength

b.   VMO setting, Gentle ROM, supported calf raises, hip work, gait re-education, light exercise bike.

2.   Week1-2

a.   Eliminate swelling, Full ROM, full strength

b.   ROM drills, VMO setting, mini squats and lunges, leg press, step ups, bridges, resisted hip work, gait re-education, single leg calf raise, balance and proprioceptive work (single leg), gentle swimming, walking, exercise bike.

3.   Weeks 2-3

a.   Full ROM, dull strength, full squat, dynamic proprioceptive training, return to running and restricted sport specific drills.

b.   As for weeks 1-2 yet increase difficulty, reps and weights, jump and land drills, agility drills,

4.   Weeks 3-5

a.   Full ROM, Strength and endurance.  Restricted training and match play.

b.   High level sport specific training.

As always, treat each patient as an individual.  Often meniscus injuries are accompanied by other structural injuries such as an MCL tear.  Remeber to work with the patient and educate them each step of the way.  Without the knowledge of what is wrong with them and relating this back to why it is important that they follow rehab protocols,  progress will be difficult and the outcomes sub-optimal.

Holly

References

Sports Medicine Australia: Meniscus Injuries

The diagnostic accuracy of clinical tests.

Meniscus repair or meniscectomy?

Long-Term Outcome After Arthroscopic Meniscal Repair Versus Arthroscopic Partial Meniscectomy for Traumatic Meniscal Tears        

Clinical Sports Medicine. (2012). Brukner & Khan                    

[everydayphysio-blog]

The Rotator Cuff interval

The rotator interval describes the anatomic space bounded by the subscapularis, supraspinatus, and coracoid.  This space contains the coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule.  The coracohumeral (CH) ligament acts as the roof of this space.  Both the coracohumeral ligament and the glenohumeral ligament have a complex relationship with the long head of biceps tendon.

Function

Glenohumeral Joint stability

Stability of the long head of biceps tendon

Plays a role in maintaining negative intra-articular pressure.

Relevance

1.  Contracture or scarring of the rotator interval structures can lead to adhesive capsulitis.  Often the client will complain of pain at night and at rest, have limited ROM, discomfort localised to the deltoid insertion and tenderness over the coracoid.

2.  Any laxity of these structures (ie GH and CH ligaments as well as the anterior joint capsule) can lead to shoulder instability.

3.  Instability of the biceps tendon is often a direct result of damage to the rotator interval. Damage to the biceps pulley structures can lead to biceps tendon subluxation or dislocation depending on the structures injured.

Why is this important?

It is important to be aware of the rotator interval structures in all patients with shoulder pain.   Even for those who present with skapula dyskenisis, acknowledging what this is doing to the rotator interval is important.  Skapula dyskensis can often cause anterior translation of the humeral head.  When this happens, the structures of the rotator interval can be compromised and stretched or torn thus causing instability.

There is an exhaustive list of why the rotator interval structures are so important when assessing the client with shoulder pain.  More information can be found here and here

Treatment

Listed below are the three main shoulder pathologies which affect the rotator interval.

Adhesive Capsulitis

Initially conservative management is recommended.   Aggressive therapy can worsen the condition in the early stages, therefore, gentle range of motion exercises are generally prescribed.  Corticosteroid injections may also be used and have been shown to help with symptomatic pain relief in the early stages of treatment.

If this fails then arthroscopic intervention may be required. manipulation under anesthetic is to date a common procedure.  

Rotator Interval Laxity

On the opposite side of the spectrum is too much movement of the glenohumeral joint.  Glenohumeral laxity often is associated with a history of trauma or overuse injuries that eventually lead to a compromise of the tissue and ligamentous structures.

Successful results have been seen with and without rotator interval closure.  It is here when treating each client as an individual is key.  Someone who is young, plays sport requiring repeated upper limb activity and is having recurrent episodes of weakness associated with instability may be the right candidate for arthroscopic surgery.  However, someone much older who does not excessively load or require repeated upper arm movement may manage well with a conservative program.

Biceps Pulley Lesions

Full lesions of the Biceps Pulley can be treated surgically yet results can be varied.   Although controversial, the general consensus for treatment seems to be Biceps Tenodosis either via open or arthroscopic approaches.  The optimal approach has not yet been established.  Most result in improved pain and functional outcomes however.

The anatomy and function of the structures of the rotator interval can be overwhelming.  But what it all comes down to is to keep an open mind.  Remember that pain must be sourced from somewhere and that when assessing the client with shoulder pain it is important to think WHY is this person experience this pain?  Symptomatic relief by means of soft tissue massage or mobilisation can be very important in a treatment program, however, dont forget to ask yourself why did this happen in the first place?  

Holly

References

The Rotator Interval: A Review of Anatomy, Function, and Normal and Abnormal MRI Appearance

The Rotator Interval: Pathology and Management

Non-Operative Rehabilitation for Traumatic and Atraumatic Glenohumeral Instability

Proximal Bicep disorders

[everydayphysio-blog]

Understanding hamstring tears and strains

The hamstring group is made up of three different muscles

·     Semimembranosus

·      Semitendinosus

·      Bicep Femoris (long and short head)

Innervation

  Tibial nerve (coming from the sciatic nerve) except the short head of Biceps Femoris, which is innervated by the common Peroneal nerve.

Origin

All from the ischial tuberosity except for short head Biceps Femoris which orionates from the linea aspera and lateral femur.

 Insertion

Semimembranosus and semitendinosus both insert medially on the tibia.

Biceps Femoris long and short head both insert lateral side of head of the fibula.

Function

The hamstrings role is both eccentric control as well as explosive concentric contractions.  As a group, they act to extend the thigh at the hip when the trunk is fixed as well as flex the knee. Semimembranosus and semitendinosus internally rotate the lower leg when the knee is bent while biceps femoris long and short head laterally rotate the lower leg when the knee is bent.

Injury

Hamstring strains and tears

These are the most common form of hamstring injury and generally occur in those playing sports requiring explosive power with rapid acceleration and deceleration forces  (e.g. AFL, soccer or sprinting).  Recent evidence has shown that the hamstring is most vulnerable during the late swing phase of gait (Goldman & Jones,2011).   Hamstring tears occur as a result of sudden forced lengthening with a powerful contraction.

It is known that those who have strained or torn their hamstring previously have a much greater risk of re-injury.  Studies in AFL football players have reported re-currency in hamstring injuries to be a s high as 31% (Liu et al, 2013).

Clinical diagnosis is generally a combination of a detailed subjective interview followed by tenderness on palp and restricted range and mobility.

For the purpose of this article we will focus only on hamstring strains and tears.

Risk Factors

Prevention is always better than cure and with an injury with such high recurrence rate this is especially true.

- Age

-  Previous injury

- Past Hx of knee injury or osteo pubis ( Varell et al, 2001)

-  Fatigue (animal studies only)

-  Reduced flexibility/stiffness (Jonhagen, Nemeth and Erikson, 1994) Note that stronger studies may be required.

-  Weakness, in particular weakness of the hamstrings and quadriceps in regards to muscle strength ratios. (Orchard et al, 1997)

Presentation

Generally the patient will present with a sudden onset of posterior thigh pain, pain on palpation and loss of function.  Thee may also be visible bruising and/or swelling.

There is generally pain on resisted knee flexion and a reduced straight leg raise compared to the other leg.

Differential diagnosis

- Minor contusion

-  Posterior compartment syndrome

-  Referred Lumbar pain

Treatment

Obviously prevention is better than cure.  there have been many studies on preventative strategies to reduce hamstring strains yet many are controversial and are of poor quality.  However based on the evidence and clinical experience, the following are recommended and are in fact implemented by top level sporting teams.

-  Strength work to ensure adequate muscle strength ratios between both legs as well as quadriceps and hamstrings

-  Improved trunk and pelvic stability (also shown to reduce knee injury risk)

- Adequate muscle length.

If your patient is injured it is important to treat them as an idividual as each presents differently.   However, in general treatment will go as follows.

1.  NSAIDS (still controversial as they may slow the healing process rather than hasten it)

2.  RICE (rest, ice, compression (controversial), elevation)

3.  Gentle range exercises (promotes healing and minimises scar tissue formation)

4.  Pain free strengthening and stretching exercises (think bike, hydrotherapy etc)

5.  Sport specific return to activity once pain free.

For a good reference as well as an example rehab protocol click here

Again it is VERY IMPORTANT to treat what you find and treat your patient as a whole be they an elite athlete or a weekend warrior.  Everyone has different needs and responds differently to therapy techniques.  Everyone has different goals in mind.  Make sure you communicate and work with the patient through the entire process.  In this way everyone comes out winning in the end.

Holly

More references

1.  Interventions for preventing hamstring injuries: a systematic review

2.  Evidence based prevention of hamstring injuries in sport

3.  Hamstring injuries

[everydayphysio-blog]

Unbelievable footage of how an ABS airbag pack may have saved this guys life

[everydayphysio-blog]

Surgical Options for high grade AC Joint injuries

As you can probably tell i have had quite an interest in AC joint injuries lately, particularly in the higher grade injuries.  Although not directly physiotherapy’s role, it is important to understand the surgical pathways our patients (or future patients) may take when injuring themselves. 

Looking at the research there seems to be two main surgery options.

Open Weaver-Dunn

The traditional approach uses the coracoacromial ligament and reattaches this ligament to the lateral end of the clavicle.  For a good description have a look here.  The procedure is an open procedure and recovery is generally around three months (until back to full function).  However, various studies have shown that the coracoacromial ligament can only withstand 20% of the load that an intact shoulder girdle complex can handle.  Think about it.  A person with a grade V AC joint separation tears the coracoclavicular ligaments as well as the  AC joint capsule ligaments.  The only ligament left intact is generally the coracoacromial ligament.  In a full functioning shoulder, all ligaments are required.  By simply re-attaching the coracoacromial ligament from the acromion to the clavicle, you cannot presume that this will be able to handle the full load that the shoulder is required to handle.

Lars Ligament Technique

This technique has only been around for the past 15 years but is proving to be superior to the traditional Weaver-Dunn method.  The LARS method uses an artificial graft.  This artificial ligament has a loop at each end which is passed around the coracoid process, threaded through itself, then passed around the posterior aspect of the clavicle and finally anchored to it with a bone screw.  (for more information click here).  The recovery rate after surgery is a lot speedier. As well as this follow up results at 34 months showed the LARS technique to have the least chance of instability and had the lowest failure rate when compared to the Weaver Dunn method.

Post opp physiotherapy

Following surgery, physiotherapy aims to restore range and strength as it was pre-injury.  Remember it is always important to read the surgeons instructions.  Never assume what happened in the theater.  There may be specific rehab guidelines to follow. 

Generally however rehab will go as follows

Day 1-7

Patient in sling even when sleeping.  Not a lot physio can do but advise wrist and elbow range exercises and hand pumps.

Weeks 1-4

Patient still in sling but able to come out for exercises. 

Active assisted Range exercises.  Flexion to 90 degrees, Abduction to 60 degrees.

Weeks 4-6

Extend on AAROM exercises and add shoulder shrugs and encourage pain free walking.

Weeks 6-10

Commence active movements with aim of flexion and abduction to 120 degrees.

Weeks 10-12

Full AROM and able to do consecutive wall pushups pain free and with good technique.

3 months plus

Continue to progress strength exercises.  Remember to keep things functional and work to the patients goals.

References

An example of a post surgery rehab protocol

Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base

Acromioclavicular Joint Injuries: Diagnosis and Management

Management of AC Joint dislocations, a review of the evidence, 2007

LARS ligament for ACJ reconstruction

Surgical treatment of chronic acromioclavicular dislocation: Comparison between two surgical procedures for anatomic reconstruction

A simple and safe technique for reconstruction of the acromioclavicular joint