Theres a Ghost in My house

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Look it's a @jeckk__

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@cptjackmilner first shaped his first board.... Glass and all!

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🍓💋 hot log 💋🍓

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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 low back pain. The implications of these results are well worth the read and may change our treatment options in this population in years to come.

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

Wind et al, 2004

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Primary Lateral Sclerosis

I have recently have had a bit to do with a little known about disease known as Primary Lateral Sclerosis (PLS).  It has been a very re-warding and educational experience.  The below is a summary of the 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

-  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.

- 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

[theresaghostinmyhouse]

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 touch 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.  Remember that meniscus damage can also be degenerative.

-       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). 

-       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.

 Clinical testing

 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)

  Other 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.

 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 ROM restrictive symptoms.  This is where it can become tricky 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.

 Resources

Sports Medicine Australia:  Meniscus Injury

Diagnostic accuracy of clinical tests

Meniscus repair or meniscectomy?

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

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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 touch 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.  They can also be degenerative.

-       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).

-       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.

Clinical Tests

-       The McMurrays test. (Video)

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 (Video)

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 (Video).

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.

 A great video of concise objective assessment for meniscus injury can be viewed here

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 ROM restrictive symptoms.  This is where it can become tricky 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.

 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

[theresaghostinmyhouse]

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

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Earlydetection of injury to the posterolateral corner of the knee

Ever wondered why some of you ACL patients just don’t seem to do well after reconstruction?  Even though the surgery went well they still have feelings of unsteadiness and don’t feel 100% months down the track. Obviously this can be due to a number of reasons yet it my have something to do with undetected damage to one or more structures of the Posterolateral complex (PLC) of the knee.

 The posterolateral complex of the knee is one, which is still to date poorly understood. Injuries to this area often can be debilitating and if not detected early, the long-term consequences can be large. According to La Prade et al., PLC injuries are present in 9.1% of those who present with acute knee injury and haemarthrosis (blood in the knee joint) (2007).  Seems like a small figure doesn’t it but if you think about it that is almost 1 in 10 of acute knees that walk through the door.

  Stabilisng structures of the PLC;

The Popliteal fibular (PFL) ligament (Limits posterior translation of tibia, varus stress and external rotation)

The Popliteal tendon (acts with the PCL and quadriceps to limit external and internal rotation, varus stress and posterior translation of the femur)

The Lateral collateral ligament (LCL)

Mechanism of injury

Hyperextension

Direct antero-medial knee trauma

Excessive varus stress

So why is this all so important to us? 

Missed PLC instability is a common cause for ACL reconstruction failure.  think about it.  How is a freshly reconstructed ACL meant to stand a chance when there still exists significant knee instability due to PLC injury?  Furthermore, after initial injury, many believe you have only a two week timeframe to operate.  So we need to be quick.  We need to understand what it is we are looking for and act on it early.

Specialised Tests

Observed excessive hyperextension

Varus stress test in both 0 and 30 degrees

Dial Test:  Can be performed with a patient lying supine or prone.  With the patient supine and the knees flexed 30° off the table, stabilize the thigh and externally rotate the foot. As the foot rotates, watch for external rotation of the Tibial tubercle of the affected knee compared to the healthy one. A difference of greater than 10-15° indicates a positive test and likely injuries to the posterolateral knee.  See a video here

Posterolateral drawer test:  The posterolateral drawer test is similar to the commonly known posterior drawer test for PCL stability. Have the patient lie on their back with the knee flexed at 90° and externally rotate the foot to approximately 15°. While stabilizing the foot, apply a posterolateral rotation force to the tibia and watch for the amount of posterolateral rotation. Increased mobility and posterolateral rotation compared to the contralateral normal side usually indicates an injury to the popliteus complex.  See a video here

Note:  It is important to note that in 15% of all PLC injuries there is associated nerve damage.  Thus be aware of any sensory or motor loss, particularly numbness, tingling, foot drop or tie extensor loss (La Prade & Terry, 1997)

Treatment

In general, any major postero lateral instability should be referred to a specialist as soon as possible.  Research has suggested that knees with major instability of the PLC do poorly with conservative management (Cooper, McAndrews & La Prade, 2006)

A quick check for PLC instability takes only seconds out of your assessment time, yet the difference could be between the success or failure of your patients ACL reconstruction.

 References

Cooper JM, McAndrews PT, LaPrade RF. Posterolateral Corner Injuries of the Knee: Anatomy, Diagnosis, and Treatment.Sports Med Arthrosc Rev. 2006;14(4)213–220

LaPrade, RF, Wentorf FA, Hollis Fritts MS, Gundry C and Hightower CD. A Prospective Magnetic Resonance Imaging Study of the Incidence of Posterolateral and Multiple Ligament Injuries in Acute Knee Injuries Presenting With a Hemarthrosis. Arthroscopy. 2007; 23(12) 1341-1347

LaPrade RF, Terry GC: Injuries to the posterolateral aspect of the knee: Association of injuries with clinical instability. Am J Sports Med. 1997;25:433–438

Other good resources

Popliteus muscle injuries

Posterolateral knee injuries

The popliteofibular ligament

[theresaghostinmyhouse]

Did you know good hip control and core stability has been proven to decrease the risk in lower limb injury? Particularly knee ACL injury. Stay tuned for more

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Did you know good hip control and core stability has been proven to decrease the risk in lower limb injury? Particularly knee ACL injury. Stay tuned for more

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15 amazing things in nature you won’t believe actually exist

Source

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THINGS I NEED TO SEE

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don’t let your dreams be dreams by Bazzerio on Flickr.

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Formed out of necessity and a mutual appreciation of legendary acts spat out of 80s Australia/New Zealand, Camperdown & Out (featuring members of Royal Headache, Raw Prawn, Dead Farmers and Marf Loth) take their name from the inner-western suburb of Sydney, combined with a few tales of woe and redemption. The 4-piece have set out to salute their heroes in the Go-Betweens, Ed Kuepper, Paul Kelly, The Clean, along with the obvious slaps on the back to internationals such as Lou Reed and sunshine British wino Kevin Ayers. 'Down and Out' is their debut single off their debut album 'Couldn't Be Better' - out early 2013. Camperdown & Out are Nathan Roche, Alex Kiers, David Akerman & Chris Shortt https://www.facebook.com/CamperdownAndOut

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Big cat

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Black tusk #whistler