1 Frozen shoulder/adhesive capsulitis 🅰️ - Primary: inflammatory condition causing fibrosis on glenohumeral joint capsule that persist more than 3 months - Secondary: excessive scar tissue or adhesion across glunohumerul jt such as past history of surgery that increased the risk develop frozen shd. Then after surgery,shd prolonged immobilization, the irsk increase. The shd capsule stiffen idopathicly. - Age: mostly affected 40-60y/o - Stages of FS Freezing stage: last 2-6 months. mod-severe pain & ROM restriction. Characterized by slow onset of widespread inflammation involving capsule and synovium of jt. Frozen stage: last 4-12 months. Severe pain in early stage 2. Reduced pain but jt stiffness in later phase stage 2. Characterized by gradual reduced inflammation and gross restriction of ROM. Thawing stage: last 6-26 months. Minimal pain and gradual resolution of jt stiffness. Progressive return of movements. Ms weakness - Symptoms: shoulder pain, ms guarding on shd, posture abnormalities, restrict shd jt mov (internal rotate, abd,flex), ms weakness. - Provocative test: shd shrug sign, coracoid pain test (dr assx), apley scratch test. 2 Shoulder impingement syndrome - 🙆🏻♀awin - primary: trapping of soft tissue in subacromial space – tendon long head of bicepbrachii or supraspinatus - secondary: repetitive overhead movement of SITS r impingement of subachromial bursa - movement: flex (90), int rot ,abd (>90-120) - P: tennis,thrower,weightlifter,swimmer - Structure: acromion process, coracoacromial lig, head of humerus (ext: subacromial bursa) Type 1: the acromion is flat on the undersurface with the anterior edge extending away from the humeral head. Type 2: the acromion is gently curved on the undersurface with the anterior edge extending parallel to the humeral head. Type 3: an inferiorly pointing, or hooked, anterior bone spur (osteophyte) narrows the outlet of the supraspinatus muscle and tendon. - Classification: Grade 1: pretear condition with subacromial bursitis and/or tendinitis. Grade 2: impingement with partial rotator cuff tears. Grade 3: impingement with complete rotator cuff tears. - Symptoms: night pain, 90 abd pain, tenderness bicep and sureior head humerus, limit abd, forward flec, crepitus at sub region, hypotrophy deltoid, pain overhead mov - Provocative test: neer impingement test, hawking kennedy, painful arc test (60-120), empty can test 3 Rotator cuff injury/tear 🅰️ - Primary: rip or tear of group of rotator cuff muscle that stabilize the shoulder - Sign: complete tear; unable to hold elevsted arm 60-120 degree - Secondary: impingement syndrome, trauma, tension overload - Trauma - - – any force that rotates the arm internally against a resistance or that prevents the arm from turning externally, as may occur during team handball, American football, or wrestling; – falling directly on the shoulder or on an outstretched arm; – lifting or throwing heavy objects. Type; partial tear and complete tear Symptoms and diagnosis: – Intense pain. The pain returns on exertion, may increase during the next 24 hours and may extend down the upper arm. A diagnosis of a tear of the supraspinatus tendon is suspected if the athlete has fallen on the shoulder, or has lifted or thrown a heavy object. – Pain is often intense, or increased, at night. The patient often complains of problems with sleeping or lying on the injured side. – Pain occurs when the arm is externally rotated or is raised upwards and outwards. When the tendon is only partially torn, the arm can be abducted to an angle of 60–80° to the body with little or no pain. The pain increases as the arm is lifted to an angle of 70–120°; it may increase once more when the arm is lowered. Between these angles the arm is also weak. When the tendon has sustained total rupture, the arm can be held at an angle of more than 120° to the body, but when it is lowered further it suddenly drops. This is an important diagnostic sign (drop arm test). Provocative tes: empty can test, lift off test, drop arm test (most cases) 4 Lateral epicondylitis with trigger point area 😺 - Tennis elbow; tennis player (35-50y/o), squash, badminton, and table tennis. Those who carry out repetitive, one-sided movements in their jobs (e.g. electricians, carpenters) or leisure activities (e.g.needlework, knitting, gardening). - Muscles: primarily extensor carpi radialis brevis and secondarily the extensor digitorum communis muscle tendon - Symptoms: - pain during supination and extend wrist – Pain lateral aspect of the elbow, but can also radiate upwards along the upper arm and downwards along the outside of the forearm. – Weakness handgrip - Provocative test – Pain occurs over the lateral epicondyle when the hand is extend at the wrist against resistance. (tennis elbow test) – A positive middle finger test: there is pain over the lateral elbow when the middle finger is extended against resistance (resistive tennis elbow test) - Tinel sign: tender point is elicited by pressure or percussion (tinel) over the lateral epicondyle - varus test. 5 Medial epicondylitis with trigger point area 😺 - Thrower’s or golfer’s elbow (repetition of pronation and flexion) - Muscles: pronator teres, palmaris longus, and flexor carpi radialis - Symptoms golfer elbow: -tenderness medial aspect and pain during pronation and wrist flexion - Symptoms thrower elbow: -giving away sensation - -pain medial aspect -valgus instability Provocative test: golfer elbow test, valgus stress test, tinel sign 6 Carpal tunnel syndrome 🅰️ - Etiology: inflammation of flexor retinaculum due to repetitive movement causing narrowing the tunnel. Impingement of median nerve - P: students, clerk, office worker, accountant - Symptoms -tenderness over palmar wrist jt -tingling and numbness to thumb and 2 and a half fingers, prominent during hyperflex -weak grip strength - Provocative test: phalen, reverse phalen, tinel sign. Medial nerve neurodynamic. 7De Quervains tenosynovitis 🅰️ - Inflammation of the sheath of the short extensor tendon (extensor pollicis brevis) and long abductor tendon (abductor pollicis longus) - Etiology: repetitive mov of thumb and wrist - Symptoms: -pain and tenderness baseof thumb -pain during extend thumb and abd against resistance - Provocative test: finklestein’s test and tinel sign. 8Trigger finger 😺 9Mallet finger 🅰️ - Etiology: Disruption of the extensor tendon at this insertion - Mechanism: forceful bending applied to an actively straightening joint, typically when a ball unexpectedly hits the fingertip and forces the finger to bend. - Symptoms: tenderness at nail and 1st DIP , fingers tip slightly bend 10Hamstring strain - 🙆🏻♀awin - Ruptures of hamstring due to result of overload forceful contraction during flexing of the knee or extension of the hip. - A: semotendinosus, semimebranosus, bicep femoris - N: tibial nerve diversion from sciatic nerve - P: Sprinters, water-skiing, middle distance runners, and participants in contact sports - Symptoms: o pop during rupture, local tenderness, hematoma, feel soreness, inability to extend knee and flex fully knee, reduce ms strength. - Grade 0 - a injureis are focal soreness after exercise, where Grade 0b represents generalised muscle soreness, which most commonly occurs after unaccustomed exercise, often with an eccentric bias and is frequently termed DOMS. - Grade 1 — tightness in the muscle while stretching, inability to fully move the leg from bending to straightened, and inability to bear weight on the affected leg. - - Grade 2 — reduced muscular strength, limping when walking, and pain when bending the knee. Grade 3 — sudden, sharp pain in the back of the thigh, inability to extend the knee more than 30 to 40 degrees, inability to walk without pain, and severe bruising around the impacted area. Provocative test: isometric test and 90-90 SLR 11Hip Adductor strain - 🙆🏻♀awin - rupture of the adductor longus muscle can occur when the muscles are tense and overused - M: pulled beyond its limit, overload of muscle activity such as kicking, running, changing direction while running. - P: soccer tackle, figure skatting, hockey player, baseball. - Symptoms: - stabbing pain in the groin. When attempts are made to restart activity, the pain returns. – Local bleeding can cause swelling and bruising – Severe dull aching pain, stretching pain of adductor, decrease ms strength, pain adducting - Provocative test: Isometric test - Muscle length: Thomas test, piriformis test, faber test 12ACL 🅰️ - Mechanism: sudden deceleration, twisting direct trauma - Etiology: Isolated injuries of the ACL can occur with a twisting impact, either in internal rotation and hyperextension or in external rotation and valgus - Etiology: ACL MCL (valgus force n external rot) ACL LCL PCL (varus force n int rot) ACL PCL (hypertext and hyperflex) - Symptoms: -after injury, pt hear pop but still can walk -giving away knee, unstable knee -swellin n discomfirt pain, hemarthrosis - Provocative test: – Lachman’s test; An anterior drawer test with the knee in 20–30° of flexion and the tibia in neutral rotation is positive. The test is performed by pulling the tibia forward in relation to the femur. positive Lachman’s test is diagnostic for an ACL tear. – An anterior drawer test in 70–90° of flexion, with the knee in neutral or internal rotation, is positive. This test is, however, not as reliable as the Lachman test, because the hamstrings and the medial posterior horn of the meniscus can resist this drawer. – The pivot shift examination, or ‘rotatory drawer test’, may be positive. This test is difficult to perform, especially in acute injury. A positive pivot shift may be an indication for surgery in active individuals since it indicates chronic ACL injury. – Valgus and varus (side) stability of the knee at 20–30° of flexion and extension should be assessed to exclude injuries to the MCL, and LCL. - Notes: quadriceps and hamstring muscles. The hamstring muscles work as an agonist to the ACL and should be exercised early 13PCL 😺 - Mechanism: 1. dashboard injury: posterior force on front of flexed knee - 2. sports: anterior force (posterior tiial translation) with hyperextend or extend knee (rugby tackle) n flexion with plantarflex (indirect combination), hyperflex with dorsiflex (isolated pcl) Symptoms: swelling, bruising, pain when flex 90. Leg felling give away. Hyperextend knee. Provocative test: posterior sag sign (knee flexed 70-90), posterior drawer test (90 knee flexed- 3-10mm partial n 10mm complete tear), reverse Lachman test Notes: quadricep strengthening 14 MCL - 🙆🏻♀awin - Mechanism: valgus force, external rotate - P: skiing, football, rugby - Symptoms: -inability to walk grade III -swelling and pain depends on degree of tear - tenderness at medial side of femoral condyle - damage of saphenous nerve - Grading: • grade 0—normal, i.e. no joint opening; • grade I—0.2 in (1–4 mm) joint opening; • grade II—0.2–0.4 in (5–10 mm) joint opening; • grade III—0.4–0.6 in (10–15 mm) joint opening. - Provocative test: valgus stress test (30), Lachman (clearance of ACL) - Notes: quadriceps strengthening 15 LCL - - - 🙆🏻♀awin Mechanism: varus force on hyperextension, severe rotational. Associated with PCL or popliteal injury Symptoms: acute (swelling, pain, foot kicking gait during midstance, foot drop, leg giving awar, inability to weight bearing, can’t perform straight leg raise). Subacute (lateral knee pain, stiffness at er flexion ext, weakness quadricep) chronic (unspecific knee pain, weakness, leg instability) Provocative test: varus test and posterior drawer test 16 Meniscus😺 - Mechanism: twisting and semi-flexed or flex knee - Commonly: medial meniscus prone to injured in twisted, external rotate, hyperflexand hypertext. For lateral meniscus, more injured in internal rotation - Etiology: Meniscus n MCL (valgus forceand external rot) - Clinical features: pt came with knee in partial flex, locally has joint effusion, joint line tenderness, pain upon palpation. - Symptoms: -pain and tenderness at medial knee jt, locking of knee flex motion, hyperextend and hyperflex cause pain, joint effusion, weak quadricep - Provocative: Mcmurray test, apley grind test, Thessaly test (5 or 20 degree) - Notes: quadricep and hamstring muscles, asap training, crutches 1-2 days 18 Ankle sprain (medial & lateral) - 🙆🏻♀awin - Etiology: ATFL, PTFL, CFL (plantarflex n inversion – lateral ankle sprain) MDL (everted n ext rot – medial ankle sprain) - Grading grade I: ligament stretch without microscopic tearing, minimal swelling or tenderness, minimal functional loss, no mechanical joint instability; – grade II: partial microscopic ligament tear with moderate pain, swelling, and tenderness over the involved structures. There is some loss of joint motion and mild to moderate joint instability; – grade III: complete ligament rupture with marked swelling, hemorrhage, and tenderness. There is a loss of function and severe joint stability. These patients have difficulties with full weightbearing. - Symptoms: -pain WB ad ankle movement, instability in total tear -hemarthrosis and bruising - Provocative test -The inversion stress test; evaluates the integrity of the CFL. With the ankle in neutral and the distal tibia stabilized, an eversion stress is placed on the heel and the tilt deformity of the hind foot relative to the distal tibia is assessed. The normal range is 0–30°. – An evaluation of an acute ankle sprain is optimally carried out 4–7 days after injury. It is then possible to detect the most tender areas by palpation, indicating where the ligament injuries are. Stability will also be more reliable. Hematoma formation and spreading can be evaluated. 19 Tendon Achilles injury/tear 🅰️ - Extrinsic factor: sudden change in activity, excessive training, sudden change in training surface characteristics, or suboptimal footwear (ex: tennis player- deceleration and then a major push-off) - Intrinsic factor: malalignment, excessive pronation, gastrocnemius-soleus stiffness, muscle imbalance, and age. Men > women, 35-40, football, team handball, volleyball, basketball, tennis, squash, runners, badminton - Symptoms: -Intense pain is over Achilles tendon at the time of injury. The injured person will often state that ‘something hit me from behind’ at the moment the pain began. There is not much pain. however, after the acute phase, and the athlete experiences an improvement of the condition. – The injured athlete cannot walk normally on the foot or on tiptoe, and cannot “push off” on that leg. – Increasing swelling, bruising, unable to plantarflex – Localized tenderness while the athlete is lying prone. – A gap can be seen or felt in the tendon. - Provocative test: Thompson, pt prone ly, feet hanging. PT squeeze calf muscle belly, the foot is bent downwards (plantar flexed) if the Achilles tendon is intact, but remains in its initial position if the tendon is torn. - Notes: partial tear TA, pt experience morning stiffness 20 Plantar fasciitis with trigger point area 😺 - Etiology: degenerative inflammation of thickband tissue called as plantar fascia. Happen when overused or stretched too far. - Symptoms: pain at heel or arch of foot, swelling heel, pain first step after sleep or prolonged sit, limited ankle mov, limping gait. - Provocative test: extend 1st phalanges passively on flat foot (windlass test) 21 Patellofemoral syndrome - 🙆🏻♀awin - Primary: muscle imbalances in knee muscle - Secondary: Damage to the articular surface of the patella causing compression forces between the patella and the femur that usually occurs in individuals aged 10–25 years - symptoms -dull aching pain, especially on walking down hills (80 flex causing more compression force) and stairs and when squatting. -previous trauma on patella causing dislocate of patella -anterior knee pain, increase force around patella, - sign -hypermobile patella, muscle hypothropy, valgus deform, abnormal shape patella n patella grove - provocative test: patella grind test, apprehension test, patella mobility, resisted knee extension - Notes: ant knee pain (bursitis, fat pad syndrome, plica syndrome, and meniscus problems) 22 Osteoarthritis hip n knee 😺 - Etiology – Primary osteoarthritis, the cause of which is unknown, occurs most frequently in women and in people with diabetes. Obesity is probably of no significance so far as onset of the disease is concerned, but it does accelerate the degenerative process once it has begun. – Secondary osteoarthritis may follow either injury or joint disease. Fractures of articular surfaces, including damaged cartilage, ligament injuries, and dislocations are all possible causes, as are infections and rheumatoid arthritis. Persistent inappropriate loading of joints, for example in joggers who run on a camber, may in rare cases also result in osteoarthritis. 24 Amputation (upper limb and lower limb) - 🙆🏻♀awin 25 Rheumatoid arthritis 😺 - an autoimmune disease (a disease of the body’s own immune system) although its precise cause is not known, is a chronic inflammatory condition which affects joints, tendons, tendon sheaths (fascia), muscles, and bursae, as well as other tissues throughout the body - women>men, 20-30 n 45-55, congenital - etiology The first stage in rheumatoid arthritis is inflammation of the synovial (joint lining) membrane (synovitis) associated with the deposition of protein (fibrin). As a result of the inflammation, fluid is secreted into the joint, causing swelling. The inflammatory tissue grows towards the center of the joint space and coats the articular surfaces and the surrounding ligaments and tendons. At the same time, the articular cartilage is destroyed systematically from its surface inwards to the underlying bone, and cysts form in the adjacent bone. As the inflammatory - - tissue begins to be replaced by scar tissue, the joint capsule becomes thickened and can consequently impede the mobility of the joint and increase the swelling symptoms – pain and swelling of joints; – joint stiffness which is particularly pronounced in the mornings and after activity; – joint deformities, muscular hypotrophy, and tendon abnormalities; – periods of relapse and remission in the course of the condition. Diagnosis 1. Morning stiffness. 2. Pain and tenderness in at least one joint. 3. Soft tissue swelling or excessive fluid in at least one joint. 4. When (2) or (3) is present, swelling in at least one other joint. 5. Symmetrical joint swelling. 6. Nodules on tendons at sites typical of rheumatoid arthritis. 26 Septic arthritis🐱 27 Gout 😺 - Due to accumulation of uric acid crystals in joints, and 95% of the victims are middle-aged men. - The first metatarsophalangeal joint (at the base of the big toe) is most frequently affect. - an acute attack—which usually lasts 2–7 days—becomes red, hot, swollen, and exquisitely painful. Chronic gout may affect more than one joint, in which case it may mimic other generalized joint diseases 28 Osteomyelitis - 🙆🏻♀awin 29 TB of bone 🅰️ 30 Burn - 🙆🏻♀awin - Degrees of burns – First degree: the skin is red. Damage is confined to the superficial layers of skin. This heals in a couple of days without treatment. – Second degree: blisters form on the skin. If they burst, a sterile bandage and possibly a medicated compress should be applied. If the burn covers a skin area greater than 10 cm2 (2 in2) a doctor should be consulted. – Third degree: all the layers of the skin are destroyed, and the victim should definitely consult a doctor. During the early stages of a burn it can be difficult to judge whether it is second or third degree.
