Musculoskeletal Pathology

Copyright Sept 2003 Ted Nissen

TABLE OF CONTENTS

1 Ankle and Foot 1

2 Cervical Spine. 44

3 Elbow.. 53

4 Hip, Pelvic Girdle, Sacroiliac and Buttock 58

5 Knee. 61

6 Leg. 66

7 Lumbar Spine. 70

8 Shoulder and Shoulder Girdle. 77

9 Temporomandibular Joint 115

10 Thoracic Spine. 116

11 Wrist and Hand. 121

1 Ankle and Foot

Back Table of Contents References

1.1 Abnormal Foot Pronation

1.2 Abnormal Foot Supination

1.3 Achilles Bursitis (Adventitious)

1.3.1 HISTORY

1.3.2 SUBJECTIVE

1.3.3 OBJECTIVE

1.3.4 TREATMENT

1.3.5 EXAMINATION

1.3.6 PATIENTS ASSESSMENT FORM

1.4 Achilles Tendonitis / Tendinosis

1.4.1 Summary

1.4.1.1 This condition is a chronic, painful inflammation of the achilles tendon and its sheath, the fibrous terminal attachment of the gastrocnemius and Soleus muscles into the calcaneus and associated structures. It is also known as Achilles or calcaneal paratenonitis. It is prevalent among runners, middle aged individuals, and proportionally distributed among men and women. The causes include; Overuse, Rough terrain, improper shoe wear, Cold weather, Biomechanical foot problems, Sudden increase in training, and absent warm-up. Typical signs include; A gradual increase in painful swelling and warmth occurs at any point along the tendon substance most commonly 3 to 5 cm proximal to the insertion onto the calcaneus.

1.4.2 Basics

1.4.2.1 Description

1.4.2.1.1 This condition is a chronic, painful inflammation of the achilles tendon and its sheath, the fibrous terminal attachment of the gastrocnemius and Soleus muscles into the calcaneus and associated structures. It is also known as Achilles or calcaneal paratenonitis.

1.4.2.2 Incidence

1.4.2.2.1 This common overuse injury is seen particularly among recreational and competitive athletes and occurs in 6% to 11% of runners.

1.4.2.2.2 It affects active persons 15 to 45 years old.

1.4.2.2.3 It is extremely prevalent in the high school and college track circuit.

1.4.2.2.4 It is found in middle to long distance runners (800 m to marathon)

1.4.2.2.5 It is more common in active middle aged individuals.

1.4.2.2.6 The male to female predominance roughly parallels that of participation in athletic activities.

1.4.2.3 Causes

1.4.2.3.1 Introduction

1.4.2.3.1.1 This overuse injury of the affected leg is often due to the following conditions.

1.4.2.3.2 Rough terrain or uneven surfaces

1.4.2.3.3 Improper shoe wear (10%)

1.4.2.3.4 Adverse weather conditions (ice, snow, cold)

1.4.2.3.5 Biomechanical abnormalities of the lower extremity, from lumbar spine to foot (up to 35% to 55%)

1.4.2.3.6 Training errors (75%) ; sudden increase in training regimen (mileage)

1.4.2.3.7 Chronically inappropriate short or absent warm-up and stretching period.

1.4.2.4 Risk Factors

1.4.2.4.1 Microvascular disease; diabetes, lupus, rheumatoid disease, endarteritis

1.4.2.4.2 Hemodialysis or peritoneal dialysis; renal disease

1.4.2.4.3 Connective tissue disease

1.4.2.5 Classification

1.4.2.5.1 Insertional versus noninsertional

1.4.2.5.2 Paratenonitis; paratenon inflammation

1.4.2.5.3 Paratenonitis with tendinosis; intrasubstance degeneration with paratenon inflammation.

1.4.2.5.4 Tendinosis; intrasubstance degeneration secondary to atrophy.

1.4.2.5.5 Terminal condition after long term symptoms, often at this point asymptomatic

1.4.2.6 Associated Conditions

1.4.2.6.1 Achilles tendon rupture

1.4.2.7 ICD-9-CM

1.4.2.7.1 726.71 Achilles tendonitis

1.4.3 Diagnosis

1.4.3.1 Signs and symptoms

1.4.3.1.1 A gradual increase in painful swelling and warmth occurs at any point along the tendon substance, from the musculotendinous junction to the bone insertion (os Calcis).

1.4.3.1.2 Most pain is 3 to 5 cm proximal to the insertion onto the calcaneus.

1.4.3.1.3 Microtrauma such as continued running, or even gross trauma such as a single leap (in jumpers), exacerbates the symptoms.

1.4.3.1.4 Pain is somewhat relieved by unloading (rest).

1.4.3.2 Differential Diagnosis

1.4.3.2.1 Precalcaneal bursitis

1.4.3.2.2 Retrocalcaneal bursitis

1.4.3.2.3 Peroneal Tendinitis or rupture

1.4.3.2.4 Posterior tibialis Tendinitis

1.4.3.2.5 Achilles tendon rupture, partial or complete; may represent terminal stage

1.4.3.2.6 Inflammatory Arthritis (Reath’s syndrome)

1.4.3.3 Physical Examination

1.4.3.3.1 A full lower extremity history should be obtained. The examiner should check for pain on dorsiflexion of the ankle. Placing both fingers around the tendon localizes the pain. In server cases the tendon sheath may be swollen and crepitant with ankle motion.

1.4.3.3.2 Use Thompson’s test to rule out tendon rupture.

1.4.3.3.3 Note any intrinsic foot , ankle , or leg deformities; pes cavus, leg length discrepancy, scoliosis, equinus deformity, residual clubfoot.

1.4.3.4 Laboratory Tests

1.4.3.4.1 Usually none are indicated. Serum chemistry study with glucose is recommended if one of the foregoing systemic conditions is suspected, if diabetes needs to be ruled out, or if an overuse history is not present. Evaluation for inflammatory arthritis if clinically indicated.

1.4.3.5 Pathologic Findings

1.4.3.5.1 Chronic inflammatory changes are noted in the sheath.

1.4.3.6 Imaging Procedures

1.4.3.6.1 Magnetic resonance imaging is indicated if the clinical picture suggest tendinosis.

1.4.4 Management

1.4.4.1 General Measures

1.4.4.1.1 Non steroidal medications, ice, rest, footwear modification, and orthotic correction of the foot and leg abnormality are used.

1.4.4.1.2 Retrocalcaneal bursa injection may also help to relieve symptoms and inflammation. For patients who are not responsive to the foregoing treatments , a trial of cast immobilization with weight bearing is appropriate.

1.4.4.2 Surgical Treatment

1.4.4.2.1 Treatment involves removal or release of the paratenon through a straight medial incision. This method is reserved for the fewer than 25% of patients in whom 3 to 12 months of conservative management has failed. Seventy percent to 90% respond favorably, with a return to activity after a further period of rest. Patients with previous surgical failures respond well to repeat surgery. If intratendinous debridement is performed, it may require augmentation or local tendon transfer.

1.4.4.3 Physical Therapy

1.4.4.3.1 Ultrasound therapy (during proliferative phase healing), phonophoresis, iontophoresis, and short-term heel wedge use (to unload tendon unit) are used.

1.4.4.3.2 Eventually, flexibility, strengthening, and conditioning through eccentric exercise gain maximal benefit.

1.4.4.4 Medical Treatment

1.4.4.4.1 Nonsteroidal anti-inflammatory drugs

1.4.4.4.2 Analgesics

1.4.4.5 Patient Education

1.4.4.5.1 Adequate pretraining stretching and warm-up

1.4.4.5.2 Proper shoe wear and terrain adjustment, with avoidance of steep hills and stairs

1.4.4.6 Monitoring

1.4.4.6.1 Routine follow-up is indicated until the symptoms are resolved.

1.4.4.7 Complications

1.4.4.7.1 Tendon degeneration and eventual rupture with loss of function, particularly with a high rate of surgical failure, are possible.

1.4.4.8 Prognosis

1.4.4.8.1 The prognosis is good; however, recovery can be prolonged.

1.4.5 Wheeless' Textbook of Orthopaedics

1.4.5.1 http://www. wheelessonline.com /05/2450.htm

1.4.6 The Merck Manual of Diagnosis and Therapy

1.4.6.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.5 Ankle Fractures

1.5.1 Wheeless' Textbook of Orthopaedics

1.5.1.1 http://www.wheelessonline.com/ooa1/29.htm

1.6 Ankle Equinus Contracture

1.6.1 Wheeless' Textbook of Orthopaedics

1.6.1.1 http://www.wheelessonline.com/ooa1/2451.htm

1.7 Ankle Sprains

1.7.1 Wheeless' Textbook of Orthopaedics

1.7.1.1 http://www.wheelessonline.com/ooa1/25.htm

1.7.2 The Merck Manual of Diagnosis and Therapy

1.7.2.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60b.htm

1.8 Ankle Sprains (Chronic Recurrent)

1.9 Ankle Valgus

1.9.1 Wheeless' Textbook of Orthopaedics

1.9.1.1 http://www.wheelessonline.com/ooa1/2351.htm

1.10 Ankle Varus Deformity

1.10.1 Wheeless' Textbook of Orthopaedics

1.10.1.1 http://www.wheelessonline.com/ooa1/2352.htm

1.11 Anterior Achilles Tendon Bursitis (Albert's Disease)

1.11.1 The Merck Manual of Diagnosis and Therapy

1.11.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.12 Anterior Compartment Syndrome

1.13 Anterior Impingement Syndrome of the Ankle

1.13.1 Wheeless' Textbook of Orthopaedics

1.13.1.1 http://www.wheelessonline.com/ooa1/28.htm

1.14 Anterior Talofibular ligament Sprain (Varus Sprain)

1.15 Anterior Tibiofibular Ligament Sprain

1.16 Anterior Tibiotalar Ligament Sprain

1.17 Arteriosclerosis

1.18 Arthrodesis of the First MP Joint

1.18.1 Wheeless' Textbook of Orthopaedics

1.18.1.1 http://www.wheelessonline.com/oo3/161.htm

1.19 Avulsion Fracture of Base of 5th Metatarsal

1.19.1 Wheeless' Textbook of Orthopaedics

1.19.1.1 http://www.wheelessonline.com/oo3/179.htm

1.20 Beal’s syndrome

1.21 Bunionette / Overlapping 5th Toe Deformity

1.21.1 Wheeless' Textbook of Orthopaedics

1.21.1.1 http://www.wheelessonline.com/oo3/173.htm

1.22 Calcaneal Bursitis (Inferior Calcaneal Bursitis) (Adventitious Bursa)

1.23 Calcaneal Fracture

1.23.1 Wheeless' Textbook of Orthopaedics

1.23.1.1 http://www.wheelessonline.com/oo3/192.htm

1.24 Calcaneal Spur Syndrome (Traction osteophytes (heel spurs))

1.24.1 Summary

1.24.1.1 Calcaneal heel spurs (Traction Osteophytes) are the growth of new bone, which develops in the area of the inferior calcaneus probably caused by the pull of the plantar fascia on the periosteum. Although X-Ray evidence of calcaneal osteophytes confirms the diagnosis a negative x-ray cannot rule out early heel spur onset as infrequently, calcaneal spurs may appear ill defined exhibiting fluffy new bone formation. Flatfeet and contracted heel cords may contribute to the development of heel spurs because of increased plantar fascial tension. When firm thumb pressure is applied to the center of the heel further pain is elicited. Inferior calcaneal pain without X-Ray evidence may be a sign of the early heel spur formation but as the spur enlarges pain often diminishes possibly because of adaptive changes in the foot and an asymptomatic period ensues. After the heel spur enlarges sudden painful onset may occur often following local trauma (sports injury). An adventitious bursa may develop and become inflamed causing the bottom of the heel to become swollen, warm, painful, and throbbing. Calf-stretching, night splinting, strapping, Oral NSAIDs, anaesthetic and or a mixture of soluble and insoluble corticosteroids injection may be effective in reducing or eliminating symptoms.

1.24.2 The Merck Manual of Diagnosis and Therapy

1.24.2.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.25 Calcaneocuboid Ligament Sprain (Varus Sprain)

1.26 Calcaneofibular Ligament Sprain (Varus Sprain)

1.27 Calcaneovalgus Foot

1.27.1 Wheeless' Textbook of Orthopaedics

1.27.1.1 http://www.wheelessonline.com/o11/208.htm

1.28 Capsular Lesions (1st Metatarsophalangeal Joint)

1.29 Capsular Lesions (Ankle Joint)

1.30 Capsular Lesions (Mid-Tarsal Joint)

1.31 Capsular Lesions (Talocalcanean/Sub-Taloid Joint and Heel)

1.32 Capsule Tightness (Ankle)

1.33 Cavovarus Foot

1.33.1 Wheeless' Textbook of Orthopaedics

1.33.1.1 http://www.wheelessonline.com/o11/205.htm

1.34 Charcot's foot Charcot-Marie-Tooth Disease)

1.35 Claw Toes

1.35.1 Wheeless' Textbook of Orthopaedics

1.35.1.1 http://www.wheelessonline.com/oo3/186.htm

1.36 Clubfoot / Talipes Equinovarus

1.36.1 Wheeless' Textbook of Orthopaedics

1.36.1.1 http://www.wheelessonline.com/o14/117.htm

1.37 Compartment Syndrome of the Foot

1.37.1 Wheeless' Textbook of Orthopaedics

1.37.1.1 http://www.wheelessonline.com/oa2/76.htm

1.38 Congenital Vertical Talus

1.38.1 Wheeless' Textbook of Orthopaedics

1.38.1.1 http://www.wheelessonline.com/o2/220.htm

1.39 Cuneo-First-Metatarsal Joint Osteoarthrosis

1.40 Curly Toes and Overlapping Toes

1.40.1 Wheeless' Textbook of Orthopaedics

1.40.1.1 http://www.wheelessonline.com/oo3/2000.htm

1.41 Dancer’s Heel

1.42 Deep Peroneal Nerve Entrapment

1.43 Diabetic Foot and Ankle

1.43.1 Wheeless' Textbook of Orthopaedics

1.43.1.1 http://www.wheelessonline.com/ortho1/974.htm

1.44 Deltoid Ligament Sprain (Valgus Strain)

1.45 Dens Fracture

1.45.1 Wheeless' Textbook of Orthopaedics

1.45.1.1 http://www.wheelessonline.com/o11/172.htm

1.46 Equinovalgus

1.46.1 Wheeless' Textbook of Orthopaedics

1.46.1.1 http://www.wheelessonline.com/o16/57.htm

1.47 Fibromatosis

1.47.1 Wheeless' Textbook of Orthopaedics

1.47.1.1 http://www.wheelessonline.com/o6/148.htm

1.48 Flexor Digitorum Longus Tendonitis

1.48.1 The Merck Manual of Diagnosis and Therapy

1.48.1.1 http://www.merck.com/mrkshared/mmanual/section5/chapter62/62c.jsp

1.49 Flexor Hallucis Longus (FHL) Tendonitis/Tenosynovitis

1.49.1 Summary

1.49.1.1 This condition is a chronic, painful inflammation of the Flexor Hallucis Longus tendon and its sheath, the fibrous terminal attachment of the Flexor Hallucis Longus muscle to the planar surface of the base of the distal phalanx of the big toe. This condition is rarely seen except in ballet dancing because of their extreme plantar flexion when going from flat foot to the en pointe position (extreme plantar flexion). Lesions develop in the tendon posterior to the medial Malleolus (tarsal tunnel) where swelling, pain, and tenderness triggering pain along tendon sheath may occur with toe flexion. Dorsiflexion of the great toe may be reduced when the ankle is placed in dorsiflexion.

1.49.2 Wheeless' Textbook of Orthopaedics

1.49.2.1 http://www.wheelessonline.com/05/247.htm

1.50 Fracture Of The Posterolateral Talar Tubercle

1.50.1 The Merck Manual of Diagnosis and Therapy

1.50.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.51 Freiburg's Arthritis

1.51.1 Wheeless' Textbook of Orthopaedics

1.51.1.1 http://www.wheelessonline.com/o11/201.htm

1.52 Haglund's Deformity

1.52.1 Wheeless' Textbook of Orthopaedics

1.52.1.1 http://www.wheelessonline.com/oo3/17441.htm

1.53 Hallux Rigidus and Cheilectomy

1.53.1 Wheeless' Textbook of Orthopaedics

1.53.1.1 http://www.wheelessonline.com/oo3/160.htm

1.53.2 The Merck Manual of Diagnosis and Therapy

1.53.2.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60d.htm

1.54 Hallux Valgus

1.54.1 Wheeless' Textbook of Orthopaedics

1.54.1.1 http://www.wheelessonline.com/oo3/151.htm

1.55 Hammer Toes

1.55.1 Wheeless' Textbook of Orthopaedics

1.55.1.1 http://www.wheelessonline.com/oo3/189.htm

1.56 Heel Pain

1.56.1 Wheeless' Textbook of Orthopaedics

1.56.1.1 http://www.wheelessonline.com/o16/1060.htm

1.57 Immobilization Limitation

1.58 Impingement Periostitis

1.59 Infections of the Foot

1.59.1 Wheeless' Textbook of Orthopaedics

1.59.1.1 http://www.wheelessonline.com/ortho1/973.htm

1.60 Ingrown Toe Nail

1.60.1 Wheeless' Textbook of Orthopaedics

1.60.1.1 http://www.wheelessonline.com/o13/4304.htm

1.61 Interdigital Nerve Entrapment

1.61.1 The Merck Manual of Diagnosis and Therapy

1.61.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60d.htm

1.62 Interosseous Muscle Strain

1.63 Joint Problems and Restrictions

1.64 Jones Fracture

1.64.1 Wheeless' Textbook of Orthopaedics

1.64.1.1 http://www.wheelessonline.com/oo3/178.htm

1.65 Kohler's Disease I

1.65.1 Wheeless' Textbook of Orthopaedics

1.65.1.1 http://www.wheelessonline.com/o11/202.htm

1.66 Ledderhose Disease: plantar fibromatosis

1.66.1 Wheeless' Textbook of Orthopaedics

1.66.1.1 http://www.wheelessonline.com/o2/led1.htm

1.67 Ligamentous Sprains

1.68 Lisfranc's Fracture / TarsoMetatarsal Injuries

1.68.1 Wheeless' Textbook of Orthopaedics

1.68.1.1 http://www.wheelessonline.com/oo3/176.htm

1.69 Lisfranc's Sprain and Minimally Displaced Fracture

1.69.1 Wheeless' Textbook of Orthopaedics

1.69.1.1 http://www.wheelessonline.com/oo3/1761.htm

1.70 Loose Body & Other Conditions

1.71 Mallet Toe

1.71.1 Wheeless' Textbook of Orthopaedics

1.71.1.1 http://www.wheelessonline.com/oo3/191.htm

1.72 Marching Fracture (Metatarsal Shafts)

1.73 Marfan’s syndrome

1.74 Medial Malleolar Fractures

1.74.1 Wheeless' Textbook of Orthopaedics

1.74.1.1 http://www.wheelessonline.com/ooa1/79.htm

1.75 Medial Metatarsalgia

1.76 Metatarsalgia (Interdigital Neuralgia, Interdigital Perineural Fibrosis, & MP Joint Disease)

1.76.1 Summary

1.76.1.1 Metatarsalgia is a general term meaning pain over the ball of the foot caused by Interdigital nerve irritation, interdigital Perineural Fibrosis (Morton’s Neuroma between 3^rd & 4^th MP joint), or disease of the metatarsophalangeal articulations. Interdigital neuralgia presents with sudden pain onset along one or multiple interdigital nerve pathways (common and proper plantar digital nerves) radiating to the ball of the foot or the toes. Interdigital neuralgia may be caused by loss of the fat pad protecting the nerves of the foot, low-grade repetitive trauma, or improper footwear. Interdigital Perineural Fibrosis is described in the section of this text on Morton's Neuroma. MP joint disease results from misalignment of the joint surfaces, causing Subluxation and capsular and synovial impingement with eventual destruction of joint cartilage (degenerative joint disease). Predisposing factors include; Rigidity and stiffness of the forefoot, hammertoe deformities, cavus (highly arched) feet, excessive eversion of the subtalar joint (rolling-in of the ankles [pronation]), and Hallux valgus deformity (bunion).

1.76.2 Wheeless' Textbook of Orthopaedics

1.76.2.1 http://www.wheelessonline.com/o16/93.htm

1.76.3 The Merck Manual of Diagnosis and Therapy

1.76.3.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60d.htm

1.77 Metatarsophalangeal Articulation Pain

1.77.1 The Merck Manual of Diagnosis and Therapy

1.77.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60d.htm

1.78 Metatarsus Adductus

1.78.1 Wheeless' Textbook of Orthopaedics

1.78.1.1 http://www.wheelessonline.com/o12/112.htm

1.79 Midfoot / Forefoot Fractures

1.79.1 Wheeless' Textbook of Orthopaedics

1.79.1.1 http://www.wheelessonline.com/oo3/175.htm

1.80 Midtarsal Fractures

1.80.1 Wheeless' Textbook of Orthopaedics

1.80.1.1 http://www.wheelessonline.com/oo3/177.htm

1.81 Mid-Tarsal Ligament Contracture

1.82 Mid-Tarsal Ligament Strain

1.83 Morton's Metatarsalgia

1.84 Morton's Neuroma: Interdigital Perineural Fibrosis

1.84.1 Summary

1.84.1.1 It is not a neuroma (type of tumor composed of nerve cells) but a Perineural fibrosis (a fibrous thickening develops around the nerve covering) characterized by a sudden onset of burning/tingling pain most commonly between the 3^rd & 4^th MP joint (80-85%), 2^nd & 3^rd (15-20%) (Does not occur between the 1^st & 2^nd or 4^th & 5^th MP joints) results in compression of the common digital nerves of the foot radiating to the ball or the toes. It is most often unilateral, found in only one MP joint (3^rd & 4^th MP), and occurs most often in women (78%). It is made worse by walking in high-heeled shoes with a narrow toe box, is relieved by rest and shoe removal. Vague pain may radiate up the leg including the achilles tendon. Lower heels, wider toe box, metatarsal pads, metatarsal bar, stiff soled shoe, orthosis, and rest may help reduce symptoms.

1.84.2 Wheeless' Textbook of Orthopaedics

1.84.2.1 http://www.wheelessonline.com/o13/78.htm

1.84.3 The Merck Manual of Diagnosis and Therapy

1.84.3.1 http://www.merck.com/mrkshared/mmanual/section5/chapter60/60d.jsp

1.85 Osteochondral Lesions of the Talus

1.85.1 Wheeless' Textbook of Orthopaedics

1.85.1.1 http://www.wheelessonline.com/oo3/230.htm

1.86 Os Trigonum (Professional Dancers) (Posterior Talar Impingement)

1.86.1 Wheeless' Textbook of Orthopaedics

1.86.1.1 http://www.wheelessonline.com/ooa1/16.htm

1.87 Paraesthesia

1.88 Peroneal Tendonitis/ Tenosynovitis

1.88.1 Summary

1.88.1.1 The synovial sheath (secretes fluid which allows the tendon to slide up and down without friction) and tendon become inflamed due to excessive pronation. Symptoms include; pain and swelling at the 1.) Base of the 5^th metatarsal 2.) Cuboid tunnel (groove for the Peroneus longus tendon) near the proximal prominence of the 5^th metatarsal. 3.) Behind the outer ankle bone (lateral malleoli). Pain is increased with inward movement of the foot (inversion and with resistance to outward movement (ankle eversion).

1.88.2 Wheeless' Textbook of Orthopaedics

1.88.2.1 http://www.wheelessonline.com/05/3429.htm

1.88.3 Valparaiso Orthopedic Clinic

1.88.3.1 http://www.valpoortho.com/index.php?practiceId=10034&dir=article&lib=Article&articleId=2180

1.89 Peroneal Tendon Dislocation/Subluxation

1.89.1 Summary

1.89.1.1 The Peroneus longus and brevis snap in and out of their groove behind the fibula when the retinaculum is torn or stretched due to traumatic injury (skiing injuries). Symptoms include; Lateral ankle pain with activity that does not resolve, Snapping of the peroneal tendons over the fibula, Tenderness behind the lateral Malleolus along the Peroneus brevis muscle; Subluxation elicited with the patient attempting to dorsiflex the affected foot from a plantar flexed, everted position.

1.89.2 Basics

1.89.2.1 Description

1.89.2.1.1 Peroneal tendon Subluxation is an increased and abnormal motion of the peroneal tendon out of its groove behind the fibula. The tendons snap in and out of their correct positions with ankle motion. The peroneal tendons may subluxate anteriorly over the fibular head if the retinaculum is torn or stretched.

1.89.2.2 Genetics

1.89.2.2.1 No known mendelian predisposition exists

1.89.2.3 Incidence

1.89.2.3.1 Rare

1.89.2.3.2 Most common between ages 10 and 25 years

1.89.2.4 Causes

1.89.2.4.1 Usually traumatic, classically occurring as a result of skiing injuries in which the ligaments of the peroneal retinaculum are torn

1.89.2.4.2 May develop spontaneously in predisposed persons, probably resulting from an underlying shallow groove behind the fibula or Ligamentous laxity.

1.89.2.5 Risk Factors

1.89.2.5.1 Athletic patients are at risk

1.89.2.6 Associated Condition

1.89.2.6.1 Ligamentous laxity

1.89.2.7 ICD-9-CM

1.89.2.7.1 718.3 Peroneal tendon Subluxation

1.89.3 Diagnosis

1.89.3.1 Signs and Symptoms

1.89.3.1.1 Lateral ankle pain with activity that does not resolve

1.89.3.1.2 Snapping of the peroneal tendons over the fibula

1.89.3.1.3 Tenderness behind the lateral Malleolus along the Peroneus brevis muscle; Subluxation elicited with the patient attempting to dorsiflex the affected foot from a plantar flexed, everted position

1.89.3.2 Differential Diagnosis

1.89.3.2.1 Ankle sprain

1.89.3.2.2 Lateral Malleolar fracture

1.89.3.2.3 Lateral ligament disruption

1.89.3.2.4 Osteochondral talar dome fracture

1.89.3.3 Physical Examination

1.89.3.3.1 Have the patient attempt to dorsiflex the ankle from a plantar flexed, everted position to reproduce the symptoms.

1.89.3.3.2 Have the patient sit facing you and ask the patient to rotate the foot in a circular fashion while you palpate behind the lateral Malleolus muscle. If a disorder is present, the peroneal tendons may glide or move out of their groove and over the fibula.

1.89.3.3.3 Peroneal tendons normally snap in place within their sheath. Only a movement out of the sheath with reproduction of symptoms is diagnostic.

1.89.3.4 Laboratory Tests

1.89.3.4.1 There are no laboratory tests for the condition.

1.89.3.5 Pathologic Findings

1.89.3.5.1 Possible shallow groove for the peroneal tendons behind the fibula

1.89.3.5.2 Attenuated superior or inferior peroneal retinaculum

1.89.3.6 Imaging Procedures

1.89.3.6.1 Computed tomography demonstrates the shape of the peroneal groove

1.89.3.6.2 Magnetic resonance imaging may demonstrate a longitudinal tear of the Peroneus brevis.

1.89.3.6.3 Plain films are needed to rule out any other ankle disorder because this is a rare entity and subjective symptoms are nonspecific.

1.89.4 Management

1.89.4.1 General Measures

1.89.4.1.1 Activity modification may reduce the occurrence of Subluxation in certain patients if it is activity specific.

1.89.4.1.2 An ankle brace may limit the excursion of the foot and may decrease the episodes

1.89.4.1.3 Conservative treatment should be employed initially.

1.89.4.1.4 Surgery is commonly necessary to resolve the patient’s symptoms if conservative treatment fails.

1.89.4.1.5 Cast treatment is unlikely to be successful in chronic cases.

1.89.4.2 Surgical Procedure

1.89.4.2.1 Subluxating tendons require a peroneal groove-deepening procedure to locate the tendons more securely in their recess behind the fibula or a repair of the peroneal retinaculum (or both).

1.89.4.3 Physical Therapy

1.89.4.3.1 Physical therapy has not been proven effective.

1.89.4.4 Medical Treatment

1.89.4.4.1 After an acute, initial episode, cast immobilization may help to relieve the patient’s symptoms and to reduce inflammation.

1.89.4.4.2 Patients with recurrent Subluxation and resistant cases may require surgery.

1.89.4.4.3 Nonsteroidal anti-inflammatory agents can be used both acutely and during rehabilitation to relieve pain and to facilitate physical therapy.

1.89.4.5 Patient Education

1.89.4.5.1 Educate the patient about the anatomy of the lower limb and which positions of eversion and dorsiflexion of the ankle are most likely to reproduce the Subluxation.

1.89.4.5.2 The condition does not lead to degenerative joint disease or permanent squelae, but it may cause the ankle to give way unexpectedly.

1.89.4.6 Monitoring

1.89.4.6.1 Reeducation in ankle strengthening exercises is sometimes necessary

1.89.4.7 Complications

1.89.4.7.1 Complications of surgery include recurrence and sural neuroma.

1.89.4.7.2 If symptomatic Recurrence develops, other surgical procedures may be employed to treat symptoms.

1.89.4.8 Prognosis

1.89.4.8.1 Some cases are managed conservatively.

1.89.4.8.2 Results are best when nonoperative measures are employed.

1.89.4.8.3 The surgical success rate is 80% to 90%.

1.89.5 Wheeless' Textbook of Orthopaedics

1.89.5.1 http://www.wheelessonline.com/05/236.htm

1.90 Pes Cavus (High Arch-Cavus Foot) (Calcaneocavus Foot)

1.90.1 Summary

1.90.1.1 A high arched foot with or without symptoms as follows; Calluses on forefoot or hind foot, May have weak push-off, May be asymptomatic, May have pain under forefoot, and Difficulty in fitting or tolerating shoes.

1.90.2 Basics

1.90.2.1 Description

1.90.2.1.1 Cavus feet have an elevation of the longitudinal arch, often with associated deformity of the hind foot or forefoot.

1.90.2.1.2 A relatively high arch characterized a cavus foot. This may be flexible or rigid.

1.90.2.2 Synonym

1.90.2.2.1 High-arched foot

1.90.2.3 Genetics

1.90.2.3.1 Many of the disorders causing cavus feet are genetic.

1.90.2.3.2 Isolated cavus feet are only occasional familial.

1.90.2.4 Incidence

1.90.2.4.1 The condition is common.

1.90.2.5 Causes

1.90.2.5.1 Muscle imbalance, such as Peroneus longus and posterior tibialis overpull, can cause the condition.

1.90.2.5.2 Weakness of the intrinsic muscle of the foot, with overpull of the long flexors, is a contributing factor.

1.90.2.5.3 Connective tissue disorders, such as Marfan’s syndrome and Beal’s syndrome, may also cause cavus foot.

1.90.2.6 Risk Factors

1.90.2.6.1 Neuromuscular disorders

1.90.2.6.2 Trauma

1.90.2.6.3 Connective tissue disorders

1.90.2.7 Classification

1.90.2.7.1 The distinction is between flexible and rigid conditions

1.90.2.7.2 Cavus: high but unbalanced arch

1.90.2.7.3 Calcaneocavus: heel as main weight bearing surface

1.90.2.7.4 Cavovarus: high arch, turned inward

1.90.2.7.5 Equinocavovarus: above, with equinus contracture

1.90.2.8 Associated Conditions

1.90.2.8.1 Compartment syndrome of leg or foot

1.90.2.8.2 Charcot-Marie-Tooth disease

1.90.2.8.3 Friedreich’s ataxia

1.90.2.8.4 Spina bifida

1.90.2.8.5 Spinal cord tumor

1.90.2.8.6 Diabetic neuropathy

1.90.2.8.7 Poliomyelitis

1.90.2.8.8 Partially treated clubfoot

1.90.2.8.9 Marfan’s syndrome

1.90.2.8.10 Beal’s syndrome

1.90.2.8.11 Idiopathic clubfoot

1.90.2.9 ICD-9-CM

1.90.2.9.1 736.70 Cavus

1.90.2.9.2 736.75 Cavovarus foot

1.90.3 Diagnosis

1.90.3.1 Signs and Symptoms

1.90.3.1.1 Signs

1.90.3.1.1.1 High arch

1.90.3.1.1.2 Calluses on forefoot or hind foot

1.90.3.1.1.3 May have weak push-off

1.90.3.1.2 Symptoms

1.90.3.1.2.1 May be asymptomatic

1.90.3.1.2.2 May have pain under forefoot

1.90.3.1.2.3 Difficulty in fitting or tolerating shoes

1.90.3.1.3 Differential Diagnosis

1.90.3.1.3.1 Muscle atrophy may cause the arch to appear higher

1.90.3.1.4 Physical Examination

1.90.3.1.4.1 Check for flexibility of the foot in weight-bearing versus non weight-bearing states.

1.90.3.1.4.2 Check inversion and eversion

1.90.3.1.4.3 Measure the strength of all muscles crossing the ankle on both legs.

1.90.3.1.4.4 Check reflexes and sensation

1.90.3.1.4.5 Observe the spine for dimples, markings, and scoliosis

1.90.3.1.4.6 Check the upper extremities

1.90.3.1.4.7 Perform Coleman’s block test for Cavovarus to determine whether the hind foot varus is flexible or rigid. In a flexible Cavovarus, a lift placed under the lateral forefoot causes the hind foot varus to correct.

1.90.3.1.5 Laboratory Tests

1.90.3.1.5.1 Electromyography and nerve conduction tests are helpful in diagnosing Charcot-Marie-Tooth disease and hereditary motor and sensory neuropathies.

1.90.3.1.6 Pathologic Findings

1.90.3.1.6.1 In almost all causes of cavus, dissection of the foot reveals some degree of atrophy or fibrosis of the foot, as well as decreased range of motion.

1.90.3.1.7 Imaging Procedures

1.90.3.1.7.1 As part of the workup of an undiagnosed cavus, x-ray studies and magnetic resonance imaging of the spine may be indicated. To assess the foot, standing anteroposterior and lateral radiographs may be obtained. Calcaneal pitch is the angle between the calcaneus and the floor. Meary’s angle is the angle between the talus and the first metatarsal.

1.90.4 Management

1.90.4.1 General Measures

1.90.4.1.1 No treatment is indicated if the patient is asymptomatic and the skin is in good condition.

1.90.4.1.2 A padded sole, soft “upper,” arch support, or metatarsal bar may help with calluses.

1.90.4.1.3 A brace may help gait in the weakened cavus foot.

1.90.4.1.4 Stretching may help prevent worsening and maintain flexibility.

1.90.4.2 Surgical Treatment

1.90.4.2.1 Plantar fasciotomy may improve the flexible cavus foot.

1.90.4.2.2 Osteotomies of the Midfoot are needed for the rigid cavus foot.

1.90.4.2.3 If there is rigid hind foot valgus, an osteotomy may be needed for the calcaneus.

1.90.4.2.4 Tendon lengthening procedures or transfers are needed to treat muscle imbalance. A transfer of the long toe extensors to the metatarsal necks is most often performed, along with Interphalangeal joint fusion.

1.90.4.2.5 Triple Arthrodesis is used mainly as a last resort, especially in patients with painful degenerative joint disease.

1.90.4.3 Physical Therapy

1.90.4.3.1 Stretching of the tight plantar fascia, and of other tight muscles, may slow progression of the condition.

1.90.4.4 Patient Education

1.90.4.4.1 Check skin for calluses or pressure sores.

1.90.4.4.2 Wear shoes that are not too tight.

1.90.4.5 Monitoring

1.90.4.5.1 Patients should be followed once or twice per year to rule out worsening of the cavus. This may be done by an orthopedist, neurologist, or generalist, depending on the underlying condition.

1.90.4.6 Complications

1.90.4.6.1 Pain

1.90.4.6.2 Pressure sores

1.90.4.6.3 Toe deformities

1.90.4.7 Prognosis

1.90.4.7.1 Most, but not all, patients with cavus have some degree of foot pain. Treatment should therefore be individualized.

1.90.5 Wheeless' Textbook of Orthopaedics

1.90.5.1 http://www.wheelessonline.com/o11/203.htm

1.91 Pes Planus (Flat Foot)

1.91.1 Summary

1.91.1.1 The normal longitudinal arch of the foot is lost with effects to the foot, ankle, and, in some cases the heel cord. This condition can be acquired or congenital. A flexible flatfoot lacks an arch only when the foot is weight bearing but not when the foot is in a dependent position or when the patient toe-stands. A rigid flatfoot lacks an arch at all times, even when the foot is dependent or when the patient toe-stands.

1.91.2 Basics

1.91.2.1 Description

1.91.2.1.1 Flatfoot or pes planus, is a deformity of the foot in which the normal longitudinal arch of the foot is lost.

1.91.2.1.2 In most cases in which the deformity is symptomatic, and associated anatomic abnormality of the foot is present.

1.91.2.1.3 The foot, ankle, and, in some cases, the heel cord may be affected.

1.91.2.1.4 A flexible flatfoot lacks an arch only when the foot is weight bearing but not when the foot is in a dependent position or when the patient toe-stands.

1.91.2.1.5 A rigid flatfoot lacks an arch at all times, even when the foot is dependent or when the patient toe-stands.

1.91.2.2 Incidence

1.91.2.2.1 Congenital flexible flatfoot that persists after infancy is a trait that often runs in families, although the pattern of inheritance is not known; it is present in approximately 15% of adults.

1.91.2.2.2 Tarsal coalitions, the most common type of congenital rigid flatfoot, are inherited in a autosomal dominant pattern and demonstrate a 4:1 female to male predominance. The overall incidence is unknown but is less than 1%.

1.91.2.2.3 Acquired flatfeet, as the name implies, are not inherited.

1.91.2.2.4 Acquired flexible flatfoot caused by posterior tibial Synovitis is the most common cause of acquired flatfoot in adults, although its incidence is not precisely known.

1.91.2.2.5 The exact incidence of other patterns of acquired flatfeet is not known, but they tend to be uncommon and are associated with severe deformity.

1.91.2.3 Causes

1.91.2.3.1 Congenital flexible flatfoot that persists into adulthood is believed to have a genetic origin.

1.91.2.3.2 Congenital rigid flatfoot resulting from tarsal coalitions is caused by genetic mutations that lead to the failure of the formation of synovial joints between the affected tarsal bones.

1.91.2.4 Risk Factors

1.91.2.4.1 Persistent congenital flexible flatfoot; other family members with the same condition, because the condition is inherited.

1.91.2.4.2 Congenital rigid flatfoot secondary to tarsal coalition with peroneal spasm; female sex as well as other family members with the same condition.

1.91.2.4.3 Acquired flexible flatfoot secondary to posterior tibial tendon Synovitis or rupture; hypertension, diabetes, and a history of trauma.

1.91.2.4.4 Other conditions; tight Achilles tendon, Neurologic diseases (e.g., poliomyelitis, spina bifida, Myelodysplasia, neurofibromatosis, stroke), Osteoarthritis, rheumatoid arthritis, calcaneal fracture, Lisfranc’s fracture-dislocation, tumors, tuberculosis, genetic diseases (trisomies) , and soft tissue dysplasias.

1.91.2.5 Classification

1.91.2.5.1 Congenital Flexible Flatfoot

1.91.2.5.2 Congenital Rigid Flatfoot

1.91.2.5.3 Acquired Flexible Flatfoot

1.91.2.5.4 Acquired Rigid Flatfoot

1.91.2.6 ICD-9-CM

1.91.2.6.1 734 Acquired flat foot

1.91.2.6.2 754.61 Congenital flat foot

1.91.3 Diagnosis

1.91.3.1 Signs and Symptoms

1.91.3.1.1 Congenital Flexible Flatfoot

1.91.3.1.1.1 Congenital flexible flatfoot that is secondary to soft tissue dysplasias such as Marfan’s syndrome or Ehlers-Danlos syndrome or that persists after infancy rarely becomes symptomatic. If symptoms appear, they are only minor, most often feet that become tired easily or achy after prolonged standing.

1.91.3.1.2 Congenital Rigid Flatfoot

1.91.3.1.2.1 Congenital rigid flatfoot caused by tarsal conditions with peroneal spastic flatfoot usually presents in adolescence or early adulthood when the bridge between the tarsal bones ossifies.

1.91.3.1.2.2 Patients with a calcaneonavicular fusion usually present at 8 to 12 years of age, whereas patients with talocalcaneal fusion normally present at 12 to 16 years of age.

1.91.3.1.2.3 Symptoms may present in both feet.

1.91.3.1.2.4 The patient complains of a painful, stiff foot and usually reports some history of trauma, often in the form of a twisting of the foot or a forceful fall onto the foot (such as stepping into a hole or missing a stair).

1.91.3.1.2.5 The associated peroneal spasm is evident as the foot remains fixed in eversion and as attempts at passive or active inversion are met with resistance; this sign is thought to be a response of the patient to restrict hind foot motion and thereby to prevent exacerbation the symptomatic tarsal bar.

1.91.3.1.3 Acquired Flexible Flatfoot

1.91.3.1.3.1 Acquired flexible flatfoot caused by Synovitis or rupture of the posterior tibial tendon presents as a gradual, progressive aching and swelling along the medial aspect of the afflicted person’s foot and ankle.

1.91.3.1.3.2 A history of trauma is noted in about half of the patients; however, the onset of this process is usually gradual.

1.91.3.1.3.3 The patient may complain of tenderness and swelling along the medial part of the foot, a diminished endurance in the foot, a decreased ability to participate in sports, and eventually a progressive difficulty in ambulating.

1.91.3.1.3.4 Because the arch is lost, women may mention difficulty in walking in high-heeled shoes.

1.91.3.1.3.5 Increased wear may be noted along the medial aspect of the shoe.

1.91.3.1.3.6 Inversion against resistance is absent or diminished, and the patient cannot toe-stand on the affected side or can do so only with pain and difficulty.

1.91.3.1.3.7 As the condition worsens, a “too many toes” sign is noted on the affected side when the foot is viewed from behind the individual.

1.91.3.2 Differential Diagnosis

1.91.3.2.1.1 The differential diagnosis should include all the possible causes of the type of flatfoot.

1.91.3.2.1.2 This diagnosis can usually be sorted out on the basis of history and physical examination.

1.91.3.3 Physical Examination

1.91.3.3.1 Of primary importance is the determination whether the condition is rigid or flexible.

1.91.3.3.2 Rigid Flatfoot

1.91.3.3.2.1 A rigid flatfoot displays a loss of the normal longitudinal arch of the foot ar all times, when the patient is standing or when the foot is in a dependent position.

1.91.3.3.3 Flexible Flatfoot

1.91.3.3.3.1 A flexible flatfoot displays a loss of arch only on standing on the affected foot, with reappearance when the foot is dependent or when the patient toe-stands

1.91.3.3.4 The presence of arch should be noted with the patient’s foot in these different positions.

1.91.3.3.5 A rigid flatfoot generally displays restricted motion of the ankle, subtalar, or transverse tarsal joints; a flexible flatfoot has normal motion of all these joints.

1.91.3.3.6 The entire foot should be palpated and observed for any deformity, swelling, or areas of tenderness.

1.91.3.3.6.1 Tenderness and swelling along the medial aspect of the foot and ankle suggest posterior tibial tendon Synovitis or rupture.

1.91.3.3.6.2 A rocker-bottom foot may be present in patients with vertical talus or Charcot’s foot.

1.91.3.3.6.3 Other processes, such as tumors, infection, arthritis, and trauma may also present with swelling, tenderness, and deformity of the foot and ankle.

1.91.3.3.7 The patient’s ability to toe-stand indicates the patient’s ability to invert the foot actively; patients with posterior tibial tendon Synovitis or tarsal coalition with peroneal spasm demonstrate the inability to toe-stand or the ability to do so only with pain and difficulty.

1.91.3.3.8 The patient’s ability to ambulate should be noted.

1.91.3.3.8.1 A “too many toes” sign is present when the invertors of the foot and ankle are not functional and thus throw the hind foot into valgus as the patient bears weight; an observer behind a walking patient notices too many toes projecting laterally.

1.91.3.3.8.2 An antalgic gait may indicate a painful disease process such as arthritis, infection, or tumor.

1.91.3.3.8.3 An awkward, foot-slapping gait may suggest a Neurologic or neuromuscular disease such as spina bifida, poliomyelitis, or Charcot’s foot.

1.91.3.3.8.4 The Achilles tendon should be examined to test whether the heel cord is tight.

1.91.3.4 Pathologic Findings

1.91.3.4.1 Because there are many different causes of flatfoot, the pathologic anatomy of the foot of a patient who presents with the fallen arch may differ according to cause; attenuated or torn posterior tibial tendon tarsal coalition, lax ligaments.

1.91.3.5 Imaging procedures

1.91.3.5.1 Three plain radiographic views of the patient’s ankle (anteroposterior, lateral, and mortise) and three views of the patient’s foot (anteroposterior, lateral, and oblique) should be obtained.

1.91.3.5.2 Standing lateral radiographs of the foot and ankle (taken with the patient bearing weight) are useful in quantifying the degree of flatfoot deformity.

1.91.3.5.3 The index generally used is the talus-first metatarsal angle, measured by drawing a line through the longitudinal axis of the talus and through the axis of the first metatarsal and measuring the angle between the two.

1.91.3.5.3.1 This angle should normally be 0 degrees with the two axes parallel to one another.

1.91.3.5.3.2 An angle up to 15 degrees represents a minor pes planus deformity, and angle of 15 to 30 degrees represents a moderate deformity, and an angle greater than 30 degrees represents a severe deformity.

1.91.3.5.4 When tarsal coalition is suspected, the following tests are used;

1.91.3.5.4.1 The oblique radiograph is the study of choice in determining whether a calcaneonavicular bar is present.

1.91.3.5.4.2 The study of choice to rule out a talocalcaneal fusion is a computed tomography scan; a 45 degree axial view of of the subtalar joint (Harris’ view) may be obtained; however, this view is not always reliable.

1.91.3.5.5 In patients with a suspected posterior tibial tendon Synovitis or rupture, a magnetic resonance imaging scan of the foot and ankle may be useful in visualizing the edematous nature of the tendon or any tears that may be present.

1.91.4 Management

1.91.4.1 General Measures

1.91.4.1.1 Congenital Flexible Flatfoot

1.91.4.1.1.1 Conservative treatment should be instituted only when the deformity persists in childhood or adulthood and is symptomatic.

1.91.4.1.1.2 Shoes with good arch supports are used.

1.91.4.1.1.3 If necessary, the patient should progress to using orthotic devices such as the Thomas heel, or either a custom made or off the shelf soft insert orthosis; however, the efficacy of orthotics has not been proven.

1.91.4.1.1.4 In the rare instance in which the deformity causes persistent pain and difficulty with weight bearing, operative treatment may be necessary.

1.91.4.1.2 Congenital Rigid Flatfoot from Tarsal Coalition with Peroneal Spasm

1.91.4.1.2.1 This condition is treated when symptomatic.

1.91.4.1.2.2 Initially, immobilization with a short leg-walking cast is attempted for 4 weeks.

1.91.4.1.2.3 If symptoms do not resolve, operative treatment is usually necessary.

1.91.4.1.2.4

1.91.4.1.3 Congenital Flatfoot Secondary to a Tight Achilles Tendon

1.91.4.1.3.1 This condition may be relieved by physical therapy and stretching exercises.

1.91.4.1.3.2 Should this approach fail, various tendon-lengthening procedures may be used.

1.91.4.1.4 Acquired Flatfoot Secondary to Posterior Tibial Tendon Synovitis

1.91.4.1.4.1 Initial treatment should be conservative.

1.91.4.1.4.2 The caregiver should institute a regimen of Nonsteroidal anti-inflammatory drugs and rest to reduce the inflammation and to allow healing.

1.91.4.1.4.3 If this fails, then a short leg cast or brace should be used for 4 to 6 weeks.

1.91.4.1.4.4 Injection of Corticosteroids is not recommended because it may weaken the already damaged and susceptible tendon and may only expedite rupture.

1.91.4.1.4.5 Should conservative treatment fail, or should the Synovitis recur, operative therapy should be instituted.

1.91.4.2 Surgical Treatment

1.91.4.2.1 Congenital Flexible Flatfoot

1.91.4.2.1.1 Surgical treatments usually consist of osteotomies that realign the foot out of valgus so weight bearing is more physiologic.

1.91.4.2.1.2 One common osteotomy is Evans’ anterior calcaneal osteotomy, also known as Evans’ opening wedge osteotomy.

1.91.4.2.2 Congenital Rigid Flatfoot from Tarsal Coalition with Peroneal Spasm

1.91.4.2.2.1 The treatment of choice for coalitions in patients who are young and shoes symptoms have been present for a short time is to resect the osseus bar with interposition of fat or muscle, usually the extensor digitorum brevis.

1.91.4.2.2.2 In adults who have had symptoms for years and who have developed extensive degenerative arthritis, subtalar fusion or triple Arthrodesis may be necessary.

1.91.4.2.3 Congenital Flatfoot Secondary to a Tight Achilles Tendon

1.91.4.2.3.1 Tendon lengthening involves either a Z-lengthening procedure or partial sectioning of the tendon.

1.91.4.2.4 Acquired Flatfoot Secondary to Posterior Tibial Tendon Synovitis

1.91.4.2.4.1 In early stages of the disease, synovectomy maybe sufficient

1.91.4.2.4.1.1 The surgeon opens the sheath of the tendon, débrides the swollen, degenerative synovial tissue, and repairs the sheath.

1.91.4.2.4.1.2 The results are usually satisfactory, and deformity can be prevented if the procedure is carried out early enough.

1.91.4.2.4.1.3 If the tendon has significantly degenerated or ruptured, or if synovectomy has failed, a tendon transfer is used, in which the flexor digitorum longus tendon replaces the posterior tibial tendon.

1.91.4.2.4.2 Synovectomy and tendon transfer are ineffective when arthrosis has developed and the hind foot and forefoot have become rigid. Fusion is necessary for alignment and to control pain.

1.91.4.3 Physical Therapy

1.91.4.3.1 Physical therapy can be used to increase ankle and foot range of motion and to stretch a tight Achilles tendon. Occupational therapists or podiatrists can help with orthotics.

1.91.4.4 Medical Treatment

1.91.4.4.1 Anti-inflammatory medications can be used if swelling and pain are significant. These agents are most useful for acute injuries or in patients with posterior tibial Tendinitis.

1.91.4.5 Patient Education

1.91.4.5.1 Patient education is important because patients with mild symptoms or those who are asymptomatic should avoid surgery for cosmetic reasons. Stretching exercises can help in patients with tight Achilles tendons, and foot orthoses may be useful for patients who want to be active.

1.91.4.6 Monitoring

1.91.4.6.1 Patients should be followed at 3 month intervals to monitor their discomfort and function and to check whether their deformity is stable or progressive.

1.91.4.7 Complications

1.91.4.7.1 Most patients have little risk of complications with nonoperative treatment. One major exception is patients with posterior tibial dysfunction (acquired flatfoot) because they may develop a rigid flatfoot.

1.91.4.8 Prognosis

1.91.4.8.1 In general, prognosis is excellent. Most patients do not develop progressive deformities and do not need surgery.

1.91.5 Wheeless' Textbook of Orthopaedics

1.91.5.1 http://www.wheelessonline.com/o11/207.htm

1.92 Plantar Fasciitis

1.92.1 Summary

1.92.1.1 Experts disagree as to the cause of plantar Fasciitis some hypothesizing that microadhesions form around the plantar fascia, especially during sleep and the first step most painful symptom is associated with tears of these microadhesions and other experts believe that chronic inflammation of the plantar fascia is the cause of plantar Fasciitis. In either case chronic inflammation is noted at the base of the plantar fascia insertion near the medial calcaneal tuberosity. Patients will complaint of heel pain that is worse in the morning or after prolonged sitting with the “first step” and lessens in severity with walking. Stretching exercises, Nonsteroidal anti-inflammatory agents, Orthoses, and when all else fails corticosteroid Injections. Surgical intervention is rarely indicated. Running and jumping Sports may cause or exacerbate the problem.

1.92.2 Description

1.92.2.1 Although plantar Fasciitis can commonly lead to heel pain, it is but one cause to consider when working up a diagnosis in a patient with heel pain. Plantar Fasciitis is commonly diagnosed with the history and physical examination alone. Patients commonly complain of heel pain that is worse in the morning with the “first step” and lessens in severity with walking. This heel pain can also occur with the first step after sitting for a prolonged period. Conservative treatment is the cornerstone for this problem and surgery is hardly ever indicated.

1.92.2.2 Other causes of heel pain include compression of the first branch of the lateral plantar nerve, fat pad atrophy, and pain associated with seronegative spondyloarthropathy. Although these causes should be considered, plantar Fasciitis is the more common cause of heel pain

1.92.2.3 The plantar fascia of the heel is involved, originating from the calcaneus inferiorly.

1.92.3 Incidence

1.92.3.1 Extremely common in adults

1.92.3.2 Most common in the third to fifth decades

1.92.4 Causes

1.92.4.1 Foot and ankle experts currently hypothesize that microadhesions form around the plantar fascia, especially during sleep. The pain that is worst with the first step may be associated with tears of these microadhesions.

1.92.4.2 Other experts believe that chronic inflammation of the plantar fascia is the cause of plantar Fasciitis. In a patient with plantar Fasciitis, the area of tenderness is in the insertion of the plantar fascia into the calcaneus.

1.92.5 Risk Factors

1.92.5.1 Running

1.92.5.2 Jumping Sports

1.92.5.3 Lupus

1.92.5.4 Spondyloarthropathy

1.92.6 Classification

1.92.6.1 Plantar Fasciitis

1.92.6.2 Retrocalcaneal bursitis

1.92.6.3 Insertional Achilles Tendinitis

1.92.7 ICD-9-CM

1.92.7.1 728.71 Plantar Fasciitis

1.92.7.2 726.79 Heel Pain

1.92.8 Diagnosis

1.92.8.1 Differential Diagnosis

1.92.8.1.1 Calcaneal apophysitis or Server’s disease in children

1.92.8.1.2 Tarsal tunnel syndrome

1.92.8.1.3 Reiter’s syndrome

1.92.8.1.4 Spinal Radiculopathy

1.92.8.2 Physical Examination

1.92.8.2.1 The shape of the patient’s foot should be noted on standing; this influences the type of treatment given.

1.92.8.2.2 The patient should then be examined with the foot at rest.

1.92.8.2.3 Palpation just medial to the heel usually elicits tenderness at the base.

1.92.8.2.4 Patients have tenderness along the plantar fascia, which should be considerably worse with the toes dorsiflexed by the examiner, a maneuver that stretches the plantar fascia.

1.92.8.2.5 Testing of sensation should be performed as indicated.

1.92.8.3 Laboratory Tests

1.92.8.3.1 HLA-B27 determination may be obtained if spondyloarthropathy is suspected.

1.92.8.3.2 Steroid injection into the plantar fascia insertion may serve both as a diagnostic test and as therapy.

1.92.8.4 Pathologic Findings

1.92.8.4.1 Chronic inflammation is noted at the base of the plantar fascia insertion.

1.92.8.5 Imaging Procedures

1.92.8.5.1 Standing radiographs of the foot should be obtained for patients with persistent pain.

1.92.8.5.2 Bone scans may show increased uptake in the heel. Patients with increased uptake on a bone scan usually have a more severe degree of plantar Fasciitis.

1.92.9 Management

1.92.9.1 General Measures

1.92.9.1.1 Stretching exercises are recommended. Some patients improve with these; they should be done before sports and on a daily basis.

1.92.9.1.2 Nonsteroidal anti-inflammatory agents are given.

1.92.9.1.3 Orthoses are used to cushion the heel and to support the arch if it is flat.

1.92.9.1.4 Injections into the painful area are useful if the condition is localized and if the pain does not respond to other measures.

1.92.9.1.5 Patients may be treated by a night brace (similar to an ankle foot orthosis) and a stiff-sole shoe (with a custom steel insert in the sole), which reduces strain on the plantar fascia. Patients resistant to this therapy may require casting with a short leg walking cast and an extension beyond the toes to prevent motion at the tarsometatarsal and Interphalangeal joints.

1.92.9.1.6 After successful treatment, the patient may be allowed to resume activities gradually; care should be taken not to resume running or jumping sports too early or too strenuously.

1.92.9.2 Surgical Treatment

1.92.9.2.1 Depends upon the underlying diagnosis

1.92.9.2.2 For plantar Fasciitis, surgery may be indicated for recalcitrant cases. This consists of dividing the plantar fascia, sometimes including osteophytes. It may be done as an outpatient procedure, through a small medial incision.

1.92.9.2.3 For resistant tarsal tunnel syndrome, decompression of the tunnel is indicated.

1.92.9.2.4 For Sever’s disease and Retrocalcaneal bursitis, surgery is not indicated.

1.92.9.3 Physical Therapy

1.92.9.3.1 Physical therapy may be helpful in teaching the patients to stretch and in supervising their return to physical activity.

1.92.9.4 Medical Treatment

1.92.9.4.1 Nonsteroidal anti-inflammatory agents are useful agents in patients with sever pain.

1.92.9.5 Patient Education

1.92.9.5.1 Instruct the patient about the anatomy of the plantar fascia and its role in stabilizing the foot.

1.92.9.5.2 Remind the patient about the importance of stretching and of moderation during a return to sports.

1.92.9.6 Prevention

1.92.9.6.1 The condition is not always preventable, but it may be limited by avoiding sudden increases in running or jumping stresses.

1.92.9.7 Prognosis

1.92.9.7.1 Most cases of plantar Fasciitis resolve by themselves; however, the conservative measures outlined may accelerate healing.

1.92.9.7.2

1.92.10 Wheeless' Textbook of Orthopaedics

1.92.10.1 http://www. wheelessonline.com /o12/104.htm

1.93 Plantar Warts: (Verruca Plantaris - Papillomas of the Sole)

1.93.1 Wheeless' Textbook of Orthopaedics

1.93.1.1 http://www.wheelessonline.com/o12/101.htm

1.94 Polydactyly of Foot

1.94.1 Wheeless' Textbook of Orthopaedics

1.94.1.1 http://www.wheelessonline.com/o16/484.htm

1.95 Poor Balance

1.96 Posterior Achilles Tendon Bursitis (Haglund's Deformity)

1.96.1 The Merck Manual of Diagnosis and Therapy

1.96.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.97 Post Ankle Sprain Adhesions

1.98 Posterior Ankle Pain

1.98.1 Wheeless' Textbook of Orthopaedics

1.98.1.1 http://www.wheelessonline.com/oo3/174.htm

1.99 Posterior Malleolar Fractures

1.99.1 Wheeless' Textbook of Orthopaedics

1.99.1.1 http://www.wheelessonline.com/ooa1/82.htm

1.100 Posterior Talar Process Fracture

1.101 Posterior Tibial Nerve Entrapment

1.101.1 The Merck Manual of Diagnosis and Therapy

1.101.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.102 Posterior Tibial Nerve Neuralgia

1.102.1 The Merck Manual of Diagnosis and Therapy

1.102.1.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.103 Posterior Tibial Tendon Rupture

1.103.1 Summary

1.103.1.1 Because the posterior tibial tendon inverts the subtalar joint during heel rise and locks the transverse tarsal joint facilitating weight transfer to the lateral foot border tendon rupture is the major cause of adult (affects adults 40-60 years old) acquired flat foot. Its causes may be tenuous blood supply and chronic tendonitis. Patients complain of a painful medial foot and ankle subsequent to a specific traumatic episode which increases along with an evident progressive flatfoot deformity marked by clinically observable “Too many toes” sign: visualizing three or more toes lateral to the lateral Malleolus when viewed from posterior.

1.103.2 Basics

1.103.2.1 Description

1.103.2.1.1 The posterior tibial tendon inverts the subtalar joint during the heel rise of the gait. The posterior tibial tendon also locks the transverse tarsal joint so the weight of the body can be transferred along the lateral border of the foot.

1.103.2.1.1.1 Posterior tibial tendon rupture is posttraumatic pain in the medial aspect of the foot, with increasing flatfoot deformity.

1.103.2.1.1.2 Most patients recall a specific traumatic episode.

1.103.2.1.1.3 Some cases present in an insidious manner.

1.103.2.1.1.4 History can be confusing in many patients with a simple complaint of a painful foot.

1.103.2.2 Synonym

1.103.2.2.1 Acquired flatfoot

1.103.2.3 Genetics

1.103.2.3.1 No Mendelian pattern is known

1.103.2.4 Incidence

1.103.2.4.1 Most common cause of adult acquired flatfoot

1.103.2.4.2 Common in patients with seronegative spondyloarthropathies

1.103.2.4.3 Affecting adults 40 to 60 years of age

1.103.2.4.4 More common in women

1.103.2.5 Causes

1.103.2.5.1 Tenuous blood supply to the tendon

1.103.2.5.2 Chronic tendonitis around the posterior tibial tendon leading to attenuation

1.103.2.5.3 Eventual rupture

1.103.2.6 Risk Factors

1.103.2.6.1 Hypertension

1.103.2.6.2 Obesity

1.103.2.6.3 Diabetes

1.103.2.6.4 Previous medial foot trauma

1.103.2.6.5 Seronegative spondyloarthropathies

1.103.2.7 Classification

1.103.2.7.1 Stage 1

1.103.2.7.1.1 Pain and weakness without deformity

1.103.2.7.2 Stage 2

1.103.2.7.2.1 Flexible flatfoot deformity

1.103.2.7.3 Stage 3

1.103.2.7.3.1 Rigid flatfoot

1.103.2.8 Associated Conditions

1.103.2.8.1 No other conditions are associated with this disorder

1.103.2.9 ICD-9-CM

1.103.2.9.1 727.68 Posterior tibial tendon rupture

1.103.3 Diagnosis

1.103.3.1 Signs and Symptoms

1.103.3.1.1 Increasingly painful foot medially with progressive flatfoot deformity

1.103.3.1.2 “Too many toes” sign: visualizing three or more toes lateral to the lateral Malleolus when viewed from posterior.

1.103.3.2 Differential Diagnosis

1.103.3.2.1 Flatfeet

1.103.3.2.2 Posterior tibial tendonitis

1.103.3.2.3 Tarsal tunnel syndrome

1.103.3.2.4 Neuropathy

1.103.3.2.5 Charcot’s joints

1.103.3.3 Physical Examination

1.103.3.3.1 Conduct a neurovascular examination of the affected foot.

1.103.3.3.2 Watch the patient’s gait

1.103.3.3.3 The patient should be unable to invert the foot from a plantar flexed, everted position (a position that isolates the posterior tibial tendon). There is tenderness at the medial insertion of the posterior tibial tendon into the navicular bone, or along the tendon itself as it curves around the medial Malleolus (most posterior tibial tendon ruptures occur between the medial Malleolus and the navicular insertion).

1.103.3.4 Laboratory Tests

1.103.3.4.1 None are needed

1.103.3.5 Pathologic Findings

1.103.3.5.1 Progressive attenuation of the tendon

1.103.3.5.2 Eventual rupture

1.103.3.5.3 Subtalar joint then falling into progressive valgus

1.103.3.6 Imaging Procedures

1.103.3.6.1 Weight-bearing radiographs to demonstrate the foot deformity

1.103.3.6.2 Anteroposterior views to assess lateral Subluxation of the talonavicular joint or divergence of the talus and calcaneus bones

1.103.3.6.3 Magnetic resonance imaging to demonstrate a posterior tibial tendon tear if the diagnosis is in question.

1.103.4 Management

1.103.4.1 General Measures

1.103.4.1.1 Immobilization is needed until the pain resolves.

1.103.4.1.2 The patient may bear weight as tolerated with immobilization.

1.103.4.1.3 Patients with incomplete tears may benefit from Nonsteroidal anti-inflammatory drugs (NSAIDs) and cast immobilization.

1.103.4.1.4 Complete tears with a flexible flatfoot usually require surgical reconstruction of the posterior tibial tendon with flexor digitorum longus tendon.

1.103.4.1.5 Patients who decline surgery may obtain support from a hind foot stabilizing orthosis.

1.103.4.1.6 Rigid flatfoot deformities may require Arthrodesis (joint fusion).

1.103.4.2 Surgical Treatment

1.103.4.2.1 Stage 1

1.103.4.2.1.1 Tenosynovectomy

1.103.4.2.2 Stage 2

1.103.4.2.2.1 Tendon transfer

1.103.4.2.3 Stage 3

1.103.4.2.3.1 Subtalar fusion

1.103.4.3 Physical Therapy

1.103.4.3.1 Physical therapy is used for muscle strengthening and range of motion.

1.103.4.4 Medical Treatment

1.103.4.4.1 Stage 1

1.103.4.4.1.1 Rest, NSAIDs, immobilization

1.103.4.4.2 Stage 2

1.103.4.4.2.1 Medial heel wedge with longitudinal arch support and medial outward flare

1.103.4.4.3 Stage 3

1.103.4.4.3.1 NSAIDs, analgesics

1.103.4.5 Patient Education

1.103.4.5.1 Inform the patient that disorder can be difficult to treat and requires prolonged immobilization.

1.103.4.6 Monitoring

1.103.4.6.1 Patients are followed every 3 months until their symptoms resolve.

1.103.4.7 Complications

1.103.4.7.1 Progressive acquired flatfoot deformity with midfoot collapse may occur.

1.103.4.8 Prognosis

1.103.4.8.1 The prognosis is good with subtalar Arthrodesis for late reconstruction. Nonoperative treatment is successful early in the disease.

1.104 Posterior Tibial Tendonitis (Posterior Tibial Tendon Dysfunction (PTTD)) (Tibialis Posterior Tendonitis)

1.104.1 Summary

1.104.1.1 Leading causes of acquired flatfoot in adults whose onset may be gradual or abrupt. Abrupt onset may be related to trauma e.g. stepping down off a curb or ladder, falling from a height or an automobile accident. PTTD increases with age and rarely seen in children. Signs include; Loss of medial arch height, Edema (swelling) of the medial ankle, Loss of the ability to resist force to abduct or push the foot out from the midline of the body, Pain on the medial ankle with weight bearing, Inability to raise up on the toes without pain, Too many toes sign, and Lateral subtalar joint (outside of the ankle) pain.

1.104.2 Wheeless' Textbook of Orthopaedics

1.104.2.1 http://www.wheelessonline.com/05/248.htm

1.104.3 My Foot Shop

1.104.3.1 http://www.myfootshop.com/detail.asp?Condition=Posterior+Tibial+Tendon+Dysfunction

1.104.3.2

1.105 Pronation - Abduction Ankle Fractures

1.105.1 Wheeless' Textbook of Orthopaedics

1.105.1.1 http://www.wheelessonline.com/ooa1/50.htm

1.106 Pronation-External Rotation Injuries of the Ankle

1.106.1 Wheeless' Textbook of Orthopaedics

1.106.1.1 http://www.wheelessonline.com/ooa1/51.htm

1.107 Recurrent Sprain

1.108 Referred Pain and Nerve Injury Patterns

1.109 Rupture of the Tibialis Posterior

1.109.1 Wheeless' Textbook of Orthopaedics

1.109.1.1 http://www.wheelessonline.com/05/249.htm

1.110 Rheumatoid Foot

1.110.1 Wheeless' Textbook of Orthopaedics

1.110.1.1 http://www.wheelessonline.com/o2/188.htm

1.111 Retro-Calcaneal Bursitis

1.112 Rheumatoid Arthritis (RA)

1.113 Sesamoiditis

1.114 Sever's Disease (AVN of Calcaneus) (Epiphysitis Of The Calcaneus) (Osteonecrosis (Avascular Necrosis)) (Aseptic bone necrosis (Osteonecrosis))

1.114.1 Summary

1.114.1.1 Avascular necrosis (AVN) is the in situ death of a segment of cancellous bone from lack of circulation caused by trauma which injures arterial vessels or a non traumatic origin possibly related to Corticosteroids and or Ethanol use. Most commonly found in the 30 to 40 year old age range, equally divided between males and females, with pain of insidious onset, described as aching, and is minimally relieved by anti-inflammatory medications. Pain increases with time and is worsened by weight bearing.

1.114.2 Basics

1.114.2.1 Description

1.114.2.1.1 Avascular necrosis (AVN) is the in situ death of a segment of cancellous bone from lack of circulation, secondary to traumatic or atraumatic causes. The most common sites are the femoral head, Scaphoid, talus, and humeral head, however, avascular necrosis can occur in any bone. It is most common in the 30 to 40 year age group, and it affects males and females equally. Legg-Calvé Perthes Disease is a type of AVN which occurs in patients 4-12 years of age.

1.114.2.2 Causes

1.114.2.2.1 Osteonecrosis can have either a traumatic or a nontraumatic origin. Traumatic Osteonecrosis is most commonly associated with femoral neck fractures, dislocations of the femoral head, displaced fractures of the Scaphoid and talar neck, and four-part fractures of the humeral head. Atraumatic Osteonecrosis is thought to be secondary to occlusion of the arterial vessels, injury or pressure on the arterial wall, or occlusion to the venous outflow vessels. The exact cause of these vascular insults is unknown, but it is currently thought to be the result of increased intramedullary pressure.

1.114.2.3 Risk Factors.

1.114.2.3.1 Trauma

1.114.2.3.2 Corticosteroids

1.114.2.3.3 Ethanol use

1.114.2.3.4 Blood dyscrasias (e.g., sickle cell disease, hypercoagulable)

1.114.2.3.5 Dysbarism (e.g., caisson disease [exposure to hyperbaric oxygen])

1.114.2.3.6 Excessive radiation therapy

1.114.2.3.7 Gaucher’s Disease

1.114.2.4 Classification

1.114.2.4.1 0

1.114.2.4.1.1 No pain, normal physical examination, normal radiographs, normal bone scan, normal magnetic resonance imaging (MRI) scan, increased intraosseous pressure.

1.114.2.4.2 1

1.114.2.4.2.1 Minimal pain, decreased internal rotation, normal radiographs, nondiagnostic bone scan, early nuclear medicine changes increased intraosseous pressures.

1.114.2.4.3 2

1.114.2.4.3.1 Moderate pain, decreased range of motion, radiographic sclerosis, positive bone scan, positive MRI scan, increased intraosseous pressure.

1.114.2.4.4 3

1.114.2.4.4.1 Advanced pain, decreased range of motion, radiographic crescent sign and femoral head flattening, positive bone scan, positive MRI scan, increased intraosseous pressure.

1.114.2.4.5 4

1.114.2.4.5.1 Severe pain, pain with any range of motion, radiographic femoral flattening and crescent sign with Acetabular degeneration, positive bone scan, positive MRI scan, increased intraosseous pressure.

1.114.2.5 Specific Sites and Eponyms

1.114.2.5.1 Legg-Calvé-Perthes disease; femoral head

1.114.2.5.2 Sever’s disease calcaneus

1.114.2.5.3 Këhlers’s disease; tarsal navicular

1.114.2.5.4 Freiberg’s infarction; second metatarsal head

1.114.2.5.5 Panner’s disease; capitellum

1.114.2.5.6 Kienböck’s disease; lunate

1.114.2.6 ICD-9-CM

1.114.2.6.1 733.40 Aseptic bone necrosis (Osteonecrosis)

1.114.3 Diagnosis

1.114.3.1 Signs and Symptoms

1.114.3.1.1 Pain is often insidious in onset, is described as aching, and is minimally relieved by anti-inflammatory medications. Pain increases with time and is worsened by weight bearing.

1.114.3.2 Differential Diagnosis

1.114.3.2.1 Initial Symptoms can mimic primary or metastatic bone tumors.

1.114.3.2.2 Late stages of the disease are difficult to differentiate from Osteoarthritis.

1.114.3.3 Physical Examination

1.114.3.3.1 Physical examination varies according to the stage of the disease.

1.114.3.3.2 Early

1.114.3.3.2.1 There may be only subtle findings such as muscle atrophy or loss of range of motion.

1.114.3.3.3 Late

1.114.3.3.3.1 In patients with arthritis, there may be severe loss of range of motion and pain on positioning of the joint.

1.114.3.4 Laboratory Tests

1.114.3.4.1 Patients with atraumatic Osteonecrosis should have a complete blood count, peripheral blood smear, and coagulation studies to rule out blood dyscrasias.

1.114.3.5 Pathologic Findings

1.114.3.5.1 Grossly necrotic bone, fibrous tissue, and subchondral collapse may be seen. Histologically, early changes involve autolysis of osteocytes, followed by inflammatory cell invasion. If the infarct is large enough and the blood supply can be reestablished, new woven bone forms, which eventually remodels through creeping substitution.

1.114.3.6 Imaging Procedures

1.114.3.6.1 Radiographs are diagnostic in later stages of the disease. MRI and a bone scan are often required for diagnosis of earlier disease stages.

1.114.4 Management

1.114.4.1 General Measures

1.114.4.1.1 The treatment of Osteonecrosis remains controversial. Many centers have had success with core decompression (drilling a 5 to 10 mm tract through the area of Osteonecrosis) in the early stages of the disease. Later stages often require total joint replacement for disease in the hip, knee, or shoulder or fusion for disease in the ankle or wrist. There is some evidence that anticoagulation therapy may be helpful.

1.114.4.2 Surgical Treatment

1.114.4.2.1 Core decompression is a procedure in which a large-bone needle is inserted into the necrotic bone and a core of bone and medullary cavity is removed. It is thought to decompress the increased intraosseous pressure and to restore blood flow to the affected segment. Many centers report up to a 90% success rate using this procedure in stage 1 and 2 disease.

1.114.4.3 Physical Therapy

1.114.4.3.1 This is not helpful

1.114.4.4 Patient Education

1.114.4.4.1 Outcomes depend on the stage of the disease and are sometimes unpredictable. Many patients ultimately require joint reconstructive procedures.

1.114.4.5 Prevention

1.114.4.5.1 Prevention includes avoidance of prolonged high-dose steroid use or alcohol abuse.

1.114.4.6 Monitoring

1.114.4.6.1 Serial radiographs and repeat MRI scans are helpful to follow the progression of the disease.

1.114.4.7 Complications

1.114.4.7.1 Collapse of the joint surface

1.114.4.7.2 Ankylosis

1.114.4.8 Prognosis

1.114.4.8.1 The prognosis depends on the age group and bone affected and is much better for children than adults. Prognosis is also improved if the disease is diagnosed in its earlier stages.

1.114.5 Wheeless' Textbook of Orthopaedics

1.114.5.1 http://www.wheelessonline.com/oo3/3000.htm

1.114.6 The Merck Manual of Diagnosis and Therapy

1.114.6.1 http://www.merck.com/pubs/mmanual/section5/chapter60/60c.htm

1.115 Shin Splints

1.116 Sprains and Minor Tears to Ligaments

1.117 Stress Fracture (Calcaneus & Navicular)

1.118 Sub-Acute Arthritis (Adolescence)

1.119 Sub-Acute Arthritis (Middle Age)

1.120 Subcutaneous Nodules

1.121 Superficial Peroneal Nerve Entrapment

1.122 Supination - Adduction Injuries of the Ankle

1.122.1 Wheeless' Textbook of Orthopaedics

1.122.1.1 http://www.wheelessonline.com/ooa1/286.htm

1.123 Supination External Rotation Ankle Frx (Weber B)

1.123.1 Wheeless' Textbook of Orthopaedics

1.123.1.1 http://www.wheelessonline.com/ooa1/48.htm

1.124 Syndesmotic Injuries of the Ankle

1.124.1 Wheeless' Textbook of Orthopaedics

1.124.1.1 http://www.wheelessonline.com/ooa1/84.htm

1.125 Talus Fracture

1.125.1 Management

1.125.1.1 General Measures

1.125.1.1.1

1.125.2 Wheeless' Textbook of Orthopaedics

1.125.2.1 http://www.wheelessonline.com/oa3/104.htm

1.126 Tarsal Coaliltion

1.126.1 Wheeless' Textbook of Orthopaedics

1.126.1.1 http://www.wheelessonline.com/oo3/181.htm

1.127 Tarsal Tunnel Syndrome

1.127.1 Summary

1.127.1.1 The posterior tibial nerve becomes entrapped by the flexor retinaculum posterior to the medial Malleolus and anterior to the Achilles tendon in an area known as the tarsal tunnel and causing referred Paresthesia and pain along the medial & lateral plantar nerves and calcaneal nerves. This condition affects middle aged to elderly men and women equally. No known causes are definitive but In general, tarsal tunnel syndrome usually results from specific injury or a space occupying lesion within the tarsal tunnel. Characteristically, patients find it difficult to describe the pain. Complaints usually are burning; tingling, and numbness of toes and plantar aspect of the foot. Symptoms are often aggravated with activity and improve with rest, although some patients feel worse at rest and better while on their feet. Approximately 33% of patients have radiation of their pain proximally along the medial aspect of the leg to the level of the midcalf.

1.127.2 Description

1.127.2.1 Tarsal tunnel syndrome is the term used to describe entrapment neuropathy of the posterior tibial nerve. Tarsal tunnel syndrome is compression of the tibial nerve behind the medial Malleolus under the Retincular ligament. The neuropathy may involve the nerve itself within the tarsal tunnel or one of its branches after leaving the canal. This condition is analogous to carpal tunnel syndrome, but it occurs much less frequently. Around the ankle, the deep fascia is strengthened posteriorly by the flexor retinaculum, which passes over the posterior tibial nerve, vessels, and tendons from the back of the ankle to the sole of the foot. The tunnel itself is fibroosseous, with the tibia anteriorly and the posterior process of the talus and calcaneus laterally. The posterior tibial nerve, a branch of the sciatic nerve, enters the tunnel proximally and within the tunnel divides into three terminal branches in 93% of cases; medial and lateral plantar and medial calcaneal nerves. The calcaneal branch shows the most variability with respect to whether it branches proximal to, within, or distal to the tarsal tunnel.

1.127.2.2 Patients are usually middle aged to elderly. Men and women are affected equally.

1.127.3 Causes

1.127.3.1 A specific cause can be pinpointed in only some patients.

1.127.3.2 In general, tarsal tunnel syndrome usually results from specific injury or a space occupying lesion within the tarsal tunnel, as follows;

1.127.3.2.1 Tendon sheath ganglion

1.127.3.2.2 Lipoma within the tarsal tunnel

1.127.3.2.3 Exostosis or fracture fragment impinging on the nerve

1.127.3.2.4 Medial talocalcaneal bar protruding into the tunnel

1.127.3.2.5 Enlarged venous complex surrounding the posterior tibial nerve within the tunnel

1.127.3.2.6 Severe pronation of the hind foot with resultant stretching of the posterior tibial nerve

1.127.3.2.7 Neurilemoma of the posterior tibial nerve within the canal

1.127.4 ICD-9-CM

1.127.4.1 355.5Tarsal Tunnel Syndrome

1.127.5 Diagnosis

1.127.5.1 Signs and Symptoms

1.127.5.1.1 Characteristically, patients find it difficult to describe the pain.

1.127.5.1.2 Complaints usually are burning; tingling, and numbness of toes and plantar aspect of the foot. Symptoms are often aggravated with activity and improve with rest, although some patients feel worse at rest and better while on their feet.

1.127.5.1.3 Approximately 33% of patients have radiation of their pain proximally along the medial aspect of the leg to the level of the midcalf.

1.127.5.2 Differential Diagnosis

1.127.5.2.1 Interdigital neuroma

1.127.5.2.2 Intervertebral disc lesion

1.127.5.2.3 Plantar Fasciitis

1.127.5.2.4 Peripheral neuritis or neuropathy

1.127.5.2.5 Peripheral neuritis or neuropath

1.127.5.2.6 Peripheral vascular disease

1.127.5.2.7 Diabetic Neuropathy

1.127.5.2.8 Ganglion

1.127.5.2.9 Fracture

1.127.5.2.10 Valgus hind foot

1.127.5.2.11 Rheumatoid Arthritis

1.127.5.2.12 Venous Varicosities

1.127.5.2.13 Tenosynovitis

1.127.5.2.14 Tarsal Coalition

1.127.5.2.15 Lipoma

1.127.5.3 Physical Examination

1.127.5.3.1 Physical examination and electrodiagnostic studies make up the mainstay of diagnosis. Some experts believe that the diagnosis can be made only with a strong history of tingling and burning, positive findings on examination, and pa positive nerve conduction study.

1.127.5.3.2 The nerve may be tender or may demonstrate Tinel’s sign (tapping of the verve with the index or middle finger) with percussion along its course.

1.127.5.3.3 Fusiform or more diffuse swelling of the soft tissues may occasionally be palpated.

1.127.5.3.4 Sensory and motor deficits often are difficult to assess and are not generally present.

1.127.5.3.5 Look at the posture and range of motion of foot to rule out an old injury or arthrosis.

1.127.5.3.6 Obtain nerve conduction studies of the medial and lateral plantar nerve.

1.127.5.3.7 Sensory conduction velocity is believed to be the most accurate study (sensitivity as high as 90%). Obtain conduction velocities of the common peroneal nerve to rule out peripheral neuropathy.

1.127.5.4 Laboratory Tests

1.127.5.4.1 Routine laboratory tests can be used to rule out other conditions that may mimic tarsal tunnel syndrome.

1.127.5.5 Pathologic Findings

1.127.5.5.1 One may find focal swelling or scarring of the nerve at surgical release.

1.127.5.6 Imaging Procedures

1.127.5.6.1 Routine radiographs

1.127.5.6.2 Magnetic resonance imaging if a space-occupying lesion is suspected

1.127.6 Management

1.127.6.1 General Measures

1.127.6.1.1 These are based on the cause of the condition.

1.127.6.2 Surgical Treatment

1.127.6.2.1 This is indicated if conservative measures fail.

1.127.6.2.2 Postoperative management consists of 3 weeks of immobilization and non-weigh bearing on the affected lower extremity.

1.127.6.2.3 Good results are generally seen when a well-localized, offending lesion is excised.

1.127.6.2.4 Of patients without an identifiable cause of the disorder 75% obtain significant relief from tarsal tunnel release; the remainder obtain little or no relief.

1.127.6.2.5 Some reports have noted recurrence, but no report has shown successful results of reoperations on these patients.

1.127.6.3 Physical Therapy

1.127.6.3.1 This may have a role in desensitization.

1.127.6.4 Medical Treatment

1.127.6.4.1 Treatment is based on the cause.

1.127.6.4.2 Space-occupying lesions must be excised.

1.127.6.4.3 Otherwise, nonsurgical treatment is indicated initially.

1.127.6.4.4 Prescribe Nonsteroidal anti-inflammatory drugs or steroid injection if adjacent Tenosynovitis is the cause.

1.127.6.4.5 Treat postural abnormalities with orthotic devices to keep the foot in a neutral position (to prevent pronation). Treat edema with elevation and compression stockings.

1.127.6.4.6 Normal activity can be performed as tolerated.

1.127.6.5 Patient Education

1.127.6.5.1 Patients are shown proper orthopedic management.

1.127.6.6 Monitoring

1.127.6.6.1 Patients are followed closely to prevent postdecompression swelling.

1.127.6.7 Complications

1.127.6.7.1 Nerve scarring and reflex sympathetic dystrophy may occur in a few cases.

1.127.6.8 Prognosis

1.127.6.8.1 The best results are obtained when specific focal lesions are found at decompression.

1.127.7 Wheeless' Textbook of Orthopaedics

1.127.7.1 http://www.wheelessonline.com/o16/106.htm

1.128 Tendinitis or Tenosynovitis (Muscle Overuse)

1.128.1 Summary

1.128.1.1 The synovial sheath surrounding some tendons secretes fluid, which allows the tendon to slide up and down without friction. Inflammation of the tendon is known as tendonitis and often includes inflammation of the surrounding sheath known as Tenosynovitis.

1.128.2 The Merck Manual of Diagnosis and Therapy

1.128.2.1 http://www.merck.com/mrkshared/mmanual/section5/chapter59/59d.jsp

1.129 Tibial Plafond Fracture

1.129.1 http://www.wheelessonline.com/ooa1/52.htm

1.130 Toe Walking

1.130.1 Wheeless' Textbook of Orthopaedics

1.130.1.1 http://www.wheelessonline.com/orthoo/3771a.htm

1.131 Toe Nail Fungus (Onychomycosis)

1.131.1 Wheeless' Textbook of Orthopaedics

1.131.1.1 http://www.wheelessonline.com/o13/4304a.htm

1.132 Traumatic Arthritis

1.133 Traumatic and Inflammatory Arthritis (Toe Joints)

1.134 Trimalleolar Fracture: (Cotton Fracture)

1.134.1 http://www.wheelessonline.com/ooa1/87.htm

1.135 Turf Toe / Dislocation of MTP

1.135.1 Wheeless' Textbook of Orthopaedics

1.135.1.1 http://www.wheelessonline.com/oo3/162.htm

2 Cervical Spine

Back Table of Contents References

2.1 Acceleration Injury

2.2 Acute Disk Bulge

2.3 Acute Torticollis

2.4 Ankylosing Spondylitis

2.4.1 Wheeless' Textbook of Orthopaedics

2.4.1.1 http://www.wheelessonline.com/oa4/48.htm

2.5 Anterior Cord Syndrome

2.5.1 Wheeless' Textbook of Orthopaedics

2.5.1.1 http://www.wheelessonline.com/o11/977.htm

2.6 Anterior Subluxation (Hyperflexion Sprain) & Wedge Fracture

2.6.1 Wheeless' Textbook of Orthopaedics

2.6.1.1 http://www.wheelessonline.com/o11/134.htm

2.7 Annular Tear

2.7.1 Wheeless' Textbook of Orthopaedics

2.7.1.1 http://www.wheelessonline.com/o12/48.htm

2.8 Atlantoaxial Rotatory Fixation (Subluxation)

2.8.1 Wheeless' Textbook of Orthopaedics

2.8.1.1 http://www.wheelessonline.com/o11/170.htm

2.9 Atlantoaxial Subluxation

2.9.1 Wheeless' Textbook of Orthopaedics

2.9.1.1 http://www.wheelessonline.com/o11/168.htm

2.10 Atlantooccipital disassociation

2.10.1 Wheeless' Textbook of Orthopaedics

2.10.1.1 http://www.wheelessonline.com/o11/161.htm

2.11 Bilateral InterFacet Dislocation

2.11.1 Wheeless' Textbook of Orthopaedics

2.11.1.1 http://www.wheelessonline.com/o11/140.htm

2.12 Brown Sequard Syndrome

2.12.1 Wheeless' Textbook of Orthopaedics

2.12.1.1 http://www.wheelessonline.com/o11/979.htm

2.13 Brachial Plexus Injuries (Upper Trunk)

2.13.1 Wheeless' Textbook of Orthopaedics

2.13.1.1 http://www.wheelessonline.com/05/25.htm

2.14 Burst Fractures (Lower Cervical)

2.14.1 Wheeless' Textbook of Orthopaedics

2.14.1.1 http://www.wheelessonline.com/o11/160.htm

2.15 Capsular Lesions

2.15.1 HISTORY

2.15.2 SUBJECTIVE

2.15.3 OBJECTIVE

2.15.4 TREATMENT

2.15.5 EXAMINATION

2.15.6 PATIENTS ASSESSMENT FORM

2.16 Central Cord Syndrome

2.16.1 Wheeless' Textbook of Orthopaedics

2.16.1.1 http://www.wheelessonline.com/o11/978.htm

2.17 Cervical Degenerative Changes (Generalized)

2.18 Cervical Facet Joint Restriction (Localized)

2.19 Cervical Facet Mechanical Block

2.20 Cervical Facet Stiffness

2.21 Cervical Instability

2.22 Cervical Nerve Root Impingements

2.23 Cervical Stenosis

2.23.1 Wheeless' Textbook of Orthopaedics

2.23.1.1 http://www.wheelessonline.com/o11/123.htm

2.24 Chance Fracture (Spine)

2.24.1 Wheeless' Textbook of Orthopaedics

2.24.1.1 http://www.wheelessonline.com/o11/198.htm

2.25 Common Muscle Injuries (Sprains and Contusions from Trauma or Overuse)

2.26 Compression Fractures

2.26.1 Wheeless' Textbook of Orthopaedics

2.26.1.1 http://www.wheelessonline.com/o11/181.htm

2.27 Congenital Scoliosis and Vertebral Defects

2.27.1 Wheeless' Textbook of Orthopaedics

2.27.1.1 http://www.wheelessonline.com/o11/84.htm

2.28 Cranial Dysfunctions

2.29 Dens Fracture

2.29.1 Wheeless' Textbook of Orthopaedics

2.29.1.1 http://www.wheelessonline.com/o11/172.htm

2.30 Diffuse Idiopathic Skeletal Hyperostosis

2.30.1 Wheeless' Textbook of Orthopaedics

2.30.1.1 http://www.wheelessonline.com/o11/25.htm

2.31 Disc Disease

2.32 Disc Herniation (Cervical)

2.32.1 Wheeless' Textbook of Orthopaedics

2.32.1.1 http://www.wheelessonline.com/o11/119.htm

2.33 Disk Protrusions (Derangements)

2.34 Disogenic Pain

2.34.1 Wheeless' Textbook of Orthopaedics

2.34.1.1 http://www.wheelessonline.com/o12/47.htm

2.35 Displacements

2.36 Eosinophilic Granuloma of the Spine

2.36.1 Wheeless' Textbook of Orthopaedics

2.36.1.1 http://www.wheelessonline.com/o6/103.htm

2.37 Extension Teardrop Fracture of C2

2.37.1 Wheeless' Textbook of Orthopaedics

2.37.1.1 http://www.wheelessonline.com/o11/147.htm

2.38 Facet Hypomobility or Hypermobility

2.39 Facet Joint Impingement (Blocking, Fixation)

2.40 Facet Joint Injuries

2.40.1 Wheeless' Textbook of Orthopaedics

2.40.1.1 http://www.wheelessonline.com/o11/110.htm

2.41 Facet Sprain (Joint Capsule Injury)

2.42 Facet Synovitis Hemarthrosis

2.43 Flexion Tear Drop Fracture

2.43.1 Wheeless' Textbook of Orthopaedics

2.43.1.1 http://www.wheelessonline.com/o11/144.htm

2.44 Forward Head Posture

2.45 Fracture Dislocations of the Spine

2.45.1 Wheeless' Textbook of Orthopaedics

2.45.1.1 http://www.wheelessonline.com/o11/199.htm

2.46 Grisel's syndrome

2.46.1 Wheeless' Textbook of Orthopaedics

2.46.1.1 http://www.wheelessonline.com/o11/2774.htm

2.47 Headache

2.48 Hangman's fracture / Traumatic Spondylolisthesis of the Axis

2.48.1 Wheeless' Textbook of Orthopaedics

2.48.1.1 http://www.wheelessonline.com/o11/148.htm

2.49 Hyperextension Dislocation Injury

2.49.1 Wheeless' Textbook of Orthopaedics

2.49.1.1 http://www.wheelessonline.com/o11/146.htm

2.50 Hyperextension Injuries: (19-38% of cervical injuries)

2.50.1 Wheeless' Textbook of Orthopaedics

2.50.1.1 http://www.wheelessonline.com/o11/145.htm

2.51 Hyperflexion Injuries

2.51.1 Wheeless' Textbook of Orthopaedics

2.51.1.1 http://www.wheelessonline.com/o11/131.htm

2.52 Incomplete Spinal Cord Lesion

2.52.1 Wheeless' Textbook of Orthopaedics

2.52.1.1 http://www.wheelessonline.com/o11/973.htm

2.53 Instability of Cervical Spine

2.54 Jefferson Fracture / Atlas Fracture

2.54.1 Wheeless' Textbook of Orthopaedics

2.54.1.1 http://www.wheelessonline.com/o11/155.htm

2.55 Kissing Laminae

2.56 Klippel Feil Syndrome

2.56.1 Wheeless' Textbook of Orthopaedics

2.56.1.1 http://www.wheelessonline.com/o11/52.htm

2.57 Kyphosis

2.57.1 Wheeless' Textbook of Orthopaedics

2.57.1.1 http://www.wheelessonline.com/o11/47.htm

2.58 Ligamentous Instability

2.58.1 Wheeless' Textbook of Orthopaedics

2.58.1.1 http://www.wheelessonline.com/o11/137.htm

2.59 Ligamentous Sprain and Rupture-Whiplash

2.60 Ligamentous Strain-Simple Overstretch or Overuse

2.61 Muscle Guarding (Splinting) and Spasm

2.62 Myelodysplasia

2.62.1 Wheeless' Textbook of Orthopaedics

2.62.1.1 http://www.wheelessonline.com/o11/75.htm

2.63 Myelomeningocele

2.63.1 Wheeless' Textbook of Orthopaedics

2.63.1.1 http://www.wheelessonline.com/o11/77.htm

2.64 Myelopathy

2.64.1 Wheeless' Textbook of Orthopaedics

2.64.1.1 http://www.wheelessonline.com/o11/2783.htm

2.65 Myofascial Restrictions-Cervical

2.66 Myofascial Restrictions-Subcranial

2.67 Occult Spondylytic Fractures

2.67.1 Wheeless' Textbook of Orthopaedics

2.67.1.1 http://www.wheelessonline.com/o11/95.htm

2.68 Os Odontoideum

2.68.1 Wheeless' Textbook of Orthopaedics

2.68.1.1 http://www.wheelessonline.com/o11/175.htm

2.69 Osteoarthritic Changes (Degenerative Joint Disease & Spondylosis)

2.70 Osteomyelitis (Vertebral)

2.70.1 Wheeless' Textbook of Orthopaedics

2.70.1.1 http://www.wheelessonline.com/oa3/80.htm

2.71 Painful Entrapment of Cervical Facet

2.72 Prevertebral Soft Tissues

2.72.1 Wheeless' Textbook of Orthopaedics

2.72.1.1 http://www.wheelessonline.com/o11/149.htm

2.73 Radiculopathy (Cervical)

2.73.1 Wheeless' Textbook of Orthopaedics

2.73.1.1 http://www.wheelessonline.com/o11/1212.htm

2.74 Rheumatoid Cervical Spine

2.74.1 Wheeless' Textbook of Orthopaedics

2.74.1.1 http://www.wheelessonline.com/o11/162.htm

2.75 Root Pressure (C1)

2.76 Root Pressure (C2)

2.77 Root Pressure (C3)

2.78 Root Pressure (C4)

2.79 Root Pressure (C5)

2.80 Root Pressure (C6)

2.81 Root Pressure (C7)

2.82 Root Pressure (C8)

2.83 Root Pressure (T1)

2.84 Root Pressure (T2)

2.85 Scoliosis

2.85.1 Wheeless' Textbook of Orthopaedics

2.85.1.1 http://www.wheelessonline.com/o11/59.htm

2.86 Sinus

2.87 Spinal Shock

2.87.1 Wheeless' Textbook of Orthopaedics

2.87.1.1 http://www.wheelessonline.com/o16/43.htm

2.88 Spine Fractures & their Mechanisms

2.88.1 Wheeless' Textbook of Orthopaedics

2.88.1.1 http://www.wheelessonline.com/o11/180.htm

2.89 Spondylosis (Cervical)

2.89.1 Wheeless' Textbook of Orthopaedics

2.89.1.1 http://www.wheelessonline.com/o11/118.htm

2.90 Spondylolysis / Spondylolisthesis

2.90.1 Wheeless' Textbook of Orthopaedics

2.90.1.1 http://www.wheelessonline.com/o11/92.htm

2.91 Spinous Process Fracture (avulsion fracture - "Clay Shoveler's Fracture)

2.91.1 Wheeless' Textbook of Orthopaedics

2.91.1.1 http://www.wheelessonline.com/o11/143.htm

2.92 Subcranial Facet Stiffness or Block

2.93 Subcranial Ligamentous Insufficiency-Rheumatoid Arthritis

2.94 Subcranial Ligamentous Rupture-Whiplash

2.95 Subcranial Vertebral Artery Syndrome

2.96 Syringomyelia

2.96.1 Wheeless' Textbook of Orthopaedics

2.96.1.1 http://www.wheelessonline.com/o11/79.htm

2.97 Tension Headache

2.98 Torticollis

2.98.1 Wheeless' Textbook of Orthopaedics

2.98.1.1 http://www.wheelessonline.com/o11/124.htm

2.99 Torticollis (Wryneck, Cervical Scoliosis)

2.100 Transverse Ligament Rupture

2.100.1 Wheeless' Textbook of Orthopaedics

2.100.1.1 http://www.wheelessonline.com/o11/167.htm

2.101 Tumors and Lesions of the Spine and Sacrum

2.101.1 Wheeless' Textbook of Orthopaedics

2.101.1.1 http://www.wheelessonline.com/o6/180.htm

2.102 Unilateral Facet Dislocation

2.102.1 Wheeless' Textbook of Orthopaedics

2.102.1.1 http://www.wheelessonline.com/o11/142.htm

2.103 Waddel Criteria

2.103.1 Wheeless' Textbook of Orthopaedics

2.103.1.1 http://www.wheelessonline.com/o11/26.htm

3 Elbow

Back Table of Contents References

3.1 Adult Lateral Condyle Fracture (Condylar Fractures)

3.1.1 Wheeless' Textbook of Orthopaedics

3.1.1.1 http://www.wheelessonline.com/o2/144.htm

3.2 Adult Humeral Inter-Condylar Fractures

3.2.1 Wheeless' Textbook of Orthopaedics

3.2.1.1 http://www.wheelessonline.com/o2/143.htm

3.3 Arthritis

3.3.1 HISTORY

3.3.2 SUBJECTIVE

3.3.3 OBJECTIVE

3.3.4 TREATMENT

3.3.5 EXAMINATION

3.3.6 PATIENTS ASSESSMENT FORM

3.3.7 Wheeless' Textbook of Orthopaedics

3.3.7.1

3.3.8 The Merck Manual of Diagnosis and Therapy

3.3.8.1

3.4 Biceps Tendonitis (Distal)

3.4.1 Illustration

3.4.1.1 Biceps Tendonitis (Distal)

3.5 Brachialis Tendonitis

3.6 Capitelar and Coronal Shear Fractures (Condylar Fractures)

3.6.1 Wheeless' Textbook of Orthopaedics

3.6.1.1 http://www.wheelessonline.com/o2/156.htm

3.7 Capsular Lesions

3.8 Capsule Tightness

3.9 Complex Elbow Dislocations

3.9.1 Wheeless' Textbook of Orthopaedics

3.9.1.1 http://www.wheelessonline.com/o2/180.htm

3.10 Cubital Tunnel Syndrome

3.10.1 Wheeless' Textbook of Orthopaedics

3.10.1.1 http://www.wheelessonline.com/o2/214.htm

3.11 Cubitus Varus

3.11.1 Wheeless' Textbook of Orthopaedics

3.11.1.1 http://www.wheelessonline.com/orthoo/96.htm

3.12 Displacements

3.13 Distal Biceps Tendon Rupture

3.13.1 Wheeless' Textbook of Orthopaedics

3.13.1.1 http://www.wheelessonline.com/05/85.htm

3.14 Distal Humeral Physeal Separation

3.14.1 Wheeless' Textbook of Orthopaedics

3.14.1.1 http://www.wheelessonline.com/o2/140.htm

3.15 Distal Radioulnar Joint (Joint Restrictions)

3.16 Distal Subluxation of the Radial Head (Pulled Elbow)

3.17 Distal Third Humeral Fracture: Holstein Lewis (Condylar Fractures)

3.17.1 Wheeless' Textbook of Orthopaedics

3.17.1.1 http://www.wheelessonline.com/o6/19.htm

3.18 Elbow Flexion Contracture

3.18.1 Wheeless' Textbook of Orthopaedics

3.18.1.1 http://www.wheelessonline.com/o13/611.htm

3.19 Elbow in RA Patient

3.19.1 Wheeless' Textbook of Orthopaedics

3.19.1.1 http://www.wheelessonline.com/oo3/145.htm

3.20 Elbow Tendonitis

3.21 Extensor Mechanism Tendonitis

3.22 Flexor Mechanism Tendonitis

3.23 Fractures of the Olecranon

3.23.1 Wheeless' Textbook of Orthopaedics

3.23.1.1 http://www.wheelessonline.com/o2/159.htm

3.24 Heterotopic Ossification of the Elbow

3.24.1 Wheeless' Textbook of Orthopaedics

3.24.1.1 http://www.wheelessonline.com/oo1/821.htm

3.25 Humeroradial Joint (Joint Restrictions)

3.26 Humeroulnar Joint (Joint Restrictions)

3.27 Injuries of the Throwing Elbow

3.27.1 Wheeless' Textbook of Orthopaedics

3.27.1.1 http://www.wheelessonline.com/o2/178.htm

3.28 Joint Restrictions-Distal Radioulnar Joint

3.29 Joint Restrictions-Humeroradial Joint

3.30 Joint Restrictions-Humeroulnar Joint

3.31 Lateral Epicondylitis (Tennis Elbow)

3.31.1 Wheeless' Textbook of Orthopaedics

3.31.1.1 http://www.wheelessonline.com/oo3/141.htm

3.31.2 The Merck Manual of Diagnosis and Therapy

3.31.2.1 http://www.merck.com/pubs/mmanual/section5/chapter62/62j.htm

3.32 Limited Elbow Extension (Tight Elbow Flexors) (Biceps or Brachialis)

3.33 Medial Condyle Fracture in Adult (Condylar Fractures)

3.33.1 Wheeless' Textbook of Orthopaedics

3.33.1.1 http://www.wheelessonline.com/o2/145.htm

3.34 Medial Epicondylitis (Golfer's Elbow)

3.34.1 Wheeless' Textbook of Orthopaedics

3.34.1.1 http://www.wheelessonline.com/o2/2230.htm

3.34.2 The Merck Manual of Diagnosis and Therapy

3.34.2.1 http://www.merck.com/pubs/mmanual/section5/chapter62/62k.htm

3.35 Median Nerve (Peripheral Nerve Entrapment)

3.36 Muscle Dysfunction after Trauma

3.37 Myositis Ossificans

3.38 Non Union of Humeral Fractures (Condylar Fractures)

3.38.1 Wheeless' Textbook of Orthopaedics

3.38.1.1 http://www.wheelessonline.com/o6/17.htm

3.39 Nursemaid's Elbow / Radial Head Subluxation

3.39.1 Wheeless' Textbook of Orthopaedics

3.39.1.1 http://www.wheelessonline.com/o2/183.htm

3.40 Olecranon Bursitis

3.41 Olecranon Fossa Impingement

3.42 Osteochondritis of the Elbow

3.42.1 Wheeless' Textbook of Orthopaedics

3.42.1.1 http://www.wheelessonline.com/o2/1700.htm

3.43 Osteochondrosis / Stress Fracture of Medial Epicondyle

3.43.1 Wheeless' Textbook of Orthopaedics

3.43.1.1 http://www.wheelessonline.com/o2/1401.htm

3.44 Panner's Disease / Osteochondrosis

3.44.1 Wheeless' Textbook of Orthopaedics

3.44.1.1 http://www.wheelessonline.com/o11/214.htm

3.45 Paraesthesia (4th & 5th Fingers)

3.46 Peripheral Nerve Entrapment

3.47 Posterolateral Elbow Instability

3.47.1 Wheeless' Textbook of Orthopaedics

3.47.1.1 http://www.wheelessonline.com/o2/2331.htm

3.48 Post Immobilization Capsular Tightness

3.49 Pronator Teres (Interosseous Nerve Entrapment)

3.50 Proximal Subluxation of Radial Head (Pushed Elbow)

3.51 Radial Head Fracture & Elbow Dislocation

3.51.1 Wheeless' Textbook of Orthopaedics

3.51.1.1 http://www.wheelessonline.com/o2/134.htm

3.52 Radial Head Fracture

3.52.1 Wheeless' Textbook of Orthopaedics

3.52.1.1 http://www.wheelessonline.com/o2/128.htm

3.53 Radial Head Meniscus

3.54 Radial Neck Fracture

3.54.1 Wheeless' Textbook of Orthopaedics

3.54.1.1 http://www.wheelessonline.com/oo3/139.htm

3.55 Radial Nerve (Peripheral Nerve Entrapment)

3.56 Supinator Brevis Tendonitis

3.57 Ulnar Nerve in Elbow Trauma (Condylar Fractures)

3.57.1 Wheeless' Textbook of Orthopaedics

3.57.1.1 http://www.wheelessonline.com/o2/155.htm

3.58 Volkmann's Ischaemic Contracture

4 Hip, Pelvic Girdle, Sacroiliac and Buttock

Back Table of Contents References

4.1 Acetabulum Fractures

4.1.1 Wheeless' Textbook of Orthopaedics

4.1.1.1 http://www.wheelessonline.com/oo4/139.htm

4.2 Adductor Longus Strain (Rider's Sprain) (Hip)

4.2.1 HISTORY

4.2.2 SUBJECTIVE

4.2.3 OBJECTIVE

4.2.4 TREATMENT

4.2.5 EXAMINATION

4.2.6 PATIENTS ASSESSMENT FORM

4.3 Ankylosing Spondylitis (SI)

4.4 Avascular Necrosis of Femoral Head

4.4.1 Wheeless' Textbook of Orthopaedics

4.4.1.1 http://www.wheelessonline.com/o15/10.htm

4.5 Capsular Lesions (Hip)

4.6 Claudication (Buttock)

4.7 Coxalgia (Hip)

4.8 Coxa Vara and Acquired Coxa Vara

4.8.1 Wheeless' Textbook of Orthopaedics

4.8.1.1 http://www.wheelessonline.com/o13/54.htm

4.9 Degenerative Joint Disease (DJD) (Hip)

4.10 Displacements (Hip)

4.11 Femoral Neck Fractures

4.12 Fracture Dislocations of the Hip

4.12.1 Wheeless' Textbook of Orthopaedics

4.12.1.1 http://www.wheelessonline.com/oo4/91.htm

4.13 Hamstrings Strain (Hip)

4.14 Heterotopic Ossification (Hip)

4.14.1 Wheeless' Textbook of Orthopaedics

4.14.1.1 http://www.wheelessonline.com/oo1/82.htm

4.15 Hip Joint Effusions

4.15.1 Wheeless' Textbook of Orthopaedics

4.15.1.1 http://www.wheelessonline.com/oo4/596.htm

4.16 Iliopectineal Bursitis

4.17 Inferior, Anterior Pubic Dysfunction (Pubic)

4.18 Intertrochanteric Fractures (Hip)

4.18.1 Wheeless' Textbook of Orthopaedics

4.18.1.1 http://www.wheelessonline.com/oo4/63.htm

4.19 Joint and Capsule Restrictions (Hip)

4.20 Left Iliac Downslip (Iliac)

4.21 Left Iliac Inflare (Iliac)

4.22 Left Posterior Iliac Rotation (Iliac)

4.23 Left Unilateral Sacral Flexion Dysfunction (Sacral)

4.24 Left-on-Left Sacral Torsion Dysfunction (Sacral)

4.25 Legg Calve Perthes Disease (Hip)

4.25.1 Wheeless' Textbook of Orthopaedics

4.25.1.1 http://www.wheelessonline.com/orthoo/242.htm

4.26 Muscle Strength or Flexibility Imbalance (Hip)

4.27 Osteoarthrosis (Hip) (Degenerative Joint Disease)

4.28 Pelvic Fractures (Pelvis)

4.28.1 Wheeless' Textbook of Orthopaedics

4.28.1.1 http://www.wheelessonline.com/oo4/107.htm

4.29 Psoas Bursitis (Buttock)

4.30 Psoas Strain (Hip)

4.31 Pubic Separation (Pubic)

4.32 Quadriceps Strain (Hip)

4.33 Right Iliac Anterior Rotation (Iliac)

4.34 Right Iliac Outflare (External Rotation) (Iliac)

4.35 Right Iliac Upslip (Iliac)

4.36 Sacral Extension (Sacral)

4.37 Sacral Flexion (Sacral)

4.38 Sacroiliac Dysfunction (Acute)

4.39 Sacroiliac Hypermobility (Chronic)

4.40 Sacrum and Sacral Fractures

4.40.1 Wheeless' Textbook of Orthopaedics

4.40.1.1 http://www.wheelessonline.com/o11/27.htm

4.41 Slipped Capital Femoral Epiphysis (Hip)

4.41.1 Wheeless' Textbook of Orthopaedics

4.41.1.1 http://www.wheelessonline.com/05/312.htm

4.42 Sub-Gluteal Trochanteric Bursitis (Buttock)

4.43 Subtrochanteric Fractures (Hip)

4.43.1 Wheeless' Textbook of Orthopaedics

4.43.1.1 http://www.wheelessonline.com/oo4/85.htm

4.44 Superior, Posterior Pubic Dysfunction (Pubic)

4.45 Symphysis Compression (Pubic)

4.46 Trochanteric Bursitis

5 Knee

Back Table of Contents References

5.1 Anterior Knee-pain Syndrome

5.1.1 HISTORY

5.1.2 SUBJECTIVE

5.1.3 OBJECTIVE

5.1.4 TREATMENT

5.1.5 EXAMINATION

5.1.6 PATIENTS ASSESSMENT FORM

5.2 Anterolateral Rotatory Instability

5.2.1 Wheeless' Textbook of Orthopaedics

5.2.1.1 http://www.wheelessonline.com/o12/13.htm

5.3 Anteromedial Rotatory Instability

5.3.1 Wheeless' Textbook of Orthopaedics

5.3.1.1 http://www.wheelessonline.com/o12/22.htm

5.4 Arthrofibrosis from ACL Injuries

5.4.1 Wheeless' Textbook of Orthopaedics

5.4.1.1 http://www.wheelessonline.com/o12/2334.htm

5.5 Baker's Cyst / Popliteal Cysts

5.5.1 Wheeless' Textbook of Orthopaedics

5.5.1.1 http://www.wheelessonline.com/o2/219.htm

5.6 Bipartite Patella

5.6.1 Wheeless' Textbook of Orthopaedics

5.6.1.1 http://www.wheelessonline.com/oo1/48.htm

5.7 Bursae and Bursitis of the Knee

5.7.1 Wheeless' Textbook of Orthopaedics

5.7.1.1 http://www.wheelessonline.com/o12/214.htm

5.8 Capsular Lesions

5.9 Chondromalacia Patellae (Patellofemoral Pain Syndrome)

5.9.1 Wheeless' Textbook of Orthopaedics

5.9.1.1 http://www.wheelessonline.com/oo1/54.htm

5.10 Chondral and Osteochondral Injuries of the Knee

5.10.1 Wheeless' Textbook of Orthopaedics

5.10.1.1 http://www.wheelessonline.com/oo1/54.htm

5.11 Coronary Ligament Sprain

5.12 Cruciate Ligament Instability

5.13 Cruciate Ligament Strain

5.14 Displacements

5.15 Discoid Meniscus

5.15.1 Wheeless' Textbook of Orthopaedics

5.15.1.1 http://www.wheelessonline.com/oo1/53.htm

5.16 Dislocations of the Knee (Traumatic

5.16.1 Wheeless' Textbook of Orthopaedics

5.16.1.1 http://www.wheelessonline.com/oo1/65.htm

5.17 Extensor Mechanism Injuries of the Knee

5.17.1 Wheeless' Textbook of Orthopaedics

5.17.1.1 http://www.wheelessonline.com/oo1/44.htm

5.18 Knee Flexion Contracture

5.18.1 Wheeless' Textbook of Orthopaedics

5.18.1.1 http://www.wheelessonline.com/oo4/1841.htm

5.19 Frictional Inflammation of the iliotibial Tract

5.20 Genu Varum (Pediatric)

5.20.1 Wheeless' Textbook of Orthopaedics

5.20.1.1 http://www.wheelessonline.com/o13/17.htm

5.21 Hemarthrosis

5.21.1 Wheeless' Textbook of Orthopaedics

5.21.1.1 http://www.wheelessonline.com/o12/211.htm

5.22 Hamstring Tendonitis

5.23 Inflammatory arthropathies

5.24 Infrapatellar Tendonitis

5.25 Intercondylar Eminence Fracture

5.25.1 Wheeless' Textbook of Orthopaedics

5.25.1.1 http://www.wheelessonline.com/oa2/11.htm

5.26 Joint Restrictions Post Immobilization

5.27 Ligamentous Lesions (General)

5.28 Loose Body (Middle-aged)

5.29 Medial Collateral Ligament Sprain

5.30 Meniscus Tears

5.31 Muscle Strength and Flexibility Imbalances

5.32 Osgood-Schlatter Disease

5.32.1 Wheeless' Textbook of Orthopaedics

5.32.1.1 http://www.wheelessonline.com/oo1/69.htm

5.33 Osteoarthritis (Degenerative Joint Disease, DJD)

5.34 Patella Alta

5.34.1 Wheeless' Textbook of Orthopaedics

5.34.1.1 http://www.wheelessonline.com/oo1/49.htm

5.35 Patella Infera

5.35.1 Wheeless' Textbook of Orthopaedics

5.35.1.1 http://www.wheelessonline.com/oo1/50.htm

5.36 Patellar Restrictions Post Immobilization

5.37 Patellar Tendon Avulsion

5.37.1 Wheeless' Textbook of Orthopaedics

5.37.1.1 http://www.wheelessonline.com/oo1/238.htm

5.38 Patellar Tendonitis (Jumper’s Knee)

5.38.1 Wheeless' Textbook of Orthopaedics

5.38.1.1 http://www.wheelessonline.com/oo1/1011.htm

5.39 Patellar Tracking Dysfunction

5.40 Patellofemoral Degeneration

5.41 Peripheral Nerve Entrapment

5.42 Pes Anserine Bursitis

5.43 Plica Syndrome

5.43.1 Wheeless' Textbook of Orthopaedics

5.43.1.1 http://www.wheelessonline.com/oo1/543.htm

5.44 Popliteal and Semimembranosus Tendonitis

5.45 Posterior Cruciate Ligament

5.45.1 Wheeless' Textbook of Orthopaedics

5.45.1.1 http://www.wheelessonline.com/o12/46.htm

5.46 Posterior Oblique Ligament Tears

5.46.1 Wheeless' Textbook of Orthopaedics

5.46.1.1 http://www.wheelessonline.com/o12/204.htm

5.47 Posterolateral Rotary Instability of the Knee

5.47.1 Wheeless' Textbook of Orthopaedics

5.47.1.1 http://www.wheelessonline.com/o12/15.htm

5.48 Q angle of the Knee

5.48.1 Wheeless' Textbook of Orthopaedics

5.48.1.1 http://www.wheelessonline.com/oo1/234.htm

5.49 Quadriceps Expansion Tendonitis

5.50 Quadriceps Tendonitis

5.51 Quadriceps Rupture

5.51.1 Wheeless' Textbook of Orthopaedics

5.51.1.1 http://www.wheelessonline.com/05/231.htm

5.52 Rheumatoid Arthritis (RA)

5.53 Running Injuries

5.53.1 Wheeless' Textbook of Orthopaedics

5.53.1.1 http://www.wheelessonline.com/o12/100.htm

5.54 Septic Knee

5.54.1 Wheeless' Textbook of Orthopaedics

5.54.1.1 http://www.wheelessonline.com/ortho1/153.htm

5.55 Sindig-Larsen-Johanssen disease

5.55.1 Wheeless' Textbook of Orthopaedics

5.55.1.1 http://www.wheelessonline.com/oo1/47.htm

5.56 Subluxation / Dislocation of the Patella

5.56.1 Wheeless' Textbook of Orthopaedics

5.56.1.1 http://www.wheelessonline.com/oo1/51.htm

5.57 Suprapatellar Tendonitis

5.58 Tibial Tubercle Avulsion

5.58.1 Wheeless' Textbook of Orthopaedics

5.58.1.1 http://www.wheelessonline.com/oo1/70.htm

5.59 Tibiofemoral Capsule Tightness

5.60 Valgus Stress Test

5.60.1 Wheeless' Textbook of Orthopaedics

5.60.1.1 http://www.wheelessonline.com/o12/1173.htm

5.61 Varus Stress Test

5.61.1 Wheeless' Textbook of Orthopaedics

5.61.1.1 http://www.wheelessonline.com/o12/1194.htm

6 Leg

Back Table of Contents References

6.1 Achilles Tendonitis

6.2 Achilles Tendon Rupture

6.3 Anterolateral Tibial Bowing

6.3.1 Wheeless' Textbook of Orthopaedics

6.3.1.1 http://www.wheelessonline.com/o2/32.htm

6.4 Avulsion of the Tibial Tubercle

6.4.1 Wheeless' Textbook of Orthopaedics

6.4.1.1 http://www.wheelessonline.com/oo1/70.htm

6.5 Blounts Disease

6.5.1 Wheeless' Textbook of Orthopaedics

6.5.1.1 http://www.wheelessonline.com/o13/15.htm

6.6 Compartment Syndrome resulting from Tibial Fractures

6.6.1 Wheeless' Textbook of Orthopaedics

6.6.1.1 http://www.wheelessonline.com/oa2/28.htm

6.7 Congenital Pseudarthrosis of Tibia

6.7.1 Wheeless' Textbook of Orthopaedics

6.7.1.1 http://www.wheelessonline.com/o2/217.htm

6.8 Dorsiflexion Muscle Weakness

6.9 Gustillo Classification of Open Tibial Fractures

6.9.1 Wheeless' Textbook of Orthopaedics

6.9.1.1 http://www.wheelessonline.com/oa2/60.htm

6.10 Infections of the Tibia

6.10.1 Wheeless' Textbook of Orthopaedics

6.10.1.1 http://www.wheelessonline.com/oa2/30.htm

6.11 Intercondylar Eminence Fracture

6.11.1 Wheeless' Textbook of Orthopaedics

6.11.1.1 http://www.wheelessonline.com/oa2/11.htm

6.12 Intermittent Claudication

6.13 Malunion of the Tibia

6.13.1 Wheeless' Textbook of Orthopaedics

6.13.1.1 http://www.wheelessonline.com/oa2/25.htm

6.14 Mangled Extremity Severity Score (MESS)

6.14.1 Wheeless' Textbook of Orthopaedics

6.14.1.1 http://www.wheelessonline.com/oa2/915.htm

6.15 Open Fractures of the Tibia

6.15.1 Wheeless' Textbook of Orthopaedics

6.15.1.1 http://www.wheelessonline.com/oa2/63.htm

6.16 Paraxial Tibial Hemimelia

6.16.1 Wheeless' Textbook of Orthopaedics

6.16.1.1 http://www.wheelessonline.com/o2/296.htm

6.17 Peronei Tendonitis (Evertor Muscles)

6.18 Plantiflexors (Short)

6.19 Posteromedial Tibial Bowing

6.19.1 Wheeless' Textbook of Orthopaedics

6.19.1.1 http://www.wheelessonline.com/o2/31.htm

6.20 Prognosis of Tibial Fractures

6.20.1 Wheeless' Textbook of Orthopaedics

6.20.1.1 http://www.wheelessonline.com/oa2/19.htm

6.21 Proximal Tibiofibular Joint

6.22 Pseudoarthrosis of the Tibia

6.22.1 Wheeless' Textbook of Orthopaedics

6.22.1.1 http://www.wheelessonline.com/oa2/22.htm

6.23 Shin Splints / Medial Tibial Stress Syndrome

6.23.1 Summary

6.23.1.1 Pain over the Posteromedial border of the middle to distal thirds of the tibia, at the periosteal/fascial junction attributed to Periostitis (Inflammation of the periosteum covering a bone) but may involve tendonitis of tibialis posterior/flexor digitorum longus/flexor hallucis longus. Causes include; improper gait, wearing old shoes, tight soleus muscle, improper muscle balance between gastroc-soleus/tibialis anterior, and improper training habits.

6.23.2 Basics

6.23.2.1 Definitions

6.23.2.1.1 Medial tibial stress syndrome is typically an overuse injury, a syndrome (a group of symptoms, signs, laboratory findings, and physiological disturbances that are linked by a common anatomical, biochemical, or pathological history) of pain over the Posteromedial border of the middle to distal thirds of the tibia, at the periosteal/fascial junction. It is generally attributed to Periostitis (Inflammation of the periosteum, the membrane covering a bone. SYN: periosteitis).

6.23.3 Wheeless' Textbook of Orthopaedics

6.23.3.1 http://www.wheelessonline.com/oa4/78.htm

6.23.4 The Merck Manual of Diagnosis and Therapy

6.23.4.1 http://www.merck.com/mrkshared/mmanual/section5/chapter62/62c.jsp

6.23.5 Unknown

6.23.5.1 http://www.mtsu.edu/~wwhitehi/atep/258/ch6.html

6.24 Tennis Leg (Plantiflexors)

6.25 Tibial Fracture References

6.25.1 Wheeless' Textbook of Orthopaedics

6.25.1.1 http://www.wheelessonline.com/oa2/20.htm

6.26 Tibial Non Unions

6.26.1 Wheeless' Textbook of Orthopaedics

6.26.1.1 http://www.wheelessonline.com/oa2/21.htm

6.27 Tibial Plafond Fracture

6.27.1 Wheeless' Textbook of Orthopaedics

6.27.1.1 http://www.wheelessonline.com/ooa1/52.htm

6.28 Tibial Plateau Fractures

6.28.1 Wheeless' Textbook of Orthopaedics

6.28.1.1 http://www.wheelessonline.com/o2/95.htm

6.29 Tibial Stress Fractures

6.29.1 Wheeless' Textbook of Orthopaedics

6.29.1.1 http://www.wheelessonline.com/oa4/655.htm

6.30 Tibialis Anterior Tendonitis (Dorsiflexor Muscles)

6.31 Tibialis Posterior Tendonitis (Invertor Muscles)

6.32 Tight Fascial Compartment

6.33 Triplane Fracture

6.33.1 Wheeless' Textbook of Orthopaedics

6.33.1.1 http://www.wheelessonline.com/oa2/42.htm

6.34 Tumors of the Proximal Tibia

6.34.1 Wheeless' Textbook of Orthopaedics

6.34.1.1 http://www.wheelessonline.com/o6/175.htm

6.35 Vascular Injuries Associated w/ Tibial Fractures

6.35.1 Wheeless' Textbook of Orthopaedics

6.35.1.1 http://www.wheelessonline.com/oa2/27.htm

6.36 X rays: for Tibial Fractures

6.36.1 Wheeless' Textbook of Orthopaedics

6.36.1.1 http://www.wheelessonline.com/oa2/18.htm

7 Lumbar Spine

Back Table of Contents References

7.1 Afebrile Osteomyelitis

7.1.1 HISTORY

7.1.2 SUBJECTIVE

7.1.3 OBJECTIVE

7.1.4 TREATMENT

7.1.5 EXAMINATION

7.1.6 PATIENTS ASSESSMENT FORM

7.2 Ankylosing Spondylitis

7.2.1 Wheeless' Textbook of Orthopaedics

7.2.1.1 http://www.wheelessonline.com/oa4/48.htm

7.3 Annular Tear

7.3.1 Wheeless' Textbook of Orthopaedics

7.3.1.1 http://www.wheelessonline.com/o12/48.htm

7.4 Anterior Cord Syndrome

7.4.1 Wheeless' Textbook of Orthopaedics

7.4.1.1 http://www.wheelessonline.com/o11/977.htm

7.5 Brown Sequard Syndrome

7.5.1 Wheeless' Textbook of Orthopaedics

7.5.1.1 http://www.wheelessonline.com/o11/979.htm

7.6 Brucellosis

7.7 Burst Fracture (Spine)

7.7.1 Wheeless' Textbook of Orthopaedics

7.7.1.1 http://www.wheelessonline.com/o11/183.htm

7.8 Capsular Lesions

7.9 Cauda Equina Syndrome

7.9.1 Wheeless' Textbook of Orthopaedics

7.9.1.1 http://www.wheelessonline.com/o11/191.htm

7.10 Central Cord Syndrome

7.10.1 Wheeless' Textbook of Orthopaedics

7.10.1.1 http://www.wheelessonline.com/o11/978.htm

7.11 Chance Fracture (Spine)

7.11.1 Wheeless' Textbook of Orthopaedics

7.11.1.1 http://www.wheelessonline.com/o11/198.htm

7.12 Coccydynia

7.13 Compression Fractures

7.13.1 Wheeless' Textbook of Orthopaedics

7.13.1.1 http://www.wheelessonline.com/o11/181.htm

7.14 Congenital Scoliosis and Vertebral Defects

7.14.1 Wheeless' Textbook of Orthopaedics

7.14.1.1 http://www.wheelessonline.com/o11/84.htm

7.15 Diffuse Idiopathic Skeletal Hyperostosis

7.15.1 Wheeless' Textbook of Orthopaedics

7.15.1.1 http://www.wheelessonline.com/o11/25.htm

7.16 Disc (Acutely Involved) (Tear)

7.17 Disc Herniation

7.17.1 Wheeless' Textbook of Orthopaedics

7.17.1.1 http://www.wheelessonline.com/o11/39.htm

7.18 Disc (Intervertebral)

7.19 Disc (Painful)

7.20 Disc (Postoperative)

7.21 Disc Lesions

7.22 Disk Extrusion (Lower Lumbar) with Nerve Root Impingement

7.23 Disk Prolapse (Outer annulus or posterior longitudinal ligament still intact) Acute (Severe) Posterolateral

7.24 Disk Protrusions (Derangements)

7.25 Disogenic Pain

7.25.1 Wheeless' Textbook of Orthopaedics

7.25.1.1 http://www.wheelessonline.com/o12/47.htm

7.26 Displacements

7.27 Eosinophilic Granuloma of the Spine

7.27.1 Wheeless' Textbook of Orthopaedics

7.27.1.1 http://www.wheelessonline.com/o6/103.htm

7.28 Facet (Denervation) Medial Branch Rhizolysis

7.29 Facet (Mechanical Block)

7.30 Facet Hypomobility or Hypermobility

7.31 Facet Joint Impingement (Blocking Fixation)

7.32 Facet Sprain (Joint Capsule Injury)

7.33 Facet-Joint Capsular Tightness (Localized) (Unilateral)

7.34 Facet-Joint Derangement (Acute)

7.35 Facet-Joints (Lumbar) Multisegmental Bilateral Capsular Restriction (Degenerative Joint Disease) (DJD)

7.36 Flat Low-Back Posture

7.37 Flexion-Distraction Injuries (Seat Belt Types)

7.37.1 Wheeless' Textbook of Orthopaedics

7.37.1.1 http://www.wheelessonline.com/o11/196.htm

7.38 Fracture Dislocations of the Spine

7.38.1 Wheeless' Textbook of Orthopaedics

7.38.1.1 http://www.wheelessonline.com/o11/199.htm

7.39 Fractured Transverse Process

7.40 Fractured Vertebral Body

7.41 Hyperacute Lumbago

7.42 Iliolumbar Ligament Strain-Sprain

7.43 Incomplete Spinal Cord Lesion

7.43.1 Wheeless' Textbook of Orthopaedics

7.43.1.1 http://www.wheelessonline.com/o11/973.htm

7.44 Instability

7.45 Kissing Vertebrae

7.46 Ligamentous Deficiency

7.47 Ligamentous Overstretching

7.48 Low Back Pain in the Adult

7.48.1 Wheeless' Textbook of Orthopaedics

7.48.1.1 http://www.wheelessonline.com/o11/11.htm

7.49 Lumbar Facet Conditions

7.50 Lumbar Stenosis

7.50.1 Wheeless' Textbook of Orthopaedics

7.50.1.1 http://www.wheelessonline.com/o11/22.htm

7.51 Muscle Guarding (Chemical)

7.52 Muscle Guarding (Splinting) and Spasm

7.53 Muscle Injuries (Strains and Contusions from trauma or overuse

7.54 Myelodysplasia

7.54.1 Wheeless' Textbook of Orthopaedics

7.54.1.1 http://www.wheelessonline.com/o11/75.htm

7.55 Myelomeningocele

7.55.1 Wheeless' Textbook of Orthopaedics

7.55.1.1 http://www.wheelessonline.com/o11/77.htm

7.56 Myelopathy

7.56.1 Wheeless' Textbook of Orthopaedics

7.56.1.1 http://www.wheelessonline.com/o11/2783.htm

7.57 Occult Spondylytic Fractures

7.57.1 Wheeless' Textbook of Orthopaedics

7.57.1.1 http://www.wheelessonline.com/o11/95.htm

7.58 Os Odontoideum

7.58.1 Wheeless' Textbook of Orthopaedics

7.58.1.1 http://www.wheelessonline.com/o11/175.htm

7.59 Osteitis Deformans

7.60 Osteoarthritic Changes (Degenerative Joint Disease and Spondylosis)

7.61 Osteoarthrosis (Degenerative)

7.62 Osteochondrosis (Adolescent)

7.63 Osteomyelitis (Vertebral)

7.63.1 Wheeless' Textbook of Orthopaedics

7.63.1.1 http://www.wheelessonline.com/oa3/80.htm

7.64 Osteophytosis (Posterior)

7.65 Osteoporosis (Senile)

7.66 Pedicles (Stretch)

7.67 Relaxed or Slouched Posture

7.68 Root Pain with Neurological Signs

7.69 Root Pain without Neurological Signs

7.70 Root Pressure (L1)

7.71 Root Pressure (L2)

7.72 Root Pressure (L3)

7.73 Root Pressure (L4)

7.74 Root Pressure (L5)

7.75 Root Pressure (S1)

7.76 Root Pressure (S2)

7.77 Root Pressure (S3)

7.78 Root Pressure (S4)

7.79 Sacral Sparing

7.79.1 Wheeless' Textbook of Orthopaedics

7.79.1.1 http://www.wheelessonline.com/o11/14.htm

7.80 Scoliosis

7.80.1 Wheeless' Textbook of Orthopaedics

7.80.1.1 http://www.wheelessonline.com/o11/59.htm

7.81 Slipped Vertebral Apophysis

7.81.1 Wheeless' Textbook of Orthopaedics

7.81.1.1 http://www.wheelessonline.com/o11/17.htm

7.82 Spinal Claudication

7.83 Spinal Shock

7.83.1 Wheeless' Textbook of Orthopaedics

7.83.1.1 http://www.wheelessonline.com/o16/43.htm

7.84 Spine Fractures & their Mechanisms

7.84.1 Wheeless' Textbook of Orthopaedics

7.84.1.1 http://www.wheelessonline.com/o11/180.htm

7.85 Spondylolisthesis

7.86 Spondylolysis

7.87 Spondylolysis / Spondylolisthesis

7.87.1 Wheeless' Textbook of Orthopaedics

7.87.1.1 http://www.wheelessonline.com/o11/92.htm

7.88 Stenosis

7.89 Sway Back

7.90 Syringomyelia

7.90.1 Wheeless' Textbook of Orthopaedics

7.90.1.1 http://www.wheelessonline.com/o11/79.htm

7.91 Tethered Cord Syndrome

7.91.1 Wheeless' Textbook of Orthopaedics

7.91.1.1 http://www.wheelessonline.com/o11/80.htm

7.92 Thoracolumbar Syndrome

7.93 Tumors and Lesions of the Spine and Sacrum

7.93.1 Wheeless' Textbook of Orthopaedics

7.93.1.1 http://www.wheelessonline.com/o6/180.htm

7.94 Ulceration (Decubiti/Pressure)

7.94.1 Wheeless' Textbook of Orthopaedics

7.94.1.1 http://www.wheelessonline.com/o16/30.htm

7.95 Vertebral Hyperostosis

7.96 Waddel Criteria

7.96.1 Wheeless' Textbook of Orthopaedics

7.96.1.1 http://www.wheelessonline.com/o11/26.htm

7.97 Zygapophyseal Joints

7.98

8 Shoulder and Shoulder Girdle

8.1 Adhesive Capsulitis

Back Table of Contents References

8.1.1 HISTORY

8.1.1.1 Bursitis tendonitis (1)

8.1.1.2 Post fracture (arm, forearm, & or wrist.) Immobilization (2)

8.1.1.3 POSTSUBLUXATION/DISLOCATION IMMOBILIZATION. (3)

8.1.1.4 JOINT STRAINS THEN SELF LIMITING RANGE BOTH ACTIVE & PASSIVE. (4)

8.1.1.5 NO HISTORY OF ACCIDENTS OR INJURIES TO SHOULDER. (5)

8.1.1.6 DIAGNOSED WITH REFLEX SYMPATHETIC DYSTROPHY. (6)

8.1.1.7 CHEST SURGERY. (7)

8.1.1.8 MYOCARDIAL INFARCTION. (8)

8.1.1.9 Diagnosed with DEGENERATIVE JOINT DISEASE. (9)

8.1.1.10 Diagnosed with rheumatoid arthritis. (10)

8.1.2 SUBJECTIVE

8.1.2.1 GRADUAL ONSET OF PAIN & STIFFNESS. (11)

8.1.2.2 TROUBLE USEING ARM TO COMBING HAIR. (12)

8.1.2.3 DISCONFORT WHEN REACHING ABOVE SHOULDER TO FASTEN A BRA ON BACK. (13)

8.1.2.4 DICOMFORT WHEN REACHING INTO HIP POCKET. (14)

8.1.2.5 DIFFICULTY PUTTING ON OR REMOVING SHIRT OR JACKET. (15)

8.1.2.6 trouble eating comfortably with the arm. (16)

8.1.2.7 trouble reaching for items on a high shelf. (17)

8.1.2.8 NO PAIN FELT DIRECTLY ON SHOULDER. (18)

8.1.2.9 PAIN RADIATES TO BELOW THE ELBOW DISTRIBUTED IN THE C5C6 SEGMENT. (19) (A)

8.1.2.10 THE PATIENT IS AWAKENED BY PAIN AT NIGHT WHEN ROLLING ON PAINFUL SIDE. (20) (A)

8.1.2.11 CONSTANT DULL ACHE PAIN. (21) (A)

8.1.2.12 PAIN IS LOCALIZED TO THE LATERAL BRACHIAL REGION. (22) (C)

8.1.2.13 PAIN DOESN’T SPREAD BELOW ELBOW. (23) (C)

8.1.2.14 THE PATIENT IS NOT AWAKENED BY PAIN AT NIGHT. (24) (C)

8.1.2.15 DULL ACHE FELT ONLY ON ACTIVITIES INVOLVING THE INVOLMEMENT INTO THE RESTRICTED RANGES. (25) (C)

8.1.3 OBJECTIVE

8.1.3.1 CAPSULAR PATTERN FROM WORSE TO BEST LATERAL ROTATION, ABDUCTION, & MEDIAL ROTATION. (26)

8.1.3.1.1 active movements

8.1.3.1.1.1 LITTLE GLENOHUMERAL MOVEMENT ON ABDUCTION,

8.1.3.1.1.2 MUCH DIFFICULTY AND SUBSTITUTION GETTING THE HAND BEHIND THE NECK.

8.1.3.1.1.3 USUALLY THERE IS SOME LIMITATION WHEN FLEXING THE ARM

8.1.3.1.1.4 DIFFICULTY TRYUING TO PUT THE HAND BEHIND THE BACK.

8.1.3.1.2 PASSIVE movements

8.1.3.1.2.1 LATERAL ROTATION IS MARKEDLY RESTRICTED,

8.1.3.1.2.2 ABDUCTION MODERATELY RESTRICTED.

8.1.3.1.2.3 MEDIAL ROTATION & FLEXION ARE SOMEWHAT LIMITED.

8.1.3.2 DISCOMFORT AT END RANGE OF ALL MOTIONS ESPECIALLY LATERAL ROTATION & ABDUCTION. (27)

8.1.3.3 FEMALE 40-50+ YEARS OLD. (28)

8.1.3.4 SCAPULAR MOBILITY NOT RESTRICTED. (29)

8.1.3.5 ACCESSORY MOVEMENTS ARE LIMITED ESPECIALLY ANTERIOR & INFERIOR GLIDES. (30)

8.1.3.6 END RANGE(CLASSICAL & ACCESSORY) HAS AN ABNORMAL CREEP RESISSTANCE . (31)

8.1.3.7 LOST RANGE/MEASURED RANGE LATERAL ROTATION=60/30, ABDUCTION=90/90, MEDIAL ROTATION=45/25, FLEXION=60/120. (32)

8.1.3.8 INTER SCAPULAR MUSCLE TIGHTNESS WITH THORACIC KYPHOSIS.. (33)

8.1.3.8.1 ALTERCATION IN SCAPULOHUMERAL ALIGNMENT=THORACIC KYPHOSIS MAY CONTRIBUTE TO INTERSCAPULAR MUSCLE TIGHTNESS. (33)

8.1.3.9 FEELING OF INCREASED MUSCLE TONE, WITH INDURATION OVER THE LATERAL BRACHIAL REGION. (34)

8.1.3.10 RESISTED ISOMETRIC MOVEMENTS STRONG AND PAINLESS, UNLESS A TENDINITIS ALSO PRESENT. (35)

8.1.3.11 MUSCLE SPASM(ACUTE) END FEEL. (36) (A)

8.1.3.11.1 ON PASSIVE MEOVEMENT LIMITATION IS DUE TO PAIN AND MUSCLE GUARDING, RATHER THAN STIFNESS PER SE.

8.1.3.12 CAPSULAR(CHRONIC) end feel (37 ) (C)

8.1.3.12.1 ON PASSIVE MOVEMENT, LIMITATION IS DUE TO CAPSULAR STIFFNESS, AND PAIN IS FELT ONLY WHEN THE CAPSULE IS STRETCHED

8.1.3.13 SUBACUTE.

8.1.3.13.1 SOME COMBINATION OF ACUTE & CRONIC SUBJECTIVE & OBJECTIVE FINDINGS.

8.1.3.14 .

8.1.3.15

8.1.4 TREATMENT

8.1.4.1 CAUSE

8.1.4.1.1 CAPSULE RESTRICTION IS CAUSED BY AN ALTERATION OF THE COLLAGEN FIBERS OR WATER CONTENT OF THE CONNECTIVE TISSUE OF THE CAPSULE THAT RESULTS IN FUNCTIONAL LOSS OF MOVEMENT ACTIVELY AND PASSIVELY.

8.1.4.2 GOALS

8.1.4.2.1 RELIEF OF PAIN & MUSCLE GAURDING TO ALLOW EARLY, GENTLE MOBILIZATION. (A) (1)

8.1.4.2.2 MAINTENANCE & GENTLE INCREASE OF ROM. (A) (2)

8.1.4.2.3 MUSCLE STRENGTHING (A) (3)

8.1.4.2.4 MUSCLE STRETCHING (A) (4)

8.1.4.2.5 PREVENTING EXCESSIVE KYPHOSIS & SHOULDER-GIRDLE PROTRACTION. (A) (5)

8.1.4.2.6 INCREASE EXTENSIBILITY OF JOINT CAPSULE, EMPHASIS ON ANTEROINFERIOR ASPECT. (C) (6)

8.1.4.2.7 STRENGTHEN SURROUNDING MUSCLES (42) (C) (7)

8.1.4.2.8 IDENTIFY FUNCTIONAL STRESSES THAT MAY BE CONTRIBUTING TO CAPSULE IRITATION. (46) (C) (8)

8.1.4.2.9 EVALUATE AND TREAT COMPENSATIONS. (47) (C) (9)

8.1.4.2.10 CAUSE CONNECTIVE TISUE ELEMENTS TO YIELD (48) (C) (10)

8.1.4.2.11 TERMINATION (C) (11)

8.1.4.3 ICE/SUPERFICIAL HEAT/ULTRA SOUND. (38) (A) (1)

8.1.4.4 GRADE 1 OR 2 JOINT-PLAY OSCILLATIONS. (39) (A) (1)

8.1.4.5 SUSTAINED GRADE 1 OR 2 JOINT-PLAY TRACTION=ESPECIALLY INFERIOR GLIDE BECAUSE MUSCLE SPASM HIKES UP HUMEROUS AND INTERFERES WITH JOINT MICHANICS. (40) (A) (2)

8.1.4.5.1 MAY INCLUDE LATERAL DISTRACTION, ANTERIOR & POSTERIOR GLIDES.

8.1.4.6 SELF ASSISTED RANGE OF MOTION EXERCISES, (WAND AND PENDULUM EXERCISES) & AUTOMOBILIZATION. (41) (A) (2)

8.1.4.7 INSTRUCTION IN ISOMETRIC STRENGTHENING EXERCISES. (42) (A) (3)

8.1.4.7.1 ISOTONIC EXERCISES MAY BE INEFFECTIVE DUE TO PAIN & REFLEX INHIBITION.

8.1.4.8 MANUAL OR HOME STRETCHING; TERES MAJOR, SUBSCAPULARIS, AND LATISSISMUS DORSI, PECTORALIS GROUP, LEVATOR SCAPULA, AND SCALINI GROUP IF TIGHT. (43) (A) (4)

8.1.4.9 INSTRUCTION IN POSTURAL AWARENESS. (44) (A) (5)

8.1.4.9.1 UPPER TRUNK & SHOULDER GIRDLES.=PATIENT LEARNS TO DIFFERENTIATE PROPRIOCEPTIVELY BETWEEN A KYPHOTIC, PROTRACTED POSTURE AND A RELATIVELY UPRIGHT, RETRACTED POSITION.

8.1.4.9.2 TEACH PATIENT TO DO REGULAR DAILY POSTUREAL CHECKS.

8.1.4.10 MANUAL OR HOME STRETCHING; ULTRASOUND PRECEDING OR ACCOMPANYING STRECHING PROCEDURES. (43) (C) (6)

8.1.4.10.1 ALSO MAY USE DIATHERMY

8.1.4.10.2 MOIST HEAT MAY BE USED ONLY IF THE CAPSULE IS MINIMALLY COVERED BY DENSE CONNECTIVE TISSUE.

8.1.4.11 SUSTAINED GRADE 1 OR 2 JOINT-PLAY TRACTION, ESPECIALLY ANTERIOR INFERIORR CAPSULR STRETCH. (40) (C) (6)

8.1.4.12 AUTO MOBILIZATION ESPECIALLY ANTERIOR INFERIOR GLIDE. (41) (C) (6)

8.1.4.13 CROSS FIBRE MASSAGE TO TENDONS; TREAT TENDINITIS AND BURSITIS(IF PRESENT) TO THE LEVEL OF LOW OR MODERATE REACTIVITY. (45) (C) (6)

8.1.4.13.1 THIS SHOULD BE DONE BEFORE TREATING CAPSULE FOR MECHANICAL EFFECTS( GRADES 3, 4, OR PROLONGED STRETCH )

8.1.4.14 ISOTONIC EXERCISES TO ROTATOR CUFF AND SHOULDER GRIDLE MUSCLES (42) (C) (7)

8.1.4.14.1 ONCE ACTIVE RANGE HAS BEEN IMPROVING PROGRESSIVELY FOR 4 WEEKS AFTER MANIPULATION AND ONCE PROPER POSTURE CAN BE MAINTAINED.

8.1.4.15 IDENTIFY FUNCTIONAL STRESSES THAT MAY BE CONTRIBUTING TO CAPSULE IRITATION. (46) (C) (8)

8.1.4.16 EVALUATE AND TREAT COMPENSATIONS. (47) (C) (9)

8.1.4.16.1 CAPSULE TRAUMA AND SUBSEQUENT INABILITY OT BOME JOINT THROUGH FUL RANGE MAY CAUSE COMPENSATIONOFMUSCLES & OTHER JOINT POSITIONING.

8.1.4.17 SUSTAINED GRADE 3 JOINT-PLAY TRACTION (48) (C) (10)

8.1.4.17.1 STRONG STRETCHING AFTER 4-6 MONTHS.

8.1.4.18 TERMINATION (C) (11)

8.1.4.18.1 WHEN RANGE OF MOTION BOTH ACTIVE AND PASSIVE AND FUNCTION HAVE PLATEAUED THEN MANIPULATION IS STOPPED AS FURTHER PASSIVE STRETCHING MAY STIMULATE THE CONECTIVE TISSUES SUCH THAT FURTHER PROLFERATION TIGHTENING OCCURS(WOLF’S LAW OF CONNECTIVE TISSUE RESPONSE STIMULUS)

8.1.4.18.2 PLACE THE PATIENT ON A HOME PROGRAM OF MAINTAINING PAIN FREE MOVEMENT WITHIN THE RANGE WHILE AVOIDING STRESSING THE END RANGE.

8.1.4.19 PROGNOSIS

8.1.4.19.1 THE LAST 5 TO 10 DEGREES OF MOVEMENT OF ALL PLANES MAY BE LIMITED AND SUBJECTIVELY DESCRIBED AS A PULLING RESTRICTION DURING FUNCTIONAL ACTIVITIES. THIS RANGE MAY BE THE GOAL OF TREATMENT.

8.1.5 EXAMINATION

8.1.5.1 ACTIVE MOVEMENTS

8.1.5.1.1 LR,ABD,FLX,MR.

8.1.5.2 PASSIVE MOVEMENTS

8.1.5.2.1 LR,ABD,FLX,MR.

8.1.5.3 JOINTPLAY

8.1.5.3.1 ANT & INFERIOR GLIDE MINIMUM.

8.1.5.4 RESISTED ISOMETRIC MOVEMENTS

8.1.5.5 PALPATION

8.1.5.5.1 LATERAL BRACHIAL REGION

8.1.5.6 INSPECTION

8.1.5.6.1 SCARS OF CHEST INDICATING SURGERY.

8.1.6 PATIENTS ASSESSMENT FORM

8.1.6.1 BURSITIS TENDONITIS. (1)

8.1.6.2 POSTFRACTURE(ARM, FOREARM, & OR WRIST.) IMOBILIZATION. (2)

8.1.6.3 POSTSUBLUXATION/DISLOCATION IMMOBILIZATION. (3)

8.1.6.4 JOINT STRAINS THEN SELF LIMITING RANGE BOTH ACTIVE & PASSIVE. (4)

8.1.6.5 NO HISTORY OF ACCIDENTS OR INJURIES TO SHOULDER. (5)

8.1.6.6 DIAGNOSED WITH REFLEX SYMPATHETIC DYSTROPHY. (6)

8.1.6.7 CHEST SURGERY. (7)

8.1.6.8 MYOCARDIAL INFARCTION. (8)

8.1.6.9 diagnosed with DEGENERATIVE JOINT DISEASE. (9)

8.1.6.10 diagnosed with rheumatoid arthritis. (10)

8.1.6.11 GRADUAL ONSET OF PAIN & STIFFNESS. (11)

8.1.6.12 TROUBLE USEING ARM TO COMBING HAIR. (12)

8.1.6.13 DISCONFORT WHEN REACHING ABOVE SHOULDER TO FASTEN A BRA ON BACK. (13)

8.1.6.14 DICOMFORT WHEN REACHING INTO HIP POCKET. (14)

8.1.6.15 DIFFICULTY PUTTING ON OR REMOVING SHIRT OR JACKET. (15)

8.1.6.16 trouble eating comfortably with the arm. (16)

8.1.6.17 trouble reaching for items on a high shelf. (17)

8.1.6.18 NO PAIN FELT DIRECTLY ON SHOULDER. (18)

8.1.6.19 PAIN RADIATES TO BELOW THE ELBOW DISTRIBUTED IN THE C5C6 SEGMENT. (19) (A)

8.1.6.20 THE PATIENT IS AWAKENED BY PAIN AT NIGHT WHEN ROLLING ON PAINFUL SIDE. (20) (A)

8.1.6.21 CONSTANT DULL ACHE PAIN. (21) (A)

8.1.6.22 PAIN IS LOCALIZED TO THE LATERAL BRACHIAL REGION. (22) (C)

8.1.6.23 PAIN DOESN’T SPREAD BELOW ELBOW. (23) (C)

8.1.6.24 THE PATIENT IS NOT AWAKENED BY PAIN AT NIGHT. (24) (C)

8.1.6.25 DULL ACHE FELT ONLY ON ACTIVITIES INVOLVING THE VOMEMENT INTO THE RESTRICTED RANGES. (25) (C)

8.1.7 Wheeless' Textbook of Orthopaedics

8.1.7.1 http://www.wheelessonline.com/orthoo/4300.htm

8.2 AC Joint Arthrosis

8.2.1 Wheeless' Textbook of Orthopaedics

8.2.1.1 http://www.wheelessonline.com/orthoo/64.htm

8.3 Acromioclavicular Joint

8.3.1 HISTORY

8.3.1.1 SHOULDER WAS IMPACTED IN AUTO ACCIDENT. (50)

8.3.1.2 DIAGNOSED WITH OSTEOARTHRITUS OF ACROMIOCLAVICULAR JOINT.

8.3.1.3 (51)

8.3.1.4 HAVE BROKEN OR DISLOCATED CLAVICLE.. (52)

8.3.1.5 PLAYED CONTACT SPORTS AND FELL ON SHOULDER. (53)

8.3.1.5.1 USUALLY TRAUMATIC, PREVALENT AMONG ATHOLETES AFTER A FALL ON THE SHOULDER.

8.3.1.6 DX IMPINGEMENT SYNDROME. (54)

8.3.1.7 PLAY OR HAVE PLAYED FOOTBALL.. (55)

8.3.1.8 HAVE FALLEN ON SHOULDER IN OTHER ACTIVITIES. (56)

8.3.2 SUBJECTIVE

8.3.2.1 trouble reaching for items on a high shelf. (17)

8.3.2.2 CAN POINT TO WHERE IT HURTS ON SHOULDER. (57)

8.3.2.3 NO PAIN DOWN UPPER OR LOWER ARM. (58) (C)

8.3.2.4 NECK DOESN’T HURT. (59) (C)

8.3.2.5 PAIN FELT IN ARM. (60) (A)

8.3.2.6 LOWER PART OF NECK HURTS. (61) (A)

8.3.2.7 TOP OF CHEST HURTS. (62) (A)

8.3.2.8 OPENING HEAVY SLIDING GLASS DOORS OR WINDOWS IS PAINFUL.. (63)

8.3.2.9 CLOSING SLIDING GLASS DOORS IS PAINFUL. (64)

8.3.3 OBJECTIVE

8.3.3.1 RARELY REFERS PAIN OUTSIDE OF JOINT DERIVED C4. (65)

8.3.3.2 THE PATIENT POINTS TO THE SPOT. (66)

8.3.3.3 INFERIOR AC LIGAMENTS MAY PRODUCE PAINFUL ARC. (67)

8.3.3.4 INFERIOR AC LIGAMENTS MAY REFER PAIN IN C5 SEGMENT. (68)

8.3.3.5 PAIN AT THE PASSIVE EXTREMES OF SCAPULAR AND ARM MOVEMENT. (69)

8.3.3.6 PASSIVE HORIZONTAL ADDUCTION PAINFUL.. (70)

8.3.3.7 ISOMETRICALLY RESISTED HORIZONTAL ADDUCTION PAINFUL. (71)

8.3.3.8 PASSIVE HORIZONTAL ABDUCTION PAINFUL.. (72)

8.3.3.9 ISOMETRICALLY RESISTED HORIZONTAL ABDUCTION PAINFUL. (73)

8.3.3.10 NO LIMITATION OF CLASSICAL ROM. (74)

8.3.3.11 OSTEOARTHROSIS WITH CALCIFICATION AND OSTEOPHYTES. (75)

8.3.3.11.1 MAY ALSO FORM WITH THE LIGAMENTS.

8.3.3.12 SUBLUXATION OF THE JOINT STRIPPING THE ATTACHMENT OF ANTERIOR DELTOID. (76)

8.3.3.13 SPONTANEOUS RECOVERY NORMALLY TAKES ONE OR TWO MONTHS. (77)

8.3.3.14 TPS IN SHOULDER GIRDLE MUSCLES. (A) (78)

8.3.3.15 ISOMETRICALLY RESISTED SUPRASPINATUS WEAK & PAINFUL. (A) (79)

8.3.3.16 ISOMETRICALLY RESISTED LATERAL ROTATION WEAK & PAINFUL.. (A) (80)

8.3.4 TREATMENT

8.3.4.1 IF AC JOINT SUBLUXED STRENGTHEN DELTOID MUSCLE. (81) (C)

8.3.4.1.1 AC SUBLUXATION OOF THE AC JOINT MAY RESULT IN STRIPPING OF THE ATTACHMENT OF SOME ANTERIOR FIBRES OF THE DELTOID MUSCLE.

8.3.4.1.2 IN DUE COURSE THE NEGHBOURING FIBRES MAY REQUIRE ATRENGTHENING IN ORDER TO ACHIEVE FULL FUNCTION.

8.3.4.2 INJECTION=STEROID SUSPENSION TO SUPERIOR AND INFERIOR LIGAMENTS OF AC JOINT. (82) (A)

8.3.4.2.1 1ML STEROIE SUSPENSION(INFERIOR LIGAMENT),

8.3.4.2.2 2ML STEROIE SUSPENSION (SUPERIOR LIGAMENT)

8.3.4.2.3 LOCATE JOINT LINE=PUT PATIENT’SG ARM IN FUL LATERAL ROTATION WITH HER ELBOW AT SIDE. FIND LATERAL EDGE OF ACROMION=JOINT LINE IS 2 CENTIMETERES MEDIAL TO THE LATERAL ACROMION.

8.3.4.2.4 PALPATE FOR TENDERNESS.

8.3.4.2.5 THE NEEDLE IS THRUST VERTICALLY DOWNWARDS. SHOULD BONE BE ENCOUNTERED AT A DEPTH OF LESS THAN 1 CM, THE TIP DOES NOT REST INTRA-ARTICULARLY AND IS ADJUSTED UNTIL IT SLIPS IN TO ABOUT 2CM.

8.3.4.2.6 THE DEEP LIGAMENT IS INFILTRATED BY 5 OR 10 DROPS DISTRIBUTED FANWISE AND THE SUPERIOR LIGAMENT IS SIMILARLY INJECTED ALONG EACH SIDE OF JOINT LINE.

8.3.4.2.7 PAIN MAY BE ELIMINATED IN 24 HRS BY AN INJECTION OF STREOID SUSPENSION.

8.3.4.3 TRANSVERSE FRICTION TO SUPERIOR LIGAMENT OF AC JOINT. (83)

8.3.4.3.1 MASSAGE ALLEVIATES THE DISCOMFORT IN A FEW WEEKS BUT THE TREATMENT IS ONLY SUCCESSFUL IF THE SUPERIOR LIGAMENT ALONE IS AFFECTED.

8.3.4.4 INJECTION OF STEROID AROUND THE SUPERIOR SURFACE OF THE CORACOID PROCESS. (84)

8.3.4.4.1 OCCASIONALLY THE TRAPEZOID AND CONOID LIGAMENTS MAY BE STRAINED. THESE RESPOND TO LOCAL INJECTION.

8.3.4.5 IDENTIFY FUNCTIONAL STRESSES; AVOID WEIGHT BEARING TO LIMB. (A&C) (85)

8.3.4.6 TP THERAPY FOR SYMPTOMATIC RELIEF. (49)

8.3.5 EXAMINATION

8.3.5.1 XRAY OF AC JOINT

8.3.5.2 PASSIVE MOVEMENTS

8.3.5.2.1 HORIZONTAL ADDUCTION; HORIZONTAL ABDUCTION.

8.3.5.3 ACTIVE RESISTED MOVEMENTS

8.3.5.3.1 HORIZONTAL ADDUCTION, HORIZONTAL ABDUCTION.

8.3.5.4 EXAMINE ACJOINT FOR SUBLUXATION.

8.3.5.5 MUSCLE TESTING.

8.3.5.5.1 DELTOID MUSCLE=ANTERIOR, MIDDLE, & POSTERIOR.

8.3.5.6 PALPATION.

8.3.5.6.1 PALPATE AC JOINT LINE FOR TENDERNESS.

8.3.5.6.2 C4 DERMATOME & SCLEROTOME.

8.3.6 PATIENTS ASSESSMENT FORM

8.3.6.1 trouble reaching for items on a high shelf. (17)

8.3.6.2 SHOULDER WAS IMPACTED IN AUTO ACCIDENT. (50)

8.3.6.3 DIAGNOSED WITH OSTEOARTHRITUS OF ACROMIOCLAVICULAR JOINT.

8.3.6.4 (51)

8.3.6.5 HAVE BROKEN OR DISLOCATED CLAVICLE.. (52)

8.3.6.6 PLAYED CONTACT SPORTS AND FELL ON SHOULDER. (53)

8.3.6.7 DX IMPINGEMENT SYNDROME. (54)

8.3.6.8 PLAY OR HAVE PLAYED FOOTBALL.. (55)

8.3.6.9 HAVE FALLEN ON SHOULDER IN OTHER ACTIVITIES. (56)

8.3.6.10 CAN POINT TO WHERE IT HURTS ON SHOULDER. (57)

8.3.6.11 NO PAIN DOWN UPPER OR LOWER ARM. (58)

8.3.6.12 NECK DOESN’T HURT. (59)

8.3.6.13 PAIN FELT IN ARM. (60)

8.3.6.14 LOWER PART OF NECK HURTS. (61)

8.3.6.15 TOP OF CHEST HURTS. (62)

8.3.6.16 OPENING HEAVY SLIDING GLASS DOORS OR WINDOWS IS PAINFUL.. (63)

8.3.6.17 CLOSING SLIDING GLASS DOORS IS PAINFUL. (64)

8.4 Acromioclavicular Joint Separation

8.4.1 Wheeless' Textbook of Orthopaedics

8.4.1.1 http://www.wheelessonline.com/orthoo/63.htm

8.5 Acromioclavicular (AC) and Sternoclavicular (SC) Joint Problems

8.6 Acute Joint Lesions

8.7 Acute Subdeltoid Bursitis

8.7.1 HISTORY

8.7.1.1 DIAGNOSED WITH CHRONIC TENDONISTIS OF ROTATOR CUFF.

8.7.1.2 GRADUAL BUILD UP OFACUTE PAIN OVER A PERIOD OF 12 TO 72 HOURS.

8.7.1.3 SIMILAR PAIN IN THE PAST (SUBJECTIVE 1-7)

8.7.1.4 DX WITH CALCIFIC TENDONITIS OF ROTATOR CUFF.

8.7.1.5 NO HX OF REPETITIVE REACHING ABOVE SHOULDER WITH ARM.

8.7.1.6 OCCUPATION DOESN’T INVOLVE REPETITIVE OVER-THE-SHOULDER ARM MOVEMENTS.

8.7.1.7 DONOT REGULARLY ENGAGE OR HAVE REGULARLY ENGAGED IN SPORTS ACTIVITY INVOLVING SWINGING OR THROWING.

8.7.1.8 HAVE NEVER BEEN DIAGNOSED WITH IMPINGMENT SYNDROME.

8.7.1.9

8.7.2 SUBJECTIVE

8.7.2.1 ALL ARM POSITIONS ARE PAINFUL. (A)

8.7.2.2 INTENSE CONSTANT PAIN. (A)

8.7.2.3 CONSTANT DULL ACHE PAIN. (21) (A)

8.7.2.4 INTERMITTENT THROBBING PAIN. (A)

8.7.2.5 PAIN IS LOCALIZED TO THE LATERAL BRACHIAL REGION. (22) (C)

8.7.2.6 VERY LITTLE RELIEF FOUND IN ANY POSITION. (A)

8.7.2.7 INTENSE PAIN DOESN’T LAST FOR MORE THAN TWO WEEKS (A)

8.7.2.8 ABSENCE OF PAIN AT REST.[1] (C)

8.7.2.9 OCCCASSIONAL DULL ACHE WITH CERTAIN ARM POSITIONS. (25) (C)

8.7.2.10 WRIST HURTS (A)

8.7.2.11 FOREARM HURTS (A)

8.7.3 OBJECTIVE

8.7.3.1 PRESENTS WITH ARM IN A SLING, OR SUPPORTING THE ARM AT THE ELBOW WITH THE UNINVOLVED HAND. (A)

8.7.3.2 HISTORY SUGGESTIVE OF CHRONIC TENDONITIS.

8.7.3.3 PASSIVE & ACTIVE MOVEMENTS SHOW MARKED RESTRICTION (NONCAPSULAR PATTERN) DUE TO PAIN.

8.7.3.4 END OF RANGE PASSIVE MOVEMENT WITH EMPTY END FEEL. (A)

8.7.3.4.1 NO RESISTANCE IS FELT TO MOVEMENT BUT PATIENT INSISTS THAT MOVEMENT STOP DUE TO PAIN.

8.7.3.5 PASSIVE ROTATION (LATERAL & MEDIAL) WITH ARM AT SIDE IS FREE.

8.7.3.6 SEVERE PAIN PROMPTS PATIENT TO STOP PASSIVE ABDUCTION >60, FLEXION >90, (A)

8.7.3.7 SOME PAIN UPON RESISTED ABDUCTION. (A)

8.7.3.7.1 DUE TO THE PINCHING OF BURSAE.

8.7.3.7.2 CAREFUL TESTING WILL REVEAL MOST CONTRAC5TIONS ARE STRONG AND PAINLESS.

8.7.3.8 POST BURSITIS RESISTED CONTRACTIONS SHOULD BE STRONG & PAINLESS.

8.7.3.9 WARMTH OVER SUBDELTOID BURSA.

8.7.3.10 SWELLING OVER SUBDELTOID BURSA.

8.7.3.11 TENDERNESS OVER SUBDELTOID BURSA.[2]

8.7.3.12 REMAINS ACUTE FOR NO MORE THAN TWO WEEKS.

8.7.3.13 ACTIVELY ELEVATE ARM TO AT LEAST 90 FLEXION OR ABDUCTION (C)

8.7.3.14 MUSCLE TEST ABDUCTORS AND FLEXORS TO MEASURE POSSSIBLE TENDONITIS.(C)

8.7.3.14.1 AFTER ACUTE BURSITIS RESOLVES.

8.7.3.14.2 CALCIFIC ROTATORY CUFF TENDINITIS IS OFTEN A PREEXISTING CONDITION

8.7.3.14.3 CLINICAL SIGNS OF TENDONITIS MAY BE OBSCURED BY THE ACUTE PHASE OF THE BURSITIS.

8.7.3.15 uncommon condition[3]

8.7.3.16 no history of injury to bursa.

8.7.3.17 WHOLE BURSA BECOMES ACUTELY INFLAMED AND IN THE COURSE OF 2 OR 3 DAYS THE PATIENT LOSES ALMOST ALL CAPACITY TO ABDUCT THE ARM.

8.7.3.18 PAIN MAY RADIATE AS FAR AS THE WRIST.

8.7.3.19 OTHER PASSIVE MOVEMENTS RETAIN VERY NEARLY FULL RANGE.

8.7.3.20 RESISTED MOVEMENTS ARE PAINLESS EXCEPT IN THE HYPERACUTE STAGE WHEN EVERYTHING HURTS.

8.7.3.21 PAINFUL ARC APPEARS ONLY AS THE CONDITION ABATES BECAUSE INITIALLY ARM ELEVATION IS IMPOSSIBLE.

8.7.3.22 PATIENT RECOVERS SPONTANEOUSLY WITHIN 4-6 WEEKS

8.7.3.23 OFTEN A HISTORY OF PREVIOUS ATTACKS

8.7.3.23.1 PARTICULARYLY IN CASES WITH SMALL AREAS OF CALCIFICATION(VISIBLE ON THE X-RAY

8.7.3.23.2 CALCIFICATION CAN BE DISSOLVED BY LOCAL ANAESTHETIC.[4]

8.7.3.24 ACUTE PAIN LASTS 7-10 DAYS AND PALPATION OUTLINES THE EXTENT OF THE TENDER AREA. PART OF THE BURSA IS SHIELDED BY THE ACROMION.

8.7.3.25

8.7.4 TREATMENT

8.7.4.1 CAUSE

8.7.4.1.1 CALCIFIC ROTATORY CUFF TENDINITIS IS OFTEN A PREEXISTING CONDITION

8.7.4.1.1.1 DEPOSIT MIGRATES SUPERFICIALLY INTO THE FLOOR OF THE SUBDELTOID BURSA[5]

8.7.4.2 GOALS

8.7.4.2.1 RESOLUTION OF THE ACUTE INFLAMMATORY PROCESS (A) (1)

8.7.4.2.1.1 TO CONTROL PAIN, EDEMA, AND MUSCLE GAURDING..

8.7.4.2.2 MAINTAINING RANGE OF MOTION (A) (2)

8.7.4.2.2.1 TO MAINTAIN SOFT TISSUE AND JOINT INTEGRITY AND MOBILITY.

8.7.4.2.2.2 to maintain integrity & fu8nction of associated areas.

8.7.4.2.3 RESOLUTION OF CHRONIC INFLAMMATORY PROCESS (C)(3)

8.7.4.2.4 RESTORATION OF FULL RANGE OF MOTION, JOINT PLAY, AND MJSCLE STRENGTH. (C)(4)

8.7.4.2.5 PREVENTING EXCESSIVE KYPHOSIS & SHOULDER-GIRDLE PROTRACTION. (A) (C)(5)

8.7.4.3 ICE/SUPERFICIAL HEAT. (38) (A) (1)

8.7.4.4 SUPPORT ARM WITH A SLING. (A) (1)

8.7.4.4.1 TO REDUCE POSTUREAL TONE IN THE MUSCLES ADJACENT TO THE BURSA THEREBY RELIEVING PRESSURE TO THE INFLAMED AREA.

8.7.4.5 GRADE 1 JOINT-PLAY OSCILLATIONS. (39) (A) (1)

8.7.4.5.1 USED WIUTH JOINT IN A PAIN FREE POSITION

8.7.4.5.2 DURNING THE FIRST 2 DAYS FOLLOWING TRAUMA, THIS TECHNIQUE MAY NOT BE TOLEER4ATED BY SOME PEOPLE. USE WITH EXTREME CARE AND ONLY IF IT HELPS RELEIVES PAIN SYMPTOMS.

8.7.4.6 SUSTAINED GRADE 1 OR 2 JOINT-PLAY TRACTION=ESPECIALLY INFERIOR GLIDE BECAUSE MUSCLE SPASM HIKES UP HUMEROUS AND INTERFERES WITH JOINT MICHANICS. (40) (A) (2)

8.7.4.6.1 MAY INCLUDE LATERAL DISTRACTION, ANTERIOR & POSTERIOR GLIDES.

8.7.4.6.2 WITH JOINT PLACED IN PAIN FREE POSITION.

8.7.4.6.3 PRECAUTION: IF THERE IS INCREASED PAIN OR IRRITABILITY IN THE JOINT FOLLOWING USE OF THESE TECHNIQUES, EITHER THE DOSAGE WAS TOO STRIONG, OR THE TECHNIQUES SHOULD NOT BE JSED AT THIS TIME.

8.7.4.6.4 CONTRAINDICATION: STRETCHING (GRADE III) TECHNIQUES. IF THERE ARE MECHANICAL RESTRICTIONS CAUSING LIMITED MOTION. APPROPRAIATE STRETCHING CAN BE INITIATED AFTER THE INFLAMMATION SUBSIDES.

8.7.4.6.5 SEE PASSIVE JOINT MOBILIZATION FOR TECHNIQUES.

8.7.4.7 passive & active RANGE OF MOTION EXERCISES (41) (A&C) (2)

8.7.4.7.1 active rom=WAND & PENDULUM) & automobillization.

8.7.4.7.2 passive= TO ALL RANGES OF PAIN-FREE MOTION. AS PAIN DECREASES, THE PATIENT SHOULD BE ABLE T0O PROGRESS TO ACTIVE ROM WITH OR WITHOUT ASSISTANCE, DEPENDING ON SEVERITY OF THE INJURY.

8.7.4.7.3 associated areas= ELBOW WRIST & FINGERS=either the theerapist or patient should perform rom to the elbow, forearm, wrist, and fingers several times each day while the shoulder is immobilized. IF TOLERATED, ACTIVE OR GENTLE RESISTIVE ROM IS PREFERRED TO PASSIVE FOR A GREATER EFFECT ON CIRCULATION AND MUSCLE INTEGRITY. HAND= SHOULDER-HAND SYNDROME(REFLEX SYMPATHETIC DYSTROPHY?)=COMPLICATION FOLLOWING SHOULDER INJURY OR IMMOBILITY-REPETITIVELY SQUEEZING A BALL OR OTHER SOFT OBJECT. EDEMA= HAND SHOULD BE ELEVATED, ABOVE THE LEVEL OF THE HEART. KEEP THE JOINTS DISTAL TO THE INJURED SITE AS AVTIVE AND MOBILE AS POSSIBLE.

8.7.4.8 ULTRASOUND (38) (C) (3)

8.7.4.8.1 THE INCREASED BLOOD FLOW INDUCED BY THE LOCAL HEAT APPARENTLY AIDS IN A MORE RAPID RESOLUTION OF INFLAMMATORY IRRITANTS AND DEBRIS.

8.7.4.9 INSTRUCTION IN ISOMETRIC STRENGTHENING EXCERCISES. (42) (C) (4)

8.7.4.9.1 TO ALL MUSCLE GROUPS OF SHOULDER. INCLUDE SCAPULAR AND ELBOW MUSCLES BECAUSE OF THEIR CLOSEASSOCIATION IWTH THE SHOULDER. INSTRUCT THE PATIENT TO GENTLY CONTRACT A GROOUP OF MUSCLES WHILE YOU APPLY SLIGHT RESISTANCE-JUST ENOUGH TO STIMULATE A MUSCLE =CONTRACTION. IT SHOULD NOT PROVLKE PAIN.TH EMPHASIS IS ON RHYTHMIC CONTRACTING AND RELAXING OF THE MUSCLES TO HELP STIMULATE BLOOD FLOW AND PREVENT CIRCULATORY STASIS.

8.7.4.10 INSTRUCTION IN POSTURAL AWARENESS. (44) (A) (5)

8.7.4.10.1 UPPER TRUNK & SHOULDER GIRDLES.=PATIENT LEARNS TO DIFFERENTIATE PROPRIOCEPTIVELY BETWEEN A KYPHOTIC, PROTRACTED POSTURE AND A RELATIVELY UPRIGHT, RETRACTED POSITION.

8.7.4.10.2 TEACH PATIENT TO DO REGULAR DAILY POSTUREAL CHECKS.

8.7.4.11 STRONG ANALGESIC INJECTED PRIOR TO STERIOD INJECTIONS.

8.7.4.12 CLUSTER OF LITTLE INFILTRATIONS OF STEROID SUSPENSION 5ML(5CM NEEDLE) TO THE ACCESSIBLE EXTENT OF THE BURSA .

8.7.4.12.1 INJECTION IS ONLY WORTH WHILE DURNING THE INITIAL 7-10 DAY PERIOD OF HYPERACUTITY.

8.7.4.13 INJECTION OF STEROID SUSPENSION 5ML TO SUBACROMIAL EXTENT OF THE BURSA WITH MULTIPLE INSERTIONS.

8.7.4.13.1 THE POINT OF THE ACROMION IS LOCATED BY THE THUMB, AND THE NEEDLE SLIDES UNDER IT SO THE APPROACH IS HORIZONTAL.

8.7.4.13.2 BY THE NEXT DAY THE PATIENT IS SORE BUT MOBLE.

8.7.4.13.3 A 2ND INJECTION MAY BE REQUIRED A FEW DAYS LATER.

8.7.5 EXAMINATION

8.7.5.1 XRAY OF GLENOHUMERAL JOINT

8.7.5.2 PASSIVE MOVEMENTS

8.7.5.2.1 M&L ROTATION,ABDUCTION.

8.7.5.2.2 DETERMINE IF NONCAPSULAR

8.7.5.3 ACTIVE RESISTED MOVEMENTS

8.7.5.3.1 ABDUCTION.

8.7.5.3.2 DETERMINE IF NONCAPSULAR

8.7.5.4 INSPECT LATERAL BRACHIAL REGION.

8.7.5.5 PALPATION.

8.7.5.5.1 PALPATE LATERAL BRACHIAL REGION FOR TENDERNESS, SWELLING, AND WARMTH.

8.7.5.5.2 C5 DERMATOME & SCLEROTOME.

8.7.6 PATIENTS ASSESSMENT FORM

8.8 Adhesions

8.8.1 HISTORY

8.8.2 SUBJECTIVE

8.8.3 OBJECTIVE

8.8.4 TREATMENT

8.8.5 EXAMINATION

8.8.6 PATIENTS ASSESSMENT FORM

8.9 Algodystrophic Arthritis

8.9.1 HISTORY

8.9.2 SUBJECTIVE

8.9.3 OBJECTIVE

8.9.4 TREATMENT

8.9.5 EXAMINATION

8.9.6 PATIENTS ASSESSMENT FORM

8.10 Anterior Instability of the Shoulder

8.10.1 Wheeless' Textbook of Orthopaedics

8.10.1.1 http://www.wheelessonline.com/o6/66.htm

8.11 Anterior Shoulder Dislocation

8.12 Bankart Lesion

8.12.1 Wheeless' Textbook of Orthopaedics

8.12.1.1 http://www.wheelessonline.com/o6/38.htm

8.13 Biceps Tendonitis[6] (Proximal)

Back Table of Contents References

8.13.1 HISTORY

8.13.2 SUBJECTIVE

8.13.3 OBJECTIVE

8.13.4 TREATMENT

8.13.5 EXAMINATION

8.13.6 PATIENTS ASSESSMENT FORM

8.13.7 Illustration

8.13.7.1 Biceps Tendonitis (Proximal)

8.14 Bursitis

8.15 Calcific Tendinitis of Shoulder

8.15.1 Wheeless' Textbook of Orthopaedics

8.15.1.1 http://www.wheelessonline.com/orthoo/6501.htm

8.16 Capsule Tightness

8.17 Capsular Adhesion

8.17.1 HISTORY

8.17.2 SUBJECTIVE

8.17.3 OBJECTIVE

8.17.4 TREATMENT

8.17.5 EXAMINATION

8.17.6 PATIENTS ASSESSMENT FORM

8.18 Capsule Instability

8.18.1 HISTORY

8.18.2 SUBJECTIVE

8.18.3 OBJECTIVE

8.18.4 TREATMENT

8.18.5 EXAMINATION

8.18.6 PATIENTS ASSESSMENT FORM

8.19 Cervical Root Palsy

8.19.1 HISTORY

8.19.2 SUBJECTIVE

8.19.3 OBJECTIVE

8.19.4 TREATMENT

8.19.5 EXAMINATION

8.19.6 PATIENTS ASSESSMENT FORM

8.20 Chronic Subdeltoid Bursitis

8.20.1 HISTORY

8.20.2 SUBJECTIVE

8.20.3 OBJECTIVE

8.20.4 TREATMENT

8.20.5 EXAMINATION

8.20.6 PATIENTS ASSESSMENT FORM

8.21 Chronic Subdeltoid Bursitis (Subdeltoid/Subscapular)

8.21.1 HISTORY

8.21.1.1 HX OF REPETITIVE REACHING ABOVE SHOULDER WITH ARM.

8.21.1.2 OCCUPATION INVOLVES REPETITIVE OVER-THE-SHOULDER ARM MOVEMENTS.

8.21.1.3 REGULARLY ENGAGE OR HAVE REGULARLY ENGAGED IN SPORTS ACTIVITY INVOLVING SWINGING OR THROWING.

8.21.1.4 HAVE BEEN DIAGNOSED WITH IMPINGMENT SYNDROME.

8.21.1.5 DX CALCIFIC ROTATOR CUFF TENDONITIS. (SEE ACUTE BURSITIS)

8.21.2 SUBJECTIVE

8.21.2.1 CONSTANT DULL ACHE PAIN. (21) (A)

8.21.2.2 OCCCASSIONAL DULL ACHE WITH CERTAIN ARM POSITIONS. (25) (C)

8.21.2.3 ABSENCE OF PAIN AT REST (ACUTE SUBD BURSITIS). (C)

8.21.2.4 CAN THROW A BALL OVERHEAD.

8.21.2.5 IT HURTS TO THROW A BALL SIDE ARM.

8.21.2.6 PAIN IS LOCALIZED IN LATERAL BRACHIAL REGION (22) (C)

8.21.2.7 PAIN VARIES FROM DAY TO DAY. [7]

8.21.2.8 AWAKENED BY PAIN AT NIGHT WHEN ROLLING ON PAINFUL SIDE. (20) (A)

8.21.2.9 NOT AWAKENED BY PAIN AT NIGHT. (24) (C)

8.21.2.10 DISCOMFORT WHEN REACHING INTO HIP POCKET. (14)

8.21.2.11 DIFFICULTY PUTTING ON OR REMOVING SHIRT OR JACKET (15)

8.21.2.12 CAN’T DO JUMPING JACKS WITHOUT PAIN AT SHOULDER LEVEL.

8.21.2.13 CAN’T SWEAR AN OATH WITHOUT DISCOMFORT IN SHOULDER.

8.21.2.14

8.21.3 OBJECTIVE

8.21.3.1 THORACIC KYPHOSIS.

8.21.3.2 LAB TESTS REVEAL IMPINGEMENT SYNDROME.

8.21.3.3 LAB TESTS REVEAL CALCIFIC TENDONITIS.

8.21.3.4 SITTING AND OR STANDING POSTURE REVEALS SUBJECT PRESENTS WITH FORWARD SHOULDERS. (SCAPULA ABDUCTED).

8.21.3.5 PECTORALIS MINOR IS SHORTENED.

8.21.3.6 CERVICAL LORDOSIS IS PRESENT.

8.21.3.7 MUSCLE TESTING REVEALS STRENGTH OR ENDUREANCE WEAKNESS IN ROTATOR CUFF MUSCLES.

8.21.3.8 PALPATION REVEALS SHOULDER MUSCLE TIGHTNESS.

8.21.3.9 JOINT PLAY MOVEMENTS ARE LIMITED.

8.21.3.10 SUBDELTOID BURSITIS: ACTIVE ARM ELEVATION IS PAINFUL OR LIMITED IN FUNCTION. [8]

8.21.3.11 SUBSCAPULARIS BURSITIS: ACTIVE HORIZONTAL ADDUCTION IS PAINFU OR LIMNITEWD IN FUNCTION.[9]

8.21.3.12 SUBSCAPULARIS BURSITIS: arm elevation, internal rotation, and external rotation painful or limited.

8.21.3.13 lying on the side of the dysfunction may be uncomfortable.[10]

8.21.3.14 SUBDELTOID BURSITIS: PATTERN #1: FULL ACTIVE ARM ELEVATION WITH OCCASIONAL DISCOMFORT AT MIDRANGE; NO DEFINITE PAINFUL ARC EXISTS; RESISTED MOVEMENTS DO NOT HURT.

8.21.3.15 SUBDELTOID BURSITIS: PATTERN #2: FULL ACTIVE ARM ELEVATION WITH DISCOMFORT AT MIDRANGE; DEFINITE PAINFUL ARC EXISTS; RESISTED CORONAL ABDUCTION REPRODUCES DISCOMFORT.

8.21.3.16 SUBDELTOID BURSITIS: PATTERN #3: LIMITED AND PAINFUL ACTIVE ELEVATION; PAINFUL ARC EXEISTS; CHANGING PATTERN OF PAIN ON RESISTED CORONAL ABDUCTION.

8.21.3.17 SUBDELTOID BURSITIS: PATTERN #4: GROSS LIMITED AND PAINFUL ACTIVE ELEVATION; TOO PAINFUL TO INTERPRET A PAINFUL ARC; RESISTED CORONAL ABDUCTION DOES NOT GIVE A CONSISTENT INTERPRETATION, THAT IS, PAIN SOMETIMES OCCURS ON RESISTANCE TESTING WHILE OTHER TIMES NO PAIN OCCURS ON RESISTANCE TESTING; SOME LIMITATION OF PASSIVE ABDUCTION.

8.21.3.18 DEEP PALPATION FOR PROVOCATION AT THE ANATOMICAL AREA OF THE BURSA REPRODUCES PAIN AND IS THE BEST DIFERENTIAL TEST.

8.21.3.19 CHRONIC SUBACROMIAL/SUBDELTOID BURSITIS IS NOT A LATER PAHSE OF THE ACUTE FORM, BUT A COMPLETELY SEPARATE CLINICAL ENTITY WHICH MAY CONTINUE INDEFINITELY.

8.21.3.19.1 ONLY A LIMITED PART OF THE BURSA IS AFFECTED AND, CALCIUM DEPOSITS MAY LEAD TO RECURRENCE.

8.21.3.20 HARD TO DISTINGUISH FROM MINOR TENDINITIS

8.21.3.21 MAY GIVE RISE TO PAINFUL ARC.

8.21.3.22 MAY GIVE PAIN ON SEVERAL RESISTED MOVEMENTS OR PAIN(OR EVEN SLIGHT LIMITATION ) ON SOME PASSIVE MOVEMENTS

8.21.3.23 FINDINGS MAY VARY FROM DAY TO DAY.

8.21.3.24 INTERNALY ROTATIN THE ARM MAY REPRODUCE THE PAIN BUIT OFTEN ONYL A PAINFUL ARC IS THE ONLY SYMPTOM.

8.21.3.25 CAN THROW OVERARM OR BOWL BUT NOT THROW SIDE-ARM.

8.21.3.26 .

8.21.4 TREATMENT

8.21.4.1 CAUSE

8.21.4.1.1 OCCUPATIONAL, FUNCTIONAL, OR SPORT OVER-STRESS TO BURSA THAT, IF NOT A DIRECT TRAUMA, MAY BE BROUGHT ON BY EITHER STRENGTH OR ENDURANCE WEAKNESS IN MUSCLES, TIGHT MUSCLES, TIGHT CAPSULE, OR BONY IMPINGGEMENT

8.21.4.1.2 POOR POSTURE

8.21.4.1.3 POOR BODY MECHANICS

8.21.4.2 GOALS

8.21.4.2.1 DECREASE INFLAMMATION. (1)

8.21.4.2.2 MAINTAINING RANGE OF MOTION (A) (2)

8.21.4.2.3 RESOLUTION OF CHRONIC INFLAMMATORY PROCESS (3)

8.21.4.2.4 RESTORATION OF FULL RANGE OF MOTION, JOINT PLAY, AND MJSCLE STRENGTH. (4)

8.21.4.2.5 PREVENTING EXCESSIVE KYPHOSIS & SHOULDER-GIRDLE PROTRACTION. (A) (5)

8.21.4.3 ULTRA SOUND, INTERFERENTIAL, IONTOPHORESIS, OR PHONOPHORESIS. (38) (1)

8.21.4.3.1 PHYSIOLOGICALLY AND SCIENTIFICALLY THE USE OF MODALITIES HAS NOT SHOWN UNEQUIVOCAL SUCCESS IN DIMINISHING OR ELIMINQATION “CALCIUM DEPOSITS”. CLINICAL SUCCESS HAS OFTEN BEEN REPORTED.

8.21.4.3.2 THE INCREASED BLOOD FLOW INDUCED BY THE LOCAL HEAT APPARENTLY AIDS IN A MORE RAPID RESOLUTION OF INFLAMMATORY IRRITANTS AND DEBRIS. qqqq

8.21.4.4 MANUAL OR HOME STRETCHING. (43) (C) (4)

8.21.4.4.1 MAY USE ULTRASOUND PRECEDING OR ACCOMPANYING STRECHING PROCEDURES.

8.21.4.4.2 ALSO MAY USE DIATHERMY

8.21.4.4.3 MOIST HEAT MAY BE USED ONLY IF THE CAPSULE IS MINIMALLY COVERED BY DENSE CONNECTIVE TISSUE.

8.21.4.5 INSTRUCTION IN SELF ASSISTED RANGE OF MOTION EXERCISES, (WAND AND PENDULUM EXERCISES) & AUTOMOBILIZATION. (41) (A) (4)

8.21.4.6 INSTRUCTION IN ISOMETRIC AND OR ISOTONIC STRENGTHENING EXCERCISES. (42) (C) (4)

8.21.4.6.1 ISOMETRIC AND OR ISOTONIC EXERCISES FOR ROTATOR CUFF AND SURROUNDING SHOULDER GIRDLE MUSCLES.

8.21.4.7 INSTRUCTION IN POSTURAL AWARENESS. (44) (A) (5)

8.21.4.7.1 UPPER TRUNK & SHOULDER GIRDLES.=PATIENT LEARNS TO DIFFERENTIATE PROPRIOCEPTIVELY BETWEEN A KYPHOTIC, PROTRACTED POSTURE AND A RELATIVELY UPRIGHT, RETRACTED POSITION.

8.21.4.7.2 TEACH PATIENT TO DO REGULAR DAILY POSTUREAL CHECKS.

8.21.4.8 SUSTAINED GRADE 1 OR 2 JOINT-PLAY TRACTION, ESPECIALLY INFERIORR CAPSULR STRETCH. (40) (C) (4)

8.21.4.9 AUTO MOBILIZATION ESPECIALLY INFERIOR GLIDE. (41) (C) (4)

8.21.4.10 EVALUATE PROGRESS AFTER 4 SESSIONS.

8.21.4.10.1 SYMPTOMS SHOULD BE DECREASING AND FUCTIONAL GAINS DEVELOPING WITHIN 4 SESSIONS.

8.21.4.11 PROGNOSIS IS EXCELLENT.

8.21.4.12 FIND TENDER EXTENT AND INJECT WITH A SOLUTION OF .5 PERCENT PROCAINE 5-10 ML IS INJECTED IN DROPLETS ALL OVER THE INFLAMED AREA. A COULPLE OF INFILTRATIONS INTO THE CORRECT SPOT ARE USUALY CURATIVE. IF NOT STREROID SUSPENSION IS ADDED.

8.21.4.13 PERSISTENT RECURRENT IMPINGEMENT MAY REQUIRE SURGERY TO THE CORACO-ACROMIAL LIGBAMENT.

8.21.5 EXAMINATION

8.21.6 PATIENTS ASSESSMENT FORM

8.22 Clavicle Fractures

8.22.1 Wheeless' Textbook of Orthopaedics

8.22.1.1 http://www.wheelessonline.com/orthoo/51.htm

8.23 Contracture Of Costocoracoid Fasica

8.23.1 HISTORY

8.23.2 SUBJECTIVE

8.23.3 OBJECTIVE

8.23.4 TREATMENT

8.23.5 EXAMINATION

8.23.6 PATIENTS ASSESSMENT FORM

8.24 Capsular Lesions

8.25 Dorsal Scapular Nerve

8.25.1 HISTORY

8.25.2 SUBJECTIVE

8.25.3 OBJECTIVE

8.25.4 TREATMENT

8.25.5 EXAMINATION

8.25.6 PATIENTS ASSESSMENT FORM

8.26 Floating Shoulder Injuries

8.26.1 Wheeless' Textbook of Orthopaedics

8.26.1.1 http://www.wheelessonline.com/orthoo/5109.htm

8.27 Fracture Of 1st Rib

8.27.1 HISTORY

8.27.2 SUBJECTIVE

8.27.3 OBJECTIVE

8.27.4 TREATMENT

8.27.5 EXAMINATION

8.27.6 PATIENTS ASSESSMENT FORM

8.28 Hill Sachs Lesion

8.28.1 Wheeless' Textbook of Orthopaedics

8.28.1.1 http://www.wheelessonline.com/o6/76.htm

8.29 Humeral Shaft Fracture

8.29.1 Wheeless' Textbook of Orthopaedics

8.29.1.1 http://www.wheelessonline.com/o6/18.htm

8.30 Impingement Syndrome

8.30.1 HISTORY

8.30.2 SUBJECTIVE

8.30.3 OBJECTIVE

8.30.4 TREATMENT

8.30.5 EXAMINATION

8.30.6 PATIENTS ASSESSMENT FORM

8.30.7 The Merck Manual of Diagnosis and Therapy

8.30.7.1 http://www.merck.com/pubs/mmanual/section5/chapter62/62l.htm

8.30.8 Wheeless' Textbook of Orthopaedics

8.30.8.1 http://www.wheelessonline.com/oa3/107.htm

8.31 Infraspinatus Tendonitis

8.31.1 HISTORY

8.31.2 SUBJECTIVE

8.31.3 OBJECTIVE

8.31.4 TREATMENT

8.31.5 EXAMINATION

8.31.6 PATIENTS ASSESSMENT FORM

8.32 Malingnant Deposits

8.32.1 HISTORY

8.32.2 SUBJECTIVE

8.32.3 OBJECTIVE

8.32.4 TREATMENT

8.32.5 EXAMINATION

8.32.6 PATIENTS ASSESSMENT FORM

8.33 Monoarthritis

8.33.1 HISTORY

8.33.2 SUBJECTIVE

8.33.3 OBJECTIVE

8.33.4 TREATMENT

8.33.5 EXAMINATION

8.33.6 PATIENTS ASSESSMENT FORM

8.34 Multidirectional Instability

8.34.1 Wheeless' Textbook of Orthopaedics

8.34.1.1 http://www.wheelessonline.com/o6/73.htm

8.35 Muscle Strength and Flexibility Imbalances

8.36 Myofascitis-Infraspinatus[11]

8.36.1 HISTORY

8.36.2 SUBJECTIVE

8.36.2.1 INTENSE DEEP PAIN IN FRONT OF SHOULDER.

8.36.2.1.1 IN 193 CASES OF INFRASPINATUS REFERRED PAIN, ALL PATIENTS IDENTIFIED THE FRONT OF THE SHOULDER AS PAINFUL.

8.36.2.2 DICOMFORT WHEN REACHING INTO HIP POCKET. (14)

8.36.2.3 DISCONFORT WHEN REACHING ABOVE SHOULDER TO FASTEN A BRA ON BACK. (13)

8.36.2.4 CAN’T ZIP UP THE BACK OF MY DRESS.

8.36.2.5 DIFFICULTY PUTTING ON OR REMOVING SHIRT OR JACKET. (15)

8.36.2.6 CAN’T REACH BACK TO THE NIGHT STAND BESIDE MY BED

8.36.2.7 LIMITS THE VIGOR OF TENNIS STROKE.

8.36.2.8 TROUBLE USEING ARM TO COMB HAIR. (12)

8.36.2.9 CAN’T LIE ON EITHER SIDE

8.36.2.9.1 ON THE SAME SIDE THE WEIGHT OF THE THORAX COMPRESSES AND STIMULATES THE INFRASPINATUS TPS.

8.36.2.9.2 ON THE OTHER SIDE , TH TOP SIDE ARM IS LIKELY TO FALL FORWARD AND PAINFULLY STRETCH THE AFFECTED INFRASPINATUS.

8.36.2.10 SLEEPING ON ARM ABOVE HEAD HURTS IN FRONT OF SHOULDER THE NEXT DAY.

8.36.3 OBJECTIVE

8.36.3.1 INABILITY TO INTERNALLY ROTATE AND TO ADDUCT THE ARM AT THE SHOULDER SIMULTANEOUSLY.

8.36.3.2 SHOULDER-GIRDLE FATIGUE.

8.36.3.3 WEAKNESS FO GRIP.

8.36.3.4 LOSS OF MOBILITY OF SHOULDER.

8.36.3.5 HYPER;HydROSIS IN THE REFERRED PAIN AREA.

8.36.3.6 SLEEPING ON ARM IN LATERAL ROTATION ABOVE HEAD HURTS IN FRONT OF SHOULDER THE NEXT DAY.

8.36.4 TREATMENT

8.36.4.1 INTERMITTENT COLD

8.36.4.2 STRETCHING & DISTRACTION

8.36.4.3 ISCHEMIC COMPRESION

8.36.4.4 DEEP STROKING MASSAGE

8.36.4.5 CONTRACT RELAX

8.36.4.6 RECIPROCAL INHIBITION

8.36.4.7 RELAXATION DURING EXHALATION

8.36.4.8 PERCUSSION & STRETCH

8.36.4.9 MUSCLE ENERGY TECHNIQUE

8.36.4.10 MYOFASCIAL RELEASE

8.36.4.11 LEWIT TECHNIQUE

8.36.4.12 ACCUPUCTURE/ACCUPRESSURE therapy

8.36.4.13 EAR POINTS

8.36.4.14 FOOT POINTS

8.36.4.15 HAND POINTS

8.36.4.16 MOTOR POINTS

8.36.4.17 RIDDLER POINTS

8.36.4.18 PATIENT SELF CORRECTION

8.36.5 EXAMINATION

8.36.5.1 REFERED PAIN AREAS & FREQUENCY -DRAW PATIENTS PAIN PATERN & DETERMINE IF IT MEETS PAIN PATTERN CRITERION FOR THIS MUSCLE. (FIG 22.1) n=193

8.36.5.1.1 MINIMUM DETERMINATES

8.36.5.1.1.1 PATIENT MUST AT LEAST HAVE B (DEEP ANTERIOR SHOULDER PAIN)

8.36.5.1.1.2 TRAVEL=REF28 N=193)

8.36.5.1.2 DEEP ANTERIOR SH0ULDER 100%

8.36.5.1.2.1 COVERING ANTERIOR DELTOID

8.36.5.1.3 ANTEROLATERAL UPPER ARM-MEDIAL & POSTERIOR DELT, BICEPS-40%

8.36.5.1.3.1 BICEPS-MEDIAL LATERAL AND ANTERIOR SURFACES

8.36.5.1.3.2 MEDIAL DELTS, QUARTER OF POSTERIOR DELTS

8.36.5.1.3.3 LATERAL UPPER ARM BELOW DELTS

8.36.5.1.4 LATERAL & MEDIAL FOREARM-21%

8.36.5.1.4.1 LATERAL- OVER BRACHIORADIALIUS FOLLOWING CONTOUR OF MUSCLE TAPPERING DISTAL TO SMALL STRIP WHICH ENDS AT BASE OF THUMB

8.36.5.1.4.2 OVER MEDIAL BRACHIORADIALIS TO ABOUT MID FOREARM TO BASE OF THUMB AT WRIST. DRAW A LINE FROM PROXIMAL MID ELBOW CREASE TO WHERE MEAT OF THUMB MAKE VERTICLE CREASE AT MID WRIST

8.36.5.1.5 SUBOCCIPITAL POSTERIOR CERVICAL-14%

8.36.5.1.5.1 ON POSTERIOR UPPER TRAP FROM ATLAS TO C-3

8.36.5.1.6 RADIAL HAND DORSAL & ANTERIOR13%

8.36.5.1.6.1 DORSAL RADIAL HAND- ON A DIAGNAL LINE FROM BASE OF THUMB TO BASE OF 5TH FINGER

8.36.5.1.6.2 ANTERIOR- FLESHY PART OF THUMB DEPRESSION IN PALM & BASE OF FIRST 2 FINGERS

8.36.5.1.7 FINGERS

8.36.5.1.7.1 DORSAL- 1ST PHALANGIAL JOINT OF THUMB AND 4 FINGERS

8.36.5.1.7.2 ANTERIOR- 1ST PHALAGIAL FROM INDEX TO 2ND FINGER

8.36.5.1.8 MEDIAL EDGE OF SCAPULA (INFREQUENT)

8.36.5.1.8.1 ON RHOMBAIDS AT EDGE OF SCAPULA ENTIRE LENGTH EXCEPT SUPERIOR ANGLE ABOVE SCPULAR SPINE

8.36.5.1.9 MARK PATIENTS PAIN PATTERN ON BODY CHART

8.36.5.2 PAINFUL MOVEMENTS -IDENTIFY PATIENTS PAINFUL/RESTRICTED MOVEMENTS/OTHER SYMPTOMS

8.36.5.3 NOTE: % FUNCTIONAL IMPAIRMENT= # OF ACTIVITIES NOT COMPLETED/ # OF ACTIVITIES COMPLETED

8.36.5.3.1 FUNCTIONAL ROM ACIVITIES OF DAILY LIVING (ADL) (INDICATE % IMPAIRMENT)

8.36.5.3.1.1 REACHING FOR BACK POCKET

8.36.5.3.1.2 FASTEN BRA/REACHING BETWEEN TIPS OF SCAPULA

8.36.5.3.1.3 ROLLING CURLERS/BRUSHING-SHAMPOOING HAIR

8.36.5.3.1.4 GETTING SORE ARM IN JACKET FIRST

8.36.5.3.1.5 REACHING BACK WITH ARM TO GET SOMETHING ON NIGHT STAND

8.36.5.3.1.6 SIDE LYING SLEEP POSTURES ARE PAINFUL CAUSING PATIENT AT LEAST THE FOLLOWING

8.36.5.3.1.6.1 RESTLESS/INADEQUATE SLEEP

8.36.5.3.1.6.2 MUST SLEEP UPRIGHT IN CHAIR

8.36.5.3.2 OTHER SYMPTOMS

8.36.5.3.2.1 EXCESSIVE PERSPERATION IN ESSENTIAL REFERANCE ZONE

8.36.5.3.2.2 WEAKNESS OF GRIP

8.36.5.3.2.3 WEAKNESS OF INFRASPINATUS

8.36.5.3.3 SPORTS LIMITATION (IF SPORTS IS A PROFESSION INDICATE % IMPAIRMENT)

8.36.5.3.3.1 TENNIS STROKE IS WEAKER AND MAY BE PAINFUL

8.36.5.3.3.2 WEIGHT LIFTING-ALL MOVEMENTS OF THE UPPER ARM MAY BE WEAK AND PAINFUL ESPECIALLY AGAINST RESISTANCE WHEN LATERLLY ROTATED

8.36.5.4 TP ACTIVATION- IDENTIFY PRECIPITATING FACTORS

8.36.5.4.1 REPEATATIVE MOVEMENTS INVOLVING EITHER EXTREAM E INTERNAL OR EXTERNAL ROTATION (REACHING BACK TO NIGHT STAND) ESPECIALLY DURNING ILLNESS WHEN MUSCLES MAY BE WEAK.

8.36.5.4.2 UNUSUAL MOVEMENTS INVOLVING INTERNAL OR EXTERNAL ROTATION AT THE EXTREAME ENDS OF RANGE WITH GREATER RESISTANCE APPLIED (SKI POLING,SKATER HELPING NOVICE, CATCHING BACKWARD FALL ON STAIRS

8.36.5.5 SPECIAL TESTS- OBJECTIVLY ASSESS PATIENTS ROM RESTRICTION

8.36.5.5.1 MOUTH WRAP (FIG22.3) INCHES FROM MID MOUTH

8.36.5.5.2 HAND TO SHOULDER BLADE (22.4) INCHES FROM BOTTOM OF SCAPULA

8.36.5.6 DIFFERIENTIAL DX-RULE OUT OTHER DIAGNOSTICS NOTE:)SEE EXAM/DIAG

8.36.5.6.1 ADHESIVE CAPSULITIS (FROZEN SHOULDER)

8.36.5.6.2 SCAPULOHUMORAL SYNDROME

8.36.5.6.3 INTERVERTEBRAL DISC DISEASE (RADICULOPATHY)(C5,C6,C7)

8.36.5.7 TP LOCATION- LOCATE PAINFUL TRRIGER POINTS

8.36.5.7.1 PALPATE MUSCLE IN MID RANGE STRETCH PER EXAMPLE (FIGURE 22.6)

8.36.5.7.2 TP 1=PERPENDICULARLY EQUIDISTAQNT FROM VERTEBRAL BORDER AND SPINE OF SCAPULA, CAUDAL TO JUNCTION OF MEDIAL AND 2ND 1/4 OF SSCAPULAR SPINE LENGTH. FLAT PALPATION

8.36.5.7.3 TP2= CAUDAL TO MIDPOINT OF SCAPULAR SPINE BUT MAY BE ON LATERAL BORDER OF SCAPULA-FLAT PALPATION

8.36.5.7.4 TP3=MID MUSCLE ALONG VERTEBRAL SCAPULAR BORDER

8.36.5.8 TP FREQUENCY-NOTE THE LIKLYHOOD OF THE OCCURANCE OF THIS PATTERN

8.36.5.8.1 N=126 INFRASPINATUS=31% LEVATOR SCAPULA=55%

8.36.5.9 ENTRAPMENTS-ARE NUROLOGICAL SIGNS RPESENT AND RELATED TO MUSCLE TIGHTNESS

8.36.5.9.1 NONE

8.36.5.10 MYOTATIC UNIT-ASSESS OTHER RELATED MUSCLE GROUPS FOR TPS AND OR WEAKNESS

8.36.5.10.1 LATERAL ROTATION (SYNERGISTIC)

8.36.5.10.1.1 TERES MINOR

8.36.5.10.1.2 POSTERIOR DELTOID(???)

8.36.5.10.2 SITS--GLENOHUMERAL STABILIZATION (SYNERGISTS)

8.36.5.10.2.1 FLEXION-BICEPS, ANTERIOR DELT,PEC CLAVICULAR, COROCOBRACHIALIS

8.36.5.10.2.2 ABDUCTION=SUPRASPINATUS,MEDIAL DELTS,BICEPS LONG HEAD

8.36.5.10.2.3 EXTENSION-POSTERIOR DELTS, TERES MAJOR, LATS, TRICEPS L. H.

8.36.5.10.2.4 ADDUCTION-BICEPS SRT H, PEC CLAV, TERES MJ,COROCOBRACHIALIS,PEC MAJ STER & COSTAL, LATS, TRICEPS L.H.

8.36.5.10.3 MEDIAL ROTATION (ANTAGONISTIC)

8.36.5.10.3.1 TERES MAJOR

8.36.5.10.3.2 LATS

8.36.5.10.3.3 PEC MAJOR CLAVICULAR, STERNAL.

8.36.5.10.3.4 SUBSCAPULARIS

8.36.5.10.3.5 ANTERIOR DELTOID

8.36.5.10.4 FIXATION (SYNERGIST)

8.36.5.10.4.1 MID AND LOWER TRPAS, RHOMBOIDS

8.36.5.10.5 ESSENTIAL PAIN REFERAL ZONE

8.36.5.10.5.1 ANTERIOR DELT- PEC MAJOR, COROCOBRACIALIS

8.36.5.10.5.2 BICEPS

8.36.5.10.5.3 FOREARM &WRIS MUSCLES

8.36.5.10.5.4 SUPRSPINATUS

8.36.5.10.5.5 PEC MINOR

8.36.5.10.5.6 UPPER CERVICAL EXTENSORS

8.36.5.10.5.7 UPPER TRAPS

8.36.5.11 MUSCLE TESTING- TEST MUSCLE FOR PAIN AND WEAKNESS

8.36.5.11.1 FIXATION STABILIZATION

8.36.5.11.1.1 FIXATION

8.36.5.11.1.1.1 MID AND LOWER TRAPS, RHOMBOIDS

8.36.5.11.1.2 STABILIZATION

8.36.5.11.1.2.1 FIX HUMOUROUS TO AVOID ABDUCTION, ADDUCTION,FLEXION,AND EXTENSION

8.36.5.11.2 POSITION/PRESSURE

8.36.5.11.2.1 PRONE,SUPINE, SEATED, & STANDING

8.36.5.11.3 MUSCLE TEST

8.36.5.11.3.1.1 PRESSURE AGAINST PATIENTS WRIST USING FOREARM AS A LEVER TO INTERNALLY ROTATE HUMEROUS

8.36.5.11.3.1.2 HUMOUROUS ABDUCTED & EXTERNALLY ROTATED 90%

8.36.5.11.3.1.2.1 MAY ABDUCT HUMOURUS MORE. (UPPER INFRA FIBRES), LESS(MIDDLE & LOWER FIBRES).

8.36.5.11.3.1.2.2 AS HUMOURUS APPROACHES FULL ADDUCTION TERES MINOR FIBRES ARE TESTED.

8.36.5.11.3.1.2.3 MAY ROTATE HUMOURUS MORE THAN 90 DEGRESS- MUSCLE WILL BE STRONGER IN SHORTENED POSITION OR LESS THAN 90 DEGREE- MUSCLE WEAKER IN LENGTHENED POSITION

8.36.5.11.3.1.3 ELBOW FLEXED 90%

8.36.5.11.3.1.4 OBSERVE SCAPULA FIXATION-HOLD SCAPULA IF NOT FIXED

8.36.5.11.3.1.5 INDICATE DEGREE OF ABDUCT OF HUMOURUS WHEN TESTED

8.36.5.11.3.1.6 GRADE MUSCLE STRENGTH FOLLOWING GUIDLINES IN GENERAL INFORMATION SECTION.

8.36.5.11.3.1.7 INDICATE DEGREE OF HUMERAL ROTATION.

8.36.5.11.3.2 PATIENTSBODY LANGUAGE TO COMPENSATE MUSCLE WEAKNESS

8.36.5.11.3.2.1 DURING TEST-PATIENT WEAKNESS COMPENSATION

8.36.5.11.3.2.1.1 MOVING HUMEROUS IN ABDUCTION,ADDUCTION,FLEXION, OR EXTENSION

8.36.5.11.3.2.1.2 PATIENT MAY ATTEMPT TO FLEX OR EXTEND ELBOW

8.36.5.11.3.3 MUSCLE TESTING

8.36.5.11.3.3.1 SEATED & STANDING

8.36.5.11.3.3.1.1 STABILIZATION MORE DIFFICULT

8.36.5.11.3.3.1.2 MAY OBSERVE SCAPULAR FIXATION

8.36.5.11.3.3.2 SUPINE

8.36.5.11.3.3.2.1 SCAPULAR FIXATION DIFFICULT TO DETECT

8.36.5.11.3.3.2.2 LESS ASSISTANCE FROM POSTERIOR DELT

8.36.5.11.3.3.2.3 LESS NEED FOR SCAPULAR FIXATION BY LOWER & MIDDLE TRAPS

8.36.5.11.3.3.3 PRONE

8.36.5.11.3.3.3.1 MAY OBSERVE SCAPULAR FIXATION

8.36.5.11.3.3.3.2 TO PERFORM TEST STAND AT HEAD OF TABLE & CUSHEN ARM WITH YOUR HAND BETWEE ARM & TABLE

8.36.5.11.3.3.3.3 MAY GRADE MUSCLE IN ANTIGRAVITY POSITION

8.36.5.11.3.4 GENERAL

8.36.5.11.3.4.1 DIFFERIENTIATE BETWEEN TERES MINOR AND INFRASPINATUS PROBLEMS

8.36.5.12

8.36.6 PATIENTS ASSESSMENT FORM

8.37 Neuritides

8.37.1 HISTORY

8.37.2 SUBJECTIVE

8.37.3 OBJECTIVE

8.37.4 TREATMENT

8.37.5 EXAMINATION

8.37.6 PATIENTS ASSESSMENT FORM

8.38 Neuropathic Shoulder

8.38.1 Wheeless' Textbook of Orthopaedics

8.38.1.1 http://www.wheelessonline.com/orthoo/42.htm

8.39 Posterior Shoulder Dislocation

8.39.1 Wheeless' Textbook of Orthopaedics

8.39.1.1 http://www.wheelessonline.com/o6/61.htm

8.40 Proximal Humeral Fracture

8.40.1 Wheeless' Textbook of Orthopaedics

8.40.1.1 http://www.wheelessonline.com/o6/12.htm

8.41 Proximal Humeral Physeal Injuries

8.41.1 Wheeless' Textbook of Orthopaedics

8.41.1.1 http://www.wheelessonline.com/o6/31.htm

8.42 Psychogenic Pain

8.42.1 HISTORY

8.42.2 SUBJECTIVE

8.42.3 OBJECTIVE

8.42.4 TREATMENT

8.42.5 EXAMINATION

8.42.6 PATIENTS ASSESSMENT FORM

8.43 Pulmonary Neoplasm

8.43.1 HISTORY

8.43.2 SUBJECTIVE

8.43.3 OBJECTIVE

8.43.4 TREATMENT

8.43.5 EXAMINATION

8.43.6 PATIENTS ASSESSMENT FORM

8.44 Referred Pain

8.45 Rotator Cuff Tears

8.45.1 Wheeless' Textbook of Orthopaedics

8.45.1.1 http://www.wheelessonline.com/orthoo/65.htm

8.46 Rupture Shoulder Tendon (Rotator Cuff or Biceps)

8.46.1 HISTORY

8.46.2 SUBJECTIVE

8.46.3 OBJECTIVE

8.46.4 TREATMENT

8.46.5 EXAMINATION

8.46.6 PATIENTS ASSESSMENT FORM

8.47 Shoulder Tendonitis (Rotator Cuff or Biceps)

8.48 Sternoclavicular Joint

8.48.1 HISTORY

8.48.2 SUBJECTIVE

8.48.3 OBJECTIVE

8.48.4 TREATMENT

8.48.5 EXAMINATION

8.48.6 PATIENTS ASSESSMENT FORM

8.49 Sternoclavicular Joint Injury

8.49.1 Wheeless' Textbook of Orthopaedics

8.49.1.1 http://www.wheelessonline.com/orthoo/5400.htm

8.50 Subacute and Chronic Joint Problems

8.51 Subcoracoid Bursitis

8.51.1 HISTORY

8.51.2 SUBJECTIVE

8.51.3 OBJECTIVE

8.51.4 TREATMENT

8.51.5 EXAMINATION

8.51.6 PATIENTS ASSESSMENT FORM

8.52 Subluxation

8.52.1 HISTORY

8.52.2 SUBJECTIVE

8.52.3 OBJECTIVE

8.52.4 TREATMENT

8.52.5 EXAMINATION

8.52.6 PATIENTS ASSESSMENT FORM

8.53 Subscapularis Tendonitis

8.53.1 HISTORY

8.53.2 SUBJECTIVE

8.53.3 OBJECTIVE

8.53.4 TREATMENT

8.53.5 EXAMINATION

8.53.6 PATIENTS ASSESSMENT FORM

8.54 Superior Glenoid Labrum Lesions (SLAP)

8.54.1 Wheeless' Textbook of Orthopaedics

8.54.1.1 http://www.wheelessonline.com/05/501.htm

8.55 Suprascapular Nerve

8.55.1 HISTORY

8.55.2 SUBJECTIVE

8.55.3 OBJECTIVE

8.55.4 TREATMENT

8.55.5 EXAMINATION

8.55.6 PATIENTS ASSESSMENT FORM

8.56 Supraspinatus Tendonitis

8.56.1 HISTORY

8.56.2 SUBJECTIVE

8.56.3 OBJECTIVE

8.56.4 TREATMENT

8.56.5 EXAMINATION

8.56.6 PATIENTS ASSESSMENT FORM

8.57 Tendonitis

8.58 Throwing Shoulder

8.58.1 Wheeless' Textbook of Orthopaedics

8.58.1.1 http://www.wheelessonline.com/o6/32.htm

8.59 Traumatic Arthritis

8.59.1 HISTORY

8.59.2 SUBJECTIVE

8.59.3 OBJECTIVE

8.59.4 TREATMENT

8.59.5 EXAMINATION

8.59.6 PATIENTS ASSESSMENT FORM

8.60 Trigger Point Assessment General

8.60.1 HISTORY

8.60.1.1 A HISTORY OF SUDDEN ONSET DURING OR SHORTLY FOLLOWINGT ACUTE OVERLOAD STRESS, OR A HISTORY OF GRADUAL ONSET WITH CHRONIC OVERLOAD OF THE AFFECTED MUSCLE.

8.60.2 SUBJECTIVE

8.60.3 OBJECTIVE

8.60.3.1 CHARACTERISTIC PATTERNS OF PAIN THAT ARE REFERRED FROM MYOFASCIAL TPS, PATTERNS THAT ARE SPECIFIC TO INDIVIDUAL MUSCLES.

8.60.3.2 WEAKNESS AND RESTRICTION IN THE STRETCH RANGE OF MOTION OF THE AFFECTED MUSCLE.

8.60.3.3 A TAUT, PALPABLE BAND IN THE AFFECTED MUSCLE.

8.60.3.4 EXQUISITE, FOCAL TENDERNESS TO DIGITAL PRESSURE (THE TP), IN THE BAND OF TAUT MUSCLE FIBERS.

8.60.3.5 A LOCAL TWITCH RESPONSE ELICITED THROUGH SNAPPING PALPATION OR NEEDLING OF THE TENDER SPOT (TP).

8.60.3.6 THE REPRODUCTION OF THE PATIENT’S PAIN COMPLAINT BY PRESSURE ON, OR NEEDLING OF, THE TENDER SPOT (TP).

8.60.3.7 THE ELIMINATION OF SYMPTOMS BY THERAPY DIRECTED SPECIFICALLY TO THE AFFECTED MUSCLE.

8.60.3.8 # 4 ESSENTIAL(EXQUISITE TENDERNESS) BUT NONSPECIFIC, # 5(TWITCH RESPONSE) & 6(REPRODUCTION OF PP) ARE SPECIFIC AND STRONGLY DIAGNOSTIC. THE MORE OF THE REMAINING FINDINGS THAT ARE PRESENT, THE MORE CERTAIN IS THE DIAGNOSIS WHICH MAY BE RECORDED AS MYOFASCIITIS.

8.60.4 TREATMENT

8.60.5 EXAMINATION

8.60.6 PATIENTS ASSESSMENT FORM

8.61 Tumors of the Proximal Humerus / Scapula

8.61.1 HISTORY

8.61.2 SUBJECTIVE

8.61.3 OBJECTIVE

8.61.4 TREATMENT

8.61.5 EXAMINATION

8.61.6 PATIENTS ASSESSMENT FORM

8.61.7 Wheeless' Textbook of Orthopaedics

8.61.7.1 http://www.wheelessonline.com/o6/161.htm

9 Temporomandibular Joint

Back Table of Contents References

9.1 Anteriorly Dislocated Disc With Reduction

9.1.1 HISTORY

9.1.2 SUBJECTIVE

9.1.3 OBJECTIVE

9.1.4 TREATMENT

9.1.5 EXAMINATION

9.1.6 PATIENTS ASSESSMENT FORM

9.2 Anteriorly Dislocated Disc Without Reduction

9.3 Degenerative Joint Disease-Osteoarthritis

9.4 Disk Derangement and Condylar Displacement

9.5 Hypermobility (Subluxation)

9.6 Hypomobility Secondary to Capsular Tightness

9.7 Muscle Imbalance of the Cervical Spine

9.8 Orofacial Imbalances

9.9 Rheumatoid Arthritis

9.10 Strain

9.11 Temporomandibular Joint Dysfunction Syndrome

9.12 Trauma and Disorders of Limitation

10 Thoracic Spine

Back Table of Contents References

10.1 Ankylosing Spondylitis

10.1.1 HISTORY

10.1.2 SUBJECTIVE

10.1.3 OBJECTIVE

10.1.4 TREATMENT

10.1.5 EXAMINATION

10.1.6 PATIENTS ASSESSMENT FORM

10.1.7 Wheeless' Textbook of Orthopaedics

10.1.7.1 http://www.wheelessonline.com/oa4/48.htm

10.2 Annular Tear

10.2.1 Wheeless' Textbook of Orthopaedics

10.2.1.1 http://www.wheelessonline.com/o12/48.htm

10.3 Anterior Cord Syndrome

10.3.1 Wheeless' Textbook of Orthopaedics

10.3.1.1 http://www.wheelessonline.com/o11/977.htm

10.4 Brown Sequard Syndrome

10.4.1 Wheeless' Textbook of Orthopaedics

10.4.1.1 http://www.wheelessonline.com/o11/979.htm

10.5 Burst Fracture (Spine)

10.5.1 Wheeless' Textbook of Orthopaedics

10.5.1.1 http://www.wheelessonline.com/o11/183.htm

10.6 Capsular Lesions

10.7 Cauda Equina Syndrome

10.7.1 Wheeless' Textbook of Orthopaedics

10.7.1.1 http://www.wheelessonline.com/o11/191.htm

10.8 Central Cord Syndrome

10.8.1 Wheeless' Textbook of Orthopaedics

10.8.1.1 http://www.wheelessonline.com/o11/978.htm

10.9 Chance Fracture (Spine)

10.9.1 Wheeless' Textbook of Orthopaedics

10.9.1.1 http://www.wheelessonline.com/o11/198.htm

10.10 Compression Fractures

10.10.1 Wheeless' Textbook of Orthopaedics

10.10.1.1 http://www.wheelessonline.com/o11/181.htm

10.11 Congenital Scoliosis and Vertebral Defects

10.11.1 Wheeless' Textbook of Orthopaedics

10.11.1.1 http://www.wheelessonline.com/o11/84.htm

10.12 Costochondritis

10.13 Diffuse Idiopathic Skeletal Hyperostosis

10.13.1 Wheeless' Textbook of Orthopaedics

10.13.1.1 http://www.wheelessonline.com/o11/25.htm

10.14 Disc Herniation

10.14.1 Wheeless' Textbook of Orthopaedics

10.14.1.1 http://www.wheelessonline.com/o11/39.htm

10.15 Disogenic Pain

10.15.1 Wheeless' Textbook of Orthopaedics

10.15.1.1 http://www.wheelessonline.com/o12/47.htm

10.16 Displacements

10.17 Dowager's Hump (Upper Thoracic Kyphosis)

10.18 Eosinophilic Granuloma of the Spine

10.18.1 Wheeless' Textbook of Orthopaedics

10.18.1.1 http://www.wheelessonline.com/o6/103.htm

10.19 Facet Joint Restrictions

10.20 Fracture Dislocations of the Spine

10.20.1 Wheeless' Textbook of Orthopaedics

10.20.1.1 http://www.wheelessonline.com/o11/199.htm

10.21 Fracture of a Rib/Stress Fracture

10.22 Hypermobility of the Ribs

10.23 Hypermobility of Thoracic Segments

10.24 Hypomobility of the Ribs

10.25 Incomplete Spinal Cord Lesion

10.25.1 Wheeless' Textbook of Orthopaedics

10.25.1.1 http://www.wheelessonline.com/o11/973.htm

10.26 Myelodysplasia

10.26.1 Wheeless' Textbook of Orthopaedics

10.26.1.1 http://www.wheelessonline.com/o11/75.htm

10.27 Myelomeningocele

10.27.1 Wheeless' Textbook of Orthopaedics

10.27.1.1 http://www.wheelessonline.com/o11/77.htm

10.28 Myofascial Imbalances

10.29 Neuralgic Amyotrophy

10.30 Neuritis (Spinal Accessory, Long Thoracic or Suprascapular Nerve)

10.31 Neuroma

10.32 Occult Spondylytic Fractures

10.32.1 Wheeless' Textbook of Orthopaedics

10.32.1.1 http://www.wheelessonline.com/o11/95.htm

10.33 Os Odontoideum

10.33.1 Wheeless' Textbook of Orthopaedics

10.33.1.1 http://www.wheelessonline.com/o11/175.htm

10.34 Osteitis Deformans

10.35 Osteochondritis (Adolescent)

10.36 Osteochondritis (Adult)

10.37 Osteomyelitis (Vertebral)

10.37.1 Wheeless' Textbook of Orthopaedics

10.37.1.1 http://www.wheelessonline.com/oa3/80.htm

10.38 Osteoporosis (Senile)

10.39 Rib Conditions

10.40 Scoliosis

10.40.1 Wheeless' Textbook of Orthopaedics

10.40.1.1 http://www.wheelessonline.com/o11/59.htm

10.41 Slipped Vertebral Apophysis

10.41.1 Wheeless' Textbook of Orthopaedics

10.41.1.1 http://www.wheelessonline.com/o11/17.htm

10.42 Spinal Shock

10.42.1 Wheeless' Textbook of Orthopaedics

10.42.1.1 http://www.wheelessonline.com/o16/43.htm

10.43 Spine Fractures & their Mechanisms

10.43.1 Wheeless' Textbook of Orthopaedics

10.43.1.1 http://www.wheelessonline.com/o11/180.htm

10.44 Syringomyelia

10.44.1 Wheeless' Textbook of Orthopaedics

10.44.1.1 http://www.wheelessonline.com/o11/79.htm

10.45 Tethered Cord Syndrome

10.45.1 Wheeless' Textbook of Orthopaedics

10.45.1.1 http://www.wheelessonline.com/o11/80.htm

10.46 Thoracic Disc

10.47 Thoracic Outlet Syndrome

10.48 Tumors and Lesions of the Spine and Sacrum

10.48.1 Wheeless' Textbook of Orthopaedics

10.48.1.1 http://www.wheelessonline.com/o6/180.htm

10.49 Waddel Criteria

10.49.1 Wheeless' Textbook of Orthopaedics

10.49.1.1 http://www.wheelessonline.com/o11/26.htm

11 Wrist and Hand

Back Table of Contents References

11.1 Abductor Longus and Extensor Brevis Pollicis (De Quervain's Syndrome)

11.1.1 HISTORY

11.1.2 SUBJECTIVE

11.1.3 OBJECTIVE

11.1.4 TREATMENT

11.1.5 EXAMINATION

11.1.6 PATIENTS ASSESSMENT FORM

11.1.7 Wheeless' Textbook of Orthopaedics

11.1.7.1 http://www.wheelessonline.com/ooa1/162.htm

11.2 Arthritis (Thumb)

11.3 Arthrodesis (Wrist)

11.3.1 Wheeless' Textbook of Orthopaedics

11.3.1.1 http://www.wheelessonline.com/ooa1/104.htm

11.4 Bennett's Fracture Dislocation

11.4.1 Wheeless' Textbook of Orthopaedics

11.4.1.1 http://www.wheelessonline.com/ooa1/185.htm

11.5 Boutonniere Injuries

11.5.1 Wheeless' Textbook of Orthopaedics

11.5.1.1 http://www.wheelessonline.com/ooa1/137.htm

11.6 Capitate

11.6.1 Wheeless' Textbook of Orthopaedics

11.6.1.1 http://www.wheelessonline.com/orthoo/155.htm

11.7 Capsular Lesions (Hand)

11.8 Capsular Pattern

11.9 Capsule Joint Tightness (Metacarpophalangeal, Proximal and Distal Interphalangeal)

11.10 Capsule Tightness

11.11 Carpal Capitate Subluxation

11.12 Carpal Instability

11.12.1 Wheeless' Textbook of Orthopaedics

11.12.1.1 http://www.wheelessonline.com/oa2/89.htm

11.13 Carpometacarpal Fracture Dislocation

11.13.1 Wheeless' Textbook of Orthopaedics

11.13.1.1 http://www.wheelessonline.com/ooa1/178.htm

11.14 Carpal Tunnel Syndrome

11.14.1 Wheeless' Textbook of Orthopaedics

11.14.1.1 http://www.wheelessonline.com/orthoo/171.htm

11.15 Cerebral Palsy (Hand)

11.15.1 Wheeless' Textbook of Orthopaedics

11.15.1.1 http://www.wheelessonline.com/o14/109.htm

11.16 Claw Hand (Intrinsic Weakness)

11.16.1 Wheeless' Textbook of Orthopaedics

11.16.1.1 http://www.wheelessonline.com/05/122.htm

11.17 Clenched Fist Injury

11.17.1 Wheeless' Textbook of Orthopaedics

11.17.1.1 http://www.wheelessonline.com/ortho1/1051.htm

11.18 Colles' Fracture

11.19 CMC Joint / CMC Arthritis

11.19.1 Wheeless' Textbook of Orthopaedics

11.19.1.1 http://www.wheelessonline.com/ooa1/135.htm

11.20 Compartment Syndromes of Hand and Forearm

11.20.1 Wheeless' Textbook of Orthopaedics

11.20.1.1 http://www.wheelessonline.com/oa2/73.htm

11.21 Congenital Deformities of the Hands

11.21.1 Wheeless' Textbook of Orthopaedics

11.21.1.1 http://www.wheelessonline.com/o15/101.htm

11.22 Distal Radial Ulnar Joint

11.22.1 Wheeless' Textbook of Orthopaedics

11.22.1.1 http://www.wheelessonline.com/orthoo/129.htm

11.23 Dorsal Intercalated Segment Instability: (DISI)

11.23.1 Wheeless' Textbook of Orthopaedics

11.23.1.1 http://www.wheelessonline.com/oa2/93.htm

11.24 Distal Phalangeal Fractures

11.24.1 Wheeless' Textbook of Orthopaedics

11.24.1.1 http://www.wheelessonline.com/o13/64.htm

11.25 Dorsal Wrist Pain

11.25.1 Wheeless' Textbook of Orthopaedics

11.25.1.1 http://www.wheelessonline.com/orthoo/1134.htm

11.26 Dupuytren's Contracture

11.26.1 Wheeless' Textbook of Orthopaedics

11.26.1.1 http://www.wheelessonline.com/o2/192.htm

11.27 Dynamic Instability

11.27.1 Wheeless' Textbook of Orthopaedics

11.27.1.1 http://www.wheelessonline.com/oa2/92.htm

11.28 Extensor Carpi Ulnaris Lesion

11.29 Extensores Carpi Radialis Lesion

11.30 Extensor Tendon Rupture: RA: (Vaughn-Jackson syndrome)

11.30.1 Wheeless' Textbook of Orthopaedics

11.30.1.1 http://www.wheelessonline.com/ooa1/121.htm

11.31 FDP Avulsion/Rupture

11.31.1 Wheeless' Textbook of Orthopaedics

11.31.1.1 http://www.wheelessonline.com/ooa1/389.htm

11.32 Finger Tip Injuries

11.32.1 Wheeless' Textbook of Orthopaedics

11.32.1.1 http://www.wheelessonline.com/o13/65.htm

11.33 Flexor Carpi Radialis Lesion

11.34 Flexor Carpi Ulnaris Lesion

11.35 Flexor Digitorum Lesion

11.36 Flexor Pollicis Longus Tendon Lesion

11.37 Flexor Tenosynovitis (Infectious)

11.37.1 Wheeless' Textbook of Orthopaedics

11.37.1.1 http://www.wheelessonline.com/oa4/991.htm

11.38 Fractures of the Radius

11.38.1 Wheeless' Textbook of Orthopaedics

11.38.1.1 http://www.wheelessonline.com/orthoo/105.htm

11.39 Gamekeeper's Thumb

11.39.1 Wheeless' Textbook of Orthopaedics

11.39.1.1 http://www.wheelessonline.com/ooa1/141.htm

11.40 Ganglionic Cysts of the Wrist

11.40.1 Wheeless' Textbook of Orthopaedics

11.40.1.1 http://www.wheelessonline.com/ooa1/115.htm

11.41 Hamate

11.41.1 Wheeless' Textbook of Orthopaedics

11.41.1.1 http://www.wheelessonline.com/orthoo/160.htm

11.42 Hand and Metacarpal Fractures

11.42.1 Wheeless' Textbook of Orthopaedics

11.42.1.1 http://www.wheelessonline.com/ooa1/168.htm

11.43 High Pressure Injection Injuries in the Hand

11.43.1 Wheeless' Textbook of Orthopaedics

11.43.1.1 http://www.wheelessonline.com/oa2/75.htm

11.44 Infections of the Hand

11.44.1 Wheeless' Textbook of Orthopaedics

11.44.1.1 http://www.wheelessonline.com/oa4/108.htm

11.45 Intrinsic Muscles of the Hand

11.45.1 Wheeless' Textbook of Orthopaedics

11.45.1.1 http://www.wheelessonline.com/05/121.htm

11.46 Kienbock's disease: Lunatomalacia

11.46.1 Wheeless' Textbook of Orthopaedics

11.46.1.1 http://www.wheelessonline.com/o11/209.htm

11.47 Ligaments of the Wrist

11.47.1 Wheeless' Textbook of Orthopaedics

11.47.1.1 http://www.wheelessonline.com/ooa1/102.htm

11.48 Ligamentous Sprains

11.49 Lunate Capitate Ligament Sprain

11.50 Lunotriquetral Dissociation

11.50.1 Wheeless' Textbook of Orthopaedics

11.50.1.1 http://www.wheelessonline.com/ooa1/96.htm

11.51 Malalignment of Carpal Bone

11.52 Mallet Deformity: (Baseball finger)

11.52.1 Wheeless' Textbook of Orthopaedics

11.52.1.1 http://www.wheelessonline.com/ooa1/144.htm

11.53 Metacarpal Joint Injury

11.53.1 Wheeless' Textbook of Orthopaedics

11.53.1.1 http://www.wheelessonline.com/ooa1/167.htm

11.54 Middle Phalanx Fracture

11.54.1 Wheeless' Textbook of Orthopaedics

11.54.1.1 http://www.wheelessonline.com/o15/71.htm

11.55 Mucous Cyst

11.55.1 Wheeless' Textbook of Orthopaedics

11.55.1.1 http://www.wheelessonline.com/o6/163.htm

11.56 Muscle Strength or Flexibility Imbalance

11.57 Osteoarthrosis

11.58 Perilunate Dislocations

11.58.1 Wheeless' Textbook of Orthopaedics

11.58.1.1 http://www.wheelessonline.com/ooa1/91.htm

11.59 Phalangeal Injury

11.59.1 Wheeless' Textbook of Orthopaedics

11.59.1.1 http://www.wheelessonline.com/ooa1/150.htm

11.60 Pisiform

11.60.1 Wheeless' Textbook of Orthopaedics

11.60.1.1 http://www.wheelessonline.com/orthoo/158.htm

11.61 Proximal Phalanx Fracture

11.61.1 Wheeless' Textbook of Orthopaedics

11.61.1.1 http://www.wheelessonline.com/o15/66.htm

11.62 Radial Collateral Ligament Sprain

11.63 Referred Pain and Nerve Injury Patterns

11.64 Rheumatoid Arthritis

11.64.1 Wheeless' Textbook of Orthopaedics (Wrist)

11.64.1.1 http://www.wheelessonline.com/ooa1/103.htm

11.65 Rheumatoid Arthritis: MP joint

11.65.1 Wheeless' Textbook of Orthopaedics

11.65.1.1 http://www.wheelessonline.com/ooa1/113.htm

11.66 Rheumatoid Hand

11.66.1 Wheeless' Textbook of Orthopaedics

11.66.1.1 http://www.wheelessonline.com/ooa1/109.htm

11.67 Rolando's fracture

11.67.1 Wheeless' Textbook of Orthopaedics

11.67.1.1 http://www.wheelessonline.com/ooa1/184.htm

11.68 Scaphoid Fracture and Lunate Dislocation

11.69 Scaphoid / Scaphoid Fracture

11.69.1 Wheeless' Textbook of Orthopaedics

11.69.1.1 http://www.wheelessonline.com/orthoo/161.htm

11.70 Scapholunate Advanced Collapse (SLAC)

11.70.1 Wheeless' Textbook of Orthopaedics

11.70.1.1 http://www.wheelessonline.com/ooa1/98.htm

11.71 Scapholunate Instability

11.71.1 Wheeless' Textbook of Orthopaedics (Wrist)

11.71.1.1 http://www.wheelessonline.com/ooa1/97.htm

11.72 Secondary Osteoarthritis (Thumb)

11.73 Stiff Hand

11.74 Swan Neck Deformity

11.74.1 Wheeless' Textbook of Orthopaedics

11.74.1.1 http://www.wheelessonline.com/ooa1/124.htm

11.75 Tendinitis

11.76 Tendon Injuries of the Hand

11.76.1 Wheeless' Textbook of Orthopaedics

11.76.1.1 http://www.wheelessonline.com/orthoo/180.htm

11.77 Thumb Deformities in RA

11.77.1 Wheeless' Textbook of Orthopaedics

11.77.1.1 http://www.wheelessonline.com/ooa1/129.htm

11.78 Thumb Fractures / Dislocations

11.78.1 Wheeless' Textbook of Orthopaedics

11.78.1.1 http://www.wheelessonline.com/ooa1/179.htm

11.79 Tumors of Hand and Distal radius

11.79.1 Wheeless' Textbook of Orthopaedics

11.79.1.1 http://www.wheelessonline.com/o6/162.htm

11.80 Transverse and Oblique Retincular Ligament

11.80.1 Wheeless' Textbook of Orthopaedics (Wrist)

11.80.1.1 http://www.wheelessonline.com/ooa1/99.htm

11.81 Trapezium

11.81.1 Wheeless' Textbook of Orthopaedics

11.81.1.1 http://www.wheelessonline.com/orthoo/156.htm

11.82 Traumatic Arthritis

11.83 Triangular Fibrocartilage Complex

11.83.1 Wheeless' Textbook of Orthopaedics

11.83.1.1 http://www.wheelessonline.com/orthoo/125.htm

11.84 Trigger Finger / Tenosynovitis

11.84.1 Wheeless' Textbook of Orthopaedics (Wrist)

11.84.1.1 http://www.wheelessonline.com/ooa1/164.htm

11.85 Tumors of Hand and Distal radius

11.85.1 Wheeless' Textbook of Orthopaedics (Wrist)

11.85.1.1 http://www.wheelessonline.com/o6/162.htm

11.86 Tunnel of Guyon

11.86.1 Wheeless' Textbook of Orthopaedics

11.86.1.1 http://www.wheelessonline.com/orthoo/159.htm

11.87 Ulna / Ulnar Shaft Fracture

11.87.1 Wheeless' Textbook of Orthopaedics

11.87.1.1 http://www.wheelessonline.com/orthoo/126.htm

11.88 Ulnar Collateral Ligament Sprain

11.89 Ulnar drift: of MP joints

11.89.1 Wheeless' Textbook of Orthopaedics

11.89.1.1 http://www.wheelessonline.com/ooa1/114.htm

11.90 Ulnar Variance

11.90.1 Wheeless' Textbook of Orthopaedics

11.90.1.1 http://www.wheelessonline.com/oa4/107.htm

11.91 Ulnar Nerve Entrapment

11.92 Ulnocarpal Impingement Syndrome

11.92.1 Wheeless' Textbook of Orthopaedics

11.92.1.1 http://www.wheelessonline.com/orthoo/1250.htm

11.93 Vascular Problems of the Wrist and Hand

11.93.1 Wheeless' Textbook of Orthopaedics

11.93.1.1 http://www.wheelessonline.com/oa3/74.htm

11.94 Volar Finger Tip Infections / Felon

11.94.1 Wheeless' Textbook of Orthopaedics

11.94.1.1 http://www.wheelessonline.com/oa4/988.htm

11.95 Volar Intercalated Segment Instability: (VISI)

11.95.1 Wheeless' Textbook of Orthopaedics

11.95.1.1 http://www.wheelessonline.com/oa2/95.htm

11.96 Wrist Joint Trauma

---

[1] KESSLER R M, HERTLING D: MANAGEMENT OF COMMON MUSCULOSKELETAL DISORDERS: PHYSICAL THERAPY PRINCIPLES AND METHODS. 2ND EDITION. J.B. LIPPINCOTT CO. 1990.

[2] IBID.

[3] CYRIAX J H: CYRIAX’S ILLUSTRATED MANUAL OF ORTHOPAEDIC MEDICINE. 2ND EDITION. BUTTERWORTH-HEINEMANN LTD 1993.

[4] IBID.

[5] MOSELEY HF: THE NATURAL HISTORY AND CLINICAL SYNDROMES PRODUCED BY CALCIFIC DEPOSITS IN THE ROTATOR CUFF. SURG CLIN NORTH AM 43:1489-1492, 1963

[6]

[7] CYRIAX J H: CYRIAX’S ILLUSTRATED MANUAL OF ORTHOPAEDIC MEDICINE. 2ND EDITION. BUTTERWORTH-HEINEMANN LTD 1993.

8 PAYTON OTTO D, DI FABIO R, PARIS SV, PROTAS EJ, VANSANT AF, (EDS): MANUAL OF PHYSICAL THERAPY. CHURCHILL LIVINGSTONE. NY. 1989. (P. 445)

9 IBID

[10] IBID

[11] TRAVELL JANET G, SIMONS DAVID: MYOFASCIAL PAIN AND DYSFUNCTION: THE TRIGGER POINT MANUAL: THE UPPER EXTREMITIES. VOL 1. WILLIAMS & WILKINS. MD. 1983.