Recent media reports reminded me of the necessity for vigilance and clinical reasoning when assessing for potential ACL deficiency.  It was highlighted from a recent sporting event – the all Ireland hurling semi-final when star player Henry Shefflin suffered a suspected ACL rupture.  For those of you unfamiliar with Gaelic games there are two codes played in Ireland; Gaelic football and Hurling.  If you have never seen hurling played I would highly recommend you check it out on YouTube. We have discussed ACL rehabilitation protocols previously here.

Now back to the story.  The player collapsed following an incident in which he reported feeling a ‘popping’ and was unable to continue but walked from the field.  He had a prior history of ACL disruption on the contra-lateral side two years previously and had verbalised to the medical staff that it felt like the same injury.  The treating physiotherapist observed that the clinical signs were relatively modest but in view of the history an MRI scan was conducted confirming an ACL disruption.  However, as the patient’s clinical signs were very modest and his functional impairment at this stage post injury was very modest it begged the question of whether it would be possible to play in the All-Ireland Hurling final in three weeks time.  There is a historic element to this as the team in question – Kilkenny, are seeking five Titles in a row which would be an unprecedented achievement and this player has played all matches.

The events that unfolded were surprising to say the least.  Within ten days of the injury eight thousand people turned up to watch the Kilkenny hurling team train and  to watch Henry Shefflin participate fully in the training session without any supportive device – part-taking in all the skill elements required for a game situation.  Apparently there had been no adverse reaction subsequently.  With the final looming in one week’s time it remains to be seen whether the player will play active roll but the story reminds me of the constant surprises we observe clinically between known pathology, clinical signs and functional impairment.

The literature would have us believe that approximately 30% of ACL disruption cases can return to competitive field sports activity without requiring surgical intervention.  Unfortunately the clinical challenge is that we cannot detect which patients are in this 30% sub-group and therefore only know by taking them through a sequential rehabilitation regime and observing achievement of milestones.  What is particularly surprising in this case was the speed of return to high level function even if the deadline is ultimately lost.  We’ll watch with interest…

There were some parallels with this example and a case of a twenty-five year old lady I had seen six weeks previously.  She presented with a spontaneous collapse of the right knee, again playing Gaelic football but this time presented with significant signs of joint effusion and functional impairment.  However, apart from the ominous signs of joint effusion I could not detect demonstrable laxity on anterior drawer, Lachman’s or pivot-shift tests.  As her functional capacity steadily improved over a number of weeks she progressed to jogging which unfortunately exacerbated her effusion.  On this basis and my suspicion of significant trauma initially (despite the absence of a full spectrum of confirmatory clinical signs) we arranged for surgical evaluation and MRI.  Again the Orthopaedic Surgeon’s physical examination was inconclusive and MRI scan confirmed a complete tear.  Surgery has subsequently being scheduled.

So take home messages from today’s discussion is the necessity for clinical reasoning when evaluating suspected ACL pathology or indeed any intra-articular pathology.  All may not be as it seems from clinical examination. The observation of suspicious features in the absence of positive definitive tests cannot always be fully relied upon.  In reality “function is king”, suspected pathology is secondary unless it is sinister or life threatening.  That is what makes the work of physiotherapist so exciting. How frequently do you see patients who fit the classic descriptions? Are there many exceptions to the rule?  Let us know.

Enjoy the clinical challenge.

David.

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Post tags: ACL, Functional Capacity, physiotherapy, rehabilitation

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Primary mechanisms relate to factors which reduce the subacromial space resulting in encroachment on the intervening tissues.

Secondary impingements do not result from space occupying pathology such as:

Osteophyytes

Tendon thickening,

AC joint mal-alignment,

Osseous anomalies in the acronimal shape.

These are variable parameters, which a treating therapist must evaluate in order to determine their relevance (or not) in the mechanism of impingement pain.

Understanding patterns of motion is essential if we are trying to determine relevant malalignment.  American physiotherapist Shirley Sahrmann in her classic text ‘Movement Impairment Syndromes’ describes a group of scapular mal-alignments associated with impingement together with a description of the functional anatomy and pathophysiology associated.

These include:

Superior scapular migration syndrome

Inferior scapular migration syndrome

Downward scapular rotation syndrome

Winging scapular syndrome

Anterior tilt

Scapular protraction.

The net result of variations in scapular position as outlined above alter the alignment of the Humerus relative to the Glenoid or perhaps more correctly, the Glenoid relative to the Humerus. This altered mechanical relationship produces changes in the length- tension characteristics of the relevant muscles of the scapular thoracic and rotator cuff complexes.  Such malalignments may alter either the antero-posterior force couple across the Gleno-humeral joint, or as is more traditionally perceived alter the superior inferior force couple across the joint with a potential for superior Humeral migration.

The challenge for the therapist in clinical practice is to….

1.       Determine the existence of the mal-alignment

2.       Identify the predominant mechanism behind this malalignment.

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Having determined the existence of one or both of these features, then the key issue is to determine its relevance.

The relevance can be ascertained by passively correcting the perceived / hypothesised mal-alignment or facilitating movement with the mal-alignment corrected.

Changes in the objective clinical signs confirm or refute  the clinical hypothesis of “scapular contribution” to shoulder impingement

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: muscle imbalance, rehabilitation, scapular alignment, Shoulder impingement

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The constraints of evidence based medicine dictate that intervention should only be undertaken on the basis of proven efficacy.  Therapeutic exercise has been shown to have a possible role in a number of conditions including the following:

• Osteoporosis
• Fibromyalgia
• Chronic Pain
• Low Back Pain
• Musculoskeletal Pain
• Cardiac Rehabilitation,
• Pulmonary Rehabilitation
• Chronic Fatigue Syndrome.

Disciplines which have been predominately passive in nature i.e. manipulative therapy have been forced to reconsider there efficacy and incorporate more dynamic patient management strategies (Waddell 1998).

This has been driven not only by the requirement for evidence based medicine but also to create patient management strategies which are patient focused and minimize demands upon the health care providers rather than creating a patient dependence as is the case with passive procedures (Koes 1991).

The physiological effects of exercise impinge upon many physiological systems including;

• Cardiovascular
• Respiratory
• Neuroendocrine
• Musculoskeletal.

The focus of this course is largely related to the musculoskeletal system.

The interaction of physiological and psychological components must also be acknowledged at this stage.  The historical medical model (based on Cartesian Philosophy of separation of mind and body) is no longer valid as it has become increasingly clear that these are intimately interrelated components.

Thus some of the benefits induced by physical means have much greater ramifications for the individual as a whole, in terms of improved self-esteem, confidence, self worth, motivation and empowerment.  Part of this course will focus on the use of group dynamics to achieve some of these objectives.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: disease prevention, Exercise, health benefits of exercise, rehabilitation

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The converse view is that manual therapy and functionally specific rehabilitation can be used directly as a cognitive-behavioural strategy to address specific patient complaints / functional impairments. As physiotherapists we need to recognise that any interactions we have with patients have cognitive / emotive connotations and there is no practical reason why physical means cannot be used to facilitate this approach as an adjunct or an alternative to psychotherapy techniques

Those who attended the “Decade of the Flags” conference in Keel university at the end of 2007 will know that primary care clinicians can now no longer hide behind professional boundaries as an excuse not to challenge patients distorted beliefs or facilitate rehabilitation programs which are tailored to their needs.

This obviously poses clinical challenges but the facts won’t go away by passing the buck.

What do you find the most challenging aspects of of this situation?

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2008. | Permalink | 2 comments | Add to del.icio.us
Post tags: low back pain, physhosocial, physiotherapy, psychosocial flags, rehabilitation

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>
1. How do we determine the relative amount of resistance for an individual?.

2. How many repetitions should be done?.

3. How much rest period is necessary?.

4. How do we determine the factors limiting exercise performance clinically?.

5.How do we determine which components of rehabilitation are appropriate targets?.

6. Where is the transition between rehabilitation and conditioning?.

7. What is the difference between physiotherapy prescribed exercise and sport rehabilation / fitness instructor?.

8. How do the principals of strength and conditioning apply to rehabilitation?.

9. What do we need to know about the structures we are rehabilitating?.

10. How do we improve exercise compliance?

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Post tags: Exercise, physiotherapy, prescription, rehabilitation

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1. Speed
2. Range of Motion
3. Base of Support
4. Plane of Motion

Combining different elements of these components allows progression or regression as required. It is essential that therapists are competent in applying these principals in a clinical setting

Click exercise variables to hear the lecture.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2008. | Permalink | No comment | Add to del.icio.us
Post tags: Exercise, rehabilitation, treatment

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