Orthopaedic Physical Therapy

Orthopaedic Physical Therapy

Orthopaedic Physical Therapy FOURTH EDITION

Robert A. Donatelli PhD, PT, oes

Michael J. Wooden MS, PT, oes

Director of Sports Rehabilitation and

Physiotherapy Associates

Outreach Programs

Decatur, Georgia

Physiotherapy Associates

Continuing Education Coordinator

Las Vegas, Nevada

Physiotherapy Associates Eaton, Pennsylvania Instructor Division of Physical Therapy Department of Rehabilitation Medicine Emory University Atlanta, Georgia

CHURCHILL LIVINGSTONE ElSEVIER

11830 Westline- Industrial Dnvf." St. Louis, �fl.ssoun 63146

ORTHOPAEDIC PHYSICAL THERAPY, FOURTH EDITION

ISBN 978-0-443-06942-0

Copyright 0 2010, 2001,1994,1989 by Churchill Livingnone, an imprinl of Elsevier Inc. All rights reserved. No part of Ihis publication may bt �produced or U'ansmined in any form or by any

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Knowled8� and best pracuc� In this fidd a� constantly changing. As n�w �rch and �x�ri�nc� broad�n our knowl�g�. chang� in pnactic�. tnatm�ot. and drug Ih�rapy may h«om� necessary or appropriar�. R��rs art' advlSC'd [0 ch«k Ih� most currt'm informal ion provid� (i) on proc�u� fearurtd or (ii) by rhr manufacrurt't of each product [0 be adminisr�rtd, to verify {h� recomm�ndro d� or formula, Ih� method and dun.rion of admlnISIn.lion. and comn.indicarions. It is rh� responsibility of pnacfitiorKrs. �Iying on th�lr own �x�ri�nc� and knowlro8� of th� pau�n{. [0 mak� diagnoses, [0 d�r�rmin� dosag� and rh� �I trea[m�nl for rach mdlvidual pati�nl. and to rah all appropriat� saf�{y pU'Cautions. To th� full�[ �x[tnt of the law, n�ith�r the Publisher nor the Authors assum� any liability for any Injury andlor damag� 10 �rsons or pro�ny arising out of or �lattd to any u� of (h� ma(�rial con[ain� in this book. Th� Publisher

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Contributors

Kenneth H. Akizuki, MD

Jean M. Bryan, PhD, MPT, OCS

Anending Physician

Professor

SportSmed Orthopaedic Group, Inc.

U.S. Army-Baylor University Graduate Program in Physical

San Francisco, California

Therapy

Attending Physician

San Antonio, Texas

San Francisco Orthopaedic Residency Program

William Jay Bryan, MD

Sr, Mary's Medical Cencer San Francisco, California

Professor Departmem of Physical Therapy

Carla Bader-Henderson, ORT /L, CHT

Texas Woman's University

Hand Therapist

urgean

Stockbridge. Georgi.

The Methodist Hospital HoustOn, Texas

David s. Bailie, MD Onhopaedic Surgeon

Kenji Carp, PT, OCS, ATC

The Orthopaedic Clinic Association. PC (TOCA)

Competency Certified Vestibular Therapist

Scottsdale, Arizona

Clinic Dicecco[ Physiotherapy Associates

Charlie Baycroft. MD

Eugene, Oregon

Medical Director Foot Science Imernarional

Allen Carpenter, PT, Cert MDT

Christchurch, New Zealand

Clinic Director

Turner A. Blackburn Jr., MEd, PT, ATC

San Francisco, California

Physiotherapy Associates Vice President Corporate Development Clemson Sports Medicine and Rehabilication

Chad Cook. PT, PhD, MBA. OCS, FAAOMPT

Manchester, Georgia

Associate Professor

Adjunct Assisranc Professor

Division of Physical Therapy

University of Sc. Augustine for Health Sciences

Department of Community and Family Medicine

Sc. Augustine, Florida

Division of Experimental

urgery

Department of Surgery

William G. Boissonnault, PT, DHSc, FAAOMPT

Duke University

Assiscanc Professor

Durham,

orch Carolina

University of Wisconsin-Madison

Lori DeMott. OTR/L,CHT

Program in Physical Thempy

Hand ReHab

Madison. \'(Iisconsin

Program Coordinaror OhioHealth Physical Rehabilitation Columbus, Ohio

v

VI

Contributors

Donn Dimond, PT, oes

Lisa M. Giannone, PT

Physical Therapist

Owner/Director

Physical Therapy Associates

Active Care Physical Therapy and SportS Medicine Fitness

Beavercon, Oregon

Center San Francisco, California

Sarah DoBroka, BS, PT, ses OcchoCarolj oa

Joseph Godges, PT, OPT, MA. oes

Huntersville, North Carolina

Assistant Professor Department of Physical Therapy

Richard Ekstrom, PT, DSc. oes

Lorna Linda University

Associate Professor

Los Angeles, California

Department of Physical Therapy University of South Dakota Vermillion, South Dakota

Bruce Greenfield, PT, PhD, oes Assistant Professor Division of Physical Therapy

Todd S. Ellenbecker, OPT, MS, ses, oes, eses

Department of Rehabilitation Medicine

Clinic Direcror

Emory University School of Medicine

Physiocherapy Associates

Atlanta, Georgia

Sconsdale Spocts Clinic National Direcror of Clinical Research

Toby M. Hall, MSc, FA(P

Physiotherapy Associates

Specialist, Musculoskeletal Physiotherapist

Director of Sporrs Medicine-ATP Tour

Adjunct Senior Teaching Fellow

Scottsdale, Arizona

Curcin University Perth, Australia

Robert L. Elvey, BAppSc. Grad. Dip. Manip. Ther.

Visiting Lecturer

Senior Lecturer

Trinity College

Curkin University

University of Dublin

Physiocherapy Consultant

Dublin, Ireland

Sourhcare Physiotherapy

Senior Teaching Fellow

Penh, Australia

University of Western Australia Director Manual Concepts

Mary L. Engles, MS, PT, oes, MTC

Booragoon, Australia

Private Practice Sports Arena Physical Therapy

Matt Holland, PT

San Diego, California

Manager, Sports Rehabilitation Methodist Sports Rehabilitation

William B. Farquhar, PhD

The Methodist Hospital

Associate Professor

Houston, Texas

Depacement of Health, Nutrition, and Exercise Sciences University of Delaware Newark, Delaware

Wendy J. Hurd, PT, PhD, ses Graduate Program in Biomechanics and Movement Science University of Delaware

Sharon Flinn, PhD, OTR/L, (HT, CVE

Newark, Delaware

Assistant Professor The Ohio State University

t Scot Irwin, OPT, MA

School of Allied Medical Professions

Director

Division of Occupational Therapy

North Georgia Physical Therapy Practice

Columbus, Ohio

Dahlonega, Georgia

David Friedberg. MS, FAes

Frank W. Jobe, MD

Austin, Texas

Medical Director

Linda Naomi Futamur a, MS, PT

Cencinela Hospital Medical Center

Physical Therapist

Inglewood, California

Biomechanics laboratOry

Physiotherapy Associates Redwood City, California

to'C....d·

Contributors

Marie A. Johanson, PT, PhD, OCS

Caroline Nichols, PT, OCS, MTC, CSCS

Assiscanc Professor

Physical Therapist

Division of Physical Therapy

Ladies Professional Golf Association

Department of Rehabilication Medicine

Daycona Beach, Florida

Emory University School of Medicine Atlanra, Georgia

Lawrence M. Oloff, DPM Surgeon

Carrie Johnson, MPT

Foot and Ankle Surgery/Podiatry

Physical Therapi"

SportS Orthopedic and Rehabilitation

Seatde Sports

Redwood City, California

Seanle, Washington

Roy W. Osborn, PT, OPT, MS, OCS Gregory S. Johnson, BS, PT

Associate Professor

Associate lnsrruccor

Departmem of Physical Therapy

Physical Therapy Schools

The University of $ouch Dakota

University of Sr. Auguscine St. Augustine. Florida

Grant D. Padley, DO

Touro Coliege

Orthopedic Surgeon

Long Island, New York

Valiey Orthopedics

Codireccor

Goodyear, Arizona

Institute of Physical Art Concinuing Education InstiCUff Steamboat Springs, Colorado

Monique Ronayne Peterson, PT, OCT Clinic Direccot

Victor Katch, MS, EdD

Physiotherapy Associates

Professor of Movement Science

Humington Beach, California

School of Kinesiology Associate Professor of Pediatrics

Robert M. Poole, PT, MEd, ATC

Section of Pediatric Cardiology

Corporate Director

School of Medicine

Human Performance and Rehabilitation Cemer

University of Michigan

Adama. Georgia

Ann Arbor, Michigan

Brian L. Shafer, MD Steven L. Kraus, PT, OCS, MTC

Sports Medicine

Clinical Assistant Professor

Arizona Bone and Joim Specialists

Division of Physical Therapy

Sco([sdale, Arizona

Department of Rehabilitation Medicine Emory University School of Medicine

Lynn Snyder-Mackler, PT, SeD, FAPTA

Adama, Georgia

Alumni Distinguished Professor

Dianna Cole McNitt, PT

Academic DirectOr

Departmem of Physical Therapy Facility Director

Graduate Program in Biomechanics and Movemem Science

Physiotherapy A ssociates at the Litcieton YMCA

University of Delaware

Lirciecon, Colorado

Newark, Delaware

Heather Moore, MPT, OPT

tRobert B. Sprague, PT, PhD, GDAMT

Director of Physical Therapy

Faculey

Mishock Physical Therapy

Maiciand-Australian Physiotherapy Seminars

Skippack, Pennsylvania

Cutchogue, New York

Scott Moorhead

Thomas A. St. John, MD

Researcher

Spine Surgeon

Department of Orthopedics

Orthopaedic Associates of Aspen & Glenwood

The Methodist Hospital

Aspen, Colorado

Houscon, Texas

jo.c..sed.

VII

VIII

Contributors

Steven A. Stratton, PhD, PT, ATC

Joseph S. Wilkes, MD

Clinical Associate Professor

Clinical Associate Professor

University Health Science Center of San Antonio

Orthopa8·69 Most often, treatment is based on the

According to Millesi et ai, joint motion causes elongation of the nerve

severity of the injury, nOt necessarily on the type of injury.

bed, co which the nerve responds by elongating

Both the type and the severity of Injury determine the length

and gliding.�8 This nerve gliding in relation to the nerve bed

of time chat it takes to recover, bur the healing process is the

is referred to as tXmrIIOfl. P.�9.60 The excursion of a nerve,

same regardless. In a recent study, a high-force conceneric

to describe mechanical stresses, may be graphed on a load­

loading injury and a di rect muscle injury were compared to

elongation curve, or a stress-strain curve.61

determine whether utilizing knowledge of the rype of injury

During the "toe region" of the curve, miOimal tension

would shorten recovery time."o Investigators concluded that

results structurally in straightening of connective tissue and

the clmician who takes inco account the type of injury knows

axons.62.64 Stiffness of the nerve is shown on this graph during

the genes associated with that injury, allowing accelerated

the linear Increase, with a steeper slope indicating increased

recovery time.10

stiffness and less elasticity i n the nerve. A point of ultimate

The stages of healing start at approximately the same time

stress represents the transition between where the nerve is still

for each injury. The inRammacion stage begins almost imme­

elastic and recoverable and where it switches to permanent

diately and lasts for approximately

deformation or the plastic region.6' It is after this plastic region

Muscle regeneration begins

I week after the injury.'1 7 to 10 days after the injury and

that the nerve reaches ulti mate failure and no longer can

peaks at around 14 days." Finally, the fibrosis stage begins at

undergo additional mechanical Stress. Several facrors may affect the ability of the nerve co elon­

approx imately 14 days and increases over time uneil approxi­ mately 4 weeks POSt injury.� 1 During the fibrosis stage, scar

gate. These factors include nerve stiffness and velocity of move­

tissue is formed, signaling the end of the mwcle repair process.

ment. Nerve stiffness has been shown CO be greater in nerves

Accord ing to Huard et ai, because of the formation of scar

with long sections as opposed to multiple branchesY· Also,

tissue, complete regeneration of the muscle does not take

velocity does affeer its stiffness. The stiffness of nerve is greater

place.'"

when it is elongated quickly.61 Compression is another daily stress that nerves often encoun­

The inRammatory period is characterized by an inflamma­ tory cell response and necrosis of muscle tissue.61 This stage is

ter. This stress can be provided by adjacent tissue Structures

discussed in depth in Chapter

such as muscles and iigaments,61 and it undergoes compressive

is presented here. The immediate response is vascular changes,

3; therefore only a briefoverview

forces as it elongates. As it elongates, the nerve is resisted by

with immediate vasoconstriction ro minimize blood loss. This

Ruid and by the connective tissue in which it is comained.58•M

is followed by the inRammatory cell response, whereby neutro­

Thus the nerve undergoes tensile stress, accompanied by com­

phils arrive at the site within

pressive forces.

insult. Neutrophils have been suggested to both help and hurt

1 to 6 hours after the initial

A few factors are affected when the nerve is placed under

the muscle regeneration process. They aid the process through

mechanical stress, whether compression or tension. With relief

phagocytosis, or clearing the injured site of waste.12 Ie has been

Orthopaedic Physica l Therapy

12

suggested in the research, however, chac neutrophils also hinder

viscosity, thus slowing bloexl flOW. 19 This results in edema at

muscle regeneration by releasing free radicals and proreases.

the injury site. The cell responds during acute inflammation

which injure the myo(ubes.n Neutrophils are followed by mac­

by localizing and destroying invading pathogenic microor­

rophages, which become predominam. Macrophages continue

ganisms. This is accomplished primarily through the ptoli­

co facilitate phagocycosis7l.74 but also cause myoblast prolifera­

feration of white blood cells (leukocytes), whose role is to

tion in virco.n+711

"clean up" the wound site. Successful cleanup of the wound

The muscle regeneration phase is characterized by the acti­ vation of satellite cells. The release of satellite cells is triggered

site

(phagocytosis) marks the end of the acute stage of

inflammation.

by lymphocytes, which have already arrived at the site of the injured muscle and have released growth [acmcs and cycokines. The release of chese causes satellite cells to self-renew, prolifer­

Chronic Inflammation

ate, and join with existing muscle cells to effect muscle regen­

Chronic

eration.79 Mononucleated satellite cells become multinucleated

microorganisms are still present after acute inflammation has

inflammation

occurs

when

persistent pathogenic

myocubes, which evencually combine with myofibets, thus pro·

occurred. In this case, chronic inflammation is an extension of the acute inflammatory response. This process can continue for

mOting skeletal muscle regrowth.80 The final stage is fibrosis, or the formation of scar tissue.

months. Chronic inflammation also may have a gradual insidi­

Scar tissue is formed from fibroblasts. It has been shown that

ous onset that eventually becomes symptomatic. 19 Examples of

transforming growth factor-� (TGF-P), which is active during

these include bursitis and tenosynovitis. Macrophages continue

this phase, stimulates fibroblast proliferation and collagen syn­

their assault on pathogenic microorganisms and are joined in

thesis at low levels. 1 However, in high concencrations, TGF-�

this stage by lymphocytes. The two types of lymphocytes seen

has been shown m inhibit fibroblast proliferation and therefore

i n chronic inflammation are T cell and B cells. They function

fibrosis. 1

when previous levels of defense have failed.

Several ami6brotic agents, such as sumarin and

decorin, have been shown therefore

have

been

m

aid i n rhe reduction ofTGF-P and

effective

in

limiting

scar

tissue

formation.11

Fibroplasia With successful elimination of foreign material from the wound site, damaged tissue enters the second stage of repair:

Connective TIssue

( l ) the proliferation (2) collagen synthesis, (3) formacion of granula­ (4) wound concraction, and (5) dense fibrous scar

fibroplasia. This stage is marked by

Damaged tissues heal through a process of fibrous scar forma­

of fibroblastS,

tion, not regeneration. The repair process is essentially the

tion tissue,

same in all connective tissue types. Connective tissue repair

formation.'8 When an inj ury occurs, the need for collagen

(3)

(I) inflammation, (2)

fibroplasia,

deposition is increased. This is accomplished through the

scar maturation.19 Even though stages have been

proliferation of fibroblasts within damaged tissues. As collagen

involves three primary stages: and

synthesis occurs, temporary scaffolding, called granulation

defined, it is important m note that healing stages overlap.

tiUllt, is laid down. It is formed from Type III collagen. This adhesion has litrie mechanical strength.l8 because Type III

Inflammation

collagen lacks the strength and stability of Type I collagen.

In response to damage. the body ini tiates a repair process called

This is important for physicaJ therapists to know because this

inflammation. The major roles of rhe process of i nflammation

weak granulation tissue is very fragile and can be broken down

include

easily by manual stretching. After wound contraction, scar

( 1 ) prOtection of the body from

infection and clearance

of rissue debris from the sire of injury, and

(2)

initiation of

formation occurs

as

the new [issue matrix slowly takes on the

Structural repair processes that take place at the site ofdamage.38

characteristics of dense fibrous connective tissue but does not

Inflammation can be characterized as acute or chtonic.

duplicate the properties of normal connective tissue.19 The transition from granulation tissue to dense fibrous tissue includes:

Acute Inflammation

"(1)

a transition from Type III collagen to Type I

collagen synthesis,

Acute in flammation is the initial response ro injury, lasting

3

tion, and

(3)

(2)

an increase in overall collagen deposi­

resorption of small bloexl vessels in [he vascular

days. The signs and sympmms of acute inflammarion

bed."'9 Increased Type I collagen formation and degradation of

include increased rissue temperature, redness, and swelling.

weaker Type III collagen contribute CO greater tensile strength

The function of acute inflammation is to localize and destroy

of the scar tissue matrix. In addition, a significant increase in

ro

4

pathogenic agents and foreign materials.19 "Ie can be character­ ized by

(1)

vascular responses that result in excess fluid accu­

mulation in the affected tissues. and

(2)

cellular responses

collagen synthesis contributes CO the increasing strength of the scar tissue matrix. In one study, investigators demonstrated that the ratios of collagen Types V to I and III to I in the

that include proliferation of white blood cells and phagocyro­

healing Mel increased by

sis."19 The vascular response that occurs during acute inflam­

week

mation consists of ( 1 ) vasodilation, thus increasing bloexl flow,

(2)

increased vascular permeability, and

(3)

i ncreased blood

52,

84%

and

1 38%,

respectively." By

the ratio of collagen Type III to Type I returned to

normal levels, but that of collagen Type V to Type I remained elevated. This continued elevation of the ratio of V to I explains

Chapter 1 Tissue Response

the uniform disrribucion of small collagen fibrils.1I1 After 1 year, (he number ofcollagen cross-links was reponed only 45% of normal .lI.\ Scar Maturation

During this scage, biomechanical properties and strength of the scar tissue matrix are determined. Scar maturation is a slow process [hac evolves over several months [Q longer than a year. "The primary [anors chat conrribuce co scar maturation are ( I ) the rate of collagen turnover, (2) an increased number of Stron­ ger collagen cross-links, and (3) linear alignment of collagen fibers."19 As scar maturation occurs, the rate of collagen syn­ theSIS versus lySIS gradually approaches normal levels. During scar maturation, collagen cross-linkage is seen in the scar matrix. This contributes co increased density but less pliability than is seen with an Immacure scar. 19 The linear alignmem of collagen fibers has been shown co correlaee direcdy with Improvement In the bone-ligament compJex.-40·II-l

Bone As was noted in the previous seer ion, soft conneerive tissue heals by scar formation. Bone heals by regeneration. This restores the normaJ struerural and biomechanical properties of the bone. The repair process can be described in four phases: ( 1 ) hemaroma formation, (2) fibrocartilaginous callous forma­ tion, (3) bony callous formation, and (4) remodeling. When a fracture occurs, bleeding is seen and a hemaroma develops around the bone ends at the fracture site. This hema­ rama, along with the mflammarary response, represents the normal initial stage of bone healing. The infiammacory response is described in the previous connective tissue section. The fracture hematoma also is the place at which the osteogenic cells necessary for collagen synthesis and new bone formation proliferate} 9 Shordy after the hematoma is formed, bone cells deprived of nutrition begm co die, and tissue at the fracture site becomes swollen, painful, and inflamed.1l A fibrocartilaginous callus is formed. Fibroblasts and osteo­ blasts (bone-forming cells) emer the fraccure site to begin co reconstruct the bone. Fibroblasts make chondrocytes. As a resule, cartilage develops In the outer part of the callus. Phago­ cytic cells invade (he area to clean (he debris. Capillaries grow into the hemaroma. As osteoblasts and osteoclasrs continue to work, the fibrocartilaginous callus is converted gradually to a hard callus that IS made of spongy bone. Formation of callus generally begins 3 to 4 weeks after injury. P Remcxlellng begins as stability of the fracture site is restored. This is the process by which bones resume their normal StruC­ ture, size, and shape. I'.! Cartilage is replaced with bone as the imercellular substance deposited between chondrocytes becomes calcified and cells die. The matrix of dead bone is removed gradually by osteoclasrs. Osteoblasts move into the spaces opened by removal of dead bone, and new living bone is deposited. The callus is removed gradually by replacement of cartilage with bone and by conversion of spongy bone ro compact bone.

13

Nerve Peripheral nerve trauma and inflammation may have many causes and may result in a myriad of orthopaedic problems. Again, similar to muscle and connective tissue, nerve goes through its own inflammation and healing process. I lowever, because of the complex nature of nerves and their healing process, complete return to funcrion is not always possible. One of the most common ailments is peripheral neuropathy. It must be noted rhat rhis is a general term encompassing hundreds of different rypes of disorders rhar can vary in severiry from intermittent numbness and tingling to paralysis. It is important to remember that nerves may be moror, sensory, or autonomic. Therefore the branch chat is impaired will determine the magnitude and exaCtness of the signs and symptoms. Peripheral neuropathies may be inherited or acquired. Inherited peripheral neuropathy can result from genetic muta­ tions. Acquired peripheral neuropathy may be seen as trauma to a nerve (e.g., constrierion from connective tissue), infection, autOimmune deficiency, or systemic disease. Again, wherher acquired or inherited, rhese neuropathies manifest in different forms from mild to extremely severe. Although clinically, peripheral nerve injury presents with a myriad of signs and symptoms, the nerve Itself exhibits only a few specific responses: neuroprnxia, axonotmesis, and neurot­ mesis. In neuropraxia, axonal conduction is disrupted segmen­ tally. The myelin sheath may be somewhat gone, but nerve rransmission although slower will continue. Depending on the extent of injury that occurs to the myelin sheath, transmission may be interrupted alrogether. Patients may exhibit pain, weakness, or loss of sensation. 8� Axonormesis IS the loss of axon continuity with continua­ tion of connective tissue. On the distal axon, Wallerian degen­ eration occurs, along with changes in the cell body that take place over 5 to 1 2 days.IM Finally, neurormesis occurs as the complete separation of rhe axon; it is the most severe of all nerve injuries. Three different modes of nerve recovery are known: remy­ elination, collateral sprouting from surviving axons, and axonal regeneration.s" Recovery from neuropraxia generally requires remyelination and rakes 6 to 8 weeks.tllI Axonotmesis requires twO processes for recovery, depending on the percentage of axons involved. If only 20 to 30% of meons are involved, then the nerve will heal via collateral axon sprouting, whIch occurs over 2 co 6 months."l When more than 90% of the axons are damaged, regeneration must occur.!I·},9Q This rate of recovery differs berween proximal regeneration, which involves 6 to 8 mm per day, and diStal regeneration, which occurs at a rate of 1 to 2 mm per day.91 However, regeneration mUSt take place withlO an 18- to 24-month time frame. because this is when Schwann cells are viable; after this period has ended, regenera­ cion is nOt possible.90 As was stated previously, these injuries manifest differently, and patients can show up in the clinic with a variety of different symptoms. Signs and symptoms may be motor, sensory, or autonomic. Moror symptoms may present as weakness or

14

Orthopaedic Physical Therapy

muscle waning. Generally, nerve injuries involve a hypotonic state. Sensory loss can be seen in a single digit or in the whole hand. It also may occur as Joss of pressure-touch, loss of posi­

within the first week, ac 1 % [0 6% per day.9II·99 Although the rate of decrease slowed as time went on, by 6 to 8 weeks, force

production had decreased by 50%.91.98.101;),0102

tion sense, or loss of temperature. Sensory impairmem in the

It is important to note that physical exercise of surrounding

hands or feet may be evidem as constanc ringling. However,

joints and muscles, as much as is allowed, helps to prevent this

one must be sure co rule our ischemic pain of peripheral vas­

atrophy. It has been shown that a 30% maximum isometric

cular disease before automatically attributing tingling and

contraction for 5 seconds once a day has been enough to prevent

sensation impairment co nerve damage. Unlike the mOtor com­

disuse atrophy.103 Recent studies have gone on to prove chat the use of electrical stimulacion of the muscle will limit [he

ponem, the sensory nerve may produce hypereschesia, or exag­ gerated sensation. The autonomic response co nerve injury is

amount of atrophy caused by immobilization. 1 04- 1

06

usually orthostatic hypotension without a change in the pulse

A significant effect on neural activation was reported in a

rate. Others such as excessive swearing may occur, but the

study by Horeob:igyi et al. 107 This study demonstrated screngch

clinician must do a thorough evaluation co determine whether

loss and muscle fiber atrophy after 3 weeks of immobiliza­

auconomic faccors [(uly are the result ofperipheral nerve injury.

tion.101 However, the amount of strength loss, 47%, did not

Finally, in the presence of demyelinating nerve injury, the

correlate with the amount of muscle fiber loss, 1 1 %_101 A study

scretch reflex may be decreased. This reflex may be diminished

by Deschenes ec al showed [hat after 14 days of immobilization,

or may not be present ac all.

cortisol levels significantly increased; this was a precursor co atrophy, and no change to muscle fiber size or type was seen,lOII suggesting that neural changes, not contractile changes,

Immobilization

affected the muscle.108 One thing that seems to increase after immobilization is muscle facigue. Many studies show chat immediacely after

MUSCLE

immobilization, the affected leg seems to exhibit increased resiscance co muscle facigue.9t1•108 Shaffer ec at POStulated chat

Many adverse effecrs may occur with immobilization of muscle.

chis had more to do with metabolic reasons buc went on co

Alchough immobiiizacion somecimes is necessary for proper recovery, it is imperative that the clinician understand that

point oue that an increase in fatigue resistance did not correlate

these adverse effens begin almost immediately and, depending

non-immobilized limb.98

on the duration of immobilization, can become significant,

co lower excremity fatiguing less rapidly than it did in the The effect that immobilizacion has on muscle fiber cype is

with longer periods being more decrimental.

inconsistent throughout the literature. However, fast twiech

The most obvious effect that immobilization has on muscle is loss of muscle mass. The most significant atrophy happens

fibers are most susceptible to disuse atrophy. One study thac

in the early stages of immobilization and may occur as early as

by Lieber et al on the immobilization of a dog's quadriceps for

demonstrated support of slow twitch muscle atrophy was done

48 hours afcer immobilization.91•93 In a study by Max, it was

1 0 weeks; researchers found that the postural muscles in faCt

demonstrated that only 3 days of immobilization resulced i n a 30% loss of the gastrocnemius in rats, and at L 5 days of immo­

were most suscepcible co disuse atrophy.l09 However, suppore for fast twitch muscle atrophy is found more commonly. Edg­

bilization, a 50% loss of muscle mass was nored.94 In a study

creon et al conducted a study on astronauts and reported a loss

done on humans, specifically young soccer players, an L L % co

of cross-sectional area in the vastuS lateral is muscle, along with

J 7% loss of muscle mass was evident in the thigh after 3 1 days

a decrease in che number of fiber types, with Type lIb showing

of immobilization.9' The maximum cross-sectional area of the

the greatest loss, followed by IIa and finally 1 . 1 10•111 Additional

triceps surae muscle was found CO be reduced by 20% co 32% after 8 weeks of casc immobilization, with the greatest loss

support was offered by Widrick et al, who measured cross­ sectional area and muscle fiber types in the soleus muscle of

reported within the first 2 weeks of immobilization.96 In addition, a 21 % decrease in cross-sectional area of the quadri­

astronautS 45 days before chey were in space and again 17 days after they were in space. I I I Researchers found that Type IIa

ceps femoris was seen after 4 weeks of casc immobilizacion.97

cross-secrionaJ area had decreased by 26%, and Type [ had

Therefore it is imperacive for clinicians co be aware that when

decreased by only 15%.111 Some studies have gone on co

a patient is immobilized, muscle atrophy can begin to happen

state that fiber cype loss presents itself more specifically co

almoSt immediately. Coinciding with che loss of muscle mass is the loss of muscle force, which also has a direct correlation to the amount of time

the extensor muscle groups, as opposed to the Aexor muscle groups.II).II .. Significant changes to the muscle were seen at the cellular

spent immobilized. However, ic should be noted chat loss of

level. A study by Oki et al showed sarcomere dissolution,

muscle mass alone does not cause a dectease in muscle force; metabolic and neurologic faCtOrs also play a part.98 In a study

accumulation of connective tissue, and endochelial degrada­ tion. I II.II' Many studies have reported a decrease in the number

by Shaffer et ai, a 45% decrease in plantar flexion peak corque

of mitochondria. 1 I6•1 I1 However, one of [he most significant

was observed after cast immobilization 8 weeks after surgery for open reduction-internal fixation (ORIP) of an ankle frac­

findings has been the disappearance of the myonuclear number. l i B An understanding of the myonuclear domain theory

cure.98 The mOSt significant loss has been shown co occur

is needed before chis last statement can be appreciated fully.

15

Chapter 1 Tissue Response The myonuclear domain (heary proposes char each nucleus

the increase in fibro farty infil trates and the random pattern of

of a muscle cell is responsible (or conrrolling a finire volume

the new collagen inhibited normal gliding movement and increased the likelihood of adhesions.121 . 122

of cyroplasm or muscle tissue. Therefore. for a muscle co hyper­ [(aphy, it must increase its number of nuclei [0 control muscle

In

immobilized

joints,

cartilage

surface

irregularities

[issue. These nuclei are derived from satellite cells that fuse

appeared after 2 weeks and progressed rapidly ro plateau after

with the muscle and donate their nuclei .119 The disappearance

8

of myonuclear number was shown by Smith er al afrer immo­ iS bilization of a rabbit's hind limb. l Omcomes, however, differ

immobilization. It is decreased up to

rate under test load is increased up to

gready on whether [he number of myonuclei or [he myonuclear

of immobilization). ' H One study performed on human spinal

weeks. In The overall thickness of cartilage is affected by the deformation (after

11

weeks

domain is decreased. Additional research is needed in chis area,

cord patients at 6,

so char researchers can learn [he exact effect char immobiliza­

progressive thinning (atrophy) of human canilage in the

rion has on myonuclear domain and number.

absence of normal joint loading and movement.121 Detrimental

It is of significam importance [Q note chac posicioning of a

12,

and

9%, and 42%

24

months POSt trauma showed

changes to carrilage are also seen with partial weight bearing.

muscle, even If it is not being used, will gready affect results

Findings

Immediately fol lowing the period of disuse. Most research in

limb, whereas no change was observed in the conrralateral

this area has been performed on unloaded limbs as opposed to

knee.ll6

immobilized

li mbs.

limb

immobilization

studies always

revealed.

changes

in

the

panial

weight-bearing

With i m mobilization, ligaments lose strength and stiffness,

reported significandy greater deficits im mediately following

and

the period of disuse. Although certainly detrimental effects did

immobil ized for

their

insertion

poinrs

are weakened .m.12!!

8 weeks showed

Ligaments

a decrease in maximum load

occur during unloading, differences among them must be

to fai lure, a decrease i n energy absorbed at failure, and an

noted. One author hypothesized that differences may be due co

increase in extensibility.'29 A study done by Woo on ligaments

the shortened posicion that the muscle mUSt maintain con­

showed that ultimate loads and energy absorbed at failure of

standy during immobilization.,o7 His study found a

the femur-MCl-tibia complex were only

47%

31%

and

18%,

loss in quadriceps muscle strength,,07 as opposed to another

respectively, of contralateral nonimmobil ized conrrols. l w A

study, which conducted limb unloading for the same time

study on the effects of physical activity on ligament insertions

period and showed only a

20%

reduction

in quadriceps

in the knees of dogs showed that failure occurred at rhe tibial insertion rather than at the midsubstance because of increasing

strength. 110 Ul timately, what immobilization leads to is lack of func­

orrhoclastic activities at the insertion site. I U It also has been

tional ability. All of the changes to muscle described previously

shown that different ligaments demonstrate different changes

will correlate with a loss in functional ability. Clinicians need

in tensile properties after immobilization.l.\1

to focus on restoring these functional deficits. Functional loss

Effects on immobil ized tendons are similar to those on liga­

is relative, and understanding the patient and his or her life­

ments. Immobilized tendons attophy, with degradation of

style will allow the rehabi litation specialist to focus trearment

their mechanical properties. .,J The space between the tendon

on the deficits that need to be treated . For example, a reti red

and its sheath is decreased significantly or is eliminated com­

70-year-old who lives a sedentary lifestyle may need to gain

pletely as a result of adhesions. This restricts the gliding action

ambulation for only short periods to be functional, but a

of the tendon within its sheath. " ;.4 The vascular supply also is

70-year-old school janitor must regain the ability to perform

affected by immobilization. Poor, random growth of blood

seeps, ambulare long distances, and stand for long periods of

vessels is the result of immobilization. \R

time. It is important to document all of this information when raking a complete hisrory.

Incteased joint stiffness is commonly seen after immobiliza­ tion. It has been shown that after

9

weeks of immobilization,

the amount of torque required to initially extend a rabbit knee is increased significanrly. m.l.J6 The Joint capsule also failed ar

CONNECTIVE TISSUE Akeson and associates have done several classic studies on the

effects of immobilization on connective tissue.121 .12l After

lower loads than in control joints. Changes in the force required for motion and i n the load at failure were evident after 16 days of immobilization.

immobilization of rabbit knee joints, they reported the follow­ ing findings:

( 1 ) loss of ground substance and warer, (2) no net 9 ro 13 weeks, (3) formation of collagen

collagen loss until

BONE

interfiber cross-links at microscopic and macroscopic levels,

Bones are immobil ized for various reasons and in different

and

ways. It is important during fracture repair/healing that frac­

(4) a

haphazard lylOg down of newly synthesized collagen

and 6bro fatty infiltrates visible at the macroscopic level. The

rure fragment position is maintained and protected ro permit

authors theorized that loss of water and GAGs, although total

solid bony union.19 Although immobilization may be necessary

collagen remained the same, would decrease the space between

for fracture healing, as well as healing of other inju ries, it has

collagen fibers in the connective tissue, thus altering free move­

detrimental effectS on bone. Bone accretion and absorption are

ment between fibers. This lack of free movemenr tended to

maintained in equilibrium by weight bearing and muscular

make the tissue less elastic, less plastic, and more brittle. Also,

conrraction.IH•I40 Immobilization changes the equilibrium and

16

Orthopaedic Physical Therapy

induces a very rapid increase in osteoclast activity. This signifi­

tissue, which actually can set the muscle up for recurring

cant rise in osceoclasric activity can be seen within 24 hours of

injury.7I Formation of scar tissue usu31ly begins at rhe second

immobil ization.141 The mineral comene of [he bone also is

to third week after injury, and scar tissue increases in size as

dimi nished during immobilization, as can be seen by increased

time goes by.11 A study that examined whether immobilization

secretion of urinary calcium. The mechanical properties of bone

or sututing was bener for fibrotic tissue concluded thar surur­

also change

with

the

loss of its

organic

and

inorganic

ing allowed the prevention of fibrous rissue deep in the muscle bur still aJlowed some scar rissue to form superfici31ly, whereas

components. The hardness of bone steadily decreases with the duration

immobilizarion allowed scar rissue to form bath deep within

ofi mmobiliz3rion. After

the muscle and superficially.l c

'" .c (J ..

-4 -6

-8 -10 -12

"

-

-"'---_--- - Radius Tibia

\ ,....... -\ '-" ...... -� Calcaneus ...... . \ ... / \ "' _ /_ Lumbar spine \ , 't---------- _T � • Fem oral neck \ / \ / \ / \ / \ / \ / \ / \ / \ / \ \ / _ -

Peripheral effects

Cardiac effects

/�

_

I PNS

I

Blood volume

I CVP

- SNS

I b Response I NE Response

I

I HR

!

�

I

r

+ Caplllarization Max co

Cardiac filling

I

II SV

ctanee

1(7)

1o, delivery

- a·v02

'>I

Bed rest 4 months

Reambulation 6 months

Figure 2-5 Changes in bone mineral density after bed rest. (From Bloomfield SA: Changes in musculoskeletal structure and function

Figure 2-6 Effect of b ed rest on maximum oxygen

consumption NOl

max). (From Convertino VA: Cardiovascular consequences of bed rest:

effect on maximal oxygen uptake. Med Sci Sports Exerc 29(2):191196, 1997.)

with prolonged bed rest. Med Sci Sports Exerc 29(2):197·206, 1997. Leblanc AD, Schneider VS, Evans HJ, Engetbretson DA, Krebs JM:

Bone mineral loss and recovery after 17 weeks of bed rest. J Bone

Miner Res 5(80):843-850, 1990.)

Exercise can attenuate the physiologic consequences of immobilization and bed resc. Isotonic exercise on a cycle ergometer during bed rest, for example. maintained plasma and

Paciencs who are able co walk during the first 2 months after

red cell volumes and peak V0 •17 The exercise was performed 2 for 30 minutes twice a day, and consisted of short-

;:: (J « ui " « z

NORMAL AND I

FOR 70 KG BODY WEIGHT

1

0 Iz w 0 z w

63

18

59.5

17

58.0

16

52.5

15

49.0

14

a.

w 0 >'

45.5

(WAnS)

50

1500 (245)

42

13

I

1350

':; «

42.0

12

38.5

11

34.0

10

31.5

9

w I

f-

(221)

I ':; «

28.0

8

!J!-

24.5

7

21.0

6

Ul 0 w (J t:

17.5

5

� :;

14.0

4

� a. :;

10.5

3

;!: z

1050

34

900 (148)

(123)

0 w

:;

�

:::;

III

.

2.5

Ul

(98)

300 (49)

7.0

3.0

2

1 1

3.0

3.5

23.0

3.0 22. 3.0 21. 3.0 20.1 3.0 19.1 14

3.0

18.0 17.

15. 14.

13.0 11 .

12

3.0 3.0 10

150 (24)

IV

25.0

3.0 24.

459 (74) 1.7

>-

1

PER 30 SEC MPH/"/.GR

3.0

600

w

II

16

1200

750

>a:

1

18

(197)

(172) >-

1

3.0 3.0 3.0 3.0 3.0 3.0

6.0 5.0 4.0 3.0 2.0 1.0

2.5

0

1.5

0

1.0

1

9. 8.0 7.0

0.5

0

Figure 2-7 Oxygen cost

of

different

stages of the Bruce treadmill protocol. (From

Whaley

guidelines

for

MH,

editor:

exercise

ACSM's

testing

and

prescription. Seventh ed, Philadelphia: 2006, lippincott Williams & Wilkins.)

Frequency

5 days per week

Intensiry

Modemte (40% to 59% of HRR)

which is appropriate for most physical thetapy patients.

Time

30 minutes (continuous or multiple bouts)

Type

Aerobic (endurance)

Moderate-intensity exercise,

Rate of progression

G",dual

HRR, Heart rate

reserve.

focus here is only on moderate-intensity physical aCClVlty, as

defined specifically by ACSM,

is 40 to 59% of heart rate or oxygen consumption reserve (Table

2-1).'·"

This is where it is helpful

(0

obtain data from a fitness test;

a more precise and customized intensiry can be given, includ­

The ACSM/AHA position paper provides examples of com­

ing a [raining heart rate range and MET range. As an example,

bining moderate and vigorous activities (hrougham rhe week,

a 40-year-old male with no risk factOrs or symptoms (risk

but-as was stated earlier-to simplify this presentation, rhe

stratification: low) has a resting heart rate of 78 beatS per

33

Chapter 2 Exercise Treatment of the Rehabilitation Patient: Cardiopulmonary and Peripheral Responses

Classification of Physical Activity Intensity

Table 2-1

Relative Intensity

Very lig ht

Light

12 MET (10, max

Maximum HR, %

(lo,R, % HRR, %

Inlensity

Absolute Intensity Ranges (METs) Across Fitness levels


ending speed of 3.4 mph and an ending grade of 14%. He

this activity can be used to modify the intensity (below 118,

reaches a peak heart rate of 178 beats per minute and a peak

speed up; above t 37, slow down).

blood pressure of 190/86. No symptoms or arrhythmias art

Without exercise or fitness testing data, a training heart rate co

noted. Estimated METs for this speed and grade are 10 (see

still can be determined by using 220 - Age

Figure 2-7). This particular patiem, with a MET value of 10,

exercise heart rate, and chen going through the same calcula­

is JUSt below the 50th percemile value of 10.9 for 40- w 6

tions as illustrated above (as above, resting heart rate needs to

49-year-old men (as depicted in Table 2_2).3U

estimate peak

be assessed). Also, without data from a fitness test, a reasonable

In this example, we will take 40% to 59% of the heart rate

assumption is that brisk walking at a pace of 3 to 4 mph rep­

reserve to come up with a training heart rate. Heart [""'Jte reserve

resents moderate-intensity exercise for mOSt adults. To further

(HRR) is calculated as follows: (Peak exercise heart rate -

guide exercise intensity, a raring of perceived exertion (0

Resting heart rate) (Desired imensity) + Resting heart rate. In

scale) of 5 to 6 can be viewed as "moderate-intensity" exer­

to

10

our example, to calculace 40% of HRR, do (he following: (178

cise.I.311 If using rhe 6 to 20 Borg Rating of Perceived Scale,

- 78) (0.4) + 78

118 bpm. To calculate 59% of HRR, do

moderate-intensity exercise would be 12 to 13. �U6,}9 It is also

rhe following: (178 - 78) (0.59) + 78 = 137 bpm. Therefore,

importane to incorporate a brief warm-up and cool-down into

=

for this hypothetical patient the heart rate training range is

(he exercise session (5 to LO minUtes each should suffice). To

118 to 137 bpm. We also can provide this patient with an

encourage lifelong participation, care should be taken to ensure

MET training range. To calculate the appropriate MET train­

that rhe person enjoys doing the activity that is being

ing range, a similar procedure is followed. Oxygen consump­

prescribed. Resistance training is also very importane but is

cion reserve(using METs) is calculated as follows: (Peak METs

discussed elsewhere in this text.

- Resting METs) (Desired intensity) + Resting METs. To calculate 40% of oxygen consumption reserve, do the follow-

Several other approaches can be used

to

provide a p
and public health in older adults: recommendation from

counrermeasure: results of the Berlin Bed Rest study,

the American College of Spons Medicine and (he Ameri­

) Appl Physiol 99(4): 1293-1 300, 2005.

can Hear< Associarion, Moo Sci Sporrs Exerc 39(8):1435-

33. Thijssen DH, Ellenkamp R, Smits P, Hopman MT: Rapid vascular adapcations

co

training and detraining in persons

wirh spinal cord injury, Arch Phys Med Rehabil 87(4):47448 1 , 2006.

1445,2007. 39. Borg GA: Psychophysical bases of perceived exertion, Med Sci Sporrs Exerc 1 4( 5):377-381, 1982.

CHAPTER

3

Sarah DoBroka, Robbin Wickham-Bruno, and Lynn Snyder-Mackler

Theory and Practice of Muscle Strengthening in Orthopaedic Physical Therapy

and the cross-bridge on rhe myosin filament binds co the actin

Muscle strengthening is a core focus of orthopaedic physical therapy practice. This chapter addresses issues of muscle physi­

filamenc. Rotation of the cross-bridge head from a 90-degree

ology, skeletal muscle force generation, muscle fatigue, (issue

angle co a 45-degree angle shorrens rhe sarcomere (Figure 3 2).

healing, immobilization, and physiologic changes in training

Cross-bridge cycling continues uncil no addidonal aerion

to provide a theoretical basis for muscle sccengthening in [rain­

potentials arc received. Throughout the action potential, the

ing and rehabilication. Case presentations are used co illustrate

SR is aerively resequestering Ca2+. In rhe absence of a new H action pocential, rhe rate of Ca uptake exceeds rhe rate of

how rhe science can inform practice.

r�lease, returning rhe cytosolic Ca2+ concentration to the resting level.l Actin resumes its resring conformation, wirh the cross­

MUSCLE PHYSIOLOGY

bridge binding sire blocked, and rhe skeleral muscle cell returns

process: (1) An action porenrial arrives at rhe sarcolemma, and CO

the relaxed stace.

ine triphosphate (AT P ) requirements. During a concentric con­

Cal+­

traction, many cross-bridges are formed, dissociared, and

[caponin, a regulatOry protein associated wirh

re-formed ar the nexc available cross-bridge site on the actin

rhe intracellular calcium (Ca2+) concemration rises; ions bind

(2)

to

Different types of muscle contmccion have different adenos­

Comraccion of a skeletal muscle cell is rhe result of a five-step

tropomyosin, causing a change in oriemarion of rhe rroponin!

filament. Each cycle, cross-bridge binding and dissociation,

tropomyosin complex (Figure 3-1); (3) cross-bridges form

requires energy input of one ATP. At low loads, the rate of

becween the actin and myosin filaments; (4) Ca2+ dissociares

fiber shortening is high and cross-bridge cycling is rapid. ATP

from [roponin once rhe stimulus is removed; and (5) accin

expenditure is consequently high. As the load is increased, the

recurns co its resting srare, and furchcr cross-bridge formarion

rare of muscle shorrening decreases with a subsequent decrease nored in AT? hydrolysis, because the rate of cross-bridge

is disallowed. This five-step process is called the cOlltractioll­

cycle. I Wle

the specific

cycling is decreased. If rhe load is further increased ro rhe paint

Contraction of a muscle under volumary comrol begins

overcome the load. no shortening occurs and the muscle con­

wirh an impulse generated in the moror corcex of the brain.

traces isometrically. AT? still is needed because the cross­

The impulse is carried from the cencral nervous system co the

bridges cycle but return to the same binding site during each

relaxation

now will rake a closer look

3r

where the muscle is unable to generate a force sufficient to

mechanisms involved in rhis process.

muscle via a peripheral nerve rhar synapses ar the sarcolemma

cycle. An eccencric contraction requires no AT? expenditure

of an individual muscle cell. Generation of an action pocenrial

because rhe cross-bridge remains in a high-energy state during

changes the permeability of che cell membrane, and sodium

dissociation and therefore can bind to the acrin filament again

and calcium ions from rhe extracellular Ruid Row inco the cell.

wirhout further energy inpuc.l

cause

Muscle requires a conSrant supply of ATP for conrraction.

a conformacional change in rhe rroponinlrropomyosin complex.

ATP promotes dissociation of the aerin-myosin cross-bridge

The inRux of exrracellular Ca2+ by itself is insufficient

ro

However, the increased intracellular Cal+ concenrrarion srimu­

(actomyosin complex). Energy resulting from hydrolysis ofcen

lares rhe sarcoplasmic reticulum (SR) to release its stored Cal+.

activates rhe dissociated cross-bridge, and another actOmyosin

Calcium ions from the SR increase the cytosolic concentration

complex can be formed. ATP also provides the energy for active

of Ca2+ to more chan 1 .. llM. Ar cyrosolic Ca1+ concencrarions

resequestering of Ca2.. from cytOsol by the SR via the Ca2+_

greater than I JlM, Ca2+ binding sites on troponin are fully

ATPase pump. In rhe absence of ATP, rigor morris ensues

occupied, thus increasing the space occupied by rhis complex.2

because the intracellular Cau concenrracion remains elevaced

Steric hindrance causes rotation of the tropomyosin and actin

and the cross-bridge is held in a fixed position on rhe actin filamen r. I •2

filamencs, leading ro exposure of the cross-bridge binding site,

37

Orthopaedic Physical Therapy

38

Contracted

100

_

Load

90' orientation

80 Strong binding and cycling

++ 4Ca

"

Tropomyosin

Load

45' orientation

Actin 40

, .... ..".. ,

20

Load

o 0.01

10

0.1

100

Myoplasmic [Ca+ +) (�M) Figure 3-1 Calcium (Cal.) ions bin d to Iroponin, a regulatory protein associated with tropomyosin, causing a change in the orientation of the actin filament. (From Koeppen B, Stanton B, levy M, el al: Physiol­

ogy, ed 4. SI. Louis, 1998, Mosby.)

Although ATP is the energy currency for all mammalian cells,

ocher

compounds,

including

reduced

nicotinamide

Figure 3-2 Sarcomere shortening as a conformation of cross-bridge changes. (From levy M, Berne R:

Principles of PhYSiology, ed 3. SI.

louis , 2000, Mosby.)

anaerobic breakdown of glucose. Two ATPs are also formed from substrate level phosphorylation during glycolYSIS. During

adenine dinucleotide (NADH) and Ravin adenine dinucleotide

screnuaus exercise, the circulacory system sometimes is unable

energy vouchers that can be convected CO

to supply sufficiem oxygen to meet cellular needs, and the

ATP under aerobic conditions. At rest, mammalian cells have

respiratory chain cannm process all of the hydrogen joined to

minimum energy requirements and intracellular ATP concen­

NADH. Under these conditions, nonoxidized hydrogens tem­

(FADH1). serve

as

concentracion inactivates the

porarily combine with pyruvate to form laccic acid. Skeletal

enzyme pathways of energy production to conserve resources

muscle is unable to use lactic acid for further energy produc­

for times of need. At the onset of exercise, the muscles use

tion. Therefore, it is removed from the muscle by the Cori cycle

trations are high. A high

intracellular ATP Stores

as

ATP

the initial energy source, but the

cell can store only enough ATP for the first 2 to 3 seconds of

and is transported to the liver, where it is converted back to pyruvate and muscle glycogen (gluconeogenesis).

exercise. The cells need a way to replenish ATP if additional

When the pyruvate formed in anaerobic glycolysis irrevers­

work is to be performed. A small amount of ATP is formed

ibly converts to acetyl-coenzyme A (CoA), it emers [he second

from the phosphorylation of adenosine diphosphate (ADP) via

stage of carbohydrate breakdown, known as the citric acid cycle

the phosphocreatine (PCr) system. PCr donates a high-energy

(also called the Krebs cycle). During the citric acid cycle, each

phosphate group to ADP under enzymatic comrol to regener­

molecule of pyruvate yields four NADH, one FADH1, and one

ate ATP. However, direct phosphorylanon from PCr provides

guanosine triphosphate (GTP) (an energy eqUivalent of ATP).

energy for only lOco 20 seconds. \.-4 Energy released in macronutriem (carbohydrate, fat, and

Thus, one molecule of glucose gives twO GTP, eight NADH, and twO FADHl from the citric acid cycle.� NADH and

protein) degradation serves the crucial purpose of ATP resyn­

FADHl must undergo further processing to

thesis. The specific pathways of breakdown differ depending

the energy.rich compound ATP.

be

converted to

on the nuuiems mecabolized. Carbohydrates are the only mac­

During oxida(ive phosphorylation, NADH and FADH2

ronuuients whose stored energy generates ATP anaerobically.

transfer twO electrons to a series of cytochromes within the

Glucose degradation occurs in twO scages. In glycolysis, the

mitochondrial inner membrane, which are alternately oxidized

first stage, a series of 1 0 enzymatically comrolled chemical

and reduced. Oxygen serves

reaccions rapidly create twO molecules of pyruvate from the

electron transport or respiratory chain. Electron transfer is

as

the final electron acceptor in the

Chapter 3 Theory and Practice of Muscle Strengthening in Orthopaedic Physical Therapy

39

accompanied by [he release of hydrogen ions (H�. The hydro­

by the body. Carbohydrate U(ilization rises precipitously

gen ion concemracion increases in the mitochondrial matrix, creating a proton gradienr. ATP is produced by pumping rhe

during exercise aboU( the ventilatory threshold where the Krebs cycle is saturated, and glycolysis again plays a primary

prawns across rhe inner membrane when oxygen is presem.

role in energy generation for exercise. Ie is important to note

This process yields 2.5 ATP for every NADH molecule and

that carbohydrate is the only substrate that can be used in

1.5 ATP for every FADH2• Overall, under aerobic conditions, one molecule of glucose will generace 2 ATP, 2 GTP, 22.5

ance activities require a very high percentage of carbohydrates

ATP from NADH, and 3 ATP from FADH" for a tOeal of

compared with a very low percentage of faes.'"

glycolysis. This explains why high-intensity sprint and endur­

approximately 30 ATPs char actually will cmer rhe cytOplasm of rhe cel1.6 Aerobic breakdown of a carbohydrate is morc effi­ cienr for generating rapid energy compared with farry acid

SKELETAL MUSCLE FORCE GENERATION

breakdown for energy production. Fats, or rriglycerides, consist of a glycerol backbone and

The force thac an individual muscle can generate is modulated

three fatty acid side chains. Relative to carbohydrates and

over a wide range. (Think of holding an egg versus gripping a

protein, stored fat provides almoSt unlimited energy. Accumu­

baseball bat.) Grading of force can be accomplished by rate

lation of triglycerides in adipose cells functions as energy

coding or recruiting motOr units. Rate coding refers ro increas­

storage during cimes of plenty (postprandial). Cells cannot use

ing or decreasing the frequency of mOtor neuron discharge,

fats direcdy [0 form ATP. The fars first must be hydrolyzed to

thus changing the firing rate of muscle fibers within the motor

constituent parts, and some carbohydrate catabolism is required

unit. The components of a mOtOr unit are the alpha motOr

to process f.1t into energy. After a series of chemical reactions,

neuron and the muscle fibers it innervates. A muscle consists

glycerol is converted to pyruvate to form ATP during subsrrate

of thousands of motOr units. Within a single motOr unie, the

level phosphorylation (glycolysis). Fatty acids undergo further

fiber type is constant. Different motor units within a single

degradation via the consecutive removal of twO carbon frag­

muscle include different types of fibers, and the proportion of

ments with subsequent conversion into acetyl-CoA through a

the three fiber types within the muscle depends on the function

process called beta oxidation. Each round of bera oxidation also

of the muscle. Individual fibers in a motOr unit cannOt function

yields one NADH and one FAOH2• Acetyl-CoA has direct

independently. Therefore, an action pOtential chat causes one

entry into the citric acid cycle, and NADH and FADH2 are oxidized in the electron transpon chain. Fats can be oxidized

fiber to fire results in firing of all fibers within that motor unit.

only in the mitochondria, and under anaerobic conditions, fat breakdown is brought to a hale" Naturally occurring fany acids have an even number of

This is known as the all-or-lJone phe!lol1le!lolJ. Skeletal muscle fibers 3re classified into three groups based on the energy production system, coments of the cytoplasm, structural characteristics, and the ability to generate tension.

carbons. The 16- and l8-carbon chains are most common in

Type I fibers (slow oxidative [SO)) rely on aerobic pathways for

biological systems. For example, palmitic acid, a 16-carbon

energy production. Consequently, oxidative enzyme concentra­

fatty acid, goes through seven cycles of beta oxidation, yielding

tions, mitochondrial content, capillary density, and myoglobin

eight acetyl-CoA, seven NADH, and seven FAOH2• Each ace­

concentrations are high. These cells generate extra AT? per

(yl-CoA yields the equivalent of 10 ATP in the cirric acid

oxidized glucose molecule. Therefore, the amount of intracel­

cycle. Thus, the cotal ATP produced by the complete oxida(ion

lular glycogen (the storage form of glucose) is typically low.s

of one molecule of palmitic acid is 108 ATP. Because 2 ATP

As can be seen in Figure 3-3, Type I fibers take longer to reach

is used to activate (he breakdown process, rhe net ATP is 106

peak force, and the twitch lasts longer. However, despite a

(compared with 30 ATP per glucose molecule).1

longer twitch, peak force OU(put is low.? Neural impulses (0

Carbohydrates and fats ideally serve as the primary energy

slow oxidative fibers are delivered in long trains of low-fre­

substrates, but dietary intake determines which fuels will be

quency pulses.lO This combination of high oxidative capacity,

utilized most by the body. Ingested protein is used [0 maintain

low force Output, and low-frequency neural input beStoWS

muscle, blood plasma, and visceral tissue protein. However,

fatigue resistance on Type 1 fibers.

protein can be used as a major source of energy production

Type Ilb fibers (faSf glycoly(ic or fase facigue [FFJ) have a

during extreme endurance-type activities and arduous training.

large cross-sectional area (CSA) composed primarily of contrac­

or during srarvation conditions." The conversion of protein to

tile proteins. These fibers rely predominantly on anaerobic

ATP is beyond the scope of this book, and the reader is referred

glycolysis for energy production. Because oxygen utilization is

to physiology, nutrition, or molecular biology books for addi­

minimal, rhe number of mitochondria, the capillary density,

tional details.

and the myoglobin concenrration are low. Glycolytic enzyme

fat utilization depends on the intensity and duration of exer­

levels are high, as are glycogen stores.s These fibers are capable of generating large forces quickly (time to peak force is fast,

cise. As the activity level increases, the percentage of usage of

and twitch duration is short), but they fatigue rapidly.9 Nerves

The relative amount of carbohydrate usage compared with

each substrate changes. At rest, the body uses almost double

that supply Type lIb fibers generate shorr bursts of high­

the quantity of farty acids to fuel metabolic processes compared

frequency impulses.10

with carbohydrates. During light to moderate activity, fats and

Type IIa fibers use boch aerobic and anaerobic energy pro­

carbohydrates each generate almOSt half of the energy needed

duction systems and are identified as fast oxidacive-glycolytic.

40

Orthopaedic Physical Therapy FF

5

0.8

�

.2 O.S

al

.� 0;

E

0.4

0 z

0.2 Figure 3-3 Modcllwilches of fasl f aligable (FF) and 0 0

20

40

so

80

100

120

140

Time (ms)

lS0

180

200

slow (5) molor units. (From Clamann HP: Motor unit recruitment and the gradation of muscle force. Phys Ther 73:830. 1993.)

or fasc fatiguc-rcsismm (FR). fibers. Type Ila fibers represent

Training techniques also inAuence the proportion of muscle

an intermediate fiber eype, where oxidative and glycolytic

fibers in a muscle. Training may develop the fibers best suited

enzymes are presenr in moderate amounts. Myoglobin, mitO­

co perform a certain task while minimizing rhe development

chondria. and capillary density also are found in moderate

of other fibers. This has rhe effect of making the percentage of

amounts. Glycogen s(Qres are high co provide substrate for (he

the developed fiber type greater on cross-sectional area while

less efficient glycolytic system. These FR fibers are capable of

nOt changing the absolute number of each fiber type.

generating large forces." The acrion potencial chac follows

The strength of a motOr unit depends on the fiber type, the

shore, high-frequency burses of stimulation resembles chur of

number of fibers, and the force per unit area (specific rension).

Type lib fibers.9,10 Generally speaking, rhe FF moror units in

Contraction strength is variable, with a twitch contraction

a particular muscle generate more force (han rhe FR fibers, and

being on average only one-fifth as scrong as a tetanic comrac­

rhe Fit motor units produce greatcr force chan rhe SO fibers.

tion. Rate coding, or increasing the frequency of stimulation

However, chis single muscle generalization does not apply

of a motOr unit, aCCOuntS for a fivefold increase in force pro­

when force outpm is comp.'lred across differem muscles within

dun ion (average range

the same organism.9

need for greater force by recruiting addicional motOr units.

==

2 to 15).9 The muscle responds to the

The proportion of differem fiber rypes in a muscle is detcr­

Recruitment order is a function of motOr lInic size, activation

mined in part by genetic predisposition, rhe rype of activity

rhreshold, and maximum force capability. Small, low-rhreshold

performed, and neural inpuc. Buller er alii demonstrated the

motor units with low strengch capacity are recruited firsr.9�.9lJ

inAuence of neural input on muscle by switching the nerves

This pattern of recruitment provides incremental increases in

supplying an SO muscle (soleus) and those supplying an FF

force production by the muscle (proportional control). For

muscle (medial gastrocnemius). Upon reinnervation, the FF

maximum force output, the largest motOr unirs with high

muscle took on properties of irs new innervation and became

thresholds must be recruited and activated at a high rate.

slower, while the SO muscle became faster. Recem studies have established thar fasc-eo-slow fiber type conversion involves morphologic and biochemical changes rhat result in altered

MUSCLE FATIGUE

concraccile propenies and endurance capacities. Functional adaptations of skeletal muscle cell electrophysiologic properties

Muscle fatigue can be defined as any acute impairment in the

also occur. Mocor neuron firing patterns concrol the expression

ability to exert force or power, regardless of whether rhe task

of isoforms of contractile proteins and metabolic enzymes on

itself still can be performed successfully. Fatigue subsequently

muscle fibers. Cominuous electrical stimulation has mimicked

can result in feelings of tiredness, exhaustion, and lack of

these firing patterns, promoting the conversion of FF fibers to

energy. It is a symptom, not a disease. Certain health problems

SO fibers.ll The exa(( cellular signaling mechanisms involved

can result in muscle fatigue, but their discussion is beyond the

in fiber type conversion still are p<x:>rly understood, but changes

scope of this chapter. Often, the fatigability of a muscle is

in incracellular free Cal+ concencration seem eo be essentially

characterized by endurance time (sustaining force or power) or

involved.1\ This conversion phenomenon has been utilized as a

the extent of reduction of force or power. . 6 How quickly rhe

treatment for heart failure. In dynamic cardiomyoplasty, the

muscle fatigues is dependent upon how efficient rhe body is in

latissimus dorsi is conditioned via electrical stimulation to

utilizing anaerobic and aerobic metabolism (i,e., how quickly

assume characteristics of cardiac muscle to augment left ven­

the body can keep generating ATP for energy). Aging also

tricular ej('Ction.l04.I� It is imponanc to note that stimularion

plays a role in the farigability of a muscle, in rhar a shift toward

programs that promoce the revers�onversion of SO to FF­

a greater proporrion of SO (Type I) muscle fibers in the body P.t should result in improved muscle endurance capacity. 9

have yet co be elucidated.

Chapter 3 Theory and Practice of Muscle Strengthening in Orthopaedic Physical Therapy

41

Fatigue can occur at ccorral or peripheral sites. Cemral

monocytes) soon follow. Neucrophils are drawn to rhe injury

fatigue is a progressive exercise-induced reduccion in the level

site by chemotaxis, and they pass from circulation inro the

of voluntary accivarion of

tissue through a process called

n

muscle that appears to be task

dependenr. Studies have shown that people who were unfamil­

diapedesiJ.

The mechanisms

responsible for recruiting macrophages remain unknown, but

iar with a fatigue [ask showed greater predisposition for central

speculations suggest that injured tissue releases a signal. The

farigue.16 Anocher study revealed chat voluntary fatigue may

interactions between neutrophils and macrophages remain

occur as a result of conscious or unconscious mechanisms. A

poorly understood, but early removal of bacteria and cellular

person may decide that a sensation is unacceptable and may

debris by phagocytosis has been shown to have a direct effect

deliberately reduce the level of activity. Alternatively, afferent

on rissue repair and regeneration.H Lymphocytes rag invading

informacion from working muscles. joines. or tendons may

bacteria for destrucrion by the immune system, and platelers

inhibit mocor activity at spinal or supraspinal levels.lO Despite

prevenr further bleeding by depositing a fibrin mesh that forms

numerous studies, comroversy srill surrounds the exact role

blood clots.

that central activation plays in healthy individuals.21

The acute inflammatory responses seen aftet an injury are

Peripheral factors responsible for muscle fatigue include

importanr to the healing process. Debare is ongoing regarding

decreased muscle membrane excitability and failure in the

which form of analgesia is most conducive to promoting early

excitation-contraction (EC) mechanism. EC failure typically

healing while simultaneously providing pain relief. Recenr

occurs during action potential propagation andlor during

animal studies have examined the effects that nonsteroidal

calcium regulation at the level of the contractile elements. In

anti-inflammatory drugs (NSA1Ds) have on tendon healing.

conjunction with neuromuscular contributions, muscle blood

Findings suggesr detrimental biomechanical effects, including

Row has an important role in the development of muscle fatigue. Blood Row alters the depletion of energy substrates and

decreased failure loads and increased races of failure, when the . medicine was initiaced immediately postoperacively.24 n Ibu­

the accumulation of metabolic byproducts, which ultimately

profen appeared to be the one exception as it showed no effect

affects the contractile properties of [he exercising muscle.16

on healing strength. Based on these conclusions. it is recom­

Blood flow occlusion during a muscle contraction also can

mended that acetaminophen and opiates be prescribed more

occur in those with larger muscle mass, resulting in premature

9fren, and that NSAIDs be used more judiciously in rhe acute

fatigue.19 All of these factors must be taken into consideration

hours following an injury.l4

when one is designing a scientifically based training or reha­ bilitation program.

Goals of rehabilitarion during the inflammatory phase are to decrease pain caused by irritating chemical agents (hista· mine, bradykinin, and prostaglandins), decrease swelling, and promore range of morion. Effective medications were discussed

TISSUE HEALING

previously, bur other physical agenrs can be used in conjunc­ tion to provide additional relief. Cold modalities are used not

After injury occurs, regardless of origin (e.g., trauma, bacterial

only for their analgesic effects, but also ro decrease the meta·

infection, surgery), the damaged tissue undergoes a typical

bolic rate of surrounding healthy tissue to minimize hypoxic

physiologic response.22 The first 24 to 72 hours, the inflamma­

injury from reduced blood supply to these tissues.

tory stage, is characterized by redness, swelling, warmth, pain,

Repair and regeneration of injured tissue characterize the

and loss of function. The goal of the inflammatory phase is to

second phase of tissue healing. Tissue repair depends on resolu·

"put out the fire," thus preventing injury to surrounding

tion of inflammarion, elimination of dead tissue, restaradon of

tissues. The immediate response is arteriolar vasoconstriction

the blood supply, and formation of scar tissue. Certain tissues

CO minimize blood loss. Injury to rhe rissue stimulates release

(epidermis, bone, and ciliated epithelial) can heal with native

of chemical messengers, including prostaglandins, histamine,

tissue in a process called

thromboxanes, and bradykinin. These chemical messengers

by fibroblasts that deposir a collagen and ground substance

liuNe regefleralion.

Scar tissue is formed

cause local vasodilation and increase vascular permeability.

connective matrix. Decreased oxygen and elevated metabolic

Vasodilation decreases the rate of blood flow through the vessel

activity in the injured area stimulate the formation of capillary

(rhink of rhe effect of opening and closing a nozzle on a water

buds from healthy vessels in nearby tissues. The new capillaries

hose), allowing blood cells, especially leukocytes, to move

interconnect to form a capillary bed that supplies nutrienrs and

toward the vessel wall (margination). Increased permeability

removes waste from the healing tissue.

resulrs from contraction of the capillary endothelial cells, creac­ ing space between adjacent cells. Blood cells and large plasma

Anti-inflammatory medications

are

useful

during this

phase, as a prolonged inRammatory response delays healing.

proteins can leave rhe vessel through rhese spaces and collect

Rehabilitation during the repair phase is focused on restoring

in the inrersririal space, creating an osmoric gradient. Water

range of motion and applying controlled stress to newly formed

is arrracred co rhe hyperosmoric area, and edema results.

tissue ro promote alignment of collagen fibers and minimize

Although edema formarion is an undesirable outcome, increased

adhesions. Because the collagen fibers are weak, it is important

capillary permeability brings leukocytes (neutrophils, mono­

nOt to oversrress the tissue and disrupt the fragile collagen scar.

cytes, and lymphocytes) and platelets to the area. Neutrophils

Tissue healing is completed when the scar matures and

are rhe first subpopulation of white blood cells (WBCs) to enrer

temodels to its 6nal form. Matute scar tissue is fibrous and

traumatized or stressed rissue, but macrophages (converted

inelastic and has no vascular supply. The scar is inregrated into

a

42

Orthopaedic Physical Therapy

the injured tissue and the collagen fibers become thicker,

may play a role in the reduction of bone growth. Bikle and

increasing tensile strength, although never to the strength of

colleagueslO4 found increased IGF-I expression during immo­

rhe original tissue. Goals of rehabilitation during rhe macuca­

bilization, implicating a membrane receptor defect as the caus­

rion phase are

ative facror in cessation of bone growth.

[Q

increase srrength and neuromuscular comrol.

with rewrn to everyday activities and recreational pursuits.

Connective TIssues IMMOBILIZATION

Immobilization adversely affects musculoskeletal tissues other than muscle and bone. Tissues that experience reduced Stress undergo physiologic and srruccural changes, resulting in

Muscle

decreased load-bearing capacity. Immobilized ligaments {hat

Immobilization has a profound and devastating effect on

have less fibroncctin,38 fewer menisci,39 and less articular car­

skeletal muscle, with atrophy nored after 1 co 2 weeks. Numer­

tilage40 show reduced aggregating proteoglycans (aggrecans),

ous

and rheir water content is increased. Evidence of reduced col­

experimems

have

demonstrated

decreases

in

muscle

weighr26 and CSA21-Z9 after immobilization. Heslinga cr alw

lagen coneene in ligarnenes/8.41 tendons,'u and menisci42 has

reported an increased rarc of atrophy in fast twitch fibers

been found because these tissues become catabolic with disuse.

compared with slow twitch fibers. Immobilization in a short­

The newly forming collagen is deposited in a haphazard

ened posicion has rhe further consequence of decreasing rhe

pattern, with resultant low tensile strength.�; Changes in com­

number of series sarcomeres, with subsequent loss of muscle 11-13 length. Ocher structural changes observed following immo­

position of the connective tissue matrix also are observed. Alterations in the matrix reduce tensile stiffness and limit the

bilization include a 50% decrease in muscleltendon contact

capacity to resist deforming forces. Articular cartilage becomes

area, with degenerative changes naced ac the myacendinous

thinner in the absence of normal joint stresses.44 Joint capsule

junction,99 formation of capillary fenestrae,H mitochondrial

adhesions forrned during irnmobilization result in decreased

swelling

range of motion (ROM) and joint volume with increased intra­

with

myofibrillar

damage,H

and

deposition

of connective tissue within the muscle.H Metabolic changes

capsular pressure.4'

also occur during periods of immobilization. Pracein synthesis is reduced as the result of decreased protein translation.IOQ Immobilization promotes insulin resiscance in muscle, leading CO

decreased glycogen stores when glucose is nac transported

into

the cell and

glycogen

synthase enzyme

PHYSIOLOGIC CHANGES OF TRAINING

activity is

reduced.101 The number of sodium (Na"K�-ATPase) pumps in the sarcolemma is decreased,29 serum creatine kinase levels are elevated,') the inorganic phosphate/phosphocreatine ratio (Pi/

Endurance Training When exposed to different functional demands, muscle fibers

is

display considerable plasticity that extends to all aspects of

decreased,102 and cytoplasm antioxidant enzyme activity is

their biomechanical and morphologic properries.46 Low-load,

PCr)

is

elevated/"

succinate

dehydrogenase

activity

increased in response to the formation of peroxide radicals and

high-repetition exercise promotes endurance gains by increas­

superoxides during muscle degeneration.103 These structural 29 and metabolic changes lead to strength deficits of 50%.28.

ing rnitochondrial density in the museleY The advantages of increased mitochondrial density include greater efficiency of

After irnmobilization, human subjects were unable to achieve

energy production, increased use of fany acids as an energy

rnaximurn contraction during a burst superimposition test (a

substrate, and decreased use of muscle glycogen. Concomitant

short burst of high-intensity electrical stimulation superim­

with the increase in mitochondria per unit area is an increase

posed on a volitional contraction), indicating a central activat­

in the activity of enzymes associated with aerobic energy pro­ . duction.48 49 Prolonged low-intensity exercise also stimulates

ing deficit.28

capillary growth, so that the oxygen diffusion distance remains low as the muscle enlarges.

Bone

In response ro endurance training regimens, changes in fiber

Immobilization is associated with reduced bone mass, osteope­

type expression and fiber CSA may be observed. If the intensity

nia, and osteoporosis, with a subsequent increased risk of frac­

of repeated muscle contractions is low, the transition from fast

ture when normal mechanical stress is applied to the weakened

to slow fiber type is slowed. On the contrary, high-intensity

bone. Absence of stress on the bone leads to decreased OSteo­

endurance training appears to induce a greater proportion of

blast activity,'6 while osteoclast activity remains constant.

fast-to-slow fiber type conversions, as well as an increase in the

Bone mineral loss does not resolve immediately upon return of

proportion of SO fibers. The CSA of fibers remains unchanged

normal stresses.

or even decreases after endurance training.46

Houde et alH reported decreased bone mineralization 5 weeks after remobilization of the hand and wrist following cast immobilization. Bone growth is regulated locally by many factors,

including

insulin-like

growth

factor

I

Strength Training

(lFG-I).

Skeletal muscle changes are more pronounced with heavy resis­

Decreased expression of lGF-l or membrane receptor resiscance

tance exercise. Within a few weeks of the start of a resistance

43

Chapter 3 Theory and Practice of Muscle Strengthening in Orthopaedic Physical Therapy

training program. changes in the myosin heavy chain (MHC)

sufficient ATP via oxidative phosphorylation.70 The capacity

isoform (one of three polypeptide chains in rhe myosin fila­

to supply the cell with nutrients and oxygen is enhanced

ment) are observed.'o The MHC isoform has a high degree of

by increased capillarity'8 and increased myoglobin concenrra­

correlation with muscle fiber type. The cocal quantity of con­

rion. Reports of decreased capillary and myoglobin density63

tractile proteins increases, leading to muscle hypertrophy and

can be explained by the dilution effecr of grearer hypertrophy

an increase in rhe CSA of the muscle fiber. Increased amino

compared

acid uptake is stimulated by tension on rhe myofilamencs.51 A

expression.

with

capillary

ingrowth

or

mitochondrial

study by Scaron er al'2 showed that high-intensity resistance training of rhe thigh musculature led to increases in maximum force ourpur. A significam decrease in Type lib fibers was

Strength Training in the Elderly

observed in as liede as 2 weeks (four training sessions), whereas

A remarkable decrease in both muscle mass and bone mineral

a simultaneous increase was nOted in Type lIa MHC proteins.52

densiry (BMD) is related to aging. Loss of muscle mass is

The shift co a greater percentage of Type lIn muscle fibers

attributed primarily to loss of alpha motoneurons and incom­

denoted

plete reinnervation of muscle cells by remaining inracr motor

an increase in oxidative capacity.

Concomicam

increases in capillary density and citrate symhase activity

units. The result is muscle atrophy, or sarcopenia. and loss of

further supported an increase in oxidative capabilities.H The

individual muscle fibers, predominantly Type II 6bers.12.73

fate of Type I fibers remains unclear because some studies show

Muscle strength declines by 15% per decade at between 50 and

increases in Type J fibers,46.H-P and others demonstrate no

70 years of age, and by 30% per decade thereafter.H•n More

change in their relative percencage.184J

recent dara demonstrate significant gender-related differences

Heavy resistance rraining aceivares the high- and low­

in rhe regulation of human skeletal muscle funcrion at the

threshold mocor units. Withom question, high-resistance

muscle and single-fiber levels. In general, older men exhibit a

strength training leads to increased muscle CSA, where gains

decline in voluneary muscle force production, and older women

of 4.5% to 19.3% are observed in the firsr few momhs of rrain­

experience a greater decrease in muscle contraction regulation,

ing.60-62 Wherher this improved CSA is anributed co muscle

which

hyperrrophy (increase in rhe radial diamerer of fibers within

function:'}

contributes

to

grearer

frailty

of

overall

muscle

rhe muscle) or to muscle hyperplasia (increase in the number

In the early 1980s, a study by Aniansson et al12 revealed

of fibers) is nor fully known. Proponenes of rhe hyperplasia

that low. intensity training led co very modest srrengch gains.

theory poine to increased numbers of muscle fibers in body­

builders6J.64 and to rhe small fiber diameter in the hyperrro­

T hese results misled the community into thinking that elderly persons could not combat sarcopenia with strength training.

phied delroid muscle of wheelchair arhleres.6' A proposed

Recenrly, high-inrensity resistance programs with elderly sub­

explanation favoring hyperplasia srates that a muscle fiber has

jects have been implemented, and strength gains of 200% have

a predetermined maximum volume, and rhat cell growth

been reponed with increases in Type I and Type II fibers.76

exceeding rhar volume causes the fiber ro split ineo tWO daugh­

Decreases in musculotendinous and musculoarcicular stiffness

ter cells.66 Most scientific studies do nor supporr the role of

also were correlated with strength training.71 Regimens typi­

hyperplasia in muscle enlargement, rather they support hyper­

cally consisted of three sets of eighr to ten repetitions at 80%

trophy during high-resistance srrength training. Muscle hyper­

of one repetition maximum in twO to three sessions per week.

rrophy occurs via an increase in the size and number of

Strength gains are even observed in those older than 87 years

myofibrils.67 Acein and myosin content within rhe cell increases,

at intensities of 1 RM. More importane is the functional car­

along with the number of series sarcomeres. The accumulation

ryover of increased walking speeds, improved stair climbing,

of coneractile proteins is accomplished by an increase in protein synthesis, a decrease in protein degradation, or both.6.l.67

day.78

better balance, and overall increased movement throughour the

Another area of coneroversy revolves around rhe "interfer­

In conjunction with srrength gains, resistance training

ence effect" seen in srrength development and muscle hyper­

has the added benefir of reducing the loss of bone density, or

trophy, when strength rraining is performed concurrently wirh

osteoporosis, that accompanies aging. Borh osteoporosis and

endurance training. As was mentioned previously, strength and

a handicap at the skeletal muscle level are highly associated

endurance training regimens may yield differences with regard

with a decreased ability to perform activities of daily living

to the degree of fast-to-slow fiber type conversions and changes

such as stair climbing and transfers, and they impair balance

in fiber CSA. Recenr studies have shown that concurrent

reactions, which increases the risk for falls. Hip fractures result­

strength and endurance rraining paradigms are aneagonistic

ing from a fall can lead to significane morbidity and are

and limit the development of muscle srrength,46 while others

the number one predicror of an inabiliry to recurn to indepen­

show no difference.p Variances in training frequency and

dent

intensity between studies accoune for the differences in resulrs.

RM can increase BMD,79 or can significantly retard the loss of

living.

Elderly persons

who

rrain

at 80%

of

1

Many other physiologic changes also occur as the result of

BMD through a process called osteogmesis. or new bone

resistance training. Convened Type lIa fibers show increased

growrh, resulting from application of stress to rhe bone.ao The

oxidative enzymatic activity," while the enzymes of anaerobic

ACSM and the AHA recently developed physical activity

glycolysis, phosphofrucrokinase, and Jacrate dehydrogenase

guidelines for older adults.81 Parameters for both strength and

remain unchanged.69•,L Glycogen, phosphocrearine, and ATP

endurance exercises for a variety of diagnoses can be found ar

stores are not increased as muscle fibers are able ro generate

www.acsm-msse.org.

44

Orthopaedic Physical lherapy chosen to mimic the movement parrerns o( the sporr. The order

Strengthening

of performance progresses from lifts or drills involving large

Strength refers to the abiliry of a muscle [Q generate force and

muscle groups or multiple joints to lifts or drills specific for

velocity of movement. 10' As was described earlier, muscle CSA

lated to creare heavy and light lifting days. Rest between setS

depends on muscle CSA, lengch, fiber rype distribution, and rdJecrs the myofibril content of the muscle. Larger muscles

have a greater number of myofibrils and therefore are able to

generate increased force. The length of rhe muscle fiber also inAuences force development according

CO Starling'S

law.

Simply scared, muscle has an optimum length at which i t is capable of generating rhe greatest force (length-tension curve).

smaller muscle groups. Volume and intensity can be manipu­

and exercise days can be changed to vary the intensity of the

tOtal workout. To increase strength, the weight chosen is usually less than 6 RM; 20 RM may be used to improve

endurance.84

Periodization applies equally to the rehabilitation process

of an injured patient. Table 3-1 depicts a periodized program

When rhe muscle is shortened (active insufficiency), myosin

for ACL reconsrruction. A close resemblance to the criterion­

preventing further shortening. If rhe muscle

and Snyder-Mackler can be seen.H1 The macrocycle encompasses

filaments collide with the Z discs, and actin filaments overlap,

lx:yond

is screeched

irs optimum lengch, the myosin-actin overlap is

red uced . and some of the cross-bridges are unable co bind

during cross-bridge cycling. Lengthening beyond the optimum

length leads to passive insufficiency. Muscles with a higher

percentage of Type IJ fibers generally are able co generate

greater force than muscles with high Type 1 content. Final ly. during concentric contraction. the muscle is able co generate greater force at lower speeds compared with higher speeds.

Previously. isokinetic testing within the first 1 2 weeks after

anterior cruciate ligament (ACL) reconstruction with a patellar

tendon graft was conducted at a rate of 180 to 300 degrees per

second co decrease the tensile forces on the patellar tendon and

patella. During eccentric contractions. the opposite holds true.

and the muscle is able to generate greater force at high speeds.

DeLorme'12 introduced strength training with weights in

the early 1 940s. He demonstrated that strength gains could be maximized

with

low-repetition. high-resistance programs.

Further work showed that maximum strength gains occur

when a load with resistance greater than 66% of 1 RM is lifted

10 times.106 For continued strength gains. the load must be

increased progressively. Failure to increase resistance progres­

sively resultS in less muscle activation, as fewer moror units are recruited to lift the unchanging load. Presently, weight lifting

is a component of the training program for all athletes. Sports­ specific resistance training increases strength, power, and

based rehabilitation program previously described by Manal

the time from injury until return to play. Mesocycles may include the preoperative phase, the early postoperative phase (days 1 to 7), the mid-postoperative phase (weeks 2 to 4), the

late postoperative phase (weeks 5 to 1 2), and the return to

activity phase (weeks 1 3 to 26). Microcycles are the specific

exercises and rreatment parameters that are used within each

daily session. Consideration for protecting healing struCtures is imperative when a srrengthening program is developed for

the injured patient population.

Electrical Stimulation for Strengthening Neuromuscular electrical stimulation (NMES) also can be used

to increase muscular strength.H6 Electrically elicited muscular

contraction, when used properly, can be more effective than volitional exercise during periods ofdecreased volitional control

or reduced willingness to recruit the desired muscuJarure. Evi­ dence for effectiveness is strong.86.87 A clear dose-response rela­ tionship has been noted between electrically elicited force and

strengthening. Guideli nes suggest a current intensity sufficient

to elicit 50% of rhe volitional isometric (orce of the targeted

muscularure. which is the minimum dose for strength gains to

be realized.- The intensity of stimulation needed to produce

the necessary force of contraction can be uncomfortable for the

patient. and the therapist must be willing and able to carry out

endurance, enhancing the athlete's performance.

the treatment at therapeutic intensities. The therapist also

reAecring rhe different rraining seasons (preseason. in-season.

to determine whether therapeutic levels are being reached.

Strength training programs change rhroughour rhe year,

off-season). Strength and conditioning specialists are experrs in

developing periodized srrength training programs ro accom­ plish the goals of each season. Although a complete discourse

on the methods of periodized program design is beyond the

must have a method of measuring the force outpUt (dose) so as

Neural Adaptation Early strength gains observed during resistance training pro­

scope of this book, it is helpful for the rehabilitation specialist

grams cannot be explained by muscle changes. as contractile

program cycles volume and intensity over specific time periods.

strength in the absence of muscle hyperrrophy is attributed to

cycle. The macrocycle describes an entire training period

output is increased by recruiting additional motor units or by

posed of several mesocycles. Mesocycles usually beg in with a

gains also can be achieved by coordinating firing of the syner­

to understand the basic tenants of periodization. A periodized

It consists of three cycles: macrocycle, mesocycle, and micro­

(usually a year for a competitive athlete) and typically is com­ high-volume phase and end with a high-intensity peaking

phase that corresponds to the different training seasons . Micro­

cycles deal with daily and weekly variations in volume. inten­

sity, loading, and exercise selection.8j Exercises typically are

protein content and muscle CSA are unchanged. Increased neural adaptation with training. As was noted previously, force increasing the rate of firing o( active motOr units. Strength

gists

to

the

contraction.

prime

mover,

or

by

inhibiting

antagonist

MotOr learning, or the integration of movement patterns

within the motOr cortex, plays a role in the strength gains

45

Chapter 3 Theory and Pradice of Muscle Strengthening in Orthopaedic Physical Therapy

Table 3-1

Periodized ACL Program

Mesocycle

Goals

Preoperative Early posroperarive (days I co

7)

Mid-postoperative (weeks 2 to 4)

Microcycle (Sample Treatment)

Full knee extension

Quad sets, straight leg raise (3) X3 ( 1 0 min)

Quadriceps activation

NMES x3 ( 10 min)

Decrease effusion

Ice, elevation, compression X3 ( 1 0 min)

ROM 0 to 90 degrees

Wall slides X3 (5 min)

Quadriceps contraction

Patellar mobilizations superior, inferior, and diagonals X3 (S min)

Ambulating without crutches

Gait training knee extension at heel strike

Flexion within 10 degrees*

Cycling x3 ( 1 0 min) Tibiofemoral mobilization with rotation (grade IlI/1V)

Full knee extension·

Prone hangs (with weights) x3 ( 1 0 min) Superior pacella glide X3 (5 min)

Quadriceps strength >50%

Isokineric imervals at 180 degrees per second , 360 degrees per second (2) x 3 ( 1 0 min) NMES x3 (10 min) Wall squats (3) X3 ( 1 0 min)

Late postoperative (wt'tks 5

(0

1 2)

Stairs, (OOt over (OOt

Scep.ups and step�downs with a 6-

Full ROM·

Prone quad stretch (5) x 3 (45 sec)

Quadriceps strength >80%

[0

8-inch block (3) x3 ( 1 0 min)

Standing terminal knee extensions (3) X3 ( 1 0 min) Leg press (3) X3 ( 1 0 min) Single leg cycling X3 ( 1 0 min) Squats (3) x3 ( 1 0 min)

Return to activiey (weeks l 3 to 26)

Coordinate muscle firing

Perturbation training (3) x3 (I m i n each exercise)

Normal gait

Treadmill x3 ( 1 0 min)

Quadriceps strength >95% Hop test >85%

. Increase intensity of exercises (3) X3 (20 min) Agility drills X3 ( 1 0 min) Treadmill running X3 ( 1 0 min) Spon-specific perturbarion training x3 ( 1 5 min)

·Comparable with Ihal or rhe uninvolved limb.

observed early in training. Practice is an integral parr of this learning process.

Research has shown that strength gains

achieved through one type of muscle contraction have little

the firing rate. It has been found that training one limb leads to increased strength in the contralateral limb, signifying a crossover effect in central processing.9L

carryover to Other ranges. Multi-angle isometrics therefore are

Measuring changes in firing rate or motor unit recruitment

used ro strengthen muscles sutrounding a painful joint.

in synergistic muscles is more difficult, but strength gains

Dynamic muscle contractions exhibit a similar specificity for

certainly suggest greater

training. Higbie et al1l9 found that subjeCtS trained with eccen­

Increased synergistic activation with training implies an inabil­

activation of synergist

muscles.

tric isokinetic exercise were stronger with eccentric testing,

ity to maximally activate the prime mover. However, Sale9l

and those trained concentrically exhibited greater strength on

reviewed studies of mOtor unit activation and concluded that

concentric testing.

untrained subjects were able to maximally activate tested

Co-conrraction of antagonist muscles is apparent during the

muscles. He postulated that the complex multi-joint move­

initial performance of any task. (Remember the first time you

ments involved in weighrlifting may result in central activa­

[ried (Q ice skate.) Antagonist contraction limits motor unit

tion inhibition nor observed in

activation in agonist muscles. Furthermore, antagonist inhibi­

motions.

tion as a result of training would be represenred as increased prime mover strength. Electromyography (EMG) is used to study the rate of action

simple, single-joint test

Synchronicity of muscle firing also can be evaluated with EMG. Strength training promotes synchronized firing of mOtor units during short, maximum contractions.9� The exact role

potentials and force OUtput. The area under the curve, the

that synchronized firing plays in strength gains is unclear

integrated EMG (l-EMG), indicates the total force Output

because asynchronous motor unit firing leads co greater force

during a conrraction. Prime mover activation can be studied

Output during submaximum contraction.92

easily by surface EMG. These studies demonstrate a correlation

Central and peripheral neural adaptation does not techni­

between increases in strength and increases in I�EMG,90 indi­

cally strengthen the muscle, but it is inextricably linked CO

cating that strength training improves activation of the prime

strengthening paradigms and programs. The therapist needs to

mover by recruiting additional motor units and by increasing

exploit neural adaptation principles for therapeutic benefit.

Orthopaedic Physical Therapy

46

�

CASE STUDY 3-1

A 1 9-year-old collegiate athlete originally dislocaced her shoulder playing lacrosse in May. She underwent arthroscopic

Diagnostic

classification:

Musculoskeletal

4D:

Late

effectS of dislocation (05.6)

Bankart repair and rehabi litation. She was deemed ade­

This case il lustrates the principles of motor learn ing,

quately rehabilitated CO cecum co playing field hockey i n

neural adaptation, and specificity of exercise. Rehabilitation

September because her shoulder would not be puc i n a

focused on exercises that were progressively more challeng­

compromised posicion by [he demands of [he spoce. At (he

ing in elevated ROM. Abduction and posterior rotator cuff

completion of her field hockey season in November, she

strengthening exercises were instituced above 90 degrees,

asked co parcicipace in twO weekend lacrosse tournaments.

with the shoulder moving into externaJ rotation. A manu­

Her surgeon was concerned abom whether her shoulder was

ally resisted D2 flexlon (proprioceptive neuromuscular facil­

srrong enough

(0

withstand the rigors of lacrosse and

referred her to a physical therapist for consultation. Physical

examination

revealed

excellent active and

itation [PNF) pattern was used, beginning at 90 degrees of flexion and moving to full flexion. Rhythmic stabilization exercise was begun in the supine position and progressed to

passive ROM, with no pain on any active or resisted motions.

the sitting position, again in elevated ROM. Plyometric

Strength and proprioceptive testing also revealed no abnQ[­

external rotation was begun in the supine position and

mali ties i n any testing below 90 degrees of flexion or abduc­

progressed to the sitting position, and finally to sranding.

tion. Above 90 degrees, however, strength and control

A weight training program modified for her stabilization

deficits were significant. Based on this evaluation, the

surgery

athlete was nOt cleared to participate in lacrosse tourna­

progression of lacrosse activities (throwing, catching, and

was

instituted,9ot and within 1 monch, functionaJ

ments. Instead, rehabilitation was reinstituted to prepare

cradling) was instituted. Return to play in February was

her for the upcoming lacrosse

uneventful.

�

season

in February.

I

CASE STUDY 3-1

A 24-year-old professional football runnjng back who tore

a 50% duty cycle at 75 bursts per second was delivered for

his left ACL in training camp was referred to physical

L O seconds, with a SO-second rest period . His maximum

rherapy 10 days post injury and 2 days after ACL reconstruc­

voluntary isometric contraccion tOrque was approximately

tion using an Achilles tendon allograft. Upon initial evalu­

75 fc/lb, but electrically elicited forces of nearly 100 fr/lb

ation,

were measured by the end of 1 0 contractions.

the patient was weari ng a postoperative knee

immobilizer and was weight bearing as tolerated using axil­ lary crutches. Both the immobilil.Cr and the surgical dress­

Diagnostic classification: Musculoskelecal 41: ACt tear

(717.8)

ing were removed, which revealed the tibial incision along

Subsequent initiaJ therapy interventions included effu­

with several arthroscopic portaJs covered with Sceri-Strips.

sion control, pateUar mobilizations, gait training without

His knee was swollen and a bit warm, but he had no real

crutches, and scar mobility once the stitches were removed.

pain. Initially, he was a bit tentative about moving his knee,

He had a history of previous surgeries but did not appear

but he responded well co encouragement.

to develop keloid scarring. Left leg strengthening was per­

An early goal was to restore full extension equaJ to the

formed i n the clinic with the use of both open and closed

opposite side within the first week.91 Range of motion was

kinetic chain exercises. and the athlete was responsible for

I degree hyperextension to 95 degrees flexion as measured

upper body and right leg weight training on non-therapy

goniomerricaIly in the supine position. He was instructed

days.

in active wall slide and quadriceps setting exercises for

The athlete was seen for 1 2 visits over 4 weeks before his

ROM. He also was able to pedal on a raised-seat stationary

care was transferred back to the athletic training staff. After

bike and maintained 60 RPMs for several minutes.

4 weeks, he exhibited equal extension bilaterally and nearly

The athlete demonstrated good quadriceps contraction

full flexion ROM. His quadriceps weakness was minimaJ as

with a small lag during leg elevation. This lack of concrol

he demonstrated only a 20% strength deficit left versus

was attributed to his knee effusion and resulting quad inhi­

right. Therefore it was recommended that NMES be dis­

bition.96 He began the NMES protocol with his knee flexed

continued. His incisions were well healed, and he had a

to 60 degrees.85 Two 3 X 5-inch self-adhesive electrodes were

normalized gait pauern. With continued strengthening and

placed over the medial quadriceps distaJly and the lateral

functional progression training. he returned to play the fol­

quadriceps proximally. A 2 5 00-Hz alternating current with

lowing spring.

47

Chapter 3 Theory and Practice of Muscle Strengthening in Orthopaedic PhYSical Therapy

SUMMARY

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muscle. ) Neurophysiol 53: 1 303. 1985. 98. Fleshman jW. Munson ) B . Sypere GW. ee al: Rheobase. IOpur resistance, and motor unit type in medial gastrO­ cnemius motoneurons in rhe car, J Neurophys 46: 1 326, 1 98 1 .

50

Orthopaedic Physical lherapy

99. Kannus P, JOloa L, Kvis[ M, ec at: The effect of immo­

103. Kondo H , Miura M . Itokawa Y: Antioxidant enzyme

bilization on myocendinous junction: an ultrastructural,

systems in skeletal muscle atrophied by immobilization,

histochemical and immunohistochemical scudy, Acca Physiol Scand 144:387, 1992. 100. Booth FW, Criswell DS: Molecular evems underlying skelecal muscle atrophy and the development of effective countermeasures, Int ) Sporrs Moo 18:5265, 1997. 1 0 1 . N icholson WF, Watson PA, Booth FW: Glucose upcake and glycogen synthesis in muscles from immobilized limbs, ) Appi Physial 56:43 1 , 1984. 102. Haggmark T, Jansson E, Eriksson E: Fiber type area and metabolic potencial of rhe thigh muscle in man after knee surgery and immobilization, Inc J SPOCtS Moo 2: 1 2, 198 1 .

PHugers Arch 422:404, 1993. 104. Bikle DO, Harri s ) , Halloran BP, ec al: Skelecal unload­ ing induces resistance ro insulin like growth factor I, ) Bone Miner Res 9: 1 789, 1994. 105. Jones DA: Strength of skeletal muscle and the effectS of rraining, Br Moo Bull 48:592, 1992. 106. Casrill DL, Coyle EF, Fink WF, er al: Adaprarians i n skeletal muscle following strength training, J Appl Physial 46:96, 1979. 107. Moritani T, deVries HA: Potencial for gross muscle hyperrcaphy 1 980.

in

older

men,

J

Geramal

35:672,

CHAPTER

4

Donn Dimond and Robert A. Donatelli

Strength Training Concepts in the Orthopaedic Patient

This chaprcr will cover the physiological adapmcions within

extended periods of time" Local muscle endurance is beSt

(he muscle following srcengrh exercises by providing examples

described as the ability co resist muscular fatigue.\ It is the

of (he changes char occur with neural adaptations within

opinion of the authors of this chapeer thac a good strength base,

muscle. The major contriburors co improving muscle screngrh

a foundation of muscular power, and muscular endurance are

will be discussed, and rhe differences between strength, power,

important

and endurance will be explained. The reader will be able to

performance.

distinguish between how

for

reestablishing

function

andlor

improving

train Type I, Type I1A, and Type

In today's therapy environment, much emphasis is placed

X (lIB) muscle fiber types and will be able to describe the

0(1. functional exercise. Unfortunately, mOSt of the exercises

changes that rake place in tendons secondary (0 srrengrhening.

regarded as functional seem co be performed in a weight­

The reader will also be able co idemify rhe number of repeti­

bearing posicion wirh significant muscular co-coneraction. In

[0

tions, sees, and rhe amount of resistance needed (0 increase

fact, srrengchening exercises have been labeled as nonfunctional

muscle srcengrh and hypertrophy, describe the effects of aging

because they are performed in the open kinetic chain (OKC).

on muscle, and describe the differences between ecceneric, con­

For the purposes of this chapter. a fimrlionol txerrJt

i

ceneric, and isometric exercises. To illustrate the strength

as an exercise specific to the muscle groups that are importane

trajning concepts there is a 7-page series of general strengthen­

to the activity the patiene wishes to return ro; sufficient resis­

ing exercise images, including exercises of the shoulders, arms,

rance, repetitions, and setS are used to stimulate the muscle to

chest, back, hips, and core.

adapt by increasing strength. Several studies have demon­

Strengthening is an imporcant part of any patient's rehabili­

strated thar when OKe exercises were used to strengthen the

tation. If a patiem is co anain optimal screngthening and

glenohumeral rotators, significane gains were made both in the

progress, numerous variables must be considered. The therapist

velocity of a baseball during a pitch and in the velocity of a

should consider the rype of exercise, the frequency, ehe imen­

tennis ball in a tennis serve.2•J Therefore, strength training for

sity, and the duration. All of these variables will determine the

the rorators of the glenohumeral joine performed by moving

success of any strengthening program. The therapist also mUSt

the shoulder into internal and external roration in an OKC

understand the physiologic and neural adaptations that occur

position is a functional exercise. AnOther study found that by

within rhe muscle, and how long it rakes co make these

strength training with weight machines, subjects between

changes. Can we convert muscle fiber rypes through scrength

and 83 years of age were able to decrease the amount of cime

60

training? Should eccencric, concentric, and/or isomerric exer­

i( took them to climb a Right of stairs.1 Finally, another study

cises, or a combination of all three, be used? I.s it necessary co

found that combining OKC exercise with functional exercise

periodize the patiene's scrength training program, and would

yielded better outcomes than did functional exercise by itself

this result in significane changes in muscle strength? How does

in patients who had undergone anterior cruciate ligament

the therapist incorporate neuromuscular exercises inco a

(ACL) reconstruction.�

strengthening program? Answers to these questions are essen­

This chapter begins by describing different types of muscle

tial co professionals who are responsible for prescribing resis­

action. Neural adaptations both at the local level and wirhin

cance exercise co improve a pacient's way of life, be it on the

the central nervous system that result from strengch training

field of play or in terms of everyday function.

are discussed. Muscle cellular adaptations, including fiber con­

Simply scated, strength is the ability of the muscle to exert I maximum force at a specified velocity. Power is defined as

version, changes in sarcomeres, and hypertrophy versus hyper­

the force exerted multiplied by the velocity of movemene.\

strength training, as well as connective tissue changes, are

fuscular pourer is a function of both strength and speed of

explained. Discussion of hormonal and metabolic changes is

movement. Endllro1Jet is the ability CO sustain an activity for

followed by discussion of the effects of aging on muscle and

a

plasia, are discussed. Mechanical muscles changes produced by

51

Orthopaedic Physical Therapy

52

exercise adaptations in [he elderly. Gender differences and

ily due to modifications of the nervous system. These modifica­

muscles changes are described. Finally, time frames for devel­

tions can occur both at the local level and at the central nervous

the amount of resistance

system level. Moritani and DeVries9 in a landmark swdy found

and the numbers of sees and repetitions needed to make these

that "neural factors" accounted for significant improvements

oping strength gains, in addition

CO

changes, are put forth. An understanding of rhe cellular and

observed during the first 4 weeks of an 8-week resistance­

molecular adapmclOns of skeletal muscle in response to strength

training program. Staron et allo demonstrated that only after

training IS importam for rhe clinician who seeks (0 provide a framework for improving performance in the athlete and for

6 weeks of training was significant muscle fiber hypertrophy

enhancing health and quality of life in rhe general population,

include decreased co-contraction of antagonists and expansion

wieh or without chronic disease.

in dimensions of the neuromuscular junction, indicating

detected. The neural adaptations elicited by resistance training

increased content of presynaptic neurotransmitter and postsyn­ aptic receptors.II.1! Greater synchronicity of the discharge of

TYPES OF MUSCLE ACTIONS

motor units after strength training also has been reported.14 Aagaard et all' suggest that increases in motoneuronal Output

Three main muscle-strengthening actions have been identified:

induced by strength training can cause increased central moror

eccemric, concentric, and isometric. Simply stated, an eccentric

drive, elevated motoneuron excitability, and reduced presyn­

acrion occurs whenever opposing forces acting on a muscle

aptic inhibition. Laqerquist et al16 described similar increases

exceed the force produced by that muscle.6 This causes the

in strength in (he (rained and the untrained soleus of subjects

muscle [0 lengthen while it is being activated. Eccentric actions

who were U"ained for 5 weeks. Based on their results, investiga­

are characterized by their ability [0 achieve high muscle

rors concluded that the increase in strength of the untrained

forces-an enhancement of the tissue damage associated with

limb may be due to supraspinal mechanisms. They go on ro

muscle sorcness-and perhaps require unique control strate­

suggest that increased force production of the trained limb

gies.' Eccentric actions are used frequently throughout every­

versus the untrained limb may be due ro a synergistic effect of

day life, and especially in athletic competition. A common

increased somarosensory stimuli and descending supraspinal

human movement strategy is to combine concentric and eccen­

commands. Anocher study found that the cross-education effect

tric actions into a sequence called the JfrefCh-shorfefi eye/t.7 This

may be controlled in part by adaptations in the sensorimoror

cycle typically involves a small-ampl itude eccentric coneraction

cortex and the temporal lobe. 11 In fact, one paper recommends

of moderate to high velocity thac is followed by a concentric

that motor learning (heory and imagined contractions should

contraction.' Eccentric contraCtions are mechanically efficient,

be incorporated with strength training. III It is importane to

can

maximize

note that eccentric contractions have been found ro induce

The second type of action is a concentric contraction. A

muscle aCtions. Zhoul9 found increases of 59f to 35% in force

attenuate

impact

forces,

and

serve

to

performance.'

gre-clter cross-education effects (han concentric and isometric

concentric contraction occurs when the force produced by the

production for the untrained limb during both isometric and

muscle exceeds the external force or load.6 This contraerion

concentric muscle actions, although Hortobagyi et aiM reported

causes the muscle [0 shorten and is the latter action of the stretch-shorten cycle. This cycle, as pointed OUt earlier, happens

increases as high as 104% during eccentric muscle action in the untrained limb.

during most day-to-day activities and occurs withom special­

Confliering views present the relative contributions of

ized training.6 Enorka6 considered that only when a concentric

neural versus muscle adaptation, with strength training lasting longer than 2 to 3 months. Deschenes et all indicate that with

contraction is performed without an eccentric aerion would muscle performance be decreased.),6 The last type of muscle action is called an iJOllltlric (lctiOl1. Isomerric strengthening occurs when the force generated by muscle and the external force are the same, and no lengthening or shorrening of the muscle occurs. Isomettic strengthening has been shown to be very joint angle specific with minimum cat­ ryover to other joint angles. Only a 20-degtee carryover is seen either way, from where the muscle was trained, although one study showed that carryover throughout the entire range is greater when the muscle has been trained isometrically in the lengthened position."

NEURAL ADAPTATIONS The first signs of muscle adaptation to strengthening exercises are neural adaptations. Several studies have demonstrated chat early strength gains induced by resistance training are primar-

prolonged resistance training, the degree of muscle hypertro­ phy is limited, and significant hypertrophic responses can occur within a finite period of time, lasting no longer than 1 2 months. A secondary neural adapcation explains the continued strength gains with prolonged resistance training. The second­ ary phase of neural adaptations takes place between the sixth and twelfth month. In contrast,

hoepe et al21 demonstrated

substantial muscle hypertrophy as a result of several years of resistance training, when compared with a group of sedentary individuals.

CELLULAR ADAPTATIONS To review, muscles are made up of hundreds of thousands of muscle cells, which also are refetred to as lIIuJde fibers. These muscle fibets are made up in p.1rt by hundreds of myo6brils, which extend along the length of the muscle fibers. The myo-

Chapter 4 Strength Trainin g Concepts In the Orthopaedic Patient fibrils are made up of (wo types of protein filaments, called thick filaments and chin filamencs. A

S(IYCOflltre

is rhe small

53

CHANGES IN SARCOMERES

scruccural unit that makes up rhe myofibril and comains both chick and chm filamems. \'(Ihen a muscle cemraers, rhe sarco­

Besides fiber type adaptations at the cellular level, other struc­

meres shorten. T hick filaments are made up of a contractile

tural signs may indicate muscle damage. Under electron micro­

pcocein called III)'OS/Il. Thin filamems are made up of three dif­

scope, it has been shown that sarcomeres may become out of

fecem contraCtile protems called aerm, IroptJlllyOJUI, and Iroponlll.

register, Z-line streaming is evident, regions of overextended

The curnover rare of chese muscle proteins is one of rhe slowest

sarcomeres are found, and regional disorganization of myofila­

rhe body. Within skelecal muscle synrhesls, growth of (on­

menrs and T-tubule damage may occur.H Evidence suggests

craccile proceins lags behind chat of other proteins such as

rhar an increase in sarcomeres occurs after bouts of eccentric

10

mlt(xhondria and sarcoplasmic rericuium:'!!·H It is rhe synthe­

exercise.u In fact, one study found an t 1% Increase in sarco­

sis and accretion of conrracrile proteins chac account for rhe

mere number after eccentric loading.U

hypertrophy chat occurs wirh resisrance naining. This hyper· rrophy, in addIrion ro hypenrophy wirhin the whole muscle (5% [Q 81Jf), occurs mostly wirhin rhe intracellular myofibrils (25% CO 35'!f).""

HYPERTROPHY VERSUS HYPERPLASIA

Jr IS Important ro nore that different rypes of muscle fibers

ReSistance exercise is a potent stimulus for Increasing the size

are found in [he hum.n body: Type I, Type II., and Type IIx

of muscle. For a muscle to become larger, it must increase in

(used co be referred as Type lib). Also within any muscle,

cross-sectional area (hypertrophy), or the number of muscle

hybrids of these fiber rypes can be found, including Type lilia,

fibers (hyperplasia) must be increased. It generally is believed

Type IIa/IIx, and Type IIIIa/IIx." Type I fibers cend [0 have a

that the number of muscle fibers is innate and does not change

slower comracrion time, high resistance co fatigue, and low

during life. H In COntrast, several researchers have reported that

force proclucrion. Type lIa fibers have a fasr contraction rime,

muscle is capable of increasing in size as the result of an

Inrermediare resistance [Q farigue. and high force producrion.

increase in fiber number. \I.n The exaCt mechanism responsible

Type I1x fibers have a very fast contraction rime, low resistance

for muscle hypertrophy is uncertain, although several theories

CO fangue, and very high force produc[lon.

have been expressed in the literarure. Skeletal muscles are capable of remodeling under various conditions. The activation of myogenic stem cells within the muscle is one of the most

MUSCLE FIBER TYPE-SPECIFIC ADAPTATIONS

important events that occur during skeletal muscle remodel­ ing.H Muscle (myogenic) stem cells remain dormant under the basement of the myofibers; upon stimulation, they differentiate

Mailsoux et al!� found thar 8 weeks of training involving

into satellite cells to form myofibers. n Muscle, or myogenic,

srretch-shonening cycle exercises Increased single fiber diam­

stem cells start to generate, and through a series of cell divi­

eter, peak force, and shortening velocity, leading to enhanced

sions, daughter cells become satellite cells. Evidence suggests

fiber power. All of rhese changes were seen in Type I, lIa, and

that strength training induces a significant increase In satellite

IIa/JIx fibers. In addition, pe'.lk power was improved in Type

cell .content in skeletal muscle, and that strength training

II. fibers.

downregulates the expression of myostatin, which is respon­

It is well documented that a prolonged program of resis­

sible for inhibiting satellite cell activation. � Because the myo­

tance training brings abom fiber rype conversion wlrhln rhe

nuclei in mature muscle fibers are not able to divide, it is

muscle. The most common finding is an increase in the per­

suggested that the incorporation of satellite cell nuclei into

centage of Type IIA fibers, along with a decrease in percentage

muscle fibers results in the maintenance of a constant nuclear!

of Type II B (Type IIx) fibers.""" I[ appears [hac as soon as

cytoplasmic ratio. T herefore, new muscle fibers are formed fol­

•

Type lIB (Ilx) muscle fiber IS stimulated, it srarrs a process of

lowing strength training. When resistance or endurance exer­

transformation coward Type IIA by changing the quality of

cises promote satellite cell proliferation, and differentiation can

proteins and expressing different types and amountS of myosin

be detected in injured fibers and those with no discernible

adenosine triphosphatase {mATPase).l'.I At the end of a resis­

damage,

tance-training program, very few Type IIB (lIx) fibers remain;

muscle.

muscle

H.J'.J7.�8

hyperplasia

occurs

in

human

skeletal

this situation is reversed during denaining. However, when

Force developed by the myofilaments (actin and myosin)

resistance tralOing is starred again, the conversion from Type

may stimulate the uptake of amino acids, thus resulting in

liB (IIx) [Q Type IIA is quicker. Although resistance training

muscle tissue growth. 39 Heavy forces encountered during resis­

promoces hypertrophy in all three major muscle fiber types in

tance training lead to disruption in the Z-lines. Disorganiza­

humans-I, IIA, lIB (IIx)-[he amount of hypertrophy differs

tion after disruption of the Z discs may cause the myofibril to

in each fiber type. Based on examinacion of pretraining to post­

split and grow back at full size.40 Furthermore, disruption and

training muscle samples, it has been established that muscle

rebuilding of the muscle result in an increase in conneCtive

hypertrophy IS 8rea[es< in Type IIA fibers, followed by Type

tissue surrounding the muscle fibers.

lIB (IIx), With Type I fibers demonstrating the least amount of hypercrophy.

IIU6�fI...U

In summary, as a result of strength training exercises, physi­ ologic adaptations of muscle result in an Increase in strength.

54

Orthopaedic PhYSical Therapy

These adaptations include hypertrophy (within the first 6 co 8

of recreational running.46 When an injury process is in place

weeks), hyperplasia, hormonal changes, increased connective

though, a tendency roward a quicker response to resistance

tissue surrounding muscle fibers, disruption of the myofila­

training is seen within the tendon in its normal scare. Kadi'"

menes, and neuromuscular changes (within rhe first 2 weeks of

showed that with eccenrric training in patients with Achilles

training), In addition, metabolic adaptacions within the muscle

(endinosus, both pathologic Achilles tendon widrh and pain

fiber enhance the ability of the muscle to generate adenosine

were decreased over a 12-week period. Because mOSt of the

criphosphate (ATP) for anaerobic mecabalism. Anaerobic

studies discussed earlier used isotonic or concenrric resistance

metabolism requires chac the muscle increase phosphocreatine

training as their mode of exercise, ir would be inreresting co

(PC) and glycogen scores, leading co an increase in the enzyme

see whac types of changes would cake place when ecceneric

creatine phosphokinase chac breaks down PC, as well as an

resistance training is used in healthy subjects, and whether

increase in the race-limiting enzyme phosphofruccokinase

Achilles tendon CSA and maximal strain would increase more quickly with eccentric loading versus conceneric or isotonic

(PFK) of glycolysis.

contractions. It is Important to noce char with a chronic overload injUry

MECHANICAL CHANGES IN PASSIVE AND DYNAMIC MUSCLE STIFFNESS At rhe mechanical level, evidence of increased dynamic and

to a tendon, upregulation of Type I and Type III collagen occurs, wirh a preference for Type 1 1 1 . ·\2 Type III collagen is

thinner than Type I and has been shown to be more prevalent at rupture sites in the Achilles tendon chan at other areas in

passive muscle stiffness can be found. II Whitehead et all2 states

the same tendon:l1 Ie is interesting to note rhat tmining can

that rhe flse

increase Type I collagen production and can improve pacients'

10

passive muscle tension is dependenr on rhe

range of length over which rhe muscle is worked. With bicep

overall symptOms involving tendinopathy; training also may

brochii eccentric loading, rhe sense organs of the muscle and

decrease their chances for acure rupcure.l1

the body's ability to sense jOlOr position have shown both an

In summary, resistance training not only changes muscles,

increase and a decrease in the flexed posicion. This seems co be

it has an effect on connecrive tissue as well. Connective [issue

dependenr on wherher a muscle spindle injury actually occurs

can increase in sile and strength, which may help to decrease

(which increases the flexed position), or whether sarcomere

rhe incidence of injury. Although the length of this rraimng

disrupcion is presenr (which decreases the flexed posicion), che

in healrhy subjects remains uncertain, through eccentric

former happening with high intensity strengrhening." Mechan­

loading of a pathologic tendon, one can improve a patiem's

ically, signs of a shift in the muscle's optimum lengrh can be

symptoms and can normalize tendon size wichin 12 weeks.

seen, coward longer muscle length, decreased active tension, increased passive tension, and muscle swelling and soreness. H Muscle swelling and soreness lead co delayed-onset muscle

Hormonal Responses

soreness (OOMS), which is thought co be purely mechanical

Resistance training has been shown to elicit a significanc acuce

and is not an IOfiammacory response:"

hormonal response, which is more critical for tissue growth and remodeling than are chronic changes in resting hormonal con­ cencrations. Anabolic sreroids such as testosrerone and rhe

Connective Tissue Changes

growth hormones (GH) have been shown co become elevated

Nor only are changes in rhe muscles and their respective cells

over I S co 30 minutes of high-volume exercise [hac is moderace

evident, buc changes also rake place in the rendons. As you will

co high in intensity, wirh short rest periods and stressing

see, tendons in trained individuals are differenr from those in

a large muscle mass, when compared with low-volume,

untrained individuals. Data from humans show thar a larger

high-intensity protocols in which long rest intervals are

cross-sectional area (CSA) of che crained tendon results in less

ptovided.'"

stress on the cendon during maximal isometric contraccions in

Alrhough single bouts of exercise can cause a significant

trained compared with untrained individuals, and it provides

acute rise in serum tOtal and free restosterone concentrations

a more injury-resistant rendon.11 Ying et alH found char the

in males, no significant rise is seen In females, regardless of

Achilles tendons of individuals with a history of physical activ­

age.III Other anabolic hormones such as insulin and insulin-like

ity had a larger CSA than those of rheir sedentary counterparts.

growrh faccor-I (lGF-1) are critical for skeletal muscle growth.

An adaptive response that results in the JOcreased net synthesis

Blood glucose and amino acid levels regulace insulin. However,

of Type I collagen in the peritendinous tissue around rhe Achil­

following resistance exercise, elevacions in circulating IGF-I

les tendon has been found to take place after 4 weeks of train­

have been reported, presumably in response co GH-stimulated

inS:u Type I collagen is the thicker fiber among all collagen

secrerion.4" A significant rise in growth hormone occurs regard­

fibers. Although an initial increase in Type I collagen occurs,

less of gender, but noc in elderly women,"1

rhis does not lead to an immediate increase in the CSA of a nonpachologic cendon. It seems that a prolonged craining effecc in nonpathologic tendons IS needed for an increase in CSA

Aging and Muscle Changes

to occur. One study found that CSA was increased by 20% to

Professional athleces are performing longer and longer over the

309f in long distance runners versus untrained subjects n Yet

pasr decade. Demographic data clearly illuscrate rhac, overall,

another scudy reported no increase in CSA after juse 6 months

the U.S. population is growing older. Aging callses loss of

..

Chapter 4 Strength Training Concepts In the Orthopaedic Patient

funccional capacity. resulting from a decre-J,Se In muscle mass (sarcopenia).4\1 Approximately one-third of coral muscle mass IS

55

Gender Differences and Muscle Changes

lost between 30 and 80 years of age,OWl This muscle loss is pri­

Gender differences

manly the resule of selective loss and remoc.leling of motor

examinacion boch before and after craining; Type JIA fibers are

units. By the sevemh decade of life, some muscles may include only half the number of maror unHS, and 75% of the {Otal

size among women.M Furrhermore, Staron et arb demonstrated

[he largesc among men, whereas Type I fibers are of greaten

number of fibers, present in the muscles of young adults.11

chac with heavy resistance craining, the conversion of Type liB

Type II fibers appear ro be [he most seriously affected; chey

(IIx) fibers co Type IIA fibers occurred at 2 weeks in females

gradually decrease in both size and number with advancing

and at ..j weeks in males.

age. Loss of fiber begins at approximately 25 years of age and

One scudy found thar when muscle quality (maximal force

accelerates chereafcer.11 However, it appears that craining can

production per unit of muscle mass) was measured, young

reverse aging atrophy and can maintain fiber eype discribucion

women (20 co 30 years) were seen ro have significanriy greater

in elderly individuals similar ro chac found in the young.

gains than young men, old men, and old women afcer 9 weeks

Several studies have determined rhat strengrh improvements

of srrength traiOlng.bi In fact. after 30 weeks of detraining,

in the elderly are coupled wirh cellular and whole muscle . hypertrophy.II.�\ �, Also, muscle hypertrophy responses to

members of the other three groups. In another study thac

resistance training have been found to be Indistinguishable

looked at muscle volume In response ro strengch trainlOg In

between young and elderly people.'u6

both old and young men and women, young men made up the

young women scill had greacer muscle quality chan did

Recently research has suggested that power (high velocity)

only group rhac was able co maintain gains In muscle volume

trainlOg may be more effective chan strength training 10

after 31 weeks of decralning.6' ApJY.lrent differences also can be seen in relation co eccentric

improving physical function in community-dwelling adults.'''' Another study found that using 80% of 1 rep max for resistance

srrength across genders and rhe life span. In borh men and

was the most effective way to achieve simultaneous Improve­

women, concentnc peak rorque was seen ro decrease farther

ments in muscle strength, power, and endurance In older

chan ecceneric peak rorque with age.6fi Investigators in another

adults.)8 It is interesting to nOte that another study reponed

scudy found that women tended to berrer preserve muscle

rhar power training increases balance over rhar seen in a non­

qualHy wich age for eccentric peak corque.(" In addition, older

training gcoup, especially when a load of 20% 1 rep max is

women seemed ro have an enhanced capacity, about a decade

used.''1

longer, to score elastic energy better chan similarly aged men

Although in general, tWO to rhree sers of srrengrh rraming

and younger men and women.6C'

is most beneficial, some studies have found chat in elderly indiViduals who do one set, exercise is sufficient co Significantly enhance muscle function and physical performance (chair rise, 6-meter backward walk, 400-merer walk, and stair climbing test), although gains 10 muscle strength and endurance are greater in the rhree-sec group.(,() Another srudy found that regardless of intensity (high

=

80% I RM, and low

=

50% I

TYPES OF MUSCLE ACTION ADAPTATIONS Eccentric Strengthening After a bout of eccentric exercise, an adapration rakes place.

RM), signi6cane improvements in strength, endurance, and

ThiS adaptacion can be called [he Yr.peaud bollt effert. When one

stair climbing rime were anained by doing a single set of 12

performs an eccentric bour of exercise. a repeared bour effect

reps.61 Anorher interesting nore is that elderly IOdividuals who

adaptarion will protect the muscle againsc further damage from

supplemented their exercise regimen with crearine exhibited a

subsequent eccentric boucs.l1 This can help to improve perfor­

greater increase in fat free mass and rotal body mass as com­

mance and prevent ,"jury. Wich eccentric strengchenlng and

pared with the placebo group with strength rraining.h1 The

the above adaptations, strengrh, CSA, and neural activacion are

recommendations for the srrength rraining variables noted

increased.M Along wlch muscle adaptacion, possible tendon

below are beneficial for use with the elderly or wich the young

adaptations have been discussed. With bicep brachii eccentric

arhlete andlor patient:

loading, muscle sense organs and the body's abilicy ro sense

• • •

Strength training reps, 6 co 12 Mulriple sets, 2 ro 3

joint posicion have shown both an increase and a decrease in che Aexecl posicion. This seems ro be dependent on whecher a

At least 2 days per week and a maximum of 3 days per week

muscle spindle injury has actually occurred (increase Aexed

of scrength craining

posHion), or only sarcomere disruption (decreased Aexed posi­

•

90 seconds to 2 minures resc becween sers

cion), the former happening wich high-intensicy strengthen­

•

Train che large muscle groups before che smaller muscle

ing.� Increased signal from a muscle spindle has been shown

•

groups

with heavy eccencric strength, although no scudies have shown

Choice of exercise should be based on an evaluacion of

more evidence of significant neural adaptacion than chose

muscle strength and of muscles thac are important ro the

involving concentric strengthening.

type of activity rhe parient wishes to return roo The grearer

TYPICally, eccentric contractions can gene race tWO ro three

che intensity of the activity che paciene wishes co recurn to,

rimes more force than concentric concractions.6'J This has led

the grearer is rhe intensiry of the recommended rehabilira­ cion andlor craining.

some auchors ro believe rhac eccentnc rraining racher than concencric strengthening leads to a greacer capabilicy of

Orthopaedic Physical Therapy

56

overloading the muscle co a greater extent, thereby enhancing

mode, and velocity of training, concenrric strengthening may

muscle mass, screngrh, and power.69 This generalization may

be more general in terms of its carryover. In one study, inves­

seem fair but may be [00 simple.

tigators found that velocity-specific concentric only strength­

Many scudies have shown an increase, a decrease. or no

ening resulced in increased peak torques above and below the

change in functional performance. concentric strength, and

training velocity,87 although another study found that concen­

eccentric strength after eccentric training.70-81 Outcomes noted

tric training was less mode and speed specific versus corre­ . sponding eccentric training.lI8 880

in rhe previous section can be 3uribured to different training prococols

and

methods

of assessmenr.70

Current research

has shown that eccentric training is more effective than coo­ cenerie training in developing eccentric strength, and chat concentric strengthening is more effective in developing con­

Isometric Strengthening The question remains regarding what types of adaptations the

centric strength.71 The specificity of training noted here repre­

muscle undergoes during isometric strengthening. One study

sems anocher application of the specific adaptations ro imposed

has reported that this is dependent on the rype or rate of con­

demands (SAlD) principle.

traction. Progressive coorractions produce modification of the

The degree of strength gain is relative ro the volume/inten­

nervous syscem at the peripheral level, whereas ballistic con­

sity and velocity of eccentric exercise. In most studies, the load

tractions affect the muscle's contractile properties.59 Another

used was appropriate to induce failure in the muscle. The actual

study found that increased isometric strength might be due to

volume does vary, but the findings of one study sUPPOr[ the use of low-volume eccentric exercise. III Another scudy found

facrors associated with hypertrophy, independent of neural adapt3cions.90

that when compared with high-intensity eccentric training, low-intensity eccentric training is seen to cause the same a�ount of muscle damage, but without the large drop in muscle performance.82 Based on these twO studies, it can be

Clinical Application How does one apply this information to a clinical sicuation?

seen that a high-intensity/volume model may nor be neooed to

First, we as clinicians need to integrate eccentric strengthening

atcain eccentric strength gains. Other research has shown chat

inco our practice. This involves more chan JUSt lowering rhe

to obtain the greaten hypertrophy and strength gains, one

weight after a concentric contraction. Because of current

must work eccentrically 180 degrees per second over the

research findings, we know that to rehabilitate a patient for

range.S3 Keep in mind though that this study was performed

functional tasks or to train an athlete, we must have them

with isokinetic equipment, and che carryover co isoronic equip­

perform eccentric movements. Remember, in rhe definicion of

ment is unknown.

a stretch-shorten cycle, an eccentric contraction is a low-ampli­ tude, moderate- to high-velocity contraction. Therefore, eccen­

Concentric Strengthening

tric movements must be faster than concencric contractions. Eccentric isotonic (raining must produce force that is twO to

As was discussed earlier, neural, contractile, and muscle fiber­

three times greater chan that of its concentric counterpart to

type adaptations are made in strength training. Mosc athletes

achieve the proper intensity. This does not necessarily mean

will use a combination of eccentric, concentric, and isometric

that the isotonic load should be doubled or tripled. Force that

contractions. To address the need to control a load when

is generated during exercise is dependenc on (he amounc of

returning it co che scarring posicion, most strengthening

resistance used; the greater the resistance, the slower is the

studies have used a combination of eccentric and concentric

speed. (Force equals mass times acceleration.) Because an eccen­

actions. As was noted previously, the stretch-shorten cycle is

tric acrion should be happening at greater speed, one may have

initiated by an eccentric anion followed by a concentric con­

to increase rhe load by only 20% to 30% if the limb is moved

traction, but an eccentric contraction can happen by itself.

twice as fast as the concentric contraction. We rhen need to

Because of this fact, whenever anyone works isotonically, he or

allow a rest period greater than 48 hours. We have to work

she is working eccentrically, even if concencrating on the short­

with patients in a specific eccencric manner to obtain maximum

ening contraction. In the real world, it is almost impossible to

gain through their rehabilitation and performance training.

work only concentrically. That is what makes it so difficult to

How to do this isotonically and safely and effectively in a

discuss the adaptations of concentric only concracrions. What

controlled clinical setting is the first question that must be

follows is an attempt co discuss concentric strengthening adap­

answered.

tations. The changes associated with concentric strength rrain­ ing are poorly understood.84 Concentric only sttengthening does not produce as much

What injuries or muscle groups would benefit rhe most from eccentric strengthening? Numerous studies have dis­ cussed the use of eccentric strengthening in the treatment of

exercise-induced muscle injury as is produced by eccentric

patients with Achilles tendinosus, patellar tendinopathy, ilio­

strengthening.'"

In fact. more muscle damage is produced

tibial band syndrome (runners), and chronic isolated posterior

when a muscle is loaded eccentrically than when it is loaded

cruciate ligament (PCl)-injured knees.91.'" Maclean et al94 showed that in knees with a peL deficit, a significantly

eccentrically and concentrically, regardless of whether this is done alrernately or at separare times.H6 Whereas eccentric

decreased eccentric/concentric ratio was noted compared with

strengthening carry-over seems ro be very specific to intensity,

the contralateral hamsrring. In rhe study by Mafi et al,91 inves-

Chapter 4 Strength Training Concepts in the Orthopaedic Patient cigators found that a greater number of patients with chronic

57

walks, and at the tOP of the exercise starts to lower his arm

Achilles cendinosus experienced bener overall satisfaction and

without assistance from the wall, he will eccentrically load that

decreased pain with eccencric strengthening training than with

tendon and may re-rupture the tendon repair. Because concen­

concentric srrengrhening training. Anocher scudy by Young

tric loading generates less force, it may be more beneficial when

ec a19) showed chac eccentric training with a decline squat

working with a repaired tendon to initially use concentric only

protocol was superior to a traditional eccentric protocol, with

strengthening when the tissue has healed enough to withstand

decreased pain and improved sporting funcrion noted over 12

an external load.

months in elice volleyball players who had suffered patellar

Isometric contractions seem to be moS( beneficial when used

cendinopachy. Kadi47 showed chac with eccentric training in

to increase the endurance of those muscles that function as

patients with Achilles rendinosus, an actual decrease in Achil­

spinal stabilizers.97 This will help to maintain low but continu­

les tendon wideh occurred. along with decreased pain. These

ous activation of the paraspinai and abdominal wall muscles

Studies tell us char eccenrric strengthening should definitely be

that function as stabilizers.98 According to recent research find­

included as part of any cendinopathy creatment.

ings, isometric contractions lend themselves more to a neural

Other applications may include use of ecceneric accions and

than to a contractile adaptation.96

loading on muscle groups thar primarily work concenuicaJly hut that have been immobilized. Take, for example, a patiem who is srams POS( aneerior cruciate ligament repair. If rhe knee has been braced and the quadriceps group has been maintained

Exercise Variables

in a shortened posirion, we know thar muscular arrophy will

If one is to achieve the physiologic adaptations described

occur, along wirh a decrease in the number of sarcomeres. This

earlier, several variables must be considered. The variables

remolding can occur within the first 5 days of immobilization.7

that must be planned for carefully in the development of an

If we eccemrically load the quadriceps group properly in the

exercise program include choice of exercise. order of exercises,

open chain, we will produce sarcomere lengthening, aJong with

number of sets. number of repetitions. intensity of exercise.

an increase in the acmal number of sarcomeres. This adaptation

duration of rest between sets and exercises, and frequency of

will help to speed up the return of a good quadriceps eccentric

training.

acrion and possibly the conceneric coneraction as well. Also

The type of exercise chosen should be specific to the specific

note that with eccemric loading of the tibia in the open chain

muscle deficits revealed in the initial evaluation. Furthermore,

position, the tibia will be gliding posteriorly, and this will

the type of exercise used should be specific to the muscle groups

eliminate any anrerior shear force on the ACL. With a concen­

that are important in improving the performance of the athlete.

tric open chain quadriceps contraction, the force generated will

For example, in the overhead throwing athlete. the external

be an anterior shear. When working with patients and athletes, we must consider

rotators-infraspinatus and teres minor-provide a breaking action in deceleration of the shoulder. Eccentric loading to the

what the specific function of a muscle is in relation to that

external rotators is a specific exercise for strengthening the

athlete's sport. Consider a track sprinter who is going through

external rOtators. and eccentric activity of the external rotators

rehabilitation from a hamsuing group suain. If the 3thlete·s

is specific to the movement pattern and to exercise performed

hamstring were properly loaded eccencrically, this may help to

by the athlete in competition. Furthermore, high-speed eccen­

prevene further injury due to the repeated bout effect. The same

tric loading is very damaging to the muscle. When the eccen­

is true with a baseball pitcher, who by eccentrically training

tric strength of the external rotators is increased, greater

the rota[Qr cuff muscles may be able to adapt to higher eccen­

protection from damage is provided to the muscle. This concept

tric forces, thereby decreasing his chances of suffering from a

is discussed in greater detail later in this chapter.

deceleration injury. To gain these benefits from eccentric train­

The order of exercises performed by the athlete typically

ing, the athlete most likely would need to be trained very

involves performance of large muscle group exercises before

specifically through training of the same muscle groups with

smaller muscle group exercises. Because metabolic demand is

the same intensity as needed by the particular sport. One study

greater for large muscle group exercises, exercises that recruit

showed a decrease in the occurrence of hamsrring strain injuries

more than one muscle group, such as closed kinetic chain

in elite soccer players who underwent eccentric overload

exercises, should be performed before isolation exercises are

training.96

performed. ,.,

Examples of when nor to use an eccentric loading accion

Once again, debate is evident in the literature regarding the

would include the time during initiaJ rehabilitation after a

numbers of sets and the frequency of strength training. For the

tendon repair, or during the initial stages of muscle healing.

athlete, the numbers of sets within a workout are directly

Because the force generated by an ecceneric action can be twO

related to (he individual training goals. Multiple-set programs

to three times greater than that of a conceneric contraction,

optimize the development of strength and local muscular

failure may be generated at the repair site, or at the site of

endurance.99 Gains in suength occur more rapidly with mul­

tissue injury. For example. if a patient has JUSt gone through

tiple-set programs than with single-set protocols"oo Single-set

a supraspinatus tendon repair and is status post 2 weeks, eccen­

exercise programs may be effective for individuals who are

tric loading obviously should be avoided. However, if the same

untrained, or for those who are JUSt beginning a resistance

patient is working on active assistive range of motion with wall

training program. Single-set workouts are also useful in

58

Orthopaedic PhYSica l Therapy

maintenance programs. Furchermore, srrength changes over a

weiglu training exercises, rhe athlete moves as fast as possible

shaH-cerm trainmg period, and nonperiodized multiple-set

rhroughout the range of motion, resulting In loss of comaer

programs may not be di fferent between one, tWO, and three sets

with the ground in an explOSive squat, or loss of comace with

of 1 0

(0 1 2 RM. to\ I lowever. when a single-set prococol is

the bar m a bench press. DUClng traditional bench press and

compared with multiple-set penodized programs, significandy

squat weighr training exercises performed ar an explosive

superior resules are observed with multiple-set periodized pro­

velocity, a recem study has shown that

grams chac lase longer chan I month.lnl Gmshalk et 31102 dem­

40'* to 60% I RM and 50% to 70% I RM, respectively, may be mOSt beneficial in the

onstrated

development of power. l l l

chac

higher

volumes

of [0[31

work

produced

significantly greater increases in circulating anabolic hormones

The final variable thar is imporrant for muscle adapration

during the recovery phase after multi ple-set heavy resisrance

from strength training is the time incerval between sets. The rest interval is dependent upon the mtensity of the training_

exercise prmocols. McLesrer er allU\ showed char training

1 day per week was

an effective way ro increase srrengrh, even in experienced rec­

For example, it has been shown thar acute force and power producrion may be compromised by short rest periods of 60

reational welghdifters. Ilowever, thiS scudy reported supenor

seconds or less . ' 1 2 long itudinal studies have shown rhat grearer

results with craining ., days per week when compared with 2

strength increases are seen with long rest periods between sets, I II thar is, 2 to 3 m i nutes versus 30 to 40 seconds. UH,1 )

days per week when ehe roeal volume of exercise was held conseant.

In conclusion, the authors of this chapter believe that if one

Advanced tf".t ining frequency varies considerably. Hoffman

is to make prog ressive, efficienc, major srrength gains in the

et allO-I demonstrated that foorball players who trained 4 to 5

J.rhlere, one must apply numerous concepts. The patient must

days per week achieved beuer results than rhose who rrained

be worked specifically tOward hiS goals, wherher they consist

6 days per week. Frequencies as high as 18 sessions per

of strength, hypertrophy, power, or endurance In the context

3 or

week have been reported in Olympic weightl ifters.w1

of life andlor sport. At the same rime, rhe tyJ.tient must vary

The intensity of the exercise or the amount of resistance

his strengrhening program with periodization if he will be

lIsed for a specific exercise is rhe mosr Important variable in

training for extended periods. The basic concept of periodiza­

resistance cralnlng. The mose common meehod of derermining

tion involves changlOg the I Otensiry, velocity, and volume of

the amOunt of resistance that should be used

a srrength­

exercise as needed . Considerarion also must be given to the type

identify the maximal load rhat can be

of muscle acrion needed (eccentric, concenrric, and isomer ric)

lifted in a given number of reperitions wirhlO one set. The

and rhe amount of focus (hat that acrion will require jf one is

emining program is

ro

10

greatest effects on strength measures, or maximal power

to help the arhlete in his sport. The aurhors recommend the

outpUtS, Jre achieved when stren.gth-rraining repetitions range

exercise variables l isted below for rehabilitating andlor training

berween

a patient:

6 and 1 2. N In ocher words, rhe maximum weighr rhar can be lifted 6 times and 6 times only is the amount of resis­

•

Strength training of 8 to ) 2 repetitions for strength and

rance co srart with. Sers and repetitions are added at subsequent

hypertrophy, 4 to

workouts until 3 sets of

repetitions for endurance

1 2 repetirions (reps) IS reached. After

6 repetitions for power, and 1 2 co 1 5

rhe above reps and sets goal is reached , reps are reduced down

•

Multiple sets for all types of strengthening

co 8, and weight is added, allOWing only 8 repetitions. Ir has

•

At least 2 days of strength training per week

been demonsrrared that once 1 5 reperi r ions are achieved wirh

•

a specific weight, the muscle no longer continues co I mprove 1 0 strength. flowever, I ighter loads that allow

tions are very effective I endurance.I(·I(,· U:'

10

1 5 co 20 repeti­

1- to 2-minute rest for smaller muscle groups, and 2- to 3-minute rest for larger muscle groups

•

Increasing absolute local muscle

Starting with multiple-joint exercise, and finishlOg with single-joint exercise

•

MaximiZing power reqUIres a good srrength base. G i ven

Intensity starting at 8 repetition (rep) max for strength and 1 0 rep max for hypertrophy, 6 rep max for power at

that both force and time components are relevant for maximiz­

high or moderare velocity, and

ing power, training co increase muscle power requires tWO

endurance

general loading srrategles. First, heavy resistance training must

•

•

muscles •

Need for periodization any time an athlere requires strength

•

Choice of exercises based on evaluation of muscle strength

training for longer than 4 weeks

strated that explosive strength rrainlng was able to improve a running

Cime for 5 ki lomerers by improvmg running

Focus on eccentric strengthening for decelerarion muscles and on eccentric and concentric tralOlng for acceleration

depending on rhe exercise, this may encompass 30t?f to 60�

of 1 RM. HIII. H N Weight traming for power has been referred 110 to as o.ploJllI: strmgth trawIllg. Paavolainen et al demon­

Velocity that is slow, moderate, or fast depending on spe­ cific goals

recruit high-threshold fast twitch muscle fibers needed for strengrh. The second strategy is co incorporate lighter loads;

1 5 rep max for muscular

economy and muscle power, although a large volume of endur­

and of muscles that are important to the type of activity in

ance training was performed concornlrandy. The maximum

which the patient participates (As was noted previously, the

amount of resistance used in the explOSIve strengrh training

greater the Intensity of the activity, the greater the intensity

exercises was ·iOr;€ of I

of the strength training should be.)

R M . When performing explosive

Chapter 4 Strength Training Concepts in the Orthopaedic Patient

General Strengthening Exercises

Fizure 4·1

Bench and reach. (From Donatelli RA: Sports-specific rehabilitati on, St. Louis, 2008, Churchill Livingstone.)

Fijlre 4-2

Arm row. (From Donatel l i RA: Sports-specific rehabilitation, St. louis, 2008. Churchill Livingstone.)

59

60

Orthopaedic Physical Therapy

Figure 4-3 Dynamic hug. (From Donatelli RA: Sports-specific rehabilitation, 51. louis, 2008, Churchill Uvingstone.)

figure 4-4 lateral pulldown. (From Donatel l i RA: Sports-specific rehabilitation, 51. louis, 2008, Churchill Livingstone,)

Chapter 4 Strength Training Concepts in the Orthopaedic Patient

61

Figure 4-5 Mid trap lift. A, Infraspinatus. 0, Supraspinatus. (From Donatel l i RA: Sports-specific rehabilitation, 51. louis, 2008, Churchill Livingstone.)

Figure 4-6 Lower trap lift. (From Donatelli RA: Sports-specific rehabilitation, St. louis, 2008, Churchill Livingstone.)

Figure 4-7 Scapular retraction. (From Donatel l i RA: Sports-specific rehabi litation, St. louis, 2008, Churchill livi ngstone.)

62

Orthopaedic Physical Therapy

Figure 4·6 Side-lying external rotation. (From Donatelli RA: Sports-spec ific rehabilitation, 51. Louis, 2008. Churchill Livingstone.)

Figure 4-9 Side-lying internal rotation. (From Donatelli RA: Sports-specific rehabilitation, 51. louis, 2008, Churchill Livingstone.)

figure 4-10 Bicep curl. (From Donatelli RA: Sports-specific rehabilitJ­ lion, 51. louis, 2008, Churchill Livi ngstone.)

Chapter 4 Strength Training Concepts in the Orthopaedic Patient

63

Figure 4·11 Tricep kickback. (From Donatelli RA: Sports·specific rehabilitation, S1. louis, 2008, Churchill livingstone.)

Figure 4-12 Standing pulley hip extension. (From Donatelli RA:

Figure 4-13 Standing pulley hip abduction. (From Donatelli RA:

Sports-specific rehabil itation, St. louis, 2008, Churchill Livingstone.)

Sports-specific rehabilitation, St. louis, 2008, Churchill Livingstone.)

64

Orthopaedic Physical Therapy

Figure 4·14 Standing pul ley hip external rotalion. (From Donatelli RA:

Figure 4-1 5 Standing pulley hip internal rotation. (From Donatelli RA:

Sports-specific rehabilitation, S1. louis, 2008, Churchill Livingstone.)

Sports-specific rehabilitation, St. louis, 2008, Church ill Livingstone.)

Figure 4-17 Side-lying hip abduction. (From Donatelli RA: Sports­ specific rehabilitation, S1. louis. 2008. Churchill Livingstone.) Figure 4·16 Prone hip extension. (From Donatelli RA: Sports-specific rehabilitation, 51. louis, 2008, Churchill Livingstone.)

Figure 4-18 Side-lying hip internal rotation. (From Donate l l i RA: Sports-specific rehabilitation. 51. louiS. 2008, Churchill livingstone.l

Chapter 4 Strength Training Concepts in the Orthopaedic Patient

65

Figure 4-19 Side-lying hip external rotation. (From Donatelli RA: Sports-specific rehabilitation, 51. louis, 2008, ChurchiIi Uvingstone.)

Figure 4-21 Curl up. (From Donatelli RA: Sports-specific rehabilita­ Figure 4-20 Sidebridge. (From Donatelli RA: Sports-specific rehabili­

tion, St. louis, 2008, Churchill llvingstone.)

tation, St. Louis, 2008. Churchill Livingstone.)

Figure 4-22 Advanced back extensor. (From Donatel l i RA: Sports­ specific rehabilitation, 51. louis, 2008. Churchill livingstone.)

66

Orthopaedic Physical Therapy

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Chapter 4 Strength Training Concepts in the Orthopaedic Patient

32. Whieehead NP, Morgan DL, Gregory )E, Proske U: Rises in whole muscle passive tension of mammalian muscle after eccenrric concraccions ae differenr lengths, J Appl PhysioI 95:1 224-1234, 2003. 33. Malina R: Growth of muscle (issue and muscle mass. In Faulkner F, Tanner J (editors): Human growth: a com­ prehensive treatise, Vol 2, New York, 1986, Plenum Press, pp 77-99. 34. Larsson L, Tesch P: Motor unit fiber density in extremely hyperrrophied skeletal muscle in men; muscle e1ecrro­ physiological signs of fiber hyperplasia, Eur ) Appi Physiol 55: 1 30-136, 1 986. 35. Van Z: Skeletal muscle aclapcacion and cell cycle regula­ cion, Ex Spore Sci Reviews 2801 :24-26, 2000. 36. Kim J. Cross j. Bamman M: impan of resistance loading on myoscacin expression and cell cycle regulation in young and older men and women,) Appi Physiol 1 0 1 :5359, 2006. 37. lrincchev A, \'V'ernig A: Muscle damage and repair in voluntarily running mice: strain and muscle differences. Cell Tissue Res 249:509-52 1 , 1 987. 38. Rosenblatt) D. Parry 0): Adaptation ofrat extensor digi­ rorum longus muscle to gamma irradiation and overlaid, Pflugers Arch 423:255-264, 1993. 39. Goldberg A, Edinger ), Goldspink D, )ablecki, C: Mech­ anisms of work-induced hypertrophy of skeletal muscle, Med Sci Spores 7:248-26 1 , 1 975. 40. Goldspink G: Changes in striated muscle fibers during contraction and growth with particular reference to myo­ fibril spliming, J Cell Sci 9: 1 23 - 1 27, 1 97 1 . 4 1 . McHugh MP: Recent advances i n the understanding of the repeated bout effect: rhe protective effect against muscle damage from a single bout of eccentric exercise, Scand J Med Sci Spores 1 3(2):88-97, 2003. 42. Kjaer M: Role of extracellular matrix in adaptation of tendon and skeletal muscle to mechanical loading, Physiol Rev 84:649-698, 2004. 43. Ying M. Yeung E, Li B, et al: Sonographic evaluation of the size of achilles tendon: the effect of exercise and dominance of ehe ankle, Ulerasound Med Bioi 29:637642, 2003. 44. Langberg H, Rosendal L, Kjner M: Training-induced changes in peri tendinous type J collagen turnover deter­ mined by microdialysis in humans, J Physiol 534:397402, 200 1 . 45. Rosager S , Aagaard P, Dyhre-Poulsen P, ee al: Load displacement properties of rhe human triceps sume apo­ neurosis and tendon in runners and non-runners, Scand ) Med Sci Spores 1 2:90-98, 2002. 46. Magnusson SP, Hansen P, Kjaer 1\'1: Tendon properties in relation to muscular activity and physical training, Scand ) Med Sci Spores 1 3:21 1 -233, 2003. 47. Kadi F: Adaptation of human skeletal muscle to training and anabolic steroids, Acta Physiologica Scandinavica Supplememum 1 68:4-53, 2000. 48. Hakkinen K, Pakarinen A, Kraemer W, et al: Basal con­ centrations and acute response of serum hormones and

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67

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68

Orthopaedic Physical Therapy

64. Arha J: Strengtheni og muscle, Exerc Spons Sci Rev 9: 1 73, 1 98 1 . 65. Ivey F, Tracy B . Lemmer J . et al: Effects of screngch (rain­ ing and deuainlng on muscle quality: age and gender comparisons, Scand J Med Sci Spores 1 4: 1 6-23, 2004. 66. Ivey F, Roth S, Ferrell R, er al: Effects of age, gender, and myostacin genocype on rhe hyperrropic response co heavy resistance strength training, J Appl Physiol 86: 195-20 I , 1 999. 67. Porter MM, Myint A, Kramer JF, Vandervoort AA: Con­ centric and eccencric knee extension serength in older and younger men and women, Can J Appl Physiol 20(4):429439, 1 995. 68. llndle RS, Metrer EJ, lynch NA, ec al: Age and gender comparisons of muscle strength in 654 women and men aged 20-93 yr, J Appi PhYSloI 83(5): 1 58 1 - 1 587, 1 997. 69. IIlgbie EJ , Curecon KJ, Warren I I I Gl, Prior 8M: Effects of conceneric and eccemric training on muscle sucngch, cross-seccional, and neural activation, J Physiol 1 9: 2 1 73-2 1 8 1 , 1 996. 70. LeScayo PC, Woolf JM, Lewek MD, ec al: Eccentrtc muscle concf3crions: their contribu[lon to Injury, preven­ tIOn, rehabdimtion, and sport, J Ortho Sports Phys Ther '13:557-57 1 , 2003. 7 1 . Tomberl l n J P, Basford JR, Schwen EE, ec al: Compara"ve srudy of is kinetic eccenuic and concentric quadriceps nds to rhe patient's symptoms

sidered for surgery after conservative care has failed. Three

and functional limitations. Palparory cests are used to evaluate

studies examined the effects of surgery and conservative care

myofascial pain and dysfunction wich respect to tenderness and

on pain for sensory loss and weakness in patients who had

tightness. Pain also can be accessed uJX>n concraction of the

minimal to mooerate cervical rad iculopathy or myelopathy.

muscle. Manual muscle and neuromotor tests are used to assess

Two studies were prospective, randomized studies that evalu­

screngch and coord ination. A postural analysis is included ro

aced a total of

evaluate for possible areas of stress concentracion. Physical

study that involved 68 participancS.I11•U9 No differences were

1 30 patiencs; the other study was a randomized

cherapiscs often determine the patlem's response to manual

found in sensation or mocor strength between patients who

traction during ehe initial examination. so they can evaluace

were treated surgically and chose who were managed conserva­

che need for mechanical cervical traction treaement . Physical examination procedures are listed in Box 7-8. Imaging scudies

fore. paciems should be informed that long-term outcomes for

may be needed if findings of the history and physical examina­

conservative treatment of minimal to moderate cervical radicu­

tion are quescionable or vague.

lopachy or myelopaehy may be the same as those reported for

cively in follow-up examinacions at 24 and 36 months. There­

Chapter 7 Temporomandibular Disorders, Head and Orofacial Pain: Cervical Spine Considerations

surgical intervemion. and in some cases, [he only reason for selecting a surgical approach may be to achieve faster pain relief. COllsert}QlilJe Care Pariems who have neck pain can choose from several comple­ memary/alternative treatments char may be parr of a physical therapist's knowledge and skill base. Complementary and alternative medicine (CAM) involves a diverse group of healrh­ relared professionals who have nor documented [he rherapeucic value of (heir alternative rrearmenrs (e.g., magnet therapy, crystal application) rhrough randomized clinic trials.1OO Physical {hecapy, however, is nO[ CAM. Physical therapists offer evidence-based rcearmems for TMDs and cervical spine disorders based on data char are well documented in peer­ reviewed journals.161.16� Physical therapists follow evidence­ based guidelines when using a mulcimodal conservative treatment approach for cervical spine sympcoms that consists of manual therapy, exercise, patient education, and mechanical cervical traction. A mulricenter, randomized, controlled crial with unblinded treatment and blinded outcome measures was conducted co investigate the efficacy of physical therapy management of cervicogenic headache.l611 A group of 200 participants who met the diagnostic criteria for cervicogenic headache were random­ ized into four creatment groups: manipulative therapy, exercise therapy, combined therapy. and no treatment. The primary outcome measured was a change in headache frequency. Ocher outcomes evaluated included changes in headache intensity and duration, improvement in the Northwick Park Neck Pain Index, reduction in medication intake, and patiem satisfaction. The physical outcomes evaluated included pain on neck move­ ment, upper cervical joint tenderness, a craniocervical Aexion muscle test, and a photographic measure of posture. The treat­ ment period was 6 weeks, with follow-up assessment after treatment, then at 3, 6, and 1 2 months. At the 1 2-moO[h follow-up assessment, manipulative therapy and specific exer­ cise had reduced headache frequency and intensity and neck pain significantly, and effects were maimained (P < .05 for all). In summary, manipulative therapy and specific therapeutic exercise reduce the symptoms of cervicogenic headache over the short and the long term.l611 Manual Tbe,.apy

Manual therapy techniques consist of a cominuum of skilled passive movements to joints or related soft tissues that are applied at varying speeds and amplitudes, including a small­ amplitude/high-velocity therapeutic movemem.l69 Mobiliza­ tion (nomhruse) or manipulation (thrust), when used with �xercise, is effective for alleviating persistem pain and improv­ ing funCtion when compared with no treatment. When com­ pared with each other, neither mobilization nor manipulation is superior. 161 The psychological, neurophysiologic, and mechanical benefits of manual therapy have been discussed adequately in the literature.17o.171

119

Exercise Exercise may be effective in creating and preventing neck pain.!"'l Specific exercises combined with manual therapy may be effective in the treatment of subacute and chronic neck pain, with or without headache, over the short and the long term. m.p) Physical therapists can identify muscles of the cervical, shoulder, and thoracic areas that are tight and weak, and for which regularion of tension levels may be difficult. Physical therapists instruct patients in exercise pro­ grams that consist of stretching, strengthening, conditioning, and coordinating that are specific to the patient's needs. Modi­ fication of the exercise program frequently is necessary afrer reevaluation of the patient; this is dependent upon changes in the patient's signs and symptoms. A successful home exercise program is a function of proper patient performance and diligence. The skill of the physical therapist in teaching correct exercise form, making modifications in the exercises based on patient response, and motivating the patient to perform his or her home program is critical for obtaining an oprimal OUtcome. Patient EdllCflti011 Patient education focuses on many elements of patient care and often involves instructing the patient on proper sirting and sleep postllres. Support for and encouragement of patients also are important in helping them to overcome fear, anxiety, and misconceptions about their condirion. Frequently, well meaning advice from friends or family members may intetfere with recovery because of misbeliefs or incorrect information. In some cases, incorrect information is received from online computer resources thac the patient has read. Frequently, phys­ ical therapists mUSt dispel myths that rhe patient may have obtained from different sources, to alleviate anxiery and (ear and to manage pain. P4.n Patients are educated by ph)'sical therapists about the meaning of their diagnosis because physical therapists typically spend more time with the patient than do medical profession­ als. Patients often perceive {hat ··something is wrong" (i.e., irreversible) from a medical diagnosis such as degenerative joint disease, when degenerative joint disease in itself is neither predictive of, nor strongly correlaced with, the patient's symp­ tOms. In this way, a medical diagnosis may enhance the feelings of fear and anxiety, which can intensify symptOms and lead the patient to believe thar a cure is not available. 1 76 Patients can become preoccupied with their diagnosis and ofren seek inva­ sive treatment in an acrempt to "fix" the condition. The health practitioner mUSt understand that a patient's fear, misunder­ standing, and beliefs about the meaning of pain may determine whether he or she progresses from acute to chronic neck pain. P7 A patient is less likely to develop a chronic pain mentality when he or she is educated about the condition after informa­ tion is obtained regarding the medical diagnosis and symp­ toms. The physical therapist plays a major role in reducing patient anxiety and fear by keeping the patient focused on functional goals.

1 20

Orthopaedic Physical Therapy

Mechanical Cervical Tractiol1

Cervical spine disorders that are treated by physical thera­ pists who use evidence-based interventions, such as manipula­

Traction is a treatmem char is based on application of a longi­

tion/mobilization and therapeutic exercise, can decrease the

tudinal force [0 the axis of the spinal column. Medically

protracted course of costly treatment and can reduce the

accepeed uses for spinal craccion include safe tissue rightness,

patient'S pain. Physical therapists, therefore, have an important

joinr stiffness, cervical radicuioparhy. and cervical myelopathy, which are caused by disc degeneradon or disc herniacion. 178

role in the management of head-neck and orofacial pain.

The therapeutic value of eraction was demonstrated in a erial

many times can be treated effectively by a physical therapist

of 30 patients who had unilateral C7 radiculopathy,179 Pariems

who has specialized skills and experiences. Consequently, phys­

Patients who present with TMD and cervical spine disorder

were assigned randomly [0 a control group or an experimental

ical therapists should be an important member of the group of

group. The application of cervical craccion, combined with

health practitioners who work with patients who have head,

electrotherapy and exercise, produced an immediate improve­

neck, and orofacial pain.

menr in hand-grip function in patients who had cervical radic­ uiopachy compared with [he control group, which received

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7 Temporomandibular Disorders, Head and Orofaeial Pain: Cervical Spine Considerations

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37. Hardy M A : The biology of scar formarion, Phys The
standing pertinent clinical findings.! Subsequendy, rhe pur­

tests and measures with high levels of sensitivity. generally

poses of this chapter are as follows:

90 or higher, and can gUide the clinICian toward the appro­

I . Oudioe rhe effective clinical reasoning processes used

priate use of tests with higher specificity, such as imaging,

during differentiation of rhe cervical and thoracic spine

biopsy, and ocher more invasive methods," Several clinical

2. Present a description of a differencial assessment between

tests such as reflex testing and sensibility testing are used fre­

rhe cervical spme and rhe thoracic spine

quently as screening tools, but they actually demonstrate poor

t Present methods lor mobilization of rhe cervical and upper

sensitivity and may nOt yield useful information dunng an . . , examination.

thoracic spine.

Confirmatory rests are used near the end of an examination and include cests and measures that demonstrate moderate to

DIFFERENTIAL DIAGNOSIS

high levels of sensitivity and higher levels of speCifiCity. � Strong confirmatOry testS and measures should be focused and precise,

Differential diagnosis is the process of weighing the probability

and should isolate the targeted regIon of interest. Confirmacory

of one disease, movement dysfunction, or pain generator vs. the

rests and measures are used to substanciate a diagnosis or to

probability of anocher. ThiS process is performed during a

confirm the guilt regarding a specific body region, tissue, or

clinical examination by analYZing [he signs and sympmms of

movement dysfunction.

the patient and determimng the most relevant criteria associ­

CLINICAL REASONING

ated with the pathologic process of the patient. I Differential diagnosis is necessary [0 direct treatmem, whatever the mode, at the source of the patient's true disorder.

SimIlar to differential diagnosis, clinical reasoning involves

For tht:: physical therapist, differentiation usually is required

higher-level recognition of pertinent clinical findings that

when (I) the physician has rendered a nonspecific diagnosis, (2)

assist in driving care-related decisions!,·q Clinical reasoning

the dmgnosis appears

be In question, andlor (3) the therapist

involves assessing the probabilICY of selected disorders and

dt"Cides that the patient's disorder may be muitistruccural andl

being able [0 discriminate among several hypotheses at any

or multisegmenral.

each

given rime. Successful clinical reasoning requires the marriage

element of the clinical findlllgs, including the subscribed diag­

of data extracted from the patient interaction and selection of the treatment technique.IO·11

co

Physical

therapists must weigh

nosis, patienc history, and physical examination. Findings from testS and measures must be analyzed for pertinence, applicabil­

During the patient interaction, tI'alnati011, as defined by the

ICY. and guilt in identifYing a pattern within the patienc's

Gnick to Physical Therapist Practice. I � IS relared intimately to

sympcoms. Differentiation demands an understanding of the

how [he term aJJeJJllltnt is used in clinical reasoning; it is the

values of tests and measures, recognition of essential aspens of

cornersrone of effective clinical practice. However, unlike eval­

patient history, and sophisticated clinical reasoning during and

uation, assessment involves a more fluid, conrinuous process

after the examination process. \

that includes intangible elemenrs of the patient interaction model. We advocate three types of assessment: assessment, (2) analytical assessment, and assessment.

161

(I) daily clinical (3) differential

Orthopaedic Physical Therapy

162

physical signs and symptOms and response panerns seen in

DAILY CLINICAL ASSESSMENT

tests and measures and with techniques of rreatment. A dif­ ferential assessment can be completed in at least four ways: (l)

Dady clmical assessmem is an unremitting process char

prognostic epidemiologic tables, (2) rradirional diagnostic

includes rbe considerations and comributions of the patient,

tests,

techniques, tests and measures, clinicians, and care pacccrns.

PE, and treatmeor, and

For the patient hiscory. an efTective formac for facilitating rhe

(3) questioning and examining during rhe patient history, (4) phYSICal ddfereoriation.

Prognostic epidemiologic tables, such as diagnostic values n.l1

flow of rhe clinical assessmem consists of (I) the nature and

and reliability measures,

kind of rhe disorder, (2) rhe area or areas of the symptoms,

(3)

knowledge but may nor prOVide useful informacion for the

the behavior of rhe symptoms, (4) percinenr present and paS[

particular patient at hand. Prognostic epidemiologic tables

may add some elemeors of

may list, compare, or discuss signs and symptOms of various

hismry. and (5) special questions. The nature and kind of rhe disorder reflect [he depiction of

disorders and are readily available in textbooks and journals.

rhe disorder. NatJlre reflects the overall description of rhe

Traditional diagnostic tesrs. such as radiographs or magneric

patient's assessment of his or her currene problem defined as

resonance imaging (MRI), may be available for study. Resules

,111

of these tests may be helpful In derermlnlng rhe source of

.tnnoyancc. an Impairment, or a disabling condition, whereas

kmd may relate CO whether the condition manifests as pain,

the patient's disorder but may be misleading in selected

stiffness, weakness, Instability, or poor coordination. Area(s) of

circumstances.11

sympcoms is an oudine of the origination and progression of

Questioning and examining dUring rhe patleor Iliscory, PE,

the putiene's disorder based on his or her description. Behavior

and treatment form the nexus of strong clinical reasonmg and

of sympcoms reAecrs changes in the condition throughout the

are discussed furrher in this chapter. Mark Jones defines physica'

progression of the day, during activities, or during a given time

differentiatIon as that which "involves altering the pain provok­

frame. Pertinent present and past history may add useful infor­

ing position, or movemenr in such a way. thac one structure is

macIOn toward the care and understanding of the patienc's

implicated as the source, while another IS eliminated from

condition. Special questIons may include spontaneous, scripted,

contention.""" The purpose of phYSICal dlfferennation is to so

or response-specific queries designed to gain useful information

stress one area that symptoms are produced from char area

that

alone; rhus, the other area(s) is (are) ruled OUt as a source of the

would

not

normally

distill

during

convencional

InCCr3(Clon.

disorder.

For the physical examinacion (PE), an effective format com­ prises tesrs,

(I)

screening rests, (2) active physiologic movemenc

0) passive physiologic movemene tesrs, (4) passive acces­

sory movemenc rests, and, if needed, (5) confirmatory testS. Further cxplanatlon is prOVIded throughout rhe chapter.

CRITICAL ELEMENTS IN THE CLINICAL REASONING PROCESS Critical elements m the clinical reasoOing process ate designed

ANALYTICAL ASSESSMENT

co improve the outcome of rhe patient IOreracrion. Germane co these processes are (1) types of e1mical decision-making pro­

Analytical assessmenc is rhe cognitive foundation of the clinical

cesses, (2) recognition of the source of rhe disorder, (3) recogni­

reasoOlng processes. Analytical assessmenc is a coneinuous

tion of clinical hypothesis coorributors, and (4) correCt use and

process that enhances all effective clinical functions; it is in a

understanding of rerminology.

sense rhe tllInking about our thinking. rhe reason why we do whar we do. It IS a series of accumulating thoughts that result in oven ans by therapists. The acts are heard as questions in

Types of Clinical Decision Making

rhe patient hiscory. are seen as objective tests in the PE, and

The process of making cllOical deciSIons IOvolves both vertical

finally are seen as rreatmenc. Analytical assessmenc is a process

and lareral thinking. Vertical thlOklng is characrerlzed by

of rhlllklng. planning, and executing, to prove or disprove a

logical, sequencial, predicrable, and what might be called con­

hypothesis. ThiS process is the key co self-improvemenr and is

vencional rhinkms. Lateral chinking IS not necessarily sequen­

essential for funhenng knowledge and quality of care. Without

tial,

analyrical assessmenc, progression of quality stagnates, currene

restructuring, an escape from old parterns and rhe crearion of

and

it

is

unpredicrable.

Lareral

thinking involves

theories and dogma are accepred without question, and new

new ones; It is concerned wirh the generation of new ideas,

and bener ideas are not developed.

and wirh looking at things in a differeor way. Although verri­ cal thinking stays within a problem space, lateral thinking tends to restructure the problem space. Vemcal thlOkmg IS

DIFFERENTIAL ASSESSMENT

hindered by rhe necessity

[()

be right ar each stage of the

thought process and by rhe auempt Differential assessmenr is largely hypothesis testing, which

[0

rigidly define every­

rhing. Lateral thinking is based on rhe notion (har premarure

takes place before, dUring, and after all phases of the patienc's

formation and expression of an idea may inhibir us natura]

\'Isic.

development.

Differential assessment primarily involves weighing

Chapter 9 Differential DiagnoSis and Mobilization of the CelVical and Upper ThoraCic Spine

Recognition of the Source of the Disorder In uncomplicated presemanons, the source of the d isorder is

163

CERVICAL AND THORACIC SPINE ANATOMY AND BIOMECHANICS

clarified dUring the patient hiscory, and an initial hypothesis is formed. This hypothesis i s confirmed, rejected, or modified

This chaprer focuses on rhe cervical and rhorarhesis caregories are e1emenrs rhat may conrribute to overall parienr presenracion, outcomes, and well-being. These categories include (I) rhe source of rhe patient's symproms, (2)

Key features of the upper cervical spine include rhe sacnfinse detected

Lt. Overall, grearer range of motion is available In flexion rhan

during rhe objective examination. Investigation demands

in exrension. The combined side (lexIon of rhe rhoC3ndylosis and upper cervical

of the patient. W

joint arrhrosis.}C).42 Empirical evidence favors the upper joints

The pacienc's general health is explored co discover serious

as being at fault.40 Many p.1.tienes will complain of a stiff neck

pathology char may have been underecced by the referring

and a morning headache at the base of the occiput or late-day

physician, and [0 determine the relevance of known health

headaches behind the ipsilateraJ eye or on the vertex of the

problems. Does the patient look unwell. and has a recent

head. Subsequene movement tests and palpations are aimed at

unplanned weight loss occurred? Does the pacienc have a

reproducing the pain of the stiff neck and a very small ponion

history of rheumacoid arthrius. which may suggest laxity of

of the headache symproms. It is most possible that the stiff

[he transverse ligament? Are there any systemic diseases,

neck and the headache are related, but it is also possible that

including recent surgery and cardiorespiracory disease, chat

they are twO separate eneities. If the relationship was not clari­

will restrict the patient's ability to perform active exercises?

fied during the patiene history, it most likely will be clarified

Are symptoms of vertebral artery disease apparent?

during the PE.

Questions regarding medications, including steroids, are

Many hypotheses regarding the proximate cause of lower

asked, so that the effects of the medications on the patient's

cervicaJ lesions have been put forth. Ligameneous lengthening

pain can be determined and any systemic effeccs of the drugs

with periosteal lifting, chronic lower cervical spine Rexion

can be estimated. The occasional use of mild analgesics that

deformation with weakening of the posterior annular wall,

eliminate the pain suggestS a moderately painful condition,

osteophyte formation, and alteration of the length and tone of

whereas regular use of strong analgesics that only reduce the

the cervical musculature are the explanations most frequently

pain suggests a more painfuJ condition. Long-term use of ste­

suggested.

roids may weaken the connective tissue. Patients who reJX>rt suspeCted osteoporosis require more cautious treatment, espe­

pist, it is importane to address posture in sicting, standing, and

cially in the thoracic spine.

lying. Few patients, except in the acute scate of a disorder, are

On completion of the patient history, the therapist has

Regardless of the treatmene approach favored by the thera­

unable to benefit from a reduction in chronic forward head

gleaned extensive and relevant information in an efficient

poseure. Many patients report significant relief from their

manner to the extent that the therapist is able to establish, in

symptoms after poseural correction alone.

many cases, a tentatiVe conclusion. When questions and answers Row in a Ruid and logical manner, a particular struc­ ture is often implicated. The assessment has been successful ro rhis point. A summary of the patient hIStOry is presented in Table 9-1.

Purpose The general purpose of the PE is to assess movemene and symptom behavior, that is, limitations, deviations, aberrations, and the effects, jf any, of movement on the patient's symptoms.

Physical Examination

Any deviation from normal movement and all symptom

The PE is a series of appropriate active and passive movement

changes are noted. Future changes in rhe patient's condition

resrs aimed at collecting additional data that will confirm or

then can be measured against the benchmarks of objective signs

deny the therapist's tentative hypotheses reached during the

and patient history-generated symproms. Movement loss may

patient history. A typical PE consists of active physiologic

be graded as major, moderate, minor, or none. This loss also

movements, passive physiologic movements, passive accessory

may be expressed as a percentage of normal or may be expressed

movemems, and special testS, as needed.

in degrees. Besides assessing movement, a second purpose of the

Treatment Modes Related to Reactivity and Stages of Scar Tissue Formation Stages

Reactivity

Treatment

inAammation

Pain, then reSIstance

Res, Immobilizaeion Grade I and II movements ActIve range-of-motion exercises Grade I and II movements

Granulaeion fibroplaseic ( heali ng) Macuration

Passive range-of-mOtion exercises Grade III, IV, and V movements

(rom Pins SV' Exm'mlty dys(unnion Institute Pms.

Adapctd 1980,

PalO and reSlseance, simultaneous Resisl3.nce. chen pain

and mobilization, Adama,

PE, especially when stiffness is treated, is to reproduce the patient's comparable sign. For example, if the patient's chief complaint is a moderate midcervical pain, and this same pain is rep rod uced by overpressure inco the quadranc posicion, (he quadrant position may be used later to assess the effects of treatmenr.4.\ A third purpose of the PE is ro determine the preferred direction of treatment movements. Repeated movements that reduce, centralize, and eliminate the patient's symptoms should be used in treatment for discogenic syndromes. Repeated movements that temporarily produce, but do not worsen, the patient's symproms are the movements that should be used

10

treatment for stiffness. If no movements, either passive or active, can be found that produce the desirable effect on the patient's symptoms, the patient may not be a good candidate for that treatmene, or the examination may be faulty.

166

Orthopaedic Physical Therapy

Instructions to Patients

disorders of the joints and muscles of the cervical spine. These structUres

are

richly

supplied

with proprioceptive nerve

The relative vigor and exccm of (he PE depend on the irritabil­

endings.'I.H Thus dizziness is not always vertehrohasilar or

Ity of the patient's symptoms. If the cervical or thoracic spine

internal carotid in origin.

is judged to be irrimble, the examination muse be gentle and

Proper radiographic evaluation of suspected atlantoaxial

limited to a few necessary movemems. The patient with an

insrability is imperative before any vigorous objective assess·

acute nerve foot irritation, with sympcoms extending below

ment is attempted. Afflictions of this joint do occur, especially

rhe elbow, deserves a gentle examination. However, a nonir­

in Down syndrome, rheumatoid arrhritis, ankylosing spondy­

Citable and moderately painful condition will require a more

litis, psoriatic arthritis, and posttraumatic conditions. Tests

vigorous and extensive examination. Few patients require

and measures such as the alar ligament stabiliry test, the Sharp

inclusion of all rest movements co satisfy rhe purpose of rhe

Purser test, and others may be beneficial during assessment hut

examInation. The therapist must know rhe scams of rhe pacient's symp­

have yet to be proven unequivocally to be effective in identify· ing patients with instabiliry.' Vigorous examinations or treat­

corns Immediately before scarring rhe examination and at rhe

ment,

conclusion of each rest movemem. Thlls rhe parienc is asked co

complications, daring back to early reports by Blaine.).! When

descnbe pretest sympcoms and co report clearly any change in

instability is expected, radiographic testing may serve as a

where

instability

exists,

have

led

to

disastrous

sympcoms during and immediately after each tesr movement.

beneficial rool, specifically when transverse iigamem instabJlity

It is also important for rhe patient [0 understand that, in most

is the source of the dysfunction. "

circumstances, some tesr movemems may make the sympcoms worse, and others may make rhem bener. The more accurarely

the patlem is able ro convey any changes to the rherapist, the more informative the examination will be, and, quite likely, the rnore effective the treatment will be.

Special Tests Before the Physical Examination

THE EXAMINATION Observation Observation is designed to provide introspective and external findings associated wirh posture, attitude, compliance, and

If sympcorns extend below rhe elbow, a neurologic examination

appearance. Sitting rhe patient on the narrow end of the rreat­

should be completed before the PE is conducted.6•n If red flags

mem table enables the therapist to observe from either side and

are suspecred, tests with high sensitivity may help [0 rule OUt

from rhe front. The clinician should note the general simng

the presence of a serious disorder.6 If rhe parient complains of

posture, static deformity, asymmetry. and the condition of rhe

diainess or other associated symptoms, an essemial part of the

skin, and should acknowledge the patient·s willingness to

examination should consist of tests that estimate the imegrity

move.

of the vertebrobasilar and rhe imernal carotid artery system.oW \Vhen these rests are performed before the PE, the effects, if any, of the examination itself rnay be assessed at the conclusion of the examination. Without a pretest, there is no benchmark from which co measure.

Test Movements Before any test movements are assessed, the present symptoms nared in rhe sitting position musr be recorded. For each test

Several cervical artery dysfunc[Jon testing merhods have

movemeor, the c1inicl3n should eS[Jmate movemem loss and

been defined within the literature. Sustained end-of-range rOta­

the relationship between the patient's symptoms and range. It

tion of the cervical spine, first described by Maitland in I 968,'n.., t. has long been suggested as the most effective method

is helpful. for the sake of consistency in recording data, for the

for verrebrobasilar Insufficiency (VBI) assessment of rhe upper cervical spine, and it is currently recommended in rhe prema­

therapist to establish a rouune sequence. A routine in rhe order of testing movements also helps

to

avoid omissions.

The appropriare method used during active movemeor is to

nipulation guidelines for rhe cervical spine4Ml-49 thur are used

test a movement once and then to repeat the same test move­

by physiotherapisrs and other manual therapists. In addition,

mem several times. Acrive movemeors may be sustained or

the practice of placing an individual in the premanipulative

oscillared to produce the desired effect. For the sake of patient

position before the procedure is performed, so the patiem's

education, it often is necessary to ask rhe patient to repeat a

tolerance to rhe position can be assessed, is advocared.'o

movement that makes him or her worse, and then to repeat a

Because use of the tesring method introduces some risk for

movement that makes him or her better. Movements must be

a posJ[ive VBI, It may be advisable to avoid performing the

sufficiently far into the range ro produce a valid response to the

test or providing treatment in cases where subjecrive symptOms

test. A sequence of testing for the cervical spine may involve

are commonly reported, or past tests have demonstrated posi­

protraction, flexion, retraction, retraction and extension, bilat­

tive findings. In the evem of a positive VBI during testing,

eral sidebend, and bilateral rotauon. Thoracic spine move­

treatment should be sropped immediately and appropriate

rnents may include plane-based movements, as well as combined

medical assistance obtalned.,p

movemenrs.

Dizziness and reflex disorders of posture and movement also

Another method of testing active physiologic movements is

may be caused by degenerative, inflammatory, or traumatic

to have the patiem move toward the pain (when treating pain)

Chapter 9 Differential DiagnoSis and Mobilization of the Cervical and Upper Thoracic Spine or to move toward che liml[ (when crearing stifn f ess). Important

(0

clarify and accuraeely record the relationship

between range and palO. A sequence of testing in balanced poscure consistS of fleXion, extension, lateral flexion, and bilat­ eral rotation. Movements also may be tested in different parts of rhe flexion/extension range. Movements may be susralned and overpressured as needed. The quadrants (a combination of extenSIOn with sidebendm8 and rotation to the same side) for rhe upper and lower cervical spines may be teseed If prevIous rests have been negative.

BOX 9-1

•

•

•

Compression and dlsm1Ccion are used when necessary. Passive rion. Tests of rhe pain-sensitive Strucrures in the intervertebral

•

canal and searlC tests for muscle pain are performed as

•

The patient is placro In a prone position for palpation tests, including remperarure and swearing, sofr rissue palpanon, positions of the vertebrae, and passive accessory intervenebral

Summary of Subjective Assessment

Type of diwrder (pain, stiflness, weakn�, ere.) •

physiologic movements also may be tested in rhe supine posi­

applifo Somatic referred pain from chese regions

and poscerior cervical srrengrh testing.bl

may presene from rhe OCCipUt, Into the shoulder, toward the

An acure histOry of trauma may suggest Instability of the

paramedian neck region, and into rhe parascapular region."

upper C-spine. Use of Canadian C-spine rules may assisr in

Somatic referred pain can radiate into the jaw and cause head­

determinlOg who benefits from a radlographb� Tests and mea­

aches.'� Radicular palO may refer Into the upper extremities

sures such as the alar ligamem stablliry rest, rhe Sharp Purser

and inca rhe scapular region. Myelopathic symproms generally

rest, and others may be useful for Jdeneifying ligamentOus

are initiated as motor deficits first, but they also may demon­

laxiry.' Ligamentous damage is common afrer motOr vehicle

strate pain or sensory changes, if chroniC.

accidents and may persisr for several monehs.M

Orthopaedic Physical Therapy

168

Symproms associated with clumsiness of the lower extremi­

Patients, if questioned rhoroughly. ofren recall previous boutS

ties and hands may reRect myelopathic changes.�·l1 whereas

of neck stiffness. Patiencs With a dlscogenic neck disorder

difficulty walking with immediate relief upon cessation of

ofeen awaken with their neck pain,

activlfY suggests spinal imermHcem c1audicarion.72 Cervical

cervical "lock," who often are awakened by {heir neck paln.ltt.114

spine myelopathy (CSM) involves spinal cord compression or inJury and is , 1997. Melzack R, WaH P: Pain mechanisms: a new theory. Science 1 50:971 -979, 1 965 BasmajianJ, editor: Manipulation, rraction, and massage, ed 3, Baltimore, 1985, Williams & Wilkins. Cynax J: Textbook of orthopedIC medicine, ed 6. Baln­ more, 1975, Williams & Wilkins. Cookson JC, Kent B: Orthopedic manual therapy: an overview. 11. The spine, Phys Ther 59:259, 1 979. McKenzie R: Manual correction of sciatic scoliosis, NZ Med J 76:484, 1 972. Gross AR, et al: A Cochrane review of manipulation and mobilization for mechanical neck disorders, Spine 29( 14): 1 54 1 - 1 548, 2004.

1 38. Fritz JM, Brennan G: Preliminary examinarion of it pro­

posed rreatment-based classification system for patients receiving physical therapy interventions for neck palO, Phys Ther 87(5): 5 1 3-524, 2007. 1 39. Turtle N: Do changes within a manual rherapy treatment session predict between-session changes for parienrs with cervical spine pam' Au" J PhYSIorher 5 1 (I ):J3�j8, 2005. 140. Hahne A, Kearing J. Wilson S: Do withlO-session

changes in pain imensity and range of motion prediCt between-session changes in patients with low back p.l1n' Aust J Physiotherapy 50: 1 7-23, 2004. 1 4 1 . Long A, Donelson R, Fung T: Does It matter which exercise? A randomized control trial of exercise for low back pain, Spine 29(23):2593-2602, 2004. 142. Childs lD, et aJ: Proposal of a classification system for patienrs with neck pain. J Orthep Sports Phys Ther 34( 1 1 ):686-696; discussion 697-700, 2004 .

1 96

Orthopaedic Physica l Therapy

143. Wyke B: The neurology of low back pain. In Jayson M,

1 50. McNair J: Acute locking of the cervical spine. In Grieve

editor: The lumbar spine and back pain, ed 3, New York,

G, editor: Modern manual therapy of the vertebral

1 987, Churchill LivingStone, p 56.

column, Edinburgh, 1 986, Churchill Livingsrone, p 357.

144. McKenzie R: The Iu.mbar spine, Waikanae, New Zealand, 145. Berrhcioc JM, et al: Concribucion of centralization phenomenon

ro

of d iskogenic

rhe diagnosis, prognosis, and treatment low

back

1 5 1 . McKenzie R: The lumbar spine, Waikanae. New Zealand. 1 98 1 , Spinal Publications.

1 98 1 , Spinal Publications.

pain,

Joint

Bone

L 52. McKenzie R: The cervical and thoracic spine, Waikanae, New Zealand, 1 990, Spinal Publications.

Spine

1 53. McKenzie R: Treat your own neck, Lower Hut, New

1 46. Werneke M, Hart 0: Centralization: association between

1 54. Lindahl 0, Hamberg J: Thoracic spine disorders as a

repeated end-range pain responses and behavioral signs

cause of angina-like pain, Pmcc Cardiol, 1 0(suppl 2):62,

2007;74:.1 1 9-323.

in paciencs with acute non-specific low back pain, J Rehabil Med 37(5):286-290, 2005. 1 47 . George SZ, Bialosky JEt Donald DA: The centralization

Zealand, 1983, Spinal Publications.

1984. 1 55. Laslerr M: The rationale for manipulative therapy in the treatmenr of spinal pain of mechanical origin. Unpub­

phenomenon and fear-avoidance beliefs as prognostic

lished workshop manual. Mark Laslett. 2 1 1 - 2 1 3 , White

facmfs (or acme low back pain: a preliminary investiga­

Swan Rd., Me. Rosekill, Auckland, New Zealand, 1 986.

tion involving patients classified for specific exercise,

1 56. McGuckin N : The T4 syndrome. in Grieve G, editor:

J Orchop Sports Phys Ther 35(9):580-588, 2005. 148. Skytte L, May S, Petersen P: Cemralization: its prognos­ tic value in patients with referred sympcoms and sciatica, Spine 30( 1 1 ):E293-E299, 2005. 149. Aina A, May S, Clare H: The cenrraJization phenomenon of spinal sympcoms: a syscematic review, Man Ther 9(3): 1 14 - 1 43, 2004.

Modern manual therapy of the vertebral column, Edin­ burgh, 1 986, Churchill Livingsrone, p 370. 1 57 . Flynn T: The thoracic spine and rib cage, Boston, 1 996, Butterworth-Heinemann.

CHAPTER

10

Todd S. Ellenbecker and David s. Bailie

The Shoulder

The shoulder is a complex :lnd highly mobile JOlm char

tenor rotator cuff through length-tension enhancement com­

requires a deGtileo undersrandlng of irs Inherem anacomy

pared wieh function in the coronal plane"·! Placement of the

and biomechanics co t'nabJe rhe clinician to perform a compre­

glenohumeral joint in the scapular plane optimizes the osseous

henSive tvaluilrion and co formulate an optimal treatmem

congruity berween the humeml head and the glenoid and IS

program. The exceptional degree of mobility and rhe requlre­

widely recommended as an optimal position for tht perfor­

mcor for dynamIC swbihzarion, coupled with rhe repetitive

mance of various evaluation cechniqllCs and for use during

n:uure of human shoulder funuion In dail)' activities and

many rehabilitation exercises. I.'

sports, produce challenges for rhe clinician during rehabillta­

Another Importane general concepr of relevance for thiS

rion. ThiS (h�lr[er will review anacomical and biomechanical

chapter is that of muscular force couples. One of rhe mose

concepts co provide [he framework for rhe presemarion of key

important blomechanical principles in shoulder function is the

clinical evaluation merhods, co allow for rhe developmenr of eVidence-based rre-.umt'oc progressions for rhe pauenr with

a j{Jr(t collple. can be defined as ewo opposing muscular forces

deJroid rOtator cuff force couple.1 ThiS phenomenon, known as

shoulder dysfunction.

working together to enable a particular motion co occur, with chese muscular forces being synergists or agonist/antagonise pairs.1 The delcoid muscle provides force primarily in a supe­

ANATOMICAL AND BIOMECHANICAL CONCEPTS OF THE SHOULDER

rior direction when it contracts unopposed dUring arm eleva­ [lon.6 The muscle tendon units of the rotaror cuff must proVI(.ie a compressive force, as well as an inferiorly or caudally dirl'Cted

Several key inherent anacomical and biomechanical concepts of

force, ro minimize superior migration and to minimize contaer

the human shoulder have �Hgnlficant ramlficanons for evalua­

or Imptngement of the rotaror cuff tendons against [he ovc:r1y­

tion and treatment. These are presented here co provide a

ing acromion.1 Failure of the rotator cuff to mJ.lOtalO humeral

framework for later discussion of clinical evaluanon methods

congruency leads to glenohumeral ,Oint Inst;:\bdity, rotatOr cuO'

and rreatmem gUJ(..Ieilnc."S. These conceprs Include scapular

tendon pathology, and labral inJUry. Imbalances In the deltoid

plane, forc:e muple, and �Ienohumeral resting IXlsicion.

rorator cuff force couple, which primarily occur during tnap­

One of the key concepts in upper extremity rehabilitation

propriate and unbalanced strength tralntng, as well as during

IS rhe .f"uplllm· pl,mt' ((mapl. The scapular plane has ramificanons

repetitive overhead sportS activities, can k-ad to developmene

in trearml'nt, in evaluation, and even in functional activity in

of the deltoid without concomitant increases in rotacor culT

sports. According to Sa.ha, the scapular plane is defined as being

strength and can increase the superior migration of the humeml

30 degrees antenor ro the coronal or frontal plane of the body.1

head

This plane IS formed by th(' retroversion of the humeral head,

impingement.

provided

by

the

deltoid.

leadmB

to

rotaror

luff

which averages 30 degrees relative co the shaft of rhe humerus,

Additionally, the serrarus anterior and trapellUS force l'ouple

coupled with the native anteversion of the glenOid, which is

is the primary muscular stabilization and prime mover of

also 30 degrees.v It is Important for clmicians ro recognize

upward rmation of the scapular dUring arm elevation. Bagg

rhis relationship during humeral head rranslation testing and

and Forrest have shown how the upper rmpeZ1US and rhe ser­

exercise IXlsitlonlng because of the inherent advantages of this

ratus anterior function during the iOitlal 0 to 80 degrees of

position. \,(/ith rhe �lenohumeral joint placed in the scapular

arm elevation, providing upward scapular rotation and stabili­

plane, bony impingement of rhe greater ruberosity against rhe acromion does nOt occur because of the alignment of the tuber­

zation.s Because of a change In the lever arm of [he lower trapezius chut occurs during rhe lateral shlfr of [he scapuimho­

osity Jnd the acromion in this orientation. I In addition ro the

cacic instantaneous center of roration with arm elevation, the

optimal bony congruency afforded

lower trapezius and the sermrus anterior funcoon as the primary

10

rhe scapular plane, this

poSitIOn decreases Stress on the anterior capsular componeors

scapular stabilizer in phases II and 111

of the glenohumeral jOint. and enhances activation of the IXls-

elevation.fI Knowledge of the important muscular force couples

197

(80

co

140 degrel's) of

1 96

Orthopaedic Physical Therapy

in the human shoulder and scapuiochoracic region is imperative

tion, as well as use of rhe hands-on-hips position to evaluate

and can lead to proper evaluation and ultimately treatment

the prominence of the scapula against the thoracic wall. Typi­

provided via strengthening and monitoring of proper srrength

cally, the dominant shoulder is significantly lower than the nondominanc shoulder in neutral, nonstressed standing pos­

balance in these important muscular pairings. Finally, the concept of glenohumeral rescing posicion

tures, particularly in unilaterally dominant arhleres like base­

deserves discussion in chis seccion of rhe chapter because of its

ball and tennis players.12 Although the exaCt reason for [his

relevance both in evaluation of the shoulder and in rhe applica­

phenomenon is unclear, theories include increased mass in the

tion of creacmenc, specifically mobilization and interventions

dominant arm, leading the dominant shoulder to be lower

performed co improve glenohumeral motion. The resting posi­

secondary to the increased weight of the arm, as well as elonga­

tion of rhe human glenohumeral joint generally is considered

tion of the periscapular musculature on the dominant or pre­

co be rhe posicion where chere is maximum range of motion

ferred side secondary to eccentric loading.

(ROM) and laxity, caused by minimal tension or Stress in rhe

In the standing position, the clinician can observe the

supportive srructures surrounding the joinc.9 This position has

patient for

been referred to as the

"xue-pack position of the joinc as well.

specifically, focal areas of muscle atrophy. One of the positions

Kaltenborn and Magee both have reported that the resting

recommended, in addition to observing the patient with the

position of the glenohumeral joinr ranges between 55 and

symmetrical muscle development and, more

70

arms at the sides in a comfortable sranding postUre, is the

degrees of abduction (trunk humeral angle) in the scapular

hands-on-hips posicion. which simply places the patient's

plane.IO,11 This loose-pack position is considered co be a "mid­

shoulders in approximately 4 5 to

range" position, but only recently has it been subjected to

slight internal rorarion. The hands are placed on rhe Iliac cresrs

experimencal testing.

of the hips such that the thumbs are pointed posteriorly. Place­

50 degrees of abduCtion with

Hsu et al measured maximal anterior posterior displace­

ment of the hands on the hips allows the patient to relax rhe

ments and total rotation ROM in cadaveric specimens, with

arms and often enables the clinICian to observe focal pockets of

altering positions of glenohumeral joint elevation in the plane

atrophy along the scapular border, and more commonly over

of the scapula.9 Their research identified the loose-pack posi­

the infraspinous fossa of the scapula. Thorough visual inspec­

tion, where maximal anterior posterior humeral head excursion

tion using this position can often identify excessive scallopmg

and maximal total roration ROM occurred within the proposed

over the infraspinous fossa, which may be present in pacients

range of 55 co

70 degrees of humeral elevation in the scapular

with rotacor cuff dysfunnion and in patients with severe

plane (trunk-humeral angle) at a mean trunk-humeral angle of

atrophy who may have suprascapular nerve involvement.

39.33 degrees. This corresponded to

Impingement of the suprascapular nerve can occur at the supra­

45% of ,he available

ROM of the cadaveric specimens, Anterior posterior humeral

scapular notch and rhe spinoglenoid notch and from paralabral

head translations and maximal cotal rotation ranges of motion

CYSt formation commonly found In patients wHh superior

were significantly less at

0 degrees of abduction and near 90

labral lesions. I � Figure 10-1 shows the isolated atrophy present

degrees of abduction, respectively, in the plane of the scapula,

in the infraspinous fossa of an overhead arhlere who presented

and were greatest near the experimentally measured rescing

with anterior shoulder palO, Further diagnostic testing of [he

position of the glenohumeral joint (39.3 degrees). This study

patient with extreme wasring of the infraspinatUs muscle is

provides key objective evidence for the clinician co obtain the

warranted to rule out suprascapular nerve Involvement.

maximal loose-pack position of the glenohumeral joint by using the plane of the scapula and approximately

40 degrees

of abduction, This information is important co clinicians who wish to evaluate the glenohumeral joint in a position of maximal excursion or translation, to determine the underlymg accessory mobility of the joint.

CLINICAL EXAMINATION OF THE SHOULDER Although it is beyond the scope of this chapter to completely discuss examination of the shoulder complex, several key areas of the examination process deserve mention and form the plat­ form for the development of an evidence-based treatment program. The reader is referred to more complete references for thorough presentations of the shoulder examination process:1

Posture and Scapular Examination Evaluation of posture for the patienr with shoulder dysfunction begins wirh shoulder heights evaluated in the standing posi-

Figure 10-1 Posterior view of a patient in the hands·on-hips position shOWing extensive infraspinatus muscle atrophy.

Chapter 10 The Shoulder

1 99

Examination of rhe scapulorhoracic jOint IS an extremely

ar approximately 140 degrees of elevation. The ICR moves

lmporcant part of the comprehensIve clinical examination

from the medial border of rhe spine of rhe scapula, With the

process for rhe patient with shoulder dysfunccion. It encails

shoulder ar approximarely 20 degrees of elevation very ne-.lf the

severaJ component pares. Understanding the normal and abnor­

side of the body. and migrates superolaterally to the region

mal movement patterns of the scapula IS imperative. Although

near rhe acromioclavicular (AC) joint at approximately 110

many variations in normal scapular position do exist, resting

degrees, Bagg and Forrest's research also Identified an Increased

scapular orientation is 30 degrees anreriorly roeared with

muscular stabilization role of the lower trapezius and sermrus

rtSpecc (0 the frontal plane as viewed from above,l" Addition­ ally, rhe scapula is roeaced approximately 3 degrees upward

elevation,

(superiorly), as viewed from rhe posterior orientation.

amerior force couple at higher, more functional positions of Typical movemem of the scapula occurs in rhe coronal,

Scapulothoracic movement was initially described in clini­

sagirral, and transverse planes. Brief descriptions hcre proVide

cal terms as "scapulo-hurneral rhythm by both Codman and

a framework for the classification of scapular dys(unuion.

is nor more rhan 60 [degrees]," and rhar rhe coral contribution

ward, internal/external, and anteflor/posrenor, along With tWO

from rhe glenohumeral Joint is not grearer than 120 degrees.

translations: superior/inferior and protraction/reuaction (Figure

The scapulohumeral rhythm was described for rhe cocal arc of

10-2).

t.

Inman.),1' Inman scated that "the total range of scapular motion

Primary movements consist of three roeations: upward/down­

elevarion of [he shoulder joint to comain 2 degrees of gleno­

Movements of upward and downward rocation occur In the

humeral marion for every degree of scapulothoracic morion.'

coronal or fromal plane. The angle typically used co descflbe

In addition

(Q

this rario of movement, Inman identified what

he termed a stlling phaJe, which occurred during rhe first 30 co 60 degrees of shoulder elevation. Inman described rhis serring

the poSItion of scapular rotation is formed between rhe splOe

and the medial border of the scapula, Poppen and Walker i" reported normal elevarion of the acromion to be approximately

phase as when "the scapula seeks, In relationship co rhe

36 degrees from rhe neurral position to maximum abduction.

humerus, a precise position of stabillCY which it may obealn in

Sagittal plane motion of the scapula is referred to as tlllterUJr/

one of rhree ways":

pOJterior Iiltlllg. The angle of scapular rilring is formed by

I. The scapula rnay remain fixed, with rnotion occurring solely

vecror passing via C7 and T7 and a veCtor passing via the

a

ar rhe glenohumeral Joint until a srable posinon IS reached.

interior angle of rhe scapula and the root of rhe spine of rhe

2. The scapula may move lateraJly or medially on (he chese

scapula.ltI Transverse plane movemem of the scapula is referred

wall. 3. In rare instances, rhe scapula may oscillate until stabiliza­ tion is achieved.

to as mlen/aland external r()taIJOII. The angle used co describe imernal/external roration of the scapula is formed by rhe coronal (frontal) plane of the body and a vector p.."lSsing via rhe

Once 30 degrees of abduction and 60 degrees of Aexion have been reached, the relationship of scapulothoracic to glenohu­ meral joint rnotion remains remarkably constant.) Observation of early motion of the scapula durtng arm elevation based on these early descriptions of scapular mechanics usually indicates glenohumeral hypomobility and/or force couple imbalance and leads rhe clinician co a more derailed examination of borh rhe scapulorhoracic and glenohumeral joints. Later research using rhree-dimensional analysis and orher laboratory-based. merhods has confirmed Inman's early descrip­ tions of scapulohumeral rhythm.tI,16 These studies have pro­ vided more detailed descriprions of the exact contributions of the scapulorhoracic and glenohumeral joints during arm e1eva­ rion in the scapular plane. Doody et al16 found that the ratio of glenohumeral ro scapuiorhoracic motion changes from 7.29: 1 in rhe first 30 degrees of elevation ro 0.78: 1 at between 90 and 150 degrees. Bagg and Forrest found similar differences based on the ROM examined.1I In the early phase of elevation, 4,29 degrees of glenohumeral joint morion occurred for every I degree of scapular morion, wirh 1.71 degrees of glenohu­

meral marion occurring for every 1 degree of scapular motion between ehe functional arc of 80 and 140 degrees. Bagg and ForreSt also clearly identified. the instantaneous center of rotation (fCR) of the scapulothoracic joint at various POlOts in the ROM.'" Figure 4.1 in the study shows rhe ICR of the scapulothoracic joint at 20 degrees of elevation, and Figure

Figure 10-2 Representation

4,2

tions and

10

the study shows the feR of [he scapulothoracic joint

two translations.

of scapular motion shOWing three rota­

Orthopaedic PhYSical Therapy

200

transverse plane projection of [he roOt of the spine of the

palsy will create a prorracted inferior border of the scapula and

scapula and the posterior angle of the scapula. 1M Abnormal

an elevared acromion.'?1

increases in [he Imernai rorarion angle of the scapula lead co

Alrhough it

IS

possible thar some parients wirh shoulder

changes in rhe oriemacion of rhe glenoid. This alcered posicion

pathology may present wirh true scapular winging, mOst

of rhe glenoid, referred to as "3nrerilring." aJlows for opening

patiems wirh shoulder pathology present with less obvious and

up of rhe amerior half of rhe glenohumeral anicularion.19 The

less severe forms of scapular dysfunction. Clinicians tradition·

amecilring of rhe scapula has been shown by Saha to be a com­

ally have had little nomenclature and few objecrive descriptions

ponent of rhe subluxacion/disloc3tion complex in patients with

for scapular dysfuncrion; this has led ro rhe use of numerous

microrrauma-induced glenohumeral Instability,l Further bio­

terms to describe nonoptimal or abnormal scapular posirions

mechanical scudy has shown mcreased scapular imernal roca­

and movemem pacrerns.11 Kibler has defined scapular dysfunc­

eion in patients wICh arraumacicglenohumeral joim inscubility.lO

tion as encompassing abnormal motion and position of the

Results of chis study support rhe use of exercise programming

scapula. Therefore. evaluation of the scapula musr Involve both

dlrt�cced at improving the strength of synergistic funceion of

staric and dynamic merhods.2)

the serratus anterior and trapezius to stabilize the scapula and

Kibler has developed a more specific scapular classification

address malposirioning of the scnpula in paCtents with gleno­

system for clinical use rhat allows clinicians to categorize

humeral joinc instability.

scapular

dysfunction

based

on

common

cltnical

findlOgs

The movement of protraction and retraction occurs literally

obtained via visual observation of both static posrure and

around the curvnture of the thoracic wall.ll Recractlon typically

dynamic upper exrremlty movemems.11•H Kibler has idencified

occurs in a curvilinear fashion around the wall, while protrac­

rhree specific scapular dysfunctions or patterns. These scapular

tion may proceed in a slightly upward or downward motion,

dysfunctions are termed I,iferi(}f' or Type I, Medial or Type II,

depending on the position of the humerus relative to the

and SlIperl(}f' or Type III; each is named for the area of the scapula

scapula.!1 Depending on the size of the individual and the

rhar is visually prominent during clinical evaluation. In the

vigorousness of the actiVity, translation of the human scapula

Kibler classificarion

during prOtraCtion and retraction can occur over distances of

morion characrerized by symmerrical scapular upward rocation

to

system, normal

symmetrical

scapular

cm.ll The scapula also can move in the coronal plane

"such that rhe inferior angles translare latemlly away from the

along the thoracic wall superiorly and inferiorly in movemencs

midline and the scapular medial border remains Rush againsr

15

L8

typically called tltt'aflon and depresSioll, respectively. Evaluation

the thoracic wall with rhe reverse occurring during

of the patienr with roeator cuff weakness often identifies exces­

lowering ....?�

sive early scapular elevation as a compensatory movement to

arm

In rhe type I or inferior angle classification of scapular dys­ function, rhe primary external visual feature is the prominence

optimize humeral movement.ll Several studies have measured the movement of the scapu­

of rhe inferior angle of the scapula (Figure

10-3).

This pattern

IOthoracic joint while providing reference information for clini­

of dysfunccion involves anterior rilting of rhe scapula in rhe

cians that is relevant during the observation phase of the

saginal plane, which produces the prominent Inferior angle of

examination. Normal scapulochoracic motion during arm ele­

the scapula. No other abnormaliry is rypically present with this

vation Includes the following key components: upward roea­

dysfunction pactern; however, the prominence of the inferior 10

CIon, external rotation, and posterior tilting. Bourne et alH

angle of the scapula does increase oftentimes

reported the following during arm elevation: 49 degrees of

hips position, as well as during accive flexion, scaprion, or

upward rotation, 27 degrees of external rot3tion, and

the hands-on­

44

degrees of posterior tllClng. Similarly, McClure et 311\ found

50

degrees,

24

degrees, and

30

degrees for those important

scapular movemenr components, respectively. The most widely described and overused term pertaining to scapular pathology is scapular u'ingillg. Scapular winging is a term that IS used to describe gross disassociation of the scapula from rhe thoraCIC wa11.1.1 Jc is typically very obvious to a trained observer who is simply viewing a padem from the posterior and lateral orlemation, and it becomes even more pronounced wlrh active or resisrive movemem ro the upper extremiries. True scapular winging occurs as the result of involvement of rhe long thoraCIC nerve..?·1 Isolated paralysis of the serratus anterior muscle with resultant "winged scapula" was first described by Velpeau in

t837.

Winged scapula is peripheral

in origin and ulrimately is derived from involvement of rhe . fifth, sixth, and seventh spinal cord segmems.1 1 Isolared ser­ ratus anterior muscle weakness due [Q nerve palsy will create a prominent superior meb the subluxation/relocation tesc IS designed

Chapter 10 The Shoulder

207

to identify subtle anterior instability of the glenohumeral joint,

pain with this maneuver. A posterior type 11 superior labrum

Credit for the development and application of this [est is also

anterior ro posterior (SLAP) lesion has also been impJ icared

given [0 Dr. Peter Fowler.67 Fowler described the diagnostic

patiems with a positive subluxation/relocation test.l>'J

10

quandary of ml croinsrab t l i ry (subde anterior instability) versus rotatOr cuff injury or both in swi mmers and advocated the use

of this importam rest co assist in the diagnosis. The sublux­

Labral Testing

arion/relocation resc is performed with the paciem's shoulder

Many tests have been proposed to assess the i ntegrity of the

held and stabi lized in the pacienc's maximal end-range of exter­

glenoid labrum. A brief discussion of the glenoid labrum and

nal roration at 90 degrees of abduction. The examiner then

its i njury patterns and characteristics will enable the clinician

provides a mild anterior subluxation force (Figure 10- 1 3 .

to better understand how clinical examination maneuvers for

A).

The patienc is asked if chis subluxation reproduces his or her

the glenoid labrum can be applied.

symptOms. Reproduction of patient sympcoms of anterior or

The glenoid labrum serves several Important funcdons,

posterior shoulder pain with subluxation leads the examiner to

including deepen ing the glenoid fossa to enhance concavity and

reposition his or her hand on the ancerior aspect of the patient'S

serving as the attachment for the glenohumeral capsular liga­

shoulder and perform a posterior-lateral directed force, using a

ments. Injury to the labrum can compromise the concavity

soft, cupped hand to minimize anterior shoulder pain from the

compression phenomena by as much as

hand/shoulder (examiner/patienc) i ncerface (see Figure 1 0- 1 3 .

with i ncreased capsular laxity and generalized joint hypermo­

B). Failure to reproduce the patient's symptoms with end­

bility have increased humeral head translation, which can

50%. '0

I ndividuals

range exrernal rotation and 90 degrees of abduccion leads the

subject the labrum to increased shear forces.7J In rhe throwing

examiner to reattempt the subluxation maneuver with

athlete, large anterior translacional forces are present at levels

1 10

degrees and 120 degrees of abduction, This modification has

up to

been proposed by Ilamner et al611 to Increase the potencial for

throwing motion, with the arm in 90 degrees of abduction and

contact between the undersurface of the supraspinatus tendon

external roration.7.2 This repeated translation of the humeral

and the posterior superior glenoid. In each position of abduc­

head against and over the glenoid labrum can lead co labral

tion (90 degrees,

1 10 degrees, and 120

degrees or abduction),

the same sequence of i nitial subluxation and subsequent reloca­

50%

of body weight during arm accelerncion of the

i n.jury. L.abral injUry can occur as tearing or as actual detach­ ment from the glenoid.

tion is performed as described previously.

Reproduction of anterior or posterior shoulder pain with the

sublu.xation portion of this test, with subsequent diminution

Lab",1 Tears

or disappearance of anterior or posterior shoulder pain with the

Terry et alH arthroscopically evaluated tears of the glenoid

relocation maneuver, constitutes a positive tesc. Produccion of

labrum in 83 patients. They classified labral tea.rs into several

apprehension with any position of abduccion during the ante­

types, including transverse tears, longitudinal tears, Aap tears,

riorly directed subluxation force phase of testing would indi­

horizontal cleavage tears, and fibril lated tears. Additionally,

cate occul t anterior instabili ty. The primary ramifications of a

Terry et alH reported the distribution of the location of these

posirive test would i ndicate subde anterior instability and sec­

labral tears in the 83 patients they evaluated arthroscopically.

ondary glenohumeral joint impingement (anterior pain) or

Pri mary tears of the glenoid labrum occurred most commonly

posterior or i nternal impi ngement in the presence of posterior

in the anterior-superior

(60%) or the posterior-superior part of

Figure 10-13 Jobe subluxation/relocation test. A, End-range external rotation in the coronal plane with subluxation force at 90 degrees of gleno­ humeral joint abduction. 8, Relocation of the humeral head during the laller portion of this test.

206

Orthopaedic Physical Therapy

the shoulder ( 1 8%). Only I CJf of rears occurred in rhe anrerior­ inferior part of rhe shoulder. Finally, rears were located in more than one location 22Cff of rhe time in the patients studied by Terry et al. \ The role of the labrum In rhe hypermobile shoulder was studied clinically by Alrchek cr al."-I In a 3-year follow-up of 40 overhead athletes who underwent arthroscopic labral debridement, 72% Initially reported relief of symptoms during rhe first year after surgery. At rhe 2-year follow-up, only 7% of patients reported symptOm relief. wirh consistent general­ ized deterioration occurring over rime. These authors con­ cluded that arthroscopIC labral debridement is not an effccrive long-term solution for labral rears and posculated that rhe underlying Instability of the shoulder that led ro labral i njury In these overhead athletes must be addressed to effectively rerum function and sympromatic relief to the patient over the long term. Lab,.t" De/tlcbmelJ/ In .tddltlon to the tearmg that can occur in the labrum, actual detachmem of the labrum from the glenoid rim has been reported. The tWO most common labral derachmems encoun­ terro clinically arc the Bankart lesion and rhe SLAP lesion. Perthest, In 1 906 was the first to describe the presence of a demchmem of the amerior labrum in patients with recurrem anterior instabil i ty. Bankart�f,·�� initially described a method for surgically repairing this lesion that now bears his name. A Bankart lesion, which is found in as many as 85% of dislocations,'K IS descnbed as a labral detachmem that occurs

humeml joint in

recommended

SO to 90 degrees of elevation in the scapular

plane, (an be Init iated to provide muscular co-contraction In a

technique

for

Figure

rhls

L0- 1 2 shows the

examination

maneuver

whereby the glenohumeral )Olnt is abduc((,>d 90 degrees in the

fu nctional position. Additionally, with this technique, a pro­

scapular plane (noce rhe poSition of the humerus ,�O degrees

[racttd scapular position can be util ized to enhance the activa­

anterior to the coronal plane). The examiner is careful to util ize

tion of the serratuS antenor,

because several studies have

a postenor-Iateral directed force along the line of the glenohu­

identified decre�ed muscular activation of this muscle in

meral joint. The examiner rhen feels for rransl.Hian of the

11·1,11\

pauencs �pven a diagnosis of glenohu meral Impingement and

humeral head along the glenoid face. Patients who present with

IOstabllity."

a lim itation

,II"

I n ild(iltion co rhe early scapular seabilization and submaxi­ mal rotatOr cuff exercise, ROM and mobilization may be indi-

III

Internal rorauon ROM who have grade II crans­

laeion should not have posterior glide acce�sory cechnlques applied to increase imernal rotation ROM because of the hypermobi lity of rhe posterior capsule made eVident during rhis Important passive clinical u�sr. It should be pointed our that incorreCt use of this posterior glide assessment techlllque may lead co rhe false Identlficacion of posterior capsular ughcness. A common error In this exami­ nation rechnique IS the use of the coronal plane for resting, as well as [he use of a straight posterior dlrecred force by the exami ner's hand, rather than rhe recommended posterior-lat­ eral force. The straighr posterior force compresses the humeraJ head into the glenOid, because of the anreverted posirion of rhe glenoid, and rhis would inaccurately lead to the assumption by the exam ining clinician that limited posrerior capsular mobil­ Ity is present. The second Important rest used co determine rhe presence of internal rotation ROM limmuion is the assessment of phYSI­ ologic ROM. Several aurhors recommend measurement of gle­ nohumeral internal rotation with the joint In 90 det:rees of abduction In the coronal plane.L

Figure 10·16 M.l nual 'i(lpultlr rE'lrilClion eX('fcisE' in sidelying.

L I '>I

Care must be taken to

stabilize the scapula With measurement taking pliKe with the

Chapter 1 0 The Shoulder

213

patJenr in the supine posltlon so chac rhe patienr's body weight

further ill ustrate rhe role of ROM and passive screrching

can minimize scapular mocion. In addition, a posteriorly

during this phase of the rehabiliration. Figures 10-17 and

directed force is used by rhe examiner on the anterior aspect of

1 0- 1 8 show versions of cli nical inrernal rotation stretching

the coraCOid and shoulder during in ternal rocarion ROM mea­

positions that utilize the scapular plane, and that can be per­

surement (see Figure 1 0-9). Internal rorarion ROM is com­

formed in multiple and varied positions of glenohumeral

pared

of isolated

abduction. Each inherendy possesses an anterior hand place­

One common finding presem during rhe exam ination of the

minimize scapular compensation, and also to provide a check­

bilaterally

with

careful

interpretation

glenohumeral motion.

menc used to give varying degrees of posterior pressure [0

overhead athleee is the rather consistent finding of increased

rein against anrerior humeral head translation during the inrer­

dominant arm external rotarion and reduced dominanr arm

nal coration stretch because of the effects of obligare translation.

glenohumeral joint internal rocarion.

\9,119-121

As mentioned

These stretches can be used in a proprioceptive neuromuscular

earlier in chis chapeer, El lenbecker er al\1 identified chat chis

facilitation (PNF) comracr-relax format o f following a low-load

consistent relationship could occur only i n a condition where glenohumeral joim rotation was measured with the scapula

prolonged scretch-type paradigm ro facilitate the increase i n 128.129 Additionally. Figures 1 0- 1 9 and 10-20 are exam­ ROM.

stabilized. Several proposed mechanisms have been discussed

ples of home scretches given to patienrs ro address i n rernal

m attempt ro explain this glenohumeral ROM relationship of increased external rotadon and lim ited inrernal rotation.

\9.Ill.m

Tightness of the posterior capsule, tight ness of the muscle tendon unit of the posterior roraror cuff, and humeral retrover­ sion all have been described as structures that limit inrernal lll glenohumeral jOlnr rotation. Crockett et al and others,z.t·'26 have shown uni lateral increases in humer.u retroversion i n throwing athletes, which would explain the increase i n external rotation noted With accompanying mternal

rotation

loss.

Recent research by Reinold et a111; demonstrated the acute effects of pitching on glenohumeral ROM. Sixty-seven profes­ sional baseball pi tchers were measured for glenohumeral joint rotational ROM with the use of scapular stabilization before and immediately after 50 to 60 pitches at fu ll inrensi ty. Results show a loss of9.5 degrees of inrernal rotation and 10.7 degrees of mtal rotation ROM during this shoft-term response to over­ head throwing. This study shows significant decreases in inter­ nal

rotanon

and

rotal

rotarion

ROM

of the

dominanr

glenohumeral joint i n professional pitchers following an acute episode of throwing. Reinold et ai m suggest that muscle ten­ dinous adaptations from eccentric loading likely are impl icated

in this ROM adaptation following throwing. This musculoten­

Figure 10-17

"

Figure

4" stretch position used to increase internal

rotation ROM. The forearm is used to obtain overpressure, while the

examiner's hand limits anterior humeral head translation by exerting a posteriorly directed force.

dinous adaptation OCCurs an addition ro rhe osseous and capsu­ lar mechanisms previously reported. m Careful measurement of glenohumeral rotational measure­ ment using the rotal rotation concept outlined earlier in this chapter guides the progression of either physiologic ROM and light scretching used in rehabilitation or the inclusion of spe­ cific mobilizarion rechnlques used ro address capsular deficien­ cies. The rotal coration ROM concepr can be used

as

illustrated

to guide the clinician during rehabiliration. specifically in the area of application of scretching and mobilization, to beSt determine what glenohumeral Joint requires additional mobil­ ity and which extremity should not have additional mobi l i ty. because of the obvious harm induced by increases i n capsular mobi lity and Increases in humeral head translation during aggressive upper exrremiry exertion. This extensive secdon outlining the importance of accurare ROM measurement and clinical decision making based on rhe larest scienrific evidence can guide rhe clinician through the rehabilitation process, since a large speccrum of mobility can be encountered when one is rreating the patienc with glenohumeral impi ngemenc. To

Figure 10-18 Imernal rotation stretch position to allow for stabiliza­

tion of the scapula and limitation of obligate anterior humeral head

translation during the stretch.

214

Orthopaedic Physical Therapy 2. Normalization of capsular relationships through the use of specific mobilization and stretching techniques

3. Early submaximal rotatOr cuff and scapular resistance training

Total Ann Strengthening/Kinetic Chain Exercise Application This phase IS dominated by strength and local muscle endur­ ance training of the rotatOr cuff and scapular stabilizers. Although the entire kinetic cham, including the lower extrem­ ity, pelvis, and trunk segments, are also critically importane, it is beyond the scope of this chapter to completely list the broad scope of all kinetic chain exercises indicated. However, this section of the chapter reviews the use of an evidence-based progression of a resistive exercise program. The primary goals are to elicit high levels of rotator cuff and scapular muscular activation using movemene panerns and pOSitIons that do nOt create subacromial concact, or undue stress to the static stabi­ lizers of the glenohumeral joint. Figure 1 0- 2 1 shows the pro­ gressIon used by thIS author for rotator cuff srrengtheOlng. These exercises are based on electromyographic (EMG) research I showing high levels of postenor rotator cufT actlvation, l l .li) and they place the shoulder in positions well tolerated by Figure 10·19 Croshum

adduction

streich .

patients with rotator cuff and scapular dysfunction. Sidelying external rotation and prone extension WIth an externally rotated (thumb our) posirion are utilized first, with progressions to prone horizontal abduction and prone external roracion with scapular retraccion fol lowing a demonstrated tolerance co the initial twO exercises. Prone horizoncal abduction is used at 90 degrees of abduction to minimize the effects resulcing from subacromial contact.It! Research has shown that this posicion creates high levels of supraspinatus muscular activation,

I \1,IH.1 n

making it an alterative to the widely used empty can exercise, which ofcen can Cause Impingement through the combined inherent movements of internal rmation and elevation. Three sets of 1 5 co 20 repetitions are recommended to create a farigue response and improve local muscular endurance.H6. I P The effi­ figure 10-20 Sleeper stretch performed in sidelying position.

cacy of chese exercises in a 4-week training paradIgm has been demonscrated, and

89f CO 1 0% increases have been noced in

isokinetically measured Internal and external rotation strengch roration ROM deficiency. No[t;' the inherent means of scapular

in healthy subjecrs. These isotonic exercises are coupled wich

srabJliz1·IS} the

concomitant procedures were performed. Basic science research

ROM are typically recommended u nless capsular plication or

combined movemenrs of elevation and internal roracion have

has provided guidance on rhe provision of early ROM fat

produced clinically disappointing results in practical applica­

patients following superior labral repair. Morgan et al69 have

tion, as well as (he common occurrence of patterns of substitu­

identified the concept of the "peel back" mechanism (see Figure The peel back mechanism occurs with the glenohu­

tion and im ptoper biomechanical execution, un Increases in

10- 1 5).

scapular internal rOtation and anterior tilting have been shown

meral joint in

when [he empty can is compared with the ful l can (scapular

a position simulacing the throwing motion. In this position,

90 degrees of abduction and external

rotarion in

plane elevation with external rotation) exercise using motion

the biceps (endon force vector has been found to assume a more

analysis. Movement p.merns characterized by scapular inrernal

vertical and posterior direction, creating {he peel back of the

rocacion and anterior tilting theoreticaliy decrease the subacro­

superior labrum. 1 n the first 6 weeks following surgery, this

mial space and could jeopard ize the ability for application of

ROM (external rotation in

repetitive movement patterns req uired for strength acquisition

and no aggressive attempts a( end ROM are recommended to

90 degrees of abduction)

is limited

needed during shoulder rehabil itation.1fP

protect the superior labral repair and to minimize any shear

Specific exercise application for the scapular stabi lizers

force applied via the bicep from ROM in this position. Gleno­

focuses on the lower trapezius and serratus aorerior muscula­ . rure, Donatelli and Ekstroml88 and othersl l >l l l S have summa­

humeral ex-ternal rotation ROM and stretching are initially

rized the upper extremity exercise movement patterns that

degrees of abduction) during [he initial 6 to 8 weeks following

elicit high levels of activation of these importanr force couple

superior labral repair.

performed i n mate neutrally abducted positions

(0

to

45

Few published reports detail the recurn of ROM following superior labrai repair. E llenbecker et all6.1 swdied *Rcferences 1 1 5 , 11.7, 1 ; 1 , I n , I H, 1-1:l,, 182, and 183.

39

paciems

with a mean age of 43 years who underwent arrhroscopic supe·

Chapter 1 0 The Shoulder

BOX 1 0-3 •

Arthroscopic Superior Labral (SLAP) Repair Postoperative Protocol

Note: Specific alterations in postoptrative protocol If SLAP repair

3. Inaiate mtacor cuff progression UStng movement patterns of

IS combmed with thermal ca�ulorrhaphy, capsular plication,

sidelying externa.l rotation, prone extension, and prone horizon­

rotator Interval c1or,ure, or repair of full-thickness rotatOr cuff Sling

tal abduction using a lightweight and/or elastic resiscnnce.

4.

repan •

225

use

as nttded for precarious activities and to minimize

biceps muscle acelvarian during initial postoperative phase. Duration and degret' of sling

use

body strengthening.

5. Perform rhythmic stabilization in 90 degrets of shoulder eleva­

determined by physician at

postel' recheck. Early lISt of stomach rubs. sawing, and wax-on/wax-off exercise recommended to stimulate home-based motion between therapy

tion with limited fleXion pressure application to protect SLAP repak

Phase III: Total Arm Strength (Weeks 6 to 10) I

VISICS

variations

for

scapu1.u

3. Advancement of rotator cuff and s
This is important nor only for

ulnar notch anteriorly and posteriorly. This ligament circles the

support of the elbow joint complex bur also for proprio­

radial head for support. The interosseous membrane is th(' con­

ception of the JOint. The capsule of the elbow will func­

nective tissue that functions to complete the Interval between

tion as a neurologic link between the shoulder and rhe

the twO bones. When a fall on the outstretched �lrm occurs, the

hand. This has an effect on upper-quarter activity and an

interosseous membrane can transmit some forces off the mdius,

obVIOUS aspect of rhe rehabilitarion process if injury does

the main weight-bearing bone co [he ulna. This can help

occur.

prevent the radial head from having forceful contaer wirh rhe

237

238

Orthopaedic Physical Therapy epicondyle to the annular ligamem. The lateral ulnar col­ --�----- Humerus--------�

lateral ligament

(VCl)

is rhe primary lateral stabilizer and

passes over the annular ligament inro the supinator cubercle. Coronoid fOSsa

_

lateral condyle

--- Trochlea

Capitellum

� � -------'

Lateral - condyle

J

•

that connects the ulna and [he radius in [he forearm. This structure prevents the proximal displacement of rhe radius on the ulna.

B

Humerus

J I

chioradialis muscles. The biceps brachii originate via twO heads proximally at the shoulder; [he long head originates from [he supraglenoid cuberosiry of the scapula, and the short head

Radius

-- Ulna .--:----

C

Dynamic Stabilizers of the Elbow Complex The elbow flexors are the biceps brachii, brachialis. and bra­

� Olecranon fossa

ligament. The annular ligament. as previously stated, is the ulna. The interosseous membrane is a syndesmotic condition

Radius

I----- Ulna

passes from the cubercle of the supinator imo the annular main support of the radial head in rhe radial notch of the

Olecranon

I

A

humeroradial joint.v The accessory lateral collateral ligament

)

M edial condyle

/ ,/' � I I

It reinforces the elbow laterally, as well as reinforcing the

Olecranon fossa

�

originates from the coracoid process of the scapula. The Inser­

I

tion is from a common rendon at the radial cuberosity and lacertus fibrosus CO origins of the forearm flexors. The biceps

0

Figure 11-1 Bony anatomy of distal humerus and elbow region.

A, Anteri o r view. 8, Posteri or view. C, Posteri or view, 90-degree

flexion . 0, lateral view. Right elbow is shown. (Modified (ro m Con­ n oll y JF: DePalma's management or fractures and dislocations. In Marx

JA: Rosen's emergen cy medicine: concepts and c l i n i cal practice, ed

6, 51 louis, 2004, Mosby.)

brachli function is flexion of the elbow and supination of the forearm.1I The brachial is originates from rhe lower (wo thirds of the anterior humerus CO the coronoid process and cuberosiry of the ulna. It functions to flex the elbow. The brachioradialis, whIch originates from the lower (wo rhirds of the lateral humerus and anaches to the lateral stylOid process of the discai radius. functions as an elbow flexor and as a weak pronator and supinator of the forearm. The elbow extensors are the triceps brachil and the anconeus muscles. The triceps brachii has a long. medial and lateral head

capitellum. DIstally, the concave radius wdl anicuJare with the

origination. The long head originates at the infraglenoid cuber­

convex ulna. With supination and pronation, the radius will

osity of the scapula, the lateral and medial heads to the poste­

move on the more stanonary ulna.

rior aspect of the humerus. The insertion IS via rhe common tendon poSteriorly at the olecranon. Through thiS JOsemon along with the anconeus muscle that asSIStS the triceps, exten­

LIGAMENTOUS STRUCTURES The stability of rhe elbow starts with rhe joim capsule and excellent bony congruity inherent in the chree aniculacions of rhe human elbow. The capsule is loose anteriorly and posteri­

sion of the elbow complex is accomplished.

Biomechanics of the Elbow Normal elbow function is Vital to the partiCipation In most

orly [0 allow for movemeor in flexion and extension,'" The joint

simple daily activities. as well as for higher-level actions such

capsule is taU[ medially and laterally because of the added

as sports. In panicular rhe art of throwing or pitching a base­

suppon of rhe collareml ligamenrs.

ball requires coordination and sequential activation of various

The medial ulnar collateral ligament (MUCL) is fan-shaped

body pans including the elbow co result

Peak

10

maximal velocity

in nawce and has three bands (Figure 1 1-2), The anterior band

at rhe rime of ball release.

of rhe MUCL is rhe primary srabiljzer of rhe elbow against

shown to be as high as 3000 degrees per second'uo Major

valgus loads when rhe elbow is near extension. \,1'> The ponerior

stresses occur at the elbow during acceleration and follow­

band of the MUCL becomes taut after 60 degrees of elbow

through that

flexion and assists in stabilizing against valgus Stress when rhe

prevent excess load from being transmitted through the articu­

a flexed posicion. The oblique band of rhe MUCL

lar and ligamentous stabilizers of the elbow. The biomechanics

elbow is

10

require

elbow accelerations have been

normal functioning

musculamre to

does nO[ technically cross rhe elbow joim and does not provide

of the elbow can be more easily understood by dividlOg [he

extensive stabilization co the medial elbow like the amerior

pitch into six phases."

and posteflor bands.

of the wrisr flexor-pronatOr group generates a varus tOrque to

During [he cocking phase contraction

The lateral elbow complex consists of four structures. The

counter the valgus extension load on the medial collateral liga­

radial collateral ligamem anachmems are from the lateral

rnenr (MCL).12 In addition, the anconeus and triceps compress

Chapter I I

Dysfunction, Evaluation, and Treatment of the Elbow

239

Medial aspect

Medial epicondyle

part Posterior art

P

J

Transverse part

.

Med1al , coilateral ligament

A Lateral aspect

Lateral collateral ligament complex

�

Annular ligament

Radial collateraIIIiO!,m.,nt

Lateral (ulnar) collateral ligament

--t--.,!;;::SO

Figure 11-2 A, The components of the medial

-i��:���I��::�::���

collateral ligament (Mel) of the right elbow.

8, The components of the lateral collateral liga­

ment of the right elbow. (From Neumann DA: Kin esiology of the musculoskeleta l system: foun­

B

dations for physical rehabilitation, 5t loui s

,

Supinator crest

2003, Mosby.)

the joinc co assist with raking pressure off of the MeL. During

However, because many overuse injUries occur in athletic indi­

acceleration, triceps activity Increases and biceps force decreases.

viduals, structural inspection of the patient or athlete with an

As the deceleration phase begins. biceps, [riceps, wrist flexor,

injured elbow can be complicated by a lack of bilateral sym­

and wrist extensor muscular concraction intensity is increased.

metry in the upper extremities. Adaptive changes are com­

The crunk and lower extremity also an co dissipate the force

monly encountered during clinical examination of rhe athletic

during follow-through, illustrating the kinetic chain concept

elbow, particularly in the unilaterally domLnant upper extrem­

and its Integral role in the throwing motion. These complex

ity athlete. In these athletes, use of the conrralateral extremity

actions must be thoroughly understood to develop the proper

as a baseline is particularly important

throwing

coordination

of actual adaptation that may be a contributing factor in the

prevent or rehabilitate injuries of the elbow that

patient's injury presentation. A brief overview of the common

required

mechanics,

[Q

muscle

strength,

and

occur during throwing.

[Q

determine the degree

adaptations that have been reported In the laerarure can provide valuable information

(0

assist the clinician during the

structural inspection of the patient with an active or athletic

CLINICAL EXAMINATION OF THE ELBOW

background. Before discussing the special tests used during a thorough

Structural inspection of the patient'S elbow must include a

elbow evaluation, specific anacomic adaptations in the areas of

complete and thorough inspection of the entire upper extrem­

range of motion, muscular strength, osseous and ligamentous

ity and trunk.ll The heavy reliance on the kinetic chain for

are presented. Each are presented in the context of the clinical

powet generation and the imponant role of the elbow as a link

examination of the patient with elbow dysfunction, WHh an

in the kinetic chain necessitates the examination of the entire

emphasis on the clinical application of how each adaptation can

upper extremity and trunk in the clinical evalu3tion.13·L4

be applied

to

the clinical examination.

240

Orthopaedic Physical Therapy sion range of motion from excessive overuse of the wrisr 8exor muscles inherent in baseball pitching.19•20 More proximally, measuremem of range of motion of humeral rotation in the older overhead athlete is also recom­ mended. Several studies have shown consisrem alterations of shoulder rotational range of motion in the overhead athlete.2Io2J Ellenbecker et al.21 has shown statistically greatcr dominam shoulder external rotation and less imernal rotation in a sample of professional baseball pitchers. Despite these dife f rences imernal and external rotation range of morion, the rotal rora­ tion OR + ER) berween exuemities remained equal, such that any increases in external roration range of motion were matched by decreases in imernal rotation range of motion in this unin­ jured population. Elite-level tennis players had significandy less internal roration and no significant difference in external roration on the dominam arm, as well as an overall decrease in tOral roeation range of motion on the dominant arm of approxi­ mately 10 degrees. Careful monitoring of proximal glenohu­ meral joinr range of motion is recommended for the athlete with an elbow injury. Based on the findings of these descriptive profiles, (he finding of an elbow flexion conrracrure and limited wrist flexion or extension range of motion, as well as reduced gleno­ humeral joint internal rotation, can be expected during the examination of an arhlete from a unilaterally dominant upper

Figure 11·3 Fl exion contracture of the dominant arm of an elite tennis player.

extremity sport.

Careful measurement during the clinical

examination is recommended to detcrmine baseline levels of range of morion loss in the distal upper extremity. This careful measurement serves to determine if rehabilitative interventions

Range of Motion Adaptations King ec 31. n initially reported on elbow range of morian in professional baseball pitchers. Fifty percent of the pitchers chey

are needed, as well as to assess progress during rehabilitarion.

Osseous Adaptation

examined were found co have a flexion Contracrure of the domi­

In a study by Priesr et al./4 84 world-ranked rennis players

nant elbow, with 30% of subjects demonstrating a cubiws

were srudied using radiography, and an average of 6.5 bony

valgus deformity. Chinn et al.16 measured world-class profes­

changes were found on the dominant elbow of each player.

sional adult [ennis players and reported significant elbow

AddirionaBy, rhey reported tWO (imes as many bony adapta­

flexion conrraccures on rhe dominant arm, bU[ no presence of

tions, such as spurs, on the medial aspen of the elbow as

a cubitus valgus deformity. Figure ll-3 shows the dominant

compared with the lateral aspect. The coronoid process of rhe

elbow of an elite tennis player revealing rhe degree of flexion

ulna was the number one site of osseous adaptation or spurring.

comracture compared with rhe nondorninanr extremity.

A n average of 44% increase in thickness of the anterior humeral

More recently Ellenbecker ec al. P measured elbow flexion

cortex was found on the dominant arm of these players, with

degrees in a population of 40 healthy

an 1 1 % increase in cortical (hickness reported in the radius of

professional baseball pitchers. Directly related to elbow func­

the dominant tennis-playing extremity. Additionally, in a mag­

concractures averaging

5

tion was wrist flexibility, which Ellenbecker et al.l7 reported as

netic resonance imaging (MRl) study, Waslewski et aLl' found

significandy less in extension on the dominanc arm because of

osteophytes at the proximal or disrai insertion of the UCL in

tightness of rhe wrist flexor musculature, with no dife f rence

5

wrist flexion range of motion between exucmirics. Wright

posterior osteophyres in 2 of 20 pitchers.

of 20 asymptOmatic professional baseball pirchers, as well as

cr al.1I9 reported on 3 3 throwing athletes before rhe comperi­ rive season. The average loss of elbow extension was 7 degrees, and the average loss of flexion was Roetertl6 measured

5.5 degrees. Ellenbecker and senior tennis players 55 years and older and

Ligamentous Laxity Manual clinical examinarion of the human elbow co assess

found flexion contractures averaging 10 degrees in rhe domi­

medial and lateral laxity can be challenging, given the presence

nam elbow, as well as significandy less wrisr 8exion range of

of humeral rocation and small increases in joint opening thar

motion. The higher use of the wrisr extensor musculature is

often appear with UCL injury. Ellenbecker et al.17 measured

likely the cause of limited wrisr flexor range of motion among

medial elbow joint laxity in 40 asymptomatic professional

the senior tennis players, as opposed ro the reduced wrist exten-

baseball pitchers, co dctermine if bilatcral differences in medial

Chapter 1 1

241

Dysfundion, Evaluation, and Treatment of the Elbow

elbow laxity exist in healthy pitchers with a long hiscocy of

elite

repetitive overuse

strength was significantly stronger than the nontennis-playing

(0

the medial aspen of the elbow. A Telos

stress radiography device was used to assess medial elbow joinc

tennis

players,

but

dominant-arm

elbow

extension

extremity.19

opening, using a scandardized valgus suess of 15 kPa (kilopas­ chals),

with the elbow p

and the forearm in a supinated position. The joint space between the medial epicondyle and coronoid process of the ulna was measured using anterior-posterior radiographs by a mus­

STRENGTH PROFILES IN ELITE-THROWING ATHLETES

culoskeletal radiologist and compared bilaterally, with and

Research on professional rhrowing athletes has identified sig­

withom the application of the valgus Stress.

nificantly greater wrist flexion and forearm pronation strength

significanc differences between extremities with stress applica­

on the dominant arm by as much as 15% to 35% compared

rion,

with (he dominam with the nondominant extremity," with no difference in wrist

nondominanr elbow opening

0.88 mm. This

difference,

although 5[atistically significant, averaged 03 . 2

extension strength or forearm supination strength between extremities. Wilk et al)1 reported 10% to 20% greater elbow

the dominant and nondominant elbow (and would be virtually

flexion strength in professional baseball pitchers on the domi­

unidentifiable with manual assessment). Previous research by

nant arm, as well as 5% to 15% greater elbow extension

Rijke et al.l6 using stress radiography had identified a critical

strength as compared with the nondominant extremity.

level of 0.5 mm increase in medial elbow joint opening in

These data help to portray the chronic muscular adaptations

elbows with UCL injury. Thus the results of the study by

that can be found in the overhead athlete who may have an

Ellenbecker et all . 1

elbow injury, as well as help to determine realistic and accurate

because asymptOmatic professional pitchers in their study

discharge strength levels after rehabilitation. Failure to rerurn

exhibited less than this 0.5 mm of medial elbow joint laxity.

the stabilizing musculature to its often-dominant starus (10% to as much as35%) on the dominant extremity in rhese arhletes may represent an incomplete rehabilitation and prohibit the

Muscular Adaptations Several method s can be used to measure upper extremity

recurn to full activity.

nrength in athletic populations. These can range from measur­ ing grip strength with a handgrip dynamometer to the use of isokinetic dynamometers to measure specific joint motions and

ELBOW EXAMINATION SPECIAL TESTS

muscular parameters. Increased forearm circumference was

In addirion to the examination methods outlined in the previ­

measured on the dominant forearm in world-class tennis

ous section, including accurate measurement of both distal and

piayers,I6 as well as in the dominant forearm of senior tennis

proximal joint range of motion,

players.27

muscular strength assessment,

Isometric grip strength measured using a handgrip dyna­

included in the comprehensive examination of the elbow of the

mometer has revealed unilateral increases in strength in elite

older active patient. Although it is beyond the scope of this

adult and senior tennis players as well. Increases ranging from

chapter to completely review all of the necessary tests,

10% to 30% have been reported using standardized measure­ 27.28 ment methods.IJ.'6.

are highlighted based on their overall importance. The reader

Isokinetic dynamometers have been used to measure specific

is referred to Morcey,1 Ellenbecker et al.,l7 more complete resources solely on examination of the elbow.

muscular performance parameters in elite-level tennis players and baseball pitchers.I)·28.19.w Specific patterns of unilateral

elbow allows the examiner [Q rule our referral symptoms and

muscular development have been identified by reviewing the

ensure that elbow pain is from a local musculoskeletal origin.

Clinical testing of the joints proximal and distal [Q the

isokinetic literature from different populations of overhead

Overpressure of the cervical spine in the motions of flexion and

athletes.

extension and lateral flexion and rotation, as well as quadrant or Spurling testl] combining extension with ipsilateral lateral

STRENGTH PROFILES IN ELITE-LEVEL TENNIS PLAYERS

flexion and rotation, spine and rule out radicular symp[Qms.� Tong et aLB tested the Spurling maneuver to determine the diagnostic accuracy of this examination maneuver. The Spurling test had a sensitiviry

Ellenbecker28 measured isokinetic wrist and forearm strength

of30% and specificity of93%. Caution therefore mllst be used

in mature adulc tennis players who were highly skilled and

when solely basing the clinical diagnosis on [his examination

found 10% co 25% greater wrist flexion and extension, as

maneuver. The test is not sensitive buc is specific for cervical

well as forearm pronation strength on the dominant extremity

radiculopathy and can be used to help confirm a cervical

as compared with the nondomjnant extremity. Additionally,

radiculopathy.

no significant difference between extremities in forearm supi­ nation strength was

measured.

In addition to clearing the cervical spine centrally, clearing

No significant difference

the glenohumeral joim is important as well. Determining the

between extremities was found in elbow flexion strength in

presence of concomitant impingement or instability is also

do

242

Orthopaedic Physical Therapy

highly recommended. I) Use of the Sulcus sign)'

CO

determine

the presence of multidirectional instability of the glenohu­ meral joint. along with the subluxation and relocation si8n� and load and shift test, can provide valuable insight into the StatuS of the glenohumeral joint. The impingement signs of Neer'" and Hawkins and Kennedy�8 are also helpful co rule oue proximal tendon pathologic condition. In addition to the clearing tests for the glenohumeral joim, full inspection of the scapulothoracic joim is recommended. Removal of the patient'S shire or examination of the patient in a gown with full exposure of the upper back is highly recom­ mended. Kibler

cr

31.19 has recendy presented a classification

system for scapular pathologic conditions. Careful observation of the padent at rest and with the hands placed on the hips, as well as during active overhead movements, is recommended co idenufy prominence of parricular borders of the scapula, as well as

a lack of close association with the thoracic wall during

movement

.

.w·"1

Bilateral comparison forms the primary basis

Figure 11�4 Valgus stress test clinical examination maneuver.

for Idenrifying scapular pathologic conditions; however, in many athletes, bilateral scapular pathologic conditions can be observed. The presence of overuse injuries in the elbow occurring with proximal injury co the shoulder complex or with scapulotho­ racic dysfunction is widely reported.I.IMl-4� and thus a thor­ ough inspection of the proximal joint is extremely important in the comprehensive management of pathologic conditions of the elbow. Several tens specific for the elbow should be performed to assist in the diagnosis of elbow dysfunction. These include Tinel's test, varus and valgus stress rens, Milking test, valgus extenSion overpressure test, bounce home test, provocadon tests, and the moving valgus tesc. The TineJ's test involves capping of the ulnar nerve in the mediaJ region of rhe elbow, over the cubical runnel retinaculum. Reproduction of paresthe­ sias or tingling along the distal course of the ulnar nerve indicates irritability of the ulnar nerve.'

Figure 11 �5 Milking sign clinical examination maneuver.

The valgus seress test is used to evaluate the integrity of the UCl. The position used for reseing the anterior band of the to 25 degrees of elbow flexion and

was always greatesr when the elbow was tested with the forearm

The elbow flexion posidon

in neutral rotation as compared with either the fully pronated

is used co unlock rhe olecranon from the olecranon fossa and

or supinated position. This study suggests testing in ehe

UCl is characterized by

15

forearm supination (Figure

11-4).

decreases the stability provided by the osseous congruiry of the

joint. ThiS places a greater relauve Stress on the MUCL.1 Reproducdon of medial elbow pain, in addition co unilateral

neutral forearm condition to uniformly identify laxity in the

VeL. The milking sign is a test the patiem performs on himself

increases in ulnohumeral joint laxity, indicates a positive tesc.

or herself, with the elbow in approximately

Grading the test is typically performed using the American

flexion (Figure

Academy of Orthopaedic Surgeons (MOS) guidelines of

with rhe comraiateral extremity. the patient grasps the thumb

5 mm, grade I; 5

0 ro 10 mm, grade II; and greater than 10 mm, greater than 25 degrees of elbow flexion will

to

grade 111.17 Use of

11-5).

90 degrees of e100w

By reaching under the involved elbow

of their injured extremiey and pulls in a lateral direction, thus imposing a vaJgus seress to rhe flexed elbow. Some patients may

increase the amount of humeral rotation during performance

nor have enough flexibility to perform this maneuver, and the

of the valgus stress test and result in misleading informadon.

examiner can Impart a valgus Stress co mimic this movement,

The test is typically performed with rhe shoulder in the scapu­

which stresses the posterior band of the UCL)

lar plane, buc It can be performed with the shoulder in the

The varus seress test is performed using similar degrees of

coronal plane to minimize compensatory movements at the

elbow flexion and shoulder and forearm positioning. This test

shoulder dunng testmg. Safran ec al. n studied the effect of

assesses the Integriry of the lateral UCl, and it should be per·

forearm rotation during performance of the valgus stress test

formed along with the valgus stress test to completely evaluate

of the elbow. They found that laxity of the ulnohumeral joim

the medial and lateral stability of the ulnohumeral Joint.

Chapter 1 1

Dysfunction, Evaluation, and Treatment of the Elbow

243

Andrews er al.�6 has reported use of the valgus extension overpressure rest co de[(�rmine whether posterior elbow pain is caused by a posteromedial osteophyte abuning the medial margin of the trochlea and the olecranon fossa. This rest is performed by passively extending rhe elbow while mainraining a valgus sm:ss to rhe elbow. The action is meanr to simulate rhe stresses Impacted

CO

the posterior medial part of rhe elbow

dunng rhe acceleration phase of rhe throwing or serving morion. Reproduccion of pain in rhe posteromedial aspen of rhe elbow indicates a posinve res£. The

use

of provocation tests can be applied when screening

rhe muscle tendon unitS of rhe elbow. Provocation tests consist of manual muscle tests to determine pain reproduction. The specific tests used to screen the elbow joint of a patiem with suspected elbow pathologic condition include wrist and finger fleXion and extension, as well as forearm pronation and supina­ tion.I� These tests can be used to provoke the muscle tendon unit at the lateral or medial epicondyle. Testing of the elbow at or near full extension can often recreate localized lateral or medial elbow pain secondary to tendon degeneration:�� Repro­ ducuon of latcral or medial elbow pain with resistive muscle testing (provocauon testing) may indicate concomitant tendon injury at the elbow and would direct the clinician to perform a more complete elbow examination. One of the more recent elbow special tests reported in the literature is the moving valgus test. III This tesc is performed with the patient's upper extremity in approximately 90 degrees of abduction. The elbow is maximally Aexed, and a moderate valgus stress is imparted [0 the elbow to simulate the late cocking phase of the throwing motion (Figure 11_6).12 Main­ taining the modest valgus stress at the elbow, the elbow is extended from the fully Aexed position. A positive test for UCl injury is confirmed when reproduction of the patient's pain occurs and is maximal over the MUCL between 120 and 70 degrees In what the authors have termed the Jhear aNgie or pam

zone.

O'Driscoli et al. Iii used the moving valgus test to examine

21 athletes with a primary complaint of medial elbow pain from MCl insuffiCiency or other valgus overload abnormality. This tesc was found to be highly sensitive (100%) and specific (759f) when compared with arthroscopic exploration of the

MUCL. The mean angle of maximum pain reproduction in their study was 90 degrees of elbow flexion. This test can provide valuable clinical input during the evaluation of the pauent with medial elbow pain. These special examination techniques are unique to the elbow. When combined with a thorough examination of the upper extremity kinetic chain and cervical spine, they can result in an objectively based assessment of the patient's patho­

Figure 11·6 Moving valgus clinical examination mer/ood injuries, �

tendons. �'.•• Recent research has described in derail the anatomy of the lateral epicondylar region.61•62 The specific location of the

Pathomechanics

extensor carpi radialis brevis tendon lies inferior to the tendi­

As a result of the valgus stress incurred during throwing or rhe

nous origin of the extensor carpi radialis longus. which can be

serving morion, traction placed via the medial aspect of the

palpated along rhe anterior surface of the supracondylar ridge

elbow can create body spurs or osteophytes at the medial epi­

JUSt proximal or cephalad to the extensor carpi radialis brevis

condyle or coronoid process of rhe elbow.6,-61 Additionally, the

tendon on the lateral epicondyle.61 Greenbaum et al.62 describe the pyramidal slope or shape of the lateral epicondyle and

which leads to the development of osteophyte formation at the

show how both the extensor carpi radialis brevis and the

posterior and posteromedial aspens of the olecranon tip,

valgus stress during elbow extension creates impingement,

Chapter 1 1

DysfunOion, Evaluation, and Treatment of the Elbow

245

REHABILITAnON PROGRESSION: HUMERAL EPICONDYLmS After the detailed examination, a total extremity rehabilitation program can commence. Three main stages of rehabilitation can conceptuaHy be applied for the patient, which include protected function, total arm strength, and the return-co-activ­ ity phase. Each is discussed in greater derail in this section of the chapter, with specific highlights on the therapeutic exer­ cises used during each stage of the rehabilitation process.

Protected-Function Phase During this first phase in the rehabilitation process, care is

MeL

taken to protect the injured muscle tendon unit from stress but Figure 11-7 Valgus overload depiction showing medial tensile over­

load and lateral compressive forces. (From Shankman G: Fundamental

orthopaedic management for the physical therapist assistant, ed 2, 5t

louis. 2004, Mosby.)

not from function. Nirschl'B and Morrey« caution against the use of an immobil izer or sling because of the further atrophy of the musculature and negative effects on the upper extremity kinetic chain. Protection of the patient from offe nding activi­ ties is recommended. however, with cessation of throwing and serving for medial-based humeral symptoms. Allowing the patient to bat or hit cwo-handed backhands allows for contin­

causing chondromalacia and loose body formacion.M The com­

ued activity while minimizing stress to the i njured area. Very

bined motion of valgus pressure with the powerful extension

often. however. all spore activity must cease to allow the muscle

of the elbow leads ro posterior osteophyte formation because of

tendon unit time to heal and. most imporrandy, to allow

impingemenc ofrhe posterior medial aspect of the ulna against

formal rehabilitation to progress. Continued work or sport

the trochlea and olecranon fossa. Joyce et al68 has reported the

performance can severely slow the progression of resistive exer­

presence of chondromalacia in the medial groove of [he troch­

cise and other long-term treatments in physical therapy.

lea, which often precedes osteophyte formation. Erosion to

Use of modalities is very helpful during this time; however,

subchondraJ bone is often WItnessed when olecranon osceo­

agreement on a clearly superior modality or sequence of modal­ . ities has not been substantiated in [he li terarure.61 '1 A meta­

phyres are inltially developing. Figure 1 1 -7 shows the valgus loading of the athletic elbow

analysis of 185 studies on treatment of humeral epicondylitis

and site of medial tension injury or valgus tensile overload

showed glaring deficits in the scientific quality of che investiga­

the Uel and medial muscle-tendon units

tions, with no significantly superior treatment approach Identi­

of the flexor-pronator group can also occur with this type of

fied. Although many modalities or sequences of modalities

response. Injury

co

repetitive 10ading.66.69

have anecdotally produced superior results. a tremendous need

During (he valgus suess that occurs to the human elbow

occurs for prospective, randomized controlled clmical trials to

during the acceleration phase of both throwing and serving of the elbow, specifical ly at the radiocapiteJlar joint. Of great

better identify optimal methods for initial treatment. Modali­ . ties such as ultf3Sound;69 n electrical stimulation and Ice, cor­ . tisone injeCtion,"9 , . nonsteroidal antiinRammatory drugs

concern In the Immature pediatric throwing athlete is osteo­

(NSAJDs),14 acupuncture/' transverse friction massage,16 and

chondritis dissecans (OCD) and Panner's disease. '\,68 Although

dimethyl sulfoxide (DMSO) application" have all been reported

morions, lateral compressive forces occu r in the lateral aspen

the inCidence of OCD and Panner's disease is low, the impor­

to provide varying levels of effectiveness historically in the

tance of obtaining radiographs in the thorough evaluation of

l i terature. Boyer and Hastings,61 in a comprehensive review of

the ped iatric elbow cannot be understated . The presence of

the treatment of humeral epicondylitis. reported no significant

OCD and Panner's disease, although not common, should be

difference with the use of low-energy laser, acupuncture, extra­

ruled out i n every case.70 The characteristics of Panner's disease

corporeal shockwave therapy, or steroid injection.

are the presence of fissuring and increased density of the cap­

The use of cortisone injection has been widely reporeed in

tiellum.1o The most common onset age of both Panner's

the l iterature during the pain reduction phase of treatment of

disease and OCD is less than 10 years. Both conditions occur

this often-recalcitrant condition. Dijs et aLM compared the

most commonly in male subjects and rypically in the domi­

effects of traditional physical therapy and cortisone injection

nam arm."'1 In the older adult elbow, the radiocapitellar joim

in 70 patients diagnosed with humeral epicondylitis. In their

can be the site of Joint degeneration and osteochondral inju,ry

research, 91 % of patients who received the coreisone injection

from the compressive load lng.66 This lateral compressive

reported initial relief, as compared with 47% who reported

loading is increased in the elbow with MUCL laxity or liga­

relief from undergoing physical therapy. However. the recur­

mem injury.n

rence rate in their study after only 3 months, showed 5 1 % i n

246

Orthopaedic Physical Therapy

the cortisone injection group and only 5% in the physical

levels as submaximal as 5% to 50% of maximum voluntary

therapy group had a rerum of primary sympcorns. Similar find­

contraction (MVC), both during the contraction and for periods

ings were reported in a study by Verhaar er al.�8 chat compared

of up to 1 minute postcontraceion.82 Several studies have shown

physical therapy consisting of Mills manipulation and cross­

superior results in the treatment of humeral epicondylitis using

friction massage with corticosteroid injection in a prospective

progressive resistive exercise compared with

randomized controlled clinical trial in

Additionally, a study by Svernl and Adolffson,&'1 moni tored 38

106 patients with

ultra5Qund.83

humeral epicondylitis. At 6 weeks, 22 of 5 3 subjects reported

patients with lateral humeral epicondylitis who were randomly

a complete relief from the cortisone injection, although only

assigned to a contract-relax stretching or eccentric exercise

three subjects had complete relief from chis type of physical therapy treaement. At I year, no differences between crearmenr

treatment group. Results of their study showed a 7 1 % report of full recovery i n the eccentric exercise group, as compared

groups were seen regard ing rhe course of [reaement. This scudy

with the group that performed contract-relax stretching, which

shows rhe short-cerm benefic from the corticosteroid inJecrion,

only found 39% of the subjects rating themselves as fully

as well as the ineffectiveness of physical therapy using manipu­

recovered. Finally, Croislor et a1.8� compared the effectiveness

lation and cross-friction massage.

of a passive standardized treatment in patients diagnosed with

Several additIOnal studIes deserve funherdiscussion, because they also can be used to d i rect clin icians in the development

chronic

humeral

epicondylitis

(nonexercise control) to a

program that included eccentric isokinetic exercise. After

of appropriate interventions. Nirschl et al.79 studied the effects

training, the patients in the ecceneric exercise group had a

of iontophoreSIS WIth dexamethasone In

199 patients With

significant reduction in pain Intensity, an absence of bilateral

humeral epicondylitis. Results showed 52% of the subjects in

strength deficit in the wrist extensors and forearm supinators,

the trearment group reported overall improvement on the

improved tendon imaging, and improved disability status with

investigators' improvement index, with only 3 3 % of the

rating scales. This study supportS the use of eccentric exercise

placebo group reponing i mprovement 2 days after the series

over the typical passive treatment in patients with chronic

of treatments with iontophoresis. One month after the treat­

humeral epicondylitis. These studies support the heavy reliance

ment, no statistical difference was seen i n the overall improve­

on the successful application of progressive resistive exercise in

ment in the patients in the treatment group versus the control

the treatment of humeral epicondylitis.

group. One additional finding from this study that has clinical relevance was the presence of greater pain relief in the group that underwent six treatments in a 1 0-day period, as opposed

Total Arm Strength Rehabilitation

to subjects in the treatment group who underwent treatment

Early application of resistive exercise for rhe treatment of

over a longer period of time. Although this study does support

humeral epicondylitis mainly focuses on the important prin­

the use of iontophoresis with dexamethasone. it does not repon

ciple that states thac "proximal stability is needed co promote

substantial benefits during follow-up.

distal mobility."t\6 The initial application of resistive exercise

Haake et al.*1 studied the effects of extracorporeal shock wave therapy in multicenter

272

patients with humeral epicondy litis in a

prospective

randomized

control

study.

They

actually consIsts of specific exercises to strengthen the upper extremity proximal force couples.8� The rotacor cuff (deltoid and serratus anterior) lower trapezius force couples are targeted

reported that extracorporeal shock wave therapy was ineffective

to enhance proximal stabilization using a low-resistance, high­

in the treatment of humeral epicondylitis. Similarly, Basford

repetition exercise format (i.e., three sets of 1 5 repetition

et al.tl1 used low-intensity Nd:YAG laser irradiation at seven

maxi mum

points along the forearm three times a week for 4 weeks and

exrernal rotation, prone horizontal abduction and prone exten­

[RM]

loading). Specific exercises such as side-lying

also reported i t to be ineffective in the treatment of lateral

sion (both with externally rorated humeral positions and prone

humeral epicondylitis.

external rotation) all have been shown to elicit high levels of

Based on this review of the l i terature, i t appears that no

posterior rotatOr cuff activarion during electromyography

standardized modality or modality sequence has been identified

(EMG) research.fl8090 Additionally, exercises such as the serratus

in the l i terature that is clearly statistically more effective than

press and the use of manual scapular protraction and retraction

any other at the present time. Clinical reviews by Nlrschl;H

resistance directly applied by the rherapist can be safely applied

Morrey, 'i and Ellenbecker and MattalinoU advocate the use of

without Stress to the distal aspect of the upper extremity

multiple modalities, such as electrical stimulation and ultra­

during this imporcant phase of rehabilitation. The lise of cuff

sound, as well as ionrophoresis with dexamethasone, to assist

weights allows some of rhe rotatOr cuff and scapular exercises

in pain reduction and encourage increases in local blood flow.

to be performed with the weight attached proximal to the

The copious use of ice or cryotherapy after increases in daily

elbow to further m inimize overload to the elbow and forearm

activity is also recommended. The use of therapeutic mooalities

during the earliest phases of rehabil iration (if needed for some

and also cortisone injection, if needed , can only be seen as one

patients).

part of the treatment sequence, with increasing evidence being generated favoring progressive resistive exercise. Exercise is one of the most powerful modalities used in

The initial application of exercise to the distal aspect of the extremity follows a pattern that stresses the injured muscle­ tendon unit last. For example, che initial distal exercise

rehabJiitative medicine. Research has shown increases in local

sequence for the patient with laceral humeral epIcondylitis

blood flow after isometric contraction of the musculature at

would include wrist flexion and forearm pronation, which pro-

Chapter vides most of the tensile seress

[0

1 1 Dysfunction, Evaluation, and Treatment of the Elbow

247

the medially inserring tendons

chain exercise such as quadruped rhythmiC stabiilzation for the

chat are not directly involved in lateral humeral epicondylitis.

upper extremity are added to promote coconrraccion and mimic

Gradual add ition of wrist extension and forearm supination, as

funCtional positions with joinr approx imation In athletes, as

well as radial and ulnar deviation exercises, are added as signs and symptoms allow. Additional progression is based on the

well as i n industrial panenrs who bear weight on their upper

extremities for job-specific functioningY I

elbow position used during distal exercises. Initially, most

In addition to the resistive exercise, the use of gentle passive

pariencs tolerate (he exercises i n a more pain-free fashion, with

stretching to optimize the muscle tendon unit length is indi­

the elbow placed in slight flexion, with a progression as signs

cated. Combined stretches with the patient in the supine posi­

and sympcoms aJlow co more extended and functional elbow

tion are indicated co elongate the biarticular muscle tendon

positions. These exercises are performed with light weights,

units of the elbow, forearm, and wrist using a combination of

often as little as l Ib or 1 kg, as well as a [an or yellow Thera­

eloow, wrist, and forearm positions (Figure 1 1 -9. A and

band , emphasizing both the concentric and rhe eccentric por­

Additional ly. stretching the disral aspect of the extremity In

tions of the exercise movemene. According to the research by Svernl and Adolffson8-1 and Croisier et al.,'" the ecceneric

varying positions of glenohumeral joint elevanon is also I ndt­ catOO.1\ Mobilization of the ulnohumeral jOlOt can also be

portion of the exercise may actually have a greater benefit than

effective in cases where signi ficant Aexion contractu res exist.

B).

rhe conceneric portion. However, more research is needed

Use of ulnohumeral distraction (Figure

before a greater and more clear understanding of the role iso­

near full extension will selectively tension the anterior Joint

lared eccenrric exercise plays in the rehabiliration of degenera­

capsule.92

tive tendon conditions is fully understood.. Multiple sets of to

15

20 repetitions are recommended to promote muscular

endurance.

1 1-9, C) with the elbow

As the patient rolerates the distal isotonic exercise progres­ sion pain-free at a level of3 to

5 Ib or medium-level elastic

cubing or bands, as well as demonstrares a tolerance to the

Once the paciene can tolerate the most basic series of diStal

oscillarory rype of exercises in this phase of rehabilitation, he

exercises (wrist Aexion and excension, forearm pronation and

or she is progressed to the isokinetic form of exercise. Advan­

supinacion, and wrisc rad ial and ulnar deviation), exercises are

tages of isokinetic exercise are the inherent accommodarive

progressed to include activities that involve simultaneous con­

resiscance and use of faster, more functional contractile veloci­ ro

rraccion of the wrist and forearm musculature with elbow

ties, in addition to providing isolated parcerns

flexion and extension range of motion. These include exercises

levels of muscular activation. The initial pattern of exercise

ehcit high

such as exercise ball dribbling (Figure 1 1 -8, II), Body Blade

used anecdotally has been wrist Aexion and extension (Figure

MN), Thera­

1 1 -10), with forearm pronation and supination added after

band (Hygenic Corporation, Akron. OH) resistance bar exter­

successful rolerance of a trial treatment of wrist Aexion and

(Hymanson , TX), Boing (OPTP, Minneapolis, nal oscillations (Figure 1 1-8,

B) (which combine wrist and

forearm stabilization with posterior rocator cuff and scapular

extension. Contractile velocities ranging between

1 80 ro 300 20 repeti­

degrees per second, with six ro eighr sets of 1 5 to

exercise), and seated rowing and other types of scapular retrac­

tions. are used ro foster local muscular endurance9i in athlecic

tion resistive exercise. Additionally, the use of closed kinecic

patients with slower contractile velocities rangtng from

1 20

Figure 11-8 A, Ball-dribbling exercise used to increase forearm and wrist strength and local muscular endurance. B, Flex-bar oscillation exercise.

248

Orthopaedic PhysiGlI Therapy

Figure 11-10 lsokinetic wrist flexion-extension exercise.

Return-to-Activity Phase Of the three phases in the rehabil itation process for humeral epicondylitis. rerurn co activity is the one chat is most fre· quently ignored or CUt shorr, resu lting i n serious consequences (or reinjury and the development o( a "chronic" stacus (or this injury. Objective criteria (or entry into this seage include the following: tolerance of the previously stated resistive exercise series, objectively documented strength equal to the contralat· eral extremity with either manual assessment (manual muscle testing (MMT) or preferably isokinetic testing and isometric strength, distal grip strength measured with a dynamometer, and a functional range of motion. It is Imporrant to note that often in the elite athlete with chronic musculoskeletal aclapta. tions, the full elbow range of motion is nor always attainable (secondary to the osseous and capsular adaptations discussed earlier in this chapter). Characteristics of interval sporr recurn programs include alternate·day performance, as well as gradual progressions of intensity and repetitions of sporr activities. For the interval tennis program, for example, using low-compression tennis balls such as the Pro·Penn Star BaJi (Penn Racquet Sports, Phoenix, AZ) or Wilson Gator Ball (Wilson Sporting Goods, Chicago,

IL)

during the initial contaer phase of the recurn to

tennis decreases impaer stress and increases tOlerance to the activi ty. Additionally, performing the interval program under supervision, either during therapy or with a knowledgeable teaching professional or coach, allows for the biomechanic Figure 1 1 -9 A, Range-of-motion stretch position to stretch the forea rm

evaluation of technique and guards against overzealous i men·

stretch the forearm pronators and wrist flexors. C, U lnohumeral dis­

tioned, moti vated patients. Using the recurn program on

traction joint mobilization technique.

alternate days, with rest between sessions, allows for recovery

supinalors and wrist extensors. 8, Range-of-motion stretch position to

sity levels, which can be a common mistake in well-inten·

and decreases reinjury. degrees per second co 2 1 0 degrees per second for less accive and

The interval tenniS program is comained i n Appendix l .

nonathletic pacients. In addition co the isokineric exercise,

This program specifically outli nes the progression for the

1 1- 1 1 , C

and

D)

B) and

wrist flips

patient after an upper extremity injury. Often, throwing ath·

are used to begin to train the active

letes are seen for medial humeral epicondylitis. Similar con·

piyomecric wrist snaps (Figure 1 1 - 1 1 , A and (Figure

elbow for functional and sport-specific demands.

cepts are used in the interval throwing program contained i n

Chapter 1 1

Dysfunction, Evaluation, and Treatment of the Elbow

249

Figure 11-11 A-H, Plyometric wrist "snaps exercise. C-D, Plyometric wrist "flips" exercise. "

Appendix

2. Again, having the patient's throwing mechanics

is i mportant

CO

coneinue

endurance.

[Q

enhance nor only strength bur also

evaluated using video (and by a qualified coach or biomecha­

muscular

Inspection

nist) is a very imporcam part of (he return-co-activity phase of

patient's tennis racquet or golf clubs is also imporcant. For

and

modification of [he

the rehabilitation process.

example, lowering the string tension several pounds and ensur­

Two other important aspects of the rerurn to sport activity

ing that the player use a more resilient or softer string such as

ue the continued application of resistive exercise and the modi-

a coreless multifilament synthetic string or gut, is widely rec­

6cacion or evaluation of the patient's equipment. Continuacion

ommended for tennis players with upper extremity inj ury his­

,f the roeal arm strength rehabilitation exercises using elastic

tories:B,4-4,49 Grip size is also very imporcant, with research

,esisrance, medicine balls, and isotonic or isokinecic resistance

showing changes in muscular aCtiviry with alteration of handle

250

Orthopaedic PhYSical Therapy

or grip size.'J.' Measuremenr of proper grip size has been described as corresponding to the d istance between the dinal tip of rhe ring finger along rhe radial border of the finger to the proximal palmar crease:11 Researchers have also recom­ mended rhe use of a counrerforce brace [0 decrease suess on rhe Insertion of the flexor and extensor tendons during work or sport activi ty.'}'

Postoperative Rehabilitation Progression: Humeral Epicondylitis In a study ofover 3000 cases of humeral epicondylitis. NirschrH has reported that

92% respond to nonoperative treatment.

Characteristics of patients who often require surgical correction for this condition are fai l ure of nonoperative rehabilitation prog rams, minimal relief with corticosteroid injection, and intense pain in the injured elbow even at rest. Surgical treat­ ment for lateral humeral epicondylitis, as reported by Nirschl,4l involves a small incision from the radial head to I inch proxi­ mal co the lateral epicondyle. Through this incision, the surgeon removes the pathologic tissue termed aflgiojibroblasrir hyperplaIla. without disturbing rhe artachment extensor apo­ neurosis to preserve stability of the elbow:H Vascular enhance­ ment is afforded by drilling holes into (he cortical bone in (he

Figure 1 1 ·12 Posterior medial osteophyte excision during elbow arthroscopy. (From Andrews JR, Soffer SR: Elbow arthroscopy, St louis, 1 994, Mosby.)

anterior lateral epicondyle to cancellous bone level. PoStopera­ tive immobil ization is brief (i.e" 48 hours), with early motion

of the wrist and fingers on postoperative day I , progressing to

removal. In their study,

elbow active assistive range of motion dUring the first

average of

2 to 3

2 1 patients were monitored for an 35 months postoperatively, rendering good and

results

in

seven and

14

weeks. Resistive exercise is gradually applied after the third

excellent

postoperative week, with a return to normal daily activities

O'Driscoll and Morrey99 reported thar arthroscopic removal of

patients,

respectively.

expected at 8 weeks poscoperatively and a rerurn ro sport activ­

loose bodies was of benefic in

ity several months thereafter.H,I.1

when loose bodies were not secondary to some other IOrraar­ ticular condition,

75% of a l l patients; however,

100% of patients raced the procedure

as

beneficial. Andrews and 1immerman1oo reviewed the results of

REHABILITATION AFTER ELBOW ARTHROSCOPY

73 cases of arthroscopic elbow surgery in professional baseball pi tchers. Eighty percene of players were able to rerurn to full activi ty, pitching at their prei njury level for at least one season.

Repeticive stresses to che athletic elbow often result in loose

Further review of these patients found that

body formation and osteochondral injury, i n addition to the

additional surgery, often requiring stabilization and recon­

25% returned for

more commonly reported tendon inj ury resulting in humeral

struction of the

epicondylitis. Andrews and SofTer'Hi reporr the moSt common

tane srudy shows the close association between medial elbow

indications for elbow arthroscopy are loose body removal and

laxity and posterior medial osreochondral injury. In addition,

Uel because of valgus i nstabili ty. This impor­

removal of osteophytes. Posteromed ial decompression includes

it highlighcs the importance of identifying subele Instability

the excision of osteophytes, wich or without resection of add i­

i n the athletic elbow.

cional posteromed ial bone from the prox imal olecranon (Fig, 1 1 _ 1 2 ).91 Early emphasis on regaining ful l extension range of

patienes who underwene elbow arthroscopy and had a mean

Reddy et aJ. 101 retrospectively reviewed a sample of

172

invasive

follow-up of 42 months. Fifty-six percene of patients had an

arrhroscopic procedure. (The author's posroperarive prorocol

excellent result, which allowed them a full return to activity,

motion

is

possible

because

of the

minimally

after arthroscopic procedures of rhe elbow is presenred in

with

Appendix 3.) Progressive application of resistive exercise

reported, wich an overall conclusion that this procedure is both

CO

36% having a good resul t . A 1 .6% complication rate was

Increase boch srrength and local muscle endurance forms rhe

safe and efficacious for the treatmene of osteochondral injury of

bulk of the rehabilitarion prorocol. Use of early shoulder and

[he elbow.

scapular srabilization is also recommended in rhese parients ro

Ellenbecker and MacrallllolJ measured muscular strength at

prepare them to return to overhead activities and aggressive

a mean ofB weeks postoperatively in eight professional baseball

fu nctional activiry after discharge.

pi tchers after arthroscopic removal of loose bodies and postenr

Oghve-l larris

et

al.'lli reported outcomes after elbow

medial olecranon spur resection. ResultS showed a complete

arthroscopy for poscerome dissociation by trisc.lpht:

Chapter 13 Reconstructive SurgeI)' of the Wrist and Hand

321

triangular fibrocartilage, synovectomy for a chronic synovitis or associaeed with rheumatoid arthrieis, and visualization of depressed mfraarticular wrist fractures during limited ORIF. This approach can limit [he amount of scarring associated with this procedure and allow for more normal recurn of funceion and

a

more

adequate

reduction

of

[he

fracture

under

visualization.

Technique Wrisr arthroscopy has become standard for treating some con­ ditions. The patient is given either a regional or a general anesthetic agent, ehe shoulder is abducted 90 degrees, and the elbow is flexed 90 degrees with the fingers suspended (usually from a finger trap device) to distract the wrise. The wrise and hand are then prepared for surgery. Archroscopic visualization

3

mm or smaller provides the best overall View and IS rhe lease

eraumatic to the wrist (Figure

13-14). The arthroscope is intro­

duced between the third and fourch extensor compartments after insufflation of the wrise Joim with normal saline by injec­ cion needle. Working instruments can be introduced either between the first and second dorsal compartment groups, more laterally between the fourth and fifth comparements, or JUSt lateral to Figure 13-13 Arthrogram of the wrist showing dye leakage through

the. sixth compartment. Visualization of the articular surfaces

the scapholunate space into the distal carpal row (arrow), indicating a disruption of the scapho lunate ligament

IS usually very good, and the imercarpal ligamems between the scapholunaee and lunorriquetral articulations can be evaluaeed (Figure

13-15).

The triangular fibrocartilage and the (ossa of

the ulnar styloid are also visualized through the arthroscope. or tnangular fibrocartilage (Figure

13-13).

Once [he diagnosis

The midcarpal joint can also be entered between ehe innate and

of intercarpal ligament rear is made, a limired intercarpal

the capitate, visualizing ehese surfaces for occule chondromala­

fusion may solve (he problem, and if a corn criangular fibrocar­

cia and loose bodies.

Cllage is found, chen it should

be repaired

if possible.

Assuming that no open procedure is necessary in association

Arthroscopic partial debridement of the rriangular fibrocarti·

with the arthroscopy, ehe patient is usually allowed co go home

lage may be sufficient. With advanced degenerarive changes

the same day with a light dressing on the wrise, and gende

from old trauma, replacement with limited intercarpal fusion

range-of-motion exercises are starred immediately. After the

co unload [he prosthesis or a wrist fusion may be necessary

(0

restOre s3risfaccory function of [he hand.

Initial soreness disappears in 2 to

5

days, physical therapy can

be Started ro increase mobility and regain srrengrh about the

After repair of an intercarpal Iigamenr or an intercarpal

wrise. When the procedure is performed under appropriate

fusion, immobilization is necessary for a sufficient length of

conditions, patients generally function at a normal level wiehin

time to allow the ligament to heal or the fusion to become

at least a few weeks, and [he return to normal activities IS much

solid. Immobilization frequently will need to include one or

faster than when an open procedure is used.

several fingers besides the wrist and forearm. The eime in the case IS usually no less than 6 weeks, and ehe wrist and hand can be very stiff once the cast is removed. Physical therapy is generally indicated [Q mcrease the range of moeion both pas­

O-verllse SYl1dromes Overuse syndromes of the wrist and hand are very common in

sively and actively, as well as to strengehen the wrise. Methods

modern work conditions. Work chat requires repetitive use of

for reduction of swelling along with heat and ultrasound can

the hand, especially assembly line activities or clerical casks

be useful

[Q

decrease the likelihood of tendonitis associated

with the prolonged immobilization.

such as key punching or invoice rectification, can produce chese overuse syndromes. Heavier work such as the use of air hammers and power equipment can also cause overuse syndromes. The

Wrist Arthroscopy Wrist arthroscopy has become standard for treating some con­

most common overuse emity is CTS (usually related to either repetitive microtrauma to the wrist char causes inflammarion of the tissues about the median nerve in the carpal canal or

dlrions. Currendy the indicaeions for wrist arthroscopy are

Inflammarion

identification of problems that may be associated with unre­

overuse syndromes include wfist Of digiral flexor and extensor

solved wrisr pain; removal of loose bodies, debridement of the

tendonitis. All of these problems can resule in eime lost from

secondary

to flexor

tendon

overuse). Other

322

Orthopaedic Physical Therapy

Figure

13·15 Intraarticular vie-.v

of the wrist.

gouty arrhriris; immune abnormalities resulting in rheumatoid arthritis or lupus arthritis; infections that can cause septic arthritis; and traumatic injuries that resule in damage or unevenness of the joint surfaces, causing rraumatic arthritis. Osteoarthritis of the wrist and hand occurs mostly in the wrist, the DIP joints of the fingers, and the carpal.rnetacarpal (CMC) joint of the thumb. The inflammation may be con­ trolled conservatively by using nonsteroidal anciinflammatory drugs (NSAIDs), hear, and maintenance of morion in rhe joints. Intermittent splinting may control developing deformi· ties, although this is necessary only in a small proportion of parients wirh osreoarthritis. Surgical procedures for severe arthritis, in which uncontrolled pain, destruction of the joint on radiographic evaluation, or deformity wirh loss of function exists, may include simple debridement of the joint with removal of osteophyres or bone spurs and debridement of abnormal carrilage in rhe joint. Capsular reinforcement may Figure 13·14 Tec hniq ue of wrist arthroscopy. A, Primary portals for the arthroscope and working instruments are between dorsal compart­ ments three and four and compartments four and five. 8, Setup for wrist arthroscopy. with the arthroscope placed in the entrance portal between the third and fourth extensor groups.

also be necessary to control deformities. For more involved destruction, fusion of the joint may be necessary or, specifically in the case of the basilar thumb joint and wrist, a prosthesis or resection arthroplasty may be useful to retain function after removing rhe abnormal joint (Figure 13- 16). Physical therapy is frequently necessary with conservative ([eatmem for main­ tenance of range of motion in acurely inflamed joints by the use of gentle range-of-motion exercises, as well as heat, paraffin

work and should be creared aggressively with spliming, ami­

baths, and massage. Again, intermittent splinting may be nec­

inAammacocy medication, and therapy, as well as evaluation of

essary for some patients. After surgical procedures, immobiliza­

rhe workplace [Q try [0 decrease rhe recurrence of repetitive-use

tion is usually needed for a rime, after which rerum of function

trauma. Appropriate medical [rearmenc and physical therapy

is achieved through exercise and strengthening.

can reduce rhe intensity and rime for recovery.

Rheumatoid arthritis is particularly debilitating to the hand, and treatment can be very involved. BrieRy, rheumatoid

Arthritis Archriris by definicion means inflammation of a joim, bur rhe

arthritis not only affects the articular surfaces bur also involves rhe soft tissues to a large extem, including the ligamemous strucrures and the tendinous strucrures about the wrist and

term generally refers co a pathologic process involving inflam­

hand. The cartilage surfaces are destroyed, and the soft tissue

mation that causes destruction of the joint. Many processes can

strucrures are weakened by degradation of the collagen and

cause arthritis, such as general wear and rear producing oS[eo�

infiltration by the rheumaroid process. The joints most often

arthritis; membolic abnormalities, such as that which causes

involved are the wrist, the CMC joint of rhe thumb, and rhe

Chapter 13 Reconstructive Surgery of the Wrist and Hand

A

igure 13-16 A, Metacarpal-phalangeal (MP) prosthesis. B, After MP �Iacemenl lon g ring and small fingers. (Courtesy Ascension Ortho­ aedics, Inc., Austin, Texas.)

323

metacarpophalangeal joints of the fingers. Deformity can occur simply by collapse of the join[ surfaces or in combination with laxicy of the surrounding capsular and ligamentous structures, causing subluxation and subsequent abnormal pull of the mus­ cuiocendon units, resulting in grossly abnormal funccion of the hand. The tendons can also become involved, particularly the flexor tendons, and chronic uncontrolled inflammation can cause rupture of [he tendons. Treatment consists of concrolling the disease process with medication, splinting to prevent stretching of the soft tissue StrUCtu.res and subsequene subluxacion of the joines, and vigor­ ous therapy to maimain strength and mocion in the digits and the wrist, Surgical treatmenc in cases of minimal involvemem of the articular surfaces can be accomplished by synovectomy and soft tissue reconstruction as necessary and then rehabilita­ tion once healing of the reconstruction has occurred. In cases of more advanced destruction of the joims along with subluxation, soft tissue releases of the tight sttuctures and reinforcemem and reconstruction of the loose srrucrures are necessary. Joine replacement of the metacarpophalangeal joims and fascial arthroplasty of the basilar joint of the thumb and the wrist may be indicated (Figure 13-17, A and 8).1) Fusion of the joincs may be required for stability if severe involvemem of the soft tissues exists. Reconstruction of ruptured tendons is necessary to regain function, but it will fail if control of the disease by medication or synovectomy is nor achieved. Prolonged dynamic splinting after reconstruction is generally necessary, with slow return of function. However, because of the severe deformities, recon­ structions of rheumatoid hands are generally very satisfying. Septic arthritis can occur either through direct introduCtion of bacteria into the joint from a puncture wound or surgical

igure 13-17 Rheumatoid arthritis. A·B, Severely degenerative rheumatoid hand sho wing degeneration and subluxation of the m etac arpal pha­ mgeal (MP) joints and severe degeneration of the wrist. C, Postoperative view with Silastic MP joints in place. -

324

Orthopaedic Physical Therapy

procedure or via the bloodstream through hemacogenoll5

JOint. Once the arthritis has set in, it is approached much like

seeding of the joim with bacteria. Sepsis in a joinr that is nOt

osteoarthricis, with conrrol by NSAlDs. Maimenance of joint

treated early will result in descruccion of the articular surfaces

mobility and function is importane. Once the disease process

of [he joint and cause septic arthritis. It, Initially. comrol of [he

had advanced past the point of comrol by conservative methods,

infection is necessary. If arthritis sets in from the septic process,

arthrodesis or replacement of the joim may be indicated.

then a fusion or resection arthroplasty may be indicated, depending on the joint involved. It is only with great hesita­ tion that an artificial joint would be placed. in a previously

AM PUTATION

septic joint. Traumatic arthritis can occur when any traumatic episode

Amputations may occur for many reasons; trauma, vascular

resules in injury to the articular surface and damage to the

disease, surgical resection of rumors, and uncontrolled. infec­

cartilaginous covering or to the ligamemous stability of the

tions are some of the possible causes. Traumatic ampu(3tions

joint that causes abnormal mechanics and motion about the

or near amputarions that have, because of the mechanism of

case Study 1 3-3: an d DIP Deceneratlve Joint

R�::=:C:�:!

A 60-year-old woman who worked 10 a cafetena had ongolOg

finger PIP Joint and fusion of the DIP Joim of the JOdex

Iimication of motion and pain i n boch hands, buc it became

finger with a Herbert screw technique (Figure 1 3- 1 8, C

acurely severe in the right index and long fingers, for which

and 0).

she came 10 for consuhation. The patienc was found co have

The patient was treated with a splint for the index

a severely swollen index finger DJP joint and long finger

finger and early range of motion for the long finger. with

PIP jOint. On examinatlon, she was found to have limitation

buddy taping to the index finger. At 4 months, she had

of motion of che index DIP joint and a large cystic mass on

excellent fusion of the DIP joint but still lacked some

the long finger PIP joint with ulnar deviation at the joint.

mocion in the PIP joim of che index finger and the long

Radiographs confirmed severe degeneration of the index

finger, The index finger had excellent range of motion at

DIP jOint and moderate degeneration with ulnar deviation

the end of 6 months, except for the DIP jOint, which was

at the long finger PIP Joint (Figure 13-18, A and B). Mter

fused. The pacient was able to gain motion in the long [0

examinatlon assuring function of the neurovascular scruc­

finger PIP joint

turcs and all rendons, the patient underwent excision of rhe

with good function In the hand. The patiem returned to

approximately 10 degrees co 90 degrees,

cySt and radial coilateral ligamenr reconstruction of the long

work and was satisfied with her resule.

Figure 13·18 A·B, Anteroposterior and lateral views of the right hand showing a severely degenerative index finger distal interphalangeal

(DIP) Joint and a large cystic mass with ulnar deviation of the proximal interphalangeal (PIP) joint of the long finger C-O, Anteroposterior and lateral views of the index finger showing (usion of the DIP jOint with a retained Herbert screw device, decreased soft tissue swelling about the PIP joint of the long finger, and decreased ulnar deviation.

Chapter

13

Reconstructive Surgery of the Wrist and Hand

325

Case Study I 3-4 : Reh.bll� Surgery of the CarpometllClirpaL History A 66-year-old left-dominam woman was referred co therapy

basilar joint, and most especially, the continued pinch strain

with a diagnosis of CMe basilar joinc arthritis and de Quer­

when using her denral instruments.

ing a jug of tea or a large object that required strain to the

vain's tenosynovitis in her right thumb and wrist. She

Supporting the fact that de Quervain's tenosynovitis is a

000-

potential diagnosis. the probable origin of this first dorsal

dominant right thumb that was arraumacic. The patient also

companment pain is most likely based on her descriprion

reported occasional, mild discomfort in her dominant left

of acquired "contorted" wrist and thumb positions to

CMC joint. Her job as a dencal hygienist included cleaning calcare­

her job. The pacient also established that the requirement

reported progressive pain in the basilar joint of her

"ptevent pain in the base of the thumb" when performing

ous deposits. accrecions, and stains from che teech and beneath the margins of che gums using dental

co wear latex gloves in her occupation as a dental hygienist

instruments.

het joint. As a result, the de Quervain's subsided, bue obvi­

limited her ability in wearing a spline at work to protect

The most scressfuL activities for the CMe joinc are rhose

ously, the CMC pain did not. The patient was discharged

char require a strong pinch, increased with applicable pres­

until surgical reconstruction (CMC arthroplasty), with a

sure, force, and tension. Gripping a dencal instrument is an

home program of splinting, joint protection techniques and

activity that requires a common pinch (tripod) associated

a home exercise program to prevent further " Rare-up" of

with symptomatic complaints of basilar joint arthritis.

tenosynovitis indicative with compensacory movements.

However, the involved CMC was her nondominant right hand. Occupational speculation reveals that a srrong lateral

Surgery

pinch is required to retraCr the mouth wirh a dental instru­

Three months after her initial consultation, the patient

ment. This positional pinch is also hazardous to a progres­

underwent resection archropiasty of the right thumb CMe.

sively degenerating joint, because the shearing force of the

The ·su.cgery was a volat approach technique, taking down

rhumb metacarpal and trapezium with prolonged lateral

tbe thenar muscles on the first metacarpal. The trapezium

pinch pressure exaggerate the articular wear.

was excised, and the metacarpal base articular surface was removed. One half of the flexor carpi radialis tendon was

Patient History

harvested and left attached distally at the base of the second

Previous symptoms include "thumb pain." This patient

metacarpal. The tendon graft was passed through a drill hole in the first metacarpal from the ptoximal cue surface and

reported that she was diagnosed with de Quervain's tenosy­ novitis and given three cortisone injections in a period of

out radially and distally on the first metacarpal . Holding

4.5 months from a previous physician with no prescription

the meracarpal in the reduced position, tbe tendon transfer

for therapy. The patient further reported that she was

was attached by sutures co the fascia and periosteum on rhe

advised to have a "first dorsal compartment release."

radial aspect. With satisfactOry stability, the thenar muscles

Diagnostic Classification: Musculoskeletal 4E: Tenosyno­ vitis (727.04)

were repaired and the wound was closed. Along with a sterile dressing, the patient was placed in a thumb spica splint.

Examination The right hand had normal attitude except for deformity at

The splint was removed at 2 weeks; her wound was well healed and thumb had good position. The patient was

the base of rhe first metacarpaL She had full range of motion

placed in a removable splint and encouraged to move the

and all tendons and nerves tested i neact. She had severe pai n

thumb in the plane of the palm two to three times per day

on first CMC grind test and a positive Finkelstein's test (for

ovet the next 2 weeks. Sbe was the then given a thumb spica

de Quervain's syndrome).

cock-up splint and referred for postoperative therapy (Figure 1 3- 1 9).

Treatment (Preoperative) She was initially positioned in a thumb spica splint to rest

Treabnent (Postoperative)

the CMC joint and the extensor pollicis brevis (EPB) and

One-Month Postoperative

rhe abductor pollicis longus in the first dorsal compartment.

The patient returned CO therapy 4-weeks postoperative right

The interphalangeal (lP) was left free for range of morion.

thumb (MC arthroplasty and reported that she was "almost

Additionally, she was treated therapeutically for the tenosy­

pain free" based on the constant pai n she had before surgery.

novitis; once subsided, the spline was reduced to a custom

She arrived to therapy with a postoperative spline immobi­

CMC joim stabilization spline.

lizing the wrist, thumb metacarpal-phalangeal (MP), and

The patient'S functional complaints of discomfort and

leaving the IP free for movement. She was cautioned regard­

weakness were mostly with grasping objects and rotarion,

ing her zeal and poscoperative excitement to anxiously

such as doorknobs, turning a key in the car ignition, carry-

"return to life."

326

Orthopaedic Physical Therapy

Case Study 1 3-4: Rehabilitation Allii.: Carpometacarpal Jolnt-cont'd

Figure 13·19 A,

Severe first carpa l -metacarpal (CMC) arthritis with

•

Evaluation (4-Weeks Postoperative) •

Range of motion:

45/0/45

•

•

Wrist extension-flexion:

Radial deviation and ulnar deviation:

•

Thumb MP:

•

Uninvolved digits (I,L,R,S): Within normal limits

15/0/15

0/20

(WNL) IP :

each fingertip, radial

Sensation: No hypersensitivity or deficits noted in super­ Edema: Moderate edema noted at base of thumb and radial wrist

No MP flexion and opposition co base of fifth

4. Perform moderate ADL while wearing the splint. Six-Weeks Postoperative

1 . Initiated MP flexion and opposition to the base of the fifth finger as the patient was able to oppose to each

Strength (gross grip and pinch): DNT (did not rest)

ficial rad ial nerve branch •

[0

3. Continue spliming after exercises and at night.

0120

because of infancy of reconstruction •

CMC abduction, opposition extension

•

• •

subluxation (arrow); 8, after CMe resection arthroplasty (arrow).

fingercip with ease and "walk" down the small finger with minimal effort to the base. 2. Reduce spline wear time; djscharge at nighr,

3 . Initiate gende isometric thenar strengthening. Eight-Weeks Postoperative

1 . Discharged spline (CMC basilar) except when per­ forming stressful activities.

Treatment Goals •

Protect reconstruction

•

Increase functional use for activities of daily living (ADL)

•

Increase range of motion

•

Increase strength

•

Decrease edema

2. Jniriaced gende grip and pinch strengthening (pacient is pain free).

Ten-Weeks Postoperative 1 . Progress with strengthening and prolonged progres­ sive pinching with grading resistance to mimic as much as possible the retraction of the mouth with dental instruments.

Treatment

2. Continue with home exercises and performing pro­

Four-Weeks Postoperative: Initial Postoperative Evaluation Modalities

gressive ADL.

Twelve-Weeks Postoperative: Dischorge Evaluation

1 . Hear: Used because the main problem was stiffness.

•

Range of motion

Heat was chosen because warmth increases circulation

•

Wrist extension and flexion:

and decreases pain and stiffness.

•

Radial deviation and ulnar deviation:

2. Therapeutic exercises: Active assisted range of motion

•

Thumb MP:

(AAROM) and AROM initiated to rhumb and wrist

•

IP:

0/60

0/35

75/0175 2010/25

Chapter 1 3 Reconstructive Sur gery of the Wrist and Hand

327

Case Study 1 1 -4 : Carpometacarpal Jolnt-cont"d •

•

Strength

Pain: The patienr was asymptomatic and reported no pain. She reported that she was ready to return co work, and her plans were to maintain a part-rime

Right gnp:

Pinch: (tip):

(Tripod):

(Lat):

43 #

7.5 #

9 #

10 #

Left grip:

Pinch: (tip):

(Tripod):

(Lat):

Fourteen-Weeks Postoperative

46 #

11 #

12 #

11 #

The patient called to report rhat she was doing very well,

position.

reporring only fatigue at the end of the day, with no pain.

injury. maintained sarisfacrory tissue on either side of rhe

of some function of the thumb, a toe-to-hand transfer using

amputation may lend themselves co reimplanrarion. This has

free-tissue technique can restore the former pincer movemenr

become a specialized area within hand surgery. The reimplanca­

of the hand.20 Amputation proximal to the base of rhe meta­

tion surgeon must consider many complex problems when

carpals is very difficult to reconstrUCt, and a prosthetic replace­

anticipating reimplanracion of a digir or hand. The length of

menr may provide satisfactory function.

the period of ischemia and the temperature of rhe divided pan

Rehabilitation when only a single digit is involved can be

during chut rime can play a very importane role in determining

as si mple as reeducating the individual in the use of the hand

whether the tissue of rhe amputated part will survive. In addi­

without the amputated digit. If a transfer of digits within the

tion. with longer periods of ischemia, rhe arcerial and venous

same hand or toe-ro-hand transfer of digits is performed co

anascomoses have a lower incidence of patency after repair. The

replace the thumb, then the rehabilitation and reeducation i n

coord ination of several procedures including fixation of the

use o f the hand can be very complex. Therapy after reimplanra­

skelecal struccure, repair of the muscle-tendon units, as well as

cion is very prolonged because of scarring through the area of

repair of the arteries, veins, and nerves that supply the parr

the amputation and repair. Consideration mUSt be given to

must be mken inm account. This is very tedious work, and

bone healing, the sliding and gliding motions of the tendons,

frequenrly failure of one or more of these areas can cause sub­

and protection of the digit until sensation returns.

sequenc loss of rhe digir. Reimplancation of digits distal co the DIP jOlOt is rarely considered except on the thumb, and reim­ plancation of ampucared tissue proximal to the wrist becomes

CRUSH INJURIES

much more complicated because of [he amounc of muscle tissue involved and the amount of myoglobin produced because of

Crush inj uries to the hand and fingers frequenrly cause damage

muscle necrosis, which can cause systemic complications, par­

to a large area and can involve multiple or all Struccures includ­

ticularly in the kidneys.11

ing fractured bones, crushed or lacerated nerves and tendons,

After loss of a part of the hand, if digits remain, then it is

tOrn ligamenrs, crushed muscles, and macerated or avulsed

very imporcanr co provide some type of pincer mechanism for

skin. Thus these injuries are frequently devastating to hand

grasping. Therefore if [he thumb has been lost, then one of the

function and present challenges for repair and reconstruction.

other digits will need to be transferred into an opposing posi­

Examination both in the emergency departmenr and in the

tion to the other one or twO digits to produce the pincer

operaring room will help identify damaged struccures, as well

motion.

as those inract and the viability of the hand and fingers.

Loss of a single digit proximal to the DIP joint from a sharp

The approach to repair is generally to restOre skeletal stabil­

amputation can necessi tate replantation for good function.18

ity, then tendon repair. These are done first to provide a stable

Loss of a single digit proximal to the PIP joint, particularly

frame and to avoid disrupting the vascular and neural repairs

[he long or ring finger, can cause dysfunction when trying co

performed at the same surgery. Loss of digits and compromised

hold fairly small objeccs such as coins, which can fal l through

function can now be prevented in some cases by the use of

the gap in the fingers.19 In these patienrs, ray amputation is

cadaver parts, including whole bones such as phalanges and

freq uently indicated to allow for more normal hand function if

tendons, especially the extensor head.

reimplanration is nor feasible. A hand with three fingers and

Rehabilitation from these injuries is prolonged, with rhe

one thumb seems co work very satisfactorily, almost as well as

challenges of extensive scarring, slow nerve recovery, and

a regular hand. Occas ionally in a heavy laborer, mainrenance

hypersensitivity, sometimes including past traumatic sympa­

of the partially ampu[3ted digit rather than ray amputation

thetic dystrophy. The approach to repair in a particular patient

may be desirable to maintain the breadth of the hand and allow

requires an assessment of the occupational and nonoccupational

for grearer grip strength. When rhe rhumb has been amputated

demands, as well as the psychosocial aspects of the patient's

or when all the digirs have been amputated wirh mainrenance

life.

328

Orthopaedic Physical Therapy I I . Schneider LH, Hunter JM: Flexor tendons late reconstruc­

REFERENCES 1. Flynn JE: Disability evahl3tions. In Flynn JE, editor: lIand surgery, ed 2, Baleimore, 1 975, Lippinco[[ Wil­ liams & Wilkins.

2. Lee M: Tendon injuries. In Crenshaw AH, editor: Camp­ bell's operative orthopaedics, ed 7, Sr Louis, 1987, Mosby.

3. Nichols 1 1M: Manual of hand injuries, Chicago, 1957, Year Book Medical Publ ishers 4. Taleisnlk J. Kelly PJ : The extfaOsseous and incraosseous blood supply of ehe scaphoid bone. J Bone Joinc Surg 48(A): 125, 1 966. S. Herbert T): Use of the Herbert bone screw i n surgery of

ehe wrisc, C1in Orehop 202:79, 1986.

6. Cooney WP, Dobyns JH, Linscheid RL: Fraceures of ehe scaphoid: a ranonal approach

(0

managemenc, Clin Orchop

149:90, 1980. 7. Lee M: Fraecores. In Crenshaw A H , ed,cor: Campbell's operative orcllopaedics, ed 7, Sr Louis, 1987 Mosby. I

8. Abouna JM, Brown H : The treatment of mallet finger: the results in a series of 148 consecmive cases and a review of ehe / ieeraeure, Br J Surg 55:653. 1968.

9. Lister GO, Kleinert HE, Kurz JE er al: Primary flexor tendon repair followed by i mmediate coorrolled mobiliza­ Cion, J Hand Surg 2:44 1 , 1977.

1 0. Pennington DG: The influence of tendon sheath integrity and vincular blood supply on adhesion formation follow­ Ing tendon repaIr in hens, Br J Plast Surg 32:302. 1979.

tion. In Green DP, editor: OperatIve hand surgery, ed 2, New York, 1988, Churchill LIvingstone.

12. Poppen NK: Recovery of sensibility after suture of digital nerves, J Hand Surg 4:212, 1979.

13. Frykman G K, Wayler J: Rehabiliraeion of peripheral nerve injuries, Orehop C1in Noreh Am 12:361 , 1981.

l 4 . Johnson RP: The acutely mjured wrist and its residuals, Clin Orehop 119:33, 1980. 1 5. Cook SD, Beckenbaugh RD, Redondo J, ec al: Long-cerm follow-up

of

pyroLytic

carbon

metacarpophalangeal

implanes, J Bone J Surg 8 I (A):635, 1999.

1 6. Neviaser RJ: Infections. In Green DP, editor: Operauve hand surgery, ed 2, New York, 1988, Churchill Livingstone. 1 7 . Urbaniak JR: Replantation of amputated parts technique, results, and indications. In AAOS surgical symposium on microsurgery: practical use in orthopaedics, St Louis,

1979, Mosby. 1 8. Soucacos PN, Beris AE. Toul iatos AS, et al: Current indi­ cations for single digit replantation, Acta Orthop Scand (suppl 264) 266: 12-15, 1995.

1 9. Chow SP, Ng C; Hand funCtion after digital amputation,

J Hand Surg [Br) 1 8:125, 1993. 20. Wei FC, el Gammal TA: Toe to hand transfer: current concepts, techniques, and research. C1in Plase Surg 23: I 03,

1 996.

CHAPTER

14

Bruce Greenfield, Marie A. Johanson, and Michael J. Wooden

Mobilization of the Upper Extremity

Joint mobilization has become an increasingly popular and

and MacConail,2 such as inrimate movements of roll, spin,

imporcanc physical therapy intervemion. As [ecendy as

glide, compression, and distraction. These movements occur

25

arlhrokinemalic) and

years ago, manipulation was a comroversial topic, considered

between the joint surfaces (hence the term

off-limits CO any practitioners other than chiropractors or osteo­

are necessary for normal, physiologic, or osteokinematic move­

paths. Thanks, however, co the dedication of many pioneers in

ment of bones. To illustrate, Basmajian and MacConaill described move­

chis field, peripheral and vertebral joim mobilization has

menr of a convex joinr surface on a concave surface (e.g., the

become standard fare in most physical therapy curricula. such reachers as

femur on the tibia). As the convex bone rolls in any direction,

Paris, Maidand. and Kalcenborn, themselves physical thera­

it mUSt simultaneously slide (minutely) in the opposite direc­

In particular rhe profession is indebted

[0

pists, as well as co such physicians as Mennell. Cyriax, and

tion on the concave bone to keep the tWO surfaces approxi­

share their knowledge. Their

mated. Conversely, when a concave bone surface moves on a

Stoddard, who were willing

[0

efforts have mushroomed inca such developmenrs as concinu­

convex one (e.g., the tibia on the femur), the glide of the

ing education courses, as well as graduate programs, residen­

concave surface will occur in the same direction.

cies, and fellowships in manual therapy and orthopaedics.

Mennell) elaborated on these arthrokinematic movements,

These programs have stimulated an increase in research, both

labeling them joint play: movemems that are small but precise,

basic and clinical. Indeed, incerest in joinc mobilization was

which cannot be reproduced by volumary muscle comrol, but

the main factor leading to creation of the American Physical

that are necessary for full, painless range of motion. Similarly,

Therapy Association's Orthopaedic Section, which has paved

Paris4 classified these movements as acceJJory

the way for specialization in physical therapy.

joint play or component. He stressed that these movements

mOtJemenlJ, either

occur nOt only during physiologic movement but also at end

An additional benefit has been the publication of some excellenc books dealing with assessmenr and rreatmenr includ­

range to protect the joint from external forces. The clinician

ing joint mobilization. Many are cited in the References and

assesses end-range joinr play by applying overpressure at end

Suggested Readings sections of this chapter and in Chapter

range to determine end-feel and the presence of pain. Kalten­

26.

born·s system' uses similar arthrokinematic principles.

The purpose of these cwo chapters is co summarize briefly the information contained in the various textbooks and co describe

The techniques described later in this chapter are primarily

the peripheral joinc techniques with which we have had the

based on accessory motion concepts and are primarily OSteo­ pathic techniques. The greater the congruency of a peripheral

most success.

joint is, the more likely it is that arrhrokinematic principles (based on the convex-concave principles) explain the effects of

GENERAL PRINCIPLES

the techniques. Joints that lack bony congruency, however, may not exhibit traditional arrhrokinematic principles, but

In general terms, mobilization is defined as rescoration of joinr

rather may be more influenced by changes in capsular tight­

motion, which can be accomplished by different forms of active

ness and direction of muscle forces. At the glenohumeral

or passive exercise or by such mechanical means as continuous

joint, for example, the head of the humerus glides in a supe­

passive motion (CPM) machines.1

rior direction during elevation of the humerus because of tightening of the inferior capsule and in a posterior direction

In the context or manual therapy, however, mobilization is passive range-of-motion exercise applied to the joint surfaces,

during external rocation because of tightening of the anterior

opposed to the physiologic, cardinal plane movement of the

capsule.6.7 However, techniques that "follow" arthrokinematic

as

joint as a whole. Passive movemenr of the joint surfaces requires

principles are often still used and may simply stretch portions

knowledge of arthrokinematics, first described by Basmajian

of the capsule via direct pressure of the humeral head. Alter-

329

330

Orthopaedic Physical Therapy

natively. acchrokinemacic principles used to determine rhe directIOn of glide based on the desired osrcokinematic move­

movement has been shown to rupture IIlfraanicular adhesions that form during immobilization.IH.l1

ment might nO[ always be assumed co be correct. For example, Johnson ec aLII demonscrated chat although both anterior and posterior

glides increased glenohumeral external rotation

Pain and Muscle Guarding

range of motion, a posterior glide (usually used (0 increase

Wyke21 has idemified receptor nerve endings in various peri­

physiologic glenohumeral internal rotation) increased external

articular scructures. These nerve endings have been shown to

rotarion more than rhe anterior glide for patient with adhesive

inAuence pain, proprioception, and muscle relaxation.

capsulare. Thus furcher ongoing research is needed to establish

Type I (postural) and type IJ (dynamic) mechanoreceptors

rhe directional effects of these techniques. However, where

are located in joint capsules. They have a low threshold and are

possible, rhe techniques described in chis chapter are linked

excited by repetitive movements including oscillations. Type

with

rhe

physiologic

movements

char

rhey

theoretically

III mechanoreceptors are found in joint capsules and extracap­ sular ligaments; they are similar to Golgi tendon organs In that

enhance.

they are excited by stretching and perhaps thrusting maneu­ vers. Pain receptors, or type IV nocice-prors, are found in cap­

THEORIES OF MOBILIZATION

sules,

ligaments, fat pads, and blood vessel walls. These

receptors are fired by noxious stimuit, as in trauma, and have In the periphery, mobilization is used either for its effect on

a relatively high threshold.

reducing Joint restrictions (mechanical) or co relIeve pain or

Pain impulses from (ype IV nociceprors are conducted

muscle guarding (neurophysiologic), This section reviews the

slowly. Impulses from type I and II mechanoreceprors are fast,

theoretic bases for each.

conducting at a much lower threshold. The differences between types I and II and type IV conductivity may explain why oscil­ lating a joint relieves pain. Theoretically, the faster mechanical

Joint Restrictions

impulses overwhelm the slower pain Impulses. Whether (his

Loss of range of motion can be caused by trauma or immobiliza­

is achieved by "closing the gate" or perhaps by release of endor­

tion or, most often, a combination of the two. Plccure a con­

phins

tracted elbow joim char has been immobilized for

6

[Q

8 weeks

"

in

the

Investigation. •

.2\

centraJ

nervous

system

IS

still

under

after a supracondylar fracture. Experience cells us chat chis

Muscle relaxation IS an additional benefit of passive move­

elbow, despite weeks of aggressive therapy, may never regain

ment. One theory is that causing type III joint receptors and

full mobility. Whac 3re rhe reasons for this? The effects of

Golgi tendon organs ro fire by stretching or thrusting a joint

U3uma and immobilization on joint-related structures are dis­

results in temporary inhibition or relaxation of muscles cross­

1. To summarize. rhe most signifl­

ing the joint.:?! This in Itself may cause an increase in range of

cussed in detail in Chapter

I cam range limiting effects are as follows: 9· H

I. Loss of extensibility of periarticular connective tissue Struc­

motion and helps prep.'Ue the joint for further stretchlllg and mobilization.

tures: ligaments, capsule, fascia, and tendons

2. Deposition of fibrofauy infiltrates acting as intraarticular "glue"

Application Many schools of thought exist regarding the hands-on approach

3. Adaptive shortening of muscles 4. Breakdown of articular ca.rtilage

to manual therapy. Mobilization can be applied with OSteo­

All of these effects could contribute to abnormal limitation of movement and must be dealt with in treatment.

pathic articulations, distraction of jOlOt surfaces, oscillations, scretching, and thrust manipulations. When using stretching

Muscle has been shown to be an incredibly plastic tissue,

and oscillations, the authors favor those techniques (hat stress

with the ability to regenerate and return to normal length even

accessory motion based on arthrokinematics. These are primar­

after prolonged immobilization. H.U However, little research

ily glides, distractions, and capsular stretches. Except for gende

has been conducted to show the direCt effects of mobilization

stretching, one should avoid mobilizing, especially thrusting,

techniques per se on immobilized connective tissue. Research­

in physiologic movements. Ultimately. which techniques are

ers have demonstrated that passive movement does seem to

chosen should not matter as long as the therapist is well trained

maintain distance, lubncatlon, and mobility between collagen I fibers. U.ll During the healing of traumatized connective tissue,

should follow Paris' four simple but critical rules before

passive movement restOres the ability of collagen fibers to glide I on one another as scar tissue matures. S Stress to this healing connective tissue, applied as early as

3 weeks but no later than

3 to 4 months after injury, appears to reduce the formation of

. cross-links between and within collagen fibers!6 P Therefore

the scar is allowed to lengthen in the direction of the stress

and follows a few guidelines. Most Importantly, {he therapist mobilizing:

1. Identify the location and direction of the limitation (e.g., In a stiff ankle, is it posterior glide of the talus (hac is restClcted?).

2. Prepare the soft {issues (i.e., decrease swelling, pain, muscle guarding or tightness).

applied as its tensile strength increases. Thus the development

3. Protect neighboring hypermobilities. This IS particularly

of 10lOt COntracture is reduced,,6.P FinaJiy, forceful passive

Important in spinal mobilization but could apply, for

Chapter 14 Mobilization of the Upper Extremity

331

example, co a shoulder dislocation chat has resulted in anre­

res[ricted joim. The reader should nme [har

rior capsule laxity. In mobiliziOg (0 increase abduction and

end range (limi[ed) will gradually approach end range (normal)

roeation, one would wane [0 avoid anterior glide or other

as trea[ment progresses. Often a restricted Joint is also painful,

maneuvers that would $Cress the anrerior capsule.

and the therapist must decide whether to treat the pain or the

10

[he laner, rhe

stiffness. One advamage of [he MaHland sys[em IS [hac grades

A fourth rule, really an extension of the previous three, applies to postsurgical cases.

of movemem provide the tools for either form of therapy.

4. Communicate with the surgeon. Find out which tissues

To generalize, grades I and II oscillation are used for pain;

have been cut or sacri6ced and what motions co avoid at

grades HI, IV, and V are for stiffness. The therapist must now

leaS[ initially.

decide when to use [hem.

Mairland'sH description of the grades of joint movement has been a major conrriburion to manua] therapy. He uses oscilla­

Mobilization With Movement

tory movementS of different ampiicudes applied at dif(erenr parts of the range of motion, either accessory or physiologic.

Mulliganl) has imroduced joim mobilization [echniques he

Grade I oscillations 3ce of very small amplicude at the begin­

classified as

ning of the range. whereas grade II oscillations are large-ampli­

niques combine traditional sustained passive accessory motion

mobllizallon with m()l'tmenr (MWM). These [ech·

tude oscillations from near [he beginning [0 midrange. No

[echniques based on ar[hrokinematics wirh accive or passive

tissue resistance is encountered with grade I or II movements,

physiologic movements. Mulligan's theory IS thac adaptIve

[hey do not '·mobilize" to increase range. However, they do

shortening does not always explain painful and restricted active

reduce pain and induce relaxation [hrough the mechanoreceptor

movements. He believes that minor positional faults often

so

mechanisms already described. The accual mobilization move­

resul[ in painfully resericced ac[ive movements; JO [hese cases

ments, rhose [hat are [aken into tissue resistance, are grades III,

he asser[s that repositioning, rather than increasing extensibJ!·

IV, and V. A grade III movement uses large amplitudes from

ity of capsular and ligamentous structures, is the key to restora·

mid- to end range, hitting at end range rather abruptly. A grade

tion of normal physiologic morions, MWM telhniques are only

IV movement also goes [0 end range but is of very small ampli­

performed when [he technique is pamless and can be followed

rude. Because they may be less painful and less likely to trau­

by [aping [echniques or self-admmisrered MWM techniques

ma[ize a joint, grade IV movements should be used before grade

[0 maintain [he positional correceion.1'

Ills, the latter being more useful as the joint becomes less acute.

Although several case reportS document good outcomes

A grade V movement is a small-amplicude [hrust beyond end

using MWM techniques,26 few clinical tri.Lis compare these

range, a so-called. manipulation.

techniques with traditional accessory techniques. other inter­

14-1, A, depIcts Maidand's grades of movemem JO a normal joim. Figure 14-1, B, shows movemems applied to a

ventions, or control groups. However, these clinical erials nre

Figure

If·

beginning to appear in [he li[eracure. Yang et al. ,� compared

Small amplitude

Large amplitude

Beginning-range

End-range

(To resistance)

(No resistance)

Beginningrange

I

..

•

II

;. N

Large amplitude

-Il

End-range (normal)

Small amplitude

Mid-range

End-range

(No resistance)

(To resistance)

A Small amplitude

"

End-range

(No resistance)

Beginning­ range

B Figure 14-1 Grades of movement. A,

II

Large amplitude

Beginning-range

(To resistance) •

II

11 Large amplitude

I

Edinburgh, 2005, Butterworth-Heinemann.)

Mid-range

(No resistance)

•

I

:

End-range (limited)

I

End-range (normal)

332

Orthopaedic Physiall Therapy

the effects of a MWM technique (see Figure 14- 16) co accessory

Subjective responses can be reinforced by assessing objec·

glides of the humeral head in midrange and at end range

tively the level of reactivity." By carefully taking the joim

among puciems with adhesive capsuliris on shoulder active

through its passive range, the therapist monitOrs the sequence

range of motion (AROM) and scapulohumeral rhythm. The

of pain versus resistance. I If the patient reports pain before

MWM technique and the accessory glides at end range boch

tissue resistance (nor muscle guarding) is felr by the therapist,

improved aCCive shoulder elevation, aaive external roracion,

then the joint is highly reactive and, theoretically, is in an acute

active internal roeation, and scapulohumeral rhythm compared

inflammatory stage. Therefore the joint should remain pro­

with the accessory glides performed in midrange. Additionally,

tected and splinted. If necessary, then the therapist can apply

rhe MWM techniques showed greater improvement in scapu­

grade I oscillations ro reduce pain.

lohumeral rhythm chan rhe accessory glides performed at end

Moderate reactivity is assumed when pain and tissue resis·

range. Paungmali et al.18 compared a MWM technique (see

tance are simultaneous. The joint injury is now subacute,

Figure 14-26) to a sham technique and a control condition on

perhaps indicating that fibroplasia and early scar formation are

pain-free grip strength for patients with lateral epICondylitis.

underway. The patient will rolerare careful active range-of­

These

investigators

reported

that

the

MWM

technique

motion exercises, as well as grade 1 and 11 oscillations to

IV) should

increased pain-free grip force compared with the sham tech­

decrease pain. Actual mobilization (grades III and

nique and control. At the lower extremity, a MWM technique

be delayed. however, to avoid disturbing the immature scar.

performed during weight bearing or nonweight bearing (see

If significant tissue resistance is felt before (or in the absence

Figure 28-26) improved posterior ralar glide compared with a

of) pain, low reactivity is assumed. By now the collagen matrix

control group receiVing no intervention among patients with

has matured, and mobilization IS needed to stress and remodel the scar. At this time grade Ill, IV, and V movements are

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t O l . Faries MD. Greenwood M : Core training: stabilizing rhe

siccing on stable and unstable surfaces , J Orchep Spons

L05. Koumamakis GA, Warson Pj . OldhamJA: Trunk muscle

1 00. \'(Iil lardson JM: COfe stability training: applications to spores conditioning programs, J

373

Cond

Res

29(2): 10-25,

2007.

102. Marshal PW, Murphy BA: Increased delroid and abdomi­ nal muscle activity during Swiss ball bench press, J Srrengrh Cond Res 20(4):745-750, 2006.

2005. 1 06. Eksrrom RA, Donarel l i RA, Carp KC: Elecrromyo­ graphic analysis of core trunk, hip, and thigh muscles during nine rehabilitation exercises, J Orehop Spores Phys Ther 37( 1 2):754-762, 2007 .

1 07 . Bolgia LA, Malone TR, Umberger B R , et al: Elecrromyo­

103. Burcher SJ , Craven BR, Chilibeck PO, er al: The effecr

graphic analysis of hip rehabi litation exercises in a group

of crunk stability training on venica! cakeoff velocity, J

of healrhy subjecrs, J Orrhop Spores Phys Ther 35:487-

Orrhop Sporrs Phys Ther 37(5):223-2 3 1 , 2007.

494, 2005.

L04. O'Sullivan PO, Dankaerts WI, Burnett A, er al: Lumbo­ pelvic kinematics and trunk muscle activity during

APPE N D I X

15 - 1 Trunk and Hip Core Evaluation Sheet

History/Pain Provocation:

Observation Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date: Anterior pelvic tilt Posterior pelvic tile Iliac crest asymmetry Feet together Feet apart Genu recurvarum Genu valgus Single-leg squat Drop-jump screening Gait

Trunk Motion (Note motion, peripheralization and/or centralization)

Flexion Extension Right-side bending Left-side bending Knees

(0

chest

Prone prop extension

Trunk Special Tests

Slump test Single-leg raise Prone instability Facet scour Sacroiliac joint Distraction Thigh thrust Gaenslen's rest Compression Sacral thrust

374

APPENDIX 15-1

Trunk and Hip Core Evaluation Sheet

375

History/Pain Provocation:-cont'd Hip Motion

Date:

Date:

R

L

Date: L

R

R

Date: L

R

L

Flexion Extension Abduction Adduction Imernal and external rotucion sitting Internal and exrernal rmurion prone Thomas (est Ober's test Craig's rest

Trunk Slabilization

Dale:

Date:

Date:

Date:

Transverse abdomtnus drawing in Mulufidus palpation

R

R

L

L

R

L

R

L

Active single-leg raise Leg-loading [est Bird dog Side bridge

Normal Ranges Right

M = 95

lef,

M = 99 sec, F = 78

sec,

F= 75

sec, sec,

M/F = 83

sec

M/F = 86 sec

Abdominal bracing Normal Ranges

M = 1 36 sec, F

=

134 sec, M/F

160 sec, F

=

IS)

=

134 sec

Sack extensor test Normal Ranges

M

=

sec,

M/F = 1 7 3 sec

HIP Mobilizer Testing

Leg Drop Test (Abduction and extension for posterior fibers of gluteus medius) Date: R

Date: L

R

Date:

Date: L

R

L

R

L

Unable to hold Unable [0 resist

Manual Muscle Testing (MMT) Date:

Date: R AlxIuction Adduction Extension Flexion Internal rotation sitting External rotation simng

L

R

Dale: L

R

Dale: L

R

L

376

Orthopaedic Physical Therapy

History/Pain Provocation:-cont'd Power and Agility Testing Date:

Date:

Date:

Date:

T-cesc Shuttle run Backward overhead tOSS

R Vertical jump Six-pound rotational throw Six-meter hop for time Single-leg hop test for distance Tri ple hop for distance Triple-crossover hop

l

R

l

R

l

R

l

PAR T

3

LOWER QUARTER

CHAPTER

16

Wendy J. Hurd and Lynn Snyder-Mackler

Neuromuscular Training*

PROPRIOCEPTION

This chapter will begin by discussing [he importance of pro� prioceprion in rhe lower limb and upper limb, rhen rhe com­ ponents of rhe sensorimotOr system, and rhe role of rhe

Why can one baseball pitcher exhibit excessive glenohumeral

sensorimoco( system in neuromuscular control. It will define

motion yet never experience injury, where-dS another pitcher

poscural control and describe how postural control is achieved

with the same glenohumeral motion require surgery to throw

in stance and gait and idenrify techniques used for assessmenr

effectively without pain? Why does one athlete experience a

of neuromuscular function. Ir will then discuss rhe various

single-episode laceral ankle sprain but the next athlere develop

effeCts an injury may have on neuromuscular funnion and

chronic ankle instability? The answer to both questions is mOSt

summarize rhe purpose(s) and components of a neuromuscular

commonly proprioception. For the healthy athlete, high levels of

training program.

proprioception can contribute ro enhanced neuromuscular

Neuromuscular concrol involves rhe subconscious integra­

concrol and functional joint stability, rhus decreasing the risk

rion of sensory information that is processed by rhe cemral

for injury. For the injured athlete , restoration of proprioception

nervous system (eNS), resulcing in controlled movement

is critical ro ward off repetitive injury (Figure

through coordinated muscle activity. I Dynamic joint stabilicy

proprioceptive training plays a key role for the athlece in both

and postural control are the result of coordinated muscle acciv­

injury prevencion and rehabilitarion.

ity achieved through neuromuscular control. Any injury that

\6-1). Therefore

Proprioception may be inferred from Sherringcon's

1906

disruptS the mechanoreceptors. alcers normal sensory input, or

descriprion of the "propriocepcive-system" as the afferenc infor­

interferes wich the processing of sensory information may result

macion from proprioceptors (e.g., mechanorecepcors) located in

in altered (also referred to as decreased or dysfunctional) neuro­

the proprioceprive field that coneributes to conscious sensa­

muscular control. Consequently, impairments of the neuro­

tions, tOtal posrure, and segmeneal l){)srure.2.} Proprioception

muscular system often resulc in dysfunctional dynamic joint

is a product of sensory information gathered by mechanorecep­

stabilicy and postural COntrol. Neuromuscular control impair­

tors.1 This definition views proprioception primarily as a

mentS can also change movement paccerns and increase the risk

sensory activity. More recendy, amhors have expanded the defi­

for musculoskeletal injury. Conversely, musculoskeletal injury,

nition of the proprioceptive system co include the complex

by disrupting the interactions within the neuromuscular

ineeraction between the sensory pathways and the motor

system, can be a cause of altered neuromuscular concrol. The

pathway (efferent system).4 One assumption underlying both

authors believe an understanding of the neuromuscular concrol

definitions of proprioception is that incoming sensory informa­

system and the funccional manifescacions of neuromuscular

tion processed by the CNS has nOt been compromised. In the

control are fundamental to designing effective rreatmenc pro­

presence of an injury char disrupts mechanoreceptor input,

grams and meaningful research studies related to dynamic joint

proprioceptive funcrion will be compromised and may lead ro

stability.

movement dysfunction. Over che years many terms have been used either synony­ mously with proprioception or to describe proprioception

·This chapu:r is reprinted from Hurd WJ. Snyder-Mackler L: Neuromuscular

including kinesthesia, joillf position sum. joi1Jl stability, and

[raming. In Donatelli R: Sports-specific rehabilitation, Sr Louis, 2007,

pol/llral (on/rol. Kinesthesia and joine position sense may both

Churchill Livingstone.

377

378

Orthopaedic Physical Therapy

receptor ideally suited for sensing the extremes of the joim's

Ligamentous injury

normal movement range. II The Golgi and Ruffini's endings

belong to a group called spray tndingJ. Collectively, these mech­ Proprioceptive deficits

anoreceptors represent a vircually continuous morphological spectrum of receptors. 11 Whether the spray endings should be divided into distinct receptor types has not been resolved. Pacini's corpuscles are the only rapidly adapting jOlm recep­ tor. Sensitive to low levels of mechanical Stress, the pacinian

Decreased neuromuscular control Figure 16-1 Functional stability paradigm depiding the progression of functional instability because of the interadion between mechani­ cal stability and decreased neuromuscular control. (From lephart 5, Reimann B. Fu F: Proprioception and neuromuscular conlrol in joint stability, Champaign, III, 2000, Human Kinetics.)

corpuscle is active only during dynamic joint scates. Therefore this receptOr is silent during static conditions and conscam velociry situations but is sensitive to joint acceleration and

deceleration. I\

Free nerve endings constitute the fourth type of Joint recep­ tor. Free nerve endings are widely distributed throughout most joint structures. These receptors are typically inactive during normal activities, but when activated by high levels of noxious stimuli they are slow to adapt during both static and dynamic states.

be viewed as submodalities of proprioception.' Kinesthesia refers ro rhe sensation of joint movement (both active and

Cutaneous Receptors

passive), whereas joint position sense refers co rhe sensation of

The CNS processes sensory information from curaneous (skin)

joint position.3 Joint stabiliry is accomplished rhrough both

receptors in conjunction with joint and muscle receptors. The

passive (osseous congruity and ligamentous restraints) and

role of cutaneous receptors in 100tiating refleXive responses,

mechanisms.

such as the flexion withdrawal reflex in response to potentially

Dynamic joinc stability is the result of neuromuscular concrol

harmful stimuli, is well established:' Cutaneous receptors may

dynamic

(coordinated

muscle

conrranions)

and proprioception, whereas postural concrol is the resule of

also signal information regarding jOint position and kinesthesia

integrated visual, vestibular, and proprioceptive inputs.',6 Con­

when the skin is stretched.I1·,(, However, no evidence mdicates

sequently, any disruption in mechanoreceptor inpur that affects

that these receptors contribute significantly

proprioception will negatively affect dynamic joint stability

sationsP or thar cutaneous receptors comribure ro joint M stability. 1

and posture.

SENSORIMOTOR SYSTEM The sensory organs in the neuromuscular system are referred to as mecha'loreceptorJ, Sensitive to various forms of mechanical

[0

these sen­

Muscle Receptors The muscle spindle and the GTO are the two primary types of muscle receptors. I' The muscle spmdle lies 10 parallel with extrafusal muscle fibers and has three main components: (1)

deformation including tension, compression, and loading rate,

inrrafusal muscle fibers, (2) sensory axons thar wrap around [he

these small sensors are located in various connective tissues

intrafusal fibers and project afferent information to rhe CNS

throughour the body. The three classifications of mechanore­

when stimulated, and (3) motor axons that innervate the Intra­

ceptors are based on tissue location: joint receptOrs, cutaneous

fusal fibers and regulate the sensitivity of the muscle spindle

(skin) receptors, and muscle receptors.

(Figure 16_2):·.,,'9,lO The primary sensory axons from the spindle make monosynaptic connections with alpha momr

Joint Receptors Ruffini's receptor endings are described as slowly adapting

neurons in the ventral roots of the spinal cord that, in turn, innervate the muscle where the muscle spindle is located.'

Collectively, this feedback loop IS called rhe 11IIIJrlt Jtrtl(h rif/tx, I)

mechanoreceptors because they continue their discharge in

Although extrafusal muscle fibers comprise the bulk of the

response to a continuous stimulus.7 These receptors have a low

muscle responsible for generating force and are innervated by

activation threshold and are active during both static and

alpha mOtor neurons, intrafusal fibers are composed of a small

dynamic joint conditions. Consequently, Ruffini's endings may

bundle of modified muscle fibers chat function to provide feed­ back to the CNS and are innervated by gamma motoneurons.21

signal static joint position, incraarcicular pressure, and ampli­ tude and velocity of joint cotacions.7.IO Golgi tendon organ (GTOHike receptors are the largest of the articular mechanoreceptors. They are also slow to adapt to

Sensirivity of the muscle spindle is continually modulated by the gamma motor system. This allows the splOdle co be fune­ rional ac all rimes during a comraction21 and modulate muscle

stimuli, have a high activation threshold, and are active only

length.l1 n24 Sensory output from the muscle spindle is trig­ ..

during dynamic joint states. Some researchers have suggested

gered at low thresholds, is slowly adapting, and senses jOlOt

that the high threshold of the GTO-like ending makes this

posicion throughout the range of motion.I

).20

379

Chapter 16 Neuromuscular Training

Static nuclear

Dynamic nuclear

Inlrafusal

bag fiber

bag fiber

muscle fibers

Dynamic gamma molor axon

Capsule

Nuclear

Static gamma motor axon Afferent

Afferent

axons

axons

-l-l-l..!-l'li'l.1

-chain fibers

[I.:���m ) Primary ending II } Secondary ending

Efferent axons

Molor endings Figure 16-2 A, Gross structure, B, St ru cture and inner­ vation of the intrafusal fibers of the muscle spindle.

(From Willia ms

�

lmm

A

GN,

Chmielewski Tl, Rud o lph KS,

et al: Oynamic knee stability: currenl t heory and impli­

B

cations for clinicians and sc ientists,

J Orthop Sports

Phys Ther 31 (10):546-566, 200 I.)

The GTO is located at the musculocendinous juncrion and

is positioned in series with exrrafusai muscle fibers and rcndon.

A single axon enters rhe GTO and rhen branches inco many unmyelinated endings char are woven in and between rhe col­

lagen fibers at rhe musculotendinolls junction. Thus during a

Table

16-1

Motor Response Intervals

Motor Response Type

Level of Mediation

Able to be Modified

Spinal reflexes

Segmenral level of

No

muscle contraction rhe tendon is screeched, straightening rhe collagen fibers and distOrting the recepeor endings of rhe GTO afferent neurons.l� Increased activity of the GTO afferems results in inhibition of the moror neurons innervating the

muscles that were srretched while exciting the motOr nerves of the amagonistic muscles. This feedback loop is often referred co fO

as

rhe inverse lfI),olatic ref/ex. Because each organ is connected

a small number of muscle fibers and can respond to low

,evels of force (as little as

spinal Long-loop reflexes

c ord

Brainstem and

No

ce rebell um Triggered reactions

Cortical centers

Yes

Voluntary reactions

Cortical

ceorers

Yes

From Hurd W), Snyder-Mackler L: Neuromuscular [minmg. In Donau�1li

Sporrs-specific

R:

rehabilitation. St Louis, 2007, Churchill Livingstone.

0.1 g),12 the GTO can provide the

eNS with specific force feedback.22-2-1 menrous failure, yet is nor considered modifiable through

Motor Response Pathways

training to aid in dynamic joint srability.;P,lll

Sensory information gathered by mechanoreceprors is sent to

lum is typically referred to as a IOllg-loop

tbe spinal cord via afferent pathways for processins and

sensory information travels a greater distance before being pro­

bltimately results in a regulation of reflexes and muscle

cessed, these responses are typicaJly longer than spinal reAexes.

Sensory information mediated at the brainsrem and cerebel­

reflex. !-.l,)

Because

�Ctivity. In addition to being influenced by incoming affer­

However, because these pathways are multisynaptic with

ent information, the resulting motor response also depends

potentially more sources of sensory inpur, long-loop reflexes are

on the level of processing of afferent inputs within the eNS.

Aexible and may adapt when feed-forward informacion is pro­

�he processing can occur at three differem levels: the spinal

vided to the sys(em.2�,2H,W As a result of boch the adaptability

cord, the brainstem and cerebellum, and the cerebral cortex

and the relative quickness with which they occur, these path­

rable

�

16-1).

ways are thought

Spinal reflexes represent the shortest neuronal pathways and

(0

be important in the maintenance of

dynamic joinr stability,1,,,

onsequently the most rapid responses co afferem stimuli.

Both voluntary reaCtions and triggered reactions are pro­

hese responses are typically uniform in nacure and modified

cessed at the cortical level of the brain and represent the longes(

y the intensity of the afferem signals. n Spinal reflexes ranse from simple monosynaptic reflexes co complex multisynaptic

circuics

resulting

in

coordinated

activity

of

groups

of

Fuscles.I},IU6 The speed of spinal reflexes is faster than liga-

motOr response times. Voluntary reactions involve the pro­ .. 17,�8.32 In

cessins of multiple variables and are highly Aexible contrast.

"triggered"

reactions

represent

preprogrammed,

coordinated reactions that occur in response to afferent stimuli

380

Orthopaedic Physical Therapy

chac trigger chern inco action.'·18 One example of a triggered reaction has been termed the wine g/asJ ef/ect18: When one holds

degrees of freedom problem is based on the concept of motor programs (a set of commands that are prestcuctured at higher

an expensive wine glass, one instinccively tightens the grip on

brain centers and define the essenrial details of a skilled action).

it if the glass begins

The most recent update ro this theory, PUt forth by Schmidt

[Q

slip. The cutaneous message chat the

object is slipping comes from the fingercips. but the muscle

and Lee/8 contends that features that do not vary among dif­

response to increase grip pressure comes from the forearm.

ferent skills-the relative timing, force, or sequence of compo­

In chis case the reaction occurs quickly, is probably not

nents-are stored in memory as motOr programs, whereas the

conscious in nacure, and appears to have the overall purpose of reorganizing the system slightly to complete an action success­

parameters that do vary (e.g., speed, duration) are specified according to the task at hand. These programs are under central

fully. Because of their pceprogrammed "aCUfe, triggered reac­

conrrol and are generally not dependent on feedback from the

tions occur slightly more quickly than voluntary reactions but

periphery.28 Feedback is, however. used to select rhe appropri­

may be unable co accommodate co circumstances in atypical

ate mOtor program, monitOr whether the movement is in

situations. I

keeping with the program, and reflexively modulate the move­

ment when necessary.27,28

The idea of a central pattern generator is similar in concept

POSTURAL CONTROL Poscural control involves controlling the body's poslrlon in

to a motor program. These conrrol mechanisms located in the spinal cord produce mainly generically defined, repetitive actions, such as gait.}7 The concept of the central pattern gen­

space for the dual purposes of stability (balance) and orientation

erator is supported by animal studies including spinalized

(maintaining an appropriate relationship between the body

models, which have shown that the rhythmic pattern of gair

segments and between the body and the environment for a task).6.H The postural control system uses complex processes

descending control from the brain.}8.4() Central pattern genera­

involving both sensory and motor components and results from

tors may be turned on or off by a variety of srimuli, alrhough

can continue in the absence of feedback from the limbs or

the combined integration of visual, vestibular, and propriocep­

they are primarily stimulated or inhibited by signals originat.

tive afferent inputs.M The combined effort of these sensory

ing in the brainsrem. J9-41 Although gait is centrally conrrolled

modalities Lays the framework for dynamic balance (stability).

at the lower brain and spinal cord level, descending influences

If feedback from any one of these modalities is impaired, then postural stability suffers.I

from higher brain centers including the cerebellum, visual cortex, hippocampus, and fromal cortex, along with peripheral

gies that result from different types of perturbations applied

sensory input, permit effective gait even when unexpected changes in the environment are encounrered.6 .l7.18 Thus gait is

during stance. Typically, if forward sway is induced as a result

conrrolled through the complex imeraction of cemral patrern

of a posterior horizontal perturbation, then muscles on the

generators, descending input from higher brain cemers, and

Investigators have identified several poscural control strate­

posterior aspeCt of the body are recruited.� Conversely, if back­

feedback from peripheral sensory receptors. Through this

ward sway is induced from an anterior horizontal perturbation,

complex interaction and similar processes that occur with other

then muscles on the anterior aspeCt of the body are recruited.}4 Additionally, small perturbations applied during standing

moror programs, the neuromuscular system acts to maintain joim stability during dynamic sicuations.'

result in sway at the ankle joint; this is called an ankle Jlrategy. n On the other hand, large perturbations result in large move­ mentS at the hip; this is called a hip strateg)', )) The hip strategy is also implemented when the individual cannot generate enough force with the ankle strategy. A third strategy, called

ASSESSMENT OF NEUROMUSCULAR FUNCTION

the stepping straltgy. is implemented when the perturbation

After injury, assessment of neuromuscular function is neces­

displaces the center of mass outside the individual's base of

sary to determine if impairments are present, aid in the devel�

support.6 PoscuraJ control strategies can be modified and are

opmem of an appropriate trearment intervention, and assess

adaptive co the circumstances of the moment; however, in the

the effectiveness of the intervention.' Various analysis tech·

absence of other instructions, they are predicrable.6 Evidence

niques are available for testing neurosensory components (e.g.,

suggests that a person's expectations of impending percurba­

kinesthesia) and neuromuscular performance (e.g., biomechan·

dons and training can have a significant effect on the magni­

ical gait analysis). Readily available clinical assessment tech·

tude and variability of the responses.6 These POStural control

niques include joint position testing; observational analysis�

strategies provide stability in stance and therefore are appli­

functional testing, such as hop testing; and threshold to

cable co the maintenance of joint stability in the lower extrem­

detection of passive motion (TID PM) testing. Stabilomec

ity during stance. I

The motOr skills that people perform daily, including

walking, pose a complicated problem for the neuromuscular

and strength testing are common clinical assessment tech­ niques that are performed with the aid of commercially avail� able equipment.

system because many muscles crossing multiple joints must be

Other techniques for identifying neuromuscular comrol

coordinated to prcxluce a given outcome. Bernstein* called this

deficits include kinetic and kinemaric evaluation with motion

the degrees of IrmJom problem. One theory for controlling the

analysis, force plates, and electromyography. These measurts

382

Orthopaedic Physical Therapy

o

hallmark of the noncoper is reduced knee motion and reduced

-...- Involved

internal knee extension moment during weight acceptance,

� Uninvolved

Coper

then the potencial copers appear to be incermediate to noncop­

-5

ers and uninjured subjects.H Before training, potential copers

(i)-10 " � -15

stiffen their knees with significantly higher muscle coconcrac­

'"

tion and slightly lower peak knee Aexion angles. These altered

E -20

1= -3.1 (+/- 1.2) U=-3.1 (+/- 1.1)

�-25

movemenc patterns indicate an undeveloped knee stabilization

t

.:i -30

1=-22.8 (+/- 1.9) U= -24.5 (+/- 1.8) ������-"

-35 -40

o

20

60

40

80

100

% Stance

strategy. After perturbation training, potencial copers can increase knee Aexion during weight acceptance and reduce the level of muscle coconrraction; they became more similar to uninjured subjects.H An increase in knee Aexion after training in conjunction with a decrease in rigid muscle cocontraction indicates the adoption of a movement panern that is consistent with clinical findings of improved dynamic knee stability.

Non-Coper

o

NEUROMUSCULAR TRAINING PROGRAMS Like the injury research, studies assessing the effectiveness of •• p ----..-

•p

20


r1y understood and controversial without a spe­

billion annually

vergent neurons. Referred pain occurs from misperception of

10

cific cause (i.e., nonspecific LSP), A significant proportion of

the origin of the signal from the common-convergent sensory

LBP IS of mechanical origin and related to clinical splOal insta­

parhway co the brain.

bility.19 Often If is idencificd clinically without regard to avail­ able biomechanical or motor control issues and diagnostic (echnlques, In many Inseances, inseabllity itself has become a diagnostic encity.

R"dimlay Pal" Radicular pain arises from irriration of a spinal nerve or its roots and often associates with radiculoparhy. The p.1in does

Low-Back Pain

nOt associate With compression of nerve rOOtS because nerve root compression does nor evoke nociceptive acrivity. Radicular

The causes of LBP are poorly understood, diagnosed. and

pain often presents as shooting pain, whereas somatic referred

(reated. Many rradltional treaements have proven unsacisfac­

pain is constant in posicion bur poorly localized and diffuse. Ir

tory, and new treatments are often implemented without clini­

is perceived as an aching sensation In a lower limb (nor rhe

cal evidence.

back). Radiculopathy refers to a neurologic condition In which

Definitions

conduction blocks in the axons of spinal nerves or rOOtS produce numbness in the sensory axons andlor weakness in the motOr

The International Association for the Study of Pain (lASP)

axons. Radiculopathy can be caused by compression or isch­

taxonomy defines pain in c1lOical terms and sets criteria for the

emia of affected axons,ll

396

Orthopaedic PhYSical Therapy "strained" muscle. When animal muscle is forcibly stre[Ched

Sources of Low-Back Pain

against conrrJ.ction, they charaCteristically fad at the myoten­

Skeleral, muscular, and neurologic sources help explalfl rhe

dinous Junction. \� This presumably could be a cause of LBP

causes of LBP (Table 1 7-3). Some have a sound [heareeical

after lateral fleXIOn or combined flexion-roca(lon Injuries; it can

basis. whereas ochers do noc. Each of rhe proposed sources (or

be associaroo wirh tenderness near rhe myotendinous Junctions

causes) of pain Include only those that meet one or all of the

of the affected muscles, but confirming data with magnetic

follOWing four crlU�rlJ.-t:

resonance Imaging (MRI) have nor been published.

1. The srruccure requires a nerve supply (withom nerve inner­ vaeions (here: would be no pain).

2. The srfucrure needs co cause pam Similar ro whac is seen chniCillly. This should be demonstrated in normal volun­

Spasm The muscle spasm notion of pain impIJes that some posrural

reers (clinical studies Introduce observer bias or poor parieor

or movemenr abnormality (or malalignmenr) makes muscle

n:llJbillry).

more chrOnically active and therefore painful. The exact physi­

". The structure should be susceptible to disease or injuries

ologic condition of spasm. particularly in the lumbar region,

chat are known co be pamful (cercain conditions may nO[ be

is difficult to duplicate reliably with or without [onic concrac­

cler('ccable because of poor techniques).

tions, Ischemia. or hyperflexion.

I. The st[unure needs be a source of pain In patients and should be evaluated using diagnostic techniques with known reliability and validity (large inwundlvidual vari­

Imbalance

ability !>omerimes inhibits estimates of true prevalence).

The clinical derection of muscle imbalance with resulting pain

Attractive explanations andlor sources of LBP in terms of

comes from observations of an imbalance berween posruraJ and

rrearmenr (re,g.trdless of actual c.luse) include sprains, spasms,

phasiC muscles, berween trunk extensors and psoas major, or

imbalances, and rrig,ger poinrs.

between trunk flexors and hip extensors. Surprisingly, such observations have not been validated, and normative data have

Strains

not been established. No studies have established how an Imbalance [riggers pain, or idencificd any structures involved.

Dam confirming that strained back muscles commonly cause

Ilowever, it has been suggesced (hac weak back muscles are

LBP are suspect and not Impressive. U Little eVidence shows

compensated by tight chest muscles. resulting In increased risk

rhat

of nerve impingement.

sustained

exertion

or

sudden

stretching produces

a

,Various Proposed Sources and Causes of Back Pain

Structure or Cause

Innervated

Pain in Normal Volunteers

Pathologic Condition Known

Prevalence Identified in Patients

Acute LBP

Chronic LBP

Vt.,rtcbral bodies

Yes

No

Yes

Yes

RMC

Rue

Kis£ln� splm:£

Yes

No

Presumed

Yes

Unknown

Unknown

Lamma ImpJuion

Yes

No

Presumed

No

Unknown

Unknown

Sponu}'lolysis

Yes

No

Yes

Yes

In advance of pred ierable chal­

clinical instability that included biomechanical parameters,

lenges to srability (planned bodily movements) .lnd coordinate

neurologic damage, and anticipated spinal

responses to afferent feedback from unpredierable challenges

loading (Table

17-4). Each item on the checklist associates with a point value,

(unforeseen

and a total score of 5 or higher ind icates presence of clinical

movement]).

lumbar spine instability. A model of the spinal stabilizing system shown i n Figure 1 7-9

t.

body

perturbations

[i.e.,

misstep.

awkward

Under this system, the neural subsystem must be able to activate muscles with the correer timing. ampli tude, and

consists of three subsystems:7

sequencing to maintain successful core stability

Spinal column that provides intrinsic (passive) stability

dynamic situations. A sufficient deficit or system failure

2. Spinal muscles, surrounding the spinal column, that provide dynamic (accive) stability

3. Neural control unit that evaluates and determines the requi rements for stability while simul taneously coordinat­

static and 10

any

of the subsystems would cause rhe whole system to malfunc­ tion, resu lting in overcompensation, underperformance or dys­ function, and pain. Because the active muscle subsystem modulares spine

ing the active, muscular response

srability, this system

Under normal condinons, the three subsystems work i n

Muscles provide mechanical stability

harmony. The passive struCtures o f t h e spine and pelvis (i.e.,

10

is most susceptible to dysfunction. 10

the same manner

as

rhe load-carrying capacity of uptight. slender columns. first

the core) contribute to control of all elements of spinal stabil­

described by Swiss mathematician Leonhard Euler in 1 744:H

Ity. The passive subsystem incorporates bones, joint structures,

The greatest mathematician of rhe eighteenth century. Euler

and spinal ligaments that control movement and stabil ity,

calculated the critical load a column could SUStain, defining it

particularly toward the end of the range of motion. The active

as rhe minimum weight placed on rhe rop of the column that

subsystem refers to the force and tension-generating capacity

would cause buckling. In other words, the ctlucal load of a

of muscles that provide mechanical ability to stabilize the spine

column directly relates to the column's sriffness. The thickest

in the upright posture. Various components of the spinal

(or stiffer) column has the greater critical minimum load and

column generate Input information about rhe spinal position,

IS a more stable column; the thlOnest column (With lower stiff-

Chapter 17 The Lumbopelvlc System ness) experiences morc column buckles at the same cricical

399

from disuse also could produce pain, as could increased adap­ tive stiffening of the spinal column over rime that forms

load. The cricical load for the lumbar spine column is about 90 N

osreophytes.

(neweons) « 20 Ib),6 chac is smaller than measured in vivo spinal loads of 1500 N or grearer.19 The ability for rhe spinal column [Q not buckle (based on rhe differences between [he i n vitro and in vivo loads) can only be explained i f rhe spinal muscles act as guy wires (see Figure

17-6)

(0

stiffen rhe spine

and thereby increase its critical load potencial.

Redcord: Applications of Suspension Exercise to Core Strengthening and Lumbopelvic Dysfunction Developed in Norway in 1 99 1 , the Redcord apparatus provides

The previous model was validated by Cholewicki and

for suspension exercises that introduce high levels of neuromus­

McGill wirh young, healthy subjects performing casks chac

cular input to optimize muscle activation of both local and

involved trunk flexion, extension, lateral bending, and twist­

global muscle systems. In both clinical and research applica­

ing.4' The researchers demonstrated that spinal stability pro­

tions for the lumbopelvic region, use of this technique shows

duced mosdy by rhe muscles was proport ional co the demands placeJ on the spine. Thus if the spinal system was challenged

promise in therapy, rehabilitation, and functional training applications.19.46.10

by a sudden increase in dynamic loading (e.g . , misstep; awkward movement; sudden hip flexion, extension, or rOta­

along with the use of scraps. elastic expanders (bungee cords),

tion), then (he spme would be at greater risk for injury even

and ropes-provides for open and closed chain movements

Figure 1 7 - 1 0 shows the Redcord apparatus. This device­

while minimally loaded . Any sudden loading chal lenges to the

incorporating controlled instability to challenge the neuromus­

spmal stability muscles could produce suboptimal neuromus­

cular system to reStOre coord inaced muscle activation. Clin ical

cular activation via feedback from the neural subccnter co redi­

experience with chis modality has shown enhanced muscle

rect signaling co global muscles to maintain spinal stability.

activation and improved joint stabilization and substantial

Any redirection of neuromotor signal control could result i n

reduction (or elimination) of LBP.

sensorimotor dysfunction and subsequenr pain. Altered signal

The Redcord approach is typically used i n four crossover

streaming would occur within cerrain reg ions of movemenr

applications that include evaluation using weak-link assess­

(beyond a pain-free zone) when muscle signal inrerruption

menrs, therapeuric exercise, preventive exercise, and functional

occurs. Evidence of sensorimotor dysfunCtion is evident i n

exercise training for fitness and sport. Following are six principle applications of Redcord for lum­

reduced lumbar stability measurements o n movement.'" Stated somewhat differently, the spinal-smbilizlng system responds

bopelvic muscle activation:

co injury by decreasing the range of motion when any move­

I . Reestablish rhe simulraneous activarion of rhe deep lumbo­

ment provokes pain. Further stabilizer muscle deaCtivation

pelvic muscle complex (transverse abdominis, deep multifi-

Figure 17-10 The Redcord Trainer. Patient performing supine bridge, illustrating use of slings, straps, and cords to modulate body weight unload· ing. as determined by the therapist. (Courtesy Redcord AS, Staubo, Norway.)

400

Orthopaedic Physical lherapy

dus, pelvic Roor, and diaphragm) independenrly of global

3. Rotate the pelvis with arms folded across the chest. The

muscle interaction (weight-bearing and nonweighc-bearing

pelvis is roeaced around the longitudinal axis on ehe sup­

muscles).

porting leg co Judge how well the Individual performs

2. Precisely grade [he overload (i.e., concrol (he incensi ry) co

3.

permit

concentranon

on

quality

of

movement

rotation i n [he ful l range of mO(lon.

4. Abduct the h l p of the free leg with the arms parallel to the

coordination.

body with the pelVIS a horizontal level .lOd the free leg

Master muscular control and resmre k inesthetic awareness

abduct(..J.

of l umbopelvic posicion sense (posrure with body weighc

5. Combine maximum free leg abduccion and pelvic roration

loading).

4. Activate local (stabi lizing) muscles with controlled incre­ mental

with the arms parallel co the body.

6. Increase the difficulty of the movements by placing 3

body weight loading and controlled inscabi lity

balance cushion between the scapulae In all progressions.

(control (he antigravity muscle support system). The body weiglu loading can be i ncremented as needed (Figure

1 7- 1 1 )

.

5. Enhance range of morion with graded overload.

6.

Weak-Link Assessment a

Establish pain-free movement in all planes.

Reckord's weak-link assessment represents

An Importune feature of Redcord's application of body

Identify a deficit wHllin tht: biomechamcal and klOeuc chalO

useful tool to

weight loading is [he ability co grade overload and use the

that often associates with pain. The deficit often produces

response as a simple assessmem tool, termed a u'Mk-lmk leSt

dysfunction and usually associates with pain provocation. This

(see

following).

deficit appears as a decrease

10

the range of mouon. reduced

Figure 1 7- 1 2 shows an example of a standard Redcord

neuromuscular control. Impaired joint stability andlor balance.

supine pelvic lift, a typical body weight-bearing movement,

impaired (reduced) muscle force. or pain avoidance. After

performed on the therapy table. (Note: These kinds of move­

rypical funcuonal tesung (Trendelenburg's tCSt) and 3cuve

menu, i n which the end segmem bears the body weight, are

movements (walking, running, one- and two-legged balanc­

often referred co as cloud killetle eh(lUl lllot'fmtNlI. ) Differem start­

i ng), bilateral weak-link testing IS lOiti:uoo (for rhe appropriare

Ing positions (Figure 1 7- 1 2, B co D) dictare how much un load­

muscle group [e.g .. supine pelvic lift, side-IYlOg hlp abduc­

ing andlor assistance the patiem requires ro correcdy perform

tion». This is done at the lowest body weighe (using appropri­

the movemem. I n the pelvic l i ft example, the progression

ace off-load ing with bungee cord SUppoH) overload level at

ladder shown in Figure 1 7 - 1 3 IS used to make the movemem

wlllch the tesc can be performed corfL'c:dy Without provoking

more challenging and consists of the following sequence:

pain or uncoordinated movemenc panerns. Overload, achieved

1 . Gradually lower the elastic cords ro reduce rhe body weight.

by manipulating either lever arm posi uon, suspension point,

2. Rorate the pelvis with the arms parallel to the body. The pelvis is rotated around the longitudi nal axis on rhe sup­

andlor movemenc plane. can be gmdually IOcreased until one of the following rhree evems occurs:

porting leg [0 Judge how well the indiVidual performs

1 . The patient cannOt perform rhe test correcdy,

rotation in rhe ful l range of motion.

2. Pain occurs.

3.

An imbalance occurs on either the lefr or nghr side of rhe body (where the movement occurs). Figure 1 7 - 1 4 shows an example of the supme pelvic life

weak-link rest. No weak link is present when the person can lift the pelvis and free leg to the level of rhe leg already

10

the

sling, wirh rhe arms crossed on the chest (or resung by rhe side), and can also do the following:

1. Hold the positIOn honzomally for 3 CO 5 seconds.

2. Maintain normal lordOSIS in the lu mbar spine.

3.

Maintain a neutral body position without rOt3ung or side bending.

4. Perform the tesc pain free. Clinical experience shows that most pauems with LBP cannOt successfully complete ehis movement with body weight loading withour provoking pain. To determine the level of performance (wiehout pain), and to set the level for the lOieia­ eion of Neurac ereaement (see following), rhe therapist can do figure 17-11 Example of Reckard body weight-bearing exercise (distal segment bearing the body weight load or part of the bOOy weight>. These exercises tend to involve both agonists and antagonists

about a joint and other muscle groups in the kinematic chain. (Cour­ tesy ActivCore Inc., Ann Arbor, Michigan.)

the following:

1 . Increase the base of support by purtlng (he arms parallel to [he body.

2. Activace the latissimus dorsi on the opposite side of the supporting leg by grabbing a suppon above rhe head and

401

Chapter 1 7 The Lumbopelvic System

Figure 17�12 Rrocord supi ne pel vic lift, closed kinetic chain movement. A, Basic starting position: Palient supine; arms on chest; strap or narrow

knee flexed; vertical rope with sli ng about 30 em above surface; wide sling attached with elastic cords under the pelviS. up a nd paraliel lo the other, and lifts the pelvis up to a straight Ix>dy position 8·0, Alternative Marting positions. ma ki ng it progressively easier to perform the pelvic lifl. (Courtesy Reckard AS, Staubo. Norway.) sling under one knee. with

The palient extends the knee in the sling, brings the free leg

pulling downwards (grabbing a person's lower leg works well).

The hallmark of Neurac is ehe abiliey to carefully increase body weight loading, with rhe IIltroduction of controlled

3. Acrivure the latissimus dorsi on boch sides by grabbing a

vibration, during movemenr (often to ehe polm of muscle

support above [he head and puBing downwards (grabbing a person's lower leg as described in seep 2).

facigue) without pain provocation. This represents a major dif­

4. Unload the welghe of the free leg by placing it in a narrow

increased Joadlllg wieh fast or jerky and uncontrolled move­

sling arcached with an elastic cord. S. ACClvare rhe transverse abdominis.

6. Use a combination of steps 1 to S.

ference with typical strength-training

techniques, where

menr panerns, wieh pain-induced fatigue. often leads

ro

poor

joinr conrrol and pam exacerbation. The support slings and ropes make ie possible to suspend rhe patiem in a pain-free position and passively move the pelvis

Neuromuscular Activation Treatment (Neurac) The application of the body weight-bearing neuromuscular

(decrease lordosis) by aCtIvating the lumbopelvic srab i lity muscles (Figure 1 7 - 1 5 ) . Patiems wieh LPB ofeen Cannoe main­ tain thiS posiCIon with the desired quality because of muscle disactivation. By placing ehe paeient in a pain-free position.

activation technique termed Ntllrar focuses on restoring conic

this prone lumbar setting stimulates

function of the local and weight-bearing muscles eypically

(dormant) muscles and often dramatically rescores pain-free

impaired with lPB. The unique aspen of ehis eechnique is ehe

lumbar movements.

these disactivared

introduction of high levels of neuromuscular overload, as well

Alehough ehe mechanism underlying ehe success of Neurac

as the Introduction of comralled instability and vibration to

is not well understood, nor documented, rhe technique repre­

both local and weighe-bearing muscles, eo rescore functional

senrs a promising new methodology. Current basic research

movement patterns. The abiliey to unload (unweighe) with

and random controlled trials are underway in Europe and the

slow, conrrolled movements in pam-free posieions enhances

United Scaees

muscle activation of the weight-bearing muscles.

modulation.

(0

facilitaee [his novel approach co pain

402

Orthopaedic Physical Therapy

r t A

c

G Figure 17-13 Supine pelvic lift progression. (Courtesy Redcord AS, Staubo, Norway.)

Chapter 1 7 The Lumbopelvlc System

403

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no rotation or side bending of the body occurs. If these condilions are attained, Ihen the therapist can record the degree of hip abduction at the level of failure (defined as the point where the hip drops below horizontal), The degree of hip abduction can be used as an Objective measure of change after appropriate intervention. (Courtesy Redcord

AS, Staubo, Norway. )

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10

mechanical engineering, Acta Orrhop Scand 20(suppl):2024, 1989. 1 3. Bernick S, Walker JM, Paule WJ: Age changes ro the annulus fibrous in human intervertebtal disc, Spine 16:520-524, 1 9 9 1 . 1 4. Mearcy M, Porrek I , Shepherd J : The effect of low-back pajn on lumbar spinal movements measured by three­ Figure 17·15 Reckord prone lumbar setting. This procedure is used both to assess and activate the deep stabilizing muscles of the lumbo­

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of functional flexion/extension radiographs of the cervical

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spine, Spine 1 8 : 1 20- 1 27, 1 993.

the low back. The therapist places one hand on the sacrum and one

1 6. Cholewicki J, McGill SM: Mechanical srability of the in

hand under the abdomen. Next the therapist gently squeezes the

vivo lumbar spine: implications for injury and chronic low

hands together to slightly induce lumbar flexion by reducing lumbar lordosis about 2 mm. The therapist slowly removes the hands and tells the p.ltient to maintain the 120 seconds (and 10 do AS, Staubo, NOf\vay,1

so

corrected position with minimal effort for or fatigue). (Courtesy Redcord

without pain

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20. Cholewicki J. e c a1: Stabilizing funccion of crunk flexor­

American

extensor muscles around a neucral spine poscure, Spine

335-372.

Academy

of

Orthoped ic

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38. Knucsson F: The instability associated with disk degenera­

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tion

2 1 . Vikne J, Oedegaard A, !.rerum E, ec al: Randomized scudy therapy for paciencs with chronic whiplash-associated dis­

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39. Merskey 1-1 , Bogduk N, editOrs: Classification of chronic

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22. Ericksen MP: Some aspens of aging in the lumbar spine,

40. Klein GN, Mannion AF, Panjabl MM, ec al: Trapped In the neurral zone: another symptom of whiplash-associated

Am J Phys AnchropoI 45:578-580, 1 97 5 . 2 3 . Friberg 0 : Lumbar instability: a dynamic approach by tcaction-compression

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4 1 . Nagl SZ, Rdey LE, Newby LG: A social epIdemIology of back pain in a general population, J ChroniC Dis 26:769-

1987.

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25. Dvorak J, Ancinnes JA, Panjabi MM, ec al: Age and

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surgery. Rockville. Md. 1 990. Aspen. Young Hing K: Surgical cechniques. In Klrkaldy. \Vi II is WHo edicor: Managmg low back pain, cd 2, New York, 1988, Churchill L,v,ngstone. p 3 15.

C HAP T E R

19

Dianna Cole McNitt

Evaluation, Diagnosis, and Treatment of the Lumbar-Pelvic-Hip Complex

diameter. It is covered wi(h hyaline cartilage, which is thicker

Musculoskeleral experts continue to debare how [he low back, pelvic girdle, and lower-extremity function in synchrony. The

centrallyl and thinner at the periphery. JUSt below the cencer

iicerarure contains informacion on a plethora of diagnostic

of the head lies the fovea centralis (capitis), which is where the

reSts, some with good psychometric propenies. However, liule

"(eres" ligament inserts. The ligamemum teres, comprised of

consistency is seen in the cescs used by differem clinicians.

three bundles, is a flattened fibrous band 3 to 3.5 em long that

Exercise and manual treatments selected by clinicians also vary

arises from the acetabular notch and inserts inco the fovea

gready, depending on their experience, education, and expo­

capitis (Figure 1 9 - 1 ,8). It lies in the Roor of rhe acetabulum

sure [0 continuing education. Few diagnostic tests used by the

and has minimal, if any, mechanical function in rhe hip joint,

physical therapist in (he pelvic-hip complex should be used in

because it comes under (ension only in adduction. Irs primary

isolation; instead the clinician muse use selected special tests

function is to protect the delicate posterior branch of the obtu­

and combine all informacion gleaned from the examination CO

rator artery, which supplies the head of the femur. In infants

form a diagnosis. When evaluating the pelvic-hip complex, it

and children, this artery is a significant source of blood to the

is essencial to consider the anatomy. biomechanical scate, and

femoral head.2 Avascular necrosis (AVN) of the femoral head

neurologic condition of this region, as well as the subjective

has been linked to interruption of this artery.

hiscory and emotional state of the patient.

The femoral neck projects laterally from the head and fans out; this projection is usually between 1 20 and 1 25 degrees in adults and is known as the

FUNCTIONAL ANAlOMY AND MECHANICS OF THE HIP

allgle of inc/illation (Figure 19-2, A).

At birth this angle is 135 degrees; by the end of the second year of life, this head-to-neck angle can be as grear as 150 degrees. The decrease in this angle from infancy to adulthood is the result of compression and bending forces acting on

Osteology of the Hip

the head during weight bearing.

The hip, or coxofemoral joint (CF]) is formed by the articula­

[han 1 20 degrees, and

tion of the head of the femur with the acetabulum of the pelvis

degrees.}

roxa ,'alga

Coxa

f'(lra

is an angle less

is an angle larger than 135

(Figure L 9- 1 , A). This joint is a classic example of a ball-and­

Coxa van is a deformity that Causes a decreased joim load

socket joint and has three degrees of freedom in motion. The

because of more balanced force distribution. The femoral neck

primary funccions of the hip joint are to increase stability and

tends to be shorter. The head maimains

to provide support for the transmission of forces between the

in the acetabulum because of the greater leverage associated

pelvis and lower extremities with dynamic activities such as

with the adducrors. This deformity, however, causes more

running, jumping, and walking. Stability is proouced in three

shearing forces that can lead to a pseudoarthrosis of the femoral

ways: ( 1 ) bony congruency, (2) capsular reinforcement, and (3)

neck.4

a

more central position

the neuromuscular system. In addition, rhe hip joint allows

Coxa valga is considered to be one of the mOSt unfavorable

significant mobility for those activities and supportS the weight

structural configurations of the hip because ir causes increased

of the upper body during static erect posture. The hip joint

joint compte5sion.4 The femoral neck tends to be longer. This

mUSt be able to resist loads, both tensile and compressive,

position of the hip leads to a loss of hip abduction moment, which causes a force imbalance and a prearthritic scare, not the

much more than body weight.

deformity itself. Eccentric control of the hip adduction is

The femur is the longest and strongest bone in the body. The proximal end of the femur includes the head, neck, and

diminished during landing (through the pelvis), leading to

trochamers. The head of the femur is ellipsoid in shape, forming

increased forces borne through the joint. The acetabular

roughly twO thirds of a sphere approximately 4 to 5 cm in

weight-bearing surface may become more oblique so rhar the

419

420

Orthopaedic Physical Therapy

Articular cartilage of acetabulum

Femoral head

Articular cartilage Acetabular labrum

Acetabulum labrum

Capsular ligaments (cuI)

A

IL�--'I:-,.;::I'1

B

Lesser trochanter

Figure 19·1 A, Coxofem ora l jOint (hip jOint). 8, ligamentum teres. (A (rom Kelley l: Secti o na l anatomy

for imagi ng p rofessi ona ls. cd 2, 51

Louis,

2007, Mosby. B from Muscalino JE: Kinesiology: the skeletal system and muscle function. 51 loui s, 2006. Mosby.)

Figure 19-2 Comparison of the newborn

�0"IOI5'

(A) and adult (8) femora l angle of inclina­

tion (lOp) and femoral angle of torsion (bottom). The enlarged views of the femoral angle or torsion show a superior perspective, l ooki ng down from Ihe head and neck

of the femur 10 the femoral con­

dyles. (From Cech D: Fu n cti ona l move-­

A

B

femoral head no longer sits in the cemer. The outer aspect of the acetabulum must then absorb more force from the femoral head, increasing rhe load on the labrum.) Two basic funcrionai adaptations have been identified in rhe StrUCture of the femoral head (Figure 19-3). I n the first (type I), rhe femoral head is greater than rwo rhirds of a sphere wirh maximal angles. les shafe is slender, and ehe associared pelvis IS small and high slung. This adaprarion is suired for speed and movemem. The cype II adaprarion has a femoral head chac is nearly a full hemisphere and has minimal angles. lrs shafc is chick. and its associaced pelvis is broad. This adapcacion is for power and screngch.

ment development across the life span, ed 2, Ph i la delph ia . 2003, Saunders.)

The crabecular bone in che femoraJ head and neck is designed to withstand high loads (see Figure 19-1, A). The design includes borh primary and secondary rensile and compressive patterns. The Ward triangle is a site of weakness; this weakness Increases with age and chis Site ofeen sustains osteoJX>rotic fracrures. A S- co 7 -degree angle exists in the shaft of the femur with respect co the vertical plane, rhus causing an ameropos­ terior bend. This bend produces strength to Withstand ground reaccion forces. The femoral head and neck project amerioriy in relarion to [he femoral condyles. This angle IS known as che angle of ded,­ natJOfI or femoral IQrJIOfI angle (Figure 19-2. B), which changes

Chapter 1 9 Evaluation, DiagnosIs, and Treatment of the Lumbar-PelvIc-HIp Complex

421

lilium _-++-_

frr.�

Fusion of ilhum. ischium, and pubic bones within the -H-::L� a cetebulum

P Bellu

Figure 19·3 Funct iona l adaptations of the femoral head and neck. Type I (A and C) has a head equal to two thirds of a sphere and maximal angles;

type II (8

and 0) has a head greater than half of a

Pubis

hemispherl;> and minimal angles. The angle of inclination is shown in

parts C and 0, and the angle of declination is shown in parts A and 8 (From KapandJi IA: The physiology of the joints. II. The lower l i mb. ed 2, Edinburgh, 1970, Churchill Livingstone.)

Fusion of ischium and pubis

Ischium

Figure 1 9-4 The innominate, acetabulum, and labrum. left innomi· nate, lateral view. Reader should note the junc.tion of thC' ischium,

from bmh co adulthood. This angle is approximarel)' 2S degrees at birch and

(030 10 [0 1 5 degrc.'es in the adule. If chis angle

ilium, and pubiC bones in the fossa of the aLC't.)bulum.

is sigOificandy increased, then (he condition known as alllet'er· SlOn

can result in a greater amounr of imernal roration (toe in).

The hlp internal rotarion will bt- Increased, and hip excernal

mentum ceres and the obturator artery where no collagen exists

romcion will be decreased; chis condmon is usually seen in

(see Figure 19-1,

children. AnteverSion may also Induce genu valgus and or

thiS point because no compression or contan by the head occurs

8). A fat pad covers the a('tabular floor at

ankle-fooc eversion, because che femoral head pomts back

there. The labrum of a healthy hip appears to have three func­

(Qward the acetabulum. If che angle of declinacion is signifi­

cions: as (J) a shock absorber, (2) a closure flng, and

candy decreased, chen retroversion resulrs in a greacer amount

rransmltcer.'

of exrernal roration (toe oue), whether the hip is positioned in

The Wiberg angle, also called rhe l"t'll1tr-t'dgt (CE) angle. is anocher architectural angle to consider (Figure 19-5). This

o or

90 degrees of hlp Aexion. Anteversion and retroversion

(3) a force

affect both rhe pattern and rhe range of morion available at the

angle indicares how much {he acet;lbulum overlaps the head.

hip joint.6

To determine che angle, firsc connect borh cenrers for

The acetabulum (or socket portion) of rhe hip joint is com­

J

base­

line. Then from the cenrer of the head, draw one line perpen­

Prised of rhe ilium, ischium, and pubic bones, which fuse co

dicular and a second line connecring wich the edge of the

form the innominate (Figure 19-4). It is ellipsoidal shape, nO{

acetabular roof. According ro Dlhlmann,lU rhe CE angle is

quire hemispheric. Irs orientation is directed anterolateral and

represented by the angle between these lines. Angles between

30 degrees in the transverse plane (from the

30 and 35 degrees are considered within normal range for

saginal plane); rhis angle is known as rhe allteverJiofJ al/gft. A

adults. II Wichln the first 2 years of age, values under 10 degrees

fibrocarrllaglnous ring called the labrtl1l1 inserts into the ace­

3re conSidered pathologIC conditions. The angle should be at

cross secrion and serves co deepen the acecabulum, increasing

age of 14, the angle should reach

inferiorly about

rabular rim (see Figure

19-1, 8). The labrum IS triangular in

concaer wich che femoral head by about 30%.1 Tightly packed

least t5 degrees from age

3 to the early teenage years. By rhe 20 degrees. Murphy ec �11.1!

demonstrated that a CE angle of less than 1 6 degrees In adults

cype I collagen bundles make up che labrum and run parallel

near the age of 65 or who are suffering from hip dyspbsia was

{o the edge of the acetabulum; some dispersed fibers run

associaced with severe arthricic changes of the hip.

obliquely as well.H The labrum bridges the acetabular notch

The osteology of rhe pelvis is described in gre.uer detail In

along with the transverse acetabular ligament in the ventro­

che discussion of the sacroi"ac joints (SlJs). For now, the pelvis

caudal labrum. Within the acetabulum is a horseshoe-shaped

can be described as a closed flng composed of rhe twO innoml­

(or an Inverced U) feacure with hyaline carcilage lining, which

nare bones, which ,lre joined 3meriorly by the pubic symphysis

is chicker and broader at che roof and chinner and narrower ac

and posceriorly by che Interposed sacrum and the resulting cwo

the floor. The outer porcion of the labrum is vascularized, and

SlJs. The pelvis functions ro tC'ansmic vertical forces from the

the middle portion is sometimes vascularized; however, the

vertebral column to the hips via the SlJs and to transmit

inner poftlon of the labrum is never vascularized.') The fovea

ground reaction forces from che legs and hips to rhe vertebral

capicis is the area in the central cartilage occupied by the liga-

column (and also via the SIJs). These force transmissions and

422

Orthop aedic Physical Therapy "Center-edge" angle

Figure 19-5 The center..edge (eE) angle indicates the relative coverage provided by the acetabulum over the femoral head within the frontal plane. This ang le (the Wiberg angle) is formed by the intersection of a vertical reference line (suppled) and a line that connects the upper edge of the acetabulum to the center of the femoral head. The normal 1 2S-degree angle of inclination of the proximal femur is also indi­ cated. (From Neumann DA: Kinesiology of the musculoskeletal system: foundations for physical rehabilitation, Stlouis, 2002, Mosby.)

dissipations are accomplished through twO trabecular systems:

(1) rhe sacroocerabular system and

(2)

the sacroischial system

(Figure 19-6). The sacroacerabular syscem resisrs che forces of compression and reaccion chrough rhe kinecic chain, whereas rhe sacroischial sysrem resisrs rhe forces of compression applied

Figure 19-6 Trabecular systems of the hip and pelvis. Main system:

(I) arcuate and (2) supporting bundles. Accessory system: J and 4.

The intersections of 1 with 3 and 1 with 2 form the main gothiC arches of the hip. A third arch, of less importance, is formed by the intersec­ tion of J and 4. Sacroacetabular trabeculae (5 and 6) reduce the stress

on the sacroi liac jOint (Sill. Set 5 converges with sel I from the femur;

to che pelvis. The sacroischial sysrem bears (he weight of the

set 6 converges with set 2. Sacroischial trabeculae (7 and 8) intersect

trunk, particularly when the individual is seared.

to bear the body weight in siuing. (From Kapandji IA: The physiology of the joints, eel 2, vol 3, Edinburgh, 1 974, Churchill Livi ngstone.)

Arthrology of the Hip Maximal joint congruence (abour 50%) of rhe hip is achieved

the acetabular labrum, the edge of rhe acetabulum, and the

in 30 to 60 degrees of Aexion, 1 5 to 30 degrees of abduCtion,

outer edge of rhe transverse acetabular ligament. Disrally, the

and abouc 1 5 degrees of excernal rorarion.13 This posicion is

posrerior capsule auaches JUSt proximal ro rhe inrertrochanreric

rermed rhe maximally /ooIe-packed pOJition (MLPP). The liga­

crest. The lateral capsule inserrs inco the anrerior femur along

menrous maximally close-packed posirion (MCPP) is found

che rrochanteric line. The capsule has synovial folds (ar rhe

insread in maximal exrension, adduction, and internal rorarion,

femoral neck) char are locaced anrerior, medial (also caBed

as well as in maximal exrension, abducrion, and exrernal rota­

frenllium of Anrantirzi or ptctilltOj()Vta1 fold and/or plica), and

rian.\} The MCPP provides rhe greatest joint stabilicy because

lateraL' Blood vessels run wirhin rhe capsule and reach rhe

of the combinadon of ligamentous righrness and joinr congru­

femoral head through rhese folds.

ity. The bony close-packed posirion is in maximal flexion,

The extraarricular ligaments, including the iliofemoral liga­

abducrion, and exrernal corarion.1} Nore rhar in rhe erect

ment, pubofemoral ligament, ischiofemoral ligament, and the

posrure, rhe femoral head is nor complerely covered by the

femoral arcuare ligament, blend wich and support rhe capsule.

acetabulum bur is exposed superiorly and anreriorly.

The cwo intraarricular ligaments are

The capsular panern of morion restriCtion has rhe grearesr Iimitarion of incernal rorarion; flexion, exrension, and abduc­

lar ligament and

(2)

(1) che rransverse acecabu­

che ligamentum ceres (see Figure 19-7).

The anterior ligaments of rhe hip are arranged in a Z shape and

rion have about equal limirarions of mocion; excernal rorarion

are analogous to the glenohumeral ligaments of rhe shoulder.

and adduction are lease Iimired. The internal rorarion is Iimiced

The iliofemoral ligamenr (che V-shaped Bercini's ligamenc or

in 0 and 90 degrees of hip Aexion.14 The fibrous membrane of rhe hip joinr capsule is cylindrical

Bigelow·s ligamenc) is considered che strongesr ligament of the body and is comprised of cwo bands: ( 1 ) rhe iliotrochanceric

and runs caudolacerally from rhe acecabular rim to rhe base of

(superior/la[era!) band and

rhe femoral neck (Figure 19-7). The fibrous membrane is com­

superior band is stronger and is 8

prised of a superficial layer of longitudinal bands and a deep

band inserts inco the lower trochanceric line. Together, chese

layer of circular fibers.

cwo bands restricc hip exrension. This ligamenc is able ro resis(

n.16

The capsule inserts into rhe base of

(2)

[he inferomedial band. The CO

10 mm thick. The inferior

Chapter 19 Evaluation, Diagnosis, and Treatment of the Lumbar-PelvlC-Hip Complex

r

423

Iliofemoral ligament

"'-

�

Ischiofemoral

-,-""- ligament

AilS

Greater trochanter of femur Greater trochanter of fem ur Ili ofemoral ligame nt

B Lesser trochanter

Posterior view

Figure 19-7 ligaments of the hip j oint . The maj or ligaments are capsular

reinforcements called the iliofemoral, pubofemoral, and ischIofemoral liga­

ments. A, Anterior view of the hip jOint l igaments. B, Posteri or view. (From Muscolino JE: Kinesiology: the skeletal system and muscle (unction,

A

Anterior view

51

louis,

2006, Mosby.)

much greater tensile forces chan the posterior ligaments.16,17

posture, all ligaments are under modest tension. In extension,

The great strength of this ligamenc may explain why only 10%

all ligaments cighten, especially the inferior band of the ilio­

to 159f of hip dislocations and subluxations occur anteriorly.

Ltl

The second anterior ligamenr, [he pubofemoral ligamem,

femoral ligament, which blends with the iliopsoas muscle and checks posterior tilting of the pelvis. In flexion, all ligaments

a[[aches on the superior ramus of the pubic bone, blends medi­

relax. In external rotation, all anterior ligaments tighten and

ally With the pectineus muscle and the inferior band of the

che posterior relax; the reverse occurs with internal rotation.

iliofemoral ligamenc, and attaches anteriorly to the incercro­

With adduction, the iliorrochanceric band tightens, the pubo­

chanreric line. Tschauner' describes chis ligament as the

femoral ligament slackens, and the ischiofemoral ligament

weakest structural link of the hip capsule. This ligamenc is

relaxes. In abduction, the pubofemoral ligament tightens. the

located between the arms of the Z. where the capsule is chinner.

iliorrochanteric band slackens. and the ischiofemoral band

The Iliofemoral bursa lies here as well, between the iliopsoas

eigheens (Table 19-1).

tendon and the capsule. The posterior ligament of [he hip, the ischiofemoral liga­ ment (Figure 19-7,8), arises from the posterior acetabular rim and the labrum and 3[(aches to the rrochanteric line, deep to

Neurovascular Supply of the Hip The innervation of the hip joint and capsule is primarily

[he iliofemoral ligament. The capsule is strengthened by the

derived from the L3 segment with spinal cord connections from

ischiofemoral ligament as it winds posteriorly around the

L2 to S1.20 The nerve supply is derived directly from the

femur to a{{ach anteriorly. The femoral arcuate ligament, formerly called the

ZOtUi

Qrbiru/aril,16 has some fibers that run

transversely to blend with the ischiofemoral ligament. The

femoral nerve through its muscular branches: the obturator nerve, the accessory obturator nerve, the nerve to the quadratus femoris, and the superior gluteal nerve (Figure 1 9-8, A). The

femoral arcuare ligament originates on the greater trochanter

great overlap of the nerves in this region creates the potencial

and insens onto the lesser trochanter. Although it does not

for a variety of pain referral patterns; therefore the clinician

cross the hlp JOint, it creates tension in the capsule at the end

must check the lumbar spine, the SIJ. and CF] in patients with

ranges flexion and extension. In tension studies, this ligament

complaints in this region.

achieved the least amount of stiffness and failed at the lowest

The blood supply is derived from the obturator, the medial

forces when compared with the other hip ligaments. The liga­

and lateral circumflex femoral arteries and veins, and the supe­

mentum teres (see Figure 1 9- 1 , 8) attaches to the fovea of the

rior and inferior gluteal arteries and veins (Figure 19-8,

femoral head and has three bands that extend to the pubic

8).21

The acetabular fossa and head of the femur receive blood supply

ponion of the lunate surface of the acetabulum, [0 the upper

from the acetabular branch of the obturator and medial femoral

border of the transverse acetabular ligament, and to the ischial

circumflex vessels, which run through the ligamentum teres.

side of the lunate fossa. When ruptured by trauma, the teres

Necrosis of (he femoral head typically begins at the anterior

ligament has been identified as a pain generator}9 The tension

aspect, because of closure of the lateral circumflex necwork.

in this ligament increases with maximal adduction.

Early traumatic dislocation can predispose one to later AVN.

In bipedal stance, both the anterior and the posterior liga­

Lymphatic drainage is accomplished primarily by the deep

ments coil in the same direction around the hip. In the erect

inguinal lymphatic chain, particularly the upper and middle

424

Physical Therapy

Orthopaedic

Table 19-1

Posterior

Muscle

Innervation

GIUlcus maximus

Inrerlor glutt-al nerve, L5

Gluteus medius

Superior glU(eal nerve, L5

GIU(eus mmimus

Supenor gluteal nerve, L5

PIriformis

II

to S2

Ligament

Restraining Function

Iliofemoral, medial pan

Extension (end range) of the hip or

and 51

and SI

posterior rile of (he pelvis External rotarion

Superior and inferior

Intcrnal rotation (to some extent)

Obturator externus

Posterior obturaror nerve, L3

ObcurJ.tor imernus

II and SI

rilt of rhe pelvis

c

Iliofemoral. lar r.ll parr

U

Extension (end range) of the hip or posterior tilt of the pelvis Adduction External rotation

Quadratus femoris

II and SI

Semitendinous

Sciaric nerve tibial portion

membranous

Extension

Pubofemoral

Bi(eps femoris

Adduction Internal rotation

1998)

Extension

peroneal L5 co 52

Medial

(Fuss. 1991)

Adduccor longus

Anterior obcur.uor nerve, L2

Adductor magnus

Obturator nerve

l·1

Adduction Ischiofemoral, �l1perior part

Internal rotation

liblal division of the sciatic nerve, L2 L4

Extension Adduction Flexion. from an extrcme adducted

Ischiofemorul. tlcernl

or (rom a middle position

inferior part (Fuss.

AdductOr brevis

Obruracor nerve, L2 IA

Pectineus

Accessory obturator nerve, L2

l3

1991)

Femoral nerve, L2 L3

FleXion

Ischiofemoral, medial inferior pan (Fuss.

Amerior

1991) FleXion (end range)

Arcuate femoral

Extension (end range) from Sizer PS, Phelps V. Brismtt c:t al: Oldsoosis-spc:cifi( orthopedic ma02gt­ mem of the hip. Mmoe:lpohs.

200R. OrthopedIC

l' -S2 Sciatic nerve long head tibial portion short head common

External rot3rion Ischiofemoml (1illman.

S2

gemelli

Extension of rhe hip or posterior

Iliofemoral magnum

50 years old), ankylosis (bony

control systems work together, proper load transfer and stabil·

bridging at L5 co S I can cause l4 and L5 and the SI] co

iry is achieved.'}� The manner in which these forces are trans­

move more) occurs, which likely decreases movement where

mitted and dispersed (i.e., from rhe tOP down versus from the bottom up) helps explain why cerra l n dysfunctional lesions of

the ankylosis is located; these changes are more marked in 1

male subjects than female subjects .67.6Ii.9

the pelvis occur regularly with certaJO actions or activities. Vleeming et al.19•w and Snijders er al.% described lumbar­

pelvic-hip region morion as involving I1IIYlnJic and txtrlnsic

INTEGRATED MODEL OF FUNalON

stability of the pelvic girdle along with the self-locking mecha­ nism. These auchors coined the terms/orm closurt and/orrt closurt

The transmiSSion of vertical forces from the spine to the lower

to describe the aC(Jve and passive forces chat help stabilize the

members, and of ground reaction forces from the lower limbs

51) and pelvis.

to the spine (figure 1 9- 1 6), occurs through trabecular lines (see

Four components

make up the integrated

model of

"OSteology of the Hip"). The 51) is a force transducer, shock ! absorber, and parr of three different chains: B•91 .9

function:

I . The lower·extremiry kinematic chain: sacrum·innominate­

2. Force closure, which are forces from myofascial action

lower extremity (LE) 2. The spine kinematic chain: L4-L5-sacrum 3. The closed chain: IOnominate-sacrum-innominate411

I . Form closure, which is structural 3. Motor conrrol, which has to do with the timing of muscle comracrion and inaction with loading 4. Emotions, which are psychological

439

Chapter 1 9 Evaluallon, Diagnosis and Treatment of the Lumbar-Pelvic-Hip Complex ,

51), the closed-packed position i nvolves full nutation of the sacrum or posterior rotation of the InnomlOa[(:.

'.t'"

For the hlJ"

it involves full extension along With maximum adduction and internal rocacion or full extension with ..bduction and external rotation.'� Positions that Involve nmaClon includt: bd.ltf:ral hlp Aexlon, standing or landing, simng With passive lordOSis, ..nd trunk Aexion.111 Sacral nuration winds up most of the SI) liga­ ments, particularly the sacrotuberous. sacrospinous, ilnd inccr­ osseous ligaments. IU6.9H Often fractures and dislocations occur

t t

when a joint is in its close-packed position and an txternal forct IS

applied. When the Joint is our of the dose-packed position, it

1\

considered an open-packed (or loost:-packtd) position. In these poSitions rhe JOint has mlOimal stabiliry, mlOimal jOint surface contact or congruency, and rhe Ilgamems are on slack. Loose­ packed position (or the 51) is coumernutation of [ht sacrum or anterior roratlon of the IOnomlnate. For the hip It

Figure 19-17 Schematic representation of form closure. (From lee 0:

The pelvic girdle, cd 3, New York, 2004, Ch urchill Livingstone.)

to 60 degrees of Aexion, 1 5 degrees

to

IS

from 30

_,0 degrees of abduCtion,

and abour 1 5 degrees of txternal roration. iK POSit ions chat involve counternutauon of rhe SIJ Indude trunk extension, lying supine, and hip hyperextension; the Ion,!.: " I t involves the timing of specific muscle action and

sion)

IS

applied ro the pelvis, rhese facrors help with stabilize

relaxation, and such coordinated muscle anion provides stabil­

The elements involved in (orm closure include the orienta­

global systems creates stability wlthour rigid posture or col­

tion of the rrabeculae, the design of the anatomy of the joinc,

lapse of the lumbopelvic region. Exercises dun focus on balanc­

,he 51) .

ity With mobility.KM The coordination between rhe local and

and the capsule and ligamenc system. Because rhe hip mUSt

Ing tension and decreasing compression using rhe sling sysu:m,

sustain pressures greater than body weight, it mUSt use the

as well as with mental imagery for rhe patient, help improve

bone, articular, and myofascial systems for stability. Each hip

mOtOr COntrol. H

jOlOt supports abour 509f of body weight during normal standing. �8.'7<J Force closure occurs with loading when increased compres­ sion, both intrinsic and extrinsic, takes place across a joint surface. The soft tissues that create force closure are the muscles, ligaments, and fascia. Both the myofascial and the neurologIC

PATIENT EMOTIONAL STATE AND DYSFUNCTION The emotions play an Imporcanc role in function of the neuro­

systems make up these dynamic forces, producing a self-lock­

musculoskeletal system. Often chronic pain patients who have

ing mechanism for the 51) . The amount of force closure needed

functional complalO(s have also had traumatic life experiences.

is dinated by the amount of load and the form closure. II Boch

Many of these patients will use motor control paHerns With

form closure (anicular) and force closure (myofascial) are neces­

defenSive posturing. In addirion, a ncgarive tmotional srate

sary to balance a heavy load. The Joinr position with tile most srability, where a maximum congruence of the Joint surfaces occurs along the ligaments.

induces Increased Stress. Such stress is a normal response required to stimulate flight

or

fighr rCilCflons. l lowever, if chis

response conunues for an excended period of ume, chcn high

placing the mOSt tension on them, is called a cloud-parked posi­

levels of epinephrine (adrenaline) and cortisol d to srand firsr on one leg and rhen on [he ocher while

co midline ,1S if co touch rhe floor. The p,lueoc's feer should be

l i fting ehe opposice knee to 90 degrt'es of hip Aexion. The PSIS

111

on rhe nonweighe-bearlng Side will move farcher inferiorly.

edge of an examlnacion r;'lblt:. A normal response would be

The welghe-bearlng side w i l l move very liede. An aleernaee

symmetrical movement of the PSISs. The Involved PSIS will

conmer wirh rhe Aoor or res[Jng on

.1

srool If seared on the

method of assessmem uses ehe S2 spmous process as a fixed

move first or farther lfJnially (i.e . . rhe blockt.-d Joinc moves

reference paille for rhe relative PSIS movemem as rhe paciem

solidly as one, while rhe SiKrum on che unblocked side is free

alcernately lifcs che knees tOward [he waist. H l p Aexion musr

90 degrees.

to move through ItS small range: of mouon wICh [he lumbar

Anterior rotation of rhe non weight­

spine). If a blockage IS deteered in rhis [est and I( is more posi­

beanng innomlllarf relauvf to che sacrum, W'.JtI6 or if ie Aex�s

tive (gn>.acer) than the resrriction noted In rhe standing flexion

reach riC leas[

it

relaeive co [he femur, indicares a posirive resr. These would

resr, rhen rhe (esr is IOdlc,HI\'e of

demonstrate a load transfer rhrough che hip and pelvis [har

twO PSISs move symmetrically, rhen an IOnominare dysfunc­

would be less stable. This cesc serves only as a screen for SI]

tion is present (if rhe: sc,lndlng lIexion or G i l ler tesc was posi­

dysfunction, because it has poor reliabilicy and sensiciviry by I icseJf.� . \(�1

boch equally "o�itivt" chen a sofr rissue lesion is a possibility.

s,llfal dysfuncrion. If che

rive). If the scanding flexion resc .1I1d the: sl{[Jng fleXion tesc are This cesc is a scn:en for SI) dysfuncrion, became i t has poor

Active Lumbar Movements Because lumbar lesions ofcen occur along WI[h sacrOiliac dys­ functions, restricrions of lumbar movemem musr also be assessed. Ofcen when

il

sacroiliac d}'sfunccion exiscs, side

bendin8 o( the lumbar spine toward che affecred side can cause exacerbarion of pain. Pain on backward bending may also be indicanve of lumbar Involve:menr.

sensitiVity and reliabi! 't}· b}· Irself. U�,

Supine Position Thigh Thrust Provocation Test (Oestgaard Provocation Test) The pa[i�nr is supine with che painful hlp flexed to

90 degrees.

no pillow under co opposite kne:c. The r("srer can srand on the

Sitting Position

paInfu l side and srabiliLl: rhe opposire ASIS. The patient's anterior knee is grasIX'd, .lI1d downward pressure is applied

The siccing position fixes rhe innomi nares to rhe chair or rable

through rhe femur. The ciininlll should make sure rhe thigh

and eliminares che InAuence of rhe hamstrings on che pelviS.

IS held in 90 degrees of fleXion .1nd neurral adducuon. ThiS rest

This allows for sacroiliac movemenr wichin che mnominares

produces an innominare ror,u ion c.le.

Chapter 21

Dysfunction, Evaluation, and Treatment of the Knee

501

fasciae Jarae, which can be separated inca tWO functional com­

femur and below to the head of the fibula; it has no attachment

ponems: ( 1 ) the ilioparcllar band and (2) the iliotibial tracr.9

CO the lateral meniscus (Figure 2 1 -9. B).

These struccures attach amerolaterally to Gerdy's tubercle on rhe lateral aspen of rhe cibia (Figure

21-8).

Also providing

The lateral capsular ligaments attach co [he lateral meniscus in much the same way that the medial capsular ligaments

suppon for the lateral side are rhe two heads of rhe biceps

anach to rhe medial meniscus. The lateral capsular ligaments

femoris. The long head and rhe shon head form a common

can also be divided into meniscofemoral and meniscoeibial sec­

tendon (lateral hamstring), which splits around rhe fibular col­

tions. These can be further subdivided into anterior. medial,

lateral ligament and attaches co the head of the fibula.

and posterior thirds. The middle third of the lateral capsular

The triangular and Aat popliteus muscle forms rhe deep

ligament provides support against anterior lateral rotatory

800r of the lower parr of the popliteal fossa (Figure 21-9, AJ.

instability. The posterolateral third of the lareral compartment

The larger part of the fossa arises on the lateral condyle of rhe

is also supported by the arcuare ligament. The arcuate ligament

femur and helps support the fibrous lateral capsule adjacent to

consists of a Y-shaped sysrem of capsular fibers, the stem of

rhe lateral meniscus. The popliteus muscle insects in the pos­

which is anached to the head of [he fibula. The tWO branches

teromedial edge of the tibia and serves co reinforce the posterior

of the upper portion extend medially ro the posterior border of

third of the lateral capsular ligament. The fibular collateral ligament appears on the lateral aspect of the knee as a large rounded cord, which is attached to the lateral epicondyle of the

Ant. 1/3

Meniscotemoral

Mid. 1/3

Post.

1/3

Tibial collateral ligament

Ill!!:n-;.-- ligament

Posterior oblique

Pes anserinus

Figure 21 -4 Muscles of the pes an seri nu s group, medial aspect of the Figure 21·6 Divisions of the medial capsular ligaments.

knee.

11A��rr--- Ti';., arm arm Semimembranosus

Figure 21·5 The five components of the semimembranosus muscle. POL, Posterior oblique l igam ent; TeL, t i bi al collateral ligament.

502

Orthopaedic PhYSical Therapy

.:s:.�c-- Ili otibial band

Figure 21-7 Allac;hmcnl of the posterior uuciate ligament. The differ­ ent bundles change in tension as the knee moves from extension to

Figure 21-8 Iliotibial band Jnd iliotibial tract and their at1.Jchment to

flexion

Gerdy's tubercle.

.

Popliteal lendon

--Ii

Arcuate ligament

Arcuate ligament Poplit eal musel,.

Fibular collateral ligament

-.....::""�':7.�

A

B

Figure 21-9 A, Th(' popliteus muscle forms the deep floo r of the popliteal fossa. 8, The fibular coliatNal ligament and Ih(> olrCU
Archrosc

8(6):337-342,

2000. open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament recon­ struction, SSTA, Knee Surg Sports Traumatol Arthrosc,

8(6): 343-348, 2000. kinetic-chain exercises after anterior cruciaee ligament Exerc SpOrt

Mosby. Jackson OW, editor: The anterior cruciate deficient knee, St Louis, 1 990, Mosby. Jackson OW: The anterior ligament: current and future con­ cepts, New York, 1 993, Raven Press.

25. Fleming Be, Oksendahl H, Beynnon B: Open- or c1osed­

2005.

Baltimore, 1 995. Lippincott Williams & Wilkins. Hughscon J: Knee ligaments: injury and repair, St Louis, 1993,

24. Morrissey MC, H udson ZL, Oreschler WI, et al: Effects of

reconstruction?

dics, New York, 1 99 1 , Churchill Livingscone. Baker CI, edicor: The Hughscon Clinic sportS medicine book,

Sci

Rev

33(3): 1 34- 1 40,

Kennedy JC: The injured adolescent knee. Balti more, 1 979, Lippincott Williams & Wilkins, SCOtt WN: Ligaments and extensor mechanism of the knee: diagnosis and treatment, St Louis, 1 99 1 , Mosby.

CHAPTER

22

William Jay Bryan, Matt Holland, and Scott Moorhead

Surgery of the Knee and Rehabilitation Principles

The spectrum of differential diagnoses of rhe knee is signifl­

some of the more common therapeuric modalities physical

candy broad and demands, of surgeon and therapist alike, an

therapists use in the treatment of knee injuries.

intimate understanding of the anacomy, surgicaJ techniques, and rehabilitation recommendations. This edition emphasizes

ANTERIOR KNEE PAIN

rhe need for solid rapport between physician and therapist, as well as profound and consistent consultation of rhe literature, wirh an eye coward more recent developments in surgical tech­

P�tellofemoral pain syndrome has become the mOst common

nique and treaement approaches. We have chosen co present

knee condition treared by orthopaedic knee surgeons and sports

copics according to three broad injury-related areas: (1) spores

medicine physical therapists alike. The term patellofemoral pain syndrome is indeed vague, and the pain generacors may be either

(2)

medicine,

traumatic

injuries,

and

(3)

degenerative

conditions.

serain of rhe tissue surrounding the patella, acuee coneusions of

A proper course of treatment begins with rhe physician and

patellar and trochlear articular cartilage, or varying degrees of

hinges on his or her ability ro properly evaluate and diren

patellar and trochlear articular cartilage breakdown. Ie is esti­

subsequenr options. Appropriate mediation of dlC transition

mated thar aneerior knee pain will beset anywhere from 7% CO

from operative and nonoperative treatment ro rehabilitation

9% of the general population.· Because anterior knee pain may

can ensure optimal care of rhe patient and ranges from prescrib­

be attribueable to a multitude of causes (Box 22-1),' a proper

ing appropriate analgesia to effectively communicating CO the

course of treatmenr requires understanding all the possibilities.

therapist key elements of ,he surgery, such as the quality of

Some of the mOSt common causes are outlined in the following

the tissues involved, rhe techniques used, and the relarive

paragraphs.

success of the procedure. As the rherapist assumes increasing

When faced with constant, nonactivity-related anterior

prominence in rhe patient's care and frequently becomes

knee pain, the surgeon must consider sympathetic mediaeed

the primary professional couchscone for the parienr during

pain, posroperative neuromas, referred radicular pain, and

recovery, mutual confidence berween physician and rherapist

symprom magnification for secondary gain: Sharp, intermit­

is critical.

tent pain is believed ro be the result of loose bodies or unstable

Arguably, the success or professional rehabilitation hinges on the physical therapist's abilit},

{Q

articular cartilage pathologic condition. Activity-related pain,

keep rhe patient engaged

on the other hand, could be the result of any number of

and compliane (which can be a rather arduous task). A potent

phenomena: soft rissue overload with patellar rnalalignmenc,

algorithm incorporates a command of currene conceprs, as well

patellar rendonieis, quadriceps tendonitis, pathologic plica

as access

{Q

the various weapons in the prepared therapise's

syndrome, fat pad syndrome. iiioribial band syndrome, or early

arsenal. In recent years a significant increase has occurred in

lateral patellar compression syndrome. Posnraumatic chondro­

rehabilirative research, especially within the spores medicine realm, which is increasingly leading

{Q

malacia patellae or arthrosis may cause arricular tissue overload,

evidence-based reha­

or it may be the resulr of degenerative arthrosis from chronic

bilitation to promoee successful outcomes. Therapists have at

malalignment.

their disposal a variety of tools, such as manual muscle testing

Inflammatory arthritis is also responsible for activity-relaced

(MMT), isokinetic exercise and testing, and endurance testing,

pain, as are systemic diseases, which produce weakness, general

in addition to a bevy of modalities (e.g., heat and cold, electri­

deconditioning. and increased loads within the knee joint.

cal stimulation, cold laser, ultrasound, cooled compression

Thus [he therapist should be attuned

devices, pereurbation boards, acupuncture, braces, and of

tions and approach each rehabilitation patiene with a fresh

course, proper exercise prescription). Table

22-1

describes

CO

a multitude of condi­

view-irrespective of the referring physician's diagnosis. 519

520

Orthopaedic Physical Therapy Common Modalities Used in Knee Injury Rehabilitation

Modality

Inflammation

Tendonitis

Bursitis

Iontophoresis

X

X

X

Pain Control

Muscle Reeducation

Scar Tissue

Joint Restriction

X

TrttnSCUlilOcl their paper on Achilles tendlnopathy and

General strength program

Lunges

4:

training became pam free. the load was increased by adding weighr and increasing the speed of the eccentric phase. Alfred­

included eccentric training for a positive patellar tendinopathy

Begin hip abduction at week 4 (i.e., Thera-Band

Phase

treatment program. Eccentric drop squats were key; when

Norwegian authors concluded that although mosr studies

sidestepPing)

Weeks 5 to 6

In a landmark 1986 study, Stanish et al.1 showed that eccentric training was a vital part of their patellar rendinopathy

Ilip abduction and adduction

Iliotibial band stretching

Phase 3:

and allow patients to participate more in a rehabilitative program, as opposed to speeding a "return to play."

Begin working on gastrocnemius strengthenlOg Closed cham work from 0 to 60 degrees

Phase 2:

modalities are meant to facilitate tissue healing and recovery

Begin Jumping and other plyometric exercises

Week 1 6

noted, however, that the presence of patellar tendinopathy is not consistent across individuals exposed to equivalem loading levels, suggesting that intrinsic factOrs also contribute. This exhaustive study of paeienrs with patellar tendonitis showed that the therapist would do well to increase thigh flexibility, because decreased thigh flexibility correlated WI[h increased incidence of patellar tendonitis.fI Leg length discrepancy was also factorial, whereupon an appropriate heel and sole lift should be instituted. Neither arch heighr nor ankle dorsiflexion

AIPFL. Mrolal patcllo(emoral ligament.

parameters have any Significance. The negative correlative

Chapter 22 Surgery of the Knee and Rehabilitation PrinCiples

523

resules should prove JOscructive, because wasting time on (00[ orchoeic devices or ankle-scretching exerCises appear [Q be of no avail in this patient population.1I

PATELLAR TENDON RUPTURE Patellar tendon rupture is a disabling injury char is most com­ monly seen in patients under 40 years old who participate in athletic acciviClCS demanding violent quadriceps muscle

COIl­

traction in a Aexed knee position. The prognosis after a patellar (cndon rupwce depends in large pan on the interval between rhe injury and repair. Surgery soon after injury IS recommended for optimal resules. Most surgeons will renpproximare rhe rup­ tured tendon ends, carefully repair any associated medial and lateral retinacular tears, and mosr imponanciy, place a reinforc­ ing cereiage surure, which may be eirher metal wire or high­ tech surure, such as FiberWire, Postsurgical care Involves the use of a hinged variable locked brace, progressive weight Figure 22-2 A decline board.

bearing, and immediate anencion co comrolled quadriceps srrengthenlng. The tensile strength of the repair progresses In a linear fashion, such that between 8 to J 2 weeks, borh the incensity and the frequency of extensor-suengrhening acrivities may be progressively expanded.

Patellar Tendon

Rupture

case

Study

History The p-Jcienc is a 30-rear-old man who was playing basket­ ball on Feb 22, 2007. During Initial push-ofT for an explo­ sive jump. the p.,t[ienc heard and fele a loud pop, followed by che lert knee giving way; the pacienc fell to che Root. The patella was observed

co

be sHung In the distal portion of

che chigh, about ·1 inches above irs normal resting position. Prior Medical History The patienr had a history of bilateral Osgood-SchLanec disease in his teenage years and

a

prior patellar tendon

rupcure and repaIr on the righc knee in March of 2004. Surgery The pacienr underwcnr surgical repair for a complete patel­ lar tendon rupture on February 27,2007, with repair using

figure 22-3 Exposure of the lateral retinaculum.

four limbs of FiberWire sutures, as well as repair of the laceral retinaculum (Figure 22-3). Diagn05tic clJ.Ssifica[ion� ImpairtdJoint Mobilicy, Motor Function,Muscle Performance, and Range of Motion Asso­

•

(med with Bony or Soft Tissue Surgery, (41)

initiate quadrjceps setS and straighc-Ieg raises

Rehabilitation Considerations for Patellar Tendon Repair •

Week 0 to 2: Nonwelgll£ be-Jnng with postoperative brace locked at 0 degn.'cs. Full extension and no exercise to be done.

Week 2: Touchdown weight bearing. Brace locked ac 0 degrees. Begin heel slid

Week 3

COnt/1llltd

528

Orthopaedic Physical Therapy Accelerated and Nonaccelerated Rehabilitation Protocols-cont'd Accelerated Protocols

Nonaccelerated Protocols

Swimming with Auner kick

Week 2

Week

Scalr-climbing machine

Week 5

Week 8

Cross-country skiing machine

Week 8

Week 8

Bike outdoors

Week 8

Week 1 2

Jog on Aat surface

Week 8

Week 1 2

4

Sport-Specific Or;/Is lateral shuffles and backward run

Week 1 2

Week 12

Figure-eight runs

Week 16

Week 24

Jumping rope

Week 1 2

Week 12

Plyometric exercises

Week 1 6

Week 2·1

From !kyonen 80. Uh BS. Johnson RJ. ('( al Rehahilit;uion after anterior crucialt' ligament m:onstrucrion a prospectln', random.Kd double-blind comparison of progFJms admlOistered 0"'('( 2 dIfferent tIme Intervals, Am J SportS Med H(3):347-.:I,59. 2005 . •NIII, NO!

applicable: rp",. revolution per minute.

chain group had KT- IOOO measurements [hat were closer to

structure of the quadriceps and gluteus maximus by more than

(0

twofold, or it can greatly exceed (by more than twofold) those

normal activities, and greater satisfaction compared with the

changes after an institutional standard rehabil i tation program.

normal, in addition to less anterior knee pain, earlier return

open chain group. Closed chain kinetic exercise appears to be

Arguably, this may be ideal for mitigating the persistent

more in favor, because multiple authors have found open

muscle

kinetic chain exercises co have more ancerior tibial translation

reconstruction.

impairments

commonly

observed

after

ACL

compared wirh closed kinetic chain exercises (in side-co-side comparisons). This is generally more evidenc in the lower degrees of fleXion from 0 CO 60 degrees.26.2� Patellofemoral joinc problems are imporranc co consider

Bracing The rationale for using postoperative bracing in ACL recon­

when comparing open and closed kinetic chain exercises.

structi on continues to

Closed chain exercises place lower suess on the patellofemoral

types of bracing are available: ( I) the rehabilitation brace and

be

somewhat conrroversial.

Two main

joim at lower flexion angles, whereas open chain quadriceps

(2) the fu nctional brace. The Immediate postoperative period

exercises place a higher stress on the patellofemoral joint at

uses a rehabilitation brace, which is thought to protect the ACL

lower flexion angles. Thus open chalO quadriceps exercises

reconstruction andlor donor site while range of motion, weight

should be avoided or reduced wirh patellofemoral symptoms,

bearing, and muscle activity are ini tiated. Once the patient has

particularly if a patient is already experiencing these, which

regained full motion, is able to bear weight without difficulty,

can imerfere with progression of therapy. Recently, Gerber er

and has regained some muscle control, the rehabilitation brace

al.28 implemented eccentric resistance training to induce con­

is generally discontinued. Functional bracing is generally used

siderable gains in muscle size and strengrh to allow further

further along into rehabi l i tation or to faci litate a return to

benefit of postoperative rehabi l itation. In their study, 40

sportS. A l though no adequate long-term studies have shown

patients were divided into tWO groups of 20 each. Both groups

the benefits of bracing, a recent study of orthopaedic surgeons

completed 2 to 3 weeks of phase-one exercises focused on con­

in 2003 showed that i n a survey of the American Orthopaedic

trol ling pain and effusion, regaining range of motion, and

Satiety of Sports Medicine, 879f of respondenrs always or

obtaining basic quadriceps function. Beginning 3 weeks after

sometimes continued to brace the ACL reconstrucred knee.19

surgery, one group began an eccentric exercise program for 1 2

Wright et al. � conducted a systematic review of level-one

weeks, consisting o f progressing negative work using one of

evidence of 1 2 randomized controlled trials to determine if

twO recumbent eccen tric ergometers. They evaluated changes

appropriate evidence existed to support bracing. In their

in muscle structure with MRI of the involved and uninvolved

reView, they discussed each of the randomized conrrolkd rrials,

thighs, borh before and after training. The volume in peak

and they found

cross-sectional areas of the quadriceps, hamstrings, and graci lis

im proved range of motion, decreased pain, Improved graft

i n proportion to the gluteus maximus were caJculated from

stab i l ity, or decreased incidence of reinjury among the braced

chese i mages. These volumes increased significancly wich both

cohort compared with the nonbmced control groups. Thus they

che

eccenuic

and

the

standard

rehabilitation

that the evidence does nOt demonsrrate

programs;

concluded use of these functional braces is not supported by

however, the Increases In quadriceps volume and peak cross­

currently available evidence. Ilowever, Fleming et al. U evalu­

seccional area were significantly greater, by more than twO

ated a particular brace (Legend,

thirds, in the eccentric group. The conclusion was that progres­

ni ficant reducrion in strain values compared with the nonbraced

sive, eccentric resistance exercise can induce changes in the

group for anrerior shear load up to 1 30 N

DJ

Ortho) and showed a sig­ 10

nonwelghr-

Chapter be-Jring and weiglu-bearing conditions. They also evaluated mrernal tibial rorque up to 9 N/mm strained in a braced knee;

22 Surgery of the Knee and Rehabilitation PnnClples Table 21-7

chis was significandy less chan rhe non braced knee when the knee was nonweiglu bearing only. I lowever, the brace did noc reduce strain values when the knt"e was subjected to external corques or varus and valgus moments In the weight-bearing and nonweighr-beanng knees. This study concludes thar a brace can prOV ide some protection to (he ACL-ACL grafe under those speClnc loading (OndHions. (Al chough rhe directions of loading used are known

[0

Injure rhe ACL, rhe loads that were

tested were well below chose chat cause Injury or char the athlete might experience during spore.) In any case, cafC must be raken

(0

differemiate thiS population from others, because

those With concomitant ligamentous or meniscal repair may require a different course of care. The question of whether patients engaged in high-demand

Factors to Consider in ACL Rehabilitation of the Female Athlete

Factor

Rehabilitation

Female subjects exhibit wider

Dynamic comrol of valgus

pelvis and increased genu valgum Female athletes recruit quadriceps

skiers w i t h ACL reconstruction. I n an evaluation o f 257 skier empio)'ees with ACL reconstrunion that wore braces compared with

563

skier employees with ACL reconstruction that did

nOt, they found that nonbmced skiers were

2.74

times more

likely to suffer subsequent injury than were braced skiers. \2 Because of the lOueased fisk of reinjury

10

[Q

question whether one could

extrapolate the results of this study

[Q

apply to other padenrs

engaged in aggressive, high-demand activity. Regard less, com­

lit

knee Joim

panern for female athlete to u.w hamstrings

Female subjects generate muscular force more slowly chan male

TralO for fast s�ds and reacrlon riming

subjecu Jumping athletes lose hip comrol

Train hip and trunk control

on landing Less-developed thigh musculature

Train hip mU3Cularure to

Genu rccurvarum and IOcreased

Train athlete

assist knee laxity Exhibit lesH�ffective dynamic

10

stabilization [0

comrol knee

extension (stability position) Enhance neuromuscular

stabilization

comrol and prot("Ctlve pauern reAexes

Poorer muscular endurance rates

Train female athlete to enhance muscular endurance

nonbraced skiers,

the authors recommend funccional bracing for skiers with ACL reconstruction. It IS reasonable

momenr

Retrain neuromuscular

muscle to stabilize knee

actiVities deserve prophylactic or prmective bracing continues to stoke debate. Stererr et al. \.! specifically addressed inj uries i n

529

From Wilk KE. Arrigo C. Andrtws Jr.

f(

,11: Reh,1biliratlOn after amt"nor

cruciafe ligament reconstru(.tlon In the female ;uhlele. J Athl Train H: 177193. 1999. ACL. Antenor cruciate b8ament

munication between the physical therapist and rhe onhopaedic surgeon remains paramount

[Q

determine the length of time

knee ligament injury In rhe female athlete (Table

22-8).

In

{hat the brace IS needed, goals that need to be obtai ned before

particular, Sporcsmetrics developed by Cincinnari Sports Medi­

advancing or graduating out of the brace, and the individual

cine, is

preferences of the orthopaedic surgeon involved. Most impor­

the athlete to preposition the entire body safely when accelerat­

a

plyometnc-type training program designed to teach

candy, expectations for whar the brace will allow the patient

ing (jumping) or decelerating (landing). The program uses a

to do and not do must be clear from the beginning. Many

series of jumping and complex multid irectional motions. These

patients view bracing as an infallible panacea for injury and

help provide neuromuscular retrai ning and reeducation. There­

rei nJury, and thiS IS clearly not the case.

fore at the completion of the program, acceleration, decelera­

Gender issues continue to play a role In ACL injuries.

tion, and multidirectional movements are safely programmed

Female subjects experience ACL tears more frequenrly than

into the body to establish a foundation of strength, coord ina­

male subjects, with an incidence rate between

2.4

and 9.7

tion, and overall physical conditioning

to

help prevent inj ury.

times greater than chat of male athletes competing in similar

Neuromuscular electrical stimulation and vo!Juonal muscle

activities. Potential reasons for the greater frequency of ACt

contractions also have been thoroughly evaluated. Consensus

tears in women I nclude a smaller I n tercondylar notch, general­

now shows that patients who undergo neuromuscular electrical

ized joint laxity, higher body mass index (BMI), hormonal

stimulation and biofeedback combi ned with volitional exer­

Auctuations, and altered neuromuscular fitlng patterns. Female

cises achieve morc normal gait parameters and better restora­

subjects, both adult and children, also have higher knee valgus

tion of extensor strength compared With rehabihtation with

angles and moments during the variety of cutting, landing,

volitional exercises alone. Schneider-Mackler et al. W showed

and squatting tasks.

\1 Other findi ngs show female subjects

this i n a randomized controlled trial of rehabilitation after ACL

demonstrate decreased hip flexion, as well as knee flexion stiff­

reconstrllction using electrical stimulation and volit ional exer­

ness during (umng tasks. In addition, evidence Indicates that

cises In combination therapy versus vohtional exercises alone.

hip adduction angles during a variety of aCtivities are greater

They found that patients who underwent the combi ned therapy

female subjects and are posiuvcly related to knee valgus

had more normal gait parameters and stronger quadriceps

10

angles. v>�" Some of these factors can be found in Table 22-7.

muscles compared with patients who underwent volitional

1ncreasing evidence suggests that core and crunk strengthening

exercises alone.

will Significantly help with female ACL rehabilitation in all

Studies have also ind icated that balance, coord ination, and

patients. Further specific training programs have been thor­

perturbation training is viral in the rehabilitation of ACL inju­

oughly evaluated and scienti fically proven to decrease serious

ries. Floyd et al .lCl demonstrated that stabiliry and balance

530

Orthopaedic Physical Therapy

ACL Rehabilitation in Women: Eight Special Considerations and Specific Exercise Drills Exercise Drills

Considerations Hip musculature to srabilize knee

lateral step-overs (regular, fast, very slow) Scep-overs with ball catches Srep-overs with roration Lareral ncp-ups on foam Dip walk Squats (foam) (Balance Master) Front diagonal lunges OntO foam

Retrain neuromuscular panern hamstring comrol

Lateral lunges scralghe Lateral lunges Lateral lunges With coeation Lateral lunges OntO foam Lateral lunges with ball catches

Squau

unstable panern

Lateral lunges jumpmg Lateral unstable p.urern Coactivation balance through biofeedback Slide board Fitter (Fitter international, Calgary, Alberta, Canada) Control valgus movement

From srep-downs Lateral step-ups with Thera-Band (The HygieniC Corporation, Akron. OH) Tile board balance throws Plyometric leg press

Control hyperextension

Plyomcrric leg press with four corners Plyometric jumps One box • •

Two boxes Four boxes

Three boxes rotation Four boxes with catches Bounding drills Forward and backward step-over drills I l igh-s� training, espteially hamstrings

lsokinetic exercises Backward lunging Shunle Lateral lunges (fast Jumps) ResiSlance tubing for hamstring Backward running Squats on tilt board

Neuromuscular reaccion

Balance beam with cords Dip walk with cords Balance throws Balance throws perturbations Lateral lunges with perturbations omo tilt board Less-developed thigh musculature

Knee extensor and flexor-strengthening exercises Squats Leg press Wal l squats Bicycling

Poorer musculature endurance

Stair climbing Bicycling Weight tr aming (low weightS, high repetitions) Cardiovascular training Balance drills for longer durations

From Wilk KE. Arrigo ... lIel

C.

And�ws Jr, 1:( 011; Rl:h01bilit01tion after anu�rior cruciate ligamenl �onSlruction in Ihe (I:mall: alhll:ll:. J ArhJ Train 34: 177-19_�.

Antl:rior cruciale ligament.

1 999

Chapter 22 Surgery of the Knee and Rehabilitation Principles training stim ulated l igamenc and capsular propnocepcocs,

reinforcing cocomracClon of muscles. leading ro Improvemem

531

ognizes rhar a problem with mocion exists, aggressive coumer­ measures should be implememed to try and prevem a fixed

In joint srabiilry. This has also shown co be beneficial in

motion loss. Prone hangs. extension boards, and manual pres­

patients who have had nonoperauve treatment of ACl injuries.

sure can be used to help wich extension lags. Wall slides, leg

Chm ielewsk i er a l. I I demonstrated chat sub,eccs With oonop­

slides, and manual pressure can help i m prove flexion deficits.

eratlve ACL Injuries are five times more likely

If the loss of motion progresses to a fixed state, rhen surgical

[Q

successfully

cecum to high-level physical activities if they receive perturba­

imervemion is often required. Once this has been complered,

tion training than if they received scandard screngrhening and

aggressive rehabiliC3tion afterwards to maimain the motion can

condltionmg alone. Based on chis Informar ion, a thorough

be institured after the acute inflammacory phase has resolved.

program of rehabil itation after ACL reconstruction includes

Another ciced problem after ACl reconstruction involves ame­

rhe standard exercises of i ncreasing motion and strengthening,

rior knee pain, che patellofemoral joint being che mosc common

as well as percurbarion exercises chat stimulate rhe knee joint,

source. The licerature remains somewhar equivocal in provid­

l igamem, and capsular mechanical receprors, as well as plyo­

ing good evidence that graft selection plays a significant role;

metric exercises co Improve voluntary macuvarion urnes and

however, in a mulristudy analysis, there was shown to be a higher IOCidence of amerior knee pain wnh che patellar cendon

strength (Table 22-9),

group at 17'K versus the hamstring group at 12%. Sachs ec al. U showed a correlacion becween development of pacello­

Complications

femoral symptoms and che presence of flexion conrra([ure and

Complications have significandy decreased in recent years with

quadriceps weakness, thus leading co early lOiciation of reha­

Improved surgical techniques, graft choices, and graft fixation� however, rhey sed I must be thoroughly evaluated quickly and

bil i cati on and range of motion and pacellar mobilization cech­ niques. I n patients who begin to demons crate pacellofemoral

rhe �urgeon's attemion as soon as concern arises.

sympcoms or anrerior knee pain, che rehabilication program

brought

(Q

Loss of motion

IS

often (Ired as the most common complication

after ACL reconstrunion. Once tht physician or therapist rec-

should be modified to elimlnace exercises that might cause further aggravation. Additional, although rare, complications afcer an ACL reconstruction, parcicularly after central-chird

Table 22-9

Postoperative ACl Rehabilitation Program to Achieve Full Range of Motion

'

pacellar cendon autografcs, include excensor mechanism prob­ lems, pacellar fractures, pacellar cendon rupture, and even quadriceps rupture. A l rhough these are extremely rare, they do require immediate attention and should be thoroughly evalu­ ated. infeccion is anocher pocemial buc fortunacely a rare com­ plicacion, affeccing less than O.211f of pacients afrer ACL

Time After Surgery

Presuibed Program

[).I)'

Cominuolls passive motion «(PM) machme ror

of surger)'

reconstruction (Box 22-2).,11

elevation and gende motion Cryocuff for compression and cold therapy Full passive extension exercises for 10 minutes ever)' wakmg hour Static flexion to at

least 90

degrees In the

(PM machine three rimes a day ActJ\'e quad riceps comractions; actjvely lift leg OUt of the CPM machine Da)' after surgery

Same exercist.'S Dls{hargoo

10

us

day of surgery

home if goals arc mer: full

hyperextenSIOn 'qual t. to normal knee. flexion to at It.·ast 90 degrees. good quadriceps leg wmrol, minimal swelling FirM week .Ifter sur�cry

Cuntlnue with prescribed cxerClSI:� Limit activities to eating and buhroom pflvi legt:s

Set:ond week after surgery

2 to 5 wet:ks after surgery

AddJ{Jonal exerci�s added to program: prong hangs. wall slides

Knee rehabllitacion afcer an IncraarCicular fracture of che knee has many variables. In general, the principle of early mocion scill prevails. I�.I� The major modificacion concerns che weighc­ bearing Status. The m�lIn goal in fi xaci on of chese cypes of fractures is anacomic alignment of che arcicular surface_ This can be accomplished through a variety of surgical interven­ cions. ranging from minimally Invasive cechniques to large open procedures. External fixacors, comoured places, and can­ nulaced screws are some of rhe choices available. Fracture SC3billcy is dependent on fracture paccern, fixacion techniques.

pacienc bone qualicy. and comorbid condlflons. Initially chere will be a period of l imned weight beanng (nonweighc beanng

Extension board used jf nceded

or [Quch toe). This usually will progress ro ful l weighc bearing

FuJI wClght-lx·aring with normal gait

over 8 co 12 weeks. However, chis is surgeon dependent, with

Additional exercises added to program heel slides, stationary biq'cle, Stairmaster

From Shdoournc KD. P,m-I DV: Trcatmc:m 01 limittJ mmion aftcr anterior uu(iJt� IiSJmem r«omtrutuon. Knt'(' SurE; SpOrt!. TraumJtol Anhrosc

7(l):R�-92. 1999

TRAUMA (EXCLUDING EX TENSOR MECHANISM ISSUES)

ACt. Anterior uuuatt' li":ilITlent

che preVI Ously menCloned faccors pla ying a role on che indi­

vidual pariem's fraccure healing. In addicion, anention must

be given co rhe fooc and ankle co help prevent an equinus contracture during che limited weight-bearing period. Early range of motion will generally be starced wichin the first post� operative week; CPM machines can be used co help facilitate

532

Orthopaedic

Box 22-2

PhYSical

Therapy

What Are Bone Bruises. and How Should They Be Treated and Rehabilitated?

Magneut rtMln(;y (RMI, In(., AII.lOt.l, Ga,)

Rehabilitation After Articular Cartilage Repair Procedures

late matrix production and Improve mechanical properties,

Reinhold et al. II. have published an excellent review of current

CP�.f machines and adherence to blcyclmg prog rams will

concepcs in che rehabi htacion after arcicuJar cartilage repair

achieve prescribed range of mocion while preventing arrhr06-

procedures

10

[he knee. They emphasize the physical therapls[

brosls. Controlled weight-bearing actiVIties are facilitated by

must ((eace an environment that facilitaees the healing process

use of assistive devices, pool therap}', and force platforms,

while avoiding potentially harmful forces to the repair site. The

which

ewo canons of rehabilitation of articular cartilage procedures

Physical

are weight-bearing restriccions and prescribed range of morion

patienes is one of the most demanding rypes of knee rehabilita­

limitation. Individual approach is of course necessary, given

tion. Gradual l y Increasing the amount of stre..s applied to the

provide

pat ients wlch

therapy

weight-bearing blOfetdback.

mOOitOrlng of articular cartilage

repair

the vanety of articular cartilage procedures that are often done

Inj ured knee must be constantly reevaluated. Patients who

In combination with other surgical repairs, A gradual progres­

develop

sion in weigh[ beanng and range of motion will nm only

provide a surefire sign that t he rissues ilrt' being overloaded,

prmecr the healing cartilage bue also has been shown to stimu-

and It is wise to avoid the painful swollen knee.

inordinate pain or effusion dUring rehabilitation

Chapter 22 Surgery of the Knee and Rehabilitation PnnClples

Box 22-4

533

Red Flags in Knee Rehabilitation

Sympathetic Mediated Pain

in the weeks after surgery as the effects of preventative antibiotic

Untoward pain with joint stiffness and red andlor shiny skm

agenrs given at surgery wane and bacteria gain a foothold into

should give concern for impending reRex sympathetic dystrophy.

injured or surgically operated tissues. A sudden report of increased

Early intervemion by pain conrrol physicians should � Invoked.

pain, along wah decreased Joint motion, should raise cherapy

Treatment involves not only Increasing pain medications but also

concern. Not aU patients demonstrate fever, but the wurmth of

a slow, (aunous approach to physical therapy durmg the initial

infected tissues is ofren dramatic. Immediate medical anention is

phases. fn add iuon. j( is often accompanied by assesm s ent of the

in order, and ora! antibiotic agents may unwittingly mask a

parient's mental health and any effect that chronic disabling pam

�rjous, deep infection, whereupon medical attention is required

may have. Recent "pproaches have featured the use of neurotrophic

as soon as possible to obtain relevant aspirated cultures. Patients

medications and psychlacric and psychologic counstling.

with deep infenion will require surgical attention and, perhaps, prolonged intravenous antibiotic agents. The situation becomes

Infection

complicated when patients are placed on suppressive oral antibiOtic

Most kn� injuries will create erythema and warmth. Postsurgical

agents, which are not curative but rather suppress and mask

patients arc no different. Most jX)Scsurgical infections may not

an

�ome apparene immediately after surgery. inStead they are noted

destruction.

According

co

Reanhold cc aI.,ii, carrilage repair rehabllita­

rion is based on four biologic phases. During phase I-the proliferarion phase--carrilage healing requires absolute prorec­

Insidious process that could

result

tn

permanent

Joint

Acupuncture Acupuncture remains a controversial adjunct in rrearing

cion againsr any excessive load during rhe first 4 to 6 weeks.

injured or arrhritic knees. Manhelmer et al.P rreated patlems

The role of rhe physical therapist is to maintain prescribed

with osreoarthritis over 26 weeks, comparing a rrue acupunc­

range of motion and muscle srrength. During phase 2-rhe

ture group with a sham group. Acupuncture seemed to provide

mlOslrion phase-which usually consises of weeks 4 to 1 2 afcer

Improvement in function and palO relief when compared with

surgery, rhe repaired [issue is galOlng strengch, which allows

credible sham acupuncture. The mechanism of aerion proves

for progression of rehabilitation exercises. During chis time,

elusive. Optimal effecrs rook a minimum of 8 weeks for func­

muscle strengrhening and endurance are featured, alrhough

tlonal lmprovemenr and 1 4 weeks for maximal pain redunion.

weight-bearing scams may still be restricced. In phase 3-the

From a physiologic perspecrive, chis delayed response is not

remodeling phase-the activities chat take place from 3 rO 6

consistent with rhe mosr commonly proposed mechanisms of

months postOperatively allow for more funcrlonal training

acupuncture (gate control or neuropeptide release). This study

while cunailing vigorous aniviry in light of pain or effusion.

was additionally flawed because parients were nOr conerolled in

Low- co moderate-impact activities will be allowed, but

pursuing any orher physical rherapy or using nonsteroidal anti­

running, Jumping, or twisting musr remain prohibited during

inflammatOry drugs (NSAJDs) or Cox-2 inhibitOrs. I

the cartilage healing and remodeling phase. In rhe final and founh phase-the mamration phase-rehabilitarion conrinues from 4 co 18 months after surgery. It is assumed thar any

CONCLUSION

canilage healing has occurred and rhat the patient may return to impact-loading accivicies.�6

This chapter outlines many of the more common knee condi­

Many aurhors have demonscrated that a rerum co com­

tions treared by rhe orrhopaedic physical therapisr. The physi­

petirive athletics can occur for microfracmre, OATS, and

cal therapiSt mUSt have a thorough understanding of rhe

ACt procedures. Chondral debridement and microfranure pro­

pathologic condition and a solid understanding of the currene

cedures should allow for return co spore in 4 to 6 months

l iterature and research regarding rhese injuries co effeceively

after surgery, whereupon canilage rransfer proceduresl such

rrear rhe knee patient in an evidence-based manner and co

as ACI or OATS, demand a minimum of 1 0 to 18 months

promote optimal outcomes.

before spons activity loads are permlned. Although ir would be ideal co know the exact extent of articular carcilage healing, clinicians' understanding IS hampered by the fact

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Chapter 22 Surgery of the Knee and Rehabilitation PnnClples

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(HAPTE R

23

Allen Carpenter and Robert A Donatelli

Dysfunction, Evaluation, and Treatment of the Foot and Ankle

This chapter briefly reviews the anatomy and normal and

occurs in all three body planes simultaneously), a complex

abnormal biomechanics of the foot and ankle. Various foot and

series of supination and pronation motions occurs there.6 In the

ankle pathologic conditions are also discussed with respect co

open kinetic chain, supination is defined as inversion, plantar

parhomechanics, evaluation, and treatment. The pathologic

flexion, and adduceion of the calcaneus on the talus; whereas

conditions include encrapmenc syndromes, traumatic injuries

pronation is defined as eversion, dorsiflexion, and abduction of

co rhe foot and ankle, and foor deformities. The biomechanical

the calcaneus on the taius.4-8 These joint motions are governed

evaluation of the foot and ankle is also described.

by ligamentous tension and bony restraint mechanisms. The d�ltoid, anterior and posterior talofibular, and calcaneofibular ligaments prevent excessive motion from occurring at the sub­

NORMAL BIOMECHANICS

talar joint_J-'·7.9 The rearfoot is separated from the forefoot by the midfoot, which is made up of the navicular and cuboid bones. The

Anatomy Some

30

midtarsal joint is the major articulation of the midfoot, and it

bones comprise the skelecal scrucmre of rhe foot and

is composed of the approximation of the navicular and cuboid

ankle.I.) This osseous scrUCture can be broken down inca a

to the talus and calcaneus, respectively.I-) As in the subtalar

forefoot, a midfoot, and a rearfoo( section. In the rearfoor, rhe

joint, the triplanar motions of supination and pronation occur

osseous structures of clinical imponance are rhe distal ends of

at the midtarsal joint. These triplanar motions at the midtarsal

rhe fibula and tibia, the talus, and the calcaneus. These four

joint occur about two joint axes:

bones interact

oblique. The longitudinal axis extends lengthwise through the

(Q

serve as supportive structures and pulley

(1)

longitudinal and (2)

systems for the various tendons that pass over the bones.6 The

foot and slopes upward and medially. 10 The mOtions of eversion

tibia, fibula, and talus together form a hinge joint: the talo­

during pronation and inversion during supination in an open

crural joint. Two types of motion occur at this joint:

kinetic chain occur about the longitudinal axis. Clinically,

(1)

arthrokinematic.2-7 Osteokinematic

inversion and eversion about the midtarsal joint can be observed

movement is the overall movement of two bones without refer­

in the normal rise and drop of the medial arch of the foot in

osteokinematic and

(2)

ence to the motion occurring between the joint surfaces (i.e.,

the weight-bearing posicion. to The oblique axis of the midtar­

flexion and extension). Arthrokinematic movement is the

sal joint is described by several authors as being inclined 52

motion actually occurring between the tWO joint surfaces (i.e.,

degrees above the horizontal and 57 degrees from the fromal

roll and spin).)

plane.1O About the oblique midtarsal joint axis, the open

Plantar flexion and dorsiflexion are the osteokinematic

kinetic chain motions of plantar flexion and adduction occur

motions occurring at the talocrural joint. Osteokinematic

duting supination, whereas dorsiflexion and abduction occur

movement at the talocrural joint is governed and restricted

during pronation.6•7•11 Ligamentous structures restraining the

primarily by the bony configuration of the joint surfaces. The

motions of supination and pronation are the bifurcate, spring

primary arthrokinematic joint motions of the talocrural joint

(calcaneonavicular), short and long plantar ligaments, and the

are roll and slide. Several ligaments help restrict the arthro­

plantar aponeurosis. H

kinematic movements found at the talocrural joint. These are

The osseous StruCtures of the forefoot are the three cunei­

the anterior tibiofibular, the anterior and posterior talofibular,

forms, the five metatarsals, the twO plantar sesamoids of the

the deltoid, and the calcaneofibular ligaments.2-7

first metatarsal, as well as the 1 4 phalanges. These bones form

A second joint found in the rearfoot, the subtaiar joint, is

several joints, of which only the metatarsophalangeal (MTP)

composed of the calcaneus inferiorly and the talus superiorly.2-8

and interphalangeal UP) joints will be briefly discussed because

Because the axis of the subcalar joint is triplanar (movement

it is the normal mobility of these joints that enables normal

537

538

Orthopaedic PhYSical Therapy

movemem and srabilHY of rhe (orerom. The mctacarsal heads rolerare the vertical forces of weight bearing while rhe toes stabilize rhe forefoot

dynamicall}'.

of 60 degrees of MTP extcnsion is needed for normal �·(TP funcrion during gair.I.t.·I· �,

The MTP JOint IS an

ellipsoidal joint char allows the osreokinemaric motions of abduction, adduction, flexion, and extension to occur. The IP joims ace pure hinge Joines chur allow the osreoklnematic

Weight-Bearing Motion Some differences exist between weight-bearing and nonweight­

motions of flexion and extension to occur. Both joints have

bearing marion in the foor and ankle. These differences are a

proper joinr capsules wirh accompanying suppornve ligamen­

resulr of rhe gravitarional and ground reaerion forces imparted

COliS Structures.

to rhe foot and ankle dunng weight beanng.t.·I'.I

1

II.'j

The foot has several muscles of clinical importance. The role

One such dife f rence III

many of chese muscles pia}" in rhe produ([ion of pathologiC

is

condition 10 rhe foot is covered in the discussion of foot patho­

{Jon In the weight-bearing condition. the calcaneus Inverts

logic conditions. Some of chese muscles are rhe gasrrocsoleus­

while rhe talus dorsiflexes and alxluccs.(i

tendoachilles complex, the peroneus brevis and longus, and the

(Jon rhe calcaneus everts while the talus plamar flexes and III. adducrs.'·1.., 1 The ··? In this type of fracture,

tunnel.�H.\II,'.1 Misalignment of (he bony structures of the talo­

direct damage occurs (Q rhe mlus as a resulr of the applied force.

crural jOint secondary to trauma and fracture can be considered

A secondary event may be disruption of the inferior tibiofibular

a combination of Internal and external pathologic conditions

syndesmosis as In an Inversion or eversion II1jUry.ll0.\9

causing a diminished tarsal runnel diameter. All of these patho­

Metatarsal fractures generally involve either the first or the

logic condirions may compromise the runnel either by occupy. 109 or by dcueasing its space.1!l H

fifth metatarsal and can be a result of either trauma or excessive stress.'\() The mechanism of injury

111

a (raumatic fracture of the

541

Chapter 23 Dysfunction, Evaluation, and Treatment of the Foot and Ankle first merararsal usually involves an abducrion and hyperAexion

Classically. four stages occur in rhe progression of this

or hyperextension force.l9·ill In a traumatic fracture of the fifth metatarsal, the mechanism of injury usually involves inversion

hallux deformiry. The predisposing fanor is a hypermobaliry . of the first meratarsaI.6 44,�1 This hypermobdity allows rhe

of rhe fooc. The peroneus brevis comracts forcefully to prevent

hallux to abduct and the first metatarsal to adduct and invert

rhe excessive inversion, thus avulsing the sryloid process of rhe

on the tarsus and the hallux. Abnormal pronation is usually

fifth meta[arsal.��·\6

the cause of the hypermobility of the first metatarsal."· "Any

Suess fractures are usually rhe result of hyperpronation of rhe midtarsal and subraiar joinrs.6.29A1 The hyperpronarion pre­ vems rhe foot from locking because of rhe lack of subtalar joint

structural or neuromuscular problem causing abnormal prona­ tion or a laterally direered muscular force may lead

abductovalgus deformity.b...jA1

(Q

a hallux

.

supination. Instead of being transmitted up the kineric chain,

In stage one a lateral subluxation of rhe base of the proximal

rhe forces of propulsion are diSSipated within rhe foot, which

phaJanx is seen on the roentgenogram. Abdunion of the hallux,

IS incapable of handling the extra stress of rhe propulsive

with indentation of rhe soft tissues larerally, IS seen once stage

(orce5,". 11 However, stress fracmres can also be a result of a lack

tWO is reached. Merararsus adducrus primus, an mcrease of rhe

of pronation in rhe subtalar joim (the supinated foot). If the

adduction angle between the first and second metatarsals, is

.

subtalar 10Int is unable to pronate. rhen proper shock absorp­

the hallmark of stage three of the deformity. A subluxation or

tion of rhe forces of compression does not take place, which

dislocation of rhe first MTP joint charactenzes srage four, with

places excess stress on the osseous s[fuctures.b

the hallux nding over or under rhe second roe." Once stage four IS reached, secondary complications can Include rhe develop­ ment of a hammertoe deformiry of rhe second toe, all the lesser

Sprains The mechanism of a talocrural sprain is eirher lateral or mediaL

toes may be dictared into valgus, andlor the enrire forefoot can fail, allowing excessive loads to be transferred OntO the It:ss{'r

with or without.1 torsional force component. In a lateral injury,

metatarsal heads.-j(o If forefoot failure occurs, then transverse

the mechanism involves an inversion force. The injury may

metararsaJgia is likely with concurrent Increased risk of stress

Involve ligamentous damage occurring in the following order:

fracrures.u.

rhe anterior talofibular, ca1caneofibular, posterior calofibular, and posterior tibiofibular ligaments. As more ligaments become . . Involved, the severiry of the injury increases.!K N u Medial mechanisms of injury are rhe resulr of eversion forces. The deltoid and tibiofibular ligaments are usually rorn in this type of Inlury.JH..'9.U An associated fracture of rhe fibula is {he USUJI complic3rion of an eversion injury.1K19.i6.J9.41 Medial inluries are rare compared wirh lateral injuries.

Hallux Rigidus and Hallux Limitus Hallux rigidus is a hypomobility of the first MTP Joint. I iallux Iimitus is an ankylosing of the firsr MTP jOint. A rigldus . il precursor to a Iimirus deformlry.L'I '

deformity may be

Several causes of hallux limirus deformity exist. llypermo­ biliry of the first ray associated with abnormal pronation and

MTP sprains normally involve a hyperAexion injury ro the

calcaneal eversion, immobilization of rhe first MTP joint,

JOint. Capsular tearing, articular cartilage damage. and possible

degenerative joinr disease of rhe firsr MTP joint. rrauma

fracturing of the tibial sesamoid are seen In MTP joint

causing an inAammarory response of the 101nt, metiltarsUS

sprains.!!(�, This type of injury is rhought

to

be a cause in

hallux limitus deformities." Tibiofibular sprains are frequently a secondary involvement of talocruraJlnJuries or

il

primus elevarus, and an excessively long first metatarsal may all be precursors.6.l8.l9 All of these precursors cause immobiliza­

resulr of a compression inJury.28 Frac­

cure of the dome of the talus or of the distal end of the fibula . is a poSSible complicarion.�H w The mechanism of injury often involves a rotational or compressive force with a concomitant ? ,!').I'J dorsiRexion force. H

tion of the first MTP joint. As a result of chis immobililaraon of a synovial joint, a limicus deformity occurs. j-.'(I The parhomechanics of a hallux lim.rus deformiry .Ire due to two problems:

(I) an mabillty of the first metar;.trsal to

plantar Rex or (2) an inability of [he firsr MTP JOint to dorsiflex. Abnormal pronation of the subtalar joint prevents rhe firsr metatarsal from plantar Rexing because of the effecr of ,ground reaction forces on rhe metatarsal. Ground reanion forces c.Ior­ siAex the first metatarsal during abnormal pronarion. An exces­

Pathomechanics

sively long first metararsaJ can also prevent the merararsal from plantar flexing. Any trauma or inA;lmmarory disease thar causes

Hallux Abductovalgus

bony deformation of rhe first MTP joint can prevent normal

By definition, hallux abducrovalgus IS adducrion of the first

MTP joint marion. If [hiS rype of immobilization continues

metatarsal wirh a valgus deformity of the prOXimal and distal

untreated, then the end result will be a ngidus (or ankylosed)

phalanges of the hallux.6

n

..

Hallux abductovalgus may be a

lI

deformity of the first MTP joint.f>·lH.

resule of hypermobility of the first metararsal in a forefoor adducrus, rheumatOid InAammarory disease, neuromuscular disease, or a resulr of postsurgical malfunction.6.44 n In all of

Tailor's Bunion

these conditions, a subluxation of rhe first MTP joint occurs

Tailor's bunion is the mirror image of an abducrovalgus defor­

Initially, followed by dislocation.6.44..ts

mity of the first ray occurnng at rhe fif[h MTP joint." Adduc-

..

542

OrthopaedIC Physical Therapy

cion of [he fifth coe and abduccion of [he fifth metatarsal are seen in chis deformity. 6,J4 The cause of a tailor's bunion can be broadly grouped as eicher srruccural or biomechanical.H Struc­

Claw Toes A claw toe deformity occurs when the MTP joint IS In exten­

rural causes can include pressure over the laceral aspen of the

sion and the DIP and PIP jOintS are In flexion.

fifth metatarsal head from right shoes, scaric foot posturing (as

possible causes are forefoot adducrus. congenirally piamar

. ':.\

,

The

in Tailor's), or a prominem lateral condyle.H Four biomechani­

flexed first metatarsal, arthCltls, spasm of the long and short

cal causes of Tailor's bunion are

toe flexors, weak gastrocnemius, forefoor suplnarus, and pes

(l)

abnormal pronation,

(2) uncompensated. forefoot varus, (3) congenital dorsiAexed fifth metatarsal, and metatarsal.�2

(4)

congenitally plamar flexed fifth

cavus.6•J2 Forefoot adductus, congenitally plantar flexed first ray, fore­ foot supinatus, and pes cavus all have rhe same parhomechani­

Abnormal pronation is reported [Q be a factor in the cause of Tailor's bunion.6.'2 For abnormal pronation

(0

cause a Tai­

lor's bunion, one of [he ocher causative factors nored previously

cal effect on the toes.'" The adduction angle of the metatarsals and the abduction angle of the phalanges increase. Instability of the MTP joints occurs as

a

result of this malalignment. The

mUSt also be present.6 Abnormal pronation causes hypermobil­

function of the lumbricals and flexors of the toes is alcered as

ity of the fifth metararsal. This hypermobility produces inter­

a result of the combmed effect of IOstabiliry and poor JOint

nal shearing between rhe metatarsal and rhe overlying sofr

position. The aJternrion of these muscle groups instigates

tissue. As the deformity progresses, the events described in the

extension of the MTP and flexion of rhe DIP and PIP jointS of

hallux abducrovalgus deformity occur.6

all the digitS of the foor."

varus, exceeding the range of

Arthritis of the MTPs leads to an overstretching of the

motion of pronation of the subtalar joint, causes the fifrh meta­

restraining mechanisms of the extensor tendons of the toes,

tarsal CO bear excessive weight. This excessive weight-bearing

much the same as In arthCltlc condItions of the hand. ThiS

Uncompensated forefoor

forces the fifth metatarsal co dorsiflex and evert. The dorsiflex­

oversrretching aJlows the rendons to drift laterally and alter

ion and eversion cause the fifth metatarsal co abduct and the

their line of pull. Again, the alteration of the line of pull causes

proximal phalanx of the fifth roe to adduct, resulting in a

the toes to be abducted, and the claw toe deformity ensues.

,l

During heel-off and toe-off, the aCtivity of the long tOC

Tailor's bunion.6 Congenital plantar flexion of the fifth metatarsal prevents

flexors increases to compensate for a weak gastrocnemius. The

the fifth metatarsal from dorsiflexing beyond rhe rransverse

Increased toe flexor activity overpowers rhe extensors of the

plane of the other metatarsal heads. This plantar flexed attitude

toes, resulting in a claw toe deformity. Spasm of the long and

and abnormally pronating foot cause the fifth metatarsal to

short toe flexors can cause a claw toe deformity

become unsmble. Ground reacrion forces force rhe fifth meta­

fashion.6

10

a similar

tarsal to evert, abduct, and dorsiflex. Eventually the fifth meta­ tarsal subluxates and is no longer functional.6 The last cause of a Tailor's bunion is a congenitally dorsi­

Mallet Toes

flexed fifrh metatarsal. The only visual abnormality present is

Mallet toe refers to a flexion deformity of the DIP of one or

a dorsally located bunion. The dorsal attitude of the fifth toe

more of the lesser toeS.'6 The flexed attitude mily be fixed or

causes abnormal shearing between the bone and the overlying

malleable. The cause of mallet toe deformity is uncertain.

dorsal soft tissues. This abnormal shearing is due to the firm

Some authors speculate that the condition is congenital or rhe . result of wearing shoes that are nOt long enough.ll·u \l> Other

fixacion of the soft tissues by the shoe.6

�M

proposed causes include traumatic, idiopathic, and neuromus­ cular disorders, Increased length of the lesser toe involved, and

Hammer Toes

use of high-heeled shoes with a narrow tOC box.'"1'1

In a hammer toe deformity. the MTP and distal interphalan­ geal (DIP) joints are in extension while the proximal interpha­ langeal joint (PIP) is in flexion.6•H•H.H Hammer toe can be

Plantar Fasciitis

flexible (dynamic) and (2)

Plantar fasciitis involves an overstretching of the planr.lr fascia

fixed (stacic). The determinant between the twO classifications

causing an inflammatory reaction, usually near rhe fasCIa's cal­

is dependent on whether available motion exists at the PIP

caneal attachment. The cause IS multifactorial, with mechaOl­

classified into twO categories:

(1)

joint.26 Plantar flexed metatarsals, loss of lumbrical function,

cal overload generally believed to be fund..memal in the

imbalance of interossei function, paralysis of the extensors of

development of the condltion.'" Excessive pronation has been

the toes, shorcness of a metatarsal, forefoot valgus, hallux

found to be an important mechanical cause of the structural

abductovalgus, trauma to the MTP joint causing instabiliry.

strain, which results in pIamar fasciitis.l>Il However, work­

and subluxation of the fifth toe into pronation are all possible

related, weight-bearing, training errors

causes of a hammer toe deformity.6.31 The common denomina­

chanical abnormalities Including, but nOt limited to, a tight

10

athletes and blome­

ror among all of these pathologic condicions is the production

Achilles tendon and reduced talocrural dorsiflexion are common

of a force Imbalance across the MTP joint. This force imbalance

predisposing factors.(,1.61 Without regard to the mechanical reason for decreased dorSiflexion (bony abnormality or tight

may lead to a joint instability of the MTP or an imbalance of the muscles crossing rhe MTP joint "'·6.�1 .

Achilles tendon) at the ralocrural joint, the resuh is compensa-

Chapte r 23 Dysfunction, Evaluation, and Treatment of the Foot and Ankle

cory excessive pronation. During gait, rhe planear fascia is overstretched, with excessive pronation and extension of rhe MTP joinc occurring simultaneously. Therefore any individual who abnormally pronares during rhe push-off phase of gait is at risk of developing plantar fasciiris. The presence of a pes cavus foot also predisposes the individual to chis condition, because in pes cavus the plantar fascia is already tight even when rhe foot is at resr.H•64-U These factOrs result in repetirive microrrauma and microtears, which impede rhe normal healing processes and result in rhe inAammacory rea([ion.�9

GENERAL E VALUATION Muscu los ke leta l Eva luation A foot and ankle evaluation begins with a visual inspection of rhe lower extremity as a whole. Any muscular imbalances affecting struccural alignmem and possibly altering normal mechanics are nored. The examiner then focuses on the foor and ankle. Areas of redness, ecchymosis, effusion, edema, bony anguJarion, and callus formarion are noted.9.'U4 The visual inspecrion is followed by a palparory examinarion, Any areas of renderness and increased rissue tension are discerned.9,H.,oI Next a range-of-motion evaluation noting the amount of dorsiflexion and plantar Aexion of the talocrural and MTP joinrs is performed.9.B.,4.67 For normal function of the lower extremity. at least 10 degrees of dorsiflexion and 30 degrees of plantar flexion of the talocrural joint should be seen,6.9.68 In addition, at least 60 degrees of dorsiflexion should be present for normal function of rhe first MTP joint.'7.1M9 A gross manual muscle test (MMn of rhe musculature about the ankle is performed next.9.H.,� Consideration should be given ro evaluating the strength of the ipsilateral hip and knee musculature as well. given their contribution to lower kinetic chain mechanics, For a more quantitative test of ankle muscle strength, an isokinetic evaluation can be performed. The examiner should expect to see normal absolute peak torque values 3r 30 degrees/second and at 1 20 degrees/second for all muscle groups rested, Peak rorque values for ankle everrors and invertors should be around 2 1 feet/lb for men and 1 5 feetllb OK MJW for women at 30 degrees/second. At 1 20 degrees/ second, the torque values should be around 1 5 feet/lb for men and 1 0 feet/lb for women.70•7 1 A general overview of the neurovascular Structure ends the general screening evaluation, Areas of decreased sensation and areas of hyperesrhesia are nored. A general circulatory examina­ tion is performed (0 establish circularory ,"tegrity of the arte­ rial supply to rhe foor and ankle. The dorsalis pedis and posterior ribial pulses are established.9.B.,4

Speci fic Eva luative Proce dures Tarsal tunnel enteapmenr may bf discerned by twO specific manual testS: (I) hyperpronation and (2) liners sign.19.3I," Hyperpronation of the subtalar joinr decreases the diameter of

543

the tarsal runnel. During the hyperpronation test, the subtalar joint is maintained in excessive pronation for 30 to 60 seconds. 'II A positive test results in the reproduceion of the patiem's symptoms on a consistem basis. In Tine!'s sign the examiner raps the posteriot tibial nerve proximaJ to its emrance to the tarsal tunnel. A positive test again results in the reproduction of the patiem's symptoms. Along with these twO manual rests, MMT and sensory resting are perfotmed to determine the extent of nerve trunk compression. Weakness, as determined by a MMT, of the muscles innervated by the medial and lareeal plantar nerves may be indicative of a peripheral nerve enrrapmenr at the tarsal runnel.19,}1 Sensory tests are performed to determine rhe pres­ ence and extenr of areas of hypoesthesia. These areas should correspond to the particular areas of innervarion of the involved nerves, 28.29.1 1 Electromyography (EMG) studies can also be performed to further document rhe presence of tarsal tunnel entrapmem. Latencies greater than 6.2 and 7.0 seconds ro the abduceor hallucis and the abductor digiti quinri. respectively, are indica­ tive of emrapmenr of the posterior tibial nerve at the tarsal tunnel. 211 The history obtained by the clinician will usually elicit complainrs of burning, tingling, or pain in the medial arch or the planrar aspect of foot. These symptoms usually are aggra­ vated by increased activity. The patient may complain of nocturnal pain with proximal or distal radiation of symptoms.2S.29,}1 During the general evaJuation, the clinician may notice a valgus attirude of the calcaneus during static standing. This posicion of the calcaneus may be a predisposing. perpetuating. or precipitating factot in tarsal runnel entrapment. One other evaluative procedure, a biomechanical foot evaluation, is also performed. In rhis evaluation other predisposing, perpetuating, or precipitating factors of rarsal tunnel may be discovered (e,g excessive subtalar joint motion).6.18.29,JI This portion of the evaluation is discussed in derail later in this chapter. Patients with neuroma typically present a history of acute episodes of radiating pains and/or paresthesias imo the toes. The onset of the pain is sudden and cramplike, Initially. the symptoms occur only when the patient is wearing shoes that compress the toes; with time the pain may become intractable. The parient reporrs that the symptoms are or were alleviated by the removal of shoes and massaging of the toes,6.28-12 Clinical signs can include tenderness within the affected inrerdigiral space, pain on metatarsal head approximation. andlor Mulder's click (felt by the examiner as the heads of the metatarsals are compressed and the planrar tissues are pushed dorsally into the space),nn Fractures and sprains of the talocrural joint are evaluated in much the same manner, The major d ifference is that the clini­ cian must wait until a fracture has healed sufficiently before proceeding with any evaluative tests, whereas in a patient who has sustained a sprain, the clinician may apply the evaluative tests immediately, The evaluation generally consists of obtain­ ing a history, performing range-of-motion measurements, strength testing, noting the presence of edema or effusion, and .•

544

Orthopaedic Physical Therapy

noung {he presence of any residual deformity In (he foot and

A biom("Chamcal foot evaluation will also be benefiCial in

ankle.

assessin� rhe effect of any foot deformities may have on the

Range-of-mooon resting first assesses rhe os((:oklncmaric motion of rhe involved joinc. The joint I(self. as well as rhe joints proximal ;lnd distal to ie, are assessed. For example,

10

a

patient's lower extremity.

1(,. "

Two added components are found In the (:'valuarion of calo­ crural and tibiofibular spmins: ( I ) ligamentous lax ity and

(2)

ralocfural franur�, rhe range of morian of rhe MTP JOintS, rhe

(alar mobility [(:srs. Three ligamt'ntolls laXity resrs are used

hlp .lnd knee. as wel l as of rhe ankle is eval uated . Once

evaluate the integri t), of the talocruml ligaments, The first is

2,�- I )

[Q

to deter­

rhe osrcokinemaric movemems of Jny joints have been assesst'd ,

the anterior and posterior drawer rcst (Figure

rhe arrhrok mematlc movements of any restricred Joints are

nllne rhe Integflty of the antenor and postenor ralofibular liga­

evaluated. "J.

'I•. ,.

Additionally, inrermcrararsal joint play

motion should be assessed

[0

dcu:rmine any lack of mobility

neofibular and delroid ligaments.""v Talar mobility tesrs conSist

secondary co Immobi liLauon . Strength IS evaluated uSln� MMT techniques andlor iso� kinetic procwures. As In rhe range-of-motion testing. the JOints proximal to, distal to, ..md at the Site of injury are all tested .

'I

If Isok inctic tc!.(S

MC

performed. then tht- involvt:d

joint is [('sted at both slow ..md fast speeds.·\ Circumferential measuremtnts of the foot and ankle are ro

ments,"" The others arc the inversion and eversion stress tests (Figure 2,)-2), These tests evaluate rhe i ntegri ty of the calea­ of medial and lateral stress tests

( Figu n: 23-3).

These tests

eval u:ue the Integrity of the inferior talofibular syndesmosis. Palpation may also be helpful In Isolarin,!.: rhe ligamenrous tissues at faulc. J '.'I In p..lthomechanlGll conditions, the major portion of the assessment I,;onSlsts of a blOmechanlcal 10m and ankle evalua­

document the presence of effusion or edema. The Aex­

tion and a proper medical workup. The m('ss test

Chapter 23 Dysfundlon, Evaluation, and Treatment of the Foot and Ankle

545

Visual Inspection The biomechanical evaluation beg ins with a visual inspc!ction of the lower extremities while the patient is standing with the feet shoulder-width apart. The clinician needs to have visual access to rhe patienr's entire lower quarter. The examiner observes for postural deviations or for signs of lower-extremity deviations.�6 Transverse plane rotations or torsions from the hip, femurs, knees, or tibias can be viewed from the front or from behind. Frontal plane deviations of varus or valgus of the tibias are viewed from behind; the examiner can view saginal plane deviations from hip flexor or extensor tightness (or genu recurvacum) laterall y.�6

Static Supine-Lying Evaluation

Figure 23-3 Medial talocrural stress lest

During the supine-lying portion of the evaluation, the first step is to observe the foot for the presence of any callosities or deformities. Mldfoot mobility is cested by a supination and pronation twist. The calcaneus is stabil ized with one h.tnd

preseming deform icy.6 Obtaining a good hiscory from the

while a supination and pronation force to the forefoot is applied

padent may be helpful initially and larer on when assessing rhe

with the orher (Figure 23-4). Next the range of morlon of rhe

effects of any treatments.

firSt M.TP joint is noted (Figure 23-5). The amount of in ter­

One pathomechanical entity requiring a slighdy di fferent

metatarsal mobility is evaluated by applying inferior and supe­

evaluative procedure is plan cur fasciitis. Along with a hiscory.

flor forces and assessing the degree of resistance that is met by

medical workup, and biomechanical evaluation, rhe cli nician

the cli nician's hands. Finally, the angle of pull of the quadri­

needs co perform a specific palpucory evaluation of the plantar

ceps muscle

fascia and calcaneal area. In rhe history. rhe parienr will com­

measured by placing the axis of a goniometer over the center

(Q angle) can further be measured . This angle is

plain of pain and tenderness localized. CO rhe plantar aspen of

of the patella, With the stationary arm aimed at the anterior

rhe foot. The pain may rad iate forward along rhe plamar aspen

superior iliac spine of the pelvis �tnd the mobile arm in line

of rhe fOOL Usually rhe pain is noted on standing after waking

With the tubercle of the tibia. The previous measurements are

in the morning or after a period of slismined nonweight bearing,

compared with chose of the other limb for any dissimilari­

and it worsens as the client increases the distance he or she

ties.6.29.H."'1.n Measurement results should be compared with

walks or runs.

the uninvolved lower extremi ty.

On visual Inspection of a patient with plantar fasciitis, the clinician may nOte the presence of a cavus foo[. Edema of the medial plantar aspect of the heel may also be seen on visual

Static Prone-Lying Evaluation

inspection. Palpation may reveal point tenderness localized to

The patient is positioned in a prone-lying attitude, with both

rhe medial aspeer of the calcaneus.19,6\.(i1 Passive toe extension

lower extremities over the edge of a supporting surface so that

may also reproduce the patient's paln,B

the malleoli of the ankles are even with the edge of the surface.

The chief physical therapy evaluative procedures for all of

Visual inspection of the lower extremity consists of noting the

these conditions are a biomechanical gan analysis and a general

presence of callosities and bony deformities of the foot and

lower kinetic chain evaluation Including the ankle-foot, knee,

ankle.6.29,5' Next the range of motion of ralocrural dorsiflexion

and hip range-of-motion and strength testing to determine any

and plantar flexion is evaluated with the knee in extension

perpetuating. predisposing, or precipl(3ting fanors to the

(Figure 23-6).

developmem of these conditions. For a more detailed descrip­

One of the client's lower extremities is placed in slight knee

tion of proximal joint contributions to lower-extremity dys­

flexion and abduction, with flexion and external rotation of the

functions, the reader should refer to the chapter on

and Trammg of lht Co,., (Chapm I S).

Et"fIlllaliofi

hlp (Figure 23-7). This posture ensures rhat the opposite extremity is in a plane parallel with the ground and the sup­ porting surface, keeping the foot at a right angle to the floor. Longitudinal bisection l i nes are now drawn with a fine-tip

Biomechanical Evaluation

marker along the posterior aspeCt of the lower third of the calf

The biomechanical assessment of the foor involves several steps.

and heel of the lower extremity.

The evaluation begins with the visual inspection of the patient

to draw these bisection lines accurately. The clinician should

�IC

It is extremely important

in a sranc srandmg posture, followed by static supine-lying,

make every effort to choose the same anaromic landmarks con­

static

sistently to ensure the reliability of present and furure measure­

prone-lying.

analyses.

static

standing.

and

dynamic

gait

ments. If the clinician ensures the consistency of the location

546

Orthopaedic Physical Therapy

Figure 234 A, Midfoot supination twist. 8, Midfoot pronation twist.

Figure 23·5 Goniometric measurement of metatarsophalangeal (MTP) joint flexion .

Figure 23-7 Prone-lying measurement posit ion .

and use of (he appropriate anatomic landmarks, then chis pro­ ced ure is reliable.7s Using the bisection l i nes, the clinician then measures the amount of subralar joint range of motion. The clinician grasps [he heel and rhe calf

as

indicated in Figure

23-8.

The heel is

moved in one d i renion (into inversion or eversion) until maximal resiscance is felr, and the angular d isplacement of the heel is recorded. The same method is repeated in rhe opposire d i recrion.77•78 The eversion and inversion angles are summed to give the cotal subtalar joint range of motion . The subtalar joint should pronate and supinate only a few degrees from the neutral position during normal gait. The most Figure

23·6 Goniometric

dorsiflexion.

measurement

of

la locrura l

joint

common method of finding the neutral posicion of the subtalar joint is by palpation, which is highly variable.�9.1J1 The anterior

Chapter 23 Dysfunction, Evaluation, and Treatment of the Foot and Ankle

Figure 23-8 A, Calcaneal inversion. 8, Subtalar i nversion.

Figure 23-9 A, Paplation for subtalar joint neutral. H, Measurement of subtalar joint neutral.

aspen of rhe head of rhe talus IS palpated with rhe thumb and middle finger of [he medial hand (Figure

23-9, A).

The exam­

iner's lateral hand grasps rhe foot at rhe base of rhe fourch and fifth metatarsals and applies a downward distracting force to remove any resting ankle dorsiflexion. The foot is chen pas­ sively Inverted and everted as calar protrusion (laterally with inversion and medially With eversIOn) is palpared. The neurral posiCion IS rhe point at which talar procrusion is felt equaJJy on both sides. Using rhe bisection lines. rhe neurral posicion IS measured with a goniometer and documented in degrees of varus or valgus (Figure

23-9, B).�6

From the subtalar neutral

position, a minimum of 4 degrees of eversion and 8 degrees of inversion of the calcaneus in the frontal plane (or rota] sub­ talnr Joint motion) are needed for normal function of the foot.·H..... ...... Once the subcalar joint is in the neutral position, the frontal plane forefoot to rearfoot posture is determined by aligning one of the arms of a goniometer along the plane of the meratarsal heads and the ocher arm perpendicular [he heel (Figure

23· 1 0).P""w

(0

[he bisection line of

The most prevalent forefoot to

Figure 23-10 Measurement of forefoot to rearfoot posture.

547

548

Orthopaedic Physical Therapy

reaefoot attitude in an asymptomatic population has been

aneneion [Q rhe knee and hip joines should also be observed.

reported [0 be a varus attitude. The least common attitude is

Excessive genu varum or valgum or excessive hip internal or

the neuerai cond ition. A normal forefoot varus a[cirude, as

external roration, as well as any limited morion, should be

measured by a goniometer, is 78

7.8 degrees, and a normal

valgus

anicude is 4.7 degrees.

The possible influence of the gasrrocsoleus complex on the

nored. This should correlate with the evaluated objective find­ i ngs of these joines. The relationship of the lower extremity to the body should also be noted. The pelvis transfers energy

subtalar joinc can also be determined in the prone-lying posi­

between the lower and upper extremities. Therefore it should

cion. Dorsiflexion at the talocrural joinc with [he knee in exten­

not move but ±S degrees (aneeroposterior and lateral tilt,

sion is compared with dorsiflexion with the knee in flexion. A

rotation)

dramatic increase in the range of motion of the talocrural joinc,

conservation.

throughout

the gait cycle co assist

i n energy

with the knee in flexion compared with extension, is an indica­ tion chat the gasrcocsoleu5 complex may be affecting 5ubcalar 6

joinc mechanics.

Static Standing Evaluation The amoune of tibial and calcaneal valgus or varus is measured

SUMMARY O F E VA LUATIVE PROCED UR ES The presence of a particular pathologic condition is not based solely on the findi ngs from any one of the previous evaluative procedures. Instead the findings from all of the procedures

with the patiene in the static scanding position and the feet

should be correlated. Combining the results of rhe biomechani­

shoulder-width apart, with equal weight on each leg. The clini­

cal and musculoskeletal examination of the entire lower kinetic

cian uses a goniometer to measure the angle of the calcaneal

chain with a detailed gait assessment provides the clinician

varus or valgus. T�e arms of the goniometer are aligned with

with a comprehensive outlook of the possibilities of dysfunc­

the longirudinal bisection line of the calcaneus and parallel to

tion. With these compounded resulrs, a decision on the par­

the ground to measure the amoune of calcaneal varus or valgus.

ticular type of or approach ro treatment should then be made.

To measure the amoune of tibial varus or valgus, the arms of

For instance, the presence of a forefoot deformity (e.g., forefoot

the goniometer are aligned with the longitudinal bisection line

valgus or varus) by itself is not indicative of a pathologic condi­

on the posterior aspect of the tibia and parallel to the ground

tion. The subtalar joint may be capable of compensating for

(Figure

2 3_ 1 1 ).6.29.5).77.82

this deformi ty. When the forefoot deformity is present along with some other factor (e.g., tight gascrocsoleus complex), the

Gait Ana lysis All of the previous i n formation is correlated with a dynamic

subtalar joint may be unable ro compensate for the deformi ty. At this time, the decision to treat the forefoot deformity by 69 18 HJ the use of biomechanical orthotic devices is made. . .

gait analysis. The patiene is instructed to ambulate on a tread­ mill or the floor, with or without shoes. The speed of the gait should be slow at first and progressively increased to a normal pace. The markings on the heel allow the clinician to observe the patiene for variances ftom the normal sequence of gait. The

Treatment Entrapments

reader will recall that from heel-strike to foot-Aat the subtalar

Treatment for tarsal tunnel entrapmer:t should address the

joine pronates (the calcaneus everts). From m idstance to heel­

predisposing and perpetuating causes of the entrapment. Per­

off, the subtalar joine resupinates (the calcaneus inverts). Close

manent biomechanical orthotic devices co control the perpetu­ ating and predisposing factors of excessive pronation are an effective method of treatment. I n addition, lower-extrem ity muscle strengthening to correct the observed faulty mechanical components is offurrher use. In cases in which the tarsal tunnel symptoms are the result of internal causes (e.g., tendonitis of the posterior tibialis tendon), the physician may prescribe anti­ inflammatory medicine. The physician may Opt to inject the area with medication or prescribe the use of iontophoresis andl or phonophoresis with an antii nflammarory cream (such as 1 % 84.8' hydrocortisone cream). Conservative treatment of patients with neuromas of the foot consists of proper shoe wear. The patient is advised to wear wider shoes. Accommodacive orchotic agents may be prescribed to relieve metatarsal head pressure on the neuroma and to correct the precipitating factor of abnormal pronation. Non­ conservative rreatment consisrs of surgical removal of the neuroma. For optimal results, nonconservative measures should

Figure 23-11 Measurement of tibial varum.

be combined with treatments addressing the precipitating or

Chapter 23 Dysfunction, Evaluation, and Treatment of the Foot and Ankle

549

. perperuaeing facrors.6 28.19,U The use of onhaeic agents, gasrroc­

involved joint, whereas the initial emphasis with sprains during

soleus stretching [Q reverse possible overpronarion because of a

the postacute phase is on improving the strength of the sur­

tight Achilles tendon. andlor lowcr-exrremicy srrengrhening

rounding musculature and che proprioceptive ability of the

in attempts co change ocher possible abnormal lower kinetic

i njured joint. The strength of the invertors, evertors, dorsiflex­

chain mechanics may all be warranted based on the findings of

ors, and plantar flexors of the ankle is i ncreased by che use of

examination.

resistive exercises progressed according to tolerance and perfor­ mance. The progression of balance and proprioceptive exercises should be incorporated from single-leg stance on various sur­

Tra uma

faces (floor, on

foam),

with eyes open and eyes closed to chal­

Trearmem of traumatic mjuries consiscs of three phases: ( 1 )

lenge

acute, (2) subacuce, and (3) poscacure rehabilitation.

mentioned, other involved muscle groups of the lower kinetic

the

three

components

of balance.

As

previously

The acute phase of treatmenc follows the basic principles of

chain (knee and hip musculature) may also need further

protection from further injury: resc, ice, compression, and ele­

srrengthening. The final rehabilication stage of both types of

phase of (rearmen[ is a passive seage for rhe padenc. This phase

che final stage is a progression to sport-specific skill and agility , exercises (e.g., figure-eight exercises, lateral slides).29 11,8IV�O

varion of rhe injured sire.29.7 1 J111 For rhe most parr, rhe acute of treatment begins immediately after injury. Its duration is roughly the same for both fractures and spmins of the foot and ankle:

24

to 48 hours. Control and reduction of the inflamma­

injury is a progression to functional activities. For the athlete,

Specific treatments of talocrural fractures include mobiliza­ tion of the talocrural, inferior tibiofibular, midtarsal intermeta­

tory process are of the utmost importance during the acute

tarsal, and MTP joints. Initially, the arrhrokinematic morions

stage. The ma.1ntenance of strength and range of motion of the

of roll and glide are restored through various mobilization

proximal and distal Joints [Q the site of the injury can further

techniques.29,1L,91 Two mobilization techniques used in treating

be a focus of the acute stage.

the talocrural joint are ( I ) posterior glide of the tibia and fibula

The subacute phase of treatment is slightly different for fractures and sprains of the foot and ankle. With fractures, the

on the talus and

(2)

long axis distraction of the talocruraI

joi nt1ol·1',91 (see Chapter 26). The glide technique is used to

stability of the fracture site is of paramount importance.

assist in restoring the osteokinematic motion of dorsiflexion

Control and reduction of edema and effusion, preveneion of

and plantar flexion. A general capsular stretch is provided by

muscle atrophy, and maimenance of cardiovascular fitness are

the distractive technique , Osteokinematic motions are also per­

key goals for the rehabilitation program during this phase of

formed along with the arthrokinematic mOtions. Usually the

treatmem of foot and ankle fractures. Elevation of the involved

ostcokinematic mOtions can be performed while the patient is

extremity, isometric exercises of the immobilized muscles, and

i n a whirlpool or after application of moist heat. The warmth

the use of upper-extremity ergometers are aJi recommended. remains

can assisc pain control and promote tissue plasticity. Heel cord stretching is also emphasized during treatment.29,7 1 .91

Treatment of sprains differs from that of fractures in that

the joint proprioceptors must also be retrained. This retraining

mobility is encouraged during the subacute phase of the reha­

consists of tilt board and progression of uni lateral weight­

bilitation program,29,11 With fractures, the patient is encour­

bearing and balance exercises on varying surfaces (on floor, on

Strengthening

of

the

available

adjacent

joints

important.29,71,8"'

Along with the improvement of movement and strength,

aged to begin sagittal plane exercises and movement. The

foam) with the eyes open and shut (with and wichout the visual

exercises promote increased circulation and prevent excessive

component of balance).811·90 Finally, in some cases, the prescrip­

joint stiffness. Compressive supports (i.e., air splines) can be

tion of a biomechanical orthotic device may be of assistance in

used to provide stability and prevent an increase in edema when

controlling any abnormal pronatory or supinatory (orces chat

the involved lower extremity is in a dependent position. Partial

may be present. The use of orthOtic devices may be of most use

weight bearing using axillary crutches is also encouraged and

in those patients who have experienced a stress fracture of the

progressed according to tolerance. Isometric exercises with the

metatarsals.

ankle muscles will be of benefit to reduce atrophy and assist

Specific treatment of MTP sprains consists of icing to reduce

with edema reduction. As in the subacute phase of traumatic

the inflammatory process, protective wrapping, and a non­

fractures, the control of effusion and edema, maintenance of

weight.bearing gait initially. Exercises chat do not increase

cardiovascular fitness, and lower-extremity strengthening of

discomfort in conjunccion with a graduated return to a pain­

the adjacent joints are emphasized during the subacute phase

free activity program will follow. Mobilization of the MTP

of sprains,29,,.,86

joint is performed when stiffness indicates this procedure to be

The postacure phase of traumatic injuries to the foot and

of value.

ankle emphasizes the improvement of mobility and strength of the involved joints and muscles. Once agai n, the treatment of fractures and the treatment of sprains parallel each other, The

Pathomechanica l Condi tions

only difference between the two types of injury is in the areas

As with entrapments, the treatments of pathomechanical con­

of emphasis i n the initial period of treatmenc

ditions address the predisposing and perpecuating faccors.

The initial

, emphasis with fractures is on the improvement of mnge of

These twO factors are usually handled by (he use of strengthen­

motion, both osteokinematic and arthrokinematic, of the

ing exercises to control abnormal transverse and frontal plane

550

Orthopaedic PhYSical Therapy

monoos In rhe lower cxcremHIt's, as well as blOmt'chanlcoli

plantar Hexed fifth meeamrsai In a Tailor's bunion, a limicus

ofrhmic devices char assist in comrol ling rhe abnormal prona­

deformity of the first MTP jOll1t, and a mallet toe deformity.

tion or SUp"hUJOn occurnng at rhe subralar joint. The Of thotic devices will also supporc varus or valgus deformities of rhe

In conjunction with the mobilization technIques, the use of appropri.ue heating modalities has been shown ro be effecClve

forefoot if presem."

in the treatment of joint hyromobdlry.' .1

Ocher (orms of treatment chat accommodact or attempt

(0

Adjunctive treatmems for II1Aam marory condiClons of the

comrol rhe" pred isposing or perpecu;1ung £'1((OrS are h(.'e1 lifts

foot and ankle include the use of cryorht'rapy to comroi any

and dccommoc.huivt' shoes. ror instance, decft."asing rhe height

edema presene. loneophoresis or phonophoresis with

0(h(,(,)5 has been recommended for individuals who abnormally

hydrocortisone cream can also be used to conerol the inAam­

1Ot',k,

pronate because of intrinsic (aecofs. i ncfC"J-SlIlg rhe heel height

matory reaction that is presem with plamar fasciltls and to

has been recommended for individuals who abnormally pronate

alleviate the presemin� symproms.

co compensate for extrinsIC muscle problems (e.g., gastrocne­

...1

SurgICal correction of any deformlCles that are presene IS a II

millS tigheness). Both of chese heel height correcrions have been

promising alternative.

recommended i n , conditions.f I'.if>.!

abduCtovalgus

tive rreatment In cases in which du.' predisposing faeror is an excessIvely long metatarsal or elevatus condltlon.6.!' Tenore­

Some pathome
limb) from a scarring position of hlp extension through a hip

of the exercise. There were 1 6 healthy volunteer.:; who com­

flexion motion i n rhe saginal plane (EMG eleccrodes Jr[ached

pleted this study. They !irudieC'J.king m mid-eccentric motion" (Boxes 29-8 and 29-9). I "

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10

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28(2):234·240, 2000.

CHAPTER

30

Toby M. Hall and Robert L. Elvey

Evaluation and Treatment of Neural Tissue Pain Disorders

Advances in the p
MECHANICAL ALLODYNIA IN RESPONSE TO PALPATION OF SPECIFIC NERVE TRUNKS

of rhe onset of pro[�tive muscle acrivi ry. should coincide with the IXtciem's reporc of onset of p'linHl) and reproduccion of rhe

An important step in the classincJrion of peripheral nerve

pam lOmplalnr. Sympcom reproduction is the second impor­

sensitization is palpa{Jon of rhe nerve crunks. If pain

t,tnt ({'spons£:. J\lrH1Jtm.r is a morc appropriate biomechanical

voked through lengthening of the nerve, then (ocoll I,ressure

term

to

.)0- 1 2

describe angular forces during limb movement. Figure

IS

IS

pro­

directly over rhe nerve trunk should also be painful.

typical of the subjects In this swdy and represents the

It is widely known that under normal Ci rcumStances,

moment of stretched tissue, measured objectively by a load cell,

peripheral nerve crunks and nerve roots do nor evoke pain m

during SLR (in rhe clin ical contexr, momenc of scretched rissue

response to non noxious mechamcal stimuli. '

IS

trast, inflamed nerve roots are exquisitely sensitive co even mild H, Ll mechanical provocarion. 1 Simi larly, Dyck'·'t reponed that

IJCrcelved by the exam mer as resismnce).'11 In rhis example,

rhe sub)t'Cr rested had significant eVidence of sciatic nerve sensitll. righi, and Ihl.' 1);1lienl's feel are lifted to the lefl to side bend the lumoor spine. Adductor strc1ln can be Figure Al-15 Treatment (or a forward bending dysfunction of ll.

reduced by slightly lifting behind the upper kn{'{'.

Flexion of the thoracolumbar junction is assisted by lifting the end of the bed. Funher flexion is produced by the therapist's knees against the back of the patient's thigh, with slight rotation of the patient's knee toward the side of tenderness. The position is one of marked flexion, rotation away, and side bending toward the restriction. The position is held and the tender spot monitored for 90 seconds.

Figure A 1·18 Treatment for l5 dysfunction. Approximat£,ly 20 degrN"S of pelvic rolation plus adduction of the thi�h reduces the tender spot under the index finger. The third finger marks the posterior superior iliac spine. Figure Al-17 Treatment for iliacus dysfunction. A tender point is located in the iliac fossa. The hips are flexed. the ankles crossed. and the thighs externally rolated.

Figure A '·19 Treatment for L3, l4, and lS dysfunctions. Adduction of the thigh is necessary at all le\lels. More rotation is needed for Ll. whereas

lS requires more extension.

Appendix I

Manual Therapy Techniques for the Thoracolumbar Spine

Figure A1.20 Starting position for a functional technique for lumbar dysfunction. The therapist palpates changes in tissue tension with the right thumb.

Figure Al·22 Technique (or correcting an lS that is flexed, rotated right, and side bent right (FRSR). The aim of treatment is to extend, rotate, and side bend left (ERSl). The patient resists lifting up of the left ankle. The patient may look over the left shoulder to reduce stress on the upper thoracic spine.

733

Figure A1·21 End position of a functional treatment technique. The . point of greatest tissue relaxation determines the movement and posi­ tion of the patient.

Figure Al-23 Technique for correcting an l5 that is extended, rotated right, and side bent right (ERSR). The aim of treatment is to flex. rotate. and side bend left (FRSl). The patient resists pushing down of both feet. The therapist protects the patient's left thigh from the edge of the bed by supporting it with his or her own left thigh.

734

Orthopaedic PhYSical Therapy

F i g ure Al·24 Technique for correcting an L4 thaI is extended, rotated righl. Jnd side bent right (ERSR) in a sitting position. The Iherapisl fll'XCS and index finger on either side of the patient's left knee, with the popliteal space covered by the web of the hand. The therapist'S right forearm is along the posterior Figure Al-S8 The therapist's left arm is placed under the patient's folded arms, and the therapist reaches across the patienl's chest while firmly holding the right shoulder. The patient leans forward as the therapist rotates the patienl lo the left. The therapist assists the rolation with the right thumb pushing on the lateral aspect of the spinous process while stabilizing the caudal spinous process with the second

aspect of the patient's left thigh. leaning \\.ell forward, the therapist thrusts through the popliteal space. Stabilization of lS is proVided by the therapist'S left forearm and thumb, which are on the lateral .1Spect of the spinous process of lS. Because

II

wide range of angles exist for

the lumbosacral facets, the degree of left hip flexion will vary 10 accommodate the sag ltal or more coronal joint plane. l

finger, reinforced by the third. Alternatively, the therapist may resist rotation of the caudal spinous process by stabilizing with the thumb instead of the ftngers.

Table AI-l

Relative Contraindications to Manipulation References

Condition

Condition Pager's disease

Articular Derangements Ankylosing spondyl l{is aher rhe a

Maitland24

Ilnldeman!\

Stoddard4 Yochumll Haldeman21 Grieve26 Rheumaroid arthritis

Bone Weakening and Destructive Disease Calve's disease

Lindnerls

Fracrun:

Gutmann2!) Heiliglll

Bourdillonl!

Maignell

Jansell

Nwugal•1

Maigne'J

Rinsky er aLl

Stoddard I

Siehlll

Yochum'!

Stoddard'\

Grieve26 Haldeman2i AClite nnkylosing spondylitis

Gurmann21l KaJrcnbornl"I

Arthritides Acute arthritis of any type

References

Bollier! DrozH Haubergl� jansefl Nwuga14 Stoddard 1 Hnldemana Grieve26

Haldemanl' Malignancy (primary or secondary)

Bourdillonl1 Gutmann2!l Muigne') Mnidandl-l Nwuga'� Timbrell-Fisher29 StoddardI Grievel!> Ilaldem3n!�

743

Appendix 1 Manual Therapy Techniques for the Thoracolumbar Spine

Table Al-l

Contraindications for Manipulation-cont'd References

Condition

Osteomalacia

Lindner"

Disk Lesions

Osteoporosis

Bolh er'

Condition

Prolapse wirh serious neurologic changes

Bourdillonll

OsteomyelitiS

References Bourd.llonll

(including cauda equina syndrome)

Cyriax)

Maigne'1

Hooper\O

NwugaL�

Jaquer'11

Siehlll

Jennett!!

Stoddard!

Nwuga·4

Grievel6

Odom'9

Haklemana

S{()ddurd�

Ilauberg"

Hlildeman1'

Nwuga'l

GrieveU,

Sando.l and

Neurologic Dysfunction

LorenL \

MiCturition with sacral

Sroddard'

root

involvement

Cyriax' S{ocIdard�

Bourdillon:J

Tuberculosis (POft'S disease)

Haldemann

llallber�(

Gneveu,

Maigne'1

Painful mo,'cmem in all directions

Siehl" Stoddard I Timbrell·Fisher .,

Maigne'1

Unclassified Infectious disease

Ma.gne"

Patient intolerance

M:lIgneY

wuga'" Lescure \l

Modlfi(-d

(rom Iiaideman

S. editOr:

Modern dc\·t!opments

In

the principles

anti

REFERENCES

12. Yochum

I. Bollier \XI: InAammarory infections and neoplastic disease of [he lumbar spine, Ann Swiss Chiropracr Assoc 1960. 2. Rinsky LA, Reynolds GG, Jameson R..M, ec al: Cervical spine cord injury after chiropractic adjustment, Paraplegia

Easl Norwalk, Conn. 1980,

TR:

Radiology

ApplelOn Unlury

the

of

Crofu.

Arthritides (lecture

notcs), Melbourne, 1978, Int Coli Chiro. 13. Siehl D: Manipulation of the spine under anaesthesia. In 1967 Yearbook, Academy of Applied OSteopaehy, Carmel, Calif, 1967. 14. Nwuga V: Manipulation of the spine, Baltimore, 1976,

13:233,1976. 3. Sandoz R, Lorenz E: Pr esentation of an original lumbar technique, Ann Swiss Chiropract Assoc 1:43, 1960. 4. Stoddard A: Manual of osteopathic practice, London, S. Cyriax J: Textbook of orthopaedic medicine, cd 8, vol 2. London,1971, Bailliere Tindall. ehe German), Beier Orchop 20:581,1973. 7. Grillo G: Anomalies of dle lumbar spine, Ann Swiss Chi­

management.

Ann

Swiss

Chiropract

Assoc

1: 170,

17, I lfluberg GV: Conmlindications of the manual therapy of the spine (translated from the German), Hippokrates, Scu[[garc, 1967. 18. Jaquet P: Clinical chiropractic:

ropracc Assoc 1 :56, 1960. 8. Janse J: Principles and practice of chiropractic: an anthol­ arional College of Chiro­

prac cic, Lombard, 1I1, 1976. 9. �laigne R: Orthopaedic medicine: a new approach to ver­ tebral manipula tions (translated by \XlT Liberson), Spring­ field, Ill, 1972, Charles C Thomas. 10. Sandoz R: Newer trends in the pa thogenesis of spinal wiss Chiropmcr Assoc 5, 1971.

11. Valentini E: The occipiro cervical region, Ann Swiss Chi­ ropracc Assoc 4:225, 1969.

spine, Ann Swiss Chiropracc Assoc I: 143, 1960.

1960.

6. Kaiser G: Orthopaedics and rraumarology (translated from

ogy. In Hildebrandt R, editor:

Lippincott, \XliJliams & W ilk i n s. 15. Lindner H: A synopsis of the dystrophies of the lumbar 16. Beyrl er W: Scheuermann's disease and its chir opractic

1969. I lutchinson of London.

disorders, Ann

prnClicc of dliropr-.tClIC.

3

study of cases, Geneva,

1978,Chrounauer. 19. Odom GL: Neck ache and back ache. In Proceedings of the NI

CDS Conference on

eck Ache and Back Ache,

Charles C Thomas, Springfield, Ill, 1970. 20. Gutma nn G: Chirorherapie, Grundlagen, Indik3tionen, Genenindikationen and objektivier, Barkeit Med Welf Bd 1978. 21. Sandoz R: About some problems pertaining to the choice of indications for chir opraccic therapy, Ann Swiss Chiro­ pracc Assoc 3:201, 1965.

744

Orthopaedic Physical Therapv

22. Bourdillon )F: Spinal manipula[ion, London, 1973, W Heinemann.

cervical

23. Draz JM: Indications and conrraindicarions of vertebral manipulations,

28. Heilig D: Whiplash mechanics of injury: management of

Ann

Swiss

Chiroprac(

Assoc

and

dorsal

involvement.

In

1965 Yearbook,

Academy of Applied Osceop.[hy. Carmel, Odif, 1965.

5:81,

29. Timbrel! Fisher AG: Trearmenc by manipulation, London,

24. Maidand GD: Vertebral manipulation, cd 4, London,

30. Hooper J: Low back pain and manipulation paraparesis

1971. 1977. Butterworth-Heinemann. 25. Haldeman S: SpinaJ manipulative therapy in [he manage­ meor of low back pain. In Finneson BE, edicor: Low back pain, ed 2, Philadelphia, 1981,)B Lippinco[[. 26. Grieve GP: Mobilization of the spine. ed 3, Edinburgh, 1979, Churchill Livingstone. 27. Kalcenborn PM: Mobilization of rhe extremity joines, Oslo, 1980, Olaf Norlis Bokhandel.

1948, H K Lewis. after treatment of low back pain by physical methods, Moo ) Ausc 1:549, 1973. 31. Jennett WB: A study of 25 cases of compression of rhe cauda equina by prolapsed IYD. J Neural Neurosurg Psy­ chiacry 8:19, 1956. 32. Lescure R:

Incidents, accidents, comreinclic3rions des

manipu.lacions de Ia colonne vercebrae, (translated from [he French), Med Hyg 12:156, 1954.

Index

A

Achilles tendon, 573-574

A band.1 AAHKS (Amrrlcan AcaJrmy of HIp and Knt'(' Surgrons), ·187-488 Abdommal eXert'l�rul. 228

)(hcmatu; for oblt'Cllvl:S of . HOI S{rt'tnm8 rool�. 162,706, "7()6t

Arthro!iC.opy ankle,'suhular Joint. PS·';ilIgatl(1Il prou:ss. "I

Ant t'r lllr superior Iliac \pine (ASIS). ,,� I ,1·ISf

rot\ltor (utT rermer. 220-226, 222b

throwillft mechanics. 2-18.2-19

Antt'nor tO�lon.6 ;;, 61"

subtalar IUlnt. P8-�79

t),pesO(CIIllIC..I,161

Antenor.repl.l�l[l(Ining Jpplian(t">. 110-111

�opcnor labral (SLAP) �t0l"t'ra{lve protocol.

upprr quant'r (S« uppet quaner asst'Ssment'

Antl·mI1l:)!.[ef10r ,L:lid{' tt'(hmqut', Hk H·lf-rH;r.

\-i2f.

22�b wnst, Ul-311. U2f

('Valuation)

\161". ')1'16(. W.zr. 596-597 wedk-!ink (Iumooptlv" s)' su.'ml, ·iO(l-IOI

Anr�·f()\Ier(:. 2111"

(:losrtllonal area), H

CoIIJu:rJ.1 sprnumlg of neI"\'C�, 1 � Colles' (dma] mdlUs) fmnurt".!o. H'j, 8M. 1'19[,

duster signs, \69

CT� Stt ,oJ,.!',,1 lum,d c1lf,.,u

(Ore musdl'S, W.?, W·j

Cubitus val�us deformities. 240

\{)'jb-.\08b, ;061, HI. .H'5!-H61

Crais's It'Sr. \')8, _��9f

CubOId whip. 59M

Colon t;1llctr, 77•78, '791

drop-Jumr It''>t.'5l. ,Bf

Curl-up t'xemst', 65r

Color dasslfl{iulon tor wound (arc, 296

\J(..('I S((lUr I("SI, \�5 Gaenslen's (cst. �56f

Curl-up exercises, 678, (17M!

Combint-J SH�S, 7 Commuted pro,ll;ennor (t'lls, 2

,.:.llt.. �52

CVA (costOvertebt'.Ii ,Ingle). tn

Comorbidny, nerve �trh� .

hlp ran,!;e or mOl ion. -".i8t--".i9t

1 19

DANE TJ UCL m:oO!ttrunion techmque,

hlp tt'l>tin,!-:, ''.i'-1�9

2)l DASII (DISolbdltit'S of Arm. �houlder. and Hand). 302, ,(Ht

Complex re,ll; ion,,1 pdin syndrome. H9·90, NY!

lump llt'iJo:ht "Jlut'S,\6'.it

Compliance (S()rl('nm�) 01 IIS\UC, 10

de Qu("r\'din's lt�nosynO\'leLS,

kn(�. 521-')2'

CompressIOn il'.LCmres. '5-11

11mb \ymmetry InJt·x (LSI).. \66b

Dt:llSlOn making . SR' 'IIJO d10l(31 reasonmg chOICe of tt'thnl4ues prrx:t:t!urts, 17.. 1

Comprt'S�lOn of nt'n:c�. 1 1

loc:,,1 lore. � 5 9-U)(}

CompmslOo (Ilium \'enlromt·.kll pro\'(XJtlUn)

lumbopdvic system. 199-100

types (It cIlnKal. 162

Dedme oolrJs. 52�r

m;lOual muo,cle teSI 8r;)dln�. _\6,1

Ottp \'elO thrombosis :, 281b Fingen. StI' oJ/,o h.mo
l"mmpml"m\. 5·j() neuromJ\. 5-H1 (Jf"\J.1 JUnod �yoJmmt'. ')·I() Il;IlIux Jhc.lu{wval�u\. 5,1 1 nJllux n":ldu�!hallux Il/nllu�. S·j I h.lmm(."r wc . ... , 512 m,lliel lOt... . 512 mt�IJJI 1J.IJ.r domt· ololrothondral lt�iOn. ,)7HI RJ)"nJ.ud\ dIO;("J.'>t', H9 \a/o(ntal ,hort T invt'�ion It"t:OH'ry (STIR) �Iuemt', \SfI, '}I-H T,ulor\ nunJUn. SjI ·').I2 1,"�IJOJl:inumbnl.'$s of. 1 \9 we: I"(·/ot,on IJIo:Jnu·nu. 9. I I Fllot and ankle IOIOflt'$, HO·,},j I Irattort'�. HO·5-1 1 ["Il'mm_'U\ brc\'l\ H.-ndon H.·ar, ')""''51 �pra,"\. H I hlOt and J.nkk mobilization, 591-59""' .lnu.-rICir J.(lJdt'. W\t'-'59 j( ulunC'(J(uhold Jothdt', 595! tUlxllJ whIp, ';96! Ji\lrat(ion. ')93f·')96f idysfuntllOns Fnllt .1OJ .lOkle sur,itlul advanu:;, Adllllt's H'ndon ..ur�t'fI("\. '5" \ Jnklt' \Iahd'lallon. 5H2 .mhf()
layers. 391

length.tension curve. 9f

lumbopelvic system, 392t. 393b. 393f. 394t

normal tissue, 1-6

connective tissue. 5-6 innervation. 5

plasticity of, 42

skeletal, 39-40

Types I and 11. 1-3 types of, 2-3

type-specific adaptations in strength training.

II

Muscle function, 97. 6 1 4 . 614f Muscle guarding. 330·331

Muscle immobilization. 1 4 - 1 5 Muscle innervations. 424r

Muscle loading, 267

Muscle mass, 29. 54-55

Muscle mobilization, 16·17, 42. 342

Muscle physiology, 37-39

Muscle play assessment. 6 1 4 Muscle receptors. 378-379

Muscle reflexogenic benefitS. 1 7 0 Muscle regeneration. 1 2

macroscopic Structure. I

Muscle spasms, 75, 396

musclt architecture. 2

Muscle rone. 98. 613-614

periphef1!.1 nerves, 7

Musclt' tremors/failure, 644

sensory feroback, 4·5

Musclt' versus n�ural adapmion, 52

microscopic structure. 1-2 organization of fiber, 2f

types of contraction, 4f

types of fiber, 2-3

origins/insenions, 275-276, 276t-277r

Muscle spindles, 4-5, 55, 378. 644, 644f

Muscle tf1!.ining. postsurgical. 576-577

Muscles, 1 -6. Sit a/J() ntNromMJ(II/ar trI/r;u age-related changes to, 54-55

forct' generated by individual, 39

from forearm bones, 277t

gender differences of, 55

from medial epicondyle. 277t

local versus glob-.I, 394

from Illural epicondyle, 276t

thumb, 278t

pes aIl2rinus group. 5 0 l f

posterior musculature, 424-427 gluteus maximus, 424

inflammalOry response to trauma, 1 1 - 1 2 mobilizer, 663

skeletal (SI'f! skeletal muscles)

Musculotendinous srrucrurt'S of hand and wrist, 274-2S3

gluteus medius, 424-425

extensor tendons. 279

obtuf1!.tor externus/internus. 426

muscles. 275-276

quadratus femoris. 426

tendons. 276

gluteus minimus, 425-426 piriformis. 426

superior/inferior gemelli, 426

semimembranous muscle, 5 0 l f

flexor tendons, 279-283

resting tOne of wrist and hand. 274.283

Muscular adaptations. 241

Muscular deficits after hip surgery. 485-486

Moror learning, 44·45

skeletal muscle components, 602-603

Muscular power/strength, 5 1 , 220

MOlor rt'Sponse intervals, 379r

StructUf1!.1 elements of, 5-6

Musculoskeletal assessment. )43. 709

Motor nerves, 83

Moror rt'Sponse pathways, 379-380

spinal, 391 -395

Structures of lumbopelvic system. 391-395

Motor skills, 5

Muscle architecture, 2

Motor vehicle accidentS (MVAs), 642, 665·666

Muscle contraction exercises

Motor units, 5, 39

Mouth, opening of, 1 1 3 . StIt a/s() bruxism

Movement. SN alsQ range of motion (ROM) active movement dysfunction, 707·710 assessment/evaluation of, 134 functional analysis of, 6 1 0 patterns of, 381

Movement funnion of bones. 6

Moving valgus maneuver. 243. 243f

MP jointS. Stt metacarpal.phalangeal (MP) joints

MPFL (medial patdlofemoral ligament) reconstruction, 520-523

M-prorein, 3

Muscle balance. 228-229

anterior rotation of the right innominate, 4 7 1 -472

posterior rotation of the right innominate. 4 7 1

superior and inferior pubic symphysis exercises, 469-470

superior iliac subluxation (upslip), 470-47 1

Muscle contractions. I , 3-4. 4f

Muscular responses co adverse stimuli, 605f Musculoskeletal impairment/dysfunction cervical spondylosis, 134

chain of reflexes in, 96·97

myofascial pain syndrome, (36 posruf1!.1 abnormaJiries, 1 3 3 referred pain, 136-137 rib dysfunction. 134

somatic, 133-134

thoracic inlet syndrome. 134 traumatic, 135-136

vertebrobasilar insufficiency. 135

adenophosphate requirementS, 37

Musculoskeletal pain, 7 1 7

eccentric, 3-4, 52, 55-56

Musculotendinous flexibility, 276t-277t

concentric, 3-4, 52. 55·56

Musculoskeletal tissues, 42

exciration-contf1!.ction coupling, 3

MVAs (motor vehicle accidents), 642, 665-

types of, 3-4, 469t

MVICs. Sn electtomyogf1!.phy (EMG)

proteins, 3

759

666

760

Index

MWM (mobiiitation with movement) ttthnique,

NeuraJ activation, 1 4

Neuromuscular training (NMT) (C,n"""tJ)

Neural adapu.tion, 44-46

S1glttal plane knee angles, 382f

Mydopathle5. 1 37 - 1 39. 139

N�ural hysteresis, 140

screening tool selection, 381b

Myocardial infa.rcuon (MI), 8 1 . 841, 86e

Neural tissue mobiliution, 7 1 7

sensorimotor system, 378-380

MyoruciaJ assessment, 613·615

Neural tissue pain assessmenueViluation

331->33. 333,. 338(, 341(, 594(

cutaneous receptors, 378

MyoWciaJ cycle. 603-60.1

active movement, 707·7 10

Joint receptors, 378

MyomciaJ pam syndrome. 136

antalglc posture, 708f

motor rtSponst pathways, 379·380

Myofasciai lri88cr points, 604

body chans. 721 f·722f

Myofucial unit dysfunwons. 603-605

brachial plexus and neurovascular bundle

Myofibnls. 2-3

palpation, 7 1 )f

muscle receptors, 378·379 vaJgus collapse positIon. 383f Neurons, 7

Myofilamems. I

c� studies, 720b.723b

NeuropathIC pun, 703·706. 7 1 8

Myo8enous temporomandibular disorders

cervH:-al spme contra1at�ral lateral Bexion, 708f

Neuroplthic Pam QuesllonlWre (NPQ), 706,

(TMDs). Stt N""," u�mporom.ndibular

compensatory mechanlSnu. 708f

disorders (TMDs)

conduction loss, 703

Neurophysiology, 9)·96, 1 70

MyogenIc (muscle) su�m cells. 53

femoral and fibular nerve palpation, 716f

Neurapralua, 1 3

Myogt'nous mvolvemcnt of ((,Nlcal spine,

hlp flexIon addUCtion maneuver, 7 1 0f

Neurotmesis, 1 3 , 3 1 7

1 1 3 - [ 14 Myogenous temporomandibular disorders (TMDs), 109. I lOb. 1 1 2-120

706,

local-area pathologies, 7 16·720

NeurovllSCular bundle palpation, 7 1 ) f

lumbar anive flexion, 709f-710f

N�urovascular components for soft tissue

lumbar d�rmatomaJ maps, 7 17t

mobilitation, 60) Neurovascular structure of ankles, )43

cervical spine consldera!Jons, 1 1 3- 1 1 4

manual �xamination of Spine, 716f

hrad/erofacial pain, 1 1 2- 1 20

mechamcal allodynia, 7 1 2·7 1 6

Neurovascular supply to hip complex, 423-424

masticatory muscle pain. 1 1 2

Neural 1issue Provocation Tl!Sfs, 7 1 1-712

Neutral alignment, 607

Neural 1issue Provocation Tests (NTPTs).

Neutrophlls, 1 1 - 1 2

Myohgamentous laxny, 99 Myology of hlp complt'x. 424 Myonuclcar domain theory. [ ·i - 1 5

7 1 1-712

Night palO, n, 1 37

neurologic function cuminatlons. 716-717

Nitroglycerin, 8 1

Myosin, I . n-B

neuropathiC paIn, 703·706

NMC. Sit O("ldr "tJmJftIJIKJlldr to"rro/ (NMC)

Myowmes. 103

passive mOVement dysfunction, 7 1 0 posltIV� and negatlve signs/symptoms, 704t

N

mtrus

NMES (neuromuscular cI«trical stlmularion), 44

postUIt:, 707

Navicular bone. 576

provocatIon testS, 7 1 2f-7 14f

Navicutllr fracwres, } 1 ·1 · 3 1 ) , 3 1 6f, 3 1 8b, 3 1 9-UO N,d cockC'd robin posItiOn, 1 )7

NMT (n�uromuscular trammg) for balance,

sc�ning tools, 706t

659-66 1

slump test, 7 1 4 f

Nodes of Ranvler, 7

straight-leg ral� (SLR). 7 1 4f-7 1 ) f

Nodules, 274

Neural tissue pa i n treatment strategIes, 7 1 7-718

Nonmusculoskeleual pathologIes, 137

fractures, 79(

cervical lateral glide techniqu�. 7 18·720, 71Sf

NonnoxlOUS pressure, 7 1 3·71 4

palnfullreslriCied mOV�m�l1t, 1 3)

lateral cervical glide. 719t

Nonsteroidal antIInflammatory drugs (NSAIDs).

lower quarter exercises, 7 1 9f

Neck paIn. 139 bruxism related to, 1 1 4

pUIO dassifica[Jon for chooslOg, 705-706

common sources of. I I ) b

right lareral flexion for leg !"lIn, 7 1 9f

�xt"rcises for, 1 1 9

upper quaner ex�rci�, 7 1 8 f

41 Nonw�lght-bcarmg n�rcises performed through arc of motion, 690·691 Nonweight-braring mOtIOn, )38

musculosk('I�lal. I H

Neural versus muscle adaptation, )2

Northwick Park Neck Pain Ind�x, 1 1 9

Neurapruia, 3 1 7

Normal functional activities, 610

with temporomandibular disord�rs, 1 1 2

Neurocom technologies. 650f

Northern State University College of Optometry

Necrosis, 97

NeurogenIc claudICation, 4 1 0

Nelson techmque, 18-1. 186f

Neurologic function assessment, 138, 716·717

NephrolithiasiS, 8" 841

NeurologiC StruCtures of hand and WflSt, 283·288

Nerve endmgs, 378

medIan nerve, 28)·286

Nervt' funciion asst'Ssmem, 7 1 7

radial nerve, 283-28)

Nerve mJunes. Sit alJo II1Nr