Monthly Archives: January 2011
Hip Strength and Flexibility in Hockey Players with Adductor Strains
By: Francois Prizinski, DPT, OCS
In 2001, The American Journal of Sports Medicine published a nice article titled, “The Association of Hip Strength and Flexibility With the Incidence of Adductor Muscle Strains in Professional Ice Hockey Players”.
The authors looked at a total of 47 players, 8 of whom experienced a total of 11 adductor muscle strains and 4 hip flexor strains. They found preseason hip adduction strength to be 18% lower in the players who subsequently sustained an adductor muscle strain compared with that of uninjured players. Adduction strength was measured at 95% compared to abduction strength in the uninjured players but only 78% in the injured players.
Preseason hip adductor flexibility was not different between players who sustained adductor muscle strains and those who did not. These results indicate that preseason hip strength testing of professional ice hockey players may be able to identify players at risk of developing adductor muscle strains. The authors found a player was 17 times more likely to sustain an adductor muscle strain if his adductor strength was less than 80% of his abductor strength (whats that on a MMT, 4+?).
This article is especially interesting as it adds unique information to what is known about the classic “adductor strain.” The results showed: 1. that flexibility was not a variable in injury among professional hockey players 2. a deficit of adductor vs. abductor strength is a variable that can lead to injury a 3. adductor strength was 86% of abductor strength on the uninjured side but only 70% of mean abduction strength on the injured side in the same athlete.
Articles like this are always meaningful and of interest when athletes are prescreened and assessed post injury. Given the sport of hockey requires strong hip abduction strength to generate a stride, hip adduction strength must also be strong enough to eccentrically control the movement. This is similar in concept to the throwing athlete, but different in that the adductors where not tight as a posterior shoulder might be.
Tyler T, Nicholas SJ, Campbell RJ, McHugh MP. The Association of Hip Strength and Flexiblity with the Incidence of Adductors Muscles Strains in Professional Ice Hockey Players. The American Journal of Sports Medicine. 2001; 29:124-28.
Thoracic Thrust/Manipulation for Shoulder Pain
Mid-Thoracic Thrust performed by Francois Prizinski, DPT, OCS
By: Francois Prizinski, DPT, OCS
There has been growing literature regarding regional interdependence of the lumbar spine and hip and their influence on more distal impairments and symptoms. In this post, I wanted to review the thoracic thrust techniques for their influence on shoulder pain. These articles make you think about the movement diagnosis from local structures and their influences on distal body parts function.
The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. MANUAL THERAPY, 14 (2009) 375–380
“Fifty-six patients (40 males, 16 females; mean age 31.2 8.9) with subacromial impingement syndrome (SIS) underwent a standardized shoulder examination, immediately followed by thoracic spine thrust manipulation (TSTM) techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change.At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p < 0.001) and the mean GRCS score 1⁄4 1.4
Cervical Radiculopathy vs. Parsonage-Turner Syndrome
By: Adrienne Zeiler, DPT
Many physical therapists have treated patients with cervical radiculopathy. Every once in a while, the patient does not respond to treatment and may get progressively worse. It is always important to make sure that a proper diagnosis has been made. The differential diagnosis for cervical radiculopathy frequently includes certain usual suspects: thoracic outlet syndrome, peripheral nerve damage, shoulder disorders, etc. A diagnosis that is not commonly in the mind of most physical therapists is Parsonage-Turner Syndrome.
Parsonage-Turner Syndrome (PTS) is also known as acute brachial neuritis. This syndrome is more common in males than females, has an incidence which peaks at 55 years of age and has an uncertain etiology. Some have postulated that the syndrome is the result of a virus or autoimmune response. The patient with PTS will likely report an immediate onset of severe pain without a history of trauma. This pain will frequently wake the patient during the night. Pain originates in the shoulder girdle (often the peri-scapular region) and radiates to the cervical spine and UE. The intense pain will resolve spontaneously in several days to several weeks. As the pain subsides, other symptoms will develop including decreased sensation, hypoactive reflexes, decreased strength and possible paralysis in the corresponding UE. These symptoms may be limited to a single peripheral nerve, the brachial plexus or specific nerve roots. Muscles innervated by C5-6 are the most commonly affected.
Diagnosis of PTS is difficult and is typically a diagnosis of exclusion. It is often wrongfully diagnosed as Cervical Rediculopathy. One of the only tests which has been shown to help diagnose PTS is an EMG. Studies have shown that 21 days after the initial symptoms appear, EMGs may be positive for fibrillation potentials, and positive waves indicating upper plexus involvement. When diagnosing a patient with cervical symptoms, it is important to know the differences between cervical radiculopathy and PTS so to avoid misdiagnosis.
Included is a chart to serve as an easy reference guide when differentiating between cervical radiculopathy and PTS. It is also helpful to discuss your findings with the patients physician or another physician with whom you are comfortable.
| Cervical Radiculopathy | PTS | |
| Onset | Onset | Immediate , severe pain without trauma |
| Cause | Disc Herniation or other space occupying lesion | Unknown. May be viral or autoimmune |
| Gender | Male>Female | |
| Incidence | 4th-5th decade | 3rd-7th decade with a peak at age 55 |
| Diagnosis | Clinical Exam findings, MRI, EMG/NCV | Diagnosis of exclusion. Possible EMG |
| Pain | Peri-scapular with referral into UE | Peri-scapular with referral into UE |
| Nerve | Any cervical nerve root | Frequently C5-6 |
| Cervical Movement | Worsens Symptoms | No change |
| Strength | Possible weakness in myotomal pattern. Worsens as pain worsens | Possible weakness; Frequently C5-6 distribution; may involve one or many nerve roots/peripheral nerves. Replaces pain |
| Reflexes | May be decreased. Worsens as pain worsens | May be decreased. Frequently C5-6 distribution. Replaces pain |
| Sensation | May be decreased in a dermatomal pattern. Worsens as pain worsens | May be decreased in a peripheral nerve or nerve root pattern. Frequently C5-6. Replaces pain |
Mamula CJ, Erhard RE, Piva SR. Cervical Radiculopathy or Parsonage-Turner Syndrome: Differential Diagnosis of a Patient with Neck and Upper Extremity Symptoms. Journal of Orthopedic and Sports Physical Therapy. 2005;35:659-664.
Elsayes KM, Sharriff A, Staveteig PT, et al. Value of magnetic resonance imaging for muscle denervation syndromes of the shoulder girdle. J Comput Assist Tomogr. 2005;29:326-29.
Ryan M, Twair A, Nelson E, et al. Whole body magnetic resonance imaging in the diagnosis of Parsonage Turner syndrome. Acta Radiol. 2004;45:534-39.
Misamore GW, Lehman DE. Parsonage Turner Syndrome (acute brachial neuritis) J Bone Joint Surg Am. 1996 Sep;78(9):1405-8.
Manual Therapy Diagnosis for C1/2 Cervicogenic Headache
By: Francois Prizinski, DPT, OCS
Hall et al. (2010) published an article in The Journal of Manual and Manipulative Therapy titled: “The influence of lower cervical joint pain on range of motion and interpretation of the flexion–rotation test.” They investigated the utility of this clinical test that is commonly used for assessing range of motion of the upper cervical spine. Mobility of C1/2 has been reported to be a source of subocciptial headaches, which should be assessed, in this clinical population. The study assessed 2 groups, subocciptial headache group from cervical facet pain group (diagnosed by guided facet joint injection), with the flexion rotation test (FRT).
FRT
“The subject lay relaxed in supine with the cervical and upper thoracic spine passively flexed to end range, or if pain prevented this, to a comfortable limit determined by the patient. The head was then passively rotated left and right. Range was determined either by the subject reporting the onset of pain, or firm resistance encountered by the therapist, whichever came first.”
Normal range of motion for unilateral rotation has been accepted to be 44 deg and symmetric
Results of this Study:
“The average range of unilateral rotation to the limited side during the FRT was 26 and 37.5deg for the cervicogenic headache and lower CFP groups respectively. The difference between groups was significant (P,0.01). Sensitivity and specificity for cervicogenic headache diagnosis was 75 and 92% respectively. A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 90% of the time (P,0.01), with a positive cut-off value of 32deg.”
The positive likelihood ratio for this test was 9.38, and negative likelihood ratio 0.27 which means that if a positive finding of 12 deg limitation unilaterally from a normal ROM of 44 deg will represent a very clinically significant interpretation of a true positive finding.
Clinically if a patient with cerviogenic headaches present with a unilateral rotation restriction >10 deg (normal 44 deg) with all other medical screening procedures cleared for vascular, neurologic, and upper cervical instability, than assess prone manually for mobility restriction and perform appropriate mobilizations with ability to use FRT as a reassessment tool. Try performing the test pre manual intervention and post manual intervention to assess a change in range of motion and patients self reported pain.
Also consider the possibility for positive FRT findings in subclinical populations, which may progress to pain later?
Though a meaningful article with clinically applicable findings, each clinician should be consumers of the literature and try to incorporate the evidence of the literature to improve your individual outcomes. Something as simple as not performing the test into end-range can bias the entire test and your interpretation. The test may have great clinical utility but always keep in mind that extraneous variables may bias your clinical findings. If your test is negative today it may be positive tomorrow, that’s the clinic . . .
Differentiation of SLAP lesions
By: Adrienne Zeiler, DPT
Pitchers are frequently seen in orthopedic clinics for injuries to their throwing shoulder. Many of these pitchers complain of a “dead arm” or a severe decrease in the velocity at which they can pitch. It is extremely important as direct access practitioners that we correctly diagnose these injuries, especially in the presence of a Superior Labral Anterior Posterior tear (SLAP) lesion. SLAP injuries frequently present with concurrent pathologies that may mask the classic signs of the SLAP. Failure to properly diagnose these pathologies may lead to further disability for the pitcher.
There are four tests and proceedures that are commonly used to diagnose shoulder impairments, in particular SLAP lesions. These include Bicipital groove tenderness, O’Brien’s Cross Arm test, Speeds Test, and Modified Jobe Relocation Test. The O’Brien’s and Speed’s test are considered highly specific for anterior Type II SLAP lesions. The Modified Jobe Relocation Test is considered highly specific for posterior Type II SLAP lesions which is the most common SLAP lesion in pitchers.
During arthoscopic surgery on pitcher’s (+) for a posterior Type II SLAP lesion, placing the shoulder in the initial position for the Modified Jobe Relocation test resulted in a (+) peel back sign with subluxation of the posterior superior labrum. During the second portion of the test, a posterior directed force is applied to the proximal humerus which puts the biceps tendon on traction and reduces the labrum to a normal position. Given this information, the Modified Jobe Relocation Test should be performed on every pitcher that presents to the clinic with c/o “dead arm” to determine whether a posterior Type II SLAP lesion is present.
Reference:
Burkhart, Stephan. “The Disabled Throwing Shoulder: Spectrum of Pathology Part II: Evaluation and Treatment of SLAP lesions in Throwers.” Arthroscopy: The Journal of Arthroscopic and Related Surgery 19.5 (2003): 530-539. Web. 21 Oct 2010.
Determining the Potential for Pulmonary Embolism
By: Adrienne Zeiler, DPT
While at a family get together last weekend, my aunt shared the painful story of her brother passing away just a week earlier. Her brother had a knee replacement in mid-October for which he was recieving physical therapy at a local outpatient clinic. He was progressing without too much difficulty until Monday just two weeks ago. He presented to the clinic for his usual PT regime and while on the exercise bike he suddenly became very short of breath. Despite calling 911 and attempts at CPR, he passed away on the way to the hospital. Final pathology report revealed that he died from a Pulmonary Embolism (PE). The most unfortunate part of the story is that, after talking with his wife, the doctors determined that he had all of the signs and symptoms of a DVT when he went to therapy that morning. He informed the PT that he had calf pain and was told that the muscle was likely tight due to the surgery and compensatory gait patterns. The PT did not further investigate his complaints…actions which could have saved his life.
It is vital that we as physical therapists not only know how to determine the likelihood that a patient has a DVT (as previously discussed by Jospeh Brence) but also the likelihood that the clot could result in a PE. This information may mean the difference between life and death in even the healthiest patients.
There have been several studies to determine the probability of a PE occuring. The combined result is the Revised Geneva Score which I have included below. PTs should be familiar with this score and understand the symptoms associated with PE so to provide the best possible care for patients (especially if we are a front line medical provider). According to the studies, one should suspect a PE when there is an acute onset of new shortness of breath or chest pain without other obvious cause. If a PE is suspected, it is important to follow the clinics protocol for an emergency situation so that the patient can get the help that they require.
Clinical Pretest Probablility of PE
0-3 points is a low, 9% probability of PE
4-10 points is an intermediate, 28% probability of PE
>11 points is a high, 72% probability of PE
Predictor Variable Score
| Age 65 years or over | 1 |
| Previous DVT or PE | 3 |
| Surgery or fracture within 1 month | 2 |
| Active malignant condition | 2 |
| Unilateral lower limb pain | 3 |
| Haemoptysis | 2 |
| Heart rate 75 to 94 beats per minute | 3 |
| Heart rate 95 or more beats per minute | 5 |
| Pain on deep palpation of lower limb and unilateral oedema | 4 |
References:
1. Le Gal G, Righini M, Roy RM, et al. Prediction of Pulmonary embolism in the emergency department: the revised Geneca score. Ann Internal Med. 2006;144:165-171.
2. Klok FA, Kruisman E, Spaan J, et al. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost. 2008;6:40-44.
3. Calisir C, Yavas US, Ozkan IR, et al. Performance of the Wells and revised Geneva scores for predicting pulmonary embolism. Eur J Emerg Med. 2009;16:49-52.
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