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Module 6: Low Back & Spine & Arm Injuries - Coggle Diagram
Module 6: Low Back & Spine & Arm Injuries
Fractures
Spondy-s (collective name)
often observed in sports involving hyperextension
Weightlifting
Throwing sports
Cricket
Tennis
Gymnastics
Spondylolisthesis
Spondylosis
can be an overuse mechanism
most commonly presents with unilateral LBP that radiates into buttock
worse with extension
may occur after a single event that precipitates the pain
most commonly affects L4/L5
Diagnosing a spondy
Imaging required
bone scan can be used
MRI may be effective
but less available
May not be visible on an x-ray
Treatment
Strengthen core
Progressive RTP once pain and symptom free
Stretch posterior chain
Pain dictated RTP
Cessation of aggravating activity
RTP often 3-6 months dependent on injury severity
Low Back Pain
Introduction
The majority of people will experience LBP at some point
most cases resolve within 3 months
50% will have recurrent episodes
Can be treated pretty well but easy to stop rehab when you feel good
most expensive and common disability in adults
results in workers compensation, lost time at work and treatment
often includes stenosis
means to narrow
compression of spinal nerves as a result of narrowing of the vertebral foramen or intervertebral foramen
Disc degeneration
intervertebral discs dessicate
Risk Factors
Smoking
Inhibits collagen and elastin production
Jobs which require:
twisting, bending, lifting
lifting techniques are often poor
vibration
prolonged vibration can cause overstimulation of muscles and fatigue them causing more reliance of intervertebral discs for stability
ex// truck drivers
Prolonged sedentary time
Having multiple children
muscles in the pelvic girdle impacted
Stress/anxiety
carry tension in the back
Changes perceptions of pain
Age
degeneration or reduction in muscle and body comp
Sources of pain
Muscles
strains
Nerves
stenosis or herniation
Ligaments
Facet Joint
Annulus Fibrosus
annulus fibrosis serves as a ring around the jelly donut
Nucleus Pulposus
herniates and compresses a nerve
Synovium
irritation of joint fluid in that area
Red Flags (when there is insidious onset)
Incontinence
Nerves not communicating properly with the brain
Related since many nerves of the cauda equina supply these areas
Inability to control bladder/bowels
Saddle anesthesia
loss of sensation
nerves from the cauda equina
Fever, night sweats, weight loss
Weakness in legs
History of cancer
IVDU
intravenous drug use
potential for an abscess
Age
exceptionally older or younger
Conditions associated with red flags
Cauda equina syndrome
a ruptured disc, infection, trauma, or lesion affects the Cauda equina
Epidural abscess
Infection/pus in the epidural space
Malignancy
cancer
Acute LBP
causes
Acute disc prolapse
Facet joint injury (fracture, capsular tear, avulsion)
Acute tear of annulus fibrosis (AF)
Muscle strain
With radicular pain (Pain which is radiating into posterior thigh)
Acute nerve root compression
most common cause
disc prolapse
disc is prolapsed into vertebral foramen and impinging
L5/S1
next most common is L4/L5
less common cause
osteophytes (older individuals)
little bony overgrowths
associated with arthritis
Nerve root anatomy
Thoracic, lumbar and sacral are named for the superior disc
ie. if L5/S1 disc is prolapsed, the L5 nerve root will be involved
Cervical nerve roots are named for the inferior vertebra (special exception for C8 (b/w C7 and T1)
Dermatomes
certain segments of skin are supplied by spinal nerves which transmit sensory information
efferents can be used for nerve root involvement
have to do with afferent fibers
can be used to test for nerve root involvment
Symptoms
sharp burning pain down the back of the leg typically
may have weakness
pain worsens with sitting, bending, coughing, sneezing
increase valsalva pressure
pain usually eased by lying down
Exam
on standing, patient may lean to one side to alleviate pain
ex// unilateral nerve root compression
limited ROM in all planes (especially flexion)
Tender with palpation of vertebra and musculature
muscle spasm and tension in paraspinals
Positive slump test
neurodynamic test for the lower limb
44-87% sensitivity, 23-63% specificity
maximally stretching the neural structures of vertebral canal and foramen
goal is to elicit pathological neurological symptoms like shooting pain, numbness and burning sensation
a positive test can indicate a herniated disc or nerve root entrapment
done by sitting right up, holding hands behind then slumping, gently apply pressure over shoulder with one arm and ask them to bring head to chest then ask them to extend the knee of affected side
add passive dorsiflexion
may show symptoms at any stage
Positive straight leg test
neurological assessment for patients who display lumbar right colopathy symptoms which are commonly caused by disc herniations
91% sensitivity, 26% specificity
patient in supine, assess unaffected leg, then flex leg and get them to tell you when symptoms appear
usually symptoms appear within range of 35-70 degrees flexion (past: lumbar and sacroiliac joint)
move out of pain range and dorsiflexion (bragard's sign) or flex neck (Neri's sign)
if pain is elicited it indicates stretch of dura mater or lesion in the spinal cord caused by tumour or disc herniation
Diagnosis and Treatment
Imaging only needed if intervention planned
Interventions
selective nerve root blocks
epidural steroid injection
discectomy
Diagnosis made through clinical exam
acute treatment is similar to acute back pain without radicular symptoms
Intervention may be required for athletes who don't improve or an abnormal progression
Without radicular pain (Pain which is radiating into posterior thigh)
Introduction
Acute disc prolapse
without nerve root impingment
with impingement you would see radicular pain
Facet joint injury
Acute tear of AF
shearing force
Exam
Pain in most ranges
restricted overall movement
Tender to palpate the area and the surrounding soft tissue
surrounding muscles seize up and start to guard
disc injuries may be tender more centrally
Facet joint injuries may be tender more laterally
Muscle spasm and tension in low back
Presentation
Pain may refer in the buttocks
Pain can be unilateral, bilateral, or central in the lower back
Pain comes on suddenly after a particular mvmt
can pinpoint the cause of pain
not insidious
Diagnosis
Imaging not usually required
direct trauma
risk of fragility
age
osteoporosis
arthritis
unless there are red flags
diagnosis made on clinical exam
MOI
Muscle strains often occur in flexion
position of vulnerability for the erector spinae
Facet joint injuries occur from rotation, often with extension
Flexion w/ rotation is most vulnerable position for lumbar position
Disk Injuries are most common in forward flexion
Treatment
find a comfortable position
avoid pain provoking positions or mvmt initially
bed rest up to 48 hours
no more than 48 hours until px starts moving
analgesics/NSAIDs
Avoid prolonged sitting
90% of individuals will have resolution of symptoms in 3 months
Injuries of the elbow
Examining the elbow
History
Changes training
velocity, pitch count, accuracy, or strength changes should be noted
Events leading up to the injury
time and onset of symptoms
Details of current injury
positions/activities of greatest discomfort
Neurologic or vascular complaints
numbness, coldness, loss of sensation
Physical Exam
look at carrying angle
changes may be due to injury or chronic elbow stress
Difficult to measure if there is elbow contracture
Measuring carrying angle
Important bony landmarks
Medial and lateral epicondyles and marking midline
Superior surface of AC joint
Space b/w radioulnar styloid processes
Manual measurement requires a goniometer
Connecting the dots
fulcrum
moving arm
fixed arm
AROM and PROM
flexion: 0-140/150 degrees
Supination/pronation: 80-90 degrees
Observe resting position of arm
swelling will close full extension
look for crepitus or pain
Observe compensation at the shoulder or scapula
unable to accomplish action at the forearm you will see compensation up
Palpate bony and soft tissue structures
around epicondyles and olecranon
Lateral Elbow Pain
most common site of elbow pain
referred pain
myofascial
upper t-spine
c-spine
Terms
lateral epicondylitis
not an inflammatory condition
Epicondylosis
likely not degenerative either
Tennis elbow
Not a medical term, and more non-tennis players are likely to present with this than tennis players
Lateral Elbow Tendinopathy (LET)
The most common cause of lateral elbow pain/discomfort in adults (in those without referred pain/symptoms)
may follow changes in exercise/work etc.
Pain in elbow/forearm, but no radiation into hand or wrist
usually insidious onset
may involve trigger points in forearm musculature
small bundles of sarcomeres which remain in the contracted position
not inflammatory but long term degradation of collagen fibers in the tendon
imaging not required but may be done in chronic cases
LET vs referred pain
Lateral elbow tendinopathy
specific activities elicit the elbow pain (especially gripping movements and wrist extension
pain in the region of the elbow and proximal forearm
pain is primary concern
referred pain
pain may begin in the neck/shoulder and radiate into the hand/wrist
sensory symptoms (paresthesia)
pain may be unpredictable or postural related
Extensor Digitorum
O: lateral epicondyle of the humerus
I: Base of 3rd MC
A: Extension and radial deviation
Inn: posterior interosseous nerve/radial nerve
Extensor Carpi Radialis Brevis
Inn: Radial nerve (C7-C8)
A: Extension and radial deviation
I: Base of 3rd MC
O: lateral epicondyle of the humerus
most vulnerable in elbow extension/forearm pronation
Treatment
Treat any concomitant spinal/neural dysfunction
individuals with associated neck pain tend to have worse outcomes
correction of faulty technique
strengthening grip, shoulder, scapular stabilizers
maintain/restore flexibility in the forearm
Basic soft tissue injury management principles
evidence that acupuncture may be beneficial
Pain control
bracing/taping
corticosteroid injection
short term relief, but potential long term risks
no patches
Platelet-rich plasma injection
Medial Elbow Pain
flexor/pronator tendinopathy
occurs in golfers and tennis players
especially those who use a top spin
issue lies in the proximal tendon of the pronator teres
less common than lateral elbow tendinopathy
can occur in climbers as well - "climber's elbow"
presents as localized tenderness in the area
Treatment
treatment is similar to that for LET
Strengthening should focus on flexors & pronators
Ulnar nerve
because of the ulnar nerve's proximity to the PT (pronator teres), there may be nerve involvement
ulnar collateral ligament injury
may be acute or chronic
typically occurs in throwing athletes
Valgus force
Force humerus in while forearm goes out laterally
The UCL is intended to resist valgus force to the elbow
UCL sprain
Presents with localized tenderness
Potential instability during valgus stress
May also occur with:
Flexion contracture of the forearm
synovitis
loose body formation around the olecranon
UCL Exam
Palpate UCL with elbow in 50-70 degrees flexion
looking for pain
entire length of ligament: medial epicondyle to proximal medial ulnar
Valgus stress can be applied to test integrity
Early Treatment
For mild/moderate injury
Correct issues with throwing technique or pitch type
Strengthen flexors and pronators of the forearm
Reduce or modify aggravating activities
soft tissue therapy
elbow strap may be worn
Surgical Treatment
Surgical intervention also indicated if loose bodies or bony spurs are present
If underlying issues aren’t addressed, there can be re-injury after surgery
With a full rupture/severe instability, surgery indicated
Decent success rate for RTP
Medial Epicondyle Apophysitis
elbow injuries in young athlete
Injuries that may damage the UCL in adults can occur at the growth plate in younger throwing athletes
weaker point of contact
Elbow Dislocations
posterior elbow dislocation
Often occurs in contact sports
Caused by posterolateral rotary force
Fall on an outstretched hand, with shoulder abducted, axial compression, forearm supinated, and forced flexion of the elbow
Major concern with elbow dislocation
Vascular supply
After elbow dislocation, check capillary refill and distal pulse
If pulses do not return after reduction, emergency surgery required
sometimes vessels can be damaged with relocation
If pulse is absent, immediate relocation is needed
nail bed should refill with blood
brachial artery and neurovascular supply
Integrity of surrounding ligaments should be checked after dislocation
Xray needed after reduction to check for fracture of coronoid process or radial head
after dislocation, may be difficult to regain full extension at the elbow
recovery depends on complexity of the dislocation, and associated soft tissue damage
Ulnar Nerve Injury
Ulnar neuropathy
ulnar nerve can become entrapped or compressed
next most common is wrist
most common site is elbow ulnar nerve is very superficial
nerve is stressed in extreme valgus (late cocking, early acceleration)
Can be secondary condition to
Compression from adhesions
Flexor/pronator over-development
Osteophytes
Friction from nerve subluxation
stretching from valgus forces
Result from older forms of UCL reconstruction surgery
Handlebar palsy
a type of ulnar neuropathy
Resting medial portion of wrist causing irritation to ulnar nerve
cyclists
Symptoms
Numbness or tingling along the nerve distribution
Pain during/after throwing
Tenderness at the point of entrapment
Pitchers may feel arm is heavy or clumsy after several innings
UN subluxation will cause ’snapping’ of the tendon
Can have progressive loss of grip or pinch strength after
prolonged neuropathy
(+) Tinel sign
Exam
Check the entire length of the UN
Rule out thoracic outlet or cervical root issues
Look for laxity at the UCL
Will strain the UN
Elbow flexion test
Elbow Is Flexed With Forearm Supinated For Several Minutes– (+)testify sxs are provoked
Treatment
Limit aggravating activity
Cryotherapy/NSAIDs if indicated
Correct mechanics
Address underlying issues
Elbow pad may be worn
Relative rest should alleviate sxs
Splinting may be indicated if there is nerve subluxation
Surgery required for those with unresolved sxs