Examination and Treatment of Achilles Tendon:       

Acute tendon rupture is most common among men aged 30-50 years (mean age, 40 years) it causes sudden severe disability.

Achilles tendon injuries tendinopathy may arise with increased training volume or intensity but may also arise insidiously. Because the prognosis for midportion Achilles tendinopathy is much better than for insertional tendinopathy, these conditions should be distinguished clinically. The condition that was previously called ‘Achilles tendinitis‘ is not truly an inflammatory condition and, thus, should be referred to as ‘Achilles tendinopathy’. The main differential diagnoses of gradual onset pain in the Achilles region arise from the neighboring anatomy.

There are two bursae in this region:

• The Retrocalcaneal Bursa
• The Achilles Bursa

1.   The Retrocalcaneal Bursa: Retrocalcaneal Bursa lies between the posterior aspect of the calcaneus and the insertion of the Achilles tendon.

2.   The Achilles Bursa: Achilles Bursa lies between the insersion of the Achilles tendon and the skin.

The posterior process of the talus or a discrete anatomical variant, the os trigonum, can each be involved in posterior impingement syndrome. This is most commonly seen in ballet dancers but occurs occasionally in sprinters and in football players. Other, much less common differential diagnoses include dislocation of the peroneal tendons, an accessory soleus muscle, irritation, or neuroma of the sural nerve, and systemic inflammatory disease. These pathologies cause pain in and also around the Achilles tendon; true tendon pain is almost always confined to the tendon itself. In adolescents, it is important to consider the diagnosis of Sever’s lesion, a traction apophysitis at the insertion of the Achilles tendon into the calcaneus. Referred pain is a very rare cause of pain in the Achilles region.

History

• The athlete with overuse tendinopathy notices a gradual development of symptoms and typically complains of pain and morning stiffness after increasing activity level.
• Pain diminishes with walking about or applying heat. In most cases, pain diminishes during training, only to recur several hours afterwards.
• The onset of pain is usually more sudden in a partial tear of the Achilles tendon. In this uncommon condition, pain may be more disabling in the short term.
• As the histological abnormality in a partial tear and in overuse tendinopathy are identical, we do not emphasize the distinction other than to suggest that time to recovery may be longer in cases of partial tear.

Examination

Palpate the painful area for tenderness, thickening, and crepitus. If the Achilles tendon seems to be the cause of pain, and the examiner is confident that the tendon is intact, the examination should aim to provoke tendon pain during tendon loading activity.  These functional tests provide a baseline against which treatment response can be compared. Another method of monitoring the clinical progress of Achilles tendinopathy is to use the VISA questionnaire. This is simple questionnaire takes less than 5 minutes to complete and once patients are familiar with it they can complete most of it themselves.

Examination involves:

1.   Observation

• Standing
• Walking
• Prone

2.   Active movements

• Plantarflexion
• Dorsiflexion

3.   Passive movements

• Plantarflexion
• Plantarflexion with overpressure
• Dorsiflexion
• Subtalar joint
• Muscle stretch
• Gastrocnemius
• Soleus

4.   Resisted movements

• Plantarflexion- calf raises

5.   Functional tests

• Single- leg calf raises
• Hop
• Eccentric drop

6.   Palpation

• Achilles tendon
• Retrocalcaneal bursa
• Posterior talus
• Calf muscle

7.   Special test

• Prone inspection for tendon rupture
• Simmond’s Calf squeeze test
• Biomechanical assessment

Investigations and Treatment of Achilles Tendons

• Plain radiographs are of limited value but, if symptoms are longstanding, they may reveal a Haglund’s deformity, a prominent superior projection of the calcaneus, or spurs projecting into the tendon.
• Posterior impingement can be shown radiographically using functional views. X-ray may reveal calcification in the tendon itself but, unless severe, this can be asymptomatic.
• In symptomatic patients, both ultrasound and MRI often reveal an abnormal signal in the Achilles tendon that generally corresponds with the histopathology of tendinosis.
• Ultrasound and MRI can help distinguish different causes of pain in the Achilles region.
• Achilles tendon insertion is abnormal in patients with pain at the distal tendon.
• It may also provide a target for treatment. Because of the variability in imaging and its inconsistent clinical correlation, the results of imaging should not dominate clinical decision making variation in symptoms such as morning stiffness and load pain should direct treatment modification. Studies in many tendons have indicated that clinical outcomes are independent of imaging and change in imaging.

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Treatment of Knee Pain:

Definition of Patellofemoral Pain

Patellofemoral pain is the preferred term used to describe pain in and around the patella. Synonyms include PFJ syndrome, anterior knee pain and chondromalacia patellae.

Patellofemoral pain is an umbrella term used to embrace all peripatellar or retro patellar pain in the absence of other pathologies. Since the cause of the pain may differ between patients, it is appropriate to review the potential sources of patellofemoral pain. A number of extra- and intra-articular components of the knee can generate neurosensory signals that ultimately result in of the patient feeling pain. Patellofemoral articular cartilage cannot directly be a source of pain.

Functional Anatomy

• At full extension, the patella sits lateral to the trochlea.
• During flexion, the patella moves medially and comes to lie within the Intercondylar notch until 130 degree of flexion, when it starts to move laterally again.
• The patell mediolateral excursion is controlled by the quadriceps muscles, particularly the VMO and vastus lateralis components.
• With increasing knee flexion, a greater area of patellar articular surface comes into contact with the femur, thus offsetting the increased load that occurs with flexion.
• Loaded knee flexion activities subject the PFJ to loads many times the body weight, ranging from 0.5 times body weight for level walking to seven to eight time’s body weight for stair climbing.

Factors That May Contribute To Development of Pain

1. Remote Contributing Factors
2. Local Contributing Factors

Increased PFJ load instigates the development of patellofemoral pain. Factors that influence PFJ load can be considered in two categories: extrinsic and intrinsic.

• During physical activities the extrinsic load is created by the body’s contact with the ground (ground reaction force) and is therefore moderated by body mass, speed of gait, surfaces and footwear.
• During weight-bearing activities, any increase in the amount of knee flexion will increase the PFJ load.
• Intrinsic factors can influence both the magnitude and the distribution of the PFJ load.
• Distribution of load is conceptualized as movement of the patella within the femoral trochlea: patella tracking.
• Local factors that influence patella movement include patella position, soft tissue tension and neuromuscular control of the medial and lateral components of the vasti.
• The clinician should assess the contribution of various extrinsic and intrinsic factors to the development of patellofemoral pain.
• This assessment is crucial in the planning of an appropriate treatment regimen.
• The history will elucidate valuable information pertaining to extrinsic factors but clinical examination is usually required to evaluate most intrinsic contributing remote and local factors.

1. Remote Contributing Factors

The following remote factors may contribute to the development of patellofemoral pain:

• Increased femoral internal rotation
• Increased knee valgus
• Increased tibial rotation
• Increased subtalar pronation
• Inadequate flexibility

It is important to assess the patient in static postures as well as functional activities. Some factors may become more obvious during specific functional tasks, such as the step-down or single-leg squat, where the postural demands are high.

2. Local Contributing Factors

Local factors that can contribute to the development of patellofemoral pain are:

• Patella position
• Soft tissue contributions
• Neuromuscular control of the vasti

Treatment of Patellofemoral Pain

The management of a patient with patellofemoral pain requires an integrated approach that may include:

• Reduction of pain and inflammation
• Addressing extrinsic contributing factors
• Addressing intrinsic contributing factors:
• Evidence base for physical intervenons
• Surgery-to be avoided

Immediate Reduction of Pain

The first priority of treatment is to reduce pain. This may require some or all of the following: rest from aggravating activities, ice, a short course of NSAIDs, electrotherapeutic modalities (e.g. ultrasound) and techniques such as mobilization or dry needling or acupuncture. Taping should have an immediate pain-relieving effect.

Addressing Extrinsic Contributing Factors

While initially it is vital to advise the patient to reduce the load on the PFJ, as rehabilitation progresses it is essential that any extrinsic factors that may have been placing excessive load on the PFJ (e.g. training, shoes and surfaces) are discussed and modified if necessary.

Addressing Intrinsic Contributing Factors

The clinician should have ascertained from the outset whether any intrinsic factors may have contributed to the development of the patient’s pain. Remote intrinsic factors may be addressed through hip muscle retraining, improving musculotendinous compliance or foot orthoses. Local intrinsic factors may be addressed with techniques such as patella taping or bracing, improving lateral soft tissue compliance, generalized quadriceps strengthening or vasti retraining.

Evidence Base for Physical Intervenons

A number of controlled clinical trials have assessed the effectiveness or efficacy of physical interventions for patellofemoral pain. While these reflect some aspects of treatment techniques, mostly the interventions are not individualized to the patients needs.

Treatment options that have gained popularity more recently have not been evaluated as thoroughly. The level 1 (systematic reviews) and level 2 (controlled clinical trials) evidence of the evaluation of physical interventions for patellofemoral pain.

Surgery-To Be Avoided

Experienced clinicians will have observed that the need for surgery in patellofemoral pain has been greatly reduced. This is likely due to the availability of evidence-based, exercise-based, physical interventions. To our knowledge, there has been no surgical randomized controlled trial showing the effectiveness of treatments such as chondroplasty or lateral release for patellofemoral pain. Thus, at a time when systematic reviews (level evidence) argue for physical therapies for this condition, it would appear that such avenues should be tried repeatedly and with various expert physical therapists before being abandoned in favor of a hoped-for surgical miracle. We note that poor surgical outcomes have been reported and often patellofemoral pain is worsened after surgery.

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Severe Low Back Pain Treatment

The majority of patients with low back pain present with mild-to-moderate pain. A small group of patients present with acute onset of severe low back pain.

The aim of initial management of these patients is to reduce the pain and inflammation as rapidly as possible. When this is done, the management of these patients relies on the same principles as those with mild-to-moderate low back pain.

Acute onset of severe low back pain in the absence of nerve root signs may be due either to an acute tear of the anulus fibrosus of the disk or to an acute locked apophyseal joint. A locked apophyseal joint is thought to be due to entrapment of an intra-articular meniscus.

Clinical Features of Severe Acute Low Back Pain

• Acute low back pain is usually of sudden onset and is often triggered by a relatively minor movement such as bending to pick up an object.
• This minor incident may be more indicative of fatigue or lack of control, rather than tissue overload. The pain may increase over a period of hours due to the development of inflammation.
• Patients with chronic low back pain may also have acute exacerbations that may become more frequent and require less initiation over time.
• The pain is usually in the lower lumbar area and may be central, bilateral or unilateral.
• It may radiate to the buttocks, hamstrings or lower leg. Sharp, laminating pain in a narrow band down the leg is radicular pain and is associated with nerve root irritation, commonly as a result of intervertebral disk prolapsed.
• More commonly, the pain referred to the buttock and hamstring is somatic in nature, with the patient complaining of a deep-seated ache.
• The patient with acute, sudden onset of low back pain often adopts a fixed position and movements are severely restricted in all directions.
• Palpation of the lumbar spine reveals areas of marked tenderness with associated muscle spasm.

Management of Severe Acute Low Back Pain

• Encourage the patient to adopt the position of most comfort position varies considerably and may be lying prone, supine or, commonly, side-lying with a degree of lumbar flexion.
• Movements that aggravate pain should be avoided, whereas movements that reduce or have no effect on pain should be encouraged.
• Bed rest in the position of most comfort may be continued for up to 48 hours depending on the amount of pain.
• Bed rest longer than 48 hours has been shown to be detrimental.
• Taping of the low back can markedly reduce acute back pain and allow quicker functional restoration.
• Analgesics may control the pain and reflex muscle spasm. NSAIDs may help reduce inflammation.
• Electrotherapeutic modalities, for example, TENS, interferential stimulation and magnetic field therapy, may be helpful in reducing pain and muscle spasm in the acute stage. However, if access to these modalities in the acute stage requires any degree of travel, then bed rest alone may be preferable.
• Exercise in a direction away from the movement that aggravates the patient’s symptoms should be commenced as early as possible. For those patients in whom flexion aggravates their symptoms, extension exercises should be performed.
• The degree of extension should be determined by the level of pain. Initially, lying prone may be sufficient. Later, extension of the lumbar spine by pushing up onto the elbows may be possible. Eventually, further extension with straight arms can be achieved.
• Exercises should be immediately discontinued if peripheral symptoms develop.
• Prolonged posture involving flexion, such as sitting, should be avoided.
• In patients for whom extension movements aggravate their pain, flexion exercises or rotation (away from pain) exercises should be performed. For these patients, prolonged posture involving extension, such as standing with excessive lumbar lordosis, should be avoided.

Manual therapy has only a limited role in treating severe low back pain. Gentle mobilization techniques, for example, posteroanterior (PA) mobilization, may be performed and the patient’s response closely monitored. If there is any deterioration of symptoms, mobilization should be immediately ceased. The mobilization should be performed in the position of comfort adopted by the patient. Manipulation should not be attempted in the presence of marked muscle spasm. Similarly, gentle (grade I) soft tissue massage may be helpful in relieving pain and muscle spasm Traction has not been found to be helpful in patients with acute low back pain.

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Treatment of Quadriceps Muscle Strain Injury (Front Thigh Muscle Pain):

Introduction

Strains of the quadriceps muscle usually occur during sprinting, jumping or kicking. Strains are seen in all the quadriceps muscles but are most common in the rectus femoris, which is more vulnerable to strain as it passes over two joints: the hip and the knee. The most common site of strain is the distal musculotendinous junction of the rectus femoris. Management of this type of rectus femoris strain and of strains of the vast muscles is relatively straightforward; rehabilitation time is short. Strains of the proximal rectus are not as straightforward and considered separately below.

Types of Quadriceps Muscle Strain

• Mild (Grade 1)
• Moderate (Grade II)
• Severe (Grade III)

Like all muscle strains, quadriceps strains may be graded into mild (grade 1), moderate (grade II) or severe, complete tears (grade III). The athlete feels the injury as a sudden pain in the anterior thigh during an activity requiring explosive muscle contraction.

There is local pain and tenderness and, if the strain is severe, swelling and bruising. Grade I strain is a minor injury with pain on resisted active contraction and on passive stretching. An area of local spasm is palpable at the site of pain. An athlete with such a strain may not cease activity at the time of the pain but will usually notice the injury after cooling down or the following day.

Moderate or grade II strains cause significant pain on passive stretching as well as on unopposed active contraction. There is usually a moderate area of inflammation surrounding a tender palpable lesion. The athlete with a grade II strain is generally unable to continue the activity. Complete tears of the rectus femoris occur with sudden onset of pain and disability during intense activity. A muscle fiber defect is usually palpable when the muscle is contracted. In the long term, they resolve with conservative management, often with surprisingly little disability.

Treatment of Quadriceps Muscle Strain

The principles of treatment of a quadriceps muscle strain are similar to those of a thigh contusion.  They are also appropriate for the treatment of quadriceps strain; however, depending on the severity of the strain, progression through the various stages may be slower.

• Although loss of range of motion may be less obvious than with a contusion, it is important that the athlete regain pain-free range of movement as soon as possible.
• Loss of strength may be more marked than with a thigh contusion and strength retraining requires emphasis in the rehabilitation program.
• As with the general principles of muscle rehabilitation, the program should commence with low resistance, high repetition exercise.
• Concentric and eccentric exercises should begin with very low weights.
• General fitness can be maintained by activities such as swimming (initially with a pool buoy) and upper body training.
• Functional retraining should be incorporated as soon as possible.
• Full training must be completed prior to return to sport. Unfortunately, quadriceps strains often recur, either in the same season, or even a year to two later.

Differentiating between a Mild Quadriceps Strain and a Quadriceps Contusion

Occasionally, it may be difficult between a minor contusion and a minor muscle strain but the distinction needs to be made as an athlete with a thigh strain should progress more slowly through a rehabilitation program than should the athlete with quadriceps contusion. The athlete with thigh strain should avoid sharp acceleration and deceleration movements in the early stages of injury. Some of the features that may assist the clinician in differentiating. Diagnostic ultrasound examination may be helpful in differentiating between the two conditions.

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Treatment of  Flexor Hallucis Longus Tendinopathy:

The flexor hallucis longus tendon flexes the big toe and assists in plantarflexion of the ankle. It passes posterior to the medial malleolus, and runs between the two sesamoid bones to insert into the base of the distal phalanx of the big toe.

Causes:

• Flexor hallucis longus tendinopathy may occur secondary to overuse, a stenosing tenosynovitis, pseuocyst or tendon tear.
• A common cause is overuse in a ballet dancer, as dancers repetitively go from flat foot stance to the en pointe position, when extreme plantarflexion is required. Wearing shoes that are too big and require the athlete to ‘toe-grip’ may also result in flexor hallucis longus tendinopathy.
• This condition is often associated with posterior impingement syndrome as the flexor hallucis tendon lies in a fibro-osseous tunnel between the lateral and medial tubercles of the posterior process of the talus.
• Enlargement or medial displacement of the os trigonum puts pressure on the flexor hallucis longus at the point where the tendon changes direction from a vertical course dorsal to the talus to a horizontal course beneath the talus.
• This can cause tendon thickening and may result in ‘triggering’ of the tendon, when partial tearing and subsequent healing of the tendon produce excessive scar tissue.

Clinical Features:

• Pain on toe-off or forefoot weight-bearing (e.g. rising in ballet), maximal over the posteromedial aspect of the calcaneus around the sustentaculum tali.
• Pain may be aggravated by resisted flexion of the first toe or stretch into full dorsiflexion of the hallux.
• In more severe cases, there may be ‘triggering’ of the first toe, both with rising onto the balls of the foot (e.g. in ballet) and in lowering from this position. Triggering occurs when the foot is placed in plantarflexion and the athlete, unable to flex the hallux, but then with forcible active contraction of the flexor hallucis longus, is able to extend the interphalangeal or metatarsophalangeal joints of the toe. A snap or pop occurs in the posteromedial aspect of the ankle when this happens. Subsequent passive flexion or extension of the interphalangeal joint produces a painless snap posterior to the medial malleolus.

Diagnosis of Flexor Hallucis Longus Tendinopathy:

MRI or ultrasound may both reveal pathology. The characteristic MRI sign is abrupt fluid cut-off in the tendon sheath; excessive fluid is found loculated around a normal-appearing tendon proximal to the fibro-osseous canal.

Treatment of Flexor Hallucis Longus Tendinopathy:

In the acute phase, treatment may include:

• Ice
• Avoidance of activities that stress the flexor hallucis longus tendon (e.g. dancer working at the barre but not rising en pointe)
• Flexor hallucis longus strength and stretching exercises
• Soft tissue therapy proximally in the muscle belly
• Correction of subtalar joint hypomobility with manual mobilization
• Control of excessive pronation during toe-off with tape or orthoses-this may be helpful but is difficult to achieve in dancers.

Prevention of  Flexor Hallucis Longus Tendinopathy:

Prevention of recurrences should focus on a reduction in the amount of hip turnout, thus ensuring that the weight is directly over the hip, avoidance of hard floors, and using firm, well-fitting pointe shoes, so that the foot is well supported and no additional strain is placed on the tendon. Technique correction is important in ballet dancers with this condition as it is thought to arise not only from excessive ankle eversion or inversion with pointe work but also from proximal weakness, such as poor trunk control. Surgical  should be considered when persistent synovitis or triggering prevents dancing en pointe. Surgery involves exploration of the tendon and release of the tendon sheath.

Symptoms and Treatment of Acute Calf Strain:

Acute strain of the gastrocnemius muscle occurs typically when the athlete attempts to accelerate from a stationary position with the ankle in dorsiflexion, or when lunging forward, such as while playing tennis or squash. Sudden eccentric overstretch, such as when an athlete runs onto a kerb and the ankle drops suddenly into dorsiflexion, is another common mechanism.

The exact moment of injury was caught on video in the case of a famous Australian batsman whose gastrocnemius strain occurred when has entire body weight was over his foot on the injured side with the center of mass well in front of the leg. The gastrocnemius muscle-tendon complex was at close to maximal length, and the muscle-tendon length was also constant at the time. Therefore, the injury probably occurred just as the muscle-tendon complex was moving from an eccentric to an isometric phase.

Signs and Symptoms

• The patient complains of an acute, stabbing or tearing sensation usually either in the medial belly of the gastrocnemius or at the musculotendinous junction.
• Examination reveals tenderness at the site of muscle strain.
• Stretching the gastrocnemius reproduces pain, as doe’s resisted plantar flexion with the knee extended.
• In grade III muscle tears, there may be a palpable defect.
• Assess functional competence of the injured muscle by asking the patient to perform a bilateral heel raise.
• If necessary, a unilateral heel raise, a heel drop or hop may be used to reproduce the pain.
• This places the muscle under progressively greater load concentrically and eccentrically.
• Calf muscle strain can be graded.
• The tightness of the muscle itself should be assessed as overuse may often lead to palpable ropelike bands or local tissue thickening, which may predispose to further injury.

Treatment

Initial treatment aims to reduce pain and swelling with the use of ice and electrotherapeutic modalities (e.g. TENS, magnetic field therapy, interferential stimulation).

• Crutches may be necessary if the patient is unable to bear weight.
• A heel raise should be used on both the injured and uninjured side.
• Gentle stretching of the gastrocnemius to the level of a feeling of tightness can begin soon after injury.
• Muscle strengthening should start after 24 hours.
• This involves a progression of exercises, commencing with concentric bilateral calf raise, followed by unilateral calf raise with the gradual addition of weights and, finally, eccentric calf lowering over a step gradually increasing speed, then adding weights.
• Low-impact cross-training such as stationary cycling or swimming can be commenced as soon as pain allows.
• When active weight-bearing muscle contraction is pain-free, sustained myofascial tension should be performed on the muscle belly with digital ischemic pressure to focal areas of increased tone and/or tenderness.
• Endeavor to correct possible predisposing factors, such as calf muscle tightness, that may arise from poor biomechanics.
• Athletes should undergo a graduated return to weight-bearing, progressing through walking, easy jogs and, as eccentric strength returns, include sprint and change of direction drills.

Tennis leg

• The term tennis leg refers to an acute muscle tear in the older athlete characterized by sudden onset of severe calf pain and significant disability.
• The injury is invariably associated with extensive bruising and swelling, and can be mistaken for a deep venous thrombosis.
• The most common site is the medial head of gastrocnemius, but occasionally the planters muscle is involved.

Symptoms And Treatment of Herniated Disc:

Acute nerve root compression is usually the result of an acute disk prolapse when the contents of the nucleus pulposus of the intervertebral disk are extruded through a defect in the anulus fibrosus into the spinal canal. There they may irritate the nerve root. The irritation of the nerve root may be due to direct mechanical compression by the nuclear material or as result of the chemical irritation caused by the extrusion. In the older athlete, nerve roots may be compressed by osteophytes formed as part of a degenerative process.

Prolapse usually occurs in disks that have been previously damaged by one of the processes mentioned already. This explains why frequently a minor movement, such as bending over to pick up an object off the floor, may cause such an apparently severe injury. Disk prolapse usually occurs between the ages of 20 and 50 years and is more common in males than females. The L5-S1 disk is the most commonly propalsed disk and L-4-5 the next most common.

Signs and Symptoms

Typically, a patient with a disk prolapse presents with acute low back pain or radicular leg pain (or both) following a relatively trivial movement usually involving flexion.

• On occasions, the presentation may be painless, with weakness or sensory symptoms only.
• The symptoms depend on the direction of the extrusion.
• Posterior protrusions are more likely to cause low back pain with later development of leg pain, whereas posterolateral protrusions may cause radicular symptoms without low back pain.
• Typical symptoms include sharp shooting pain in a narrow band accompanied by pins and needles, numbness and weakness.
• Pain is often aggravated by sitting, bending, lifting, coughing or sneezing.
• Pain is usually eased by lying down, particularly on the asymptomatic and is often less after a night’s rest.
• On examination, the patient often demonstrates a list to one side, usually, although not always, away from the side of pain.
• This is a protective scoliosis. Examination may be difficult if there is severe pain and irritability.
• Straight leg raise is usually limited (less than 30 degree in severe cases) and all active movements, particularly flexion, are usually restricted.
• Palpation usually reveals acute muscle spasm with marked tenderness but occasionally it may be unremarkable.
• A neurological examination should always be performed when pain extends past the buttock fold or there are subjective sensory/motor changes.

Treatment

In the acute phase, the most appropriate treatment is rest in bed in a position of maximum comfort with administration of analgesics and NSAIDs.

• The patient should lie as much as possible and avoid sitting.
• Extension exercises should be commenced as soon as possible. However, if exercises cause an increase in peripheral symptoms, they should be ceased.
• Mobilization techniques should be performed with great care.
• Rotations may be effective but should be performed gently as patients with disk prolapse may be made considerably worse with aggressive mobilization.
• Manipulation is contraindicated in conditions with acute neurological signs and symptoms.
• Traction is often helpful in the treatment of acute disk prolapsed with distal symptoms.
• However, it is not uncommon for the patient to experience considerable pain relief while undergoing traction, only to have increased symptoms after treatment.
• A transforaminal epidural injection of corticosteroid may help if there is no significant improvement in symptoms and signs with rest.
• Surgery may be required if neurological signs persist or worsen. If bowel or bladder symptoms are present, emergency surgery may be necessary.
• An open Laminectomy or percutaneous diskectomy using a needle aspiration technique may be performed.
• Chymopa pain injection may be helpful when a unilateral disk bulge is present.
• As the acute episode settles, it is important to restore normal pain-free movement to the area with localized mobilization and stretching.

 Following restoration of range of movement, active stabilization exercises should be performed. Postural advice, including correction of poor lifting techniques and adjustment of sporting technique, where necessary, is most important.

Symptoms And Treatment of Anterior Instability:

Shoulder Instability may be anterior, posterior, inferior or multidirectional.

Anterior Instability

Anterior glenohumeral instability may be post-traumatic, as a result of an acute episode of trauma causing anterior dislocation or subluxation, or a traumatic, or a combination-for instance, an acute traumatic episode in a lax shoulder.

In differentiating between the two types of anterior instability, the history is the most useful factor. In post-traumatic instability, the patient usually reports a specific incident that precipitated the problem. This is commonly a moderately forceful abduction and external rotation injury. Following this episode, however, the patient reports that the shoulder has never returned to normal. In many post-traumatic types of instability a true dislocation may not have occurred and the symptoms are related to recurrent subluxation. The atraumatic type of abnormality is common in people with capsular laxity including sportspeople, especially those involved in repeated overhead activities such as baseball pitchers, javelin throwers, swimmers and tennis players.

Symptoms of Anterior Instability

The symptoms of anterior instability include recurrent dislocation or subluxation, shoulder pain and episodes of dead arm syndrome.

• Pain usually arises from impingement of the rotator cuff tendons with recurrent anterior translation of the humeral head and recurrent silent subluxation.
• This is aggravated by the eventual weakening of the rotator cuff muscles which, in turn, fail to depress the humeral head adequately.
• The recurrent episodes of impingement result in a rotator cuff tendinopathy.
• Anterior shoulder pain in association with post-traumatic anterior instability may be due to catching of a labral detachment.
• This pain and sensation of catching may be reproduced on anterior drawer or load and shift testing.
• The dead arm effect is thought to arise from traction or impingement on the neurovascular structures, causing transient numbness and weakness of the arm.
• This usually resolves after a few minutes. The episodes of subluxation and dislocation usually increase in frequency.

Occasionally, a stage is reached where relatively minor activities such as yawning or rolling over in bed may result in a subluxation or dislocation.

Treatment

As outlined earlier, a traditional sling should not be used to manage instability.

• If aggressive non-operative treatment is to be pursued, then the arm should be placed in external rotation of 30 degree for three weeks night and day to reduce the Bankart lesion.
• There are a large number of different procedures used to treat shoulder instability. In athletes, particularly those whose dominant throwing arm is involved, the underlying mechanical lesion should be corrected.
• In most cases, this involves repair of the Bankart lesion, which may be performed either as an open or arthroscopic procedure.
• Other mechanical problems such as a tear in the rotator cuff may also be corrected.
• If an extremely large Hill’-Sachs lesion is present, then a procedure such as bone grafting may be necessary.
• In treating atraumatic instability, intensive rehabilitation involves strengthening of the dynamic stabilizers (rotator cuff muscles) and scapular stabilizing muscles, with particular emphasis on the muscles opposing the direction of the instability.
• Modification of sporting activity may also be helpful. If conservative measures fail, then surgery should be considered .This usually involves a capsular shift procedure.

Sports Activities with Rehab Treatment:

The maintenance of cardiovascular fitness is another essential component of the rehabilitation process. No matter what type of injury the athlete has sustained, it should always be possible to design an exercise program to enable cardiovascular fitness to be maintained.

In injuries to the lower limb that require a period of restricted weight-bearing activity, cardiovascular fitness may be maintained by performing activities such as cycling, swimming or water exercises. These activities can be used in a training program that follows the same principles as the athlete’s normal training. Depending on the athlete’s particular sport, this may include a combination of endurance, interval, anaerobic and power work.

It is important to maintain these alternative training methods for cardiovascular fitness even after the patient has resumed some weight-bearing training of his or her own. The clinician must explain to the patient that while he or she is gradually returning to weight-bearing activity, the cardiovascular endurance aspect of training should be performed as non-weight-bearing.

Following complete recovery and return to sport, it may be advantageous, particularly in patients who have had an overuse injury, to incorporate some of these non-weight-bearing forms of training as a substitute for some weight-bearing training.

Progression of Rehabilitation

There are several different parameters that the therapist may manipulate to progress the athletes program to a level at which return to sport is possible. These parameters are:

• Type of Activity
• Duration of Activity
• Frequency of Activity/Rest
• Intensity of Activity
• Complexity of Activity

Type of Activity

In the early stages of the rehabilitation program, we recommend activities that do not directly stress the injured area. However, these exercises may still result in some mobilization or strengthening of the injured area, for example, tennis ground strokes following an ankle injury, cycling following shoulder impingement. Later in the program, activities specifically involving the injured area will test its integrity and prepare it for functional activity.

Duration of Activity

Once the activity is directly stressing the injured area, the time spent performing that activity must be increased very gradually. It is advisable to slowly increase the amount of time spent performing a particular activity, for example, jogging, and then hold it constant at a particular level and vary one of the other parameters, such as frequency.

Frequency

An integral part of the rehabilitation program is recovery. It allows tissues to adapt to the stress of exercise. For example, a runner with Achilles tendinopathy may initially run every third day, then every second day, then two out of every three days and ultimately six or seven days per week. On non-running days, the athlete should maintain fitness by swimming or cycling as well as performing the other elements of the rehabilitation program, for example, muscle strengthening.

Intensity

As the athlete progresses through the rehabilitation program, the intensity (speed and power) of the activity will increase. A rehabilitation program for a sprinter may involve progression from half pace to three-quarter pace to full pace. Race starts will be included later in the program. Other variables include surfaces and shoes. Progression can be made from softer surfaces to harder surfaces or from flat running shoes to spikes once full speed is achieved.

Complexity of Activity

The athlete can progress from simple activities to more complex movements. For example, a basket-baller dribbles slowly in a straight line gradually increasing speed and introducing turns, or a tennis player progresses from ground strokes to incorporating overhead shots and rallying drills before playing points competitively and ultimately six or seven days per week. On non-running days, the athlete should maintain fitness by swimming or cycling as well as performing the other elements of the rehabilitation program, for example, muscle strengthening.

Benefits And Tips of  Exercises Activities:

Most types of activity programs are preferable to a sedentary lifestyle for patients with osteoporosis and with a 20-minute warm-up, comprising 10 minutes of gentle stretching and range of motion activity followed by 10 minutes of aerobic exercises. For cardiovascular exercises, targeted heart rate should be 60% of maximum heart rate (220 – age) for a beginner or a deconditioned woman and 70-75% for those in more intermediate health. Weight training with light free weights and rubber tubing can then be incorporated.

Benefits for Osteoporosis Exercise

As per standard resistance training, the exercises should target the major muscle groups.

• Effective upper arm exercises include pushing against a wall or pulling and twisting against a partner.
• Quadriceps strength can be improved with a wall slide (squat) exercise or by practicing standing from a seated position.
• Trunk stabilization (i.e. core stability) exercises are often introduced in the crooklying position and progressed to sitting and standing.
• Trunk stabilization exercises target the recruitment of transversus abdominis and the internal and external obliques rather than rectus abdominis.
• Due to the propensity to develop a kyphotic posture with osteoporosis, back posture correction exercises should also be emphasized and can be done standing, in a chair or prone.
• Balance exercises can be introduced initially by having individuals hold a tandem stance for 10 seconds with their eyes open while holding onto the kitchen counter for support.
• Other balance exercises include single leg stance with eyes open (then eyes closed), tandem forward walking, walking backwards, and tandem backwards walking.
• The exercise program should conclude with a 15-minute cool down period and warm-down stretches can be done sitting on the floor.
• Remember also that the assessment for exercise prescription should allow the practitioner to discover what activities the client values.
• Many popular activities require some degree of strength, flexibility, endurance, balance and coordination. For example, a good line dancing class emphasizes posture and the attributes listed, is fun, and does not require a partner.

Community Based Exercise Program For Osteoporosis

‘Osteofit’ is an exercise-based program devised by staff of the British Columbia Women Health Center Osteoporosis Program in Vancouver, Canada. This community-based program for women and men aims to reduce participant’s risk of falling and improve their functional ability and thereby enhance their quality of life. It differs from typical seniors exercise classes by specifically targeting posture, balance, gait, coordination, and trunk and pelvic stabilization rather than general aerobic fitness.

‘Osteofit Tips’ For Exercise

A typical class consists of a warm-up, the workout and a relaxation component, which are outlined below. ‘Osteofit’ classes also include ‘Osteofit Tips’ a 5-minute health education topic that the instructor shares with participants.

• The work-out itself consists of strengthening and stretching exercises intended to improve posture by combating medially rotated shoulders, chin protrusion (excessive cervical extension), thoracic kyphosis and loss of lumbar lordosis.
• Exercises to improve balance and coordination may progress from heel raises and toe pulls to the mildly challenging two-legged heel-toe rock and the more challenging tandem walks and obstacle courses.
• Pelvic stabilization is trained using leg exercises (e.g. hip abduction and extension) or balance exercises.
• After appropriate training and progression through less challenging positions, trunk stabilization is addressed when the participant is cued and positioned to do all standing exercises with resistance for the arms (e.g. biceps curls) and shoulders (e.g. lateral arm raises).
• The abdominal muscles are strengthened in their function as stabilizers rather than as prime movers.
• Exercises to improve functional ability include chair squats and getting up and down off the floor.
• Upper and lower body activities are alternated to reduce the risk of tendinopathy.
• If the class includes more than one set of an exercise, the sets are separated by a short rest period.
• Repetitions are kept to between eight and 16 and weights are relatively light so that participants do not work to fatigue with each set.
• The exercises are arranged so that the less strenuous exercises, such as hamstring stretching, are at the end of the work-out.
• The last few minutes of the class are devoted to relaxation techniques such as deep breathing, progressive muscle tensing and relaxing, and visualizations to a background of soft music and/or nature sounds.
• ‘Osteofit‘ is one form of safe and effective exercise for a population that is at high risk of osteoporotic fracture.