Chapter 11: Musculoskeletal Medicine

A tender and perhaps clicking temporomandibular joint (TMJ) is a relatively common problem presenting to the general practitioner. In the absence of obvious malocclusion and organic disease, such as rheumatoid arthritis, simple exercises can alleviate the annoying problem in about 2 weeks. Three methods are described as alternatives to splint therapy.

Method 1

1. Obtain a cylindrical (or similar-shaped) rod of soft wooden or plastic material, approximately 15 cm long and 1.5 cm wide. An ideal object is a large carpenter’s pencil or piece of soft wood.

2. Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward.

3. The patient then rhythmically bites on the object with a grinding movement (Fig. 11.1) for 2 to 3 minutes at least 3 times a day.

Method 2

1. Instruct the patient to rhythmically thrust the lower jaw forward and backward in an anterior–posterior direction with the mouth slightly open, rather like a cheeky schoolchild exposing the bottom lip (Fig. 11.2).

2. This exercise hurts initially but should soon lead to relief of the uncomplicated TMJ syndrome.

Method 3: The ‘six-by-six’ program

This is a specific program (separate from the exercises above) recommended by some dental surgeons. The six exercises should be done 6 times each time, 6 times a day. It takes 1 minute to do them. Instruct the patient as follows:

1. Hold the front one-third of your tongue to the roof of your mouth and take six deep breaths.

2. Hold the tongue to the roof of your mouth and open your mouth 6 times. Your jaw should not click.

3. Hold your chin with both hands, keeping the chin still. Without letting your chin move, push up, down and to each side. Remember not to let your chin move.

4. Hold both hands behind your neck and pull the chin in.

5. Push on the upper lip so as to push the head straight back.

6. Pull your shoulders back as if to touch the shoulder blades together.

Repeat each exercise 6 times, 6 times a day.

Note: Patients should use a visual cue to remind them to do the exercises.

These exercises should be pain-free. If they hurt, do not push patients to the limit until the pain eases.

Method 4: Resisted ‘jaw’ opening

For this isometric contraction method the patient grasps the jaw mainly on the jaw angle and strongly resists opening of the jaw. This simple exercise is repeated many times a day.

This program is reserved for an acutely painful TMJ condition.

• When eating, avoid opening your mouth wider than the thickness of your thumb and cut all food into small pieces.

• Do not bite any food with your front teeth—use small bite-size pieces.

• Avoid eating food requiring prolonged chewing, e.g. hard crusts of bread, tough meat, raw vegetables.

• Avoid chewing gum.

• Always try to open your jaw in a hinge or arc motion. Do not protrude your jaw.

• Avoid protruding your jaw, e.g. talking, applying lipstick.

• Avoid clenching your teeth together—keep your lips together and your teeth apart.

• Try to breathe through your nose at all times.

• Do not sleep on your jaw: try to sleep on your back.

• Practise a relaxed lifestyle so that your jaws and face muscles feel relaxed.

The patient may present with a unilateral or bilateral dislocation. The jaw will be ‘locked’ and the patient unable to articulate.

Method

1. Get the patient to sit upright with the head against the wall.

2. Wrap a handkerchief around both thumbs and place the thumbs over the last lower molar teeth, with the fingers firmly grasping the mandible on the outside.

3. Firmly thrusting with the thumbs, push downward towards the floor and at the same time press upwards on the chin with the fingers (Fig. 11.3).

This action invariably reduces the dislocation, with the reduction being reinforced by the fingers rotating the mandible upward as the thumbs thrust downward.

Method 1

Simple diagrams obviate the need for copious notes when recording the range of movement of the cervical spine. They are of particular value to the ‘whiplash’ accident patient, who requires repeated assessment and accurate recording. Done serially, the diagrams are an excellent guide to progress, and assist in the compilation of medicolegal reports.

The neck movement grid (Fig. 11.4a) provides a two-dimensional field on which to record movements of the neck as viewed when standing behind and above the patient (looking down on the patient’s head). Not only is the range of movement written on the grid, but pain can be recorded also.¹

Table 11.1 shows the movements recorded for the patient in Fig. 11.4b.

Method 2

One can use a special direction of movement (DOM) diagram to record movements for all spinal levels. Figure 11.4c illustrates restricted and painful movements (blocked, indicated by II) in flexion, left lateral flexion and left rotation but pain-free extension, right lateral flexion and right rotation (free movements).

Spinal mobilisation and manipulation are examples of physical therapy that can be very beneficial in many spinal conditions where hypomobility that causes pain and stiffness is present.¹

These therapies improve the range of joint movement, decrease stiffness and reduce pain. Mobilisation of the spine is a safe procedure but manipulation can have serious sequelae, especially if given inappropriately to the cervical spine. For the cervical spine, mobilisation is a relatively simple and most effective technique, with a similar outcome to manipulation (evidence-based). Manipulation should be left to the experts and is best avoided if possible.

Key concepts

• Mobilisation is a gentle, coaxing, repetitive, rhythmic movement within the range of movement of the joint (Fig. 11.5).

• Manipulation is a high-velocity thrust at the end range (Fig. 11.5).

• If in doubt, use mobilisation in preference to manipulation.

• Always mobilise or manipulate in the direction of no pain.

• Manipulation is generally more effective and produces a faster response, but requires accurate diagnosis and greater skill, and can aggravate some spinal problems.

Important contraindications to spinal manipulation

• Disease of the spine (e.g. osteoporosis, neoplasm, rheumatoid arthritis).

• Neurological changes.

• Evidence of nerve root compression (e.g. sciatic pain in the leg, pain extending to the forearm or below the knee).

• Instability of spine following trauma.

• Cerebrovascular disease (for neck).

• Anticoagulation therapy.

• The elderly patient (my rule: avoid > 65 years).

A golden rule: Opposite movement, no pain. This generally means that manipulation achieves a gapping or opening up of the painful side.

Anterior directed gliding—an example of spinal mobilisation

The technique of anterior directed gliding, also termed posterior-anterior mobilisation, can be applied directly to the spinous process centrally (Fig. 11.6) or over tender points unilaterally. It is a very simple technique, directed either with the thumbs (placed side by side) or the pisiform process of the leading hand (for central mobilisation only). This method is suitable for anywhere along the spine, but particularly for the cervical spine and more so at lateral tender points.

Method (using thumbs)

1. The patient lies prone, with head turned to one side and arms by the side.

2. For the thoracic and lumbar spines, stand at the patient’s side and place your thumbs over the tender area. For the cervical spine, stand behind the patient’s head.

3. Lean over the patient with your arms perfectly straight and head and shoulders over the treatment area.

4. Obtain an oscillatory movement by gently rocking the upper trunk up and down, with pressure being transmitted to your thumbs by the shoulders and arms.

5. Go as deeply as possible without causing pain.

6. Provide a small-amplitude, controlled oscillation at the rate of two per minute. Maintain this for about 30 to 60 seconds, with two or three repeats in one treatment session.

Pain originating in the cervical spine is commonly, although not always, experienced in the neck. The patient may complain of headache, or pain around the ear, face, shoulder, arm, scapulae or upper anterior chest.

If the cervical spine is overlooked as a source of pain, the cause of symptoms will remain masked and mismanagement will follow.

Possible symptoms

• Neck pain

• Neck stiffness

• Headache

• Migraine-like headache

• Arm pain (referred or radicular)

• Facial pain

• Ear pain (periauricular)

• Scapular pain

• Anterior chest pain

• Torticollis

• Dizziness/vertigo

• Visual dysfunction

Figure 11.7 indicates the typical directions of referred pain. Surprisingly, headache, which is commonly caused by cervical problems, is often not considered by clinicians.

Pain in the arm (brachialgia) is common, and tends to cover the shoulder and upper arm area indicated in Figure 11.7. This is the zone of referred pain that is not caused by nerve root compression. It can be a difficult diagnostic dilemma, because pain reference from the fifth cervical nerve segment (C₅) involves musculoskeletal, neurological and visceral structures. Virtually all shoulder structures are innervated by C₅. See dermatome chart (Fig. 11.21).

The practitioner must first determine whether the pain originates in the cervical spine or the shoulder joints, or in both simultaneously, or some other structure. The often missed diagnosis of polymyalgia rheumatica should be considered in the elderly patient presenting with pain in the zone indicated, especially if bilateral.

Palpation of the neck to determine the precise level of pain or tenderness can be difficult; however, if the surface anatomy of the neck is clearly defined, the affected level can easily be determined.

Method

1. The patient lies prone on the examination couch with hands (palms up) resting on the forehead. The shoulders should be relaxed.

2. Systematically palpate the spinous processes of the cervical vertebrae:

   • C₂ (axis) is the first spinous process palpable beneath the occiput

   • C₇ is the largest ‘fixed’ and most prominent process at the base of the neck

   • C₆ is also prominent and easily palpable, but usually ‘disappears’ under the palpating finger with extension of the neck

   • the spinous process of C₁ (atlas) is not palpable, but the tip of the transverse process is: it lies between the angle of the jaw and the mastoid process

   • the spinous processes of C₃, C₄ and C₅ are difficult to palpate because of cervical lordosis, but their level can be estimated (see Fig. 11.8).

An amazingly effective treatment for an acute wry neck is muscle energy therapy, which relies on the basic physiological principle that the contracting and stretching of muscles leads to the automatic relaxation of agonist and antagonist muscles.

Note: Lateral flexion or rotation or a combination of movements can be used, but treatment in rotation is preferred. The direction of contraction can be away from the painful side (preferred) or towards the painful side, whichever is most comfortable for the patient.

Method

1. Explain the method to the patient, with reassurance that it is not painful.

2. Rotate the patient’s head passively and gently towards the painful side to the limit of pain (the motion barrier).

3. Place your hand against the head on the side opposite the painful one. The other (free) hand can be used to steady the painful level—usually C₃–C₄.

4. Ask the patient to push the head (in rotation) as firmly as possible against the resistance of your hand. The patient should therefore be producing a strong isometric contraction of the neck in rotation away from the painful side. Your counterforce (towards the painful side) should be firm and moderate (never forceful), and should not ‘break’ through the patient’s resistance. To reinforce the effect of this contraction (although not essential), you can ask the patient to inhale and hold the breath and also to look upward in the direction of the contracting muscles (Fig. 11.9a).

5. After 5 to 10 seconds (average 7 seconds) ask the patient to relax; then passively stretch the neck gently towards the patient’s painful side. During this phase the patient is asked to exhale slowly and to look downward to that side (Fig. 11.9b).

6. The patient will now be able to turn the head a little further towards the painful side.

7. This sequence is repeated at the new and improved motion barrier. Repeat 3 to 5 times until the full range of movement returns.

8. Ask the patient to return the following day for another treatment, although the neck may now be almost normal.

The patient can be taught self-treatment at home using this method.

This technique demonstrates the use of longitudinal traction of the neck, especially for the upper cervical spine, as a muscular energy therapy. Coordination of breathing is considered to be a most effective facilitator of this method. It is very safe and gentle, and particularly helpful in the elderly with painful dysfunctional necks.

Method

1. The patient sits on the chair (sitting is preferable to lying supine), with the head in a ‘neutral’ position.

2. Stand behind the patient and place the palms of your hands on the sides of the patient’s face (to spread the pressure evenly around the face and not in one or two sites).

3. Ask the patient to simultaneously breathe in and look upwards (without extending the neck).

4. Hold the patient’s neck in a fixed position with very slight traction during this inspiration phase (Fig. 11.10a). The neck muscles will contract during this phase.

5. Ask the patient to then exhale while looking down. Apply a gentle but firm upward stretch (Fig. 11.10b). Maintain this traction for about 7 seconds.

6. Repeat this procedure about 4 times, applying traction during each expiration phase.

Indications

Dysfunction of neck, including tenderness and stiffness, usually following injury.

Method

The objective is to produce a smooth, circular motion to the end range in all directions so that stretching occurs at the end range.

1. Patients are instructed to ‘draw circles in the air’ (Fig. 11.11a) or ‘roll their head around their halo’. A wide arc of movement is not necessary, provided that stretch is obtained.

2. The roll is performed at a slow to medium pace, so that tender or painful areas can be avoided by moving just short of this level. As stretch is obtained, these areas become less painful, allowing further stretching.

3. Patients can be taught to stretch the neck themselves (Fig. 11.11b), including the use of a muscle energy technique. No matter how stiff the neck initially, it is surprising how much immediate improvement can be obtained from simple, gentle, lateral stretching.

Patients should be instructed to train themselves into a permanent daily habit of rolling the neck to assess flexibility.

This unilateral mobilisation method is directed at the tender costotransverse joint of the thoracic spine. The joint, which is about 4–5 cm from the midline, is arguably the most common source of musculoskeletal pain in the thoracic spine. The tender area determined by palpation is the target for mobilisation.

Method

1. With the pad of the thumbs applied over the rib (Fig. 11.12), apply a rhythmic oscillating movement (about two per second) at right angles.

2. Maintain this for 30 to 60 seconds with as much pressure as possible without causing discomfort.

A note of caution: Take care in patients with ‘red flags’ such as previous malignancy and cerebrovascular disease. Avoid manipulation in these patients using the following two techniques and ensure that the neck is not extended. Direct thrust techniques can be dangerous in women over 55, especially in the presence of risk factors for osteoporosis.

Manipulation for the mid-thoracic spine¹

Of the dozens of manipulative thrusts for dysfunction of the thoracic spine (T₃–T₈), the most effective is the postero-anterior indirect thrust, using the underlying hand as a block over the affected area.

Method

1. The patient lies supine on a low couch, with a pillow supporting the head.

2. The patient folds the arms across the body with hands resting on opposite shoulders, the uppermost forearm being the one furthest from you.

3. Roll the relaxed patient towards you.

4. Place your cupped hand (Fig. 11.13a) on the spine at the painful level, with this level in the palm.

5. Roll the patient back onto the hand, which should feel comfortable (if not, readjust).

6. Lean well over the patient, placing your forearm directly on theirs, and grasp the patient’s far elbow with your hand.

7. Rest your chest on your uppermost arm.

8. Ask the patient to inhale and exhale fully.

9. As the patient commences to exhale, lean down to take up the slack on your bottom hand.

10. Towards the end of exhalation, apply a sharp downward thrust (but not too forcefully) with your chest and upper arm directly through the patient’s chest onto your hand (Fig. 11.13b).

Rotation in the sitting position

In this very effective technique, the patient fixes the pelvis by straddling a low couch or a chair; the couch provides the better position, because it allows greater flexibility of the trunk.

The main indications are unilateral pain at the thoracolumbar junction. The method can be used also for pain (unilateral and bilateral) of the lumbar spine and the lower thoracic spine. The usual rules and contraindications apply. The technique must be coordinated with deep breathing.

Method

1. The patient straddles the end of the couch and sits firm and erect. Alternatively the patient can straddle a chair, facing the back of the chair with a pillow used against the chair to protect the thighs. It must be a standard, open chair, with a carpeted floor.

2. The patient crosses the arms over the chest so that the hands rest on the opposite shoulders. The patient should be comfortable throughout the procedure, and proper padding should rest against the inner thighs.

3. Stand directly behind the patient. Adopt a firm, wide-based stance.

4. Grasp the patient’s shoulders with your hands.

5. Ask the patient to take a deep breath in, exhale fully and relax.

6. When you feel the patient relax, grasp the shoulders and rotate the patient’s trunk steadily and firmly, away from the painful side, to the limit of rotation. Before rotation is attempted the patient must be at the absolute limit of stretch. Gently oscillate the trunk at this position of full stretch.

7. If any sharp pain is reproduced at this end range abandon the treatment.

Mobilisation: Consists of performing a gentle, repetitive, oscillatory rotation of the trunk at this end range for up to 30 seconds.

Manipulation: Consists of a sharp, well-controlled rotation.

Variations of this technique

An alternative and better strategy is to ‘hug’ the patient’s trunk, using the arm that embraces the trunk to grasp the arm near the elbow on the side to be rotated. The thrusting hand can be applied to a specific area of the back corresponding to the level of pain. Thus, a type of ‘push–pull’ manoeuvre can be achieved, with the embracing arm pulling into rotation and the other hand pushing to achieve a complementary smooth rotation of the trunk. Coordinate this with breathing so the rotation only occurs during the relaxed exhaled stage.

Figure 11.14a demonstrates the technique for a right-sided problem at the thoracolumbar junction, while Figure 11.14b demonstrates the technique for low lumbar pain. Both rotations are to the left, since rotation to the right reproduces pain.

A working knowledge of the bony landmarks of the lumbar spine is vitally important for determining the level of the spinal pain and for procedures such as epidural injections and lumbar punctures.

This anatomical knowledge is readily determined by using the iliac crests as the main reference point.

Method

1. For the examination the adequately exposed patient should be relaxed, lying prone, with the arms by the sides.

2. Standing behind and below the patient, place your fingers on the top of the iliac crests and your thumbs at the same level on the midline of the back. This level will correspond with the fourth and fifth lumbar interspace (Fig. 11.15), or slightly higher at the fourth lumbar spinous process.

3. Consequently, the thumbs will either feel the L₄–L₅ gap or the L₄ spinous process.

(When inspecting X-rays of the lumbar spine, it becomes apparent that the upper limits of the iliac crest usually lie opposite the L₄–L₅ interspace.)

The reference points should be marked and the level of each lumbar spinous process can then be identified.

Several tests are useful in differentiating between organic and non-organic back pain (e.g. that caused by depression or complained of by a known malingerer).

Magnuson method (the ‘migratory pointing’ test)

1. Request the patient to point to the painful sites.

2. Palpate these areas of tenderness on two occasions separated by an interval of several minutes, and compare the sites.

Between the two tests divert the patient’s attention from his or her back by another examination.

Burn ‘kneeling on a stool’ test

1. Ask the patient to kneel on a low stool, lean over and try to touch the floor.

2. The person with non-organic back pain will usually refuse on the grounds that it would cause great pain or that he or she might overbalance in the attempt.

Patients with even a severely herniated disc usually manage the task to some degree (Fig. 11.16a, b).

The ‘axial loading’ test

1. Place your hands over the patient’s head and press firmly downward (Fig. 11.17).

2. This will cause no discomfort to (most) patients with organic back pain.

The ‘hip and shoulder rotation’ test

1. Examine for pain by rotating the patient’s hips and shoulders while the feet are kept in place on the floor (Fig. 11.18).

2. The manoeuvre is usually painless in those with an organically based back disorder.

There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine, rotation is not so important. The movements that should be tested, and their normal ranges, are as follows:

• extension (20–30°) (Fig. 11.19a)

• lateral flexion, left and right (30°) (Fig. 11.19b)

• flexion (75–90°: average 80°) (Fig. 11.19a).

Measurement of the angle of movement can be made by using a line drawn between the sacrum and the large prominence of the C₇ spinous process.

Pain in the leg from discogenic lesions in the lumbosacral spine is commonly due to pressure on the L₅ or S₁ nerve roots. Unlike discogenic lesions in the cervical spine, more than one nerve root can be involved with prolapses of the L₄–L₅ or L₅–S₁ discs, but this is uncommon.

Working guidelines are given in Table 11.2 and Figure 11.20. It is worthwhile to know and refer to the dermatome chart, especially for the lower limb (Fig. 11.21).

The slump test is an excellent provocation test for lumbosacral pain and more sensitive than the straight leg raising test. It is a screening test for a disc lesion and dural tethering. It should be performed on patients who have low back pain with pain extending into the leg, and especially for posterior thigh pain.

A positive result is reproduction of the patient’s pain; this may appear at an early stage of the test (at which point the test is ceased).

Method

1. The patient sits on the couch in a relaxed manner.

2. The patient then slumps forward (without excessive trunk flexion), then places the chin on the chest.

3. The unaffected leg is straightened.

4. The affected leg only is then straightened (Fig. 11.22).

5. Both legs are straightened together.

6. The foot of the affected straightened leg is dorsiflexed.

Note: Take care to distinguish from hamstring pain. Deflexing the neck relieves the pain of spinal origin, not hamstring pain.

Significance of the slump test

• It is positive if the back or leg pain is reproduced.

• If positive, it suggests disc disruption.

• If negative, it may indicate lack of serious disc pathology.

• If positive, one should approach manual therapy with caution

This technique is very useful for acute low back pain of the spine, especially where manipulation is contraindicated or of doubtful value. Patients tend to prefer gentler mobilisation to spinal manipulation. There are several grades of this technique.

Method

1. The patient lies on the pain-free side, with the head supported by a pillow.

2. The lower shoulder is pulled forwards by grasping the arm at the elbow and gently rotating the spine. The uppermost arm rests on the lateral wall of the chest.

3. The uppermost leg is flexed at the hip (30–90°) and the knee flexed to a right angle. The patient places the palm of the lowermost hand under the head.

4. You stand behind the patient, opposite the pelvis.

5. Place both hands over the pelvis and apply a gentle, small-amplitude oscillatory movement (Fig. 11.23).

6. This is a gentle ‘push and pull’ method, with emphasis on the push.

7. The rocking movement occupies 30 to 60 seconds. It can be repeated 2 or 3 times on any one treatment visit.

This is a traditional method used for a thrusting manipulative movement but steady stretching is simpler and safer.

Method

1. The patient lies on the pain-free side, reasonably squarely on the lower shoulder. The body should be in a straight line with the lower leg extended. The upper leg (on the painful side) can be either falling freely over the side of the couch or flexed with the foot tucked into the popliteal fossa of the lower leg. The lower arm should lie comfortably in front of the trunk. Alternatively, the hand of the lower arm can be placed under the head.

2. Stand behind the patient at the level of the patient’s waist.

3. Ask the patient to take a deep breath and breathe out.

4. When the patient has exhaled and relaxed, use one hand to push the trochanteric area of the hip forwards, and the other to gently force the front of the shoulder downwards (Fig. 11.24). It is best to keep hands in contact with the skin (avoid grasping clothing).

5. Apply steady rotational movement until a full stretch is applied to both shoulder and hip. Do not force the shoulder down too hard—take care to keep it firm and steady during the stretch.

6. Maintain sustained pressure for about 7 seconds at the end range.

7. Repeat this stretch twice.

Manipulation: If desired, this position can be used to apply a sharp rotational thrust to the hip with the force along the axis of the femur.

This is the ideal stretching or manipulative technique for the lumbar spine and is the procedure of first choice for lumbar problems. It is designed to mobilise the lower lumbosacral segments, which are responsible for most of the problems in the lower back.

The stretch

Method

1. The patient lies on the pain-free side in a relaxed position with the head on a pillow facing the therapist. The uppermost leg is flexed at the hip and the knee, both to about 45°, with the foot tucked into the popliteal fossa of the lower leg.

2. Position yourself at the level of the patient’s waist.

3. Ask the patient to turn his or her head and look up at the ceiling.

4. Carefully rotate the trunk by grasping the patient’s lowermost arm just above or around the elbow and gently pulling the arm outwards.

5. Maintain smooth slow rotation of the trunk until you sense it is taut down to the upper lumbar spine.

6. Fix the trunk by asking the patient to place the hand of this arm under the head.

7. Rest the fleshy part of your upper forearm against the patient’s shoulder and upper chest via the axilla, and your other forearm over the ischium, just below the iliac crest.

8. Ensure that you are properly balanced.

9. Apply a distracting force for several seconds, gently rocking back and forth with the forearms as you move towards maximal rotating stretch. This stretching is usually sufficient to achieve the desired therapeutic effect (Fig. 11.25a, b).

The manipulation

If desired, especially for a ‘locked’ lumbosacral level, this position can be used to perform a sharp manipulative thrust—but only from the position of full stretch.

Method

1. When all the slack is taken up by your forearms, ask the patient to take a deep breath and exhale.

2. At the end of the exhalation execute a sharp increase of rotatory pressure through both forearms, especially through the short lever to the pelvis.

Note: It is important not to dig the elbow of the proximal arm into the patient’s body, since this can be painful. Likewise it is important to find a position for the distal forearm that is comfortable for the patient, and to avoid using the point of the elbow for thrusting, as the buttock area is very sensitive to sharp pressure.

The following yoga-like exercise is highly recommended for patients with pain in the lumbosacral spine, usually after any muscle spasm has resolved.

Guidelines

It is preferable to perform the exercise on a couch or very firm bed, but it can be done on the floor. It can be performed repeatedly throughout the day but should be repeated at least twice a day for about 3 to 5 minutes at a time.

Method

1. Lie on your back.

2. Bend the leg on the painful side and stretch it across the body while turning the head to the opposite side.

3. If possible, hang onto the side of the bed or couch with your free hand (the hand that is on the same side as the leg which is crossed over).

4. Use the other hand to grasp the bent leg at the level of the knee and increase the stretch as far as possible (Fig. 11.26).

5. Relax and return to the resting position.

6. Repeat on the opposite side, especially if that side also hurts.

7. Repeat several times, concentrating on stretching the painful joints.

Note: If someone pins your shoulders to the floor or bed while you are performing this exercise, the stretch is better.

Types of dislocation

• Anterior (forward and downward)—95% of dislocations

• Posterior (backward)—difficult to diagnose

• Recurrent anterior dislocation

Anterior dislocation of the shoulder

Management

An X-ray should be undertaken to check the position and exclude an associated fracture. Reduction can be achieved under general anaesthesia (easier and more comfortable) or with intravenous pethidine ± diazepam. The following methods can be used for anterior dislocation.

Kocher method (Figure 11.27)²

1. The patient’s elbow should be flexed to 90° and held close to the body.

2. Slowly rotate the arm laterally (externally) as you apply traction.

3. Adduct the humerus across the body by carrying the point of the elbow.

4. Rotate the arm medially (internally).

Hippocratic method

Apply traction to the outstretched arm by a hold on the hand with countertraction from a stockinged foot in the medial wall of the axilla. This levers the head of the humerus back. It is a good method if there is an associated avulsion fracture of the greater tuberosity.²

Milch method³ (does not require anaesthesia or sedation)

1. The patient reclines at 30° and with guidance slowly bends the elbow to 90° (Fig. 11.28a).

2. The patient is asked to lift the arm up slowly with the elbow bent so that they can pat the back of their head (requires considerable reassurance and encouragement).

3. At this position, traction along the line of the humerus (with countertraction) achieves reduction (Fig. 11.28b).

Variation of Milch method

This relies more on intervention by the therapist, who supports the shoulder with the thumb held firmly against the dislocated humeral head while the other hand facilitates adduction of the arm to the overhead position. At this position, the humeral head is pushed by the thumb into its normal socket.

Scapula pressure method

1. The patient lies prone with the dislocated arm hanging freely over the table.

2. Steady traction is applied to the arm by an assistant.

3. Firm pressure is then applied by the ‘butt’ of the hand to the inferolateral border of the scapula. The pressure is directed towards the glenohumeral joint.

Free-hanging method⁴

The free-hanging method is relatively painless, yet simple. It is gentler than traditional methods, without rotational forces or direct pressure to the glenohumeral joint. It can be used with or without an intravenous analgesic or relaxant, which is not usually required for recurrent dislocation or in the elderly patient.

Preparation

1. Insert a ‘butterfly’ needle into a vein on the dorsum of the non-involved hand.

2. Prepare two solutions: (a) 10 mg of diazepam diluted to 5 mL with isotonic saline; (b) 50 mg of pethidine diluted to 5 mL with isotonic saline.

3. The patient sits at right angles to the chair with only half the buttock on the seat. The affected arm hangs freely over a pillow placed on the back of the chair and tucked into the axilla. The hand with the intravenous needle rests on the opposite knee (for easy access to the practitioner).

4. You sit on a very low stool, facing the back of the chair.

Method

1. With both hands working simultaneously on the dislocated limb, grasp the patient’s wrist with one hand and exert a steady, downward pressure.

2. Place the other hand in the axilla, with the palm exerting a direct outward pressure against the upper part of the shaft of the humerus (Fig. 11.29).

3. When appropriate muscle relaxation is achieved, the head of the humerus slips up and over the glenoid rim.

Analgesia and relaxation (if necessary)

Steady traction should be maintained during administration of analgesic; 2.5 mL pethidine (25 mg) is given intravenously over 60 seconds (and may be repeated), then 1 mL diazepam (2 mg) a minute, until reduction is achieved.

Note: Carefully monitor the patient’s vital signs.

This technique, described by Zagorski,⁵ aims to reduce anterior shoulder dislocation without the need for any sedating or narcotic analgesics. It is very helpful in more remote situations and is ideal for recurrent dislocation. Fractures must be excluded.

Method (e.g. left-sided dislocation)

1. Explain the procedure to the patient, emphasising its gentleness.

2. The patient sits upright in a straight-backed chair (no arm rests).

3. An assistant stands behind the patient with a hand on each shoulder to prevent tilting of the shoulder girdle. Alternatively, the assistant can prevent the patient tipping sideways to the affected side by supporting them with a towel passing under the injured axilla across to the opposite (normal) shoulder.

4. The doctor kneels facing the patient with the left knee beside the patient’s knees.

5. The patient rests his or her left hand on the doctor’s left shoulder.

6. The doctor places his or her left hand on the patient’s forearm just distal to the elbow (Fig. 11.30).

7. Very gentle downward traction is applied and gradually increased as the patient, distracted somewhat by conversation, is encouraged to relax (there should be minimal pain).

8. The doctor’s right hand feels for relaxation of the shoulder and the position of the humeral head as downward traction is maintained (it usually reduces after 1 to 2 minutes).

9. If not reduced by now, very gentle external rotation is applied by leaning around the outside of the patient away from the affected side. Reduction is heralded by a gentle click. Sometimes it feels that nothing has happened so traction should be relaxed, the shoulder reassessed and, if still dislocated, traction applied. Often the release of traction leads to relocation of the joint.

Rules

• Patient must be relaxed and distracted.

• Patient must not tilt to one side.

• Gentle steady traction to avoid spasm and pain.

For this condition, there is a way of effecting reduction without the use of force.

Method

1. The patient sits comfortably on a chair with legs crossed.

2. The patient then interlocks hands and elevates the upper knee so that the hands grip the knee (Fig. 11.31).

3. The knee is allowed to lower gradually so that its full weight is taken by the hands. At the same time the patient has to concentrate on relaxing the muscles of the shoulder girdle.

Recurrent dislocation requires definitive surgery; the development of arthritis increases with the number of dislocations.

This typically occurs in children under 8 years of age, usually at 2 to 3 years, when an adult applies sudden traction to the child’s extended and pronated arm: the head of the radius can be pulled distally through the annular radioulnar ligament (Fig. 11.32a).

Symptoms and signs

• The crying child refuses to use the arm.

• The arm is limp by the side or supported in the child’s lap.

• The elbow is flexed slightly.

• The forearm is pronated or held in mid-position (Fig. 11.32b).

Note: If atypical history, including significant pain or swelling or failed reduction, ensure that a fracture has not been overlooked.

The following methods have proven effectiveness.⁶

Supination treatment method

• 1. Sit the child on the parent’s lap. Gain the child’s confidence. Ask the parent to hold the unaffected arm as the child faces you.

• 2. Hold the child’s wrist or hand (on the affected side) as if to shake it.

• 3. Place one hand around the child’s elbow to give support, pressing the thumb over the head of the radius.

• 4. Using gentle traction, firmly and smoothly twist the forearm into full supination (Fig. 11.32c) as you fully flex the forearm. A popping sound indicates relocation of the radial head.

Hyperpronation manoeuvre (as per RCH)

Follow steps 1–3 (above).

• 4. Fully pronate the forearm and then flex the forearm (elbow).

Combined manoeuvre

An alternative and preferred method to the traditional method is to very gently alternate pronation and supination through a small arc as you flex the elbow.

If you cannot get the child’s cooperation apply a ‘high’ sling and send them home with a follow-up appointment. It may reduce spontaneously within a few days.

A dislocated elbow is caused by a fall on the outstretched hand, forcing the forearm backwards to result in posterior and lateral displacement (Fig. 11.33). The peripheral pulses and sensation in the hand must be assessed carefully. Check the function of the ulnar nerve before and after reduction.

Usual treatment

Attempt reduction with the patient fully relaxed under anaesthesia. It is important to apply traction to the flexed elbow but allow it to extend approximately 20–30° to enable correction of the lateral displacement with the hand pushing from the side, and then the posterior displacement by pushing the olecranon forward with the thumbs.

A simple method of reduction

This method reduces an uncomplicated posterior dislocation of the elbow without the need for anaesthesia or an assistant. The manipulation must be gentle and without sudden movement.

Method

1. The patient lies prone on a stretcher or couch, with the forearm dangling towards the floor.

2. Grasp the wrist and slowly apply traction in the direction of the long axis of the forearm (Fig. 11.34).

3. When the muscles feel relaxed (this might take several minutes), use the thumb and index finger of the other hand to grasp the olecranon and guide it to a reduced position, correcting for any lateral shift.

4. After reduction the arm is held in a collar-and-cuff sling, with the elbow flexed above 90°, for 1 to 3 weeks.

A simple cure—the wringing exercise

Chronic tennis elbow (lateral epicondylitis) can be alleviated by a simple wringing exercise using a small hand towel.

Method

1. Roll up the hand towel.

2. With the arms extended, grasp the towel with the wrist of the affected side placed in slight flexion.

3. Then exert maximum wring pressure (Fig. 11.35):

   • first fully flexing the wrist for 10 seconds

   • then fully extending the wrist for 10 seconds

   • alternate flexion and extension between hands.

This is an isometric ‘hold’ contraction.

Frequency

This exercise should be performed only twice a day, initially for 10 seconds in each direction. After each week, increase the time by 5 seconds in each twisting direction until 60 seconds is reached (week 11). This level is maintained indefinitely. Apply ice for 10 minutes after completion, especially last thing at night.

Note: Despite severe initial pain, the patient must persist, using as much force as possible.

Review at 6 weeks (there is usually some relief by 4 to 6 weeks), to ensure that the patient is doing the exercise exactly as instructed.

Exercises

Stretching and strengthening exercises for the forearm muscles represent the best management for tennis elbow.^7,8 The muscles are strengthened by the use of hand-held weights or dumbbells. A suitable starting weight is 0.5 kg, building up gradually (increasing by 0.5 kg) to 5 kg, depending on the patient.

Method

1. To perform this exercise the patient sits in a chair beside a table.

2. The arm is rested on the table so that the wrist extends over the edge.

3. The weight is grasped with the palm facing downwards (Fig. 11.36a).

4. The weight is slowly raised and lowered by flexing and extending the wrist.

5. The flexion/extension wrist movement is repeated 10 times, with a rest for 1 minute and the program repeated twice.

This exercise should be performed every day until the patient can play tennis, work or use the arm without pain.

For medial epicondylitis (forearm tennis elbow, golfer’s elbow), perform the same exercises but with the palm of the hand facing upward (Fig. 11.36b).

Tip: In colder conditions, keep the elbow warm with a woollen sleeve around it such as two or three modified old socks.

De Quervain disease is a stenosing tenosynovitis of the abductor pollicus longus or extensor pollicus brevis tendons over the radial styloid of the wrist, or both. It results from repetitive activity, such as that engaged in by staple gun operators on assembly lines, or from direct trauma.

Symptoms

The major symptoms are:

• pain during pinch grasping

• pain on thumb and wrist movement.

Tetrad of diagnostic signs

Four key diagnostic signs are:

• tenderness to palpation over and just proximal to the radial styloid

• localised swelling in the area of the radial styloid

• positive Finkelstein’s sign

• pain on active extension of thumb against resistance.

Finkelstein test

Method

1. The patient folds the thumb into the palm with the fingers of the involved hand folded over the thumb.

2. Deviate the wrist in an ulnar direction (medially) to stretch the involved tendons (Fig. 11.37).

3. A positive test is indicated by reproduction of or increased pain.

The carpal tunnel syndrome, caused by compression of the median nerve, is a common disorder that is usually easily diagnosed from the history. The most common and easily recognised symptoms are early-morning numbness and tingling or burning in the distribution of the median nerve in the hand. In the physical examination for the suspected carpal tunnel syndrome, a couple of simple tests can assist with confirming the diagnosis. These are the Tinel test and the Phalen test. The definitive test is neuromuscular conduction studies.

The Tinel test

1. Hold the wrist in a neutral or flexed position, and tap over the median nerve at the flexor surface of the wrist. This should be over the retinaculum just lateral to the palmaris longus tendon (if present) and the tendons of flexor digitorum superficialis (Fig. 11.38a).

2. A positive Tinel sign produces a tingling sensation (usually without pain) in the distribution of the median nerve.

The Phalen test

1. The patient approximates the dorsum of both hands, one to the other, with wrists maximally flexed and fingers pointed downward (Fig. 11.38b).

2. This position is held for 60 seconds.

3. A positive test reproduces tingling and numbness along the distribution of the median nerve.

This method employs the principle of using the patient’s body weight as the distracting force to achieve reduction of the dislocation. It is relatively painless and very effective. Getting a good grip is very important, so wrap a small strip of zinc oxide adhesive plaster around the finger.

Method

1. Face the patient, both in standing positions.

2. Firmly grasp the distal part of the dislocated finger.

3. Request the patient to lean backwards, while maintaining the finger in a fixed position (Fig. 11.39).

4. As the patient leans back, sudden, painless reduction should spontaneously occur.

Method

1. Instead of strapping an injured finger circumferentially, it is more comfortable and more effective to place a single strip of adhesive tape 2.5 cm or less in width on the dorsum of the finger from the tip of the nail to the carpometacarpal line (Fig. 11.40a).

2. The direction of the tape should follow the line of the extensor tendon (Fig. 11.40b). The effect is the use of the skin traction as a suspensory sling for the finger. The flexor and extensor tendons are allowed to relax with a decrease in position maintenance strain and pain. At the same time the finger is free to flex with recovery, and frozen finger is unlikely.

3. The degree of mobility of the finger is adjusted by altering the tension along the line of the tape.

A forced hyperflexion injury to the distal phalanx can rupture or avulse the extensor insertion into its dorsal base. The characteristic swan neck deformity is due to retraction of the lateral bands and hyperextension of the proximal interphalangeal joint.

The 45° guideline

Without treatment, the eventual disability will be minimal if the extensor lag at the distal joint is less than 45°; a greater lag will result in functional difficulty and cosmetic deformity.

Treatment

Maintain hyperextension of the distal interphalangeal joint for 6 weeks, leaving the proximal interphalangeal joint free to flex. Even with treatment the failure rate is high—only about 50–60% recover.

Equipment

• Friar’s Balsam (will permit greater adhesion of tape).

• Non-stretch adhesive tape, 1 cm wide: two strips approximately 10 cm in length.

Method

1. Paint the finger with Friar’s Balsam (compound benzoin tincture).

2. Apply the first strip of tape in a figure-of-eight conformation. The centre of the tape must engage and support the pulp of the finger. The tapes must cross dorsally at the level of the distal interphalangeal joint and extend to the volar aspect of the proximal interphalangeal joint without inhibiting its movement (Fig. 11.41a).

3. Apply the second piece of tape as a ‘stay’ around the midshaft of the middle phalanx (Fig. 11.41b).

Reapply the tape whenever extension of the distal interphalangeal joint drops below the neutral position (usually daily, depending on the patient’s occupation). Maintain extension for 6 weeks.

Other splints

There are a variety of splints. A popular one is a simple plastic mallet finger splint. One can improvise by cutting the handle of a large plastic milk carton or other similar household container.

Surgery

Open reduction and internal fixation are reserved for those cases where the avulsed bony fragment is large enough to cause instability leading to volar subluxation of the distal interphalangeal joint.

The ‘button hole’ deformity is a closed rupture of the extensor tendon apparatus over the PIP joint, which is permanently flexed towards the palm (Fig. 11.42).

Treatment of uncomplicated deformity

1. Splint the PIP joint in full extension for 8 to 10 weeks.

2. Leave the DIP joint free for movement (Fig. 11.43).

Tenpin bowler’s thumb is a common stress syndrome in players. It usually presents as a soft-tissue swelling at the base of the thumb web (Fig. 11.44), with associated pain and stiffness of the digits used for bowling.

Management

The patient will need:

• rest

• massage

• to bevel the bowling ball holes to reduce friction

• an intralesional injection of 0.25 mL of long-acting corticosteroid mixed with local anaesthetic (resistant cases).

A special injury is skier’s thumb (also known as gamekeeper’s thumb) in which there is ligamentous disruption of the metacarpophalangeal joint with or without an avulsion fracture of the base of the proximal phalanx at the point of ligamentous attachment (Fig. 11.45). This injury is caused by the thumb being forced into abduction and hyperextension by the ski pole as the skier pitches into the snow.

Diagnosis is made by X-ray with stress views of the thumb. Incomplete tears are immobilised in a scaphoid type of plaster for 3 weeks, while complete tears and avulsion fractures should be referred for surgical repair.

Features

• A supination fracture of distal 3 cm of radius.

• Commonly caused by a fall onto an outstretched hand.

• The fracture features (Fig. 11.46):

  • impaction

  • posterior displacement and angulation

  • lateral (radial) displacement and angulation

  • supination.

Method of reduction

Under appropriate anaesthesia:

• traction on hand (to disimpact)

• an assistant maintains countertraction

• pronate

• ulnar deviation for 10° (to correct radial displacement)

• flexion (10–15°).

Immobilise the wrist and forearm in a well-padded, below-elbow plaster for 4 to 6 weeks—forearm in full pronation, wrist in corrected position (ulnar deviation, slight flexion) described above (Fig. 11.47).

A scaphoid fracture (Fig. 11.48) is caused typically by a fall on the outstretched hand with the wrist bent backwards (dorsiflexed). The pain may settle after the injury, so presentation may be later. One has to be careful not to treat it as a simple sprain. The signs are:

• tenderness in anatomical snuffbox (the key sign)

• loss of grip strength with pain

• swelling in and around the ‘snuffbox’

• pain on axial compression of thumb towards radius.

If a fracture is suspected clinically but the plain X-ray is normal, a fracture cannot be ruled out. An MRI scan or isotope bone scan can be helpful after 24 hours post injury. If scans are not available, immobilise the wrist in a scaphoid plaster for 10 days, remove it and then re-X ray.

For an undisplaced stable fracture, immobilise for 6 weeks in a below-elbow plaster cast (Fig. 11.49). Displaced fractures require reduction (either open or closed) and, if unstable, internal fixation. All fractures require a later X-ray to check for non-union.

Metacarpal fractures can be stable or unstable, intra-articular or extra-articular, and closed or open. They include the ‘knuckle’ injuries resulting from a punch, which is prone to cause a fracture of the neck of the fifth metacarpal. As a general rule, most metacarpal (shaft and neck) fractures are treated by correcting marked displacements with manipulation (under anaesthesia) and splinting with a below-elbow, padded posterior plaster slab that extends up to the dorsum of the proximal phalanx, and holds the metacarpophalangeal joints in a position of function (Fig. 11.50).

There is often a tendency for metacarpal fractures to rotate and this must be prevented. This is best achieved by splinting the MCP joints at 90°, which corrects any tendency to malrotation. If there is gross displacement, shortening or rotation then surgical intervention is indicated. A felt pad acts as a suitable grip. The patient should exercise 3 fingers vigorously. Remove the splint after 3 weeks and start active mobilisation.

Hip disorders have a significant age relationship (Fig. 11.51).

• Children can suffer from a variety of serious disorders of the hip, e.g. developmental dysplasia (DDH), Perthes’ disorder, tuberculosis, septic arthritis and slipped upper capital epiphysis (SCFE), all of which demand early recognition and management.

• SCFE typically presents in the obese adolescent (10 to 15 years) with knee pain and a slight limp.

• Every newborn infant should be tested for DDH, which is diagnosed early by the Ortolani and Barlow tests (abnormal third or clunk on abduction or adduction). However, ultrasound examination is the investigation of choice and is more sensitive than the clinical examination, especially after 8 weeks.

Hold the leg in the hand with the knee flexed—thumb over groin (lesser trochanter) and middle finger over greater trochanter (Fig. 11.52). Steady the pelvis with the other hand.

Ortolani test (IN test)

Flex hip to about 90°, gently abduct to 45°, and then note any click or jerk as the hip reduces, allowing the hip to abduct fully (Fig. 11.52a).

Barlow (OUT test)

Flex the hip to 90°, abduct to 10–20°, and then adduct and note any click or jerk as the hip ‘goes out’ of the acetabulum (Fig. 11.52b).

Referred pain from the hip to the knee is one of the time-honoured traps in medicine. The hip joint is mainly innervated by L₃, hence pain is referred from the groin down the front and medial aspects of the thigh to the knee (Fig. 11.53). Sometimes the pain can be experienced on the anteromedial aspect of the knee only. It is not uncommon that children with a SCFE present with a limp and knee pain.

The four-step stress test

Degeneration of the hip joint is a common problem in general practice, and may present with pain around the hip or at the knee. Early diagnosis is very useful, and certain tests may detect the problem. It is worth remembering that, of the six main movements of the hip joint, the earliest to be affected are internal rotation, abduction and extension. A special stress test is described here that is sensitive to diagnosing disease in the hip.

Method

1. Lay the patient in the supine position.

2. Flex the hip to about 120°.

3. Adduct to about 20–30° (Fig. 11.54).

4. Internally rotate.

5. Compress the joint through pressure down the axis of the femur.

Dysfunction of the joint may be evident when internal rotation is attempted. Any internal rotation may be virtually impossible because of stiffness or pain.

If a man presents with ‘sciatica’, especially confined to the buttock and upper posterior thigh (without local back pain), consider the possibility of pressure on the sciatic nerve from a wallet in the hip pocket. This problem is occasionally encountered in people sitting for long periods in cars (e.g. taxi drivers). It appears to be related to the increased presence of plastic credit cards in wallets.

Surface anatomy

The sciatic nerve leaves the pelvis through the greater sciatic foramen and emerges from beneath the piriformis muscle at a position just medial to the midpoint of a line between the medial surface of the ischial tuberosity and the tip of the greater trochanter (Fig. 11.55). The lateral border of the nerve usually lies at this midpoint. It lies deep to the gluteus medius in the buttock.

‘Tailor’s bottom’ or ‘weaver’s bottom’, which is occasionally seen, is a bursa overlying the ischial tuberosity. Irritation of the sciatic nerve may coexist and the patient may appear to have sciatica.

Features

• Severe pain when sitting, especially on a hard chair.

• Tenderness at or just above the ischial tuberosity.

Treatment

• Infiltration into the tender spot of a mixture of 4 mL of 1% lidocaine and 1 mL of LA corticosteroid (avoid the sciatic nerve).

• Foam rubber cushion with two holes cut out for ischial prominences.

To test hip and sacroiliac joint disorders.

Fabere is an acronym for Flexion, Abduction, External Rotation and Extension of the hip.

Method

1. The patient lies supine on the table and the foot of the involved side and extremity are placed on the opposite knee.

2. The hip joint is now flexed, externally rotated and adducted. (This position stresses the hip joint, so that inguinal pain on that side is a pointer to a defect in the hip joint or surrounding soft tissue.)

3. The range of motion for the hip joint in this position can be taken to the endpoint (thus fixing the femur in relation to the pelvis), by pressing the knee downward and simultaneously pressing on the region of the anterior superior iliac spine of the opposite side (Fig. 11.56). This stresses the hip joint as well as the sacroiliac joint on that side.

Thus, if low back pain is reproduced, the cause is likely to be a disorder of the sacroiliac joint. Such a lesion is uncommon, but is seen in nursing mothers and in those with inflammatory disorders of the joint (e.g. ankylosing spondylitis and reactive arthritis) and with infection (e.g. tuberculosis).

Some patients complain of a clunking, clicking or snapping hip. This represents a painless, annoying problem.

Causes

One or more of the following:

• a taut iliotibial band (tendon of tensor fascia femoris) slipping backwards and forwards over the prominence of the greater trochanter

• the iliopsoas tendon snapping across the iliopectineal eminence

• the gluteus maximus sliding across the greater trochanter

• joint laxity.

Treatment method

There are two major components of the treatment:

1. explanation and reassurance

2. exercises to stretch the iliotibial band.

1. The patient lies on the ‘normal’ side, and flexes the affected hip (with the leg straight and a weight around the ankle; Fig. 11.57) to a degree that produces a stretching sensation along the lateral aspect of the thigh.

2. This iliotibial stretch should be performed for 1 to 2 minutes, twice daily.

Posterior dislocation of the hip is usually caused by a direct blow to the knee of the flexed leg (knee and hip flexed).

The painful shortened leg is held in:

• internal rotation

• adduction

• slight flexion (Fig. 11.58a).

With anterior dislocation, the shortened leg is held in abduction, external rotation and flexion.

Principles of management

• Adequate analgesia, e.g. IM morphine for pain.

• X-rays to confirm diagnosis and exclude associated fracture.

• Reduction of the dislocated hip under relaxant anaesthesia with some urgency since devascularisation of the femoral head is a concern.

• Follow-up X-ray to confirm reduction and exclude any fractures not visible on the first X-ray.

Method of reduction A

Standard method for posterior dislocation

With the patient under relaxant anaesthesia and lying on the floor and with an assistant steadying or fixing the pelvis by downward pressure:²

• Apply traction as the hip is flexed to 90°.

• Then apply gentle external rotation and abduction (maintaining traction) with hand pressure over the femoral head (Figs. 11.58 a, b).

For anterior dislocation, the leg is internally rotated and adducted under traction.

Method of reduction B

Dependent reduction method

This is especially useful if there is an associated fracture of the femur on the same side (Fig. 11.59).

The anaesthetised patient lies prone on the table:

• drop the leg and flex the dislocated hip over the edge of the table

• apply steady downward traction on the flexed hip

• gently rotate externally with hand pressure on femoral head (from gluteal region).

Emergency pain relief can be provided by a femoral nerve block with local anaesthesia (see Femoral nerve block).

A UK study has highlighted the fact that the most common cause of knee pain is simple ligamentous strains and bruises due to overstress of the knee or other minor trauma. Traumatic synovitis may accompany some of these injuries. Some of these so-called strains may include a variety of recently described syndromes such as the synovial plica syndrome, patellar tendonopathy and infrapatellar fat-pad inflammation (Fig. 11.60).

Low-grade trauma of repeated overuse such as frequent kneeling may cause prepatellar bursitis, known variously as ‘housemaid’s knee’ or ‘carpet layer’s knee’. Infrapatellar bursitis is referred to as ‘clergyman’s knee’.

Osteoarthritis of the knee, especially in the elderly, is a very common problem. It may arise spontaneously or be secondary to previous trauma with associated internal derangement and instability.

The most common overuse problem of the knee is the patellofemoral joint pain syndrome (often previously referred to as chondromalacia patellae).

Injuries to the medial and lateral menisci of the knee are common in contact sports, and are often associated with ligamentous injuries.

Table 11.3 is a useful aid in the diagnosis of these injuries. There is a similarity in the clinical signs between the opposite menisci, but the localisation of pain in the medial or lateral joint lines helps to differentiate between the medial and lateral menisci (Fig. 11.61).

Note: The diagnosis of a meniscal injury is made if three or more of the five examination findings (‘signs’ in Table 11.3) are present.

The Lachman test is a sensitive and reliable test for the integrity of the anterior cruciate ligament. It is an anterior draw test with the knee at 20° of flexion. At 90° of flexion, the draw may be negative but the anterior cruciate torn.

Test method

1. Position yourself on the same side of the examination couch as the knee to be tested.

2. The knee is held at 20° of flexion by placing a hand under the distal thigh and lifting the knee into 20° of flexion. The patient’s heel rests on the couch.

3. The patient is asked to relax, allowing the knee to ‘fall back’ into the steadying hand and roll slightly into external rotation.

4. The anterior draw is performed with the second hand grasping the proximal tibia from the medial side (Fig. 11.62) while the thigh is held steady by the other hand.

5. The feel of the endpoint of the draw is carefully noted. Normally there is an obvious jar felt as the anterior cruciate tightens. In an anterior cruciate deficient knee there is excess movement and no firm endpoint. The amount of draw is compared with the opposite knee. Movement greater than 5 mm is usually considered abnormal.

Note: Functional instability due to anterior cruciate deficiency is best elicited with the pivot shift test. This is more difficult to perform than the Lachman test.

The knee is very prone to overuse disorders. The pain develops gradually without swelling, is aggravated by activity and relieved with rest. It can usually be traced back to a change in the sportsperson’s training schedule, footwear, technique or related factors. It may be related also to biomechanical abnormalities ranging from hip disorders to feet disorders.

Overuse injuries include:

• patellofemoral joint pain syndrome (‘jogger’s knee’, ‘runner’s knee’)

• patellar tendonopathy (‘jumper’s knee’)

• synovial plica syndrome

• infrapatellar fat-pad inflammation

• anserinus bursitis/tendonopathy

• biceps femoris tendonopathy

• semimembranous bursitis/tendonopathy

• quadriceps tendonopathy/rupture

• popliteus tendonopathy

• iliotibial band friction syndrome (‘runner’s knee’)

• the hamstrung knee.

It is amazing how often palpation identifies localised areas of inflammation (tendonopathy or bursitis) around the knee, especially from overuse in athletes and in the obese elderly (Fig. 11.63a, b).

‘Jumper’s knee’ or patellar tendonopathy (Fig. 11.64a) is a common disorder of athletes involved in repetitive jumping sports, such as high jumping, basketball, netball, volleyball and soccer. The diagnosis is often missed because of the difficulty of localising signs.

The condition is best diagnosed by eliciting localised tenderness at the inferior pole of the patella with the patella tilted.

Method

1. Lay the patient supine in a relaxed manner with head on a pillow, arms by the side and quadriceps relaxed (a must).

2. The knee should be fully extended.

3. Tilt the patella by exerting pressure over its superior pole. This lifts the inferior pole.

4. Now palpate the surface under the inferior pole. This allows palpation of the deeper fibres of the patellar tendon (Fig. 11.64b).

5. Compare with the normal side.

Very sharp pain is usually produced in the patient with patellar tendonopathy.

Treatment

Explanation and conservative management including activity modification, stretching exercises and a strengthening program are the first-line treatment. However, the problem can be stubborn, and surgery has an important place in the management.

Pain felt in the anterior part of the knee is very common and is most commonly caused by the patellofemoral joint pain syndrome. It needs to be distinguished from arthritis of the knee joint. It is common in sports medicine and is referred to sometimes as ‘jogger’s knee’, ‘runner’s knee’ or ‘cyclist’s knee’.

This syndrome, also known as chondromalacia patellae, is characterised by pain and crepitus around the patella during activities that require flexion of the knee under loading (e.g. climbing stairs).

Signs

Patellofemoral crepitation during knee flexion and extension is often palpable, and pain may be reproduced by compression of the patella onto the femur as it is pushed from side to side with the knee straight or flexed (Perkins test).

One method for the patella apprehension test (Fig. 11.65)

1. Have the patient supine with the knee extended.

2. Grasp the superior pole of the patella and displace it inferiorly.

3. Maintain this position and apply patellofemoral compression.

4. Ask the patient to contract the quadriceps (a good idea is to get the patient to practise quadriceps contraction before applying the test).

5. A positive sign is reproduction of pain under the patella and hesitancy in contracting the muscle.

Treatment

Figure 11.66 illustrates a simple quadriceps exercise. A series of isometric contractions are each held for about 4 seconds and alternated with relaxation of the leg. This exercise can be repeated many times in one period and throughout the day.

Typical features

• An injury of children and young adults (especially females). Also common in sport.

• Caused by contraction of quadriceps with a flexed knee.

• There is always lateral displacement.

• Knee may be stuck in flexion.

Method of immediate reduction

The following can be attempted without anaesthesia (preferably immediately after the injury) or by using pethidine and IV diazepam as a relaxant.

1. Place your thumb under the lateral edge of the patella.

2. Push it medially as you extend the knee.

Important points

• Exclude an osteochondral fracture with X-rays.

• Post-reduction rest with knee splinted in extension and crutches for 4 to 6 weeks.

• Arthroscopic inspection and repair may be advisable.

• Recurrent dislocation in young females (14 to 18 years) requires surgery.

Athletes, especially runners and joggers, are prone to painful problems in the lower legs (Fig. 11.67). Diagnosis of the various syndromes can be difficult, but Table 11.4 will be a useful guide. The precise anatomical site of the painful problem is the best pointer to a diagnosis.

The so-called torn ‘monkey muscle’, or ‘tennis leg’, is actually a rupture of the medial head of gastrocnemius at the musculoskeletal junction where the Achilles tendon merges with the muscle (Fig. 11.68). This painful injury is common in middle-aged tennis and squash players who play infrequently and are unfit.

Clinical features

• A sudden sharp pain in the calf (the person thinks he or she has been struck from behind, e.g. by a thrown stone).

• Unable to put heel to ground.

• Walks on tip toes.

• Localised tenderness and hardness.

• Dorsiflexion of ankle painful.

• Bruising over site of rupture.

Management

• RICE treatment for 48 hours.

• Ice packs immediately for 20 minutes and then every 2 hours when awake (can be placed over the bandage).

• A firm elastic bandage from toes to below the knee.

• Crutches can be used if severe.

• A raised heel on the shoe (preferably both sides) aids mobility.

• Commence mobilisation after 48 hours rest, with active exercises.

• Physiotherapist supervision for gentle stretching massage and then restricted exercise.

A complete rupture of the Achilles tendon can be misdiagnosed because the patient remains able to plantar flex the foot by virtue of the deep long flexors. Two tests should be performed to confirm the diagnosis.

Palpation of tendon

Palpate for a defect in the Achilles tendon. This defect could be masked by haematoma if the examination is performed more than a couple of hours after the injury.

The ‘calf’ squeeze test

With the patient prone and both feet over the edge of the couch, squeeze the gastrocnemius soleus complex of both legs. Plantar flexion of the foot indicates an intact Achilles tendon (Fig. 11.69a); failure of plantar flexion indicates total rupture (Fig. 11.69b).

Most of the ankle ‘sprains’ or tears involve the lateral ligaments (up to 90%), while the stronger tauter (deltoid) ligament is less prone to injury.

The treatment of ankle ligament sprains depends on the severity of the sprain. Most grade I (mild) and II (moderate) sprains respond well to standard conservative measures and regain full, pain-free movement in 1 to 6 weeks, but controversy surrounds the most appropriate management of grade III (complete tear) sprains.

Grades I & II sprains

• R rest the injured part for 48 hours, depending on disability

• I ice pack for 20 minutes every 3 to 4 hours when awake for the first 48 hours

• C compression bandage, e.g. crepe bandage

• E elevate to hip level to minimise swelling

• A analgesics, e.g. paracetamol

• R review in 48 hours, then 7 days

• S special strapping

Use partial weight bearing with crutches for the first 48 hours or until standing is no longer painful, then encourage early full weight bearing and a full range of movement with isometric exercises. Use warm soaks, dispense with ice packs after 48 hours. Walking in sand, e.g. along the beach, is excellent rehabilitation. Aim towards full activity by 2 weeks.

Strapping of the ankle

Method

1. Maintain the foot in a neutral position (right angles to leg) by getting the patient to hold the foot in that position by a long strap or sling.

2. Apply small protective pads over pressure points.

3. Apply one or two stirrups of adhesive low-stretch 6–8 cm strapping from halfway up the medial side, around the heel and then halfway up the lateral side to hold the foot in slight eversion (Figs. 11.70a, b).

4. Apply an adhesive bandage, e.g. Acrylastic^® (6–8 cm), which can be rerolled and reused.

5. Reapply in 3 to 4 days.

6. After 7 days, remove and use a non-adhesive tubular elasticised support until full pain-free movement is achieved.

Hiking (bushwalking) tip for rolled sprained ankle

Some experienced leaders carry Voltaren^® (or similar) gel and plastic wrap when taking a walking group. If the ankle is injured (sprain is a common problem) and ICE treatment is unavailable, apply the gel or ointment to the injured ankle, cover with plastic wrap and then bandage.

The medial-lateral gliding mobilisation of the subtalar joint is indicated by a loss of function of the subtalar ankle joint, commonly with chronic post-traumatic ankle stiffness, with or without pain. The most common cause is the classic ‘sprained’ ankle.

The objective of therapy is to increase the range of inversion and eversion.

Method

1. The patient lies on the side (preferably the problematic side), with the affected leg resting on the table. The foot hangs over the end of the table with the lower leg supported by a flexible support, such as a rolled-up towel, small pillow, sandbag or lumbar roll. The foot is maintained in dorsiflexion by support against the therapist’s thigh.

2. Stand at the foot of the table facing the patient’s leg.

3. Grasp the patient’s leg with the stabilising hand just above the level of the malleolus.

4. The mobilising hand firmly grasps the calcaneum.

5. Apply a firm force to the foot at right angles to the long axis of the foot, so that an even up and down (medial-lateral) rocking movement is achieved. The movement should be smooth (not too forceful or jerky) and of consistent amplitude (Fig. 11.71).

Proprioception exercises

Strengthening of the leg muscles and the ligaments of the ankle can be improved by the use of a wobble board. The patient stands on the board and shifts his or her weight from side to side in neutral, forward or extended body positions to improve proprioception and balance.

An improvised wobble board

Patients can construct a simple wobble board by attaching a small piece of wood (10 cm × 10 cm × 5 cm (deep)) to the centre of a 30 cm square piece of plywood or similar wood about 2 cm thick. (Suitable for patients with good balance.)

Alternative

Patients can simply place their slab of wood on a dome-shaped mound of earth.

The Bosu-Ball

This is a fitness training device for yoga gym exercises. It is ideal for ankle exercises since it is a half sphere with a round bottom half and a flat surface on top.

The ‘aeroplane’ exercise

1. Instruct the patient to stand in a neutral position and shift his or her weight from side to side to improve balance and proprioception.

2. After 2 or 3 days, perform the balancing exercises by leaning forwards in addition to using the neutral position (Fig. 11.72).

3. After a further 2 or 3 days, practise the exercise by leaning backwards—thus adding to the difficulty of the exercise.