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Contents 1 2011 1.1







7 April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


About (2011-04-20 12:49) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


HAND THERAPY (2011-05-10 05:49) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


June . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Are you suffering from back pain? Are you looking to get rid from back pain? (2011-06-30 11:15)


July . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Are you in Pain? Do You Need a Physical Therapist? (2011-07-23 07:50) . . . . . . . . . .


Do you have neck pain that keeps you from being as energetic as you would like? (2011-07-23 07:56) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


August . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Foot Pain? (2011-08-26 06:45) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Wrist Pain (2011-08-26 07:05) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Arthritis Types, Symptoms, Causes and Treatment (2011-11-22 10:50) . . . . . . . . . . . .


December . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Treat Herniated Disk with Physical Therapy.. (2011-12-08 07:05) . . . . . . . . . . . . . . .


Treat Spondylolysis and Spondylolisties With Physical Therapy... (2011-12-13 10:11) . . . .


2 2012 2.1



27 January . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Are You Suffering from Your Hip Joint..??? (2012-01-14 11:33) . . . . . . . . . . . . . . . .


Physical Therapy Treatment for Injuries Around The Ankle Joint (2012-01-20 10:27) . . . .


March . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Injuries Around the Elbow (2012-03-12 10:36) . . . . . . . . . . . . . . . . . . . . . . . . . .


Archillies Region - Types,Causes & Treatment (2012-03-23 13:05) . . . . . . . . . . . . . . .


April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41 3

Ankle Fractures (2012-04-07 11:49) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Sports Injuries (2012-05-08 11:26) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Stress Fracture (2012-05-30 12:03) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


June . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Treatment of Lumbar Disk Disease and Spinal Canal Stenosis (2012-06-12 08:59) . . . . . .


Distal Forearm Fractures (2012-06-21 10:34) . . . . . . . . . . . . . . . . . . . . . . . . . . .


Disorders of the Hand (2012-06-22 11:58) . . . . . . . . . . . . . . . . . . . . . . . . . . . .


July . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Congenital Disorders of Upper Limb (2012-07-04 09:39) . . . . . . . . . . . . . . . . . . . .


Shin Pain (2012-07-11 10:06) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


ANTERIOR KNEE PAIN (2012-07-18 05:16) . . . . . . . . . . . . . . . . . . . . . . . . . .


August . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Cervical Headache (2012-08-11 06:53) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


The Benefits of Physical Activity in the Elderly (2012-08-28 12:07) . . . . . . . . . . . . . .


Chronic Fatigue Syndrome (CFS) (2012-08-31 12:23) . . . . . . . . . . . . . . . . . . . . . .


September . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Diabetes Mellitus Treatment (2012-09-12 10:10) . . . . . . . . . . . . . . . . . . . . . . . . .


Lateral Ankle Pain (2012-09-27 09:32) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


October . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Rotator Cuff Injuries (2012-10-04 08:46) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Hand and Finger Injuries (2012-10-23 12:00)

. . . . . . . . . . . . . . . . . . . . . . . . . .


2.10 November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Acute Wrist Injuries (2012-11-06 08:57) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to Recognize a Condition Masquerading as a Sports Injury? (2012-11-21 10:46) . . . .


How we get relief from Minimizing Extent of Injury (RICE)? (2012-11-29 06:21) . . . . . .


2.11 December . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Are you being affected by Lower Back Pain? (2012-12-17 07:01) . . . . . . . . . . . . . . . .


How to Prevent Patella Fracture? (2012-12-27 07:46) . . . . . . . . . . . . . . . . . . . . . .


How to treat Longstanding Groin Pain? (2012-12-31 10:57) . . . . . . . . . . . . . . . . . .








3 2013 3.1


115 January . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to Care for Muscle Injury Pain? (2013-01-03 12:14) . . . . . . . . . . . . . . . . . . . .


How we treat Fracture of Femur? (2013-01-10 11:26) . . . . . . . . . . . . . . . . . . . . . .


How to get comfort from Thoracic Outlet Syndrome (Neck Tingling)? (2013-01-22 10:36) .



February . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How Foot and Ankle Discomfort is treated? (2013-02-04 06:17) . . . . . . . . . . . . . . . .


How to cure Ankle Tibial Nerve? (2013-02-22 10:13) . . . . . . . . . . . . . . . . . . . . . .


How do you heal OLECRANON BURSITIS? (2013-02-27 07:19) . . . . . . . . . . . . . . .


March . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to get relief from Wrist Joint Pain? (2013-03-13 04:43) . . . . . . . . . . . . . . . . . .


How to prevent Foot Bone Injury? (2013-03-26 05:31) . . . . . . . . . . . . . . . . . . . . .


What are the classifications of Capitellum (Elbow) Fracture? (2013-03-30 06:17) . . . . . .


April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to cure Wrist Bone Fracture? (2013-04-19 10:40) . . . . . . . . . . . . . . . . . . . . .


Physical Therapy treatment for Back Pain (2013-04-25 10:32) . . . . . . . . . . . . . . . . .


Mechanisms of Spinal Cord Injury (2013-04-27 07:18) . . . . . . . . . . . . . . . . . . . . .


May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to get Relaxation from Neck Pain? (2013-05-07 10:34) . . . . . . . . . . . . . . . . . .


What are the Causes of Achilles Tendonitis (Heel Pain)? (2013-05-24 05:15) . . . . . . . . .


How to Recover from Knee Injuries? (2013-05-29 10:26) . . . . . . . . . . . . . . . . . . . .


July . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to cure Foot Pain? (2013-07-15 09:03) . . . . . . . . . . . . . . . . . . . . . . . . . . .


August . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


What are the Symptoms of Trigger Finger? (2013-08-28 09:15) . . . . . . . . . . . . . . . .


September . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


How to cure Plantar Fasciitis? (2013-09-17 04:20) . . . . . . . . . . . . . . . . . . . . . . . .


October . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Physical Therapy Post Knee Replacement (2013-10-09 09:25) . . . . . . . . . . . . . . . . .


3.10 November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Vestibular Rehabilitation Therapy (2013-11-15 06:49) . . . . . . . . . . . . . . . . . . . . .


3.11 December . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Identifying and Treating Cluster Headaches (2013-12-20 09:50) . . . . . . . . . . . . . . . .









4 2014 4.1



165 January . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Skier’s Thumb: Causes, Symptoms and Treatments (2014-01-20 09:37) . . . . . . . . . . . .


March . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Anterior Knee Pain (2014-03-31 10:32) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Becker Muscular Dystrophy (2014-04-09 11:33) . . . . . . . . . . . . . . . . . . . . . . . . .

170 5

Knobby Knees (2014-04-19 12:11) 4.4


. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Alliance Rehab & Physical Therapy Clinics offer Treatments for Auto- Accident Injuries (2014-05-22 11:05) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Chapter 1

2011 1.1


About (2011-04-20 12:49) At Alliance Rehab & Physical Therapy we provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. With eight convenient locations in the Metro Area, we are able to serve the Northern VA and DC region. We are located in [1]Alexandria-near Alexandria Hospital, [2]AlexandriaMount Vernon, [3]Fairfax, [4]Leesburg-Lansdowne, [5]Springfiel d, [6]Tyson’s Corner,[7] Woodbridge and downtown[8]Washington DC. Rehab Programs Physical Therapy, Orthopedic Rehabilitation, Neurological Rehabilitation, Hand Therapy, Vestibular Rehabilitation, Women’s Health Programs, Industrial Rehabilitation, Functional Capacity Evaluations and Work Hardening Program. Rehab Benefits at Alliance • [9]SAME DAY scheduling available • [10]Physical Therapy Expert especially in WORK INJURIES, AUTO INJURIES and SPORTS INJURIES • [11]Early Morning, Late Evening, and Weekend appointments available • [12]Over 90 % of our referrals come from local physicians • [13]BILINGUAL Staff Treatments • [14]Low Back Pain • [15]Neck Pain • [16]Muscle Strain/Joint Sprains 7

• [17]Post Surgical Rehab • [18]Chronic Pain • [19]Athletic and Sports Injuries • [20]Heel Pain / Plantar Fasciitis • [21]Ergonomics • [22]Gait Instability • [23]Tendonitis / Bursitis • [24]Vestibular Rehab • [25]Neurological Impairment/Injuries • [26]Worker’s Comp Injuries • [27]No-Fault Injuries • [28]Auto Injuries 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.




HAND THERAPY (2011-05-10 05:49) Does your [1]hand hurt? Have you noticed symptoms of pain, discomfort, fatigue and weakness in one or both of your hands? Are your fingers locking and unable to extend, without assistance from the other hand? Have you experienced numbness and tingling that has gotten progressively worse? Does your hand feel clumsy and are you noticing that you drop things from your hand more frequently or are unable to pick up things or open containers with your hands? If so, you may be suffering from one or more of the following chronic hand and upper extremity [2]conditions such as arthritis, tendinitis, or nerve conditions such as carpal tunnel syndrome. Has your hand or upper extremity been affected by an accident or trauma leaving you with wounds, scars, burns, injured tendons or nerves, fractures, dislocations or amputations of your fingers, hand or arm? Have you undergone prolonged casting or underwent a surgical procedure? Are you now experiencing severe [3]pain and limitations in motion and function, associated with your injuries? Whether you are suffering from a [4]chronic hand and upper extremity condition or recently experienced an acute injury, you may be a candidate for hand therapy. If your physician has not already recommended it, you should ask him for a referral so that you can expedite your recovery process. What is [5]hand therapy? Hand therapy is specialized therapy that focuses specifically on conditions affecting the hand and upper extremity. It can be performed by an [6]Occupational Therapist or Physical therapist who has a high degree of specialization that requires continuing education and often advanced certification. What can hand therapy do for me? " Provide preventative , Non-operative or conservative treatment " Manage acute or chronic pain " Provide wound care to include care of open and or sutured wounds (prevention of infection and assistance in healing) " Control hypertrophy (raised and/or swollen) scars or hypersensitive scars " Reduce swelling " Instruct in desensitization and sensory re-education following nerve injury or trauma " Fabricate splints for prevention or correction of injury or to protect surgical sites or to increase movement " Design and implement home exercise programs to increase motion, dexterity, and/or strength " Train in the performance of daily life skills through adapted methods and equipment " Conditioning prior to returning to work What is a [7]Certified Hand Therapist? A Certified Hand Therapist (C.H.T.) is an occupational/physical therapist who specializes in the treatment of hands. They must have a minimum of 5 years postgraduate experience with at least 4,000 hours in hand therapy and have successfully challenged the Hand Therapy Certification Commission exam in order to obtain these credentials. [8]CHT’s are dedicated professionals who have a commitment to meet the highest standards of their profession. The hand and arm have an extremely intricate anatomy and complexity. Rehabilitation of the hand and arm requires in-depth knowledge and up-to-date techniques. Certified Hand Therapists have the highest level of competence in the rehabilitation of upper extremity injuries. Certified Hand Therapists are able to initiate treatment immediately following surgery often while stitches are still in place. Early referral to a hand therapist is effective in preventing further surgeries and obtaining 9

an optimal outcome. Hopefully, this information helps you to make the right decision, when consulting your medical specialist. [9]“Restoring life back into your hands�

1. 2. 3. 4. 5. 6. 7. 8. 9.



Are you suffering from back pain?

Are you looking to get rid from back pain?

(2011-06-30 11:15)

Overview: [1]Back pain is becoming one of the most common American health problems, affecting around 80 % people at some point during their lives. It could be from minor pain, regular pain to sudden become chronic and severe pain. The pain can be acute if for few days but consider [2]chronic if more than four to six weeks. Anatomy: There are numerous complications on [3]spine and complaints about back pain can be categories based on the spinal column curvature and understand the 33 [4]vertebras. The neck pain ([5]Cervical: 1-7 vertebras), upper back pain ([6]Thoracic: 8 to 19 vertebras), lower back pain ([7]lumbar: 20-25 vertebras) and tailbone ([8]pelvic: 26-31 vertebras) and two (32-33)[9] coccygeal vertebrae rarely focused. 10

[10] [12] Causes:


Usually, [13]back pain originates from the muscles, nerves, bones, joints and some time from the other structures in the human spine. Back pain can be divided into [14]neck pain, [15]upper back pain, and [16]lower back pain. Back pain can be occur due to various reasons like muscle strain, sprain or slipped disc. There are many causes of Back Pain but one of the most common reason of back pain is doing work with which you are not used to, like carrying heavy things, engaging in strenuous physical work and so on. So the most common cause in back pain is wrong posture, auto or work injury and if your cause is over-weighted then back pain can be worst. Demography:

Mostly, younger people (30 to 60 year old) can suffer from back pain which originates from the disc space itself. Older adults (e.g. over 60) can suffer from Back Pain which is related to joint degeneration. Diagnosis/Symptoms: See your doctor without any delay in case of any pain in spine. Get plenty of rest and use regular an anti-inflammatory medicine to relieve pain. If your pain is severe, lost feeling see your doctor or go to the emergency room or call 9-1-1 right away. X-rays is the basic option for radio-graphic assessments for low back pain. You doctor may suggest you other diagnosis in cases in of congenital defects, trauma, metastatic cancer or bone deformity as a cause of lower back pain. Treatment and Precautions: 11

There are various benefits that are provided by the [17]physical therapy and [18]rehabilitation for back pain and other spine related problems. The goals of physical therapy are to reduce your pain, and educate you not only in your daily and work routine but also maintain treatment program so that further recurrences can be prevented. There are many different types of treatments provided by physical therapy for back pain. Actually, the physical therapist may focus on reducing pain with passive physical therapy. These are the considered passive therapies because they are done to the patient by the therapist. In addition to passive therapies, active physical therapy (exercise) is also necessary to rehabilitate the spine and restore your daily routine. If you are suffering from Back Pain and want to get rid of this Pain then search physical therapy clinic near you and consult only professional, licensed and experienced [19]physical therapist today. EMERGENCY IN CASE OF LIFE THREATENING AUTO ACCIDENT OR WORK INJURIES; Call 911 for an ambulance right away. Do not try to drive to the emergency room, and try to move as little as possible.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Webbers (2011-07-01 07:42:12) I have gone through many articles and glog on the internet. I would like to appreciate the author of back pain article here. Thanks Webbers




Are you in Pain? Do You Need a Physical Therapist? (2011-07-23 07:50) [1]Physical therapy is the procedure of analysis and healing from your injury or physical disorder. If you have an injury or infirmity that results in physical destruction or loss of function, then a [2]physical therapist can help you. A Physiotherapist is a skilled expert to help renovate your potency, motion and activity. After understanding the mechanics of your body he designs a [3]treatment program for you. You can learn specific stretches, exercises and other specialized techniques to recover your body. [4]Physiotherapists make use of many different techniques to decrease your pain of your body and inflexibility. He improves motion, potency and mobility. [5]Physical Therapy For Low Back Pain The most common analysis seen in several [6]physical therapy clinics is Lower Back Pain. Mostly it happens due to poor sitting position, [7]muscle sprain, lifting weighty objects, and forward bending. Physical therapy can help you to remain as active as possible. Low back pain can be a severe trouble and it is enormously recommended to seek advice from a [8]physician or [9]physiotherapist. [10]Physical Therapy For Knee Pain The human knee is a hinge joint (turning point) that is comprised of the tibia (shin) and the femur (thigh). [11]Knee Pain can be caused by repetitive trauma and twist or by wound. Occasionally it occurs for no apparent reason. When [12]knee pain occurs, you may experience practical limitations that include difficulty in walking, rising from sitting, or going upstairs. If you refer [13]physical therapy for the [14]knee pain, the early visit is important to ensure correct analysis and proper supervision. During this visit, your physiotherapist will discuss with you to collect information about the history of your trouble, about the irritating and relieving factors, and about any past medical history that may give the overall problem. From the gathered information, a focused inspection will be conducted. [15]Physical Therapy For Hip Pain The hip is actually close to the low back, and it can be complex to conclude if your [16]hip pain is actually coming from hip or coming from your low back. If this pain remains for more than 2 or 3 weeks or occurs as the consequence of major trauma, a visit to a physician, physiotherapist, or healthcare provider is recommended. The physiotherapist may use physical agent like heat or ice help with inflammation. Exercises to improve hip muscle or mobility may be started. You also may have to perform movements or workout at home every day. [17]Physical therapy is beneficial in treating many diverse medical disorders. [18]Sport and orthopedic injury, [19]neurological and [20]muscular infirmity, [21]cardiopulmonary diseases are only a few [22]pathological situations in which physical therapy plays a vital treatment role. 1. 2. 3. 4. 5. 6. 7.


8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Do you have neck pain that keeps you from being as energetic as you would like? (2011-07-23 07:56)

Did you get up this morning with a stiff painful neck? Are you ready to be completely cured of neck pain forever? If fair enough, then you must appoint a [1]physiotherapist. [2]Physical Therapy is the best and cost effective solution for neck pain.One of the supplest regions of the spine is the neck (cervical) region, which consists of vertebrae, seven shock-absorbing discs, muscles, and [3]vertebral ligaments to clutch them in consign. The primary [4]cervical disc connects the top of the spinal column to the bottom of the skull. The [5]spinal cord, which sends nerve impulses to each part of the body, runs through a canal in the cervical vertebrae and continues all the way down the spine. Pain in the [6]cervical area can cause arm pain as well as the �ache in the neck.� [7]TREATMENT Several physical therapists prefer ice (cold therapy) because of its efficiency in diminishing pain and tenderness. Heat (heat therapy) also provides release to some people, but should be used with care because it can sometimes make an inflamed region inferior. Apply warmth or ice for 15-20 minutes at a moment, and give yourself a 40-minute break among applications. [8]Treatments may comprise [9]manual therapy, ultra sound, [10]cervical traction, TENS, exercises, myofacial release. [11]How Physical Therapy Can Help With Neck Pain? [12]Physical therapy always begins with a complete history and valuation of the trouble. Your physical therapist will take many things into story, including your age, general health, work, and way of life. If major strain or disease is concerned, your [13]physical therapist will work with you in discussion with a physician. 1. 2. 3.


4. 5. 6. 7. 8. 9. 10. 11. 12. 13.



Foot Pain? (2011-08-26 06:45) The [1]foot is one of the most complex parts of the body, consisting of 28 bones linked by several [2]joints, [3]tendons, [4]muscles and [5]ligaments. Foot is the foundation of athletic movements of the lower extremity. Pain indicates that there is something wrong with the interaction of internal structures of the foot. Causes: [6]Foot pain frequently cause by inappropriate foot function. Improperly fitted shoes can make it worse and in some cases, cause foot harms. Shoes that fit properly and give good arch support can avoid irritation to the foot joints and skin. There are lots of foot problems that influence the heels, toes, nerves, tendons, ligaments, and joints of the foot. Foot pain may be caused by many unusual conditions or injuries. [7]Acute or repeated trauma is the most frequent cause of foot pain. [8]Trauma is an outcome of forces external to the body either directly impacting the body or forcing the body into a situation where a particular or mixture of forces result in damage to the structure of the body. Wearing shoes that are too tight or high heels can cause pain in the region of the balls of the feet and the bones in that part. Shoes that are tied too tightly may cause pain and bruising on the top of the foot. Anatomy of Foot: Your foot consists of 28 bones. These are

• 7 [9]Tarsal Bones • 5 [10]Metatarsal [11]Bones • 5 [12]Proximal Phalanges • 4 [13]Middle Phalanges • 5 [14]Distal Phalanges • 2 [15]Sesamoid Bones 15

[16] Symptoms: [17]Pain and point tenderness are the instant indicators that somewhat is wrong in a specific region. When the [18]pain begins to obstruct with your activities of everyday or if you cannot act upon your desired activities without pain, you should consider seeking medical attention. Indicators that you should seek medical care are if the area looks distorted, you have loss of function, large amount of swelling with pain, prolonged change of skin or toenail color, change of sensation, the affected area becomes warmer than the adjacent areas or becomes tender to the touch. Physical Therapy for Foot Pain [19]Physical therapy is frequently one of the most important ways to treat the symptoms of [20]foot pain. Gentle stretching of the foot helps to improve the uneasiness felt due to foot pain. Rarely with [21]plantar fasciitis a brace is worn at night to remain the foot in a stretched situation. Following are the five simple and easy movements or exercises to stretch the structures of the foot:

• The Long Sitting Stretch • Achilles Stretch • Stair Stretch 16

• Can roll • Toe Stretch [22]Physical Therapy is vital in retuning a patient rapidly to their daily routine as well as athletic activities. Restoring proper mobility of the different ankle bones in addition to strengthening of the ankle is necessary in preventing future injuries to the foot, knees, hip and back. Calcaneus Talus Medical Cuneiform Intermediate Cuneiform Lateral Cuneiform Cuboid Navicular 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

How to cure Plantar Fasciitis? | Alliance Physical & Physical Therapy (2014-04-05 12:24:50) [&] Sometimes plantar fasciitis can be associated with heel spurs. These spurs are outgrowths of bone on the calcaneus (heel bone). They are sometimes painful and may occasionally require surgical treatment. [&] How to cure Plantar Fasciitis? | Alliance Rehab and Physical Therapy (2013-09-17 04:56:47) [&] plantar fasciitis can be associated with heel spurs. These spurs are outgrowths of bone on the calcaneus (heel bone). [&] How to cure Plantar Fasciitis? Alliance Rehab & Physical Therapy Blog (2013-09-17 04:57:59) [&] plantar fasciitis can be associated with heel spurs. These spurs are outgrowths of bone on the calcaneus (heel bone). [&]


Wrist Pain (2011-08-26 07:05) [1]Wrist pain is any pain or discomfort that occurs in the wrist. The wrist contains many small bones, cartilage, muscles, blood vessels, and tendons, and is particularly vulnerable to injury. Wrist pain is commonly caused by soreness or injury but may also arise from infectivity or a [2]tumor on the wrist. Wrist pain is particularly general complaint, and there are many common causes of this problem. It is important to make an accurate opinion of the cause of the symptoms so that suitable action can be directed at the cause. [3]Causes for wrist pain: [4]Tendonitis Tendonitis is a standard problem that causes wrist pain and enlargement. This is due to swelling of the ligament cover. Wrist pain treatment which is caused by tendonitis does not need surgical procedure. [5] Sprain Wrist sprains are regular injuries caused to the ligaments around the wrist joint. gin problems by restraining the use of our hands.

Sprains can ori-

[6] Carpal Tunnel Syndrome Carpal tunnel disorder is the state that results from dysfunction of one of the nerves in the wrist. In carpal tunnel syndrome the median nerve is squeezed together or strained off, as it pass through the wrist joint. [7]Arthritis Arthritis is one of the troubles that can originate wrist pain and complexity in performing daily or general activities. There are a number of causes of arthritis and luckily there are a lot of wrist arthritis treatments.

[8]Ganglion Cyst A ganglion cyst is a type of swelling that frequently occurs over the back of the hand or wrist. These are a sort of fluid-filled capsules. Ganglion cysts are not cancerous. They will not enlarge and they will not spread to other parts of your body.

[9]Gout This occurs when there is too much production of uric acid and a waste product. tals in joints rather than being excreted in the urine. 18

This forms crys-

[10]Pseudogout This occurs when calcium deposit in the joints (wrists or knees) causing ache and enlargement.

[11] Fractures A wrist fracture is a general orthopedic injury. Patients with a broken wrist may be treated in a cast, or they may need surgical treatment for the fracture.

When do you need to [12]call your physician about your wrist pain? If you are not confident about the cause of your wrist pain, or if you do not know the definite cure recommendations for your condition, you should seek medical consideration. Treatments for these situations must be directed at the specific cause of your problem. Some [13]symptoms seen by a physician include:

• Inability to carry objects • Injury that causes deformity of the joint • Wrist pain that occurs at night or while sleeping • Wrist pain that persists beyond a few days • Failure to flatten the joint • Swelling or major bruising around the joint • Symptoms of an infection, including fever • Any other strange symptoms What are the[14] best treatments for wrist pain?

The treatment of wrist pain depends completely on the cause of the problem. Thus, it is very important that you understand the cause of your symptoms before you decide for a treatment plan. If you are uncertain for your diagnosis or for the severity of your condition, you should look for medical guidance before the start of any treatment. All treatments listed here are not appropriate for every situation, but may be helpful in your situation.

• [15] Rest Activity Modification: 19

The first treatment for many common conditions that cause wrist pain is to relax the joint and allow the acute swelling to drop. It is important, however, to use warning when relaxing the joint, because causing no motion to the joint can result a stiff joint. Adjusting your activities so as not to disturb the joint can help prevent worsening of wrist pain.

• [16]Ice and Heat Application: Usually Ice and heat pads are commonly used for treatments of wrist pain. But the question arises, which one is the right one to use, ice or heat? And how long should the ice or heat treatments last? Read on for more information about ice and heat treatment or consult your physician.

• [17]Wrist Support: Support braces can aid patients who either had a recent [18]wrist sprain injury or those who tend to hurt their wrists easily. These braces act as a tender support to wrist activities. They will not avoid severe injuries, but may help you to carry out simple activities while rehabilitating from a [19]wrist sprain. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.



Arthritis Types, Symptoms, Causes and Treatment (2011-11-22 10:50) Literally, many elder people have [1]arthritis, but today it’s not just a problem of the old. Some forms of arthritis affect kids still in diapers, while thousands of people are suffering in the prime of their lives. The general denominator for this condition is [2]joint and musculoskeletal pain, which are grouped together as 20

[3]’arthritis.’ Often that pain is a result of [4]swelling of the joint lining. [5]Arthritis is the most common cause of inability in the USA. Types of [6]Arthritis: [7]Arthritis is of two types. One is [8]Osteoarthritis Arthritis and other on is [9]Rheumatoid Arthritis. [10]Osteoarthritis Arthritis is local or generalized degeneration of the articular cartilage and the formation of “lips and spurs” at the edges of [11]Joints. An exaggeration of the normal aging process. [12]Rheumatoid Arthritis is an inflammatory disease involving the synovial membranes and the particular structures. [13]Symptoms: The main [14]symptoms of Osteoarthritis are: " Progressive pain " Joint enlargement " -lived stiffness in morning " Difficulty moving " A grating or crackling sound or sensation in your joints The main [15]symptoms of Rheumatoid Arthritis are: " Joint swells with redness and tenderness " Symmetrical joint involvement is common " Migrate from joint to joint " Inflammation around the joints and in other areas [16] Causes: [17]Arthritis is cleanly defined as [18]swelling in the joints. There are different types of [19]arthritis, but the two most common types are [20]rheumatoid arthritis and [21]osteoarthritis. [22]Joint stiffness and joint pain are the two most common symptoms of [23]arthritis. Those with [24]arthritis may experience more than one [25]inflamed joint. Main [26]Causes are: " Main Cause of this disease is Inflammation of synovial membrane tissue. This tissue lining the [27]joints in human body and when this tissue becomes [28]swollen, it results to severe pain and stiffness in that body part. " Being inflexible, unwilling to change, fear, anxiety, depression, deep shock all these are [29]Arthritis Psychological Causes. " Poor digestion, Hyperacidity, Enzyme deficiency, Poor Skin, Kidney, Gallbladder and Liver activity, spinal imbalance causing reflex conditions as above leading t accumulated toxins which cause an inflammation reaction. " Excessive use of Meat, soda drinks, coffee, salt, excess refined carbohydrates, sweets, raw vegetable deficiency all these cause [30]arthritis. " Fatigue can enhance the feeling of pain and more fatigue increase in [31]arthritis pain. [32]Treatment: 21

" Raw Vegetable and Juice fasting is the fastest method of attaining result. Fasting period depends upon the patients and conditions and may range from 7-21 days. " Take Raw Non Citrus Vegetarian diet and avoid coffee, tea, alcohol, sweets etc. " And one of the best treatment for this is [33]Physical therapy and Hydrotherapy like Hot and cold showers to stimulate general circulation and act as general tonic, Hot compress, Cabinet Bath, Sauna bath, Paraffin bath etc. " [34]Daily Massage with olive and peanut oil. " Or sometimes [35]Joint replacement surgery may be required in eroding forms of [36]arthritis.

Best treatment for [37]arthritis is [38]Physical exercise. [39]Low impact aerobic exercise is best. Talk to your medical professional regarding which types of exercises are ideal for you. And people who are suffering from [40]Arthritis due to Physiological cause they must laugh, shed their stress, loose weight, and have more intimacy with outer world. And do regular exercise.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.


34. 35. 36. 37. 38. 39. 40.

Dave (2011-11-25 04:46:02) The article has valuable information. The way you write and guide about the arthritis was easy to understand. Thanks for wonderful posting and Thanks for helping community.



Treat Herniated Disk with Physical Therapy.. (2011-12-08 07:05) Sandwiched between each of the [1]vertebrae in your [2]spinal column is a disk of [3]cartilage that acts as a [4]shock-absorbing pad. These disks have a soft, jellylike center and a tough, fibrous outer layer. A tear in this outer layer will allow some of the soft center to [5]bulge out. This bulge on the nerve roots emerging from the spine in the region of the damaged disk. CAUSES Any activity that puts increased [6]pressure on the disks of your [7]spine can lead to a disk hemlation.This can occur in the [8]cervical spine, or, more commonly in the [9]lower back. He general gear and tear that comes with age can also contribute, making middle-aged people susceptible to if they bend suddenly or lift an awkward weight. SYMPTOMS AND DIAGNOSIS Depending on the location of the herniated disk, symptoms can vary, but there is usually [10]severe pain and restriction of movement. In the [11]lower back, the pain tends to be a deep [12]unrelenting ache, which may radiate out to your hips; groin buttocks and legs. You may also develop sciatica-a sharp pain, radiating down one leg accompanied by numbness or tingling. [13]Herniated disks can also occur in the [14]neck, causing [15]severe pain that may spread into your [16]shoulders, arms and hands, making it difficult to turn your head or move it backward or forward. You will usually [17]feel pain in only one side of your body. Your doctor will make a [18]diagnosis by performing a physical examination; if your symptoms persist, he may order further tests, such as an [19]MRI or [20]CT scan. RISK AND DISCOVERY Recovery from a [21]slipped disk usually takes 4-6 weeks .However if a [22]disk herniated protrudes fully into the [23]spinal curial; it can compress the caudal equine and damage the [24]nerves leading to your legs, [25]bladder and Bowles. This may result [26]weakness and [27]numbness in both legs and the lower part of your body, loss of bladder and bowel control, and even impotence. Although this rarely happens, it is an [28]emergency and you should seek immediate [29]medical help. 1. 2. 3.


4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

Mubeen (2011-12-08 07:51:19) During my sciatica, I found physical therapy of stretches best. But the problem was, how to imitate exercises. This sciatica relief app helped me to remove pain through stretches.

Treat Spondylolysis and Spondylolisties With Physical Therapy... (2011-12-13 10:11) [1]SPONDYLOLYSIS AND SPONDYLOLISTIES These linked conditions generally affect your [2]lower back but may occur in may part of your [3]spine.[4]Spondylolysis occurs when a defect or weakness in a vertebrae develops into a [5]fracture. The vertebra is then at risk of slipping out of line with the vertebrae adjacent to it, leading to [6]spondylolosthesis, which can be debilitating and [7]painful, or may be painless and go unnoticed. CAUSES [8]Spondylolysis may start with a minor [9]crack the narrow arch of bone in a vertebra,known as the usually it is the result of a fall or due to strain and overuse .some sports such as cricket and soccer repeatedly put stress on the [10]arches of the vertebrae ,which can lead to minor [11]cracks or [12]breaks.[13]Spondylolisthesis generally develops from [14]spondylolysis ,with the crack widening to a complete break due to further [15]stresses and [16]strains .This break allows the damaged vertebra to slip out of line, which can irritate the linked [17]facet joints and ligaments and possibly trap a nerve. SYMPTOMS AND DIAGNOSIS 24

The [18]pain from a displaced vertebra due to [19]spondylolisthesis depends on the degree of slippage. A slight slip may cause little or no [20]pain, while a greater degree of slippage can lead to more [21]intense pain because of the irritation to the spinal joints and ligaments .If your nerve is trapped, there may be some pain numbness, or [22]“pins and needless� in one or both of your legs. Your doctor will make a diagnosis through a [23]physical examination and testing including on [24]X-ray, [25]MRI scan and myelogram. RISKS AND RECOVERY Back strengthening [26]exercises can help stabilize your posture, but where vertebrae have severely slipped, nerve entrapment can develop that may require [27]surgery. Young people [28]diagnosed with spondylolisthesis should avoid contact sports and activities with a high risk of [29]back injury .A young person who is still growing should be [30]monitored every six months, using X-rays to detect further movements and shift in the [31]spinal column. Once growth stops, the [32]vertebrae are unlikely to slip any farther. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. file://localhost/mnt/ext/blogbooker/tmp/5wzhtcn0/SpondylolysisandSpondylolisties 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.



Chapter 2

2012 2.1


Are You Suffering from Your Hip Joint..??? (2012-01-14 11:33) [1]Injuries around the [2]hip constitute one of the most difficult injuries to treat and predict the outcome. But the best way to treat your [3]pain is by [4]Physical Therapy without any Burn and Injury. In dashboard injuries, the impact is driven to the knee of the patient which passes on the energy of [5]hip joint causing posterior dislocation of hip. Examination Inspection Attitude: The examination of attitude in a [6]hip joint injury is very useful. In posterior dislocation of hip, the hip will be in [7]flexion, adduction and internal rotation. In intracapsular fracture neck of femur, the lower limb lies in external rotation and minimal shortening. In [8]trochanteric fractures, the lower limb lies in complete external rotation and the limb appears shortened. In anterior dislocation of [9]hip, there will be flexion, abduction and external rotation deformity. Swelling: In dislocation of hip, the femoral head may be felt either in the [10]gluteal region or in the perineal region or [11]iliac region. In trochanteric fracture, there will be diffuse swelling around the [12]hip and thigh. Palpation The bony landmarks to be palpated are: 1.Greater trochanter: The position of greater trochanter helps us in the [13]diagnosis of fractures around the hip. The greater trochanter, anterior superior iliac spine (ASIS) and [14]ischial tuberosity have a constant relationship to each other which will be altered in affections of hip joint and [15]proximal femur. Bryant’s triangle is formed by a line connecting ASIS and greater trochanter, line dropped from the ASIS perpendicular to the floor and the line connecting the greater trochanter and the perpendicular line. The base of the Bryant’s triangle is measured and compared with opposite side. In fractures of the [16]neck and dislocations of hip, the base will decrease to the [17]proximal migration of the trochanter. In posterior [18]dislocations of hip, the greater trochanter will be more anteriorly felt near the ASIS. In anterior dislocations, it will be felt more posteriorly. It should be palpated for tenderness, thickening or irregularity. In [19]subtrochanteric fractures, Bryant’s triangle will not be altered but there will be loss of transmitted movements between the proximal and distal femur. 2.Head of femur: Normally, the [20]femoral arterial pulsation is felt against the head of femur. In dislocations, this resistance is lost thereby altering the intensity of pulsation. The femoral head may be felt posteriorly or anteriorly depending on the type of dislocation. A smooth round bony hard mass which moves with rotational 27

movements of the shaft of femur is nothing but the head of [21]femur. The medial surface of the medial femoral condyle is in the same direction as that of the head of femur. This gives a rough guidance to locate the head in an intact femur. Neurological examination In posterior [22]dislocations of hip, the nerve to be commonly affected is the [23]sciatic nerve. The common peroneal part of the sciatic nerve is most often involved than the tibial part manifesting as foot drop. So Treat your problem of [24]Hip Joint with Physical Therapy at [25]Alliance Rehab And Physical Therapy which is located in eight prime locations in Northern VA and DC region.[26]

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.


Physical Therapy Treatment for Injuries Around The Ankle Joint (2012-01-20 10:27)

[1][2][3] [4]Injuries Around the Ankle Joint& [5]Ankle sprain is an extremely common complaint with many causes. An ankle sprain occurs when the ligaments surrounding the [6]ankle joint are stretched or torn as the [7]ankle joint and [8]foot is turned, twisted or forced beyond it’s normal range of motion. The most common cause of an ankle pain in athletes is a missed step or a missed landing from a jump or fall. [9]Ankle sprains vary in severity and are classified by the degree of severity. History The usual mechanism of injury to the[10] ankle joint is a rotational violence in which the body swings around a trapped foot. Depending on the quantum of force, there may be ligamentous injury or [11]bony injury around the ankle. The exact position of the foot at the time of [12]injury is elicited. [13]Ankle injuries are usually classified by the direction of the force and the position of the [14]foot at the time of injury. Following a tibial plateau fracture or talar fracture, the ankle and [15]subtalar joint may go in for secondary degenerative arthritis, which can present as [16]chronic pain and recurrent effusions of the ankle joint. Presence of knee pain and hip pain should be asked for as the foot and [17]ankle disorders can alter the biomechanics of the limb predisposing the knee and hip to degenerative osteoarthritis. Examination Inspection The foot,[18] ankle and the leg are completely exposed. The position of the foot in relation to the leg is determined. The [19]foot may be displaced anteriorly, posteriorly or sideways depending on the type of injury. The foot is usually displaced laterally in external rotation injuries. It may be displaced medially in adduction injuries and displaced upwards and laterally in vertical compression [20]injuries. In vertical compression injuries with diastasis of inferior tibiofibular joint, the ankle may appear broadened. In fracture dislocation of the talus, the displaced fragment may stretch the skin of the dorsum of the ankle and may impend rupture of the skin. Palpation The bony points palpated are: Lower end of tibia and fibula including the malleoli: As these bones are subcutaneous, it is easy to find out any [21]fractures, irregularity abnormal mobility. In ligamentous [22]injuries around the ankle, the insertion sites of these ligaments such as anterior talofibular ligament, deltoid ligament may be tender to palpation. To demonstrate the ligamentous injury further, the ankle joint is stressed by giving valgus and varus forces to it. Any abnormal opening out can be demonstrated both clinically and radiologically. Tarsal bones: The calcaneum is palpated bidigitally on either side to demonstrate tenderness or thickening or irregularity. In chronic degenerative arthritis of [23]subtalar joint, tenderness and restriction of movements of subtalar joint will be present. Metatarsal bones: In Jones fractures the base of the Vth metatarsal is avulsed due to the pull of the peroneus brevis muscle. Fractures of the shaft of the metatarsals are demonstrated by eliciting tenderness on axial pressure over the metatarsal head. Diffuse swelling over the [24]tarsometatarsal joints may be seen in Lanfranc’s fracture dislocation. In ’march fracture’, there will be diffuse swelling over the neck of lInd metatarsal with [25]pain. Muscular compartment: Tendo-Achilles which gets inserted in the calcaneum is frequently injured resulting in loss of active [26]plantar flexion. Thompson’s test: Squeezing the calf muscle will cause plantar flexion of the [27]ankle joint. When there is a discontinuity in the tendon, this manoeuvre will not cause plantar flexion. Movements: In acute injuries, active movements may not be possible. Measurement The leg segment is measured from the medial joint line to the malleolus.The vertical height of the heel is measured from the tip of the medial malleolus to the floor in a standing patient. In [28]fractures of the talus and calcaneum, this height may be decreased. The longitudinal measurement of the foot from the tip of the [29]heel to the 29

tip of great toe and then to the tip of the little toe are measured. Circumferential measurement of the foot at the level of the ankle joint, at the level of maximum arch and at the level of the metatarsal heads are measured and compared with the normal side. Neurovascular examination [30]Ankle injuries may rarely be associated with posterior tibial artery and nerve [31]injuries. In Lanfranc’s fracture dislocation, the digital arteries and nerves may get damaged and careful animation is needed to diagnose this. The chronically disabled group usually suffers from the sequelae of old [32]trauma or inflammatory infective or degenerative or neoplastic causes. These patients need to be examined by proper history, detailed examination of the individual bone and joints. After eliciting a detailed history, the examiner should arrive at a provisional differential diagnosis based from the history and then proceed to physical examination. This will help in finding the subtle signs of the disease. Clinical Features The Patient typically present with a twisting injury of the foot following which they complain of inability to bear weight, pain around the [33]ankle and very often swelling around the ankle. Clinically the stability of the ankle joint must be tested by valgus and varus stress under anaesthesia, Associated injury to the tendons and the neurovascular bundles, which run in close vicinity to the [34]joint, has to be ruled out. The state of skin must be checked. The skin over the deformed ankle may get unduly stretched, resulting into necrosis, if not reduced immediately. [35]Physical therapy modalities (such as ultrasound) and manual therapy modalities (such as friction massage) are often used when the acute phase is over.A Physical Therapistis a specialist trained to work with you to restore your activity, strength and motion following an [36]injury or surgery. Physical therapists can teach specific exercises, stretches and techniques and use specialized equipment to address problems that cannot be managed without this specialized physical therapy training. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.


30. 31. 32. 33. 34. 35. 36.

Dave (2012-01-20 19:36:28) This is one of the best article for Ankle injury and pretty much guidelines for the physical therapy. Thanks for porting this articles. Keep continue with healthy articles like this.



Injuries Around the Elbow (2012-03-12 10:36)

[1] Our elbow joint is made up of bone, cartilage, ligaments and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems.Our [2]elbow joint is made up of bone, cartilage, ligaments and fluid. [3]Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is [4]tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a [5]sports injury, often from playing tennis or golf. You may also get tendinitis from overuse of the elbow The injuries around the elbow will be described under the following heads:

• Fractures of the distal end of the humerus • Dislocation of the elbow • Fractures of the proximal ends of the radius and ulna. Fractures of the distal end of humorous: • Supracondylar fracture 31

• Intercondylar fracture • Fracture of the lateral epicondyle • Fracture of the medial epicondyle • Fracture of the capitellum. Supracondylar Fracture Of The Humerus [6]Supracondylar fracture of the humerus is one of the most common fractures in the children, and occurs in the age group of 3-13 years.

Mode of Injury

This fracture is caused by a fall on the outstretched hand.


The fracture line runs transversely just above the [7]condyles of the humerus. On the basis of the displacements, fracture is classified into two types:

• Extension type: In this type the [8]distal fragment is displaced posteriorly.This is the most common type and discussed here. • Flexion type: In this rare type, the fragment is displaced anteriorly. Most of the fractures are displaced fractures. In an extension type the distal fragment is: (i) Displaced posteriorly

(ii) Tilted posteriorly

(iii) Titled medially

(iv) Internally rotated.


Clinical Features

The child complains of severe pain and [9]swelling in the elbow following a history of fall. The child holds the elbow in a flexed position and resists any movement to the elbow. When brought early, the swelling is less and the following signs can be elicited:

• There is tenderness over the distal end of humerus, • [10]Crepitus can be elicited, although it causes pain and therefore should be avoided, • Since the fracture line is above the condyles, and the whole of the distal end of humerus carrying the [11]elbow joint is displaced backwards, normal three bony point relationships is maintained. When presented late, gross, tense swelling sets in which fills up the hollows around the elbow and obscures the bony landmarks. Sometimes even [12]blisters develop over the elbow. In such a situation the fracture signs cannot be elicited. At the time of injury the distal fragment is displaced posteriorly there by pulling the brachial artery and the median nerve against the sharp distal end of the proximal fragment. This may cause injury to the brachial artery and/or the median nerve. It is therefore important to feel the [13]radial pulse and test the nerve functions at the time of initial examination and make a record of it.

If the distal circulation is affected due to an [14]arterial injury, the following features (5 Ps) may be seen:

• Pain- severe • Pallor • Pulselessness • Paraesthesia, and • Paralysis. Investigations

Anteroposterior (AP) and lateral view radiographs of the elbow are essential. The AP view shows the fracture line which runs transversely just above the condyles. The distal fragment is displaced and rotated. The lateral view shows the posterior displacement of the distal fragment.



An undisplaced fracture is treated above-elbow PoP slab for 3 weeks. A displaced fracture can be treated by one of the following methods:

• Closed reduction: The fracture is reduced by closed manipulation under general[15] anesthesia. The reduction is obtained by gentle traction to the forearm, manual manipulation of the fragments to align them properly, and then flexing elbow a little beyond 90°. If the radial pulse becomes feeble or disappears during flexion of the elbow, then the elbow is extended gradually till the pulse reappears. The [16]fracture is then immobilized with the elbow in the same position. The fracture may be stabilized by passing. K-wire percutaneously. The extension type of the fracture is immobilized in an above-elbow PoP slab with the [17]elbow in flexion, whereas the flexion type (less common) of the fracture is immobilized with the elbow in extension. In either case, the plaster is removed after 3 weeks.

• Traction: The cases which report late (more than one week) with marked [18]swelling and blisters etc. are treated by continuous (Dunlop) traction for 3 weeks. • Open reduction: Open reduction of the fracture is indicated when: • The closed manipulation fails, • The brachial artery is injured and needs exploration, and • There is an associated nerve palsy which needs exploration. • After open reduction the fracture fragments are fixed internally with Kirschner wires-(commonly called K-wires) Early complications

These complications occur at the time of injury immediately after. 1. Injury to the brachial artery: This is the most dreaded complication; the brachial artery is injured by the sharp edge of the proximal fragment. The artery may actually be lacerated, thrombosed or may just go into spasm. The blood supply to the[19] flexor muscles of the forearm may be affected resulting into Volkmann’s ischaemia. This requires immediate[20] treatment.

Volkmann’s ischemia: Injury to the brachial artery leads to impairment of circulation to the forearm and hand. There occurs ischemia of the deeper muscles of the flexor compartment of the [21]forearm, such as flexor pollicis longus and flexor digitorum profundus. The muscle ischemia, in turn, leads to compartment syndrome.



• There is severe, sudden increase in pain in the forearm • Stretch pain. There is [22]severe pain in the flexor aspect of the forearm when the fingers are passively extended. This is the most important test and is pathognomonic of muscle ischaemia.

Treatment: The case of Volkmann’s ischaemia must be handled as an absolute [23]emergency because changes may soon become irreversible.

• Remove tight bandage/splints/plasters etc. immediately. • The forearm is elevated and hot bottles are applied to the other three limbs to promote general vasodilation. • If no improvement occurs within 2 hours, the operation of [24]fasciotomy is undertaken, if the flexor compartment is tight. In this operation an incision is made from skin down to the deep fascia to decompress the compartment. • If the injury to the brachial artery is established by angiography/Doppler, exploration of the brachial artery is undertaken. 2. Injury to the nerves: Median, radial and ulnar nerves may be injured, in that order. In majority of the cases the nerve palsy recovers spontaneously.

Late complications

• Malunion: Malunion is the most common complication of [25]supracondylar fracture of the humerus and results in a cubitus varus deformity. This deformity occurs if the fracture has been allowed to unite with appreciable medial and internal rotation of the distal fragment. • Treatment: If the deformity is unacceptable cosmetically, a corrective osteotomy in the supracondylar area is performed (French osteotomy). • Myositis ossificans: Myositis ossificans is ectopic new bone formation around the elbow. This is a common complication which occurs following massage to the elbow after the injury and results in [26]stiffness of the elbow. 35

Treatment: In the acute painful stage, the elbow is immobilized in an above-elbow plaster slab for about 3 weeks. Otherwise, the main treatment is mobilization of the elbow, despite some pain. Volkmann’s ischaemia contracture (VIC): Volkmann’s ischaemia, if not treated in time, gradually progresses to Volkmann’s ischaemia contracture.

The ischemic muscles are gradually replaced by fibrous tissue, which contracts and draws the wrist and fingers into flexion. If the [27]peripheral nerves are also damaged by ischaemia, there will be sensory and motor paralysis in the forearm and hand.

Diagnosis: There is marked atrophy of the forearm muscles. There is the characteristic deformity of flexion of the wrist and fingers.

Volkmann’s sign: This sign is characteristic of VIC where the fingers cannot be fully extended passively with the wrist extended: but when the [28]wrist flexed, the fingers can be fully extended passively. This happens because the shortened/contracted flexor muscle-tendon units do not permit full extension of the fingers and wrist simultaneously.

Treatment: In established cases to normal is impossible because irreversible damage has occurred to the import and nerves. However, reconstructive [29]surgery can only improve some function of the hand.

• Mild cases can be treated by: (i) Stretching exercises by a [30]physiotherapist and also by the use of

(ii) Turnbuckle splint which gradually stretches the contracted muscles.

• Moderate cases require a muscle slide surgical operation where the flexor group of the muscles is released from their origin from the[31] medial epicondyle of the humerus and ulna. • Severe cases can be treated by shortening of the forearm bones, proximal row carpectomy and wrist arthrodesis etc. Considerations

Even after the[32] fracture has healed, full motion of the elbow may not be possible. In most of these cases, the patient cannot fully straighten his or her arm. Typically, loss of a few degrees of straightening will not 36

have an impact on how well the arm will work in the future, including for sports or heavy labor. So treat your problem of [33]Elbow Injury with Physical Therapy. [34]Physical Therapy is the best treatment for the Elbow Injury.

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Dave (2012-03-27 04:38:56) Good and knowledge article. Keep continue on it. Thanks


Archillies Region - Types,Causes & Treatment (2012-03-23 13:05) [1]Achilles is a common overuse [2]injury that occurs in people of all fitness levels. The causes can be variable, but one factor that seems to be consistent with all cases is stress to the gastroc and soleus [3]muscles in the calf region with irritation and loading at the tendon insertion at the heel bone. This stress may be a result of continued forces placed through the tendon structure from activities ranging from standing, walking, [4]exercise, to recreational activity or sport.

[5] History The [6]athlete with overuse tendinopathy not ices a gradual development of symptoms and typically complains of [7]pain and morning stiffness after increasing activity level. Pain diminishes with walking about or applying heat (e.g. a hot shower). 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 [8]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 [9]tendinopathy are identical. We do not emphasize the distinction other than to suggest that time to recovery may be longer in cases of [10]partial tear. A history of a sudden, severe pain in the [11]Achilles region with marked disability suggests a complete rupture. Types of Achilles Midportion Achilles tendinopathy It is important to distinguish between [12]midportion and insertional Achilles tendinopathy as they differ in their [13]prognosis and response to treatment. We briefly review the pathology of Achilles tendinopathy, list expert opinion of the factors that pre dispose to [14]injury, and summarize the clinical features of the condition. The subsequent section details the [15]treatment of midportion tendinopathy. 38

Treatment of Midportion Archillies [16]Archillies tendinopathy Level 2 evidence -based treatments for Achilles tendinopathy include heel-drop exercises, nitric oxide donor therapy (glyceryl trinitrate [GTN] patches), sclerosing injections and micro current [17]therapy (see below), In addition, experienced clinicians begin conservative treatment by identifying and correcting possible etiological factors. This may include relative rest, orthotic [18]treatment (heel lift, change of shoes, corrections of malalignment) and stretching of tight muscles. Whether these ’commonsense’ interventions contribute to outcome is unlikely to be tested. The sequence of management options may need to vary in special cases such as the elite [19]athlete, the person with acute tendon pain unable to fully bear weight, or the elderly patient who may be unable to complete the heel-drops. As always, the clinician should respond to individual patient needs and modify the sequence appropriately. Insertional Achilles tendinopathy, retrocalcaneal bursitis and Haglund’s disease These three [20]’diagnoses’ are discussed together as they are intimately related in pathogenesis and clinical presentation. Relevant anatomy and pathogenesis The [21]Achilles tendon insertion, the fibro cartilaginous walls of the retrocalcaneal bursa that extend into the tendon and the adjacent calcaneum form an ’enthesis organ’. The key concept is at this site the tendon insertion, the bursa and the bone are so intimately related that a prominence of the calcaneum will greatly predispose to [22]mechanical irritation of the burs a and the [23]tendon. Also, there is significant strain on the tendon insertion on the posterior aspect of the tendon. This then leads to a change in the nature of those tissues, consistent with the biological process of [24]mechanotransduction. Treatment [25]Treatment must consider the enthesis organ as a unit, isolated treatment of insertional Tendinopathy is generally unsuccessful. For example, Alfredson’s pain, full heel-drop protocol (very effective in midportion, tendinopathy) only achieved good clinical results in approximately 30 %ofcases of insertional tendinopathy. Patients with more than two years of [26]chronic insertional tendinopathy, sclerosing of local neo vessels with polidocanol cured eight patients at eight -month follow-up. Other Causes of pain in the Achilles region [27]Achilles bursitis is generally caused by excessive friction, such as by heel tabs, or by wearing shoes that are too tight or too large. Various types of rather stiff boots (e.g. in skating, cricket bowling) can cause such friction, and the pressure can often be relieved by using a punch to widen the [28]heel of the boot and providing ’donut’ protection to the area of bursitis as it resolves. Referred pain to this region from the [29]lumbar spine or associated neural structures is unusual and always warrants consideration in challenging cases. Clinical perspective [30]Acute tendon rupture is most common among men aged 30- 50 years (mean age, 40 years); it causes sudden severe disability. Overuse Achilles tendon injuries-tendinopathy may arise with increased training volume or intensity but may also arise insidiously. Because the prognosis for [31]midportion Achilles tendinopathy is much better than for insertion tendinopathy, these conditions should be distinguished clinically. Most textbooks suggest that rupturelim its active plantar flexion of the affected leg- but beware, 39

the patient can often [32]plantarflex using an intact [33]plantar is and the long toe flexors. The condition that was previously called ’Achilles tendinitis’ is not truly an inflammatory condition and, thus, should be referred to as [34]’Achilles tendinopathy” pathology that underlies the common tendinopathy. Whether you [35]treat an Achilles tendon rupture with surgery or use a cast, splint, brace, walking boot, or other device to keep your lower leg from moving (immobilizing your leg), after treatment it’s important to follow the [36]rehabilitation program prescribed by your doctor and [37]physical therapist. This program helps your tendon heal and prevents further injury. [38] 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

aspx 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38.




Ankle Fractures (2012-04-07 11:49) [1]Broken Ankle (Ankle Fracture) - Types, Treatments, Complications [2]Ankle [3]fractures are the fractures involving the distal end of tibia and fibula. Ankle fractures are [4]common injuries and can vary from a stable fracture to a complex, unstable fracture dislocation.

Mechanism of Injury: [5]Fractures of the ankle can result from low-or high-energy forces. forces may be caused by one of the following mechanisms:

Fractures due to low-energy

1. Rotational stresses to the ankle caused by twisting forces at the[6] ankle joint while walking, running etc. This is the most common mode of injury. 2. Axial stress on the ankle joint results in[7] fracture involving tibial plafond The high-energy forces, such as road traffic accidents, cause severe injuries, usually[8] fracture dislocations. The pattern of [9]ankle injury depends upon a combination of: (i) The position of the foot at the time of injury (ii) The deforming force. The position of the foot at the time of injury can be supination or pronation and is described first. The deforming force, which can be adduction, abduction, external rotation and vertical loading; is described next. Twisting force produces external rotation. Fall to one side produces adduction or [10]abduction injury. The four most common deforming forces are: supination/external rotation, pronation/external rotation, supination/adduction and pronation/abduction. Classifications of Ankle Fractures Lauge-Hansen classified the [11]ankle fractures based on the pathogenesis or the deforming force (i.e. the mechanism of injury). This classification helps in the manipulative reduction of the fracture, if the displacement is understood correctly. The first part of the classification specifies the position of foot during injury and second part of the title specifies the deforming force, for example: 1. Supination-external rotation injury (most common mechanism of injury) 2. Supination-adduction injury 3. Pronation-external rotation injury 4. Pronation-abduction injury 5. Vertical-compression injuries. 41

However, there is another classification by Danis and Weber which is relatively simple. Modified Danis-Weber classification: This is based upon the level of fibular fracture and is purely a radiological classification. In this classification, the fibula is considered as the key to the [12]ankle stability. The higher the fibular fracture, the more extensive is the damage to the tibiofibular ligaments and thus greater the instability of the ankle mortise.

Type A: Fibular fractures below the level of inferior tibiofibular syndesmosis Fibula: Transverse avulsion fracture at or below the level of ankle joint: or rupture of the lateral ligament complex. Medial malleolus: Intact or sheared, with almost a vertical fracture. Posterior malleolus: As a rule intact. Syndesmosis (Tibiofibular ligament complex): Always intact.

Type B: Fractures at the level of inferior tibiofibular fibular syndesmosis. Fibula: Oblique fracture of the fibula at the level of the ankle joint. Medial malleolus: Avulsion fracture (fracture line horizontal) or rupture of the deltoid ligament. Posterior malleolus: Either intact or sheared off as a posterior lateral fragment. Syndesmosis: Usually, intact or partial rupture.

Type C: Suprasyndesmotic fibular fractures unstable injury. Fibula: Shaft fracture anywhere between the syndesmosis and the head of fibula. Medial malleolus: Avulsion fracture or rupture of the deltoid ligament. Posterior malleolus: Either intact or pulled off. Syndesmosis: Always disrupted. Clinical Features: The[13] patient typically present s with a twisting injury to the foot following which they com plain of inability to bear weight, pain around the ankle and very often[14] swelling around the ankle. Clinically the stability of the ankle joint must be tested by valgus and varus stress under anesthesia. 42

Associated injury to the tendons and the neurovascular bundles, which run in close vicinity to the joint, has to be ruled out. The state of the skin must be checked. The skin over the deformed ankle may get unduly stretched, resulting into necrosis, if not reduced immediately. Radiological Features Antero posterior, lateral and mortise view must be taken to define the exact[15] fracture pattern. Management The ankle fractures must be reduced accurately. Since ankle is a major weight joint, any incongruity of the articular surface, or tilt or disruption of the ankle mortise can lead to early [16]osteoarthritis. The aim of the treatment in ankle fractures therefore is: 1. Anatomical positioning of the talus. 2. To obtain a smooth articular alignment of the ankle mortise. For management and prognosis, ankle fractures may be grouped into stable and unstable fractures, depending upon the position and the talus, and its instability on light stress. This classification is of importance in treatment and prognosis. Conservative treatment Conservative[17] treatment is suggested in treating stable fractures viz. isolated fibular fractures without a medial side injury. These fractures can be treated by below-knee plaster casts for 4-6 weeks followed by graduated weight bearing In unstable fractures with displaced talus closed reduction is achieved by manipulating talus under anesthesia and protecting it with above knee plaster cast for 4-6 weeks. Open reduction and fixation: This is advocated in unstable injuries and in those injuries where the [18]ankle joint is not properly aligned. Internal fixation is achieved by 1. Tension band wiring 2. Malleola screws 3. Plate and screw fixation for lateral malleolus. Complications Major injuries of the ankle may be associated with the following complications: 1. Non union: Neglected fracture of the medial malleolus may go into nonunion. reduction of the [19]fracture and the ankle mortise may be difficult impossible.

In old injuries

2.[20] Stiffness of the ankle. 3. Osteoarthritis: If the fracture has not been treated properly leading to incongruity of the articu43

lar surface, early osteoarthritis may set in. The patient has[21] chronic pain and [22]swelling of the ankle necessitating ankle arthrodesis.

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Sports Injuries (2012-05-08 11:26) Sports Injuries and Its Classifications: INTRODUCTION: [1]Sports medicine, like all other branches of medicine, aims at the complete physical, mental and spiritual well-being of a sportsperson. A healthy mind in a healthy body is a concept, which is more true to a sportsperson than anybody else is. Positive thinking, fair play and sportsmanship should be the hallmark of a true sportsman. We, the doctors and the[2] therapists, aim to keep a sportsperson physically fit so that the rest of the objectives mentioned above are attained automatically. 44

Like in other branches of medicine so in sports medicine, prevention is better than cure. To prevent sports injuries, the first step is to ascertain whether a person choosing sports is fit to take it. An unfit person taking up sports is a sure prescription for future[3] sports injuries. A fitness testing for those who wish to take up sports, as their career should include various relevant parameters However, one has to remember that [4]fitness testing is not done only at the initial stages but needs to be done repeatedly at every stage of an athlete or a sportsperson’s life. The second stage of prevention of sports-related injuries is assessing whether a sportsman is fit enough to resume the sporting activity after the initial layoff. There is nothing more dangerous than an unfit or partially fit person resuming the sporting activity. It may spell a doom to his otherwise flourishing career in sports. A[5] sportsperson has to satisfy certain norms before he can finally be sent back to the field. CLASSIFICATION OF SPORTS INJURIES Among the various classifications proposed for sports injuries, the one proposed by Williams (1971) is widely used and recommended. Williams’ Classification:



Among the Consequential Injuries Primary Extrinsic

• This is further subdivided into: • Human: Black eye due to direct blow. • Implemental: May be incidental (as in blow from a hard ball) or due to overuse (blisters from oars). • Vehicular: Clavicle fracture due to fall from cycle, etc. • Environmental: Injuries in divers. • Occupational: Jumper’s knee in athletes, chondromalacia in cyclists, etc Primary Intrinsic This could be acute or chronic.

• Incidental: Strains, sprains, etc. • Overuse: 1. Acute, e.g. acute tenosynovitis of wrist extensors in canoeists. 2. Chronic, march fracture in soldiers, etc. Secondary Short-term: For example, quadriceps weakness. Long-term: Degenerative [7]arthritis of the hip, knee, ankle, etc. No Consequential Injuries These are not related to sports but are due to injuries either at home or elsewhere and are very not connected to any sports (e.g. slip and fall at home). COMMON SPORTS INJURIES [8]Sports medicine usually deals with minor orthopedic problems like soft tissue trauma. Very rarely, there may be serious fractures, head injuries or on the field deaths. There is nothing unusual about these 46

injuries except that a sportsperson demands a 100 percent cure and recovery while an ordinary person is satisfied and happy with a 60-80 percent recovery. The difference is because of the desire of the sports person to get back to the sport again, which requires total fitness. The following are some of the most common sports -related injuries one encounters in clinical practice.


Upper Limbs 47

• Shoulder complex 1. [10]Rotator cuff injuries 2. Shoulder dislocations 3. Fracture clavicle 4. Acromioclavicular injuries 5. Bicipital tendinitis or rupture. • Elbow 1. Tennis elbow 2. Golfer’s elbow 3. Dislocation of elbow. • Wrist 1. [11]Wrist pain 2. [12]Carpal tunnel syndrome • Hand 1. Mallet injury 2. Baseball finger 3. Jersey thumb 4. Injuries to the finger joints. Lower Limb

• Hip 1. Iliotibial or tract syndrome 2. Quadriceps strain 3. [13]Hip pain 4. Groin pain due to adductor strain • Knee Joint 48

1. Jumpers Knee 2. Chondromalacia 3. Fracture patella 4. Knee ligament injuries 5. Meniscal injuries. • Legs 1. Calf muscle strain 2. Hamstrings sprain 3. Stress fracture tibia 4. Compartmental syndrome of the leg. • Ankle Injuries 1. [14]Ankle sprain 2. Injuries to Tendo-Achilles 3. Tenosynovitis. • Foot 1. March fracture 2. Jones fracture 3. Forefoot injuries 4. Injuries of sesamoid bone of the great toe. • Head, Neck, Trunk and Spine 1. Head injuries 2. Whiplash injuries 3. Rib fractures 4. Trunk muscle strains 5. Abdomen muscle strain 6. Low backache 49

All these injuries have been discussed in relevant sections. Investigations These are the same as for any ortbopedic-resared disorders and consist of plain X-ray, CT scan, bone scan, MRI, arthroscopy, arthrography, stress X-rays etc. TREATMENT OF SPORTS INJURY This is discussed under three headings prevention, treatment proper and training. Preventive Measures The best way to treat a sports injury is to prevent it from happening. Nothing is better than preventing the injury. Treatment Treatment of individual [15]sports-related disorders is discussed under suitable sections. However, a mention is made here of the general principles of treatment which is applicable to all sports injuries. General Principles • Concept of RICEMM: This sums up the early treatment methodology of sports injuries and consists of: R-Rest to the injured limb I-Ice therapy C-Compression bandaging E- Elevation of the injured part M- Medicines like painkiller s, etc. M- Modalities like heat, straps, supports, etc. • After immobilization and rest, early vigorous exercises should be commenced at the earliest to prevent muscle weakness and atrophy. • To prevent[16] joint stiffness, early mobilization ha s to be done first by passive movements and later by active movements. To improve the strength, resistive exercises are added. • Unlike the conventional once a day treatment, a sportsperson needs to be seen at least 2-3 times a day. • As mentioned earlier, allow resumption of sporting activity only after the sportsperson assumes 100 percent[17] fitness. • Mind training is as important as physical training. By repeated counseling, improve the psychological status of the patient to avoid depression, anxiety and negative attitudes, which may develop during the injury. 50

• Orthopedic and surgical treatment to be undertaken at appropriate situations. Training The physiotherapist has to train a sportsperson in various exercises to enable him to keep his fitness level very high. After conducting a fitness testing, the[18] therapist has to subject an athlete to various forms of exercises to increase the endurance, strength, running, weight bearing, etc. The following are the various forms of exercises. Measures of Relaxation After the vigorous workout mentioned above, the sportspersons are taught methods of relaxation and body stretches. Before an athlete or a sportsperson resumes his sporting activities, a fitness testing is carried out and only then, he is allowed to take to the sports provided he is 100 percent fit. 1. 2. 3. 4. 5. 6. 7. 8. 9. jpg 10. 11. 12. 13. 14. 15. 16. 17. 18.

Stress Fracture (2012-05-30 12:03) How Physical Therapy Treatment Works With Bone Injury [1]Stress fractures, a common [2]injury among sportspeople, were first reported in military recruits in the 19th century. A stress fracture is a [3]microfracture in bone that results from repetitive physical loading below the single cycle failure threshold. Overload stress can be applied to bone through two mechanisms: 1. The redistribution of impact forces resulting in increased stress at local points in[4] bone. 2. The action of [5]muscle pull across bone. Histological changes resulting from [6]bone stress occur along a continuum beginning with [7]vascular congestion and thrombosis. This is followed by osteoclastic and osteoblastic activity leading to rarefactio , 51

weakened trabeculae and microfracture and ending in complete fracture. This sequence of events can be interrupted at any point in the[8] continuum if the process is recognized. Similarly ,the process of [9]bony remodeling and stress fracture in athletes is recognized as occurring along a clinical continuum with [10]pain or radiographic changes presenting identificable markers along the continuum. Since radioisotopic imaging and MRI can detect changes in bone at the phase of accelerated remodeling, these investigations can show [11]stress-induced bony changes in the continuum. Stress fractures may occur in virtually any bone in the body. The most commonly [12]affected bones are the tibia, metatarsals, fibula, tarsal navicular, femur and pelvis. A list of sites of stress fractures and the likely associated sports or activities . The diagnostic features of a [13]stress fracture. It is important to note that a, [14]bone scan although a routine investigation for stress fractures, is non-specific, and other [15]bony abnormalities such as[16] tumors and osteomyelitis may cause similar pictures. It may also be difficult to localize the site of the area of increased uptake precisely, especially in an area such as the foot where numerous [17]small bones are in close proximity. [18]Diagnostic Features 1. Localized pain and tenderness over the [19]fracture site. 2. A history of a recent change in training or taking up a new activity. 3. X-ray appearance is often normal or there may be a [20]periosteal reaction. 4. Abnormal appearance on radioistopic bone scan (scintigraphy), CT scan or MRI. MRI is being increasingly advocated as the investigation of choice for stress fractures. Even though MRI does not image fractures as clearly as do computed tomography (CT) scans, it is of comparable sensitivity to radioisotopic bone scans in assessing bony damage. The typical MRI appearance of a stress fracture show [21]speriosteal and marrow edema plus or minus the actual fracture line. The [22]treatment of stress fractures generally requires avoidance of the precipitating activity. The majority of stress fractures heal within six weeks of beginning relative rest. [23]Healing is assessed clinically by the absence of local tenderness and functionally by the ability to perform the precipitating activity without pain. It is not useful to attempt to monitor healing with X-ray or radioistopic bone scan. CT scan appearances of healing stress fractures can be deceptive as in some cases the fracture is still visible well after clinical healing has occurred. The return to spot after [24]clinical healing of a stress fracture should be a gradual process to enable the bone to adapt to an increased load. An essential component of the management of an over use injury is identification and modification of risk factors. There are, however, a number of sites of stress fractures in which delayed union or non-union of the fracture commonly occurs. These fractures need to be treated more aggressively. The sites of these fractures and the recommended treatment. 1. 2. 3. http://http// 4.

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Treatment of Lumbar Disk Disease and Spinal Canal Stenosis (2012-06-12 08:59) Do you want to get relief of your Lower Back Pain ? SPINAL CANAL STENOSIS [1]Spinal canal stenosis is narrowing of the spinal canal and the consequent compression of the cord and the nerve roots. It may affect the [2]cervical thoracic or lumbar spine. [3]Canal stenosis is common in[4] lumbar vertebrae. One or more roots of the cauda equina may be affected due to the constriction in spinal canal before it exits through the foramen. This condition was first described by Portal in 1803. LUMBAR CANAL STENOSIS [5]Lumbar canal stenosis is a cauda equina compression in which the lateral or anteroposterior diameter of the spinal canal is narrow with or without a change in the cross-sectional area. The [6]nerve root canals and the IV foramen may also be narrowed. Patient may present with [7]low backache, neurological symptoms in the [8]lower limbs and bladder, bowel dysfunctions in extreme cases CLASSIFICATION

1. Generalized/localized 2. Segmental (local area of each vertebral spinal segment is affected). 53

• Central • Lateral Recesses • Foraminal • Far Out 1. Anatomical area: • Cervical (seen) • Thoracic(rare) • Lumbar (most common) CAUSES 1. Pathological:

• Congenital , For Example. Achondroplasia • Acquired- degenerstive , iatrogenic, and spondylitic. 2. Other Causes:

• Paget’s Disease • Flurosis • Kyphosis • Scoliosis • Fracture Spine • DISH (Diffuse idiopathic skeletal hyperostosis) syndrome. 3. Latrogenic causes ,For Example, hypertrophy of posterior bone graft, incomplete treatment of stenotic condition, etc. Degenerative [9]lumbar disk disease leading to thickening and narrowing of the spinal canal is the most common cause. CLINICAL FEATURES [10]Lumbar canal stenosis is common in males above 50 years. Usually, the symptoms are fewer in number, but the patient may complain of low backache. Cauda equina claudication is the common symptom. Here, the patient complains of pain in the buttocks and legs after walking, which decreases sitting, rest and forward bending. Patient may complain of 54

[11]hypoesthesia and [12]paresthesia. Usually, the patient finds no problem walking uphill or riding a bicycle. Nerve root entrapment in the lateral recess causes claudication and sciatica. INVESTIGATIONS Radiographs of the [13]lumbar spine consisting of AP, lateral and oblique views are recommended. However radiology may not show stenosis. The following points are looked for:

• Reduced interpedicle distance. • AP or midsagittal diameter of the affected vertebra (Normal-15 mm), absolute midsagittal diameter of the canal is decreased. • Measurement of the lateral sagittal diameter. • Hypertrophy and sclerosis of the facet joints. • Reduced interlaminar space and short, stout spinous process. • Associated features like presence of [14]listhesis, prolapsed disk, [15]osteophytes, etc. TREATMENT Conservative Methods This aims at symptomatic relief of [16]pain.

• Drug therapy like the NSAIDs, etc. • Epidural steroids may help in some cases. • Physiotherapy with heating modalities helps. • Pelvic traction may help relieve compression. • Exercises: General conditioning exercises like walking, swimming and flexion-oriented exercises are useful. • Deweighted Treadmill Ambulation: This consists of applying vertical traction with a harness while doing the treadmill exercises. This offers twin benefits of both exercises and traction. • Belts and corsets (soft): These may offer some relief. Surgical Methods Most of the [17]surgical methods described for lumbar canal stenosis aim at decompressing the constricted lumbar canal. Laminectomy is useful in central canal stenosis. Diskectomy and osteotomy of inferior articular process to remove the hypertrophic elements help. For lateral canal stenosis laminotomy, disk excision, partial medial facetectomy and foraminotomy help. [18]Spinal fusion to stabilize the [19]lumbar spine is usually not required as instability is less commonly seen in lumbar canal stenosis. 55

It should be noted that neurogenic claudication responds poorly to the conservative treatment but responds well to surgical decompression. 1. 2. http://http// 3.

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Programs-Physical-Therapy-Orthopedic-Neurological-Hand-Therapy.aspx 9. http://http// 10.


Programs-Physical-Therapy-Orthopedic-Neurological-Hand-Therapy.aspx 11. http://http// 12.


Programs-Physical-Therapy-Orthopedic-Neurological-Hand-Therapy.aspx 13. http://http// 14. http://http// 15.


Programs-Physical-Therapy-Orthopedic-Neurological-Hand-Therapy.aspx 16. http://http// 17. 18. http://http// 19. http://http//

Distal Forearm Fractures (2012-06-21 10:34) Treatment of Hand and Wrist Fracture: [1]Colles’ Fracture This is also called as Poutteau’s fracture in many parts of the world. scribed in the year 1814.

Abraham Colles first de-

Definition It is not just [2]fracture lower end of radius but a fracture dislocation of the inferior [3]radioulnar joint. The fracture occurs about 11/2” (about 2.5 cm) above the carpal extremity of the radius. Following this fracture, some deformity will remain throughout the life but [4]pain decreases and movements increase gradually. Mechanism of Injury 56

The common mode of [5]injury is fall on an outstretched hand with dorsiflexion ranging from 40900 .The force required to cause this fracture is 192 kg in women and 282 kg in men. Fracture pattern: It is usually sharp on the palmar aspect and comminution on the dorsal surface of the [6]lower end of radius. Clinical Features Usually, the patient is an elderly female in her 60s and the history given is a trivial fall on an outstretched hand. The patient complains of pain, [7]swelling, deformity and other usual features of fracture at the lower end of radius. Though dinner fork deformity is a classical deformity in a Colles’ fracture, however, it is not found in all cases but seen only if there is a dorsal tilt or rotation of [8]Colles’ Fracture. Styloid Process Test Normally, the[9] radial styloid process is lower by 1.3cm when compared to the ulnar styloid process. In Cones’ both radial and ulnar styloid processes are at the same level and are found in all displacements of Colles’ fracture. Hence, this is a more reliable sign than dinner fork deformity. Radiology Radiographs of the wrist both AP and lateral views of the affected [10]wrist and lower end of the radius are taken. The Points noted in the AP view are metaphyseal comminution, fracture line extending into the radiocarpal or inferior radioulnar joint and fracture of the [11]ulnar styloid process (seen in about 60 % of the cases). In the lateral view, the points noted are dorsal displacement and dorsal tilt of the distal fragment, sharp palmar surface and dorsal comminution of the lower end of radius, distal radioulnar joint subluxation, etc. Classification Contrary to popular belief, Colles’ fracture is both intra-articular and extra-articular and not only [12]extra-articular. Frykmann’s classification takes into consideration both and the fracture of [13]ulna. Treatment Methods Aim: The aim of treatment is to restore fully functional [14]hand with no residual deformity. treatment methods include Conservative methods, Operative methods and External fixators.


Conservative Methods Here fracture reduction is carried out by closed methods under general anesthesia (GA) or local anesthesia (LA). The examiner holds the hand of the patient as if to shake hand. With an assistant giving counteraction by holding the[15] forearm or arm of the patient, the examiner gives traction in the line of the forearm. This disimpacts the fracture and the examiner corrects the other displacements of the fracture. At the end of the procedure, styloid process test is carried out to check the accuracy of reduction. If the level of the styloid processes is restored back to normal, it indicates that the reduction has been achieved satisfactorily. Then the limb is immobilized by any one of the methods in the table above (mainly Cones’ cast) and a check radiograph is taken. The plaster cast is removed after 6-’8 weeks and [16]physiotherapy is begun. 57

The common causes for failure of reduction are incomplete reduction of the palmar fracture line and dorsal comminution of the lower end of radius. Operative methods Operative treatment is rarely required for Colles’ fracture and may be required in the following situations: Indications: Extensive comminution, impaction, median nerve entrapment and associated injuries in adults. Modalities of operative treatment: Depending upon the degree of comminution and the intra-articular extensions, one of the following [17]surgical methods is chosen: Closed reduction and percutaneous pinning with K-wires: Here, after closed reduction by the usual methods the fracture fragments are held together by percutaneous pinning by one or two K-wires. Arm control: This method is known to prevent collapse and gives good results in a few select cases. Open reduction: in certain fractures involving of the distal articular surfaces (Bartons variety open reduction and [18]plate fixation (Ellis’ plate) is advocated. Indications: Same as for external fixation and for marginal volar or dorsal Barton’s fractures. Advantages

• Provides buttress • Resists compression • Load sharing • Early mobilization External fixators These are found to be extremely useful in highly comminuted fractures, unstable fractures , compound fractures and bilateral Colles’ fracture. Through a lightweight UMEX frames, two pins are placed in the [19]forearm bones and two pins in the metacarpal [20]bones of the hand. These pins are then fixed to an external frame and the fracture fragments are held in position by ligamentotaxis. The frame should be applied after obtaining closed reduction by the usual method. Complications The important complications of Colles’ fracture are listed in. Few significant complications are discussed here.

• Malunion: This is the most common complication of Colles’ fracture. Six important causes are responsible for it. 58

• Improper reduction: If the fracture is not reduced properly, in the initial stages it may result in mal-union later. • Improper and inadequate immobilization: This fracture needs to be immobilized at least for a period of six weeks failing which malunion results. • Comminuted dorsal surface: Due to extensive comminution, the [21]fracture collapses and recurs after reduction and casting. • [22]Osteoporosis may lead to collapse and recurrence. • Recurrence: This is due to extensive comminution and osteoporosis. • Rupture of the distal radioulnar ligament: This usually goes undetected in the initial stages of [23]treatment and is responsible for the later recurrence. Treatment There are six options of treatment in a malunited Colles’ fracture:

• No treatment is required if the patient has no functional abnormality. • Remanipulation is attempted if [24]fracture is less than 2 weeks old. • Darrach’s operation is more often indicated if the patient complains of functional disability. • Corrective osteotomy and grafting if the patient wants cosmetic correction and if the patient is young (Fernandez and Campbell). Fernandez is a dorsal wedge osteotomy and Campbell is a lateral wedge osteotomy. • Arthrodesis (for intra-articular fracture): The patient complains of pain in the [25]wrist joint due to traumatic osteoarthritis following an intra-articular fracture. In these patients, [26]arthrodesis of the wrist in functional position is the surgery of choice. • Combination of these like Darrach’s operation with osteotomy, etc. is also tried in some situations. Rupture of extensor pollicis tendon: This occurs due to the attrition of the tendon as it glides over the sharp fracture surfaces. This usually occurs after 4-6 weeks and may be repaired or left alone with no residual disability. Sudeck’s osteodystrophy: This is due to abnormal sympathetic response, which causes vasodilatation and osteoporosis at the fracture site. The patient complains of pain, swelling, [27]painful wrist movements and red-stretched shiny skin. Treatment consists of immobilization of the affected part with plaster splints, injection of local anesthetics near the sympathetic ganglion in the axilla or [28]cervical sympathectomy in extreme cases. Frozen hand shoulder syndrome: This is a troublesome complication, which develops due to unnecessary voluntary [29]shoulder immobilization by the patient on the affected side for fear of fracture displacements. It is said that the patient has performed a mental amputation and kept the [30]limb still. Carpal tunnel syndrome: Malunion of Colles’ fracture crowds the carpal tunnel and compresses the [31]median nerve. 59

Nonunion: This is extremely rare in Colles’ fracture because of the cancellous nature of the [32]bone, which enables the fracture to unite well. However, [33]soft tissue interposition may cause this problem. The [34]treatment consists of open reduction, rigid internal fixation and bone grafting.

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Disorders of the Hand (2012-06-22 11:58) Symptoms And Treatment of Hands Infection: [1]Hand is a very important organ of the body. Disorders affecting the hand could lead to loss of hand function in various forms and degrees. Thumb itself accounts for over 40 percent function of the hand. It is imperative that the problems affecting the hand should be diagnosed and managed correctly. The following are the various disorders affecting the hand. CONGENITAL ANOMALIES OF THE HAND: Some of the important [2]congenital anomalies of the hand are: Polydactyly: purposes.

It is a duplication of one or more digits and may require amputation for cosmetic

Syndactyly: This is fusion of digits and usually occurs between the middle and ring [3]fingers and is 3 times more common in males.The fusion may be only in the skin or all the structures. In the latter case, [4]surgery is done early at 18 months age and in the less severe former case, surgery is done after 5 years. Macrodactyly: This is a rare congenital anomaly and is characterized by enlargement of all structures especially of the [5]nerves of a single or more digits. It is often associated with neurofibromatosis, lymph-angioma, arteriovenous malformation, etc. Congenital trigger digits: [6]Thumb is more commonly involved. It is frequently bilateral and is due to flexion contracture of the [7]distal joint of the thumb. More than 30 percent of these cases resolve after first year and the remaining may require surgical release after 2 years of age. Streeter’s dysplasia: This is a syndrome of congenital constrictions, which may affect any part of the body. In the[8] hand, it may range from simple constriction to congenital amputation. To prevent distal circulatory compromise, it frequently requires surgical release by Z-plasty. Camptodactyly: This is a flexion contracture of the proximal interphalangeal joint especially of the little finger. It may rarely be seen in other [9]fingers too. Severe deformity in older patients requires tendon lengthening procedures. Clinicodactyly is angulation of the finger in radioulnar direction. Mild clinicodactyly is seen in normal children, while the severe ones are associated with mental retardation. Cleft hand (also called Lobster claw hand): This is frequently bilateral and is associated with [10]cleft foot, [11]cleft lip, cleft palate, etc. There are two varieties: in the first type, a deep palmar cleft separates the two central metacarpals; and in the second type, the central rays are absent .Both the varieties require surgical excision and Z- plasty. Mirror Hand (reduplication of ulna): Here the [12]ulna and [13]carpus are reduplicated and there may be seven or eight fingers with no thumb. Pollicisation of a finger solves the problem of the absent thumb. Congenital absence of radius or ulna: Congenital absence of radius is more common than that of ulna. The radius may be completely absent or in parts. The [14]forearm is short, wrist is highly unstable and the hand is deviated radially. It requires complex and difficult surgical corrections. This deformity of radius absence is also called radial club hand and the absence of ulna is called the [15]ulnar club hand. 61

Kirner’s deformity: This is a spontaneous injuring of the terminal [16]phalanx of the fifth digit. is a rare disorder and is more often seen in females.


Infections of the Hand The effects of hand infection can be as devastating as major [17]trauma. Trivial injuries like a scratch, a prick, small punctured wounds, etc. cause [18]hand infections. Staphylococcus aureus (80 %) ,Streptococcus pyogenes and gram-negative bacilli are the famous trio who inflict the infective unmitigated disaster in the hand. The sequelae of these infections are edema, abscess, necrosis, fibrosis and lastly contractions leading to a grotesque, debilitating hand. The presence of an abscess seems to send a message to the surgeons, ”Drain me I’ll drain Myself! ” Hence, an abscess caused should be drained; the surgeon only has to decide the proper time and incisions. Early use of potent antibiotics has considerably downed the threat of serious hand infections. Treatment As elsewhere before we delve into the discussions on individual hand infections, it helps considerably to know the principles of [19]treatment:

• Hands should be kept elevated to facilitate gravity to drain and thereby prevent edema and [20]swelling of the hand. • Following the treatment, the hand needs to be placed in functional position for optimum results. • Early and appropriate use of IV antibiotics prevents pus formation (within 24-48 hours). • If pus is formed, let it out through proper incisions at the appropriate time. • Local anesthetic may help the spread of [21]infection and adds more fluid to the already existing swelling. Hence, general anesthesia or regional block is preferred. • Tourniquet is indicated, but exsanguinations are not preferred as it helps spread the infection (alternatively, elevation of hand for three minutes is ideal). • Do not forget the all important hand aftercare, which has a direct bearing on the outcome of the hand function. With the principles of treatment as a backdrop, let us now consider the important [22]hand infections in order of importance. 1. 2. 3. 4.

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Congenital Disorders of Upper Limb (2012-07-04 09:39) WRYNECK : Causes, Symptoms and Treatment [1]Congenital disorders are defined as those abnormalities of development that are present at the time of [2]birth. It is quite a common problem exceeded in frequency only by those of CNS and CVS systems. Congenital disorders can be placed in three groups.

• Those easily noticed by the mother, e.g. clubfoot. • Those not readily noticed, e.g. congenital dislocation of [3]hip (CDH). • Those clinically undetected but diagnosed radiologically, e.g. spondylolisthesis. Congenital disorders are more prevalent in diabetic mothers, multiple pregnancies, older mothers, etc. Male and female have equal predilection. Causes The exact cause is not known. Most congenital disorders begin early in the life of the embryo when cell division is most active. Although a few congenital disorders may be due to uterine malposition, most are believed to be due to [4]genetic defects, environmental influences or a combination of both. Genetic Factors [5]Defects in the chromosomes of sperm and ovum result in specific disorders ,which follows Mendel’s law. Embryonic Trauma 63

Congenital disorders can also result from [6]injury to the developing embryo at the time of differentiation of embryonic tissue into specific tissues by extraneous factors. CONGENITAL TORTICOLLIS (WRYNECK) [7]Congenital torticollis is a condition where the sternocleidomastoid muscle of the [8]neck undergoes contractures pulling it to the same side and turning the face to the opposite side. The exact cause of this condition is unknown; but hypothetically, it may be due to fibromatosis within the sternomastoid muscle. Etiology

• Middle part of the sternomastoid is supplied by an end [9]artery, which is a branch of the superior [10]thyroid artery that is blocked due to trauma, etc. • Birth trauma-Breech delivery, improper application of forceps, etc. may cause [11]injury to the sternomastoid muscle. The above two reasons can result in sternocleidomastoid muscle ischemia, necrosis and fibrosis later on. Clinical Features Deformity is the only complaint initially. Later, facial changes and macular problems in the retina may develop. Radiograph Plain X-ray of the neck AP and lateral views are essential to detect any congenital abnormality of the [12]cervical vertebra that could lead to this condition. Treatment Principles

• During infancy, conservative treatment consists of stretching of the sternomastoid by manipulation and [13]physiotherapy. Excision is unjustified in infancy. • [14]Surgery is delayed until fibroma is well-formed. The muscle may be released al one or both ends and the muscle may be excised as a whole. • If the muscle is still contracted at the age of 1 year, it should be released. • If [15]wryneck is persistent for I year, it will not resolve spontaneously and needs to be interfered operatively. • [16]Exercise program is successful: 1. When restriction of motion is less than 30 degree. 2. When there is no facial asymmetry. 64

• Non-operative [17]treatment after 1 year is rarely successful. • Any permanent torticollis becomes worse during growth. Head is inclined towards the affected side, face is turned towards the opposite side, ipsilateral [18]shoulder is elevated and the fronto-occipital diameter is increased. Surgical Method The most commonly employed surgical method is subcutaneous tenotomy of the clavicular attachment of the sternomastoid muscle. This procedure is inaccurate and dangerous as there could be an injury to the external jugular vein and phrenic [19]nerve. Hence, release from its attachment on the mastoid process is also tried. Open tenotomy if done before the child is 1 year old, tethering of the scar takes place. If the surgery is done between 1 and 4 years of age, tilt of the head and facial asymmetry are corrected less satisfactorily. If done after 5 years of age, the secondary deformities are less corrected. For older children or after failed operation, bipolar release of the [20]muscle from both sides, Ferkel’s modified bipolar release or Z-plast of the muscle is tried. 1. 2. 3.

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Shin Pain (2012-07-11 10:06) How you get relief from Stress Fracture of the Tibia? Symptoms: 65

[1]Stress fractures are more commonly a cause of [2]shin pain in athletes in impact, running and jumping sports. Overall [3]limb and [4]foot alignment as well as limb length discrepancy may also play a role. The incidence of stress fractures is increased by playing on more rigid, unforgiving surfaces. Approximately 90 % of tibial [5]stress fractures will affect the postero-medial aspect of the tibia, with the middle third and junction between the middle and distal thirds being most common. Proximal metaphyseal stress fractures may be related to more time loss from [6]sports as they do not respond as well to functional bracing, which allows earlier return to play. Stress fractures on the anterior edge of the [7]tibia, the tension side of the bone, are more resistant to [8]treatment and have a propensity to develop a non-union when compared to the risk of posteromedial stress fractures. A simple memory tool for the problematic [9]anterior tibial stress fracture is anterior is awful. A classic case presentation for a routine postero-medial stress fracture is as follows:

• Gradual onset of [10]leg pain aggravated by exercise. • [11]Pain may occur with walking, at rest or even at night. • Examination-localized tenderness over the [12]tibia. • Biomechanical examination may show a rigid, cavus foot incapable of absorbing load, an excessively pronating foot causing excessive [13]muscle fatigue or a leg length discrepancy. • Tenderness to palpation along the medial border with obvious tenderness. A stress fracture of the posterior cortex produces symptoms of [14]calf pain. • [15]Bone scan and MRI appearances of a stress fracture of the tibia. MRI scan is of particular value as the extent of edema and cortical involvement has been directly correlated with the expected return to sport. • A CT scan may also demonstrate a stress fracture. Treatment: Prior to initiating [16]treatment or during the treatment plan, it is important to identify which factors precipitated the stress fracture. The most common cause is an acute change in training habits, such as a significant increase in distance over a short period of time, beginning double practice days after lying off training for a season, or a change to a more rigid playing surface. Shoe wear, biomechanics and repetitive impact sports such as running and gymnastics have also been implicated. The [17]athletes coach can play a key role in modifying training patterns to reduce the risk of these [18]injuries. In women, reduced bone density due to hypoestrogenemia secondary to athletic amenorrhea (the female athlete triad) may be a contributing factor. All female athletes with a first-time stress fracture should be screened for the female athlete triad. The classic treatment plan is as follows:

• Initial period of rest (sometimes requiring a period of non-weight-bearing on crutches for [19]pain relief) until the [20]pain settles. 66

• The use of a pneumatic brace has been described. Studies have shown a markedly reduced return to activity time with such use compared with average times in two of three studies and compared with a traditional [21]treatment group in the third. In this latter study the brace group returned to full, unrestricted activity in an average of 21 days compared with 77 days in the traditional group. The brace should extend to the knee as the mid-leg version may actually increase the stresses across a mid shaft stress fracture. Once a stress fracture is clinically healed the athlete is advised to use the brace during practise and competition. Clinical healing implies minimal to no palpable [22]pain at the fracture site and minimal to no [23]pain with activities in the brace. Using this plan, there have been no reported cases of progression to complete catastrophic fracture of the tibia. • If pain persists, continue to rest from sporting activity until the bony tenderness disappears (four to eight weeks). • Once the patient is pain-free when walking and has no [24]bony tenderness, gradually progress the quality and quantity of the exercise over following month. The athlete should be asked to continue to use a pneumatic brace to complete the current season until an appropriate period (four to eight weeks) of rest can occur. • Cross training with low impact [25]exercises, including swimming, cycling and deep water running, maintains conditioning and reduces risk of recurrence. • Pain associated with soft [26]tissue thickening distal to the fracture site can be treated by soft tissue techniques. • General principles of return to activity following overuse [27]injury should be followed. 1. 2. 3. 4. 5.

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ANTERIOR KNEE PAIN (2012-07-18 05:16) Symptoms And Treatment of Knee Pain : [1]Anterior knee pain is the most common presenting symptoms in many [2]physiotherapy and sports physician practises.1 It contributes substantially to the 20-40 % of family practise consultations that relate to the musculoskeletal system. Two common causes of anterior knee pain in [3]sports people are patellofemoral pain and patellar tendinopathy. We first outline a practical approach to assessing the patient with anterior knee pain particularly with a view to distinguishing the common conditions; we then detail their [4]management. These concludes with an outline of other cause of anterior knee pain such as fat pad impingement, which may mimic features of both patellofemoral [5]pain and [6]patellar tendinopathy. Clinical approach Distinguishing between patellofemoral pain and patellar tendinopathy as a cause of [7]anterior knee pain can be difficult as their clinical features can be similar. Furthermore, on occasions, the two conditions may both be present. History There are a number of important factors to elicit from the history of a sportsperson with the general presentation of anterior knee pain. These include the specific location of the [8]pain, the nature of aggravating [9]activities, the history of the onset and behaviour of the pain and any associated clicking, giving way of [10]swelling. Although it may be difficult for the [11]patient with anterior knee pain to be specific, the area of pain often gives an important clue as to which structure is contributing to the [12]pain .For example, retropatellar or peripatellar pain suggests that the patellofemoral [13]joint (PFJ) is a likely culprit, [14]lateral pain localized to the lateral femoral epicondyle indicates iliotibial band friction syndrome and inferior patellar pain implicates the patellar tendon or infrapatellar fat pad. The patient presents with bilateral knee pain is more likely to have patellofermoral pain or tendinopathy than an interal derangement of both knees. The onset of typical patellofemoral pain is often insidious but it may present secondary to an [15]acute traumatic episode (e.g. falling on the knee) or post other [16]knee injury (e.g. meniscal, ligament) or [17]knee surgery. The patient presents with a diffuse ache, which is usually exacerbated by loaded activities, such as stair ambulation or running. Sometimes patellofemoral pain is aggravated by prolonged sitting (movie-goers knee), but sitting tends to aggravate pain of patellar tendinopathy so is not diagnostic of patellofemoral pain. Pain during running that gradually worsens is more likely to be of patellofemoral origin, whereas pain 68

that occurs at the start of activity, settles after warm-up and returns after activity is more likely to be patellar tendinopathy. To clinical differentiation of patellofemoral pain, patellar tendinopathy and fat pad impingement. As these conditions can coexist, accurate [18]diagnosis can be challenging. A history of recurrent crepitus may suggest [19]patellofemoral pain. A feeling that the patella moves laterally at certain times suggests recurrent patellofemoral instability. An imminent feeling of giving way may be associated with patellar subluxation, patellofemoral pain or meniscal abnormality, although frank, dramatic giving way is usually associated with anterior cruciate [20]ligament instability. Nevertheless, giving way due to [21]muscle inhibition, or due to pain, is not uncommon in anterior knee pain presentations. Examination Initially, the primary aim of the clinical assessment to determine the most likely cause of the patient’s since location of tenderness and aggravating factors are integral to the differential diagnosis, it is critical to reproduce the patient’s [22]anterior knee pain. This is usually done with either a double- or single-[23]leg squat. A squat done on a decline may make the test more specific to the anterior knee. The clinician should palpate the anterior knee carefully to determine the site of maximal tenderness. Examination includes: 1. Observation

• standing • walking • supine 2. Functional tests

• squats • step-up/step-down • jump • lunge • double-then single - leg decline squat 3. Paplation

• patella and inferior pole • medial lateral retinaculum • patellar tendon • infrapatellar fat pad 69

• tibial tubercle • effusion 4. PFI assessment static assessment of patella position

• superior • inferior • medial • lateral glide • dynamic assessment of patella position • assessment of vasti function 5. Flexibility

• lateral soft tissue structures • quadriceps • hamstring • iliotibial band • gastrocnemius Investigations Imaging may be used to confirm a clinical impression obtained from the history and examination. Structural imaging includes conventional radiography, ultrasound, CT and MRI. Occasionally, radionuclide [24]bone scan is indicated to evaluate the metabolic status of the [25]knee (e.g. after trauma, in suspected [26]stress fracture). The majority of patients with patellofemoral [27]pain syndrome will require either no imaging, or plain radiography consisting of a standard AP view, a true lateral view with the knee in 300 of flexion, and an axial view through the knee in 300 of flexion. Plain radiography can detect bipartite patella and [28]osteoarthritis, provide evidence of an increased likelihood of Sinding-Larsen-Johansson lesions as well as rule out potentially serious complications such as [29]tumor or infection .Although CT and three dimensional CT have been used to assess the PFI ,MRI is gaining increasing popularity as an investigations of patellofermoral pain, and the unstable patella because of its capacity to image the patellar articular cartilage. Treatment [30]Treatment of patellar tendinopathy requires patience and a multifaceted approach, which is outlined. It is essential that the practitioner and patience recognize that tendinopathy that has been present for 70

months may require a considerable period of [31]treatment associated with [32]rehabilitation before symptoms disappear. Conservative management of patellar tendinopathy requires appropriate strengthening exercises, load reduction, correcting biomechanical errors, and [33]soft tissue therapy. An innovation has been the use of sclerotherapy of neovessels with polidocanol. [34]Surgery is indicated after a considered and lengthy conservative program has failed. This section outlines the [35]physical therapy approach of correction of biomechanics that might be contributing to excessive load on the tendon, targeted exercise therapy and soft tissue treatment before outhning [36]medical treatments including medication, sclerotherapy and surgery. 1. 2.

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Cervical Headache (2012-08-11 06:53) Treatment of Headache: [1]Cervical or cervicogenic [2]headache is a term used to describe headache caused by abnormalities of the [3]joints, muscles, [4]fascia and neural structures of the cervical region. There are a number of classifications for cervical or cervicogenic headache with differing criteria for physical dysfunction. Mechanism The mechanism of production of [5]headache from abnormalities in the cervical region is variable. It may be primarily referred [6]pain caused by irritation of the [7]upper cervical nerve roots. This may be due to damage to the atlantoaxial joint or compression of the nerves as they pass through the muscles. Headache emanating from the [8]lower cervical segments probably originates from irritation of the posterior primary rami, which transmit sensation to the spinal portion of the trigeminocervical nucleus. Commonly, pain may also be referred to the [9]head from active trigger points. Frontal headaches are associated with trigger points in the suboccipital [10]muscles, while temporal headaches are associated with trigger points in the upper trapezius, splenius capiitis and cervicis, and sternocleidomastoid muscles. Clinical Features History A [11]cervical headache is typically described as a constant, steady, [12]dull ache, often unilateral but sometimes bilateral. The patient describes a pulling or gripping feeling or, alternatively, may describe a tight band around the [13]head. The headache is usually in the suboccipital region and is commonly referred to the frontal, retro-orbital or temporal regions. Cervical headache is usually of gradual onset. The patient often wakes with a headache that may improve during the day. Cervical headaches may be present for days, weeks or even months. There may be a history of acute trauma, such as a whiplash [14]injury sustained in a motor accident, or repetitive [15]trauma associated with work or a sporting activity. Cervical headache is often associated with neck pain or stiffness and may be aggravated by [16]neck or head movements, such as repetitive jolting when traveling in a car or bus. It is often associated with a feeling of light-headedness, dizziness and tinnitus. [17]Nausea may be present but vomiting is rare. The patient often complains of impaired concentration, an inability to function normally and depression. Poor 72

posture is often associated with a cervical headache. This may be either a contributory factor or an effect of a [18]headache. The abnormal posture typically seen with cervical headache is rounded [19]shoulders, extended neck and protruded chin. This results in tightness of the upper cervical extensor muscles and weakness of the cervical flexor muscles. [20]Stress is often associated with cervical headache. It may be an important contributory factor to the development of the [21]soft tissue abnormalities causing the headache or may aggravate abnormalities already present. Thus, it is important to elicit sources of stress in the clinical history. Exercise-Related Causes of Headache Benign Exertional Headache Benign [22]exertional headache (BEH) has been reported in association with weightlifting, running and other [23]sporting activities. The IHS criteria include that the headache:

• Is specifically brought on by physical exercise • Is bilateral, throbbing in nature at onset and may develop migrainous features in those patients susceptible to [24]migraine • Lasts from 5 minutes to 24 hours • Is prevented by avoiding excessive exertion • Is not associated with any systemic or intracranial [25]disorder. The onset of the headache is with straining and [26]Valsalva maneuvers such as those seen in weightlifting and competitive swimming. The major differential diagnosis is subarachnoid hemorrhage, which needs to be excluded by the appropriate investigations. It has been postulated that exertional headache is due to dilatation of the [27]pain-sensitive venous sinuses at the base of the [28]brain as a result of increased cerebral arterial pressure due to exertion. Studies of weight- lifters have shown that systolic blood pressure may reach levels above 400 mmHg and diastolic pressures above 300 mmHg with maximal lifts. A similar type of headache is described in relation to sexual activity and has been termed benign sex headache or orgasmic cephalalgia (IHS 4.6). The [29]management of this condition involves either avoiding the precipitating activity or drug treatment, for example, indomethacin (25 mg three times a day). In practise, the headaches tend to recur over weeks to months and then slowly resolve in some cases they may be lifelong. Treatment

• [30]Treatment of the patient with cervical headache requires correction of the abnormalities of joints, muscles and neural structures found on examination as well as correction of any possible precipitating factors such as postural abnormalities or emotional stress. • [31]Treatment of cervical intervertebral joint abnormalities involves mobilization or manipulation of the Cl-2 and C2-3 joints. • Stretching of the cervical extensor muscles and strengthening of the [32]cervical flexor muscles are important. 73

• [33]Soft tissue therapy to the muscles and the fascia of the cervical region is aimed at releasing generally tight muscles and fascia (commonly the cervical extensors). • Active trigger points should be treated with spray and [34]stretch techniques or dry needling. • Cervical muscle retraining has been shown to be beneficial by itself and in combination with manipulative [35]therapy in reducing the incidence of cervicogenic headache. • This includes retraining of the deep cervical flexors ,extensors and scapular stabilizers. • Postural retraining is an essential part of treatment. The patient must learn to reduce the amount of cervical extension by retracting the chin. • Identification and reduction of sources of stress to the patient should be incorporated in the[36] treatment program. 1. 2. 3. 4. 5.

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The Benefits of Physical Activity in the Elderly (2012-08-28 12:07) Physical Health Benefits of Exercise:

[1]Physical activity benefits all body organs as well as the psyche. The most dramatic benefits have been found in the [2]cardiovascular system. Exercise interventions in older patients with coronary [3]heart disease decreased morbidity, mortality and symptoms, and reduced cardiac re-hospitalizations. Benefits of Exercise Numerous mechanisms may contribute to these [4]benefits. Increased demand on the myocardium improves oxygen utilization. Capillaries dilate and multiply to improve the delivery of oxygen and other nutrients to [5]muscles. The myoglobin content of muscle is increased, thus improving the transfer of oxygen from the red blood cells to muscle cells. Inside the cell, the number of mitochondria increases, enhancing aerobic metabolism. There is also an increase in the glycogen storage sites of muscle. Here following are the [6]exercise benefits:

• Exercise tends to lower the resting [7]heart rate and the resultant increased diastolic time allows improved coronary blood flow. Stroke volume increases. • [8]Exercise also has an effect on blood lipid levels, raising levels of high-density lipoprotein cholesterol, the cardio protective lipid, and lowering levels of low-density lipoprotein [9]cholesterol. • Exercise lowers blood pressure and reduces obesity. A combination of these two factors, in addition to the reduction in cholesterol, decreases the risk of ischemic heart disease. • Exercise may also improve exercise tolerance in older people with [10]chronic obstructive pulmonary [11]disease. They will also benefit from the associated benefits of aerobic [12]fitness. • Exercise may improve blood sugar control in people with diabetes by decreasing insulin resistance, and may reduce the need for medication. • Resistance training and high-impact activities help maintain bone mass in the [13]elderly. • An exercise program may also be beneficial for older people with [14]osteoarthritis by improving joint mobility and increasing muscle strength. • Exercise in the form of strength and balance training has been shown to reduce an older person’s risk of falling. 75

• Along with the [15]physical benefits of exercise, the older athlete benefits from improved sleep, cognitive function and mood. • The muscle control and weight loss associated with exercise may lead to improvements in body image and reverse the elderly person’s fear of [16]activity. • Exercise reduces [17]anxiety in elderly patients, especially in those recovering from illness. • Exercise can lessen depressive symptoms and perhaps even reduce the risk of developing depression. Risks of Exercise in the Elderly The risks associated with a sedentary lifestyle are well known although difficult to quantify objectively and compare with the risks associated with exercise in later years. Underlying co-morbidity is often cited as a reason to preclude exercise despite the overwhelming evidence to support the benefits of exercise in many common and [18]chronic diseases. From a safety standpoint, clinicians prescribing exercise for older people are concerned that exercise may induce [19]myocardial ischemia and, in turn, precipitate myocardial infarction or sudden death. Gill and colleagues have provided recommendations regarding precautions that can be taken to minimize the risk of serious adverse cardiac events among previously sedentary older persons who do not have symptomatic [20]cardiovascular disease and are interested in starting an exercise program. Reducing the Risks of Exercise Before starting an exercise program, all older persons should have a complete history and physical examination performed by a [21]physician. Contraindications to exercise outside of a monitored environment include: myocardial infarction within six months, angina or physical [22]signs and symptoms of congestive heart failure, and a resting systolic blood pressure of 200 mmHg or higher. A functional test of cardiac capacity is to ask the patient to walk 15 m (50 ft) or climb a flight of stairs. A resting ECG/EKG should be reviewed for new Q waves, ST segment depressions or T-wave inversion. Persons who have features of cardiovascular disease should be referred for appropriate management. If the patient has no overt cardiovascular disease, and no other medical or [23]orthopedic contraindications to exercise, he or she can begin a low-intensity [24]exercise program. 1. 2. 3. 4.

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Chronic Fatigue Syndrome (CFS) (2012-08-31 12:23) Symptoms and Causes of Chronic Fatigue Syndrome: [1]Chronic Fatigue Syndrome (CFS) is a controversial condition, the existence of which is hotly debated within the medical profession. The term itself was first used in 1988 but the syndrome has existed for much longer. It has previously been known as neurasthenia and myalgic encephalomyelitis (ME). The term CFS has been adopted to define a sufficiently homogeneous group of patients to allow research into etiology, pathogenesis, natural history and [2]management. As the word syndrome suggests, CFS is not recognized as a distinct [3]disease process. Definition A number of definitions of CFS have been proposed. All include the concept of [4]fatigue that interferes with activities of daily living and is of at least six months duration. The Center for Disease Control (CDC) in Atlanta has defined CFS as the presence of:

1. Clinically evaluated, unexplained, persistent or relapsing fatigue that is of new or definite onset; is not the result of ongoing [5]exertion; is not alleviated by rest; and results in a substantial reduction of previous levels of occupational, educational, social or personal [6]activities. 2. Four or more of the following [7]symptoms that persist or recur during six or more consecutive months of illness and that do not predate the fatigue: • Self-reported impairment in short-term memory or concentration • [8]Sore throat • Tender cervical or axillary nodes • [9]Muscle pain • Multi -joint pain without redness or swelling • Headaches of a new pattern or severity 77

• Un-refreshing sleep • Post-Exertional malaise of at least 24 hours Symptoms The most prominent [10]symptom of CFS is usually overwhelming fatigue, especially after exercise.

• Other [11]common symptoms include headaches, sore throat, enlarged lymph nodes, muscles pain especially after exercise, un-refreshing sleep, chest and abdominal [12]pains. • The diagnosis of CFS is difficult to confirm in the absence of any definitive sign or test. • It is often a [13]diagnosis of exclusion. • The other problem with the diagnosis of CFS is that there are a number of conditions whose symptoms overlap with those of CFS. • The two most significant are fibromyalgia and [14]depression. • The major presenting symptom in fibromyalgia is usually widespread muscle and [15]joint pain but fatigue is nearly always present. • [16]Fibromyalgia is characterized by the presence of multiple tender points in the muscles. • Trigger points are also frequently seen in patients with CFS and form an important part of the treatment. • Fatigue is often the primary presenting symptom in patients with depression and many of the symptoms described in CFS are found in depressive patients. Management [17]Management of the patient with CFS (or fibromyalgia and depression) is a considerable challenge for the practitioner. The natural history of CFS is of a very gradual improvement over a period of months and sometimes years.

• [18]Treatment should be oriented towards psychological support and symptom relief. • It is essential that the treating practitioner acknowledges that the patient has a real problem and is prepared to give the patient a diagnosis. • It is important to give the patient plenty of time and both the patient and those close to her (or him) will have many questions. • We recommend seeing the patient at least weekly in the initial treatment phase and later on a less frequent but still regular basis. • Exercise is the cornerstone of treatment of [19]chronic fatigue. • This may seem strange when one considers that post-exercise fatigue and muscle pain are two of the most significant features of the [20]disease but a slow, graduated increase in activity is an essential part of management. 78

• The exercise program may have to commence at a ’ridiculously’ low level considering the history of some athletes. • But it should commence at a level that the patient can achieve comfortably with minimal or no adverse effects in the 24-48 hours post-exercise. • The increase in activity should be very gradual and if adverse symptoms develop, the patient should return to the previous level of [21]activity and build up even more slowly. • In a six-month randomized blinded prospective trial in individuals with CFS, it was found that a graded exercise program significantly improved both health perceptions and the sense of fatigue whereas the use of an antidepressant (fluoxetine) improved depression only. • Another study of 66 patients with CFS also demonstrated a positive effect with graded aerobic [22]exercise. • Many [23]drug treatments have been advocated but with little evidence of their efficacy. • Simple analgesics may be helpful and we recommend the use of a tri- cyclic antidepressant (e.g. amitryptiline 10-25 mg) in a single nocte dose. • This drug seems to improve sleep quality and patients will usually wake up more refreshed as a result. • Many nutritional supplements have also been advocated but again there is no evidence of their efficacy we have found the [24]treatment of muscle trigger points with dry needling to be helpful in reducing muscle pains and headaches in a number of patients with CFS. Other Causes of Tiredness A number of psychological problems are associated with a feeling of excessive tiredness. The two most common states are [25]anxiety and depression. These problems may be related to the athletes sporting endeavors or, alternatively, may be quite unrelated.

• The presence of eating disorders such as [26]anorexia, nervosa and bulimia should also be considered. • Hypothyroidism is more common than most realize, occurring in 1 % of adults, with subclinical disease in Solo. The condition can affect any organ system. • Hypothyroidism is characterized by a general slowing of body processes and can present as chronic fatigue, cold intolerance, weight gain and, in women, menorrhagia. • It is often associated with high [27]cholesterol levels. • An elevated serum [28]thyroid stimulating hormone level is a sensitive indicator and patients with this condition generally respond well to treatment with levothyroxine. • Diabetes, neuromuscular disorders and [29]cardiac problems are all associated with excessive tiredness. • Exercise induced as the major symptom rather than the more typical cough, chest tightness or shortness of [30]breath post exercise. • A number of medications may cause excessive tiredness. • These include beta-blockers, [31]antihistamines, diuretics, anticonvulsants, sedatives and muscle relaxants. 79

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Diabetes Mellitus Treatment (2012-09-12 10:10) Exercise of Type 1 Diabetes and Type 2 Diabetes Disease: Firstly, the adjustments the athlete with [1]diabetes might make if he or she wishes to [2]exercise and, secondly, what the risks and benefits are, both in the short term and long term, of exercise to the patient 80

with diabetes. There are many examples of athletes with diabetes who have been extremely successful. British rower Steven Redgrave developed diabetes at the age of 35 having won gold medals at each of the previous four Olympic Games. Following his diagnosis he was able to continue training and competing and won a fifth consecutive gold medal in the Sydney Olympics Games 2000. There are two distinct types of [3]diabetes mellitus:

1. Insulin-Dependent (Type 1) 2. Non-Insulin-Dependent (Type 2) Type 1 Diabetes Type 1 Diabetes(Insulin-Dependent Diabetes Mellitus, IDDM), previously known as juvenile-onset diabetes, is thought to be an inherited [4]autoimmune disease in which antibodies are produced against the beta cells of the pancreas. This ultimately results in the absence of [5]endogenous insulin production, which is the characteristic feature of type 1 diabetes. The incidence of type 1 diabetes varies throughout the world but represents approximately 10-15 % of diabetic cases in the western world. The onset commonly occurs in childhood and adolescence but can become symptomatic at any age. Insulin administration is essential to prevent ketosis, [6]coma and death. The aims of [7]treatment are tight control of blood glucose levels and prevention of micro vascular and macro vascular complications. Type 2 Diabetes Type 2 Diabetes (Non-Insulin-Dependent Diabetes Mellitus, NIDDM), previously know maturity-onset or adult-onset diabetes, is a disease as the former names suggest, of later onset ,linked to both [8]genetic and lifestyle factors. It is characterized by diminished insulin secretion relative to serum glucose levels in conjunction with [9]peripheral insulin resistance, both of which result in chronic hyperglycemia. Approximately 90 % of individuals with diabetes have [10]type 2 diabetes and it is thought to affect 3-7 % of people in Western countries. The prevalence of type 2 diabetes increases with age. The pathogenesis of type 2 diabetes remains unknown but it is believed to be a heterogeneous disorder with a strong genetic factor. Approximately 80 % of individuals with 2 diabetes are obese. Type 2 diabetes is characterized by three major [11]metabolic abnormalities:

• Impairment in pancreatic beta cells insulin secretion in response to a glucose stimulus. • Reduced sensitivity to the action of insulin in major organ systems such as [12]muscle, [13]liver and adipose tissue. • Excessive [14]hepatic glucose production in the basal state. Exercise and Diabetes: The [15]sports physician should be encouraged to work closely with the endocrinologist when considering [16]exercise prescription for a diabetic patient. The target of an adult should be to achieve at least 30 minutes of continuous moderate activity, equivalent to brisk walking five or six days a week, with the flexibility 81

of shorter bouts of more intense activity being considered important. This is provided that [17]cardiovascular and hypertensive problems are taken into account. [18]Heart rate may be an unreliable indicator of exertion because of autonomic [19]neuropathy, and the rating of perceived exertion scales may be more useful. Although exercise in conjunction with a proper diet and medications is the cornerstone in the treatment of diabetes, special care must be taken in those taking insulin. Both insulin and exercise independently facilitate glucose transport across the [20]mitochondrial membrane by promoting GLUT4 transporter proteins from intracellular vesicles. The action of insulin and exercise is also cumulative. As such, an exercising type 1 diabetic will have lowered insulin requirements, and may notice up to a 30 % reduction in insulin requirements with exercise. Importantly, in the person with [21]type 1 diabetes, glycemic control may not be improved with regular exercise if changes in the individuals diet and insulin dosage do not appropriately match exercise requirements. In the absence of exercise, even for a few days, the increased insulin sensitivity begins to decline. All patients with diabetes should carry an identification card or bracelet identifying them as having diabetes. They should be educated to be alert to the early signs of [22]hypoglycemia for at least 6-12 hours after exercise. It is essential that they carry glucose tablets or an alternative source of glucose with them at all times. [23]Dehydration during exercise should be prevented by adequate fluid consumption. It is also recommended that the diabetic athlete exercise with somebody else, if possible, in case of adverse reactions. Benefits of Exercise:

• The [24]benefits of exercise in type 1 diabetics include improved insulin sensitivity, improved blood lipid profiles, decreased heart rate and blood pressure at rest, decreased body weight and possible decreased risk of coronary heart disease. • It does not appear that exercise improves glycemic control; however, insulin requirements may be decreased slightly. • While exercise may not improve glucose control, the benefits of exercise in those with diabetes occur mainly through reducing the risk factors for cardiovascular disease. • People with type 1 diabetes typically live longer if they participate in regular [25]physical activity as a part of their lifestyle. • It is well recognized that exercise reduces the risk of developing type 2 diabetes. There are also considerable benefits for those with type 2 diabetes. • A program of regular physical activity can reverse many of the defects in metabolism of both fat and glucose that occur in people with type 2 diabetes. As noted above, Hb is used as an index of long term blood glucose control. The lower the value, the better. Hb is reduced by chronic exercise in people with type 2 diabetes. The evidence for improvement of Hb with exercise in type I diabetes is not as convincing. Exercise and Type 1 Diabetes Control of blood glucose is achieved in a patient with type 1 diabetes through a balance in the [26]carbohydrate intake, exercise level and insulin dosage. The meal plan and insulin dosage should be adjusted according to the patient’s response to exercise. Unfortunately a degree of trial and error is necessary for type 1 diabetics taking up new activities. Frequent self-monitoring should occur, at least until a balance is 82

achieved among diet, exercise and insulin parameters. Those with blood glucose levels less than 5.5 mmol/L (100 mg/dL) require a pre-exercise carbohydrate snack (e.g. sports drink, juice, glucose tablet, fruit).

• Exercise of 20-30 minutes at less than 70 % VO (e.g. walking, golf, table tennis) requires a rapidly absorbable carbohydrate (15 g fruit exchange or 60 calories) before exercise but needs minimal insulin dosing adjustments. • More vigorous activity of less than I hour (e.g. jogging, swimming, cycling, skiing, tennis) often requires a 25 % reduction in pre-exercise insulin and 15-30 g of rapidly absorbed carbohydrate exchange before and every 30 minutes after the onset of activity. • If early morning activity is to be performed the [27]basal insulin from the evening dose of intermediateacting insulin may need to be reduced by 20-50 %, with checking of the morning blood glucose level. • The morning regular-acting insulin dose may also need to be reduced by 30-50 % before breakfast, or even omitted if exercise is performed before food. • Depending on the intensity and duration of the initial activity and likelihood of further activity, a reduction of 30-50 % may be needed with each subsequent meal. • After exercise hyperglycemia will occur, but insulin should still be decreased by 25-50 % (because insulin sensitivity is increased for 12-15 hours after activity has ceased). • Consuming carbohydrates within 30 minutes after exhaustive, glycogen-depleting exercise allows for more efficient restoration of [28]muscle glycogen. • This will also help prevent post-exercise, late-onset hypoglycemia, which can occur up to 24 hours following such exercise. • If exercise is unexpected, then insulin adjustment may be impossible. Instead, supplementation with 20-30 g of carbohydrate, at the onset of exercise and every 30 minutes thereafter, may prevent hypoglycemia. • In elite athletes and with intense bouts of exercise, reductions in insulin dosage may be even higher than those listed above. • During periods of inactivity (e.g. holidays, recovery from injury), increased insulin requirements are to be expected. Exercise and Type 2 Diabetes

• Those patients with type 2 diabetes who are managed with diet therapy alone do not usually need to make any adjustments for exercise. • Patients taking oral hypoglycemic drugs may need to halve their doses on days of prolonged exercise or withhold them altogether, depending on their[29] blood glucose levels. • They are also advised to carry some glucose with them and to be able to recognize the symptoms of hypoglycemia. • Hypoglycemia is a particular risk in those people with diabetes taking sulfonylureas due to their long half lives and increased endogenous insulin production. 83

• [30]Biguanides provide less of a problem as they do not increase insulin production. Exercise and the Complications of Diabetes: Exercise is often neglected when the secondary complications of diabetes occur. Some unique concerns for the patient with diabetes that warrant close scrutiny include autonomic and [31]peripheral neuropathy, retinopathy and [32]nephropathy. Poor glucose control appears to be associated with an increased occurrence of neuropathy.

• Abnormal autonomic function is common among those with diabetes of long duration. • The risks of exercise when autonomic neuropathy is present include hypoglycemia, abnormal heart rate and [33]blood pressure responses (e.g. postural drop), impaired sympathetic and parasympathetic nervous system activity and abnormal thermoregulation. • Patients with autonomic neuropathy are at high risk of developing complications during exercise. Sudden death and [34]myocardial infarction have been attributed to autonomic neuropathy and diabetes. High-intensity activity should be avoided, as should rapid changes in body position and extremes in temperature. Water activities and stationary cycling are recommended. • Peripheral neuropathy (typically manifested as loss of sensation and of two point discrimination) usually begins symmetrically in the lower and upper extremities and progresses proximally. • Podiatric review should occur on a regular basis, and correct footwear can prevent the onset of [35]foot ulcers. • Regular close inspection of the feet and use of proper footwear are important and the patient should avoid exercise that may cause [36]trauma to the feet. • [37]Feet and toes should be kept dry and clean and dry socks should also be used. • Non-weight-bearing activities, such as swimming, cycling and arm exercises, are recommended in those with insensitive feet. • Activities that improve balance are appropriate choices. • Diabetics with proliferative retinopathy should avoid exercise that increases systolic blood pressures to 170 mmHg and prolonged Valsalva-like activities. • Exercise that increases blood pressure may worsen retinopathy. • Exercise that results in a large increase in systolic pressure (such as weightlifting) can cause retinal hemorrhage. • Exercise for these patients could include stationary cycling, walking and swimming. If possible, blood pressure should be monitored during the exercise program. • Exercise is contraindicated if the individual has had recent photocoagulation [38]treatment or [39]surgery. • These include lifting heavy weights and high-intensity [40]aerobic activities. Activities that are weightbearing yet low impact are preferable. • It is important to wear well-cushioned shoes. Renal patients should be fully evaluated before commencing an exercise program. Fluid replacement is extremely important in these patients. Specific training programs for patients undergoing hemodialysis are advised. 84

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Lateral Ankle Pain (2012-09-27 09:32) Clinical Features, Causes And Treatment of Ankle Pain: [1]Lateral ankle pain is generally associated with a biomechanical abnormality. The two most common causes are [2]peroneal tendinopathy and sinus tarsi syndrome. Examination Examination is as for the patient with [3]acute ankle injury with particular attention to testing resisted eversion of the peroneal tendons and careful palpation for tenderness and crepitus. Peroneal Tendinopathy The most common overuse [4]injury causing lateral [5]ankle pain is peroneal tendinopathy. The peroneus longus and peroneus brevis tendons cross the [6]ankle joint within a fibro-osseous tunnel, posterior to the lateral malleolus. The peroneus brevis tendon inserts into the tuberosity on the lateral aspect of the base of the fifth metatarsal. The peroneus longus tendon passes under the plantar surface of the [7]foot to insert into the lateral side of the base of the first metatarsal and medial cuneiform. The peroneal tendons share a common tendon sheath proximal to the distal tip of the fibula, after which they have their own tendon sheaths. The peroneal [8]muscles serve as ankle dorsi flexors in addition to being the primary evertors of the ankle. Causes Peroneal Tendinopathy may either as a result of an acute ankle inversion [9]injury or secondary to an overuse injury. Soft footwear may predispose to the development of peroneal tendinopathy. Common [10]causes of an overuse injury include:

• Excessive eversion of the foot such as occurs when running on slopes or cambered surfaces. • Excessive pronation of the foot. • Secondary to tight ankle [11]plantar flexors (most commonly soleus) resulting in excessive load on the lateral muscles. • Excessive action of the peroneal (e.g. dancing, basketball, volleyball). An inflammatory [12]arthropathy may also result in the development of a peroneal tenosynovitis and subsequent peroneal tendinopathy. It has been suggested that peroneal tendinopathy may be due to the excessive pulley action of, and abrupt change in direction of, the peroneal tendons at the lateral malleolus. 86

There are three main sites of peroneal tendinopathy:

• Posterior to the lateral malleolus • At the peroneal trochlea • At the [13]plantar surface of the cuboids. Clinical Features The athlete commonly presents with:

• Lateral ankle or [14]heel pain and swelling which is aggravated by activity and relieved by rest. • Local tenderness over the peroneal tendons on examination sometimes associated with [15]swelling and crepitus (a true paratenonitis). • Painful passive inversion and resisted eversion, although in some cases eccentric contraction may be required to reproduce the [16]pain. • Possible associated [17]calf muscle tightness. • Excessive subtalar pronation or stiffness of the subtalar or [18]midtarsal joints that is demonstrated on biomechanical examination. Investigations MRI is the recommended investigation and shows characteristic features of [19]tendinopathy-increased signal and tendon thickening.13 If MRI is unavailable, an ultrasound may be performed. If an underlying inflammatory arthropathy is suspected, obtain blood tests to assess for [20]rheumatologic and inflammatory markers. Treatment

• [21]Treatment initially involves settling the pain with rest from aggravating activities, analgesic medication if needed and soft tissue therapy and [22]physical therapy. • Stretching in conjunction with mobilization of the subtalar and Midtarsal joints may be helpful. • Footwear should be assessed and the use of lateral [23]heel wedges or orthoses may be required to correct biomechanical abnormalities. • Strengthening [24]exercises should include resisted eversion (e.g. rubber tubing, rotagym), especially in plantar flexion as this position maximally engages the peroneal muscles. In severe cases, [25]surgery may be required, which may involve a synovectomy, tendon debridement or repair. 1. 2. 3.


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Jayson Gelger (2013-01-29 17:21:52) diabetes mellitus is quite hard on the patient and anyone suffering from it., Most recently released content on our own internet site



Rotator Cuff Injuries (2012-10-04 08:46) Causes And Treatment of Rotator Cuff Tendinopathy: [1]Rotator cuff tendinopathy is a common cause of [2]shoulder pain and impingement in athletes. In this condition, the rotator cuff tendons become swollen and hyper cellular, the collagen matrix is disorganized and the tendon weaker. Studies in running rats and in human swimmers suggest the major determinant of the onset of tendinopathy is the volume (e.g. distance swum, time running) of work. Apoptosis (programmed cell death) and associated pathways are increased in overuse [3]tendinopathy and may play a role in the pathogenesis of tendinopathy. Clinical Features The athlete with rotator cuff tendinopathy complains of [4]pain with overhead activity such as throwing, swimming and overhead shots in racquet [5]sports. Activities undertaken at less than 90 degree of 88

abduction are usually pain-free. There may also be a history of associated symptoms of instability, such as recurrent subluxation or episodes of dead [6]arm. On examination, there may be tenderness over the supraspinatus tendon proximal to or at its insertion into the greater tuberosity of the humerus. Active movement may reveal a [7]painful arc on abduction between approximately 70 degree and 120 degree. Internal rotation is commonly reduced. The most accurate method to clinically assess rotator cuff strength is to measure developed resistance when the [8]scapula is stabilized in a retracted position. For the athlete with rotator cuff tendinopathy, symptoms can be reproduced with impingement tests, as well as pain at the extremes of passive flexion. Pain will also occur with resisted contraction of the supraspinatus, which is best performed with resisted upward movement with the [9]shoulder joint in 90 degree of abduction, 30 degree of horizontal [10]flexion and internal rotation .The investigation of choice in rotator cuff tendinopathy is MRI. These examinations may also demonstrate the presence of a partial tear of the rotator cuff. Treatment of Rotator Cuff Tendinopathy The[11] treatment of rotator cuff tendinopathy should be considered in two parts.

• The first part is to treat the tendinopathy itself. The patient should avoid the aggravating activity and apply ice locally. • There is no level 2 evidence to support NSAIDs, ultrasound interferential stimulation, laser, magnetic field therapy or local massage. • There is level 2 evidence to support nitric oxide donor [12]therapy (glyceryl trinitrate [GTN] patches applied locally at 1.25 mg/day) and for a single corticosteroid injection. • Glyceryl trinitrate patches come in varying doses: a 0.5 mg patch should outcomes occurred at three to six months, so patients need to have this explained. • A corticosteroid injection into the subacromial space may reduce the athlete’s symptoms sufficiently to allow commencement of an appropriate [13]rehabilitation program. • It has been reported that the second part of the treatment of rotator cuff tendinopathy should be the correction of associated abnormalities. • These include glenohumeral instability, [14]muscle weakness or in coordination, soft tissue tightness, impaired scapulohumeral rhythm and training errors. • Impaired scapulohumeral rhythm may predispose to rotator cuff tendinopathy and must be assessed and treated. • The treatment of scapulohumeral rhythm abnormalities is considered. • Decreased rotator cuff strength or an imbalance between the internal and external rotators of the shoulder also predisposes to the development of rotator cuff tendinopathy. • Treatment involves strengthening of the external rotators as they are usually relatively weak compared with the internal rotators. • An exercise program to strengthen the rotator [15]cuff muscles is described. 89

• Posterior capsular tightness is commonly associated with decreased internal rotation and reduced rotator cuff strength. • Stretching of the posterior capsule is helpful. [16]Instability is a common cause of rotator cuff tendinopathy and must be considered in any patient who presents with symptoms typical of rotator cuff tendon problems. • If the presence of instability is not recognized, rotator cuff tendinopathy is likely to recur upon return to sport. • While it is possible that correction of any of these disorders may improve tendinopathy, there is no level 2 evidence to support any particular rehabilitation strategy or regimen for managing supraspinatus tendinopathy. • This provides fertile ground for novel clinical research trials. • Tightness and focal muscle thickening of the rotator cuff muscle hems may also predispose to the development of rotator cuff tendinopathy. • These changes reduce the ability of the musculotendinous complex to elongate and absorb shock. They may also alter biomechanics by reducing the full range of motion and impairing scapular control. • These [17]soft tissue abnormalities should be corrected. Abnormalities along the kinetic chain must be identified and corrected. • Technique faults, for example, in throwing or swimming, should be corrected with the aid of a coach. Training errors need to be corrected. • Overuse should be avoided. 1. 2. 3. 4. 5. 6. 7.

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Hand and Finger Injuries (2012-10-23 12:00)

Symptoms and Treatment of Hand Pain: [1]Hand and finger injuries finger injuries are extremely common in sport and, although the majority require minimal treatment, some are potentially serious and require immobilization, precise splinting, or even surgery. Finger injuries are often neglected by [2]athletes in the expectation that they will resolve spontaneously. Many present too late for effective [3]treatment. The importance of early assessment and management must be stressed so that long-term deformity and functional impairment can be avoided. Many hand and finger injuries require specific [4]rehabilitation and appropriate protection upon resumption of sport. [5]Joints in this region do not respond well to immobilization, therefore, full immobilization should be minimized. Mechanism of Injury: The mechanism of injury is the most important component of the history of acute [6]hand injuries. A direct, severe blow to the fingers may result in a [7]fracture, whereas a blow to the point of the finger may produce an interphalangeal [8]dislocation, joint sprain or long flexor or extensor tendon avulsion. A punching injury often results in a fracture at the base of the first metacarpal or to the neck of one of the other metacarpals usually the fifth. An avulsion of the flexor digitorum profundus tendon, usually to the fourth finger, is suggested by a history of a patient grabbing an opponent’s clothing while attempting a tackle. Associated features such as an audible crack, degree of pain, [9]swelling, bruising, and loss of function should also be noted. Signs and Symptoms: Carefully palpate the [10]bones and soft tissues of the hand and fingers, looking for tenderness. The examiner should always be conscious of what structure is being palpated at any particular time. The joints should be examined to determine active and passive range of movement and stability. Stability should be tested both in an anteroposterior direction and with [11]ulnar and radial deviation to assess the collateral [12]ligaments. The cause of any loss of active range of movement should be carefully assessed and not presumed to be due to swelling. Normal range of motion for the second to fifth digits is approximately 80 degree of flexion at the DIP, 100 degree of flexion at the PIP and 90 degree of flexion at the MCP joint. A common injury site that can be overlooked is the volar plate, a thick fibrocartilagenous tissue that reinforces the phalangeal [13]joints on the palmer or volar surface. The extensor tendons of the hand are often divided into six compartments. At the [14]wrist on the dorsal side of the hand, the [15]tendons are encased in synovial sheaths as they pass under the extensor retinaculum. When palpating in the most radial of the distal end of the radius. The extensor pollicis longus angles sharply around the [16]bony prominence and can damage or even rupture the tendon after a serious [17]wrist fracture. The anatomical snuffbox is composed of the extensor pollicis longus and brevis and abductor pollicis longus. The floor of the snuffbox is the carpometacarpal joint of the thumb. Clinically this is a significant region for several reasons. Tenderness may suggest scaphoid fracture. The deep branch of the radial arterial passes through as well as the superficial branch of the radial [18]nerve; consequently, if a cast or splint is applied too tightly, it can lead to numbness in the thumb. Examination Involves: 91

1. Observation and sensation testing as per the [19]wrist. Special note should be made of the [20]hand arches and any deformities at the proximal or distal interphalangeal joints. • Hand at rest • Hand with clenched fist 2. Active movements-fingers (all Joints)

• Flexion • Extension • Abduction • Adduction 3. Active movements-[21]thumb

• Flexion • Extension • Palmar abduction • Palmar adduction • Opposition 4. Resisted movements (tendons)

• Flexor digitorum profundus • Flexor digitorum superficialis • Extensor tendon 5. Special test

• Ulnar collateral ligament of the first MCP joint • IP joint collateral ligaments Diagnosis of Hand Injuries: Routine radiographs of the hand include the PA, oblique and lateral views. All traumatic [22]finger injuries should be X-rayed. Ideally, ’dislocations’ need to be [23]radiographed before reduction to exclude fracture and after reduction to confirm relocation. Even when pre-reduction radiographs are not performed because reduction has occurred on the field, post-reduction films should be obtained after the game. Care should be 92

taken with lateral views to isolate the affected finger to avoid bony overlap. The use of more sophisticated investigation techniques is usually not required. Treatment of Hand Injuries:

• The functional hand requires mobility, stability, sensitivity, and freedom from [24]pain. It may be necessary to obtain stability by surgical methods. • However, conservative [25]rehabilitation is essential to regain mobility and long-term freedom from pain, Treatment and rehabilitation of hand injuries is complex. • As the hand is unforgiving of mismanagement, practitioners who do not see hand injuries regularly should ideally refer patients to an experienced [26]hand therapist, or at least obtain advice while managing the patient. • Inflammation and swelling are obvious in the hand and fingers. • During the inflammatory phase, the [27]therapist must aim to reduce [28]edema and monitor progress by signs of redness, heat and increased pain. • During the regenerative phase (characterized by proliferation of scar tissue), the [29]therapist can use supportive splints and active exercises to maintain range of motion. • During remodeling, it is appropriate to use dynamic and serial splints, and active and active assisted exercises, in addition to heat, stretching and electrotherapeutic modalities. 1. 2. 3. 4. 5. 6.

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Acute Wrist Injuries (2012-11-06 08:57) Diagnosis and Treatment of Wrist Injuries: The [1]wrist joint has multiple axes of movement: flexion-extension and radial ulnar deviation occur at the radiocarpal joints, and pronation-supination occurs at the distal and proximal radioulnar joints. These movements provide mobility for [2]hand function. Injuries to the wrist often occur due to a fall on the outstretched hand. In sportspeople, the most common [3]acute injuries are fractures of the distal radius or scaphoid, or damage to an intercarpal ligament. Intercarpal [4]ligament injuries are becoming more frequently recognized and, if they are not treated appropriately (e.g. including surgical repair where indicated), may result in long-term disability. The anatomy of the [5]wrist and hand is complex and therefore a thorough knowledge of this region is essential to diagnose and treat sports injuries accurately. The bony anatomy consists of a proximal row and a distal row, which are bridged by the scaphoid [6]bone. Normally, the distal [7]carpal row should be stable; thus, a ligamentous injury here can greatly impair the integrity of the wrist. Here a ligamentous injury disrupts important kinematics between the scaphoid, lunate, and triquetrum, resulting in carpal instability with potential weakness and impairment of hand function. History: It is essential to determine the mechanism of the [8]injury causing wrist pain. These injuries are commonly encountered in high-velocity activities such as snowboarding, rollerblading, or falling off a bike. A patient may [9]fracture the hook of hamate while swinging a golf club, tennis racquet or bat and striking a hard object (e.g. the ground). It is very useful to determine the site of the [10]pain; the causes of volar pain are different from those of dorsal wrist pain. Other important aspects of the history may include:

• Hand dominance • Occupation (computer related, manual labor, food service industry) • History of past upper extremity fractures including childhood fractures/injuries • History of [11]osteoarthritis, [12]rheumatoid arthritis, thyroid dysfunction, diabetes • Any unusual sounds (e.g. clicks, clunks, snaps, etc.) 94

• recurrent [13]wrist swelling raises the suspicion of wrist instability • Musician (number of years playing, hours of practise per week, change in playing, complex piece, etc.) Examination Involves: 1. Observation 2. Active movements

• [14]Flexion/ extension • Supination/pronation • Radial/[15]ulnar deviation 3. Passive movements

• Extension • Flexion 4. Palpation

• Distal forearm • Radial snuffbox • Base of [16]metacarpals • Lunate • Head of ulna • Radioulnar joint 5. Special tests

• Watson’s test for scapholunate injury • Stress of triangular fibrocartilage complex • Grip- Jamar dynamometer (may be contraindicated if a maximal effort is not permitted, e.g. after [17]tendon repair) • Dexterity- Moberg pick-up test • Sensation- Semmes Weinstein monofilament testing • [18]Nerve entrapment- Tinel’s sign 95

6. Standardized rating scales

• Several valid and reliable assessment scales can quantify function of the wrist specifically or the upper extremity after an Injury. Diagnosis of Wrist Injuries:

• Plain Radiography If [19]ligament injury is suspected, also obtain a PA view with clenched fist. A straight lateral view of the wrist, with the dorsum of the distal forearm and the hand forming a straight line, permits assessment of the distal radius, the lunate, the [20]scaphoid, and the capitate and may reveal subtle instability. The lateral radiograph of the normal wrist can be. These bones should be aligned with each other and with the base of the third metacarpal. A clenched fist PA view should be taken if scapholunate instability is suspected.

• Special Imaging Studies The combination of the complex anatomy of the wrist and subtle wrist injuries that can cause substantial morbidity has led to development of specialized wrist imaging techniques. A [21]carpal tunnel view with the wrist in dorsiflexion allows inspection of the hook of hamate and ridge of the trapezium. For suspected mechanical pathology, such as an occult ganglion, an occult fracture, non-union or [22]bone necrosis, several modalities are useful (e.g. ultrasonography, radionuclide bone scan, CT scan or MRI). [23]Ultrasonography is a quick and accessible way to assess soft tissue abnormalities such as tendon injury, synovial thickening, ganglions, and synovial cysts. Bone scans have high sensitivity and low specificity; thus, they can effectively rule out subtle fractures. Treatment of Wrist Injuries: Treatments for wrist problems vary greatly. [24]Treatment for wrist injury may include first aid measures. Treatment depends on:

• The position, type, and seriousness of the injury. • How long ago the injury happened. • Your age, [25]health problem and actions (such as work, sports, or hobbies). 1. 2. 3. 4. 5.

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How to Recognize a Condition Masquerading as a Sports Injury? (2012-11-21 10:46) Conditions Masquerading as Sports Injury:

[1] Not every patient who presents to the [2]sports medicine clinician has a sports-related condition. Sports medicine, like every branch of medicine, has its share of conditions that must not be missed but appear at first to be rather benign conditions. The aim of this article is to remind you that the patient with the minor ’[3]calf strain’ may, in fact, have a deep venous thrombosis, or that the young basketball player who has been labeled as having Osgood - Schlatter [4]disease because of playing may actually have an[5] osteosarcoma. The first part of the article outlines a clinical approach that should maximize your chances of recognizing a condition that is masquerading as a sports-related condition. The second part of the article describes some of these conditions and illustrates how they can present in the sports medicine setting. Examination The key to recognizing that everything is not as the first impression might suggest is to take a thorough history and perform a detailed [6]physical examination. If the clinician has not recognized a masquerading condition from the history and examination, it is unlikely that he or she will order the 97

appropriate investigations to make the diagnosis. For example, if a patient presents with tibial pain and it is, in fact, due to [7]hypocalcaemia secondary to lung cancer, a bone scan of the tibia looking for stress fracture will usually not help with the diagnosis, but a history of weight loss, occasional hemoptysis and associated shoulder pain, the history of associated [8]arm tightness and the physical finding of prominent superficial veins are more important clues to axillary vein thrombosis than would be a gray-scale ultrasound scan looking for [9]rotator cuff tendinopathy. If there is something about the history and examination that does not fit the pattern of the common conditions, then consider alternative, less common conditions. To be able to make the diagnosis of a rare or non-[10]musculoskeletal condition, you must ask yourself, Could this be a rare condition or unusual manifestation? Then other options are entertained, and the appropriate diagnosis can be conceived. Thus, successful [11]diagnosis of masquerading conditions requires recognition of a discrepancy between the patient’s clinical features and the typical pattern that one is familiar with from clinical experience. Bone and Soft Tissue Tumors Primary malignant [12]tumors of bone and soft tissues are rare but when they occur it is most likely to be in the younger age group (second to third decade). Osteosarcomata can present at the distal or proximal end of long bones, more commonly in the [13]lower limb, producing joint pain. Patients often recognize that pain is aggravated by activity and hence present to the sports medicine clinic. The pathological diagnosis of osteosarcoma is dependent on the detection of tumor producing bone and so an X-ray may reveal a moth eaten appearance with new bone formation in the soft tissues and lifting of the periosteum (Codman’s triangle) .In young patients, the differential diagnosis includes [14]osteomyelitis. It is recommended that any child or adolescent with [15]bone pain be X-rayed. Surgery is the preferred treatment. Synovial sarcomata frequently involve the larger lower joints such as the [16]knee and [17]ankle. Patients present with pain, often at night or with activity, maybe with instability and swelling. Synovial chondromatosis and pigmented villonodular synovitis are benign tumors of the synovium found mainly in the knee, which present with mechanical [18]symptoms. Osteoid osteoma is a benign bone tumor that often presents as exercise-related bone pain and tenderness and is, therefore, frequently misdiagnosed as a [19]stress fracture. The bone scan appearance is also similar to that of a stress fracture, although the isotope uptake is more intense and widespread. This condition is characterized clinically by the presence of night [20]pain and by the abolition of symptoms with the use of aspirin. The tumor has a characteristic appearance on CT scan with a central nidus. Ganglion cysts are lined by connective tissue, contain mucinous fluid and are found mainly around the [21]wrist, hand, knee and foot. They may be to a joint capsule or [22]tendon sheath and may have a connection to the synovial cavity. They are usually asymptomatic but can occasionally cause pain and deformity. Rheumatological Conditions These are dealt with in greater detail in the section on multiple joint problems. Patients with inflammatory musculoskeletal disorders frequently present to the sports medicine clinic with a masquerading traumatic or mechanical condition. Low back pain of ankylosing [23]spondylitis, psoriatic enthesopathy or early rheumatoid arthritis is common examples. In patients presenting with an acutely swollen knee without a history of precipitant trauma or 98

[24]patellar tendinopathy without overuse, the clinician may be alerted to the possibility that these are inflammatory in origin. Prominent morning joint or [25]back stiffness, night pain or extra-articular manifestations of rheumatologlcal conditions (e.g. skin rashes, nail abnormalities), bowel disturbance, eye involvement (conjunctivitis, iritis) or urethral discharge may all provide clues. Disorders of Muscle [26]Dermotomyositis and polymyositis are inflammatory connective tissue disorders characterized by proximal [27]limb girdle weakness, often without pain Dermatomyositis, unlike polymyositis, is also associated with a photosensitive skin rash in light-exposed areas (hands and face). In the older adult, dermatomyositis may be associated with malignancy in approximately 50 % of cases. The primary malignancy may be easily detectable or occult. In the younger adult, weakness may be profound (e.g. unable to rise from the floor) but in the early stages may manifest only as under-performance in training or competition. Dermatomyositis and [28]polymyositis may also be associated with other connective tissue disorders such as systemic lupus erythematosus or systemic sclerosis, and muscle abnormality is characterized by elevated creatine kinase levels and electromyography (EMG) and [29]muscle biopsy changes. Regional dystrophies such as limb girdle dystrophy and facio-scapulo-humeral dystrophy may also adults. They are also associated with characteristic changes. Endocrine Disorders Several endocrine disorders, for example, hypothyroidism and hyperparathyroidism, may be associated with the deposition of calcium pyrophosphate in joints. Patients may develop acute pseudo gout or a [30]polyarticular inflammatory [31]arthritis resembling rheumatoid arthritis. X-rays of the wrists or knees may demonstrate chondrocalcinosis of the menisci or triangular fibro cartilage complex. Adhesive capsulitis or septic arthritis may be the presenting complaint in patients with diabetes mellitus and those with other endocrine disorders such as acromegaly may develop premature osteoarthritis or [32]carpal tunnel syndrome. Patients with hypocalcaemia secondary to malignancy (e.g. of the lung) or other conditions such as hyperparathyroidism can present with bone pain as well as constipation, confusion and renal calculi. A proximal myopathy may develop in patients with primary Cushings syndrome or after [33]corticosteroid use. Vascular Disorders Patients with venous thrombosis or arterial abnormalities may present with limb pain and swelling aggravated by exercise. [34]Calf, femoral or [35]axillary veins are common sites for thrombosis. While a precipitant cause may be apparent (e.g. recent surgery or air travel), consider also the thrombophilias such as the antiphospholipid syndrome or deficiencies of protein C, protein S, anti thrombin III or factor V Leiden. The [36]Claudicant pain of peripheral vascular disease is most likely to be first noticed with exercise and so patients may present to the sports medicine practioner. Remember also that arteriopathy can occur in patients with diabetes. Various specific vascular entrapments are also found, such as popliteal [37]artery entrapment, which presents as exercise related calf pain, and thoracic outlet syndrome. Genetic Disorders Marfans syndrome is an autosomal dominant disorder of fibril in characterized by musculoskeletal, cardiac and ocular abnormalities. Musculoskeletal problems are common due to joint hyper mobility, ligament laxity, scoliosis or [38]spondylolysis. In patients with the Marfanoid habitus, referral for echocardiography 99

and ophthalmological opinion should be considered as sudden carac death or lens dislocation may result. Hemochromatosis is an autosomal recessive disorder of iron handling, which results in iron overload. Patients may present with a calcium pyrophosphate arthropathy with characteristic involvement of the second and third [39]metacarpophalangeal joints and hook-shaped osteophytes seen on X-ray of these joints. While ferritin levels are raised in patients with hemochromatosis, it is important to remember that ferritin is also an acute-phase protein and so levels can be elevated in response to inflammatory arthropathy. Infection [40]Bone and joint infections, while uncommon, may have disastrous consequences if the diagnosis is missed. Bone pain in children, worse at night or with activity, should alert the clinician to the possibility of [41]osteomyelitis. Bone infection near a joint may result in a reactive joint effusion. Septic arthritis is rare in the normal joint. In arthritic, recently arthrocentesed or diabetic joints, sepsis is much more common. Rapid joint destruction may follow if left untreated. Even though Staphylococcus aureus is the causative organism in more than 50 % of cases of acute septic joints, it is imperative that joint aspiration for Gram stain and culture and blood cultures are taken before commencement of antibiotic [42]treatment. Once only or repeated joint lavage may be considered in patients receiving intravenous antibiotic treatment. The immune compromised patient may present with a [43]chronic septic arthritis. In this situation, tuberculosis or fungal infections should be considered. Regional Pain Syndromes [44]Complex regional pain syndrome type 1 (formerly known as reflex sympathetic dystrophy [RSD]) is a post-traumatic phenomenon characterized by localized pain out of proportion to the injury, vasomotor disturbances, edema and delayed recovery from injury. The vasomotor disturbances of an extremity manifest as vasodilatation (warmth, redness) or vasoconstriction (coolness, cyanosis, mottling). [45]Early mobilization and avoidance of surgery are two important keys to successful management. [46]Myofascial pain syndromes develop secondary to either acute or overuse trauma. as regional pain associated with the presence of one or more active trigger points.

They present

Fibromyalgia is a chronic pain syndrome characterized by widespread pain, [47]chronic fatigue, decreased pain threshold, sleep disturbance, psychological stress and diffusely tender muscles. It is often associated with other symptoms, including irritable bowel syndrome, dyspareunia, headache, irritable bladder and subjective joint swelling and pain. Fibromyalgia is diagnosed on the examination finding of 11of 18 specific tender point sites in a patient with widespread pain. Current treatment evidence is for a stepwise program emphasizing education, certain medications, exercise and cognitive [48]therapy. Chronic fatigue syndrome has many similarities to fibromyalgia’s and may be the same disease process. It may present as excessive post-exercise muscle soreness but is always associated with excessive fatigue. Behavioral therapy and graded exercise therapy have shown promise as [49]treatment. At [50]Alliance Rehab & Physical Therapy we provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. For More Information Call Now at: [51]703-751-1008 [52] 1. 2.


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How we get relief from Minimizing Extent of Injury (RICE)? (2012-11-29 06:21)

Meaning of R.I.C.E.[1] The most important time in the [2]treatment of acute soft tissue injuries is in the 24 hours immediately following [3]injury. When soft tissue is injured, [4]blood vessels are usually damaged too. Thus, blood accumulates around damaged tissue and compresses adjoining tissues, which causes secondary hypoxic injury and further tissue damage. Consequently, every effort should be made to reduce bleeding at the site of injury. The most appropriate method of doing this is summarized by the letters[5] RICE. • R - Rest • I - Ice • C - Compression • E - Elevation Rest Whenever possible following injury the athlete should cease activity to decrease bleeding and [6]swelling. For example, with a thigh contusion, bleeding will be increased by contraction of the [7]quadriceps muscle during running. Where necessary, complete rest can be achieved with the use of crutches for a lower limb injury or a sling for [8]upper limb injuries. Ice Immediately after injury, ice is principally used to reduce tissue metabolism. Ice is also used in the later stages of [9]injury treatment as a therapeutic modality. Ice can be applied in a number of forms: 102

• Crushed ice can be wrapped in a moist cloth or towel and placed around the injured area, held in place with a crepe bandage. • Reusable frozen gel packs. • Instant ice packs that do not need pre-cooling. • Ice immersion in a bucket (useful for [10]treatment of injuries of the extremities). • Cold water and cooling sprays, which are often used in the immediate treatment of injuries but are unlikely to affect deeper tissues. Although there is no high-quality evidence for how long, and how often, to apply ice after an acute injury, a systematic review suggested that intermittent 10-minute [11]ice treatments are most effective at cooling injured animal tissue and healthy human tissue. Many practitioners apply ice for 15 minutes every I -2 hours initially and then gradually reduce the frequency of application over the next 24 hours. Ice should not be applied where local tissue circulation is impaired (e.g. in Raynaud’s phenomenon, [12]peripheral vascular disease) or to patients who suffer from a cold allergy. Other adverse effects of prolonged ice application are skin burns and [13]nerve damage. Compression [14]Compression of the injured area with a firm bandage reduces bleeding and, therefore, minimizes swelling. Compression should be applied both during and after ice application; the width of the bandage applied varies according to the injured area. The bandage should be applied firmly but not so tightly as to cause [15]pain. Bandaging should start just distal to the site of bleeding with each layer of the bandage overlapping the underlying layer by one-half. It should extend to at least a hands breadth proximal to the injury margin. Elevation [16]Elevation of the injured part decreases hydrostatic pressure and, thus, reduces the accumulation of interstitial fluid. Elevation can be achieved by using a sling for upper limb injuries and by resting lower limbs on a chair, pillows or bucket. It is important to ensure that the lower limb is above the level of the [17]pelvis. Other minimizing factors In the initial phase of injury (first 24 hours), heat and heat rubs, alcohol, moderate/intense activity and vigorous [18]soft tissue therapy should all be avoided? Whether or not electrotherapeutic modalities (e.g. magnetic field therapy, interferential stimulation, TENS) provide effective [19]pain relief and reduction of swelling in the initial period is a subject of debate. It is usually suggested to exercise R.I.C.E. at duration of 4 to 6 time for up to 48 time after an damage. Heat therapies are appropriate for some accidents, but should only be regarded after swelling has receded, roughly 72 time after an damage. If the part of one’s body does not reply to [20]R.I.C.E. treatment within 48 time, it would be sensible to seek advice from your doctor in the occasion a serious damage has happened such as inner blood loss or a damaged cuboid. 103

At [21]Alliance Rehab & Physical Therapy Our team works with individuals who have undergone a total hip or knee replacement with arthroscopic or other surgeries, sustained trauma to a bone, or have a bone or soft tissue disease. We focus on helping patients regain their strength, mobility and endurance so they can return home and resume their regular routines.For More Information Call At: [22]




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Are you being affected by Lower Back Pain? (2012-12-17 07:01)

Spondylolisthesis: Back Condition And Treatment[1] [2]Spondylolisthesis refers to the slipping of part or all of one [3]vertebra forward on another. The term is derived from the Greek spondylos, meaning vertebra and olisthanein, meaning to slip or slide down a slippery path. It is often associated with [4]bilateral pars defects that usually develop in early childhood and have a definite family predisposition.[5] Pars defects that develop due to [6]athletic activity (stress fractures) rarely result in spondylolisthesis. Spondylolisthesis is most commonly seen in children between the ages of 9 and 14, in the vast majority of cases it is the LS vertebra that slips forward on the S1. The [7]spondylolisthesis is graded according to the degree of slip of the vertebra. A grade I slip denotes that a vertebra has slipped up to 25 % over the body of the vertebra underlying it; in a grade II slip the displacement is greater than 25 %; in a grade III slip, greater than 50 %; and in a grade IV slip, greater than 75 %. Lateral X-rays best demonstrate the extent of [8]vertebral slippage. Clinical Features [9]Grade I spondylolisthesis is often asymptomatic and the patients may be unaware of the defect. Patients with grade II or higher slips may complain of [10]low back pain, with or without leg pain. The back pain is aggravated by extension activities. On examination, there may be a palpable dip corresponding to the slip. Associated [11]soft tissue abnormalities may be present. In considering the [12]treatment of this condition, it is important to remember that the patient’s low [13]back pain is not necessarily being caused by the spondylolisthesis. Treatment [14]Treatment of athletes with grade I or grade II symptomatic spondylolisthesis involves:

• Rest from aggravating activities combined with abdominal and extensor stabilizing exercises and [15]hamstring stretching. • Antilordotic bracing, which may also be helpful. 105

• Mobilization of [16]stiff joints above or below the slip on clinical assessment; gentle rotations may be helpful in reducing [17]pain; manipulation should not be performed at the level of the slip. • Athletes with grade I or grade II spondylolisthesis may return to [18]sport after [19]treatment when they are pain free on extension and have good [20]spinal stabilization. • If the symptoms recur, activity must be ceased. • Athletes with grade III or [21]grade IV spondylolisthesis should avoid high speed or contact sports. • [22]Treatment is symptomatic. It is rare for a slip to progress; however, if there is evidence of progression, [23]spinal fusion should be performed. If you are being impacted in low back pain again then come instantly at Alliance Rehab & Physical Therapy Center in VA & DC. Our Reduced Lower back Program uses a consistent, functional and outcomes-oriented approach to care that concentrates specifically on the lower back. Through an active and educational procession of treatment, our practitioners assist the affected person in returning to normal, activities as soon as possible. By providing comprehensive education in structure, pathology and proper proper the lower back, the affected person is motivated to participate in his or her recovery and in the prevention of future injury. For more information Call Now at: [24]703-205-1919 [25] 1.

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How to Prevent Patella Fracture? (2012-12-27 07:46)

Clinical Features and Treatment of Acute Patellar (Kneecap) Trauma: [1] [2]Acute trauma to the patella (e.g. from a hockey stick or from a fall onto the [3]kneecap) can cause a range of [4]injuries from fracture of the patella to osteochondral damage of the [5]patellofemoral joint with persisting patellofemoral joint [6]pain. In some athletes, the pain settles without any long-term sequelae. If there is suspicion of [7]fracture, X-ray should be obtained. It is important to be able to differentiate between a fracture of the [8]patella and a bipartite patella. A skyline view of the patella should be performed in addition to normal views. If there is no evidence of fracture, the patient can be assumed to be suffering acute patellofemoral [9]inflammation. This can be a difficult condition to treat. Treatment consists of NSAIDs, local electrotherapy (e.g. interferential stimulation, TENS) and avoidance of aggravating activities such as squatting or walking down stairs. Taping of the patella may alter the mechanics of patellar tracking and therefore reduce the irritation and [10]pain. Fracture of the Patella

• [11]Patellar fractures can occur either by direct [12]trauma, in which case the surrounding retinaculum can be intact, or by indirect injury from quadriceps contraction, in which case the [13]retinaculum and the vastus muscles are usually torn. • Undisplaced fractures of the patella with normal continuity of the extensor mechanism can be managed conservatively, initially with an extension [14]splint. • Over the next weeks as the fracture unites, the range of flexion can be gradually increased and the quadriceps strengthened in the inner range. • Fractures with significant displacement, where the extensor mechanism is not intact, require [15]surgical treatment. This involves reduction of the patella and fixation, usually with a tension band wire technique. • The vastus [16]muscle on both sides also needs to be repaired. The [17]rehabilitation following this procedure is as for undisplaced fracture. Patella Dislocation

• [18]Patella dislocation occurs when the patella moves out of its groove laterally onto the lateral femoral [19]condyle. • Acute patella dislocation may be either traumatic with a good history of trauma and development of a hemarthrosis following [20]injury, or atraumatic, which usually occurs in young girls with associated 107

ligamentous laxity, does not have a good history of trauma, and is accompanied by mild-to-moderate [21]swelling. Clinical Features Patients with traumatic patella dislocation usually complain that, on twisting or jumping, the [22]knee suddenly gave way with the development of severe pain. Often the patient will describe a feeling of something popping out’. Swelling develops almost immediately. The [23]dislocation usually reduces spontaneously with knee extension; however, in some cases this may require some assistance or regional anesthesia (e.g. femoral [24]nerve block). A number of factors predispose to dislocation of the patella:

• Femoral anteversion • Shallow femoral groove • Genu valgum • Loose [25]medial retinaculum • Tight lateral retinaculum • Vastus medialis [26]dysplasia • Increased Q angle • Patellar alta • Excessive subtalar pronation • Patellar dysplasia • General [27]hypermobility The main differential diagnosis of patella dislocation is an [28]ACL rupture. Both conditions have similar histories of twisting, an audible pop’, a feeling of something going out’ and subsequent development of hemarthrosis. On examination, there is usually a gross effusion marked [29]tenderness over the medial border of the [30]patella and a positive lateral apprehension test when attempts are made to push the patella in a lateral direction. Any attempt to contract the quadriceps muscle aggravates the pain. X-rays, including anteroposterior, lateral, skyline, and intercondylar views, should be performed to rule out osteochondral fracture or a loose body. Treatment

• [31]Treatment of traumatic patella dislocation depends on presentation. Relatively atraumatic dislocations are treated conservatively. • Traumatic first- or second-time dislocations (hemarthrosis present) are treated with [32]arthroscopic washout and debridement. • Recurrent dislocation is treated with [33]surgical stabilization. • As a result, the [34]rehabilitation program is lengthy and emphasizes core stability, pelvic positioning, vastus medialis obliquus strength, and stretching of the lateral structures when tight. 108

• The most helpful addition to patellofemoral rehabilitation in the recent past is increased emphasis on core stability. • Similar to [35]ACL intervention exercises, rotational control of the limb under the pelvis is critical to knee and kneecap stability. Patella Fracture is common among athletes. It is an injury to kneecap. Major symptom of Patella Fracture is knee swelling. Alliance Rehab & Physical Therapy is the best Rehab & Physical Therapy center in Virginia. We provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. Contact Us at: [36]703-751-1008 [37] 1. 2. 3. 4. 5. 6. 7. 8.

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How to treat Longstanding Groin Pain? (2012-12-31 10:57)

Treatment of Adductor-Related Longstanding Groin Pain: [1] Longstanding adductor-related [2]groin pain is localized medially in the groin and may radiate down along the [3]adductor muscles. The key examination features that distinguish this clinical entity from others are maximal [4]tenderness at the adductor [5]tendon insertion and pain with resisted adduction. Weakness of the adductor muscles is common and palpation of the adductors reveals generally increased muscle tone with trigger points along the [6]adductor longus. The pubic symphysis is frequently tender but this does not help to differentiate the four clinical entities. Occasionally there may be an obvious adductor [7]tendinopathy or enthesopathy with localized tenderness, [8]pain, and weakness on contraction, especially eccentric contraction, and a typical appearance of tendinopathy on ultrasound or MRI examination. More frequently there is no specific tendinopathy present. Signs and Symptoms of Groin Pain Unfortunately most patients with adductor-related [9]groin pain continue to train and play until pain prevents them from running. When the condition has reached that stage, a lengthy period of rest and [10]rehabilitation is usually required. However, if early warning signs are heeded, appropriate measures may prevent the development of the full blown [11]syndrome. These early clinical warning signs are (from most common to least):

• Tightness/[12]stiffness during or after activity with nil (or temporary only) relief from stretching • Loss of acceleration • Loss of maximal sprinting speed • Loss of distance with long kick on run • Vague [13]discomfort with deceleration. 110

Treatment of Groin Pain Traditional [14]treatment for most types of groin pain was rest’ but this most often resulted in a return of symptoms on resumption of activity. Compared with rest and passive [15]electrotherapy, active rehabilitation provides more than 10 times the likelihood of pain-free successful return to [16]sport. Thus, we outline a treatment protocol that combines experience and evidence from leading clinical centers. Five basic principles underpin a treatment regimen:

• Ensure that exercise is performed without [17]pain. • Identify and reduce the sources of increased load on the pelvis. • Improve lumbopelvic stability. • Strengthen local musculature using proven protocols. • Progress the patient’s level of activity on the basis of regular clinical assessment. These are outlined below. 1. Ensure that exercise is performed without pain The first and most important step is for the patient to cease training and playing in pain. Pain-free exercise is absolutely crucial for this [18]rehabilitation program. If pain is experienced during any of the rehabilitation activities, or after them, that activity should be reduced or ceased altogether. Experienced clinicians use absence of pain on the key provocation tests (e.g. squeeze test and Thomas test) as a guide to progress the rehabilitation program and minimize the mechanical [19]stress on injured [20]tissues. 2. Identify and reduce the sources of increased load on the pelvis As discussed previously, it is essential to identify and reduce the sources of increased load on the pubic bones. This may involve:

• Reducing adductor muscle tone and guarding with [21]soft tissue treatment and/or dry needling • Correcting [22]iliopsoas muscle shortening with local soft tissue treatment, neural stretching and mobilization of upper [23]lumbar intervertebral [24]joints • Reducing glutens medius muscle tone and myofascial shortening with soft tissue [25]treatment and/or dry needling • Identifying and correcting any [26]hip joint abnormality • Mobilizing stiff intervertebral segments • Improving core stability, especially activation of transversus abdominis and anterior pelvic floor [27]muscles. 3. Improve lumbopelvic stability Research has demonstrated a delayed onset of action of transversus abdominis activity in patients with 111

longstanding groin pain, suggesting that impaired core or [28]lumbopelvic stability plays a role in the development of this condition. 4. Strengthen local musculature using proven protocols Once pain has settled and muscle shortening has been corrected in the [29]adductor, iliopsoas and [30]gluteal muscles, then a graduated pain-free muscle strengthening program can be commenced. A similar pre-season adductor muscle strengthening program reduced the incidence of adductor [31]muscle strains in ice hockey players who were identified as at risk. 5. Progress the patient’s level of activity on the basis of regular clinical assessment The aim of the graded exercise program is to gradually increase the load on the pubic [32]bones and surrounding [33]tissues. Once the patient is pain-free, pain-free walking can begin and be gradually increased in speed and distance. The criteria for when the patient may return to running are when:

• Brisk walking is pain-free • Resisted [34]hip flexion in the Thomas position is pain-free • There is no crossover’ sign • There is minimal adductor guarding. Other non-surgical treatments

• Compression shorts have been advocated for those with mild pain who insist on continuing to train and play, and for those returning to sport after [35]rehabilitation. • The shorts substantially reduced pain when worn during exercise. • The mechanism of action of compression shorts remains unclear, but Dutch researchers have reported that [36]groin pain on resisted adduction (the squeeze test’) was significantly reduced by the application of a [37]pelvic belt. • They speculated that relative pelvic instability may contribute to the groin pain typically attributed to [38]tendinopathy. Groin Pain is very common among athletes. A significant cause of long-standing issues is adductor-related groin discomfort. Alliance Rehab and Physical Therapy provide 24/7 access to online appointments. If you are suffering from Groin Pain then Contact us at our [39]website or Call us at: [40]703-750-1204 [41] 1. 2. 3. 4. 5. 6.



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Chapter 3

2013 3.1


How to Care for Muscle Injury Pain? (2013-01-03 12:14) Types,









Definition of Muscle Injury: [2]Injury to the muscle and tendons is called [3]strain. Reasons

• Sudden unaccustomed or abrupt action or movements may tear the muscles. • Direct [4]trauma can also injure the muscles and[5] tendons. • Overstretching of muscles due to indirect trauma, especially in [6]sports persons. Types

• Acute Strain: This is due to sudden violent force or direct trauma. • Chronic Strain: This is due to injury existing since a long period leading to [7]muscle ischemia and fibrosis. 115

Path physiology Injury to the muscles leads to [8]pain. As a result, the muscle goes into spasm to limit the movements and reduce pain. Nevertheless, paradoxically, this protective [9]muscle spasm causes pain due to stimulation of pain fibers and thus a vicious cycle sets. The painful stimuli cause muscle spasm through the [10]peripheral nociceptive stimuli. Severity of Strain

• First Degree [11]Strain (Mild Con Tusion) • This is due to blunt injury and is due to direct trauma of lose intensity. • Pathology: Few muscle fibers torn. Bleeding is minimal and the [12]fascia remains intact. Clinical Features

• Localized pain and tenderness. • [13]Pain and spasm prevents muscle stretching. • Function is not impaired largely. • Tenderness over the affected [14]muscles. Management:

• First aid is by [15]Cryotherapy (by application of ice) for a period of 20 minutes. • Gentle active muscle stretch may be permitted after 20 to 60 minutes. • Compression bandaging with optimum pressure. • Low dose and low power ultrasound helps. • Gentle massaging of the surrounding area helps. • If [16]pain is minimal, the patient can be allowed to do the light work the next day. Second Degree Strain Cause: Here the [17]trauma is more serious.

• Pathology • Greater number of muscle fibers is torn. • There is bleeding. • The fascia is still intact. 116

• [18]Hematoma is still localized. Symptoms: Here are the symptoms.

• Pain is more severe. • Tenderness is severe. • [19]Severe muscle spasm. • The patient is unable to move the [20]limb. Third Degree Strain Cause: Undoubtedly, these injuries are due to trauma of a greater magnitude. Pathology: Larger area and greater number of muscle fibers are involved. More than one muscle group may be involved. The [21]fascia is partially torn. Bleeding is widespread and more. There could be both [22]intramuscular and inter muscular bleeding. The patient experiences severe pain and loss of function. Symptoms: Here all the above symptoms are of greater intensity. Treatment in Grade II and III Strains

• For first 24 hours • Immediate application of ice. • Compression bandage. • Limb elevation. • [23]Limb immobilized in splints. • Isometrics to the muscles, which are immobilized. • Active exercises to the unaffected [24]joints. • Pulsed electromagnetic field [25]therapy (PEMF) is known to help. • No active movements to the affected muscles. During the Next 24 to 48 Hours

• The pressure bandage is removed and active [26]muscle exercises are begun. • Stretching within the limits of pain is commenced. • Thermotherapy: Ultrasound, short wave diathermy and TENS help to relieve pain. 117

• Slow rhythmic massaging helps relieve the [27]muscle • Non weight bearing on crutches is slowly started • Rest of the measures is the same as above. Between 48 and 72 hours Apart from all the measures mentioned so far, the additional measures during this phase include:

• More vigorous active movements are encouraged. • Deep transverse friction [28]massage is added. • Partial weight bearing can be permitted. After 72 hours All the above measures are pursued in a more vigorous manner.

• Pressure bandage is totally removed. • Progressive resisted exercises using the Fowler technique by taking out 10 to 12 repetition maximum (RM), is practiced. • Full weight bearing should be permitted in injuries of the [29]lower limbs. • After full movement is regained, the patient is allowed to walk and jog. • Full functional activity should be regained by 4 to 6 weeks. • The various drugs used in the [30]treatment of muscle strain to relieve pain and [31]muscle stiffness is depicted. Grade Four Strain Cause: This is usually caused by [32]severe trauma. Pathology

• Complete tear of the muscle. • The fascia is tom. • Considerable bleeding which is intramuscular and diffuse. • Gross [33]swelling is present. Clinical Features 118

• Excruciating pain. • Severe tenderness is present. • A snapping sound may be heard by the patient. • Palpable gap between the [34]muscles felt. • Severe loss of function. • Active movements produced by the agonist are absent. • Active muscle contraction is absent. • [35]Joint function is not lost. • Muscle spasm is very severe. Treatment [36]Surgery is advised. This involves opening the ruptured site, evacuating the hematoma and suturing the [37]fascia sheath. Direct muscle repair is avoided.

• Compression bandage is applied and the [38]limb is immobilized for 2 to 3 weeks. • Active exercises to the unaffected joints. • Slow rhythmic [39]isometric exercises to the affected muscles. • Non-weight bearing after 48 hours. • The use of low frequency current (faradism) to obtain passive contraction is very useful. • Deep heating modalities like ultrasound, etc. help. • Rest of the measures is same as for [40]Grade II / III injuries. If you suffer a muscle injury(Strains) which fails to respond after a few days or continues to niggle, please contact Alliance Rehab & Physical Therapy for more specific advice. For more detailed Information Call Now at: [41]703-205-1919 [42] 1.


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How we treat Fracture of Femur? (2013-01-10 11:26)

Classification And Treatment in Supracondylar Fracture of Femur:[1] [2]Supracondylar region extends from the [3]femoral condyles to the junction of metaphysis with femoral shaft .The distal fragment is displaced and angulated posteriorly due to the pull of gastrocnemius [4]muscle. Mechanism of Injury It is due to severe [5]valgus or varus forces with axial loading and rotation due to RTA, fall, etc. Classification

1. Nears’s Classification • Undisplaced Fracture • [6]Displaced Fracture • Medial Displacement • Lateral Displacement • Comminuted Fracture 1. Muller’s AO Classification • Type A: Extra-articular Fractures. • Type B: Unicondylar Fractures. • Type C: [7]Bicondylar Fractures. Each is further subdivided into 1-3 depending on the severity of comminution.

1. OTA Classification of Supracondylar Fractures of Femur 121

Supracondylar Fractures of Femur • Type A: [8]Extra-articular. • Type B: Partial articular (Unicondylar). • Type C: Total articular (Bicondylar). 1. Further Subdivisions Type A • Simple • Metaphyseal Wedge • [9]Metaphyseal Comminution Type B • Fracture lateral condyle. • Fracture medial condyle. • [10]Frontal fracture. Type C • Articular and metaphyseal simple. • Articular simple and metaphyseal comminution. • Total comminution. Clinical Features It consists of the usual features of [11]fractures, but what is specific to this fracture is the [12]flexion deformity caused by the pull of gastrocnemius. Hemarthrosis is commonly seen, especially with fractures extending into the [13]joint. Radiographs Radiograph helps to study the fracture pattern more accurately. Routine AP, lateral and oblique (45degree) views are required. Arteriography: This should be performed in suspected [14]vascular damage or in associated dislocation of the [15]knee joint. Treatment The [16]treatment usually consists of conservative methods, traction and operative methods. 122

• Conservative Methods: This has a limited role and is usually useful in impacted and undisplaced fractures. In the former, a long [17]leg or Spica cast is sufficient and in the latter, a long above [18]knee cast after an initial period of skin or skeletal traction is all that is required. • Traction Methods: The choice is mainly skeletal traction and two methods are described. • Upper Tibial Traction: Here the skeletal traction is applied through the upper end of [19]tibia. Initial weight used is around 15-20 lbs and is subsequently reduced. The traction is given for a period of 8-12 weeks and the patient is put on cast braces. To prevent the [20]knee stiffness from developing, the patient is encouraged to carry out the knee movements during the traction itself. • Two-Pin Traction Method: In this method, traction is added through the [21]distal femur apart from the traction given through the upper end of tibia. This helps in accurate reduction of the fracture and maintains the reduction so obtained. The disadvantage of this technique is that it is cumbersome and may cause [22]neurovascular compressions in and around the knee. • Operative Methods: This consists of DRIP and is preferred as the closed reduction is associated with troublesome complications like limited knee motion, residual varus and internal rotation deformities. The advantages of open reduction are [23]early mobilization of the knee joint and an accurate reduction and rigid fixation. • Fixation Methods: The choice is between [24]medullary fixation and blade plate fixation. • Intramedullary Fixations: Rush pins, Ender’s nail, medullary nails, split nails, static locking nails, etc. are some of the commonly used medullary fixation methods. They offer biological fixation but the fixation offered is less stable. • Trigen (Third generation) Knee Nail: Inserted in a retrograde fashion. It is a titanium nail and has two holes for oblique screws and one for transverse screw at the insertion end. At the opposite locking end two holes are present in the [25]anteroposterior plane and 2 holes in the lateral plane. The results are encouraging. Complications The complications commonly encountered in [26]supracondylar fractures are delayed union, mal union, nonunion, [27]injury to the popliteal vessels and common peroneal [28]nerves, knee stiffness, deep vein thrombosis, infection, implant failure, etc. If you are being affected bone fracture of femur and come instantly our clinic Alliance Rehab & Physical Therapy. Our highly skilled hand therapists are proficient in the treatment of hand and upper extremity pathologies, from the acute to the chronic. Under the direction of the referring physician, our team designs each treatment based on the physician’s diagnosis and the specific needs of the patient. Conditions treated include, but are not limited to arthritis, fractures, tendon injuries, peripheral nerve injuries, carpal tunnel syndrome, crush injuries and repetitive motion disorder. For more detailed information our clinic Call Now at: [29]703-205-1919 [30] 1. 2. 3. 4. 5.


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How to get comfort from Thoracic Outlet Syndrome (Neck Tingling)? (2013-01-22 10:36) Clinical Features and Treatment of Thoracic Outlet Syndrome:

[1] The space at the [2]thoracic outlet or inlet when it is less than adequate, subjects the [3]neurovascular structures seeking to gain entry into the [4]upper limbs via this space, to undue pressure. The blame for the neurovascular complaints should be placed at the doorstep of the decreased space and not at the structures producing the problems. This [5]syndrome results from the compression of neurovascular bundle comprising of [6]subclavian artery and [7]vein, [8]axillary artery and vein and [9]brachial plexus at the thoracic outlet. Thoracic outlet is a space 124

between the first rib, clavicle, and the [10]scalene muscles. Sites of Compression The sites of compression could be either Supraclavicular, Subclavicular or Infraclavicular.

• Supraclavicular: Interscalene triangle between the anterior scalene muscles. • Subclavicular: Interval between the second [11]thoracic rib, clavicle, and subclavius. • Infraclavicular: Beneath an enclosure formed by the coracoid process, [12]pectoralis minor, and costocoracoid membrane. Rare Cause Scissor-like encirclement of axillary artery by the median [13]nerve. Contributing Factors Dynamic Factors [14]Arm when in full abduction pulls up the artery by 180 degree causing compression in the short [15]retroclavicular space. Static Factors

• Vigorous occupation: Increases the [16]muscle bulk and thereby decreases the space. • Inactive occupation: Decreases the muscle bulk and thereby increases the space. • Congenital: [17]Cervical rib decreases the interscalene space and thereby decreases the retroclavicular space. • Traumatic: Malunion or nonunion of [18]fracture clavicle. Anomalies of the first thoracic rib. Miscellaneous

• [19]Tumor arising from the upper lobe of the lung. • [20]Cervicothoracic scoliosis. • Abnormal variations of the [21]scalene muscles. 125

Clinical Features Obviously, this syndrome poses two major problems. The first one relates to the compression of the major [22]vessels and secondly to the compression of the nerves. 1. Vascular Problems Here the compression could be [23]arterial or venous. During the arterial compression, which is mild in the early stages the patient complains of numbness of the whole arm with rapid fatigue during overhead exercises. If the compression is significant, the patient will complain of [24]cold, cyanosis, [25]pallor, and Raynaud’s phenomenon. Venous compression leaves the [26]limb swollen and discolored after exercises, which disappears slowly with rest. 2. Neurogenic Problems Patients complain of par esthesia along the medial aspect of the arm, [27]hand, little and ring fingers. There is weakness of the hand also. Complications

• Subclavian [28]artery compression • Results in poststenotic dilatation • Stasis favors [29]thrombosis • The thrombi break and migrate distally causing embolization Investigations

• X-ray Neck: To rule out intrinsic causes like [30]cervical spondylosis, cervical rib, etc. • Nerve Conduction Studies: Difficult to determine the nerve conduction velocity through the thoracic outlet, but its biggest value is to rule-out problems like entrapment, e.g. ulnar nerve at [31]elbow, [32]wrist, etc. Treatment

• Conservative treatment: Consists of rest, [33]physiotherapy, exercises like shoulder shrugging, etc. • Surgical [34]treatment Thoracic Outlet problem is a number of conditions that happen when the veins or anxiety in the thoracic store the area between your collarbone and your first rib become compacted. This can cause discomfort in shoulder area and throat and pins and needles in your fingertips. Call now for best Physical Therapy: [35]703-205-1919 [36] 126

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Alliance Rehab and Physical Therapy (2013-04-20 10:57:35) Thanks for your valuable feedback and appreciation and we continuously trying our level best to provide you with the best possible information available. Dominique (2013-04-16 09:02:45) This is really interesting, You’re a very skilled blogger. I’ve joined your feed and look forward to seeking more of your excellent post. Also, I have shared your site in my social networks!




How Foot and Ankle Discomfort is treated? (2013-02-04 06:17)

Causes and Treatment of Hallux Valgus: [1] [2]Hallux Valgus is defined as a static [3]subluxation of the first [4]metatarsophalangeal joint. It is characterized by valgus (lateral) deviation of the great [5]toe and varus (medial) deviation of the first metatarsal. [6]Bony exostoses develop around the first metatarsophalangeal joint, often with an overlying [7]bursitis. In severe cases, exostoses limit first metatarsophalangeal joint range of motion and cause [8]pain with the pressure of footwear. Causes The development of hallux valgus appears to occur secondary to a combination of [9]intrinsic and [10]extrinsic causes. Recognized causative factors include:

• Constricting footwear (e.g. high heels) • Excessive pronation-increased pressure on the medial border of the [11]hallux, resulting in deformation of the medial capsular structures. • Others-cystic degeneration of the medial capsule, [12]Achilles tendon contracture, neuro-muscular [13]disorders, collagen deficient diseases. Clinical Features

• In the early phases [14]hallux valgus is often asymptomatic, however, as the deformity develops, pain over the medial eminence occurs. • The pain is typicaIly relieved by removing the shoes or by wearing soft, flexible, wide-toed shoes. Blistering of the skin or development of an [15]inflamed bursa over the medial eminence may occur. • In severe deformity, [16]lateral metatarsalgia may occur due to the diminished weight-bearing capacity of the first ray. 128

• Examination reveals the hallux valgus deformity often with a tender [17]swelling overlying the medial eminence. Investigation Plain X-rays should be performed to assess both the severity of the deformity and the degree of first [18]metatarsophalangeal joint degeneration. Treatment

• Initial [19]treatment involves appropriate padding and footwear to reduce friction over the [20]medial eminence. • Correction of foot function with [21]orthoses is essential. • In more severe cases surgery may be required to reconstruct the first metatarsophalangeal joint and remove the bony exostoses. • [22]Orthoses are often required after surgery. Hallux valgus is a situation that impacts the combined at the platform of the big toe. This condition is commonly known as [23]bunion. The big toe of the feet is known as the hallux. If the big toe begins to vary inward towards the child toe the situation is known as hallux valgus. [24]Alliance Rehab & Physical Therapy is best Rehab & Physical Therapy center in Virginia. Call now for quick Appointment: [25]703-704-5771 [26] 1. 2. 3. 4. 5.

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How to cure Ankle Tibial Nerve? (2013-02-22 10:13) Clinical Features, Investigation and Treatment of Tibial Nerve:

[1] [2]Stress fracture of the [3]medial malleolus is an unusual [4]injury but should be considered in the runner presenting with persistent medial [5]ankle pain aggravated by activity. Although the [6]fracture line is frequently vertical from the junction of the tibial plafond and the medial malleolus, it may arch obliquely from the junction to the [7]distal tibial metaphysis. Clinical Features

• Athletes classically present with medial ankle pain that progressively increases with running and jumping activities. • Often they experience an acute episode, which leads to their seeking medical attention. • Examination reveals [8]tenderness overlying the medial malleolus frequently in conjunction with an [9]ankle effusion. Investigations

• In the early stages, X-rays may be normal, but with time a linear area of [10]hyperlucency may be apparent, progressing to a lytic area and fracture line. • If the X-ray is normal, a radioisotopic [11]bone scan, CT or MRI will be required to demonstrate the fracture. Treatment 130

• If no fracture or an undisplaced fracture is evident on X-ray, [12]treatment requires weight-bearing rest with an air-cast brace until local [13]tenderness resolves, a period of approximately six weeks.

• If, however, a displaced fracture or a fracture that has progressed to non-union is present, surgery with internal fixation is required.

• Following [14]fracture healing, the practitioner should assess [15]biomechanics and footwear. A graduated return to activity is required.

Stress bone injuries of the inside malleolus generally happen over time with extreme standing and walking action such as running. Physical rehabilitation treatment is essential for all sufferers with a stress crack of the inside malleolus to speed up treatment, avoid repeat and make sure an maximum result. At Alliance Rehab & Physical Therapy we provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. For Best Rehabilitation and Physical Therapy Call now at: [16]703-750-1204 [17] 1. 2. 3. 4. 5. 6. 7.

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How do you heal OLECRANON BURSITIS? (2013-02-27 07:19)

[1] This is a [2]chronic inflammation of the [3]olecranon bursa. It may be the result of repetitive minor [4]injuries or irritation, microcrystalline deposition. [5]Infection occurs due to chronic friction as in students who tend to keep their [6]elbows repeatedly over the table, bench, etc. over long periods during writing, reading, etc. Clinical Features: It usually manifests as a swelling over the tip of the olecranon. There may be [7]pain, if there is inflammation. Inspection or palpation usually easily detects it. Investigations: Aspiration and culture of the [8]bursal fluid are necessary in order to exclude the possibility of an infectious etiology. Treatment: [9]Treatment is essentially conservative and consists of NSAIDs, local steroids, etc. Surgical excision is done in chronic cases. Microcrystalline-induced bursitis has a good prognosis and the symptoms usually resolve after a few days, whether treated or not. However, bursitis due to repeated minor irritation is more difficult to treat. Do not worry about Olercranon Bursitis now. We are here to [10]diagnose you. [11]Alliance Rehab & Physical Therapy is best Rehab & Physical Therapy center in Virginia. Call now for quick Appointment: [12]703-704-5771 Visit our website now: [13] 1. 2.


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How to get relief from Wrist Joint Pain? (2013-03-13 04:43) Clinical Features and Treatment of Wrist Joint Injury:

[1] [2]Wrist Joint is a common [3]carpal dislocation and can lead to severe disability of the [4]wrist function. Mechanism of injury This is due usually due to fall on the out-stretched [5]hands. It can cause late carpal instability and [6]arthritis. Hence, prompt and correct [7]treatment is mandatory. Clinical Features

• Patient presents with [8]pain • [9]Swelling • Tenderness 133

• Loss of wrist movements. Radiograph • In radiograph of the lateral view, normally [10]lunate forms a half-moon shape, which is lost in this dislocation. • Moreover, in the anteroposterior view the normal rectangular profile is lost. Treatment Problems • This may cause compression of the median [11]nerve. • If left untreated it may cause permanent palsy, hence, reduction should be carried out as an emergency procedure. Methods • If seen early, reduction is easy and immobilization for 3 weeks with wrist in slight [12]flexion usually gives good results. • If seen after 3 weeks, open reduction is done. • If lunate cannot be reduced by open reduction, resection of the proximal [13]carpal bones or arthrodesis of the [14]wrist may be necessary. Alliance Hand Therapy is currently providing care throughout Northern Virginia from our clinics located in Alexandria, Fairfax, Springfield and Woodbridge. Call today at: [15]703-205-1919 [16] 1. 2. 3. 4. 5. 6.

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How to prevent Foot Bone Injury? (2013-03-26 05:31) Clinical Features and Investigation of Foot Bone Injury:

[1] [2]Foot injuries are rare [3]injuries and are usually due to indirect forces. More commonly, they are associated with injuries to the [4]tarsometatarsal joints. Clinical Features

• [5]Pain • [6]Swelling • Tenderness • Limp and [7]pain on weight bearing Investigations Plain X-ray (AP, lateral, oblique views) with CT scan of the [8]foot. Classification Group A: Extra-articular Group B: Partly intra-articular (involves other navicular [9]cuneiform or [10]metatarsal [11]cuneiform joints). Group C: Involves both [12]articular surfaces. Treatment Non-operative: Short leg cast for 6 to 8 weeks for undisplaced fractures. Operative: For displaced fractures, open reduction and internal fixation with pins or screws. [13]Alliance Rehab & Physical Therapy provide 24/7 access to [14]online appointments, with most of the requests scheduled in less than 48 hours. If you are suffering from Foot Bone Injury then visit [15] or contact us at: [16]703-670-9935. 1. 2.


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What are the classifications of Capitellum (Elbow) Fracture? (2013-03-30 06:17) Classifications and Treatment of Capitellum Fracture (Elbow Injury):

[1] [2]Capitellum is the anterior portion of the lateral [3]humeral condyle. This fracture is unique in being intra-articular always. Mechanism of injury Fall on an outstretched hand, with [4]flexion or extension of the [5]elbow and the resulting shear forces through the radial head slices the capitellum. Classifications Based on the size of the articulating fragment, it is classified into three types:

• Type I (Hahn-Steinthal variety): This involves a large portion of the [6]capitellum and a small chunk of trochlea with less of [7]subchondral portion. • Type II (Kocher-Lorenz variety): Here only a large portion of the capitellum is involved with a huge chunk of subchondral bone. • Type III: Comminuted [8]fracture. 136

Clinical Features

• The patient complains of [9]pain and [10]swelling over the lateral aspect of the elbow. • [11]Elbow and forearm movements are also restricted. Radiographs A true lateral view of the elbow is mandatory to accurately [12]diagnose this fracture. The characteristic finding of this fracture is the presence of ”double arc sign” described by McKay over the X-ray. Treatment

• Undisplaced fractures can be managed conservatively by an above [13]elbow plaster cast or slab for 3 to 4 weeks. • Displaced fractures need open reduction and internal fixation with minifragment screws. [14]Alliance Hand Therapy is currently providing care throughout Northern Virginia from our clinics located in Alexandria, Fairfax, Springfield and Woodbridge. Our Hand therapy Program is a [15]specialized treatment program focusing primarily on conditions affecting the hand and upper extremities. Our Certified Hand Therapists have a high degree of specialization that requires several thousands of hours continuing education and advanced certification. Call today for best Hand Therapy: [16]703-726-9352 [17] 1. 2. 3. 4.

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How to cure Wrist Bone Fracture? (2013-04-19 10:40) Classification and Treatment of Wrist Bone Fracture:

[1] [2]Trapezium bone accidents are unusual carpal bone accidents. They can either happen in solitude or along with other [3]carpal bony injury. This accounts for 1 to 5 percent of [4]wrist fractures. It could be isolated fracture or dislocations. Mechanism of Injury • Fall on an outstretched [5]hand. • Direct blow over the dorsum of the hand. Classifications Trapezium fractures are divided into: • Body fractures • Ridge fractures (Palmar) • Dislocations: This could be dorsal, palmar or [6]radial and may be associated with [7]fracture of the scaphoid and trapezium. Clinical Features The patient complains of: 138

• [8]Pain • [9]Swelling • Tenderness over the [10]wrist • Resisted flexion produces pain Investigations Plain X-rays though useful are not reliable. CT scan is a better option. Treatment

• Undisplaced fracture: [11]Thumb spica for 4 to 6 weeks. • Displaced fracture: Open reduction and rigid internal fixation is advised. • Dislocation is [12]treated by open reduction and K-wire fixation. [13]Alliance Hand Therapy is currently providing care throughout Northern Virginia from [14]our clinics located in [15]Alexandria, Fairfax, Springfield and Woodbridge. Our [16]Hand therapy Program is a specialized [17]treatment program focusing primarily on conditions affecting the hand and upper extremities. Call now at: [18]703-750-1204 or Visit: [19] 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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Physical Therapy treatment for Back Pain (2013-04-25 10:32) Treatment for Back Pain:

[1] [2]Back pain and [3]injuries can be treated and managed extremely well using a range of physical therapies in combination with controlled exercise programmes. Often this is combined with medication to provide patients with a good outcome and relief of their [4]pain and symptoms. The aim of this approach is to:

• Decrease pain and [5]stiffness • Improve daily quality of life • Improve and maintain fitness, strength and posture • Increase flexibility and endurance Several avenues and professionals people are available to help with this conservative [6]treatment. Exercise

• People who are physically fit usually suffer less [7]back pain, and recover from injuries more quickly. • The muscular supports of the spine are crucial to maintaining good function and stability of the back. • With ageing, [8]injury or underlying spinal problems, the back muscles can easily become weakened, lose tone and are quickly tired. • It’s known that poor muscle condition can in itself be a cause of disability and pain. • Bed rest for more than one or two days can delay recovery and slow progress, as it results in joint mobility loss and deterioration in physical fitness. • A programme should include specific exercises to help your condition as well as to strengthen your back, [9]leg and abdominal [10]muscles. 140

• If you have [11]pain during the exercise, it may mean you’re not doing it correctly or that it’s not suitable for you. Talk to your doctor or [12]physiotherapist. • Walking, swimming and riding an exercise bike are good ways to improve fitness, but always seek professional advice, as some may aggravate back problem (for example, some swimming strokes). Physical Therapy Using a variety of techniques and equipment (including Pilates), and working closely with the patient, a [13]physiotherapist is professionally trained to:

• Assess and [14]treat your back pain with medical consultation and in partnership with your spinal surgeon • Help you restore normal back and spinal function • Help you learn how to prevent further injury • Provide specific exercises for your back condition Our [15]Lower Back Program uses a standardized, functional and outcomes-oriented approach to care that focuses specifically on the lower back. Through an active and educational continuum of treatment, our therapists assist the patient in returning to normal, daily activities as soon as possible. By providing comprehensive education in anatomy, pathology and care of the lower back, the patient is empowered to participate in his or her recovery and in the prevention of future injury. Call now for Best Physical Therapy: [16]703-704-5771 [17] 1. 2. 3. 4. 5.

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Mechanisms of Spinal Cord Injury (2013-04-27 07:18) Causes and Syndromes of Spinal Cord Injury:

[1] [2]Injuries to the [3]cervical spine constitute uncommon but nonetheless devastating occurrences to those participating in athletic events. These injuries happen primarily to athletes involved in the contact sports of football, wrestling, and ice hockey, with football injuries constituting the largest number of cases. The important work of Schneider in the mid 1960s, focusing on football-related head and [4]neck injuries, resulted in a significant reduction in the incidence of these accidents owing to improvements in equipment, education in proper techniques, offseason conditioning, and rule changes. Causes and Mechanisms of Spinal Cord Injury • The mechanism of [5]spinal cord injury can be sport related, but it is more commonly independent of the sport. • The major mechanism of serious cervical injury is an axial load, or a large compressive force applied to the top of the head. • This mechanism is more dangerous when the neck is slightly flexed, because the [6]spine is brought out of its normal lordotic alignment, which does not allow for proper distribution of force to the thorax. • Flexion puts the cervical spine in a straight line; thus, the musculature cannot assist in absorbing the force. • Torget al indicated that [7]injury occurs to the cervical spine when it is compressed between the body and the rapidly decelerating head. • When a fracture results, if the bone fragments or herniated disc materials encroach on the spinal cord, neurologic damage will occur. 142

• This mechanism is the primary cause of cervical [8]fracture, dislocation, and quadriplegia. Syndromes of Spinal Cord Injury [9]Spinal trauma may result in a variety of clinical syndromes, according to the type and severity of the impact and bony displacement as well as the subsequent secondary insults such as: • Hemorrhage • [10]Ischemia • Edema Complete spinal cord injury is a transverse myelopathy with total loss of spinal function below the level of the lesion. This insult is caused by either anatomic disruption of the [11]spinal cord or, more commonly, hemorrhagic or ischemic damage at the site of injury. Although the spinal cord usually remains in continuity, a physiologic block to impulse transmission results in the complete injury. Complete injury patterns are rarely reversible, although with long-term follow-up, improvement of 1 spinal level may be seen when the initial segmental traumatic [12]spinal cord swelling resolves. • Several patterns of incomplete spinal cord injury are common, usually produced on a vascular basis. • The central cord syndrome causes incomplete loss of motor function with a disproportionate weakness of the upper extremities as compared with the lower extremities. • This condition is thought to be the result of hemorrhagic and ischemic injury to the corticospinal tracts because of their somatotopic arrangement. Fibers of cervical nerves that innervate the [13]upper extremities are arranged more medially than those subserving function to the lower extremities. The originally described central cord syndrome also includes nonspecific sensory loss and bladder and sexual dysfunction. This injury pattern is also often seen in older patients with vertebral osteophytes and in those with hyper-extension injuries. [14]Alliance Rehab & Physical Therapy provide a comprehensive, multi-disciplinary approach to [15]neurological rehabilitation that includes muscle and sensory re-education, coordination activities, range of motion and speech therapy to those patients who have experienced a neurological disorder such as a [16]stroke or spinal cord injury. Call now for Quick Appointment: [17]703-205-1919 [18] 1. 2. 3. 4.

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How to get Relaxation from Neck Pain? (2013-05-07 10:34) Causes of Neck Pain:

[1] [2]Neck pain can be caused by irregularities in the [3]soft tissues areas, namely in the [4]muscles, ligaments, and [5]nerves. The irregularities can also occur in the bones and joints of the spine. The most common causes of neck pain in the soft-tissue regions are due to [6]injuries, degeneration, or prolonged wear and tear on the muscles and ligaments. In rare cases, infections or tumors may be the cause of neck pain. For some people, neck problems may be the source of [7]pain in the upper back, [8]shoulders, or arms. Other causes of neck pain can be caused by: INFLAMMATORY DISEASES - [9]Rheumatoid arthritis can cause destruction of the joints of the neck. Rheumatoid arthritis typically occurs in the upper neck area. CERVICAL DISK DEGENERATION - The [10]cervical discs act as a shock absorber between the bones in the [11]neck. In cervical disk degeneration, which typically occurs in people age 40 years and older, the normal gelatin-like center of the disk degenerates and the space between the vertebrae narrows. As the disc space becomes narrow, additional stress is placed on the joints of the [12]spine. INJURY - Because the neck has so much flexibility and it must constantly support the head, it is extremely susceptible to [13]injury. Motor vehicle or diving accidents, participation in contact sports, traumatic injuries, or falls may result in neck injuries. The regular use of safety belts in motor vehicles can help to 144

minimize or prevent [14]neck injury. OTHER CAUSES - Tumors, Infections, or Congenital abnormalities of the vertebrae may also cause neck pain and range of motion limitations. Risks and Prevention of Neck Pain You may be most shocked to learn that you do much of your standing, sitting, [15]exercise and other activities with a forward head. Test yourself and see if you have a tendency to tilt forward:

• Stand with your back to a wall, but not touching the wall. • Back yourself up to the wall until something on your body makes contact. Start paying attention to how other people sit while eating or how they tend to carry a large purse or backpack. Does their neck tilt forward against the load or are they using muscles to hold the spine in a healthy position? The average person will overstretch their [16]neck and upper body unequally so often, it is a mystery that they don’t have more pain.


• Stand with your whole body (heels, hips, upper back, and the back of your head) against a wall. • Bring the back of your head against the wall without raising or dropping your chin, or arching your back. • If you cannot keep your heels, hips, upper back, and the back of your head against the wall in a comfortable position or you crane your neck, you are too tight to stand up straight. Many people are susceptible to neck and shoulder pain because of repetitive [18]work-related issues, poor posture, and overall bad habits. The things listed below will help you assess your situation and your likely cause of neck and shoulder pain. Be aware of your Posture If you are sitting in the same position for long amounts of time you are a prime canditate for [19]neck stiffness and pain. 145

• Identify the risks associated with your job and your daily work routine. If you are required to lift heavy objects or are at risk of injury due to a fall or other trauma, you may eventually sustain a more serious injury which causes neck pain. Be certain you take the necessary precautions and safety measures while working. • Make an [20]appointment with your [21]doctor for a full check-up annually, especially if you are at increased risk of osteoporosis or congenital problems. • Examine your lifestyle for habits that may lead to [22]pain. Pay attention to how you fall asleep, or when you are resting on the couch. Pillows that are very soft or filled with feather or down are likely to cause bad posture during sleep. You should investigate pillows that support the natural curve of your back and neck. Make sure you have suitable furniture in your home. A desk chair that is not supportive or a pillow that doesn’t offer enough neck support will lead to bad posture and result in neck pain. • Use relaxation techniques when you are under mental and emotional stress. Stress is a major culprit in bad cases of [23]neck pain. Incorporate the following daily exercises and activities into your day to keep muscles flexible and healthy. Exercising regularly will also reduce tension and stress hormones in your body. [24]Aquatic therapy or pool therapy consists of an exercise program that is executed in the water. It is a valuable form of therapy that is useful for a range of medical conditions. Aquatic therapy utilizes the physical properties of water to aid in patient healing and exercise performance. Call today at: [25]703-670-9935 [26] 1. 2. 3. 4.

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What are the Causes of Achilles Tendonitis (Heel Pain)? (2013-05-24 05:15) Symptoms and Causes of Achilles Tendonitis: [1]Achilles Tendonitis is inflammation of the Achilles tendon. In most cases, it is a type of overuse [2]injury and is more common in younger people. Professional and weekend athletes can suffer from Achilles tendonitis, but it is also a common overuse injury in people not involved in sport. [3]Treatment includes rest, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and avoiding activities that aggravate the condition.

[4] Symptoms of Achilles Tendonitis Symptoms of Achilles Tendonitis include:

• [5]Pain in the back of the [6]heel • Difficulty walking – sometimes the pain makes walking impossible • [7]Swelling, [8]tenderness and warmth of the Achilles tendon Causes of Achilles Tendonitis Some of the causes of Achilles tendonitis include:

• Overuse injury –This occurs when the [9]Achilles tendon is stressed until it develops small tears. Runners seem to be the most susceptible. People who play sports that involve jumping, such as basketball, are also at increased risk. • Arthritis – Achilles tendonitis can be a part of generalised inflammatory [10]arthritis, such as ankylosing spondylitis or psoriatic arthritis. In these conditions both tendons can be affected. • Foot problems – Some people with flat feet or hyperpronated feet (feet that turn inward while walking) are prone to Achilles tendonitis. The flattened arch pulls on calf muscles and keeps the Achilles tendon under tight strain. This constant mechanical stress on the heel and tendon can cause inflammation, pain and swelling of the [11]tendon. Being overweight can make the problem worse. 147

• Footwear – Wearing shoes with minimal support while walking or running can increase the risk, as can wearing high heels. • Overweight and obesity – Being overweight places more [12]strain on many parts of the body, including the Achilles tendon. Diagnosis of Achilles Tendonitis To confirm the diagnosis and consider what might be causing the problem, it’s important to see your doctor or a [13]physiotherapist. Methods used to make a diagnosis may include:

• Medical history, including your exercise habits and footwear. • Physical examination, especially examining for thickness and tenderness of the Achilles tendon. • Tests may be required. These may include an x-ray of the foot, ultrasound and occasionally blood tests (to test for an inflammatory condition), and an MRI scan of the tendon. Treatment for Achilles Tendonitis The aim of the [14]treatment is to reduce strain on the tendon and reduce inflammation. Strain may be reduced by:

1. Avoiding or severely limiting activities that may aggravate the condition, such as running. 2. Using shoe inserts (orthoses) to take pressure off the tendon as it heals. In cases of flat or hyperpronated feet, your doctor or podiatrist may recommend long-term use of orthoses. 3. Inflammation may be reduced by: • Applying icepacks for 20 minutes per hour during the acute stage • Taking non-steroidal anti-inflammatory drugs Other Treatment that may be Recommended You may also be given specific [15]exercises to gently stretch the calf muscles once the [16]acute stage of inflammation has settled down. Your doctor or [17]physiotherapist will recommend these exercises when you are on the road to recovery. Recovery is often slow and will depend on the severity of the condition and how carefully you follow the [18]treatment and care instructions you are given. [19]Alliance Rehab & Physical Therapy is the Best Physical Therapy Clinic. At Alliance Rehab & Physical Therapy we provide 24/7 access to online appointments, with most of the requests scheduled in less than 48 hours. Call now for Quick Appointment: [20]703-356-3470 [21] 1. 2. 3.


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How to Recover from Knee Injuries? (2013-05-29 10:26) Prevention of Knee Injuries: The [1]knee joint allows you to run, walk and play sport. Awkward movements, falls and collisions, sudden twists, excessive force or overuse can result in a range of injuries to the knee joint and the structures supporting it. Common knee injuries include [2]ligament, tendon and cartilage tears, and [3]patello-femoral pain syndrome.


First aid for Knee Injuries in the first 48 to 72 hours

Suggestions for first aid [5]treatment of an injured [6]knee include:

• Stop your activity immediately. Don’t work through’ the [7]pain. • Rest the joint at first. • Reduce pain, [8]swelling and internal bleeding with icepacks, applied for 15 minutes every couple of hours. 149

• Bandage the knee firmly and extend the wrapping down the lower leg. • Elevate the injured leg. • Don’t apply heat to the [9]joint. • Avoid alcohol, as this encourages bleeding and swelling. • Don’t massage the joint, as this encourages bleeding and swelling. Prevention tips for Knee Injuries You can help to prevent injuries if you:

• Warm up joints and [10]muscles by gently going through the motions of your [11]sport or activity and stretching muscles. • Wear appropriate footwear. • Avoid sudden jarring motions. • Try to turn on the balls of your feet when you’re changing direction, rather than twisting through your knees. • Cool down after exercise by performing light, easy and sustained stretches. • Build up an exercise program slowly over time. Professional help for Knee Injuries Mild [12]knee injuries may heal by themselves, but all injuries should be checked and diagnosed by a doctor or [13]physiotherapist. Persistent knee pain needs professional help. Prompt medical attention for any knee injury increases the chances of a full recovery. [14]Treatment options include:

1. Aspiration – If the knee joint is grossly swollen, the doctor may release the pressure by drawing off some of the fluid with a fine needle. 2. Physiotherapy – Including ultrasound and electrical muscle stimulation [15]treatment, kneecap taping, exercises for increased mobility and strength, and associated [16]rehabilitation techniques. 3. Arthroscopic surgery or keyhole’ surgery – Where the knee operation is performed by inserting slender instruments through small incisions (cuts). [17]Cartilage tears are often treated with arthroscopic surgery. 4. Open surgery – Required when the injuries are more severe and the entire joint needs to be laid open for repair. [18]Aquatic therapy or pool therapy consists of an exercise program that is executed in the water. It is a valuable form of therapy that is useful for a range of medical conditions. [19]Aquatic therapy utilizes the physical properties of water to aid in patient healing and exercise performance. Call now for Quick Appointment: [20]703-670-9935 150

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How to cure Foot Pain? (2013-07-15 09:03) Causes and Symptoms of Foot Pain:

[1] [2]Foot pain can affect any part of your foot, from your toes to your [3]Achilles tendon at the back of your [4]heel. Some foot pain is just an annoyance, but foot pain can also be more serious, especially if it’s the result of an injury or certain chronic conditions. Minor foot pain usually responds well to home [5]treatment but more severe foot pain needs medical attention. If not treated, some types of foot pain can lead to long-term damage or disability. 151

Causes of Foot Pain Most foot pain is due to poorly fitting shoes, [6]injury or overuse. But structural defects and medical conditions, such as arthritis and diabetes, also can lead to foot problems. Foot pain may be caused by many different conditions or injuries. Acute or repeated injury, disease, or a combination is the most common causes of foot pain. Injury is a result of forces outside the body either directly impacting the body or forcing the body into a position where a single or combination of forces results in damage to the structures of the body. Poor biomechanical alignment may lead to foot pain. Wearing shoes that are too tight or high heels can cause pain at the balls of the feet and the bones in that area. Shoes that are tied too tightly may cause pain and bruising on the top of the foot.

• Injuries such as [7]ligament sprains, bruises, [8]muscle strains and fractures commonly happen suddenly (acutely). • Sprains, strains, bruises, and fractures may be the result of a single or a combination of stresses to the foot. • A sprain of the foot or [9]ankle happens when ligaments that hold the bones together are overstretched and their fibers tear. • The looseness of ligaments in the joints of the foot may lead to foot pain. The muscle’s bursa and fascia of the foot can be strained by overstretching, overuse, overloading, bruising, or a cut (such as by stepping on a sharp object). Achilles tendonitis is a common injury to the tendon that attaches at the back of the heel.

• Injury to the bones and joints of the foot can be caused by a single blow or twist to the foot, or also by repetitive injury that can result in a stress fracture. • A blunt-force injury such as someone stepping on your foot may result not only in a bruise (contusion) injury but also damage to the [10]muscles and ligaments of the foot. • Direct blows to the foot can cause bruising, breaking of the skin, or even fracturing of bones. • [11]Metarsalgia is the irritation of the joints of the ball of the foot. ”Turf toe” is a common athletic injury in which the tendon under the joint at the base of the big toe is strained. • Injury to the toenail can cause pooling of blood under the nail and the permanent or temporary loss of a toenail. • Repetitive injury to the [12]bones, muscles, and ligaments can result in extra bone growth known as spurs or exostosis. Symptoms may accompany foot pain Pain and point tenderness are the first indications that something is wrong in a specific area. The onset of pain, whether suddenly or over time, is an important indicator of the cause of the problem. Bones of the [13]foot are joined together by ligaments. A [14]sprain happens when the ligaments that 152

hold the bones together are overstretched and the fibers tear. Point tenderness and looseness of a [15]joint are indications of a sprain. Injury to the bones of the foot can be caused by a single blow or twist to the arch or also by repetitive injury that can end in a stress fracture. Fractures are indicated by a small point of pain that may be exquisitely tender on the bone. There may be a noticeable lump or gap at the site of the fracture. A turned toe or forefoot may also be a sign of a fracture. Injury to the bones of the foot can be caused by a single blow or twist to the arch or also by repetitive injury that can end in a stress fracture. Fractures are indicated by a small point of pain that may be exquisitely tender on the bone. There may be a noticeable lump or gap at the site of the fracture. A turned [16]toe or forefoot may also be a sign of a fracture. Prevention of Foot Pain

• To prevent injuries and pain, the following issues should be addressed before starting an [17]exercise routine. • Are you in good health? A general physical exam by a physician will help to evaluate your cardiovascular function, the possibility of disease or any other general medical problems that you may have. • Before beginning activities, diseases such as gout, diabetes, certain types of arthritis, and neuropathies should be treated. Treatment for Foot Pain When the pain begins to interfere with your daily living activities or if you cannot perform your chosen activities without pain, you should consider getting medical attention. Indications that you should seek medical care are: The area looks deformed, you have loss of function, change of sensation, a large amount of [18]swelling with pain, prolonged change of skin or toenail color, the affected area becomes warmer than the surrounding areas, becomes extremely tender to the touch, or is causing you to move differently. At [19]Alliance Rehab & Physical Therapy we provide 24/7 access to online [20]appointments, with most of the requests scheduled in less than 48 hours. Visit here for more information: [21] 1. 2. 3. 4.

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What are the Symptoms of Trigger Finger? (2013-08-28 09:15) Causes, Symptoms and Treatment of Trigger Finger: [1]Trigger finger is a condition in which it is difficult to straighten a [2]finger (or fingers) once bent. The medical term for trigger finger is stenosing [3]tenosynovitis.


Causes of Trigger Finger

Trigger finger results from inflammation or [5]swelling of the fibrous sheath that encloses the [6]tendons. A tendon is a band of strong fibrous tissue that connects a [7]muscle to a [8]bone. The straightening mechanism hesitates for a few moments before the tendon suddenly overcomes the resistance. The finger then straightens with a sudden jerk or triggering motion. Symptoms of Trigger Finger Symptoms include:

1. A snapping sensation (triggering) in the affected finger or [9]fingers 154

2. Inability to extend the finger smoothly or at all (it may lock in place while bent) 3. Tenderness to the touch over the tendon, usually at the base of the finger or palm 4. Soreness in the affected finger or fingers Diagnosis of Trigger Finger Your [10]health care provider will review your [11]symptoms and examine you. Treatment of Trigger Finger Sometimes it is helped by ice and anti-inflammatory medicine, such as ibuprofen. If this does not work, your health care provider may give you an injection of a local anesthetic to keep you from feeling pain in the area and a corticosteroid to reduce the inflammation of the tendon sheath. If necessary, surgery will be done to remove the part of the tendon sheath that is causing the tendon to get stuck. Ways to take care of yourself

• It is important to follow your health care provider’s instructions. • In addition, rest and limit the activity of the affected finger or fingers and of the [12]hand and [13]wrist. Prevention of Trigger Finger Since the cause of [14]trigger finger is unknown, there is no reliable way to prevent this condition from developing. [15]Alliance Hand Therapy is currently providing care throughout [16]Northern Virginia from [17]our clinics located in Alexandria, Fairfax, Springfield and Woodbridge. Call Us at: [18]703-750-1204 1. 2. 3. 4. 5. 6. 7. 8.

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How to cure Plantar Fasciitis? (2013-09-17 04:20) Symptoms and Treatment of Plantar Fasciitis:

[1] [2]Heel pain is a common complaint that has many causes. Heel pain may result from inflammation of the [3]tissue on the bottom of the foot. This is called [4]plantar fasciitis. The plantar ([5]foot) fascia (connective tissue) stretches under the skin across the [6]arch of the foot from the heel to the base of the toes, when this tissue is tom, overused, or improperly stretched. It can become inflamed (fasciitis) Soreness, [7]tenderness, and palm result. Persons who are overweight, female, or older than 40 years or who spend long hours on their feet are especially at risk of developing plantar fasciitis [8]Athletes, especially joggers and runners, may develop plantar fasciitis. Sometimes [9]plantar fasciitis can be associated with heel spurs. These spurs are outgrowths of bone on the calcaneus (heel bone). They are sometimes painful and may occasionally require surgical [10]treatment. Symptoms

• Heel Pain, especially in the early morning or after a period of rest • Increasing pain with standing • [11]Pain in the heel after exercising Treatments

• Rest • Arch supports (sometimes called orthotics) to be worn in shoes • Stretching the calf muscles and [12]Achilles tendon • Ice packs • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen • Reducing excess body weight • Corticosteroid injections may be used in select cases 156

• Surgery may be helpful if other [13]treatments are not successful Other causes of Heel Pain It is important to understand that all heel pain is not from plantar fasciitis. Other medical problems can cause [14]foot and heel pain. Diabetes and blood vessel disease, both serious medical problems, can cause heel pain. Arthritis, traumatic injury and bruising, gout, stress fractures (caused by repeated stress on bone), and other diseases can also cause heel pain. Rarely, tumors (either benign or cancerous) or infections can cause heel pain. If you develop persisting heel pain, see your [15]doctor for an evaluation. [16]Plantar fasciitis is common in middle-aged people. It also happens in young individuals who are on their legs a lot, like sportsmen or military. It can occur in one feet or both legs. For best treatment of Plantar fasciitis Visit [17] Contact Us at: [18]703-751-1008. 1. 2. 3.

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Physical Therapy Post Knee Replacement (2013-10-09 09:25) Knee tends to be the most common joint to be replaced in the human body. People are advised Knee Replacement surgery if, either [1]arthritis, bone diseases and some fracture has deteriorated the joint or if alignment problems have started hindering daily activities like walking, sitting and standing. [2]Post Knee Replacement Physical Therapy [3]Physical Therapy techniques after Knee Replacement Surgery help you to heal and resume your routine activities faster. [4]Physical Therapist provides you with [5]rehabilitation services during and after hospitalization. 157

While you are in the hospital after surgery, a [6]physical therapist will : "Educate you about practice walking with help of a walker or crutches "Guide you regarding getting in and out of a chair or bed safely "May employ electrical stimulation to decrease pain and swelling "Administer isometric exercises to prevent blood clotting and to enhance blood circulation. After you are discharged, your [7]physical therapist will execute a customized treatment plan including various progressive exercises catering to your specific needs and goals as well : "Motion Exercises : Pain and swelling can impede the progress of your replaced joint. Physical Therapists, to regain your motion, make you learn[8] exercises that will enhance blood circulation and reduce swelling and as well prevent blood clotting. Below listed exercises may be performed to heighten the range of motion: 1.Ankle Pumps 2.Knee Bending 3.Heel Slides 4.Knee Straightening Stretch "Strengthening Exercises : These exercises strengthen the otherwise weakened muscles of thigh and lower leg. Physical Therapists administer these exercises to strengthen your muscles and to stabilize[9] knee joint. Following exercises are performed to revitalize your muscles : 1.Lying Kicks 2.Quadriceps Sets 3.Straight Leg Lifts 4. Exercycling "Balance Training: Specific balance training exercises are taught and performed to [10]help patients to gain gait stability. These exercises are administered when you become able to put full weight and pressure on your replaced knee. These may include : 1.Leg Slides 2.Sitting Unsupported Knee Bends 3.Knee Exercises with Resistance "Functional Training: [11]Physical Therapists forward this training when you become capable to walk freely without feeling any pain or strain. This program is executed to heighten your activity level. They may include following [12]exercises in your schedule : 1.Stair Climbing and Descending 2.Prolonged Knee Stretch 3.Standing Knee Bends 4.Community based actions viz. Crossing a busy street, Getting on and off escalator [13]Contact [14]Alliance Rehab And Physical Therapy for your successful recovery after Knee Replacement and to get back to your feet as soon as possible. We develop a customized treatment plan after collaborating with your consulting surgeon and will help you to [15]rehabilitate quickly. [contact-form][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][contact-field label=’Location’ type=’select’ options=’Alexandria,Alexandria-Mt.Vernon,Fairfax,Fredericksburg,Tyso ns Corner / Vienna,Springfield,Stafford Leesburg / Lansdowne,Woodbridge,Washington DC’/][contact-field label=’Phone ” Number’ type=’text’ required=’1’/][/contact-form] 1. 2. aspx



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Vestibular Rehabilitation Therapy (2013-11-15 06:49) What Is Vestibular Rehabilitation Therapy? Vestibular Rehabilitation Therapy (VRT) is a specific exercise based program that is designed and developed by a [1]professional Physical Therapist to maximize the natural bodily capacities to compensate for the balance disorders and as well to lessen the dizziness related problems. Through Vestibular Rehabilitation Therapy [2]physical therapists treat variety of [3]symptoms related to vestibular disorders viz.

• Dizziness [4]

Symptoms Related to Vestibular Disorders

• Vertigo • Imbalance • Nausea • Anxiety • Fatigue • Trouble concentrating 159

• Blurred Vision • Muscle or Neck Stiffness or pain • Headaches Which are the tests conducted under Vestibular Rehabilitation Therapy? Before designing an efficient [5]Vestibular Rehabilitation Therapy plan for a patient, following tests are conducted to recognize his symptoms and to identify problem areas:

• Examination of patient’s medical history • Identifying and measuring balance, gait and posture • Eye- head Co-ordination tests • Questions are asked in form of Questionnaire to measure the severity of symptoms What type of exercises is prescribed under Vestibular Rehabilitation Therapy? The brain of a patient suffering from [6]vestibular disorders can not depend upon the information it receives from vestibular system. As a result of this, his ability to maintain balance gets affected and the symptoms start getting worse and heightened, day by day. To overcome such conditions,[7] vestibular exercises including the following are practiced under [8]Vestibular Rehabilitation Therapy to improvise gait and gaze stability of a patient:

• VOR Stimulation Exercises: This include the exercises which help to stabilize gaze and visual focus as well.During the course, the patient is asked to fix his vision on a set target while moving his or her head. • Ocular Motor Exercises: This include a course of exercises, wherethe patient traces the field with the movement of his eyes only, i.e. without stirring his or her head. • Balance Retraining Exercises: This incorporates the set of exercises, which aid to better the co-ordination of muscular responses and structuring of sensory information as well, which in turn results in improved balance control. • Canal Re-positioning Maneuvers: These are administered to dislocate the debris with in the affected canal. This debris consists of small crystals of calcium carbonate that get collected with in the canal of inner ear. • Aquatic Physiotherapy: It is beneficial for the patients suffering from the problem of chronic dizziness. During the course, all of the exercises are administered in a pool. If the patients [9]suffering from vestibular disorders perform their exercises correctly and regularly, in most of the cases the balance problems are improvised ad more over symptoms like muscle tension, dizziness, vertigo, headaches, fatigue begin to diminish or disappear completely with time. 160

[10]Alliance[11] Rehab and Physical Therapy offers a wide range of [12]support services to the patients. Our trained and [13]qualified physical therapists provide reliable and customized [14]treatment plans as per requirement and condition of the patients and help them to rehabilitate as soon as possible. 1. 2. 3. 4. 5. 6.

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Identifying and Treating Cluster Headaches (2013-12-20 09:50) What are Cluster Headaches? [1]Cluster Headaches are one-sided headaches which occur in cyclic patterns or clusters and are marked by the tearing of the eyes and stuffy nose. It is amongst the most agonizing and traumatic types of pain. Such headaches occur at the same time every year and is much more painful if it strikes you at night as compared to the day time. Episodes of pain occur constantly for one week to one year. Who normally get affected by Cluster Headaches? Men are at higher risk of getting affected by [2]Cluster Headaches than women. These headaches can strike at any age but are more likely to occur at adolescent or middle age. These are commonly inherent and are transmitted through genes. What triggers Cluster Headaches? The exact causes of Cluster Headaches are still not known to the physicians, but the following are considered as the potential [3]causes of Cluster Headaches:

• Sudden release of Histamine or Serotonin 161

• In taking alcohol or Smoking cigarettes • Bright Lights • Exertion • Heat • Nitrites rich food • Cocaine • Stress and Anxiety • Season(common in spring or autumn) What are the symptoms associated with Cluster Headaches? These [4]headaches arise frequently and without any warning signals but the pain most commonly attacks 2 or 3 hrs. after you fall asleep. Following can be enlisted as the signs and symptoms of Cluster Headaches:

• Excessive or throbbing pain; commonly concentrated around or in one eye • One sided pain; from neck to temples • Uneasiness • Excessive Tearing • Redness in the affected side eye • One sided runny nose • Sweating • Swelling around the affected side eye • Drooping eyelids What are the [5]treatments available for Cluster Headaches? Physicians adopt two types of techniques to treat Cluster Headaches viz.

• Abortive Medications: These medications are prescribed to treat pain when it strikes. Imitrex or some other triptans are prescribed to subside pain when it occurs. At times, oxygen therapy is also administered, where you have to inhale oxygen through face mask. • Preventive Medications : These medicines are prescribed by your doctor to minimize the time duration of[6] cluster headaches and to reduce the severity of pain during[7] cluster headaches. 162

How [8]Physical Therapists can help to treat Cluster Headaches? [9]Physical Therapists can assist you in getting rid of your Cluster Headaches beyond medications. Practicing exercises under the surveillance of an expert and trained [10]Physical Therapist can enable you to relax muscle tension and as well to relieve stress. [11]Physical Therapists prescribe following exercises to treat Cluster Headaches :

• Physical Therapists administer various relaxation techniques to help you to relax the muscles of your neck, jaw and shoulders. Progressive Relaxation techniques are also administered and practiced to relax each and every muscle of your body. • Cluster Headaches occur due to stress. Your breathing patterns get disturbed, when you are stressed. So to alter these disrupted breathing patterns, [12]Physical Therapists practice different breathing exercises and make you relieved. These exercises are really advantageous when you are suffering from pain. • Exercises that help to alleviate stress are followed. These help to reduce the occurrence ands severity of headaches. These also heighten the level of beta- endorphins which are your natural stress relievers. [13]Contact Alliance Rehab And Physical Therapy for the efficient management of any type of pain. Timely [14]diagnosis and treatment can save you from further pain and suffering and as well help you to lead a healthy and quality life. 1. 2.

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Chapter 4

2014 4.1


Skier’s Thumb: Causes, Symptoms and Treatments (2014-01-20 09:37) What do we mean by Skier’s Thumb? Skier’s Thumb is described as an [1]injury caused to Ulnar Collateral Ligament (UCL) of thumb joint. The twisting and tearing away of UCL results this condition. Any [2]injury to UCL weakens thumb’s gripping strength and as well causes loss of function. In other words, it unstables or loosens the thumb joint. As this injury recurrently happens during skiing accidents, therefore it is referred to as [3]Skier’s Thumb. But it does not imply that this injury occurs to skiers’ only. It can affect anybody who falls on an [4]outstretched hand with sufficient force applied to thumb that extends it away from the index finger.


Skier’s Thumb Treatment & Management

What are the causes of Skier’s Thumb? Following conditions can be cited as the common causes of Skier’s Thumb:

• A straight away or direct [6]injury to your thumb • Extending away of thumb from the palm of your hand • Falling on your open hand with tucked in thumb • Repetitive and gradual traumas to your thumb 165

• Slipping on the ski-slopes while holding or hands strapped to ski pole What are the signs and symptoms of Skier’s Thumb?

• [7]Pain, tenderness and swelling at the inner base of your thumb • Bruising • Difficulty in holding objects and moving your thumb • Difficulty in applying force using your thumb • Ability to pinch and grasp things with thumb and index finger gets impaired • Difficulty in throwing objects • Unstable Thumb • A lump in your thumb • Deformed thumb What are the treatment options available for Skier’s Thumb? The [8]treatment for Skier’s Thumb depends upon the extent of injury, patient’s condition and his specific needs and requirements. Following treatment options are followed to [9]treat Skier’s Thumb:

• To ease pain and swelling, ice pack may be placed on your thumb for 2 or 3 days after injury • To immobilize or reduce the movement of thumb, support devices like; splint, brace or thumb cast may be used. The splints or thumb casts are worn for 4 to 6 weeks and thereafter, a[10] physical therapy regime is followed and adopted to mobilize the thumb again. It includes:

• Ultra sound therapy; where sound waves are used to treat injury to soft tissues. • Massage Therapy is administered to repair the affected ligament. • Mobilization[11] exercises are performed to restore thumb functioning and movement. • [12]Physical Therapists make use of [13]Hand Therapy balls and Therapeutic Putty to restore thumb strength and dexterity. • Strengthening exercises are performed to strengthen the otherwise loosened thumb. [14]Contact Alliance Rehab and Physical Therapy for efficient [15]treatment of any of your musculoskeletal problems. Our patients’ well being and care are our top most priorities. Our brigade of exuberant, determined and acknowledged [16]physical therapists strives to provide finest [17]clinical treatments to our patients in friendly and caring environment. 166

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Anterior Knee Pain (2014-03-31 10:32) Chondromalacia Patellae: Causes, Symptoms and Treatment


Chondromalacia Patellae

[2]Chondromalacia Patellae, also known as runner’s knee’ is the most common cause of [3]chronic knee pain. It often affects the young athletics, but may also happen to-older people with arthritis and females as well, as they have less muscle mass than males. What do we mean by Chondromalacia Patellae? [4]Chondromalacia Patellae is a condition, where the cartilage under your patella or knee cap softens and wears away or deteriorates. Poor alignment or overuse of [5]knee cap or patella wears down the cartilage and as a result, knee cap begins to rub against the thigh bone which further leads to grinding sensations and 167

chronic pain in the front of the knee.

What are factors leading to Chondromalacia Patellae? When you bend your knee; the backside of your knee cap slides over the femur (thigh bone). But when the knee cap does not move properly it begins to rub with the thigh bone leading to swelling and pain. Many factors including the following lead to the improper movement of knee cap which ultimately results in [6]Chondromalacia Patellae:

• Weak hamstrings and quadriceps (back and front thigh muscles) • Imbalance between the adductors and abductors (the muscles on the outside and inside of your thigh) • Improper tracking of knee cap • Trauma to knee cap like; Dislocation or Fracture • Repetitive stress on knee joint due to activities like; running, jumping, twisting, skiing and playing soccer • Over-weight • [7]Knock-knees or Flat foot • Unusual or improper shaped patella under surface • [8]Arthritis What are the signs and symptoms associated with Chondromalacia Patellae?

• [9]Chondromalacia Patellae generally leads to a vague discomfort in the front of the knee, generally known as patellofemoral pain. This pain worsens with the activities like; sitting, bending, standing for longer periods and exercising • Feeling of tightness in the knee area • Reduction in thigh muscle mass • Minor swelling in the knee area • Loss of thigh muscle strength • Grinding or cracking sensation when knee is extended • Pain increases with kneeling down and squatting • You may feel trouble moving your knee joint past a certain point 168

What are the treatment options available to treat Chondromalacia Patellae? Non-surgical treatment techniques are generally adopted to treat Chondromalacia Patellae. The most effective treatment technique is to adhere to a well-organised [10]Physical Therapy treatment program. A [11]Physical Therapy treatment program comprises of a complete rehabilitation program improving your muscle function and flexibility while relieving you from pain and swelling. Following treatment techniques are adopted under a complete [12]Physical Therapy Rehabilitation Program: Initially for the management of pain and swelling, physical therapists may recommend:

• Resting your knee • Avoiding activities that irritate your knee cap • Icing your knee • Knee braces or arch supports to protect your knee joint and to improve the alignment as well • Special shoes inserts and support devices (orthotics) for flat feet Once the pain and swelling subsides below mentioned treatment techniques are employed by the Physical Therapists to help the patients to regain pain-free functioning and activity:

• Selective strengthening exercises are recommended to strengthen the inner portion of thigh muscles • Stationary bicycling, pool running or swimming are advised to maintain cardiovascular conditioning • Isometric exercises involving the tightening and releasing of muscles are recommended to maintain muscle mass • Taping of knee is recommended to reduce pain and as well to enhance the exercising ability • Specific exercises to correct the misalignment and muscle imbalance are recommended [13]Contact Alliance Rehab and Physical Therapy Contact [14]Alliance Rehab and Physical Therapy for the efficient and state-of-art treatment and quick relieve from any of your musculoskeletal pains. Our compassionate [15]physical therapists make use of minimum invasive diagnostic and [16]treatment techniques to save you from further pain and suffering and assist you to lead an active and healthy life. 1. 2. 3. 4. 5. 6.

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Alliance Rehab and Physical Therapy (2014-04-17 05:45:36) Hey Thanks Alot Dear. knee pain (2014-04-10 08:06:48) Thank you very much. I agree with your article, this really helped me. I appreciate your help. Thanks a lot. Good website.



Becker Muscular Dystrophy (2014-04-09 11:33)


What do we mean by Becker Muscular Dystrophy?

[2]Muscular Dystrophy belongs to that group of genetic degenerative disorders which involve progressive weakness and wasting of voluntary muscles of the body. This condition is named after the German doctor Peter Emil Becker who first described the disorder. [3]Becker Muscular Dystrophy (BMD) is among those common nine kinds of dystrophies; which are characterized by the slow weakness and wasting of skeletal muscles that are used for movement and heart muscles as well. Such dystrophies are common among the men than women. Being a genetic disorder; your family history of disease increases your risk of getting affected. Despite of being more common in men than women; males usually inherit it from their mothers, i.e. females are the carriers of this disease but they usually do not exhibit any symptoms. How is the Becker Muscular Dystrophy an inherited disease? When a particular flawed gene or mutation of a particular gene on the X-chromosome makes its associated protein (named as dystrophin) partially functional, this results in the [4]Becker Muscular Dystrophy. 170

That is the reason that [5]Becker Muscular Disease is also known as X-linked recessive genetic defect’ i.e. it is inherited due to a defective gene on the X-chromosome. Males manifest the symptoms of this disease because they have only one X- chromosome. While the females have two X- chromosomes, so they usually do not show any signs or symptoms as the healthier X- chromosome compensate for the defective one. What are the signs and symptoms of Becker Muscular Disease? The symptoms usually begin to appear during the childhood and are diagnosed by the age of 11 years. But the severity of the disease varies from person to person. The symptoms may include: " " " " " " " " " " "

Gradual but progressive muscle weakness Muscles cramps on exercising Inability to walk independently by the age of 16 Loss of walking by the age of 40 -60 and at times, 20-30 Severe upper extremity and trunk muscle weakness Toe-Walking and frequent falls Difficulty in breathing and Heart disease; particularly, Dilated Cardiomyopathy Skeletal and Muscular Deformities Fatigue Difficulty in getting up from the floor and Climbing stairs Loss of balance, co-ordination and muscle mass

What are the treatment options suggested to treat Becker Muscular Dystrophy? The treatment is generally focused at treating the symptoms and enhancing the patient’s quality of life. Treatment options suggested are generally supportive and include the following: " Physical therapy is suggested to encourage the activity as the inactivity (like bed rest) can further worsen the condition. Muscle strengthening exercises are suggested to maintain muscle strength. " Massage, Compression treatment and night Splints may be advised to treat muscle cramps. " Use of assistive devices like; knee, leg or back braces are suggested to keep the muscles flexible. " Occupational Therapy is advised; where patients are helped and taught to use orthopedic appliances like; wheel chairs and other assistive devices as well to improve movement and training for doing the daily tasks in new ways is also provided. [6]Contact Alliance Rehab and Physical Therapy for the adequate and enhanced treatment of any of your neuromuscular disorder. Our [7]certified therapists develop customized treatment plans according to your needs and preferences and utilize patient proven treatment techniques to heighten the quality of your life. 1. 2. 3. 4. 5.

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Knobby Knees (2014-04-19 12:11) Osgood Schlatter Disease Osgood Schlatter Disease (OSD) or [1]Knobby Knees is a common cause of [2]knee-pain among the teenagers. This pain mostly affects the boys between 13 to 14 years of age and the girls between 11 to 12 years. This problem mostly occurs during the growth spurt. What do we understand by Osgood Schlatter Disease? [3]Osgood Schlatter Disease is an overuse [4]injury of the knee resulting in pain and swelling below the knee cap over the shin bone. This disease is marked by the inflammation of the bone cartilage and /or tendon at the top of the shin bone, where the tendon from the knee cap attaches. It commonly affects the teens who are engaged in vigorous sports activities which involve lots of running, jumping and swift direction changes, as in; basket ball, gymnastics, soccer, figure skating, ballet and volley ball. What are the potential signs and symptoms of Osgood Schlatter Disease? Osgood Schlatter Disease usually harms one knee at a time but it may affect the both knees. It lasts for months and recurs until the child stops growing. Following signs and symptoms may be observed in the teens with OSD:

• Pain below the knee cap • Severe [5]pain during and after the activity • A tiny and soft bony bump under the knee cap • The swelled area becomes tender to pressure • Limping after the physical activity • Pain Easing with Rest • Tightness in the muscles surrounding the knee. What are the factors leading to the Osgood Schlatter Disease? At times, Osgood Schlatter Disease develops for no apparent reason. But the below mentioned factors may lead to the condition:

• Repeated small [6]injuries to knee before the growth spurt is over • Overuse of thigh muscles resulting in swelling • Repeated strain on the attachment of the patellar ligament • Formation of callus (healing bone) resulting into hard bony bump What are the treatment options suggested to heal Osgood Schlatter Disease? Osgood Schlatter Disease usually heals itself after the child’s bones stop growing. Till then, a customized 172

physical therapy treatment program targeted at relieving pain and swelling are practiced, following techniques are employed to treat the symptoms:

• Activity modification and in more severe cases, activity elimination is advised • R.I.C.E. Therapy (Rest, Ice, Compression and Elevation) is suggested to relieve pain • Stretching exercises; concentrated on the stretching of thigh muscles, are recommended • Strengthening exercises may be advised to stabilize the knee joint • To shield the sensitive area, the physical therapists may recommend to wear knee pads during the sport • Bracing, strapping and wrapping of knee area may be recommended for support Contact Alliance Rehab and Physical Therapy [7]Contact Alliance Rehab and Physical Therapy to proficiently manage and relieve any type of musculoskeletal pain. Our diversified team of [8]trained and certified therapists will develop a customized treatment plan for you while taking due care of your needs and urgencies and will help you to regain health and proper functioning. Check Our Latest Videos:

• [9]Alliance Rehab & Physical Therapy • [10] Alliance Rehab & Physical Therapy in DC • [11]Alliance Rehab & Physical Therapy Springfield VA • [12]Alliance Rehab & Physical Therapy Woodbridge 1. 2. 3.

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Alliance Rehab & Physical Therapy Clinics offer Treatments for Auto- Accident Injuries (2014-05-22 11:05)

[1] [2]Auto-Accidents are said to happen every 5 seconds in the United States and these figures continue to rise. Victims of auto-accidents usually suffer from [3]skeletal, muscular, neurological and [4]soft-tissue injuries which are not detectable initially as they do not cause much pain. So the victims ignore them and do not seek professional [5]treatment. This causes the biggest blunder. With [6]auto-accident injuries, immediate and specialized treatment is needed to avoid developing long term discomfort and chronic pain. A pro-active [7]Physical Therapy treatment and Rehabilitation plan can save the victims from surgical interventions and long term reliance on medications as well. [8]Physical Therapy modalities while conditioning your muscles and bones also help to alleviate pain and relieve the debilitating effects of [9]auto-accident injuries. Vehicular injuries often develop the symptoms like; back pain, whiplash, fatigue, headache, muscle-spasms, nausea, neck pain, tendinitis, shoulder pain, problems with vision, dizziness etc. [10]Physical Therapists are experts at diagnosing, evaluating and treating these injuries. They re-align your vertebrae and help to restore your lost structural balance and treat soft tissue injuries with customized[11] rehabilitation program. Various structural evaluation techniques including; X-rays, Spinal Joint Movement Evaluation, Gait and Postural Analysis, Joint Range-of Motion Testing, Strength and Reflex Evaluation, CAT or CT scan and MRI are conducted and adopted to detect and correct various musculoskeletal injuries. [12]Physical Therapy is mainly directed towards maximizing the motion of spine, curing spinal disc, alleviating muscle spasm and improvising the muscular strength. Following Physical Therapy modalities are used to [13]treat auto-accident injuries:

• Hands-On Therapy and therapeutic equipments are used for the vestibulo-ocular rehabilitation of the victims. • Corrective exercises are used to stretch and strengthen the damaged muscles. • Range-of Motion exercises are prescribed to improvise function and mobility • [14]Spinal Decompression therapy is employed to relieve [15]back pain due to herniated disc or Sciatica • Therapeutic exercises targeting and strengthening the joints are suggested. So if you have been a victim of vehicular accident and sustained a musculoskeletal injury and want to get relief without pain-killers and surgical interventions, then Physical Therapy is the most influential treatment available. [16]Contact Alliance Rehab & Physical Therapy for the skilled and prompt treatment of[17] auto-accident injuries. Our board certified therapists are specialized in diagnosing, treating and managing auto-accident whiplash injuries and have helped numerous patients to recover successfully from whiplash. 174

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