REHABILITATE, INVESTIGATE OR OPERATE?
ABOUT THE AUTHOR
Karen Finnin Musculoskeletal Physiotherapist BAppSc(Physio), MMuscPhys,
Karen graduated as a Physiotherapist from LaTrobe University in Melbourne, Australia in 1998, and subsequently completed a Masters in Musculoskeletal Physiotherapy. With over a decade working in Private Practice, Karen has extensive experience in managing spinal injuries, general sporting injuries and work related conditions. She has travelled interstate and overseas with sporting teams, and has developed a number of education programs in fields such as core stability retraining, fit ball use, and injury management. Karen is the Director of Physios Online, an online Physiotherapy Practice that specializes in providing long distance consultations for injured people working in remote areas. Karen is committed to improving access to quality injury management for people living and working in remote locations. You can contact Karen at karen@physios-online.com, or visit the Physios Online website at www.physios-online.com. 1
REHABILITATE, INVESTIGATE OR OPERATE?
ACKNOWLEDGEMENTS The author wishes to acknowledge the following sources: Dan Uden Sports Physiotherapist BExSc, BPhysio, MSportsPhys Greg Dea APA Sports Physiotherapist MPhysio(Sports), BPhysio(Hons), BSc Clinical Sports Medicine By Peter Brukner and Karim Khan Published 2007 by McGraw Hill Australia Pty Ltd in North Ryde, NSW Referenced Journal Articles: 1. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 2011. 93-A(2): p. 113-20. 2. Russell, T.G., Blumke, R., Richardson, B., Truter, P., Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother.Res. Int., 2010. 15: p. 167-175. 3. Kairy, D., Lehoux, P., Vincent, C., Visintin, M., A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation, 2009. 31(6): p. 427-447. 4. Russell, T.G., Buttrum, P., Wootton, R., Jull, G.A., Rehabilitation after total knee replacement via low-bandwidth telemedicine: The patient and therapist experience. J Telemed Telecare, 2004. 10(Suppl 1): p. 85-87.
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REHABILITATE, INVESTIGATE OR OPERATE?
CONTENTS
4
Introduction
8
Common Injury One: Neck Pain
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Common Injury Two: Shoulder Pain Insidious Onset
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16
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Common Injury Three: Shoulder Pain Acute Onset
Common Injury Six: Knee Pain Insidious Onset
Common Injury Nine: Ankle Injury
Common Injury Four: Elbow Pain
Common Injury Seven: Knee Pain Acute Onset
Common Injury Five: Low Back Pain
Common Injury Eight: Shin Pain
Common Injury Ten: Foot Arch Pain
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REHABILITATE, INVESTIGATE OR OPERATE?
Efficient Referring… One of the most powerful skills for any medical practitioner to have is to know when and where to refer a patient when assistance is required beyond their own circle of expertise. This is especially true for health professionals servicing remote locations, where the desire to act fast often competes with the upheaval and cost of increased travel for specialized services. Referral to health services, particularly in remote areas, is becoming easier and more efficient than ever before. This is largely due to the development of ‘eHealth’ initiatives. ‘eHealth’ refers to the progression of healthcare into the use of digital and online technologies. It is a broad term, and can include the digitizing of patient records, transmission of test results, and performance of health related consultations online. 4
REHABILITATE, INVESTIGATE OR OPERATE?
Research has proven that online consultation is as effective as ‘on site’ consultation in many areas of health. This certainly is true for online Physiotherapy consultation [1-4], meaning that quality diagnosis and management of musculoskeletal injuries is now increasingly accessible to people living and working in remote locations. When dealing with musculoskeletal injuries, medical practitioners are generally deciding between three main referral points: Do I refer the patient for rehabilitation, such as Physiotherapy? Do I refer the patient for an investigation, such as xray? or Do I refer the patient for opinion by a specialist, such as an orthopaedic surgeon? In this book, we have simplified these three options with the following terms:
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Rehabilitate?
ie, when is referral to Physiotherapy warranted? Referral is generally made to an ‘on site’ Physiotherapist, if there is one readily available. This includes private Physiotherapy services through a Private Practice, or public Physiotherapy services, often accessed through the outpatient department of a local Hospital or Community Centre. 5
REHABILITATE, INVESTIGATE OR OPERATE?
If an on site Physiotherapist is not readily accessible for the patient, referral can be made to an online Physiotherapy service. In many cases, the online service is as reliable as the ‘on site’ equivalent [Refs 1-4], and, if an online Physiotherapist feels that the patient requires an ‘on site’ health consultation, they will not hesitate to refer.
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Investigate?
Ie, when is referral for imaging required? What sort of imaging is required? Getting x-rays and scans performed can be expensive and inconvenient for the patient, and exposure to radiation must be minimized. It is therefore paramount to be aware of the correct clinical cues for investigation referral. Further investigation, including imaging, is always required if ‘red flags’ are present, eg • night sweats • waking in the night • unexplained weight loss • change in bladder or bowel function • severe and escalating pain • history of tumor There is a decreased threshold to investigate the injuries of patients under 18 and over 55 years of age. The immature and ‘over mature’ musculoskeletal systems of these populations can have a higher propensity for structural damage.
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REHABILITATE, INVESTIGATE OR OPERATE?
Operate?
ie, when is referral to the relevant surgeon/specialist required? Referral to a surgeon is for opinion regarding management options, and does not necessarily infer the patient will undergo surgery. In the case of musculoskeletal injuries, an Orthopaedic Surgeon is generally the specialist of choice. In the case of spinal issues with associated neurological changes, referral to a Neurological Surgeon may be warranted. Rehabilitate, Investigate or Operate? outlines referral guidelines for the ten most common musculoskeletal injuries. It is designed to assist the decision making process performed by medical practitioners, and should only be used in conjunction with a thorough clinical assessment, current research findings, and consideration of both musculoskeletal and medical differential diagnoses. To ask questions, give feedback or obtain further copies of this book, please contact enquiries@physios-online.com.
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY ONE:
Neck Pain Summary
Neck pain is often triggered by damage to a disc, facet joint or muscle. The longer the duration of the neck pain, the more factors tend to contribute, such as stress, posture, central sensitization, and weakness of the deep neck flexor muscles. Neck pain that includes persisting pins and needles, numbness and/or weakness in the arm must be investigated, and may require surgery in severe circumstances.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Neck pain, that is not improving, lasting more than 3 days
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray if any of these factors are present: • A history of trauma to the neck • A history of acceleration/deceleration injury • General neck pain lasting more than 3 months Refer for x-ray and MRI if any of these factors are present: • Upper limb pins and needles and/or numbness and/ or weakness lasting more than 2 weeks • Severe Sharp shooting pain lasting more than 2 weeks (bad enough to interrupt sleep) *generally referred for by specialist
Operate Refer to a specialist/surgeon if any of these factors are present: • Upper limb pins and needles and/or numbness and/ or weakness lasting more than 2 weeks • Severe Sharp shooting pain lasting more than 2 weeks (bad enough to interrupt sleep)
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY TWO:
Shoulder PainInsidious Onset Summary Insidious onset shoulder pain is often caused by the rotator cuff tendons, and generally results in issues with tendon impingement. Unless the tear is full thickness, conservative management is often adequate. Frozen shoulder can develop following injury or surgery, or can be idiopathic. Despite the intense pain that can result, management is also largely conservative, although capsular release or hydrodilatation in the early stages may expedite the drawn out recovery process.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Shoulder pain lasting more than 1 week
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray and ultrasound if any of these factors are present: • Unsatisfactory improvement following a 6 week rehabilitation program (ie continued impairment of ADLs or sport) • Marked weakness with arm elevation past shoulder height, lasting more than 6 weeks • Pain interrupting sleep for more than 2 weeks
Operate Refer to a specialist/surgeon if any of these factors are present: • Ultrasound proven full thickness tendon tear • Unsatisfactory improvement with 6 weeks of a rehabilitation program (ie continued impairment of ADLs or sport)
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY THREE:
Shoulder InjuryAcute Onset Summary Shoulder trauma can range from reaching quickly to grab a falling object, to forceful dislocation from body contact. Dislocation can sometimes cause a Bankart lesion to the anterior glenoid, or a HillSachs compression fracture to the posterior humeral head – these often require surgical review. Despite this, dislocations can often be managed conservatively, unless they become recurrent. Forcefully resisted muscle contraction around the shoulder can cause labral injuries (eg SLAP or non-SLAP), or a rotator cuff tear. A fall onto the shoulder can cause acromio-clavicular joint separation, or clavicle fracture.
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REHABILITATE, INVESTIGATE OR OPERATE?
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Shoulder pain lasting more than 1 week
Investigate Refer for x-ray if any of these factors are present: • History of a full dislocation Refer for x-ray and MRI if any of these factors are present: • Marked weakness with arm elevation persisting past 5 days
Operate Refer to a specialist/surgeon if any of these factors are present: • A history of 3 dislocations • Unsatisfactory improvement with 6 weeks of a rehabilitation program • Findings of full thickness tendon tear, a labral lesion, or fracture
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY FOUR:
Elbow Pain Summary Elbow pain is most commonly an insidious onset of pain through overuse, but a direct blow, forced movement, or fall onto the outstretched arm can also cause issues. Lateral epicondylalgia (‘tennis elbow’) is the most common cause of pain in the elbow, with irritation at the common wrist and finger extensor bone/tendon junction caused by repeated use. Trauma related bony tenderness requires investigation.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Elbow pain lasting more than 2 weeks
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray if any of these factors are present: • Significant trauma, particularly in the presence of bony tenderness and swelling Refer for x-ray and ultrasound if any of these factors are present: • Unresolving pain lasting 3 to 6 months
Operate Refer to a specialist/surgeon if any of these factors are present: • Confirmed fracture or avulsion • Unresolving pain or restricted ROM lasting more than 6 months, including unsuccessful 6 week rehabilitation program
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY FIVE:
Low Back Pain Summary Low back pain is often triggered by damage to a lumbar disc, facet joint or muscle. Defects in the bony structure of the vertebrae, such as spondylolysis (pars defect or stress fracture) or spondylolisthesis (vertebral slip) are also possible, particularly in adolescents. The longer the duration of the back pain, the more factors tend to contribute, such as stress, central sensitization, and weakness of the core stabilizing muscles. Back pain that includes persisting pins and needles, numbness and/or weakness in the leg must be investigated, and may require surgery in severe circumstances. Immediate referral to hospital is required for a person presenting with Cauda Equina symptoms (marked change in bladder or bowel function, saddle/ crutch paraesthesia, severe pain, and/or marked leg numbness and weakness) 16
REHABILITATE, INVESTIGATE OR OPERATE?
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Back pain, that is not improving, lasting more than 3 days
Investigate Refer for x-ray if any of these factors are present: • History of trauma to the back • General back pain lasting more than 3 months Refer for x-ray and MRI if any of these factors are present: • Pain with spinal extension and/or rotation, linked with a history of repeated extension/rotation load eg gymnastics, fast bowling Refer for x-ray and ultrasound if any of these factors are present: • Lower limb pins and needles and/or numbness and/or weakness lasting more than 2 weeks • Severe, or sharp, shooting pain lasting more than 2 weeks (bad enough to interrupt sleep) *generally referred for by specialist
Operate Refer to a specialist/surgeon if any of these factors are present: • Lower limb pins and needles and/or numbness and/ or weakness lasting more than 2 weeks • Severe, or sharp, shooting pain, not improving, and lasting for more than 2 weeks (bad enough to interrupt sleep)
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY SIX:
Knee Pain Insidious Onset Summary Knee pain that develops gradually is often due to tracking issues with the patello-femoral joint, but can also be due to degenerative changes of the articular surfaces, meniscal bruising or various tendinopathies. Persistent locking, catching or giving way can be indicators of structural damage requiring investigation, as can persisting effusion.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Knee pain lasting more than 2 weeks
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray if any of these factors are present: • Inability to flex knee past 90 degrees • Inability to weight bear for more than 4 steps (limping is OK) Refer for x-ray and MRI if any of these factors are present: • Locking, catching or giving way persisting despite rehabilitation • Significant intracapsular effusion • Pain unresolved/ unchanging after 12 weeks, including 6 week rehabilitation program *generally referred for by specialist
Operate Refer to a specialist/surgeon if any of these factors are present: • Severe pain lasting more than 4 months
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY SEVEN:
Knee Pain Acute Onset Summary
Acute knee trauma often occurs on the sports field, but can also occur through motor vehicle accidents, slips and falls. A knee with a history of twisting mechanism, click or pop at that time, and instant swelling, must be assumed to have an ACL rupture until proven otherwise through MRI. Most other knee ligament injuries are managed conservatively, particularly if no other accompanying damage is found. Persisting mechanical failure must be investigated.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Knee pain lasting more than 1 week
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray if any of these factors are present: • History of a traumatic incident, particularly in the presence of bony tenderness • Inability to flex knee past 90 degrees • Inability to weight bear for more than 4 steps (limping is OK) Refer for x-ray and MRI if any of these factors are present: • Locking, catching or giving way persisting despite rehabilitation • Significant intracapsular effusion • Pain unresolved/ unchanging after 6 week rehabilitation program *generally referred for by specialist
Operate Refer to a specialist/surgeon if any of these factors are present: • History of triad- twisting injury, click or pop, and instant swelling in half hour or less • Locking, catching or giving way persisting despite rehabilitation • Persisting significant intracapsular effusion • Pain unresolved/ unchanging after 6 weeks of rehabilitation program
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY EIGHT:
Shin Pain Summary The most common cause of shin pain is medial or anterior tibial periostalgia, commonly known as ‘shin splints’. There is usually a history of commencing or increasing impact activity, which results in a traction overload of the muscles around the tibia where they attach to the bone periosteum. In severe situations, this can result in tibial stress fracture, in which the pain is more severe and point specific. In non-responding shin pain, a differential diagnosis of compartment syndrome must be considered, particularly if the area of pain corresponds to the anterior, or deep posterior muscle compartments.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Shin pain lasting more than 2 weeks 22
REHABILITATE, INVESTIGATE OR OPERATE?
Investigate Refer for x-ray if any of these factors are present: • History of a traumatic incident, particularly in the presence of bony tenderness Refer for x-ray and MRI if any of these factors are present: • Site specific pain with impact and focal bony tenderness Refer for a compartment pressure test* if there is: • Escalating pain with activity, failed rehabilitation program, pain in the distribution of the deep posterior compartment (medially), or anterior compartment (antero-laterally) *generally referred for by a sports physician
Operate Refer to a specialist/surgeon if any of these factors are present: • Positive finding on a compartment pressure test (pressure greater than 25 to 30 mmHg post exercise)
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY NINE:
Ankle Injury Summary The most common acute ankle injury is the inversion sprain, with damage to the anterior talo-fibular ligament and, in more severe cases, the calcaneo-fibular ligament. The same general mechanism of injury can cause a malleolar fracture which may or may not require surgical fixation, so bony tenderness needs to be investigated. Inversion injury with peroneal contraction can sometimes cause an avulsion fracture of the base of the 5th metatarsal, so bony tenderness in this area should also be investigated. An ankle sprain that is not recovering should be checked for damage to the cartilage surface of the talar dome with an MRI.
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REHABILITATE, INVESTIGATE OR OPERATE?
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Any acute ankle injury
Investigate Refer for x-ray if any of these factors are present: • Bony tenderness over the lateral or medial malleolus, navicular, or the base of the 5th metatarsal • Bony tenderness along the posterior border of the tibia or fibula, in the distal 6cm segment • Inability to weight bear for more than 4 steps at time of injury, and at time of assessment Refer for MRI* or bone scan if any of these factors are present: • Significant pain and disability persisting 6 weeks post ankle injury, despite rehabilitation *generally referred for by specialist
Operate Refer to a specialist/surgeon if any of these factors are present: • Confirmed fracture • History of recurrent instability (ie ankle ‘rolls’ repeatedly with minimal provocation) • Significant pain and disability persisting 12 weeks post ankle injury, despite rehabilitation
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REHABILITATE, INVESTIGATE OR OPERATE?
COMMON INJURY TEN:
Foot Arch Pain Summary The predominant cause of insidious onset arch of foot pain is Plantar Fasciitis, with peak tenderness at the back of the arch next to the heel. It is often mistakenly referred to as a ‘heel spur’, however the finding of a heel spur on xray has proven to be unrelated to the condition. It can be stubborn to treat, but will usually resolve with time and persistent rehabilitation. Taping of the arch by a Physiotherapist or Podiatrist can be very effective for shorter term pain relief.
Rehabilitate Refer to a Physiotherapist if any of these factors are present: • Foot arch pain lasting more than 2 weeks
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REHABILITATE, INVESTIGATE OR OPERATE?
Investigate • Investigation is rarely required
Operate Refer to a specialist/surgeon if any of these factors are present: • 3 months of non improving pain, including failed rehabilitation program, for possible injection therapy
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ABOUT PHYSIOS ONLINE www.physios-online.com
Physios Online is an online Physiotherapy Clinic, specializing in distance injury management through the use of digital technologies. Physios Online is great at helping people who are injured, but live or work in a remote location. At Physios Online, Physiotherapists trained in distance injury management, can assess, diagnose and treat musculoskeletal injuries, using a combination of digital media, such as online assessment forms, video and audio communication, and email. For more information:
enquiries@physios-online.com www.physios-online.com
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