Lunchtime Lecture 14th May 2012 by Dr Tim Wood, Sports Physician, Glenferrie Private Hospital, Hawthorn, Melbourne 3122 held at Albert Street Sports and Spinal Injuries Centre, Warragul
Topics discussed:
Why does tendinopathy occur?
Overload. Trauma such as a sudden blow to the elbow (inflammatory in acute stages) - NSAIDs may be beneficial here. Rest rarely cures the problem - we need to load the tendon at a level that it can cope with and challenge it from there.
Pathophysiology of tendinopathies - healthy tendon comprises of tight collagen fibres, tenosites and protein ?ground substance. When the collagen breaks down, ground substance infiltrates the spaces and allows for neovessels to become embedded. It is still uncertain what causes the pain associated with tennis elbow but perhaps the nociceptive neovessels could be responsible. The increase in ground substance can lead to partial tears in the tendon. Both ground substance build up and neovessels can be shown up on ultrasound, both musculoskeletal and Doppler.
Cortisone, Autologous Blood Injection, Platelet Injection & Surgery - what works well?
Less use of cortisone in sub-acute to chronic stages, unless pain is constant and severe as CSI can be an effective pain reliever. Autologous Blook Injections are now performed in-rooms in Melbourne and also under ultrasound guide. Platelet injection is expensive and used less regularly but provided 8-9x greater effect of blood injection than the ABI. Surgery is now less common due to poor results. The only surgeon in Melbourne still to perform this type of surgery is Greg Hoy at the Melbourne Orthopaedic Group.
Rehabilitation protocol:
Broomstick exercise 3x15 reps daily
Find the centre where weight is eveny distributed. Start at that level with supination and pronation exercises and as pain allows, gradually moved hand down towards the top of the handle, 1cm by 1cm over a 12 week period.
Sunday 13 May 2012
Thursday 3 May 2012
Diagnosing Acute Knee Injuries
Presentation by Clare Walsh, Sports Physiotherapist for Clinical Edge (www.clinicaledge.com.au)
SUBJECTIVE EXAMINATION
1. Was the injury contact or non-contact?
2. Did you play on? If so, how long could you play on for?
3. Did you or anyone around you, hear a pop or a crack, or did you feel a pop?
4. Was there immediate swelling or did it take a couple of days to develop?
5. Is there any clicking, popping or giving way at the knee joint?
Giving way associated with twisting or turning which usually means that rotational instability is caused by the ACL, and also buckling in a straight line due to quads insufficiency if knee is weak or there is swelling.
If there is immediate swelling, this indicates a haemarthrosis and this can really only mean three things:
1. An ACL rupture, because of the rich blood supply to the ligament
2. Patella dislocation
3. Fracture
If milder swelling, more indicative of intra-articular pathology
OBJECTIVE EXAMINATION
Gait assessment
Squat - assess if they are able to compress the knee joint and whether WB is equal
In supine, assess the swelling with the swipe test, sweeping the fluid from the medial pocket to the lateral - a positive test will produce a pocket of fluid on the medial side
72-90% of ACL injuries are non-contact injuries
ACL rupture occurs when the athlete is decelerating and pivoting, or landing suddenly (maybe avoiding a tackle in rugby league) - the tibia moves forwards on the femur and ruptures the ACL. This is very painful and will usually result in the athlete grabbing the flexed knee.
Lachman's - looking for an end feel with anterior drawer
Reverse Lachman's - looking for an end feel with posterior drawer (assessing integrity of PCL)
Surgery is recommended for complete ACL ruptures. Recent studies have shown that at 8 years post injury with conservative management only, those with partial ACL tears did very well but those with compete ruptures did not have good outcomes.
Surgery is done arthroscopically, either with a hamstring tendon or patella tendon graft from the same knee, or more recently through a LARS procedure (ligament augmentation and reconstruction system) using a synthetic allograph. The LARS procedure has a reduced recovery time as there is no donor site and therefore no specific hamstring or patella tendon healing time required
Prevention Injury and Enhanced Performance is a programme that was started in the USA and is being rolled out in Australia. This is a warm up that has been proven to reduce ACL injury by 42% and involved neuromuscular control and proprioception exercises.
MCL sprain occurs with a valgus force to the knee, commonly in skiing and basketball. This can occur in isolation, or along with a medial meniscal injury. There can be some swelling localised to the ligament itself but there will not be any effusion inside the knee joint.
Grade I: Painful but no laxity
Grade II: Painful++ and some laxity
Grade III: Obvious laxity and no end feel
Test the MCL with a valgus stress at 30 degrees flexion. Grade II and III tears should be supported with a hinged knee brace to allow the ligament to tighten. Knee strengthening is essential to provide some stability to the knee joint. Straight line activity only for 4-6 weeks with grade II, possibly 8 weeks with grade III.
PCL tears usually occur with a hyperextension injury. PCL reconstruction was the preferred choice a number of years ago, but recent research suggests that the patient can get just as good recovery, if not better, from conservative management.
To test the PCL, first assess tibial sag in crook lying.
PCL injuries requires lots of VMO and control work to prevent patellofemoral problems from occurring.
LCL injuries are rare but occur with a varus stress to the knee joint. The LCL is part of the postero-lateral corner of the knee, including the biceps femurs and the postero-lateral capsule and the arcuate ligament.
If there is a complete rupture of the postero-lateral corner of the knee, this will require surgery as the knee will be very unstable. There could also be a lateral meniscus tear or a B Femoris tear in isolation.
Meniscal injuries are very common and result in an effusion that presents over a day or so, usually around the periphery/joint line, especially with a bucket handle tear. Medial are more common than lateral, and can be diagnosed by subjective questioning, palpation and McMurray's test. MRI can also be used to confirm diagnosis.
The McMurray's test can only be done in full flexion. If the knee is too painful to achieve full flexion, then a diagnosis cannot be made. The McMurray's test is done by taking the knee into full flexion then applying a varus and valgus stress to the knee. If locking, arthroscopy will be effective. For smaller tears in the posterior horn, a conservative approach will be tried in the first instance. If continual swelling and pain, best to refer on to an orthopaedic surgeon for a surgical opinion.
The articular cartilage can be damaged through knee injury, especially with impact which can cause a chondral pathology. in some cases, there may already be damage to the articular cartilage which becomes worse with impact. Chondral injuries commonly occur with ACL injuries and meniscal injuries. To diagnose a chondral injury, it is likely that you have ruled out any other meniscal or ligamentous damage but there is still effusion present. MRI can diagnose this injury.
To treat the articular cartilage injuries, you can't treat the cartilage itself so treat the symptoms.
Chondroplasty is the most common form of surgery (debridement through arthroscope) which lets the area bleed and scar over, providing a little more shock absorption at the joint. Chondral cell implantations are being carried out but it is a drawn out process. Chondral cells are grown in a petri dish then implanted back into the injured site. Unfortunately, there is a long period of NWB which brings other issues. Stem cells (greater than 10 years away before using as a regular form of treatment).
Patella dislocations present similarly to ACL ruptures. To relocate the knee, extend the knee with hip flexed. The patella dislocation causes a haemarthrosis and tenderness on the medial side where the retinaculum is likely to have been torn when the patella has dislocated laterally. The patella apprehension test (passive lateral glide) will be positive for apprehension. Usually tape the knee and allows a more normal gait pattern.
Patella fracture can be treated in an extension zimmer brace for 6-8 weeks and may require K-wiring.
Tibial plateau fracture can occur with ACL tears and meniscal injuries but can also occur in isolation. They may or may not occur internal fixation but requires a period of non-weightbearing.
Patella tendon rupture results in the distal end of the patella tendon coming way. Surgery is essential.
SUBJECTIVE EXAMINATION
1. Was the injury contact or non-contact?
2. Did you play on? If so, how long could you play on for?
3. Did you or anyone around you, hear a pop or a crack, or did you feel a pop?
4. Was there immediate swelling or did it take a couple of days to develop?
5. Is there any clicking, popping or giving way at the knee joint?
Giving way associated with twisting or turning which usually means that rotational instability is caused by the ACL, and also buckling in a straight line due to quads insufficiency if knee is weak or there is swelling.
If there is immediate swelling, this indicates a haemarthrosis and this can really only mean three things:
1. An ACL rupture, because of the rich blood supply to the ligament
2. Patella dislocation
3. Fracture
If milder swelling, more indicative of intra-articular pathology
OBJECTIVE EXAMINATION
Gait assessment
Squat - assess if they are able to compress the knee joint and whether WB is equal
In supine, assess the swelling with the swipe test, sweeping the fluid from the medial pocket to the lateral - a positive test will produce a pocket of fluid on the medial side
72-90% of ACL injuries are non-contact injuries
ACL rupture occurs when the athlete is decelerating and pivoting, or landing suddenly (maybe avoiding a tackle in rugby league) - the tibia moves forwards on the femur and ruptures the ACL. This is very painful and will usually result in the athlete grabbing the flexed knee.
Lachman's - looking for an end feel with anterior drawer
Reverse Lachman's - looking for an end feel with posterior drawer (assessing integrity of PCL)
Surgery is recommended for complete ACL ruptures. Recent studies have shown that at 8 years post injury with conservative management only, those with partial ACL tears did very well but those with compete ruptures did not have good outcomes.
Surgery is done arthroscopically, either with a hamstring tendon or patella tendon graft from the same knee, or more recently through a LARS procedure (ligament augmentation and reconstruction system) using a synthetic allograph. The LARS procedure has a reduced recovery time as there is no donor site and therefore no specific hamstring or patella tendon healing time required
Prevention Injury and Enhanced Performance is a programme that was started in the USA and is being rolled out in Australia. This is a warm up that has been proven to reduce ACL injury by 42% and involved neuromuscular control and proprioception exercises.
MCL sprain occurs with a valgus force to the knee, commonly in skiing and basketball. This can occur in isolation, or along with a medial meniscal injury. There can be some swelling localised to the ligament itself but there will not be any effusion inside the knee joint.
Grade I: Painful but no laxity
Grade II: Painful++ and some laxity
Grade III: Obvious laxity and no end feel
Test the MCL with a valgus stress at 30 degrees flexion. Grade II and III tears should be supported with a hinged knee brace to allow the ligament to tighten. Knee strengthening is essential to provide some stability to the knee joint. Straight line activity only for 4-6 weeks with grade II, possibly 8 weeks with grade III.
PCL tears usually occur with a hyperextension injury. PCL reconstruction was the preferred choice a number of years ago, but recent research suggests that the patient can get just as good recovery, if not better, from conservative management.
To test the PCL, first assess tibial sag in crook lying.
PCL injuries requires lots of VMO and control work to prevent patellofemoral problems from occurring.
LCL injuries are rare but occur with a varus stress to the knee joint. The LCL is part of the postero-lateral corner of the knee, including the biceps femurs and the postero-lateral capsule and the arcuate ligament.
If there is a complete rupture of the postero-lateral corner of the knee, this will require surgery as the knee will be very unstable. There could also be a lateral meniscus tear or a B Femoris tear in isolation.
Meniscal injuries are very common and result in an effusion that presents over a day or so, usually around the periphery/joint line, especially with a bucket handle tear. Medial are more common than lateral, and can be diagnosed by subjective questioning, palpation and McMurray's test. MRI can also be used to confirm diagnosis.
The McMurray's test can only be done in full flexion. If the knee is too painful to achieve full flexion, then a diagnosis cannot be made. The McMurray's test is done by taking the knee into full flexion then applying a varus and valgus stress to the knee. If locking, arthroscopy will be effective. For smaller tears in the posterior horn, a conservative approach will be tried in the first instance. If continual swelling and pain, best to refer on to an orthopaedic surgeon for a surgical opinion.
The articular cartilage can be damaged through knee injury, especially with impact which can cause a chondral pathology. in some cases, there may already be damage to the articular cartilage which becomes worse with impact. Chondral injuries commonly occur with ACL injuries and meniscal injuries. To diagnose a chondral injury, it is likely that you have ruled out any other meniscal or ligamentous damage but there is still effusion present. MRI can diagnose this injury.
To treat the articular cartilage injuries, you can't treat the cartilage itself so treat the symptoms.
Chondroplasty is the most common form of surgery (debridement through arthroscope) which lets the area bleed and scar over, providing a little more shock absorption at the joint. Chondral cell implantations are being carried out but it is a drawn out process. Chondral cells are grown in a petri dish then implanted back into the injured site. Unfortunately, there is a long period of NWB which brings other issues. Stem cells (greater than 10 years away before using as a regular form of treatment).
Patella dislocations present similarly to ACL ruptures. To relocate the knee, extend the knee with hip flexed. The patella dislocation causes a haemarthrosis and tenderness on the medial side where the retinaculum is likely to have been torn when the patella has dislocated laterally. The patella apprehension test (passive lateral glide) will be positive for apprehension. Usually tape the knee and allows a more normal gait pattern.
Patella fracture can be treated in an extension zimmer brace for 6-8 weeks and may require K-wiring.
Tibial plateau fracture can occur with ACL tears and meniscal injuries but can also occur in isolation. They may or may not occur internal fixation but requires a period of non-weightbearing.
Patella tendon rupture results in the distal end of the patella tendon coming way. Surgery is essential.
Advanced Ankle Rehab
Clinical Edge video by Russell Wright (www.clinicaledge.com.au)
ROM
Once the inflammatory stage has passed, soft tissue release techniques can be used, especially targeting the peroneals. Slow, firm pressure is more comfortable for the patient. The patient can self release the tension with a foam roller. A good peroneal stretch is standing either side of a rolled up towel and going into a small squat position, keeping knees pointing forwards. Hold 30 secs x 3.
Mulligans MWM with the seatbelt can help improve DF range - ask the patient to put their foot on a chair, have the seatbelt around the back of their calf (mid-distal region) and the seatbelt around your hips as you kneel on the ground. Apply an AP pressure to the talus as the patient dorsiflexes and you pull back on the seatbelt with your hips. 3x 6-10 reps.
If there is still restricted mobility, look to the deeper compartments e.g. tibialis anterior or further up the kinetic chain e.g. sacroiliac joint or hip.
STRENGTHENING
Bilateral heel raises with theraband around the injured lower leg (distal segment) - this will allow them to focus on maintaining a neutral foot position, not inverting. The theraband will be attached to their right hand side if working on their right leg, and their left hand side if working on their left leg. Progress accordingly into single heel raises, once again using the theraband. Aim for 10-15 reps x 2 sets.
BALANCE
This can be started with SLS in the first week post-injury. The wobble board can be used in the interim period between single leg stance and step to land activities, usually about 1 week. Current evidence by Refshauge shows that the wobble board is only effect for improving proprioception at lower velocities; it does not address the prevention of ankle sprain at higher velocities/during sport specific activities.
Once the patient has mastered single leg stance, balance can be challenged further with wobble board with someone throwing a ball. Then onto hop on the spot, hop to the spot, hop in/out of box as fast as the patient is able x 5 (each set is timed - this adds fatigue component and is a validated test for balance) and figure of 8 hopping to start power training (strength at speed). Skipping can also be added.
ENDURANCE
Return to running as soon as the patient feels able. Check with 50 repetition hop test. Start with 10-15 minutes on the flat. Heel inserts or Mulligan's fibular taping can be effective with return to running, if dorsiflexion range is still restricted.
POWER
Once the patient is able to manage 3 minutes of skipping comfortably, then progress to plyometric vertical jump. Each jump should have a rest in-between as the patient is aiming for maximal velocity with each jump. Then progress to lateral jumps and forwards/backwards jumps (also zig zag jumps if applicable). If the sports demands it, progress then to single leg jump. Can jump up to a box if more comfortable.
RETURN TO SPORT
Pass the agilities test:
1. 90% ROM compared with non-injured side or <2cm difference on dorsiflexion lunge test
2. Single leg heel raise test with theraband peroneal bias compared with non-injured side
3. Balance testing - timed figure of 8 hop test x 3 or square run x 3
4. Single leg vertical jump, using chalk as a marker
5. Motor control - SKB
6. Assessment of running gait
On returning to sport, start with slow warm up drills and ball drills and gradually progress from there.
POOR RECOVERY?
If not improving, check for:
Soft tissue impingement with meniscoid lesion at the antero-lateral joint line (MRI/referral to see if arthroscope is appropriate)
Fracture ( do not trust A&E x-ray! re-xray or CT scan then onward referral to specialist if fracture found)
Syndesmosis (high ankle sprain) which could involve the AITFL/PITFL and would lead to a longer recovery period, with possible stabilisation surgery required at the 12 week mark if there is little improvement
If a talar dome lesion is suspected with pain on weigh bearing and catching along the joint line, refer patient for MRI and seek specialist opinion after 3 months to see if an arthroscope is required.
Deltoid ligament sprain is suspected if there is more pain antero-medially. This should be supported with taping.
ROM
Once the inflammatory stage has passed, soft tissue release techniques can be used, especially targeting the peroneals. Slow, firm pressure is more comfortable for the patient. The patient can self release the tension with a foam roller. A good peroneal stretch is standing either side of a rolled up towel and going into a small squat position, keeping knees pointing forwards. Hold 30 secs x 3.
Mulligans MWM with the seatbelt can help improve DF range - ask the patient to put their foot on a chair, have the seatbelt around the back of their calf (mid-distal region) and the seatbelt around your hips as you kneel on the ground. Apply an AP pressure to the talus as the patient dorsiflexes and you pull back on the seatbelt with your hips. 3x 6-10 reps.
If there is still restricted mobility, look to the deeper compartments e.g. tibialis anterior or further up the kinetic chain e.g. sacroiliac joint or hip.
STRENGTHENING
Bilateral heel raises with theraband around the injured lower leg (distal segment) - this will allow them to focus on maintaining a neutral foot position, not inverting. The theraband will be attached to their right hand side if working on their right leg, and their left hand side if working on their left leg. Progress accordingly into single heel raises, once again using the theraband. Aim for 10-15 reps x 2 sets.
BALANCE
This can be started with SLS in the first week post-injury. The wobble board can be used in the interim period between single leg stance and step to land activities, usually about 1 week. Current evidence by Refshauge shows that the wobble board is only effect for improving proprioception at lower velocities; it does not address the prevention of ankle sprain at higher velocities/during sport specific activities.
Once the patient has mastered single leg stance, balance can be challenged further with wobble board with someone throwing a ball. Then onto hop on the spot, hop to the spot, hop in/out of box as fast as the patient is able x 5 (each set is timed - this adds fatigue component and is a validated test for balance) and figure of 8 hopping to start power training (strength at speed). Skipping can also be added.
ENDURANCE
Return to running as soon as the patient feels able. Check with 50 repetition hop test. Start with 10-15 minutes on the flat. Heel inserts or Mulligan's fibular taping can be effective with return to running, if dorsiflexion range is still restricted.
POWER
Once the patient is able to manage 3 minutes of skipping comfortably, then progress to plyometric vertical jump. Each jump should have a rest in-between as the patient is aiming for maximal velocity with each jump. Then progress to lateral jumps and forwards/backwards jumps (also zig zag jumps if applicable). If the sports demands it, progress then to single leg jump. Can jump up to a box if more comfortable.
RETURN TO SPORT
Pass the agilities test:
1. 90% ROM compared with non-injured side or <2cm difference on dorsiflexion lunge test
2. Single leg heel raise test with theraband peroneal bias compared with non-injured side
3. Balance testing - timed figure of 8 hop test x 3 or square run x 3
4. Single leg vertical jump, using chalk as a marker
5. Motor control - SKB
6. Assessment of running gait
On returning to sport, start with slow warm up drills and ball drills and gradually progress from there.
POOR RECOVERY?
If not improving, check for:
Soft tissue impingement with meniscoid lesion at the antero-lateral joint line (MRI/referral to see if arthroscope is appropriate)
Fracture ( do not trust A&E x-ray! re-xray or CT scan then onward referral to specialist if fracture found)
Syndesmosis (high ankle sprain) which could involve the AITFL/PITFL and would lead to a longer recovery period, with possible stabilisation surgery required at the 12 week mark if there is little improvement
If a talar dome lesion is suspected with pain on weigh bearing and catching along the joint line, refer patient for MRI and seek specialist opinion after 3 months to see if an arthroscope is required.
Deltoid ligament sprain is suspected if there is more pain antero-medially. This should be supported with taping.
Tuesday 1 May 2012
Acute Ankle Inversion Injury
Subjective Examination
Important to obtain mechanism of injury - usually occurs when walking or running on uneven surface, or when pushing off laterally from an acute cutting movement
Use the OTTAWA Ankle rules and OTTAWA Foot rules (designed for emergency department originally) to determine if x-ray is required. 6 cm up the lateral or medial side of the lower leg from the malleoli, or unable to weight bear determines if ankle x-ray required. If tender over navicular or base of 5th metatarsal, or unable to weight bear determines if foot series x-ray is required.
Acute management
PRICER - recent evidence shows compression to be the most important factor over the first 24-72 hours
Objective Examination
Palpation:
ATFL, CFL, anterior portion of the deltoid ligament
Anterior joint line (talus)
Peroneal tendons as they pass posterior to the lateral malleolus (longus and brevis)
Peroneal tertius as it passes anterior to the lateral malleolus, inserting onto the base of the 5th metatarsal
Tibialis posterior, FHL and FDL as they pass posterior to the medial malleolus
ROM
DF/PF/IV/EV (NWB)
Standing DF lunge when tolerated (compare to other side with %)
Supination/Pronation to eliminate midfoot injury
Strength testing
Resisted isometric tests
Bilateral heel raises as tolerated (testing peroneals in a more functional manner - if weight bearing on the lateral border, could be lengthened and weak peroneals (and/or tight tibialis). Also look for toe grabbing which is often a compensatory thing for poor balance.
Balance
If SLS is 30 secs +, the test is too easy and so progression to the 3 point star test is merited. The patient has 3 attempts at each of the 3 points and the best reading is taken for each point. Use this as an outcome measure.
Ligament testing:
1. Anterior drawer test (PA glide of the talus) - compare with other side. If excessive movement, you are suspecting rupture to the ATFL and possibly anterior fibres of deltoid lig. If the ankle has excessive movement, but is mainly moving into inversion, then it is likely that the ATFL is the main injured ligament.
2. Talar tilt test - looking for excessive laxity at the CFL ligament
Ligament grading:
Grade I: No laxity on stability testing, tenderness over ATFL = microtrauma
Grade II: Laxity on ligament testing with anterior drawer and/or talar tilt, with end feel
Grade III: Laxity in the absence of end feel
Prognosis/Healing Times
Grade I: 2-4 weeks
Grade II: 4-6 weeks
Grade III: 6-8 weeks
1. Aim to improve ROM within comfortable ranges
ROM can be limited in the early stages by swelling, increased muscle tone and possible joint subluxation. Starting with gentle dorsiflexion and plantar flexion slides in sitting, then progress to active inversion and eversion. In order to reduce muscle tone, dry needling can be effective and is not likely to worsen the inflammation. Mulligans MWM at the fibula (apply a posterior superior glide) can be effective in improving inversion/eversion ROM. Maintain glide for the whole movement and complete 3 x 6-10 repetitions. In order to improve dorsiflexion range, the MWM can also be effective. In supine, use your anterior thigh to support the sole of the patient's foot. Using one hand, apply an AP glide to the talus, whilst using the other hand to support under the calf. Ask the patient to actively DF as you maintain the AP glide throughout the movement. Ask the patient to relax as you keep the AP glide on during the return to neutral.
2. Re-activate the peroneals (excessive tone as a protective response to injury)
In sidelying, ask the patient to PF the EV against gravity. Ensure toes are switched off and can palpate the peroneal tendons during the movement to ensure correct activation. 5x10 reps in one session per day
3. Improve balance as early as possible
Standing on one leg, with soft knee to activate gluts and quads, and core muscles switched on. Encourage the patient to stand for as long as possible, resting when getting uncomfortable. If too easy, progress to star excursion test
4. Function
Return to normal walking as soon as possible. Mulligan's fibula taping can be effective in improving range of motion and reducing pain. Using hypo fix and rigid tape, apply tape at fibula, around the back of the achilles and attaching anteriorly, using a posterior-superior glide to the fibula when applying tape.
5. Endurance
Cycling (encourage pushing through the knee) or swimming (using a pull buoy until more comfortable)
Evidence Based Practice
The Association Between Degenerative Hip Joint Pathology and Size of the Gluteus Medius, Gluteus Minimus, and Piriformis Muscles
Dr A Grimaldi et al, Manual Therapy, 14 (2009) 605-610
This study looked at the difference in size of the abductor synergy in the control group (no OA) compared
to mild and advanced OA of the hip using MRI.
(N = 12 with pathology, N=12 control)
The hypothesis was that there would be significant asymmetry of the GMED, GMIN and PIRI muscles at the affected hip, compared with the non-affected hip, and that the GMED, GMIN and PIRI muscles would be smaller with more advanced OA.
Those with mild OA tend to increase adduction at the hip during stance, and those with advanced OA tend to reduce adduction by increasing the frontal plane of the trunk.
The study concludes that there are changed in the GMED and PIRI muscles (smaller) in those with advanced OA. However, the study also concludes that the abductor synergy does not respond uniformly with changes in pathology. The GMED, GMIN and PIRI muscles may atrophy but the TFL and Upper glut max continue to work effectively. it has also been found that with mild pathology, GMED may actually hypertrophy rather than atrophy.
"Assessment and rehabilitation strategies should carefully consider stage of pathology and specific changes occurring within the abductor synergy. This more specific approach may improve long term outcomes of conservative intervention in the management of OA of the hip, and may provide a direction for future prevention programmes."
Lateral Hip Pain: Mechanisms and Management (Article in InTouch magazine, APA)
Written by Dr A Grimaldi
Lateral hip pain has commonly been referred to as trochanteric bursitis. Recent evidence shows there is more bursal distension rather than acute or chronic inflammation, secondary to the compressive forces that occur along the lateral side of the hip with glut med (or min) tendinopathy. Compression is thought to be a key factor in the development of insertional tendinopathies . Compression of the glut med and min tendons into the lateral and anterior aspects of the greater trochanter occurs beneath the level of the ITB; with increased tightness of the ITB, compression loading and overactivity then occurs in the superficial lateral stability system, namely TFL, upper glut max and vastus lateralis. Sitting in saddle chairs can promote excessive static abduction, thus tightening the above structures and causing lateral hip pain in those who are largely sedentary at work. On rising from a chair, the hips are brought into adduction, thus compressing the lateral structures, particularly glut med and min, causing pain.
Grimaldi reports that a study by Birnbaum et al (2004) found that in neutral adduction, there is only 4N of loading over the greater trochanter. With only 10 degrees of adduction, this rises to 36N and rises again to 106N with 40 degrees of adduction. Therefore stretching the lateral structures can often exacerbate the problem.
Aggravating factors such as sitting for prolonged periods, sitting cross legged, sleeping on both the affected and non-affected side and standing in the positive Trendelenberg position can all affect the length-tension relationship of the lateral structures. Excessive lengthening of the lateral structures contributes to the increased adduction in stance and thus increases the compressive force over the greater trochanter. The increase in adduction also biases the superficial abductors and shows poor recruitment in the deeper rotators/abductors.
Other factors can predispose an athlete to this condition. For example, pelvic obliquity with scoliosis, leg length discrepancy, hip flexor dysfunction (think soccer players striking the ball with their leg crossing the midline) and running/walking gait abnormalities, especially on the camber of a road or uneven surface like sand.
Treatment strategies are now moving away from the ice, ultrasound and stretching regime commonly associated with bursitis. Education has been proven to be effective with exercise decompression compliance programmes and also reassures the patient that tendon recovery will take time. Addressing negative habits such as sitting cross legged, standing hanging on one hip or sitting with feet wide and knees together will help with pain relief in the short term and reduce the pull of the TFL on the gluteal and thoracodorsal fascia. Avoiding low chairs or using a wedge cushion to bring the hips higher than the knees can also be effective.
Night pain is difficult to address but trying to sleep supine with a pillow under the knees can often take the pressure off the hips. Sidelying using a pillow to keep the affected side in neutral adduction can sometimes work.
Short term relief can be achieved by dry needling, heat, massage and trigger pointing and physiotherapists can show their patients how to perform self trigger pointing. Long term relief can only come from addressing the poor recruitment patterns and working on the muscle dysfunctions.
Lateral stability mechanism
Deepest layer is Gluteus Minimus, which attaches to the superior joint capsule, contributing to joint stability and protection.
The intermediate layer consists of all 3 sections of Gluteus Medius, and also Piriformis. GMED comprises of anterior, posterior and superficial segments, all with separate innervation and all with independent movement patterns.
In order to maintain the pelvis in a neutral state, the gluteals contribute 70% of the workload and TFL/UGM and the ITB contribute 30% (with VL helping out).
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