JAYPEE

Basics of Orthopedic

PHYSIOTHERAPY

Basics of Orthopedic

PHYSIOTHERAPY

Subhash M Khatri  BPT MPT(Ortho) PhD (Physiotherapy) FIAP

Principal College of Physiotherapy Pravara Institute of Medical Sciences Ahmednagar, Maharashtra, India Foreword

Kristina Kindblom

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected] This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Basics of Orthopedic Physiotherapy First Edition: 2013 ISBN 978-93-5090-278-3 Printed at:

Dedicated to In loving memory of my father Maniklal Shivlal Khatri who raised me, guided me and believed in me no matter what. I could not have asked for a better teacher and mentor than my father. Several of individuals who suffer with musculoskeletal disorders and to Physiotherapists who try to improve their comfort and function and my children Trishla and Uday, I always felt that I could not give enough time to both of them.

Foreword

I am delighted to provide foreword for Basics of Orthopedic Physiotherapy written by Dr Subhash M Khatri. He reminds of a great philosopher Socrates. I have worked with him during my job as a Visiting Professor at Pravara Institute of Medical Sciences (PIMS), Ahmednagar, Maharashtra, India. During this period, we had talked about the similarities, differences and the areas of common interests including the basic body awareness concept of physiotherapy in Sweden and India. Having read the manuscript of this book, I liked the contents especially the Spine chapter. The author has taken care of putting the concept in a simple way that helps in understanding the subject matter. In my opinion, it is a very good book to understand orthopedic physiotherapy treatment for common musculoskeletal conditions and the excellent part of this book is his advice about memory tricks and the inclusion of real-life situations with his clinical experiences. I liked the way he has explained conceptual overview, clinical pearls, key concepts about physiotherapy and orthopedic manual therapy.

Kristina Kindblom  RPT PhD(Sweden)

Visiting Professor Pravara Institute of Medical Sciences (PIMS) Ahmednagar, Maharashtra, India

Preface

Everyday, we generally come across various physical forces such as warming rays of sun, light of moon, force of gravity, movement of our body, our ability to move from one place to another, our ability to move an object from one place to another, movement and flow of cold water, movement and flow of hot water, electrical changes, magnetism and so on. Almost all these things around us form the part of nature’s inexhaustible and powerful array of forces. The same physical forces, harnessed and properly directed are of great value in promoting the healing. They can relieve pain, increase circulation, speed up repair and healing of injured body part, improve body mechanics, metabolism, inhibit growth of germs, restore disturbed function, cure the diseased status of body, restore homeostasis, improve health and so on. This could be the basis of physical medicine. It appears that the evolution of physical medicine or physiotherapy has occurred gradually but the physical agents in some or the other form which are used for the treatment purpose are quiet old may be as old as the matter itself. Physiological stress, load and movement are essential for the development, maintenance, and continuing health of the musculoskeletal tissues. Inactivity, faulty movement patterns and posture, trauma, or disease can result tissue changes with symptoms and dysfunction. Healing, the tissue response that can restore tissue structure and function can be facilitated by means of physiotherapeutic interventions. Therefore, physiotherapy is an important and almost always necessary nonsurgical treatment approach in reducing pain, maintaining nutrition, and improving mobility. Physicians like Hippocrates and Hector are believed to have been the first practitioners of a primitive physical therapy. The earliest documented origins of actual physical therapy as a professional group, however, date back to 1894 when four nurses in England formed the Chartered Society of Physiotherapy. Other countries soon followed and started formal training programs. Specialization for physical therapy in the US occurred in 1974, with the Orthopedic Section of the APTA being formed for those physical therapists specializing in orthopedics. In the same year, the International Federation of Orthopedic Manipulative Therapy was formed, which has played an important role in advancing manual therapy worldwide ever since. Today, orthopedic physiotherapy is an essential and indispensable subject for physiotherapy students. There are enough and more books available on this subject by foreign authors. But, personally, I feel that there are very few books available on this subject by authors who can understand the needs of students in better way. So, a need was felt to bring out a book, which will comprehensively cover orthopedic physiotherapy in brief and straightforward manner. The purpose of this book is to provide a foundation of knowledge for the management of some of the basic

x  u  Basics of Orthopedic Physiotherapy musculoskeletal disorders. Since no one book possibly would contain all that is necessary to know orthopedic physiotherapy and, hence, other textbooks can be referred for more particulars. The contents recorded herein have been carefully selected after intensive investigation and painstaking evaluation as the method of treatment. The organization of material is put up in an order of key points, overview, possible causes of the dysfunction and five clinical conditions. Emphasis is strongly on physiotherapy treatment. All the musculoskeletal disorders are not covered in this book and related information can be found in any other larger textbook on the same subject. I cannot urge strongly that when information concerning a particular problem is being sought, the entire chapter be read since in many instances more than one method of treatment is presented. By reading the entire chapter, a better idea of the specific problem will be gained. Although the book is primarily written for physiotherapeutic professionals, much of the information in this book may be useful for other clinicians who are actively involved in the management of patients with musculoskeletal afflictions. Medical and physiotherapy knowledge is constantly changing. As new information becomes available, changes in treatment procedures and techniques in clinical situations become necessary. As far as possible, care has been taken to ensure that information given in this book is accurate and up-to-date. Nevertheless, readers are strongly advised to confirm the information. I have included my personal thoughts and comments and they should be taken as just guidelines and not the cookbook approach that will fit all possible patients. However, readers can plan a tailored physiotherapy treatment program for their patients in the light of knowledge provided in this book. Every chapter consists of clinical pearls and modalities, appliances, movements and advice (MAMA) approach that will help you to recall the treatment outline quickly. So, if you like it and feel like appreciating, then please write or mail to me, since your small appreciation will throw away my memories of all painful hours of working on my personal computer and yelling at my kids when they dared to stop me! A large number of references and suggested readings have been included at the end. This will help the more interested readers to conveniently look for an extra material on the subject of their interest.



Subhash M Khatri

Acknowledgments

I have received valuable assistance from various people in the preparation of Basics of Orthopedic Physiotherapy. I would like to thank all of them for their suggestions and help. I am particularly thankful to my mentors MG Mokashi, Sudhakar Nayak, VK Bhaskaran, Jaspal Singh Sandhu, P Srikumar, M Natrajan, GJ Ramteke, Mangala Deshpande, Dilip Patel and Neeta Vyas, my colleagues Sanjiv Kumar and Sridhar Nayak, and my students Peeyosha, Leena Adkar, Aparna Kulkarni, Siddhi Masurkar, Vibha Badami, Sukhada Kulkarni, Amruta Pawar, Srikant Sant, Roshani, for their constant inspiration, literature search and important feedback. I am grateful to my brothers Mohanlal Khatri, Jeevan Khatri and Sanjay Kumar Khatri for their constant encouragement and support in various ways for the modest help in the typing and correction of the text. I am indebted to my wife Sejal Khatri. The publishers, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, bestowed upon this work with their highly painstaking efforts in the examination of this text, its editing and printing. I hereby thankfully acknowledge all the assistance.

Contents

1. Conceptual Overview

1

• Classification of Musculoskeletal Disorders  1  • Psychological Reactions to Injury  2  • Musculoskeletal Dysfunctions  3  • Musculoske­letal Pain Characteristics  8  • Articular and Muscle Pain  9  • Effects of Immobilization  9  • End Feel  9  • Joint Mobility Scale  11  • Joint Screening  11  • Diagnostic Inference of Movements  12  • Musculoskeletal Imaging  13  • Surface Anatomy  13  • Pain Assessment  14  • Grading of Nerve Injuries  14  • Myotomes Dermatomes  15  • Role of Physiotherapist  15

2. Spine

20

• Prolapsed Intervertebral Disc  22  • Lumbar Spondylosis  29  • Thoracic Outlet Syndrome  32  • Scoliosis  37  • Sacroiliac Joint Dysfunction  44

3. Shoulder

49

• Frozen Shoulder  50  • Shoulder Dislocation  56  • Supraspinatus Tendoinitis  62  • Proximal Humeral Fracture  66  • Rotator Cuff Tear  70

4. Elbow • Tennis Elbow  78  • Supracondylar Fracture of Humerus  83  • Golfer’s Elbow  86  •  Elbow Dislocation  89  • Student’s Elbow  94 

76

xiv  u  Basics of Orthopedic Physiotherapy 5. Wrist and Hand

98

• Colles Fracture  98 • Carpal Tunnel Syndrome  102  • Flexor Tendon Injury  106 • De Quervain’s Disease  109  • Extensor Tendon Injury  112

6. Arthritis

115

• Ankylosing Spondylitis  115 • Osteoarthritis  119  • Rheumatoid Arthritis  126  • Fibromyalgia   133 • Osteoporosis  136

7. Hip

140

• Proximal Femoral Fractures  141  • Hip Dislocation  145  • Trochanteric Bursitis  150  • Total Hip Replacement  152  • Above Knee Amputation  154

8. Knee

158

• Anterior Cruciate Ligament Reconstruction  159  • Supracondylar Fracture Femur  162  • Total Knee Replacement   165  • Patellofemoral Joint Dysfunction   169  • Osgood-Schlatter Disease  173

9. Ankle and Foot

177

• Ankle Sprain  178  • Plantar Fasciitis  184  • Pott’s Fracture  188 • Pes Planus  193  •  Pes Cavus  198  • Ankle Foot Pain Handout for Patients  200

10. Orthopedic Manual Therapy • Manual Therapies  202  • Maitland’s Concept  204  • McKenzie’s Approach  204  • Cyriax Approach  205  • Positional Release Therapy  206  • Myofascial Release  206  • Manual Traction  207 •  Manual Lymph Drainage  207  • Muscle Energy Technique  208 

201

Contents  u xv • Craniosacral Therapy (Cst)  209  •  Ischemic Compression Technique  209  • Neurodynamic Release  210  • Kaltenborn’s Mobilization  210  • Janda’s Approach  211  • Combined Movements  211

Appendix 213 Glossary 219 Suggested Readings 227 Index 235