Advanced Musculoskeletal Physiotherapy Self-directed Learning Module 1: Musculoskeletal Conditions

Orthopaedic and Neurosurgical Screening Clinics

Prepared by Alfred Health on behalf of the Victorian Department of Health 2014

Contents

Module 1: Musculoskeletal Conditions

1 .1 Shoulder & Upper Arm

Theme 1 History taking for shoulder and upper arm problems/injuries

Theme 2Focused clinical assessment of shoulder and upper arm problems/injuries

Theme 3 Common investigations for shoulder and upper arm problems/injuries

Theme 4Common pharmacology for the management of shoulder and upper arm injuries/problems

Theme 5Management of shoulder and upper arm injuries/problems

1.2: Elbow

Theme 1 History taking of elbow problems/injuries

Theme 2 Focused clinical assessment of elbow injuries

Theme 3 Common investigations for elbow problems/injuries

Theme 4Common pharmacology for the management of elbow injuries/problems

Theme 5 Management of elbow injuries/problems

1.3 Wrist

Theme 1 History taking for wrist injury/problems

Theme 2Focused clinical assessment of wrist problems/injuries

Theme 3 Common investigations for wrist injury/problems

Theme 4Common pharmacology for the management of wrist injury/problems

Theme 5 Management of wrist injuries/problems

1.4 Hand

Theme 1 History taking for Hand injury/problems

Theme 2Focused clinical assessment of hand injury/conditions

Theme 3 Common investigations for hand injuries/problems

Theme 4Common pharmacology for the management of hand injuries/problems

Theme 5 Management of hand injuries/problems

1.5: Hip

Theme 1 History taking specific to hip injuries/conditions

Theme 2Focused clinical assessment specific to hip injuries/conditions

Theme 3Common investigations specific to hip injuries

Theme 4Common pharmacology specific to hip injuries/conditions

Theme 5 Management of specific to hip injuries/conditions

1.6: Knee

Theme 1 History taking specific to knee injuries/conditions

Theme 2 Focused clinical assessment specific to knee injuries/conditions

Theme 3 Common investigations specific to knee injuries /conditions

Theme 4 Common pharmacology specific to knee injuries/conditions

Theme 5 Management of specific to knee injuries/conditions

1.7: Ankle

Theme 1 History taking specific to ankle injuries / conditions

Theme 2 Focused clinical assessment specific to ankle injuries/conditions

Theme 3 Common investigations specific to ankle injuries /conditions

Theme 4Common pharmacology specific to ankle injuries/conditions

Theme 5Management of ankle injuries/conditions

1.8: Foot

Theme 1 History taking specific to foot injuries/conditions

Theme 2 Focused clinical assessment specific to foot injuries/conditions

Theme 3Common investigations specific to foot injuries/conditions

Theme 4 Common pharmacology specific to foot injuries/conditions

Theme 5Management of foot injuries/conditions

1.9: Cervical Spine

Theme 1 History taking for cervical spine pain & injury

Theme 2 Focused clinical assessment of cervical spine pain & injury

Theme 3 Common investigations for cervical spine pain & injury

Theme 4Common pharmacology for the management of cervical spine pain, & injury

Theme 5 Management of cervical spine pain & injury

1.10 Thoracic spine

Theme 1 History taking for thoracic spine pain & injury

Theme 2 Focused clinical assessment of thoracic spine pain& injury

Theme 3 Common investigations for thoracic spine pain &injury

Theme 4Common pharmacology for the management of thoracic spine pain & injury

Theme 5 Management of thoracic spine pain & injury

1.11 Lumbar Spine

Theme 1 History taking for lumbar spine pain & injuries

Theme 2 Focused clinical assessment of low back pain & injuries

Theme 3 Common investigations for lumbar spine pain & injuries

Theme 4 Common pharmacology for the management of lumbar spine pain & injury

Theme 5 Management of low back pain & injury

Module 1: Musculoskeletal Conditions

1.1Shoulder and upper arm

1.2Elbow and forearm

1.3Wrist

1.4Hand

1.5Hip and thigh

1.6Knee and lower leg

1.7Ankle

1.8Foot

1.9Cervical Spine

1.10Thoracic Spine

1.11Lumbar Spine

1

1 .1 Shoulder & Upper Arm

Theme 1 History taking for shoulder and upper arm problems/injuries

LEARNING OBJECTIVES:
  1. To understand the key principles of history taking of shoulder and upper arm problems/injuries in the context of the setting of a Screening Clinic
  2. To understand the importance of mechanism of injury to the shoulder and upper arm
  3. To identify early, presentations of the shoulder of non musculoskeletal origin that may require inter-disciplinary care
  4. To establish a preliminary differential diagnoses

ASSUMED KNOWLEDGE:
Routine physiotherapy subjective assessment of the upper limb and cervical spine
KNOWLEDGE:
  • Discuss the relevance of the following areas to mechanism of injury of the shoulder1-3, 5
  • Crush
  • Direct trauma
  • Fall on outstretched hand (FOOSH)
  • Fall from standing
  • Fall from height/bike
  • Cause of fall
  • Associated injuries such as headstrike, LOC
  • Axial loading or “jamming”,
  • Position of arm
  • Compression/distraction, varus/valgus forces
  • Direction of force including position of distal joints
  • Skin integrity
  • Time of injury, ability to move arm post injury
  • Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling
  • Consider other sites for injury/pain and relevant associated questions required
  • Facial/head/neck/thorax injury
  • Chest/Jaw/arm/hand pain
  • What key information is required to assess for red flags?4
  • What key information is required in the setting of chronic shoulder and upper arm problems?5
  • What key information would you ask to differentiate atraumatic shoulder/upper arm pain from non musculoskeletal causes?5
  • What key information in a patient’s past medical history is important in shoulder and upper arm problems/injuries? 5
  • What are important risk factors should be identified in a patient’s history that may indicate non musculoskeletal causes of shoulder and arm pain?5
  • What key information in a patient’s medication history is important in shoulder and upper arm problems/injuries? 5,6
  • What key information in a patient’s social history is important in shoulder and upper arm problem/injuries? 5
  • What is the relevance of determining any intervention or treatment to date?
  • What is the relevance of determining the compensable status or health insurance status of the patient?

RECOMMENDED RESOURCES
1. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.
2. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder.
3. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Chapter 4, The neck and upper limbs, p78-91.
4. WorkCover SA (2013) Red Flags: Identify red flags in low back pain

Up to date
5. Anderson, B. (2012). Evaluation of the patient with shoulder complaints
6. FitzGerald, R. J. (2009). Medication errors: the importance of an accurate drug history. British journal of clinical pharmacology, 67(6), 671-675.

Theme 2Focused clinical assessment of shoulder and upper arm problems/injuries

LEARNING OBJECTIVES:
  1. To understand the key aspects in clinical assessment of shoulder and upper arm problems/injuriesin the context of the Screening clinic
  2. To establish key findings to support/refute preliminary differential diagnosis?

ASSUMED KNOWLEDGE
  • Anatomy of the shoulder and upper arm: bones, joints, muscles, tendons, ligaments.
  • Routine physiotherapy objective assessment of the shoulder including:
  • Cervical spine assessment
  • Upper limb neurological assessment including peripheral nerves

KNOWLEDGE:
  • Name the vascular supply of the upper limb3
  • How would you assess the neurovascular status of the upper limb?5
  • How do assess the integrity of the glenohumeral joint?11
  • What is the relevance of any local skin changes / open wounds to the upper limb?
  • How would differentiate shoulder/arm pain originating from the cervical spine?13
  • How you would differentiate musculoskeletal shoulder pain from non musculoskeletal shoulder pain?10
  • What are the most common non-musculoskeletal presentations of shoulder pain10
  • What does your clinical assessment need to include if non-musculoskeletal causes are suspected?
  • What findings would you expect to see on assessment?
  • What action needs to be taken?
  • Discuss abdominal , cardiovascular, thoracic, neurological causes

RECOMMENDED RESOURCES
1. Brukner and Khan (2012) Clinical Sports Medicine. 4th Edition. McGraw-Hill Medical.
2. Cameron P, Jelinek G, Kelly A, Murray L, Brown A, & Heyworth J, (2004) Adult Emergency Medicine. Churchill Livingston, Sydney. p132-6.
3. Drake, R, Vogl, W & Mitchell, A (2005) Gray’s Anatomy for Students. Churchill Livingstone Elsevier. Chapter 7, Upper limb, p707-728.
4. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.
5. Judge, NL (2007) Neurovascular assessment. Nursing Standard. Vol 21, No 45, 39-44

6. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder.
7. Purcell, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier: UK Chapter 4, The neck and upper limbs, p78-91.
8. Walsh & Sadowski (2001), Systemic Disease Mimicking Musculoskeletal Dysfunction: A Case Report Involving Referred Shoulder Pain. Journal of Orthopedic Sports Physical Therapy. 31, (12), p696-701.
9. Zuluga, M (1995) Sports Physiotherapy – Applied Science and Practice. Churchill Livingstone, Melbourne.
Up to date
10. Anderson, B & Anderson,R (2012) Evaluation of the patient with shoulder complaints

11. Dixon, J & Simons, S (2013) Physical examination of the shoulder
12. Gelb (2012) Neurological exam

13. Issac, A & Anderson, B (2013) Evaluation of the patient with neck pain and cervical spine disorders

Theme 3 Common investigations for shoulder and upper arm problems/injuries

LEARNING OBJECTIVES:
  1. To understand the common investigations for shoulder and upper arm problems/injuries

KNOWLEDGE:
  • When would you consider obtaining an X-ray for a patient with a shoulder and upper arm problem/ injury?4,7
  • When would a CT scan be indicated for a patient with a shoulder and upper arm problem/injury? 4,7,9
  • When would an MRI scan be indicated for a patient with a shoulder and upper arm problem/injury? 4,7,9,10
  • When would an ultrasound be indicated for a patient with a shoulder and upper arm problem/ injury? 4,7,9
  • When would blood investigations be indicated for a patient with a shoulder and upper arm problem/injury?8
  • What are other investigations that may be indicated in a patient with shoulder and upper arm pain? 7

CLINICAL APPLICATION:
Describe the normal x-ray of an shoulder and upper arm1
Complete the online interactive radiology tutorial and quiz3,10,11,12
RECOMMENDED RESOURCES
1. Anderson, J, Read J (2008) Atlas of Imaging in Sports Medicine. 2nd Edition. McGraw-Hill.
2. Begg, J (2005) Accident and Emergency X-rays Made Easy. Churchill Livingstone. Chapter 7, The upper limb, p143-185.
3. Gay, S, Kuntz, A, Lai, W, Norton, P, Yao, L (Date Unknown) Skeletal Trauma Radiology, University of Virginia Health Sciences Centre.

4. Government of Western Australia, Department of Health (2012) Diagnostic Imaging Pathways – Shoulder Pain/Instability.

5. Jan van der Woude, H & Smithuis, R (2012) Shoulder MR – Anatomy, Normal anatomy, Variants and Checklist, Radiology Assistant, Rijnland Assistant

6. Raby, N, Berman, L, de Lacey, G (2005) Accident and Emergency Radiology: A Survival Guide 2nd edition. Elsevier Saunders. Chapter 4, Shoulder, p68-89
Up to date
7. Jude, C & Modarresi (2012) Radiological evaluation of the shoulder

8. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain
9. Baccei, S, Kim, C, & Weissman, B (2013) Diagnostic imaging of joint pain

10.Shoulder MRI Anatomy, Radiology Assistant
11. Shoulder MRI Bankart Lesions, Radiology Assistant

12. Radiology Masterclass: upper limb

Theme 4Common pharmacology for the management of shoulder and upper arm injuries/problems

LEARNING OBJECTIVES:
  1. To understand the common pharmacological agents for shoulder and upper arm injuries/problems

KNOWLEDGE:
  • Analgesic agents1-8
  • What is appropriate for pain control in the patient with minor shoulder and upper arm injury/problem?
  • What is appropriate for pain control in the patient with moderate to severe pain with shoulder and upper arm injury/problem?
  • Anti-inflammatory agents5, 8,10,11
  • What and when is it appropriate to use anti-inflammatory agents?
  • Antibiotics9
  • When are antibiotics indicated for shoulder and upper arm injuries and why?

RECOMMENDED RESOURCES
1. Australian and New ZealandCollege of Anesthetists and Faculty of Pain Medicine (2006) Managing Acute Pain A Guide for Patients.

2. Bryant, B., Knights, K (2011) Pharmacology for Health Professionals. 3rd edition. Mosby Elsevier. Chapter 15, Analgesics, p277-307/
3. Egol, K, Koval, KJ, & Zuckerman, JD (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 7, Orthopaedic Analgesia, p63-76.
4. eTG complete (2013) Therapeutic Guidelines (subscribed)

5. Hamilton, B, Milne, C, Orchard, J, & Paoloni, J (2009) Non-steroidal anti-inflammatory drugs (NSAIDs) in sports medicine. Guidelines for practical but sensible use. British Journal of Sports Medicine (subscribed).

6. Macintyre, P, Scott, D, Schug, S, Visser, E, & Walker, S (2010) Acute Pain Management: Scientific Evidence, Third Edition, Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine.

7. Neal, M (2009) Medical Pharmacology at a Glance. 6th edition. Wiley-Blackwell. Chapter 29, Opioids and analgesics, p64-65; Chapter 32, NSAIDs, p70-71.
8. Vargus Schaffer (2010) Is the WHO analgesic ladder still valid? Canadian Family Physician. 56, 6, p514-517.

Up-to-date
9. Helfgott, S. M. (2013) Evaluation of the adult with monoarticular pain
10. Lexicomp (2013) Ibuprofen: Drug Information

11. Solomon, D (2012) NSAIDs: mechanism of action

Theme 5Management of shoulder and upper arm injuries/problems

LEARNING OBJECTIVES:
  1. To understand the common management principles for shoulder and upper arm injuries/problems in the context of the Screening clinic

ASSUMED KNOWLEDGE:
  • Physiotherapy management of acute, sub-acute and chronic shoulder, upper arm and cervical pain of a musculoskeletal origin
  • Simple first aid management of shoulder and upper arm injuries
  • Application of slings to the shoulder and advice re: use of slings

KNOWLEDGE:
  • What type of shoulder injuries or presentations would require the involvement of the Orthopaedic team on the day of assessment
  • What type of shoulder injuries or presentations would require referral for future involvement of the Orthopaedic team
  • Describe how your management of a shoulder injury will vary if your patient is:
  • Diabetic13
  • On anti-coagulants1, 2
  • Discuss the signs, symptoms and management of2-6, 8-12, 14 - 18
  • Fracture of the clavicle
  • Fracture of the body of the scapula
  • Fracture of the neck of the scapula
  • Fracture of the acromion process
  • Fracture of the coracoid process
  • Dislocation of the sterno-clavicular joint
  • Strain of the sterno-clavicular joint
  • Subluxation and dislocation of the acromio-clavicular joint
  • Strain of the acromio -clavicular joint
  • Subluxation/Dislocation of the shoulder and associated injuries
  • Anterior, posterior, inferior (luxatio erecta)
  • Rupture of the rotator cuff
  • Chronic labral tear
  • Degenerative tear of rotator cuff
  • Rotator cuff – full and partial tear
  • Supraspinatus tendonopathy
  • Acute calcific tendinitis
  • Subacromial bursitis
  • Impingement
  • Winging of the scapula
  • Fracture of the neck of the humerus
  • Fracture of the greater tuberosity
  • Fracture of the shaft of the humerus
  • OA/RA/AVN of the shoulder
  • Thoracic outlet syndrome
  • Adhesive capsulitis
  • Cervical/thoracic referred pain
  • Brachial plexus neuritis
  • Supra-scapular nerve entrapment
  • Biceps rupture
  • How would you provide adequate pain control if required?

RECOMMENDED RESOURCES
1. Chan, T. Y. (1005). Adverse interactions between warfarin and nonsteroidal anti-inflammatory drugs: mechanisms, clinical significance and avoidance. Ann Pharmacother 29(12): 1274-83.
2. Dossett, L. A., Riesel, J. N., Griffin, M. R. & Cotton, B. A. (2011). Prevalence and Implications of Preinjury Warfarin Use, an analysis of the National Trauma Databank, Arch Surg 146(5): 565-570.
3. Egol, K, Koval, K & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and upper arm.
4. McRae, R & Esser, M (2008). Practical Fracture Treatment. 5th Edition. Churchill Livingstone, Edinburgh.
5. McRae, R (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The shoulder.
6. Purcell, D. (2010) Minor Injuries A Clinical Guide. Churchill Livingstone Elsevier UK. Chapter 4, The neck and upper limbs, p78-91.
7. Wilson, S (2013) Shoulder dislocation in the Emergency Department. Medscape reference.

Up to date
8. Bassett, R (2012) Midshaft humeral fractures in adults

9. Bassett, R (2013) Stress fractures of the humeral shaft

10. Bassett, R (2013) Proximal humeral fractures in adults
11. Clugston, J, Hatch, R & Taffe, J (2013) Clavicle fractures

12. Dixon, J & Simons, S (2013) Biceps tendinopathy and tendon rupture
13. Hordon, L. D. (2013) Musculoskeletal complications in diabetes mellitus
14. Koehler, S (2013) Acromioclavicular joint disorders
15. Kronfol, R (2012) Splinting of musculoskeletal injuries

16. Kruse, D & Rotator cuff tendinopathy (2012)
17. Prestgaard, T (2013) Frozen shoulder (adhesive capsulitis)
18. Schaider, J & Sherman, S (2012) Shoulder dislocation and reduction

Module 1.1: Musculoskeletal conditions – Shoulder and upper arm 1

1.2: Elbow

Theme 1 History taking of elbow problems/injuries

LEARNING OBJECTIVES:
  1. To understand the key principles of history taking of elbow problems/injuries in the context of the Screening clinic
  2. To understand the importance of mechanism of injury to the elbow
  3. To identify early, presentations of the elbow of non musculoskeletal origin that may require inter-disciplinary care
  4. To establish a preliminary differential diagnoses

ASSUMED KNOWLEDGE:
  • Routine physiotherapy subjective assessment of the elbow

KNOWLEDGE:
  • Discuss the relevance of the following areas to mechanism of injury of the elbow1-3, 5
  • Crush
  • Direct trauma
  • Fall on outstretched hand (FOOSH)
  • Fall from standing
  • Fall from height/bike
  • Cause of fall
  • Associated injuries such as headstrike, LOC
  • Axial loading or “jamming”,
  • Position of arm
  • Compression/distraction, varus/valgus forces
  • Direction of force including position of distal joints
  • Skin integrity
  • Time of injury, ability to move arm post injury
  • Symptoms such as numbness, pins and needles , ‘dead arm’ , tingling
  • Consider other sites for injury/pain and relevant associated questions required
  • What key information is required to assess for red flags?4
  • What key information is required in the setting of chronic elbow problems?5
  • What key information would you ask to differentiate atraumatic elbow pain from non musculoskeletal causes?5
  • What key information in a patient’s past medical history is important in elbow problems/injuries? 5
  • What key information in a patient’s medication history is important in elbow injuries? 5,7
  • What key information in a patient’s social history is important in elbow problem/injuries? 5
  • What is the relevance of determining any intervention to date? 5
  • What is the relevance of determining the compensable status or health insurance status of the patient?

RECOMMENDED RESOURCES
1. Egol, K, Koval, K, & Zuckerman, J (2010) Handbook of Fractures 4th edition. Lippincott Williams and Wilkins. Chapter 11, Shoulder and Upper arm; Chapter 12, Elbow and Forearm.
2. McRae, R. (2010) Clinical Orthopaedic Examination 6th edition. Churchill Livingstone Elsevier. The elbow.