Descriptions of common injurys routinely treated by physical therapy.

Rotator Cuff Injuries

Rotator Cuff Muscles: supraspinatus, infraspinatus, teres minor, and subscapularts

Injury or disease may damage the musculotendinous rotator cuff, producing instability of the glenohumeral (shoulder) joint. Trauma may tear or rupture one or more of the tendons of the muscles forming the rotator cuff. Acute tears may occur when the arm is violently pushed into abduction, such as when a hockey player is pushed into the boards while using the upper limbs to cushion the impact. The person may tear the rotator cuff and report a sharp pain in the anterosuperior part of the shoulder. Rotator cuff injuries are also common in baseball pitchers and third basemen who throw the ball hard. Rotator cuff tears also follow dislocation of the shoulder.

Degenerative tendonitis of the rotator cuff is common, especially in old people. To test for this disease, the person is asked to lower the fully abducted limb slowly and smoothly. From approximately 90° abduction, the limb will suddenly drop to the side in an uncontrolled manner if the rotator cuff (especially the supraspinatus part) is diseased and torn. The supraspinatus tendon is the most commonly torn part of the rotator cuff, probably because it is relatively avascular. When the tendon tears acutely, or when it is eroded by chronic abrasion, especially in older persons, the two associated bursae communicate. The injury often results from an indirect force to the abducted arm, such as a fall during skiing in a person older than 45 years. Acute tears are uncommon in young persons. This injury causes tenderness around the greater tubercle of the humerus and pain during 45° of passive abduction.


Tendonitis (Calcific)

Inflammation and calcification of the subacromial bursa result in pain, tenderness, and limitation of movement of the glenohumeral joint. This condition is also known as calcific scapulohumeral bursitis. Deposition of calcium in the supraspinatus tendon is common. This causes increased local pressure that often causes excruciating pain during abduction of the arm; the pain may radiate as far as the hand. The calcium deposit may irritate the overlying subacromaial bursa, producing an inflammatory reaction known as subacromial bursitis. As long as the glenohumeral joint is adducted, no pain usually results because in this position the painful lesion is away from the inferior surface of the acromion. In most patients, the pain occurs during 50 to 130° of abduction because during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion. This condition is sometimes referred to as the painful arc syndrome. The pain usually develops in males 50 years and older after unusual or excessive use of the shoulder (e.g., during a tennis game).

Bursitis

Several bursae containing capillary films of synovial fluid are in the vicinity of the glenohumeral joint. Bursae are located where tendons rub against bone, ligaments, or other tendons and where skin moves over a bony prominence. The bursae around the glenohumeral joint are of special clinical importance. Some of them communicate with the joint cavity (e.g., the subscapular bursa); hence, opening a bursa may mean entering the cavity of the shoulder joint.

Subscapular Bursa

This bursa is located between the tendon of the subscapularis and the neck of the scapula. The bursa protects the tendon where it passes inferior to the root of the coracoid process and over the neck of the scapula. It usually communicates with the cavity of the shoulder joint through an opening in the fibrous capsule; thus, it is really an extension of the glenohumeral joint cavity.

Subacromial Bursa

Sometimes referred to as the subdeltoid bursa, this large bursa lies between the deltoid, the supraspinatus tendon, and the fibrous capsule of the glenohumeral joint. Its size varies, but it does not normally communicate with the cavity of the shoulder joint. The subacromial bursa is located inferior to the acromion and corcoacromial ligament, between them and the supraspinatus. This bursa facilitates movement of the supraspinatus tendon under the coracoacromial arch and of the deltoid over the fibrous capsule of the shoulder joint and the greater tubercle of the humerus.

Dislocation of Glenohumeral Joint

Because of its freedom of movement and instability, the glenohumeral joint is commonly dislocated by direct or indirect injury. Because of the presence of the coracoacromial arch and the support of the rotator cuff, most dislocations of the humeral head occur in the downward (inferior) direction; however, they are described clinically as anterior or (more rarely) posterior dislocations, indicating whether the humeral head had descended anterior or posterior to the infraglenoid tubercle and the long head of the triceps and ends up lying in front of or behind the glenoid cavity.


Anterior dislocation of the glenohemeral joint occurs most often in young adults, particularly athletes. It is usually caused by excessive extension and lateral rotation of the humerus. The head of the humerus is driven inferoanteriorly, and the fibrous capsule and glenoid labrum may be stripped form the anterior aspect of the glenoid cavity in the process. A hard blow to the humerus when the glenohumeral joint is fully abducted tilts the head of the humerus inferiorly onto the inferior weak part of the capsule. This may tear the capsule and dislocate the shoulder so that the humeral head comes to lie inferior to the glenoid cavity and anterior to the infraglenoid tubercle. The strong flexor and abductor muscles of the glenohumeral joint usually subsequently pull the humeral head anterosuperiorly into a subcoracoid position. Unable to use the arm, the patient commonly supports it with the other hand.

Axillary Nerve Injury

The axillary nerve may be injured when the glenohumeral joint dislocates because of its close relation to the inferior part of the articular capsule of this joint. The subglenoid displacement of the head of the humerus into the quadrangular space damages the axillary nerve. Axillary nerve injury is indicated by paralysis of the deltoid and loss of sensation in a small area of skin covering the central part of the deltoid.

E.) Glenoid Labrum Tears

Tearing of the fibrocartilaginous glenoid labrum commonly occurs in athletes who throw a baseball or football or in those who have shoulder instability and partial dislocation (subluxation) of the glenohumeral joint. The tear often results from sudden contraction of the biceps of forceful subluxation of the humeral head over the glenoid labrum. Usually a tear occurs in the anterosuperior part of the glenoid labrum (Halpern, 1994). The usual symptom is pain while throwing, especially during the acceleration phase, but a sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm.

Adhesive Capsulitis

Adhesive fibrosis and scarring between the inflamed articular capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid usually cause adhesive capsulitis (“frozen shoulder”). A person with this condition has difficulty abducting the arm. They can obtain an apparent abduction of up to 45° by elevating and rotating the scapula. Because of the lack of movement of the glenohumeral joint, strain is placed on the AC joint, which may be painful during other movements (e.g., elevation (shrugging) of the shoulder). Injuries that may initiate acute capsulitis, usually in 40 to 60 year old persons, are glenohumeral dislocations, calcific supraspinatus tendinitis, partial tearing of the rotator cuff, and bicipital tendinitis (Salter, 1998).


Knee Joint Replacement

A.) Alternative names

Total knee replacement; Knee arthroplasty

B.) Definition

Knee joint replacement is surgery to replace a painful damaged or diseased knee joint with an artificial joint (prosthesis)

C.) Description

The operation is performed under general anesthesia. The orthopedic surgeon makes an incision over the affected knee. The patella (knee cap) is moved out of the way, and the ends of the femur and tibia are cut to fit the prosthesis and to provide better adhesion of the prosthesis. Similarly, the undersurface of the knee cap is cut to allow for placement of an artificial component.

The two parts of the prosthesis are implanted onto the ends of the thigh bone (femur), the shin bone (tibia), and the undersurface of the knee cap (patella) using a special bone cement. Usually, metal is used on the end of the femur, and plastic is used on the tibia and patella, for the new knee surface. However, newer surfaces including metal on metal, ceramic on ceramic, or ceramic on plastic are now being used.

You will return from surgery with a large dressing to the knee area. A small drainage tube will be placed during surgery to help drain excess fluids from the joint area.

Your leg may be placed in a continuous passive motion (CPM) device after surgery. This is a mechanical device that flexes (bends) and extends (straightens) the knee to keep the knee from getting stiff.

Gradually, the rate and amount of flexion will be increased as tolerated. The leg should always be in this device when in bed. The CPM device helps speed recovery, decreases post-operative pain, bleeding and infection.

You will experience moderate pain after surgery. However, you may receive injections of narcotic medications, patient-controlled analgesia (PCA) or epidural analgesics (spinal) to control your pain for the first 3 days after surgery.

The pain should gradually decrease, and by the third day after surgery, oral medications may be sufficient to control your pain. Try to schedule your pain medications about one half hour before walking or position changes.

You will also return from surgery with several IV lines in place to provide fluid and nutrition. The IV will remain in place until you are taking adequate amounts of fluids by mouth.

Antibiotics may be given to reduce the risk of developing an infection, necessitating removal of the artificial joint.

You will also return from surgery wearing anti-embolism stockings or inflatable pneumatic compression stockings. These devices are used to reduce your risk of developing blood clots, which are more common after lower extremity surgery.

Additionally, you will be encouraged to start moving and walking as early as the first day after surgery. You will be assisted out of bed to a chair on the first day after surgery. When in bed, bend and straighten your ankles frequently to prevent development of blood clots.

You may be instructed on how to use an incentive spirometry device (a plastic device to encourage deep breathing), and cough and deep breathing exercises to gradually increase the depth of your respirations in order to prevent lung collapse and pneumonia.

A foley catheter may be inserted during surgery to monitor the function of your kidneys and hydration level. This will be removed on the second or third day after surgery. You will be encouraged to try to walk to the bathroom with assistance.

D.) Indications

Knee joint replacement may be recommended for:

• knee pain that has failed to respond to conservative therapy (including medication, injections,and physical therapy for 6 months or more)

• knee pain that limits or prevents activities of importance to the patient

• arthritis of the knee

• decreased knee function caused by arthritis

• inability to sleep through the night because of knee pain

• some tumors involving the knee

Knee joint replacement is usually not recommended for:

• current knee infection

• poor skin coverage around the knee

• paralysis of the quadriceps muscles

• severe peripheral vascular disease or neuropathy affecting the knee

• severe limiting mental dysfunction

• terminal disease ( metastatic disease)

• morbid obesity (over 300 lb.)

E.) Risks

The risks of this surgery include:

• blood clots in the legs (deep vein thrombosis or DVT)

• DVT that breaks loose and goes to the lungs (embolus)

• Pneumonia

• Infection necessitating removal of the joint

• Loosening of the prosthesis

• Dislocation of the prosthesis

People who have a prosthetic device ( such as an artificial joint) need to take special precautions against infection. You should carry a medical identification card indicating that you have a prosthetic device. Also, always inform your health care provider of your prosthetic knee joint. You should receive prophylactic antibiotics prior to dental work or any invasive procedure.

F.) Expectations after surgery

The results of a total knee replacement are often excellent. The operation relieves pain in over 90% of patients, and most need no assistance walking after recovery. Most prostheses last 10 to 15 years, some as long as 20 years, before loosening and requiring revision surgery.

G.) Convalescence

The hospital stay generally lasts 4-5 days, but the total recovery period varies from 2-3 months to a year. Walking and range-of-motion exercises will be started immediately after surgery. Some surgeons recommend using a machine that will bend the knee for the patient in bed.

Some patients require a short stay in a rehabilitation hospital to become safely independent in their activities of daily living. It may be necessary to use crutches or a walker for a few weeks or even months after surgery.

The physical therapy initiated in the hospital will continue after discharge until your strength and motion return. Contact sports should generally be avoided, but low impact activities, such as swimming and golf, are usually possible after full recovery from surgery.

Total Hip Replacement

Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two

parts-the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the “ball” or head of the thigh

bone (femur).

During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal.

These artificial pieces are implanted into healthy portions of the pelvis and thigh bones and affixed with a bone cement.

A.) Cementless total hip replacement

An alternative hip prosthesis has been developed that does not require cement. This hip has the potential to allow bone to grow into it, and therefore may last longer than the cemented hip. This is an important consideration for the younger patient. In some cases, only one of the two components

(socket or stem) may be fixed with cement and the other is cementless. This would be called a “Hybrid” hip prosthesis.

B.) Indications

Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies.) Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons. Circumstances vary, but generally patients are considered for total hip replacements if:

• pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living

• pain is not relieved by arthritis (anti-inflammatory) medicines, the use of a cane, and restricting activities

• significant stiffness of the hip

• x-rays show advanced arthritis, or other problems

C.) Expectations after surgery

A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your physician’s instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.

D.) Risks

Total hip replacement is a major operation. The effect of most complications is simply that the patient stays in the hospital longer. The most common complications are not directly related to the hip and so not usually affect the result of the operation. These include:

• blood clots in the legs

• blood clots in the lungs

• urinary infections or difficulty urinating

Complications that affect the hip are less common, but in these cases, the operation may not be as successful:

• differences in leg length

• stiffness

• dislocation of hip (ball pops out of socket)

• infection in hip

A few of the complications, such as infection or dislocation, may require reoperation. Infected artificial hips sometimes have to be removed, leaving a short (by one to three inches), somewhat weak leg, but one that is usually reasonably comfortable and one on which you can walk with the aid of a cane or crutches.

E.) Outcome over time

As noted earlier, 90-95 percent of hip replacements are successful up to 10 years. The major long-term problems are loosening or wear. Loosening occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (resorbs) from the cement. By 10 years, 25 percent of all artificial hips will look loose on an X-ray. Somewhat less than half of these (about 5% to 10% of all artificial hips) will be painful and require revision. Wear can occur in the plastic socket after some years. Small wear particles can cause inflammation resulting in thinning of the bone and risk of fracture.

Loosening and wear are in part related to how heavy and how active you are. It is for this reason we do not operate on very obese patients or young, active patients. Loose, painful artificial hips can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complications are higher.