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The anatomy of the wrist joint is extremely complex, probably the most complex of all the joints in the body. The wrist is actually a collection of many bones and joints. These
bones and joints let us use our hands in lots of different ways. The wrist must be extremely mobile to give our hands a full range of motion. At the same time, the wrist must provide the strength for heavy gripping.

This guide will help you understand:

• what parts make up the wrist
• how those parts work together

The important structures of the wrist can be divided into several categories. These include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels

Bones and Joints

There are 15 bones that form connections from the end of the forearm to the hand. The wrist itself contains eight small bones, called:

Carpal Bones

These bones are grouped in two rows across the wrist. The

Proximal Row

is where the wrist creases when you bend it. Beginning with the thumb-side of the wrist, the proximal row of carpal bones is made up of the scaphoid, lunate, and triquetrum. The second row of carpal bones, called the:

Distal Row

meets the proximal row a little further toward the fingers. The distal row is made up of the trapezium, trapezoid, capitate, hamate, and pisiform bones.

The proximal row of carpal bones connects the two bones of the forearm, the radius and the ulna, to the bones of the hand. The bones of the hand are called the
metacarpal bones. These are the long bones that lie within the palm of the hand. The metacarpals attach to the phalanges, which are the bones in the fingers and thumb.

One reason that the wrist is so complicated is because every small carpal bone forms a joint with the bone next to it. This means that what we call the wrist joint is actually made up of many small joints.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage can be up to one-quarter of an inch thick in the large, weight-bearing joints. It is thinner in joints such as the wrist that don’t support a lot of weight. Articular cartilage is white, shiny, and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage.

The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. In the wrist, articular cartilage covers the sides of all the carpals and the ends of the bones that connect from the forearm to the fingers.

Ligaments and Tendons

Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine to form a:

Joint Capsule

A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid. In the wrist, the eight carpal bones are surrounded and supported by a joint capsule.

Two important ligaments support the sides of the wrist. These are the collateral ligaments There are two collateral ligaments that connect the forearm to the wrist, one on each side of the wrist.

As its name suggests, the ulnar collateral ligament (UCL) is on the ulnar side of the wrist. It crosses the ulnar edge (the side away from the thumb) of the wrist. It starts at the ulnar styloid, the small bump on the edge of the wrist (on the side away from the thumb) where the ulna meets the wrist joint. There are two parts to the cord-shaped UCL. One part connects to the pisiform (one of the small carpal bones) and to the transverse carpal ligament, a thick band of tissue that crosses in front of the wrist. The other goes to the triquetrum (a small carpal bone near the ulnar side of the wrist). The UCL adds support to a small disc of cartilage where the ulna meets the wrist. This structure is called the triangular fibrocartilage complex (TFCC) and is discussed in more detail below. The UCL stabilizes the TFCC and keeps the wrist from bending too far to the side (toward the thumb).

The radial collateral ligament (RCL) is on the thumb side of the wrist. It starts on the outer edge of the radius on a small bump called the radial styloid. It connects to the side of the scaphoid, the carpal bone below the thumb. The RCL prevents the wrist from bending too far to the side (away from the thumb).

Just as there are many bones that form the wrist, there are many ligaments that connect to and support these bones. Injury or problems that cause these ligaments to stretch or tear can eventually lead to arthritis in the wrist.

At the wrist, the end of the ulna bone of the forearm articulates with two carpal bones, the lunate and the triquetrum.

A unique structure mentioned earlier, the triangular fibrocartilage complex (TFCC), sits between the ulna and these two carpal bones.

The TFCC is a small cartilage pad that cushions this part of the wrist joint. It also improves the range of motion and gliding action within the wrist joint.

There are several important tendons that cross the wrist.

Tendons connect muscles to bone. The tendons that cross the wrist begin as muscles that start in the forearm. Those that cross the palm side of the wrist are the flexor tendons. They curl the fingers and thumb, and they bend the wrist. The flexor tendons run beneath the transverse carpal ligament (mentioned earlier). This structure lies on the palm side of the wrist. This band of tissue keeps the flexor tendons from bowing outward when you curl your fingers, thumb, or wrist. The tendons that travel over the back of the wrist, the extensor tendons, run through a series of tunnels, called compartments. These compartments are lined with a slick substance called tenosynovium, which prevents friction as the extensor tendons glide inside their compartment.

Muscles

The main muscles that are important at the wrist have been mentioned above in the discussion about tendons. These muscles generally start further up in the forearm. The tendons of these muscles cross the wrist. They control the actions of the fingers, thumb, and wrist.

Nerves

All of the nerves that travel to the hand cross the wrist. Three main nerves begin together at the shoulder: the radial nerve, the median nerve, and the ulnar nerve. These nerves carry signals from the brain to the muscles that move the arm, hand, fingers, and thumb. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

Radial Nerve

runs along the thumb-side edge of the forearm. It wraps around the end of the radius bone toward the back of the hand. It gives sensation to the back of the hand from the thumb to the third finger. It also goes to the back of the thumb and just beyond the main knuckle of the back surface of the ring and middle fingers.

Median Nerve

The Median Nurve travels through a tunnel within the wrist called the carpal tunnel. The median nerve gives sensation to the palm sides of the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.

The ulnar nerve travels through a separate tunnel, called Guyon’s canal. This tunnel is formed by two carpal bones (the pisiform and hamate), and the ligament that connects them.

After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger.

Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

The nerves that travel through the wrist are subject to problems.

Constant bending and straightening of the wrist and fingers can lead to irritation or pressure on the nerves within their tunnels and cause problems such as pain, numbness, and weakness in the hand, fingers, and thumb.

Blood Vessels

Traveling along with the nerves are the:

Large Vessels

that supply the hand with blood. The largest artery is the radial artery that travels across the front of the wrist, closest to the thumb. The radial artery is where the pulse is taken in the wrist. The ulnar artery runs next to the ulnar nerve through Guyon’s canal (mentioned earlier). The ulnar and radial arteries arch together within the palm of the hand, supplying the front of the hand and fingers. Other arteries travel across the back of the wrist to supply the back of the hand and fingers.

As you can see, the wrist is a complex area of the body. When you realize all the different ways we use our hands every day and all the different positions we put our hands in, it is easy to understand how hard daily life can be when the wrist doesn’t work well.

As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint. Mild injuries of the TFCC may be referred to as a wrist sprain.  Significant disruption of this area through injury or degeneration, however, can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition.

This guide will help you understand:

• what parts if the wrist are involved
• how these injuries occur
• how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the wrist are involved?

The wrist is actually a collection of many bones and joints. It is probably the most complex of all the joints in the body. There are 15 bones that form connections from the end of the forearm to the middle of the hand.

The wrist itself contains eight small bones, called carpal bones. These bones are grouped in two rows across the wrist. The proximal row is where the wrist creases when you bend it. The second row of carpal bones, called the distal row, meets the proximal row a little further toward the fingers.

The proximal row of carpal bones connects the two bones of the forearm, the radius and the ulna, to the bones of the hand. On the ulnar side of the wrist, the end of the ulna bone of the forearm moves with two carpal bones, the lunate and the triquetrum.

The TFCC suspends the ends of the radius and ulna bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions: bending, straightening, twisting both ways, and side-to-side.

The entire TFCC sits between the ulna and the two carpal bones (the lunate and the triquetrum). The TFCC inserts into the lunate and triquetrum via the ulnolunate and ulnotriquetral ligaments. It stabilizes the distal radioulnar joint while improving the range of motion and gliding action within the wrist.

There is a small cartilage pad called the articular disc in the center of the complex that cushions this part of the wrist joint. Other parts of the complex include the dorsal radioulnar ligament, the volar radioulnar ligament, the meniscus homologue (ulnocarpal meniscus), the ulnar collateral ligament, the subsheath of the extensor carpi ulnaris, and the ulnolunate and ulnotriquetral ligaments.

Injury to the TFCC involves tears of the fibrocartilage articular disc and meniscal homologue. The homologue refers to the piece of tissue that connects the disc to the triquetrum bone in the wrist. The homologue acts like a sling or leash between these two structures.

Another important structure to make note of with TFCC injuries is the ulnar fovea. The fovea is a groove that separates the ulnar styloid from the ulnar head. The groove is at the junction of the ulnar bone and wrist. The styloid is a small bump on the edge of the wrist (on the side away from the thumb) where the ulna meets the wrist joint. Later we will talk about the fovea test to diagnose TFCC injuries.

What causes this problem?

The TFCC stabilizes the wrist at the distal radioulnar joint. It also acts as a focal point for force transmitted across the wrist to the ulnar side. Traumatic injury or a fall onto an outstretched hand is the most common mechanism of injury. The hand is usually in a pronated or palm down position. Tearing or rupture of the TFCC occurs when there is enough force through the ulnar side of the hyperextended wrist to overcome the tensile strength of this structure.

High-demand athletes such as tennis players or gymnasts (including children and teens) are at greatest risk for TFCC injuries. TFCC injuries in children and adolescents occur more often after an ulnar styloid fracture that doesn’t heal. Power drill injuries also often cause TFCC rupture when the drill binds and the wrist rotates instead of the drill bit. TFCC tears can also occur with degenerative changes. Repetitive pronation (palm down position) and gripping with load or force through the wrist are risk factors for tissue degeneration. Degenerative changes in the TFCC structure also increase in frequency and severity as we get older; thinning soft tissue structures that occur with age can result in a TFCC tear with minor force or minimal trauma.

There may be some anatomical risk factors for TFCC injuries. Studies show that patients with a torn TFCC often have ulnar variance and a greater forward curve in the ulnar bone. Ulnar variance means the ulna is longer than the radius because of congenital (present at birth) shortening of the radius bone in the forearm.

What does the condition feel like?

Wrist pain along the ulnar side is the main symptom. Some patients report diffuse pain, which means the pain is throughout the entire wrist area and can’t be pinpointed to one area. The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction. This includes simple activities like turning a doorknob or key in the door, using a can opener, or lifting a heavy pan or carton of milk with one hand.

Other symptoms include swelling, clicking, snapping, or crackling (called crepitus) and weakness of the wrist. Some patients report a feeling of instability, like the wrist is going to give out on them. Others report that it is as if something is catching inside the joint. There is usually tenderness on palpation along the ulnar side of the wrist.

In cases of a traumatic injury a fracture needs to be ruled out. If a fracture at the wrist end of the ulna bone is present along with soft tissue instability, then forearm rotation may be very limited. The direction of limitation (palm up or palm down) depends on which direction the fractured portion of the ulna dislocates.

How do health care professional diagnose the problem?

Diagnosis begins with a complete history of your injury. Your Physical Therapist at First Choice Physical Therapy will ask questions about where precisely the pain is, when the pain began, if there was a specific injury that occurred or whether the pain gradually developed over time, and what movements aggravate or ease the pain.  They will also ask if there is any swelling, clicking, catching, or weakness in the wrist.

Next they will do a physical examination. Your therapist will palpate all around the wrist to determine your most tender point. They will also look for swelling or redness in the area. Next they will check the strength of your muscles around the wrist, elbow, and hand. They will ask you to resist certain movements while checking for pain as well as strength deficits. They may also do a grip strength test to determine if your injury has caused you to lose some of your strength and to get a baseline measure so they can easily track your improvement with rehabilitation.

Other tests may be done to provoke the symptoms and test for excess or restricted movement at the wrist. These tests include hypersupination (overly rotating the forearm in a palm-up position), loading the wrist in a position of ulnar deviation (moving wrist away from the thumb), and passively putting the wrist into a fully extended position.

A new test called the fovea sign applies external pressure to the area of the fovea on the ulna bone. The examiner compares the involved wrist with the normal wrist. Tenderness and pain during this test is a sign that there may be a split-tear injury (down the middle length-wise) of the TFCC.

Split tears are more common with lower energy, repetitive torque injuries such as from bowling or golfing. This type of ligament injury was first discovered when a surgeon pushed on the area of pain while using an arthroscope to look inside the joint. When the surgeon did this he saw the ligament open up like a book.

X-rays may show disruption of the TFCC when there is a bone fracture present, however ligamentous instability without bone fracture appears normal on standard X-rays. An X-ray with a dye injected is called a wrist arthrography. Arthrography is positive for a TFCC tear if the dye as seen on X-ray leaks into any of the joints. During this test there are three specific joint areas tested, so this test is called a triple injection wrist arthrogram.

Acute injuries can be painfully swollen preventing proper physical examination. In such cases, more advanced imaging such as MRIs can be used to detect ligamentous or other soft tissue damage. MRIs can be useful to detect TFCC injuries even without dye injected.  When the MRI is done with a dye injected into the area, however, the test is called an MRI arthrogram. If the dye moves from one joint compartment to another, a tear of the soft tissues is suspected. Unfortunately studies show that almost half the patients with a true TFCC tear have normal arthrograms.

Wrist arthroscopy is really the best way to accurately assess the severity of damage with a TFCC injury. At the same time as assessing the TFCC, the surgeon performing the arthroscope looks for other associated injuries of related ligaments and cartilage. The surgeon performs the arthroscope by inserting a long thin needle into the joint. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the tissues of the joint.

Using a probe, the surgeon tests the integrity of the soft tissues. A special trampoline test can be done to see if the fibrocartilage disk is okay. During this test the surgeon presses the center of the disk with the probe. Good tension and an ability for the tissue to bounce back shows that the disk is attached normally and is not torn or damaged. If the probe sinks, as if on a feather bed, the test is positive (indicating a tear). One advantage of an arthroscopic exam is that treatment can often be done at the same time.

An accurate diagnosis and grading of the injury (degree of severity) is important. There are two basic grades of triangular fibrocartilage complex injuries. Class 1 is for traumatic injuries. Class 2 is used to label or describe degenerative conditions. Usually, the grade is based on how much disruption of the ligament has occurred (minimal, partial, or complete tear).

What treatment options are available?

Nonsurgical Treatment
If the wrist is still stable, then conservative (non-operative) care is advised. You may be given a temporary splint to wear for four to six weeks. The splint will immobilize (hold still) your wrist and allow scar tissue to form at the injury site. Anti-inflammatory drugs may be prescribed and Physical Therapy will be recommended. You may benefit from one or two steroid injections spaced apart by several weeks.

If the wrist is unstable but you don’t want surgery, then your doctor may put a cast on your wrist and forearm. In some cases it is possible to use a splint for six weeks instead of casting, and to start Physical Therapy once the immobilization period is over.

With appropriate non-surgical treatment and adherence to a rehabilitation program at First Choice Physical Therapy many patients with a mild triangular fibrocartilage complex injury are able to return to work and/or sports at a preinjury level. Pain-free movement and full strength are possible.

Non Surgical Rehabilitation

The initial aim of treatment for a TFCC injury at First Choice Physical Therapy will be to decrease the inflammation and pain around the area. Simply icing your wrist assists with the inflammation and often relieves a great deal of the pain. In cases of more chronic pain, heat may be more useful. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and inflammation. Massage for the muscles of the forearm may also be helpful at this stage.

As many wrist motions easily aggravate this injury it is important to stop or change any activities that are causing symptoms. If possible, your therapist will encourage you to avoid repetitive hand motions such as heavy grasping, wringing, as well as turning and twisting movements of the wrist. Lifting objects with one hand should also be avoided. If it is unavoidable to use your hand, then taking frequent breaks during activity is a must.

In addition to giving the wrist as much rest as possible, keeping your wrist in a neutral alignment will also assist in the healing process. In other words, keeping it in a straight line with your arm, without bending it up or down or twisting it.  You may have already used a splint suggested by your doctor, but if not, your Physical Therapist may suggest you start using one.  Tape or strapping can sometimes be an alternative to a splint, or can be used in addition to one. Tape, however, is not as sturdy as a splint so generally does not provide as much relief or as optimal of a healing environment as a rigid brace. That being said, tape may be a useful alternative for when full immobilization of the wrist is not feasible.

As part of your treatment your Physical Therapist may check your workstation posturing and the way you do your daily tasks. We will also educate you about healthy body alignment and proper wrist positions. It is our belief at First Choice Physical Therapy that preventing future problems is as much a part of our treatment as treating the current injury.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the mobility and strength of your wrist and hand. They will take measurements of your wrist range of motion and grip strength to determine if there are any specific deficits to work on and to track your progress.

Simple wrist and finger stretching exercises will be prescribed and should be done within the limits of pain.  Exercises to improve the motions of bending and straightening of the wrist, turning your palm up (supination) and then back over (pronation,) moving your wrist towards your little finger (ulnar deviation) and then towards your thumb (radial deviation), as well as twisting of the wrist will be given.

Strengthening exercises will also be prescribed. These exercises will focus on improving both the strength of the wrist as well as the ability of the hand to grip and exert force when twisting, grabbing, bearing weight, or doing functional activities such as those required for your work or sport. Exercises to improve strength will include eccentric exercises for the forearm muscles. Eccentric contractions occur as the muscle lengthens and the tendon and muscle is put under stretch. Eccentric exercises for the wrist are initiated by dropping the wrist down slowly at first and then also slowly returning to the neutral position.  As able, the drop portion of the exercise is progressed to a quick motion. These exercises will help to build up the tensile strength in the tissues and associated muscles of the wrist to be able to control and protect the wrist.  Strengthening exercises will be prescribed not only for the bending motion of your wrist, but also for the motion where your wrist moves towards and away from your thumb (ulnar and radial deviation.) This motion, along with rotation of the wrist, are particularly stressful to the TFCC area. Your therapist will ensure that your injury is at an appropriate stage of healing before introducing eccentric exercises or strengthening ulnar and radial deviation as these types of exercises put significant stress through the TFCC area and can aggravate a healing injury.  Another stressful exercise for the tissues of the TFCC is one that involves putting weight-bearing force through the wrist, such as when you push a door open with your hand, or do a push up.  Your therapist will add these types of exercises once they know the healing process has progressed enough to not aggravate your wrist. These exercises should begin in a neutral position (such as the position you would use when making a fist) and progress to a position where weight is being put through the wrist while it is extended (such as a wall or floor push up position).

Therapeutic tools such as elastic putty or gripping balls might be used to add resistance for your wrist. As you become stronger, weights or resistance bands will be used to further build up strength.  Fine motor control and dexterity exercises for your thumb and hand may also be added into your rehabilitation routine depending on your occupation or the cause of your injury. Your therapist may ask you to do daily functional tasks such as fold the laundry, twist door handles, or unload the dishwasher as part of your therapy.  These exercises force the wrist to do combined motions such as rotation and extension, and stress the tissues of the TFCC in ways similar to how it is stressed during everyday activities.

Proprioception is the ability for you body to know where it is in space without looking at it.  With any injury, this ability declines. A period of immobilization adds to this decline.  Without proper proprioception any joint is at an increased risk of injury. Your therapist will prescribe exercises to address proprioception of your wrist. The may ask you to roll a ball with your hand against a wall or gently toss and catch a light ball. Many advanced exercises for strength also incorporate proprioception.

Residual laxity may remain after nonoperative treatment of a TFCC injury. If conservative care is unsuccessful, persistent joint laxity and instability can lead to degeneration of the joint’s articular cartilage. Too much force or compression on either side of the joint can lead to pain and altered movement patterns. If non surgical treatment is not effective then surgery may be needed to restore normal wrist movement.

Surgical treatment is based on the specific injury present. Instability as a result of a complete ligamentous rupture, especially with a bone fracture, requires surgery as soon as possible.

The outside perimeter of the TFCC has a good blood supply. Tears in this area can be repaired. There is no potential for healing when tears occur in the central area where there is no blood supply. In these cases arthroscopic debridement of the damaged tissue is required.

During arthroscopic debridement the surgeon smooths or shaves any tears of the disc or meniscal homologue that might catch against the joint surfaces. The surgeon then looks for any problems with the foveal ligament. A probe is used to detect tension or laxity (looseness) of the ligaments. Laxity is a sign of injury.

Arthroscopic debridement works well for simple tears. Much of the damaged tissue can be removed while still keeping a stable wrist joint. The torn structures can be reattached with repair sutures. Some surgeons perform an arthroscopic wafer procedure (see below) in addition to the TFCC debridement especially when both TFCC disruption and positive ulnar variance are present. Further studies are needed to see if the combined procedure results in a more satisfactory outcome than current methods and to evaluate the rotational loss that can occur with this combined procedure.

Some ligamentous ruptures with a fracture can also be repaired arthroscopically with reattachment and instrumentation. Instrumentation refers to the use of hardware such as wires and screws to help hold the repaired tissue in place until healing occurs.

Although they are not common, there are some complex tears that require open repair. Open repair means the surgeon makes an incision and opens the tissues to perform the operation. This gives the surgeon a better view and better access of the area. The specific procedure required depends on the tissues injured and the extent of the injury. For example, detachment of the radioulnar ligaments usually requires open repair. Instability of the distal radioulnar joint may require the use of wires to hold the area together until healing occurs.  In other cases, surgery has been delayed so long that the torn ligament has retracted (pulled back) too far and a direct repair can’t be done. In these cases, a tendon graft may be needed to help strengthen the repair.

Chronic and degenerative TFCC tears may require a different surgical approach. Debridement is not as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulnar bone at the wrist to obtain pain relief. There are two procedures used to shorten the ulna and unload the ulnocarpal joint. These are the ulnar (diaphyseal) shortening method and the distal ulnar head shortening osteotomy (Feldon wafer method). If lunate-triquetrum instability is present, ulnar shortening can be done to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.

When making the decision as to which procedure to use the surgeon weighs the amount of shortening needed and the structure of the distal radioulnar joint, which will affect the joint loading.

With the diaphyseal shortening method (using internal fixation – plate/screws) there is a higher complication rate (ie. delayed union, nonunion, hardware removal).

Distal ulnar head shortening osteotomy (ie. Feldon wafer method) is an arthroscopic or open method (only 2-3mm of shortening.) It is less invasive and provides equal relief to diaphyseal shortening.

Your wrist will be immobilized in a bulky dressing or cast. The type of immobilizing device used and the position your wrist is placed in depends on the type of surgery you had. Your surgeon may encourage simple finger and elbow motions soon after surgery.

Pain relief, improved motion, and increased function are the main goals of surgery for most patients. The surgeon is also interested in restoring wrist stability and the load bearing function of the wrist. After the initial soreness from the surgery is gone, you should experience a significant decrease in pain. Many patients report being pain free.

The follow-up plan after surgery may vary depending on the type of procedure used by your surgeon. Newer and improved methods have made it possible for some patients to return to full, unrestricted activity as early as six weeks post-op.

The standard surgery usually follows a typical course. One week after surgery, the splint will be replaced with a fiberglass type cast (still in a supinated position). The elbow is left free to move fully. The cast will be removed six weeks after the operation. Cast removal is followed by Physical Therapy for six to eight weeks.

What should I expect after surgery?

Rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon allows it. Each surgeon will set his or her own specific activity restrictions based on the surgical procedure used, their personal experience, and whether or not wrist is healing as expected.

Even while the cast is on and before extensive Physical Therapy begins, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  Activities such as walking or using a stationary bike or stepper machine are easy activities that can be done even while the wrist is healing.  Avid runners may be able to continue running with clearance from their doctor.  Weights or weight machines for your lower extremity and opposite arm are also acceptable to use as long as the restrictions regarding your healing wrist are strictly abided by. Lifting any weight at all with your injured side will not be allowed while your wrist is in the initial healing stages so you may require a friend to assist you with your workout if you are keen to continue during this time.  Your Physical Therapist at First Choice Physical Therapy can discuss the most appropriate way for you to maintain your fitness while abiding by your doctor’s restrictions, and can provide a general fitness program specific to your needs.

When the cast is first removed after surgery you may experience some pain when you start to move your wrist, elbow and forearm. This pain is from not using the joints regularly while your wrist has been immobilized as well as from the surgical process itself. Your Physical Therapist at First Choice Physical Therapy will focus initially on relieving this pain. They may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the wrist or anywhere along the arm or into the hand. In addition, they may massage the hand, forearm, wrist, or elbow to improve circulation and assist with pain.

The next part of your treatment will focus on regaining the range of motion, strength, and dexterity in your wrist, hand, elbow, and shoulder. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of a home exercise program. These exercises may include the use of rehabilitation equipment such as pliable balls, exercise bands, or small weights that provide added resistance for your hand and wrist. Your Physical Therapist may even give you exercises for your shoulder.  The shoulder is the link of the upper limb to the rest of the body so it needs to be strong and well controlled for the upper extremity, particularly the wrist and hand, to work well.  In addition, compensatory motions of the shoulder can affect how you use your wrist and lead to secondary pain in your shoulder.

The initial exercises prescribed will not require you to put any of your body weight through the wrist; you may simply be moving the wrist back and forth, side to side, turning your palm up and down, and rotating your wrist within the limits of pain. As your healing wrist allows, your Physical Therapist will add in exercises where you are putting more stress through the wrist by taking the wrist into full ranges of motion, doing quick wrist motions, and doing eccentric strength exercises (see description under non-surgical rehabilitation). At the appropriate time your therapist will add in exercises where you are putting some of your body weight through your wrist via your hand, such as when pushing on a door or doing push ups against a wall.

Some patients have difficulty regaining pinch grip and grip strength after TFCC surgery so this will be addressed with specific exercises. Your therapist at First Choice Physical Therapy will also focus particularly on gaining back those ranges of movement which are commonly lost after this type of surgery.  These include ulnar deviation, supination, pronation, and wrist extension.

If necessary, your Physical Therapist will mobilize your joints in order to gain range of motion. This hands-on technique encourages any stiff joints in your wrist, hand and elbow to move gradually into their normal range of motion.

As a result of any injury, the receptors in your joints and ligaments that assist with proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobilization will add to this decline. Although your wrist is not traditionally thought of as a weight-bearing joint, even activities such as pushing up to get off of the couch, pulling a glass from a cupboard, or pushing a door open, require weight to be put through or lifted by your wrist and for your body to be proprioceptively aware of your limb. If you are active in sport, then proprioception of your upper extremity is paramount in returning you to your sport after surgery for a TFCC injury.  Your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain this proprioception. These exercises may include activities such rolling a ball on a surface with your hand, holding a weight up overhead while moving your shoulder, or lightly tossing an item up and catching it. Advanced exercises wil
l include exercises such as ball throwing or catching overhead.

Fortunately, gaining range of motion, strength, and proprioception after surgery for a TFCC injury occurs fairly quickly. You will notice improvements in the functioning of your wrist even after just a few treatments at First Choice Physical Therapy.  As you improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your healing wrist allows. Once your wrist can tolerate it, advanced exercises may include activities such as holding a push up position with your hands on a basketball, or dips in a chair where you are taking nearly your whole body weight through your wrist.  It is crucial at each stage of rehabilitation to closely follow the instructions of your Physical Therapist as the TFCC area can be easily aggravated if too much is done too quickly.

Generally, the wrist responds very well to the Physical Therapy we provide at First Choice Physical Therapy after surgery for a TFCC injury. Many patients are able to return to work with no restrictions. A small number of patients may require some work restrictions or permanent changes in work tasks. It should be noted, however, that in some cases complications such as persistent pain and stiffness occur. Your therapist will ask you to follow-up with your doctor if they feel your rehabilitation is not progressing as it should. Other complications such as infections, delayed union, or nonunion of bone fractures may also be a problem. In some cases further surgery may be needed to revise the first operation. Some patients need another surgery to remove any hardware used to stabilize the joint. In other cases the bottom of the ulna called the styloid may have to be removed. In rare cases, the procedure fails to provide the desired results and a wrist fusion may be the next step.

Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury. This produces pain, weakness, and swelling of the knee joint. Patellar tendonitis (also known as jumper’s knee) is a common overuse condition of one of the knee tendons that is associated with running, kicking, and repetitive jumping and landing.

This guide will help you understand:

• what parts of the knee are involved
• how the problem develops
• how your health care professional will diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the knee are involved?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the tibia (shin bone.)

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of the tibia just below the patella. This is called the infrapatellar tendon or patellar tendon. Another tendon, the quadriceps tendon, attaches from the quadriceps muscle into the top of the patella. These two tendons, together with the patella, are called the quadriceps mechanism.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The long bones of the femur and the tibia act as level arms, placing force or load on the knee joint and surrounding soft tissues. The amount of load can be quite significant. For example, the joint reaction forces of the lower extremity (including the knee) are two to three times the body weight during walking and up to five times the body weight when running.

What causes this problem?

Patellar tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Repetitive knee flexion and extension that occurs in such activities as running, jumping, and rising from a deep squat contribute to this condition. Overuse from repetitive sports activities is the most common cause of patellar tendonitis but anyone can be affected, even those who do not participate in sports or recreational activities.

There are both extrinsic (not related to the body) and intrinsic (pertaining to the body) factors that can contribute to the development of patellar tendonitis. Extrinsic factors include inappropriate footwear, training errors such as doing too much too quickly, and inappropriate sport training/playing ground (i.e. hard surface, cement.)

Intrinsic factors such as age, flexibility, and joint laxity are also important. Misalignment of the foot, ankle, and leg can play a key role in tendonitis. Factors such as a flat foot position, tracking abnormalities of the patella, rotation of the tibia (tibial torsion,) and a leg length difference can create increased and often uneven load on the quadriceps mechanism that can contribute to the development of patellar tendonitis.

An increased Q-angle or femoral anteversion are two common types of misalignment that contribute to patellar tendonitis. The Q-angle is the angle formed by the patellar tendon and the axis of pull of the quadriceps muscle. This angle varies between the sexes. It is larger in women compared to men. The normal angle is usually less than 15 degrees. Angles more than 15 degrees create more of a pull on the tendon, and can create painful inflammation. Femoral anteversion is an anatomical inward twisting of the femur (thigh bone.) This twisting affects where the patella sits on the top of the knee joint as well as how the force of the quadriceps muscle pulls along the quadriceps mechanism.

Any muscle imbalance of the lower extremity (from the hip down to the feet) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to patellar tendonitis.

Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibers that make up the tendon. Overuse is simply a mismatch between load or stress on the tendon and the ability of that tendon to distribute the force. If the forces placed on the tendon are greater than the strength of the structure, then injury can occur. Pain develops when microtrauma to the musculotendinous junction develops due to the repetitive pull during knee flexion and extension. Tissue breakdown then occurs triggering an inflammatory response that leads to tendonitis.

Chronic overuse leads to a problem called tendonosis. Unlike with tendonitis, inflammation is not present in tendonosis. Instead, degeneration and/or scarring of the tendon due to long term wear and tear develop and are the cause of the problem. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

What does patellar tendonitis feel like?

Pain from patellar tendonitis is felt just below the patella, often right at the tendon attachment to the kneecap. The pain is most noticeable when you move your knee or try to kneel. The more you move your knee, the more tenderness that develops.

There may be swelling in and around the patellar tendon and the tendon may be very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. The pain is worse when rising from a deep squat position. Resisted quadriceps contraction with the knee straight also aggravates the condition.

How do health care professionals diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your Physical Therapist at First Choice Physical Therapy will ask questions about where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.  As mentioned above, extrinsic factors such as training history as well as type of footwear are important for us to inquire about. The history alone will often lead your Physical Therapist to the suspicion of patellar tendonitis.

Next your Physical Therapist will do a physical examination of the knee and entire lower extremities. They will palpate, or touch, around the knee and particularly along the patellar tendon to determine the exact location of pain. Your Physical Therapist will look for the individual intrinsic factors mentioned above, such as alignment, flexibility and joint laxity that may be affecting your knee. They may want to look at how you stand, your foot position, or watch you walk, squat, or jump. Your Physical Therapist in Lynn Haven and Panama City Beachwill also check the strength and lengths of the muscles surrounding and affecting the knee joint such as the quadriceps, hamstrings, calves, hip flexors and buttocks muscles. All of these muscles, if weak or tight, can contribute to the forces applied to the knee joint and contribute to the development of patellar tendonitis. Providing resistance while you straighten your knee generally reproduces the pain associated with patellar tendonitis so this will also be tested. Lastly, your Physical Therapist will assess the stability of the knee joint to determine if the laxity of the ligaments and tissues surrounding the knee joint are contributing to the problem.

Often patellar tendonitis can be positively diagnosed from the history and physical examination and does not require further investigations. At times, however, further diagnostic tests may be required to either confirm or rule out the diagnosis, or to determine if there are any micro tears in the tendon that may be limiting the tendon from healing as expected. Tests such as ultrasonography or magnetic resonance imaging (MRI) may be used in these cases. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves (rather than X-rays) to create pictures that look like slices of the knee. Normal MRIs do not require any needles or special dyes and are painless.  These pictures show the soft tissues of the body. Usually, this test is done to look for other injuries such as tears in the quadriceps.  It is also used, however, to identify tears in the patellar tendon and can also confirm inflammation in the area.

If your Physical Therapist determines that it would be useful in your case to obtain an ultrasound or MRI, they will inform you of the quickest and most appropriate method of obtaining the investigation.

What treatment options are available?

Nonsurgical Treatment

Patellar tendonitis is usually self-limiting. That means the condition will resolve with rest, activity modification, and Physical Therapy. Recurrence of the problem is common for patients who fail to let the patellar tendon recover fully before resuming training or other aggravating activities.

Your initial treatment for acute patellar tendonitis at First Choice Physical Therapy will aim to decrease the inflammation and pain in the knee. Simply icing your knee can often assist with the inflammation and relieve a great deal of the pain from patellar tendonitis. In cases of chronic tendonitis, heat may be more useful in decreasing pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and inflammation. Massage especially for the quadriceps muscle may also be helpful.

Medication to ease the pain or inflammation can often be very beneficial in the overall treatment of patellar tendonitis. Your Physical Therapist may suggest you see your doctor to discuss the use of anti-inflammatories or pain-relieving medications in conjunction with your Physical Therapy treatment. Your Physical Therapist may even liaise directly with your doctor to obtain their advice on the use of medication in your individual case.

As inflammation of the patellar tendon most often occurs due to repetitive activity, rest is an important part of the treatment of patellar tendonitis.  ‘Relative rest’ is a term used to describe a process of rest-to-recovery based on the severity of symptoms. If you are experiencing pain while doing nothing (resting) it means the injury is more severe and your Physical Therapist will advise a period of strict rest and possibly even a short time of immobilization in a splint or brace to prevent any repetitive knee flexion/extension. When pain is no longer present at rest, then a gradual increase in activity is permitted so long as there is no return in resting pain.

Once the initial pain and inflammation has calmed down, your Physical Therapist in Lynn Haven and Panama City Beach will focus on improving the flexibility, strength, and alignment around the knee joint and entire lower extremity. Static stretches for the muscles and tissues around the knee (particularly the quadriceps and iliotibial band on the outside of the knee) will be prescribed by your Physical Therapist early on in your treatment to improve flexibility. Again, any tightness in the muscles or tissues around the knee can increase the pull on the patellar tendon or affect alignment during walking, running or jumping so it is important to address this immediately. Dynamic stretching (rapid motions that stretch the tissues quickly) will also be taught and will be incorporated into your rehabilitation exercise routine as part of your warm-up once you return to doing more aggressive physical activity. Dynamic stretches are used to prepare the tissues for activity whereas static stretches focus more on gaining flexibility.

Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten. Your Physical Therapist will determine which muscles in your individual case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important.  When bending the knee, the patellar tendon is placed under load while it is stretching. This load can be tremendous especially when jumping or landing. In order to prepare the healing tendon to take this load, your Physical Therapist will prescribe ‘eccentric’ muscle strengthening. Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch.  Bending your knee quickly into a squatting position and then stopping rapidly (drop squats) encourages the knee to adapt to the force that will eventually be needed to return to physical activity. When appropriate, weights can be added to simulate the increased body weight that the knee endures during running and jumping. Your Physical Therapist may even ask you to do this exercise on board slanting downwards (approximately 25 degrees) which has been shown to also increase the force through the tendon. In addition, an electrical muscle stimulator may be used which encourages improved recruitment of the muscles it is stimulating. All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon.

In addition to stretching and strengthening the knee, bracing or taping the patella can help you do exercises and activities with less pain. Your Physical Therapist can educate you on which brace would be most appropriate for you. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. These braces work by encouraging proper alignment of the patella in the femoral groove and/or by distribute the force on the patellar tendon. This in turn is thought to improve the functioning of the quadriceps mechanism. An alternative to bracing is to tape the patella in place. Your Physical Therapist can do this for you and also teach you how to do it for yourself. Taping is an easy and cost-effective way to determine if a brace will decrease your pain before actually investing in one. Patients commonly report less pain and improved function with both taping and bracing.

Proper alignment of your entire lower extremity is paramount to decreasing the overall stress that is placed on your patellar tendon. In addition to strengthening and stretching, foot orthotics may be useful to correct your foot position, which in turn then encourages proper alignment up the lower extremity chain. Your Physical Therapist can advise you on whether orthotics would be useful for you, and also on where to purchase them.

A critical part of our treatment for patellar tendonitis at First Choice Physical Therapy includes education on returning to physical activity. Bending and straightening your knee occurs often even in everyday activities such as walking or stair climbing so a patellar tendon that is recovering from injury can easily be aggravated.  Returning to your normal physical activity at a graduated pace is crucial to avoid repetitive tendonitis pain or a chronic injury. Your Physical Therapist will advise you on the acceptable level of activity at each stage of your rehabilitation process and assist you in returning to your activities as quickly but as safely as possible.

With a well-planned rehabilitation program and adherence to suggested levels of rest and activity modification, most patients are able to return to their previous level of activity without recurring symptoms.

Some cases of patellar tendonitis, unfortunately, even with appropriate treatment can be recalcitrant.  In these cases, your Physical Therapist at First Choice Physical Therapy may ask you to return to see your doctor to discuss more aggressive forms of treatment.

Cortisone injections may be used directly into the tendon if oral anti-inflammatories and conservative Physical Therapy has not eased the pain. Doctors are cautious, however, with the use of cortisone near tendons as repetitive injections can weaken the tendon and cause further problems.

Extracorporeal shock wave therapy is a form of therapy that uses high intensity sound waves directed at the tendon to promote healing and may be effective in relieving the pain associated with patellar tendonitis.

Autologous blood injections are a relatively new form of treatment where a portion of the patient’s own blood (plasma) is injected directly into the patellar tendon. This is thought to stimulate healing in the injured tendon. Ongoing research regarding its effectiveness is needed.

Surgery is rarely needed to treat patellar tendonitis. If nonsurgical treatment fails to improve your pain and allow return to your activity, however, then surgery may be suggested.

Surgery is designed to stimulate healing through revascularization (restoring blood supply). Weak, damaged tissue is removed and the injured tendon is repaired. Some extreme cases may require surgery, which relocates the attachment of the patella in order to change the force that goes through it. Arthroscopic revascularization procedures can usually be done on an outpatient basis (you can leave the hospital the same day.) If your problem requires a more involved surgical procedure (moving the patellar tendon attachment) you may need to spend one or two nights in the hospital.

What should I expect as I recover?

After Surgery

Surgeons will generally have their patients take part in formal Physical Therapy after patellar tendon surgery. More involved surgeries for patellar realignment or restorative procedures for tendon tissue require a delay before going to therapy and rehabilitation may be slower to allow the tendon to heal before too much strain is put on the knee.

Once clearance is given by your surgeon, our treatment at First Choice Physical Therapy will be similar to the rehabilitation outlined above. If, however, during post-surgical rehabilitation your pain continues longer than it should or Physical Therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the tendon is tolerating the rehabilitation well and ensure that there are no complications that may be impeding your recovery.

Chronic, or long-term, tendon problems are common. Tendon problems are especially common in people who play certain types of sports.  For instance, tendon problems account for almost 30 percent of all running injuries and 40 percent of all tennis injuries.

We commonly use the term tendonitis, which means inflammation of the tendon, to refer to these chronic tendon problems. Health professionals now know, however, that the tendon does not always show signs of inflammation when it is injured. Other changes aside from inflammation in the tendon and surrounding tissue can cause the discomfort associated with chronic tendon pain. The term tendonitis is still the most commonly used term to describe any problem with the tendon, but for accuracy it should be reserved to describe acute problems involving inflammation of the actual tendon tissue.  The term ‘tendonosis’ is a better and forthcoming term used for chronic tendon problems, and generally should replace the term tendonitis in chronic tendon cases.  The suffix “osis” simply means that the tendon is affected with an abnormal process.  With tendonosis the structural make-up of the tendon itself is exhibiting degenerative change rather than simply being inflamed. For the purpose of this article however, the term tendonitis will continue to be used as we discuss both acute and chronic tendon problems.

This guide will help you understand:

• how tendonitis develops
• how health care professionals diagnose the condition
• what can be done for tendonitis
• First Choice Physical Therapy’s approach to rehabilitation

Where does tendonitis develop?

Tendons connect muscle to bone. A tendon is made of material called collagen. Collagen is a key building block of the body and is considered a connective tissue which forms tough strands that are like the strands of a nylon rope. Like the strands in a rope, the strands of collagen line up. The more strands, and the better they line up, the stronger they are. The tendon is wrapped in a thin, slippery covering called the tendon sheath. The tendon sheath allows the tendon to slide easily against the tissues around it.

Many parts of the tendon can be injured. Tendon problems can involve the area where the tendon attaches to the bone, the tissue that surrounds the tendon (the tendon sheath), or the main tissues of the tendon. Doctors use different terms to specifically refer to injuries of different parts of the tendon, however, again it should be noted that the term tendonitis is often used in layman’s terms as a general catch-all term that describes any process affecting the tendon whether it be the tendon itself, the sheath, or its attachment to the bone.

Tendon injuries can show up anywhere in your body. However, health care professionals most commonly see tendonitis at certain sites.

Achilles Tendonitis

The tendon sheath, the tissues of the tendon, and the attachment to the bone can all become injured in the Achilles tendon, found in the lower leg. Damaged Achilles tendons carry a higher risk of rupturing because of the weight they bear while standing and walking.

Posterior Tibial Tendonitis

Tendonitis along the inside edge of the ankle and into the instep of the foot is called posterior tibial tendonitis. It is usually caused by age-related degeneration. If this tendon breaks, it can cause the arch of the foot to become flat and painful, and severely limit your ability to stand up onto your toes.

Patellar and Quadriceps Tendonitis

Problems in the tendons of the knee occur mostly in people whose exercise involves running or jumping. Patellar tendonitis is also called jumper’s knee. It occurs in the tendon directly below the knee cap. Quadriceps tendonitis affects the tendon directly above the knee cap.

De Quervain’s Disease and Trigger Finger

Tendon problems are common in the hand and wrist. De Quervain’s disease or tendonitis causes pain in the wrist just above the thumb. Folding your thumb into your hand and tilting your hand down causes excruciating pain with this injury. Trigger finger generally causes pain in the palm just below the knuckles when the inflammation first begins, but eventually the tell-tale sign of this injury is that it catches through movement. The finger snaps as you try to open or close your fist instead of smoothly bending.
Lateral Epicondylitis

Lateral epicondylitis, also called tennis elbow, affects the area where the tendons coming from the muscles of the forearm attach to bone on the outside of the elbow. It causes pain when using the wrist and hand and you do not need to be a tennis player to develop this! Any excessive use of your wrist or hand (especially gripping activities, wrist rotating or bending and straightening activities, as well as excessive vibration through the wrist and forearm) can lead to this injury.

Medial Epicondylitis

Medial epicondylitis, also called Golfer’s elbow, affects the area where the tendons coming from the muscles of the forearm attach to bone on the inside of the elbow. It also causes pain when using the wrist and hand.  Patients other than golfers can develop this condition with excessive wrist bending and straightening, side-to-side wrist motions, or excessive gripping activities

Rotator Cuff Tendonitis

Rotator cuff problems of the shoulder range from mild pain and damage to the tendons, right up to complete tears of the tendons. Rotator cuff problems can cause pain at rest, and even a mild tendonitis can limit shoulder activities especially those that are done at or above shoulder height.

Often, the muscles or other tissues of the shoulder joint become tight, misaligned, or weak around the area of shoulder tendon injury, which can lead to chronic problems and quickly adds to the wear and tear that occurs on the tendon. Some of the pain and swelling associated with a rotator cuff tendonitis may also be in the surrounding tissues of the shoulder.

Why do I have this problem?

Health care professionals don’t always know exactly what causes each tendon problem.  It is believed that repetitive and/or excessive stress on the tendon is the most common cause. The tendons can be injured by the repetitive pounding of running and jumping, or by the stress caused by lifting heavy loads over and over again but can also be injured by simple repetitive movements such typing, painting, or gripping. In general, the heavier the load or the more often the stress is repeated, the more likely you are to develop tendonitis.  Tendonitis usually builds up over weeks or months although it can occur as a result of a single trauma such as a fall or blow directly onto a tendon.  If the tendon is too damaged, or if it doesn’t get time to heal, the problem becomes chronic (long-lasting). In medical terms, it is generally accepted that the term chronic refers to injuries lasting longer than 3 months.

Aging seems to cause tendon damage in some cases. As we age, the tissues of the tendon can break down, or degenerate. Age-related tendon problems however, do not seem to cause inflammation which is seen in classic tendonitis. The tendon material itself is more affected in these conditions and, as described above, in such cases these changes are better termed tendonosis.

Some researchers think that a decreased blood supply to the tendons can cause the tendon damage in tendonosis. The decreased blood supply does not allow the tendon to get enough oxygen. This leads to a condition where the tendon degenerates. The collagen material that makes up the tendon actually becomes weaker and loses its nylon rope appearance. This type of degeneration has specifically been noted in the rotator cuff around the shoulder, in the Achilles tendon in the heel and in the tendons of the elbow.

What does tendonitis feel like?

Tendonitis causes pain. This is the primary symptom of tendonitis (and tendonosis.) The affected tendons are sometimes swollen, but often the swelling is difficult to see from the outside, or there isn’t any swelling at all. In some cases this swelling occurs from actual thickening of the tendon itself. In other cases the swelling comes from thickening or swelling of the tendon sheath or other tissues near the tendon. Tendon problems often cause pain after resting, such as when you first get up in the morning. This pain usually goes away within minutes, or even seconds of moving the affected part, but returns if you repetitively start using the tendon again such as during running, or lifting.

The pain or swelling in your tendon may make your joint hard to move. Some types of tendon problems cause crepitus, a crackling feeling when the joint moves. In rare instances the weakened tendon may actually rupture, or break with a sudden force and this may require surgery to repair.

How do health care professionals identify tendonitis?

Your health care professional will take a detailed medical history, including many questions about your activities, your job, and your symptoms. They will also physically examine the sore area. The probing and movement may cause pain, but it is important for them to know exactly where it hurts.

X-rays do not usually show tendon damage but you may still be asked to get an X-ray or another imaging test to rule out other problems. Sometimes tendon injuries and other joint or muscle problems occur together. In some cases a magnetic resonance imaging (MRI) scan may be recommended to look at the tendons. The MRI scan is a test that uses magnetic waves instead of X-rays. This test shows the tendons and other soft tissues of the body. Unlike an x-ray it can show the damage in the material that makes up the tendon. Ultrasound images are also often used to identify tendon problems, but are not as detailed as MRIs.

In some cases it is difficult to find the exact source of your pain. In these cases, you may be asked to go through more sophisticated imaging tests such as ones which require a dye to be injected prior to the imaging test.  This dye shows up on the imaging test and helps to identify the source of pain . To help with diagnosing the source of your pain your doctor may also try injecting a local anesthetic into the tendon suspected of causing the pain. If your pain goes away, it indicates that the correct tendon causing the pain has been located.

What can be done by your doctor for the problem?

Tendon problems can be difficult to treat effectively. They can last for many months to several years, even with treatment. You should expect your treatment to take from six to nine months. Even if treatment is effective, your pain may come back. The exact treatment recommended would depend on which tendon is affected and how the tendonitis is affecting your daily life.  Starting treatment early on, as soon as your symptoms occur, can be the key to a much quicker and a complete recovery.

In regards to medication your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control the inflammation and pain. NSAIDs are usually only used for a short time with tendon problems because, as mentioned previously, eventually the inflammation goes away and is not the source of the problem; the resultant tendon degeneration becomes the issue.

Corticosteroid injections around the tendon are also sometimes used however doctors disagree on whether to use corticosteroid injections for tendon problems. In some cases injections into the tendons can cause more injury such as a tendon tear. It is generally recommended to give no more than three corticosteroid injections, at least three months apart as the corticosteroid, although often helpful for the pain, can weaken the tendon fibers and thus make the tendon more susceptible to a tear. Patients need to avoid heavy activity for a few weeks after the injection.

Physical Therapy at First Choice Physical Therapy will help immensely with any tendon problem you have, whether acute or chronic. Beginning treatment with us as early as you can once you develop the problem is the best way to guarantee that the problem resolves and that it does not become chronic.

On your first visit to First Choice Physical Therapy your Physical Therapist will ask you questions about where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.  If you are involved in sport, your training history including any increases in frequency or intensity of activity or change in equipment will also be important for us to inquire about.  If you have not seen your doctor, and your problem has not been identified, then the history alone will often lead your Physical Therapist to your tendon being the source of your pain.

Next your Physical Therapist will do a physical examination of the area around the tendon as well as your entire associated limb and other joints near the area. Your Physical Therapist will assess your postural alignment, flexibility and joint laxity with regards to the closest joint and may want to look at how you stand or sit. If the tendon is in your lower extremity, they will also observe your foot position and watch you walk, and possibly squat, run, or jump. If you are involved in sport, they may also ask you to bring in some of your equipment to the next appointment, such as your running shoes or tennis racket, so it can be examined for potential faults or factors that may be contributing to the development of your pain.

Next your Physical Therapist will check the strength and lengths of the muscles directly attaching to your painful tendon as well as any other related muscles. If any muscles are weak or tight, they can contribute to the stress on the related tendon.  Often joints that may seem unrelated to the problem to you will need to be assessed by your Physical Therapist as weaknesses or imbalances in and around other areas frequently contribute to the pain that arises in a tendon of the associated arm or leg. For instance, the grip strength of your hand may be tested even if it is your elbow that is causing your pain, or the strength around your hip may be assessed if your Achilles tendon is the issue.

Initially the treatment at First Choice Physical Therapy will focus on decreasing any inflammation and pain around your tendon. Your Physical Therapist may use electrical modalities to do this such as ultrasound or interferential current.  Heat and/or ice can also be very useful at any stage of tendon healing to decrease pain and also inflammation if there is any.  Your Physical Therapist can advise you on whether heat or ice or both is the best treatment in your particular case. Your Physical Therapist may also use massage for the muscles around the tendon or even directly over the tendon to ease your discomfort and again assist with decreasing any inflammation if it is present.

A crucial component to the healing of any tendon injury is relative rest.  As most tendon injuries result due to repetitive activities over time that cause too much stress on the tendon and then lead to pain, your Physical Therapist will strongly advise you to avoid any activities that cause you discomfort. This may mean, for instance, if it is a tendon in your elbow that is affected, that you have to use your other arm as often as possible to give the painful tendon a period of relative rest.  This may also mean resting for a short period from any sport you do, or at least decreasing the amount you play over a period of time. Your Physical Therapist will specifically guide you regarding the needed rest for your individual injury. This rest may seem quite difficult to achieve, however it is well known that generally without relative rest for an injured tendon, there is little chance for it to heal and the problem can easily become chronic, or can lead to a more severe injury, such as a tear in the tendon.  A period of rest where the tendon is not being aggravated also greatly improves the ability of any medication you may be taking along with the Physical Therapy treatment you are receiving to assist the healing of the injury.  This rest period allows a short time frame where the tendon is not being aggravated while at the same time, it is also receiving the necessary treatments to expedite healing of the tendon. After your period of rest your Physical Therapist will advise you when it is safe to slowly start back at your activity.

There are many braces on the market that are designed to assist with the rehabilitation of tendonitis injuries. There is basically a brace for all potential areas of tendonitis in the body including areas such as the Achilles, elbow and wrist. Your Physical Therapist can advise you regarding whether a brace would be useful in your case, and can also advise you on where to purchase them. Quite often your Physical Therapist will trial some strapping or taping prior to you investing in a brace for the affected area. Taping the area is obviously cheaper than a brace, and gives you and your Physical Therapist a good idea as to whether a brace would help with your pain. Tape, although often helpful, can not often be used for long periods or repetitive treatments because the skin gets irritated, and in addition it may be difficult for you to tape the area independently when you are not at First Choice Physical Therapy. For this reason, a brace is often recommended.

In certain tendon problems, such as Achilles tendonitis, other types of orthotics may be suggested.  The pain associated with Achilles tendonitis often responds well to a heel insert that lifts the heel of the affected side, and shortens the relative length of the tendon. This in essence decreases the stretch on the tendon and can often be enough to allow some relative rest for the injured area.

In the case of any lower extremity tendon issue, shoe orthotics may also be suggested by your Physical Therapist.  Poor alignment of the lower extremity will put undue stress on the tendons of the lower extremity. Correcting the position of your foot, if it is a contributing factor to this misalignment, will decrease this stress and will also assist the healing process of the tendon.

During the next part of treatment your Physical Therapist will prescribe stretching and strengthening exercises for your affected area. Your Physical Therapist may do some stretching for you in the clinic, but they will also teach you how to stretch the affected area as well as any related muscles as part of your home program. Strengthening the affected tendon and associated muscles will also be a part of your home program. Initially strengthening will be simple exercises and may or may not include using any weights. As soon as appropriate, however, your Physical Therapist will prescribe eccentric exercises which are crucial to making a full recovery from a tendon injury.

Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch.  Landing from a jump is an example of an eccentric contraction for the knee or Achilles tendon. These types of contractions encourage the tendon to adapt to the more aggressive force that will eventually be needed to return to regular physical activity.

Adding weights to these exercises as well as doing the exercises in a speeded fashion will also encourage the tendon to adapt to the more aggressive forces that it will need to endure repetitive activities of daily living or sporting activities.  All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon.

Maintaining proper posture and alignment of your body during regular everyday activities can also greatly affect how quickly your tendon heals.  For upper extremity issues, good sitting posture is vital in order to decrease the stress on the arms, neck and back.

Shoulders should remain upright and out of the slouched position as this puts stress on the neck, upper back, and shoulders, and in turn affects how well you can use your arm. If you are frequently using a computer, the position of your hand on the keyboard or mouse over a prolonged period can also add stress to your tendons and accentuate the problem. Your Physical Therapist will advise you regarding your posturing as well as make suggestions for ergonomic tools that may help you decrease the stress on your tissues and encourage more rapid healing. If you are a manual worker the amount of lifting and gripping involved in your day will be assessed. Excessive gripping or lifting especially without having good grip (ie: using too large or poorly gripped gloves) will add to the strain on your injured body part, so changes to these activities in your everyday life will be suggested.

For lower extremity issues, the alignment of your hips over top of your feet can add to or decrease the stress that is put through your injured area. Your Physical Therapist will advise you on proper alignment of your hips, knees, ankles and feet, and will encourage you to maintain and use this posture throughout your day even during simple activities such as walking or climbing stairs. These simple changes can make a massive difference to the cumulative stress that is placed on your painful tendon.

As soon as it is appropriate your Physical Therapist will integrate you back into the activities that you were having difficulty doing, whether that be typing on the computer, or playing high-level sport. A period of controlled and supervised slow reintegration is crucial to avoid further pain or a flare up of the healing area.

Most people with acute or chronic tendon problems, with the help of Physical Therapy at First Choice Physical Therapy, are relieved of their pain and can eventually take part in their normal activities. In a few cases, however, a high level of pain lingers on even after the appropriate rest and a significant amount of therapy.  For these patients, a more aggressive form of treatment will need to be considered. In these cases, your Physical Therapist will refer you back to your doctor. A relatively new form of treatment may be available to you called platelet rich plasma injections (PRP.) Platelet-rich plasma refers to a sample of serum (blood) plasma that comes from the patient themselves, and is treated to extract as much as four times more than the normal amount of platelets. Platelets are the smallest cells in the blood and are essential for blood clotting and injury healing. This serum is then injected back into the problem area to encourage new tissue healing.  PRP treatment enhances the body’s natural ability to heal itself and can shorten recovery time from acute and chronic soft tissue injuries.

If no other conservative treatment is successful, surgery may be necessary to debride the degenerative tendon and encourage new healing. Surgery can be very successful in treating the problem of chronic tendon pain but ongoing rehabilitation after surgery will be necessary to ensure complete success.  If surgery is necessary for your tendon problem, your Physical Therapist at First Choice Physical Therapy can guide you through the appropriate post surgical rehabilitation necessary that is specific to your injury and your individual requirements in order to return you as quickly as possible back to your everyday and sporting activities.

The rotator cuff is a unique structure in the shoulder that is formed by four tendons. These four tendons attach to four muscles that help keep the shoulder stabilized in the shoulder socket and help rotate the upper arm inward and outward. If the rotator cuff is  severely torn and is not repaired, a type of arthritis of the shoulder may develop over time, which is termed rotator cuff arthropathy. The prefix ‘arthro’ means joint and ‘pathy’ means disorder therefore in simple terms, a ‘joint disorder’ develops. If you develop rotator cuff arthropathy your shoulder will be painful and movement and strength of the shoulder will be decreased. Moving the arm away from the body and raising it over your head can be particularly difficult.

This guide will help you understand:

• what parts of the shoulder are involved
• what causes this condition
• how healthcare professionals diagnose this condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the shoulder are involved?

The shoulder joint is also called the glenohumeral joint. The shoulder joint is made up of three bones; the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone).

The humerus bone has a ball, called the humeral head, on the top end of it. The humeral head fits into a small, shallow cup called the glenoid fossa (shoulder socket). The glenoid fossa is part of the shoulder blade bone (the scapula). The roof of the glenoid fossa is also formed by a part of the scapula called the acromion.

The rotator cuff is made up of tough, fibrous tissue. It forms a cuff (or capsule) covering the shoulder joint. There are four tendons that help form the rotator cuff. Tendons attach muscles to bones. Muscles move the bones by pulling on the tendon that they attach to. The rotator cuff muscles help raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket.
The muscles that attach to the cuff tendons are the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles rotate the shoulder outward and inward. Along with another muscle, the deltoid, they also help lift the arm away from the body.

As mentioned above, the socket of the shoulder is part of the scapula bone and is called the glenoid fossa. The glenoid fossa is very shallow and flat so without the rotator cuff muscles the top part of the humerus (the humeral head) would slide out of the centre of the fossa as it moves.

As we raise our arm, part of the rotator cuff slides between the humeral head and the acromion.  This sliding occurs over and over during everyday use.  The rotator cuff tendons can be pinched in this space due to a number of reasons, including altered biomechanics from an injury or simply from repetitive use. This pinching is called impingement. Over time this pinching can lead to damage and weakening of the rotator cuff tendons, and an eventual fraying or tearing of them.

What causes this condition?

Dr. Charles Neer described rotator cuff tear arthropathy in 1977. Today, doctors generally refer to this as simply cuff tear arthropathy. Cuff tear arthropathy is actually a type of ‘wear and tear’ degenerative arthritis of the shoulder that develops over time after the rotator cuff is damaged.

Normally, when the rotator cuff muscles contract, they pull the head of the humerus tightly into the socket of the shoulder. This stabilizes the shoulder and allows the large deltoid muscle to raise the arm over the head as it rotates the humeral head like a pulley. This motion needs the rotator cuff and deltoid muscles to work together in balance, in order for proper biomechanics to occur.

When the rotator cuff is torn, the shoulder becomes unbalanced. The deltoid muscle pulls the head of the humerus up into the acromion in a sliding motion rather than in the smooth balanced movement that the shoulder was designed to undergo. Over time this abnormal sliding motion causes wear and tear on the joint surfaces, which is termed arthritis. Due to the arthritis, motion of the shoulder becomes painful and the shoulder becomes weaker and weaker until you can no longer raise the arm above the head.

Rotator cuff tears are very common. Rotator cuff damage can occur from a single traumatic injury, such as a fall, lifting something heavy, or pulling forcefully. Most often, however, damage to the rotator cuff occurs gradually. Age can be a factor in this degeneration. As we age, the tendons of the rotator cuff become weaker and are more likely to be injured. In addition, with age, the blood supply to the tendons diminishes so any damage that does occur does not heal as well. Rotator cuff tears are much more likely to occur after the age of 40.

Certain activities can increase the wear and tear on the rotator cuff. For example repetitive overhead activity such as painting, plastering, racquetball, weightlifting, and swimming can all cause wear-and-tear of the rotator cuff.

Surgeons will generally recommend surgery to repair a severe rotator cuff tear when it occurs. A successful surgical repair of a torn rotator cuff tear can make the development of cuff tear arthropathy much less likely. Sometimes, however, a rotator cuff tear cannot be repaired. The tissue is simply too damaged and cannot be fixed. This is common in older patients with rotator cuff tears.  In other situations, although possible to repair, the patient elects not to have surgery to fix the rotator cuff tear and chooses to simply live with the discomfort and limitations it may impose. Over several years, both of these situations can result in the eventual development of rotator cuff arthropathy.

What does this condition feel like?

The most common symptom of rotator cuff tear arthropathy is pain in and around the shoulder. The pain can also radiate into your neck or arm, and even into your wrist or hand. The pain is usually worse at night and can interrupt your sleep, especially if you try to sleep on the affected shoulder. The shoulder is often particularly painful when trying to lift the arm, or rotate it outward. If untreated, the pain can be severe and nearly continuous.

Weakness of the shoulder due to arthropathy makes it difficult, and nearly impossible, to lift the arm overhead. Often even starting the lifting motion can be difficult and for this reason, the tendency is to shrug your shoulder upwards in order to be able to lift the arm part of the way. Over time, the weakness of the rotator cuff muscles gets worse and range of motion can become quite limited. Routine things, like reaching behind your back, reaching into a cabinet, or combing your hair become difficult. You may notice a crackling or popping sensation coming from your shoulder blade area, which develops due to the altered mechanics in this area of the shoulder. When there is arthritis of the glenohumeral joint, there is often an associated creaking or grating sound inside the joint.

How do healthcare professionals diagnose this condition?

Your healthcare professional will conduct a thorough history and carry out a clinical exam in order to determine that your problem is due to rotator cuff arthropathy. Your healthcare professional will inquire about when your pain started and if it occurred due to a specific injury or whether it came on gradually. They will also ask you about general activities that may have injured your shoulder and will also want to know about what makes your pain better or worse. In addition, your healthcare professional will want to know the level of your pain, and what activities in your daily life are limited by your shoulder injury.

Next your healthcare professional will do a physical examination. Firstly, they will look at your shoulder to see if there are any bony deformities, or if there is any atrophy (wasting) of your muscles. They will feel your shoulder to determine which area is most painful for you.  Next they will assess the range of motion of your shoulder and will also assess the strength of your shoulder and shoulder blade muscles. Your healthcare professional will also check to see how stable your shoulder is in the shoulder socket.

As mentioned above, with a complete rotator cuff tear, moving the arm away from the body can be nearly impossible. A common test to be done when there is suspicion of a rotator cuff tear is the Drop Arm Test. For this test your healthcare professional lifts your affected arm for you and asks you to hold it there. If you cannot hold it up, this test is considered positive and usually indicates that the rotator cuff is torn.
Other areas such as the neck will also be evaluated for range of motion and strength. A pinched nerve in the neck can mimic a rotator cuff tear. A neurological examination, which includes checking your reflexes and sensation, may also be included.

Investigations

What investigations will need to be done?

Your healthcare professional will request X-rays of your shoulder. X-rays show the shape and positioning of your bones and joints. When the rotator cuff is torn, the shoulder will often ride high, meaning that it sits higher in the joint than it should. An X-ray can also show how much damage has occurred to the joint surfaces.

You may be asked to have an electromyogram (EMG), which checks the function of the muscles of the shoulder. An EMG uses a small needle in the muscle being tested. It measures the electrical activity of the muscle at rest, and when tightened.

Magnetic resonance imaging (MRI) allows your healthcare professional to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays, to show the muscle, tendons, and ligaments of the shoulder. MRIs will show tears of the rotator cuff tendons. Atrophy of the muscles can also be evaluated with MRI.

A computerized tomography (CT) scan shows slices of bone. Like X-rays, this test uses radiation. A CT scan can help to more accurately determine the degree of damage of the glenohumeral joint. A CT scan is especially useful to plan for surgery if a surgery is considered for treatment.

What treatment options are available?

Nonsurgical Treatment

Conservative care for arthropathy includes Physical Therapy as well as oral anti-inflammatories. A corticosteroid injection into the shoulder joint is also sometimes helpful. Steroids are very powerful anti-inflammatory medications that can reduce pain temporarily. These injections will not heal the original tear but may give pain relief for several weeks to months, and may allow you enough pain-free time to assist with making gains during rehabilitation. The goal of conservative treatment is to reduce pain, and increase range of motion and function.

Nonsurgical Rehabilitation

Physical Therapy at First Choice Physical Therapy can be very helpful if you are suffering from rotator cuff arthropathy.
The goal of Physical Therapy is to decrease your pain, and improve your range of motion, strength, and overall function as much as possible. Preventing further wear-and-tear on your joint is also an important goal.
As an initial treatment your therapist may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around your shoulder, or anywhere along your arm, or into your hand. Due to some of the muscles of the neck and upper back connecting to the shoulder, you may also have pain in these regions, which your therapist can treat in order to make movement of your entire upper body easier. Your therapist may also use massage or mobilizations for your neck, upper back, shoulder, shoulder blade, elbow, or wrist in order to improve circulation and assist with any pain that may be present.

Next your therapist will focus on your range of motion. The exercises they prescribe will focus on the ranges of motion that are most limited as well as those which are most useful to your overall daily functioning.  Your therapist may encourage the use of poles or pulleys in order to gain passive range of motion of your shoulder without causing any pain.  Passive range of motion helps provide nutrition to the joint and stretch the muscles and tissues of the joint into ranges that you are unable to achieve by using your own muscle strength. Your therapist may also assist your range of motion by mobilizing your shoulder joint or shoulder blade or assisting with some specific range of motion stretches. Other areas such as your neck, elbow, or upper back may also become stiff as a result of dealing with a rotator cuff arthropathy. When necessary your therapist will mobilize these areas and also prescribe exercises to assist with range of motion for these areas.

In addition to range of motion exercises, strengthening exercises will be prescribed. These exercises may include the use of rubber bands or tubings, weight machines, free weights, or they may simply make use of your own body weight.  In order to function properly and avoid further injury, both the strength of the muscles supporting the shoulder joint (the rotator cuff) as well as the strength of the muscles around the shoulder blade (scapula) need to be adequate.

Proprioception is the ability to know where your body is without looking at it. As a result of any injury or surgery, this ability declines in function. A period of decreased joint mobility adds to this decline. Although your arm and shoulder girdle are not traditionally thought of as weight-bearing parts of the body, even an activity such as assisting yourself with your arms to get out of a chair or pulling a glass from a cupboard requires weight through your shoulder girdle and for your body to be proprioceptively aware of your limb.

The proprioceptive control of the scapula on the rib cage (scapulothoracic motion) is especially important in being able to use your shoulder girdle and upper limb effectively without causing further injury to your shoulder. For this reason, your Physical Therapist will teach you how to properly control your scapula during your rehabilitation exercises as well as during everyday activities.  Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up while moving your shoulder, or doing push-ups on an unstable surface. Advanced exercises may include activities such as ball throwing or catching.  As often as possible exercises that simulate your everyday activities such as grooming yourself and getting dressed, in addition to those activities that simulate your work or hobbies will also be incorporated.

Regaining proprioception of the shoulder girdle and upper limb can require concentrated work, and most people have not previously needed to focus so intently on such controlled motions of this joint. The concentrated effort of shoulder rehabilitation, however, has a substantial reward; good scapulothoracic control is the key to regaining maximum shoulder range of motion and thus improved shoulder functioning while avoiding future pain.

As part of your rehabilitation your therapist may choose to use tape on your shoulder joint or your shoulder girdle in order to assist with your pain. Taping the shoulder can also assist with proprioception of the joint.

Your Physical Therapist will also remind you about maintaining good shoulder posture when sitting or using your upper limb in activities below shoulder height, such as working on the computer. Rounded shoulders in this position crowds the shoulder joint and can lead to shoulder impingement and pain. Excellent posture is also required when doing activities at or above shoulder height in order to avoid further injury. Your therapist will also discuss ways you can protect your shoulder during daily activities and show you ways to move in order to avoid causing more damage to your joint.

Sometimes, even with conservative treatment, your pain remains continuous and severe, and your range of motion remains significantly limited. In these cases your therapist may refer you to an orthopaedic surgeon as surgery may need to be considered as a treatment option.

What surgery can be done to help?

Surgery for cuff tear arthropathy is done when pain and decreased motion continue even after trying conservative care. As indicated previously, cuff tear arthropathy is the result of a long-standing lack of rotator cuff function. For this reason, in almost all cases, surgical repair of the rotator cuff tear is no longer an option. The simplest surgical procedure to try and improve the situation is a debridement. During a debridement, the surgeon will surgically remove (debride) any inflamed tissue, bones spurs and loose flaps of tendon tissue that may be catching in the joint and causing pain. This procedure may reduce pain, however, it does not always improve range of motion, strength, or function of the shoulder.

Patients with rotator cuff arthropathy would seem to be good candidates for a shoulder replacement, but unfortunately replacing the shoulder in the typical fashion has not been successful. Replacing the shoulder with a special type of artificial shoulder joint, however, is becoming more popular. This procedure is called a reverse shoulder replacement.

The traditional shoulder replacement was designed to simulate our real shoulder. The glenoid component of the replacement (the socket) was designed to replace our normal shoulder socket by using a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus by using a metal ball that sits on top of the glenoid. This situation has been compared to placing a ball on a shallow saucer. Without ‘something’ to hold the metal ball in place, the ball simply slides around on the saucer. In a normal shoulder that ‘something’ is the rotator cuff and the rotator cuff muscles. With a traditional shoulder replacement it was found that without a rotator cuff to hold the metal ball centered in the plastic socket, no meaningful movement could be accomplished. Unfortunately the metal quickly wore out the plastic socket, and the joint became painful once again.   Even the large deltoid muscle, in this type of shoulder replacement, is unable to assist enough without a rotator cuff in order to produce any useful motion of the shoulder.

Due to this ‘no rotator cuff’ dilemma the mechanics of the shoulder joint needed to be reconsidered and a design for an artificial shoulder that worked differently than the real shoulder joint needed to be created. The solution that evolved was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket use to be and the socket where the ball or humeral head use to be. This new design has led to a much more stable shoulder joint that can function much better without a rotator cuff. The artificial joint itself provides more stability to the shoulder by creating a deeper socket that prevents the ball from sliding up and down as the shoulder is raised. The large deltoid muscle that covers the shoulder can be used more effectively to lift the arm, which provides better functional use of the shoulder. The final result is a shoulder that functions better, is less painful and can last for years without loosening.

What should I expect after surgery?

What you do for post-surgical rehabilitation depends on what type of surgery you have had. Those who have had a surgical debridement will require much less intense therapy than those who have had a full reverse shoulder arthroplasty.  No matter which type of surgery you undergo, you will most likely require the use of a sling or shoulder brace after the surgery to protect your joint while it heals.

Generally after any type of surgery for rotator cuff arthropathy, a Physical Therapist will see you in the hospital the day after surgery to begin your rehabilitation program. Your therapist will make sure you are safe when getting in and out of bed and moving about in your room with your sling on.  Next, if your surgeon allows it, they will prescribe specific range of motion exercises for you.  Your therapist will teach you how to remove your sling for your exercises and also how to put it back on after you have completed your exercises. After a major surgery such as the reverse shoulder replacement the sling should be worn at all times except during showering and while performing rehabilitation exercises.

When the immobilizer is removed following surgery, you will experience some pain when you start to move your shoulder, wrist, elbow and forearm. This pain is normal and is from not using the joints very efficiently previous to the surgery and also from the surgical process itself. The pain you feel with movement should only be mild to moderate and any sharp or severe pain should be heeded.  In addition, after surgery the muscles in your arm may appear small and atrophied. Again, this is normal; once your strength begins to return your arm will start to look more normal again.

Simple finger, hand and wrist movements, as well as elbow and neck range of motion exercises will be prescribed to ensure you regain motion in these joints.  Pendular exercises for your shoulder will be prescribed along with passive range of motion exercises that encourage shoulder elevation (raising in front) as well as gentle external rotation. Pendular exercises are performed by leaning forward or to the side, letting the arm hang clear of the chest, and then initiating movement with your trunk so that the dangling limb passively and gently moves. These exercises assist with pain, help to maintain some shoulder range of motion, and assist in preventing unwanted scar tissue forming in the joint. This pendular action also provides some traction to the glenohumeral joint, which aids in pain relief, and also assists the shoulder into a relatively elevated motion (in relation to the trunk). It is important that the pendular activity is done as passively as possible without initiating motion from the shoulder muscles. This exercise should be similar to a weighted pendulum that randomly swings on the end of a piece of string.  Icing your shoulder will be encouraged after your exercises as well as several other times during the day.
Once you are managing your exercises well in the hospital, you are independent in doing most activities to care for yourself, and when your surgeon feels it is appropriate, you will be sent home.  You will need to continue an extensive rehabilitation program once you are discharged from the hospital.  In some cases, a Physical Therapist or occupational therapist may visit your home to check to see that you are safely getting around within your home and managing your everyday tasks with your arm in your sling.  Your therapist may also review and assist you with your exercises at this time. If it is particularly difficult for you to get out of your home to attend Physical Therapy at First Choice Physical Therapy then a Physical Therapist may continue to visit you at your home for several treatments in order to review and advance your exercises. As soon as you are able, however, it is best for you to attend rehabilitation at First Choice Physical Therapy as there are several more modalities as well as exercise equipment that can be used in the clinic versus at home, which can expedite your recovery.

As an initial goal of rehabilitation your Physical Therapist at First Choice Physical Therapy will focus on relieving your pain and decreasing any swelling that may be lingering from the surgery. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with pain or decrease any swelling you have around your shoulder, anywhere along your arm, or into your hand. Due to some of the muscles of the neck and upper back connecting to the shoulder, you may also have pain in these regions, which we can also treat in order to make movement of your entire upper body easier. We may also use massage or mobilizations for the neck, upper back, shoulder, elbow, forearm, or wrist to improve circulation and assist with any pain that may be present.

If a reverse shoulder replacement has been done then protecting the new joint is of particular importance.  Due to the biomechanics of a reverse arthroplasty there is a higher risk of shoulder dislocation than after a traditional shoulder replacement.  With a traditional shoulder replacement the shoulder is more likely to dislocate with the arm in abduction and external rotation.  With the reverse shoulder replacement dislocation is most likely during isolated extension as well as the combined movements of extension, internal rotation, and adduction therefore these movements should be avoided. Your therapist will review these movement precautions with you and you should refrain from putting your shoulder in any of these positions on their own or in combination for a minimum of 12 weeks post-surgically.  Activities involving these positions, such as tucking in one’s shirt or performing personal hygiene of the back passage, are simple activities but can lead to dislocation so they must be strictly avoided.  It can be helpful in respecting these precautions by remembering that you should always be able to see the elbow on your surgical side during all activities with that arm.

The next part of our post-surgical treatment will focus on regaining the range of motion, strength, and dexterity in your shoulder, elbow, hand and wrist. Your Physical Therapist at First Choice Physical Therapy will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include the use of rehabilitation equipment such as pulleys and poles for range of motion exercises, and light weights or exercise bands for resistance work of your upper limb. The shoulder joint is the upper limb’s link to the rest of the body so it needs to be strong and well controlled for the limb and hand to work properly. If you have access to a pool your therapist may suggest you do some of your rehabilitation exercises in the pool where the warmth of the water and the hydrostatic properties of the water can be of assistance.

As time and range of motion progress, strengthening will become the major focus and will be advanced so that heavier weights or elastic bands are used and endurance of the muscles is improved.  Your therapist will monitor your progress and advance your exercises as your shoulder can tolerate them.  Along with more advanced strengthening exercises, active range of motion of the shoulder will be encouraged in order to assist with strengthening and control of the entire shoulder girdle.

Proprioception is the ability to know where your body is without looking at it. As a result of any injury or surgery, this ability declines in function. A period of immobilization adds to this decline. Although your arm and shoulder girdle are not traditionally thought of as weight-bearing parts of the body, even an activity such as assisting yourself with your arms to get out of a chair or pulling a glass from a cupboard requires weight to be put through or lifted by your shoulder girdle and for your body to be proprioceptively aware of your limb.

The proprioceptive control of the scapula on the rib cage (scapulothoracic motion) is especially important in being able to use your shoulder girdle and upper limb effectively without causing further injury. For this reason, your Physical Therapist will teach you how to properly control your scapula during your rehabilitation exercises as well as during everyday activities. Your Physical Therapist will also remind you about maintaining good shoulder posture at all times even when sitting or using your upper limb in activities below shoulder height, such as working on the computer. Rounded shoulders in this position crowds the shoulder joint and can lead to shoulder impingement and pain.

Regaining proprioception of the shoulder girdle and upper limb can require concentrated work, and most people have not previously needed to focus so intently on such controlled motions of this joint. The concentrated effort of shoulder rehabilitation, however, has a substantial reward; good scapulothoracic control is the key to regaining maximum shoulder girdle control and improved shoulder functioning while avoiding future shoulder pain.
Proprioceptive exercises might include activities such as rolling a ball on a surface with your hand, holding a weight up while moving your shoulder, or push-ups on an unstable surface. Advanced exercises may include activities such as ball throwing or catching.  Exercises that simulate your everyday activities such as grooming yourself and getting dressed, in addition to those activities that simulate your work or hobbies will also be incorporated.

At First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while recovering from surgery.  Several types of cardiovascular machines can be used such as a stationary bike, a stepper, or a treadmill for walking.  Cardiovascular activity in a pool may also be appropriate. Your Physical Therapist at First Choice Physical Therapy can discuss when cardiovascular activity would be appropriate for you and which cardiovascular activity would be best.  Most importantly, your surgical shoulder needs to be protected at all times so your therapist will educate you on how to do this.

Generally rehabilitation at First Choice Physical Therapy after surgery for rotator cuff arthropathy goes smoothly. If, however, during rehabilitation your pain continues longer than it should or therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon or doctor to confirm that the shoulder is tolerating the rehabilitation well and to ensure that there are no hardware issues that may be impeding your recovery.

The shoulder is an elegant piece of machinery. It has the greatest range of motion of any joint in the body. However, this large range of motion can lead to joint problems.

Understanding how the different layers of the shoulder are built and connected can help you understand how the shoulder works, how it can be injured, and how challenging recovery can be when the shoulder is injured. The deepest layer of the shoulder includes the bones and the joints. The next layer is made up of the ligaments of the joint capsule. The tendons and the muscles come next.

This article will help you understand:

• what parts make up the shoulder
• how these parts work together

Acromioclavicular Joint

The important structures of the shoulder can be divided into several categories.

These include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels
• bursae

Bones and Joints

The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed by a part of the scapula called the acromion.

Shoulder Bones

There are actually four joints that make up the shoulder. The main shoulder joint, called the glenohumeral joint, is formed where the ball of the humerus fits into a shallow socket on the scapula. This shallow socket is called the glenoid.

The acromioclavicular (AC) joint is where the clavicle meets the acromion.

Acromioclavicular and Glenohumarel Joint

The sternoclavicular (SC) joint supports the connection of the arms and shoulders to the main skeleton on the front of the chest.

Sternoclavicular and Scapulothroacic Joints

A false joint is formed where the shoulder blade glides against the thorax (the rib cage). This joint, called the scapulothroacic joint, is important because it requires that the muscles surrounding the shoulder blade work together to keep the socket lined up during shoulder movements.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in most large, weight-bearing joints. It is a bit thinner in joints such as the shoulder, which don’t normally support weight. Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. In the shoulder, articular cartilage covers the end of the humerus and socket area of the glenoid on the scapula.

 

Ligaments and Tendons

There are several important ligaments in the shoulder. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments that connect the humerus to the glenoid. These ligaments are the main source of stability for the shoulder. They help hold the shoulder in place and keep it from dislocating.

Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony knob that sticks out of the scapula in the front of the shoulder.

A special type of ligament forms a unique structure inside the shoulder called the labrum. The labrum is attached almost completely around the edge of the glenoid. When viewed in cross section, the labrum is wedge-shaped. The shape and the way the labrum is attached create a deeper cup for the glenoid socket. This is important because the glenoid socket is so flat and shallow that the ball of the humerus does not fit tightly. The labrum creates a deeper cup for the ball of the humerus to fit into.

The labrum is also where the biceps tendon attaches to the glenoid. Tendons are much like ligaments, except that tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The biceps tendon runs from the biceps muscle, across the front of the shoulder, to the glenoid. At the very top of the glenoid, the biceps tendon attaches to the bone and actually becomes part of the labrum. This connection can be a source of problems when the biceps tendon is damaged and pulls away from its attachment to the glenoid.

Labrum

The tendons of the rotator cuff are the next layer in the shoulder joint. Four rotator cuff tendons connect the deepest layer of muscles to the humerus.

Muscles

The rotator cuff tendons attach to the deep rotator cuff muscles. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in the many directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding the humeral head in the glenoid socket.

Rotator Cuff Tendons

The large deltoid muscle is the outer layer of shoulder muscle. The deltoid is the largest, strongest muscle of the shoulder. The deltoid muscle takes over lifting the arm once the arm is away from the side.

Nerves

All of the nerves that travel down the arm pass through the axilla (the armpit) just under the shoulder joint. Three main nerves begin together at the shoulder: the radial nerve, the ulnar nerve, and the median nerve. These nerves carry the signals from the brain to the muscles that move the arm. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

Blood Vessels

Traveling along with the nerves are the large vessels that supply the arm with blood. The large axillary artery travels through the axilla. If you place your hand in your armpit, you may be able to feel the pulsing of this large artery. The axillary artery has many smaller branches that supply blood to different parts of the shoulder. The shoulder has a very rich blood supply.

Bursae

Sandwiched between the rotator cuff muscles and the outer layer of large bulky shoulder muscles are structures known as bursae. Bursae are everywhere in the body. They are found wherever two body parts move against one another and there is no joint to reduce the friction. A single bursa is simply a sac between two moving surfaces that contains a small amount of lubricating fluid.

Think of a bursa like this: If you press your hands together and slide them against one another, you produce some friction. In fact, when your hands are cold you may rub them together briskly to create heat from the friction. Now imagine that you hold in your hands a small plastic sack that contains a few drops of salad oil. This sack would let your hands glide freely against each other without a lot of friction

As you can see, the shoulder is extremely complex, with a design that provides maximum mobility and range of motion. Besides big lifting jobs, the shoulder joint is also responsible for getting the hand in the right position for any function. When you realize all the different ways and positions we use our hands every day, it is easy to understand how hard daily life can be when the shoulder isn’t working well.

 

Transient synovitis affects the inner lining of the hip joint including the synovium and joint capsule. The synovium is a membrane that seals the synovial fluid in the joint to lubricate the joint surface. It is between the articular cartilage and the joint capsule. The joint capsule is a watertight sac that surrounds a joint. In the hip, the joint capsule is formed by a group of three strong ligaments that connect the femoral head to the acetabulum. These ligaments are the main source of stability for the hip. They help hold the hip in place.

Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage is about one-quarter of an inch thick in the large, weight-bearing joints like the hip. In the hip, articular cartilage covers the end of the femur and the socket portion of the acetabulum in the pelvis. The cartilage is especially thick in the back part of the socket, as this is where most of the force occurs during walking and running.

Articular cartilage is white and shiny and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. 

 What causes this condition?

The exact cause of this problem is unknown. In some cases, it may develop after a recent viral infection (such as a cold or upper respiratory infection). In a smaller number of children, trauma to the hip is followed by transient synovitis.

There is much debate about a possible link between transient synovitis and another condition called Legg-Calve-Perthes disease. In Perthes disease, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals.

Only a small number of children with transient synovitis develop Legg-Calvé-Perthes disease. It’s possible the prolonged increase in pressure inside the joint causes loss of blood supply to the hip. Some experts suspect children who develop Perthes disease may have undetected transient synovitis before collapse of the femoral head occurs.

What are the symptoms?

Inflammation and effusion (swelling) can cause sudden hip pain. Usually only one hip is involved. The child may refuse to walk or may limp when walking as the first sign of a problem. Younger children who aren’t walking yet stop crawling or change the way they get around. They may cry at night or when having the diaper changed.

Your child may have a slight fever. A high fever is usually a sign of something more serious such as septic arthritis (bacterial infection of the hip) or osteomyelitis (bone infection).

In all age groups, there is usually a loss of hip motion. The child doesn’t want to put weight on that leg. The painful symptoms may travel to the thigh, groin, or knee on the same side. Sometimes there isn’t hip pain but just groin, thigh, or knee pain.

Your child may want to keep the hip and leg in a resting position of flexion (bent), external rotation (turned outward), and abduction (away from the other leg). This position opens up the joint capsule helps reduce the pain by taking pressure off the soft tissue structures.

How do health care professionals diagnose this condition?

The history and physical examination are probably the most important tools the used to diagnose transient synovitis of the hip. When you first visit First Choice Physical Therapy your Physical Therapist will ask you or, if your child is old enough, even ask your child questions about when the pain started, where exactly the pain is, and what motions or activities make the pain better or worse.
Our Physical Therapist in *client_area* will also conduct a physical examination to determine which movements cause pain or are limited. They will also palpate around the hip to locate the exact location of the pain.

The majority of patients will be referred to a doctor for further diagnostic tests such an X-ray, an ultrasound, and/or blood tests that can help to confirm or rule out the diagnosis. Once the diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed the recovery of your child so they can return to the carefree and active lifestyle they are meant to be living.

The main goal of treatment for transient synovitis of the hip in children is to decrease the pain and maintain hip range of motion. After assessing your child, our Physical Therapist at First Choice Physical Therapy may choose to use ice on the hip if it is in the acute phase of pain or may apply heat at a later phase to decrease inflammation and assist with pain control.

Next, some gentle exercises may be prescribed by your Physical Therapist to ensure that the hip maintains its range of motion and to assist in the healing process. These exercises should not cause pain.  Many children will feel most comfortable if they keep the leg turned out during rest so they should be allowed to do this. Any position that is comfortable will help the healing process. Your Physical Therapist will answer any questions you have on the ‘do’s’ and ‘don’t’s’ regarding exercise and positioning while the hip is healing.

Painful weight bearing on the injured leg should be avoided in order to decrease pain and allow healing. Some patients may need crutches to avoid painful weight bearing. Before leaving the clinic your Physical Therapist will assess whether crutches should be used to ambulate for your child and, if needed, can adjust and fit the crutches. Generally, if the child cannot walk somewhat normally due to pain, then your Physical Therapist will suggest that crutches be prescribed.

Finally, our Physical Therapist in Lynn Haven and Panama City Beach can advise on a return to activity schedule; vigorous physical activities such as running, jumping, and participating in sports activities should be avoided during the acute phase and will be added back as tolerated on the recommendation of your Physical Therapist.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

X-rays are usually taken. Though radiographs don’t show synovitis, they do help the physician rule out a fracture, tumor, or slipped capital femoral epiphysis (slippage of the growth plate). More advanced imaging such as MRI or bone scan may be needed if there is a need to rule out other more serious problems.

A blood test will show mild inflammation. If needed, the physician may order an ultrasound of the hip. This test will show any effusion (fluid collection) in the hip joint. Drawing the fluid out with a needle called needle aspiration will show if there is pus in the joint from septic (bacterial) arthritis. The fluid is clear in transient synovitis.

Antiinflammatory drugs will likely be prescribed along with rest from activity during the acute phase of pain.

Surgery is not usually necessary. In severe cases of transient synovitis children may be hospitalized for observation and leg traction. Applying pull on the hip through the leg can reduce the pressure inside the joint capsule. If the child is cooperative, home traction may be possible.

Rotational deformities of the legs and feet in children are often a cause of concern for parents. Most people think of the deformities as either toeing in or toeing out. The deformity actually comes from rotation of the femur and the tibia. Rotation of the legs at birth is normal. Most of the time, the deformities correct themselves by age seven or eight.

Rotational deformities are usually due to position and pressure in the uterus during pregnancy. It is important to determine if the deformity is from this, or from something more serious – like a neurological problem.

This guide will help you understand:

• what parts of the body are affected
• how the condition develops
• how the condition is diagnosed
• what treatment options are available

What parts of the body are affected?

The two main long bones of the leg are the femur and the tibia. The femur is the bone of the upper leg or thigh. The tibia is the larger bone in the lower leg. The front part of the tibia forms the shinbone. The smaller lower leg bone is called the fibula. Excessive rotation (also called torsion) of the femur and/or tibia will cause the foot to appear to either toe in or toe out.

The anatomy of the hip also affects the rotation of the entire leg. The femoral shaft, or thigh bone, attaches to the femoral neck near the hip joint. The femoral neck in turn attaches to the femoral head, the round ball that actually fits into the hip socket. How the femoral neck attaches to the femoral shaft affects how the entire leg lines up with the body.

There are two angles between the femoral shaft and the femoral neck that are important. Looking at the front of the body, there is an angle formed where the femoral neck joins the femoral shaft. Looking at the shaft of the femur from the top (along the axis of the femoral shaft), there is also an angle formed between the knee joint and the femoral neck. Doctors call this angle the version of the femoral neck. If the angle is more to the front (anterior) it is called anteversion and if it is more to the back (posterior) it is called retroversion. Normally the version of the hip in the adult is about 15 degrees anteversion.

Version of Femoral Neck

Version can be difficult to understand – even for health care professionals. But remember, the end result is that too much or too little anteversion will make the entire leg look like it is twisted – either the toes turn in or they turn out. Too much femoral anteversion and the toes turn in; too little and they turn out.

How does this problem develop?

The vast majority of rotational deformities that are seen in children – and worry their parents and grandparents – are normal variations that will improve with time. The infant skeleton is made up of mostly cartilage. It is immature bone. It has not been calcified. This makes it fairly flexible. Babies are packed inside the uterus tightly. Position and compression in the uterus can shape the cartilage. Most fetuses are in a crossed-leg position in the uterus. This affects how our legs look when we are born. Rotation of the legs at birth is not abnormal.

 

There are usually contractures (tightness of certain soft tissues and ligaments) in the hip and knee joints at birth. This also comes from positioning in the uterus. This can be a part of the cause of these various deformities. Positions for sleeping and play may also help shape the various deformities. Immediately at birth though, changes begin to take place. Throughout childhood, the femur and tibia (and the version of the hip) will continue to change and move towards what is normal for the adult.

Sometimes the rotation at birth is excessive. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure in the uterus. An unstretched uterus in a first pregnancy causes greater pressure. This makes the first-born child more prone to rotational deformities. The unborn child grows a lot during the last 10 weeks. The compression or pressure in the uterus increases.

Premature infants have less rotational deformities than full-term infants. This is possibly due to decreased pressure in the uterus. Twins tend to be crowded in the uterus. They are more likely to have rotational deformities.

Sometimes, what is thought to be a rotational deformity is something different. Bowed legs are not necessarily considered a rotational deformity. When rotation is not involved the deformity is called an angular deformity. What looks like bowing of the lower leg can actually be caused by internal rotation of the tibia (lower leg). Because of this, the calf muscles lie on the outside of the leg instead of in the back of the leg. This gives the leg a bowed appearance.

What are the symptoms?

Rotational deformities are most often painless. The exception is with exaggerated femoral internal torsion (or femoral anteversion). Some teenagers and older children with exaggerated femoral internal torsion may develop pain in the front of the knee. Climbing stairs usually aggravates this. Rotational deformities normally do not cause problems in adulthood.

Children with internal femoral torsion may have a habit of sitting in a “W” position, or on their feet, rather than crossed legged. Some children will trip over their feet if they toe in excessively. There is not a delay in the normal development of sitting, crawling, and walking.

“W” Position

There are four rotational deformities that affect the leg:

• Internal tibial torsion (ITT) – causes toeing in
• External tibial torsion (ETT) – causes toeing out
• Internal femoral torsion (IFT) – causes toeing in
• External femoral torsion (EFT) – causes toeing out

 

Internal tibial torsion (ITT) is the most common of the rotational deformities. It causes toeing in. It is usually noticed at birth or early infancy. Your child being cross-legged during growth in the uterus causes it. It often goes unnoticed until your child begins walking. The deformity is more obvious when standing. It usually goes away by age two or three. If internal tibial torsion is significant, and lasts past the age of five, surgery to derotate the tibia may be necessary, although this is very rare.

External tibial torsion (ETT) causes toeing out. While the child is in the uterus, the foot is held in extreme dorsiflexion. This means that the top of the foot lies against the shin of the same leg. This causes the foot to be in an externally (outward) rotated position. When your child stands, the foot will appear to toe out.

Internal femoral torsion (IFT) is the most common cause of toeing in after age three. If the tibia and femur are both internally rotated, toeing in may be even worse. This occurs more often in girls than boys. IFT can be diagnosed by comparing internal and external rotation range of motion of the hip. Your child will be placed on their stomach with knees bent. Normal children have equal amounts of internal and external rotation. In children with IFT there is an increase in the amount of internal hip rotation (torsion). Children with internal femoral torsion will want to sit in a “W” position, or on their feet, rather than crossed legged.

External femoral torsion (EFT) is much less common. This is because the usual position in the uterus makes the femur rotate internally, not externally. External femoral torsion can also be a cause of toeing out.

A significant difference between the left and right leg may mean that a deformity is caused by something else. Tumors, abnormal bone formation, fracture, and infection of the bone are possible causes. Excessive toeing out of one foot can be a sign of hip disease. Further evaluation is necessary. A child with progressive bowed legs after 20 months may have a pathological deformity known as Blount’s disease. Rickets can also cause bowed or knocked knees. Rickets is a vitamin D deficiency. It is also seen in kidney problems. Neurological and muscular disorders can also cause deformities of the legs.

Being that most rotational deformities in children occur without symptoms, it is likely that if you are discussing rotational deformities with your Physical Therapist, your child has symptoms that are either a result of the rotational deformities or are aggravated by them.  These may include things such as hip or foot pain, and more commonly knee pain. In taking the medical history of the present injury, your Physical Therapist therefore may ask many questions regarding your child’s birth. He/she may ask about the pregnancy, labor, and delivery of your child. Your Physical Therapist may need to know when the deformity was first noticed. Some are noticed right after birth, others when the child starts to stand or walk, and some are not noticed until after age three. Your Physical Therapist will also want to know if the deformity has gotten worse or better over time and if you have noticed an increase in symptoms since the rotational deformity was noticed.

Your Physical Therapist will want to examine your child’s legs while your child is in different positions such as standing, or while they are on their stomach with their knees bent. If your child walks, he will want to watch him/her walk. In addition, they will want to feel range of motion of the joints. The legs of the parents may also be examined to see if there is a similar deformity in adulthood.

Non-surgical Rehabilitation

Most children require no active treatment whatsoever. Generally there are no restrictions placed on young children. Being a child IS the treatment. Allowing the child to pursue normal activity will result in a completely acceptable outcome.

If, however, your child is experiencing symptoms such as hip, ankle, or knee pain, as a result of the rotational deformity, your Physical Therapist can help. Commonly older children or teenagers with exaggerated femoral internal torsion may develop pain in the front of the knee.

Initially, the treatment we provide will be focused on pain relief for your child. In the clinic we may use modalities such as ice, heat, or taping and will educate you on the use of these modalities at home as well. Taping the knee can assist in modifying the alignment of the knee joint and kneecap and in doing so, decrease the pain your child feels when walking or being active.

Your Physical Therapist is skilled in biomechanical assessment and gait analysis.  The next part of your child’s treatment will include an analysis of their alignment and walking pattern. The hip joint is an important controller of knee function therefore this joint will be included in our biomechanical assessment.  From this analysis, we will suggest specific individualized exercises for your teen to help strengthen and stretch the muscles around the knee and hip.

Lastly, your Physical Therapist at First Choice Physical Therapy will be available to discuss any remaining questions you may have about your child’s condition and, if needed, will refer you onto a Doctor for further discussion.

Post Surgical Rehabilitation

Physical Therapy post-surgically focuses on the same principles as non-surgical treatment. Your Physical Therapist will first assist with surgical pain management by applying ice and encouraging gentle range of motion exercises.  Once the timing is appropriate, your Physical Therapist will assess how your child is using his hip and knee joint post-surgically and also assess their walking pattern. If needed, we will provide the necessary strengthening and stretching exercises to ensure that your child regains the normal use of their leg as quickly as possible.

Your child’s doctor may want to perform a neurological examination as well. This is to make sure there are no symptoms of cerebral palsy, or muscle disease that could be causing the deformity.
The diagnosis of rotational deformity is usually made by the findings of the physical examination. X-rays or other imaging is rarely needed.

If internal tibial torsion (ITT) lasts 18 months after the start of walking, some doctors will suggest the use of a Denis-Browne splint. A bar is attached to the sole of high-top shoes. The splint is worn at bedtime. The feet are forced into a toeing out position.
Your child’s doctor may want you to follow up periodically. This is to make sure the skeleton is developing as expected. Most rotational deformities correct themselves by age eight.

Surgery is rarely needed to correct the majority of rotational deformities in either the femur or tibia. If external tibial torsion (rotation) is very severe and lasts longer than age four, surgery may be recommended to better align the tibia. Similarly, if surgery on the femur is recommended, it is usually done after the age of eight.

Surgery to correct the deformity is done only when the deformity is severe and affects the child’s function. In general, the type of surgery performed to improve the rotational deformity is called a derotational osteotomy. Derotation means to remove the rotation and osteotomy means to cut the bone.

A derotational osteotomy requires the surgeon to cut the bone, rotate it to improve the alignment and hold the bones in that position while they heal. Some type of metal hardware is generally used to hold the bones in place until they heal.

 

Nursemaid’s elbow is a common injury in young children. It occurs most often around age two and is rarely seen after age eight. Lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child away from a dangerous situation can result in a subluxation or complete dislocation of one of the bones in the elbow. This condition is also known as pulled elbow or radial head dislocation.

This guide will help you understand:

• what can cause this condition
• what the symptoms are
• how your health care professional will diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

 

What part of the elbow does this problem affect?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

 

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius, or radial head. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well.

 

In the elbow, two of the most important ligaments are the medial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is a severe injury or dislocation of the elbow. These ligaments are not generally injured in the condition referred to as nursemaid’s elbow.

 

There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring-shaped. The annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.

How does this problem develop?

In young children, the annular ligament of the radial head is thin and weak. A sudden pull on the forearm can tear this soft tissue structure. The radial head is pulled down through the tear. The annular ligament slips into the radiohumeral joint and becomes trapped between the two joint surfaces when the arm is let go. This is a radial head subluxation. When the annular ligament is pinched it causes pain.

This is a common injury in children. A sudden jerk on the arm is the main cause. As mentioned, lifting the child up a step by the hand, giving the hand a sudden jerk, or pulling the child by the hand or forearm away from a dangerous situation can result in an elbow injury of this type. Playing with other children where one child swings the other around by the arms can also result in this injury.  The term ‘nursemaid’s elbow’ dates back to when nursemaids or nannies were the common caregivers who would be minding the children and most commonly holding onto their hands.

 

As a child gets older, a true elbow dislocation is more common and is often the result of a fall or trauma (rather than just a pull on the hand) which leads to fracture and dislocation. This is a much different and much more serious injury than nursemaid’s elbow. The most common site of the fracture associated with dislocation in this age group is a supracondylar fracture. The fracture is located below the humeral shaft (upper arm bone) where the olecranon (the tip of the elbow) fits into the humerus. The bone is thin here in children.

What does nursemaid’s elbow feel like?

These injuries commonly occur in children too young to actually tell a parent or health care provider what happened. In young children, crying and refusing to use the arm while holding it against the body are common behaviors associated with nursemaid’s elbow. Pediatricians, family physicians, orthopedic surgeons and Physical Therapists usually recognize the pattern quickly because the injury is so common. Once a health care professional has seen a child with this condition, it is relatively easy to spot.

Pain and an inability to straighten the elbow or supinate the forearm (turn the palm up) are typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body). Bruising around the elbow several days after the injury is common.

In contrast, if the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Swelling on either side of the elbow may be a sign that there is a bone fracture. Pain can be intense until the arm is relocated.

How do health care professionals diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your Physical Therapist at First Choice Physical Therapy will ask questions about when the pain began, what your child was doing when the pain started, and what movements your child has avoided since the injury occurred. The history alone will often lead your Physical Therapist to the suspicion of nursemaid’s elbow. Next your Physical Therapist will do a physical examination of the elbow.  They may move the elbow passively to assess the range of motion deficits. Movement with this injury can be very painful, especially as the elbow is extended and supinated. This is another sign that nursemaid’s elbow is the likely cause. Lastly, we will also check for any signs of injury to the nerves or blood vessels.

If your Physical Therapist deducts from the history and physical examination that nursemaid’s elbow is the likely cause of your child’s pain, we will refer you on to your doctor or emergency room for reduction of the joint back into place and possible x-rays.

Reduction of the joint means that the joint is put back into normal alignment. Closed reduction refers to the fact that the subluxation of the annular ligament and radial head are put back in place without surgery. Generally this procedure is done in a clinic or hospital setting.

The technique of reduction is relatively simple. Once your child is calm and trust is established, the elbow is gently taken through a full range of motion from completely extended to fully flexed. While flexed the forearm is maximally supinated. In some cases, a small pop is felt or heard. This can indicate that the radial head and annular ligament have returned to their normal position.  After relocation your child is encouraged to use the arm.  In many cases, within minutes your child will be using the arm normally. If the child needs to feel more secure, a light splint can be used for a day or two.

It is also possible for the nursemaid’s elbow to relocate by itself even before you seek medical aid.

X-rays are consistently negative in children with elbow subluxation or dislocation due to the large amount of fibrous cartilage present around the elbow before the bones are fully formed. It is easy to misinterpret the irregular or fragmented growth lines as fractures. Additional views may be needed to help the radiologist make an accurate diagnosis. Before age five (when the bones start to ossify or become bony) a separation of the growth plate at the end of the bone may go undetected. Many doctors, however, will not even order X-rays if they suspect nursemaid’s elbow but will simply try to reduce the subluxation with a gentle manipulation.

If your child continues to exhibit pain after manipulation, however, X-rays may be ordered to make sure that no other injuries are present in the elbow such as a fracture. If the X-rays are normal, then your child will be placed in a sling to rest the painful elbow and will be observed for several days. They will then likely be scheduled to return for re-evaluation in 7-10 days. Over time, the vast majority of cases of nursemaid’s elbow resolve spontaneously and only in rare circumstances require any additional treatment.

What can be expected from treatment at First Choice Physical Therapy?

Nonsurgical Rehabilitation

Often, if the reduction of the joint is uncomplicated, then as mentioned above, most children require no additional treatment and they are simply just encouraged to use the arm normally. If, however, your child continues to suffer from pain or lack of range of motion after the joint has been reduced (and a fracture has been ruled out,) Physical Therapy is recommended. First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Initially, the treatment we provide will be focused on relieving any pain your child has. In the clinic we may use modalities such as ice, heat, or taping and will educate you on the use of these modalities at home as well. Taping the elbow can assist in modifying the alignment of the joint and in doing so, decrease the pain your child feels when using the elbow or being active. We may also use other electrical modalities to help treat the pain if we feel it is necessary.

The next part of our treatment will focus on normalizing any deficits that may have developed in the range of motion and strength of your child’s elbow joint. Your Physical Therapist at First Choice Physical Therapy may assist in stretching your child’s elbow while in the clinic and, if necessary, will ‘mobilize’ the joint. This hands-on technique encourages stiff joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of stretching exercises that we will encourage your child to do as part of a home exercise program. Being that the most common age to suffer nursemaid’s elbow is from two to eight, these exercises will be simple activities that you can incorporate into the everyday activities of your child. For example, if your child is very young, your Physical Therapist may show you some simple games that you can play to encourage your child to improve range of motion with daily activity. If they are older, we may teach them a few specific but simple exercises that will again be encouraged throughout regular daily activity.

Similarly to the range of motion deficits, strength deficits will also be addressed.  Again, your Physical Therapist at First Choice Physical Therapy will show you how to incorporate strengthening exercises into your child’s normal activities such as playing or eating.  Even regular playing with toys, for example, can be used to strengthen your child’s elbow and upper limb.

The final part of our First Choice Physical Therapy treatment will be ensuring that your child’s coordination of the limb has returned to normal after the dislocation. Even a short period of abnormal joint use can cause the coordination and proprioception (the ability to know where your body is without looking at it) to decline in function. Exercises, such as weight bearing through the hand, ball tossing, and rotating the forearm will be encouraged throughout playing and everyday activities once your Physical Therapist determines these are safe activities to undertake. Activities that cause further traction on the elbow, such as pulling a door open or lifting a bag, will be discouraged until full ligamentous healing has occurred, which can take up to 6 weeks depending on the severity of injury.

Education is a fundamental part of our treatment at First Choice Physical Therapy therefore It is worthy to mention that parents of small children are cautioned to avoid pulling or lifting by the hand to prevent injuries or re-injuries of this type. Young children should always be picked up under the arms, especially if they have previously had a nursemaid’s elbow injury. Children should never be forcibly pulled, lifted or swung through the air by the hand or wrist.

Fortunately, gaining lost range of motion, strength, and coordination goes quickly after suffering from nursemaid’s elbow. You will notice improvements in your child’s elbow function even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. If your child’s pain continues longer than it should or therapy is not progressing as your Physical Therapist at First Choice Physical Therapy would expect, we will ask you to follow-up with your child’s doctor to confirm that there are no complications that may be impeding your child’s recovery. Generally, however, children respond very well to the Physical Therapy we provide at First Choice Physical Therapy. Under the supervision of one of our Physical Therapists your child should be back to the daily activities they enjoy in no time.

Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip in teenagers between the ages of 12 and 16 most often. Cases have been reported as early as age nine years old. In this condition, the growth center of the hip (the capital femoral epiphysis) actually slips backwards on the top of the femur (the thighbone). If untreated, this can lead to serious problems in the hip joint later in life. Fortunately, the condition can be treated and the complications avoided or reduced if recognized early.

Surgery is usually necessary to stabilize the hip and prevent the situation from getting worse.

This guide will help you understand:

• what can cause this condition
• what the symptoms are
• how your health care professional will diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What part of the hip is affected?

The hip joint is where the thighbone (femur) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball-and-socket joint is what allows us to move our leg in many directions in relation to our body.

Femoral Head

In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.  The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)

The blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis.

Causes

How does this problem develop?

SCFE develops at a specific age. The changes occurring in the growing skeleton during puberty play into the chances that a child will develop SCFE. The cartilage epiphyseal plate is weaker than the surrounding bone. Children who are overweight are more prone to developing SCFE. This suggests that the main cause of SCFE is from increased force on the hip at a time when the femoral head is not quite ready to support these forces. The femoral head fails at the weakest point, through the epiphyseal plate. As a result, a condition similar to a stress fracture develops.

SCFE may affect both hips. In fact, 20 to 40 percent of the time the condition is bilateral (meaning that it affects both hips). Only one hip may be painful, so it is common for doctors to carefully watch the other hip to recognize the disease as early as possible. The earlier the diagnosis is made, the more effective the treatment. Studies have shown that the more severe the slip, the worse the long-term outcomes. The earlier the diagnosis is made, the more effective the treatment.

What does the problem feel like?

 

Most teenagers with SCFE develop pain in the hip, and they begin to walk with a limp. In addition, the motion of the hip is abnormal and restricted. Because the anatomy of the hip joint is altered, patients usually walk with the foot and leg turned out on the affected side.

Interestingly, problems in the hip sometimes do not cause pain in the hip itself. The knee is where the pain is felt. This can be confusing both to patients and health care professionals. In general, a teenager with knee pain who has no clear-cut reason to have knee pain should be examined for possible SCFE. This usually includes X-rays of the hips to make sure that SCFE is not missed.

The main problem with SCFE is that it changes the structure of the hip joint. How much it affects the way the hip joint works depends on how much the epiphysis slips. The more the slip, the more likely there will be problems later in life.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear-and-tear arthritis). Just like a machine that is out of balance, the hip joint wears out and becomes painful.

There are two complications of SCFE that may occur immediately after the condition develops. The first complication is chondrolysis, a condition where the articular cartilage of the hip joint is destroyed. Articular cartilage is the smooth material that covers the joint surface. It is unclear why this condition develops. It may occur if the SCFE has been treated with or without surgery. This condition results in narrowing of the joint space and a painful, stiff hip.

The other possible complication is called avascular necrosis of the capital femoral epiphysis. This usually occurs when the blood vessels that provide blood to the epiphysis are damaged, torn, or pinched. This can happen when the SCFE develops very rapidly and presents like a true fracture. This can also occur when attempting to reduce, or align, the two parts of the femoral head before inserting a screw. The result is that the epiphysis dies and the bone collapses causing further deformity. This can lead to early arthritis in the hip joint.

Avascular Necrosis

How do health care professionals identify the problem?

At First Choice Physical Therapy your Physical Therapist will initially take a thorough history of when and how your child’s pain started. It is important to for us to determine if the pain began insidiously (for no particular reason) or occurred as a result of a trauma (i.e.: a fall or specific incident.) SCFE pain is generally of insidious onset.  In deducing the cause of the pain it is also important for us to determine if the pain is constant or occurs only with specific activities. Pain caused by SCFE is more likely to be relatively constant but can increase during weight bearing activities. If your child is walking with a limp or with an altered foot position due to the pain, your Physical Therapist may ask to watch your child walk to assess the limp during the gait cycle.

Next your First Choice Physical Therapy Physical Therapist will then palpate around any areas of pain. . As mentioned above, the pain from SCFE is most often felt in the hip but may also cause pain in the knee. For this reason we may also palpate around the knee. We may also need to examine related areas such as the low back or anywhere along the lower limb in order to identify the location of the actual problem.

Following palpation your Physical Therapist will assess the range of motion of your child’s joints and compare them to the other side. They will also check the strength of the muscles on both sides and may check for the integrity of the ligaments around the joints.

The history, and physical examination are usually enough to make a health care professional highly suspicious about the diagnosis of SCFE in children of the appropriate age. If SCFE is suspected, your First Choice Physical Therapy Physical Therapist will recommend that your child is reviewed by a doctor for investigative tests to confirm or rule out this diagnosis.

What treatment options are available?

Nonsurgical Treatment

Treatment of SCFE usually requires surgery. If surgery is absolutely not possible for other reasons, then placing the child in a type of body cast called a hip spica may be an option. This is not as successful as surgery and is not the preferred choice.

The primary goal of the treatment of SCFE is to stop any further slippage of the capital femoral epiphysis. The less slip, the lower the risk of problems in the hip during the child’s life.

Once the epiphysis has closed, slippage will stop. Epiphysis closure occurs when the two areas of bone, the epiphysis and metaphysis, join, or fuse, into one single bone. At that point there is no cartilage growth plate remaining between the two parts of the femur. Surgery usually speeds up the process of epiphysis closure.

Once the diagnosis of SCFE is made, surgery is usually recommended immediately. The surgery is scheduled within a few days following the diagnosis. Until the surgery can be performed, it is highly advisable to use crutches and restrict activities to a minimum in order to decrease pain and stop any further slippage. The surgery can usually be done as an outpatient. General anesthesia (where the patient is put completely to sleep) is usually recommended, unless there are reasons not to use a general anesthetic. If so, a spinal block may be used instead.

The preferred method for stopping the epiphysis from slipping further is to place a large screw into the epiphysis to hold it in place. This screw is placed using a special X-ray machine called a fluoroscope. The fluoroscope allows the surgeon to see an X-ray image on a TV monitor while doing the surgery. In this way, the surgeon is able to accurately place a screw into the epiphysis using a small incision in the side of the thigh.

Other types of surgery have been used in the past. For many years surgeons thought it necessary to use two or three screws to hold the epiphysis. This has been shown to be unnecessary in most cases. Using additional screws may actually increase the risk of complications. Open operations using much larger incisions have also been used in the past. These procedures have been abandoned because using a single screw works better and is easier to do.

If there is a serious structural change in the anatomy of the hip, there may need to be further surgery to restore the alignment closer to normal. This procedure is usually not considered until the child is done growing. As a child grows, there will be some remodeling that occurs in the hip joint. This may improve the situation such that further surgery is unnecessary.

In the case of unilateral (one-sided) SCFE, experts also recommend pinning the normal hip. This is called prophylactic pinning. The child with moderate to severe unilateral SCFE is at risk for slippage to occur on the other side.

Prophylactic treatment is easy to do and can be done at the time of the operation on the involved side. Taking this step reduces the need for repeated X-rays to check the normal side for any sign of SCFE. The child can remain more active without constant worry that the hip will slip. The complications of chondrolysis, avascular necrosis, and/or degenerative arthritis can also be avoided.

Post surgically the surgeon will take X-rays to make sure that the screw remains in the right place. The X-rays are also required to determine when the epiphyseal plate fuses. At that point, there won’t be any chance that the slip will get worse. When it is confirmed that the plate has fused, the follow up visits will be focused on whether the abnormality is likely to need any additional surgery to realign the hip.

Opinions differ on the need to remove the screw once the epiphysis has fused. Removing the screw requires a second surgery that can be expensive and carries a slight risk due to the need for anesthesia. The hole left when the screw is removed also increases the risk of fracture after the screw is taken out. If the screw is removed, the surgeon may recommend crutches for three to six weeks afterward. Many surgeons feel that the screw should be left in place if it isn’t causing problems.

Rehabilitation

What should be expected from rehabilitation post surgery?

Following surgery for SCFE, Physical Therapy treatment is very useful in returning your child to their pre-injury activity level as quickly as possible. Physical Therapy can also assist in avoiding other compensatory problems in the back or lower limb in the future. First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Rehabilitation at First Choice Physical Therapy can begin as soon as your child’s surgeon recommends it. Each surgeon will set his or her own specific restrictions based on the child’s individual severity of injury, the surgical procedure used, personal experience, and whether the SCFE is healing as expected.

Initially your Physical Therapist at First Choice Physical Therapy may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain associated with the surgery. Crutches and a non-weight bearing status are standard following surgery for SCFE but within three to five days most patients will be able to start putting some weight down while standing or walking. Your Physical Therapist at First Choice Physical Therapy will ensure your child is using the crutches safely and appropriately and that they are abiding by the weight bearing restrictions set by their surgeon. Your Physical Therapist will also ensure that your child can safely use the crutches on stairs. We generally recommend that until it is possible to walk without a significant limp, either one or two crutches continue to be used. Improper gait can lead to a host of other pains in the knee; hip and back so it is prudent to continue on crutches until near normal walking can be achieved. Your Physical Therapist will give advice regarding the appropriate time for your child to be walking without any support at all. Once the crutches are no longer required, your Physical Therapist will assist with gait re-education.

The next part of our treatment at First Choice Physical Therapy will focus on normalizing any deficits that may have developed in the range of motion and strength of your child’s lower limb joints. Your Physical Therapist may assist in stretching your child’s limb or lower back while at the clinic and, if necessary, will ‘mobilize’ the joints of your child. This hands-on technique encourages the stiff joints to move gradually into their normal range of motion. In addition to the hands-on treatment in the clinic we will also prescribe a series of stretching exercises that we will encourage your child to do as part of a regular home exercise program.

Similarly to the range of motion deficits, strength deficits will also be addressed. Strength building exercises will be taught in the clinic and added to their home program. We may incorporate items such as Theraband or light weights into the exercises to provide additional resistance for the limb.

The final part of our First Choice Physical Therapy treatment will be ensuring that your child’s coordination and balance have returned to normal after their surgery. Following even a short period of walking with crutches or with an altered weight bearing status, your child’s normal balance, coordination, and proprioception (the ability to know where your body is without looking at it) can decline in function. Exercises, which may include balancing on one foot, jumping, and quick agility movements will be encouraged at an appropriate time in line with the surgeon’s restrictions.

Fortunately, gaining lost range of motion, strength, and coordination after surgery for SCFE goes quickly. You will notice improvements in your child’s function and gait even after just a few treatments with your Physical Therapist at First Choice Physical Therapy. If, however, your child’s post-surgical Physical Therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the hip is tolerating the rehabilitation well and ensure that there are no post-surgical complications that may be impeding your child’s recovery.