Physio S1 EOY Assessment

1. Introductions (HAIDET)
2. Current History.
3. Past History.
4. Pain and irritability.
5. General Health.
6. Relevant investigations.
7. Social history.

Loose-Packed Position
This is the position where the capsule is most relaxed due to minimal joint contact and maximal joint play. It is considered to be at about
- 30 degrees Hip Flexion
- 30 degrees Hip Abduction
- Slight external Rotation


Close-Packed Position
The position where the capsule is most tensed due to maximal joint contact and minimal joint play (accessory movement ability). It is considered to be at:
- Maximal hip extensions
- Slight internal rotation
- Slight abduction

Extrinsic (Extra-articular) Disorders: Involve structures outside the joint capsule, such as tendons, bursae, muscles, or nerves.
- Tendinopathies of the hamstrings, adductors, gluteus muscles
- Hip and groin pain due to sports-related injury
- Disease of local structures eg; lymphadenopathy
- Referred pain from lumbar spine somatic structures

Intrinsic (Intra-articular) Disorders: Involve the hip joint itself, including the labrum, articular cartilage, or femoral head.
- FAI
- OA
- Labral Tears
- GTPS
- LFCN Entrapment

The abnormal contact between the femoral head and acetabulum, leading to premature wear and labral damage. 20% of the population have FAI with 20% of this population experiencing hip pain. The two types include:
Cam – The femoral head and neck are not perfectly round, creating a "bump" that causes abnormal contact with the socket, frequently damaging articular cartilage. This type is often more common in young athletic men

Pincer – The socket (acetabulum) rim is overgrown or covers too much of the femoral head, leading to the labral cartilage being pinched. This type is more common in females.

FAI looks like groin and anterior hip pain + decreased ROM for Hip Flexion and Internal Rotation. Therefore to assess it we use FADIR

Labral Tears are common in athletic populations and presents with groin pain. Its typically a result of a twisting or loading injury and its more prevalent amongst populations with FAI or developmental dysplasia (abornmal formation of the hip joint in infants where the acetabulum is too shallow).

A major cause of lateral hip pain in females over 40 typically due to gluteal tendon tears or irritation. Symptoms are a deep aching or sharp pain on the lateral hip/thigh, tenderness when pressing the hip, pain lying on the affected side, climbing stairs or STS

Tendinopathies are also common in the athletic populations presenting itself as groin pain (adductor, iliopsoas, rec fem) and lateral hip pain (gluteus medius, minimus). Tendinopathies will present pain on static contraction, palpation and stretch

Loose-Packed Position
This is the position where the capsule is most relaxed due to minimal joint contact and maximal joint play. It is at about 25 degrees knee flexion

Close-Packed Position
The position where tension on the joint capsule and ligaments is maximal and causes the joint surfaces to become fully approximated. This is full extension combined with external tibial rotation

- Most prevalent in 18-25 year old active individuals. 2/3rd are non-contact injuries (twisting, changing direction) and 1/3rd are contact

- Typically a twisting, knee hyperextension mechanism, followed by an audible ‘pop’ and immediate swelling, pain and inability to WB

- Diagnostic Accuracy for ACL injuries remain effective: Lachman Test is highly sensitive (ability to detect the condition) and specific (ability to rule out those without an ACL tear – false positives)

- This injury is most often associated with a traumatic event in the younger population
- Mechanism of Injury (MOI) is typically a twisting movement on a flexed knee with the foot anchored on the ground.
- The medial meniscus is the most vulnerable while the tibia externally rotates on the femur (usually the posterior 1/3rd). The Lateral meniscus is susceptible to injury during IR of the tibia (usually the middle 1/3rd)
- Diagnostic Accuracy for Meniscal Injury: McMurray’s test, Apleys grind test, Joint line tenderness etc all demonstrate variable and often average sensitivity and specificity across different studies

- A valgus force will tear the deep fibres while an ER force will tear the more superficial fibres. Tears are classed according to the grade of injury
- Grade 1: Medial knee pain, no effusion but inability to straighten the knee known as pseudolocking, tenderness over proximal medial condyle. The Valgus stress test should reproduce pain but no laxity (stable joint i.e not loose)

- Grade 2: Possibly effusion, especially with the tear of deeper fibres. The valgus stress test will reproduce pain and increased laxity with end feel

- Grade 3: Usually associated with ACL injury, it will be tender, and swollen. The valgus stress test will produce little to no pain, with no end feel and massive laxity. A brace of 30-90 degrees should be worn for 3-4/52

Maximal joint play or the ‘Loose-packed position’ is approximately:
- TCJ 10 degrees plantarflexion in midway pronation/supination
- Subtalar Joint in midway pronation/supination
- Distal TFJ 10 degrees plantarflexion
- Mid tarsal in subtalar joint pronation

Minimal joint play or the ‘Close-packed position’ is approximately:
- TCJ in full dorsiflexion
- STJ in full dorsiflexion
- Distal TFJ in full dorsiflexion
- Mid tarsal in subtalar joint supination

These are high ankle sprains – that is injury to inferior tibiofibular joint ligaments. The MOI for these are excessive external rotation and/or DF of talus. These present themselves by:
- Pain and swelling on more proximal and medial parts
- Pain on active ER of foot
- +ve squeeze test if severe

- Major public health issue with an incidence of hip fractures rising exponentially after the age of 55 years old
- Occurs mostly in elderly populations after low velocity falls or other less traumatic events such as catching the foot while walking or twisting the foot in WB
- Treatment is determined by the site, nature and age of patient
- Total Hip replacements (THR) is an artificial joint where both the femoral and acetabular sides of the hip are replaced. A THR will only be given in severe, symptomatic degenerative joint disease such as OA to disable pain and improve the functional limitation of the hip despite the patients best conservative efforts eg; physio, medication etc

- Avoiding Hip flexion greater than 90, Hip adduction past midline and hip IR is crucial. This is because dislocations, sciatic nerve damage and leg length inequalities may occur requiring surgical interventions
- Post-op exercises and mobilisations begin day 1 with appropriate walking aid prescription

- Where the femoral and tibial joint surfaces are re-surfaced with metal components and a polyethylene insert fits between (the patella may or may not be resurfaced)
- Indications for a TKR include knee OA, Rheumatoid Arthritis (where the immune system attacks joint linings), Post-traumatic arthritis and avascular necrosis
- Post-Op care for TKR is less complicated than THR’s as there is no risk of dislocation, however issues may arise with wound healing such as infection, stiffness and chronic postsurgical pain.
- Common post-op management treatments include; ice or cryocuffs, early mobilisation, gait education ad of course exercises to regain knee ROM, strengthen hip and knee muscles, and enable balance.

When the knee is flexed and the quadriceps muscles are relaxed, the patella can be forced laterally by direct trauma or the slipping of the lateral femoral condyle to the outer side of the knee. A reduction is the process of returning the patella back to place following a dislocation.
- Minor dislocations can reduce easily under passive knee extension
- Significant dislocations need reduction under anaesthetic, again the knee would be extended requiring manual reduction

Treatment wise, post patella dislocation the knee is mobilised straight in a zimmer splint for 2-3 weeks. Quadricep exercises begin immediately in the splint such as leg raises. Walking is allowed as soon as the patient can straight leg raise. Once the splint is removed, flexion is usually quickly regained. Patella taping to facilitating patella tracking and prevent lateral subluxation is advised.

Exercise Selection: Concentric and Eccentric contractions under load

Expected Outcome: Hypertrophy (increased cross sectional area of the muscle)

Progression: Load is then increased to progress training.

Exercise Selection: Concentric contractions (acceleration), Interval training alternate high speed contractions with slower contractions

Expected Outcome: Aims to achieve hypertrophy, particularly of muscles with FT fibres

Progression: Increase speed and number of intervals to progress training

Exercise Selection: Repeated concentric and eccentric contractions at a steady state for long reps

Expected Outcome: Hyperttrophy, particularly of muscles with ST fibres, time to fatigue increases (cardiovascular / muscular endurance)

Progression: Increase reps to progress training

Exercise selection: Isometric contractions, eccentric / concentric contractions under load (deceleration)

Expected Outcome: Hypertrophy, particularly of muscles with predominately ST fibres

Progression: Increase reps or increase time under load (time of rep) to progress training

Exercise Selection: Static Stretching, Passive stretching (Active-assisted if need be)

Expected Outcomes: Increased total ROM

Progression: PROM / AAROM --> AROM --> PNF and Static --> To make ROM gains permanent, you must strengthen the muscles surrounding the joint at its new, extended limits

Exercise Selection: Dynamic Stretching and PNF

Expected Outcome: Increased Total ROM

Progression: PROM / AAROM --> AROM --> PNF and Static --> To make ROM gains permanent, you must strengthen the muscles surrounding the joint at its new, extended limits

Exercise Selection: Weight Bearing exercises in up-right position

Expected Outcome: Cortical thickness increases and number and thickness of trabeculae increases

Progression: Bone mineral density cannot be progressed beyond normal range

Exercise selection: Concentric and eccentric contraction of muscle under load

Expected Outcome: Tensile strenght increases

Progression: Increase load to progress training

- Prescribed exercise is effective for most pain conditions as people with chronic pain are generally less active than healthy control populations
- Exercise for people with chronic pain can; reduce pain sensitivity, improve physical function and improve overall physical and mental health

Mobilization-induced analgesia (reduction of pain) works through the periaqueductal gray (PAG). Mobilisation relieves pain through stimulation at the dorsolateral PAG and later the ventrolateral PAG to cause hypoalgesia and result in a non-opioid form of analgesia accompanied by sympatho-excitation

- Exercise-induced Hypoalgesia (EIH) is where an acute bout of exercise leads to a period of hypoalgesia (a decrease in sensitivity to painful stimuli), lasting for up to 30 minutes in pain-free people
- EIH in chronic MSK pain varies. LT exercise training can provide pain relief across various chronic pain conditions however ST pain exacerbation may occur after exercise being a barrier to adherence.
- Its more effective after aerobic than resistance exercise and you will not experience EIH after isometric exercise.

1) Initial Stage
- Regain ROM and reduce pain
- Gain control of neutral position of the affected joint
- Light resistance in neutral, isometrics and working in force coupling around the joint in increasing ROM, ensuring quality of movement and quality of contraction

2) Intermediate Stage
- Continue to treat joint, muscle and neurodynamic problem as necessary
- Strength and endurance training can commence for progression of cardiorespiratory fitness
- Specific functional training (low load, high volume)
- Proprioception work through increasing range

3) Advanced Stage
- Progress strength and endurance exercises using principles of overload
- Increase the intensity and specificity of function
- Progression through functional activity

4) Return to Functional Activity (work, sport etc)
- Resolution of all pathology – patient is now symptom free
- Adequate strength, endurance and power to perform tasks
- Management strategies and warning signals are educated
- Patient confidence increased, graded return

Quadriceps Strengthening exercise
• Quads over roll (myofascial release)
• Knee extension in sitting
• Knee extension with hold at 30 degrees knee flexion
• Outer range knee extension

Each Exercise 2-3 sets of 10 repetitions with 5-10 second hold unless specified otherwise. Resistance equivalent to 10-rep maximum and rating of 5-8/10 for pain index. Resistance using ankle weights

- Common in runners this pathology can be insertional or mid-portion (most common)
- It is characterised by morning stiffness, pain made worse with activity, oedematous, thick and tender.
- Its associated with rear foot abnormalities, training ‘factors’ such as increase in intensity/frequency, training on hard surfaces, poor footwear and tight or weak calf muscles
Exercise Considerations
• Isometric Exercise – 45° flexion x 5 (Double leg --> Single leg) BW or Weighted
• Isotonic Exercise – Conc/ecc eg; slow and heavy weighted calf raises
• NO DF movements if its insertional (within 2cm of achilles insertion) as this will compress the tendon

- Clinical tests like single leg 5x hop or 3x hop for hight (+ve will be stiff hop or worse height on leg with PT)
- Isometric exercise: Spanish squats, leg extension machine, 45 degree holds. Isometric knee extension reps (there may be intitial pain which should decrease with reps unlike PFP where reps will worse pain)
- Isotonic exercise: Slow and heavy 4 sets at 6-8RM
- Energy storage exercise: Once quad strength has been achieved (0.5 bw on single leg press)

- Isometric: Hip abduction exerices supine on floor ('stretch the floor')
- Isotonic: Conc / Ecc Isotonic strengthening exercises (start with DL, progress to SL) eg; bridging, squat with abduction or STS variations. 4 sets 6-8RM.

AVOID CLAM EXERCISE OR OPEN CHAIN HIP ABD --> CAUSES COMPRESSION. ALSO AVOID
- Trendelenburg posture
- Standing with one hip in Add
- Excessive lateral pelvic tilt/shift during dynamic SL loading tasks
- Avoid stretching, massage and foam rolling

Typically presents in the athletic population such as rugby players, distance runners, sprinters etc.

Pain should be loaclised deep and near the ischial tuberosity (origin) and reproduced with resisted stretch and compression tests (hamstring bridge, arabesque, maximal Hip Flexion with Active Knee Extension MHFAKE)

Sciatic Nerve often irritated concurrently meaning pain may not be as localised (need +ve neurodynamic testing)

Assess kinetic chain: Contralateral side tght Hip flexors or decreased hip E

• AVOID stretching and any compression positions
• Isometrics again avoiding compression, therefore neutral – 30° eg; leg curl, bridge holds
• Isotonic exercise in positions of increased hip flexion = more compression (70 - 90 degrees)
• Energy-storage loading

Loose Packed Position: Maximal joint play
Horizontal abduction to 55-70 degrees of Glenohumeral joint
Acromioclavicular joint: arm resting by the side in the normal physiological position

Close Packed Position: Minimal Joint Play
Glenohumeral joint at maximal abduction and ER
Acromioclavicular joint at arm abduction to 90 degrees

Grade 1 sprain involves the capsular ligaments of the AC joint or partial stretching of the shoulder joint

Grade 2 sprain involves the complete capsular disruption (complete AC tear) and partial tearing of the coracoacromial ligament. Collarbone may look sligtly out of place = subluxation (a slight "bump" on the shoulder)

Grade 3 sprain entails both the AC and CC ligaments are completely torn, resulting in a visible bump and significant separation of the collarbone from the shoulder blade

a common cause of shoulder pain occurring that ivolves the narrowing of the subacromial space, leading to mechanical compression of the rotator cuff tendons (mainly supraspinatus) and bursa between the humeral head and the coracoacromial arch. This causes an inflammatory and degenerative cycle, often driven by repetitive overhead activities,

Thus repeated compression of the subacromial contents causes micro pockets of damage which eventually summate and may inflame.

Test using impingement tests

The resection of the anterioinferior surface of the acromion to remove subachromial impingement. This can be done solely or in conjunction with a repair / replacement of rotator cuff

- If the shoulder is left immobile after surgery, adhesive capsulitis or frozen shoulder may occur.
- Wound healing, haemotoma and infection
- Axilliary nerve damage

A procedure that replaces damaged, arthritic, or fractured shoulder joints with metal and plastic prosthetic components to relieve pain and restore motion. Most commonly, the TSA specifically replaces the ball (humeral head) with a metal ball and the socket (glenoid) with a plastic cup, mimicking natural anatomy. Requires a functioning rotator cuff.

Indications include debillitating pain, limited ROM and strength eg; arthirits

Total Shoulder Athroplasty - Working / in-tact rotator cuff
Reverse Total shoulder athroplasty - Patients with severe rotator cuff damage (cuff tear arthropathy) where both the ball and socket are replaced, but reversed in their positions: a prosthetic ball is attached to the socket side, and a prosthetic socket is attached to the humerus.
Hemiarthroplasty - Replaces the humeral head

Recurrent shoulder dislocation commonly occurs in two main types based on direction—anterior (most common, ~90-95%) and posterior (less common, ~3-10%)—or by etiology, as traumatic (TUBS) or atraumatic (AMBRII/laxity). These instability issues often follow a primary injury, leading to damage like Bankart lesions (labral tears).

Anterior Instability (TUBS): Typically caused by trauma, this is the most common form. The arm is often forced into abduction and external rotation. It is often remembered as Traumatic, Unilateral, Bankart lesion, Surgery (TUBS).

Atraumatic/Multidirectional Instability (AMBRII): Often presents in both shoulders (bilateral) due to loose ligaments (hyperlaxity), characterized as Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior capsular shift, Interval (interval)

Shoulder (Ball-and-Socket): The rounded head of the humerus fits into the shallow socket of the scapula, allowing for the widest range of motion, including rotation, flexion, extension, abduction, and adduction.

Elbow (Hinge): The trochlea of the humerus fits into the trochlear notch of the ulna, acting like a door hinge to allow only flexion and extension (bending and straightening).

Knee (Modified Hinge): Similar to a door hinge, but also allows for a small amount of medial/lateral rotation, especially when the knee is bent. It involves the femur, tibia, and patella.

Wrist (Condyloid/Ellipsoid): Oval-shaped articulating surfaces (the radius and carpals) allow for biaxial movement: bending (flexion/extension) and side-to-side movement (abduction/adduction).

Ankle (Hinge): The articulation between the talus and the tibia/fibula acts as a hinge, allowing for dorsiflexion (lifting the foot) and plantarflexion (pointing the toes)

Close-Packed: Full extension and full supination.

Loose-Packed: 70 degrees flexion and slight supination

TENS stands for Transcutaneous Electrical Nerve Stimulation and refers to low intensity currents and short impulses applied mainly for targeted pain relief. TENS uses a balanced, biphasic current with a pulse duration/width varying between 50 and 400 nanoseconds, applied via skin electrodes, to relieve pain by stimulating sensory nerves to block pain signals and triggering endorphin release. It works through the selective depolarisation of peripheral sensory (s), sensorimotor (s-m) and sensorimotor nociceptive (s-m-n) nerve fibres in the skin layers.

Conditions: Effective for muscular strains, arthritis, post-operative pain, sciatica, and chronic neckack pain.

Usage: Recommended for 20-30 minutes per session, but can be used multiple times a day.

Pain Modulation (Gate Control Theory): High-frequency TENS activates large-diameter afferent (A beta) nerve fibers, which send inhibitory signals to the spinal cord, blocking smaller pain-carrying (C) fiber signals from reaching the brain.

Endorphin Release: Low-frequency or acupuncture-like TENS triggers the body to release endogenous opioids (endorphins, enkephalins) that act as natural painkillers.

TENS sends electrical impulses that overload the peripheral nerves, blocking pain signals from traveling to the central nervous system.

The presence of pain is the primary indicator, this includes:
• Chronic Pain Conditions: Arthritis (rheumatoid and osteoarthritis), spinal cord injuries, phantom limb pain, neuropathy, and chronic musculoskeletal pain.
• Acute Pain Management: Post-operative pain (e.g., knee/hip replacement, C-section), sports injuries (sprains/strains), and pain from burns.
• Musculoskeletal Pain: Neck pain, lower back pain (lumbago), and sciatica.
• Other Pain Applications: Cancer-related pain, migraines/tension headaches, and pain during Labor (childbirth).

- Anterior transcervical area (Brainstem and Vagas nerve risk)
- Pharyngeal region (carotid sinus stimulation  blood pressure monitor for brain  acute hypotension and cardiac arrythmias)
- Transthoracic (across chest/heart)
- Cardiac pacemakers (current can interfere with device function)
- Insensitive skin (USE SHARP-BLUNT DISCRIMINATION TEST)
- Pregnancy
- Lotions on skin

Paramters: Conventional TENS uses Modulated Mode, high-frequency (50-150 Hz), short pulse duration (50-100 nanoseconds), and low-intensity stimulation to produce a comfortable, tingling sensation without muscle contraction. Used for about 30-60 mins

Nerve Fibres: Large Diamter A-beta afferents (s)

Mechanism: These are non-noxious (non-painful) sensory fibres responsible for touch and pressure. Stimulating them "closes the gate" in the spinal cord, blocking pain signals from reaching the brain.

Indications: Acute pain, superficial pain, and immediate relief

Parameters: Low Frequency (<10Hz), typically 2-4Hz, High Intensity (strong but comfortable muscle twitch) and long pulse duration 100–400 (nanoseconds), with treatment lasting 20–30 minutes.

Nerve Fibers Excited: Small Diameter (A-delta) afferents and motor nerves (s-m)

Mechanism: This stimulates motor nerves and small diameter pain-related fibers (without causing high pain) to trigger the release of endogenous opioids (endorphins) for long-lasting, deep-tissue pain relief

Indications: Chronic pain, deep-seated muscular pain, and trigger points

Paramters: High Frequency (>80Hz) and Long Duration (>150 nanoseconds), Used for short periods, usually less than 15 minutes. It combines both acupuncture like TENS and Conventional TENS

Nerve Fibres Excited: Stimulates small-diameter (A-delta) afferents to block pain transmission in peripheral nerves (s-m-n)

Mechanism:

Indications: VERY RARE: Someone in very large amounts of pain whom you want to settle down quickly and take the risk of electircal burn eg; Short-term, intense pain, such as dressing changes or stitches

Parameters: High-frequency pulses delivered in low-frequency "bursts". Frequency (pulse rate) Set to low, generally between 2-10 Hz to promote endorphin release. Pulse Width (duration) usually set to a higher width than normal TENS to allow for comfortable muscle contraction. FOR 30-60 mins

Low-frequency (bursts per second), high-intensity (amplitude), and long pulse duration (width)

Nerve Fibers Excited: Combines stimulation of both A-beta and A-delta fibers. Each burst will produce excitation in the Aδ fibres, therefore stimulating the opioid mechanisms

Mechanism: Delivers the benefits of both Conventional (tingling) and AL-TENS (muscle twitching)

Nonsteroidal anti-inflammatory drugs (NSAIDs).

NSAIDs such as ibuprofen work by inhibiting the enzyme cyclo-oxygenase. This enzyme is involved in the production of prostaglandins in the body. Some prostaglandins are normally produced and help to maintain various functions in the body. Others are induced by injury and have an inflammatory effect. By inhibiting the cyclo-oxygenase enzyme, we can reduce the production of prostaglandins and reduce inflammation

Pharmacokinetics describes the time course of the drug in the body and there are a number of processes that determine how much drug actually reaches the bloodstream and the site of action and how quickly the drug is removed from the body. These processes are absorption, distribution, metabolism and excretion.

There is the pharmacokinetic phase which is the way that the drug is absorbed, distributed and eliminated from the body and then there is the pharmacodynamic phase which is the effect that the drug has on the body.

Drugs are commonly administered as oral formulations- for example as tablets or capsules. The drug in the tablet or capsule is usually not in solution (not dissolved). The tablet or capsule must disintegrate to form smaller particles and the drug must dissolve from those particles in the gut fluids. The drug must be dissolved before it can be absorbed across the GI tract membrane. Drug in solution crosses the GI tract membrane and reaches blood vessels. These drug vessels take the drug directly to the liver where there are enzymes that can metabolise and break down the drug. The drug that gets through the liver then goes into the systemic circulation

Once a drug reaches the systemic circulation, it undergoes distribution in the body. Different drugs will distribute to different extents. Some drugs distribute widely in the body while others only show limited distribution. Drugs such as anaesthetics can rapidly distribute across the blood-brain barrier into the brain and exert their effect. Other drugs are unable to cross the blood-brain barrier. Drugs may cross the placental barrier and distribute between mother and foetus. Drugs may also distribute into breast milk.

Drugs entering the body are treated as foreign substances. The body will act on drugs to try and eliminate them. One way the body does this is to change the chemical structure of the drug by metabolism using enzymes mainly present in the liver. Usually, drugs are converted to metabolites that have less or no activity. However, some drugs may be metabolised to metabolites with similar or possibly greater activity than the parent drug. An example of a drug that is metabolised to a more active metabolite is morphine. Morphine is metabolised by glucuronidation. One of the metabolites produced is morphine-6-glucuronide which has been shown to be 4 to 20 times more potent as an analgesic than the parent drug morphine

Agonist drugs bind to receptors and activate them to produce a biological response, mimicking natural neurotransmitters or hormones.
EXAMPLE: Morphine (activates opioid receptors to reduce pain).

Antagonist drugs bind to the same receptors but block or inhibit them, preventing activation and reducing the effect of agonists
EXAMPLE: Naloxone (blocks opioid receptors to reverse heroin/fentanyl overdose