Download Systematic Approach to Plain Film Assessment of Traumatized Knee

William Sy-Wei Hsu, D.C., DACBR, FCCR (C)
Dr. Hsu is a 1992 graduate of CMCC. He completed his
Radiology residency in 1995 and has since been a guest
speaker at numerous Chiropractic College of Radiologist
workshops. He was President of the College of Chiropractic
Radiologists of Canada from 2003-2006. Dr. Hsu is a
faculty Radiologist and Associated Clinical Professor at
CMCC and Adjunct Faculty (Assistant Professor) at
D’Youville College, Buffalo, New York, USA and past
radiology instructor for Nichibei Chiropractic College in Osaka, Japan. He has authored and
co-authored numerous papers in referred Journals including JCCA, JMPT and JNMS and a
chapter in Haldeman’s textbook, The Principles and Practice of Chiropractic.
Seminar topics
Review of plain film findings of trauma related injuries of shoulder, elbow, wrist, pelvis,
knee and ankle – from the obvious to the subtle injuries that may lead to chronic pain
and failure to return to sport.
Imaging of stress related injuries of lower extremities. Assess the advantages of
imaging modalities such as bone scan, SPECT, CT and MRI in the evaluation of
athletes with chronic lower extremity complaints.
Systematic Approach to Plain Film Assessment of Hip
1. Signs of soft tissue swelling/joint effusion
 Capsular fat planes and obturator internus fat plane
2. Bony structures
 Femoral head/neck
 AIIS, ASIS, ischial tuberosity, greater and lesser trochanters
 Iliac crest apophysis
 Pubic tubercle
3. Alignments
 Kohler’s line
 Acetabular depth
 Cross-over sign
Systematic Approach to Plain Film Assessment of Traumatized Knee
1. Signs of soft tissue swelling/joint effusion
 Anterior knee soft tissues – Hoffa’s fat pad, suprapatellar fat pad, prefemoral fat pad,
suprapatellar recess, deep infrapatellar bursa, superficial infrapatellar bursa,
prepatellar bursa, patellar tendon
 Medial joint line – medial collateral ligament
 Lateral joint line – Segond fracture
 Posterior knee soft tissues – non-specific
2. Bony structures
 Tibial eminences
 Medial femoral condyle vs lateral femoral condyle
 Patella
 Tibial tuberosity
3. Alignment
 Posterior Femorotibial alignment
Systematic Approach to Plain Film Assessment of Ankle
1. Signs of soft tissue swelling/joint effusion
 Anterior and posterior joint capsule, Kager’s fat pad, Achilles tendon, soft tissue
adjacent to medial and lateral malleoli
2. Bony structures
 Malleoli – medial, lateral and posterior
 Articular margins – tibial plafond and talar dome
 Distal fibula
 Anterior tibial tubercle and lateral clear space
 Talus – posterior process, lateral process, dorsum of talar neck
 Calcaneus – body, lateral border
 Navicular – dorsum, medial tubercle
 Styloid process of the 5th metatarsal
 Os peroneum, os tibiale externum, os trigonum
3. Alignment
 Medial clear space and lateral clear space
Systematic Approach to Plain Film Assessment of Shoulder
1. Signs of soft tissue swelling/joint effusion
 FBI sign
2. Bony structures
 Humeral head, greater and lesser tuberosities
 Glenoid fossa rim
 Acromion
 Scapula – coracoid, spine, neck and body
 Clavicle
3. Alignment
 Glenohumeral joint
 Acromioclavicular joint
 Sternoclavicular joint
Systematic Approach to Plain Film Assessment of Elbow
1. Signs of soft tissue swelling/joint effusion
 Anterior and posterior humeral fat pads
 Supinator fat plane
2. Bony structures
 Radial head/neck
 Capitellum
 Olecranon
 Medial and lateral epicondyles
 Coronoid process
3. Alignment
 Anterior humeral line
 Radiocapitellar line
http://www.radiologyassistant.nl/en/4214416a75d87
Systematic Approach to Plain Film Assessment of Wrist
1. Signs of soft tissue swelling/joint effusion
 Navicular fat plane
 Pronator quadratus fat plane
2. Bony structures
 Distal radius – metaphysis, epiphysis, styloid process
 Ulna – styloid process
 Scaphoid – proximal pole, waist, distal tubercle
 Lunate
 Triquetrum
 1st metacarpal – base
 Hamate – hook
3. Alignment
 Carpal arcs
 Scapholunate angle
 Volar tilt of radius
 Ulnar variant – positive, negative and neutral
Gregory Doerr, DC, CCSP, ART, CKTP
Dr. Gregory H. Doerr is a graduate of the New York
Chiropractic College, in Seneca Falls, NY. He completed a
certification
in
Chiropractic
Sports
Medicine
in
1998
(CCSP). Dr. Doerr lectures for Graston Technique and The
Council on Chiropractic and Extremity Procedures (CCEP). He
has lectured at the US Olympic Training Center and
internationally at the College of Chiropractic and Sports
Sciences and Central American Sports Medicine Congress on
treatment
and
rehabilitation
of
the
endurance
athlete. Doctor Doerr has had the pleasure of working with athletes from the AVP Volleyball
Tour in 2007, the Gold Cup in 2007, Central American Games in July of 2006, with
Washington Redskins in March of 2004 and the University of Colorado in 2004. He currently
is the doctor for 2 club soccer teams and a club volleyball team. Doctor Doerr has a growing
reputation
with
marathon
runners treating athletes
from
running clubs
in
NJ
and
Manhattan. He has served on the medical staff of two 19K foot climbs including Mt.
Kilimanjaro in Africa and El Misti in Peru.
FAKTR-PM was developed to help speed recovery from acute and chronic
musculskeletal pain syndromes. Chronic pain results from dysfunction of the sensorimotor system, which is manifested in soft tissue and fascia. This new treatment
approach to soft tissue dysfunction combines instrument-assisted soft tissue
mobilization with proprioceptive techniques to reduce pain and return function.
Combining manual treatment of soft tissue with propriceptive exercises produces
faster results than conventional treatment methods.
Tom Hyde, DC, DACBSP
[email protected]
Greg Doerr, DC, CCSP
[email protected]
with contributions from
MANY DC’s and PT’s
Warren Hammer, DC, MS, DABCO
www.faktr.com
www.faktr-pm.com
• What is FAKTR(PM)?
– Functional : treat during function; not just static
– Kinetic: assess & use entire kinetic chain
– Treatment: variety of soft-tissue techniques
– Rehab: incorporate resistance & proprioceptive ex
– Provocation: reproduce pain and treat
– Motion: treat with motion if more painful
2
Introduction
• Brief History
– Developed by Tom Hyde DC and Greg Doerr DC
– Contributed to by PTs and DCs
– Originated from Graston® Technique
– Directly addresses patient complaints of pain and
incorporates movement into treatment
3
Introduction
• 3 Key Components
– Soft Tissue Mobilization
– Movement
– Proprioception
4
Introduction
• 1. Soft Tissue Mobilization
– Purposes
• Mechanical effects: collagen remodeling
• Neural effects: touch, afferent stimulation
• Vascular effects: tissue viscosity
– Types:
• IASTM (Graston, ASTYM, Gua Sha)
• STM, Cross Friction massage
• Cyriax, ART
5
Introduction
• 2. Movement
– Purposes:
•
•
•
•
glide fascia & soft tissue
Incorporate kinetic chains
Initiate proper collagen alignment
Increases afferent stimulation
– Types:
• Active
• Resisted (concentric / eccentric)
• Functional patterns
6
Introduction
• 3. Proprioception
– Purposes:
• Increase afferent input
• Restore motor programs
– Types:
• Skin proprioception
• Joint proprioception
7
Introduction
• Algorithm
– Test
– Treat
– Re-Test / Re-Treat
– Train (Exercises / Adjuncts)
8
Introduction
• 1. Test
– Determine provocative position; rate pain 1-10
– Add active movement (note change in pain)
– Add resistive movement (note change in pain)
– Add functional movement (note change in pain)
– Add proprioception (note change in pain)
9
Introduction
• 2. Treat
– Treat soft tissue in painful position (with or
without motion, resistance or proprioception)
– May also treat areas of reduced ROM or function
– 30 seconds to 2 minutes
10
Introduction
• 3. Re-test / Re-treat
– Reassess provocative position/activity; rate pain 110
– Re-treat up to 3 times
– Continue to move up or down kinetic chain
– Progressively add more complex testing positions
with improvement
11
Introduction
• 4. Train
– Restore muscle balance
– Train movement patterns
– Apply adjuncts (Kinesiotaping, etc)
12
Introduction
• Indications
– Tendinopathies
•
•
•
•
Tennis elbow
Rotator cuff tendinopathy
Achilles tendinopathy
Patella tendinopathy
– Fascial Syndromes
• ITB Syndrome
• Trigger Finger
• Indications
– Entrapment Syndromes
• Carpal Tunnel Syndrome
• Thoracic Outlet Syndrome
– Ligament Pain
• MCL Sprain
• Ankle Sprain
• AC Ligament Sprain
– Scar Tissue / Adhesions
– Edema
13
Introduction
• Clinical Decision Making
–
–
–
–
Use in both assessment and treatment
Perform comprehensive clinical examination
Integrate in treatment ; no protocols or boundaries
If patient improves, then symptoms return, do not
treat more than twice without further assessment, 2nd
opinion, etc.
• Indicates FAKTR may not be appropriate treatment
14
Soft Tissue Techniques
• There are many soft tissue techniques employed
by chiropractors, osteopaths, physical therapists,
medical practitioners, massage therapists,
occupational therapists and others around the
world. All are designed to assist in the treatment
of disorders related to soft tissue lesions.
Various Soft Tissue Techniques
•
• Cross Friction
• Trigger Point
•
• Myofascial Release
•
(MFR)
• Active Release
•
Technique (ART)
• Strain-Counterstrain •
• Post isometric relaxation
(PIR)
•
• Barnes
•
Post facilitation stretch (PFS)
Nimmo
Proprioception Neuromuscular
Facilitation (PNF)
Graston Technique (GT)
Instrument Assisted Soft Tissue
Mobilization (IASTM)
Active Isolated Stretch (AIS)
This represents a partial list
The Kinetic Chain:
• Barker and Briggs
• Thomas Myers Anatomy Trains
• Tensegrity
SUPERFICIAL POSTEROR SPINAL
FASCIAL LAMINA
Barker PJ, Briggs CA.
Attachments of the
Posterior Layer of Lumbar
Fascia. Spine 24
(17):1757-64.
Deep
Posterior
Spinal
Lamina
FUSION OF
SUPERFICIAL
& DEEP
LAMINAE
Barker PJ, Briggs CA. Attachments of the
Posterior Layer of Lumbar Fascia. Spine 24
(17):1757-64.
SERRATUS
POSTERIOR
INFERIOR
GLUTEUS
MEDIUS
SACROTUBEROUS
LIGAMENT
Anatomy Trains
 Myofascial Chains
 Muscular system intimately
linked with fascial system
 Muscle and fascia influence
each other throughout
body
 Skeletal keystones link
muscles via fascia
Chain Reactions
• Anatomy Trains (Superficial Back Line)
Plantar Fascia
Scalp
21
Chain Reactions
• Anatomy Trains (Upper Extremity)
Trapezius
Fingers
22
Anatomy Trains
Upper Part
• Serape Effect
• Santana
Lower Part
• Sling mechanism
• Peronei and tibialis
anterior
Tensegrity
• This refers to structures that maintain their
integrity due primarily to a balance of
continuous tensile forces through the
structure as opposed to leaning on continuous
compressive forces.
•
Thomas Myers – Anatomy Trains
Tensegrity
• Tensegrity structures offer a maximum
amount of strength for a given amount of
material.
•
Thomas Myers – Anatomy Trains
Tensegrity
• Tensegrity structures are characterized by continuous
tension and local compression. They naturally
transmit themselves over the shortest distance
between 2 points, so the members of tensegrity
structures are precisely positioned to best withstand
stress.
•
Thomas Myers – Anatomy Trains
Tensegrity in the Human Body
REHABILITATION TOOLS
29
Rehab Tools
• Resistance Tools
• Balance & Proprioception Tools
• Vibration & Oscillation Tools
30
Rehab Tools
• Resistance
– Isotonic (dumbbells, pulleys, cuff weights, soft
weights)
– Elastic (Thera-Band, loops, tubing, FlexBars)
– Isometric (manual resistance)
– Body Weight
31
Rehab Tools
• Resistance
– Thera-Band
Different Thera-Band colors indicate
progressive resistance with increasing
thicknesses of material
32
Rehab Tools
Thera-Band® Force-Elongation in Pounds
25%
50%
75%
100%
125%
150%
175%
200%
225%
250%
Yellow Red Green Blue Black Silver Gold
1.1
1.5
2
2.8
3.6
5
7.9
1.8
2.6
3.2
4.6
6.3
8.5 13.9
2.4
3.3
4.2
5.9
8.1 11.1 18.1
2.9
3.9
5
7.1
9.7 13.2 21.6
3.4
4.4
5.7
8.1
11 15.2 24.6
3.9
4.9
6.5
9.1 12.3 17.1 27.5
4.3
5.4
7.2 10.1 13.5 18.9 30.3
4.8
5.9
7.9 11.1 14.8
21 33.4
5.3
6.4
8.8 12.1 16.2
23 36.6
5.8
7
9.6 13.3 17.6 25.3 40.1
Page, et al. JOSPT 30(1):A47. 2000.
Rehab Tools
• Resistance
– Thera-Band Eccentrics
• Inherent elastic recoil in elastics make ideal for slow
and controlled eccentric contractions
• Eccentrics are very effective at treating tendinopathies
• Metabolically more efficient than concentric
contractions
• Eccentrics are functional for phasic / gravity-resistance
muscles that are typically weak
34
Rehab Tools
• Eccentric FlexBar for Tennis Elbow
http://info.thera-bandacademy.com/FlexbarElbow
35
Rehab Tools
• Balance & Proprioception
– Sensorimotor System
•
•
•
•
Joint stabilization
Balance
Postural Stability
Core Stabilization
Controlled by
Sensorimotor
System
36
Rehab Tools
• Balance & Proprioception
– Sensorimotor System
• Sensory System : Afferent proprioceptive input
– Joint Mechanoreceptors
– Muscular Receptors
– Exteroceptors
• Motor System: Efferent motor output
– Muscle Facilitation
– Muscle Inhibition
37
Rehab Tools
– Balance & Proprioception
• Labile surfaces ↑ afferent
input,↑ speed of contraction,
↑ motor output
•
•
•
•
•
Stability Trainer
Balance Board
Exercise Ball
Minitrampoline
Balance Sandals
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Arokski et al. 1999
Balogun et al. 1992
Beard et al. 1994
Blackburn et al. 2002
Bullock-Saxton et al. 1993
Clark et al. 2005
Eils et al. 2001
Heitkamp et al. 2001
Ihara & Nakayama 1996
Lanza et al. 2003
Linford et al. 2006
Myers et al 2003
Osborne et al. 2001
Rodd et al. 2002
Vera Garcia et al. 2000
Wise et al. 2001
Rehab Tools
• Balance & Proprioception
– Balance Balls
• Exercise ball bridge position
curl-up compared to stable
surface
• Significantly more (4x)
external oblique activity
• Significantly ↑ lower abs
activity
Vera-Garcia et al. 2000
39
Rehab Tools
• Balance & Proprioception
– Stability Trainers
• 4 levels of progressive challenge
– Foam: Green, Blue
– Air: Black, Silver
– Foam surfaces ↑ EMG 41-57% in
lower leg (Lanza et al. 2003)
© 2008. The Hygenic Corporation
40
Rehab Tools
• Balance &
Proprioception
– BOSU Ball
41
Rehab Tools
• Balance & Proprioception
– FlowIn
42
Rehab Tools
• Balance & Proprioception
– Perfect Push-Up
43
Rehab Tools
• Balance & Proprioception
– Balance Boards
• Neutral stance in different axes of
board while maintaining short foot
• Small movement of board simulates
walking on uneven ground,
stimulating automatic postural
reactions
© 2008. The Hygenic Corporation
44
Rehab Tools
• Balance & Proprioception Research:
– Trunk stabilizers are best activated on
unstable surfaces or with unilateral
resistance exercises
– However, unstable surfaces reduce force
output (up to 70%) which might not be
sufficient stimulus to overload muscle
• Practice:
– Use unstable surfaces for trunk
stabilization, NOT extremity training
– Use light to moderate instability and reduce
© 2008. The Hygenic Corporation
extremity resistance
Behm & Anderson, 2006
Rehab Tools
• Vibration & Oscillation
– Vibration facilitates a vibratory reflex, which
stimulates muscle spindle (Roll et al. 1989; Hagbarth
et al. 1998)
– Popular methods of treatment with mostly
anecdotal evidence
46
Rehab Tools
• Vibration & Oscillation
– I-Joy Board
47
I Joy Board
I Joy Board
49
I Joy Board
50
I Joy Board
51
Rehab Tools
• Vibration & Oscillation
– FlexBar
• 4 progressive levels
– YELLOW
– RED
– GREEN
– BLUE
© 2008. The Hygenic Corporation
52
Rehab Tools
Thera-Band® FlexBar Oscillation (Green)
Page et al. 2004
• Rehab Station
Rehab Tools
Multi-Planar Wall Unit
with Coordinates
Pro Series™ Exercise Balls
Fixed Length Tubing
4 Instructional Posters
Accessories
Stability Trainers
Floor Unit
FAKTR:
Bringing Soft Tissue and Exercise Rehabilitation
together
• Rehab / proprioceptive techniques
• Functional movement patterns utilizing the
kinetic chain
• Movements and/or positions of provocative to
recreate symptoms, referral patterns,
imbalances, instabilities, weaknesses,
functional loss or injuries.
• Performed with many different soft tissue
techniques
Why Dynamic activities during soft tissue
treatments?
Structural/Physiological
• Soft tissue treatments increases fibroblastic
proliferation
• Active motions, functional positioning, and
exercise rehabilitation during the soft tissue
treatment initiate proper alignment of
collagen synthesis and soft tissue remodeling
through fibroblastic activity
Why Dynamic activities during soft tissue
treatments?
• Dynamic activities force fascial planes to move
against each other
• If there is an adhesion preventing proper fascial,
muscle, ligament, soft tissue function why would we
ever treat statically
• We can use dynamic activities to assist us in
separating adhesions with our soft tissue treatment
and promote proper fascial glide
Why Dynamic activities during soft tissue
treatments?
Neurological
• Increased afferent input from joints, muscles, skin,
ligaments
• Sensory gating mechanisms associated with pain
Why Dynamic activities during soft tissue
treatments?
Vascular/Microcirculatory
• Improves viscosity of tissue/extracellular matrix
• Assists in the pumping of edema and metabolites
from injured/sore areas
• Improves blood flow to an area: hyperemia
on Ligaments
INSTRUMENT-ASSISTED CROSS FIBER MASSAGE
ACCELERATES KNEE LIGAMENT HEALING: Dept of
anatomy and cell biology, Indiana University. Loghmani,
MT et al., 2006
• Controlled study: 20 rats underwent surgical bilateral
transection of the MCL.
• 7 days postoperatively GT was used on the left MCL
for one minute 3x per week for 3 weeks.
• Results: “Ligaments treated with IACFM were found
to be 31% stronger and 34% stiffer than untreated
ligaments.”
• Article will appear in JOSPT.
Effect of GT on Ligamentous Healing
20R 506004 4wk untreated 20R PH2
Before Treatment: Irregularly
oriented and diminished amount of
fibroblasts
20L 506004 4wk treated 20L PH2 4wk
treated
The treated appears to have increased
cellularity and more regularly oriented,
elongated fibroblasts.
Graston Technique Instrument-Assisted
Soft Tissue Mobilization (GISTM)
Moderate
Heavy
GISTM
GISTM
pressure
pressure
Increased pressure increased the amount of fibroblasts.
Light GISTM
pressure
Gehlsen, G. M., Ganion L. R., et al. (1999). Fibroblast responses to
variation in soft tissue mobilization pressure." Medicine & Science in
Sports & Exercise, 31(4): 531-5.
on Tendons
Achilles
Tendinosis
Langberg H, et al Eccentric rehabilitation exercise increases peritendinous type I
collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports
2007;17:61-66.
Training Schedule for Chronic Achilles
Tendinosis
• Two times daily for 12 weeks, 3 sets of 15 heel raises
(eccentric)
• Wear a backpack containing 20% of body weight.
• Increase weight as soon as no pain immediately after
training or the next morning.
• Expect pain to increase during first 3-4 weeks. Continue
even if pain persists.
• Continue with sport if pain does not increase.
Langberg H. et al. Eccentric rehabilitation exercise increases peritendinous type I
collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports
17;2007:61-66.
Eccentric Loading for Achilles Tendinosis
Knee
straight
Knee bent
Alfredson H. Chronic midportion achilles tendinopathy: an update on research and
treatment. Clin sports Med 22:4;2003:727-741.
Eccentric Contraction without Concentric
Contraction
PAINFUL ECCENTRIC WRIST FLEXION
2 sets of 15 reps two times per day
Rehab Tools
• Eccentric FlexBar for Tennis Elbow
http://info.therabandacademy.com/FlexbarElbow
79
on Fascia
F.A.K.T.R. ON FASCIA
• Muscle bundles will only elongate to the
extent that their fascial sheath will permit
• Fascial contracture restricts muscular
elongation and joint ROM
• Each muscle spindle is enclosed within fascia
that limits elongation and is thus involved in
neuromuscular function.
Calliet R. ;Hand Pain and Impairment. 4th edition. Philadelphia,
PA: FA Davis Co.; 1994:74.
F.A.K.T.R. ON FASCIA
When a relaxed muscle is physically
stretched, it’s the connective tissue and
sheathing within & around the muscle
that offers resistance.1,2.
1.
Casell C. Tensile force in total striated muscle, isolated fibre and
sarcolemma. Acta Physiol Scand 1950;21:380-401.
2. Ramsey R, Street S. The isometric length-tension diagram of
isolated skeletal muscle fibers of the frog. J Cell Comp Physiol
1940;15:11-34.
MUSCLE
fascicle
fascia
muscle
fiber
epimysium
perimysium
endomysium
myofibril
Thoracolumbar Fascia
Load Transfer: Superficial & deep TLF transmits tension
from the biceps femoris, sacrotuberous ligament,
and gluteus maximus across the sacroiliac joint to
the contralateral latissimus dorsi.
- a pathway is thus provided for an uninterrupted
mechanical transmission between the pelvis and
trunk.
Barker PJ, Briggs CA. Attachments of the posterior layer of lumbar fascia. Spine:17571764:1999.
Langevin’s research on the effect of
acupuncture on soft tissue relates directly to
the effects of Graston Technique®.
• Creates a deformation of the
extracellular matrix
• Changes were shown to occur within 1
minute in the fibroblasts when the
needle was rotated
[1]Langevin HM, Churchill DL, Wu J, Badger GJ et al. Evidence of connective tissue involvement in acupuncture. The FASEB Journal ezpress
article 10.1096/fj.01-0925fje. Published online April 10, 2002.
[2] Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of
acupuncture. The FASEB Journal 15; 2001:2281.
Fibrosis
• “Increased connective tissue stiffness due to fibrosis is
an important link in the pathogenic mechanism leading
to chronicity of pain.”
• Loose connective tissue is the interstitial tissue
fascia that allows normal motion between muscles,
tendons and ligaments.
• Ex: gluteal hip rotator muscles to sacrum and TLF.
Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system
mechanisms. Medical Hypotheses 68 (1),2007:74-84.
Langevin HM, Sherman KJ. Pathophysiological model for chronic low back
pain integrating connective tissue and nervous system mechanisms. Medical
Hypotheses (2006), article in press.
• Langevin and Sherman write that not enough attention has
been paid in the research world to connective tissue in
relation to low back pain, especially the loose connective
tissue and fascia compared with specialized connective
tissues such as cartilage.
• Authors give many examples showing how LOW BACK PAIN
relates to FIBROSIS i.e. repetitive strain, immobilization,
inflammation, altered biomechanics, hypoxia, cytokines, etc
• Authors state that ability to change fibrotic lesion is major
reason techniques exerting mechanical load are successful.
Connective Tissue Healing
in 3-D Matrix
Grinnell F “Fibroblast Mechanics in 3-D Collagen Matrices”
•
As Fibroblasts
Migrate they pull
the disrupted
Extracellular
Matrix
•
This is the
Theoretical Model
for Wound Healing
Connective Tissue Healing
in 3-D Matrix
Grinnell F “Fibroblast Mechanics in 3-D Collagen Matrices”
•
Actual Remodeling
following 1 hour of
migration
•
In a high tension state,
the cell body size of the
fibroblast enlarges and
becomes metabolically
active producing collagen
and ECM
•
In a low tension state,
fibroblasts cell body is
smaller and it is in a
dendritic state with
many interconnections
Nerve Fibers in Fascia
Siegfried Mense, MD
• Dense Network of
Nerve Fibers
• In close association
with vascular tissue
Innervation by layers of TLF
Siegfried Mense, MD
•
90% of all nerve fibers
were located in the
superfical layer of TLF
•
Middle layer
composed of dense
collagen bundles with
few fibers
•
Inner layer was
likewise few nerve
fibers
Types of Fibers found in the TLF
Siegfried Mense, MD
•
Substance P and CGRP
Free nerve endings
were discovered in
abundance in
superficial layers
•
No substance P ending
in the middle layer
Distribution of Nerve Fibers in TLF
Siegfried Mense, MD
•
Greater than 90% in
Superfical Layer
•
Over 40% of nerve fibers
were Sympathetic
EFFERENT endings
•
Effectively leading to a
possible pathway for CNS
mediated event leading to
vasoconstriction and a
change in viscosity of the
TLF
Are Humans Rats?
Siegfried Mense, MD
•
On cross sectional
analysis of Human TLF
the findings of Nerve
Endings in Rat TLF was
found to be of equal
proportions to that of
Human TLF
•
Rat = Human
Neurologic Hypothesis
• Johannson: Gamma/Alpha Loop
• Schleip: Mechanoreceptor stimulation
– Vascular
– Neurologic
– Endocrine
– Fascial smooth muscle cells
• Johansson etal have
proposed it is the gamma
motor neurons that chiefly
influence the alpha system,
through extensive
interconnections in the spinal
cord.
• The sensory afferents from
the skin, ligaments, muscles
and tendons have extensive
interconnections on the
gamma motor neurons in the
cord....not the alpha motor
neurons.
• These soft tissues are constantly
relaying messages to the gamma
motor neurons, which feedback
onto the intrafusal fibers of the
muscle spindles and therefore set
the reaction time of the muscle.
• We stimulate the skin, fascia and
ligaments over a joint and start to
introduce normal motion (FAKTR)
• Creating a barrage of
proprioceptive input that alters
muscle reaction time and "resets"
normal tone in the muscles.
• End Result of FAKTR may not be
the break down of adhesions as
much as proprioceptive reflex on
the gamma-alpha loop
Fascia; “interstitial myofascial receptors”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
• A neuro and vascular cascade of events occur
from soft tissue manipulation
– changes in muscle tone via stimulation of the gamma
motor system.
– Ruffini endings lowers sympathetic tone…affecting
vasodilation
– Type III/IV receptors may stimulate extrusion of
blood plasma from blood vessels into the interstitial
fluid matrix…resulting in a change of extracellular
matrix viscosity.
www.worldofwallpapers.nuche.org
Fascia; “intrafascial circulatory loop”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
Fascia; “interstitial myofascial receptors”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
• It is thought that the interstitial receptors
may affect the hypothalamus resulting in
a “deep and healthy” change of the
global;
– neuromuscular system
– emotional state and
– cortical and endocrine function
• The “Hypothalamus Loop”
Fascia; “the hypothalamus loop”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
Fascia; “the ACTIVE adaptive organ”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
• Yahia etal, 1993 & Chaitow & Delany 2000
describe a “ligament contraction”
– lumbodorsal fascia was discovered to stiffen
(increase its resistance) when held on length
isometrically…similarly to visceral muscle (Price,
1981)
• Electron microscopy by Staubesand and Li 1996
found smooth muscle cells in fascia.
– this work also confirmed findings of an elaborate
network of vascular tissue, autonomic and sensory
endings
Fascia; “fascial contraction loop”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
Fascia; “rationale of short-term plasticity;
summary”
Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003.
Cervical Spine Disorders
FAKTR-PM Cervical Spine
– Posterior Cervical Group
• GT
• Active Isolated Stretch
– Anterior Cervical Group
• GT
• Active Isolated Stretch
– Upper Trap/ Levator
• GT
• Myofascial Release
– TMJ
FAKTR-PM Treatment
•
• Treat in Position of
provocation
– Single plane
– Coupled
• Treat in Motion of provocation
– Single plane
•
– Coupled motions
• Treat with Resistance
– Static
– Motion
– Iso/Concentric/Eccentric
Treat with Functional
positions
– Chin tucks, Heading ball,
etc
– With or without
resistance
Treat with any of the above
with added proprioception
– Oscillation/Vibration
– Unstable surfaces
FAKTR-PM Upper Trap/Levator Scap
CS with Active Isolated Stretch
CS with Active Isolated Stretch
CS with Rotation
FAKTR-PM Occiput
Occiput, Posterior Cranial Muscles
Suboccipital Muscles
Suboccipital
Cervical Spine GT
Cervical GT for Traction
FAKTR-PM Cervical Flexion/Extension
FAKTR-PM Cervical Spine
FAKTR-PM Cervical Spine
FAKTR-PM Cervical Spine
FAKTR-PM Cervical Spine
FAKTR-PM Thoracic Spine
FAKTR-PM Cervicothoracic
FAKTR-PM CS
with Rotation
FAKTR-PM Chin Tuck
FAKTR-PM Algorithm for the Cervical
Spine
• Determine provocative position for the CS if one: treat in this
position
• Add active movement if necessary: treat in motion pattern
(note change in pain)
• Add resistive movement if necessary: treat under load (note
change in pain)
• Add functional movement: treat in sport specific or functional
activity (note change in pain)
• Add proprioception: create unstable environment and treat
(note change in pain)
LUMBAR SPINE
Examination:
• Functional Movements
– Trunk
• Bend
• Twist
• Stabilize
133
Training
• Functional Movement for Spine
Stabilize
Twist
© 2008. The Hygenic Corporation
Bend
FAKTR-PM Lumbar Spine
• Quadratus Lumborum
– GT
– Nimmo
• Erector Spinae
– GT
– Pin and Stretch
• Gluteals/Piriformis
– GT
– Nimmo
• Cross Crawl
• Psoas
– GT
– Cross Friction/ Nimmo
FAKTR-PM Treatment
• Treat in Position of provocation • Treat with Functional
positions
– Single plane
– Any kinetic chain activity
– Coupled
– With or without
• Treat in Motion of provocation
resistance
– Single plane
• Treat with any of the above
– Coupled
with added proprioception
• Treat with Resistance
– Oscillation/Vibration
– Static
– Unstable surfaces
– Motion
– Concentric/Eccentric
FAKTR-PM Lumbar Spine
FAKTR-PM Lumbar Spine
GT Lumbar Spine
GT with Crossed Extension
GT with Ball Extensions
FAKTR-PM LS Standing
FAKTR-PM LS Standing
LS Standing with Resistance
LS Standing with Resistance
FAKTR-PM Seated LS
LS Standing Ball with Alternating
Knee Flexion
LS GT with Ball
GT Lumbar Spine
FAKTR-PM Abdominals
FAKTR-PM Abdominals
FAKTR-PM Abdominals
FAKTR-PM Abdominals
FAKTR-PM Abdominals
FAKTR-PM Psoas
FAKTR-PM Psoas
FAKTR-PM Lumbar Spine
FAKTR-PM Algorithm for the Lumbar
Spine
• Determine provocative position for the LS if one: treat in this
position
• Add active movement if necessary: treat in motion pattern
(note change in pain)
• Add resistive movement if necessary: treat under load (note
change in pain)
• Add functional movement: treat in sport specific or functional
activity (note change in pain)
• Add proprioception: create unstable environment and treat
(note change in pain)
Rotator Cuff Injury
Rotator Cuff Anatomy
•
•
•
•
•
Shoulder Girdle
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Shoulder Girdle
• Bones
–
–
–
–
–
Clavicle
Acromion
Coracoid Process
Glenoid
Humeral Head
• Ligaments/Cartilage
–
–
–
–
–
Coracoclavicular Lig
Coracoacromial Lig
Acromioclavicular Lig
Labrum
Articular Cartilage
Supraspinatus
• Attachment Sites
– Supraspinous Fossa
– Greater Tuberosity
• Nerve Supply
– Surpascapular Nerve
– C4,5,6
• Action
– Shoulder Abduction
– Dynamic stabilizer of the
humeral head in the
glenoid
Supraspinatus
Infraspinatus
• Attachment Sites
– Infraspinatus Fossa
– Greater Tuberosity
• Nerve Supply
– Suprascapular Nerve
– C4,5,6
• Action
– External Rotator of
Humerus
– Dynamic stabilizer of the
humeral head in the
glenoid
Infraspinatus
Teres Minor
• Attachment Sites
– Upper 2/3 of lateral
border of scapula
– Greater Tuberosity
• Nerve Supply
– Axillary Nerve
– C4,5,6
• Action
– Adductor and External
Rotator of humerus
– Dynamic stabilizer of the
humeral head in the
glenoid
Teres Minor
Subscapularis
•
•
•
Attachment Sites
– Medial 2/3 of anterior
surface of scapula
– Lesser Tuberosity, shoulder
joint capsule, humeral shaft,
transverse humeral ligament
Nerve Supply
– Subscapular nerve
– C5,6,7
Action
– Adductor and Internal
Rotator
– Dynamic stabilizer of the
humeral head in the glenoid
Subscapularis
Rotator Cuff Insertions
Clark J et al. Tendons, ligaments, capsule of
the rotator cuff. J Bone Jt. Surg.1992;74A:713-25.
Mechanism of Injury
•
•
•
•
•
•
Tensile Failure of rotator cuff fibers
Poor Scapular Mechanics
Rotator Cuff Imbalance
Anterior Capsular Laxity
Posterior Capsular contracture
Supraspinatus outlet narrowing
Examination:
• Standing
–
–
–
–
–
AROM
MMT: Supra, Biceps, IR & ER,
Ortho: Lift Off
Scapular Mechanics
Shoulder Girdle Testing
• Seated:
– Ortho: Hawkin’s, Impingement, AC Add, O’Brien’s, Ant Shift
– Labral Tests
• Supine:
– PROM
– Labral Tests
– Relocation
• Functional: Push, Pull, Reach, Press Down
Examination:
• Functional Movements
– Upper Body
•
•
•
•
Push
Pull
Reach
Press Down
169
Training:
• Functional Movements for Upper Body
Pull
Press
Push
© 2008. The Hygenic Corporation
Lift
FAKTR-PM Treatment
using individual muscles
SEATED
•
Deltoid
–
–
•
Supraspinatus
–
–
•
•
•
–
–
–
–
–
Prone
•
Lat
GT
NIMMO
•
GT
NIMMO
Pin and Stretch
GT
Myofascial Release (Axilla)
Serratus Anterior
GT
Cross Friction (tendon)
Myofascial Release (Axilla)
Scapular Stabilizers
GT
Myofascial Release
Subscapularis
–
–
–
–
Infraspinatus/Teres Minor
–
–
•
•
GT
Pin and Stretch
Subscapularis/Axillary Fascia
–
–
–
–
–
GT
Cross Friction
Biceps
–
–
•
GT
NIMMO
SUPINE
•
Pectoralis Major
GT
Myofascial Release
GT
Myofascial Release
Triceps
–
–
GT
Cross Friction
FAKTR-PM Treatment
• Treat in Position of
provocation
– Single plane
– Coupled
• Treat in Motion of
provocation
– Painful arch
• Treat with Resistance
– Static
– Motion
– Iso/Concentric/Eccentric
• Treat with Functional
positions
– Throwing position
– With or without
resistance
• Treat with any of the above
with added proprioception
– Oscillation/Vibration
– Unstable surfaces
FAKTR-PM Deltoid
Isometric Supraspinatus
Subacromial Space
FAKTR-PM Biceps
FAKTR-PM Biceps
FAKTR-PM Posterior Rotator Cuff
FAKTR-PM Subscap
FAKTR-PM Serratus
FAKTR-PM Scapular Stabilizers
FAKTR-PM Scapular Stabilizers
FAKTR-PM Scapular Stabilizers
FAKTR-PM Scapular Stabilizers
Scapular Mobilization
Scapular Mobilization
FAKTR-PM Lat
FAKTR-PM Pec
FAKTR-PM Shoulder
Rehab Tools
Thera-Band® FlexBar Oscillation (Green)
Page et al. 2004
FAKTR-PM Algorithm for Shoulder
• Determine provocative position for the shoulder if one: treat in
this position
• Add active movement if necessary: treat in motion pattern (note
change in pain)
• Add resistive movement if necessary: treat under load (note
change in pain)
• Add functional movement: treat in sport specific or functional
activity (note change in pain)
• Add proprioception: create unstable environment and treat (note
change in pain)
191
Knee Disorders
Examination:
• Functional Movements
– Lower Body
•
•
•
•
Step
Lunge
Squat
Press
193
Training
• Functional Movement for Lower Body
Lunge
© 2008. The Hygenic Corporation
Squat
FAKTR-PM Treatment
• Quadriceps
•
•
•
•
•
•
•
•
•
•
Hamstrings
Pes Anserine
Coronary Ligaments
Infra/Supra Patella Ligaments
MCL/LCL
ITB
Meniscus
Patella
Plicae
Gastrocsoleus
FAKTR-PM Treatment
• Treat in Position of provocation
– Single plane
– Coupled
• Treat in Motion of provocation
– Flex/Extension
– Open chain/Closed chain
• Treat with Resistance
– Static open/closed chain
– Motion open/closed chain
– Concentric/Eccentric
• Treat with Functional
positions
– Squating, bike, lunge,
kicking
– With or without resistance
• Treat with any of the above
with added proprioception
– Oscillation/Vibration
– Unstable surfaces
Quadriceps
FAKTR-PM Quad
FAKTR-PM Quad, Patellar Tendon, ITB,
ADDuctors, Hamstring
FAKTR-PM Patellar Tendonopathy
FAKTR-PM Quad
FAKTR-PM ITB
Hamstring Insertion
Hamstring Insertion
Gastrocsoleus w/wo
Resistance
FAKTR-PM Gastroc
FAKTR-PM Gastroc
FAKTR-PM Hamstrings
FAKTR-PM Hamstring
FAKTR-PM Hamstring
FAKTR-PM Algorithm for the Knee
• Determine provocative position for the knee if one: treat
in this position
• Add active movement if necessary: treat in motion
pattern (note change in pain)
• Add resistive movement if necessary: treat under load
(note change in pain)
• Add functional movement: treat in sport specific or
functional activity (note change in pain)
• Add proprioception: create unstable environment and
treat (note change in pain)