Download Chiropractic Treatment Profiles - 2003

Printed cover ex (Converted)-2 23/01/2003 10:36 Page 1
Chiropractic Treatment
Profiles 2003
Composite
Contents
Introduction
3
Section One
Code
N131.
N142.
N143.
S561.
S570.
S571.
S572.
S574.
N12C0
N12C1
N12C2
XaO6Y
Identifier
Cervicalgia - Chronic/Recurrent Neck Pain
Low Back Pain, Acute Back Pain Lumbar, Lumbago
Sciatica
Sprain SI Joints
Sprain Cervical Spine
Sprain Thoracic Spine
Sprain Lumbar Spine
Sprain Coccyx
Cervical Disc Prolapse
Thoracic Disc Prolapse
Lumbar Disc Prolapse
Whiplash
Range
10 – 16
14
14
14
10 – 16
8
14
8
16 – 20
10 – 16
16 – 24
15
Trigger
18
18
18
18
16
12
18
12
20
16
24
18
Page
5
9
13
15
19
23
25
29
31
33
35
37
Range
12
10
8
10
12
10
10
10
12
12
12
8
10
10
10
12
10
10
12
Trigger
14
14
12
12
16
16
12
12
14
14
12
12
14
14
14
16
14
14
16
Page
39
41
45
47
49
51
53
55
57
59
61
63
65
67
69
71
75
77
81
6
8
Section Two
Code
S460.
S461.
S50..
S500.
S503.
S504.
S507.
S51..
S52..
S522.
S523.
S53..
S533.
S540.
S541.
S542.
S54x1
S550.
S5504
S5512/3
Identifier
Meniscal Tear Medial
Meniscal Tear Lateral
Sprain Upper Arm/Shoulder
Sprain Acromio-Clavicular Ligament
Sprain Infraspinatus Tendon
Sprain Rotator Cuff
Shoulder Joint Sprain
Sprain Elbow/Forearm
Sprain Wrist/Hand
Sprain Thumb
Sprain Finger
Sprain Hip/Thigh
Sprain Quadriceps Tendon
Sprain Lateral Collateral Ligament Knee
Sprain Medial Collateral Ligament Knee
Sprain Cruciate Ligament Knee
Sprain Gastrocnemius
Sprain Ankle
Sprain Achilles Tendon
Sprain Metatarso-Phalangeal Joint/
Interphalangeal Joint
Contents
Printed Body ex Format
85
Chiropractic Treatment Profiles – 2003
1
23/01/2003, 10:09
1
Contents
Code
S5y3.
F340.
N211.
N2131
N2132
N2174
N22..
2
Identifier
Sprain Rib Cage
Carpal Tunnel Syndrome
Rotator Cuff Syndrome
Medial Epicondylitis (Elbow)
Lateral Epicondylitis (Elbow)
Tendonitis Achilles
Tenosynovitis/Synovitis Upper/Lower Limb
Range
6
12
12 – 16
12
12
12
16
Contents
Printed Body ex Format
Trigger
10
16
18
14
16
16
16
Page
87
89
91
95
97
99
103
Chiropractic Treatment Profiles – 2003
2
23/01/2003, 10:09
Introduction
The Chiropractic Treatment Profiles 2003 have been developed by the New
Zealand Chiropractors’ Association as a joint initiative with ACC.
These Treatment Profiles are published in two sections. Section One features
treatment profiles for vertebral injury. ACC-registered chiropractors who treat
a vertebral injury listed in this section may be eligible for payment by ACC.
Section Two features treatment profiles for extra-vertebral injuries. At the
time of going to print, ACC does not pay chiropractors for treatment related
to non-vertebral injuries.
The profiles are a consensus of opinion as to what is considered appropriate
and common current practice.
The profiles are to help encourage common accepted standards and should be
seen as a step to developing evidence-based best practice guidelines.
The Read codes relate to a specific diagnosis that has no complications and
has been referred for, or has accessed, chiropractic treatment at an early
appropriate stage in the healing process. It is accepted that conditions that are
more complicated may differ from the treatment description and differ from
the average number of treatments suggested by the profiles.
There is acknowledgement that some of the Read codes are general in nature.
Some specific Read codes have had descriptions added to them to aid in the
interpretations. In particular, N12C of Disc Prolapse and Radiculopathy has
been broken up into Cervical, Thoracic and Lumbar regions.
Some profiles cover a number of Read codes as the treatment given is the
same for each condition.
Number of Treatments
Treatment numbers stated in this document relate to a specific diagnosis
without complications, which has been referred for treatment at an
appropriate stage in the healing process.
The numbers have not been developed as evidence-based practice guidelines,
but rather to provide a consensus on acceptable treatment ranges.
Trigger Numbers
Trigger numbers indicate the number of treatments after which ACC would
appropriately seek a review of the services that have been provided.
Any treatment provided for a particular individual will be considered in
consultation with the provider chiropractor. The trigger number is the
appropriate time for a case manager to approach the chiropractic provider
and consider requesting a review by an assessor.
Key Points
Some profiles have had this section added to act as a rider to more clearly
define the particular condition.
Special Considerations
This section highlights special concerns that need to be considered when
treating this condition.
History
This section gives a general overview of the significant factors that should be
considered in the history of each condition.
Introduction
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
3
23/01/2003, 10:09
3
Introduction
Examination
This section outlines the main components that should be undertaken in a
normal examination. This is not an exhaustive list and clinicians may have
other investigations that they would routinely take into account. Generally
the examination would cover subjective and objective examination
procedures which would include most of the following:
•
•
•
•
•
•
•
Observation
Active movement testing
Passive movement testing
Accessory movement testing
Palpation
Muscle tests
Functional tests
Differential Diagnosis
This section outlines the major conditions that should be considered when
making a provisional diagnosis and also serves to outline what conditions are
not being considered in the profile. This is not an exhaustive list and
clinicians are encouraged to seek second opinions on conditions that seem
unusual.
Complications
This section gives clinicians some examples that may hinder the recovery
time of a patient or move the patient outside the scope of these
‘uncomplicated’ injury profiles and would then require the appropriate
referral action.
Treatment Rehabilitation
This section is divided up into two sub sections, acute and sub-acute. Within
the literature there is great variation as to when a condition moves from being
acute to chronic. For the purposes of these profiles acute has been described
as within the first 10 to 14 days of an injury occurring, or post surgical
intervention. Sub-acute is considered any time after this.
Onward Referral
This section gives the appropriate referral that should be considered if the
patient’s condition causes concern to the treatment provider.
• Radiographic referral is a general term used that would include all
appropriate imaging techniques
• GP referral may be for medication or further testing and consideration
• Specialist referral would be to the medical/surgical speciality that the
condition requires
• Chiropractors in general are encouraged to refer on to recognised
specialists or assessors within the profession for a second opinion for more
complex cases
4
Introduction
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
4
23/01/2003, 10:09
Printed cover ex (Converted)-2 23/01/2003 10:37 Page 2
Section 1
Composite
Cervicalgia
(Chronic/Recurrent Neck Pain)
Read Code:
N131.
Number of treatments: 10–16
Triggers:
18
KEY POINTS
• An accurate clinical history is necessary
• Identify the need for any further treatment or examinations
• The cervical spine is treated differently from the lumbar spine
• Traumatic causes may include “whiplash” (treated in a separate protocol)
• Exacerbations and remissions are common
• Cervical spine injuries can lead to varied symptoms – dizziness, blurred
vision, tinnitus, chest pain, nausea, dysphagia, headache, loss of balance,
loss of consciousness
Special considerations
• Screen for possible VBI
• Instability
History
• Record the nature and mechanism of the injury – gradual or acute onset
• Pain and injury location
• Previous history and response to treatment
• Differentiate acute from chronic
• Red and Yellow Flags
• Non-traumatic aetiology may include DJD, osteophyte formation,
discopathy, trauma
• Review sports and occupational activities
• Obtain an accurate history including the site and nature and behaviour of
pain and any aggravating or relieving factors
• Prescribed and self medication
• Include current and past illnesses
Examination
• Diagnostic triage
• Psychological barriers to recovery
• Goals for the examination:
– obtain a baseline for the level of function and activity
– alleviate uncertainty about the regional nature of neck pain
– exclude neurological catastrophe
• Posture
• ROM – cervical spine, shoulder girdle
• Palpation of joints and muscles – temperature, spasm, pain
• Neurological (if applicable)
• VBI provocative tests
Differential diagnosis
• DJD of facets/disc
• Lateral canal stenosis
• Myofascial trigger points/pain syndrome
• Fracture
Cervicalgia (Chronic/Recurrent Neck Pain) N131.
Printed Body ex Format
5
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
5
Cervicalgia
(Chronic/Recurrent Neck Pain)
•
•
•
•
•
•
•
•
•
•
•
Facet trophism
TOS
IVF encroachment
Non-traumatic onset/pathology
Referred pattern from cardiac, gallbladder, Pancoast tumour
Exclude vertebral artery, fracture, increased ADI, inflammatory arthritides
Chronic neck pain (requires different management)
Referred dental pain
Temporo-mandibular joint dysfunction
Peripheral nerve lesion
Instability, eg acute inflammatory arthritides, increased ADI, hypermobility
syndromes
• Osteoporosis
Investigations
• X-ray – standard 3-view and obliques if necessary
• Refer for full blood count and ESR/CRP if signs or symptoms of serious
disease are present (Red Flags) – spinal cord injury, weight loss, history of
cancer, fever, intravenous drug use, steroid use, immunosuppression, age
>50 years or <20 years, severe, unremitting night-time pain
• Widespread neurological symptoms
• Structural deformity
• Psychological barriers to recovery – use a questionnaire
Complications
• Trauma upon pre-existing injury or degeneration
• Chronic neck pain (which should not be treated as if it were acute or
recurrent neck pain)
• Radiculopathy
• Instability
• Fracture
• Osteoporosis
• VBI
• Inflammatory disease
Treatment/Rehabilitation/Management
• Shift from passive to rehabilitative/restoration of function as soon as
possible
Acute:
• Ice and gentle mobilisation tx, manipulation/adjustment
• Provide an explanation, reassurance, advice on staying active
• If bed rest, no longer than 3 days
• Manipulation after the acute phase (if any neuro deficits are present use
the N12CO protocol)
• Modify ADLs
• Analgesics (such as paracetamol and NSAIDs) or consider conventional
(NSAIDs or paracetamol) or natural medication for muscle spasm,
inflammation and tissue healing. Refer for pain control if necessary
6
Cervicalgia (Chronic/Recurrent Neck Pain) N131.
Printed Body ex Format
6
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
Cervicalgia
(Chronic/Recurrent Neck Pain)
Sub-acute:
• Moist hot packs/wheat sacks for home use
• Myofascial tx
• Trigger point therapy
• Isometric exercises
Home care:
• Cervical collar in severe cases for first 2 weeks only
• Care with lifting over 5 kilograms
• Adequate sleep – refer for medication if necessary
• May swim backstroke in the first month for rehabilitation
• ADL review and management
• Home exercises for self management
• Review ergonomic factors including postural and sleeping habits
• Patients who have not returned to normal ADL and failed to respond to
treatment require referral. Consider psychosocial factors
Referral
• Refer to GP for:
– TOW
– pain control
– lack of progress
– Red Flag investigations
– other
• Refer to radiographer if no X-ray facilities in office
• Refer to occupational therapist for OSH/workplace review (consult with
ACC case manager)
Cervicalgia (Chronic/Recurrent Neck Pain) N131.
Printed Body ex Format
7
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
7
8
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
8
23/01/2003, 10:09
Low Back Pain (Low Back Pain,
Acute Lumbar Pain, Lumbago)
Read Code:
N142.
RED FLAG:
For potentially serious conditions:
Number of treatments: 14
Triggers:
18
Features of Cauda Equina syndrome
(especially urinary retention,
KEY POINTS
• A good case history greatly helps in determining the need for further
investigation
• Psychosocial factors strongly influence chronic LBP
• There is usually no pain below the knee
• Refer to sciatic protocols if there is pain below the knee
bilateral neurological symptoms and
signs, saddle anaesthesia) – this
requires very urgent referral
Significant trauma
Weight loss
History of cancer
Special considerations
• Previous episode of LBP
• Age
• Regional pain syndrome
• Keeping mobile helps in recovery
Fever
History
• Identify any Red/Yellow Flags and Blue/Black Flags where possible:
– Black Flags require possible OSH review
– Blue Flags should be considered throughout treatment
• Mechanism of injury – chronic trauma, micro trauma, increased weight
bearing (obesity), degenerative changes, faulty posture
• Contributing factors include leg length inequality, muscle imbalance,
excessive foot pronation
• Other factors – disc, facet, sacroiliac, stenosis, spondylolisthesis,
acetabulum
• Onset history – insidious, sudden, trauma
• Better/worse and provoking factors
• Pain type and distribution
• Previous history and management
• Current management including investigations
• Determine any change to activity and ADLs
• Significant trauma
• Use an outcomes measurement where appropriate
• Determine progress goals
Pain that gets worse when patient is
Intravenous drug use
Steroid use
Patient aged over 50 years
Severe, unremitting night-time pain
lying down
YELLOW FLAG:
Psychosocial factors that increase the
risk of developing or perpetuating longterm disability and work loss
associated with low back pain:
Attitudes and beliefs about back pain
Behaviours
Compensation issues
Diagnostic and treatment issues
Emotions
Family
Work
Examination
• Exclude neurological complications
• Posture – including scoliosis
• Palpation – spasm, tenderness, joint fixation
• ROM and pain response
• Test to appraise IVD, mechanical LBP, sprain, SI lesion, myofascitis,
sciatica, Red Flags including fracture
• Lower extremity pulses
• Most orthopaedic tests are benign
Low Back Pain (Low Back Pain, Acute Lumbar Pain, Lumbago) N142.
Printed Body ex Format
9
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
9
Low Back Pain (Low Back Pain,
Acute Lumbar Pain, Lumbago)
Differential diagnosis
• Nerve root pain/radiation
• Red Flags
• Cauda Equina syndrome – requires immediate referral
• Chronic LBP
• Facet syndrome with pain referred to groin
• Myofascial pain syndrome
• Contributing structural factors – spondylolisthesis, pseudoarthroses, facet
trophism etc
• Muscle tears in hamstring
• Hip, SI
• Lumbar instability
Investigations
• If pain remains after 1 month, consider further investigation – X-ray
• If X-raying in the first 4 weeks, document the rationale
• If Red Flags are present, refer for further investigation (CBC, ESR/CRP)
Complications
• Secondary gain
• Stenosis
• Neurological involvement
• Chronic LBP or history of repetitive injury
• Underlying pathology
• The work/home environment, including stress
Treatment/Rehabilitation/Management
Acute:
• Encourage and advise to remain mobile
• Explain the nature of lower back pain (LBP) to reassure and allay fears of
incapacity
• Pain management
• Bed rest – encourage a rest and walk routine
• Manipulation/adjustment
• Mobilisation
• Exercises to tolerance
• Short-term support
• ADL advice
Sub-acute:
• Pain management
• Ergonomic advice for at home/work, lifting, sitting, sleeping etc
• Continue advice on maintaining mobility and modified ADLs
• Exercises for centralisation, strength, stabilisation and mobility
• Encourage self management
Chronic:
• Psychosocial assessment – use a questionnaire
• When treatment is ongoing, review and document progress regularly
• If the patients needs supportive care, provide adequate documentation and
a treatment plan
10
Low Back Pain (Low Back Pain, Acute Lumbar Pain, Lumbago) N142.
Printed Body ex Format
10
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
Low Back Pain (Low Back Pain,
Acute Lumbar Pain, Lumbago)
•
•
•
•
•
Self management
Goal setting and review from history
Use outcome measurements regularly to determine MCI or MMI
Management plan for residuals
Approximate expected healing periods are:
– mild strain – 7-10 days
– moderate strain – 2-4 weeks
– mild sprain – 1-4 weeks
– moderate sprain – 1-12 months
• Severe strains/sprains may require surgical intervention
Referral
• Refer to GP:
– for TOW
– for Cauda Equina syndrome
– for spinal pathology
– for nerve root pain that has failed to improve after 4 weeks
– for home help if necessary – may also involve case manager
– if Yellow Flags dominate or affect return to work, requiring psychologist
or vocational management
• Refer to occupational therapist for OSH review
• Refer to X-ray if not available on-site
• Liaise with the patient’s employer
Low Back Pain (Low Back Pain, Acute Lumbar Pain, Lumbago) N142.
Printed Body ex Format
11
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
11
12
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
12
23/01/2003, 10:09
Sciatica
Read Code:
N143.
RED FLAG:
For potentially serious conditions:
Number of treatments: 14
Triggers:
18
Features of Cauda Equina syndrome
(especially urinary retention,
KEY POINTS
• Sciatica is most frequently caused by IVD derangement
• It may be unilateral or bilateral
• Traction is contraindicated during the acute phase
• Prolonged bed rest may cause extended recovery and rehabilitation
bilateral neurological symptoms and
signs, saddle anaesthesia) – this
requires very urgent referral
Significant trauma
Weight loss
Special considerations
• Multiple aetiological factors can be involved
History of cancer
Fever
Intravenous drug use
History
• Peripheral nerve compression
• IVD herniation
• DJD
• Traumatic injury
• Fracture
• Lower back strain
• Sacroiliac joint
• Piriformis syndrome
• Stenosis
• Spinal or visceral pathology
• Prior history
Steroid use
Patient aged over 50 years
Severe, unremitting night-time pain
Pain that gets worse when patient is
lying down
YELLOW FLAG:
Psychosocial factors that increase the
risk of developing or perpetuating longterm disability and work loss
associated with low back pain:
Examination
• Examination depends upon the case history
• IVD signs
• Piriformis spasm/syndrome
• SLR, Bragards, Bechterew, Lasegue, Well leg raise
• Neurological evaluation (sensory, motor and DTRs)
• Palpation of popliteal fossa and gluteals
• Antalgic gait
• Weight bearing
Attitudes and beliefs about back pain
Behaviours
Compensation issues
Diagnostic and treatment issues
Emotions
Family
Work
Differential diagnosis
• Vascular
• Cellulitis
• Fracture
• Spinal pathology
• Myofascial pain syndrome
Investigations
• X-ray if you are uncertain of aetiology or possible contributing factors
• CT scan or MRI, nerve conduction studies (via referral)
Sciatica N143.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
13
23/01/2003, 10:09
13
Sciatica
Complications
• Manipulation while joint effusion/inflammation is present
Treatment/Rehabilitation/Management
Acute:
• Ice packs to promote vasoconstriction
• Pain assistance
• Bed rest – no longer than 3-5 days
• Lumbar traction
• Lumbar support if necessary
• Stretching and ROM exercises within pain-free ROM
Sub-acute:
• Manipulation
• Moist heat
• Trigger point
• Myofascial release
• Massage
• Spray and stretch
• Exercises – stretch, strengthening of lower back, trunk and hamstrings
• Patient education about lifting
Referral
• Refer to GP for:
– TOW
– pain assistance
– further imaging referral
• Refer to physiotherapist for TENS, other forms of electrical stimulation,
lumbar traction, acupuncture
14
Sciatica N143.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
14
23/01/2003, 10:09
Sprain Sacroiliac Joints
Read Code:
S561.
Number of treatments: 14
Triggers:
18
KEY POINTS
• Psychosocial factors may influence recovery
• There is usually no pain below the knee
• Refer to sciatic protocols if there is pain below the knee
• A good case history is important
Special considerations
• Any previous episodes
• The patient’s age
• Regional pain syndrome
• Keeping mobile helps in recovery
• Manipulation is contraindicated if there is joint effusion or active joint
inflammation
History
• Identify any Red/Yellow Flags, and Blue/Black Flags where possible:
– Black Flags require possible OSH review
– Blue Flags should be considered throughout any treatment
• Work or sport injury
• Contributing factors can be leg length inequality, muscle imbalance or
excessive foot pronation
• Better/worse and provoking factors
• Pain type and distribution
• Previous history and management
• Current management, including investigations
• Any change to activity and ADLs
• Significant trauma
• Use an outcomes measurement where appropriate
• Determine the progress goals
• History may include immediate and transitory pain, followed by pain-free
intervals
• The condition usually presents with stiffness, decreased mobility and
muscle spasm, with variable pain increasing on muscle resistance
• The patient may have difficulty arising from supine or seated positions
Examination
• Exclude neurological complications
• Posture – antalgia
• Gait
• Palpation – spasm, tenderness and joint fixation
• ROM and pain response in active and passive modes
• Test to appraise IVD, mechanical LBP, sprain, SI lesion, myofascitis,
sciatica, Red Flags including fracture
• Lower extremity pulses
• Most orthopaedic tests are benign
• The patient may have reversal of lordosis owing to multifidus spasm
Sprain Sacroiliac Joints S561.
Printed Body ex Format
15
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
15
Sprain Sacroiliac Joints
Differential diagnosis
• Nerve root pain/radiation
• Red Flags
• Cauda Equina syndrome – requires immediate referral
• Exacerbation of chronic LBP
• Facet syndrome with pain referred to groin
• Myofascial pain syndrome
• Inflammatory diseases, eg AS
• Contributing structural factors – spondylolisthesis, pseudoarthroses, facet
trophism etc
• Muscle tears in hamstring
• Hip
• Lumbar instability
• Metastatic lesions
• Facet trophism
Investigations
• If pain remains after 1 month, consider further investigation – X-ray
• If X-raying within the first 4 weeks, document the rationale
• If Red Flags are present, refer for further investigation (CBC, ESR/CRP)
Complications
• Secondary gain
• Stenosis
• Neurological involvement
• Chronic LBP or history of repetitive injury
• Underlying pathology
• Work/home environment, including stress
Treatment/Rehabilitation/Management
Acute:
• Encourage and advise the patient to remain mobile
• Explain the nature of lower back sprain to reassure and allay fears of
incapacity
• Pain management
• Manipulation
• Mobilisation
• Exercises to tolerance
• Short-term SIJ or lumbar support
• ADL advice
• Home care advice
Sub-acute:
• Pain management
• Ergonomic advice for when at home/work, lifting, sitting, sleeping etc
• Continue advice on maintaining mobility and modified ADLs
• Exercises for centralisation, strength, stabilisation and mobility
• Encourage self management
• Approximate healing periods are:
– mild strain – 7-10 days
– moderate strain – 2-4 weeks
16
Sprain Sacroiliac Joints S561.
Printed Body ex Format
16
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
Sprain Sacroiliac Joints
– mild sprain – 1-4 weeks
– moderate sprain – 1-12 months
• Severe strains or sprains may require surgical intervention
Referral
• Refer to GP for:
– TOW
– Cauda Equina syndrome
– spinal pathology
– nerve root pain that has failed to improve after 4 weeks
– home help if necessary (you may also need to involve the patient’s ACC
case manager)
– if Yellow Flags dominate or affect return to work, requiring a
psychologist or vocational management
• Refer to occupational therapist for OSH review
• Refer to physiotherapist for TENS, other forms of electrical stimulation,
lumbar traction, acupuncture
• Refer to X-ray if not available on-site
• Liaise with the patient’s employer
Sprain Sacroiliac Joints S561.
Printed Body ex Format
17
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
17
18
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
18
23/01/2003, 10:09
Sprain/Strain Cervical Spine
Read Code:
S570.
Number of treatments: 10–16
Triggers:
16
KEY POINTS
• Cervical sprain/strain includes soft tissue injury
• Whiplash is covered under a separate protocol
• An accurate clinical history is necessary
• Identify the need for any further treatment or examinations
• Cervical spine injuries can lead to varied symptoms – dizziness, blurred
vision, tinnitus, chest pain, nausea, dysphagia, headache, loss of balance,
loss of consciousness
Special considerations
• Screen for possible VBI
• Instability
History
• Record the nature and mechanism of injury – gradual or acute onset
• Pain and injury location
• Previous history of cervical injury/treatment and response
• Differentiate between acute and chronic
• Red Flags
• Yellow Flags if apparent
• Underlying cervical conditions that may complicate recovery may include
DJD, osteophyte formation, discopathy, trauma
• Review sports and occupational activities, including ADL changes
• Obtain an accurate history including the site and nature and behaviour of
pain and any aggravating or relieving factors
• Prescribed and self medication
• Include current and past illnesses
Examination
• Examine as cervicalgia
• O’Donoghue manoeuvre, Rust’s sign, Soto-Hall sign
• Use a cervical screen/algorithm if signs are unclear
• Myofascial trigger points/pain syndrome
Differential diagnosis
• DJD of facets/disc
• Lateral canal stenosis
• Fracture
• Facet trophism
• TOS
• IVF encroachment
• Non-traumatic onset/pathology
• Referred pattern from cardiac, gallbladder, Pancoast tumour
• Exclude vertebral artery, fracture, increased ADI, inflammatory arthritides
• Chronic neck pain (requires different management)
Sprain/Strain Cervical Spine S570.
Printed Body ex Format
19
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:09
19
Sprain/Strain Cervical Spine
•
•
•
•
Referred dental pain
Tempro-mandibular joint dysfunction
Peripheral nerve lesion
Instability, eg acute inflammatory arthritides, increased ADI, hypermobility
syndromes
• Osteoporosis
Investigations
• X-ray – standard 3-view and obliques if necessary
• Refer for full blood count and ESR/CRP if signs or symptoms of serious
disease are present (Red Flags) – spinal cord injury, weight loss, history of
cancer, fever, intravenous drug use, steroid use, immunosuppression, age
>50 years or <20 years, severe, unremitting night-time pain
• Widespread neurological symptoms
• Structural deformity
• Psychological barriers to recovery – use a questionnaire
Complications
• Trauma upon pre-existing injury or degeneration
• Chronic neck pain (should not be treated as if it were acute or recurrent
neck pain)
• Radiculopathy
• Instability
• Fracture
• Osteoporosis
• VBI
• Inflammatory disease, eg ankylosing spondolysis, RA
Treatment/Rehabilitation/Management
• Shift from passive to rehabilitative/restoration of function as soon as
possible
Acute:
• Ice and gentle mobilisation tx and manipulation
• Provide an explanation, reassurance and advice on staying active
• If bed rest, no more than 3 days
• Manipulation after the acute phase (if there are any neuro deficits present,
use N12CO protocol)
• Modify ADLs
• Analgesics (such as paracetamol and NSAIDs) or consider conventional
(NSAIDs or paracetamol) or natural medication for muscle spasm,
inflammation and tissue healing. Refer for pain control if necessary
Sub-acute:
• Moist hot packs/wheat sacks for home use
• Myofascial tx
• Trigger point therapy
• Isometric exercises
• Continued manipulation as required
20
Sprain/Strain Cervical Spine S570.
Printed Body ex Format
20
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Sprain/Strain Cervical Spine
Home care:
• Cervical collar in severe cases for the first 2 weeks only
• Care with lifting over 5 kilograms
• Adequate sleep – refer for medication if necessary
• May swim backstroke in the first month for rehabilitation
• ADL review and management
• Home exercises for self management
• Review ergonomic factors including postural and sleeping habits
• Patients who have not returned to normal ADL and failed to respond to
treatment require referral. Consider psychosocial factors
Referral
• Refer to GP for pain control, lack of progress, Red Flag investigations
• Refer to occupational therapist for OSH/workplace review (consult with
ACC case manager )
• Refer to physiotherapist for TENS or other forms of electrical stimulation,
acupuncture
• Refer to X-ray if not available on-site
Sprain/Strain Cervical Spine S570.
Printed Body ex Format
21
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
21
22
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
22
23/01/2003, 10:10
Sprain/Strain Thoracic Spine
Read Code:
S571.
Number of treatments: 8
Triggers:
12
KEY POINTS
• If direct trauma or pathology is excluded, thoracic pain is frequently the
result of postural changes
Special considerations
• Age
• History of thoracic pain/conditions
History
• Record the nature and mechanism of injury – direct blow/fall
• Gradual/Acute onset
• Pain and injury location
• Previous history of thoracic injury, treatment and response
• Differentiate acute from chronic
• Red Flags – drug use, alcohol abuse, corticosteroid use, diabetes, direct
trauma, cancer, infection
• Yellow Flags if apparent
• Underlying thoracic conditions that may complicate recovery include DJD
and osteoporosis
• Review sports and occupational activities including ADL changes
• Obtain an accurate history including the site and nature and behaviour of
pain, and aggravating and relieving factors
• Prescribed and self medication
• History should include current and past illnesses including Scheurmann’s
• If >70 years consider compression fracture
Examination
• Postural
• ROM – active and passive
• Deformity
• Trauma
• Skin lesions – herpes, skin cancer
• Palpation and percussion
• Differentiate stiffness from loss of ROM
Differential diagnosis
• Scheurmann’s in teenagers
• Cushing’s syndrome
• Cardiac
• Compression fracture
• Chance fracture
• Ankylosing spondylosis
• Rib fracture
Sprain/Strain Thoracic Spine S571.
Printed Body ex Format
23
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
23
Sprain/Strain Thoracic Spine
Investigations
• X-ray – AP and lateral views
• Oblique views to evaluate ribs for fracture, vertebral bodies for trauma to
ring apophyses
• MRI, bone scans and tomograms are usually reserved for spinal infection,
tumour, such as metastases and osteoid osteomas, and the rare disc
herniation
Complications
• Infection
• Primary bone tumour
Treatment/Rehabilitation/Management
Acute:
• Mobilisation
• Manipulation
• Palliative techniques
• Exercise
Sub-acute:
• Workstation review for desk workers with chronic pain
• Long-term control with exercise if posture implicated
Referral
• Refer to GP for:
– TOW
– unstable fracture infection, primary tumour/metastasis
– specialist – severe or rapidly progressing scoliosis
– complications owing to corticosteroid use
– pain control
• Refer to physiotherapist for TENS or other forms of electrical stimulation,
acupuncture
• Refer to occupational therapist for workstation evaluation (consult with
ACC case manager)
24
Sprain/Strain Thoracic Spine S571.
Printed Body ex Format
24
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Sprain Lumbar Spine
Read Code:
S572.
RED FLAG:
For potentially serious conditions:
Number of treatments: 14
Triggers:
18
Features of Cauda Equina syndrome
(especially urinary retention,
KEY POINTS
• Psychosocial factors may influence recovery
• There is usually no pain below the knee
• Refer to sciatic protocols if there is pain below the knee
• A good case history is important
bilateral neurological symptoms and
signs, saddle anaesthesia) – this
requires very urgent referral
Significant trauma
Weight loss
Special considerations
• Any previous episodes of LBP
• The patient’s age
• Regional pain syndrome
• Keeping mobile helps in recovery
• Manipulation is contraindicated if there is joint effusion or active joint
inflammation
History of cancer
Fever
Intravenous drug use
Steroid use
Patient aged over 50 years
Severe, unremitting night-time pain
Pain that gets worse when patient is
History
• Identify any Red/Yellow Flags, and Blue/Black Flags where possible:
– Black Flags require possible OSH review
– Blue Flags should be considered throughout any treatment
• Work or sport injury
• Contributing factors can be leg length inequality, muscle imbalance or
excessive foot pronation
• Better/worse and provoking factors
• Pain type and distribution
• Previous history and management
• Current management, including investigations
• Any change to activity and ADLs
• Significant trauma
• Use an outcomes measurement where appropriate
• Determine the progress goals
• History may include immediate and transitory pain, followed by pain-free
intervals
• The condition usually presents with stiffness, decreased mobility and
muscle spasm, with variable pain increasing on muscle resistance
• The patient may have difficulty arising from supine or seated positions
lying down
YELLOW FLAG:
Psychosocial factors that increase the
risk of developing or perpetuating longterm disability and work loss
associated with low back pain:
Attitudes and beliefs about back pain
Behaviours
Compensation issues
Diagnostic and treatment issues
Emotions
Family
Work
Examination
• Exclude neurological complications
• Posture – antalgia
• Gait
• Palpation – spasm, tenderness and joint fixation
• ROM and pain response in active and passive modes
• Test to appraise IVD, mechanical LBP, sprain, SI lesion, myofascitis,
sciatica, Red Flags including fracture
• Lower extremity pulses
• Most orthopaedic tests are benign
• The patient may have reversal of lordosis owing to multifidus spasm
Sprain Lumbar Spine S572.
Printed Body ex Format
25
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
25
Sprain Lumbar Spine
Differential diagnosis
• Nerve root pain/radiation
• Red Flags
• Cauda Equina syndrome – requires immediate referral
• Exacerbation of chronic LBP
• Facet syndrome with pain referred to groin
• Myofascial pain syndrome
• Inflammatory diseases, eg AS
• Contributing structural factors – spondylolisthesis, pseudoarthroses, facet
trophism etc
• Muscle tears in hamstring
• Hip
• Lumbar instability
• Metastatic lesions
• Facet trophism
Investigations
• If pain remains after 1 month, consider further investigation – X-ray
• If X-raying within the first 4 weeks, document the rationale
• If Red Flags are present, refer for further investigation (CBC, ESR/CRP)
Complications
• Secondary gain
• Stenosis
• Neurological involvement
• Chronic LBP or history of repetitive injury
• Underlying pathology
• Work/home environment, including stress
Treatment/Rehabilitation/Management
Acute:
• Encourage and advise the patient to remain mobile
• Explain the nature of lower back sprain to reassure and allay fears of
incapacity
• Pain management
• Manipulation
• Mobilisation
• Exercises to tolerance
• Short-term SIJ or lumbar support
• ADL advice
• Home care advice
Sub-acute:
• Pain management
• Ergonomic advice for when at home/work, lifting, sitting, sleeping etc
• Continue advice on maintaining mobility and modified ADLs
• Exercises for centralisation, strength, stabilisation and mobility
• Encourage self management
• Approximate healing periods are:
– mild strain – 7-10 days
– moderate strain – 2-4 weeks
26
Sprain Lumbar Spine S572.
Printed Body ex Format
26
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Sprain Lumbar Spine
– mild sprain – 1-4 weeks
– moderate sprain – 1-12 months
• Severe strains or sprains may require surgical intervention
Referral
• Refer to GP for:
– TOW
– Cauda Equina syndrome
– spinal pathology
– nerve root pain that has failed to improve after 4 weeks
– home help if necessary (you may also need to involve the patient’s ACC
case manager)
– if Yellow Flags dominate or affect return to work, requiring a
psychologist or vocational management
• Refer to occupational therapist for OSH review
• Refer to physiotherapist for TENS, other forms of electrical stimulation,
lumbar traction, acupuncture
• Refer to X-ray if not available on-site
• Liaise with the patient’s employer
Sprain Lumbar Spine S572.
Printed Body ex Format
27
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
27
28
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
28
23/01/2003, 10:10
Sprain Coccyx
Read Code:
S574.
Number of treatments: 8
Triggers:
12
KEY POINTS
• Coccygeal pain may be protracted
• The outcomes are variable and unpredictable
Special considerations
• Paying attention to exacerbating factors will help in recovery
• It is important to consider seating
• Activities such as standing and walking are generally not affected
• Physical therapy modalities are usually ineffective
History
• Postpartum
• Trauma
• Fall
Examination
• Coccyx tenderness
• Internal examination if necessary
• Lumbar spine referral
• Sacroiliac referral
Differential diagnosis
• Fracture
• Traumatic arthritis of sacrococcygeal joint
• Functional coccydynia
• Lumbar spine
• SI joint
• Visceral referral
• Psychogenic pain
• Pilonidal cyst
• Perirectal abscess
Investigations
• X-ray if a fracture is suspected
Complications
• Associated trauma, including fracture
Treatment/Rehabilitation/Management
Acute:
• Reassurance
• Ice therapy
• Coccygeal/ring cushion
• Chair modification
Sprain Coccyx S574.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
29
23/01/2003, 10:10
29
Sprain Coccyx
• Mobilisation to pain tolerance
• Pain management
Sub-acute:
• Continued pain management
• Education on exacerbating factors
Referral
Refer to GP:
• for pain assistance if unresponsive
30
Sprain Coccyx S574.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
30
23/01/2003, 10:10
Cervical Disc Prolapse Radiculopathy
Read Code:
N12CO
Number of treatments: 16–20
Triggers:
20
KEY POINTS
• An accurate clinical history is necessary
• Record the nature of the injury
• Identify the need for any further treatment or examinations
• The cervical spine is treated differently from the lumbar spine
• Cervical radiculopathy is more frequent in the >30 years age group
• Traumatic causes may include “whiplash” (covered in a separate protocol)
• Causes include non-traumatic aetiology – DJD, osteophyte formation,
discopathy, trauma
• Exacerbations and remissions are common
• Cervical disc prolapse is most common at C5 and C6
• It is characterised by severe night-time pain, which may ease with walking
or upright posture
• It is important to use outcomes/pain assessment throughout care
Special considerations
• Screen for VBI
History
• Accident and onset circumstances
• Gradual or rapid onset
• Pain location
• Previous history and response to treatment
• Radiculopathy of C5-C8
• Numbness/tingling of distal dermatomal patterns
• Differentiate between acute and chronic
• Red/Yellow Flags
• History of arthritides/degeneration
Examination
• Diagnostic triage
• Pain increased by active or passive ROM
• Pain increases with hyperextension or deviation of head to involved side
• Pain increases with forward flexion of cervical spine
• +ve Valsalva’s, cervical compression, swallowing sign, Bakody’s, brachial
plexus tension test
Differential diagnosis
• DJD of facets/disc
• Lateral canal stenosis
• Myofascial trigger points/pain syndrome
• Fracture
• Facet trophism
• TOS
• IVF encroachment
Cervical Disc Prolapse Radiculopathy N12CO
Printed Body ex Format
31
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
31
Cervical Disc Prolapse Radiculopathy
• Non-traumatic onset/pathology
• Referred pattern from cardiac, gallbladder, Pancoast tumour
Investigations
• X-ray – standard 3-view and obliques if necessary
• MRI is the study of choice
• Use CT if MRI is not available
• EMG and NCV are also helpful
Complications
• Trauma upon pre-existing injury
• Posterior ligament changes may lead to posterolateral herniation and
subsequent impinging on spinal cord or nerve roots
• Straight midline posterior herniation is an acute surgical emergency
Treatment/Rehabilitation/Management
• Shift from passive to rehabilitative/restoration of function
• Bed rest for no more than 3 days
• Use manipulation/mobilisation only after the acute phase and where there
are no neurological deficits
• After the acute phase, manipulation may be attempted. Do not manipulate
in a position that produces pain
• Early exercise programme after 2-3 days of bed rest
• Check motor, sensory and reflexes each visit
• No progress after 2 weeks indicates referral
• Consider conventional or natural medication for muscle spasm,
inflammation and tissue healing
• Home care should consider cervical collar, moist heat for muscle spasm,
ADL review and management, tailored home exercises
Referral
• Refer to GP:
– for specialist referral
– if nerve root pain fails to settle
– for pain control
– for Red Flags
• Refer to X-ray if not available on-site
32
Cervical Disc Prolapse Radiculopathy N12C0
Printed Body ex Format
32
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Thoracic Disc Prolapse Radiculopathy
Read Code:
N12C1
Number of treatments: 10–16
Triggers:
16
KEY POINTS
• Thoracic disc lesions are rare
• Anterior disc lesions are frequently visualised on X-ray but are usually
asymptomatic and clinically quiescent
Special considerations
• Age
History
• Record the nature and mechanism of the injury – direct blow/fall
• Gradual/acute onset
• Pain and injury location
• Previous history of thoracic injury/treatment and response
• Red Flags – drug use, alcohol abuse, corticosteroid use, diabetes, direct
trauma, cancer, infection
• Yellow Flags if apparent
• Underlying thoracic conditions that may complicate recovery include DJD,
osteoporosis
• Review sports and occupational activities,including ADL changes
• Obtain an accurate history including the site and nature and behaviour of
pain and any aggravating/relieving factors
• Prescribed and self medication
• Include current and past illnesses, including Scheurmann’s
• If the patient is >70 years, consider compression fracture
• If the injury resulted from a fall on the buttock, consider compression
fracture
• If the patient was involved in a car accident, consider chance fracture
• If the injury resulted from a direct blow, consider rib fracture
Examination
• Postural
• ROM – active, passive, accessory
• Deformity
• Palpation, percussion, vibration, compression
• Differentiate stiffness from loss of ROM
• Skin lesions
Differential diagnosis
• In the upper thoracic spine differentiate between the 4 TOS syndromes
(anterior scalene, cervical rib, costoclavicular, pectoralis minor)
• Anterior scalene is the TOS most likely to be associated with trauma
• The abduction and external rotation (AER) test/Roos test is the most
reliable provocative test for TOS
• Pulsus obliterans is fairly common in asymptomatic population during
Adson’s test
Thoracic Disc Prolapse Radiculopathy N12C1
Printed Body ex Format
33
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
33
Thoracic Disc Prolapse Radiculopathy
• Facet trophism
• Neurofibromatosis
• Ankylosing spondylosis
Investigations
• X-ray – AP and lateral views
• Oblique views to evaluate ribs for fracture, vertebral bodies for trauma to
ring apophyses
• MRI, bone scans and tomograms are usually reserved for spinal infection,
tumour, such as metastases and osteoid osteomas, and the rare disc
herniation
Complications
• The thoracic spine is rarely unstable owing to the rib cage
• Respiratory conditions
• Neurofibromatosis
• Scoliosis/kyphosis
• Scheurmann’s disease (disc degeneration is secondary to end plate
herniation)
• Psychosocial issues
Treatment/Rehabilitation/Management
Acute:
• Mobilisation
• Manipulation/adjustment
• Palliative techniques
• Exercise
• Education
Sub-acute:
• Exercises to restore ROM and strength
• General fitness
• Postural and ergonomic advice for work and home
Referral
• Refer to GP for pain control or further referral/investigation
• Refer to case manager if Yellow, Blue or Black Flags apparent
• Refer to occupational therapist for workstation evaluation (consult with
ACC case manager)
34
Thoracic Disc Prolapse Radiculopathy N12C1
Printed Body ex Format
34
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Lumbar Disc Prolapse Radiculopathy
Read Code:
N12C2
Number of treatments: 16–24
Triggers:
24
KEY POINTS
• The mechanism is frequently a rotational or compression injury, producing
circumferential and radial tears
• The condition is more common among people aged 30-50 years and the
elderly when the disc is fibrotic
Special considerations
• Leg pain frequently predominates over back pain
• Psychosocial factors may colour the symptom presentation
• Regional pain syndrome
History
• Sudden trauma
• Discal degeneration
• Gradual micro trauma
• Frequently history of LBP and/or leg pain over months or years
• Increased pain with forward flexion, coughing or sneezing
• Complications include bowel/bladder dysfunction or Cauda Equina
syndrome – all are medical/surgical emergencies
• Morning stiffness
• May occur gradually after trauma
• History of steroids or medications
Examination
• Hypothesia over affected dermatome
• Muscle weakness of quadriceps and dorsiflexors of ankles and toes
• Diminished or absent DTR
• Diminished lumbar lordosis
• Antalgia
• Minor’s sign
• Myospasm over lumbar and gluteals
• ROM
• Orthopaedic tests – SLR, Kemp’s, Lasague, Bowstring, Well leg sign
• Document with outcome assessment tools
Differential diagnosis
• Red Flags
• Facet syndrome
• Myofascial pain syndrome
• Sacroiliac dysfunction
• Referred pain – visceral
• Spondylolisthesis
• Circulatory disease
Lumbar Disc Prolapse Radiculopathy N12C2
Printed Body ex Format
35
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
35
Lumbar Disc Prolapse Radiculopathy
Investigations
• X-ray if Red Flags exist
• MRI
Complications
• Manipulation is contraindicated in the presence of peripheralisation,
lesions above L1-2, saddle anaesthesia or bladder/bowel dysfunction
• Symptom peripheralisation
• Claudicant symptoms – intermittent and neurogenic
Treatment/Rehabilitation/Management
Acute:
• Ice massage, cold packs
• Pain management
• Short-term bed rest with knees flexed
• Prolonged bed rest and inactivity are to be discouraged
• Reduce/eliminate aggravating movements or activities
Sub-acute:
• Trigger point therapy
• Lumbar support
• Flexion/distraction
• Manipulation – with caution after 24-48 hours – is considered safe
• Rehabilitation exercises (the patient should cease if peripheralisation
occurs)
• Self management
• Pain management
• Evaluation of ergonomic factors at home and work, including lifting
• Evaluation of sporting activities and postures
Referral
• Refer to GP for:
– specialist referral
– pain assistance
– TOW
– psychological referral
• Refer to X-ray if not available on-site
• Refer to case manager if necessary
36
Lumbar Disc Prolapse Radiculopathy N12C2
Printed Body ex Format
36
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Whiplash
Read Code:
XaO6Y
Number of treatments: 15
Triggers:
18
KEY POINTS
• Fractures or dislocations may complicate whiplash injuries
• Whiplash may be caused by car, sports or work injury
• Pain may be immediate or occur weeks after trauma
• Injury may be superimposed upon pre-existing cervical conditions,
complicating recovery
Special considerations
• Look for poor recovery signs – numbness and pain in the upper limbs, a
sharp reversal of the cervical spine, prolonged dependence on a cervical
collar, anterior head carriage
• Consider using the Foreman and Croft outcomes measure for prognosis
• A detailed case history is important to eliminate Red Flags that may
masquerade or influence flexion and extension injury
History
• An accurate clinical history is necessary
• Record the nature of the injury accurately
• Identify the need for any further treatment or examinations
• Pain may radiate to shoulders, mid-scapular region, arms and hands
• The patient may display multiple symptoms – tinnitus, Horner’s syndrome,
visual disturbance, cephalgia, loss of balance, chest pain, dyspnoea
Examination
• Trigger points
• Moderate to severe paraspinal muscle spasm in the thoracic and posterior
cervical spine
• Tenderness SCM, scalenes and longus coli
• Quadrant’s test, George’s test, valsalva and foraminal compression
• Motor challenge upper extremities
• Determine the degree of injury – complicated, chronic
Differential diagnosis
• Cervical disc lesion
• Cervical sprain
Investigations
• X-ray – standard 3-view
• If symptoms persist, a flexion/extension study should not be performed
until after the first month
• Arrange further imaging if signs of increased ADI, retropharyngeal or
retrotracheal space
Whiplash XaO6Y
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
37
23/01/2003, 10:10
37
Whiplash
Complications
• Pre-existing inflammatory diseases or arthritides
• Increased ADI, retropharyngeal or retrotracheal space may indicate
inflammation or haematoma
• Significant haematoma is an indication for immediate referral to
emergency care
Treatment/Rehabilitation/Management
• There is little evidence for using cervical collars – using them for longer
than 72 hours may prolong injury
• Manipulation is contraindicated if there is increased ADI
• Use manipulation/mobilisation only after the acute phase and if there are
no neurological deficits
• After the acute phase, manipulation may be attempted. Do not manipulate
in a position that produces pain
• Use manual cervical traction during the acute and sub-acute phases
• Early exercise programme after 2-3 days of bed rest
• Check motor, sensory and reflexes each visit
Acute (moderate injury 4-6 weeks):
• Use ice and gentle mobilisation techniques and manipulation
Sub-acute:
• Use hot packs, moderate myofascial tx and trigger point therapy
• Isometric exercise
• Spinal manipulation
Rehabilitation:
• Gentle ROM exercises
• Increase ROM gradually
• Shift to active then active-with-resistance exercises
• Implement a home exercise programme if the patient is willing
Referral
• Refer to GP for:
– TOW
– pain assistance
• Refer to emergency care
• Refer to physiotherapist for TENS, other forms of electrical stimulation,
acupuncture
38
Whiplash XaO6Y
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
38
23/01/2003, 10:10
Printed cover ex (Converted)-2 23/01/2003 10:38 Page 4
Section 2
Composite
Meniscal Tear (Medial)
Read Code:
S460.
Number of treatments: 14
Triggers:
12
KEY POINTS
• A good history is important
• Vertical, stable, peripheral tears will often heal
• Most other tears will progress to recurrent bouts of swelling and pain, with
decreased asymptomatic periods
• Many tears require referral for arthroscopy examination
• Medial tears are more frequent than lateral tears
Special considerations
• Refer persistent knee symptoms
• Older people may present as chronic knee pain
• Occupational requirements at work
• Contributory lumbopelvic dysfunction (primary or secondary)
History
• Type of injury
• Twist injury, dashboard injuries, frequently with flexed knee
• Sudden onset with movement
• Sporting level
• Speed of onset of swelling
• Degree of force
• Mobility since injury
• Locking/giving way
• Degree of mobility needed for work/ADLs
Examination
• Medial joint line tenderness/pain
• The extent of oedema
• Gait alteration, including the ability to bear weight
• Limited ROM, especially on extension
• Challenge knee with compression and rotation
• Meniscus tests – Apley’s compression/distraction, McMurray’s, Bounce,
Childress
• Muscle tone/testing
• Effusion
• Limited ROM – especially extension
• Ligamentous stability
• Pain on flexion/extension with foot rotated (medially or laterally)
• Lumbopelvic dysfunction
Differential diagnosis
• ACL tear
• Collateral ligament tear
• Osteochondritis dissecans/osteochondral fracture
• Tibia/fibula joint dysfunction
Meniscal Tear (Medial) S460.
Printed Body ex Format
39
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
39
Meniscal Tear (Medial)
•
•
•
•
•
•
•
Hamstring, gastrocnemius, popliteus involvement/strain
Ilio-tibial band syndrome
Baker’s cyst
Patello-femoral pathology
Haemarthrosis
Tumour
Xanthoma
Investigations
• X-ray if suspected fracture, osteochondritis dissecans
• May require MRI or CT
Complications
• Quadriceps wasting
• Long-term DJD
• Recurrence
• Loose bodies
• Haemarthrosis
• Instability
• Patello-femoral problems
• ITB problems
• Congenital deformities
• Valgus/varus deformity
Treatment/Rehabilitation/Management
Acute:
• RICE
• NSAIDs or alternative pain management
• Swelling management
• Mobility assistance if necessary
• Support/strapping if necessary
• Manipulation of the lumbar spine and pelvis, if involved
Sub-acute:
• As for acute phase
• Transverse friction massage
• Mobilisation/manipulation
• Stretching and strengthening exercises
• Evaluate lifestyle and work stressors
• Muscle balance
• Pelvic stability
• Manipulation of the lumbar spine and pelvis, if involved
Referral
• Refer to GP for work-related absence, pain control, further imaging
• Refer to GP for specialist referral if:
– McMurray’s test remains after 2 weeks
– persistent, unresolving symptoms
– history of locking or giving way
– recurrent or persistent effusion
– haemarthrosis detected
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to X-ray if not available on-site
40
Meniscal Tear (Medial) S460.
Printed Body ex Format
40
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Meniscal Tear (Lateral)
Read Code:
S461.
Number of treatments: 14
Triggers:
10
KEY POINTS
• A good history is important
• Vertical, stable, peripheral tears will often heal
• Most other tears will progress to recurrent bouts of swelling and pain, with
decreased asymptomatic periods
• Many tears require referral for arthroscopy examination
• Lateral tears are less frequent than medial tears
• Lateral tears often require more rehabilitation
Special considerations
• Lateral tears may be associated with ACL injury
• Refer persistent knee symptoms
• Older people may present as chronic knee pain
• Occupational requirements at work
• Lumbopelvic dysfunction may become a secondary problem resulting from
the knee injury
History
• Type of injury
• Twist injury, dashboard injuries, frequently with flexed knee
• Sudden onset with movement
• Sporting level
• Speed of onset of swelling
• Degree of force
• Mobility since injury
• Locking/giving way
• Degree of mobility needed for work/ADLs
Examination
• Lateral joint line tenderness/pain
• Extent of oedema
• Gait alteration, including ability to bear weight
• Limited ROM, especially on extension
• Challenge knee with compression and rotation
• Meniscus tests – Apley’s compression/distraction, McMurray’s, Bounce,
Childress
• Muscle tone/testing
• Effusion
• Limited ROM – especially extension
• Ligamentous stability
• Pain on flexion/extension with foot rotated (medially or laterally)
• Lumbopelvic dysfunction
Meniscal Tear (Lateral) S461.
Printed Body ex Format
41
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
41
Meniscal Tear (Lateral)
Differential diagnosis
• ACL tear
• Collateral ligament tear
• Osteochondritis dissecans/osteochondral fracture
• Tibia/fibula joint dysfunction
• Hamstring, gastrocnemius, popliteus involvement/strain
• Ilio-tibial band syndrome
• Baker’s cyst
• Patello-femoral pathology
• Haemarthrosis
• Tumour
• Xanthoma
Investigations
• X-ray if suspected fracture, osteochondritis dissecans
• May require MRI or CT
Complications
• Quadriceps wasting
• Long-term DJD
• Recurrence
• Loose bodies
• Haemarthrosis
• Instability
• Patello-femoral problems
• ITB problems
• Congenital deformities
• Valgus/varus deformity
Treatment/Rehabilitation/Management
Acute:
• RICE
• NSAIDs or alternative pain management
• Swelling management
• Mobility assistance if necessary
• Support/strapping if necessary
• Manipulation of the lumbar spine and pelvis, if involved
Sub-acute:
• As for acute phase
• Transverse friction massage
• Mobilisation/manipulation
• Stretching and strengthening exercises
• Evaluate lifestyle and work stressors
• Muscle balance
• Manipulation of the lumbar spine and pelvis, if involved
Referral
• Refer to GP for work-related absence, pain control, further imaging
• Refer to GP for specialist referral if:
– McMurray’s test remains after 2 weeks
42
Meniscal Tear (Lateral) S461.
Printed Body ex Format
42
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
Meniscal Tear (Lateral)
– persistent, unresolving symptoms
– history of locking or giving way
– recurrent or persistent effusion
– haemarthrosis detected
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to X-ray if not available on-site
Meniscal Tear (Lateral) S461.
Printed Body ex Format
43
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:10
43
44
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
44
23/01/2003, 10:11
Sprain Upper Arm/Shoulder
Read Code:
S50..
Number of treatments: 8
Triggers:
12
KEY POINTS
Special considerations
• Diagnosis of exclusion – eliminate:
– fractures of clavicle, AC/SC and GH joint strain
– rotator cuff syndrome/strain
– cervical and thoracic spine involvement
– biceps, supraspinatus tendon ruptures
– shoulder girdle muscle strain
– shoulder dislocation/subluxation
– upper arm/shoulder tenosynovitis upper limb
– labral tear
History
• Mechanism of injury to exclude other shoulder syndromes/strains
Examination
• Observation
• Shoulder ROM
• Tenderness – specific and generalised
• Condition-specific tests
• Bursitis
• Labral tear
• Joint stability
• Individual and group muscle test
• Cervical and thoracic spine, if involved
Differential diagnosis
• Exclude underlying pathology or infection
• Rotator cuff syndrome/strain
• Cervical and thoracic spine involvement
• Biceps, supraspinatus tendon ruptures
• Shoulder girdle muscle strain
• Shoulder dislocation/subluxation
• Upper arm/shoulder tenosynovitis upper limb
Investigations
• X-ray, especially if the patient is elderly or a child and the diagnosis is
inconclusive
Complications
• Restricted shoulder movement
Sprain Upper Arm/Shoulder S50..
Printed Body ex Format
45
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
45
Sprain Upper Arm/Shoulder
Treatment/Rehabilitation/Management
Acute:
• Ice therapy
• Pain management
• Massage
• Strengthening exercises
• Gentle mobilisation
• Manipulation of cervical and thoracic spine, if involved
Sub-acute:
• Strengthening/stretching exercises
• Pain management
• Mobilise/manipulate any involved adjacent areas – cervical/thoracic/ribs/
shoulder
• Myofascial tx
Referral
• Refer to radiography if in-house not available
• Refer to GP for:
– pain assistance
– further evaluation
• Refer to physiotherapist for EMS, acupuncture
• Refer to X-ray if not available on-site
46
Sprain Upper Arm/Shoulder S50..
Printed Body ex Format
46
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Acromio-Clavicular Ligament
Read Code:
S500.
Number of treatments: 10
Triggers:
12
KEY POINTS
• Compare the injured side with the patient’s other side
• X-ray, including weight bearing
• This injury is rare in children
• Elderly people are more likely to fracture than sprain
• Elderly people may be prone to complications, including stiffening
• Use RICE therapy early
Special considerations
• Other conditions may be involved and excluded:
– AC/SC and GH joint strain
– rotator cuff syndrome/strain
– cervical spine involvement
– biceps, supraspinatus tendon sprain
– shoulder girdle muscle strain
– shoulder dislocation/subluxation
– upper arm/shoulder tenosynovitis upper limb
History
• Blow or fall onto shoulder
• Contact sport – volleyball, football, basketball etc
• Non-contact sport/activities – skiing, heavy labour etc
• Repetitive action
• Previous shoulder dislocation
• Fracture to surrounding area
Examination
• Grade strain
• Local pain
• Swelling/bruising
• Loss of shoulder mobility
• Deformity compared with the patient’s other side
• Instability and tenderness at AC joint
• Increased pain with weight bearing, dangling of arm
• Weakness
• Review neck ROM
• Differentiate compression/separation
• Codman’s, apprehension, Dugas, Yergason tests
• Skin abrasion/stretching – watch for infection
• Cervical spine
Differential diagnosis
• Shoulder dislocation
• Anterior humerus dislocation
• Glenohumeral joint/rotator cuff
Sprain Acromio-Clavicular Ligament S500.
Printed Body ex Format
47
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
47
Sprain Acromio-Clavicular Ligament
•
•
•
•
•
Cervical spine involvement/injury
Impingement
Sterno-clavicular joint
Fracture to clavicle or humerus
Acute traumatic bursitis (supraspinatus or acromial bursa)
Investigations
• X-ray for Grades 2 and 3
• X-ray for Grade 1 if no improvement after 2 weeks
• Diagnostic/therapeutic injections at 2 weeks after X-ray
• Complications
• Fracture
• Severe injury/deformities
• Chronic recurrent injury
• Unstable joints if Grade 3 not referred
• Damage to underlying structures (neurovascular, tendon, lung)
Treatment/Rehabilitation/Management
Acute:
• Ice therapy for the first 24-48 hours
• Pain relief
• Sling, tape or strap if necessary
• Early mobilisation
• Manipulation of cervical spine, if involved
Sub-acute:
• Soft tissue management
• Mobilisation of associated joints
• Shoulder girdle functional strengthening, education
• Rest (avoid sport and lifting)
Grades 1-2:
• Mobilise at 2-3 weeks
Grade 3:
• Immobilise up to 6 weeks
• Refer if no improvement after 2 weeks
• Education
Referral
• Refer to radiography
• Refer to GP for:
– Grade 3 injuries or if the patient is concerned about deformity
– specialist referral for fracture, chronic ligament/tendon involvement or
A/C joint dislocations
• Refer to physiotherapist for EMS, acupuncture
• Refer to X-ray if not available on-site
48
Sprain Acromio-Clavicular Ligament S500
Printed Body ex Format
48
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Infraspinatus Tendon
Read Code:
S503.
RED FLAG:
If patient cannot push hand away
Number of treatments: 12
Triggers:
from lumbar region, this indicates
16
a major tear of R/C
Elderly patients (more likely to
KEY POINTS
• Check elderly patients for fracture
• Ensure early mobilisation in elderly people to prevent stiffening
• The elderly have an increased risk of tendon rupture
fracture and develop stiff joint)
Special considerations
• Use care if using immobilisation or rest, especially slings
History
• Acute onset – recent sprain/trauma
• Chronic onset – overuse/incorrect use
• May result from a recent injury such as a fall or twist
Examination
• Resisted external rotation painful
• Localised tenderness over the tendon
• Glenohumeral aberrant function
• Scapular stability
• Cervical and thoracic spine
• Ligament tests
• Exclude fracture
• Ligament stability
Differential diagnosis
• Capsulitis
• Bursitis
• Glenoid labrum tear
• AC joint strain
• Cervical or thoracic involvement
• Pain and/or instability when stressing specific ligament or tendon
Investigations
• X-ray (exclude fracture)
• Ultrasound (if available)
Complications
• Tendon rupture
• Fracture
• Chronic, recurrent injury, tendonitis
• Development of tendonitis in partial tendon tear
Treatment/Rehabilitation/Management
Acute:
• Ice therapy for the first 24 hours
• Pain relief
Sprain Infraspinatus Tendon S503.
Printed Body ex Format
49
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
49
Sprain Infraspinatus Tendon
• Isometric exercises
• Soft tissue, scapula and joint mobilisation (especially in the elderly)
• Sling if necessary
Sub-acute:
• Strength and stability exercises
• Cervical/thoracic mobility/manipulation, if involved
• Posture review
• Isometric exercise
Referral
• Refer to GP for:
– pain relief if necessary
– specialist if required
– home help
– radiography if not in-house
• Refer to physiotherapist for EMS, acupuncture
• Refer to X-ray if not available on-site
50
Sprain Infraspinatus Tendon S503.
Printed Body ex Format
50
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Rotator Cuff
Read Code:
S504.
RED FLAG:
If patient cannot push hand away
Number of treatments: 10
Triggers:
from lumbar region, this indicates
16
a major tear of R/C
Elderly patients (more likely to
KEY POINTS
• It is rare for children to sprain ligaments
• Check elderly patients for fracture or tendon rupture
• Early mobilisation and RICE speed recovery
fracture and develop stiff joint)
Special considerations
• Age
• Inflammatory arthritides
• Steroid therapy
• Level of physical activity, eg competitive sport
• Lifestyle
• Diagnosis of exclusion – eliminate:
– AC/SC and GH joint strain
– cervical spine involvement
– biceps, supraspinatus tendon sprain
– upper arm/shoulder tenosynovitis upper limb
History
• The mechanism of the injury – trip, sports, twisting, other trauma
• A history of injury to the area
• Restrictions to ADLs
• Pain behaviour
Examination
• Active, passive and resisted ROM
• Cervical, thoracic, scapula, elbow, GH and AC ROM/stability
• Palpation – joint and soft tissue
• Glenohumeral instability testing
• Swelling
• Exclude fracture
• Neurovascular status
Differential diagnosis
• Other joints – cervical, thoracic, AC
• Thoracic outlet syndrome
• Viscero/Somatic referral
• Radiculopathy/nerve entrapment
• Glenohumeral instability
• Myofascial pain syndromes
• Arthritis – inflammatory and degenerative
• Tendonitis/bursitis
• Impingement
• Fracture/infection/pathology
Sprain Rotator Cuff S504.
Printed Body ex Format
51
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
51
Sprain Rotator Cuff
Investigations
• X-ray if clinically indicated
• Ultrasound depending on the symptoms and response
Complications
• Avulsion
• Complete tear
• Calcification
• Subacromial bursitis
• Recurrent injury
• Tendonitis
Treatment/Rehabilitation/Management
Acute:
• Ice therapy up to the first 48 hours
• Modify activity
• Early stretching/light mobilisation
• Home care and management
• ROM within the pain-free range
• Manipulation of cervical spine, if involved
• Pain control
• Sling if necessary
Sub-acute:
• Pain control
• Scapula/humeral stability
• Graduated exercise rehabilitation
• Advice on movement and use of the arm
• Transverse friction massage
• Ergonomic information, including specific activity
• Education about the risk of re-injury
• Gentle manipulation/mobilisation of associated structures
Referral
• Refer to GP for:
– pain control or no improvement after 3 weeks
– ultrasound if unable to exclude rupture
– radiographic if not available in-house
• Refer to physiotherapist for EMS, acupuncture
• Refer to X-ray if not available on-site
52
Sprain Rotator Cuff S504.
Printed Body ex Format
52
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Shoulder Joint
Read Code
S507.
RED FLAG:
If patient cannot push hand away
Number of treatments: 10
Triggers:
from lumbar region, this indicates
12
a major tear of R/C
Elderly patients (more likely to
KEY POINTS
• Ligamentous/Capsular injury to glenohumeral joint
• Check elderly patients for fracture
• Elderly patients require early mobilisation
• There is a risk of tendon rupture in elderly people
fracture and develop stiff joint)
Special considerations
• Diagnosis of exclusion – eliminate:
– AC/SC and GH joint strain
– cervical spine involvement
– biceps, supraspinatus tendon sprain
– upper arm/shoulder tenosynovitis upper limb
History
• Nature of injury
• Fall
• Trauma
• Twisting injury
• Sporting injury
Examination
• Instability testing
• Rotator cuff tests
• Scapular/humerus movement
• Thoracic spine and scapular function
• Impingement testing
• Neurological evaluation
• Cervical and thoracic spine
• Swelling
• Exclude fracture
• Assess/exclude ligament/tendon injury
• Neurovascular status
• Active, passive and resisted ROM
Differential diagnosis
• Labral tear
• Impingement
• Fracture
• AC/SC joint
• Tendonitis/bursitis
• Cervical and thoracic spine
• Instability
• Biceps, supraspinatus tendonitis
Sprain Shoulder Joint S507.
Printed Body ex Format
53
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
53
Sprain Shoulder Joint
Investigations
• X-ray if indicated
• Ultrasound
Complications
• Adhesive capsulitis
• Glenohumeral and general shoulder instability
• Disuse atrophy
• Neurological complications
• Traumatic arthritis
• Recurrent or chronic injury
• Tendonitis
Treatment/Rehabilitation/Management
Acute:
• Ice therapy up to the first 48 hours
• Pain management
• Gentle joint mobilisation to tolerance
• Ergonomic education
• Early exercise for strength/stabilisation where possible
• Manipulation of cervical spine, if involved
Sub-acute:
• Sling if necessary
• Pain management
• Graduated strengthening and stretching exercises
• Manipulation and mobilisation of shoulder and associated structures
Referral
• Refer to GP for:
– steroid injection if no improvement after 3 weeks
– ultrasound referral if necessary
– radiographic if not available in-house
• Refer to physiotherapist for EMS, acupuncture
• Refer to X-ray if not available on-site
54
Sprain Shoulder Joint S507.
Printed Body ex Format
54
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Elbow/Forearm
Read Code:
S51..
Number of treatments: 10
Triggers:
12
KEY POINTS
• This injury is rare in children <12 years
• Early RICE therapy is useful
• Monitor older patients for tendon rupture or fracture
• The sprain involves injury to muscles and tendons and occasionally to the
joint itself
• It usually follows a sharp twist
• Rule out cervical radiculopathy
Special considerations
• Elderly patients need early mobilisation to prevent stiffening
• Occupation
• Age
• Activity
History
• Determine the mechanism of injury – it is frequently a twisting injury after
a fall, trip, sports etc
• Loss of mobility – the injury may result from a gradual onset process
• If you are not the initial provider, obtain any management information to
date
• Previous injury
• Functional limitations
• Type of work and sports activities
Examination
• Pain/tenderness to touch/pressure
• Exclude fracture
• Ligament stability and function
• Joint effusion
• Neurological evaluation of the involved upper extremity
• Cervical and upper thoracic spine
Differential diagnosis
• Fracture
• Dislocation
• Infection
• Muscle/tendon rupture
• Avulsion injuries of medial epicondyle
• Joint arthritides
• Soft tissue ectopic calcifications
• Medial/lateral epicondylitis
• Referred pain – cervical and upper thoracic spine
• Nerve entrapment/stretch – usually posterior interosseous, ulnar nerve
• Osteochondritis dessicans
• Apophysitis
Sprain Elbow/Forearm S51..
Printed Body ex Format
55
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
55
Sprain Elbow/Forearm
Investigations
• X-ray (to exclude fracture)
• Ultrasound referral if the injury is slow to recover and affecting the
patient’s ADLs
Complications
• Chronic recurrent injury
• Muscle – tendon ruptures
• Grade 3 sprain
• Unstable joint
• Fractures
• Dislocations
• Arthritides
• Excessive swelling/haemarthrosis
Treatment/Rehabilitation/Management
• NSAIDs if pain control is necessary (note this may delay healing)
• Splintage as required for pain relief (broad arm sling)
Acute:
• Ice for the first 48 hours followed by heat and/or massage
• Temporary immobilisation with elastic support
• Advise the patient to avoid painful activities
• Joint/soft tissue mobilisation
• Stretching exercises/mobilisation – especially with elderly patients
• Cervical manipulation if indicated
Sub-acute:
• Gradual increase in activity
• Continue stretching exercises and introduce strengthening exercise if
necessary to prevent muscle wasting
• Manipulation/mobilisation as indicated
Referral
• Refer to GP for:
– fracture
– specialist referral if the injury is a Grade 3 ligament injury
– rapid haemarthrosis
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to X-ray if not available on-site
56
Sprain Elbow/Forearm S51..
Printed Body ex Format
56
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Wrist/Hand
Read Code:
S52..
Number of treatments: 12
Triggers:
14
KEY POINTS
• 90% of wrist sprains are flexion sprains with no fracture
• They are usually strains of tendon attachments or injuries to the bone
• They may include multiple tissues and surrounding structure and joints
• The patient may present with multiple or singular onsets (acute, chronic,
gradual)
• Elderly patients are more prone to fracture or tendon rupture
• The injury requires early mobilisation
• Apply RICE therapy early
• A complete rupture may be decreased or involve no pain
• Painless hypermobility is seen in chronic ligamentous rupture
• Rule out cervical radiculopathy
Special considerations
• Grade 3 frequently requires referral
History
• The mechanism of the injury – fall, trauma, implement use
• Flexion, extension or rotational force that may be sudden or repetitive
• Previous therapy or management
• Previous history of injury or pathology
• ADL and functional restrictions
• Symptom duration
• Hand dominance
• Pain radiation to elbow, shoulder girdle or neck
Examination
• Carpal lift sign
• Cervical and thoracic spine
• Neurological evaluation of the involved upper extremity
• Grip test
• Deformity
• Tenderness
• Swelling
• ROM
• Exclude fracture
• Neurovascular status
Differential diagnosis
• Carpal tunnel syndrome
• Avascular necrosis (especially in scaphoid fractures)
• Tendon rupture
• Referred pain to elbow, shoulder and cervical spine
• Fractures of wrist and forearm
• Acute nerve/arterial injury, eg ulnar nerve compression
Sprain Wrist/Hand S52..
Printed Body ex Format
57
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
57
Sprain Wrist/Hand
•
•
•
•
De Quervains and other tendonopathies
Epiphyseal injuries (radial epiphysis in children)
Impingement syndromes
Dislocation
Investigations
• X-ray to exclude fracture. A bilateral X-ray may be needed for comparison
Complications
• Arthritides
• Excessive swelling
• Associated vascular or neurological change
• Carpal tunnel
• Chronic recurrent tendonitis or injury
• Unstable joints
Treatment/Rehabilitation/Management
Acute:
• RICE where appropriate
• Pain management
• Immobilisation initially, then gentle mobilisation
• Sling if needed
• Cervical manipulation if indicated
Sub-acute:
• Support instability
• Strengthening
• Functional activity exercises
• Avoid provocative activity during healing
Referral
• If there is no improvement, or there is deterioration, in the first 2 weeks,
or stalled progress after 4 weeks, seek a second opinion
• Refer to GP for treatment or onward referral if:
– fracture
– dislocation
– gross instability
– neurovascular condition
– no improvement over 2 weeks
• Refer to GP for home help if necessary
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to X-ray if not available on-site
58
Sprain Wrist/Hand S52..
Printed Body ex Format
58
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Thumb
Read Code:
S522.
Number of treatments: 12
Triggers:
14
KEY POINTS
• A history and mechanism information are important
• Measure the instability in full extension
• X-ray all but the most trivial injuries
• Elderly patients are more likely to fracture than sprain
• Elderly patients require early mobilisation
• Apply RICE therapy early
• Watch for tendon rupture in elderly people
Special considerations
• Unstable injuries need referral
• >30o movement on stressing UCL implies rupture and must be referred
• Collateral ligament tear (complete) needs surgical repair <7 days
• Early mobilisation within 7-10 days is important
• Site of pain and swelling
• Past history
History
• History of trauma
• Hyperextension, hyperflexion +/- lateral or rotary force
• Mechanism of injury – force, degree and direction
• Symptom duration
• Past injury
• History of arthritides
• Work/recreational/ADLs involving joint
• Hand dominance
Examination
• Compare the injured hand with the other hand
• Determine the degree of sprain – measure instability in full extension
• ROM
• Functional ability – loss of pinch grip
• Inflammation
• >30o movement on stressing UCL implies rupture
• Tenderness over joint
• Joint stability – passive and active
• Neurovascular status
Differential diagnosis
• Fracture, including avulsion
• Muscle tear
• Arthritides
• Tendonitis or tendon injury
• Grades 2 to 3 (dislocations)
• Full rupture
• Dislocation
Sprain Thumb S522.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
59
23/01/2003, 10:11
59
Sprain Thumb
Investigations
• X-ray to exclude fracture
• Refer if a stress-view X-ray is necessary
Complications
• Missed Grade 3 or avulsion
• Infection
• Instability
• Other joints involved
• Arthritides
• Complex regional pain syndrome
• Dysfunctional grip owing to instability
• Stiffness
• DJD
Treatment/Rehabilitation/Management
Acute:
• Grade 1:
– RICE
– rest and support to allow healing
– NSAIDs or similar analgesia if necessary
– educate about healing and activities
• Grade 2:
– as for Grade 1
– thumb splice splint if necessary – may need referral
• Grade 3:
– Urgent referral is necessary if UCL is ruptured
Sub-acute:
• Grade 1:
– joint mobilisation
– soft tissue mobilisation
– support (splint/strap)
• Grade 2:
– as for Grade 1
– strengthening exercises as appropriate
– avoid provocative activity during healing
– volar plate and flake fractures should be referred
Referral
Refer to GP for:
• flake fractures and plate injuries
• specialist referral for:
– ulna collateral ligament rupture
– flake fractures at base of proximal phalanx displaced >2mm
– fractures >25% joint surface
– unstable volar plate injuries
– rupture of central extensor slip
– Grade 3 ligament damage
60
Sprain Thumb S522.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
60
23/01/2003, 10:11
Sprain Finger
Read Code:
S523.
Number of treatments: 12
Triggers:
12
KEY POINTS
• Treatment is frequently delayed as the injury is often thought to be minor
• A history and mechanism information are important
• Sprains of Grades 1 to 2 involve an incomplete tear of the ligament or
tendon
• The patient may remain symptomatic for several months
History
• Trauma, sometimes thought insignificant at the time of the injury
• Direct impact
• Traction
• Torsional forces
• Symptom duration
• Acute, chronic or recurring
• Site of pain
• Occupational
• Sport
• Hand dominance
Examination
• Vascular
• Neural – 2-point discrimination, sensory, motor, muscle/tendon
• Deformity – rotational/angular
• Swelling
• Pain to touch
• Weakness with grip
• Stability under varus/valgus stress
• ROM
• Determine the injury grade
• If a fracture is suspected, also search for dislocation
Differential diagnosis
• Dislocation
• Avulsions
• Infection
• Surgical intervention unlikely unless Grade 3
• Fracture
• Tendon injuries
• Arthropathies
Sprain Finger S523.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
61
23/01/2003, 10:11
61
Sprain Finger
Investigations
• X-ray is necessary with most finger injuries
Complications
• Missed diagnosis, Grade 3, avulsion injury
• Failure to seek initial treatment
• Residual instability
• Chronic recurrent tendonitis
• Unstable joints
• Underlying pathology
Treatment/Rehabilitation/Management
Acute:
• RICE
• Pain management
• Immobilisation
• Support/splint or buddy strapping in mild cases
• Rest and support to allow healing
• Strengthening exercise as the injury settles
• Education
Sub-acute:
• Pain management
• Support
• Strengthening exercise
• Avoid provocative activity during healing
• Encourage early use once symptoms abate
• Strap if playing sport
• Mobilise early in elderly people
Referral
• Refer to GP for:
– pain assistance
– home help if necessary
– onward referral of fracture, avulsion or Grade 3
62
Sprain Finger S523.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
62
23/01/2003, 10:11
Sprain Hip/Thigh
Read Code:
S53..
RED FLAG:
Children and elderly – a careful
Number of treatments: 8
Triggers:
assessment is required where the
12
history is not consistent with the
severity of symptoms. Seek
KEY POINTS
• Keep elderly patients mobile. If they are immobile, mobilise them as soon
as possible
• The history and mechanism of the injury are important for accurate
diagnosis
advice early
Special considerations
• The young and elderly need careful examination
History
• The injury mechanism is important
• Trauma onset and type
• Fall
• Blow
• Trip
Examination
• ROM
• Tenderness
• Muscle strength
• Palpation
• Weight-bearing ability
• Gait/mobility
• Observation
• Sensory
Differential diagnosis
• Fracture (in the elderly)
• Stress fracture (in high-level athletes)
• Apophysitis, slipped epiphysis, avascular process (in younger people)
• Myofascial
• Visceral referred (renal, genitourinary)
• Capsular involvement of hip
• Synovitis
• Arthritides
• Hernias
• Lower back pain
• Contusion
• Lumbar spine or knee referred pain
• Bursitis
• Tumour
• Periostitis
• Infection
Sprain Hip/Thigh S53..
Printed Body ex Format
63
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
63
Investigations
• X-ray if the injury is traumatic or there is no obvious soft tissue injury
• Ultrasound
• MRI for tumour or infection
• CT for pelvic fracture
Complications
• Hip pathology
• Chronic recurrent injury
• Myositis ossificans
Treatment/Rehabilitation/Management
Acute:
• RICE up to the first 48 hours
• Light mobilisation to pain tolerance
• Pain moderation if necessary
Sub-acute:
• Exercise programme – stretch/strength/isometric
• Muscle imbalance – assessment/programme
• Pain moderation as necessary
• Refer for mobility assistance if necessary (crutch etc)
• Keep the elderly as mobile as possible
Referral
• Refer to GP for:
– fracture
– avascular necrosis
– dislocation
– tumour
– infection
– hernia
– Grade 3 ligament injuries
• Refer to X-ray if not available on-site
64
Sprain Hip /Thigh S53..
Printed Body ex Format
64
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:11
Sprain Quadriceps Tendon
Read Code:
S533.
Number of treatments: 10
Triggers:
14
KEY POINTS
• Children <12 years rarely sprain their ligaments
• Elderly patients are much more likely to fracture bones than sprain
ligaments
• Elderly patients are prone to suffer stiffening of their joints, eg frozen
shoulder, even in more peripheral injuries, and need early mobilisation
• RICE therapy is useful early (for the first 24 hours, possibly 48) for most
sprains
• Watch for tendon ruptures in older patients
Special considerations
• Activity/sport
• Age
History
• Trauma – direct blow/sudden onset
• Mechanism of injury – sport/recreation/work
• Lumbar spine
• Hip joint
• Fall
• Trip
• Sports injury
• Twisting injury
Examination
• Knee joint
• Patello-femoral joint
• Selective tissue tension testing
• Pain pattern
• Swelling
• ROM
• Neutral tension
• Palpation
• Biomechanical assessment
• Pain and/or instability when stressing tendon
• Function to exclude fracture
• Gap in tendon
Differential diagnosis
• Bursitis
• Osgood-Schlatter disease
• Patello-femoral syndrome
• Chondromalacia patella
• Plica’s syndrome
• Patella fracture
Sprain Quadriceps Tendon S533.
Printed Body ex Format
65
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
65
Sprain Quadriceps Tendon
•
•
•
•
•
•
•
•
Infrapatella fat pad
Haematoma
Lumbar spine
Hip joint
Fracture
Tendon rupture
Muscle tear
Infection/abscess
Investigations
• X-ray, to exclude fracture
• Ultrasound by an experienced sonographer
Complications
• Functional rehabilitation
• Biomechanical adjustment
Treatment/Rehabilitation/Management
Acute:
• RICE
• Palliative techniques
• Strap/wrap/brace
• Gait re-education
• Active exercises/isometric stretch
• Walking aid
Sub-acute:
• Stretches
• Deep tissue massage
• Strengthening exercises
• RICE in first 24 hours
• NSAIDs may have a place, but may also delay healing
• Splintage or knee brace as required for pain
• Early mobilisation, especially in the elderly
• Isometric exercise training as a prevention of muscle wasting, especially
for all knee injuries
Referral
• Refer to podiatrist
• Refer to GP for referral to specialist if:
– fracture
– Grade 3 ligament injury
– ligamentous or tendon inflammation has become chronic
– large haematoma
• Refer to X-ray if not available on-site
66
Sprain Quadriceps Tendon S533.
Printed Body ex Format
66
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Lateral Collateral Ligament Knee
Read Code:
S540.
Ottawa Knee Rules
X-ray if:
Number of treatments: 10
Triggers:
patient > 55 years
14
tenderness present at head of fibula
isolated tenderness over patella
KEY POINTS
• Use RICE therapy early
• Use removable splints and physiotherapy rather than casts
• Children <12 years rarely sprain their ligaments
• Elderly patients are more likely to fracture than sprain
• The majority achieve functional recovery if the injury is uncomplicated
• It is important to rule out lumbar spine involvement
• A lateral collateral ligament sprain is less likely to tear than a medial
collateral ligament sprain
• Injuries are usually accompanied by other tissue injuries
inability to flex knee to 90o
inability to transfer weight for 4 steps
both immediately after injury and at
examination
Exclusion criteria:
Age < 18 years
Isolated superficial injuries being
re-evaluated
Patients with altered levels of
Special considerations
consciousness, paraplegia,
• Degree of damage (Grades 1, 2, 3)
or multiple injuries
• Involvement (undiagnosed) of other structures
• ADLs/sport/occupation
Pittsburgh Knee Rules
• Lumbopelvic dysfunction may become a secondary problem resulting from Indicate radiography if the mechanism of injury
the knee injury
is blunt trauma or a fall, and either:
the patient is < 12 or > 50 years of age; or
History
• Difficulty with cutting moves in sports
• Location of pain/tenderness
• Onset of swelling at the time of the injury
• Loss of function/ability to continue activity
• Determine the mechanism of the injury
• Weight bearing ability
• Locking, giving way, clicking
• Steroid use
• Diabetes, rheumatoid arthritis
the injury causes an inability to walk
4 weight-bearing steps at examination
Exclusion criteria:
Knee injuries that occur over 6 days
before presentation
Patients with only superficial lacerations
and abrasions
Those with a history of previous
Examination
• Determine the degree of damage (Grades 1, 2, 3)
• ROM/Strength
• Area of pain or tenderness
• Joint stability
• Lumbar spine/hip
• Neurological examination of the involved lower extremity
• Observe gait, whether the patient usually walks with their knee in slight
flexion
• Swelling, ROM
• Ligament laxity/resistance
• Difficulty climbing or descending stairs
• Lachman’s, McMurray’s tests
• Acute oedema
Sprain Lateral Collateral Ligament Knee S540.
Printed Body ex Format
67
surgeries or fractures on the
affected knee
Reassessments of the same injury
RED FLAG:
If the knee opens to valgus/varus
stress while fully extended this
implies a posterior capsular tear of
the knee and should be referred
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
67
Sprain Lateral Collateral Ligament Knee
Differential diagnosis
• ACL injury
• Meniscal injury
• Muscle injury – hamstring, popliteus, gastrocnemius
• Posterior capsule
• Iliotibial band
• Lumbar spine
• Fracture
• Patella injury
Investigations
• X-ray – see Ottawa and Pittsburgh Rules
Complications
• Patello-femoral syndrome
• Knee instability
• Quadriceps atrophy
• Meniscus injury
Treatment/Rehabilitation/Management
Acute:
• RICE
• Education about the injury
• NSAIDs or alternative pain management
• Knee brace/strap/tubigrip
• Mobility aid
• Lumbopelvic dysfunction if involved
Sub-acute:
• As for acute phase
• Strengthening exercises
• Stretching exercises
• Modify sport and recreational activity
• Gait retraining
• Proprioception
• Joint mobilisation
Referral
• Refer to GP for:
– pain control
– referral to specialist if Grade 3 sprain, recurrent strains, instability or
fracture
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to occupational therapist if rehabilitation is difficult at work or home
• Refer to X-ray if not available on-site
68
Sprain Lateral Collateral Ligament Knee S540.
Printed Body ex Format
68
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Medial Collateral Ligament Knee
Read Code:
S541.
Ottawa Knee Rules
X-ray if:
Number of treatments: 10
Triggers:
patient > 55 years
14
tenderness present at head of fibula
isolated tenderness over patella
KEY POINTS
• Use RICE therapy early
• Use removable splints and physiotherapy rather than casts
• Children <12 years rarely sprain their ligaments
• Elderly patients are more likely to fracture than sprain
• The majority achieve functional recovery if the injury is uncomplicated
• 2nd and 3rd degree sprains usually result from forced valgus knee injury
• 1st degree may be the result of chronic strain through valgus loading
factors (pronation)
• It is important to rule out lumbar spine involvement
inability to flex knee to 90o
inability to transfer weight for 4 steps
both immediately after injury and at
examination
Exclusion criteria:
Age < 18 years
Isolated superficial injuries being
re-evaluated
Patients with altered levels of
Special considerations
consciousness, paraplegia,
• Degree of damage (Grades 2, 3)
or multiple injuries
• Other injured structures
• ADLs/sport/occupation
Pittsburgh Knee Rules
• Lumbopelvic dysfunction may become a secondary problem resulting from Indicate radiography if the mechanism of injury
the knee injury
is blunt trauma or a fall, and either:
History
• Location of pain/tenderness
• Onset of swelling at the time of the injury
• Loss of function/ability to continue activity
• Determine the mechanism of the injury
• Weight-bearing ability
• Locking, giving way, clicking
• Steroid use
• Diabetes, rheumatoid arthritis
• Medial knee pain above or below joint
the patient is < 12 or > 50 years of age; or
the injury causes an inability to walk
4 weight-bearing steps at examination
Exclusion criteria:
Knee injuries that occur over 6 days
before presentation
Patients with only superficial lacerations
and abrasions
Those with a history of previous
surgeries or fractures on the
Examination
• Determine degree of damage (Grades 1, 2, 3)
• ROM/strength
• Joint stability
• Lumbar spine/hip
• Neurological examination of the involved lower extremity
• Observe gait, including pronation
• Ligament laxity/resistance
• Palpable tenderness proximal rather than distal
• Acute oedema
• Lachman’s, McMurray’s tests
affected knee
Reassessments of the same injury
RED FLAG:
If the knee opens to valgus/varus
stress while fully extended this
implies a posterior capsular tear of
the knee and should be referred
Differential diagnosis
• Cruciate ligament injury
• Meniscal injury
• Fracture
Sprain Medial Collateral Ligament Knee S541.
Printed Body ex Format
69
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
69
Sprain Medial Collateral Ligament Knee
•
•
•
•
Patella tendon
Patello-femoral syndrome
Muscle injuries
Bursitis
Investigations
• X-ray – see Ottawa and Pittsburgh Rules
Complications
• Knee instability
• Quadriceps atrophy
• Meniscus injury
• Patello-femoral syndrome
Treatment/Rehabilitation/Management
Acute:
• RICE
• NSAIDs or alternative pain management
• Knee brace/strap/tubigrip – especially if the cruciate ligament is involved
• Mobility aid
• Lumbopelvic dysfunction, if involved
Sub-acute:
• As for acute phase
• Strengthen medial and lateral stabilisers
• Stretching exercises
• Modify sport and recreational activity
• Gait – correct pronation if necessary
• Proprioception
• Joint mobilisation
• After 2 weeks, resume straight line activities
Referral
• Refer to GP for:
– time off work
– referral to specialist for Grade 3 sprain, recurrent strains, instability or
fracture
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to occupational therapist if rehabilitation is difficult at work or home
• Refer to X-ray if not available on-site
70
Sprain Medial Collateral Ligament Knee S541
Printed Body ex Format
70
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Cruciate Ligament Knee
Read Code:
S542.
Number of treatments:
12
Triggers:
16
Ottawa Knee Rules
X-ray if:
patient > 55 years
tenderness present at head of fibula
isolated tenderness over patella
o
inability to flex knee to 90
KEY POINTS
inability to transfer weight for 4 steps
• The patient may have a previous history or be unstable
• If the injury is acute or has happened to a sports person, it may require
both immediately after injury and at
surgical repair
examination
• Start treatment early – either the same day or the next – to prevent muscle
atrophy
Exclusion criteria:
• Fractures rather than sprains are more likely in elderly people
Age < 18 years
• Use RICE
Isolated superficial injuries being
• There is a higher risk of tendon rupture in elderly people
re-evaluated
• It is important that the patient regains complete flexion/extension after the
injury while restricting rotation
Patients with altered levels of
• 70% of anterior cruciate ruptures need immediate surgery
consciousness, paraplegia,
or multiple injuries
Special considerations
• Associated meniscus injury is common
Pittsburgh Knee Rules
• Elderly people require early mobilisation
Indicate radiography if the mechanism of injury
• The knee should normally be immobilised for no more than 3 days
• Lumbopelvic dysfunction may become a secondary problem resulting from is blunt trauma or a fall, and either:
the patient is < 12 or > 50 years of age; or
the knee injury
the injury causes an inability to walk
History
• The patient may present in the acute or chronic phase
• Acute injuries involve a sudden onset of pain following forced
hyperextension, flexion or direct contact
• Audible “pop” or “snap” felt
• History of forced flexion or forced hyperextension against resistance
• General instability
• Unresolved previous injury
• Loss of function
• Rapid swelling (usually in first 4 hours) implies ACL/PCL rupture or
fracture
4 weight-bearing steps at examination
Exclusion criteria:
Knee injuries that occur over 6 days
before presentation
Patients with only superficial lacerations
and abrasions
Those with a history of previous
surgeries or fractures on the
affected knee
Reassessments of the same injury
Examination
• Lachman’s, Drawers, pivot shift
• Test gait – limp, loss of function
• Wasting, muscle spasm
• Quadriceps mechanism/joint stability
• Swelling
• Gait
• ROM
• Lumbopelvic dysfunction if involved
• Locking/loose body or avulsion in joint
Differential diagnosis
• Medial, lateral ligament injury and meniscal tears
• Fracture
Sprain Cruciate Ligament Knee S542.
Printed Body ex Format
71
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
71
Sprain Cruciate Ligament Knee
•
•
•
•
•
•
•
Anterior/Posterior cruciate – partial/complete tear
Rupture of quadriceps mechanism
Patello-femoral pain or dysfunction
Hip and lumbar pain or dysfunction
Gout
Tendonitis/bursitis
Rheumatoid arthritides
Investigations
• Ottawa or Pittsburgh Rules for X-raying knee
• MRI may help determine the extent of an ACL tear
• Diagnostic arthroscopy may be necessary to confirm the diagnosis
Complications
• Fractures
• Associated meniscus injury
• Patellar dislocation
• Osteoarthritis
• Chronic instability
• Unstable knee
• Bursitis
• Capsulitis
• Hip/lumbar dysfunction
• Patello-femoral syndrome
• Unstable knee
• Rupture of quadriceps mechanism, including wasting
Treatment/Rehabilitation/Management
Acute:
• RICE
• NSAIDs or alternative pain relief
• Manual therapy
• Light knee wrap/tubigrip to bracing depending on the extent of the injury
• Education about the injury mechanism and sporting activities
• Lumbopelvic dysfunction if involved
Sub-acute:
• Continuation as for acute
• Stability exercises
• Strengthening exercises (hamstring strengthening/flexibility, closed chain
quadriceps)
• Avoid seated knee extensions
• Grade 3 or bone avulsion needs specialist referral
Referral
• Refer to GP for specialist referral for:
– fracture
– functional instability
– ACL/MCL injury
– rupture
– ACL with bone attached
72
Sprain Cruciate Ligament Knee S542.
Printed Body ex Format
72
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Cruciate Ligament Knee
– meniscal injury
– rupture quadriceps mechanism
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to occupational therapist for return to work assessment if necessary
• Refer to X-ray if not available on-site
Sprain Cruciate Ligament Knee S542.
Printed Body ex Format
73
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
73
74
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
74
23/01/2003, 10:12
Sprain Gastrocnemius
Read Code:
S54x1
Number of treatments: 10
Triggers:
14
KEY POINTS
• Elite athletes require prompt treatment
• Sprain gastrocnemius often occurs in middle-aged athletes
• Ultrasound imaging is the preferred diagnostic modality (though rarely
used)
• Children <12 years rarely sprain their ligaments
• Elderly patients are more likely to fracture or rupture
• Elderly people require early mobilisation
• Apply RICE therapy early
• Rule out lumbar spine/radiculopathy
Special considerations
• Refer if full tear – may require casting
• Lumbopelvic dysfunction may become a secondary problem resulting from
the knee injury
• If chronic, check sacrum
History
• The condition frequently occurs when the knee is extended while the foot
is dorsiflexed, or during dorsiflexion of the ankle/foot with the knee
already extended
• Sudden onset of pain while moving
• Age usually >20 years
• Described as feeling shot/kicked in the back of the knee
• Restricted dorsiflexion of ankle
• Previous injury
• Existing neuromuscular disease
Examination
• Neurovascular status
• Pain on resisted plantar flexion
• Localised pain/tenderness and swelling, usually at upper medial calf
• There may be a step or gap in the muscle
• Visible bruising and/or swelling
• Pain on walking, especially on tiptoes
• Lumbopelvic exam
• Neurological exam of the involved lower extremity
Differential diagnosis
• DVT
• Spinal/sacral origin
• Baker’s cyst
• Knee referral
• Ankle sprain
• Partial/complete muscle tear
Sprain Gastrocnemius S54x1
Printed Body ex Format
75
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
75
Sprain Gastrocnemius
• Rupture of the Achilles tendon
• Lumbar spine/radiculopathy
Investigations
• Investigations may require referral to GP:
– Doppler if DVT is suspected
– ultrasound if the extent of the rupture is unknown (rarely used)
– X-ray of the lumbar spine, if involved
Complications
• Suspected fracture
• Not responding to conservative treatment
• Muscle rupture/necrosis
• Achilles tendon damage
• Current/recurrent tendonitis
• Missed tendon rupture
Treatment/Rehabilitation/Management
Acute:
• RICE
• Analgesia
• Strapping/bandage/tubigrip
• Temporary heel raise (6mm-12mm)
• Crutches if necessary
• Management advice
• Manipulation of lumbar spine and pelvis, if involved
Sub-acute:
• Gradual stretching exercise programme after 1 week
• Functional re-education
• Biomechanics assessment, including pelvis
• Gait re-education
• Muscle balance assessment/programme
Referral
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to podiatrist
• Refer to GP for:
– suspected rupture
– suspected DVT
– associated fracture
– injuries not responding over 2 weeks
• Refer to X-ray if not available on-site
76
Sprain Gastrocnemius S54x1
Printed Body ex Format
76
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Ankle
Read Code:
S550.
Ottawa Ankle Rules
X-ray if:
Number of treatments: 10
Triggers:
unable to bear weight (take 4 steps)
at time of injury and at examination
14
bone tenderness at posterior edge or
tip of either malleolus
KEY POINTS
• Use RICE therapy early
• Use the Ottawa Rules for X-raying the ankle injury
• Grade 3 and ruptures require referral
bone tenderness over the naviculus or
base of fifth metatarsal
RED FLAG:
Special considerations
• The patient’s age
• Elderly patients are more likely to fracture than sprain
• Children <12 years rarely sprain their ligaments
• Lumbopelvic dysfunction may be a contributory factor to the injury or
may become a secondary problem resulting from the ankle injury
Prolonged symptoms >6 weeks of
appropriate rehabilitation (pain,
swelling, antalgia, decreased range
of motion) suggestive of
osteochondral injury/capsulitis.
Re-X-ray and refer
All children <12 years
History
• The injury mechanism
• Is the injury the result of trauma or a recurrent injury?
• Recreational and work activities
• Functional ability
• Pain management
• Weight bearing ability
• Site of pain
• Pain elsewhere in the limb
• Any previous injury and treatment
• Residual dysfunction if previously injured
• Examination
• Weight-bearing function or instability
• Abnormal gait
• Point tenderness over ligament or insertion point
• Pain in the sinus tarsi region suggests ATF ligament tear
• Decreased ROM
• Degree of ligament damage
• Check the full length of the fibula
• Check the 5th metatarsal
• Joint stability/laxity
• Neurovascular status
• Ecchymosis, swelling, areas of tenderness
• Drawer sign
• Lumbopelvic dysfunction
Elderly patients
Differential diagnosis
• Rule out fibula fracture and mortise widening
• Rule out avulsion of bone
• Rule out 5th metatarsal fracture
• Rule out ruptured syndesmosis
• Tarsal syndrome
• Ligamentous laxity
Sprain Ankle S550.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
77
23/01/2003, 10:12
77
Sprain Ankle
•
•
•
•
•
•
Subtalar joint dysfunction
Peroneal nerve neuropathy
Rupture tibialis posterior tendon, especially if the patient is >45 years
Anterior tibia-fibular tear
Lateral ligament sprain – exclude fracture of the 5th metatarsal
A medial ligament sprain is usually accompanied by another sprain or
fracture
Investigations
• X-ray – use the Ottawa Rules
• X-ray – a mortice view may be necessary
• Image the full length of the fibula if necessary
• Consider stress views if there is instability
• Refer for a bone scan if indicated
• MRI only if pain continues (to rule out talar bone lesion)
Complications
• Avulsion fracture
• Recurrence
• Instability
• Arthritis
Treatment/Rehabilitation/Management
Acute:
• Goal – reduce swelling and pain. Avoid full weight bearing
• Use RICE
• Immobilise to allow healing if necessary
• Talar or tibial adjustment, depending on severity
• Crutch-walking – toe touching only for 1-3 days with Grade 2 injuries
• Open chain exercises – mild isometrics in neutral (no closed chain
exercises)
• Check for weakness in the hip abductors
• Evaluate for pronation/supination
• Mild, passive ROM
• Strap/Wrap/Brace
• Proprioceptive training
• Manipulation of the lumbar spine and pelvis, if involved
Sub-acute:
• Goal – progress to full weight bearing, full ROM, no swelling
• Talar or tibial adjustment
• Ice after activity
• Decrease crutch dependency after 1-2 days of gradual weight bearing
• Ankle support for full weight bearing
• ROM – postisometric relaxation re stretching
• Open chain exercises
• Closed chain exercises
• Proprioceptive training – weight bear with taping/support if necessary
• Check shoes re heel counter
78
Sprain Ankle S550.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
78
23/01/2003, 10:12
Sprain Ankle
Chronic:
• Goal – proprioceptive stabilisation, correct underlying causes
• Navicular, cuboid, calcaneal and talar adjustment as necessary
• Athletes need support during restrengthening/sports
• Elastic bandage for walking if necessary
Grade 1:
• Review in 1 week if no improvement
• Manipulation of the lumbar spine and pelvis, if involved
Grade 2:
• RICE
• Review after 2-4 weeks if no improvement
Grade 3:
• Refer acutely
Referral
• Refer to podiatrist
• Refer to GP for specialist for:
– Grade 3 injuries
– fractures
– tendon injuries
– medial ligament sprains
– tibialis posterior rupture
– rupture of inferior tibia/fibula ligament
• Refer to physiotherapist for acupuncture
Sprain Ankle S550.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
79
23/01/2003, 10:12
79
80
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
80
23/01/2003, 10:12
Sprain Achilles Tendon
Read Code:
S5504
Number of treatments: 12
Triggers:
16
KEY POINTS
• Elite athletes need timely treatment
• Ultrasound is the preferred diagnostic modality
• The patient may require POP in full equinus for 10 days, semi equinus for
7-10 weeks
Special considerations
• Occupation and sport
• Systemic corticosteroid medication
• Sports – particularly those requiring ballistic-type activities and hard
surfaces
• Systemic corticosteroid medication may contribute or predispose the
patient to injury
• Lumbopelvic dysfunction may become a secondary problem resulting from
an ankle injury
History
• Mechanism and type of injury
• Acute trauma (sudden onset if sprain) versus gradual onset (weeks)
• Present and past history of injury
• Pain distribution and description (niggly, severe if running, tightness)
• Functional limitations – walking, running
• Current and past training schedules
• Equipment, eg footwear (oversized or tight), orthotics
• Functional limitations
• Excessive morning stiffness
• Contributing factors such as gait/biomechanics – rear foot pronation,
tendonopathies
• Medications
• Trigger event (change in footwear, self-prescribed orthotic etc)
• Difficulty and pain or cannot dorsiflex ankle
• Previous injury or injection
• Gout
• Triceps surae tightness may be a contributing factor
Examination
• Compare with the other side
• Pain on dorsiflexion
• Step or gap in tendon on palpation
• Tendon tenderness
• Swelling/thickening of tendon
• Calf squeeze (Thompson test)
• ROM
• Soft tissue or joint restriction
• Strength – weight bearing, non-weight bearing
Sprain Achilles Tendon S5504
Printed Body ex Format
81
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
81
Sprain Achilles Tendon
•
•
•
•
Biomechanical
Gait
Ankle joint dysfunction
Lumbopelvic dysfunction
Differential diagnosis
• Bursitis (retro calcaneal)
• Rupture of Achilles tendon
• Gout
• Bruising
• Associated fracture
• Osteo/rheumatoid or inflammatory arthropathy
• Partial/complete rupture
• Retrocalcaneal bursitis
• Tendonitis – tibia posterior, peronei, flex hall longus
• OS trigonum fracture, calcaneal fracture
• Sever’s disease
• Compartment syndrome
• Haematoma
• CRPS
• SI reflex
• Subtalar or talo crural joint dysfunction
Investigations
• X-ray to rule out fracture/rheumatoid arthritis and erosive calcaneal
changes
• MRI can help differentiate between tendonitis and partial rupture (but is
used rarely)
Complications
• Recurrence
• Rupture
• Tendonitis
• Steroid depositions
• POP effects
• Gradual injury process
• Severe biomechanical dysfunction
• Rupture of tendon
Treatment/Rehabilitation/Management
• Some patients may require referral for equinus POP for 7-10 days
• Stretches – soft tissue mobilisation
• Manipulation of the lumbar spine and pelvis, if involved
Acute:
• If patient has self medicated, advise them that NSAIDs will be of limited
help
• Ice massage every 15 minutes/2-hourly if necessary
• Moderate activities that exacerbate or aggravate
• Limit movements to allow the inflammation to subside
82
Sprain Achilles Tendon S5504
Printed Body ex Format
82
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Achilles Tendon
•
•
•
•
•
Use other palliative techniques if necessary
Use heel raise/strapping to produce mild equinus/stability
Implement a graduated eccentric loading exercise programme
Education – sport modification/rest
Manipulation of the lumbar spine and pelvis, if involved
Sub-acute:
• Transverse/longitudinal friction massage
• Correct talus and calcaneal fixations
• Graded strengthening exercises of gastrocnemius, soleus and tibialis
anterior
• Tubing/stretching/flexibility exercises
• Increase pain-free mobility
• Proprioception exercise if necessary
• Foot/ankle biomechanics
• Orthotics may help with hyperpronation problems
• Home care advice on exercise intensity, shoes, support if returning to
vigorous exercise
Goals:
• Decrease pain, increase mobility in pain-free range, return to pre-injury
status
• The patient should participate in these recovery goals
Referral
• Refer to specialist if:
– suspected or complete rupture
– suspected DVT
– no improvement over 2 months
• Refer to GP for:
– work incapacity
– previous rupture
– associated fracture
• Refer to podiatrist for orthotics/footwear advice
• Refer to physiotherapist for electrical stimulation, acupuncture
Sprain Achilles Tendon S5504
Printed Body ex Format
83
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
83
84
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
84
23/01/2003, 10:12
Sprain Metatarso-Phalangeal Joint/
Interphalangeal Joint
Read Code:
S5512/S5513
Number of treatments: 6
Triggers:
8
KEY POINTS
• Refers to sprain after fracture excluded
• Plantar displacement is best seen on a lateral X-ray
• If the patient is in persistent pain after 7-10 days, re-X-ray for occult
fracture
• Undisplaced intra-articular fractures require re-X-ray at 1 week to exclude
displacement
• Gout may be triggered by trauma, presenting 2-5 days after injury
• MTP joints must heal with normal mobility to maintain normal gait
• In rare cases, 3rd degree sprain may result in dislocation
Special considerations
• Occupation, sport and daily activities
• Vascular disease – peripheral and systemic (diabetes)
• The patient’s gender
• Lumbopelvic dysfunction may become a secondary problem resulting from
the foot injury
History
• Good history and examination are important
• Painful weight bearing
• Mechanism of injury and force
• Management to date
• Heavy blow or object falling onto the foot or toes
• Twisting injury
• Hyperextension
• Change in activities
• Change of shoes
Examination
• Local pain over involved ligament or tendon, increasing when stressed
• Gait
• Foot and lower limb biomechanics
• Footwear
• Proprioception
• Neurovascular status
• Deformity
• Ecchymosis
• Swelling
• Lumbar spine exam
Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint S5512/S5513
Printed Body ex Format
85
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
85
Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint
Differential diagnosis
• Sesamoids
• Flexor hallicus tendonitis
• Arthritides
• CRPS
• Metatarsalgia
• Morton’s neuroma
• Fracture of MT neck, stress fracture intra-articular fracture
• Gout
Investigations
• X-ray to exclude toe, foot and occult fracture
• Sesamoids
• X-ray lumbar spine, if involved
Complications
• Neuroma
• Altered biomechanics
• Fracture or dislocation
Treatment/Rehabilitation/Management
Acute:
• RICE
• Joint mobilisation
• Proprioceptive retraining
• Stretching exercises specific to injury
• NSAIDs or other analgesia
• Manipulation of lumbar spine, if involved
Sub-acute:
• Joint mobilisation
• Gait re-education
• Education/self management
• Stretching and strengthening exercises depending on the injury
• Buddy strap
• Hard-soled shoes
• Review and re-X-ray in 1 week if intra-articular fracture is suspected
• Manipulation of lumbar spine, if involved
Referral
• Refer to podiatrist
• Refer to GP for:
– bloods if gout suspected
– fracture of the MT neck with tilt on MT head
– displaced intra-articular fracture
– tendon rupture
• Refer to physiotherapist for acupuncture
• Refer to X-ray if not available on site
86
Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint S5512/S5513
Printed Body ex Format
86
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:12
Sprain Ribcage
Read Code:
S5y3.
Number of treatments: 6
Triggers:
10
KEY POINTS
• A good history and examination are essential
• Review the patient for soft tissue damage to intercostal structures
• Pain control
• If in doubt, refer for a second opinion or emergency care
Special considerations
• Decreased lung function/PEF
• Decreased ROM of arm, cervical spine, thoracic spine
• Chronic pain
History
• Look for an injury history of internal or external force, eg cough, sneeze
versus sport contact, fall
• Osteoporosis
• Whether pain is frequently specific or local
• Dyspnoea – may be painful
• ROM pain
• Referred pain
• Pleuritic chest pain
• Asthma
• Cardiac or respiratory disease
• Cervical spine/brachial plexus
• Coughing secondary to chest infection, allergy etc
Examination
• Local/point tenderness
• Decreased ROM
• Decreased accessory movements
• Muscle spasm
• Cervical and thoracic spine and shoulder involvement
• Contusion, ecchymosis
• Cervical spine
• First rib structures/articulations
• Referred pain
• Fever
Differential diagnosis
• Herpes
• Thoracic spine injury/referral
• Cervical spine injury/referral
• Viscero-somatic pain
• Tumour
• Chest wall contusion
• Costo-vertebral or costo-sternal
Sprain Ribcage S5y3.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
87
23/01/2003, 10:13
87
Sprain Ribcage
• Pneumothorax/haemothorax
• Pleurisy
• Fracture
Investigations
• X-ray – refer for expiratory and oblique
• The patient may need referral for CT views if their first rib is involved
Complications
• Haemothorax, pneumothorax
• Exacerbation of pre-existing respiratory condition
• Pneumonia
• Steroid use
• Hypoxia
Treatment/Rehabilitation/Management
• RICE
• ROM exercises, including for associated joints
• Bracing or padding for sport
• Pain relief
• Manipulation
Referral
• Refer to GP for:
– TOW
– pain assistance
• Refer to physiotherapist for TENS, other electrical simulation, acupuncture
88
Sprain Ribcage S5y3.
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
88
23/01/2003, 10:13
Carpal Tunnel Syndrome
Read Code:
F340.
Number of treatments: 12
Triggers:
16
KEY POINTS
• There is an increased incidence of carpal tunnel syndrome among females
• Multiple factors influence the symptoms
• Rest is very important
• Different conditions may have similar causation
• It is important to consider associated conditions such as myxoedema or
pregnancy
Special considerations
• Aetiology includes carpal subluxation, malhealed fracture, tenosynovitis,
tumour, congenital malformation
• May also be secondary to pregnancy, diabetes, rheumatoid arthritis,
sarcoidosis, thyroid
• Also associated with menstrual cycle and menopause and obesity
• Rule out a cervical component creating a “Double Crush Syndrome”
History
• Usually gradual, insidious onset
• Episodic and nocturnal pain and numbness which may awaken the patient
• Parasthesiae and loss of sensation
• Exacerbated by manual activity
• Decreased grip strength
• Fluid retention
• Idiopathic
• Post Colle’s fracture
• RA
• Pain aggravated by excessive, prolonged or repetitive movements and
activity
• Other medical conditions
• Cervical spine symptoms
• Referred pain
Examination
• Phalens, Tinel
• Decreased pain sensation
• Weakness and/or atrophy in the abductor pollicus brevis muscles
• Decreased grip strength
• Pain over palmar aspect of wrist, may radiate up forearm
• Sensory changes in hand and fingers
• Cervical spine exam
• Sensory and motor exam of the involved upper extremity
Differential diagnosis
• Cervical spine C6 nerve root compression
• Brachial neuritis
Carpal Tunnel Syndrome F340.
Printed Body ex Format
89
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
89
Carpal Tunnel Syndrome
•
•
•
•
•
•
•
•
•
•
Trauma
Fracture
Tenosynovitis
Myofascial trigger point referral
Tunnel of Guyon entrapment
Thoracic outlet syndrome
Space occupying lesion
Capitate-lunate dysfunction
Organic or systemic disease
Double Crush Syndrome
Investigations
• Nerve conduction studies
Complications
• Recurrence
• Nerve damage
• Chronic pain
• Partial tear or rupture of the tendon
• Occupational problems
Treatment/Rehabilitation/Management
Acute:
• Splint or taping of wrist
• Cryotherapy/ice massage
• Pain management
• Rest
• Mobilisation
• Education on aggravating factors
• Early strengthening exercises
• Manipulation of the cervical and thoracic spine, if necessary
• Manipulation of carpals
Sub-acute:
• Pain management
• Task modification
• Working splints (short term)
• Gradual return to work
• May need referral for workplace assessment
• Myofascial tx to forearm
Referral
• Refer to GP for:
– pain management if necessary
– onward referral if failure to respond
• Refer to physiotherapist for:
– TENS, acupuncture
– splints if required (resting and work splints if complex)
• Refer to occupational therapist for task modification/workplace assessment
90
Carpal Tunnel Syndrome F340.
Printed Body ex Format
90
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Rotator Cuff Syndrome
Read Code:
N211.
Number of treatments: 12–16
Triggers:
18
KEY POINTS
• Rotator cuff shoulder syndrome results from a progressive, degenerative
process
• It initially starts as a dull ache in the deltoid region, frequently after
strenuous exercise. Pain may become persistent and nocturnal – associated
with tendon inflammation
• The patient may present with a prolonged history of pain with associated
tendon degeneration/rupture
• It is associated with impingement/painful arc syndrome
• Rotator cuff shoulder syndrome is usually due to more than one event
• Patients who have had cuff corticosteroid injections are more likely to
develop tears
Special considerations
• Occupational activities
• Cervical spine referral and involvement
• Patients aged 35-50 years
• Female predominance
History
• Repetitive or strenuous overhead work
• Fall on outstretched arm
• May be secondary to DJD or rheumatoid arthritis
• Previous history or chronicity
• Referred pain to neck or deltoid insertion
• Previous treatment, management and investigations
• Night pain
• Nature of pain
• Aggravating or easing factors
• Functional limitations
• General health, past and present
• Special question – steroids, anticoagulants, diabetes, rheumatoid arthritis
• Male >40 years
• Trauma
Examination
• Visual inspection
• Painful and diminished abduction and during arc (60-120¡)
• Crepitus
• Include a neurological assessment to exclude other causes
• Active and passive ROM
• Test scapula rotator muscles for weakness
• Stability and strength tests
• Palpation – loss of muscle tone, local tenderness, swelling, Apley’s,
Codman’s, Mazion’s tests
Rotator Cuff Syndrome N211.
Printed Body ex Format
91
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
91
Rotator Cuff Syndrome
• Cervical spine
• Disuse atrophy
• X-ray – inferior malposition of humerus, chronic tear may reveal sclerosis
and irregularity of greater tuberosity, narrowing of acromiohumeral
interval to 5mm or less
Differential diagnosis
• Cervical and thoracic arthrosis
• Muscle tear/rupture
• Bursitis
• Biceps tendon rupture
• Cardiac condition
• Cancer
• AC/SC/GH joint DJD
• Calcific tendonitis
• Traumatic injury (anterior humeral subluxation, rotator cuff, biceps or
subscapularis tear/rupture)
• Adhesive capsulitis
• Thoracic outlet syndrome
• Radiculopathy
• Impingement syndrome
• Myofascial pain syndrome
Investigations
• X-ray
• Ultrasound
• Arthrogram or MRI if chronic
• EMG/Nerve conduction if neurological
Complications
• Fracture/dislocations/avulsion
• Inflammatory diseases including bursitis
• Neurological disease/involvement
• Tendon rupture
• Decreased shoulder movement
• Calcification
• Chronic pain
• Chronic shoulder dysfunction
Treatment/Rehabilitation/Management
• Goal – decrease pain and restore ROM
Acute:
• Initially rest – sling if necessary
• Pain control – NSAIDs or similar
• Modify activity
• Palliative tx
• Isometric/active exercises to tolerance
• Early stretching
• Light mobilisation
• Ergonomic information
92
Rotator Cuff Syndrome N211.
Printed Body ex Format
92
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Rotator Cuff Syndrome
Sub-acute:
• Palliative tx
• Muscle stretches
• Continue exercises – stretch/strengthen/stabilise
• Mobilisation GH/AC
• Cervical and thoracic manipulation/mobilisation/adjustment
• Transverse friction massage
• Gentle manipulation scapula, humerus, AC and SC joint
• Educate on activities
• Supplementation
Referral
Refer to GP for:
• subacromial injection
• pain relief
• home help if necessary
• Medial Epicondylitis (Elbow)
Rotator Cuff Syndrome N211.
Printed Body ex Format
93
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
93
94
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
94
23/01/2003, 10:13
Medial Epicondylitis (Elbow)
Read Code:
N2131
Number of treatments: 12
Triggers:
14
KEY POINTS
• The injury requires careful differential diagnosis
• It generally results from gradual process
• It is important to evaluate for stressors and try to modify them
• Steroid injections are usually effective if the response to treatment is slow
• This condition is not usually seen in people <18 years
• Rule out cervical radiculopathy
Special considerations
• NSAID therapy
• Previous steroid injection
• Occupation
History
• Determine if the injury has resulted from an acute or recurrent injury or
gradual onset
• Assess pain with grip
• OOS (repetitive/forceful activity)
• Occupation/sport/recreation
• Ageing/arthritis
• Question the patient about neck and shoulder injuries
• Dominant versus non-dominant extremity
• Other upper limb symptoms
Examination
• Local medial epicondyle pain, tenderness or swelling
• Increased pain with resisted wrist motion – flexion
• Cervicothoracic spine
• Neurological evaluation of the involved upper extremity
• Examine all upper extremity joints
• Neurovascular status
• Crepitus (tendon)
• Forearm muscle strength/atrophy
• Golfer’s elbow
Differential diagnosis
• Intra-articular pathology
• Painful arc (shoulder)
• Nerve entrapment/irritation
• Cervical nerve root irritation
• Tendon/ligament injuries or instability
• Infection
• Medial epicondyle fracture
• Referred pain from cervical spine, shoulder or wrist
• Myofascial trigger points
Medial Epicondylitis (Elbow) N2131
Printed Body ex Format
95
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
95
Medial Epicondylitis (Elbow)
Investigations
• X-ray to rule out intra-articular pathology (if there is no response to
treatment or there are atypical features)
• Ultrasound referral if the injury is slow to recover and affecting the
patient’s ADLs
Complications
• Failure to identify and decrease the aggravating activity
• Rotator cuff/biceps tendon rupture
• Complex regional pain syndrome
• Psychosocial factors
• Joint stiffness
• Muscle weakness/loss
Treatment/Rehabilitation/Management
Acute:
• Treat for up to 1 month then transition the patient to a home exercise
programme
• RICE
• Rest
• Educate the patient about aggravating the activity throughout treatment
and rehabilitation
• NSAIDs or similar
• Supportive elbow band or strapping
• Start stretching exercises immediately
• Joint mobilisation
• Cervical manipulation
Sub-acute:
• Transverse friction massage
• Trigger point
• Moist heat
• Continue stretches
• Strengthening exercises as pain subsides
• Manipulate/mobilise subluxations/fixations of radial head, olecranon and
wrist, cervical and thoracic spine, ribs
• Forearm myofascial release
• Specific work/sport assessment if necessary
• Cervical manipulation
Referral
• Refer to GP if the patient is unable to work or perform ADL without
requiring assistance
• Refer to GP for:
– nerve entrapment
– tendon rupture
– suspected infection
– bloods
– specialist referral
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to occupational therapist for ADL workplace assessment if necessary
• Refer to X-ray if not available on-site
96
Medial Epicondylitis (Elbow) N2131
Printed Body ex Format
96
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Lateral Epicondylitis (Elbow)
Read Code:
N2132
Number of treatments: 12
Triggers:
16
KEY POINTS
• This injury requires careful differential diagnosis
• It is generally the result of gradual process
• It is important to evaluate for stressors and try to modify them
• Steroid injections are usually effective if the response to treatment is slow
• This injury is not usually seen in people <18 years
• Rule out cervical radiculopathy
Special considerations
• NSAID therapy
• Previous steroid injection
• Occupation
History
• Determine if the injury is the result of acute or recurrent injury or gradual
onset
• Assess pain with grip
• OOS (repetitive/forceful activity)
• Occupation/sport/recreation
• Ageing/arthritis
• Question the patient about neck and shoulder injuries
• Dominant versus non-dominant extremity
• Other upper limb symptoms
Examination
• Local lateral epicondyle pain, tenderness or swelling
• Increased pain with resisted wrist motion – extension
• Increased pain with finger extension
• Cervicothoracic spine
• Neurological evaluation of the involved upper extremity
• Examine all upper extremity joints
• Neurovascular status
• Crepitus (tendon)
• Forearm muscle strength or atrophy
• Grip strength
• Cozens/Mills/Kaplan’s/Tinel
Differential diagnosis
• Intra-articular pathology
• Painful arc (shoulder)
• Nerve entrapment/irritation
• Cervical nerve root irritation
• Tendon/ligament injuries or instability
• Infection
• Referred pain from cervical spine/shoulder/wrist
• Myofascial trigger points
• Rotator cuff injury
Lateral Epicondylitis (Elbow) N2132
Printed Body ex Format
97
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
97
Lateral Epicondylitis (Elbow)
Investigations
• X-ray to rule out intra-articular pathology (if there is no response to
treatment or there are atypical features)
• Ultrasound referral if the injury is slow to recover and affecting the
patient’s ADLs
Complications
• The failure to identify and decrease the aggravating activity
• Rotator cuff/biceps tendon rupture
• Complex regional pain syndrome
• Psychosocial factors
• Joint stiffness
• Muscle weakness
Treatment/Rehabilitation/Management
Acute:
• Treat for up to 1 month then transition the patient to a home exercise
programme
• RICE
• Rest
• Educate the patient about aggravating activity throughout their treatment
and rehabilitation
• NSAIDs or similar
• Supportive elbow band or strapping
• Start stretching exercises immediately
• Joint mobilisation
• Cervical manipulation
Sub-acute:
• Transverse friction massage
• Trigger point
• Moist heat
• Continue stretches
• Strengthening exercises as pain subsides
• Manipulate/Mobilise subluxations/fixations of radial head, olecranon and
wrist, cervical and thoracic spine, ribs
• Forearm myofascial release
• Specific work/sport assessment if necessary
• Cervical manipulation
Referral
• Refer to GP if the patient is unable to work or perform ADLs without
requiring assistance
• Refer to GP for:
– nerve entrapment
– tendon rupture
– suspected infection
– bloods
– specialist referral
• Refer to physiotherapist for electrical stimulation, acupuncture
• Refer to occupational therapist for ADL/workplace assessment if necessary
• Refer to X-ray if not available on-site
98
Lateral Epicondylitis (Elbow) N2132
Printed Body ex Format
98
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Tendonitis Achilles
Read Code:
N2174
Number of treatments: 12
Triggers:
16
KEY POINTS
• Elite athletes need immediate treatment
• Casting in full/semi equinus may help in non-athletic or elderly people
• If the injury is a rupture, consider surgery owing to the high re-rupture
rate
• Achilles tendonitis is classified as a fatigue disorder
• Rule out lumbar spine radiculopathy
Special considerations
• Occupational risks
• Sports, particularly those requiring ballistic-type activities and hard
surfaces
• Systemic corticosteroid medication may contribute or predispose people to
injury
• Lumbopelvic dysfunction may become a secondary problem resulting from
the ankle injury
History
• Mechanism of injury – overuse, trauma, repetitive stress, hard surfaces
• Acute trauma (sudden onset if sprain) versus gradual onset (weeks)
• Rheumatoid arthritis
• Present and past history of injury
• Pain distribution and description (niggly, severe if running tightness)
• Functional limitations – walking/running
• Current and past training schedules
• Equipment, eg footwear (oversized or tight), orthotics
• Increased morning stiffness
• Age, activity level and sport
• Symptom behaviour with weight-bearing activity
• Gait and biomechanics – rear foot pronation, tendonopathies
• Medications
• Trigger event (change in footwear, self-prescribed orthotic etc)
• Difficulty and pain or cannot dorsiflex ankle
• Previous injury or injection
• Gout
• Triceps surae tightness may be a contributing factor
Examination
• Compare with the other side
• Pain on dorsiflexion
• Step or gap in tendon on palpation
• Tendon tenderness
• Swelling/thickening of tendon
• Calf squeeze (Thompson test)
• ROM
Tendonitis Achilles N2174
Printed Body ex Format
99
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
99
Tendonitis Achilles
•
•
•
•
•
•
Gastrocnemius tightness
Other soft tissue or joint restriction
Gait
Ankle joint dysfunction
Lumbopelvic exam
Neurological exam of the involved lower extremity
Differential diagnosis
• Bursitis (retro calcaneal)
• Rupture of Achilles tendon
• Gout
• Bruising
• Associated fracture
• Osteo/rheumatoid or inflammatory arthropathy
• Partial/complete rupture
• Retrocalcaneal bursitis
• Tendonitis – tib. posterior, peronei, flex. hall. Longus
• OS trigonum fracture, calcaneal fracture
• Sever’s disease
• Compartment syndrome
• Haematoma
• CRPS
• SI reflex
• Subtalar or talo crural joint dysfunction
Investigations
• X-ray to rule out fracture/rheumatoid arthritis and erosive calcaneal
changes
• Refer for ultrasound – the preferred diagnostic modality – if necessary
• MRI can help differentiate between tendonitis and partial rupture (but is
used rarely)
Complications
• Recurrence
• Rupture
• Tendonitis
• Steroid depositions
• POP effects
• Gradual injury process
• Severe biomechanical dysfunction
• Rupture of tendon
Treatment/Rehabilitation/Management
• Severe cases may require referral for equinus cast for 7-10 days
Acute:
• If patient has self medicated, advise them that NSAIDs will be of limited
help
• Ice massage every 15 minutes/2-hourly if necessary
• Moderate activities that exacerbate/aggravate the injury
• Limit movements to allow the inflammation to subside
100
Tendonitis Achilles N2174
Printed Body ex Format
100
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Tendonitis Achilles
•
•
•
•
•
Use other palliative techniques if necessary
Use heel raise/strapping to produce mild equinus/stability
Manipulation of lumbar spine and pelvis, if involved
Employ a graduated eccentric loading exercise programme
Education – sport modification/rest
Sub-acute:
• Transverse/longitudinal friction massage
• Correct talus and calcaneal fixations
• Graded strengthening exercises of gastrocnemius, soleus and tibialis
anterior
• Tubing/stretching/flexibility exercises
• Increase pain-free mobility
• Proprioception exercise if necessary
• Foot/ankle biomechanics
• Orthotics may assist with hyperpronation problems
• Home care advice on exercise intensity, shoes, support if returning to
vigorous exercise
Goals:
• Decrease pain, increase mobility in pain-free range, return to pre-injury
status
• The patient should participate in these recovery goals
Referral
• Refer to GP for:
– specialist referral if suspected or complete rupture
– suspected DVT
– no improvement over 2 months
– work incapacity referrals
– associated fracture
• Refer to podiatrist for orthotics/footwear advice
• Refer to physiotherapist for electrical stimulation, acupuncture
Tendonitis Achilles N2174
Printed Body ex Format
101
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
101
102
Printed Body ex Format
Chiropractic Treatment Profiles – 2003
102
23/01/2003, 10:13
Synovitis and Tenosynovitis
Read Code:
N22..
Number of treatments: 16
Triggers:
16
KEY POINTS
• Synovitis and tenosynovitis involve inflammation of the synovial sheath
around the tendon
• Hand – de Quervains, intersection, extensors, long flexors, trigger finger
• Biceps – bicipital tenosynovitis
• Rest is very important
• The condition usually occurs after adolescence/18 years of age
• Rule out cervical spine involvement
Special considerations
• Different conditions may have similar causation
• Work environment
History
• Injury
• Gradual onset/cumulative strain
• Infection
• Previous history
• Specific activities – work/recreational activities may provoke the
condition
• Repetitive injury/OOS
• Pain, swelling or stiffness in the affected area
• Crepitation may be present
• The condition usually affects the hand, forearm, wrist, biceps
• Work environment demands
• Myxoedema
• Pregnancy
• Rheumatoid arthritis
• SLE
• Gout
• Gonorrhoea
Examination
• Crepitation
• Strength
• ROM
• Local posture
• Localised tendon sheath tenderness
• Pain with tendon glide – active and passive
• Swelling/inflammation – heat
• Joint effusion
• Cervical spine
Synovitis and Tenosynovitis N22..
Printed Body ex Format
103
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
103
Synovitis and Tenosynovitis
Differential diagnosis
• Tendonitis
• Gout
• Undiagnosed fracture
• Muscle tear or strain
• Carpal tunnel/injury
• Pregnancy
• Diabetes
• CRPS
• Carpal tunnel syndrome
• Myxoedema
• Inflammatory arthritis
• Joint sprain
• Cervical and thoracic spine dysfunction
• Nerve entrapment
Investigations
• X-ray to rule out pathology or tendon calcification
Complications
• Neural involvement
• Joint stiffness
• Muscle weakness
• OOS
• Chronic pain state
• Partial tear or rupture of the tendon (especially after a steroid injection)
• Ergonomic factors in occupational or recreational activities
• SLE
• Rheumatoid arthritis
Treatment/Rehabilitation/Management
Acute:
• RICE
• Discontinue any activity that causes pain
• NSAIDs or alternative pain assistance
• Advice and education
• Gentle mobilisation if possible
• Temporary splint or strapping
• Manipulation of the cervical and thoracic spine, if involved
Sub-acute:
• Stretches
• Strengthening
• Further education specific to the patient’s situation where possible
• Functional re-education
• Myofascial release
• Manipulation of the cervical and thoracic spine, if involved
• Return to work and home activities
• Workplace assessment
• Refer for possible steroid injections if not settling after 1 month
104
Synovitis and Tenosynovitis N22..
Printed Body ex Format
104
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
Synovitis and Tenosynovitis
Referral
• Refer to GP for:
– referral for nerve conduction tests and joint microscopy if necessary
– referral to a hand therapist for splints
– referral to a pain clinic
– associated medical problems
– associated work problems
• Refer to occupational therapist to assess workplace and for occupation
advice
• Refer to physiotherapist for electrical stimulation, acupuncture
Synovitis and Tenosynovitis N22..
Printed Body ex Format
105
Chiropractic Treatment Profiles – 2003
23/01/2003, 10:13
105
Printed cover ex (Converted)-2 23/01/2003 10:37 Page 3
Printed January 2003 • ISBN 0–478–25182–3 • ACC 1032
Composite