the clinical assessment: history, physical examination ... · the clinical assessment: history,...
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The clinical assessment: history, physical examination, load
assessment, demandRod Whiteley, PhD
Physiotherapist
Co
ok,
J. &
Pu
rdam
, C. B
JSM
20
09
Is t
end
on
pa
tho
log
y a
co
nti
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um
? A
pa
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y m
od
el t
o e
xpla
in t
he
clin
ica
l pre
sen
tati
on
o
f lo
ad
ind
uce
d t
end
on
op
ath
y
Pathology
Pain
Function
“My knee hurts” – what could this be?
• Patellar (Quads) tendonopathy
• PFPS, patellar instability
• Fat pad/bursitis
• ITBFS
• Physeal (tibia, patella, femur)
• Intra-articular (meniscal, loose body)
“My knee hurts”
• Where does it hurt?
• How did this start?
• What have you tried for this?
• Does your knee click/clunk? Does this hurt?
• Does your knee “lock up”? Does this hurt
• Does your knee “give way”?
• Focal, in the tendon
• Loading history (abrupt ↑ or ↓)
• What helps, what aggravates?
• ITBFS, Plica, crepitus, meniscal, patellar subluxation
• “Stiffening” after immob’n v mechanical
• “It goes out” v Quads inhibition
Where does it hurt?
Focal pain, in the tendon
PFJ
• Localised tenderness unusual
• Stairs/Squat/Sit-Stand usually bad
• Worse in flexion
• Dislikes heels
• Rarely swollen
Fat Pad
• Locally tender
• Standing/walking usually bad
• Likes standing in Flexion
• Heels can relieve pain
• Fat pad usually swollen
Activity
• “Warms up” (tendon) versus “Gets worse” (PFP, other inflammatory)
Onset
Tendon
• Jumping, direction change
PFP
• Running, stairs, loading in knee flexion
Acute:Chronic Workload Ratio
Ch
ron
ic w
ork
load
(%
of
no
rmal
ave
rage
)
110 4.7 4.1 3.6 3.4 3.2 3.3 3.5
100 4.3 3.7 3.4 3.3 3.3 3.6 4
90 3.9 3.5 3.3 3.3 3.6 4.2 4.9
80 3.5 3.3 3.3 3.7 4.3 5.3 6.6
70 3.3 3.3 3.7 4.6 5.8 7.5 9.5
60 3.3 3.8 4.9 6.6 8.8 11.6 14.9
50 4 5.5 7.9 11 14.9 19.6 24.1
40 6.6 10.1 14.9 20.9 28.2 36.7 46.5
30 14.9 23.2 33.7 46.5 61.4 78.6 98
60 70 80 90 100 110 120
Acute workload (% of normal average)
In season
• Past history of injury predicts injury because of training load changes
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Acute and Chronic Workloads
Acute Chronic
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Acute and Chronic Workloads
Acute Chronic
“Let’s have a look at your knee”
• Swelling – tendon v fat pad v intra-articular (v extra-articular)
• Adolescents – Osgood-Schlatter’s/S-L-J, SCFE, Perthe’s
• “Any kid with a limp needs their hip checked”
EffusionTendon
• Localised tendon swelling (US)
• Nothing intra-articular
PFP
• Tendon normal
• Intra-articular oedema
• (Pre-patellar bursitis)
Palpation
TendonopathyNot tendonopathy
Palpation Painful 40 84
Palpation Not Painful 1 193
Sensitivity | Specificity 0.98 0.70+LR 3.22-LR 0.04
Physical exam
• Reproduce the focal pain while loading the tendon – focal v diffuse
• Decline squat – jump landing 2 to 1 legs – repeated landings
Setter
Outside
Outside
Opposite
Middle
(Libero)
0%
5%
10%
15%
20%
25%
30%
10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% >90%
Perc
enta
ge o
f se
aso
n ju
mp
s
Jump heights (as a percentage of maximum jump height)
Distribution of jump heights over one professional volleyball club season based on player position
Setter Middle Outside OppositeChris Skazalski (@cskazalski)
Loading and tendonopathy eg Jumps
• Current load
• Desired/required load
(Patellar) tendonopathy
• Get the diagnosis right
• Understand the loading parameters for this sport, this athlete
• Load is king
• Tenonopathy v PFPS, OA (etc)
• Understand how this happened & what to do about it to return the athlete safely
• No short-cuts
0
0,2
0,4
0,6
0,8
1
1,2
1,4
0
20
40
60
80
100
120
Whole squad jump load
4 week average 1 week average 1 wk / 4 wk
0
20
40
60
80
100
120
Daily Average Jumps Whole Squad
Chris Skazalski (@cskazalski)
Jumps every dayJumps every week7 day rolling average28 day rolling average7 Day : 28 Day (A:CWR)
Kjaer
• Extracellular matrix in skeletal muscle
Purdam – tendon loading
• Rate of loading of the tendon versus peak loading
• Symptoms the following day (delay in symptoms – look at collagen proliferation v degeneration curve) 24-72 hour response; “how it feels today reflects the response to the previous day’s loading”
• VISA questionnaires
• Reassess with decline squat. Hops, but watch for the same time of the day (not first thing in the morning)
• Pain and function – pain can stay the same if function is increasing
• 3 day load cycles
Rate of loading for same peak loads
• (Bodyweight per sec)
• Seated calf, standing calf, controlled push < half of
• Dynamic push, jumping, max hop, acceleration
Cook Purdam loading stages
• 1 4 daily sessions of heavy iso
• 2 Strength followed by isometrics followed by strength
• 3 strength FastElasticFunction iso strength fast iso optional
• 4 iso strength fast iso strength fast recuperateMon Tue Wed Thu Fri Sat Sun
1 4X daily iso
2 Str Iso Str Iso Str Iso Option
3 Str FEF Iso Str FEF Iso Option
4 Iso Str FEF Iso Str FEF Recup
TeamTraining
Game
Stress Shielding
• Preferential loading of parts of the tendon
Lyman et al AJSM 2004
Lyman et al AJSM 2004
1
3 4
2
5
Almekinders et al Strain patterns in the patellar tendonand the implications for patellar tendinopathy Knee Surg, Sports Traumatol, Arthrosc (2002) 10 :2–5