Manual Muscle Testing (MMT) grade.

Definition
Muscle testing is an attempt to determine a patient's ability to voluntarily contract a specific muscle. (Keep in mind that this does not provide information on the patient's ability to use the muscle in daily activities, or if the muscle interacts with other muscle around it in a synergistic pattern). 

Purpose
Muscle testing is indicated in any patient with suspected or actual impaired muscle performance, including strength, power, or endurance. Identification of specific impaired muscles or muscle groups provides information for proper treatment. 


Grading

5	Normal	subject completes ROM against gravity with maximal resistance
4+	Good Plus	completes ROM against gravity with moderate-maximal resistance
4	Good	completes ROM against gravity with moderate resistance
4-	Good Minus	completes ROM against gravity with minimal-moderate resistance
3+	Fair Plus	completes ROM against gravity with only minimal resistance
3	Fair	completes ROM against gravity without manual resistance
3-	Fair Minus	does not complete the range of motion against gravity, but does complete more than half of the range
2+	Poor Plus	is able to initiate movement against gravity
2	Poor	completes range of motion with gravity eliminated
2-	Poor Minus	does not complete ROM in a gravity eliminated position
1	Trace	muscle contraction can be palpated, but there is no joint movement
0	Zero	patient demonstrates no palpable muscle contraction

Frozen Shoulder

Frozen Shoulder

Definition

  Permanent severe limitation of the range of motion of the shoulder due to inflammation and subsequent scarring around the shoulder joint (adhesive capsulitis) . Frozen shoulder may occur following an injury or immobilization of the shoulder joint, and it occurs more commonly in people with diabetes and certain other health conditions than in the general population.

Anatomy

   The shoulder joint is formed where the humerus (upper arm bone) fits into the scapula (shoulder blade), like a ball and socket. Other important bones in the shoulder include, the acromion is a bony projection off the scapula. The clavicle (collarbone) meets the acromion in the acromioclavicular joint. The coracoid process is a hook-like bony projection from the scapula. The shoulder has several other important structures, the rotator cuff is a collection of muscles and tendons that surround the shoulder, giving it support and allowing a wide range of motion. The bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff. A cuff of cartilage called the labrum forms a cup for the ball-like head of the humerus to fit into. The humerus fits relatively loosely into the shoulder joint. This gives the shoulder a wide range of motion, but also makes it vulnerable to injury.

   The rotator cuff is a group of tendons and muscles in the shoulder, connecting the upper arm (humerus) to the shoulder blade (scapula). The rotator cuff tendons provide stability to the shoulder, the muscles allow the shoulder to rotate. The muscles in the rotator cuff include, Teres minor, Infraspinatus, Supraspinatus, Subscapularis. Each muscle of the rotator cuff inserts at the scapula, and has a tendon that attaches to the humerus. Together, the tendons and other tissues form a cuff around the humerus.   

Pathophysiology

   Frozen shoulder can be classified by two that is Primary and secondary frozen shoulder. Primary frozen shoulder is cause by diabetes mellitus (both insulin-dependent and non-insulin-dependent types),  especially retinopathy, but exists also with hypo- and hyperthyroidism. Dupuytren’s disease is shown to be related to frozen shoulder, Dupuytren’s disease is significantly more common than usual among male relatives to frozen shoulder  and the microscopic changes in the anterior capsule and coracohumeral ligament are very similar to those in Dupuytren’s disease of the hand, Similarities with Dupuytren’s are shown when analysing the fibrotic capsule for cytokines and proteinases. There is an involvement of the capsule in the glenohumeral joint.  The capsule volume is reduced and this is the cause for the restricted range of motion, look arthroscopically in the joint is technically more difficult than in a normal shoulder.  The dense capsule is difficult to penetrate and the tight joint with marked reduced volume is demanding to visualise without compromising the joint surfaces.  The capsule is tight and its synovial surface is showing signs of vascular inflammation.  Usually, no intra articular adhesions are seen.

   For Secondary frozen shoulder the cause of the syndrome is usually easy to define. In the posttraumatic cases there is clear evidence of a trauma and usually also structural changes within or adjacent to the joint, such as fractures, chondral lesions, avascular necrosis or tendon injuries.  Scarring following traumatic tissue injury is another cause. The iatrogenic cases occur following treatment, usually surgery.  In these cases extreme scarring following tissue repair may occur or surgical mistakes such as over tightening of soft tissue may be responsible for the following limitation in range of movement.

 

 The pattern in which frozen shoulder usually is developed may be described as three time periods of six months each, 1st period(Freezing). The freezing stage shows an insidious onset where pain is dominating the clinical picture.  Quite often, subacromial impingement is initially suspected because of the involvement of the subacromial bursa.  At the end of this period range of motion becomes limited in the typical way and diagnosis is usually no longer a problem. 2nd period(Frozen). The frozen period shows reduction of pain but the restricted mobility remains.3rd period(Thawing). The thawing includes successive reestablishment of normal or near normal range of motion.

Causes

  Frozen shoulder can develop when you stop using the joint normally because of pain, injury, or a chronic health condition, such as diabetes or a stroke. Any shoulder problem can lead to frozen shoulder if you do not work to keep full range of motion. Frozen shoulder occurs, after surgery or injury, most often in people 40 to 70 years old, more often in women (especially in postmenopausal women) than in men, most often in people with chronic diseases.

Sign and symptoms

Movement of the shoulder is severely restricted, with progressive loss of both active and passive range of motion. The condition is sometimes caused by injury, leading to lack of use due to pain, but also often arises spontaneously with no obvious preceding trigger factor (idiopathic frozen shoulder). Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limitation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

  In frozen shoulder, there is a lack of synovial fluid, which normally helps the shoulder joint, a ball and socket joint, move by lubricating the gap between the humerus (upper arm bone) and the socket in the shoulder blade. The shoulder capsule thickens, swells, and tightens due to bands of scar tissue (adhesions) that have formed inside the capsule. As a result, there is less room in the joint for the humerus, making movement of the shoulder stiff and painful. This restricted space between the capsule and ball of the humerus distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder.

  People with diabetes, stroke, lung disease, rheumatoid arthritis, or heart disease are at a higher risk for frozen shoulder. Injury or surgery to the shoulder or arm may cause the capsule to tighten from reduced use during recovery. Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART).

  The condition rarely appears in people under 40 years old and, at least in its idiopathic form, is much more common in women than in men (70% of patients are women aged 40–60). Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population, and the recovery is longer.Cases have also been reported after breast and lung surgery

 

Doctor management

   Physical Examination, after discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.Imaging Tests, other tests that may help your doctor rule out other causes of stiffness and pain include, X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis. Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff. Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling. Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.Surgical Treatment, if your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Physiotherapy management

Modalities

  Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular-mediated relaxation. Patients improved with combined therapy which involved hot and cold packs applied before and after shoulder exercises were performed. However,  ultrasound, massage, iontophoresis, and phonophoresis reduced the odds of improved outcomes for patients with adhesive capsulitis.

Initial Phase

   As stated previously, treatment should be customized to each individual based on what stage or phase of adhesive capsulitis they are in.Pain relief should be the focus of the initial phase, also known as the Painful, Freezing Phase. During this time, any activities that cause pain should be avoided and pain-free activities should be allowed. Better results have been found in patients who performed pain-free exercise, rather than intensive physical therapy. In patients with high irritability, range of motion exercises performed with low intensity and a short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds at a pain-free range, two to three times a day. A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately forty degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation. Positional stretching of the coracohumeral ligament was performed for a patient in the first phase of adhesive capsulitis. The patient's Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation from 20 degrees to 71 degrees.

  The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fiber orientation. The rationale behind this was to produce tissue remodeling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this. In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder. Concominant exercises to steroid injections included isometric strengthening in all ranges once motion was reached in 90% of normal ranges, theraband exercises in all planes, scapular stabilization exercises, and later, advanced muscular strengthening with dumbbells.

Second Phase

  During the adhesive phase, the focus of treatment should be shifted towards more aggressive stretching exercises in order to improve range of motion. The patient should perform low load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance. Demonstrated success of a non-operative treatment through a four-direction shoulder stretching exercise program in which 90% of the patients reported a satisfactory outcome. During the second phase of treatment, movement with mobilization and end range mobilization have shown to be successful, according to a randomized multiple treatment . In this trial, the patients had statistically significant improvements in the Flexi-Level Scale of Shoulder Function (FLEX-SF), arm elevation, scapulohumeral rhythm, humeral external rotation, and humeral internal rotation. Mobilization with movement also corrected scapulohumeral rhythm significantly better than end range mobilization did. The goal for end range mobilization was not only to restore joint play, but also to stretch contracted periarticular structures, whereas the goal for mobilization with movement was to restore pain-free motion to the joints that had painful limitation of range of motion. Showed that physical therapy paired with dynamic splinting had better outcomes compared to physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a Shoulder Dynasplint System (SDS) for daily end-range stretching. Methods for this treatment include moist heat, patient education and re-evaluation of symptoms, joint mobilization (limited to progressive end-range joint mobilization), passive range of motion, active range of motion and PNF, and therapeutic exercise. The SDS was worn twice each day for seven days per week and was set at  for the first week in order to allow the patient to accommodate to the stretching. After accommodation, the setting was increased to, which equals three foot lbs of force. The progression of the stretch as well as the adjustment for pain or soreness was standardized, and instructions were given to the patient to follow accordingly. Patients were instructed to increase the duration in the SDS unit for 20 – 30 minutes twice each day (with the intention to stretch 60 minutes each day. The combination of physical therapy with dynamic splinting had significant improvements in active, external rotation in patients with adhesive capsulitis.

Third Phase

  During stage three, also known as the Resolution Phase, treatment is progressed primarily by increasing stretch frequency and duration, while maintaining the same intensity, as the patient is able to tolerate. The stretch can be held for longer periods, and the sessions per day can be increased. As the patient’s irritability level becomes low, more intense stretching and exercises using a device, such as a pulley, can be performed to assist tissue remodeling influence .

Example of exercise and treatment

The Stages Of Stroke Recovery

BRUNNSTROM STAGES

The Brunnstrom Approach was developed in the 1960’s by Signe Brunnstrom, an occupational and physical therapist from Sweden. With seven stages, the Brunnstrom Approach breaks down how motor control can be restored throughout the body after suffering a stroke.

Normally, muscle movements are the result of different muscle groups working together. Researchers have termed this collaboration between muscles as “synergies”. The brain has the delicate task of coordinating these movements, many of which become severely affected after a stroke.

After the stroke has occurred, your muscles become weak due to the lack of coordination between the brain and body. This causes the muscle synergies to move in abnormal patterns. Most treatments offered to stroke patients will focus on trying to inhibit atypical muscle synergies and movements. The Brunnstrom Approach, on the other hand, teaches patients how to use the abnormal synergy patterns to their advantage.

This approach has become a popular choice among both occupational and physical therapists as well as patients since its inception. It can be effective in clinical settings and can dramatically improve voluntary muscle movements after suffering a stroke.

The Seven Stages Of Stroke Recovery

Stage 1 

Flaccidity

The first stage in Brunnstrom’s Approach is flaccidity in muscles. During this stage, the patient has no voluntary muscle movements in the areas affected by the stroke. Typically, a patient will lose motor function in their legs, arms, feet, or hands.

Stage 2

Spasticity Appears

The second stage in stroke recovery is when the patient begins to regain a small amount of motor function, but muscle movements are usually not voluntary. Muscles begin to make small, spastic, and abnormal movements during this stage.

While these movements are mostly involuntary, they can be a promising sign during your recovery. There are also no discernible synergy patterns within the muscles, which is what causes the involuntary movements. Minimal voluntary movements might or might not be present in stage two.

Stage 3

Increased Spasticity

Spasticity in muscles increases during stage three, reaching its peak. Synergy patterns also start to emerge, and minimal voluntary movements should be expected. However, your movements will be small and abnormal.

The increase in voluntary movement is due to being able to initiate movement in the muscle, but not control it (yet). The appearance of synergy patterns and coordination between muscles facilitate the voluntary movements which become stronger with occupational and physical therapy.

Stage 4

Decreased Spasticity

During stage four, spastic muscle movement begins to decline. You will also begin to regain a significant amount of motor control in the affected extremities. Furthermore, you will start making normal, controlled movements on a limited basis.

Synergy patterns within the muscles become stronger during this stage. However, many movements are out of sync with muscle synergies and abnormal movements should still be expected.

Stage 5

Complex Movement Combinations

Spasticity continues to decline in stage five. Synergy patterns within the muscles also become more coordinated, and your voluntary movements begin to become more complex.

Abnormal movements also start to decline dramatically during this stage, but some may still be present. You will be able to make controlled and deliberate movements in the limbs that have been affected by the stroke. Isolated joint movements might also be possible.

Stage 6

Spasticity Dissapears

At stage six, spasticity in muscle movement disappears completely. You are able to move individual joints, and synergy patterns become much more coordinated. Motor control is almost fully restored, and you can coordinate complex reaching movements in the affected extremities. Abnormal or spastic movements have ceased, and a full recovery is on the horizon.

Stage 7

Normal Function Returns

The last stage in Brunnstrom’s Approach is when you regain full function in the areas affected by the stroke. You are now able to move your arms, legs, hands, and feet in a controlled and voluntary manner.

Since you have full control over your muscle movements, synergy patterns have also returned to normal. Reaching stage seven is the ultimate goal for therapists and patients alike.

Plantar Fasciitis and Bone Spurs

Plantar Fasciitis and Bone Spurs

This article is also available in Spanish: Fascitis plantar y protuberancias óseas.

Plantar fasciitis (fashee-EYE-tiss) is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.

Plantar fasciitis occurs when the strong band of tissue that supports the arch of your foot becomes irritated and inflamed.

Anatomy

The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot, and supports the arch of your foot.

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Cause

The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.

Risk Factors

In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:

• Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your shin
• Obesity
• Very high arch
• Repetitive impact activity (running/sports)
• New or increased activity

Heel Spurs

Although many people with plantar fasciitis have heel spurs, spurs are not the cause of plantar fasciitis pain. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs has foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.

Heel spurs do not cause plantar fasciitis pain.

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Symptoms

The most common symptoms of plantar fasciitis include:

• Pain on the bottom of the foot near the heel
• Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
• Greater pain after (not during) exercise or activity

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Doctor Examination

After you describe your symptoms and discuss your concerns, your doctor will examine your foot. Your doctor will look for these signs:

• A high arch
• An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
• Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
• Limited "up" motion of your ankle

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Tests

Your doctor may order imaging tests to help make sure your heel pain is caused by plantar fasciitis and not another problem.

X-rays

X-rays provide clear images of bones. They are useful in ruling out other causes of heel pain, such as fractures or arthritis. Heel spurs can be seen on an x-ray.

Other Imaging Tests

Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose plantar fasciitis. They are rarely ordered. An MRI scan may be used if the heel pain is not relieved by initial treatment methods.

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Treatment

Nonsurgical Treatment

More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.

Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).
Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.
Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.
Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.

• Calf stretch
  Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
• Plantar fascia stretch
  This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.

Soft heel pads can provide extra support.

Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.
Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.
Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia.
Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Hip Fracture

Hip Fractures

A hip fracture is a break in the upper quarter of the femur (thigh) bone. The extent of the break depends on the forces that are involved. The type of surgery used to treat a hip fracture is primarily based on the bones and soft tissues affected or on the level of the fracture.

Anatomy

Normal anatomy of the hip.

The "hip" is a ball-and-socket joint. It allows the upper leg to bend and rotate at the pelvis. An injury to the socket, or acetabulum, itself is not considered a "hip fracture." Management of fractures to the socket is a completely different consideration.

Causes

Hip fractures most commonly occur from a fall or from a direct blow to the side of the hip. Some medical conditions such as osteoporosis, cancer, or stress injuries can weaken the bone and make the hip more susceptible to breaking. In severe cases, it is possible for the hip to break with the patient merely standing on the leg and twisting.

Symptoms

The patient with a hip fracture will have pain over the outer upper thigh or in the groin. There will be significant discomfort with any attempt to flex or rotate the hip.

If the bone has been weakened by disease (such as a stress injury or cancer), the patient may notice aching in the groin or thigh area for a period of time before the break. If the bone is completely broken, the leg may appear to be shorter than the noninjured leg. The patient will often hold the injured leg in a still position with the foot and knee turned outward (external rotation).