Principles of diagnostic sonography in iliopsoas tendon pathology: A case report.

This article describes the diagnostic value of musculoskeletal sonography in the management of tendon pathology and outlines a clinical example of its scope of utilization. Herein we describe the case of a 65-year-old man who sought rehabilitation services for left groin pain following a period of intense trekking and uphill walking. He presented with left hip flexor weakness and local tenderness over the left iliopsoas tendon with negative findings on neurological evaluation. Additionally, he presented with left hip capsule and hip flexor tightness with left gluteus maximus and gluteus medius weakness. The left hip capsule tightness was predominantly in the posterior fibres, with restriction of hip internal rotation. The clinical picture overall was suggestive of the presence of risk parameters for iliopsoas tendinopathy. Plain radiographs of the hip revealed mild degenerative changes with a mild pincer impingement. While his clinical and radiological picture was suggestive of degenerative and soft tissue pathology of the hip, a real-time sonographic study was useful in the quantitative confirmation of a partial tear of the left iliopsoas tendon. Additionally, a repeat sonographic study performed four weeks later, revealed a healing iliopsoas tendon seen as a decrease in the width of the hypoechoic presentation of the tear. To summarize, the value of musculoskeletal sonography as a diagnostic tool as well as the assessment of the progression of tendon healing is discussed. Sonography is safe, noninvasive, and does not use ionizing radiation. It is steadily gaining popularity in the diagnosis of tendon lesions.

The scapula backward tipping test: An inter-rater reliability study.

BACKGROUND & PURPOSE: The purpose of this study was to determine the reliability of the scapula backward tipping test (SBTT) in detecting the presence of pectoralis minor (PM) tightness and subsequently scapula forward tipping, in a symptomatic population. PM tightness with scapula forward tipping has been described to cause pain and dysfunction in the shoulder region. METHODS: 30 patients with a diagnosis of shoulder pain were randomly assigned and examined by 2 musculoskeletal physical therapists at a time. The procedure consisted of having the individual lay on the stomach in a neutral head position with palms in the anatomical position. The examiner firmly stabilized the inferior angle of the scapula with one hand and the fingers of the other hand hooked the under surface of the coracoid process. A gentle yet firm pull was imparted in an upward direction to sense tightness and to observe movement of the acromion up to the tragus of the ear. A comparison was made with the other side to sense restriction. Inter-rater reliability was determined using the kappa statistic. RESULTS: The SBTT was found to be reproducible between examiners (Kappa = 0.735, SE of kappa = 0.123, 95% confidence interval), with a percentage agreement of 86.67%. CONCLUSION: The SBTT may be incorporated as a simple yet effective test to determine the presence of PM tightness and subsequently scapula forward tipping.

Cervical extensor endurance test: a reliability study.

BACKGROUND & PURPOSE: The purpose of this study was to determine the inter-rater reliability in detecting the presence of weakness of the neck extensors and differentiate the presence of weakness of the superficial versus the deep neck extensors in a symptomatic population. The presence of weakness of the neck extensors has been described to cause pain and dysfunction in the cervical region. METHODS: 30 patients with a diagnosis of neck pain were randomly assigned and examined by two musculoskeletal physical therapists at a time, in order to determine the presence of weakness of the superficial versus the deep neck extensors. With the patient lying prone and head and neck past the edge of the table and the cervico-thoracic junction stabilized, the ability of the individual to sustain a chin tuck position in neutral for 20 s was evaluated. A positive finding for weakness of the deep neck extensors is the 'chin length' increasing with neck extension, as observed on the inclinometer, indicating a dominance of the superficial extensors of the neck. Weakness of both deep and superficial neck extensors was identified by the presence of neck flexion indicating an inability to hold the head up. Inter-rater reliability was determined using the Cohen's un-weighted kappa statistic. RESULTS: For the cervical extensor endurance test, the inter-rater reliability was 'very good' (k = 0.800, SE of kappa = 0.109, 95% CI). CONCLUSION: The cervical extensor endurance test may be incorporated as a simple yet effective test to determine the presence of weakness of the neck extensors and differentiate the presence of weakness of the superficial versus the deep neck extensors in a symptomatic population. The accuracy of the CEET as a test is still debatable, as it has not been compared to a diagnostic gold standard. Based on the results of this study, we speculate the CEET may still offer an initial sense of direction for clinicians treating neck dysfunction.

Lower thoracic syndrome - a differential screen for back pain following vertical compression injury: a case report.

A 36-year-old male experienced left sided back and radiating flank pain, following a fall on his buttock. A detailed medical evaluation ruled out the presence of red flags. Initial examination revealed positive findings of comparable local tenderness over the left T11, T12 and left paraspinal area, and a 2 cm shortening of the left leg. 8 treatment visits for a period of 4 weeks addressed mechanical dysfunction at the T11, T12, lumbar and pelvic region, comprising manual therapy, therapeutic exercise and pain relieving modalities. Reduction of local tenderness, back and radiating flank pain was observed. Additionally, resolution of the persistent apparent shortening of his left leg was observed, following a high velocity thrust (HVT) manipulation of the T11, T12 segments. The vertebral motion segment of T11, T12, the thoracoabdominal nerves, the 12th rib, the quadratus lumborum and the serratus posterior inferior are speculated to be potential symptom mediators. The findings in the case report suggest the lower thoracic region to be included during the evaluation process of back pain, especially when the mechanism of injury is a vertical compression.

The sitting active and prone passive lag test: an inter-rater reliability study.

BACKGROUND & PURPOSE: To determine inter-rater reliability in identifying a knee extension lag using the sitting active and prone passive lag test (SAPLT). METHODS: 56 patients with a diagnosis of knee pain were randomly assigned and independently examined by two physical therapists at a time, to determine the presence of an active or a passive extension lag at the knee. An active lag was determined by the inability of the erectly seated subject to actively extend the involved knee in maximal dorsiflexion of the ankle to the same level as the normal knee held in maximal extension and ankle in maximal dorsiflexion, as seen by the levels of the toes. A passive lag was determined by placing the subject prone with the knees just past the edge of the table and determining the high position of the heel in a fully resting extension position compared to the heel on the normal side. RESULTS: For the sitting active lag test, the inter-rater reliability was 'good' (Kappa 0.792, SE of kappa 0.115, 95% confidence interval). For the prone passive lag test, the inter-rater reliability was 'good' (Kappa 0.636, SE of kappa 0.136, 95% confidence interval). CONCLUSION: The SAPLT may be incorporated as a simple yet effective test to determine the presence of a knee extension lag. It identifies the type of restraint, active, passive or both, and is suggestive of the most appropriate management.

T2 radiculopathy: A differential screen for upper extremity radicular pain.

Radicular pain in the upper extremity can have a cervical origin terminating at the cervicothoracic junction (C8, T1). Review of the literature suggests cutaneous representations of T2 nerve root to the axilla, posteromedial arm, and lateral forearm, suggesting yet another source of upper extremity radicular pain. A 53-year-old female experienced insidious right upper thoracic pain radiating into the right axilla, upper arm, and lateral forearm (10/10 numerical pain rating scale (NPRS)) of 1-week duration. Medical referral suggested cervical radiculopathy, however, cervical spine examination was unremarkable. She presented with mechanical dysfunction of C8, T1; T1, T2; and T2, T3 vertebral segments with restricted cervical extension. Firm compression over the right lateral aspect of the second and third thoracic vertebrae reproduced her symptoms markedly. There was a predominance of right axillary pain. Cervical extension reproduced local upper thoracic pain. Nine treatment visits for a period of 3 weeks addressed mechanical dysfunction at the cervicothoracic junction and upper thoracic region, comprising manual therapy, corrective exercise, and pain modalities. Reduction of local tenderness, and radiating axillary and right arm pain was observed (2/10 NPRS), with improved cervical extension. The second thoracic intercostal nerve and the adjoining intercostobrachial nerve, medial antebrachial cutaneous nerve, and the posterior brachial cutaneous branch of the radial nerve are speculated to be potential symptom mediators. They have a representation to the axilla, medial and posterior arm, and lateral forearm - a representation supporting the speculation of upper extremity radicular symptoms following mechanical dysfunction of the upper thoracic vertebrae.

Triangular interval syndrome: A differential diagnosis for upper extremity radicular pain.

This case report describes a 57-year-old female who experienced symptoms of scapular pain with pain radiating into the right upper extremity. Initial medical referral suggested, nerve entrapment of a cervical origin. However, the patient did not fit the clinical prediction rule for cervical radiculopathy. Radial nerve bias was positive without cervical provocation, with symptom reproduction at the lateral scapular area. Treatment addressed mechanical dysfunction at the triangular interval formed by the teres major and triceps, comprising manual therapy, neural mobilization, corrective exercise and pain modalities. Reduction in symptoms was observed with a decrease in right scapular and arm pain and improved radial nerve mobility. The triangular interval is described as a predominant contributor to the symptomatology secondary to entrapment and adverse neural tension of the radial nerve. The anatomical and physiological basis is enumerated.

Thoraco lumbar junction syndrome: a case report.

This case report describes a 46-year-old female who experienced symptoms of low back pain with pain radiating into the right gluteal area. Initial intervention addressed mechanical dysfunction at the lumbosacral junction. Reduction in symptoms was observed following manual therapy procedures that addressed the lumbosacral junction; however, the right gluteal pain persisted with recurrence of back pain. Subsequent examination revealed non-neutral dysfunction at the thoracolumbar junction. Treatment was continued with manual therapy procedures that addressed facet restriction and soft tissue dysfunction in the thoracolumbar junction. A marked relief in symptoms was reported thereafter, with a decrease in right gluteal pain and improved functional ability. The anatomical and clinical relevance to this scenario is described. The thoracolumbar junction is described as a predominant contributor to the symptomatology. Its complementary role to the lumbosacral junction is enumerated.