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Failure of Voluntary Activation of the Quadriceps Femoris Muscle After Patellar Contusion Manal TJ, Snyder-Mackler L. JOSPT, Volume 30, Number 11. November 2000. 654-60. A patellar contusion often leads to patellofemoral syndrome, with an inflammatory response including joint effusion and pain. Quadriceps weakness is a common clinical finding associated with knee trauma. Some investigators have speculated that the weakness is quadriceps inhibition, or a failure of voluntary muscle activation. The purpose of this study was to examine the extent of quadriceps inhibition in subjects with a recent patellar contusion. The subjects included sixteen patients ages 19-59 who had suffered a unilateral contusion within the previous 4 months. The mechanism of injury included a direct blow to the patella (i.e., car dashboard during a MVA, hockey stick) or a direct fall onto the patella (i.e., rollerblading, tripping). Each subject rated their knee function using the Activities of Daily Living Scale, Knee Outcome Survey, and the Sports Activity Scale when applicable. The subjects also rated their knee function on a global scale from 0-100 with 100 being their level of performance prior to the injury. The researchers used the quadriceps maximal volitional isometric contraction test to analyze muscle performance using a KinCom dynamometer. The uninvolved extremity was used as the control for each subject. They were seated with hip at 90° and knee at 60° of flexion. Two 3” x 5” gel electrodes were placed over the quadriceps muscle. To ensure entire muscle recruitment, the motor points of the four heads were contained in the electrical field. Subjects then performed a 4-second maximal volitional isometric contraction. Three seconds into the contraction a 100 Hz, 10-pulse-tetanic train was applied to the muscle. If the subject was not maximally recruiting the quadriceps, the superimposition results in an increase in the recorded force. Thus, quadriceps inhibition was defined as the difference between the maximal volitional force and the maximal force generated with the electrical stimulation. All of the subjects generated significantly less force with their involved extremity versus their uninvolved side. However, only five of the subjects (31%) met the definition for quadriceps inhibition. In theory, all patients with patellar contusion would have demonstrated quadricep inhibition, however this hypothesis was not supported by this study. The subjects with inhibition did have more pronounced strength deficits, but the overall quadriceps weakness among both groups is a source of clinical concern. The weakness found is more likely due to disuse atrophy rather than quadriceps inhibition. These findings suggest a high level resistive strengthening program may be sufficient to rehabilitate the quadriceps muscles. Treatment emphasis may be more appropriately aimed at improvement in the generation of quadriceps force, rather than focus on quadriceps inhibition in this population. Diagnosis of Intermittent Vascular Claudication in a Patient With a Diagnosis of Sciatica Gray JC. Physical Therapy. June 1999. Volume 79, pages 582-590. This article is a case report, which illustrates the importance of a thorough evaluation to rule out diseases that may mimic other musculoskeletal disorders. Sciatica has been described as an impingement of lumbar nerve roots by a herniated disc. There are other pathologies, however, that can mimic sciatica. These include tumors, neuropathy, and vascular disease. Arterial insufficiency to the lower extremities is often associated with lower extremity pain, numbness, tightness, cramping, and fatigue. These symptoms are often mistaken for true sciatic symptoms. Symptoms usually increase with walking and resolve with rest. Aortic stenosis creates bilateral symptoms, while more distal stenosis will create unilateral symptoms. The patient used in this case study was referred to physical therapy with a diagnosis of sciatica from her primary physician. She was initially evaluated by a physical therapist and given the diagnosis of right upslip and rotated ilia. Left radicular symptoms were also noted. Her care was transferred to a different therapist due to scheduling issues. Upon reevaluation, it was noted that she had bilateral lower extremity weakness every time she walked half a block, had no leg pain, and all lower extremity nerve tension tests were negative. A medical history revealed family history of cardiovascular disease. This led the therapist to suspect that her symptoms might be related to something other than an orthopedic condition. She presented with full active range of motion of the lumbar spine without recreation of symptoms, normal strength in the lower extremity, and normal sensation through the lower extremities. Pulses were noted to be diminished for the dorsalis pedis on the left. A van Gelderen bicycle test was performed as a means to assess the lower extremity vascular system. The patient cycled for five minutes at a moderate pace, at which time her legs collapsed upon stepping off the bike and she had an abolished pulse for the left dorsalis pedis. A physical therapy diagnosis of intermittent vascular claudication secondary to occlusive vascular disease was established. The patient was referred back to her primary physician to rule out vascular disease. Treatment of this patient’s sacroiliac dysfunction was contraindicated at this point due to the proximity of the iliac arteries to the sacroiliac joint. Subsequently, this patient was seen by her primary care physician and then referred to a cardiac specialist. Her final diagnosis was “high grade circumferential stenosis of the distal-most aorta at its bifurcation. Two months later, she underwent angioplasty with stents implanted into the aorta. Following the surgery, she had a complete resolution of symptoms. This case clearly illustrates the importance of a thorough evaluation by all health care professionals involved with patient care. It can truly be a life and death issue. Examination and Treatment of a Patient With Hypermobility Syndrome Russek L.N. Physical Therapy. 2000;80:386-398 This case study reports that hypermobility syndrome (HMS) has been widely recognized in the rheumatology literature, but it has seldom been discussed in the orthopedic literature and has only recently been described in the physical therapy literature. The pathophysiology in HMS is apparently not well understood, however, the disorder appears to be a systemic collagen abnormality. The primary manifestation is excessive laxity of multiple joints. Laboratory tests are used to rule out other systemic disorders when HMS is suspected. Also, fibromyalgia syndrome often coexists with HMS and is 3.8 times more common in adults with HMS than in those without HMS. Patients may be seen within the medical system multiple times over a period of years without recognition of the underlying HMS. Recognition of HMS underlying common orthopedic problems may facilitate appropriate patient education and management. Education about the nature of HMS can reassure patients that they have a real disorder that is not inherently progressive. However, there is no cure for HMS and, therefore, the goal for treatment is not return to "normal" joint mobility, but to restore relatively pain-free function. The patient in this case study was a 28-year-old woman with complaints of chronic, multiple-joint pain. A rheumatologist had recently diagnosed her as having HMS, after years without a diagnosis. The primary emphasis of physical therapy intervention for this patient was education about the syndrome, body mechanics, joint protection, and lifestyle modification. It was explained to the patient that her joints were vulnerable to stress at end-range, and that passive stretches and positions that would not cause problems for an individual without HMS could cause chronic or recurrent problems for her. She was instructed to modify her body mechanics and ergonomics to avoid these positions during work, daily activities, and exercise. This patient did not participate in guided exercise in the clinic, as she was a physical therapist, so therapy involved less intervention than might be appropriate for another patient with HMS. Patients with HMS often benefit from guided, progressive exercise programs in the clinic emphasizing joint stabilization and joint position sense. One month following the physical therapy consultation, she reported that pain had decreased by approximately 30%. She consciously avoided end-range and passive joint stretches during both vocational and avocational activities. Her pain was 0-3/10 on average and 3-5/10 at worst. She estimated that 30% of her waking time was pain-free. One year following the initial evaluation, she reported further decrease in frequency of joint pain (50% of the time she was pain-free). She was able to manage her joint pain and was moderately content with her modified lifestyle. She was also able to recognize the onset of both acute and overuse injuries sooner and intervene to decrease severity. There is no published literature on the efficacy of medical or physical therapy management of HMS. Education and activity modification provide the core of intervention for HMS. Strengthening, proprioception exercises, and protective splints may be helpful to improve muscular stability at specific joints. Treatment of specific joint disorders may be appropriate, especially in the presence of acute trauma or inflammation. Physical therapists should recognize and address the underlying hypermobility. Intervention emphasizes joint protection and injury prevention, as both traumatic injuries and chronic pain are likely to be recurrent.
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