Chiropractic Treatment Profiles – 2003 - ACC

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Composite

Chiropractic TreatmentProfiles 2003

Chiropractic Treatment Profiles – 2003 1

Introduction 3

Section One

Code Identifier Range Trigger Page

N131. Cervicalgia - Chronic/Recurrent Neck Pain 10 – 16 18 5

N142. Low Back Pain, Acute Back Pain Lumbar, Lumbago 14 18 9

N143. Sciatica 14 18 13

S561. Sprain SI Joints 14 18 15

S570. Sprain Cervical Spine 10 – 16 16 19

S571. Sprain Thoracic Spine 8 12 23

S572. Sprain Lumbar Spine 14 18 25

S574. Sprain Coccyx 8 12 29

N12C0 Cervical Disc Prolapse 16 – 20 20 31

N12C1 Thoracic Disc Prolapse 10 – 16 16 33

N12C2 Lumbar Disc Prolapse 16 – 24 24 35

XaO6Y Whiplash 15 18 37

Section Two


S460. Meniscal Tear Medial 12 14 39

S461. Meniscal Tear Lateral 10 14 41

S50.. Sprain Upper Arm/Shoulder 8 12 45

S500. Sprain Acromio-Clavicular Ligament 10 12 47

S503. Sprain Infraspinatus Tendon 12 16 49

S504. Sprain Rotator Cuff 10 16 51

S507. Shoulder Joint Sprain 10 12 53

S51.. Sprain Elbow/Forearm 10 12 55

S52.. Sprain Wrist/Hand 12 14 57

S522. Sprain Thumb 12 14 59

S523. Sprain Finger 12 12 61

S53.. Sprain Hip/Thigh 8 12 63

S533. Sprain Quadriceps Tendon 10 14 65

S540. Sprain Lateral Collateral Ligament Knee 10 14 67

S541. Sprain Medial Collateral Ligament Knee 10 14 69

S542. Sprain Cruciate Ligament Knee 12 16 71

S54x1 Sprain Gastrocnemius 10 14 75

S550. Sprain Ankle 10 14 77

S5504 Sprain Achilles Tendon 12 16 81

S5512/3 Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint 6 8 85

Contents

Contents

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2 Chiropractic Treatment Profiles – 2003


S5y3. Sprain Rib Cage 6 10 87

F340. Carpal Tunnel Syndrome 12 16 89

N211. Rotator Cuff Syndrome 12 – 16 18 91

N2131 Medial Epicondylitis (Elbow) 12 14 95

N2132 Lateral Epicondylitis (Elbow) 12 16 97

N2174 Tendonitis Achilles 12 16 99

N22.. Tenosynovitis/Synovitis Upper/Lower Limb 16 16 103

Contents

Contents



The Chiropractic Treatment Profiles 2003 have been developed by the NewZealand Chiropractors’ Association as a joint initiative with ACC.

These Treatment Profiles are published in two sections. Section One featurestreatment profiles for vertebral injury. ACC-registered chiropractors who treata vertebral injury listed in this section may be eligible for payment by ACC.Section Two features treatment profiles for extra-vertebral injuries. At thetime of going to print, ACC does not pay chiropractors for treatment relatedto non-vertebral injuries.

The profiles are a consensus of opinion as to what is considered appropriateand common current practice.

The profiles are to help encourage common accepted standards and should beseen as a step to developing evidence-based best practice guidelines.

The Read codes relate to a specific diagnosis that has no complications andhas been referred for, or has accessed, chiropractic treatment at an earlyappropriate stage in the healing process. It is accepted that conditions that aremore complicated may differ from the treatment description and differ fromthe 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 theinterpretations. In particular, N12C of Disc Prolapse and Radiculopathy hasbeen broken up into Cervical, Thoracic and Lumbar regions.

Some profiles cover a number of Read codes as the treatment given is thesame for each condition.

Number of Treatments

Treatment numbers stated in this document relate to a specific diagnosiswithout complications, which has been referred for treatment at anappropriate 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 wouldappropriately seek a review of the services that have been provided.

Any treatment provided for a particular individual will be considered inconsultation with the provider chiropractor. The trigger number is theappropriate time for a case manager to approach the chiropractic providerand consider requesting a review by an assessor.

Key Points

Some profiles have had this section added to act as a rider to more clearlydefine the particular condition.

Special Considerations

This section highlights special concerns that need to be considered whentreating this condition.

History

This section gives a general overview of the significant factors that should beconsidered in the history of each condition.

Introduction

Introduction



Examination

This section outlines the main components that should be undertaken in anormal examination. This is not an exhaustive list and clinicians may haveother investigations that they would routinely take into account. Generallythe examination would cover subjective and objective examinationprocedures 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 whenmaking a provisional diagnosis and also serves to outline what conditions arenot being considered in the profile. This is not an exhaustive list andclinicians are encouraged to seek second opinions on conditions that seemunusual.

Complications

This section gives clinicians some examples that may hinder the recoverytime of a patient or move the patient outside the scope of these‘uncomplicated’ injury profiles and would then require the appropriatereferral action.

Treatment Rehabilitation

This section is divided up into two sub sections, acute and sub-acute. Withinthe literature there is great variation as to when a condition moves from beingacute to chronic. For the purposes of these profiles acute has been describedas within the first 10 to 14 days of an injury occurring, or post surgicalintervention. Sub-acute is considered any time after this.

Onward Referral

This section gives the appropriate referral that should be considered if thepatient’s condition causes concern to the treatment provider.

• Radiographic referral is a general term used that would include allappropriate 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 morecomplex cases

Introduction

Introduction



Composite

Section 1


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)

Cervicalgia (Chronic/Recurrent Neck Pain) N131.



• 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 ofcancer, 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 aspossible

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





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)







Read Code: N142.

Number of treatments: 14

Triggers: 18

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


• Previous episode of LBP• Age• Regional pain syndrome• Keeping mobile helps in recovery

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 weightbearing (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

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)

Low Back Pain (Low Back Pain, Acute Lumbar Pain, Lumbago) N142.

RED FLAG:

For potentially serious conditions:

Features of Cauda Equina syndrome

(especially urinary retention,

bilateral neurological symptoms and

signs, saddle anaesthesia) – this

requires very urgent referral

Significant trauma

Weight loss

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

lying down

YELLOW FLAG:

Psychosocial factors that increase the

risk of developing or perpetuating long-

term 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




• 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


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





• 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







Read Code: N143.


Triggers: 18

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


• Multiple aetiological factors can be involved

History

• Peripheral nerve compression• IVD herniation• DJD• Traumatic injury• Fracture• Lower back strain• Sacroiliac joint• Piriformis syndrome• Stenosis• Spinal or visceral pathology• Prior history

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


• 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

Sciatica N143.

RED FLAG:







Significant trauma

Weight loss

History of cancer

Fever


Steroid use




lying down

YELLOW FLAG:






Behaviours

Compensation issues


Emotions

Family

Work



Complications

• Manipulation while joint effusion/inflammation is present


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

Sciatica

Sciatica N143.



Read Code: S561.


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


• 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

Sprain Sacroiliac Joints S561.




• 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


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





– 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







Read Code: S570.


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


• 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


• 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

Sprain/Strain Cervical Spine S570.



• 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 ofcancer, 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


• Shift from passive to rehabilitative/restoration of function as soon aspossible

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





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







Read Code: S571.


Triggers: 12

KEY POINTS• If direct trauma or pathology is excluded, thoracic pain is frequently the

result of postural changes


• 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


• Scheurmann’s in teenagers• Cushing’s syndrome• Cardiac• Compression fracture• Chance fracture• Ankylosing spondylosis• Rib fracture

Sprain/Strain Thoracic Spine

Sprain/Strain Thoracic Spine S571.



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 discherniation

Complications

• Infection• Primary bone tumour


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 withACC case manager)

Sprain/Strain Thoracic Spine

Sprain/Strain Thoracic Spine S571.



Read Code: S572.


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


• 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

• 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 Lumbar Spine

Sprain Lumbar Spine S572.

RED FLAG:







Significant trauma

Weight loss

History of cancer

Fever


Steroid use




lying down

YELLOW FLAG:






Behaviours

Compensation issues


Emotions

Family

Work




• 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


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

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






Read Code: S574.


Triggers: 12

KEY POINTS• Coccygeal pain may be protracted• The outcomes are variable and unpredictable


• 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


• 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


Acute:• Reassurance• Ice therapy• Coccygeal/ring cushion• Chair modification

Sprain Coccyx

Sprain Coccyx S574.



• Mobilisation to pain tolerance• Pain management

Sub-acute:• Continued pain management• Education on exacerbating factors

Referral

Refer to GP:• for pain assistance if unresponsive

Sprain Coccyx

Sprain Coccyx S574.



Read Code: N12CO


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


• 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


• DJD of facets/disc• Lateral canal stenosis• Myofascial trigger points/pain syndrome• Fracture• Facet trophism• TOS• IVF encroachment

Cervical Disc Prolapse Radiculopathy

Cervical Disc Prolapse Radiculopathy N12CO



• 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


• 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

Cervical Disc Prolapse Radiculopathy

Cervical Disc Prolapse Radiculopathy N12C0



Read Code: N12C1


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


• 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


• 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

Thoracic Disc Prolapse Radiculopathy N12C1



• 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 discherniation

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


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)

Thoracic Disc Prolapse Radiculopathy

Thoracic Disc Prolapse Radiculopathy N12C1



Read Code: N12C2


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


• 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


• Red Flags• Facet syndrome• Myofascial pain syndrome• Sacroiliac dysfunction• Referred pain – visceral• Spondylolisthesis• Circulatory disease

Lumbar Disc Prolapse Radiculopathy

Lumbar Disc Prolapse Radiculopathy N12C2



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


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

Lumbar Disc Prolapse Radiculopathy

Lumbar Disc Prolapse Radiculopathy N12C2



Read Code: XaO6Y


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


• Look for poor recovery signs – numbness and pain in the upper limbs, asharp reversal of the cervical spine, prolonged dependence on a cervicalcollar, 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


• 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

Whiplash XaO6Y



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


• There is little evidence for using cervical collars – using them for longerthan 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

Whiplash

Whiplash XaO6Y



Composite

Section 2


Read Code: S460.


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


• 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


• ACL tear• Collateral ligament tear• Osteochondritis dissecans/osteochondral fracture• Tibia/fibula joint dysfunction

Meniscal Tear (Medial)

Meniscal Tear (Medial) S460.



• 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


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

Meniscal Tear (Medial)

Meniscal Tear (Medial) S460.



Read Code: S461.


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


• 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)

Meniscal Tear (Lateral) S461.




• 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


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





– persistent, unresolving symptoms– history of locking or giving way– recurrent or persistent effusion– haemarthrosis detected








Read Code: S50..


Triggers: 12

KEY POINTS


• 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


• 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 isinconclusive

Complications

• Restricted shoulder movement

Sprain Upper Arm/Shoulder

Sprain Upper Arm/Shoulder S50..




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

Sprain Upper Arm/Shoulder

Sprain Upper Arm/Shoulder S50..



Read Code: S500.


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


• 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


• Shoulder dislocation• Anterior humerus dislocation• Glenohumeral joint/rotator cuff

Sprain Acromio-Clavicular Ligament

Sprain Acromio-Clavicular Ligament S500.



• 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)


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

Sprain Acromio-Clavicular Ligament

Sprain Acromio-Clavicular Ligament S500



Read Code: S503.


Triggers: 16

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


• 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


• 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


Acute:• Ice therapy for the first 24 hours• Pain relief

Sprain Infraspinatus Tendon

Sprain Infraspinatus Tendon S503.

RED FLAG:

If patient cannot push hand away

from lumbar region, this indicates

a major tear of R/C

Elderly patients (more likely to

fracture and develop stiff joint)



• 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


Sprain Infraspinatus Tendon

Sprain Infraspinatus Tendon S503.



Read Code: S504.


Triggers: 16

KEY POINTS• It is rare for children to sprain ligaments• Check elderly patients for fracture or tendon rupture• Early mobilisation and RICE speed recovery


• 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


• 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

Sprain Rotator Cuff S504.

RED FLAG:



a major tear of R/C





Investigations

• X-ray if clinically indicated• Ultrasound depending on the symptoms and response

Complications

• Avulsion• Complete tear• Calcification• Subacromial bursitis• Recurrent injury• Tendonitis


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


Sprain Rotator Cuff

Sprain Rotator Cuff S504.



Read Code S507.


Triggers: 12

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


• 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


• Labral tear• Impingement• Fracture• AC/SC joint• Tendonitis/bursitis• Cervical and thoracic spine• Instability• Biceps, supraspinatus tendonitis

Sprain Shoulder Joint

Sprain Shoulder Joint S507.

RED FLAG:



a major tear of R/C





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


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


Sprain Shoulder Joint

Sprain Shoulder Joint S507.



Read Code: S51..


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


• Elderly patients need early mobilisation to prevent stiffening• Occupation• Age• Activity

History

• Determine the mechanism of injury – it is frequently a twisting injury aftera 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


• 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

Sprain Elbow/Forearm S51..



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


• 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


Sprain Elbow/Forearm

Sprain Elbow/Forearm S51..



Read Code: S52..


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


• 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


• 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

Sprain Wrist/Hand S52..



• 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


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

Sprain Wrist/Hand

Sprain Wrist/Hand S52..



Read Code: S522.


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


• 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


• Fracture, including avulsion• Muscle tear• Arthritides• Tendonitis or tendon injury• Grades 2 to 3 (dislocations)• Full rupture• Dislocation

Sprain Thumb

Sprain Thumb S522.



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


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

Sprain Thumb

Sprain Thumb S522.



Read Code: S523.


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


• Dislocation• Avulsions• Infection• Surgical intervention unlikely unless Grade 3• Fracture• Tendon injuries• Arthropathies

Sprain Finger

Sprain Finger S523.



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


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

Sprain Finger

Sprain Finger S523.



Read Code: S53..


Triggers: 12

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


• 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


• 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

Sprain Hip/Thigh S53..

RED FLAG:

Children and elderly – a careful

assessment is required where the

history is not consistent with the

severity of symptoms. Seek

advice early



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


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


Sprain Hip /Thigh S53..



Read Code: S533.


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


• 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


• Bursitis• Osgood-Schlatter disease• Patello-femoral syndrome• Chondromalacia patella• Plica’s syndrome• Patella fracture

Sprain Quadriceps Tendon

Sprain Quadriceps Tendon S533.



• 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


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


Sprain Quadriceps Tendon

Sprain Quadriceps Tendon S533.



Read Code: S540.


Triggers: 14

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


• Degree of damage (Grades 1, 2, 3)• Involvement (undiagnosed) of other structures• ADLs/sport/occupation• Lumbopelvic dysfunction may become a secondary problem resulting from

the knee injury

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

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

Sprain Lateral Collateral Ligament Knee S540.

Ottawa Knee Rules

X-ray if:

patient > 55 years

tenderness present at head of fibula

isolated tenderness over patella

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

consciousness, paraplegia,

or multiple injuries

Pittsburgh Knee Rules

Indicate radiography if the mechanism of injury

is blunt trauma or a fall, and either:

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

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




• 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


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

Sprain Lateral Collateral Ligament Knee

Sprain Lateral Collateral Ligament Knee S540.



Read Code: S541.


Triggers: 14

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


• Degree of damage (Grades 2, 3)• Other injured structures• ADLs/sport/occupation• Lumbopelvic dysfunction may become a secondary problem resulting from

the knee injury

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

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


• Cruciate ligament injury• Meniscal injury• Fracture

Sprain Medial Collateral Ligament Knee

Sprain Medial Collateral Ligament Knee S541.

Ottawa Knee Rules

X-ray if:

patient > 55 years






examination

Exclusion criteria:

Age < 18 years


re-evaluated










Exclusion criteria:


before presentation


and abrasions



affected knee


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



• 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


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

Sprain Medial Collateral Ligament Knee

Sprain Medial Collateral Ligament Knee S541



Read Code: S542.


Triggers: 16

KEY POINTS• 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

surgical repair• Start treatment early – either the same day or the next – to prevent muscle

atrophy• Fractures rather than sprains are more likely in elderly people• Use RICE• There is a higher risk of tendon rupture in elderly people• It is important that the patient regains complete flexion/extension after the

injury while restricting rotation• 70% of anterior cruciate ruptures need immediate surgery


• Associated meniscus injury is common• Elderly people require early mobilisation• The knee should normally be immobilised for no more than 3 days• Lumbopelvic dysfunction may become a secondary problem resulting from

the knee injury

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

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


• Medial, lateral ligament injury and meniscal tears• Fracture

Sprain Cruciate Ligament Knee

Sprain Cruciate Ligament Knee S542.

Ottawa Knee Rules

X-ray if:

patient > 55 years






examination

Exclusion criteria:

Age < 18 years


re-evaluated










Exclusion criteria:


before presentation


and abrasions



affected 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


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





– 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







Read Code: S54x1


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


• 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 footis dorsiflexed, or during dorsiflexion of the ankle/foot with the kneealready 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


• DVT• Spinal/sacral origin• Baker’s cyst• Knee referral• Ankle sprain• Partial/complete muscle tear

Sprain Gastrocnemius

Sprain Gastrocnemius S54x1



• 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


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


Sprain Gastrocnemius

Sprain Gastrocnemius S54x1



Read Code: S550.


Triggers: 14

KEY POINTS• Use RICE therapy early• Use the Ottawa Rules for X-raying the ankle injury• Grade 3 and ruptures require referral


• 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

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


• 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

Sprain Ankle S550.

Ottawa Ankle Rules

X-ray if:

unable to bear weight (take 4 steps)

at time of injury and at examination

bone tenderness at posterior edge or

tip of either malleolus

bone tenderness over the naviculus or

base of fifth metatarsal

RED FLAG:

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

Elderly patients



• 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


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

Sprain Ankle

Sprain Ankle S550.



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

Sprain Ankle S550.





Read Code: S5504


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


• 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

Sprain Achilles Tendon S5504



• Biomechanical• Gait• Ankle joint dysfunction• Lumbopelvic dysfunction


• 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 calcanealchanges

• MRI can help differentiate between tendonitis and partial rupture (but isused rarely)

Complications

• Recurrence• Rupture• Tendonitis• Steroid depositions• POP effects• Gradual injury process• Severe biomechanical dysfunction• Rupture of tendon


• 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





• 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 Metatarso-Phalangeal Joint/Interphalangeal Joint

Read Code: S5512/S5513


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


• 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




• 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


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

Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint

Sprain Metatarso-Phalangeal Joint/Interphalangeal Joint S5512/S5513



Read Code: S5y3.


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


• 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, sneezeversus 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


• Herpes• Thoracic spine injury/referral• Cervical spine injury/referral• Viscero-somatic pain• Tumour• Chest wall contusion• Costo-vertebral or costo-sternal

Sprain Ribcage

Sprain Ribcage S5y3.



• 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


• 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

Sprain Ribcage

Sprain Ribcage S5y3.



Read Code: F340.


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


• 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


• Cervical spine C6 nerve root compression• Brachial neuritis

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome F340.



• 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


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

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome F340.



Read Code: N211.


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 – associatedwith tendon inflammation

• The patient may present with a prolonged history of pain with associatedtendon 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


• 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

Rotator Cuff Syndrome N211.



• Cervical spine• Disuse atrophy• X-ray – inferior malposition of humerus, chronic tear may reveal sclerosis

and irregularity of greater tuberosity, narrowing of acromiohumeralinterval to 5mm or less


• 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


• 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





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)







Read Code: N2131


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


• NSAID therapy• Previous steroid injection• Occupation

History

• Determine if the injury has resulted from an acute or recurrent injury orgradual 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


• 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)

Medial Epicondylitis (Elbow) N2131



Investigations

• X-ray to rule out intra-articular pathology (if there is no response totreatment or there are atypical features)

• Ultrasound referral if the injury is slow to recover and affecting thepatient’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


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 withoutrequiring 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

Medial Epicondylitis (Elbow)

Medial Epicondylitis (Elbow) N2131



Read Code: N2132


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


• NSAID therapy• Previous steroid injection• Occupation

History

• Determine if the injury is the result of acute or recurrent injury or gradualonset

• 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


• 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)

Lateral Epicondylitis (Elbow) N2132



Investigations

• X-ray to rule out intra-articular pathology (if there is no response totreatment or there are atypical features)

• Ultrasound referral if the injury is slow to recover and affecting thepatient’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


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 withoutrequiring 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

Lateral Epicondylitis (Elbow)

Lateral Epicondylitis (Elbow) N2132



Read Code: N2174


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


• 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

Tendonitis Achilles N2174



• Gastrocnemius tightness• Other soft tissue or joint restriction• Gait• Ankle joint dysfunction• Lumbopelvic exam• Neurological exam of the involved lower extremity


• 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 calcanealchanges

• 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


• 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

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






Read Code: N22..


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


• 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

Synovitis and Tenosynovitis N22..




• 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


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





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 occupationadvice

• Refer to physiotherapist for electrical stimulation, acupuncture





Composite

Printed January 2003 • ISBN 0–478–25182–3 • ACC 1032

Documents

Chiropractic Treatment Profiles – 2003 - ACC