Orthopedic Jayant Joshi

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Essentials of Orthopaedics and Applied
Physiotherapy
THIRD EDITION
Jayant Joshi
Ex-Superintendent, Physiotherapy, All India Institute of Medical Sciences,
Ex-Consultant, Physiotherapy and Rehabilitation, Sitaram Bhartia Institute
of Science and Research, New Delhi, INDIA
Prakash Kotwal
MBBS, MS (Ortho), FAMS, FIMSA, Senior Consultant and Head,
Department of Orthopaedics, Pushpawati Singhania Research Institute, New
Delhi
Formerly, Professor and Head, Department of Orthopaedics, All India
Institute of Medical Sciences, New Delhi, India
Table of Contents
Cover image
Title page
Copyright
Dedication
Preface to the third edition
Preface to the first edition
Contributor
1. Orthopaedics and physiotherapy

Bibliography
Physiotherapy as applied to orthopaedics
Chest physiotherapy
2. The bones and the joints

3. Inflammation and soft tissue injuries
References
Inflammation
Soft tissue injury
Musculoskeletal disorders
4. Fractures (general)
Bibliography
5. Injuries around the shoulder
6. Injuries of the arm
7. Injuries of the elbow
8. Injuries of the forearm
9. Injuries of the wrist
10. Injuries of the hand
11. Injuries of the spine

Bibliography
12. Injuries of the pelvis

13. Injuries of the hip
Lower extremity
14. Injuries of the thigh
15. Injuries of the knee
16. Injuries of the leg
17. Injuries of the ankle and the foot

Bibliography
18. Common paediatric and adolescent musculoskeletal disorders and

fractures
Bibliography
19. Prevention of fractures
20. Emergency management of a polytrauma patient
21. Infections of the bones and joints
22. Metabolic bone diseases
23. Bone tumours
24. Arthrodesis, arthroplasty and osteotomy

References
Total hip replacement arthroplasty (thr)
Girdlestone arthroplasty
Total knee replacement arthroplasty
Arthroplasty of ankle
Arthroplasty of shoulder
Arthroplasty of hand
25. Amputations
Bibliography
26. Lesions of the brachial plexus
27. Peripheral nerve injuries

Bibliography
Brachial plexus lesions
Peripheral nerve injury
28. Poliomyelitis
Bibliography
29. Arthritides
Bibliography
Rheumatoid arthritis
Haemophilia
30. Deformity
Bibliography
31. Locomotion and gait

Bibliography
32. Spine
Bibliography
Spina bifida
Cervical syndrome
Low back pain
Lumbar spondylolisthesis
33. Regional orthopaedic soft tissue lesions of the shoulder, elbow,

forearm, wrist and hand
Bibliography
34. Hand
Bibliography
35. Regional orthopaedic conditions at the hip

Bibliography
36. Regional orthopaedic conditions at the knee

Bibliography
37. Regional orthopaedic conditions at the ankle and foot

Bibliography
38. Yoga, yoga asanas and physiotherapy

Bibliography
39. Sports medicine

Bibliography
Index
Copyright
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Essentials of Orthopaedics and Applied Physiotherapy, 3e, Jayant
Joshi (Late) and Prakash Kotwal
Copyright © 2017, by RELX India Pvt. Ltd.

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Dedication
Dr Jayant Joshi left for his heavenly abode on 2 Februaruy

2015. He had completed the work on the third edition
manuscript just 4 days before his death.
Preface to the third edition
Prakash Kotwal
It is indeed a pleasure to present the third edition of the book

Essentials of Orthopaedics and Applied Physiotherapy. Bringing out a new
edition provides an opportunity to update the book in accordance
with the recent advances in the subject. This is exactly what has been
done with this edition of the book. Most of the chapters have been
revamped with addition of new/better photographs and tables for
better understanding.
This edition contains 39 chapters, against the 26 in the second
edition. The bigger chapters have been split into multiple chapters,
organized region wise in body, with a view to update the chapters
and easy accessibility to a topic.
The project of writing this book was conceptualized with the
intention of providing knowledge about orthopaedic conditions and
procedures to the physiotherapy students, practising physiotherapists
and orthopaedic surgeons alike. The book was also meant to discuss
the physiotherapy protocols after an orthopaedic procedure or
treatment. To take this intention further, selected physiotherapy
procedures/manoeuvres are being provided along with this edition of
the book. The videos of the physiotherapy procedures have proper
citations in the text. The videos comes at no extra cost, demonstrating
the correct methods of physiotherapy procedures/manoeuvres.
I take this opportunity to pay homage to my co-author, Mr Jayant
Joshi, who passed away a few months back. He was the main
inspiration behind starting this book project. His passion and
dedication for this book was so great that he completed the majority of
the manuscript just before he passed away.
I would like to express my gratitude to all those who helped me in
the preparation of the manuscript of this book.
I thank Mrs Kanchan Mittal for accepting the task of completing the
physiotherapy part of the book.
My friends Siddharth and Reena Mishra deserve a special mention
and thanks for undertaking the clinical photography job with a
professional finesse. I would like to thank my colleagues Dr Bhavuk
Garg, Prof. Shah Alam Khan, Dr Md Tahir Ansari and Dr Abhinav
Agarwal for providing certain clinical photographs for this book. I am
also grateful to Dr Vivek Shankar for his extensive help at various
stages of the preparation of manuscript.
I owe my life to my parents, Shri P.D. Kotwal and Mrs Usha
Kotwal, and career to Mr P.S. Samvatsar and Mrs Sushma Samvatsar.
Last, but not the least, special thanks to my wife, Arundhati, for the
encouragement, patience and the unconditional support in my
professional pursuit.
Preface to the first edition
Jayant Joshi
Prakash Kotwal
Physiotherapy has come of age and is now an integral part of

orthopaedic practice. In fact, orthopaedics per se is
incomplete in the management of a patient without
physiotherapy. Orthopaedic physiotherapy is one of the
major specialities of the science of physiotherapy and plays a
significant role in restoring full function at the earliest.
There are a large number of books on orthopaedics and

physiotherapy but each deals with the subjects as a separate
entity. As such, it is not always convenient to refer to them to
get an overall view of the total therapeutic management.
Therefore, a need was felt to bring out a book with an

interspeciality therapeutic approach to get the overall picture
of the total therapeutic management. We sincerely hope that
this book, the first of its kind, would fill this gap and would
provide useful guidance not only to the students of
physiotherapy and practising physiotherapists but also to the
orthopaedic surgeons, physiatrists and others engaged in the
rehabilitation of the physically handicapped.
Most of the chapters in this book start with a treatise on

relevant applied anatomy, predisposing factors, clinical
features, diagnosis and comprehensive orthopaedic and
physiotherapeutic management of all the common
orthopaedic conditions including fractures and dislocations.
A large number of line diagrams and photographs have been
used to describe the various aspects of diagnosis and
treatment of a particular condition. Some of the latest
research works have also been included in the References for
further reading on the subject. Tables have been used,
wherever necessary, to present the matter in a concise or
comparative form.
We are grateful to Professor P Chandra and Professor PK

Dave for their constant guidance and encouragement during
the preparation of this book. Our special thanks are due to
our spouses, who tolerated our passion for this book,
supported and assisted us while we were working on the
manuscript. We are also thankful to Mr Viney Patil, Mr
Kamalakar Patil, Ms Sweta, Mr Tara, Mr Tiwari, Mr Anil and
others for their co-operation and assistance.
Contributor
Kanchan Mittal, Superintendent of Physiotherapy, Department of

Orthopedics, All India Institute of Medical Sciences, New Delhi
CHAPTER
1
Orthopaedics and physiotherapy
OUTLINE
◼ Goal and role of both the sciences
◼ Orthopaedic disorders
◼ Systematic approach
◼ Principal methods of orthopaedic management
◼ Orthopaedic physiotherapy and cardiopulmonary
conditioning
◼ Chest physiotherapy
◼ Cardiopulmonary resuscitation or ABC of life support
The term orthopaedics is derived from two Greek words orthos and
pedios. Orthos means straightening and pedios means child. Originally
the field of orthopaedics was limited to manipulating and correcting
the deformed limbs in children. The age-old definition of this science
is grossly wrong. Nowadays, the remarkable spurt of advancements
in the technology has revolutionized the whole process of orthopaedic
management; from correcting deformities in children, it has
progressed to the level of organ replantation.
Similarly, the field of physiotherapy which used to be limited to
massage and simple movements to the joints following fracture has
developed into an independent specialty of medical sciences. Its
nonpharmacological exercise-oriented approach and multidisciplinary
applicability has widened its horizons tremendously. Besides therapy,
its preventive role is being recognized all over the globe. However,
the science of physiotherapy has a special hand-and-glove
relationship with orthopaedics, as it plays a predominant role in the
management of the whole gamut of orthopaedic sciences. To quote
one of the reputed orthopaedic surgeons of India, Late Prof P
Chandra, Emeritus Professor, All India Institute of Medical Science,
New Delhi, ‘The success of orthopaedic treatment depends largely on
a physiotherapist. The surgeon should never pick up the knife unless
he/she has a competent physiotherapist.’
Goal and role of both the sciences

The ultimate goal of orthopaedic treatment as well as orthopaedic
physiotherapy is to restore the maximum possible physical
independence to a patient, in performing the physical tasks involved
in the activities of daily routine (ADR) and occupation (before injury
or altered occupation after rehabilitation) within the limits of
disability or the disorder (Fig. 1-1).
FIG. 1-1 Goal and role of orthopaedics and physiotherapy.
Orthopaedic management provides the basic structural stability to the

body, whereas physiotherapy works towards achieving the maximum
functional restoration.
Orthopaedic disorders
The disorders in orthopaedics are broadly classified into two
categories:
1. Traumatic (Table 1-1) and
2. Nontraumatic (Table 1-2)

Table 1-1
Major Traumatic Orthopaedic Disorders
Bone Injuries Soft Tissue Injuries

• Fractures Injury to the
• Subluxations • Muscles
• Dislocations • Ligaments
• Multiple trauma involving multiple fractures, injury to the soft • Blood vessels
tissue and visceral organs (e.g., caused by RTA, earthquake) • Nerves
• Skin
• Fascia
• Other connective tissues like
joint capsule, synovium,
bursae
Abbreviation: RTA, road traffic accident.
Table 1-2
Major Nontraumatic Orthopaedic Disorders
Disorder Aetiology Example

Pathological fractures • Occur as a result of weakening of the • Fracture due to
1. bone due to generalized or localized metastatic lesion, a
bone disease fracture through the bone
cyst, or due to
osteoporosis, etc.
Congenital anomalies • Mostly developed during intrauterine • Congenital absence of
2. period bones
• CTEV, scoliosis,
congenital dysplasia, etc.
Developmental • Developed due to faulty development • Achondroplasia
3. disorders of bone or cartilage • Paget disease
• Osteochondritis
Infective diseases • As a result of infection by • Osteomyelitis
4. microorganisms • Tuberculosis
• Septic arthritis
Metabolic diseases • As a result of imbalances in mineral • Rickets
5. exchange between the bone reservoir • Osteoporosis
and intracellular fluid regulated by • Hyperparathyroidism
hormones and local factors
Endocrinal disorders • As a result of hormonal imbalances • Hypothyroidism
6. (cretinism)
• Hypopituitarism
(dwarfism)
Inflammatory disorders • Inflammation which progresses to the • Rheumatoid arthritis
7. bones and joints systemic soft tissue • Ankylosing spondylitis
from diseases
Neoplasia (tumours) • Development of benign or malignant • Osteoma (benign)
8. tumours of the bone • Osteosarcoma
(malignant)
Degenerative joint • Wear and tear of the joint cartilage • Osteoarthritis
9. disorders • Spondylosis
10. Neuronal and muscular • Could be congenital, acquired, • Cerebral palsy
disorders developmental, infective or due to • Neuropathy
compressive pathology • Poliomyelitis
11. Regional Soft tissue lesions due to • Sports injuries
musculoskeletal • Overuse of specific muscles and joints, • Cervical spondylosis
conditions of the neck, or trauma • Low back pain
spine, upper and lower • Wrong postural habits • Adhesive capsulitis
limbs • Lack of exercise, etc. (frozen shoulder)
Abbreviation: CTEV, congenital talipes equino varus.
Some common traumatic disorders are listed below.
◼ Fracture: When there is discontinuity at the outermost hard layer of

the bone (cortex).
◼ Subluxation: When a joint is only partially displaced from its

compact original position with the retention of some articular
contact.
◼ Dislocation: When a joint is displaced from its compact natural

anatomic configuration with partial or complete disruption of the
joint capsule and the ligaments.
◼ Strain: When a muscle or a ligament is torn as a result of excess

violence.
◼ Stress: When the ligaments protecting the joint are injured due to
sudden excessive twisting violence to the joint.
Systematic approach
Correct diagnosis is the key to the successful management of a patient.
The following criteria help to arrive at the diagnosis:
1. Sound basic knowledge of the subject including the latest

developments in the field
2. Critical clinical and physical examination and objective evaluation

of the patient provide definite clues to a provisional diagnosis
3. Correct interpretation of the results of evaluation including
investigations confirms the diagnosis
4. Appropriate patient-oriented therapy
5. Educating the patient on preventing the recurrence of the disorder

or disease as well as wilful acceptance of healthy exercising lifestyle
Steps in the process of evaluation towards diagnosis

(tables 1-3 and 1-4)
1. Observational analysis
2. History taking
3. Collection of subjective data from a patient
4. Objective clinical data, through physical examination and

evaluation
5. Functional evaluation
Table 1-3
Steps in Orthopaedic and Physiotherapeutic Evaluation
1. Observational • To observe the patient for obvious • Overall physical status

analysis physical discrepancies, e.g., posture, gait, • Areas of major physical
deformity when the patient is ambulatory disability
2. History of • Offers broad classification of the present • Identification of the major
onset and episode and possible pathology, e.g. category of disorder:
course of the • Is it traumatic or nontraumatic? • Traumatic or nontraumatic
disorder or • Is it congenital or acquired? • Congenital or acquired
disease • Is it associated with • Infective disorder
• Fever, chill, rigors, sweating (possible • Inflammatory disorder
infective pathology) • Metabolic disorder
• Seasonal variation (possible inflammatory • Endocrinal disorder
pathology) • Certain orthopaedic disorders
• Constitutional symptoms like rapid are commonly encountered at
weight loss, anorexia (e.g. neoplasia) certain age groups and related to
• Hormonal imbalance (e.g. sex
hypothyroidism, hypopituitarism)
• Joint pain at advanced age (degenerative
disorder)
• Age and sex (certain orthopaedic diseases
are common at certain age groups and sex)
Developmental diseases
• Occur later during the growing period
3. Subjective data • Information from the patient regarding • To guide physical
collection • Occupation rehabilitation, schedule
• Subjective perception of the present • To decide therapeutic
episode and its overall impact approach
4. Objective • To evaluate and record the informative Provide objective data to
examination data through physical examination • Plan therapeutic programme
and evaluation • Inspection • Judge therapeutic response of
• Carefully inspect skin health, wounds, the patient and the prognosis of
scars, stretchability, sensation, etc. recovery
• Objective evaluation of tenderness,
swelling, deformity, atrophy
• Palpation
• For temperature difference, anatomical
integrity of the bones and joints,
interrelationship of the bony prominences
and soft tissues (e.g., presence of nodules)
• Movements: Evaluation of passive as well
as active ROM at the joints
• Muscle functions: Critical evaluation of
strength, endurance, flexibility, tone,
movement control and coordination
• Sensory status: Critical evaluation of the
sensations, kinaesthetic and proprioceptive,
touch, pinprick and the reflexes
• Joints: Examine the joints for stability,
integrity, musculoskeletal stretchability,
ROM and deformity
5. Functional • To critically assess the physical efficacy of • Provides guidance in
evaluation performing the various activities of daily formulating individualized
routine (ADR) therapeutic prescription – to
• Detailed evaluation of the improve deficient functional
neuromusculoskeletal deficiencies hindering performance
the ADRs
Abbreviations: ADRs, activities of daily routine; ROM, range of motion.
Table 1-4
Specific Orthopaedic and Physiotherapy Examinations to Reach Final Diagnosis
Specific Orthopaedic
Examination to Reach the Final Specific Physiotherapy Examination to Plan Therapeutic Programme
Diagnosis
• Radiography • Body structure, body weight, height and body composition
To evaluate skeletal integrity • Overall physical capacity to withstand exercise and any
It could be contraindications
• Plain radiography • Accurate goniometric measurement of ROM, deformities, etc.
• Contrast radiography • Detailed assessment of muscle functions
(e.g., arthrography) • Muscle power (strength), especially of the functional groups
• CT scan: Provides detail of • Endurance
the skeletal lesion (with 3- • Flexibility
dimensional reconstruction) • Tone (hypertonia, hypotonia or atonia)
• MRI: Provides better • Examination of the joints
delineation of the soft • Details of the movement patterns, movement control and
tissues and to some extent, coordination and balance
changes in the bone • Neuromuscular integrity by EMG, stimulation, RD test
• Angiography, biopsy and • Gait pattern analysis
other relevant diagnostic • Diagnostic physical tests to identify the site and extent of the soft
laboratory tests tissue or neuronal injury (e.g., musculotendinous complexes,
• Radioisotope bone scan ligaments, lesions of the central nervous system and peripheral
• PET scan nerves
• Open or closed biopsy
(FNAC)
Abbreviations: CT, computed tomography; EMG, electromyogram; FNAC, fine-needle

aspiration cytology; PET, positron emission tomography; RD, reaction of degeneration; ROM,
range of motion.
It not only provides definite clues to the final diagnosis but also
greatly assists in formulating the therapeutic procedures.
Functional evaluation
◼ Evaluation of the whole body’s efficacy to perform ADR and
occupation-related physical tasks, recording specific deficiencies
blocking a particular activity
◼ Detailed neuromusculoskeletal evaluation of the individual-

deficient segment obstructing the function, e.g., range of motion
(ROM), muscle functions, movement control and coordination,
balance, sensorium and ambulatory status, gait pattern and efficacy
in managing slopes, stairs
Note: Extensive stepwise evaluation is not always necessary or
possible. A single step may be adequate to arrive at the diagnosis.
Principal methods of orthopaedic

management
Basically the following two principal methods are used in the
treatment:
◼ Conservative
◼ Surgery
Conservative method
Appropriate pharmacological agents:
◼ To reduce pain
◼ To control inflammation
◼ To control infection by microorganisms
◼ To control reflex muscular spasm
◼ Rest to the injured area by proper positioning of the injured limb
◼ To immobilize the injured or diseased area by
◼ Strapping
◼ Plaster of Paris (POP) slab/cast
◼ Orthosis
◼ Skin or skeletal traction
◼ Graded manipulation and serial POP casting to correct deformity
◼ Joint manipulation under GA to mobilize stiff joint
◼ Closed reduction and manipulation with or without GA to correct

anatomical alignment of broken bones (fractures) or dislocated joints
Surgery
◼ Open reduction and internal fixation (ORIF) to fix fractured bones
◼ Replacement of fractured or diseased bones or joints by artificial
components, e.g., arthroplasty
◼ Bone grafting to fill up a gap, strengthening the bone or to stimulate

the growth of bone in fractures nonunions
◼ Osteotomy – producing fracture to correct bony deformity, or

malalignment of a joint
◼ To adjust the line of weight bearing or to correct limb length

disparity
◼ Arthrodesis – fusion of the joint in a functional position when no

alternative is available to facilitate function
◼ Reconstructive surgery – to repair the damaged soft tissues like

nerve, muscle, fasciae, etc.
◼ Vertebroplasty – use of bone cement to fill up the gap and

strengthen the diseased or broken vertebrae
◼ Replantation – reattachment of the severed part of the limb (e.g.,

hand, digits)
Preventive role of physiotherapy

1. Preventive: Primary and secondary prevention (Table 1-5)
2. Restorative: To restore the near-normal functional status (Table 1-6)
3. Rehabilitative: To restore the maximum possible functional

independence within the limits of the disease and the disability (Table
1-7)
Primary prevention and secondary prevention: Mainly it refers to the

prevention of traumatic lesions and life-threatening conditions like
coronary heart disease (CHD), hypertension and
hypercholesterolaemia.
Secondary prevention and/or better control of the disease:

Development of complications is common not only following
fractures but even after contacting any disease, which has adverse
effects on the progress of recovery. These hazards can be effectively
dealt with by critical regular monitoring and taking instant
controlling measures.
Table 1-5
Preventive Role of Physiotherapy in Orthopaedics
Primary prevention of Methods

• Fracture • Exercise training (endurance) to optimize physical
• Dislocation fitness
• Subluxation • Concentrated musculoskeletal conditioning of the
• Strains, sprains areas susceptible to injury
• Common soft tissue disorders • Guidance on correct body mechanics
• Guidance to control or avoid activities susceptible
to injury
• Sports- and occupation-related musculoskeletal
conditioning
• Guidance on the work as well as rest-related
wrong postural attitudes
Secondary prevention of • Rest, adequate support and frequent monitoring
• Expected common complications for the signs and symptoms of the expected
following injury – fractures, dislocations, complications
subluxation, etc. • Guidance to the patient on the signs and
• Complications due to rigid symptoms of the possible complications
immobilization (e.g. POP cast, skeletal
traction)
• Complications due to prolonged • Full ROM exercise and passive stretching at the
recumbency suspected sites
• Soft tissue tightness, contractures • Frequent positional changes in bed, skin care,
• Joint stiffness protection of pressure points
• Pressure sores • Gradually progressive exercise
• Generalized weakness and muscular • Chest physiotherapy
atrophy • Early initiation of progressive functional activities,
• Reduced respiratory efficiency PRE, earliest introduction of ambulatory training
• Generalized detoning of all the systems of • Emphasis and guidance to continue exercises as
the body taught
• Recurrence of the earlier disorder
Table 1-6
Restorative Role of Physiotherapy in Orthopaedics
• Reduction and Methods

control of • Comfortable positioning, rest and appropriate physiotherapy modality
• Pain and tenderness • Early cryotherapy
• Swelling • Limb elevation compression bandage
• Reflex muscular • Pain-free early isometrics and active repetitive movements to the distal
spasm joints, cryotherapy
• Early initiation of Formulating exercise training prescription to improve
functional restoration • Muscle functions
• Joint ROM must restore functional ROM earliest
• Neuromuscular coordination and joint control–movement coordination
• Motivation of a patient to perform functional activities independently or
with assistive aids
• Using suitable modality as per the needs (e.g., massage, SWD, ultrasonic
therapy)
• Monitoring progress with regular re-evaluation
• Providing necessary guidance to prevent recurrence
• Use of specialized exercise techniques like PNF, manipulation and
mobilization and manual therapy as per the needs
• Restore the preinjury physical status
Abbreviations: PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; SWD,

shortwave diathermy.
Table 1-7
Rehabilitative Role of Physiotherapy in Orthopaedics
• For patients suffering from severe Methods

involvement or irreversible systemic • Improving the strength and the function of the
damages, e.g., quadriplegics, paraplegics paretic muscle groups
and neuronal diseases like cerebral palsy: • Identify and strengthen muscle groups to
To provide maximum functional compensate for the weaker or paralysed muscles and
independence within the limits of the introduce functional training at the earliest
disease and the disability • Strengthen the compensatory mechanisms to
substitute or assist the functional activity
• Early provision of assistive aids and devices to assist
function
• Concentrate on functional training with aids
• Training on the alternative mode for performing
function, e.g., when ambulation is not feasible,
preparing and teaching the patient on wheelchair
ambulation
• Use of specialized exercise techniques like PNF and
Bobath to improve movement control, posture,
balance, movement coordination, motor and sensory
re-education, transfers, balance, ambulation and self-
sufficiency in performing the activities of daily routine
and the activities involved in the occupation or work
Abbreviation: PNF, proprioceptive neuromuscular facilitation.
Moreover, physiotherapy has emerged as great asset due to its

exercise-oriented approach. Its salutary effect helps in
1. increasing the efficiency of all the organs and the systems of the
body.
2. increasing the immune responses of the body.
3. positively influencing the psychological status.
Role of physiotherapy in orthopaedics

Combination of all these benefits with physical fitness plays a key role
as a preventive specialty.
Planning of physiotherapeutic programme

After critical evaluation, depending upon the expected role (i.e.,
preventive, restorative or rehabilitative), a comprehensive
physiotherapy prescription is formulated to adequately meet the
individual needs of a patient.
A large number of physiotherapeutic modalities are available to
pick and choose from. However, exercise remains the basic mode of
treatment. Assistive modalities provide assistance in the relief from
pain and swelling and help in movement re-education and functional
restoration (Table 1-8). Besides, specialized exercise techniques like
proprioceptive neuromuscular facilitation (PNF), Bobath Brunnstrom
and Maitland, and specialized techniques like manipulation and
mobilization and manual therapy are initiated.
Table 1-8
Planning of Physiotherapeutic Programme
Basic Mode of Treatment Assistive Mode of Treatment

Exercise a: To improve Massage
(a) Joint functions • Cryotherapy
• Static and dynamic stability • Thermotherapy
• Achieving normal or functional ROM • Electrical stimulation
(b) Muscle functions • Interferential currents
• Strength • Ultrasonic therapy
• Endurance • TENS
• Flexibility • Maintenance and use of orthotic, prosthetic and
• Tone functionally assistive devices to support, protect, hasten
(c) Movement the process of recovery or to perform functional
• Character activities
• Control
• Coordination (single and multiple
joints)
• Sensory motor re-education
(d) Balance
• Static and dynamic balance
(e) Functional training: To achieve self-
sufficiency in performing the ADR at
home and at work place with or without
aids
Abbreviations: ADR, activities of daily routine; ROM, range of motion; TENS, transcutaneous
electrical nerve stimulation.
aExercise is a multifactorial common entity and varies from life-saving manoeuvres like ABC
of life support and emergency chest physiotherapy to functional restoration and rehabilitation.
However, the success of a therapeutic programme heavily depends

upon how efficiently patients perform exercise on their own.
Exercise specificity
Our inborn lethargy towards exercise even in normal health is
compounded further by pain, weakness and depression. Moreover,
therapeutic exercise for benefits needs to be done several times. Under
such circumstances, motivating and educating a patient to perform
exercise efficiently and repetitively calls for certain must-be observed
principles:
◼ Spend enough time in explaining the why and how of exercises.

Being exercise-oriented professionals, somehow we tend to forget –
that the patient also knows about exercises as well as we do.
◼ Ideally use the better part or normal limb or use a method of ‘SELF-
DEMONSTRATION’, audiovisual media, diagrams, etc., for the
patient to understand the correct methodology of exercise.
◼ Always begin with the simplest possible exercise.
◼ Select exercise in a preferential order as per the demand of the

patient’s condition.
◼ Select minimum number of very specific exercises and teach only

one exercise at each sitting till a patient grasps it and performs it
with maximum efficiency.
◼ Always check the specificity of previously taught exercise before

proceeding to the next exercise.
◼ As far as possible, the exercise regimen should be competitive and

based on the functional ADRs.
◼ To break the monotony of exercise but, at the same time, to ensure

several repetitions, teach one exercise in the different fundamental
positions of the body (e.g., exercise of knee flexion–extension can be
performed in all the fundamental postures of the body (Fig. 1-2).
FIG. 1-2 Performance of same movement (e.g. knee flexion) in various

body postures: (A) supine, (B) low sitting (C) high sitting, (D) prone lying,
(E) standing. It helps to break the monotony of exercise and encourages
repetitions.
By this approach, a patient’s acceptance of exercise is ensured.
General plan of physiotherapeutic management in orthopaedics
A. Acute multitrauma: prehospital care

◼ Make a quick assessment of the patient’s general condition
by reviewing the vital signs.
◼ If needed, immediately start emergency measures to save

life, e.g. ABC of life support (cardiorespiratory
resuscitation).
◼ Control bleeding.
◼ Provide temporary support splinting to an injured limb

and measures to prevent further damage.
◼ Arrange for immediate safe transfer of a patient to the

nearest hospital or emergency management facility.
B. Routine cases treated conservatively
◼ Perform critical evaluation to assess the degree of major

physical problems.
◼ Formulate exercise prescription on an individual basis.
◼ Initiate educating a patient on simple but specific exercise

training as well as functional training programme.
◼ Cultivate interest in exercise lifestyle emphasizing its

health benefits.
◼ Monitor the conducting of the exercise training and the

efficiency of patient’s performance, and use special exercise
techniques.
◼ Plan a weekly or biweekly goal of expected improvement

and review the progress critically by objective and
subjective evaluation.
◼ Educate the patient on the don’ts and teach to prevent

recurrence.
C. Cases treated by surgery
◼ Make preoperative assessment and conditioning (in

preplanned surgical patients).
◼ Make preoperative evaluation and education – on the

postoperative exercise training sessions and functional
training schedules.
◼ Prescribe necessary orthotic devices or aids needed for

postsurgical functional training.
◼ Plan weekly goal of expected recovery.
◼ Review at regular intervals to ensure recovery.
◼ Cultivate patient’s interest in accepting exercise lifestyle as

a disease preventive entity.
Planning of physiotherapeutic management

Due to the great variety of modalities and specialized treatment
techniques, it is extremely difficult to generalize the therapeutic
programme of physiotherapy. It is further complicated by the severity
of the dysfunction, prognosis of recovery and individual variations.
Based on the expected duration of rehabilitation, patients are
broadly classified into the following three categories (Table 1-9):
Table 1-9
Classification of Patients on the Basis of the Approximate Time Required for
Rehabilitation
1. Short duration (3–6 weeks) • Simple neuromusculoskeletal disorders or undisplaced

uncomplicated fractures
2. Intermediate duration (12–30 • Fractures and/or dislocations of major bones and joints
weeks) • Crush injuries; with complications
• Early detected bone diseases
3. Long duration (30–52 week or • Conditions needing long periods of recumbency
more) • Patients with low physical capacity
• Patients with irreversible neuronal damages or bone diseases
• Recurrent systemic diseases like rheumatoid arthritis
• Loosening of the artificial implants needing revision or multiple
surgeries
• Delay in reporting for treatment after developing complications
• Failure in motivating patients even with uncomplicated disorders
Short-duration rehabilitation patients: This includes patients with

simple, reversible neuromusculoskeletal dysfunctions, mostly
involving soft tissues or simple fractures. The dysfunction is
completely resolved within 3–6 weeks by appropriate physiotherapy
measures.
◼ Control of pain and swelling by selecting appropriate modality
◼ Provide adequate supporting aid to prevent further damage, and

pain due to movement at the injured area
◼ Encouraging pain-free isometrics progressing gradually to full

ROM exercise against resistance
◼ Effective home management programme, postural guidance and

guidance to avoid recurrence
◼ Correct use of aids and appliances whenever prescribed
Intermediate-duration rehabilitation patients: This includes fractures

or fracture dislocations of major bones and joints associated with
complications, repetitive surgery, or not so complicated fractures, but
patients have associated diseases (e.g., rheumatoid arthritis,
pathological fractures, tumours). Functional independence in such a
patient may require 12–30 weeks.
The basic physiotherapy remains same as mentioned for short-
duration patients, however, with the following modifications.
Considering the complexities involved, there are more chances of
slow rate of progress, difficulties in the performance of exercise and
greater chances of developing soft tissue or joint contractures. The
following treatment programme is instituted:
◼ Educate patients on simple but selective specific exercises.
◼ Provide support splint to prevent contractures and stiffness of

functionally important joints or soft tissues.
◼ Provide functional training like changing position in bed, sitting up,

shifting, transfers, standing and ambulation.
◼ Prescribe assistive aids as early as possible.
◼ Provide all the possible encouragement to put in hard efforts

towards self-sufficiency.
Long-duration rehabilitation patients: This category includes patients

with extensive irreversible damages with prognosis of poor recovery.
These patients require extensive long duration rehabilitative
physiotherapy to bring them to the level of achieving functional
independence. It may take 30–52 weeks or even more and sometimes,
the patient may still remain dependent on physical assistance,
particularly patients with irreversible neuronal damage, congenital
anomalies, etc.
Concept of total rehabilitation: ‘To bring a patient to the level of
self-sufficiency in vocational, socioeconomic and psychological status,
through restoration of physical independence in performing the
occupational tasks and ADRs within the limits of the disease and the
disability.’
How is physiotherapy the mainstay of total rehabilitation of a

severely handicapped patient?
Physiotherapy not only contributes significantly to achieving physical
(functional) independence but also indirectly promotes vocational
potentials which, in turn, augment the psychological status of a
patient leading to the attainment of socioeconomic security (Fig. 1-3).
FIG. 1-3 Role of physiotherapy in the total rehabilitation of a severely

handicapped patient.
Role of physiotherapy in total health care
A. Primary prevention: Structured exercise training and its regularity

have been proved to play a significant role in the primary prevention
of contacting serious injuries and diseases like:
◼ Coronary artery disease (CAD), cardiovascular disease

(CVD)
◼ Certain cancers
◼ Hypertension
◼ Fractures and soft tissue injuries
◼ NIDDM
◼ Obesity
It is mainly through achieving optimal level of physical

fitness and overall increase in the body’s immunity.
B. Secondary prevention: When the disease has already occurred,

regular structured exercise programme has been proved to assist in
the arrest of its progression and improve responses to its basic therapy
(e.g. antihypertensive drugs).
Education and integration of exercise lifestyle

Physical inactivity and wayward eating habits are the major causative
factors in inviting all these diseases; therefore, educating, emphasizing
and integrating an exercise lifestyle in every orthopaedic patient is the
responsibility of the physiotherapist.
Why is it ideal to integrate orthopaedics with an exercise-oriented

lifestyle?
◼ Longer duration of recumbency or immobilization of the lower

limbs for injuries or disease
◼ Longer periods of reporting to the department for treatment
◼ Home visits for treatment
◼ Most importantly, exercise-oriented therapy

Today’s physiotherapy approach demands major emphasis on
integrating and educating the patient on an exercise-oriented lifestyle
(ELS) without giving an opportunity to say ‘I HAVE NO TIME’ or any
other excuse.
Areas needing special consideration for earlier and better results
◼ Avoid late referral: Irrespective of the mode of orthopaedic

management employed, the patient should be referred for
physiotherapy on the same day and regularly thereafter to avoid
preventable complications like swelling, joint pain and stiffness, and
generalized detoning.
◼ Preoperative education: Educating a patient on the postoperative

care, and the exercise regimen on the contralateral normal limb or by
self-demonstration greatly enhances the recovery.
◼ Early weight bearing and ambulation: The present trend of early

ambulation may lead to fear complex, discomfort and limp. Instead,
efforts should be made to achieve prerequisites of ease in
ambulation like adequate ROM, muscle strength, balance and
coordination. Considering the advantages of erect upright posture,
well-supported graduated sustained standing, weight transfers,
practising stepping, i.e., practising forward and backward stepping
in supported static standing should be encouraged as early as
possible. However, independent ambulation should not be enforced
in a hurry before achieving adequate pain-free stability.
◼ Cardiorespiratory endurance: Considering the tremendous

increase in the incidence and magnitude of RTAs, cardiovascular,
metabolic, neoplastic disorders and obesity, integration of
cardiorespiratory conditioning training is ideal as well as
inescapable. Therefore, every physiotherapist is duty bound to
impart lifestyle exercise along with orthopaedic care.
Orthopaedic physiotherapy and

cardiopulmonary conditioning
Cardiopulmonary conditioning (CPC) is an exercise-oriented
procedure which results in the improvement of endurance of cardiac
and pulmonary systems. It works on the principle of overload,
allowing adequate intake of oxygen and its transport efficiently to the
working muscles.
CPC has been proved to be a major contributory factor in the
primary as well as secondary prevention of cardiovascular diseases.
However, the overall benefits of CPC are of much greater significance
to us. The benefits of CPC are as follows:
1. It improves all the physiological parameters of the

cardiopulmonary system (Table 1-10).
2. It provides a wide range of benefits to the various systems of the

body (Table 1-11).
3. It also greatly influences the neuromusculoskeletal systems of the

body with salutary influences on the psychological status of the
patient (Table 1-12).
Table 1-10
Influence of CPC on Cardiovascular Parameters
Increases Decreases
Blood supply to heart and stroke volume Resting heart rate and BP
Oxygen uptake and utilization Exercise HR and BP.RPP (double product)
Beneficial blood cholesterol (HDL) Harmful blood cholesterol (LDL)
Exercise tolerance and functional Oxygen demands of the heart and psychic
capacity stress
Abbreviations: BP, blood pressure; HDL, high-density lipoprotein; HR, heart rate; low-density
lipoprotein; RPP, rate pressure product.
Table 1-11
Overall Benefits of CPC
Improves
Haemodynamics
Hormonal production
Metabolism
Glucose tolerance
Thyroid and lung
functions
Table 1-12
Benefit of CPC Closely Related to Routine Physiotherapy
Improvement in
Neuromusculoskeletal system
Muscular strength and endurance
Flexibility of the joints and muscles
Neuromuscular coordination
Exercise tolerance, functional capacity and joie de
vivre
Psychological status
Considering the overall benefits, integration of CPC in routine

orthopaedic physiotherapy will certainly be instrumental in providing
early and better results besides preventing musculoskeletal and
cardiovascular problems.
To integrate CPC in routine orthopaedic physiotherapy, it is not
necessary to alter the basic regime planned for an orthopaedic
dysfunction. It only needs certain modifications in the exercise regime
to incorporate the principles of CPC.
Methodology and principles of CPC

1. Preliminary screening
2. Clinical examination and evaluation
3. Formulating specific exercise prescription
Preliminary screening
Preliminary screening is done to ensure safety to the patient. Firstly,
the medical history and the investigation reports are scrutinized to
identify the presence of any serious cardiovascular disease. Secondly,
the patient should be carefully observed for the presence of any
potential risk factors for cardiovascular disease – CVD (Table 1-13).
Such patients should first be referred for medical clearance. When no
such problem is present, the patient can safely be included for CPC.
Table 1-13
Potential Risk Factors (RF) for CVD
Lifestyle RF Obesity, smoking, sedentary lifestyle, excessive use of alcohol and stressful
personality
Medical RF Diabetes, hypertension, hyperlipidaemia, rheumatic fever or congenital heart disease
Hereditary Family history of heart disease
RF
Clinical examination and evaluation
(a) Assessment of cardiopulmonary parameters is done at rest,

during exercise and also during recovery: Monitoring heart rate,
blood pressure and double product (HR × systolic BP) assesses the
cardiac response to exercise with a rough estimate of myocardial
oxygen consumption.
(b) Exercise tolerance: As the requirements of the conditioning

involve vigorous exercise to be continued for a longer period, it is
imperative to evaluate the functional capacity or the exercise tolerance
of the patient. It can be evaluated by various simple tests in nonrisk
patients and is ideally monitored by graded exercise tests (GXT) like
treadmill test, bicycle ergometry and arm crank ergometry for patients
with cardiopulmonary disease or with present risk factors. The
exercise puts physiological stress on the cardiopulmonary system and
puts volume load on the left ventricle, quickly increasing the oxygen
uptake by lungs with rapid increase in the heart rate. Systolic BP is
also increased with increased cardiac output. Diastolic BP usually
remains steady with increasing energy requirements.
Simple tests: These are called performance, field or fitness tests.

Broad estimation of aerobic capacity, cardiopulmonary
status and exercise tolerance can be done by these tests.
Distance test: The distance covered in a 12-min walk, jog or

run is measured. The heart rate is checked at 2, 6 and 9 min
during the full 12-min protocol.
Time test: Time taken by an individual to cover 2–4 km is

recorded.
Both these tests can be done on a wheel chair in patients with

weakness or paralysis of the lower extremities.
Crompton test: In this test, the pulse is recorded after 3 min

of rest in a supine position. Pulse is rerecorded
immediately on standing. The difference indicates overall
simple heart performance. The difference of 4 beats is an
indicator of total fitness, whereas the difference of more
than 20 is an indicator of poor cardiovascular fitness.
Step test: After 3 min of relaxation in a chair, the pulse is

recorded. Then the subject is made to step up and down a
16-inch step. The patient begins with the left leg up, then
the right leg is stepped up; after that, the left leg is brought
down, to be followed by the right leg; this completes one
step. The speed of stepping is kept at 1 step every 3 s or 20
steps in a minute (in 80 counts/min). This is done
continuously for 2 min. Then the subject relaxes in a chair
and the pulse is re-recorded after 1 min rest. Excellent to
good capacity is assumed if the difference between the
pulse rates is within 10 counts, but the difference of more
than 40 beats is an indicator of poor fitness.
GXT: These are more specific tests than the tests described
earlier. Here the load is gradually increased with equal
grades. The cardiovascular response to the increasing load
is monitored to a certain level. This level could be till the
heart rate reaches up to 85% of the age-predicted maximal
heart rate; then it is known as submaximal graded exercise test
(submax. GXT). When the test is continued till the patient
attains the level of age-predicted maximal heart rate (e.g.,
totally fit person), it is called maximal graded exercise test
(max. GXT).
This test can be performed by using simple wooden steps of

varying height. However, more precise monitored graded
tests are performed with treadmill, ergocycle or arm crank
ergometry, etc.
Graded step test: This test is done as described earlier; only

the step height is increased gradually from level stepping
to a 16-inch step (Fig. 1-4) and the test is conducted for 3
min at each level (Table 1-14) followed by 1-min rest at
each level – when the pulse rate and BP are monitored
(American Heart Association Publication, 1979, 1989).
FIG. 1-4 Graded step test. (A) Left foot over the step at count one. (B)
Right foot over the step at count two. (C) Left foot back to the floor at count
three. (D) Right foot back to the floor at count four.
Table 1-14
Graded Step Test
Stepping Time/Rest
Stage Steps/min Counts
on Ratio
I Level 3:1 min 20 80
II 4-inch step 3:1 min 20 80
III 8-inch step 3:1 min 20 80
IV 12-inch 3:1 min 20 80
step
V 16-inch 3:1 min 20 80
step
The test is to be monitored carefully and the exercise, heart rate and
BP are recorded at the end of each of five stages of the test as indicated
in Table 1-14.
The test is continued till the desired level (age-predicted maximal or
submaximal) is reached. It should be conducted carefully and should
be discontinued if any signs of intolerance appear.
Termination of the test: The test must be terminated, immediately,
if the following symptoms or signs appear:
1. Progressive angina or chest discomfort
2. Progressive drop in the systolic blood pressure or heart rate
3. Undue dyspnoea
4. Raised BP – systolic from 230 to 250 mm Hg and diastolic exceeding

130 mm Hg or falls below the resting level
5. Undue fatigue
6. Musculoskeletal pain and discomfort
7. Pale and clammy skin (signs of vasoconstriction)
8. Feeling of dizziness
9. Atrial fibrillation
10. Atrial tachycardia
11. Progressive ST changes (elevation, widening of the QRS complex)
12. Ventricular tachycardia (30 or more consecutive beats). Before

testing, it is absolutely essential to identify patients who are
vulnerable and need special precautions
13. Patient’s request to stop
Vulnerable Group
◻ Patients with risk factors
◻ Asymptomatic but with abnormal exercise test
◻ Dysrhythmias induced or aggravated with activity
◻ Patients with significant hypertension and with low

functional capacity
Special Precaution Group
◻ Anaemia with haemoglobin below 10 mg/100 mL
◻ Uncontrolled metabolic diseases like diabetes,

thyrotoxicosis and myxoedema
◻ Uncontrolled congestive heart failure (classes III and IV)
◻ Acute myocarditis or cardiomyopathy within past 1 year
◻ Uncontrolled hypertension
◻ Dysrhythmias
◻ Significant cardiac enlargement
◻ Moderate-to-severe valvular disease

◻ Recent pulmonary embolism (PE)
◻ Inappropriate BP response to exercise
◻ Painful limbs, as the test involves vigorous exercise, it can

be administered only to the normal or near normal limbs
(Table 1-15)
Table 1-15
Physical Disability and the Exercise Tolerance Test
Normal or Near Normal

Test
Extremities
Graded step test Lower extremities
Stationary bicycle ergometer Lower extremities
12-min run, jog, walk test Lower extremities
Climbing and descending 40 Lower extremities
steps
Arm crank ergometer Upper extremities
12-min wheelchair propelling Upper extremities
Recovery: At the conclusion of the test, heart rate (HR), BP and ECG
are monitored during the recovery. These should return to near
resting level within 2–8 min. Abrupt increase in BP, HR or ST changes
during recovery indicate abnormality.
(c) Evaluation of pulmonary function: Estimation of the vital capacity

(VC) and 1-s forced expiratory volume (FEV1) can be done by a simple
spirometer test.
Nonforced expiration of air through the mouth (clamping the nose)

which is followed by maximum inhalation gives the measure of VC.
For measuring FEV1, the breath is held briefly following maximal
inhalation, the subject exhales as hard and as fast as possible. These
tests can provide the initial evidence for early cardiopulmonary
disorders, especially in individuals complaining of unexplained
dyspnoea on exertion.
Note: The conditioning or target range begins at 60% of maximal HR
and is safe up to 75% of MHR. Ideal training range is between 70%
and 85% of MHR or the range of oxygen uptake between 57% and
78% of maximal aerobic capacity (VO2 max).
Exercise tolerance can adequately be assessed by the patient’s own

subjective rating of the perceived exertion – RPE (Table 1-16), where
each grade corresponds near to the level of HR (e.g., grade 11 on the
RPE scale corresponds close to the HR of 110; (Borg, 1970).
Table 1-16
Borg Scale of Perceived Exertion
Perception of
Grade
Exertion
6–7 Very, very light
8–9 Very light
10–11 Fairly light
12–13 Somewhat hard
14–15 Hard
16–17 Very
18–19– Very, very hard
20
After assessing the haemodynamic cardiorespiratory response to the

exercise test and the overall exercise tolerance, suitable exercise
prescription is formulated on an individual basis.
Principles of formulating exercise prescription

Certain basic principles need to be followed while planning an
exercise prescription for CPC. They are as follows:
(i) Education on the self-determination of HR: The HR is determined

by counting the radial pulse manually for 10 s. It is then multiplied by
6 to get the HR (beats) per minute. The patient needs to be educated
on this important aspect to monitor the HR during rest as well as
exercise.
(ii) Calculating the range of target HR: The predicted maximum HR

can be calculated by deducting the age of the patient from 220.
However, whenever stress test is available, the accurate exercise HR
can be calculated by the Karvonen equation:
To calculate age-predicted maximum heart rate, subtract patient’s age
from 220. Thus, for a 60-year-old patient, maximum heart rate would
be 220 – 60 = 160 beats/min.
The target range of exercise heart rate for a 60-year-old person can
be calculated as follows:
60% of the maximum heart rate will be
75% of MHR will be 120.
85% of the MHR will be 136.
The target heart rate range for the 60-year old patient will be from 96
to 136 (60–85% of MHR). The target range of heart rate for various age
groups is illustrated in Table 1-17 and Fig. 1-4.
(iii) Exercise specificity: This is concerned with the three important

factors of the exercise programme:
◼ Intensity: The prerequisite for the CPC is to overload the

oxygen transport system to the heart. This is possible only
when the exercise is continuous and the target HR range is
maintained throughout the stimulus phase of the exercise.
The intensity should exceed the usual mild demands, but
must fall short of producing excessive fatigue. The
appropriate level of training leads to exertion with
perspiration. There is an increase in the rate of breathing
but the patient will not be out of breath (talk test). There is
a feeling of pleasant tiredness but not an unpleasant
fatigue.
◼ Duration: The duration of conditioning exercises should

be brief to begin with, increasing gradually. It could be
begun at 15 min and increased gradually to 30–45 min.
Minimum total time should be 3 h a week.
◼ Frequency: The frequency of exercise sessions should be at

least three sessions a week. It should not be done on
successive days. This frequency of three times a week
provides an option to concentrate on the orthopaedic
problem on the remaining 4 days of the week.
(iv) Mode of exercises: Isotonic or dynamic mode is the best mode of

exercise. The movements should be continuous rhythmic involving
the larger muscle groups. Continuous mode can be changed to
intermittent mode but the interval has to be very brief and activity at a
slower pace is continued even during this brief interval. Slow-paced
activity reduces physiological demand, and the levels of lactic acid,
thereby reducing muscle fatigue. This, in turn, facilitates stronger
effort when vigorous exercise is begun again, allowing extra resistance
at reduced physiological demand. It also slows down the rate of
respiration reducing breathlessness, which is particularly useful in
patients with respiratory insufficiency.
Table 1-17
Agewise Target Heart Rate
Avg. max. HR Target Zone

Age
HR 60% 70% 75% 80% 85% 90%
20 200 120 140 150 160 170 180
25 195 117 136 146 156 165 175
30 190 114 133 142 152 161 171
35 185 111 130 138 148 157 166
40 180 108 126 135 144 153 162
45 175 105 122 131 140 148 157
50 170 102 119 127 136 144 153
55 165 99 115 123 132 140 148
60 160 96 112 120 128 136 144
65 155 93 108 116 124 131 139
70 150 90 105 113 120 127 135
Isokinetic mode of exercise is ideal as resistance is accommodated

according to the force of muscular contraction.
Isometric mode of exercise is generally contraindicated or done
with caution. Isometrics provoke Valsalva manoeuvres, rhythm
alterations and pressor responses. Therefore, it is contraindicated in
patients with hypertension or done carefully, monitoring the BP
responses.
The exercise programme should be directed to involve larger
muscle groups to facilitate augmentation of the heart rate. To avoid
fatigue to one particular limb or muscle group, it should alternate
between the lower limbs, upper limbs and the trunk. Unilateral limb
exercise is not adequate; therefore, simultaneous movements of either
the upper limbs or the lower limbs are necessary.
Phases of conditioning exercise

Conditioning exercises are to be done in three different phases:
Warm-up phase: This phase is the initial phase of conditioning. It

facilitates the necessary adaptations of myocardium, joints, skeletal
muscles, tendons and ligaments to prepare the body for the vigorous
conditioning phase. The efficiency of muscular contraction is greatly
improved due to increased circulation; the raised temperature
decreases the viscosity of blood. It also helps to reduce the chances
of musculoskeletal injury. Continuous rhythmic aerobics or
calisthenic movements are used to gradually increase the heart rate
close to the level of 60% of MHR. Warm up can be given for 5 min.
Stimulus, endurance or conditioning phase: This is the most

important phase of conditioning. It is a progression over the warm-
up phase as the heart rate is increased to the training level from 60%
to 70%, 75% or even 85% of MHR. This phase needs careful
monitoring to maintain the training range of heart rate as well as
vigilance for any adverse symptoms. It consists of more vigorous
dynamic exercises alternating the movements and the body
segments with very brief intervals. This could be begun for 10–15
min initially, gradually increased to 30–40 min. Exercise equipment
can be used to attain and maintain the target range.
Cool-down phase: It is the phase of gradually tapering down the
intensity of the exercise. Exercises at low level help maintain
sufficient cardiac output following vigorous exercise. It helps to
transport and remove the waste products of metabolism by
augmenting the venous drainage. Abrupt termination of exercise
may lead to excessive demand of myocardial oxygen consumption
thus elevating the heart rate. Increased hypotension may result in
the decrease of blood supply to the brain leading to light
headedness, dizziness or even fainting. Eliminating lactic acid along
with metabolic wastes also reduces the chances of developing
muscular soreness. Slowing the pace of conditioning exercise and
the movements of slow stretching of the musculotendinous
complexes are ideal. It is to be done for 5 min.
Ideally, relaxation techniques should follow the cool-down phase.

Besides, inducing an overall feeling of betterment, these techniques
are instrumental in reducing heart rate, blood pressure and even
cardiac dysrhythmias.
Integration of CPC
The detailed physical evaluation of the orthopaedic problem should
be analysed in relation to the prerequisites of conditioning.
Warm-up phase: According to the CPC needs of this phase, weak or

involved limb/limbs can be included in the exercise programme, as
the exercises during this phase are to be performed with lower
intensity.
Stimulus or conditioning phase: This phase needs continuous,

intensive and vigorous exercise. Therefore, stronger components of
the body should form the basis during this phase.
Cool-down phase: This phase involves active slow stretching

procedures of the musculoskeletal structures of the involved limb. It
can be used advantageously either alone or in association with the
contralateral limb.
However, exercise planning for conditioning needs to be done on an
individual basis and therefore no rigid procedures can be enlisted.
Example of integration
For the planning of a therapeutic programme, the basic needs of the
patient’s therapy are important.
A young man with traumatic paraplegia will need the following:
Strength – in the upper extremities to ease transfer activities and

ambulation
Endurance – to propel wheelchair, and ambulation with aids and

appliances
Flexibility – to facilitate self-care
All these basic needs should be incorporated as per the requirements

of the CPC as follows:
Warm-up phase (5 min)
◼ Neck and trunk movements
◼ Arm movements with light dumbbells
◼ Passive bilateral hip, knee flexion
Stimulus or conditioning phase (beginning with a 10-min exercise

session and working up gradually to at least 30 min, only three
times a week)
◼ Pulley weights
◼ Prone push-ups
◼ Arm crank ergocycle

◼ Ambulatory activities with wheelchair or ambulatory aids
(Fig. 1-5)
◼ Rowing
◼ Wheelchair push-ups (Fig. 1-6)
Cool-down phase (5 min)
◼ Back stretch – prone and supine
◼ Leg stretch
◼ Arm stretch
FIG. 1-5 Arm crank ergometry in a paraplegic to assess exercise

tolerance.
FIG. 1-6 Six- or 12-min wheelchair propelling test, to assess exercise

tolerance in a paraplegic.
Therefore, incorporation of CPC in routine orthopaedic physiotherapy

procedures for a mild neuromusculoskeletal dysfunction and
gradually progressing to a major physical handicap assumes high
priority. Every effort should be made, whenever possible, to practise
such an integrated approach.
Chest physiotherapy
Chest physiotherapy has a vital role to play not only in medical or
surgical chest conditions but also in surgical procedures involving
spine, pelvis, extremities and abdomen.
Chest physiotherapy also plays a significant role in the prevention
of common postoperative complications, or in reducing their severity
when they occur. It is also instrumental in the early return of the
patient to his/her preoperative status.
Objectives of chest physiotherapy

1. To help remove secretions
Percussion – Cupped hands are applied rhythmically to the

thorax. Precautions include rib fractures, costo chondritis,
haemoptysis, blood coagulation problems, dysrhythmias,
pain, severe dyspnoea, pneumothorax and increased
bronchospasm.
Shaking – Following inspiration, a ‘bouncing’ or ‘thumping’

manoeuvre is applied to the rib cage.
Vibration – Isometric cocontraction of the arms is applied to

the thorax; it is usually used in conjunction with shaking,
percussion and postural drainage positioning.
2. To help clear the airway
Cough – Forcefully expelling air following a deep inhalation

and closing of the glottis to expel mucus.
Forced expiration technique – One or two forced expirations

with relatively low lung volumes, the glottis is not closed.
Ideal for patients with chronic obstructive pulmonary
disease (COPD).
Huffing – Similar to a cough with an open glottis. Patient may

say Ha, Ha during expiration.
Assisted coughing – Similar to the Heimlich manoeuvre done

during expiration.
3. To improve gaseous exchange and increase lung volume
Three breathing exercise techniques are useful:
1. Diaphragmatic breathing
2. Segmental breathing
3. Pursed lip breathing
Physiotherapeutic approach
The approach of a physiotherapist should basically be problem
oriented, to prevent or minimize the expected complications following
surgery.
Early identification of patients who are at risk of developing
complications is of primary importance. This is done by preoperative
observations and assessment of various parameters in relation to the
patient’s condition, planned surgical procedure and the patient’s
physical work requirements for job as well as for hobbies.
Risk factors likely to cause postoperative complications
◼ Preexisting history of respiratory disorder, CV disorder,

haemophilia, circulatory insufficiency (e.g., varicose veins, venous
stasis)
◼ Malignant disease
◼ Diabetes
◼ Poor nutritional status
◼ Obesity
◼ Alcoholism
◼ Smoking
◼ Low breathing capacity due to acquired or congenital

musculoskeletal deformity or diseases like scoliosis, kyphosis,
pectus carinatum (pigeon chest), pectus excavatum (funnel chest),
barrel chest and ankylosing spondylitis
◼ Delayed prothrombin time
Subjective assessment
In subjective evaluation, it is important to know the duration, severity,
pattern and factors associated with the following when present:
◼ Dyspnoea or breathlessness
◼ Orthopnoea or breathlessness while lying flat
◼ Paroxysmal or nocturnal dyspnoea
◼ Cough
◼ Sputum and haemoptysis
◼ Type of chest pain: pleuritic, tracheitic, musculoskeletal, angina or

pericarditis
◼ The chief disturbing factors as expressed by the patient

Objective assessment
It is vital to record other relevant information about the symptoms,
past and present medical history, clinical and laboratory
investigations and also physiotherapeutic evaluation.
◼ Respiratory rate (normal adult: 12–16 breaths/min)
◼ Chest expansion (normal adult: 3–5 cm)
◼ Breath sounds: Auscultation with stethoscope during inspiration is

useful in detecting sputum retention. The opening of the alveoli and
small airways during inspiration produces sharp crackling sound or
continuous musical sound. These added breath sounds indicate
alveolar narrowing and mucus retention. It helps in localizing the
area of retention, its detachment and elimination. It can be
correlated with the other signs of retention (Table 1-18).
◼ Forced vital capacity (FVC)
◼ Forced expiratory volume in 1 s (FEV1): Measurement of FVC and

FEV1 can be done by spirometry. The ratio of FEV1 to FVC provides
a direct measure of the degree of airway obstruction. The ratio of
less than 75% is graded as mild, less than 60% graded as moderate
and less than 40% is graded as severe (American Thoracic Society,
1986).
◼ Peak expiratory flow (PEF)
◼ Values of arterial blood gases: Normal values in adults:
◼ pH = 7.35–7.45
◼ PaO2 = 80–100 mm Hg
◼ PaCO2 = 35–45 mm Hg
◼ HCO3 = 22–26 mmol
◼ Base excess = –2 to +2
◼ Flow volume curves
◼ Chest radiograph
◼ Strength and endurance of the muscles of respiration
◼ Pattern of respiration including the efficiency of diaphragm or the

degree of substitution by the accessory muscles of respiration
◼ Range of body temperature (normal adult 36.5–37.5°F)
◼ Heart rate (normal adult between 60 and 100 beats/min)
◼ Blood pressure (normal adult between 95/60 and 145/90)
◼ Body weight (normal adult BMI = 20–25 kg/m2)
◼ Exercise tolerance – tested by 6-min distance walk test (SMD) or 12-

min walk test
Table 1-18
Signs of Sputum Retention
Auscultation Localized or scattered short and sharp interrupted crackles, which may move with
coughing
A continuous musical sound or wheeze may be present or absent
Sputum Thick, more viscid of any colour
Other signs Pyrexia, ineffective coughRespiratory muscle weakness
Besides these, observation of fingertips for clubbing, colour of eyes,

cyanosis, jugular venous pressure (JVP) and peripheral oedema
provide important clues.
Assessment of patients in ICCU

◼ Measurement of central venous pressure (CVP), pulmonary artery
pressure (PAP) and intracranial pressure (ICP) is important
◼ Mode of ventilation (e.g., supplemental oxygen positive airway

pressure, intermittent positive pressure ventilation)
◼ Route of ventilation (e.g., mask, endotracheal tube tracheostomy)
Depending upon the correct and critical interpretation of assessment,

therapeutic regime is to be planned on an individual basis.
After assessment, the physiotherapy has two basic functions:
(a) Preoperative guidance and training
(b) Postoperative management
Before dealing with these two aspects, it is important to know the

possible postoperative complications.
Common complications following general anaesthesia

1. (a) Excessive bronchial secretions and their stagnation
(b) Reduction of lung volume
(c) Reduction of functional residual capacity (FRC)
2. Postoperative pain
3. Deep vein thrombosis (DVT)
4. PE
1. Reduction of the lung volume and FRC, and accumulation of

secretions
◼ General anaesthesia provokes irritation of the bronchial

mucosa, inhibits ciliary movement and promotes excessive
bronchial secretions and their retention. There is
impairment in the movement of mucus. This mucus
plugging may lead to regional hypoventilation, airway
obstruction and may even cause collapse of the lung tissue
distal to the obstructed airway, or may even precipitate
infection.
◼ There is marked reduction in the lung volume.
◼ The FRC may be reduced between 18% and 30%.
◼ There is respiratory depression and the efficiency of

collateral ventilation is decreased markedly.
◼ Abdominal distension may be present limiting the

excursion of the diaphragm.
◼ The pleural cavity may also be reduced due to gas or fluid.
All these factors result in marked deficiency in the whole

process of the normal respiratory cycle.
Persistent postoperative pain causes reduction in the lung

volume, inhibits the clearance of bronchial secretions and
may even cause spasm of the trunk muscles. All these
factors also result in marked inefficiency of the mechanism
of respiration, as it adversely affects the patient’s active
cooperation to perform exercise to eliminate secretions.
3. DVT (Fig. 1-7)

The DVT or PE may occur as a result of damage to the vessel
wall, venous stasis or changes in the blood clotting factors.
A clot or thrombus may be formed in the deep veins of the
pelvis or in the calf vein-plexus in the soleus muscle.
Patients with earlier history of DVT, varicose veins, venous
stasis, obesity, malignant disease, hypercoagulability of
blood and advanced age are more prone to develop DVT.
Therefore, such patients need critical monitoring following
surgery of abdomen, pelvis and lower extremity. A
thrombus formed in the deep vein may produce local
inflammatory changes or may migrate to the lung resulting
in PE.
The thrombus formation becomes obvious only by the end of

a week or 10 days following surgery. Early signs of
inflammation are pain, tenderness and warmth over the
calf region with a mild rise in the body temperature. The
positive sign of DVT is the increase of pain on passive
dorsiflexion of the foot (Homans sign).
Treatment: Accurate diagnosis of DVT in the suspected

patients is possible with venography or phlebography.
Anticoagulant therapy and aspirin, with graduated elastic

stockings, are the effective measures to treat DVT.
Embolectomy, by using cardiopulmonary bypass, and
heparin followed by oral anticoagulant therapy are the
measures to control PE.
Vigorous ankle, foot and toe movements, elastic stockings,

ambulation at the earliest, mechanical electrical stimulation
of the calf muscle during surgery and special boots to
accelerate venous return which produce intermittent
pressure on the limb could be helpful in the prevention of
these complications. Therefore, active vigorous movements
of toes with limb elevation, whenever possible, should be
concentrated throughout the period of two weeks
following surgery as an effective preventive measure.
4. PE
The signs of PE:
◼ Central chest pain or pleuritic pain
◼ Severe breathlessness, haemoptysis or cyanosis.

Pulmonary angiography or scan can confirm the diagnosis
of PE
FIG. 1-7 Deep vein thrombosis (DVT) (longitudinal section of a vein):

development site of DVT inside the vein..
Physiotherapeutic management
1. Preoperative guidance and training
After evaluation and planning of a type of surgical

procedure, the physiotherapist must apprise the patient
about the detrimental effects of general anaesthesia.
The patient should be made aware of the procedures to

minimize the ensuing complications during immediate and
late postoperative phases. Ideally, sessions on sequentially
progressive postsurgical therapeutic regime should be
taught during this preoperative period.
2. Postoperative physiotherapeutic management
The basic function of physiotherapy is firstly to improve

breathing control by training of normal tidal breathing,
making it relaxed and least exerting, and secondly, to
eliminate postsurgical secretions. This is achieved by (a)
positioning of the patient and (b) teaching and practising
active cycle of breathing techniques (ACBT).
(a) Positioning of the patient: To increase FRC as well as

preventing lung collapse, upright erect posture should be
assumed as early as feasible. The ambulation is resumed
at the earliest possible opportunity; it could be assisted
and well supported.
(b) Breathing techniques: The basic techniques of chest

physiotherapy are known as the ACBT.
Components of ACBT are (a) breathing control or normal

relaxed breathing, (b) thoracic expansion technique or
inspiratory control technique and (c) forced expiration
technique or expiratory control technique.
(a) Breathing control technique: It is a technique of

relaxed, smooth, normal tidal breathing, primarily using
the lower chest. Formerly known as diaphragmatic
breathing technique, it is actually accomplished by the
coordinated activity of the abdominals, external and
internal oblique muscles, the scalene muscles and the
diaphragm.
Advantages
- Improves inspiratory control
- Minimizes the work of breathing
- Helps to relieve breathlessness at rest and on exertion
- Facilitates return of the normal patterns of breathing
- Improves ventilation of the bases of lungs preventing

collapse, hyperventilation and fatigue
Technique: The patient is positioned in a relaxed sitting

position, with back, head and shoulders fully supported
and the abdominal wall fully relaxed. It can be performed
even in the high side lying position. Hands are placed on
the anterior costal margins. The patient is taught to breathe
out as quietly as possible sinking down the lower ribs and
the abdomen without any force. It must be remembered
that forced or prolonged expiration will increase the work
of breathing and may even increase air flow obstruction.
This is followed by a gentle, active phase of deep inspiration

through the nose. Passage of air through the nose allows
the air to be warm, humidified and filtered before it
reaches the upper airway. During this phase of inspiration,
the abdomen should bulge out to its fullest extent. A
careful watch is needed to ensure that the upper chest and
the accessory muscles (e.g. sternomastoid, trapezius) are
not over-used as this may result in early fatigue due to
increased oxygen consumption caused by the excessive
work of the accessory muscles of respiration.
(b) Thoracic expansion technique or inspiratory control

technique: It is a technique of deep breathing with effort
and emphasis on active inspiration as against relaxed
effortless techniques of breathing control.
Advantages
- Assists in losing of excessive bronchial secretions
- Facilitates the movement of secretions
- Assists in the re-expansion of the lung tissue
- Improves lung volume and mobilizes the thoracic cage,

promoting air flow through the collateral ventilatory
channels, thus getting air exactly behind bronchial
secretions
- Improves ventilation–perfusion relationship

- Prevents collapse of the lung tissue
Technique: After deep inspiration with maximum expansion

of the thoracic cage, air is held for 3 s like in pranayama
(Chapter 38). This is followed by relaxed passive
expiration. As it is a tiring procedure, there should be a
pause for relaxation after four to five deep breaths. The
patient may feel dizzy owing to hyperventilation. Ideally,
every four to five expansion exercises should be followed
by a pause for relaxation by repeating the breathing control
technique.
This technique can be performed in half-lying position with

the knees slightly flexed over a pillow or sitting on an
upright chair or stool.
This technique is specially important during early

postoperative phase to prevent lung collapse, facilitate
mobilization of secretions and decrease atelectasis (Ward,
Danziger, Bonica, Allen & Bowes, 1966). The clearance of
secretions can be facilitated further by performing the
technique in an appropriate postural drainage position
(Table 1-19). Whenever feasible, chest clapping, shaking
and vibrations may be incorporated for more effective
drainage of the secretions.
The manoeuvres of chest clapping, shaking and vibrations

are contraindicated or done very carefully in patients with
the following:
◻ Osteoporosis of ribs
◻ Metastatic deposits affecting the ribs or vertebral column
◻ Haemoptysis
◻ Acute pleuritic pain
◻ Active pulmonary infections (e.g., tuberculosis)
Contraindications for postural drainage:
◻ Recent severe haemoptysis
◻ Hypertension
◻ Cerebral oedema
◻ Aortic and cerebral aneurysms
◻ Acute asthma, emphysema, or dyspnoea
(c) Forced expiration technique or expiratory control

technique: Excessive bronchial secretions are eliminated
by this technique of forceful expiration. It is a
combination of one or two forceful expirations (huffs or
coughs) followed by intermittent periods of breathing
control to prevent possible occurrence or sudden increase
in the bronchial spasm. The important part of the
clearance mechanism by huff or cough is the narrowing,
dynamic compression and collapse of the airways
towards the mouth (West, 1992). The technique may
incorporate chest percussion and/or vibratory chest
shaking.
To mobilize and clear peripheral secretions, huffing or
coughing is initiated from the mid-lung volume, i.e.,
following a medium-size inspiration. Air is squeezed out
forcefully by using the abdominal and chest wall with the
mouth open. However, it should be longer to reach and
loosen the secretions from the peripheral airways.
To clear the secretions that have already reached to the more

proximal airways, huffing or coughing has to be initiated
from the high lung volume, i.e., following full deep
inspiration.
A rapid flow of secretions results when a forced expiratory

effort is made with coughing against a closed glottis which
raises intrathoracic pressure. Then, when the glottis opens
abruptly there occurs a large pressure gradiant between
the alveolar pressure and the upper tracheal pressure,
resulting in rapid flow of secretions. To produce a huff, a
forced expiratory effort is made with the glottis remaining
open. This compresses the intrathoracic trachea and
bronchi, dislodging and moving the mucus up the
bronchial tree.
Technique: To produce effective elimination of secretions by

huff or cough, it is mandatory to take a deep breath before
coughing. Strong contractions in the abdominal muscles
are needed to produce effective cough. A single continuous
huff down the same lung volume or a series of huffs and
coughs without intermittent inspirations could be used.
After one or two huffs or coughs there should be a pause of

varying durations of 5–20 s for relaxation or relaxed
breathing (breathing control). Gravity-assisted postural
drainage positions may be valuable in patients with
excessive secretions (Hofmyer, Webber & Hodson, 1986).
Modifications in the ACBT: Although ACBT constitutes (a)

breathing control, (b) thoracic expansion and (c) forced
expiration techniques, this sequence may not always be
adequate if the secretions are not lost enough to be
eliminated. In such a situation, it may become necessary to
perform additional or more than one manoeuvre of
thoracic expansion technique (Fig. 1-8). It must be
remembered to add breathing control techniques in
between thoracic expansion and forced expiration
technique.
Reassessment and revision of breathing techniques for

evaluation of its efficacy and to maintain patient’s
compliance are necessary at regular intervals.
ACBT done in gravity-assisted positions is also an alternative

method of clearing secretions, and can be safely used if the
ACBT is not productive.
If the cause of reduced lung volume is atelectasis or lobar

collapse due to retained secretions, the patient may fail to
respond to ACBT. It may be necessary to adopt measures
like antibiotics, oxygen therapy or mechanical adjuncts like
periodic continuous positive airway pressure (PCPAP),
intermittent positive pressure breathing (IPPB) or positive
expiratory pressure (PEP) mask. Incentive spirometry may
be considered along with the ACBT in gravity-assisted
positions.
1. Adequate doses of analgesics should be given to control

pain and its effects on respiratory efficiency. If not
successful, inhalation of Entonox (mixture of nitrous
oxide and oxygen in equal amounts) in sitting posture
with manual hyperinflation or IPPB. It facilitates ACBT.
2. TENS: Low-intensity, high-frequency transcutaneous

electric nerve stimulation (TENS) inhibits transmission of
pain via small diameter nociceptive fibres, through the
activation of large diameter A fibres (e.g., pain following
fracture of ribs).
3. Passive movements to the joints away from the

immobilized joints can also be used to provide pain
relief.
4. Relaxation techniques and relaxing postures like

Shavasana or TM may also help in reducing the intensity
of pain.
FIG. 1-8 Active cycle of breathing techniques.
Table 1-19
Gravity-Assisted Postural Drainage Positions
Lobe Position
Upper 1, Apical 1 Sitting upright
lobe 2 bronchus,
Posterior
bronchus
(a) Right 2(a) Lying on the left side horizontally, turned 45° on to the face, resting
against a pillow, with another supporting the head
(b) Left 2(b) Lying on the right side, turned 45° on to the face, with three pillows
arranged to lift the shoulders 30 cm (12 inches) from the horizontal
Lingula 3 Anterior 3 Lying supine with the knees flexed
bronchus
4 Superior 4 Lying supine with the body one quarter turned to the right maintained by
bronchus and a pillow under the left side from shoulder to hip
5
5 Inferior The chest is tilted downwards to an angle of 15°; foot end of the bed
bronchus raised to 35 cm (14 inches)
Middle 4 Lateral 4 Lying supine with the body one quarter turned to the left maintained by a
lobe bronchus and pillow under the right side from shoulder to hip
5
5 Medial The chest is tilted downwards to an angle 15°; foot end of the bed raised
bronchus to 35 cm (14 inches)
Lower 6 Apical 6 Lying prone with a pillow under the abdomen
lobe bronchus
7 Medial basal 7 Lying on the right side with the chest tilted downwards to an angle of
(cardiac) 20°; foot end of the bed raised to 45 cm (18 inches)
bronchus
8 Anterior basal 8 Lying supine with the knees flexed, buttocks resting on a pillow and the
bronchus chest tilted downwards to an angle of 20°; foot end of the bed raised to 45
cm (18 inches)
9 Lateral basal 9 Lying on the opposite side with pillow under the hips, the chest tilted
bronchus downwards to an angle 20°; foot end of the bed raised to 45 cm (18
inches)
10 Posterior basal 10 Lying prone with a pillow under the hips and chest tilted downwards to
bronchus an angle of 20°; foot end of the bed raised to 45 cm (18 inches)
Alternative breathing techniques as adjuncts to chest

physiotherapy
1. Autoassisted positive pressure breathing or glossopharyngeal
breathing (GPB)
This breathing technique is a form of positive pressure

ventilation produced voluntarily by the patient as a ‘trick
movement’. It is effective in patients who are able to breath
spontaneously but who have inadequate power to cough
or clear the secretions. The patient gulps down boluses of
air into lungs by using mouth, lips, tongue, soft palate,
pharynx and larynx.
Technique: To begin with, the mouth and the pharynx are

filled with air by depressing the cricoid cartilage and the
tongue. Then the lips are closed and the air is trapped in
the chest by the larynx acting as a valve, when the mouth is
opened for the next gulp. Then the floor of the mouth and
the cricoid cartilage are raised to the normal position,
while the air is pumped through the open larynx into the
trachea and soft palate, preventing the leakage of air
through the nose. VC can be increased by adding several
glossopharangeal gulps. This technique is extremely useful
in patients with reduced VC as a result of paralysis of the
respiratory muscles, e.g., tetraplegics, poliomyelitis.
2. Autogenic technique of draining secretions
In this technique, the drainage of secretions is achieved by

the following three phases by maximizing the air flow
within the airways:
Phase I – unstick: A phase of getting adherent secretions

mobilized or released by breathing at the low lung volume.
Phase II – collect: A phase of collecting together the mucus

secretions in the middle airways by tidal breathing.
Phase III – evacuate: A final phase of evacuation of the

secretions collected in the middle airways by breathing at
higher lung volume. Coughing or huffing can be
incorporated to improve drainage. Alternatively, it can be
practised by breathing around the tidal volume and
holding the breath for 2–3 s at each inspiration followed by
forceful expiration
3. Manual hyperinflation
Mobilization and clearance of excessive secretions can be

assisted along with reinflation of the areas of lung collapse
in intubated patients by this technique.
Technique: This is done by using a hyperinflation bag. The

bag is connected to the endotrachial or tracheostomy tube.
It is squeezed to inflate the lungs with a slow but deep
inspiration. At full inspiration, after a brief pause, brief and
quick chest compressions are applied and the bag is
quickly released to attain high expiratory flow rate. Suction
is applied following six to eight breaths and, if possible, the
patient is encouraged to attempt coughing. When the
respiratory muscles are paralysed, besides manual
hyperinflation, rib springing is more effective. Manual
pressure is given through the phase of expiration and it is
maximized at the end of expiration to squeeze out residual
air. Then the pressure is released quickly to allow optimal
expansion during inspiration.
4. Respiratory muscle training
The procedure is aimed to improve the strength and

endurance of respiratory muscles. The patient is trained to
perform resistive respiration through special devices,
keeping the breathing frequency, tidal volume and
inspiratory or expiratory time constant. By adjusting the
degree of resistance and length of time, strength as well as
endurance of the respiratory muscles can be improved. The
efficacy of the procedure can be judged by evaluating
maximal inspiratory mouth pressure (Pi max) and maximal
expiratory mouth pressure (Pe max). This type of training is
extremely useful in respiratory muscle paralysis following
cervical or high thoracic spinal injuries.
5. PEP device
(a) Mask device: Flak in 1984 devised a mask and reported a

better sputum yield by PEP on peripheral airways and
collateral channels in postoperative patients. Either low-
pressure (10–20 cm H2O) or high-pressure (50–120 cm H2O)
PEP may be used depending upon the degree of adherence
of the secretions. The device uses a face mask with a one-
way valve to which expiratory resistance can be applied.
(b) Flutter device: It is a simple portable device like a dry

spirometer with a blowing pipe with a series of small
openings at the top of the bowl. A small density ball-
bearing is enclosed in a small cone in the bowl. Following
full inspiration and a hold of 2- to 3-s, air is slowly but
completely blown with lips sealed around the mouth piece
creating PEP. It improves lung function, oxygenation and
expectoration of bronchial secretions (C. Liardet and
S.A.Vario Raw, Switzerland, Personal communication,
1990).
6. Intermittent Positive Pressure Breathing (IPPB)
This technique is aimed at the maintenance of positive

airway pressure through the phase of inspiration. Thus, the
airway pressure returns to atmospheric pressure during
expiration. It reduces the work of breathing during
inspiration and augments tidal volume. It helps in clearing
bronchial secretions in semicomatose, neuromuscular
disease patients or patients with chest infection.
7. Continuous positive airway pressure (CPAP)
This technique maintains positive pressure through both the

phases, inspiration and expiration. This is possible only
when the patient’s inspiratory flow rate always remains at
a higher level. (CPAP is produced by using a high flow
generator device with mouth piece and nose clip or a
mask. It reduces the work of breathing and improves
functional residual capacity (FRC).)
8. Incentive spirometry
It is a simple mechanical device where the patient breathes in

slow and deep to a preset volume, and then holds the
breath for 2–3 s at full inspiration, with emphasis on the
expansion of the lower chest. This device assists greatly in
the prevention of postoperative pulmonary complications.
It prevents lung collapse by increasing ventilation to the
dependant parts of the lung.
9. Drug inhalers
Various handy devices are available for effective inhalation

of drugs. A correct technique is necessary to make
inhalation reach the bronchi effectively.
After expiration, putting the inhaler in the mouth, the drug

should be released with slow and deep inspiration lasting
to the count of 30 or approximately 10 s. A nebulizer which
breaks solution to be inhaled into droplets, suspended in a
gas, is a better device. Bronchodilators, corticosteroids,
antibiotics and analgesic drugs can be effectively inhaled
by this method. Use of mucolytic agents like hypertonic
saline (3–7%), when inhaled before physiotherapy, has
been found to be effective in the clearance of secretions.
10. Humidification
It may become necessary to use humidification when airway

humidification or mucociliary escalator does not function
(e.g., endotracheal on tracheostomy tube insertion).
Various types of humidifiers are available. The choice
depends upon the purpose. Ultrasonic humidifiers are
ideal; being an irritant, these promote coughing.
11. Oxygen therapy
Impairment of tissue oxygenation needs extra oxygen during

inspiration. It has to be monitored carefully by recording
oxygen saturation or blood gas analysis. Oxygen therapy
may be administered by a fixed performance device
exceeding the patient’s inspiratory flow rate, or by a
variable performance device, where the oxygen flow is less
than the patient’s minute volume.
The IPPB device and nebulizers are many a times powered

by compressed oxygen, oxygen being used as a driving
gas. Portable oxygen cylinders may be used for improving
the ambulatory status during SMD test or training to
improve breathlessness.
Caution
Critical assessment and careful monitoring of the efficacy of
alternative techniques as well as adjuncts used to facilitate chest
physiotherapy is a must before deciding on any therapeutic
technique on an individual basis.
Cardiopulmonary resuscitation or abc of life

support
A recent WHO statement that the lives of over 50% of patients
following acute myocardial infarction could have been saved if
instantaneous application of resuscitation speaks volumes of its
importance. Therefore, it is a must-know not only for clinicians but
also for each and every individual.
It is a simple manual technique which can be performed in any
cardiopulmonary emergency.
Indications for CPR

◼ Violent orthopaedic polytrauma
◼ Drowning
◼ Electric shock
◼ Drug intoxication
◼ Suffocation
Early identification
Unconsciousness
Severe hypoxia of brain leads to unconsciousness. It rapidly spreads
to the myocardium resulting into spontaneous heart failure.
Therefore, quick restoration of airways (A), breathing (B) and
circulation (C) (or ABC of life support) is the immediate priority to
save life.
Identify the system failure

First identify the system failure; is it a respiratory failure, a circulatory
failure, or a failure of both?
Respiratory failure can be identified by feeling for the breath at the
nostrils and normal up and down movement of the ribcage, whereas
circulatory failure can be identified by the absence of the central
carotid/radial pulse.
Basic principles of CPR
1. To restore average normal rate of breathing of 8–12 ventilations/min

(or one ventilation for every 5 s), done by direct blowing of air into the
victim’s mouth.
2. To restore circulation, manual rhythmic chest or myocardial

compressions are given at the average normal heart rate of 60
beats/min (or one compression every minute).
Methodology of CPR
Airway clearance: Roll the victim on the back (supine) on a hard flat
surface.
◼ Clearance of airways that may be obstructed due to the

accumulation of saliva and other exudates.
◼ Open the airways to the maximum by giving well supported head

tilt position (sometimes positioning and clearance itself may restore
spontaneous respiration).
Breathing (Fig. 1-9):
◼ Maintaining head in a backward tilted position, block both

the nostrils with index finger and the thumb and open the
victim’s mouth by using ‘jaw thrust’.
◼ Take full-deep breath.
◼ Quickly seal the victim’s open mouth with your mouth

and forcefully blow air into the victim’s mouth.
◼ Now remove mouth, allowing the victim to breath out

passively, listening carefully and feeling for the exhaled
air.
◼ The slow up and down chest movement is an indicator of

effective ventilation.
FIG. 1-9 (A AND B) Pulmonary resuscitation.
Caution
No attempt is to be made to turn a victim with injury to the cervical
spine or fascial fractures to supine head tilting position.
Patients with fascial injuries need removal of blood stain, debris
and pulling tongue forward before initiating ventilation.
Circulation (Fig. 1-10):
◼ Keeping the victim in supine position, loosen clothes and

bare the chest.
◼ Identify the centremost notch on the ribcage where the

margins of the ribs join (xiphisternal junction).
◼ Determine a central point on the sternum at about three-

finger distance above the tip of the xiphoid.
◼ Place the heel of one hand at that point.
◼ Place the other hand exactly above the hand placed earlier,
so that the hand and fingers are at right angles to the long
axis of the sternum.
◼ Now position your shoulders exactly above the hands,

keeping elbows straight and using the weight of the upper
body, conduct smooth but definitive series of chest
compressions at the rate of 60 compressions/min (i.e., 1
compression/s). At each compression, the ribcage is pushed
downwards with a sudden jerk. There will be an elastic
recoil of the rib cage as soon as the force of compression is
released instantaneously. Give a slight pause before the
next compression. Continue the cycle of compression till
the restoration of circulation is evident.
◼ Each compression results in the ejection of blood from the

ventricles (ventricular systole).
◼ Momentary pause following each compression results in
filling of the blood into ventricles (ventricular diastole).
FIG. 1-10 (A AND B) Circulatory resuscitation.
Ensure the restoration of circulation by palpating the carotid pulse

following each compression cycle.
Failure of both the systems
In the event of the failure of both the systems, ideally two rescuers
should be available to maintain smooth continuity.
However, only a single person has to manage the failure of both the
systems by switching on alternately from one system to the other. In
such an event, average normal chest compressions of 60 beats/min and
an average normal rate of respiration is maintained by 15:2 ratio of
chest compressions to lung inflation has to be completed every 15 s by
quick switch overs.
Caution
This process of resuscitation once begun should be continued till the
restoration of the system failure, sometimes even up to the moment
the patient reaches the hospital emergency ward.
Tests for the successful application of life supports:
1. The adequacy of cerebral circulation
◻ Test by pupillary reaction
2. Adequacy of respiration
◻ Return of the slow up and down movement of the chest

(rib cage)
3. Adequacy of circulation
◻ Return of the central carotid pulse, its volume and rhythm
◻ CPR in infants and children
◻ Avoid exaggerated head-tilt
◻ For artificial ventilation, rescuer’s mouth should be

covering both the nose and the open mouth
◻ Smaller breathes needs to be delivered at a faster rate of

one every 3 s
◻ For cardiac arrest, give external cardiac massage.
◻ For external cardiac compressions, use the heel of only one

hand or the index and the middle fingers
◻ The sternal depressions are smaller: 0.75–1 inch for infants

and 1–1.5 inches for children
◻ The rate of chest compression should be faster about 100

beats/min
Precordial Thump (Fig. 1-11)
Precordial thump is performed when a cardiac arrest occurs

without hypoxia.
Only one quick and strong hard blow is delivered over the
midsternal area by the ulnar aspect of the hand with
forearm supinated.
If there is no restoration of heart beats, the conventional

method of the cycle of chest compressions is initiated
instantly.
Normal and functional range of movements at various joints

are depicted in Table 1-20.
FIG. 1-11 Precordial thump.
Table 1-20
Normal and Functional Range of Movements at Various Joints (in Degrees)
Normal Functional Normal Functional

Joint Movement Joint Movement
ROM ROM ROM ROM
Hip Flexion 0–125– 90–110° Shoulder Flexion-elevation 0–170– 0–120°
130° joint 180°
Extension 0–20° 0–5° Abduction-elevation 0–170– 0–120°
180°
Abduction 0–45– 0–25° Extension 0–60° 0–30–40°
50°
Adduction 0–40– 0–20° Abduction (true) 0–90° 0–60–70°
45°
External 0–45° 0–15° External rotation 0–90– 0–45°
rotation (with arm in 100°
abduction and elbow
flexed to 90°)
Internal 0–40– 0–20° External rotation 0–70° 0–30°
rotation 45° with elbow in
extension
Knee Flexion 0–130– 0–110° Internal rotation with 0–80° 0–45°
140° arm in abduction
Extension 0 0–5° of Internal rotation with 0–70° 0–45°
terminal elbow in extension
extension
Ankle Dorsiflexion 0–20° 0–10° Elbow Flexion 0–135– 0–90°
or extension joint 140°
Planar flexion 0–45° 0–20° Extension 0° 20–30°
or flexion short of
terminal
extension
Inversion 0–35° 0–25° Forearm Supination 0–80– 0–50°
90°
Eversion 0–10° 0–10° Pronation 0–80– 0–50°
90°
Toes Wrist Flexion 0–75° 0–50°
Metatarsophalangeal Flexion 0–30– 0–10° joint Extension 0–70– 0–30°
joints 35° 75°
Extension 0–70° 0–60–65° Radial deviation 0–20° 0–10°
Interphalangeal Flexion 0–50– 0–10° Ulnar deviation 0–35– 0–15°
joints 80° 40°
Extension 0–80° 0–60–65° Finger Flexion (MCPs) 0–90° 0–5°
a joints
Cervical spine Flexion 0–50– (PIPs) 0–100° 0–7°
55°
Extension 0–70° (DIPs) 0–70° 0–8°
Lateral flexion 0–45° Thumb
or flexion to
either sides
Rotation to 0–80– CM Extension 0–45– 0–50
either sides 85° joint 50°
Thoracolumbar spine Flexion 0–60° Abduction 0–70° 0–50°

Extension 0–35– MP Flexion 0–70– 0–50°
40° joint 80°
Lateral or side 0–25– IP Flexion 0–70– 0–20°
flexion to 30° joint 80° short of
either side full
extension
Rotation to 0–20–
either side 25°
Abbreviations: DIP, distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal
interphalangeal.
aJoshi and Gopinath (1991).
Bibliography
Physiotherapy as applied to orthopaedics

1. 1979 The exercise standards book.: American Heart Association
Publication. 1989.
2. Blomquist CG, Saltin B. Cardiovascular adaptations to
physical training. Annual Review of Physiology. 1983;45:169-189.
3. Borg G. Perceived exertion as an indicator of somatic stress.
Scandinavian Journal of Rehabilitation Medicine. 1970;2:92.
4. Fardy PS, Yanowitz FG, Wilson P K. 2nd ed Cardiac
rehabilitation, adult fitness and exercise testing.: Lea and Febiger.
1988.
5. Joshi J Gopinath, N. Study of normal range of motion at neck.
ICMR research project 5/4-5/3/Ortho/89 NCDI. 1991.
Chest physiotherapy
6. American Thoracic Society. The evaluation of impairment
disability secondary to respiratory disorders. American Review of
Respiratory Disease. 1986;133:1205.
7. Hofmyer J L, Webber B A, Hodson M E. Evaluation of positive
expiratory pressure as an adjunct to chest physiotherapy in the
treatment of cystic fibrosis. Thorax. 1986;41:951.
8. Ward RJ, Danziger F, Bonica JJ, Allen GD, Bowes J. An
evaluation of postoperative respiratory maneuvers. Surgery,
Gynecology and Obstetrics. 1966;123:5.
9. West JB. Pulmonary patho-physiology 4th ed . Baltimore:
Williams and Wilkins. 1992;7.
CHAPTER
2
The bones and the joints
OUTLINE
◼ Human skeleton
◼ Structural and microscopic composition of a bone
◼ Development and growth of a long bone
◼ General structure of a long bone
◼ Blood supply to a long bone
◼ Joints
◼ Broad classification of joints
Bone is a highly specialized tissue designed to perform multiple vital

functions of the body. Some of them are as follows:
◼ It gives shape to the body in the form of the human skeleton
◼ It gives protection to the body’s vital organ systems by forming

compact cavities (e.g., chest cavity protecting the heart and the
lungs)
◼ It forms a major organ of our life, i.e., movement through

systematic arrangement of the joints and muscular attachments
◼ It serves as a storehouse for important nutrients and minerals (e.g.,

99% of the body’s calcium is stored in the bones) required to
maintain the perfectly balanced metabolism of our body
◼ The body’s defence in the form of WBCs and platelets are also
produced in the bone marrow.
◼ Although it appears to be an inactive solid mass, bone factually is a

very active tissue, e.g., immediately following a fracture, the activity
of bone formation begins at the fractured bony ends. Therefore,
fracture reduction and achieving a correct anatomical alignment of
the fractured bony ends must be done as early as possible.
Human skeleton
The systematic and schematic arrangement of bones of various shapes
and sizes forming the basic structure of the body is known as the
skeleton (Fig. 2-1).
FIG. 2-1 Human skeleton.
The bones and the joints in a human skeleton are so organized that
they provide the basic stability to the body to facilitate the required
functional mobility.
The stability to the body is provided by the girdles and the
functional mobility is provided through the limbs and their joints.
The skeleton is composed of 206 bones and is categorized into two
basic types:
1. Axial skeleton – It is composed of 80 bones and forms the upright
axis of the whole body.
2. Appendicular skeleton – It is composed of 126 bones which mainly

include both the shoulder and the hip girdles and the long bones of
both the upper and lower extremities (Table 2-1).
Table 2-1
Bones in the Axial and Appendicular Skeleton
Appendicular or
Axial Skeleton Number Number
Skeleton
• Skull • Shoulder girdle
• Cranium 8 • Clavicle 2
• Face 14 • Scapula 2
• Vertebral • Upper extremity
column
• Cervical 7 • Humerus 2
vertebrae 12 • Radius 2
• Thoracic 5 • Ulna 2
vertebrae 1 • Carpals 16
• Lumbar 1 • Metacarpals 10
vertebrae • Phalanges 28
• Sacrum a
• Coccyx b
• Sternum 1 • Hip girdle 2
• Manubrium 1 • Os coxa
• Body 1
• Xiphoid
process
• Ribs 12 pairs
• Hyoid 1 • Lower extremity
• Ear ossicles 2 • Femur 2
• Malleus 2 • Tibia 2
• Incus 2 • Fibula 2
• Stapes • Patella 2
• Tarsals 14
• Metatarsals 10
• Phalanges 28
Total 80 206
aSacrum is composed of 5 fused bones.
bCoccyx is composed of 3–5 fused bones.
Types of bones
The 206 bones of the human skeleton are shaped and sized according
to their functions.
1. The long bones (e.g., femur, tibia): These serve as levers to

facilitate muscular action.
2. Short bones: These are generally found where only limited

movements are required. Mainly, these bones provide strength and
stability to the strong muscular action by providing a stable base (e.g.,
carpal bones).
3. Flat bones: These are composed of a thin layer of cancellous bone

covered on both the sides by a parallel layer of compact bones, (e.g.,
skull, scapula, pelvic bones). The scapula provides free but stable
mobility to the shoulder and arm, whereas the skull and the pelvis
protect vital soft organ systems.
4. Irregular bones: These are irregular in shape with small bony

appendages, e.g., vertebrae. These bones provide stable flexibility to
the trunk while protecting the spinal cord.
5. Sesamoid bones: These are small rounded or triangular bones

which develop in the substance of a tendon or fascia to protect and
facilitate muscular action, e.g., patella – a typical resemblance to the
‘sesame seed’.
Structural and microscopic composition of a

bone
A bone consists of two major portions: cortex and medulla.
Cortex
Cortex is the outermost hard layer giving shape, strength and
protection from injury. It has a smoother covering layer (periosteal
layer) which also gives attachment to muscles, tendons and ligaments.
It allows remodelling of the bone throughout the life.
Medulla
Medulla is the softer inner lining of the bone with a cavity within it
(medullary cavity). Medulla is a storehouse of important minerals,
calcium and a major seat where the RBCs and WBCs originate.
Microscopic composition of bone

The structural unit of a lamellar bone is Osteon, which consists of a
series of concentric laminations surrounding the central longitudinal
Haversian canal which contains a nutrient artery supplying blood to
the bone.
Bone cells
There are three types of bone cells:
1. Osteoblasts – bone forming cells
2. Osteoclasts – bone resorbing cells
3. Osteocytes – resting cells which can act as both osteoblasts and

osteoclasts as per the need
Microscopically, bone is classified as follows:
◼ Woven – It is an immature bone where the cells and the collagen are
arranged in a random pattern. It is found during the initial stage of
bone formation after fracture – when the bone is in the process of
formation.
◼ Lamellar – The bone is in a fully matured stage where the cellular

distribution is set in an orderly fashion and the collagen fibres are
also properly oriented. The dense arrangement of lamellae is present
in the cortical bone, whereas the lamellae are arranged loosely in a
cancellous bone.
Development and growth of a long bone

The development and growth of a long bone (except clavicle) begins
during the intrauterine period (Fig. 2-2) and continues to the period of
skeletal maturity (around the age of 16–18 years).
FIG. 2-2 Development of a long bone from beginning to maturity. Events in
the formation of a long bone: Hyaline cartilage template. (1) Appearance of
pericondrium bone collar followed by calcification of the walls. (2)
Appearance of capillaries and primary centre of ossification. (3) Nutrient
vessel entering the middle of the bone (diaphysis). (4) Perichondrium is
converted into periosteum. (5) Appearance of secondary centre of
ossification. (6) With osteoid formation and ossification of the shaft,
secondary centre of ossification is formed at the distal end. (7) Full
ossification of the epiphysis and diaphysis occurs which are separated by
epiphyseal plates (cartilage). (8) Finally, the epiphyseal plates are replaced
by bone indicating full maturity with articular cartilages and cancellous bone
at both proximal and distal ends. (9) A compact bone at the shaft.
Events in the development and growth of a bone

1. Development of the cartilaginous model
2. Ossification of the cartilaginous model to bone
Development of a cartilaginous model

The bone begins to develop during the embryonic life from
cartilaginous primordia (enchondral ossification) by the process of
condensation of the mesenchyme – as hyaline cartilage surrounded by
pericondrium.
Ossification of a cartilaginous model to bone

Around the fifth week of the intrauterine period, the ossification
begins by the appearance of the primary centre of ossification (PCO)
at the middle of the bone, when it is invaded by capillaries. The
pericondrium is converted to periosteum and the osteoid is produced
around the shaft. The shaft begins to grow longitudinally by the
resorption of the inner surface.
During the late fetal stage or early childhood, two secondary centres
of ossification (SCO) appear (the epiphyses). The first SCO appears at
the upper epiphysis followed by the second SCO at the lower
epiphysis.
Both the SCOs are responsible for the radial growth of a bone. The
consolidation and thickening of the periosteum occurs by the process
of subperiosteal new bone deposition. The SCOs are also called
apophysis (e.g., apophysis of the greater trochanter).
As the bone approaches adult size, the diaphysis and epiphyses are
gradually ossified fully, but are still separated by epiphyseal plates
(cartilage).
As the epiphyseal plates cease to grow, the longitudinal growth of a
bone stops. At the end of the growth period of a bone, the epiphysis
fuses with the diaphysis leaving a definite area of hyaline layer at the
articular surface of a bone.
Remodelling of bone
Throughout the lifespan, the bone has an ability for remodelling. A
variety of alterations in the size, shape and structure appear in a fully
matured healthy bone. This remodelling occurs as a result of its
hypertrophy as a response to stress. Bone hypertrophy occurs in the
plane of a stress.
Note: The time and the sequence of the appearance, and the fusion
of epiphysis have a great clinical relevance:
◼ In differentiating an epiphyseal plate from a fracture.
◼ In confirming a true bone-age of a person.
General structure of a long bone (fig. 2-2e)

Epiphysis
In growing children, the long bone consists of two ends known as
epiphysis. It forms a support for the joint surface. It is susceptible to
developmental problems (epiphyseal dysplasia), degenerative
changes, injury and avascular necrosis due to ischaemia.
Diaphysis
A large part of the long bone or shaft constitutes diaphysis. It is made
up of strong cortical bone but due to mechanical disadvantage, it
always remains susceptible to fracture with angulation. The process of
healing is slow as compared to metaphysis. It may develop dysplasias
or infection.
Metaphysis
The portion of the bone adjacent to each epiphysis is known as
metaphysis. It is made up of cancellous bone where the process of
healing is fast. It is susceptible to bone infection, dysplasia and
tumours.
Growth plate
There is a thin plate of growth cartilage, one at each end called
‘growth plate’. At the time of maturity, this growth plate fuses with
metaphysis. The articular surfaces of the epiphyses are covered with
an articular cartilage. The rest of the bone is covered with periosteum
which provides attachment to tendons, ligaments and muscles.
Although mechanically weak, it helps in longitudinal growth of a
bone.
It is susceptible to injury or slipping (slipped femoral epiphysis),
tumour and osteomyelitis. It is also susceptible to growth arrest as
well as deformed growth.
Note: Bone has the ability for remodelling or changing its shape in
response to stress.
Blood supply to a long bone

The blood supply to the long bone is derived from four vessels (Fig. 2-
3).
FIG. 2-3 Blood supply to a long bone: EP: epiphyseal vessels. Directly
enter and supply epiphysis. MP: metaphyseal vessels – numerous small
vessels derived from the anastomosis around the joint. Piercing metaphysis
along the line of joint capsule. NV: major vessel entering the bone around
its middle-nutrient vessel. The periosteum of a bone also has a rich blood
supply through the small vessels supplying the bone cortex. A:
anastomosis.
Metaphyseal vessels
Metaphyseal vessels are numerous small vessels derived from the
anastomosis at the joint. They enter the metaphysis along the line of
attachment of the joint capsule.
Nutrient artery
The major vessel providing nourishment to the long bone enters the
bone around the middle of the shaft and immediately bifurcates
running in opposite directions towards the proximal and distal end of
the bone as medullary vessels. Then each one further divides into a
number of parallel vessels towards the respective metaphysis.
Epiphyseal vessels
Epiphyseal vessels enter the epiphysis providing independent
nutrition to the epiphysis or epiphyseal site.
Periosteal vessels
The periosteum is richly supplied with blood which it receives from a
number of small vessels. These directly enter the bone and supply
mainly the cortical area of a bone. These vessels play an important
role in the process of the healing of the bone following fracture.
Joints
Joints represent the sites where two bones come together. These are
designed on the basis of their function.
Functions of the joint

◼ To protect vital organs from injury (e.g., brain)
◼ To provide adequate mobility of the body part to facilitate

functional activity (e.g., limbs)
◼ To provide only restricted mobility to facilitate the function of the

internal organs and protect them (e.g., lungs)
Broad classification of joints

Mobile Joints Partially Mobile Joints Nonmobile or Fixed Joints
(Synovial) (Cartilaginous) (Fibrous)
• Uniaxial • Synchondrosis • Syndesmosis
• Biaxial • Symphysis • Sutures
• Multiaxial • Gomphosis
Synovial joints
Synovial joints are so called because the joint space has a special lining
membrane called the synovial membrane (Fig. 2-4). It secretes a highly
thick oily lubricating fluid. Synovial fluid allows freedom of
movement to the joint and also provides nourishment to the articular
cartilage. They are of three types:
1. Uniaxial synovial joints
These joints permit movement in only one plane and one

axis. They could be the following:
◻ Hinge joints: Movement taking place around the

horizontal axis (e.g., elbow, knee – Fig. 2-5A)
◻ Pivot joints: Movement taking place around the vertical

axis (e.g., atlanto-axial joint, superior radio ulnar joint –
Fig. 2-5B)
2. Biaxial joints
In these joints, the movement takes place in two planes and

two axes which are at right angles to each other. They are
as follows:
◻ Saddle joint: Like a saddle, the articular surface of the

proximal bone end is concave in one direction and convex
in the other and that of the other bone forming the joint is
exactly opposite or convex to ensure the congruity e.g.,
carpometa carpal joint of thumb (Fig. 2-5C).
◻ Condyloid joint: In this type, the oval shaped condyle of

one bone fits into an elliptical socket of the other bone, e.g.,
knee joint (Fig. 2-5D).
3. Multiaxial joints
In these joints, the axes are two or even more and the
movement takes place in three or more planes. It has two
varieties:
◻ Ball and socket joint: These joints are unique as they

permit joint movement which are multi-axial and
multiplane, in widest and free range. The joint is shaped so
that one bone has a ball-shaped head and the other a close
fitting concave socket, e.g., hip joint (Fig. 2-5E).
◻ Gliding joints: These joints allow free gliding movements

in all the planes; although the movement of lateral glide
has a restricted range, (e.g., the joints between the carpal
and tarsal bones (Fig. 2-5F).
FIG. 2-4 Typical synovial joint (knee).

FIG. 2-5 (A–F) Types of synovial joints (diarthrosis). (A) Hinge joint
(uniaxial – elbow, knee, finger and toe). (B) Pivot joint (atlantoaxial joint).
(C) Saddle joint (carpometacarpal joint of a thumb). (D) Condyloid joint
(radiocarpal joint of knee). (E) Ball and socket joint (hip and shoulder). (F)
Gliding joint (wrist, ankle and foot).
Cartilaginous joints or amphorthrosis

Cartilaginous joints are partially mobile joints formed by hyaline or
fibrocartilage interposed in between the bones forming the joint.
These are of two types:
Synchondrosis
In synchondrosis, the hyaline cartilage is interposed between the
bones forming the joints, e.g., articulations between rib and sternum.
Symphysis
The fibrocartilage is interposed in between the bones forming the
joints, e.g., pubic symphisis at the pelvis.
Fibrous joints or synarthrosis
Fibrous joints are the joints which are firmly fixed. The articular
surfaces of the two bones forming the joint are bound together. These
are of three types:
Syndesmosis
The dense fibrous membrane holds tight the articular surfaces of the
bones forming the joints, e.g., distal tibiofibular joint.
Sutures
In sutures, the bony margins of the flat bones are firmly fixed to each
other, e.g., skull sutures.
Gomphosis
In gomphosis, the conical end of one bone fits and is fixed in the
socket of the other, e.g., between the teeth and the sockets of the
mandible.
CHAPTER
3
Inflammation and soft tissue injuries
OUTLINE
◼ Inflammation
◼ Soft tissue injury
◼ Muscle and tendon injury
◼ Injury to the ligament
◼ Injury to the synovial membrane
◼ Injury to the nerve
◼ Injury to the blood vessel
◼ Injury to the bursa
◼ Injuries of the musculotendinous complex
◼ Rare soft tissue injuries
Inflammation
Inflammation is the reaction of the body tissues to an irritant. The
irritant could be traumatic, bacterial, degenerative or even
regenerative. During the initial phase, inflammation is very essential
as it acts as the chief defence mechanism and promotes healing.
Therefore, it often becomes necessary to induce inflammatory reaction
to promote the process of repair.
Physiotherapy plays an important role in the treatment of
inflammation. Properly applied physiotherapy measures facilitate
early resolution of inflammation and promote recovery, reducing its
ill effects. Therefore, it is necessary to understand the pathology of
inflammation, and principles of treatment in the various stages.
The inflammation could be acute, subacute or chronic.The
procedures of management vary in all the three stages. The
distinguishing features of acute, subacute and chronic inflammation
are discussed in the following sections.
Acute inflammation
Signs, symptoms and pathology
The cardinal signs of acute inflammation are listed in Table 3-1.
1. Pain is present over a diffuse area due to pressure on the nerve

endings.
2. The pain is present even during rest and is aggravated by activity; it

may be referred to other areas from the site of primary inflammation.
3. Skin temperature is raised at the site of the lesion with marked

tenderness, effusion, swelling and redness. This occurs due to
increased blood flow caused by dilatation of capillaries.
4. There is increased capillary permeability with leakage of protein

and plasma. The tissue fluid with high degree of fibrinogen seeps out
into the adjacent tissues, giving rise to swelling. Leucocytes migrate
from the vessels to the affected tissues to destroy the irritant.
5. Passive range of motion (ROM) may be painful and restricted due

to pain and protective spasm in the antagonistic group of muscles.
However, there is no real restriction of the ROM.
6. There may be a temporary loss of function of the affected area,

depending upon the degree and site of inflammation.
7. There is usually a history of a recent injury preceding the
occurrence of symptoms.
8. There may be a history of earlier episodes of a systemic disease like

rheumatoid arthritis.
Table 3-1
Cardinal Signs of Acute Inflammation
• Colour • Warmth
• Rubor • Redness
• Tumour • Swelling
• Dolour • Pain
• Rigour • Stiffness
• Functio • Loss of
laesa function
Progress of inflammation
The inflammation thus set in may get completely resolved if the
reticuloendothelial cells destroy and ingest the invading organisms. In
some infectious diseases, the lymphocytes and plasma proteins may
build up antibodies, providing immunity to the patient.
If the organism is virulent or the patient’s reticuloendothelial
system is poor, the organism may get into the blood stream via the
lymphatic system and may precipitate septicaemia.
Repair
Repair may be by the formation of the following:
(a) Homogenous tissue: The new tissues are exactly like the original
tissues, e.g., bone, fibrous tissue and epidermal structures.
(b) Scar tissue. The original tissue is replaced by fibrous tissue during
the process of repair, e.g., deep cuts involving the dermis, muscles
and nerves. This will naturally result in the reduction of optimal
function of that tissue even after repair.
Effects of inflammation on various tissues

1. Skin: Lack of normal blood supply makes the skin dry, papery thin
and brittle. It becomes highly prone to infection.
2. Fibrous tissue: The fibrous tissue gets thickened and shortened. This
results in tightening and contractures ultimately giving rise to
deformity.
3. Muscle tissue: The lack of oxygen supply and the accumulation of

waste products decrease its efficiency, rendering it weak. If the blood
supply to the muscle is reduced further, there may be ischaemia or
total cessation of blood supply. This may result in fibrosis of the
muscle fibres losing their functional properties. The body of a muscle
is enclosed in a fibrous tissue. Therefore, inflammation will result in a
scar tissue formation which may result in fibrous adhesions. This
results in atrophy, restricted activity and weakness.
4. Nervous tissue: The nerve fibres may get fibrosed or necrotic directly
blocking the muscle activity.
If the inflammatory reaction damages the central nervous

system, irreversible degenerative changes occur. This will
further complicate the situation as loss of control,
coordination, strength and sensations may occur.
5. Fibrous soft tissues. The fibrous soft tissue repairs using fibrin. If it is
laid in excess, it can also lead to adhesion formation.
6. Cardiovascular and respiratory systems. An inflammatory reaction to

any of these systems leads to inadequacy of the normal metabolic
processes and circulation. This insufficiency can adversely affect any
other system and/or the tissues mentioned in Points 1–5.
Management of acute and subacute phase
◼ Acute stage (first 4–6 days) is also called a stage of protection. The
main objectives in this stage are:
1. To protect the inflamed area from further damage
2. To use proper modality to reduce the harmful effects of

inflammation
3. To provide guidance and education to the patient on self-

care
◼ Subacute stage (17–21 days) from onset is the stage to educate the
patient on the correct methodology on how to initiate controlled
mobilization; and also to remain watchful for the signs of progress
as well as regress of inflammation.
◼ The chronic stage of inflammation (21 days onwards) is a stage of

the return of full function. It requires properly guided repetitive
efforts to achieve preinjury status in all respects, focusing on the
deficiencies.
The basic approach of physiotherapy during the acute phase should

be a combination of pathology-oriented as well as disability-oriented
therapeutic measures.
1. Reduction of the signs and symptoms of inflammation by using the

principles of rest, ice, compression and elevation (RICE)
2. Relaxation of the inflamed area as well as the whole body
3. Prevention of further damage and the expected complications
4. Education of a patient on self-care of the injured part; graduated

specific exercise programme and transfer or ambulatory activities
5. Maintenance of the ROM and muscle function to the optimal in a

pain-free range
6. Guidance to perform safe and gradually progressive functional

activities
1. Reduction of signs and symptoms of inflammation:
(a) Immobilization. Selective rest or immobilization of the

affected area plays a significant role in the control of
inflammation. The period of immobilization has to be just
enough to subside inflammation because excessive
immobilization is known to produce biochemical,
physiological as well as structural changes, resulting in
restriction of motion (Saaf, 1950; Ekholm, 1951; Salter and
Field, 1960; Enneking and Horowitz, 1972). Reduction of
inflammation can be promoted by using certain
electrotherapeutic modalities like pulsed electromagnetic
field therapy (PEMF), ultrasound sonography,
transelelectrical nerve stimulation (TENS) at the
acupuncture points and iontophoresis. Limb elevation,
isometrics and elastocrepe bandage along with graded
speedy isometrics help in reducing swelling. Inflammation
in the subacute phase responds very well to superficial
heating procedures like infrared, hydrocollator packs and
radiant heat, by reflex reciprocal blood flow between the
integument and the deeper tissues.
(b) Anti-inflammatory drugs and analgesics are effective in

reducing pain and inflammation.
(c) Strong movements to the related joints improve

circulation to the inflamed part hastening its resolution.
2. Relaxation of inflamed area: This can be achieved by guiding a

patient on simple techniques of relaxation by adopting a position of
ease of the whole body as well as the affected area (Table 3-2).
Guidance on diversional activities also induces relaxation.
3. Prevention of further damage and complications:
(a) Prevention of further trauma plays an important role in

hastening the resolution of inflammation. Any further
trauma increases inflammation and may result in
complications like joint capsule contracture due to scar
tissue formation (Evans, 1980). To avoid this, especially
overenthusiastic patients need to be educated on the
proper positioning of the affected area during rest, as well
as during controlled activity.
(b) Longer immobilization may result in complications like

muscle atrophy, partial loss of strength, endurance and
flexibility, weakness of the ligaments with reduced tensile
strength, loss of elasticity of the collagen fibres and
stiffness of the joints.
All these complications can be effectively prevented by early

initiation of isometrics as well as guided mobilization.
However, selection of appropriate intensity, duration,
frequency and the specific technique of exercise is the
decisive factor in providing quick relief.
4. Education of patient on self-care: Proper guidance on self-assisted

activities of daily routine like dressing, taking bath, shaving and
combing should be given, which will promote healing as well as avoid
any further complications.
5. Maintenance of muscle function and ROM: This can be achieved

by the following:
(a) Graduated relaxed passive or free active movements

(b) Continuous passive motion (CPM) equipment
Gentle passive movements not only reduce the inflammation

but also are instrumental in providing pain relief
(Maitland, 1983; Barak, Rosen & Sofer, 1985).
Isometrics during total immobilization or partial range

passive exercises and assisted active movements are
effective in improving or maintaining muscle function and
ROM. Guidance is necessary to ensure that the joint is
moving in its proper groove and the muscle action is
optimal in its direction and force.
6. Guidance to perform functional activities: ADLs like sitting,

transfers, standing, ambulation and work requirements also need
guidance to avoid overstrain to the inflamed part.
Table 3-2
Position of Ease of Commonly Involved Joints
Joint Position of Ease

• • Adduction and internal rotation
Shoulder
• • Flexion with forearm in pronation or midprone
Elbow position
• • Flexion
Wrist
• • Flexion
Fingers
• Hip • Flexion–abduction with external rotation
• Knee • Flexion
• • Plantar flexion
Ankle
Chronic inflammation
Chronic inflammation indicates an attempt at repair of the whole
process.
1. Pain is usually absent during rest. The pain may be present over a
localized area near the site of the lesion and is aggravated by specific
activities which result in the stretching of the inflamed area.
2. There is presence of granulation tissue.
3. The skin temperature is not raised; effusion is absent; tenderness, if

at all present, is minimal.
4. Passive ROM is restricted but is not painful.
5. Pain is elicited only when the joint is stretched to the point of its
restriction. This restriction of ROM is usually due to tendon
shortening, adhesions or capsular fibrosis in the soft tissues.
6. There is a history of long standing problem or recurrence.
Management during chronic phase

Identification of the possible pathology of the dysfunction is essential
to plan appropriate therapeutic measures. The possible underlying
pathology could be as follows:
1. An abnormal pattern of remodelling of the tissues during the

process of healing, e.g., fibrosis, adhesions, scarring, nonunion or
malunion of fractures.
2. Tissue may yield under conditions of excessive stresses due to

sudden trauma or the summation of the several microtraumas. The
tissue breakdown predominates as rate of attrition exceeds the rate of
tissue repair. All stressful conditions of bones, muscles, articular
cartilages are the result of such situations.
3. Tissue hypertrophy: Tissues with good regeneration capacity, when

acting for a longer period, may become stiff and yield under
conditions of loading. This may be associated with low-grade
inflammation accompanied by pain and tissue hypertrophy.
4. Psychological trauma: Persistence of pain and dysfunction causes
tremendous psychological impact on the patient. Any therapeutic
measure cannot be successful by overlooking this aspect in the
treatment of chronic conditions.
The extent of the actual damage and the causative factors need to be
identified by a thorough physical examination and clinical
investigation reports. Correlation of the examination findings with the
patient’s subjective expression is essential to plan appropriate
therapy. On many occasions, there is marked exaggeration of the
symptoms due to psychological factors, rather than due to the real
pathology. Therefore, handling of chronic dysfunction needs more of
a psychologically oriented physiotherapy.
There are a number of procedures and modalities in the
armamentarium of a physiotherapist to effectively deal with such a
situation. However, the competence of the physiotherapist to choose a
suitable modality and to motivate the patient, with all possible
encouragement, plays a vital role in the management of chronic
dysfunction or disorder. The following points should be kept in mind.
1. Reassure the patient by explaining to him the exact nature of the

pathology of dysfunction.
2. Assure relaxation of the body and the area of disorder by applying

a relaxing modality like deep thermotherapy.
3. Exercises are instrumental in reducing anxiety and depression

(Taylor, Sallis & Needle, 1985).
Exercises should be absolutely specific, avoiding too many in

numbers.
1. They should be well planned with gradual loading.
2. They should increase the surface area of loading.
3. Avoid sustained straining by early or prolonged weight bearing.

4. Detailed instructions should be given on Dos and Don’ts, especially
the latter.
5. Simple instructions should be given on exercises to improve

strength, endurance, extensibility and neuromuscular coordination,
progressing to the resumption of high-stress activities.
6. Systematic graduated procedures of muscle stretching, by accessory

movements performed at the limit of the pathologic ROM, may be
necessary to relieve soft tissue contractures.
7. The functional use of the part, without causing much discomfort, is

to be guided and encouraged as it provides natural exercise.
8. Aerobics like jogging, running, swimming have been proved to be

more beneficial as these promote a feeling of well-being, facilitating
vigour and better physical fitness. These induce relaxation responses
due to the increase in the alpha wave activity (De Vries, 1985).
9. Special treatment techniques like functional electrical stimulation,

TENS, biofeedback may be necessary in some chronic disorders.
However, individualized personal attention is the most important

aspect.
SUMMARY: INFLAMMATION
Stage of
Objective
Inflammation
•Acute stage • Use of appropriate modality to reduce the signs and symptoms of
inflammation (e.g., by RICE)
• To provide adequate rigid support to prevent even a minute stress around
the site of inflammation
• Guidance on relaxed positioning of the limb
• Subacute stage • To promote correct healing of the injured tissues by educating the patient
of tissue repair on mode-degree and safety of the initial movements to be performed
• Educate the patient on self-exercising and gentle stretching of the injured
tissues
• Chronic stage • Provide guidance on using injured limb as an assisting limb while
of the return of performing light activities of daily living (ADLs) with the normal limb
function • Prevention of developing tightness or contractures
• The progression of the vigorousity of all exercise in graduate steps to
achieve maximally strong and mobile limbs
• Special exercise session to increase the efficiency of performing ADLs as
well as work-related activities to reach the preinjury level
Remember
Inflammation is an essential process of early healing.
MANAGEMENT GUIDELINES DURING THE

ACUTE OR PROTECTIVE STAGE OF
INFLAMMATION (DURING 4–6 DAYS
POSTINFLAMMATION)
Expected Problems
• Continuation of the symptoms and signs of acute inflammation
• Impaired movement and function
• Reduced or limited use of the associated parts of the body
Objective Management
• To reduce the acute signs • Application of the principles of RICE

and symptoms of
inflammation • Provide complete rest to the injured part in a relaxed position by
proper supportive means (e.g., cast, splint or bandage)
• Educate the patient to avoid any stress to the affected area
• Apply suitable modality to reduce oedema, pain or spasm
• To maintain the integrity of • Initiate mild and small-range isometrics to the encased part of the
the soft tissue and the joint unaffected limb
• Full-range resistive movement to the rest of the joints and

muscles, which are not immobilized
• To maintain integrity and • Full use of the unaffected parts for activities of daily living
function of the associated
areas • Educate the patient to use the affected parts totally or largely
assisted by the normal contra lateral limb
Contraindications: ‘No’ to stretching, repetitive movements or any

type of resistive movement to the injured area.
Note: Carefully keep watch to ensure the definite reduction in the
signs and symptoms of inflammation.

SUBACUTE STAGE OF CONTROLLED
MOBILIZATION (17–21 DAYS FROM THE
ONSET)
Expected Problems
• Pain near the end of the available ROM
• Initial stage of the development of tightness in the soft tissues,

muscles and joint
• Slow process of developing muscle weakness (atrophy in the

encased part)
• Decreased ability or inability to use the affected part for activities

of daily living
• Guidance and education of the patient • On progressive modes of correct exercises from
passive self-assisted ROM to self-resistive exercises
and applying the self-stretch–hold technique
intermittently
• Check the performance of each mode to ensure the

correctness of the relative mode
• Warn the patient against pain while performing the

self-stretch–hold technique
• Promote healing and controlled • Momentarily discard the protective or assistive

lengthening of the inflamed tissues devices and achieve maximum ROM
• Use the technique of multiple isometrics to enhance

strength a
• Increase repetitions of isotonic exercises
• Improve neuromuscular coordination • Introduce low intensity (weight) and short duration
and control, muscular strength as well as functional movements. Encourage full joint ROM as
endurance of the involved related muscle well as stretching manoeuvres
groups
• Progress towards near-normal • Ensure progress in each type of exercise procedures

functional activities
aImportance of early initiation of isometrics: It places the

contracting muscle in a shortened relaxed position so that the newly
forming scar is not unduly stretched. Always keep or control the
intensity of contraction below the level of perception of pain and
discomfort.
Caution
During this stage of healing, carefully watch for recurrence of the
signs and symptoms of acute inflammation; if suspected
momentarily, return to the necessary rest.

STAGE OF RETURN OF FUNCTION (WEEK 3
ONWARDS) EXPECTED PROBLEMS
• Formation of adhesions and development of tightness, or soft
tissue contractures
• Subnormal muscular functions of strength and endurance
• Decreased functional performance of the involved part
• Plan and organize exercise training programme to be focused on

the existing deficiency, e.g., repetitive self-stretch–hold to improve
ROM in the instance of tightness, contracture or adhesion
formations.
• Educate on graduated progressive resistance exercises (PREs) to

the full passive joint range of motion (JROM) in the instance of
below normal muscle functions.
• Teach safe-body mechanics and ergonomic counselling ease

functional performance in patients who lack confidence in
performing ADLs.
• Organize special training sessions of work-related activities to

facilitate back to the preinjury job or house-hold work in patients
who are hesitant to begin work on their own.
• Conduct re-evaluation sessions to assess the progress and plan

programme to pinpoint specific needs.
• Use simple to complex motions, to control proximal stability,

superimpose distal motion and sessions of speeds coordination
training if and when neuromuscular control, muscular strength
and endurance is lacking.
Note: Increase the vigorousity of all the exercise procedures to

return the patient to the preinjury status as early as possible.
Soft tissue injury

Soft tissues which form protective cover to the bone are the first
targets to face the ravages of direct or indirect trauma. Besides, each
soft tissue plays a vital role in functional tasks (Table 3-3).
Table 3-3
Distinguishing Characteristic of Major Soft Tissue Injuries and Their Comprehensive
Management
Injury to the Injury to

Injury to the Muscle Injury to the Blood Injury to the Injury to
Ligament Peripheral
(Strain) Vessel Synovium Bursa
(Strain) Nerve
Grade I (contusion) Grade I Grade I Acute Grade I Irritative
• Blunt injury (minor (contusion/haematoma) synovitis (neuropraxia) bursitis
• Intact muscle sprain) • Blunt injury • • (adventitious)
and fascia • Twisting patchy Common Sustained •
• Haematoma – injury • Collection of site: knee compression Excessive
patchy and • Positive blood and exudate joint • Intact repetitive
localized at the stretch test Grade II rupture • axis pressure,
site of injury Grade II (partial) Trauma, cylinder friction or
Grade II (partial (partial • Associated with infective • trauma
rupture) rupture) injury to the bone or Reversible • Pain
• Isometrics elicit • (e.g. fracture, inflammatory neuronal • Tender
sharp pain Gradually dislocation) joint signs and red and
• Some muscle appearing • Pulselessness or disease, symptoms hot
fibres may tear, swelling doubtful arthritis, • Intact localized
intact fascia • Joint peripheral etc. nerve swelling
Grade III (complete involved is circulation • Slowly conduction Infective
rupture) unable to • Cramp-like pain, developing Grade II bursitis
• Loss of take pallor, red hot, (axonotmesis) •
continuity in the pressure paraesthesia soft and • Infective,
muscle belly with (e.g., paralysis localized, Endoneurium inflammatory
palpable gap weight Grade III (complete fluctuating intact or
• Complete loss bearing in rupture or total swelling • Axonal metabolic
of voluntary lower limb blocking of blood • Positive breakdown disorders
movement injuries) flow) Homans • •
• Complete Grade III • Flexor muscle sign Wallerian Antibacterial
division of (complete fibrositis • Pain degeneration drugs
muscle and fascia rupture) • Uncontrolled and sets in; Chronic
Healing • Rapid bleeding heaviness good bursitis
• Abundant onset of • Pulselessness in recovery •
blood supply so effusion • Blocking of the performing but may Excision
healing is fast • Marked blood flow may active not be drainage
• If smooth instability result in serious movements complete local
interface is in the joint consequences like Chronic Grade III infiltration,
available, muscle • Due to MI, internal synovitis (complete modified
fibres grow at the poor blood thrombosis, • section of foot-ware
rate of 1.0–1 mm supply, neuromuscular Negligible the nerve) Adventitious
per day they take necrosis or pain • bursae
• If smooth long time gangrene • Blocking • Medial
interface is not to heal Effusion of nerve side of
available, Healing turns into conduction great toe
fibroblasts secrete • If not a hard • Both • Ischial
procollagen and displaced, mass proximal tuberosity
then regeneration immobilization • and distal True
occurs with a scar with a POP Atrophy degeneration bursae
tissue which can cast for 6–8 of muscle • No •
cause shortening weeks close to recovery Subacromial
or contracture • If the Healing bursaBursae
displaced, involved • Rate of in knee
needs joint axonal and heels
surgical • Joint growth: 1
repair and instability mm per
immobilization when day
in POP for ligament • Muscle
6–8 weeks is also proximal
involved to the site
• of injury
Tenosynovitis recover
• first
Inflammation (motor
of the march)
synovial •
lining of a Damage
tendon to the
sheath endoneural
• Pain tube may
and result in
crepitus neuroma
on
palpation
over the
tendon
Tenovaginitis
• Fibrous
sheath of
a tendon
is affected
• No
crepitus
•
Tendency
for
progressive
contracture
of tendon
(e.g., De
Quervain)
Causes of soft tissue injury

1. Direct, blunt or lacerative trauma – due to fall, road traffic accident,
assault, etc.
2. Indirect trauma – due to a sudden violent muscle pull when one is

not aware of it. It may result in ligament sprain at the impacting joint
(e.g., ankle sprain), or avulsion injuries.
Commonly injured soft tissues

◼ Muscle and tendons
◼ Ligaments
◼ Peripheral nerves
◼ Blood vessels
◼ Synovium
◼ Joint capsule
◼ Bursae
◼ Fascia and subcutaneous connective tissue
◼ Skin
Of these, injuries to the muscles, tendons, ligaments, blood vessels

and nerves demand special attention due to their major role as the
functional units of the body.
Role and objectives of physiotherapy

With physiotherapy being a major discipline employed to restore
function, the physiotherapist must have adequate knowledge and skill
of the following:
◼ Early detection and correct diagnosis through critical evaluation
◼ Planning patient-oriented correct methods of management
◼ Conducting planned therapy and educating the patient on exercise

and self-care
◼ Re-evaluation at regular intervals to ensure progress
◼ Postrecovery dos and don’ts and guidance on preventing

recurrence
Note: Early initiation of active movements within the pain-free range
provides ideal background for recovery.
Examination and evaluation

Subjective
Overall impression of a patient about the disorder and the main
subjective difficulty may not always correlate with the findings of the
clinician’s evaluation.
Objective
Considering the nature of injury, soft tissues must be examined first to
assess the site and the extent of damage to the respective soft tissues.
Scientific and critical evaluation of the neuromusculoskeletal system
by physical examination using established tests and ordinal scales are
used to describe each test (e.g., muscle power, ROM, pain) should be
done.
Functional: Careful evaluation of the effect of injury on routine

functions and ADLs is a must. Although it is of great importance, it
is usually neglected in the routine evaluation done by the
physiotherapist. At the same time, it is equally necessary to curb
certain attitudes and activities of overenthusiastic patients which
may prove detrimental to their recovery, e.g., antigravity shoulder
abduction in the presence of a rotator cuff injury.
Interpretation: The findings of the aforementioned data should be

properly interpreted in relation to the clinician’s evaluation data and
the records of the investigations so that an optimally effective
therapeutic programme can be formulated.
Response: Response of a patient to treatment needs to be evaluated

carefully and critically at regular intervals. The treatment
programme may need some modifications and alterations from time
to time.
Functions and objectives of physiotherapy

These fall into two categories:
1. Immediate restorative measures
2. Late restorative measures
1. Immediate restorative measures
(a) Control bleeding

(b) Reduce swelling
(c) Minimize pain and inflammation
(d) Prevention of further damage
(e) Prevention of stiffness of joints and soft tissues
(f) Maintenance of muscle functions
2. Late restorative measures
(a) Re-education of movement
(b) Increase strength, power, endurance and flexibility of the

affected muscles in particular and the whole body in
general
(c) Increase optimally the mobility of the affected joint and

soft tissues
(d) Restoration of kinaesthetic/proprioceptive mechanisms
(e) Restore confidence and provide all necessary

encouragement
(f) Correct guidance in patient-oriented self-exercise training

programmes
(g) Intensive programme to facilitate ADLs
(h) Training in specific home treatment programme
(i) Guidance to prevent recurrence

(j) Emphasis on regular check-up and follow-up advice.
Clinically, the major soft tissue injuries are divided into six
categories:
1. Muscle and tendon injury
2. Injury to the ligament
3. Injury to the synovial membrane
4. Injury to the nerve
5. Injury to the blood vessel
6. Injury to the bursa
7. Injuries to the musculoskeletal complex
Muscle and tendon injury

Muscle and tendon injury (strain) (box 3-1)
Injury to the muscle is classified into four categories on the basis of
damage to the muscle tissue:
1. Grade I strain: Superficial contusion
2. Grade II strain: Deep and widely spread contusion
3. Grade III strain: Partial rupture of the muscle or tendon
4. Grade IV strain: Complex rupture of the muscle or tendon

Box 3-1
STRAIN (INJURY TO MUSCLE)
• Grade I (contusion)
• Blunt injury
• Intact muscle and fascia
• Haematoma – patchy and localized at the site of injury
• Grade II (partial rupture)
• Isometrics elicit sharp pain
• Some muscle fibres may tear, intact fascia
• Grade III (complete rupture)
• Loss of continuity in the muscle belly with palpable gap
• Complete loss of voluntary movement
• Complete division of muscle and fascia
Healing: Abundant blood supply so healing is fast.

If smooth interface is available, muscle fibres grow at the rate of
0.1 mm per day.
If smooth interface is not available, fibroblasts secrete procollagen
and then regeneration occurs with scar tissue that can cause
shortening or contracture.
Grade I strain or contusion

This injury results mostly from a blunt injury.
Pathology
1. Intact fascia
2. Minimal intramuscular bleeding causing patchy localized
haematoma
Clinical features
1. Localized pain and tenderness
2. Reflex muscular spasm
3. Limitation of movements close to the injury
4. Typical signs of inflammation may be present
Healing
Being abundantly vascularized, the process of healing is

speedy and complete. However, original muscular tissue is
replaced by fibrous tissue resulting in a decrease in the
efficiency of contraction.
Management
◼ Treatment by applying the principles of RICE
◼ Cryotherapy in the form of ice application for the first 24 h is very

effective (three to four sittings of cryotherapy each for 20 min)
Beneficial effects of cryotherapy
◼ Reduces tissue oedema (Mc Master and Liddle, 1980; Masten,

Questad & Masten, 1975)
◼ Slows down localized blood flow (Abramson, Tuck, Lee,

Richardson & Chu Luke, 1966; Knight and Londerce, 1980)
◼ Lowers intraarticular and intramuscular temperature and reduces

pain (Cobbold and Lewis, 1956; Wakim, Porter & Krusen, 1951;
Johnson, Moore, Moore & Oliver, 1979; Chambers, 1969; Lane, 1971;
Rocks, 1979)
◼ Reduces metabolic function and brings about vasoconstriction

(Clarke, Mellon & Lind, 1958; Janssen and Waaler, 1967)
◼ Reduces sensory and motor nerve conduction velocities (Fox, 1961;

Lee, Warren, & Mason, 1978)
◼ Produces analgesia by increasing the threshold of stimulation of

pain nerve fibres (Stangel, 1975)
◼ Increases neuromuscular function
◼ There may be an increase in the muscle strength after the treatment
Caution
Excessive cooling beyond 15°C is contraindicated. At this
temperature, vasodilation occurs as a protective tissue response to
prevent necrosis (Lewis, 1941).
It is contraindicated in collagenous diseases where there is
possibility of increasing pain and stiffness (Backlund and Tiselius,
1967).
It is also contraindicated in Raynaud disease, as it produces
excessive digital arterial spasm and ischaemic tissue necrosis
(Goldberg and Pittman, 1959).
It is also contraindicated in some people who have an allergy to
cold. It may produce cold erythema and cold hypersensitivity
syndrome (Shelley and Caro, 1962).
Note
■ Grade I or superficial contusion – it settles quickly just by RICE.
■ Grade II or deeper contusion takes more time for the dispersal of

haematoma.
■ Grade III or deep and widespread contusion not only requires
longer time to settle, but, if it is close to the joints like elbow or hip,
the patient is also susceptible to develop myositis ossificance – a joint
stiffening complication. In such a situation, application of heat,
massage or forced passive movements to improve passive joint
range of motion (JROM) are totally contraindicated.
Grade II strain (deep and wide contusion) – possibly due to more

violent blunt trauma
Pathology: wide and deep haematoma
◼ Intact fascia
◼ Greater number of muscle fibres are traumatized
◼ More internal bleeding
◼ More than one muscle group may be involved
Symptoms
◼ More severe localized pain and tenderness
◼ Severe reflex muscle spasm
◼ Fascia may remain intact or may be torn
◼ Loss of voluntary active movement
◼ Attempted isometrics elicit sharp pain
◼ Both intra- and intermuscular bleeding may occur
Grade III strain (partial rupture)
◼ There is tearing of greater number of muscle fibres.

◼ It may involve more than one muscle groups.
◼ Fascia may be partially torn.
◼ Widespread intra- and intermuscular bleeding may occur.
Cause
Grade III strain is caused by incoordinated sudden violent

muscle pull when the muscle is not prepared for it (e.g.,
sudden violent stretching of the muscle in a contracted
state, as in sports). Although the torn muscle fibres are
replaced by fibrous tissue (scar), adequate function of the
injured muscle can be regained if it is kept supple by
relaxed early mobilization and controlled stretching
manoeuvre.
Management of grade II and III strains
During the first 24 h:
◼ Immediate application of RICE principles
◼ Immobilization of the limb in a splint or a pressure isometric

bandage
◼ Begin with pain-free isometrics both in speedy and sustained mode

against pressure bandage with the limb elevated
◼ Vigorous active exercises to the uninvolved joints
From 48 to 72 h:
◼ Pressure bandage is removed and pain-free relaxed rhythmic

movements are begun in a small pain-free range.
◼ Carefully controlled gentle stretching is introduced.
◼ Soothing thermotherapy modality followed by progressive mode of

exercise is initiated.
◼ Light ADLs, may be assisted with the normal limb (self-assisted),

are introduced and non–weight-bearing (NWB) crutch walking is
started.
During 48–72 h:
◼ Vigorousity and the duration of exercises are progressed.
◼ Ultrasonic exposures are ideal to reduce pain as well as haematoma,

if present.
◼ Light functional activities are continued with NWB crutch walking.
After 72 h:
◼ Usually the pressure bandage is off by now, unless swelling

persists.
◼ Gradual introduction of self-resistive exercises incorporating exercise

patterns of proprioceptive neuromuscular facilitation (PNF) is
included if feasible and pain free.
◼ Systematic introduction of the DeLorme technique of repeated

maximum strength (RMS) is tried.
◼ Allow carrying or lifting heavier weights and all FWB in

ambulation in a graduated manner.
◼ Preinjury functional status should be restored within 3–6 weeks.
◼ Advise against overuse or recurrence.
Grade IV strain (a complete rupture)

Causes
Causes can be severe lacerative trauma or a violent

stretching of a muscle during active contraction. It may
occur through the tendon or close to the point of its
attachment to the bone. It results in a piece of bone getting
avulsed along with the tendon (Fig. 3-1). Avulsion may
occur due to attrition of the tendon or roughening of the
bony groove in which it lies or as a result of sharp and
violent laceration. It is associated with the rupture of a
blood vessel with haematoma developing in the gap
between the ruptured fragments. It is replaced by vascular
fibrous tissue. This vascular fibrous tissue eventually
organizes as scar tissue prone to developing shortening or
contracture.
FIG. 3-1 A CT scan-3-dimentional reconstruction image.
Test
There will be loss of the primary function of the involved
muscle, e.g., in the rupture of the tendoachilles, active toe
raising test will be POSITIVE, even though the patient may
be able to perform weaker plantar flexion by using peronei
and the long toe flexors. The sequential steps of healing of
the ruptured muscle and tendon are presented in Fig. 3-2.
FIG. 3-2 Sequential healing of the muscle and tendon injury. (A) Intact
tendon with longitudinally placed collagen fibres. (B) Cut tendon with both
the cut ends in correct alignment. (C) Formation of fibrin clot (early repair
process). (D) Within 3–5 days fibroblasts proliferate and begin production of
collagen fibres. (E) By 2 weeks, the collagen scar begins to remodel (an
important period to apply graduated longitudinal stretch. (F) Remodelled or
properly aligned collagen.
Pathology
◼ A palpable gap may be felt at the point of a complete rupture
◼ Tearing of the fascia
◼ Considerable intra and intermuscular bleeding
◼ Gross swelling over the site of rupture and its periphery
Clinical features
◼ Severe localized pain and tenderness
◼ A snapping sound may be heard by the patient
◼ A total loss of muscular contraction
◼ Severe reflex muscular spasm
◼ A visible gap in the continuity of a muscle at the site of rupture
Treatment
◼ There is no alternative to surgical repair.
◼ Opening the ruptured site, haematoma is evacuated and suturing of

the fascial sheath is performed. Direct muscle repair is avoided.
◼ Compression bandage is applied.
◼ Limb is immobilized (in elevation) for 2–3 weeks.

◼ Light, pain-free, speedy or slow-speed isometrics are performed at
the earliest.
◼ Faradic stimulation over the repaired muscle will be useful in

maintaining and influencing fast as well as slow twitch muscle
fibres, in the distribution of motor units and the fusiomotor systems
(Pette 1980).
◼ Superficial thermotherapy could be altered to deep heating

thermotherapy to improve circulation, to reduce pain, to increase
metabolism; selective action on different tissues and generalized and
localized relaxation (Griffin and Karselis, 1978).
The therapeutic mode should be progressed on the same lines as

described for grade II and III strains.
Note: Exercise to augment specificity: the process of recovery for
muscle and tendon.
For muscle injury:
1. Progressive tensile loading at various speeds recruits different

motor units.
2. Low-load exercises to the point of a muscle fatigue promote

metabolic adaptations.
For tendon injury:
1. Progressive tensile loading
2. Strength training exercises
3. Exposure to tensile loads over a longer period increases size

concentration and collagen crosslinking
Compression bandage: Compression bandage is applied with

moderate even pressure without a gap to control the oedema.
Intermittent pneumatic compressive therapy has been proved to be
very effective (Airaksinen, 1989). The technique of combination of
intermittent compressive system and ice as described by Murphy
(1988) should also provide an effective measure to reduce pain and
oedema.
Positioning and movements: Elevation of the affected part and active

movements of the distal body segment, and isometrics further
increase the efficiency of compression bandage in reducing swelling
and oedema. The patient should be educated to prevent further
trauma by proper, controlled positioning and transfers.
◼ Active relaxed rhythmic movements are initiated to the

distal-most segment (e.g., toes) supported in elevation.
◼ Low-dose insonation is an extremely effective means of

reducing haematoma.
◼ Soothing effleurage helps in the dispersal of swelling and

haematoma.
◼ Movements are to be progressed depending upon the

discomfort; ideally initiated following soothing superficial
thermotherapy.
◼ Isometrics and self-resistive modes of exercises play a vital

role in the recovery.
◼ Light functional activities are safe.
◼ Period of full recovery is 8–10 days.
Management of a ruptured tendon (fig. 3-2)

A ruptured tendon is usually sutured and immobilized for 2–9 weeks.
The period of immobilization actually depends upon various factors
like the method and type of suture, and the expected degree of stress
on the tendon. For example, a large tendon bearing excessive stresses,
like tendoachilles, needs 9–10 weeks of postop immobilization. The
treatment follows the same routine as described for grade IV muscle
rupture, except the following:
◼ Extra emphasis should be put on low-load stress on the sutured

tendon.
◼ Careful progressive application of tensile loading is required.
◼ Strength training exercises with deep friction massage and

ultrasonics play an important role in the maintenance of the tendon
length.
◼ Thorough guidance should be provided on the correct application

of sustained self-stretching.
◼ Slow-stress activities can be started by 10–12 weeks.
◼ Competitive sports can be allowed after 16–18 weeks with several

practice sessions.
Injury to the ligament (table 3-4)

Injury to the ligaments are also addressed as sprain. Ligaments are
major stabilization forces of a joint and in turn the whole body during
our most important static as well as dynamic activities.
Table 3-4
Classification of the Extent of Injuries to the Ligaments
Mild (Grade Severe (Grade

Characteristics Moderate (Grade II)
I) III)
Pain Minimal (+) Moderate Complete tear
Tenderness (+) (++) (+++)
Instability Nil Minimal Marked (+++)
Localized Negligible (+) (++)
oedema
Passive stress Increased Extreme pain Excruciating pain
test pain
Joint separation Up to 5 mm Between 5 and 10 >10 mm
mm
According to the degree of damage, ligament injuries are classified

into three grades: I–III.
Functional anatomy
The ligaments are made up of longitudinally arranged fibres to ensure
adequate and safe excursion of a joint during high-stretching activities
of the body.
They are compact fibrous tissues, which reinforce the joint capsule.
As they have no tone like a muscle tissue, they are inadequate to
offer sole defence to the joint. To cover this inadequacy, they are
always reinforced and supported by muscles. This combined action of
muscles and ligaments is further facilitated by receiving the same
neural innervations as its paired muscle, totally handling the excessive
stretch by increasing its tone (e.g., if there is excessive strain on the
medial collateral ligament, the supporting vastus medialis muscle will
be activated to reduce stress on the medial collateral ligament and the
medical compartment of the knee joint).
Main functions of the ligaments

◼ To provide support by reinforcing the joint capsule
◼ Joint stability: To provide major support to hold together the bony

ends forming the joint
◼ Protection: Being tough and pliable, they have the ability to

withstand excessive stress over the joint
◼ Efficiency of movement: To provide great mechanical advantage to

the joint movement with reduced load and stress on the prime
mover muscle group
Problems in healing of the ligaments
◼ Poor vascularity results in undue delay in the process of healing
following an injury.
◼ Repair always takes place by scar tissue, as they do not have

specialized cells to mimic the original tissue.
◼ As and when the ligaments are not protected from stress for a
longer duration, the process of repair takes place with excessive
fibrous tissue. This results in the lengthening of the healing
ligament, which results in its laxity giving rise to permanent laxity
or loosening of the joint (hyper laxity).
◼ Continuous pull on the injured ligament during the early sessions

of passive JROM exercises may give rise to periosteal irritation and
serofibrinous exudates – leading to organization of fibrous
adhesions and finally resulting in painful stiffness of the related
joint.
Therefore, while initiating early passive ROM exercises or stretches,

one must not cross the boundary of pain and discomfort.
Caution
While applying stretch on a healing ligament, it should be
INTERMITTENT and controlled carefully to achieve the objective of
strong ligament.
Ligamentous injury is classified into three grades (Box 3-2; Fig. 3-3):
Grade I: Minor sprain
Grade II: Moderate sprain
Grade III: Complete rupture

FIG. 3-3 Grades of ligament injury. (A) Grade I – sprain. (B) Grade II –
partial rupture. (C) Grade III – complete rupture.
Box 3-2
SPRAIN (INJURY TO THE LIGAMENT)
• Grade I (minor sprain)
• Twisting injury
• Positive stretch test
• Grade II (partial rupture)
• Gradually appearing swelling
• Joint involved is unable to take pressure (e.g., weight

bearing in lower limb injuries)
• Grade III (complete rupture)
• Rapid onset of effusion

• Marked instability in the joint
Due to poor blood supply, they take long time to heal.

Healing
• If not displaced, immobilization with a POP cast is needed for 6–8
weeks.
• If displaced needs surgical repair and immobilization in POP for 6–

8 weeks.
Grade I injury
Grade I injury is easy to deal with and instant application of all the
four principles of RICE with analgesic and anti-inflammatory
medication are adequate.
Clinical features
◼ Localized pain and tenderness
◼ Slight swelling may be present
Test
◼ Passive stress test is the diagnostic sign; it will be positive when

sprain has occurred.
◼ Separation of the joint surfaces up to 5 mm may sometimes be

present.
◼ Partial loss of function may be present due to pain.
Treatment
First day
◼ With limb in elevation, active movements are to be
encouraged to the distal-most joints.
◼ Pain-free light isometrics are guided.
◼ Functional activities should be encouraged, depending

upon the area of involvement.
Second day
◼ Replace cryotherapy with superficial thermotherapy.
◼ Increase vigourosity of isometrics, emphasizing repetitive

performance.
◼ Educate on safe and appropriately grooved active self-

assisted to active movements.
◼ Rapidly progress exercise mode to self-resistance or

progressive resistance exercise (PRE), if possible.
◼ Allow functional activities gradually if no discomfort.
◼ Full recovery is expected within a week or 10 days.
Grade II injury (moderate sprain)

Here the ligament is either partially torn or detached from its bone of
attachment.
Clinical features
Moderate localized pain and tenderness
Test
◼ Passive stress test is extremely painful with joint
separation varying between 5 and 10 mm.
◼ This type of injury being common at the knee, walking or

weight bearing is painful and associated with a limp.
Treatment
◼ RICE methodology is used with cryotherapy for the first

24 h.
◼ For compact immobilization, cast (long) is applied for 3–6

weeks.
◼ Early isometrics within the pain-free range are encouraged

and guided as early as possible.
After removal of the cast
◼ Stiff and painful movements are expected, especially in the

terminal JROM – need early and immediate attention.
◼ Begin with a small range of rhythmic relaxed active free

movements, progressing to self-assisted mode.
◼ Wherever possible, introduce correct education to perform

self-resistance movements.
◼ Rapidly progress to PRE, passive stretching, PRE or CPM,

if feasible.
◼ Progress to PWB ambulation to FWB with gait training

sessions.
◼ Full recovery is expected within 3 weeks.
Grade III injury (a complete rupture)

It is a severe injury putting the injured muscle totally out of action,
due to sudden violent injury.
Clinical feature
◼ Profuse swelling with marked localized tenderness
◼ Unremitting pain and discomfort to the whole limb
Test
◼ Passive stress test is impossible
◼ Marked joint instability
◼ Impossible to bear body weight on the injured limb
◼ Joint separation of >10 mm
Treatment for undisplaced ligament injury
◼ Usually treated by a conservation approach of immobilization in a

long leg cast for 6–8 weeks.
◼ Limb is maintained in elevation.
◼ Initiate vigorous, repetitive full ROM movements to the distal

joints.
◼ Initiate early isometrics to the encased muscles.
◼ Diapulse, which can be given with the cast on, is ideal if available.
◼ NWB crutch walking is progressed to PWB first with crutches and

with cane by 4–6 weeks.
After removal of the cast
◼ Kneecap or a crepe bandage is applied.
◼ Isometrics are intensified.
◼ Superficial thermotherapy, followed by rhythmic, relaxed, free,

active knee mobilization, is emphasized.
◼ The patient is well educated and guided on the techniques of self-

assisted and self-stretched modes for knee flexion emphasizing
sustaining and holding.
◼ Repetitive quadriceps exercises are performed against gravity.
◼ Active self-resistance exercises are important at this stage along

with strong isometrics to the quadriceps.
◼ The best method of strengthening, increasing muscle power and

endurance along with JROM is to teach and guide patients on self-
resistance and self-stretching modes of exercise.
◼ By 10–12 weeks, the patient should reach a stage of preinjury status.
Treatment for displaced or completely torn ligament
It may be a surgical emergency.
The usual surgical procedures employed are as follows (Fig.

3-4):
◼ Suturing
◼ Reattachment
◼ Advancement
◼ Replacement
The complete rupture of the following ligaments is

commonly seen in a knee joint: MCL, LCL and ACL. The
treatment consists of reconstructing the torn ligament by
an appropriate tendon graft; which is usually undertaken
as follows:
◼ MCL (medical collateral ligament) is replaced by either

semitendinosus or hamstring.
◼ LCL (lateral collateral ligament) is replaced by the muscle

biceps femoris or TFL (tens- or fascia lata).
◼ ACL (anterior collateral ligament) is replaced by iliotibial

band.
After the surgical repair the limb is encased in a long POP

cast to avoid stress to the operated area.
Physiotherapy during immobilization
◼ Perform limb elevation.
◼ Provide active movements to the free joints and the distal

joints (toes or fingers).
◼ Carry out regular activities with the sound limb.
◼ Gradually use the injured limb assisted by the sound limb

to perform light ADLs.
◼ No weight bearing is allowed at this stage.
After removal of the cast, the physiotherapy regimen follows

the same line of treatment as discussed for displaced
ligamentous injury.
FIG. 3-4 Surgical repair of ligament injury: (A) Repair. Minor grade I tear
can be managed by simple repair (suturing) of the partially ruptured
ligament. (B) Reattacment. When there is detachment of the ligament from
the bone of insertion, procedure of re-attachment is advisable. (C)
Advancement of attachment. A procedure of advancement becomes
necessary to impart better stability to the joint over which the ligament
passes. (D) Replacement with tendon. Replacement of the total ligament is
indicated when it is totally destroyed and cannot be repaired. Replacement
is performed either with tendon or by a prosthesis.
Note: One must be extra careful while applying stretch to the

replaced muscle; imbalanced application may lead to a limitation
when the applied stretch is inadequate to a lax joint when there is
overstretching, giving rise to instability to the related joint
(especially the weight-bearing joint).
Injury to the synovial membrane (synovium)

(box 3-3)
Synovium is a lining covering important tissues like joints, capsules,
tendon sheaths and articular surfaces of joints. It is richly supplied
with blood vessels, lymph vessels with abundant nerve endings.
Box 3-3
INJURY TO THE SYNOVIUM
Acute synovitis
• Common site – knee joint
• Trauma, infective or inflammatory joint disease, arthritis, etc.
• Slowly developing red hot, soft and localized, fluctuating swelling
• Positive Homans sign
• Pain and heaviness in performing active movements
Chronic synovitis
• Negligible pain
• Effusion turns into a hard mass
• Atrophy of muscle close to the involved joint
• Joint instability, when ligament is also involved
Tenosynovitis
• Inflammation of the synovial lining of a tendon sheath
• Pain and crepitus on palpation over the tendon
Tenovaginitis
• Fibrous sheath of tendon is affected – no crepitus
• Tendency for progressive contracture of the tendon (De Quervain)
Functions
It has the following three most important functions:
◼ It secretes smooth viscous synovial fluid, minimizing joint wear and

tear due to repetitive movements in various directions.
◼ It provides nourishment to the joint cartilage preventing early

degeneration.
◼ It also promotes interchanges of substances between the blood and

the joint structures.
Prone to inflammation
Synovium is prone to developing inflammation (synovitis) as a result
of infection, injury to the joint, rheumatoid arthritis (like RA),
haemophilia, chondromalacia, etc.
Types of synovitis
Acute: Commonly occurs as a result of injury or trauma
Chronic: Due to diseases like tuberculosis, rheumatoid arthritis or

even as a result of old injury
Acute synovitis
Clinical features
◼ Swelling develops slowly within 2–4 h.
◼ Cardinal signs of acute inflammation like warmth, redness,

swelling, pain, joint stiffness and loss of function appear.
◼ The involved joint adapts flexion attitude as a natural position of

ease.
◼ Joint is swollen due to the accommodation of excess fluid;

unremitting pain is present even at rest during the acute stage of
inflammation.
◼ Muscle atrophy quickly appears, particularly in the quadriceps,

when synovitis affects the knee joint, which is a common site for
synovitis.
Management
First 24–48 h
◼ Application of the principles of RICE (ice application

during the first 24 h completely encasing the knee)
◼ Gentle but speedy isometrics to the quadriceps with the

limb elevated
◼ Vigorous active movement to the toes, slow repetitive

movements to the ankle (when pain-free)
◼ Diapulse, insonation or superficial thermotherapy

advantageously applied to reduce pain
After 48 h
◼ The joint may be aspirated if the swelling persists.
◼ Speedy isometrics to reduce swelling and sustained

isometrics to strengthen quadriceps are initiated to prevent
atrophy.
◼ Small-range active movements are initiated as rhythmic,

relaxed free movements.
◼ Carefully monitored, sustained passive stretching may be

applied to improve JROM.
◼ Dynamic knee orthosis is given to maintain the knee in full

or near-full extension. It may also help minimize limp in
the future.
◼ Training for graduated weight transfers is important.

Ambulation, whenever feasible, could begin with NWB,
progressed to PWB and then to independent walking.
◼ Safety, guidance and education of the patient on self-

performance of exercise can be instrumental in preventing
knee flexion contracture and quadriceps atrophy.
How to identify the progression of synovitis and synovial
rupture?
Progression
The synovial effusion, which is fluctuating initially, gradually
assumes firm character turning to thick firm and nonfluctuating with
simultaneous reduction in the intensity of pain.
Synovial rupture
◼ The patient notices shooting pain at the posterior aspect of the knee
while getting up from a stool or chair.
◼ Getting down steps with the unaffected leg down develops

tremendous tension in the affected knee on the upper step bearing
the total body weight.
◼ The swelling may spread to calf resulting in a positive Homans

sign.
Chronic synovitis
Chronic synovitis is easily distinguishable on the basis of the
following signs and symptoms:
◼ Marked reduction in the intensity of pain
◼ Appearance of visual atrophy in the quadriceps especially on the

anterior aspect of thigh just above the knee (upper pole of patella)
◼ Firm swelling over the joint (synovial effusion) with typical shapes
at various sites
The sites and the shapes of the synovial effusion:
◼ At knee, it is horseshoe shaped.

◼ At the prepatellar bursa, it is egg shaped.
◼ At the tendon sheath, it is sausage shaped.
◼ There is considerable stiffness in the joint.
◼ Setting in of laxity in the ligament results in joint instability.
Treatment
As the main hindering factor to exercise is minimized, liberty should
be taken in rapid exercise progressions as follows:
◼ Strong, self-resisted isometrics to the quadriceps (Fig. 3-5)
◼ Monitored PRE to the quadriceps, hamstrings and hip joint muscles
◼ Sustained passive stretching of the knee to improve JROM; may be

in combination with hot packs
◼ Graded stretching or intermittent or sustained traction to ease

organized joint contractures
◼ If residual flexion contracture persists, a knee stretching orthosis

may be given, which can serve both the purposes of continued
stretching as well as easing ambulation
◼ Encourage self-monitored exercise training procedures to its

maximum
FIG. 3-5 SLR assistance is provided by physiotherapist posteriorly just

proximal to the ankle joint by one hand and below knee by the other.
Injury to the nerve

Occasionally, there may be injury or entrapment of the peripheral
nerve as a result of soft tissue injury (Box 3-4).
Box 3-4
INJURY TO THE PERIPHERAL NERVE
• Grade I (neuropraxia)
• Sustained compression
• Intact axis cylinder
• Reversible neuronal signs and symptoms

• Intact nerve conduction
• Grade II (axonotmesis)
• Endoneurium intact
• Axonal breakdown
• Wallerian degeneration sets in
• Good recovery but may not be complete
• Grade III (complete section of the nerve)
• Blocking of nerve conduction
• Both proximal and distal degeneration
• No recovery
Healing
• Rate of axonal growth: 1 mm per day
• Muscle proximal to the site of injury recovers first (motor march)
• Damage to the endoneural tube may result in neuroma
Nerve entrapment syndrome

Some extrinsic source may put pressure on the nerve at the point of its
exit from the intervertebral foramina or a peripheral nerve may get
compressed by a muscle belly or a tight fascia, e.g., median nerve in
the carpal tunnel.
Pressure alters conduction along the largest fibres and along the
smallest. The subjective and objective manifestation should be
detected by clinical examination as well as by sophisticated
electrodiagnostic tests.
Symptoms
1. Paraesthesia (pins and needles)
2. Dysaesthesia (altered sensation)
3. Pain
Pain is common in cases when the pressure is at the nerve root

level. Pins and needles or paraesthesia are common in cases where the
pressure is on the periphery of the nerve, e.g., thoracic outlet
syndrome, ulnar nerve palsy and carpal tunnel syndrome.
The nature of pain is usually sharp, shooting and dermatomic. This
pattern may change to a dull aching sclerotomic type when the large
fibres cease to conduct and the small unmyelinated fibres are
stimulated. This indicates that the pressure has progressed further.
The peculiarity of paraesthesia is that it may occur with the onset of
pressure, or when the pressure is released, or both.
The earliest evidence of decreased conduction appears in the
functions mediated by the largest myelinated fibres, which are most
sensitive to pressure. Therefore, reduced vibration sense is the earliest
clinical sign. If the pressure continues, there will be reduction or
absence of deep tendon reflexes followed by muscular weakness.
Finally, sensation will be reduced first to light touch and then to
noxious stimulation. Because of the presence of multisegmental
innervation to the muscles, skin and the overlapping dermatomes and
myotomes, even completely severed nerve root may cause only minor
sensory deficit.
Management
Once the diagnosis and the extent of injury to the nerve are
established, the following appropriate therapeutic procedures should
be initiated:
1. In case of sensory deficits, measures should be taken to avoid

damage due to sensory loss.
2. Adequate static or dynamic splints may be necessary to avoid

overstretching of the paralysed muscles and the concerned joint.
3. Immobilization, whenever given, should be critically checked to

avoid undue pressure hindering the circulation. Also ensure that free
passive ROM at the nonimmobilized joints is not blocked.
4. Re-education of muscles, affected by the nerve injury, should be

started following nerve conduction test. Re-education may be done
using various techniques like biofeedback, stimulation and PNF
technique.
5. Passive ROM movements and methodology of self-active

movements with a visual feedback should be taught to the patient to
avoid joint stiffness.
6. The progress of the nerve should be assessed by

electrophysiological tests. If the progress is not satisfactory, necessary
action should be taken.
The management of common soft tissue injuries and disorders is

enlisted in Box 3-5 on p. 44 and discussed in the chapter under
respective heads. The common soft tissue involvements marked are
discussed in this chapter.
Box 3-5
REGIONWISE LIST OF COMMON SOFT
TISSUE INVOLVEMENTS AND INJURIES
Note: Individually they are as follows:
• Spine
• Wry neck
• Low back ache
• Shoulder and shoulder girdle
• Adhesive capsulitis (periarthritis or frozen shoulder)
• Supraspinatus tendinitis or tear
• Rotator cuff tendinitis or tear
• Infraspinatus tendinitis
• Subscapularis tendinitis
• Long head of biceps tendinitis
• Subdeltoid bursitis
• Elbow
• Tennis elbow
• Golfer’s elbow
• Olecranon bursitis (minor’s elbow)
• Ruptured biceps tendon
• Wrist and hand
• Wrist sprain
• Ganglion
• Carpal tunnel syndrome
• Dupuytren contracture
• De Quervain disease (tenosynovitis tenovaginitis)
• Trigger finger
• Mallet finger
• Pelvis and hip
• Iliotibial tract syndrome
• Piriformis syndrome
• Knee
• Ligament and meniscal injuries
• Quadriceps apparatus injury
• Quadriceps strain
• Hamstring strain
• Calf strain
• Patellar tendinitis
• Prepatellar bursitis
• Plica syndrome
• Ankle and foot
• Ankle sprain
• Plantar fasciitis and calcaneal spur
• Tarsal tunnel syndrome
• Injuries to tendoachilles
• Metatarsalgia
• Morton neuralgia
Note: These injuries have been discussed in the respective regional
chapters.
Injury to the blood vessel (box 3-6)

Blood vessels and the peripheral nerves usually run in close proximity
to each other, and at certain sites, these are very close to the bones.
Therefore, they always remain susceptible to injury, fractures or
dislocations at these sites (Table 3-5).
Table 3-5
Possible Sites of Injury to the Blood Vessel and Peripheral Nerve
Injury and Site Susceptible Blood Susceptible Nerve

Vessel
Fractures Subclavian vessels Brachial plexus
• Clavicle Axillary vessels Axillary nerve
• Proximal humerus – Radial nerve
• Shaft humerus Brachial vessels Median nerve
• Supracondylar humerus Anterior interosseous –
• Both bones of forearm – Posterior interosseous
• Monteggia – nerve
• Hook of hamate – Ulnar nerve – deep
• Wrist Popliteal vessels branch
• Supracondylar femur Posterior tibial Median nerve
• Proximal tibia vessels –
• Both bones of legs Posterior tibial Posterior tibial nerve
• Ankle injuries vessels –
• Neck fibula Posterior tibial Posterior tibial nerve
Dislocations vessels Lateral popliteal
• Posterior dislocation of – Median nerve
elbow Brachial vessels Femoral nerve
• Hip joint (anterior) Femoral vessels Sciatic nerve
(posterior) – Common peroneal
• Knee Popliteal vessels
Box 3-6
INJURY TO THE BLOOD VESSEL
• Grade I (contusion/haematoma)
• Blunt injury
• Patchy collection of blood and exudates
• Grade II rupture (partial)
• Associated with injury to the bone (e.g., fracture,

dislocation)
• Pulselessness or doubtful peripheral circulation
• Cramp-like pain, pallor, paraesthesia, paralysis
• Grade III (complete rupture or total blocking of blood flow)
• Ischaemia to the muscles
• Uncontrolled bleeding
• Pulselessness
• Blocking of the blood flow may result in serious
consequences like MI internal thrombosis, neuromuscular
necrosis, gangrene
Causes of vascular injury
◼ Direct blunt injury
◼ Compression by fractured bony fragment, tight bandage or

haematoma
◼ Reflex vasospasm
◼ Incomplete or partial tear
◼ Complete tear
◼ Blockage due to callus, scar, internal thrombus or atherosclerotic

plaque
Clinical features
Depending upon the type of injury, the clinical signs could be as

follows:
◼ Ecchymosis contusion and haematoma
◼ Localized cramp-like pain, rapidly increasing swelling
◼ Pulselessness
◼ Paraesthesias
◼ Paralysis
◼ Pallor, cold extremities, muscle ischaemia (e.g., Volkmann

ischaemic contracture – VIC) – grossly insufficient blood supply
may lead to necrosis
Contusion: A blunt injury of mild intensity causes damage to the

capillaries with extravasation of blood in the subcutaneous tissues.
Normal flow of blood is affected because of the occlusion of
capillaries and pressure of the swelling.
Ice massage, cold compresses and pressure bandages

provide relief from pain and gradual reduction of the
swelling.
Ultrasonic therapy is also very useful, its effect adjunct,

lasting for 24–48 h.
Haematoma: Organization of haematoma occurs as a result of

blockage in the blood and lymph vessels due to spasm, pain and
compression of veins by congestion and is aggravated further by the
lack of muscular action in the muscle facial pump.
A greater intensity blunt trauma may cause damage to the

blood vessels within the intact muscle sheath
(intramuscular haematoma).
If the muscle sheath is torn, the extravasated blood may seep

in between muscles in a facial plane (intermuscular
haematoma).
In intermuscular haematoma, bleeding continues for a longer

period and the haematoma is diffuse. The extravasated
blood shows discolouration beneath the skin.
Local pain, tenderness and impaired function due to pain are

the presenting features.
Treatment: Same as for contusion, takes longer for resolution,
48–72 h or more.
Diagnosis
Injury or obstruction to the blood vessel is confirmed by

angiography or Doppler test.
Treatment
◼ Contusion
◼ Cold compression
◼ Pressure bandage with limb elevation in a splint
◼ Ultrasonic therapy
◼ The tendency of acute flexion at the adjacent joints of the

injured limb to be corrected
◼ Haematoma
◼ For subcutaneous intra- or intermuscular haematoma, the

treatment is same as for contusion.
◼ Deeper trauma – where the smooth flow of blood through the

peripheral circulation is doubtful, but continuity of the vessel is
maintained:
◼ Exploration of the vessel
◼ Release of vasospasm by sympathectomy, papaverine or

xylocaine injection
◼ Thrombectomy or segmental excision and anastomosis
◼ Complete rupture of the vessel
◼ End-to-end repair
◼ Grafting by using a vein or synthetic graft
◼ Graduated relaxed passive movements or active free

movements progressing to full-range resistive movement
are ideal
◼ Progressive functional training in a graded manner to

avoid stresses on the end-to-end repair
Caution
• Watch for the return of pulse within an hour.
• Carefully observe for the return of the peripheral circulation. Cold

extremities herald the onset of gangrene.
• Joint movements close to the site of injury must be conducted and

progressed, with utmost care during the initiation of mobilization.
• Pain-free gentle isometrics performed often are important.
• Discomfort, which begins just before the pain, is an alarming signal

to limit the ROM while conducting exercise training.
Injury to the bursa (box 3-7)

A bursa is a thin membranous pouch or a sac lined with synovial
membrane. Its function is to prevent friction where two structures like
tendons or bones are exposed to repetitive friction, a common cause of
overuse injury.
Box 3-7
INJURY TO BURSA
Irritative bursitis (adventitious)
• Excessive repetitive pressure friction or trauma
• Pain
• Tender red and hot localized swelling
Infective bursitis
• Infective, inflammatory or metabolic disorders
• Antibacterial drugs
Chronic bursitis
• Excision
• Drainage
• Local infiltration, modified footwear
Adventitious bursae
• Medial side of great toe
• Ischial tuberocity
True bursae
• Subacromial
• Elbow
• Knee
• Heel
Functions
◼ To protect tissues from undue pressures, trauma and their wear and
tear
◼ To protect common expected repetitive frictional sites like

acromion, elbow, knee and heel
Besides these true bursae, false bursa or so-called adventitious

bursa appears due to external trauma or excessive one-point pressure
where inflammation sets in causing the typical signs of acute
inflammation.
Cause of bursitis
◼ Trauma – may be a single blow or a repetitive one
◼ Infection – acute or chronic (TB)
◼ Metabolic disorders like gout
◼ Abnormal external pressures – ischial tuberosity of hip
◼ Inflammatory disorders – classical example is that of rheumatoid

arthritis
◼ Unaccustomed activity – ill-fitting foot wear causing excessive

tightness at certain points where the bone is close to the skin, e.g.,
olecranon bursitis
Injuries of the musculotendinous complex

The musculotendinous complex may be injured at the following sites:
(a) Musculoperiosteal junction
(b) Musculotendinous junction
(c) Tendoperiosteal junction
(d) Tendon itself
In a majority of injuries, the common cause is indirect injury where

continuity is maintained. These injuries are treated conservatively.
Rarely, the continuity of a tendon may be disrupted due to a cut
injury.
Clinical features
Localized pain, tenderness, swelling and functional

impairment are the usual presenting features. Attempted
movements are extremely painful, and the degree of loss of
function depends upon the severity of injury.
Treatment
Tendon repair is indicated in the instances of cut injuries.
Tendency for adhesion formation after repair restricts tendon

excursion because of the following:
◼ Proliferation of fibroblast and vascular elements damaged

at the time of injury.
◼ Transformation of the resting tenocytes into tendoblasts

within the cut ends of a tendon.
This requires specialized splinting and therapeutic approach of
controlled movements to restore normal excursion of the repaired
tendon (see Chapter 34).
Note: Resistive movements in the antagonistic direction, assisted
active movements in the agonistic direction and performance of
maximal relaxed stretches in both agonistic and the antagonistic
directions provide ideal environment for early and complete
recovery of the musculotendoskeletal injuries. If painful, emphasize
pain-free isometrics.
Rare soft tissue injuries

◼ Fibromyalgia
◼ Fibrositis
◼ Haematoma
Fibromyalgia
Fibromyalgia is a common rheumatological disorder, which can easily
be distinguished because of its symptoms. It is present with multiple
tender and painful points all over the body without any fibrous
nodules.
Incidence
◼ Overall 2.5%
◼ About 8–10 times more common in women than in men
Causes
◼ Any condition that lowers the endurance of a muscle
◼ Irritable bowel syndrome

◼ Dysmenorrhoea
◼ Psychological disturbances
◼ Hypo- or hyperthyroidism
◼ Trauma
◼ Infection
◼ Connective tissue disorders
Clinical symptoms
◼ Stress due to widespread painful tender points
◼ Early fatigue and discomfort
◼ Restricted movements at the joints
◼ Chest and abdominal pains
Diagnostic criteria
◼ Widespread extraordinarily sensitive and tender trigger points
◼ Lack of sustained muscular activities
◼ Longer lasting widely distributed tender points lasting even for

several months
◼ Tenderness in the joints
◼ Family history of fibromyalgia symptoms, rheumatoid arthritis and

lupus
◼ Develops a typical vicious circle of pain cycle. Pain reduces activity

– weakens muscles, require extra efforts to perform ADLs, which
results in pain
◼ Past history of several unsuccessful therapeutic interventions.
Treatment
Essentially multidisciplinary approach is required.
Initially, the following should be performed:
◼ Physiotherapy in the form of thermotherapy by soothing

superficial procedures alternated with deep and
penetrative modes like SWD, insonation, TENS over the
acutely painful points
◼ Soothing massage, followed by active, relaxed, free

exercises to be initiated and progressed as the pain eases
out
◼ Encourage and assist the patient in performing low-grade

Multidisciplinary approach
◼ Psychotherapy: To reduce stress
◼ Injection therapy
◼ Dry needling over the tender points
◼ Injecting normal saline
◼ Local anaesthetic injections
◼ Steroid injections may be helpful in reducing pain and

tenderness
◼ Diet therapy: Rich protein diet, with amino acids and minerals
◼ Yoga therapy: To reduce stress
◼ Acupressure: Over specific tender points, to reduce pain, is safe
◼ Hypnosis
Fibrositis
Some muscles have a tendency to develop localized small but firm
and tender fibrous nodules. It is a nonspecific entity of unknown
aetiology.
Characteristics of nodules
They are palpable and intramuscular, small sized,

immovable but painful nodules developed in the belly of
certain muscles.
They are nonspecific and develop in certain muscles like

trapezius, lower lumbar area and around the posterior iliac
spines (commonly present in patients with low back ache).
They are harmless and do not present any functional

impairment.
Treatment
◼ These nodules respond very well to hydrocollator packs,

ultrasonics, localized friction massage and SWD.
◼ Rarely, localized steroid infiltration may become necessary.

Haematomas
Collection of blood in the body of the muscle itself or in between the
muscles is termed as haematoma.
Intramuscular haematoma
◼ The blood gets organized within the muscle bound by an intact

muscle sheath.
◼ Bleeding takes places within 2 h of injury and stops, giving rise to

localized haematoma.
◼ There may be a localized swelling.
Intermuscular haematoma
◼ The tears in the muscle sheath result in extravasations of blood

between the planes of muscle and fascia.
◼ The haematoma is deep and more diffused causing discoloration

beneath the skin.
◼ There is moderate pain and tenderness over the haematoma.
◼ The discoloration takes place within first 48 h of trauma, confirming

the diagnosis of intermuscular haematoma.
◼ Swelling may be present over the localized site of injury or else due
to gravity, sometimes. It may track down and present away from the
site of injury.
◼ Generally, there is no loss of function if it follows grade I strain, but

in muscle injury, if it follows grade II and III strains, there is
possibility of loss of function.
Treatment
◼ The first objective is to control any further bleed
◼ Give rest to the part
◼ Apply the principles of RICE with appropriate orthosis, if necessary
In musculoskeletal disorders, the aim is to provide optimal functional
independence within the limits of the disability and the disease. The
physiotherapist has to use various methods of assessment to reach the
diagnosis and then plan the education of the patient on self-
performance of simple but specific exercises. The patient performance
has to be supervised and initially, the therapeutic programme has to
be personally conducted. The therapeutic regime is reviewed at
regular intervals to make necessary alterations to suit each patient.
This involves the following:
1. Assessing the exact nature and extent of the lesion
2. Recording of qualitative and quantitative data by a thorough

examination to diagnose the cause, extent and effects of the
dysfunction
3. Accurately assessing the extent of the disability and its impact on

the functional activities of occupation, house tasks and hobbies
4. Planning of the therapeutic programme on an individual basis by

methodical interpretation of the data of examination
5. Carrying out the planned therapy and making suitable alterations,

whenever necessary
6. Objective recording of the patient’s progress at regular intervals and

also the subjective response of the therapy is important to decide and
plan the future course of management
7. Discharging advice with education and guidance to avoid
recurrence
8. Regular follow-up reassessment and advice
Physiotherapeutic management should not only be disability

oriented but has to be pathology oriented also to resolve both the
factors for an optimal recovery.
Pathology of dysfunction
A homeostatic mechanism is responsible to maintain a perfect balance
between the processes of tissue breakdown and repair. The body
tissues suffer breakdown due to stresses, whereas repair occurs
through the formation of new tissue. The body continuously tries to
maintain perfect balance between these two processes which occur as
a result of normal daily use. Any imbalance results in musculoskeletal
dysfunction or disorder. This imbalance could be as follows:
1. Increased rate of tissue breakdown
2. Decreased rate of tissue breakdown
3. Increased rate of tissue production
4. Decreased rate of tissue production
1. Increased rate of tissue breakdown
When the rate of tissue breakdown exceeds the rate of tissue

repair, excessive stress level leads to hypertrophy of the
tissues, e.g., repetitive loading results in hypertrophy of
muscle. Similarly, a well vascularized bone will
hypertrophy; however, excessive stress on the bone may
lead to a stress fracture.
The articular cartilage, which is poorly vascularized and has
a lower metabolic rate, tends to break and degenerate
under the conditions of stress.
Therefore, when excessive tissue is of the same nature as the

original, the function improves (e.g., muscle hypertrophy
following regular sessions of PRE). However, if the repair
is replaced by a different type of tissue, it will result in
deficiency in a regular function (e.g., formation of
excessive collagen will lead to lack of extensibility resulting
in partial fibrosis of the joint capsule).
The therapeutic programme needs to be planned in such a

way that it is sufficient to promote the process of repair. It
should neither be too aggressive to disturb the repair, nor
too inadequate to facilitate the process of repair by tissues
other than the original one.
As circulation plays a predominant role in the process of

tissue repair, dysfunction at the sites where the tissue is
poorly vascularized or has a low metabolic rate needs to be
handled before further breakdown takes place. Circulation
is augmented by limb elevation, deep heating procedures
or resistive exercises to the adjacent muscle groups, but at
the same time early stress on loading exercises is
contraindicated.
A classical example of this is supraspinatus tendinitis. The

rate of breakdown at the insertion of this tendon exceeds
due to fatigue and reduced vascularity. The body
compensates its inability to produce new tendon by
causing calcification. When exercise or activities causing
extra stress, like shoulder abduction against gravity, are
performed, partial rupture may progress to complete
rupture.
2. Decreased rate of tissue breakdown
Immobilization always brings about a decrease in the rate of

tissue breakdown due to decrease in stress. This sets in the
disuse atrophy of muscles, ligaments, joint capsules as well
as the bones.
The approach of physiotherapy should be to impart some

stress on the immobilized tissues. Proper training of
isometric exercises, vigorous exercises to the joints adjacent
to the immobilized joints and early initiation of whole
body movements, e.g., transfers, protected standing and
early initiation of functional activities, are required.
3. Increased rate of tissue production
The process of repair following inflammation may lead to the

excessive proliferation of collagen tissue. The new collagen
tissues may be laid in abnormal patterns resulting in
interfibre crosslinks. This increased rate of collagen
formation in the immobilized joint results in loss of
extensibility leading to painful and/or stiff joints.
Asymmetrical collagen with interfibre crosslinking may
result in the loss of the normal groove and also the
character of movement.
4. Decreased rate of tissue production
Here the process of tissue repair is prolonged due to a

decrease in the rate of tissue production. Change in the
metabolic status is the basic factor. The tissue equilibrium
is destroyed due to abnormal hormonal levels, nutritional
deficiencies or reduced vascularity. These types of
imbalances are complex in nature and cannot be improved
greatly by physiotherapy. However, general toning of all
the body systems through safer limits of exercises could be
contributory. Advice on the measures to protect the tissue
from further damage is also necessary.
Postmenopausal osteoporosis in the cancellous bones is an

example of alteration in the hormonal level. Repetitive
stress on the osteoporotic bones could be harmful. Strong
repetitive trunk flexion exercises to relieve back pain have
been shown to produce compression fractures in the spine
of women with postmenopausal osteoporosis (Sinaki, 1982;
Sinaki and Millkclsen, 1984).
Examination of musculoskeletal dysfunction

Accurate, subjective, as well as objective critical examination of a
patient is important to the diagnosis and hence is key to successful
management. The process of examination falls into four stages:
1. Subjective examination
2. Objective examination
3. Functional examination
4. Psychological and vocation-oriented assessment
1. Subjective examination
The subjective examination is basically history taking. The

clinician aims at collecting data from the patient which are
relevant to the dysfunction.
(a) Patient’s own assessment of the dysfunction and the

major problem (self-perceived)
(b) When and how did the dysfunction start?
(c) Site, time, quality and behaviour of pain
(d) Previous history of such dysfunction and how it was

controlled
(e) Factors aggravating and relieving the symptoms
(f) Any associated symptoms or the history of associated

disease
(g) General health of the patient
(h) Influence and the extent of disability on the patient’s

functional activity
Assimilation of the subjective data is important to interpret and

arrive at the diagnosis and the intensity of the patient’s problem. Also,
it is vital to plan the exact therapy and judgement of the patient’s
response to therapy.
Symptom-provoking or -relieving diagnosis and therapy-oriented

selective tension test
Selective tension test to localize the focus of a lesion:
◼ Selective passive tension is applied carefully with

adequate stabilization – provokes or recreates the patient’s
symptoms or may help in alleviating or providing relief to
the symptoms.
◼ It helps in detecting whether the lesion is present within

the inert joint structures like bone, joint capsule, ligaments
and fasciae, or whether it is localized to the contractile unit.
Besides, it is extremely beneficial in formulating the suitable

therapeutic prescription.
Observation
As the patient walks in, critical observation related to his/her

overall problem should be done. This will give the first
impression of his/her posture, ambulation and major
impact of the dysfunction, along with most conspicuous
skeletal deformities.
2. Objective examination
Objective examination is a test of the knowledge and skill of

the physiotherapist. It needs correct methodology and
knowledge of the following:
(a) Surface anatomy of the human body bony landmarks

(Table 3-6)
(b) Anatomical configuration, alignments of bones and

joints
(c) Range and anatomical limitations, the patterns of

restriction of movements and end feel of a joint
(d) Biomechanics of movements
(e) Correct evaluation of the tone, strength, power,

endurance and flexibility of the required muscle groups;
degree of neuromusculoskeletal coordination can also be
assessed
(f) Active as well as passive JROM
(g) Diagnostic procedures and tests and their appropriate

interpretation related to the objective evaluation
(h) Components and neuromusculoskeletal demands of the

(i) The knowledge of pathology, physiology, anatomy,

kinesiology, clinical course and the prognosis of a
disorder is a must
Table 3-6
Key Bony Landmarks
Spinous process Iliac crests

Scapular border Anterior and
posterior
Mastoid process Iliac spines
Clavicle Ischial tuberosities
Acromial process Greater trochanters
Greater tubercle Adductor tubercles
Olecranon Patellar borders
Humeral epicondyles Tibial heads
Radio ulnar styloid Malleoli
process
Lister tuberosities Talar heads
Carpal bones Navicular tubercles
Objective examination includes analysis of the following:

1. Inspection and palpation
2. Evaluation of movements:
(a) Active
(b) Passive
(c) Resistive
3. Neuromuscular tests
1. Inspection and palpation
(a) Examination of the bones and their structural alignment

is done to detect any malalignment, tenderness or
enlargement.
(b) When suspected, measurement of the limb length

disparity is done.
(c) Girth measurement or volumetric measurements are

done at specific locations from the bony prominences to
assess any muscular hypertrophy, atrophy, oedema or
effusion.
(d) Subcutaneous soft tissues are palpated for generalized

or localized oedema or effusion, tenderness, articular
effusion, hypertrophy or atrophy. It is necessary to
examine for the presence of cyst, nodule or ganglion.
(e) Muscle joints, ligaments, tendon sheaths are examined

for tenderness, malalignment, synovial hypertrophy,
sensory impairment, crepitus, etc.
(f) The skin and nails are examined for the presence of
temperature alterations, vascular changes like erythema,
cyanosis, pallor, moisture or dryness, atrophy, scaling,
scars, ulcers and infection. If skin lesion is present, it
should be documented by size, location and the stage of
healing.
(g) Loss of tissue continuity, if present, should be

documented.
(h) Examine resting pulse rate, pulse rhythm and the

cardinal signs of any inflammation.
2. Evaluation of movements (selective tissue tension tests): Active,

passive and resisted movement tests are the specific means of
detecting the nature and extent of pathology.
Active movement tests are as follows:
◼ Accurate assessment of the active ROM as well as the

strength of related muscle groups is objectively recorded
by goniometry and muscle testing (MMT) procedures.
◼ The presence of pain, crepitus or any other symptom is

noted.
◼ The degree of pain is evaluated by using visual analogue

scale; although it is more or less subjective. It is useful to
know the progress in the absence of any objective pain
index test.
◼ The presence of fine crepitus indicates early wearing of the

articular cartilage or a tendinous problem. More coarse
crepitus indicates considerable degeneration of the
cartilage.
◼ Painful arc or sudden weakness in the portion of the arc

will indicate tendinitis (as in supraspinatus tendon).
◼ Gentle overpressure may be applied to assess the effect of

stretch at the terminal range of the movement.
◼ Active movements are also tested to evaluate the strength,

endurance, flexibility, coordination, speed and agility.
◼ Manual muscle testing (MMT) is an important test to

evaluate the muscle strength.
Passive movement test – pattern of restriction:
◼ Passive movement is tested in its full or available range in

all the planes and axes of a joint. The patient should be
relaxed to the maximum and proper stabilization to the
bone adjacent to the joint to be tested must be assured.
◼ When properly done, it can provide an important clue to

the nature and extent of the disorder. Passive ROM, could
be normal or in excess (indicating hypermobility), or
restricted. When restricted at the end of passive ROM,
gentle overpressure is given to assess the end feel.
◼ The restriction of passive (JROM) could be (a) capsular or

(b) noncapsular.
(a) Capsular restriction: It indicates the loss of mobility of

the entire joint capsule. In the capsular pattern of
restriction, only certain movements are restricted. This
provides guidance to detect the capsular pattern of
restriction. The capsular pattern of restriction of the
major joints of upper and lower extremity is illustrated in
Table 3-7.
The capsular restriction may follow acute trauma

inflammation or effusion to the joint. It may be present
following long immobilization, arthritis or degenerative
joint disease.
(b) Noncapsular restriction: There is abrupt restriction of

ROM due to intraarticular mechanical blocking, or extra-
articular lesion. The limitation of movement may be
present in only one direction.
Capsular adhesions or even adherence of an isolated

ligament during healing (following injury) may cause
noncapsular restrictions (e.g., anterior capsular tightness
resulting in loss of external rotation following anterior
dislocation at the shoulder, or limitation of knee flexion
due to the adherence of medial collateral ligament to the
medial femoral condyle following knee sprain).
Mechanical blockage may be due to the torn meniscus or a

loose body which may get displaced into the joint, blocking
joint movement (e.g., locking of the movement of knee
extension with free flexion following bucket handle tear of
medial meniscus).
Extra-articular soft tissue tightness may result in reduction of

the JROM from fibrosis or myositis.
Extra-articular effusion or inflammation accompanying
bursitis may also give rise to noncapsular restriction.
End feel: End feel is a test carried out at the point of

restriction of the passive ROM of a joint. It is done by
applying gentle overpressure at the end of the passive
JROM. The end feel may be normal or pathologic.
Types of end feel
◼ Soft tissue approximation end feel: The end feel is soft and
rubbery as there is approximation of the normal muscular
tissues providing resistance to further JROM. When there
is significant muscular hypertrophy, this end feel is felt
earliest in the JROM; this apparently reduces the normal
ROM. Therefore, it is customary to compare ROM on
contralateral joints.
◼ Capsular end feel: A firm and leathery feeling without any

effusion or inflammation indicates the presence of capsular
fibrosis.
◼ Bony end feel: An abrupt end feel which fails to yield

further ROM, locking the joint totally, is typical of bony
end feel. It may be present following malunited fracture or
in hypertrophic bony changes following degenerative joint
changes.
◼ Pathologic end feel (muscular spasm end feel): Abrupt

resistance with rebound to the passive range may be
encountered in its arc due to reflex contractions in the
muscle. However, further ROM is possible with little extra
pressure. When it is present with a capsular pattern of
restriction, synovial inflammation of part of joint capsule
may be suspected.
◼ Boggy end feel: It is a soft and mushy end feel associated

with joint effusion. It may be accompanied frequently by
the capsular pattern of restriction.
◼ Internal derangement end feel: Loose body in the joint or

displaced meniscus results in a mechanical block to the
passive ROM. This offers marked springy rebound at the
terminal point of ROM. The pattern of restriction is
invariably noncapsular.
◼ Empty end feel: The movement is suddenly stopped, not

due to restriction but because of severe pain. It is noticed in
painful extra-articular lesions (e.g., bursitis, neoplasm).
Pain and mobility: The presence or absence of pain and the

extent of mobility provide useful guidance in detecting the
lesions of the articular capsule and the major ligaments of a
joint.
Pain at the extreme ROM: Pain is elicited as a result of

stretching of the painful structure itself. The lesion may be
either musculotendinous or capsuloligamentous in origin.
However, the movement, when resisted, will be painful in
musculotendinous lesion, whereas it would be pain-free in
a capsulotendinous lesion.
Painful arc: Pain is felt only during a certain small part of the
arc of ROM. This occurs when a painful structure is
temporarily squeezed at a particular part of ROM in extra-
articular lesion. Pain disappears instantaneously as soon as
the movement is progressed further, when more pressure
on the painful structures is relieved.
Passive joint play: Systematically performed passive joint

play movement test produces stress on
capsuloligamentous complex. Positive passive joint play
(eliciting pain) test indicates the presence of lesion of the
major ligaments or the joint capsule.
Mobility of a joint: The passive mobility of a joint may be

affected either way. It may be in excess of the normal ROM
(hypermobility), or less than the normal ROM
(hypomobility).
Hypermobility is present when there is loss of continuity,

e.g., partial or a complete rupture of muscle, tendon or a
joint ligament.
Hypomobility indicates fibrosis. Fibrosis may occur due to

adhesions, low-grade inflammation in the adjacent tissues,
due to excessive collagen formation, localized protective
muscular spasm following acute inflammation or chronic
stress.
Interrelationship between pain and mobility can provide

useful information on the probable cause and the type of
dysfunction (Table 3-8).
Presence of crepitus: Crepitus may be felt on passive ROM of

the joints of cervical spine, shoulder and knee
(patellofemoral). This indicates the presence of
degenerative joint changes.
Resisted movement tests: Interrelationship between pain and

strength of a joint movement can provide guidance to
detect the expected nature of the dysfunction.
The maximum resistance to the movement (isometric) is

tested in the strongest part of the arc of ROM (outer part of
middle range). It provides information about the optimal
strength and efficiency of a particular muscle or muscle
group. The degree of pain can give a clue to the nature of
lesion including the neurological status (Table 3-9).
3. Neuromuscular tests: The detection of the site, nature and extent of

neuromuscular deficit is done by using appropriate manual and
neurophysiological tests. This includes the following:
(a) Test for strength, endurance, tone and flexibility of

muscle groups and its objective documentation
(b) Test for the sensory status and its documentation on the
body chart
(c) Diagnostic electrophysiological testing like EMG and

nerve conduction tests to evaluate the neuromuscular
status – EMG provides an excellent means of early
detection of degenerative lower motor neuron lesion and
also the first sign of reinnervation of a muscle
(d) Tests for the deep tendon reflexes
(e) Test for neuromuscular coordination, including fine and

speedy coordination, is done for the upper extremity
particularly in relation to hand function; in the lower
extremity, the testing can be done by slow walking, fast
walking and spot running
(f) Character of pain – Initially the pain is shooting, sharp,

burning and dermatomic in nature; this pain may change
to a dull aching sclerotomic type when the large fibres
cease to conduct and the small unmyelinated C fibres are
stimulated; this indicates an increase in pressure
(g) Testing balance; equilibrium – standing and balancing

on an alternate leg
3. Functional examination
This is done to assess the functional status of the patient. The

functional efficiency is tested by recording the dexterity,
speed and the overall functional capacity of the affected
limb and the patient as a whole. The movement
combination involved in the performance of the daily
activities is critically analysed and recorded. Synchronized
coordination and strength of all the four major components
(shoulder, elbow, wrist and hand) and fine speedy
coordination of hand along with the degree of trunk
stabilization needs is assessed for the upper extremity.
Gait, balance and various parameters of ambulation and
the efficiency of adopting floor squatting and cross-leg
sittings are evaluated in the lower extremities in relation to
the patient’s work requirements and daily routine. It will
facilitate appropriate planning of therapeutic measures.
4. Psychological and vocational assessment
During the course of subjective and objective examination, it

is extremely important to understand the general
psychological getup of a patient. Information on the
patient’s state of mind, impact of disorder, understanding
capacity and the will to get well are important. Similarly,
vocational status and physical requirements of the job are
necessary for the planning of the therapeutic programme.
For the physiotherapy to be successful, it needs proper
coordination of the body and the mind. It is a self-effort-
oriented therapy basically involving physical exercise and
the patient’s voluntary efforts. Therefore, unless the patient
is motivated enough, no physiotherapeutic procedure can
be successful.
Table 3-7
Capsular Pattern of Restriction of Major Joints
Moderate
Joint Maximum Restriction Mild/No Restriction
Restriction
Neck Extension Rotation, Lat Flexion
flexion
Shoulder External rotation Abduction Flexion and internal
rotation
Elbow Flexion Flexion Extension
Forearm (distal radio ulnar – – Supination and pronation
joint)
Wrist Flexion and (equal limitation of ROM)
extension
Thumb (trapeziometacarpal – Abduction Flexion
joint)
Metacarpophalangeal – Flexion Extension
Interphalangeal – Extension Flexion
Hip Internal rotation, Flexion-extension External rotation
abduction
Knee Flexion – Extension
Ankle – Plantar flexion Dorsiflexion
Subtalar joint Inversion (varus) – Eversion (valgus)
Digits
MCP (great toe) – Extension Flexion
MCP (toes II to V) – – Flexion
IP joints – – Extension
Table 3-8
Pain Mobility and Possible Lesion
Pain and Mobility Possible Lesion

Pain-free, normal NAD
mobility
Normal mobility with Minor sprain
pain
Painless hypomobility Contracture or adhesion of the involved structure being tested
Painful hypomobility Painful guarding, it may be due to acute inflammation, sprain, tear or
rupture
Painless hypermobility Complete rupture of the structure with severance of pain conducting fibres
Painful hypermobility Partial tear which exerts stress on some intact fibres
Table 3-9
Resisted Movement Test and the Possible Lesion
Pain and Strength of Resisted Possible Lesion

Movement
Strong and pain-free No musculotendinous lesion orneurologic deficit
Strong but painful Minor lesion of musculotendinousorigin
Weak and pain-free (a) Complete rupture of the tested muscle
(b) Some interruption of nerve supply to the muscle
tested
Weak and painful (a) Partial rupture of the muscle or tendon
(b) Painful inhibition due to fracture or acute
inflammation
(c) Serious pathology like neoplasia may also be
suspected
Diagnosis
Identification of the involved tissues can be determined by methodical
analysis and interpretation of the subjective, objective as well as
functional examination data. However, adequate knowledge of
anatomy, kinesiology, biomechanics, physiology and pathology is
necessary. At the same time, knowledge of aetiology, symptoms,
clinical course and limitation of the disorder is absolutely essential to
arrive at the possible diagnosis (Table 3-10). Records of clinical
investigations and physical examination should provide further
guidance to arrive at the final diagnosis.
Table 3-10
Characteristic Features of Clinical Examination and Probable Diagnosis
Characteristic Features Probable Diagnosis

Structural deformity, joint play with passive movement at the Fracture, dislocation
1. site; acute inflammation and pain
2. Boggy end feel with limitation of movement in capsular pattern Synovitis
End feel is empty and painful; local tenderness with limitation of Bursitis
3. joint movement in capsular pattern
Painful but normal amplitude joint range with localized Mild ligamentous sprain
4. tenderness and mild effusion
Joint play with pain and hypermobility Severe ligamentous sprain
5.
Passive stretch or compression results in the joint giving way Complete ligamentous rupture
6. with hypermobility; pain may or may not be present
Pain and early fatigue with strong resisted test to the involved Minor lesion of tendon (tendinitis)
7. musculotendinous structures
Marked weakness; pain may or may not be present Complete rupture of a tendon (e.g.,
8. tendoachilles rupture)
Local tenderness, full passive stretching and resisted test to the Muscular strain
9. muscle are positive with localized tenderness
10. Resisted test of strength is positive but pain-free; a gap in the Complete rupture of a muscle
continuity of a muscle may be visible with loss of function
11. Articular cartilage: Presence of crepitus, broken cartilage present • Degenerative articular
as a loose body, locking of the joint changes
• Late stage of degenerative
joint disease
• Tear of medial meniscus or
entrapment of loose body in the
joint
12. lntra-articular fibrocartilage: Clicking of the joint Minor displacement of
fibrocartilage (e.g., bucket handle
tear)
General plan of physical examination and evaluation

The patient should be examined with minimum inconvenience. The
examination should be organized in such a manner that all the
possible tests in a particular body posture are done at the same time.
From the data of the basic subjective and objective examination, the
physiotherapist should be able to identify the major areas of
emphasis. The general plan of examination is detailed to provide the
necessary guidance.
A general plan of physical examination in various fundamental
body positions is as follows:
A. Standing
1. General observation: The posture is observed from the

front, behind and the side for any conspicuous structural
deviation from the normal:
(a) Shoulder levels
(b) Spine
(c) Pelvic level
(d) Alignment of hip, knee and ankle joints
2. Observation of the gait pattern: The gait should be

observed from the front, back and sides for any
deviations in the average speed, cadence and the pattern.
3. Observation of the ROM: Wherever possible, overall range

of active movements can be judged in some of the major
joints by observation.
4. Muscle power: Generalized evaluation of the strength of

important muscle groups can be assessed by observing
simple movements.
5. Functional test: Functional test checks the ability to adopt

floor squatting and cross-leg sitting. Double-leg
balancing, single-leg balancing, spot marching or double
ups and hopping should be tested to assess the efficiency
or the level of neuromusculoskeletal control and
coordination.
Gait analysis is discussed in a separate chapter.
B. In sitting position
1. Evaluation of ROM: The neck, upper extremity, back and

the lower extremity joints to be tested for ROM and
strength
2. Dural mobility: Knee extension, ankle dorsiflexion, with

neck flexion (slump test)
3. Reflexes: Knee jerk and ankle jerk
4. Evaluation of strength: The degree of resistance can be

tested for movements of the neck, upper extremities,
trunk, hip flexors, knee extensors (L3, L4 myotomes),
resisted ankle dorsiflexion (L4 myotome), resisted
dorsiflexion eversion (L4, L5 myotomes) and resisted
great toe extension (L5 myotome)
C. Supine lying
1. ROM: Evaluation of passive ROM for all the joints except

hip and spinal extension
2. Dural mobility: SLR, with neck flexion
3. Muscle strength: Neck flexors, shoulder flexors, external

and internal rotators, elbow flexors, abdominals
4. Reflexes: Biceps, triceps, pronator–supinator and
abdominal
5. Testing the sensory status over the anterior aspect of the

body and limbs
6. Extensibility of the hip flexors, abductors, adductors,

hamstrings and the gastrosoleus
D. Side lying
1. Muscular strength of hip abductors on the same side and

adductors of the opposite hip
2. Extensibility of the iliotibial band
E. Prone lying
1. ROM of spinal extension, shoulder and elbow extension,

hip extension and knee flexion
2. Strength of spinal extensors, hip extensors, hamstrings

(S1, S2 myotomes) and soleus
3. Sensory status over the posterior aspects of the body

On the basis of the findings of examination and their critical
evaluation, the therapeutic programme is planned to provide optimal
functional efficiency to a patient.
The major parameters of evaluation and treatment planning are
elaborated under each heading.
The general plan of treatment goals and strategies to be adopted for
musculoskeletal disorders is summarized in Table 3-11.
Table 3-11
Treatment Goals and Strategies for Musculoskeletal Disorders
Goals Strategies
Resolve Acute symptoms; promote Correct positioning, appropriate modality, immobilization,
correct alignment and healing controlled movements, drugs and surgical procedure
Prevent Soft tissue, joint contractures • Early guided movements
and recurrence • Education on conditioning exercise, guidance on body
mechanics and dos and don’ts
Restore • Muscle functions • Objective progressive exercise procedures to improve
• Joint alignment and strength, endurance and flexibility of muscles
mobility • Surgical procedures, corrective exercise, orthotic or
• Muscular balances and ambulatory aids
movement control • Specialized exercise techniques, education of patients on
• Maximal functional correct and controlled exercise training
independence • Maximal physical independence through progressive
exercise, ambulatory and other aids
Test to assess functional self-sufficiency: After arranging a general

plan of physical examination in each fundamental position, a patient
is guided and directed to perform each functional activity
independently, e.g., assuming steady standing posture with both the
legs placed wide, progressing to close-leg standing, momentary
standing and balancing on an alternate leg. The skill and speedy
coordination activities like spot-jogging and running are also tested.
The same pattern of graded exercises should be planned for other
fundamental positions followed by tests. Specially planned exercise
programmes should be arranged and undertaken for other activities.
Systematic musculoskeletal examination at a glance

◼ Demographic data: Age, sex, height, weight
◼ Social history: Family and support system at home and at the place
of work
◼ Occupation
◼ Current
◼ Physical activity level involved in profession or

occupation
◼ History: Onset of the present episode
◼ If the onset is traumatic, mechanism of trauma
◼ If the onset is nontraumatic, past history of onset, course of

the disease and treatment
◻ Final outcome in both traumatic and nontraumatic

incidences
◻ Residual or present physical problems
Examination by
◼ Inspection and palpation
◼ Skin, subcutaneous tissue for temperature, texture,

oedema, continuity, scars and lumps
◼ Muscles, for tone, tenderness, trigger points, swelling and

continuity
◼ Joints, for alignment and bones, tenderness, bursae,

nodules
◼ Detailed examination of musculoskeletal parameters
◼ Tests of provocation
◻ Active ROM
◻ Passive ROM
◻ Resistive ROM
◼ Special tests for the joints and muscle performance
◼ Neurological tests
◼ Key muscles
◼ Motor ability
◼ Sensory perception
◼ Nerve mobility, conductivity and control
◼ Functional performance test
◼ Functional efficiency of affected part and whole body
◼ Gait – stability, pattern, other ambulatory activities
◼ Body mechanics and related activities
◼ Upper limb functional performance
◼ Coordination, movement control, agility and skill
◼ Additional tests and investigation reports to ensure adequacy of

exercise tolerance
Physiotherapist’s skill in educating and

guiding self-efforts and dependency
Soft tissue injuries in fractures
Fractures, whether closed or open, are associated with an injury to the
soft tissues close to its site. The classification of soft tissue injuries in
closed and open fractures is depicted in Table 3-12 as an important
guideline to eliminate complications as a result of soft tissue injuries
like:
◼ Risk of infection
◼ Delay in healing
◼ Compartment syndromes
◼ Contractures
◼ Nonunion
◼ Amputations
Table 3-12
Classification of Soft Tissue Injuries in Closed and Open Fractures
Tschernés Classification of Closed Fracture ST Gastilo–Anderson Classification of Open Fractures

Injuries ST Injuries
Grade I Type I
• No soft tissue damage • Wound of <1 cm
• Indirect forces resulting in torsion fractures • Minimal soft tissue damage, e.g., simple
Grade II transverse or short oblique fractures with
• Fracture fragment pressure from within may comminution
cause only superficial contusion or abrasion Type II
• Fracture may be of mild to moderate severity • Wound of >1 cm
Grade III • Extensive soft tissue damage
• A direct hit results in deep, contaminated Type III
abrasion with localized muscular or skin • Extensive soft tissue damage and soft tissue
contusion • Unstable fractures with comminution
• May have comminuted or segmental injury • Associated with neurovascular injuries besides
Grade IV skin and muscles
• Extensive contusion of the skin with muscle Type III A
• Associated with severe skin or muscle • Highly comminuted or segmental fractures due
damage to high energy trauma; do not require free flaps
Compartment syndrome is a common Type III B
complication • Extensive soft tissue injury with periosteal
• Crush injury may occur in muscles by direct stripping exposing the concerned bone
injury or may have contusion • Need debridement and irrigation; exposed
bone requires local or free flap
Type III C
• Arterial injury needing urgent repair
• Have high rate of amputation (25–90%)
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Chapter 4
Fractures (general)
Outline
◼ Types of fractures
◼ Diagnosis of fractures
◼ Healing of fractures
◼ Treatment of fractures
◼ Complications of fractures
A fracture is defined as a break in the continuity of a bone. It

is usually due to direct or indirect trauma. A fracture can be
simple or compound, as described in the following sections.
When it occurs in a diseased bone following a trivial trauma,
it is termed as pathological fracture, e.g., fracture through a
bone cyst or a metastatic lesion.
Types of fractures
A fracture can be of two types:
1. Simple or closed
2. Compound or open
Simple or closed fracture

In this type, the fracture does not communicate with the
exterior as there is no wound directly over the fracture.
Compound or open fracture
In this type, the fracture communicates with the exterior

through a wound over the fracture. The management of
compound fracture may pose problems of skin and soft
tissue loss and subsequent infection, etc.
The following terms are used to describe a fracture (Fig. 4-1):
1. Transverse fracture: The fracture line is transversely placed.

It results from a direct injury to the bone.
2. Oblique fracture: The fracture line is obliquely placed. An

indirect injury causes this type of fracture, which is usually
unstable and may need internal fixation.
3. Spiral fracture: It results from a twisting (rotational) force to

the bone. The fracture line is spirally placed. Union in a
minimally displaced or undisplaced fracture is faster since
there is a large surface area of the fractured bone.
4. Impacted fracture: The fractured bone ends are driven into

each other maintaining close approximation.
5. Comminuted fracture: The fractured bone is broken into

more than two pieces. It occurs due to a direct injury.
6. Segmental fracture (double fracture): A bone is fractured at

two different levels with a large segment of bone between
the two fracture lines. The middle segment of bone may lose
its blood supply resulting in nonunion at one of the fracture
sites.
7. Incomplete fracture: Only one cortex of a bone is fractured

without any change in the alignment of the bone.
8. Greenstick fracture: It is a variety of incomplete fracture

seen in children. In this type, one or both cortices of a bone
are broken, but since a periosteal hinge remains intact, the
bone may be bent but there is no discontinuity.
9. Compression fracture: It is produced as a result of

compressive forces on the bone. The bony mass gets
compressed within itself. It is common in cancellous bones
(e.g., vertebral body).
10. Avulsion fracture: Sudden contraction of a muscle, when it

is not fully prepared to take it, may result in fracture, e.g.,
fracture patella due to sudden contraction of quadriceps
femoris or contraction of the triceps resulting in fracture of
the olecranon.
FIG. 4-1The common patterns of fracture: (A) T:

Transverse, (B) O: Oblique fracture of radius and ulna,
(C) S: Spiral, (D) IM: Impacted, (E) CM: Comminuted,
(F) I: Incomplete, (G) G: Greenstick with broken cortex
on one side, (H) CO: Compression vertebral fracture,
(I) D: Double or segmental fracture of tibia, (J) AV:
Avulsion fracture of patella.
Displacements
After a fracture, the bone ends may get displaced from its
original position either due to a sudden pull of the attached
muscle or due to gravity. The displacements are as follows
(Fig. 4-2):
(a) Lateral, where the fragments of the fractured bone are

displaced laterally
(b) Angular, where fragments of the bone may form an angle

with each other
(c) Overriding, where the fractured ends overlap each other
(d) Rotational, where the fragments of the bone may be

rotated in relation to each other
FIG. 4-2(A) Common displacements in a fracture: L:

Lateral, A: Angular, O: Overlapping, R: Rotational. (B)
Radiograph showing overriding, lateral displacement
and angulation in a fracture shaft of femur.
Diagnosis of fractures
The diagnosis can be arrived at from the following:
1. History of sudden trauma (except in pathological fractures),

localized pain and bony tenderness are the definite features
of a fracture.
2. Symptoms
(a) Pain is the most consistent symptom present in every

fracture.
(b) Localized swelling occurs due to (i) haemorrhage from the

fracture ends and injury to the surrounding soft tissues and
(ii) inflammation within an hour of injury.
(c) Deformity: A deformity occurs in a displaced fracture or in

a dislocation. Sometimes, the deformity is masked in the
presence of profuse oedema.
(d) Loss of movement: In dislocation, no movement is possible

at that joint. The function is also impaired in the joint or the
extremity, itself.
(e) Inability to use or bear weight: In fractures or dislocations of

the upper extremity, the patient is not able to use the
extremity, whereas in the injuries of the lower extremity, the
patient is not able to bear weight on the affected extremity.
3. Signs
(a) Muscle spasm and tenderness: Reflex muscular spasm

appears in the muscle groups close to the site of fracture.
(b) Oedema: The soft tissue injury accompanying fracture
often results in haematoma, and oedema over the fracture
site. The process of repair begins with inflammation.
(c) Warmth: There may be a rise in the local temperature due

to increased vascularity to the area of injury.
(d) Crepitus: Passive movements over the fracture site

produce grating between the broken ends which is called
crepitus. It is, however, painful and therefore should be
avoided.
(e) Deformity: Deformity is obvious in a displaced fracture.

However, it may be missed in the presence of profuse
oedema.
(f) Abnormal mobility: The diagnosis of a fracture is obvious

when abnormal mobility is seen in the limb at the fracture
site or swelling is present over the fracture site.
(g) Ecchymosis: This is commonly seen in the skin due to soft-

tissue injuries around the site of the fracture. A common
example is fractures of the proximal humerus, where
ecchymosis is seen in the arm, axilla and even the chest wall.
4. Investigations
(a) Radiography: It is an important tool in the diagnosis of a

fracture. Plain AP (anteroposterior) and lateral view
radiographs are routinely done in every case. Sometimes,
oblique views or special views are required in the diagnosis
of difficult fractures.
(b) Computerized tomography (CT) scan: CT scan is not
routinely required in the diagnosis of a fracture. However, it
is useful in the diagnosis of fractures of small bones (such as
carpal bones) (Fig. 4-3A) and spine (Fig. 4-3B). 3-D (three
dimensional) reconstruction of CT images helps in better
evaluation of fractures (Fig. 4-4). CT scan also helps in
deciding the treatment of a fracture since it gives minute
details of the fracture fragments.
(c) Magnetic resonance imaging (MRI) scan: MRI scan gives a

better delineation of the soft tissue, ligaments and bones. It is
useful in showing changes in the soft tissue such as oedema,
effusion and haematoma after trauma (Fig. 4-5). MRI of the
spine shows status of the spinal cord and the surrounding
soft tissue (Fig. 4-6).
(d) Radioisotope scan or bone scan. This is useful in the

diagnosis and differentiation of various traumatic and
nontraumatic conditions (Fig. 4-7).
FIG. 4-3(A) CT scan showing disruption in the

alignment of lunate and capitate resulting in perilunate
dislocation. (B) CT scan of the cervical spine showing
subluxation of C5 over C6 vertebrae.
FIG. 4-4(A) CT scan showing posterior dislocation of

the right hip joint. Note the fracture of the posterior lip
of acetabulum. (B) CT scan with 3-D reconstruction
shows posterior dislocation of the femoral head.
FIG. 4-5The various images of the MRI of knee joint

showing gross effusion (seen as white).
FIG. 4-6MRI scan of a patient showing fracture

dislocation of D8-9 vertebrae with compression of the
spinal cord.
FIG. 4-7Bone scan showing increased uptake in the left

wrist following trauma.
Caution
Epiphyseal lines in children and the adolescents, vascular

markings, accessory bones may mimic the presence of a
fracture or subluxation in a radiograph.
Healing of fractures
The healing of fractured bone occurs in three phases (Fig. 4-
8):
1. Inflammatory phase
2. Cellular proliferation phase
3. Remodelling phase
FIG. 4-8Stages of healing of the fracture.
Inflammatory phase
Haematoma (a clot) is formed between and around the

broken bone ends. It follows vasodilation, release of protein
and blood cells in this area. Histocytes, mast cells and
polymorphonuclear leucocytes invade the toxic bacteria and
clear the debris. New granulation tissue is formed due to cell
proliferation between the bone ends.
Cellular proliferation phase
The granulation tissue thus formed between the bone ends

bridges the gap between the fractured bone ends. The bone
ends become rarified and calcium is laid down in the
granulation tissue as callus. Similar activity goes on in the
medullary cavity also. The external and the medullary callus
may meet and unite the fracture. At this stage, the fracture is
said to be united clinically, but it is not strong enough to be
exposed to stress.
Remodelling phase
This is the phase of remodelling of the callus towards normal

ossification. The soft callus gets consolidated by the
deposition of bone salts. This is carried out by osteoblasts.
The multinucleate osteoclasts then come into action and
properly control the density of the new bone. The medullary
cavity is reproduced and the marrow cells reappear. The
process of remodelling ends by reconstruction of new bone
similar to the one before injury.
The bone tissue always heals by forming new bone which

has all the characteristics of a normal bone. Healing never
occurs by scar formation like other body tissues.
Union of fractures
The union of a fracture depends upon various factors; the

important ones are as follows:
1. Type of bone and its thickness
2. Type of fracture
3. Extent of blood supply to the site of fracture
4. Position of the bony ends at the site of fracture
5. Age of the patient
1. Type of bone
The cancellous bone has a wider surface area and abundant

blood supply. Therefore, healing is quick. In the cortical bone
(shaft of a long bone), the blood supply may be precarious in
some areas; here the healing process may be slow.
2. Type of fracture
Spiral or oblique fractures unite faster compared to

transverse fractures (Table 4-1). Transverse fractures take
nearly twice the time for union compared to spiral or oblique
fractures. Upper extremity fractures heal faster than the
fractures in the lower extremity.
3. Extent of blood supply to the site of fracture
As the whole process of healing is the result of various

events primarily occurring due to blood, healing directly
depends upon the extent of blood supply to the site of
fracture and the bone.
4. Position of the bony ends at the site of fracture
For the union to be optimal and faster, proper alignment of

the fractured bone ends is vital. Improper alignment results
in delayed union, malunion, nonunion and their
complications.
Age also plays an important role in the union of fractures.

Fractures unite faster in children than in adults and may take
longer in elderly patients. In children, there is a great
potential to correct fracture displacement and even
angulation to a certain extent by remodelling. Rotational
malalignment, however, does not get corrected. In adults, on
the other hand, it is essential to obtain a good reduction of
fracture, as major displacements may not get corrected by
remodelling.
Table 4-1
Approximate Time of Consolidation in Spiral and Transverse

Fractures in the Upper and Lower Limbs
Type of Upper Lower
Fracture Limb Limb
Spiral 6 weeks 12 weeks
Transverse 12 weeks 24 weeks
Source: Perkins (1980).
Treatment of fractures
Newer techniques of treatment are added every now and
then. However, the basic principles are as follows:
1. To achieve anatomical alignment of the fractured bone

ends (reduction)
2. To ensure correct immobilization (maintenance of

reduction), till the fracture unites
3. To reduce inflammation and pain
4. To provide necessary compressive forces to the embryonic

callus and, at the same time, discourage stretching situations
to this raw callus
5. To restore maximum possible functional independence to

the patient as a whole and the fractured limb in particular
Fundamental stages of the management of fracture are (i)

reduction, (ii) immobilization, and (iii) mobilization and
rehabilitation (Table 4-2).
Table 4-2
Fundamental Stages of the Treatment of Fractures

Stage Purpose Methodology
Stage I • To secure closest • Manipulative

Reduction of apposition of fractured reduction under
the fractured bony ends in the perfect general or local
bones anatomical alignment – anaesthesia
at the earliest (at least
within 48 h) • Open reduction
and internal
fixation (ORIF) in
displaced or
unstable fractures
Stage II • Ensures union of the • POP cast

fracture in perfect
Immobilization anatomical alignment • Skin or skeletal
of a reduced traction
fracture • Reduces pain
• Open reduction
• Allows functional and internal
freedom to the fractured fixation (ORIF)
limb
• External fixation
by applying
external fixator
Stage III • To restore maximum • Restoring normal

possible functional self- ROM to the joint
Mobilization sufficiency to the patient affected following
of the by various immobilization
fractured joint physiotherapeutic
and the limb measures • Achieve minimal
possible required
functional ROM
when a fracture
involves a joint
• Restore to the
maximum all the
functions of the
muscles affected
by fracture and
immobilization
• Training to use
assistive aids for
functional self-
sufficiency
• Use of
specialized
exercise techniques
Reduction
The aim of reduction is to achieve perfect anatomical

alignment and length of bone. Reduction of a fracture could
be (i) closed, where the alignment of fractured bony ends is
achieved by manipulation, and (ii) open, where alignment is
achieved by surgery.
Immobilization
Maintaining or holding the fracture reduction is important

and can be achieved by immobilization. The methods of
immobilization are as follows:
1. Traction
2. Plaster of Paris cast
3. Functional cast bracing
4. Internal fixation
5. External fixation
Traction
It exerts an axial pull while the countertraction localizes the

effect of traction. The external traction force is provided by
gravity, part of the body weight and pulley system. The
internal force is generated by voluntary isometric muscle
contractions or muscular spasm. Countertraction is provided
by gravity or splint (Thomas splint – Fig. 4-9).
FIG. 4-9Thomas splint.

Types of traction
Skin traction: Provides generalized pull to the whole limb

(Fig. 4-10A). An adhesive bandage or foam is applied on the
medial; a lateral aspects of the limb, and held in position by a
tight bandage; a weight is suspended at the distal end
through a spreader and rope. It is a noninvasive procedure
and can be used where light traction is required, since it can
take only up to 5 kg of weight.
FIG. 4-10(A) Skin traction with spreader and weight.

(B) Skeletal traction with Thomas splint.
Skin traction cannot be used in very elderly patients where

the skin is papery thin and may be peeled off easily, and also
in patients allergic to the adhesive bandage.
Skeletal traction: This traction exerts effective pull on the bone

(Fig. 4-10B). A Steinmann pin or a Kirschner wire (also called
K-wire) is passed through the bone (commonly through the
upper tibia and lower tibia). A stirrup is applied over the
pin/wire and the weight is suspended through a rope and
pulley. Skeletal traction is used for giving heavy traction (up
to 10–15 kg). It can be used in elderly patients. It is however
an invasive procedure and can have the problems of pin
traction infection, cut through the bone, or fracture. The
common sites of skeletal traction are as follows:
◼ Upper and lower tibia

◼ Lower femur
◼ Calcaneum
◼ Skull traction in cervical spine injuries (Fig. 4-11): The pins

of the Crutchfield tongs are passed into the outer table of the
skull in the parietal bone as shown in the figure. Weight is
then suspended through a rope and pulley.
FIG. 4-11Skull traction by Crutchfield tongs.
Gallows traction: For the treatment of fracture shaft of femur

shaft in children below 2 years of age, bilateral above or
below knee skin traction is applied and the limbs are
suspended vertically upwards. The buttocks of the child are
kept off the bed so that the body weight acts as
countertraction (Fig. 4-12). It also helps in toileting, etc.
FIG. 4-12Gallows traction.
Perkins traction: It allows early mobilization of the knee (Fig.

4-13) while the limb is in traction. Note that the buttock is off
the bed.
FIG. 4-13Perkins traction.
Halopelvic traction: It is used for the correction of spinal

deformity. In this method, pins are passed into the outer
table of the skull bones and also into the pelvic bone. These
pins are attached to an outer metal ring around the skull and
the pelvis. Distraction is then given by attaching threaded
rods to these rings, as shown in Figure 4-14.
FIG. 4-14Halopelvic traction.
Plaster of paris cast
Plaster of Paris cast is a standard method of immobilization

of fractures. The plaster cast incorporates one joint above and
one below the fractured long bone. However, stiffness of
joints and slow dissipation of oedema in the limb are the
main disadvantages of this method, particularly in case of
prolonged immobilization.
Functional cast bracing
The functional cast bracing allows movement of the joint

thereby facilitating correct collagen remodelling of the
tissues during healing along with required immobilization.
This is applied after an initial period of traction or plaster for
2–3 weeks (Fig. 4-15).
FIG. 4-15(A) Functional cast brace, applied in the

treatment of fracture shaft of femur. POP cast is
applied over the thigh and upper third of leg with a
hinge joint at the knee. (B) Functional brace:
Immobilization – the brace confines the soft tissues in a
tight compartment developing hydraulic pressure
within the braced compartment. Healing – axial
compression due to weight bearing promotes healing.
Functional freedom – provides the joy of early
ambulation.
Internal fixation
Internal fixation is done by various types of implants such as

screws, plates and nails (Fig. 4-16). Internal fixation is
indicated in the following:
FIG. 4-16Internal fixation devices: (A) Plate and screw:

pre- and postoperative X-rays of fracture shaft of
humerus treated by plating. (B) Interlocking nail. (C)
Intramedullary nail. (D and E) Trochanteric fracture,
treated by dynamic hip screw fixation, dynamic hip
screw. (F) Malleolar screw; plate and screw. (G)
Compression screw with washer. (H) Transverse
fracture of patella treated by tension band wiring.
Fresh fractures
◼ Grossly displaced fractures where closed reduction has
failed
◼ Fractures where the fragments are pulled apart by

muscular action, e.g., fracture of patella and olecranon
◼ Fractures where prolonged immobilization (in the form of

traction or plaster cast) is contraindicated, e.g., fractures in
elderly patients
◼ Multiple fractures
◼ Fractures associated with vascular injury
◼ Pathological fractures
Internal fixation is performed along with cancellous bone

grafting in case of delayed union or nonunion.
External fixation
External fixation is an excellent method of treating an open

or compound fracture with severe soft tissue damage. It
stabilizes the fractured bone; it allows easy wound care, and
permits surgical procedures like skin grafts and bone
grafting. The external fixator can be a tubular fixator where
Schanz pins are passed into the bone and connected to a
tubular rod (Fig. 4-17), or a ring fixator where wires are
passed into the bone under tension and connected to a half
or full circle ring (Fig. 4-18). However, the external fixator
occasionally poses the problems of pin tract infection and
loosening of pins.
FIG. 4-17Uniplanar biaxial fixator (A) Radiograph. (B)

Clinical photograph.
FIG. 4-18Ring fixator (also called Ilizarov fixator)

applied in the treatment of fracture of both bones of
leg. (A) Clinical photograph. (B) As seen on
radiograph.
Mobilization and rehabilitation

It is the final stage of fracture treatment. The objective is to
restore near-normal mobility to the fractured limb and make
the patient physically independent. It is in fact the total
responsibility of the physiotherapist.
Role and functions of physiotherapy
Role and Responsibility: The role of physiotherapy in

fracture management is so valuable that none can boast of a
100% recovery without the attention and care by a
physiotherapist.
Irrespective of the method of management of a fracture,

whether conservative or surgical, the physiotherapist should
take all the possible measures to achieve quick and complete
or at least optimally functional recovery.
The quantum of recovery, besides physiotherapist’s

knowledge, largely depends upon his or her skill to educate,
guide and supervise patient’s performance. Responsibility of
total treatment should be of the nature of self-management,
fully guiding a patient on every aspect of the
poststabilization period.
Objective of physiotherapy
The objective is to restore to the maximum the function and

the efficiency of the injured musculoskeletal complex along
with other adjacent joints of the affected limb and to
maintain or improve the functional capacity of the
unaffected parts of the body.
Any bone fracture or joint dislocation goes through the
following two main stages:
(1) Immobilization:
(a) Reduction of the fracture either by conservative or

surgical approach
(b) Retention of the reduction
(2) Mobilization: It is required when the joints adjacent to

the fractured bone get stiff and painful because of prolonged
immobilization.
Physiotherapeutic management of fractures
Return of normal to near-normal function following correct

and timely management of a fracture is possible by simple
methods of physiotherapy. But the physiotherapist faces a
challenge in regaining the functional independence in a
patient with complicated multiple fractures, mismanaged
fractures, nonunions and fractures where surgery is
contraindicated.
The role of physiotherapy remains unaltered but the

approach varies with the individual situations.
1. Management of a fracture: It could be surgical or

conservative
2. Site of involvement: The body segment, e.g., upper

extremity, lower extremity, trunk and their sub segments
3. Type of fracture: Simple, compound, comminuted
4. Associated problems: A fracture may be associated with

joint complications, and injuries to the soft tissues like
muscles, tendons, ligaments and nerves.
A physiotherapist has not only to use professional skill but

also has to modify the procedures of physiotherapy to suit
each stage of healing of the fracture (Table 4-3). To achieve
early success one has to consider the patient’s physical
status, age, level of cooperation, ability to understand and
above all the occupational demands. The ability to motivate
the patient to actively perform the movements is vital. All
these procedures demand an individualized approach to the
problem.
Table 4-3
Scheme of Progressive Exercise during Various Stages of the

Healing of Fracture
Stage of
Mode Purpose
Healing
Passive full ROM • To educate the patient Preoperative

and functional on correct groove of the
ROM (PROM) or movement
normal limb
(1) Isometrics a • Localized • Following

voluntary inbuilt strengthening of a reduction of a
of muscular muscle group fracture and
contractions • To improve the immobilization
stability of the joint (as soon as the
pain allows)
• To promote fracture
healing through
localized increase in the
circulation
(2) Isotonic • Relaxed free active • Immediately

(dynamic) exercises (to improve after the
ROM) removal of
immobilization
• Active resistive
exercise • As soon as
the pain is
• To strengthen the reduced
muscle group and its
endurance • As early as
possible with
• Small intensity emphasis on
sustained passive stretch self-resistance
to further improve the and several
ROM repetitions
(3) Isokinetic • Strengthen muscle • As soon as

action through the the joint is
Full ROM active maximum arc of the fairly mobile
joint movements ROM
performed • Excellent
maximum at a • Improves joint control mode to
constant speed and movement improve
with automatic coordination muscular
strength variation strength
full ROM
(4) High- • A multijoint resistive • Late stage of

performance exercise with fixed distal healing when
exercises segment (e.g., floor the fracture
squats) of the exercising union is
(a) Closed kinetic limb. Strengths all confirmed
chain exercise important muscle
(CKC) groups of a whole limb • To prepare
for sports
(b) Open kinetic • Linking together the
chain exercise force and the speed of • Before
(OKC) – Fig. 4-19 the movement joining sports
(explosive reactive during the end
(c) Polymetric movement (e.g., PNF stage of
exercise pattern following quick healing
stretch reflex)
FIG. 4-19Closed and open kinetic exercise (CKCE and

OKCE).
Principal functions of a physiotherapist
1. Identification of the nature of injury: If a fracture is suspected,

refer to the consultant, and if it is only a soft tissue injury
treat by appropriate measures.
2. Physical assessment: This should be done systematically to

assess the nature and extent of the disability. Identify the
possible complications to the joint, muscle, tendon and
nerves. Other complications like adult respiratory distress
syndrome (ARDS), venous thrombosis, soft tissue and bone
infections and pressure sores should be prevented by
appropriate measures.
3. Confirm the diagnosis by interpretations of the findings of

physical examination and investigations, e.g., radiographs.
4. Identification of associated diseases in which

physiotherapy or any of its modalities are contraindicated.
5. Plan the procedures of physiotherapy on an individual

basis.
6. Reviewing patient’s response to the therapy: The therapeutic

programme may be modified, if necessary.
7. At discharge, advise for regular home exercise with

emphasis on the prevention of recurrence and for reporting
for follow-up at regular intervals.
8. Review the patient at home or at work and offer guidance.
Once the fracture is reduced, the physiotherapist has to take

the major responsibility of restoring normal to near-normal
functional self-sufficiency of the fractured limb as well as the
whole body.
Physiotherapy care during immobilization

◼ The major principle of management is to retain the perfect
anatomical alignment of the fractured bony fragments,
achieved by closed reduction or open reduction and internal
fixation (ORIF).
◼ Try to minimize the adverse effects of acute inflammation

and immobilization like pain, oedema and active movements
of the distal joint with the affected limb placed in elevation.
Checking POP cast
■ Ensure that it is neat and tidy.
■ Ensure that it is not digging in the limb at any end.
■ Ensure that it is not extending and blocking the

movements of the distal joints free from POP cast (e.g.,
metacarpophalangeal [MP] joints in the upper limbs and
metatarsophalangeal [MTP] joints in the lower limbs).
■ Check the finger/toe tips for cyanosis, cold feel, lack of

active mobility by using thin long objects likes a metallic or
plastic foot ruler.
◼ Check POP cast – thoroughly to prevent complication due

to improper POP.
◼ Joints and muscle complexes not included in the

immobilization should be vigorously exercised to improve
circulation to the limb.
◼ The muscle groups under immobilization should be

exercised with isometrics within the limit of pain and
discomfort.
◼ Gradually increase the strength and duration of these

isometric contractions.
◼ Rest is only for the affected area and limb and not for the
whole body; direct the patient to carry out activities of daily
living (ADLs) by the nonaffected part of the body.
◼ Begin bedside standing on one leg and non-weight-

bearing (NWB) ambulation on a walker.
◼ Explain the expected schedule of exercise on the

nonaffected side.
◼ Each fracture is susceptible to develop related

complications besides the usual complications of
immobilization. Educate the patient on the symptoms and
alarm of such susceptible situations and report immediately
to the nurse to prevent them from occurring, so that
necessary care can be taken on the spot (e.g., tight POP cast 0
bivalve it examining the fracture site and take necessary
steps, may be replastering).
◼ This will greatly prevent the miseries of organized

complication, after the removal of immobilization.
◼ During the entire phase of immobilization, keep a watch

on the possibility of developing complications due to the
immobilization itself.
◼ Keep a watch on general complications of immobilization,

e.g., plaster cast.
◼ Tight POP cast or a bandage may cause cynosis, ischemia,

compartment syndrome or nerve compression, pressure sore,
etc.
◼ Loose POP cast: Attempts or involuntarily moved

immobilized limb will give rise to sharp intractable pain at
the fracture site and the whole limb, especially during NWB
walking on a walker.
◼ Eventually it leads to nonunion.
◼ Skeletal traction sites of pin piercing the skin should be

examined every day for suspected infection. Skeletal long
pin may even cause injury to the soft tissue or vessels.
◼ During surgery, the peripheral nerve may be injured. This

may be noticed late only after immobilization.
Besides all these, immobilization itself has many adverse side

effects, e.g., weakness of muscles under immobilization,
disuse atrophy and loss of tone and joint stiffness.
Make it a point to take advantage of immobilization to

promote an activity-oriented lifestyle, e.g.,
1. General body exercise, not with breaks but in a continuous

mode.
2. Strengthen functional muscle groups to ease functional

performance of the whole body. Besides, focus on muscle
groups at the next stage of mobilization.
3. Use this opportunity to take advantage of educating and
practising lifestyle exercises – both cardio-protective and
diseases-preventive modes of exercise are must for each
patient requiring longer period of recovery.
The possibility of generalized detoning of all the systems and

the organs of the body due to sedentary attitude can be
controlled by initiating early activities to the different body
parts encouraging functional use.
Physiotherapy during stage III mobilization
Responsibility of the physiotherapist
◼ The physiotherapist provides education, guidance and

supervision to a patient to fulfil all the requirements and
follows the specific methodology of the exercises taught.
◼ The best and sure way to expect excellent outcome is to

perfectly train a patient on the methods of self-performance
rather than depending on a physiotherapist.
◼ Of course, specialized exercise techniques and initial

training for functional independence will be provided and
guided by a physiotherapist.
◼ Intermittent evaluation of progress will be monitored

regularly by the treating physiotherapist.
Objective of physiotherapy
◼ Physiotherapy restores preinjury status to the affected
limb.
◼ The most important aspect is to mobilize the immobilized

joints and all functions (e.g., strength, power, endurance, and
flexibility) of the muscles of immobilization.
Methodology of approach
◼ Examine the health of the skin under the cast, and surgical
scar in operated cases.
◼ Soothing massage for a short period over the skin, before

exposure to superficial heat like that of infrared ray, radiant
bath, etc., will prepare the limb for mobilization.
◼ Always begin with small-range, free and relaxed rhythmic

pendulum movements to ensure better relaxation and
educating the exact groove of the range of motion (ROM).
◼ Gradually introduce progressive modes of exercise like

self-assisted, self-resisted ones performed several times by
the patient.
◼ Techniques like proprioceptive neuromuscular facilitation

(PNF) and progressive resistive modes are introduced
gradually to meet the goal of optimal muscle functions, full
or at least a functional range of joint movement of the injured
joint or a bone close to the site of a fracture.
Functional use – Physiotherapy is first initiated as an assisted

hand and progressed later to an independent one. Similarly,
stable and free ambulation is also initiated.
In patients who have suffered irreversible neural, muscular

or skeletal damages, alternative methods should be planned
and taught to perform functional activities like:
1. Hypertrophy of the intact muscle groups to substitute for

the paralysed muscle groups
2. Controlled release or relaxation of the agonistic group to

perform antagonistic action (graduated release of the
contracted biceps to achieve controlled elbow extension in
the paralysis of triceps)
3. Educating a patient on the tricky movements by modifying

the movement pattern, strengthening the substituting
muscles and by use of gravity, postural modifications and/or
assistive aids
Examples
1. Hypertrophy of latissimus dorsi, triceps, wrist extensors

and finger flexors to facilitate crutch walking, hypertrophy of
the long head of biceps to abduct arm in the absence of
deltoid by fixing shoulder in external rotation
2. Jerky shoulder girdle elevation with trunk deviation to the

opposite side for momentary shoulder abduction
3. Jerky pelvic elevation with trunk deviation to the opposite

side to step forward when the limb is flailed or the knee joint
as a fixed extension deformity
4. Suggesting modification in the usual aids and appliances
to assist function
5. A brief review of specialized assistive techniques in

physiotherapy to facilitate early recovery during the
postimmobilization period
Specialized assistive therapeutic techniques in physiotherapy
1. Massage: All the five manipulations, e.g., effleurage,

stroking, kneading, rolling–wringing and Frictions, have a
selective influence on various tissues of the body. Above all,
the feeling of betterment and relaxation which follows it has
no parallel. As such, one must try to incorporate a brief
session of massage.
2. PNF: Proprioceptive neuromuscular facilitation is a

specialized exercise technique based on the most beneficial
therapeutic principles to promote recovery following any
neuromuscular disorder.
Moreover, its basic principles may be used individually to

emphasize certain aspects of the therapy (e.g., resistance,
approximation, pattern of movement).
3. Manipulation and mobilization: To restore the anatomical

alignment of displaced skeletal units (e.g., facet joints), to
relieve pain and above all to mobilize stiff and painful joints.
4. Manual therapy: This has revolutionized the treatment

procedures of tissue repair, systematic collagen remodelling,
the dynamics of tissue fluid, resolution of tissue damages,
and permanent gain in the length of the contracted or
shortened musculotendinous tissues.
5. McKenzie’s technique: A technique emphasizing correct

body positioning and self-performed spinal manipulation
has simplified the resolution of most popular common low
back pain.
Such new, specialized approaches and techniques are being

developed, but each one demands specialized training to
understand its nuances.
However, nothing can beat proper guidance even in a few

specific exercises, performed willingly in several short bouts.
A brief review of the assistive physiotherapeutic modalities

in orthopaedics is depicted in Table 4-4.
Table 4-4
Brief Review of the Assistive Physiotherapy Modalities in

Orthopaedics
Technique and Therapeutic
Modality
Contraindications Benefits
Cryotherapy • Crush ice (28–32°F or • Ideal to

(cold) 0–20°C) is formed into subside the
packs and applied ravages of
directly over the site of inflammation,
injury or pain for 15 to 20 ideal in closed
minutes transcranial wounds
direct-current
• Ideal for
stimulation (TDS) thermal burns,
to reduce
• Cold water immersion localized
muscle spasm
• Massage with ice cube and
contraindications; collagenosis
anaesthetic areas,
circulatory insufficiency,
open wounds or gross
oedema
Thermotherapy • Hot packs: • Improves

conventional hot water localized
(a) Superficial bag wrapped in a folded circulation and
heating wet towel applied nutrition;
modalities directly for 15 to 20 relieves
minutes TDS superficial
pain, relaxes
• Infrared lamps: direct joints and
application of dry heat muscles,
by IR rays for 18–20 min softening of the
superficial
• Paraffin wax bath: a subcutaneous
mixture of liquid paraffin tissues and the
and petroleum jelly is skin
melted. 10 dips forming
10 layers of wax covering • Ideal for stiff
maintains heat and also and painful
soothes the skin hands
Contraindications: Acute
injuries, epiphyseal areas
or neoplasia
(b) Deep heating • Short wave diathermy • Ideal in

modalities (SWD): deeper tissue deeper chronic
heating up to 30–50 mm joint pains,
depth through helps in the
electromagnetic concentration
induction by high- of WBCs and
frequency currents. antibodies
Never used in acute
injuries • Reduces
deeper
• Ultrasonics (US): high- localized pains
frequency sound waves due to
with deeper thermal neuromuscular
effects at the tissue pathology
interface. It brings about
molecular rearrangement • Improves
and is ideal to reduce membrane
adhesions, reduce permeability,
haematoma; safe to be collagen
used in acute conditions. synthesis, pain
Contraindications: threshold,
neoplasia, metallic resolution of
implants, pregnancy, scar tissue and
myositis joint adhesions,
wound healing
and
remodelling of
the scar
Hydrotherapy: • Water heated at (98– • Has an

whirlpool 104°F or 39–40°C) is overall
constantly kept whirling; comfortable
it assists active feeling due to
movement of the limb warmth,
and joints immersed in a elimination of
comfortable manner gravity and the
movement of
Contraindication: water
anaesthetic skin, open
wounds • Promoting
the active
efforts by the
patient and
therefore is
ideal for
postoperative
mobilization
Therapeutic pool A deeper pool where any Ideal for

joint movement ambulatory
including ambulation is training and
possible general body
exercise like
swimming
TENS: Direct electrical Mainly reduces

Transcutaneous stimulation by low as the acuteness
nerve stimulation well as high-frequency of pain by
currents of less or more blocking the
than 10 Hz is applied. pain pathways.
Contraindications: Ideal for
anaesthetic skin, open postoperative
wounds or chronic
pains
Laser (low- Low-frequency light Relieves acute

frequency light waves produce as well as
waves) photochemical reactions chronic
within the tissue cells muscular or
neuropathic
pain
Interferential It simultaneously applies Spontaneous

currents two out of phase currents reduction of
musculoskeletal
pain as well as
constant pain
in chronic
conditions
Iontophoresis • It involves transfer of Useful in

the charged ions reducing:
intradermally by means
of a direct electric • Fungal skin
current. infection
• Drugs like • Ischaemic
dexamethasone are ulcers
transferred intradermally
• Oedema
• Applying
local dermal
anaesthesia
Electrotherapeutic Examples include RD

and diagnostic test, electromyography
procedures (EMG) nerve conditions
velocity test and
therapeutic electrical
stimulation. The
specialized tests are
covered in Chapter 14
Physiotherapeutic management following specific methods of

fracture treatment
1. Fractures treated without any splinting: Some fractures are

occasionally treated without any splinting, reduction or
surgery when surgery is contraindicated. In such cases, the
fracture is ignored; and controlled mobilization is started at
the earliest. Initiation of safe and adequate mobility to regain
functional independence is the important role of
physiotherapy in such fractures, irrespective of union or
alignment of the fracture, e.g., compression fracture of the
spine, fractures of ribs, and fracture neck of femur in a sick
patient.
2. Fractures treated by traction: Certain fractures (e.g.

trochanteric fracture) in elderly patients, where surgery
cannot be done, are treated by traction of long duration. The
physiotherapist should check the alignment and the force of
the traction; he/she should also detect development of
pressure sores or nerve palsy (the most common being
lateral popliteal nerve) due to pressure from a splint or
bandage. Isometrics to the quadriceps, hamstrings and ankle
movements should be given regularly. Ankle movements are
particularly important as they improve circulation in the calf
veins and thereby prevent deep vein thrombosis.
3. Fractures treated by cast brace: A fracture of the mid-shaft of

femur is at times treated by a cast brace having an orthotic
mechanical knee joint. It is the responsibility of the
physiotherapist to check the alignment of the knee joint and
begin early re-education in walking.
4. Fractures treated by internal fixation: A fracture treated by

internal fixation usually does not require prolonged external
immobilization after the operation. The immobilization is
maintained only for 2–3 weeks, after which mobilization can
be started.
5. Fractures and dislocations associated with ligament injuries:

Certain fractures and/or dislocations around shoulder,
elbow, interphalangeal joints and ankles are associated with
injury to the joint capsule and ligaments. Extensive efforts
are, therefore, needed to mobilize these joints and also to
treat the accompanying soft tissue damage.
6. Fractures treated by external fixator: In a compound fracture

with soft tissue loss, the fracture is stabilized with an
external fixator. The extent of injury to the soft tissues should
be assessed and inspection of the open wound should be
done frequently for infection. Vigorous movements should
be started early to the joints free from immobilization and
even NWB crutch walking can be initiated early. The
movements of the joints adjacent to the fractured bone are
deferred till there is definite evidence of fracture union. Once
the union is ascertained, extensive physiotherapeutic
measures are taken to improve mobility of the joint, strength
and endurance of the concerned muscles and early
functional independence.
7. Fractures treated by total joint replacement: The greatest

advantage of this procedure is that it allows early
mobilization and ambulation besides providing stability to
the joint. The physiotherapy is directed to re-educate the
functional activity at the earliest.
8. Fractures treated by leaving them alone: Certain fractures,

which cannot be treated by standard procedures if the
patient is not fit for surgery, are left alone. The fracture is
neglected and patient’s mobilization is started as early as
possible by using pain-relieving modalities, manual
assistance, aids and devices to provide maximum self-
sufficiency.
Fractures of the lower extremity: Specific considerations

Physiotherapeutic management of fractures of the lower
extremity demands a different type of approach for two
reasons:
1. Its important function of ambulation
2. Its role in the adaption of functional positions, e.g., cross-

leg sitting and floor squatting
The physiotherapist’s priorities should be as follows:
1. To reduce the impact of stresses on the three major weight-

bearing joints of the lower extremity
2. To acquire the requisite ROM
3. To improve strength, endurance and flexibility of the

functionally important muscle groups
1. To reduce the stresses on the weight-bearing joints: The weight-

bearing joints, especially the hip and the knee, are exposed to
tremendous amount of stresses during ambulation and while
adapting functional positions. The resultant joint force was
found to be approximately four times the body weight at the
hip and three times at the knee (Paul, 1967). The smooth
absorption of the ground reaction forces is the primary
requirement for rhythmical and effortless ambulation. When
these forces are not absorbed by the weight-bearing joints,
the muscles and ligaments are put to extra strain and early
fatigue. The weight-bearing joints should be in perfect
alignment to accept the impact of these forces. The alignment
can be maintained by avoiding tightness, contracture or
deformity (Wallace, 1983). The physiotherapy programme
must be directed to avoid this situation right from the first
day.
2. To acquire the necessary ROM: Regaining an adequate free

ROM is essential for the various activities of the lower limb
such as walking, climbing, floor squatting, cross-leg sitting
and kneeling.
The minimum ROM required for ambulation and chair

sitting is shown in Table 4-5 (Johnston and Smidt, 1969).
Table 4-5
Minimal Required Functional ROM for Ambulation and

Chair Sitting
ROM for ROM for Chair
Joint Movement
Ambulation Sitting
• Hip Flexion 20–25° 50–52°
• Extension 10°
• Abduction 12°
• External 13–15°
rotation
• Knee Flexion 60° 60–70°
• Extension 170°
• Ankle 10–15° 5°
• Dorsiflexion 45–50° 15°
• Plantar flexion
• Toes Flexion 20–25° Full
• Extension
However, the task of floor squatting and cross-leg sitting is

possible only when hip flexion, abduction and external
rotation and the knee flexion and ankle dorsiflexion acquire
a near-normal ROM. Therefore, our objective in mobilization
should be aimed at regaining a near-normal range.
Specific movements and limb positioning have a common

tendency to develop contractures. Ideally, they should be
performed in the neutral position and encouraged to move
through full ROM.
Common sites of contractures
Hip Flexion, abduction, adduction, occasionally

rotation
Knee Flexion
AnklePlantar flexion
Toes Flexion (curling)
3. To improve strength, endurance and flexibility: Several

repetitions of strengthening, endurance and stretching
exercises should be done. They should be simple, objective
and within the limits of discomfort. The programme should
include the following:
(a) It has been found ideal to initiate isometric contractions to

the important muscle groups of the hip, knee and ankle as
early as possible.
(b) One must remember that the responsibility of the

physiotherapist does not end with demonstrating or teaching
isometric contractions. The patient usually demonstrates
ideal performance of exercises to the physiotherapist on
ward round. However, he/she neglects it during the rest of
the time. As soon as ROM exercises are permitted, preference
should be given to self-built-up internal tension exercises
and eccentric exercises.
The following muscle groups need concentrated efforts for

stable ambulation and standing.
Hip: extensors, abductors
Knee: extensors, flexors
Ankle: dorsiflexors, plantar flexors
In our experience, emphasis on these muscle groups is

essential to promote early stable standing and walking.
Walking re-education
Prewalking education
Re-education in walking should begin as early as possible

after surgery or plaster application for a fracture. One should
not wait till the fracture is united. The basis of locomotion is
stability and smooth movements.
The stability of all the three principal weight-bearing joints

has to be ensured. Strong and repeated isometrics to the
glutei should be initiated early, as they are the main guiding
force to provide the pelvifemoral stability in standing and
single leg balancing. NWB supine lying thrust of the leg in
the axial direction (Fig. 4-20) helps in creating partial loading
situation to the injured limb, which stimulates callus
formation and promotes healing of the fracture. Isometrics to
the quadriceps and hamstrings are important in providing
co-contractions to stabilize the knee on weight bearing.
Ankle and foot stability is of primary importance during the
single leg mid-stance when the whole body weight is
balanced on it. Intrinsic muscles play a major role in
stabilizing the foot on the floor. Therefore, early initiation of
exercises to the intrinsic muscles and the anterior and
posterior tibial muscles plays a vital role.
FIG. 4-20Application of early partial loading: Axial

thrust to the leg is applied when supine lying by
pressing a pillow with the foot, maintaining the knee
joint in full extension with the ankle and foot in
neutral. Hold and release pressure with Quadratus
lumborum action.
Mobility at all the three weight-bearing joints is important.

The following ROM is necessary for smooth ambulation and
should be regained as early as possible:
Coordinated controlled movements of both the legs are also

essential for effective walking. This aspect does not usually
get enough attention in the early stage.
The patient should be educated on the exact sequence of

walking. Supine cycling (Fig. 4-21) improves controlled
coordination and induces relaxation and confidence.
FIG. 4-21Supine cycling to re-educate on prewalking

controlled coordination.
The need for any orthosis or supporting ambulatory aid

should be assessed at this stage and orthosis is fabricated for
use on the very first day of ambulation.
These preambulatory sessions should be well understood

and practised by the patient regularly.
Crutch walking: Crutch walking is a common mode of early

ambulation following fractures of the lower extremity.
1. It helps in early functional ambulation and a back to work

situation, even before the fracture or the soft tissues have
healed.
2. It supports the body weight by relieving undue stress on

the fractured leg.
3. It may help in early union of the fracture due to
compressive impact.
4. It provides stimulus for growth and union.
5. It improves the bony mass, thus preventing osteoporosis.
6. It improves blood circulation to the limb.
7. It facilitates re-education of the normal gait pattern.
8. It offers stability and confidence to the patient.
Basic principles
(a) Crutch measurement: Crutch measurement should be

taken from the anterior fold of the axilla to the medial
malleolus. This prevents axillary pressure and crutch palsy.
In spite of the correct crutch size, patients tend to exert
pressure through the axilla. Alternatively, measure from a
point 2 inches below the axilla to a point 6 inches in front
and 2 inches lateral to the foot.
Elbow crutch should be measured from the point of the

elbow to the ground; the cuff should cover the proximal
third of the forearm, about 1–2 inches below the elbow.
(b) Weight bearing on crutches: With either type of crutches,

the weight bearing should be through 30-degrees flexed
elbows and hands with extended wrist.
With elbow crutches, the body weight should be transmitted

through the forearm.
Cane and walker measurements: 20–30-degrees of elbow flexion

measured from the greater trochanter to a point 6 inches to
the side of the toes.
(c) Strengthening of muscle groups: Special attention to

strengthen certain muscle groups like triceps, shoulder
depressors, latissimus dorsi, wrist extensors and finger
flexors in the upper extremity is necessary in the
preambulatory period. In the lower extremity, the following
muscle groups should be strengthened: glutei, quadriceps,
ankle dorsi and plantar flexors and toe flexors.
(d) Standing: Correct standing posture should be assured

with the head erect, shoulders and pelvis properly levelled,
hips and knees extended and feet exactly below the hip
joints. The accuracy of weight transfers on both the legs and
then on alternate legs is important to prevent limp. Any limb
length disparity should be compensated before the patient is
made to stand. When standing is initiated with crutches, the
crutches should be held away from the body. They should be
placed 6 inches in front and at least 4 inches lateral to the feet
from below. This gives wider base and support areas.
Extrinsic stability is enhanced further with better arm
stabilization (Fig. 4-22).
(e) Crutch balance: Balancing the body on a single crutch is

taught first. One crutch is moved freely in all directions,
maintaining steady balance on one or both legs and one
crutch. The same procedure is then repeated on the other
side.
(f) Proper sequences of gait cycle: Proper sequences of gait
cycle including even steps and stride length should be
practised first on parallel bars and later on with crutches.
(g) Techniques of transfers: Techniques of transfers forward,

backward, side walk and turning with crutches should be
taught. However, independence in ambulation cannot be
completed without freedom in negotiating the stairs and
slopes.
FIG. 4-22Ideal-standing crutch stance to provide larger

supporting base and supporting areas. RL: Right leg,
RC: Right crutch, LL: Left leg, LC: Left crutch.
Methods of crutch walking (fig. 4-23)
1. Swing to and swing through gait: In this technique, both

crutches are moved forward, one by one. The whole body
weight is then transferred on crutches and the patient swings
his/her body forward up to the arbitrary horizontal line
formed by the tip of the crutches. This is later on progressed
to the ‘swing through’ gait in which the patient swings
his/her legs beyond the arbitrary horizontal line (Fig. 4-23A
and B).
Here the propulsive force is generated by pushing the body

forward on the arms, which are stabilized by the fixed points
of the crutch tips with the ground. The major force to propel
the body is provided by the latissimus dorsi muscle.
2. Partial weight bearing (PWB) (three-point gait): In this gait,

both the crutches and the affected leg move together. The
body weight is transferred over these three points of contact
and the sound limb is brought forward. This can be
progressed to one crutch in a contralateral pattern. Even
stepping is monitored carefully (Fig. 4-23C).
3. Alternate crutch and leg gait (four-point and two-point gait):

Initially, the right crutch is put forward followed by the left
leg, then the left crutch is put forward followed by the right
leg. The gait can thus be progressed by simultaneous
movements of the right crutch and the left leg, and vice versa
(Fig. 4-23D).
4. Shadow walking (NWB gait): It aims at maintaining the

normal pattern of gait in the absence of actual weight
bearing. It is difficult to learn, but once organized, it helps in
establishing the correct pattern of the gait. The crutch on the
opposite side of the NWB limb is put forward first to be
followed by forward movement of the NWB leg. Next, the
other crutch is put forward to be followed by the normal
limb (Fig. 4-23E).
Relaxation of the whole body and smooth ambulation
training should be emphasized to prevent undue fatigue and
excessive energy consumption to ensure confidence.
FIG. 4-23Types of crutch gaits: (A) Swing to gait. (B)

Swing through gait. (C) Partial weight-bearing gait. (D)
Four-point gait. (E) Shadow walking non-weight-
bearing gait.
Principles and methodology of ambulatory training
The following guidelines in bearing body weight on the

fractured limb must be strictly observed during the
sequential stages of ambulation.
In all fractures of the lower extremity, it is most important to

know how much of body weight is to be put on the fractured
limb.
There are three basic stages of weight bearing:
i. NWB: This does not allow any type of body weight on the
fractured limb.
ii. PWB: Weight could be placed in a graduated manner as

follows:
◼ Toes-down or toe-down weight bearing (TDWB): Toes are

put down on the ground to accept partial body weight.
◼ Weight bearing to tolerance (WBTT): The body weight is

put on the affected limb till it does not cause pain or
discomfort at the fracture site.
iii. Full weight bearing (FWB): Full weight of the body is

borne on the fractured limb. FWB is always started initially
with an assistive aid which is weaned off gradually. The use
of a cane is preferred in elderly individuals as a safety
measure.
Methodology
◼ NWB: Use parallel bars to enthuse confidence and to learn
the normal gait pattern. Progressing to crutches/crutch or
cane.
◼ TDWB: Always begin TDWB with a walking aid (walker)

or in parallel bars. Begin TDWB when an active leg control is
adequate and the patient is able to perform the straight leg
raise (SLR) correctly.
◼ WBTT: The best method of teaching progressive controlled

weight bearing and reducing subjective fear complex is to
give a trial on a weighing scale to assess the weight the
patient can take without pain. Progress weight bearing
gradually, by 5–10 kg increments, to the point of pain-free
FWB.
◼ FWB: Always begin with an assistive aid and give

vigorous gait training to prevent organized limp for no
cause. Radiographic evaluation provides important guidance
to finalize the methodology of WB to be followed.
General plan of weight bearing in lower limb fractures
By 6 weeks: PWB on the crutches
By 8 weeks: PWB on a cane
By 12 weeks: Assisted ambulation or with slight support or

begin with and progress to unsupported ambulation
By 16–24 weeks: Graduated resumption of sports

Weight bearing in lower limb fractures is depicted in Table 4-
6.
Table 4-6
Weight Bearing in Lower Limb Fractures

Fracture and Type PWB FWB
1. Pelvis • TDWB 0–7 days 8–12

weeks
Stable • WBTT 4–8 weeks
12–16
Unstable • TDWB by a week weeks
• WBTT >7 days
2. Hip • WBTT >7 days 6–12

weeks
Posterior dislocation
3. Femur • WBTT 3–7 days 6–12

weeks
(a) Neck (intra- and THR: TDWB or
extracapsular)
• WBTT cemented 2
days
• TDWB
noncemented
• TDWB 4–6 weeks

(b) Shaft WBTT 0–6 weeks 6–12

weeks
Stable WBTT 6–12 weeks
6–12
Unstable TDWB 0–6 weeks weeks
>12
weeks
(c) Distal end WBTT 8–12 weeks 3–6

months
4. Patella WBTT 2–3 weeks 6–12

weeks
5. Tibia TDWB 8–10 weeks 12 weeks
Plateau (10 mm depression) WBTT 3–10 weeks >12

weeks
Shaft TDWB 0–6 weeks
>12
– Treated conservatively WBTT 6–12 weeks weeks
– Treated with IF or external TDWB 6–8 weeks
fixator
WBTT 8–12 weeks
Distal tibia(pilon fracture)
6. Ankle TDWB 2–3 weeks >4 weeks
Stable WBTT 3–4 weeks >6 weeks
Unstable (treated by ORIF) TDWB 2–6 weeks
Fracture management by open reduction and internal

fixation
Orthopaedic management
Management of an open fracture
◼ Stop bleeding by applying a compression bandage.
◼ Splint the injured limb to prevent further damage.
Wound management
1. Irrigation and debridement: The former flushes the foreign

matter and contaminated blood clots. In irrigation, large
quantity of normal saline reduces bacteria. It cleans all the
soft tissue, e.g., skin, fasciae, muscles, tendons, nerves, even
bones and joints.
2. Wound coverage: It plays an important role in preventing

tissue necrosis and infection.
In compound fractures, wound coverage can be obtained by
any of the following methods, of course, apart from starting
appropriate antibiotics:
1. Primary wound closure
2. Delayed primary closure
3. Secondary closure
4. Skin grafting, when the wound cannot be closed by any of

the afore-mentioned methods
Fracture stabilization
In open fracture, the wound needs regular dressing – access

directly to the wound is essential.
Treatment
When the limb is immobilized in a plaster cast, a window is

made in the POP for dressing and wound inspection.
1. The window in POP is closed and the plaster is completed

after the wound has completely healed.
2. Skeletal traction: In open tibial fractures, skeletal traction is

applied and limb is placed on a Bohler Braun splint.
3. External fixator (Fig. 4-24). It is the most commonly

employed method in the treatment of open fractures. It
provides stability to the fracture while providing easy access
to the wounds for inspection, dressings and maintenance of
wound hygiene. It is also ideal for any intervention and
adjustments. In open fracture of tibia, three pins each are
applied to the proximal and distal fragments.
4. Internal fixation: Although not a very favourite method in
compound fractures, it can be undertaken in selective cases.
FIG. 4-24(A and B) Clinical and X-ray picture of a ring

external fixator applied in the leg. It is also called as
Illizarov external fixator.
Complications
◼ Tetanus
◼ Gas gangrene
◼ Chronic osteomyelitis
◼ Nonunion
Physiotherapy in fractures treated by open reduction and internal

fixation
◼ Before suture removal, follow these points:
◼ Carefully watch for any signs of infection.
◼ Maintain elevated position of the limb.
◼ Only gentle movements are allowed for the distal joints.
◼ Active exercises are encouraged within a pain-free range

to the affected joints.
◼ Gentle isometrics for the affected joints.
◼ Vigorous exercise for the nonimmobilized parts.
◼ After suture removal, follow these points:
◼ Affected joints are gradually encouraged to perform active

small ROM exercises
◼ Graduated sitting up in bed and standing with arms

supported is begun.
◼ If permitted, gradual weight bearing is initiated on the

affected limb for a smart period.
◼ Progress further rehabilitation to FWB ambulation as in

closed fractures.
Open Fractures: As open fractures communicate openly with

the external atmosphere, they are usually surgical
emergencies (Fig. 4-25).
FIG. 4-25Open Fracture of the distal forearm and wrist.
Moreover, due to exposure to sudden violent trauma, these

injuries may be associated with a multiskeletal and
multisystem trauma, and the patient is usually in shock.
Therefore, the first objective is to stabilize the patient’s
general condition. Wound is to be kept sterile and clean to
prepare for the necessary surgical procedure at the earliest.
After debridement and wound irrigation, the fracture is
immobilized by an external fixator which is the most
preferred method of immobilization in compound (open)
fractures.
Physiotherapy management in compound fractures
◼ Depending upon the severity of compounding, these types

of fractures are fixed mostly by external fixators or by
interlocking nailing.
◼ The first priority goes to wound care and wound

inspection at regular intervals.
◼ Care should be taken of the sites of the pin insertion.
◼ Limb is kept to maximum possible elevation.
◼ Gradual isometrics are taught to the immobilized muscles.
◼ Carefully supported patient is encouraged to self-standing

and balancing at the bedside.
◼ The patient may be encouraged to use crutches and take

lessons on crutch standing or balancing.
After bony and soft tissue healing, follow these points:
◼ Light active exercises may be begun as early as possible.
◼ Increase the intensity of the exercises to make them

vigorous.
◼ The patient is taught to balance with required assistive
devices, preferably on bilateral axillary crutches to ensure
balance.
◼ Strengthening and ROM exercises especially in a self-

performed manner are welcomed.
◼ Training in ambulation is introduced in gradual steps and

progressed along with vigorous ROM and muscle
strengthening procedures.
Pathological features
The cause of such fractures is bone pathology which has

made the bone weak following certain local or generalized
skeletal disease or a disorder.
Clinical features
There is a history of discomfort and pain at the bony site of

the suspected fracture.
Generalized Local Disorders

Disorders
Perioperative pathological fracture
Senile Metastatic carcinoma
osteoporosis
Lower end of Primary in the lungs, breast, prostate,
radius thyroid or kidney.
Ribs
Neck of Common sites
trochanter femur
Thoracic or Thoracolumbar vertebral bodies
lumber body
Shaft tibia or Proximal half of humerus
femur
Paget disease Bone cyst at a long bone
Repetitive microtrauma is the usual cause and the common

site is the third metatarsal (MT) bone. There is always an
increase with exertion or activity significant local tenderness,
localized swelling. X-ray shows a fluffy callus surrounding a
faint fracture line Fig. 4-26
FIG. 4-26Stress Fracture of the third metatarsal. There

is exuberant fluffy callus seen around a faint fracture
line in the third metatarsal bone.
It heals and gets united just by rest and some orthotic
support.
Common sites (table 4-7)
◼ March fracture (second MT bone) or a continuous

marching (e.g., in soldiers)
◼ tibia, fibula (caused by overrunning or dancing)
◼ Occasionally, fracture of femur
Table 4-7
Site of Injury Involving Blood Vessels and Nerves

Involved Blood
Site of Injury Injured Nerves
Vessel
Upper limb
Fracture of clavicle Subclavian Brachial plexus
vessels
Fracture of proximal Axillary vessels Axillary nerves
humerus
Fracture of Brachial vessels Radial nerve
supracondylar
humerus
Posterior dislocation of Brachial vessels Median nerve
elbow
Fracture of both bones Anterior
of the forearm interosseous
artery
Lower limb
Hip dislocation Femoral vessels Sciatic nerve
(posterior)
Hip dislocation Femoral vessels Femoral nerve
(anterior)
Supracondylar fracture Popliteal vessels
of femur
Dislocation of knee Popliteal vessels Common
peroneal nerve
Fracture of proximal Posterior tibial Posterior tibial
tibia vessels nerve
Fracture of tibia and Posterior tibial
fibula vessels
Injuries of ankle Posterior tibial
vessels
Monteggia fracture Posterior
interosseous
nerve
Fracture of hook of Deep branch of
hamate ulnar nerve
Injury of the wrist Median nerve
Fracture of neck of Lateral Popliteal
fibula nerve
Treatment
Complete rest for 1 week
Physiotherapy management
Pathological fractures are commonly treated by ORIF, either

with or without bone cement and bone grafting. The union of
these fractures may take any of the following courses:
◼ may unite in usual time
◼ may take longer time
◼ may remain unidentified
◼ or may unite only after chemo or radiotherapy
The results of physiotherapy in achieving independent

ambulation always remain unpredictable.
In such difficult situations, wheel chair ambulation remains

the only alternative. However, such patients are treated to be
as self-sufficient as possible within the limits of the disease
and the disability. Concentrate only on the able limbs, and
teach the patients to use them as much as possible (Table 4-
8).
Table 4-8
Physiotherapy Guidelines for the Fractures Treated with

POP Cast, Poststabilization
During Immobilization During Mobilzation
Limb elevation to reduce oedema Elastic bandage and limb
elevation
Start with slow-speed small- Active exercise for the
range isometrics for the muscle affected and unaffected
groups under immunization joints
Earliest starting functional Isometrics, isotonics and
activities by unaffected limb and isokinetics for efficiency
slowly taken over by affected of the limb
limb (maybe with assistance)
Nearly full functional use by the Progress functional
affected upper limb and crutch activities with the
walking or walking with a cane affected limb; ambulatory
activities and gait
training
Open fractures
In an open fracture, the integrity of skin is lost, and therefore

the fractured bone communicates with the exterior
environment.
Open fractures are also called compound fractures. Being

open, they are highly susceptible to infection due to
contamination by dust particles, bacteria, gravel, etc.
Contamination of a wound by bacteria
◼ May block fluent flow of blood to bone, fasciae muscles,

thereby further increasing the infection.
◼ Impaired vascularity to the uniting fracture may result in

delay in fracture union or may even cause nonunion.
◼ Open fractures are classified into five classes according to

the size of the fracture, skin wound, tissue damage and the
level of contamination: for example, the smallest wound of
size <1 cm is considered class A and the largest with
extensive skin damage and an arterial injury is class 5
fracture (also called class E fractures).
Complications of fractures
Prevention of complications as a result of fractures is the
most important milestone in successful management and
early recovery. The complications are classified into the
following three categories (Table 4-9):
◼ Immediate or early complications
◼ Intermediate or delayed complications
◼ Late complications
Table 4-9
Complications of Fractures
Early Delayed Late Complications
Complications Complications
• Hypovolemic • Adult respiratory • Delayed union

shock distress syndrome
(ARDS) • Nonunion
• Injury to the
major blood • Infection • Malunion
vessels
• Deep venous • Joint stiffness
• Injury to the thrombosis (DVT)
nerves • Avascular necrosis
• Compartment (AVN)
• Injury to the syndrome • Reflex sympathetic
muscles dystrophy (RSP)
• Crush syndrome
• Late nerve palsy
• Myositis
ossificance and
ectopic ossification
• Secondary
osteoarthritis
• Limb length
disparity
• Prolonged bed
immobilization
• Volkmann
ischaemic
contracture (VIC)
Basic principles of preventing complications following

fractures
◼ Knowledge about the possible complication in relation to

the individual fracture and methods of its prevention
◼ Early detection by skilled critical regular monitoring
◼ Educating and guiding a patient on the expected early

signs and symptoms of the possible complications related to
a particular fracture, and to report immediately (the
complications of fractures are presented in Table 4-10 and
Figures 4-27–4-32)
FIG. 4-27Compartment syndrome (cross-section of

forearm).
FIG. 4-28Volkmann ischaemic contracture (VIC).

FIG. 4-29Atrophic nonunion. Note the sclerosis at the

fracture ends and little callus. The medullary canal is
closed at the fracture site.
FIG. 4-30Reflex sympathetic dystrophy (RSD) of right

hand. The normal left hand is shown for comparison.
FIG. 4-31Cubitus valgus deformity on the right side.
FIG. 4-32Ectopic new bone formation (myositis

ossificans) on the anterior aspect of the elbow.
Table 4-10
Nature of Injury and the Possible Complications

Nature of Injury Possible
Complication
• Violent trauma RTA, multiple fractures, •

compound fractures, fractures of hip, pelvis, Hypovolaemic
femoral head, neck; fractures of skull, spine shock
or violent visceral injuries
• Fracture of proximal humerus, through • Avascular
the waist of scaphoid bones, injury to lunate necrosis
bone (Kienbock disease), fracture of neck,
head or posterior hip dislocation
• Supracondylar fracture of humerus or • Volkmann

fracture of both bones of forearm, elbow ischaemic
joint dislocation contracture
(VIC)
• Myositis
ossification at
elbow
• Fracture of both bones of the forearm or •

leg just proximal to the wrist or ankle, Compartmental
respectively syndrome
• Fractures of radius and ulna at the same • Cross-union

or close level to each other
• Colles fracture or fractures at the distal • Reflex

end of radius sympathetic or
Sudeck
dystrophy
(RSD)
• Major fractures around the hip – central • Deep venous
dislocation, fractures around the hip joint thrombosis
(DVT)
• Fracture of skull, vertebral column, • Ectopic

posterior or central dislocation of hip ossification
To deal effectively with the complications following

fractures, one must carefully keep a watch on the possible or
incoming complication common to certain types of injuries
or fractures as presented in the following tabular format.
(A) Immediate complications
Hypovolaemic shock
Causes
• Severe trauma (road traffic accident [RTA])
• Multiple fractures
• Fractures: pelvis and long bones
• Severe visceral injuries
Clinical features
• Shock
• Coma
• Cardiorespiratory failure
• Excessive external or internal bleeding (blood loss of >1500

mL)
• Renal failure
Therapeutic approach
• Control bleeding by the following:
• Localized external pressure at the bleeding point
• Compression bondage
• Keeping limb in elevation
• Start i.v. line 1 colloids after blood grouping and cross-

matching
• Instant cardiopulmonary resuscitation
• Restoration of cardio respiratory function
• Restoration of blood fluid volume
• Immediate surgery to repair vessel and nerve
• Catheterization of urinary bladder
• Measures to prevent infection
• Instant splinting of the injured limb

• Pelvic compression clamp to prevent excessive bleeding
and stabilize pelvic fracture as well
Specific physiotherapy measures
• Limb supporting splint
• Chest physiotherapy to improve respiratory function
Injury to blood vessels
Causes
• Blunt or sharp injury
Blood vessel may have the following:
• Vasospasm
• Incomplete or complete tear
• Compression by fracture fragment, haematoma, tear,

internal thrombus, tight POP cast or bandage
Clinical features
• Limb may be cyanosed, cold and pale at the distal end.
• There may be pulselessness or feeble pulse.
• Gradual onset of ischaemia may lead to gangrene.
• Supportive splinting
• Immediate reduction of the fracture
• Explore and repair artery or vein and improve distal

circulation
• Localized pressure at the bleeding points
• Compression bandage
• Limb support and keep in elevation (no thermotherapy)
• Early possible active, or assisted movements to distal joints
• Intermittent monitoring
Injury to nerves
Causes
Nerve may be injured by crushing, stretching, compression

or by division.
Clinical features
• Assess neurovascular status distal to injury for the

following:
• Gradual sensory impairment in its distribution
• Paresis or paralysis in the innervated muscle groups

• Cold limbs, of associated vessel injury
• Provide splint to prevent overstretching of the injured

nerve and contractures
• Protect anaesthetic areas from heat, cold or injury
• Repair of the severed nerve
• Provide suitable splint (static)
• Conduct diagnostic tests to assess injury
• Continue distal movements
After repair – sensory and motor
• Re-education
• Biofeedback
• Functional restoration
Injury to muscles
Causes
• Direct or indirect injury
Clinical features
• Localized haematoma, swelling over the injured area with
redness, warmth and tenderness
• Painful isometric as well as isotonic contractions
• Painful or lost function of the injured muscle, if cut
• Fast healing due to abundant blood supply
• Rest and support to the adjacent joint
• Immobilization by splint or bandage
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Prevent contractions by supportive splint.
• Muscle injury heals by fibrosis and may form adhesions.

Early movements are therefore begun to prevent
contractures.
(B) Delayed complications
Ards
Causes
• Multiple fractures, or fracture of pelvis, or long bones

• Inflammatory reaction set up by microemboli of fat
released from the fracture (bone marrow)
• Dyspnoea
Clinical features
• Dyspnoea with increased rate of respiration due to

deficiency of gaseous diffusion in the lungs
• Multiple opacities in the lung
• Small patches on the chest wall
• Oxygen to restore PaO2
• Tracheostomy
• Positive pressure ventilation
• Pharmaceutical drugs – steroids, heparin, low-molecular-

weight dextran, antibiotics, etc.
• Definitive fracture treatment
• Concentrated chest physiotherapy procedures
• Early mobilization with monitored breathing
Infection
Causes
• In open fractures
• After surgical operations
• Neglected wounds
Clinical features
• Healthy wound is erythematous and clean
• If contaminated with dead soft tissue, may even destroy

bone (necrosis)
• Antibiotics
• Regular dressing
• Wound care
• Irrigation
• Debridement
• Wound closure
• Rest and proper splinting
• If the limb is immobilized, vigorous active movements are

given to the free joints to augment circulation
• IR, ultrasonics or UV radiation or hydrotherapy
Deep venous thrombosis (dvt) and pulmonary embolism
Causes
• Major fracture around the hip joint, spine, femur, tibia
• Pathogenesis Virchow’s triad of venous stasis, vascular

damage and hypercoagubility
• Thrombus formed in the venous plexus may lead to clot

formation which may get detached and pass onwards to the
lungs or brain with possible fatal consequences
Clinical features
• Delayed clinical signs (by 4–8 days)
• Pain, redness, warmth with oedema in the calf muscles
• Positive Hoffmann sign (forced ankle dorsiflexion

produces calf pain)
• Fever may be present
• Elastic compression bondage
• Anticoagulant therapy
• Measures to reduce pain (no thermotherapy)
• Early pain-free active limb movement
• Vigorous toe and ankle movements with limb well

supported in elevation
Compartment syndrome (orthoengorge)
Causes
• Vascular compromise occurs in tight compartment due to

tight bandage or POP applied after an injury
• Common sites: inflammation
• Lower forearm above the wrist
• Lower leg above the ankle joint
• Supracondylar fracture in children and crush injuries in

adults
Clinical features
• Excruciating local pain (poorly localized)
• Pale, cold distal part of the limb, with reduced or no

pulsation
• Passive extensions of fingers elicit pain due to an ischaemic

necrosis of the tissues contained within the volar
compartment following an improperly fitting forearm splint
/POP
• Remove tight bandage or POP.
• Keep limb in elevation and observe for a few hours.
• If no improvement, perform surgical decompression by

dividing skin and fasciae.
• Leave wound open till swelling completely subsides.
• Close the wound by secondary suture or skin grafting.
• Careful examination and regular monitoring of the

immobilization
• Vigorous active and resisted fingers toe movements
• Monitor the progress
• Early protected functional use of the related limb
Volkmann ischaemic contracture (vic)
Causes
• Impaired vascular integrity results in muscular ischaemia.

The ischaemic muscles are gradually replaced by fibrous
tissue which progresses to fibrosis, contractures and
shortening of the muscles, hence the name.
• It mainly affects the flexor group of muscles of forearm and

fingers. Tight bandage or POP cast is the main cause.
• Ischaemia may damage the peripheral nerve too.
Clinical features
• Severe pain – from forearm to hand
• Gradually progresses to sensory and motor paresis to

paralysis
• Progresses to flexion deformity at the wrist and fingers
• Develops typical Volkmann sign
• Fibrosis of the flexors of wrist and fingers causes

shortening and fixed flexion deformities at the wrist and
fingers.
• If detected early, remove compressive cause, begin with

vigorous physiotherapy with dynamic orthosis – good
results
• Late, moderate cases: Flexor-slide (Maxpage) operation of

releasing flexor group of muscles from their origin
• Severe cases: Shortening of the bones of the forearm,

proximal row of carpal bones with wrist arthrodesis in
functional position
• Early full ROM exercises with emphasis on full finger

extension with wrist joint extended fully
• Dynamic VIC splint: Splint to retain continuously stretch

on flexors of wrist and fingers
• Active mobilization
• Functional training in postsurgery patients: Re-education

of the muscle function and full ROM
• No heat or electrical modality
Crush syndrome (2–3 days following injury)
Causes
• Massive crushing of the muscle tissue following violent

direct trauma (e.g., RTA, natural calamities like earthquake)
• May occur due to inappropriate application of tourniquet,

gas gangrene or acute compartmental syndrome
Clinical features
• Muscular crushing results in the release of

myohaemoglobin into the circulation. It spreads to the renal
tubules leading to renal failure
• Scanty urine
• Urinary incontinence and reduced urinary output
• Acute renal failure
• Catheterization
• Immediate application of tourniquet and its gradual

release to limit the entry of deleterious substances in
circulation
• Haemodialysis – to prevent total renal failure
• Superficial thermotherapy to lower abdomen and deep

pressure massage (kneading)
• Early sustained upright posture (may be assisted, e.g., an

on tilt table)
• Counselling to overcome depression
Prolonged bed immobilization
Causes
• Certain conditions, like RTA, fractures of the hip joint in

elderly, spinal head injuries or operable cases, require longer
bed immobilization or unconsciousness.
• Longer immobilization invariably results in a number of

complications including gross detoning of all the systems
and the organs of the body.
Clinical features
• Hypostatic pneumonia
• Deterioration of all the vital functions
• Muscular, other soft tissues weakness, and bone

demineralization
• Joint contractures and stiffness
• DVT
• Deterioration in the renal function with susceptibility to

urinary infection
• Pressure sores
• Generalized systemic and organs detoning
• Depression and anxiety
• Prevention of all these complications is the major need

rather than treatment.
• Physiotherapy in the form of multiple measures from chest

physiotherapy, to critical monitoring of early initiation of
individually planned exercise training and functional
training predominate the therapy. It can prevent, if not, still
play a major role in reducing the gravity of such
complications if and when they occur.
(C) Late complications
Prolonged bed immobilization
Causes
When the bone fails to unite in the stipulated time.
• Severe anaemia
• Localized bone disease
• Reduced blood supply at the fractured site
• Malnutrition
Clinical features
• Continued pain at the fracture site with stiffness in the

adjacent joint
• Crepitus at bony ends with passive movement
• Radiological investigation confirms nonunion
• Extensive measure to treat the underlying disease causing

nonunion
• If no signs of union: Bone grafting with or without internal

fixation
• Ensure correct immobilization, strictly preventing stress on

the fracture site
• Active resistive exercises to improve overall circulation of

limb
• Repetitive movements of the distal free joints
Nonunion of a fracture
Causes
• Extensive bone loss due to injury
• Incorrect or inadequate treatment (e.g., reduction and

immobilization)
It could be of two types:
• Atrophic – rounded off fractured bony ends with no

evidence of callus formation
• Hypertrophic – excessive bone formation at the site of a

fracture (elephant-foot) but with the fracture line still
existing
Clinical features
• Adequate stabilization of the fracture may occur.

• Pseudarthrosis or a false joint may be evident at the
fracture site – on passive movement or on bearing weight
with inability to bear body weight femoral neck, scaphoid
bone, long bones like humerus or tibia.
• Movement at the fracture site is pain-free and abnormal.
Radiological investigations:
• Bone sclerosis with obliteration of medullary cavity
• External fixation by Ilizarov fixator
• Bone grafting with or without internal fixation
• Bone grafting with or without internal fixation
• Early graded functional training, with fixator
• Early graded safe weight bearing with bilateral axillary

crutches
• Vigorous hip movements in supported standing on the

normal limb
Malunion and delayed union of a fracture
Causes
• Union of fracture occurs in a malposition like angulation or

rotation
Clinical features
• Obvious malposition of the fractured bones
• Limb length disparity
• Leave alone if the function without discomfort is retained
• Corrective osteotomy with internal fixation and bone

grafting
• Progressive functional training
• Assisted active movements at the initial stage
• After healing of osteotomy, vigorous functional training
Stiff joint
Causes
• Traumatic: when the injury or fracture is close to the joint
• Nontraumatic – when the disease process involves joint
Clinical features
• Adhesion formation taking place around the joint

• More susceptible joints: shoulder, elbow, hand and knee
• Initially painful stiffness, later the pain is reduced but

stiffness remains
• Vigorous physiotherapy
• Wedge POP
• Manipulation under general anaesthesia (GA) (not very

popular due to reformation of adhesions)
• Surgical release of adhesions
• Starting early vigorous mobility exercise
• Low-intensity, pain-free, sustained stretch and hold
• Continuous passive motion (CPM)
Avascular necrosis
Causes
• In certain fractures, the blood supply to a segment of bone

is deficient and is susceptible to bone necrosis (e.g., fracture
of head femur, fracture of proximal half of scaphoid through
its waist, body of talus)
• Prolonged steroid therapy

• Alcoholism
• Renal dysfunctions
• Postpartum
Clinical features
• Early aching type of pain occurs on the anterior aspect of

hip or thigh or groin – even at rest.
• ROM of hip joint is full, painful at the extreme range.
• Later on stiffness develops and there is more pain.
• Use of hand is painful in scaphoid involvement.
• Radiographically affected bone appears more dense

(sclerotic) and may have areas of collapse at advanced stage
of the disease. Bone scan provides early detection of bony
sclerosis.
• Core decompression of femoral head by vascularized bone

grafting and internal fixation is performed.
• In extensive destruction of the head of femur, total hip

replacement (THR) is advisable.
• In scaphoid bone involvement, ORIF by K wire is

advisable.
• Fractured neck of talus needs to be treated immediately to

prevent avascular necrosis (AVN) of the body of talus, as the
blood supply to the body of talus passes through the neck of
talus.
• Hypertrophy of the functional muscle groups over the

affected bone and joint
• Maintenance of functional ROM
• Adequate support (aid) to relieve ambulatory body weight

or power movements of upper limp
Reflex sympathetic dystrophy (rsd)
Causes
• Sympathetic disturbances
• Generally seen after fracture of distal end of radius (Colles

fracture)
• When occuring at the wrist joint, it is called Sudeck

atrophy
Clinical features
• Hand is oedematous with severe pain and redness.
• Skin is cold and may be cyanosed (blue).
• Wrist, palm and fingers are tender with painful stiffness.

• Radiograph shows osteoporosis.
• Bone scan shows increased uptake.
• Sympathetic block by anaesthetic injection near the

sympathetic ganglion in the axilla or Cervical
sympathectomy
• Suitable supporting and resting orthosis
• Pain relief by transcutaneous nerve stimulation (TENS) or

cryotherapy (no thermotherapy)
• Maintain ROM of involved finger and wrist joints by

assisted passive ROM
• Progressive active ROM exercises
• Graduated pain-free functional training in improving hand

functions
Late nerve palsy
Causes
• Nerve entrapment in a fractured bone
• Progressive development of deformity following fracture –

putting stretch on the nerve causing neuritis or delayed
nerve palsy (e.g., development of cubitus valgus putting
stretch on the ulnar nerve behind the medial epicondyle
following fracture of the lateral condyle of the humerus).
Clinical features
Gradual development of the symptoms and signs of ulnar

nerve compression in the tissues of its innervation, e.g.:
• Paraesthesia, sensory loss in its distribution in the hand
• Paresis leading to paralysis in the muscles of its

innervation
• Gradual development of the deformity of ulnar claw hand
• Surgical release of the stretched nerve by transposing it to

the anterior aspect of the elbow to relieve stretch (anterior
transposition) on the ulnar nerve or Tardy ulnar nerve palsy
• Strict monitoring of the possible stretch symptoms and

signs
• Hand splint static to prevent contracture and deformity
• Active movements or bio feedback to put in voluntary

efforts
Postsurgical measures:
• Wound care
• Dynamic hand splint
• Assisted active exercises
• Biofeedback to re-educate the deficient movements
Myositis ossification or ectopic ossificans
Causes
• Myositis ossification: Following injury or fracture, new

bone formation takes place due to bleeding into the
periosteum, joint capsule and the muscles with formation of
haematoma; passive movements, forceful or hard massage
aggravates bone formation.
• Ectopic ossification – head or spinal cord hip injury

forming ectopic ossification at the hip joint
Rarely shoulder, knee or ankle may develop myositis.
Clinical features
A classical example is the injury to or around the elbow.
Early local signs:
• Warmth, redness and tenderness
• Painful limitation of ROM
• Late-stage loss of movements in the terminal ranges (both

flexion and extension)
Radiographically, initially fine amorphous flakes of calcium
– progress to calcified mass blocking ROM, which becomes
pain-free with mechanical blockage to the movement
• Careful handling of the suspected sites:
• Early immobilization
• Careful graded mobilization when the acute symptoms

disappear
• Following radiological consolidation of the myositis mass,

it may be surgically excised (controversial due to recurrence).
• In grossly blocking functional activities, excisional or

replacement arthroplasty may be undertaken for ectopic
ossification.
• Trauma at the elbow, shoulder, hip, knee and ankle should

be carefully handled, monitoring correct early
immobilization and the signs and symptoms of acute stage to
prevent it from occurring.
• On removing immobilization, gradual initiation of only

relaxed rhythmic free active movements is given and ROM is
progressed.
• No massage, or passive movements or manipulation is

required.
• Postsurgery, concentrate on functional training
emphasizing on achieving functional ROM.
Secondary osteoarthritis
Causes
Degenerative wear and tear in the weight-bearing joints
• Age-borne disease
• History of injury/fracture close to the joint
• Avascular necrosis (AVN)
Clinical features
• Pain on weight-bearing or pressurized power hand

functions
• Tenderness and crepitus
• Synovial inflammation
• Progressive stiffness in the joint
• Joint deformity
• Painful limp
Radiological investigation
• Narrowing of the joint space with formation of osteophytes

and loose bodies
• Subchondral sclerosis, cystic changes in the joint
• NSAIDs to relieve pain
• Chondroprotective drugs like glucosamine, chondroitin

sulphate
• Intra-articular sodium hyaluronan injection
Surgery
• Arthroscopy
• Intertrochanteric osteotomy
• Joint replacement arthroplasty
• Deep heating modality to relieve pain
• Exercises mainly to retain full ROM
• Education of a patient on proper body mechanics in

• Gait training with ambulatory aids
Surgical
• Early isometrics
• Graduated mobilizational and functional activities
Limb length disparity
Causes
• Malunion overlapping or angulation at the fracture site
• Loss of bone piece at the time of injury
• Bone compression at the cancellous bone end
• Damage or bone disease at the epiphyseal plate
• Reduced blood supply, e.g., post polio residual paralysis

(PPRP)
• Lengthening: Increased vascularity at epiphyseal plate
Clinical features
• Limp during ambulation
• Cosmetic deformity
Late: Secondary osteoarthritis (OA) at the involved joint
• Growth stimulating procedures
• Electrical stimulation by DC current of ≤1 V
• Electromagnetic method
• Surgical distraction technique following osteotomy and
distracting bones and applying external fixator
• Shortening exceeding 2 cm or half compensatory shoe raise
• Following surgery – functional training ambulation with

bilateral axillary crutches (PWB) to hasten callus formation
• Vigorous strengthening exercise including moving

operated leg
Rare complications
Cross-union: Mid-shaft fracture of radius and ulna at the

same level may result in a cross-union in between both the
bones (Fig 4-33). It happens due to the dispersal of
haematoma of a fracture and extension of the callus
formation – restricting the rotary forearm movement of
pronation and supination.
FIG. 4-33Cross-union between radius and ulna.
In children, it is treated by manipulation under GA followed

by POP immobilization. For 3–6 weeks, in adults, ORIF with
intramedullary nailing is done.
Physiotherapy for this complication mainly concentrates on

achieving stable functional midprone position of forearm.
Bibliography
1. Johnston RL, Smidt C L. Measurement of hip motion

during walking. Journal of Bone and Joint Surgery. 1969;51-
A:1083.
2. Paul J P. The biomechanics of the hip joint and its clinical

relevance. Proceedings of the Royal Society of Medicine.
1967;59:943.
3. Perkins G, Wale J O. 11th edn Tidy’s Massage and

Remedial Exercises in Medical and Surgical Conditions.
1980;11.
4. Wallace W A. The increasing incidence of fractures of

proximal femur: an orthopaedic epidemic. Lancet.
1983;1:1413.
CHAPTER
5
Injuries around the shoulder
OUTLINE
◼ Fractures of the clavicle
◼ Fractures of the scapula
◼ Dislocation of acromioclavicular (AC) joint
◼ Dislocation of sternoclavicular joint
◼ Dislocation of shoulder
◼ Anterior dislocation
◼ Posterior dislocation
◼ Luxatio erecta
◼ Recurrent anterior dislocation of shoulder
◼ Fracture dislocation of shoulder
◼ Fracture of greater tuberosity of humerus
◼ Fractures of the proximal humerus
Fractures of the clavicle

Fracture of the clavicle is one of the commonest injuries, seen at all
ages. It is commonly fractured at the junction of its middle and lateral
third; fracture of the lateral third is the other common site.
Mode of injury
Fractures of the clavicle usually result from a fall on the outstretched
hand (Fig. 5-1A and AA) or due to a direct trauma to the bone.
FIG. 5-1 Fracture clavicle. (A) Common fracture site. (AA) Radiograph. (B)
Immobilization by figure-of-eight bandage (FE) with triangular sling (TS).
Diagnosis
The clinical diagnosis of a fracture is usually not difficult as it is a
subcutaneous bone. In fractures of the middle third, the lateral
fragment is displaced forwards and downwards by the weight of the
limb while the medial fragment is pulled upwards by the
sternomastoid muscle (Fig. 5-1A).
Treatment
1. A triangular sling to support the affected limb is all that is needed
in undisplaced fractures in adults and even for displaced fractures in
children. The sling is maintained for a period of 2–3 weeks.
2. A figure-of-eight bandage is tied over a pad of cotton wool in each

axilla and crossed between the scapulae in such a way that both the
shoulders are braced up (Fig. 5-1B). The figure-of-eight bandage is
kept in position for a period of 3–4 weeks. The affected limb is also
supported in a triangular sling. However, the current trend is to
support the limb only in a triangular sling (without using a figure-of-
eight bandage). A tight figure-of-eight bandage can cause
compression in the axilla, thereby causing vascular embarrassment or
pressure on the brachial plexus resulting in tingling, numbness or
paraesthesia in the affected upper limb. When such a situation arises,
the bandage should be removed and the limb should be supported in
a sling.
The figure-of-eight bandage may get loosened after a few

days and needs to be tightened or changed.
The fracture almost always clinically unites in 3 weeks. The

sling and/or figure-of-eight bandage should be discarded
after 3 weeks and the shoulder be mobilized.
3. Open reduction and internal fixation (ORIF) may be indicated
rarely in cases where sharp spurs of the bone endanger the underlying
vessels or threaten to perforate skin. The clavicle can be internally
fixed with a nail or a special plate (Fig. 5-2).
4. In a patient with multiple injuries who is totally bedridden and

cannot be made to sit up, the figure-of-eight bandage cannot be tied.
In such a situation, a roll of cotton wool or a towel is placed between
the two shoulder blades. This braces the shoulder backwards and
reduces the fracture. This is maintained for a period of 3 weeks.
FIG. 5-2 A displaced fracture of the clavicle treated by open reduction and
internal fixation. (A) Preoperative radiograph. (B) Postoperative radiograph.
Complications
1. Injury to the subclavian vessels or brachial plexus can be caused by
a spike of the bone.
2. Malunion: Although displaced fractures treated conservatively

often malunite, remodelling of the bone, in due course of time,
corrects the deformity of the bone. It does not usually lead to any
functional disability.
3. Nonunion of the clavicular fracture is very rare. In an established

case of nonunion, ORIF and bone grafting are indicated.
Basic objective: To restore active full range of all the movements of
the shoulder complex.
1. Conservative treatment
During immobilization (first 3 weeks)
(a) To check the alignment of the fractured bone ends with

immobilization.
(b) To check the arm sling to ensure that there is total

support to the elbow, to avoid gravitational force
exerting any pull in the shoulder girdle and the shoulder
joint complex.
(c) When the figure-of-eight bandage is applied, make sure

that it is holding the scapula in a properly braced up
position.
(d) Confirm that the bandage in the axillae is not causing

undue pressure on the brachial plexus.
(e) Properly supported resistive full range movements to

be explained to the patient for the elbow, forearm, wrist
and hand.
Mobilization (after 3 weeks): Mobilization should be

initiated in a small range; relaxed movements using
Codman’s pendulum exercise regime gradually increasing
the range as further relaxation is achieved.
For further increase of range, relaxed passive movements

with the patient in supine position should be initiated at
the earliest. Attempts should be made to get to the extreme
of each range with emphasis to hold the terminal position.
As this technique is invariably discomforting, especially in
the terminal range of elevation and external rotation,
suitable adjunct like hydrocollator pack may be used
before, after or even during this manoeuvre.
Resisted exercises using dumbbells or self-resistance should

be practiced in between the sessions of stretching.
Self-resistive exercises and mobilization with a wand should

be taught as home exercise regime, besides functional use
of the whole limb.
The results are excellent and by 6 weeks, the patient should

get back fully mobile and with a fairly strong shoulder.
2. Surgical treatment
In the event of ORIF, gradual mobilization should be started

by 8–10 days.
Initially, the mobilization is started within the sling by

teaching relaxed pendulum movements assisted by gravity
and momentum.
Pain at the site of operation needs special attention and

should be taken care of by using suitable adjuncts such as
thermotherapy or cryotherapy.
Rest of the management technique should be progressed on

the same lines as described for fractures treated by
conservative approach.
The functional results are excellent by 6 weeks following

surgery.
CAUTION
1. While initiating early movements within the sling, it is necessary
to confirm that no movement is occurring at the fractured bone
ends.
2. Injury to the brachial plexus, though rare, should be observed with

careful examination and taken care of at the earliest.
Fractures of the scapula (fig. 5-3)

The scapula may be fractured through:
1. The body
2. The neck
3. The spine of scapula
4. The coracoid process
FIG. 5-3 Fracture of the scapula through: (A) acromion process, (B)
coracoid process, (C) neck and (D) body.
Mode of injury
◼ Direct or crushing injury
◼ Fall on the shoulder or on the outstretched hand
The scapula is completely surrounded by muscles and fascia and

hence, displacement of the body of scapula is unimportant. However,
a displacement through the glenoid fracture, which constitutes an
intra-articular fracture, needs accurate reduction.
Treatment
Fracture of scapula is generally treated by conservative methods. The
limb is supported in a sling for about 2 weeks. Mobilization of the
shoulder is started as soon as the pain permits.
Operative treatment
Operative treatment in the form of internal fixation by screws or plate
is taken up when there is marked displacement of fragments,
particularly in comminuted fractures of neck of scapula involving the
glenoid also. The congruity of the glenoid articular surface needs to be
restored (Fig. 5-4).
FIG. 5-4 Comminuted fracture of the scapula treated by open reduction

and internal fixation. (A) Preoperative radiograph shows comminuted
fracture involving the glenoid. (B) A 3-dimensional CT scan reconstruction
image. (C) Fixation by various plates and screws restoring the articular
surface of the glenoid.
Basic objective: To regain active full range of all the movements of the
shoulder complex. Because the scapula is enveloped all round by
strong muscles, displacement of the fracture fragments is rare. As the
period of immobilization is short (2 weeks), mobilization is not
difficult.
During immobilization (first 2 weeks): Physiotherapeutic
management is the same as outlined for fracture of the clavicle.
Only isometric exercises to the shoulder girdle muscles can be
initiated early.
Mobilization: The scapula with its extensive muscular attachment
plays an important role in the strength as well as range of all the basic
movements of the shoulder complex. Therefore, the degree of pain
and discomfort at the initiation of mobilization is a common feature
following its fracture.
Proper stabilization to the body of the scapula and suitable
physiotherapeutic modality to control pain is essential.
Mobilization is gradually progressed as detailed for the
management of fracture of the clavicle.
Extra emphasis is to be given to the programme of strengthening
exercises using proprioceptive neuromuscular facilitation (PNF),
dumbbells and self-resistive exercise techniques.
In the event of surgery or in older patients, special mobilization
techniques may be necessary for the scapula.
Full range of fairly strong movements of the shoulder complex
should be obtained by 4–6 weeks.
Dislocation of acromioclavicular (AC) joint

This injury results from a fall on the shoulder with impact on its outer
side. There is tenderness and swelling of the joint and the examining
finger finds a difference in the level of the outer end of the clavicle
and the acromion (Fig. 5-5A).
FIG. 5-5 (A) Dislocation of acromioclavicular joint: clinical examination. (B)
Subluxation of the acromioclavicular joint.
Diagnosis
Radiograph will show the lateral end of the clavicle at a higher level
in relation to the acromion (Fig. 5-5B).
Treatment
1. Conservative: Strapping of the joint for 3 weeks.
2. Surgical: ORIF is performed using special plates, Kirschner wires

(K-wires) (Fig. 5-6) or by tension band wiring.
FIG. 5-6 Open reduction of the dislocation and fixation by K-wires.

It is also necessary to reconstruct or repair the coracoclavicular
ligaments. These days, the coracoclavicular ligaments can be
reconstructed using synthetic threads called Mersilene tape or tight rope
or mini anchor sutures (Fig. 5-7).
FIG. 5-7 Pre- and postoperative X-rays of dislocation of AC joint.

Postoperative X-ray shows reconstruction of coracoclavicular ligaments
using mini anchor sutures in the coracoid process.
A relatively minor injury in an elderly person may be treated

conservatively; while for a major injury in an active young person,
early operative treatment will yield best results.
Basic objective: To regain active full range of motion at the shoulder
complex.
During immobilization (first 3 weeks): As it involves strapping,

movements are deferred to the shoulder joint for 2–3
weeks.
(a) Careful checking of the immobilization.

(b) Full range and strong movements to the elbow,
forearm, wrist and fingers should be started
immediately.
Mobilization (3 weeks onwards)
1. Start with adequately supported pendulum swinging

with the sling. The arc of the movement should not cause
pain; however, the AC joint and the shoulder girdle
should be well supported to protect the conoid and
trapezoid ligaments and the torn joint capsule.
2. Relaxed passive mobilization with the patient in supine

position may be initiated. More emphasis is needed on
passive abduction elevation as well as horizontal
adduction and horizontal abduction. These movements
put stretch on the AC joint.
3. Assisted active movements with emphasis beyond 90

degrees of abduction needs to be concentrated and
regained at the earliest as the AC joint has a vital role to
play in the range of abduction–elevation beyond 135
degrees.
4. Appropriate thermotherapy modality may be used as an

adjunct to relieve pain and induce relaxation. Sling
should be discarded and exercises to be progressed to
self-resistive regime at home and by using graduated
dumbbells in the department.
Full range, strong active function should be regained by 6–8

weeks.
2. Surgical treatment: As the procedure involves internal fixation and
repair of the coracoclavicular ligament, the approach of physiotherapy
differs slightly.
(a) Shoulder mobilization is to be started after 4 weeks of

surgery.
(b) The movements are more painful and there is greater

reluctance by the patient towards mobilization. This
could be helped by thermotherapy before and after the
regime of exercises.
(c) Self-resisted isometric shoulder horizontal abduction

and horizontal adduction has a special significance for
strengthening the repaired coracoclavicular ligament.
Rest of the treatment procedure follows on the same lines as

described for conservative management.
Near-normal function and full active range of shoulder

movements should be regained by 8–10 weeks.
Dislocation of sternoclavicular joint

This is a rare injury that occurs following a major road accident; the
mechanism of injury is lateral compression of the shoulder or a direct
blow to the chest.
The dislocation can be anterior (commoner variety) or posterior.
Diagnosis
Plain radiograph may not help much in the diagnosis but a CT scan
will clinch the diagnosis.
Treatment
The dislocation is reduced by manipulation and maintained in a
figure-of-eight bandage.
Dislocation of shoulder
The types of dislocation of shoulder include:
1. Anterior
2. Posterior
3. Luxatio erecta
Since anterior dislocation of the shoulder is the commonest type

seen in clinical practice, it will be discussed here in some detail.
Anterior dislocation
The most common mode of injury is fall on the outstretched hand
with the limb in lateral rotation. In this position, the head of the
humerus is thrust against the tightened anterior capsule, which gets
torn or avulsed from the anterior rim of the glenoid. Rather than
abduction as was thought earlier, lateral rotation of the arm is
particularly important in causing this injury. In this type of
dislocation, the position of the head of the humerus may slip to one of
the following positions (Fig. 5-8A–D):
1. Subcoracoid – Fig. 5-8A, B
2. Subglenoid – Fig. 5-8C
3. Subclavicular – Fig. 5-8D
1. Subcoracoid: The dislocated humeral head comes to lie anteriorly

below the coracoid process. Since this is the commonest amongst the
various types of dislocations of the shoulder, it will be discussed here
at length. The patient presents with pain, inability to move the
affected shoulder, supporting the injured limb by the other hand. On
examination, the rounded contour of the shoulder may be lost since
the humeral head is not in its normal position. The axillary nerve may
be injured and can result in paralysis of the deltoid muscle.
Radiograph is done to confirm the diagnosis and also to look for any
associated fracture, usually of the proximal humerus.
2. Subglenoid: The head of the humerus comes out through the lower
part of the capsule and remains beneath the glenoid cavity.
3. Subclavicular: Rarely, the head of humerus occupies a position just

below the clavicle.
FIG. 5-8 Anterior dislocation of shoulder. (A) Subcoracoid. (B)

Subcoracoid dislocation as seen on a radiograph. (C) Subglenoid. (D)
Subclavicular. (E) Immobilization by strapping the arm in adduction and
internal rotation.
Treatment of subcoracoid anterior dislocation of
shoulder
The dislocation is reduced by manipulation either under sedation or
under general anaesthesia by Kocher’s manoeuvre. The reduction is
maintained by immobilizing the limb in adduction and internal
rotation with the hand of the affected side close to the opposite
shoulder (Fig. 5-8E). The immobilization is secured by strapping the
arm to the trunk for a period of 3 weeks. This provides adequate
healing time for the tear in the anterior capsule of the shoulder joint
through which the head had dislocated. Inadequate immobilization
increases the chances of recurrent dislocation of the shoulder.
Basic objective: To regain full range active movements of the
shoulder complex with an emphasis on the early return of
movements of abduction and external rotation.
During immobilization (first 3 weeks): As the arm is strapped to the

trunk in a position of adduction and internal rotation, only wrist and
finger movements are possible. Full range strong resistive
movements at these joints should be practised at regular intervals.
Self-resistive: Isometric contractions can be safely instituted to the

deltoid, biceps and triceps.
Mobilization (after 3 weeks): After the removal of strapping, the limb

is supported in a sling. Elbow should be mobilized to the full extent
by removing the sling intermittently.
Mobilization of the shoulder flexion–extension should be initiated

as small range pendulum swinging movements in a forward stoop
position. These movements should be carried out with the arm within
the sling. However, the sling can be loosened to accommodate greater
range of motion.
Initiation of shoulder abduction and external rotation: As these two
movements are instrumental in causing redislocation, they have to be
initiated with utmost care and adequate stabilization at the
glenohumeral joint.
Relaxed passive abduction up to 45 degrees should be the initial
aim. It is done with the patient lying supine; the physiotherapist
passively performs the arc of abduction with the arm in internal
rotation.
External rotation should be initiated in the same position and by the
same technique. It should be done with the arm adducted by the side of
the body.
As it is important to avoid secondary adhesive capsulitis, relaxed
passive movements to the shoulder should be carried out to the full or
near-normal range at the earliest. Self-assisted relaxed movements
with wand in supine position are also helpful at this stage.
Once a good passive range is attained, regime of strengthening is
begun. Self-resisted isometric and slow isotonic movements should be
taught as a home treatment programme. Resistive devices like
dumbbells could be used in the department.
The programme should be monitored at regular intervals to ensure
that 90% of the full range is achieved by 6–8 weeks following
dislocation. Heavy resistive exercise, passive stretching and forced
external rotation and abduction are safe after 12 weeks. It may be
difficult in some patients to achieve the terminal range of abduction–
elevation and external rotation. This could be painful and needs to be
facilitated by a suitable thermotherapy adjunct.
Majority of patients regain full function by 12 weeks following the
injury.
Caution
The patient needs to be warned against performing movements
involving sudden abduction and/or external rotation to avoid
recurrence.
Complications
1. Fracture of the greater tuberosity or surgical neck of the humerus
2. Supraspinatus tendinitis
3. Rotator cuff injury
4. Recurrent anterior dislocation of the shoulder
5. Injury to the axillary nerve during reduction
All these complications should be detected at the earliest by careful

examination. For complications 1, 2, 3 and 4, the mode of treatment
remains the same as described under each heading.
Lesion of the circumflex nerve is rare and when present, the chances
of recovery are good. Early detection as well as early initiation of
isometric contractions for the deltoid muscle during immobilization is
adequate to avoid deltoid atrophy and augment the recovery.
Posterior dislocation of the shoulder is relatively less common than
the anterior dislocation and is caused by a direct blow on the front of
the shoulder with arm in internal rotation, e.g., during
electroconvulsive therapy or epileptic attack or severe electrical shock
(Fig. 5-9).
FIG. 5-9 (A) Plain X-rays showing posterior dislocation of the shoulder. (B)
CT scan showing the same. (C) 3-D reconstruction CT scan.
Treatment
The dislocation is reduced by manipulation and the limb is
immobilized in a sling for 2–3 weeks.
The major problem is stiff and painful movements of shoulder
abduction and external rotation. Therefore, slow and graduated
mobilization to restore these two movements is to be emphasized.
However, other movements should also be handled to prevent
adhesive capsulitis.
Precautions
The movement of adduction should be done with the shoulder in
external rotation and the movement of internal rotation should be
done with the shoulder in abduction. Patients need to be cautioned
against performing these movements either simultaneously or
separately with jerk.
Fresh dislocation is treated by manipulative reduction.
Luxatio erecta
In rare cases, the limb is strongly abducted, e.g., holding a branch of a
tree with the arm in wide abduction while falling down from the tree.
As a result of this injury, the head of humerus is pushed down
underneath the glenoid and the arm is held fixed in wide abduction–
elevation almost by the side of the head. This type of dislocation is
therefore termed as luxatio erecta.
Recurrent anterior dislocation of shoulder

Recurrent dislocation is characterized by repeated dislocation of the
shoulder joint in a person, following one episode of acute dislocation.
It occurs due to failure of healing of the torn avulsed capsule
anteriorly, maybe because of inadequate treatment (immobilization)
during the first episode. Repeated dislocations usually require less
violence and therefore, subsequent dislocations occur when the arm is
externally rotated and abducted during routine movements of
dressing or playing. It is a common phenomenon accounting for more
than 80% of dislocations of the upper extremity. This type of traumatic
instability of the shoulder is now also termed as TUBS (traumatic
unidirectional Bankart lesion; surgery is usually required).
There is also another type of recurrent shoulder instability which
presents without any history of trauma. It is called AMBRI (atraumatic
multidirectional bilateral; rehabilitation is the treatment where inferior
capsular shift may be undertaken occasionally).
Traumatic pathology
Bankart lesion: The avulsion of the glenoid labrum and anterior capsule
creates a pouch anterior to the neck of the scapula into which the
humeral head slips with every dislocation (Fig. 5-10B).
Hill–Sachs lesion: Hill–Sachs lesion is a defect in the posterolateral

quadrant of the head of the humerus. It is caused by the anterior
edge of the scapula when the dislocated head impinges against the
glenoid (Fig. 5-11).
FIG. 5-10 Bankart lesion: (A) normal relationship of head of humerus vis-
à-vis the labrum, and (B) head of humerus dislocated anteriorly, into the
capsular pouch causing avulsion of the labrum and capsule.
FIG. 5-11 Hill–Sachs lesion, where the dislocated head impinges against
the glenoid.
Clinical presentation
The patient presents with a history of repeated dislocations of the
shoulder, which occur with less violence and often reduced by the
patient himself. On examination, the patient resists any attempted
movement of abduction and external rotation due to the apprehension
of dislocation. This is called apprehension sign.
Treatment
The treatment invariably is surgical. Although a large number of
surgical operations have been described, the following operations are
performed commonly:
1. Bankart’s operation: The tear in the anterior capsule is repaired and

the avulsed part of glenoid labrum is re-attached.
These days, repair of the Bankart lesion is done mostly

arthroscopically. However, sometimes mini open surgery
may be done. Since this is a minimally invasive surgery, it
has definite advantages. The postoperative morbidity is
less and the rehabilitation is faster.
2. Latarjet procedure: It is also known as Latarjet–Bristow procedure.

This is a surgical operation which is indicated in recurrent dislocation
of shoulder where there is bony defect or a fracture of the glenoid. In
this procedure, a section of the coracoid process is removed and
transferred to the front of the glenoid. This transferred piece of bone
will now act as a barrier and prevent the head of humerus from
slipping/dislocating anteriorly (Joshi et al., 2013; Lafosse & Boyle,
2010; Young et al., 2011).
3. Putti–Platt operation: This procedure is indicated in cases of bony

Bankart lesion, i.e., when there is bony avulsion from the anterior
glenoid. In such a situation, the labrum cannot be repaired and
therefore, the Putti–Platt operation is performed. In this operation, the
subscapularis muscle is divided along with the anterior capsule and it
is sutured back by overlapping (double-breasting) both the divided
edges of the subscapularis muscle along with the capsule.
Postoperatively, the limb is immobilized in internal rotation by the
side of the trunk for a period of 3 weeks, after which the shoulder is
mobilized.
Physiotherapy can play a very important role in preventing recurrent
anterior dislocation.
Physiotherapy to prevent recurrence: By isometrics and conditioning
the muscles of the shoulder girdle and the shoulder joint itself.
Preventive regime of physiotherapy: The principal objectives of
physiotherapeutic management:
1. To strengthen the ligaments and muscles crossing the shoulder joint

to the optimum level
2. To regain full passive range of motion (ROM) of all the movements
Strengthening procedure: To be successful, the exercise needs

several repetitions. The best approach is to teach the
patient self-resisted eccentric, as well as isometric
contractions (reversal technique) for all the shoulder
movements. The exercises should be taught in standing or
sitting position so that they can be conveniently performed
several times. Self-resisted small range reversal technique
for various agonists and respective antagonist groups is
very well accepted by the patient (Fig. 5-12).
In the department, weighted dumbbells, or weight belts may

be used so that the progress and the extent of muscular
strength can be assessed and monitored at regular
intervals.
To achieve and maintain full range passive motion: Initially, it has

to be done by a physiotherapist with the patient in supine
position. The arc of movements of abduction–elevation,
flexion–elevation and external rotation needs to be done
gradually and carefully. To assure total relaxation, it is
ideal to use some thermotherapy or cryotherapy adjunct
before initiating these movements. Once the near-normal
or full range is achieved, the patient is taught to carry out
these movements. Extra care should be taken during the
terminal range of elevation and external rotation. As
adequate stabilization of the shoulder girdle facilitates
relaxation of the glenohumeral joint, the patient should be
advised to get some assistance at home while performing
these movements. However, proper guidance to stabilize
the shoulder girdle has to be learnt from the
physiotherapist before carrying it out at home.
For the success of this regime of prevention, long-standing

efforts (3–6 months) and skilful education of the patient are
essential.
Surgically managed patients: The regime of physiotherapy

for patients treated with surgery proceeds on the same
lines as described for anterior dislocation. The main
difference is the secured safety of performing the
movements. The joint is stable as the head of the humerus
is enveloped firmly by overlapping of the divided parts of
the subscapularis. Therefore, passive sustained stretching
is safe. But, it needs hard effort to achieve active terminal
range of elevation and external rotation.
Usually, the extreme range of external rotation remains

deficient. However, a strong and functional shoulder can
be achieved within 10–12 weeks.
On the whole, the results are excellent.

FIG. 5-12 Self-resisted reversal technique of exercise to strengthen

muscles around shoulder.
Fracture dislocation of shoulder

Dislocation of the shoulder may be associated with fracture of the
neck of humerus (Fig. 5-13). Closed reduction may be difficult or
impossible due to a fracture fragment through the neck of humerus
obstructing the reduction.
FIG. 5-13 Fracture dislocation of the shoulder joint.
Treatment
1. As mentioned earlier, closed reduction may be difficult and surgery
may have to be resorted to.
2. ORIF (Fig. 5-14) may be indicated in younger patients. Although the

results, in terms of movements, may be unpredictable.
3. In fractures through the anatomical neck of humerus, prosthetic

replacement of the shoulder may be performed (Fig. 5-15). In elderly
patients, due to expected osteoporosis, it is not safe to conduct
reduction with manipulation. It is rather treated by physiotherapy to
restore maximum ROM at the dislocated shoulder after rest in a sling
for 2–3 weeks.
4. In elderly patients, it may be advisable to leave the fracture alone
and start mobilization as soon as pain permits. Some functional range
or movements may be obtained.
FIG. 5-14 Treatment of fracture of the proximal humerus by plating. (A)

Preoperative radiograph. (B) Fracture fixed with a plate.
FIG. 5-15 (A) Preoperative radiograph of fracture of the proximal humerus.
(B) Treated by hemi-replacement arthroplasty.
Complications
1. Joint stiffness
2. Avascular necrosis of the humeral head
Fracture of greater tuberosity of humerus

It is of two types.
1. Contusion fracture of the greater tuberosity
A fall on the side of the shoulder results in a comminuted

fracture of the greater tuberosity. A direct blow to the side
of the shoulder can also cause this injury. Although this is
usually a comminuted fracture, the fragments are seldom
displaced (Fig. 5-16A).
Treatment: It consists of supporting the limb in a sling for a

week or two. Active movements of the fingers, wrist and
elbow are encouraged from the beginning while shoulder
mobilization is started as soon as the pain diminishes. If
passive stretching is avoided, full movements are regained
within a few weeks.
2. Avulsion fracture of the greater tuberosity
This injury results from a fall on the outstretched hand.

Contraction of the supraspinatus tendon against resistance
causes avulsion of a small fragment of the bone which may
or may not be displaced from its original position (Fig. 5-
16B).
Treatment: For an undisplaced fracture, supporting the limb

in a sling for a week or two is adequate. If, however, the
fragment is completely avulsed, operative treatment is
indicated. The avulsed fragment is reduced and fixed with
a screw (Fig. 5-17).
FIG. 5-16 Fracture of the greater tuberosity of humerus. (A) Undisplaced

contusion fracture. (B) Avulsion fracture – avulsion occurs as a result of pull
by the contraction of supraspinatus.
FIG. 5-17 (A) Preoperative radiograph showing displaced fracture of the

greater tuberosity associated with dislocation of the shoulder. (B)
Postoperative radiograph. The dislocation is reduced and the greater
tuberosity is fixed with screws.
Basic objective: To regain active full range of motion at the shoulder
complex.
In both these injuries, unless there is complete avulsion of

the greater tuberosity, there exists reasonable stability of
the fracture. Therefore, the management is simple.
During immobilization (initial 2 weeks): The physiotherapeutic

programme is the same as described for the fractures of clavicle or
scapula. However, strong isometrics to the deltoid under POP cast
need extra emphasis.
On rare occasions, the callus formation may impede the

movement of the biceps tendon. This may result in pain
and stiffness. To avoid this situation, efforts should be
made to achieve full range of movements at the shoulder,
with special emphasis on the terminal arc of the
movements of abduction–elevation and flexion–elevation.
Friction massage and ultrasonics over the area of the tendon

can be helpful to prevent or to treat such adhesions
allowing the freedom of movement.
Full function and normal range of motion should be regained

by 6–8 weeks after injury.
Fractures of the proximal humerus

Fractures of the proximal humerus occur most commonly in middle-
aged or elderly patients (Fig. 5-18). In these patients, it usually occurs
following a trivial trauma and the displacements are not so marked.
Occasionally, these fractures do occur in young individuals following
a severe injury and are associated with considerable displacements of
fragments.
FIG. 5-18 Fracture of the proximal humerus. (A) Undisplaced fracture. (B)
Displaced fracture with dislocation of head of humerus. (C) CT scan with 3-
dimensional reconstruction showing the fracture dislocation clearly.
Mechanism of injury
Fractures of the proximal humerus can occur due to any of the
following:
1. Fall on the outstretched hand
2. Road traffic accidents (RTAs)
3. During an epileptic fit
Classification
Although many classifications have been proposed, the Neer’s four-
part classification is the most widely accepted classification. This
classification involves the four major segments of the proximal
humerus, namely, the head, the greater tuberosity, the lesser
tuberosity and the shaft. It is also based on the principle that the
fracture occurs through the old physical lines among these segments.
One-part fracture: The fragments are undisplaced and hence the results
are good.
Two-part fracture: One segment is separated from the others. These

fractures can usually be managed by closed manipulation.
Three-part fracture: Two fragments are displaced.
Four-part fracture: All the major fragments are displaced.
Clinical features
Pain and swelling around the shoulder are the presenting symptoms.
Ecchymosis may develop within 24–72 h over the shoulder and arm
and may extend up to the elbow and chest wall.
Diagnosis
Diagnosis can be confirmed by plain radiographs; however, a CT scan
can give a better evaluation of the extent of the comminution of the
fracture (Fig. 5-19).
FIG. 5-19 Fracture of neck of humerus treated by Kirschner wires, passed

percutaneously.
Treatment
Minimally displaced fractures are treated by a triangular sling for a
period of 2–3 weeks, followed by mobilization of the shoulder.
Two- and three-part fractures in young adults can be treated by the
following methods:
1. Closed manipulation and immobilization in an arm–chest bandage

or a plaster of Paris (POP) U-slab for 3–4 weeks.
2. Closed manipulation and percutaneous K-wire fixation (Fig. 5-20).

3. Open reduction and internal fixation (ORIF) by special types of
plates (Fig. 5-14).
FIG. 5-20 Type II epiphyseal injury of upper end of humerus. (A)

Diagrammatic representation, (B) as seen on a radiograph.
Four-part fractures are best treated by prosthetic replacement of the

proximal humerus (Fig. 5-15).
In children
In children, up to 17 years of age, these injuries are Salter–Harris
Grade II epiphyseal injuries (Fig. 5-20). Most of these injuries can be
treated conservatively; up to 30 degrees of angulation is acceptable
since remodelling leaves little disability.
Complications
1. Joint stiffness: Joint stiffness is a common complication which can
occur at all ages, except in children. The incidence of joint stiffness
may be present in both (conservative as well as operative) methods.
2. Malunion: Malunion may lead to restricted movements at the

shoulder joint but does not cause much disability.
3. Avascular necrosis: In fracture through the anatomical neck of

humerus, the proximal fragment may develop avascular necrosis.
4. Injury to vessels and nerves: Severe violence with marked

displacement of fracture fragments may cause injury to axillary
vessels and nerve.
The physiotherapeutic management depends upon the type of
fracture and the mode of management.
Basic objective: To regain full active range of movements at the
shoulder complex.
1. Impacted fractures of neck of humerus: Healing of the fracture is

no problem, although the fracture is commonly seen in elderly people.
The important task for a physiotherapist is to avoid stiff and painful
shoulder or shoulder–hand syndrome by starting judicious mobility
exercise at the earliest.
Conservative approach: during immobilization

(a) Initially cryotherapy, TENS or diapulse or ultrasonics
can be given for the reduction of pain.
(b) Self-resisted full range elbow, forearm, wrist and hand

movements to be encouraged.
Mobilization
(i) Shoulder mobilization: Relaxed pendular movements, in

small range with the arm in a sling can be started as early
as after 1 week, (ii) relaxed passive movement working up
gradually to overhead abduction as well as rotation should
be attempted as soon as the sling is removed, progressing
from supine to sitting to standing position. The result
depends upon the skill of the physiotherapist to teach the
patient the proper techniques of self-mobilization. Usually,
functionally acceptable results can be achieved in the
majority of patients within 6–8 weeks.
2. Unimpacted fractures of neck of humerus: Both types of fractures,

i.e., unimpacted adduction fractures or abduction fractures, are either
treated conservatively or by ORIF.
Conservative approach – during immobilization: When treated

conservatively, a sling is given for a period of up to 3
weeks. The treatment is on the same lines as described for
impacted fractures.
Care should be taken to ensure adequate relaxation and least

discomfort by adequately supporting the site of fracture and the
weight of the arm while initiating early mobilization.
The best way is to start rhythmic pendular movements in a small
range, beginning with extension and swinging of the arm forwards.
After attaining relaxed flexion–extension swing, adduction–abduction
and rotation may be initiated in a small range (Fig. 5-21).
FIG. 5-21 Rhythmic relaxed pendular abduction–adduction exercise.
In the conservative approach, when closed reduction and

manipulation is done, shoulder is immobilized in an ‘axillary muff
and collar and cuff’. No movement at the shoulder is permissible up
to 3 weeks.
Therefore, the chances of developing a painful stiff shoulder are
quite high and need early attention.
Deep heating thermotherapy procedures like short-wave
diathermy, ultrasonics or relaxing thermotherapy, e.g., hot packs and
relaxed passive movements are important.
Maximum emphasis has to be given to educating the patient for
repeated relaxed auto-assisted shoulder movements with due stress
on abduction, starting with pendular movements.
A regular watch needs to be kept to assure improvement in the
range of abduction.
Once the active range is achieved, resisted exercises can be started.
Good functional results can be achieved by 6–8 weeks.
Fractures managed surgically: ORIF is done for younger patients.
Keeping in view the functional requirements and the possibility of
early healing, the approach of treatment has to be more vigorous. Full
advantage needs to be taken of the shorter period of immobilization,
i.e., 2 weeks. Emphasis should be laid on isometric exercises to the
deltoid and strengthening exercises at the earliest.
Relaxed passive as well as auto-assisted exercises by the use of
contralateral, normal upper extremity should be taught to the patient
immediately after the sling is removed, to regain strength as well as
full range of all movements.
Quicker rate of progression from active to active resisted
movements and functional use to be ascertained. Excellent results can
be obtained by 6–8 weeks.
CHAPTER
6
Injuries of the arm
OUTLINE
◼ Fractures of shaft of humerus
Fractures of shaft of humerus

Fracture of the shaft of humerus can be transverse, oblique, spiral,
comminuted or segmental (Fig. 6-1).
FIG. 6-1 Fractures of the shaft of humerus. (A) Transverse. (B) Oblique.
(C) Spiral. (D) Comminuted. (E) Segmental.
The mode of injury may be (a) direct or (b) indirect trauma.

Direct injury will cause either a comminuted or a transverse fracture
while an indirect trauma will result in a spiral or oblique fracture. A
pathological fracture is also seen in the humerus since it is a common
site for a bone cyst in children and metastases in adults.
The fracture in the mid-shaft of the humerus has a tendency to
lateral angulation; the proximal fragment being abducted by the
strong pull of the deltoid muscle.
Clinical features
The patient presents with pain, swelling, deformity and abnormal
mobility in the arm following an injury.
In the clinical examination, it is important to test for the function of
the radial nerve. The radial nerve supplies the extensors of the elbow,
wrist, fingers and thumb. It lies close to the middle of the humerus in
the spiral groove and therefore may be injured in the fractures in this
region resulting into wrist drop.
X-ray: An X-ray (AP and lateral views) of the arm will show the
type of fracture of humerus and its displacements (Fig. 6-2A and B).
FIG. 6-2 Fractures of the shaft of humerus. (A) AP view and (B) lateral
view. (C) Plating of the humerus. Fracture united.
Treatment
The fracture of the shaft of humerus may be treated by the following
methods:
1. POP-U-slab: The fracture is manipulated with the patient in sitting

position. The elbow is held in 90 degrees flexion and the downward
pull to the distal fragments corrects the overriding of the fragments.
The arm is immobilized in a POP-U-slab with the arm by the side of
the trunk and the elbow in 90 degrees flexion (Fig. 6-3). The limb is
supported in a sling. The fracture usually takes about 6–8 weeks to
unite. In spiral fractures, however, it may unite in 3–4 weeks.
2. Open reduction and internal fixation: This may be undertaken in the

following circumstances:
(a) Unacceptable reduction following closed manipulation,

which may be due to the interposition of soft tissues
between the fractured fragments
(b) Nonunion
(c) Injury to the radial nerve in an open fracture
FIG. 6-3 Immobilization by POP-U-slab.

Internal fixation may be achieved by: (a) intramedullary nailing
(Fig. 6-4); it can be a conventional Kuntscher’s nail or an interlocking
nail, the latter is preferred (Fig. 6-4B), and (b) plating of the humerus
(Fig. 6-2). Postoperatively, the limb is immobilized in a POP-slab for
4–6 weeks. The shoulder is then mobilized.
FIG. 6-4 (A) Internal fixation by Kuntscher’s intramedullary nail. (B)

Internal fixation by interlocking nail.
External fixator: External fixator (Fig. 6-5) is a good alternative in

the treatment of open or infected fractures.
FIG. 6-5 Fracture shaft of humerus treated by external fixator: (A)

Postoperative radiograph. (B) Patient using the limb with the fixator in
position.
Complications
1. Injury to the radial nerve: The radial nerve is in close proximity to the
humerus in its middle third region where the nerve lies in the spiral
groove. A fracture in the middle third of the humerus may, therefore,
be associated with injury to the radial nerve.
2. Nonunion: Nonunion of the humerus is treated by internal fixation

along with bone grafting. Postoperatively, the limb is immobilized in
a POP-U-slab and sling for a longer period, i.e., 6–8 weeks.
Basic objective: Return of full range active movements at the shoulder
complex.
1. Transverse fractures treated by conservative approach
During immobilization (first 6–8 weeks): Check the limb for

the presence of radial nerve injury. Strong wrist and finger
movements working in full range of joint motion are
started immediately.
As the POP-U-slab with a sling is given, isometric exercises

for the deltoid, triceps and biceps to be initiated, but no
other active physiotherapy is possible.
It is very important to check for the involvement of the radial

nerve for a few weeks. Many a times the radial nerve gets
involved in the callus that is forming around the fracture
site.
Mobilization (from 6–8 weeks onwards): Longer period of

immobilization results in stiff and painful shoulder.
Before initiating shoulder movements a suitable pain

relieving modality like hot packs (HP), transcutaneous
electrical nerve stimulation (TENS), ultrasonics or short
wave diathermy (SWD) is necessary.
Mobilization on the first day should begin as a self-assisted

or even as a relaxed passive movement in a small range.
The patient holds the arm in sling position by the other
hand with the elbow of the fractured arm in 90 degrees of
flexion. The patient then supports the fractured limb with
the other hand and moves it as a rhythmical relaxed
passive movement (Fig. 6-6).
This eliminates the effect of gravity and prevents stretching

and pain. Easy movements of small range of flexion–
extension or abduction–adduction are well accepted by
patients in the initial stage. Later on, all the other
movements including circumduction can be started.
Then, progress to Codman’s pendular regime in standing,

and relaxed passive self-stretching of abduction–elevation
and flexion–elevation in supine.
Progress to active and gradually to resisted regime by self-

resistive technique, using weighted dumbbell, weight belts,
or pulley and weights.
Use of wand, shoulder wheel and skates can be helpful as an

assisted exercise modality.
Terminal range of elevation and rotation should always be

emphasized to avoid lingering pain and stiffness.
The period of recovery to full function varies from 3 to 4

months.
Spiral fracture: It is also treated conservatively. Union occurs

early and the period of immobilization in U-slab and sling
is only 3–4 weeks. Therefore, it is treated on the same lines
as a transverse fracture. Since the period of immobilization
is about one-half that of a transverse fracture, good results
are expected in just half the time.
2. Fractures treated by surgery: Plating of the humerus which
involves immobilization with POP-U-slab and sling for 4–6 weeks is
to be treated on the same lines as in the conservative approach. The
difference is proper evaluation of the extent of injury to the radial
nerve if present and its management by appropriate methods. In
addition, the inspection of the surgical scar and its management may
be necessary.
In the presence of nonunion, postoperative immobilization is

extended to 6–8 weeks due to internal fixation and bone
grafting. Since, in these cases, the extent of stiffness and
pain are more, it takes longer time for resolution of these
problems. Physiotherapeutic programme needs to be
progressed gradually. Recovery of function may take even
longer time, anywhere between 4 to 5 months.
FIG. 6-6 Self-assisted relaxed passive mobilization with the sling on.
CHAPTER
7
Injuries of the elbow
OUTLINE
◼ Fracture of the capitulum
◼ Supracondylar fracture of the humerus
◼ Intercondylar fracture of the humerus
◼ Fracture of single condyles of the humerus
◼ Pulled elbow
◼ Dislocation of the elbow
◼ Fracture of the olecranon
◼ Fracture of the head and neck of the radius
◼ Sideswipe injury of the elbow
Fracture of the capitulum

This fracture occurs in adults as a result of fall on the outstretched
hand. The injuring force is transmitted through the radial head to the
capitulum resulting in a fracture of the latter. It is, therefore, also
usually associated with fracture of the radial head. The size of the
fractured fragment may vary from a flake of bone to the entire
anterior half of the capitulum (Fig. 7-1A and B). A fracture with a
small fragment may be missed on radiograph; it may result in stiffness
of the elbow subsequently. A CT scan may be required occasionally to
delineate the fracture anatomy better and also to detect any other
fracture, particularly that of the radial head.
FIG. 7-1 Fracture of the capitulum. (A) Diagrammatic representation of a

displaced fracture of the capitulum (F). (B) As seen on a radiograph. (C, D)
A case treated by internal fixation by two special types of screws.
Treatment
1. Manipulative reduction and plaster: Manipulation is possible in fresh
fractures. Accurate reduction of the fracture is essential to obtain a
smooth articular surface. The elbow is immobilized in a plaster cast
for 3 weeks.
2. Open reduction: It is indicated in displaced fracture of the cases

where closed reduction fails. The fragment is fixed with the help of
screw(s) (Fig. 7-1C and D). After surgery, the elbow is immobilized in
a plaster cast for 3 weeks.
3. Excision of the fragment: In late neglected cases, if the displaced bony

fragment blocks the flexion movement, it may be excised (Fig. 7-2).
Postoperatively, the elbow is supported in a sling for about 1 week.
FIG. 7-2 X-ray showing excision of the radial head.
Basic objective: Return of the full range of active elbow and forearm
movements
A. Cases managed with closed or open reduction
During immobilization (first 3 weeks)
1. Checking the cast immobilization
2. Strong and full-range movement of shoulder complex,

fingers and thumb
Mobilization (from 3 weeks onwards): As soon as the plaster cast

is removed, the following should be done:
1. Accurately evaluate the active range of motion (ROM).
2. Initiate full-range movements for the wrist.
3. For the stiff and painful elbow, mobilization should follow

the application of paraffin wax bath or steam packs.
(a) Assisted mobilization by using roller skates: Begin with

relaxed rhythmical movements in a small range followed
by an objective increase of flexion as well as extension
range with emphasis on the extreme arc of the range.
(b) Relaxed active movements can be initiated with the

patient in prone position with elbow over the edge of the
treatment table. During this movement the shoulder is
placed in 90 degrees of abduction (Fig. 7-3A).
(c) Relaxed active free flexion can be further progressed by

the modified use of knee ratchet (Fig. 7-3B). Use of roller
skates on a powdered sun mica board is ideal (Fig. 7-3C).
The same method can be used to improve the range of
elbow extension.
(d) The forearm pronation and supination should be

initiated as rhythmic active assistive or free active
movement by keeping the forearm fully supported on
the thigh with elbow in flexion (Fig. 7-4).
FIG. 7-3 (A) Relaxed active free elbow flexion and extension in prone. (B)
On knee ratchet. (C) With roller skates.
FIG. 7-4 Relaxed free pronation and supination with the forearm fully
supported on the thigh.
When the pain is substantially reduced, a wand could be used to

begin active movement. It can apply gentle stretch to regain the
extreme range of all the four movements (Fig. 7-5) by contralateral
hand.
FIG. 7-5 Active elbow mobilization with wand. Gentle self-assistive stretch
may be applied to further the range of motion after assuring pain-free
relaxation.
Functional use of elbow and forearm has to be emphasized except

lifting heavy objects.
Caution
By 5 weeks following the injury or 2 weeks following mobilization,
if there is no appreciable improvement of elbow ROM, elbow should
be carefully examined for suspected bony block. This may need
surgical intervention.
B. Fractures managed by excision of the displaced fragment
The regime of physiotherapeutic management, in the event of

excision of the bony fragment, follows the same pattern as outlined for
conservative management.
The patients treated surgically may have persistent pain for a longer
time. Home treatment with exercises in warm water and use of
whirlpool or steam pack in the department may be useful.
An acceptable range of all the four movements should be regained
by 5–6 weeks following injury.
Supracondylar fracture of the humerus

It is one of the most common fractures in children. This fracture
results from a direct injury, e.g., fall on the point of elbow, or an
indirect injury, e.g., fall on the outstretched hand. The distal fragment
may be displaced posteriorly (extension type of fracture) or anteriorly
(flexion type of fracture). The former is the most common type (Fig. 7-
6).
FIG. 7-6 Supracondylar fracture of the humerus. (A) Flexion type. (B)
Extension type.
The brachial artery and the median nerve may be injured by the
sharp distal end of the proximal fragment (Fig. 7-7). It is therefore
important to test for the neurovascular status distally.
FIG. 7-7 The brachial artery may be injured by the sharp edge of the
proximal fragment.
X-ray: An X-ray (AP and lateral views) is essential to study the type
of fracture and the displacements (Fig. 7-8 A and B).
FIG. 7-8 Internal fixation of supracondylar fracture by Kirschner wires. (A,

B) Preoperative and (C, D) postoperative radiographs.
Treatment
1. Closed reduction: The fracture is reduced by closed manipulation
under general anaesthesia. After reduction, the extension type of
fracture is immobilized in an above-elbow plaster slab with the elbow
in flexion, whereas the flexion type (less common) of fracture is
immobilized with the elbow in extension. In either case the plaster is
removed after 3 weeks.
2. Traction: In cases where closed reduction has failed or in late (more

than a week old) cases, the fracture is treated by Dunlop traction (Fig.
7-9). The traction is maintained for 3 weeks.
3. Open reduction: Open reduction of fracture is indicated when (a) the

closed manipulation fails, (b) the brachial artery is injured and needs
exploration and (c) there is an associated nerve palsy which needs
exploration.
FIG. 7-9 Treatment of supracondylar fracture by Dunlop traction.
The fracture fragments are fixed internally with Kirschner (K-)

wires (Fig. 7-8). Postoperatively, the limb is immobilized in a posterior
slab with the elbow in flexion for 3 weeks. The K-wires are also
removed after 3 weeks and the elbow is mobilized.
Complications: The complications of supracondylar fractures can
be divided into the following two groups:
(a) Early complications

(b) Late complications
Early complications
These complications occur at the time of injury or

immediately thereafter.
1. Injury to the brachial artery: This is the most serious

complication in which the radial artery is injured by the
sharp edge of the proximal fragment (Fig. 7-7). The
artery may actually be lacerated or may just go into
spasm. This jeopardizes the blood supply to the flexor
muscles of the forearm resulting into Volkmann
ischaemia. This condition should be diagnosed early and
treated immediately.
Diagnosis: There is a sudden increase in pain in the forearm and

stretch pain. Stretch pain is elicited on the flexor aspect of the
forearm when the fingers are passively extended.
Treatment: A suspected case of Volkmann ischaemia should

be treated as an emergency to prevent irreversible changes.
The treatment consists of the following:
◼ Removal of the tight bandage/plaster/splint immediately
◼ Elevation of the forearm
◼ If no improvement is seen within 2 h, surgical operation of

decompression of the tight flexor compartment
(fasciotomy)
◼ Surgical exploration and repair of injury to the brachial

artery
2. Injury to the peripheral nerves: Median, radial and ulnar

nerves may be injured, in that order. In the majority of
cases the nerves may recover spontaneously.
Late complications
1. Malunion: Malunion is the most common complication

of supracondylar fracture of the humerus, resulting in a
cubitus varus deformity (Fig. 7-10).
Treatment: If the deformity is unacceptable cosmetically, it

needs corrective osteotomy in the supracondylar area of
the humerus.
2. Myositis ossificans: Myositis ossificans is ectopic new

bone formation around the elbow (Fig. 7-11). This is a
common complication, which occurs following massage
to the elbow after injury and results in stiffness of the
elbow.
Treatment: In the acute painful stage, the elbow is

immobilized in an above-elbow plaster slab for about 3
weeks. Otherwise, the treatment is mobilization.
Occasionally, an attempt may be made towards surgical
excision of the myositis mass followed by mobilization of
the elbow, after the myositis mass has consolidated.
However, recurrence is common.
3. Volkmann ischaemic contracture (VIC): Volkmann

ischaemia, if not treated in time, gradually progresses to
VIC. The ischaemic muscles are gradually replaced by
fibrous tissue, which contracts and draws the wrist and
finger into flexion. If the peripheral nerves (commonly
the median nerve) are also damaged by ischaemia, there
will be sensory and motor paralysis in the forearm and
hand.
Diagnosis:
(i) There is marked wasting of the forearm muscles and the

characteristic deformity of flexion of the wrist and fingers
(Fig. 7-12).
(ii) Volkmann sign: In this sign, the finger cannot be fully

extended passively with the wrist extended; but fingers
can be fully extended passively when the wrist is flexed
(Fig. 7-13). This sign is pathognomonic of VIC.
Treatment: In established cases, restoration to normalcy is

impossible because irreversible damage has occurred to the
important muscles and nerves. However, reconstructive
surgery can improve some function in the hand.
Mild cases can be treated by (i) stretching exercises and (ii)

use of a turnbuckle splint (Fig. 7-14), which gradually
stretches the contracted muscles.
Moderate cases require a muscle slide surgical operation (also

called Maxpage operation) where the flexor group of muscles
are released from their origin.
Severe cases can be treated by proximal row carpectomy and

wrist arthrodesis.
FIG. 7-10 Cubitus varus deformity of the left elbow.

FIG. 7-11 Myositis ossificans on the anterior aspect of the elbow.

FIG. 7-12 Volkmann ischaemic contracture (VIC) with typical posture of

the wrist in flexion, metacarpophalangeal (MCP) joints in hyperextension,
and proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in
flexion.
FIG. 7-13 Volkmann sign: (A) The fingers can be fully extended with the
wrist in flexion. (B) When the wrist is extended, the fingers go into flexion
and full extension of the fingers is not possible.
FIG. 7-14 Turnbuckle splint used for correction of Volkmann ischaemic

contracture.
Basic objective: The basic objective is to achieve active full-range
movement of the elbow and forearm.
Supracondylar fractures in children: The most common fracture in
children is the extension type where the lower end of humerus is
displaced posteriorly.
The physiotherapeutic programme depends upon the type of initial
management of the fracture.
Conservatively managed fractures
During immobilization (first 3 weeks): The fracture is managed

either by (a) manipulation with closed reduction, or by (b)
Dunlop traction.
(i) Proper checking of plaster slab/traction to ensure proper

immobilization and freedom of the thumb and fingers
(ii) Vigorous, strong full-range movement for free joints to
reduce inflammation and augment healing
Mobilization (after 3 weeks)
(i) Evaluation of the ROM at the elbow and the forearm

should be accurate.
(ii) Before initiation of mobilization, adjuncts of

thermotherapy like paraffin wax bath and hydro collator
packs should be applied. They induce relaxation, reduce
pain and augment local circulation providing comfort
and encouragement for exercise.
(iii) Movements at the elbow should be initiated in the

form of active assisted rhythmic movements in a gravity-
eliminated position. Use of roller skates provides
excellent means at this stage. It can be carried out several
times at home on a dining table. However, alignment of
the elbow joint and proper stabilization of the arm,
leaving the elbow joint free to move (avoiding friction of
elbow with the top of the table), has to be ensured.
(iv) Flexion is an important component of the elbow

movements. It should be initiated and emphasized as
described earlier in prone position (Fig. 7-3A), or by
modified use of the knee ratchet (Fig. 7-3B) or by roller
skates (Fig. 7-3C).
Extension at the elbow also needs to be emphasized.

Tendency for cubitus varus or valgus needs to be checked
at the extreme range of extension and recorded.
(v) Relaxed swinging of elbow flexion with supination and
elbow extension with pronation are ideal. It not only
induces relaxation at the elbow, but also promotes the
range of supination and pronation.
(vi) After a brief session of relaxed rhythmical free active

mobilization, further range should be attempted by
sustained stretching beyond the existing limitation for
both the movements.
The progress of the movement needs to be monitored at regular

intervals. The results in children are usually good and full range of
movement should be expected within 6–8 weeks.
Caution
Vigorous passive movements or passive stretching at the end of the
limitation or any kind of massage should be forbidden to prevent
myositis ossificans.
Fractures treated surgically
For fractures treated by K-wire stabilization following open

reduction, the physiotherapeutic management remains the same as
described for conservative management.
Adequate protection and care for the area of incision, and extra
encouragement are necessary in the process of mobilization.
If the fracture is associated with nerve injury, proper protective and
re-educative procedures are necessary along with other mobility
procedures.
Intercondylar fracture of the humerus

Adults following a fall on the point of elbow usually sustain this
fracture. The olecranon process is driven between the condyles, which
are fractured from each other and from the shaft by a T- or Y-shaped
fracture line (Fig. 7-15A). Comminution is commonly seen in these
fractures.
FIG. 7-15 Intercondylar fracture of the humerus. (A) Y-shaped and T-

shaped fractures. (B) Overhead traction immobilization. (C–E) Pre- and
postoperative radiographs of intercondylar fracture of humerus as treated
by internal fixation by plate and screws.
Diagnosis
The elbow joint is swollen and painful. The movements are grossly
restricted.
A radiograph of the elbow shows the diagnosis of the fracture. The
intercondylar fracture of the humerus is usually comminuted and
therefore a CT scan is often required to delineate the exact anatomy of
the fracture – this usually helps in planning the treatment.
Treatment
1. Plaster cast: An undisplaced or a minimally displaced fracture can
be treated using an above-elbow POP cast for 3–4 weeks.
2. Traction: Skin or skeletal overhead traction is applied to the forearm

(Fig. 7-15B). It is maintained for 3 weeks.
3. Open reduction and internal fixation: Open reduction is indicated in

fractures where the comminution is not severe. The fragments are
fixed internally with screws and/or plates (Fig. 7-15C–E).
Postoperatively, the elbow is immobilized in a plaster slab for about a
week. The elbow is mobilized early.
In this fracture, both the condyles of the humerus are separated from
the humeral shaft in the shape of a T or Y. The fracture not only
results in a gross injury to the soft tissues around the elbow joint but
also disorganizes the joint. Therefore, the results are usually poor. The
degree of stiffness is severe, when the fracture is comminuted.
Fractures treated by a conservative approach

Immobilization (First 3 Weeks)
1. Vigorous strong movements for the joints which are free; wrist to be
moved with assistance by temporarily removing hand support sling in
traction, besides finger and thumb movements
2. Carefully monitored isometrics to be initiated for deltoid without

disturbing the immobilization
Mobilization (After 3 Weeks):

Mobilization needs to be taken as an important priority and
maximum efforts are needed to achieve it.
Initially, suitable thermotherapy adjunct should be given for an
extended period to obtain maximum relaxation. Techniques of
mobilization described earlier for supracondylar fracture (Figs 7-1, 7-3
and 7-4) should be used.
However, considering the poor prognosis, periods of sustained
gentle stretches by using modified knee ratchet techniques for
improving the range of flexion and extension are ideal (Figs 7-1 and 7-
5). At the same time, efforts should be made to achieve early the
maximum range of pronation and supination. In the absence of the
acceptable range of flexion and extension, good return of the
movements of forearm rotation assists in the functional use of hand
and is therefore important.
Tying a cuff and collar sling in the maximally attained flexion exerts
continuous gentle traction facilitating flexion for the functional use of
hand (Fig. 7-16). Although this technique facilitates flexion, it has the
disadvantage of restricting the range of extension at the elbow and,
therefore, needs to be used judiciously.
FIG. 7-16 Maintenance of extreme flexion achieved following mobility
exercise to offer continuous light stretching effect by cuff and collar sling.
A careful and controlled passive stretching technique can be used

after 6 months to regain further ROM (Stoddard, 1971).
Fractures treated by a surgical approach

Open reduction and internal fixation (ORIF) by multiple screws or
plating has two distinct advantages:
1. Stabilization of the fracture
2. Initiation of active physiotherapy immediately following healing of

the soft tissue in 8–10 days
The chances of regaining the functional range of movement are

better.
The method of management is the same as described for the
conservative approach. However, care should be taken of the surgical
incision.
Fracture of single condyles of the humerus

Isolated fractures of the lateral condyle of the humerus and medial
epicondyle of the humerus are seen in children. Fracture of the lateral
condyle of the humerus is more common and seen in the age group of
3–6 years (Fig. 7-17). Displacement in these fractures is common due
to the strong pull of common origins of the flexor and extensor groups
of muscles in the medial epicondyle and lateral condylar fractures
respectively. Undisplaced fractures are treated by a plaster slab for 2–
3 weeks.
FIG. 7-17 (A) Line diagram showing a displaced fracture of the lateral
condyle of humerus. (B) As seen on a radiograph. (C) Normal radiograph of
the elbow for comparison. (D) Fracture of the lateral condyle of the
humerus fixed by K-wires.
Displaced fractures need ORIF by K-wires (Fig. 7-17D). Fracture of

the medial condyle of the humerus in adults needs internal fixation
with plate and screws (Fig. 7-18). Postoperatively, the elbow is
immobilized in 90 degrees of flexion for 3 weeks.
FIG. 7-18 (A) Comminuted fracture of the medial condyle of the humerus
in an adult. (B) Treated by plating.
Complications
1. Nonunion of the fracture is usually seen in untreated displaced
fractures.
2. There is tardy ulnar nerve palsy.
3. Nonunion of the lateral condylar fracture can cause cubitus valgus

deformity in growing children. The cubitus valgus deformity can in
turn be a cause of tardy (late) ulnar nerve palsy (Fig. 7-19).
4. Injury to the ulnar nerve may be associated with fracture of the

medial epicondyle of the humerus.
FIG. 7-19 (A) Cubitus valgus deformity of the right elbow following
nonunion of the fracture of the lateral condyle of the humerus and (B) ulnar
nerve palsy on the right side in the same patient. The wasting of the
interossei is conspicuous on the dorsum of the hand.
These fractures are treated conservatively or by reduction and K-wire
stabilization. In both the approaches of management, active
physiotherapy for the elbow is begun after 3 weeks of immobilization.
It is to be carried out in the same phases as described for the
supracondylar fracture. The following measures will also be needed.:
1. The parents need to be educated to watch for any signs of ulnar

nerve compression in patients with fractures of the medial epicondyle.
2. Possible weakness of flexor muscles in case of isolated fracture of

the medial epicondyle needs to be watched.
3. The extensor group of muscles in fracture of the lateral condyle

need to be watched critically. If weakness is present, appropriate
strengthening techniques for the affected muscle group should be
incorporated in the mobilization programme.
Pulled elbow
When a child, younger than 4 years, is lifted with a jerk by his/her
hand, the radial head can slip partly out of the annular ligament or the
annular ligament can slip over the radial head and cause severe pain.
The child does not use the hand and even resists examination. The
radiograph is normal.
Treatment
The forearm is gently pulled, with the elbow flexed, supinated and
pronated. This manoeuvre reduces the radial head back into the
annular ligament with instant relief from pain.
Dislocation of the elbow

Posterior dislocation of the elbow is commonly seen following a fall
on the outstretched hand with the elbow slightly flexed (Fig. 7-20).
The radius and ulna are pushed backwards resulting in rupture of the
periosteum from the lower end of the humerus and injury to the
brachialis muscle from the coronoid process.
FIG. 7-20 Posterior dislocation of the elbow: (A) Diagrammatic

representation. (B) Radiographic representation.
Rarely, anterior, lateral, medial or divergent dislocations of the

elbow may be seen.
The dislocation of the elbow may quite commonly be associated
with fracture of the coronoid process of ulna. Less commonly,
fractures of the condyles of the humerus, head and neck of radius may
also be present.
The ulnar nerve may get injured in a dislocation of the elbow and,
therefore, the clinical examination/evaluation must include tests for
ulnar nerve function.
Treatment
1. Closed manipulation, done under general anaesthesia, is often
successful. The limb is immobilized in an above-elbow plaster slab
with the elbow in flexion and the forearm in supination for 3 weeks.
2. Open reduction may be necessary:
(i) Where closed manipulation fails
(ii) In late cases
Complications
1. Stiffness of the elbow: It is usually seen if the dislocation is reduced

after 2–3 weeks of injury.
2. Myositis ossificans: Painful passive stretching, massage and

haematoma in the brachialis muscle can result in myositis ossificans
which, in turn, causes stiffness of the elbow.
3. Injury to the ulnar nerve
Results: The results are generally good in fresh cases treated

adequately in time.
The results of this type of injury largely depend upon three basic
factors:
1. Time of reporting
2. Adequacy of the initial management
3. Associated injury
In the first two approaches of closed manipulation and open

reduction, acceptable return of function is expected.
During the Period of Immobilization (First 3 Weeks)
1. Check the plaster cast to ensure freedom of movement of the free

joints.
2. Provide vigorous and strong exercises to all the free joints,

especially full-range shoulder abduction in elevation and rotation.
Finger and thumb exercises in elevated position with arm resting on
the tabletop are important. All these reduce swelling, and also the
process of inflammation.
3. This period should also be gainfully utilized to explain and guide

the total exercise regime on the normal side. This facilitates the
exercise programme on the affected side during mobilization.
Mobilization After 3 Weeks
1. Careful evaluation of the ROM of flexion and extension at the elbow

and pronation and supination at the forearm is done.
2. Evaluation of the degree of pain and swelling is also done.
3. Suitable thermotherapy modality may be used as an adjunct before

starting mobilization. Paraffin wax bath and warm saline water can be
used in the department and home, respectively.
4. Relaxed and rhythmical active assisted mobilization of the elbow

and forearm to be initiated as described previously.
5. To initiate mobilization, roller skates, wand or whirlpool bath, if

available, could be used.
6. Pronation and supination should be initiated in forearm lap

position.
7. Maintain the extreme range of elbow flexion and extension achieved

after exercises by properly tying sling in that position of flexion (Fig.
7-16) and by the assistance of a normal hand for extension. Valgus
stress at the elbow must be avoided while exercising.
During the process of mobilization, proper watch has to be kept for

the possible complication of myositis ossificans. Excessive tenderness
and inflammation around the brachialis insertion and reduction in the
ROM may be early signs of myositis ossificans. These, therefore, need
to be carefully monitored at each visit of the patient. Vigorous passive
movements, passive stretching and massage are strictly
contraindicated for the same reason.
The regime of exercises is progressed further emphasizing full-
range active movements and functional use of the whole upper
extremity.
By the end of 6–8 weeks, functionally acceptable results can be
achieved.
Fracture of the olecranon

This fracture occurs in adults following a direct injury due to fall on
the point of elbow; or an indirect injury due to fall on the hand with
elbow in slight flexion. Direct injury results in a transverse fracture.
The proximal fragment is displaced proximally by the pull of the
triceps muscle (Fig. 7-21).
FIG. 7-21 Fracture of the olecranon. (A) A fracture without displacement –

treated by an above-elbow POP cast. (B) A displaced fracture – treated by
internal fixation by screw or tension band wiring. (C) Comminuted fracture –
treated by excision of the fragments and reattachment of the triceps.
Diagnosis
There is pain and swelling on the posterior aspect of the elbow joint.
The patient will not be able to actively extend the elbow.
Radiograph: An X-ray (especially a lateral view) gives the diagnosis
of the fracture as well as the displacements of the fracture fragments.
The X-ray also gives information about the comminution of the
fracture, if present – this helps in deciding the exact method of
treatment.
Treatment
1. A fracture without displacement is treated with an above-elbow
POP cast (Fig. 7-21A).
2. ORIF with screws or tension band wiring is done for transverse

fractures (Fig. 7-21B).
3. ORIF by plating: A special olecranon plate is used in comminuted

fractures of the olecranon, which cannot be fixed by tension band
wiring (Fig. 7-22). Plating is also indicated in fractures of the
olecranon where the fracture extends into the shaft of the ulna.
4. In severely comminuted fractures, where reduction and internal

fixation is not feasible, excision of the proximal fragment of the
olecranon is done and the triceps is repaired (Fig. 7-21C).
FIG. 7-22 Special plate used for fixation of fracture of the olecranon.
In these methods, the elbow is immobilized in a POP slab for a

period of 2 weeks.
The physiotherapeutic management basically remains the same as for
supracondylar fractures.
Early return of terminal range of flexion and extension

Relaxed elongation of triceps is necessary for the terminal range of
flexion and that of biceps brachii for the terminal range of extension.
Therefore, gravity-assisted relaxed swinging in the terminal range of
flexion needs to be encouraged at the earliest. This should be followed
by terminal active stretch and hold. This will maintain the achieved
range of flexion. Repeat the same procedure for extension also.
Similarly, stretching and strengthening exercises to triceps need to
be instituted early to regain full function of surgically repaired triceps
in case of comminuted fractures.
Fracture of the head and neck of the radius

Fracture of the head of the radius is common in adults (Fig. 7-23),
while the fracture of the neck of the radius is usually seen in children
(Fig. 7-24). Both these fractures result when the elbow is subjected to
valgus strain during a fall.
FIG. 7-23 Fracture of the head of the radius. (A) Minimally displaced. (B)
Displaced fracture. (C) Comminuted fracture. (D) Fracture of the head of
the radius, as seen on radiograph.
FIG. 7-24 Fracture of the neck of the radius in a child.
The patient presents with pain and mild swelling over the lateral
aspect of the elbow following a fall on the outstretched hand.
On examination, there is tenderness over the head of the radius and
restriction of supination and pronation movements.
Radiograph: An X-ray can confirm the diagnosis and show the
fracture which can either be an incomplete fracture, a displaced
fracture or a comminuted fracture (Fig. 7-25).
FIG. 7-25 Mason classification.
Treatment
Fracture of the head of the radius
1. Conservative treatment: Undisplaced fractures are treated by a

posterior plaster slab for 2–3 weeks.
2. Surgical treatment:
(a) ORIF: Displaced fractures of the radius are treated by

ORIF with the help of special plates and screws (Fig. 7-
26).
(b) Excision of the radical head: A comminuted fracture in an

elderly person with low functional demands is treated by
excision of the head of the radius. The elbow is
immobilized, postoperatively, in a POP slab for a week
and then mobilized (Fig. 7-27).
(c) Replacement of the radial head: Comminuted fractures of

the head of the radius can also be treated by excision and
replacement of the radial head by a prosthesis (Fig. 7-28).
FIG. 7-26 Fracture of the head of the radius. (A and B) Preoperative and
(C) postoperative radiographs showing fracture of the head of the radius
treated by internal fixation using special plates.
FIG. 7-27 X-ray shows excision of the radial head.

FIG. 7-28 Replacement of the radial head by a prosthesis.
Fracture of the neck of the radius

Since this fracture occurs in children, the fracture fragments are never
excised for fear of impairment of growth. The fracture is reduced
either by closed manipulation or by ORIF using K-wires. The elbow is
immobilized in a plaster slab for 2 weeks. It is then mobilized after
removal of the K-wires.
In adults, the fracture of the neck of the radius can also be treated
by open reduction and internal fixation.
The programme of management is based on the same lines as for
supracondylar fracture.
The rotational movements of the forearm, i.e., pronation and
supination, need extra attention. As the movements are painful, the
forearm should be well supported on the thigh while sitting, and
active relaxed repeated rotation in both the directions needs to be
initiated early. The progress of rotation should be monitored at
regular intervals.
Complications following fractures around the elbow joint: The
complications following immobilization are more disabling then the
fracture itself. Therefore, prevention of the following expected
complications is of primary importance.
Common Complications
A. VIC
B. Injury to the peripheral nerves
C. Malunion
D. Myositis ossificans
E. Osteoarthritis
A. VIC: VIC occurs as a result of occlusion of the arterial circulation. If

not detected early, it may progress to muscular ischaemia (muscles on
the flexor aspect) which may progress to fibrosis, resulting in typical
Volkmann sign and the deformity of flexion of the wrist and fingers. If
not stretched, the progressive fibrosis of the flexors results in fibrous
ankylosis of the wrist and finger joints – giving rise to a typical VIC
deformity with wrist in flexion, metacarpophalangeal (MCP) joint in
hyperextension and flexion at the proximal interphalangeal (PIP) and
distal interphalangeal (DIP) joints (see Fig. 7-12). Ischaemia of median
and ulnar nerve results in sensory loss making the patient prone to
injury. Ultimately, it may result in a totally nonfunctional hand.
REMEMBER
Be extremely watchful for this dreaded VIC following fractures
around the elbow forearm and hand.
Signs and symptoms: Within 3–4 h following immobilization:

1. Severe intractable continuous pain all along the area
distal to the site of occlusion. Pain increases in intensity
on passive finger extension.
2. The fingers and toes become swollen and discoloured,

first pale and then blue, resulting in difficulty in
performing movements. Even blisters may appear.
3. Radial pulse is absent.
4. Muscular spasm develops with a hard and woody feel

on touching.
5. Loss of muscle extensibility – there is a feeling of

stiffness in the distal joints.
6. There is gradual loss of sensory status and motor

functions.
7. A typical diagnostic sign – the Volkmann sign –

develops (Figs 7-12 and 7-13).
If not attended immediately, it may progress to an

irreversible typical VIC deformity. The fibrosis of the flexor
group of muscles leads to flexion deformity at the elbow,
wrist, fingers and thumb. The forearm remains in
pronation and MCP joints in hyperextension. If not noticed
even at this stage, an increase in the compartmental
pressure may cut off the circulation completely leading to
gangrene. The median and ulnar nerves may also get
involved. The probable causes are as follows: (i) sustained
pressure on blood vessels due to tight POP, bandage or
splint applied for immobilization, (ii) injury to the brachial
artery, and (iii) latent disease of the vessel.
Preventive measures
1. The most important aspect of prevention is the education

of the patient or the parents regarding the expected signs
and symptoms of VIC. They must keep a close watch on
these and should report to the casualty at the earliest
indication. They may themselves remove the cast,
bandage or splint, causing pressure, in case they expect
delay in reaching the hospital. Ideally, the patient should
be properly checked daily for the symptoms of VIC for a
week.
2. Thorough examination of the POP splint or bandage to

confirm that it is not causing any undue pressure.
3. Check the radial pulse bilaterally, if feasible, to compare

and ensure that the radial pulse on the affected side is
not weaker compared to its counterpart.
4. Check the nail bed circulation by applying pressure on

the nail beds. The pressure causes whitening of the area
pressed, but it returns to normal as soon as the pressure
is released. It is an alarming sign if it remains white for a
longer period indicating that the circulation is slow.
5. Check the motor power and sensory status of the fingers

free from immobilization.
6. Check the distal free limb joints for the feeling of

coldness in comparison to the normal contralateral area.
Treatment (suspected cases): In case any of these signs
appear, perform the following:
1. Immediate removal or discontinuation of pressure

causing factors, e.g., splint, POP cast, bandage
2. Limb elevation and passive as well as active vigorous

movements of segments distal and proximal to the
affected area
3. Heat to be applied to the other limbs and the trunk to

promote general vasodilation (Adams, 1981)
4. Contrast bath, steam packs, massage and stimulation to

be used to augment local circulation and nerve
excitation, provided the sensory status of the affected
area is intact
Established cases: The prognosis depends upon the degree

of permanent damage to the muscle and nerves.
The prognosis is poor if there is total loss of sensation, feeble

motor function, stiffness in the joints and fibrosis of the
muscles.
However, functionally useful status can be achieved through

constant efforts by the patient and the team of specialized
personnel.
The first objective of the management is to stretch the

contracted and fibrosed soft tissues on the flexor aspect of
the forearm, wrist and hand to the maximum possible
extent. This is done by proper stabilization and carefully
graded relaxed passive stretching.
It is equally important to retain the stretch and elongation of

the soft tissues, achieved by relaxed passive stretching, by
using a turnbuckle splint.
The therapeutic approach depends upon the type of VIC.
1. Mild type: There is ischaemia of the flexor digitorum

profundus. It can be managed by exercises and dynamic
splinting to maintain finger extension.
2. Moderate type: It involves superficial as well as deep

finger flexors, and flexors of the wrist and thumb. If these
muscles are still functional, the conservative approach of
graded splinting and exercises are useful. Muscle
lengthening operation may be necessary in
nonresponding cases.
3. Severe type: Invariably needs surgery as the contractures

are progressed beyond the scope of conservative
management. However, preoperative passive relaxed
stretching and dynamic splinting facilitate surgery. Serial
splinting, as advocated by Sir Robert Jones in three
positions or stages, is ideal:
Stage I: The maximum extension is achieved and held at the

interphalangeal joints, wrist and MCP joints in full flexion
and the fingers are separately splinted.
Stage II: Maintaining extension at the interphalangeal joints,

gradual extension is achieved at the MCP joints by a splint
extending to the wrist.
Stage III: Maintaining extension at the interphalangeal and
MCP joints, graduated extension is achieved at the wrist.
Dynamic splint which provides graduated extension at the
wrist joint (extending from finger tips to elbow) is
incorporated with the previous two splints (Fig. 7-14).
The ultimate aim is to achieve maximum extension at the

wrist, which is a functional requirement. This needs careful
fabrication, fitting, use and maintenance of the splint,
which is the responsibility of an orthotist and
physiotherapist. The splint has joints at the wrist, MCP and
interphalangeal joints that can be easily adjusted at desired
angles. For increasing the extensibility of the contracted
soft tissues on the flexor aspect, effective adjuncts like
massage, ultrasonics and axial traction can be used, besides
relaxed passive movements. If the swelling persists, strong
voluntary movements with the limb in elevation should be
given. As and when the condition improves, the exercise
programme should be modified to achieve optimal
function.
Surgical treatment: In severe cases, recovery of normal

function is impossible. However, the following surgical
procedures may be done in selected cases:
(i) Shortening of forearm bones: It is done to overcome

contracture of the flexor group of muscles.
(ii) Muscle sliding operation: The contracted common flexor

groups of muscles are detached from their origin and are
allowed to slide distally. Also called Max Page operation,
this allows correction of the flexion contractures at the
wrist and finger joints.
(iii) Excision of the dead muscles: The necrotic muscle mass is

excised and replaced by a healthy muscle obtained from
the neighbourhood or from a distant site using
microvascular techniques in the latter case.
(iv) Nerve grafting: If the median nerve is damaged beyond

repair, nerve grafting may sometimes be helpful.
Physiotherapeutic management following surgery: In all the four

surgical procedures, the objective of physiotherapy is the
re-education of the muscle action. It depends upon the
extent of paralysis.
The muscle power, the joint range and the sensory status are
assessed preoperatively.
Postoperative management: The most important aspect is to

provide a corrective splint, incorporated with
immobilization. This is to maintain the corrected position
of the contractures, and assists, in movements.
Measures like diapulse, hand elevation and active resistive

movements of the related joints are carried out to reduce
inflammation and pain.
During mobilization: The basic therapeutic principles are as

follows:
1. Care of the anaesthetic areas
2. Re-education of the muscle action

3. Sensory re-education
4. Improvement of the functional efficiency
5. Modifications in the splint to further improve the

function
All these will proceed on the same lines as described for

peripheral nerve injuries.
During immobilization (4–6 weeks): Routine physiotherapeutic

measures are taken to reduce pain, inflammation and
swelling.
During mobilization: Emphasis is placed on early mobilization

of the elbow joint and strengthening of the elbow and
forearm muscles.
Regime of physiotherapy is the same as described for the

fractures in the region of the elbow joint.
B. Injury to the peripheral nerves: Median and ulnar nerves may be

involved. However, shortening and fibrosis of flexor muscles may
lead to ineffectiveness of the muscles supplied by the radial nerve.
If the sensory status is not adversely affected,

electrodiagnostic testing should be done to assess the
degree of nerve damage. The critical interpretation of these
diagnostic procedures forms the basis of treatment.
Principles of treatment
1. Prevention of contractures: It is achieved best by relaxed

passive full-range movements which should be self-
assisted and taught, to be practised slowly with proper
proximal stabilization and low-intensity sustained
stretching procedures.
Secondly, splints which can maintain constant small stretch

should be fabricated. The patient should be taught how to
apply and maintain them. Intermittent removal of the
splints is necessary.
2. Maintenance of circulation to the denervated muscles: It is

achieved by measures like limb elevation, crepe bandage
and passive ROM. Thermotherapy and electrical
stimulation can be given only if there is no sensory
deficit.
3. Strengthening of muscles and movements: There is a close,

interdependent relationship between the conducting
power of peripheral nerves and the strength of voluntary
contraction. Therefore, while planning an exercise
programme, maximum importance needs to be given to
this aspect. Meticulously planned and executed
strengthening exercises balanced with stretching
techniques form the most effective aspect of
improvement.
4. Concentration of functional movements: Graduated resistive

functional movements, as they are performed in daily
routine, need to be stressed. They contribute significantly
to improving the strength of activities and the
conducting capacity of the peripheral nerve fibres. In the
absence of true recovery, such attempted functional
movements with correct splints promote the activity by
compensatory mechanism. Therefore, care must be taken
to encourage such movements only when further chances
for nerve muscle recovery are extremely limited.
C. Malunion: Malunion or union of a fracture in malposition may

result in a deformity.
Following conservative management: The deformity is

treated conservatively if it is not severe and not causing
any pressure on vital structures like the peripheral nerve.
In this situation, the job of a physiotherapist is to improve

the functional performance, strengthen the muscle power
and educate for better performance of the whole extremity.
Functional splint can be given to minimize the effects of
deformity.
Following surgical management: The malunited

supracondylar fracture of the humerus causes either
cubitus varus or valgus deformity. The former is more
common. This deformity is corrected surgically by
performing corrective osteotomy. Postoperatively, the limb
is immobilized in a POP slab with flexion at the elbow for a
period of 4–6 weeks. The elbow is then mobilized.
D. Myositis ossificans: This is the most common and yet the most
difficult complication of injuries around the elbow joint (see Fig. 7-11).
Considering the degree of disability it causes, maximum

efforts should be made towards its prevention.
Preventive measures
1. A fracture should be fixed with proper alignment of the
elbow joint.
2. Proper immobilization of the elbow joint following

injury: Discourage early passive mobilization of the
elbow, so that the haematoma around the joint is allowed
to get absorbed rather than to dissipate into the
surrounding muscles and get ossified.
3. Signs and symptoms like local oedema, tenderness, pain

and decrease in mobility should be watched carefully. If
any of these is present, rest with total immobilization is a
must for 14–21 days.
4. Early vigorous movements, massage and passive

movements should be strictly avoided. These are
reported to be the causative factors of myositis ossificans.
In suspected cases: Rest with immobilization has to be

continued further. Regular check-up of ROM and
radiographs is done till the ossification progresses to the
third and final stage of dense shrunken mass.
In confirmed cases: Once the progress is arrested, a vigorous

exercise programme including graduated, sustained but
gentle passive stretching can be started to regain maximum
possible ROM.
The patient needs to be educated and guided on the process

of these exercises to make the home treatment programme
effective.
Vigorous active exercises by using aids like roller skates help

in improving the mobility in the available ROM, which is
required in the functions of daily routine.
Surgical treatment: Surgery is rarely indicated in myositis

ossificans. Surgical excision of the myositis mass is
undertaken only after the radiographic evidence of its
consolidation. It may take 6–9 months for the myositis
mass to consolidate. Since there is a high incidence of
recurrence following surgery, the role of surgery is
controversial. It is done only if the elbow is ankylosed in a
functionally unacceptable position.
Postoperatively, the limb is immobilized in a plaster slab for

a period of 1 week, following which movements are
started.
Physiotherapeutic management: The basic objective of

physiotherapy is to restore maximal ROM and strength at
elbow.
During immobilization
1. To control pain and inflammation, diapulse can be

effective
2. Resistive full ROM to shoulder and hand
3. Light isometrics to muscle groups around elbow
Mobilization (2–3 weeks)
Gradual mobilization should be started after removal of the

slab.
1. It should be started as an assisted active free movement
by using roller skates, sling suspension or hydrotherapy.
2. Carefully monitored relaxed passive movements can be

started avoiding passive stretch.
3. Accurate measurement of ROM should be done at

regular intervals.
4. Gentle isometrics should be provided to the flexors as

well as extensors.
5. Gravity-assisted elbow flexion and extension should be

started on the knee ratchet maintaining low-intensity
long gentle stretch for further increase in the ROM.
6. Free self-assisted forearm pronation and supination

should be initiated by placing forearms on the thighs.
7. It is important to maintain the ROM of flexion by

adjusting the angle of the sling.
8. Gentle stretching sessions may be preceded by

superficial heating procedures like hydropacks.
After 3 weeks
If inflammation, swelling as well as pain have reduced, the

methods of mobilization and stress are made progressive.
The range of forearm rotation should be full by this time.
Vigorous active free movements are encouraged by using

skates. They can be made resistive by putting weight (e.g.,
sandbag) over the roller skates and performing them
slowly.
By 6 weeks, a good functional range and strength should be

regained.
But, on many occasions, a stiff or flail elbow may be

encountered. The former may be considered for
manipulation under general anaesthesia and intensive
muscle strengthening procedures for the latter.
Sideswipe injury of the elbow

This injury results when, for example, the flexed elbow, sticking out of
a car or bus window, is hit by another passing vehicle. It is often an
open injury (Fig. 7-29) and consists of fractures of the lower end of the
humerus, upper end of the ulna and the radius with anterior
dislocation of the elbow (Fig. 7-30).
FIG. 7-29 Radiograph showing various fractures around the elbow and
clinical photograph showing the associated open injury.
FIG. 7-30 Sideswipe injury to the elbow. DH: fracture of the distal end of
the humerus, FU: fracture of the upper end of the ulna, AD: anterior
dislocation of the elbow.
Treatment
It is a difficult injury to treat. The problems are too many: open
wound, dislocation of elbow and multiple fractures (Fig. 7-31).
Treatment of dislocation gets priority over the fractures. The trend is
to immobilize the limb in an external fixator for a period of 6–8 weeks
because of the open wounds.
FIG. 7-31 Fractures of both bones of the forearm. AP and lateral

radiographs showing transverse fracture of the radius and oblique fracture
of the ulna.
However, occasionally the fractures in the humerus or ulna can be

fixed internally by a plate or nail (Fig. 7-32).
FIG. 7-32 Fractures of the humerus and ulna fixed internally by plates and
screws; dislocation of the radial head reduced.
Results: The results are poor as stiffness invariably results.
Basic objective: To regain maximum functional range of movements
of elbow and hand.
As the extent of damage and the management of this injury is
complex, the results are poor as regards ROM.
Physiotherapeutic treatment is the same as for posterior dislocation
of the elbow. In spite of the poor prognosis, efforts should be made to
regain the maximum possible range of movements.
Encouragement is given to early functional use of the elbow and
forearm rather than repeatedly attempting for the anatomically correct
groove of movement.
If the affected limb is nondominant, return of rotation movements
of the forearm gives the patient an acceptable functional range as the
stability of the elbow is not a problem. Therefore, whenever it is not
possible to regain the functional range of elbow flexion and extension,
efforts are concentrated on improving the range of pronation and
supination. Strengthening of the wrist and fingers, shoulder and
forearm should be initiated from the initial phase of treatment to
provide maximum compensation for the stiff elbow joint.
CHAPTER
8
Injuries of the forearm
OUTLINE
◼ Fractures of the radius and ulna
◼ Isolated fractures of the radius and ulna
◼ Fracture and dislocation of the forearm
Fractures of the radius and ulna

Fractures of the shaft of both the forearm bones (radius and ulna) are
seen at all ages. A direct injury results in a transverse (see Fig. 7-31) or
a comminuted fracture which may be an open fracture. An indirect
injury, e.g., fall on the outstretched hand, causes oblique or spiral
fractures. Displacements of the bone fragments commonly occur due
to the pull of supinator and pronator group of muscles (Fig. 8-1). In
the forearm, there is a predominance of supinators (biceps and
supinator) on the proximal fragment which produce an unopposed
supination of the proximal radius fragment. Similarly, in the distal
half of the forearm, there is dominance of pronators (pronator teres
and pronator quadratus, which produce pronation of the distal radial
fragment. Fractures in children are usually of a greenstick variety (Fig.
8-2).
FIG. 8-1 Preponderance of supinators in the proximal part of the forearm,

and pronators in the distal half.
FIG. 8-2 Greenstick fracture of the lower end of radius.
Treatment
The treatment of these fractures can be conservative or operative.
An undisplaced fracture does not need manipulation. For

displaced fractures, closed manipulation under anaesthesia
is carried out. In children, closed reduction alone is often
successful. While in adults an attempt is always made to
reduce the fracture by closed manipulation. If the fracture
pattern is of an unstable variety or the reduction is
unsatisfactory, open reduction becomes necessary.
After reduction, the limb is immobilized in an above-elbow

plaster cast with the elbow in flexion. Some surgeons
prefer to keep the forearm in supination for upper one-
third fractures, in mid-prone position for mid one-third
fractures and in full pronation for the lower third fractures.
The rationale for these positions of immobilization is that
there is preponderance of supinator muscles in the
proximal third of the forearm while pronators are
dominant in the distal third. Others prefer to immobilize in
mid-prone position only to facilitate the functional
performance in the event of stiffness. The plaster is
maintained for 3–6 weeks in children and 8–10 weeks in
adults.
2. Operative treatment
It is indicated where closed manipulation has failed or a

good initial reduction has been lost subsequently in the
plaster. The bone fragments get displaced because the
swelling subsides after some time and the plaster becomes
loose.
Operative treatment is also carried out in fresh open

fractures. Stabilization of these fractures by external
fixators facilitates wound care.
The commonly used method of internal fixation is by plates

and screws (Fig. 8-3A). Another method of internal fixation
by intramedullary nails (Fig. 8-3B) is also employed
occasionally.
After internal fixation, the limb is immobilized in an above-

elbow plaster cast for a period of 4–6 weeks, with the
elbow in flexion and forearm in mid-prone position.
FIG. 8-3 Internal fixation by (A) plating, (B) intramedullary nailing.
Complications
1. Nonunion: When the fracture fails to unite, open reduction and
internal fixation along with bone grafting are indicated.
Postoperatively an above-elbow plaster cast is maintained for a period
of 6–8 weeks.
2. Malunion: Angulatory deformity of the forearm results when the

fracture unites in a malposition. It not only results in an ugly
deformity but also leads to restriction of rotation of the forearm.
If the angulation/deformity is severe, surgical correction of

the deformity with internal fixation and bone grafting is
undertaken. The period of immobilization after surgery is
6–8 weeks.
3. Cross-union: When the fractures of radius and ulna are at the same
level, the chances of cross-union due to fibrous or bony bridging (Fig.
8-4) are high. Cross-union causes restriction of pronation and
supination of the forearm. In such fractures, the forearm is preferably
immobilized in mid-prone position. Should cross-union occur, the
forearm would still be in a functional position.
FIG. 8-4 Cross-union between radius and ulna.
Fractures treated by conservative approach
During immobilization (first 3–6 weeks in children and 8–10 weeks in
adults): Initially, all the measures to control the process of
inflammation are adopted.
As soon as the fracture is reduced and the patient is in a position to
do exercises, active full range strong movements should be initiated to
the muscles and joints which are not immobilized (e.g., shoulder,
fingers and thumb). Shoulder movements should be emphasized to
the full range, especially in adult patients to avoid secondary stiffness
and pain and to improve circulation to the whole limb. At the outset,
the physiotherapist must check that a full range of passive flexion at
the metacarpophalangeal (MP) joints is possible and that the plaster is
not hindering the terminal range of flexion at these joints. While
encouraging and emphasizing the movements of digits to improve
circulation and oedema, the movements should be fast, strong and
forceful to dissipate the lymphatic fluid effectively (Basley, 1981).
Somehow the tendency is to be gentle and to accept the patient’s
reluctance.
The patient should be taught to do isometrics for elbow flexors and
extensors while the limb is in the cast.
Mobilization (after 3–6 weeks in children and 8–10 weeks in
adults): Vigorous active relaxed movements of the elbow and wrist
should be initiated. One has to be careful in initiating and
emphasizing the movements of pronation and supination. It is carried
out as relaxed free movements with the forearm fully supported over
the thigh with the patient in sitting position (see Fig. 7-4). As the pain
becomes less, self-assisted stretching by the contralateral hand should
be started (Fig. 8-5).
FIG. 8-5 Self-assisted passive stretching pronation and supination. (A) By
using contralateral hand and (B) by wand.
The patient is made to sit on a stool with his back against a wall.
The elbow is kept at 90 degrees with its posterior aspect touching the
wall. The active relaxed stretching of pronation and supination are
facilitated by holding a wand. Supination and pronation combined
with relaxed active elbow flexion and extension, respectively, facilitate
early return of these movements. We have found this method very
effective.
Gradual progression may be made to full range resistive pronation
and supination.
Children generally get full function within 8–10 weeks, while adults
require 14–16 weeks and yet may not get full range of rotation.
However, functionally adequate range is usually regained.
Fractures treated surgically: In fractures treated by external fixator
or by internal fixation, the period of immobilization is usually short
(4–6 weeks). Moreover, the stability of the fracture is assured. These
two factors contribute towards an early mobilization and better
recovery.
Vigorous exercise programme can be initiated after removal of the
external fixator or plaster cast.
The physiotherapeutic treatment is the same as described for the
fractures treated by conservative methods.
A near normal range of motion including strong rotation can be
achieved by 8–12 weeks.
Complications: When surgery is performed for nonunion or

malunion, the regime of postoperative physiotherapeutic
management remains the same as described earlier.
Restricted movements: Passive stretching to regain

maximum possible range of pronation and supination has
to be initiated immediately after removal of the plaster.
In case of cross-union, the movements of pronation and
supination are invariably restricted. The patient has to be
trained to perform the activities of daily living (ADLs) by
adopting compensatory techniques, e.g., abduction of the
shoulder joint to compensate for forearm pronation and
shoulder adduction to compensate for forearm supination.
Isolated fractures of the radius and ulna

Isolated fracture of the radius in the lower fourth region commonly
occurs in children due to a fall. It is a greenstick fracture which needs
a below-elbow plaster cast for only 3 weeks. Results are good.
Isolated fracture of the ulnar shaft occurs in adults following a
direct blow (Fig. 8-6). By natural reflex, it is the forearm (ulnar aspect)
that is brought forward to protect the face from a blow or an injury. It
is also called nightstick fracture.
FIG. 8-6 Isolated fracture of the lower end of ulna.
Treatment
It is treated by an above-elbow plaster cast for about 6 weeks.
Displaced fractures may need open reduction and internal fixation.
Occasionally, nonunion may occur. However, overall results are
excellent.
Fracture of radius in the lower fourth region: No specific techniques in
physiotherapy are needed. The patient may be guided on simple
techniques of mobilization of the elbow and forearm.
Isolated fracture of the shaft of ulna: The physiotherapeutic
management remains the same as described for fractures of both
bones of forearm. Regaining full range of pronation and supination
does not pose any problems as radius is not affected.
Full range of motion (ROM) is regained within 8–12 weeks.
Fracture and dislocation of the forearm

There are two types of injuries where fracture of one forearm bone is
associated with dislocation of the radio-ulnar joint. These injuries are
as follows:
Monteggia fracture
In this injury, fracture of the upper half of the ulna is associated with
anterior dislocation of the radial head (Fig. 8-7).
FIG. 8-7 Monteggia fracture. (A) Normal relationship of ulna and radius at
the elbow, (B) fracture of the upper half of the ulna with dislocation of the
head of radius and (C) as seen on a radiograph.
Treatment
In children, the fracture dislocation is reduced by closed
manipulation. Immobilization is carried out in an above-elbow plaster
cast with the elbow in flexion and the forearm in supination for a
period of 4–6 weeks.
In adults, in fresh cases, closed manipulation is often successful in
reducing both the radial head dislocation as well as the fracture of
ulna. The limb is immobilized in an above-elbow plaster of Paris
(POP) cast for 4–6 weeks. Sometimes the fracture of ulna may be fixed
internally by a plate which can reduce the period of immobilization to
about 4 weeks. Late reported cases may need internal fixation of the
ulna and excision of the head of radius. The results are not good in the
latter.
1. Treated conservatively: In children, the physiotherapeutic

management does not pose any problems and full function is possible
in 8–10 weeks with simple guidance on elbow and forearm
movements.
In adults, initial measures are taken to control inflammation,

pain and swelling. Strong and full range movements,
especially to the metacarpophalangeal joints, need to be
emphasized.
After removal of the plaster cast, a vigorous exercise

programme for elbow flexion–extension and forearm
pronation–supination has to be concentrated and
progressed as outlined earlier for fractures of both bones.
The only difference being the persistence of elbow stiffness
for a long period due to anterior dislocation of the radial
head.
2. Treated surgically: The physiotherapeutic management basically

follows the same stages as outlined for conservatively treated
Monteggia fractures.
If reduction of the head of radius is achieved and

maintained, then the results are good and effectively
functional range can be achieved by 8–12 weeks. However,
in late reported cases, even after surgical procedures, the
results are unpredicted as regards ROM.
Galeazzi fracture
Fracture of the lower third of the radial shaft is associated with
dislocation of the inferior radio-ulnar joint (Fig. 8-8).
FIG. 8-8 Galeazzi fracture dislocations: (A) normal anatomy of radius, ulna
and inferior radio-ulnar joint and (B) Galeazzi fracture dislocation. Note the
fracture of the lower half of the radius (R) with dislocation of the inferior
radio-ulnar joint. (C) Galeazzi fracture: fracture of the lower third of the
radius with dislocation of the inferior radio-ulnar joint as seen on
radiograph. (D) Fracture of the radius fixed internally by a plate. Note that
the inferior radio-ulnar joint is also reduced.
Treatment
Closed reduction of the fracture rarely succeeds; even after a good
reduction, the fragments get redisplaced after a week or two in the
plaster. The treatment of choice, therefore, is ORIF of the fracture.
Plate and screws are used for internal fixation of the fractures (Fig. 8-
8D). Postoperatively an above-elbow plaster cast is given for 4–6
weeks.
It proceeds almost on the same lines as described for Monteggia
fracture.
It differs from Monteggia fracture in that the injury is away from
the elbow joint and as such, return of the range of elbow joint
movement is faster and better. But dislocation of the inferior radio-
ulnar joint delays the return of pronation and supination of forearm.
Therefore, these movements need special emphasis. Acceptable range
of pronation and supination as well as wrist flexion–extension can be
achieved by 8–12 weeks in almost all patients.
CHAPTER
9
Injuries of the wrist
OUTLINE
◼ Colles’ fracture
◼ Smith’s fracture
◼ Barton’s fracture
◼ Fracture of the distal radius: current status
◼ Fracture of the scaphoid
◼ Injuries of the lunate
Colles’ fracture
Fracture of the lower end of radius within 1 inch of the distal articular
surface of radius is called Colles’ fracture. This fracture occurs at the
cortico-cancellous junction of the bone and hence, it almost always
unites. It is the commonest fracture seen in middle-aged and elderly
patients, particularly women, following a fall on the outstretched
hand with the wrist in extended position. Amongst the important
displacements of this fracture, the distal fragment is displaced and
tilted dorsally (Fig. 9-1) which gives the hand and wrist a typical
deformity called ‘dinner fork’ deformity. The other displacements are
proximal impaction, radial deviation and supination of the distal
fragment.
FIG. 9-1 Colles’ fracture. (A) Extra-articular fracture with dorsal

displacement and tilt of the distal fragment resulting in a deformity which
resembles a (B) dinner fork. (C) Colles’ fracture as seen on radiographs.
Treatment
Manipulation: Closed manipulation is performed under anaesthesia
and the limb is immobilized in a below-elbow plaster cast for 4–6
weeks.
Displaced fractures can be treated by any of the following methods:
1. External fixator: Stabilization of the fracture by an external fixator is
indicated if the fracture is grossly comminuted (Fig. 9-2).
2. Internal fixation: In markedly displaced fractures, open reduction

and internal fixation is done by a buttress plate (Fig. 9-3) or by special
plates (Fig. 9-4).
FIG. 9-2 External fixator for distal radius.

FIG. 9-3 Fracture of the distal radius fixed by buttress plate.

FIG. 9-4 Fracture distal radius fixed by special plates.
Complications
1. Stiffness: Stiffness of the fingers and shoulder are the most common
avoidable complications of Colles’ fracture. The patient should be
encouraged to move the fingers, elbow and shoulder joints right from
the second day of injury.
2. Malunion: It is quite common in the event of total neglect of the

injury or by seeking the advice of quacks. It may also result if the
reduction had been inadequate or had slipped inside the plaster.
Severe comminution causes collapse of the multiple bony fragments
leading to malunion. A malunited fracture leaves an unsightly
deformity and there is restriction of palmar flexion, ulnar deviation
and supination.
3. Sudeck’s osteodystrophy: It is characterized by pain and stiffness in

the wrist and fingers, red shiny skin and osteoporosis of the bones of
the wrist and hand. The main problem is the stiffness of finger joints,
pain and oedema of hand (Fig. 9-5). The treatment consists of
maintaining finger joint mobility despite pain.
4. Carpal tunnel compression: The median nerve may get compressed in

the carpal tunnel following a Colles’ fracture. Though rare, early
decompression of the carpal tunnel is indicated for better results.
5. Rupture of the extensor pollicis longus tendon: The tendon of the

extensor pollicis longus may get ruptured in rare instances by attrition
over the rough area at the site of fracture. The treatment is repair of
the tendon or extensor indicis tendon transfer.
6. Nonunion: It is extremely rare but may require open reduction,

internal fixation and bone grafting.
FIG. 9-5 Sudeck’s osteodystrophy of the left hand: (A) Osteoporosis. (B)
Shiny skin and swollen hand. (C) Stiffness of the finger joints.
Giving due importance to the high incidence of the injury and also the
complications, the management programme needs extra attention and
proper guidance.
During immobilization: After reduction and immobilization,
proper guidance is needed to reduce oedema by the following
methods:
(a) Elevation of hand above the elbow, and elbow above the shoulder
(Boyes, 1964).
(b) Alons in his monogram advocated the use of electrical stimulation

on a sensory excitation level. He proposed that the electrical field
created in the tissues may trigger the lymphatic system to absorb
excessive fluid.
(c) Sorenson (1983) advocated the use of pulsed galvanic stimulation

to reduce oedema. His technique was to place the negative pole over
the oedema area and the positive pole at a proximal point, usually
over median or ulnar nerve distribution on the upper arm, to
stimulate good muscle pump action.
(d) Jobst (1983) devised an intermittent pressure glove to reduce

swelling in the exposed fingers and thumb. The pressure should be at
a point that is well tolerated and not more than 66–70 mm Hg. This is
usually done for 45 min to 1 h.
(e) A technique involving string wrapping the individual finger as

well as the exposed metacarpal volar pads also helps in reducing
oedema. Objective circumferential measurements before and after
treatment will determine the success of the technique.
(f) Checking the plaster cast to see that it is not hampering the full
range of metacarpophalangeal joints of the fingers and thumb.
(g) Full range passive as well as strong forceful active movements of

fingers effectively drain the excess lymphatic fluid from the digits in
the hand (Basely, 1981).
(h) Full excursion of all the movements at elbow as well as shoulder.
(i) Intermittent use of sling with elbow in at least 70 degrees of flexion,

as it maintains the elevated position of hand.
(j) Adjuncts like moist hot pack, infrared, warm soaks; cryotherapy
with ice massage and TENS could also be used.
All these procedures are helpful in improving circulation and
decreasing pain and oedema. They also alter the elasticity of tissues
and the viscosity of the synovial fluid. This further helps in
preventing joint stiffness besides augmenting bone healing.
On removing the plaster (3–6 weeks): If earlier programme is
carried out effectively, the only job that remains now is to concentrate
on the wrist and forearm movements.
A soothing heat therapy using hydrocollator pack or paraffin wax
bath induces relaxation, improves local circulation and puts wrist and
forearm in an ideal situation for exercises.
Wrist mobilization is initiated with a small range of relaxed speedy
flexion–extension with forearm in mid-prone position. The patient is
taught to stabilize the forearm just above the wrist joint. This
eliminates the force of gravity during flexion and extension at the
wrist (Fig. 9-6).
FIG. 9-6 Relaxed free active wrist mobilization.

As the wrist is immobilized in ulnar deviation, the movement of
radial deviation needs to be emphasized in the initial stages.
To initiate pronation and supination, the exercise described on the
lap is ideal.
If swelling and pain persist even after a session of exercise, use of an
intermittent sling may be necessary. After 1 week of discontinuing the
immobilization, the exercise regime should be made vigorous to
regain further range of motion at the wrist and forearm. A variety of
exercises using various aids like wand can be given. However, a
simple but effective regime, which can be done without aids, is as
follows:
1. Exercises to improve flexion–extension at the wrist: The patient, sitting

with palm over the edge of table, stabilizes hand by putting palm of
the other hand over it. The patient then gradually lowers the forearm
downwards for wrist flexion or upwards to improve wrist extension.
Initially, the relaxed speedy movements are done in a small range and
then slow stretch is applied to improve the range further (Fig. 9-7).
2. Exercise to improve pronation and supination: Wand or the good

hand can be used (as described for fracture of both bones of forearm).
FIG. 9-7 (A) Self-assisted passive stretching with palm over the edge of a
table. (B) and (C) Self-assisted wrist flexion and extension.
As the range improves, the movements can be made strong by

teaching isometric as well as isotonic self-resistive exercises or using
weights. Very often, passive range exceeds the active range of motion,
where adhesions of the tendons or weakness of the muscles is
predominant. The former needs measures like ultrasound, friction
massage or dynamic stretching splints and the latter needs resistive
exercises.
Functional use of the whole upper extremity and especially the
forearm, wrist and hand has to be encouraged and progressed right
from the initial stage.
The results are good by 8–10 weeks. However, if palmar angulation
of the articular surface is not achieved perfectly, there is a bony
obstruction to the range of flexion. These patients have limitation of
palmar flexion. Patients who are too sensitive to pain and do not allow
the terminal stretching of rotation usually have lack of full range of
pronation and supination.
In the majority of patients, adequate amount of motion and strength
are possible (Riggs & Conney, 1982).
Management of complications
1. Stiffness of fingers and shoulder: This is an avoidable complication
if the patient is referred for physiotherapeutic guidance on the second
or third day after plaster application. The best way is to demonstrate
to the patient full range movements on the normal side. The patient
should then be made to practise them on the fractured side under
supervision of the attending physiotherapist.
2. Malunion: As the union has already taken place, the

physiotherapist can attempt to seek further improvement of the range
of motion by using the technique of relaxed sustained stretch. If it
fails, compensatory tricky movements by manoeuvring shoulder
movement of abduction and adduction to facilitate apparent
pronation and supination, respectively, remain the only alternative.
3. Sudeck’s osteodystrophy: When present, physiotherapy is directed

to relieve pain, oedema and to check further development of stiffness
at the wrist, fingers and thumb. Proper positioning of the limb with
frequent elevation and a modality like ultrasound or TENS can be
used as an adjunct to reduce oedema and pain. However, major
emphasis has to be on the range of motion by active exercises.
Maximum possible use of these joints should be promoted by
encouraging functional movements of daily routine.
As the process of recovery is extremely slow in the majority
of patients, proper education on the home treatment
programme is important. The development of flexion
deformities of fingers should be checked by teaching self-
stretching exercises. This is done by teaching the patient to
keep the hand on the table with the palmar surface in
contact with the top of the table. Then the patient gradually
puts the normal hand over the dorsum of the affected hand
and exerts gradual pressure. This can be made effective by
putting a small sandbag to maintain sustained stretch or by
using a splint.
Residual flexion deformity of the metacarpophalangeal and

interphalangeal joints of fingers may persist even after
prolonged physiotherapy. The functional status of the
hand can be greatly facilitated by early control of pain and
use of the hand in day-to-day activities.
In some patients, the full functional recovery of hand may

take up to 3 years.
4. Carpal tunnel syndrome: see Chapter 27
5. Rupture of the extensor pollicis longus tendon
Early detection of this complication and surgical repair are

essential for obtaining good results.
After surgical repair of the tendon, measures for control of

pain and swelling are instituted. The emphasis should be
on (i) mobilization of the interphalangeal (IP) joint of
thumb and (ii) re-education of the repaired tendon to
effectively flex and extend the thumb at the
interphalangeal joint. Graduated self-resistive exercise with
proper stabilization of the thumb proximal to the IP joint
further improves range of motion (ROM) and strength at
the interphalangeal joint.
Smith’s fracture
It is a reverse Colles’ fracture where the distal fragment is displaced
volarwards (Fig. 9-8).
FIG. 9-8 Smith’s fracture – the distal fragment is displaced volarwards.
Treatment
Closed manipulation is performed under anaesthesia followed by an
above-elbow plaster cast for 4–6 weeks with elbow in flexion and
forearm in full supination. Open reduction and internal fixation by
buttress plate and screws may be necessary if closed reduction fails.
Barton’s fracture
It is an intra-articular fracture of the lower end of radius. The fracture
line is placed obliquely, separating either a large volar fragment (volar
Barton fracture) or a dorsal fragment (dorsal Barton fracture – Fig. 9-
9).
FIG. 9-9 Volar Barton’s fracture: (A) there is a fracture of the volar cortex
of the radius. The dorsal cortex is intact. (B) As seen on a radiograph.
Treatment
1. Closed manipulation is done under anaesthesia, followed by an
above-elbow plaster cast for 4–6 weeks.
2. Open reduction and internal fixation (Fig. 9-10) is indicated if closed

reduction fails or if the reduction is lost in plaster as it is prone to
redisplacement.
FIG. 9-10 Volar Barton’s fracture treated by internal fixation.
Physiotherapy for the Smith’s and the Barton’s fractures on the whole
follows the same pattern as described for the Colles’ fracture.
Fracture of the distal radius: Current status

The pattern of fractures of the lower end of radius (also called distal
radius) has changed considerably over the years from a relatively
simple Colles’ fracture to a much complex, often comminuted
fracture. The fractures seen these days are high energy injuries which
occur as a result of motorcycle accidents and sports injuries. The
newer classification of the fractures of distal radius broadly divides
them into the following three basic types:
1. Extra-articular fractures
2. Partially articular fractures
3. Combined extra- and intra-articular fractures.
Treatment
The following treatment modalities are used:
◼ Plaster of Paris (POP) cast
◼ Percutaneous pin fixation (Fig. 9-11)
◼ A combination of pin fixation and POP cast (Fig. 9-12)
◼ External fixator: The external fixators are of two types – bridging

and nonbridging (Figs 9-13 and 9-14).
◼ Bridging external fixator: It is the commonly employed

method. In this method, the proximal pins of the fixator are
put into the radius, proximal to the fracture, while the
distal pins are fixed in the second metacarpal bone. The
fixator thus spans across the fracture site.
◼ Nonbridging external fixator: In this method, the

placement of the proximal pins is the same but the distal
pins are passed into the distal fragment, thus sparing the
wrist joint.
◼ Internal fixation with special plates (see Fig. 9-4)
FIG. 9-11 Percutaneous pin fixation.

FIG. 9-12 Pre- and postoperative X-rays of fracture of distal radius treated
by (A) pin and plaster and (B) K-wires – a cost-effective and easy option.
FIG. 9-13 Bridging external fixator in the treatment of fracture of the distal
radius.
FIG. 9-14 Fracture of the distal radius treated by nonbridging external

fixator. Note that the distal pins are in the distal fragment keeping the wrist
joint free.
Fracture of the scaphoid

Fracture of the scaphoid is the commonest amongst all the carpal
bones. It is seen in adults following a fall on the outstretched hand.
The bone may be fractured at any of the three anatomical sites (Fig. 9-
15A) – the distal pole (the tubercle), the middle (the waist) or the
proximal pole. Fracture through the waist is the commonest of the
three. Union is generally not a problem in fractures of the distal pole.
However, the blood supply to the proximal fragment may be cut off in
fractures of the waist and the proximal pole as the vessels run in the
bone from the distal to the proximal end. Nonunion of the fracture
and avascular necrosis of the proximal fragment, therefore, may result
in fractures through the waist or proximal pole of the scaphoid.
FIG. 9-15 Fracture of scaphoid. (A) Common sites of fracture. T, tubercle;

W, waist; PP, proximal pole; VF, vascular foramina. (B) Immobilization by a
scaphoid POP cast gripping the first metacarpal and the proximal segment
of thumb. (C) Fracture of the scaphoid as seen on radiograph. (D) Fracture
united after internal fixation by a screw.
Treatment
1. POP Cast: Undisplaced or minimally displaced fractures are treated
by POP scaphoid cast. A scaphoid plaster cast is applied with the
wrist in slight dorsiflexion and radial deviation. The thumb is held
away from the palm in ‘glass holding’ position. The thumb is
incorporated in plaster up to the base of the nail while the finger
knuckles are kept free (Fig. 9-15B).
In fractures of the distal pole, the plaster is maintained for a

period of 3 weeks whereas for fractures of the waist and
proximal pole, the limb is immobilized for a period of 8–12
weeks.
2. Internal fixation:
(a) Minimally invasive surgery: Minimally displaced or

undisplaced fracture of the scaphoid through its waist or
proximal pole can be fixed internally with a cannulated
screw percutaneously by a minimally invasive surgical
technique.
(b) Open reduction and internal fixation: Displaced

fractures of the middle third or proximal pole of
scaphoid need open reduction and internal fixation using
Kirschner (K-) wires or cannulated screws (Fig. 9-15D).
Complications
1. Nonunion: In fractures of the scaphoid, the incidence of nonunion is
rather high. It is treated using ORIF by a K-wire or a screw and bone
grafting.
2. Avascular necrosis: In fractures of the waist and proximal pole of the

scaphoid, the blood supply to the proximal fragment may be cut off
resulting in avascular necrosis of the proximal fragment. In such a
case, excision of the proximal fragment and radial styloid gives good
results. The wrist is immobilized for a week after surgery.
3. Osteoarthritis of the wrist: Osteoarthritis of the wrist may develop in

later years following avascular necrosis and/or nonunion of the
fracture scaphoid (Fig. 9-16).
FIG. 9-16 Osteoarthritis of the wrist.
One of the following surgical procedures may be done to relieve

pain:
1. Excision of the proximal fragment and radial styloid.
2. Wrist arthrodesis: The limb is immobilized in a below-elbow plaster

cast for 3 months with the wrist in slight dorsiflexion and the knuckles
free.
During the initial period of immobilization, vigorous movements of
the shoulder, elbow, forearm, metacarpophalangeal and
interphalangeal joints should be encouraged and checked.
Resistive movements to the fingers and elbow are necessary to
augment the circulation at the fracture site.
After removal of the plaster: Fractures of the distal pole of the
scaphoid are easy to treat and do not need specific physiotherapy as
the period of immobilization is only 3 weeks.
Fractures at the waist and proximal pole require longer
immobilization. These fractures are difficult to unite in spite of the
longer period of immobilization, due to jeopardy in the blood supply.
Heavy resistive exercises to the free joints are, therefore, especially
important in these fractures.
Immediately after removal of the cast, reduction of pain assumes
priority and modalities like ultrasound, TENS and hot pack may be
employed.
Active mobilization of the thumb should be started immediately.
Power grasp should be avoided as it may put extra stress and increase
pain.
Relaxed passive mobilization is initiated and resistance is to be
added as early as permissible since stiffness may set in due to the long
period of immobilization.
Protective splint to immobilize the thumb may be necessary if the
wrist remains weak (Basley, 1981). Within 1–5 weeks following
removal of the cast, full and strong movements should return to the
wrist (Taleisnic, 1982).
Carefully controlled physiotherapy may succeed in achieving good
and strong hand function. In that case, surgical intervention may not
be necessary even in the presence of nonunion, avascular necrosis or
osteoarthritis of the wrist.
Noninvasive pulse electromagnetic field (PEMF) can be used
effectively to deal with nonunion or delayed union. It modifies cell
behaviour by inducing weak electrical currents. It vascularises and
calcifies the fibrocartilage which is replaced with bone. It has been
found to be highly successful in 84% cases of nonunion (Bassett et al.,
1982).
When excision of the proximal fragment and radial styloid is
performed, acceptable functional results can be achieved with routine
physiotherapy in 6 weeks.
In the event of wrist arthrodesis, besides other physiotherapeutic
procedures, special attention is necessary to re-educate and guide the
patient about the use of hand with ankylosed wrist joint. ADL training
assumes an important role in the management.
Injuries of the lunate

Fracture of the lunate is often missed on radiographs, if not looked
for carefully.
The lunate may be fractured through its body, following a fall on
the extended hand. Occasionally, there may be dislocation of the
lunate from its bed resulting in a rather complicated injury (Fig. 9-17).
Dislocation of the lunate is caused by forceful hyperextension of the
lunate.
FIG. 9-17 Dislocation of lunate. (A) Diagrammatic representation of the

normal disposition of the carpal bones as seen on a lateral view. (B) Line
diagram showing dislocation of lunate (arrow). (C) As seen on radiograph.
Treatment
Conservative treatment
The fracture of lunate is treated by immobilization in a below-elbow
plaster cast for about 3 weeks.
Dislocation of lunate needs reduction under anaesthesia, followed
by immobilization in a below-elbow plaster cast for about 3–4 weeks.
Surgical treatment
Late cases may require open reduction of the lunate bone. However,
fusion (arthrodesis) of the wrist is indicated in cases having severe
osteoarthritis and instability of the wrist.
Complications
Avascular necrosis of the lunate (Kienbock disease): Blood supply to
the lunate may occasionally be cut off following an injury (fracture or
dislocation) resulting in Kienbock disease which is characterized by
sclerosis and collapse of the lunate (Fig. 9-18).
FIG. 9-18 Kienbock disease: Avascular necrosis of the lunate.
The patient complains of pain in wrist and instability with

weakness of grip strength. Osteoarthritis of wrist may set in after a
few years.
1. In conservatively managed patients:
During immobilization (3–4 weeks): The period of

immobilization is longer. Therefore, all the precautions
should be taken to maintain the strength and regain full
ROM of the uninvolved joints of the fractured limb.
Special efforts to guide positioning of the limb and
supervised vigorous and slow stretched finger movements
should be carried out as often as possible.
Strong repetitive isometrics to both the flexor as well

extensor groups under immobilization at the wrist should
be taught and checked.
Paraesthesia in the distribution of median nerve due to

compression or injury to the median nerve may be
encountered occasionally and should be checked
repeatedly.
Mobilization (after 4 weeks): As there is every possibility of

articular and ligamentous damage, there is significant
limitation and pain at the wrist joint. Reduction of pain
and relaxation of the stiff wrist joint needs early attention.
Modalities like partial weight bearing (PWB) and hot pack
(HP) may be used before initiating mobilization.
Mobilization following relaxation should be started in the

gravity eliminated position as described for the Colles’
fracture.
Progressive resistive exercises should be started using low

weight dumbbells.
The patient’s forearm is placed on a table in a position of

supination or pronation with the wrist and hand hanging
over the table. He holds a dumbbell in his hand while the
physiotherapist stabilizes the forearm just proximal to the
wrist joint. The weight of the dumbbell and the force of
gravity will offer stretch to the wrist joint to improve
mobility, whereas active movement with the dumbbell
against gravity will provide strengthening.
Hand functional activities emphasizing wrist extension

movements play an important role along with strong
gripping finger actions.
Generally acceptable results can be achieved within 8 weeks.

However, return to heavy labour may take 6 months or
even longer (Green, 1982).
2. In surgically managed patients:
The line of treatment remains the same as described

previously, only deep heating modality like ultrasound or
friction massage for the surgical scar may be necessary to
control pain and adhesions. The PEMF can be used to a
great advantage.
CHAPTER
10
Injuries of the hand
OUTLINE
◼ Fracture of metacarpals (closed injuries)
◼ Bennett’s fracture dislocation
◼ Fracture of the phalanges
◼ Mallet finger
Fracture of metacarpals (closed injuries)

Fractures of the metacarpals are caused by direct injuries to the hand
or due to the fall of a heavy object on the hand. A fracture in the
metacarpal can occur through its neck, shaft or base (Fig. 10-1).
Fractures of multiple metacarpals and open fractures (due to machine
injuries) are common (Fig. 10-2). Fractures of the neck usually occur in
the 5th metacarpal. Fracture through the shaft occurs in any
metacarpal and can be transverse or oblique, whereas fractures at the
base commonly involve the first metacarpal or thumb.
FIG. 10-1 Sites of fracture in the metacarpal: through neck, shaft and
base.
FIG. 10-2 Open fractures of the metacarpals.
Treatment
Conservative treatment is the treatment of choice for undisplaced or
minimally displaced fractures. A below-elbow plaster of Paris (POP)
slab is given for 3 weeks after which the hand is mobilized. Fracture
through the neck of the metacarpal with volar angulation (Fig. 10-3)
needs reduction and immobilization in flexion.
FIG. 10-3 (A) Fracture through the neck of the metacarpal is usually
angulated. (B) Fracture of the neck of the 5th metacarpal seen on
radiograph.
Displaced fractures are treated by internal fixation using Kirschner

wires or occasionally by plating (Fig. 10-4 A and B). Postoperatively a
below-elbow POP slab is maintained for about 10 days before
mobilization is begun. Comminuted or open fractures can also be
treated by external fixator (Fig. 10-5). Oblique fractures of the shaft of
the metacarpal are unstable injuries and cause overriding of the bone
leading to shortening of the metacarpal. Shortening, in turn, will cause
change in the level of the knuckles resulting in limitation of flexion at
the metacarpophalangeal (MP) joint. The patient will not be able to
make a full fist. These fractures, therefore, can be treated by
transfixing the other metacarpals by K-wire, maintaining the length of
the metacarpal (Fig. 10-6).
FIG. 10-4 Fracture of the shaft of the 5th metacarpal. (A) Preoperative and
(B) postoperative radiographs of the fracture treated by plating.
FIG. 10-5 (A) Fracture of the 5th metacarpal treated by external fixator and
(B) clinical photograph of the same patient.
FIG. 10-6 (A) Displaced fracture of the 4th metacarpal. (B) Treated by
transfixation with the other metacarpals by K-wire.
The basic objective is to provide functional painless ROM of the
fingers.
During immobilization (2–3 weeks)
1. It is important to control oedema of the hand to prevent

extensor tendon adhesions and future deformity.
Compression dressing, elevation, pulsed galvanic
stimulation, massage (milking massage), electrical
stimulation on a sensory excitation level and nylon and
string wrapping are some of the effective measures.
2. Check the position of the fractured finger frequently for

any rotational or angulation deformity, especially in
cases of 4th or 5th metacarpal fractures. Protective splint
is applied to avoid retraction of the collateral ligaments,
which may cause extension contracture.
3. Circulation is to be augmented by vigorous active

movements of the adjacent free joints.
4. Relaxed passive movement should be initiated in small

range in the proper groove of movements, with the line
of pull perpendicular to the joint surface. Intrinsic
contracture is to be prevented by early maximum passive
flexion of PIP and DIP joints while maintaining the MCP
joints in neutral.
5. TENS, phonophoresis, ultrasound or diapulse can be

used to reduce pain.
Mobilization (3 weeks onwards): This is an important phase of

initiating tendon glide. Active mobilization to glide the tendons of
flexor digitorum sublimis and profundus, extensor digitorum
communis, extensor indicis propreus and extensor digiti quintii are
carried out meticulously:
1. Properly executed active movements are important to

prevent adhesions between bone and tendon
(osteotenodesis), between tendon and tendon (tenodesis)
or tendon and skin (dermotenodesis). Active movements
improve circulation, decrease residual oedema and also
exert compression at the fracture site, thereby prompting
early healing. To achieve full range of tendon glide as
well as selective tendon gliding, exercises should be
performed in the following three different fists (Webbe,
1987):
(a) Claw fist: Flexion of the PIP and DIP joints maintaining
MCP in neutral extension. This exercise produces
maximum gliding of FDP tendons. The palmar aspect of
the finger and the tips should contact the palm. It should
be held in this position as much as possible to facilitate
maximum gliding and further ROM.
(b) Sublimis fist: In this fist, the MCP and the PIP joints are
flexed and the DIP joints are maintained in extension
(maximum gliding occurs at FDS and FDP tendons – Fig.
10-7).
(c) Full fist: Simultaneous full flexion of the MCP, DIP and
PIP joints.
Correct stabilization and assisted guidance are necessary to

achieve effective gliding.
2. Passive ROM exercises done to maximize the range of

motion can also improve the active range of motion as
well as the healing of the articular cartilage.
3. Splint: The initial static splint should have 50–70 degrees

of flexion at the MCP joint with full extension at the IP
joints. At this stage, this should be changed to a dynamic
splint with a low load sustained stretching device.
4. Resistive exercises are important as they provide
strength to the hand function. Resistive movements in a
small range can be started by 4 weeks. They are delayed
only in fractures treated by percutaneous pinning or in
avulsion and spiral fractures.
The graduated compressive forces due to these exercises lead

to early fracture healing and correct scar remodelling.
5. Proper measures to maximize ideal collagen synthesis

during the period of scar remodelling need to be
observed to avoid adhesions and deformities.
6. Functional activities may be included at the earliest but

without subjecting the fracture site to strenuous
activities.
The hand should regain full functional status by 8–12 weeks.

FIG. 10-7 Simultaneous flexion of the MCP, PIP and DIP joints.
Bennett’s fracture dislocation

It is an intra-articular fracture of the base of the first metacarpal or
thumb (Fig. 10-8A).
FIG. 10-8 Bennett’s fracture dislocation. (A) Fracture with dislocation at

the base of the thumb. (B) Internal fixation by K-wires.
Treatment
It is an unstable fracture and often needs internal fixation by a
Kirschner wire or a screw (Fig. 10-8B). The period of postoperative
immobilization is 3 weeks.
During immobilization: Measures are taken to reduce pain and
inflammation. Healing may be augmented by the use of diapulse.
Mobilization: Intensive therapeutic procedures are initiated to improve

ROM, strength and endurance of the muscles of thumb. Dynamic
flexion splint and scar remodelling to be emphasized to the extensor
pollicis longus tendon.
Gradually progressive therapy should be given so that the

thumb regains normal function by 10–12 weeks.
Complications
1. Malunion: Malunion of a metacarpal fracture may result in
angulation or rotational deformity, which may need correction by
osteotomy (Fig. 10-9).
2. Stiffness of the hand: Prolonged immobilization or inadequate

physiotherapy may cause stiffness of the hand. However, it can be
prevented by controlling oedema and swelling, minimum splintage
and early mobilization.
3. Osteoarthritis of the first carpometacarpal joint: It occurs in Bennett’s

fracture dislocation where joint incongruity persists.
FIG. 10-9 Malalignment of the finger due to a malunited phalangeal

fracture in the ring finger of the patient’s left hand. The right hand is shown
for comparison.
Fracture of the phalanges

Phalanges are fractured due to direct trauma or a twisting force. Distal
phalanges get comminuted fractures due to crushing injuries. Direct
injury to the phalanx results in a transverse or oblique fracture,
whereas a twisting injury causes a spiral fracture (Fig. 10-10).
FIG. 10-10 Sites and types of fracture in the phalanx. Common types:
LSP, long spiral; OBL, Oblique; TR, transverse fracture of shaft; CF,
comminuted fracture of the distal phalanx.
Treatment
Proximal and middle phalangeal fractures are usually treated by
closed manipulation and splintage in a ‘ball bandage’ or by splinting
the injured finger to the adjacent intact finger (Fig. 10-11A) (called
buddy splint) for a period of 3 weeks. Grossly displaced fractures may
need internal fixation by a Kirschner wire or mini screws (Fig. 10-11B).
FIG. 10-11 (A) Immobilization by buddy splint. (B) A spiral fracture of

phalanx fixed by multiple screws.
Fractures of the distal phalanx do not need any splinting. They are
generally treated as soft tissue injuries.
Fracture of the proximal phalanx: Proximal phalanx is very important
for various functions due to their anatomical positioning.
Fracture healing with angular or rotational deformity results in
stiffness of the MCP and PIP joints and adherence of the flexor and
extensor tendons thereby causing functional inadequacy of the hand.
During immobilization: Routine measures are taken to control
oedema, inflammation and pain. Improved circulation by vigorous
movements and resistive exercises of the joints in the exact groove to
the free fingers are important.
Mobilization: When the fracture is stable, mobilization should be
made vigorous by gentle relaxed passive movements in the maximum
arc. Well-supported active exercises can be given. Static or dynamic
splint to prevent or to minimize deformity as well as to aid scar
modulation is necessary.
Continuous and repeated active movements play an important role
in facilitating tendon glide and strength.
The exercise programme should be made progressive and
functional.
Good hand function should be regained by 3 months.
Fracture of the middle phalanx: The basic objective of
physiotherapy is to regain full active ROM of the joints proximal and
distal to the fractured middle phalanx.
During immobilization: All the routine measures to control
inflammation, pain and swelling are taken.
Irrespective of the method of immobilization, early measures to
initiate mobilization are extremely important (5–15 days).
Individual joint ROM exercises, passive as well as active, are given
by stabilizing the phalanx just proximal to the joint being exercised.
This helps to obtain effective tendon glide by avoiding tendon
adherence to the callus.
Mobilization: After 2 weeks, active flexion–extension exercises are
started for the immobilized PIP joint. Care must be taken to avoid the
terminal range of extension with the use of a dorsal block splint (Fig.
10-12). Extension is limited to 30 degrees and 15 degrees during the
first and second weeks, respectively.
FIG. 10-12 Fracture of the middle phalanx. Dorsal block splint to limit
extension up to 30 degrees during the first week, 15 degrees during the
second week, and finally allowing full extension by the third week.
After 4 weeks, extension can be initiated at the PIP joint and a

dynamic extension splint is given to further the extension (Belsole,
1980).
Therapy progresses on the same lines to attain full function.
However, it may need 6 months to get full active extension at the PIP
joint.
Mallet finger
The tendon of the extensor digitorum communis sometimes gets
avulsed from its insertion to the base of the distal phalanx (Fig. 10-
13A). The tendon may be avulsed along with a small piece of bone
from the distal phalanx (Fig. 10-13B and C). Sudden forced flexion of
the distal phalanx is the usual mode of injury.
FIG. 10-13 Mallet finger: (A) extensor tendon avulsion – the distal phalanx
is in flexion, (B) tendon avulsion may occur along with a bone fragment, (C)
radiograph showing avulsion fracture of the distal phalanx and (D) mallet
finger splint.
The patient complains of pain and swelling of the distal phalanx of

the finger and is unable to actively extend the finger at the distal IP
joint. However, the finger can be fully extended passively.
Treatment
Fresh cases are treated by immobilization in a POP cast or plastic/PVC
splints with the proximal interphalangeal joint in 60 degrees of flexion
and the distal interphalangeal joint in hyperextension (Fig. 10-13D).
The immobilization is maintained for 3–4 weeks. Extension block
wiring is also a method of treating mallet finger. Two Kirschner wires
are passed percutaneously and maintained for 3–4 weeks with good
results (Fig. 10-14).
FIG. 10-14 (A) Mallet finger, (B) and (C) treated by percutaneous fixation
with two K-wires. (D) End result following K-wire fixation.
The ruptured tendon is sometimes repaired by surgery. The avulsed

bony fragment is fixed to its parent bone by a Kirschner wire.
Postoperatively the finger is immobilized in a cast or splint for 3–4
weeks. Late cases are treated by open reduction and repair of the
tendon or the avulsed fragment. Rarely, when the pain and deformity
persist, arthrodesis of the distal IP joint in 15 degrees of flexion is
performed. The postoperative immobilization after arthrodesis is
generally prolonged for a period of 8–10 weeks.
The basic aims of physiotherapy:
1. To regain voluntary extension at the distal IP joint
2. Full ROM and strength at the distal IP joint
Cases treated by immobilization/surgical repair

During immobilization: The patient is encouraged to use hand with a
splint or POP cast.
Vigorous early movements are begun to all the fingers and MP and
PIP joints of the index finger with the splint protecting the DIP joints.
Measures are also taken to control inflammation, oedema and pain.
Mobilization
1. Paraffin wax bath is extremely useful to improve ROM of the distal
IP joint and to facilitate stretching of the injured or repaired tendon.
2. Encourage maximum active movements to the DIP joint with

emphasis on flexion. Special attention may be necessary for exercising
the extensor digitorum communis.
Extensor lag due to extensor tendon attenuation may be

present.
3. Strengthening and re-education of the extensor digitorum

communis is achieved by synchronizing voluntary exercise efforts
with electrical stimulation.
Exercises of the lumbrical are also important.

Splint is continued till voluntary full extension at the distal IP joint
is regained.
Active use of hand with splint and light hand activities without
splint are encouraged. Use of splint is gradually weaned off as the
voluntary extension returns.
Full function should return by 3–4 weeks following mobilization.
Long period of immobilization results in pain and stiffness of the
PIP joint. Therefore, several sessions of mobilization in a day are
extremely important.
Guidance in the functional use of the hand initially with
immobilization and later following mobilization is important.
Caution
The patient needs to be warned against performing forced flexion
movements like tight grasp and lifting weights to avoid recurrence.
CHAPTER
11
Injuries of the spine
OUTLINE
◼ Injuries of the vertebral spine
◼ Injuries of the cervical spine
◼ Injuries of the lower cervical spine
◼ Fracture of the lower cervical spine
◼ Injuries of the thoracolumbar spine
◼ Fractures at the thoracic spine
◼ Thoracolumbar spine injuries
◼ Lumbar spine injuries
Injuries of the spine are serious injuries since they may be associated
with injury to the spinal cord resulting in paralysis which may be
irreversible. Injuries are common in the most mobile segments of the
spine, i.e., lower cervical and thoracolumbar spine.
Spinal cord injuries need extensive acute care to avoid seriously
disabling consequences.
Injuries of the vertebral spine

Brief Functional Anatomy: Vertebral spine, the backbone of all the
physical activities of our daily life, is composed of 33 vertebrae,
forming four compact units.
◼ Cervical unit of 7 vertebrae
◼ Dorsal or thoracic unit of 12 vertebrae
◼ Lumbar unit of 5 vertebrae, and
◼ Sacrococcygeal unit of 9 fused vertebrae
The units are specially designed to perform the following three

functions:
1. Free mobility to the neck by the cervical unit, and free mobility of the
trunk by the thoracolumbar unit
2. Stability (static as well as dynamic) to the body’s movement by the

thoracic and sacrococcygeal unit
3. Protection to the soft vital organs by the thoracic unit and to the
spinal cord by the vertebral chain formed by the cervical, dorsal as
well as lumbar units
Incidence
Vertebral injuries account for 5–6% of all trauma cases. The common
sites of injury being the cervical spine followed by the thoracolumbar
spine.
Causes of spinal injury

Spinal injury is caused by direct or indirect trauma like fall of a heavy
object or a fall from height, road traffic accident (RTA), diving into
shallow water, or a direct injury by bullet or lathi.
Clinical features: Signs and symptoms

◼ Unconsciousness, spinal shock
◼ Cardiorespiratory insufficiency or failure

◼ Deficiencies in the neuronal system with impaired or loss of motor
power (e.g., quadriplegia or quadriparesis following injuries of the
cervical spine and paraplegia or paraparesis following injuries to the
cervical and thoracolumbar injuries)
◼ Sensory impairment with altered reflexes
◼ Impaired bladder and bowel functions
Planning the treatment programme

The treatment programme is planned on the basis of the mechanism
of injury and the status of the stability of the injured spine.
Direct injury – bullet or a lathi blow – directly over the spine can
smash any part of the spine. A lathi blow generally causes fracture of
the spinous or transverse processes.
Status of stability of the injured spine

The characteristics of stable and unstable injuries are listed in Table
11-1.
Table 11-1
Characteristics of Stable and Unstable Injuries
Stable Injury Unstable Injury

Intact intervertebral linkage and anatomical Disturbed intervertebral linkage and anatomical alignment
alignment
Intact posterior longitudinal ligament Break in the continuity of the posterior longitudinal ligament
Injury in only one direction e.g., true flexion History of rotational element in the mode of injury
or extension
Regaining full consciousness and alertness Usually associated with unconsciousness, cardiorespiratory
and usually without neurological defects episode or appearance of flaccid paralysis of the limbs
Denis determined the stability on the basis of the involved vertical

columns. The vertebral body is divided into two vertical columns,
whereas post elements of the vertebra constitute the third column. The
injury is labelled as stable when only the anterior column is involved,
whereas it is labelled unstable when two or all the three columns are
involved (Fig. 11-1).
FIG. 11-1 Denis’s three-column concept: (a) anterior column, (b) middle
column, and (c) posterior column.
Examination
◼ Quick survey of all the vital signs and possible associated injuries to
the head and viscera is done.
◼ Critical examination of the neuromusculoskeletal parameters

including bulbocavernosus reflex is conducted.
◼ Spinal examination is done with extra care to avoid further damage

to the injured spine.
◼ Strictly avoid jerky movements to the spine during resuscitation,

turning, examination, etc.
◼ Assess overall functional status (abilities as well as inabilities)
◼ Assess renal function with urine output and the overall bladder and
bowel control.
Investigations
Radiographic investigation provides important information about the
site and type of lesion.
Digital AP and lateral radiographic views in general
◼ Oblique view of the suspected rotational injury
◼ Open mouth view of upper cervical lesions, suspected at C1, C2

level
◼ CT scan: To identify spinal canal compromise
◼ MRI scan: Provides precise information about bony integrity, status

of spinal cord, IV discs, neural structures including nerve roots and
musculotendinous complexes
General plan of treatment of spinal injuries

Treatment of stable injuries without displacement or paralysis is done
by a conservative approach
◼ Bed rest
◼ Immobilization in a four-poster cervical collar, extended plaster

jacket (Minerva jacket), Minerva jacket brace or hollow cast
◼ Reduction of the unstable fractures or fracture dislocation by heavy

skeletal traction up to 9 kg; then a light skeletal traction is
maintained for 3–6 weeks followed by a four-poster collar for
another 3–4 months
Surgical treatment
Surgery by the following is indicated in uneducable or highly unstable
injuries:
◼ Anterior decompression with removal of the vertebral body and the

IV disc followed by stabilization with bone graft and spinal
instrumentation
◼ Posterior decompression by removal of lamina and the spinous

process followed by stabilization with bone grafting and spinal
instrumentation
The technique of bone grafting and spinal instrumentation

markedly reduces the period of recumbency along with providing
stability of the injured spine.
Injuries of the cervical spine

Fractures of the cervical vertebrae often result in paralysis
(quadriplegia) and could even be fatal.
Common injuries at the upper cervical spine include the following:
1. Fracture of the atlas (Jefferson’s fracture)
2. Atlantoaxial subluxation
3. Hangman’s fracture
4. Fracture of the odontoid process
Injuries to the upper cervical spine

Injuries to the upper cervical spine especially at C1–C2 with occiput
and the base of the skull are devastating due to respiratory failure; the
patient invariably succumbs to it. Even if the patient survives, he may
develop crippling quadriplegia.
The common sites of injury are C1–C2 and at C5–C6 levels. Nearly
40–60% of the patients have associated spinal cord injury and the
residual neurological defects.
1. Fracture of the atlas (Jefferson’s fracture): A common injury is

vertical compression injury due to the axial force through the skull,
breaking either one or both the arches of the atlas (Fig. 11-2). It is a
stable injury sparing the spinal cord.
Treatment:
Immobilization is performed with a moulded high cervical

collar, four poster cervical collar, Minerva POP jacket or
Minerva jacket brace for 3 months.
2. Atlantoaxial subluxation: It is caused by injury to the atlas and the

transverse ligaments or following neck or throat infection. It may be
associated with fracture of the odontoid process mostly at its base as a
result of forward displacement due to jerky flexion injury. The
displacement will be backwards in extension injury.
The spinal cord however is usually spared.
Treatment:
◼ Undisplaced fracture is treated by a high four-poster collar

for 3 months.
◼ Displaced fracture is treated by skull traction for 4 weeks,

followed by a Minerva jacket or a hollow cast cervical
brace.
Persistent instability is treated by atlantoaxial fusion.
3. Hangman’s fracture: Injury usually involves axis at the neural arch

along with traumatic spondylolisthesis of C2.
Treatment:
It is treated by skull traction followed by a four-poster

cervical collar.
4. Fracture of the odontoid process: Many a times this fracture is

missed on a routine X-ray. It is better seen in an AP view taken with
the patient’s mouth kept open during the investigation. However, this
fracture is suspected when the patient complains of severe pain and
tenderness at the base of the skull. Luckily, most of the time, the
spinal cord is spared. The fracture at the odontoid may occur either at
the tip (oblique) or at the junction of the odontoid process and the
body of the vertebra (transverse) or through the upper portion of the
vertebral body.
Treatment:
Skull traction followed by halocervical orthosis or cast (see

Fig. 11-12).
FIG. 11-2 Possible common sites of fracture in the atlas (C1) vertebra.
Objectives
The objectives in the treatment of injuries of the cervical spine are as
follows:
1. To restore the normal or at least functional ROM of all the basic four
movements of the neck (Table 11-2).
2. To restore adequate muscular strength and endurance to make the

patient functionally independent in the use of the neck.
Table 11-2
Normal and Functional ROM at the Cervical Spine
Normal Functional
Movement
ROM ROM
Flexion 0–65º 0–40º
Extension 0–65º 0–30º
Lateral flexion (either 0–45º 0–20º
side)
Rotation (either side) 0–75º 0–45º
Expected problems
The complications include the following:
◼ Irreversible paralysis (motor as well as sensory)
◼ Bladder and bowel incontinence
◼ Severe psychological trauma with loss of interest in life in severely

disabled
◼ Life dependency and strenuous efforts to perform activities of daily

living (ADLs) in patients who suffer from spinal cord lesions
If the injuries to the upper cervical spine are undisplaced or stable

without causing damage to the spinal cord, the physiotherapeutic
management may be uncomplicated.
Jefferson’s fracture or fracture of the first vertebra or atlas
The fracture is immobilized in a moulded high cervical collar, a four-
poster cervical collar or a Minerva jacket brace for 8–12 weeks.
During immobilization:
◼ Check the immobilization for a close fit ensuring that it

checks the close skin edges of a brace for discomfort or
excessive pressure.
◼ Strictly instruct the patient not to put any uncalled-for

efforts to move neck in collar, and teach and guide moving
the whole body rather than follow the natural instinct to
move the neck.
◼ Provide guidance to carry out activities of daily routine

with a brace.
◼ Demonstrate and guide the patient to work up light

isometrics in a pain-free range by pressing against the
immobilization.
During mobilization:
◼ Begin with a gentle soothing massage before initiation of

mobilization.
◼ In the supine position, with neck and head resting on a

soft pillow, initiate relaxed rhythmic small-range free
active rotation.
◼ Initiate gradual flexion and extension with the patient

sitting in an arm chair with the back totally supported.
◼ Guide the patient on performing strong isometrics against
self-resistance using palms as a resistive force.
◼ As the ROM of all the four basic cervical spine movements

improve, guide the patient on self-stretch-hold modes to
gain further ROM.
◼ Encourage the patient to carry out all the ADLs.
◼ Increase the vigorosity of exercises to reach the preinjury

level by self-efforts.
◼ By 16 weeks, the preinjury freedom of ROM and adequate

strength should be restored.
Physiotherapy for the other three stable upper cervical spine

injuries (atlantoaxial subluxation, Hangman’s fracture and fracture of
the odontoid process) follows the same pattern.
Guidance to continue for further improvement and also to prevent
recurrence is a must.
Precaution
To prevent discomfort during night, guidance may be given in
ergonomics of the cervical spine. In addition to this, the use of a soft
conventional collar may also be advised.
Injuries of the lower cervical spine

Lower cervical spine injuries commonly involve the C5–C6 vertebrae.
These injuries can cause severe damage to the spinal cord resulting in
quadriplegia.
The lower cervical vertebra has a cylindrical body; the posterior
neural arch is made up of a pair of pedicles, a pair of lateral masses, a
pair of laminae and bifid spinous processes. The lateral processes have
a deep bony canal for the passage of spinal nerves and the vertebral
artery through the foramina transversarium.
The types of injuries depend on the mechanism of the injury:
◼ Flexion injury causes wedge compression fracture.
◼ Flexion–rotation injury will cause subluxation or dislocation.
◼ Hyperextension injury will cause rupture of the anterior

longitudinal ligament with wide anterior opening of the bodies.
◼ Vertical compression injury will result in a burst fracture of the

body of vertebra, fragments of which may impinge upon the spinal
cord.
Treatment
1. Treatment of the stable injuries
2. Treatment of the unstable injuries
3. Management of paralysis (quadriplegia)
The treatment is discussed in subsequent sections.
During immobilization:
◼ Conduct detailed objective clinical examination.
◼ Strong isometrics are given to the muscles of the neck within the
limits of pain.
◼ Provide full-ROM resistive movements to all the joints of the

nonimmobilized sections of the body, along with chest
physiotherapy during decumbency.
◼ Guide all the functional activities as early as possible, avoiding

excessive stress over the injured section of the spine.
During mobilization:
Begin well-supported relaxed active free exercises to ensure early
mobilization in a graded manner, gradually working towards full
ROM.
Patients treated with surgery need to be taught and guided on the
techniques to perform functional tasks by compensatory mechanisms
using dorsolumbar spine and the joints of the lower limbs.
Aetiology
1. Fall from a height
2. RTAs
3. Diving injuries
Injuries to the cervical spine are caused by the following forces,

either singly or in combination:
1. Flexion
2. Extension
3. Rotation
4. Vertical compression
1. Flexion injuries: Most flexion injuries (about 75%) occur in the

lower cervical spine. There may be a wedge compression fracture of
the vertebral body (Fig. 11-3A and B). Subluxation or dislocation may
occur due to disruption of the posterior ligaments (Fig. 11-3C), the
severity of injury depending upon the extent of ligament disruption.
Involuntary forced flexion may result in avulsion fracture of

the spinous process of C6, C7 or Tl vertebra (Fig. 11-3B),
called clay-shoveler’s fracture.
A flexion tear drop fracture indicates complete disruption of

the posterior ligaments and a large triangular fragment of
bone avulsed from the anterior aspect of the vertebral
body.
Complete disruption of the posterior ligament complex can

also cause bilateral facet dislocation, with anterior
displacement of the vertebra.
2. Extension injuries: Hyperextension and distraction cause rupture

of the anterior longitudinal ligament (Fig. 11-4A) with posterior
dislocation of the vertebra. The dislocation often gets reduced during
transportation and handling of the patient; therefore a radiograph
taken later in the casualty department may not show any bony injury,
although the patient has quadriplegia. This injury, therefore, becomes
evident on forced extension radiographs of the cervical spine.
Extension teardrop fracture results from a hyperextension

injury. In this fracture, a large triangular fragment of the
anterior superior or inferior corner of the vertebral body
gets avulsed along with the anterior longitudinal ligament.
Fracture of the atlas, axis and odontoid process (Fig. 11-4B)

may also occur.
3. Flexion with rotation: Excessive flexion force with rotary

displacement causes unilateral facet dislocation, with mild
displacement of the vertebral body. Severe injury may cause
dislocation of the C5 vertebra with injury to the spinal cord (Fig. 11-5).
4. Hyperextension with rotation: Hyperextension with rotation

causes fracture of the lateral masses of the vertebra, which are called
pillars. This fracture also includes a portion of the articular facet joint.
5. Vertical compression: Vertical blow on the head as in a diving

accident can cause burst fracture of the vertebral body (Fig. 11-6).
FIG. 11-3 Flexion injuries of the cervical spine. (A) Wedge compression
fracture (WCF). (B) Wedge compression fracture of C5 vertebra, as seen
on an X-ray. (C) Subluxation of the cervical spine at C5–C6 level (SU):
avulsion fracture of the spinous process (AVS).
FIG. 11-4 Extension injuries of the cervical spine. (A) Rupture of the
anterior longitudinal ligament. (B) Fracture of the odontoid process with
posterior dislocation of the vertebra.
FIG. 11-5 Flexion with rotation injury. Marked dislocation of the C5

vertebra over the C6 vertebra is likely to cause injury to the spinal cord.
FIG. 11-6 (A) Burst fracture of the atlas by vertical compression. (B)
Possible common sites of fracture in the atlas (C1) vertebra.
Fracture of the lower cervical spine

Burst fracture of the cervical vertebrae, commonly affected level is C5-
C6, may cause quadiplegia, can result from vertical compression force.
Displacement of the fractured fragments can cause compression of the
spinal cord leading to significant neurological deficit (Fig. 11-7).
FIG. 11-7 (A) Burst fracture due to vertical compression with crushing of
the entire vertebral body with its posterior projection causing pressure on
the spinal cord (SPC). (B) Burst fracture impinging the spinal cord.
Mechanism of injury and common sites

1. Flexion injury – fall from height on the heels or the buttocks (C5–C7;
L1>L2>D12) (Fig. 11-8A)
2. Flexion-rotational injury – heavy blow over one shoulder causing
sudden flexion and rotation to the opposite side. (CL1, D12; C5–C7)
(Fig. 11-8B)
3. Flexion-distraction injury – violent jerky flexion of upper trunk over

the seat belt on sudden stoppage of a car (dorsal spine) (Fig. 11-8C)
4. Extension or hyperextension injury – forehead striking against the

windscreen and violently forcing neck into hyperextension or in rear-
end automobile collisions (whiplash injury) (C5–C6; lumbar spine)
(Fig. 11-8D)
5. Vertical compression injury – fall from height with head erect, or a

heavy object striking the head from above (C5–C6) (Fig. 11-8E)
FIG. 11-8 Mechanism and types of spinal injuries: (A) flexion injury; (B)
flexion–rotation injury; (C) flexion–distraction injury; (D) hyperflexion injury;
(E) vertical compression injury.
Investigations
The following investigations may help in the diagnosis of the body
injury as well as in the evaluation of injury to the spinal cord:
1. Radiographs
2. CT scan
3. MRI scan
Treatment
The treatment of cervical spine injuries can be broadly divided into
the following categories:
1. Treatment of stable skeletal injuries
2. Treatment of unstable skeletal injuries
3. Management of paralysis (quadriplegia)
1. Treatment of stable injuries: Stable injuries of the cervical spine,

without displacements and paralysis, are treated by immobilization of
the cervical spine by a four-poster cervical collar (Fig. 11-9), a POP
Minerva jacket (Fig. 11-10A), a Minerva jacket brace (Fig. 11-10B) or by
halo casts (Fig. 11-10C). The immobilization is maintained for a period
of 6–8 weeks.
2. Treatment of unstable injuries: Unstable fractures or fracture

dislocations of the cervical spine are reduced and immobilized by
skeletal traction. The reduction is achieved by heavy skeletal traction
given up to 20 pounds (9 kg) through Crutchfield tongs (Fig. 11-11)
applied into the skull.
The reduction is confirmed by portable radiographs taken in

bed with the traction on. After the reduction is achieved, a
light skeletal traction is maintained for a period of 6–8
weeks, after which the neck is supported in a four-poster
collar for another 3–4 months. The paralysis may also
improve after reduction of the fracture/dislocation.
FIG. 11-9 Stable injuries: (A and B) four-poster collar.

FIG. 11-10 Stable fracture of the cervical spine – methods of

immobilization. (A) POP Minerva jacket. (B) Minerva jacket brace. (C) Halo
cast
FIG. 11-11 Crutchfield skull traction.

Operative treatment
In selected cases the dislocation is reduced by surgical operation and
stabilized by spinal instrumentation (Fig. 11-12). The spine is also
fused either posteriorly or anteriorly (Fig. 11-13). The neck is
supported in a collar for a period of 3 months. However, spinal
stabilization reduces the period of recumbency and thereby the
subsequent complications of the latter.
FIG. 11-12 Spinal instrumentation with plate and screws.

FIG. 11-13 Spinal fusion single interbody block fusion. (A and B) Widening
of the spinal defect and graft (G) secured with isthmus wire (IW). (C) Graft
in place. (D) Double-dowel interbody block fusion.
1. Treatment of stable uncomplicated injuries: The role of
physiotherapy in these types of injuries is limited only to continuing
general exercises or strengthening of the weak muscles. Ergonomic
advice to manage activities without putting strain on the cervical
region during immobilization is important. Graduated neck
movements, in smaller range, can be started as soon as the
immobilization is discontinued. Full recovery occurs within 3–4
weeks.
2. Treatment of unstable injuries: As soon as the reduction of the

fracture and/or dislocation is stabilized and light skeletal traction is
applied, a thorough physical examination is conducted. The level of
the lesion and the extent of cord damage are identified (Table 11-3)
and, accordingly, therapeutic programme is planned and instituted
(Table 11-4). In patients without severe neuromuscular defects,
vigorous bedside physiotherapy is given during immobilization. As
soon as traction is discontinued and a four-poster collar is given,
graduated mobilization in the form of turning, sitting, standing and
ambulation is begun. Patients with paralysis need extensive
physiotherapy.
3. Management of patients with paralysis (quadriplegia): To provide

maximum functional independence to the patient with various
degrees of paralysis is a challenging proposition. It requires untiring
efforts both from the physiotherapist and the patient. The
achievement depends mainly upon the site and nature of the lesion,
the degree of residual neuromusculoskeletal deficiencies and
application of the correct methods of physiotherapy.
Table 11-3
Relationship between the Spinal Segment and the Cord Segment at Different Levels
Spinal Segment Cord Segment

Cervical vertebrae Add 1 to the vertebral
level
Upper dorsal Add 2 to the vertebral
vertebrae level
Lower dorsal Add 3 to the vertebral
vertebrae level
At D10 vertebra All dorsal segments over
At D12 vertebra All lumbar segments over
At L1 vertebra All sacral segments over
Below L1 vertebra Cauda equina
Note: Due to the disproportionate growth of the vertebral column and the spinal cord, the
spinal cord segment corresponding to the given vertebra is always above the level of that
particular vertebra. The spinal cord ends at the lower border of the first lumbar vertebra (L1).
Beyond this, up to S2 there is only a dural sac containing a bunch of nerve roots – the cauda
equina.
Table 11-4
General Guide to the Mechanism of Injury, Common Sites of Injury, Column
Involvement and the Stability of the Spine
Common Column
Mechanism of Injury Type of Injury Stability
Site Involvement
Flexion injury Compression • C5– Only anterior Stable
• Fall on buttocks fracture C7 column failure
• Heavy object falling on the flexed •
spine (see Fig. 11-1A) L1>L2>D12
Flexion–rotation injury Fracture • C5– All the three Unstable
• Fall on one side dislocation C7 columns
• Blow on the side (see Fig. 11-1B) •
L1>D12
Flexion–distraction injury Chance Dorsal Middle and posterior May be
• Car seat belt injury or hypertension fracture spine columns unstable
injury (see Fig. 11-1C)
Extension injury Burst fracture • C5– Only anterior Stable
• Whiplash injury C6 column
• Shallow water diving (see Fig. 11- •
1D) Lumbar
spine
Vertical compression injury Burst fracture • C5– May be
• Fall from the top with head erect C6 unstable
• Heavy object falling on top of the
head (see Fig. 11-1E)
Direct injury, e.g., bullet injury Fractures of Any Anterior and middle Variable
• Uncontrolled muscle contraction the region column
• Spinous
process
•
Transverse
process
Any/all column’s Variable
failure
Note: Guidelines to assist in the whole process of physical
rehabilitation are presented in, tables 11-3 to 11-6 and 11-8 to 11-12.
Table 11-5
Major Segmental Innervation of the Muscles of the Upper Limb
C2 C3 C4 C5 C6 C7 C8 T1
Sternomastoid
Trapezius
Levator scapulae
Diaphragm Deltoid
Rhomboids
Teres minor
Supraspinatus
Infraspinatus
Biceps, brachialis
Brachioradialis,
supinator,
subscapularis,
teres major,
coracobrachialis
Serratus anterior, latissimus
dorsi, extensor carpi radialis
longus
Pectoralis major
Pronator
teresPectoralis
minor
Extensor-
digitorum
Flexor carpi
radialis
Triceps, extensor carpi radialis
brevis, palmaris longus
Flexor carpi ulnaris,
extensor carpi ulnaris,
flexor digitorum
superficialis and
profundus, extensor
indicis, abductor
pollicis longus and
brevis, opponens
pollicis, flexor pollicis
longus, extensor
pollicis longus brevis
Adductor pollicis
Flexor
pollicis
brevis,
abductor
digiti
minimi,
opponens
digiti
minimi,
lumbricals,
interossei
Table 11-6
Major Segmental Innervation of the Muscles of the Lower Limb
L1 L2 L3 L4 L5 S1 S2 S3
Psoas
minor
Psoas
major
Iliacus
Sartorius
Hip adductors
Quadriceps
Obturator
externus
Tensor fascia lata
Tibialis posterior
Tibialis anterior, extensor hallucis longus,
extensor digitorum longus, peroneus tertius,
popliteus
Gluteus
medius
Gluteus
minimus
Quadratus femoris,
semitendinosus,
semimembranosus, biceps femoris,
peronei
Obturator internus
Gastrocnemius
Gluteus maximus
Flexor
hallucis
longus
Flexor
digitorum
longus
Soleus
Interossei
Abductor hallucis, adductor
hallucis, lumbricals, abductor
digiti minimi
Table 11-8
Guide to Functional Control of the Joints in Relation to the Segmental Levels
Upper Extremity
Joint Segmental Level
C5 C6 C7 C8 T1
Shoulder, Poor Fair Normal
Elbow
Wrist Poor Fair Normal
Hand Poor Fair Normal
Lower Extremity
Joint Segmental Level
L2 L3 L4 L5 S1
Hip Poor Fair Fair Normal
Knee Poor Fair Normal
Ankle Fair Fair Normal
Foot Poor Fair Normal
Table 11-9
Expected Self-Care Independence in Relation to the Segmental Level of Involvement
and the Areas of Therapeutic Emphasis
Segmental Expected Self-Care Independence

Areas of Therapeutic Emphasis
Level Self-Care Aids Transfers
C4 Strengthening upper trapezius, sternomastoid, Typing with Mouth stick, Total
platysma; use of special respiratory equipment; special dental bite, dependence
using vasomotor control by using neck, typewriter, turn robotic arms,
shoulders and visuospatial feedback to learn pages, use of other
balance and equilibrium; tilt-table standing telephone, electronic
wheelchair training painting aids
Power wheel
chair, controlled
by chin or
breath
controlled ‘puff
suck’ tubes in
the mouth
C5 Strengthening biceps, trapezius, wrist Eat, type, move Cock-up Needs
mobilization to attain flat palm and elbow papers splint for physical
locking in hyperextension. This assists body Manage wrist assistance
lifting in the absence of triceps. wheelchair stabilization
Mobilization of scapulae and shoulder girdles; brakes Slot on the
Intensive mat work, turning, rolling, sitting up, Push palmar
self-assisted moving of paralysed limbs; wheelchair on surface of
assisted standing in parallel bars plain surfaces splint to
Trunk rotation and flexion through neck and hold light
shoulder girdle muscles gadgets like
spoon.
C6 Strengthening extensor carpi radialis to facilitate Slow writing, Light leather Bed to
wrist extension to achieve finger grasp by eat, drink, strap with wheelchair
tenodesis; also strengthen supination to further wash, shave, slot to hold and back
tighten the grip brush hair small light with
Sitting from objects sliding
lying and board
reverse
Dress upper
Dress upper
half
Push
wheelchair on
sloped ground
C7 Strengthening triceps, wrist flexors, extensor Turn in bed Flexor hinge Wheelchair
carpi radialis Independence splint to to toilet,
Vigorous mat work in dressing facilitate car and
Effective use of pincer grip bath
hand
Wheeling over
uneven ground
and small kerbs
Pick up objects
from the floor
Table 11-10
Level of Lesion and the Recovery of Function
Level
of Initial Stage Following Rehabilitation
Lesion
Above Mostly fatal as all the functions areIf survives, requires training in the use of special respiratory
C5 severely affected, including equipment
breathing Physical dependency for most functions
Some self-propulsion in powered wheelchair may be possible
manipulating with teeth
Devices like environmental control units, robotic arms, other
electronic aids to increase independence
C5 Loss of all functions of the limbs, Physical assistance is required in dressing, personal hygiene,
thorax and trunk, sensation as well transfers and writing. Independent in powered wheelchair
as visceral functions ambulation and eating skills
C6 All functions are impaired except Majority need physical assistance for personal hygiene,
some muscle of the upper limbs dressing and transfers; independence in wheelchair
ambulation, eating and slow writing is possible
C7– Personal hygiene, dressing, eating, Almost all achieve independence in all functions consistent
T1 writing, transfers and ambulation with living alone; physical assistance may be needed by some
impaired
T3– Personal hygiene, dressing, Independence in wheelchair ambulation, personal hygiene,
T6 transfers, ambulation impaired dressing, and transfer are possible
T7– Personal hygiene, dressing, Bladder and bowel functions recover totally
T12 transfers, ambulation impaired Walking, only as exercise; independent in transfers,
wheelchair ambulation, dressing and driving
L1– Bladder, bowel and walking Bladder and bowel functions recover totally; short-distance
L4 impaired independent walking can be regained
L5, Bladder, bowel and walking Bladder and bowel functions recover totally; walking with two
S1, S2 impaired canes or crutches, may need below-knee orthosis; prolonged
standing difficult
S2, Only bladder and bowel functions Total recovery

S3, S4 impaired
Table 11-11
Expected Status of Standing and Ambulation in Relation to the Segmental Level of
Involvement
Segmental
Status of Standing and Ambulation
Level
C4 Only tilt-table standing; power-driven wheelchair
C5–C6 Standing with total assistance with or without orthosis in parallel bars; wheelchair
ambulation
C7–C8 Swing-to gait in parallel bars; wheelchair ambulation
T1–T5 Swing-to and four-point gaits in parallel bars; free ambulation with wheelchair
Swing-to on crutches
T6–T9 Stair management on crutches with assistanceChair to crutches and back
T10–L1 All the three ‘crutch gaits’, managing stairs, ramps and kerbs; crutches to floor and back
Below L1 Freedom in ambulation either with two canes or crutches; prolonged standing may remain
impaired
Table 11-12
Guidelines for the Expected Appliance According to the Level of Lesion
Level of the
Ambulation and the Appliance
Lesion
Below T6 Wheelchair ambulation
T6–T9 Bilateral above-knee orthosis with attached spinal support
T10–T12 Bilateral AK orthosis with pelvic band
L1–L3 Bilateral AK orthosis with pelvic band; pelvic band can be discarded in due
course
L4–L5 BK orthosis
Below L5 Foot drop assist
Phasewise physiotherapeutic functions
a. Acute phase of spinal shock (first 8–10 days)
Immediately following an acute cervical lesion, the emphasis

of physiotherapy is on the stabilization of cardiorespiratory
status and prevention of early complications.
During this early phase, there is marked cardiorespiratory

insufficiency and destruction of nerve cells at the actual
level of the lesion with loss of function below the level of
the lesion.
There is disruption of the reflex arc, reflexes and the reflex

activity of bladder and bowel. There is loss of tone of
muscles at and below the level of the lesion including the
urethral mucosa, resulting in flaccid paralysis and
incontinence of bladder and bowel. Deep and superficial
sensations are lost. Therefore, immediate measures of
resuscitation may be needed to save the patient’s life.
Patients with lesion at C4, those with severe chest injury, or
with a history of chronic pulmonary disease usually need
tracheostomy and ventilatory support.
Vital capacity (VC) needs to be monitored frequently,

because VC levels below 500–600 mL require
tracheostomy.
Whenever possible the use of accessory muscles of

respiration like sternomastoid, trapezius and scaleni with
higher segmental supply is instrumental in assisting
breathing in the C4 lesion with paralysis of the diaphragm.
Patients with moderately stable cardiorespiratory status

need concentrated chest physiotherapy in the form of
intermittent positive pressure breathing, deep breathing
techniques and assisted coughing. Prophylactic chest
physiotherapy to prevent chest infection assumes priority.
However, if the patient develops chest infection, postural
drainage at regular intervals assumes priority over other
chest procedures.
Prevention of early complications
1. Pulmonary embolism: The danger of pulmonary embolism

is precipitated following venous thrombosis. Therefore,
regular checking for the signs of thrombosis like leg
swelling with erythema or a low-grade fever is
necessary.
2. Renal complications: It is a well-documented fact that

renal complications account for the majority of deaths
following spinal cord injury. Therefore, initially,
intermittent catheterization is done three times a day as a
safety measure.
3. Complication due to improper positioning in bed:

Correct positioning of the patient in bed during this
critical phase is of vital importance for the following
reasons:
(a) Prevention of pressure sores: Susceptible pressure points

like sacrum, trochanters, ischial tuberosities, fibulae,
malleoli, posterior aspect of heels, fifth metatarsals,
occiput and elbows need adequate protection against
pressure. The deficient vasomotor control results in
ischaemia over these bony prominences. Keeping skin
over these parts clean and dry, and regular changing of
the patient’s position in bed without disturbing the
alignment of the shoulders and neck is necessary in these
patients (Fig. 11-14).
(b) Prevention of deformity: Malpositioning of the limbs

invariably results in tightness of the soft tissue which
results in contractures and later on organize into
deformity (e.g., equinus deformity due to the neglect of
positioning of the ankle and foot). Thus, these susceptible
sites should be taken care of by proper positioning,
supports and gentle full-ROM exercises along with
frequent checks.
(c) Maintenance of correct alignment of fracture: Proper

positioning of the neck in relation to the body is
important to maintain the correct alignment of the
fracture. Therefore, this also needs regular checks.
(d) Prevention of heterotrophic ossifications: Excessive

stretching of some of the susceptible joints or the spastic
muscles (e.g., at hip, knee, elbow and medial aspect of
femur) may result in ectopic ossification (Fig. 11-15), a
complication which further complicates rehabilitation.
Overstretching of the joints in the terminal range should
be strictly avoided.
(e) Prevention of oedema: The loss of vasomotor control and

muscle tone results in stasis and the hands and feet are
prone to develop gravitational oedema. Therefore,
proper positioning of the limbs with elevation and other
physiotherapeutic measures are necessary to reduce
oedema to the maximum. Persistence of oedema may
lead to trophic changes, hand stiffness, or even Sudeck’s
osteodystrophy. While maintaining correct positioning of
the body, maintenance of paralysed hand in good
functional position is important. This is achieved by
using a short cock-up splint, palmar roll and bandage.
The wrist is maintained in 45° of extension, the
metacarpophalangeal (MCP) joints in 90° of flexion, IP
joints in 30° of flexion and thumb in opposition. Keeping
MCP joints in full flexion puts stretch on the collateral
ligaments preventing the swelling (Cheshire and Rowe,
1970–71). However, regular sessions of relaxed full-range
passive movements by removing bandage and splint are
necessary to avoid tightness.
(f) Autonomic dysreflexia: It occurs as a result of

malfunctioning of the body’s normal regulatory
mechanisms for blood pressure and temperature in the
lesions above T10 level. It is a serious complication which
could be life-threatening if not detected and controlled at
the initial stage. The signs and symptoms of autonomic
dysreflexia are as follows: irregularity in the level of
blood pressure which may shoot up suddenly, variation
in the skin temperature and colour, excessive sweating
above the level of lesion, severe headache and feeling of
congestion. Factors like bladder distension, urinary
complications, stool impaction and pressure sores may
produce irritation or discomfort to the body below the
level of injury. Autonomic dysreflexia is more commonly
seen in patients with lesions above T5 level, but it can be
avoided with early detection and proper measures.
When any of the for-mentioned symptoms is noticed, it is

necessary to check for the distension of bladder, bowel
obstruction due to accumulation of stools, skin irritation
or lesion due to tight clothing, appliance or aids, etc.
Adopting sitting or semireclining posture and adequate

measures to control the respective causative factors is
useful to control autonomic dysreflexia (Ozer et al.,
1987).
(g) Chronic pain: Receiving and processing of the sensory

information from the periphery continues below the level
of the lesion. However, it is blocked at that level and
cannot be transmitted to the higher centres, resulting in
the loss of normal smooth interplay and appropriate
action. This malfunctioning of both the reflex centres
results in an overexcited response to the stimuli entering
the spinal cord. The stimuli are perceived either as
inappropriate sensations of pain without any tissue
damage or as uncontrolled muscle contractions like
spasticity.
The pain could be mechanical (sharp, localized and

aggravated by movements), inflammatory (not localized
to the site of injury), due to contracture, arthritis, or
inflammation of the joints and tendons, or as a phantom
sensation of tingling, burning or dull ache in the back,
legs or feet.
The treatment depends upon the clinical evaluation.

Combination of treatment like appropriate choice of
physiotherapeutic modality, exercises, medication and
psychotherapy are effective. Transcutaneous electrical
nerve stimulation (TENS), however, is the treatment of
choice.
(h) Prevention of osteoporosis: Immobilization and prolonged

bed rest are associated with atrophy of the
musculoskeletal system which alters the mineral
mechanism of bone formation resulting in osteoporosis.
Osteoporotic bone becomes susceptible to spontaneous
fracture even with sudden stretching of the joints.
Frequent turning in bed during early stage, passive
movements to the paralysed limb, resisted movements to
the paretic limbs and early weight bearing like tilt-table
standing can prevent osteoporosis.
(i) Early identification of paralytic ileus: The presence of

abdominal distension with breathing difficulty and
nausea is the sign of paralytic ileus. This interferes with
respiration and needs immediate medical attention.
b. Weaning phase of the spinal shock
1. A thorough evaluation of the residual

neuromusculoskeletal deficiencies
2. Planning and efficiently conducting the therapeutic

programme on an individual basis
FIG. 11-14 Positioning of the patient in bed to prevent pressure sores (side
lying).
FIG. 11-15 Radiograph of the hip joint showing ectopic bone formation
connecting the ilium bone with the trochanteric region.
When the symptoms of the acute spinal shock recede, the cells of
the isolated cord recover function. Spasticity sets in with the return of
reflexes. However, when there is longitudinal vascular damage to the
cord, or when the cord is injured in longitudinal as well as transverse
planes, flaccidity may persist. In incomplete and bilaterally
asymmetrical lesions, there may be return of power in the muscle
groups whose segmental innervation is spared.
Physical examination: As this phase is the most important phase of
rehabilitation needing vigorous physiotherapy, detailed
neuromusculoskeletal examination needs to be conducted. This helps
to identify the site and the degree of damage to the cord and the
prognosis. In fact, this forms the basis of planning the regime of
physiotherapy.
Manual muscle testing of various muscle groups is critically done
and analysed with reference to the segmental innervation charts
(Tables 11-5, 11-6, 11-9 and 11-10). The tone of muscles is assessed
through passive ROM, palpation and limb positioning. Evidence of
nerve irritation is demonstrated at one level above the actual site. For
example, symptoms of lesion at the C5 level will be present when
actual damage occurs at the C6 level. Therefore, spasticity will be
present in the deltoid, elbow flexors and forearm supinators when the
actual level of the lesion is at C6. The presence of spasticity in a
particular muscle group can be identified by typical spastic posture of
the arm in bed. Muscle length and joints are carefully examined for
the functional requirement of the individual joints as well as the
whole limb. Sensory status is examined in detail for pain, touch,
position sense and superficial and deep reflexes.
Guidance to formulate the individualized management programme
is provided by a series of the following tables only after critical
evaluation (Table 11-7).
Table 11-7
Guidance to Identify the Involved Nerve Root by the Respective Decrease in the
Sensory Motor Response
Involved Decrease in the Sensorium or Sensory
Decrease in the Motor Response
Nerve Root Response
C2 Over the back of scalp
C3 Over the anterior aspect of neck In C2–C4 nerve root injuries, survival of a
patient itself is rare
C4 Over the lateral aspect of neck and inferiorly
over the clavicle down to the ribs
C5 Over the lateral part of deltoid muscle Voluntary activity of the deltoid and biceps
C6 Over the radial aspect of forearm, thumb, Extensor carpi radialis longus (ECRL) and
index and middle finger brevis (ECRB)
C7 Over the ulnar border of ring and little finger Triceps, finger extensors, pronator teres and
flexor carpi radialis (FCR)
C8 Over the ulnar border of forearm and hand Flexor digitorum superficialis (FDS) and/or
flexor digitorum profundus (FDP)
T1 Over the medial aspect of upper arm
T2 Over the anterior chest wall above the nipple Intrinsic hand function is intact
Hands and legs are examined for oedema. Lack of muscle tone and
vasomotor-control deficiency greatly enhances oedema. Persistence of
oedema converts collagen deposits into fibrous tissue, resulting in
fibrous contractures. The findings of all these tests are correlated with
the relative spinal segmental innervation to confirm the lesion.
After extensive evaluation of patient’s ability and the inability
records, the prognosis of recovery should be considered as the first
priority to design correct formulation of the therapeutic plan.
Therapeutic procedures
Passive movements: Relaxed slow and rhythmic passive movements aid

in improving circulation, preventing deformities, reducing oedema,
educating movement patterns and reducing spasticity.
Caution
Movements should be performed without eliciting muscular spasm.
Overstretching of the spastic muscle group should be strictly
avoided as it may result in complications like ectopic ossification,
rupture of muscle fibres or even spontaneous fractures.
Mobility exercises: Mobility exercises provide the mobility of scapulae,

elbow, wrist and fingers. Maintenance of the normal length of the
muscles passing over more than one joint is of extreme importance in
quadriplegics. They are needed to facilitate functional activities, and
hence need special emphasis.
Active movement: Movements in the muscle groups with intact

innervation should be progressed in grades from assisted active to
active resistive modes to repetitive performance of guided self-
resistive mode wherever possible to hypertrophy of the paretic
muscle groups. Proprioceptive neuromuscular facilitation (PNF)
techniques with precision are extremely useful. However,
compensatory mechanisms like tenodesis and other functional
controls should always be kept in mind and emphasized more than
the usual muscle strengthening procedures (Table 11-8).
Vasomotor control: The blood vessels in the viscera fail to constrict on

assuming vertical posture when the vasomotor control is lost.
Adequate compensation can be achieved by the training of the reflex
arc by breathing exercises, altering the position in bed and gradually
progressing to sitting or standing on the tilt table.
Postural sensibility: Kinaesthesia below the level of lesion results in loss

of perception of movements and position of the body and limbs in
space. The new postural sense is developed through visual feedback.
This is facilitated by long practice sessions in front of mirror. It takes
a long time and needs tremendous efforts.
Control of oedema: Oedema can be controlled by elevation of the foot

end of the bed, keeping the oedema to limb in further elevation,
using hand splints with bandage and inflatable plastic splints.
Regular relaxed passive movements or speedy isometrics, whenever
possible, play an important role in the control of oedema.
Control of spasticity: Spasticity greatly obstructs smooth and

coordinated movements and self-care. Therefore, it is essential to
control it as soon as it sets in. This is done by proper positioning of
the limb. Proper positioning in the early phase inhibits the onset of
severe spasticity and also influences the pattern of spasticity. Reflex
inhibiting postures on mat, standing with correct posture and
weight distribution, relaxed controlled passive movements, PNF
techniques and carefully monitored cryotherapy are useful.
Re-education of self-care: The attainment of independence in self-care is

the ultimate aim of treating these patients; therefore, it needs to be
initiated right from the earliest stage. The degree of functional
independence depends not only on the extent of the spinal cord lesion but
also on the physical proportions, e.g., height, weight, arm length in
relation to the length of the trunk, early adequate management and
motivation of the patient.
Therapeutic procedures and self-care training are planned by

referring to the segmental innervation charts (Tables 11-5, 11-6, 11-9
and 11-10), expected joint control as related to the level of the lesion
(Table 11-8) and the degree and distribution of spasticity as recorded
in the physical examination chart. Mat activities are instrumental in
initiating the training of the major self-care re-education activities like
turning, rolling, sitting from lying, lying from sitting, trunk balance in
sitting and balanced transfers. Training for wheelchair manoeuvres is
initiated along with the mat training. The self-care training is greatly
facilitated by the intelligent assistance of the surviving muscles,
compensatory mechanisms, tricky movements and various simple
adaptations (Table 11-9; Figs 11-16 and 11-17).
Standing and ambulation: Standing, although not practical in high cord

lesions, is initiated with assistance for its following advantages:
◼ It prevents renal complications.
◼ It reduces spasticity.
◼ It stimulates circulation.
◼ It prevents osteoporosis.
◼ It improves postural sensibility and vasomotor control.
◼ It provides tremendous psychological influence on the

patient.
◼ Standing and ambulatory capabilities related to the

various spinal lesions are elaborated in Table 11-11 and the
guidelines for the expected appliances and assistive aids in
Table 11-12.
Bladder and bowel management: During the acute stage of spinal

shock, the paralysed bladder is unable to empty because of the
suppression of the automatic cord reflex of micturition. This results
in the loss of reflex detrusor contraction and the bladder gets
distended. Therefore, prevention of overdistension is a must at this
stage. This can be managed by intermittent urethral catheterization,
indwellling catheter or indwelling suprapubic catheter. Periodic
irrigation of the bladder with mild antiseptic solution is a must to
prevent infection.
The behaviour of the bladder following this acute phase of

shock depends upon the level and the extent of injury.
Neural control of the bladder: The reflex centre controlling the

bladder is situated at S2–S3 level of the spinal cord. This, in
turn, is controlled by the inhibitory influences from the
cortex.
The basic principles of bladder training programme include

the following:
1. Training of the bladder to hold reasonable quantity of

urine before it empties
2. Training for regulation of the interval for bladder
emptying
3. Training to initiate the flow of urine
4. Training to minimize the residual urine
Automatic (reflex) bladder: When there is complete

transaction of the spinal cord above T10–T11, a reflex-
controlled automatic neurogenic bladder develops within
3–6 weeks following injury. This is also called upper motor
neuron bladder. The reflex arc which extends from the
bladder to the sacral cord synapses and then forms a
connection with the bladder thus provides a simple reflex
control to the bladder. On full distension of the bladder,
the bladder wall is stretched, and sets a reflex activity
which involuntarily empties the bladder. The patient has
no voluntary control except the sensation of fullness in the
abdomen. The intrinsic stimulus in the bladder wall or the
extrinsic stimulus that provokes may lead to closure of the
reflex arc due to summation of the afferent stimuli. It
suddenly brings about involuntary emptying of the
bladder. With training, the reflex action can be initiated on
stimulation of certain ‘trigger points’. This area is to be
identified and tapping is done to set in the reflex for
voiding. The quantity of residual urine after involuntary
emptying is marginal and hence is not prone to frequent
infections. The bladder reconditioning is achieved by reflex
voiding of the bladder by clamping the urinary or the
suprapubic catheter. The catheter or the suprapubic tube is
removed when the reflex emptying of the bladder is learnt.
Autonomous neurogenic (nonreflex) bladder: This type of
bladder is also known as lower motor neuron or atonic
bladder. This develops when the spinal cord lesion is
longitudinal or on the lower motor neuron. Therefore, the
bladder now totally depends for its control on the detrusor
ganglia, an intrinsic plexus which is situated in the bladder
musculature. This type of bladder needs training, and
physiotherapy plays an important role in the training.
Training of abdominals, diaphragm and pelvic floor
muscle contraction and their sustenance increases the intra-
abdominal pressure and facilitates bladder emptying. If
this is not achieved due to involvement of the abdominals,
the bladder can be emptied by teaching the patient to exert
manual pressure on the lower abdomen directly over the
suprapubic area.
For female patients, no satisfactory urine bags are available;

therefore pads and rubber pants are the only alternatives.
Training methods otherwise are the same as for males. The
bladder training programmes need careful monitoring. The
bladder should be emptied to the maximum; otherwise the
amount of residual urine in this type of bladder is quite
large (200–400 cc). It may predispose the bladder to
recurrent infections.
The bladder training programme has to be associated with

increased amount of fluid intake (at least 2–3 L a day),
regular bladder wash, maintaining the fluid intake and
urinary output chart, and closely monitoring the signs and
symptoms of bladder infection.
Bowel management: The paralysis of the bowel may lead to

discomfort due to faecal retention or uncontrolled bowel
movements. In case of permanent incontinence, the patient
needs to be trained in the following:
1. Attempted evacuation at regular periods (every second

day)
2. Control of diet and fluid intake – to soften the faecal

matter
3. Use of suppositories
4. Use of enema
5. Digital evacuation
It is important to find out the most suitable method on an

individual basis and also regularize it.
Sexual functions: In male paraplegics with complete lesion,

orgasm and erection are difficult; however, production of
semen, which depends upon the gonadotropic hormones,
is not affected. Ejaculation, which is reflex in nature, can
occur; thus the power of recreation is not lost. In
incomplete lesions, a great deal of variation occurs. When
it returns, it does so with the reappearance of reflexes.
In females, menstruation, and even pregnancy, usually

returns within 2–3 months even in complete lesions of the
cord.
Proper guidance and counselling play an important role in

adjusting sexual problems in these patients.
FIG. 11-16 Guidelines for performing functional activities. (A) Rolling. (B)
Sitting.
FIG. 11-17 Guidelines for performing functional activities. (A) Transfer
from wheelchair to bed. (B) Standing with assistance.
Injuries of the thoracolumbar spine

Fractures of the transverse processes, spinous
processes and pars interarticularis
The fractures of the transverse process are seen occasionally, but those
of the spinous processes are rare. Fractures of the transverse processes
of the lumbar vertebrae may be associated with fractures of the spine
or pelvis. Isolated injuries are usually avulsion injuries because of the
pull of the powerful muscles attached to the transverse processes.
Treatment
It consists of bed rest and analgesics. In fractures of the transverse
processes of the lumbar vertebrae, keeping a pillow under the knee
joints in supine position may help relieve the pain. By keeping the
knee joints in slight flexion, the lumbar lordosis is obliterated, thereby
relaxing the paraspinal muscles.
Measures to control inflammation, pain and swelling are necessary.
Diapulse, TENS and ultrasound can be used as adjuncts. The patient is
advised bed rest.
Early initiation of indirect isometrics through neck or legs as small-
range active movements may be started, after 2 weeks.
The rest of the mobilization, strengthening and back to work
programme is followed on the same lines as for the fractures of the
vertebral body.
Fractures at the thoracic spine

◼ Common fracture types include the following:
◼ Compression fractures
◼ Burst fractures
◼ Flexion–distraction fracture
◼ Fracture dislocation
◼ Subset
◻ Flexion–rotation
◻ Flexion–distraction
◻ Shear fracture
Thoracic spine injuries

Fractures of the thoracic vertebrae are relatively less common. In the
upper dorsal (thoracic) spine, the rib cage offers stability and hence,
generally compression (wedge) fractures of the vertebra occur (Fig.
11-18A). However, when the injury is severe, a fracture dislocation
may occur (Fig. 11-18B). The spinal canal is relatively narrow in this
area and therefore the spinal cord gets invariably damaged in this
type of injuries resulting in paraplegia.
FIG. 11-18 Injuries of the thoracic and lumbar spine. (A) Stable to
uncomplicated wedge compression fracture (intact spinal cord) due to
flexion force. (B) Complicated or unstable fracture dislocation due to
combined flexion–rotation force producing transaction of the spinal cord.
Thoracolumbar spine injuries

The thoracolumbar spine is more mobile, and therefore injuries to this
region are quite common. The injuries may belong to one of the
following.
McAfee classified thoracolumbar injuries into the following four
varieties:
1. Wedge compression fracture
2. Burst fracture
3. Chance fracture
4. Translational injuries
1. Wedge compression fracture. It is the most common type of

vertebral fracture which occurs due to flexion injury. It is a stable
injury since the posterior ligament complex is intact; it is also common
in osteoporotic patients (Fig. 11-19).
2. Burst fracture: Severe compression force ‘breaks’ the vertebra into

multiple pieces. The fragments of the body of the vertebra may get
displaced into the spinal canal causing compression of the spinal cord.
This can be a stable or instable injury depending upon the damage.
3. Fracture dislocations: This type of injury is grossly unstable and is

associated with paraplegia. It is a combined flexion–compression and
rotational injury (translational injury) (Fig. 11-20).
4. Chance fracture: It is a combination of flexion–distraction injury,

e.g., sudden forward throwing of the chest and upper trunk forward
against the seat belt causing grossly unstable injury on applying
sudden brake while driving (Fig. 11-1C).
FIG. 11-19 Wedge compression fracture.

FIG. 11-20 Translational injuries.

Lumbar spine injuries
Types of injuries to the lumber spine
Fracture patterns
◼ Flexion pattern: Compression or axial burst fracture
◼ Extension pattern: Flexion–distraction or chance fracture
◼ Rotational pattern: Fracture dislocation
◼ Fracture transverse process (in forceful side flexion injury)
Since the spinal cord ends below the lower border of the L1
vertebra, fractures of the vertebra below this level usually result in
injury to the nerve roots with resultant incomplete paraplegia. The
chances of neurological recovery are quite high in these cases.
Clinical features
◼ History of RTA or a fall from height
◼ Localized pain, tenderness, swelling or a step
◼ Back held rigid
◼ May have positive neurological signs with incomplete paraplegia

(also called paraparesis) or complete paraplegia.
◼ Cauda equina lesion
◼ Bladder incontinence
Investigations
◼ Digital radiograph (especially lateral view)
◼ MRI if necessary to identity the soft tissue involvement along with
skeletal injuries
Treatment
It can be divided into the following:
1. Treatment of the skeletal injury
2. Treatment of the paralysed patient
Treatment of the skeletal injury

The following methods of treatment are employed depending upon
the severity and the level of injury.
(a) Bed rest: A stable, uncomplicated fracture of vertebra is treated by

simple bed rest on a hard bed for a period of 4 weeks.
(b) Plaster jacket: A stable fracture, without paraplegia, may also be

treated by a plaster jacket for 8–12 weeks.
(c) Brace: A spinal brace – Jewett brace or CASH brace (cruciform

anterior spinal hyperextension brace) for 8–12 weeks – may be used
instead of a plaster jacket.
(d) Postural reduction: The patients having fracture dislocation with

paraplegia are treated by rest in bed with a pillow placed under the
fractured part of the spine. The patient is given a spinal brace after 4–6
weeks and mobilized.
(e) Spinal stabilization: A patient with fracture dislocation of spine with

paraplegia is nowadays treated by spinal stabilization. The fractured
segment of the spine is opened up by operation, reduced if possible,
and fixed internally with a variety of internal fixation devices.
Although neurological recovery is not guaranteed following this
operation, particularly in cases where the cord is damaged
considerably, the patient can be mobilized early, almost on the second
or third day after operation. Early mobilization eliminates the
problems of prolonged recumbency in a paraplegic patient.
Surgical treatment
Surgery is indicated in patients with
◼ Unstable injuries
◼ Deteriorating motor paralysis
◼ Bony fragment compressing the spinal cord or in total lesion of the

spinal cord to facilitate ambulatory activities
Surgical procedures
1. Posterior decompression by laminectomy and excision of

the spinous process and stabilization of the spine
transpedicular screws (Fig. 11-21)
2. Anterior decompression by carpectomy and spinal

stabilization by bone grafting and spinal instrumentation
3. Spinal fusion conducted with laminectomy to provide

better stability to the injured spine or in old fractures
with painful kyphosis
Postoperatively, the patient is nursed in bed for 3–4 weeks

after which he is given a spinal brace (support) and
mobilized.
Spinal fusion: Rarely, this operation is indicated in the following

situations:
◼ Along with the operation of laminectomy: combined with

laminectomy by some surgeons, with the idea of giving
stability to the spine
◼ In old cases of fracture of the spine where painful kyphosis

results
FIG. 11-21 Fracture dislocation of the dorsal spine. (A) Lateral view
radiograph showing gross displacement (arrow) of the vertebrae. (B) AP
view. (C) MRI scan of the same patient showing fracture dislocation of D8–
9 vertebrae. (D and E) Lateral and AP views showing reduction of the
fracture dislocation and fixation with pedicular screws.
Cases treated by conservative approach
Objectives:
1. To restore normal or at least functional ROM at the

thoracolumbar spine (Table 11-13)
2. To optimize the strength, power and endurance of the

muscles of trunk and upper limbs, with special efforts to
work on the functional muscles required to assist
ambulation, e.g., quadratus lumborum, latissimus dorsi,
trapezius, paraspinal muscles, biceps, triceps and wrist
extensors
3. To achieve self-sufficiency in the management of the

problems of bladder and bowel incontinence, and ADLs
like self-dressing, maintenance and also in the correct use
of devices or appliances.
4. To provide exercise to quadratus lumborum, multifidus,

transverse abdominals for providing better stability to
the spine
5. To increase the strength of these muscles for reducing

symptoms and pain and preventing recurrence
Expected problems:
Spinal canal being relatively narrow, extensive spinal cord

damage is suspected. This may result in paraplegia with its
complications.
Immobilization:
1. Maintenance of the proper posture of immobilization.
2. Graduated isometric contractions are given to the spinal

extensors and abdominals. If a POP jacket has been
given, the isometrics can easily be performed by pressing
against the plaster. If only positioning is selected as a
method of immobilization, resistive flexion and
extension of the neck will induce static contractions in
the abdominals and spinal extensors, respectively. They
are important in preventing atrophy and improving
circulation at the site of fracture. Active exercises to the
neck as well as hips are useful.
Caution
Exercises like SLR put excessive compression stress on the lumbar
region and hence should be initiated late and with extreme caution.
Table 11-13
Normal ROM at the Thoracolumbar Spine
Movement Normal ROM

Flexion 0–60º
Extension 30–40º
Lateral 0–30º on either
flexion side
Rotation 0–20º on either
side
3. The excursion of thorax is restricted either because of

fixed lying or due to the plaster jacket. Early initiation of
deep breathing is very important. Maximum expansion
of the thorax and its recoiling should be encouraged
either against hands or plaster. VC should be regularly
monitored by spirometry.
4. Full-ROM, resisted arm and leg movements should be

initiated without causing extra fatigue or pain. Slow
cycling movement one leg at a time is ideal if not painful.
Patients treated by a POP jacket can be made to sit up and

ambulate earlier as it is safe. However, they need training
sessions of sitting, getting up, standing, balancing, weight
transfers and gait training initially. They should be given
functional training on the activities of daily work.
Mobilization:
1. Mobilization should be started by training the correct

method of turning in bed with the knees bent and with
adequate arm support.
2. The correct method of sitting up in bed, avoiding undue

strain on the fracture site, is taught, totally using both the
arms.
Caution
Flexion and rotational attitudes of the spine in flexion injuries, and
hyperextension in extension injuries should be strictly avoided.
3. Graded extension exercises with elbow or forearm

support should be begun for patients with flexion injury
and graded flexion exercises for patients with extension
injuries.
4. Side flexion of the trunk should be started with the

patient sitting with hands at the back of head, and the
physiotherapist stabilizing the pelvis.
5. Spinal rotation should be initiated in the same position.
6. All the exercises should be made progressive in ROM,

strength and endurance.
7. Progressive ergonomic training for the spinal mechanics

during various daily activities is of vital importance.
8. Heavy outdoor activities, games, swimming and cycling

can be progressed in stages, to regain the preinjury
status.
Physiotherapy for patients treated by surgery

Stabilization procedures:
Spinal stabilization procedures facilitate early safe mobilization of a
patient as the stability to the injured spine is ensured.
First two days: Careful monitoring to prevent the expected post-

surgical complications.
Third day onwards: Gradual mobilization is begun; ‘block rolling’ is

initiated so that the whole body is turned together as a block. This
has to be observed strictly as it prevents rotational torque to the
trunk.
It is progressed to supported sitting. The patient can be transferred to

a tilt table for the initial period of standing. This is progressed to
standing in parallel bars with adequate orthoses fabricated before
surgery. This can be eventually progressed to ambulatory training in
phases.
Laminectomy and spinal fusion: After surgery, besides the routine

measures to prevent postsurgical complications, efforts are made to
elicit voluntary contractions in the paralysed muscles. Possible
muscle recovery following decompression should be monitored
carefully and adequate therapy is given to strengthen these muscles.
When no muscle recovery is noticed, treatment should progress on the

same lines as described for stabilization procedures. However, if the
strength in the muscle groups improves, concentrated therapy is
given before deciding about the orthosis.
A patient with a chronic back pain over the thoracolumbar area may
report for physiotherapy. Ensure that there is no vertebral fracture,
as 65% of vertebral fractures are asymptomatic and may remain so
for 1.5 years following the injury.
Identify such patients from associated symptoms like
◼ Reduced spinal mobility
◼ Impaired pulmonary function
◼ Osteoporosis
◼ Slow ambulation with gait abnormalities
◼ Impaired balance
Treatment of a paralysed patient (paraplegia)

Basic objective: To provide optimal physical independence within the
limits of the disability.
General principles:
1. Prevention of complications
2. Maintenance of good morale
3. Maximal return of self-care and functional status, through untiring

efforts
The phases of management:
◼ Acute phase
◼ Rehabilitation phase
During both the phases, the basic mode of physiotherapy, including

bladder management in thoracolumbar lesions, remains the same as
described for the cervical lesions. The major difference is the better
self-care and functional control in the former because of the normal
sensory-motor status of neck, upper extremities and upper trunk in
majority of the patients. However, some areas need greater emphasis
in the management as listed here.
1. Prevention of deep venous thrombosis: Legs are the common sites

of deep venous thrombosis. Regular checking of the legs for swelling
and erythema associated with low-grade fever is necessary.
Movements of the legs should be avoided if signs and symptoms of
venous thrombosis are present – to avoid serious complications of
embolism.
2. Reduction of spasticity: The presence of severe spasticity greatly

influences the achievement of ambulatory efficiency, as it needs extra
attention right from the initial phase.
Proper positioning of the lower limbs is essential during the

acute phase of spinal shock. Careful clinical examination is
conducted to identify the pattern and the degree of
spasticity and the muscle groups involved. Necessary
measures like the reflex inhibiting postures, relaxed
passive movements, prolonged stretching, longer periods
of standing and walking and hydrotherapy or cryotherapy
are taken to reduce spasticity.
3. Prevention of ectopic ossification: The common sites of developing

this complication are the lower extremities (e.g., hip joint, medial
aspect of femur and knee). Therefore, stretching around these areas
should be strictly avoided. Regular checking is done to detect early
signs of heterotopic ossification like spongy feeling of the joint during
movements, tenderness, warmth and erythema over these sites.
4. Prevention of tightness and contractures: Common sites to develop

tightness and contractures like hip flexion and adduction, knee flexion
and ankle plantar flexion need regular monitoring. Adequate
measures like proper positioning, splinting and procedures to fully
stretch these soft tissues are important.
5. Strengthening and re-education of specific muscle groups: Besides
hypertrophy of innervated muscle groups, some muscle groups like
latissimus dorsi (Fig. 11-22A and B), trapezius, abdominals play an
important role in the maintenance of trunk balance. The muscle
groups facilitating crutch walking and transfers like shoulder
abductors, depressors, elbow and wrist extensors and finger flexors
and quadratus lumborum (Fig. 11-22C) need special attention.
Besides, there are activities helpful in the hypertrophy of the
functional muscle groups such as:
◼ Wheelchair – transfers to and from bed
◼ Driving wheelchair with partial application of the brake
◼ Push-ups in the wheelchair (Fig. 11-22D)
◼ Use of dumbbells, weight belts will add to the confidence

of a patient
6. Standing-gait and ambulation: Correct methods of standing from

wheelchair (Fig. 11-23), standing balance, weight transfers and pelvic
tilting are taught in parallel bars and in front of wall bars (Fig. 11-24).
Gait training is also initiated first in parallel bars. Basic

methodology of gait training like single leg balance,
moving hands first, proper placement of the feet,
transferring the body weight through feet, and lifting body
rather than dragging feet is emphasized. Long and
repeated sessions of practice are needed to learn perfect
balance, timing, rhythm and coordination of independent
controlled walking.
Other ambulatory requirements like turning, side walking

and back walking, climbing steps, negotiating slopes and
ramps, getting down and up from the floor on to crutches
are also practised in lesions between T6 and T10 with good
abdominals (Fig. 11-24).
In general, functional walking is not expected in lesions

above T6 level. Below this level, gait training and
ambulation need adequate appliances and a specific
pattern of gait depending upon the level of lesion (see
Tables 11-11 and 11-12).
Gait patterns: The type of gait also depends on the level of

lesion. During the initial phase of training, the patient is
first made to walk with the simplest and the safest pattern
of gait, i.e., the ‘shuffle gait’. In this gait, the patient brings
both the arms forward one after the other (later on
crutches) and brings both the legs forward simultaneously
with toe drag.
The patterns of gait for these patients:
◼ Swing-to gait
◼ Swing-through gait
◼ Four-point gait
Swing-to gait: This is the safest and simplest type of gait and
hence is known as a universal pattern. Therefore, this gait
is taught wherever there is marked instability, e.g., in
patients with level above T10 lesion. Bilateral above-knee
(AK) orthoses with axillary crutches are necessary. Some
patients may even need spinal support during the initial
stage.
Swing-through gait: This is the fastest and most useful
pattern of gait which is very much acceptable to patients.
This is possible only after a long practice as it requires
skilled balance to lift both the feet above the ground and
carry them forward beyond the level of the crutches.
Four-point gait: This is the slowest of the three, but is more

like a normal walk. This gait needs to be included as a
therapeutic measure as it improves strength, balance and
coordination. It also greatly helps in learning turning in
confined spaces. As it needs good balance and dynamic
limb control, patients with lesion lower than T12 acquire
proficiency in this gait.
7. Appliances: The physiotherapist has to prescribe and check all the

appliances needed by a patient. They need to be checked and adjusted
while being used (e.g., braces in standing). The limb needs to be
checked at the pressure points to the brace during its use.
The patient is also trained to put on and remove the

appliances, their correct use as well as their maintenance.
While planning the therapeutic regime, it is absolutely

essential to give due importance to vocational planning
following rehabilitation. The physical activities expected in
the postrehabilitation phase need to be incorporated in the
therapeutic procedures to facilitate vocational tasks.
The goal of the physical, vocational, social and psychological

independence is usually very complex. The major share of
success rests with the physiotherapist because achieving
social, psychological or vocational independence is
impossible without physical independence.
The untiring efforts by the patient and motivation and skill
of the physiotherapist are the major requirements of
rehabilitation of tetraplegic and paraplegic patients.
FIG. 11-22 Strengthening exercises for functionally important muscle

groups. (A and B) Latissimus dorsi. (C) Quadratus lumborum. (D)
Wheelchair push-ups against body resistance.
FIG. 11-23 (A–C) Standing from wheelchair.
FIG. 11-24 (A) Standing balance in parallel bars. (B) Standing balance on
crutches. (C) Weight transfer.
Bibliography
1. Denis F. Three column spine andits significance in the
classificaFon of acute thoracolumbar spine injuries. Spine.
1983;8(8):817-831.
CHAPTER
12
Injuries of the pelvis
OUTLINE
◼ Fractures of the pelvis
◼ Injuries of the coccyx
◼ Fracture of the ribs
Fractures of the pelvis

Fractures of the pelvis can constitute a major injury and can result
from road traffic accidents. They are broadly classified into two types:
due to low-impact trauma, e.g., fall on the side and heavy impact
trauma – fall from height.
1. Isolated fractures of the ilium, pubic rami and sacroiliac subluxation
These are generally stable injuries since the pelvic ring is

intact (Fig. 12-1).
Treatment of these injuries consists of bed rest for 2–3 weeks

only.
2. Fractures of the pelvis with disruption of the pelvic ring

These fractures occur as a result of direct trauma, e.g., in
vehicular accidents or after fall of heavy objects. These are
unstable injuries since the pelvic ring is disrupted and one
segment of the pelvis may get displaced considerably (Fig.
12-2).
These injuries may also be associated with complications

such as haemorrhage, injury to the urethra, rectum and
vagina.
FIG. 12-1 Isolated fractures. The pelvic ring is intact. A, B, C: common

avulsion fracture sites – (A) anteriosuperior iliac spine; (B) anteroinferior
iliac spine; (C) ischial tuberosity; (D) fracture of the ischium; (E) fracture of
the ileum.
FIG. 12-2 Fracture pelvis: (A) pelvic ring broken at one level, and (B) ring
broken at two levels.
Treatment
The treatment can be conservative or operative.
The patient is treated with heavy skeletal traction to reduce the
displacements of the pelvic segments. The traction is maintained for a
period of 6 weeks after which the patient is gradually mobilized.
Operative treatment
The fracture can be fixed surgically by plates and screws or by an
external fixator (Fig. 12-3). The patient can be mobilized 3 weeks after
surgery.
FIG. 12-3 External fixator in the treatment of fracture pelvis: (A)

diagrammatic representation. (B) Radiograph showing fixator in situ. (C) A
patient with fixator in position. (D) Preoperative radiograph showing
displaced fracture of pelvis. (E) Postoperative radiograph after open
reduction and internal fixation with special plates.
Surgical reconstruction for urethral injuries is taken up later when

the patient is mobilized.
Objectives
1. To restore a stable pelvis, with normal anatomical alignment in

weight-bearing postures and also during static and dynamic activities.
2. Freedom of walking and performing ambulatory activities; and near

normal gait pattern.
3. To restore normal or at least functional range of motion (ROM) of

all the movements of the hip.
4. To optimally strengthen and increase the endurance of the major
muscles around the hip.
Expected problems: In severe, rotationally and vertically unstable

fractures.
During the early stage after injury:
◻ The patient may be in hypovolaemic shock due to

intrapelvic haemorrhage from the veins in the pelvic wall.
◻ Injury to the major vessels and nerves in the pelvic viscera.
◻ Complicated injuries to the viscera like intestine, bladder,

urethra, rectum and vagina.
◻ Initial reluctance to take side turns, sit, stand and bear

weight with lack of freedom of the movements and
weakness of the hip joint.
◻ Continued uneven step gait and a limp – for a long period.

Physiotherapy management has to be planned on the basis of Tile’s
classification of the stability of the pelvis.
Tile’s classification
Group A: Stable fractures, where the integrity of the pelvic ring is not
affected.
Group B: Partially stable, where the fractures are vertically stable but
rotationally unstable.
Group C: Both rotationally and vertically unstable fractures.
A. Isolated fractures of the ilium, pubic rami and the sacroiliac

subluxation: These are closed, stable injuries. As such they do not
need any specific physiotherapy.
◼ During bed rest, strong full range movements of the ankle

and toes.
◼ Isometrics for the quadriceps, hamstrings, glutei and trunk

are to be done at regular intervals.
◼ Active ROM exercises for ankles and toes.
After the period of immobilization,
◼ Instructions for gradual weight bearing and ambulation to

be given.
◼ If pain persists, appropriate deep heating may be used.
◼ The patient should be back to routine activities by 3–4

weeks.
B. Fracture of the pelvis with disruption of the pelvic ring
Patients treated by conservative approach: These injuries are unstable

injuries and need heavy skeletal traction for a period of 6 weeks.
Therefore, the programme underlined for isolated fractures of ilium,
pubic rami and sacroiliac subluxation has to be carried out during
immobilization.
Mobilization: Initially, mobility as well as isometric strengthening

exercises should be started for the lower limbs in supine position.
◼ Initiate and educate the patient on the techniques of self-

rolling and supportive sitting on the bed.
◼ Guidance may be given for sitting on the bedside with the
knees hanging.
◼ Progress to sitting and assisted standing. Weight bearing

and walking should be initiated in parallel bars on the
second or third day of mobilization with guidance.
◼ Gait training may be necessary initially.
◼ Postural guidance for functional movements like sitting,

getting up and turning should be given.
◼ Prolonged sessions of lying in prone position with isolated

hip extension may be necessary in patients who have
developed flexor tightness at the hip or to prevent it from
occurring.
◼ The patient should attain full function by 8–10 weeks.
Patients treated by surgery: For fractures of the pelvis treated

surgically, the period of immobilization is short (3 weeks).
Therefore, there is an advantage of early mobilization. But this
becomes difficult because of the patient’s reluctance to do exercises,
firstly, because of the operation and, secondly, because of the
external fixator.
Patients should be encouraged to carry on exercises without

worrying about possible harm due to the external fixator. If
the physiotherapist succeeds in gaining patients’
confidence in this aspect, early return of function is
possible by 8–12 weeks of surgery.
Initial weight bearing and ambulation may be started on a

walker or in parallel bars. The parallel bars need to have a
mobile full view mirror to give an opportunity for self-
correction to the patient. This should be progressed to
independent ambulation at the earliest.
Injuries of the coccyx

A fall on the buttocks may cause fracture of the coccyx which may go
unnoticed radiographically. The patient has considerable pain which
may persist for months.
Treatment
The treatment consists mainly of rest, analgesics and physiotherapy.
Persistence of pain for a longer period is known following injuries to
the coccyx. These injuries are difficult to treat. Firstly, because of the
position of the coccyx which is covered by thick fatty and muscular
pads of gluteus maximus and secondly, the area is prone to postural
pressure in sitting.
◼ Modalities like ultrasound and transcutaneous electrical nerve

stimulation (TENS) may be used for relief of pain.
◼ Sitting on a ring cushion and occasional transfer of body weight

over the alternate buttocks should be advised.
◼ Sitz bath and strong repeated contractions of gluteus maximus in

standing, sitting, prone as well as in supine position indirectly
improves circulation over the coccygeal area.
◼ Long sitting postures must be avoided. The pain does disappear

and there is no functional handicap following this injury.
◼ Unremitting pain cases are treated by local hydrocortisone

infiltrations.
Fracture of the ribs
◼ Fractures of the rib occur rarely, mainly as a result of a direct injury.
◼ The common site of injury happens to be the angle of the ribs, a

point of maximum convexity.
Clinical features
◼ Localized pain and tenderness.
◼ Pain during inhalation when the rib cage goes into expansion.
◼ Inability to lie on the side of the traumatized ribs.
Radiograph: Plain X-ray of the chest identifying the location of

fractures.
Management
◼ Interlocking pattern of intercostal muscles provide natural
immobilization beside voluntary control over the extent of
inhalation.
◼ Pain reduction could be achieved by local ultrasound exposure or

TENS.
◼ The point of fracture may be provided with additional support by

adhesive tape or strapping.
Complications
Chest complications like haemothorax or pneumothorax may be
expected in rare occasions.
◼ Deep breathing exercise with slow and deep inhalation with the
patient supporting the injured area with hands.
◼ Speedier breathing programme may be incorporated to improve the

mobility of thorax.
Home treatment with hot packs with deep breathing exercises could
be very useful in reducing pain and breathing discomfort.
CHAPTER
13
Injuries of the hip
OUTLINE
◼ Dislocation of the hip
◼ Injuries of the hip
Dislocation of the hip

Dislocation of the hip is a serious injury. The head of the femur slips
out through the capsule and displaces according to the direction of the
force.
Dislocation of the hip is of three types:
A. Posterior dislocation
B. Anterior dislocation
C. Central dislocation
It is the commonest out of the three types of dislocations of the hip. It
occurs when the adducted and flexed femur is pushed backwards by a
violent thrust to the knee, e.g., when a passenger’s knee hits against
the dashboard of a car. The femoral head is pushed backwards,
sometimes fracturing the posterior lip of acetabulum (Fig. 13-1).
FIG. 13-1 (A) Posterior dislocation of the right lip of acetabulum. Note the
break in the Shenton’s line, and (B) radiograph showing the same.
Clinical signs
◼ Marked localized pain and tenderness
◼ The attitude of the limb is flexion, adduction and internal rotation

at the hip. There is also marked shortening of the limb.
◼ Stiff and painful attempted movement
◼ Localized haematoma
◼ Femoral head is palpable posteriorly at the gluteal region
◼ Diminished or absent pulsations of the femoral artery in the

inguinal region. The diminished femoral pulsations are not because
of any vascular injury to the femoral artery, but due to the following
reason: normally, the femoral pulsations are felt in the inguinal
region against the head of the femur, which is right posterior to the
femoral artery. Therefore, when the head of the femur is dislocated
out the acetabulum, the femoral artery pulsations cannot be felt well.
Diagnosis: An X-ray of the pelvis with both hips will clinch the
diagnosis of posterior dislocation of hip (Fig. 13-1). Occasionally, a CT
scan may be required to look for any associated fracture of the
acetabulum.
Treatment
The dislocation is reduced under general anaesthesia (GA) by the
classical Watson–Jones axial traction technique with the limb in
neutral. In fresh dislocations, closed reduction may be successful;
whereas in old dislocations or in cases of associated fractures of the
acetabulum, open reduction becomes necessary. A substantially large
bony fragment of the acetabulum is fixed internally with the help of
screws (Fig. 13-2).
FIG. 13-2 Posterior dislocation (of Fig. 13-1B) with reduced and bony
fragment of acetabulum fixed by screws.
The period of immobilization after closed or open reduction is 6–8

weeks. The limb is immobilized either in a Thomas splint with skin
traction or in a plaster of Paris (POP) hip spica. Mobilization of the hip
is started after 6–8 weeks.
Anterior dislocation
It is rare and occurs due to a violent abduction force, with thigh
flexed. It occurs in road traffic accidents (RTAs). The dislocated head
of the femur may lie on the obturator foramen (Fig. 13-3) or the
symphysis pubis.
FIG. 13-3 Anterior dislocation of hip – obturator type. Note that the head of
femur is lying against the obturator foramen.
Clinical features
◼ Localized pain, stiffness and tenderness
◼ Inability to bear weight
◼ The limb is externally rotated with apparent lengthening
Treatment
Manipulative reduction under GA and immobilization in a hip spica
or in a Thomas splint for 6–8 weeks are done. Open reduction may
become necessary when the attempted reduction fails.
Central dislocation
This type of dislocation results following a fall on the greater
trochanter, or due to RTAs. The floor of the acetabulum is fractured
and the head of femur is pushed into the pelvis (Fig. 13-4).
FIG. 13-4 Central fracture dislocation left hip: (A) diagrammatic

representation, (B) as seen on radiograph.
Clinical features
◼ Severe localized pain and stiffness
◼ Hip abduction and rotation is markedly restricted with severe pain

on attempted movement of the hip joint.
◼ Bony mass is palpable in per rectal examination.
◼ The limb remains in neutral rotation and short.
Treatment
The dislocation is reduced by traction with pelvic compression (Fig.
13-5A) or heavy skeletal traction in two directions, longitudinally
along the line of the leg and laterally through the greater trochanter
(Fig. 13-5B). After reduction, the traction is maintained for 6–8 weeks.
The hip is mobilized after 6–8 weeks. Full weight bearing, however, is
started after about 3 months, after obtaining radiographic evidence of
consolidation of the acetabular floor.
FIG. 13-5 (A) Traction with pelvic compression. (B) Two directional
skeletal traction. LO, longitudinal along the line of leg; LA, lateral through
the greater trochanter.
Grossly displaced fractures, these days, are also fixed internally by

special plates (Fig. 13-6).
FIG. 13-6 Hip fracture treated by internal fixation.
During immobilization: It proceeds on the same lines as described for
fracture of the femoral neck. In order to gain control of the hip joint,
strong isometrics to the glutei, hip flexors, quadriceps and
hamstrings should be ensured at the earliest.
In patients treated with skeletal traction, small range

movements can be started by 3 weeks. Care should be
taken while performing movements which predispose to
dislocation, e.g., hip adduction and internal rotation with
flexion in posterior dislocation; hip abduction and external
rotation in anterior dislocation.
During mobilization: Vigorous exercises should be initiated to regain

range of hip movements, and strength at the dislocated hip. Knee
mobilization becomes necessary in patients treated with hip spica.
Assisted straight leg raise (SLR) should be initiated and

emphasized to regain control of the hip joint.
Once controlled hip movements are regained, ambulation

can be initiated with enough assistance by 12 weeks.
The patient should be independent in ambulation by 15–16

weeks.
Complications
1. Associated fractures of acetabulum, or rarely, head of the femur.
2. Injury to the sciatic nerve: It may occur as a result of the injury itself
or following manipulative reduction.
3. Avascular necrosis (AVN) of the head of femur: It may eventually lead

to degenerative arthritis requiring either arthrodesis or joint
replacement.
4. Unreduced dislocation: An old dislocation cannot be reduced by

closed methods or even by open reduction, at times.
5. Osteoarthritis of hip joint: It may eventually require total hip

replacement.
6. Ectopic ossification: Ectopic ossification can occur around the hip

joint, after posterior dislocation (see Fig. 11.15). It can give rise to pain
and limitation of movements of the hip joint.
Comparative Features of Hip Joint Dislocations
Posterior Dislocation Anterior Dislocation Central Dislocation

Incidence: about 70% of total dislocations About 10–15% of total Very rare
dislocations
May be associated with a fracture of the The femoral head may be May be associated with a burst
femoral head dislocated either anteriorly fracture of the floor or rim of
or posteriorly the acetabulum
Diagnostic features: Typical flexion– Diagnostic features: • No limb shortening
adduction and internal rotation deformity, Position of the limb: • Neutral limb positioning
with limb shortening Superior type: • Positive per rectal
• Flexion, abduction examination
and external rotation
Inferior type:
• Extended and
externally rotated
Treatment: Reduction of dislocation, Following classic method Skeletal traction or open
commonly by Watson–Jones method reduction internal fixation
(ORIF)
Complications: Complications: Complications:
Early: Early: Early:
• Sciatic nerve palsy • Injury to the femoral • Sciatic nerve palsy
• Irreducible fracture – dislocation, artery, vein or nerve • Thrombophlebitis
sometimes due to fracture of the rim of Late: • Recurrent dislocations
acetabulum or femoral head • Posttraumatic early Late:
• Recurrent dislocation osteoarthritis. • Posttraumatic
Late: • Recurrent dislocation osteoarthritis
• Avascular necrosis of the head of • Avascular necrosis of the
femur femoral head
• Myositis or ectopic ossification • Nonunion
• Posttraumatic early osteoarthritis • Myositis
The treatment needs to be started at the earliest to reduce the

hazards of complications or their severity. The following measures
can be taken:
1. Earliest possible reduction and stabilization of the dislocation will

be effective in reducing the injury to the sciatic nerve, and incidences
of neurovascular trauma.
2. Avoid recurrence by developing/strengthening the muscles around

the hip.
3. Earliest initiation of repetitive strong isometrics to the gluteal

muscles indirectly may help in increasing circulation to the femoral
head and neck.
4. Give instructions not to resort to early passive movements, joint

stretching, and massage, which may reduce the magnitude of myositis
or osteoarthritis.
5. Early vigorous movements to the calf muscles and isometrics to the

knee may contribute significantly towards the prevention of
thrombophlebitis.
Lower extremity
Injuries of the hip

Avulsion injury of the lesser trochanter
Sudden powerful contraction of the iliopsoas muscle can cause
avulsion of the lesser trochanter of femur. This injury occurs in sports.
Treatment
Rest in bed for 2 weeks with the hip in flexed position is all that is
necessary.
No specific procedure is needed. Treatment programme should
proceed on the same lines as described for avulsion injuries to
sartorius, rectus femoris and hamstrings.
Fracture of the neck of femur

There are two types of fractures of the neck of femur:
(a) Intracapsular fractures
(b) Extracapsular fractures: These are, in fact, trochanteric fractures and

shall be discussed in subsequent pages.
Intracapsular fracture of the neck of femur

This injury commonly occurs in elderly persons, particularly women,
following a trivial fall, e.g., a slip in the bathroom or a stumble over a
carpet. The femoral neck is also a common site for a pathological
fracture due to metastatic deposits.
Clinical features
◼ Pain, stiffness and localized tenderness
◼ Inability to bear body weight (except in impacted fractures)
◼ Active SLR is absent
Classification of the fractures of the neck of femur (fig.

13-7)
1. Abduction/adduction type. The abduction type of fracture is always
impacted and hence may unite with conservative treatment. In the
adduction or the unimpacted variety of fracture, the bony fragments are
subjected to shearing forces causing movements at the fracture site.
Since the fracture line here is more or less vertical, weight bearing will
push the trochanter upwards. Therefore surgical intervention to treat
this fracture is a must; otherwise nonunion may result.
2. Anatomical classification. In intracapsular fractures, the fracture

may be close to the head of the femur, called subcapital fracture, or it
may be somewhere in the neck away from the head called transcervical
fracture. The fracture can be at the base of the neck of femur, when it is
called basal fracture (Fig.13-8).
In an intracapsular fracture, the blood supply to the proximal

fragment (i.e., the head of femur) may be cut off, since the
blood supply to the femoral head comes mainly from the
distally placed extracapsular arterial ring. Only about 10%
of the head receives its blood supply from the artery of the
ligamentum teres. This may result in AVN of the head of
femur and may also cause nonunion of the fracture.
3. Garden’s classification. This is based on displacements of the head
(Fig. 13-9). It is most prognostic for development of AVN of the
femoral head.
Type I: Incomplete fracture, usually an impacted fracture
Type II: Complete undisplaced fracture
Type III: Partially displaced as distal fragment displaces the

fragment
Type IV: Complete fracture with fully displaced fracture
4. Pauwel’s classification. By measuring the angle formed by a

fracture line with the horizontal (Pauwel’s angle – Fig. 13-10).
Type I – < 30°
Type II – 30–70°
Type III – > 70°

FIG. 13-7 Intracapsular fractures of the neck of femur. (A) Abduction or

impacted fracture. (B) Adduction or displaced fracture.
FIG. 13-8 Fracture neck of femur: anatomical classification.

FIG. 13-9 (A) Radiograph showing the trabecular pattern in the neck of the
femur. (B) Garden’s classification.
FIG. 13-10 Pauwel’s classification. The fracture line is horizontal in type I;

hence stability is more, the fracture line is vertical in type III.
Treatment
It can be
1. Conservative or
2. Surgical
Conservative treatment is indicated in fractures in children

and in impacted (abduction) type of fractures. The various
treatment modalities can be
(a) Skin traction: It is given for a period of 4–6 weeks (Fig. 13-
11).
(b) POP hip spica for 6 weeks: Hip spica is used only on
children (Fig. 13-12). In elderly patients, it is
contraindicated because of the various problems of
prolonged recumbancy.
(c) POP boot and bar: It is also called a derotation bar and is
given for 4–6 weeks. In elderly patients, in case of
impacted fractures, a small below-knee plaster (boot) with
a horizontal bar is applied to prevent rotation of the limb
(Fig. 13-13). Although in all these modalities the
immobilization is maintained for 6 weeks generally, the
weight bearing is started only after the fracture is united
radiographically, i.e., after about 10–12 weeks.
(d) Painless pseudarthrosis: Patients who are not fit for surgery
or any other method of treatment mentioned earlier are
mobilized as early as the pain permits. The aim here is to
achieve painless pseudarthrosis.
2. Surgical treatment
Various methods of internal fixation have been used.

However, none of these has proved to be the best and
ideal. The commonly used surgical methods are as follows:
In children: Fracture of the neck of femur is fixed internally by

multiple Knowles or Moore’s pins (Fig. 13-14).
In young adults: Internal fixation of the fracture is achieved by

multiple cancellous screws (Fig. 13-15) or dynamic hip
screws (DHS).
In elderly patients: In elderly patients, the femoral head is

excised and replaced by a prosthesis (called
hemireplacement arthroplasty [HRA]).
Replacement arthroplasty of the hip: In patients over 60

years of age, replacement arthroplasty of the hip joint is
preferred to internal fixation mainly because of the
following two reasons:
1. Replacement arthroplasty permits early mobilization
and weight bearing. The patient can be made to bear
partial weight as early as 2–3 days after surgery.
2. The incidence of failure after internal fixation of this

fracture is quite high even in the best of hands. AVN of
the head of femur may also occur following this injury.
In the event of either of the situations described here, a
second operation becomes necessary while primary
prosthetic replacement of the head obviates these
problems.
Replacement arthroplasty is of three types:
1. Hemireplacement arthroplasty (Fig. 13-16): This is a

commonly performed operation where the head of the
femur along with the part of the neck proximal to the
fracture line is removed and replaced with a metal
prosthesis (e.g., Austin Moore or Thompson femoral
prosthesis).
2. Bipolar arthroplasty: This type of HRA is performed more

commonly these days. Bipolar means head within head.
In this type of surgical procedure, the femoral head is
replaced by a metallic prosthesis and the head of this
prosthesis is covered by a metallic cup which is placed
into the acetabulum without replacing the acetabulum
(Fig. 13-17). The advantages of bipolar arthroplasty are as
follows:
• The range of motion at the hip is better.

• The wear and tear of acetabulum is less.
• Revision total hip replacement is easier later on.
3. Total hip replacement arthroplasty (THR) (Fig. 13-18): Some

surgeons prefer to do a total hip replacement following a
fracture of the neck of femur. In this operation, along
with the replacement of the head and neck of femur, the
acetabulum is also replaced by an artificial acetabular
cup.
FIG. 13-11 Below-knee skin traction.

FIG. 13-12 Plaster of Paris (POP) hip spica.
FIG. 13-13 Immobilization with below-knee plaster cast with boot and
horizontal bar (H) or derotation bar to prevent external rotation.
FIG. 13-14 Fracture of neck of femur in children fixed with multiple Moore’s
pins.
FIG. 13-15 (A) Fracture of neck of femur. (B) Fracture of neck of femur
fixed by multiple screws.
FIG. 13-16 Fracture of neck of femur treated by Austin Moore prosthesis

(hemireplacement arthroplasty).
FIG. 13-17 (A and B) Fracture of neck of femur treated by bipolar

arthroplasty.
FIG. 13-18 Total hip joint replacement arthroplasty (THR) – both

acetabulum and femoral head replaced.
Conservative approach: Fracture is treated by skin traction, skeletal
traction and derotational bar
Objectives
◼ To restore full or at least functional range of motion (ROM) to the

hip joint.
Normal and Functional ROM at Hip and Knee
Movement Normal Functional

ROM ROM
Hip joint
Flexion 0 → 125– 0 → 90–110º
Extension 130º 0 → 5º
Abduction 0 → 20º 0 → 20º
Adduction 0 → 45–50º 0 → 20º
External 0 → 40–45º 0 → 15º
rotation 0 → 45º 0 → 20º
Internal 0 → 40–45º
rotation
Knee joint 0 → 135– 0 → 110º
Flexion 140º 0º
Extension 0º
◼ To restore adequate strength, power and endurance to the muscle

groups around the hip and the knee.
◼ To acquire self-sufficiency in performing all the ambulatory

activities with ambulatory aids or suitable orthosis whenever
necessary.
Expected problems
During 1st week:
1. Be alert and watchful for the symptoms and signs of

thromboembolism, pulmonary embolism or hypovolaemia.
2. Strictly keep a check on the process of healing, anatomical bony

alignment and the open reduction internal fixation (ORIF).
During immobilization: As the patients are generally in the age group

of 60 years and above, the following measures are taken:
1. Adequate chest physiotherapy to avoid respiratory complications.
2. Repeated checks to assure correct positioning of the fractured limb;

with special attention to avoid limb rotation.
3. Resistive movements to the toes and ankle joint of the fractured

limb and other body joints.
4. Strong isometrics to the quadriceps, hamstrings, hip extensors and
abductors. Each static contraction should be strongly held at least for
10 s (or 30 counts), to avoid postimmobilization atrophy and
weakness.
5. It is ideal to initiate early knee mobilization whenever special bed is

available (slit-bed).
6. Initiate sitting on bed at the earliest opportunity; may be with

backrest at the beginning.
7. Site of the skeletal traction pin should be inspected often for

infection/loosening.
Mobilization: As soon as active mobilization is allowed, efforts

should be concentrated to get maximum possible active ROM at the
hip and knee.
Weight transfers and brief periods of full weight bearing on the
affected leg alone are very important to balance the whole body
weight on the affected leg during standing and walking. Guided
training is needed to master it. Periods of prone lying, four-point
kneeling and knee walking are extremely useful as a pre-weight
bearing exercise (Fig. 13-19). This knee standing should be progressed
to knee walking (Fig. 13-20). Strengthening exercises for the glutei and
quadriceps should be done by progressive resistance exercise (PRE)
techniques. Passive stretching ROM exercises can be progressed to get
full ROM at the hip and knee joints. Supported squatting in front of
wall bars and cross-leg sitting with back supported against the wall
can be started with guidance and gradual progression.
FIG. 13-19 Graduated weight bearing on the operated hip is facilitated by

knee standing and knee walking with hand support.
FIG. 13-20 Total weight bearing on the operated hip is facilitated by knee
standing and knee walking without hand support.
The patient should be functionally independent by 8–12 weeks.
Patients treated with hip spica: This method is rarely adopted due to its
various disadvantages. When treated by this method, strong resisted
toe movements, and isometrics inside hip spica are taught and
ensured. Sessions of assisted bedside standing should be initiated at
the earliest.
During mobilization, the measures and sequence of
physiotherapy remains the same as described for treatment
by traction and derotation bar.
Patients treated by pseudarthrosis: Patients who are not fit for plaster,
traction or surgical methods of treatment are left to pseudarthrosis
at the fractured hip.
Persisting annoying pain is the typical feature of these

patients; therefore, the basic approach of physiotherapy is
directed towards the relief of pain. Pain can be controlled
by the following methods:
1. Movements started in combination with transcutaneous

electric nerve stimulation (TENS).
2. The patient should be taught accurate methods of

transfer and limb positioning during the activities.
3. Emphasis is laid on repeated sustained isometric

contractions to strengthen the functionally important
muscle groups.
4. Isotonic exercises and hasty partial weight bearing

should be discouraged, as they produce movements at
the fracture site leading to nonunion.
Gradual weight bearing should be started with adequate support to
avoid pain.
As the degree of pain reaches an acceptable level, progressive
physiotherapeutic measures should be adopted to ease ambulation.
Majority of the patients achieve functional independence. However,
some may need a walker or two crutches for ambulation, because of
persistent pain.
Surgical approach
◼ Carefully inspect the surgical wound for early signs of wound

infection.
◼ Check the immobilized limb for comfortable positioning.
◼ Guide and teach an attendant on repetitive check of positioning of

the limb and how to perform assistive side turning in the bed
(keeping a pillow in between the two legs to avoid or prevent
pressure sores).
◼ No passive movements are initiated before 2 weeks of surgery.
◼ Educate and guide the patient, at the earliest, to perform both the
modes of strong static contractions to the quadriceps to prevent
disuse atrophy.
◼ Strong ankle and toe movements, and full ROM to the hip and knee
to improve circulation to the fractured bone.
◼ The duration of the self-assisted, resistive isometrics to the gluteus

maximus and quadriceps by simply pressing down the whole leg on
the bed is easiest and self-controlled.
During week 2 and 3

By this time, the stiches are removed and the soft tissue healing has
progressed adequately.
◼ Small range passive relaxed movements to the operated leg are

begun.
◼ Make it self-assistive by heel drag technique providing only the

required passive assistance. You may use sunmica flat board. Spread
talcum powder to reduce frictional resistance (heel drag) as shown
in Fig. 13-21.
◼ Use of controlled, pain-free continuous passive motion (CPM) may
be added.
◼ Whenever CPM apparatus is available, it can be used gainfully to

initiate relaxed passive hip and knee flexion–extension. The patient
is taught to operate it so that maximum possible work for the range
of motion is facilitated.
◼ Progressive assisted active range of flexion can be achieved by self-

assisted dragging of the heel.
◼ Sitting and transfer with legs hanging over the edge of the bed can
be made self-assisted. The patient supports the operated leg by the
normal leg.
◼ Assisted abduction can be initiated by sling suspension, self-

assisted technology, or the patient using the sound leg as support
underneath the fractured leg.
◼ Self-assisted SLR may be begun as early as possible, in spite of little

discomfort.
◼ Knee swinging sitting at the edge of the bed can be made resistive
either by self-resistance technique using the normal leg or by graded
resisted exercises using weight belts or the DeLorme shoe.
FIG. 13-21 Initiation of hip flexion by self-assisted “heel drag”.
During weeks 4–8
By this time, hip flexion should attain the 90º mark.
It is the appropriate time to build up and strengthen the usually

painful and weak hip flexors by self-assistive hip flexion in supine
position or at bedside sitting or heel drag in the supine.
Isometrics to gluteus maximus as well as medius should reach peak

holds and strong muscular contractions.
After 8 weeks
Hush up exercise intensity to reach maximal muscular contractions

both in strength and the ROM.
By 16–18 weeks
There will be no harm in introducing full weight-bearing activities

and spot marching.
Balance and weight bearing must reach a stage of adequate stable one
leg stand.
Correction of the limp: Limp in gait should not be allowed to get
organized. Repetitive sessions of self-resistance exercise, gait training
with correct comfortable footwear and home practice in front of a
postural mirror is ideal.
Prevent fracture susceptive tendencies like excessive tendency to
bring the affected limb into adduction and internal rotation in
walking. It is commonly seen in patients treated by ORIF.
The other managemental programmes should be followed on the
same lines as described for the conservative treatment of these
fractures. Partial weight bearing can be started after 6–8 weeks, while
full weight bearing may be deferred till 12 weeks.
If there are no complications, patients of any age should be
functionally independent by 3–4 months.
Hemireplacement arthroplasty (HRA): A procedure of choice if the

acetabular cartilage is viable and not damaged.
Total hip replacement arthroplasty: When both femoral head as well

as the acetabular cartilage are not viable or damaged.
Prevention of fractures at the pelvis and hip
◼ Most important contribution comes from achieving stable balance.
◼ Adequate warming up before undertaking any heavy activity.
◼ Every year, bone mineral density (BMD) along with other checks is
advised.
◼ Nonexerting full ROM movements but not hard impact exercises

when osteoporosis is confirmed.
◼ Correction in home hazards.
◼ Use cane support, in case of difficulty in walking unsupported.
Functional activity guidelines for femoral fractures

From lying in bed
◼ Intermittent lying on the side of the normal limb – mainly turning

from the shoulder on the side of the fracture.
◼ Sitting up in bed from supine position, maximally using upper

limbs and a normal lower limb.
◼ Pushing forward – same as sitting up.
◼ Learn walking, hopping with walker on the unaffected limb.
◼ Toilet activities – using walking aid or a walker, high commode seat

or a chair with arm supports.
◼ Wearing trousers from the side of the fractured leg first while
removing it is performed by the affected side first.
◼ Rolling body on the unaffected side before getting up from the

supine.
◼ Maintain neutral position of the affected limb, whether non-weight

bearing (NWB) or partial weight bearing (PWB). If permitted, keep
hip and knee in slight flexion.
A flow chart (Flowchart 13-1) depicts the sequence of mobilisation.

FLOWCHART 13-1 Sequence of mobilisation.
Note: Required healing time in fractures of femoral neck is 12–16

weeks.
Required period of adequate self-sufficiency is 15–30 weeks.
Caution
1. The most important aspect of this period is to regain maximum
(near normal) range of hip flexion. Once the fibrous ankylosis is
allowed to organize at this stage, regaining the range of flexion
becomes impossible at a later stage.
2. All the measures to avoid fixed flexion or abduction deformity at

the hip should be strictly observed.
3. If the patient starts complaining of excruciating pain and

tenderness around the operated area as well as progressive
limitation in the ROM at hip, complications like nonunion,
loosening of the internal fixation, AVN or ectopic ossification
should be suspected and reported immediately.
Management of old fractures: Procedures of open reduction
1. McMurray’s osteotomy
2. Meyer’s procedure
1. McMurray’s intertrochanteric osteotomy: This is done to convert the

shearing stresses at the fracture site into compressive forces (Fig. 13-
22).
2. Meyer’s procedure: The muscle pedicle bone graft within the

quadratus femoris is applied on the posterior aspect over the fracture
site supplementing the fracture by multiple screws (Fig. 13-23).
FIG. 13-22 McMurray’s osteotomy. Osteotomy done below the greater

trochanter; the distal fragment is displaced medially; the transmission of
body weight occurs from the head of femur to the distal fragment directly,
bypassing the fracture.
FIG. 13-23 Meyer’s procedure: (A) Posterior aspect–position of quadratus

femoris muscles, and (B) fracture fixed with compression screws.
Quadratus femoris harvested along with a block of bone from its insertion
and rotated to the fracture side.
Complications
◼ Nonunion: When there is no radiographic evidence of bone union

by 6–12 weeks with the presence of telescoping, positive
Trendelenburg’s sign and diminished pain, treatment of choice is
either Pauwel’s osteotomy or else by hemireplacement or THR.
◼ AVN: Late on radiography (6 months to 2 years), shows collapse of

the head of femur; it is also treated by osteotomy or replacement
arthroplasty.
◼ Osteoarthritis – Radiographic evidence appears lately (few years).
◼ Stiffness, pain on weight bearing and marked limp.
Treatment
◼ McMurray’s osteotomy in young patients

◼ Total hip replacement in older patients
1. After McMurray’s osteotomy (during immobilization, first 6–8 weeks):

If the hip spica is applied, there is not much of a scope for active
physiotherapy. However, the following programme should be
initiated:
(a) Strong and vigorous toe movements
(b) Technique of supported rolling to the side in bed
(c) Isometrics for the hip and knee muscles
(d) Ankle, foot and knee on the normal side needs to be

vigorously exercised by hanging the leg over the edge of
the bed.
When the osteotomy is fixed internally with plate and

screws, mobilization can be started after 3 days. The
physiotherapeutic programme is followed on the same
lines as detailed for the fractures of the neck of femur. The
patient regains adequate functional status by 3 months if
treated in a hip spica and by 6–8 weeks when treated by
osteotomy with internal fixation. Occasional inexplicable
weakness of the hip flexors has been noticed in patients
treated by hip spica. Therefore, active assisted hip flexion
needs to be initiated early.
2. After Meyer’s muscle pedicle bone grafting: The physiotherapeutic

management proceeds on the same lines as described for internal
fixation of fracture of the femoral neck.
3. After hip replacement and arthrodesis: The physiotherapeutic
management after these procedures is discussed elsewhere.
Trochanteric fractures
A fracture in the region of the greater trochanter (up to the lesser
trochanter) is called intertrochanteric fracture (Fig. 13-24). A fracture
distal to the lesser trochanter (within 2 inches) is called subtrochanteric
fracture of the femur. Trochanteric fracture is also called extracapsular
fracture of neck of the femur since the fracture line is distal to the
femoral attachment of the hip joint capsule.
FIG. 13-24 Intertrochanteric fracture of femur.
Trochanteric fractures are common in elderly patients in whom the

bones are osteoporotic and, therefore, trivial trauma like a stumble or
a fall can cause this injury. However, this fracture is rare in young
adults and results following a major trauma. The fracture may be
displaced or undisplaced and may be comminuted.
Clinically the limb appears short and markedly externally rotated
(much more than is seen in the fracture of neck of femur) following
injury. The diagnosis is confirmed on radiography.
Treatment
A trochanteric fracture generally unites readily as it occurs in the
region of cancellous bone. The treatment, therefore, is aimed at
maintaining alignment of the fracture fragments either by
conservative or operative methods.
The following methods may be used:
1. Skin traction (see Fig. 13-11)
2. Skeletal traction
3. POP hip spica
4. POP derotation bar
Skin or skeletal traction (Fig. 13-25) is applied to the leg and maintained
for 6–8 weeks. Active mobilization of the hip is then started.
However, weight bearing should be started only after 3 months,
depending upon the type of fracture and the evidence of sound
radiographic union.
POP hip spica (see Fig. 13-12): This is indicated rarely, only in young
adults. The plaster spica is given for 6–8 weeks.
FIG. 13-25 Trochanteric fracture treated by skeletal traction on a Bohler–

Braun splint.
In very elderly patients when surgery is contraindicated due to

medical problems, occasionally POP boot and bar (derotation bar) is
given (see Fig. 13-13). It keeps the limb in neutral rotation and thereby
prevents any external rotation deformity. It, however, does not reduce
the fracture accurately and, therefore, the fracture invariably
malunites with shortening and coxa vara. POP boot and bar is also
used in elderly patients with undisplaced trochanteric fractures.
Operative treatment
Although a trochanteric fracture can be treated by conservative
methods, the operative treatment offers the advantage of accurate
reduction and early mobilization, particularly in elderly patients. The
operative treatment thus avoids the complications of prolonged
recumbency.
The fracture is reduced by open reduction, under radiographic
control, and fixed internally by DHS (Fig. 13-26) or dynamic
compression screw (DCS) (Fig. 13-27) or Ender’s nail (Fig. 13-28).
Many other fixation devices are also available nowadays which give
better fixation. For example, proximal femoral nail (PFN) is a better
fixation device in unstable trochonteric fractures (Fig. 13-29) by the
use of interlocking nail.
FIG. 13-26 (A and B) Pre- and postoperative radiographs of a case of
trochanteric fracture treated by dynamic hip screw fixation.
FIG. 13-27 Trochanteric fracture of femur treated by dynamic compression

screw.
FIG. 13-28 Trochanteric fracture of femur treated by multiple Ender’s nail.

FIG. 13-29 (A and B) Fixation by proximal femoral nail.
Postoperatively the patient is given only a dressing (no external

immobilization). The patient can be made to sit up in bed the next day
and the hip is mobilized as soon as the pain permits; full weight
bearing, however, is started after about 3 months.
Special precautions in subtrochanteric and intertrochanteric
fractures
Do not neglect the possibility of developing the following
complications during the immediate postsurgical phase like:
◼ Infection
◼ Blood clots progressing to deep vein thrombosis (DVT)
There is a possibility of complications like malunion, delayed union,

nonunion, limb shortening, angular deformity, as well as rotational
malunion.
Several factors are responsible for these complications, such as:
◼ These fractures are extracapsular.
◼ They occur through the cortical bone.
◼ There is a large biomedical stress at the site of a fracture.
◼ Imbalanced pull of the strong muscular attachments to the

fractured bones.
◼ Short external rotators are attached to the proximal head and neck,
whereas internal rotators of the hip remain attached to the distal
fragment.
Therefore, limb positioning maintaining proper anatomical

alignment of the fractured bony ends is of primary importance during
the early stage of fracture healing. It has to be ensured with repetitive
inspections, guidance to the patient and radiological checks.
Plus point: The bone at the site of the fracture is cancellous in
nature, as such, the rate at which the fracture heals is faster and much
better as compared to intracapsular fractures.
Complications
1. Malunion: Inadequate fixation/immobilization, implant failure or

severe comminution often results in malunion. The fracture malunites
in coxa vara (Fig. 13-30) which produces shortening and limp.
Treatment: Correction of coxa vara deformity is achieved by

corrective osteotomy and internal fixation.
2. Nonunion of trochanteric fractures is extremely rare.
Treatment: Internal fixation with bone grafting.

FIG. 13-30 (A) Normal neck shaft angle; coxa vara (dotted line). (B) Coxa
vara, after fixation.
The physiotherapeutic management of trochanteric fractures, treated
conservatively or surgically, proceeds on the same lines as described
for fracture of the neck of femur.
CHAPTER
14
Injuries of the thigh
OUTLINE
◼ Fractures of the shaft of femur
Fractures of the shaft of femur

Fractures of the shaft of femur occur at all ages and are caused by
severe trauma, except in cases where the bone is destroyed and
weakened by disease. For example, in children, the femur may be
affected by a bone cyst while in the elderly, it may be weakened by a
metastatic lesion. Fracture occurring in a diseased bone is called
pathological fracture. It results following a trivial trauma.
In adults, generally, there is marked displacement of the fragments
due to the pull of strong muscles surrounding the femur (Fig. 14-1).
FIG. 14-1 Fracture shaft of femur: displacement of fragments by pull of

muscles.
In a case of fracture of the shaft of femur, there is generally,

considerable blood loss from the fractured bone ends and also from
the traumatized soft tissues. The patient, therefore, may be in a state
of shock when first seen.
Treatment
The immediate treatment includes blood transfusion to combat shock,
and temporary splintage of the fracture.
Fracture of the shaft of femur can be treated by both conservative as
well as operative methods.
It depends upon the age of the patient:
1. Children under 2 years of age: Fracture of the shaft of femur in
children below 2 years of age is treated by Gallow’s traction (see Fig.
4-12) for 3–4 weeks.
2. Older children: In older children, this fracture can be treated by any

of the following methods:
◼ Skin traction on pillows (Fig. 14-2)
◼ Skin traction in a Thomas splint
◼ Plaster of Paris (POP) hip spica
FIG. 14-2 Skeletal traction on pillows.
The period of immobilization is 6–8 weeks.
3. Adults: Fracture of the shaft of femur in adults and elderly patients

is treated by skin or skeletal traction in a Thomas splint (Fig. 14-3) or a
balanced traction over pulleys in a Bohler–Braun splint, Rusell’s
traction (see Fig. 13.25). The period of immobilization is longer, i.e.,
12–14 weeks. Methods of traction immobilization, although uniting
the fractured bone, are associated with deformities like limb
shortening or angular deformities; moreover, long (12–14 weeks)
immobilization results in complications.
Functional cast bracing: Fracture of the shaft of femur in

adults can also be treated by functional cast bracing. In this
method, the fracture is initially treated by traction for
about 4 weeks. As the fracture becomes ‘sticky’ and some
callus is seen on the radiographs, a cast brace (Fig. 14-4) is
applied. The cast brace permits flexion at the knee joint as
well as ambulation.
FIG. 14-3 Skeletal traction in a Thomas’s splint.

FIG. 14-4 Functional cast bracing.
Operative treatment
1. Internal fixation: Open reduction internal fixation of fracture

fragments is generally indicated in adolescent, adult and elderly
patients. It is rarely indicated in very young children where some
amount of angulation and overriding of the bony fragments are
acceptable. In young children, these deformities get corrected in the
process of remodelling of the bone.
Wherever indicated, the femur is internally fixed with

Kuntscher’s intramedullary nail (Fig. 14-5) or plate and
screws (Fig. 14-6). Interlocking nail is a further
development over the Kuntscher’s nail (Fig. 14-7). An
interlocking nail provides rotational stability to the fracture
and thereby facilitates fracture healing.
2. External fixation: Stabilization of the fracture by external fixator (Fig.

14-8) is ideal for open fractures with contaminated wounds.
FIG. 14-5 (A) Radiograph showing a fracture in the middle of shaft of

femur (arrow). (B) Internal fixation by a Kuntscher’s nail.
FIG. 14-6 (A and B) Fracture of the shaft of femur treated by compression

plating.
FIG. 14-7 Fracture of the femur treated by interlocking nailing.

FIG. 14-8 Fracture of the shaft of femur treated by external fixator. (A) Line
diagram, (B) as seen on X-ray.
Advantages of operative treatment
◼ Period of hospitalization and recumbency is less.
◼ Generally, no external immobilization is needed and hence knee

mobilization can be initiated early (after 2 weeks). Although, weight
bearing should be started only after the radiographic evidence of
sound union is obtained, i.e., after 2–3 months.
Complications
1. Injury to vessels and nerves: Although rare, a sharp bony fracture
fragment can cause injury to the femoral artery and femoral and
sciatic nerves. In such a situation, it requires urgent repair.
2. Infection: An open fracture is likely to get infected. Infection during

surgery can also lead to chronic osteomyelitis of the femur.
3. Delayed union and nonunion: If a fracture of the shaft of femur is

treated with inadequate immobilization, it can go into delayed union
or nonunion. Other common causes of nonunion include infection and
interposition of soft tissues between the fracture fragments.
Delayed union or nonunion is treated by open reduction,

internal fixation and bone grafting.
4. Malunion: Improperly treated fractures can unite in a malposition

resulting in shortening and deformity of the limb.
Malunited fracture can be treated by corrective osteotomy.

The bone is internally fixed with nail or plate.
5. Knee stiffness: Varying degrees of knee stiffness commonly result

after femoral shaft fractures. The possible causes are as follows:
◼ Prolonged immobilization of the knee.
◼ Adhesions of the quadriceps muscle to the bone and callus

at the fracture site.
◼ Intra-articular and peri-articular adhesions of the knee

joint.
Knee stiffness can be treated by intensive knee mobilization
programmes. Severe degree of knee stiffness can be treated surgically
by an operation – quadricepsplasty. In this operation, lengthening of
the quadriceps muscle is carried out. Postoperatively, intensive knee
mobilization is required, initially in a Thomas splint with the Pearson
knee attachment.
These days, knee stiffness can also be treated by arthroscopic
surgery. In this operation, the adhesions inside the joint are broken
arthroscopically.
Early physiotherapy during immobilization follows the same pattern
as described for trochanteric fractures. The skeletal traction here plays
an important role as there is likelihood of marked displacement of the
fractured ends because of the strong muscular action. In fracture of
the upper third of the shaft of femur, the proximal fragment is flexed,
abducted and externally rotated due to the actions of iliopsoas, glutei
and short hip external rotators, respectively; the distal fragment is
adducted due to the actions of strong adductors.
In fracture of the mid shaft region, the proximal fragment is flexed
by the iliopsoas and drawn inwards by the adductors. The distal
fragment is tilted backwards by the lower part of adductor magnus
and is drawn upwards by the hamstrings and rectus femoris.
When the fracture is treated by skeletal traction, as the period of
traction extends up to 12 weeks, early knee mobilization, which is
important, can be initiated with traction and split bed (Fig. 14-9). Early
initiation of isometrics to the quadriceps is essential to gain early
control of quadriceps for knee flexion.
FIG. 14-9 Early knee mobilization with maintenance of traction.
When treated by intramedullary nail, mobilization of the hip and

the knee can be initiated early, by 2–3 weeks. Early return of
quadriceps strength and control is emphasized to achieve
independent SLR by 2–3 weeks when fibrous union is established.
Partial weight bearing can be initiated by 6–8 weeks and full weight
bearing by 12 weeks.
Rest of the treatment programme is on the same lines as described
for the trochanteric fractures treated by internal fixation.
Note: Since these types of fractures are usually associated with
extensive soft tissue injury, training isometrics is difficult and
painful, but can be made effective by training to simultaneously
contract the same muscle groups on both the sides (e.g., bilateral
static quadriceps contractions) or hams contractions.
CHAPTER
15
Injuries of the knee
OUTLINE
◼ Supracondylar fracture of the femur
◼ Intercondylar fracture of the femur
◼ Physiotherapeutic management of supracondylar and
intercondylar fractures of the femur
◼ Fracture of the patella
◼ Acute dislocation of the patella
◼ Recurrent dislocation of the patella
◼ Dislocation of the knee
◼ Fractures of the tibial condyles
◼ Intercondylar fractures of the tibia
Supracondylar fracture of the femur

The fracture line is just proximal to the femoral condyles. The distal
fragment is pulled backwards by the pull of the gastrocnemius
muscle. The sharp edge of the fracture fragment can injure the
popliteal artery (Fig. 15-1). The fracture is often comminuted
depending upon the severity of the force.
FIG. 15-1 (A) Pull of the gastrocnemius angulates the distal fragment
posteriorly and may cause injury to the popliteal vessels (diagrammatic
representation). (B) Radiograph showing the fracture with posterior
displacement of the distal fragment.
Treatment
This fracture can be treated by conservative as well as operative
methods.
Conservative methods
The fracture is reduced under general anaesthesia and the limb is
immobilized in a Thomas’ splint. Skeletal traction is applied through
the upper end of the tibia and the knee is maintained in 30 degrees of
flexion using a Pearson knee attachment (Fig. 15-2). The limb is
immobilized for 8–12 weeks.
FIG. 15-2 Fracture of the distal femur: treatment by skeletal traction

through upper tibial pin. Pearson knee attachment to the Thomas’ splint
facilitates movement at the knee joint, which the patient can do himself.
Operative methods
Surgery is indicated in cases where closed reduction fails or injury to
the popliteal artery necessitates repair. The fracture is reduced by
operation and fixed by a condylar blade plate (Fig. 15-3), a dynamic
compression screw (DCS) (Fig. 15-4) or an intramedullary
supracondylar nail (Fig. 15-5). Various other fixation devices are also
available. Postoperative mobilization can be started after 2 weeks.
However, weight bearing is started after about 3 months.
FIG. 15-3 Treatment by condylar angled blade plate. (A) Line diagram. (B)
As seen on a radiograph.
FIG. 15-4 Treatment by dynamic compression screw (DCS).

FIG. 15-5 Treatment by intramedullary supracondyler nail.
Complications: The complications include malunion, nonunion and

knee stiffness. The treatment of these complications is the same as that
for fracture of the shaft of the femur. Injury to the popliteal artery,
described earlier, is a serious complication encountered in this
fracture. Repair of the artery or grafting is indicated urgently in such
cases. The fracture is also fixed internally.
Intercondylar fracture of the femur

It generally occurs as a result of severe trauma. Either single or both
condyles may be fractured. When both condyles are fractured, the
fracture line may pass through the condyles resulting in a T- or Y-
shaped fracture (Fig. 15-6). Since it is an intra-articular fracture, it is
usually associated with haemarthrosis.
FIG. 15-6 Intercondylar fracture of femur. (A) Y-shaped fracture. (B) T-

shaped fracture.
Treatment
It can be treated by conservative or operative methods.
The plan of treatment is the same as for supracondylar fractures of the
femur. Skeletal traction is applied through the upper tibia and is
maintained for 6–8 weeks. Knee mobilization is started after 6–8
weeks.
Operative treatment
In all intra-articular fractures, accurate reduction of the fracture,
thereby achieving congruity of the articular surfaces, is essential.
Therefore, if the fracture is not too comminuted, open reduction and
internal fixation of the fracture is indicated. Internal fixation is
achieved by multiple screws, Kirschner wires or blade plate. Knee
mobilization is started early, i.e., after 2 weeks only.
Complications
◼ Injury to the popliteal neurovascular bundle, especially injury to the

popliteal artery needs immediate repair.
◼ Postoperatively, there is a danger of infection to the superficially

placed implants. This needs careful monitoring.
◼ Knee stiffness, osteoarthritis of the knee joint and malunion are

possible late complications.
Physiotherapeutic management of
supracondylar and intercondylar fractures of
the femur
The common problems with these injuries:
1. Gross effusion of the knee

2. Knee stiffness – due to adhesions and involvement of the articular
surfaces
3. Knee instability – the fracture, especially a comminuted one, may be

associated with injuries to the soft tissues including ligaments; unless
the soft tissue repair and bone architecture are properly restored,
instability and stiffness of the knee are common features
4. Reflex inhibition of the quadriceps (extensor lag) – due to quadriceps

insufficiency
Right from the initial period, it is absolutely essential to plan

appropriate physiotherapeutic measures to control these four
complications. Therapeutic measures are employed to minimize
effusion; and acquire early ROM at the knee while maintaining
reduction and emphasis on the early and strong isometrics to the
quadriceps.
Initially, when the fracture is treated with skeletal traction, the
following programme is instituted:
1. Limb elevation, pressure bandage and isometrics to the quadriceps

and glutei are performed.
2. Strong ankle and toe movements are given.
3. Gradual knee mobilization is started after a week or 10 days. It may

be started as a relaxed passive movement preceded by thermotherapy
or cryotherapy. Self-controlled mobilization by continuous passive
motion (CPM) is very effective. Early mobilization improves and
maintains the tone and strength of the quadriceps besides facilitating
gliding planes of quadriceps mechanism.
4. Self-assisted relaxed knee swinging with the patient sitting at the

edge of the bed and supporting the operated leg by the good one is
the ideal technique of mobilization.
5. Non–weight-bearing crutch walking should be initiated to make the

patient ambulatory.
6. By 4–6 weeks, comfortable ROM of knee flexion beyond 90 degrees

should be attained, with minimal effusion and full extension at the
knee.
7. All the programmes should be made vigorous to gain further range

and strength.
8. Partial weight bearing is initiated by 9 weeks following surgery and

the patient is given proper re-education in walking.
9. Full weight bearing is permitted by 8–12 weeks. Proper gait

training, ambulation and functional training are initiated.
10. Early knee mobilization and early weight bearing with cast brace
has been reported by Borgen and Sprague (1975) for open or closed
supracondylar and intercondylar fractures. Cast brace with
polycentric hinges is applied between 3 to 6 weeks (see Fig. 14.4).
Standing and walking in parallel bars and knee movements are begun
on the next day after applying the brace.
Fracture of the patella

Patella is the largest sesamoid bone in the body situated in the strong
quadriceps tendon. It increases the efficiency of the extensor
mechanism of the knee by increasing the leverage. It has an articular
surface which articulates with the intercondylar groove at the lower
end of the femur. The patella may be fractured due to (1) a direct
injury or (2) an indirect injury.
1. A direct injury can cause an undisplaced crack fracture of the

patella or a comminuted ‘stellate’ fracture of the patella (Fig. 15-7).
2. An indirect injury results in a transverse fracture of the patella with

displacement of fragments (Fig. 15-8). The displaced fragments are
treated by tension band wiring (TBW). This is caused by forced
passive flexion of the knee when the quadriceps muscle is in a state of
contraction. The fracture fragments are pulled apart by the pull of the
quadriceps muscle. Active extension of the knee, in these fractures, is
impossible as the extensor mechanism of the knee is ruptured. A
major direct trauma can cause a comminuted fracture (Fig. 15-9).
FIG. 15-7 Fracture of patella: stellate fracture.

FIG. 15-8 Transverse fracture.

FIG. 15-9 Comminuted fracture.
Diagnosis
The patient will have pain and tenderness over the patella in cases of
undisplaced fractures of patella, while in displaced fractures, there is
haemarthrosis and inability to actively extend the knee joint. A
radiograph would confirm the type of fracture.
Treatment
The treatment can be (a) conservative or (b) operative.
An undisplaced fracture (crack or stellate type) is treated by a POP
cylinder or an above-knee POP cast (Fig. 15-10) for 4 weeks. It must be
remembered that the extensor mechanism should be intact.
FIG. 15-10 Stellate or undisplaced fracture treated by walking POP

cylinder.
Operative treatment
It is always indicated in transverse displaced fractures and rarely, in
undisplaced fractures where the extensor mechanism is torn. The
following surgical procedures are commonly employed:
1. Internal fixation: A transverse fracture is fixed internally either by a

screw or by TBW (Fig. 15-11). The extensor mechanism is also
repaired. An above-knee POP cast is applied for 4–6 weeks after
which knee mobilization is started.
2. Excision of the patella: In severely comminuted fractures where

internal fixation cannot be done or in elderly patients, who show signs
of osteoarthritis, the patella is excised partially or completely (partial
or total patellectomy) (Fig. 15-12) and quadriceps mechanism is
repaired. The period of postoperative immobilization is 5–6 weeks.
FIG. 15-11 (A and B) Displaced fracture of patella treated by tension band

wiring.
FIG. 15-12 Comminuted fracture treated by excision of patella, and repair

of the quadriceps mechanism.
The basic principles of physiotherapy:
1. To reduce effusion, pain and inflammation.
2. To provide effective quadriceps mechanism.
3. To regain maximum possible ROM of flexion–extension.
All efforts are concentrated to get the quadriceps mechanism re-

established at the earliest.
Undisplaced fractures: It is usually treated in a plaster cast applied

for 3–4 weeks.
1. Static quadriceps contractions are initiated early in the

plaster. Similarly, begin with assisted SLR early,
although not strong enough to provoke pain. Repetition
of SLR and holding it for 10 s, the POP slab itself
provides good assistance as well as resistance.
2. Weight bearing and crutch walking is started

immediately the next day and the patient resumes work
in 3–4 days.
3. The POP cylinder cast is removed after 4–6 weeks and

knee flexion is initiated as relaxed passive movement,
with or without CPM.
4. Knee flexion may be preceded by thermotherapy or

cryotherapy and made vigorous to attain early
movement.
5. Correct weight bearing and gait pattern should be re-

established to avoid limp. Full function should be
regained by 8–12 weeks.
Displaced fractures: These are usually treated by internal fixation by

TBW or screw fixation. It is also treated by patellectomy.
Physiotherapeutic management (TBW treatment): The basic

objective of physiotherapy is to attain mobile and strong
knee with emphasis on the return of a strong quadriceps
mechanism.
The obvious advantages of this procedure are as follows:

1. The surgical procedure is not as extensive as
patellectomy.
2. The patella is retained with its muscular attachments.
3. The period of immobilization is short.
These factors allow early mobilization of the knee, which is

important to regain strength and mobility.
(a) Preoperative evaluation and education: Due to the presence

of pain and haemarthrosis, accurate assessment is not
feasible. Therefore, the postoperative regime of
physiotherapy should be explained on the normal side.
(i) The physical requirements of the patient’s routine and

work should be assessed in relation to the knee.
(ii) The adjacent joints should be examined to rule out any

dysfunction.
(b) Postoperative regime (1–10 days): The limb is immobilized

in a posterior plaster cast or in a pressure bandage.
(i) The limb encased in a plaster cast should be elevated

over pillows. If pressure bandage is applied, the pillows
should be so arranged that there is no sudden slipping of
the limb. Even a slight sudden flexion at the knee should
be avoided.
(ii) Diapulse may be given over the cast or bandage.
(iii) Vigorous ankle and toe movements and relaxed

passive movements to the hip should be given.
(iv) Direct isometrics to the quadriceps should be deferred

for 3–4 days. Indirect isometrics can be initiated by
pushing down the whole leg against the mattress, a small
and soft pillow under the knee or with strong and
sustained ankle dorsiflexion.
(v) Graduated assisted SLR can be started by 3–4 days, but

it should not be painful.
(vi) Non–weight-bearing crutch walking to be initiated as

soon as it is painless.
Mobilization (10 days onwards): The stitches are out by 10–

14 days. This is the vital period to regain knee ROM as well
as strength in the quadriceps and hamstrings. The pain is
usually due to the setting in of retropatellar degenerative
changes. Therefore, physiotherapy should be directed
towards strengthening of quadriceps and ROM of the knee
avoiding undue strain on the repaired extensor
mechanism.
1. Mobilization should be initiated within a small range

either by CPM apparatus or as a relaxed passive
movement.
2. Strong isometrics to the quadriceps by the use of a

wedge or self-assisted exercise by using the web between
the thumb and index finger (Fig. 15-13), repeated every
hour, are important.
3. Self-assisted stretching of the knee in the range of flexion

as well as terminal extension with knees hanging at the
edge of the bed is ideal.
4. Gradual weight bearing to be initiated after 6 weeks, in

parallel bars with correct methods of weight transfers
and gait. It should be progressed to a cane. The whole
regime of management should be made progressive with
progressive resistive exercise (PRE) and prone kneeling.
The patient must regain adequate knee ROM and muscle

power by 6–8 weeks. It takes between 8 and 12 weeks to
gain full ROM. However, mild extensor lag may continue
for about 6 months (Dudani & Sancheti, 1981).
Comminuted fracture: treated by patellectomy
First week: Strong ankle and foot movements with the leg in
elevation are started immediately.
The surgical incision and the sutured ligamentum patellae

may be painful initially while doing isometrics to the
quadriceps. Therefore, mild indirect contractions to the
quadriceps should be initiated by putting a soft wedge
under the knee. Feeble static contractions to the quadriceps
should be ensured. Patients usually use the gluteus
maximus for the quadriceps. Isometrics to quadriceps at
this painful stage are possible only when the patient has
had adequate preoperative training.
Electrical stimulation can be used as an adjunct to re-educate

the quadriceps contractions.
Assisted SLR with enough assistance to initiate the lift

should be started at the earliest, without much discomfort.
Second week: Partial weight-bearing gait training should be

added, making the previous programme or exercise more
vigorous.
Mobilization
1. As the soft tissue healing is adequate to begin gradual

mobilization in a small range in patients treated by
bandage, self-assisted small arc passive movements are
ideal to initiate mobilization.
2. Controlled CPM or relaxed passive movements are

extremely effective at this stage.
Third week onwards:
1. Assisted active movements to be initiated with

graduated weight-bearing gait training.
2. In patients treated with posterior splint, the splint

should be removed intermittently for exercises and
reapplied for walking.
3. In patients treated with POP, non–weight bearing

facilitates them to go back to work as the POP cylinder is
continued up to 6 weeks.
4. Vigorous exercise programme needs to be given to

patients treated by 6 weeks’ immobilization as the knee
joint is considerably stiff and painful.
5. Hydrotherapy is an effective measure to achieve
mobility and strength.
6. PRE has to be carried out intensively to strengthen the

quadriceps, hamstrings and the ligaments of the knee
joint.
7. Proper gait training and functional positions are guided.
8. The results are generally good and an adequate range of

motion and strength returns by 8–12 weeks after surgery.
FIG. 15-13 Self-assisted or resisted isometrics to isolated quadriceps by

using the web between the thumb and the index finger.
After patellectomy there is an urgency to concentrate maximally on

quadriceps strengthening procedures. Initiating isometrics at the
earliest opportunity and regularly monitoring the strength are
essential to strengthen the quadriceps.
Acute dislocation of the patella
The patella always dislocates laterally. The injury occurs in a
semiflexed knee with the relaxed quadriceps muscle. The patella is
forced laterally.
Treatment
The patella may be pushed back into its place easily. However, the
reduction may have to be done under general anaesthesia. An above-
knee POP cast is given for 3–4 weeks after which the knee is
mobilized.
1. Gentle isometrics to the quadriceps are initiated as early as possible.

Limb encased in a cast is pressed downwards by placing a pillow
under the foot which indirectly initiates static contractions in the
quadriceps (Fig. 15-14).
2. SLR by the physiotherapist, fully supporting the weight of the limb,

also helps in initiating isometrics to the quadriceps besides improving
hip control and strength.
3. PWB crutch walking can be started as soon as pain is reduced.
4. Vigorous exercise to improve the extensor mechanism and

procedures to mobilize the knee are begun on removal of the cast and
progressed. Full knee ROM and adequate control of knee mechanics
should be regained by 6–8 weeks.
FIG. 15-14 Early initiation of isometrics to quadriceps and gluteus

maximus and minimus by pressing pillow downwards and to the side of
fracture by blocking with a soft pillow.
Recurrent dislocation of the patella

In recurrent dislocation of the patella, the patient has repeated
episodes of dislocation of the patella. The patient is usually
asymptomatic between the attacks.
In habitual dislocation of patella, the patella dislocates with every
flexion of the knee, but reduces spontaneously as soon as it is
extended.
In either type of dislocation, the patella always dislocates to the
lateral side. The causes of recurrent dislocation of patella include
laxity of the ligaments, weak musculature, poorly developed lateral
femoral condyle and small or abnormally placed patella.
Clinical features
Recurrent dislocation of the patella may occur with/without injury.
The patella dislocates laterally with severe pain. Apprehension test may
be positive which is when the patella is pushed laterally and the knee
is flexed, the patient resists this manoeuvre.
Treatment
Surgical operation is the only effective treatment for recurrent
dislocation of the patella. The basic principle of surgical operation is
realignment of the quadriceps mechanism, so that the patella is
prevented from dislocating laterally when the knee is flexed.
However, in adults, there may be an associated osteoarthritis of the
knee joint and therefore, the patella is removed and the quadriceps
mechanism is repaired.
Postoperative regime
Postoperatively, an above-knee POP cast is given for 4–6 weeks, after
which the knee is mobilized.
Physiotherapy following surgery
During immobilization (4–6 weeks)
1. Strong toe movements and active hip movements to be started as

early as possible.
2. On the second postoperative day, non–weight-bearing crutch

walking can be initiated.
3. Indirect isometrics to the quadriceps should be initiated in the form

of assisted SLR (Fig. 15-15) or by pushing the leg encased in the cast
downwards on the mattress in supine lying. Direct weak isometrics to
the quadriceps should be begun inside the cast within the limits of
discomfort.
FIG. 15-15 SLR assistance is provided by physiotherapist posteriorly just

proximal to the ankle joint by one hand, and below the knee by the other.
Mobilization
1. Gradual knee mobilization is begun in a small range ideally by

CPM, relaxed passive movements or as self-assisted (using normal
leg) knee swinging.
2. Hydrotherapy in the form of whirpool is extremely useful at this

stage.
3. Assisted SLR to be initiated.
4. Self-resistive hamstring exercises and sessions of endurance training

in the maximum extension position of the knee should be emphasized.
5. Knee orthosis may be used, as a protective measure for 8–10 weeks

while walking, till the patient regains full active extension and 70–90°
of flexion.
6. Quadriceps and hamstrings co-contractions could be beneficial in

achieving good control of movements.
7. Isokinetic exercises are valuable means of improving endurance.

The exercises should be progressed to resistive exercises.
By 10–12 weeks, body resistive squats may be begun with brief

periods of jogging, running and light sports.
The physiotherapeutic management following patellectomy is
described earlier.
Dislocation of the knee

It is a rare injury caused by considerable violence. The cruciate and
collateral ligament(s) are usually torn.
Treatment
The dislocation is reduced under general anaesthesia as an
emergency. Open reduction may have to be performed, if closed
reduction fails. Repair or reconstruction of the torn ligaments may
also be required. An above-knee POP cast is worn for 12 weeks.
Following closed reduction: Initially the limb is rested on a back
splint with knee in 15 degrees of flexion.
1. Ankle and toe movements are checked along with the sensory
status to exclude injury to the popliteal nerve.
2. Circulation in the foot is examined to exclude injury to the popliteal

artery.
3. Vigorous ankle and toe movements with leg in elevation are given
to reduce swelling.
4. When the swelling has subsided, POP cast is applied for 12 weeks.
Following surgical reconstruction (during immobilization)
1. Isometrics to the quadriceps and glutei are emphasized right from

the first day, besides points 1, 2 and 3 described earlier, after closed
reduction.
2. Non–weight-bearing crutch walking to be started on the second or

third day.
3. Assisted SLR to be begun by 1 week and progressed to voluntary

SLR by the patient.
4. Gradual weight bearing can be initiated with plaster as soon as the

patient can perform SLR; and can be progressed to full weight
bearing.
Mobilization: The nature of injury and long period of

immobilization poses two main problems:
1. Stiff and painful knee
2. Instability of the knee with increased anteroposterior glide or lateral

wobble
Therefore, extra efforts are needed to concentrate on mobilization as

well as controlled stabilization of the knee. The maximum range as
well as endurance is to be regained at the earliest. It proceeds on the
same lines as described for patellectomy. However, manipulation
under GA may become necessary to assist further mobilization when
the knee is not yielding to routine exercises.
Fractures of the tibial condyles

Fractures of the medial or lateral tibial condyles occur as a result of
varus or valgus strain respectively. Fracture of the lateral condyle of
tibia, also called ‘bumper fracture’, is more common and occurs
following an injury by the bumper of a car on the lateral aspect of the
knee joint (Fig. 15-16). These fractures are usually associated with
injury to the collateral ligaments on the opposite side. Fractures of the
lateral condyles are occasionally comminuted fractures with marked
depression of the tibial plateau (Fig. 15-17A and B).
FIG. 15-16 Fracture of the lateral condyle of tibia resulting from injury by
bumper of the car.
FIG. 15-17 Comminuted fracture. (A) Diagrammatic representation with

marked depression, and (B) as seen on a radiograph of the lateral plateau.
Following an injury, the patient presents with a painful, swollen

knee with haemarthrosis of the knee joint.
Treatment
Plaster immobilization: This method is indicated only in undisplaced

fractures. An above-knee plaster cast is applied for 3–4 weeks. Knee
mobilization is started after removal of the plaster. Weight bearing,
however, is allowed after 3 months.
Traction: This is a simple and commonly employed method of

treatment for displaced fractures. A below-knee skin traction or
skeletal traction through the tibia is given for 3 weeks. After 3
weeks, the knee is mobilized. However, weight bearing is started
after the union is consolidated, usually after 3 months. The
disadvantage of this method is prolonged immobilization. However,
generally good results, in terms of knee movements, are obtained by
this method.
Surgical treatment
Open reduction and internal fixation of this fracture is ideally
indicated in grossly displaced and/or fractures where the tibial
plateau is depressed due to impact by the lateral femoral condyle. In
the latter situation, the tibial plateau is elevated and the fracture is
fixed by a special type of plate (Fig. 15-18). Bone grafting is also
required to support the tibial plateau.
FIG. 15-18 The fracture fixed with plate and screws. Note that the
depression in the lateral tibial plateau has been corrected by surgery.
Undisplaced fracture can be treated by a long screw.

Postoperatively, knee movements can be started after 1 week but
weight bearing is allowed after 3–4 months.
The patient may have some limitation of knee movements in
severely displaced and/or comminuted fractures in spite of open
reduction and internal fixation.
In grossly displaced or comminuted fractures, open reduction with
internal fixation is done. Knee mobilization can be initiated early
during the second postoperative week. Mobilization procedures need
extra emphasis and should be repeated often in spite of discomfort to
achieve early functional range of motion. Fractures often result in stiff
knee due to severe articular damage.
Undisplaced fractures which are treated by conservative methods do
not pose any specific problems.
◼ Early initiation of isometrics to the quadriceps and hamstrings is

important.
◼ Vigorous toe movements in POP immobilization; and ankle and

foot movements in patients treated with traction are repeated often.
◼ Assisted SLR can be initiated early in patients treated with plaster

immobilization as soon as it is painfree.
◼ Non–weight bearing to be initiated on axillary crutches to

encourage early ambulation on the third or fourth postoperative
day.
Mobilization
◼ Knee mobilization is of vital importance and with correct methods

of mobilization, early return of near normal to normal mobility is
restored. Suitable electrotherapeutic modality, CPM and relaxed
passive movements are instrumental.
◼ While mobilizing, the knee joint should be carefully examined for

the possibility of genu valgum, especially in fractures of the lateral
tibial condyle.
◼ Regaining early extension is important to avoid extra stress leading
to osteoarthritic changes and poor gait.
◼ Strengthening procedures for the quadriceps and hamstrings are

equally important. They need special emphasis in view of the
expected osteoarthritic changes. The damaged articular surface of
the tibial condyle often remains irregular.
◼ If the union of the fracture is acceptable, graduated partial weight

bearing may be started after 10 weeks – from two axillary/elbow
crutches and progressed to one crutch, to one cane and no aid, by 12
weeks.
◼ Other ambulatory activities and gait training should be added.

Medial shoe insert or wedge may be necessary in patients with
residual genu valgum deformity to relieve compression at the lateral
compartment of the knee joint.
Intercondylar fractures of the tibia

A fracture through both the medial and lateral condyles of tibia occurs
following a force that pushes the femoral codyles on the tibial plateau,
e.g., fall from a height. It results in a T- or Y-shaped fracture through
the tibial condyles. It is a rare injury.
Treatment
The fracture fragments are reduced under anaesthesia and the limb is
immobilized by skeletal traction applied through the lower end of the
tibia. The traction is maintained for 4–6 weeks and then the knee is
mobilized. Full weight bearing is permitted after 3 months.
Operative treatment
Open reduction and internal fixation of the fractured fragments is
achieved with the help of screws or special plates. Postoperatively,
knee mobilization is started after 1 week or 10 days, but weight
bearing is allowed after 3–4 months.
Physiotherapeutic management proceeds on the same lines as
described for fractures of the tibial condyles.
CHAPTER
16
Injuries of the leg
OUTLINE
◼ Fracture of the tibia and fibula (fractures of both bones of the
leg)
Fracture of the tibia and fibula (fractures of

both bones of the leg)
These are common injuries and result mainly from road traffic
accidents. As the tibia is a subcutaneous bone, its fractures are often
open (compound) fractures.
An angulatory force produces a transverse or short oblique fracture
(Fig. 16-1); rotational force produces a spiral fracture and direct blow
to the tibia can result in a comminuted fracture.
FIG. 16-1 Fracture of the shafts of tibia and fibula.
Treatment
An open wound, which can be extensive, poses a problem in the
management of these fractures. However, these injuries can be treated
by any of the following methods:
1. Plaster: The fracture is manipulated under general anaesthesia and

an above-knee POP cast is applied. Static quadriceps exercises are
begun as soon as pain permits. Non–weight-bearing crutch walking
can be started after 2 weeks. Union of the fracture may take 3–6
months. Weight bearing is allowed only after the union is
consolidated.
2. Functional cast bracing: Relatively stable transverse fractures of the

tibia may be treated by an above-knee POP cast for the initial 3–4
weeks. The plaster is then changed into a patellar tendon bearing
(PTB) cast (Fig. 16-2). This allows knee mobilization and early weight
bearing.
3. Traction: Severely comminuted fractures can be treated by skeletal

traction applied through the lower tibia or calcaneum (Fig. 16-3). The
traction is maintained for 10–12 weeks.
4. Operative treatment: It is indicated when closed reduction fails or the

fracture is displaced in the plaster. Open reduction is performed and
the fracture is internally fixed by plate and screws or intramedullary
nail (Fig. 16-4). These days, fracture of the tibia is treated by closed
interlocking nailing (Fig. 16-5). After surgery, knee mobilization is
started after a week or two. Weight bearing, however, is allowed after
3 months.
5. External fixation: The tibia is fixed with two or three pins passed
transversely in the tibia on either side of the fracture (Fig. 16-6). It is
indicated in severely comminuted fractures and where there is
marked soft tissue damage. This method facilitates care of the wound
and the patient can walk with the help of crutches (non–weight
bearing).
FIG. 16-2 Patellar tendon bearing (PTB) cast.

FIG. 16-3 Skeletal traction through calcaneum.

FIG. 16-4 Treatment by compression plating of the tibia.

FIG. 16-5 Fracture of tibia treated by interlocking nailing.

FIG. 16-6 (A and B) Fracture of tibia treated by an external fixator.
Complications
1. Infection: As already discussed, open fracture of the tibia and fibula
are quite common. The bone is likely to get infected and may develop
osteomyelitis.
2. Injury to the vessels: The popliteal artery may be injured in fractures

of the upper third of the tibia. The artery needs to be repaired
urgently.
3. Compartment syndrome: In a closed fracture, bleeding from the
fractured bone ends causes a rise in the pressure in the fascial
compartments of the leg. This, in turn, leads to muscle ischaemia. A
tight plaster may also have the same effect. Removal of the tight
plaster or surgical decompression of the tight compartment is the
treatment.
4. Delayed union and nonunion: Undue delay in union or failure to unite

(Fig. 16-7) necessitates bone grafting operation along with internal
fixation of the fracture.
5. Malunion: It may cause angulatory deformity and/or shortening of

the leg (Fig. 16-8). It may also predispose the patient to osteoarthritis
of the knee and/or ankle joints.
FIG. 16-7 Nonunion of the fracture of tibia and fibula.

FIG. 16-8 Malunion of the fracture of tibia and fibula resulting in

angulation.
Objectives
◼ Restore normal ROM at the knee and ankle joint – if not normal, at
least the functional ROM, i.e., 0–110 degrees at hip and knee; at the
ankle, dorsiflexion of 0–10 degrees and plantar flexion of 0–20
degrees each
◼ Improve the strength, power and endurance in the muscles around

the ankle and toes and in the inverters and dorsiflexors
◼ Offer stability in all ambulatory activities and the near-normal

pattern of gait
Expected problems
◼ Infection – high incidence of compound fractures and in

subcutaneous location, the fracture is susceptible to infection
◼ Limb shortening – as a result of overlapping or malunion
◼ Malunion precipitating early osteoarthritis changes
◼ Joint stiffness – due to the fear of pain, tendency of not moving the
knee as well as ankle joint; it is a common expected problem
◼ Delayed union or nonunion – failure of bony union is common in

about 10% cases which may need surgical intervention
◼ Occasionally, preventable complications like claw toes, fat

embolism may be seen
Fractures treated by plaster: Immobilization of the knee, ankle and

foot leads to stiffness of these joints and weakness of the muscle
groups around them. Strengthening of these muscles takes priority
over other measures. The following measures are adopted:
1. Isometrics to quadriceps, hamstrings
2. Assisted SLR
3. Repeated strong and resistive movements to toes

4. Resisted as well as strong isometrics to the glutei
5. Knee mobilization to be initiated and made vigorous as

soon as pain permits
6. Vigorous self-passive stretching exercises to be guided to

regain mobility at the foot and ankle
7. Non–weight-bearing crutch walking to be initiated as

soon as leg hanging in standing becomes painless – to
facilitate going back to work and performing daily
activities (about 2 weeks)
8. Full weight bearing to be initiated on the radiographic

evidence of fracture union (usually 3–6 months)
9. Correct walking and functional guidance
Fractures treated by traction: Due to the prolonged immobilization in

skeletal traction (usually 10–12 weeks), the chances of the knee
becoming stiff are quite high. Isometrics, therefore, need maximum
attention. Rest of the programme is the same as described for
fractures treated by plaster.
Fractures treated by cast bracing: When the stable transverse

fractures of tibia are initially treated by POP cast for 4–6 weeks, the
physiotherapeutic programme is the same as for fractures treated by
plaster. The above-knee POP cast is then replaced by functional PTB
plaster; it allows early mobilization and weight bearing. Therefore,
early return to fully active life is facilitated. However, vigorous
programmes for knee mobility, strength and endurance are to be
emphasized.
Fractures treated by surgery: Here the knee mobilization can safely be

started by the end of 2 weeks. This facilitates regaining knee
mobility and a strong extensor mechanism.
Partial weight bearing can be initiated by 8 weeks, if not very

painful, and full weight bearing by 12 weeks.
Fractures treated by external fixation: These fractures are usually

comminuted and associated with extensive soft tissue damage. The
wound is watched for infection, etc. Vigorous exercises to the ankle,
toes, glutei, quadriceps and hamstrings play an important role in
improving circulation of the whole limb and also the injured area
facilitating an early healing.
The patient should be given confidence and assistance in

early standing and non–weight-bearing crutch walking
with the leg in external fixator by 2 weeks.
Management of complications
1. Infection: Keen observation, wound care and improvement of

circulation to the limb are important measures to avoid or reduce
infection.
2. Compartment syndrome: Haemorrhage, oedema or tight plaster may

result in ischaemia leading to fibrosis or even gangrene (like VIC).
Therefore, a proper watch is kept on the symptoms of ischaemia like
increase of pain, swelling, pallor, absence of distal pulse in the foot
and blueness of the toe nails.
3. Delayed union and nonunion: Fracture of the lower third of tibia is

prone for nonunion due to poor blood supply to this area. Therefore,
in such fractures, the circulation can be improved by vigorous
exercises to adjacent joints.
4. Malunion: Improper reduction of the fracture or loss of reduction in

plaster can lead to malunion. Detection of the cause and its early
correction is necessary. Limb shortening due to overriding is
compensated by exact shoe raise to prevent osteoarthritis. Malunion
with angulation may need early osteotomy to avoid osteoarthritis.
CHAPTER
17
Injuries of the ankle and the foot
OUTLINE
◼ Fractures around the ankle
◼ Hind foot fractures
◼ Fracture of the talus
◼ Fracture of the calcaneum
◼ Midfoot fractures
◼ Forefoot fractures
◼ Fractures of other tarsal bones
◼ Fracture of the metatarsals
◼ Fatigue or stress fracture of the metatarsal
◼ Fractures of phalanges
Fractures around the ankle

Classification
◼ Malleolar fractures or adduction–abduction fractures
◼ Hind foot fractures – fracture of the calcaneum and talus
◼ Midfoot fractures – fracture of the navicular, three cuneiform bones

and cuboids
◼ Forefoot fractures:
◼ Fracture of the proximal phalanx of the great toe
◼ Fracture of the phalanges of the 2nd to 5th toes
◼ Fractures of the 1st to 4th metatarsals
◼ Fractures of the 2nd to 5th metatarsals
◼ Fracture of the base of the 5th metatarsal C joints fracture
◼ Metatarsal inversion injury – on a plantar flexed ankle
Malleolar fractures (or adduction–abduction fractures)

Fractures around the ankle are produced by forced adduction or
forced abduction of the foot, often associated with an element of
rotation or vertical compression.
Forced abduction produces rupture of the medial ligament of the
ankle, fracture of the medial malleolus or fracture of both malleoli
(Fig. 17-1).
FIG. 17-1 Abduction injury. (A) Fibular fracture at the syndesmosis, and
(B) as seen on radiograph. Note the horizontal fracture line in the medial
malleolus.
Forced adduction produces rupture of the lateral ligament, fracture

of the lateral malleolus or fracture of both the malleoli (Fig. 17-2).
FIG. 17-2 Adduction injury fracture of the medial malleolus with a vertical
fracture line.
When both malleoli are fractured, it is also called Pott’s fracture.
Treatment
The main objective of the treatment is to restore the alignment of ankle
mortice by accurate reduction of the fractures.
The treatment can be conservative or operative.
The fracture is manipulated under general anaesthesia and
immobilized in a below-knee plaster cast for 6–8 weeks. The ankle
may be mobilized after 8 weeks; however, weight bearing is allowed
only after about 12 weeks.
Operative treatment
Open reduction internal fixation is indicated where closed reduction
has failed or the fracture gets redisplaced in the plaster or the fracture
is grossly displaced. The fractures of medial and lateral malleoli are
fixed internally by a screw or tension band wiring. The fracture in the
fibula can also be fixed by a plate (Fig. 17-3).
FIG. 17-3 (A) Fracture of the medial malleolus fixed by tension band
wiring. (B) Fracture of the medial malleolus fixed by malleolar screws while
the fracture of the lateral malleolus is fixed by plating.
Complications
1. Malunion: It leads to distortion of the ankle mortice and deformity.
In later years, osteoarthritis may set in.
2. Nonunion: It is common with fracture of the medial malleolus.

Internal fixation by a screw or tension band wiring with bone grafting
is the treatment.
3. Joint stiffness: It results following prolonged immobilization and

oedema. It can be prevented by accurate reduction of the fracture and
adequate physiotherapy as early as permissible.
Objectives
◼ To restore the maximum passive range of movements of the ankle,

subtalar, metatarsophalangeal (MTP) and interphalangeal (IP) joints
(Table 17.1).
◼ Acceptable form has to be associated with increased strength and

endurance of the muscle groups acting over the ankle, subtalar, MTP
and IP joints.
◼ Steadiness and stability in standing, performing functions and

while doing ambulatory activities without limp.
◼ Concentrated exercise training session for the intrinsic muscles.
Table 17-1
Standard Normal and Functional Range of Ankle and Foot Movements
Normal Functional
Movements
ROM ROM
Ankle dorsiflexion 0–20 5–10
Ankle planters 0–45 0–20
flexion 0–35 0–25
Foot inversion 0–10 0–10
Foot everton
Expected problems
◼ Lingering heel pain on weight bearing results in a permanent

limping gait.
◼ Later on, subtler joint osteoarthritis changes are observed.
◼ Flattening of the foot area and weight-bearing pain results in

uneven stepping and a limp.
Fractures treated with a short leg brace
◼ Check the cast to ensure full ROM at the knee and MTP joints.
◼ Begin early active movements to the toes.
◼ Keep leg elevated to prevent oedema.
8–12 weeks after removal of the cast
◼ Active relaxed free rhythmic movements are guided to be

performed in warm water.
◼ Self-assisted passive, active, resistive and most importantly self-

passive stretch-hold to improve ankle dorsi- and plantarflexion are
concentrated to get maximum ROM in these two movements.
Weight bearing
◼ Graduated weight bearing is initiated in parallel bars, walking aids

or crutches to eliminate limp to the maximum with cast.
◼ Full weight bearing after 12 weeks.

Fractures treated by conservative management
◼ Limb elevation
◼ Strong repeated movements for the toes, knee and the hip.
◼ Diapulse may be applied over the POP cast.
◼ Non–weight-bearing crutch walking can be initiated on the second

or third day.
During mobilization
1. Early passive mobilization: Early initiation of relaxed passive range of

motion exercises is important. The patient should be made well
conversant to practise them often. This can be done best by the patient
sitting in a chair with the back supported. The distal portion of the
affected leg rests just over the knee on the sound thigh. The ankle and
foot, which are free to move, are grasped by the patient using both
hands. Full range relaxed passive movements of the ankle and foot
can be improved effectively (Fig. 17-4) with repetitive efforts with the
use of HP or warm water immersions.
Relaxed passive movement in the maximum possible range,

especially circumduction, causing minor discomfort but
not pain are ideal to begin with (Cyriax, 1978). The passive
movement should not be so forcible as to overstretch the
fibrils that are gaining longitudinal attachment within the
healing breach; nor should they be so gentle as to fail to
disengage those fibrils that are gaining abnormal
transverse adherence. Deep friction massage is also useful
in preventing adhesions.
2. Thermotherapy: If there is no oedema, thermotherapy is advisable. It
increases capillary permeability, promoting the reabsorption of
extravasated fluid and dissolution of organized haematoma, helping
early healing (Griffin and Karseli, 1978).
3. Early muscle strengthening: Exercises to strengthen all the muscles

should also be started as early as possible. The technique may be the
same as described for early mobilization, except that the movements
are active in this exercise. It can be made self-resistive also, if there is
no pain. The movements should be taken to the maximum range, with
isometric holding at the end of the range. As the exercises are self-
resistive, the degree of resistance can be controlled to the level of pain
and discomfort.
While strengthening the muscles the patient should be told

to concentrate more on the muscles of the anterior and
lateral compartments of the leg which are usually weaker
as compared to those of the posterior compartment.
Exercising the toe flexors and intrinsic muscles should not be

neglected, to maintain the tone and strength of the foot
arches. In fact, active slow circumduction with toes tightly
clenched is a simple and more effective exercise.
4. Stretching exercises (Fig. 17-5): It is important to stretch the posterior

calf muscles. This needs prolonged gradual relaxation of the calf. It
can be done by keeping the forefoot on a block or a book and pushing
the heel down with the knee straight in standing, or with the knee
bent to 90 degrees in sitting; putting a downward pressure over the
knee with a block or a book placed under the forefoot. In standing, the
body weight presses the heel down and stretches the gastrosoleus.
5. Re-education in weight bearing: Proper placement of the injured limb,

gradual weight bearing and the normal pattern of gait are to be
progressed in stages. Weight bearing is started after 12 weeks.
6. Speedy movements: Gradual initiation and progress to more vigorous
exercises like toe walking, heel walking, spot jogging and single leg
hopping.
FIG. 17-4 Self-assisted relaxed passive movements of the ankle and foot.
FIG. 17-5 Self-assisted calf stretching in (A) sitting, (B) standing and (C)
step standing.
Fractures treated by open reduction and internal fixation

The period of cast immobilization after surgery is usually less, about
3–4 weeks. Therefore, mobilization can be started early. Gentle relaxed
passive movements as well as self-assisted procedures followed by
thermotherapy should be started.
The rest of the physiotherapeutic regime is the same as described
for the conservative approach. However, SWD or US is
contraindicated due to the metallic implants used for internal fixation.
Pilon fractures of the tibia

Pilon fractions of the tibia consist of comminuted fractures of the
distal tibia including the distal tibial articular surface. There is usually
a fracture of the distal third of the fibula also (Fig. 17-6). This fracture
usually results from a high-energy trauma due to road traffic
accidents or fall from a height. It is also usually associated with
considerable swelling and ecchymosis in and around the ankle joint.
FIG. 17-6 (A and B) Preoperative X-rays of Pilon fracture of tibia. Note the
fracture of fibula also.
Treatment
The swelling and oedema around the ankle (due to injury) necessitates
elevation of the limb and waiting for a period of about 1 week for the
swelling to subside.
Initially the fracture may be treated by an external fixator for
stabilization. Subsequently, the fractures are treated by open
reduction and internal fixation (Fig. 17-7).
FIG. 17-7 Pilon fracture treated by open reduction and internal fixation.
Hind foot fractures

Injuries of the talus
Talus is an important tarsal bone which is a part of both the medial
and the lateral longitudinal arches of the foot. Majority of the talar
surface is intra-articular and it has no musculotendinous attachments.
The blood supply to the body of talus is precarious since it passes
through the neck of the talus. A fracture through the neck of talus,
therefore, may cause avascular necrosis of the body of talus if not
treated properly.
Injuries of the talus are rare and result from a fall from height or
forced dorsiflexion injury to the ankle.
The talus may be fractured through its body or neck (Fig. 17-8) or
may be dislocated from the ankle mortice without a fracture.
FIG. 17-8 Fracture of the neck of talus.
Treatment
The fracture or dislocation is manipulated under general anaesthesia
and immobilized in a below-knee plaster for 6–8 weeks. The ankle is
then mobilized; however, weight bearing is allowed only after 3–4
months.
Late neglected cases, where closed reduction cannot succeed, are
treated by skeletal traction applied through the calcaneum.
Operative treatment
Open reduction of the fracture or dislocation is indicated where closed
reduction fails or the fracture is widely displaced. The fracture is fixed
internally by Kirschner wires or screws (Fig. 17-9).
FIG. 17-9 (A and B) Pre- and postoperative radiographs of fracture of

talus treated by fixation by screws.
Postoperatively the limb is immobilized in a below-knee plaster for

8–10 weeks.
Complications
Avascular necrosis: Fracture through the neck of talus or dislocation can
cut off blood supply to the body of talus. This subsequently leads to
avascular necrosis of the talus. It may cause osteoarthritis in later
years which may require ankle arthrodesis.
The physiotherapeutic programme for the cases treated by
conservative as well as surgical methods is the same as described for
abduction and adduction injuries of the ankle.
The problem associated with this fracture is the shortening of the
tendo-achilles, resulting in limitation of dorsiflexion. It makes floor
squatting impossible due to the restricted range of anterior tibial
excursion on the foot. Therefore, the patient needs to be taught an
alternate method of floor squatting. This method includes the
fractured leg to be maintained in forward position so that the pelvis
can be lowered down more on the sound limb (Fig. 17-10).
FIG. 17-10 Floor squatting with the fractured leg forward.
To avoid this, concentrated exercise is necessary to get maximum

early dorsiflexion. If the patient regains good range of dorsiflexion,
floor squatting can be attained by stabilizing the body weight on the
sound limb to avoid excessive stretching and pain in the affected foot.
As the pain reduces, it can be progressed to near normal floor
squatting.
Fracture of the talus
Objectives
◼ To restore full ROM of ankle and the foot.
◼ To restore strength and endurance of all the muscle groups moving

the ankle and foot.
◼ To restore functional tasks such as floor squatting, and pre-injury

sports and recreational activities.
Expected problems
As a result of the possibility of complications such as infection,
nonunion, delayed union, malunion and AVN, and posttraumatic
osteoarthritis. They may lead to the following:
◼ Painful limping
◼ Inability to sustain standing, perform flexor – squats, brisk walks or

sports
◼ Shortening/contracture of tendoachilles (TA)
Physiotherapy for conservatively managed patients

◼ Keep limb in elevation and begin active full range movements for
the MTP and IP joints.
◼ Initiate active knee movements as soon as pain is reduced.
◼ 3rd day – supported standing, non–weight-bearing walking with

crutches.
On the removal of immobilization:

◼ Under warm water, small-range active free movements to subtalar
and ankle joints are guided, for home treatment.
◼ Self-assisted, gentle self-stretch-hold techniques are guided to

improve the ambulation – prolonged period of NWB (8–10 weeks)
JROM.
◼ Graduated steps to progress towards PWB by 8–10 weeks,

independent ambulation (FWB by 12 weeks)
Physiotherapy for surgically treated patients

◼ Patients treated by ORIF
◼ Most procedures involved are similar to that for conservatively

managed patients
◼ Ambulation – PWB can be safely started by 4–6 weeks and full

weight bearing by 8–10 weeks
◼ Guidance and short training and practice may be needed to perform

lower limb activites
Fracture of the calcaneum

Applied anatomy of calcaneum
Calcaneum is a large tarsal bone which articulates anteriorly with the
cuboid. It forms the posterior pillar of both the arches, and plays an
important role in the transmission of body weight in all weight-
bearing activities. The centre of the calcaneal tuberosity lies lateral to
the line of the weight-bearing axis; therefore, the fracture lines usually
run obliquely from the superolateral to the inferomedial aspect.
Tuber joint angle

The normal angle between the superior articular surface of the
calcaneum and the upper surface of calcaneal tuberosity is 35–40
degrees.
Fracture of the calcaneum results from a fall from height. The
calcaneum is pushed up against the talus and gets crushed.
Basically two types of fractures occur:
1. Extra-articular fracture: Fracture of the calcaneum where the

subtalar joint is not involved (Fig. 17-11).
2. Intra-articular fractures: Fracture of the calcaneum involving the

subtalar joint. Here the fracture line extends into the subtalar joint
(Fig. 17-12). Osteoarthritis of the subtalar joint may develop a few
years later.
FIG. 17-11 Extra-articular fractures of the calcaneum: (a) – through the

posterior part of the body, and (b) – fracture of tuberosity.
FIG. 17-12 Tuber joint angle: (A) normal, (B) in a comminuted fracture of
the calcaneum, the tuber joint angle is either obliterated or reduced, and
(C) a comminuted fracture of the calcaneum, as seen on radiograph.
Clinical features
◼ Severe pain and tenderness over the heel.
◼ The heel appears broader from behind.
◼ There might be ecchymosis at the heel.

◼ Inability to bear any weight on the fractured foot.
Treatment
Fractures of the calcaneum can be treated by the following methods:
1. POP cast: A below-knee POP cast is applied for 3–4 weeks, after
which the foot is mobilized and gradual weight bearing is started.
2. Open reduction and internal fixation: Displaced and/or comminuted

fractures are treated by open reduction and internal fixation by special
plates (Fig. 17-13).
3. Arthrodesis: Some surgeons prefer to treat severely comminuted

fractures of the calcaneum by primary arthrodesis of the subtalar joint
in view of the inevitable secondary osteoarthritis of the subtalar joint.
FIG. 17-13 Fracture of the calcaneum fixed by a special plate.
Complications: The following complications are commonly seen,

mainly due to the inability to accurately reduce the fracture in most of
the cases and also due to the type of fracture (whether involving the
subtalar joint).
1. Persistent pain in the heel and joint stiffness.
2. Osteoarthritis of the subtalar joint, which may need arthrodesis.
It proceeds on the same lines as described for adduction and
abduction injuries around the ankle. However, the following
modifications are necessary to deal with the common problems
following this fracture.
1. Persistence of pain while resuming weight bearing: Therefore, partial

weight bearing should be deferred to 8 weeks. A cane may be
necessary to avoid painful weight bearing for a prolonged period.
Appropriate thermotherapy should be given just before standing.
2. Specificity of gait: Both the phases of gait are usually painful.

Therefore, initial gait training may need modification to minimize the
period of walking cycle at the cost of ideal gait.
3. (a) Subtalar joint stiffness: If not mobilized early, it leads to marked

limitation of eversion and inversion of foot. Therefore, early
mobilization of these movements is emphasized, especially when the
articular surface is fragmented and driven down in the body of
calcaneum which itself is crushed.
(b) Limitation of dorsiflexion: Immobilization leads to

limitation of ROM of dorsiflexion, and the related
problems, as discussed in the fracture of talus.
First 2 weeks
◼ Active full ROM moments to the toes and MTP joints.
◼ Position leg and foot in elevation.
◼ Partial weight bearing may be started for muscular and cuboids

bone fractures.
◼ Remaining fractures are not allowed weight bearing.
By second week
◼ Isometric (light and slow speed) may be begun for all the muscle
group covering ankle and foot.
By 6–8 weeks
◼ Make isometric strong and sustained.
◼ Free active small ROM exercise begun for all the four major groups
around the ankle in warm water.
◼ Begin PWB for Lisfranc injuries.
Eight weeks onwards
◼ Guide and supervise self-resistive mode of exercise for all the four
major muscles group
◼ Gradual progressive weight bearing is initiated.
Midfoot fractures
Fractures of other tarsal bones
Fractures of the tarsal bones other than the talus and the calcaneum
are relatively rare.
Treatment
These fractures do not require manipulation and are treated in a
below-knee POP cast for 3 weeks.
Physiotherapeutic treatment
Fractures of other tarsal bones not associated with crushing injuries do
not pose difficulties. Routine measures of physiotherapy are adequate
to deal with these types of fractures. Vigorous exercises to the intrinsic
muscle should be emphasized right from the initial stages.
Fracture of the metatarsals

Fracture of the metatarsal usually occurs due to fall of a heavy object
on the foot or in roadside accidents. The base of the fifth metatarsal
may be fractured by sudden pull of the peroneus brevis muscle, due
to forced inversion and plantar flexion of the foot (Fig. 17-14).
FIG. 17-14 Fracture of the base of the fifth metatarsal bone.
Treatment
Conservative treatment.
For undisplaced or minimally displaced fractures: The treatment of choice
is conservative. The foot is immobilized in a below-knee POP cast for
3–4 weeks. Mobilization and gradual weight bearing is then started.
Operative treatment.
Grossly displaced fractures are fixed internally by Kirschner wires (Fig.
17-15) or screws. Postoperatively a below-knee POP slab is given for
2–3 weeks after which mobilization is started. Weight bearing is
allowed after 4–6 weeks.
FIG. 17-15 (A) Grossly displaced fractures of the 2nd and 3rd metatarsal
bones. (B) Internal fixation by K-wire.
Objectives
◼ To restore normal JROM of ankle joint, subtalar joint, and MTP and
IP joints.
◼ To increase strength, power and endurance of the long flexors and

the extensors of the toes (intrinsic muscles), evertors and invertors of
the foot.
Expected problems
◼ Painful restriction of full and strong ROM of the toes to facilitate

floor gripping required for balance and gait.
◼ In the commonly encountered fractures of the 1st and 5th

metatarsals, the time of bone healing is longer (6–8 weeks) as
compared to the other forefoot bones (4–6 weeks), extending the
period of bone tenderness and inability for weight bearing.
The management of fractures of metatarsal bones proceeds on the

same lines as described for the tarsal bones. However, the possibility
of damage to the anterior transverse arch of the foot must be
remembered. Efforts to get vigorous contractions in the intrinsic
muscles at the earliest should not be neglected. During mobilization,
Faradic foot bath may be necessary to enforce active intrinsic
exercises.
Flat foot exercises, proper weight transfers to the foot and gait
training may be necessary.
Full function should be restored by 5–6 weeks.
Fatigue or stress fracture of the metatarsal

Prolonged walking in persons not accustomed to it may give rise to a
hairline fracture in the metatarsal tie (march fractures). There is no
history of trauma; the patient starts feeling pain spontaneously at the
site of the fracture on walking with acute tenderness and swelling.
The common site of this fracture is the shaft or neck of the second or
third metatarsal bone (Fig. 17-16).
FIG. 17-16 Stress fracture: radiograph showing a faint fracture line in the
neck of the second metatarsal with exuberant callus (arrow).
Treatment
As the fracture heals spontaneously with abundant callus formation,
the treatment is only symptomatic. In certain cases where the pain is
severe, immobilization in a below-knee walking plaster for a period of
4 weeks may be necessary. No specific physiotherapeutic measures
are needed to treat these fractures.
Forefoot fractures
Fractures of phalanges
Satisfactory alignment is preserved even in comminuted fractures of
phalanges. It needs no rigid immobilization, only protection from
injury has to be ensured. Soft woolly dressing for 2 weeks followed by
active physiotherapy is adequate.
Physiotherapy during week 1 and 2
◼ For stable phalange fractures – free active movements for MTPs.
◼ For fractures of 1st MT, sesamoid and 1st phalanx – no ROM or

strengthening exercise.
◼ No weight bearing for the fractures of 1st and 5th MTs, first
phalanx and sesamoid bone.
◼ Weight bearing can be initiated for stable fractures of other

metatarsals.
By the end of 2 weeks, graduated weight bear can be initiated

keeping pain as the main guiding factor.
◼ After 2nd week – PWB for 1st and 5th MT, sesamoid fractures.
◼ By 6–8 weeks – active full ROM exercise to all the toes, ankle and
foot.
◼ By 8–12 weeks – full weight bearing is safe.
◼ Session of standing on the fractured leg alone.
◼ Guidance to perform self-resistive exercises to the long toe

flexors along with self-stretch-hold technique is important.
Increase the vigorousity all exercises programmes
gradually.
Bibliography
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Livingstone. 1981.
2. Bassett CAL, Mitchell SN, Schink M M. Treatment of
therapeutically resistant non-unions with bone grafts and
pulsating electromagnetic field. Journal of Bone & Joint Surgery.
1982;64:1214.
3. Basley R W. Hand Injuries. Philadelphia: Saunders. 1981.
4. Belsole R. Physiological fixation of displaced and unstable
fractures. Orthopedic Clinics of North America. 1980;11:393.
5. Borgen D, Sprague B L. Treatment of distal femoral fractures
with early weight bearing. Clinical Orthopaedics. 1975;111:156.
6. Boyes J H. Bunnel’s Surgery of Hand . Philadelphia: JB
Lippincott Co. 1964.
7. Cheshire DJE, Rowe G. The prevention of deformity in the
severely paralysed hand. Paraplegia. 1970–1971;8:48.
8. Cyriax J. Vol. I Textbook of Orthopaedic Medicine Diagnosis
of Soft Tissue Lesions 7th ed . London: Bailliere Tindall. 1978.
9. Green D P. D. P. Green Operative Hand Surgery Carpal
Dislocations. New York: Churchill Livingstone. 1982.
10. Griffin JE, Karseli T. Physical Agents for Physical Therapist.
Springfield, IL: Charles C Thomas. 1978.
11. Dudani B, Sancheti K M. Management of fracture patella by
tension band wiring. Indian Journal of Orthopaedics. 1981;15:43.
12. Haxton H A. The function of the patella and effects of its
excision. The Journal of Surgery, Gynecology and Obstetrics.
1945;80:389.
13. Jobst. Moran C. A Hand Rehabilitation: Clinics in Physical
Therapy Intermittent pressure glove. Edinburgh: Churchill
Livingstone. 1983.
14. Joshi M, Young AA, Balestro J-C, Walech G. The Latarjet-Patte
procedure for recurrent anterior shoulder instability in contact
athletes. Clinics in Sports Medicine. 2013;32(4):731-739.
15. Kaufer H. Mechanical function of the patella. Journal of Bone
and Joint Surgery,. 1971;53-A:1551.
16. Laffose L, Boyle S. Arthroscopic Latarjet procedure. Journal of
Shoulder and Elbow Surgery. 2010;19(2Suppl):2-12.
17. Lavack B, Flannagan JP, Hobbs S. Result of surgical treatment
of patellar fractures. Journal of Bone and Joint Surgery. 1985;67-
B:416.
18. Meyer M H, Harvey J P, Jr & Moore, T. Treatment of displaced
subcapital and transcervical fractures of the femoral neck by
muscle pedicle, bone graft and internal fixation a preliminary
report on 150 cases. Journal of Bone and Joint Surgery. 1973;55:257.
19. Ozer MN, Britell CW, Philips L. L. Philips M. N. Ozer P.
Axelson & H. Chizeck Spinal Cord Injury: A Guide for Patients
and Family Chronic pain, spasticity and autonomic dysreflexia. New
York: Raven Press. 1987;135.
20. Rene C. Knee pain and disability. Southern Medical Journal.
1954;47:716.
21. Rockwood C A. C.A. Rockwood & D. P. Green Fractures
Dislocation about the shoulder. Philadelphia: J B Lippincott. 1975.
22. Riggs SA, Conney W P. External fixation of complex hand and
wrist fractures. The Journal of Trauma. 1982;23:332.
23. Sorenson. Pulsed galvanic muscle stimulation for
postoperative oedema in the hand. Pain Control. 1983;37.
24. Srinivasulu K, Marya RS, Bhan S, Dave P K. Results of surgical
treatment of patellar fractures. Indian Journal of Orthopaedics.
1986;20:158.
25. Stoddard A. Manipulation of the elbow joint. Physiotherapy.
1971;57:259.
26. Stougard J. Patellectomy. Acta Orthopaedica Scandinavica.
1970;41:110.
27. Taleisnic J. D. P. Green Operative Hand Surgery Fractures of
carpal bones. New York: Churchill Livingstone. 1982.
28. Webbe M A. Tendon gliding exercises. American Journal of
Occupational Therapy. 1987;41:164.
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Surgery. 1962;44-A:1089.
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procedure for management of bone loss in anterior instability of
the glenohumeral joint. Journal of Shoulder and Elbow Surgery.
2011;20:S61-S69.
CHAPTER
18
Common paediatric and adolescent

musculoskeletal disorders and fractures
OUTLINE
◼ Fractures in children
◼ Common paediatric and adolescent musculoskeletal
disorders
Musculoskeletal disorders in children and adolescents can be basically

classified into three categories:
1. Congenital – since birth
2. Developmental or acquired – during the growth period due to

nontraumatic diseases (infective, viral, metabolic diseases)
3. Traumatic – fractures, subluxation, dislocation, or due to repetitive

microtrauma
Whatever may be the cause, the earliest possible identification

remains a major factor for effective management.
Both the paediatric orthopaedic surgeon and the paediatric
physiotherapist play a decisive role in the process of early detection,
more so in a congenital variety of musculoskeletal diseases.
The complete programme of management of such cases is discussed
in detail in the relevant chapters.
Overall common musculoskeletal disorders seen in children and
adolescents, their salient features and major principles of management
are described in the following sections.
Fractures in children
Fractures in children differ from those in adults due to bone
peculiarities and the pattern of bone healing.
1. Relative weakness of the physis of the longitudinally growing bone

makes them susceptible to epiphyseal injuries.
2. The periosteum in children’s bones is attached loosely to the bone

and gets stripped off easily by the collection of haematoma under it.
This haematoma turns into exuberant callus – a characteristic in
children.
3. Periosteum is thick and attached loosely to the cortex, whereas

bones are pliable. Bending of bones rather than breaking occurs,
resulting in an incomplete fracture of one cortex only, called greenstick
fracture (Fig. 18-1).
4. The intact periosteum may buckle resulting in buckle or torus

fracture close to the physeal plate or the joint (Fig. 18-2).
5. Periosteum being highly cellular heals fast, quickly gets remodelled

and corrects angulation or overriding amazingly; however, it fails to
correct rotational misalignment.
6. Remodelling is better in younger children and in fracture which is

in the region of metaphysis and close to the growing end.
FIG. 18-1 Greenstick fracture. (A) Diagrammatic representation. (B)

Greenstick fracture of tibia as seen on radiograph.
FIG. 18-2 Torus fracture of lower third of radius (single arrow). Note the
greenstick fracture of the ulna (double arrows).
Causes of fracture in children

◼ Fall and sports injuries: 20–25%
◼ RTAs: 10–15%
◼ Birth injuries: fractured clavicle, humeral shaft or shaft of femur
◼ Pathological fractures: osteomyelitis, fibrous dysplasia, osteogenic

imperfecta, rickets, bone cyst (Fig. 18-3), etc.
FIG. 18-3 Pathological fracture of humerus in an aneurysmal bone cyst.

Note the break in the cortex (arrow).
Common types of fractures in children

Greenstick fracture
◼ Fractures of a single cortex usually occur in the forearm bones

following a bending strain
◼ One cortex gives way while the other remains intact. (Fig. 18-1)
Treatment: Greenstick fracture is treated by closed reduction and

POP cast immobilization. Sometimes an incomplete fracture is
converted into a complete fracture to correct angulation. It is then
immobilized.
Torus or buckle fracture

Axial compressive force causes a torus fracture where the periosteum
remains intact and buckles, but the cortex is broken.
Treatment: Treatment is done by immobilization in a plaster cast.
Epiphyseal injuries
Physis is the weakest region that gives away easily resulting in
epiphyseal injuries (Table 18-1).
Table 18-1
Five Types of Epiphyseal Injuries
Type There occurs complete separation of the epiphysis from the metaphysis without a break (Fig. 18-4
I A,B) – commonly occurs at the lower end of radius
Type Physeal separation along with a triangular piece (avulsion) of metaphysis (Fig. 18-4C) – common at
II lower radial and tibial epiphysis
Type Fracture involving epiphysis running along the growth plate (Fig. 18-4E) – common at the epiphysis
III of medial malleolus
Type The fracture line runs through the epiphysis as well as through the metaphysis (Fig. 18-4F,G) –
IV commonly seen at the lateral condyle of humerus
Type Vertical compression of epiphysis and the physis, resulting in complete loss of growth potential of
V the bone (Fig. 18-4H) – common at the lower tibial epiphysis
FIG. 18-4 Epiphyseal injuries: (A) Line diagram of type I injury. (B) Type I
epiphyseal injury of lower end of radius as seen on radiographs. (C) Line
diagram of type II injury. (D) Type II epiphyseal injury of the lower end of
tibia. Note the displacement of the epiphysis along with the metaphyseal
fragment. (E) Type III epiphyseal injury. (F) Line diagram of type IV injury.
(G) Type IV epiphyseal injury of lateral condyle of the humerus as seen on
an X-ray. (H) Type V epiphyseal injury (diagrammatic representation).
Classification of epiphyseal injuries: The classification of

epiphyseal injuries has a prognostic significance in respect to the
potential of growth disturbances. The Salter–Harris classification that
has the five types explained in Table 18-1 is commonly used (Salter,
1963).
Treatment: Epiphyseal injuries need accurate reduction to minimize
subsequent growth inequalities. Undisplaced injuries are treated by
POP case immobilization while displaced injuries need open
reduction and interval fixation (ORIF) by K-wires.
Complications
◼ Epiphyseal injury can cause the following:
◼ Growth arrest – leading to limb length shortening
◼ Unequal bone growth – partial injury to the epiphysis

results in unequal growth and angular deformity at the
related joint
◼ Overgrowth – may occur due to excessive growth

stimulation (e.g., common at the fracture of shaft of
femur)
◼ Injury to nerves/vessels – for example, injury to the

brachial artery in injury to the distal humeral epiphysis
◼ Compartment syndrome – similar to fractures,

epiphyseal injury can also cause compartment syndrome
Common paediatric and adolescent
musculoskeletal disorders
Developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) was earlier called
congenital dislocation of the hip (CDH). The change in terminology
came with the understanding that the hip joint may be normal or
mildly subluxated, dislocating gradually during the early years of life.
In adolescence, it can be diagnosed easily by physical examination
and X-ray. Sometimes, mothers can also make out that the hip is not in
position due to altered gait.
Treatment is immobilization by special orthosis. Surgery may be
required in the form of open reduction and osteotomy of the pelvis or
femur for proper containment of the femoral head. See the ‘Congenital
Dislocation of the Hip’ section in Chapter 30, on Deformity, for further
details on DDH.
Legg–calve–perthes disease
Legg–Calve–Perthes disease is the idiopathic osteonecrosis or AVN of
the femoral head and is commonly seen in the age group of 5–7 years.
The child complains of pain in the groin, which may radiate down to
the knee; the child walks with an antalgic gait. The early sign is
limitation of internal rotation of the hip; later on, the all movements of
the hip become stiff.
Investigations
The diagnosis is made by an X-ray and MRI. Treatment is rest to the
limb, which may be given by bracing the limb in abduction. Surgery
may be necessary.
Details in Chapter 35, see section Perthes Disease.
Slipped capital femoral epiphysis

The posteroinferior displacement of the proximal femoral epiphysis of
femur is known as slipped capital femoral epiphysis. It is a
developmental condition common in adolescents. The main
symptoms are stiffness of the hip joint with weakness of abduction of
the hip. There is a tendency to keep leg externally rotated; passive
internal rotation is painful. Limb shortening is present and the
displacement diagnosis is easily made by X-rays. The treatment is to
stop weight bearing. Surgery is done for stabilization of the slipped
epiphysis by pins and screws. If the slip is severe, then femoral
osteotomy is done to achieve the correction of the slip.
Disorders of the knee

Osgood–schlatter disease
Osgood–Schlatter disease is again an adolescent disorder commonly
seen at the age of 10–15 years. There is traction apophysis of the tibial
tubercle, with symptoms of localized knee pain or tenderness. There
may be anterior knee pain while running or jumping.
Treatment
Although it is a self-limiting disease, relieved within 12–18 months,
subjects are given rest and NSAIDs, with precautions to avoid
running and jumping for some time.
Sinding–larsen–johansson syndrome (jumper’s knee)

This syndrome has symptoms similar to those of Osgood–Schlatter
disease but is painful, and tenderness is present over the inferior pole
of the patella. This is also a self-limiting disease, relieved within 3–12
months.
Genu varum and genu valgum

Deformity is visible in both the cases so diagnosis is easy to make.
Physiological deformity of 10–15 degrees gets corrected in 12–18
months and 3–4 years for genu varum and genu valgum, respectively.
However, all the cases are not resolved, so monitoring is necessary.
Treatment
Mothers can be taught to apply repeated gentle stretches in both cases.
It persists up to puberty; thereafter, surgery (osteotomy) is required.
Disorders of the foot

Calcaneal apophysitis (sever disease)
It is common before the fusion of apophysis (9 years in girls and 11
years in boys). Repetitive microtrauma at the tendo-Achilles, tendon–
bone junction results in apophysitis, with localized heel pain at the
Achilles tendon insertion and there is a limp.
Treatment
The disorder is self-limiting, relieved within 6–12 months. Rest to the
limb with NSAIDs and gentle passive stretching is the treatment of
choice with heel pad application. If there is severe pain, the POP cast
may be given.
Disorders of the neck

Congenital muscular torticollis
It is a unilateral contracture of the sternocleidomastoid at birth or
within the first 2 months. It may be due to intrauterine malpositioning
of the head or intrauterine vascular insult resulting due to scanning or
imaging.
Treatment
Mothers are educated to apply multiple gentle stretching throughout
the day. Adjustable moulded cervical collar is also given in some cases
to maintain the position. In resistive cases, surgical release is beneficial
before the age of 3 years.
Klippel–feil syndrome
This is an abnormality of the cervical spine due to incomplete
segmentation of vertebrae which is congenitally present. It varies from
the fusion of two to all vertebrae. Physically, the subject has a short
neck with low posterior hairline. Clinically, there is limitation of neck
ROM.
Treatment
Generally not reported in the smaller age group and there is no
specific treatment.
Disorders of the shoulder

Anterior dislocation or subluxation
It is the most common disorder in children that occurs during sports.
It has a tendency for recurrence.
Treatment
Treatment is done by immobilization in a sling and later on a vigorous
strengthening programme to prevent recurrence.
See the ‘Anterior Dislocation’ section in Chapter 5 for further
details.
Sprengel deformity
This happens during the development stage when normally the
scapula descends but in this case, one or both scapulae fail to descend.
Diagnosis can be made by palpation of the scapula and limitation of
the ROM of the scapulothoracic joint.
Treatment
Surgical releases may be necessary.
Disorders of the elbow

Subluxation of the head of radius
Subluxation of the head of radius is commonly seen in toddlers with
trival trauma. Diagnosis is with the help of X-ray.
Treatment
Close reduction is done by flexing the elbow with supination of the
forearm.
Throwing injuries
Apophysitis
Due to repetitive throwing in sports, sometimes, there is apophysitis
of the medial epicondyle of humerus. There are complaints of pain
only.
Treatment
This is treated by rest and NSAIDs, and by stopping sports for at least
6 weeks.
Osteochondritis of capitulum
This is again because of repetitive action of the arm. Pain, swelling,
tenderness and limitation of range of movement at elbow involving
capitulum on the lateral side of elbow are the common symptoms.
Disorders of the back

Scoliosis
This is a deviation of the curvature of spine laterally and is pain free.
It is more common up to the age of 10 years. It can be congenital,
idiopathic or neuromuscular. Diagnosis is made on the basis of
physical examination and X-rays.
Scoliosis with thoracic deformity is prone to cardiac abnormalities
and with lumber deformity, it is prone to gastrointestinal or renal
abnormalities.
Treatment
Lateral curve <20 degrees is only treated by positioning and is
observed on regular check-up. A curve between 20 degrees and 40
degrees requires bracing for at least 23 h a day.
More than 40 degrees curves are cases for surgical fusion or spinal
instrumentation, strengthening, postural exercises and postural re-
education.
Scheuerman disease
This is common in adolescents in the age group of 14–17 years. It
involves familial osteochondrosis of the thoracic spine. This is a
typical deformity of rigid thoracic kyphosis due to anterior vertebral
wedging and compensatory lumbar hyperlordosis. There may be
tightness of the hamstring muscle.
Treatment
Concentrate on mobility and postural exercises to the spine along with
Milwaukee brace. When the curve is >70 degrees, surgery is the
correct option.
Spondylolisthesis
It is seen in young athletes when sport requirements include repetitive
hyperextensions of the lumber spine putting mechanical stress on the
pars interarticularis. In X-ray, forward slipping of the fifth lumbar
vertebrae over S1 is commonly seen. There is flattening of the normal
lumbar curve. A toe touch test is positive. Tightness of the hamstring
muscle is also there. Nerve compression may or may not be present.
Treatment
Acute injury may require immobilization in a body jacket. Special
spinal brace is given in mild-to-moderate slipping. In cases of severe
slipping, surgery is required. Postural mobility and re-education
exercises are done later on.
Cerebral palsy
It is a crippling disease of CNS either due to faulty development of the
CNS, prenatal birth anoxia, injury due to application of forceps or
postnatal causes like head injury, meningitis or encephalitis. Major
symptoms are delay in the milestones from head control to walking
and speaking. Spasticity and ataxia–athetosis are the major features,
which may be associated with mental retardation and speech defects.
Treatment
Treatment requires strengthening and endurance exercises for the
whole spine, abdominal and extremities also. Passive movement and
PNF techniques are given to prevent deformities and to develop the
normal pattern in the brain.
It also requires multispecialty care including occupational therapy,
speech therapy and orthopaedic treatment for correction of or release
of tenderness. Long-time tireless efforts should be made to bring the
child to a level of self-care. In severe cases, mothers have a major and
important role.
Bibliography
1. Salter R B, Harris W R. Injuries involving the epiphyseal plate.
Journal of Bone & Joint Surgery. 1963;45:587-622.
CHAPTER
19
Prevention of fractures
OUTLINE
◼ Major causes of fractures
◼ To overcome and reduce the miseries due to avoidable or
preventable fractures
Is it ever possible to prevent fractures?

Certainly not, however, the incidence of fractures can be brought
under control. It requires planned efforts on a large scale at various
levels, mainly the authorities from departments like public health,
transport, education, information and broadcasting, housing and
construction, press and media and last but not the least ‘WE
OURSELVES’.
What is a fracture?
Fracture is a break in the continuity of a bone.
Why does the bone break?
1. A healthy bone breaks when it encounters a violent force or a

trauma, which exceeds the tenacity of that bone.
2. Certain healthy bones have a tendency to partially break as a result

of a summation of stereotype small microtraumas. It is called a stress
fracture (commonly seen in sports personnel who put sustained stress
on a certain bone, also in policemen, nurses or soldiers who perform
standing duty for long hours).
3. Another variety of fractures is known as pathological fractures, which

occur in a bone weakened due to a disease, a yields even to a small or
trivial injury.
The possible causes of pathological fracture can be as follows:

deficiency in the process of bone formation and consolidation or
imbalance between the process of bone resorption and bone
formation, where the former exceeds the latter.
Major causes of fractures

◼ Direct or indirect trauma
◼ Bone weakened by infective, metabolic, developmental bone

disease or bone tumours
Direct or indirect trauma

Fractures in the normal bones due to direct or indirect trauma are a
major problem which requires multiprong action as mentioned earlier.
Stress fractures
These are fractures occurring due to stereotype stress overload
commonly seen in professions involving long standing hours (e.g.,
nurses and policemen). They are also seen in sportspersons usually
involving leg and foot bones. They can be prevented by the following
measures:
◼ Intermittent breaks in the continued activity
◼ Comfortable footwear
◼ Being watchful during games for any pain or discomfort
◼ Regularly performing conditioning exercises to the susceptible

musculoskeletal complexes
Fractures due to pathological bone disorders

◼ Prevention of the nutritional deficiencies by vitamin D3 and calcium
supplements
◼ Prevention of osteoporosis or a loss of bone density in elderly men

and postmenopousal women by vitamin D, calcium supplements
and appropriate therapy, respectively
◼ Adopting lifestyle with regular exercise
Younger women
Injuries can be prevented by being watchful and remaining physically
fit. Generally, women with a craze to achieve a paper-thin figure go
for crash dieting and lose body weight dangerously. They develop
malnutrition and become susceptible to fractures following even a
mild-to-moderate trauma (anorexia nervosa). Therefore, women and
even men should not strive only for an outward ideal physical form,
but also be physically fit.
Senior citizens
The incidences of fracture are commonest amongst senior citizens
following a fall which happens to be the single common cause.
Regular intake of vitamin D supplements may reduce the incidence of
fractures in these people.
However, there are certain other causative factors that are
associated with old age and may be responsible for a fracture. They
are as follows:
◼ Progressive demineralization of bones
◼ Poor vision and loss of hearing
◼ Lack of movement control, coordination and balance

◼ Overall state of disorientation and confusion, etc.
◼ Above all, general debility and weakness and which is made worse
when associated with central nervous system (CNS) lesion.
To overcome and reduce the miseries due to

avoidable or preventable fractures
The primary approach is to educate the masses on the safety
precautions to prevent fractures. They should be provided with
guidance on the rules and regulations to be observed strictly to avoid
accidents (RTAs). Provide better facilities to the public for safe
performance of work and other activities of the daily routine. At the
same time, strictly curb and punish individuals indulging in wrong
attitudes, especially during driving.
Prevention of fractures is a huge proposition and is possible only
with a team approach. The following government departments can
play a vital role in dealing with each and every fracture-prone
situation:
1. Department of transport
2. Department of information and broadcasting
3. Department of housing and construction
4. Department of health and social welfare
5. Department of education
Example: Since a majority of fractures occur due to road traffic

accidents, a safe transport system can play a vital role in the
prevention.
Transport department
◼ Providing public transport services which are safe.
◼ Strict discipline in driving, issuing driving licences, etc.
◼ Curbing strictly the use of mobiles, smoking or drunken driving.
◼ On the spot strict punishment for defaulters.
◼ At the same time, condition of the roads and road signals should be
well maintained.
Department of information and broadcasting, press and

media
◼ Repeatedly projecting the hazards of undue hurry and carelessness
by story-based films, road demonstrations, etc.
◼ Emphasize the importance of healthy exercise-oriented lifestyle.
◼ Films on early detection of infective diseases, metabolic bone

diseases like rickets, osteoporosis, tuberculosis and bone tumours.
◼ Emphasize the dangers of wrong methods of excessive weight

reduction to achieve paper-thin figure.
◼ Emphasize the dangers of obesity as well.
Department of housing and construction

◼ Safety measures at the site of construction to prevent accidents.
◼ Provide ideal steps of small height with railings on both sides.
◼ Entrance should have slope with a railing.
◼ The floor in toilets, bath and under the water basin should not be
slippery.
◼ Adequate space in rooms to move about freely.
◼ Avoid door steps in between rooms.
Department of health and social welfare, and preventive

medicine
◼ Extensive training of peripheral health workers to detect
pathological fracture-prone diseases early.
◼ Peripheral centres should have adequate supply of vitamins and

nutrients.
◼ Availability of specialists services intermittently at peripheral

centres.
Educational institutes and parents

Educational institutes and parents should cultivate an active lifestyle
by extra emphasis on sports, PT with regular monitoring.
Role of physiotherapy in fracture prevention

◼ Physiotherapists can play a major role by encouraging all
acquaintances and friends, and in fact, every one they meet to get
habituated to an active lifestyle by highlighting the health benefits of
exercise. While treating patients for some other cause, the
physiotherapist must practically get them interested in an exercise-
filled lifestyle, preferably by self-demonstration.
◼ Provide guidance on safer physical activity performance, strictly

avoiding fracture-prone behavioural attitudes.
◼ Discourage elderly people from instant sitting up from the lying

down position, standing and starting to walk. These manoeuvres
may cause postural hypotension resulting in giddiness and a
tendency to fall.
◼ Concentrate and emphasize on practicing and achieving
momentary body balance on a single leg. It will go a long way in
improving the body balance in ambulation or while performing
activities while standing. It is possible only with the long sessions of
balance training. It may cause sudden giddiness leading to a fall.
◼ Never turn or roll your neck instantly while walking.
◼ Safe and well-balanced wide–based (steps) gait training provides

stability to the gait. It can be achieved by giving special training in
the gym.
◼ Correct methods of transfers in bed, standing, sitting over with a

pause in between the stages to restore perfect balance before the
next stage of a particular activity is begun.
◼ Provide necessary assistive aid to facilitate good balance while

performing functional activity. Generally, using a cane is never
accepted wilfully by any individual. Therefore, it is essential to
convince them of the benefits of a cane, at the same time, pointing
out to them the consequences of not using the cane.
◼ Before the patient is discharged, home visit is a must to check:
◼ The house entrance has a slope or small steps with

railings.
◼ The indoor as well as the outdoor areas are well lit.
◼ Walking area and room floors are clear of obstacles (e.g.,

not too many furniture items), loose carpeting, and have
even flooring without steps in between rooms.
◼ No soapy and slippery flooring in toilets and bathrooms

(common places of falls).
◼ Furniture items are of the correct height.
◼ Lamp switch and telephone are placed so that they are

operable from the bed itself.
Footwear safety
◼ Nonskid soles
◼ Narrow heels or toe areas
◼ Ensure close fitting of footwear before initiating standing or

ambulation.
Exercise training programme

There are two basic modes of exercise training depending upon the
degree of physical fitness.
1. Structured exercise training – ideal for younger age group with

good exercise tolerance and the absence of cardiorespiratory anomaly,
as it involves rather vigorous and continuously performed exercise.
2. The second or lifestyle exercise programme or exercise lifestyle

programme which does not require continued exercise but is in
vigorous bouts in between.
Exercise prescription for the structured exercise programme

(table 19-1)
Table 19-1
General Characteristics of Structured Exercise Programme
Exercise Initial Stage of Beginning

Progression of the Exercise
Specificity Exercise
Type and mode Aerobics (dynamic) Make vigorous by adding resistive mode
a
Intensity 40–60% of HRmax 60–70% of HRmax; if possible 70–85% HRmax
Duration 5–15 min session Gradually work up to 20–30 min per session or if feasible
> 30 min
Frequency Twice a week At least three times a week; may be increased up to 5
times a week
aMust include impact loading of the spine and the lower limbs (e.g., jogging, spot running,
brisk or marathon type of walk) to improve BMD and prevent osteoporosis. Cardiac clearance
and exercise tolerance must be obtained before beginning this type of exercise training.
Exercise lifestyle training programme

Individuals who cannot perform exercises continuously for 30 min
may change to three bouts of exercise with each bout lasting for 10
min, else incorporate the CRC type exercise, activities of daily routine
so that the heart rate reaches the level of training heart rate range of
60% of HRmax.
This requires purposely planning a bout of performing that
particular activity vigorously to reach the HR to the training level.
◼ Create an opportunity to have a brisk walk in between your daily

schedule (e.g., parking vehicle away from the place of work and
performing a brisk walk to and from the office.
◼ Make it a point not to use elevators, rather prefer brisk stair

climbing. In fact, purposely try to repeat stairs at every opportunity.
◼ While watching TV, during the ad breaks, stand up and do some

brisk exercises like spot marching, vigorous arm and lower limb
movements. DO NOT KEEP MUNCHING while watching TV.
◼ Try to remain maximally active during leisure time.
◼ Avoid playing long, sedentary games.
◼ Get habituated to play at least one brisk outdoor game at least

thrice a week.
◼ During long periods of sitting, perform antigravity arm movements

overhead or sideways; stand and perform brisk antigravity hip
movements.
◼ Never ask for even a glass of water, please go and get it yourself.
In short, plan and make it a point to remain physically active as

much as possible and whenever feasible. Major requirement is to
make each and every physical activity as brisk as possible.
Last but not the least:
Do not forget that you are the best controller of your body.
So avoid:
◼ Undue hurry while performing physical activity.
◼ Never indulge in:
◼ Drunken driving
◼ Smoking while driving
◼ Using mobile during driving
◼ Driving too fast or attempt wrong hurried overtakes
◼ Likewise catching or alighting from a moving train or bus
◼ Go for complete medical checkup after 40 years of age
◼ Healthy diet
Go for healthy exercising lifestyle and minimize incidences of
avoidable fractures.
CHAPTER
20
Emergency management of a polytrauma patient
OUTLINE
◼ Management at the site of accident
◼ Management in the hospital
◼ Pattern of orthopaedic injuries
◼ Disaster management
The rapid increase in the number of automobiles, technologies and

industries, and above all speedy lifestyle, has resulted in an alarming
increase in the incidence of acute polytrauma. Polytrauma may also
damage the vital organ systems in the thoracic, abdominal and pelvic
viscera with serious consequences or even death.
Table 20-1 shows the trimodal distribution factors of death
following acute polytruama and preventive measures.
Table 20-1
Trimodal Distribution of Fatal Peaks, Possible Causative
Cause – Common Organ System

Fatal Peak Prevention
Damage
First peak of immediate death Severe injury to the brain, spinal Only possible by educating
(50%) cord, heart, lungs or major blood masses on preventive safety
vessels measures on RTAs
Second, intermediate peak of Occurs commonly due to airway Possible with immediate
early death; Few hours after the disruption or failure of the initiation of resuscitation (ABC of
injury (30%) respiratory mechanism life supports)
Third or late peak of delayed Due to failure of multiorgan systems Possible with appropriate early
death (20%) or sepsis measures (hospital care)
Objectives of management
◼ Preserving life by instant application of manual resuscitation
◼ Careful handling of the patient during transfers from the site of

accident to a safe place and early transfer to a hospital or
multidisciplinary health care facility
◼ Appropriate therapeutic measures to promote recovery – therefore,

correct quick assessment and control of the vital parameters (e.g.,
adequacy of respiration, cardiac function, shock, unconsciousness,
excessive blood loss need immediate attention)
The management of acute polytrauma patients is discussed in two

sections: (i) at the site of the accident, and (ii) at the hospital.
Management at the site of accident

1. Get one of the bystanders to call for ambulance and police.
2. Safe transfer: Correct lifting and shifting of person from the site of
the accident should never be done alone. Take help of at least two
bystanders, guide them on how to protect damaged areas (e.g., in
cervical injury) and prevent further damage during the transfer.
3. Area of transfer: Patient should be placed on a well-ventilated, even

and hard surface. Loosen tight clothing worn by the patient if
required. Place the neck in slight extension so that the nostrils point
upwards, to ensure unobstructed ventilation; also get help to clear the
crowd close to the patient.
4. After safe transfer perform a quick survey of lethal injuries:

(a) Respiration
(b) Circulation
(c) Control of haemorrhage or excessive bleeding
Whenever injury to the cervical spine is suspected,

immobilize and support the cervical spine with makeshift
arrangement (e.g., conventional cervical collar or wrapping
the neck with available cloth or rigid support).
Excessive uncontrolled bleeding may result in patient going

into shock with its typical symptoms and signs (Box 20-1).
(d) Examination of neurological function
i. The level of consciousness to be assessed objectively by

Glasgow coma scale (GCS) (Table 20-2)
ii. Pupillary response
iii. Voluntary limb movements
Table 20-2
Glasgow Coma Scale
1. Eye opening (E)

• Spontaneous eye opening 4
• Opening eye in response to verbal 3
command
• Opening eye in response to pain 2
• Does not open the eye at all 1
2. Verbal response (V)
• Oriented 5
• Disoriented 4
• Inappropriate words 3
• Incomprehensible sounds 2
• No response 1
3. Motor response (M)
• Obeys commands 6
• Localized pain 5
• Withdrawal (pain) 4
• Flexion (pain) 3
• Extension (pain) 2
• No response 1
BOX 20-1
SIGNS AND SYMPTOMS OF SHOCK
• Unconsciousness
• Profuse sweating
• Tachycardia
• Pale appearance
• Hypotension
Once the patient is stabilized, conduct quick survey of the lethal

injuries of the whole body from head to toe.
Conducting quick survey of other lethal injuries

Head and cervical spine injuries
Open skull injuries should be covered by clean cloth. Conduct
neurological examination. In suspected cervical fractures or
dislocation, temporary stabilization of neck is of vital importance.
Injury to the chest and thorax

Open chest injuries should be covered with a clean cloth with
application of firm pressure over the open wounds. Development of
flail chest or pneumothorax is an emergency and should be prevented
by quick restoration of breathing.
Injury to the abdomen
Intra-abdominal injury is an emergency as such and needs careful
examination. Rigid abdomen suggests blunt injury and may inflict
damage to the vital organs like liver or spleen. Open abdominal
injuries should be covered with a clean cloth and application of a firm
pressure.
Injury to the pelvis

Pelvic compression and distraction test should be employed; a
positive test eliciting severe pain is indicative of pelvic fractures.
In pelvic injuries, there is always a likelihood of internal
haemorrhage and damage to the intrapelvic organs like kidneys,
bladder and genitourinary system. Suprapubic swelling indicates
injury to the bladder, scrotum or perineal haematoma indicating
urethral rupture.
Injury to the spine

Rigid motionless holding of the neck indicates serious injury to the
cervical spine confirmed by the level of consciousness (GCS).
Acute tenderness over the spinous processes and rigid holding of
the thoracic and lumbar spine are indicative signs of fractures at these
sites with graduated onset of paraparesis.
Injuries to the limbs

Typical signs of localized pain, swelling, tenderness, limb positioning,
bony deformity (or malalignment) and loss of function due to a
sudden increase of pain indicate the presence of fracture.
Whenever limb fracture or dislocation is suspected, immediate rigid
splinting and immobilization should be applied by whatever material
available (e.g., using folded newspaper or an umbrella (Fig. 20-1).
FIG. 20-1 Emergency splinting (a first step in fracture management).

Emergency splinting with any object is a must to prevent further damage to
the soft tissues by fractured bony ends.
Remember
Treating fracture is not an emergency. Restoration of airways and
circulatory function is the first priority along with immediate
arrangement to transfer patient to a multidisciplinary facility centre.
Management in the hospital

As soon as a patient is brought to the hospital emergency, accurate
quick survey is done of the whole body to find out the lethal injuries
needing immediate attention and care. Meanwhile, measures like IV
antibiotics, analgesics, tetanus toxoid, wound care and debridement
should be undertaken to prevent infection and reduce pain.
Restoration of breathing
◼ Airway clearance
◼ Mechanical suction of secretions from oropharynx
◼ Endotracheal intubation
◼ Oxygen inhalation
◼ Presence of flail chest or pneumothorax
◼ Needs immediate attention
◼ Ventilator
Restoration of circulation (cardiac function) and treatment of shock
◼ Once the cardiac function is restored by resuscitation, restore

adequate circulating blood volume by the following:
◼ Start IV fluids.
◼ Perform compatible blood transfusion.
◼ Control external bleeding by local pressure and limb

elevation.
◼ Start immediate vascular repair or grafting if become

necessary.
Assessment of neurological dysfunction
◼ Level of consciousness
◼ Pupillary response
◼ Voluntary limb movements
Assessment of abdominal injuries

Closed abdominal injuries are assessed by the following:
◼ Sonography at substernal, right and left subcostal, and suprapubic

regions
◼ Immediate exploration and repair of open abdominal injury
Immediate surgery
Immediate surgical procedure may be needed for head, chest and
abdominal injury patients.
This is followed by the management of other body systems like
digestive system, excretory system and, lastly, fracture management.
Pattern of orthopaedic injuries in polytrauma

Orthopaedic injuries are always associated with various types of
injuries to the soft tissues surrounding the bones and joints.
◼ Head, cervical spine, and maxillofacial injuries
◼ Lower rib fractures with injuries to liver, spleen and kidney
◼ Injuries to the lumbar spine and intra-abdominal injuries with

damage to the organ systems in the abdominal viscera
◼ Pelvic fractures with injuries to the genitourinary system (e.g.,

kidney, bladder, urethra) with excessive bleeding
◼ Lower limb fractures

◼ Multiple fractures in a single limb
Definitive orthopaedic treatment

Orthopaedic care at the site of injury
◼ Apply makeshift support to maximally immobilize the areas of

fracture or dislocation, e.g., cuff and collar, paper roll or umbrella to
support lower limbs and conventional cervical collar by wrapping
available cloth.
◼ Applying localized pressure over the bleeding points and covering

the open wounds with clean cloth.
Orthopaedic care at the hospital

Once the patient’s condition is stabilized, a detailed survey is
conducted to know the extent of orthopaedic injuries along with
radiographic investigations.
After initial wound care, fractures are treated with internal fixation.
Soft tissue repair or reconstructions like vascular, neurological repair,
grafting, tendon transfers, suturing are done along with the proposed
management of bony injuries (e.g., fractures or dislocations).
Disaster management
Calamities like earthquake, downpours, war, railway accidents and
terrorist attacks result in mass injuries of varying intensity and there
are always an inadequate number of care-taking personnel.
As such the patients are sorted out and categorized on the basis of
the severity of involvement into four major categories, and referred to
four groups according to the severity of injuries.
Triage sort
Category I: Critical, needing immediate intervention, e.g., patients with
airway obstruction or injuries to the large blood vessels
Category II: Urgent but can wait for some time, e.g., open fractures
Category III: Less serious injuries, not endangered by delay
Category IV: Severe injury, survival not likely in spite of intervention
Treatment is carried out as per the individual needs.

In the triage, a survey is done to divide the dead and the
individuals who are ambulatory into separate groups. The general
plan of management of a polytrauma patient is depicted in Table 20-3.
Table 20-3
General Plan of Management of a Multitrauma Patient
At the Site of the Accident At the Hospital

Instant cardiopulmonary resuscitation in the Restore haemodynamic stability by aggressive CPR, oxygen
event of cardiac or respiratory failure inhalation, defibrillation, using ventilator, etc.
Safe transfer to protected area Send blood for
Airway and circulatory stabilization; control • Grouping
of blood loss; examination for shock • Cross matching
• Clotting
Neurological examination for Control excessive blood and fluid loss by establishing
• Level of consciousness adequate circulating blood volume by
• Pupillary response • IV line for fluid, plasma or blood as required
• Voluntary limb movements • Starting central venous pressure measurement
• Controlling external bleeding points by local pressure
Temporary closure of open injuries (at the • Emergency surgical repair or reconstruction for
chest, abdomen, or pelvis) by clean cloth extensively damaged vital visceral organ systems and
vessels
Early identification of serious injuries Definitive orthopaedic care
needing immediate attention • Radiographic investigations of suspected damaged
• Faciomaxillary injuries bones and joints
• Thoracic injuries: • Sonography
• Flail chest • Substernal region
• Pneumothorax • Subcostal region
• Lacerations involving cardiac and • Suprapubic region
large vessels • Closed reduction of fractures or open reduction with
• Closed abdominal and pelvic injuries internal fixation along with soft tissue repair
Bleeding • Immobilization
Role of physiotherapy
Physiotherapists can provide valuable assistance in various ways.
Adequate expertise in the following:
◼ Identifying serious injuries and their priorities
◼ Carrying out the procedure of saving life using CPR and basic life
supports
◼ Managing patients with uncomplicated injuries
◼ Emergency chest physiotherapy
◼ Providing immediate splintage, correct posture of the body and the

injured part.
◼ Active assistance in conducting various assessment procedures

(e.g., quick neuromuscular evaluation)
◼ Adopting measures to prevent possible ensuing complications as a

result of wrong handling, positioning, injury itself, or following
reduction and immobilization by intermittent monitoring to
encourage functionally oriented early mobilization after the
stabilization of injury
◼ Education of public on emergency life-saving procedures

CHAPTER
21
Infections of the bones and joints
OUTLINE
◼ Osteomyelitis
◼ Acute haematogenous osteomyelitis
◼ Exogenous osteomyelitis
◼ Chronic osteomyelitis
◼ Subacute osteomyelitis
◼ Osteomyelitis in HIV disease
◼ Skeletal tuberculosis
◼ Tuberculosis of the spine (Pott disease)
◼ Tuberculosis of the hip joint
◼ Tuberculosis of the knee joint
◼ Tuberculosis of the ankle joint
◼ Tuberculosis of the shoulder joint
◼ Tuberculosis of the wrist joint
◼ Tuberculous osteomyelitis
◼ Pyogenic arthritis (septic arthritis, infective arthritis,
suppurative arthritis)
◼ Acute septic arthritis of infancy (Tom Smith arthritis)
◼ Gonococcal arthritis
◼ Syphilitic infection of the bones and joints
◼ Fungal infections of the bone
Like any other tissue in the body, bones are also infected by
microorganisms. The common bone infections are as follows:
Common Bone Infection

Microorganism
Staphylococcus aureus Osteomyelitis
Mycobacterium Tuberculosis
tuberculosis
Pyogenic arthritis (septic-
arthritis)
Osteomyelitis
Infection of the bone and bone marrow by pyogenic organisms is
called osteomyelitis. It may be acute or chronic.
The most common causative organism is Staphylococcus aureus. The
other organisms are Streptomyces albus, streptococci, pneumococci,
Escherichia coli, etc. Mycobacterium tuberculosis may also cause
osteomyelitis, which is discussed separately.
Microorganisms may enter and infect the bone by any of the
following three routes:
◼ Haematogenous route: Most common entry through the

bloodstream, common in children (osteomyelitis)
◼ Direct route: Directly through the neighbouring infected tissue

(septic arthritis)
◼ Exogenous route: Through open fracture, open wound, surgical

incision, etc.
Acute haematogenous osteomyelitis

Acute haematogenous osteomyelitis is mostly caused by S. aureus.
Streptomyces albus or streptococcus may be responsible for a mild type
of infection.
Even mild skin infection like a boil or tonsillitis may be a
predisposing factor.
Acute osteomyelitis generally follows a history of trauma. It occurs
most commonly during the period of active growth, i.e., between 3
and 16 years of age. The causative organisms spread through the
bloodstream from the original focus such as tonsils, respiratory tract
and intestines to the bone.
The long bones of the lower limbs are commonly involved, the
upper end of the tibia and the lower end of the femur being the most
common sites. The upper end of the femur may be involved in
infancy.
The initial focus of infection is usually the metaphysis because of
the following reasons:
◼ It is highly vascular.
◼ The sharp looping of the nutrient artery (hairpin bend; Fig. 21-1) is
an ideal site as it slows down the circulation encouraging the
harbouring of bacteria.
◼ A recent trauma may result in reduced tissue resistance because cell

destruction due to haemorrhage helps in localizing infection in the
metaphysis.
◼ Other factors like reduced immunity, anoxia, vasospasm, defective

phagocytosis and anaemia may aggravate the infection.
◼ The organisms multiply, set up inflammatory exudate and result in

abscess (pyogenic) formation.
◼ The pus enters various sites of the bones like the medullary canal
and the periosteum through the Haversian canals (Fig. 21-2).
FIG. 21-1 Factors promoting infection and its spread.

FIG. 21-2 Osteomyelitis stages. (A) Acute haematogenous osteomyelitis.

Spread of pus from its origin in metaphysis to (1) the medullary canal, (2)
under the periosteum, (3) the joint, particularly where the metaphysis is
intra-articular, (4) the joint directly, particularly in infants, and (5) outside the
bone through a sinus. (B) NS: Necrotic segment. (C) SE, sequestrum; S,
perforating sinus; I, involucrum.
An abscess is formed and the infection spreads to the medullary

cavity of the diaphysis or the shaft. It may spread underneath the
periosteum. This results in lifting of the periosteum thereby cutting off
the blood supply to the underlying bone and resulting in its death
(necrosis) and formation of sequestrum. Subsequently, the tense (Fig.
21-2B) abscess ruptures the periosteum and pus comes out through a
sinus (Fig. 21-2C). In children, the periosteum is loosely attached to
the bone and therefore gets lifted off easily by the underlying pus,
resulting in a large diaphyseal sequestrum (Fig. 21-3). On the other
hand, in adults, the periosteum is closely adherent to the bone and
therefore cannot be lifted off easily. If not controlled, it may spread to
other parts of body.
FIG. 21-3 Chronic osteomyelitis of humerus, showing a large diaphyseal
sequestrum.
In most of the long bones, the metaphysis is extra-articular and

therefore when the abscess bursts open, it does not involve the joint
(Fig. 21-4). In certain situations where the metaphysis is intra-
articular, the abscess bursts open directly into the joint cavity and
causes septic arthritis. The most common example is the hip joint. At
the upper end of the femur, the neck of the femur is the metaphysis,
which is intra-articular and therefore an abscess in the metaphysis will
drain directly into the joint cavity (Fig. 21-5). The other sites where the
metaphysis is partially or totally intracapsular are the upper end of
the humerus, the lower end of the humerus and the lower end of the
femur.
FIG. 21-4 The position of metaphysis is outside the joint capsule.

FIG. 21-5 Metaphysis at the proximal femur is within the joint capsule.
In this situation, the pus bursts open outside, through the

periosteum, resulting in multiple discharging sinuses.
Acute osteomyelitis, when not treated promptly and adequately,
may result in chronic osteomyelitis. Chronic osteomyelitis may also
develop in bones following a compound fracture or following surgery.
Another variety of chronic osteomyelitis, i.e., tuberculous
osteomyelitis, presents insidiously in the chronic stage only, without
presenting in the acute form.
In chronic osteomyelitis, the dead bone (called sequestrum)
becomes surrounded by infected granulation tissue; it becomes a
chronic source of pus discharge through the already formed sinus.
Reparative new bone is laid down beneath the elevated periosteum.
It is called involucrum. In neglected cases, the infection may become
chronic resulting in repeated bouts of acute exacerbations, with
discharging sinuses (Fig. 21-6) and progressive destruction of the
affected bone and the surrounding soft tissues.
FIG. 21-6 Discharging sinus in the right thigh, due to chronic osteomyelitis
of the femur. Note that the affected thigh is short, as seen by the different
levels of the knee joint.
Clinical features
The diagnosis of acute osteomyelitis is essentially clinical. The onset of
symptoms may be preceded by a history of trauma to the affected
part. A primary focus of infection may also be detectable somewhere
in the body, e.g., skin and tonsils.
In the acute stage, the child presents with high fever, headache,
irritability and mild swelling. On examination, signs of dehydration
may be found. The affected limb is kept in a position of slight flexion
of the adjacent joint. This position relaxes the joint capsule and
increases its capacity to accommodate the effusion, which is usually
sympathetic. Tenderness and signs of inflammation are present over
the metaphysis. Swelling may become apparent when the pus comes
into muscular or subcutaneous plane. The child resists any
examination or even change of bed sheets, etc. because of severe pain.
In rare cases, there may be signs of toxaemia.
Investigations
The following investigations may help in the diagnosis of acute
osteomyelitis, though they may not be specific.
1. Blood
(a) Leucocytosis should be up to 20,000 cells.
(b) Erythrocyte sedimentation rate (ESR) level is elevated.
(c) Blood culture may be positive for the organism.
2. Radiograph of the affected part
(a) The radiograph is usually normal in the first week.
(b) A periosteal reaction may be seen between 7 and 10

days.
3. Bone scan: It shows an increased uptake by the affected bone.
Treatment
The key to successful treatment of this condition is its early diagnosis.
Acute osteomyelitis should be suspected if there is tenderness over
the metaphyseal area of the bone, and any attempt to move the
joint/limb causes excruciating pain. The following measures are
adopted in its treatment.
Early stage
◼ Antibiotics: Appropriate antibiotics are administered intravenously

after determining the sensitivity of the organism from the blood or
pus for the first 7–10 days; oral administration is continued further
for at least 8–12 weeks. Blood transfusion may be necessary.
◼ Rest and proper positioning of the limb (area of infection) with a suitable
POP cast with the limb elevated: The POP cast decreases pain and
stops the spread of infection by reducing muscle action and blood
flow.
◼ Adequate balanced diet and fluid intake have to be ensured.
◼ Regular monitoring of general condition, fever, pulse and the state

of hydration, etc., has to be done.
◼ Observation: The affected area should be observed for soft tissue

oedema, redness of skin, warmth, soft tissue abscess and discharge,
etc.
◼ IV fluids are administered in case of marked dehydration, or blood

transfusion if the patient is anaemic.
Surgical treatment
Surgery is indicated if there is no favourable response to conservative
treatment by 48 h. By this time, an abscess usually forms, which needs
drainage. In addition to the incision and drainage of pus from the
subcutaneous abscess, multiple holes are drilled into the cortex of the
bone for proper drainage of the pus. Sometimes, a small window may
be made in the cortex of the bone for better drainage.
Physiotherapy objectives
◼ To plan graduated exercise in relation to the muscles skeletal

destruction by the disease process
◼ To restore optimal range of motion (ROM) or at least functional

ROM to the affected joint
◼ To maximally increase the strength and endurance of the muscle

groups in the proximity of the diseased bone
◼ To plan tailored programme of exercises towards maximizing the

functional independence to the patient, heavily depending upon
correct guidance to the mother or child’s attendant, providing the
necessary devices, aids or orthoses
Expected problems
◼ Acute exacerbations or recurrence
◼ Joint stiffness and weakening of the muscles close to the site of

lesion
◼ Possibilities of a pathological fracture
◼ Deformity or a limb length discrepancy
◼ Prolonged nonhealing sinuses
Salient features of the disease to plan the therapeutic approach

• S. aureus is the common organism which precipitates the disease
with an affinity to attack the epiphysis.
• It commonly affects children.
• It involves the metaphysis.
• Fever is a common presenting symptom.
• Conservative approach with rest, nutritious food and drugs can

effectively control the disease.
Physiotherapy in acute haematogenous osteomyelitis
◼ Pain and muscular spasm should be controlled by cryotherapy with

icepacks or ice water packs.
◼ Splinting of the affected joint in functional position should be done.

Guide mother in changing posture and repetitive toe movements.
◼ As far as possible, the affected limb should be comfortably placed in

an elevated position to reduce oedema.
◼ As soon as there is an evidence of the disappearance of the acute

symptoms like fever, rigors, chills, although persistence of pain
remains, superficial thermotherapy may be introduced to reduce
pain and spasm.
◼ Unaffected joints are moved through the active full range by

guiding the mother.
◼ Brief and light isometrics are initiated to the muscles under

immobilization by self-efforts within the pain-free range.
◼ Mother of the child should be warned not to allow or hastily carry

out bearing weight of the affected limb to avoid undue stress over
the affected joints.
◼ The vigorousity and self-resistive modes of exercise to the

unaffected joints are guided and supervised.
◼ Isometrics under the splints are progressed to strong and sustained

mode, especially focusing on the functional muscle groups.
Late stage
◼ Initiate light rhythmic relaxed self-active movements within the

pain-free ROM.
◼ The joint stiffness and muscular weakness, which have occurred
during immobilization are major problems that needs concentrated
efforts to improve.
◼ Wherever possible, educate mother to encourage the child on self-

performed exercises in a gradual mode.
◼ Encourage maximally the self-stretching-hold technique to improve

the ROM of the postimmobilization joint stiffness.
◼ As the deformity is minimal, in due course, initiate standing

balance, weight transfers in the parallel bars.
◼ Provide proper orthoses if needed and initiate ambulation in a

parallel bar.
◼ Progress the exercise mode to antigravity or self-resistive one.
◼ Guide the mother adequately to help the child to properly carry out
functional activities as independently as possible and be alert and
watchful for the signs and symptoms of recurrence and report
immediately.
◼ The mother should be taught the technique of friction massage in

the event of formation of an adherent scar.
◼ Beside ambulation, focus on achieving strong and maximum ROM

at the hip and knee towards functional ambulation, with the limit of
the process of recovery of the disease.
NOTE: Every child has high potential to be progressive towards
self-sufficiency, which itself many times provides clues to help in
achieving the goal early.
Exogenous osteomyelitis
In exogenous osteomyelitis, the microorganism enters through an
open wound, an open fracture or following surgery. Within 2–3 days,
a purulent discharge develops, accompanied by fever.
This type of osteomyelitis can be prevented by early surgical
intervention. Otherwise, appropriate antibiotics and regular dressing
remain the mode of treatment.
Complications
◼ Septic arthritis
◼ Chronic osteomyelitis: If the disease is not treated enthusiastically in

the acute stage, the condition slips into a chronic stage and is then
called chronic osteomyelitis
◼ Destruction of a growth plate: When the infection involves the growth

plate, it causes destruction of the growth plate; this in turn causes
premature closure of the growth plate resulting in either shortening
of the limb or deformity (Fig. 21-7)
FIG. 21-7 Destruction of the epiphysis of tibia, due to infection, causing

deformity at the ankle.
Chronic osteomyelitis
Acute (pyogenic) osteomyelitis, when treated inadequately, passes on
to chronic osteomyelitis. The other causes are weak host defence
mechanism due to malnutrition, etc., or high virulence of the
organisms.
Pathology
When the periosteum is lifted off due to pus, the underlying bone
loses its blood supply, becomes dead and forms a sequestrum. The
process of repair continues and new bone is laid down
subperiosteally. This is called involucrum. The new bone is laid down
in an irregular fashion which gives an irregular surface to the bone.
The sequestrum is defined as a piece of dead bone surrounded by
infected granulation tissue. It has a smooth surface which is ‘bathed’
in pus and an irregular edge which is surrounded by granulation
tissue. The size of the sequestrum may vary from a flake of a bone to a
large diaphyseal segment of the bone.
Involucrum is the new bone laid down under the raised periosteum,
as a part of the repair process. It lies outside the sequestrum and
develops holes in the bone through which the pus drains out. The
holes are called cloacae.
The following are the characteristic features of chronic
osteomyelitis:
1. Discharging sinus (Fig. 21-6), which is usually fixed to the

underlying bone
2. Irregular thickening of the bone (Fig. 21-8)
3. Irregular surface of the bone
4. Deformity of the limb
5. Shortening of the limb
6. Joint stiffness
FIG. 21-8 Radiographic features of chronic osteomyelitis: (A) Cavities

seen in the bone. (B) Thickening, irregularity and deformity of the bone.
Loss of distinction between the cortex and medulla of the bone.
Radiographic features
◼ Thickening and irregular cortex and deformity of bone (Fig. 21-8)
◼ Patchy sclerosis giving honeycomb-like appearance
◼ Bony cavity (area of rarefaction surrounded by sclerosis)
◼ Formation of granulation tissue surrounding the sequestrum giving

the appearance of radiolucent zone around it
◼ Involucrum with sinus holes (cloacae) visible outside the

sequestrum
A pathological fracture is shown in Fig. 21-8
Complications
1. Acute-on-chronic osteomyelitis: Acute exacerbations of a chronic

disease can occur repeatedly and are treated with antibiotics, and
drainage of pus, if required.
2. Stiffness of the adjacent joints: This can occur due to the

following:
(a) Soft tissue contractures
(b) Secondary septic arthritis (Fig. 21-9)
3. Pathological fracture: This can occur through the weakened part of

the bone. This is generally treated by conservative methods. However,
nowadays, it can very well be treated by Ilizarov fixation technique.
4. Deformity can occur due to the following:
(a) Malunion of a pathological fracture
(b) Premature arrest of the epiphyseal growth plate due to

infection (Fig. 21-10)
5. Limb length discrepancy
(a) Shortening occurs when the growth plate is damaged

due to infection.
(b) Lengthening may occur occasionally because of

increased vascularity in the region of the growth plate as
a result of osteomyelitis.
6. Malignancy: A long-standing discharging sinus may in rare cases

transform into squamous cell carcinoma.
FIG. 21-9 Septic arthritis of the right hip joint.

FIG. 21-10 Premature closure of the distal epiphysis of tibia, caused by

infection, leading to shortcoming of tibia and the resultant deformity at ankle
joint.
Treatment
Antibiotics
Antibiotics are given as per the pus culture and sensitivity reports.
Surgical operations
The following surgical operations are performed either singly or in
combination.
Sequestrectomy: Removal of the necrotic bone (sequestrum) with

curettage of the cavity is carried out. The infected granulation tissue
is also excised.
Curettage: The cavity in the bone allows accumulation of pus and
bacteria inside it. The cavity is curetted and after a thorough
curettage, it may be filled with cancellous bone grafts or a viable
muscle.
Saucerization: Pus gets collected in the deep cavity in the bone (Fig.

21-11A). The cavity is therefore made shallow like a ‘saucer’, by
removing its overhanging edges which prevents accumulation of
pus. This procedure is called saucerization (Fig. 21-11).
Excision of the sinus tract: The sinus tract is excised and the wound
is allowed to heal slowly.
Amputation: It is indicated in very rare situations when a

discharging sinus of longstanding duration undergoes a malignant
change or when other organs of the body get involved due to the
infection.
FIG. 21-11 Saucerization: (A) A deep cavity in the bone is converted into
(B) a shallow (saucer-shaped) cavity.
Physiotherapy management of chronic osteomyelitis

When the active disease is controlled, it leaves certain chronic
musculoskeletal deficiencies.
Therefore, maximum efforts are introduced to restrict the residual
disabilities to the minimum.
Limb length imbalance

There may be a limb shortening due to damage to the growth plate by
the disease, whereas limb lengthening may occur as a result of
localized increased vascularity at the growth plate. This requires
periodical checking of the leg length and providing correct raise in the
affected or the contralateral limb.
Deformity
◼ Initially by the passive stretching mode
◼ Adjustable dynamic orthosis
◼ Wedge serial POP cast
Adherent scar
◼ Sustained and gradually passive stretching combined with friction

massage may be tried.
◼ Ultrasound exposure has been found to be effective.
◼ Ambulatory assistive devices like LL braces, crutches, canes with

gait training sessions may be required. Increase the vigorousity of
exercise modes to depend heavily on self-performed exercise
training.
◼ Resistance exercises and resistive functional movements are

maximized to ease the stability as well as the freedom of movements
and the ADLs.
Amputations
Long-standing infection may undergo malignant changes, and one
has to undertake limb amputations. The standard methods of
sequential stages of rehabilitations following limb amputations are
used.
Subacute osteomyelitis
When the disease is caused by organisms of low virulence or the host
has a high resistance, the disease presents itself primarily as subacute
osteomyelitis; with insidious onset.
Subacute osteomyelitis may present as one of the following three
categories:
1. Salmonella osteomyelitis
2. Brodie abscess (Fig. 21-12)
3. Sclerosing osteomyelitis of Garre
FIG. 21-12 Brodie abscess: (A) Diagrammatic representation. (B) As seen

on a radiograph; note the oval-shaped lytic lesion.
Salmonella osteomyelitis
Salmonella osteomyelitis is a subacute type of osteomyelitis which
presents during or following enteric fever.
Salient features: Mostly bilaterally symmetrical involving ulna or
tibia, and involving the diaphysis
Radiography: Area of rarefaction in the cortex surrounded by the
sclerosis
Treatment: Antibiotics, curettage or drainage of the abscess
Remember
The rate of recurrence is high and therefore adequate treatment and
regular follow-up are advisable.
Brodie abscess
Brodie abscess occurs from low-grade infection of the bone by
staphylococcus.
Salient features
A single abscess is commonly formed in the metaphysis of the long
bones, especially the lower end of the femur or upper end of the tibia.
Clinical features
Brodie abscess is commonly seen in adolescents. Dull and deep pain is
felt over the site when the abscess is studded with pus and
granulation tissue. Initially, it is asymptomatic due to the body’s own
defence mechanism.
Radiography
Round or oval-shaped lytic lesion surrounded by the zone of sclerosis
is seen distinctly in the metaphysis (Fig. 21-12).
Treatment
◼ Antibiotics
◼ Drainage of the abscess or curettage of the cavity
◼ If the cavity is large, surgical evacuation of the abscess followed by

cancellous bone grafting is done under antibiotic cover
Sclerosing osteomyelitis of garre
◼ It is a diffuse sclerosing inflammatory lesion of unknown aetiology.
◼ It is commonly seen in children, affecting long bones.
Clinical features
◼ Chronic dull pain over the site of lesion (usually tibia) which
worsens at night.
◼ Deep bony tenderness
◼ No discharging sinus
◼ Radiography: Increased density and cortical thickening over the
affected part of the bone with obliteration of the medullary canal are
seen
Treatment
◼ Antibiotics
◼ Excision of the thickened bone
◼ Differentiation from Ewing sarcoma, osteosarcoma, or osteoid

osteoma which have a similar radiographic picture
Physiotherapy
◼ During the initial phase, rest in a proper splint in a relaxed position

is provided for augmenting healing of the lesions by antibiotics.
◼ Perform limb elevation to help drainage of the waste following

drainage of the abscess or curettage.
◼ Following excision and bone grafting, strictly check the close fit
position of the immobilization.
◼ Provide vigorous exercise to the nonaffected limb joints and to the

toes of the involved limb.
◼ Gentle short-duration isometrics are initiated as soon they are not

painful.
◼ Gradually increase the vigorousity of the therapeutic exercises from

free rhythmic relaxed movements to self-resistive mode.
◼ Check the adjacent joint for joint tightness or contractures and begin
with self-stretch-hold mode.
◼ Posterior above-knee (AK) orthosis or cast may be necessary during

early ambulatory training sessions.
◼ Ambulation is progressed from supported to independent mode
correcting the limb by gait training.
Osteomyelitis in HIV disease

The rate of bone destruction greatly exceeds the rate of new bone
formation. The areas of lower femur and upper tibia are the common
sites and the disease is often bilateral with secondary septic arthritis
further complicating the condition.
Skeletal tuberculosis
Tuberculosis of bones and joints accounts for about 3% of all types of
tuberculosis; the maximum incidence being that of the spine (>50%)
followed by hip, knee, shoulder, elbow and hand.
Tuberculosis is a systemic disease which may affect various organs.
Skeletal tuberculosis, i.e., tuberculous infection of the bones and joints,
is almost always secondary to an infection elsewhere in the body,
usually in the lungs, lymph glands or intestines, etc. Young children
and adolescents are commonly affected. Debility, general weakness
and unhygienic surroundings could be the predisposing factors.
Injury may be a precipitating cause, resulting in small haemorrhages
inside the bone. Such haemorrhages cause vascular stasis which
favours deposition of the organisms in the injured area.
The causative organism, the tuberculous bacillus (M. tuberculosis),
enters the body by inhalation, by ingestion or by inoculation. The
bacilli multiply after invasion infecting the bone at the epiphyseal
cartilage. An inflammatory reaction sets up and eventually a typical
tuberculous follicle is formed. There occurs destruction of the bone
with pus formation. The infected granulation tissue and pus spread to
the nearby soft tissues and subperiosteal planes – as ‘cold abscess’ and
may find its way to the exterior as sinus. Later on, there is an attempt
at fibrosis at the periphery. Tuberculous infection of the bone is seen
in vertebrae, phalanges and metacarpals and rarely in long bones.
Infection of the synovial membrane occurs in tuberculous arthritis.
Clinical features
Tuberculous arthritis is usually monoarticular but may involve
multiple joints occasionally. Hip, knee and elbow joints are commonly
involved, whereas wrist and tarsal joints may occasionally be affected.
Tuberculosis can be seen at any age but it is more common before
the age of 30 years. Both sexes are equally involved. The onset is
insidious and may be associated with constitutional symptoms like
low-grade evening rise of temperature, loss of appetite and weight,
night sweats and anaemia. Early inexplicable appearance of atrophy
in a muscle close to the site of infection may also be found.
In the early stage, the synovial membrane is affected. A soft, tender
swelling develops over the affected joint. Attempted movements of
the joints are extremely painful, when the bony ends of the joint are
involved. Joint movements are restricted due to muscle spasm, and
involvement of the cartilage.
If treated early and adequately, there may be good recovery. Delay
in treatment may result in the fibrous ankylosis, bony ankylosis, joint
destruction and even dislocation.
In fibrous ankylosis, the cartilage and the synovial membrane are
replaced by fibrous tissue. The bony ankylosis may be due to the
knitting of the bony ends following destruction of the cartilage, or
ossification may occur in the fibrous tissue surrounding the joint (Fig.
21-13).
FIG. 21-13 Tuberculous arthritis involving knee. (A) TSY, thickened
synovial membrane; EX, exudate-turbid fluid or pus. (B) FA: fibrous
ankylosis. (C) BA: bony ankylosis.
Dislocation of the joint may occur due to destruction of the

ligaments supporting the joint.
Investigations
1. Radiographic investigations:
(a) As the radiographic changes are minimal in the early

stage, radiograph may be taken of both the sides (bilateral)
for comparison.
(b) Tuberculous osteomyelitis: A well-defined area of bony

destruction without any new bone formation (unlike
pyogenic infection) (Fig. 21-14).
(c) Tuberculous arthritis: Reduction of joint space, erosion of

articular surface with marked periarticular destruction,
rarefaction (no subchondral rarefaction like osteoarthritis
or septic arthritis) (Fig. 21-15).
(d) Radiograph of chest to detect any primary lung lesion.
2. Blood investigations: Investigations show slightly raised ESR, and

lymphocytic leucocytosis, normal or low haemoglobin.
3. Mantoux test: It is a skin test which gives information whether a

person has been infected with Tuberculous bacilli or not.
4. Serum ELISA: It is done for detecting antimycobacterium antibodies

to mycobacterium antigen.
5. TB Gold test: It is a blood test that detects whether a person is

infected with tuberculous infection or not.
6. Synovial fluid aspiration: It is done to confirm inflammation; may

show raised protein content at early stage along with leucocytosis and
decreased glucose level.
7. Aspiration of cold abscess and pus examination for tuberculous

bacilli are done.
8. Histopathological test: It is the examination of the granulation tissue

of biopsy or curetted tissues.
9. CT scan: It is useful in small lytic or destructive lesions especially

cervicodorsal junction not visualized by plain radiograph (Fig. 21-16).
10. MRI: Early detection is much better not only in bony but also in
soft tissue lesions (Fig. 21-17).
11. Biopsy: Biopsy from bone cavity or synovium can provide

confirmed diagnosis.
12. Confirmatory tests: Ziehl–Neelsen stain for acid-fast-bacilli (AFB)

and growth from the joint aspirate or biopsied tissue are confirmatory
tests.
FIG. 21-14 Tuberculosis osteomyelitis of the neck of femur. There is

destruction of the bone (cavity) without any new bone formation.
FIG. 21-15 Tuberculous arthritis of the elbow joint. There is considerable

soft tissue swelling and destruction of the olecranon of ulna including the
articular surface.
FIG. 21-16 CT scan of cervicodorsal spine shows subluxation of C5-C6

vertebrae.
FIG. 21-17 MRI of the spine showing tuberculosis of D10-11 vertebrae.
Treatment
Conservative
1. Bed rest and well-balanced nutritious diet are given.
2. Drug therapy: Initially, four drugs – rifampicin, INH (isoniazide),

pyrazinamide and ethambutol – are given for 2–3 months, followed
by 2 drugs – rifampicin and INH – for 18 to 24 months.
Second line of antituberculous drugs is given if the patient

fails to respond to the aforementioned primary drugs.
3. Rest to the affected part in the acute stage may be achieved by

traction or splinting or POP cast in the optimal position of the joint.
Optimal positioning of the affected joint and the limb are of primary
importance to avoid deformity and contractures (Table 21-1).
Table 21-1
Optimal Positioning of Joints to Ensure Rest and Possible Prevention of Deformities
Joint Optimal Positioning

Hip Neutral extension, 15–30° of abduction and neutral rotation
Knee As much extension as possible
Ankle and Neutral position of dorsi and plantar flexion (at right
foot angles)
Shoulder Abduction of 40–45° with internal rotation
Elbow In flexion close to right angle
Wrist In 15–20° of extension
Surgical
The surgical treatment depends upon the stage and the extent of the
disease and its complications.
1. Drainage of the abscess is done.
2. Curettage: A cavity in the bone is curetted thoroughly, with or

without bone grafting.
3. Joint debridement: The infected focus, including the granulation

tissue and necrotic material, is removed from the joint. This helps in
early healing of the disease.
4. Decompression of the cord is performed.

5. Arthrodesis: The joint is fused in the functional position when the
joint is destroyed beyond repair.
6. Arthroplasty: Excisional arthroplasty (also called Girdlestone

arthroplasty) is done in cases of tuberculosis of the hip. In this
operation, the infected/affected head and neck of the femur are
excised. A part of the acetabulum may also be excised (Fig. 21-18).
This helps in the healing of the disease. Excisional arthroplasty has the
advantage of giving a mobile hip where the patient can even squat but
leaves the hip unstable and the limb short.
FIG. 21-18 Girdlestone arhtroplasty of the hip. Please note that the head
and neck of the femur have been excised.
Objectives
◼ To reduce the possibility of fixed bony deformities
◼ To improve the lung function to the normal or near-normal level
◼ To optimally restore the ROM of the joints close to the lesion
◼ To optimize all the muscular functions close to the site of lesion and
the whole body
◼ To provide graduated functional training towards self-sufficiency
Expected problems
◼ Possibility of developing body ankylosis around the lesion
◼ Possibility of developing sinuses, cold abscess or secondary

infections
Physiotherapy for conservatively treated patients

Early stage
◼ Active exercise to the unaffected areas
◼ Chest physiotherapy to improve respiratory function
◼ Proper limb positioning, comfortable and well supported posture,

not promoting the possible kyphosis
◼ Frequent position change to prevent pressure sores, and expected

contractures
Late stage
◼ As soon as the healing of the lesion is conformed, vigorous but

gradually progressive modes of exercise are initiated.
◼ Stepwise training of exercise to the spinal extensors is initiated
beginning isometric in side lying, and progressed to prone lying.
◼ Isometric flexion and rotational exercises also incorporated to

improve the overall mobility of the spine.
◼ Initiate supported sitting. If no paralysis, progress to supported

standing with spinal brace and maybe with walking aids.
◼ Teaching ADLs by self-effort is a must.
◼ Vigorous training sessions are devoted to standing balance, weight

transfer to supported ambulation. Progress gradually to
independent mode.
Prognosis of recovery
◼ Most patients respond favourably to chemotherapy.
◼ Majority of the cases with neurological defect recover by drugs and

rest, remaining may need curettage or decompression.
◼ The patients who undergo surgery usually show good recovery.
Tuberculosis of the spine (pott disease)

Pott disease which is also known as caries (decay) spine is the
tubercular infection of the vertebrae by M. tuberculosis. Vertebra is the
most common site of tuberculosis accounting for nearly 50% of the
cases; out of which, 60–80% are seen in the lower dorsal and lumbar
spine. This is due to the cancellous nature of bones and body weight
transmission through these areas. The disease is more common in
children between the age group of 5 and 10 years. The bacteria reach
the spine via the haematogenous route from lungs or lymph nodes
and spread via the paravertebral plexus of veins (Batson plexus)
which communicates freely with the visceral plexus of the abdomen.
The disease process may involve the metaphyses or the superior and
inferior end plates of the vertebra; less commonly the anterior portion
of the body is involved. The lesion is common at the contiguous areas
of the two adjacent vertebra including the intervening intervertebral
disc, and adjacent paradiscal area, anterior central or posterior parts of
the vertebral body are rarely involved (Fig. 21-19A and B). The disease
may spread from this primary focus to the adjacent vertebra. Rarely,
the posterior elements of the vertebra, i.e., lamina, spinous process,
etc., may be affected. The disease, as it progresses, destroys the bone
substance of the vertebra and may lead to its collapse due to the
formation of a cavity (Fig. 21-20). The spinal cord in the affected
region may get compressed due to collection of pus or sequestra or
angular deformity of the spine, leading to paraplegia/quadriplegia
(Fig. 21-21). The anterior collapse of the vertebra may cause an
angular (kyphotic) deformity resulting in prominent spinous process
which is known as a ‘gibbus’ (Fig. 21-22).
FIG. 21-19 Vertebral tuberculosis (lesion sites). (A)(B) MRI of the same
case showing destruction of vertebrae and a soft tissue mass encroaching
posteriorly into the spinal canal. (C) MRI lateral view. (D) Cross-sectional
view indicating the location of an active disease on the anterior aspect of
L4-5, invading and destructing the intervertebral disc.
FIG. 21-20 (A and B) Tuberculosis of spine: Note the destruction of

vertebra and loss of intervertebral disc space (arrow).
FIG. 21-21 Vertebral collapse due to Pott spine. DIVD, destruction of the
intervertebral disc; AC, anterior body collapse due to erosion.
FIG. 21-22 Gibbus (arrow) in tuberculosis of spine.
The common site of infection in the spine is the junction of the

lower thoracic and upper lumbar spine. Caries of the cervical as well
as the dorsal vertebrae is also seen.
Clinical features
A patient with tuberculosis of the spine presents with pain and
rigidity in the back. The pain is usually localized over the affected
vertebra(e). However, it may radiate along the spinal nerves. Pain
from a lesion in the dorsal spine may radiate to the front of the chest
and is called ‘girdle pains’.
The presence of an abscess is another important symptom in
tuberculosis of the spine. It may either be associated with pain in the
back or be the presenting symptom. The pus may trickle down, from
the vertebra, along the course of a nerve or vessel and present over the
chest wall or back, or may be seen on radiographs as a ‘paravertebral
shadow’. Since this abscess is generally away from the site of activity,
i.e., the site of the disease, it does not have redness or raised local
temperature and is hence called a ‘cold abscess’.
The patient may also have other features of tuberculosis such as
low-grade fever, loss of appetite, and loss of weight and cough. When
the disease is advanced and has produced compression of the cord
due to pus and/or sequestra, etc., it may result in complete or
incomplete paraplegia.
On examination, marked tenderness is found over the spinous
process of the involved vertebra with occasional girdle pains.
Protective spasm may be present in the muscle groups close to the site
in order to provide natural immobilization. Movement of spinal
flexion produces a sudden increase in pain.
The common deformity due to collapse of the vertebra is that of
kyphosis. However, there may be scoliotic deformity when the disease
affects lateral border of the vertebra.
Pott paraplegia: The onset of paraplegia may occur during the early
active stage of the disease due to cold abscess, necrotic debris and
sequestrae or endarteritis of spinal blood vessels.
Pott paraplegia may also occur at the late stage of the disease due to
reactivation of the disease or due to mechanical stretching of the
spinal cord over the deformity.
Investigations
◼ Radiography: The affected bones are rarefied and are osteoporotic,

with loss of intervertebral space.
◼ At a later stage, the vertebral body collapse occurs.
◼ Cold abscess may present as an enlarged soft tissue shadow.
◼ CT scan: Fine calcification of the paravertebral shadow is diagnostic

besides showing neural compromise.
◼ MRI: It indicates the amount of canal compromise and the status of

soft tissue.
◼ Biopsy: It is the most specific investigation which confirms the

diagnosis of tuberculosis.
Complications
◼ Abscess formation
◼ Paraplegia
Treatment
Conservative
1. Specific drug therapy, nutritious diet and rest are given.
2. Immobilization of the spine is done by bed rest or by plaster jacket

or a brace. Immobilization in prone-lying position is more
advantageous as it further diminishes the compressive force on the
vertebrae, relieves pain and thereby prevents the commonly seen
flexion deformities.
3. Care of the back and bladder should be taken if a patient develops

paraplegia.
As the disease becomes quiescent, the patient may be allowed to sit

up and walk with proper spinal support (e.g., POP jacket or spinal
brace) till the process of repair is consolidated.
Surgical
Indications for surgery
◼ No response to chemotherapy
◼ Setting in and worsening of paraplegia in spite of chemotherapy
The basic principle of surgery in tuberculosis of spine is drainage of

pus and decompression of the cord. This may be achieved by any of
the following surgical operations:
1. Aspiration of the cold abscess
2. Costotransversectomy: Through a posterior approach, a part of the rib

and transverse process of the affected vertebra are removed to drain
out the paravertebral abscess (Fig. 21-23A).
3. Anterolateral decompression: This operation is a further extension of

costotransversectomy. In this operation, in addition to the part of the
rib and transverse process, the pedicle and posterior part of the body
of vertebra are removed (Fig. 21-23B). The spinal cord is, thus,
decompressed from the anterior and lateral aspects. By this operation,
the pus is drained and the infected granulation tissue and sequestra,
etc. are removed. A maximum of three ribs may be excised to gain
access to the lesion.
Postoperatively, the patient is nursed in bed for 3 weeks,

after which he/she may be made to sit up with the support
of a spinal brace.
4. Anterior decompression (Fig. 21-23C): This is a major surgical

undertaking in which the cord is decompressed through an anterior
approach. The diseased vertebra, infective granulation tissue and pus,
etc. are removed through a transthoracic or transabdominal approach.
The gap thus created is bridged by taking bone grafts from ribs and
iliac crests.
After operation, the spine should be supported in a spinal

brace for about 3–4 months till the fusion between the
bodies of the vertebra consolidates.
5. Laminectomy (Fig. 21-23D): It is rarely indicated in the treatment of

tuberculosis of spine. The only indication is a disease of the posterior
elements of the vertebra, such as lamina and spinous process.
FIG. 21-23 (A) Costotransversectomy. The shaded areas are excised. (B)
Anterolateral decompression: the shaded areas of bones are excised. (C)
Anterior debridement and decompression with rib graft. (D) The shaded
areas of bone are excised in laminectomy.
For patients treated conservatively: During the initial stage, it is
directed to prevent the complications arising out of prolonged
immobilization.
1. The patient should be educated on the postural attitudes which may

further compress the cord with its subsequent complications.
2. Gentle full-range active movements are given to cervical spine and

upper and lower extremities.
3. Spinal immobilization reduces the efficiency of the respiratory

system and therefore slow and deep breathing is valuable in
maintaining the vital capacity.
4. Proper positioning of the body is explained with emphasis on

protecting the pressure points to avoid bed sores.
5. Strength of the muscle groups, innervated by the spinal segment of

the affected vertebra, should be checked often and exercised.
After healing of the lesions
1. Gradually progressive exercises are begun to mobilize and

strengthen the spine. Isometrics to the spinal flexors, rotator and side
flexors can be initiated.
2. Costal, diaphragmatic as well as apical breathing should be made

vigorous to improve mobility of the thoracic spine.
3. Begin spinal exercise with extension gradually progressing to

hyperextension in prone lying. Mobility and strengthening of side
flexion, rotation and flexion should be initiated in stages.
4. Mobility should be progressed further as small active free trunk

movements.
5. Sitting up, standing and ambulation to be initiated with spinal

brace.
6. Preventive measures to avoid recurrence need to be explained and

the use of spinal brace to be continued during working.
If the patient develops paraplegia, the treatment proceeds on the

same lines as described for traumatic paraplegia.
For patients treated by surgery: Preoperative assessment of the
neuromusculoskeletal system is done and a special emphasis is put on
the respiratory system by thorough physical examination.
Preoperative training: Postoperative regime of physiotherapy during
the subsequent weeks is explained. The emphasis of training includes
the following:
1. Chest physiotherapy
2. Positioning and movements to avoid immediate postsurgical

complications like thrombosis
3. Methodology of safe bed activities like turning, transfers with corset

or POP jacket
4. Techniques of sitting from lying, getting down from bed, standing

balance and ambulation
5. Mobility and strengthening exercises to the spine
6. Correct principles of ergonomics to be strictly observed

postoperatively and in future
Immediate postoperative phase
◼ The surgical procedure involves resection of the ribs, transverse

processes and sometimes even the affected vertebra with
decompression of the spinal cord. The patient is nursed in bed;
therefore, care should be taken to avoid stresses over the operated
area.
◼ Chest physiotherapy in the form of deep breathing exercises and

diaphragmatic breathing are initiated to avoid chest complications.
Rib resection makes breathing difficult and painful. It needs to be
carefully done by the physiotherapist supporting the rib cage with
both hands.
◼ Thrombosis is prevented by early strong movements of the ankle

and toes. In the presence of paraplegia, passive movements and
positioning of the body and lower extremities are important.
◼ Susceptible pressure points should be carefully inspected and

protected.
◼ Simple resistive movements may be initiated to the arms, avoiding

overhead stretching as this will put extra strain on the spine.
Similarly, strenuous lower extremity exercises like SLR and pelvic
rolling are contraindicated. Paretic but functionally important
muscles should be exercised to improve their strength and
endurance.
During mobilization
Gradual mobilization is carried out only after thoroughly checking
the accurate fitting of the spinal corset.
Log rolling, standing and ambulation are initiated and progressed
as described for spinal fusion.
When the fusion between the bodies of the vertebrae consolidates,
mobilization of the spine can be started. Vigorous strengthening of the
spinal extensors and abdominals can be initiated and progressed.
Ergonomic principles of back care programme are observed strictly
and overstraining activities like carrying weights and bending
forward are discouraged.
The use of corset is gradually weaned off and daily activities are
encouraged.
Patients with paraplegia are managed as described in the section on
spinal injuries.
Broad outline for planning specific physiotherapy approach
depends mainly on the following factors:
1. The site of infection
2. The extent of infection
3. Specific tissue damages to the involved soft tissues and the bone
during the active stage of the disease and residual permanent tissue
damages after the healing phase
4. Method of orthopaedic management

5. Expected prognosis of recovery
◼ When synovium is involved, maintenance of joint ROM

with early mobilization is done.
◼ When the articular cartilage is destroyed, maintaining

functional position of the joint as required for ankylosis or
arthrodesis should be the aim.
◼ When functionally imported joints like elbow, hip and the

knee are involved, prevention of contractures is of primary
importance.
◼ When treated conservatively by POP cast for 6–9 months,

partial weight bearing (PWB) is allowed only after 6
months, and calipers and crutches are discarded only after
about 2 years (in hip joint tuberculosis).
◼ Knee joint is usually prone to develop a deformity due to

the spasm and shortening of hamstrings.
◼ As such, minimizing the forces responsible for the

deformity needs frequent checks and maximal corrective
approach is necessary to maintain functional position of
the involved joint.
Tuberculosis of the hip joint

It is always secondary to the tuberculosis of lungs, lymph nodes or
gastrointestinal tract at the early age of >30 years.
Common sites
◼ Roof of the acetabulum

◼ Femoral capital epiphysis
◼ Femoral neck
◼ Greater trochanter
Clinical features
◼ Localized pain and stiffness – pain is worst at night
◼ Tenderness at the femoral triangle
◼ Gradual development of a flexion deformity – which progresses to

flexion–adduction–internal rotation deformity
◼ Limp is typical with a short stance on a good leg and sudden

forward jump (at the late stage)
◼ Painful limitation of all hip joint movements
Pathology
If not arrested, it progresses in three phases (Table 21-2):
Table 21-2
Progressive Stages of the Disease
Phase Limb Length Attitude of the Limb

Phase I of synovitis Apparent limb lengthening due to Abduction–external rotation to
downward tilting of the pelvis accommodate excessive fluid
Phase II of arthritis Apparent limb shortening due to Flexion–adduction–internal
upward tilt of pelvis rotation
Phase III (late arthritis leading to True shortening of the limb; pelvis Flexion–adduction–internal
erosion and bone destruction) remains tilted upwards rotation deformity
The bacillus infects the bone adjacent to the joint with the formation
of pus and granulation tissue. Multiple cavities may appear in the
femoral head or the acetabular roof. The femoral head or the
acetabulum gets absorbed – causing dislocation of the head into the
ilium – wandering acetabulum (Fig. 21-24).
FIG. 21-24 Tuberculous lesion in the acetabular roof in the left hip (arrow).
Radiographic features
◼ Begins with reduction of the joint space with bony haziness
◼ Destruction of the acetabulum
◼ Dislocation of the acetabulum (like Perthes hip)
Treatment
Conservative
◼ Antituberculosis chemotherapy
◼ Immobilization with below-knee (BK) skin traction to prevent

flexion deformity at the affected hip
Surgery
◼ The surgical procedure depends upon the pathology.
◼ In the early stage of the disease, synovectomy or arthrotomy is

performed.
◼ In the late stage when the joint is ankylosed in an unacceptable

position, osteotomy is performed to put the hip joint in the position
of optimum function.
◼ When the hip is destroyed/ankylosed with loss of function, total hip

replacement may be performed only if the disease is healed
completely.
Girdlestone excisional arthroplasty or osteotomy is performed in

severely affected cases.
During acute stage, follow these points:
◼ Cryotherapy in the acute stage should be altered to superficial

thermotherapy at the later stage if pain persists.
◼ Give vigorous movements to the joints free of immobilization.
◼ Carefully watch the positioning to prevent development of a flexion

contracture at the hip (repetitive isometric gluteus maximus
settings).
◼ Strong static quadriceps settings with a definite pause in fully

extended position should be used.
◼ When the disease is quiescent, assisted active mobilization of the

hip is begun and gradually progressed to achieve maximum ROM of
each hip movement.
◼ Well-protected non–weight-bearing (NWB) is initiated on crutches
gradually progressed to toe-touch weight bearing (TTWB) and PWB
– and ultimately to full weight bearing (FWB).
◼ Gait training to minimize the limp is emphasized.
◼ Postsurgical physiotherapy – as it depends upon the surgical

procedure, follow the relevant discussion for the relevant surgical
procedure.
Tuberculosis of the knee joint

Tuberculosis of the knee joint can start as synovial involvement or
osseous disease. The synovial involvement is more common; the
synovium is inflamed and gets hypertrophied. Subsequently, the
articular cartilage/bone may not get affected. The products of
inflammation may result in destruction of the joint cartilage and
ligaments causing joint subluxation of the joint. Eventually, a triple
deformity develops at the knee joint, which consists of flexion at the
knee joint and posterolateral subluxation and abduction of the leg as
the tibia flexes, slips backwards and rotates externally, respectively
(Fig. 21-25).
FIG. 21-25 Triple deformity of the knee. (A) Note the flexion deformity
along with posterior subluxation of the tibia. (B) External rotation deformity
of the leg.
Clinical features
Tuberculosis of the knee joint is commonly seen in the age group of
10–25 years.
◼ Progressively increasing pain and stiffness with flexion attitude
◼ Inflammatory exudate causes suprapatellar fullness of the fossae on

either side of the patellar tendon
◼ Inability to bear weight on the affected limb and tendency to prefer

using a cane and to hop on the normal leg
◼ Marked tenderness over the joint line
Radiographic investigations
◼ Diffuse osteoporosis of the bones is seen around the knee
◼ Juxta-articular lytic lesions may be seen.
◼ There is erosion of the joint surfaces.
◼ Triple deformity could be evident.
◼ Synovial biopsy and culture LJ medium are confirmatory tests.
Treatment
◼ Antituberculosis chemotherapy with immobilization of the limb in

a BK skin traction
◼ Followed by above-knee cast
Surgery
Synovectomy and joint debridement are performed either by open
surgery or by arthroscopy
In late neglected cases

Arthrodesis of the knee joint is done with the knee in 5° of flexion
using Charnley’s compression device (Fig. 21-26) or an Ilizarov
fixator.
FIG. 21-26 Arthrodesis of knee using Charnley’s compression device.
Supracondylar osteotomy is indicated in marked genu varum or

valgus knees.
◼ Initially the major objective is to prevent the occurrence of triple

deformity by repetitive observation of the limb positioning and
repetitive speedy and sustained isometrics to the quadriceps (of
course, pain-free – maximum), with the limb under skin traction.
◼ Begin early NWB ambulation on crutches.
◼ Initiate gradually progressing mobilization and strengthening

programmes to knee.
◼ Relaxed free active pendular knee flexion–extension should be

initiated in the pain-free range as early as possible.
◼ Progress to PWB, FWB and gait training to prevent limp.
◼ Self-assisted and self-stretch-hold technique is guided and

continued to achieve functional or a normal knee flexion.
Tuberculosis of the ankle joint

Tuberculosis of the ankle joint is rare. The infective process mainly
attacks synovium of the ankle joint initially.
Synovium
◼ Ankle joint remains positioned in plantar flexion.
◼ Pain, swelling and antalgic gait manifest early.
◼ Tuberculosis may proceed to gross destruction of the joint which

may result in anterior dislocation of the ankle joint.
Treatment
ATT BK POP cast may require 12 weeks to heal tuberculosis. BK brace
may be given after 6 months and continued for another 3 months till
the joint becomes pain-free.
◼ During early stage, the limb is immobilized in a BK POP cast as

such.
◼ Vigorous repetitive movements for the toes are given with the limb
in elevation.
◼ Unaffected joints are exercised to maintain their normalcy.
◼ Hip movements of straight leg raise (SLR), straight leg abduction

(SLAB), straight leg adduction (SLADD) and straight leg extension
(SLEXT) provide self-resistive strengthening besides improving
circulation to the lesion.
◼ Crutch walking is initiated as soon as it becomes pain-free.
◼ After 6 months, BK brace with 90 degrees foot drop stops to be

given and continued for longer periods.
◼ FWB should be initiated with the brace when it becomes pain-free.
◼ Proper gait training with emphasis on initial heal strike to facilitate

the stance phase of the gait cycle.
In cases treated by synovectomy and debridement, follow these

points:
◼ Reduce pain by superficial thermotherapy and swelling by limb

elevation and toe movements.
◼ Begin joint mobilization with relaxed, rhythmic exercises.
◼ Educate and guide the patient on efficient self-assisted and self-

stretch-hold mode to improve the joint ROM further.
◼ Begin ambulation with a pair of crutches, progress to a single crutch

to a cane and, finally, to independent walking.
◼ Ensure that there is no limp by providing long duration gait
training guidance.
Note: Standing on the affected leg alone is the key to improve the
gait pattern.
Tuberculosis of the shoulder joint

This tuberculosis is very rare, seen in adults, mostly with a history of
pulmonary tuberculosis which is its peculiarity; it is ‘dry’ without any
joint effusion and hence known as ‘caries sicca’. A common site is
glenoid or head of the humerus.
Clinical features
◼ Pain and stiffness of the shoulder (abduction) are observed.
◼ Cold abscess may appear over deltoid region, biceps or

supraspinous fossa.
◼ Erosion of the joint occurs with osteoporotic appearance.
◼ Osteolytic areas may be present over the humeral head.
Treatment
◼ Chemotherapy
◼ Immobilization:
The shoulder joint is immobilized in functional position of

‘saluting’ 90° of abduction, 30° of flexion and internal
rotation at the shoulder.
After 3 months, a fabricated abduction frame may be given

till healing occurs.
◼ Arthrodesis – rarely undertaken in extreme cases of continued pain,
disease is uncontrolled or recurs.
◼ Longer immobilization poses problem; however, functional use in

immobilized position should be encouraged as early as possible,
with the help of unaffected upper limb.
◼ Strong repetitive isometrics to the deltoid on removal of

immobilization.
Efforts are concentrated to teach patient on the

compensatory methods of using trunk and shoulder girdle
muscles for the functional tasks.
Efforts to mobilize the affected shoulder are continued to

ease functional activities, mainly by self-efforts.
Tuberculosis of wrist joint

◼ Very rare
◼ Tenderness, pain and swelling localized to the wrist
Treatment
◼ Chemotherapy is started.
◼ The wrist joint is immobilized in a POP cast in functional position.
◼ The infection may involve flexor tendons or may manifest as a

carpal tunnel syndrome. Physiotherapy is directed to early
functional rehabilitation using immobilized wrist without causing
pain.
Vigorous finger, thumb and elbow movements should be
performed repetitively to prevent formation of palmar
ganglion or CTS, mainly by guidance to carry out self-
exercising progressive modes.
Tuberculous osteomyelitis
The infective focus involves only the short bones (e.g., calcaneum) or
short long bones like metacarpals or phalanges. The neighbouring
joint structures are unaffected.
The disease progresses by the formation of a cold abscess, sinus,
ulcer and irregular bony cavities with sclerotic margins. The infection
involving phalanges results in localized spindle-shaped swelling of
fingers known as spina ventosa (Fig. 21-27).
FIG. 21-27 Tuberculosis of the proximal phalanx of the little finger. Note
the swelling and a discharging sinus.
Treatment
◼ ATT by chemotherapy
◼ Immobilization
Physiotherapy
◼ Prevent stiffness of the fingers free of infection by full ROM active

movements to the unaffected digits.
◼ Regularly check and take care of the immobilized finger till the
healing of the lesion.
After healing, graduated repetitive self-efforts should be

made to achieve full ROM and function of the involved
finger.
Concentrate on strengthening hand functions using involved

digits.
Pyogenic arthritis (septic arthritis, infective

arthritis, suppurative arthritis)
Pyogenic infections of the joints, i.e., pyogenic (septic) arthritis, are
caused commonly by Staphylococcus and less commonly by
streptococci, pneumococci, gonococci, meningococci, etc. The invasion
of the organisms into the joint may occur through the following
means.
1. Haematogenous: Spreads through the bloodstream from a focus of

infection elsewhere in the body such as tonsils, teeth, respiratory tract
and intestines
2. Secondary to osteomyelitis in the adjacent bone, e.g., septic arthritis

of the hip following osteomyelitis of the upper end of the femur
3. Direct implantation of the bacteria into the joint through a

punctured wound over the joint, infection from a compound fracture
4. Iatrogenic: Following surgical procedures on the joint such as

aspiration, arthrotomy, and arthroscopy
Pathogenesis
There is inflammation of the synovial membrane with excessive
production of joint fluid/pus. The fluid contains a large number of
cells, bacteria and fibrin. There occurs destruction of the articular
cartilage and the underlying bone. When the joint is distended with
pus, pathological dislocation of the joint may occur (Fig. 21-28). The
capsule may get perforated and the pus may escape out forming
sinuses. If untreated, the joint may get disorganized and end up into
fibrous or bony ankylosis.
FIG. 21-28 Pyogenic arthritis of the right hip joint. Note the soft tissue
swelling and the pathological dislocation of the hip (arrow).
Clinical features
Pyogenic arthritis commonly affects infants and young children. It
commences rapidly with high-grade fever, swelling and pain in the
joint. Movements at the affected joint are not allowed by the child due
to pain and muscle spasm.
Investigations
Radiographic investigations
◼ Early radiographs may be normal or may show increased joint

space due to fluid or pus collection.
◼ Later radiographs show destruction of the cartilage, new bone

formation, eventually bony ankylosis or even pathological
dislocation.
◼ Ultrasonography is required especially in children to detect

collection of fluid.
Blood test
◼ Marked elevation of ESR and leucocyte count
◼ Neutrophillic leucocytosis
◼ Blood culture shows growth of causative organism
◼ Aspiration of the joint fluid may show organisms on smear and

culture
Treatment
1. Rest should be given to the joint by traction or splinting or by
plaster of Paris slab till the symptoms subside.
2. Appropriate broad-spectrum antibiotic drugs are started at the

earliest.
3. Arthrotomy: Arthrotomy means opening of the joint. Open drainage

of the pus is carried out as early as possible to prevent permanent
damage to the articular cartilage.
4. Gradual mobilization of the joint should be done.
5. If the disease is advanced with destruction of the articular cartilage,

the joint is immobilized in the optimal position (described earlier) and
allowed to ankylose.
During the active stage of the disease
◼ Check immobilization for comfortable resting position of the

affected joint.
◼ No ROM or strengthening exercises are required.
◼ No attempt should be made to subject the limb to strenuous

activities or weight bearing by assisted ambulation.
During the inactive or quiescent stage
◼ Relaxed rhythmic active movements should be started to the

affected joint by providing the required assistance.
◼ Educate and guide the patient on how to perform self-movements –

beginning with self-assisted mode progressing gradually to active,
self-resistive to self-stretching under the guidance and supervision
of the physiotherapist.
◼ Isometrics should be guided to the functional muscle groups.
◼ Begin special session on assisted functional training tasks and

compensatory methods to facilitate ADLs.
◼ Get necessary orthotic and prosthetic devices early to facilitate

training towards self-sufficiency.
Acute septic arthritis of infancy (tom smith arthritis)

This arthritis is commonly seen in children younger than 1 year when
the head of the femur is cartilaginous and susceptible to complete
destruction by the infection.
It occurs due to the spread of infection from the neighbouring bone
lesion or from a septic umbilicus.
Clinical features
◼ Fever occurs with signs of toxaemia.
◼ Painful hip.
◼ Swelling and tenderness around the hip joint.
◼ Occasionally in late presentations, the child may present only with

a limp when he/she begins to walk.
◼ Positive ‘telescoping’ and limb shortening are indicative of head

destruction.
◼ The condition resembles congenital dislocation of hip (CDH).
Investigations
Radiography
Complete loss of head and neck function with poorly developed
acetabulum is seen. There is marked upriding of the trochanter (Fig.
21-29) with absence of femoral head and neck.
FIG. 21-29 Late sequelae of septic arthritis of infancy of the left hip. Note
the complete destruction of the head and neck of femur; with upriding of the
trochanter.
Significant feature
The hip joint is hypermobile as against stiff and ankylosed joints in
other infective conditions.
Treatment
Drainage of joint in acute stage: In delayed cases, the major problem is
the instability of the hip joint. Reconstructive stabilization procedure
is carried out.
The end result is ambulatory independence with residual limp.
Same as for infective arthritis; but, due to the involvement of the hip
joint, the therapeutic procedures are directed mainly to achieve
independence in ambulation, whether treated by conservative or
surgical approach.
Gonococcal arthritis
Although rare, it may be seen due to inadequate treatment of the
primary gonococcal infection, and may occur a few weeks after the
onset of gonococcal urethritis.
◼ It affects males between 20 and 30 years of age.
◼ It usually affects the knee joints.
◼ Pain, swelling and the usual signs of inflammation are present over
the affected knee joint.
◼ Periarticular oedema of the affected joint develops.
◼ The infection usually settles to the subsynovial layers.
Treatment
◼ Rest and chemotherapy
◼ Aspiration or arthrotomy if required
◼ This management generally follows the same pattern as described
for septic arthritis.
◼ As the knee joint is affected in young adults, the most important

objective is to prevent flexion contracture at the knee joint.
◼ Secondly, maintain or achieve at least functional ROM at the knee,

and maximally strengthen the quadriceps and hamstrings.
Early phase
◼ The supporting splint should be adjusted with maximal positioning
of the knee extensions.
◼ Cryotherapy may be applied for pain relief.
◼ Maintain limb elevation as much as possible to reduce oedema.
Late phase
◼ Removing the splint, the knee is mobilized by relaxed free rhythmic

active movements. Self-performed intermittent exercises are guided
and supervised to achieve maximum knee extension.
◼ Initially, dynamic AK splint with an adjustable kneecap to achieve

maximum knee stretches is ideal.
◼ Gradual assisted ambulation is initiated and progressed to

unsupported ambulation.
◼ Putting maximum emphasis on the heel strike phase of the gait

cycle promotes stretching of the knee to extension, which is so
important in gait training.
Syphilitic infection of bones and joints

This is a rare condition caused by the microorganism Treponema
pallidum. The syphilitic infection may be congenital or acquired. If
mainly affects the elbow or the knee joint. The diagnosis is confirmed
by a positive test for syphilis.
The early congenital variety occurs during infancy as
osteochondritis in the juxtaepiphyseal region.
It is bilaterally symmetrical with swelling due to serous synovitis.
Painless swelling develops with marked effusion (Clutton’s joints). In
the secondary stage, there is transient fleeting polyarthralgia. In the
tertiary stage, there is marked bony changes with disorganization of
joint with neuropathic or Charcot joint.
In acquired syphilis, marked bony changes with periosteal reaction
and a zone of sclerosis like acute osteomyelitis may occur.
◼ Generally, it follows the same pattern of treatment as discussed for
infective arthritis.
◼ As the infection commonly involves the elbow and the knee joints,
earliest opportunity to initiate functional training of the involved
limb is important.
◼ If required, any assistive aid or device should be provided as early

as possible. It indirectly increases the strength and endurance of the
prime movers.
◼ Special sessions to improve the joint ROM of the affected joint

should be concentrated.
Fungal infections of the bone

Patients with immunocompromised status are commonly affected by
fungal infection particularly in the rural setup. A common site of
fungal infection caused by Maduramyces is the foot – it was first
observed in Madurai in South India and therefore is also known as the
‘Madura foot’. Infection that begins as a nodular swelling over the
dorsum or sole of the foot eventually bursts into discharging sinuses.
Clinically, large diffuse swelling with sinuses develops over the
foot. Usually bones are not involved but if secondary function starts,
tarsal bones may be extensively destroyed.
The discharging pus contains black granules and fungus is found to
be present in the microscopic examination.
Treatment
Early stage: Massive doses of penicillin or dapsone are very effective.
Late stage: When the foot is completely disorganized, amputation
may be indicated.
◼ As the common site of infection centres around the ankle and foot,
the foot must be rested in a posterior splint in the midposition of
dorsi and plantar flexion – to prevent tightness or contracture of TA.
◼ Multiple active sinuses may be present, which need to be taken care

of with rest, splint and repetitive toe movements.
◼ Gait training assumes an important role in controlling the tendency

of NWB on the affected limb or using whole foot on the ground
through the gait cycle instead of a normal heel–toe sequence.
◼ In patients treated by amputation, training with prosthesis assumes

highest importance besides strengthening the muscle groups that
primarily stabilize the pelvis and hip during ambulation.
CHAPTER
22
Metabolic bone diseases
OUTLINE
◼ Metabolic disorders of the bone
◼ Osteomalacia
◼ Hyperparathyroidism
◼ Osteoporosis
Although the bone appears as a hard, strong, inactive and resilient

tissue, physiologically the bone is one of the most active tissues of the
body. A process of mineral exchange between the bone reservoir and
the extracellular fluid, regulated by hormones and the local factors,
goes on continuously to maintain the normal level of bone mineral
density (BMD). Any disturbance in this exchange system results in a
metabolic bone disease.
Composition of bone
The inorganic elements mainly minerals – calcium and phosphates
(accounting for 65% of the bone weight) – play a major role in the
process of bone mineralization.
The organic components, which account for about 25% of the bone
weight, are contributed by collagenous matrix, polysaccharides, lipids
and bone cells, while about 10% of the bone’s weight is contributed by
water.
Calcium metabolism
Out of a total amount of 1100 g of calcium in a young adult, 99% of it
is stored in the bones. Therefore, the bone plays an important role in
calcium homeostasis. On average, 507.5 mmol of calcium is exchanged
in and out of the bone daily. Therefore, perfect regulation of calcium
metabolism is essential to maintain the normal level of BMP or bone
metabolism.
Regulation of calcium metabolism
1. Calcitrol or 1,25 dihydroxy cholecalciferol: A steroid hormone formed

from vitamin D by successive hydroxylations in the liver and kidneys
increases the absorption of calcium from the intestine in the event of
hypocalcaemia and reduces when the level of serum calcium is high
(hypercalcaemia).
2. Parathyroid hormone (PTH): The parathormone hormone is secreted

by the parathyroid gland and has the following functions:
(a) To mobilize calcium from the bone
(b) To increase urinary phosphate excretion
(c) To increase reabsorption of calcium in the kidney
3. Calcitonin: This is a hormone secreted by the cells in the thyroid

gland that inhibits bone resorption. When the level of serum calcium
is low, the body tries to raise its level by the following:
(a) Increased absorption of calcium from the intestine
(b) Mobilization of calcium from the bone or
(c) Increased reabsorption of calcium in the kidneys

Thus, regulation of calcium metabolism is most important in the
mineralization of bone as well as its constant maintenance of normal
mineralization.
Role played by bone cells

There is a balanced interaction between the three types of bone cells
contained in the vascular fibrous layer of the periosteum. Each type of
cells play a different role as follows:
◼ Osteocytes: These are parent cells of the matured bone which

remain constant and are unable to divide.
◼ Osteoblasts: These are osteogenic or bone forming cells.
◼ Osteoclasts: With their phagocytic action, these remove excess of

bone cells.
Well-controlled and coordinated intercellular activity of these three

types of cells is essential to maintain the normal level of BMP.
Metabolic disorders of the bone

The following are the common metabolic disorders of the bone:
1. Rickets
2. Osteomalacia
3. Hyperparathyroidism
4. Osteoporosis
5. Fluorosis
Classification of metabolic bone disease
1. Osteopenic (e.g., osteoporosis): There is generalized reduction in

the BMD.
2. Osteosclerotic (e.g., fluorosis): The proportion of bone mass is

increased due to excessive deposition of calcium.
3. Osteomalacic (e.g., nutritional rickets, osteomalacia): The available

organic matrix remains undermineralized; mineralization terminates
at the stage of osteoid formation. The bone remains soft and malleable
instead of becoming tough and hard (Table 22.1).
4. Mixed variety (e.g., hyperparathyroidism): It is a coexisting

combination of osteopenia and osteomalacia.
Table 22-1
Metabolic Bone Disease of Children
Disease Pathology Salient Features Management Physiotherapy

(Orthopaedic)
Infantile Failure of mineralization • General • Prevention of • Educate
rickets of the organic bone matrix debility, deformities by correct the mother
(<4 (osteoid) due to deficiency hypotonia, orthosis (e.g., on
years) of vitamin D and the weakness of Mermaid splint) positioning
disrupted calcium the proximal • Heavy oral dose of and carrying
metabolism muscles with vitamin D (6 lakh the child
irritability units); maintenance • Simple
• Tendency to dose of calcium: 0.5–3 limb
develop g/day, vitamin D: movements
typical 10,000 IU/day • General
rachetic • Treatment of body UV
deformities fractures and exposure
and fractures deformities •
• Strengthening
Radiographic exercise to
investigations the weak but
functionally
important
muscles.
• Guidance
on the use of
orthosis and
ambulation
Nutritional infant rickets

Rickets is a metabolic disorder of children younger than 4 years,
which is caused due to the deficiency of calcium and phosphate. In
rickets, the osteoid formation in the bones is normal but its
mineralization is defective. This results in the formation of uncalcified
bone matrix. There is an arrest of activity of the growth plate cartilage
resulting in retardation of the ossification bone growth. There is
softening of bone which causes deformities of long bones.
Nutritional rickets is the most common type of rickets seen in
developing countries. It is caused by deficiency of vitamin D. Vitamin
D deficiency results from lack of dietary intake and insufficiency of
exposure of the body to sunlight.
The absorption of calcium and phosphate from the intestine is
reduced due to deficiency of vitamin D. A fall in the level of blood
calcium stimulates hypersecretion of PTH. This, in turn, mobilizes
calcium from the bone, which leads to deficient calcium in the bone;
making them soft and easily malleable to pressure or body weight.
This causes typical deformities in the weight-bearing bones.
Clinical Features: The child is inactive/apathetic, has abnormal
dentition and muscle weakness due to loss of muscle power. The
bones may get fractured or deformed due to weakness of bones.
The common deformities in infantile rickets (Fig. 22-1A and B):
1. Skull
(a) Craniotabes: The fontanelle remains open even after the

age of 2 years.
(b) Frontal bossing: There is prominence (bossing) of the

frontal and parietal bones.
2. Chest
(a) Pigeon chest: The thoracic cage is compressed at the

sides, and is raised and elongated anteroposteriorly, the
sternum being prominent and thrusted forward.
(b) Rickety rosary: Bony enlargement occurs at the junction

of the ribs with cartilages. It gives an appearance of a
‘rosary’, hence the name.
(c) Harrison sulcus: It is a transverse groove in the anterior

part of the lower chest, caused by the muscular pull of
the diaphragm.
3. Spine: Kyphosis involving both the thoracic and lumbar spines may
be present which may subsequently lead to lumbar lordosis as the
child starts walking.
4. Abdomen: The abdomen is protuberant and gives a ‘pot-belly’

appearance; largely due to muscular hypotonia.
5. Upper limb: There is widening at the epiphyseal regions of the

wrist (Fig. 22-2).
6. Lower limb: Deformities like coxa vara, genu varum, genu valgum
(Fig. 22-3), bow-legs or forward bowing of tibia and flat feet occur due
to the compressive pressure of the body weight on soft decalcified
bones (Fig. 22-4). Occasionally, a peculiar deformity called wind-swept
deformity of genu valgum on one side and genu varum on the
contralateral knee may be seen (Fig. 22-5).
7. Pelvis: The size of the pelvis may be reduced; the overall growth of
the child is arrested, all resulting in stunted growth or dwarfism.
FIG. 22-1 Typical features of a child with nutritional rickets. (A) Line
diagram. (B) Clinical photograph.
FIG. 22-2 (A) Clinical photograph showing widening of the wrist. (B)
Radiograph showing cupping and widening of the metaphysis of radius on
both sides. (C) Normal radiograph of wrist for comparison.
FIG. 22-3 Genu valgum deformity.

FIG. 22-4 Deformity (bowing) of the tibia and fibula.

FIG. 22-5 Windswept deformity.
Overall, the child looks weak, sick, irritable, morose and stunted in
growth (Fig. 22-1).
Summary Box
Nutritional rickets: clinical features
• Skull • Craniotabes
• Frontal bossing
• Chest • Pigeon chest
• Rickety rosary
• Harrison sulcus
• Pelvis • Reduced size
• Spine • Increased dorsal

kyphosis
• Lumbar lordosis
• • Pot belly
Abdomen
• • Genu valgum/varum
Extremities
• Bowing of bones
• Coxa vara
• Wind-swept
deformity
Investigations
Blood serum chemistry: Serum calcium level may be normal or low

but the serum phosphate is low. Serum alkaline phosphatase is
markedly raised during the active stage of the disease.
Radiography: Radiograph of the wrist shows widening of the
epiphyseal plate with fluffy and irregular edges. There is ‘cupping’
of the metaphysis.
Treatment
Medical treatment: Administration of high doses of vitamin D with

calcium supplements is the mainstay of treatment.
Orthopaedic treatment: Mild deformities in the limbs should be

treated by the use of splints (Mermaid splint). Marked deformities
may need surgical correction by corrective osteotomy.
Fractures are treated by adequate immobilization by plaster of Paris

(POP).
Objectives
◼ Prevention of deformities (at the trunk and limbs)
◼ Maintain or improve muscle functions and ROM
◼ Functional re-education
Early stage: The most important stage when a sick and irritable

child is likely to develop multiple problems such as general debility,
hypotonia, weakness of the proximal limb muscles and the spinal
group of muscles.
1. Therefore, correct education of the mother as regards positioning,

handling and carrying the child and not allowing weight bearing is
important to prevent limb deformities or even fractures.
2. General body exposure to UV rays at subthermal dose of 3300–2900

A is useful.
3. Put the child on the floor in different positions and let it perform
free movements of the limbs and the trunk.
4. Chest physiotherapy helps in improving general health by

increasing oxygen uptake and also in preventing chest infection. As
the general condition improves, child will become more active. For
chest physiotherapy, if active exercises are not possible, passive
(gentle) breathing exercises can be given.
5. Initiate intelligent objective modes of getting purposeful functional

exercises done, offering resistance wherever possible (e.g., kicking a
ball).
6. Initiate controlled resistive proprioceptive neuromuscular

facilitation (PNF) patterns with guided assistance.
7. If a child attempts to stand and walk, provide orthosis or a brace to

prevent limb deformities when there is definite evidence of
calcification.
Late stage: Increase the vigorousity of exercise concentrating

mainly on the functional muscle groups. Continue progression till the
child is functionally self-sufficient and free from deformity.
Following surgery: Surgery is mostly undertaken to treat fractures
and correct deformities by osteotomy.
Appropriate physiotherapeutic measures of progressive
mobilization and strengthening of the related muscle groups
facilitates early return of function.
Though these measures appear easy, tremendous long-standing
effort is needed to successfully manage a child with rickets. The child
may be given supportive orthoses to give ambulatory training, which
could be gradually waned and discarded later.
Other types of rickets
1. Vitamin D resistant rickets: It is due to the deficiency of blood

phosphate (hypophosphataemia). Because of the resistance to vitamin
D, normal bone formation needs high doses of vitamin D.
2. Hypophosphatasia: The calcium deposition in the bone is deficient

although its supply is normal. This occurs due to the inherited lack of
the enzyme alkaline phosphatase.
3. Renal rickets: Inadequate secretion of phosphorus by the kidney

results in fall of phosphate in the blood. This follows malfunctioning
of the kidneys. There is an increased secretion of PTH which mobilizes
calcium from the bones, rendering them soft and liable to deformities.
Osteomalacia
Vitamin D deficiency in adults causes osteomalacia. The patient
presents with generalized bone pains. In fact, it is the adult
counterpart of rickets in children.
Clinical features
The patient presents with bone pain in the legs, low backache and
occasionally with pathological fracture. The patient may have muscle
pains and difficulty in going up the stairs.
Radiographs: In osteomalacia, decalcification radiographically
appears as bands of radiolucency called Looser zone or Milkman fracture
(Fig. 22-6). Milkman fracture is a pseudofracture commonly observed
at the femoral neck, pubis, upper humerus, scapula and ribs.
However, the incidence of pathological fractures is common in this
condition.
FIG. 22-6 ‘Looser zone’ (pseudofracture) in the calcar femoral of the

femoral neck on the left side (arrow).
Investigations
Serum calcium and phosphate may be decreased while the alkaline
phosphatase is elevated.
Biopsy of the bone reveals unmineralized osteoid seams.
Treatment
◼ The deficiency of vitamin D is corrected by diet and by

supplementing vitamin D in high doses.
◼ A fracture in the bone may require open reduction and internal

fixation.
Hyperparathyroidism
Hyperthyroidism is also called by other names such as von
Recklinghausen disease and osteotitis fibrosa cystica. It occurs as a
result of excessive secretion of the PTH, usually as a result of
hyperplasia or adenoma of the parathyroid gland. This hyperactivity
of the parathyroid gland inhibits resorption of phosphates from the
kidney which results in phosphaturia and hypophosphataemia. The
fall in the blood phosphate level results in the corresponding increase
in the level of blood calcium by way of mobilization of calcium from
the bones. The decalcified bones become susceptible to deformities or
pathological fractures. Bone cysts filled with brownish tissue, also
called brown tumours, renal stones or soft tissue calcification may also
occur.
Hyperthyroidism can be of the following types:
1. Primary hyperthyroidism: A hormone secreting adenoma of the

parathyroid gland causes excessive secretion of the PTH resulting in
primary hyperthyroidism.
2. Secondary hyperthyroidism: A kidney disorder or malabsorption

syndrome lowers the serum calcium level, which in turn causes
excessive secretion of the PTH to mobilize calcium from the bones.
This is called secondary hyperthyroidism.
3. Tertiary hyperthyroidism: During the course of secondary

hyperthyroidism, an autonomous nodule develops in the parathyroid
which continues to secrete excessive PTH even after the underlying
cause of excess secretion is cured. It is termed as tertiary
hyperthyroidism.
Clinical features
The onset is insidious with abdominal cramps, nausea, vomiting,
generalized muscular weakness and anorexia due to excessive levels
of calcium in the blood.
The presence of generalized bone pain may be due to osteoporosis;
pathological fractures may also occur through the localized cystic
lesion or due to osteopororsis.
Investigations
There is high serum calcium, low serum phosphorus and high alkaline
phosphatase.
Radiography
◼ There is generalized demineralization of the bones.
◼ There is widening of the medullary canals of long bones, with

thinning of the cortex.
◼ Bone cysts and pathological fractures may be seen.
◼ Subperiosteal resorption of the phalanges (hand) is a classical sign

of hyperparathyroidism.
◼ There is absence of lamina dura of the teeth sockets in the mandible.
Treatment
◼ Surgical removal of the parathyroid tumour stops excessive

production of parathormone and thereby returns the bones to
normalcy.
◼ The main objective is prevention of deformities and fractures by

providing adequate splints, and orthoses. Deformities may need
corrective osteotomy.
Physiotherapy
◼ Physiotherapy is directed towards checking the orthoses, and

educating the patient on safe functional movements, with or without
orthoses. Cane is a must to carry.
◼ Plan exercises to weakened muscles and maintain full ROM of the

joints. Follow therapeutic regime as described for osteotomy when
undertaken.
Osteoporosis
Osteoporosis is acquiring epidemic proportions and is becoming a
major incapacitating metabolic disease all over the globe, because of
its asymptomatic nature in the early stage. According to the World
Health Organization definition, osteoporosis is ‘a systematic skeletal
disease characterized by low bone mass and microarchitectural
deterioration of bone tissue leading to enhanced bone fragility and a
consequent increase in fracture risk’ (Dandy & Edwards, 2014).
Normally, there exists a balance between bone formation and bone
resorption. In osteoporosis, the rate of bone resorption exceeds the
rate of bone formation rendering the bone weak and brittle with loss
of bone mass resulting in the reduction of BMD due to the deficiency
of vitamin D and calcium (deficient calcium absorption from the
intestine→ stimulates parathyroid gland→ PTH resorbs calcium from
the bone→ OSTEOPOROSIS).
Risk factors
Osteoporosis slowly sets in when certain risk factors are present
(Table 22-2). They are of two types.
1. Modifiable – can be reduced with proper early investigations and

care
2. Nonmodifiable – cannot be avoided
Table 22-2
Risk Factors for the Development of Osteoporosis
Modifiable Risk Factors Nonmodifiable Risk Factors

1. Hormonal deficiency of gonadal hormones or oestrogen 1. Family history of osteoporosis
Hypersecretion of adrenocortical hormone 2. History of repetitive fractures
2. Nutritional deficiency (e.g., calcium, phosphorus, proteins) with negligible trauma
3. Diseases of liver, kidney, GI, neoplasia, hyperthyroidism 3. Age above 55
4. Long-duration immobilization due to the loss of stress and 4. Small body frame
strain required to maintain BMD
5. Highly sedentary lifestyle
6. Postmenopausal state
Abbreviation: BMD, bone mineral density; GI, gastrointestinal system.

Classification of osteoporosis (table 22-3)
Osteoporosis is classified as follows:
1. Primary osteoporosis, which is further divided into the following:
(a) Type 1 – Postosteoporosis
(b) Type 2 – Senile osteoporosis
2. Secondary osteoporosis
Table 22-3
Osteoporosis at a Glance
Characteristics Senile Osteoporosis Postmenopausal Osteoporosis

• Pathogenesis • ↑ Osteoblastic activity • ↑ Osteoclastic activity
• Type of bone loss • Both cortical and trabecular short • Largely trabecular
• Rate of bone loss duration • Long duration
• BMD • Normal or low • 2 SD below normal level
• Clinical signs • Deep spinal pain and tenderness • Deep pain
with development of dorsal hump • Stress fractures at vertebrae,
• Vertebral compression fracture distal radius, hip (intracapsular)
• Fracture of distal radius, hip or • Loss of teeth
proximal tibia
Laboratory • Normal • Increased
investigations • Increased • Decreased
Urine calcium PTH • Primarily reduced due to • Secondarily reduced due to
function decreased response reduced PTH
Renal conversion of
35 (OH)2 0–1.25
(OH) D
Abbreviation: BMD, bone mineral density; PTH, parathyroid hormone.
Primary osteoporosis
Postmenopausal osteoporosis occurs due to the deficiency in the
secretion of oestrogen hormone after menopause.
Senile osteoporosis occurs in the elderly with a female
preponderance (female: male ratio 2:1).
Primary osteoporosis may be idiopathic.
Secondary osteoporosis
Secondary osteoporosis develops at any age, with equal distribution
among males and females. It is usually secondary to some underlying
disease such as endocrine disorders, malignancy or due to the
prolonged intake of certain medicines, e.g., steroids and antiepileptic
drugs.
Clinical features
In the early stage, the low and asymptomatic progress of the disease
goes unnoticed.
◼ However, in the late stage, the patient develops pain in the

dorsolumbar spine.
◼ There is development of a kyphotic hump deformity due to

osteoporosis collapse of multiple vertebrae and loss of vertebral
height.
◼ There is generalized rarefaction of bone, making them susceptible

to fractures after a trivial injury/fall.
◼ There is early fatigue.
Diagnosis
Several methods are available:
◼ Radiography – loss of bone density, presence of a ballooning of the

IV disc (Fig. 22-7) or compression fracture of the body of vertebra
◼ Dual energy X-ray absorptiometry (Dexa-scan) – for progressive

investigation of risk
◼ MRI scan – details patterns of bone trabeculae
◼ Neutron activation analysis – to measure the activity of calcium in

bone
FIG. 22-7 Senile osteoporosis. Radiograph (lateral view) of the spine

indicating loss of bone density in the bodies of vertebrae with ballooning
(saucerization) of the intervertebral spaces.
BMD evaluation
An important test to evaluate the mineral density of a bone or overall
skeleton:
1. Peripheral ultrasonography graphically analyses the BMD level.
2. WHO (1994) standardized a procedure to assess the BMD level

based on comparison of the BMD level with standard BMD value in
normal young adults.
WHO Classification of BMD by T-Score (i.e., a Threshold for

Fracture Risk and Treatment)
◼ Normal bone – T-score not less than 1.00 (1 SD) below the level of
normal value of BMD of young healthy adult
◼ Osteopenia (early osteoporosis): T-score between 1.0 and 2.5 (SD)
◼ Osteoporosis: T-score of >2.5 (SD)
◼ Severe osteoporosis: T-score lower than 2.5 with a history of

prevalent repetitive fractures
Treatment
◼ Regular check-up of the level of BMD after 50–55 years or

menopause in women
◼ Good nutritious diet to control malnutrition
◼ Additional calcium intake to curb bone loss (1000–1500 mg/daily)
◼ Vitamin D to facilitate calcium absorption from the gut
◼ Hormone replacement therapy (HRT) in postmenopausal women
◼ Selective oestrogen receptor modulation (SERM) – raloxifene is a

drug of choice
◼ Calcitonin secreted by thyroid gland – improves bone mass,
preventing fracture
◼ Osteophos (containing sodium alendronate)
Associated symptoms
1. Backache (kyphosis) is treated by Taylor brace or anterosuperior

hypertension brace (ASHE brace)
2. Fractures of the femoral neck or distal radius may require surgical

intervention with intramedullary nails or plates. Osteoporotic (thin)
bones usually do not offer a good bone stock for rigid fixation by
plates and screws. The implants usually cut through easily requiring
re-surgery. However, newer implants such as locking compression
plates (LCPs) offer a better stability to the fixation (Fig. 22-8).
FIG. 22-8 Locking compression plates offer a better stability to the fixation.
Vertebrae
◼ Usually have compression fracture of the body, leading to collapse

of the vertebra.
◼ Effectively treated by a new technique called vertebroplasty where
bone cement is injected into the body of the vertebra to restore the
vertebral height (Fig. 22-9).
◼ Kyphoplasty: In this procedure, the height of a collapsed

osteoporotic vertebra is restored by inserting a balloon,
percutaneously, in the affected vertebra. The balloon is then inflated
by injecting cement into it (Fig. 22-10). Kyphoplasty is a relatively
safe/better procedure than vertebroplasty. Since in kyphoplasty, the
cement is injected into a balloon, the chances of cement leaking
out/spilling into the vertebral canal are much less, making it a
relatively safe procedure.
FIG. 22-9 Vertebroplasty. (N) Needle to inject bone cement, to fill the
spaces in the bone, due to the compression fracture of the body of D-11
vertebra.
FIG. 22-10 Kyphoplasty. (A) X-ray shows collapse of L3 vertebra, the

vertical height of the vertebra is much reduced. (B) MRI of the same
patient. (C) Bone cement in a balloon injected into the vertebra restoring its
vertical height considerably.
Physiotherapy plays a significant role, in both primary and secondary
prevention.
For primary prevention: There are two different systems of
exercise to be incorporated depending upon patient’s age and
physical fitness. This is done only after testing exercise tolerance and
cardiac clearance.
1. A system of structured exercise is ideal for young adults and

middle age group individuals and physically and medically fit elderly
people (Table 22-4).
2. Lifestyle exercise (get habituated to active lifestyle)
(a) It simply means not to avoid a single opportunity to

perform some physical activity by increasing the speed,
frequency and vigorousity of each physical activity one
performs in a daily routine. It should be directed
specially to overload the susceptible musculoskeletal
complexes (e.g., frequent standing up and sitting, spot
marching or double ups during short breaks while
watching TV, purposely parking vehicle at a distance
from the place of working, not using a lift, instead do
faster stair climbing)
(b) Those who are unable to perform vigorous exercise

should try and increase the duration of specific exercise
at a slower speed.
Table 22-4
Exercise Prescription of Structured Exercise Programme
Exercise Specificity
Type Aerobics (dynamic) exercise with emphasis on trunk and lower limbs involving impact
and loading of the body weight with the floor
mode
Intensity To begin with 40–60% of the HRmax (heart rate maximum) gradually progressing to 70–
75% of HRmax
In elderly people, to 60–65% or more if feasible
Duration Begin with 10–15 min of stimulus phase of exercise working up to 30 min or more
Frequency At least thrice a week
Rate In each exercise, the rate of repetition per minute varies from 40 to 100
Secondary Prevention: Once the diagnosis is confirmed,
physiotherapy is directed to prevent or control the expected
complications:
1. Tendency to develop postural deformity of kyphosis leading to

vertebral compression fracture – use of Taylor brace or ASHE brace
anterosuperior, postural guidance in lying in bed or sitting and trying
to perform only hyperextension exercises, or longer periods of lying
prone.
2. Incidences of hip fractures are controlled by applying the methods

of safe ambulation (e.g., using cane, gait training, nonslippery floors)
and exercises to improve strength and endurance of functionally
important muscle group around the hip (e.g., hip extensors and
abductors).
3. Incidences of Colles fracture: Incidences happen during repetitive

performance of resistive or strong isometrics to the wrist flexors and
the extensors, forearm pronators and the supinators.
4. Avoid hurry, be watchful always.
5. Get BMD level checked at regular intervals.
6. Be regular on calcium and vitamin D supplements and HRT in

postmenopausal women.
Characteristics of some common metabolic diseases are

depicted in Table 22-5.
Table 22-5
Metabolic Bone Diseases of Adults
Disease Pathology Salient Management Physiotherapy

Features (Orthopaedic)
Adult Failure of • Bony • Calcium and • General body exercise
rickets, mineralization tenderness vitamin D to maintain strength and
osteomalacia with excessive and pain supplements mobility
accumulation of • Hip joint • Preventive • Careful watch on
osteoid due to and back measures for possible deformities
abnormal vitamin spinal spinal • Provide orthosis or aid
D and phosphorus deformities deformities to prevent fractures at the
metabolism or • Treatment of spine and hip, e.g., NWB
pathological hip and spinal ambulation
fractures fractures
•
Radiographic
investigations
Osteoporosis • Progressive • Gradual • BMD • Exercise training by
diffuse reduction development evaluation • Structured exercise or
in the mineral of a dorsal • High vitamin lifestyle exercise
density of bones hump D, protein and conditioning of the
(BMD) (kyphosis) calcium muscle groups guarding
• Loss of bone • The supplements – the areas susceptible for
mass and bone common in senile fractures (e.g., wrist,
proteins results in sites of variety spine and hip)
fractures with a pathological • Oestrogen • Impact weight-bearing
mild trauma fractures: supplementation exercises are ideal to
Vertebral (HRT), improve BMD (e.g.,
compression calcitonin or jogging, running spot
fractures bisphosphonates marching, jumping
• Fractures in besides spinal loading
at the neck postmenopausal exercises and isometrics
femur osteoporosis to the wrist)
• Fractures • Treatment of
at the wrist fractures when
• they occur
Radiographic • Use of bone
investigations cement to
• BMD compensate for
investigation the bone loss
(vertebroplasty)
Abbreviation: NWB, nonweight-bearing.
CHAPTER
23
Bone tumours
OUTLINE
◼ Tumours
◼ Classification of bone tumours
◼ Benign bone tumours
◼ Malignant bone tumours
◼ Primary bone tumours
◼ Secondary bone tumours (bone metastases)
Tumours
A tumour is a swelling due to excessive neoplasia or new growth of a
tissue. It may affect any tissue cell in the body.
Bone tumours are of two types:
1. Benign (Fig. 23-1)
2. Malignant (Fig. 23-2)

FIG. 23-1 Benign tumours. (A) ECH; ecchondroma, ENC; enchondroma.

(B) OC; osteochondroma. (C) GCT; giant cell tumour (osteoclastoma).
FIG. 23-2 Malignant tumours of bone. (A) Osteosarcoma. (B) Ewing

tumour. (C) Metastatic tumours.
The distinguishing characteristics of both these types of tumours are
classified in Table 23-1.
Table 23-1
Distinguishing Characteristics of Benign and Malignant Bone Tumours
Characteristics Benign Malignant

Onset Insidious with slow Acute with rapid growth rate
growth rate
Fever, weight Nil Associated with severe unremitting pain and disability
loss, anorexia or
few
Lesion Well circumscribed and Not well circumscribed and invading
noninvading
Spread of Do not metastasize Metastasize
tumour
Radiographic Confined to the involved Has ill-defined borders, mottled appearance, the bony cortex
lesion bone only may be broken with loss of continuity of the involved bone
(pathological fracture)
Prognosis Generally good; can be Generally poor and depends upon the nature and extent of the
cured with timely and tumour; could be fatal
correct therapy
In this chapter, the classification of bone tumours and the basic

principles of management are discussed. It is outside the scope of this
book to discuss these tumours in detail.
Bone tumours
Bone tumours could be primary, when they arise from the bone itself,
and occur mainly in young adults. They are highly malignant and
may be fatal.
Secondary bone tumours occur as a result of metastases usually
from the carcinoma of breast, kidney, lung, prostate or thyroid.
The classification of bone tumours is depicted in Table 23-2.
Table 23-2
Classification of Bone Tumours
1. Bone-forming tumours
Benign
• Osteoma
• Osteoid osteoma
• Osteoblastoma
Malignant
• Osteosarcoma
2. Cartilage-forming tumours
Benign
• Chondroma
• Osteochondroma
• Chondroblastoma
• Chondromyxoid fibroma
Malignant
• Chondrosarcoma
• Osteosarcoma
3. Giant cell tumours
• Osteoclastoma
4. Marrow tumours
• Ewing tumour
• Myeloma
• Malignant lymphoma of
bone
5. Vascular tumours
Benign
• Haemangioma
• Lymphangioma
• Glomous tumour
Malignant
• Angiosarcoma
• Malignant
haemangiopericytoma
6. Connective tissue tumours
Benign
• Lipoma
• Fibroma
Malignant
• Liposarcoma
• Fibrosarcoma
7. Tumour-like lesions
• Bone cysts
• Fibrous dysplasia
• Eosinophilic granuloma
8. Secondaries in bone
Diagnosis
Diagnosis of bone tumours is based on the following steps:
◼ History of medical and subjective characters.
◼ Physical examination – size, shape and skin.
◼ When close to a joint, active and passive ROM of adjacent joints.

◼ When close to a peripheral nerve or vertebrae, presence of any
neural or vascular compressions must be examined.
Laboratory investigations
◼ Very high levels of WBC count, serum alkaline phosphatase, serum

acid phosphatase and ESR with reduced level of haemoglobin.
◼ Radiograph: AP and lateral views indicate abnormality, e.g.,

sclerosis or increased bone density, destruction of bone, lytic lesions
and pathological fractures. Chest radiograph is essential to rule out
secondaries.
◼ CT scan: To detect metastasis at any other skeletal site.
◼ MRI scan (Fig. 23-3): To know the boundaries of the tumour spread
to the bones as well as the soft tissues.
◼ Open biopsy or close needle biopsy confirms the diagnosis.
◼ According to the location of the tumour, the following

investigations may be necessary:
Intravenous pyelography (IVP), barium studies, thyroid scan

or arteriography.
FIG. 23-3 (A) MRI scan of spine showing a metastatic lesion in the lower
lumbar vertebra, and (B) PET scan of the same patient showing metastatic
cancer. It shows involvement of multiple vertebrae, in addition to the one
seen in MRI.
Benign bone tumours

Benign tumours may overgrow and cause pressure syndromes, e.g.,
pain and weakness due to interference in muscle action. It may
weaken and fracture the affected bone (pathological fracture) or may
even progress to malignancy (Tables 23-3 and 23-4).
FIG. 23-4 (A) Diagrammatic representation of osteoid osteoma. (B)

Osteoid osteoma as seen on radiograph.
Table 23-3
Essential Features and Management of Benign Bone Tumours
Tumour (Age Common Radiographic

Origin Location Clinical Features Treatment
in Years) Sites Investigations
Osteoid Enchondral bone Diaphysis Tibia, • Localized A zone of • Usually
osteoma (10– of long and tenderness, sclerosis rest and
25 years) bones posterior vague which is salicylates
(Fig. 23-4) elements intermittent surrounding a • Excision
of pain worst at radiolucent of the
vertebrae night but nucleus – tumour
relieved nidus along with
completely nidus
with
salicylates
• Back pain
when
vertebrae are
involved
Osteoma(30– Bones Flat Face or • Pain-free Medulla and • Excision
40 years) bones skull bony lump the cortex of of osteoma
near the end outgrown if the size
of long bones tumour are in is bigger
• Bony continuity and causes
deformity with the hindrance
may occur parent bone or for
(diaphyseal cosmetic
aclasis) reasons
Haemangioma Vascular • • May be There is loss Radiotherapy
(young- (haemangiomatous Skull asymptomatic of horizontal
adults) (Fig. origin) • or develop striations with
23-5) Vertebrae persistent appearance of
pain vertical
• Vertebral striations
involvement
may result in
cord
compression
Table 23-4
Essential Features and Management of Benign Tumours which Tend to Develop into
Malignancy
Radiographic and
Tumour
Origin Site Clinical Features Laboratory Treatment
(Common Age)
Investigations
Enchondroma Cartilaginous • • Small-sized • Cystic lobulated • Single
(15–50 years) Metaphysis slow tumour could be small
(Fig. 23-1A) of short progressing contained in bone tumour –
long swelling with (enchondroma), or curettage
bones, or without perforating the bony • Large
e.g., pain outline tumour –
• • Lobulated (eccondroma) excision
Phalanges enlargement • Stippling or with
• at the tumour calcification may be removal of
Metacarpals site seen capsule
• Rarely • Thin and • When the
humerus, expanded long bones
pelvis cortex are involved
– radical
resection
with bone
grafting
Osteoclastoma Bone • • Pain, • Cystic lesion with • Curettage
(giant cell Epiphysis tenderness, trabeculae which and bone
tumour) (15–35 of long brownish appear like ‘soap grafting
years) (Fig. 23- bones swelling bubbles’ • Excision
1C) • lower containing • Erosion of with
end blood-filled epiphyseal line reconstruction
femur cavities. appears with the •
• upper • May have development of Arthrodesis
end ‘egg shell malignancy with turn-o-
tibia crackling’ • Histopathology– plasty
• lower due to fragile multinucleated giant •
end cortex cells in fibrous Amputation
radius • stroma preceded by
pathological • Spindle cells radiotherapy
fractures
Osteochondroma Cartilage • • Early stage • Pedunculated • Surgical
(adolescents) Metaphysis asymptomatic outgrowth of bone excision of
M>F of long appearance in continuation with the tumour
(Fig. 23-1B) bones of pain, cortex and
• swelling and medullary portions,
Shoulder other with cartilaginous
• Elbow complications cap
• Hip, • May • Tumour grows in
knee, compress on an opposite
ankle bursae direction to the
neurovascular growing end of the
structures, or bone
result in stiff
joints
Chodroblastoma Cartilaginous • Long • Pain, • Thinning of cortex • Small
(10–20 years) highly bones swelling and • Lytic lesion tumour –
(Fig. 23-6) cellular and • joint effusion surrounded by curettage +
vascular Epiphysis • Tumour is sclerosis bone
close to positioned • Multiple areas of grafting
the eccentrically calcification within • Large
growth to bone the tumour with tumour –
plate mottled appearance excision +
• bone
Femur grafting
around
knee is
commonly
involved
Such benign tumours need surgical treatment like (a) intralesional

excision or (b) curettage.
1. Intralesional excision could be a ‘wide excision’ where a tumour

mass is excised with a rim of normal tissue around it.
2. The procedure of curettage is always followed either by

cryotherapy or the use of bone cement to kill the leftover tumour cells
following curettage.
Prognosis: Generally good, however, some benign tumours may

turn malignant.
FIG. 23-5 Haemangioma: vertical striations.

FIG. 23-6 Chondrosarcoma of the lower end of the femur.

FIG. 23-7 Multiple myeloma. (A) Multiple punched-out lesions in the skull
are typically seen, and (B) multiple lytic lesions are also seen in the pelvis
and femur.
Malignant bone tumours

These tumours present as pain and swelling of the affected area (Table
23-5).
Table 23-5
Essential Features and Management of Malignant Bone Tumours
Tumour
Common Clinical Radiographic, Laboratory
(Age of Origin Treatment
Sites Features Investigations
Onset)
Multiple • Plasma Flat • Early • Skull – punctuated •
myeloma cells in bones phase– out lytic lesions Preventive
(40–60 bone • Skull asymptomatic • Vertebrae – wedge measures
years) (Fig. marrow • Ribs • Later – collapse for
23-7) • Solitary • bouts of • Pathological pathological
lesion Lumbar sharp pain, fractures fractures
(plasma spine swelling at • Ectopic bone •
cytoma) • Sacrum the tumour formation – kidneys, Chemotherapy
• Multiple • Pelvis site lungs; • Surgery
myeloma • Bone Histopathology: ↓Hb, (suitable)
marrow is ↑ESR, total proteins, •
replaced by serum calcium; bone Decompressive
plasma cells biopsy – gamma laminectomy
– causing globulin, features of • IM
anaemia, multiple myeloma; fixation for
haemorrhages urine – Bence Jones pathological
• Late signs proteins fracture
of renal • Palliative
failure due –
to blockade radiotherapy
by protein when the
casts tumour is
(myeloma – widely
kidney) spread and
is
nonoperative
Ewing • Bone Diaphysis • • Rarefaction, lytic • Tumour is
sarcoma • of long Intermittent lesions in medullary highly
affecting Reticulum bones vague pain region radiosensitive
mainly cells lining • Femur worst at • Bone destruction and • Chemo +
children (4– the • Tibia night subperiosteal new radiotherapy
25 years) marrow • Fibula • Redness bone formation • Surgery
(Fig. 23-2B) spaces • of skin, • Expansion of tumour • Debulking
Numerous dilated raises periosteum of tumour
• Rarely veins which appears like by surgery
flat bones • Tumour ‘onion peel’. • Limb
spreads to Histopathology: sheets of preservation
medullary round cells surgery
cavity •
• Metastasis Irradiation
to skull, followed by
vertebrae resection or
through the amputation
blood,
lymphatics
• Periods of
exacerbations
and
remissions
Primary – • Bone • • • Tumour site – •
osteosarcoma tissue Initiates Intermittent sclerotic lesion Chemotherapy
(10–25 from at night pain, • Laying down of •
years)(Fig. multipotent epiphysis tenderness bone along the blood Radiotherapy
23-2A) mesenchymal but, after and vessels gives an –
cells fusion of swelling appearance of ‘sun preoperative
• Tumour epiphysis • Egg shell rays’ mega-
could be occupies cracking • Codman’s triangle is voltage
fibroblastic metaphysis may be present therapy
osteoblastic • Long present • Pathological (4000–6000
or bones • Dilated fractures may occur rad)
chondroblastic • Lower veins •
ends of • Fatigue, Immunotherapy
femur anaemic – allogenic
• Upper metastasis sarcoma
end of to lungs or tumour cell
tibia or lymphatics vaccine
humerus through the • BCG
or lower blood or vaccine can
end of lymphatics be used
radius • Early
radical
ablation
Local tenderness, warmth over the skin, with visible dilated veins,
severe pain and joint stiffness may be present. There is sudden
appearance and increase of swelling as the growth of the tumour is
rapid. Malignant tumours very often metastasize to lungs.
Primary bone tumours

The diagnosis is confirmed by biopsy. Once the malignancy is
confirmed, the treatment is started immediately.
Treatment
The treatment could be either single or a combination of the following:
1. Surgical excision or amputation
2. Radiotherapy
3. Chemotherapy (Table 23-6)
Table 23-6
Surgical and Nonsurgical Methods of Treating Malignant Bone Tumours
Surgical Methods Nonsurgical
Methods
• Curettage • Adjunctive
therapy
• Excision • Radiotherapy
• Excision with reconstruction • Chemotherapy
• Limb salvage procedures • Hormone
• Resection arthrodesis therapy
• Turn-o-plasty •
• Joint arthroplasty – either by allograft or metallic Immunotherapy
prosthesis
• Amputation
Surgical excision or amputation

The treatment specifically depends upon the nature of involvement.
Complete surgical excision of the tumour is the treatment of choice if
there are no metastases.
Limb salvage procedures: The current trend is to employ limb
salvage procedures (any of the following) after complete excision of
the tumour.
1. Resection arthrodesis: The tumour is excised and the gap, thus

created, is bridged with the help of fibular and cancellous bone
grafting (Fig. 23-8). If this procedure is done for a tumour at the lower
end of the femur or upper end of the tibia, then the knee joint loses its
movements.
2. Turn-o-plasty: This procedure is usually done for a tumour at the

lower end of the femur or upper end of the tibia. After excision of the
tumour, other intact bone is split into two halves and the bone
required to bridge the gap is turned upside down and fixed to the
remaining stump of the bone (Fig. 23-9).
3. Arthroplasty: After excision of the tumour, the affected joint is

reconstructed using either an allograft or a metallic prosthesis
(artificial joint), custom-made for individual patients (Fig. 23-10). If
limb salvage is not feasible, amputation of the affected limb is
undertaken, in highly invasive tumours.
4. Amputation: The amputation can be palliative or definitive. Palliative

amputation is performed, when inoperable metastases are present, to
relieve pain or to prevent bleeding from a fungating tumour.
FIG. 23-8 Resection arthrodesis by fibular grafting. (A) Osteosarcoma

proximal tibia in a 14-year-old boy, and (B) postoperative X-ray of the same
patient treated by resection arthrodesis.
FIG. 23-9 Turn-o-plasty. (A) Preoperative radiograph of the knee and leg
in a 16-year-old boy with osteosarcoma of the upper tibia, and (B)
postoperative radiograph of the same patient treated by turn-o-plasty,
showing good union.
FIG. 23-10 Pre- and postoperative X-rays of osteosarcoma of the distal

end of the femur in an 18-year-old boy treated by resection of tumour and
endoprosthetic replacement.
FIG. 23-11 Aneurysmal bone cyst in humerus.

FIG. 23-12 Simple unicameral bone cyst in a child.
Single metastases, e.g., in lungs may be excised. As a protective

measure, radiotherapy may follow amputation even if there are no
metastases. In the presence of metastases, usually radiotherapy is the
treatment of choice.
Definitive amputation is done when complete removal of the tumour
is possible and there are no metastases. The tumour is excised along
with a safe margin of normal tissues/adjacent compartment to prevent
recurrence (Table 23-6).
The level of amputation is divided by the site or the location of the
tumour (Table 23-7).
Table 23-7
Site of Tumour and the Level of Amputation
Site of Tumour Level of Amputation

• Upper end of • Four-quarter
humerus amputation
• Upper end of • At an early stage
femur • Hip disarticulation
• At late stage
• Hindquarter
amputation
• Lower end of • At an early stage
femur • Mid-thigh
amputation
• At late stage
• Hip disarticulation
• Upper end of tibia • Mid-thigh
amputation
Radiotherapy
Radiotherapy helps in the shrinkage of the tumour mass. It, many a
times, offers relief in pain. It is one of the effective palliative measures
in reducing the residual mass of tumour either before surgery or in
cases where surgery cannot be performed.
Chemotherapy
Chemotherapy is helpful when used in combination with
radiotherapy and/or surgery. The drugs (cytotoxic drugs) used in
chemotherapy are of various types and are used in a combination of
2–4 drugs. The drugs commonly used in the treatment of malignant
bone tumours are cyclophosphamide, adriamycin, vincristine,
nitrogen mustard, methotrexate and actinomycin-D.
However, the cytotoxic drugs are extremely toxic and produce
marked side effects in patients.
Prognosis
The prognosis of malignant bone tumours is generally poor; however,
a combination of surgery and chemotherapy has improved the
prognosis remarkably, over the years. The 5-year survival rate after
the combination treatment has been reported as 70%.
Secondary bone tumours (bone metastases)

Secondary bone tumours are metastatic deposits from primary
tumours in some other tissues. The carcinoma of breast, kidney, lung,
thyroid and prostate usually metastasize in the bone during or after
middle age. The common sites of metastatic deposits are vertebrae,
pelvis, ribs, proximal humerus or proximal femur.
Routes of metastasis
Through
◼ Blood
◼ Direct spread
◼ Lymphatic spread
Treatment
The treatment modalities will vary by the severity of the stages and
the methodology of the management of the disease (Table 23-8).
Table 23-8
Essential Features and Management of Pseudo-Tumours or Resorptive Bone Tumours
Clinical
Pseudo-Tumour Origin Common Site Radiographic Features Treatment
Features
Aneurysmal Bone Ends of long bones Localized Centrally placed •
bone cyst (10–40 (metaphysis) pain and radiolucent areas in the Curettage
years) M>F (Fig. swelling metaphyseal ends of and bone
23-11) long bones grafting
• Excision
of the
lesion
Simple Localized Metaphyseal region Asymptomatic Well-defined centrally • May
unicameral bone cystic of the long bones till placed lytic area. Break heal
cyst (children bone (e.g., proximal pathological may occur in the cortex spontaneously
and adolescents) lesion humerus) (Fig. 23-5) fracture resulting in a •
M>F (Fig. 23-12) close to a growth occurs pathological fracture Aspiration
plate (Fig. 23-5) of a cyst,
inject
methyl
prednisolone
•
Curettage
and bone
grafting in
a large
cyst
Drugs
◼ Analgesic drugs to control pain. Hormonal drugs in carcinoma of

breast and prostate.
◼ Chemotherapy: To control primary focus and the spread.
◼ Radiotherapy: To obtain shrinkage of tumour.
Surgery
It involves decompression when the tumour mass compresses upon
the spinal cord. Division of the sensory nerves, nerve roots or nerve
tracts may be necessary to control severe pain. If the tumour fungates,
its excision or amputation may be necessary. Pathological fractures
due to secondary metastases of the long bones may need internal
fixation.
Physiotherapeutic management (table 23-9)

Objective: The main objective is to use all the necessary
physiotherapeutic measures to maintain and promote the optimal
function of the affected part in particular and the whole body in
general.
Table 23-9
General Principles of Physiotherapy
Early stage
• Keep up the morale of patients who are highly • Counselling
depressed • Emphasizing moving unaffected body parts
(ability) and maximizing functional activities
• Diversion procedures as per aptitude (e.g.,
reading and playing cards)
• Reduction of pain • Pain-free relaxed rhythmic movements
• Cryotherapy if accepted well
• Medications
• Reduction of oedema • Lymphoedema which persists longer and is
difficult to control; it is treated by
• Relaxed full ROM free active movements to
distal most joints
• Limb elevation
• Improvement in muscle function and joint • Intermittent compression
flexibility • Gentle effleurage
• Simple full ROM or maximum ROM exercise,
progressing (PRE) in a graduated manner
Late stage
• Improving restoring function in complicated • Early initiation of assistive functional
cases involving limbs or major surgical activities, to provide optimal functional
procedures independence
• Guidance and training in the use of orthosis
or prosthesis for functional self-sufficiency
Definitive physiotherapy measures cannot be specified due to the

complexities of the disease and remarkable individual variations in
the disease process and the medical management.
Some broad outlines
◼ Psychological upgrading: The patient usually suffers from a great

psychological trauma resulting in depression, anxiety and loss of
self-confidence. Along with appropriate comforting
physiotherapeutic measures, the physiotherapist has to provide all
possible encouragement through counselling along with emphasis
on the patient’s abilities rather than inabilities.
◼ Worrying over the disease and remaining sedentary happens to be

a natural human tendency in any sickness. Longer periods of
personal attention during the treatment right from the initial stage,
use of touch and support provide adequate assistance in winning
the confidence of a patient to perform difficult physical activities.
Assessment: Routine procedures of assessment should be carefully

employed to assess the specific problems; they should be recorded as
initial evaluation, along with other investigations and planned
medical treatment.
The whole process of physiotherapy should be drawn in gradually
progressive steps.
Contraindications
◼ Not to use any physiotherapeutic modality which results in increase
in circulation (especially early stage).
◼ No thermotherapy should form part of therapy.
◼ Deep heating modalities close to the site of lesion are totally

contraindicated.
Early stage
Measures to control oedema: When lymphoedema is present, it is
difficult to control and takes long time to reduce.
Measures to control pain
◼ Joint movements: Encourage and promote ROM by slow-relaxed-

brief active movements.
◼ Muscular weakness: Repetitive movements are done with slow

speed for a brief period. Controlled isometrics are ideal to improve
muscular strength.
◼ Functional activities: Nonexerting performance of the functional

activities of daily routine. They may vary from sitting up and
transfers to ambulation.
Late stage
◼ If surgery is performed, depending upon the type and the extent of

surgery, all postsurgical physiotherapeutic techniques described,
under each heading should be employed.
◼ The procedures to improve strength and endurance should be
started.
◼ In selected cases, low intensity, brief sessions of cardiorespiratory

conditioning to provide multiple benefits should be attempted
ensuring safety, e.g., especially in young adults.
CHAPTER
24
Arthrodesis, arthroplasty and osteotomy
OUTLINE
◼ Arthrodesis
◼ Intra-articular arthrodesis
◼ Extra-articular arthrodesis
◼ Arthroplasty
◼ Arthroplasty of the hip joint
◼ Arthroplasty of the knee joint
◼ Arthroplasty of the ankle joint
◼ Arthroplasty in the upper limbs
◼ Arthroplasty of the elbow joint
◼ Arthroplasty of the wrist joint
◼ Arthroplasty of the hand
◼ Arthroplasty of the PIP joints
◼ Osteotomy
Arthrodesis
With the advent of replacement arthroplasty and other reconstructive
surgical procedures, arthrodesis is undertaken selectively only as a
salvage procedure.
This procedure involves fusion of a joint which has been
damaged/destroyed due to disease/trauma beyond repair or
reconstruction with marked instability, severe pain and functional
handicap.
The procedure provides remarkable relief of pain and offers
maximum stability to the joint, but at the cost of mobility. It is
generally performed only at one joint in a limb provided the other
joints of the same limb as well as those of the contralateral limb are
good. It is always performed to fuse the affected joint in a functional
position, to promote the use of the limb for ease of activities of daily
living (ADLs); which are not possible otherwise.
Indications of arthrodesis
1. Infection, e.g., tuberculosis
2. Paralytic conditions: Arthrodesis is done for a flail joint, e.g.,

shoulder in brachial plexus injuries, arthrodesis of foot joints in
poliomyelitis.
3. Malignancy: The involved joint is fused after excision of a malignant

joint.
4. Degenerative conditions: Arthrodesis is done to relieve severe pain,

e.g., arthrodesis of the subtalar joint in secondary osteoarthritis of the
subtalar joint following an intra-articular comminuted fracture of the
calcaneum.
5. Miscellaneous: Arthrodesis is also indicated after failure of a total

joint replacement.
The operation of arthrodesis is performed in two ways:
1. Intra-articular arthrodesis
2. Extra-articular arthrodesis
Intra-articular arthrodesis
In this procedure, the articular cartilage is removed from both the
opposing bony ends of the joint and the bone ends are cut and shaped
to fit in an optimum functional position (Fig. 24-1). The fusion is
secured by internal fixation, an external fixation device, by a plaster
cast, or by a combination of these methods. This type of arthrodesis is
commonly performed in the hip and knee joints for tuberculosis.
FIG. 24-1 (A) Intra-articular arthrodesis of the shoulder joint. (B) As seen
on a radiograph. (C) Extra-articular arthrodesis of the hip joint.
Extra-articular arthrodesis
In extra-articular arthrodesis, the joint surfaces are not denuded of its
articular cartilage but the fusion is achieved in the position of
optimum function, by a bone graft placed outside but adjacent to the
joint (Fig. 24-1), e.g., hip and shoulder joints.
Position of arthrodesis
The position of arthrodesis for a joint depends upon the functional
requirements of the individual. The standardized functional positions
of arthrodesis for various joints are as follows (Table 24-1):
1. Shoulder: The shoulder joint is arthrodesed, in 40–50 degrees of

true abduction, 15–20 degrees of flexion and 25 degrees of medial
rotation. This position facilitates the hand to reach the mouth.
2. Elbow: Arthrodesis of the elbow joint is rarely performed. The

indication includes destruction of the joint by infection or trauma.
When only one joint is affected, it is arthrodesed in a position of 75–90
degrees of flexion, for sedentary jobs whereas for bilateral arthrodesis,
one elbow is fused in 110 degrees of flexion to enable the patient to
reach the mouth, the other elbow in 65 degree to facilitate toileting,
etc.
3. Wrist: Wrist joint fusion is commonly performed for the following

conditions: tuberculosis, rheumatoid arthritis, secondary osteoarthritis
following fractures of scaphoid and lower end of the radius, as a
reconstructive procedure for nerve and tendon injuries, Volkmann
ischaemic contracture, poliomyelitis and cerebral palsy.
In unilateral wrist arthrodesis, it is fused in 10–20 degrees

extension (Fig. 24-2) whereas for bilateral disease, one
wrist is fused in 20 degrees of extension and the other in
slight flexion.
4. Hand: Arthrodesis of the smaller joints of the hand is indicated

when the joint is damaged by injury or disease resulting in pain,
deformity or instability.
Fingers: The metacarpophalageal joint is fused 20–30 degrees

of flexion. The proximal interphalangeal joint is
arthrodesed in 40–50 degrees of flexion (slightly less in the
index and middle fingers), while the distal interphalangeal
joints are fused in 15–20 degrees of flexion.
Thumb: Instability, pain or deformity due to trauma burns,

contracture, nerve palsy, injury to the collateral ligament or
osteoarthritis of the carpometacarpal joint may require
arthrodesis. The interphalangeal joint of the thumb is
arthrodesed in 15 degrees of flexion (Fig. 24-3) and the
metacarpophalangeal joint in 10–20 degrees of flexion. The
carpometacarpal joint is fixed in 40 degrees of palmar
abduction and 20 degrees of radial abduction.
5. Hip: The arthrodesis of hip is generally indicated when the articular

cartilage is eroded, the joint is destroyed to an extent where a mobile
joint cannot be expected. The commonest indication for fusion of the
hip is tuberculosis. Arthrodesis should, however, be performed in an
adult patient only. The optimum position for arthrodesis of the hip
joint is as follows:
Flexion: The flexion actually varies with age; degree of

flexion for each year of age is up to a maximum of 20
degrees. To facilitate standing, walking and sitting, the
usual choice of arthrodesis is 15–20 degrees of flexion.
(a) Abduction: The extent of hip abduction depends upon

the degree of the limb length disparity as abduction leads
to apparent lengthening of the limb. The usual position
of arthrodesis is the neutral position of abduction and
adduction.
(b) Rotation: The hip joint is usually arthrodesed in the

neutral position of external and internal rotation or in
slight external rotation.
6. Knee: The knee joint is arthrodesed, mostly for tuberculosis, either

in full extension or in 20 degrees of flexion.
7. Ankle: In men, the ankle joint is arthrodesed in the neutral position

while in women, who wear high heels, in 15–20 degrees of plantar
flexion. It is commonly indicated in secondary osteoarthritis following
trauma or tuberculosis.
8. Subtalar (talocalcaneal) joint: It is arthrodesed in the neutral

position. The talocalcaneal joint arthrodesis is most commonly
performed following comminuted fracture of the calcaneum with
severe pain and inability to bear weight. This joint is fused along with
the talonavicular and calcaneocuboid joints (triple arthrodesis) in
deformed/flail foot in poliomyelitis (Fig. 24-4).
9. Great toe: The metatarsophalangeal joint (MP) is arthrodesed in a

few degrees of extension and slight valgus (Fig. 24-4) (a little more
extension for women wearing heels). It is performed for painful
conditions such hallux rigidus and hallux valgus. The interphalangeal
joints are arthrodesed in the neutral position in addition to tendon
transfers in poliomyelitis.
10. Rest of the toes: The rest of the toes are arthrodesed in the neutral
position.
11. Spine: Arthrodesis of the spine is routinely performed for a large

number of conditions. The types of spinal fusion are as follows:
(a) Posterior spinal fusion: This is commonly performed in

scoliosis, old healed tuberculosis, in association with disc
excision surgery, in fracture dislocations of the cervical
spine, etc.
(b) Posterolateral fusion is performed in spondylolisthesis.
(c) Transalar fusion is performed between the transverse

processes of the lower lumbar vertebrae and the ala of
the sacrum. It is commonly performed in
spondylolisthesis at L4–5 or L5–S1 levels.
(d) Anterior spinal fusion is done in tuberculosis of the

spine, spondylolisthesis and in patients who have had
laminectomy.
FIG. 24-2 Wrist arthrodesis.

FIG. 24-3 Thumb arthrodesis.
FIG. 24-4 Triple arthrodesis: (A) equinus deformity, and (B) correction of
deformity and fusion of talonavicular, subtalar and calcaneocuboid joints.
Table 24-1
Position of Arthrodesis of Various Joints
Joint Position of Arthrodesis

• Hip • In 15–20° of flexion with neutral position of abduction,
adduction and rotation
• Sometimes in a few 5–10° of external rotation to facilitate
ambulation
• Knee • In full extension or 20° of flexion
• Ankle • In men: neutral position
• In women who wear high heels, 15–20° of plantar flexion is
preferred
• Subtalar joint (talocacaneal joint) • In neutral position
• Big toe (metatarsophalangeal • In a few degrees of extension and valgus
joint)
• Rest of the toes • In neutral position
• Shoulder • In 40–50° of abduction, 15–20° of flexion with 25° of internal
rotation
• Elbow (single joint involvement) • In 75–90° of flexion (for sedentary jobs)
• Elbow (bilateral involvement): on • In 90–110° of flexion
the side of eating hand
• On the side of the hand used for • In 65–70° of flexion
toileting
• Wrist (unilateral) • In 20° of extension
• Wrist (bilateral) • One fused in 20° of extension and the other in 10° of flexion
• Forearm • In 10° of pronation
• Metatarsophalangeal joints (MP) • In 30–35° of flexion
• Proximal interphalangeal joints • In 40–50° of flexion (slightly less in index and ring fingers)
• Distal IP joints, thumb • In 15–20° of flexion
• Carpometacarpal joint is fixed in 40° of palmar abduction
and in 20° of radial abduction
• Metacarpophalangeal joint in 10–20° of flexion
• Interphalangeal joint in 15° of flexion
• Spine
•Anterior, spinal fusion • Anteriorly, the vertebrae are fused, e.g.,
• Tuberculosis of spine
• Spondylolisthesis
• Postlaminectomy
• Posterior spinal fusion • Posteriorly, the spine is fused, e.g., scoliosis, disc excision,
fracture dislocation of cervical spine
• Posterolateral fusion • In spondylolisthesis
• Transalar fusion • Fusion between the transverse processes of the lower
lumbar vertebrae and the ala of sacrum
• In spondylolisthesis, at L4–L5 or L5–S1 levels
The postoperative regime after all these types of spinal fusion is

almost similar. Initially, the patient is nursed in bed for a period of 2–3
weeks. After this period, the patient is given a spinal support which
may be a corset, plaster jacket or a brace (depending upon the disease
and the level of fusion) till the fusion consolidates which may take 3–6
months.
The basic objective is to train the patient to functionally use the
arthrodesed joint and the limb.
Preoperative education
Depending upon the joint to be arthrodesed, the related
musculoskeletal structures needed to facilitate functional tasks after
arthrodesis should be identified and given special exercise training to
improve:
◼ The strength, endurance and flexibility of the muscle groups

required to perform the functional activities, ideally using
proprioceptive neuromuscular facilitation (PNF) techniques.
◼ To improve the range of motion (ROM) of the related joints by

repetitive short duration sustained stretches (manual therapy). For
example, in a planned shoulder arthrodesis, sessions are given to
improve muscle function of the following:
◼ Shoulder girdle muscles
◼ Elbow flexors and extensors
◼ Forearm pronators and supinators
◼ Wrist and hand muscles and all the associated joints
◼ Strong resistive isometrics to the muscle groups – passing

over the joint to be arthrodesed, this programme should be
made vigorous during postoperative mobilization by
performing activities of daily routine (ADRs) against
graded resistance) as soon as it is pain free.
Postoperative education
1. To prevent and/or manage the possible postoperative

complications.
2. Maintenance of proper position of the operated joint. The limb

should be protected against postures putting strain on the joint.
3. Strengthening and ROM exercises for the joints free from

immobilization.
4. Initiating early nonweight–bearing ambulation in case of hip, knee

and ankle arthrodeses. The functional use is encouraged and initiated
early in upper extremity arthrodesis. These approaches of early
functional mobilization need to be emphasized as immobilization
following arthrodesis is often prolonged.
The major objective of physiotherapy is the education of the patient

to perform the functional activities of daily routine. It is achieved by
using compensatory mechanisms altering the biomechanics of the
associated joints and the various postural adaptations. Encouraging
persuasion of the patient to untiring efforts is an important aspect of
the success.
During mobilization
The whole limb is to be exercised in the functional patterns of
movements. Ideally, it should be incorporated with some objective
and competitive tasks. Several repetitions of such sessions are
necessary to improve function in the upper extremity. In the lower
extremity, gradual and correct weight bearing, weight transfers and
balancing should be initiated with adequate aid.
Functionally important muscle groups and compensatory
techniques, e.g., trick movements, are to be strengthened to facilitate
ADLs.
Guidance and assistance with several sessions a day are needed to
achieve functional proficiency. A patient should be left alone to work
out and surprisingly he/she may report back with self-developed
compensatory methods to perform functional tasks many a times
unknown to the physiotherapist.
Optimal function should be regained by 4 weeks following
mobilization.
Physiotherapy following spinal arthrodesis: This is covered in Chapter
15, the section on Scoliosis.
Note: Arthrodesis provides required stability in performing major
activities like standing balance and ambulation, and the functional
activities of the upper limbs at the cost of mobility as such is the last
resort.
Arthroplasty
Arthroplasty is performed to restore pain-free functional range of
motion (ROM) in a stiff and or painful joint by replacing the joint
partially or totally with an artificial joint.
Arthroplasty of the lower limbs

Arthroplasty of the hip joint
This may be of two types:
1. Replacement arthroplasty
2. Excisional arthroplasty
Replacement arthroplasty
Replacement arthroplasty is reconstruction of the joint by replacing
the joint partially or totally. It can be:
1. Hemireplacement
2. Total joint replacement
Hemireplacement arthroplasty
Hemireplacement arthroplasty is indicated in fractures of the femoral
neck in elderly patients. In this operation, the femoral components of
the head and the neck are replaced with a metal prosthesis. Two types
of prostheses – Austin Moore and Thompson prostheses are being
commonly used (Fig. 24-5). It can be used with or without bone
cement (methyl methacrylate). However, nowadays, a bipolar
prosthesis is more common. The stem of the prosthesis is implanted
into the upper shaft of the femur with the help of bone cement while
the head of the prosthesis is put in the acetabulum inside a metal cup
which moves freely into the acetabulum (Fig. 24-5). The advantage of
this prosthesis is that the wear of the acetabulum is relatively less and
the subsequent conversion into a total hip replacement (THR) is also
easy.
FIG. 24-5 (A) Austin Moore prosthesis. (B) Thompson prosthesis. (C)
Fracture of the neck of the femur treated by Austin Moore prosthesis
(replacement arthroplasty).
Postoperatively the patient is nursed in bed in supine position with

the limb in abduction to prevent dislocation of the prosthesis. A
pillow or a wedge-shaped foam block can be kept between the legs to
keep them in abduction. In an elderly, disoriented or uncooperative
patient, a below-knee skin traction is applied to the operated limb to
avoid unwanted movements of the limb. The movements of flexion
and adduction are particularly avoided for a period of 4–6 weeks as
these movements may precipitate dislocation of the prosthesis. The
traction is maintained for about a week after which mobilization is
initiated. While in bed, the patient should be turned frequently to
prevent bed sores, etc.
Partial weight-bearing crutch walking is started after 3 weeks, and
full weight bearing (FWB) is allowed after 4–6 weeks.
Total hip replacement (THR)

In this operation, the acetabular as well as the femoral head
components are replaced. There are two types of total hip joint
implants:
1. Cemented implants
2. Noncemented implants
(i) In the cemented hip, the acetabular as well as the

femoral components are fixed into place with the help of
bone cement (methyl methacrylate; Fig. 24-6). This
technique is generally used in elderly patients where the
bone stock is poor, i.e., the bones are osteoporotic (Fig.
24-6A–C).
(ii) Noncemented hip arthroplasty, the acetabular

component is fixed into place with the help of screws and
the femoral component is fitted snugly into the
medullary canal of femur (Fig. 24-7A and B). Bone
growth around the stem of the prosthesis secures its
placement in about 2–3 months. This technique is
therefore used in young patients where the bone stock is
good.
FIG. 24-6 (A) Acetabular cup, (B) femoral component and (C) cemented
THR.
FIG. 24-7 (A) Preoperative radiograph showing osteoarthritis of both hip

joints, (B) postoperative radiograph after noncemented total hip
arthroplasty has been done on both sides.
Total surface replacement arthroplasty of the hip

This is a newer development in the field of arthroplasty of the hip. In
this procedure, only the articular surfaces of the femoral head and the
acetabulum are replaced by thin prostheses, leaving behind the
healthy host bone largely intact (Fig. 24-8A and B). It is indicated in
younger patients and is reported to give better and long-lasting
results.
FIG. 24-8 (A and B) Total surface replacement arthroplasty of the hip.
Postoperative regime: The patient is nursed in bed in supine

position. The movement of flexion and adduction is avoided to
prevent dislocation of the hip. In these patients, however,
mobilization is started early in the postoperative period. The patient
can be made to stand up as early as on the third postoperative day.
Initially, crutches and later on a walking stick may be used for
support.
Objectives:
◼ To restore near normal or at least functional ROM to the hip joint.
◼ To prevent redislocation of the prosthesis in the early postoperative

period.
◼ To restore adequate strength, power and endurance to the
functionally important muscle groups like hip extensors, abductors,
knee extensors, flexors and dorsi and plantar flexors.
◼ To facilitate stability in the ambulatory activity.
Hemireplacement arthroplasty: Hemireplacement is a common

procedure done for fresh and ununited fractures of the femoral neck
in the elderly and in avascular necrosis of the femoral head.
The objective of pre- and postoperative evaluation and education as
well as postoperative physiotherapeutic regime follows the same
routine as described for THR.
The basic differences, however, are as follows:
As the surgical procedure involves the replacement of only the head
and neck of the femur, the whole programme can be initiated earlier
than THR.
Other precautions during the early postoperative phase:
◼ Avoid active flexion and adduction but continue self-resistive

isometrics to these muscles by blocking these movements with the
help of the contralateral limb after adequate guidance.
◼ Encourage isometrics to the hip extensors by pushing the whole

limb down on the bed within a pain-free range. Increase its duration
and intensity as the pain reduces.
◼ Prevent the development of pressure sores by alert nursing care.
◼ Avoid undue stiff knee by early check and guidance.
Guidance in ambulation:
◼ Initiate ambulation on a walking aid (walker) to gain confidence.
◼ Start partial weight bearing (PWB) by 3 weeks, first with a walker,

gradually weaning to a single crutch to a cane – not to compromise
the gait pattern.
◼ By 6–8 weeks, FWB is safe with restoration of near-normal ROM at
the hip joint.
The range of flexion of the hip in THR is contraindicated beyond 90

degrees; no such limitation is to be observed with hemireplacement
patients. It can be taken to the near-normal range at the earliest to
facilitate floor squatting at a later stage. However, excessive adduction
with rotation should be avoided, to prevent subluxation or dislocation
of the hip.
The programme of exercises to facilitate floor squatting and cross-
leg sitting can be started early.
The exercises include the following:
1. Self-assisted hip flexion in supine lying or in sitting with back

supported
2. Prone kneeling (Fig. 24-9A)
3. Knee support squatting against stall bars (Fig. 24-9B)
4. Back supported, assisted cross-leg sitting (Fig. 24-9C)

FIG. 24-9 Self-assisted early initiation of hip and knee flexion which also
promotes weight bearing on the operated leg. (A) Prone kneeling. (B) Knee
support squatting. (C) Back supported cross-leg sitting.
The exercise must give a feeling of soft tissue stretching but not
pain.
FWB is quite safe by 8 weeks following surgery provided it is well
accepted, and there are no complications.
The patient should be fully independent functionally by the end of
12 weeks.
THR: The basic objective is to offer a painless, mobile, stable and
functionally acceptable reconstructed hip joint.
The physiotherapeutic programme is broadly divided into:
A Preoperative regime
B Postoperative regime
Preoperative regime: The objective of the preoperative

programme includes: (1) evaluation and (2) education of
the patient.
1. Evaluation: The following parameters are used to

evaluate the patient:
(a) Pain
(b) Deformity including limb length
(c) Range of motion at the hip and related joints
(d) Muscle power and muscle atrophy
(e) Ambulation and gait
We have used the functional assessment criteria as

formulated by Lansky (1967) with slight modifications. We
suggest that rating with numerical scores should be
incorporated in all the centres (Table 24-2).
2. Preoperative education: It is extremely important to

educate the patient on the exact regime of physiotherapy
to be followed in the early postoperative period.
Table 24-2
Functional Assessment Criteria
Ambulatory Aids Ability to do Floor Sitting (Cross-Leg Sitting)

Total assistance (bed ridden) 1 Unable to do 1
Chair life 2 Able to do partially on plinth with back supported 2
Two crutches 3 Able to do on high plinth without support 3
Two sticks 4 Able to do on the floor with considerable support 4
One cane (always) 5 Able to do with some assistance 5
One cane (outdoor only) 6 Able to do independently but with pain 6
No aid 7 Able to do without discomfort 7
Walking ability Ability to do floor squatting
Bed ridden or a few yards 1 Able to do partially with considerable support 2
Limited time and distance 2 Able to do partially without assistance 3
Limited with one cane 3 Able to do completely but with considerable support 4
Long distance with one cane 4 Able to do, needs some assistance 5
No aid but limp 5 Able to do independently but with pain 6
Normal for age and 6 Able to do without any discomfort 7
condition
Gait without aids
Cannot walk 1 Functional ambulation requires an ability to walk over 100 ft (30.5
m)
Shuffles with small steps 2
Walks with gross limp 3
Walks with marked limp 4
Walks with slight limp 5
No limp 6
Stair management
Unable to do 1
Does with assistance 2
Does independently 3
Toilet activity
Needs assistance 1
Manages independently 2
It should be taught first on the sound limb or by self-demonstration

for easy grasp. It is also necessary to make sure that the patient has
followed these techniques.
Preoperative physiotherapy
1. Deep breathing and coughing to improve vital capacity of the lungs

and to be able to get rid of the postanaesthetic secretions.
2. Strong and sustained isometric contractions to glutei, quadriceps

and the hamstrings to improve strength and endurance of both the
limbs.
3. Guidance on ROM and strengthening exercises for both the limbs to

avoid stiffness and incoordination.
4. Resistive exercises for the ankle and foot on the affected side and for
the weight-bearing muscle groups of both the arms, to facilitate early
ambulation with walking aids.
5. Teach proper limb positioning of the operated leg in consultation

with the surgeon to avoid hip dislocation in the postoperative period.
Limb positioning depends upon the surgical approach to be used.
6. Teach appropriate techniques of transfers, avoiding undue strain on

the operated hip.
7. Mentally prepare the patient for the painful active stage ahead.
Postoperative physiotherapy
Broad outlines of the physiotherapeutic schedule are given in Table
24-3.
Table 24-3
General Outline of Physical Therapy Schedule for Total Hip Replacement (THR)
Day 1: 1. Chest PT
2. Vigorous toe and ankle movements
3. Isometrics to quadriceps
Day 2: 1. Sitting up by gradually raising the back rest
2. Bed transfers
3. Standing, walking with partial weight bearing (PWB) or toe down weight bearing (TDWB)
with a walker
Day 3– 1. Isometrics to gluteus maximus, medius and minimus
7: 2. Assisted hip flexion (heel drag) and hip abduction
3. Initiate prone lying
4. Thomas stretch
5. Relaxed passive hip movements
Week 2: Active hip flexion, knee extension (bedside sitting or chair sitting with back rest)
Week 3: PWB walking on crutches with free swinging of the operated leg
Week 4: 1. Pedo cycle or static bicycle (possible free ROM)
2. Stair climbing going up with the GOOD LEG first. Coming down with the OPERATED
LEG first
3. Initiate leg rotation in supine and progress to against gravity and against resistance
Week Gradually increase hip abduction and rotation in supine and bedside sitting
5–6:
Week Achieving near normal strength, ROM, balance standing on the operated leg alone
6–8
Ambulation and Weight Bearing Schedule
Cemented prosthesis
As the stability of prosthesis is achieved within 15 min of surgery, weight bearing to tolerate (WBTT) can
be started on a walker immediately or on the second day
• Progress to crutch walking and continue crutch walking up to 6 weeks
• Use a cane for 4–6 months
Noncemented prosthesis
PWB or TDWB on walker for 6 weeks
Progress to crutch walking and continue up to 8–12 weeks
Use cane for 4–6 months
Provided there is no limp or pain on weight bearing. If pain persists, go slow on FWB, give repetitive
sessions of standing on the operated leg alone. Eight week onwards: FWB – minimally assisted walking;
by 12 weeks: independent (unsupported) free walking
Precautions
Prevention of hip dislocation
1. Avoid early initiation of hip adduction and rotation
2. Always use pillow between the legs in resting, sitting, while turning in bed or during transfers
3. Hip flexion ROM to be restricted to 80 degrees
Prevention of Trendelenburg limp
1. Initiate isometrics to gluteus medius, minimus and maximus at the earliest
2. Avoid straight leg raise (SLR) or hip abduction against gravity as it puts tremendous load on the hip
joint
3. Proper gait training on crutches and cane
4. Continue cane support till the limp persists
5. Initiate early supported standing on the fractured leg alone without Trendelenburg sign; and
progress to independent standing to eliminate limp
Prevention of hip flexion deformity
1. Initiate Thomas stretch within 2–3 days of surgery
2. Frequent periods of prone lying
3. True hip joint extension in prone lying
First week
1. Chest physiotherapy to avoid postoperative chest complications.
2. To prevent pulmonary embolism: Pulmonary embolism following

THR is quite common. Evarts and Feil (1971) reported an incidence of
venous thrombosis in as much as 53.6% of the patients. Massive
embolus usually comes from the leg veins and not from the pelvic
veins. Physiotherapy plays an important role in its prevention.
Charnley (1968) states, ‘The physiotherapist should forget the
operated hip for the first 3–4 days and should be on duty throughout
the 24 hours just to avoid this hazard’.
(a) Careful watch to detect any local swelling, tenderness,

warmth or oedema in the leg and foot.
(b) Vigorous resistive/active exercises are given to the

ankle and foot with concentration on the gastrosoleus
and the toe flexor groups (elastic crepe bandage may be
used to resist active contractions).
(c) The knee should be supported in slight flexion by a

knee roll. Hyperextension at the knee should be avoided.
3. Strong and sustained isometric contractions to the gluteus

maximus–medius–minimus, quadriceps, dorsiflexors and the toe
extensors should be done simultaneously on both sides. This exercise
improves joint stability (Yoslow et al., 1976).
4. Relaxed passive movements – small-range relaxed passive

movements for flexion of the operated hip could be initiated.
Continuous passive motion (CPM) equipment provides an excellent
means of initiating these movements. Isometric programme can be
intensified by adding resistance at the terminal range of the available
movement.
Second week
1. Relaxed passive and assisted/active movements to be progressed so

that, by this time assisted hip flexion should be possible up to 90
degrees.
2. To attain further mobility, the range of CPM should be progressed.

Methods like suspension therapy or using roller skates with a special
board are excellent.
3. Special attention needs to be given in exercising tensor fascia lata.
The iliotibial band forms a unit with tensor fascia lata and the
superficial fibres of gluteus maximus muscle, giving stability to the
hip joint and preventing dislocation.
4. Turning in bed: Turning in bed to be initiated on the sound side with

a pillow in between the legs (knees) to avoid adduction, keeping the
knees bent. Bedside independent sitting should be initiated with
knees hanging and transferring the weight on both the hip joints.
5. Standing: Transfers from bed to wheelchair and to the parallel bars.

Brief periods of PWB can be initiated if it is not painful.
Third week
Weight bearing: Ambulation with PWB in parallel bars is safe. Watch
for gait deviations.
Progress to ambulation with crutches the next day. The progression
in ambulation from walker to elbow crutches, a cane or independent
walking should not be hurried up at the cost of the normal pattern of
gait. Therefore, in our patients, we avoid the development of wrong
pattern of weight bearing. Instead, we concentrate on vigorous
strengthening exercises to stabilize hip, knee and the ankle muscles.
The single leg standing sessions on the operated side alone, knee
standing as well as knee walking are excellent methods of training
progression in weight bearing. This methodology reduces the degree
of apprehension while bearing weight in standing independently and
contributes significantly to the stable and good pattern of gait. Beber
and Covery (1987) advocated the use of two crutches up to the end of
6 weeks. One crutch up to 8 weeks and progress to ambulating with a
cane and continue for 4–6 months. Overemphasis on unsupported
ambulation has to be avoided till the patient is stable and acquires
acceptable gait. Patients with gluteal lurch or Trendelenburg limp
must continue to use cane. The quality of gait can be improved further
by the techniques of rhythmic stabilization and resistive gait as
advocated by Knott and Voss (1968).
Caution
The overenthusiastic patient should be warned against any attempt
to overstretch the hip joint to attain floor squatting or cross-leg
sitting.
Fourth week
1. Further progression of all the exercises.
2. Stair climbing to be added. While climbing up the steps, the patient

should step up with the sound limb. For coming down the steps, step
down with the operated leg first.
3. Initiate exercises on pedo cycle or static bicycle.
4. Initiate external and internal rotation in supine position.
5. The patient should be discouraged from adopting positions like

long sitting and reaching forward to touch the toes, crossing the knees
in sitting, floor squatting and cross-leg sitting. These positions may
cause hip dislocation due to movements like flexion beyond 90
degrees with adduction and internal rotation.
Fifth week onwards

Progress all exercises, especially hip external and internal rotation, to
achieve strong and functionally stable hip joint. By 12 weeks, the
patient should be back to the prefracture status. This regime of
physiotherapy may need modifications to suit individual
requirements. In our experience, the results of THR have been good
except in cases of ankylosing spondylitis. In ankylosing spondylitis,
there is a tendency for reankylosis.
Broad Guidelines for Graduated Weight-bearing Following THR
1. Initial ambulation on a walker – adequate support to prevent

development of a limp – first 4–6 weeks
• Practising standing balanced with equal weight bearing

on both the legs.
• Efficient in weight transfer to the affected limb.
• Brief independent standing on the operated leg alone.
2. Using both crutches – may be continued for another 2 weeks.
3. Using a single crutch up to 8 weeks.
4. Walking stick – up to 6 months or could be permanent in

weak/elderly patients.
5. Any walking aid which is needed for an adequately confident

ambulation may have to be continued in patients with associated
neurological disease.
(Programme of vigorous strong isometrics to the glutei,

quadriceps and hamstrings is to be continued during
ambulatory training)
Precautions: Activities contraindicated for patients treated with

THR.
1. Squatting on the floor.
2. Cross-leg sitting
3. Hip flexion beyond 90 degrees
4. Position of flexion–adduction and internal or external rotation, e.g.,

knee crossing in sitting in the chair.
5. Long sitting and excessive trunk flexion stressing the hip joint, e.g.,
attempted toe touching.
Excisional (girdlestone) arthroplasty
Excisional arthroplasty of the hip is indicated in the following
conditions:
1. An advanced case of tuberculosis of the hip where extensive

destruction of the femoral head and/or acetabulum has taken place
and the joint cannot be salvaged.
2. Severe osteoarthritis in the elderly where any other reconstructive

procedure is contraindicated.
3. Painful ankylosis of the hip in ankylosing spondylitis.
4. Rarely, septic arthritis of the hip.
5. Pyogenic infection of the hip following surgical procedures or

fracture of the neck of femur or THRs.
6. Unsuccessful cases of THR or failed open reduction internal fixation

(ORIF) in severe fractures of the hip.
In this procedure, the femoral head and neck are resected down to
the base of the trochanter; the superior margin of the acetabulum is
also resected to curette out the diseased portion. A gap is thus created
between the acetabulum and the trochanter (Fig. 24-10).
FIG. 24-10 Excision arthroplasty at the hip.
The patient is given skeletal traction through the upper tibia for a
period of 5–6 weeks. However, intermittent mobilization to the knee
and hip is started after 4 weeks while in traction. Nonweight–bearing
crutch walking is started after 6 weeks. FWB is started after 3–4
months.
After this operation, the patient regains a painless, mobile hip but
loses stability at the hip and the length of the limb.
This procedure, also known as excisional arthroplasty, is a salvage
procedure. It is indicated in selected cases of tuberculosis and septic
arthritis of the hip. The aftermath of surgery poses three main
problems:
1. Fairly mobile but unstable hip joint
2. Marked shortening of the limb
3. Weakness of the muscles around the hip
The objective of physiotherapy is to provide maximum functional

stability to the operated hip. The physiotherapeutic programme is
divided into two parts:
1. Preoperative evaluation and education
2. Postoperative therapeutic regime
1. Preoperative evaluation and education
(a) Considering the longer period of postoperative

immobilization, isometric exercises for the glutei, knee
extensors and flexors should be started at the earliest
and, ideally, they need to be repeated for 5 min every
hour.
(b) Resisted ankle movements.
(c) The expected outcome of the surgical procedure should

be explained to the patient.
2. Postoperative therapeutic regime
First and second week

Physiotherapeutic measures:
1. Chest physiotherapy
2. Prevent pulmonary embolism and thrombosis

3. Prevent muscle atrophy
4. Check the position of the limb and the traction
5. Vigorous isometric to the hip and muscles passing over the knee
joint
6. Resistive exercises to the normal limb and ambulatory muscles of

the upper extremities.
7. Strictly ensure that the immobilized limb is maintained to prevent

dislocation of the prosthesis in the early postoperative period.
Third and fourth week

The traction is discontinued intermittently to initiate mobilization.
1. Small range of relaxed passive movements should be initiated at the

hip. Begin with hip flexion and extension. Progress to abduction and
rotation.
2. Full range active resistive movements to the knee and ankle.
3. Sitting: Initiate passive hip flexion up to 60 degrees by raising the

head end or using a back rest, with the traction on.
4. Measures to prevent fixed flexion deformity (FFD) at the hip.
Fifth and sixth week
1. All the earlier therapeutic programmes should be intensified.
2. Suspension therapy can be given to promote mobilization.
3. Short periods of relaxed passive stretching of hip flexion, extension

and abduction movements are important at this stage to avoid
fibrosis.
4. Isometric contractions: The patient should be taught to actively

contract gluteus maximus by pushing the limb against the mattress or
pillow and sustaining it for 10–15 s.
Sixth week onwards

Traction is removed and the patient is put on vigorous exercises.
1. Nonweight–bearing standing: Bedside sitting and short-duration

standing on the sound limb should be started.
2. Intensive stretching: Any limitation of ROM in the hip can be safely

stretched to the maximum. Supportive modality in thermotherapy
may be used.
3. Continuous stretching: To prevent hip flexion and adduction

contractures, gentle sustained traction may be necessary. The patient
should be encouraged to frequent prone lying and to perform
isometrics to the glutei.
4. Strengthening exercises: Gravity resisted hip movements and graded

exercises on static bicycle should be started to strengthen the hip
muscles.
5. Limb length disparity: Limb length disparity should be accurately

measured and compensated. However, there is another school of
thought which prefers delay in correction in the limb length by at least
6 months for the fear of progressive upriding of the trochanter, due to
weight bearing.
6. Weight bearing:
(a) PWB crutch walking should be initiated in parallel bars

or with the help of double crutches.
(b) FWB: Total weight bearing should be started 12 weeks

after the surgery. Partial compensation for limb
shortening may be provided. Migration of the proximal
end of the excised femur is a problem as it disturbs the
stabilizing abductor mechanism.
Weight bearing may be started in parallel bars basically to

train weight bearing and balancing on the operated leg
alone, then progressed gradually to single crutch and cane.
Cane may remain as a permanent aid, especially for
outdoor walking. The patient should be guided to avoid
undue weight bearing stresses to prevent further
complications such as backache and early osteoarthritis of
the normal hip and knee joints. Stair activities should be
started along with ambulation on slope and rough
surfaces.
With the help of regular home exercises, the patient should

be independent by 14–16 weeks.
From our experience, we feel that patients with tuberculosis

or infective arthritis generally do well as compared to the
patients with ankylosing spondylitis (Joshi, 1979).
7. Prone kneeling, cross-leg sitting: These can be safely initiated and

assisted to gain further range and strength in adopting these
positions.
Caution
Postoperatively relaxed passive full range mobilization should be
initiated and taken to the fullest range at the earliest. The
movements of hip flexion and abduction with external rotation need
to be emphasized in view of the functional postures of floor
squatting and tailor sitting.
Prone lying and hip stretching into extension should be initiated
early to avoid flexion deformity at the hip. Flexion deformity
complicates efficiency in ambulation and produces excessive strain
on the back.
Arthroplasty of the knee joint
Total knee replacement arthroplasty (fig. 24-11)

Total knee replacement (TKR) arthroplasty is indicated when there is
unremitting severe pain in the knee with or without deformity. The
pain or deformity may be due to osteoarthritis (primary or
secondary), rheumatoid arthritis and various other nonspecific
arthritides. TKR relieves pain, provides adequate mobility and
corrects the deformity.
FIG. 24-11 AP and lateral radiographs showing total knee replacement

arthroplasty.
TKR can be:
1. Unicompartmental (unicondylar)
2. Bicompartmental
3. Tricompartmental
1. Unicompartmental arthroplasty: It is also called unicodylar arthroplasty

(UKR). The articular surfaces of the femur and the tibia of either the
medial or the lateral compartment of the knee are replaced by an
implant (Fig. 24-12). The other compartment of the knee joint is left
intact. This type is obviously indicated for disease pertaining to one
compartment only, e.g., osteoarthritis.
2. Bicompartmental arthroplasty: In bicompartmental arthroplasty, the

articular surface of the tibia and the femur of both medial and lateral
compartments of the knee joints are replaced by an implant. The third
compartment, i.e., the patellofemoral joint, is however left intact.
3. Tricompartmental arthroplasty: The articular surfaces of the lower

femur, upper tibia and the patella are replaced by prostheses. The
prosthesis consists of a tibial component, a metal femoral component
and a high molecular weight polyethylene (HMWPE) button for the
articular surface of the patella.
FIG. 24-12 Implant placed in unicompartmental arthroplasty of knee.
Postoperatively the knee is mobilized after about 4–5 days.
The principal aim of the physiotherapy is to offer maximum static as
well as dynamic stability to the knee. Severe pain, instability of the
joint or deformity which cannot be corrected by osteotomy are the
chief indications for total knee arthroplasty.
Preoperative assessment: A thorough assessment is done prior to
the surgery, and the postoperative regime of physiotherapy is
explained to the patient.
◼ Pain: The degree, site and the positions aggravating/relieving the

pain are recorded.
◼ Deformity: The degree of deformity is measured in weight bearing

as well as nonweight–bearing positions. The degree of deformity is
recorded when the whole body weight is borne over the affected
knee alone, maybe with some support if required.
◼ ROM: Accurate measurements of the active as well as passive ROM

at the knee are recorded. Patellar mobility is also checked and
graded. Ligamentous stability around the knee is evaluated.
◼ Strength and endurance: Strength and endurance of the quadriceps,

hamstrings and glutei are evaluated. The quality of quadriceps
contractions need to be assessed in particular.
◼ Effusion and atrophy: The area and extent of effusion as well as

muscle atrophy (especially of quadriceps) are documented.
◼ The other related joints, i.e., hip, ankle and foot are assessed for
their alignments, ROM and strength.
◼ Complete gait analysis, status of ambulation and functional

competence are documented.
◼ Physical requirements of the patient’s working situation are

reviewed.
Preoperative training: It includes the following:
◼ Explain to the patient the total postoperative regime. Biomechanics

of the movements at the knee to be explained on the normal knee
and the importance of regaining early ROM at the knee is
emphasized.
◼ Educate the patient on the measures taken for prevention of

oedema, deep venous thrombosis and chest complications.
◼ Training of isometrics (speedy as well as sustained) to quadriceps,

hamstrings and glutei.
◼ Self-assisted passive mobilization, relaxed free movements, and

assisted active and resistive exercises are taught on the sound limb.
◼ Put maximum emphasis on self-exercising methods to improve

ROM and strength training mode.
Postoperative regime (Table 24-4)
Table 24-4
General Outline of Physical Therapy Schedule for Total Knee Replacement (TKR)
Day 1:
1. Chest PT
2. Vigorous toe and ankle movements
3. Maintain the limb in extension (with heel or lower leg resting on a pillow)
4. Static glutei by pressing the pillow below the heel
5. Gentle isometrics to quadriceps
Day 2–3:
1. Transfers in bed
2. Gentle patellar mobilization
3. Rapid isometrics to quadriceps (speedy and with 10 s hold)
4. Heel-assisted SLR
5. Stand and ambulate with a walker (WBTT for cemented and TDWB or PWB for noncemented)
6. Nontouch SLR – posterior aspect of the heel should not be allowed to touch the bed while bringing
down the leg from the peak SLR position
Day 4–6:
1. Transfers in chair
2. Self-assisted passive knee flexion
(a) Heel drag in supine (simultaneous hip and knee flexion in lying supine) position
(b) Bedside sitting, relaxed knee movements with the help of sound leg (in unilateral TKR)
(c) Sitting with feet planted on the ground, lift and push forward by raising trunk on arms
3. CPM 5–10 degrees daily (1 cycle per minute)
• Range of knee flexion MUST NOT EXCEED 40 degrees because transcutaneous O2 tension of the
skin near the incision decreases significantly after 40 degrees of flexion
4. Begin active or active assisted exercises, if the wound is clean and dry
5. Bedside active knee flexion–extension (self-assisted, if necessary)
6. Ambulation without plaster of Paris (POP) (can do 13 continuous nontouch SLRs without POP)
Day 7–10:
1. Work up towards 90 degrees knee flexion by 10–14 days
2. Hamstrings strengthening
3. Assisted step and stairs
Day 11 to week 3: Progress all exercises
Week 4–6:
1. Work up towards knee flexion 110–115 degrees
2. Quadriceps dips and steps up
3. Stationary bicycle
4. TWB with cane
Weeks 6–11: Progressive weight bearing walking with cane, FWB by 12 weeks
First week
◼ Appropriate chest physiotherapy.
◼ Limb positioning to avoid rotation and encourage knee extension.

Ideally, the heel resting on a pillow and pressing the pillow will
encourage static quadriceps and gluteus maximus contractions
along with extension stretch to knee.
◼ Gentle isometrics to the quadriceps could be started. It should be

progressed to rhythmic speedy quadriceps contractions and
relaxations which will promote patellar excursion and reduce
oedema.
◼ Sustained isometrics to quadriceps, reinforced by simultaneous

strong dorsiflexion of the ankle, are ideal. Slow isometrics should
follow the rule of ‘tens’, i.e., holding maximum contractions for at
least 10 s, to be done 10 times in each session and each exercise
session to be done 10 times a day.
◼ Isometrics to hamstrings, glutei and hip abductors should also be

included.
◼ Supported SLR could be initiated with simultaneous isometrics to

quadriceps and ankle in maximum dorsiflexion (initially, with
assistance under the heel).
◼ Bed transfers, standing or even well-assisted ambulation with

walker could be attempted by third or fourth postoperative day.
◼ For cemented prosthesis, weight bearing to tolerance (WBTT) or
PWB can be initiated while toe down weight bearing (TDWB) is
done for noncemented TKR.
◼ The patient should be educated on relaxed self-assisted passive or

active free knee flexion extension in small range or CPM with a
speed of one cycle per minute. CPM angle should progress 5–10
degrees daily (Coutts et al., 1989). However, the range of flexion
should never exceed 40 degrees within the first 3 days.
◼ If the wound is dry and clean, assisted active or active knee

mobilization can be started.
Second week
◼ SLR should be made intensive by slow speed SLRs with self-

generated tension in the quadriceps without relaxation in between
SLRs.
◼ Intensify relaxed passive and assisted active knee flexion exercises.

By this time the range of knee flexion should reach 90 degrees or
close to it.
◼ At the same time, independent SLR without reflex inhibition of

quadriceps should be achieved.
◼ Once three independent SLRs against gravity in supine position are

achieved, ambulation without immobilizer can be started.
◼ Weight transfers and PWB on the operated limb may be started on

crutches.
Three to six weeks
◼ Work up to achieve knee flexion close to 110–115 degrees.
◼ Single crutch walking and well-assisted stair activities should be

introduced.
◼ Sessions on pedo cycle or even stationary bicycle could be started.
◼ Gait training with emphasis on free knee swinging can be started

with a cane and progressed from PWB to total weight bearing.
◼ Hydrotherapy or pool exercises are ideal at this stage if the surgical

wound has healed.
◼ Quadriceps dips and step and stairs in normal pattern could be

initiated with assistance.
Six weeks onwards
◼ The patient’s gait with cane should be assessed for any deviation.
Also ensure that both the tibio-femoral compartments of the
prosthesis are loaded evenly and not like a normal knee joint where
the loading is predominantly medial.
◼ Specific exercise for the still persisting deficiencies to be planned

and taught.
◼ Guided assistance may be provided for the higher levels of

functional and ambulatory activities.
◼ Cane should be discarded by assuring normal gait pattern and the

degree of stress during job requirements by 12 weeks.
Caution
■ The range of knee flexion must not exceed 40 degrees within the
first three postoperative days as the transcutaneous oxygen tension
of the skin near the incision decreases significantly when the knee
is flexed above 40 degrees. This may delay wound healing.
■ Lack of patellar mobility and weak quadriceps have been found to

be the cause of pain persistence. These two aspects need special
emphasis (Dorr & Boiardo, 1986).
■ The chances of developing quadriceps lag due to reflex inhibition

postoperatively must be observed carefully and taken care of.
■ Activities causing undue compression at the knee joint should be

avoided (e.g., excessive sitting–standing or stairs activities).
Arthroplasty of the ankle joint

Total joint replacement of the ankle is indicated in selected cases of
rheumatoid arthritis, osteoarthritis and haemophilic arthropathy. On
the contrary, arthrodesis of the ankle joint is still a common
procedure.
The presently available ankle joint prosthesis consists of a metal
plate over the dome of the talus which articulates with a platform,
consisting of HMWPE, attached to the lower end of the tibia (Fig. 24-
13).
FIG. 24-13 Total ankle joint replacement arthroplasty.
Postoperatively, mobilization is begun as soon as the pain permits

and weight bearing is allowed after 2 weeks.
Preoperative evaluation
◼ Passive and active ROM at the ankle
◼ Muscle power, endurance of the muscle groups around ankle and

foot
◼ Ligamentous stability and joint stability

◼ Gait pattern
◼ Adopting functional positions like floor-squatting and cross-leg

sitting
Postoperative management: The ankle and foot are immobilized in

a pressure bandage or a sling for 3 weeks.
◼ Limb in elevation, repeated toe movements to reduce oedema to be

concentrated.
◼ Active movements of the hip and knee joints to improve the overall
circulation to the operated area.
◼ Totally supported relaxed small range dorsiflexion and plantar

flexion may be initiated by the fifth day, if wound healing is
progressing well. The pressure bandage may be reduced.
◼ Active ROM exercises, in assisted form, to be started after the

sutures are removed.
◼ PWB can be initiated by 2 weeks if the wound has healed

completely and pain and discomfort are minimal.
◼ Walking with PWB by using elbow crutches is ideal for gradual

increase in weight bearing and re-education of gait.
◼ While working on the ROM, dorsiflexion should be emphasized to

facilitate functional floor-squatting posture.
◼ Stretching of the scar and the replaced joint should always be

carried out in a controlled manner with relaxed passive sustained
stretching, and guided for self-stretching mode.
◼ If the gait is near normal and weight bearing is not very painful, a
cane may be used instead of elbow crutches.
◼ Functional activities like squatting with assistance of wall bars and
standing ankle stretches with minimal discomfort could be initiated
to gain further range of plantar flexion and dorsiflexion.
◼ Negotiating steps with the normal leg leading while going up and
the operated leg leading while coming down is taught, with minimal
assistance.
◼ Cane support is reduced and progressed to independent walking

only when the pain is minimal and there is no limp.
◼ The patient should be back to his/her normal activities by 8–10

weeks.
Caution
Prosthetic loosening and deep infection are the common
complications to be watched for during rehabilitation. The results
have been generally superior in rheumatoid arthritis as compared to
posttraumatic arthrosis (McGuire et al., 1988).
Arthroplasty in the upper limbs
Arthroplasty of the shoulder joint

Like the hip, the arthroplasty of the shoulder is also of two types:
1. Hemireplacement arthroplasty
2. Total joint replacement
Hemireplacement arthroplasty
It is indicated in severely comminuted fractures of the proximal
humerus. In this procedure, the fractured humeral component is
replaced by a prosthesis and fixed with the help of bone cement (Fig.
24-14A and B).
FIG. 24-14 (A) Preoperative radiograph showing comminuted fracture of

the proximal humerus. (B) Postoperative radiograph showing prosthetic
replacement in situ.
Total joint replacement

In total shoulder arthroplasty, the humeral head and the glenoid
articulating surfaces are replaced by prosthetic components. total
shoulder arthroplasty may be indicated in severely comminuted
fractures of the shoulder, secondary osteoarthritis or rheumatoid
arthritis of the shoulder joint.
The Neer prosthesis (Neer and Watson, 1982) is most commonly
used. In this, the scapular surface is replaced by a shallow cup while
the humeral surface is replaced by a ball (Fig. 12-15).
FIG. 24-15 Total shoulder arthroplasty.
The Liverpool (reverse) shoulder prosthesis (Beddow & Elloy, 1977)

has a reverse ball and socket arrangement, the ball being on the
scapular side and the cup on the humeral side (Fig. 24-16). Although
technically it is a demanding surgical operation, excellent pain relief
has been reported apart from a sound scapular fixation.
FIG. 24-16 Reverse total shoulder joint replacement.
The shoulder joint is mobilized 2–3 weeks after the operation.
Normally the shoulder joint is an unstable joint which owns its
stability to the strong muscles and ligaments around it. Laxity of
ligaments due to rheumatoid arthritis, weakness of muscles due to
mechanical disadvantage, nonuse or partial use, or even ruptures of
the rotator cuff pose the problem of return of early and strong
movements following surgery. The movement of rotation is prone to
precipitate dislocation and needs careful monitoring. Therefore, the
physiotherapy should be planned keeping note of all these situations.
Preoperative assessment
◼ ROM active as well as passive
◼ Functional status of the whole limb
◼ Muscle power of the shoulder girdle muscles
◼ Professional or daily activities of the patient
First two weeks
◼ The arm is immobilized in a sling under the clothes.
◼ No shoulder movement is attempted.
◼ Active movements to the wrist, hand and fingers are encouraged

and repeated as often as possible.
Three to six weeks
◼ The sling can be worn outside the clothes and graduated

mobilization is begun.
◼ Relaxed passive swinging of the shoulder in a small range of

flexion–extension is begun in stoop standing with sling.
◼ Abduction and adduction can be initiated in sling suspension with

total arm support or only as a small range of relaxed passive
movement in supine position, or with CPM.
◼ Active assisted flexion–extension and abduction–adduction are

initiated with the patient in supine position with the elbow
maintained in 90 degrees of flexion throughout. The physiotherapist
stabilizes the shoulder girdle and takes total weight of the arm.
Alternatively, CPM can be used to a great advantage.
◼ No attempt should be made to perform rotation, either passive,

active or active assisted.
◼ Regular increase in the ROM is to be assured. In standing, swinging

arm with elbow in extension is encouraged.
◼ Assisted programme should be progressed to active or if possible

with small and graded resistance.
◼ Passive range of 90–120 degrees of flexion elevation and 70–90

degrees of abduction should be attained by this time.
After six weeks
◼ Passive range of lateral rotation to be initiated gradually, beginning

with arm by the side of the body.
◼ Other movements to be progressed to active resistive regime.

Passive stretching, hold-relax PNF techniques, passive self-
stretching sessions in supine position to be concentrated to gain
further ROM.
◼ Introduction of functional activities with guided resistance or

assistance should be encouraged. In the majority of cases, adequate
functional ROM and muscle power should be regained by 10–12
weeks.
◼ Normal to near-normal functional shoulder should be restored by

10–12 weeks.
Caution
The movement combination of abduction with external rotation, and
adduction with internal rotation should be avoided to prevent
dislocation.
Note: If a strong shoulder is not restored, the patient has a tendency

of insecurity while performing ADLs.
Arthroplasty of the elbow joint

Arthroplasty of the elbow joint is indicated in posttraumatic stiffness
of the elbow, rheumatoid arthritis and arthritis secondary to
inflammatory or degenerative disease.
Types of arthroplasty:
1. Resection (excisional) arthroplasty (Fig. 24-17A)
2. Interpositional (fascial) arthroplasty (Fig. 24-17B)
3. Implant (total joint replacement) arthroplasty (Fig. 24-18A–D)

FIG. 24-17 Excisional arthroplasty. (A) AE: area of excision of bones. (B)
TFL: covering the excised ends by interposing a strip of tensor fascia lata to
form arthroplasty.
FIG. 24-18 Total elbow joint replacement arthroplasty. (A) Preoperative

and (B) postoperative radiographs. (C and D) Result showing good range
of movement.
Excisional arthroplasty
It is indicated in a stiff (ankylosed) elbow joint due to rheumatoid
arthritis or trauma.
In this operation, a gap is created by excision of the lower end of the
humerus and/or upper end of the ulna and radius (Fig. 24-17A). Some
surgeons prefer to use a strip of fascia lata to interpose between the
cut ends of these bones (Fig. 24-17B).
Postoperative regime: The elbow is immobilized in an above-
elbow POP slab after the operation. The slab is removed after 2–3 days
and the limb is given a below-elbow skin traction and suspended in
an overhead traction. Mobilization of the elbow in traction is started
as soon as the pain permits. The traction is removed at the end of 2–3
weeks after operation and the mobilization programme is intensified.
The patient may regain a functional range of elbow movement but
may lose stability and strength at the elbow to a certain extent.
Notwithstanding these limitations, patients generally do well.
Elbow joint management whether surgical or conservative always
poses problems, especially in adults.
Excisional arthroplasty gives a mobile elbow joint but at the cost of
its stability. Therefore, physiotherapy is mainly directed to achieve
active mobility of the joint. This includes painful, tiring and
concentrated efforts by the patient. The management falls into two
phases:
1. Preoperative assessment and training
2. Postoperative hard work
1. Preoperative assessment and training: Assess the elbow

joint thoroughly and objectively for:
(a) The strength of the muscles around the elbow joint
(b) Active as well as passive ROM of elbow flexion–

extension, pronation and supination
(c) Assessment of the range of motion and muscle power at

the adjacent joints
The physiotherapist should explain to the patient the

postoperative regime of exercises. The preoperative
training can be practised on the normal elbow. Electrical
stimulation can be used as an adjunct to educate as well as
to strengthen the flexor and extensor muscles of the stiff
elbow joint. When the joint is not totally ankylosed,
surgery should be undertaken only after strengthening the
muscles around the elbow joint. These include repeated
self-resisted isometric and isotonic contractions of the
flexor and extensor muscles as well as pronator and
supinator muscles.
Ideally the surgery should never be undertaken without

enough preoperative physiotherapy or enough strength in
these muscle groups.
2. Postoperative physiotherapy: Immediate postoperative

phases
◼ Maintain operated limb in elevation (sling suspension)
◼ Deep breathing exercises and coughing to avoid chest

complications
◼ Pulsed electromagnetic therapy like diapulse can be given

over the cast
◼ Initiation of static contractions inside the cast ensure its

efficacy by palpation
◼ Full range of movements to the shoulder, wrist and hand
should be given as soon as pain permits. Repeated
movements to the related joints promote reduction in pain
and swelling by improving circulation.
◼ Repetitive self-assisted shoulder movements (relaxed

rhythmic pendulum mode) are ideal.
Third day to tenth day
1. Intermittent removal of cast and initiation of small range of relaxed

passive movements, if the pain and swelling permit. Small range CPM
roller skates are helpful.
2. Vigorous isometric contractions should be done for 5 min every

hour.
3. Sessions of electrical stimulation synchronised with active effort by

the patient are very useful during this period. It promotes re-
education of the muscle power.
From tenth day to 3 weeks

This is the most crucial period which needs concentrated effort. By
now the stitches are out and the swelling and pain are less.
Mobilization: There are two methods of mobilization which are
more acceptable to patients.
1. Small-range pendular movements of flexion–extension: The patient

assumes prone-lying position with the shoulder in 90 degrees of
abduction, elbow hanging over the edge of the plinth (see Fig. 7.3) and
does self-controlled relaxed free movements of elbow flexion–
extension.
2. Arm well supported over a sand bag and placed on the table with
the shoulder in abduction and a few degrees of horizontal abduction.
The physiotherapist stabilizes the humerus just above the elbow joint
(Fig. 24-19). Roller skates can be used to perform small range of active
free movements of elbow flexion–extension (see Fig. 7.3B). This
should be performed several times a day.
3. Pronation–supination can be initiated by the patient sitting with the

back against the wall and the posterior aspect of the elbow touching
the wall. The physiotherapist stabilizes just above the elbow joint. The
patient with his/her normal hand supports just above the wrist and
performs relaxed assisted movements of forearm pronation–
supination (see Fig. 8.5).
FIG. 24-19 Active assisted, gravity eliminated elbow flexion–extension.
Caution
While doing this exercise, the elbow, flexed to 90 degrees, should be
kept in contact with the trunk. This will avoid tricky movements in
which the patient has a compensatory tendency to abduct the
shoulder for pronation and adduct it for supination.
4. Vigorous progressive resistive exercise programme for the wrist

and finger flexors as well as for the extensor muscles is of immense
value. Strengthening of these muscles improves the stability of the
elbow joint.
5. The range of motion and muscle power are reassessed.
6. Hydrotherapy can prove very effective at this stage.
Though the elbow flexors are functionally important, extra attention

is necessary to strengthen the triceps. The posterior surgical approach
involves incision of the triceps which causes great mechanical
disadvantage to the action of the triceps resulting in weak extension of
the elbow. By the end of 3 weeks, a definite trend of improvement
should be noticed.
After 3 weeks
This is the phase of vigorous physiotherapy to regain maximum
mobilization and muscle strength. However, pain may be aggravated
during this period as gentle sustained stretching techniques are
incorporated.
Stretching for flexion

This is done by the assistance of gravity and if possible with small
weight (e.g., 1/2 lb weight belt). We use a knee rachet in this
technique.
The patient is in supine position; the operated arm is well secured
over the ratchet. Initially, relaxed active movement of flexion is
performed towards gravity. After doing it several times, a small
weight is added. The patient relaxes the elbow joint to the maximum
and the flexion is facilitated by weight and gravity (Fig. 24-20A). If
painful, the patient can support forearm by the contralateral hand.
FIG. 24-20 (A) Gravity, weight-assisted flexion. (B) Extension on knee

rachet.
For extension, hinge of the rachet joint is straightened and the same
principle is used to promote extension (Fig. 24-20B).
Programmes of mobilization with roller skates and strengthening
are made vigorously.
The patient should be made to hold this position with active effort.
By this time, pronation–supination should be near normal.
If the skin condition and the surgical incision are healthy, paraffin
wax bath preceding mobilization and stretching manoeuvres provides
excellent relaxation for the afore-mentioned procedures.
Progressive strengthening exercises for the biceps brachii against
graded weights can be given by holding wand and weight in sitting.
For the triceps, the position should be prone lying with the shoulder
in abduction and the forearm hanging over the edge of the plinth.
Functional use of the hand in activities like eating, lifting and
placing light objects, combing hair, shaving, buttoning, dressing and
scratching the back should be encouraged, may be with little
assistance. These natural movement patterns are effective means of
treatment.
Judicious planning and executing the regime of exercises can result
in a functionally useful elbow within 8–12 weeks of surgery.
Note:
◼ After each exercise session, the elbow should be maintained in the

position of maximum flexion achieved with exercise.
◼ At this stage, guiding and supervising the patient in performing

self-strength mode is a must.
Observations
1. Excessive surgical excision of the joint can result in flail and

unstable elbow. The relative lengthening of the common flexor and
extensor groups renders great mechanical disadvantage to the
effective action of these muscles. Therefore, it results in an unstable
and weak elbow joint where flexion and extension more or less remain
only a passive entity. In these patients, a brace with an elbow hinge
provides a mechanical advantage to facilitate muscle action, and
strengthening. In case of a weak elbow, the brace can be locked at a
desired angle for functional use.
2. Surgery in long-standing ankylosis may give a partially mobile but

weak elbow joint. This may be due to the marked disuse atrophy of
the muscles.
Interpositional (fascial) arthroplasty

In this procedure, the lower end of the humerus and the upper end of
the ulna are excised. The exposed ends of both these bones are
covered by fascia lata strip.
The postoperative management including physiotherapy is similar
to that of excisional arthroplasty.
Implant (total joint replacement) arthroplasty

Total replacement of the elbow joint is undertaken when there is
massive destruction of the joint due to rheumatoid arthritis,
posttraumatic arthritis, etc., and as a reconstructive procedure after
tumour resection.
In total replacement arthroplasty of the elbow, the joint is replaced
by metal or plastic hinge prosthesis.
This procedure succeeds in providing adequate stability and
mobility to the joint to a limited extent, allowing light sedentary
functions.
Physiotherapeutic management preoperative assessment:
It consists of evaluation of:
1. Range of motion, passive as well as active
2. Muscle power and endurance of the flexors, extensors, pronators

and the supinator groups
3. Degree of deformity
4. Sensory status of the arm, forearm, wrist and hand
5. Integrity and functional efficiency of the shoulder, wrist and hand
Preoperative training
1. In view of the expected postoperative weakness, vigorous exercise

regime is taught to improve the strength and endurance of the elbow
flexors, extensors and forearm rotators. The programme of training
should be initiated on the normal/better limb.
2. To improve the overall functional efficiency of the extremity as a

whole, free and strong range of movements should be achieved at the
related joints. This will facilitate function in the presence of
moderately stiff and weak elbow joint.
Postoperative phase
During immobilization (first week)

The limb is immobilized in elevation with pressure bandage and
posterior plaster shell. The physiotherapy is aimed at:
1. Reduction of inflammation
2. Thorough check on positioning and immobilization
3. Early active movements to the fingers and thumb
4. Checking the integrity of the radial, median and ulnar nerves
5. Examining the status of circulation
6. Initiating isometric light contractions to biceps brachii and triceps

within the limit of pain
Mobilization (second week onwards): If the soft tissue
healing is satisfactory and the reconstructed joint is stable
in the optimal position, low-grade mobilization may be
initiated at the earliest. The splint is removed temporarily
for exercises.
1. Initiation of movements: Elbow is put in a gravity

eliminated position over the top of the table with the
shoulder in full abduction and 30 degrees of flexion. The
arm is supported by a thick pad from axilla to well above
the elbow joint. This allows the elbow to be free from any
friction. Physiotherapist stabilizes the arm above the
elbow with one hand, and totally supports the forearm
just proximal to wrist from below by the other hand (Fig.
24-20). The patient then actively attempts to flex the
elbow. He/she is trained to reinforce elbow flexion by
clinching fingers and holding wrist in flexion, while
attempting flexion. The whole procedure is reversed to
initiate extension. The elbow is put back in the splint
after exercises.
2. Isometrics are made vigorous within the splint.
3. Gravity-assisted flexion with arm secured on a rachet (as

described earlier for elbow mobilization) should be
started.
4. If feasible, CPM or roller skates could be used to great

advantage.
5. The movements of pronation and supination initiated as

relaxed passive procedure may be progressed to assisted
active and active movements.
6. Functional training in sedentary activities to be

instituted and encouraged. Heavy movements like
carrying or lifting weights are to be discouraged.
Similarly, using the arm for weight bearing, like
supporting over the arm rest of a chair while getting up
or sitting is to be strictly avoided.
Fairly useful function should be regained by 8–12 weeks.
Arthroplasty of the WRIST joint (fig. 24-21A and B)

Total replacement of the wrist joint has not been in much demand
because of two reasons:
1. It is difficult to achieve balanced action of the wrist flexor and

extensor muscles due to the extensive destruction of the tendons with
anterior subluxation as in rheumatoid arthritis.
2. Arthrodesis provides better functional stability to the wrist which

facilitates hand function.
FIG. 24-21 (A and B) Total wrist joint arthroplasty.
However, a total joint prosthesis allows limited mobility and pain

relief. The metacarpal component is fitted into the capitate, third
metacarpal bed, and the radial component is fitted with cement into
the distal radius.
After operation, the wrist is immobilized for about 8–10 days, after
which gradually the mobilization is begun. However, a splint is used
intermittently for the next 6 weeks.
Physiotherapeutic management (table 24-5)
Preoperative assessment: Wrist joint is evaluated for:
◼ Active as well as passive range of motion
◼ Muscle power and endurance of the wrist flexors and extensors
◼ Grip and pinch strength measurement by dynamometer
◼ ROM and strength of the other joints of the extremity
Table 24-5
Physiotherapy Schedule for Total Wrist Arthroplasty
First week
Hand splinted in slight radial deviation to counter ulnar deviation forces; repeated movements of
shoulder, elbow and fingers to be done
Second week to fifth week
Relaxed passive and active assisted wrist movements, avoiding ulnar deviation, should be initiated and
progressed
Selective strengthening of wrist extensors, to strengthen the grip
Dynamic splint should replace the static hand splint
Sixth and seventh week
Initiate full range passive movements without ulnar or radial deviationConcentrate strengthening all the
hand grips as well as the coordinated movements of hand in relation to shoulder, elbow and forearm
Caution
No lifting of heavy weight of more than 5 lbs in future; no heavy pulling or pushing using operated hand;
body weight stretch like putting body weight on arms are contraindicated
Note: Wrist is the only joint where arthrodesis is a preferred method
of treatment as stability is a better choice than weak functional
mobility.
Preoperative training: It is basically directed towards the following:
◼ Strengthen the flexor and extensor muscle groups at the wrist.

These muscles are usually weak because of the distortion of the
joint. They are at a great mechanical disadvantage to act effectively.
Strengthening procedures are taught with correct stabilization of
both the segments (distal part of the forearm and proximal portion
of hand). Isometrics are extremely valuable. Isotonic in a limited
pain-free ROM should be autoresisted and in the correct groove of
movement.
◼ Stiffness or weakness at any other related joints of the extremity

should be treated to increase the strength and freedom of the
movements to the maximum.
◼ Teaching of postoperative physiotherapy regime.
Postoperative regime: The wrist and the hand are fixed with
dressing plaster splint. The arm is kept in elevation.
◼ Careful check of the immobilization is done.
◼ Status of circulation, sensation and any nerve compression

symptoms are checked.
◼ Early initiation of finger, shoulder and elbow movements

supporting the operated arm is taught to the patient. These self-
assisted movements should be performed in the maximum possible
range.
Mobilization
When the cast is removed, wrist mobilization and strengthening
techniques should be initiated and progressed gradually.
◼ Relaxed passive wrist flexion and extension is initiated in a gravity-

eliminated position with full support and secured stabilization (on
the same lines as for elbow).
◼ Active and active assisted movements to be made intensive.

Functionally important position of wrist extension needs extra
emphasis.
◼ Functional activities (self-assisted) to be initiated and progressed at

the earliest.
◼ Functionally useful, painless wrist joint should be regained by 4–6
weeks.
Arthroplasty of the hand

Arthroplasty of the joints of the hand is indicated in painful stiff joints
and/or in case of deformity preventing hand function, following
rheumatoid arthritis, degenerative or traumatic conditions or crush
injury.
Excisional (resection) arthroplasty

Excisional arthroplasty of the proximal interphalangeal (PIP) joints of
the finger is rarely indicated in cases of infective arthritis. In this
operation, the head of the proximal phalanx is excised, the wound is
closed and the finger is given traction through the distal phalanx (Fig.
24-22) for about 6 weeks. The patient may regain some degree of
useful movements at the PIP joint but usually instability at the joint
persists.
FIG. 24-22 (A) Resection arthroplasty splint with traction through the distal
phalanx. (B) Implant arthroplasty. Splint holding metacarpophalangeal
(MCP) joints in maximum corrected position.
Implant (replacement) arthroplasty

This type of arthroplasty is commonly indicated in MP joints and
occasionally in PIP joints. Swanson (Swanson et al., 1982) silicon
prostheses are most commonly used in this procedure. The articular
surfaces of the two adjoining bones of a particular joint of the finger
are excised and the stems of the finger joint prosthesis are fixed into
the medullary canals of the two bones (Fig. 24-23). Postoperatively the
joint is mobilized after a week or 10 days.
FIG. 24-23 Rheumatoid hand – implant arthroplasty. (A) Preoperative –

ulnar deviation of fingers. (B) Postoperative photograph after MCP joint
arthroplasty – deformity corrected. (C) Postoperative radiograph – after
MCP joint arthroplasty.
Aim: Return of optimal pain-free maximal functions of the hand.
Preoperative assessment
◼ Evaluation of the active and passive ROM of the concerned joint
◼ Evaluation of strength and endurance of the related muscle groups
◼ Evaluation of strength of hand and pincer grip by dynamometer
◼ Evaluation of degree of pain and its character
◼ Overall functional evaluation of the whole limb and in relation to

the ADLs
◼ Education on the postoperative regime
◼ Evaluate and analyse the difficulties of the patient in performing

certain ADLs, to facilitate focused therapeutic procedures
Excisional or resection arthroplasty

◼ Check the alignment of the traction and circulation to the finger
◼ Prevention of inflammation and its complications
◼ Active resistive movements to the joints free of immobilization
Instability at the resected joint is the major drawback of this surgical

procedure. Therefore, maximum emphasis is on various strengthening
procedures to the flexor and extensor groups. As soon as traction is
discontinued, graduated mobilization is given to the
metacarpophalangeal (MCP), PIP and distal interphalangeal (DIP)
joints.
Isometric and isotonic exercises for both flexor and extensor muscle
groups are concentrated at the PIP and DIP joints.
◼ Active use of hand is encouraged. A splint may be necessary to
stabilize the MCP joint.
◼ Resistive exercises should be initiated as early as possible to regain

full function.
Implant arthroplasty
Early postoperative regime is the same as described for resection
arthroplasty. A dynamic splint holding the MCP joints in maximum
corrected position and offering resistance to flexion can also be
applied.
Postoperative regime: After surgery, the hand is supported in a
pressure dressing with elevation.
1. Control inflammation.
2. Full arc movements to the shoulder and elbow help improve

circulation to the operated area.
3. Fingertips and thumb should be checked for the status of

circulation.
Mobilization: Controlled mobilization by dynamic flexion

assist splint plays an important role in the return of
function following implant arthroplasty. The methods of
mobilization fall into three types as advocated by three
eminent hand surgeons.
1. Madden (1977) advocated the use of dorsal splint

stabilizing the wrist in 15–20 degrees of extension. The
splint has an adjustable transverse bar to secure a rubber
band and loop for each finger. This splint is applied as
soon as the swelling is reduced. He recommended early
initiation of passive movements with prolonged use of
the dynamic splint.
2. Wynn Parry (1981) preferred plaster cast for a long
duration till healing of the extensor expansion was
complete up to 3 weeks. MCP flexion is limited to 30
degrees but full flexion–extension is allowed at the
interphalangeal joints. After 3 weeks, the exercise
programme is gradually progressed from relaxed passive
movements to resisted movements of the MCP joints.
3. Swanson regime: As soon as swelling of the hand is

reduced, protective movements are initiated on the third
or fifth postoperative day. Dynamic splint with rubber
outrigger is positioned accurately to prevent ulnar
deviation, and allows 70 degrees of flexion at the MCP
joints. Maintenance of flexion in 70 degrees is of vital
importance during the period of 3 weeks. The brace
needs to be continued in the event of extensor lag,
tendency for ulnar deviation or flexion contracture.
ADL using the affected hand is encouraged along with other
progressive procedures of improving strength, ROM and endurance.
Periodical monitoring of grip and pinch strength is done to assure
improvement.
Fully functional hand should be restored within 3 months of
surgery.
Arthroplasty of the PIP joints

As this operation does not involve tendon reconstruction, active
physiotherapy can begin early.
◼ A splint is applied to maintain neutral position of the PIP joint.
◼ Active flexion can be started as early as 3–5 days, postoperatively.
◼ Adequate measures should be adopted to evaluate and treat

extensor lag, which is a common feature following this operation.
◼ Proper watch should also be kept on the development of angular

deformity. Strapping of the aluminium splint to the appropriate side
of the finger may be necessary to control angular deformity.
Osteotomy
The major objective of this procedure on the bones is to improve the
functional status of the limb.
It is achieved either by surgical correction of the bony deformity or
by providing stability to the joint.
It is done by dividing or cutting the bone wedge and realigning or
reconstructing the joint.
Basically, it converts the shearing force into a compressive force by
changing the line of weight bearing.
It is performed in three distinct stages.
Stage I: A stage of division of the bone

The bone is cut or divided close to the deformity by (a) single
transverse cut, or (b) by removing a piece of bone (wedge), (c) by
reconstructing the joint following division, the two ends of the bone
are brought together to correct the anatomical alignment, or
reconstructed to provide stability to the joint, or by altering shearing
forces at the fracture site into compressive forces by changing the line
of weight bearing (Fig. 24-24).
FIG. 24-24 Some osteotomy procedures.
Stage II: A stage of immobilization

After achieving the objective of correct anatomical alignment or
stability to the joint, immobilization is done in this position either by
POP cast, internal fixation or by external fixation as feasible.
Stage III: A stage of achieving the optimal functional

restoration
Once the proper consolidation of osteotomy is ensured, vigorous
physiotherapy is required to restore the optimal function of the
concerned joint or limb.
Osteotomy is indicated in several bony and joint dysfunctions or
bony deformities for various purposes (Tables 24-6–24-8).
Table 24-6
Indications for Osteotomy
Objective Indication
• To correct the bony deformity (e.g., angulation, bowing or • Malunited fractures
rotation) • Structural bony deficiencies
• To centralize the long axis of a limb or joint to control e.g., rickets, Paget disease
deformity, pain and progressive worsening • Compartmental degenerative
joint changes
• Unequal bone growth due to
epiphyseal injury or disease
• To correct joint subluxation, dislocation, or slipping of the • Perthes disease
epiphysis (slipped upper femoral epiphysis) by bony • Congenital dislocation of hip
reconstruction (CDH)
• Slipped femoral epiphysis
• Correction of the fixed joint deformities obstructing the joint • Fixed deformities at the
function shoulder or hip joint
• To augment union in ununited fractures • Old ununited fracture of femur,
nonunion fracture of the neck of
femur
• To correct cosmetic defects • Excessive bowing or
angulation, etc.
• To correct leg length disparity • Shortening or lengthening the
bones
Table 24-7
Osteotomies in the Upper Extremities and Spine
Shoulder joint Painful arc syndrome of shoulder

(scapula)
Stamm’s glenoid
osteotomy
Humeus (upper) • When the shoulder joint has fixed in adduction and internal rotation deformity
• Abduction
osteotomy
Elbow • To correct marked cubitus varus by removing wedge on the lateral side of the
• Wedge humerus
osteotomy • To improve elbow flexion by inserting a bony wedge posteriorly into the lower
(French end of the humerus
osteotomy)
Forearm and wrist • To correct deformity following malunited Colles’ fracture
• Fernandez
and
Campbell’s
distal radius
osteotomy
Spine
Vertebral • When there is lumbar spinal fusion (severe fixed flexion deformity occurs at the
osteotomy lumbar region) following ankylosing spondylitis; posterior wedge osteotomy from
the bodies of the two adjacent vertebrae helps produce angular lordosis at the
lumbar region
Table 24-8
Osteotomies in the Lower Extremities
Bone or Joint Purpose
Pelvis To prevent or control congenital dislocation of hip
• Salter’s osteotomy (CDH), OA hip, fracture of femoral neck
• Chiari’s osteotomy
• Pemberton’s osteotomy
• Pauwel’s osteotomy
Hip joint • To correct valgus deformity by varus
• Coxa valga (McMurray’s displacement osteotomy
osteotomy) • To correct varus deformity by valgus
• Coxa vara (McMurray’s intertrochantric osteotomy in old fractures of the femoral neck
osteotomy)
• Intertrochantric triplane osteotomy or Dunn’s • When the fusion of the epiphyseal plate has
procedure of cervical osteotomy taken place
• Pauwel’s osteotomy • When epiphyseal plate is not closed
• Shaft of the femur or tibia corrective osteotomy • OA hip or nonunited fracture of the neck of
• Lower tibial osteotomy the femur
Knee joint • Varus osteotomy to correct valgus deformity,
(Genu valgum or fixed flexion deformity) e.g., OA knee
• High tibial osteotomy, femoral supracondyler • Valgus osteotomy to correct varus deformity,
osteotomy or Maquet’s dome osteotomy (genu e.g., OA knee
varum) • Bowing or angulation following rickets,
• High tibial osteotomy or femoral (supra- fibrous dysplasia, or malunited fractures or
condyler osteotomy) Paget disease
• To prevent secondary OA changes following
malunited fracture at the ankle
Ankle and foot • To correct foot deformity in CTEV
• Dawyer’s osteotomy • To correct varus foot in CTEV
• Dilwyn Evans osteotomy
Toe • To correct hallux valgus deformity
• Osteotomy of first metatarsal • To correct talipes equinovarus, claw foot
• Osteotomies at
• Calcaneous
• Mid tarsal joints
• Tarso-metatarsal regions
Note: There is a long list of such corrective and stabilizing
osteotomies. The surgical procedures of various osteotomy sites are
presented with each joint in the relevant chapters.
Physiotherapeutic management following osteotomy

Objective: To improve both ROM and muscle functions.
Pre-operative education
◼ The related musculoskeletal structure of the joint to be operated

should be given special sessions of exercise and movement training.
It may include compensatory trick movements, postural
adaptations, orthotic aids, etc. to perform functional tasks (e.g.,
substitution of shoulder abduction by shoulder girdle elevation,
trunk lateral flexion to the opposite side – a planned shoulder joint
arthrodesis).
◼ If not, restore full ROM with improvement of strength, endurance

and flexibility of the related joints of the joint to be arthrodesed.
◼ Measures to reduce pain and swelling, placing a limb in

comfortable relaxed position.
◼ Keeping a watch on the expected postsurgical complications as

related to the procedure of surgery and the site.
◼ Ensure the stability of the operated joint.
◼ Initiate repetitive isometrics in repetitive small bouts to the muscle

groups under immobilization.
◼ Strong active movements to the joints free of immobilization and

the functional muscle groups.
◼ Initiate preliminary functional activities with guidance and

assistance (e.g., shifting in the bed, sitting up, supported standing
progressing to non-weight bearing (NWB) ambulation or using
operated upper extremity as an assisting arm).
During mobilization
◼ Improving all the functions of the muscle groups, especially around

the operated joint and concentrated mobility exercise training to
improve the ROM should be initiated immediately. Objective
training on tricky movements.
◼ Isometrics and self-resistive type of exercise training to improve

strength and endurance and relaxed free repetitive movements are
the mainstay as soon as the immobilization is discontinued.
◼ Adjunctive procedures of thermotherapy like hydropack around
the operated area (excluding skin incision) are ideal to induce
relaxation and comfort before mobilization.
◼ Initially well-supported objective functional re-education should be

begun as early as possible in a graded manner and guidance.
◼ Manual therapy procedures and PNF techniques play an important

role in achieving early optimal functional restoration.
Note: Longer period of immobilization is always associated with
limitation of joint movement and disuse atrophy of the muscle
groups under immobilization needs extra efforts and early attention.
References
Total hip replacement arthroplasty (THR)

1. Beber CA, Covery F R. Management of patients with total hip
replacement. Phy Ther,. 1987;52:823.
2. Charnley J. Total prosthetic replacement of the hip in relation
to physiotherapy. Physiotherapy,. 1968;54:406.
3. Evarts CM, Feil E T. Prevention of thromboembolic disease
after elective surgery of the hip. J Bone Joint Surg. 1971;53A:1271.
4. Knott M, Voss D E. Proprioceptive neuromuscular facilitation.
NY, Evanston, and London: Harper & Row Publishers. 1968.
5. Lansky M G. A method for grading hips. J Bone Joint Surg,.
1967;49B:644.
6. Yoslow W, Simeone J, Huestis D. Hip replacement:
rehabilitation. Arch Phys Med and Rehabil. 1976;57:275.
Girdlestone arthroplasty
7. Joshi J. Our experience with the girdlestone arthroplasty. J Phy
Occ Therapy & Rehab, III. 1979;7.
Total knee replacement arthroplasty
8. Coutts F, Hewetson D, Matthews J. Continuous passive
motion (CPM) of knee joint, used at the Royal National
Orthopaedic Hospital. Physio. 1989;75:427.
9. Dorr LD, Boiardo R A. Technical considerations in total knee
arthroplasty. Clin Orthop. 1986;205:5.
Arthroplasty of ankle
10. Mc Guire MR, Kyle RF, Gustilo RB, Premer R F. Comparative
analysis of ankle arthroplasty versus ankle arthrodesis. Clin
Orthop,. 1988;226:174.
Arthroplasty of shoulder
11. Beddow FH, Elloy M A. Joint replacement in the upper limb
The Liverpool total replacement for the glenohumeral joint. London:
Mechanical Engineering Publications Ltd. 1977;21-25.
12. Neer CS, Watson K C. Recent experience in total shoulder
replacement. J Bone Jt Surg,. 1982;64A:319-377.
Arthroplasty of hand
13. Madden JW, de Vore G, Aren A J. A rationale of postoperative
programme for metacarpophalangeal implant arthroplasty. J
Hand Surg. 1977;2(5):358.
14. Swanson AB, DeGroot Swanson, G & Leonard, J. A. E. Inglis
Symposium on total joint replacement of upper extremity
Postoperative rehabilitation programme in flexible implant
arthroplasty of the fingers. St. Louis: Mosby. 1982.
15. Wynn Parry C B. Rehabilitation of hand 4th ed The rheumatoid
hand. London: Butterworths. 1981.
CHAPTER
25
Amputations
OUTLINE
◼ Definition
◼ Indications for amputation
◼ Level of amputation
◼ Foot amputations
◼ Prosthesis
◼ Prosthesis for lower limbs amputations
◼ Prosthesis for upper limbs amputations
◼ Upper and lower limb combination
◼ Instant prosthesis
Definition
Removal of limb, partly or totally, from the body, is termed as
amputation. Disarticulation is removing the limb through a joint.
Amputations are more common in men and more often in the lower
limbs.
Indications for amputation

1. Trauma: With an alarming incidence of road traffic accidents
(RTAs), amputation following trauma has become a common feature.
Attempts are always made to save the limb as far as possible. When
there is extensive loss of tissue and disruption of blood supply, no
other alternative is left to the surgeon but to amputate.
2. Malignant tumours: Amputation is considered for extensive

malignancy. This is done to save life and to prevent recurrence.
However, the increased use of limb salvage procedures has reduced
the need for amputation.
3. Nerve injuries and infections: Anaesthetic limb often develops

ulcerations, infections and severe tissue damages. The tissue damage
due to repeated infections and ulcerations may lead even to
autoamputation in neglected patients (e.g., Hensen disease). When
ulceration and infection persist and fail to respond to the medical
treatment, amputation is performed.
4. Extreme heat or cold: Injuries following electrical burns, accidental

burns as well as exposure of the limb to extreme cold conditions may
need amputation. Thermal injuries may at times lead to extensive
tissue destruction or deformities. Prolonged exposure of the limb to
extreme cold conditions results in the blockage of the blood
circulation leading to gangrene.
5. Peripheral vascular insufficiency: Irreversible loss of vascularity to a

limb due to diseases like diabetes, Berger disease, atherosclerosis,
embolism, arterial thrombosis, arteriovenous aneurysms or trauma,
leading to gangrene are absolute indications for amputation.
Advances in arterial surgery have reduced the incidence of
amputation following these conditions. However, in neglected cases,
many a time massive tissue destruction and gangrene leave no
alternative, other than amputation.
6. Congenital absence of limbs or malformations: Various types of

congenital malformations and the absence of bones are not
uncommon. There may be an incidence of rudimentary limb
structures proximally with apparently normal terminal segment or its
reverse. Bilateral rudimentary distal segment amputees can be
managed with bilateral orthoses specially designed to accommodate
the deformity. But, when rudimentary portions of limb interfere with
fitting of the prosthesis, amputation becomes necessary.
Reconstructive procedures with repeated surgery in

childhood many a times result in severe limb length
discrepancies incompatible with normal walking, and
hence may need an amputation/disarticulation. An
example can be proximal focal femoral deficiency (PFFD)
where severe shortening may necessitate amputation and a
proper prosthetic fitting.
7. Severe infection: Severe infections like gas gangrene, or chronic

intractable infections like osteomyelitis and unstable diabetes mellitus
may also need amputation.
Level of amputation
In a limb, an amputation is carried out at a level which will give the
stump an optimum length to facilitate subsequent prosthetic fitting.
For example, for an above-knee amputation (now termed as
transfemoral amputation), the optimum length of the stump is taken as
25–30 cm as measured from the tip of the greater trochanter. Similarly,
for a below-knee (transtibial) stump, the suggested optimum length is
15 cm as measured from the tibial tubercle. However, with recent
developments in the fabrication and fitting of prosthesis, it is not
necessary to stick to these stump lengths. The prosthesis (artificial
limb) can be custom-made to fit at different lengths. The level of
amputation is determined by the viability of the tissues. It is, however,
important that the stump should have a well-healed, nontender,
supple scar. It is also important that a joint must always be preserved,
whenever possible.
Upper extremity (fig. 25.1A–C)
◼ Forequarter amputation (scapulothoracic amputation) is carried out
proximal to the shoulder joint. It is indicated for malignant bone
tumours of the upper end of the humerus. In this type of
amputation, part of the scapula and clavicle are removed along with
the shoulder girdle muscles.
◼ Shoulder disarticulation is generally not so popular in the upper limb

except at shoulder. Even in disarticulation of shoulder, the head of
the humerus is preserved, wherever possible, to maintain the
contour of the shoulder for cosmosis.
◼ Above-elbow (AE) amputation (transhumeral amputation): A 20-cm-

long stump as measured from the tip of the acromion is ideal (Fig.
25.1C).
◼ Below-elbow (BE) amputation (amputation through the forearm

bones, now termed as transradial amputation): The optimum length of
a BE stump is 20 cm as measured from the tip of the olecranon (Fig.
25.1C), with a minimum length of 7.5 cm.
◼ Krukenberg amputation: This is performed in patients, usually with

bilateral BE amputations, who have a sufficiently long BE stump. In
this operation, the forearm is split between the radius and the ulna
to provide the pincer grip. The patient can hold a spoon or lighter
objects with this ‘fork’. For cosmetic purposes and for lifting heavy
objects, a BE prosthesis or a ‘hook’ prosthesis, respectively, can be
put over this stump.
◼ Amputation through the hand: This is designed to preserve as much

length as possible to contribute to the overall function. Exception to
this dictum is traumatic amputation through the proximal phalanx
of a finger. Here the short stump is of no use and, in fact, hinders
with the function of the hand, as things keep falling through the
gap. Therefore, the ray is removed by amputation through the neck
of the metacarpal. Ray amputation through the neck of the
metacarpal is also done in index and little fingers for cosmetic
reasons. However, in case of thumb amputations, the maximum
possible length is preserved without any reservations. Subsequent
reconstructive procedures, such as metacarpal lengthening (Fig. 25-
2) or composite bone grafts or toe transfer, are performed for a
thumb with a short stump.
FIG. 25-1 Levels of amputation. (A) Upper extremity. FQ, forequarter; SD,
shoulder disarticulation; AE, above elbow; ED, elbow disarticulation; BE,
below elbow; WD, wrist disarticulation. (B) Lower extremity. HQ, hind
quarter; HD, hip disarticulation; ST, subtrochanteric; AK, above knee; SC,
supracondylar; TK, through knee; BK, below knee; SY, Syme’s; CH,
Chopart; TM: transmetatarsal. (C) Ideal length of the stump at various
levels: 1. above elbow (20 cm), 2. below elbow (20 cm), 3. above knee (25–
30 cm), 4. below knee (14 cm).
FIG. 25-2 Metacarpal lengthening for a thumb with a short stump. (A)
Preoperative radiograph. (B) Lengthening is being done after corticotomy of
the metacarpal and distraction by an external fixator.
Lower extremity (fig. 25-1B and C)

◼ Hindquarter amputation (transpelvic amputation): It is indicated for
malignant tumours at the upper end of the femur or in pelvic bones.
In this operation, part of the pelvis is removed along with the lower
extremity.
◼ Hip disarticulation: It is an occasionally performed operation where the
femur is removed from the acetabulum. It is not a usual operation as the
prosthesis has high-energy requirements for walking.
◼ Above-knee amputation (amputation through the thigh, now termed

as transfemoral amputation): The optimum length of the above-knee
stump is about 25–30 cm as measured from the tip of the greater
trochanter (Fig. 25.1C). The minimum length for a useful stump is
about 7.5 cm.
◼ Knee disarticulation: It can be done through the knee as well.

However, through knee disarticulation is cosmetically unacceptable
in women as the prosthesis required is rather bulky at the knee and
hence not attractive. Transtibial amputation is generally preferred to
the through knee disarticulation. However, a well-performed
amputation may provide a good weight-bearing platform.
◼ Below-knee amputation (now termed as transtibial amputation): It is the

most commonly performed amputation, mostly following severe
trauma to the foot and leg and gangrene of various aetiology.
◼ Crush injuries of the foot.
◼ Malignant bone tumour of the lower end of tibia.
◼ The amputation is performed through the leg bones. The optimum

length of the below-knee stump is 14 cm from the tibial tubercle
(Fig. 25.1C). A patellar tendon bearing (PTB) prosthesis can be fitted
over a stump of adequate length, while for a very short stump, the
conventional below-knee prosthesis is the only alternative. The
energy consumption for walking in a transtibial amputee is less
because the knee joint is preserved.
◼ Syme’s amputation: In this operation, the tibia and fibula are divided
just above the ankle joint. The intact skin over the heel is attached
back to the end of the stump with or without a part of the calcaneum
(Fig. 25-3). Because of the intact heel, it becomes an end-bearing
stump and the patients generally manage very well walking even
bare foot after this type of amputation.
FIG. 25-3 Syme’s amputation.
Foot amputations
◼ Toes: Amputation of great toe and other toes.
◼ Metatarsals: Amputation through metatarsal bones.
◼ Lisfranc amputation: Amputation at the level of tarso-metatarsal

joints.
◼ Midtarsal joint amputation: Also known as Chopart’s amputation,

where the amputation is performed at the level of midtarsal joints.
Amputation through various parts of the foot has almost become

obsolete these days. Wherever possible, a below-knee amputation is
preferred.
Types of amputation
There are two types of amputation: (i) closed amputation and (ii) open
amputation.
Closed amputation
In this type of amputation, the stump is closed primarily over the
bony stump by retaining skin and muscles at least 5 cm distal to the
bone end to facilitate closing of the stump. All elective amputations
are closed amputations.
Sequential steps in a closed amputation
Level of amputation
Amputation is performed retaining skin and muscles at least 5 cm
distal to the bony ends to facilitate stump closure. The muscles
provide a cushioning effect to the bone ends.
◼ The edges of the tibia are bevelled.
◼ Myoplasty is performed.
◼ Final closure of the stump with the skin is done.
◼ Fibular stump is always kept at a higher level than the tibial stump.
Open amputation (guillotine amputation)

It is undertaken as an emergency procedure and is also called
guillotine amputation. In this type of amputation, the skin is not closed
over the amputation stump. After amputation, the stump is left open
and dressed regularly till the infection subsides and the stump wound
becomes healthy. The stump is then covered by skin grafting or
secondary closure.
Open amputation is indicated in cases where the wound is grossly
contaminated or in cases of severe infections.
Care during the process of amputation

◼ Tourniquet: Except ischaemic limbs, malignancies or infections, for
the fear of spread of the disease, tourniquet is commonly applied
during amputation.
◼ Skin flap and scar: Stump must always be covered with a healthy
skin flap. Care should be taken not to allow the scar to be adherent
to the bone.
◼ Blood vessels: Should be individually isolated and ligated with

double ligation of the major vessels.
◼ Nerves: Must be isolated carefully, pulled and divided to avoid

stump neuroma.
◼ Muscles: They should be divided distal to the level of the bone cut.
Opposite groups of muscles are sutured together distal to the bone,
it (myoplasty). When the muscles are sutured to the end of the bone,
it is called myodesis.
◼ Bone: Excessive stripping of the periosteum may cause ring

sequestra and as such is contraindicated. The bone must be bevelled
or rasped to avoid bony prominences jutting at the skin.
◼ Drain: To prevent haematoma formation, suction drain is applied.
These factors will largely prevent post-operative

complications.
Postoperative management
The postoperative management of the stump is done by the following
two techniques:
1. Immediate postsurgical prosthetic fitting
A plaster cast mould is applied over the amputation stump

immediately after surgery to which a temporary prosthesis
(pylon) is attached the next day (Fig. 25-4). The patient is
then allowed partial weight bearing as early as the pain
permits. It has many advantages:
1. The plaster cast forms a protective cover over the stump,

preventing infection, etc. from outside.
2. Early ambulation improves circulation in the stump,

thereby facilitating healing.
3. Early ambulation in a temporary prosthesis instills

confidence in the patient and increases the chances of
early acceptability of a permanent prosthesis.
It, however, involves teamwork, and a perfect coordination

between the surgeon, the orthotic expert and the
physiotherapist.
2. Soft tissue technique
In cases where a temporary prosthesis is not fitted

immediately after surgery, an elastocrepe bandage is used
after applying sterile dressing. The stitches are removed
after 2 weeks.
The use of a crepe bandage, however, is continued for

another 3 weeks. It helps in shaping the stump well into a
conical shape which is considered ideal for the subsequent
prosthetic fitting.
FIG. 25-4 (A) Immediate postsurgical BK prosthesis. (B) Temporary pylon

with rocker bottom.
Physiotherapeutic management of the amputee

Physiotherapy plays the most significant role in the management of an
amputee from the time the surgeon decides for amputation till the
patient is back to his work. It involves an intensive course of
purposeful training and repeated long sessions of untiring effort.
The basic approach of physiotherapy is to establish a new
proprioceptive system of integrated impulses, which the nervous
system can understand, by vigorous training and association. To be
effective, it has to be adequately supported by visual and auditory
feedback. The management can be divided into three stages:
1. Preoperative stage
2. The early postoperative stage
3. The mobility stage
Stage wise principles of physiotherapy
1. During preoperative stage:
(a) Assurance
(b) Critical examination and assessment
(c) Education of major cares and graduated exercise along

with self-management procedures
2. During early postoperative stage
(a) Measures to prevent postsurgical complications
(b) Maintenance of strength and mobility of the joint

adjacent to the operated limb
(c) Management of the stump
(d) Stump conditioning
3. A stage of mobility and self-sufficiency

(a) Thorough checking of the fabricated prosthesis for a
comfortable fit
(b) Training on the methodology of applying prosthesis; its

care and maintenance
(c) Functional training and re-education with prosthesis

towards optimal self-sufficiency
1. Preoperative stage: It has the following functions:
(a) Assessment
(b) Preoperative training
(c) Reassurance
(a) Assessment: The preoperative assessment of the

affected limb as well as the patient as a whole is
conducted thoroughly. The ROM, muscle power,
condition of the skin, status of circulation and sensory
index need to be evaluated critically. The status of vision
and hearing, which plays an important role in training,
should also be assessed. The overall functional status of
the amputee, before surgery, needs to be analysed and
recorded.
The other important aspects like age, sex, occupation, general

physical status and the level of intelligence should be
observed carefully before planning the therapeutic regime
and the type of prosthesis. The underlying condition
necessitating amputation also needs careful consideration,
as it may be associated with future complications, e.g.,
vascular disease like atherosclerosis, systemic disease like
diabetes mellitus, trauma, tumour and congenital defects.
Assessment of the psychological status is extremely

important. The idea of losing a limb itself produces great
psychological trauma leading to depression. The degree of
psychological trauma to the patient is so high that on many
occasions, it is experienced that the patient prefers to have
his own functionally useless limb rather than having a
functionally working artificial limb. In the words of
Gordon Taylor, ‘It is no small presumption to dismember
the image of God’. The physiotherapist, due to his/her
constant association, is in the best position to convince and
boost the morale of an amputee, thereby greatly assisting
in improving the psychological status.
Besides these factors, it is important to know about the

environment of the patient’s home and his/her working
place, and also the nature and extent of the support he/she
is likely to get from friends or relatives.
(b) Preoperative training: Once the decision is taken on the

future plan of treatment, it is important to train the
patient on the postoperative therapeutic regime.
The basic aim of the preoperative training is to prevent the

complications of the postoperative phase, thereby reducing
the cost and the period of rehabilitation.
The preoperative training programme depends upon the

area of involvement, the methodology of management and
the ultimate objective of amputation. The programme
includes:
(i) Prevention of thrombosis by maintaining circulation

through movements of the other good limbs.
(ii) Prevention of chest complications by deep breathing,

coughing and postural drainage.
(iii) Preserve mobility of all the joints with emphasis on the

susceptible joints.
(iv) Improved mobility of other related areas like trunk,

pelvis or shoulder girdle to compensate for deficiencies
and restrictions due to prosthesis.
(v) Teach the methodology to be adopted for mobility and

limb positioning in bed.
(vi) Educate the patient on the techniques of transfers,

monitoring the wheelchair, single limb standing and
balancing.
(vii) It is necessary to explain to the patient all the

important aspects of balance, equilibrium, standing and
walking techniques he/she is supposed to adopt later on.
Ideally, this can be done by showing a video recording of
a patient using a similar prosthesis.
(viii) The patient should also be educated to detect possible

complications like soft tissue tightness, care of the
pressure points, and be made aware of the expected
degree of pain and phantom sensation.
(ix) Last but not the least, emphasis on training the exercise
techniques should be concentrated upon. Self-resistive
exercises, progressive resistive exercises as well as simple
techniques to improve endurance are taught on the
sound limb and their efficiency checked.
(c) Reassurance: Psychological reassurance plays a

dominant role in the recovery following amputation.
Reassurance with all possible encouragement is
absolutely necessary. It can be best done by practical
demonstration by a patient who has undergone similar
surgery and is now physically independent.
2. Early postoperative stage
(a) To check the efficacy of preoperative training: To check

and efficiently conduct the measures taught to prevent
chest complications. Provide guidance and assistance.
(b) Prevention of contractures and deformities: The

common contractures are adduction and rotation
contractures in upper extremity amputees; hip flexion
and abduction contractures following an above-knee
amputation and knee flexion contractures after below-
knee amputations. Bilateral amputees are more prone to
develop hip and knee contractures due to decreased
mobility and prolonged sitting postures, and need
special attention. These contractures can be prevented by
proper training in the positioning of the amputated limb,
at all the times – right from the day after surgery. The
common practice of using a pillow under the thigh or the
knee, although relieving pressure over the end of the
stump and giving comfort, is one of the commonest
causes of soft tissue contracture; therefore, it should be
discouraged. Hip flexion contracture can be prevented by
sessions of prone lying, initiated as early as possible. It is
also important to inspect and train to maintain the
proper level of the pelvis in all the postures.
Long periods of sitting as well as soft mattresses can

predispose to the development of flexion contracture at the
hip; hence, it should be avoided. Simple methods like
repeating sustained isometrics to the susceptible areas and
repetitive periods of lying prone can effectively prevent
development of flexion contractures at the hip, the most
disabling state to fit prosthesis as well as in performing
ambulatory activities. Repetitive check to prevent flexion
contracture at the hip is a must.
(c) Maintenance of strength and mobility: The patient

should be encouraged to move in the bed by pushing up
the body on the arms rather than dragging or using
monkey rings. This push-up exercise has the added
advantages of strengthening the muscle groups which
may be necessary for using ambulation aids at a later
stage, especially in bilateral amputees or in the older age
group. Vigorous ROM and strengthening exercises
should be given for the whole body except for the joint
proximal to the amputation. Bed activities like bridging
and rolling can be useful to initiate bed mobility.
After 3–4 days of surgery, stump exercises can be initiated as

active assisted or self-resisted exercises in a small range of
motion. This can be best done by the patient himself.
Assisted hip flexion, abduction and adduction movements
can be performed in back-rest sitting. Frequent periods of
prone lying and attempted hip extension with strong and
sustained contractions of the gluteus maximus are
valuable. Strong isometrics and slow self-generated tension
exercises provide good endurance training, as they are less
painful. They should be performed repeatedly for the
important functional muscle groups. If the patient is able to
sit and push his body in sitting, transfer activity can be
safely introduced at this stage.
Management of the stump: Improper management of the stump is
one of the major causes of delayed rehabilitation. Stump oedema
delays the prosthetic fitting and amputation.
Causes of stump oedema
◼ Surgical trauma itself – most common
◼ Incorrect bandaging of the stump
◼ Incorrect stump positioning
◼ Associated degenerative joint disease
◼ Uncontrolled diabetes
◼ Atherosclerotic disease
◼ Renal disease
The following measures should be taken to control oedema of the

stump:
1. Stimulation with limb in elevation with elastic bandage.
2. Resistive exercises to the stump and the rest of the joints.

3. Stump bandaging and conditioning: Bandaging plays an important
role in conditioning and shaping the stump by reducing stump
oedema. It accustoms the stump to the conditions of pressure. A crepe
or elastic bandage of sizes 4 or 6 inches is necessary. Usually a six-inch
bandage is used for above-knee stump and a four-inch bandage for
below-knee stump. The bandage should be worn during the night and
taken off during exercises.
Principles of bandaging the stump (Fig. 25-5)
1. The pressure of the bandage should be moderately firm and evenly

distributed, decreasing proximally. Extra pressure is necessary over
the corners to obtain a conical shape of the stump.
2. Diagonal, oblique or spiral turns should be used while bandaging,

as circular turns may produce a tourniquet effect leading to ‘choking’
of the stump.
3. In case of an above-knee amputation, the bandage must extend up

to the groin to prevent a roll of flesh forming over the adductor
tendons which may later on lead to follicle infection due to friction
with the socket of the prosthesis.
4. An above-knee stump should be bandaged with the hip in

extension and adduction. The below-knee stump should be bandaged
with knee in slight flexion.
Intermittent variable air pressure machine: This machine, also

known as a controlled air pressure machine, is used to control
oedema and preserve tissues by normal gaseous and water
exchange. It works on the principle of varying air pressure
around the stump, modifying the circulation of blood and
lymph.
Shrinker socks: An otherwise healed stump but with the

problem of persistent oedema can be managed by elastic
stump socks.
Rigid dressing: Below-knee amputation in young patients

without associated problems can be given a rigid plaster of
Paris dressing. Fitting of an early POP socket or a socket
made of thermoplastic material may be provided for upper
extremity amputees. This will reduce the oedema as well
as provide an attachment to the early postoperative
prosthetic device.
Caution
In patients with peripheral vascular disease and/or diabetes, stump
bandaging has to be done with utmost care, because when the
pressure of the bandage in these conditions exceeds the arterial
pressure in the stump, it causes pressure necrosis. Therefore, the
bandage should be applied with mild pressure. In these patients, the
stump must be checked repeatedly for any signs of pressure necrosis
to avoid revision of amputation.
FIG. 25-5 Stump bandages. (A) Above elbow. (B) Above knee.
Stump hygiene: This includes regular washing of the stump

with warm disinfected soap water and thorough drying.
The patient should also be educated on protecting the areas
and positions causing undue pressure on the raw areas of
the stump.
After removal of stitches: When the stitches are removed and
the suture line healed satisfactorily, the most important
aspect is stump conditioning.
Stump conditioning: This is to acclimatize the stump to

various situations of pressure to be experienced after the
fitting of the prosthesis.
An ideal stump is one which is well healed, firm, conical and with
minimal flabby tissue.
(i) Bandaging: Firmness of the stump to withstand all the conditions of

pressure can be achieved by constant and proper application of elastic
bandage.
(ii) Exercise: By repeated sustained isometric exercises for the muscles

of the stump, especially the two joint muscles, which originate above
the joint proximal to the amputation. Educate the patient on the
correct methods of self-resistance mode of exercise with emphasis on
its repetitive performance. Ensure that a programme of strong and
sustained isometrics to the important functional muscle groups is
continued.
(iii) Massage: Massage or repeated tapping can be a stage of

mobilization and restoration of function used for improving the tone
of the muscles.
(iv) Stimulation: Electrical stimulation with the stump in elevation can

improve the muscle tone as well as reduce oedema.
(v) Pressure: Exposing the stump to pressure either by early use of

pylon or gradual training of bearing weight on the terminal weight-
bearing area of the stump. This can be done by providing soft
cushioning and adjusting the height of the stool in parallel bars (Fig.
25-6). Crawling or knee walking on a mattress placed over a bed with
hardtop is ideal as a pressure bearing technique for the above-knee or
through-knee amputations.
FIG. 25-6 Initiating early graded weight bearing and balancing on the
stump in parallel bars.
The patient exerting axial pressure and approximation over the end
of the stump by using his hands is also another self-controlled
technique for conditioning in parallel of the stump.
Prevention of contractures: Development of soft-tissue contractures
is a common complication following amputations. If neglected, it may
present the following problems.
1. Hinders the fitting of prosthesis.
2. Even though the prosthesis may be well fitting to the stump, the
patient is unable to bear weight during the single-leg weight–bearing
phase.
3. Attempted weight-bearing effort results in:
◼ Marked imbalance
◼ Pain and discomfort
◼ Needing excessive supporting aid
(e.g., a patient who should be able to manage ambulation

unsupported needs walker or remains nonambulatory).
4. Marked gait deviation with tendency for antalgic gait.
Common sites of developing contractures
◼ Hip-flexion or abduction contracture
◼ Knee-flexion contracture
◼ Ankle-fixed plant or flexion or equinus
◼ Shoulder-adduction rarely abduction contracture
◼ Elbow-flexion contracture
Prevention of contractures therefore is the total responsibility of the

physiotherapist.
Methods of prevention of contractures
1. Early identification
2. Postural guidance
3. Strong exercise to the antagonistic muscles of the responsible

agonists and their associated soft tissues
4. Use of sustained low-weight traction
5. Corrective splint at a very initial stage of formation of contracture
6. Repetitive strong isometrics to the gluteus maximus
7. Long periods of lying prone
Early identification: Tendency for development of

contraction at the possible sites must be carefully checked
at every visit. An early sign of developing contracture is a
tight feeling with pain at the end range of passive
antagonistic movement.
Immediate sessions of repetitive sustained stretches (manual

therapy) should be introduced.
Postural guidance: The posture which keeps the tightness

prone area stretched should be emphasized (e.g., prone
lying for suspected contracture of hip flexors) besides this,
postures promoting development of contracture (e.g.,
keeping soft pillow under the stump in sitting or supine
lying) should be discouraged. At the same time, the patient
should be taught to carry out sessions of self-stretching as
much and as many times as possible.
Orthotic devices, weight belts or sandbags can be used to
provide sustained stretch by the patients themselves.
Sessions of sustained stretches should be preceded by
relaxed passive mobilization.
Strengthening exercises: PRE against gravity to the

anatagonists of the tight muscle groups are important.
Proprioceptive neuromuscular facilitation (PNF) and
mobilization techniques are ideal.
Use of traction: Sustained sessions of gentle traction to

stretch the contracture developing areas like hip or knee
flexors.
Use of corrective splint: Corrective splint with adjustment to

increase the pull gradually (velcro straps, buckles and/or
broad cuffs can be extremely useful to induce low-intensity
sustained stretching).
Remember
Flexion contracture at the hip is
■ the commonest,
■ most misleading,
■ most difficult to eliminate and
■ causes maximum instability in upright functional tasks (e.g.,

standing balance and ambulation).
As such, it needs regular monitoring and preventive procedures

right from the initial stage following lower extremity amputations.
Prevent persistence of haematoma: Persistence of
haematoma has several risks, e.g., it increases the risk of
infection by acting as a nidus for causing infection, besides
causing delay in the process of wound healing.
Therefore, it should be prevented by the use of suction drain

and proper haemostasis. When present, aspiration
followed by firm compression dressing must be done.
Prevent infection: Patients with peripheral vascular disease

or diabetes are easy targets for infection. Appropriate
antibiotics following culture and sensitivity tests should be
started urgently.
Prevent necrosis: Development of necrosis may occur in

poorly prepared skin flaps with compromised vascularity.
Prevent neuroma: The cut end of the nerve may develop into
a painful stump neuroma when it gets adherent to the scar
tissue. This can be prevented by incising the nerve deep in
the soft tissue.
3. Mobility stage: This is the stage of mobilization and restoration of

functional independence. It starts with crutch walking at the earliest
opportunity. The normal alignment of the pelvis and the reciprocal
movement of the stump should be maintained during walking. It has
been observed that patients usually tend to walk on crutches holding
the stump in flexion; this needs immediate attention. Elderly patients
may need initial ambulation practice in parallel bars. Freedom of
managing various activities with crutches is very important. The
patient may have to remove the prosthesis temporarily for certain
postures and activities. Ladies generally prefer to remove the
prosthesis for toilet activity. Therefore, functional training with
crutches should be given to all hemipelvectomy, hip disarticulation
and above-knee amputees. Resistive mat activities using PNF
techniques are valuable to offer easy and stable mobility.
Mobilization and strengthening exercises: Mobility of the

body segment proximal to the amputation and
strengthening of the functionally important muscle groups
need special emphasis (Table 25-1).
PNF techniques, PRE and strong endurance exercises to the

specific muscle groups are needed to facilitate effective
body functions with the prosthesis.
(a) Disarticulation of the arm: Shoulder elevators,

depressors, protractors and retractors. Mobility exercise
to the neck and trunk are also important.
(b) AE amputation: Flexors, abductors and extensors of the

shoulder; scapular elevators and retractors on the normal
side.
(c) BE amputation: Elbow flexors, extensors, pronators and

supinators of the forearm with mobilization of the trunk.
(d) Hip disarticulation: Pelvic rotators and elevators
(e) Above-knee amputation: Hip extensors, abductors,

flexors and shoulder girdle muscles
(h) Below-knee amputation: Knee extensors and flexors,

hip abductors and extensors
(g) Syme’s amputation: Same as in below-knee amputation

ROM exercises: Full ROM exercises are regularly given to the
joint proximal to the stump and also to other joints
susceptible to developing contractures. Longer periods of
prone lying should be encouraged.
Table 25-1
Guidance to Emphasize Optimal Strength, Endurance and Mobility Training to the
Muscle Groups Following Amputation at Various Levels
Level of Muscle Group to Optimize Strength and

Mobility Exercise
Amputation Endurance
1. Shoulder girdle muscle elevators, depressors, • Neck and trunk
Disarticulation protractors and retractors on the side of the • Excessive stretching at the
of the proposed amputation as well as on the terminal ROM of the normal limb
shoulder contralateral limb (to provide better assistance to the
joint prosthesis limb)
2. AE • Flexors, extensors, abductors and adductors Mobility of the trunk and pelvis
amputation of the shoulder
• Scapular elevators and retractors to facilitate
movements of the prosthetic elbow joint
3. BE Elbow flexors, extensors and forearm Trunk mobilization
amputation pronators and supinators
4. Hip Pelvic elevators and rotators Excessive mobility of the upper
disarticulation and the lower trunk
5. AK • Hip flexors, extensors and adductors Trunk and pelvis
amputation • Shoulder girdle muscles
6. BK Knee–flexors and extensors Hip joint
amputation
7. Syme’s Hip flexors, extensors and adductors knee Hip and knee
amputation flexors and extensors
Restore free mobility to the upper and lower trunks and the pelvis.
Do’s and don’ts for the amputee
(A) During the first visit of the patient
◼ Long explanatory and encouraging counselling
◼ Critical assessment
◼ Preoperative guidance and training
(B) Early postoperative phase

◼ Long session of counselling
◼ Preoperative training
◼ Measures to control oedema and pain
◼ Prevention of contractures:
◻ Soft mattress bed is an invitation for developing hip

flexion contracture, so also long periods of sitting. Even 5–
10 degrees of FFD can result in difficulties in standing
balance along with a limping gait.
◻ Regular monitoring of the stump to ensure adequacy of

circulation and healing of the surgical wound.
◻ Guide and supervise to ensure strong and sustained

isometrics to the functional muscle group of both upper
and lower limbs required for ambulation and other
functional activities of daily routine (ADRs).
◻ Initiate weight bearing on the stump on a soft mattress by

alternate weight transfer in knee-standing postures.
◻ Sessions of improving free and easy mobility to the upper

and lower trunk and the pelvis.
◻ Extensively educate the patient on bandaging and ideal

posture.
◻ Give patient the responsibility of early and sound recovery

by emphasizing and insisting on easy but beneficial modes
of self-performance.
(C) Late postoperative phase
◼ Increase the vigourosity of exercises.
◼ Longer sessions of progressive ambulatory activities, e.g.,

stairs, slopes.
◼ Guidance to self-control whatever deviations present in

the gait.
◼ Correct application and maintenance of the prosthesis.
◼ Sensory re-education towards the feel of the original

normal limbs.
◼ Functional training towards the requirements of the job or

work of daily routine.
◼ Alterations if required in the house or at the working

place.
◼ Additional efforts to restore pre-amputation lifestyle.
Prosthesis
Prosthesis is a Greek word meaning ‘addition’, i.e., prosthesis is the
substitution of a missing body part by artificially fabricated
replacement to perform the basic functional task of the lost or missing
part.
Classification of prosthesis
Prosthesis can be of the following types:
◼ Endoprosthesis: Replacing the missing body part inside the body

by an artificially fabricated similar prosthesis, e.g., joint replacement
◼ Exoprosthesis: Replacing the externally missing part of the body to

perform its functional tasks, e.g., prosthesis designed for the missing
external segment of the upper and lower limbs.
The materials used in the fabrication of prosthesis include the

following:
Metal: Steel and other alloys are used for the hip and knee mechanics.
Duralumin is used for the outer shell and the socket.
Leather: Soft leather is used for the suspension straps while hardened
leather (block leather) is used for the socket and thigh corset.
Plastics: Thermoplastic materials like polypropylene are used for the

inner lining of the socket.
Plastic form is also used to support the distal tissues of the stump and
the cosmetic covering of the prosthesis.
Wood: It is usually preferred as a socket material and the prosthetic

feet, especially in tropical climates.
Stages in the application of prosthesis

During the early immediate postoperative phase, the patient is
provided with a temporary prosthesis. Later on, it is replaced by a
final prosthesis.
Temporary prosthesis
A lightweight, mechanically simple temporary prosthesis (rocker
pylon) is given to assess the potentials of the patient and to encourage
early standing (see Fig. 25.3). It can be fitted following stitch removal
within 2 weeks. The patient is given training in balancing and
standing in the parallel bars.
Final prosthesis
A final prosthesis is prescribed after critically assessing the
performance of the patient with the temporary prosthesis.
Basic features of a prosthesis (fig. 25-7)

1. Socket: It provides weight bearing and receptive areas for the stump.
2. Suspension: It holds the prosthesis to the stump.
3. Joints: The joints which are amputated are replaced by artificial

mechanical joints.
4. Base: It provides contact with the floor.

FIG. 25-7 Hip disarticulation prosthesis and its basic features. SO, socket;
SU, suspension; J, joint; B, base.
Methods of fabrication of prosthesis

1. Conventional or exoskeletal prosthesis: The strong outside shell
supports the body weight of the patient.
2. Modular assembly prosthesis (MAP) or endoskeletal prosthesis:

Here the patient’s weight is supported by a metal tube with soft
cosmetic covering. The present trend is to provide a lightweight
endoskeletal prosthesis with one-piece cosmetic covering.
The mechanical joints are constructed according to the functional

demands of the amputated joints, giving the necessary mobility as
well as stability. Locking mechanism can be automatic, semi-
automatic or manually operated. The joint can be free, with a
restricted arc of motion or it can be one with constant friction.
Prescription of the prosthesis

The type of prosthesis to be prescribed depends on various factors
like:
2. General physique of the patient
3. Length of the stump
4. Status of circulation to the stump, e.g., a suction socket should not

be prescribed for a patient with insufficient limb circulation
5. Strength, ROM, stability and mobility of the related body segments
6. Requirements of job and daily living
Prosthesis for lower limbs amputations

Depending upon the level of amputation, there are seven types of
prosthetic designs for lower extremity amputations:
1. Hemipelvectomy amputation
2. Hip disarticulation
3. Above-knee amputation
4. Through-knee amputation
5. Below-knee amputation
6. Syme’s amputation
7. Partial foot amputation
Designs of fabrications vary with level of amputation.
Hemipelvectomy
In this operation, half of the pelvis and complete lower limb is
removed.
Hip disarticulation (fig. 25-7)

In this, the pelvis is intact but the whole of the lower limb is removed
from the acetabulum.
Prosthetic design (components)
◼ Socket: A totally embracing socket is given which encloses

both the iliac crests. In case of hemipelvectomy, the weight-
bearing area is the ischial tuberosity and the buttock of the
other side, while for hip disarticulation, the weight-bearing
area is the ischium and the buttock of the amputated side.
◼ Suspension: Through the total tissue contact with locking

over the iliac crests. Additional shoulder suspension may
be necessary.
Joints
Artificial joints of the prosthesis could be
1. Manually operated
2. Semi-automatic
3. Automatic
Hip mechanism: It could be either of the following:
1. Standard hip joint which locks automatically in

extension.
2. Canadian tilting mechanism which is fitted anteriorly on

the socket. It locks anteriorly on the socket. It also locks
automatically when the patient stands. At the same time,
it allows 20 degrees of hip flexion during the swing
phase of the gait.
Knee: The knee joint is constructed in slight hyperextension

to offer stability during the stance phase: This allows the
ground reaction force to pass anterior to the knee joint.
Knee lock could be hand operated, semi-automatic or with
constant friction device.
Feet: Ideally SACH (solid ankle cushion heel) foot is given to

offer maximum stability during floor contact (Fig. 25-8).
FIG. 25-8 Solid ankle cushion heel (SACH) foot. TRB, toe (rubber)
bumper; RH, rubber heel wedge.
Above-knee amputation
Prosthetic designs
Socket: Quadrilateral H-type socket, in which most of the body

weight is transmitted through the ischial seat and the posterior brim
of the socket.
Suspension: Suspension with double swivel pelvic band with

multiaxial joint provides all the basic movements at the hip.
However, rigid pelvic band allowing only flexion and extension at
the hip is preferred in cases where the muscle control and stability of
the joint are deficient (Fig. 25-9).
Suction socket or a modular prosthesis: Suction socket with valve,

which requires a cylindrical stump that fits snugly and has two-way
valves is ideal. It has a mechanism for the maintenance of a negative
pressure which holds the prosthesis in place with total stabilization
during performance of both static and dynamic ambulatory
activities (Fig. 25-9B), modular prosthesis (Fig. 25-9C).
Suction sockets have the following advantages:
◼ Greater feel of a close contact promoting the sensation of a

most stable normal limb.
◼ There are less chances of infection.
◼ Stump socks are not necessary.
However,
◼ Nonsuction sockets provide comfortable fit.
◼ No difficulty in changing the stump circumduction.
◼ There is lesser discomfort of perspiration.
Knee mechanism: Hand-operated or semi-automatic locking

mechanism along with constant friction device or knee
joint with free mechanism at swing can be given.
Feet: Uniaxial or multiaxial SACH foot is preferred. It

stimulates plantar flexion through compression of rubber
heel. Uniaxial foot permits both dorsiflexion and plantar
flexion. The biaxial foot also allows eversion and inversion.
The foot made of wood moulded with plastic material is
incorporated with rubber bumpers to provide necessary
movements.
■ Note: Suction socket is never prescribed for amputees with
circulatory disturbances.
■ It is ideal for young adults.

■ Conventional type of prosthesis is safe and suitable for weak and
elderly patients, labourers and those requiring long standing.
FIG. 25-9 Above-knee amputation prostheses. (A) With pelvic band. (B)
With suction socket. (C) With modular assembly.
Through-knee amputation (fig. 25-10)

FIG. 25-10 Conventional prosthesis for below-knee and through-knee

amputations.
Prosthetic design
Socket: A self-suspending thigh corset with ischial seating area made

of blocked leather or metal or a total contact of plastic material is
used. It could be made a rigid contact from the plastic material.
Suspension: It may be a rigid pelvic band, shoulder suspension or a
waist band.
Knee: Uniaxial knee joint with automatic or manual locking ring.
Feet: Either uniaxial or a SACH foot.
Through-knee and above-knee amputees have to depend upon

prosthetic knee joints for mobility as well as for stability. It takes them
a longer time to get adjusted to it. Younger patients learn to manage
independent ambulation early while older patients need to lock knee
joint and a walking aid.
Below-knee amputation
Two types of prosthesis are used: (i) conventional prosthesis with
thigh corset (Fig. 25-10), (ii) PTB prosthesis (Fig. 25-11).
(i) Conventional prosthesis with thigh corset: It is preferred in patients

with:
(a) An unstable knee joint
(b) Flexion deformity of more than 25 degrees
(c) Very short stump
(d) Anaesthetic stump
(e) Patellar malformation
(f) Those who have to perform heavy duties
Thigh corset: It is made up of blocked leather with steel

uprights and front fastening.
Socket: It is a proximal weight-bearing socket made of metal,
wood or moulded polyester resin. It extends 3 cm proximal
to the lower pole of patella.
Suspension: Rigid pelvic band, shoulder strap or waist belt

suspension may be used.
Knee joint: Uniaxial knee joint allowing free movements.
Feet: Uniaxial foot.
(ii) PTB prosthesis (Fig. 25-11): The PTB prosthesis is ideal and handy
for patients with a long stump. It offers normal gait and early
rehabilitation.
Socket: Soft inner socket with a hard covering is set in slight

flexion at the knee to ensure correct weight bearing. Major
weight-bearing area is on the patellar tendon emphasized
by the counterforce of the upper part of the posterior wall.
Weight-bearing areas: Patellar tendon area, medial flare of the

tibia and tibial condyle. The lateral flare of the tibia to a
lesser extent and posterior muscle bulk (Fig. 25-12).
Pressure-sensitive areas: The proximal end of the tibia, the

crest of tibia and tibial tubercle, head of fibula and medial
and lateral insertion of hamstrings (Fig. 25-12).
Suspension: Elastic stocking suspension and supracondylar

cuff.
Feet: Either uniaxial, multiaxial or SACH can be used.

FIG. 25-11 Patellar tendon bearing prosthesis. (A) Lateral view. (B)
Application of PTB prosthesis.
FIG. 25-12 Critical areas on the anterior and posterior aspects of below-
knee stump. (A) Pressure-tolerant areas or weight-bearing areas. (B)
Pressure-sensitive areas.
Almost all patients can be made ambulatory with a normal or near-

normal gait. Younger patients can manage all the activities including
running and sports without any aid (Brouwer et al., 1989).
Syme’s amputation (see fig. 25-3)
(i) Plastic Syme prosthesis: A hard plastic outer socket is lined by a

pelite liner with medial or posterior access panel. The foot could be
uniaxial or SACH.
(ii) Three-strip Syme posterior steel socket is fully articulated to the

foot. The socket is anteriorly connected by two side steels and an
inverted Y-shaped front steel part. The socket is made of leather with
an access opening posteriorly.
(iii) Enclosed metal Syme: There is a leather liner with a posterior flap
opening fitting inside the metal socket. The uniaxial foot is used.
(iv) Tongue and bolt Syme: A leather socket with front open and two
side steels connect the socket to the foot piece.
These patients need no support and can manage all activities freely,
including sports.
Partial foot amputation
1. A simple shoe filler made of leather, covered with ortholene, is

fitted in the shoe.
2. A short leather ankle corset is attached to the wooden foot worn

inside the shoe. The design of the prosthesis depends upon the
individual stump and thus several designs can be fabricated.
Patients achieve total freedom of ambulation and all the activities.
Prosthesis for bilateral amputations

Bilateral amputees pose problems in balancing and equilibrium
because of the total loss of proprioceptive feedback from the walking
surface. They invariably need temporary short prosthesis which
brings down the centre of gravity to ease the learning process.
The presence of a natural knee joint is very important and therefore,
bilateral below-knee amputees have good potentials for ambulation.
Prosthetic rehabilitation is possible in patients where there is at least
one-knee joint and the other hip is free from flexion contracture. In
bilateral above-knee amputees with long stump or through-knee
amputations without hip flexion deformity, indoor walking with
plastazote stump covers, or short crutches is possible (Fig. 25-13). For
an elderly obese patient, wheelchair provides an ideal means of
mobility.
FIG. 25-13 Bilateral through- or above-knee amputee ambulation with

plastazote stump covers and short arm crutches.
The length of the short prosthesis is increased at the second stage. If

patient attains proficiency, the final prosthesis can be given in the
third stage. The type of the final prosthesis depends upon the patient’s
ability.
Considerable time and efforts are needed to train bilateral amputees
to check and adjust the prosthetic alignment in balancing, standing,
walking, transfers and stair climbing.
The physiotherapeutic programme, besides ROM strengthening and
balancing, should be concentrated on achieving maximum trunk and
pelvic mobility for easy postural adaptations for balance. One knee is
kept locked during all the activities and at least double cane support is
needed for stable balance.
Prosthesis for bilateral hip disarticulation

It is rare and difficult to manage. Physical independence is difficult to
achieve, particularly stability in sitting balance and transfer. A special
sitting ‘shell’ is necessary to learn balance (Fig. 25-14).
FIG. 25-14 Bilateral hip disarticulation. Ambulation with special ‘sitting

shell’ and push-up blocks.
In a patient with very strong arms and trunk muscles, good balance
and good pelvic mobility and lumbar mobility, limited ambulation
may not be impossible with prosthesis and bilateral axillary crutches
or push-up blocks. But the patient needs help for wearing the
prosthesis and also for assuming standing as well as sitting positions
from standing. He also cannot manage on uneven ground, slopes and
stairs.
A fibre glass total chest contact jacket prosthesis consisting of
anterior and posterior shells was reported by Cosla et al. (1965). This
provides the necessary stability for wheelchair ambulation as well as
floor ambulation using small hand crutches.
Bilateral below-knee amputees, through-knee amputees or
combination of above-knee and below-knee amputees can be given
prosthesis in stages, starting with temporary simple prosthesis.
Prosthesis for upper limbs amputations

The ratio of upper to lower limb amputations is approximately 1:24.
Upper limb amputation may be:
1. Acquired
2. Congenital
1. Acquired: Due to trauma or diseases like tumour, leprosy, peripheral

vascular diseases like Buerger or Raynaud disease and thrombosis or
embolism.
2. Congenital: There may be congenital absence of part of the limb or

congenital deformity. These conditions need a highly individualized
approach and long efforts, as the problems are complicated and
specific to each patient. The basic aims of treatment are improvement
of joint mobility, strength, balance and coordination, control of
oedema and the maintenance of neurophysiological movements.
In upper extremity amputees, immediate (within 48 h)

postsurgical fitting of a temporary prosthesis is highly
successful. Plaster of Paris or thermoplastic materials are
used for BE amputees and a learner socket with sockets
and split hook for the AE amputee.
There are six types of prosthetic designs for upper extremity

amputees depending upon the level of amputation:
1. Forequarter amputation
2. Shoulder disarticulation
3. AE amputation
4. BE amputation
5. Wrist disarticulation
6. Mechanical terminal devices
1. Forequarter amputation: The whole arm is removed along

with the clavicle and scapula. A plastazote cap, padded
with foam and retaining straps, may be provided. Only a
sleeve-fitter cosmetic prosthesis can be supplied.
2. Shoulder disarticulation: It incorporates an extended

shoulder cap to hold the prosthesis. The elbow joint of
the prosthesis can be flexed by strong protraction of the
shoulder girdle which puts tension on the flexion cord.
Hand piece can be purely cosmetic or the split hook type
(Fig. 25-15).
3. AE amputation: The prosthesis is the same as for shoulder

disarticulation. In this, flexion of the elbow joint, attained
by the combined action of scapular protraction and arm
flexion is comparatively stronger. Automatic functional
locking can be achieved by reverse movement of
combined depression and extension of the arm.
4. BE amputation (Fig. 25-16): (a) A cup socket, harnessed

with an operational cord, can be given to activate the
terminal device and (b) the terminal device is operated
by a loop harness attached to a self-suspending
supracondylar socket.
5. Wrist disarticulation: For wrist disarticulation or long BE

stump, split socket forearm with wrist rotation unit can
be given. A locking device can be provided for pronation
and supination (Fig. 25-17).
6. Terminal devices
(a) Mechanical thumb abduction for grasp can be attained

by tension on the operational cord.
(b) Mechanical hand allowing grippy flexion of the index

and middle fingers with the thumb are available.
(c) Split hook: A popular terminal device with one fixed

and the other movable jaw operated by power of the
shoulder girdle muscles is used as a strong working
hand.
(d) Battery-operated myoelectric device for grip (Fig. 25-

18): Other terminal devices for the specific tasks are also
available or can be fabricated.
FIG. 25-15 Shoulder disarticulation prosthesis.

FIG. 25-16 Below-elbow prosthesis with loop harness and split hook
terminal device. AS, axillary strap; OC, operational cord; LH, loop harness;
SH: split hook.
FIG. 25-17 Wrist disarticulation or long below-elbow stump: split socket

forearm prosthesis. LD, Wrist rotation unit with locking device; SH, split
hook.
FIG. 25-18 Battery-operated cosmetic glove (myoelectric device) for three-

point grip and release action on activation of flexor and extensor group of
muscles, respectively.
Upper and lower limb combination

1. One upper and one lower limb: The lower limb prosthesis is fitted first,
while exercise and other programme of management are continued.
Upper-limb prosthesis is fitted at a later date after regaining
proficiency in ambulation.
2. One upper and bilateral lower limbs: Here the upper limb prosthesis is
fitted first and the lower limbs prosthesis is fitted subsequently.
Congenital absence and deformities

The majority of these deficiencies are present in the upper limbs. The
ratio of upper limb to lower limb anomalies is approximately 5:1. A
child can be born with total absence of one to all limbs.
The commonest upper limb deficiency is absence of hand or the
remnants of forearm (hemimelia). As soon as the child starts sitting (6
months age), he is fitted with a passive arm to get adapted.
At the age of 2 years, a body-powered working prosthesis
diminutive model of a split hook type could be given and the child
taught to use it with play activities. At school-going age, it may be
replaced by an externally-powered prosthesis.
Myoelectric prosthesis
Effective hand function has been reported by myoelectrically
controlled prosthesis in adults as well as in children. The prosthesis
has a self-suspending socket with pick up electrodes placed over the
flexors and extensors for the movements of flexion and extension,
respectively. These electrodes pick up the myopotentials generated by
the contractions in the respective muscles. The electrical potentials are
amplified by microcircuitry. The motion power is derived from
compact 6 volt batteries. Thought and voluntary effort producing
flexion contractions will switch on flexion or grasping motion of pinch
grip at the hand.
Reversing the process to the extensor group initiates extension or
the release of grasp. The main advantage is the combination of
function and cosmesis.
In the lower extremity, the prosthesis is prescribed as per the extent
of the deficiency. The time of fitting a prosthesis could be anywhere
between 6 and 8 months. At this age, the child attempts to pull up to
standing; till that time, physiotherapeutic measures as described in
the preprosthetic stage should be initiated. Children pick up very
quickly provided proper education is given to the parents.
Limb deficiencies that can be compensated by a prosthesis can be
easily managed by training.
Application and checking of the prosthesis

The prosthesis should be thoroughly checked for smoothness of
contact areas, joint alignments and character of movements of the
prosthetic joints in relation to the needs of the patient.
Points to be checked before and after fitting the prosthesis – before
proceeding with functional use and ambulatory training – are
presented in Box 25-1.
Box 25-1
Important Points to be Checked before and
While Applying the Prosthesis
• Check the alignment of the joint and its ROM.
• Socks should be pulled up and fastened firmly.
• The prosthesis should be applied in the functional position, e.g.,
• In sitting for the upper limb
• In standing for the lower limb, etc.
• Check firm heel contact with the ground in standing with equal
weight on both the limbs. Also check the anatomical alignment of
both the limbs.
• Check for pain or discomfort on body weight transfer on the

prosthetic limb or standing on the prosthetic leg alone.
• Ensure the position of the axis of weight bearing.

• Firm fitting of the socket, corset, pelvic band over the anterior
superior iliac spine (ASIS).
• Check position and functions of the prosthetic joints.
• Check the length of the prosthesis with balanced standing by the

position of the ASIS. Confirm that they are in a perfect horizontal
line.
The sock is pulled well on the stump and secured properly. The
prosthesis is applied and checked in the functional position. The
patient standing in parallel bars with the feet two inches apart is the
ideal position for checking the lower limb prosthesis. The upper
extremity prosthesis is checked with the patient in sitting position.
Anatomical alignment of the prosthetic joints is checked in relation to
the normal limb joints. Various levels of the body are checked
anteriorly, posteriorly and from the sides, e.g., shoulder, pelvis, knee
joints and feet with equal body weight borne on both the legs. Any
discomfort on the pressure areas is noted. Proper weight transfer on
weight-bearing areas should be ascertained. Axis of weight bearing
and the axis of the prosthetic joints are checked the former in standing
on the prosthetic leg alone and the latter by voluntary movements of
the limb with prosthesis. Total alignment of all the components of the
prosthesis in relation to the stump and the whole body is carefully
done in functional positions as well as by initiating and assisting
functional activities.
Socket: Overall fitting of the socket is to be checked. Weight-bearing

areas, e.g., upper brim of the ischial seat, should not be biting into
the flesh. Weight bearing should not cause discomfort on the
terminal end of the stump.
Corset: It should be close fitting with the thigh. Weight bearing is

through the ischial seat area or inguinal region. It should provide
proper support without discomfort on bearing weight.
Suspension: It may be in the form of a rigid pelvic band, Silesian belt,
shoulder suspension or waistband with down straps. If there is
proper fitting of the socket, the role of suspension is just to provide
additional stability.
Prosthetic joints: Prosthetic joints should be thoroughly checked for

their axes, arcs and movements with and without prosthesis.
Base: Rocking mechanism SACH uniaxial or biaxial foot of the brace

should be checked properly, both with and without prosthesis.
Length: Accurate check of the length is necessary for the lower

extremity prosthesis. It is done by using the shortening blocks and
observing steady standing posture.
Re-education with prosthesis

Once the fitting of the prosthesis is found satisfactory, the process of
training and re-education of the amputee begins for functional use of
the prosthesis. It includes:
1. Correct method of application and removal of the prosthesis.
2. Early detection of any complications arising due to prosthesis.
3. Functions of the various components of the prosthesis and overall

limitations on the activities of the prosthetic limb.
4. Gait training in lower limb amputees.
5. Functional training in the use of the upper extremity prosthesis.
6. Guidance on proper maintenance of the prosthesis.
Ambulation and gait training forms the major part of rehabilitation

programme for lower limb amputees. The main problem in gait
training is the difficulty in maintaining balance and equilibrium. Total
lack of proprioception from the floor is the root cause.
It is, therefore, important to initiate standing and gait training at the
earliest, with adequate visual compensation and pre-ambulatory
training (Figs 25-19 and 25-20).
FIG. 25-19 (A and B) Below-knee amputee practising four-point and two-

point kneeling.
FIG. 25-20 Bilateral above-knee amputee. (A) Preambulatory push-ups.
(B) rising from chair by locking left knee. (C) Walking with two canes. (D)
Climbing stairs with one cane and holding stair railing on the other side.
Gait training
It is initiated, by careful monitoring of the patient, in the gradually
progressive stages outlined as follows.
Training in Parallel Bars
1. Standing balance with equal weight on both legs.
2. Correct method of weight transfers on an individual leg.
3. Weight transfers on both legs alternately emphasizing single-leg

standing on the prosthetic leg.
4. PNF techniques of resistive gait, rhythmic stabilization and

approximation are to be emphasized.
5. Normal coordinated stepping in parallel bars with bilateral hand

support to be initiated as early as possible. It needs careful training in
all the aspects of normal gait.
6. Progress to single hand support.
7. Raising to standing from sitting and sitting from standing.
8. Sidewalks and turning.
The various ambulatory activities like sitting, standing, negotiating

slopes and stairs and getting up from the floor should be taught.
While guiding these activities, basically, the patient should be trained
to maintain balance and stability by the maximum use of the
unaffected or strong parts of the body and the sound limb (for details,
readers are recommended to refer to Engstorm Van de ven).
Once the patient is proficient in parallel bars, he is made to walk on
the footmarks on the floor in front of a postural mirror. It provides
enough scope for self-corrections. This encourages the patient to
watch and correct the pattern of gait himself.
Frequent checks of the skin, especially the pressure areas, and
precise analysis of the gait deviations are necessary.
Besides using PNF techniques to attain efficiency in ambulation,
considerable time should be spent on balancing on the affected leg
alone. This offers stability and prevents limp. One should remember
that proficiency in the pattern of gait must not be attempted at the cost
of the three ‘Ss’, i.e,. security, stability and safety of ambulation.
Caution
1. Undue haste to minimize the walking aid should never be

attempted. This may lead to a permanent lack of confidence or a
habitual limb. It may even lead to a patient refusing to walk.
2. The amount of energy consumption during walking with different

levels of amputation should be considered while planning the
programme of ambulation. The percentages of excessive energy
consumption are as follows:
Unilateral below-knee amputee: up to 9%
Unilateral above-knee amputee: up to 49%
Bilateral above-knee amputee: up to 80%
Gait deviations in lower limb amputees: The deviations from the

normal pattern of gait could either be because of the musculoskeletal
deficiencies in the body and the concerned limb or due to defect in the
prosthesis. It is, therefore, important for the physiotherapist to
identify the cause and rectify it. Gait deviations are usually minimal, if
the patient has had proper education during the preprosthetic stage.
Common gait deviations and their possible causative factors are
depicted in Tables 25.2 and 25.3.
Table 25-2
Gait Deviations with the PTB Prosthesis and the Possible Causes
Deviation Amputation Cause Prosthetic Cause

During stance
Excessive knee flexion 1. Flexion deformity at hip/knee 1. Excessive
2. Pain dorsiflexion
2. Ill-fitting socket
3. Faulty cuff
suspension
4. Stiff plantar flexion
bumper
Insufficient flexion or 1. Weak vastus medialis 1. Excessive foot
hyperextension 2. Unstable knee plantar flexion
3. Stump discomfort 2. Hard plantar flexion
4. Patient habituated to corset bumper
prosthesis 3. Incorrectly aligned
socket
Trunk lateral bending 1. Painful stump 1. Short prosthesis
2. Lack of balance 2. Socket in adduction
3. Weakness of hip abductors 3. Too lateral foot
setting
Foot rotation 1. Pain 1. Hard plantar flexion
2. Unstable knee joint 2. Ill-fitting socket
3. Weak hip muscles 3. Poor suspension
During swing 1. Limitation of pelvic and hip 1. Inadequate
Delayed knee flexion movements suspension
2. Stiff knee after having used AK/BK
prosthesis
Note: There is a general tendency of excessive dorsiflexion during the heel strike phase in all
lower limb amputees as a safety measure to quickly transfer and balance on the prosthetic
limb.
Table 25-3
Gait Deviations and Possible Causes with AK and Through-Knee Prosthesis
Deviation Amputation Cause Prosthetic Cause

At stance 1. Weakness of hip 1. Loose socket
1. Foot rotation extensors and medial 2. Incorrect prosthetic alignment
rotators (too much toe out)
2. Lumbar lordosis 1. Hip flexion 1. Insufficient flexion in the
contracture socket alignment
2. Weak hip extensors 2. Discomfort on ischial-bearing
3. Weak abdominals area
4. Attempts to bring 3. High heel on prosthetic shoe
centre of gravity
forward
3. Drop off – body moving down 1. Incorrect shoe 1. Too soft dorsiflexion bumper
with weight bearing on prosthetic in prosthetic foot
foot
4. Foot slap 1. Habit 1. Too soft plantar flexion
2. Incorrect shoe bumper
To prosthetic side
5. Lateral or side bending 1. Stump with 1. Short lateral socket wall,
abduction contracture insufficient support to femur
2. Short stump 2. Too short prosthesis
3. Painful stump 3. Abducted socket
4. Hurting medial brim of the
socket
To normal side
1. Weak abductors on 1. Top long socket
the amputated side 2. Incorrect alignment of
prosthesis socket too abducted
Short stance phase on amputed side 1. Lack of balance on 1. Ill-fitting socket causing
weight bearing discomfort
Uneven arm swing 2. Lack of confidence
Uneven timing 3. Weak trunk or leg
4. Habit
5. Hurting at ischial
seat
During swing
1. Circumduction 1. Abduction 1. Too long prosthesis
contracture 2. Inadequate suspension
2. Weak abductors
2. Vaulting (heel raise on normal 1. Fear of toe catching
leg) on prosthetic side
2. Very short stump
3. Poor muscle control
of hip flexors (hip
hiking)
3. Medial or lateral whip 1. Habit due to stump 1. Internal or external rotation at
discomfort the prosthetic knee alignment
2. Too tight or too loose socket
3. Excessive valgus or varus in
prosthesis at knee level
General pattern
1. Abduction of prosthetic leg (wide 1. Abduction 1. Long prosthesis
base gait) contracture 2. High medial brim of socket
2. Abductor roll 3. Insufficient support at the
lateral wall of the socket
4. Rigid pelvic band
5. Adducted socket
Long step of prosthetic leg

2. Uneven step length
1. Weakness of hip 1. Flexion contracture at hip not
extensors accommodated in the prosthesis
2. Hip flexion 2. Too long prosthesis
contracture
3. Lack of confidence
4. Early habit
Short step of prosthetic leg
1. Lack of confidence 1. Ill-fitting socket causing
2. Pain discomfort
2. Too flexed socket
3. Forward trunk flexion 1. Weak hip extension 1. Insufficient flexion built in
2. Hip flexion the socket
contracture 2. Socket discomfort
3. Poor general posture
4. Spinal kyphosis
5. Habit due to looking
constantly down at
feet
6. Poor eyesight
Instant prosthesis
In 1963, Dr Weiss revolutionized the management of AK and BK
amputation by introducing instant prosthesis followed by immediate
postoperative ambulation. The various stages of instant prosthesis are
as follows:
1. Functional amputation stump was constructed and shaped by

anchoring the muscles that cross two joints, by tension myoplasty
procedure, with the limb in neutral position.
2. The stump is covered with contoured surgical dressing over which

a sterile stump sock is applied.
3. A plaster cast is then applied over the sock with even pressure. This
is known as rigid dressing.
4. A coupling device with steel straps is incorporated over this cast by

POP bandages.
5. Premeasured walking pylon with SACH foot is attached to this

coupler. The cast may get loosened and may have to be reapplied by
the end of a week.
6. After 3 weeks, the cast is split and measurements are taken for the
final prosthesis.
7. The splint cast is taped back and continued to be used till the
prosthesis is ready.
Standing and partial weight bearing (about 8–9 kg) can be instituted
as early as the next day of surgery. Full weight bearing is permitted by
6 weeks when the tissues are healed well and are ready to take the
body weight.
Advantages of instant prosthesis
1. Initiation of standing and partial weight-bearing ambulation from

the next day of surgery minimizes the following problems:
(a) Stump oedema
(b) The complications of prolonged prosthetic period
(c) Unstable nonweight–bearing crutch walking
(d) Contracture and deformities
(e) Regime of strengthening and ROM exercise is

minimized
(f) Rigid cast socket coupled with pylon promotes

conditioning of the stump
(g) Prevents or provides relief in the phantom limb

sensation
(h) The patient is discharged early with either a temporary

or a permanent prosthesis; the patient quickly picks up a
stable and good pattern of gait.
2. The most important advantage of the surgical procedure is that it

reduces the neurologic silence below the level of amputation. The
significant part of the feed-in mechanism is preserved which quickly
establishes communication with the proximal parts. Re-establishing
proprioception and feedback by contact with the floor, substantiated
with visual and auditory feedback, alerts the appropriate muscles for
normal synchronized actions. It re-establishes the signalling system. It
promotes stabilization, weight transfer and early ambulation.
Although this procedure was not reported to be successful by many

centres in the UK due to problems of poor vascularity and healing,
Stovlov et al. (1971) thought it to be ideal in patients without vascular
disease.
Re-education of the upper extremity amputee

The basic responsibility of the physiotherapist in the re-education of
an upper extremity amputee is to train the patient for functional
activities.
The training aspect has the following objectives:
1. To increase the mobility of the related adjacent body parts so that

some compensation can be achieved for the absence of the true limb.
2. To strengthen the muscles directly involved in activating the

prosthesis.
3. To increase the endurance of these muscle groups to sustain the

motion of the prosthetic joint whenever necessary.
4. To prevent soft tissue contractures in certain muscle groups like

shoulder adductors, and rotators and elbow flexors.
Standard basic areas

Ae amputee
Mobility should be concentrated to scapulohumeral and
scapulothoracic motions along with the neck and trunk.
Powerful arm flexion is needed for producing strong flexion at the
prosthetic elbow while extension is needed for controlling the locking
mechanism of the prosthetic elbow joint.
Be amputee
For forearm and wrist amputees, the mobility of the shoulder girdle,
shoulder joint and elbow needs to be improved but more emphasis
should be placed on the forearm. Although prosthesis cannot perform
pronation and supination, it can have a device to lock the forearm in
the necessary functional position.
Strengthening and endurance exercises should be planned for the
shoulder complex, elbow as well as forearm. All these play a key role
in the prosthesis.
Training of the prosthesis controls: Four basic body controls are
necessary to operate the upper extremity prosthesis (Aylesworth,
1952).
1. In the beginning, the patient is trained to perform one basic

movement, e.g., true shoulder flexion without the movement
occurring at the shoulder girdle (arm flexion control motion). This is
the major control for the AE amputee. When proficiency is attained in
performing one basic body motion, then coordination of the
individual motions can be taught for the operation of prosthesis.
Manually operated accessories like wrist flexion unit are not operated
by a control system and can be taught to be prepositioned or fixed
(Fletcher, 1954).
2. BE single control system: Patients with forearm amputation or wrist

disarticulation use BE single control system to operate the prosthesis.
For example, the patient is first trained to flex the elbow to 90 degrees
and then flex the shoulder till the terminal device becomes operational
(Taylor, 1955).
3. AE dual control system: Patients with AE or through-elbow

amputation use the dual control system. Here, the arm flexion control
motion is used to teach the following two prosthetic operations:
(a) With the prosthetic elbow unlocked, flexion at the
shoulder produces flexion at the elbow of the prosthesis.
(b) With prosthetic elbow locked, flexion at the shoulder

operates the terminal device. To begin with, combined
operation of the elbow flexion by flexing the shoulder
and locking the elbow by protraction of the shoulder is
taught. When this is achieved, the amputee is trained to
operate the terminal device.
4. AE triple control system: The standard AE amputee is trained by a

triple control system. The amputee is first trained to control elbow
flexion and elbow lock as mentioned in the dual control system.
Elbow flexion is produced by the arm flexion control motion, locking
of the elbow is achieved by arm extension control motion. Operation
of the terminal device is achieved by controlled shrugging motion on
the normal side. Practice makes it possible to coordinate all these
movements together.
Besides these, guidance is also necessary to use this prosthetic hand

for various other activities of daily life.
Complications
1. Phantom pain: It is a common complication where the patient feels
persistent pain in the nonexistent, already amputated part of the limb.
It is due to persistence of nerve impulses caused by local anoxia,
neuroma or atherosclerosis. The most important mode of treatment is
reassurance. In addition, do the following:
(a) Percussion – light rhythmic hammering with a small

hammer starting proximally working up to the painful
area till it is numb.
(b) Ultrasonics, thermal modalities and transcutaneous
electric nerve stimulation (TENS) may be used. A low
frequency TENS has been reported to be not only
effective in reducing the phantom pain but also in
healing (Finsen et al., 1987). Preoperative (72 h before
amputation) lumbar epidural blockade has also been
found to be effective in eliminating the phantom pain
(Bach et al., 1987).
(c) Ice packs
(d) Brushing with a battery-operated rotating brush
(e) Exercises (general)
(f) Local injection of hydrocortisone
(g) Exploration and removal of neuroma
(h) Psychological counselling
2. Painful adhesive scar formation: An adherent painful scar over the

surgical incision hinders the fitting of the prosthesis. Mobilization of a
painful scar should begin as early as possible, before it gets organized
as adherent. Ultrasonic and deep friction massages are helpful in the
mobilization of a scar.
3. New bone formation at the amputation sites: In electrical burn

amputees, new bone formation has been reported 5 weeks after
amputation. It may require revision of amputation and refabrication
of the prosthesis. The stump should, therefore, be watched closely for
any signs and symptoms of new bone formation like excessive
tenderness, warmth and swelling (Helm & Walker, 1987). If such
symptoms are observed, the fitting of the final prosthesis should be
delayed.
4. Flexion deformity: The presence of a flexion deformity complicates

the process of prosthetic fitting and ambulation. However, the
prosthesis may be modified to accommodate the deformity and
provide ideal weight-bearing alignment. Alexander and Herbison
(1965) reported successful ambulation in a patient with right above-
knee and left below-knee amputation with bilateral hip flexion
contractures of 60 degrees and left knee flexion contracture of 90
degrees.
5. Haematoma: Delays wound healing and becomes a site of infection.
6. Infection: Especially in diabetics and in peripheral vascular disease.
7. Necrosis of the skin flaps due to press on the distal part of a stump
leading to ischaemia
8. Neuromas at the end of the cutaneous nerve.
Latest advancement in upper extremity prosthesis:

Bionic arm (thought-operated prosthesis)
A new prosthesis had been developed by the Centre for Artificial
Limbs at the Rehabilitation Institute of Chicago by Dr Todd Kuiken,
Director of Neuro-engineering.
It is an advancement over the conventional prosthetic arm which
has flexion and extension of the arm. This device is capable of 22
discrete movements including:
◼ Rotation of the upper arm
◼ Bending elbow
◼ Closing and opening the fist
It works on the principle of muscle reinnervation through nerve

grafting.
The greatest advantage of this bionic arm is that it is thought
operated, the activities are not controlled mechanically, but are
controlled by the brain like we do normally (e.g., if a patient thinks of
closing the fist, the electrical signals are sent through the surgically
rerouted nerves resulting in smooth closing of the fist). The shoulder
nerves, which used to go to the arm are rerouted and grafted to the
pectoral muscles. The grafts receive thought-generated impulses, and
the muscle activity is picked up by the electrodes which relay the
signals to the arm’s computer, which then causes motors to move the
elbow and hand mimicking a normal arm.
The initial trials of thought-operated devices have been a 100%
success.
Latest advances in prosthetic hand

The world’s first bionic hand with a return of the sensation of feeling
and touch has been designed and reported by Selvestero Miceria in
February 2013.
It can identify:
◼ The shape of the object held
◼ Consistency of various objects being touched
◼ Strength of the grasp
It works on the principle of reactivation and restores reduced

sensitivity in the median and ulnar nerves due to disuse.
Report by british surgical team which reported

electronic devices known as acti-gait
The electronic device, Acti-Gait, implanted in the upper thigh, sends
radio signals to the calf and foot muscles. A tiny computer on the
waist sends radio signals via external antenna to a stimulator which
fires an electrical current to the calf muscle fitted with electrodes. The
circuit is completed by a small switch in the user’s shoe, which makes
sure that the foot does not hit the ground hard.
Bibliography
1. Alexander J, Herbison G. Prosthetic rehabilitation of a patient
with bilateral hip flexion contracture: a case report. Archives of
Physical Medicine and Rehabilitation,. 1965;47:708.
2. Aylesworth R D. UCLA department of engineering manual of
upper extremity prosthesis. 1952.
3. Bach S, Noreng MF, Tjellden N U. The incidence of phantom
pain in amputees after preoperative lumbar epidural blockade.
Acta Orthopaedica Scandinavica,. 1987;58:700.
4. Brouwer BJ, Allard P, Labelle H. Running patterns of juveniles
wearing SACH and single axis foot components. Archives of
Physical Medicine and Rehabilitation,. 1989;70:128.
5. Cosla HW, Forsters & Benton, J. Prosthesis fitted after bilateral
hip disarticulation. Report of a case. Archives of Physical Medicine
and Rehabilitation,. 1965;46:705.
6. Vol 67. Summary in phys Trial of the Swedish myoelectric hand
for young children.: DHSS Publication. 1981;312.
7. Finsen V, Person L, Lovlien M, Veslegaurd EK, Simenson M,
Gasvann A K. Lower quency TENS after major amputations.
Acta Orthopaedica Scandinavica,. 1987;58:452.
8. Fletcher M J. The upper extremity armamentarium. 1954.
9. Helm PA, Walker S C. New bone formation at amputation
sites in electrically burnt injured patients. Archives of Physical
Medicine and Rehabilitation,. 1987;68:284.
10. Stovlov WC, Burgess EM, Romanto R L. Progression of weight
bearing after immediate prosthesis fitting following below knee
amputation. Archives of Physical Medicine and Rehabilitation,.
1971;52:491.
11. Taylor C L. The biomechanics of control in upper extremity
prosthesis. Artificial Limbs,. 1955;2:4.
12. Report from EPFL (Switzerland) and SSSA (Italy) ‘New bionic
hand’. 2014.
CHAPTER
26
Lesions of the brachial plexus
OUTLINE
◼ Brachial plexus
◼ Erb palsy
◼ Klumpke paralysis
◼ Brachial neuritis
◼ Radiation-induced brachial plexus lesion
Brachial plexus
Brachial plexus, a major source of motor and sensory supply to the
shoulder girdle, the upper trunk and the whole of the upper
extremity, is composed of a highly complex neuronal organization.
Anatomy and composition of brachial plexus (fig. 26-1)

1. Five nerve roots: Basically, it is composed of five nerve roots formed
by the anterior rami of C5 to T1, situated between the scalenus
anterior and the medius.
2. Formation of nerve trunks: Integration of these five nerve roots (C5

to T1) forms three distinct nerve trunks from the lateral border of the
scaleni as follows:
(a) The upper trunk is formed by the anterior rami of the C5
and C6 nerve roots.
(b) The middle trunk is formed by a single C7 nerve root.
(c) The lower trunk is formed by the C8 and T1 nerve roots.
(d) Each of the three major trunks thus formed divides into
anterior and posterior divisions.
3. Formation of three cords: Integration of the divisions of these three

nerve trunks results in the formation of three cords: the medial cord,
the lateral cord and the posterior cord. It takes place as follows:
(a) The anterior division of the lower trunk forms the

medial cord
(b) The anterior division of the upper and middle trunk

forms the lateral cord
(c) The posterior divisions of all the three (i.e., upper,

middle and lower) trunks integrate to form the posterior
cord
FIG. 26-1 Brachial plexus. DS, dorsal scapular nerve; S, scapular nerve;
SUB, nerve to subclavius; LT, long thoracic; LP, lateral pectoral; USUB,
upper subscapular; LD, nerve to latissimus dorsi; LSUB, lower subscapular;
MC, musculocutaneous; AX, axillary nerve.
These three cords join, leading to the formation of terminal

branches, as follows:
◼ The branches of the lateral cord: Lateral head of pectoral nerve,

musculocutaneous nerve and lateral head of median nerve.
◼ Branches of the posterior cord: Axillary, upper and lower

subscapular, thoracodorsal and radial nerves.
◼ Branches of the medial cord: Medial pectoral, medial brachial

cutaneous, medial antebrachial cutaneous, ulnar and medial head of
the median nerve.
The following nerves are given off at the root level:
◼ The dorsal scapular nerve from the C5 nerve root supplies the
rhomboids.
◼ The long thoracic nerve from the C5 to C7 nerve roots supplies only
the serratus anterior.
◼ The axillary nerve originating from the posterior cord supplies the
deltoid and the teres minor.
◼ The musculocutaneous nerve from the C5 to C7 nerve roots

supplies brachialis, biceps and coracobrachialis.
Types
Fig. 26-2 depicts types of brachial splexus lesions.
FIG. 26-2 Types of brachial plexus lesions.
Lesions of the brachial plexus: Causative factors

Traumatic causes
◼ Birth injury (most common).
◼ Shoulder dislocation, penetrating injuries (gunshot), scapular or

humeral fractures.
◼ Bike injury (common in adults as a result of violent fall on the

depressed shoulder with neck in lateral flexion).
Nontraumatic causes
◼ Anatomical abnormalities like cervical rib, thoracic outlet

syndrome.
◼ Following surgery of the tumour, cervical rib or heart.
◼ Compressive lesions like crutch palsy or malpositioning of the arm

during anaesthesia or during the unconscious state.
◼ Fibrosis following radiation-induced plexopathy or following

brachial neuritis.
Remember
◼ The roots and trunks of the brachial plexus are supraclavicular.
◼ The cords and nerves of the brachial plexus are infraclavicular and
follow the pattern of the related nerve either alone or in various
combinations.
◼ The supraclavicular lesions of the brachial plexus are common and

may occur in five different root combinations: (C5–C6), (C5–C7),
(C8–T1) or (C5–T1) of these five combinations.
Lesion of the upper trunk

◼ The upper trunk lesion at the C5–C6 nerve roots is most common
(e.g., birth injury and bike injury)
◼ When the injury is complete, the nerve roots at C5–C6 levels are
completely avulsed from the spinal cord with totally flail and
hanging arm (policeman or waiter’s tip).
Lesions of the middle trunk

These mainly involve the C7 nerve root, but rarely in isolation; they
mostly occur in combination with either upper or lower trunks.
Lesions of the lower trunk

These lesions involve the C8 and T1 nerve roots; although rare, when
present, they result in ‘Klumpke palsy’ or ‘thoracic outlet syndrome’,
following sternotomy.
Types of supraclavicular lesions

Principally, the lesions of the brachial plexus are of two types:
1. Preganglionic lesion: Where the nerve root is avulsed out of the

spinal cord. This type has a poor prognosis.
2. Postganglionic lesion: These are of two types:
(a) Lesion in continuity – The nerve root and its sheath are
intact and hence recovery is spontaneous.
(b) Lesion with discontinuity – In this type, the nerve root

is intact but there is rupture in the nerve sheath; the
lesion could be complete or partial. In complete lesion,
there is an involvement of all five roots (C5–T1). Partial
lesions may involve either upper trunk (C5–C7) or lower
trunk (C8–T1).
Identification of the exact site of the lesion is important from

the point of view of management.
Immediate surgical repair may be necessary in upper trunk

postganglionic lesions.
To determine the site of the lesion and its extent, various

investigations are available besides a thorough clinical
examination of the patient.
Preganglionic lesion (fig. 26-3a)
History: There is usually a history of a high speed head-on collision

accident. The head is forced away from the shoulder. Severe injury
occurs, causing unconsciousness, fractures and associated head
injury.
Signs
1. Horner’s sign: There is damage to the sympathetic nerve

supply to the eye as it merges at the T1 root. Ptosis with
constriction of the pupil will be present. Deficit of facial
sweating can be noticed on the affected side.
2. Positive sensory action potentials (SAP).
3. Meningocoele may be seen in a myelogram.
4. A typical crushing or sharp constant pain even at rest.
5. Usually, there is high cervical scoliosis.

FIG. 26-3 Pre- and postganglionic lesions. (A) Preganglionic lesion: motor
and sensory nerve roots (MR and SR) avulsed from the spinal cord. (B)
Postganglionic lesion: root intact, nerve sheath either intact or ruptured.
Caution
As there are chances of plexus injury going unnoticed because of
unconsciousness, careful examination at an early stage is important.
Postganglionic lesion (fig. 26-3b)

History: Usually there is a history of slow-speed trauma, a person
being thrown on the ground due to sudden halt of a motorbike.
Associated injuries or loss of consciousness are rarely seen.
Signs
1. No Horner’s sign.
2. Absence of SAP.
3. No pain.
4. A positive Tinel’s sign (Copeland & Landi, 1979) or

neuroma sign may be present. While tapping along the
course of the nerve from distal to proximal, a referred
tingling is felt in the distribution of that nerve. There may
be two Tinel sites, one at the level of the lesion and the
other at the point of regeneration. Stronger distal signs
than the proximal ones indicate axonal regrowth and the
possibility of a clinical recovery.
Tapping over the plexus above the clavicle produces tingling in the
anaesthetic arm or hand. This indicates distal rupture (postganglionic)
indicating the availability of proximal axons for grafting.
Examination of the passive range of motion

The passive range of motion (ROM) of all the joints of the upper limb
should be done to assess any sign of soft tissue tightness. Soft tissue
contractures may be present in patients with severe lesions and flail
arms. Common sites of contractures are as follows:
1. Shoulder elevation, abduction and external rotation
2. Elbow extension and supination

3. Wrist palmar flexion and extension
4. Metacarpophalangeal joints flexion
5. Interphalangeal joints extension
In addition, reduction of the thumb web space, shortening of the

long flexor tendons with loss of full extension of digits and wrist in
extension may be present. Any sign of tightness, which precedes the
contracture, must be carefully examined to avoid contractures. Also
examine for subluxation of the shoulder joint. Proper guidance to fully
stretch these movements to the full ROM is necessary. Shoulder needs
more emphasis on abduction and external rotation as brachial plexus
cannot be exposed for surgical intervention without full external
rotation at the shoulder joint.
Examination of sensibility
Sensibility evaluation for light touch, pinprick and proprioception is
documented on the body chart. It can provide definite guidance in the
diagnosis of the lesion.
Evaluation of vascular status

It can be done by palpation of pulses (either radial or carotid). If
necessary, angiography can provide further information.
Vasomotor changes like dry and cold skin, or the presence of
oedema indicates significant nerve injury.
Manual muscle testing

Manual muscle testing (MMT), though time consuming, still remains
the most vital part of the evaluation. MMT as applied to plexus injury,
however, needs a thorough knowledge of the anatomical
interrelationship of various muscle groups, their innervation and
action. Common trick movements, e.g., winging of the scapula with
the lesion of the spinal accessory nerve, should be looked for. This
muscle is innervated by the C5, C6 and C7 branches which come off
immediately after the nerve roots exit from the intervertebral
foramina. Injury to them could be because of root avulsion.
If the serratus anterior is intact, and the supraspinatus and
infraspinatus are paralysed, the lesion could be infraganglionic in the
region of Erb’s point where the C5–C6 join to form the upper trunk.
If the serratus anterior is intact with paralysis of the deltoid and the
biceps, the lesion could be more distal in the terminal branches of the
plexus.
Radiological examination
Radiological examination is done basically to rule out fractures.
Fractures of the transverse process may result in avulsion of the
corresponding nerve root, because of the attachment of the deep
cervical fascia between the cervical nerve roots and the vertebral
transverse processes (Sunderland, 1978). Widely displaced fracture of
the clavicle or scapula can produce traction injury.
MRI: An MRI may show root avulsions or discontinuity in the

nerves/cords of the brachial plexus.
MR neurogram: A relatively newer investigation, MR neurogram,

may also show discontinuity or absence of the neural tissue of the
brachial plexus.
Electrodiagnostic tests
As the electrical changes are parallel to the pathophysiology of
denervation or to the loss of axonal continuity, they provide
significant information:
1. To confirm denervation
2. To diagnose the nature of lesion, whether it is preganglionic

(avulsion) or postganglionic
Electromyography
The following investigations should be conducted 4 weeks after
injury:
1. Electromyography (EMG) of the limb and the shoulder girdle
muscles
2. Motor and sensory nerve conduction velocity
3. Somatosensory evoked potentials and the ‘F’ responses
EMG: The muscle which is innervated normally does not exhibit

spontaneous electrical activity at rest. Therefore, the presence of small
fibrillation potentials or large potentials called sharp positive waves at
rest, when the muscle is examined with needle electrode, indicate
Wallerian degeneration.
The absence of fibrillation potentials or sharp positive waves at rest
indicate postganglionic lesion (Leffert, 1988).
The presence of polyphasic units indicates regeneration. This is
important as electrical evidence precedes clinical evidence by many
weeks.
Electrical silence both at rest and at attempted activity indicates
interference with the conduction of the nerve impulses.
Electrical silence at rest but normal action potentials with complete
interference patterns on voluntary activity indicates an intact
conduction.
Investigations of SAP
When there is avulsion of the root, the process of Wallerian
degeneration occurs in the motor nerves. However, the axons in the
same spinal nerves will not degenerate, unless there is an
infraganglionic rupture in addition to the supraganglionic avulsion.
The detection of either reduced or normal amplitude SAP, with the
absence of motor conduction, in a flail and anaesthetic limb is a bad
prognostic sign. It indicates that the nerve is in continuity with its cell
body, with the lesion being present proximal to the dorsal root
ganglion (preganglionic). This in turn indicates avulsion of the root. A
negative reading implies a lesion distal to the dorsal root ganglion
with an intact root (postganglionic).
Somatosensory evoked potentials
Zalis et al. (1970) and Jones et al. (1981) reported on the
electrophysiological diagnosis of traction lesions of the brachial plexus
by sensory nerve action potentials and somatosensory evoked
potentials. They provide information about the different pathways
and the condition of the intraspinal root. If the afferent pathways are
intact, the evoked potentials may be recorded from the scalp
electrodes over the contralateral hemisphere of the brain on
stimulation of the median and/or ulnar nerves at the wrist and elbow.
If the root is avulsed, the evoked potential will not be obtainable
because of the lack of central connection, even though the sensory
peripheral nerve conduction may be normal. The exposed parts of the
brachial plexus are stimulated directly during surgery. Intraoperative
use of this technique is valuable to verify the central connections of
the nerve root for grafting to a distal part of the plexus.
Nerve conduction velocity

A normal nerve conduction velocity indicates intact conductivity.
When it is not measurable, it indicates the severance of nerve fibres
with Wallerian degeneration. Both the techniques of motor and
sensory nerve conduction velocities should be done to distinguish
root avulsion from the distal rupture.
Percutaneous electrical stimulation

Abnormality in conduction can be verified by plotting strength–
duration curves by percutaneous electrical stimulation.
Factors like sharp curve, long chronaxie, low rheobase and the
absence of contraction with repetitive stimuli (strength interval curve)
can indicate abnormality of impulse conduction, i.e., PRD, CRD or
even A & D or complete denervation.
Myelogram
Myelography with radiopaque dye will show ‘meningocoele’ in the
presence of avulsion. But this test is by no means infallible and hence
not conclusive.
CT scan and magnetic resonance imaging
CT scan is a method of radiological imaging that has developed over
the last decade. It gives a cross-sectional display of the anatomy and
pathology. Magnetic resonance imaging (MRI) is the latest of the
imaging modalities. It makes use of the magnetic properties of atomic
nuclei. It has two main advantages over CT scanning. The technique is
safer and it delineates soft tissue structures better.
Physiotherapeutic management is offered only in conservatively
managed patients.
Treatment
The treatment is divided into three stages:
1. Early stage
2. Intermediate stage
3. Late stage
1. Early stage: The following measures are necessary.
(a) Measures to control pain and oedema.
(b) Measures to prevent complications due to anaesthesia

in the limb.
(c) Maintenance of full mobility of the soft tissues and the

joints, keeping in view the susceptible areas of
contractures and deformities.
(d) Splinting: Cosmetically acceptable functional flail arm

splint (FAS) has been reported by Framton (1984) for
patients with total brachial plexus lesion. It allows
shoulder abduction, prevents glenohumeral subluxation
and also allows five different positions of elbow with
locking system. It provides a platform on the flexor
aspect of the forearm on which standard artificial limb
appliances like split hook or universal holder can be
fitted. This functional prosthesis can be operated through
a cable to a shoulder strap secured to the opposite
normal shoulder like a standard artificial limb.
Partial lesion can be fitted with splints with the necessary

modifications to protect weaker areas and to facilitate the
functional activity. Modifications like providing elbow lock
or elbow lock with wrist drop appliance are useful.
Caution
It is important to keep in mind the sensory loss while adopting
every therapeutic measure.
1. Applying TENS is the best way to control sharp bouts of pain but
the intensity as well as the duration should be carefully operated as
afferent input is poor.
2. Passive ROM exercises can overstretch the soft tissues and joints,
in the presence of sensory loss and therefore, they should be
properly regulated.
3. Splint: It should be checked repeatedly for any local pressure

areas.
2. Intermediate stage: After 3 weeks, the extent of the lesion should be

reassessed to establish the prognosis.
Re-education: If evidence of reinnervation is present, exercises
to re-educate movements should be initiated.
(a) Weaker movements are repeated with self-resistive

techniques by the patients themselves.
(b) Proprioceptive neuromuscular facilitation (PNF)

technique can be used to strengthen the simultaneous
action of various muscle groups in functional diagonal
patterns.
(c) Possible functional activities by the involved upper

extremity should be encouraged either by a
physiotherapist or by self-assistance only after guidance,
education and supervision by a physiotherapist.
(d) Percutaneous electrical stimulation of the functionally

important muscle groups synchronized with patient’s
voluntary efforts can be helpful in re-educating accurate
muscle action. As the success of motor re-education
largely depends upon sensory re-education, concentrated
efforts aided by visual and auditory feedback are most
important.
(e) Stimulating technique like icing and brushing (Rood,

1956) can be effective at this stage.
(f) If the pain persists, intensity and duration of

transcutaneous electric nerve stimulation (TENS) can be
increased to a suitable level.
(g) Splints may need modifications like making it short,

increasing its dynamicity or resistance.
3. Late stage: By 2 years, most of the recovery would have taken place.
Therefore, reassessment is necessary. Response to the treatment is
assessed by electrodiagnostic tests. If the recovery is stagnant, it may
be necessary to plan for the possible reconstructive surgery.
Surgery
Exploration of the brachial plexus, suture or nerve graft may be done
using an operating microscope. However, in root avulsion injuries, it
is worthless.
In residual paralysis, reconstructive surgical procedures may be
undertaken depending upon the extent of involvement of the
trunk/roots to improve shoulder functions, especially abduction. If the
lower trunk is spared, the hand function may be retained. In such
cases, shoulder function can be improved by arthrodesis of the
shoulder or by tendon/muscle transfers (refer to Fig. 28-2). Trapezius
transfer to the neck of humerus can provide a useful range of
abduction (Fig. 26-4).
FIG. 26-4 Trapezius transfer for right shoulder. Note that the acromion
process has been relocated at the neck of humerus and fixed with two
screws. The acromion process carries the insertion of trapezius muscle
which helps in abdomen of shoulder.
The elbow function can be improved by transferring latissimus

dorsi or pectoralis major to biceps, or by Steindler’s flexorplasty (refer
to Fig. 28-3).
Wrist and finger extension may be achieved by the following
muscle transplants:
1. Transfers of flexor carpi ulnaris to extensor digitorum and extensor

pollicis longus or flexor digitorum superficialis to extensor digitorum
and extensor pollicis longus.
2. Palmaris longus to abductor pollicis longus.
3. Pronator teres to extensor carpi radialis brevis.

For the success of the surgical procedures of tendon/muscle transfers,
careful preoperative assessment and training with well-planned re-
educative measures are important.
The following play an important role in the re-education of the
transplanted muscle:
1. Appropriate splint to stabilize the transplanted muscle and to

facilitate its re-education
2. Electrical stimulation
3. Biofeedback techniques
4. Self-assisted and guided functional movements
5. Relaxed passive movements, active assisted movements, progressed

to resisted exercises. It provides the necessary strength and endurance
to the transplanted muscle
6. Extensive education on self-controlled exercises is most important
ERB palsy
It is the lesion of the 5th cervical root. It occurs as a result of birth
injury due to traction between the child’s head and shoulder. The
principal strain falls on the upper root (C5) of the brachial plexus.
Often the force may be excessive enough to involve the root below
(C6) (Fig. 26-1).
Injury to the 5th cervical root alone results in weakness or the loss
of:
1. Shoulder: abduction and external rotation
2. Elbow: flexion
3. Forearm: supination
This occurs due to the involvement of deltoid, rhomboids,
supraspinatus, infraspinatus and teres minor at the shoulder complex;
biceps and brachialis at the elbow and supinators at the forearm.
Involvement of the 6th cervical root results in the loss of wrist
extension (radial side) due to the involvement of extensor carpi
radialis longus and brevis.
The involvement of these muscle groups results in the typical
posture of ‘waiter’s or policeman’s tip’ position to the involved limb.
The arm loosely hangs by the side of the trunk internally rotated with
elbow in extension.
Anaesthesia may be present over the outer border of the arm and
forearm, on both anterior as well as posterior aspects. When the 6th
nerve root is involved, anaesthesia extends medially and also involves
the thumb.
Treatment
Conservative – splints and physiotherapy
◼ To avoid soft tissue contracture, abduction splint

(aeroplane splint) may be given (Fig. 26-5). This maintains
the shoulder in abduction and external rotation, elbow in
90 degrees flexion, forearm in supination and wrist in a
few degrees of extension.
◼ However, this splint is too cumbersome for a child during

sleep and therefore the mother is taught to keep the child’s
arm in this position by using small sand bags.
◼ Passive full range movements to prevent contractures are

taught to the mother.
◼ The involved muscles are activated by assisted active

movements using sensory stimulus. Bilaterally
symmetrical PNF patterns may be included to achieve
irradiation from the normal contralateral limb or from the
surviving strong muscles of the affected limb.
◼ In later life, a similar condition may occur as a result of

violent injury to the brachial plexus. The clinical picture
depends upon the degree of involvement of the brachial
plexus. The plan of treatment is similar to that of the Erb
palsy. However, as the patient is able to follow the
instructions, the therapeutic procedures can be more
precise like:
◼ Involved individual muscles groups can be exercised and

re-educated.
◼ Electrical stimulation can be used as an adjunct.
◼ Trick movement for functional achievements can be taught

effectively (e.g., substitution by the long head of biceps
brachii and brachioradialis with flexors to achieve shoulder
abduction and elbow flexion, respectively).
◼ Conservative treatment is successful only in children with

mild involvement or in adults with incomplete severance
of the nerve roots.
FIG. 26-5 Aeroplane splint.
Surgery
Most cases may recover spontaneously without treatment.
In some cases, exploration and repair of the injured nerve roots may
be undertaken. The results, however, are unpredictable.
Tendon/muscle transfers around the shoulder may rarely be
indicated to improve the abductor or external rotation of the arm.
If fixed deformities have developed, surgical release of the
contracted soft tissues or osteotomy to correct the rotational deformity
of the arm or forearm may be indicated.
Physiotherapy follows the same routine as described for nerve
repair, tendon transfers, release of the contracted soft tissues and
osteotomy under the respective headings.
Klumpke paralysis
The traction between the arm and trunk exerts pull on the 8th cervical
and first thoracic roots (C8 and T1) (Fig. 26-1). It may occur as a
complication of a shoulder injury or due to sudden fall of the body
weight on the arm, e.g., a person grasping some support during fall
from a height, suddenly taking body weight on the arm leading to
severe traction between the arm and the trunk.
Injury to the 8th cervical root results in loss of grip or grasp because
of paresis or paralysis of the wrist and finger flexors.
Involvement of the first thoracic root results in paralysis of intrinsic
muscles of the hand weakening the grip. Anaesthesia due to the
involvement of the first thoracic root is present over the back and the
front of the inner (medial) side of the forearm. Anaesthesia due to the
lesion of the 8th cervical root presents as a long strip from the arm, lies
medial to the area of the first thoracic in the forearm and extends to
the little finger.
A combined lesion of C8 and Tl roots results in a functionally
useless flaccid hand. A deformity of claw hand eventually develops
with the thumb lying in the same plane as that of the fingers. The
hand presents the picture of a combined median and ulnar nerve
lesion (Fig. 26-6).
FIG. 26-6 Klumpke paralysis (lesion involving C8–T1 roots). A typical claw
hand deformity. Hypothenar and thenar wasting.
Treatment
A dynamic splint is given to maintain the wrist and
metacarpophalangeal (MCP) joints in flexion, IP joints in slight flexion
and the thumb in flexion and opposition.
The treatment follows on the same lines as described for the
combined medial and ulnar nerve lesions.
Brachial neuritis
It is characterized by an acute episode of pain lasting up to 3 weeks or
more. It is followed by paralysis of the muscles in the distribution of
the brachial plexus. An annual incidence of 1.64/10000 is found in the
population between 12 and 47 years age group.
Aetiology
Trauma, infection, vaccination, allergic desensitization or lumbar
puncture comprise the aetiology. They may be associated with
systemic lupus erythematosus, temporal arteritis, polyarteritis nodosa
and in rare instances familial disorders.
Nerves commonly involved in brachial neuritis are long thoracic
(most common), suprascapular, axillary, musculocutaneous, anterior
interosseus and radial.
Prognosis of recovery is good but slow and it takes even up to 3
years or even longer to complete axonal regeneration.
Diagnosis
◼ Clinical examination of myotomal and dermatomal innervation.
◼ Electrophysiological studies reveal reduction in sensory nerve

action potential (SNAP) amplitudes in the involved nerve
distribution; absence of fibrillation in paraspinal muscles.
Treatment
◼ Rest, splint related to the involved nerve.
◼ NSAID, corticosteroids.
◼ Gentle maximal range relaxed passive movements to prevent

contracture till recovery occurs.
◼ Vigorous progressive exercise modes are applied as the gravity of

pain is reduced.
Radiation-induced brachial plexus lesion

Usually the onset is delayed after radiation but most patients develop
symptoms immediately (common after breast surgery following
radiation).
Clinical features
Clinical features involve pain, paraesthesia, paresis or paralysis of the
innervated muscles of the injured nerve.
Diagnosis
It is confirmed by the EMG (NCV) which indicates:
◼ Chronic partial denervation and reinnervation.
◼ Reduced SNAP.
Treatment
On the same lines as described for brachial neuritis.
CHAPTER
27
Peripheral nerve injuries
OUTLINE
◼ Formation of a peripheral nerve (PN)
◼ Structure of the peripheral nerve (PN)
◼ Pathophysiology of nerve degeneration and regeneration
◼ Classification of peripheral nerve injuries
◼ Steps in the evaluation and diagnosis of PN injury
◼ Injuries to the major peripheral nerves
◼ Median nerve (nerve roots C5–T1)
◼ Ulnar nerve (root value C7–T1)
◼ Radial nerve (C5–T1 nerve roots)
◼ Obturator nerve (L2–L4)
◼ Femoral nerve
◼ Sciatic nerve
◼ Common peroneal nerve (lateral popliteal nerve)
◼ Posterior tibial nerve
◼ Treatment of foot drop
Considering the key role played by them in the achievement of

functional independence, it is important to know the following
aspects of a peripheral nerve (PN).
1. Formation of a PN
2. Structure of a PN
3. Pathophysiology of a PN
4. Classification of PN injuries
5. Diagnostic evaluation of PN injuries
6. General principles of management
Formation of a peripheral nerve

The dorsal and the ventral nerve roots arising from the spinal cord
come together and join at the level of intervertebral foramina to form
the spinal nerves. In our body, there are 31 pairs of spinal nerves – 5
sacral and 1 coccygeal each representing a segment of a spinal cord (8
cervical, 12 thoracic and 5 lumbar). The 12 thoracic spinal nerves
provide myotomal and dermatomal supply to each intercostal
segment. The remaining 19 spinal nerves (8 cervical, 5 lumbar, 5 sacral
and 1 coccygeal) are instrumental in forming four plexuses.
Each spinal nerve has three components – sympathetic, motor and
sensory. The sympathetic components of all the 31 spinal nerves leave
along 14 motor roots (12 thoracic and 2 lumbar).
Each spinal nerve divides into a larger anterior ramus and a smaller
posterior ramus. The anterior rami form a group known as a plexus.
Each plexus integrates and gives rise to an individual peripheral
nerve.
Plexuses
◼ The cervical plexus is formed by the anterior rami of the upper four
cervical nerves.
◼ The brachial plexus is formed by the anterior rami of the lower four
cervical nerves and the upper thoracic nerves.
◼ The lumbar plexus is formed by the anterior rami of the lumbar
nerve.
◼ The sacral plexus is formed by the fifth lumbar and part of the
fourth sacral nerve.
◼ The posterior rami supply the skin of the back and the paraspinal
muscles.
◼ Both spinal as well as peripheral nerves are mixed type of nerves.
Structure of the peripheral nerve

It is a mixed nerve. Each peripheral nerve is composed of a compact
group of individual nerve fibres, each with an individual
neurolemmal tube. The nerve fibre is enclosed in a collagen
connective tissue covering known as the endoneurium. A number of
nerve fibres with endoneurium are bound together by a fibrous tissue
covering called the perineurium. A group of nerve fibres with their
endoneurium and perineurium sheaths together is known as a
faciculus. A number of such fasciculi is further enclosed by a tough
tissue sheath called the epineurium. Each peripheral nerve is an
individual compact bundle of such fasciculi (Fig. 27-1).
FIG. 27-1 Cross-section of a nerve.
Each nerve fascicle contains Schwann cells, fibrocytes, axons,

myelin sheaths, collagen fibrils, endoneurium and the blood vessels.
The diameter of the axons of a PN varies between 1 and 20 microns.
The junction between each Schwann cell is called a node of Ranvier
where the axons remain insulated.
Pathophysiology of nerve degeneration and

regeneration
Degeneration
Structure of the intact PN is shown in Fig. 27-2A. Within 72 h
following injury, the part of the nerve (neuron) distal to the site of
injury undergoes secondary or Wallerian degeneration and is
destroyed by phagocytosis. Whereas, the proximal end of the injured
nerve undergoes primary or retrograde degeneration for a single node
of Ranvier (Fig. 27-2B).
FIG. 27-2 (A) Structure of nerve fibre. NC, nerve cell, nucleus; NB, Nissl
bodies and nerve fibrils arising from them; MYL, myelin sheath; NUS,
nucleus of Schwann cell; NR, nodes of Ranvier. (B) Wallerian degeneration
following axonotmesis or neurotmesis. LL, level of lesion; ENU, enlarged
nucleus; CB, cell body empty of Nissl bodies; CB, cell body empty of Nissl
bodies; DN, degeneration of neurofibrils to the nearest node of Ranvier. (C)
Types of neuroma.
Regeneration
Regeneration begins within 24 h of injury at the proximal end of the
injured nerve only if the endoneurial tube filled with Schwann cells is
intact; the axonal sprouts readily pass across the site of injury (termed
as motor march). The rate of nerve regeneration is 1 mm per day.
When the endoneurial tube is not intact, the growing sprouts (about
100 from one axonal stump) migrate aimlessly into the epineurium,
perineurium and into the adjacent area to form end neuroma – or
neuroma in continuity. When the proximal end of the nerve is widely
separated from the distal end, it may result in formation of an end
neuroma. When the nerve has suffered only a partial cut, it results in
the formation of a side neuroma (Fig. 27-2C).
Classification of peripheral nerve injuries

A. Seddon’s classification (1943)
According to this classification, the severity of injuries to the

nerve is divided into three classes.
1. Neurapraxia
It is the contusion of the nerve only; anatomically the axis

cylinder is well preserved. There is only a temporary
physiological disruption of the conduction of nerve
impulses. No Wallerian degeneration occurs. Complete
recovery occurs within 3–6 weeks (e.g., Saturday night
palsy).
2. Axonotmesis
The axons are damaged but the endoneurial tube remains

intact. Wallerian degeneration occurs in the distal segment
of the injured nerve. Intact epineurium, perineurium and
endoneurium guide the regenerating axons to their
appropriate connections. Partial to complete recovery may
occur within 3–6 months (e.g., fractures and dislocations).
3. Neurotmesis
The nerve is either completely cut or disorganized to an

extent where spontaneous recovery is impossible.
Wallerian degeneration sets in early and the neural
elements mingle with the fibrous elements to form a
neuroma, which needs surgery. The prognosis of recovery
is poor (e.g., cut injury, open lacerated wound, severe
crushing or a traction injury).
B. Sunderland’s classification (1951)
According to this classification, nerve injuries are classified

into five grades in an ascending order depending upon the
extent of injury to the axon, endoneurium, perineurium,
entire nerve trunk, myelin; motor march; Tinel’s sign and
overall prognosis of recovery (Table 27-1).
Table 27-1
Sunderland’s Classification of Peripheral Nerve Injury
Grade I II III IV V
• Axon Contusion Disrupted Disrupted Disrupted Disrupted
• Intact Intact Disrupted Disrupted Disrupted
Endoneurium
• Intact Intact Intact Few fibres Disrupted
Perineurium preserved
• Entire Intact Intact Intact Intact Disrupted
nerve
• Myelin Intact Intact Intact Intact Disrupted
• Motor Absent Present Present Absent Absent
march
• Tinel’s Absent Present Present Absent Absent
sign
• Recovery Complete Good Incomplete No recovery No
recovery recovery recovery recovery
Remember
PN injuries do not always rigidly follow these classifications. A
single nerve injury may include neuropraxia, axonotmesis and
neurotmesis simultaneously.
Incidence
The average frequency with which various PN nerves are prone to
injuries in percentage of all the PN injuries are as follows:
◼ Radial nerve: 45–50%
◼ Ulnar nerve: 20–30%
◼ Median nerve: 15–20%
◼ Common peroneal nerve: 10–15%
◼ Lumbosacral plexus: 3–5%
◼ Tibial nerve
Aetiology
◼ Direct injury: Fractures and dislocations alone account for over 40–
50%. Sharp cuts, lacerations, piercing injuries, nerve entrapment
between the fractured bony ends at the time of a fracture.
◼ General causes: Metabolic diseases, collagen diseases, infections,

excessive cooling (freezing) excessive heating (burns), neurotoxic
drugs like tetracycline, quinidine, radiation therapy for cancer,
carelessly given intramuscular injections directly piercing the nerve,
excessive traction or a friction of the nerve (e.g., skeletal or pin
traction), prolonged ischaemia (e.g., VIC) and electric shock.
◼ Late causes: Compressive pathology due to growing tumour,

excessive callus, malunion, fibrosis and adhesions.
Clinical features/signs and symptoms

◼ Early signs
◼ Pain due to injury may be present with stiffness of the

adjacent joint.
◼ Setting in of paresis or paralysis of the muscles innervated

by the injured nerve.
◼ Loss of skin sensation to touch, pain, temperature and

steriognosis.
If the motor supply remains intact, the perception of joint

position, joint movement, deep pressure and vibration will
be preserved.
◼ Anaesthetic skin area which feels cool and dry.
◼ Presence of Tinel’s sign.
◼ Late signs
◼ Muscle paresis gradually progress to paralysis.
◼ Deep tendon reflexes are reduced or lost.
◼ Trophic changes like dry, thin and glossy skin, nails

appearing brittle, hair fall; even bones develop a tendency
for osteoporosis.
◼ Typical deforming attitude, related to muscular

imbalances due to paralysis gradually setting in.
◼ Atrophy of the muscles of innervation.
Steps in the evaluation and diagnosis of PN

injury
1. History: Emphasis is needed on three factors; each is directly related
to the prognosis.
◼ When? – How long back?
◼ How? – Injury type: cut, laceration, blunt injury or

nontraumatic?
◼ What happened following injury? For example:
◻ The presence of excessive bleeding indicates associated

vascular injury, the onset of numbness indicate break in
the continuity of the nerve.
◻ The earlier treatment and its response.
2. Extensive motor and sensory evaluation:

◼ Motor evaluation: Critical evaluation of the strength and
other muscle functions.
◼ Supplementary action of the projected tendon, e.g.,

projection of the tendon of abductor pollicis brevis into the
terminal phalanx produces strong extension of the terminal
interphalangeal (IP) joint of the thumb (in the presence of
radial nerve lesion).
Remember
This tenodesis effect as well as other trick movements should be
encouraged and strengthened to facilitate hand function in
nonrecoverable nerve lesions.
Spot diagnosis (by testing motor status)

Simple and specific physical examination greatly helps in the
spontaneous diagnosis of the injured peripheral nerve.
Identification of the injured peripheral nerve by simple observation
and clinical examination
1. Clinical motor test of the muscles innervated by the respective

peripheral nerve (Table 27-2).
2. Localized atrophy of the muscles (Table 27-3) innervated by a

relevant injured peripheral nerve.
3. Typically abnormal postural attitudes as a result of paralysis of the

muscle groups innervated by the injured peripheral nerve (Table 27-
4).
4. Susceptible areas of the limb where the nerve lies superficially

between the skin and the bone (Table 27-5).
5. Site of injury to the bone and the joint where damage is expected to
a particular peripheral nerve (Table 27-6).
6. Impaired sensorium to touch and pain (pin prick) (Table 27-6B).
Table 27-2
Simple Diagnostic Clinical Motor Tests
Nerve Innervated Muscles Motor Test

• • Opponens pollicis • Opposition: Approximation of the palmar surface of the tip
Median of thumb to the tip of the little finger without flexing IP joints
nerve (Fig. 27-4)
• Flexor digitorum • Pointing index finger: When the fingers of both the hands are
profundus to index clasped together the index finger remains extended (Fig. 27-5)
and middle fingers • Benediction test: Same as aforementioned but here both the
(Oschner’s pointing index and the middle fingers remain extended, like a
index finger test) clergyman’s hand position when he blesses the just married
couple
• Abductor pollicis • Pen test: Hand resting on a table with palm facing up. A
brevis (pen test) patient is asked to touch the pen held up perpendicular to the
plain of the palm ; in a case of median nerve palsy, the patient
fails to abduct the thumb (Fig. 27-6)
• • Palmar interossei • Card test: Grip card or a paper held between the extended
Ulnar (perform palmar fingers (Fig. 27-7)
nerve adduction of all the
fingers – (PAD)(card
test))
• Dorsal interossei • Egwa test: Resting palm on the table with palm facing down
(perform abduction of and fingers in extension; the index finger is passively held in
the fingers – (DAB) abduction; the patient is asked to abduct the middle finger
(Egawa test)) towards the abducted index finger (Fig. 27-8)
• First dorsal • Book test or Froment’s sign: The patient is asked to grip and
interosseous and hold a book between the extended index finger and the thumb;
adductor pollicis the patient’s, attempts to hold result in flexion of the IP joints
(Froment’s sign) (median supply; Fig. 27-9)
• • Wrist drop – loss of • Total loss of wrist and finger and thumb extension (Fig. 27-
Radial extension of the wrist 10)
nerve and fingers (total wrist • Hitchhiker’s sign: Inability to extend the IP joint of the
drop) thumb
• • Muscle trapezius • Elevation of shoulder girdle is lost
Spinal
accessory
nerve
• • Serratus anterior • Winging of the scapula when the patient attempts to push
Long muscle against the wall with extended elbow joints
thoracic
nerve
• • Deltoid muscle • Failure to abduct shoulder
Axillary
nerve
•
Sciatic
nerve
(a) • Extensors and the • Loss of dorsiflexion of the ankle joint (foot drop; Fig. 27-11)
Common everters of the foot
peroneal
nerve
(b) • Gastrosoleus muscle • Failure to perform controlled plantar flexion after heel strike
Tibial (calcaneus gait)
nerve
(lateral
popliteal)
Table 27-3
Localized Atrophy of the Muscles Innervated by the Injured Nerve
• Axillary Flattening of the shoulder contour due to paralysis of the

nerve deltoid
• Median Flattening of the muscles of the thenar eminence
nerve
• Ulnar Flattening of the muscles of the hypothenar eminence
nerve
• Femoral Wasting over the anterior thigh above knee
nerve
•Posterior Wasting over the calf on the posterior aspect of leg
tibial
Table 27-4
Typical Abnormal Postural Attitudes as a Result of Paralysis of the Muscle Groups
Innervated by the Injured Nerve
• Brachial plexus Waiter’s or policeman’s tip

• Thoracodorsal Winging of the scapula
• Radial nerve Wrist drop
• Ulnar nerve Ulnar claw hand
• Median nerve Medial claw hand
• Median + ulnar nerve True claw hand involving all the four fingers (Fig. 27-12)
injury
• Median nerve injury Simian hand or monkey thumb with wasting of the thenar or
muscles
Table 27-5
Susceptible Areas of the Limb Where the Nerve Lies Superficially between the Skin and
the Bone
• Radial nerve Laterally winding over the spiral groove over the midshaft area of the
humerus
• Median nerve Palmar aspect of the forearm just proximal to the wrist joint
• Ulnar nerve Over the medial epicondyle of the humerus
• Axillary nerve Close to the fibrous septa in the axilla
• Common peroneal Winding course over the fibular head and neck
nerve
Table 27-6
Site of Injury to the Bone and the Joint Where the Damage is Expected to the Relevant
Peripheral Nerve
Fracture of the clavicle – brachial plexus injury

Fracture of the proximal humerus – axillary nerve injury
Fracture of the midshaft of the humerus – radial nerve injury
Posterior dislocation of the elbow – radial nerve
Injury to the palmar aspect of the forearm just proximal to the wrist – median
nerve
Monteggia fracture – posterior interosseous nerve
Fracture of the medial epicondyle – ulnar nerve
Posterior dislocation of the hip – sciatic nerve
Anterior dislocation of the hip – femoral nerve
Dislocation of the knee joint – common peroneal nerve
Fracture of the neck of the fibula – lateral popliteal nerve
Fracture of the proximal tibial shaft or ankle injuries – posterior tibial nerve
Impaired sensorium to touch and pinprick (pain):
•Index finger – in median nerve lesion
• The tip of the little finger – in the lesion of the ulnar nerve
Testing sensory status (fig. 27-3)

Sensory status testing gives a profile of the sensory pathways.
FIG. 27-3 (A–D) Sensory innervation of hand.

FIG. 27-4 True opposition: approximation of the palmar surfaces of the tip
of the thumb with the tip of the little finger without flexing the IP joints.
FIG. 27-5 Oschner’s pointing index test. The index finger remains
extended due to the paralysis of long flexors in a median nerve lesion.
FIG. 27-6 Pen test. In a case of median nerve palsy, due to the paralysis
of the abductor pollicis brevis, the patient is unable to perform thumb
abduction.
FIG. 27-7 (A) Card test for interossei in ulnar nerve injury. (B) Testing the
palmar interossei by asking the patient to perform adduction of all the
fingers. (C) Testing the dorsal interossei by asking the patient to perform
abduction of all the fingers (ulnar nerve).
FIG. 27-8 (A) Testing the first dorsal interosseous muscle by asking the
patient to perform abduction of the index finger. (B) Egawa test: the patient
is asked to abduct the middle finger towards the index finger passively held
in abduction.
FIG. 27-9 Froment’s sign.

FIG. 27-10 Total wrist drop.

FIG. 27-11 Foot drop.

FIG. 27-12 Main-en-griffe true claw hand (median and ulnar nerve
damage).
Sensory pathway
The sensory pathways can be divided into four major components:
1. The receptor field
2. The conducting lines – axons

3. The central conduit – the spinal cord
4. The central decoding apparatus – cerebral cortex
The sensory impulses begin in the receptor field and depend

upon the qualities of various receptors.
The axons are divided into three groups: A, B and C.
Group A: These axons are the largest and carry tactile stimuli
which can be tested effectively.
(a) Quick adapting fibres: The 90% of A-axons consist of

quick adapting fibres, which respond to the stimulus
with a short burst of firing and then stop firing till the
stimulus is removed. They respond with a rapid short
burst of firing as the stimulus is removed. They also
respond to vibratory stimuli of varying frequency, either
at 30 or 256 cps (cycles per second). These quick adapting
fibres can be tested by tuning forks.
(b) Slow-adapting fibres: These constitute the remaining

10% of A-axon fibres. They are responsible for the
sensation of constant touch. They respond to a stimulus
with a burst of firing and then constantly keep on firing
till the stimulus is removed. The fibres are tested by two-
point discrimination test.
(c) The sensation of pressure, cold and warmth are

conducted by small myelinated axons of the delta group
and the smaller unmyelinated axons of group C.
Testing the pattern of recovery of sensibility

The sequence to be followed:
A. Vibration of 30 cps
B. Moving touch
C. Constant touch
D. Vibration of 256 cps
When a patient recovers these sensibility qualities, the two-point

discrimination and Von Frey pressure test can be done.
Early tests
There are six sensory tests:
1. Vibratory test
2. Pseudomotor activity test
3. Two-point discrimination test
4. Von Frey pressure test
5. Pickup test
6. Pin-prick test
1. Vibratory test: It is an important early diagnostic test. This is done

with a tuning fork with stimulus of either 30 cps or 256 cps. It
stimulates the quickly responding fibres which are also in the majority
(90% of A-axon). It should be done early to know the extent and the
prognosis of the lesion (Dellon et al., 1972).
2. Pesudomotor activity test: Sweating in the area supplied by the

peripheral nerve is one of the initial tests indicative of regeneration,
whereas dryness of the skin over the distribution of a peripheral nerve
indicates severe laceration.
3. Two-point discrimination test: To be done when the perception to
light constant touch returns. As slow-adapting fibres are being
stimulated, the test should include moving as well as static two-point
discrimination.
It can be done with an ordinary paper clip, with the patient

observing and then with the eyes closed. Ten separate
stimuli are given; seven correct responses are essential to
adequate conduction (Dellon, 1978; Moberg, 1958; Weber,
1935).
4. Von Frey pressure test: This test is a pressure test to detect the
perception of light touch. The hand should be marked into seven
zones. The monofilament of a horse hair of varying thickness and
stiffness is placed and pressed on the area under examination until it
bends; the examiner can judge the force of pressure required to evoke
response (Von Frey, 1922).
5. Pickup test: It is important as it combines sensibility and sensory

inputs with motion. The blindfolded patient is given nine objects of
different shapes and sizes. He is instructed to pick up one object at a
time and place it into a small container. Time taken to perform this is
compared with the contralateral normal limb. It usually takes 5–8 s for
a young adult male.
6. Pin-prick test: This test is commonly used to assess the sensation of

pain. The patient is blindfolded and is asked to count the pricks
applied intermittently.
Acute laceration of a nerve can be diagnosed by vibratory

and pin-prick tests. Two-point discrimination and pickup
tests are employed to record recovery after nerve repair.
However, a patient with a lesion in continuity needs all the
six tests. Development of hyperaesthesia, pain or ‘pins and
needles’ indicates recovery of sensation.
Special investigations
◼ Electrodiagnostic tests
◼ Electromyography
◼ Nerve conduction velocity (NCV) studies
◼ Strength–duration curves (SD curve)
Electromyography (fig. 27-13)

It is the most useful test to distinguish between:
◼ The presence or absence of nerve injury.
◼ When present, whether the nerve injury is complete or incomplete.
◼ Whether the regeneration of the injured nerve is taking place or not.

FIG. 27-13 EMG patterns.
It displays on the monitor the various aspects of the nerve injury

with precision by virtue of the established patterns of the intact nerve
and that of the injured nerve (Table 27-7).
Table 27-7
EMG Characteristics of Normally Innervated Muscle and the Denervated Muscle by
Needle Electromyography
Normally Innervated Muscle Denervated Muscle

• At rest: • At rest:
No electrical activity Show denervation potentials, with
• At weak voluntary attempt: spontaneous electrical activity by 1–2
Displays only a single motor unit action potential weeks after injury
• During the attempted strong voluntary muscle • If these denervation potentials fail
contraction – number of motor units firing simultaneously to appear by 3 weeks after muscle
are superimposed giving rise to the interference pattern of denervation, it indicates good
motor action potentials prognosis of recovery
However, EMG fails to indicate the level and the degree of injury to
the nerve with precision.
NCV studies (table 27-8)

Motor NCV
The nerve to be studied is stimulated at two levels and the latent
period between the application of the stimulus and the ensuring
muscular contraction is determined.
◼ The distance between two levels (D) is measured.
◼ The stimulating electrode is applied directly at the point over the

nerve trunk. The response is picked up by the second electrode
placed over the muscle to be stimulated (Fig. 27-14).
◼ The precise value of the NCV is calculated by dividing the

difference between the proximal and distal stimulation in mm.
PL = Proximal latency
DL = Distal latency
D = Distance between the proximal and distal stimulation

points (ideal distance between the two points of
stimulation should not be less than 10 cm).
FIG. 27-14 (A) Motor nerve conduction velocity of median nerve (electrode
placement). (B) Sensory nerve conduction velocity of median nerve
(electrode placement).
Table 27-8
Normal Values of the Motor and Sensory Nerve Conduction Velocities (Mean ± SD)
Nerve and the Site of

Latency (ms) Amplitude (mV) NCV (m/s)
Stimulation
Motor NC Sensory NC Motor NC Sensory Motor Sensory
NC
• Median nerve Sensory: From digit to wrist
• Axilla 9.81 ± 2.84 ± 7.2 ± 38.5 63.4 ± 56.2
• Elbow 0.89 0.34 2.9 ± 6.257.7 ± ±
7.39 ± 7.0 ± 15.6 4.9 5.8
0.69 2.7
• Ulnar nerve: Motor: Recorded from abductor digiti Sensory: Digit to wrist
minimi
• Axilla 9.90 ± 2.54 ± 5.6 ± 35.0 66.5 ± 6.3 54.8
• Above elbow 0.91 0.29 2.1 ± 61.0 ± 5.5 ±
• Below elbow 8.04 ± 5.5 ± 14.7 58.7 ± 5.1 5.3
0.76 1.9
6.1 ± 5.5 ±
1.69 2.0
• Radial nerve: – – 11.7 ± 4.0 ± 69.0 ± 5.6 71.0
• Axilla to elbow – – 7.0 1.4 62.0 ± 5.1 ±
• Elbow to forearm – 13.0 ± 4.0 ± – 5.2
• Wrist to thumb 8.2 1.4 –
13.0 ± – 58.0
7.5 ±
6.0
Sources: Kimura (1986), Kimura (1983), and Trojaborg and Sundrip (1969).
Sensory NCV
Determined by stimulating a point over the skin or a digit with the
action potentials picked up by the electrodes along the course of the
nerve at two different points. The sensory NCV is calculated by the
same method as the motor NCV. However, the conduction of the
sensory impulse is much faster than the motor nerve conduction.
Remember
There is always a possibility of overlapping of the sensory
innervation in certain nerves. However, a small area of total
anaesthesia known as the autonomous zone is present in all types of
nerve injuries.
The development of hyperaesthesia, pain, pins and needles over
the distribution of an injured nerve trunk are good prognostic signs
of the recovery.
Normally a muscle when stimulated with a shorter duration (1 ms)

current responds with a minimal contraction. It keeps on responding
as the duration of the current is reduced beyond 1 ms, although it
needs higher intensity current and produces a normal smooth SD
(strength–duration) curve.
Whereas, when the muscle is denervated, as the duration is
shortened, progressively higher intensity current is required to
produce minimal contraction as it stimulates the muscle directly.
The resulting curve for the denervated muscle rises steeply.
The early sign of reinnervation is the appearance of a ‘kink’ in the
curve. The shifting of this kink towards the left side of the curve
indicates progression of reinnervation, whereas, when its progress
stops, by 6 weeks, it indicates termination of the reinnervation. The
kink completely disappears following reinnervation.
Strength–duration curve (SD curve)
◼ A curve plotted between the strength (intensity) current and the

varying durations (ranging from 0.01 to 800 ms) of.
◼ The nerve is stimulated at the motor point to elicit minimal

muscular contraction.
◼ The SD curve provides objective evidence of the integrity of the

nerve as shown in Fig. 27-15:
◼ By 7 days: Whether the nerve trunk is intact and

conducting impulses normally (no RD; the SD curve is
smooth)
◼ After 3 weeks: When the reaction of degeneration is set in
and the nerve responds with a muscular contraction
directly through the stimulation of the muscle only at
higher intensity of current and longer duration is
indication of partial reaction of degeneration (PRD).
◼ The upward small curve (kink) in the curve indicates the

beginning of reinnervation. The progression of the kink
towards the left of the curve indicates the progress of
reinnervation of the nerve.
◼ After 6 weeks: The nerve requires not only higher intensity

but also stops responding even if the duration of the
stimulus is applied indefinitely. It indicates the complete
reaction of degeneration with poor prognosis of recovery.
Rheobase and the chronaxy: Rheobase is the least amount of

current required to produce minimal perceptible muscular
contraction in the stimulated muscle in milliamperes.
Chronaxie is the duration of a current required to excite a

muscle with a current strength of double the rheobase.
FIG. 27-15 Strength–duration curve. N, normal; PRD, partial denervation;

CRD, complete denervation.
Additional tests
Vascular test
A strong association exists between vascularity and nerve conduction.
Entire physiologic function including that of the motor and sensory
end organs is involved distally (e.g., VIC, diabetes and collagen
vascular disease). It is done by palpating distal pulses or
plethysmography may be used to assess pulse volume.
Blood flow detection test

The status of arterial and venous blood flow is evaluated by Doppler
test.
Skin resistance test
Sympathetic nerve involvement gives rise to dry and glossy skin. In
partial lesions, vasomotor changes like pallor, cyanosis or excessive
sweating may occur. Trophic changes like brittle nails and trophic
ulcers may also be present.
Sweat test
The presence of excessive sweating over the area of skin within the
autonomous zone of the injured nerve indicates only partial
interruption in the conduction of impulses, and a good prognosis.
Tinel’s sign
A simple clinical test that helps in the diagnosis as well the prognosis
of the injured nerve.
Test for tinel’s sign

In the process of regeneration of an injured peripheral nerve, the
myelination occurs progressively from the proximal to the distal at a
rate of about 1 mm a day. When a regenerating nerve is tapped
progressively along its course from distal to proximal, a sensation of
paraesthesia (pins and needles) is felt due to exposure of raw
degenerating neurons.
Thus:
(i) The test locates the exact point of nerve regeneration (Tinel’s point).
(ii) The distal advancement of this Tinel’s point is the indicator of the
progression of recovery or regeneration of the injured nerve.
(iii) If this Tinel’s point remains stationary, it indicates the termination

of recovery. This may occur as a result of the formation of a neuroma
due to the entrapment of the cut ends in a scar (needs exploration).
Treatment planning
After confirmed diagnosis, while planning the methodology of
treatment, due emphasis must be given to certain factors directly
influencing the prognosis of recovery (Table 27-9).
Table 27-9
Factors Influencing the Prognosis of Recovery
Influencing Factor Prognosis of Recovery

Age Lower the age, better the prognosis
Tension or stretch at the site of injuryMore the tension, poorer the prognosis
Late reporting No chance of motor recovery, sensory status may recover
Location of injury The proximal the injury, worse the prognosis
Type of involved nerve Primary motor nerve has a better prognosis than a mixed nerve
Degree of damage to the nerve Excessive damage to the nerve (e.g., crush injury), poorer is the
chance of recovery
Associated factors Factors like late reporting, early mismanagement adversely
affects the recovery
Size of the gap between the cut ends or More the gap, reduced chance of recovery unless grafting is done
separated ends
Delay in the nerve repair Reduces the chances of recovery
Associated injuries Injury to the vessels, tendons, delays the recovery process
Infection Not only delays the recovery but also may result in poor
prognosis due to further damage
Operative neglect Excessive traction, cut injury, tight POP may directly result in
damage to the PN
Due to the multifactorial dependency of the recovery, only the

general plan of treatment forms the basic procedures of treatment
(Flow chart).
The standard orthopaedic management of fractures is applied. Most of
the time, the nerve injury is associated with a fracture.
◼ Bone and vascular repair takes precedence over the repair of the
nerve.
◼ Primary nerve repair: Carried out within 6–8 h only when the open
wound is clean. The cut ends of the nerve trunk are brought close
and sutures are applied with a fine silk material. The sutured nerve
is immobilized and protected from tension or stretches by orthosis.
◼ If the wound is contaminated, the sutures are applied between 7
and 18 days, only after ensuring proper wound care.
◼ Secondary repair: By 18 days to 3 weeks in certain situations like:
◼ Failure of the conservative treatment.
◼ Symptoms of definite nerve irritation.
◼ No symptoms of recovery.
◼ Poor general condition of patient.
Late direction
Surgical methods of nerve repair

1. Nerve suture (neurorrhaphy) and nerve grafting
(a) Epineural repair: Carried out by suturing the epineurium

(Fig. 27-16A).
(b) Fascicular repair: After excising the epineurium, the

fascicles are separated. Then the fascicles of both the
nerve ends are matched together and sutured using
microsurgical techniques (Fig. 27-16B).
(c) Both epineural and perineural repair (Fig. 27-16C): When

the approximation of the cut ends of the nerve becomes
difficult due to the formation of end neuroma, the
excision of the neuroma is carried out, followed by
adequate mobilization of the nerve to gain a shortened
length; then suturing is carried out by:
i. Immobilizing the joint close to the course of the nerve in
slight flexion. Sutures are applied only after gaining
adequate length for suturing, e.g., anterior transposition
of the ulnar nerve when injured behind the medial
epicondyle of the humerus.
ii. Sacrificing the unimportant branches of the nerve

hampering the nerve mobilization.
(d) Nerve grafting: When the gap between the cut ends is 10
cm or more, it is bridged over by nerve grafts obtained
generally from the sural nerve or the lateral cutaneous
nerve of the thigh (Fig. 27-16D).
The neuroma is cut before nerve grafting is performed (Fig.

27-16E).
(e) Decompression of the nerve: Median nerve compressed

in the muscular or fibro-osseous tunnel is decompressed
surgically (Fig. 27-16F).
2. Neurolysis
Sometimes the continuity of the nerve is well maintained but

its conductivity is hampered due to its entrapment with
the scar formation, fibrosis and excessive callus formation.
The fibrosis may be:
◻ External – formed outside the nerve trunk.
◻ Internal – formed within the nerve trunk.
◼ External fibrosis is treated by external neurolysis; the

nerve is freed from the fibrous tissue without opening the
sheath.
◼ Internal fibrosis – the nerve fibres are freed from the

intervening fibrous tissue after opening the nerve sheath
(Fig. 27-16G).
FIG. 27-16 Nerve repair.
Reconstructive surgical procedures

By 18 months, the conduction of impulses across the injured nerve
completely stops, indicating complete nerve degeneration. This
requires reconstructive surgical interventions like:
◼ Tendon transfers (Fig. 27-17).
◼ Joint stabilization (arthrodesis) in a functional position to facilitate

and restore functional tasks.
FIG. 27-17 Bunnell’s sublimis tendon transfer operation. (A) Preoperative
position of flexor digitorum sublimis as flexor of the MP and PIP joints. (B)
Postoperative position after rerouting and attaching it to the dorsal
expansion to facilitate flexion at MP and extension at PIP and DIP joints.
Common tendon transfer procedures

1. To restore elbow extension (in high radial/nerve lesion):
a. Pectoralis major or latissimus transfer to triceps.
b. Gradual release of contracted biceps brachii assisted by

gravity brings about controlled elbow extension, for
functional purposes, when the innervation of biceps
brachii is intact.
2. To restore wrist extension: Pronator teres supplied by the median

nerve is transferred to the extensor carpi radialis longus and brevis (in
a radial nerve lesion).
3. To restore finger extension at the MP joints: Flexor carpi ulnaris is

divided into four or five slips and transferred dorsally into four
fingers (radial nerve lesion between the spiral groove and the lateral
epicondyle).
4a. To restore thumb extension and abduction: The palmaris longus

(supplied by the median nerve) is transferred to the extensor pollicis
longus or abductor pollicis longus. Alternatively, the pronator teres
can also be used (in radial nerve lesion).
4b. To restore thumb opposition: Transfer of flexor digitorum

sublimes or extensor indicis to abductor pollicis brevis.
5. To correct ulnar claw hand (Boyle’s procedure): The tendons of the

flexor digitorum sublimis are transferred to the extensors (e.g., in
Hansen disease) (Fig. 27-14).
6. To correct foot drop (in lateral popliteal nerve palsy): The muscle
tibialis posterior is transferred to the dorsum of the foot.
Physiotherapy management (flowchart 27-1, table 27-10)

Physiotherapy has a most significant role in the management of all the
types of peripheral nerve lesions:
FLOWCHART 27-1 Stagewise principles of physiotherapy following injury

to the peripheral nerve
Table 27-10
General Plan of Physiotherapy at Various Periods Following Peripheral Nerve Injury
Patients Treated with

Patients Treated with Conservative Approach Surgical Approach
• 0–3 weeks • Nerve repair (0–3

• To assist in confirming the diagnosis weeks)
• Control of pain, oedema During immobilization:
• Measures to prevent possible complications due to injury • Control pain and
• Provide suitable orthosis oedema
• Care of the anapestic area • Static orthosis to
• Full ROM progressive movements to the unaffected muscles and joints prevent stretch on the
adjacent to the injured nerve repaired nerve
• Efforts to initiate small range active contractions in the paralysed • Encourage self-
muscles with orthosis on attempted contractions
in the muscle group
innervated by the
injured nerve
• Full ROM movements
to the adjacent joints
and precisely
graduated relaxed
passive/assisted
movements to the
affected muscles (by 10
days)
• 3 weeks onwards Mobilization: 3–6
Confirm neuronal damage by using electrodiagnostic tests weeks
• Repeating motor and sensory evaluation and comparing it to the • Electrodiagnostic
baseline records tests to apprise status of
• Replace static splint with a dynamic orthosis repaired nerve
• Motor and sensory re-education • Maximize sensory
• Maximize patients active efforts with: audiovisual re-enforcement and motor re-education
• Neuromuscular techniques like PNF, Rood’s technique, electrical • Special exercise
stimulation or EMG assisted biofeedback techniques
• Maximize efforts to perform functional activities • Audiovisual or EMG
• Late stage (18–24 weeks) biofeedback
• Maximize functional
training with or
without orthosis
• Treat with
reconstructive
procedures
• Preoperative sessions
of strengthening donor
muscles groups
• Re-education of the
transplanted muscle to
perform new role of
action with self-efforts
or actively assisted
guidance
• Progressive resistive
functional training
Patients with irreversible neural damage
• Prepare patients to perform functions by compensatory methods:
muscular hypertrophy of the associated muscle groups to compensate
for the paralysed muscles, e.g., long head of biceps to compensate
deltoid action; altered body mechanics to perform function (e.g., trunk
deviation to the opposite side to facilitate shoulder abduction with
synchronized shoulder girdle elevation)
deviation to the opposite side to facilitate shoulder abduction with
synchronized shoulder girdle elevation)
During early stage (first 3 weeks)
1. Control of pain:
◼ Relaxed totally supported positioning of the affected limb

with a suitable orthosis
◼ TENS over area nearest to the intact sensorium
◼ Recommended standard orthoses:
o Brachial plexus injury – aeroplane splint
o Injury to the axillary nerve – shoulder abduction splint
◻ Radial nerve injury – static cock-up splint
◻ Ulnar nerve – strapping fingers together by a loose rubber

strap – to assist passive finger adduction and resistance to
abduction
◻ Median nerve injury – static-to-dynamic knuckle bender

orthosis
◻ Opponens assisting static or dynamic orthoses
◻ For grasp and release – dynamic wrist assisted orthosis

with arrangement to lock wrist in flexion and extension (to
assist tenodesis effect)
◻ Common peroneal nerve injury – BK arthrosis

◻ Dynamic toe pickup orthosis
2. To control oedema
◼ Limb elevation with supportive orthosis
◼ Repetitive active, assisted or passive full ROM movements

to the distal joints
◼ Gentle effleurage
◼ Compressive elastic bandage
3. Assist in early detection of possible nerve injury, and the prevention

of expected complications due to injury or due to treatment (e.g., tight
POP), or skeletal pin traction, or accidental nerve injury during
surgery, or due to altered sensorium (anaesthetic areas).
◼ Identifications of paretic and/or paralysed muscles and

baseline motor and sensory evaluation.
◼ Mapping the areas of paraesthesia and its protection when

present. The patient should be instructed thoroughly how
to protect these areas.
Three weeks onwards (recovery stage)
◼ Confirm the neural damage by electrodiagnostic tests and clinical

tests like Tinel’s sign to apprise status and the prognosis of recovery.
◼ MMT and the areas of sensory impairment re-evaluated and

compared to the baseline data.
◼ Stretch fully the adjacent joints to the injury, to ensure full ROM.
◼ Techniques of assisting active efforts to the paretic muscles or
paralysed muscles is promoted through audiovisual of patients
efforts and techniques like PNF, using stretch reflex or biofeed by
electrical stimulation of EMG.
◼ Efforts to achieve isometric contraction and sustaining efforts

should be guided.
◼ Possible functional education with or without orthosis should be

encouraged.
◼ Techniques of sensory re-education and motor control should be

regularly attempted.
Late stage
◼ Alternate route of guiding a patient to facilitate functional tasks

like:
◼ Hypertrophy of the muscle groups which can compensate

for the permanently paralysed muscles (e.g., use of the
long head of biceps to achieve shoulder abduction in the
absence of deltoid).
◼ Static or dynamic orthosis to assist stabilizing the joint (static

opponens splint) for functional use.
◼ Cock-up splint with locking system to lock in extension for a

stronger grip or release.
◼ Altering the biomechanics of the body to assist functional activity

(e.g., shoulder girdle elevation synchronized with trunk lateral
flexion to the opposite side to facilitate elbow, wrist and hand
function in the absence of shoulder abduction).
Remember
Our body is exceptionally good in acquiring compensatory
mechanisms. Study the patient’s own efforts in performing functions
and guide them.
Injuries to the major peripheral nerves

◼ Median nerve
◼ Ulnar nerve
◼ Radial nerve
◼ Femoral nerve
◼ Obturator nerve
◼ Sciatic nerve
◼ Common peroneal nerve (lateral popliteal and the posterior tibial

(medial popliteal) nerve
Median nerve (nerve roots C5–T1)

◼ A mixed nerve derived from the C5 to T1 nerve roots via medial
and lateral cords of the brachial plexus.
◼ Common sites of injury – a sharp cut close to the wrist and cubital
fossa.
Sites of lesion, clinical features and causes of injury of the median

nerve are depicted in Table 27-11.
Table 27-11
Site of Lesion, Clinical Features and Causes of Median Nerve Injuries
Common Site of
Lesion Motor and Sensory Innervation (Clinical Features) Cause of Injury
• In the arm Motor loss: All the muscles innervated by the median Rare site of injury
(above elbow) nerve in the forearm and hand; sensory loss: thumb, index
finger and radial half of ring finger
• Forearm (close Pronator teres, palmaris longus, flexor carpi radialis and Rare injury, if
to elbow) flexor digitorum superficialis occurs usually cut
due to sharp object
• Cut injury with a
sharp object
• Supracondylar
fracture
• Elbow
dislocation
• Distal to • Motor loss flexor pollicis longus, flexor digitorum • Cut injury with a
pronator teres, as profundus I and II and pronator qudratus glass or a sharp
anterior • Sensory: palmar cutaneous piercing object like
interosseous • Motor loss: abductor pollicis brevis, flexor pollicis knife
nerve brevis, opponens pollicis, lumbricals I and II sensory • Compressive
• Proximal to the Digital (1, 2, 3 and half of 4th digit) neuropathy (carpal
wrist carpal tunnel syndrome)
tunnel
• Distal to the
wrist in the hand
(commonest site
of injury)
Notes: Major motor and sensory innervation: except flexor carpi ulnaris, forearm flexors
pronators, terminal phalanges flexors and thenar muscles; sensory: lateral aspect of the palm
and the dorsal surface of the terminal phalanges along with the palmar surface of 1, 2, 3 and
half of the ring finger.Most reliable test to diagnose median nerve lesion: the intact function of
the abductor pollicis brevis, as there is always a chance of variation in the remaining two
muscles of the thenar eminence – opponens pollicis and the flexor pollicis brevis.
Anatomy
Course and innervation (Fig. 27-18): In the arm, it runs close to the
brachial artery and has no supply. It enters the forearm between the
two heads of the pronator teres, supplies the pronator teres and gives
branches to the palmaris longus, flexor carpi radialis and flexor
digitorum superficialis. Then it gives a muscular branch to the
anterior interosseous nerve which supplies the flexor digitorum
profundus I and II, flexor pollicis longus and pronator quadratus.
Proximal to the carpal tunnel, it gives a sensory branch, palmar
cutaneous, supplying the thenar eminence, descends down and passes
through the carpal tunnel. In the hand, it supplies the abductor
pollicis brevis, flexor pollicis brevis, opponens pollicis, lumbricals I
and II and digital to 1, 2, 3 and the half of the fourth digit.
FIG. 27-18 Median nerve (C5–T1 nerve roots): course and innervation.
Deformities: Ape thumb – there is wasting of thenar muscles and the

thumb lies adducted and in the plane of the palm of hand (Fig. 27-19).
Simian hand – in this deformity, the plane of the thumb is much more
in line with the palm, with wasting of the thenar and hypothenar
muscles. This deformity, therefore, occurs due to combined median
and ulnar nerve palsy.
FIG. 27-19 (A) Median nerve palsy, note the wasting of the thenar muscles
and the thumb lying in the plane of the palm (ape thumb). (B) Normal hand,
note the position of the thumb which lies at right angle to the palm.
Treatment
◼ Fresh injuries are treated by nerve repair.
◼ Chronic injuries require excision of neuroma followed by nerve

grafting.
◼ In injuries beyond repair, tendon transfer procedures are performed
to improve function. Brand’s opponensplasty is done using the
tendon of the flexor digitorum sublimis of the ring finger in median
nerve palsy to restore opposition of the thumb (Fig. 27-20).
FIG. 27-22 Phalen’s test in the diagnosis of carpal tunnel syndrome. The
position of wrist when kept for 60 seconds precipitates symptoms on the
affected side.
In Simian hand, opponensplasty is done using the tendon of the

extensor indicis proprius to restore opposition (Fig. 27-21).
FIG. 27-21 Tendon transfer. (A) Ape thumb deformity due to median nerve
paralysis. (B) Opponensplasty performed using the tendon of extensor
indicis proprius (EIP). Note the active tendon causing abduction of the
thumb.
Compressive lesions of the median nerve

Carpal tunnel syndrome
Carpal tunnel is the overcrowded fibro-osseous canal formed
between three carpal bones (scaphoid, trapezoid and hamate) and the
transverse carpal ligament. The median nerve and the nine tendons of
the digital flexors pass through this 2–2.5 cm tunnel. Therefore, any
bony or soft-tissue pathology to it precipitates compressive forces
over the median nerve passing through it.
Aetiology
◼ Occupational overuse of wrist joint, e.g., computer keyboards
◼ Malunited Colles’ fracture, rheumatoid or osteoarthritis
◼ Ganglia or haematoma at the wrist
◼ Connective tissue disorders (amyloidosis)
◼ Endocrine disorders like DM, hypothyroidism, menopause
◼ Metabolic causes like gout
◼ Growth hormone abnormality (acromegaly)
◼ Pregnancy
Clinical features
◼ Pain and discomfort at the wrist during movements or even at rest.
◼ Burning, aching, warmth, paraesthesia in the hand and wrist in the

distribution of the median nerve (tingling, numbness or burning
sensation); relieved by shaking hands.
◼ Vasomotor symptoms like swelling, cold, dry and shiny skin.
◼ Motor weakness of opponens, flexor pollicis brevis results in

difficulty in making circle with thumb and index finger. Bottle sign –
poor contact of thumb and index finger due to the paralysis of
abductor pollicis brevis, causing difficulties in gripping a cylindrical
object, e.g., bottle or cylinder.
◼ Loss of true opposition.
◼ Late stage muscular atrophy – thenar muscles of the hand (clinical

tests: Figs 27-4–27-10).
Symptom provocative motor tests
1. Phalen’s Test (Phalen, 1966)
Static holding of the wrist in extreme flexion or extension.

Positive sign is the appearance of sensory symptoms by 1
min of the hold (Fig. 27-22).
2. Modified Phalen’s Test
Forceful flexion of the thumb and the fingers with wrist held
in acute flexion for 1 min or more leads to sensory
symptoms of tingling, numbness or burning in the hand
(Smith et al., 1977).
3. Reverse Phalen’s test (Werner et al., 1994)
Wrists as well as the fingers are held in the position of

extreme extension. The sensory symptoms begin to appear
by 1 min.
4. Tourniquet sign
When the arm cuff of the BP instrument is inflated beyond

the level of systolic BP of an individual, the sensory
symptoms appear in the distribution of the median nerve.
5. Bilateral arm percussion test
The sensory symptoms in the innervated area of the median

nerve appear on applying equal pressure on the medial
side of the palm just about the wrist (over the carpal tunnel
area).
6. Vibratory test
Application of a tuning fork of 256 cps over the same area

results in appearance of symptoms. Slowing of the
conduction of the CNV can diagnose median nerve lesions
even before the clinical symptoms.
Treatment
Conservative
◼ Treatment of the relevant causative factor which has precipitated

the syndrome.
◼ A simple splint that blocks movements at the wrist is adequate to

avoid compressive stretches to the carpal tunnel.
◼ Nonsteroidal anti-inflammatory drug (NSAID) agents
◼ Local ultrasonic exposure
◼ Pain-free relaxed passive or speedy active movements are

encouraged in the pain-free range by removing the splint.
◼ Cryotherapy, TENS over the palmar aspect of the wrist may be

tried.
◼ Local corticosteroid injection may be given only after confirming

the absence of sensory deficit.
Surgical
Surgical release of the median nerve may have to be undertaken by
the division of the carpal flexor retinaculum and/or transverse carpal
ligament either by open surgery (Fig. 27-23) or by endoscopic surgery.
FIG. 27-23 Operative photograph of carpal tunnel release. There is visible

constriction of the median nerve, after division of the volar carpal ligament
(ligament not seen in the picture).
Anterior interosseous syndrome

Rare pain in the forearm and elbow because the sensory fibres from
the wrist and the carpal bones travel in the anterior nerve.
Identifying signs
◼ Muscles of innervation:
◼ Flexor pollicis longus

◼ Flexor digitorum profundus I and II
◼ Pronator quadratus
◼ Functional difficulty in using hand like picking up a cup, tearing a

paper, using spoon and fork.
◼ Motor weakness – performing forearm pronation against resistance.
Ulnar nerve (nerve roots C8–T1)

It is derived from the medial cord of the brachial plexus. It descends
medially in the arm close to the brachial artery and the median nerve.
It does not give branches. At the elbow, it lies in the condylar groove
and enters the cubital tunnel, gives branches to the flexor digitorum
profundus III and IV, and flexor carpi ulnaris. At the wrist, it passes
between the pisiform bone and the hook of hamate through Guyon’s
canal, gives the superficial sensory and the deep peroneal motor
branch. The sensory branch supplies the ulnar half of the fourth and
the whole of the fifth digit. The deep motor branch supplies the
hypothenar muscles (opponens digiti minimi, abductor digiti minimi
and flexor digiti minimi). Then it deviates to the lateral aspect of the
hand, supplying the muscles, adductor pollicis, interossei, 3rd and 4th
lumbricals.
It has two other sensory branches supplying to the hand (palmar
and dorsal cutaneous branch) arising from the distal forearm but
which do not pass through the Guyon’s canal.
Course and the branches of the ulnar nerve (Fig. 27-24, Table 27-
12):
Deformity Deformities due to the lesion of the ulnar nerve
◼ ‘Main-en-griffe’ or ulnar claw hand – It results in

hyperextension at the MP joints due to the paralysis of
lumbricals (lateral two) and unopposed action of the
extensor digitorum communis, whereas intact long flexors
produces flexion at both the IP joints of the ring and the
little finger (Fig. 27-18).
◼ The medial claw hand – the deformity is similar to the

ulnar claw hand but instead of the ring and the little
fingers, the clawing appears at the index and the middle
(Fig. 27-19B).
◼ The true claw hand: A combined lesion of both the ulnar

and the median nerve results in a true hand, where the
clawing is present in all the four fingers (Fig. 27-19C) (e.g.,
Hansen, disease, VIC, PPRP, progressive muscular
dystrophy, peripheral neuritis).
FIG. 27-24 Ulnar nerve (course and innervation).
Table 27-12
Areawise Local Causes of Lesions of the Ulna Nerve
Site of
Causes
Lesion
In the axilla • Constant crutch pressure
• Axillary vessel aneurysm in the axilla
• Sharp cut injury
In the arm • Fracture of the humeral shaft
• Penetrating injuries like gunshot
At the elbow • Fracture of the lateral epicondyle of humerus
• Repetitive occupational stress (overuse)
• Recurrent subluxation of the nerve
• Compression by the osteophytes as in RA and OA or by an accessory
muscle
• Anserina epitrochlearis
• Cubitus valgus due to repetitive friction (tardy ulnar nerve palsy)
At the • Fracture of both bones of the forearm
forearm • Penetrating wounds of the forearm
At the wrist • Compression by the osteophytes
• Fracture of the hook of hamate
• Compression by ganglion
• Injuries to the wrist
At the hand • Blunt trauma
• Penetrating injuries
• Operation of high-speed drill on hard surfaces
• Associated ulnar artery aneurysm
Ulnar Nerve: the Level of Lesion and the Respective Lost or Spared Function
Site of Lesion Function Spared or Lost

Above the elbow All the functions are lost
At the junction of middle and lower third of the • Spared: FDP and FCU
forearm • Lost: motor HTM, INT, LUMB and PB
• Sensory: hand over the dorsal aspect
Proximal to Guyon’s canal • Spared: FDP, FCU dorsal sensation
• Lost: Valor sensation same as earlier
Distal to Guyon’s canal • Spared: FDP, FCU, HTM, PB and dorsal and
valor sensation
• Lost: INT and LUMB
Notes: FCU, flexor carpi ulna; FDP, flexor digitrum prefunds; HTM, hyposthenia muscle; INT,
interpose; LUMB, lumbricals; PB, palmaris bravis.
Clinical tests for ulnar nerve injury

Froment’s sign: The patient is asked to hold a book between the
thumb and the other fingers. Coordinated, combined action of these
muscles – first palmar interosseous, adductor pollicis and flexor
pollicis longus – is required. In ulnar nerve lesion, the first two
muscles are paralysed; thus, the patient has to depend only on the
flexor pollicis longus which mainly flexes the thumb proximally ; this
confirms the lesion (Fig. 27-9).
Card test (a test for palmar interossei): Inability to hold a card or

paper in between the fingers due to a loss of adduction of the fingers
which is performed by the palmar interossei (Fig. 27-7).
Egawa test (a test for dorsal interossei): With palm resting on the
table, the patient is asked to move the middle finger sideways
towards the index finger held passively in abduction (Fig. 27-8).
Ulnar paradox
The higher the lesion of the median and the ulnar nerve injury, the
less prominent is the deformity and vice versa. This happens because
in higher lesions, the long finger flexors are paralysed; the loss of
finger flexion makes the deformity obvious.
The extent of clawing appears less in spite of the higher level of
lesion as a result of the paralysis of the flexor digitorum profundus.
◼ Functional inabilities due to the claw hand:
◼ Weak grip due to the weak MP flexion.
◼ Inability to produce activities like pinching due to the

paralysis of interossei.
◼ Weakness of grasp and the action of finger rolling.
Treatment
◼ Knuckle bender arthosis to block the hyperextension at MP joints
automatically keeps fingers extended.
◼ Functional training with orthosis
Nonrecoverable lesions
◼ Tendon transfers: To correct claw hand (Bunnell’s operation)
◼ Wrist stabilization by arthrodesis in 15-degree extension, or

capsulodesis.
Compressive lesions of the ulnar nerve

◼ Tardy ulnar nerve palsy (Fig. 27-25):
The major cause is the repetitive friction or compression of

the ulnar nerve in the cubital tunnel in situations like the
following:
◼ Cubitus valgus deformity
◼ Tension over the supracondylar grove or cubital tunnel or

repetitive friction due to overuse, e.g., postmedial or lateral
epicondyle fracture (malunion), excessive callus formation,
Hansen disease and ganglia.
FIG. 27-25 Claw hand deformity due to ulnar nerve injury.
Clinical features
Motor paralysis of the muscles supplied by the ulnar nerve, sensory
tingling and numbness in the 4th and 5th fingers with wasting,
proximally radiating pain.
Diagnostic motor test: The elbow joints are held in complete flexion
with the wrists extended fully. In a positive test, by 3 min, the
symptoms of pain, tingling and pins and needles begin to appear in
the distribution of the ulnar nerve, which disappear on extending the
elbows.
Treatment
◼ NSAID, rest with elbows in extension
◼ Local US exposure and orthosis
◼ Release of entrapment by medial epicondylectomy
◼ Anterior transposition of the ulnar nerve
Claw hand
Claw hand presents as a typical deformity with hyperextension of the
metacarpophalangeal joints and flexion of the interphalangeal joints.
The involvement depends upon which of the two nerves is
damaged.
When the ulnar nerve is damaged, it will result in isolated ulnar
claw hand involving the fingers supplied by the ulnar nerve (e.g., ring
and small finger; Fig. 27-25).
Whereas, when the lesion occurs in the median nerve, it will result
in median claw hand with clawing present in the index and the
middle finger only.
When a combined lesion of both the ulnar and the median nerve
occurs, the result will be a ‘true claw hand’ involving all the four
fingers of the hand with an ape thumb deformity where the thumb
lies in the plane of the palm (Fig. 27-20).
FIG. 27-20 Intraoperative photograph of Brand’s opponensplasty. FDS

tendon of the ring finger harvested through a small incision in the palm,
routed through a pulley made of a half tendon of FCU at the wrist, tunnelled
subcutaneously and inserted at the level of MCP joint of the thumb.
Clinical features
Hyperextension at the MP joint is most disabling, resulting in the
following:
◼ Fingers lose the stabilizing effect, resulting in a weather grasp,

pinch, as well as grip.
◼ There is a loss of sensation on the skin along the distribution of the

involved peripheral nerve.
◼ Wasting and weakness of the intrinsic muscles of the hand,

resulting in wasting (hollowing) at the intermetacarpal spaces on the
dorsum of the hand.
◼ Wasting of the thenar and hypothenar muscles.
Treatment
The treatment is centred on controlling the hyperextension at the MP
joints, to facilitate the functions of the finger movements. Active
method is by surgically transferring the tendon whenever it fulfils all
the required criteria.
Radial nerve (C5–T1 nerve roots)

Radial nerve is the continuation of the posterior cord of the brachial
plexus. In the upper arm, it supplies the three heads of the triceps
muscle and the anchoneus. Then it winds around the shaft of the
humerus in the spiral groove; at this level, it gives the sensory
posterior antebrachial cutaneous branch. Below the insertion of the
deltoid, it is superficial; over the lateral aspect of the arm, it supplies
the brachialis, brachioradialis, extensor carpi radialis longus and
extensor carpi radialis brevis. At the level of the lateral epicondyle, it
lies lateral to the biceps, and enters the forearm between the brachialis
and the brachioradialis. In the proximal forearm, it divides into the
posterior interosseous and the superficial radial cutaneous branch.
The posterior interosseous, supplies the supinator and pierces it.
Distal to the supinator, it supplies the extensor digitorum communis,
extensor carpi ulnaris, extensor digiti minimi, extensor indicis,
extensor pollicis longus, abductor pollicis longus and extensor pollicis
brevis. The superficial radial cutaneous nerve descends along the
lateral border of the forearm and supplies the dorsum of the hand.
Course and the innervation of the radial nerve (Fig. 27-26; Table
27-13):
◼ High lesion above the spiral groove: Total palsy except triceps.
◼ Low lesion I between spiral groove and the lateral epicondyle:

Elbow spared, extensor of wrist, thumb and finger extensors are
paralysed.
FIG. 27-26 Radial nerve (C5–T1 nerve roots) – course and innervation.
Table 27-13
Site of Lesions, Innervation and Causes of Injury to the Radial Nerve
Motor and Sensory Innervation

Site of Lesion Cause
(Clinical Features)
• Upper arm Motor • Aneurysm of
• Axilla • Three heads of triceps and axillary vessel
anconeus • Long duration
shoulder
dislocation
• Crutch palsy
• Close to the spiral groove Motor • Fracture of the
• Brachialis midshaft humerus
Sensory: antebrachial • IM injection
posteriors • Saturday night
palsy
• Iatrogenic
(excision of the
head of the
radius)
• Surgical
positioning
(Trendelenburg)
• Tourniquet
palsy
• Elbow close to the level of lateral Motor • Dislocation of
epicondyle (cubital fossa) • Brachioradialis elbow
• Extensor carpi radialis • Supracondyler
longus fracture
• Extensor carpi radialis • Fracture of the
brevis humeral condyles
• Supinator • Cubitus valgus
• Fracture of the
radial head
• Elbow posterior
dislocation
• Monteggia
fracture
• Proximal to forearm: distal to supinator Motor • Fracture of both
Divides into two: • Extensor digitorum the bones of
• Posterior interosseous nerve (motor communis forearm
branch) and superficial radial cutaneous • Extensor carpi ulnaris • Gunshot or
(sensory branch) • Extensor digit minimi piercing injury
• Extensor indicis • Monteggia
• Extensor pollicis longus fracture
and brevis
• Abductor pollicis longus
Sensory: Interosseous
antibrachii posterior dorsum
of first web space
Sensory and Motor Features as Related to the Levels of Lesions in Radial Nerve Injury
Level of Injury Features
High level: Above the spiral groove • Total wrist drop
• Sensory loss: Over the dorsum of
thumb
Low: Between the spiral groove and the lateral • Spared: Elbow extensors
epicondyle • Lost: Wrist, thumb and finger extensors
a
• Sensory loss: Dorsum of the first web
space
Low: Below the elbow • Spared: Elbow extensors and wrist
extensors
• Lost: Thumb and finger
• Sensory loss: First web space
aMisguidance: The dorsal interossei, which are supplied by the ulnar nerve, can actively
extend the IP joints as they are inserted into the base of the proximal interphalangeal joints of
the first three fingers in the absence of the extensor digitorum due to injury of the radial nerve.
Deformities
◼ Total wrist drop: Simultaneous extension at the wrist, fingers and
the thumb is lost (Fig. 27-26) due to the loss of finger and thumb
extensors.
◼ Hitchhiker’s sign: Inability to extend the IP joint of the thumb due

to paralysis of the extensor pollicis longus and brevis is the only
clinical sign to suspect radial nerve lesion during the early stage of
injury.
Treatment
In closed injury
◼ Cock-up splint, initially static and at the later stage,

dynamic.
◼ Full ROM passive movements to the wrist, fingers and the

thumb.
◼ Progress to active assisted movements, self-effort, Rood’s

technique, EMG biofeedback, or initiating contractions
with PNF technique by using stretch reflex.
In open fractures
Nerve repair procedure along with the reduction of a fracture.
◼ Late or nonrecovered lesions: Surgical procedures like the

following:
◻ Tendon transfers
◻ Wrist joint arthrodesis in the functional position of the

wrist
Possible testing error
Remember, intrinsic muscles (dorsal interossei) of the hand

are capable of extending the fingers at the interphalangeal
joints in the injured radial nerve due to the advantage of
their insertion at the base of the proximal phalanges of the
first three fingers.
Compressive lesions of the radial nerve

The common sites of compressive lesions could be
1. In the axilla
2. Retrohumeral at the posterior aspect of the humerus (arm)
3. At the proximal forearm
4. At the distal forearm
Lesion in the axilla

Either due to crutch pressure or during sleep. Crutch palsy,
involves triceps and all distal muscles innervated by the
radial nerve.
Retrohumeral lesion
A lesion at the posterior aspect close to the spiral groove of

the humerus.
◼ Saturday night palsy – sustained compression due to

malpositioning of the arm during deep sleep (common in
alcoholics), during general anaesthesia or tourniquet
application or wrong IM injection directly on or injuring
the nerve may appear late as a result of compression by a
callus formation, following fracture of the shaft of
humerus.
◼ Motor weakness – all the extensors of the wrist, fingers

and thumb (weakness of supinator and brachioradialis).
◼ Sensory: Over the dorsum of the thumb.
Lesion at the proximal forearm
◼ Involves the posterior interosseous nerve.
Motor: weakness of the wrist and MCP joint extensors,

extension at the IP joints is preserved as the intrinsics
supplied by the median and ulnar nerves are spared.
Lesions at the distal forearm

Superficial cutaneous radial nerve entrapment: A nerve may be entrapped
due to compression by a tight cast, a tight band of a wrist watch or a
handcuff. It results in altered sensorium, over the small area of the
dorsum of a thumb web.
Usually a surgical release of the radial nerve at the elbow is
indicated.
Treatment
◼ Static or dynamic cock-up splint
◼ Full ROM passive movements to the wrist and hand joints
◼ Educate patient on assisted active movement of wrist, fingers and

thumb extension, elbow flexion in supination and forearm
supination.
◼ PNF, biofeedback sessions.
Surgery
When recovery does not take place by 18 weeks, surgical exploration
and repair, release or reconstructive procedures is the only alternative.
Peripheral nerves of the lower limb (table 27-

14)
The myotomal and the dermatomal innervation of the lower limbs are
provided by two plexuses.
1. The lumbar plexus (derived from the anterior rami of the L1–L4
nerve roots).
2. The sacral plexus (derived from the L4–S3 nerve roots) (Fig. 27-27A
and B).
FIG. 27-27 Lumbar and sacral plexuses: (A) Lumbar plexus. (B) Sacral
plexus.
Table 27-14
Lower Extremity Peripheral Nerve Lesions Motor and Sensory Characteristics
Plexus and
Peripheral Motor Supply Sensory Supply Any Other
Nerves
• • All adductor muscles of • Anterolateral • All PN injuries have
Lumbar thigh (except adductor thigh (by lateral general signs and
plexus magnus which is supplied by cutaneous nerve) symptoms of pain,
(L1–L4) sciatic nerve) tenderness for 1–2 weeks
• • Followed by wasting over
Obturator the distribution of the nerve
nerve after 2–3 weeks
(L2–L4)
• • Iliacus, pectinius, psoas, • Front of the • Positive femoral stretch
Femoral gracilis, sartorius and thigh sign
nerve quadriceps • Medial side of • Absence or loss of knee
(L2–L4) leg and foot jerk
• Sacral • Deformity: Unstable knee
plexus (genu recurvatum at late
(L4–S3) stage
• • Gluteus medius Upper lateral • Weak or absent knee jerk
Superior • Gluteus minimus thigh • Gluteus medius lurch
gluteal • Tensor fascia lata
(L4–S1)
(L4–S1)
• • Gluteus maximus • Posterior lurch
Inferior
gluteal
(L5–S1)
• Sciatic • Hamstrings • Lateral half of • Wasting of thigh, calf and
nerve • Leg and foot leg sole of the foot, trophic
(L4–S3) • Dorsum of the ulcers or foot drop
foot and entire • Ankle jerk is absent or
sole reduced
• • Superficial peroneal branch: • Superficial • Foot drop
Common • Peroneus longus peroneal: • High stepping gait
peroneal • Peroneus brevis • Front, lateral • Toes drag gait
nerve • Deep peroneal (branch) and posterior leg
(L4–S2) • Tibialis anterior • Dorsum of the
• Extensor hallucis longus foot leaving
• Extensor dig longus and extreme medial
brevis and lateral strips
• Peroneus tertius • Deep peroneal:
Small area of skin
at the web space
between 1st and
2nd digits
• • Gastroc-soleus • Sole of the foot • Calcaneus deformity
Posterior • Tibialis posterior including nail • Calcaneus gait (foot slap)
tibial • Flexor hallucis longus beds and the distal • Later stage: trophic ulcers
nerve • Flexor digitorum longus phalanges
(L4–S3)
• • Flexor digitorum brevis
Medial • First lumbrical
plantar
branch
• • Two, three and fourth • Sole of the foot
Lateral lumbricals
plantar • Dorsal and plantar interossei
branch • Adductor hallucis
Lumbar plexus
It gives rise to two major mixed nerves, the femoral and obturator
nerves and the purely sensory nerve – lateral femoral cutaneous nerve
of the thigh.
Obturator nerve (l2–l4)

It exits the psoas muscle medially and supplies the adductor group of
muscles of the thigh.
Femoral nerve (fig. 27-28)

It is formed by the dorsal portion of the anterior rami of the L2–L4
nerve roots. It descends down and passes between the psoas and the
iliacus muscles and lies most laterally in the femoral triangle.
FIG. 27-28 Femoral nerve (course and innervation).
Then it divides into the anterior and posterior divisions. The

anterior division supplies the anterior thigh through the intermediate
cutaneous branch and the medial thigh through the medial cutaneous
branch. The anterior division also supplies to the pectineus and
sartorius muscles.
The posterior division supplies the hip and knee joint, the
quadriceps muscle and terminates as a long cutaneous which supplies
the skin over the anteromedial aspect of the leg and foot.
In the inguinal canal, it gives the cutaneous branches ilioinguinal,
iliohypogastric, genitofemoral and the lateral cutaneous branch.
Sacral plexus
Formed by the L4–S3 nerve roots in front of the sacroiliac joint, it gives
two branches:
1. Superior gluteal (L4, L5; S1) innervates the gluteus medius,

minimus and tensor fascia lata
2. Inferior gluteal nerve (L5–S1) innervates the gluteus maximus and

sciatic nerve (L4, L5; S1–S3)
Sciatic nerve (fig. 27-29)

The longest and thickest nerve in the body, the sciatic nerve
innervates important muscle groups of the lower limb. Although
strong, it is highly susceptible to injury due to its intrapelvic position.
FIG. 27-29 Sciatic nerve (course and innervation).
It emerges out of the pelvis through the sciatic notch along with the
superficial gluteal nerve, inferior gluteal nerve and posterior
cutaneous nerve of the thigh. In the thigh, it lies at the middle of the
posterior aspect of the thigh, a common site of sciatic pain.
The injury to the sciatic nerve may occur due to traumatic or
compressive pathology.
Traumatic Causes Compressive or Stretching (Traction)

• Posterior dislocation of hip joint • Malpositioning of body
• Posterior dislocation of hip joint • Malpositioning of body
• Fractures around pelvis, hip joint, proximal shaft of femur • Comatose state
• Deep surgical incision (e.g., THR) or penetrating injury • Sitting over the edge of hard
• Intramuscular injection surface (e.g., bed frame)
• Muscular scarring during reduction of hip dislocation • Compression due to
following lithotomy position • Tumour
• Lymphoma
• Banker cyst
• Other causes:
• Vasculilis
• Thrombosed aneurysm
The proximal lesion of a sciatic nerve in the pelvis or close to the

sciatic notch results in:
◼ Involvement of the gluteal muscles and sensory loss in the

distribution at the posterior cutaneous of thigh.
◼ Weakness of
◼ Hamstrings
◼ All the muscles below the knee
◼ Sensory loss over the leg and foot below knee
Distal lesion
Behind the popliteal fossa, it divides into two branches, the lateral
popliteal or common peroneal and the posterior tibial nerve.
Common peroneal nerve (lateral popliteal nerve) (fig. 27-

30)
The lateral trunk of the sciatic nerve descends obliquely through the
popliteal fossa as a lateral cutaneous branch supplying the anterior,
lateral and posterior aspect of the leg, then it winds round the fibular
neck where it is most superficial, and therefore, a common site of
injury. Then it passes through the fibular tunnel and divides into two
branches:
1. Superficial peroneal
The superficial peroneal innervates the peroneus longus and
brevis and provides cutaneous supply to the anterolateral
leg and dorsum of the foot.
2. Deep peroneal nerve
The deep peroneal nerve innervates the anterior

compartment muscles:
(a) Tibialis anterior
(b) Extensor digitorum longus and brevis
(c) Extensor hallucis longus
(d) Peroneus tertius
The terminal cutaneous branch supplies a small area (web

space) between the first and the second toe.
FIG. 27-30 Common peroneal (lateral popliteal) nerve – course and

innervation.
Posterior tibial nerve (fig. 27-31)

The medial trunk of the sciatic nerve continues posteriorly below the
popliteal fossa as a posterior tibial nerve. It innervates:
◼ Both heads of the gastrocnemius and the soleus muscles

◼ Tibialis posterior, popliteus, flexor digitorum longus and flexor
hallucis longus.
◼ At the ankle under the flexor retinaculum (tarsal tunnel), the

posterior tibial nerve divides into the medial and lateral plantar
nerves after giving a branch to calcaneum.
◼ The medial plantar branch innervates the first lumbrical and the
lateral plantar branch innervates the second, third and fourth
lumbricals. The sensory innervation of the dorsal as well as the
plantar surface comes from various cutaneous branches: saphenous,
superficial and deep peroneal; medial and lateral plantar nerve,
calcaneal and sural nerve.
FIG. 27-31 Posterior tibial nerve (course and anterolateral innervation).
Sural nerve
It is purely a sensory nerve from S1 to S2 roots. It is formed by the
joining together of two branches, the medial branch is derived from
the tibial and the lateral branch from the peroneal nerve.
Being deep, it is rarely injured. It may be compressed by Baker cyst,
scar tissue following fractured fifth metatarsal, ganglia, etc.
It innervates the posterolateral aspect of the distal leg, a small strip
over the lateral-most foot (Fig. 27-32).
FIG. 27-32 Sensory innervation foot (plantar aspect).
Note: The lateral-most aspect of the foot is supplied by the sural

nerve.
Foot drop (see fig. 27-11)

Foot drop or dropping of the foot into plantar flexion position is the
most common disability encountered of all the peripheral nerve
injuries.
Foot drop may arise due to several causes extending from spine to
foot.
Causes
At the Spine At and Around Knee

• PIVD • Fracture of the neck of fibula
• Spina bifida • Fracture of the lateral femoral or
• Localized spinal tumour tibial condyle
• Knee dislocation at superior
• At the hip: Posterior dislocation and fractures around the • Lateral meniscal injury, cyst or
hip, and femur and acetabulum and deep IM injection tumour
• At the thigh: Deep IM injection or deep penetrating injury • Dislocation of superior
• Fracture of the shaft of femur tibiofibular joint
• Tight POP cast around knee or
while applying tibial skeletal
traction
• Direct piercing injuries, e.g.,
gunshot
• Hansen disease
Level of lesion:
The motor and sensory involvement depends upon the level of the
lesion.
High lesion: Both common peroneal and tibial nerves are involved; causing
Above the knee before the TRUE FOOT DROP involving all the foot muscles (flail foot)
division of sciatic nerve Sensory: spared peroneus longus and brevis
Low lesion: All the extensor group of muscles of the ankle and toes including
Lesion below the knee peroneus tertious are involved
Common peroneal nerve Spared: plantar flexors and toes flexors (intrinsics)
involvement (lateral Sensory: first web space
popliteal)
Posterior tibial nerve Paralysis of the plantar flexor group, toe flexors (intrinsics)
Spared: ankle and foot dorsiflexors, peroneus longus, brevis
Sensory: distal part of the calf and sole of the foot
Early detection
◼ Common peroneal high stepping gait or toe drag.
◼ Posterior tibial lesion: Foot slap immediately following heel strike

(calcaneus gait).
Treatment of foot drop
Early treatment
◼ Whatever may be the causative factor, the first priority is to provide

a splint which will maintain the foot in neutral position of dorsal
and plantar flexion. Avoid soft tissue stretching and stretch on the
involved peripheral nerve.
◼ Orthosis could vary from static POP posterior slab, KFO or toe
pickup orthosis (Fig. 27-33A and B).
◼ Depending upon the causative factor and ascertaining the

diagnosis, anti-inflammatory or steroid agents may become
necessary.
FIG. 27-33 (A) Below-knee splint to prevent equinus deformity. (B) Toe
pickup orthosis.
Physiotherapy
Extensive evaluation will dictate the line of treatment.
◼ Control of pain
◼ Control of inflammation
◼ Preventing joint stiffness or fixed deformity due to skeletal or soft

tissue contractures
◼ Exercise forms the basis of therapy. The choice of the type of

exercise depends upon the degree of involvement and the progress
of recovery
◼ Full ROM passive movements
◼ Assisted active movements – slowly done, maximum effort by

patient is very important.
◼ PNF technique of bilaterally symmetrical pattern combined with a

strong stretch reflex at the initiation of a pattern or even repetitive
stretches to ankle plantar flexion stimulate the lost muscular action
of the ankle and foot dorsiflexion, which is very encouraging to a
patient.
◼ EMG – biofeedback using visual as well as auditory feedback,

sensation of the areas close to the anaesthetic area by electrical
stimulation helps in regaining lost sensation along with other
techniques.
◼ Providing the necessary orthosis
◼ Gait training: Static or dynamic splint

◼ Complete foot drop (involvement of both common
peroneal and tibial nerve), static moulded BK splint which
keeps the ankle joint in neutral.
◼ BK brace with foot drop stopped at 90 degrees.
◼ Toe pickup orthosis which maintains foot in neutral but

allows active plantar flexion is ideal when the posterior
tibial nerve is spared or in upper motor lesions.
Surgical procedures
The type of surgical procedure to be chosen depends on the site, the
extent and the severity of neuronal damage.
◼ Fixed equines due to TA tightness or contracture – tendo-achilles

lengthening.
◼ Paresis or paralysis due to thickened and tender nerve caused by

tuberculoid leprosy (Hansen) – peroneal nerve stripping.
◼ Fixed varus deformity of the foot – subtalar joint stabilizing

procedure (arthrodesis).
◼ Fixed varus at the subtalar joint – triple arthrodesis.
Tendon transplant procedures
◼ Single transplant: Tibialis posterior which escapes paralysis in

common peroneal lesion is transplanted to the midfoot.
◼ Double transplant: Anterior transposition of tibialis posterior fixed

transferred to the extensor hallucis longus combined with peroneus
brevis transfer to prevent excessive valgus due to strong peronei.
Physiotherapy following surgery (table 27-15)

Nerve repairs
Initial ( < 3 weeks) stage

Immobilized limb: Measures same as described earlier to reduce pain,
inflammation; exercise to improve (muscle and joint) functions of
unaffected joints.
Table 27-15
General Principles of Physiotherapy
Paralytic • Splint, control of pain, oedema

stage (up to • Prevent contractures
3 weeks) • Full passive ROM (relaxed and slow)
Postparalytic • Emphasis on motor and sensory, re-education by using electrical stimulation,
stage (>3 EMG biofeedback techniques, dynamic orthotic aid/static orthosis
weeks) • Functional training with/without orthosis
Nerve • Active or assisted motor and sensory re-education
repairs • Static or dynamic orthosis
• Functional re-education
Tendon • Encouraging and re-educating the altered action of the donor tendons
transfers
Intermediate stage
◼ After 3 weeks: Electrodiagnostic test, assisted active exercises to the

affected joints related to the nerve repaired without causing stretch
to the repaired nerve, progress to active strong sustained efforts.
Late stage: After (6–8 weeks)
◼ Add graded resistance to the muscle action of the repaired

nerve.
◼ Maintain full passive ROM of the related joint.
◼ Initiate functional activities.
◼ Functional use of upper extremity.

◼ Standing, balancing, gait training with or without orthosis.
Comprehensive Physiotherapy Measures
During the Stage of Paralysis During the Postparalytic Stage

Measures to reduce pain and oedema Motor and sensory re-education with self-performed
exercises with emphasis on audiovisual feedback
synchronized with active efforts
Immediate orthotic splint to control Diagnostic electrical stimulation
tendency for developing tightness or soft
tissue contracture
Prevention of joint stiffness Therapeutic electrical stimulation as a feedback synchronized
with patient’s own active efforts
Protection of anaesthetic areas from injury Guidance on maintenance and the correct use of orthosis with
or stretch gait training or functional use
Emphasis on both motor and sensory re- Provide ambulatory aid but do not let the organization of a
education limp
Remember
Preoperative education and emphasis on the following:
◼ Hypertrophy or strengthening of the donor muscle groups at least

to grade 4 of MMT.
◼ Repetitive slow and sustained longitudinal stretching session (self)

to the donor muscle and related joint to facilitate postoperative
mobility.
◼ Postoperative education to the new role.
◼ Training and re-education on the exact groove of the expected

movement which differs from its normal (a new role) earlier action.
Compressive lesions of the lower limbs

Meralgia paraesthetica
Occasionally the lateral cutaneous femoral nerve of the thigh gets
entrapped at the inguinal tunnel or at the fascia medial to the anterior
superior iliac spine.
Causes
◼ Tight corset, seat belt or obesity
◼ Psoas abscess, retroperitoneal tumour or postoperative scarring in

the region of the iliac fossa.
◼ The patient complains of pain and paraesthesia in the distribution

of the nerve, i.e., on the anterolateral aspect of the thigh, which gets
worsened by weight bearing or ambulation.
◼ Sensory loss restricted to a small size over the anterolateral aspect

of the thigh.
Treatment
◼ Anti-inflammatory or neuronal drugs
◼ Local steroid infiltration
◼ Surgical decompression of the lateral cutaneous nerves (rare)
Sciatic nerve: Heavy retraction during surgery of hip

dislocation may cause sciatic nerve compression.
Common peroneal nerve: The most common lesion.
Subcutaneous compression over the neck of fibula, e.g., tight

BK cast, or BK orthosis, ganglia at the proximal tibiofibular
ligament, sustained cross-leg sitting and side sleeping on a
hard bed.
It results in foot drop.

Posterior tibial nerve (tarsal tunnel syndrome): Compression
over the medial aspect of the ankle following arthritis of
the ankle or marked valgus deformity of the ankle. The
nerve is compressed between the tendons of flexor
digitorum longus and flexor hallucis longus. The patient
presents with burning pain over the plantar surface of the
foot.
◼ Orthosis is prescribed with modifications in the shoe.
◼ NSAIDs.
◼ Cortisone injection may be tried locally.
◼ Excellent results with surgical release of compression.Scarred nerve

excision and nerve repair may be done.
It follows the same pattern as detailed for foot drop in both the
treatment approaches. Motor and sensory re-education plays a major
role in both the therapeutic approaches along with extensive guidance
to the patient to prevent damage to the anaesthetic area.
Bibliography
Brachial plexus lesions

1. Copeland S, Landi A. Value of the Tinel sign in brachial plexus
lesions. Annals of the Royal College of Surgeons of England
1979;61:470.
2. Framton V. M. The flail arm splint, treatment note. Physiotherapy
1984;70:428.
3. Jones S.J, Wyn-Perry C.E, Landi A. Diagnosis of brachial plexus
traction lesions sensory nerve action potentials and somatosensory
evoked potentials. Injury 1981;12:376.
4. Leffert R. D. Brachial plexus traction injuries. Clinical
Orthopaedics and Related Research 1988;237:24.
5. Rood M. S. Neurophysiological mechanisms utilized in the
treatment of neuromuscular dysfunction. American Journal of
Occupational Therapy, 1956;10:220.
6. Sunderland S. Nerve and nerve injuries. 2nd ed. Edinburgh:
Churchill Livingstone 1978;
7. Zalis A.W, Oester Y.T, Rodrigues A. A. Electrophysiological
diagnosis of cervical root avulsion. Archives of Physical Medicine and
Rehabilitation, 1970;51:708.
Peripheral nerve injury

8. Dellon A. L. Clinical use of vibratory stimuli to evaluate peripheral
nerve injury and compression neuropathy. Plastic and Reconstructive
Surgery, 1980;65:466.
9. Dellon A. L. The moving two-point discrimination test clinical
evaluation of the quickly adapting fibre/receptor system. Journal
of Hand Surgery 1978;3:474.
10. Delton A.L, Curtis R.M, Edgerton M. T. Evaluating recovery of
sensation in the hand following nerve injury. The Johns Hopkins
Medical Journal 1972;130:235.
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of sensibility in the hand. The Journal of Bone & Joint Surgery,
1958;40-B:454.
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Journal of Bone & Joint Surgery, 1978;60-A:412.
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14. Phalen G. S. The carpal tunnel syndrome, 17 years experience in
diagnosis and treatment. The Journal of Bone & Joint Surgery,48-A
1966;211.
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syndrome contribution of flexor tendons. Archives of Physical
Medicine and Rehabilitation, 1977;158(58):379.
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Philadelphia: WB Saunders 1980;582.
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Neerlandaises De Physiologie 1922;7:142.
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und Wissenschaftliche Medicin, 1935;152.
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as an aid in diagnosing carpal tunnel syndrome. Archives of Physical
Medicine and Rehabilitation, 1994;75:783.
CHAPTER
28
Poliomyelitis
OUTLINE
◼ History
◼ Virology
◼ Pathology
◼ Clinical characteristics
◼ Differential diagnosis
◼ Course of recovery
◼ Treatment
◼ Prevention of late effects of poliomyelitis
Poliomyelitis is an endemic and epidemic infectious viral disease,

mainly affecting children under the age of 5 years.
The disease is transmitted by droplet infection and by oral
ingestion. The period of incubation varies from 3 to 30 days.
In the nonimmune stage, there are three distinct phases of the
disease:
1. Initial incubation period
2. Prodromal nonparalytic stage
3. Definitive paralytic phase

The symptomatic illness following infection is due to the
destruction of the anterior horn cells of the spinal cord and the
brainstem for which the virus has a selective affinity (Fig. 28-1). The
result is flaccid paralysis without a sensory loss.
FIG. 28-1 Section of the spinal cord showing the site of attack by polio
virus, at the anterior horn cells.
The involvement is predominant in the lower limbs, particularly in

the extensor group of muscles. Muscular weakness and muscular
imbalance are the main factors in producing the crippling deformities.
History
The withered and deformed limbs noted in the ancient Egyptian
mummies trace the incidence of poliomyelitis nearly to 6000 years
back. The first known description of polio was provided by
Underwood in 1789. The first epidemic of polio was reported in the
island of Helena in 1834; Duchenne in 1855 first reported the
involvement of the anterior horn cells. In 1909, Landsteiner
successfully transferred the disease to monkeys. The first type of virus
was detected by Bodian in 1949. The year 1954 saw the first large-scale
trial of Salk dead vaccine (1956) by injection. An effective
immunization came in 1958 by the use of the oral sabine (live
attenuated) vaccine (1959).
Virology
The poliovirus is a spherical virus of 25–27 microns in diameter. The
following three types of viruses, responsible for causing poliomyelitis,
have been isolated:
◼ Type I – Brunhilde
◼ Type II – Lansing
◼ Type III – Leon
Infection by one type will give immunity to all the strains of that
type, but not to the other strains of the virus. The virus is resistant to
all antibiotics and may survive for months in the infected stools. It is
destroyed by oxidizing agents and heat at 55°C for 30 min. The virus
colonizes and grows in the intestinal tract, and prevents growth of
virulent strain – a common cause of failure of the sabine type of
vaccine in tropical countries. The clinicopathological effects of each
type of virus are indistinguishable.
Pathology
The virus makes its entry into the tonsillopharyngeal lymphoid tissue,
Peyer’s patches and in the corresponding regional lymph nodes. The
virus It then multiplies and disseminates throughout the body
(Bodian, 1952; Horstman & McCollum 1953; Horstman et al., 1954).
The antibody, when present, inactivates the virus while it is in
circulation in the blood. This is the stage of minor illness. During this
phase, symptoms like sore throat, gastrointestinal upsets and transient
fever may be present in about 40% cases. These symptoms are so mild
that they usually go unnoticed. During the phase of major illness,
there is widespread entry of virus into the neurons throughout the
central nervous system giving rise to inflammatory reaction of the
nervous tissue and meninges, a classical manifestation of
poliomyelitis. The onset of meningitis corresponds to a highly
dangerous phase of virus multiplication within the nerve cells of the
spinal cord and brain. There may be associated symptoms like fever,
malaise, nausea and vomiting. Pain and tenderness in the spine, trunk
and limbs is of diagnostic value in this phase. Inflammatory cells in
the acute stage are polymorphs, which are later replaced by
lymphocytes. Degeneration of the anterior horn cells begins with the
loss of Nissl’s granules and the nucleus, which complete the
disappearance of the cell. The cell death is so rapid that the fate of the
involved neurons is settled within a few hours. The motor fibres
arising from the destroyed cell disappear.
Occasionally, posterior horn cells, posterior columns and other
spinal cells may also be affected in this stage, but their residual effects
are rare.
The true cerebral lesions are usually confined to the brainstem, with
the involvement of the lower cranial nuclei. Short-term
unconsciousness, impaired sphincter control, unilateral facial
paralysis and irregularity of respiration due to the involvement of the
respiratory centre may be present (polioencephalitis).
Clinical characteristics
Incidence
Incidence is maximum in children under 12 months of age but may
occur up to 5 years of age.
Sex: No differentiation.
In the affected limbs and muscle groups there is localized pain,
tenderness and awkward limb positioning due to acute muscle spasm.
Involvement
Lower extremities predominate; however, the whole body may be
affected including bulbar paralysis.
Paralysis or paresis is asymmetrical and flaccid in nature.
Deltoid in the upper extremity and quadriceps and tibialis anterior
in the lower extremities are commonly affected.
◼ No sensory impairment.
◼ Cold limbs due to impaired circulation.
◼ Reduced or loss of reflexes.
Early detection
◼ Tenderness over the affected muscle groups.
◼ Flaccid paralysis.
◼ Restlessness may be associated with fever.
◼ Usually history of inadequate or no vaccination against all the three

polio viruses.
Stages of the disease

1. Acute phase (0–2/3 weeks)
During the acute phase, the child is restless and irritable due
to pain and muscular tenderness, with spasm in the muscle
groups. Joints of the affected limb may be painful because
of stretching of the muscles that are in spasm as a result of
neuronal irritation.
General malaise, headache and bowel upsets may be present

with low-grade fever and sore throat. In rare cases, there
may be involvement of the brain giving rise to varying
symptoms of polioencephalitis.
2. Convalescent or recovery phase (week 3 to 12 months)
As soon as the acute symptoms subside, the phase of

recovery begins. In this phase, there is either spontaneous
recovery (up to 5 weeks) of the affected muscles or various
grades of paralysis may develop. The rate of recovery
slows down, and hardly continues beyond 6–12 months.
3 Chronic or residual phase (12–18 months)
There is no hope of further neuronal recovery. The pattern of

paralysis is organized in the affected muscles. The degree
of paralysis depends on the extent of neuronal damage and
the efficacy of physiotherapeutic management during
theconvalescent phase.
Physical examination of the patient

Major characteristic features of poliomyelitis:
◼ Predominantly lower extremities are involved.
◼ Asymmetric nature of paralysis.
◼ Deltoid in the upper limb and quadriceps in the lower limb have
paresis but tibialis anterior is a common muscle which tends to be
completely paralysed.
◼ Reflexes are reduced but sensorium remains undisturbed.
◼ General observation of posture to detect the areas of

involvement.
◼ A thorough examination is essential to assess the degree of
involvement. The degree of consciousness, choking, squint,
spontaneous nystagmus, facial paralysis, disinclination to
move or change position, feeble cry or cough, diminished
respiratory excursion and accumulation of secretions
should be carefully examined to detect a brain lesion.
Inability to move one particular limb indicates the
involvement of that limb.
◼ Spinal rigidity: Neck and the whole spine should be

examined for rigidity.
◼ Strength of intercostals, diaphragm and abdominals can be

assessed by simple observation.
Intercostal and diaphragmatic weakness will be indicated by

insufficiency of inspiration whereas weakness of
abdominals will produce deficient expiration. Paralysis of
diaphragm is associated with some segmental involvement
of the muscles of the neck and shoulder. In extensive
paralysis of the trunk, an acting leaf of the diaphragm will
balloon to the corresponding side of the abdomen during
inspiration. Paralysis of the intercostals can be detected by
direct palpation of the intercostal spaces. Feeble cry or
feeble coughing will indicate deficient abdominals.
Deviation of the umbilicus upwards, downwards or to one
side indicates segmental weakness of the abdominals.
The ability to ventilate can be measured by spirometry.
5. Extremities: The extremities are examined to (a) recognize gross

weakness of the limb and (b) assess the degree of paralysis in the
individual muscle groups. Manual muscle testing is done by using
MRC scales (Medical 1943). This will help predict the future course of
muscle recovery or possible complications due to muscular imbalance.
6. Reflexes and sensations: The tendon reflexes disappear as paralysis

develops. Therefore, the absence of reflexes confirms a lower motor
neuron lesion. The plantar reflex is absent, or generally flexor. The
absence of the abdominal reflex indicates involvement of the
abdominal muscles. Sensations are not affected in poliomyelitis.
7. The degrees of contractures and deformities should be accurately

assessed and recorded at each stage to control them with early care.
Common Causative Factors for Developing Contractures
During the early acute phase Faulty limb positioning due to pain and spasm in the affected muscle
groups
Wrong habitual postures
During the convalescent Asymmetry or imbalanced recovery of muscle strength
phase
During the chronic phase Tightness of muscle and soft tissue contractures
To plan appropriate measures of physiotherapy, it is important to

understand the pathology and the pattern of recovery following
poliomyelitis.
Differential diagnosis
Poliomyelitis needs to be differentiated in both the acute and the late
stages from other conditions (Table 28-1).
Table 28-1
Poliomyelitis: Distinguishing Characteristics
Acute
Distinguishing Characteristics
Condition
Pyogenic Muscular spasticity instead of flaccidity
meningitis
Guillain– Bilaterally symmetrical involvement
Barre
syndrome
Acute Signs of localized acute inflammation (warmth, redness at the bony ends with painful
osteomyelitis limitation of joint movement)
Peripheral Definite history of injury, paralysis involves muscle groups innervated by the injured
nerve injury peripheral nerve
Spina bifida Congenital, bilaterally symmetrical paralysis of muscles
Cerebral Spastic paralysis with exaggerated reflexes, typical arm posture of adduction and internal
palsy rotation
Erb palsy H/o birth trauma, involves only one upper extremity
Muscular Bilaterally symmetrical with characteristic involvement of muscles like hypertrophy in PMD,
dystrophies paralysis of limb girdle muscles in limb girdle, muscular dystrophy; paralysis of facial-
scapulohumeral muscles in the onset is late
Myopathies Bilaterally symmetrical involvement; commonly occur late
Course of recovery
Maximum spontaneous recovery occurs during the 3rd, 4th and 5th
week after the onset and is due to the reversal of acute neuronal
disturbances (Table 28-2). However, the spurt of recovery is
considerable during the first 6 months, it becomes slow from 6 to 10
months, and by 12 months, 92–95% of the total possible recovery is
attained. It becomes negligible 16 months onwards (Green, 1949).
Table 28-2
General Pattern of Paralysis and Expected Recovery Following Acute Episode
Day 1 to 2–3 weeks Period of the onset of maximum

paralysis
Week 3–5 Period of spontaneous recovery
Week 6 to 6 months Period of slow recovery
6 months to 12–16 Period of negligible recovery
months
After 18 months to 2 Negligible recovery
years
REMEMBER:
Vigorous concentrated physiotherapy from week 3 or as soon as
tenderness subsides up to 6 months is crucial. Maximum advantage
should be derived at this stage.
Neuropathology of muscle recovery

The early spontaneous recovery occurs due to the following:
1. Reversal of the sublethal injury: A process of reversibility occurs in the
cells where destruction does not attain a lethal injury. Such cells revert
to complete normalcy in due course of time.
2. Resolution of temporary interruption: The mechanical compression

exerted by the inflammatory exudate during the acute phase blocking
the conduction of the cells, eventually gets resolved with absorption
of the exudate. This relieves pressure on the nerve cells and they start
functioning.
3. Reversal of function at higher levels of CNS: The reversal of temporary

dysfunction at the cortical and subcortical levels facilitates the
excitation of internuncial and lower motor neurons, which in turn,
promote recovery.
4. Return of the cells to normal morphology: The second phase of

recovery, which lasts up to 10 months, is the result of some cells
returning to normal morphology. Mild cellular reaction in the form of
perivascular cuffing reverting the morphological abnormalities occurs
in some cell bodies (Bodian, 1959).
5. Re-routing of functional pathways: The final phase of neuronal

recovery, which goes on up to 16–18 months could be because of re-
routing of functional pathways in the spinal cord in the vicinity of the
severe neuronal destruction. In some living cells, the short terminal
axonal segment may degenerate centripetally at the initial stage, but
subsequently regenerate (Brooks, 1953).
6. Axonal sprouting: There exists a definite histological evidence of

axonal sprouting in the active neurons, extending their field of action
by branching terminally. This will lead to re-innervation to the
adjacent denervated muscle fibres (Hoffman, 1959; Morris, 1953).
7. Neuronal hypertrophy and hypertrophy of the surviving muscle fibres:

The motor neurons supplying active muscle fibres in a paretic muscle
have a tendency and potential for hypertrophy. Therefore, there is
every possibility of improving the strength and endurance of muscle
fibres by producing hypertrophy of these surviving muscle fibres
(Edds, 1950).
8. Involvement of large anterior horn cells: The largest of the anterior horn
cells are preferentially destroyed in the spinal cord in poliomyelitis
(Russel, 1956). This is the underlying pathology of early fatigue of
reduced endurance, which is one of the basic characteristics of the
paretic muscles.
Therefore, there is a definite evidence to plan effective

physiotherapeutic programme based on the potentials of various
processes of recovery and compensatory mechanisms that occur in the
affected neurons.
The focus of physiotherapy should be planned precisely on the
pattern of paralysis and the recovery of muscle power (Table 28-2).
Objectives
◼ To restore maximum strength and endurance in the affected muscle
groups.
◼ Maximum emphasis on the prevention of deformities.
◼ Allot extra time to educating parents on simple exercises for home

management.
◼ Provide early assistive aids or orthoses to promote independent

ambulation and to prevent organization of deformities.
Possible problems
Early stage
◼ Possibility of developing contractures.
◼ Overenthusiastic parents.
◼ Institute early weight-bearing process as tenderness begins to wean

off.
◼ Discouraging and disheartening process of slow recovery,

especially when the upper extremity is paralysed.
The important aspects to be emphasised precisely from the early

stage are as follows:
1. Accuracy of manual muscle testing
2. Correct assessment of the prognosis of recovery of the affected

muscle groups
3. Prevention of deformity
4. Educating the parents on simple specific exercises for home

treatment
Manual muscle testing (table 28-3)

This should be done with great precision.
1. Check the consistency of one’s own testing by repeating the test

without referring to the previous test data within an interval too short
for any recovery to take place.
2. The accuracy of testing is to be kept in mind while testing

functionally important muscle groups.
3. Extra time, efforts and skill are needed in assessing certain groups
like the muscles of the trunk, rotators of the hip and serratus anterior.
Final grade should be given only after repeating the test.
4. Muscle power imbalance in the groups opposite to each other
(agonists and antagonists) should be done precisely and noted, as this
could be a causative factor in future contractures.
5. While assessing the progress of recovery from grade 4, it must be

remembered that the grade 4 muscle requires double the time to
progress by one grade (i.e., from grade 4 to grade 5) as compared to
the grades 1, 2 and 3. In other words, when the muscle in grades 1, 2
and 3 progresses to 2, 3 and 4, respectively, the grade 4 muscle must
have progressed only to 4+ and not 5 (Sharrard, 1955b). Therefore, it is
necessary to add grade 4+ in the manual muscle test (MMT) chart as
equivalent to 1 unit of recovery so that the normal grade or grade 5
will remain constant for the other grades of the paretic muscles.
6. Manual muscle testing also needs to be put into proper perspective.

It has been identified that grades alloted by manual testing markedly
overestimate paretic muscle strength.
The clinical grade of 5 (normal) was found to be only about

60% of the torque registered by the normal muscle
(Beasley, 1961; Hill et al., 1983). Sharrard (1953) found that
the muscle graded as 4 by MMT may have the destruction
of more than half of its anterior horn cells. This could be
explained by early fatigue in the polio-affected limb in the
presence of clinically good (grade 4) muscle power. These
observations clearly limit the extent of exercising to the
level short of fatigue.
7. The expected recovery status of the affected limb as a whole should

be determined in relation to the future functional independence.
8. The prognosis of the individual paretic and paralytic muscle groups

should be predicted and recorded to evaluate the efficacy of the
therapeutic programme.
Table 28-3
Manual Muscle Test (MMT) Grades
100% 5 N Normal Normal complete range of motion against gravity with full
resistance
75% 4 G Good Complete range of motion against gravity with some resistance
50% 3 F Fair Complete range of motion against gravity
25% 2 P Poor Complete range of motion with gravity eliminated
25% 1 T Trace Evidence of slight contractility; no joint motion
0 0 0 Zero No evidence of contractility
Prognosis of recovery in relation to the initial assessment of

muscle power
All the muscle groups of the affected limb should be divided into two
groups:
1. Group I – muscles that are partially paralysed (MMT grade = 1 to 3)
2. Group II – muscles that are totally paralysed (MMT grade = 0)
The patterns of recovery of these two groups are different and

predictable at a particular interval from the onset. This has been
extensively studied and reported by Sharrard (1955a). His
observations are as follows:
Group I – the prognosis of recovery in partially paralysed or paretic

muscle groups: Paretic muscles will always increase in power after
the first month. It is predictably so uniform, that the eventual power
of any paretic muscle can be determined at any point of time from
the onset.
(a) One month after the onset: Few failed to improve. Most
improved by one, two or three grades. Few gained as
much as four grades.
Average increase of about two grades was made by all the

muscles in the lower limbs and two and a half grades in
the upper limbs; whether their grade at that time was one,
two or three.
(b) Two months after the onset: Small proportions failed to

improve. Small proportions made spectacular recovery.
Most improved by one or two grades. Average increase
being about one to one and a half grades in lower limb
and two grades in the upper limb.
(c) Four months after the onset: One-fourth of the muscles

improved by two grades. Another quarter of them failed
to improve. The rest improved by one grade. Average
increase in grade being one grade in the lower limbs and
a half grade in the upper limbs.
(d) Six months after the onset: Almost half the muscles
improved by one grade, over one-third failed to improve,
and a small proportion improves by two grades.
Average increase in the muscle grade being three-quarters of a

grade in the lower limbs and one grade in the upper limbs.
On an average, the final grade of a paretic muscle in the

lower limb may be estimated by adding two to its grade at
1 month, one and a half to its grade at 2 months, one to its
grade at 4 months, and three-fourth to its grade at 6
months; the corresponding figures for the upper limbs
being two and a half grades by 1 month, two grades by 2
months, one and a half grade by the end of 4 month and by
one grade at the end of 6 months.
This uniform trend of the quantum of recovery of the paretic

muscles is of great significance in clinical practice. It
provides valuable guidance:
1. to determine the final grade of the expected recovery of a

muscle group.
2. to determine the expected quantum of recovery at a

definite interval.
3. to assess whether the recovery is progressing as

expected.
4. to warrant alteration in the therapeutic regime if the

progress is unsatisfactory.
5. to assess the final picture of recovery of the whole limb

and its possible ultimate functional status.
Group II – the prognosis of recovery in totally paralysed muscles: The

prognosis of recovery of the totally paralysed muscle groups
depends on the degree of destruction of the motor cells and their
topographical relationship in the spinal cord segment.
1. When all the motor nerve cells in the spinal cord

supplying the muscles are destroyed, the muscles cannot
recover.
2. If the motor nerve cells are destroyed partially, clinical

activity in the muscle fibres will return and can be
detected at any point of time. A muscle that shows no
clinical recovery at 1 month has only about 50% prospect
of any degree of recovery at all. If no recovery is noticed
by 6 months, 90% will remain permanently paralysed.
However, when a muscle shows return of activity, it
follows the pattern of recovery same as that of the paretic
muscles.
3. The process of destruction of the motor cells in the spinal

cord has been found to occur regionally (Elliot, 1942;
Sharrard, 1953). Therefore, the extent of paralysis of the
muscles supplied by the same and the adjoining spinal
cord segment can provide information regarding the
course of recovery of the totally paralysed muscle. The
muscles supplied by the same or the adjoining spinal
cord segments are referred to as associated muscles. For
example, complete paralysis of quadriceps (L2, L3, L4)
and tibialis posterior (L4, L5) indicates that the tibialis
anterior (L4), which, if completely paralysed, has
practically no chance of recovery. If both the associated
muscles of the quadriceps (hip flexors and adductors) are
paretic, the possibility of recovery of the paralysed
quadriceps is very good. Guidance for the topographical
relationship of the associated muscles and the possibility
of its recovery for the lower limb is given in Table 28-4.
Prognosis is bad when all the muscles of a limb or of the

same spinal segment are paralysed.
Table 28-4
Segmental Association of Major Muscle Groups of the Lower Limb
Muscle or Muscle Group Associated Muscle Group

Hip flexors Quadriceps, hip abductors
Quadriceps Hip flexors, hip abductors
Hip abductors Gluteus maximus, tensor fascia lata
Gluteus maximus Hip abductor, biceps femoris
Tibialis anterior Tibialis posterior, extensor hallucis longus
Tibialis posterior Tibialis anterior, extensor hallucis longus
Extensor hallucis Extensor digitorum longus, peronei
longus
Extensor digitorum Extensor hallucis longus, peronei
longus
Gastrosoleus Biceps femoris, flexor digitorum longus
Peronei Extensor digitorum longus, extensor hallucis
longus
Deformity
Contracture, which gets organized into a deformity, complicates the
process of recovery in the following ways:
1. It prevents the surviving motor units to participate in the process of

recovery as they remain inactive.
2. It causes disuse of active muscles and makes them weak.
3. It produces angulation, stiffness and even displacement of the

joints.
The causative factors are as follows:
1. Muscle spasm
2. Influence of gravity
3. Muscular imbalance
During the acute phase of the disease, muscle spasm of the involved
muscle groups results in contracture which may lead to deformity.
Weight of the limbs, habitual postures and malpositioning
compounded by the influence of gravity and muscle weakness may
also result in deformity.
During the subacute phase, the deformity results from the muscular
imbalances due to asymmetrical paresis or paralysis of the muscle
groups controlling a particular joint. If the deformity is not properly
controlled at this stage of the disease by appropriate
physiotherapeutic measures and appliances, it deteriorates further,
when the concerned joint is exposed to stresses of weight bearing.
Prescribing correct appliance, checking its proper fit and educating
patient on its correct use, as well as its maintenance is the
responsibility of the treating physiotherapist.
During the chronic phase, there is always a tendency of discarding
the appliances. This not only results in deterioration of the deformity
but also causes secondary complications by exposing the joints to
imbalanced stresses.
Therefore, prevention of deformity forms the basis of treatment not
only during all the phases of the disease but even in the later phases of
life.
The common sites of deformity and their causative factors have
been well documented by Singer and Roseinnes (1963) and are
illustrated in Table 28-5.
Table 28-5
Common Deformities and Their Causative Factors
Possible Deformity Deforming Forces

1. Early, extensively paralysed
patients
Flattening of all spinal curves Gravity, supine position
Shoulder adduction–internal Adductor spasm, deltoid failure, malpositioning, e.g., in respirator
rotation Flexor spasm, wrong positioning
Elbow flexion Gravity, supine position
Palmar flexion at wrist Abductor spasm, gravity in supine position
Hip flexion–abduction–external Flexor spasm
rotation Calf spasm, gravity
Flexion at knee Gravity, tibialis posterior and toe flexor spasm
Ankle equinus
Forefoot equinovarus
2. Axial weakness
Neck flexion and atlanto occipital Gravity, erect posture
extension Intercostal weakness, gravity, supine and erect posture
Rib droop Gravity, erect, intercostal, paraspinal and abdominal weakness
Scoliosis Abdominal weakness, gravity, erect posture and sitting
Pot belly
3. Upper limb
Vertical subluxation of shoulder Gravity, erect posture, severe paralysis
Elbow extension Gravity, flexor failure
Forearm supination and ulnar Gravity, pronator and radial extensor failure
deviation of wrist Thenar muscle failure
Flat nonopposable thumb
4. Hip and knee
Trendelenburg dip at the hip Abductor failure, early weight bearing
Subluxation of hip Abductor, extensor, internal rotator failure
Genu recurvatum Quadriceps failure or hamstrings failure, early weight bearing,
External rotation of tibia gastrosoleus spasticity
Gravity, supine, weight bearing on valgus foot, medial hamstrings
failure
5. Ankle and foot
Valgus foot Invertor failure, weight bearing
First metatarsal head depression A component of isolated tibialis anterior paralysis
Inversion Evertor failure, weight bearing
Equinovarus with inversion of heel Failure of all but plantar flexors, intrinsic muscles and invertors
Calcaneovalgus Failure of plantar flexors and evertors, weight bearing
Treatment programme (table 28-6)

Acute phase (first 3–5 weeks)
It is also called the prodromal or preparalytic stage. Complete
physiological rest to the nervous system with maximum possible
measures to achieve relaxation of the whole body is the basic aim.
1. Relief of pain.
2. Supportive medication for the relief of pain and relaxation.
3. Relaxation of painful spasm: Local tenderness and pain due to

spasm of the offending muscle groups can be effectively managed
with hydrocollator packs or warm wet towels placed over the tender
muscle groups. Excessive heating should be strictly avoided.
4. Prevention of contractures: It is a major goal to be achieved during

early convalescence (Green, 1949). Proper positioning of the whole
body and especially the involved limb is critical. The contracture and
deformities begin to appear at this stage. Therefore, a carefully
planned educative management programme needs to be followed at
this stage. It is preferable to put the limb in proper position for
prevention of deformities rather than applying rigid splints. Parents
should be guided on the methods of proper positioning of the limb.
Special care in positioning should be taken at the common sites of
contractures and deformities.
Common sites of early contractures (Table 28-7)
◼ Hip – flexion abduction
◼ Knee – flexion
◼ Ankle and foot – plantar flexion (equinus), varus or valgus
◼ Shoulder – abduction
◼ Elbow – flexion
Whenever muscular pain or spasm permits, relaxed passive

movements to be initiated at least once in a day.
Contractures later on organize into deformity.
5. Avoidance of activity: Any type of unnecessary activity is

contraindicated at this stage of the disease. The contrary effects of
excessive physical activity have been proved experimentally
(Levinson et al., 1945).
6. Prevent invasive techniques: Inoculation, injection, local trauma and

any surgical procedure should be avoided as these induce cell
vulnerability (McCloskey, 1950).
7. Least exerting transfers: Transfers of patients should be carried out

carefully especially when involving long distance journey and muscle
power assessment. The extent of paralysis is assessed only cursorily as
detailed examination is difficult and may even be harmful.
8. Special care of the severely affected patients: Patients having

involvement of the whole body or bulbar palsy with respiratory
paralysis need intensive care.
Table 28-6
General Principles of Management at Each Phase of the Disease
Phase Measures to Control

Phase I. Acute phase of paralysis (onset to 2–3 weeks)
• Sick and irritable child may be associated with • Bedrest or resting the affected limb in a
respiratory failure comfortable position
• Low grade fever for the first 2–3 days • In cases with bulbar paralysis, ventilator
• Tendency to develop spasm and tenderness in support may be necessary
the affected muscle groups • Drugs to control fever and other associated
• Faulty deformity prone limb positioning and symptoms
wrong postural attitudes • Warm and moist packs to control tenderness,
• Strictly prevent the development of deformity due spasm and stiff, painful joints
to tenderness and muscle spasm • General tendency to adopt flexion attitude of
the limbs, e.g., knees, which is relaxing but
prone to develop permanent contractures should
be discouraged and corrected as much as
possible
• Corrected position has to be maintained by
plaster splints, or at least by using sand bags
Phase II. A phase of recovery: (A) 3–5 weeks from the onset; (B) 6–12 weeks from the onset
• A focus on specific exercises to the paretic A. 3–5 weeks is the period of spontaneous
muscle groups to further strengthen graduated muscle recovery as the swelling due to
steps from active movements to resistive mode inflammation interrupting the nerve conduction
• Warn parents not to put undue emphasis on is resolved
standing or walking unsupported or without an • Critically carry out MMT and formulate-plan-
orthosis exercise programme accordingly
• In a limb with asymmetrical or imbalanced • At this stage, pool exercises are ideal, which
return of muscular power, a danger of are most acceptable to kids
developing deformity persists; correct, check • Teach simple specific exercises as needed to
and control by an appropriate orthosis is a must parents for home management
• Repeat muscle chart after 2 weeks of therapy
to judge the extent and pattern of muscle
recovery, and continue
• Provide protective orthosis if there is a
tendency for unsupported ambulation, with
deformity
• Continue progressive recovery modes to the
weaker but voluntarily active muscles
B. 6–8 weeks to 6 months: As the neuronal
recovery is rapidly weaning, emphasis should be
placed and functional education and guidance
given to patients on home treatment programme
Phase III. A phase of residual paralysis (after 18 months of the onset)
As there are maximum chances of developing deformity • Critical objective examination of the affected
due to the progression of tightness of the soft tissues – limb in relation to the whole body’s activities
progressing to the deformities – protection and • Assess the physical abilities and disabilities as
prevention of such attitudes deserves first priority related to the ADLs
• All the possibilities of improving functional
performance should be assessed for further care
and re-education, e.g.
• Modification and alterations in the orthoses or
a brace
• Strengthening and encouraging compensatory
body movements
• Is there any chance of rehabilitative and
reconstructive surgical procedure?
• If so, what mode of physiotherapy should be
ideal to facilitate functional independence?
• Plan a new therapeutic training schedule, e.g.,
hypertrophy of the muscle group chosen for
transplant
• Check-up orthosis with the wrist joint fixed in
15 degree of extension, before planning wrist
arthrodesis
• Encouraging ‘trick movements’ to compensate
for weak functions
Table 28-7
Common Causative Factors for Developing Contractures
During early acute Faulty limb positioning due to pain and spasm in the affected muscle groups;
phase wrong habitual postures
During the Asymmetry or imbalanced recovery of muscle strength
convalescent phase
During the chronic Tightness of muscle and soft tissue contractures
phase
Bulbar paralysis
Pharyngeal paralysis: This leads to inability to swallow; the patient

chokes even on liquid food and is unable to swallow saliva. It can
cause death if not prevented. At the same time, difficulty in
coughing or speaking is also noticed.
Bulbar paralysis may be associated with polioencephalitis.
Respiratory paralysis: Respiratory paralysis results in mental

disturbances or even coma. This may be as a result of the
involvement of:
(a) Respiratory centre
(b) Intercostal muscles: It could be asymmetrical, if

intercostals are unilaterally involved.
(c) Involvement of diaphragm will give rise to paradoxical

respiration. The early signs will include breathlessness,
suffocation, cyanosis and use of alae nasi.
Tracheostomy or intermittent positive pressure respiration (IPPR)

or a respirator may be necessary. The most important role of the
physiotherapist is to use postural drainage and improve vital capacity.
Recovery phase (4–18 weeks)

This is divided into two phases:
1. Early convalescence
2. Late convalescence
1. Early convalescence (3 weeks to 6 months): Treatment at this vital

phase of recovery has to be planned and carried out with utmost skill.
The emphasis of the therapeutic programme should be clearly
distinguished on the basis of the MMT. The treatment programme
needs to be individualized for the paretic or paralysed muscle groups.
The methodology of treatment in the department by the
physiotherapist differs markedly from that of the home treatment.
(a) At the department
(i) Planned exercises to the specific individual muscles to

attain maximum physiological hypertrophy of the intact
muscle fibres.
(ii) Use of advanced neurophysiological techniques like

PNF.
(iii) Pool therapy: Exercises in warm water pool are

extremely effective at this stage. While giving them, the
natural tendency for compensatory tricky movements
should be prevented. Therefore, the exercises in water
should be done with absolute specificity of the groove of
the movement.
(iv) Assisted exercises like tricycling (may be by tying

ankles and feet for the peddling) provide high incentive
and maintain proper groove of the movement.
(v) Unnecessary splinting should be avoided to reduce the

effect of immobilization. If at all splints are given, they
should be used to provide graduated exercise (Wickman,
1913).
(vi) Children who attempt to stand with support and take

steps on their own should immediately be given
necessary appliances. This should be done irrespective of
the accepted usual rule of prescribing appliances only
after 6 months of onset. This is done to prevent
deformities occurring due to early weight bearing.
(b) Home treatment
(i) Initially, only important muscle groups should be

included for the exercises. Simple but specific
methodology should be taught to maintain the efficacy of
the exercise. Frequent checking of the basic principles is
necessary.
(ii) Only one or maybe two exercises should be taught in

one session.
(iii) Methods of prevention and/or management of

contractures and deformities should be checked
regularly.
(iv) Parents should be warned against any weight-bearing
activities on the affected limb at this stage. Enthusiastic
early weight bearing on weak muscles may lead to
deformities like subluxation of the hip (Dutta et al., 1975),
genu recurvatum (Joshi et al., 1976), genu valgum, genu
varum and valgus foot.
(v) Parents should be instructed to bring the child regularly

for physiotherapy to the department and not just depend
on the home exercise programme. The recovery of
muscle power has been found to be much better in
children treated in the department by a physiotherapist
as compared to those managed on home treatment
programmes alone (Joshi et al., 1979).
2. Late convalescence (6 months to 1 year): This is a phase of recovery

that is due mainly to the hypertrophy of the residual muscle fibres
that needs an adequate programme of graded resistance to the
concerned muscles.
Resistance becomes more acceptable when given during the

performance of daily activities. Resistance can be applied to a great
advantage while tricycling. The feet are lightly secured to the peddles;
graded resistance is applied at the seat when the child moves the
tricycle with own efforts. This not only helps in offering resistance but
also improves coordination as it becomes a competitive sport and is
very well accepted by a child.
Another method of applying natural resistance is by resisting the
gait or resisting the movements performed with braces. Prescribing
adequate bracing, training in their appropriate use and maintenance
are the responsibilities of a physiotherapist.
Aerobic programmes like swimming, fast walking and sports can be
initiated and made competitive whenever feasible.
Limb length discrepancy is commonly seen in children with unilateral
lower limb involvement. It needs to be assessed and properly
compensated at regular intervals.
Chronic or residual phase (after 1 year to 18 months)

As the chances of neurological recovery are practically nil at this stage,
more emphasis should be on further strengthening the functional
needs of the patient. Singer and Roseinnes (1963) observed a small
degree of muscle recovery up to 24 months associated with intensive
training. Instead of specific muscular exercises, the emphasis should
be on functional exercises. These movements should be made stronger
by graduated resistance. Any additional guidance aids or supports to
facilitate functional as well as physical work requirements may be
given, if necessary.
The maximum importance is to be given to stop the posture,
positions and activities that put compressive or stretching forces on
the involved muscles and the joints supported by them.
Correct use of braces, canes, crutches, wheelchairs or any orthosis is
to be assured.
Advice on the prevention of contractures and deformities will
remain a constant feature at all times.
Functional recovery
Functional recovery plays an important role in providing functional
independence to the patient. It should be initiated as early as possible.
However, it is important to observe certain methodology in relation to
the stages of recovery and the degree of muscle power.
1. During the phase of recovery, the functional activity should not be

replaced by compensatory muscle action (tricky movements). This
will result in lack of concentration to the exercise necessary for
hypertrophy of the weak but innervated muscle.
2. Proper and adequate support by orthosis is needed to prevent

fatigue of the recovering muscle groups and overstretching of the
paralysed muscles and joints.
3. When the recovery phase is over, compensatory mechanisms to
perform functional activities should be encouraged and strengthened
by a programme of resistive exercises PRE.
4. Avoid pain or fatigue during functional activities as recent studies

have demonstrated the ill-effects of such excesses (Agre et al., 1998).
Functional assessment
Assessment of the following activities:
1. Ability to turn
2. Ability to sit up
3. Assistance to sit
4. Ability to sit up without assistance – posture and balance.
5. Ability to stand – (a) support required, (b) independent, (c) balance

and (d) posture of head, spine, hips (Trendelenburg), knees and feet.
6. Walking – unaided, aided – what aids gait and speed.
7. Braces – details.
8. Managing curbs, stairs – independent, with aid (type of aid); ability

to do floor sitting, squatting, cross-leg sitting.
Surgery
During this phase, some surgical intervention may be necessary.
The common surgical procedures are correction of the soft tissue
contracture; correction/prevention of deformity by tendon transfers or
bony stabilization procedures; tendon transfers to improve function
and correction of limb length disparity.
Upper limb
Abduction at the shoulder can be improved by transfer of a strong
trapezius muscle to the neck of the humerus or by arthrodesis in
functional position (Fig. 28-2). Postoperatively, plaster of Paris (POP)
shoulder spica is given for 6 weeks after muscle transfer and for 8–12
weeks after arthrodesis.
FIG. 28-2 Arthrodesis of the shoulder.
Paralysis of flexors of the elbow results in loss of active flexion at the

elbow. However, if the forearm and finger flexors are strong, the
common origin of the flexor group of muscles, at the medial
epicondyle of humerus is transferred to the front of the lower end of
the humerus (Steindler’s flexoroplasty Fig. 28-3). An above-elbow
POP slab is given for 4–6 weeks postoperatively. Training of the
muscles after removal of the slab improves elbow flexion to a
functional range. There may be limitation of the terminal 20–30
degrees of extension at the elbow.
FIG. 28-3 (A) Steindler’s flexoroplasty: common flexor muscle origin is

detached from the medial epicondyle and transferred to the lower end of
the humerus – in front. (B) and (C) postoperative result after Steindler’s
flexoroplasty.
Function at the wrist can be improved by tendon transfers (Fig. 28.4)

or by fusion of the wrist (see Fig. 27-20). Wrist flexors are transferred
to the finger extensors to improve extension of the fingers.
FIG. 28-4 Transfer of flexor digitorum sublimis from the middle phalanx of
the middle finger to the thumb, to facilitate (1) carpometacarpal and
metacarpophalangeal opposition and flexion (2) extension at the
interphalangeal joint.
In the hand, loss of opposition is a disabling problem and may

require a tendon transfer (opponensplasty). Usually the sublimis
tendon is detached from its insertion on the middle phalanx and is
transplanted into the abductor pollicis brevis to improve opposition of
the thumb (Fig. 28-4). Plaster immobilization with thumb in
opposition is given for 3–5 weeks.
Spine: Paralysis of trunk muscles results in scoliosis. It usually causes a

long dorsolumbar curve that is largely correctable. It needs surgical
treatment in the form of spinal fusion with or without anterior or
posterior instrumentation.
Lower limb
Release of soft tissue contractures
Hip: The flexion contracture at the hip is corrected by Soutter’s

operation in which the tight structures along the anterior iliac crest
are released and the deformity is corrected. The abduction
contracture is corrected by release of abductors, fascia lata and the
iliotibial band. Postoperatively, the patient is given a POP hip spica,
in the corrected position, for about 4–6 weeks. The joints are then
mobilized but the correction is maintained in a caliper.
Knee: Mild flexion contractures are generally due to tight iliotibial

band that is divided. Moderate degrees of flexion contracture can be
treated by lengthening of the hamstrings. Severe flexion contractures
require lengthening of hamstrings and posterior capsulotomy of the
knee (Wilson’s operation). Postoperatively, an above-knee plaster
cast for 4–6 weeks followed by mobilization is the usual regime. The
correction is maintained in a caliper.
Ankle: The commonest deformity is equinus, which results from

contracture of the tendoachilles. Lengthening of the tendoachilles by
Z-plasty is undertaken (Fig. 28-5). An above-knee plaster cast for 3–6
weeks is given after operation. A below-knee caliper is usually worn
for 3–6 months to prevent recurrence.
Foot: Contracture of the plantar fascia produces a cavus deformity of

the foot. The tight plantar fascia is stripped from its attachment to
the calcaneus (Steindler’s operation). In the postoperative period, a
below-knee plaster is given for 2–4 weeks, after which a night splint
is used for 2–4 months.
FIG. 28-5 Lengthening of the contracted tendoachilles by Z-plasty. GS,

gastrosoleus; TAT, tendoachilles tendon.
Tendon transfers
Hip: Paralysis of the glutei can result in serious disabilities including

paralytic dislocation of the hip. Gluteus maximus paralysis causes
exaggerated lumbar lordosis and a backward lurch during walking.
Paralysis of the gluteus medius produces a lateral lurch on the same
side with an unstable gait.
Surgery for paralysis of these muscles is rarely undertaken as

the results are unpredictable. However, iliopsoas or erector
spinae muscles are transferred into the gluteus maximus
for paralysis of the latter, while the tensor fascia lata is
transferred posteriorly for gluteus medius paralysis.
Knee: Quadriceps paralysis is commonly seen in poliomyelitis. The

quadriceps may be strengthened by transfer of hamstrings into the
patella. Postoperatively the knee is immobilized in an above-knee
plaster cast in full extension for 4–6 weeks, followed by a night
splint for another 4 weeks.
Foot: Tendon transfers for correction of paralytic foot deformities are

usually done in conjunction with stabilization operations on the
foot. The basic principle of tendon transfers in the paralytic foot is to
remove the deforming force and to use an active muscle to replace
the paralysed muscle.
The following could be deformities of the foot:
1. Talipes equinus: It can be corrected by Lambrinudi triple

arthrodesis (Fig. 28-6A). Since this operation is generally
performed after 12 years of age, the paralytic equinus
deformity can be corrected by a caliper in the early years
of life. Organized equinus can be corrected by triple
arthrodesis (Fig. 28-6B) by a fusion of the three joints of
the foot – the subtalar, calcaneocuboid and talonavicular
joints after taking suitable wedges to correct the
deformity (Fig. 28-7).
2. Talipes calcaneus: It is a progressive deformity caused

by the paralysis of the gastrocnemius. In addition to the
calcaneus, a cavus deformity of the foot may develop
subsequently. In the younger children, the deformity is
corrected by a two-staged surgical procedure (Elmslie’s
operation). In the first stage, the cavus deformity is
corrected by fusion of the talonavicular joint and release
of the tight plantar fascia (Steindler’s operation). A
below-knee plaster is maintained for 6–8 weeks. In the
second stage, the active tendons of the tibialis posterior,
peronei and long toe flexors are transferred into the
tendoachilles, in association with fusion of the subtalar
joint. Postoperatively, a plaster cast is maintained for 8–
10 weeks.
3. Talipes varus: Paralytic varus deformity of the foot

results from paralysis of the peronei muscles and the
overaction of the tibialis anterior and posterior muscles.
This deformity is corrected by transfer of the tibialis anterior

tendon into the cuboid bone. Postoperatively, a below-knee
plaster cast is given in the corrected position for a period of
3–6 weeks, after which the foot is mobilized.
4. Talipes valgus: It is caused by paralysis of the tibialis

muscle. The overaction of the peronei results in valgus
deformity and also causes drop of the first metatarsal.
Since the tibialis anterior is paralysed, the long toe
extensor acts as dorsiflexor of the ankle and further
aggravates the clawing of the big toe.
The valgus deformity is corrected by transfer of the peroneus

brevis into the medial cuneiform bone. Bony stabilization
of the talocalcaneal joint, with the help of a strut graft can
correct this deformity in children above 4 years of age.
The first metatarsal drop is corrected by an operation

(modified Jones’ operation) consisting of transfer of the
extensor hallucis longus tendon into the neck of the first
metatarsal and fusion of the interphalangeal joint of the big
toe. A below-knee plaster cast is given for 6–8 weeks after
the operation. In cases untreated up to the age of 13 years,
triple arthrodesis is indicated to correct the deformity.
Triple arthrodesis: This is a commonly performed bony stabilization

procedure for paralytic foot. It is performed after 13 years of age. If
performed earlier, the fusion may not be solid due to abundance of
cartilage and may also result in a short foot due to growth
disturbances.
In this operation, the subtalar (talocalcaneal), talonavicular

and calcaneocuboid joints are fused. A below-knee plaster
cast is applied for 3 months after the operation.
FIG. 28-6 (A) Lambrinudi triple arthrodesis. Bones in the shaded area are
excised to get the correction of the deformity. (B) Triple arthrodesis. (C)
Postoperative X-ray showing triple arthrodesis using staples.
FIG. 28-7 Triple arthrodesis. Note that the talonavicular, talocalcaneal and
calcaneocuboid joints have fused well. The joints have been fixed with
multiple screws.
Correction of the limb length disparity

Moderate-to-severe paralysis of the lower extremity almost always
results in shortening of the affected limb. The degree of shortening
perhaps has some relationship with the severity of the paralysis, i.e.,
the more severe the paralysis, the more will be the shortening.
The methods of correction of disparity in the lower limb are as
follows:
1. Shortening of the normal (or longer) limb: The normal limb may be
shortened by arrest of the epiphyseal growth or by resection of bone
from the femur or tibia. This operation is, however, rarely ever
performed.
2. Lengthening of the affected (short) limb: The procedure of lengthening

is undertaken in the femur or tibia depending on the site of
shortening. The degree of real shortening of the limb is measured both
clinically and by scanograms. The amount of lengthening to be
achieved is then calculated accurately and the surgery is planned. If
the shortening is in both the femur and the tibia, the bones can be
lengthened simultaneously or in stages.
The lengthening of the femur or tibia can be undertaken by any of

the following methods:
(a) Tubular fixator (Wagener’s technique)/femoral lengthening: The

femur is osteotomized (cut) through the shaft and an external fixator
(with distractor) is applied (Fig. 28-8). The femur is then gradually
distracted every day, achieving the desired amount of lengthening
over a period of time (usually in weeks). The lengthened portion of
bone gets filled up spontaneously with bone or alternatively, bone
grafting and plating is done to hasten the process of consolidation. In
the former situation, the external fixator is maintained for a period of
3–6 months, till the bone forms adequately; while in the latter case, the
fixator can be removed at the time of plating operation. Mobilization
of the adjacent joints may be started early, in consultation with the
surgeon, while weight bearing is delayed till the bone consolidates.
Tibial lengthening: It is carried out in two stages. In the first

stage, the lower fourth of the fibula is fixed to the tibia so
that the ankle mortise remains stable during the second
stage of leg lengthening (Fig. 28-9). The rest of the
procedure is same as that for femur, i.e., osteotomy of the
tibia followed by gradual distraction. It can also be
continued either in the external fixator or fixed internally
with a plate.
(b) Ring fixator (Ilizarov technique): In this method, thin wires are
passed into the bone under tension and connected to half- or full-circle
rings. The most commonly used ring fixator is called the Ilizarov
fixator, after its innovator. The bone is cut (by corticotomy) in the area
of metaphysis (either the proximal or distal) and gradual distraction is
done to increase the length of the bone. New bone, called regenerate,
forms into the gap, thus created by distraction.
FIG. 28-8 Femoral lengthening (Wagener’s technique). (A) Femur

osteotomized at shaft and external fixator with distractor applied. (B)
Desired lengthening has been achieved and bone formation has taken
place in the gap. (C) Plate and screws are applied and external fixator
removed.
FIG. 28-9 Tibial lengthening (Wagener’s leg lengthening technique). (A)

Tibia and fibula are osteotomized and the distraction apparatus is attached
medially, leaving the desired gap between the bony ends. (B) Bone
formation takes place in between the osteotomized bony ends. (C) Plate
and screw fixation is done to achieve consolidation of the new bone formed
and external fixator is removed.
Complications
1. Nerve complications: These develop due to rapid distraction. The

patient complains of tingling, numbness and pain in the part distal to
the lengthening. If these symptoms develop, the distraction is stopped
temporarily till the symptoms disappear.
2. Vascular complications: These are rare. Sudden distraction may

cause spasm of the arteries leading to vascular embarrassment of the
distal segment of the limb.
3. Deformities of the foot: These are common in tibial lengthening.
Tight heel cord causes equinus deformity of the foot. Manipulation or
surgical stabilization may be required for correction of the
deformities.
4. Pin tract infection: Infections in the pin tract may have some pus
discharge requiring regular dressings. Pin tract infection may also
loosen the pin requiring replacement of the pins.
5. Arthritis of the adjacent joints
6. Fracture through the lengthened part: Premature weight bearing,

before the bone consolidates, may cause fracture of bone through the
lengthened segment. This may require prolonged plaster
immobilization.

The basic approach of physiotherapy varies according to the type of
the surgical procedure:
1. After release of the soft tissue contractures, measures should be

taken to avoid recurrence of contracture.
2. Following tendon transplants, the emphasis is on re-education of

the transplanted muscle to its new role.
3. Following the joint arthrodesis, the emphasis is on educating the

functional use of the limb in which the joint is arthrodesed.
Release of the soft tissue contractures

Preoperatively, the joint over which the contracted soft tissue passes is
kept in a state of maximum mobility by passive stretching and passive
movements. Postoperatively, during immobilization, vigorous
exercises are given to the joints that are free from immobilization.
1. Positioning: Positioning of the operated limb in particular and of

the body as related to the joint of the soft tissue release is of primary
importance. This positioning should not facilitate recurrence of the
contracture. Long periods of prone lying are important to prevent
recurrence of hip flexion contracture following Soutter’s release.
Maintaining optimal extension at the knee after release of the iliotibial
band and the hamstrings are important. Maintaining neutral
dorsiflexion is mandatory in the release of tendoachilles. Many a
times, it is necessary to retain the posterior shell of POP or suitable
orthoses till the position of correction is maintained with active efforts
by the patient.
2. Mobilization: Graded mobilizing procedures are used to regain

early full ROM at the joint related to the soft tissue release. Relaxed
passive movements following soothing heat are ideal.
3. Muscle strengthening and endurance exercises: To achieve active

maintenance of the corrected position of the joint concerned, exercises
are given to improve strength and endurance of the muscle groups
antagonistic to the ones that were released surgically. Therefore,
gluteus maximus in the release of hip flexion contracture and
quadriceps in the release of knee flexion contracture need special
attention. Agonistic control as well as overall strengthening of the
other muscle groups of the limb should not be neglected. Surgical scar
should be mobilized by friction massage or ultrasound, to avoid it
getting adherent.
4. Re-education: Re-education in the proper use of the joint, weight

bearing and gait is done to avoid recurrence of soft tissue
contractures.
5. Home treatment programme: Simple regular regime of correct

positioning and exercises need to be continued at home.
Tendon transfers
Preoperative management and training – preoperatively, four factors
need special consideration:
1. Due to imbalanced muscular action, the concerned joint is most
likely to get stiff in the direction of the weaker muscle, e.g., limitation
of inversion in dorsiflexion when anterior tibial group is paralysed
and peronei are strong. The transplant can never be effective unless
full ROM is achieved at the concerned joint in the direction of the
proposed action of the transplant.
2. The muscle to be transplanted is bound to get weak after the

transposition and therefore it should be stronger before surgery.
Therefore, concentrated sessions of preoperative training of
strengthening and isometric holding of the muscle to be transplanted
is a must.
3. There is a tendency for the transplanted muscle to continue its

previous action even after transposition. This is avoided by adequate
training of the patient on the contralateral limb, e.g., correct groove of
dorsiflexion with inversion is repeatedly practised on the contralateral
limb before undertaking peroneal transplant for the paralysed anterior
tibial group.
4. Specific strengthening procedures are given to the associated

muscle groups of the movement for which the transplant is planned.
These muscle groups are instrumental in assisting the performance of
the transplanted muscle. For example, extensor digitorum and
hallucis longus are strengthened when the peroneal transplant to the
dorsum of the foot is planned to assist dorsiflexion.
Therefore, adequate preoperative training and exercises are

absolutely essential before surgery. Postoperatively, re-education of
the transplanted muscle is equally important.
◼ Begin with guided passive full-range movement in the exact groove

of the expected arc of movement. Gradually progress to assisted
movement by encouraging the patient to actively contract the
transplanted muscle.
◼ Electrical stimulation synchronized with the patient’s effort is
extremely useful in re-education. Biofeedback also provides an
excellent means of re-education.
The sessions of muscle re-education and strengthening should be

continued and progressed till strong and controlled movements by the
transplanted muscle are achieved. Guided functional training hastens
the recovery.
Dynamic orthosis may sometimes become necessary to provide
assistance and to avoid unwanted movements.
Arthrodesis: This is a joint stabilizing procedure where
immobilization is usually done for a long period.
The patient is taught the procedures of functionally using the limb
effectively, e.g., non–weight-bearing crutch walking. Exercises are
given to strengthen the movements of the joints adjacent to the joint to
be arthrodesed.
Mobilization of the shoulder girdle and pelvic girdle are given
when the arthrodesis is planned for shoulder and hip, respectively. It
helps in the functional use of the limb following stabilization.
During immobilization: Vigorous exercises are given to the joints free

from immobilization.
Gait training is started as soon as the pain recedes.
Mobilization: The exercise programme is made vigorous, emphasizing

endurance training. As the initial weight bearing is painful, weight
transfers to the limb; single leg balance and ambulation are done in a
graduated manner. Adequate walking aid may be necessary
initially, but it should be waned gradually.
Functional use of the operated joint is emphasized by

teaching compensatory mechanisms by using adjacent
joints.
Correction of the limb length disparity: Like arthrodesis, the period of

immobilization is long and therefore strengthening and endurance
exercises are emphasized to all the free joints.
Proper positioning of the limb is ensured in the external fixator.

Isometrics to the glutei and quadriceps are given on removal of the
external fixator or POP. Gradual training in weight bearing, weight
transfers, balance and gait is initiated and progressed to normal use.
Rehabilitative surgery
Orthopaedic surgery plays a crucial role in patients after 18 months to
2 years when the period of neuronal recovery comes to a standstill.
Objectives
◼ To correct or minimize the influences of soft tissue contractures
◼ Reconstructive surgery in the form of tendon transfers to
◼ Compensate for a loss of function due to the paralysis

affecting the prime movers of a particular movement
◼ To eliminate the deforming forces
◼ To improve muscle imbalances, giving rise to marked

instability while performing functional activities
Joint arthrodesis
To permanently stabilize a flail joint not allowing functions of the
distal nonparalysed muscle groups, e.g., hand grip in flail wrist.
Osteotomy – correcting bony deformities hindering the function.
Examples
1. Correction of deformity due to soft tissue contractures
Joint Contracture Surgical Procedure
Hip Flexion Soutter’s release
contracture
Knee Flexion Mild degree – division of iliotibial tractModerate degree – lengthening of
contracture hamstrings Severe degree – Hamstrings release coupled with posterior
capsuloctomy of the knee joint
Ankle Contracture Z-plasty, release of a tight tendoachilles (Fig. 28.6)
of
tendoachilles
Foot Tight Surgical release
plantor
fascia
Cavus Steindler’s procedure
deformity
2. Tendon transfer procedure

Muscles used for transfer To compensate for a paralysed muscle
Shoulder: trapezius To the neck of the humerus to compensate for the paralysis of deltoid
muscle for shoulder abduction
Elbow: common origin of Transferring common flexor origin at the medial epicondyle to the
elbow flexors anterior aspect of the lower end of the humerus (Fig. 28-3)
Hand: FDS tendon from the Transferred to the abductor pollicis brevis to act as thumb abductor To
middle phalanx of the middle facilitate opposition at the carpometacarpal and metacarpophalangeal
finger to the thumb (Fig. 28-5) opposition and flexion, and extension at the IP joint of thumb
• Iliopsoas and erector • Transferred to paralysed gluteus maximus to compensate for

spinae paralysed hip extensors
Tensor fascia lata Transferred to paralysed gluteus medius to act as hip abductor
Hamstrings Transferred into patella to act as knee extensors (quadriceps)
Tibialis Tibialis tendon to the cuboid bone to act as ankle and foot eversion
(peroneal muscle) to compensate for talipes varus due to paralysed
peronei
Peronei Talipes valgus due to paralysis of tibialis anterior – peroneal muscles are
transferred to the cuboid bone to control talipes valgus
Extensor hallucis Transfer of the tendon of the extensor hallucis into the neck of the first
metatarsal bone with fusion of the IP joint of a great toe, to reduce the
dropping of the head of the 1st metatarsal bone
3. Joint arthrodesis: fusion

Joint Purpose
Wrist To stabilize the wrist joint in 15 degree extension to improve grip by
facilitating stronger finger flexion improving grip strength
Spine Fusion to provide stability to the spine (with or without instrumentation)
Talipes calcaneus (due to Stage I: Correction of cavus by the fusion of talonavicular joint with
paralysis of gastrosoleus) Steindler’s release
Stage II: Transfer of tibialis posterior, or peronei or the long toe flexors
into tendoachilles
Talipes equinus Triple arthrodesis (Fig. 28-7, B and C; Fig. 28-8)
4. Osteotomy – to correct bony malalignments and deformities like

genu varum.
5. To correct the disparity in the leg length like shortening of the

affected lower extremity by Ilizarov technique, Wagner’s technique
(Figs. 28-8 and 28-9).
Prevention of late effects of poliomyelitis

Recent studies on the follow-up observations of the polio epidemics of
1935–1955 have highlighted certain late complications.
Late complications
1. Joint pains and degenerative joint disease
2. Myofascial pains
3. Gradually decreasing endurance
4. Gradually decreasing strength in the affected as well as unaffected

muscles
5. High incidence of fractures
6. Increasing respiratory insufficiency (in bulbar poliomyelitis

patients)
7. Compressive neuropathy
8. Decreased ability to ambulate and in performing ADLs (Agre et al.,

1998; Halstead & Rossi, 1985; Perry et al., 1988)
All these complications arise due to the following factors:
1. Lack of regular checkup
2. Discontinuance of exercises
3. Discontinuing supportive aids
4. Deconditioning from injury or immobilization
5. Disregarding the advice to avoid sustenance of posture and

activities causing excessive stretch or joint compressions
6. Lack of exercises, excessive sedentary lifestyle with increased body

weight
The major factor of increasing age in these patients cannot be
overlooked. However, certain measures and advice will definitely
prevent these complications or reduce the intensity of ill-effects due to
them.
Physiotherapeutic advice cannot be generalized as the expected
complications depend upon the degree and the area involved in an
individual patient. It has to be planned on an individual basis. At
discharge, the patient should be fully assessed for the expected
complications and given a suitable programme to prevent them. The
following measures should be taken:
1. Identification of the susceptible areas and thorough education to

prevent them.
2. Insist on follow-up visits at regular intervals so that any faulty

attitude can be rectified at the earliest.
3. Complications like articular pains, due to joint generation and pains

of muscular origin are all related to the modern, physically
overdemanding lifestyle. Therefore, proper advice on controlling
daily activity by proper energy consumption or energy conservation
by the use of wheelchair or motorized scooter or other assistive aids
may be necessary. Postural requirements of job or work also need to
be critically analysed and corrected, along with other activities of
daily routine.
4. Exercise programme should be directed to improve strength,

endurance and flexibility of the specific muscle groups that are
functionally important. At the same time, it should not result in the
overuse of weak muscles. The regime of exercise as reported by Perry
et al. (1987) has proved to be beneficial. It consists of moderate
intensity exercise with low rate of repetition. 60–70% of the maximum
resistance is applied for 5–10 repetitions to each functionally
important muscle group, done once a day. This has resulted in
increased endurance, agility and the functional ability (walking) of
postpolio patients.
Study conducted by Perry et al. (1988) indicated that the

instances of overuse were present in the following muscle
groups:
◼ The biceps femoris (82%)
◼ The quadriceps (53%)
◼ The soleus (34%)
◼ The gluteus maximus (34%)
Therefore, these muscle groups should be given regular

strengthening exercises, but at the same time, the activities
putting extra strain on these muscle groups should be
prevented. To prevent contractures, simple techniques of
sustained stretching should be taught to the common
susceptible musculotendinous complexes.
5. Regular use of aid and appliances: The ambulatory aids and

orthoses prescribed at the time of discharge should be continued to
avoid undue strain. Patients should not discard them unless advised
to do so.
6. For the patient with respiratory insufficiency, the emphasis should

be on respiratory exercises to improve vital capacity.
7. Compressive neuropathy: Carpal tunnel syndrome and ulnar

neuropathy at the cubital tunnel may result from overuse and
compressive forces from the incorrect use of cane, crutch and
wheelchair. The patient using assisting devices should be educated on
the proper use of these aids and to report immediately if any
symptoms occur, so that they can be controlled at the earliest.
8. Control of body weight: Patients with sedentary life-style should be

strictly warned against the possible ill effects of overweight.
9. Properly controlled programme of aerobics may be helpful in

improving the overall physical fitness.
10. Susceptibility to injury and fractures can be avoided by advising

against continuation of strenuous activities after muscle fatigue.
Reconstructive surgery and tendon transfers may be necessary to

correct deformity and its ill effects. Joint stabilization procedures may
be necessary to offer stability to the unstable joint. A stable joint will
prevent undue stresses in the related joints, e.g., triple arthodesis will
prevent strains on the hip and knee. Thus, regular monitoring of these
factors is necessary to prevent or to reduce the gravity of such late
effects.
Summary
Anterior poliomyelitis is an infective viral disease transmitted through
the droplets infection or by oral ingestion.
The virus is resistant to antibiotics, enters through the
tonsilopharyngeal route, multiplies and disseminates in the CNS. It
has a specific affinity to the anterior horn cells of the spinal cord
causing their destruction and permanent damage. Affects mainly
children within 1 year age but may affect children up to 5 years. The
phases of the disease are as follows:
Acute phase: During the acute inflammatory phase of (first 2–3

weeks), the virus multiplies and spreads to the CNS. It is associated
with fever and tenderness in the affected limb muscles; restlessness
may be present.
Subacute phase (3–6 weeks to 6 months): A phase of maximum

recovery and a phase of maximum physiotherapeutic efforts to
strengthen the paretic muscle.
Chronic phase: When there are no chances of further muscular

recovery.
More than 18 months of the onset: The treatment is mainly

concentrated on functional re-education of the affected limb or limbs
by providing aids, appliances, reconstructive surgical procedures
and compensatory techniques to assist ADRs.
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Chapter 29
Arthritides
Outline
◼ Classification of arthritis
◼ Osteoarthritis (general)
◼ Osteoarthritis of the hip
◼ Osteoarthritis of the knee
◼ Osteoarthritis of the ankle
◼ Osteoarthritis of the foot
◼ Osteoarthritis of the wrist and hand
◼ Osteoarthritis of the shoulder
◼ Osteoarthritis of the elbow
◼ Osteoarthritis of the wrist
◼ Osteoarthritis of the trapeziometacarpal joint of the

thumb
◼ Osteoarthritis of the temporomandibular joint
◼ Osteoarthritis of the sacroiliac joint

◼ Rheumatoid arthritis
◼ Juvenile rheumatoid arthritis
◼ Seronegative spondyloarthritis
◼ Still disease
◼ Haemophilia (haemophilic arthritis)
◼ Ankylosing spondylitis
◼ Other forms of seronegative arthropathies
◼ Metabolic arthritis
◼ Connective tissue diseases
◼ Charcot joint
◼ Miscellaneous conditions
Arthritis
Inflammation of a joint is called arthritis. Affections of the
joint may be generalized, as a part of a systemic disease; or
may be localized with the involvement of a particular joint
due to some local problem.
Classification of arthritis
Arthritis is classified into several categories as listed in Table

29.1.
Table 29-1
Classification of Arthritis
1. Osteoarthritis (a) Primary

(degenerative)
(b) Secondary
2. Rheumatoid arthritis (a) Seropositive
• Rheumatoid arthritis
• Juvenile rheumatoid
arthritis
(b) Seronegative
• Ankylosing spondylitis
• Reiter disease
• Psoriatic arthritis
• Enteropathic arthritis
3. Neuropathic arthropathy
4. Metabolic arthritis (a) Gout
(b) Pseudogout
(c) Alkaptonuric arthritis
Haemophilia
5. Arthritis in systemic
disease
6. Miscellaneous (a) Villonodular synovitis
(b) Synovial chondromatosis
Osteoarthritis
Osteoarthritis is a noninflammatory degenerative disorder of
the joints characterized by progressive deterioration of the
articular cartilage and formation of new bone (osteophytes)
at the joint surfaces. It is called (a) primary when the
aetiology is natural wear and tear with aging, overuse or
obesity and (b) secondary when it follows some known
primary cause, e.g., trauma, infection and rheumatoid
arthritis (RA).
It is more common in weight-bearing joints such as the hip

and the knee. It is also seen in the spine, carpometacarpal
joint of the thumb and distal interphalangeal (DIP) joints of
fingers. The concept of ‘wear’ and ‘tear’ is generally
attributed as a cause of osteoarthritis. It holds true as
osteoarthritis is seen commonly in weight-bearing joints,
predominantly in the middle and older age groups. Various
other factors such as obesity and hormonal and genetic
factors have been found as a pathology to predispose to
idiopathic osteoarthritis.
Common sites of osteoarthritis
◼ Weight-bearing joints: Hip, knee, ankle and spine
◼ Overused joints: wrist joints, carpometacarpal joint of

thumb, distal metacarpophalangeal joints, etc.
◼ Most common site: knee joints
In osteoarthritis, there occurs loss of the ground substances

of the cartilage, which results in disturbance of dissipation of
the stresses. The collagen fibres are, therefore, subjected to
excessive stresses and strains leading to their rupture. The
cartilage develops fissures, gets eroded and exposes the
underlying subchondral bone. Microfractures of the
trabeculae develop in the subchondral bone. Resorption of
these microfractures results in subchondral cyst formation, a
characteristic radiographic feature of osteoarthritis.
Inflammatory synovitis, may occur; the new bone and
cartilage outgrowths developed at the margins of the
articular cartilage are seen as osteophytes on radiographs
(Fig. 29-1A and B).
FIG. 29-1(A) Course of osteoarthritis of hip –

diagrammatic representation. (B) Preoperative
radiograph. (C) Postoperative radiograph after
noncemented total hip arthroplasty done on both sides.
Clinical features
Pain is the main presenting symptom. Initially, the pain

occurs usually during or after weight-bearing activity, or at
the end of the day. Later on, it becomes continuous,
occurring even at rest. The joint becomes swollen due to
synovitis. Stiffness gradually sets in, following severe pain
and capsular contractures. In the late stages of the disease,
the joint becomes deformed. A common example is genu
varum deformity at the knee (see Fig. 29.4). It may be caused
by ligamentous instability, capsular contractures or muscle
imbalance at the later stage of the disease.
On examination, there is swelling due to synovial thickening

and/or effusion, muscle wasting and prominence of the
articular margins due to osteophytes. Movements are painful
and restricted. Crepitus is felt on passive joint movement. In
the late stages of the disease, loose bodies may develop in the
joint, causing recurrent joint effusion, pain, swelling and
locking of the joint.
Radiographic examination reveals the following main

features (Fig. 29-2):
◼ Narrowing of the joint space
◼ Osteophytes at the margins of articular cartilages
◼ Sclerosis and cysts in the subchondral bone

FIG. 29-2Osteoarthritis of both hip joints. Note the

reduction in joint space, osteophyte formation and
subchondral cysts. There is also deformation and
collapse of the femoral head.
Treatment
Reduction in the quantum of load on the joints is an

important aspect of the treatment of osteoarthritis. An obese
patient should be advised to reduce weight and minimize
compressive forces on the affected joint by proper body
mechanics and the use of ambulatory aids. Analgesics and
anti-inflammatory drugs are used to control pain with
correct pain-relieving physiotherapeutic modality.
Excessive jerks and strenuous movements should be avoided

to protect the joint from injury. Joint deformity should be
prevented as it alters the biomechanics and puts uneven
strain on the joint. Physical therapy is the mainstay of the
treatment and should be started early.
Surgical treatment
In osteoarthritis, surgery is indicated in progressively

increasing pain that is not relieved by conservative
treatment. The surgical treatment is discussed in the
following pages in connection with the disease of individual
joints.
Principles of physiotherapeutic management (general) in

osteoarthritis
Osteoarthritis is neither a condition of relentless progression

nor a disease. It is the result of imbalance between the
mechanical stresses on the joint and the ability of the tissues
to withstand them (Radin, 1987).
General principles of treatment
1. Prevention
2. Control of pain
3. Prevention of further damage

4. Improvement in range of motion (ROM)
5. Improvement in strength, endurance and muscle functions

of muscle groups passing over the involved joints
6. Improvement in the functional status of the involved joint

and the whole body – with correct ergonomic control
The methods of management vary with each joint, its

functions and the degree of its involvement.
To plan an appropriate physiotherapeutic programme, it is

essential to conduct a thorough physical examination and
correlate it with other clinical investigations.
The physiotherapist should be able to detect the altered joint

kinematics, through joint play movements, at the early stage.
The therapy is concentrated not only on improving the
muscle strength, endurance and mobility, but also on
restoring normal movements and muscle action at the joint.
Assessment
1. Assessment of pain: Pain is an index of the degree of joint

irritability. The site of pain, its nature and duration are
noted. The factors that precipitate pain-like jarring and
compression (weight bearing), sustained stress, specific
movement, rest and posture should be recorded since
prevention of further damage is directly related to these
factors. Similarly, factors providing relief of pain are also
recorded. These factors are modified and are made more
effective by providing guidance to the patient. Rest or
particular movement or postural adjustment may relieve
pain. First evaluate the intra-articular factors causing pain.
Pain may be the result of the following:
(a) Destruction of the cartilage exposing the subchondral

bone to compressive forces
(b) Osteophytes that may encroach upon the synovial lining

of the joint – The osteophytes may directly exert compression
on the soft tissues of the joint as loose bodies; overall pain
can be reliably assessed by the visual analogue scale (VAS)
(c) Imbalanced stretch that may occur on the weight-bearing

joint surfaces due to wear and tear of the cartilage.
2. Assessment of function: The impact of the disease on the

functional performance of the patient is examined and
recorded on a functional evaluation chart.
3. Assessment of joint stiffness: Accurate evaluation of the

passive ROM with its end feel is an important index of
stiffness. The type of joint restriction, whether capsular or
noncapsular, should be noted. The capsular type is indicated
by the loss of mobility of the entire joint capsule. A firm and
leathery end feel without effusion indicates capsular fibrosis,
while an abrupt locking end feel without any apparent
stretching of the antagonists indicates bony ankylosis. The
range at which pain or discomfort sets in is also recorded
along with the overall basic and accessory movements.
4. Assessment of strength, endurance, tone and volume of the

muscle groups related to the involved joints are
systematically recorded.
5. Assessment of tenderness: The degree and the area of

tenderness, effusion and crepitus are carefully examined by
palpation, volumetric measures or measuring tape and
relaxed passive ROM, respectively.
6. Assessment of deformity: It is extremely important to

measure the degree of deformity accurately. The deformity
may be fixed or dynamic when exposed to compression. The
assessment should, therefore, be done in the position of
maximum compression, e.g., weight bearing on the affected
leg alone.
Prevention: Physiotherapy can play a vital role in the

prevention of the painful symptoms of osteoarthritis.
Understanding the following factors in the pathogenesis of
osteoarthritis facilitates the planning of a prevention
programme.
1. History of trauma: A single episode of trauma causing

excessive compression of the cartilage is enough to initiate
the degenerative changes. Therefore, individuals with a
definite history of trauma to the knee are susceptible to
develop osteoarthritis.
2. Characteristics of joint cartilage: The joint cartilage is

avascular and aneural, with the absence of pain receptors.
Therefore, it is susceptible to fatigue. It also lacks the normal
inflammation and repair response. These factors lead to the
advancement of degeneration with microfractures without
any symptoms. The symptoms of pain, stiffness,
inflammation occur only in the advanced stage of
degeneration, when the synovial effusion stretches the joint
capsule and the pain sensitive receptors are fired. Initiation
of appropriate physiotherapy is advisable at the early stage
(may also result in acute synovitis).
3. Effects of immobilization: Prolonged immobilization

results in irreversible osteoarthritic changes. Knee
immobilization for 4 weeks produces compression between
the articular surfaces, which is approximately three times its
initial level. This is accompanied by shrinkage of
periarticular soft tissues with marked increase in the
synthesis of collagen and glycosaminoglycans (Eronen,
Videman, Friman & Michelson, 1978). Increased fibrosis of
periarticular tissues, cartilage proliferation at the joint edges,
atrophy in the weight-bearing areas, regional bony
eburnation, sclerosis and resorption can occur even after 2
weeks of immobilization (Langenskiold, Michelsson &
Videman, 1979). This proves the importance of early
mobilization.
4. Weight bearing: Early and unprotected weight bearing

also leads to unequal stresses on the joint. The presence of a
deformity, even of a mild nature, increases the susceptibility
of the imbalanced compressive forces on the joint. Early
measures should be taken to detect and check the disposition
of weight-bearing axis, especially in relation to the lower
extremity joints.
5. Full ROM exercises: It has been observed that

osteoarthritis of the hip is rare in the population where the
hip joint is frequently subjected to full ROM. This
observation proves the importance of full ROM as a
preventive factor. In floor squatting, the total area of the
articular cartilage is intermittently subjected to compression
due to weight bearing and should be encouraged.
Measures of prevention
1. Early identification of individuals at risk, e.g., with a

history of trauma to the joint, those with obesity and
deformities at the related joints, those with a stressful
overuse joint tendency, should be done.
2. Critical examination of the joint kinematics in weight-

bearing and non–weight-bearing positions should be done as
well as examination of the end feel and joint play
movements, and excursion of the axis of weight bearing.
Radiographic findings can also help in early detection.
3. Guided measures are to be taken depending on the

findings of the examination to prevent or control further
deterioration of degeneration like:
(a) Strengthening, improving flexibility and endurance of

concerned muscle groups
(b) Corrective measures to compensate the influence of

altered stresses on the joints by using viscoelastic inserts,
avoiding undue strain
(c) Exercises to be directed to lower the impact of excessive

force across the involved joint: This is achieved either by
decreasing the contractile force of the muscles or by making
muscles more efficient so that they do not contract as
strongly to produce the same effect; thus, controlled activity
of the muscle group can prevent compression of the joint due
to excessive contraction
(d) Guidance on avoiding various postures and activities

causing excessive compression of the susceptible joints, e.g.,
repetitive sitting and standing, long standing, step climbing
(e) Nutritional guidance for obese individuals
(f) Inhibition of degenerative changes during immobilization

by providing safe and limited ROM devices like non–weight-
bearing functional orthosis – Traction or continuous passive
motion (CPM) are also useful (Videmann, 1987) and strong
repetitive isometrics
(g) Early management of congenital anomalies (congenital

hip dislocation and acetabular dysplasia), infective
conditions of joints and intra-articular fractures
(h) Graduated resistance to the full arc of movement or

controlled loading through full ROM: It is necessary to
expose the maximum area of cartilage to the stimulus of
weight bearing; public awareness of these facts can prevent
progression of osteoarthritis
Treatment
The treatment is planned by giving due considerations to the

patient’s lifestyle, physical requirements, body weight and
the reports of evaluation. It is difficult to generalize the
treatment for all patients of osteoarthritis. The basic
approaches can be enumerated as follows:
1. Pain control
(a) To control pain, suitable electrotherapeutic modality

should be used. In the acute phase, pain relief is achieved
better by superficial heat modalities or cryotherapy.
Ultrasound therapy, transcutaneous electrical nerve
stimulation (TENS), diapulse, pulsed diathermy and
stimulation are also effective. Short-wave diathermy (SWD)
may be used in the later phase when the tissue oedema is
less.
(b) Hydrotherapy is particularly useful when the weight-

bearing joints are affected.
(c) The compressive forces on the joint can be reduced by

resting in a proper position, splints or joint distraction by
manual or mechanical traction, CPM or functional bracing.
2. Improvement of muscle power, endurance and tone:

Graduated exercise programme is initiated, which consists of
progressive resistive exercises (PRE), strong and sustained
repeated sessions of isometrics (5 min every hour) holding or
sustaining muscle contractions in static midrange position of
the isotonics.
3. Improvement in ROM
(a) Active free relaxed rhythmic movements improve the

range as well as promote relaxation of the joint.
(b) Relaxed passive movements should be started first to
mobilize stiff joints. Hydrotherapy and proprioceptive
neuromuscular facilitation (PNF) techniques are useful in
improving ROM. When mechanical dysfunction blocks the
movement, manipulation and mobilization and manual
therapy techniques are effective.
4. Improvement of functional independence: Function of the

whole body in relation to the degenerated joint can be
improved by the following:
(a) Proper guidance to relieve compression over the affected

joints
(b) Providing assistive aids, modified supports, corrective

orthoses, adaptations and ergonomic advice on the
performance of ADLs, and special shoes with inserts.
Osteoarthritis of the hip

Primary osteoarthritis of the hip joint is rare in India but
commonly seen in Western countries. Secondary
osteoarthritis, however, is seen more frequently following
old trauma, Perthes disease and avascular necrosis of the
femoral head. Traumatic conditions that may develop
secondary osteoarthritis include fracture of the neck of
femur, dislocation of the hip and fractures of the acetabulum.
Clinical features
The presenting features are progressively increasing pain

and limitation of movements. Gradually, all the movements
of the hip are restricted except in some cases; a good range of
flexion may be preserved for quite some time. This may be
because flexion is required in the movement of squatting – a
movement required so often in the Indian setting.
Treatment
It is treated initially by conservative treatment in the form of

deep healing modality, body ergonomics exercises,
analgesics, etc. Weight reduction may be helpful in obese
persons. Use of a walking stick in the opposite hand should
be encouraged as it reduces the load on the affected hip joint
and minimizes pain and a limp.
Common sites of osteoarthritis:
1. Hip
2. Knee
3. Hand
Surgical treatment
Any of the following surgical procedures may be performed:
1. Osteotomy – to centralize weight-bearing axis
2. Arthrodesis – only at a late stage, just to provide a stable

hip
3. Pauwell’s varus osteotomy in patients with coxa valga
4. McMurray’s displacement is performed in patients with

coxa vara
5. Arthroplasty (total hip joint replacement [THR]) – to

provide mobility
Osteotomy: Displacement or McMurray’s osteotomy is

performed in relatively early cases to relieve pain. However,
the relief in pain is temporary and, therefore, this operation
is rarely performed for osteoarthritis of the hip. It is still
occasionally performed for the treatment of intracapsular
fracture of the neck of femur. It is discussed in detail in
Chapter 5.
Arthrodesis: It gives a pain-free but a fixed joint. It is ideal

for young adults, particularly heavy manual labourers. It is
discussed in a separate chapter devoted to these three
surgical procedures.
Arthroplasty: THR is the most commonly performed

operation for osteoarthritis of the hip. It is also discussed in
detail in a separate chapter.
The objective of physiotherapy is to provide pain-free and

functionally acceptable hip joints.
Control of pain
1. In the acute phase, the painful muscle spasm can be

relieved by ice massage, ice packs in resting positions.
2. Gentle intermittent traction may be effective as it relieves

compression of the affected joint surfaces. However, it may
not suit every patient. Sustained low-grade traction is
another alternative. Even minimal force of traction may be
helpful as it provides rest, relaxation and prevents
deformity.
3. Deep heating modalities like ultrasound, pulsed SWD,

TENS, interferential currents or any other suitable pain-
relieving modality may be used.
Joint mobilization
Various methods of joint mobilization can be applied. They

should progress gradually according to the patient’s
response.
1. Initially, relaxed ROM swinging exercises are ideal. The

physiotherapist carries the total weight of the limb without
involving any voluntary muscular contractions in the
muscles that are in spasm. The ROM should be progressed in
gradual steps with stretching modes with holds.
2. Progress to small-range assisted free active movements by

using ped-o-cycle, stationary bicycle or roller skates in a
restricted range. Sling suspensions to mobilize the range of
abduction are ideal but should be done for both hips
simultaneously to prevent the compensatory pelvic tilt due
to stiffness of the affected hip joint.
3. Maitland techniques of low-grade mobilization, gradually

progressed to higher grades, provide early mobility, which is
pain free.
4. Hydrotherapy with correct guidance in the form of pool

therapy promotes relaxation, improves mobility, strength
and confidence.
5. PNF techniques can be used provided they are not painful

(possible only in the middle ROM).
Muscle strengthening
Improving strength and endurance of the important muscle

groups that offer stability to the hip and the body in weight
bearing and weight transfers, like gluteal muscles, should be
initiated. Controlled isometrics done repeatedly but not
strong enough to cause pain are ideal. Strengthening the
knee extensors, flexors as well as ankle dorsi and plantar
flexors is also important.
There may be abnormal reflex activity in the absence of

normal arthrokinematics. Strengthening of the muscles alone
may have a deleterious effect on the joint. The plan should
be, therefore, to restore the normal accessory and component
movements at the involved joint on a biomechanical basis
because the joint problem in osteoarthritis is that of
mechanical dysfunction.
Isometrics should be progressed, in graded steps, to PRE for
the ultimate strengthening of these muscle groups.
Exercise should preferably be self-performed with correct

guidance and emphasis with self-generated internal
resistance.
Gait re-education
1. The correct methods of weight transfers and the stages of

gait cycle need to be educated to provide near normalcy in
gait.
2. If any limb length disparity exists, it should be adequately

compensated before gait re-education.
3. Necessary walking aid may be given to assist weight

transfers, along with other functional aids. The general
tendency among patients is to discard the walking aid. This
should be discouraged by properly explaining to them the ill
effects of joint compressive forces due to weight bearing.
4. Other ambulatory activities like stair climbing and

descending, back- and sidewalks should be taught in the
proper sequence (e.g., going up the steps with the good leg
leading and coming down with the affected leg leading).
Floor squatting and cross-leg sitting may not be possible for

tense patients because of the limited ROM. However, the
patient should be trained to perform ADLs with guided
assistance.
Secondary osteoarthritis of the hip
Causes
◼ Unstable hip joint, e.g., subluxation
◼ Angular pressure load, e.g., anteversion, coxa vara
◼ Old direct trauma or infective disease
◼ Constitutional factors, e.g., hyperthyroidism and obesity.
◼ Loss of incongruity of the joint surface, e.g., Perthes

disease
Progression of disease
◼ The progress is relentless.
◼ As it occurs in the younger age group, surgical

intervention at the earliest helps in maximum resolution.
Postoperative procedure
The same pattern is followed as that in other hip joint

osteoarthritis surgeries.
Osteoarthritis of the knee

In Indians, primary osteoarthritis of the knee joint is more
common than the secondary osteoarthritis. It is perhaps due
to the frequent need of squatting and sitting cross-legged. It
is commonly seen in middle-aged obese females; however,
males are not exempted.
Causes of primary and secondary osteoarthritis (knee)
Primary osteoarthritis
◼ Repetitive weight bearing or prolonged weight bearing on

the susceptible joints
◼ Competitive sports with inadequate rest periods
◼ Excessive sedentary attitude and obesity
◼ Multiple endocrinal disorders
◼ Multiple metabolic disorders
Secondary osteoarthritis
◼ Obesity, varus or valgus deformity at the knee
◼ Intra-articular injury or fracture
◼ RA infection or TB
◼ Hyperparathyroidism
◼ Haemophilia
◼ DM
◼ Excessive steroid therapy
The presenting complaints are pain, stiffness, limitation of

movements and swelling occasionally with clicking sounds.
There may be instances of locking of the joint in some
advanced cases.
On examination, there will be synovial thickening as

indicated by a joint line tenderness with effusion,
crepitations are felt on movement. There may be some
flexion deformity of the knee joint with limitations of
movement. In advanced cases, advanced genu varum
deformity causes ligamentous laxity on the lateral side of the
knee with unusual opening of the lateral joint space as seen
on X-rays (Fig. 29-3).
FIG. 29-3 X-ray of the knee joint shows genu varum

along with unusual opening of the lateral joint space.
There may be involvement of one or more compartments of

the knee joint, i.e., medial, lateral or patellofemoral
compartments. When the medial compartment of the knee
joint is predominantly involved, genu varum deformity
results (Fig. 29-4 A–C).
FIG. 29-4Osteoarthritis of the knee – radiographic

features: involvement of the medial tibiofemoral. (A)
Patellofemoral compartments. (B) Anteroposterior
view (AP). NJS: narrowing of the joint space at the
medial tibiofemoral compartment with genu varum.
OST: osteophytes at the joint margins (lipping). SCL:
sclerosis at the joint margins. CYS: cystic changes. LB:
loose body in the joint. B: lateral view. NJS: narrowing
of the patellofemoral joint space with lipping at the
superior margin of patella. SCL: sclerosis at the joint
margin. CVS: cystic changes. LB: loose body in the
joint. (C) Genu varum deformity in osteoarthritis of
knee.
Treatment
The conservative treatment includes anti-inflammatory

drugs and electrotherapy for relief of pain, and exercises to
strengthen the quadriceps muscles and to restore or maintain
full mobility of the knee joint. Early use of cane and proper
ambulatory training with special modified footwear should
be done whenever applicable. Nowadays, offloading braces
are available which are used to shift the weight-bearing
stresses from one compartment of the knee (usually the
medial) to the other which causes relief of pain.
Surgical treatment
Any one of the following surgical procedures may be

performed depending upon the occupation and the
functional needs of the patient.
1. Osteotomy: This is the most commonly performed

operation for osteoarthritis of the knee joint. It is ideally
indicated in a unicompartmental disease (medial or lateral)
with marked varus, or less commonly, valgus deformity. The
high tibial osteotomy is performed 2 cm distal to the tibial
articular surface but proximal to the tibial tubercle, i.e.,
proximal to the insertion of the ligamentum patellae. The
genu varum deformity, which is more common, is treated
either by a closed wedge osteotomy (Fig. 29-5) or by an open
wedge osteotomy with internal fixation. Femoral
(supracondyler) osteotomy may be performed for the
deformity of genu valgum (Fig. 29-5B).
The osteotomy may be fixed internally by staples or special

plates or immobilized in an above-knee or cylinder plaster
cast.
By doing an osteotomy, the deformity (varus or valgus) is

corrected, thereby redistributing the load from the medial
compartment of the knee. It helps in relief of pain in majority
of the patients.
Postoperatively, the knee is immobilized in a plaster cast for
a period of 3 weeks where staples have been used for
internal fixation, or for 6 weeks where no staples are used.
Weight bearing in the plaster may be allowed at the end of
4–6 weeks in the latter case. After removal of the plaster,
knee mobilization is initiated. Full weight bearing is
permitted after 8–10 weeks.
2. Arthrodesis: It provides a pain-free stable but stiff knee

joint. It is, however, not performed generally for
osteoarthritis of the knee joint where alternatives of
providing a mobile joint, such as an arthroplasty, are
available.
3. Arthroplasty: Total knee joint replacement is indicated in

elderly patients with marked disorganization of the joint due
to osteoarthritis. It is discussed in detail elsewhere.
4. Arthroscopic surgery: Arthroscopic surgery is employed

more often in the treatment of mild-to-moderate degree of
osteoarthritis of the knee joint. The arthroscopic procedures
include lavage of the joint with removal of osteochondral
loose bodies, shaving of the osteophytes, and the removal of
degenerated and frayed or torn menisci. These procedures,
however, provide temporary relief from pain.
FIG. 29-5(A) High tibial osteotomy for genu varum.

Postosteotomy position of correction of genu varum.
(B) Femoral supracondylar corrective osteotomy for
genu valgum osteotomy. BW: outline of bony wedge to
be resected from supracondylar region of femur.
In osteoarthritis of the knee, the major problems are pain,

stiffness, joint instability, deformity and functional
inadequacy at the later or chronic stage.
Pain: Pain is assessed for its character, degree, posture and

duration. Pain is usually noticed when the degenerated joint
is exposed to compressive forces. In some patients, pain at
rest may be present due to the hypervascularization of the
neighbouring bone.
Tenderness and effusion: The sites and degree are recorded.
Range of movement: Passive ROM including the end feel is

recorded.
Deformity: Its nature and extent are assessed at hip, knee,

ankle and foot during total weight bearing on the affected
leg alone.
Stability: The stability of the joint is assessed in supine

position and with weight bearing on the affected knee alone.
Strength, endurance and flexibility of the quadriceps,

hamstrings and glutei should be recorded. Wasting should
also be measured.
Efficacy of performing functional activities and the pattern of

gait and other ambulatory parameters are evaluated. Knee
rating scale (Table 29-2) is ideal to assess pain and functional
status.
The duration of the ability to stand on the affected leg alone

is also noted.
Physical demands: Physical demands of the patient’s daily

routine need to be evaluated in relation to the degree of
involvement.
Table 29-2
Knee Rating Scale for Pain and Functions (50 Points)
Pain-free standing and long walk 50
Mild pain, painless walking up to 1 km 40
Considerable pain on long standing/walking 20
Pain free up to less than 0.5 km 10
Severe pain on standing/walking or even at 5

rest
0
Unable to walk
After physical examination, it is necessary to confirm the site

and extent of degeneration by radiographic investigations.
RADIOGRAPHIC CLASSIFICATION
Stage Bony spurs only

I
Stage Narrowing of joint space, less than half of the normal
II joint space
Stage Narrowing of the joint space, more than half of the
III normal joint space
Stage Obliteration of joint space or bone attrition under 1 cm
IV
Stage Major bone attrition, more than 1 cm, subluxation or
V secondary lateral arthrosis
Stages I and II can be managed conservatively. The

osteoarthritic changes are usually confined to one of the
following three arbitrary sites:
1. Retropatellar or patellofemoral compartment
2. Medial tibiofemoral compartment
3. Lateral tibiofemoral compartment
Medial tibiofemoral compartment with genu varum is the

most common site of degenerative changes.
Early diagnostic signs
◼ Common in middle-aged women with tendency for

obesity
◼ Tendency to lead easy, nonexerting lifestyle
◼ Mild joint pain on bearing body weight while assuming

certain posture or positions, floor squats, ambulatory
advances such as stair climbing; usually the pain and
discomfort is relieved on sitting or lying
◼ Tenderness over the joint line
◼ Tendency for gluteus medius limp (trunk side bending)
Treatment
Self-care and self-help: The most important aspect of

physiotherapeutic management is to educate the patient on
self-care or self-help methods of treatment by simple
procedures that reduce the compressive forces on the knee
joint. These avoid repetitive impulse loading and
compressive forces on the knee joint, e.g., frequent standing
and sitting.
◼ Level walking: The maximum compressive force is as

much as three times the body weight (Morrison, 1969).
◼ Climbing up the steps: The compressive force is to the

tune of 4.25 times the body weight (Morrison, 1969).
◼ Raising from a normal chair without arm supports: The

compressive forces on the knee joint are as high as up to 7
times the body weight, whereas during rising from a chair
with the help of arm supports, the forces are reduced to less
than half the body weight (Ellis, 1981).
The first objective of the treatment is to reduce the degree of

compressive forces on the knee to the maximum.
This can be achieved by avoiding the following:
1. Prolonged standing and repetitive sit–stand activity
2. Long walk
3. Unsupported climbing, or climbing with the affected leg

leading
4. Unarmed chairs
5. Unsupported squatting or getting up from squatting

6. Positions like kneeling, squatting
7. Sustained positions of knee flexion like cross-leg sitting
8. Walking without walking aids or prescribed orthosis
9. Walking carrying heavy weights
10. Heavy exercises like half squats
11. Long immobile sitting e.g., during travelling, watching

TV, a movie or a stage performance without moving the
knees
Pain: During the acute phase of exacerbation, pain can be

managed effectively by cryotherapy, hydropack, TENS,
ultrasound therapy, pulsed diathermy and maximum care to
prevent compressive forces on the knee. Chronic pain can be
adequately relieved by deep thermotherapy. Various trials
conducted to prove the efficacy of a particular modality have
not conclusively proved the superiority of any modality over
the other. However, exercise has proved to be a single
common factor as regards therapeutic effectiveness
(Chamberline, Care & Harfield, 1982; Clarke, Willis, Stenners
& Nichols 1974; Quirk, 1985).
Therefore, the role of any electrotherapeutic modality is

limited to offering some relief of pain and hence acts mainly
as an adjunct to facilitate the exercise programme.
Exercise programme
The exercise programme should be simple but specific
according to the physiological changes in the joint. It should
be developed on the basis of the normal kinematics, to regain
the correct mechanics of the knee joint.
1. Isometrics: In the presence of effusion, speedy isometrics to

the quadriceps and hamstrings are useful. It should be
repeated every hour with the limb in elevation. The slow and
sustained isometrics help in reducing pain and improving
strength.
Quantitative progressive exercise (QPE) programme with

emphasis on maximum isometrics to quadriceps and
hamstrings at various hip and knee angles, isotonics with
and without resistance and speedy contractions have proved
extremely effective (Fisher, Gresham & Pendergast, 1988).
2. Speedy active relaxed free movements: Active relaxed free

movements, within the limits of pain, are useful in
improving the ROM and inducing relaxation. They are easy
to perform, too. They also improve the free mobility of the
joint, maintaining the lubrication. Repeated relaxed knee
swinging in supine or sitting posture are also useful (see Fig.
1-2) to further relaxation and mobility.
3. Isokinetic exercises: Isokinetics are a mode of exercise with a

capacity to adjust the resistance according to the varying
muscular strength. This effect, to a certain extent, can also be
obtained by the therapist manually applying resistance.
Another substitute to isokinetics is by the patient himself,
applying resistance by the other leg. These exercises are self-
controlled and hence are better accepted by the patient (Fig.
29-6). They can be repeated frequently.
4. Straight leg raising (SLR): SLR is made effective by

simultaneous isometrics to the quadriceps with the foot held
in dorsiflexion. It can be made resistive by adding weight or
resistance by the other leg. It improves stability to the knee
during weight bearing.
Suggested progressive self-resistive SLR
Slow and continuous SLR with simultaneous isometro–

isotonic exercise mode to the level of muscle fatigue (Figs 29-7
and 29-8).
(a) Begin with strong isometric holds to quadriceps and the

ankle and foot dorsiflexors.
(b) Now perform SLR at a slow speed as much as possible

using the time to generate more intramuscular isometric
tension.
(c) After SLR to a certain angle (which may vary according to

the strength), slowly bring the leg down.
(d) Before the heel touches the bed, raise straight leg up
again.
(e) Continue repeating to the level of fatigue or pain.
Advantages
◼ It improves strength, endurance as well as power at one

go.
◼ Performing SLR at a slow speed induces early fatigue in all
the participating muscle groups.
◼ It provides advantages of maximum exercise to all the

participating muscle groups in a shorter period.
◼ Along with these major benefits, it will also improve the

movement control for the whole limb.
5. Hamstrings stretching: Stretching of the hamstrings is

important to prevent knee flexion deformity. Short sessions
of toe touching in long sitting are useful (Fig. 29-9).
Isometric co-contractions of the hamstrings along with

quadriceps should be encouraged during the acute (painful)
stage. It helps to prevent the adaptive shortening of the
hamstrings which usually begins during this stage.
The exercise programme should be simple, brief yet specific

and should be repeated several times.
6. Posture, gait and simple modifications in the assistive devices:

Correct posture, near-normal pattern of gait and adequate
assistive aids like cane, crutch and orthoses have an
important role in reducing the compressive forces on the
knee.
Modifications to ease pain and functional activities
◼ Special chair with higher sit and double arm support

should be used.
◼ Ambulatory training should be provided with proper

assistance which reduces the discomfort during weight
bearing.
◼ No still standing; if compelled to, then the body weight

should be well balanced by placing the feet with at least 12-
inch wide base.
◼ Never use Indian toilet; opt for a commode sit.
◼ Toilet and bathroom should be fitted with a hand rail and

toilet seat with a handle to take the body weight on the
hands.
◼ Use slow and steady steps on stairs which are provided

with a bilateral hand rail.
◼ If using a cane for walking, height of the walking assistive

device should be at the wrist level with elbow held in
extension.
◼ Adopt sustained lying repetitively to prevent developing

hip flexion attitude (e.g., playing carrom, reading)
7. Wedge insole: Properly measured wedge insole provides

relief by reducing the compressive forces on the affected
compartment on bearing body weight. It also reduces the
excessive tensile force on the opposite compartment (Sisaki
and Kazunori, 1987). It has been reported to be clinically
effective up to three radiographic stages of osteoarthritis (but
not in stages IV and V). Therefore, wedge insole with an
exterior height of 7–12 mm should be tried, so that the
sagittal axis of the posterior part of calcaneus is tilted
laterally at an angle of 5 degrees to the floor. The period of
using insole should be increased gradually to allow
adaptation and continued in spite of setting in of early
fatigue and discomfort.
FIG. 29-6Self-resisted exercise using contralateral leg to
perform isokinetic-type exercises.
FIG. 29-7Isometric contraction of quadriceps.

FIG. 29-8Straight leg raising.

FIG. 29-9Toe touching to stretch hamstrings.
The proper control of exercises, rest and self-care are the

most important measures to limit imbalances between
mechanical stresses and improvement in the ability of tissues
to adequately withstand such stresses.
Dos and don’ts for OA joints is presented in Table 29-3.
Table 29-3
Don’ts and Dos for Osteoarthritic Joints

Don’ts Dos
Hip, Knee and Ankle Always Begin Exercise with
• Exposing the joint • Performing pain-free relaxed

to a sustained load rhythmic free active movements to
(e.g., remaining in full or maximum ROM
one posture for a
longer duration, such
as sitting and
standing)
• Repetitive joint • Mobilize the joint with relaxed free

compressive stress active movements before bearing
(e.g., frequent position weight (e.g., standing after long
changes like sitting to duration sitting)
standing, stair,
inclined or rough
surfaces with ups and
downs)
downs)
• Sudden stressful • Perform self-resistive pain-free and

rotatory activity (e.g., endurance exercises at every
spontaneous turning possible opportunity (e.g., while
with feet firmly sitting and talking, watching TV)
grounded)
• Unsupported • Correct use of assistive aids to

ambulation in spite of ensure transference of body weight
pain and limp (a very from the affected joint to the walking
common situation, aid (e.g., using cane)
invariably
unacceptable to the
majority of
population)
Wrist and Hand Always Begin Exercise with
• Avoid repeatedly • Wrapping hot water rubber bag in

performing stressful a wet Turkish towel and securing it
movements. (e.g., properly around the painful joint for
activities of daily 20 min three times a day. Besides
routine including giving a soothing warmth, it also
lifting weight objects, provides compulsive rest. During
purposed less passive intermittent episodes of pain, use a
compression of MCPs, simple technique of applying hot
PIPs and DIPs with pack and perform relaxed free active
other hand or movements in a pain-free ROM
sustained tight grip)
• Dynamic orthosis immobilizing
• Dynamic orthosis immobilizing
the CMC joint of the thumb
• Restrict using distal IP joints of

fingers.
• Carry out full ROM passive flexion

at the DIPs of fingers to prevent
organization of a flexion deformity
Osteoarthritis of the hand

Osteoarthritis affects the interphalangeal joints of the hand.
The DIP joints are commonly involved initially but proximal
interphalangeal (PIP) joints may get involved later on. In rare
instances, metacarpophalangeal joints may also be involved.
Osteophyte formation at the margins of these joints gives rise
to hard prominences known as Heberden nodes at the DIP
joint and Bouchard nodes in the PIP joint (Fig. 29-10). The
occurrence of these nodes in the dominant hand, particularly
in women, indicates excessive use as one of the aetiological
factors.
FIG. 29-10Chronic degenerative changes with

formation of nodules at the IP joints.
Initially, pain in these nodes is minimal. However, further

constant use precipitates inflammatory reaction with
increase in pain and decreased function of the hand.
Inflammation may lead to a cystic swelling containing
gelatinous material which is extremely painful and may even
burst.
Treatment
1. Rest should be provided in a splint with elevation.
2. Relaxed passive ROM exercises should be done once a day

to maintain ROM.
3. Small-range active movements with maximum relaxation

without exerting any stress on the involved joints are
important.
4. Cryotherapy, TENS, ultrasound, etc. could be tried for

pain relief; however, using repetitive hot packs is ideal.
Osteoarthritis of the trapeziometacarpal joint of

the thumb
The carpometacarpal (trapeziometacarpal) joint of the thumb
may be involved (Fig. 29-11).This involvement results in pain
and limitation of function as the thumb plays a dominant
role in the hand function. It may give a squarish appearance
to the base of the thumb, causing further difficulty in grasp.
FIG. 29-11Osteoarthritis of the trapeziometacarpal joint

(thumb).
Physiotherapeutic measures have limited scope and
therefore surgical intervention in the form of excision of the
trapezium or a silastic implant may be required.
Physiotherapeutic assessment
Accurate recording of the following is done:
1. ROM of individual joints of the involved hand is measured

either by finger goniometer or by a malleable wire. It is
important to record passive as well as active ranges.
2. Grading of individual muscles is done after proper

stabilization without causing pain.
3. Sensory status, especially at the fingertips, should be

recorded.
4. Functional use of the hand: Each type of grasp involving

individual fingers and thumb should be assessed along with
the status of hand functions on the whole.
5. Grip strength and efficacy of grasps should be evaluated

objectively.
Treatment
The following should be done during acute phase or

exacerbations:
1. Rest should be provided in a splint with elevation.

2. Gentle, relaxed passive ROM exercises should be done at
least once a day to maintain the range of joint motion.
3. Small-range active free movements should be given

without causing extra strain to the involved joints.
4. Suitable form of cryotherapy or TENS may be used for the

relief of pain preceding movements.
Mobilization phase
When symptoms of acute inflammation subside, a phase of

vigorous mobilization to improve ROM, strength and
endurance of the hand function is initiated. Use of corrective
splint should be continued till adequate control of the hand
function is returned.
Exercises causing pain and excessive stress on the affected

joints should be avoided.
Assisted individual joint movements with axial traction and

proper stabilization in the correct groove of movement are
effective.
Exercises designed to incorporate various hand functions

should be guided and encouraged.
Besides hip, knee and hand, osteoarthritis may involve

shoulder, elbow, wrist and temporomandibular or sacroiliac
joints.
Osteoarthritis of the shoulder

Osteoarthritis of the shoulder is rare and usually needs
conservative treatment in the form of anti-inflammatory
drugs and physiotherapy. However, the role of total
shoulder joint replacement in osteoarthritis of shoulder is
discussed elsewhere.
Objective: The objective is to maintain functional

independence of the upper extremity with minimal
discomfort.
◼ Pain during movements and occasionally during rest is the

main cause of disability. The correct choice of therapeutic
modality is necessary. Deep heat, cryotherapy, ultrasound
therapy, interferential currents and TENS are some of the
common modalities used. The choice of a particular modality
depends upon the patient’s response.
◼ Hydrotherapy, which promotes relaxation and at the same

time facilitates movements, is the treatment of choice.
◼ Exercises are aimed at improving ROM of shoulder which

many times is prevented by protective muscular spasm.
Therefore, relaxed passive movements are taken to reduce
pain, prevent spasm as well as promote further ROM at the
glenohumeral joint.
◼ Active resistive movements or PNF techniques are useful

in improving strength and endurance of the shoulder
muscles besides assistance in gaining ROM.
◼ Maintenance of functional ROM and strength is greatly
facilitated by providing guidance in the use of the whole
arm.
◼ Use of axial traction relieves pressure on the sensitive

intra-articular structures and is useful in relieving pain and
muscular spasm.
Osteoarthritis of the elbow

Osteoarthritis of the elbow joint is usually secondary and
leads to a stiff joint.
Treatment
Arthroplasty (excisional or total joint replacement) may be

indicated in selective patients.
Therapeutic modality is employed to induce relaxation and

to reduce pain to the maximum.
Functional use is encouraged and guided within the limits of

pain and discomfort as early as possible.
Self-resistive controlled active movements are encouraged

without causing excessive compression and pain at the
elbow joint.
Self-assistive exercises like roller skates and wand are

beneficial to improve joint mobility.
Maintaining a pain-free maximum angle of elbow flexion for

sustained periods is ideal.
Osteoarthritis of the wrist and hand

Osteoarthritis of the wrist is usually secondary to trauma
(fracture of the scaphoid or fracture/dislocation of other
carpal bones) or avascular necrosis of the lunate.
Pain and stiffness of the wrist are the presenting symptoms.

If not relieved by physiotherapy, arthrodesis of the wrist in a
position of slight extension is performed (Fig. 29-12).
FIG. 29-12Arthrodesis of the wrist joint.
In the hand, osteoarthritis of the carpometacarpal joint of the

thumb is common (Fig. 29-13). It is usually treated
conservatively by analgesics and physical therapy. Severe
painful cases are treated by excisional arthroplasty of the
carpometacarpal joint and in rare cases by arthrodesis (Fig.
29-14).
FIG. 29-13Osteoarthritis of the CMC joint of thumb.

FIG. 29-14Excisional arthroplasty of the CMC joint

performed for OA. Note that the trapezium has been
excised, creating a space in the joint.
DIP joints of the fingers are usually affected by osteoarthritis.

Clinically, it presents as mild deviation of the digit at the DIP
joints with Heberden nodes (see Fig. 29-10). They require no
specific treatment.
In addition to the measures to control pain, induce relaxation
and improve strength, the patient may be provided with a
splint. A cock-up splint maintaining the wrist in extension
not only provides rest to the arthritic joint, but also facilitates
hand function without causing much discomfort.
Maintaining optimal pain-free function of the hand and

functional re-education are the basis of the therapy.
Osteoarthritis of the ankle and foot

Osteoarthritis of the ankle joint is rare and is usually
secondary to some old trauma or disease.
The surgical treatment includes either arthrodesis or total

joint replacement (Figs 29-15 and 29-16).
FIG. 29-15(A) Ankle arthritis. (B) Arthrodesis of the

ankle done using Ilizarov fixator.
FIG. 29-16Total ankle joint replacement: (A)

Preoperative X-ray showing osteoarthritis. (B) After
total ankle joint replacement.
Osteoarthritis of the joints of the big toe is seen occasionally

and is discussed under hallux valgus and hallux rigidus.
Osteoarthritis of the subtalar (i.e., talocalcaneal) joint is

secondary to an old fracture of the calcaneum. A severely
disorganized, painful joint may need arthrodesis of the
subtalar joint for relief of pain (Fig. 29-17).
FIG. 29-17Subtalar arthrodesis.
Very rare and needs measures to reduce bearing body

weight on the affected joints, rest and hot packs. Operated
cases are treated with graduated mobilization of the ankle
and foot joints.
Restoring ROM of ankle to the plantigrade position must be

achieved. Soft padded footwear helps in reducing pain
during ambulation; correct gait training is inescapable.
Osteoarthritis of the temporomandibular joint
Anti-inflammatory drugs and analgesics combined with
ultrasonic therapy are useful in relieving pain. Movements of
the jaw are encouraged to avoid ankylosis.
Osteoarthritis of the spine (lumber spondylosis)

Degenrative changes like reduction of disc space, sclerosis
and osteophyte formation is commonly seen at the lumbar
spine.
Both weight bearing and overuse are the precipitating

factors, as the highest incidence of spondylosis is evident at
the L5-S1 segment of the lumbar spine (Fig. 29-18). These
degenerative changes may progress and compress the nerve
roots at their exit at the intervertebral foramen and could
result in neurological compression syndrome.
FIG. 29-18Lumbar spondylosis.
Conservative treatment by physiotherapy is the initial

relieving modality, but surgery may have to be carried out if
the symptoms are progressive in nature.
Osteoarthritis of the sacroiliac joint (lumber

spondylosis)
Low back pain, tenderness over the involved sacroiliac joint
and stiffness following rest are the common features. It is
often unilateral and can be detected by radiographic
evidence of degenerative changes in the joint.
Appropriate therapeutic modality like ultrasonic therapy

and ergonomic advice to prevent excessive stress on the
sacroiliac joint provide relief of pain and facilitate pain-free
function.
Physiotherapeutic management following surgical

procedures is described under respective headings:
◼ Other rare forms of osteoarthritis
◼ Osteoarthritis of the acromioclavicular joints
◼ Hereditary severe erosive osteoarthritis of PIPs and DIPs,

with fixed deformities resulting in joint ankylosis
◼ Bunion – a combination of osteoarthritis along with a

deformity of the first metatarsophalangeal joint
◼ Mucinous cysts – the cyst contains degenerative

myxomatus fibrous tissue at the DIP or PIP joints
Rheumatoid arthritis (RA) is a systemic disease which results
in chronic inflammation and destruction of synovial joints. It
is an autoimmune disease that involves systems/organs other
than the bones and joints alone.
Aetiology
The aetiology is unclear; however, various factors like

climate, race, diet, psychosomatic disorders, trauma,
endocrine dysfunction, biochemical disorders, hereditary
influences, disturbances in the autoimmunity and infection
have been found to initiate the rheumatoid process.
Environmental conditions precipitate the disease in
genetically predisposed individuals. It is possible that
genetic factors predispose certain individuals to tissue
damage by infection; even viral infections may predispose
RA.
Diagnosis
The diagnosis of RA is based more on clinical criteria than on

laboratory tests alone.
The criteria for diagnosis as formulated by the American

Rheumatism Association are shown in Table 29-4. It
enumerates the features of RA.
Table 29-4
Criteria for the Diagnosis of Rheumatoid Arthritis (American

Rheumatism Association)
Morning stiffness (>6 weeks)
1.
Pain on motion or tenderness in at least one joint (>6
2. weeks)
Swelling of one joint either due to soft tissues or effusion
3. or both
Swelling of at least one other joint with an interval free of
4. symptoms no longer than 3 months
Symmetrical joint swelling (same joint)
5.
Typical radiographic changes that must include
6. demineralization in periarticular bone as an index of
inflammation with subcutaneous nodules
Positive test for rheumatoid factor (Rh factor) in serum
7.
Synovial fluid showing poor mucin clot formation when
8. added to dilute acetic acid
Histopathology of synovium consistent with rheumatoid
9. arthritis
10.Characteristic histopathology of rheumatoid nodules
Note: Presence of >5 criteria concludes diagnosis of RA.
Detection of the abnormal protein, known as rheumatoid

serum factor (Rh factor), forms one of the bases of diagnosis.
Laboratory tests:
1. Rheumatoid factor and anti-CCP (anti-cyclic citrullinated

peptide) tests are positive.
2. Abnormalities occur in the serum proteins: The erythrocyte

sedimentation rate (ESR) is raised. There is an increase in the
serum fibrinogen with reduction in albumin and marked
increase in the immunoglobulins.
3. The CRP (C-reactive protein) is also elevated.
4. Examination of the synovial fluid: The clarity, colour and

viscosity of the synovial fluid can assist in the diagnosis as
well as differential diagnosis from other traumatic and
degenerative conditions. Predominance of
polymorphonuclear leukocytes in the synovial fluid is
peculiar to RA (Table 29-5).
Table 29-5
Synovial Fluid Analysis

White Special
Colour Clarity Viscosity
Cells Features
Normal Straw Clear High ±200 Nil
(25%
polys)
Traumatic Yellow Clear Moderately 2000 ± Red cells +
or red or high to +++
Cloudy
Degenerative Straw Clear High 700 ± Cartilage
arthritis fibrils
Rheumatoid Yellow Cloudy Low 5000– Phagocytes
or 40,000 +Rose–
green (75% Waaler test
polys) +
Clinical features
The onset of the disease is common between the age groups

of 35 and 55 years, and women are affected more than men
in a ratio of 3:1.
The disease involves several organs and tissues, with various

systemic manifestations.
Involvement of the synovial tissue is present in a majority of

the cases. Involvement of the synovial lining of tendon
sheaths, bursae and ligaments gives rise to pain, swelling,
increased redness and warmth and stiffness. Tense synovial
effusion and thickening may provoke capsular ruptures or
joint herniation. When the extruded synovial fluid irritates
the soft tissues of the calf, it may result in phlebitis.
Involvement of ligaments in the cervical region may produce

subluxation with pain and neurological signs. The other
nonarticular features are enumerated in Table 29-6.
Table 29-6
Nonarticular Features of Rheumatoid Arthritis

Systemic illness: Malaise, weakness, loss of weight, fever
1.
Blood disorders: Anaemia, increase or decrease in white
2. blood cell count
Vascular: Involvement of small arteries, arterioles, veins,
3. mono-or polyneuritis
Cardiac: Myocarditis, pericarditis, valve lesions
4.
Respiratory: Pharyngitis, laryngitis, pleuritis, diffuse
5. pulmonary fibrosis
Reticuloendothelial: Lymph node enlargement,
6. splenomegaly, hepatomegaly, overall increased liability
to infections
Skin: Ulcerative lesions, purpura, erythema, pigmentary
7. disorders, leucoderma
Eyes: Conjunctivitis, keratitis, keratopathy, uveitis
8.
Serological: Dysproteinaemia with increase in fibrinogen
9. and immunoglobulins; raised ESR and C-reactive protein
10.Renal, hepatic and gastrointestinal lesions occur
frequently and often silently
The involvement of articular surfaces of the joints and their

surrounding soft tissue produces cardinal joint symptoms
that eventually are responsible for the crippling
disorganization of the concerned joint. The extent of physical
disability is directly proportional to these changes. They
begin with pain, tenderness, warmth, erythema and effusion.
If not controlled, they progress to stiffness, cartilage wear
and tear, and osteoporosis resulting in joint subluxation and
dislocation. Progressive weakness of the muscle groups
further complicates the situation. In the majority of patients,
the wrist, metacarpophalangeal and knee joints are involved
early compared to the other joints. Joint changes progress
through the following three stages (Fig. 29-19):
Stage I: Inflammation of the synovial membrane spreads to

the articular cartilage and other soft tissues. There occurs
limitation of joint movements with pain and muscle spasm.
Stage II: Formations of granulation tissue occurs within the

synovial membrane and spreads to periarticular tissues. The
cartilage starts disintegrating and the joint is filled with
granulation tissue. There occurs thickening of the joint
capsule, tendons and their sheaths impairing the joint
movement permanently.
Stage III: The granulation tissue gets organized into fibrous

tissue with adhesion formation between tendons, joint
capsule and the articular surfaces. The articular surfaces get
partly covered by cartilage and partly by fibrous tissue. They
may give rise to contractures and even ankylosis of the joint,
or secondary osteoarthritis.
FIG. 29-19Stagewise joint changes in rheumatoid

arthritis (knee). (A) Stage I: inflammation and
thickening of the synovial membrane (SM). (B) Stage II:
disintegration and erosion of cartilage. (C) Stage III:
secondary osteoarthritis.
Individual joint involvements
1. Cervical spine: Subluxation is common at the atlantoaxial

joint. It may produce root symptoms, upper motor neuron
symptoms, visual disturbances, transient hemiparesis and
vertigo.
2. Temporomandibular joint: Pain and limitation of

movements.
3. Cricoarytenoid joint: It may progress from hoarseness of

voice to stridor and as such needs careful watch.
4. Shoulder joint: Glenohumeral joint and rotator cuff

involvement are common.
5. Elbow: Limitation of extension is common. It may affect

forearm movements also. Occasionally, compression of the
ulnar nerve may be present.
6. Wrists: Subluxation of the distal end of the ulna may result

in stiffness, deformity and pain. This may also cause rupture
of the extensor tendons of the third, fourth and fifth fingers,
ulnar deviation deformity at the wrist and occasionally
carpal tunnel syndrome.
7. Hands: Palmar subluxation and ulnar deviation are the

common deformities due to the involvement of
metacarpophalangeal and PIP joints. A typical swan-neck
deformity and boutonniere deformity also may occur (Fig.
29-20).
8. Hip: Erosion of the head of femur occurs with its

protrusion into the acetabulum (protrusio acetabuli).
Trochanteric bursitis may also occur. Eventually, the hip may
become stiff.
9. Knee: Beginning with synovial swelling, it may lead to
severe destructive changes resulting in deformity (flexion
deformity or wind-swept deformity – flexion with valgus on
one side and varus on the other). Marked instability and
secondary degenerative changes occur in the late stage.
10. Ankle and foot: Ankle joint may be spared but the distal
joints may usually be involved leading to valgus foot.
11. Metatarsophalangeal joints: Subluxation may occur at these

joints with hallux valgus and toe fanning.
FIG. 29-20(A) Swan-neck deformity. (B) Boutonniere
deformity. (C) A rheumatoid hand showing both types
of deformities.
The basic aim of physiotherapy is to make the patient self-

reliant.
Treatment
◼ Anti-inflammatory and immunosuppressive drugs
◼ Appropriate static splints
◼ Intralesional injections of corticosteroids
◼ Physiotherapy
Surgical treatment
Common procedures
1. Synovectomy: Excision of the inflamed synovium when

the articular cartilage is not eroded
2. Osteotomy: To correct varus or valgus deformity at the hip

or knee
3. Arthroplasty: In the advanced stage of the disease when

the joint is destroyed beyond salvage
4. Arthrodesis: To stabilize the joint
5. Reconstructive surgery of the hand, e.g., tendon transfers

and soft tissue release
Principles of physiotherapy
1. Relief of pain and inflammation
3. Correction of deformity
4. Restoration and maintenance of joint motion
5. Improvement of muscle strength and endurance
6. Guidance and training to achieve optimum function
7. Education on the management of recurrence
As the course of the disease is unpredictable, accurate

assessment of the condition is a must at the time of reporting
as well as at regular intervals.
Objective evaluation of the patient is carried out as follows:
1. Pain: Body image pain chart and VAS
2. Swelling: Volumetric measures

3. Skin: Erythema, temperature, skin lesion, presence of
nodules, texture of nails and hair
4. Deformity: Exact degree of deformity
5. Joint range: By goniometry
6. Muscle strength and endurance of the muscles of the joints

involved and the related joints
7. Respiratory functions: Vital capacity (VC), forced expiratory

volume (FEV1) and thoracic excursion to be evaluated
8. Postural deviation: Measurement
9. Hand function: Measurement of various grip strengths
10. Gait analysis
11. Efficiency of performing activities of daily living (ADLs)
12. Physical requirements of the vocation
13. General psychological status
The type of measures adopted depends on the clinical status

of the disease.
The clinical course of RA is divided into two phases:
1. Acute phase or active phase
2. Chronic phase
The treatment differs radically in both these phases of the
disease. There may be remissions and exacerbations during
the course of the disease.
Any form of active exercise is contraindicated during the

acute phase or the acute-on-chronic phase (exacerbations).
However, the tendency for developing tightness or
contractures should be avoided.
During the chronic phase, various forms of vigorous

exercises are given as the pain is less. Functional training
should also be intensified.
Acute phase (3–4 weeks)
During the acute or active phase of the disease, the acute

symptoms – pain, erythema, tenderness and swelling – are
present.
1. Properly supported positioning of the involved joints and

correct bed posture are important. The use of firm mattress
or occasional back support minimizes the effects of
malpositioning and thereby preserves the integrity of the
affected joints. The limb is placed in a position of minimal
discomfort; however, contracture should be avoided.
2. Splints and sandbags may provide additional support to

the limb. Special attention is needed for the knee and elbow
joints as they are prone to develop flexion contractures. The
use of casts should be kept to the minimum. Splints or casts
should be checked regularly to avoid complications due to
them.
3. Deep breathing exercises are important to improve the VC.
4. Joints and muscles free from immobilization and the active

disease need to be put through the full ROM and PRE.
5. Functional mobility should be encouraged and maintained

within the pain-free limits.
6. Postural guidance and methods of performing activities

without putting extra strain on the affected joints are taught.
7. In cases where weight-bearing joints are involved, the

upper extremities should be prepared for future crutch
walking.
8. Isometrics: Isometric exercises do not involve movements

of the joints and are therefore relatively painless. They
should be started early. Muscles like quadriceps and deltoid
are susceptible to disuse atrophy and hence need repeated
sessions of isometrics. Other functional muscles concerned
with weight bearing and body balance need strengthening
and improved endurance and thus require repetitive
isometrics.
9. Speedy isometrics to the affected limb in elevation reduce

swelling and effusion (especially of the knee). No heat
therapy should be given to the joints that are already warm.
10. TENS, pulsed ultrasound, ice massage or ice packs for

longer periods offer reduction in the muscle spasm and pain.
Interferential current of 90–100 Hz reduces the
accommodation of nerves, whereas a frequency of 50–100 Hz
improves healing, blood supply and membrane permeability
by improving absorption.
11. Properly guided pool therapy for the whole body

provides an ideal medium for exercises.
Chronic phase
It is a phase of vigorous activity to train the patient to use the

involved joints to the greatest extent for physical
independence. By 4–5 weeks of the onset, independent
sitting by the use of hands can be started. If pain permits,
active and functional therapeutic programmes should be
initiated. This will include standing and walking. However,
weight bearing should be deferred till pain and discomfort
subside.
Before allowing weight bearing, it is absolutely essential to

provide the necessary orthotic support or walking aid to
relieve compressive forces on the affected joints. This should
be done between the parallel bars to judge the effects of
weight bearing on the diseased joints.
Sustained or intermittent stretching procedures may be

necessary for the joints that have developed tightness or
contractures during the acute phase. Deep heat (if
acceptable), ultrasonics, TENS and other adjuncts may be
used to relieve pain.
Efforts should be made to improve the strength and

endurance of the muscles related to the affected joints.
Education and assistance are provided in adopting

functional positions, speed and proper gait.
Job-oriented performance should be imparted in the exercise

regime.
Relapse
Relapse is common in RA. It should be treated on the same

lines as detailed for the acute phase.
Caution
Since it is a systemic disease, it is usually accompanied by

early fatigue. Therefore, exercise sessions should be brief.
Usual sites of contractures and their prevention
1. Back: There is a generalized tendency for flexion attitude of

the spine, which gives rise to an exaggerated kyphosis and
obliteration of the lumbar lordosis. Therefore, stooping
posture should be avoided at rest as well as during activity.
Repeated prone posture should be encouraged.
2. Hip joints: Tendency for developing hip flexion contracture

is common in the acute phase due to prolonged recumbency.
Therefore, use of a firm mattress, no pillow under the knee
as well as prone postures can effectively avoid flexion
contractures at the hip joint. Once contractures develop, they
are very difficult to correct and they adversely affect the
weight-bearing activities.
Prognosis of the disease: The prognosis of the disease is very
unpredictable.
(a) There may be partial or total remission.
(b) It may remain as a mild disease.
(c) It may be insidiously progressive in nature.
(d) It may be progressive, but the progress of the disease

may be (i) rapid, (ii) slow or (iii) intermediate.
The time factor is variable, so also is the response of a patient

to drugs. However, poor prognosis can be predicted by the
presence of ocular involvement, nodules, vasculitis and other
complications. Tissue typing also provides a clue to the
prognosis. Patients with an acute attack show better
improvement than those in which the onset is insidious.
Considering the complexities involved in the disease, it is

essential to individualize the treatment plan after critical
overall assessment of a patient and the response to a
particular therapeutic measure.
3. Knee joints: The knee joints are more prone to develop

flexion contractures than any other joint. Relaxing flexion
attitude during the acute phase of the disease is the main
cause. Taking adequate measures to prevent the flexion
deformity, or to keep it to the minimum, is the first priority.
The patient’s own active or assisted efforts play an important
role. Holding the position of maximum stretching in
extension is more effective than applying repeated stretches.
Resisted early movement through full range is important.
Unsupported early weight bearing should be discouraged to
avoid valgus and varus deformities.
4. Ankle and foot: Maintenance of neutral position and full

ROM exercises to the intrinsic muscles are important to
reduce the expected deformities of valgus foot and
metatarsus valgus. Tendency for the deformity should be
detected early and checked by varus pad in the shoe or a
splint.
5. Shoulder joint: Limitation of the range of terminal shoulder

abduction in elevation should be repeatedly checked as the
limitation usually begins in this range. Extreme range of
abduction and external rotation should be concentrated next.
Full ROM to the shoulder with cuff and collar in the initial
stage is important. Strenuous abduction should be prevented
to avoid injury to the rotator cuff, by exercising in supine
position.
6. Elbow joint: Limitation of extension or tendency to develop

flexion contracture is the common deformity next only to
flexion deformity of the knee.
Immobilization of the elbow in extension during active phase

prevents this deformity. Gravity-assisted elbow extension
enforced subsequently with low-grade resistance by weight
belt within the limits of pain provides an ideal method of
applying effective stretch. Signs of ulnar nerve compression
syndrome should be looked for.
7. Wrist and hand: Tendency to develop flexion contracture

with ulnar deviation has to be controlled by simple self-
assisted passive stretching movements, positioning and
splints. Swan-neck deformity – flexion at the
metacarpophalangeal joint, hyperextension at the PIP joint
with flexion at the DIP joint – should be watched for and
controlled.
Role of splints
There are two classes of splints:
1. Static splints: To provide rest, support and prevent

deformity
2. Dynamic splints: To re-educate and strengthen weak

muscles and to carry out functional tasks
Characteristics of an ideal splint
The splint should have the following features:
1. Inexpensive
2. Easy and quick to make
3. Comfortable
4. Light and neat
5. Strong
6. Functionally accurate
7. Fitting optimally
8. Cosmetically acceptable
Splints provide an excellent means of immobilization and

rest. They are essential during the acute phase of the disease,
particularly with polyarticular involvement. However, the
following disadvantages restrict the use of rigid splints
occasionally.
Disadvantages
1. Possibility of muscular weakness and wasting (disuse

atrophy)
2. Loss of mobility
3. Tendency for the joint to get fixed in the position of

splinting
4. Fabrication, trials and application of splints are painful
Advantages
1. Corrects the deformity (serial splinting)
2. Provides support and rest (acute phase)
3. Easy application and removal: It prevents static deformity

unlike rigid immobilization
4. Prevents dynamic instability due to the imbalanced

muscular forces
5. Provides stability to the weak or deformed unstable joints,

acting as an alternative to surgery
6. Offers functional efficiency to the ADLs as an adjunct to

surgery
7. Reduces the impact of unwanted and harmful forces acting

on the body due to the structural changes in the joints
(inserts and wedges in shoes, knee cage, etc.)
8. Provides means of strengthening re-educative and

assistive aids: Ambulatory devices like canes, crutches,
walkers and wheelchairs may also provide stability of
weight bearing during ambulation
Dynamic splints are elaborated in Chapter 34.
Juvenile rheumatoid arthritis

A seropositive autoimmune connective tissue disease
commonly affects female adolescents, mainly affecting
connective tissues. It follows the course of RA mostly
affecting small joints of the hand and feet.
1. Systemic onset (Still disease): Rashes, high fever,

lymphadenopathy, splenomegaly, carditis and arthritis
2. Pauciarticular onset: Involving less than four joints
3. Polyarticular onset: Involving four or more joints

4. Iridocyclitis: Leading to blindness
Seronegative spondyloarthritis
The conditions under this category are similar to RA but
without the presence of the rheumatoid factor in the serum.
The disorders include:
1. Ankylosing spondylitis
2. Reiter syndrome
3. Psoriatic arthropathy
4. Reactive arthropathy
Still disease
This is a juvenile chronic polyarthritis, which could be any of
the following:
1. Systemic
2. Polyarticular
3. Oligoarticular
In the systemic disease, malaise, weight loss and evening rise

of temperature are present with enlargement of spleen and
lymph glands. Rashes appear with fever or following the use
of external heat. Polyarticular involvement develops into
chronic arthritis. The disease has a better prognosis when it
affects fewer joints (oligoarticular). An accompanying eye
disease (iridocyclitis) may lead to blindness, especially if
there are positive antinuclear antibodies (ANAs).
Treatment
Drug treatment is the same as for adult RA except that

corticosteroids are used with precision.
Physiotherapy
A thorough assessment of the patient is carried out. The

general approach of the treatment remains the same as for
RA. However, protection of the optimal functional
alignments of the involved joints is important. These
children are more prone to develop contractures and
deformities. Lack of movements may lead to overall growth
retardation. Therefore, concentrate on the following:
1. Prevention of deformities
2. Early splints in functional positions
3. Vigorous exercises to uninvolved joints and muscles
4. Maintenance of functional activities with adequate splints

and adaptations
5. Gait training and guidance to avoid limp – the most

important aspect being the active participation of parents in
home treatment programmes.
Factors complicating the management
1. Neurological problems: Nerve root compressions, upper

motor neuron lesions, transient cerebral and cerebellar
lesions may occur as a sequela to disease in the cervical
region. Mononeuritis, carpal tunnel syndrome or peripheral
neuropathy may be associated with vasculitis.
2. Cardiac lesions: Pericarditis, constrictive pericarditis and

incompetence of the aortic valve may occur.
3. Pulmonary complications: Pleural effusion, pulmonary

nodules, interstitial fibrosis or fibrosing alveolitis may occur.
4. Alimentary problems: Drug therapy often causes gastric

ulcers, haematemesis and melaena leading to anaemia.
5. Vascular complications: Vasculitis leads to sensory

peripheral neuropathy in feet, purpura, leg ulcers and
gangrenous digits.
6. Nodule formations: Subcutaneous nodules over pressure

points overlying bony prominences may develop. They are
common over the extensor aspect of the forearm.
7. Renal complications: Frequent urinary tract infections may

occur. Drugs like analgesics, after prolonged use, may lead to
renal impairment.
8. Muscle: Muscular atrophy, weakness as well as shortening

(contractures) commonly occur in the vicinity of the inflamed
joints.
9. Bone: Periarticular osteoporosis of the involved joints
occurs as a result of steroid therapy and lack of movements.
10. Oedema: Lack of pumping action of muscles, immobility

or anaemia may precipitate oedema.
11. Ocular complications: Cataract, retinal changes and corneal

deposits may occur as a complication of drugs.
12. Amyloidosis: Deposition of a cheese-like material in the

reticuloendothelial system, liver, spleen and kidneys may
occur due to prolonged inflammation leading to nephrotic
syndrome.
13. Septic arthritis: It leads to exacerbation of symptoms in the

involved joint. It is associated with fever, leucocytosis and
low blood pressure.
14. Iatrogenic diseases, e.g. Cushing syndrome may be seen

due to the overuse of corticosteroids.
Surgery
The objectives of surgery:
1. Improvement mobility
2. Providing adequate stability
3. Correction of deformity
4. Increase in control of muscles

5. Relief from pain
6. Early return to normal domestic tasks
Indications for surgery
1. Failure of medical treatment
2. Disturbing pain
3. Persistent synovitis
4. Tenosynovitis, bursitis
5. Tendon rupture
6. Nodule formation causing pressure syndromes
7. Faulty alignment of the joint
8. Nerve compression
9. Joint ankylosis
10. Cosmesis
Contraindications for surgery
1. Progressive or active disease
2. Poor medical control
3. Widespread disease in aged patient

4. Adequate functional status
5. Adaptation of the body to the deformity
6. Lack of cooperation
7. Apathy and depressed patient
8. Severe amyloid disease
9. Arteritis
Timing of surgery
Lower limb surgery should be performed first. Upper

extremity surgery should be performed in proximal-to-distal
direction (Savili, 1964).
Stages of the disease and the type of surgery
Barron (1969) adequately described the type of surgical

procedures to be adopted during various stages of the
disease.
Stage I: An early stage of proliferation.
Synovectomy for pain relief and to protect articular cartilage,

tendon and nerve from continued damage.
Stage II: An intermediate stage of soft tissue destruction.
1. Deformities like boutonniere, swan-neck and ulnar drift,

which are in their earlier stage, are corrected by
reconstructive surgery.
2. Tendon ruptures and trigger fingers could be managed

effectively by reconstructive procedures.
Stage III: This late stage of skeletal collapse results in

ankylosed or unstable joints. Joint reconstructive procedures
like arthroplasty and arthrodesis are performed. Joint
reconstruction can be successful only when the tendon
mechanism is intact. Therefore, tendon repair has to be
performed before reconstruction of a damaged joint.
Common surgical procedures in rheumatoid arthritis
1. Synovectomy: It is a commonly performed surgical

procedure. It consists of excision of the thickened and
inflamed synovial membrane of the joint or tendon sheath. It
is indicated in the joints where the articular cartilage is not
eroded. Synovectomy relieves pain, possibly by retarding the
disease process and thereby preserving the articular
cartilage. It can be performed on the knee, wrist and small
joints of the hand and occasionally foot and tendon sheaths
of the hands.
Postoperative regime (knee joint): The limb is immobilized in a

Thomas splint with Pearson knee attachment. Flexion
exercises at the knee, in the splint, are started as soon as the
pain permits. CPM may be initiated within 48 h. The stitches
and splint are removed after 2 weeks and mobilization is
started because of the tendency of the knee joint to get stiff
following synovectomy. Isometrics to the quadriceps should
be initiated at the earliest to prevent its disuse atrophy.
If satisfactory ROM at the knee joint is not regained by the

end of 3 weeks, the knee joints should be manipulated under
general anaesthesia. This should be followed by an intensive
mobilization programme.
Partial weight-bearing ambulation should be started after 3–

4 weeks. Full weight bearing can be resumed by the end of
4–6 weeks. However, full weight bearing with cane can
safely be started earlier provided the pain permits and the
quadriceps mechanism is adequate.
Synovectomy of the other joints: Following synovectomy of the

wrist and small joints, rigid immobilization in a cast is not
always necessary. A pressure bandage is given for the initial
3–4 days. This facilitates early mobilization of these joints.
Light weight functional activities of the wrist and hand
should be started as early as possible.
2. Osteotomy: It is done in the upper tibia or upper femur,

in that order. It is performed mainly to correct the valgus or
varus deformity at the knee and hip.
3. Arthroplasty: It is performed in the advanced stage of the

disease where the joint is destroyed beyond salvage. Two
types of arthroplasty procedures are commonly performed.
(a) Excisional arthroplasty: It is done in the hip, small joints of

the hands and feet and elbow joint. In this, the diseased
portion of the joint is excised and a gap is thus created
between two adjacent bones of the joint. This provides better
mobility with relief from pain.
(b) Total joint replacements: This is an advancement over

excisional arthroplasty. In this, the joint is replaced totally,
thus providing a stable, pain-free and mobile joint. This
operation can be performed for hip, knee, small joints of
hand and less commonly for shoulder, elbow and wrist.
4. Arthrodesis: It is also performed in the later stages of the

disease in the joints of the spine, shoulder, elbow, knee, wrist
and ankle. Though it provides a stable and pain-free joint, it
is not a procedure of choice as it results in a fused joint. The
total joint replacement is, therefore, preferred wherever
possible.
5. Tendon reconstruction (reconstructive surgery of the

hand): Reconstructive procedures are necessary for tendon
ruptures and deformities in the hand (Table 29-7).
Table 29-7
Reconstructive Surgical Procedures for the Hand

Involvement of Surgery
1. Wrist joint • Excision of lower end of ulna
• Dorsal synovectomy
• Arthrodesis
• Extensor tendon repair

2. Metacarpophalangeal • Synovectomy
joint
• Correction of ulnar deviation
• Arthroplasty
3. Proximal • Synovectomy
interphalangeal joint
• Correction of boutonniere
deformity
• Correction of swan-neck
deformity
• Arthrodesis
4. Distal interphalangeal • Correction of mallet finger

joint
• Arthrodesis
5. Thumb • Interposition arthroplasty
(a) Carpometacarpal joint • Replacement arthroplasty
(b) Metacarpophalangeal • Synovectomy

joint
• Arthrodesis
(c) Interphalangeal joint
• Synovectomy
• Arthrodesis
6. Flexor tendon • Synovectomy
• Tendon repair
7. Nerves • Repair
• Grafting
The physiotherapeutic management proceeds on the same

lines as described under the various headings in this chapter.
Hand surgery and stabilizing reconstructive surgery form

the basis of the management of RA. While planning
physiotherapy, one must remember the overall impact of the
disease and its involvement.
Early mobilization is the key to success. The period of

immobilization should be the shortest (Wynn Parry, 1982).
Physiotherapy to the other parts free of immobilization
needs regular exercises performed personally and not by just
instructions.
The ultimate goal should be to regain adequate functional

independence for domestic tasks and employment.
Haemophilia (haemophilic arthritis)

Haemophilia is a systemic arthritis as a result of a bleeding
disorder that is caused by deficiency of an antihaemophilic
globulin (factor VIII) resulting in insufficient coagulation.
The coagulation time may be increased up to 60 min, as
against the normal range of 4–10 min. This disease is
transmitted as a sex-linked character by females but
manifested only in males. Another bleeding disorder, known
as Christmas disease, results from deficiency of plasma
thromboplastin component (factor IX).
Pathology
Bleeding occurs into (i) joint and (ii) muscles.
1. Haemarthrosis or bleeding into the joints is the most

common manifestation of this disease. The commonly
involved joints are knee, elbow and ankles, whereas hip,
shoulder, wrist, hand and foot are less frequently involved.
Haemophilic arthropathy results from repeated attacks of
bleeding into the joints. The synovium gets thickened and
hypertrophic, organization of the exudate causes joint
adhesions with subsequent reduction in the joint space. The
late sequelae are subchondral bone resorption with collapse,
osteoporosis, osteoarthritis and even ankylosis of the
involved joint (Fig. 29-21).
2. Bleeding may occur into the muscle following a trivial

trauma or even an intramuscular injection. The muscles of
buttock and thigh are the usual targets of bleeding.
FIG. 29-21Ankylosis of the knee resulting in fixed

flexion deformity as a late sequela of haemophilia.
Initially, there occurs a clot formation with protective muscle

spasm resulting in a flexion deformity of the hip or equinus
at the ankle (depending on the site of bleeding). This is later
on followed by fibrosis and features of compartmental
syndrome.
Intramuscular bleeding may also cause compression over

peripheral nerves. The most common example is
involvement of the femoral nerve in a thigh bleeding.
Similarly, median, sciatic and posterior tibial nerves may get
involved.
Symptoms
1. Pain
2. Haemorrhage
3. Swelling
4. Muscle atrophy (in late stage)
5. Crepitus
6. Limitation of ROM of the affected joint
7. Flexion contracture
8. Joint instability (late stage)
Treatment
Treatment consists of (i) correction of the factor VIII

deficiency and (ii) treatment of the musculoskeletal
manifestations.
1. Correction of the factor deficiency is achieved by transfusing

fresh frozen plasma or cryoprecipitate, or human or animal
AHG.
2. Treatment of the musculoskeletal manifestations depends on
the degree of involvement of a joint, muscle and/or nerve.
Acute haemarthrosis: Fresh bleeding is stopped by

replacement of the factor. The pain and swelling of the joint
can be reduced by a compression bandage or POP cast.
Physical therapy is initiated, as soon as the pain and swelling
permit, by removing the splint/cast intermittently under the
cover of factor VIII. The main goal is to prevent residual joint
deformity.
Chronic haemarthrosis: The treatment is directed towards

development of good muscle power and prevention of any
contracture/deformity. Braces and plaster splints may be
used for this purpose. Surgery may be done for release of
contractures and correction of deformities, at specialized
centres.
Muscle bleeding: The treatment of a muscle bleeding is

complete rest using splints. Physiotherapy is started
gradually after factor replacement.
Nerve involvement: The treatment is the same as described for

muscle bleeding. Splintage is necessary to prevent joint
contractures.
Haemophilic arthropathy: An established arthritis may require

surgery in the form of patellectomy, meniscectomy,
synovectomy, or total joint replacement. Any surgical
procedure needs a careful monitoring of factor VIII or IX
assessment and its adequate replacement throughout the
period of surgery and postoperative phase.
The basic objectives of treatment:
1. Alleviating pain
2. Preventing further haemarthrosis that results from

weakness or joint instability by encouraging normal activity
3. Reducing periods of immobilization following joint or soft

tissue haemorrhage
4. Reducing deformity and crippling by restoring muscular

strength and ROM
5. Emphasizing strengthening of the muscles around the

affected joint to provide joint protection
Therefore, clinical assessment of all these symptoms is the

basis of planning a physiotherapy programme. Classification
and grading proposed by the World Federation of
Haemophilia provide a useful means of assessment (Table
29-8).
Table 29-8
Classification and Grading Proposed by the World

Federation of Haemophilia (Used to Assess the Shoulder,
Elbow and Wrists)
Pain
Grade 0 No pain
No functional
deficit
Grade 1 Mild pain
Does not interfere

with normal use
Occasional
analgesia
Grade 2 Moderate pain
Some interference
with normal use
Occasional
analgesia
Grade 3 Severe pain
Interference with
normal use
Frequent
analgesia
(narcotic)
Haemorrhage (Incidence in Any 1 Year)a

Grade 0 No haemorrhages
Grade 1 No major
haemorrhages
1–3 minor
haemorrhages
Grade 2 1–2 major

haemorrhages
4–6 minor
haemorrhages
Grade 3 3 or more major

haemorrhages
7 or more minor
haemorrhages
Clinical Features Score

Swelling Nil 0
Present 2
Muscle Nil 0
atrophy
Present 1
Joint Nil 0
crepitus
Present 1
Range of <10% loss of total range 0

movement
10–30% loss 1
>30% loss 2
Flexion <15° 0
contracture
>15° 2
Instability Nil 0
Present – function unaffected 1
Present – interferes with 2

function and may require
bracing
a
A minor haemorrhage lasts less than 24 h.
Besides these, functional analysis of the involved upper and

lower extremities in relation to the whole body functions
should be done.
Acute phase
First day:
1. The patient is given the replacement therapy. The joint is

in a state of acute bleeding. No active physiotherapy is given.
The limb is rested in an optimal position of comfort with
posterior POP slab or moulded thermoplastic splint for the
resolution of haemarthrosis.
2. Hyaluronidase iontophoresis can be given to promote

haemorrhagic reabsorption (Magistro, 1964).
Second and third days:
1. Gentle isometrics can be started to the quadriceps and

hamstrings in a splint if there is decrease in pain and
effusion. The common bleeding sites should be checked
thoroughly following the exercise.
2. Resistive exercises to the unaffected limbs can be started.
Fourth day onwards:
Gradual mobility exercises as well as strengthening

procedures can be started. Isometrics should be made more
vigorous as they increase strength and elasticity of the
ligaments, muscular strength and bone mineralization.
Isometric exercises can improve strength to the tune of 40–
70% (Pelletier, Findley & Gemma, 1987).
If pain and swelling are well controlled, partial weight

bearing on two axillary crutches may be started.
The tightness in the joint is corrected by serial POP casts.

Sessions of graduated stretching are continued till the
prebleeding status of the joint is attained. PNF techniques of
rhythmic stabilization and hold–relax movements within the
limits of pain are useful at this stage.
Full weight bearing, with correct transfers of the body

weight and gait training are initiated in stages.
Hydrotherapy
Hydrotherapy provides an ideal medium of exercise after
surgery.
Pulsed short-wave diathermy
Pulsed short-wave diathermy (SWD) has been reported to be

an effective modality in both muscle and joint bleeds. It
promotes the resolution of bleeding along with pain relief. It
can be used in acute and subacute stages as well as in joints
where surgical procedures with metal implants have been
done (Buzzard and Jones, 1988).
Tens
This pain relieving modality has been safely used even in the
acute joint bleeding stage(Martinowicz, Heim, Beeton,
Tuddenham & Krnoff, 1986).
Ultrasonics and interferential currents are useful in relieving

pain and preventing adhesions.
Functional training
The patient should be educated on safer but progressive

techniques of self-care activities, ambulation and functional
positions, depending on the site of involvement. The patient
should be educated to detect symptoms of bleeding.
Caution
Overstretching of the affected joint, active or passive, and
injury should be avoided as these may cause recurrence of
bleeding.
Chronic stage including arthropathy
The physiotherapeutic measures are aimed at (i) prevention

and maintenance of correction of the deformities, (ii)
improving the power and endurance of the affected muscles
and (iii) proper use of assistive aids and appliances.
In cases where surgical procedures like synovectomy,

arthrodesis or joint replacement have been performed, the
physiotherapeutic regime follows the same pattern as for the
nonhaemophilia patients. However, a gentle and graduated
approach is necessary to prevent secondary haemorrhage.
Ankylosing spondylitis
It is a seronegative chronic inflammatory (perhaps
autoimmune) disorder affecting primarily the spine and
sacroiliac joints, and secondly the other major joints (hip,
knee, shoulder, etc.) in the body. It is more common in males
(male/female ratio 9:1), the age of onset being 15–20 years.
The exact cause of this disease is not known. However,

genetic predisposition has been observed. It is sometimes
associated with urethritis, ulcerative colitis and
conjunctivitis.
The disease has an insidious start with intermittent backache.

The patient has stiffness of the back that is worst in the
morning initially, and progresses the whole day.
Occasionally, the pain may radiate to the lower limbs
simulating a disc lesion. The stiffness of back increases
progressively, affecting the whole of the spine. The other
peripheral joints also become stiff gradually.
On examination, initially there is vague tenderness over the

lumbosacral spine and the sacroiliac joints. The chest
expansion decreases, usually being less than 2 inches
initially, and gradually progresses to a mere half inch. This is
due to the involvement of the costochondral joints. The
spinal mobility is decreased considerably. The gait in these
patients is very characteristic – the patient walks with a stiff
spine swinging his arms in an arc.
The mobility of other joints will also be diminished in

advanced cases.
The radiographs of the sacroiliac joints show involvement of

the joints gradually leading to fusion. Similarly, the whole
spine may get fused eventually; it is then called ‘bamboo
spine’ (Fig. 29-22).
FIG. 29-22A typical ‘bamboo spine’ deformity due to

fusion of the intervertebral joints in ankylosing
spondylitis.
Treatment
Physical therapy plays an important role in the management

of this disease throughout its whole course, more so in the
initial stages. A general exercise programme is prescribed to
maintain the mobility of the spine as well as other joints after
critical musculoskeletal evaluation, as a baseline assessment,
as much as possible. Breathing exercises are important to
maintain chest mobility and expansion.
Analgesics and anti-inflammatory drugs are given for

symptomatic pain relief.
Surgery
The following surgical procedures may be undertaken in the

advanced cases.
(a) Total joint replacements: For ankylosed hip and knee joints,
THR and total knee replacement are done respectively.
(b) Excisional (Girdlestone) arthroplasty of the hip: Rarely,

excisional (Girdlestone) arthroplasty is done for an
ankylosed hip to regain movements. An early and vigorous
exercise programme is instituted after the for-mentioned
surgical procedures, as these patients have a tendency for
stiffness and re-ankylosis, due to ectopic bone formation.
(c) Osteotomy of the spine: In advanced cases of ankylosing

spondylitis, ankylosis of the spine leads to a fixed flexion
deformity of the spine, restricting the field of vision and the
respiratory function.
In such cases, spinal osteotomy is indicated and is performed

at the lumbar region, usually at the level of the L2 vertebra.
The spinous processes are osteotomized and cut into small
strips to be used as bone grafts later. Oblique osteotomy is
performed through both the superior articular facets of the
vertebra below and the inferior articular facets of the
vertebra above. The spine is then extended by raising the
head and the foot of the operating table. The flaps of the
bone from the laminae adjacent to the osteotomy are raised
and the defect is bridged with the bony strips obtained from
osteotomy of the spinous processes (Fig. 29-23). By this
procedure, the exaggerated dorsal kyphosis remains
uncorrected; however it improves the posture.
Postoperatively a plaster cast, a combination of spinal jacket
and short hip spica, is given for a period of 6–12 weeks.
FIG. 29-23Spinal osteotomy to reduce kyphosis

following ankylosing spondylitis. (A) Osteotomy of the
spinous processes (OSP) and oblique osteotomy
through the superior and inferior articular facets of the
adjacent vertebral joints (OIAP). (B) Raising the flaps of
bone from the laminae adjacent to the osteotomized
spinous processes (RFB). (C) Bridging the defect by
bone grafts (BG) obtained from the osteotomized
spinous processes.
Physiotherapy
Physiotherapy for the total joint replacement and excisional

arthroplasty is described in Chapters 13 and 24. Following
osteotomy of the spine, immobilization is done by a
combination of spinal jacket and short hip spica for 6 weeks.
Thus, deep breathing, resistive arm, knee, ankle and toe
movements are done vigorously during this period.
Following removal of the immobilization, vigorous

mobilization is done for the hip joints. However, graduated
mobilization of the patient from turning to sitting up and
standing is done. Postural guidance based on ergonomic
principles is emphasized to maintain the correction during
daily activities.
Physiotherapeutic management of the patients treated

conservatively: Ankylosing spondylitis is one of the most
disabling chronic inflammatory affections of the joints of the
spine. The inflammatory process initially affects the
sacroiliac joints in a young adult and gradually progresses to
the whole spine and other major joints of the body. Although
the natural course of the disease leads to a typical ‘poker
back’ or ‘bamboo spine’, the physiotherapy is directed to
retain the functional mobility through compensatory
movements of the joints.
Physiotherapeutic management depends on the stage of the

disease. Before planning the therapeutic regime, the patient
is carefully assessed as follows:
A. General posture: The patient is observed from anterior,

posterior as well as from both the sides to detect the overall
postural deviations.
Initially the whole spine assumes a stiff posture. Later on, it

may get totally fused. The spinal fusion gives rise to a stiff
and deformed posture where the cervical spine is fixed in
flexion with atlantoaxial hyperextension. Thoracic spine is
fused in marked kyphosis leading to a rounded back. The
hips and the knees tend to assume compensatory attitude of
flexion. Accurate measurements of the posture are taken at
regular intervals with the help of spondylographs and/or
clinical photographs.
B. Assessment: Passive as well as active ROM is measured

separately for:
1. Cervical spine: By goniometry (Joshi, Singh, Kanta &

Verma, 1978) – The extent of cervical flexion deformity is
evaluated by measuring the distance from wall to tragus
(Figs 29-24 and 29-25).
2. Thoracolumbar flexion and extension: The distance between

the prominent seventh cervical vertebra and the
sacrococcygeal junction is measured in the erect posture in
full flexion and in full extension.
3. Lumbar flexion and extension: On the patient’s back, two
points are taken as landmarks: one midway between the
spinous processes of the fourth and fifth lumbar vertebrae
and another 10 cm above this. The difference between the
two points measured in full flexion and extension provides
the range of flexion–extension.
4. Lateral flexion: The distance between the fingertip and the

floor with the patient in maximum side flexion is measured.
5. Rotation: The pelvis is rotated with the patient in supine

position, with hips and knees flexed. The movement is then
recorded.
6. Spinal flexion with hip flexion: From erect posture, patient

bends forward without flexing the knees. The distance
between the fingertip and the floor provides a combined
measure of hip and spinal flexion. Major arc of movement is
contributed by hip joints. However, this assessment is
important from the point of view of functional activities.
7. Examination of the peripheral joints: Commonly involved

peripheral joints like temporomandibular, shoulder, hip and
knee should be examined for active and passive ROM.
8. Respiratory function: An early involvement of

costovertebral joints results in gradual restriction of the
movement of ribs, which reduces the respiratory capacity.
The chest expansion is markedly reduced, often less than 2.5
cm (average normal chest expansion: 7.5 cm). Chest
expansion should be recorded at two levels: at the xiphoid
process (seventh rib) and at the nipple (fourth rib). The VC,
peak flow and FEV should also be recorded.
9. Functional status: Functional status of the patient in relation

to the disability and the type of daily work is evaluated. This
will help to provide the necessary guidance and adaptations
to plan work-related therapy.
FIG. 29-24Cervical goniometry to evaluate ROM at
cervical spine. (A) For measuring flexion and
extension. (B) For measuring lateral flexion. (C) For
measuring rotation.
FIG. 29-25Measurement of tragus-to-wall distance in

ankylosing spondylitis to assess fixed flexion deformity
at cervical spine.
Treatment: Mobility of the whole body and spine in

particular is the area of maximum emphasis.
1. Pain: The pain and muscular spasm in the acute stage are
controlled by superficial modalities such as hydrocollator
packs or cryotherapy. Deep heating is effective in the chronic
stage.
Steam bath preceding the exercise controls pain and induces

relaxation.
2. Mobility: The objective is to maintain mobility of the spinal

intervertebral joints by various procedures. Mobilization of
the facet joints by specialized techniques as described by
Maitland (1977) is effective.
The most important technique is the repeated small-range

mobilization of the spine incorporated in the activities of
daily routine. The patient should be educated on the correct
procedure and the feel of segmental mobilization.
Pool therapy is an excellent means of providing pain relief. It

also improves mobility and gives a feeling of fitness as the
whole body is exercised.
3. Respiration: Free active exercises with deep breathing

maintain the mobility and improve respiratory capacity.
Localized thoracic breathing without back support improves

the breathing capacity.
4. Body ergonomics: Body attitudes promoting deformities

should be discouraged. Maximum emphasis needs to be
given to static as well as dynamic postural attitudes, e.g.,
keeping the chin tucked in, repeated prone lying with
hyperextension at the dorsal spine on forearm supports, hip
hyperextension in prone and trunk lateral bending with deep
breathing.
The usual tendency to stoop should be strictly discouraged.

Instead, the chest should be held up and forward with the
shoulders retracted. Repetitions of isometric shoulder
bracing are valuable and should be made a part of daily
routine.
5. Improvement of muscle power and endurance: Muscles that are

strong and capable of maintaining contractions will provide
the necessary force to sustain correct posture. To induce
relaxation and to improve mobility, active free movement
plays an important role.
The progression of the disease usually stops after 10–15 years

leaving a permanent residual deformity. In a majority of
patients, total functional independence returns except for the
fused spine.
Surgery may be necessary when there is ankylosis of the

joints with severe fixed deformity. Hip ankylosis may need
excisional or replacement arthroplasty. Severe flexion
deformity of the spine may need wedge osteotomy.
Appropriate physiotherapeutic measures will be necessary
as per the type of surgery.
Due to rigidity, the whole spine develops an attitude

towards flexion. Flexed and rigid spine discourages attitude
towards lying prone, which in turn results in FFD at the hips,
occasionally hip joints get ankylosed – with inability even to
stand, they may need THR.
Other forms of seronegative arthropathies
1. Psoriatic arthritis
2. Reiter syndrome
3. Reactive arthritis and postdysenteric Reiter syndrome
4. Enteropathic arthritis
Psoriatic arthritis is associated with skin lesions. Reiter

syndrome may have urethritis, balanitis, skin lesions,
conjunctivitis and oral ulcerations. Ulcerative colitis and
Crohn disease (regional ileitis) – the inflammatory bowel
conditions are present in enteropathic arthritis.
Besides all their characteristic symptoms, arthritis is common

to all these conditions. Arthritis presents in two forms: (i)
peripheral when there is an involvement of peripheral joints
– it may be monoarthritis – and (ii) axial arthritis resembling
ankylosing spondylitis.
Physiotherapeutic management is basically on the same lines

as for RA and ankylosing spondylitis.
Physiotherapeutic modality like ultraviolet radiations may

be used to treat the skin lesions of psoriasis. Advice on the
proper care of skin and prevention from further damage due
to trauma needs to be provided to patients. Footwear
adaptations and modifications may be necessary, along with
assistive walking aids. Maintenance of joint range,
improvement of muscle power, and prevention of
deformities are the basic therapeutic objectives. Repeated
sessions of guided functional activities are of primary
importance in all types of spondyloarthropathies.
The patient who is depressed due to the complexities of the

disease needs to be assured to get his or her active
cooperation.
Metabolic arthritis
Gout
Excessive concentrations of uric acid and some purine bodies

in blood precipitate gout. The kidney is unable to separate
this combination of uric acid and purine bodies. The uric
acid salts accumulate in the blood. It mainly affects the joints,
but other constitutional disturbances may also accompany.
The disease is commonly seen in the first
metatarsophalangeal and metacarpophalangeal joints in men
older than 40 years. Deposits of biurate of soda occur around
the affected joint (Fig. 29-26). The joint changes include
subchondral cysts, osteophyte formation and in the late
stages, reduction in joint space.
FIG. 29-26Gout.
During an acute phase, the involved joint has signs and

symptoms of acute inflammation with a hard and tender
nodule known as ‘chalk stones’ or ‘tophi’. Fever often
accompanies excruciating night pain, but the involved joint
is comparatively pain free during the day.
Treatment
Acute stage: Colchicine, probenecid, indomethacin 75–200

mg. In addition, anti-inflammatory analgesic drugs are
prescribed along with colchicine.
Lithium ionization is sometimes done in between the acute
attacks. This iontophoresis forms soluble lithium urate in
place of insoluble sodium urate.
Cryotherapy in the form of crushed ice-packs and other

nonthermal modalities may be tried to reduce inflammation
and pain.
Pseudogout
Pseudogout is usually present in the older age group and

affects knee and wrist joints. It can be polyarticular with an
evidence of calcification of the cartilage (chondrocalcinosis).
There is deposition of calcium pyrophosphate crystals. The
signs and symptoms resemble acute arthritis.
Treatment
The treatment is the same as for gout.
Alkaptoneuric arthritis (syn: Ochronosis)
It is due to the absence of homogentisic acid oxidase – which

appears in the body fluids and urine.
Clinical features
Normal colour urine of a child turns black on exposure to air

– later the pigment gets deposited in various connective
tissue matrices – leading to painful stiffness in the spine and
large appendicular joints with calcification of the
intervertebral discs.
Treatment
Treatment is mainly symptomatic.
Physiotherapy is mainly directed to maintain or improve the

mobility to control stiffening of the affected joint, besides
encouraging self-sufficiency in the ADRs.
Connective tissue diseases

The major connective tissue diseases include:
1. Systemic lupus erythematosus (SLE)
2. Systemic sclerosis (scleroderma)
3. Dermatomyositis: (polymyositis)
4. Mixed connective tissue disease (MCTD)
Anti-inflammatory drugs and corticosteroids are necessary

to combat the acute inflammatory phase. Necessary
physiotherapy also needs to be planned according to the
symptoms and involvement.
Systemic lupus erythematosus
It has a complicated symptomatology. Various antibodies

like ANA may be present. Usually, young females are
affected.
Skin lesions are widespread including the butterfly rash.
Joint changes like RA may occur.
The lesions may affect lungs, pleura, CNS and may

accompany Raynaud phenomenon.
Treatment
Nonsteroidal anti-inflammatory drugs (NSAIDs) and

corticosteroids may be necessary in nonresponding cases.
Physiotherapeutic measures are taken to control acute joint

problems, to improve muscular weakness and to prevent
deformities. As the acute symptoms recede, the programme
of exercises and activities is increased. Prolonged sessions of
exercises or activities should be avoided as a precaution.
The approach of physiotherapy varies according to the

involved body systems. Repeated sessions of deep breathing
exercises are important to maintain the VC.
Encourage patients to remain active and actively participate

socially.
Systemic sclerosis (scleroderma)
Raynaud phenomenon with skin adherence (sclerodactyly)

over the dorsum of the fingers is a distinguishing feature.
Tightening of the skin around eyes, nose and diminished
oral aperture may result. The kidneys may be involved
resulting in hypertension.
Treatment
Drugs like penicillamine with colchicine may be given.
Sclerodactyly may give rise to limitation of flexion of the

affected fingers. All the physiotherapeutic measures are
directed to retain the mobility at least to the functional level.
Relaxed graded passive movements and self-assisted
stretching of the finger flexion is to be repeated several times.
Friction massage and ultrasound is advisable to promote
mobility of these joints.
Dermatomyositis: Polymyositis
Skin rashes resembling SLE may occur, but are often

associated with oedema over the eyelids. Erythema may
occur over knuckles and nail folds.
Inflammatory changes occur in muscles with weakness of

proximal limb muscle groups. Calcific lesions may occur in
skin, muscles, tongue and even brain.
Treatment
Corticosteroids are effective.
During the acute stage, proper positioning of the limbs is of

vital importance to avoid deformities.
As pain is reduced, early active movements should be

initiated to the weaker proximal group of muscles.
Recording and monitoring of the muscle power in the initial
stage and subsequently are important to judge the progress.
Mixed connective tissue disease
The symptoms of all the first three varieties of connective

tissue disease are present in MCTD.
Polyarteritis nodosum (PAN): Inflammation occurs in the

arteries. This results in ischaemia of the end organ. Skin
lesions (vasculitis) and renal complications may be present.
Polymyalgia rheumatica: Pain and stiffness of the neck and

shoulder in the morning with tenderness are common.
Synovitis may occur in hands and knees. Arteritis involving
temporal arteries may be present.
Corticosteroids are effective in combating the disease.
Erythema nodosum: In this disease, erythematous raised

lesions are present on the anterior aspect of the skin. The
symptoms of arthritis may occur.
Corticosteroid therapy is effective.
Sjogren syndrome: Dryness of eyes and mouth with

peripheral arthropathy are present. RA, thyroid, hepatic or
renal diseases may accompany.
Charcot joint
It is a neuropathic joint that occurs in syphilis (acquired or
inherited) and is characterized by gross disorganization of
major joints of the body. The knee, ankle, hip or shoulder
joints are commonly affected. However, in rare instances,
other smaller joints may also be affected.
There occurs rapidly progressive painless disorganization of

the affected joint, without associated muscular atrophy.
There may be signs of ataxia (locomotor incoordination, as in
tabes dorsalis) and trophic (nonhealing) ulcers over the sole
of foot.
Treatment
The treatment is unsatisfactory and disappointing. Splinting

is impractical and the results of surgery (arthrodesis) are
unpredictable.
It is not possible to outline the definite therapeutic measures

to be adopted to treat Charcot joint. They vary according to
the demands of the involved joint, existing pathology and
the symptoms of the disease.
Preventive measures like education on proper foot care to

avoid trophic changes are taken. Splints or braces may be
used to stabilize the disorganized joints. Graduated
stretching of the joint is necessary to avoid contractures.
Maintenance of the optimal function of the muscles and

joints free from the disease, and guidance on safe
continuation of functional performance are important.
Miscella neous conditions
Synovial chondromatosis
Cartilaginous loose bodies are formed from the surface of a

synovium. These get detached as loose bodies.
Treatment
Treatment is done by synovectomy and lavage of loose

bodies.
Physiotherapy
Graduated ROM mobility exercises and exercises to improve

muscle functions are performed.
Table 29-9 depicts distinguishing characteristics of RA,

ankylosing spondylitis and osteoarthritis.
Table 29-9
Characteristics of Rheumatoid Arthritis (RA), Ankylosing

Spondylitis (AS) and Osteoarthritis (OA)
Rheumatoid Arthritis Ankylosing Osteoarthritis
(RH) Spondylitis (SA) (OA)
• Inflammatory joint • Chronic •

disease inflammatory Noninflammatory
disease degenerative
disease
–
• Autoimmune • Due to wear
disease and tear of the
reticular cartilage
–
• Presence of RA • Absence of
(rheumatic factor) rheumatic factor
with absence of but presence of
rheumatic factor HLA-B27
• More common in • More common in • Common in

females between the males (M/F ratio females older
age group of 30 and 9:1) between the than 40 years
50 years age group of <40
years, the age of
onset being 15–20
years
• Mostly bilateral • Involves SI and • Usually single
joint affection later on – spinal joint affection,
joints later on may
(intervertebral involve other
joints) side
• Signs of • Causes localized • Causes

inflammation at the tenderness and localized
affected joint (e.g., vague pain at the tenderness and
redness, warmth, site of involvement pain with
effusion) and low back pain; stressful
sleep-disturbing movements
acute pain at night
or during rest
• Morning stiffness • Morning • Morning

which prolongs stiffness localized stiffness as well
longer to back, relieved as stiffness
with movement following
prolonged rest,
reduced with
movement
• Multijoint affection • Involves SI, • Commonly

common at small intervertebral involves weight
joints of hands and joints and may bearing,
feet involve joints like overused joints
hip (e.g., hips, knees)
hip (e.g., hips, knees)
• Systemic • Gradual setting • Pain, stiffness,

involvement with in of spinal localized to the
feeling of sickness, stiffness, loss of involved joints
early fatigue, loss of lumbar lordosis only
body weight
• Extra-articular • Extra-articular • No extra-

lesions like vasculitis, lesions like uveitis, articular lesions
subcutaneous CNS disturbances, are generally
nodules, osteoporosis, pulmonary seen
heart, lung, complications,
neuromuscular and conduction defects
reticuloendothelial in heart may occur
system affections may
be seen
• Prognosis: • Prognosis: • Prognosis:

Controllable, but Controllable, Good
unpredictable with spinal stiffness
chances of recurrence remains a
permanent feature
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Chapter 30
Deformity
Outline
◼ Congenital deformities
◼ Radioulnar synostosis
◼ Madelung deformity
◼ Radial club hand
◼ Contracted fingers
◼ Other congenital deformities (syndactyly, polydactyly

and ectrodactyly)
◼ Congenital pseudoarthrosis of the tibia
◼ Klippel–Feil syndrome (short neck)
◼ Congenital dislocation of the hip (CDH)
◼ Acquired deformities
◼ Developmental disorders of the bone
◼ Osteogenesis imperfecta (syn: fragile ossium)
◼ Fibrous dysplasia
◼ Paget’s disease (osteitis deformans)
◼ Congenital multiple exostosis (diaphyseal aclasis)
◼ Cerebral palsy
◼ Muscular dystrophy
Introduction
Deformity
Deformity is an alteration in the shape of the basic normal

structure of a body anywhere from head to toe. It has a great
association with orthopaedic science. In fact, the word
orthopaedics itself is derived from two Greek words ‘orthos’
meaning to straighten and ‘pedios’ meaning a child.
Therefore, orthopaedic specialty began with the correction of
deformities in children. Besides cosmetic disfigurement,
deformity may lead to impairment or even a loss of function.
Deformity may occur following any orthopaedic disorder
irrespective of its basic pathology or after a muscle injury,
posing a major challenge to the orthopaedic surgeon as well
as the physiotherapist.
Commonly, a deformity can be classified as follows:
1. Congenital
2. Acquired
Congenital deformity
Incorrect position in the uterus, failure to develop normally,
and abnormal development of the neuromusculoskeletal
tissues due to a combination of genetic and/or environmental
factors are the main causes of congenital deformity. The
congenital deformity may or may not be hereditary.
Acquired deformity
Acquired deformity develops after birth. It can be produced

as a result of the following causes:
1. Bone disease: Diseases like tuberculosis, carcinoma, and

rickets may produce bony deformity by affecting the
composition of the bone. Chronic infections like
osteomyelitis can also cause deformity.
2. Joint diseases: Like arthritis and gout.
3. Muscular causes include the following:
(a) Deformity can be caused due to muscular imbalance

resulting from paralysis. Continuation of this muscular
imbalance may eventually produce articular changes which
further aggravate the deformity.
(b) Muscle spasticity leading to malpositioning in the

direction of spastic muscle groups may become organized
into deformity (a classical example is equinus deformity at
the ankle and foot due to spastic gastroc-soleus).
(c) Muscular disease like muscular dystrophy produces

deformity in due course.
(d) Shortening of musculotendinous complex or contracture
of the muscle due to various causes may result in a
deformity.
4. Trauma: Malunited fractures can result in a deformity.

Epiphyseal injuries in children may lead to premature
closure of the growth plates and cause deformity or
shortening. Scar formation following burns or soft tissue
injuries can develop soft tissue contractures, resulting in a
deformity.
5. Postural causes: Long periods of bad habitual postures,

lack of correct postural reflex, altered joint mechanics could
be the precipitating factors for a deformity.
6. Nerve lesions: Gross sensory and/or imbalanced motor

impairment following injury or neuronal diseases may result
in the loss of sensations and joint sense. This, in turn, causes
uncontrolled perception to pressures resulting in a deformity
or even loss of a segment of the limb, as occurs in Hansen
disease.
Classification of the degree of deformity
A deformity is classified into the following three grades:
1. First degree: The deformity is mild and can be corrected

completely by passive stretching.
2. Second degree: Shortening in the soft tissues prevents full

passive correction of the deformity. Attempted passive
correction results in pain. Minimal bony changes may be
present.
3. Third degree: The deformity is rigid and cannot be

corrected by passive stretching or manipulation. It may be
associated with bony changes.
Methods of management
Assessment
The first principle of management is accurate assessment of

the deformity.
◼ The extent of the deformity is evaluated objectively by

goniometric measurement.
◼ Passive correction, if possible, should be recorded.
◼ Related body segments should be examined for any effect

sequelae of the deformity.
◼ The causative factor of the deformity should be

ascertained.
◼ The overall impact of the deformity, functionally as well as

cosmetically, should be assessed.
Depending upon the evaluation, the therapeutic approach

should be planned, keeping in mind the patients’ or the
parents’ cooperation, since the treatment is tedious and time
consuming.
Principles of management
1. Treat the causative factor, i.e., muscular

imbalance/biomechanical shifts because of habitual posture
or any underlying disease by corrective measures.
2. Correct the deformity to the maximum.
3. Passive maintenance of the correction by rigid support

(e.g., plaster of Paris [POP] cast).
4. Re-education to actively maintain the correction or

reduction by dynamic orthosis (e.g., toe-pick up orthosis).
5. Control the factors which may produce secondary

deformity.
6. Avoid recurrence of the deformity.
Methodology to correct the deformity depends upon the

degree of deformity and its overall functional impairment.
Management of first- and second-degree deformities
It can be corrected by measures like:
1. Graduated passive stretching.
2. Exercises to correct the muscular imbalance.
3. Strapping by kinesiology tape helps to strap the deformity

in slightly overcorrected position, and still allows movement.
4. Maintenance of correction by adequate immobilization.
5. Regular check-up of the correction during immobilization.
6. Re-education exercises.
7. Corrective splinting to maintain the correction.
8. Appropriate orthosis – its care and maintenance.
9. Functional re-education with the orthosis.
10. Emphasis on reporting for regular check-up and advice to

avoid recurrence.
Management of third-degree deformities
In the presence of third-degree deformities, the management

is difficult, time consuming with unpredictable results. The
treatment involves a series of corrective manipulations
and/or surgical procedures on soft tissues and bones.
Congenital deformities
Sprengel shoulder
Sprengel shoulder, also called congenital high scapula, is

characterized by an abnormally raised small scapula, on one
or both the sides (Fig. 30-1). The aetiology is unknown.
FIG. 30-1Sprengel shoulder. Note that the right scapula

is at a higher level (arrow).
The scapular muscles are poorly developed and may be

represented by fibrous bands. It may be accompanied by
scoliosis (thoracic curve) with convexity on the involved
side. The movement of scapula is markedly limited due to
the fibrous bands or a bony bar resulting in limitation of
shoulder abduction and elevation. However, the functional
disability is usually minimal. Very little improvement can be
offered by way of corrective exercises.
Surgical treatment
It consists of excision of the fibrous band or bony bar and

bringing the scapula down to its normal position.
Physiotherapy after surgery
1. Gradual relaxed passive mobilization of the shoulder and

scapula.
2. Suitable pain reducing modality.
3. Special attention is given to achieve early mobility of the

scapula and shoulder abduction and elevation.
4. Overall mobilization of the shoulder girdle muscles.
5. Strengthening of all the groups of muscles.
6. Maximum possible correction of the posture and its

maintenance is important. This will help in learning habitual
correction of the posture.
Radioulnar synostosis
In this deformity, the radius and ulna are fused at the

proximal radioulnar joint (Fig. 30-2). There is restriction of
the movements of rotation of the radius over the ulna (i.e.,
pronation and supination of the forearm). This results in
functional impairment of the arm.
FIG. 30-2Congenital radioulnar synostosis.
When the forearm is fixed in the near range to mid-position

of the forearm or pronation, the arm can be effectively used
for functional activities by manoeuvring movement at the
shoulder, elbow and wrist joints.
However, when the forearm is fixed in an abnormal position,

osteotomy may be indicated.
In conservatively managed patients, guidance is given to

strengthen the compensatory muscle groups and joints.
Operative treatment: If the rotational deformity is

unacceptable, an osteotomy of the radius and ulna is done to
fix the forearm in an acceptable rotation position for
optimum functional result. No pronation/supination
movement, however, is possible.
Madelung deformity
It is a congenital anomaly associated with defective

development of the medial part of the lower radial epiphysis.
This results in growth disorders of the medial side of the
radius, while the outer part of the radius and the ulna
continues to grow at a normal pace. Subsequently, the radial
shaft bows backwards and the lower end of the ulna
subluxates backwards (Fig. 30-3A and B).
FIG. 30-3(A and B) Madelung deformity.
The deformity is usually bilateral, commonly seen in

adolescent females and presents with weakness of the hand
and wrist. The movement of dorsiflexion at the wrist is
limited; occasionally, in severe cases, supination and
pronation are also limited.
Treatment
The treatment consists of shortening the distal fourth of the

ulna and corrective osteotomy of the radius. The plaster cast
is required to be maintained for 6–8 weeks.
Radial club hand (fig. 30-4)
There is partial or complete absence of the radius, associated

with hypoplastic or absent thumb. This results in radial
deviation of the hand and wrist with bowing of the ulna. The
thumb may be hypoplastic, floating (Fig. 30-4B), or
completely absent. The muscles on the radial side of the
forearm are also abnormal or underdeveloped.
FIG. 30-4Radial club hand. Excessive radial deviation

of wrist due to the absence of radius. (A) X-ray and (B)
photograph.
X-rays: X-ray of the forearm and wrist shows the following

◼ Strong, stout and curved ulna.
◼ Absent radius; radius may be present in proximal half and

may be rudimentary.
◼ Thumb may be absent or hypoplastic.

FIG. 30-5Radial club hand. Note the strong, stout ulna

along with rudimentary radius.
Treatment
Initially, the contracted soft tissues are stretched by serial

plaster casts until a full passive correction of the deformity is
obtained. Subsequently, carpus of the hand is (surgically)
centralized over the ulna. The ulna is aligned with the third
metacarpal (Fig. 30-6).
FIG. 30-6(A) Radial club hand deformity. (B)

Centralization procedure done – distal end of the ulna
is aligned with the third metacarpal. Note that the
radius is absent. (C) Result – after correction of the
deformity.
When the thumb is absent, the index finger is reconstructed

into a thumb, a surgical procedure called pollicization – this
is done subsequently as a secondary procedure (Fig. 30-7).
FIG. 30-7(A) Radial club hand with hypoplastic thumb,

(B) deformity corrected by surgery and (C)
pollicization done. Index finger converted into thumb.
Postoperative mobilization
1. Maintenance of proper positioning of the wrist in

overcorrected position has to be strictly observed. Ideally the
splint should be prepared before surgery, leaving the minor
adjustments to be done during the actual fitting.
2. Sessions of gentle relaxed passive movements towards

overcorrection as well as wrist extension should be
concentrated.
3. Strengthening procedures for the muscle group

antagonistic to the side of the deformity need special
attention.
4. The functional use of the hand with splint needs to be

educated and repeated several times.
5. The splint is gradually weaned off if the correction

achieved is maintained voluntarily.
6. Regular follow-up to be emphasized to prevent recurrence.
Contracted fingers
Congenital contractures in the ring and little fingers are seen

due to the tightness in the fascia and skin of the fingers. It
usually presents as a flexion deformity at the proximal
interphalangeal joint with extension at the
metacarpophalangeal and distal interphalangeal joints.
In mild cases, if detected early, the deformity can be

corrected by applying finger splints which keep the fingers
straight. The proximal interphalangeal (PIP) joint can easily
be stretched to extension by relaxed passive movement. This
passive manipulation needs to be done several times and the
splint to be applied immediately to retain the correction.
Neglected cases need surgical correction where the fascia is
divided.
Postoperatively, application of splint and the regular regime

of relaxed passive stretching along with strengthening
exercises and functional use should be encouraged. As with
any other hand surgery, strict vigil is needed to avoid
recurrence.
Other finger deformities (syndactyly, polydactyly and

ectrodactyly)
Syndactyly: There is webbing of two or more digits (Fig. 30-

8). The fingers are separated by surgery only (Fig. 30-9).
Polydactyly: The digits are more than five in number (Fig.

30-10). The extra digits are excised surgically.
Ectrodactyly: Lobster-claw appearance of hand with pincer

grip. The lobster-claw hand is corrected by reconstructive
surgery (Fig. 30-11).
FIG. 30-8Syndactyly in both hands. The middle and

ring fingers are fused.
FIG. 30-9Syndactyly release—result.

FIG. 30-10Polydactyly.
FIG. 30-11Lobster claw hand: (A) Preoperative picture.

(B) Postoperative result.
Congenital pseudoarthrosis of the tibia
It is a rare familial condition where nonossified tissue is

present at the junction of the middle and distal third of the
tibia. It may remain ununited or result in a pathological
fracture following a trivial trauma.
There may be anterior bowing of the tibia or there may be
abnormal mobility at the site of nonossification (Fig. 30-12).
FIG. 30-12Congenital pseudoarthrosis of the tibia.
Treatment
The union is difficult to achieve in this type of nonunion of
the tibia. Many treatment methods have been described; a
few of them are as follows:
1. Excision of the abnormal bone mass, internal fixation of

the nonunion and bone grafting.
2. Ilizarov fixator treatment.
3. Excision of the abnormal bone mass/segment of the tibia

and vascularized fibular grafting and internal fixation. The
vascularized fibula is placed in the gap in the tibia using
microvascular technique (Fig. 30-13).
FIG. 30-13Congenital pseudoarthrodesis tibia: (A)

Preoperative X-ray. (B) Postoperative result.
Physiotherapy is directed mainly to keep a regular check on

immobilization–correct positioning of the limb. On the
removal of POP, carefully graduated weight-bearing and
ambulatory training are instituted.
Torticollis
A developmental defect in one sternomastoid muscle or

malposition of the neck in the uterus can give rise to this
deformity. The shortening of the sternomastoid is the
principal causative factor. There may be an associated
shortening of the scalene, platysma, splenius or trapezius
muscles. Incidence is more common in girls, and the side
affected is usually left. Occasionally, it may be bilateral. The
affected sternomastoid may get atrophied and facial
asymmetry may occur in untreated cases.
Nature of the deformity
The head is fixed in side flexion to the same side (i.e., on the
side of the affected muscle), while it is rotated to the opposite
side. The shoulder on the affected side is raised. Scoliosis
with convexity to the sound side may be present in the
cervical region. Facial asymmetry with smaller eye and
lowering of the corners of the mouth and eye with deviation
of nose on the affected side may be present (Fig. 30-14).
FIG. 30-14Torticollis. Note the contracted
sternocleidomastoid muscle on the right side and the
facial asymmetry.
In rare bilateral affections, both the sternomastoids are

contracted. The head is protruded forward with associated
kyphosis.
Treatment
The basic objectives:
1. To correct the deformity by release of the contracted soft

tissues
2. To maintain the correction by suitable exercise regime,

avoiding recurrence
Early mild cases: Children with mild degree of deformity

reporting early for treatment can be managed with
physiotherapy. The following physiotherapy procedures are
employed:
1. Evaluation: Careful evaluation of range of motion (ROM)

and the degree of deformity.
2. Massage: Massage can relax the muscle preceding the

stretching manoeuvres.
3. Carefully administered thermotherapy modality induces

relaxation.
4. Passive movements: The child is placed in supine position
with head beyond the edge of a table with neck in extension
by positioning a pillow under the thoracic region. Shoulders
are stabilized by an assistant.
(a) To attain relaxation, all the movements of the cervical

spine are done in a form of slow relaxed passive movements.
(b) This should be followed by sustained passive stretching

to the affected sternomastoid, e.g., when the right
sternomastoid is involved, the head should be gradually bent
in side flexion to the left, held there for a while and then
rotated gradually to the right. Try to gain as much
overcorrection as possible by applying gradual traction to
gain further stretching.
(c) Maintenance of correction: Once the correction is

achieved, it has to be maintained by passively holding or
keeping a sand bag.
(d) The same manoeuvre can be repeated during subsequent

visits.
(e) Active correction: Active correction is best achieved by

assisting the child’s head to follow an object moved in the
proper arc of correction. A bright coloured sound-producing
object is ideal to attract the child’s attention.
(f) PNF: Patterns of neck extension can be used at an

advantage with emphasis on stretch and traction.
(g) Home treatment programme: This assumes an important

role as these manipulations need to be repeated. The mother
should be trained properly for this. The best method is to put
the child in a prone position and teach the mother to
carefully move the head towards the affected side; the child
is encouraged to look back over the right shoulder.
(h) Positioning: Exact positioning of the head during sleep is

important. The child should be made to sleep on the opposite
side of the lesion and the position of head adjusted by pillow
or sand bag in a maximally corrected posture. This
positioning has two advantages. First, there is natural
relaxation of the muscle and secondly, whatever correction is
achieved, it is maintained for a longer period during sleep.
However, the mother should intermittently check the
correction.
Older children and adults: With advancing age, the

deformity gets organized and does not get corrected by
conservative management.
Surgical
The sternal and the clavicular heads of the sternomastoid are

divided close to the origin along with release of the tight
fascia. The head is then immobilized in a plaster cast in an
overcorrected position for 2–4 weeks. Mobilization is begun
as soon as the cast is removed.
Physiotherapeutic management following surgery
Since the contracture is released surgically, passive sustained

stretching is not necessary. However, the following measures
are undertaken:
1. Control of pain: Pain at the surgical incision may persist,

particularly during exercises. Pain relieving modality like hot
pack or infrared should be given before exercises.
2. Active movements: Emphasis should be on active

movements, especially for the sternomastoid which becomes
weak following surgery. Initially, free active movements are
encouraged. Then specific exercise for the sternomastoid in a
correct groove to attain lateral flexion to the opposite side
and rotation to the same side is encouraged. Whenever
possible, this movement combination should be made
resistive.
3. Self-correction: Methods of self-correction in front of a

mirror and its maintenance by active efforts should be well
educated.
4. Collar: Specially moulded cervical collar should be used

during the rest of the period and proper posture should be
checked and maintained during sleep. The collar should be
removed for exercises and discarded only after maximum
correction is achieved.
5. Working posture: Guidance on the proper posture while

working or during the activities of daily life forms an
important part of the treatment to avoid recurrence.
Klippel—feil syndrome (short neck)
There is fusion of two or more cervical vertebrae. There is

characteristically a low hairline with variable restriction of
movements of the neck. The neck is unusually short. There is
n specific treatment.
Cervical rib (fig. 30-15)
Cervical rib is the presence of an extra rib or a fibrous band,

the extension of the costal process of the seventh cervical
vertebra. It may give rise to vascular symptoms when it
exerts pressure on the axillary artery. It may press on the
lower part of the brachial plexus giving rise to neurological
symptoms like paraesthesia in the hand, hypothenar
wasting, atonia in the shoulder girdle muscles with drooping
of shoulder or lower trunk paresis. Sympathetic disturbance
with increased sweating in the hand may be present.
FIG. 30-15Cervical rib on the left side (arrow).
Treatment
Treatment depends upon the presenting symptoms. Anti-

inflammatory drugs and analgesics with appropriate
therapeutic measures are prescribed as per the symptoms.
However, strengthening of the shoulder girdle muscles,
especially elevators and retractors, is important. Self-
resistive, progressive resistive exercises or scapular PNF
patterns are effective.
Excision of the cervical rib is undertaken in cases with

vascular and/or neurological pressure symptoms.
Physiotherapy is directed mainly towards strengthening of

the muscles of the shoulder girdle and neck extensions.
Note: Spina bifida and scoliosis are discussed in Chapter 32

on ‘Spine’.
Developmental dysplasia of the hip (fig. 30-16)
The term developmental dysplasia of the hip (DDH) is being

used nowadays in place of the conventionally used term
congenital dislocation of the hip (CDH).
FIG. 30-16(A) Congenital dislocation of the right hip.

Note that the acetabulum is shallow and the femoral
head is out of the acetabulum. (B) Congenital
dislocation of the right hip: pathological changes
(diagrammatic representation).
CDH or DDH includes subluxation, dislocation or dysplasia

of the hip. In subluxation of the hip, there is only partial
contact between the femoral head and the acetabulum. In
dislocation of the hip, there is no contact between the
acetabulum and the femoral head. Dysplasia of the hip refers
to inadequate development of the acetabulum, femoral head
or both.
CDH can be because of abnormalities in the bones as well as

in the soft tissues. The skeletal anomalies include shallow
acetabulum, posterior displacement of the head of the femur
with tendency for flattening, change in the neck shaft angle
of the femur or excessive anteversion of the neck.
Clinical features
In early childhood, observant parents may notice asymmetry

in the buttock folds (Fig. 30-17) and limitation of movements
of the hip joint. In the older child, walking may be delayed or
the child may walk with a limp (in unilateral dislocation) or
with a waddling gait in bilateral dislocation.
FIG. 30-17Asymmetry to the buttock folds, as seen

from behind.
On examination, there may be asymmetry of the buttock
folds when the child is standing upright and limitation of
abduction of the hip, particularly in flexion (Fig. 30-18).
There is shortcoming of the affected lower extremity.
Galeazzi test: In supine position, when both the hip and

knee joints are held in flexion with feet resting on the bed,
there is lowering of the knee on the affected side (Fig. 30-
18C).
In the newborn, the following two clinical tests are

performed to detect instability of the hip:
Barlow test: This will test the subluxation of the hip which is
the most common abnormality encountered. The examiner
grasps the upper part of both thighs, with his thumb in front
of and fingers on the back of the hip joint. The hip and knee
are flexed and the hip is gently adducted. During adduction,
a gentle posterior force is applied which will dislocate the
femoral head posteriorly with an audible or palpable ‘click’
(considered as a ‘posture test’). The hip is then pushed back
into the acetabulum with gradual abduction (Fig. 30.19).
Ortolani test: This is a test of reduction in the hip. The thighs

are held as described in the previous test. The hip is
gradually abducted and with gentle traction, the femoral
head reduces into the acetabulum, from the position of
dislocation, with a click (Fig. 30-20).
FIG. 30-18(A) Radiograph of both hips showing

dislocation of the left hip joint. (B) Closed reduction in
the dislocated hip has been done under general
anaesthesia. The head of the femur (on the left side) is
inside the acetabulum, and has been fixed with a
Kirschner wire. (C) Congenital dislocation hip (early
detecting clinical tests and signs): congenital signs.
FIG. 30-19Barlow’s test: (A) femoral head is pushed

with thumb, and (B) femoral head dislocates.
FIG. 30-20Ortolani’s test: (A) from the position of

dislocation, the femoral head is pushed into, and (B)
acetabulum by gradual abduction.
Summary
Barlow test: Test of subluxation of the hip

Ortolani test: Test of reduction of the hip
Soft tissue anomalies
Ligaments
1. Ligamentum teres is either rudimentary or absent.
2. Joint capsule is overstretched, hypertrophied or adherent

anteroinferiorly.
3. The joint cartilage may be defective and the glenoid

labium may be absent.
Muscles
All the long muscles crossing the hip joint, e.g., sartorius,
rectus femoris, hamstrings, tensor fascia lata, quadriceps
femoris and adductor group get shortened.
Short muscles passing over the hip joint like glutei,

obturators, psoas, quadratus femoris are altered in their
action. They cannot act effectively as their direction and line
of action are altered. They are at a mechanical disadvantage
and thus fail to act normally. The weak action of the
abductors results in marked pelvic instability, during weight
transfers. Similarly, weakness of the gluteus maximus
predisposes posterior instability of the pelvis. Excessive
tension on the psoas compresses the joint capsule and the
lumbar spine is pulled forward producing exaggeration of
the lumbar lordosis with hip flexion deformity. Thus,
complications like instability, Trendelenburg and marked
limp are noticed.
Unilateral scoliosis may result with convexity towards the

sound side.
Radiography
Plain X-ray of the pelvis with both hips shows the following
1. The epiphysis of the head of the femur appears small.
2. The epiphysis of the head of the femur is displaced

upwards and laterally away from the acetabulum.
3. The acetabulum is shallow; its roof has an upward slope.
Ultrasonography
Ultrasonography may help in detecting the position of the

head of the femur in the newborn, when diagnosis on an X-
ray may be difficult.
Treatment
The aim of the treatment is to reduce the hip and maintain it

till the hip becomes stable.
The treatment of CDH is age-related and can be divided into

the following groups:
1. Up to 6 months of age: Application of a splint, like von
Rosen splint or Pavlik harness (Fig. 30-21A and B), in the
position of hip flexion and abduction facilitates spontaneous
reduction.
2. Six months to 2 years of age: The dislocation is reduced by

manipulation under general anaesthesia and maintained in a
POP hip spica. The spica is removed after 3 months to check
the stability of the joint. In some cases, after 6 months of age,
soft tissue contractures, particularly the hip adductors,
develop. This adduction contracture prevents reduction in
the hip joint by closed manipulative methods. Therefore,
adductor tenotomy is done followed by reduction in the hip
by skin traction. Alternatively, the reduction, after adductor
tenotomy, can also be maintained in a POP hip spica for 3–6
months.
Open reduction is indicated when the conservative methods

fail.
3. Two years to 8 years of age: A dislocated hip in this age

group cannot be reduced by conservative methods. It always
requires open reduction with or without pelvic osteotomy
(Salter, 1961). This osteotomy tilts the acetabulum
downwards, forwards and laterally, providing better
containment of the femoral head inside the acetabulum (Fig.
30-22). In children above 4 years of age, some sort of shelf
operation is generally required as there are no further
potentials for remodelling of the joint (Fig. 30-23). In older
age group, Chiari pelvic osteotomy is more suitable. The
ilium is divided immediately above the level of the head and
displaces the lower fragment with the femoral head medially
under cover of the upper fragment. A bony shelf could be
constructed over the femoral head (Wainwright, 1976) (see
Fig. 12.24).
The femoral anteversion is corrected by derotation

osteotomy of the proximal femur.
Plaster immobilization is continued till the osteotomy is

united, following which mobilization is started by
physiotherapy.
4. Above 8 years of age: The results of any form of treatment

are poor in this age group. The patient is, therefore, left alone
at this stage and is considered for total joint replacement at a
later age when secondary osteoarthritis develops.
FIG. 30-21(A) Pavlik harness. Maintaining the hip in

flexion and abduction. (B) Plaster of Paris (POP) hip
spica. Maintaining the hip in abduction and internal
rotation.
FIG. 30-22Salter’s osteotomy. Wedge of bone put after

osteotomy.
FIG. 30-23Shelf operation. A shelf is created by

reflecting a chunk of bone from the ilium.
During immobilization: Active movements to be encouraged

whenever possible, e.g., when immobilization is done with
pelvic harness, even hip movements within the available
range should be encouraged. If possible, isometrics to gluteal
muscles and quadriceps should be taught.
Mobilization: As the limbs are immobilized in abduction for
a prolonged period, the maximum limitation is present in the
movement of adduction.
Mechanically malaligned gluteal muscles are weak.

Therefore, all the measures for gradual mobilization of the
hip, especially adduction, are taken. Relaxed passive
adduction in a very small range should be initiated and
progressed. Care is to be taken to stabilize the pelvis to avoid
tilting during adduction.
Other movements of the hip should also be given to improve

ROM. Hip rolling can be started with stabilization of the
pelvis. Strengthening exercises should be well planned and
progressed to the glutei. Ideally, it should be started as a
quadruped knee standing and progress to knee standing
(kneeling).
Walking should be initiated with enough support so that

proper weight bearing and weight transfers without
dropping of the pelvis are achieved. It may be necessary to
initiate ambulation with a wide base.
Assisted ambulation should be made independent as the

muscle power, stability and ROM improve.
Caution
The movements of hip adduction and internal rotation

should be performed gradually to avoid recurrence of
dislocation.
Congenital coxa vara
This condition is also called infantile coxa vara. Coxa vara

means reduction in the neck-shaft angle of the femur, from
the normal of about 125 degrees to 90 degrees or less. There
is a developmental defect at the inferior part of the neck of
the femur (Fig. 30-24).
FIG. 30-24Congenital coxa vara. Note the reduction in

the neck of the shaft angle with a separate triangular
piece of bone.
It is often bilateral and is noticed by a painless limp when the

child begins to walk. On examination, the greater trochanter
is raised and there is limitation of abduction and internal
rotation at the hip. There is often shortening. Laxity and
great mechanical disadvantage occurs to the weak abductor
muscle groups. They become weak and ineffective, especially
when the weight is borne on the single limb. Adductor
muscle group tends to become short and contracted. There is
also marked limitation of the passive range of abduction and
flexion, with excessive extension. There is limitation of
external rotation but internal rotation is in excess.
Standing posture: The patient stands with the hips in

adduction and external rotation and the foot in eversion.
Gait: In bilateral coxa vara, there is waddling gait with

occasional scissoring. It is also associated with bilateral
lateral swaying of the trunk.
In unilateral affections, there is marked limp. The patient

drops the pelvis towards the sound side every time the
weight is borne on the affected limb. To counteract this, the
trunk is jerked to the opposite direction (i.e., towards the
affected side). There may be associated compensatory
lordosis and scoliosis with apparent limb shortening.
Treatment
In severe cases, the deformity is corrected by a

subtrochanteric valgus osteotomy (Fig. 30-25).
FIG. 30-25(A) Congenital coxa vara: Wedge of bone

(shaded area) to be removed in valgus osteotomy. (B)
Neck of theshaft angle restored after valgus osteotomy.
The osteotomy has been fixed internally with a plate
and screws.
Physiotherapy treatment: When treated by traction in

abduction, frequent movements to the ankle and toes are
advised.
Isometric exercises for the hip abductors are taught with the
traction on.
Intermittent removal of traction and relaxed full range hip

and knee movements are given once a day.
After removal of traction, the patient may or may not need

weight relieving orthoses. Correct standing with equal
weight on both the hip joints is taught. It is then progressed
to assisted weight bearing on the affected leg with gait
training.
Full range of abduction is initiated early as a relaxed passive

movement, progressed to assisted and finally to resisted
movements.
Congenital short femur
The proximal femur is usually short and rudimentary

resulting in marked shortening of the leg (Fig. 30-26). The
limb length disparity gives rise to difficulty in standing and
walking, besides putting extra strain on the normal limb.
FIG. 30-26(A and B) Proximal focal femoral deficiency.
Treatment
It depends upon the degree of limb length disparity.

Compensatory shoe raise can be given in mild cases.
Surgical treatment: Surgery can be performed either on the

affected limb or on the normal limb.
On the affected limb
Limb lengthening operation may be performed either on the

femur or the tibia.
On the normal limb
Sometimes growth of the normal limb is checked or stopped

by epiphysiodesis. In this procedure, the epiphyseal growth
is checked by a bone block or by inserting staples (Fig. 30-27).
FIG. 30-27Methods of arrest of bone growth. (A)

Epiphysiodesis, BG: bone graft. (B) Epiphyseal
stapling, ST: Staples.
After surgery
Maximum caution is necessary while initiating weight

bearing on the operated leg. It has to be gradual maintaining
accurate alignment of the axis of the lower limb.
Talipes
The word ‘talipes’ means foot.
The foot has four basic movements:
1. Dorsiflexion at the ankle joint
2. Plantar flexion at the ankle joint
3. Inversion and adduction at the subtalar
4. Eversion and abduction at midtarsal joints
The various deformities of the foot are described as follows:
1. Talipes equinus: ankle and foot in plantar flexion.
2. Talipes calcaneus: ankle in dorsiflexion.
3. Talipes varus: foot is adducted and inverted.
4. Talipes valgus: foot is everted and abducted.
Besides these major deformities, there can be:
5. Pes-planus or flat foot where the arches of the foot are

depressed. Flat foot can be of three types:
(a) Pes planus: A foot where there is dropping of the foot

arches without eversion.
(b) Pes valgus: There is no dropping of the arches but the

foot is everted.
(c) Pes plano valgus: Here the combination of dropping of

the arches is present along with eversion.
6. Pes cavus: Foot arches are exaggerated.
These deformities of the ankle and foot present in various

degrees, from mild to severe. Mild deformities are easily
stretchable needing rigid immobilization in a corrected
position. Severe ones are rigid.
Many a times, these deformities are present in combination.

In about 50% of the cases, they are bilateral; when unilateral,
involvement of the right foot is more common. Four common
deformities are as follows:
1. Congenital talipes equinovarus (clubfoot)
2. Calcaneo valgus
3. Flat foot (vertical talus)
4. Metatarsus adductus (metatarsus varus)
Congenital talipes equinovarus (ctev)-clubfoot
Congenital talipes equinovarus is one of the commonest

congenital anomalies seen.
The word talipes is derived from ‘talus’ and ‘pes’ and was
applied to those walking on their neglected deformities
wherein the talus rested on the ground as the foot (pes).
It is characterized by plantar flexion (equinus) at the ankle
joint, inversion at the subtalar joint and adduction at the
forefoot (Fig. 30-28).
FIG. 30-28Bilateral congenital talipes equinovarus

(CTEV).
Clinical features
1. The inner border of the foot is raised and shortened with

cavus.
2. The longitudinal arch is exaggerated.
3. The outer border of the foot is convex and bears weight.

The skin in this region eventually gets thickened and
callosities and false bursae develop.
4. The heel remains inverted and small with thin skin.
5. The foot may be small with shortening of the leg.
6. In bilateral cases the gait is awkward and waddling.
7. There is marked limitation of eversion and dorsiflexion.
This deformity is difficult to treat. The treatment continues

for a long time and there is a high incidence of recurrence if
the child is not followed up properly.
The correction of this deformity has to be done in a definite

order. In the conventional Kite method, forefoot adduction
deformity is corrected first, followed by correction of heel
inversion, then cavus and equinus in the end.
The correction is said to be complete when the child can

voluntarily perform foot dorsiflexion with eversion.
Treatment
The method of treatment depends upon the age at which the

child is brought for treatment (Cranna, 1967). Following are
the corrective methods:
Manipulation: Passive manipulation should be taught to the

mother for children below 2 months of age. The heel is
stabilized by one hand and by the other hand the forefoot
adduction is corrected first. This is followed by correction of
inversion by exerting pressure over the undersurface of the
4th and 5th metatarsal heads. Dorsiflexion of the foot
combined with pressure on the inner border of heel corrects
the cavus, equinus and inversion of the heel.
In children above 2 months of age, manipulation is carried

out by the same technique and maintained by strapping,
(Fig. 30-29), splintage or serial POP cast. The POP should
extend from toes to thigh with the knee bent at right angles.
The plaster is changed every 2 weeks. Mild-to-moderate
deformities may be corrected by serial plaster casts.
Following this, Dennis Brown splint (Fig. 30-30) is applied
and retained till full correction is achieved. However, these
days a new brace called Wheaton brace (Fig. 30-31) is used
which can go inside a normal shoe.
Tenotomy of the tight tendoachilles may sometimes be

necessary if full correction is not achieved and the heel
remains tightly drawn up.
Ponseti method: In this method, the foot is manipulated in a

particular sequence and immobilized in an above-knee POP
cast. The plantar flexion of the first ray is corrected first,
maintaining the foot supinated inside the cast. In the next
sequence, the calcaneum is abducted, extended and everted
under the talus in a supinated foot by pressing against the
head of the talus. The fully abducted foot is then dorsiflexed
for the correction of the equinus. Percutaneous tenotomy of
the tendoachilles may be necessary in some cases. The
number of serial casts required is much less, usually 2–4. The
reduction is subsequently maintained in a Dennis Browne
splint.
Wrenching: More resistant feet, chronic deformed feet or feet
with relapse need wrenching and tenotomies.
Surgical release: Surgical release of soft tissues is indicated in

rigid and neglected feet after the age of about 6–9 months.
FIG. 30-29Strapping to correct congenital talipes

equinovarus (CTEV).
FIG. 30-30Dennis Brown splint.
FIG. 30-31Wheaton brace.

Surgical procedures
1. A long incision is made from behind the medial malleolus

to the base of the first metatarsal. Tight structures on the
inner side of the foot are divided under vision. This included
(i) tibialis posterior tendon; (ii) the capsule of the
talonavicular joint; (iii) the tendon sheaths along the long
flexors; (iv) the plantar calcaneonavicular ligament with the
capsule of the subtaloid joint; and (v) the origin of the
plantar muscles and fascia. The tendoachilles is lengthened
by Z-plasty (Fig. 30-32). This procedure will give adequate
overcorrection of the deformity. Following this, the foot is
immobilized in a POP cast for 4–6 weeks.
2. Bony correction: Triple arthrodesis or subtaloid-midtarsal-

arthrodesis.
Bony deformities get organized in still older and neglected

cases. This operation is performed only after the age of 12
years and in cases where there is relapse even after soft
tissue correction (Fig. 30-33).
3. Wedge tarsectomy: A wedge of bone is removed from the

tarsal bones – calcaneum, cuboid and talus of the foot (Fig.
30-34). The talonavicular joint and the deltoid ligaments are
divided. POP cast is applied after manipulating the foot in
the corrected position. Plaster is maintained for 6 weeks.
FIG. 30-32Tendo-achilles lengthening: (A) foot in

equinus and (B) equinus deformity of the foot
corrected by Z-plasty of tendoachilles.
FIG. 30-33Subtaloid midtarsal arthrodesis to correct

inversion of forefoot and heel. (A) Triple arthrodesis:
resection site of the calcaneocuboid and talonavicular
joints. (B) Correction of adduction and inversion of
forefoot. (C) Resection site of talocalcaneal joint. (D)
Correction of inversion of heel.
FIG. 30-34Wedge tarsectomy. (A) wedge of bone to be

removed and (B) correction of deformity.
Congenital talipes equinovarus: When reported early, most

the children can be managed by passive manipulation. It
should be followed by immobilization either by strapping, if
the deformity is minimal, or by POP cast.
Manipulation
There are three components of the deformity:
1. Pes cavus or the exaggerated arch
2. Adduction and inversion of the forefoot and heel
3. Plantar flexion of the ankle

Graded manipulation by passive movement is done in the
direction opposite to the deformity. The pes cavus deformity
is corrected first. The contracted soft tissues at the sole of the
foot are stretched gradually till total correction is achieved.
Secondly, the adduction deformity is corrected by keeping

the thumbs of both the hands over the talus; the talus thus
becomes the fulcrum of the movement. The fingers of the
distal hand hold the foot and those of the proximal grasp the
lower portion of the leg and medial aspect of the heel. The
distal hand will abduct and evert the foot, turning the sole
downwards and outwards (eversion and dorsiflexion).
Thirdly, by shifting the distal hand along the length of the

sole, the foot is raised to dorsiflexion, thus correcting the
component of plantar flexion.
By using the same order of manipulation, all the three

movements can be combined in one operation.
The most important factor is the optimal maintenance of

correction. The mother should be educated to identify any
distortion if it occurs. Regular follow-up is required to avoid
any lapse on the mother’s part, which may hamper the
improvement.
In mild cases, immobilization can be done by a strip of

adhesive plaster. A strip of plaster is taken from the medial
condyle of the knee passed under the heel to pull it to the
valgus and taken right up to the outside of the knee. Another
strip is taken from below the lateral malleolus, across the
dorsum of the foot, under the great toe to pull the foot into
valgus position terminating on the outer side of the knee.
This can be continued for 2 months. If there is no correction,
then
1. Serial POP casts may be applied.
2. Dennis Browne splint could be given (Fig. 30-30).
3. Padded simple aluminium splint – applied over the lateral

border of the leg and foot – may be necessary. This
aluminium splint is light and can be gradually bent till
overcorrection is achieved. Care should be taken regarding
the following:
(a) Correct method of applying.
(b) Repeated checks on the maintenance of alignment.
(c) To check for the areas of pressure of the splint or POP.
(d) To check that the circulation of the limb is not interfered

with, at the same time, ensure that gradual correction of the
deformity is being attained.
With plaster casts, only toe movements and the movements

to hip and knee can be encouraged by tickling or just holding
the child high in suspension with hands supporting the
lateral part of the chest under the axilla.
In surgically treated cases, if these children are of walking

age, gradual walking with underarm supports or walkers
can be given.
Maintenance of correction of the deformity after removal of
the cast is very important. It also helps in preventing
recurrence.
Night splints or resting posterior corrective splints are ideal

in the prevention of recurrence as the foot is maintained in
an overcorrected position.
Active movements stimulated through tickling or objectively

by placing some toy should be encouraged in proper and
correct groove of the movement.
Ambulatory training with maintenance of the foot in the

corrected position is to be taught in the department with the
physiotherapist supporting the foot in a corrected position.
For free walking, correct BK orthosis should be given so that
the foot is maintained in the correct position. Orthosis should
be reviewed at regular intervals and the mother should be
educated on the correct method of applying it.
The child should be seen at least once a week, then every

month and also at later stages.
The physiotherapist must remember that the ultimate

success of the treatment depends upon how effectively the
mother is taught the home care programme.
Calcaneovalgus deformity
Here the foot is excessively dorsiflexed at the ankle with

eversion of the sole; strong calf muscles are instrumental in
recovery. Passive overcorrection is also unnecessary.
Spontaneous recovery occurs as the child starts walking.
Light aluminium splint may be necessary in some children.
Mild cases: As there is excessive dorsiflexion, there occurs

limitation of plantar flexion. Gradual sustained passive
stretching in the direction of plantar flexion and its
maintenance forms an important part of exercise.
Splint: An aluminium splint may be given holding the foot in

the corrected and stretched position. It, however, needs to be
checked regularly and the technique of application taught to
the parents.
Active exercises: Active or even resisted movement of

plantar flexion is valuable. Sometimes sessions of passive
stretching followed by active resisted exercises are sufficient
to correct this deformity.
Surgical cases: Treatment approach is the same as described

for talipes equinus. The only difference is that the treatment
is concentrated to re-educate and regain the range and
power of plantar flexion.
Passive correction of the position of foot during the phase of

toe off needs special attention.
Congenital flat foot (vertical talus)
The foot has an appearance of a ‘rocker bottom’ deformity.

The longitudinal arch is completely obliterated. The sole of
the foot is convex downwards with apex at the midtarsal
joint (Fig. 30-35).
FIG. 30-35(A) Diagrammatic representation of a

congenital flat foot with vertical talus (VT). (B)
Congenital VT – note the vertical position of the talus
on both sides. (C) Clinical photograph of congenital
VT. (D) Result - after surgical correction. Note the
corrected position of the talus.
Radiologically the lateral view shows that the head of the

talus points almost vertically downwards with upward
displacement of the navicular. In the anteroposterior view, it
points medially towards the other foot at an angle of 65–70
degrees instead of straight forward towards the great toe.
There may be associated tightness of the tendoachilles.
Treatment – orthopaedic management

1. Manipulation: By manipulation the forefoot is adducted,
inverted and plantar hexed. Later the tight tendoachilles is
stretched taking care not to allow recurrence of ‘rocker
bottom’ at the midtarsal joint. Mid-thigh cast is applied with
the foot in corrected position.
2. Surgery: The surgical treatment consists of open reduction

in the talus.
During the period of immobilization in a POP cast, strong

toe flexion movements and movements to the other free
joints are encouraged.
Following surgery and removal of POP: Gradual

mobilization of the foot is started with emphasis on the
intrinsic muscles. Frequent cupping of the foot, toe curling or
holding a piece of foam rubber or cloth inside warm water
helps in strengthening small muscles of the foot.
Standing, mainly on the outer border of the foot, with curling

of the toes and cupping of the foot is made interesting with
timing. The child is encouraged to walk in this position for a
small distance at a slow speed, bearing weight mainly on the
outer border of the foot. Proper gait training with surgical
boots is necessary. Walking on sand (barefoot) helps in
developing these small muscles of the foot.
Metatarsus adductus (metatarsus varus)

Here the forefoot is adducted at the tarsometatarsal joints but
the foot is plantigrade. Even an easily corrective deformity
has a tendency of recurrence in spite of prolonged
immobilization. Considering this and the negligible
disability, no specific treatment is given.
Surgical
In selected cases, osteotomy of the metatarsal neck may be

performed. Postoperatively the foot is immobilized in a
plaster cast for 2–3 weeks. In cases where there is neuroma of
the digital nerve, the neuroma is excised. This causes
spontaneous relief of pain.
Foot exercises and re-education in walking are gradually

included with proper thesis.
Exercise programmes to strengthen the lumbricals and

interossei are intensified.
Acquired deformities
The following acquired deformities are commonly
encountered:
1. Acquired torticollis (see page 486)
2. Dupuytren’s contracture
3. Coxa vara (see page 533)
4. Genu valgum (see page 564)

5. Genu varum (see page 565)
6. Talipes equinus (see page 577)
7. Pes cavus (see page 578)
8. Hallux valgus (see page 580)
9. Hallux rigidus (see page 581)
10. Hammer toe (see page 581)
11. Metatarsalgia (see page 574)
Developmental disorders of the bone

Deformities may be formed as a result of disturbances of
growth and the development of the bone. They are known as
developmental disorders of the bone.
The disturbance in the maintenance of perfect homeostasis of

haematopoiesis, reticuloendothelial system and calcium
metabolism results in the disturbance of growth and
development of bones and cartilages – a root cause of
developmental bone disease.
Classification of developmental disorders:
1. Bony dysplasias – may be due to one of the following three

factors:
(a). Decreased osteoid formation (e.g., osteogenesis

imperfecta)
(b). Increased osteoid formation (e.g., osteopetrosis)
(c). Abnormal osteoid formation (e.g., fibrous dysplasia)
2. Cartilaginous dysplasias
(a). Mucopolysaccharidosis (MPSI) (e.g., chondro-

osteodystrophy)
(b). Idiopathic (e.g., achondroplasia)
(c). Heterotrophic proliferation of epiphysis (e.g.,

enchondromatosis)
Osteogenesis imperfecta (syn: Fragile ossium)

Decreased osteoid formation and defective type I-collagen
formation render bone soft and brittle.
The bones are short and have bubous epiphyseal expansion.
A familial inherited autosomal dominant disease in which a

child may be born with multiple fractures, or remain highly
susceptible to fractures with a trivial trauma, which
decreases if the child survives. The child may develop blue
sclera, deafness, joint laxity and cardiac anomalies too (Fig.
30-36A–C).
FIG. 30-36(A, B and C) Osteogenesis imperfecta.
Treatment
Protection from fractures by the use of supportive orthoses

supplemented by mother’s education and guidance is the
best treatment.
As the fractures are prone to develop malunion (Fig. 30-37),

the bones should ideally be treated by internal fixation,
followed by graduated physiotherapy measures to provide
maximum self-sufficiency.
FIG. 30-37Osteogenesis imperfecta: gross deformity of

the right femur due to malunion of a fracture. Note the
deformity of the left femur also.
Osteopetrosis
It is known as marble bone disease (Albers-Schonberg
disease) due to imbalanced reaction between the osteoblasts
and the osteoclasts. The skeletal system becomes dense and
brittle with susceptibility for fractures. Decrease in the
marrow cavity results in anaemia and immunocompromised
status.
When the base of the skull is involved, it may cause

blindness and sensory neural deafness or multiple cranial
nerve palsies. However, it is a self-limiting disease with a
better prognosis when the child survives beyond childhood.
Fibrous dysplasia
A bone is replaced by fibrous tissue, eroding it and resulting
in irregular bent long bones with possible shortening and
recurrent pathological fractures. Fibrous dysplasia is
commonly seen in children or adolescents involving single
bone (monostotic–femur, tibia, or mandible) or multiple
bones (polyostotic).
Radiograph shows typical expansible lytic lesion with

ground glass appearance (Fig. 30-38).
FIG. 30-38Fibrous dysplasia.
Symptomatic cases are treated with curettage and bone

grafting; open reduction and internal fixation (ORIF) may be
required for pathological fractures.
Chondro-osteodystrophy (morquio-brailsford
disease)
It is an autosomal recessive disease due to abnormal
metabolism of mucopolysaccharides resulting in defective
ossification in the spine and hip. Normal child up to the age
of 3 years starts developing kyphosis at the dorsolumbar
junction. The neck is shortened and displaced forward. The
sternum becomes prominent with pectus carinatum. A child
with genu valgum stands with hips and knees in flexion.
Radiologically, there is flattened and elongated with tongue

like projections. All the epiphyses are bulbous and enlarged
with delayed ossification.
The prognosis is poor and fatal in early childhood.
Achondroplasia
It is an autosomal dominant disease with defects in the
endochondral ossification, mainly in the long bones, causing
dwarfism (Fig. 30-39). The dwarfism is disproportionate as
the size of the trunk remains normal. The limb shortening is
more marked in the proximal segment; the central three
digits are equal in length; the head is abnormally large and
the life expectancy is normal. Due to abnormal body
structure and normal average intelligence, patient remains
gainfully employed as clowns and comedians.
FIG. 30-39Achondroplasia.
Multiple enchondromatosis (ollier disease and

dychondroplasia)
The cartilage cells fail to ossify and remain in the
metaphyseal region of the long and short bones. Hands are
commonly involved with enchondromatosis (Fig. 30-40) with
multiple cavernous haemangiomatas.
FIG. 30-40Multiple enchondromatosis.
Painful lesions are treated with curettage and bone grafting.

Lesions are likely to develop malignancy.
Paget disease (osteitis deformans)

It is a suspected viral pathology of increased bone resorption
and disorganized bone formation. Bone pain, bowing and
thickening radiograph shows honeycomb-like spongy and
widespread appearance.
Pathological fractures usually occur.
Paget disease is treated by calcitonin and bisphosphonates.
Congenital multiple exostosis (diaphyseal

aclasis)
This is a congenital autosomal dominant disease
characterized by multiple cartilage capped bony exostosis at
the metaphysis of the long bones because of failure of
remodelling forming exostosis from the epiphyseal cartilage
plate.
Usually the patients are short statured with prominences

over the ends of long bones and deformities.
Radiographically, multiple pedunculated exostosis are seen

pointing away from the joint. Metaphyseal ends are broad
with a trumpetting appearance (Fig. 30-41).
FIG. 30-41Diaphyseal aclasis.
This disease is treated by excision of the symptomatic

exostosis
Due to the multiplicity of the basic pathology and varied

deformities, each condition needs an independent suitable
approach of physiotherapy with the ultimate objective of
achieving maximum self-sufficiency in performing activities
of daily routine (ADRs).
Besides, congenital, acquired and developmental disorders, a

variety of deformities are seen in the disorders of the
neurological and muscular origin. For example:
◼ Anterior poliomyelitis (discussed in Chapter 28)
◼ Neuropathies (discussed in Chapters 26 and 27)
◼ Cerebral palsy
◼ Muscular dystrophy
Cerebral palsy
It is nonprogressive as a result of neuronal under
development in the brain. The clinical picture depends upon
the area of lesion and its varied forms, e.g., spasticity, ataxia
and athetosis. It may develop during intrauterine (prenatal),
perinatal or postnatal periods. Occasionally, it is associated
with mental retardation (MR).
Multiplicity of a clinical disposition needs a team approach

by various specialists. Physiotherapy plays a dominant role
in the management to provide maximum self-sufficiency.
The child always remains prone to develop a variety of

deformities of neuromusculoskeletal origin and requires
watchful efforts to prevent these deformities. Common
amongst them are mainly due to the muscular imbalances.
Physiotherapy besides preventing the development of

deformities plays a most important role in guiding a child to
improve lost or insufficient motor control by using various
modalities and specialized exercise techniques like Bobath
facilitation technique.
The prognosis is poor when it is associated with MR.
Muscular dystrophy
It is a group of muscular disorders (inherited myopathy)
with progressive weakness of muscles and named after the
more commonly involved muscle groups (Table 30-1).
Table 30-1
Characteristics of the Types of Muscular Dystrophy

Limb-Girdle
Pseudohypertrophic
Facioscapulohumeral Type of
Muscular
Muscular Dystrophy Muscular
Dystrophy (PMD)
Dystrophy
Inherited an x- An autosomal dominant The disease is
linked recessive disease both
gene transmitted autosomal
only to boys dominant as
through a female well as
carrier recessive
dominant
Onset around 3 Commonly seen in May occur at
years age adolescents of both the any age in
sex both the sexes
Mainly involves
lower limbs with a
complaint of
frequent falls
Progressive It mainly affects the Pelvic girdle
weakness develops; muscles of face, thus muscles are
however, a typical affecting speech. involved first.
feature is the false Gradually the speech Later on,
hypertrophy of the becomes indistinct shoulder
calf muscles and girdle muscles
deltoid too are
involved
Diagnosis: Raised Shoulder girdle muscles Winging of
levels of serum involving the limb get the scapula
creatinine– atrophied and weak becomes
phosphokinase progressively evident
Muscle biopsy, no The deltoid and the The progress
specific treatment wrist flexors are spared of the diseases
as the disease is slow
gradually
progresses
Physiotherapy, to The treatment heavily Treatment is
prevent depends on mainly by
contractures, keep physiotherapy in a form physiotherapy
child as mobile as of prevention of the to prevent
possible with deformities and all the deformities
appropriate efforts are functionally and to keep
orthoses and self-sufficient with the patient
guidance to the fabrication of orthoses mobile.
parents as per the individual Maximum
requirementsProgressive efforts are
in nature essential as
the instability
is more
marked due
to
involvement
of muscles of
both the
girdles
Prognosis is poor The lifespan is normal The lifespan is
and death occurs by normal
early adult life
when the paralysis
involves respiratory
muscles or by chest
infection
Some common examples:
1. Pseudohypertrophic muscular dystrophy (PMD) or

Duchenne muscular dystrophy
2. Facioscapulohumeral muscular dystrophy
3. Limb-girdle type muscular dystrophy
4. Arthrogryposis multiplex congenital
Other rare conditions

◼ Arthrogryposis multiplex congenita: Striated muscles are
replaced by fibrous tissues giving rise to muscular weakness
and soft tissue contractures. Rigid CTEV and hip dislocation
are the most common deformities. Soft tissue release and
open reduction in dislocated hip joints may require
physiotherapy to prevent deformities, and postsurgical
functional maintenance is usually needed (Fig. 30-42).
◼ Myositis ossificance progressive: Characterized by the
ectopic ossification in the muscles of neck, trunk and the
limbs. As and when the disease progresses, it may result in
further limitation of ROM of the involved joint. Most
common site is elbow joint.
FIG. 30-42Arthrogryposis multiplex congenita.
Physiotherapy is concentrated to keep maximum possible

mobility of the joints where the ectopic ossification begins to
appear.
Bibliography
1. Cranna D D. Congenital defects of the foot. Physiotherapy.
1967;53:131.
2. Lovel WW, Winter R B. Pediatric orthopaedics.
Philadelphia: JB Lippincott Co. 1978.
3. Salter R B. Innominate osteotomy in the treatment of

congenital dislocation and subluxation of the hip. The Journal
of Bone and Joint Surgery. 1961;43-B:518.
4. Wainwright D. The shelf operation for hip dysplasia in

adolescence. The Journal of Bone and Joint Surgery,. 1976;58-
B:156.
CHAPTER
31
Locomotion and gait
OUTLINE
◼ Locomotion
◼ Methods of gait evaluation
◼ Gait abnormalities
◼ Gait training
Locomotion
What is gait?
Gait is the process of purposefully losing or disturbing the body’s
balance and then regaining it at each step by counterbalancing the
various external and internal forces which try to disturb the balance.
It is a highly complex mechanism, requiring the precisely
coordinated controlled and synchronized action of various muscle
groups and related joints to re-establish the disturbed balance of the
body.
A forward pedal locomotion of the body is composed of a series of
forward steps. A step of each individual leg is in itself one gait cycle.
To understand the complicated mechanism of a gait cycle and and
perform a gait analysis, it is important to know the following three
aspects of a gait:
I. Gait cycle
II. Kinetics and kinematics of gait
Gait cycle
Each gait cycle has two phases:
1. Stance phase
2. Swing phase
Sequential events of a gait cycle (Fig. 31-1):
1. Stance phase: It has five phases and occupies 60% of the gait cycle.
(a) Heel strike (HS): The heel strikes the ground making
initial contact (or early stance) with the ground.
(b) Foot flat (FF): The whole foot rests on the ground and
the body weight begins to transfer to the foot.
(c) Midstance (MS): The loading of the body weight

reaches its maximum.
(d) Heel off (terminal stance): Heel begins to rise from the
ground.
(e) Toes off or push off (PO): When the toes begin to
prepare for early swing when the toes are raised off the
ground.
2. Swing phase: It has three phases, and it occupies 40% of the gait
cycle.
(a) Acceleration: Initial stage of swing begins with

acceleration of the leg.
(b) Midswing: The swing reaches its maximum
(decelerate).
(c) Deceleration: The swing begins to slow down

(decelerate), and the heel gets ready for the heel strike
with the ground. Thus, completing a gait cycle.
FIG. 31-1 Sequential events of a complete gait cycle and their duration in
forward progression. HS, heel strike; MS, midstance; PO, push off; SW,
swing.
In a normal gait, each leg alternately moves through a stance and a

swing phase, with an intermittent brief phase of double limb support,
lasting for about 10–11% of the gait cycle.
Human body participates in a gait cycle with two distinct units.
1. Passenger unit: The involved body segments do not actively

participate in locomotion but are just the passengers.
2. Locomotor unit: Where the involved body parts actively participate

in the locomotion as follows:
1. Passenger unit components 2. Locomotor unit

components
• Head, neck, arms and the upper trunk
• Lumbosacral spine,
• Shoulder joints – respond by coordinated rhythmic relaxed, free, pelvis
alternate arm swings
• Both the hip joints
• Both the knees
• Both the ankle joints

• Both the subtalar joints
• Both the
metatarsophalangeal joints
Importance of centre of gravity (CoG) and the gravitational force

in a gait cycle:
◼ The body uses the gravitational force as a major propulsive force in

moving the body forwards.
◼ But, technically, the body at this stage is falling from the stance limb
to the contralateral limb.
◼ At this moment, CoG comes into action in maintaining the body’s

balance – by its appropriate displacement.
◼ Type of the displacement of CoG is important to maintain body’s

balance during a gait cycle.
Kinetics and kinematics of gait cycle

Kinetics of gait
It is the study of the forces that produce or change motion. It is
concerned with the internal forces developed within the body by
muscular action as well as external mechanical stresses acting on the
body. The external forces acting on the body are as follows:
1. Gravitational force
2. Ground reaction forces
These two external and internal forces acting on the body are
important in the analysis of locomotion.
Centre of gravity
CoG plays an important role in the balance of a body. It is an
imaginary point at which all the body weight is assumed to be
concentrated. In a normal erect posture, it lies just anterior to the
second sacral vertebra. Its position is rhythmically displaced and
replaced during each gait cycle as follows:
1. Vertical displacement of CoG: The highest point of displacement

occurs when the supporting limb is in midstance and the lowest at the
time of double limb support. The range of vertical displacement is
about 5 cm in normal walking (Fig. 31-2A).
2. Lateral displacement of CoG: The shift of pelvis and trunk to the

side of the weight-bearing leg displaces the CoG laterally to that side.
This excursion of CoG is also normally around 5 cm and remains over
the supporting leg (Fig. 31-2B). Therefore, the displacement is
proportional to the width of the walking base.
3. Horizontal dip of the pelvis and CoG: In normal walking, there is

continuous horizontal dipping of the pelvis on the side of the weight-
bearing limb. The extent of this horizontal dipping on the side of the
weight-bearing limb does not exceed 5 degrees in normal walking
(Fig. 31-2C).
4. Transverse rotation of the pelvis and CoG: Transverse rotation of

the pelvis around its vertical axis takes place to facilitate the
advancing leg. If the width of the walking base is maintained within
the normal limits, the lateral displacement of CoG will be minimal
(Fig. 31-2D).
FIG. 31-2 Displacement of the centre of gravity (CoG) of the body and
pelvis while walking. (A) Vertical displacement: CoG assumes highest point
when the supporting limb is in midstance and lowest at double limb support.
(B) Lateral displacement: during the transference of weight to the forward
leg, the CoG as well as the pelvis oscillates laterally from side to side. (C)
Horizontal dip (tilt) of the pelvis occurs in the frontal plane at midstance. (D)
Transverse rotation of pelvis: the transverse rotation of pelvis around the
vertical axis occurs to assist forward movement of one leg while the other
leg is firm on the ground.
The various displacements of CoG aided by selective muscular

contractions help in energy conservation during continued
ambulation.
Velocity of the CoG of a body: At normal optimal velocity of 2.5–3
miles/h, the energy consumption is minimal. If abnormality in gait
function occurs, a change and restriction in the velocity of CoG will be
necessary to retain balance.
What is the centre of pressure (COP)?
It is a point around which all the forces act during ambulation (e.g.,
walking aids, or plantar surfaces of the feet).
Ground reaction force (fig. 31-3)

This is expressed as a vector. It is a line that represents the direction
and magnitude of the force encountered by the body at heel strike. Its
relationship to all the joints of the body determines the mechanical
interaction of gravitational and muscle forces about each joint.
FIG. 31-3 Ground reaction force and its components at heel strike. V,
vertical force; H, horizontal force; R, resultant force.
It is the single force which produces the same effect as two or more
forces. The length of the vector is proportional to the magnitude of the
force. The ground reaction force, horizontal as well as vertical, can be
measured by force platforms (force plates). As the patient walks over
a force platform, the components of force which are equal and
opposite to that exerted by the patient are registered.
Vector and the phases of gait cycle: At heel strike, the vector acts
anterior to the hip causing hip flexion, anterior to the knee causing
knee extension and posterior to the ankle causing plantar flexion
movements.
At foot flat, the vector is still anterior to the hip maintaining flexion,
but it is posterior to the knee and ankle causing knee flexion and ankle
plantar flexion. At midstance, it passes through the hip joint
stabilizing the hip in neutral, passes posterior to the knee causing
knee flexion and anterior to the ankle causing dorsiflexion. At heel off,
it passes posterior to the hip causing hip extension, passes anterior to
the knee and ankle causing knee extension and ankle dorsiflexion.
At toe off and during swing, the ground reaction loses its
significance as a majority of the body weight is transferred to the
contralateral supporting limb. At heel strike and single leg stance, the
vertical ground reaction force is 1.2 times the body weight. It is
around 0.8 times the body weight at midstance and nearly 3 times the
body weight in running.
Kinematics of gait (table 31-1)

Kinematics of the gait, also called kinesiology, is the study of the
pattern of angular movements and their excursion by smooth
coordinated muscular control. It analyses the gait in terms of time,
space, velocity and acceleration.
Table 31-1
Kinetics and Kinematics of a Gait Cycle
At Stance Phase
Joint Heel Strike Foot Flat Midstance Heel Off Toes Off
Hip Flexion (25–30 Flexion 25–30 Extension Extension Flexion
Motion degrees) degrees Anterior → Posterior Posterior (0
GRF Anterior Anterior posterior Extension degree)
MovementFlexion Flexion Flexion (0 degree) Adductors Extension
Muscles Gluteus Gluteus No muscular Flexors
acting maximus maximus action
Hamstrings
Adductor
magnus
Knee Flexion (5 Flexion Extension Extension/flexion Flexion
Motion degrees) Posterior Posterior → Anterior → Posterior (0
GRFV Anterior Flexion anterior posterior degree)
MovementExtension Quadriceps Flexion/extension Extension/flexion Flexion →
Muscles Quadriceps Quadriceps Gastro- Gastro-popliteus
acting Hamstrings popliteus
Popliteus
Ankle PF (0 degree) PF DF DF → PF PF
Motion Posterior Posterior Anterior Anterior Anterior
GRF PF PF DF DF DF → (0 degree)
MovementDorsiflexors Dorsiflexors PF PF PF
Muscles
acting
At Swing Phase
Joint Acceleration Midswing Deceleration
Hip Flexion Flexion Flexion with extension at the end
MovementFlexors Adductor longus, Extensors
Muscle gracilus
acting
Knee Flexion Extension Extension → flexion
MovementHamstrings, sartorius, gracilis Hamstrings Hamstrings, quadriceps, popliteus
Muscles
acting
Ankle Dorsiflexion Dorsiflexion Dorsiflexion
MovementDorsiflexors Dorsiflexors Dorsiflexors
Muscles
acting
A: DF, dorsiflexion; GRF, ground reaction force; PF, plantar flexion.
Movement components at both the phases of a gait

cycle
Stance phase
Spine and pelvis: The pelvis rotates towards the opposite side and
prevents dropping of the pelvis on the unsupported side.
Hip: Reduction of flexion and external rotation followed by slight

internal rotation. Prevention of abduction of thigh and dropping of
pelvis to the opposite side.
Knee: Slight flexion at the moment of contact followed immediately by

extension.
Ankle and foot: Slight plantar flexion followed by slight dorsiflexion
and prevention of further dorsiflexion caused by body weight,
plantar flexion of ankle and hyperextension of metatarsophalangeal
joints at the end of the propulsive phase.
Swing phase
Spine and pelvis: Rotation of the pelvis towards the opposite side;
prevention of dropping of pelvis on the unsupported side.
Hip: Flexion, external rotation because of pelvis rotation, adduction at

the beginning and abduction at the end phase, especially if the stride
is long.
Knee: Flexion during the first half; extension during the second half.
Ankle and foot: Dorsiflexion to prevent toe drag.
Various studies have established the arc of joint movements and the
character and activity of various muscle groups during both the
phases of the gait cycle.
The electrogoniometric data and electromyographic (EMG) findings
of various studies are compiled at each phase of the gait cycle at the
three basic segments of lower extremity: hip, knee and ankle (Fig. 31-
4).
FIG. 31-4 (A) Electrogoniometric data of hip, knee and ankle during both
the phases of the gait cycle. D, dorsiflexion; P, plantar flexion. (B)
Electromyographic data on the activity of major muscle groups in walking (i)
at hip, (ii) at knee and (iii) at ankle. (i) AB, Abductors. EXT, extensors; ADD,
adductors. (ii) QUD, quadriceps; HAM, hamstrings. (iii) PT, pretibial; PF,
plantar flexors.
Muscular activity at each phase of a gait cycle

Stance phase
Early stance
Hip: When the heel comes in contact with the floor, the hip is
flexed to 25–30 degrees for forward reaching of the step.
Just after heel strike (at about 5% of gait cycle), the
abductor muscle group shows peak activity (90% of its
maximum), basically to provide lateral stability to the
pelvis. This prevents the opposite side of the pelvis from
sagging. This activity of abductors tapers but continues to
40% of the gait cycle. Hip extensor shows maximum
activity (90% of its maximum) after heel strike at 10% of
the gait cycle, to control further hip flexion and to ensure
stability and erect posture over the base. Hip adductors
also assist hip abductors during this phase. The maximum
electrical activity is present in all the hip stabilizer muscle
groups during 10–15% of gait cycle.
Pelvic rotation and relative pelvic drop also occur on the side
of the advancing leg.
Knee: At heel contact, the knee is nearly extended, slight

flexion (about 10 degrees) occurs immediately after heel
contact under the impact of body weight.
Quadriceps show peak activity at this stage (about 90% of its

maximum at about 7–8% of the gait cycle). Acting
eccentrically, it controls the rate of knee flexion and is the
main force preventing buckling of the knee. It also controls
the path of the CoG from falling or rising abruptly.
Ankle: At heel strike, as the heel strikes the ground, the angle
between the foot and the leg is about 90 degrees (neutral).
As weight bearing is transferred to the foot by
advancement of the body, the sole of the foot is lowered
gradually to the ground.
The dorsiflexors (pretibial group) show peak activity (90% of

its maximum) immediately after heel strike (from 5% to
15% of the gait cycle) to check sudden plantar flexion with
controlled lengthening contractions (eccentric). Peroneus
longus shows a small burst of activity during weight
acceptance as a co-contraction to the tibialis anterior
(Winter & Yack, 1987). Immediately after heel strike,
hamstrings acting as hip extensors, along with soleus and
posterior tibial muscles decelerate the forward movement
of the tibia, preventing the trunk from flexing forward on
the femur by inertia.
Midstance
Hip: The hip assumes neutral position as the trunk advances

forward on the fixed leg.
Knee: As the leg reaches vertical position, the knee attains 10

degrees of flexion and continues to extend till it gets locked
in neutral. The activity of the quadriceps drops sharply
and stops completely by the time the gait cycle reaches
20%, which is well before midstance. This proves that the
quadriceps activity is not needed at midstance.
Ankle: At midstance, the ball of the foot makes contact with

the ground. The leg starts pivoting forward over the ankle.
Thus, the ankle joint moves from 5 degrees of plantar
flexion to 10 degrees of dorsiflexion.
At this phase, the maximum lengthening activity of
controlled elongation takes place at the plantar flexors. It
starts at 10% of the gait cycle and reaches its maximum at
about 45% of the gait cycle. Long toe flexors and intrinsic
muscles are active during all the parts of the stance phase.
Late stance
Hip: At late stance, the hip is in an extended position of 10

degrees as the body has crossed forward. This hip
extension lessens (10 to 0), and it starts flexing due to
plantar flexion of the foot. Adductor longus and magnus
activity give stability by restraining the lateral shift.
Knee: There is a rapid marked knee flexion (0–50%) without

the activity of the hamstrings. This flexion occurs as a
result of the small ground reaction force and plantar
flexion of the foot. Second quadriceps activity is noticed at
about 50% of the gait cycle during the transition from
stance to swing phase. This is because the rectus femoris
prepares to act as a hip flexor to initiate the swing.
Ankle: At the near culmination of the stance phase, as the

limb prepares for forward swing, the heel raises from the
ground with simultaneous flexion at the knee. The ankle
reaches 20 degrees of plantar flexion. Gastrosoleus along
with peroneus longus shows peak activity of shortening
contraction. They actively plantar flex the foot and
generate explosive force to push off to initiate the swing
(estimated at 250% of body weight in tension). Minor
degree co-contractions are noticed in the extensor
digitorum longus (EDL) to stabilize the ankle joint at push
off (Winter & Yack, 1987). At this stage of onset of heel
raise, the intrinsic activity occurs (at 35% of gait cycle) as
body weight concentrates on the forefoot (Basmajian &
Stecko, 1963; Mann & Inman, 1964).
Swing phase
The swing phase begins with toe off and ends with heel strike.
The forward acceleration of the limb is brought about by gradual
hip flexion to about 20–30 degrees and knee flexion of around 40–65
degrees. The ankle reaches neutral and gradually attains the position
of 5 degrees of dorsiflexion.
The muscle activity is present in the hip flexors at the initial stage.
The hip adductors control abrupt external rotation and abduction.
Rapid knee extension from 50 to 60 degrees of flexion occurs due to
the relaxation of hamstrings. The knee then begins to extend with
pendular action and mild contractions of the quadriceps muscle.
However, hamstrings show peak activity at the terminal stage of
swing (from 85% to 100% of the gait cycle). They act as hip extensors
mainly to decelerate and control the excessive forward flexion of the
leg. The dorsiflexors (pretibial group) are active throughout the swing
to prevent foot drop and show maximum shortening activity in the
late swing phase (concentric) to prepare the ankle and foot for heel
strike (at 90–100% of the gait cycle).
It must be remembered that the muscle activity in walking is mainly
shock absorbing rather than propulsive.
The limb moves forward mainly by inertia with minimal muscular
activity.
Role of reciprocal arm swinging: The reciprocal relaxed arm swinging
provides opposite reaction forces. Arm movements in conjugation
with trunk rotation offer necessary balance as well as symmetry to the
gait. Thus, it forms one of the important components of gait
assessment and gait training, an aspect which is not given its due
importance.
Methods of gait evaluation
1. Observational method: This method was first reported by Weber
and Weber (1836). In this method, the skill and experience of the
clinician is the basic factor which records deviations in the gait cycle
by visual observation. Brunnstrom (1964) assigned numerical values
to the quality of movement pattern at specific anatomical sites (hip,
knee and ankle) in the adult hemiplegics.
2. Photographic method: It includes video, cine and TV film analysis.

Marey (1855), Fisher (1898) and Murray et al. (1964) used photography
to measure various kinematic components like velocities, acceleration,
linear and angular displacements during gait cycle.
3. EMG methods: This method involves the study of muscular forces

on the muscles participating in the gait cycle of various joints
(Johnston & Smidt, 1969). Scherb (1938) also reported on the
myokinetics of gait which is useful in neurological or myopathic
disorders.
4. Force studies method: This method is the analysis of a gait cycle by

the data of reaction of forces. Morrison (1969) presented data on floor
reaction forces. They have reported forces to the tune of four and three
times the body weight to the concerned joint at the hip and knee,
respectively.
5. Electrogoniometric method: Johnston and Smidt (1969) and Smidt

(1971) reported objective studies on the range of motion of joints
participating in the gait cycle by strapping on a electrogoniometer.
6. Energy cost and energy requirement method: This method analyses

the energy requirements and energy expenditure during each gait
cycle. It has been proved that the energy cost of gait in pathological
conditions is much higher than the normal.
7. Spatial and temporal measurement method: Analyzes the basic

temporal and spatial characteristics, speed and distance parameters of
gait.
8. Combination of various methods: Simultaneous record

accelerograms, EMG and high-speed motion pictures are used to
correlate normal and pathological gaits (Liberson et al., 1962).
9. Multichannel functional stimulation method: Use of multichannel

functional electrical stimulation (FES) to six main anatagonistic
groups, i.e., ankle dorsiflexors, plantar flexors, knee extensors and
flexors, hip extensors and triceps surae, has been reported as a
successful method of gait analysis and training (Bogataj et al., 1989;
Malezi et al., 1984), but it involves the factors of time and cost.
At present, a number of gait laboratories with sophisticated

methodology have come up at various centres. These will be able to
detect and record the minute details regarding deficiencies in gait. It is
not feasible to have such extensive and expensive laboratories for
routine clinical practice. Therefore, some simple, cheap, less time
consuming but reasonably objective methodology has to be evolved as
a practical alternative.
Suggested method of gait analysis. To evolve such a methodology, we
suggest a technique which is based on a combination of (a)
observational data on the major segmental deviations at the hip, knee
and ankle–foot joints and (b) qualitative analysis of the temporal and
distance parameters. This method should be able to provide adequate
data to detect major deficiencies of the gait so as to plan the gait
training programme. Basic, well-established data are available on the
following parameters:
1. The range of movement at the joints participating in normal gait.
2. The degree of electrical activity of the various muscle groups during

normal gait.
3. Common deviation in pathological gaits as a result of expected

deficiencies.
We suggest that the observational gait analysis should be adopted

as a basic procedure to evaluate the major deviations from the normal.
The data thus recorded can be correlated by clinical examination of
the patient.
Secondly, a simple but objective method of quantitative analysis of
the temporal and distance parameters of gait is carried out critically.
The combination of both these methods can provide adequate
information on the patient’s gait deviations. This will help not only in
planning the gait training programme but also in assessing the
efficiency of the technique.
Methods of observational analysis

As a routine, every physiotherapist has to develop an art of
observation or eye ball analysis to critically record gait deviations
during both the phases of the gait cycle. Although these visual
impressions cannot be quantified, they can provide useful information
to assess the major deviations from the normal. This has been
adequately demonstrated by Brunnstrom in 1964. In this method, the
physiotherapist systematically and critically observes and records the
minute deviations at the three main weight-bearing joints: the hip,
knee and ankle. Total attention needs to be concentrated on a single
joint at a time. The joint needs to be carefully observed from the
anterior, lateral as well as posterior aspects during both the phases of
the gait cycle. The observations are to be recorded at both the phases
and subphases of the gait cycle by several repetitions. The patient is
asked to walk at his normal walking speed. This analysis as a rule
should be preferably done without any assistance. Along with hip,
knee and ankle, the observations for trunk and pelvis should also be
recorded separately. The interpretation of the data thus recorded can
provide an overall picture of the patient’s gait.
The major deviations or deficiencies thus identified should be
correlated with the clinical examination of the patient in various basic
body postures, especially in standing, to formulate the gait training
programme.
Evaluation of the temporal and spatial characteristics of

gait
To assess the overall performance of a patient, quantification of the
ambulation profile is very essential. Normal values for this have been
established. A clinical method of quantitative gait evaluation is
reasonably adequate, simple and inexpensive. It also does not require
large space or time-consuming methodology (Cerny, 1983). The
parameters of temporal and distance data include stride length, step
length, step width, velocity and cadence.
1. Stride length: Distance between two consecutive ipsilateral heel

contact marks.
2. Step length: Distance between two consecutive contralateral heel

contact marks.
3. Step width: Distance perpendicular to the line of progression from

left contact mark to right contact mark and from right to left.
4. Velocity: Distance between the first and last heel contact mark
divided by the time required to cover that distance.
5. Cadence: Steps per minute calculated by dividing the product of

number of marks and 60 by the number of seconds it took to traverse
the total distance.
This method needs a 16-m (50-feet) walkway, which is divided into

three segments: two 5-m segments on either side of the 6-m segment
which is the main area of evaluating the gait. Two felt-tip-marking
pens are taped to the back of the patient’s shoes so that the tip just
reaches the floor and puts a mark on the floor at every step. We
suggest modification to Cerny’s method by adding one more marking
pen to be secured anteriorly at the centre of the toe line of the shoe,
which will put a mark at toe offstage (Fig. 31-5). Joining the line of the
heel and toe markers will provide information about the angle of the
foot in relation to the midline.
FIG. 31-5 Felt tip pens (FTP) taped to the front (centre) and the back
(centre) of the shoe.
The patient is asked to walk at his usual speed. The physiotherapist,

using a stopwatch, records the total time taken to cover the centre 6-m
area to calculate the velocity and the cadence. Measurements of the
stride length, step length, step width and foot angle (as suggested by
us) can be done by joining and measuring the contact pen marks to
the midline within the central 6-m walkway (Fig. 31-6).
FIG. 31-6 A simple method of quantifying various parameters of gait. SL,

stride length; SW, stride width; STL, step length; FA, foot angle.
By this method, a variety of temporal and spatial variables can be

quantified and used to describe an individual’s gait.
This method of evaluation can also be used effectively to assess the
efficiency of the treatment programme.
To understand the deviations from the normal, it is essential to
know the standard values of various important parameters of gait.
The standard values are shown in Table 31-2 (Murray et al., 1964).
Table 31-2
Parameters of Normal Gait
Parameter Measure
Duration of stance 0.59–0.65
Duration of swing 0.38–0.42
Duration of double limb support 0.10–0.12
Complete cycle 0.98–1.08
Steps per minute 111–122
Mean step length Left to right: 75.9–81.1 cm
Mean stride length Right to left: 74.9–81.4 cm
Mean stride width 150.8–162.5 cm
Foot angle, degrees of out toeing 7.1–9.6 cm
Average speed weight; acceptance Mean right, 6.7°
and push off Left, 6.8°
3 mph of (130 cm)
The vertical floor reaction force is 115% of the body weight
during the midstance
At the comfortable walking speed of 3 miles per hour, the energy

cost and the muscle force are minimal. The work of moving the body
forward is done mainly by gravity and inertia, the ground reaction
forces being mainly absorbed by the weight-bearing joints.
Gait abnormalities
Relationship of physical deficiencies and gait abnormality:
Pathological gaits due to various deficiencies vary markedly due to
the different compensatory methods adopted by the body.
Pathological gait abnormalities and the probable

causative factors (table 31-3)
Weakness of biceps femoris, fixed inversion of the heel results in hip
internal rotation gait.
Table 31-3
Common Pathological Gaits
Patological Gait, with Probable Causes

Hip • On bearing body weight, patient leans on the affected side
• Hip pain • Pelvis drops on the normal side on bearing body weight
• Abductor weakness (Trendelenburg gluteus medius dip)
• Hip extensor weakness • Backward thrust of the trunk on bearing body weight
• Loss of movement control of • Hip circumduction to clear the ground
hip flexors and hamstrings, • Combined action of quadratus lumborum, lateral abdominals to
e.g., stroke elevate pelvis to clear the ground and then leg is propelled
• Hip hiking – spasticity in forward with a pendular swinging action
the hip extensors, foot drop or • Biceps femoris weakness, fixed inversion of the heel
weak hip or weakness of hip • Fixed eversion of the weak tibialis anterior, posterior and plantar
flexors flexors
• Internal rotation of hip
• Hip external rotation
Knee • Knee stabilization by jerky hyperextension with both hand
• Paralysis or paresis of supports above the knee, with trunk bent forward
quadriceps or unstable knee • Knee is stabilized in slight flexion, or else stiff knee gait, short
joint on bearing body weight step forward with longer step by the less painful leg
• Arthritic knee
Ankle–Foot • Excess hip flexion to clear the ground
• High step • There is no phase of toes off in a gait cycle. Entire sole is used for
• Foot drop push off, e.g., hammer toes, metatarsalgia or fixed position of foot
• Pescalcaneous in neutral or slight plantar flexion like ankle arthrodesis
• Varus with inversion • Peroneal paralysis
• Valgus foot with eversion • Anterior tibial group paralysis
CNS affections • Parkinson disease, ataxia to secure balance
• Speedy shuffling gait with • Hip circumduction due to the loss of hamstrings control,
small steps; trunk bent inability to flex knee and hip on the affected side
forward with rigidity of the • Scissors gait (spastic gait)
whole body • Does not lift legs which otherwise can do so against resistance,
• Cardiovascular accident mostly walks with shuffling gait but in between with near normal
(CVA) or hemiplegic gait gait
• Spastic paraplegia or CP
• Hysterical gait
Weakness of hamstring, tibialis anterior, posterior or plantar flexors

results in hip external rotation gait.
Some of the basic deviations in gait are as follows:
1. Weakness of hip flexors: The patient is unable to flex the hip and
shortens the step length during the swing.
The compensatory mechanism adopted by the patient will be

a backward thrust of the trunk with circumduction, lateral
trunk movement towards the side with elevation of the hip
on the affected side or hip hiking.
2. Weakness of hip abductors: Dropping of the pelvis on the opposite

side with lateral flexion of the trunk and head on the affected side.
This is known as Trendelenburg or gluteus medius dip gait.
Compensated gluteus medius gait: Here the gluteus medius

weakness is compensated by the medial deviation of the
hip on the affected side. The trunk bends sideways on the
affected hip on weight-bearing, and the opposite hip is
lifted up for the clearance of the ground. In the presence of
limb length disparity, the patient has similar tendency
which needs to be rectified by limb length measurement
and manual muscle test.
3. Weakness of hip extensors: In gluteus maximus gait, following heel

strike of the affected leg, jerky backward thrust of the trunk occurs
with simultaneous protrusion of the affected hip. Backward thrust of
the trunk keeps the CoG behind the hip joint to counteract the inertia
produced by the forward movement of the trunk. At midstance, the
knee is held in extension.
Exaggeration of lumbar lordosis: During the stance phase,
the gait may suggest hip flexion contracture on the side of
the stance leg.
Persistent inclination of the pelvis, to one side during all the

phases of gait cycle, combined with lack of heel strike
suggests an adduction contracture on the side of the
inclination.
4. Weakness of quadriceps: There is forcible extension on the knee at

heel strike. This is done by using ‘hand support on thigh’ position at
midstance, knee can be drawn backward by hip extensor as well as by
gastro-soleus on weight bearing by producing equinus foot.
Unprotected repeated extension may result in genu recurvatum.
5. Weakness of hamstrings, especially along with gastrocnemius: It

may give rise to genu recurvatum due to repeated posterior thrust of
weight bearing.
6. Weakness of dorsiflexors: This produces foot slapping at early

stance and foot drop at the swing phase. It is compensated by
excessive flexion at the hip and knee (high stepping gait). When the
hip flexors are too weak to perform hip flexion, the foot may be
dragged forward with external rotation of the whole limb.
Moderate weakness of dorsiflexors may not produce foot

drop during the swing phase but may result in foot slap at
heel strike.
Mild weakness of the dorsiflexors will give rise to foot slap

only during speedy walk or after the subject is tired.
7. Weakness of plantar flexors: It results in dropping of the pelvis on

the affected side with slowing of the forward movement at the
terminal phase of stance phase. Speedy walking increases calf limp
whereas it decreases during a gluteus medius limp. It must also be
remembered that in gluteus medius limp, the pelvis on the side
opposite to the affected limb is dropped as against the calf limp.
8. Antalgic gait: In antalgic gait, due to the pain arising from ankle,
foot, knee or hip, the stance period is reduced on the side of the
painful leg. At the onset of the stance, the patient jerks his head, arms
and trunk downwards; then with a jump and a long forward step
leans towards the affected side and quickly shuffles the normal limb
with a jump and a long forward step. This manoeuvre decreases
downward force of gravity. This type of gait is commonly seen in
patients following fracture or injury to one lower limb.
In degenerative disease of the hip, the patient walks with extended

stance. There occurs excessive hip abduction, rotation of the trunk
laterally over the affected extremity and maximum external rotation
just after heel strike. These modifications are the purposeful
compensations to minimize the resultant force transmitted through
the hip joint and to increase lateral stability (Wardsworth et al., 1972).
Common gait deviations in certain diseases like Parkinson disease,
stroke hemiplegic and Duchenne muscular dystrophy are easily
identified because of their well-established peculiar gait patterns.
Gait training
It is important to note that gait training should be started after the first
evaluation of a patient and not only when the patient is allowed to
stand and walk. It consists of five phases:
1. Pregait training evaluation
2. Detection of the restricting factors
3. Therapeutic measures
4. Commencement of gait training

5. Independence in other activities of ambulation
1. Pregait training evaluation

It is done on the basis of the biomechanical, kinetic as well as
kinematic requirements of the normal gait. It involves careful
examination of the following:
1. Range of motion of the joints principally involved in ambulation

with measurement of limb length.
2. Muscle strength and endurance of the muscle groups participating

in ambulation.
3. Status of coordination of the joints of ambulation having fixed

deformity.
4. Overall sensory status of the limb, particularly of the distal

segment.
5. Status of static and dynamic balance.
6. Age, body built, cooperation and attitude of a patient towards

walking.
7. Type of physical activities involved at work and at home.
8. Degree and guidance of the possible assistance at home.
9. Diagnosis and general cardiorespiratory status and exercise

tolerance of a patient.
2. Detection of the restricting factors

Proper interpretation of this data will help in detecting the possible
restricting factors in gait and will also help in predicting the ultimate
outcome.
3. Therapeutic measures
Appropriate therapeutic measures to correct or reduce the influence of
restricting factors can be taken, e.g., correction of the soft-tissue
contracture or deformity. It may be necessary to enhance strength,
endurance and coordination to prepare the upper extremities to
facilitate the use of a walking aid which may be required in future.
4. Commencement of gait training

The commencement of gait training will depend upon any of the
following conditions of the patient:
(a) Nonambulatory phase
(b) Ambulatory phase
(c) Special training sessions to teach other advanced activities in

ambulation
Nonambulatory phase
The mode of gait training will depend on whether the patient needs
non–weight-bearing or partial weight-bearing ambulation. The patient
may need total or partial support of the assistive device.
During non–weight-bearing ambulation, the gait is nowhere near
normal and the patient manages only by hopping on two crutches.
But, at times the programme of conditioning the non–weight-bearing
leg for future gait training needs more emphasis than crutch walking.
As soon as the patient is allowed, partial weight-bearing becomes
important to educate and guide him on the requirements of normal
gait cycle. No matter even if one has to continue with adequate
assistance of walking aids. Efficacy of gait at this early stage of
ambulation should never be sacrificed. Therefore, the assisted walking
should be critically observed for all the characteristics of the normal
gait. Shadow walking should be initiated as early as possible.
Ambulatory phase
At the baseline, the gait should be thoroughly evaluated and recorded
for future review. A careful correlation of the deviations in gait in
relation to actual deficiencies as noted earlier should be established.
The end result of optimal expected correction in the gait training
should be planned and begun. Important factor to gait training is the
education of the patient to normalize the abnormal attitudes by self-
correction and encouragement. The ultimate goal is the normal to near
normal pattern of gait which is safe and effortless.
If any compensation in length or orthotic device or walking aid is
necessary, it should be given before starting gait training.
On the spot correction with the patient made to practise in front of a
postural mirror over the footmarks marked on the floor provides an
excellent mean of gait training.
It is generally observed that overemphasis on ambulation at an
early stage sometimes gives rise to a limp. If imposed on patients, it
gets habitual and organized and is very difficult to rectify at a later
stage.
The usual physiotherapy techniques are practised to provide sound
static and dynamic balance and stability to the gait; improving
efficiency of gait along with training sessions for adopting the
functional positions.
Reciprocal arm swinging provides opposite reaction forces. Arm
movements in conjugation with pelvis and trunk rotation offer the
necessary balance as well as symmetry to the gait. This forms a very
important component of gait training. Unfortunately, this aspect is not
given enough attention in our clinical programmes of gait training.
This arm swing is basically a reflex action and if prevented, the upper
trunk tends to rotate in the same direction as the pelvis, causing tense
and awkward gait.
Judicious application of various physiotherapy gait training
techniques supported by appropriate assistive devices and orthotic
and prosthetic appliances can contribute potentially towards the
improvement of the stability and gait pattern.
PNF techniques of resistive gait (pelvic resistance) with
approximation at heel strike and rhythmic stabilization are very
effective for any gait training programme (Voss & Knott, 1968).
Long sessions of standing balance on the affected leg alone are very
effective to give confidence in improving the stability and the pattern
of gait.
It may be ideal, to provide normal pattern of gait to a patient.
However, one must never forget that in pathological situations, the
limp is a compensatory mechanism at the lowest energy cost of
ambulation.
Undue long sessions with emphasis on normal gait may lead to
more complex gait problems rather than ease of ambulation.
Therefore, the physiotherapist must be skilled enough to judge the
extent of gait training programme as per the limits of the patient’s
condition and give the patient a gait with three ‘S’-its stability,
security and safety.
5. independence in other activities of ambulation

Gait training cannot be considered complete unless the patient learns
other ambulatory activities. Guidance and graded techniques of
controlled resistance are very useful in providing independence in the
following ambulatory activities:
1. Back walks
2. Turning
3. Side walks
4. Managing steps
5. Negotiating rough, uneven surfaces and slopes
6. Falling on the floor and raising
Several sessions of practice and efforts are needed to achieve

proficiency in these tasks.
The metabolic cost of walking increases significantly in patients
with lower extremity deficiencies resulting in early fatigue.
Caution
Any breathlessness, early fatigue, chest pain and allied symptoms of
cardiovascular origin need to be monitored carefully.
Whenever possible, analysis of the parameters of oxygen

consumption, endurance, cadence, step length and pulse rate may be
done. This will provide objective assessment of the ability to walk
(Stoodley & Sikorski, 1987) along with the patient’s tolerance to
walking.
Bibliography
1. Basmajian J V & Stecko, G. The role of muscles in arch support
of the foot. Journal of Bone and Joint Surgery. 1963;45-A:1184.
2. Bogataj U, Gross N, Malezic M, Kilajic M, Acimovic R.
Restoration of gait: two to three weeks of therapy with
multichannel electrical stimulation. Physical Therapy.
1989;69:319-327.
3. Brunnstrom S. Recording gait patterns of adult hemiplegia.
Physical Therapy. 1964;44:11-18.
4. Cerny K. A clinical method of quantifying gait assessment.
Physical Therapy. 1983;63:1125-1126.
5. Fisher O. 21–28 Abh Keonigl Saechs Geselisch Wissensch Bd
Der Gang des Menschen. 1898;1898-1904.
6. Johnston RC, Smidt G L. Measurement of hip motion during
walking. Journal of Bone and Joint Surgery. 1969;51:1088-1094.
7. Liberson WT, Holmquest HJ, Halls A. Accelographic study of
gait. Archives of Physical Medicine. 1962;43:547-551.
8. Malezi KM, Stanic U, Kijajic M. Multichannel electrical
stimulation of gait in motor disabled patients. Orthopaedics.
1984;7:1187-1195.
9. Mann RA, Inman V T. Phasic activity of intrinsic muscles of
foot. Journal of Bone and Joint Surgery. 1964;46-A:409.
10. Marey E J. Paris La Methode graphique dans less sciences
experimentales. 1855.
11. Morrison J B. The function of the knee joint in various
activities. Biomedical Engineering. 1969;4:473-480.
12. Murray MP, Drought AB, Kory R C. Walking patterns of
normal men. Journal of Bone and Joint Surgery. 1964;46-A:335-360.
13. Scherb R. Ueber Myokinetische problem in der unteren
Extremtaet. Beilageheft ztschr. Orthop Chir. 1938;67:101.
14. Smidt G L. Hip motion and related factors in walking. Physical
Therapy. 1971;51:9-22.
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assessment of patients with arthropathy of the hip and knee.
Clinical Orthopaedics and Related Research [Chanu12].
1987;224:110.
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. New York, Evanston and London: Hoeber Medical Division,
Harper & Row Publishers. 1968.
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subjects with hip diseases. Physical Therapy. 1972;52:829-837.
18. Weber W, Weber E. Mechanik der Mensehilichen
Genwerkzeuge . Dietrich: Gottingen. 1836.
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walking: stride to stride and intersubjecl variability.
Encephalography and Clinical Neurophysiology. 1987;67:402.
CHAPTER
32
Spine
OUTLINE
◼ Congenital spinal anomaly
◼ Developmental disorders of the spine
◼ Low back pain
◼ Degenerative disc diseases
Congenital spinal anomaly

Spina bifida
Spina bifida, a neural tube defect, is the result of the defective fusion
of one or more posterior vertebral arches with resultant protrusion of
the contents of the spinal canal.
Classification
1. Spina bifida occulta (Fig. 32-1B)
2. Spina bifida cystica (manifesta)
(a) Meningocoele (Fig. 32-1C)
(b) Myelomeningocoele (Fig. 32-1D)

1. In spina bifida occulta, there is merely a radiographic defect between
the laminae. The presence of an overlying midline skin defect, such as
haemangioma, lipoma or a tuft of hair, points to an underlying spina
bifida occulta (Fig. 32-2). It is rarely associated with neurological
deficit. These children, therefore, do not require any specific
treatment. Simple physiotherapeutic procedures can be effective to
make them functionally independent.
2. In spina bifida cystica, there is a developmental deficiency of laminae,

spinous processes and the overlying muscles and skin.
(a) Meningocoele: In this variety, usually the spinal cord and

its nerve roots are intact, only the covering membrane
(meninges) projects as a dural sac (Fig. 32-1C). If this
defect is closed by early surgery, paralysis in the lower
limbs is avoidable and the rehabilitation is easy.
(b) Myelomeningocoele: Here, the spinal cord is exposed to

the surface as a plaque or nervous tissue. It is invariably
associated with muscle paralysis, sensory loss and
paralytic deformities of the lower limbs, and
involvement of the urinary bladder and bowel. It may
present anywhere from the fourth thoracic to the first
sacral vertebra. However, it is more common in the
lumbosacral region (Fig. 32-1D).
This type is associated with the usual complications of

paraplegia, bladder and kidney infections, skin ulceration,
etc. It may also be associated with deformities, and is prone
to develop pathological fractures, meningitis and
hydrocephalus.
FIG. 32-1 Spina bifida, meningocoele and myelomeningocoele. (A) Normal

with well-formed and posteriorly closed neural arch. (B) Spina bifida
occulta. SD, depression in the skin; AP, articular process; SN, spinal nerve.
(C) Meningocoele, S, skin and subcutaneous covering; DS, dural sac, F,
fluid collection. (D) Myelomeningocoele. SC, spinal cord.
FIG. 32-2 Spina bifida. Note the tuft of hair.
Treatment
Physiotherapeutic approach
Considering all these complicated factors, a generalized prescription
of physiotherapeutic management is impossible. Each problem has to
be managed on its own merit.
The extent of deformities, paralysis as well as sensory impairment
needs to be evaluated thoroughly. Muscular paralysis is the main
disabling factor. The paralytic involvement depends upon the level of
the lesion.
Although difficult, careful and thorough assessment of the neuro-
musculosketetal system is the first priority of any therapeutic
procedure.
The basic objective of physiotherapeutic management is to reduce
the deformities, improve the muscle power to the maximum and
make the child functionally independent, especially in ambulation.
1. Paralysis at the thoracic level: Because of the higher level of the lesion,
there are multiple problems such as loss of trunk control and paralysis
of both the lower extremities; bladder and bowel incontinence are the
major areas of management. The goal to offer maximum physical
independence can be achieved by imparting proper education to the
child’s mother to take proper measures to avoid complications, and
offer assistance. A fair amount of physical independence is possible as
children have tremendous potential towards self-adaptations and
adjustments.
2. Paralysis below the first and second lumbar nerve roots: There is
complete paralysis of hip abductors and extensors. Due to the
unopposed action of hip flexors and adductors, the child is prone to
develop hip dislocation or flexion contracture. Regular monitoring
and avoiding improper weight bearing are the most important aspects
of the management.
3. Paralysis below the third or fourth lumbar roots: Hip flexors and
adductors and extensors of the knee are normal and the tibialis
anterior may be active with the paralysis of the glutei, hamstrings
gastrosoleus and toe flexors.
This imbalanced action at the hip, knee and ankle may give
rise to hip dislocation, rigid genu recurvatum and
calcaneovarus deformity, respectively. Measures to avoid
deformity due to muscular imbalance need special
attention and care.
4. Paralysis below the level of the fifth lumbar nerve root: As the hip
abductors are active, the chances of hip dislocation are rare. Similarly,
activity of the medial hamstrings reduces the incidence of rigid genu
recurvatum. The degree of deformity at the ankle and foot is reduced
due to the activity of long toe extensors.
However, the possibility of hip flexion contracture and

limitation of plantar flexion may exist. Measures to avoid
them by repeated check are important.
5. Paralysis below the first sacral nerve root: Weakness exists in the
gluteus maximus, biceps femoris, triceps surae and intrinsic muscles
of the foot. Hence, there is a possibility of developing hip flexion
contracture, calcaneus deformity with limitation of plantar flexion.
Physiotherapeutic management includes the following:
1. Prevention and management of deformities
2. Management of muscle paralysis
3. Care of skin and joints
4. Management of bladder and bowel incontinence
5. Education in ambulation, and self-care
1. Prevention and management of deformities: All measures should

be taken to prevent deformities, as far as possible. The mother should
be taught simple procedures such as passive stretching and the use of
night splints.
Mild to moderate deformities may be treated conservatively

by passive stretching and adequate splinting. Rigid
deformities may need manipulation under general
anaesthesia, followed by plasters and splints.
Several deformities need surgical correction. Deformities

such as congenital or acquired dislocation of the hip may
need early surgery. The tendon of iliopsoas is detached
from its insertion and transplanted posteriorly through a
hole in the ilium to augment the action of the abductors
and extensors.
After surgery: Re-education of the transplanted iliopsoas to

function as an effective hip abductor and extensor is of
primary importance. This maintains reduction of the hip
joint and provides stability to the hip on bearing weight.
When surgical elongation of the quadriceps is done to
release the rigid genu recurvatum, it needs concentrated
efforts to improve the muscle strength and range of
movement (ROM) at the knee so as to stabilize the knee in
standing and walking. Tendon transfer surgery may also
be necessary to correct inversion or calcaneus deformity.
Proper measures are necessary to re-educate the
transferred muscles and to maintain an adequate range of
motion at the ankle and foot. Efforts to achieve plantigrade
position of the foot needs to be emphasized as this position
of the foot is important for proper foot contact and weight
transfer during ambulation.
2. Management of muscle paralysis: Depending upon the level of the
lesion, priority should be given to:
(a) Arm and shoulder girdle muscles. These should be

developed for crutch walking and transfers.
(b) Functionally important weight-bearing muscles such as

hip abductors and extensors, knee extensors, ankle dorsi
and plantar flexors should be strengthened to the
maximum.
(c) Establish the body equilibrium in various positions.

This can be achieved by using arm muscles and visual
and auditory feedback techniques. It can be initiated as
rolling and progressed gradually to sitting.
Children with thoracic lesions need re-education of the trunk

muscles.
(d) Proper re-education of the transferred muscles.
3. Care of skin and joints: Anaesthetic skin and insensitivity of the

joint position need to be given due importance to avoid further
damage and complications.
While using splints and braces and during passive

stretching, protection of the skin from pressures and
ulcerations is necessary. This is done by proper checking of
the appliance and by frequent careful examination of the
skin at pressure points. Parents should also be warned
against exposing the insensitive parts of the limb to
extreme hot and cold situations.
Loss of joint position sense can be compensated by
appliances and visual and auditory reflexes.
4. Management of bladder and bowel incontinence: Applying

manual pressure above the symphysis pubis at regular intervals can
be helpful in emptying bladder in boys. In girls, it is difficult to obtain
such control.
Children who dribble constantly may develop ulcers at the

napkin area, thus needing frequent examination of these
areas and the necessary skin care.
Infection of the urinary tract and failure of the kidney

function can be avoided by surgical diversion of the urine
to a receptacle.
Bowel incontinence is manageable as most of the children

develop an automatic bowel action. If necessary,
suppositories or enema may be used.
5. Education in ambulation and self-care: Preparing a child for

ambulation is the principal goal, and all the efforts to achieve this are
initiated right from the beginning.
It has to be systematically progressed to:
(a) Strengthen the upper extremity, shoulder girdle and

trunk muscles.
(b) Prevent adverse factors such as hip flexion, knee flexion

and ankle dorsiflexion contractures by emphasizing hip
extension, knee extension and ankle plantigrade
programmes, respectively.
(c) Develop equilibrium reactions.
(d) Develop static and dynamic weight-bearing

programmes with properly fitting appliances.
(e) Re-education standing and gait training.
The goal of ambulation differs primarily with the

neurological level of the lesion (Fiewell, 1980; Hoffer,
Fiewell, Perry, Perry, & Bonned, 1973). Besides this, factors
such as mental retardation, spasticity, hydrocephalus and
spinal deformity can limit ambulation.
Patients are classified into four levels of functional groups (Fiewell,
1980):
1. Thoracic patients
2. High lumbar patients
3. Low lumbar patients
4. Sacral level patients
1. Thoracic patients: Children in the thoracic group rarely achieve

independent ambulation due to total lack of muscle power and
sensations in both lower limbs. They generally depend on wheelchair
ambulation and, therefore, should be trained in transfer and self-care
activities.
2. Upper or high lumbar patients: In this group, the muscle power is

present in hip flexors and knee extensors. These patients can be made
ambulatory by an AK orthosis with pelvic band.
3. Lower lumbar patients: Patients in this group can be made

ambulatory with the help of a BK orthosis due to the presence of
power in the following muscle groups: hip flexors and abductors;
knee flexors and extensors and ankle dorsiflexors.
4. Sacral level patients: These patients have a high potential for

ambulation due to the presence of power in the additional muscle
groups such as hip extensors, plantar flexors and toe flexors.
Developmental disorders of the spine

Scoliosis
A lateral curvature of the spine is termed as scoliosis (Fig. 32-3).
Basically, it is of the following two types:
1. Postural scoliosis (nonstructural)
2. Structural scoliosis
1. Postural scoliosis: This type of scoliosis has no structural

(bony) changes in the vertebrae. The causes may be
wrong postural habits, shortening of one leg, a disc
lesion (sciatic scoliosis) or psychological factors.
2. Structural scoliosis. In this type of scoliosis, there is defect

in the bone which results in contractures of the soft
tissues on the concave side of the curve and reciprocal
stretching on the convex side.
FIG. 32-3 (A) Radiograph of the whole spine (AP and lateral views)
showing dorsolumbar scoliosis. (B) AP view radiograph showing the normal
spine for comparison.
Structural scoliosis can also be classified as follows:
1. Idiopathic scoliosis
2. Paralytic scoliosis
3. Congenital scoliosis
Idiopathic scoliosis
Infantile idiopathic scoliosis – Onset during the age of 3 years

Juvenile idiopathic scoliosis – The age of onset is between 3 and 10 years
Adolescent idiopathic – The age of onset is between 10 and 20
scoliosis years
Adult idiopathic scoliosis – The age of onset is over 20 years
Infantile idiopathic scoliosis: Usually there is spontaneous resolution

of the curve. However, children for whom the curve progresses
rapidly need early surgery.
Juvenile idiopathic scoliosis: Rapid progression of the curve occurs
due to growing age. If bracing fails to control the deterioration,
surgery may be indicated.
Adolescent idiopathic scoliosis: If detected earlier, acceptable
correction is achieved by bracing.
Adult idiopathic scoliosis: In rare instances, scoliosis may develop as a
result of disc degeneration. When the deterioration is rapidly
progressive, surgery may be indicated.
Idiopathic scoliosis is more commonly seen in girls in the adolescent
age group. Thoracic spine is involved often. Initially, there is slight
curvature of the spine which may go unnoticed until asymmetry of
the chest or shoulder develops. The evolution of the scoliosis is
discussed in the following pages.
The curve may progress until skeletal maturity. If not treated, the
curve may cause cosmetically unacceptable deformity,
cardiorespiratory compromise and pain from degenerative changes in
the spine later in life.
Paralytic scoliosis
Poliomyelitis, cerebral palsy or spina bifida may result in paralytic
scoliosis. Greater degree of muscle imbalance and growing age
complicate and rapidly deteriorate the scoliosis in these children.
Surgery is indicated if there is rapid progression of the curve.
Congenital scoliosis
Congenital anomalies of the vertebra such as hemivertebra or block
vertebrae (Fig. 32-4) cause congenital scoliosis.
FIG. 32-4 (A) Radiograph of congenital scoliosis showing hemivertebra.

(B) Congenital scoliosis. Note the hemivertebra (diagrammatic
representation of the radiograph in Fig. 32-4A).
If severe, the curve may be detected at birth; in milder forms, it may

appear at the time of the adolescent growth spurt. Its complications
render the brace ineffective, and surgery may be required.
Scoliotic curves
1. Compensatory curve due to primary curve: In the presence of a primary
curve, the erect body is put to tremendous gravitational forces on the
convex side of the curve. To avoid this imbalanced strain and fatigue,
compensatory secondary curve develops opposite to the primary
curve (see Fig. 32-3).
2. Compensatory curve due to deformities in other parts of the body:

Deformities of the neck, arm, trunk or leg may also give rise to
compensatory curves. These may be due to postparalytic, congenital,
rachitic or static causes. Unilateral organ diseases such as pleurisy,
empyema or disc lesion may also give rise to scoliosis.
3. Rotational element: Structural scoliosis is accompanied by rotation of

the vertebrae towards the convexity of the curve. However, the
spinous processes are rotated away from the convexity (Fig. 32-5). The
ribs are thrust backwards on the convex side. This element of rotation
creates problems in the correction of the deformity.
FIG. 32-5 (A) Thoracic scoliosis showing rotation of vertebrae. The

vertebrae at the upper and lower ends of the curve have normal rotation –
the tip of the spinous process is in the centre of the body of the vertebra
and the pedicles are symmetrically placed. The vertebrae in the centre of
the curve are rotated – the tip of the spinous process is eccentric and only
one pedicle is seen. (B) Radiograph (AP view) showing the normal spine
for comparison.
Course and prognosis:
It depends upon the age of onset, time of detection, site of the primary
curve and institution of treatment.
If the onset is at an early age, the curve tends to increase with age
till the end of skeletal growth. The prognosis in such a case is poor,
particularly in the thoracic curves. The thoracic curve also interferes
with breathing efficiency. Thoracolumbar or lumbar curves
compensate well, are far less noticeable and do not cause any
functional deficiency.
In double curve, when the thoracic curve is primary, the situation is
complicated further.
Treatment
Therapy plan
A complete evaluation is essential before planning the therapeutic
programme.
Evaluation (fig. 32-6)

The evaluation is done by critical examination at various spinal levels.
The patient stands with the bare back to the light. The examination is
done by:
1. Inspection
2. Curve measurement
1. Inspection: The general outline of the spine is observed. The

various anatomical levels are identified.
(a) Level of the ears and contour of the neck: Disparity in the
level of ears or neck indicates the presence of a cervical
curve.
(b) Shoulder level: Any disparity in the level indicates the

presence of a cervico-dorsal or a high dorsal curve. The
shoulder will be higher on the convex side of the curve.
(c) Scapular level: A shift in the level of the inferior angle

and the vertebral border of the scapula away from the
midline along with higher scapula and eversion of the
inferior angle indicate a dorsal curve.
(d) Position of the arms and the waist line: The arm on the side
of the high shoulder hangs close to the body and the
waist line may be more on the opposite. The back
appears wider on the convex side due to the bulging ribs.
(e) Thorax: The ribs appear to be crowded on the concave

side, and further apart on the convex side. When the
dorsal curve is more pronounced, there is rotation of the
thorax (more apparent from the front). The ribs bulge
backward on the convex side and appear flattened on the
concave side.
(f) Hips: The hip and the posterior superior iliac spine are
higher on the concave side.
(g) Pelvis: Forward rotation of the pelvis occurs on the

concave side of the lumbar curve. Iliac crest will be
prominent and higher on the concave side. Also, the
gluteal fold on the side of the raised pelvis appears
higher. The presence of coxa vara, fixed flexion and
adduction deformities also need to be assessed.
(h) Knees: The alignment of the knee joints is checked. The

shortening of leg should be measured. The levels of both
patellae and their disposition are checked.
(i) Feet: Any deformity in the feet and toes is noted.
ROM assessment: All the spinal movements are evaluated.
Forward bending test: The patient in stride standing bends

forward. In postural scoliosis, the curve is corrected with
this test, but in structural scoliosis, the curve remains
unaltered.
2. Curve Measurement: The scoliotic curves are termed by the apex

of the curvature.
(i) Cervical scoliosis: The apex of the curve is between C1

and C6.
(ii) Cervico-thoracic scoliosis: The apex of the curve is at the

cervico-thoracic junction.
(iii) Thoracic scoliosis: The apex of the curve is between

thoracic 2 and thoracic 11 vertebrae.
(iv) Thoracolumbar scoliosis: The apex of the curve is at the

thoracolumbar junction.
(v) Lumbar scoliosis: The apex of the curve is between

lumbar 2 and lumbar 4 vertebrae.
(vi) Lumbosacral scoliosis: The apex of the curve is at the

lumbosacral junction.
FIG. 32-6 Evaluation and inspection of various anatomic levels, plumb line
to assess the trunk alignment.
The scoliotic curve is measured by Cobb’s method.

Cobb’s method: A posteroanterior radiograph of the spine is taken
for measurements. The vertebra at either end of the curve which is
tilting towards the concavity of the curve is taken as the end vertebra.
A straight line is drawn which passes through the upper border of the
upper end vertebra; and another that passes through the lower border
of the lower end vertebra. The angle formed by the lines
perpendicular to these lines represents the angle of scoliosis (Fig. 32-
7). A curve measuring 60 degrees or more with respiratory
insufficiency is an absolute indication for surgery.
Respiratory status: In scoliosis of the thoracic spine, the vital capacity

and chest expansion are reduced. These should be measured and
recorded. The exercise tolerance of the patient is also evaluated.
Rib hump: At the thoracic curve, the rib hump is measured with a
gauge. The depth of the valley is measured in the low thoracic or
lumbar curve either in forward flexion or in prone position by a
scoliometer (Fig. 32-8A). The outline of the hump can be traced and
transferred to a graph paper. Distortion also occurs in the ribs and
vertebrae in the thoracic curve (Fig. 32-8B).
The physiotherapist marks the following bony points with a skin

marker: The spinous processes, the inferior angles of
scapulae, the posterior iliac spines and the anterior
superior iliac spines. The spinous processes are marked
again after achieving maximum correction of the curve
with postural manoeuvres. Taking photographs in the
corrected position as well as in the position of maximum
curves is helpful in providing the exact therapeutic
programme to a patient and also in assessing the results.
Test for function: Range of movement is tested and recorded for

flexion, extension, lateral flexion as well as rotation (the method is
the same as described under low back pain).
Test for pain: The whole spine is palpated with finger tips over the
spinous processes from occiput to the sacrum.
FIG. 32-7 Measurement of the scoliotic curves by Cobb’s method.

FIG. 32-8 (A) Rib hump deformity in the patient, as seen from behind. (B)
Rotation of the vertebra and distortion of the rib cage.
Tenderness or pain indicates the presence of some inflammatory

lesion.
Patient in stable standing: If this test is positive, further investigations

are conducted to ascertain the exact pathology.
In the presence of an inflammatory lesion, active physiotherapy

would be strictly contraindicated.
Monitoring curve progression: Scoliosis in growing children or

adolescents needs to be monitored till the cessation of spinal growth.
This coincides with the cessation of growth in the iliac apophysis,
known as Risser’s sign. The apophysis appears at the anterior end of
the iliac crest and gradually progresses posteriorly (Fig. 32-9). As
seen in the radiographs, fusion of the iliac apophysis to the medial
end denotes completion of the growth of the spine. All these
measurements are repeated at regular intervals to assess the
progress.
Treatment: The prevention or control of the curve in the early phase

assumes priority.
FIG. 32-9 Iliac crest apophysis starts ossifying anteriorly and progresses
posteromedially (as shown by arrow).
Preventive role
1. Ideally, a screening programme of all children in the age group of

10–14 years is necessary. This age group has been proved to be the
most vulnerable one.
2. Parents can also play an important role in the early detection of a

scoliotic curve. Therefore, education of the parents on simple
observational techniques may be helpful.
Conservative treatment is indicated in growing children with a

curve of less than 40 degrees.
Mild postural curves

(Curve less than 40 degrees)
1. Active correction: As these curves are correctable, the

physiotherapist identifies the postural adaptations by asking the
patient to move and place the legs or trunk in such a position that
optimal self-correction of the curve is attained. Once the correction is
achieved, its maintenance becomes the basis of therapy.
2. Passive correction: Hanging provides the best method of passive

correction; unequal hanging or hanging with one arm. Hanging in the
head suspension apparatus always gives satisfactory results. If
hanging is not feasible, sufficient amount of axial traction can be given
by two therapists. One physiotherapist grasps the pelvis and gives
traction towards the legs while the other grasps the chin and the
occiput and stretches the spine in the opposite direction in the
forward lying position.
3. Maintenance of correction: The most important aspect in postural

curves is to educate the patient to maintain the correction by active
efforts.
Management of postural scoliosis (grade I)

The correction of the deformity is obtained by progressive re-
education of the bad posture.
The regimen includes the following:
1. General body relaxation by using the whole body relaxation

technique.
2. The patient is trained to feel and hold the corrected posture.

However, this may not be always possible.
3. The postures should be corrected passively by the physiotherapist.
4. Repeated sessions of maintenance of the corrected posture till

correction becomes automatic.
5. General free mobility exercises to the whole spine and

strengthening exercises to the spinal extensors and abdominals.
6. Deep breathing should be incorporated.

7. Balance exercises, e.g., walking with a book on the head in a
corrected posture is valuable.
8. Stretching of the tight soft tissues and their sustenance forms the
most important aspect of therapy. Correction of the contractures and
shortening of the soft tissues on the concave side of the curve can be
achieved by guiding the correct posture in lying. This substantially
helps the other methods of active postural correction.
9. After good correction, the patient should be advised to continue

with exercises, avoiding especially the positions and the activities
prone to produce the existing deformity.
10. The patient must report regularly for screening.
Management of structural scoliosis (grade II)

Structural curves of less than 40 degrees are treated conservatively. If
it is almost impossible to achieve correction, active self-correction as
well as maintenance of a brace (orthosis) is indicated to prevent
deterioration of the curve. The brace also helps in gaining some
correction while allowing the continued growth of the spine during
adolescence. The braces for spine for use in scoliosis are named as
follows:
(i) TLSO: Thoracolumbosacral orthosis
(ii) CTLSO: Cervico-thoraco-lumbosacral orthosis
(iii) CTO: Cervico-thoracic orthosis
The most commonly used orthosis is the Milwaukee brace (CTLSO)

(Fig. 32-10). It has a contoured girdle which covers the pelvis firmly. It
has an occipital pad and a chin pad. A lateral pad is placed over the
rib hump. This orthosis immobilizes the spine and maintains a
stretching effect. The Boston brace is another orthosis used for
scoliosis below T8 level. Some other orthoses are the Wilmington
TLSO and the Charleston bending brace.
FIG. 32-10 Milwaukee brace. CCP, curve correcting pad.
The correction achieved in the orthosis is maintained by active

exercises. The exercise programme is the same as for postural
scoliosis.
1. Mobility exercises are more important as the spine remains

immobilized in brace.
2. Deep breathing exercises are also important as the excursion of ribs

is limited due to the brace.
3. Lumbar lordosis is usually associated with these curves; therefore,

exercises to reduce and correct the anterior pelvic tilt are important.
4. Correction of a major curve is also achieved by putting a pad over

the rib hump in the brace on the convex side of the curve (Fig. 32-10).
5. Repeated stretching sessions for hip flexors and hamstrings are

important, as these have a tendency to shorten because of the pelvic
tilt.
6. Hanging in head suspension apparatus or on stall bars can provide

effective stretch to the whole spine.
The whole programme and the brace need to be continued

uninterrupted during the day and night. The brace also needs
repeated adjustments and is continued until the child attains skeletal
maturity. It can be weaned off gradually thereafter. Miyasaki (1980)
reported the efficacy of thoracic flexion exercises in the Milwaukee
brace in reducing apical vertebral rotation and the thoracic curve. It is,
therefore, necessary to teach this exercise with the brace on.
Severe structural curves (grade III)

Curves greater than 40 degrees need surgical intervention. In these
patients, preoperative evaluation and training are essential.
Preoperative physiotherapeutic assessment and training
1. The parameters relevant in the immediate postoperative

management should be repeated.
2. Measurement of the rib hump is done in prone.
3. Assessment of pulmonary function: It is necessary to check the

overall efficiency of breathing. If necessary, it may be taught again
along with the technique of intermittent positive pressure (IPP), which
may be needed in some cases.
4. Muscle charting of the body and limbs should be done, especially

below the level of fusion.
5. Detailed neurological examination is necessary to detect any

compressive symptoms of the spinal cord. These may be present due
to ischaemia following excessive stretching.
6. Vigorous and strong ankle and toe movements with isometrics

should be taught to the gluteal and quadriceps muscles.
7. Gait analysis and functional status should be assessed, and

requirements of normal gait explained.
8. Postural guidance: Guidance is given to learn the techniques of

correction of the posture and its maintenance in front of a postural
mirror. Correct technique of even weight bearing on the pelvis and
lower limbs needs to be understood.
9. Spinal stretching and mobility: Stretching the whole spine to the

maximum, maintenance of the stretch as well as techniques of
improving the overall intervertebral mobility are important. This
stretches the contracted soft tissues in preparation for the surgery of
fixation of spine in corrected position.
Various forms of traction
1. Skeletal traction may be applied in the following forms:
(a) Halofemoral traction
(b) Halopelvic traction (see Fig. 4.9)
(c) Halo wheelchair traction

2. Nonskeletal methods of traction can be:
(a) Intermittent traction followed by sustained traction
(b) Cotrel traction
(c) Gravitational traction
(a) Intermittent traction, followed by sustained static

traction as applied commonly in LBP patients. It offers
relaxation, which, in turn, promotes stretching of the
spinal structures. The stretching is to be maintained by
static traction.
(b) Cotrel traction (Fig. 32-11): This has double effect as it is

a combination of sustained traction which is
superimposed on intermittent traction and is operated by
the patient himself. A constant traction of 2-kg weight is
attached to the cervical halter at the head end of the bed.
Intermittent traction is applied by the pulley system in
such a manner that the extension of arms and legs
provides extra force for spinal distraction.
(c) Gravitational traction: The patient lies supine on the

tilted table with feet away from the foot plate. A corset is
firmly secured in this position so that the body weight
and the gravitational force provide graded traction to the
spine as the angle of the tilt-table is altered from 30
degrees and 60 degrees to 90 degrees (Fig. 32-12). Initial
traction time of 12 min may be increased to 1 h.
FIG. 32-11 Cotrel traction in extended position.

FIG. 32-12 Gravitational traction. As the angle is increased in graduated

steps of 30 and 60 to 90 degrees, the traction force increases.
This method has been found to be twice as effective as the Cotrel

traction.
Caution
This method is contraindicated in arterial hypertension, congenital
spinal malformations, in the presence of any neurological disease
and in the flaccidity of the ligaments of the cervical spine.
The patient should be warned about the temporary increase in
pain following surgery.
Surgical treatment
Indications for surgery: Surgery is indicated in the following
circumstances:
1. Cord compression: It is commonly seen in kyphotic deformities.

Decompression of the cord is done and is usually followed by
correction of the deformity with fusion of the spine.
2. Rapid progression of the curve: This is caused by the adolescent

growth spurt or due to disc degeneration in older patients.
3. Pain: Correction of deformity only after thoroughly investigating

the anatomical source of pain.
4. Respiratory impairment: Patients with severe paralytic deformities

involving thoracic spine may develop respiratory insufficiency.
Surgical correction and spinal fusion become necessary in these
patients.
5. Cosmetic: Thoracic scoliosis with severe hump due to vertebral

rotation is occasionally treated surgically for cosmetic reasons.
The basic principles of surgical treatment in scoliosis are as follows:
◼ Correction of the curve, if possible.
◼ Maintenance of the correction achieved by spinal instrumentation

and/or spinal fusion.
The aims of treatment in scoliosis are as follows:
◼ To restore the symmetry of the trunk as much as possible by

correction of the curve.
◼ To straighten the thoracic curves to stop the deterioration in the

pulmonary functions.
Correction of the curve: The scoliotic curve is corrected as much as

possible before surgery. In congenital scoliosis and in rigid scoliosis of
neurofibromatosis, no attempt is made to correct the curve, lest the
patient may develop neurological symptoms. Early fusion of the spine
checks the progression of the deformity. Any of the following
methods are employed to achieve maximal correction of the curve.
1. Corrective cast: The patient is made to sit on a stool and an attempt is
made to correct the scoliotic curve using a head halter. A plaster of
Paris (POP) cast is then applied over the trunk with the scoliotic curve
in the corrected position. A few days later, a window is made in the
cast over the spine, through which the surgery of spinal fusion is
performed. Since the cast maintains the correction of the curve, there
is no need for any spinal instrumentation. The cast is maintained
postoperatively for about 6 months till the fusion consolidates. This
technique is generally employed in children.
2. Distraction techniques: Certain distraction techniques, such as

halofemoral distraction and halopelvic distraction, are employed to
correct the deformity of the spine. The spinal deformity is corrected by
gradual distraction, and subsequently surgery is performed with the
distraction apparatus in situ.
3. Loosening of the curve: In rigid scoliotic curves, the operation of

loosening of the curve is performed as a first stage procedure. In this
operation the intervertebral discs of the affected vertebrae are
removed so that the spine gets loosened. Now a distraction technique
(such as halopelvic traction) is used to achieve straightening of the
spine (as much as possible). Spinal fusion with instrumentation is
subsequently performed after about 4–6 weeks as a second stage
procedure. These days, alternatively, two procedures of loosening of
the curve and spinal fusion with instrumentation are performed in
one single operation. This, of course, is a major surgical undertaking
and requires the use of spinal monitoring during surgery to avoid
traction injury to the spinal cord.
Maintenance of the correction achieved: This is achieved by

fusion of the spine along with some sort of internal fixation
of the spine (spinal instrumentation). The only exception to
instrumentation being the cases where a POP cast has been
applied preoperatively, as described earlier.
1. Spinal fusion: Fusion of the spine is performed through a
posterior approach. The area of deformity in the spine is
fused along with at least two vertebrae proximally and
two distally. After spinal fusion, a plaster jacket is
applied, which is maintained for about 6 months till the
fusion consolidates.
2. Spinal instrumentation: As described earlier, the scoliotic

curve is corrected first, then the spine is fused and
stabilized with any of the following instrumentations:
(a) Harrington instrumentation: It consists of a Harrington

rod and two hooks. After fusion, each hook is fixed into
the posterior elements of the vertebra at either end of the
curve; the rod is then threaded through these hooks.
Moderate distraction is applied to achieve maximum
possible correction of the curve. The Harrington
instrumentation now maintains the correction achieved
(Fig. 32-13). Postoperatively, a plaster jacket or a brace is
given for about 4–6 months. However, Harrington
instrumentation is now being replaced by newer
methods of segmental instrumentation, which also obtain
better correction in terms of rotation of the vertebrae.
(b) Segmental spinal (Luque) instrumentation: In this

operation, multiple wires are passed beneath the laminae
of the vertebrae in the curve on either side of each
spinous process. The wires are then twisted around two
rods placed on the other side of the spinous processes
and tied (Fig. 32-14). This instrumentation not only
corrects the curve but also enhances the arthrodesis. The
fixation is usually rigid and does not require external
immobilization.
However, the passing of wires beneath the laminae makes it

a technically difficult operation and more prone to
neurological complications postoperatively.
The use of Harrington and segmental spinal (Luque)

instrumentation has almost become obsolete and are
replaced by newer instrumentations as discussed in the
following pages.
(c) Spinal instrumentation: Many internal fixation devices

are available to choose from which involve the use of
pedicular screws and rigid rods (Fig. 32-15). This type of
instrumentation obtains better correction of lateral
angulation as well as the rotation of the vertebrae. It is a
major surgical undertaking and is not without serious
complications, including paraplegia.
Video-assisted thoracoscopic surgery (VATS): Endoscopic

thoracic surgery is also employed in the spinal deformity
correction and anterior instrumentation. With this
technique, the postoperative morbidity is much less but
there is certainly a steep learning curve.
FIG. 32-13 Harrington rod instrumentation to maintain correction of

scoliosis.
FIG. 32-14 Luque’s segmental instrumentation.

FIG. 32-15 (A and B) Surgical treatment of the case shown in Figure 32-
3A. Correction of the curve and spinal instrumentation are seen.
Postoperative physiotherapeutic management

The regimen of physiotherapy remains unaltered. Minor alterations
may be necessary in relation to the surgical procedure performed.
The basic approach during the postoperative phase is as follows:
First two days

1. Respiratory status: In patients with the anterior approach of
surgery, this assumes primary importance. Besides, deep breathing
and vibrations with assisted coughing need emphasis.
2. Strong sustained as well as speedy ankle and toe

movements and active upper extremity movements are
initiated to the maximum painless range.
3. Slow relaxed passive movements to the lower limbs

assist in relieving pain and stiffness and improve
circulation.
4. Neurological symptoms need careful assessment and

treatment, if necessary.
5. Patients are turned to the sides alternating with prone

lying every 2 h.
Third and fourth day: Increased full range passive and active
movements to the hip and knee joints alternated with relaxed
passive movement may provide pain relief.
The rib hump should be measured at this stage to ascertain

the change.
After 5 days
1. Assisted guidance: Guidance in rolling, sitting and

standing can be initiated with assistance, e.g., sitting up,
getting down the bed by standing up and going to the
bed from the reverse position, e.g., in prone position but
sitting up, getting down. Reverse climb down technique
without putting extra strain on the spine is initiated.
Getting out of bed is taught by rolling to prone position,
coming to kneeling position in prone and getting down
by slowly sliding down from the foot end of the bed. The
same technique is applied for getting into bed, climbing
up is done by a forward approach.
2. Sitting: The standing is initiated from supine position,

hanging legs and raising torso with arms support.
3. Chair sitting: Initially, lumbar roll may be provided in

sitting. Progress to chair sitting without back rest with
correct guidance. This will help the patient to learn to
support the spine actively (McKenzie, 1981).
4. Standing and walking: Functional (assisted) standing to be

initiated in supine position, hanging the legs at the side
end of the bed and lifting the trunk (torso) with hand
support. To begin with, assistance is needed in standing
balance as the balance may be impaired because of
fixation or impairment of proprioception. This leads to
imbalance and postural deficiency, as the postural
balance is regulated by the receptor system in the
connective tissues and the muscles around the upper
vertebral synovial joints. Gradual sitting should be
started with a back rest. It should be progressed to
unsupported sitting and standing as the proprioception
returns.
5. Walking: As soon as balance in standing is acceptable,

walking is initiated with correct gait pattern and
progressed to achieve physical independence.
The patient should be made to walk in parallel bars with the height
of the hand rail raised and adjusted to avoid forward flexion of the
spine as forward stooping puts maximum stress on the lumbar spine.
The patient should be made ambulatory at the earliest, and initially
may need axillary crutches.
Caution
In the presence of unsteadiness, a spinal jacket may be necessary in
thoracolumbar fusion. Exercise may occasionally cause excessive
strain and pain. Therefore, the exercise programme should have
periods of enough rest in-between.
Physiotherapeutic management for other surgical procedures of the

spine remains the same as described earlier. However, the specific
points to be remembered under each heading can be summarized as
follows:
1. In one Level one anterior fusion: By 2 weeks, after suture removal, if

the spine is stable with good muscle control, a corset is given, or else a
POP jacket is applied for 3 months and then changed to a corset.
Exercises for the back are not advised, except the isometrics.
Exercises are to begin only 3 months after surgery as
simple movements to the spine. Swimming is an ideal
mode of exercise to achieve mobility of the spine.
2. Level two anterior spinal fusion: The period of POP jacket is 3–6
months. Hip spica is necessary for patients with L5–S1 fusion. This
needs suitable modifications in the programme of ambulation.
Otherwise the management proceeds on the lines of general regimen.
3. Posterior fusion with the Harrington instrumentation: Rolling is taught

as a one-piece rolling (log rolling) to avoid trunk rotation. POP jacket
is to be worn for 6 months. Activities of daily living (ADLs) and work
training are to be taught with the jacket on.
4. In combined anterior and posterior fusion with Harrington rod: Turning
in bed is used to facilitate safe rolling. This is progressed to tilt-table
activity. The patient is given a single above-knee hip spica, POP jacket
or a corset. By 4 weeks, specific aids may be given for dressing and
other ADLs, including correct walking aid and ambulatory
techniques.
5. In anterior and posterior fusion 2 weeks apart: There is excessive

muscular weakness because of repeated surgery. Hydrotherapy is
ideal. The combined procedure gives better and quicker results as
regards pain and mobility.
6. In laminectomy/discectomy: If laminectomy is done for spinal stenosis,

only isometrics are taught to the patient. A corset may be applied at
the time of discharge.
If nerve root decompression with partial laminectomy is performed,

2 weeks bed rest is followed by corset.
Caution
Following any surgical procedure to the spine, excessive strain of
lifting and bending is to be avoided. This should be taught on
ergonomic principles, as detailed for LBP patients.
Postsurgical complications: The common complications are as

follows:
1. Deep vein thrombosis
2. Pulmonary embolism
3. Paralytic ileus
4. Associated stiffness of spine, neck or shoulder
5. Wound infection
6. Neuralgia
7. Graft site pain
8. Plaster sores
Physiotherapy plays an important role in the prevention as well as

management of all these complications.
Kyphosis
Kyphosis or round back is the exaggeration of the posterior spinal
curve and is generally localized to the dorsal spine (Fig. 32-16). The
back is rounded, the head is carried forward and the chest is flattened.
This results in typical round shoulders with excessive protrusion of
the scapulae.
FIG. 32-16 Adolescent exaggerated thoracic kyphosis with compensatory

lumbar lordosis.
Habitual bad posture at school is the common cause. It could

develop as a result of undetected defects of vision or hearing. Mental
or physical fatigue could also precipitate such habitual postural
tendencies.
In the adolescent age, this deformity may occur as a result of
arthritis, rheumatism, lung affections (e.g., emphysema) and vertebral
diseases besides habitual bad sitting postures.
In old age, it may be the result of previous bad posture, muscular
weakness, osteoporosis and degenerative diseases of the spine.
The deformity may be divided into three degrees according to its
severity:
1. First degree
2. Second degree
3. Third degree
Progress of the deformity from first to third degree: A bad habitual

posture is the precipitating factor. Initially (first degree), if not
corrected at this stage, it progresses to the second degree.
(a) The pectoral muscles become short, thereby restricting the chest
expansion.
(b) Longitudinal back muscles, rhomboids and the middle trapezius

are unduly stretched and weakened with loss of tone.
(c) Posterior ligaments are lengthened with corresponding shortening

of the anterior structures. This gives rise to increased posterior laxity
and a typical kyphotic deformity.
(d) During the adolescent stage of the growth period, wedging of the
vertebral bodies may occur.
Kyphosis can also occur due to tuberculosis, ankylosing spondylitis,

Scheuermann’s disease or congenital anomalies. Total assessment of
the kyphotic deformity is to be done on the same lines as described for
scoliosis.
Treatment
As in scoliosis, early detection by screening forms an important part of
its prevention. Other methods as described under scoliosis should be
adopted. Physiotherapeutic management basically depends upon the
stage of the condition and its ill effects.
First degree kyphosis: It is postural and should be detected early.
1. Relaxation of the body, especially the upper back.
2. Repeated stretching sessions of shortened anterior

structures by bracing the shoulders.
3. Maintaining posture of the head, neck and shoulder

during activity or rest in optimal position should be
trained and checked.
4. Mobilization of the whole spine, particularly neck,

scapulae and shoulders.
5. Diaphragmatic and costal breathing with emphasis on

inspiration.
6. When precise mobility is attained, specific isometric and

resistive exercises can be added.
7. Efficiency of home management programme is vital for

good results. Therefore, it needs to be emphasized and
checked regularly.
8. The efficiency of home management in the form of

watchful monitoring and correction is important.
Second and third degree kyphosis: As wrong adaptation of the soft

tissues is in the advanced stage, its active correction and
maintenance are difficult. The Milwaukee brace is prescribed with
pads applied on the posterior uprights.
Exercises: With the brace on, the patient is encouraged to apply

maximum pressure over these posterior pads. It stretches the
shoulders, shoulder girdles and the kyphotic curve. Sustenance of
this active stretching is very important.
It is difficult to achieve enough correction but it certainly

helps in preventing further deterioration of the curve.
Exercises to improve mobility and respiration reduce the

overall impact of the deformity.
Surgery and postsurgical management

When surgery is undertaken, it involves gradual controlled halo
traction for several weeks. Bone graft may be necessary to maintain
the correction achieved through traction. In severe kyphotic curves,
congenital or due to tuberculous lesions, spinal cord decompression
and spinal stabilization may be necessary through anterior approach.
Besides gradual progression of the corrective mobilization and
strengthening, special emphasis should be on prevention of
postsurgical complications, especially the respiratory ones.
In the second stage of surgery, the spine is fused in the corrected
position, and the regimen of physiotherapy is the same as described
under spinal fusion.
Lordosis
Lordosis is the exaggeration of the anterior curve of the spine.
Common sites of the lordosis are cervical and lumbar spine. The
causes are (a) hip flexion contracture due to disorders of the hip, e.g.,
congenital; (b) positional or habitual tightness of hip flexors due to
paralysis of abdominals or the flexors of lumbar spine; (c) it could be
adaptive when it is developed to compensate for altered balance, e.g.,
pseudo-hypertrophic muscular dystrophy, ankylosing spondylitis,
fixed flexion deformities at the hip or the knee; (d) congenital or
acquired spinal deformities such as spondylolisthesis; (e) it could be
due to habitual posture; and (f) obesity with protruding abdomen.
The forward tilting of pelvis produces compensatory exaggerated
lumbar lordosis. This leads to stretching of the abdominal muscles
and the anterior spinal ligaments. There is reciprocal shortening of the
posterior ligaments and muscles. It may be associated with weakness
of the glutei and lengthening of the hamstrings.
Treatment
It is mainly directed towards the following:
1. Mobilization of the lumbar spine.
2. Anterior stretching of the lumbar spine by concentrating on

exercises to achieve posterior tilt of the pelvis.
3. Strengthening of the abdominals, glutei and hamstrings.
4. Training in graded correction of the pelvic tilt has to be emphasized.

Active posterior pelvic tilting by contracting abdominals and glutei in
supine position is initiated. It is progressed to sitting and standing.
Maintenance of the corrected posture is vital. ‘Make yourself as tall as
you can’ or toe touching in long sitting or forward bending sitting are
simple procedures. To be effective, these should be repeated often.
Caution
Attitudes involving spinal extension or hyperextension should be
strictly avoided.
Kypholordosis
This is a combination of the preceding two conditions, lordosis
usually being the primary curve. Therefore, early detection and
measures to treat primary lordosis can successfully prevent the
occurrence of compensatory kyphosis.
Treatment
The management on the whole remains the same. The only care one
has to take is to restrict and localize the exercise to the exact segment,
e.g., the thoracic spine must remain extended while exercising the
abdominal muscles. The flexion of the lumbar spine should not
produce flexion of the thoracic spine as well. Appropriate corrective
braces should be applied, if required. The whole approach should be
individualized.
As the corrective methods take longer time, emphasis on regular
checkups and thorough evaluation is to be observed strictly.
Efficacy of the home exercise programme is of vital importance.
Flat back
This is a spinal deformity which is reverse of lumbar lordosis. The
pelvis is tilted backwards with associated shortening of the
hamstrings. There is flattening of the normal lumbar lordosis.
The aim of treatment here is to increase the lumbar lordosis, which
results in forward tilting of the pelvis.
Maintenance of the arch by active holding and also passive support
in sitting are effective in maintaining lordosis.
Mobility and strengthening exercises are important.
Caution
While treating spinal deformities, certain precautions should be
observed, such as the following:
1. The holding or maintenance of the corrected position should not

be continued beyond the point of muscle fatigue.
2. The patient should be taught to localize the corrective exercises.

Careful monitoring of the effects of exercise on the deformity is
necessary.
3. Necessary compensations or appropriate braces are necessary to

square the pelvis.
4. Breathing capacity needs careful monitoring in the thoracic curves.

Cervical syndrome
Pain in the neck and its associated complications is a regular feature to
any orthopaedic clinic. The major contributory factor is bad postural
habits.
Other causes
1. Ischaemia: The origin of ischaemia is in the soft tissues. Increase in

the intramuscular pressure constricts the blood vessels, stops the
internal circulation thereby causing stagnation of waste products
which results in ischaemic pain.
2. Inflammation: Acute inflammation occurs in the superficial layers of

the posterior longitudinal ligament and capsules of the apophyseal
and interbody joints. It subsequently leads to chronic hyperplasia,
resulting in narrowing of the intervertebral canals.
3. Haemorrhage: Acute traumatic bleeding can also lead to narrowing

and compression of the nerve roots.
4. Ligamentous and capsular instability: After injury, the process of

repair is extremely slow due to precarious blood supply to the
ligaments. The repair may occur by the formation of scar tissue, with
reduced tensile and elastic properties, resulting in stiffness.
5. Disc lesions: The incidence of cervical disc extrusion is less common

due to the presence of lateral interbody joints.
6. Degenerative changes: These are common in the areas of maximum

stress (C4–C6). This leads to joint pain and limitation of movements.
However, thickening and fibrosis of the ligamentous and capsular
structures further narrows the intervertebral canal, thereby
precipitating the symptoms. Occasionally, osteophytes may be formed
at these sites.
7. Repeated muscular strains: Certain muscle groups are exposed to

repeated strain by performing one particular movement more often
than the other. Sudden or jerky movement may also result in this type
of strain.
8. Bad postural habits: Sustained, bad occupational posture or habitual

wrong posture of the neck in relation to the thoracic spine and
shoulder joints results in stretching of the soft tissues on one side and
elongation or lengthening of the ones on the opposite side. This can
cause irritation and strain of ligaments, muscles or joints, precipitating
cervical pain.
Characteristics of pain
Pain originating from the ligamentous or muscular lesion can either
be localized or radiating. The radiation however is diffused and
without any precise trajectory (cervico-brachialgia). Neural pain
(involvement of the nerve root) results in a radicular pain which
radiates to a precise trajectory (dermatomal and myotomal
distributions).
Neurovascular symptoms may be associated with neck pain as
autonomic nerve fibres, and the vertebral artery runs in close
proximity to the joints of the cervical spine.
Movements at the cervical spine

The anatomical configuration of the cervical spine allows remarkable
freedom of movements to the neck in all the axes and planes.
However, the following four movements are taken as the principal
movements:
1. Flexion – in sagittal plane
2. Extension – in sagittal plane
3. Lateral flexion to right (R) and left (L) – in frontal plane
4. Rotation to right (R) and left (L) – in transverse plane

The major part of mobility to the cervical spine occurs between the
occiput, atlas and axis (occiput, C1 and C2) vertebrae.
Between the occiput and the atlas, the ROM is 35 degrees (10 degree
of flexion and 25 degree of extension). In the movements of rotation
and lateral flexion, the occiput and the atlas move as one piece.
The greatest movement of the cervical spine occurs between the
atlas and the axis. Almost 50% of the movement of total rotation
(approximately 80 degree) occurs at these joints, the rest 50% is
contributed by the remaining cervical vertebrae.
The movements of lateral flexion and rotation never occur as
isolated movements like flexion and extension. Both these movements
are inter-related, occurring with the participation of all the
intervertebral joints below the level of C2.
Flexion stretches both the cervical and the thoracic to the extent of
the dura mater. It also compresses the anterior portion of the disc,
resulting in opening of the intervertebral foramina, whereas extension
results in their narrowing. The movements of lateral flexion and
rotation bring about the closure of the foramina on the same side of
lateral flexion or rotation, at the same time resulting in opening of the
foramina on the opposite side.
The region between C4 and C6 interspaces is most mobile during
the movements of flexion and extension. This is also the region of
maximum stress. Therefore, it is the most susceptible site for wear and
tear (cervical spondylosis) as these two movements are repeated
several times in the ADRs.
Physical therapy management

To plan the appropriate therapeutic measures, a thorough physical
examination of the neck, scapulae and arm is conducted. It consists of
the following:
1. Observation
2. Active movements
3. Passive movements
4. Resisted movements
5. Neurological examination of the upper extremity
6. Neurological examination of the lower extremity
Physical examination
1. Observations: The posture of the patient’s head, neck and shoulders

is critically observed when the patient walks, sits or lies down.
2. Active movements: Examination of the active movements gives

information of the active ROM, muscle power and voluntary
movement control.
3. Passive movements: The pattern of movements provides guidance in

the assessment of the inert structures. The pattern of movement can be
as follows:
(a) Capsular – where all the movements except the cervical

flexion are limited.
(b) Noncapsular – ligamentous adhesions, where only the

movements with adherent scar in a particular ligament
are painful and slightly limited. Noncapsular pattern
with internal derangement results in blocking of one or
more movements with pain only at one side of the
movement.
(c) End feel – overpressure at the completion of passive

range tests the cervical joints’ restrictions.
(d) Presence of muscular spasm

(e) Hypo- or hypermobility of the joint – to assess
hypomobility or the joint restrictions, passive accessory
and intervertebral movement testing (central
posteroanterior pressure) using Maitland’s technique
(1977) is extremely useful.
(f) Quadrant test (foraminal compression test) – put the

patient’s head in a combined position of rotation, side
flexion and extension to one side. Then apply gentle axial
compression by pressure over the top of the head (Fig.
32-17). In a positive test, this manoeuvre produces pain,
which indicates interforaminal nerve root impingement.
It also provides a clue to identify the localized capsular
facet joint tightness.
4. Resisted motion test: It tests the following:
(a) The integrity of the cervical myotomes
(b) The lesions of the cervical muscles
(c) The strength of the cervical muscles
Pressure on the nerve trunk may cause paraesthesia but not

pain, whereas pressure on the dural sleeve results in pain
in the dermatomal distribution.
Passive flexion of the neck stretches both the cervical as well

as the thoracic extent of the dura mater, eliciting pain in the
disc lesion. Pain on the scapular approximation indicates
affection of the thoracic spine.
5. Examination of the upper extremity (nerve root impingement test): A

complete neurological examination of the upper extremity is done to
ascertain the level of nerve root and the disc lesion (Tables 32-1–32-4).
6. Examination of the lower limbs for cord signs: Presence of a spastic gait,
incoordination of lower limbs and extensor plantar response indicate
a cord lesion.
FIG. 32-17 Quadrant test for cervical spine to detect interforaminal nerve
root compression.
Table 32-1
Movements of the Neck and Upper Extremity and Their Relative Level of Segmental
Association
Level of
Movement
Association
Neck rotation C1
Shoulder shrugging C2, C3, C4
Shoulder abduction and external C5
rotation
Elbow flexion, wrist extension C6
Wrist flexion and elbow extension C7
Wrist ulnar deviation, thumb motion C8
Finger abduction/adduction T1
Table 32-2
Level of Nerve Root Lesion and Cutaneous Analgesia
Nerve
Analgesia
Root
C4 Trapezial ridge to the tip of the shoulder
C5 Upper scapula and deltoid; lateral brachial region and radial aspect of forearm
C6 Upper scapula, lateral brachial region, radio-volar aspect of the forearm and tips of the thumb
and index finger
C7 Mid scapula, posterior brachial region, dorsum of the forearm, hand and index, middle and ring
fingers
C8 Ulnovolar aspect of the forearm and ulnar border of ring and little fingers
Table 32-3
Guidance to Detect the Level of Lesion
Root Motor Reflex

Level Sensory Changes
Involved Changes Alterations
C4– C5 Deltoid Numbness over deltoid Biceps ↓
C5
C5– C6 Wrist Dorsolateral aspect of thumb Brachioradialis ↓
C6 extensors
C6– C7 Wrist flexion Index, middle and dorsum of hand Triceps ↓
C7
C7– C8 Finger flexion Medial border of forearm (volar) ring and little None
C8 finger
Note: Tendon jerks associated with nerve roots: biceps and brachioradialis C5–C6; triceps
C7–C8.
Table 32-4
Type of Lesion and the Symptoms
Lesion Symptoms
1. Paraesthesia without pain
Compression
of the nerve
trunk
2. Pain in the dermatomal distribution
Compression
of the dural
sleeve
3. Disc Passive full ROM, neck flexion elicits pain (stretches the cervical and thoracic extents of
lesion the dura mater)
(cervical,
thoracic)
4. Lesion of Painful scapular approximation
the thoracic
spine
5. Localized Quadrant test positive on the involved side; unilateral scapular and arm pain after fatigue
cervical
facet joint
restriction
6. Capsular pattern of movements. Limitation of movement is mild in flexion, moderate in
Degenerativelateral flexion and severe in extension; pain and stiffness in the neck; bilateral radiating
changes pain in the arms; headache radiating from the occiput to the frontal area
involving
facet joints
7. Presence of spasticity, incoordination and plantar extensor response
Compression
of the
spinal cord
Treatment
Data thus recorded are correlated with the subjective symptoms and
other clinical observations. Diagnosis is ascertained and a therapeutic
plan is drawn which can include any or a combination of the
following:
1. Physical agents and massage
2. Exercises
3. Cervical traction
4. Manipulation
5. Cervical collar
6. Postural and ergonomic advice
Multicentre trial has shown better relief from symptoms with a

combination therapy than with single modality (Brewerton, 1966).
Physical agents and massage

Various physical agents are routinely used mainly to:
1. control inflammation,
2. control pain and muscle spasm,
3. control stiffness of soft tissues and joints,
4. assist mobility,
5. increase blood supply and to relieve ischaemia.
Initial relaxation is achieved by the following:
1. Superficial thermotherapy modalities such as hydrocollator packs

and infrared; later on, deep heating modalities such as short-wave
diathermy, microwave and ultrasonics can be used.
2. Pain-reducing procedures of cryotherapy in the form of ice massage

and ice packs, TENS, interferential currents and diapulse are useful.
Relaxation thus achieved can be useful in procedures such as

mobilization, manipulation, general exercises or specialized exercise
techniques such as PNF and cervical traction.
Massage: Deep and sedative massage manipulations such as
effleurage, circular kneading and frictions to the localized areas
effectively reduce the spasm and pain, and thereby induce relaxation.
The relaxation thus achieved facilitates initiation of therapeutic
programmes.
Exercises
The type and extent of exercises are to be planned according to the
patient’s needs, inabilities and comfort.
1. Relaxed passive movements – this includes manipulation and

mobilization when the chief aim is mobilization.
2. Strong isometrics are indicated when mobility is contraindicated

but strength, endurance and tone of the cervical muscles need to be
improved (Fig. 32-18).
3. Active assisted movements – when the basic objective is to improve

the weak muscles without exertion.
4. Active resisted exercises – to strengthen the cervical muscles.
5. PNF techniques ideally combine all the afore-mentioned four effects

selectively.
FIG. 32-18 Self-resisted isometric neck exercise. (A) For flexors. (B) For
extensors. (C) For lateral flexors. (D) For rotators.
The effects of exercises are as follows:
1. Elongation of the tightened soft tissues to their normal range
2. Minimize the periarticular fibrous contractures
3. Regain normal length of the muscles
4. Increase circulation to deeper neck tissues
5. Improvement of the posture and functions of neck
6. Provide encouragement and an overall feeling of physical

betterment
Cervical traction
Cervical traction is a modality of choice for many cervical
dysfunctions. It is applicable in a wide range of problems from sprain
to fractures and dislocations of the cervical vertebrae.
Types of traction
1. Continuous
2. Static
3. Intermittent
4. Polyaxial
1. Continuous traction: The traction is usually continued for 24 h. The

force of traction is minimal, i.e., 5–15 lbs.
(a) Sustained small pull for long hours induces relaxation

of the muscle spasm and gradual vertebral separation. It
relieves compression on the nerve roots or the spinal
cord.
(b) It reduces the fractures and dislocations of the

vertebrae.
(c) It offers immobilization.
(d) It may help the prolapsed disc to move back into its
place.
It is, therefore, indicated in patients with fractures,

dislocations, spinal cord or nerve root compressions and
disc prolapse.
2. Static traction: Traction with a constant pull varying from 10 to 30

lbs is applied for 20–25 min. It is indicated in the presence of definite
neurological signs, including radiating pain, not relieved by other
conservative modes. It can also be given in minor disc prolapse. The
signs and symptoms gradually improve with traction.
3. Intermittent traction: Traction with alternate phases of stretching

(pull) and relaxation is the popular mode of traction. It produces the
effects of massage on the muscular, ligamentous and capsular
structures. It promotes circulation and reduces swelling, thereby
reducing inflammation, spasm and pain. It also prevents adhesion
formation between the dural sleeves of the nerve roots and may also
help in breaking the adhesions.
4. Polyaxial cervical traction: Goodley (1981) invented a polyaxial

system of cervical traction which exerts precise tractive force to a
particular segment. It increases the effectiveness of the treatment
besides having the advantage of being a patient-controlled technique.
Its modified halter prevents pressure and pull over the
temporomandibular joint.
Angle of pull of traction: The angle of head and neck in relation

to the thorax plays an important role on the various
segments of cervical spine.
Traction in flexion: Maximum pull and vertebral separation

occur at the lower segments of the cervical spine. Traction
in flexion of 24 degrees brings about greater intervertebral
separation posteriorly, thus increasing the diameter of the
intervertebral foramen, which is a common seat of
compression over the nerve roots (Collachis & Strohm,
1966). Importance of traction in flexion for cervical
radiculitis has been reported by Krusen (1955) and Crue
(1957). The vertical diameter of C5–C6 vertebral foramen
increased by 1.5 mm when the neck moved from 10
degrees of extension to 20 degrees of flexion. A small
weight produced no clinical change when applied to an
extended neck but it did produce relief when applied in
flexion.
Traction in neutral: It offers maximum pull and intervertebral

separation to the middle segments. It is indicated in
herniated discs (Delacerda, 1979).
Traction in hyperextension: It exerts maximum pull and

intervertebral separation at the upper segments of the
cervical spine.
Duration of traction: It varies as per the requirements of the

underlying pathology. Continuous traction may be needed
for several weeks in cases of fractures, dislocations,
prolapsed disc and pressure on the nerve root. Static
traction may be needed for 20–25 min once a day or on
alternate days. Intermittent traction is usually given for 15–
20 min on alternate days.
Tractive force: Continuous traction is applied with smaller

tractive force from 5 to 15 lbs. Static and intermittent
traction is to be started initially with 10–15 lbs and to be
increased to 30 lbs or more. The higher the force of traction,
the lesser its duration and vice versa. Tractive force can
vary between 1/10 and 1/7 of the patient’s body weight.
Patient’s position during traction: The convenient position of

applying overhead traction in sitting position is a common
practice. However, ideally, traction should be given with
the patient in supine position (Fig. 32-19). Traction in
supine position produces better relaxation, greater
posterior intervertebral separation, decreased muscle
guarding and increased stability. In supine position, lesser
force is required to overcome the weight of the head, and
at the same time the patient feels much more comfortable.
A correct traction pull should be ensured, as pull under the
chin forces the head into extension while a pull under the
occiput forces the head into flexion.
However, the patient’s response, comfort and reduction of

the symptoms are the basic guidelines of applying traction
successfully.
Application of traction: Traction should be applied in the

position of greatest comfort. This position is detected by
pretraction evaluation. It consists of applying gentle
manual traction in various combinations of flexion,
rotation and lateral flexion, using passive physiological
intervertebral movement testing techniques.
FIG. 32-19 Cervical traction in the most relaxed supine lying position with
the rope pulled at 45 degrees of flexion.
Caution
Cervical rotation should never be given during traction. It produces
extra stretching of the ligaments at the atlantoaxial level and is
prone to produce traumatic inflammatory reaction and increased
symptoms.
Contraindications to traction: Traction is contraindicated in the

following:
1. Marked ligamentous instability immediately inferior to the specific

traction level.
2. Malignancy involving cervical or thoracic spine.
3. Signs and symptoms of spinal cord involvement.

4. Rheumatoid arthritis with necrosis of the ligaments adjacent to the
traction level.
Manipulation
Reduction of the intra-articular displacement in cervical spondylosis
by manipulation is very effective, provided the spondylosis is not too
advanced. It is always carried out during strong traction.
Manipulation needs to be maintained correctly to prevent
recurrence. Moulded cervical collar (thermoplastic material)
supporting the mandible is given, with proper fitting of the occipital
piece, not pushing the head forwards.
Contraindications to manipulation: It is contraindicated in the
following:
1. Evidence of impaired pyramidal function.
2. Root palsy – excluding minor paraesthesia.
3. Primary posterolateral onset – where the symptoms appear in a

reverse order, e.g., paraesthesia occurring first in the digits, followed
by pain in the forearm, arm and then in the scapular region.
4. Cervical movements provoking brachial pain – instead of scapular

region, the increased pain is felt in the upper limb.
5. Long-standing brachial pain – unilateral brachial pain for more than

a 2-month duration.
6. Never attempt manipulation without thorough knowledge and

practice.
Cervical collar
The use of a cervical collar nowadays is generally discouraged. It is
advised for acute disc lesions following surgery or reduction of
fractures and dislocations. However, it may occasionally be useful in
mild cervical dysfunctions where temporary rest is needed, e.g.,
during strenuous forward bending postures at work or riding or
driving automobiles.
Functions of cervical collar
◼ Rigid immobilization
◼ Partial immobilization
◼ Support and relaxation of muscles and soft tissues
◼ Carrying out repeated isometric exercises
◼ Correction of deformity
◼ Conventional soft wrap around the neck using folded towel at night
with correct height of pillow to maintain optimal neutral position of
the neck in relation to shoulders is extremely effective in common
neck pains.
Proper fitting of a collar is necessary, e.g., its fitting in flexion is

advocated where separation of facets and opening of foramina is the
aim.
Postural and ergonomic advice

Advice on the maintenance of posture of the neck in relation to the
various body positions and ergonomics plays a predominant role in
the majority of patients with cervical pain. Faulty posture also
accelerates degenerative changes.
The correct posture of neck during working as well as rest (sleep)
should be observed to avoid excessive stress (Fig. 32-20).
Physiologically and mechanically the ideal posture is straight neck
with the chin tucked in. Ergonomic advice is the single most
important approach which can prevent recurrence of neck pain. Mass
education on correct ergonomic principles is ideal to prevent common
neck pains.
FIG. 32-20 Ideal neck posture in lying. (A) Supine lying. (B) Side lying.
Osteoarthritis of the cervical spine

It is commonly known as cervical spondylosis, spondylitis,
spondylarthritis or spondylarthrosis and begins as a degenerative
process in the central intervertebral (body) joints. Subsequently, it
affects the posterior intervertebral (apophyseal) joints (Fig. 32-21).
FIG. 32-21 Cervical spondylosis. Note the narrowing of disc spaces with
osteophytes (arrow).
Pain and stiffness at the neck are the primary symptoms. Often,
there may be referred symptoms to the upper limb.
There occurs degeneration and narrowing of the disc, with bone
reaction at the periphery resulting in osteophytes with wear and tear
of the articular cartilage. Osteophytes may press on the cervical nerve
root at the intervertebral foramina, leading to compression symptoms.
Osteophytes may encroach upon the cord and cause pressure over the
spinal cord in rare cases. The symptoms vary with the degree and site
of compression (Table 32-4).
Repetitive movements or postural strains may give rise to pain on
the posterior aspect of the neck over the trapezius. Stiffness and
grating may also be present on movement.
Radiation of pain from the shoulder to the digits along the course of
the nerve indicates nerve root compression. Paraesthesia in the form
of tingling, pins and needles may be present in the hand. Muscular
weakness or sensory impairment also happens in rare cases.
Diagnosis
Often, every neck pain is labelled as cervical spondylosis. This
diagnosis causes unnecessary worry to the patient. Therefore, it is
necessary to distinguish it from other causes of pain in the neck and
upper extremity, which could be as follows:
1. Congenital: torticollis, malformations, cervical rib
2. Infective: tuberculosis and pyogenic infections of the spine
3. Degenerative: osteoarthritis, disc prolapse
4. Tumours: tumours involving the (a) vertebra and (b) spinal cord
5. Plexus lesions: injury, causalgia, distal nerve lesions, e.g., ulnar

neuritis and carpal tunnel syndrome
6. Miscellaneous: rheumatoid arthritis, fibrositis, heart disease (e.g.,
myocardial infarction)
7. Shoulder lesions: e.g., periarthritis
8. Elbow lesions: e.g., tennis elbow
Prolapsed cervical disc

Although uncommon, when present, it is accompanied with
neurological manifestations in the upper extremities; in rare cases the
signs of spinal cord compression may be present.
The disc rupture may occur as a result of intrinsic changes in the
disc substance or an injury.
A part of gelatinous nucleus pulposus extrudes through a rent in
the annulus fibrosus at the weakest part of the cervical spine. The C5–
C6 or C6–C7 intervertebral levels are the common sites of disc
protrusion (Fig. 32-22).
FIG. 32-22 Lateral prolapse of the cervical disc (LP).
The protrusion may be:
1. Mild – causing compression of the posterior longitudinal ligament,

and localized pain.
2. Moderate – when it herniates through the posterior ligament and

presses laterally on the emerging nerve root, causing lateral disc
prolapse.
3. Severe – central protrusion compresses over the spinal cord.
The symptoms may be present in the neck and/or upper limb.

A clinical and neurological examination with emphasis on the
movements of neck, arm, muscle bulk, sensory status and reflexes will
provide information regarding the extent, site and nature of the
pathology (Fig. 32-23).
FIG. 32-23 Dermatomes and myotomes. (A) Dermatomes. (B) Myotomes.

(C) Reflexes.
Treatment
It depends on the severity of the condition. However, it is claimed that
in disc prolapse, there is a tendency for spontaneous recovery.
◼ Mild symptoms can usually be controlled with rest in a

conventional cervical collar, postural guidance and drug therapy.
◼ In severe cases, there is stiff and painful neck with positive

neurological signs. Immobilization of the neck in a moulded or POP
collar may be necessary for 6 weeks, or continuous cervical traction
may be given till signs reduce or disappear.
◼ Disc lesion with rupture of annulus may be treated by manipulation

(Cyriax, 1954).
◼ Traction is suited best for irreducible nucleus pulposus protrusion

(Cyriax, 1954).
1. Check the traction (positioning, line of pull and the magnitude)
2. Postural guidance with immobilization
3. Full ROM exercises for the shoulder joints
4. Maximum use of upper extremities
5. Scapular protraction–retraction and other shoulder girdle

movements with sustained holds
6. Deep breathing and cycling motions without straining the neck
7. Isometrics to cervical muscles with mild tension
Mobilization
1. Checking and training in the application of cervical collar
2. Relaxing thermotherapy modality
3. Stronger but pain-free isometric exercises
4. Intermittent cervical traction
5. Relaxed passive mobilization of neck
6. Gradually increasing ROM and strengthening exercises
7. Postural guidance to avoid excessive flexion attitudes; wearing

collar during working and conventional soft collar at night
Cervical rib
It is a fibrous or bony overdevelopment of the costal process of the
seventh cervical vertebra. It may be unilateral or bilateral. It is
congenital and generally asymptomatic in the early years. During
adult life, a person with this anomaly develops depressed and round
shoulders. Neurological and/or vascular symptoms may appear.
Symptoms
Neurological symptoms
Usually the lowest nerve trunk of the brachial plexus may be pressed
against the rib (Fig. 32-24).
1. There may be complete sensory anaesthesia in the forearm and

hand over the area supplied by the lowest trunk of brachial plexus.
2. Pain and paraesthesiae may be present on the ulnar aspect of the

forearm and hand; occasionally relieved by changing the position of
hand.
3. Weakness of the finer movements of hand may be present.

4. Atrophy may be present in the interossei, and the muscles of the
thenar and hypothenar eminence at a later stage.
FIG. 32-24 Cervical rib on the left side (arrow).
Vascular symptoms
1. Absence or feeble radial pulse
2. Dusky cyanosis of the forearm and hand
It is important to rule out peripheral vascular diseases such as
Raynaud’s disease. Certain other conditions such as syringomyelia,
motor neuron disease, poliomyelitis and muscular dystrophy should
also be kept in mind.
Treatment
Surgery is indicated in patients with established progressive vascular
and neurological signs. It consists of removal of the pressure-causing
elements, i.e., cervical rib and the associated fibrous band and
occasionally dividing the scaleni group of muscles.
The choice of therapeutic method depends upon the symptoms:
1. Postural guidance
2. Thermotherapy modality for pain relief
3. Exercises to improve distal circulation of hand and fingers
4. Exercises to improve tone, power and endurance of the whole arm

in general and small muscles of the hand in particular.
The most important aspect is to carefully identify the movements

which relieve symptoms. It is commonly noticed that the movements
of the shoulder girdle such as retraction and raising the arm overhead
with elbow extended wrist in neutral with interlocked fingers would
relieve the symptoms. Axial traction is applied to both the arms, and
holding for 10–30 s may bring spontaneous relief. Therefore, the
following specific exercises to develop these muscle groups are
extremely important:
1. Self-resisted scapular elevation (Fig. 32-25)
2. Self-resisted scapular adduction (shrugging)
3. Improving endurance of the muscles of the shoulder girdle by

endurance training exercise
4. Progressive resistance exercise (PRE) for the shoulder girdle
muscles with weight belt (Fig. 32-26)
5. Maximum isometric holds
FIG. 32-25 Self-resisted scapular elevation.

FIG. 32-26 Scapular elevation against the resistance of weight belt.
Caution
Thermotherapy for pain relief should not be used if there is
complete sensory impairment.
Spasmodic torticollis
Typical torticollis posture presents with acute muscle spasm and pain.
Malalignment of the neck posture at night is the predisposing cause of
acute inflammation. It can also be due to hysteria. The inflammatory
process can be controlled with appropriate drugs, thermotherapy and
exercises.
Soothing superficial or deep heating modality may be used as an
adjunct.
1. Relaxed passive movement of head in the opposite direction of

spasmodic muscles gradually altered to active movement is the best
form of exercise.
2. Controlled manipulation is beneficial.
3. The movements of rotation and side flexion are repeated in the

painless direction under traction.
4. Other relaxed slow full-range movements are helpful.
A temporary soft collar is useful during working and sleep to

maintain proper posture till acute pain subsides.
Vertebro-basilar syndrome
Two posterior cerebral arteries, which originate from the basilar
artery, supply the temporal lobes and visual cortex in the brain. The
vertebro-basilar artery passes through the foramina in the lateral
masses of the cervical vertebrae. Osteophytes may cause pressure on
the vertebral artery, particularly during the movements of extension
and rotation of the neck. This, in turn, causes transient ischaemia of
these areas of the brain. This results in vertigo.
Test for vertigo

A patient stands with the arms stretched out horizontally in front with
the eyes closed. He is asked to rotate the head fully to one side and
stay for 1 min. He is then asked to turn his head to the other side. Any
straying of the arms away from the horizontal is suggestive of cerebral
ischaemia.
Management
1. Postural guidance to avoid sudden extension or rotation of the head

and graduated slow changing of posture, all with eyes open; to first
come to side lying and sit up in grades with arm supports.
2. Use of collar during working.
3. Strong isometric exercises to neck muscles.
4. Synchronization of eyeball movements with movements of the

head.
5. Decompression of the vertebral artery.
Thoracic outlet syndrome

The classical feature of the thoracic outlet syndrome is the nocturnal
appearance of pins and needles in the fingers which disappear when
the patient changes position or sits up. The symptoms reappear on
elevation of the arms overhead or elevation of the scapulae. Pressure
on the lower trunk of the brachial plexus results due to drooping of
the pectoral girdle. These symptoms occur when the space between
the clavicle and the first rib is reduced.
Treatment
Postural guidance and strengthening exercises to the shoulder girdle
muscles. Weight carrying, cycling, driving and swimming to be
avoided.
Needs postural training in maintaining braced shoulders
posteriorly, not allowing a common tendency of protruding them
forward. A narrow osteomuscular space, traversed by neurovascular
structures, including the lower trunk of the brachial plexus, is
compressed. Repetitive performance of PNF scapular patterns with
isometric hold is ideal.
Surgical treatment
The indications of surgical treatment in cervical rib (thoracic outlet)
syndrome are as follows:
1. Evidence of neuro and/or vascular disturbances.
2. Severe symptoms incapacitating the patient: The surgical treatment

consists of removal of the cervical rib and the fibrous band which are
causing abnormal pressure on the subclavian vessels and/or brachial
plexus.
Occasionally, abnormal insertion of the scaleni muscles is

responsible for the abnormal pressure, and thereby the symptoms. In
such cases the insertion of these muscles is released to relieve the
pressure.
Postoperatively, a small dressing is maintained for about 2 weeks.

Routine measures to control pain and inflammation are taken
following surgery. Shoulder movements can be initiated after 8–10
days as relaxed passive or assisted active movements.
Active mobilization begins after 2 weeks and is intensified
gradually along with functional re-education. Full function is
restarted by 4–6 weeks.
Scalenus syndrome
It is a neurological manifestation of the cervical rib due to
compression of the lowest trunk of brachial plexus between the first
rib and the clavicle. This costo-clavicular compression occurs as a
result of the presence of tough fibrous band in the body of the
scalenus medius muscle.
The management proceeds on the same lines as described for the
‘cervical rib’.
Cervical spondylolisthesis
Forward displacement of the upper cervical vertebra occurs in relation
to the lower vertebrae (Fig. 32-27). It may occur as a result of the
following three causes:
1. Congenital nonfusion of the dens (odontoid process) with the body

of the axis; only fibrous tissue is present as a link.
2. Softening of the transverse ligament of the atlas as a result of an

inflammatory lesion in the upper part of the neck.
3. Instability developed from previous injury or inflammatory reaction

following rheumatoid or infective lesions of ear, throat or neck.
FIG. 32-27 Cervical spondylolisthesis showing subluxation of C5 on C6

cervical vertebrae.
Initial painful flexion deformity of the neck with stiffness may

progress to nerve root symptoms or even spinal cord compression.
Treatment
1. In the inflammatory type, the displacement is reduced by constant
head traction. The neck is then immobilized in a plaster jacket in
extension. If no relief is felt, atlantoaxial fusion may be necessary.
2. Congenital or post-traumatic instability – if the neurological signs

are absent, treatment by moulded plastic collar is enough.
When the neurological symptoms and severe displacement

are present:
(a) Reduction in displacement by skull traction is

attempted.
(b) If no relief, fusion of the affected segments may be

necessary.
Following conservative management: Patients are treated with
moulded collar or by constant bed traction:
1. Mobility of the legs and arms is maintained along with

strengthening techniques.
2. Emphasis is placed on the shoulder girdle and scapular muscles.
3. Gradual mobilization of the cervical spine and progressive resistive

techniques in the available range are given with emphasis on
isometrics for the cervical extensor group of muscles.
Following surgical management: The same regimen as described for

cervical disc prolapse is to be followed.
Caution
Overstretching of the fused segments of the cervical spine should be
avoided.
Studies reported on the survey of cervical syndrome by Basmajian
(1976) and Patric (1978) can be summarized as follows:
1. Females are more prone to develop cervical syndrome.
2. There is a close relationship between cervical syndrome and the

mental and psychic status of the patient.
3. Ultrasound therapy was found to be more effective in the treatment

of patients with localized tender points and those with tension
myositis.
4. Intermittent traction was found to be more effective than static

mode of traction in relieving radicular pain.
High cervical pain

The pain may be felt over the occipital area and may occasionally
radiate to the temporal region in the form of headaches (Fig. 32-28).
The pain will aggravate with the movement of the high cervical spine
(e.g., nodding). The site of emergence of the occipital nerves will be
tender.
FIG. 32-28 High cervical pain radiating to the occiput due to involvement of
the cervico-occipital junction.
Test to identify the lesion at the cervico-occipital junction

Head is bent forward (flexed) at the cervico-occipital junction, keeping
the rest of the neck straight (Fig. 32-29). The patient is then asked to
rotate the head to right and left, preventing rotation of the inferior
cervical spine. Occurrence or aggravation of pain on rotation confirms
the origin of pain at the cervico-occipital junction.
FIG. 32-29 Test to identify lesion at the cervico-occipital junction. Rotation

of the head in atlanto-occipital flexion with straight neck.
Treatment
◼ Rest in a soft cervical collar and analgesics or anti-inflammatory
drugs
◼ Pain reducing electrotherapy modality
◼ Relaxed passive mobilization
◼ Graded mobilization avoiding sudden movements
◼ Manipulation
Levator scapulae syndrome

Certain repetitive movements, e.g., typing with a bad posture,
sustained cervico-dorsal stooping posture, results in a habitual wrong
posture. Psychological tension can also give rise to this syndrome.
On examination, contractions of the muscles inserted at the
superomedial angle of scapula and at the superior portion of the
cervical spine are noticed. In unilateral involvement, a clear-cut
disparity is seen at the scapular level.
On palpation, tender nodules may often be felt.
Cervical disc lesion symptoms
◼ Unilateral or alternating scapular pain.
◼ Bilateral neck pain.
◼ Headache by extrasegmental dural reference.
◼ Unilateral scapulo-brachial pain with or without nerve root palsy.
◼ Pain in the upper limbs and paraesthetic hands as a result of

bilateral protrusion.
◼ Paraesthesia in hands and feet as a result of central protrusion.
◼ Spinal cord compression with one or more root palsies in one or

both upper limbs with spastic paresis in the lower limbs.
Osteophytic compression symptoms
◼ Pressure on one or more nerve roots, respective root symptoms.
◼ Compression of the spinal cord may cause paraesthesia of hands

and feet.
◼ Compression of the anterior spinal artery may cause paraplegia.
◼ Kinking of the vertebral artery by an osteophyte on the superior

articular process may cause impairment of basilar circulation and
vertebro-basilar symptoms.
◼ Upper cervical pain or headache when there is involvement of the

upper two cervical joints.
◼ However, osteophyte formation at the vertebral body or foramen,

as well as narrowing of one or more disc spaces, could be
symptomless. Therefore, it is important to plan therapeutic
measures on the basis of clinical examination to identify the internal
derangement, rather than excessive reliance on radiography (Cyriax,
1971).
Treatment
◼ Anti-inflammatory drugs
◼ Local infiltration by lidocaine or steroids
◼ Ultrasound and friction massage of contracted soft tissues
◼ Gentle mobilization of the neck, shoulder girdle and arms
◼ Posture training
Cervical disc syndrome: Surgical treatment

Surgery in cervical disc syndrome is rarely indicated except in cases
with cord compression.
The following surgical procedures may be performed:
1. Discectomy: Removal of the involved disc may be performed

through anterior or posterior approach. When performed through the
anterior approach, postoperatively a soft cervical collar is given for 2–
3 weeks, after which mobilization may be started.
Disc excision through the posterior approach may require

laminectomy. After laminectomy, a POP Minerva jacket or
a four-poster collar is given for a period of 4–6 weeks (Fig.
32-30).
2. Disc arthroplasty: In cervical spine, the herniated disc is removed

and replaced by an artificial disc (total disc replacement). The disc
consists of an artificial end plate as well as a simulated nuclear core,
which is inserted through an anterior approach.
3. Spinal fusion: Fusion of the spine is indicated after an extensive

laminectomy is done for cord decompression and disc excision.
Postoperatively, a POP Minerva jacket is given for about 3 months.
FIG. 32-30 Four-poster cervical collar to immobilize the cervical spine.
Preoperative evaluation: Preoperatively, careful and thorough physical
examination is conducted to assess the following:
◼ Degree of pain
◼ Respiratory status (vital capacity)
◼ Neuro-musculoskeletal status
◼ Subjective influence of the dysfunction
The patient is to be trained on the postoperative regimen of

physiotherapy with reassurance.
Postoperative management: The postoperative management proceeds
on the same lines as for all the three surgical procedures of discectomy
through anterior approach, posterior approach and spinal fusion. The
only difference being the period of immobilization, which varies with
the surgical technique, and thus the mobilizing procedures to the
cervical spine.
During the early postoperative phase, chest physiotherapy, body
positioning and resistive movements to the lower extremities and
simple nonstrenuous movements to the upper extremities are
initiated. Excessive stress on the shoulder joint and shoulder girdle
should be avoided during arm exercises.
A thorough neuromuscular examination should be conducted and
compared with the preoperative status. The neuromuscular status of
the upper limbs forms the basis of the appropriate therapeutic
programme.
Phase of mobilization.
As soon as the POP collar, four-poster collar or POP Minerva jacket is
fitted, graduated mobilization begins.
Beginning with rolling mobilization, it is progressed to arm-
supported sitting at the edge of the bed, standing balance and
ambulation. The technique and the progress of mobilization depend
upon the degree and the areas of neuromuscular deficits. Exercises to
the functionally important muscle groups are made vigorous to assist
early functional independence.
Graduated mobilization of the cervical spine is begun after 3 weeks
in patients with discectomy through anterior approach, after 6 weeks
in discectomy through the posterior approach and after 12 weeks in
patients treated for spinal fusion.
Functional re-education should be planned, giving due
consideration to the patient’s daily routine activities and job
requirements to achieve early return to job. Patients with spinal fusion
need to be educated on the movement techniques based on ergonomic
principles to compensate for surgically fused segments of the spine.
Low back pain

The incidence of low back pain (LBP) has lately reached epidemic
proportions. A number of population studies reported the incidence
of LBP between 2% and 5%.
Since the time of acquiring the erect two-legged posture from the
ancient quadruped state, the lumbosacral junction has remained weak
due to its structural and biomechanical inadequacies. Fortunately, this
has resulted in the presence of mechanical LBP in the majority of
patients, whereas LBP due to prolapsed intervertebral disc (PIVD) and
other causes requiring extensive treatment occurs only in about 1%–
2% patients of LBP.
Structural and biomechanical considerations of the

lumbosacral complex
◼ Clinical anatomy
◼ Pathophysiology
◼ Biomechanics
It is interesting to note that the structural composition of the whole

vertebral chain is architextured in relation to the functional
requirements of the individual vertebral unit (Table 32-5).
Table 32-5
Structural Composition of the Vertebral Chain as Related to the Functional
Requirements of an Individual Vertebral Unit
Unit Functional Requirement Structural Composition

• • Free ROM through 1. Atlas with articular condyles forms compact head–neck unit
Cervical 180 degrees 2. Cylindrical odontoid serves as an axis for freedom of
unit rotation of head and neck
(7, 3. Nonobstructive anterior vertebral borders of C3–C7
vertebrae) vertebral bodies allow free movement of neck flexion
• • Protects vital delicate • Posterior articulation with vertebral bodies form compact
Thoracic organ systems in the closed rib cage
unit chest viscera
(12,
vertebrae)
• • Offers freedom of • The vertebral bodies are larger and stronger and interwoven
•
• Offers freedom of • The vertebral bodies are larger and stronger and interwoven
Lumbar movement to the with cancellous shock absorbing intervertebral discs
unit whole spine
(5, • Protects spine from
vertebrae) injuries
• • Offers stability to • Fusion with pelvis offers stability for the static and dynamic
Sacral facilitate freedom of activities of the whole body
unit movement to the
(fused whole spine
5, • Forms compact
vertebrae) envelope with broad
pelvic bone offering
protection to the
delicate organ systems
in the pelvic viscard
•
Facet
joints
• • Stability with safe- • Anterior and posterior longitudinal ligament protects the
Spinal restricted mobility and spinal cord on both the sides
ligaments strength to the spine • Posteriorly placed additional short ligaments enforce
posterior aspect of the spine, preventing injury and prolapse
of the IV disc
•
Muscles
• On • Thoracic – loosely • Provide anterior flexion force to the abdomen, and loose
the attached attachments accommodate abdominal organ systems without
anterior causing undue strain
aspect
• On • Tightly attached • Provide posterior protection from injury.
the small posterior • Provide strength, endurance with restricted mobility to the
posterior muscles body
aspect
• • To allow restricted • The short and more horizontally placed facet joint in the
Facet and safe mobility cervical spine gradually assumes vertical direction towards
joints preventing injury to the lumbar unit. Therefore, the cervical spine is more
the spinal cord susceptible for dislocation than fracture, whereas fracture
dislocations are more common at the lumbar spine
Lumbosacral complex (fig. 32-31)

It is an important functional unit of the body. It consists of five lumbar
vertebrae and the sacrum. The lumbar vertebrae, because of their
weight-bearing function, are large and massive. They are
characterized by the lack of foramen in their transverse processes, as
found in the cervical region, and by the absence of articulating facets
on the body itself, as in the thoracic region. The spinal canal in the
lumbar region is smaller and triangular as compared to that in the
cervical region. The short and strong pedicles that arise from the sides
of the upper portion of the vertebral body proceed posteriorly to form
the superior and inferior vertebral notches. The inferior portion of the
pedicle above and the superior portion of the pedicle below form the
intervertebral foramen, through which the spinal nerves pass. The
space within the foramina is particularly vulnerable for impingement
of the emerging spinal nerve by tumour, trauma or degenerative
changes.
FIG. 32-31 Lumbosacral complex. SAP, superior articular process; TP,

transverse process; IAP, inferior articular process; IVD, intervertebral disc;
P, pedicle; SP, spinous process; S, sacrum; VB, vertebral body of L4; ISL,
interspinous ligament; SSL, supraspinous ligament; ALL, anterior
longitudinal ligament; 5LN, fifth lumbar nerve.
The facet joints which are formed by the inferior facet of the upper
vertebra and the superior facet of the lower vertebra are true
diarthrodial joints, complete with joint capsule and synovial lining.
Within each intervertebral space, there is an intervertebral disc with
a central nucleus, surrounded by annulus fibrosus. The central
nucleus pulposus has gelatinous qualities which dissipate mechanical
stresses. The whole disc acts as a shock absorber and is repeatedly
subjected to stress, and hence is vulnerable to early degeneration and
displacement.
The whole complex consists of a series of joints,
musculoligamentous structures, with neural elements in close
proximity. All these structures are meticulously designed to offer
controlled mobility. However, there are some structural deficiencies
which contribute to its susceptibility to back pain in the absence of
proper body mechanics and exercise.
Structural and biomechanical inadequacies of lumbosacral

complex
Structurally and biomechanically the inadequacies in the following
aspects at the L5–S1 intervertebral segment make it susceptible for
injury or disc prolapse:
1. Bony configuration
2. Ligaments
3. Muscles
4. Blood supply
5. Nerves
6. Biomechanical factors
(a) The L5–S1 segment bears maximum weight as

compared to any other intervertebral joint.
(b) The centre of gravity directly passes through these

vertebrae.
(c) It is a site of transition between the freely mobile

lumbar vertebrae and the relatively fixed pelvic girdle.
(d) There is a sudden change in the angle at these two

vertebrae, making these susceptible for instability or
slipping (spondylolisthesis, lumbarization or
sacralization).
(e) Vertebral foramen becomes more triangular as it

approaches the L5 level. As the pedicles at this level
shorten, the space of the spinal canal is reduced, making
it more susceptible to compression.
(f) 60%–70% of the spinal flexion occurs at the L5–S1

junction.
2. Ligaments
The stability to the lumbosacral and sacroiliac complexes is

provided by the posterior longitudinal ligament, which is
of special significance, as prolapse of the intervertebral disc
usually occurs through a tear in this ligament. It occupies
the middle portion and is deficient on either side.
Therefore, central protrusion meets a strong barrier, and
the protrusion has a tendency to shift laterally which is the
zone of less resistance. Therefore, the laterally weak
posterior longitudinal ligament is the main cause of the
commonly seen lateral protrusion of the lumbar disc (Fig.
32-32). Excessive stress on this ligament is prevented by the
physiological lumbar lordosis.
The anterior longitudinal ligament spans over the entire

length of the vertebral column. It provides anterior
stability and restricts excessive extension of the spine.
The supraspinous ligament extends up to the spinous

process of L5. It certainly provides excessive mobility at
L5–S1 segment at the cost of stability.
The other ligaments, e.g., sacrotuberous, sacrospinous,

dorsal and ventral sacroiliac ligaments, interosseous and
iliolumbar ligaments provide stability and strength directly
to the whole sacroiliac complex and indirectly to the
lumbosacral complex.
3. Muscles
The following muscles provide stability to the vertebral

column, and strength and endurance to the back (Fig. 32-
33):
(a) Errector spinae
(b) Intercostalis dorsi
Each muscle group has three parts. The erector spinae

consists of the iliocostalis, longissimus and spinalis.
The rectus abdominis provides remarkable leverage in
flexing the spine and also offers anterior stability and
cushioning effect by increasing intra-abdominal and
intrathoracic pressures. However, ironically, the limb
muscle, such as psoas, which originates from the spine,
may produce instability of the spine by exerting anterior
pull when it contracts strongly in a movement such as
resisted hip flexion (especially in an unstable
spondylolisthesis).
4. Blood supply
Spinal arteries are derived from the vertebral arteries of the

cranial region. They proceed inferiorly as the anterior
spinal artery and the paired posterior spinal arteries. They
diminish in size as they run inferiorly, and alone they are
insufficient to supply the caudal portion of the cord. They
are reinforced at various levels by the branches of the
lower intercostal or upper lumbar arteries. Spinal branches
from one or more of these arteries give off a significant
branch (radicular artery), which travels along the nerve
root. The branch makes an important contribution to the
spinal arteries. When this radicular artery is compromised,
necrosis of the cord below that level may result.
5. Nerves
The major nerve supply is through the posterior and anterior

primary divisions of the nerve roots and nerves of Von
Luschka. Pain production involves the nociceptive systems
of the musculoskeletal tissues of the vertebral column. The
nociceptive system distribution in the tissues of the
intervertebral segment gets triggered and its activation
gives rise to the appreciation of pain. This system facilitates
activity in the ‘T’ cells opening the gate. The nociceptive
system of nerve endings is widely distributed in all the
tissues of the whole complex.
Histochemistry: ATPase which breaks the ATP to produce

energy has been reported to be deficient in patients with
positive nerve root signs.
6. Biomechanical factors
Instead of being straight, the spinal chain assumes a typical

curvacious posture. It has two lordotic curves at the
cervical and lumbar spinal segments and a kyphotic curve
at the dorsal region. These postural adaptations which
occur under the impact of the gravitational force play a
significant role in the distribution of the weight of the bony
structures and the organs from head to pelvis besides
offering free spinal mobility. The role of lumbar lordosis in
reducing the LBP is well recognized.
Daily activities put tremendous repetitive, compressive and

shearing stresses on the bony components of the back, and
tensile stresses on the muscular and ligamentous
components. The shearing stresses on the intervertebral
ligament and the apophyseal joints of the lumbosacral
junction are proportional to the angle formed by the
superior surface of the sacrum with the horizontal surface.
At a normal sacral angle of about 40 degrees, the shearing
force is 65% of the superincumbent weight (Fig. 32-34A).
This shearing force increases if the anterior tilt is increased,
and diminishes when the back is flattened (Figs 32-34B and
C). Therefore, a protective spasm of extensors occurs
following strain which flattens the lumbar curve to
diminish the shearing stress.
Intervertebral discs act as shock absorbers and provide

hydraulic resistance to motion under high pressure. The
lumbar spine is mounted on the sacrum at an angle of 45
degrees and is always eccentric in position, needing some
external support for balance. This position produces larger
shearing force on the lumbar spine. Maximum strain
occurs on the lumbar ligaments during flexion. Greater
activity from the lumbar spine results in variations in the
intradiscal (ID) pressure. Nachemson (1966, 1976) and
Nachemson and Elfastrom (1970) reported data on
intradiscal pressures in different postures, activities and
exercises. It is extremely important to understand the
extent of load on the spine in different situations to guide
and plan the precise therapeutic programme (Tables 32-
6–32-8).
Active trunk flexion from the supine position raises

intradiscal pressure tremendously. Intradiscal pressure of
100 kg during standing rises to 280 kg. Similarly, active
hyperextension raises the intradiscal pressure to 180 kg.
This needs due consideration before initiating these
exercises.
FIG. 32-32 Posterior longitudinal ligament: tapering, as it approaches L5

causing lateral deficiency, a common cause of lateral protrusion of disc at
L4–L5 and L5–S1 levels.
FIG. 32-33 Muscles over the lumbosacral complex. SD, spinalis dorsi; LD,
longissimus dorsi; ID, intercostalis dorsi; IL, lliocostalis lumborum.
FIG. 32-34 Lumbosacral angle. (A) Normal angle (NLS). (B) Increased
angle resulting in exaggerated lumbar lordosis (ILS). (C) Decreased angle
resulting in flattening of the normal lordotic curve at the lumbar spine (DLS).
Table 32-6
Intradiscal Pressure Load in Various Body Positions (in a 100-kg Individual)
Load
Position
(kg)
Standing still 100
Supine/prone 25
Side lying 75
Supine (leg rested with hip and knee bent to 90 degrees) 35
Sitting with back straight and unsupported arms 140
hanging
Sitting forward stoop, back unsupported 185
Sitting forward stoop, lifting weight, back unsupported 275
Table 32-7
Intradiscal Pressure Load in Various Activities (in a 70-kg Individual)
Load
Activity
(kg)
Walking 85
Twisting 90
Lateral bend 95
Coughing 120
Laughing, straining 120
Lifting weight 20 kg (straight back, knees 210
bent)
Lifting weight 20 kg (bent back, knees 340
straight)
Table 32-8
Intradiscal Pressure (Load) on the Third Lumbar Disc during Various Exercises (in a 70-
kg individual)
Load
Position and Exercise
(kg)
Standing still 70
Supine
In traction (30 kg) 110
Isometric abdominal exercise 110
Bilateral straight leg raising 120
(SLR)
Sitting
Sitting up with knees extended 175
Sitting up with knees flexed 180–210
Prone
Back hyperextension (active) 150
Standing
Bending forward by 20 degrees 150
With 10-kg weight in each hand 185
Recent observations
Forward flexion of the spine with 20 degrees rotation during standing
increases the load on the lower lumbar segments by as much as 40
times (Kelsey et al., 1984; Punjabi et al., 1983). Therefore, an activity of
bending forward with rotation to pick up an object (e.g. suitcase)
precipitates acute lumbago or disc prolapse.
Thus, the structural and functional deficiencies of the lumbosacral
complex and its correlation to the person’s day-to-day work will not
only be helpful in the diagnosis of the possible lesion but will also
help in planning the appropriate therapy.
Aetiology of low back pain

The LBP can arise due to various reasons:
1. Traumatic – sprain, strain, vertebral fracture
2. Discogenic LBP – due to the lesion in the IV disc
3. Structural defect – mainly in the vertebral spine (e.g., spina bifida,

sacralization, scoliosis and spondylosis)
4. Functional defects – wrong postural attitudes, contractures at the

hip and knee, limb length discrepancy, etc.
5. Degenerative – degenerative disc disease (DDD), osteoarthritis
7. Metabolic – osteoporosis, osteomalacia
8. Neoplastic – benign or malignant tumours
9. Referred LBP from the lesions in the viscera:
(a) Abdomen
i. Duodenal ulcer
ii. Aortic aneurysm
(b) GI system
i. Renal calculus
ii. WT infection
(c) Gynaecological diseases and genitourinary system
10. Miscellaneous causes:
(a) Functional backache

(b) Habitual bad posture
(c) Pot belly, etc.
11. Idiopathic LBP
Pathology of low back pain

To identify the exact pathology of the LBP, extensive physical
examination and evaluation is necessary and should include the
following:
1. History
2. Examination of posture
3. Evaluation of pain characteristics
4. Palpation
5. Range and rhythm of spinal movements
6. Neurological examination
7. Diagnostic physical tests
8. Evaluation of functional status
History
Previous or present history related to the present problem, its
treatment and the response: Clinical signs and symptoms indicating
or suspecting the presence of infection, tumour, systemic disease,
vascular disease, rheumatic affection and GI tract, endocrinal and
gynaecological diseases should be carefully screened to rule out these,
as they could be associated with LBP.
Vascular lesions, viscerogenic disorders, genitourinary disorders
and gastrointestinal lesions are known to cause referred LBP.
Information about the working posture or a leisure time posture
adopted for longer periods (e.g., sedentary games and watching TV)
should be noted in relation to the LBP.
Examination of posture
The normal physiological postural curves and gait should be observed
from the front, back and the side.
Assessment of pelvic tilt: Deviation from the normal angle of
pelvic tilt is assessed in standing position. The tilting of the pelvis
could be anterior, posterior or lateral.
Anterior pelvic tilt: The anterior tilting of the pelvis may occur as a
result of the protruding abdomen (e.g., in obese people), tight low
back muscles, tight hip flexors, weakness in the abdominal muscles,
tight hamstrings or in spondylolisthesis. When present, it puts
excessive pressure on the posterior aspect of the vertebral bodies and
the facets, as there is exaggeration of the lumbar lordotic curve.
Posterior pelvic tilt: Posterior tilt may result from tight or
overdeveloped low back muscles. Weakness of hip flexors (psoas) or
localized muscular spasm may result in the obliteration of normal
lumbar lordosis into a flat back.
Lateral pelvic tilt: In lateral pelvic tilt, the pelvis drops on one side.
It could be due to limb length disparity, unilateral lumbosacral strain,
structural scoliosis or scoliosis due to unilateral muscular spasm.
Reasons may also include muslce imbalances, such as weakness of
gluteus medius, with strong hip adductors and lateral rotators on the
raised side of the pelvis, with tightness of the adductors and TFL on
the opposite side or unilateral PIVD.
Objective measurements of pelvic tilt: Anterior and posterior
pelvic tilts are measured on a radiograph lateral view. The angle
formed by a line parallel to the superior level of sacrum with the true
horizontal line is measured. The normal angle is in the vicinity of 30
degrees. It increases in the lordotic curve (Fig. 32-34).
Lateral pelvic tilt is objectively measured by measuring leg length
when there is discrepancy in one leg. It can also be assessed by
measuring the difference in the true horizontal line and the horizontal
line passing over the tips or the bony prominences of anterior or
posterior iliac spines.
Evaluation of pain characteristics

The characteristics of pain type, site and its behaviour provide
important clues to the diagnosis of LBP. The where, when and how
characteristics of the pain should be noted (Table 32-9).
Where – furnishes the information about its location

When – indicates the time, duration, posture or activity precipitating the pain
How – relates to the position or activity aggravating, relieving and reproducing the
pain
Table 32-9
Pain Characteristics Related to the Specific Spine Tissue Involvement
Tissue
Pain Characteristics Innervation (Pain Sensitivity)
Involved
Ligaments Localized and deep pain Posterior longitudinal ligament is richly
innervated, other ligaments are innervated
unevenly
Muscles Localized dull ache Extremely sensitive and have abundant
innervation
Nerve Pain over the dermatomal distribution or Richly innervated and highly sensitive
roots throughout the length of the nerve in
inflammatory conditions
Blood Deep pain Vertebral venous plexus is richly
vessels innervated and is extremely sensitive
Bones Deep, often radiating pain Periosteum is richly innervated and
extremely sensitive
Facets Dull diffuse pain with specific radiation patterns; Joint capsule and ligaments have numerous
joints Referred pain covering longer distance may be nerve endings and are highly sensitive
present
Disc Lumbago when posterior longitudinal ligament is Depends upon the innervation and pain
compressed or sciatica when the nerve root is sensitivity of the tissue compressed by the
compressed disc
The type of pain such as sharp, stabbing or burning originates from

the nerves; nonspecific and vague pain is present due to soft tissue
inflammation; radiating pain could arise as a result of nerve
pathology, whereas constant severe pain even during rest may
indicate a tumour.
Areas of pain should be clearly marked on the body chart for easy
reference (Fig. 32-35).
FIG. 32-35 Body charts to mark characteristics of pain.
The exact area of pain should be pinpointed by the patient on the

bare body, and documented on the body chart.
Subjective recording of the gravity of pain should be made by using
a visual analogue scale (Fig. 32-36) or the McGill pain questionnaire
(Melzack, 1975).
FIG. 32-36 Horizontal pain perception visual analogue scale (VA scale).
Palpation
Palpation helps in recognizing the specific tissues at fault. It can be
done effectively in prone position. Each spinous process is palpated
separately with firm pressure in the anterior and lateral directions.
Bony tenderness is palpated over the paravertebral and interspinous
areas, lumbosacral junction and sacroiliac joints.
Palpation is done to detect local muscular spasm and trigger points
over the paravertebral region, posterior aspect of gluteal region, thigh
and calf.
Percussion: Lightly percuss the spine from the root of the neck to the
sacrum with the patient in forward bend position. Marked pain
indicates tuberculosis or any other infection.
Localized muscular tenderness is examined by picking up and
rolling manipulations of various muscle groups of the lower limbs.
Documentation on the body chart can help correlate the myotomic
distribution to detect the level of the lesions.
Nodules, when present, can be detected by picking up and rolling
of the muscles over the paravertebral region.
Deep tenderness should be tested over the sciatic notch. Jabbing
pressure with the heel of hand is applied to detect tenderness over the
intervertebral joints. Compression test to the pelvis is employed to test
sacroiliac joint pathology.
Intervertebral joint alignment is tested by palpating over the
spinous processes. Undue prominences of the spinous process with a
definite gap (step) and exaggerated lumbar lordosis indicate
spondylolisthesis.
Palpation for temperature changes and sweating should be done
with the back of the hand to detect local inflammation. Peripheral
pulses should be palpated to assess the circulatory status. Gentle tap
over the kidney area in the absence of localized signs and the presence
of girdle pain indicate renal pathology.
Range and rhythm of the spinal movements

The movements of the lumbosacral complex include basically the
movements at the intervertebral joints of the lumbosacral spine and
the synchronized movement or stabilization of the pelvis in relation to
the hip joint. The principal movements to be examined at the
lumbosacral complex are flexion, extension, lateral flexion and
rotation to either side.
Characteristics of movements
The aim is to reproduce the patient’s symptoms by doing movement
or by appropriate joint sign. Normally the movement should be of full
range and pain free with overpressure. Sometimes sustained test for
extension, lateral flexion and quadrant test towards the symptomatic
side may be required to reproduce the symptoms.
The movements are tested as active ROM, resistive (isometric) small
arc movements and passive movement with overpressure at the
terminal range. Besides these, passive accessory intervertebral
movements are tested at the early, mid and late ranges to elicit the
‘joint sign’. A ‘joint sign’ is an alteration in active, passive,
physiological or accessory joint mobility relative to pain, resistance or
spasm which limits the ROM of the joint. The joint sign helps in
detecting the exact vertebral level involved and also the status of the
passive mobility of the intervertebral joints.
The restriction of active range indicates segmental soft tissue
inflexibility of the functional units, facet capsules, ligaments and
fascia. Resistance to movement will produce pain in the
musculotendinous lesions. Pain on passive movement will produce
compression in the joint – producing pain due to joint pathology or
nerve compression.
Application of overpressure also increases pain at the site of the
lesion and increased radiation.
To find out the appropriate structures related to pain, the symptoms
should be reproduced by performing movement enough to the point
of first increase in symptoms.
Flexion (lumbar pelvic rhythm): It is tested by asking the patient to
bend forward (toe touching) from stride standing without bending the
knees. The movement involves synchronized movement of flexion at
the intervertebral joints of the lumbar spine and rotation of pelvis
around the hip joint. In this rhythm the lumbar lordosis gradually
flattens and turns into a kyphosis at the terminal range of flexion (Fig.
32-37). This puts tremendous amount of compressive force and load
on the anterior vertebral margins with opening up of the posterior
vertebral margins.
FIG. 32-37 Normal lumbar pelvic rhythm showing the normal lumbar
lordosis turning into a kyphosis at the terminal range of flexion and its
measurement by sliding ruler arrangement.
The restriction of flexion indicates the soft tissue inflexibility at the

lumbosacral complex and/or pelvis due to protective reflex spasm
from pain or guarding (tightness of hamstrings could also result in
altered rhythm).
Occasionally, trunk flexion may be associated with rotation to one
side. This indicates the presence of structural scoliosis, indicating
lumbosacral facet tropism. It may be limited to the hip joint, the
lumbar spine remaining rigid as in ankylosing spondylitis. Persistence
of lumbar lordosis instead of kyphosis at the terminal range of flexion
is an indication of hypermobility of the lumbosacral spine.
The patient gradually attains erect posture from flexion. This is
achieved by reversal of lumbar pelvis rhythm, the movements of the
pelvis on hip and lumbosacral spine. Derotation of pelvis occurs and
lumbar kyphosis changes to lumbar lordosis. Normal range is 80
degrees.
Extension: From the erect stride standing posture, the patient is
asked to extend the whole spine beyond midline to the maximum
range (Fig. 32-38). This movement produces compression on the
posterior vertebral bodies and facet joints with the opening up of the
vertebral bodies anteriorly. It produces pain due to compression of the
posterior structures. Normal range is 20–30 degrees.
FIG. 32-38 Spinal extension and its measurement by plumb line pointer.
Lateral flexion: A patient with knees straight is asked to bend the

trunk to one side sliding his hand (finger tips) as near to the floor as
possible from the lateral aspect of the leg. This movement compresses
the tissues on the lateral side of the spine on the side of bending and
causes stretching of the tissues on the contralateral side. If flexion
towards the painful side aggravates the pain, the lesion could be
either due to intra-articular pathology or a disc lesion lateral to the
nerve root. If lateral flexion away from the painful side increases pain,
then the lesion may be articular or muscular in origin; disc protrusion,
if present, is likely to be medial to the nerve root. Normal range is 40–
45 degrees (Fig. 32-39).
FIG. 32-39 Lateral flexion of the spine and its measurement by sliding ruler
arrangement.
Rotation: Rotation is tested with the patient lying on the side or

sitting with the hip and knee in flexion. The movement is tested on
both sides (right and left). The site of pain is noted, and is assessed in
relation to the other movements tested earlier.
Objective methods of measuring spinal movements

Flexion
1. Macrae and Wright (1969) described the skin distraction method.

Three ink marks are made. First at the lumbosacral junction over a line
joining the dimples of venus. Other two marks are made at 5 cm
below the first mark and 10 cm above it. The distance between the
upper and lower marks before and after the movement denotes
flexion (Fig. 32-40).
2. The same method can be used by putting marks on the spines of T1

and S1. The normal increase in distance is about 10 cm in adults.
3. It can also be assessed by measuring the distance between the

middle finger tip and the floor in forward flexion. Normally, the
fingertip touches the floor or remains within 7 cm from it (Fig. 32-41).
FIG. 32-40 A method of measuring lumbar flexion by skin markings.

FIG. 32-41 Measurement of lumbar flexion by fingertip to floor distance

measurement.
Extension
The distance traversed by the plumb line pointer held at the side of
the trunk (see Fig. 32-38) provides a measure of extension (Moll,
Liyange, & Wright, 1972). The upper mark represents the intersection
of a horizontal line through the xiphisternum with the coronal line.
The lower mark represents the intersection of a horizontal line
through the highest point on the iliac crest with the coronal line.
Lateral flexion
1. The landmarks are the same as described for extension. The

difference between these two marks in erect standing and after lateral
flexion is measured.
2. It can be measured by fingertip to floor method while the patient is

performing lateral flexion, the arm being held on the lateral side of the
leg with the elbow extended (see Fig. 32-39).
3. It can also be measured by measuring the angle formed between the

line drawn through T1, S1 and the vertical (see Fig. 32-39). The
average range is 30 degrees.
Rotation
The subject lies on one side with hips and knees flexed to 90 degrees.
The shoulders are rotated to prone position, and the head is rotated to
the opposite direction. The surface inclination to the vertical is
measured by placing a goniometer on the forehead and on T1, T12
and the sacrum. The regional spinal rotation can be calculated from
distances between adjacent inclinations as described by Loebl (1973).
It can also be measured in sitting position. Ask the patient to rotate
to one side. On completing the rotation, the angle formed between the
planes of shoulders and the pelvis is measured (Fig. 32-42). The
normal value of ROM is 40 degrees, mainly thoracic, the lumbar
contribution is only of around 5 degrees (Macrae and Wright, 1969).
FIG. 32-42 Method of measurement of spinal rotation.
Spondylometer or inclinometer can also be used for objective

measurements.
Chest expansion
It is necessary to measure chest expansion using measuring tape,
especially in young males where ankylosing spondylitis is suspected.
Neurological examination
Examination of the nervous system consists of checking the sensory
status, the motor power, atrophy of the muscle groups, tenderness
and the tendon reflexes.
Sensory status: The sensory supply is carried through various

dermatomes representing particular nerve root or spinal segmental
levels. Therefore, sensory paraesthesia in the distribution of a
particular dermatome can detect the neurological level of the lesion
(see Fig. 32-73A). Areas of sensory deficits should be marked on the
body (limb) chart to identify the level of the lesion and to correlate it
with the findings of the other tests.
Motor power: The muscles receive their motor innervation from

specific nerve roots. Therefore, muscular weakness or atrophy of a
particular muscle group is related to a specific nerve root.
The orderly sequence of motor innervation of the limb

musculature (myotomes) provides information about the
possible levels of the lesion (see Fig. 32-73). In general, each
joint and muscle group is innervated by multisegmental
roots. However, there are always predominant nerve roots
for each muscle group (as shown in Tables 32-10 and 32-
11). Thus, the dominating level can be identified.
Predominant root involvement level can also be worked
out by using adjacent segmental supply. For example, hip
flexor and adductor groups receive their innervation from
L2 and L3 segments, whereas quadriceps receive
innervation from L3 and L4 segments. Thus, if the
quadriceps is normal in the situation of hip flexor
weakness, the predominant lesion could be at L2.
Manual muscle testing (MMT) is inadequate; endurance of a

specific muscle group rather than strength is a more
precise test. Muscle endurance is tested by repeated
resistive isotonic movements (isokinetic) to the muscle or
isometric hold. Early fatigue indicates lack of endurance.
The myotomic representation of such a muscle group will
indicate the level of the lesion. While testing muscular
endurance, it may be remembered that weakness first
appears in the extensor hallucis longus before the other
dorsiflexors in a lesion of L4–L5 level. Similarly, flexor
hallucis longus becomes weak before gastrocnemius in a
lesion of L5–S1 level. Therefore, these muscle groups need
special attention in the expected lesions at L4–L5 or L5–S1
level.
Muscular atrophy: It can be assessed by measuring the girth of the

thigh (quadriceps) and leg (calf) or by volumetric method (water
displacement technique).
The innervation of the major movements (the prince maers)

is very useful (see Fig. 32-73).
Muscular tenderness: The presence of tenderness in the muscle

groups can provide further confirmation of the level of the lesion (as
described under palpation and in Table 32-12). The tender areas also
need to be accurately marked on the body chart.
Tendon reflex test: It provides information about the integrity

of the reflex arc in identifying the level of the lesion (Table
32-13).
Knee jerks or quadriceps tendon reflex: Done in sitting position with

the legs hanging at the edge of the table, or in supine position with
knee flexed. Patellar tendon is tapped with a hammer, which elicits
involuntary knee extension.
If it is sluggish or absent, it indicates lesion at L4 root
involving L3–L4 disc.
Medial and lateral hamstrings reflex: It can be done in prone

position with knee supported (relaxed) in flexion. Reduced
or absent medial hamstrings reflex response indicates
lesion at L5–S1 level.
Ankle jerks: It can be tested in sitting, supine or prone position,

assuring relaxation of the ankle. Sluggish or absent ankle jerk
indicates the lesion at S1 root involving L5–S1 disc.
Plantar response: Scratching of the sole of the foot produces sudden

reflex contraction of the extensor hallucis longus. This pulls up the
limb into flexion–abduction and internal rotation at the hip.
Weakness or loss of plantar response indicates lesion at S1.
Cauda equina lesion: Impaired bladder function, loss of

perianal sensation and rectal tone to be assessed, as they
indicate massive herniation of the disc into the spinal
canal.
Table 32-10
Segmental Innervation of Joint Movements
Segmental Spinal
Joint Movements
Innervation
Hip Flexion, adduction, internal rotation L2 and L3
Extension, abduction, external L4 and L5
rotation
Knee Extension L3 and L4
Flexion L5 and S1
Ankle Dorsiflexion L4 and L5
Plantar flexion S1 and S2
Foot Inversion L4
Eversion L5 and S1
Intrinsic S1, S2 and S3
Table 32-11
Segmental Supply of Lower Extremity Muscles
Muscle Group Segment

Psoas, adductors of hip L2 and L3
Quadriceps L3 and L4
Tibialis anterior L4
Tibialis posterior L5 and S1
Extensor hallucis longus L5
Flexor hallucis longus S1
Peronei L5 and S1
Toe extensor L5 and S1
Calf, toe flexor S1 and S2
Hamstrings and gluteus L5, S1 and
maximus S2
Table 32-12
Nerve Root Irritation and Muscular Tenderness
Nerve Root Tender Muscle Groups

L4 Quadriceps
L5 Tibialis anterior
S1 Gastrosoleus
Emotional Subcutaneous surface of
overtone tibia
Table 32-13
Segmental Representation of Tendon Reflexes
Joint Reflex Segment

Knee Quadriceps L3 and L4
Hamstrings L5, S1 and
S2
Ankle Gastrosoleus S1 and S2
Plantar S1
response
Diagnostic physical tests

The data collected from history and physical examination are correctly
interpreted. Specialized diagnostic neuro-musculoskeletal tests can be
done whenever necessary to arrive at the exact diagnosis.
Presence of sciatica: If there is unilateral trunk deviation giving rise to
sciatica during trunk flexion, it is a diagnostic sign of possible
unilateral disc protrusion. When the disc protrusion lies in the axilla
of the root, the trunk is deviated towards the painful side, whereas if
the protrusion lies lateral (shoulder) to the nerve root, the patient
will try to prevent further root compression by deviating away from
the painful side (Fig. 32-43).
Straight leg raising (SLR) or Laseque’s sciatic nerve test: It is one of

the important diagnostic tests. It is a protective reflex test which
causes traction on the sciatic nerve, lumbosacral nerve roots and
dura mater. It is a passive test done in supine position (Fig. 32-44).
Appearance of pain in the distribution of the sciatic nerve up to 45
degrees of hip flexion with extended knee indicates positive SLR
test. If the pain thus felt is aggravated by passive flexion of the neck
and passive dorsiflexion of the foot, it is a ‘positive neural sign’ or
positive SLR. The real stretching of the inflamed dura is possible
only with all these three manoeuvres. While conducting SLR test, it
must be remembered not to confuse it with hamstrings stretch due
to straight leg raising, especially in patients with tight hamstrings
confirmed by dull pain over the posterior aspect of the knee joint.
Performance of SLR on the contralateral side draws the dural

tube downwards, exerting tension directly on the nerve
root of the affected side eliciting back pain. It indicates
nerve root compression (Fajersztajn test), and must be
included.
FIG. 32-43 Diagnostic sign of unilateral disc protrusion. (A) Disc protrusion
lateral to the nerve root; the list appears to the side opposite to sciatica. (B)
Disc protrusion medial to the nerve root; the list appears to the side of
sciatica.
FIG. 32-44 Straight leg raising (SLR) test. Pain in the distribution of sciatic
nerve at 45 degrees of hip flexion with knee in extension indicates positive
SLR. The tension on the sciatic nerve is increased further by a passive
dorsiflexion of the ankle and foot.
Slr and the type of lesion
1. Small protrusion: Arc of SLR may be painful, or pain may be felt only
at the extreme of SLR.
2. Moderate protrusion: Positive SLR but no neurological deficit. It

indicates minor pressure near the intervertebral foramen, interfering
with mobility but not with conduction.
3. Large protrusion: Positive SLR with neurological deficit indicating

compression at the root sleeve as well as the parenchyma.
4. Elicitation of back pain on SLR: This is suggestive of central disc

protrusion, whereas pain in the posterior aspect of the leg is
suggestive of lateral protrusion.
Pitfalls of slr test
1. In the event of root atrophy, due to massive posterolateral

protrusion, the nerve root becomes insensitive due to ischaemia. In
such a situation, although the SLR may be negative, it is accompanied
with numbness in the foot, an indication of progressive lesion.
2. The SLR test is valid only to test the mobility of the fourth and fifth
lumbar nerve roots. It is not valid in the first three lumbar and the first
sacral lesions.
Alternate SLR: Whenever there is doubt about the genuineness of the

test, ask the patient to sit up with legs straight. If the sitting posture
can be assumed without flexing the knee, the test is negative (Fig.
32-45).
Prognostic value of SLR: When the disc protrusion is either mild or
moderate, where SLR is positive without neurological deficits,
usually conservative treatment is indicated. Under such
circumstances, accurate measurement of the angle of SLR where the
sciatic radiation begins is measured. Subsequent increase in the
angle of SLR with lesser pain indicates good prognosis.
Bowstring sign: In this test the SLR is carried out until the pain is
reproduced. At this point the knee is gradually flexed till pain
disappears. The examiner rests the limb on his shoulder and places
the thumb in the popliteal fossa over the sciatic nerve. Sudden firm
pressure on the nerve reproduces pain in the back, or the pain
radiating down the leg indicates positive bowstring sign or
significant root tension (Fig. 32-46).
Slump test for mobility at the intervertebral foramen and the spinal
cord: Passive neck flexion and straight leg raising help in detecting
any reduction in the mobility of pain sensitive structures within the
intervertebral foramen or the vertebral canal. If these prove
negative, the ultimate test for mobility of these structures is done by
the ‘slump test’.
The patient is made to sit in a slouch sitting with knees in

relaxed flexion at the edge of the table. The physiotherapist
passively bends the head and the trunk forward, as much
as possible, with total support, bringing the head down in
between the knees. The patient is then asked to extend the
knees alternately to the maximum, maintaining the foot in
dorsiflexion. If pain is produced on attempting knee
extension, the limiting range is noted. The positive test
indicates interference of the mobility at the intervertebral
foramen or the vertebral canal (Fig. 32-47). It may be noted
that this test will also be positive in the presence of
hamstrings tightness.
Lumbar third nerve root test (reverse Lasegue test): The patient is
made to lie in prone position, maintaining the hip in neutral
extension. The knee is passively flexed. Pain in the distribution of
femoral nerve indicates irritation of the third lumbar nerve root. The
test is positive if the symptoms are aggravated on passively
extending the hip (Fig. 32-48).
Test for pain of muscular origin (resisted isometric test): Applying

increased resistance to the muscle action without producing
movement builds up tension in the muscle. It would give rise to
pain if the lesion is in the muscle. This test can be done on any
muscle to diagnose muscular lesion.
Test for the pain originating at the articular structures: Full range

passive movement is carried out with relaxation of the concerned
muscle group. Pain due to slight overpressure beyond this point
indicates joint pathology.
Test for sacroiliac irritation: Presence of tenderness on palpation at

the sacroiliac joint is tested further to confirm the lesion at this joint
by the following two tests:
1. Gaenslen’s test: The patient is made to lie on the side of

the unaffected hip joint and asked to flex the unaffected
hip to the knee–chest position. He firmly holds the thigh
against the chest. The examiner passively extends the
other hip joint, keeping the knee straight. This produces
rotary strain on the pelvis and tends to rotate half of
ilium against the sacrum, eliciting pain at the SI joint in
the presence of SI joint pathology (Fig. 32-49).
2. Pain is produced in the sacroiliac joint by pelvic

compression or by attempting to ‘open out’ the pelvis.
This is done with the thumbs hooked round the anterior
superior iliac spines (Fig. 32-50).
Provocative test for acute disc herniation: Kopp, Alexander, Turocy,

Levrini, and Lichman (1986) reported a test to detect whether the
disc herniation is only intrinsic (with intact annulus bulging) or
extrinsic (nucleus extrusion through the tear in the posterior
annulus into the spinal canal).
In this test, the patient in prone position is asked to passively

extend the lumbar spine by pushing up on forearms, and
then on the hands by extending the elbows (Fig. 32-51).
This forces the nucleus anteriorly. This test will be negative
when the herniation is intrinsic but will be positive if it is
extrinsic. Intrinsic extrusion can be treated successfully by
conservative approach; however, extrinsic extrusion needs
surgical intervention.
Test for root irritation: Presence of tenderness in the muscle is a

positive sign of root irritation. During palpation, tenderness over
quadriceps, anterior tibial group and calf muscles is a positive sign
of the nerve root irritation at L4, L5 and S1 levels, respectively.
Test for root conduction: Impairment of nerve root conduction is

confirmed by dermatomal sensory loss, myotomal motor weakness
and impairment of the respective reflex response. In later stage (after
3 weeks of prolapse), muscular atrophy may occur in the respective
muscle group.
Disc protrusion level: A disc herniation at L4–L5 level actually

affects the fifth lumbar nerve root because of the upward migration
of conus medullaris during development. Similarly, herniation
between the fifth lumbar vertebra and the sacrum (L5 and S1)
usually compresses the first sacral nerve root rather than the fifth
lumbar nerve root.
A central or midline disc protrusion of the fourth lumbar
disc may cause compression of the fifth lumbar nerve root,
first sacral nerve root or even all the sacral nerve roots due
to the proximity of these nerve roots in the spinal canal.
This will be confirmed by the involvement of the bladder
and paralysis of foot muscles.
Test for hip pathology (Faber’s sign):
1. Pain is felt in the hip joint on attempting hip flexion–

abduction with external rotation.
2. The patient is placed supine with the hip held in flexion.

Full range of passive external and internal rotation is
attempted with slight overpressure at the end of the
range. If there is pain-free normal ROM with
overpressure, the hip pathology is eliminated (Fig. 32-
52).
Test for back pain due to dorsal ramus syndrome (DRS): Low back
pain radiating to the lower extremity with concurrent spasm in the
back muscles may be due to disc pathology or mechanical irritation
of specific tissues of the lower back (e.g., interspinous ligaments,
multifidus muscle, zygapophyseal joints). Irritation of the dorsal
ramus (Bogduk, 1980) can give rise to pain in the lower back region,
radiating to the posterolateral aspect of the leg. However, the nature
of pain due to the dorsal ramus syndrome is a deep and dull ache as
against a sharp and precisely located pain due to disc pathology.
The symptoms also have no segmental distribution.
The pain radiating down the leg and below the knee arises
from disc levels at L4–L5 or L5–S1. The pain radiating from
L3–L4 level or higher does not radiate below the knee.
Lumbar flexion–extension test to differentiate between disc and
facet joint pathology: This test is performed to differentiate
between disc lesion and facet joint pathology. The movement of
lumbar flexion increases the compression force between the two
adjacent vertebrae anteriorly, causing the disc to move posteriorly,
and increases the patient’s pain as it causes nerve root compression.
At the same time, it decreases the compression force between the
adjacent facet joints and there is reduction in pain if it is due to
compression of the facets joint.
Conversely, lumbar extension will increase compression

force between the two adjacent vertebrae posteriorly,
allowing the disc to move anteriorly, reducing pain if it is
due to disc pathology, whereas it increases the
compression force on the facet joints, increasing the pain if
pathology exists in the facet joint.
Identification of functional LBP: There is discrepant motor

weakness. Initiation of movement even against weak resistance is
pretended to be not possible but, at the same time if taken passively,
the patient has the ability to hold the same extreme position of the
movement. Similarly, relaxation is jerky and irrespective of the
resistance. This is usually seen in psoas (hip flexion). The patient
may complain of constant pain, but there is marked discrepancy in
all the tests.
Identification of nerve root tension: Sciatic nerve root tension: Pain

reproduction by applying stretch to a peripheral nerve, e.g.,
reproduction or aggravation of pain by forced dorsiflexion of ankle
at the limit of slow passive SLR. Pain is relieved by passive knee
flexion. If, however, the pain persists or increases on further hip
flexion, emotional imbalance or hip joint pathology could be
suspected.
Relationship of list to the severity of condition: When list is present,

it is important to find out if it is correctable. If the symptoms are
reproduced (e.g., whole leg pain and foot paraesthesia) by the
passive correction of the list by 25%, the presenting condition is
severe and irritable.
Recent tests: The following tests predict the prognosis and the

possible therapeutic planning:
1. Use of lumbar extension
2. Hip, knee 90–90 test.
(a) Use of lumbar extension: Based upon the clinical and

experimental work of Mckenzie (1981) and Nachemson
(1976), Kopp et al. (1986) reported the following test: The
patient in prone lying position is asked to hyperextend
the spine on the forearm support; it is then gradually
progressed to hand support. If he succeeds in attaining
30 degrees of hyperextension within 3–5 days of therapy,
the lesion is not a true prolapse, and perhaps does not
require surgery. Therefore, an early response to
extension therapy is an indication of conservative
management (see Fig. 32-51).
(b) Hip, knee 90–90 test (Cotrel & Lossing, 1986): Patient lies
in supine position. Examiner bends both knees of the
patient to 90 degrees with the thighs vertical. By keeping
the arms under the thigh supporting the weight of the
legs, examiner raises the bent legs and buttocks vertically
upwards, elevating the pelvis. This tilts the pelvis
posteriorly, overcoming the lumbar lordosis and
flattening the lumbar spine. This manoeuvre opens up
the intervertebral foramina, stretches the paraspinal
muscles and aligns the facet joints. If it relieves pain, the
lesion is not a true prolapse and the patient is suitable for
conservative management and the treatment by 90–90
traction (Fig. 32-53).
FIG. 32-45 Alternate SLR: assuming sitting posture without flexion at the
knees indicates negative test.
FIG. 32-46 Bowstring test: appearance or increase of pain on sudden firm
pressure on the sciatic nerve in the popliteal fossa indicates positive test.
FIG. 32-47 Slump test: patient in slouch sitting, head passively flexed
between the knees, active knee extension with foot dorsiflexion reproduced
symptoms when the test is positive.
FIG. 32-48 (A and B) Reverse Lasegue test: Passive extension of hip with
knee in flexion causes pain in the distribution of femoral nerve indicating
positive test.
FIG. 32-49 Gaenslen’s test: Pain at SI joint on passive extension of hip

with knee in extension and normal lower leg in knee–chest position
indicates SI joint pathology.
FIG. 32-50 Pelvic compression test for SI joint pathology: Passive

compression or opening up of the pelvis with firm pressure elicits pain at
the SI joint.
FIG. 32-51 (A and B) Provocative test for acute disc herniation: graded
passive back hyperextension provokes symptoms in the presence of
nuclear extrusion.
FIG. 32-52 Faber’s test (sign) to detect the presence of hip joint pathology
as a causative factor for LBP.
FIG. 32-53 Hip–knee 90–90 test. When passive raising of pelvis with hip
and knee in 90 degrees of flexion relieves symptoms, pelvic traction in this
position is effective.
Other investigations
◼ Laboratory investigations are necessary when LBP is suspected

because of malignancy, metabolic disorder or infective disease.
◼ Plain radiographs (AP and lateral) done as a routine.
◼ CT scan and MRI are ideal in fractures and soft tissues pathology
respectively.
◼ Bone scan – in metastatic diseases and tumour suspicions.
◼ EMG – in localizing nerve root lesions.
◼ Rectal and pelvic examination.

The data thus collected through subjective and objective
examinations should be correlated with the other investigations to
arrive at the final diagnosis.
Evaluation of functional status

Early initiation of guarded functional activities in the management of
LBP is gaining more popularity. Therefore, it is important to
objectively evaluate the activities of daily life and the functional levels
of each patient.
Evaluation of ROM, muscle strength and endurance constitutes the
index of activities of daily living and should be rated on a graduated
numerical scale. They can be divided into five grades from 0 to 4
depending upon the degree of assistance required in carrying out each
activity.
The functional activities to be evaluated are as follows:
1. Personal hygiene.
2. Dressing.
3. Rising from sitting position to standing and reverse.
4. Level walking.
5. Walking up steps and inclines, and coming down.
6. Running.
7. Gait involves rotation of the pelvis and lateral bending which are
reduced because of pain, thereby resulting in decreased speed.
Objective evaluation of gait is hence necessary (time and distance
parameters).
8. Maintenance of a static posture: In the functional positions, static

hold can be made objectively by recording the period (time) of
holding that position before the symptoms appear. If there is no
difficulty, weight can be added to test the holding position. Whenever
feasible, activities such as jogging, jumping and running should also
be objectively assessed and documented.
The scoring scale for the functional activities is as follows:
0 = Unable to perform the activity

1 = Able to perform only with adequate assistance
2 = Able to perform with minimal assistance
3 = Able to perform independently but has pain while
performing
4 = Pain-free, normal activity
General plan of examination
1. Patient standing
Observe General body built, physiological spinal curves, spinal alignment, pelvic obliquity, buttock
crease (sag may be present in S1 joint lesion)
Document Site, size, nature and the degree of pain
Palpate Local muscular spasm, trigger zones, myofascial nodules, sciatic nerve tenderness, prominence
for of spinous processes
Test Range and rhythm of spinal movements of flexion, extension, lateral flexion and rotation;
document the movements aggravating and relieving pain. Muscle endurance:
Tip-toe walking tests gastrosoleus (S1 lesion): If knee buckling occurs, quadriceps weakness
should be suspected (L4 lesion)
Heel walking: To test active dorsiflexion and great toe extension (L4–L5)
Compression test: To test sacroiliac joint tenderness
Measure ROM of spinal movements, angle of pelvic tilt
Look for Limb length disparity (block measurement)
2. Patient supine
Observe General posture
Palpate Flattening of the lumbar lordosis during leg raising
for
Abdomen: Listen for bruit, intra-abdominal mass
Inguinal: Listen for bruit
Peripheral pulses and skin temperature for vascular insufficiency
Muscle tenderness: Hip flexors (L2–L3), quadriceps (L4) and foot dorsiflexors (L5)
Test Passive spinal movements and end feel for flexion and rotation
Hip flexor tightness and hamstrings tightness
Full ROM hip movements (to exclude hip pathology)
Passive SLR: Foot dorsiflexion at the end (sciatic nerve root tension and dural sheath tension)
Bowstring sign (root compression): Passive neck flexion (mobility of dura mater)
Passive neck flexion with SLR (involvement of the spinal cord with L4–L5 nerve roots)
Contralateral SLR (massive disc herniation medial to the root), SI joint: Pelvis opening up and
compression test (to exclude SI joint pathology), pelvic examination in females
Sensory Lower limbs (respective dermatomes)
status
Muscle Abdominals (upper and lower)
endurance
Hip flexors, knee extensors and foot dorsiflexors, extensors and flexor hallucis longus
Measure Leg length (tape measure)
Reflex Medial hamstrings reflex (L5)
Plantar response (S1)
3. Patient side lying
Test Muscle endurance: gluteus medius, S1 joint pathology by:
Lateral compression test
Rectal examination
4. Patient prone
Palpate Vertebral alignment, muscle spasm, local tenderness, nodules, renal tenderness, gluteus
for maximus hamstrings and calf tenderness
Test Intervertebral accessory movements
Femoral nerve stretch test
Muscle Hip extensors, spinal extensors and hamstrings
endurance
Sensory Dermatomes on the posterior aspect from buttocks to feet
status
Reflex Ankle jerk (S1)
Measure Thigh and calf girth for atrophy
5. Patient sitting
Test Muscle endurance:
Hip flexors (L2–L3), quadriceps (L3–L4), extensor hallucis longus (L5)
Flexor hallucis longus (SI)
Hamstrings for tightness
Reflex Knee jerk (L3–L4)
Measure Calf circumference, chest expansion
Working diagnosis of low back pain

Such an extensive and elaborate physical examination, although ideal,
is not always feasible in all patients of LBP. A quick working
diagnosis can be made by examining certain major characteristics of
signs and symptoms chosen from the general plan of examination to
identity and rule out the serious underlying pathology.
The presence of a serious pathology can be identified by keen
observation as the patient walks into the room and relates the history
of his episode. On the basis of this, priorities in the physical
examination can be chosen to arrive at the working diagnosis such as
the following:
1. Severe degree pain at rest: Infectious or neoplastic lesion may be

present.
2. Acute pain radiating to leg; list, positive neurological signs and positive
SLR or cauda equina syndrome: Major disc lesion, fracture or infectious
disease may be suspected.
3. Pain relieved by rest: Lesion most probably be of mechanical origin.
Treatment
Physiotherapeutic modalities in the management of low

back pain
A number of studies have been reported to find out the most effective
modality in the treatment of idiopathic LBP. None of the studies so far
has proved the definite superiority of a particular modality. The
objective findings of various studies can be summarized as follows:
1. Properly controlled exercise programme is a common effective

modality with any of the therapeutic approaches.
2. Manipulation has a definite edge over the other approaches in

selective cases.
3. Maximum benefit was observed in patients treated early (within the

first month of the onset).
4. Postural guidance during rest and at work (back ergonomics) is

very important.
5. The results are better in patients treated with a combination of more

than one approach, rather than those treated with a single modality.
The following modalities, single or in combination, are

generally employed in the conservative management of
LBP:
1. Spinal exercises
2. Physical agents
3. Spinal traction
4. Role of lumbar spinal supports
5. Specialized techniques
Before discussing the rationale of each of these modalities, it is

necessary to highlight the importance of ergonomic advice which
consists of educating the patient on postural adaptations (static as well
as dynamic) to reduce strain on the back.
Role of spinal exercises

A great deal of controversy still exists regarding the exact indication
and the type of exercise for a particular aetiology of LBP. Specific
optimal regimen of exercise is nonexistent.
If the purpose is reduction of pain, exercise should be limited to the
point of discomfort. However, if the purpose of the exercise is to
regain mobility, the movement has to be carried well into a
perceptible pain and maintained in spite of little discomfort; it should
be performed often and be progressive. The exercise programme aims
to:
1. decrease pain,
2. strengthen weak muscles,
3. improve endurance of muscles,
4. decrease mechanical stress to spinal structures,
5. stabilize hypermobile structures,

6. improve posture,
7. improve mobility and flexibility and
8. improve fitness level to prevent recurrence.
Effects of exercises
1. They increase strength of bones, ligaments and muscles.
2. They improve nutrition to joint cartilage, including intervertebral

disc.
3. They enhance oxidizing capacity of skeletal muscles.
4. They improve neuromotor control and coordination.
5. They increase the level of endorphin in the cerebrospinal fluid (CSF)

and blood, which is found to be reduced in patients with LBP.
Endorphin has been proved to have a significant pain-modifying
effect.
6. Exercises have tremendous psychogenic effects and reduce the

symptoms of depression and anxiety.
7. They promote the feeling of well-being, as there is an increase in the

alpha wave activity, producing central and peripheral relaxation and
decreasing the muscle tension (Colt, Wardlao, & Frantz, 1981; De
Vries, 1968; Edgerton, 1976; Farmer et al., 1978; Fraioli et al., 1980;
Hammand and Froelincher, 1986; Tylor, Sallis, & Needle, 1985).
Exercises have been shown to be more effective than a dose of
meprobamate in decreasing muscular tension (De Vries, 1968), in
addition to their positive response in inducing sleep.
Supervised activation, sometimes even beyond the pain limit but

with controlled biomechanical activities, seems to be a more effective
modality than any other therapeutic procedure (Cathlove & Cohen,
1982; Choler, Larson, Nachemson, & Peterson, 1985; Nachemson,
1983).
The exercise programme should be minimal and as specific as a
drug needed in proper dosage. The authors feel that it is high time to
develop a scientific approach rather than blindly treating all patients
of backache with hyperextension exercises.
It is important to understand the effects of a particular type of
exercises on the spine and its periphery. It is also highly improper to
hand over one standard manual of back care and home exercise
programme to all the patients irrespective of the cause of LBP.
1. Flexion exercises: Williams (1965) advocated trunk flexion exercises

for the following aims:
(a) To open the intervertebral foramen and facet joints,

reducing compression on the nerves.
(b) To stretch (tight) back extensors, reducing stress on the

lumbar spine.
(c) To strengthen abdominal muscles.
(d) To increase endurance of abdominal muscles.
(e) To free posterior fixation of lumbosacral articulation.
(f) To protect the lumbar disc from excessive

posteroanterior pressure through the development of
intra-abdominal pressure (Bartelink, 1957; Morris, Lucas,
& Bresler, 1961). However, internal and external oblique
muscle groups have been found to be instrumental in
generating the reflex intra-abdominal pressure (IAP).
They also have an added advantage of avoiding range of
true flexion, and hence need special attention.
Caution
It must be remembered that the excessive participation of the rectus
abdominis and obliques results in compressive forces, and hence are
to be avoided (Valsalva manoeuvre). Graded shoulder lift sit-up
with rotation of the trunk in hook lying position is the ideal exercise
to emphasize the action of oblique muscles (Fig. 32-54). Flexion
without rotation strengthens the rectus abdominis (Figs 32-55A,B
and C). Graded holding of knee–chest position (Figs 32.55D and E)
stretches tight spinal extensors responsible for exaggerating the
lumbar lordosis.
FIG. 32-54 Exercises for external and internal oblique muscles by graded
shoulder lift with spinal rotation.
FIG. 32-55 (A–C) Graded rectus abdominis exercise. (D) Initial phase of
single knee–chest position. (E) Final knee–chest position of bilateral full
ROM knee flexion which maximally stretches posterior soft tissues, opens
up posterior intervertebral disc spaces and opens up facet joints.
Contraindications
1. In acute disc prolapse, as exercises exert excessive load

on the lumbar discs and open the posterior intervertebral
space.
2. After prolonged rest, when the disc is hyperhydrated, it

is more susceptible to injury (Nachemson, 1980).
3. When the postural LBP is due to posterior pelvic tilt.
4. In the presence of a lateral trunk shift/list (McKenzie,

1979).
5. In patients with osteoporosis, where incidences of
compression fractures and wedging have been reported
(Sinaki & Mikkelsen, 1984), as these exercises will
increase compressive forces on the vertebrae.
2. Extension exercises: Effects of extension exercises are as follows:
(a) They promote normal physiological lumbar curve of the

spine, allowing it to withstand axial compression force
(Kapandji, 1979; White & Punjabi, 1978), thus facilitating
lifting loads.
(b) They improve the motor recruitment, strength and

endurance of the extensor muscles of spine and hip
(Sinaki & Mikkelsen, 1984).
(c) In postural LBP patients, where the extensors develop

tightness due to the prolonged flexion attitude of posture
in sitting or standing position.
(d) They unload the disc and allow the fluid influx;
therefore, important in patients with suspected posterior
or posterolateral discs.
(e) They are the main muscle groups in postural holding

and in the eccentric control of trunk flexion (Pauley,
1966).
(f) They improve the mobility of the spine.
(g) They improve tone in the extensor muscles, which is

often reduced because of the maximum natural flexion
attitude of the human body.
(h) Rare incidence of LBP in patients with strong extensors
(Davies & Gould, 1982), and decreased endurance in
patients with LBP suggests the important role of strong
extensors (De Vries, 1968).
Extension exercises are of two types:
(a) Extension to neutral: It involves concentric contraction

of the back extensors from the flexion of 40–45 degrees of
the trunk. The advantage of this exercise is that it
involves eccentric contractions of the extensors when the
trunk returns to its initial position of 40–45 degrees of
flexion (Fig. 32-56A). Controlled assistive support needs
to be given over the chest or shoulders.
(b) Hyperextension exercises: In prone position, the patient

extends the spine beyond the neutral position up to 15–
30 degrees of hyperextension (Fig. 32-56B).
Contraindications
1. Acute disc lession.
2. Pathological conditions such as spinal stenosis,

spondylolisthesis (Kapandji, 1979).
3. In a multioperated back where sufficient disruption of

the extensor muscles and spinal mechanics have
occurred.
4. Patients with limited forward mobility following

scarring from previous surgeries (Mckenzie, 1982).
3. Rotational exercises: Exercises involving the movement of rotation
are important due to the following reasons:
(a) The movement of rotation of spine forms the basic

component of mobility for functional efficiency.
(b) The external and internal oblique muscles provide

anterior stability to the lumbar spine and flexion of the
spine without excessive compression (Halpern & Bleck,
1979).
(c) The rotators contribute significantly to the development

of intra-abdominal pressure and are effective in
maintaining anterior and posterior balance of the trunk,
which is disturbed in LBP. They are also important in
performing controlled rotatory activity of the spine.
(d) The rotational movement of the intervertebral segment

provides overall relaxation to the spinal muscles,
reducing tightness, spasm and pain.
4. Mobility exercises: Functional efficiency of the lumbar spine

depends upon its flexibility (Farfan, 1978). Similarly, pelvic mobility is
needed for various activities such as bending and lifting
(Gracovertsky, Farfan, & Lamy, 1981). Apophyseal joints of the spine
require mobility or movement to facilitate nutrition and to prevent
degeneration of the articular cartilage (Enneking & Horowitx, 1972).
Therefore, mobility exercises are the main contributors to the
mechanical efficiency of the spine and the whole body.
Mobility exercises can be passive or active and should

include all the movements. Relaxation of the concerned
muscles and joints is important to improve mobility. The
speed and the arc of movements need to be progressed
only when enough relaxation is achieved. The effective
exercises improve relaxation and mobility of the
lumbosacral complex which can be achieved by self-
assisted pelvic rotation and chest roll performed by the
patient.
In supine lying with hips and knees bent and the feet resting
on the treatment table, the patient initiates a small range of
pelvic rotation on either side. As relaxation is induced,
further range can be gained, progressing to complete
rotation of the pelvis (Fig. 32-57). Alternately, chest roll in
either supine or sitting position may be included to
improve the mobility of the whole spine (Fig. 32-58). These
exercises, before the passive mobilization technique,
facilitate the process of manipulation and mobilization.
Ideally, these relaxed mobility exercises should be initiated
as soon as one wakes up, in the bed itself, to overcome the
stiffness of night rest.
FIG. 32-56 (A) Active assisted spinal extension from 40 to 45 degrees of
flexion. (B) Active spinal hyperextension.
FIG. 32-57 Rotational exercises to the spine: pelvic rolling. (A) Starting
position. (B) Position of extreme rotation of pelvis to the left.
FIG. 32-58 Rotational exercise to the upper spine (chest roll).
Caution
Mobility exercises are contraindicated in (a) the presence of
segmental hypermobility and (b) acute disc lesions.
5. Stretching exercises: These are of two types:
(a) General stretching exercises
(b) Specific stretching exercises
(a) General stretching exercises: They offer stretching to all

the soft tissues and the spinal joints which remain
contracted when one type of posture is sustained for a
long time. Generalized stretching is needed to avoid
adaptive shortening of the soft tissues, good posture,
mobility and, above all, the feeling of well-being and
alertness.
(b) Specific stretching exercises: They are of special

significance when the basic cause of LBP is the adaptive
soft tissue shortening. Long sessions of low intensity
sustained stretching techniques may be required.
6. Self-correction and its maintenance: Proper and adequate

education on self-corrective techniques of incorrect postural habits
may be necessary. Maintenance of the postural self-correction forms
an important part of this technique.
7. Exercise specificity: Once the type of exercise has been selected, the

specificity has to be decided on the basis of the findings of
examination. The exercise must not be PAINFUL. The major types of
exercise techniques are as follows:
(a) Isometric
(b) Isotonic
(c) Isokinetic
The efficiency of the selected exercise technique is to be

checked at regular intervals.
8. Aerobics: Gradual introduction of aerobics is proving extremely

effective in the control of LBP. These should be started gradually so
that there is no undue strain. Activities such as brisk walking, jogging,
swimming, cycling, rope jumping and dancing have been found to be
very useful in controlling as well as preventing LBP. They need to be
supervised and controlled biomechanically by the physiotherapist.
They must begin with relaxed free movements of the whole spine.
Efficacy of exercise programme: As an optimal regimen of exercise

is nonexistent, it is important to monitor the efficacy of the exercise
programme right from day one. Changes in the intensity of pain and
its location provide valuable guidance.
1. Centralization of pain to the centre of the back is an important clue

to the correctness of the therapeutic programme. Incorrect posture,
improper exercise or wrong activities cause pain to move away from
the centre of the spine to the periphery (Table 32-14).
(a) Rotational exercise, added gradually only when pain free.
(b) Aerobics – only after cardiac clearance and rapid longer

duration movements are possible.
2. At the initial exercise session, slight increase in pain is expected.

The pain should decrease in the subsequent sessions with
centralization. However, increase in the intensity of pain and its
migration to the periphery is a warning to stop exercise immediately
and seek further advice.
3. Approach to the exercise should be cautious when even gentle

exercise or graded positioning of the body is uncomfortable.
4. In situations where tightness or weakness of muscles and fascia is

the cause of LBP, increase in pain is expected due to repeated
stretching and muscle fatigue.
5. Initially, new pain may be noticed as a result of corrective

procedures of the established wrong postural attitudes in postural
LBP.
6. The response may be slow and the improvement may be delayed in

patients with longer duration LBP. It may take even 10–15 days for a
noticeable relief.
Table 32-14
Guidance to Select Flexion versus Extension Exercise on the Basis of Pain Reduction
or a Relief
Flexion Exercises Extension Exercises

Relief of pain on • In lying position
• Sitting • On walking
• Forward bending • Decreased lumbar lordosis
Has lumbar lordosis • Repeated back bending
Has fixed lumbar lordosis with forward
bending
Or
Increase of pain on Pain unchanged on stopping
• Standing still forward
• Sustained bending forward • Sitting
• Repeated backward bending • Driving
• Raising to standing from chair
• Forward bending or stooping
• Repeated forward bending
Exercises to be avoided: Certain exercises should either be totally

avoided or be initiated with extreme caution. Examples of such
exercise are as follows:
1. Forward bending and trying to touch the toes in sitting and

standing positions.
2. Bilateral straight leg raising in supine lying position.
3. Prone lying, lifting both the arms overhead and both the legs with
knees straight, and arching the back posteriorly.
4. Backward bending in standing position.
All these exercises put tremendous stress on the concerned tissues.

The lumbar extensor group of muscles, being antigravity muscles,
are stronger right from younger age. They remain so unless they are
incised during surgery. As such, strengthening procedures are not
really needed for these muscles unless they are for a specific purpose.
The strengthening may lead to their shortening and limitation of
trunk flexion. This should be considered in planning the exercise
programme and during training to attain normal lordotic lumbar
curve and its maintenance.
Physical agents
Various types of physical modalities can be applied as adjuncts in the
treatment of LBP. Selection of a modality depends upon the mode of
action of the modality to suit symptomatology and the nature of tissue
involvement. The objectives of using various physical agents are as
follows:
1. To control pain and spasm.
2. To reduce inflammation.
3. To facilitate the use of specialized techniques such as mobilization,

traction and exercise.
4. To reduce depression, tension or any other psychological factor.
The various physical agents are discussed below.
1. Ultrasound: Ultrasound has been in use since the 1950s and is

definitely advantageous in the following situations:
(a) It can be given in acute as well as chronic phases of

LBP.
(b) It can be used for driving the medications such as

hydrocortisone and xylocaine into the skin over the
targeted tissues by phonophoresis.
(c) It increases cortisol present in the spinal nerve roots and

lumbosacral plexuses, thereby improving mobility by
decreasing pain (Touchstone, Griffin, & Kasparow, 1963).
(d) It increases extensibility of the connective tissues such as
tendons and joint capsules (Lehmann, 1970). This particular
action of ultrasound is important, as it can improve the
accessory movements in the apophyseal joints. Therefore, it
is ideal before applying mobilization techniques.
(e) It has been found to reduce spasm in lumbar

radiculopathy (Clarke & Sterner, 1976).
Although the dosimetry of ultrasound is based on tolerance,

an output intensity of 1.5 W/cm2 with continuous mode of
application for a period varying from 5 to 10 min is a
standard pulsed ultrasound ideal for acute LBP.
2. Cryotherapy: It is a simple and effective procedure which

reduces muscle spasm and inflammation in the acute phase.
Ice massage with ice cubes for 3–5 min or with ice bag for 15
min can be used directly over the painful areas; it also acts as
an analgesic and provides the most needed compulsive rest.
3. Transcutaneous electrical stimulation: Transcutaneous

electrical stimulation (TENS) over the trigger points or
acupuncture points has been reported to be effective in both
acute and chronic conditions (Ersek, 1976). It reduces the
perceived pain by:
(a) elevating endogenous opiate levels in the brain and spinal

cord (Bonica, 1979), and
(b) continuous stimulation of cutaneous afferents which

blocks pain in the substantia gelatinosa of the spinal cord
(Melzack & Wall, 1965).
Frequency of 2–4 Hz, output intensity of 50 MA, pulse rate at
2 pulses/s and pulse width between 30 and 60 min have been
reported to be an effective mode of application in chronic as
well as acute conditions.
4. Moist heat: Moist heat in the form of hydrocollator packs

reduces pain and spasm in the acute phase. It can be used as
an effective adjunct before applying specialized techniques
or even before TENS, short-wave diathermy (SWD) or
ultrasonics because of the comfortable heat along with forced
rest for a longer period.
5. Electroacupuncture: It has been reported to be an effective

pain controlling modality but needs special equipment. It
also needs specific knowledge of the theory of acupuncture
and is difficult to practise as a routine therapy (Santiesteban,
1980).
6. Diathermy: Diathermy is preferred for deep heating of the

tissues over larger areas. However, drum electrodes or
induction electrodes can be used where superficial heating is
advisable (Griffin & Karselis, 1978).
Of the two modes of diathermy – (a) continuous and (b)

pulsed or nonthermal – the latter is ideal in dealing with
acute conditions or after surgery. In chronic LBP, a
continuous modality is preferred.
Various new modalities such as interferrential currents,

diapulse, megapulse and laser beams are added to physical
therapy. Helium–neon laser has been reported to be
significantly effective in the control of back pain with
musculoskeletal trigger points (Synder-Mackler, Barry,
Perkins, & D’Soucek, 1989).
7. Electrical stimulation: High intensity electrical

stimulation over the trigger area may respond favourably,
especially in LBP of psychogenic origin.
8. Massage: Gentle soothing massage is instrumental in

reducing local muscular spasm. It helps in removing
nociceptive substances by improving blood circulation. It
also gives a feeling of betterment by inducing relaxation.
The efficacy of a particular modality should be evaluated

periodically during the course of treatment. The selection of
a particular physical agent should be done as per the
underlying pathology.
Spinal traction
It is a popular modality in the management of LBP.
Range of traction force: There exists a great deal of variation

in the spectrum of the effective traction force. To overcome
the force of friction, a force equivalent to the body weight is
necessary. Therefore, the traction force required to produce
distraction in the vertebrae ideally should be of at least half
the body weight. The range of traction force may vary from
37 to 91 kg (Hickling, 1972; Judovich, 1955; Mathews, 1972).
As a result of traction, the range of vertebral distraction as

reported in various studies varies from 0.3 to 4.0 mm. The
maximum distraction reported is 2.0 mm (Harris, 1960).
Effects
1. Traction produces relaxation of tight muscles and

tautening of viscoelastic ligaments.
2. It increases the intervertebral distance, allowing reduction

in disc protrusion.
3. It relieves pressure on the nerve roots and their dura.
4. It offers positive decompression, drawing the protrusion

towards the centre by suction and brings about separation of
the facet joints.
5. Traction has been found to be effective in the presence of

dural signs and root palsy.
Direction of traction: The direction of pull must be

underneath the pelvis so that there is posterior tilting of the
pelvis, decreasing the lumbar lordosis (Fig. 32-59).
FIG. 32-59Lumbar traction – direction of tractive force.

(A) Incorrect tilting of pelvis anteriorly results in
exaggeration of lumbar lordosis. (B) Correct tilting of
pelvis posteriorly results in flattening the lumbar
curve.
However, whatever method is used, one must remember

that the effectiveness of traction does not depend upon the
magnitude of the tractive force. The criterion for selecting
traction as a treatment modality is the reduction of the
symptoms.
Types of spinal traction
1. Continuous traction: Continuous traction provides stability

and muscular relaxation. It is advocated in patients
complaining of excruciating localized or radiating pain. A
traction force in the range of 10–25 lbs is adequate for pain
relief. It is applied for several hours with the foot end of the
bed raised to provide counter traction. The pulley system of
the traction should be 10 inches above the mattress. The force
of traction rotates the pelvis backwards and maintains the
lumbar spine in neutral position (Kottke, 1961).
However, continuous traction sometimes produces pain due

to muscle fatigue. On such occasions the traction should be
discontinued temporarily.
If supine lying is painful, sustained traction can be given in

prone position, provided the patient is comfortable and
indicates relief. Disc protrusion can be treated effectively
with the patients in prone position (Saunders, 1983).
2. Sustained traction: In supine lying, the static traction with

tractive force of not less than 50%–60% of the body weight is
applied for 20–30 min. If more distraction is needed, heavy
but tolerable weight is applied for a short duration. It is
advisable in sciatic type of pain.
Indications
1. Disc protrusion.
2. Degenerative disease with osteophytes exerting pressure

on the nerve root or dural sheath (heavy traction for 30 min).
3. Unilateral lumbar traction when stronger force is desired

on one side of the spine (e.g., unilateral joint dysfunction,
sciatic scoliosis).
4. Pain arising as a result of secondary disc lesion in

spondylolisthesis.
5. First and second lumbar disc lesions secondary to lumbar

arthrodesis or failed manipulation.
6. Recurrence of pain following surgery, e.g., laminectomy.
3. Intermittent traction: Alternate application of traction and

its release is the most popular method of applying lumbar
traction. It has vascular massaging effect, and relaxation is
produced in the tight soft tissues. The combination of
alternating stretch and release promotes relaxation. It is well
accepted by the patients as compared to sustained traction.
Indications
1. Disc protrusion accompanied by stiff back (60-s hold, 20-s

rest).
2. Joint dysfunction or degenerative disc (shorter hold and

rest period).
4. Manual traction: Traction is applied manually for a few

seconds by the physiotherapist. However, it is not commonly
used as the patient cannot anticipate the amount of tractive
force, and thus fails to relax during traction.
5. Positional traction: If only one side of the spinal segment is

involved, the patient is positioned in lateral bending by
using sandbags, pillows or blocks.
6. Autotraction: A special traction table provides a facility to

angulate or rotate an individual segment of the spine. The
patient can manoeuvre the direction and magnitude of the
traction. It needs constant supervision. Although it is self-
monitored, it has not gained popularity in practice.
7. Gravity lumbar traction: It is a traction where the body is

vertically suspended by a special vest securing the rib cage.
Gravity and weight of the hips and legs provide the traction
force on the lumbar spine (about 40% of body weight).
Gravity traction in inverted position has been reported with

straps securing the pelvis or boots (Gianakopoulos Waylonis,
Gant, Tottle, & Blazek, 1985; Nosse, 1976). Here the weight of
the upper body, head and arms provide a tractive force
(about 50% of the body weight).
However, these types of gravity tractions are not generally

used because of their inability to attain relaxation in vertical
hanging. Secondly, one has to constantly watch for the
obvious effects of inversion on the patient’s
cardiopulmonary systems (Gianakopoulos et al., 1985).
Ideal methods of spinal traction
1. 90–90 position (Fig. 32-60): Cotrel and Lossing (1986) have

described a method which appears to be ideal for the
following reasons:
(a) The patient is in supine position.
(b) The legs are bent 90 degrees at the knees and hips and
supported on a chair at a proper height.
This position reduces the intradiscal pressure at the lumbar

spine to the maximum (Splatts, 1977) and offers relaxation to
the lumbar area. Gradual traction in this position promotes
opening of the intervertebral foramina, aligns the facet joints
and provides even stretching of the paraspinal muscles. It is
not suitable when there is painful limitation of extension.
2. Neutral position of the lumbar spine: The patient is placed in

supine position with a pillow under the knees. This position
puts the lumbar spine in neutral.
FIG. 32-60The 90–90 position: resting in supine with

hip and knee joints supported in 90 degrees flexion
reduces intradiscal pressure.
Chest and pelvis harnesses are applied and the traction force
is gradually increased to an adequate level.
Ideally, the traction should be preceded by an appropriate

modality such as hydrocollator pack or diathermy to induce
relaxation. The newer traction tables also have microwave
units for simultaneous use.
Precautions
1. Constant supervision is necessary, when the patient is

under traction, to detect any difficulty in breathing or other
GI or cardiopulmonary complications.
2. Gradual increase of tractive force to be regulated to the

level of comfort and reduction in the symptoms. Release of
traction should also be gradual.
3. Bouts of cough and sneeze during traction can aggravate

pain. Therefore, before applying traction, make sure that the
patient is not having cough or cold. If present, he should
avoid jerking the back.
Contraindications
1. Acute lumbago following acute strains, sprains and

inflammation.
2. Patients with impaired cardiac or respiratory functions,

e.g., cardiac failure, emphysema and asthma.
3. Instability of the spine.
4. Marked osteoporosis, hiatus hernia, claustrophobia,

pregnancy.
5. In structural disease secondary to tumour or infection.

6. In vascular compromise, and in any condition for which
the movement is contraindicated (Yates, 1972).
7. Massive disc prolapse causing sciatica with neurological

deficit (Weber, 1975).
8. Patients with pain during rest, indicating root

interruption.
9. Spinal infections, i.e., osteomyelitis, tuberculosis.
10. Malignant disease, metastatic or local.
11. Rheumatoid arthritis.
Role of lumbar spinal support
The present trend is to discourage the use of

lumbar/lumbosacral support in LBP. This is because it
reduces the muscular activity, resulting in weakness, atrophy
and reduction of tone. However, it is beneficial under certain
situations. The advantages of lumbar spinal support are as
follows:
1. It enhances the natural splintage effect, as it maintains the

physiological lumbar curve which is the basis of treatment of
LBP these days (e.g., McKenzie’s technique).
2. It provides partial immobilization, and thus protects the

lumbar spine from stress of movements. Immobilization
helps in reducing pain due to muscle spasm. Restriction of
movement allows early safe mobility, which is preferred to
rest and immobilization.
3. It allows transmission of the forces of gravity and weight,

facilitating early ambulation.
4. It provides support and reassurance to the patient.
5. It is especially beneficial in acute lumbago or disc lesions.
6. It facilitates the natural splintage effect provided by the

abdominal and spinal muscles.
7. It uplifts and supports the abdomen, thereby unloading

the effects of gravity on the discs.
Indications for lumbosacral support
1. Acute vertebral pain
2. Acute disc lesion
3. Spondylolisthesis
4. Following spinal surgery
5. During work activity to patients who were mobilized

earlier
6. Chronic recurrent LBP
The physiotherapist must first check the fitting of the corset,

and educate the patient on the correct methodology of its
application and maintenance. Emphasis has to be laid on the
early but graduated weaning of the corset to avoid its ill
effects.
Specialized techniques
1. McKenzie’s approach
2. Manipulation and mobilization
Mckenzie’s approach
The basic principles of this approach can be underlined as

follows:
(a) McKenzie (1981, 1982) utilizes the response of the patient

to the repetition of all four basic movements of the lumbar
spine. Identification of the movement which reduces pain or
brings about its centralization (i.e., peripheral pain is moved
towards midline of the spine) forms the basis of the therapy.
Hence, it is called movement therapy.
(b) He also stresses the importance of maintenance of the

normal physiological curve of the lumbar lordosis in all the
body positions and activities, besides back ergonomics.
Prolonged flexion posture elongates the posterior tissues

such as posterior longitudinal and supraspinous ligaments,
the facet capsules and posterior annular fibres of the disc,
putting excessive compression over the anterior surfaces of
the vertebral bodies. This forces the nucleus pulposus
posteriorly, causing nuclear bulging, or some herniation,
whereas lordosis at the lumbar spine is ‘physiological’,
which forces the nucleus anteriorly, away from the neural
contents of the spinal canal. Therefore, his approach lays
emphasis on the maintenance of the lumbar lordosis.
He categorized the origin of LBP basically because of three

principal pathological conditions, and termed them as
follows:
1. Derangement syndrome
2. Dysfunction syndrome
3. Postural syndrome
1. Derangement syndrome: In derangement syndrome,

anatomical disruption or displacement occurs within the
intervertebral disc. In younger age group, there is
displacement of the annulus complex or fluid nucleus,
whereas in older age group degenerated annulus or fibrosed
nucleus may be present.
The disc derangement may be:
(a) minor or major posterior disc disturbance;
(b) minor or major posterolateral disc disturbance with

impingement of nerve root and dural sleeve with sciatica
with or without deformity;
(c) anterior or anterolateral disc disturbance.
Symptoms of various disc displacements are presented in

Table 32-11.
Patients with ipsilateral shift or in whom the trunk is listed
towards the painful side, with sciatica and neurological
signs, are resistant to mechanical therapy.
The basic approach of mechanical and movement therapy in

posterior derangement syndrome is as follows.
2. Dysfunction syndrome: The incidence of LBP due to

dysfunction syndrome is common in the age group of 30
years. Lack of exercise, poor postural habits or organization
of fibrous collagenous scar tissue during the process of repair
may be the precipitating factors.
Pain is felt adjacent to the spine only at the extreme range of

movements because of the overstretching of shortened soft
tissues, and never during movements.
The treatment consists of extension in lying, flexion in lying

or side gliding in standing positions. As it involves
stretching of the contracted soft tissue, some pain is
expected. To be effective, exercises are performed long
enough to maintain stretched positions. They should also be
performed in various positions, e.g., for flexion dysfunction
if the improvement is not achieved with flexion in lying,
change it to flexion in standing or may be to flexion in step
standing.
Rotation manipulation combined with mobilization may be

necessary if the patient ceases to improve.
3. Postural syndrome: Postural syndrome is common in

younger age group (below 30 years). Pain is present adjacent
to the spine. The cause is the overstretching of the normal
tissues because of poor sitting or standing postures or lack of
stretching exercises in sedentary professions.
The basis of treatment is the training of self-corrective

postural exercises. This may be associated with ‘new pains’
due to adjustments to the new postural attitudes.
It must be remembered that in all the techniques of this

approach, back care programme on biomechanical principles
and maintenance of lumbar lordosis are essential. Mckenzie’s
method has gained popularity and has been proved
objectively effective in various conditions (Vanharanta,
Videman, & Mooney, 1987).
Methodology of mckenzie’s approach
1. The patient is taught self-correction of his bad posture

with emphasis on maintaining normal lumbar lordosis in all
the situations.
2. Exercise programme begins as an extension exercise,

flexion attitudes are incorporated later (by 2–3 weeks) or
only when acute pain subsides.
Extension to restore normal lumbar lordosis:
1. Prone lying: Brief periods of prone lying for relaxation of

the back muscles (Fig. 32-61).
2. Prone lying in extension with forearm and elbow support:

In this position, the elbows are placed in line with the
shoulder joints. Trunk is raised in extension by leaning on
the forearm and curling of shoulders and upper back (Fig.
32-62).
Progress to exercises 3 and 4 when the constant pain is

relieved.
3. Prone lying extension on hand support: In this position,

hands are placed in line with the shoulder joints, and trunk is
gradually extended by leaning on the hands (Fig. 32-63).
4. Standing extension: Stand upright, keep hands over the

small of the back. Bend trunk backwards as much as
possible.
FIG. 32-61Relaxed prone lying with pillow under the

legs.
FIG. 32-62Prone lying with forearm support.
FIG. 32-63Prone lying: further progression of spinal

extension to hand support without lifting the pelvis.
Progression of exercises from 1 to 4 is done in stages.

Exercises 1 and 2, if pain free, can be given in acute pain.
Extension exercises are not enough unless the ways and
means of maintaining normal lordosis of the lumbar spine by
self-corrective methods is taught.
When there is no relief even by 3–4 days of extension

exercise and the pain is only on one side, shift away the
pelvis from the painful side; relax in this position (Fig. 32-64)
and then perform exercise 1 in this altered position. Progress
to exercise 3 in this modified position. Centralization or even
distribution of pain following this manoeuvre is an
indication of its efficacy.
FIG. 32-64Relaxation with the left pelvis away from the

painful right side.
Flexion exercise – to improve flexibility – begins after 2–3

weeks or when the acute pain has subsided:
1. Flexion in supine lying with both the knees bent: Bend one
knee, hold with both the hands, swing it rhythmically in a
graduated manner to knee–chest position and hold to 10
counts. Repeat the procedure with the other knee. Then
bring both the legs to knee–chest position. First give slow
rhythmic swings and hold with hands in the maximally
stretched pain-free knee–chest position to the count of 30 or
10 s or more.
2. Flexion in sitting: Long sitting with feet apart and firm on

the ground; gradually bend forward. Initially, hands
supported on thighs are brought forward gradually towards
feet and held in the maximally stretched position without
pain to reach just above the ankle joints (Fig. 32-65). Then,
progress further to reach tiptoes. Hand support can be
waned gradually once the pain-free lumbar–pelvic rhythm is
achieved.
FIG. 32-65Supported trunk flexion in long sitting.
Spinal manipulation
Manipulation is a very specialized technique which involves

skilled, gentle, precisely passive movements of a joint either
within or beyond its active range of motion by manual force.
A small and firm but gentle force is applied to restore the lost
movement by producing a desired ‘joint play’ or to achieve
unlocking. It can be carried out successfully only by
thorough training and practice based on sound knowledge of
the neurophysiological and biomechanical processes as
applied to a specific joint and its movement. A beginner
should undertake manipulations only under supervision of
an experienced colleague. Unskilled attempted manipulation
on the basis of theoretical knowledge alone can be
disastrous.
The aims of manipulation are to:
1. relieve pain
2. promote increased function
Effects of joint manipulation
1. Mechanical: It improves the extensibility of the connective

tissue elements of the capsule, ligament, muscle and fascia.
2. Neurophysiological: It blocks the centripetal transmission

of nociceptive (pain) pathways through sensory input, which
could be cutaneous, muscular, articular or auditory.
3. Sensory stimulation: Skilled evaluation of the joint

mechanics and soft tissues itself provides enough sensory
stimulation and encouragement to the patient.
Indications of manipulation
1. Vertebral malposition
2. Abnormal vertebral motions
3. Abnormal joint play or end feel
4. Soft tissue abnormalities
5. Muscle contracture or spasm
6. Severe nerve root pain
7. Chronic spondylotic changes
8. Chronic discogenic pain
Techniques: There are four basic techniques.
1. Oscillation technique: It is employed in a recently injured joint

where minimal movement is indicated to retain its function.
2. Stretch technique: Joints presenting restriction due to capsular

or myofascial changes are benefited by ‘stretch
manipulations’.
3. Thrust technique: Joints demonstrating sudden hard stop to a

movement in one direction due to adhesions will respond
better to a thrust technique.
4. Rotation and side bending technique: When there is restriction of

the facet joint mobility. During the movements of forward,
backward or side bending, the facets slide on each other.
During rotation, the facets distract from each other.
Restrictions in the mobility of lumbar facet joint
instantaneously respond to rotation and side bending
manipulation techniques (Haldeman, 1983; Maitland, 1977;
Paris, 1983).
Contraindications
1. The most important contraindication is the unskilled

manipulator
2. Patients with prolapsed disc (acute discs with advancing

neurological signs)
3. Instability, spondylosis and fracture
4. Fever, influenza, rheumatoid arthritis
5. Active inflammatory joint disease
6. Advanced osteoporosis and diseases of bone
7. Bleeding disorders
8. Pregnancy
Support modalities such as heat, massage, ice, ultrasound

and TENS relax the soft tissues and may be used as an
effective adjunct before and/or after manipulation.
Treatment of idiopathic low back pain
In idiopathic LBP, it is necessary to recognize the nature of

the LBP syndrome. It may be static or dynamic; static when
pain is present during stationary position, and dynamic
when it appears during movements. The complex nature of
the origin, symptomatology, the individual’s perception of
pain and its overall influence lead to marked variation to the
therapeutic approach (Table 32-15). The basic therapeutic
regimen during the acute and subacute stages is outlined as
under.
Table 32-15
Therapeutic Approach for Treatment of Idiopathic Low Back

Pain
Cause of LBP Clinical Signs and Symptoms
• Cauda equina • Bilateral sciatica, saddle

compression anaesthesia, bladder and bowel
incontinence
• Abdominal • Tearing, throbbing back pain,

aneurysm syncope, dizziness or hypotension
• Pulsatile mass, abdominal bruits,

decreased peripheral pulsation
• Infective disease
affecting lumbar spine
• Bacterial infection • Persistent pain even at rest,
exacerbated by movement, stiffness

exacerbated by movement, stiffness
with acute toxic symptoms
• Tuberculosis and • Loss of body weight, pain over the

fungal infections affected vertebrae with reflex spasm
• Discitis with • Postlumbar disc surgery, acute

pyogenic sacroiliitis symptoms fever, SI joint pain and
tenderness
• Tumours • Nocturnal and pain even at rest
• Benign • Localized pain, stiffness, involves

mostly posterior elements of
• Malignant involved vertebrae
• Diffused pain, systemic symptoms

and mostly involves anterior
vertebral elements
• Inflammatory • Long lasting morning stiffness,

spondyloarthropathies persistent pain
• SI joint arthritides • Localized SI joint pain and

tenderness, iritis, gradually
• Ankylosing increasing stiffness (whole spine)
spondylitis
• Associated with conjunctivitis,
• Reiters disease urethritis pain localized to lumbar
spine
spine
• Psoriatic spondylitis • Psoriatic skin patches, localized

pain lumbar region
• Metabolic bone • Midline bony tenderness, pain over

diseases: affected vertebrae, dorsal kyphosis,
vertebral compression fracture
• Osteoporosis
• Degenerative joint • Localized pain and tenderness

diseases
• Mild morning stiffness
• Osteoarthritis
• Increased pain while performing
• Degenerative disc spinal extension or standing
disease (DDD)
• Articular
degeneration
• Referred LBP: • Dull diffused, deep pain in the

Viscerogenic disorder abdomen or may radiate to hips or
thighs
• Vascular lesions
• Constant pain over costo-vertebral
• Genitourinary angle
lesions
• Colic pain or dull flank pain
• Kidney • Pain centred round sacrum or

• Kidney
• Pain centred round sacrum or
girdle pain along the belt line
• Urethral
• Bladder infection
• Gastrointestinal • History of excess alcohol

consumption
• Pancreatitis
• Pain relieved after eating
• Peptic ulcer
• Peristaltic colic pain
• Colon or rectal
disorders
• Polymyalgia • Proximal shoulder or hip joint

stiffness in 75-year-old individual
• Rheumatica with ESR level
• Fibromyalgia due • Diffused muscular pain

to:
• Widespread tender areas or trigger
• Chronic fatigue points
• Irritable bowel • No other relevant clinical or

syndrome laboratory finding
• Psychotic
Note. Before planning treatment do not forget to eliminate

disabling disorder causing LBP and rule out the cases of
referred LBP.
Acute phase: This is the phase of excruciating pain.

Therefore, reduction of pain, spasm and inflammation
assumes priority over all other symptoms.
1. Muscle spasm: Spasm is protective in nature during the

initial stage. Therefore, stretching of the muscles should be
avoided. However, it must be remembered that if it is
allowed to persist, it may lead to contracture of the soft
tissue elements such as erector spinae muscles, lumbosacral
fascia, ligaments and facet joint capsules. Therefore, early
attempts to release spasm through relaxation techniques are
of primary importance. Cryotherapy/steam packs are
effective in relieving the spasm.
2. Bed rest for first 3–5 days or well-guarded relaxed

movements only in the pain-free range.
3. Proper back care avoiding strain.
4. Frequent change of posture ‘in bed’; preferably lying

prone whenever possible, may be with assistance.
5. Analgesics and anti-inflammatory drugs.
6. Pain relieving physiotherapeutic agents to control pain

and inflammation.
7. If the pain is radiating in nature, light lumbar traction

(continuous) may be indicated, which mainly serves as
immobilization rather than traction. If the symptoms persist
for over 5 days, patients may need prolonged bed rest with
or without gentle traction.
8. However, the modern concept of treating acute LBP

advocates earliest return to controlled activities rather than
bed rest. Activities should be performed only in the pain-free
range.
Subacute phase: When the symptoms improve, further

relief can be achieved by gradual mobilization through
relaxation.
1. Continuous relaxed rhythmic passive movements: They have

been proved to be beneficial in further reducing pain and
improving nutrition of the disc (Choler et al., 1985).
2. Relaxation techniques: (a) Use of appropriate physical agent

to induce relaxation; (b) initiation of relaxed pelvic and chest
rotation; (c) use of PNF techniques (Voss & Knot, 1968) only
if pain-free.
3. Specific corrective exercises: Once relaxation is achieved,

specific exercise programme, depending upon the patient’s
problem, has to be started based on biomechanical
principles. The specific technique is aimed at not only
correcting the faulty elements but also maintaining the
corrected posture. Sometimes, LS support may be needed to
ensure the maintenance of the normal lumbar lordosis. (The
specific exercises for a particular postural fault are
elaborated separately on the rationale of causative factors.)
4. Mobilization: Early initiation of mobilization, conditioning

and fitness programme, sometimes including even aerobics,
has proved effective.
The exercise programme should be aimed at gradual loading

associated with initiation of activity of larger muscle groups.
These exercises not only promote healing of the cartilage,
ligaments and tendons but also influence the chemical
modulating system. They increase the level of endorphin in
the blood and cerebrospinal fluid, reducing the sensitivity to
pain (Salter, 1982; Woo et al., 1981).
5. Activities of daily routine: Initiate the activities the patient is

supposed to carry out in the daily routine at the earliest
possible opportunity. Early but gradual and biomechanically
controlled return to the activities of daily routine has proved
to be the best method of treatment (Nachemson, 1983).
Low back pain due to faulty postural attitudes
Faulty habitual postural attitudes often give rise to LBP. The

abnormal pelvic tilt is a common feature, which could occur
as a result of various musculoskeletal imbalances. Habitual
wrong posture results in muscular tightness, eventually
leading to fixed deformity. Pelvic tilt or trunk flexion
deformity due to such wrong postures may precipitate LBP
(Table 32-16). The pelvic tilt is of three types (Kendall,
Kendall, & Boyton, 1960):
1. Anterior
2. Posterior or
3. Lateral
1. Anterior pelvic tilt: It puts undue compression stress on
the posterior part of the vertebral bodies and articulating
facets. At the same time there is increased stretch or tension
on the anterior longitudinal ligament. This results in the
exaggeration of lumbar lordosis. This is found commonly in
obese individuals with a protruding abdomen.
Anterior pelvic tilt could result from any of the following

muscle imbalances:
(a) Weak abdominal muscles (upper or lower)
(b) Tight low back muscles
(c) Tight hip flexor muscles
(d) Weak hamstrings muscles
(a) Weak abdominal muscles: The pain presents as fatigue or

ache which becomes worst as the day passes on and is
relieved by rest or back support. The strength of the
abdominals should be carefully evaluated by recording
isometric holding time or any other technique. Tightness in
the low back muscles and hip flexors can be detected by
passive tests.
(b) Tight low back muscles: Tight low back muscles give rise to
dull ache which increases on attempted lifting and is present
during movement as well as rest. This type of back is
mechanically weak but the back muscles are strong and
rather overdeveloped.
(c) Tight hip flexor muscles: The tightness of hip flexor muscles
results in exaggerated lordosis in standing or supine lying
with hips and knees in extension. Pain is present during
standing and is relieved by sitting or supine with hips and
knees in flexion. The relief in pain is due to the reduced
tension on the hip flexor muscles. The tightness in hip flexor
muscles can be easily detected by the Thompson test in
supine position (Fig. 32-66).
(d) Weak hamstring muscles: This is a rare phenomenon but in

association with abdominal weakness it exaggerates the
anterior pelvic tilt and lumbar lordosis. Static posture of
standing with knees hyperextended and pelvis tilted
anteriorly puts tension on hamstrings, causing gradually
increasing stretch weakness of the hamstring muscles.
Therefore, it is essential to differentiate between weakness
and tightness of hamstrings for planning the treatment
programme.
2. Posterior pelvic tilt: It may give rise to the following:
(a) Rigid flat back with tightness and overdevelopment of

the low back muscles. Forward bending movement gives rise
to acute strain and pain.
(b) The lumbar spine assumes a position of flat back or there

may be slight kyphosis when it is associated with weakness
of hip flexors (psoas).
(c) The positions of standing, sitting and bending put undue

strain on the anterior surfaces of the bodies of lumbar
vertebrae, posterior spinous ligaments and muscles of low
back.
3. Lateral pelvic tilt: It usually presents as a unilateral
lumbosacral strain with tenderness over the articulating facet
of the 5th lumbar vertebra on the dominant side. The lateral
pelvic tilt produces muscle imbalance. On the raised side of
the pelvis, there is weakness of the gluteus medius, stronger
hip adductors and lateral trunk muscles, while on the
opposite side there is tightness of hip abductors and tensor
fascia lata.
Pain may be present in the lower back region or legs.
When the cause of LBP is muscular imbalance, it needs to be

treated with specific exercises to correct these imbalances
along with ergonomic advice.
Leg length disparity must be checked, as it could result in

lateral pelvic tilt.
FIG. 32-66Test for tight hip flexors on the right side.
Table 32-16
Deformity and the Probable Cause
Deformity Causative Factor
1. Pelvic tilt
Anterior Weak abdominals

Tight low back muscles
Tight hip flexors, tensor fascia lata
Weak hamstrings
Posterior Tightness and overdevelopment of low
back muscles
Lateral Scoliosis (structural or sciatic)
Limb length disparity
Cartilaginous locking in flexion to
2. Trunk flexion accommodate posterior protrusion
deformity
Specific exercises for backache due to muscular imbalance
For weak upper abdominal muscles: Supine with a small pillow

under the knees. Initially, tilt the pelvis to flatten the back.
Maintaining the pelvic tilt with arms extended forward, raise
the head and shoulders high enough to clear the scapulae off
the table (Fig. 32-67). Hold this position. Alternatively,
without hold, bring the shoulders down slowly but not
enough to make contact with the table. Repeat till fatigue sets
in. Record the time of hold or the number of lifts at a time.
For weakness in the lower abdominals, pelvic tilt to flatten

the back with strong lower abdominals is ideal. Bilateral
straight leg raising can be an alternative exercise, provided
there is no back pain.
For tight lower back muscles: Sit with back against a wall,
keeping a small pillow under the knees. Reach forward
towards the toes by tilting the pelvis and bending at the
lower back. Stretch should be felt at the lower back and not
the knees or upper portion of the back (see Fig. 32-65).
FIG. 32-67Exercise for weak upper abdominal muscles.
Caution
Exercises or positions promoting hyperextension are

contraindicated, e.g., hyperextension exercises in prone
lying, double leg raising or sit-ups.
For weak/tight hamstring muscles: Accurate diagnosis is

necessary to ascertain whether the hamstrings are weak or
tight. Weakness in the hamstrings is often associated with
weak abdominals giving rise to anterior pelvic tilt and
exaggerated lumbar lordosis. Therefore, exercises to correct
anterior tilt of the pelvis relieve tension on the hamstrings.
Self-resistive knee flexion exercises in sitting are preferred as
they can be easily repeated by the patient several times.
For posterior pelvic tilt: Hyperextension exercises with

localization at the lumbar region – prone lying with hands
over the lumbar region. Lifting head and shoulders with
lumbar extensors, avoiding strain at the neck and upper
thoracic region. Hold and then bring the shoulders down in a
small range to lift them again with extra efforts (Fig. 32-56).
If there is an associated weakness in the psoas, strengthening

hip flexion exercises in sitting position should be added.
For lateral pelvic tilt: Basically, heel raising is needed on the

side of dropping of the pelvis. Exercises to strengthen the
weak gluteus medius are needed on the side of the raised
pelvis. Exercises to stretch tight abductors on the side of the
dropping of the pelvis are to be taught.
For stretching tensor fascia lata: To stretch the left tensor fascia
lata, the patient assumes the right-side lying position with
hip and knee bent. Pelvis on the right side should be
stabilized firmly. Draw the left thigh slightly backwards on
the table. Inward rotation at the knee due to tight tensor
fascia has to be avoided. It can be done in prone lying
position, stretching the hip into extension with knee in
flexion. Extension of the hip should be in the neutral position
of abduction and adduction.
For stretching of the tight heel cord: Occasionally, there may be
unilateral or bilateral tightness of the heel cord. This puts
excessive strain on the hamstrings and lumbosacral spine. It
is noticed in forward bending. Unilateral heel cord tightness
may cause pelvic rotation and lateral flexion.
During physical examination, many a times, alterations may

be observed in the normal curves of spine, e.g., exaggerated
dorsal kyphosis with round shoulders. These also need
appropriate corrective exercises and ergonomic advice.
Physiotherapeutic management of chronic low back pain
The treatment of chronic LBP is a complex problem. Pain is a

perception which reflects not only bodily events but also
thoughts and emotions. At times the cause of chronic LBP
may be psychosomatic. Disorders such as peptic ulcer,
allergic rhinitis, asthma, colitis, migraine, tension headache,
idiopathic cardiac palpitations, angio-neurotic oedema,
neurodermatitis, eczema and psoriasis may give rise to LBP.
Peptic ulcer alone accounts for about 72% cases of
psychosomatic LBP. It is believed that these disorders
originate in the limbic nuclei and are mediated through the
autonomous nervous system. Tension myositis is also one of
the common basic factors in chronic LBP (Sargent, 1946;
Sarno, 1976). Its typical characteristics are as follows:
1. Minor trauma is enough to precipitate acute, excruciating

LBP.
2. Sudden shifting of the back pain from one leg to the

opposite leg which is contrary to the true radiculopathy of
spinal origin.
3. Long standing pain without any obvious neurological

deficit or objective parameters.
4. Patient complaining of pain simultaneously in the muscles

of the upper and lower back.
5. Persons with certain personality characteristics such as

overambitious, compulsiveness, perfectionism, depression
and over anxieties are more prone (Blumer & Heibronn,
1982; Sternbatch, 1977).
As the localization of pain usually does not fit in any typical

area of distribution, it can be easily diagnosed as tension
myositis. A questionnaire that includes dermographic
information can be used. Ask the patient to draw painful
areas (pain drawings) on the body chart. In certain cases, it
may be necessary to get a psychological evaluation done
without the patients’ awareness (Deyo & Diehl, 1983). The
physiotherapist with his psychological background and with
the help of various treatment modalities, is the right person
to deal with this problem.
To be successful, the physiotherapist has to change the

patient’s attitude towards pain. Planning of treatment
schedule, choosing appropriate modality, initiating therapy –
all have to be done, giving due importance to the patient’s
acceptance.
Physiotherapeutic schedule
1. Awareness of diagnosis: For an effective management, the
first important responsibility of the physiotherapist is to
gradually convince the patient to accept the diagnosis.
2. Choice of the correct modality: There is no study about the

efficacy of a particular modality of physiotherapy. However,
TENS has been reported to be effective in 83.8% of patients
with chronic LBP (Fried, Johnson, & McCraken, 1984; Loeser,
Black, & Christman, 1975).
3. Exercise
(a) Gradual active mobilization: Psychogenic effects of

exercises in reducing anxiety and depression are well
documented (Blair, Jacobs, & Powel, 1975; Tylor et al., 1985).
Similarly, the ill effects of inactivity have been adequately
demonstrated in psychosomatic conditions as well as in
other chronic LBP patients. Excellent results have been
reported by the use of active mobilization in patients even
after failure of surgery (Mayer et al., 1985).
(b) Strengthening exercises: Exercises to strengthen the back

extensor muscles play an important role in the control of
chronic LBP. Improved tone of the erector spinae gives a
feeling of better physical fitness.
(c) Endurance exercises: Improvement in endurance of the

larger muscle groups also plays a decisive role. These
exercises increase the level of endorphin in blood and CSF,
which has been reported to be diminished in chronic LBP
(Puig, Laorden, Maralles, & Olason, 1982).
(d) Isometrics: Strong isometric exercises are effective in
chronic back pain, especially of myofascial origin (Wong &
Burlingame, 1986).
(e) Progressive mobility and active exercises: Progressive

mobility exercises are important to improve flexibility of the
body and ease of function.
(f) Physical fitness through aerobics: Positive correlation

between physical fitness through aerobics is an efficient
method of decreasing muscular tension. Aerobics increase
alpha-wave activity, producing central and peripheral
relaxation response (De Vries, 1968; Farmer et al., 1978).
Aerobics preceded or succeeded by relaxation techniques
such as shavasan should be ideal in inducing freshness and a
feeling of well-being. Aerobic exercises are also well
accepted, being a popular craze of the present time. Aerobics
such as swimming, cycling and brisk walking need to be
emphasized as they also provide diversion from pain.
4. Specific exercises and body mechanics: When recurring strain

is the cause of chronic LBP, advice on biomechanically
controlled body mechanics and back care programme should
be emphasized.
Lesions of the intervertebral disc
Pathology of disc lesions
Discogenic low back pain
The intervertebral disc is a hydrodynamic system with

centrally placed nucleus. The nucleus is surrounded by inner
and outer annular collagen fibres (Fig. 32-68), which restrain
the contents of the nucleus within its central region. The disc
is basically aneural. However, the extreme outer layer of the
annulus is innervated and could well be the site of
nociceptive stimuli. Vascularization, inflammation,
autoimmune responses and stimulation of the nerve endings
can occur as the annulus tear progresses. The disc allows
some compression, flexion and rotatory torque and acts as a
shock absorber protecting the neural elements. Besides soft
tissues, such as muscular and ligamentous structures, the
disc is protected by the facets. The disc separates the
vertebral end plates, maintaining the patency of the spinal
canal and the intervertebral foramina. Therefore, any
impairment in the integrity of the disc is enough to
precipitate LBP and its related symptoms, depending upon
the extent of the disc lesion.
FIG. 32-68Intact intervertebral disc. OA, outer annulus;

IA, inner annulus; N, nucleus; NR, nerve root; CC,
central canal.
Disc lesions
The disc, basically a soft fibrocartilaginous structure, is

entrapped in between hard vertebral bodies, and therefore
remains susceptible to extrusion with compressive forces.
Before discussing various disc lesions, it is important to

know the possible cause of LBP, whether it is discogenic or
due to muscular or joint dysfunction. Mennel (1960)
provided guidelines to identify the offending tissues
precipitating LBP (Table 32-17). If the lesion is due to disc
pathology, it is important to identify the type, extent and site
of the lesion (Tables 32-18 and 32-19). Provocative nuclear
test as described by Kopp et al. (1986) is done. In this test,
passive maximum hyperextension in prone lying position is
tested first on elbows, progressing to hands. Passive
hyperextension of the lumbar spine forces the nucleus
anteriorly. Therefore, when the lesion is self-contained, there
is no increase in the symptoms. However, when there is
herniation into the canal, it is compressed further,
reproducing or increasing the symptoms, such as radicular
pain. Thus, it identifies the patient who is likely to respond
to conservative mode of treatment or else may need surgery.
Table 32-17
Characteristics of Low Back Pain Due to Joint Dysfunctions,

Musculotendinus Dysfunction and Disc Lesions
Joint Muscle
CharacteristicsDysfunction Dysfunction Discogenic
Onset Sudden Sudden Sudden

During With lifting With stressful
movement movement
With snap or With With lock
lock feeling of
tearing
Effect of rest Relieving Stiffening Relieving
Effect of Aggravating AggravatingAggravating
activity
Location Over L5–S1 Over Over
(tenderness) junction or muscle intervertebral
sacroiliac joint junction
Architectural Segmental No change Segmental
changes alteration of in spinal alteration of
normal curve curve normal curve
Curve convex on Curve
side of pain with concave on
iliac crest raised the side of
on side of pain pain with iliac
crest lower on
the side of
pain
Mobility Localized loss Less well Localized loss
localized
Percussion Short sharp pain – Short sharp
pain, often
with radiation
Obvious One joint No joint One junction
Physical signs One level No area Same level
Physical signs One level No area Same level
joint
General Pain may be Pain in Radiating
referred muscle pain
Observations No neurological No Mixed
sign neurological neurological
sign signs
Patient lies still Patient Patients lies
varies still
position
No signs of No signs of No signs of
systemic disease systemic systemic
disease disease
No fever No fever No fever
X-ray findings Negative Negative Negative
except with
special
techniques
(MRI)
Laboratory Negative Negative Negative
findings except
increased
protein
content in the
CSF
Table 32-18
Symptoms Related to the Type of Disc Displacement

Disc Displacement Pain
Location Deformity
Pain Radiation
Central or May radiate
No
• Posterior disc symmetrical to buttock or
deformity,
displacement across L4/L5 thigh or flat or
region kyphotic
lumbar
spine
Unilateral or May radiate No
• Posterolateral asymmetrical to buttock or deformity,
disc displacement across L4/L5 thigh or lumbar
scoliosis
Unilateral or Intermittent Sciatic
• Posterolateral asymmetrical or constant scoliosis
disc displacement pain across sciatica with
with impingement L4/L5 buttock or
of nerve root and thigh pain
dural sleeve
Symmetrical May radiate Accentuated

• Anterior or or to buttock or lumbar
anterolateral disc asymmetrical thigh lordosis
displacement pain across
L4/L5
Notes: Features of L1–L2 nerve root involvement:
• Cauda equina lesion
• Groin or testicular pain
• Positive stretch test

• Late stage – atrophy of the involved limb
Table 32-19
Differential Diagnosis of Lumbar Canal Stenosis and

Herniated Disc
Spinal Stenosis Disc Herniation
More incidence in younger
1. Onset is comparatively at age
old age
Acute pain
2. Chronic pain
Lumbar lordosis flattening is

3. Lumbar lordosis usually common
maintained
Sciatic tilt common

4. Sciatic tilt is less common
Loss of tone with drooping of

5. Gluteal muscles unaffected the gluteal fold is common
Marked restriction of spinal

6. Less restriction of spinal movements
movements
Marked restriction of SLR,

7. Symptoms usually and symptoms usually
bilateral and less restriction unilateral
of SLR
Unilateral involvement is
8. Bilateral involvement of more common
more than one nerve root
Hyperextension relieves pain

9. Even minimal
hyperextension causes pain
10. Walking uphill is easy;

walking down the hill is
painful
The commonly affected discs in the lumbar region are the

fourth and the fifth discs. Basically, there are two types of
disc lesions:
1. Self-contained disc lesion
2. Disc lesion with nuclear extrusion
1. Self-contained disc lesion: In the self-contained disc

lesion, the disc and the nucleus pulposus remain intact
within the confines of the disc. The outer annulus fibres
which are longer and occupy a more distant place from the
axis of rotation may be exposed to excessive stress (torque
force) during rotation, and thus tear occurs more easily.
When the tear of the outer annulus fibres is minimal, the rest
of the intact annulus fibres are sufficient to prevent nuclear
extrusion or the extrusion of the annulus fibres into the canal
(Fig. 32-69). Similarly, the tear may occur at the inner
annulus fibres causing some extrusion of the nucleus.
However, when sufficient outer annulus fibres are intact, the
extrusion of the outer annulus (bulging) into the canal is
prevented (Fig. 32-70).
2. The disc lesion with nuclear extrusion: The lesion is

characterized by the extrusion of disc material into the
central (posterocentral) or foraminal canal (posterolateral).
This lesion is of two types:
(a) Inner nuclear extrusion with protrusion of the outer annulus:

The central or posterolateral extrusion of the nucleus (Fig.
32-71) causes external protrusion of outer annulus (annular
bulge). The protrusion encroaches through the rent in the
longitudinal ligament and impinges on the emerging nerve
root. The neurological tests specific to that nerve root are
positive.
Diagnostic tests such as discograph, CT scan, myelography

and MRI may reveal the bulging disc.
(b) True herniation (Fig. 32-72): The extrusion of the nucleus

occurs through the ruptured outer and inner annulus into
the central or foraminal canal. The signs and symptoms will
depend upon the site and extent of the extrusion of the
nuclear material. The extrusion may be:
i. Central extrusion: The extrusion of the nuclear material

presses the posterior longitudinal ligament, giving rise to
LBP, which may involve the lumbosacral area and buttocks.
The lumbar spine assumes antalgic posture. Nuchal flexion
aggravates the pain.
The radiograph will show obliteration of the lumbar lordosis.
CT scan, myelograph or MRI may indicate bulge without the
displacement or encroachment of the nerve roots.
Both the flexion and extension attitudes are contraindicated

for a week or so to avoid further herniation. Corset may be
useful.
ii. Posterolateral extrusion: Herniated nuclear fragment, when

encroaches on the passing nerve root through a rent in the
longitudinal ligament, may damage the nerve. The
symptoms specific to the impingement of a nerve root may
be identified by the pain, point of specific tenderness,
sensory (dermatomal), motor (myotomal) and other
neurological tests as related to its segmental representation
(Figs 32-73A, B and C).
The classical signs and symptoms are as follows:
1. Trunk flexion is painful and limited; when it is attempted,

there is no reversal of lumbar lordosis. The flexion occurs
only because of the rotation of the pelvis on hip joint. Sciatic
scoliosis (list) will be present.
2. Straight leg raising will be positive with positive dural

sign. When there is significant entrapment of the involved
nerve root, contralateral SLR may also be positive.
3. Sensory impairment over the dermatomal distribution,

and motor weakness over the myotomal distribution of the
involved nerve root will be present.
4. The reflexes will be either sluggish or absent.

FIG. 32-69Self-contained disc lesion with tear of the

outer annulus (OA) with intact nucleus.
FIG. 32-70Self-contained disc lesion with tear of the

inner annulus (IA) causing some extrusion of the
nucleus, but outer annulus is intact.
FIG. 32-71Central nuclear extrusion causing protrusion

of the outer annulus (annular bulge B).
FIG. 32-72True herniation: extrusion of the nucleus

through the ruptured outer and inner annulus into the
foramen against the nerve root.
FIG. 32-73(A–D) Segmental sensory (dermatomal)

innervation. (A) Anterior aspect of the body. (B)
Posterior aspect of the body. (C) Course and the
relationship of the spinal nerve roots to the vertebral
levels. (D) Segmental myotomal distribution of the
movements of the lower limb. (E) Clinical features to
herniated disc at various intervertebral levels. (F) MRI
views showing posterolateral disc protrusion at L5–S1
levels.
Various diagnostic tests may be necessary to assess the

extent of nerve entrapment.
Anterior or anterolateral disc lesion: Anterior or

anterolateral disc lesion, although rare, may also occur.
Protective accentuation of the lumbar lordosis is a definite
sign. Symmetrical or asymmetrical pain may be felt across
the L4–L5 region or may radiate to buttock or thigh.
The attitudes of extension or hyperextension are strictly
avoided.
Treatment of disc lesion
Conservative management.
Acute phase: During the acute phase, the aim of the

treatment is as follows:
1. Prevention of progression of the prolapse
2. Control of pain and inflammation
3. Gradual mobilization
1. Prevention of progression of prolapse and reduction of the

suspected disc prolapse is attempted by the following:
(a) Bed rest in optimal posture, minimizing intradiscal

pressure, e.g., maintaining normal lumbar curve.
(b) Any flexion attitude of the lumbosacral complex, even

isometrics to the abdominals is deferred.
(c) In a bulging or herniated disc, gentle pelvic traction can

be given only for brief periods, provided it does not
aggravate the symptoms. Static traction for a longer duration
may result in absorption of additional fluid by the nucleus
during the period of traction and may lead to high discal
pressure on its release, thus aggravating the symptoms.
2. Pain and inflammation are controlled by a suitable

modality, such as cryotherapy, hydrocollator packs, pulsed
diathermy, diapulse, TENS or ultrasound and drugs.
3. Intermittent brief periods of protected mobilization using

lumbosacral spinal support may be attempted when safe.
Sound ergonomic principles should be used and the
mobilization should be gradual. Brief periods of lying with
adequate assistance should be encouraged, gradually
increasing its duration. Relaxed continuous passive
mobilization of the lumbar spine, pelvis and lower limbs has
been reported to be effective in the healing of tissues and
also in improving nutrition to the disc. Whenever feasible it
should be initiated in a very small range and with great
caution (Choler et al., 1985).
Caution
It should be remembered that subjective improvement is not

a definite indication of the reduction of a disc prolapse.
Apparent relief may be experienced by the patient when the
lesion is actually progressing. Once the nuclear material
escapes the confines of the outer annulus and posterior
longitudinal ligament, it may not exert significant
compression on nerve roots. Therefore, other parameters of
objective assessment should be relied upon.
Subacute phase: When the acute symptoms recede and

definite improvement is objectively seen, the programme of
mobilization is made intensive in steps.
Gentle extension exercises are started initially on forearm

supports, and advanced to full extension on hands if there is
no increase in symptoms.
Intermittent traction can provide gentle compression and

elongation of collagen fibres, thus augmenting disc healing.
Flexion should be initiated gradually in the form of

isometrics to the abdominals. Combination of flexion and
rotation should be deferred to avoid stress on the healing
disc. Trunk flexion should be progressed initially, using
spinal corset.
Stretching of low back muscles to avoid their shortening is

initiated with single leg hip and knee flexion (knee–chest
position) and progressed to bilateral knee–chest position in a
graduated manner (see Fig. 32-55D and E).
Extension and flexion exercises, which have been passive so

far, are made active and progressed to resistive exercises
along with stretching procedures. However, intensive flexion
exercises, such as bilateral straight leg raising, which puts
tremendous stress on the back (Fig. 32-74), is
contraindicated.
FIG. 32-74Exercise for lower abdominals.
Aerobics – such as fast walking, jogging, running and sports

– could be gradually resumed.
Ergonomic advice and home exercise programme to be

emphasized to avoid recurrence.
Lesions with self-contained discs or annular protrusion need

to be treated with emphasis on gradual extension from the
initial phase, avoiding flexion and rotation.
Basic differences between the exercise prescriptions for disc

lesions:
1. When the disc lesion is self-contained, the emphasis is on

initiating gentle extension, first passive, then active.
Movements of trunk flexion and rotation are contraindicated.
The condition is self-limited and responds very well to
conservative treatment. However, greater emphasis is laid on
avoiding recurrence.
2. The treatment of an inner annulus tear with external

annulus protrusion follows the same pattern as mentioned in
(1) but it is necessary to observe any increase in the
symptoms.
3. When there is true herniation of the nucleus pulposus,

extension positioning or extension exercises are strictly
avoided, as it may lead to the entrapment or further
protrusion. Flexion exercises are also avoided to prevent
further herniation. Therefore, no exercises are initiated at
least for a week. If any movement is attempted, it has to be
done strictly with the lumbar spinal corset.
Graded pelvic traction with careful monitoring is useful in

reducing lordosis, elongating the spinal canal and reducing
erector spinae spasm.
If there is neurological deficit, abnormal bladder function

and impaired perianal sensation, surgical intervention is the
only alternative.
Surgical management.
The indications of surgery (discectomy, i.e., disc excision) in

a case of PIVD are as follows:
1. Backache with or without radicular pain, associated with

neurological deficit.
2. Cauda equina syndrome.
3. Persistent severe backache with a CT scan or MRI scan

proves disc herniation even without neurological deficit.
1. Disc excision: The following operative techniques are

used for disc excision:
(a) Interlaminar or fenestration technique: The prolapsed disc is

excised through a space created between the laminae of two
adjacent vertebrae after removing the ligamentum flavum
(Fig. 32-75). In this technique, the posterior ligament complex
and thereby the stability of the spine is not disturbed.
(b) Laminectomy: A wide and adequate exposure can be
obtained by laminectomy. The spinous processes and
laminae are excised from one or two vertebrae and the disc is
excised through the opening thus created (Fig. 32-76). A
wide laminectomy can jeopardize the stability of the spine.
This procedure is also useful in cases where there is an
associated lumbar canal stenosis.
(c) Hemilaminectomy: The lamina of only one side is removed

to take out the disc material. The damage to the stability of
the spine is much less as compared to laminectomy.
(d) Microdiscectomy: The disc is excised through a small

incision using an operating microscope.
(e) Percutaneous discectomy: It is a minimally invasive

technique where the disc excision is performed using an
endoscope.
(f) Disc arthroplasty: Disc arthroplasty involves either

replacement of the disc nucleus alone (nucleus replacements)
or the whole of the disc with end plates (total disc
replacements). Total disc replacement consists of placing an
artificial end plate as well as a simulated nuclear core
through an anterior approach.
2. Spinal fusion: Some surgeons prefer to do spinal fusion

in addition to disc excision. It helps to stabilize the spine for
the instability caused by the degenerative changes in the
intervertebral (apophyseal) joints. However, in our opinion,
spinal fusion is rarely indicated.
FIG. 32-75Interlaminar or fenestration procedure for

unilateral single protrusion: extruded disc is excised
through the space created between the laminae of the
two adjacent vertebrae after removal of ligamentum
flavum. (A) Extent of removal of bone. (B) Exposure
available as related to spinal theca and extrathecal
roots.
FIG. 32-76Complete laminectomy: extruded disc is

excised through the opening created by removal of
spinous processes and laminae from one or two
adjacent vertebrae.
Postoperative management: The patient should be kept in bed

for at least 10–12 days after operation. No useful purpose is
served by endeavouring to get the patient up and walking in
a few days as advised by many surgeons.
Patients of disc excision by the ‘fenestration’ method are

allowed to take turns in bed on the second or third
postoperative day. Spinal extension exercises are started at
the end of the first week. The patient is made ambulatory in
the second week.
In the case of patients who have undergone laminectomy,
mobilization is deferred until the end of the third week.
Patients with spinal fusion are given a POP jacket or a

lumbosacral corset for 3 months.
Principles of physiotherapy
The patient is mobilized as early as possible to prevent the

complications of prolonged bed rest (e.g., thrombophlebitis,
gastrointestinal disturbances, muscular weakness and
atrophy and urinary tract infections).
Therefore, safe methods of early mobilization in graduated

steps should be concentrated on.
Strenuous exercises such as trunk flexion which put extra

strain on the operated area should not be included during
the first week following surgery.
The normal physiological lumbar curve must be maintained

during all static and dynamic postures.
Ergonomic advice, depending upon the patient’s daily

routine postures, should be initiated with the mobilization.
Patients with lumbar fusion should not be mobilized in

haste, giving due consideration to the complexities of the
surgical procedure.
Physical therapy management following surgery
1. Following interlaminar or fenestration technique

Week 1 and 2: Excision of the prolapsed disc by this technique
allows early mobilization, as the stability of spine is not
disturbed. In the immediate postoperative phase, the
following are advised:
(a) Vigorous ankle and toe movements.
(b) Chest physiotherapy.
(c) Upper extremity movements.
(d) Static gluteal and quadriceps exercises.
(e) Graded hip and knee flexion by heel drag in supine.
On the 2nd and 3rd postoperative day:
(f) Turning in bed from supine to side lying to be initiated

with assistance. This is done by bending the hips and knees
with foot resting on the bed. The whole body is turned as
one unit.
By the end of 1st week:
(g) Assisted spinal extension exercises are initiated by

forearm supports in prone position (see Fig. 32-62).
(h) Isometrics for the abdominals are started and progressed

to the limit of pain and discomfort.
(i) Supported sitting is begun, maintaining the lumbar

lordosis.
(j) Guided ambulation and graduated flexion with trunk
rotation can be initiated.
By 3rd week:
(k) Ambulation with correct posture and gait: Spinal

extension exercises are made progressive in stages, from
forearm support to hand support and finally with hands on
the back.
(l) Graduated spinal rotation, forward flexion and side

flexion are introduced and progressed.
(m) Proper ergonomic advice is emphasized with retention

of lumbar lordosis during activities.
The patient should be back to normal activities by 6–8 weeks.
2. Following laminectomy: The basic approach of

physiotherapy during the initial stage remains the same as
mentioned earlier in (1) except for the initiation of spinal
mobilization and ambulation. Spinal movements are
progressed gradually as follows:
(a) Back arching in supine (bridging) is initiated by the

second week with assisted turning in bed.
(b) Strong isometrics to the abdominals are carefully

controlled without producing spinal flexion.
(c) Prone lying and forearm-supported hyperextension to be

initiated by 2nd–3rd week. Sitting up from side lying is
initiated by 3rd week.
(d) Ambulation and other spinal movements can be begun
by the end of 4th week.
Caution
(i) The normal lumbar lordosis should be maintained during

all activities and rest. The flexion exercises should be
deferred to 6–8 weeks, or until they are painful.
(ii) Hyperextension exercises are made vigorous and without

arm support. Ergonomic advice and avoidance of forward
bending and weight lifting to be ensured. Guarded sport
activities are safe only after 12 weeks.
3. Following hemilaminectomy: The physiotherapeutic

management following this procedure proceeds on the same
lines as described for laminectomy. As the surgical
procedure is less extensive, mobility procedures can be
initiated earlier. The patient should be back to his
preoperative activities in 4–6 weeks.
4. Following spinal fusion: The extensive surgical

procedure and the subsequent prolonged immobilization
lead to muscular weakness and limitation of spinal
movements. Physiotherapy, therefore, needs to be
concentrated on two aspects.
Initially, immobilization is given in a plaster jacket. Besides

the other procedures described for laminectomy, special
attention is needed for the following:
(a) To improve the tone and strength of the spinal extensors

and flexors. Regular and repeated isometrics are given while
in plaster jacket.
(b) Gradual turning in bed to side and prone can be initiated

by the 3rd week.
(c) Assisted sitting from side lying to be initiated by the 4th

week with lumbosacral corset.
(d) Graduated walking and other ambulatory procedures can

be introduced by the 6th week.
(e) Spinal movement in smaller range can be initiated by the

8th week. Flexion should be initiated carefully with rotation.
(f) Spinal corset can be gradually weaned off from 10 weeks

and discarded by the 12th week.
(g) Spinal mobilization and strengthening to be made

vigorous. All the movements should be made vigorous. The
patient should resume his daily activities and light sports by
8–12 weeks and continue to follow the principles of back
ergonomics.
Treatment of disc herniation by chemonucleolysis:

Chemopapain, an enzyme derived from the leaves of papaya
plant, breaks down the protein polysaccharide complexes of
cartilage. When this enzyme is injected into the degenerated
disc, it digests the nucleus pulposus. This offers an
alternative to laminectomy in selected cases (Smith & Brown,
1967).
Degenerative disc diseases
Spondylosis or degenerative osteoarthritis
The lumbar complex has always been a seat of degenerative

changes due to excessive mobility over this area of spine. The
annulus fibres undergo fibrillation, which predisposes
annulus tears. The area of maximum mobility and stress, L4–
L5 and L5–S1 interspaces are common sites of such annulus
tears. Dehydration sets in at the intervertebral disc, resulting
in the reduction of disc space. The reduced disc space brings
about approximation of the zygapophyseal and facet joints,
resulting in slackening of posterior longitudinal ligament.
The slackening of the posterior longitudinal ligament
detaches it from the periosteum due to increased intradiscal
pressure, resulting in disc extrusion. The extruded disc
material becomes fibrous and eventually gets calcified into a
spur (Fig. 32-77). This gives rise to the following symptoms:
◼ Tenderness over the lower facet joints.
◼ Restriction of movements in all directions.
◼ Early morning stiffness.
◼ Generalized backache.
◼ Intermittent acute attacks of pain with periods of total

relief.
◼ Radiographic evidence of segmental scoliosis at L4–L5 or

L5–S1 level with facet degeneration. Asymmetrical disc
degeneration may also occur.
FIG. 32-77(A and B) Lumbar spondylosis. There is

diminution of disc space with osteophyte formation.
Treatment
◼ Nonsteroidal anti-inflammatory medication.
◼ Local injection of anaesthetic agent or steroid preparation

may be indicated in severe pain.
◼ Cryotherapy for acute pain.
◼ Diapulse, ultrasound therapy and TENS may be useful.
◼ Gentle spinal mobility exercises are initiated at the earliest.
◼ Gentle flexion rotatory manipulation is beneficial.
◼ As the problem is mechanical in origin, prevention of its

recurrence is difficult. Therefore, ergonomic advice for back
care is extremely important.
◼ Relaxed mobilization of spine after recumbency is a must.
◼ Long periods of recumbency as well as standing or

walking is to be discouraged.
Sciatica
The disc degeneration may result in the degeneration of

cartilage with capsular thickening. Osteophytic impingement
and posterior articular closure may lead to narrowing of the
intervertebral foramen, causing root entrapment. The root
entrapment results in a typical radicular pain of sciatica. The
radicular pain is felt over the buttocks, posterior thigh,
radiating down to the calf. The entrapment may result in
further closure of the foramen by activities such as sudden
trunk forward bending and straightening with twisting. The
radicular pain is reduced on trunk flexion with
contralateral/lateral flexion. With this manoeuvre, pressure
on the entrapped nerve root is relieved. Therefore, a patient
usually develops pelvic tilt as a compensatory mechanism to
avoid compression.
Treatment
It follows the same pattern as described for spondylosis.

Emphasis is laid on posture and exercises that relieve
symptoms.
Strengthening of the abdominals and minimizing lumbar

lordosis by encouraging flexion are initiated in stages.
Patients with persistent symptoms and neurological deficit

may need surgery in the form of foraminectomy.
Lumbar canal stenosis
The further narrowing of the anatomically narrower spinal

canal in the lower lumbar region due to a structural
abnormality is termed as spinal stenosis. Since this occurs
most commonly in the lumbar spine, it is known as lumbar
canal stenosis. It presents as backache with radicular pain in
the legs, brought on by exercise or walking for a particular
distance.
Classification
1. Congenital or developmental stenosis
The lower lumbar canal becomes narrow due to laminar

thickening of developmental origin or congenital as seen in
achondroplastic dwarfs.
2. Acquired stenosis
The canal becomes narrow over a period of time due to

various causes:
(i) Degenerative disease: Osteophytes encroach upon the space

of the lumbar canal and cause compression (Fig. 32-78).
Ligamentous laxity due to degenerative disease of lumbar
vertebral joints leads to subluxation of these vertebrae,
thereby narrowing the canal.
(ii) Degenerative spondylolisthesis: The canal becomes narrow

due to slip of the vertebrae, particularly at L4–L5 level.
(iii) Miscellaneous: Conditions such as fluorosis and Paget’s

disease are associated with a narrow lumbar canal. Spinal
stenosis may also develop following laminectomy or spinal
fusion and following trauma.
FIG. 32-78Lumbar canal stenosis. (A) Normal canal

with adequate space for cauda equina. (B)
Encroachment of the central canal by osteophytes and
changes in the neural arch (B) and vertebral body (A).
Clinical features
The patient classically presents with symptoms of

intermittent claudication. He develops pain, heaviness or
paraesthesia in the lower limbs after walking for a certain
distance. The symptoms become so severe that he has to take
rest (sit down) immediately for a few minutes. The
symptoms settle down temporarily and allow him to walk
further the same distance.
Neurological examination of the lower limbs may be normal

or may show a bizarre neurological deficit. In severe cases,
there may be signs of cauda equina compression with loss of
bladder and bowel control. Thorough examination is
necessary to rule out disc herniation (Table 32-19).
Investigations
1. Plain radiograph of spine: Measurements of the lumbar

canal will show decreased anteroposterior diameter of the
canal or narrowing of the interlaminar space (Fig. 32-79).
2. Myelography is useful in the diagnosis. It shows multiple

indentations in the dye column (Fig. 32-80).
3. CT scan and MRI are also helpful in the diagnosis.

FIG. 32-79Radiographic method of measurement of the

spinal canal stenosis by calculating the canal to body
ratio (AB:CD). A, interpedicular distance; B, front to
back distance of spinal canal; C, vertebral body width;
D, front to back measure of vertebral body. Normal
ratio is about 1:2 to 1:4.5; values greater than 4.5
suggest stenosis.
FIG. 32-80Myelography: AP view of the LS spine

showing multilevel spinal stenosis (SS).
Treatment
The treatment could be:
1. Conservative
2. Surgical
The conservative approach is basically to emphasize flexion
exercises and generalized flexion attitudes, avoiding
extension.
1. Drugs to control pain and inflammation.
2. Improve strength, endurance and tone of the abdominal

muscles: This greatly helps in the maintenance of flexed
posture, which provides comfort to these patients. It should
be initiated as an isometric mode so that excessive motion to
lumbar spine and tension on the caudal roots is prevented.
3. Back ergonomics, avoiding extension attitudes are taught.
4. Lumbar traction may be beneficial if comfortable.
5. Lumbar corset should be used during strenuous activities.
6. Gentle passive manipulation technique is effective.
Surgical treatment
The aim of surgery is to decompress the cord by performing

laminectomy. In cases of spondylolisthesis, the spine
becomes unstable after laminectomy, and hence an
intertransverse fusion is done.
Physiotherapy, following surgery, is described under

respective headings.
Facet joint arthritis

Degeneration of the cartilage of the facet joints can occur as a
result of excessive lordosis, asymmetry of facets, abnormal
postural activity and faulty extension from trunk flexion.
Treatment
The treatment will be directed mainly to avoid undue

compression of the facet joints which occurs with spinal
extension. However, isometric resistive exercise to the spinal
extensor group of muscles is necessary. Strengthening of the
abdominals (rectus abdominis and obliques) is also included
to achieve strength and improve the balance between trunk
flexors and extensors, thereby exerting lesser strain on the
facet joints.
Anti-inflammatory and pain controlling medication is useful.

Hydrocortisone may be injected at the localized facet joints
when there is severe pain.
Spondylolysis
Spondylolysis is the defect in the neural arches of L5–S1 or

L4–L5 vertebrae, where the bone is replaced by fibrous tissue
with loss of continuity between the superior and inferior
articular processes. It could be congenital or acquired
following vertebral fracture. The common site of
spondylolysis is L5–S1 interspace. The chief causative factor
is the comparatively unstable anatomical configuration at
L5–S1 junction. The body of the 5th lumbar vertebra, which
is exposed to the major portion of body weight from head
downwards to trunk, rests on unstable L5–S1 disc space.
Instead of being horizontal similar to other disc spaces, the
body of L5 slopes anteriorly downwards, causing excessive
tension and making it susceptible to slip forward on the
corresponding surface of the sacrum. When there is no
slipping of L5 vertebra, in spite of the defect in neural arch, it
is termed as spondylolysis. A loss of bony continuity
between the superior and inferior articular processes bridged
by fibrous tissue gives the typical Scottish dog appearance
with neck belt (Fig. 32-81).
FIG. 32-81(A) Oblique radiograph view of the

lumbosacral spine showing ‘Scottish dog’ appearance.
(B) Line diagram to show the ‘dog’ better. The neck of
the ‘dog’ is formed by the pars interarticularis. (C)
Spondylolysis; note the break in the pars
interarticularis.
Spondylolysis may remain quiescent or may give rise to LBP

radiating to buttocks.
Treatment
When symptomatic, the management follows on the same

lines as described for grade I spondylolisthesis.
Anterior slipping of one vertebra over another is termed as

spondylolisthesis (Fig. 32-82). It commonly occurs between L5
and S1 vertebrae. However, a slip between L4 and L5
vertebrae is also seen. It could be congenital or acquired.
FIG. 32-82Lateral radiograph indicating slipping of the

fifth lumbar vertebra over sacrum.
Congenital spondylolisthesis
The incidence of congenital spondylolisthesis, also called

dysplastic, is reported to be 6% in a survey of 500 school
children of adolescent age group (Fredrickson, Baker,
McHollick, Yuan, & Lubicky, 1984). The body of the 5th
lumbar vertebra slips forward on the 1st sacral vertebral
body. Congenital maldevelopment of the neural arch of the
5th lumbar vertebra may be present, resulting in the
displacement of L5 on S1 vertebrae with kyphosis at L5–S1
junction. Pain and symptoms of compression of lumbosacral
nerve roots may occur along with lumbosacral segmental
instability.
Acquired spondylolisthesis
The acquired type of spondylolisthesis can be of the

following types:
1. Isthmic: This is the most common type seen in younger

people. There is a break in the pars interarticularis, i.e.. the
part between the superior and inferior articular processes.
2. Traumatic
3. Degenerative: Seen in the old age, the displacement is

mainly due to ligamentous instability and degeneration at
the facet joints.
Clinical presentation
The slipping of the vertebral body may result in low

backache due to the following reasons:
1. Lumbosacral segmental instability
2. Compression of the dura mater and lumbosacral nerve

roots
3. Reduction of the spinal canal
4. PIVD: The pathophysiology of low backache.
(a) During early stage of the disease, particularly in

adolescent patients, acute low backache may be present.
(b) Increased stress on the pars may lead to marked

paraspinal muscle spasm and localized lumbar back pain
(Gramse, Sinaki, & Illstrup, 1980). There may be tightness in
the hamstrings, producing positive SLR test.
(c) Majority of patients present with recurrent episodes of

low backache after exertion. This is due to the ligamentous
strain as a result of instability at the level of slip. The
segmental instability may cause reduction in the diameter of
spinal canal with symptoms of compression.
(d) Fibrous tissue due to pseudo-arthrosis of

spondylolisthesis may cause irritation of the nerve roots
resulting in radicular pain.
(e) Local lesions in the muscle, ligament or joint may give

rise to referred pain.
(f) Osteophytes at the posterior joints may also cause

pressure on the nerve roots (Fitzgerald & Newman, 1976).
5. Cauda equina syndrome: In rare instances, a severe rapid slip

may present with symptoms of cauda equina syndrome, i.e.,
bilateral pain, neurological deficit and even urinary
retention. The physical and radiographic examinations
reveal exaggeration of lumbar lordosis. History is typical of
increased symptoms of back exertion. Palpation reveals step
at the level of slipping of vertebra with marked segmental
instability.
Diagnosis
Radiographic examination (lateral view) of lumbosacral

complex reveals various aspects of listhesis, which are as
follows:
1. Percentage of slip: It can be calculated by measuring the

anterior slip of the vertebral body. Myerding (1931, 1932)
classified slip in the following four grades:
Grade I: Slip from 0 to 25% up to one-fourth length
Grade II: Slip from 25% to 50% up to half length
Grade Slip from 50% to 75% up to three-fourth

III: length
Grade Slip more than 75% up to three-fourth length

IV:
Tillard (1954) formulated a simple equation to calculate the

percentage of slip:
2. Sacral inclination: This is measured as an angle formed by
the posterior sacral border with the vertical border (Fig. 32-
83).
3. Overall degree of lumbar lordosis: This is measured from the

top of T12 to the top of both L5 and S1. These can be
accurately determined from the lateral radiograph.
FIG. 32-83(A) Formula for calculating the percentage of

slip: Percentage slip = X/Y × 100. (B) Calculating the
degree of sacral inclination by measuring the angle
between the posterior sacral border and the vertical
line perpendicular to the floor (Z).
MRI scan may be necessary to detect cord compression or

disc prolapse.
Treatment
The aim of treatment is to achieve maximum correction of

the exaggerated lordotic curve and maintenance of the
correction.
The grade of slipping of the vertebral body determines the

approach of treatment. Grade I and II can be managed
successfully by conservative treatment (Bell, Ehrlich, &
Zaleske, 1988). However, Grade III and IV with unremitting
symptoms need surgical intervention.
Conservative management
1. Bracing: Bracing forms an important part of conservative

management. Antilordotic total contact, thoracolumbosacral-
moulded brace (orthosis), is fabricated in the corrected
position of lordosis (Fig. 32-84). The measurement of the slip
percentage, sacral inclination and the degree of lumbar
lordosis are taken into consideration while fabricating the
brace. The brace has to be worn continuously. Bell et al.
(1988) has reported successful results of conservative
treatment but it needed brace for an average period of 25
months.
2. Deep heat modality: It is effective in providing relief of pain.
3. Correct posture: Correction of posture at rest as well as

during work plays a key role. Maintenance of flexion attitude
is important.
4. Correction of deformity by corrective exercises
(a) Exercises to improve relaxation and general mobility of

the spine are initiated first.
(b) Obliteration of the exaggerated lumbar lordosis in supine
lying is taught by active posterior pelvic tilt and its
maintenance (Fig. 32-85).
(c) Strong abdominal exercises are taught, maximal effort

being placed over the lumbar spine.
(d) Arm chair sitting with lower back resting against the back
of the chair. Gradual forward bending of the trunk at the
lumbar region with strong abdominal contractions, and
holding the breath (Fig. 32-86).
5. Regular periods of prone lying and hamstrings stretching:

These are necessary to control the advancement of the
lordotic tendency.
FIG. 32-84Antilordotic total contact-moulded

thoracolumbosacral brace.
FIG. 32-85Exercise to achieve active correction of the

exaggerated lumbar lordosis. (A) Exaggerated lumbar
lordosis. (B) Actively correcting the anterior pelvic tilt
to the posterior pelvic tilt using lower abdominal
muscles.
FIG. 32-86Forward bending of trunk at the lumbar

spine in chair-sitting with strong abdominal
contractions.
Periodic radiographic checkup should be done, and periods

of wearing brace to be waned gradually till the correction is
maintained voluntarily.
Caution
(a) Spinal extension exercises, which increase the lordosis

further, are contraindicated.
(b) Wrong body mechanics or excessive standing and

ambulation may give rise to fracture of the pars
interarticularis. Therefore, it needs to be restricted.
Surgical management
Surgery is indicated if there is neurological deficit or the pain

is disabling or the slip progresses rapidly. The various
surgical procedures performed are as follows:
1. Spinal fusion: The spine is fused in situ, i.e., without

correcting the slip. Posterior, posterolateral or anterior spinal
fusion may be performed. However, posterolateral fusion is
common. The loose posterior element of the vertebra may be
removed to decompress the nerve roots (Fig. 32-87).
Postoperatively, the patient is nursed in bed for 4–6 weeks,

after which a lumbosacral corset is given and the patient is
mobilized. Some surgeons prefer a plaster jacket for 3
months after surgery.
The corset is discarded after the fusion consolidates, i.e., after

6–9 months.
Spinal fusion prevents further progression of slip.
2. Reduction of the listhesis (slip) and spinal fusion: Some

surgeons reduce the slip of vertebrae and fuse the spine
posteriorly. The spine is stabilized internally with the help of
rods or plates (Fig. 32-88) or some instrumentation. It
requires extensive surgery and great expertise.
FIG. 32-87Posterolateral fusion. (A) Anteroposterior

view, bone formed along the transverse processes and
the ala of sacrum. (B) Lateral view.
FIG. 32-88Internal stabilization after reduction of the

slip.
1. Deep breathing and arm movements encouraged with

ankle and foot movements.
2. Assisted knee movements.
3. Hip flexion, when given, should not be taken beyond 60

degrees.
4. Isometrics to the glutei.
Mobilization: A POP jacket is applied by the 2nd week of

operation. The jacket continues for a very long time,
sometimes even up to 6 months or till the fusion is evident.
Therefore, total mobilization with the jacket should be
instituted immediately. Educating and guiding the patient to
perform functional activities forms an important part of the
management so that he does his activities of daily life and
goes back to work.
When the jacket is removed, gradual mobilization of the

spine is initiated as described in the conservative
management section and progressed till total functional
independence is achieved. It may take 7–8 months to regain
full function.
Miscellaneous: LBP may occur as a result of conditions such

as diskitis, Paget’s disease, metabolic bone disease and
multiple myeloma. The pain is usually severe and does not
respond to any therapy, including medications. It needs
appropriate investigations and therapy to control the disease
as the first priority.
The following conditions, although rare, need to be

identified:
1. Piriformis syndrome
2. LBP of thoracic origin.
Piriformis syndrome
Many a times, typical symptoms such as classical sciatica

may appear due to entrapment of sciatic nerve in the
piriformis muscle.
Tests to confirm the piriformis syndrome
1. The patient is asked to lie on the unaffected side. The knee

of the painful leg is flexed to 90 degrees. Catching the foot
behind the calf of the healthy leg, the knee of the affected leg
is gradually brought down till it touches the top of the
examination table. This results in the combination of
adduction–internal rotation and flexion at the hip. As this
manoeuvre produces further compression of the entrapped
sciatic nerve, there is sudden increase in the symptoms of
sciatica.
2. Pressure can be directly exerted over the piriformis muscle

by vaginal or rectal examination. If present, it can be treated
conservatively with deep heating modality, stretching
exercises or local infiltration of hydrocortisone.
Low back pain of thoracic origin
The characteristics of pain of thoracic origin resemble those

of LBP. The distinguishing features are as follows:
Palpation of a well-localized point on the iliac crest, 8–10 cm

from the mid-line produces pain in the low back region.
Palpation in the region of the posterior intervertebral joints
T12–L1 on the same side is particularly painful.
Subcutaneous tenderness is felt over the buttock by pinch
roll manoeuvre. Infiltration of this spot with local anaesthetic
provides immediate relief.
Arachnoiditis
It is an inflammation of the pia-arachnoid of spine and cauda

equina. Arachnoid is a nonvascular membrane which
envelops the spinal cord and dural sheaths of caudal nerves.
Pia-arachnoid inflammation results in the formation of
fibrous strands around the nerve roots. The fibroblastic
activity and collagen deposition further thicken the pia-
arachnoid tissues (Fig. 32-89). This results in compression
and atrophy of the concerned nerve roots and even spinal
cord.
FIG. 32-89Arachnoiditis natural evolution. (A) PA: Pia-

arachnoid, SAS: Subarachnoid space, N: Normal nerve
roots. (B) Thickening of pia-arachnoid with swelling of
nerve roots. (C) Pia-arachnoid becomes adherent with
fibrous strands, and atrophy sets in the nerve roots.
Infection, trauma, allergic tissue reaction, autoimmune

reaction, chemical irritation by contrast dyes of myelography
and spinal surgery may precipitate this condition.
Symptoms and signs
◼ Continuous LBP unrelated to postures
◼ Radiating pain
◼ Pain aggravated by trunk flexion and relieved by

extension
◼ SLR may be positive
◼ Symptoms of cord compression depending on the size and

extent of the lesion
Treatment
The treatment of arachnoiditis offers some relief but

complete relief is difficult.
Local deep heat procedures, and postural training and

education on the guided activities may provide some relief.
The therapeutic approach depends upon the degree of
involvement of the spinal cord and its related neuromuscular
involvement. Intrathecal steroid injections and surgical lysis
of adhesions may rarely be indicated.
Scheuermann’s disease
Scheuermann’s disease, also called adolescent kyphosis,
usually affects the thoracic spine in adolescents, particularly
boys. There occurs rounded kyphosis of more than 40
degrees due to anterior vertebral wedging of three or more
vertebrae (Fig. 32-90).
FIG. 32-90(A) Scheuermann’s disease with round

dorsal kyphosis. (B) The anterior margins (AM) of
vertebral bodies are irregularly indented.
Aetiology
The aetiology of Scheuermann’s disease is not known. The

child presents with a thoracic kyphosis, which is relatively
rigid. Pain is an occasional feature. Hamstring tightness is a
consistent finding. Mild scoliosis may be present. There is
usually a compensatory hyperlordosis at the lumbar spine.
Treatment
The aim of treatment is to maintain the extended position of

spine.
Localized extension exercises to the spine may be advised.

However, these are not effective. A spinal brace or a plaster
jacket is given with pressure over the apex of the kyphosis. It
is maintained till the kyphotic deformity is decreased to 20
degrees.
Surgical treatment
Surgical treatment is rarely indicated in Scheuermann’s

disease. However, in severe cases, Harrington
instrumentation or segmental spinal instrumentation may be
undertaken. In some cases, combined anterior and posterior
spinal fusion may be indicated.
Cases treated conservatively:
Positioning: The patient should be taught to assume prone

lying position as frequently as possible and to remain in this
posture for longer durations. This reduces strain on the
inflamed epiphyses of the involved vertebrae besides
minimizing the expected flexion deformity.
Exercises: Deep breathing exercises are taught to maintain
and improve the respiratory capacity. Spinal extensors
should be exercised isometrically if active extension is
painful. However, isotonic hyperextension in prone position
should be initiated as soon as it is pain free.
Exercises to the posterior muscles of the neck, dorsal spine

with shoulder girdle retraction are useful to minimize the
deformity of round back. With increased thoracic kyphosis,
the possibility of developing lumbar lordosis should be
considered and exercises of posterior pelvic tilting should be
initiated early.
Postural guidance: Guidance for correct technique of wearing

spinal brace with padding over the gibbus or apex of the
kyphosis is provided. Correct posture of lying, sitting,
standing and walking with brace and later without brace is
important.
Exercises for mobilization and strengthening are made

vigorous as the acute symptoms subside. However, flexion
exercises to the spine should be initiated with caution to
keep a watch on the symptoms of pain and fatigue.
Cases treated with surgery: They are treated on the same

lines as described for scoliosis since the surgical procedures
are the same, namely Harrington instrumentation, segmental
spinal instrumentation or combined anterior and posterior
spinal fusion.
Prevention of low back pain

Preventive aspect of LBP has not received enough attention
except for a few reports in the recent years (Kirkaldey-Willis,
1983). With the established knowledge of the aetiology and
advanced methods of examination and investigation,
management and prevention of LBP has become more
precise. The observation that higher incidences of LBP are
due to faulty postural mechanisms emphasizes the
importance of correct body mechanics in the prevention of
LBP in majority of the population (White, 1983).
Prevention through controlling the predisposing factors

seems to be an ideal approach.
Prevention broadly falls into three categories:
1. Primary prevention: To prevent the disorder before it

occurs.
2. Secondary prevention: To limit the development of disorder

before it becomes symptomatic.
3. Tertiary prevention: To limit the complications of the

established disorder (Anderson, 1984).
Measures of prevention can be as follows:
(a) General preventive measures
Mass education of the public at an early age on the principles

of ergonomics at rest and work is important.
Identification of the subjects who are prone to develop LBP

due to wrong postural attitudes and muscular imbalances is
important. Simple programmes to correct these attitudes will
help its prevention.
Guidance and education on the measures to prevent direct or

indirect trauma by avoiding accident-prone attitudes.
(b) Specific preventive measures
Physical fitness: Physical fitness is one of the major

contributory factors in the prevention of LBP (McQuade,
Rurner, & Buchner, 1988). Therefore, proper fitness
programme should be initiated at an early age. The physical
fitness programme should be planned to include the whole
body and not just the trunk and lower extremities.
Occupational hazards: Frequent change in the posture should

be advised to a person engaged in an occupation which
demands heavy lifting, repeated trunk twisting and static
stooping and/or forward bending. Specific conditioning
exercises should be planned to suit an individual’s
professional demands.
(c) Preventive measures in other situations
Early detection of conditions such as scoliosis, ankylosing

spondylitis, spinal canal stenosis, spondylolisthesis, fractures
and other infective and inflammatory conditions.
Psychological conditions such as depression, anxiety should

be detected and treated adequately.
Physiotherapy has a predominant role to play in all the three
types of preventive measures. It can be instrumental in mass
education on the basis of back care and ergonomics (Fig. 32-
91).
1. Retention of natural spinal curvatures: The natural

physiological curvatures of spine should be retained as they
protect the spine by absorbing shocks and preventing it from
undue compressive and shearing forces. Emphasis on the
maintenance of lumbarlordosis is of primary importance in all
static and dynamic positions (McKenzie, 1981).
2. Sustained wrong postures: When work involves periods of

long sitting position, frequent changes of posture is
necessary. Sitting with hips at a lower level than the knee
should be emphasized in patients with exaggerated lumbar
lordosis. However, this position does not hold true for
patients with normal lumbar lordosis or those with flat
backs, as it produces lumbar kyphosis.
3. Standing from sitting: Preferably use arm chair as it reduces

weight on the lumbar region by 30% (Nachemson, 1985).
While getting up from sitting position, first move to the front
of the seat. Stand up by straightening the knees, maintaining
lumbar lordosis without bending forward.
4. Lying: Use firm bed with wood base, keeping a roll under
the lumbar area and knees in flexion (Fig. 32-57A). However,
the best sleeping posture is side lying with hip and knee in
flexion.
5. Sitting up: While getting up from the lying position, turn to

the side and draw bent knees forward over the edge of the
bed. Gradually, lift trunk to sitting by supporting on both
hands and simultaneously bringing the legs down keeping
knees and feet together. The head and feet remain in a
straight line throughout (Fig. 32-91B), and trunk forward
bending should be strictly avoided.
6. Sneezing/coughing: To avoid sudden jerky forward flexion

of spine during sneezing and coughing, stand up, keep the
back straight or bend it backwards, preferably holding with
hands to prevent excessive jerk.
7. Forward bending: As far as possible, bending forward

should be avoided. When it is a must, initiate the bending at
the hip and knee joints, keeping the back straight. First 60
degrees of forward bending puts maximum strain on the
lumbar spine. Therefore, initiate bending at the hip and knee
joints with arms supporting over the thighs or with some
other stable support.
8. Pushing: Do not push heavy objects by bending the trunk;

rather it should be done from the buttocks by turning
around.
9. Lifting: Lifting weights should be avoided totally. If it is a

must, it has to be done with more of flexion and extension at
the hip and knee. After lifting, stand upright and bend
backwards a few times. Take a deep breath just before lifting;
then as the trunk moves upwards hold the breath, keeping
the abdominals contracted. The rise in intra-abdominal
pressure against the contracted diaphragm lifts the thoracic
spine upwards, relieving the lumbar spine of some weight
and providing cushioning effect anteriorly on the
dorsolumbar spine (Fig. 32-91C-1).
10. Carrying weight: Do not carry weight in one hand only,

carry it in both hands. While carrying heavy objects, balance
the weight of the object on the hip. It helps the stress pass
directly through the hip, rather than through lumbar spine.
Always carry object close to the body (Fig. 32-91C-2).
11. Crouching: Crouching or relaxed sitting should not be

adopted even after strenuous work or fatigue. In crouching,
as the muscles relax, the body weight is borne by joints and
ligaments. The latter are over stretched and the vertebrae
and discs are compressed.
FIG. 32-91(A) Back ergonomics in fundamental

postures: (i) in supine, (ii) inside lying, (iii) sitting, (iv)
standing. (B) Sitting from supine lying B1 to B6. (C) (i)
Lifting, (ii) carrying.
Other precautionary measures
To increase physical fitness, conditioning and strengthening

of the extensor group of muscles, rotators and flexors, in that
order, should be done regularly (Cady, Bischoff, O’Connel,
Thomas, & Allan, 1979). Strong erector spinae, obliques,
gluteus maximus and hamstrings are of special importance
for persons engaged in heavy lifting and bending activities.
The back care programme should be planned on an

individual basis, since the back care techniques vary with
individual problems and postural attitudes during work and
other activities of daily routine.
A quick look at postural deviations from the normal, and

brief examination of soft tissue imbalances should be useful
to prevent LBP due to these causes.
Frequent checks on the back care programme are extremely

important.
Prevention of recurrence of low back pain
Once LBP is controlled, it is most important to prevent its

recurrence. This is achieved by the following:
◼ Continuing the exercise programmes and ergonomic

advice.
◼ Maintenance of correct posture during rest and work.
◼ Avoiding the postural attitudes that are likely to induce

excessive stress.
◼ Regaining the maximum flexibility of soft tissues of the

lumbosacral region and pelvis.
◼ Further improving the strength and endurance of flexor,
extensor and trunk rotators, and gradually progressing to the
maximum.
What to do when there is recurrence of pain:
◼ Pain reducing modalities such as hydrocollator packs, ice

massage, relaxation techniques and rest with proper posture.
◼ Specific exercise programme, which gave relief at the

earlier episode, should be gently introduced.
◼ Any posture or exercise causing excessive pain should be

totally eliminated.
◼ Avoid one constant posture for long periods even if it

gives relief.
◼ Analgesics and anti-inflammatory drugs can be started.
◼ If the pain is not relieved within a day or two, immediate

consultation is necessary.
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to low back pain. St Louis, MO: CV Mosby 1983;
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Collins E. Controlled trial of mobilization and manipulation for
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1979;2:1318.
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mobilisation on flexor tendon healing. A biomechanical study. Acta
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traction. Physiology 1972;58:55.
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Research 1988;236:192.
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(etude de 50 lacs). 1954;
Chapter 33
Regional orthopaedic soft tissue lesions of the

shoulder, elbow, forearm, wrist and hand
Outline
◼ Functional anatomy of shoulder
◼ Soft tissue lesions at neck and shoulder
◼ Frozen shoulder (syn: adhesive capsulitis, periarthritis)
◼ Painful arc syndrome
◼ Lesions of the rotator cuff
◼ Infraspinatus tendinitis
◼ Soft-tissue injuries at the elbow
◼ Tennis elbow (lateral epicondylitis)
◼ Golfer elbow or medial epicondylitis
◼ Olecranon bursitis (minor elbow)
◼ Wrist sprain
◼ Ganglion
◼ De Quervain disease
◼ Trigger finger
Functional anatomy of the shoulder joint

Factors like proximal positioning, free all-round mobility,
overuse and comparatively unstable joint surrounded by
crowded soft tissues make the joint susceptible to fractures
and a great variety of soft-tissue lesions.
Movements
Perfectly synchronized action of the shoulder complex,

consisting of four different articulations, is necessary for the
optimal function of this joint. The components of the
shoulder complex are as follows (Fig. 33-1):
1. Glenohumeral joint
2. Acromioclavicular joint
3. Sternoclavicular joint
4. Scapulothoracic joint
FIG. 33-1Shoulder joint complex. ACL,

acromioclavicular joint; GLH, glenohumeral joint; SCL,
sternoclavicular joint; SCTH, scapulothoracic joint.
Multidirectional wide arcs of movements are the results of

the immaculate structural design of the shoulder complex.
The dynamic force and stability to this complex are provided
by precisely controlled muscular actions. The structure and
disposition of these muscles provide a base for a wide range
of controlled activities from strong and powerful actions in
sports and heavy work to the fine coordinated prehensile
finger movements of a musician.
The normal process of raising the arm to a vertical position

above the head is carried out with smooth, uninterrupted
motion at all the afore-mentioned four joints of the shoulder
complex. The intricate interplay of all the four joints was
termed as scapulohumeral rhythm by Codman (1934), which
was later modified by McMillan (1966) to
scapulohumeroclavicular rhythm, as the clavicle also
participates along with the scapula and humerus. However,
the appropriate terminology to describe the movement of the
whole complex would be scapulohumeroclaviculothoracic
rhythm since scapulothoracic articulation is also actively
involved apart from the other three joints.
In the total arc of 180 degrees of elevation, contribution from

the glenohumeral joint is 120 degrees while the remaining 60
degrees is contributed through the outward rotation of the
scapula, i.e., in the ratio of 2:1. For every 15 degree of arm
abduction, 10 degrees of abduction takes place at the
glenohumeral joint, the remaining 5 degrees being
contributed by rotation of the scapula upon the thorax. Out
of the total 60 degrees of scapular rotation, 30 degrees occur
due to elevation of the clavicle at sternoclavicular joint and
the remaining 30 degrees at the acromioclavicular joint. At
the same time, axial rotation of the clavicle by as much as 50
degrees is also an important contributory factor in this
mechanism (Singleton, 1966) (Fig. 33-2).
FIG. 33-2Components of the total arc of shoulder

abduction elevation. Total range = 0–180 degrees. (A)
Glenohumeral joint ABC = 120 degrees, outward
rotation of (ADE) = 60 degrees (acromioclavicular 30
degrees = sternoclavicular 30 degrees). (B) Besides
these, the clavicle rotates around its axis by 50 degrees
(CR).
Kent (1971) noted that elevation at the sternoclavicular joint

occurs during the first 90 degrees of arm elevation. For every
10 degrees of elevation of arm, 4 degrees of elevation occurs
at the sternoclavicular joint, thus at 90 degree, the clavicle
has elevated to 36 degrees, whereas motion at the
acromioclavicular joint occurs during the first 30 degrees and
thereafter, after 135 degrees of abduction.
Muscle action
The complex mechanism of arm elevation to 180 degrees is
made possible by the coordinated actions of different muscle
groups that act through two mechanical force couples. A
force couple is defined as two equal forces acting in opposite
directions to turn the part about its axis of rotation.
Glenohumeral force couple (fig. 33-3)
The first mechanical force couple acts on the glenohumeral

joint in the following sequence:
1. The supraspinatus fixes the head of the humerus to the

glenoid.
2. The humeral head is maintained and stabilized in the

glenoid cavity by the downward pull of short rotators, i.e.,
the infraspinatus, subscapularis and teres minor.
3. The secured head of the humerus can be efficiently pulled

into abduction by the strong action of the deltoid.
FIG. 33-3Events at the glenohumeral force couple

which facilitates abduction elevation. DEL, deltoid; ISP,
infraspinatus; SSP, supraspinatus; SUBSC,
subscapularis; TEMI; teres minor.
Thus, the supraspinatus (SSP) fixes the head of the humerus

to the glenoid; the infraspinatus (ISP), subscapularis (SUBSC)
and teres minor (TEMI) exert a downward pull and stabilize
the humeral head in the glenoid, facilitating the strong action
of the deltoid (DEL) to pull the arm in abduction elevation.
Scapulohumeral force couple (fig. 33-4)
The second mechanical force couple acts on the scapula. It is

the main force behind the 60 degrees of outward rotation of
the scapula.
1. The upper portion of the trapezius acting on the acromion
rotates the scapula outwards.
2. The lower portion of the trapezius pulling on the lower

scapular spine carries further the outward rotation of the
scapula.
3. At this stage, the serratus anterior provides the strongest

force in outward rotation of the scapula.
FIG. 33-4Scapulohumeral force couple which facilitates

outward rotation of scapula. LOTR, lower trapezius;
SEANT, serratus anterior; UPTR; upper trapezius.
The combined effect of both these mechanical force couples

provides the arc and strength to the
‘scapulohumeroclaviculothoracic rhythm’.
To summarize, the glenohumeral motion is accomplished by

(a) fixation of the humeral head to the glenoid by the
supraspinatus, (b) the humeral head is maintained in the
glenoid cavity by the downward pull of the short rotators
(infraspinatus, subscapularis and teres minor) and (c)
abduction of the arm is achieved by the deltoid.
The upper trapezius (UPTR) rotates the scapula outwards

from upper scapular region. It is further supplemented by
the lower trapezius (LOTR) and the strong action of the
serratus anterior (SEANT).
The rotation of the scapula is made possible by the action of

the second force couple. The coordinated action of these
muscles rotates the scapula outwards and thereby, the
glenoid is pulled upwards.
Scapulohumeral group of muscles: Subscapularis, teres

minor and infraspinatus function as depressors as well as
stabilizers of the head of the humerus against the glenoid
during arm elevation. The subscapularis also functions as an
internal rotator while the teres minor and infraspinatus act as
external rotators of the humerus. The subscapularis also acts
as a strong protector of the anterior portion of the joint.
Axioscapular group of muscles: Trapezius, rhomboids,

serratus anterior and levator scapulae act as an anchoring
force giving support to the scapula on the thoracic cage and
at the same time allowing freedom of motion. The upper and
lower portions of the trapezius and levator scapulae anchor
the scapula vertically. The serratus anterior also gives
horizontal stability to the scapula preventing its ‘winging’.
Axiohumeral group of muscles: The pectoralis major and

minor and the latissimus dorsi help to move the scapula and
push the pectoral girdle upwards when the deltoid is weak
or paralysed.
Rotator cuff: It consists of four muscles, namely, the

supraspinatus, infraspinatus, teres minor and subscapularis.
They terminate into short, flat and broad tendons which fuse
intimately with the capsule of the shoulder joint to form a
musculotendinous cuff. These muscles act as a force couple
with the deltoid. The deltoid’s pull on the humerus is
upwards and outwards. If this muscle acts alone, it will only
succeed in jamming the head of the humerus against the
acromion instead of producing abduction. On the other
hand, if the cuff muscles act alone, only depression of the
head of the humerus results. However, if both actions are
combined, the motion of abduction is produced. Therefore,
the impairment of either of these components of the force
couple usually results in impaired shoulder abduction.
Specific muscle actions
Studies conducted by various methodologies including

electromyography by Inman et al. (1944), Basmajian (1967),
MacConaill and Basmajian (1969) give a clear picture of
specific muscle actions and peak of muscle activity during
specific arc of a movement.
Trapezius: Upper fibres – scapular elevation; lower and

middle fibres – scapular retraction; lower half of trapezius –
forward flexion at the glenohumeral joint; middle fibres –
abduction at the glenohumeral joint. During scapular
adduction – all portions of the muscle are active.
Serratus anterior: Upper digitations – flexion at the
glenohumeral joint; lower fibres – abduction at the
glenohumeral joint.
Rhomboids: Similar to middle trapezius.
Deltoid: All elevation movements at the glenohumeral joint;

peak activity in 90–180 degrees of abduction. Forward
flexion – all the three components, i.e., anterior, middle and
posterior fibres act together but with less amplitude.
Pectoralis: Both clavicular and sternal portions together –

forward flexion against resistance. Only clavicular portion –
forward flexion without resistance.
Latissimus dorsi: Forward flexion – peak activity at 57

degrees and again at 115 degrees. Internal rotation and
adduction of humerus. Less activity in the backward
extension.
Rotator cuff: All the four components of the rotator cuff act
continuously during both abduction and flexion.
Infraspinatus demonstrates peak activity at 180 degrees of
abduction. In forward flexion, it has two peaks of activities:
one at 60 and the other at 120 degrees. The greatest activity
of this muscle is seen during forward flexion rather than
during abduction.
Teres minor: The activity of this muscle demonstrates a

pattern similar to that of the infraspinatus.
Supraspinatus shows peak activity at 80 degrees during the

movement of forward flexion and at 100 degrees of
abduction.
Subscapularis demonstrates peak activity during 90–130

degrees of abduction and between 110 and 130 degrees of
forward flexion.
Biceps: Both heads are active during forward flexion at the

glenohumeral joint. The long head produces abduction of the
humerus when the arm is externally rotated.
Teres major: It is not active during the motion of the

shoulder. It is however active if static contraction is required
during abduction of the humerus. It shows maximum
activity during maintenance of a static arm posture at 90
degrees of abduction.
Soft-tissue lesions at neck and shoulder
Neck
Acquired torticollis
This is a rotational deformity of the neck where the head is

tilted to the affected side and chin is deviated to the opposite
side.
In the majority of patients, it occurs as a result of

malpositioning of the neck–head component during sleep.
The neck is held in malposition due to spasm in the

sternomastoid muscle. Attempted active or passive
movements are limited and painful with localized
tenderness.
It is easily controllable by thermotherapy, nonsteroidal anti-

inflammatory drugs (NSAIDs), relaxed movements, using a
conventional collar and correct well-protected posture (see
Fig. 32-20).
In rare instances, it could be infective following acute

cervical lymphadenitis or could develop due to the
contracture of sternomastoid muscle of psychogenic origin.
Shoulder
It happens to be a common site of both direct and indirect

injuries to the bones and the soft tissues. The possible causes
can be (i) its proximal position as a joint of the upper
extremity, which (ii) bears maximum stresses of functional
activities. (iii) It is also a relatively unstable joint.
Each condition can be diagnosed from its typical

characteristics (Table 33-1).
Table 33-1
Characteristics of Identifying Soft-Tissue Injuries at the

Shoulder
Injury Identifying Characteristics
Subacromial Pain during resistive abduction and internal
bursitis rotation
Frozen Painful limitation of elevation in flexion and
shoulder, abduction and external rotation
adhesive
capsulitis or
periarthritis
shoulder
Rotator cuff Passive pain-free normal to near normal
syndrome joint excursion
Marked weakness with inability to perform

shoulder overhead elevation through
flexion or abduction of a shoulder joint
(arm cannot be abducted beyond 45
degrees)
Painful arc Pain experienced only in a particular arc of

syndrome, shoulder joint, overhead elevation through
superficial abduction between 45 degrees and 160
lesion in the degrees
supraspinatus
Deep and distal Full passive elevation is painful
lesion
Complete Pain-free total loss of active abduction
rupture
Infraspinatus Pain only during resistive external
tendinitis: rotationPainful arc
Strain
Full passive elevation is painful
Superficial
rupture Pain-free weakness, with pain-free arc, loss
of 30° of external rotation
Distal deep
rupture
Complete
rupture
Subscapularis Pain in the terminal stage of resistive

tendinitis internal rotation, passive movement is pain-
free
Bicipital Pain tenderness in the intertubercular
tendinitis groove during lifting or pulling
Resistive elbow flexion and supination

elicits pain
Note: A combination of a painful arc syndrome and adhesive

capsulitis may be present in some patients.
Frozen shoulder (syn: Adhesive capsulitis,

periarthritis)
Frozen shoulder is a clinical syndrome with painful
restriction of both active and passive shoulder movements.
The condition is aggravated by systemic problems like
diabetes mellitus, cardiovascular disease and reflex
sympathetic dystrophy.
The term ‘frozen shoulder’ is often used injudiciously for any

painful condition of the shoulder joint. However, there are
two known entities which must be differentiated and a
proper diagnosis should be arrived at, since the treatment of
each is different. These conditions are as follows:
1. Painful shoulder: Any condition, around the shoulder, that

causes pain and limitation of the movements of the shoulder
may be included in this group. In this, there is no true
contracture of the capsule of the shoulder joint. The various
conditions include tendinitis of the rotator cuff, sprain and
tears of the rotator cuff, bicipital tenosynovitis and synovitis
of the shoulder.
The patient has limitation of movements which is more due

to pain rather than due to intra-articular or capsular
contractures. Radiograph may show areas of calcification
around the shoulder indicating calcific tendinitis.
Arthrograph will rule out a capsular contracture.
Magnetic resonance imaging (MRI) of the shoulder would

help rule out tears in the rotator cuff. Treatment depends
upon the primary lesion. Manipulation should not be
undertaken.
2. Adhesive capsulitis or frozen shoulder: Capsular adhesions

form as a result of inflammation in the capsule and
synovium. The adhesions are more marked in the axillary
fold. Neviaser and Neviaser (1987) have classified this
condition into four stages: (1) preadhesive stage, (2) acute
adhesive stage, (3) stage of maturation and (4) chronic stage.
The exact cause of the capsular contracture is not known.

However, relative immobility of the shoulder due to
coronary artery disease, mastectomy or other operations over
the chest and cervical spondylosis may precipitate frozen
shoulder. Even not performing full shoulder stretches in our
daily activities may lead to capsular contracture and thereby
a stiff shoulder in majority of individuals.
Diagnostic tests
1. Active test of range of motion (ROM) with slight

overpressure at the terminal point of each movement: This
test will reveal definite capsular restriction of the
glenohumeral joint. The movements principally involved
will be abduction and external rotation; the movements of
flexion and internal rotation are involved to a lesser extent.
No apparent muscular weakness will be present in the
available ROM, but overpressure at the end of the range will
elicit pain.
2. Active resisted test of ROM: At the initial range, usually

there is no pain; however, considerable resistance may be
painful.
3. Passive test of ROM: With the patient in supine position,

this test confirms the capsular pattern of restriction of the
joint and the diagnosis of adhesive capsulitis (Kessler &
Hertling, 1983).
Treatment
It is treated mainly by analgesics and physiotherapy with

shoulder mobilization exercises. Occasionally, a periarticular
injection of hydrocortisone is given to reduce pain and
inflammation. These days, arthroscopic capsular release is
done which improves the range of movements.
Physiotherapy plays an important role in the prevention as
well as resolution of this condition.
Preventive programme
1. Prevention of primary capsulitis: The natural history of the

disease is still undecided as regard to the aetiology of this
condition. It is very difficult to know the onset of the disease
in its early phase as the symptoms of pain and stiffness are
not acute. However, from our observations, we have noticed
that the initial pain and stiffness were elicited when the
shoulder was passively taken to its terminal range of
overhead adduction in elevation (Fig. 33-5). Secondly, the
early symptom is pain in lying on the side of the affected
shoulder.
Therefore, the regular practice of this particular movement

could be instrumental in prevention, early detection and
lessening the impact of this condition.
2. Prevention of secondary capsulitis: Careful early

mobilization to the extreme ROM needs to be emphasized
for the other benefits of exercise in addition to the prevention
of secondary adhesive capsulitis in the following situations:
(a) All the procedures around the chest and shoulder

requiring prolonged immobilization.
(b) All situations requiring prolonged bed rest, e.g., coronary

artery disease; fractures in the upper limb.
(c) Paralysed arm following stroke.

(d) Unconscious patient following head injury.
(e) Mastectomy.
3. Prevention of further damage: Further damage to the joint

can be done by avoiding the following actions: (i) Suddenly
applied jerky stretching and (ii) crude self-styled
manipulations by a quack. These result in high tensile
resistance and give rise to further constriction of the already
constricted capsule (Kottke et al., 1966). Thus, there is an
increase in pain due to muscle spasm leading to further
stiffness.
Adhesive capsulitis can be avoided through proper measures

and by education to the masses to seek proper advice on
simple terminal stretching of the shoulder.
FIG. 33-5Test for early diagnosis of adhesive capsulitis:

extreme range of passive overhead adduction of the
shoulder in full range of motion (ROM) of elevation in
supine position elicits pain – tightness.
Restorative programme
The basic aim of the restorative programme is
1. To reduce pain,
2. To increase extensibility of the thickened and contracted

capsule of the joint at the anteroinferior border and at the
attachment of the capsule to the anatomic neck of the
humerus,
3. To improve mobility of the shoulder and
4. To improve strength of the muscles. However, it may be

remembered that strengthening of muscles is secondary to
mobilization.
Mobilization is attained through three basic approaches:
1. Relaxation
2. Specific exercise to offer graduated stretching
3. Passive mobilization technique
To have better results, strengthening done within available

range helps in further movement as because of strength in
the available range, the person is now able to use the hand to
the available range; this encourages him or her to use it to try
doing movement more than available.
1. Relaxation:
Through prior heating: Prior heating of the joint has been

found to facilitate relaxation and mobilization (Gersten, 1955;
Lehmann et al., 1954). One may use any heat modality
suitable to the patient’s response. However, ultrasound
therapy, besides deep heating, has the added advantage of
increasing extensibility of the contracted soft tissues and is
therefore preferred. Stanley (1972) advocated the use of
ultrasound via axilla over the anteroinferior border of the
capsule to be closer to the seat of actual defect.
Relaxed passive mobilization: The patient is placed in supine

position with the affected shoulder in maximum possible
abduction, neutral rotation and elbow in 90 degrees of
flexion.
The physiotherapist grasping the arm below the shoulder

joint carries out relaxed passive gliding movements of the
head of the humerus on the glenoid (Fig. 33-6). Axial traction
and approximation is carried out along with anteroposterior
glide and abduction–adduction glide. To induce relaxation,
always begin with slow rhythmic movements.
Slow and rhythmic circumduction at the glenohumeral joint,

in forward stoop position, effectively induces relaxation and
promotes mobility. It should be done by stabilizing the
shoulder girdle with one hand and grasping just above the
wrist joint with the other hand (Fig. 33-7). Gentle relaxed
passive movements short of pain and pathologic limits of
motion reduce pain (Maitland, 1983). The reduction in pain
occurs because of the neuromodulation effect on the
mechanoreceptors within the joint (Barak et al., 1985).
Mobilization by passive accessory movements of the

acromioclavicular (AC), sternoclavicular (SC) and/or
scapulothoracic joint articulations are also extremely helpful.
2. Exercise Programme: Exercise plays an important role in

the management of adhesive capsulitis (Lee et al., 1973; Rizk
et al., 1983).
While planning the exercise programme, one must give due

importance to the observations of Bohanan et al. (1985),
Kottke et al. (1966, 1983), Rizk et al. (1983), Sapega et al.
(1981) who proved that contracted soft tissues when
subjected to repeated prolonged mild tension show
extensibility and plastic elongation.
Secondly, Lee et al. (1973) and Rizk et al. (1983) also noted
that an increase in the movement following the sessions of
prolonged stretching was usually associated with a
corresponding increase in other movements too. However,
Maitland (1983), although in general agreement with these
findings, cautioned that improvement in the range of other
movements is not always at the same rate. Our clinical
experience agrees with the statement of Maitland.
Giving due weightage to these clinical observations, ideally,

the specific exercise programme should include the
maximum number of combinations of various movements by
minimizing the number of exercises.
We advocate graduated relaxed sustained stretching based

on the PNF patterns. We have designed two movement
combinations of
(a) Shoulder elevation with flexion, abduction and external

rotation (Fig. 33-8A).
(b) Shoulder internal rotation with extension, adduction and

elbow flexion, i.e., attaining ‘hand to lumbar’ position (Fig.
33-8B).
FIG. 33-6Rhythmic relaxed passive gliding of the

humerus on the glenoid with axial traction.
FIG. 33-7Rhythmic relaxed passive mobilization with

the patient in supported stoop standing while the
physio therapist moves the glenohumeral joint with
one hand and stabilizes the shoulder girdle with the
other.
FIG. 33-8Self-assisted relaxed mobilization followed by
gentle but sustained passive stretching. (A) Shoulder
elevation with flexion abduction and external rotation.
(B) Extension with adduction and internal rotation.
Following the preparatory programme of inducing

relaxation, the afore-mentioned regime of exercise can be
done in two ways:
(i) By pulley and tolerable weight in supine or sitting

position.
(ii) By self-assisted stretching: The patient uses normal or

better contralateral arm to gradually stretch the affected
shoulder, maintaining the specific groove of these two
exercises after self-induced relaxed passive mobilization.
While applying weights, one must be careful not to

overstretch the contracted capsule which induces pain.
Ideally, it is better to start with minimal weight and increase
it gradually, without causing any discomfort to the patient.
Remember
Stretching with pain should never be given or advised but

can be given within the limitation of pain.
3. Passive mobilization technique: Methods described by

Codman, manipulation and mobilization techniques by
Maitland (1983) and specialized techniques of PNF by Voss
and Knott (1968) could be used with great advantage.
Middleditch and Jarman (1984) reported objective response
in 78% patients treated with ultrasonics, ice pads and ice
massage over the hot spots detected by thermography.
However, in spite of the various reports on the doubtful

periods of resolution of the stiffness, we have observed that
majority of patients respond favourably within a period of 6
months with a properly guided simple and specific exercise
programme which ensures relaxed graduated stretching of
the contracted capsule. However, it must be remembered
that the ultimate results depend upon the efficacy of home
treatment regime.
Irregular or nonresponding patients are benefited by the

special mobilization techniques of Maitland (1983).
Caution
1. The importance of regular stretching has to be emphasized

to the patient even after he is relieved of stiffness and pain to
avoid recurrence.
2. Patients with diabetes respond slowly to treatment and

feel much more pain and discomfort as compared to
nondiabetics. Therefore, explain the prognosis, achieve
maximum relaxation and go slow in patients with diabetes.
Varying periods of total resolution from 1 to 3 years have
been recorded in a number of studies (Reeves, 1975; Grey,
1978).
3. Nocturnal pain: Patients complaining of nocturnal pain

should not be treated by thermotherapy. This type of pain
has a low threshold for pain; therefore, the pain increases on
warming up of the body at night. Thermotherapy is likely to
increase pain in such patients (Lewis, 1942); if given, it
should be monitored at regular intervals.
4. The contralateral normal shoulder should always be

examined in the extreme ROM as a precautionary measure.
Painful arc syndrome

In this syndrome, the arc of shoulder abduction elevation is
painful from about 45–160 degrees, but this is painless up to
the initial 45 degrees as well as in the terminal range from
about 160 degrees to full elevation. The passive ROM is pain
free.
The cause is mechanical – the tender structure get nipped in

between the tuberosity of the humerus and the acromion
process or coracoacromial ligament.
Five types of lesions can give rise to this syndrome (Fig. 33-
9).
1. Minor tear of the supraspinatus tendon
2. Supraspinatus tendinitis
3. Calcified deposit in the supraspinatus tendon
4. Subacromial bursitis
5. Crack fracture of greater tuberosity of humerus
6. Bicipital tenosynovitis
FIG. 33-9(A) Painful arc syndrome (PAS). (B) Five

possible causes of painful arc: 1. Incomplete
supraspinatus tear, 2. Supraspinatus tendinitis, 3.
Calcified deposit in supraspinatus, 4. Subacromial
bursitis, 5. Crack fracture of greater tuberosity.
Investigations
X-rays: Plain X-ray of the shoulder joint may show

calcification in the region of the supraspinatus tendon. In a
longstanding tear of the supraspinatus, the space between
the acromion and the head of the humerus may be reduced
due to upward migration of the humeral head (Fig. 33-10).
FIG. 33-10X-ray of the shoulder showing upward

migration of the head of the humerus due to rotator
cuff arthropathy.
MRI: An MRI may show collection of fluid or altered signals

in and around the supraspinatus tendon (Fig. 33-11).
FIG. 33-11MRI of the shoulder showing collection of

fluid and altered signals around the supraspinous
tendon.
The acromion process may show downward displacement of

its tip causing impingement of the underlying rotator cuff
(Fig. 33-12).
FIG. 33-12MRI of the shoulder shows downward slope

of the tip of the acromion causing subacromial
impingement.
◼ History of injury is suggestive of supraspinatus strain or

fracture of greater tuberosity.
◼ Spontaneous onset suggests tendinitis or subacromial

bursitis.
◼ Acromioclavicular joint arthritis may also cause painful

arc, but the pain appears later in the range and it also
increases when nearing to the extreme range of abduction.
Calcified deposit can be confirmed by radiography.
Treatment
1. Initial rest in a sling.
2. Short-wave diathermy is very effective.
3. Relaxed passive pain-free full range elevation in supine

position.
4. Gradual progression in abduction; begin with active

assisted movement in a gravity-eliminated position
progressing to antigravity exercises and then to graduated
progressive resistive exercises (PREs).
The cases which do not respond to the conservative

treatment may require surgery as follows:
1. (a) Open anterior acromioplasty: In this operation, a part

of the anteroinferior undersurface of the acromion is
removed. The aim of this operation is to remove the anterior
acromial overhang and to produce a flat undersurface to the
acromion and thereby create more room.
(b) Arthroscopic acromioplasty: Anterior acromioplasty can

also be performed by arthroscopic surgery. It is a minimally
invasive surgery and therefore carries lesser morbidity.
2. The space between the humeral head and the acromion is

widened. The neck of the scapula is divided, and the glenoid
fragment with the glenohumeral joint is displaced
downwards.
The calcific deposits in the region of the supraspinatus

tendon may require removal/excision to improve the ROM.
3. Repair of the rupture. The repair may be achieved by open

or arthroscopic methods.
Immobilization (2–3 weeks): Vigorous exercises for the joints

free from immobilization.
Mobilization:
1. Relaxed passive pendular flexion–extension with sling.
2. Gravity-eliminated assisted abduction.
3. Strong isometrics to abduction with self-generated internal

tension.
4. Gradual progress to active-resisted abduction.
Lesions of the rotator cuff

Aetiology
The tendinous fibres of the rotator cuff muscles at or near

their insertion into the tuberosity undergo degenerative
changes with advancing age. Disintegration of the tendon
predisposes to rupture. Neer (1972) emphasized subacromial
impingement as an important aetiological factor in rotator
cuff tears. Intrinsic tendon degeneration is also,
undoubtedly, a substantial contributory factor to most
rotator cuff defects (Keyes, 1933, 1935). All rotator cuff tears
are the result of some combination of age-related
degeneration, trauma and subacromial impingement.
Mode of injury
A fall on the shoulder or an attempt at lifting a heavy object

or throwing a heavy object with overhead action may cause
tear of the rotator cuff. A severe acute pain and snap in the
shoulder is felt immediately, and the patient is unable to
actively abduct the arm. In a senile person in whom the
tendon is quite degenerated, rupture may occur with trivial
trauma and minimum pain. Often, the pain is referred to the
deltoid insertion.
Clinical picture
The arm can be raised actively to about 45 degrees by the

deltoid, after which elevation from flexion as well as
abduction of the arm is accomplished by elevating the
shoulder girdle. The pain is most severe in the arc from 45 to
90 degrees when the traumatized tendon is compressed
between the tuberosity and the coracoacromial arch.
If the arm is elevated passively above the horizontal, further

abduction is possible with very little discomfort. The pain is
most pronounced when the painful tear is exposed to
compression. The following signs can be elicited for
diagnosis:
Neer’s (1972) Impingement Sign: This sign is elicited by

passively fully abducting the arm overhead which causes
pain by compressing the inflamed subacromial bursa and
rotator cuff against a prominent anterior acromion (Fig. 33-
13).
FIG. 33-13Neer’s impingement test.
Hawkins Sign (Hawkins & Hobeika, 1983): Hawkins sign,

also called impingement reinforcement sign, is performed
with the arm in 90 degrees of elevation in the scapular plane.
The humerus is internally rotated so that the greater
tuberosity passes under the coracoacromial arch. This causes
pain in cases of impingement syndrome (Fig. 33-14).
FIG. 33-14Hawkin’s sign.
The pain reduces gradually and the active range of

abduction improves. Eventually, a full range of painless
motion results. However, the arm is weak for more than
ordinary use and sustained work above the horizontal is
difficult.
Treatment
Ideally, the tendon should be repaired immediately in a case
of fresh rupture. After which active exercises are instituted.
A chronic tear can be treated either by conservative methods

or by surgical repair. Anterior acromioplasty (open or
arthroscopic) is performed as an adjunctive procedure to
rotator cuff repair.
A neglected case will develop stiffness and weakness of the

shoulder. Physiotherapy including application of heat and
exercises will mobilize the joint for better evaluation. When
full passive abduction and flexion to elevation are possible,
active abduction and flexion by the shoulder girdle defines a
tear of the cuff.
Injury to the rotator cuff, though commonly observed, is

quite often wrongly diagnosed and treated as adhesive
capsulitis.
Therefore, proper examination, evaluation and clinical

diagnosis are necessary for correct management as the
methodology of treatment differs widely.
The basic aims and objectives of physiotherapy are as

follows
1. Preventive measures: To avoid its occurrence:
(a) Avoid sudden lifting of heavy weight. When the weight

exceeds the tensile strength of the tendon, it invariably
ruptures the tendon.
(b) Avoid repeated compression and nipping of the tendon,

e.g., professions involving repeated movement of strenuous
abduction and flexion.
(c) People in age group prone for degenerative changes need

to take extra cautions while attempting these movements
with weights.
(d) Strengthening of the rotator cuff muscles by PRE. It

should be planned on an individual basis specifically to
strengthen all the three components of the rotator cuff,
namely, abductor, internal rotator and external rotator
muscle groups.
(e) Avoid sports involving repetitive movements of elevation

without specific conditioning and strengthening programme.
Rotator cuff injury has been reported by McLeod and
Andrews (1986) in 68% of throwing athletes as a result of
summation of microtrauma due to several repetitive sessions
of practice.
2. Prevention of further damage
(a) Positioning during standing: Even hanging the arm by the

side of the body for a longer period puts constant strain on
the rotator cuff. Therefore, guidance to use support of good
arm should be taught or an arm sling with proper and
secured support to the shoulder and elbow may even be
considered.
(b) Positioning during exercise: In the presence of a rupture,

the patient should be taught the correct positions and actions
so that the ruptured tendon is not exposed to any further
stretch and damage. Shoulder movements, especially flexion
and abduction against gravity or resistance, should be
discontinued. They should be initiated in a gravity-
eliminated position.
(c) Passive full ROM to avoid adhesive capsulitis is to be

kept in mind and taught to the patient as self-assisted
movements in supine lying position and not in standing or
sitting positions.
3. Restoration of function: During the early phase of an

acute episode:
(a) Rest with proper support in a sling,
(b) Movements of elbow, forearm, wrist and hand,
(c) Cryotherapy, transcutaneous electrical nerve stimulation

(TENS), ultrasonics.
After acute symptoms are abated, isometric contractions

should be given to all the three muscle groups with special
emphasis on abductors and flexors with self-built-up pain-
free controlled contractions.
Transverse friction massage just below the acromion is useful

(Cyriax, 1978). Friction massage is contraindicated in older
patients, where shredding of the tendon could have
occurred.
Deep heating modality like short-wave diathermy could be

given provided the patient does not complain of increased
pain during the exposure.
Exercise programme
1. Relaxed passive movements: Relaxed passive full range

movements with the patient in supine lying position for
abductors and side lying for flexors should be started at the
earliest. Care should be taken to secure total relaxation and
proper stabilization, especially during abduction. The aim is
to achieve full range movements without further injury to
the rotator cuff.
2. Active or active-assisted exercises: This programme is of vital

importance in the return of function. Optimal strength of the
cuff muscles is the guiding principle to plan exercise.
However, initiation of abduction, rotation and flexion has to
be started with gravity-eliminated positions.
With the patient in supine position, the arm is held in neutral

position of rotation with the elbow in flexion. Stabilization is
given just above the glenohumeral joint over the shoulder
girdle. The patient is then asked to the abduct the arm. If the
patient can perform this, the lever arm is lengthened by
extending the elbow joint. The patient should be taught to
perform movements without elevating the shoulder girdle. If
both these movements are not possible, assisted abduction
should be initiated with the physiotherapist totally
supporting the weight of the arm. During this manoeuvre,
the elbow is held in flexion, and the shoulder girdle is
stabilized with the other arm (Fig. 33-15). Rotation should be
initiated in sitting and flexion in side-lying position. This
regime should be gradually progressed to abduction and
flexion against gravity.
3. Resisted exercises: Finally, manual resistance or resistance

with dumbbells starting with minimal weight could be
added. The shoulder needs to be compared with the normal
side to assess the progress. Properly controlled resisted
exercise programme for rotator cuff muscles and self-
generated tension are important because the scapular
muscles are the ‘power house’ of the shoulder movements,
whereas the muscles of the humerus are primarily oriented
to provide greater range of movement.
FIG. 33-15Active assisted shoulder abduction in

gravity-eliminated supine position.
Supraspinatus tendinitis/tear
A complete tear of the supraspinatus results in total loss of
active abduction at the glenohumeral joint. Many tears of the
supraspinatus may be asymptomatic; however, some
patients may have stiffness of the shoulder, in addition to the
loss of voluntary abduction.
The partial tear or tendinitis results in classical ‘painful arc
syndrome’. Pain is felt around 90 degrees of abduction.
Diagnostic test
1. Active test of the ROM of shoulder abduction with slight

over pressure at the terminal point of movement: The ROM
for all the movements will be near normal (except in chronic
lesions). Weakness and/or pain during the selected range of
the arc of abduction are a major finding, indicating a strain.
2. Active resisted test of the ROM of shoulder abduction: The

muscular resistance to the movement will be affected; it will
be weaker as compared to the contralateral shoulder and
may be painful.
3. Passive test of ROM of abduction: It will not reveal

marked limitation or pain, if done gradually with the patient
fully relaxed.
4. In moderate to complete tear of supraspinatus, the active

abduction will indicate total loss of true abduction. Patient’s
attempt to actively abduct the shoulder will result only in
elevation and retraction of the shoulder girdle. The passive
ROM test will not indicate the capsular pattern of the
restriction.
Treatment
Asymptomatic cases usually do not require any treatment.

Surgical treatment
Symptomatic cases with weakness and limitation of

abduction may require surgical treatment. The surgical
procedures may be repair of the torn tendon and/or
subacromial decompression.
Physiotherapy
Strain or partial rupture: In scarring or strain of the

supraspinatus, pain is present only on resisted abduction. In
partial rupture, the painful arc is present in the ROM of 60–
120 degrees of abduction.
In both the situations, a carefully guided exercise

programme (as described for the rotator cuff tear) is to be
planned following cryotherapy, wet heat or ultrasound as an
adjunct.
Relaxed full range passive movements in supine lying

position are done to avoid secondary adhesive capsulitis.
In a complete tear, there is disruption of abduction and

restoration of the function depends upon the method of
treatment. After surgical repair, the arm is immobilized for 3
weeks.
First 3 weeks: Only elbow, forearm, wrist and hand

movements are given. Static contractions for the abductors
can be initiated gradually by 8–10 days if they are not
painful.
After 3 weeks: Exercise measures could be made intensive to
strengthen and re-educate the abductor mechanism. Van
Linge and Mulder (1963) observed that full abduction was
possible without the supraspinatus but abduction against
resistance was diminished. Therefore, proper strengthening
methods using resistance by graduated dumbbells are
necessary till a fairly acceptable result is obtained. In case
surgery is not performed, compensatory mechanism to
abduct the shoulder by using the long head of the biceps or
by bringing the arm forward in flexion and to perform
abduction with flexion should be taught.
Infraspinatus tendinitis
A complete rupture, strain or tendinitis may occur in this
muscle, though it is rare. Painless weakness and painful arc
with loss of 30 degrees of lateral rotation at the shoulder are
the salient features of a complete rupture. In tendinitis and
strain, pain is elicited during resisted lateral rotation,
whereas other resisted movements at the shoulder are
painless. If neither of these movements produces pain, then
the lesions exist in the middle part of the tendon. A painful
arc denotes a superficial lesion of the tendon.
If the lesion is deep and distal, full passive elevation will be

painful because the tendon is caught between the tubercle of
the humerus and the acromion.
Diagnostic test
1. Active test of the ROM of the shoulder external rotation

with slight over pressure at the terminal point of range: Pain
appearing at the end of the range of external rotation is
indicative of tendinitis of infraspinatus.
2. Active resistive test of the external rotation of shoulder:

Degree of resistance will be good but considerable pain will
limit the force of muscular contractions.
3. Passive test of ROM of external rotation will not reveal

much limitation or pain.
In rupture of the infraspinatus, both active and active

resistive tests will indicate definite muscular weakness
without the capsular pattern of restriction of joint
movements.
Treatment
Treatment consists of (i) physical therapy and (ii) injection

therapy.
Physical therapy
Besides various modalities used as an adjunct, deep friction

massage over the area of tendon has a definite place.
The treatment of other symptoms directly depends upon the

site and type of the lesion.
The only affected movement is the loss or weakness of

external rotation at the glenohumeral joint. Pain on resistive
movement, without weakness, indicates that the lesion is
probably in the tendon or at its insertion.
Strengthening of external rotation without any resistance

should be the initial approach. Progressively as the pain
becomes less self-resistive, exercise is the best mode of
exercise (Fig. 33-16).
FIG. 33-16Self-resisted external rotation exercise for

infraspinatus tendinitis.
In deep lesion, full passive elevation is painful. Full passive

elevation could be effectively obtained with elbow relaxed in
90 degrees of flexion with the patient in supine position.
Superficial lesion gives rise to painful arc which should be

treated as described earlier. Complete rupture of the tendon
gives rise to painless weakness and eventually may result in
limitation of external rotation.
Full range relaxed passive arc of external rotation and

gravity-assisted external rotation should be instituted as
early as possible. It should be gradually progressed to
increase resistance till strong and painless maximum arc is
attained.
Injection therapy
Injection hydrocortisone may be given at the site of the

lesion.
Subscapularis tendinitis
Stress injury because of overstrain or continued overuse
could be responsible for damage to the subscapularis.
Passive range of shoulder internal rotation is usually full and
painless. Only the movement of resisted medial rotation is
painful. Adduction is usually pain-free unless there is an
associated involvement of the pectoralis major, latissimus
dorsi or teres major.
Diagnostic test
1. Active test of the ROM of shoulder internal rotation is

performed with slight overpressure at the end point of the
range. Pain will be present at the end of the range of
shoulder internal rotation indicating tendinitis of the
subscapularis.
2. Active resistive test of shoulder internal rotation: The

overall force of resistance will be good, but there will be
definite increase in the degree of pain with increase in the
force of resistance.
3. Passive test of the ROM of internal rotation will not reveal

marked limitation or pain.
In the event of rupture of subscapularis, both active and

active resistive tests will reveal definite weakness of the
muscular action, but without the capsular pattern of
restriction of movements.
Treatment
It consists of (i) physical therapy and (ii) injection therapy.
Physical therapy
The early stage of the syndrome is to be managed by

cryotherapy or ultrasound along with rest. Movements to
other joints are to be started immediately. The value of
friction massage is disputable. However, manipulations like
gentle circular kneading could be given for relaxation (Cash,
1984; Cyriax, 1978).
Strengthening of the movement of internal rotation: The

movement of internal rotation is painful when carried out
against resistance. Therefore, self-assisted movement or
movement against self-resistance, not strong enough to cause
pain, should be initiated (Fig. 33-17). It could be progressed
further as the pain reduces.
FIG. 33-17Self-resisted internal rotation exercise for

subscapularis tendinitis.
If the patient feels pain during the movement of resisted
adduction due to the involvement of the pectoralis,
latissimus dorsi and teres major, bilateral resisted adduction
as well as abduction could be useful. This, of course, should
be done with well-controlled resistance (may be negligible)
to the painful side. Relaxed pain-free full-range passive
movements, at least once a day, should not be overlooked to
avoid secondary stiff shoulder.
Injection therapy
Hydrocortisone may be injected at the site of the lesion.
Rupture of long head of the biceps brachii

(tendon)
A complete rupture of the long head of the biceps brachii is
rare and usually occurs in a degenerated tendon which is
subjected to repeated strains in the elderly male. The
presenting symptoms in the initial stage are pain with a
feeling of giving way while lifting or pulling. There is
localized tenderness in the intertubercular sulcus. Resisted
elbow flexion causes pain, while the strength of flexion as
well as supination is not significantly affected. At a later
stage, a bulge may be noticed in the arm (Fig. 33-18).
FIG. 33-18Rupture of the long head of the biceps

brachii muscle (arrow).
Tendinitis occurs due to overuse or severe strain. Resisted

supination and/or flexion of the elbow produces pain. The
other movements are pain free.
Diagnostic test
1. Active and active resistive movements to the shoulder

alone are not limited or painful.
2. Passive ROM to the shoulder will not indicate any

limitation of ROM.
3. Only the initiation of pain during the terminal range of

elbow flexion or forearm supination, especially against
resistance, confirms the diagnosis of tendinitis of the long
head of the biceps.
When the tendon of the long head of the biceps is ruptured,

there is a definite weakness of the movements of elbow
flexion or forearm supination.
Treatment
No treatment is necessary. The patient is given reassurance

and symptomatic treatment which may consist of the
following:
1. Analgesics: These are given at any stage if the pain is

severe.
2. Rest and sling: For the first 2–3 days. The sling may be
discarded after 3 days. However, if rest is still indicated, the
patient may be advised to put his hand in the pocket.
3. Physical therapy: Whether it is tendinitis or rupture of the

long head of the biceps brachii, the basic problem is not the
strength, but pain, tenderness and the feeling of insecurity
while lifting or pulling.
Pain and tenderness can be adequately controlled with

thermotherapy or cryotherapy along with analgesics and
rest.
Initially, wrist and finger movements should be encouraged
and isometrics to the triceps and pronators could be tried for
the reciprocal relaxation of the biceps brachii.
Cyriax (1978) advocated the use of transverse friction

massage.
Relaxed passive full range movements in supine position

with or without sling should be started to avoid a stiff
shoulder.
Graduated strengthening of elbow flexion and forearm supination
Begin with relaxed passive movements of elbow flexion and

forearm supination. When active painless range is achieved,
carefully graduated assistive and then resistive movements
can be given. By 3–4 weeks, functionally useful movements
should be attained.
Surgical treatment: End-to-end suture of the ruptured muscle

belly gives satisfactory results. Postoperatively, the arm is
immobilized with the elbow in acute flexion for a period of
3–4 weeks.
Postsurgical management by physiotherapy follows the

same routine as described for rotator cuff syndrome with
emphasis on graduated re-education of elbow flexion and
forearm supination.
Subacromial or subdeltoid bursitis

The subacromial bursa is situated under the upper part of
the deltoid muscle and the acromion process (see Fig. 33-19).
It reduces friction and thereby permits internal rotation of
the greater tuberosity of the humerus under the acromion in
movements of abduction and internal rotation of the
shoulder.
Subacromial bursitis always occurs following a lesion of the

neighbouring structures. The patient complains of pain in the
shoulder on abduction and internal rotation of the humerus.
The tenderness is over the greater tuberosity which
disappears on abduction.
Treatment
Most of the cases respond to conservative treatment.

Analgesics and rest may be sufficient to relieve pain.
Injection therapy may be undertaken in moderately severe
cases. Hydrocortisone is infiltrated into the area of the bursa.
In patients with intense pain, surgical excision of the

inflammed bursa may be done.
Physical therapy management
The acute stage is associated with severe disabling pain for

2–3 days. Measures like cryotherapy, TENS could be used
along with sling immobilization to combat pain.
Relaxed passive movements should be started at the earliest

after ensuring that they are painless.
Gentle mobility exercises carried out judiciously not only
induce relaxation but also bring about improvement in
muscle capillary filling.
Ultrasonography during the subacute phase of bursitis

induces hyperaemia and facilitates absorption of the calcium
deposits when present (Kessler & Hertling, 1983).
Re-education of abduction
When the pain subsides, careful re-education could be

started with the patient in supine lying position and
progressed gradually in phases as movements become
strong (as described for adhesive capsulitis).
Subdeltoid bursitis (fig. 33-19)

A bursa situated between the deltoid and the capsule of the
shoulder joint may get inflamed due to rheumatism,
infection, direct trauma or inflammatory changes secondary
to local deposition of calcium salts.
FIG. 33-19Subdeltoid (subacromial) bursitis.
In the acute stage, local inflammatory symptoms like

tenderness, severe pain on shoulder movements, especially
abduction, and warmth may be present. The onset may be
gradual or sudden.
Treatment
Initially, rest in a triangular sling. Appropriate pain relieving

heat modality should be applied.
When the pain subsides, gradual mobilization should be

begun with adequate support and stabilization. Relaxed
passive movements to the available pain-free range should
be encouraged to avoid a stiff shoulder.
Exercises should be progressed to active, resisted movements

gradually.
Local infiltration with hydrocortisone can be given to relieve

acute symptoms; deep friction massage following infiltration
is also effective. Complete relief may take 4–6 weeks.
Soft-tissue lesions at the elbow
Elbow
1. Tennis elbow
2. Golfer elbow
3. Olecranon bursitis
Wrist and hand
1. Carpal tunnel syndrome
2. Wrist sprain
3. Ganglion
4. De Quervain disease
5. Dupuytren contracture
6. Tenosynovitis
7. Tenovaginitis
8. Trigger finger
Functional anatomy of the elbow joint
The elbow joint is a complex hinge joint formed by the

articulations of the lower end of the humerus with the upper
end of the ulna and the head of the radius.
The strong movement of elbow flexion occurs as a result of

the action of the biceps brachii, brachialis, supinator and
brachioradialis. Extension is the result of the action of a
strong triceps muscle.
The three important peripheral nerves – median, radial and

ulnar lie in close relationship with the elbow joint.
The important bony landmarks are the medial epicondyle,

lateral epicondyle and the olecranon process. When these
lines are joined together by the arbitrary lines, they form the
following:
◼ An isosceles triangle when the elbow joint is flexed.
◼ A straight line when the elbow is fully extended; this

relationship gets disturbed in injuries to the elbow.
Tennis elbow (lateral epicondylitis)
Tennis elbow is a common entity characterized by pain and
tenderness at the common origin of the extensor group of
muscles of the forearm. It is an extra-articular condition
believed to be caused by strain or incomplete rupture of the
forearm extensor muscles or aponeurotic fibres at their
origin, respectively. It is called tennis elbow because it was
thought to be caused by an awkward stroke during the game
of tennis. However, it is usually an overuse injury in the day-
to-day activities of pulling, lifting, pushing, etc.
On examination, there is tenderness over the lateral

epicondyle of the humerus. Pain is aggravated by stretching
the extensor muscles, e.g., extension at the wrist against
resistance with the forearm pronated. Movements of the
elbow are full as it is unaffected.
Treatment
The treatment consists of rest and trying to avoid the

movements that cause pain.
NSAIDs and a tennis elbow splint are used for pain relief
(Fig. 33-20).
FIG. 33-20Tennis elbow splint.
Local injection of hydrocortisone with local anaesthetic

solution relieves pain in majority of cases.
1. Cryotherapy: Ice pack for 30 min or ice massage for 7 min

over the painful area of entire muscle belly.
2. Supportive measures: Initially, rest with a splint holding

wrist in mild degree of extension and sling with elbow in
flexion and forearm in supination. Posterior slab can also be
given for the first 2–3 weeks.
Unfortunately, this is usually not done and the arm is

allowed free movements which delay the recovery.
3. Electrical stimulation: Sinusoidal stimulation for 20 min

with arm in elevation relieves muscle spasm, prevents
formation of adhesions and reduces oedema.
4. Iontophoresis: It can help in reducing pain and

inflammation.
5. Diapulse, ultrasonics, TENS: These can be effective in

controlling pain and inflammation. Ultrasonography with
hydrocortisone cream of 0.05% concentration as a coupling
agent has been reported as a useful modality (Hayden, 1972).
Binder et al. (1985) suggested that ultrasound therapy
enhanced recovery in 63% cases. Review by Labelle (1992),
Wright and Vicenzeno (1997) however suggested that
ultrasound provides little benefit beyond that of a placebo.
6. Gentle effleurage and kneading during the first 2 weeks.
7. Gentle active movements of elbow, wrist and hand and

isometrics at the end of each range, if these are not painful,
should be carried out with emphasis on the wrist extensors.
8. Mild resistive exercises: Self-controlled resistive exercises by

using the good arm to resist the movements of wrist
extension, radial deviation, finger flexion and forearm
supination should be initiated.
9. Vicenzino and Wright (1995), Brien and Vicenzino (1998)

and Kavanagh (1999) demonstrated improvement in both
pain and function following treatment with Mulligan’s
lateral glide treatment.
Operative treatment
In rare instances, surgery is indicated in resistant cases not
responding to conservative treatment. The extensor muscles
are stripped from their origin, i.e., lateral epicondyle, and are
allowed to fall back. An above-elbow slab with elbow in 90
degrees flexion is given for a period of 10 days
postoperatively. The elbow is then mobilized.
Trial of resistive exercises could be given with 1 lb or 0.5 kg

dumbbell, and gradually progressed to 2 lbs, 3 lbs or 1.5–2 kg
dumbbells. The aim is to achieve 15 repetitions of each
movement without pain.
Patients with articular involvement respond with difficulty

and usually need prolonged rest. Active movement is begun
only after 3–4 weeks, if not painful.
Manipulation could be effective in cases where pain is

provoked with active use of extensor muscles by Mills
manoeuvre (1937). However, manipulation is
contraindicated in case of pain at rest, stiffness after rest and
fibrositis.
1. Measures to reduce pain and inflammation.
2. Limb elevation and speedy as well as sustained active

movements to the joints free of immobilization.
When mobilization is allowed (1 week)
3. Begin with slow relaxed full ROM passive movements to

the elbow, forearm and wrist.
4. Shoulder and shoulder girdle should be mobilized to full

ROM to avoid adhesive capsulitis.
5. Begin with gradual active-assisted exercises and progress

to self-resistive techniques. Ultrasonics, TENS, diapulse can
be used as adjuncts to reduce pain.
6. Functional movements, carefully avoiding repeated

supination, wrist extension and strong grip.
7. Progress gradually to PRE. By 5–6 weeks, functionally

painless elbow, forearm and wrist movements should be
regained.
Physiotherapy plays an important role in the management of

‘tennis elbow’.
Preventive management: Repeated forceful jerky

movements to the common origin of extensor group of
muscles are the main cause.
Activities like wringing washed clothes, using a wrench,

tightening a screw and even a vigorous hand-shake should
be avoided. Mechanical professions and sports involving
repetition of these movements are more prone to getting
tennis elbow. Similarly, repeated supination using heavy
rackets or weights should also be discouraged.
Proper conditioning and specific regime of strengthening
exercises to the extensor carpi radials longus and brevis as
well as supinator forms the basis of preventive programme.
Generalized strengthening of the common extensor group
and avoiding improper strain because of wrong attitudes in
the game, e.g., top spine back hand, or playing tennis with a
small handle racket.
Prevention of further damage: It is important to prevent

further damage and thereby develop a chronic tennis elbow.
1. Adequate care during the acute phase, resting the elbow

joint with proper support.
2. Instructing and guiding the patient against repetitive

stretching or trauma to the affected muscles by avoiding
movements of supination, wrist extension, radial deviation
and tight grips.
3. Avoiding hasty mobilization: Early active movement

causes repeated breakdown in the formation of scar tissue
which subsequently prolongs the inflammatory reaction and
leads to the formation of adhesions.
Restoration: For the restorative programme to be effective, it

is absolutely essential for the physiotherapist to carefully
evaluate the exact nature of involvement.
1. Strain and tear of muscle: Tenderness will be present at the

musculotendinous junction of the extensor carpi radialis
brevis.
2. Epicondylitis: Partial tear of the tendon at their origin,

with lesion in the subtendinous space. Tenderness is felt
exactly over the lateral epicondyle. Granulation tissue
formation as well as adhesions may be present.
3. Bursitis: Develops a bursa in the subtendinous space.
4. Articular involvement: Painful joint movement.
Golfer elbow or medial epicondylitis

This condition is not as common as the tennis elbow. The site
of tenderness being the medial epicondyle of the humerus
and the seat of inflammation is the common origin of the
flexor group of muscles. The muscles of the common flexor
group are strained or torn from the medial epicondyle of
humerus. Pain is produced by extension of the elbow,
supination and valgus strain. It is called Golfer elbow
because it is thought to be caused when a golfer hits the
ground instead of the ball, thus producing a valgus strain to
the elbow thereby straining the flexor group of muscles.
Treatment
A steroid injection is given locally into the muscle belly at its

origin. The physiotherapeutic management programme
proceeds on the same lines as for lateral epicondylitis.
Olecranon bursitis (minor elbow) (fig. 33-21)

Repeated trauma to the posterior aspect of the elbow joint is
the precipitating cause for olecranon bursitis, hence the name
‘minor’s elbow.’ It is occasionally found in patients with
rheumatoid arthritis.
FIG. 33-21Olecranon bursitis. (A) Note the
prominence/swelling at the point of elbow. (B) Normal
elbow for comparison.
It is most often pain free, and it does not need any treatment
except avoiding strain and friction.
It could become painful if there is associated bacterial

infection. An infected bursa is treated by antibiotics, and
drainage of the pus, if required.
Wrist sprain
Sudden thrust results in a sprained wrist. It is usually
strained in the acute position of flexion or extension, the
latter being more common. The degree of damage to the soft
tissues, the muscles and the ligaments depends upon the
extent of violence.
Violent force in the direction of extension often inflicts injury

to the flexor group of muscles passing over the wrist joint
and the anterior radiocarpal ligament. Injury with the wrist
in flexion results in damage to the soft-tissue structures on
the dorsal aspect. Many a times the medial or lateral
radiocarpal ligaments are also injured.
The involvement of a particular ligament can be detected by

the presence of localized tenderness. Local pain and swelling
may extend to the forearm.
Treatment
Once a bone injury is ruled out, the treatment is usually
conservative.
1. A firm pressure bandage or strapping is given. If the injury

is extensive, posterior slab, which provides better
immobilization, may be applied. Cuff and collar sling is also
advisable in major sprains. It helps in reducing the swelling
by keeping the wrist in elevation.
2. Adequate umbrella of analgesic and anti-inflammatory

drugs is also advised.
3. Cold compress or ice massage followed by prolonged

anodal galvanism reduces swelling by iontophoretic effect.
4. Relaxed passive movements should be carried up to the

limit of pain to prevent stiffness.
5. Active movements to the fingers reduce swelling and

improve circulation. Full range movements to the shoulder
and elbow should be advised at hourly intervals by
removing the sling.
6. The plaster slab may be discontinued as soon as the pain

and swelling permit, but crepe bandage may be used. Active
movements with crepe bandage are encouraged as it
provides active resistance to movements. Full range of
movement and adequate strength should be regained by 2
weeks after mobilization.
7. Passive stretching, deep transverse friction massage and

ultrasonography may be necessary if some limitation of
movements or pain persists.
Caution
Regular watch should be kept to detect the development of

tenosynovitis of the flexor tendons early.
Ganglion (fig. 33-22)

Ganglion, a round subcutaneous swelling which initially
appears as a very small pouch, is a cyst of the synovial
membrane. It is a fibrous sac containing viscid material. The
small cyst may either disappear spontaneously or may
increase in size when the site of ganglion is exposed to
repeated friction or pressure. Such a ganglion may occur
over the palm of the hand, on the outer side of the knee, the
dorsum of the foot or over the dorsal surface of the wrist.
The commonest site is dorsum of the wrist. It may be painful
and increase in size as the wrist is frequently subjected to
friction and pressures of daily activities.
FIG. 33-22Ganglion.
Treatment
Avoid friction or massage over the ganglion. Local

infiltration with hyalase is also one of the methods of
treatment.
When recurrence occurs or there is unremitting pain, it may

be necessary to excise the ganglion.
Simple active movements following excision are good

enough to recover full function.
De quervain disease
This is an inflammation (tenosynovitis) of the tendon sheaths
of the abductor pollicis longus and extensor pollicis brevis at
the point where they cross the styloid process of the radius
(Fig. 33-23). The tendon sheaths get thickened and
sometimes crepitus may be present on palpation. Summation
of microtrauma due to repeated friction is the common
precipitating factor.
FIG. 33-23De Quervain disease: Inflamed sheaths of the

tendons of the abductor pollicis longus and extensor
pollicis brevis.
Movements of the thumb are very painful. It may be

associated with pain in the wrist with weakness of grip.
Treatment
◼ Drug therapy to combat inflammation.
◼ Restriction of movements by applying a small hand splint

in functional position with immobilization of the thumb.
◼ During early stage, ice massage, and at the later stage,

ultrasound or any deep heating modality helps in reducing
Cyriax (1978) advocated transverse friction massage, as the

precipitating factor is repeated exposure to longitudinal
friction.
Local corticosteroid infiltration may be effective in some

cases.
Surgical intervention in the form of splitting the lateral wall

of the tendon sheath may be necessary in nonresponding
cases. Carefully controlled early initiation of tendon
movement in the form of relaxed passive movements is of
primary importance. Rapid progression to assisted active
then to active and finally to resisted movements is important
to restore pain-free hand function.
Tenosynovitis
Following an infection or an injury, the synovial lining of the
tendon sheath responds by secreting excessive synovial
fluid. This condition is called tenosynovitis.
When it is traumatic, it affects the tendons of the abductor

pollicis longus and extensor pollicis brevis, which form the
radial boundary of the anatomical snuff box.
Suppurative tenosynovitis
It is a serious form of tenosynovitis where pus formation
occurs in the sheaths of the flexor tendons of the thumb and
fingers. It is extremely painful and needs early attention. The
hydrostatic pressure of the pus may build up to such an
extent that it may block the blood supply to the tendons,
resulting in stiff and functionally useless fingers.
Intramuscular injection of an antibiotic in time can save the
hand.
Tenovaginitis
In tenovaginitis, the difference in the pathology is that
instead of secreting abnormal amount of synovial fluid, the
tendon gets thickened and fibrosed. This limits the
movement of the tendon within its sheath.
Hard tender swelling with pain during the movements of

thumb or wrist is the common symptoms. In suppurative
tenosynovitis, pain is present even during rest. Excessive use
of hand for hard work is a common cause and is one of the
most common industrial diseases.
Treatment
1. During the early stage with acute inflammatory

symptoms, rest is needed. It may be done by application of a
crepe bandage.
2. A rigid thermoplastic splint is ideal to provide rest and

avoid overstretching at work.
3. A modality like diapulse, ultrasound, TENS, cryotherapy

or iontophoresis is useful in controlling pain and
inflammation.
4. Gentle relaxed finger movements with hand in elevation

are useful.
5. Isometrics within the limits of the pain should be

encouraged.
6. Relaxed full range passive movements are important to
avoid contractures.
7. Cyriax (1978) and Tidy (1968) found deep friction massage

across the affected tendon very effective.
By 10 days to 2 weeks, considerable relief should be

obtained.
In resistant cases, surgery may be needed. The stenosed or

thickened sheath may be incised and decompressed.
Initially, limb elevation, finger movements and diapulse can

be given with rest in a splint. After removal of stitches, active
mobilization of the wrist, thumb and finger could be
progressed till full function without pain is obtained.
Programmes to strengthen the muscles passing over the

wrist, thumb and fingers are concentrated on. Splint is
continued for some time while using the hand.
Trigger finger
There is a momentary locking of the flexor tendon on
attempting to extend it, following flexion, due to the
formation of a nodule in the tendon distal to a constriction in
the tendon sheath (Fig. 33-24). It gets released with a sudden
snap by passively moving the finger in the extension (Fig. 33-
24).
FIG. 33-24Trigger index finger. (A) Formation of

nodule (N) in the flexor tendon. (B) Entrapped nodule
(N) in the fibrotic zone at the base of the
metacarpophalangeal joint on flexing the index finger.
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CHAPTER
34
Hand
OUTLINE
◼ Anatomy of the hand
◼ Functional requirements of the hand
◼ Methods of evaluation of the hand
◼ Injuries of the hand
◼ Splints
◼ Tendon injuries
◼ Burns of the hand
◼ Infections of the hand
◼ Vasospastic diseases of the hand
◼ Jersey finger
◼ Crush injuries and finger amputations
Hand is a major functional component of our body with important

functions. It is therefore important that the hand therapist keeps pace
with the newer developments which happen every now and then. The
advent of microsurgery, replantation and small joint replacements has
revolutionized the whole concept of hand management.
However, before proceeding to the techniques of treatment of hand
injury, it is necessary to understand the applied anatomy of the hand
and the factors which contribute towards the optimal functioning of
the hand (Backhouse, 1968).
Anatomy of the hand

The hand is an end organ which is designed to obtain information and
an organ of execution too. The architecture of the hand is briefly
discussed as follows.
Carpometacarpal joints
The carpometacarpal (CMC) joints of the index, middle and ring
fingers are plane joints that allow flexion and extension only, for firm
gripping. The CMC joint of the little finger, however, is a semisaddle
joint capable of rotational movement needed for opposition. The CMC
joint of the thumb is a seller joint which allows movements in two
planes. The reciprocal concave–convex surfaces allow flexion–
extension, whereas the convex–concave surfaces allow abduction and
adduction and rotation.
Metacarpophalangeal joints
The metacarpophalangeal (MP) joints of the fingers and the thumb are
condylar joints, allowing radial and ulnar deviation, and flexion–
extension. The greater slope of the radial shoulder produces ulnar
drift or deviation at these joints.
Proximal interphalangeal joints and distal

interphalangeal joints
The proximal interphalangeal (PIP) and distal interphalangeal (DIP)
joints are bicondylar joints allowing opposition with the thumb, and
assist in joint mobilization techniques, without exerting stress on the
capsular tissues.
Joint capsule: The capsule is made up of dense and fibrous tissue
which can sustain stress and at the same time permit stretch. The joint
capsule develops adaptive shortening and stiffness when
immobilized.
Ligaments
The ligaments of the radiocarpal, intercarpal, carpometacarpal and
metacarpophalangeal joints provide stability to the hand. The
transverse intermetacarpal ligament is the most important
extracapsular ligament of the hand. The full extensibility of this
ligament is necessary for grasping and prehensile activities. The
capsular and extracapsular ligaments are instrumental in providing
support and stability to the hand.
Muscle and nerves

The hand activities are brought about by two muscle groups: (i)
intrinsic and (ii) extrinsic.
1. Intrinsic muscle groups are the muscles which originate within the
hand and act upon the digits. These include the thenar, hypothenar,
lumbricals and interossei muscle groups.
2. Extrinsic muscle groups originate in the forearm, proximal to the

wrist and act on the hand. The integrated functioning of both these
groups is the prerequisite for a variety of hand activities.
The thenar muscle group includes the abductor pollicis brevis,

flexor pollicis brevis, opponens pollicis and adductor pollicis. Only
adductor pollicis receives innervation from the deep branch of the
ulnar nerve; the rest are supplied by the motor branch of the median
nerve.
The hypothenar muscle group includes the abductor digiti minimi,
flexor and the opponens digiti minimi. Three volar interossei and four
dorsal interossei are supplied by the ulnar nerve. The two lateral
lumbricals are innervated by the median nerve while the two medial
lumbricals are innervated by the ulnar nerve.
Skin
Extensibility as well as sensory perception plays a significant role in
the ultimate function of the hand. Efficient tactile gnosis needed on
the volar aspect of the hand is met with by extensive innervation. The
fat pads, eccrine glands and creases on the volar aspect absorb shock
and stresses, and allow nonslippery grasps.
Functional requirements of the hand

The hand function is based on the variation of two basic grips: (i)
power grip and (ii) precision grip.
Power grip
It is a grip which requires firm control of holding an object during
activity (e.g., handling a hammer). This is achieved not only by true
anatomical flexion of the fingers but also by the components of
rotation and ulnar deviation towards the thenar eminence. The thumb
assumes side position and controls the leverage. This is further
enhanced by the wrist occupying the position of extension with ulnar
deviation (Fig. 34-1A).
FIG. 34-1 The types of hand grips. (A) Power grip. (B) Opposition or
palmar prehension grip. (C) Pinch grip. (D) Lateral prehension grip.
However, an activity like carrying a bag requires only true digital

flexion, as seen in mass grasp (Fig. 34-2).
FIG. 34-2 Flexion of fingers in carrying a briefcase.
Precision grip
Precision grip basically needs perfectly coordinated interplay of the
small muscles of the hand. They are of four types:
1. Flexion–extension at the fingers: The main precisive activity of

flexion–extension occurs at the MP joints. Interphalangeal joints are
held practically immobile in slight flexion (e.g., typing).
2. Opposition or palmar prehension: It needs an accurate pad-to-pad

contact of the thumb with an individual finger. The components are as
follows: abduction–rotation at the thumb, slight inward rotation and
ulnar deviation at the index and middle fingers, and inward rotation
and radial deviation at the ring and little fingers (Fig. 34-1B).
3. Pinch: This is same as opposition, the only difference being that it is

associated with strong flexion at the IP joints of the thumb with the
concerned finger (Fig. 34-1C).
4. Lateral prehension: Commonly known as key grip, it constitutes

strong adduction, flexion and opposition of the thumb to the radial
side of the index finger. This provides useful grip in the absence of
true opposition. (Fig. 34-1D).
Muscular activity
Electromyographic (EMG) studies conducted by Long and Brown
(1964) and Landmaster and Long (1965) have greatly contributed to
the understanding of the muscle function of the hand.
Flexor digitorum profundus (FDP) has been found to be most active
in flexion, whereas flexor digitorum sublimis (superficialis) is active
only when true power movements and grip are needed in sustained
efforts (e.g., holding and carrying baggage).
The two interossei to each finger together produce MP joint flexion
along with the necessary rotation and deviation to the side of its
insertion. Therefore, they are crucial both in power grip and in
precision grip. At the same time, they act as strong extensors at the IP
joints acting through the extensor aponeurosis.
Extensor digitorum longus primarily acts during extension at the
MP joints. Though lumbricals primarily are flexors at the MP joints,
they act mainly in extension of the IP joints. Lumbricals act as flexors
only when the interphalangeal joints are held in extension (e.g.,
holding a newspaper). Lumbricals with their richly innervated
sensory end organs appear to be instrumental in the proprioceptive
balancing mechanism. Their action controls the coordination between
flexion and extension mechanisms. Their function is more precisive
rather than acting as muscles of strength or power.
Opposition of the thumb needs strong activity not only in the
opponens pollicis but also in abductor and flexor pollicis. They
combine to give true and strong opposition.
A lesion of the ulnar nerve greatly handicaps the power grip as
there is loss of ulnar deviation of fingers with loss of FDP and
lumbricals to the ring and little fingers, and flexor carpi ulnaris.
A lesion of the median nerve produces loss of opposition of the
thumb towards the index and middle fingers along with flexion of the
index and middle fingers, thus hampering the precision activity of the
hand. The wrist extensors offer significant stability to the grasps and
should not be overlooked while assessing the hand.
Sensory control
The precision movements of the hand are greatly dependent on the
degree of sensory reception from the skin as well as deeper tissues.
The presence of enormous number of Meissner’s tactile receptive
corpuscles and epicritic sensibility give the hand a status of a
specialized organ of touch. In the event of a nerve damage and
reduced epicritic sensibility, the efficiency of hand function is greatly
diminished. The physiotherapist, under such situations, should
concentrate on the techniques of sensory re-education, by several
repetitions of accurate movements and the use of audiovisual
feedback.
Methods of evaluation of the hand

A careful evaluation of the hand function is done by assessing the
following:
Range of motion
Goniometric measurement of both active and passive range

of motion (ROM) at each joint should be recorded by using
a finger goniometer. This will provide quantitative data on
ROM and strength at an individual joint. The total motion
at each digit is the sum of the flexion measurements of MP,
PIP and DIP joint minus the extension deficit (if present) of
the same three joints.
Oedema
Volumetric measurement of water displacement or tape
measure can be used. Change in hand size due to oedema
or muscle atrophy can be quantified.
Muscle performance
The technique of manual muscle testing (MMT) as designed

by Lovett and Martin (1916) can be used to assess muscle
strength, and the subsequent changes in the muscle power.
Muscle–tendon continuity, gliding capacity of the tendon,
neuromuscular communication and volitional control also
need to be assessed.
Sensation
Sensory status has to be evaluated carefully as the hand

function depends largely on the sensory integration. Finer
sensory evaluation has become important after the advent
of microsurgery which has improved the return of sensory
status. The skin and nails should be examined for
temperature, dryness and denervation, and recorded on a
body chart.
Tactile cutaneous sensation can be assessed by using horse

hair of various thicknesses or nylon filament of 20 different
thicknesses (Werner & Omer, 1970).
Static and moving two-point discrimination (2PD) tests are

used to evaluate the functional sensibility (Fig. 34-3).
Moving 2PD test is reported to be abnormal in patients
with peripheral nerve lesion (Dellon et al., 1987). Blunt tip
calibrated calliper can be used to discriminate between
smoothness and toughness.
Perception of vibratory stimuli should be done by using a

tuning fork of 256 Hz which is more sensitive. However,
these results are useful but not quantifiable.
Dexterity
Dexterity denotes the skill of using a hand. As the test-tools

cannot be generalized, they are selected as per the abilities
and daily activity needs of a patient. The time taken to
complete the broad range of hand functions of vocational
or daily activities (Jebsen et al., 1969), functional efficiency
and hand coordination can be objectively recorded. The
performance of the following tasks helps in the evaluation:
1. Writing
2. Picking up small and large objects
3. Cord turning
4. Eating
5. Dressing
6. Other ADLs
7. Five speedy coordination
Functional sensibility
Identification and differentiation of the shapes of various

objects by grasping are also important. Seddon’s coin test is
a useful measure to assess functional sensibility (Seddon,
1975).
Function and physical capacity
Physical capacity of the patient to perform functional

activities like various grips, prehensile movements and
their strength can be objectively evaluated by hand
dynamometer. This will greatly facilitate the specific areas
to be emphasized during treatment.
FIG. 34-3 Two-point discrimination test.
Injuries of the hand

Injuries of the hand are broadly classified into the following two
categories (Table 34-1):
1. Closed injuries
2. Open injuries
Table 34-1
Classification of Hand Injuries
Closed Injuries Open Injuries

• Fractures, dislocations • Fractures of
• Dislocations commonly of the MP joint of index finger or thumb metacarpals and the
(Bennett fracture dislocation) phalanges
• Fractures of the metacarpals and phalanges by a direct trauma or • Cuts by sharp
twisting, may be displaced or undisplaced instruments
• Injury to the collateral ligament of the thumb is common • Lacerations
• Crush injuries
• Amputations
• Tendon injuries
Closed injuries
These are usually fractures, dislocations or ligament injuries.
◼ Dislocations of the MP joints: Dislocation of the MP joint of the

index finger is the commonest injury seen while that of the thumb is
the second commonest. On clinical examination, the dislocated head
of the metacarpal can be palpated on the volar aspect of the palm.
◼ Bennett fracture dislocation: It is an intra-articular fracture of the

base of the first (thumb) metacarpal, with subluxation or dislocation
of the carpometacarpal joint (Fig. 34-4) caused by a direct blow to
the thumb.
◼ Fractures of the metacarpals: A fracture of the metacarpal can occur

through its neck, shaft or base. Fracture of the neck of the
metacarpal is commonly seen in the little finger.
◼ Fractures of the phalanges: Fractures of the phalanges are caused by

direct trauma or twisting injury and can be displaced or
undisplaced.
◼ Ligament injuries: Injuries of the collateral ligament of the MP joint
are usually seen. The most commonly seen injury is that of the ulnar
collateral ligament of the thumb, called gamekeeper’s thumb.
FIG. 34-4 Bennett fracture dislocation. (A) Line diagram showing the
fracture and the displacement and (B) as seen on a radiograph.
Open injuries
◼ Fractures of metacarpals and phalanges may be associated with
open injuries.
◼ Cuts and lacerations: Cut wounds are caused by sharp

objects/weapons, whereas lacerations are caused by blunt objects.
◼ Crush injuries are quite common and often serious injuries.
◼ Amputations of thumb/fingers may also be seen.
◼ Tendon injuries are common injuries and often missed in the initial
examination leading to marked disability.
These injuries are important and are therefore discussed in some

detail in the following pages.
During the secondary assessment, a definitive treatment is planned.
Management
Closed injuries management
◼ Undisplaced fractures are treated conservatively by closed

reduction, and immobilization.
◼ Displaced fractures are treated by manipulation and cast

immobilization.
◼ Displaced fracture is prone to redisplacement (e.g., Bennett fracture

dislocation) or grossly displaced fractures are treated by internal
fixation by Kirschner wire or mini-screws after open reduction.
◼ Fractures of the distal phalanx do not require immobilization.
Open injuries management

Open injuries require special aseptic measures to prevent infection –
the most common complication of injury to the hand.
Assessment: A thorough assessment of the injury is done in two
stages:
◼ Preliminary assessment of the extent of injury is done in the

emergency room to plan the tentative line of treatment.
◼ Secondary assessment is carried out in the OT under anaesthesia

when the injury is deep and complicated.
Debridement
Thorough cleaning of the wound is done under GA with irrigation by
saline water or sterile water to get rid of foreign bodies, dirt, necrotic
tissue, etc. or ligament injuries.
Reduction
In fractures or dislocations, bony stabilization by reduction may be
required, preferably done with internal fixation devices.
Nerve repair
It is undertaken earliest in healthy and clean wounds.
Cut tendons: These are already discussed in detail, earlier in this
chapter.
Wound closure
Clean wound is closed by primary sutures or else covered by a flap or
a skin graft.
Dressing and splinting: A fluffy compressive dressing is applied with
cotton wool and gauze pieces. The hand is then immobilized in a POP
with MP joints at 90 degrees (James position), PIP and IP joints in
extension and thumb in abduction and opposition (Fig. 34-5) to reduce
the chances of contractures of the ligaments leading to contracture.
FIG. 34-5 James position of immobilization of the hand.
Treatment of open injuries

The fractures of metacarpals and phalanges are treated by internal
fixation and wound repair.
Cuts and lacerations
◼ Clean wounds: wound suturing is required.
◼ Contaminated wounds: debridement wound care is required and

later on sutures of skin graft if needed.
◼ Crush injuries: It may be with skin loss – needing wound care or

skin grafting.
◼ Amputations – Amputation of digits is common.
◼ Fingertip amputation requires full-thickness flap.

◼ When good length of stump is available, closure of the stump is
done after trimming of the bone ends.
◼ In the amputation of the thumb, the length of the remaining stump

is maximally saved.
◼ Replantation: It is done only in clean-cut, fresh amputations of less

than 6 h duration.
Complications
◼ Malalignment: Phalangeal fractures may unite with angulation or

rotational malalignment.
◼ Stiffness: It is common at the adjacent interphalangeal joint.
Both complications result in impaired hand function.

Treatment procedures are detailed in Chapter 4.
Basis of physiotherapeutic management

The objective of physiotherapy is to restore both the static and
dynamic hand functions to the fullest possible extent with least
discomfort.
The anatomical and kinesiological complexities of the hand as well
as the pathophysiology and biomechanics of wound healing pose a
great challenge in its management. The treatment of hand injuries is
based on (i) biology of scar and (ii) anatomical configuration.
Biology of scar: The granulation scar tissue (the body glue) has the
ability to imitate and reproduce to the maximum possible extent the
characteristics of the damaged tissue. Therefore, the basis of the
surgical, pharmacological and therapeutic management depends
upon skilful organization of enhancing the potentials of the scar to
duplicate the desired outcome (Hardy, 1989).
Anatomical configuration: While treating hand injuries, it must be
remembered that even the minimal anatomical changes in the
arrangement of bones and soft tissues may have profound effect on
the function.
Wound healing: The process of wound healing following injury or
surgery must be understood clearly to adopt precisive therapy. The
wound healing has three phases (Table 34-2):
1. Inflammatory phase (up to 4 days)
2. Fibroplasia phase (5 days to 3 weeks)
3. Remodelling phase (3 weeks to 6 months)
Table 34-2
Wound Healing Stages and Techniques of Management
Healing Phase Techniques of Management

Phase I: Inflammatory phase (0 to 3– • Wound cleaning
4 days) • Debridement of necrotic tissue
• Antibiotics
• Good nutrition
Phase II: Fibroplasia phase (day 5 to • Elevation
3 weeks) • Reduction of inflammation
• Slow relaxed passive ROM exercise
• Controlled contractions
• Gentle active movements for the acceleration of tensile
strength
Phase III: Remodelling phase (3–6 • Passive mobilization
weeks) • Dynamic serial splint or casts
• Maximum range of active movement (in months or 1 year)
with the proper groove
• Electrical stimulation to re-educate muscular action, tone and
endurance
• Controlled functional activities, ROM and (PRE) to regain
preinjury status
The techniques of management at each stage of healing are

elaborated in Table 34-2.
1. Inflammatory phase: The phase of initial inflammation is within the

first 4 days after injury. All the injured tissues react with inflammation
and cellular proliferation. This results in a single scar, binding all the
tissues together. This is known as one wound one scar concept. If it is in
excess, it leads to excessive joint distension and oedema which results
in pain and stiffness. A process of phagocytosis and
neovascularization occurs during this stage.
Prevention of infection: The basic need of treatment at this

stage is prevention of infection. A careful watch has to be
kept to detect the signs and symptoms of infection like:
(a) Prolonged swelling
(b) Excessive skin sloughing
(c) Temperature changes
(d) Progressive pain and paraesthesia
The following measures should be taken:
(a) Restrict oedema at the earliest
(b) Reduce pain – TNS, VS
(c) Improve circulation by active movements of the related

free joints adjacent to the affected joint
(d) Wound debridement if necessary without delay
(e) Absolute rest and good nutrition
(f) Ensure proper positioning of the affected area to avoid

any stress, and to assist circulation
2. Fibroplasia phase (5 day to 3 weeks): It begins with the production of

primary cells of scar tissue – the fibroblasts. While the wound
contraction is progressing, the tropocollagen molecules are
synthesized by the excretion of fibroblasts and balanced supplies of
oxygen, ascorbic acid, zinc, iron and copper (fibroblasts).
These tropocollagen molecules have three helical chains.

They form collagen fibril with microscopic cross-links
which imparts tensile strength to the wound. The collagen
mass becomes strong enough to withstand controlled
motion by 3 weeks (Fig. 34-6).
Steps followed during this phase:
(a) Graduated progressive steps are initiated in a

graduated manner.
(b) Controlled passive movements should be started early

as they are important to maintain mobility of the
repaired tendon (Merritt, 1984).
(c) Active assisted movements should be encouraged to

enhance functional control of the repaired tendon. It
stimulates further repair and improves strength (Mason
& Allen, 1941).
(d) Gentle assistive active movements with controlled

contractions are necessary for acceleration of the tensile
strength.
(e) Splint: Depending upon the nature of injury and the

surgery, a proper splint is applied. The splint should
decrease undue tension on the repaired tendon, allowing
free movements of the remaining joints. Some commonly
used splints are described in the following pages.
3. Remodelling phase (3 weeks to 6 months): This is the most important

phase of management. Collagen realignment has to be organized to
prevent cross-linking of collagen. The collagen fibres between the
coapted tendon ends must organize in parallel alignment to provide
tensile strength. The fibres along the longitudinal surface of the
tendon must disorganize in a random orientation to facilitate tendon
gliding, thereby preventing adhesions.
Realignment of collagen: As the collagen fibril matures, it

forms cross-linking between its own chains
(intramolecular) and with other collagen fibrils
(intermolecular) (Fig. 34-7). A favourable cross-linking is
done by the following theories.
(a) Induction theory: It is based on the fact that the scar

tissue attempts to develop the characteristics of the tissue
it is healing, e.g., a tissue which is dense will induce
dense and highly cross-linked scar tissue. Therefore, if a
tendon repair is postponed and immobilization is done
following a fracture, bony adhesion and nongliding
tendon will result. This occurs due to wrong modelling
of the scar into a dense tissue with higher degree of
cross-linking. The scar will attempt to imbibe the
characteristics of the bone. This highlights the
importance of early tendon repair to reduce the incidence
of stiff joints following immobilization.
(b) Tension theory: During this phase, application of stress

or tension is successful in achieving lengthening of a
scar.
This has revolutionized the whole concept of management.

Long-duration stress or tension can be applied by
i. Dynamic serial splinting
ii. Casting
iii. Application of heat with stretch
iv. Relaxed gradual passive mobilization
v. Active mobilization to the maximum range in the correct

groove of movement
vi. Electrical stimulation to be used to re-educate muscle

actions, and to improve their strength, endurance and
tone
vii. Selective hand activities with proper guidance: Besides

remodelling, tension has been found useful in the
regeneration of nerves (Bora, Richardson, & Black, 1980)
The low-load tension, to be effective, has to be controlled and

retained. The beneficial effects of controlled tension and
mobilization are as follows:
i. Hastens intrinsic healing
ii. Promotes synovial diffusion

iii. Augments repair site cellularity
iv. Improves tensile strength
v. Increases peritendinous vessel density and configuration
vi. Improves tendon excursion
vii. Facilitates nerve regeneration
viii. Prevents shortening, obstructions and developing

contractures
FIG. 34-6 Fibroplasia phase (day 5–3 weeks) synthesis of tropocollagen

molecule. CF, collagen fibres; CFB, collagen fibril; CFI, collagen filament;
TU, tropocollagen unit.
FIG. 34-7 (A) Intramolecular cross-linking amino acid chain (AAC) from
weak cross-linking (CL) in a single collagen filament (CF). (B)
Intermolecular strong cross-linking (CL) between one collagen filament
(CFI) with an other collagen filament (CFI).
If proper measures are taken to control this stage, optimal

restoration of the hand is possible. Methodology varies with the seat
of tendon repair and is elaborated under each heading.
Caution
The tension to be applied to the repaired tendon as well as to other
scar tissues has to be precise in direction and magnitude. A stronger
stress leads to disruption of the tissue repair.
Hand splints
Splints are basically of two types:
1. Static splints
2. Dynamic splints
Static splints provide rest and stability (e.g., following fracture or

acute inflammation).
Dynamic splints assist and guide movement in its proper groove
(movement re-education) and even resist and strengthen weak
movement.
Splinting materials
1. High-temperature plastics: These require mould for fabrication.
2. Low-temperature plastics: These are very common, cosmetically

acceptable, light material and easy to fabricate; orthoplast, aquaplast
and polyform are some of the commonly used materials.
3. Materials which do not need any heating, e.g., a material like plaster of
Paris: It can be used alone as a static splint or in combination with an
outrigger as dynamic digital splint providing traction.
The splint strapping material should be firm, comfortable, pressure

controlled and with well-secured strapping. Velcro straps are ideal.
Functions of a static splint

1. It provides protective immobilization to the joint. It is instrumental
in supporting and providing rest to the acutely inflamed joints
following injury or disease (e.g., soft tissue injury, fracture,
rheumatoid arthritis, burns).
2. It aids in the resolution of inflammation, thereby hastening the

process of repair.
3. It maintains joints in correct alignment preventing tightness,

contractures and deformity.
4. It provides stability and support to lax joints.

5. It maintains the corrected or improved ROM gained by therapeutic
measures.
6. It can provide stability to a proximal joint (when it is unstable) to

facilitate the action of the distal joint, e.g., cock-up splint to stabilize
the weak wrist extension and to facilitate finger flexion.
7. It corrects the deformity by graduated progressive stretching (e.g.,

serial splinting).
Functions of a dynamic splint

1. The most important function of a dynamic hand splint is to provide
the necessary constant low stretch to facilitate correct remodelling of
the scar tissue. The calculated stretch is applied by sling and rubber
band. Therefore, it acts as a valuable therapeutic adjunct.
2. It can provide controlled resistance to the tendons for easy gliding,

preventing adhesions and stimulating circulation thereby assisting in
reducing oedema.
3. It provides mobility to the stiff joints by controlled sustained low

load stretching. Constant stretch lengthens the shortened
musculotendinous units and the tight articular structures as well.
4. It provides re-education to the weak or paralysed muscles with

synchronization of active efforts, e.g., extension deficiency following
radial nerve lesion or in silastic implants following MCP joint
reconstruction (Fig. 34-8).
5. It protects overstretching of the weak muscles by the strong pull of

normal opposing muscle groups.
FIG. 34-8 Dorsal dynamic extension assist splint following radial nerve
palsy or following MCP silastic implant arthroplasty.
Biomechanical principles (duncan, 1989)

A majority of hand splints work on the principle of three-point
pressure and belong to the class I of the lever system. The mechanical
advantage (MA) is equal to the ratio of the length of the forearm (FA)
and that of the resistance arm (RA), i.e.,
Therefore, an increase in the length of the forearm or a decrease in

the length of the resistance arm will provide maximum mechanical
advantage of the lever. The proximal and distal ends of the splint
serve as counter forces to the opposing central force. Correct balance
of the forces is necessary for any splint.
To decrease the compression and distraction of a joint, the rotational
force has to be maximum. This is achieved at the position of 90
degrees.
While applying sustained pressure in the dynamic splint, the
principle of F = F/A has to be remembered. Thus, the greater the width
of the finger sling, the lower will be the pressure at the point of its
application.
The dynamic splint can be low profile or high profile. The basic
difference between the low-profile splint and the high-profile
dynamic splint is the role of the outrigger. In a low-profile splint, the
outrigger is not attached to the rubber band. It exerts a steady low
load stretching effect, e.g., stiff joint. In a high-profile dynamic splint,
the outrigger is attached to a rubber band facilitating weak movement
and resisting the strong one. Besides these major hand splints, the
upper extremity may need the following splints.
Static splints
1. Anti–swan neck splint: It is a simple splint that may be fabricated by
using plastic material. It prevents hyperextension at the PIP joint (Fig.
34-9).
2. Antiboutonniere splint: It is reverse of the anti–swan neck splint (Fig.

34-10).
3. Opponens splint: This splint maintains the web space of the thumb,
thus holding the thumb in maximum opposition (Fig. 34-11).
4. Safe position splint: It is mainly a resting or positioning splint. The

wrist is fixed in slight dorsiflexion (30 degrees), MP joints in 90
degrees of flexion, PIP and DIP joints in neutral extension and thumb
is placed in abduction and opposition to allow ROM at the CMC joint
(Fig. 34-12). The hand is safe from developing flexion contractures and
it promotes functional use at a later stage. This is useful to prevent
contractures following burns.
5. Factional position splint: It is very similar to the safe position splint,
the only difference being that the flexion at the MP and PIP joints is
fixed at 40–50 degrees and the thumb in abduction and opposition to
facilitate the functional activity.
6. Wrist cock-up splint: A common splint which maintains the wrist in a

functional position of 25–30 degrees of extension (Fig. 34-13). In cases
of lack of extension control at the MP joints, outriggers may be
applied to make it dynamic, e.g., radial nerve palsy.
FIG. 34-9 Anti–swan neck splint: to prevent hyperextension at the PIP

joint.
FIG. 34-10 Antiboutonniere splint: to prevent flexion at the PIP joint.
FIG. 34-11 Opponens splint.

FIG. 34-12 Safe position splint: wrist is fixed in slight extension, MP joints
in 90 degrees of flexion, PIP and DIP joints in neutral and thumb in
abduction and opposition.
FIG. 34-13 Wrist cock-up splint: with wrist joint in functional position of 25–
30 degrees of extension.
Dynamic splints
1. Dynamic wrist flexion–extension splint: It allows both the movements
of flexion and extension at the wrist with a provision to maintain any
of these movements fixed at a desired range. It can be made either low
profile or high profile as per the need by adjusting the outrigger. It is
advised after flexor or extensor tendon repair or after wrist
arthroplasty to assist wrist ROM.
2. Metacarpophalangeal joint flexion–extension splint: This splint can be

assistive as well as resistive to the movements of flexion or extension
or both, depending upon the purpose. This is provided by effective
pull of the outrigger applied at the proximal phalanges and adjusted
at an angle of 90 degrees. It is advised after MCP arthroplasty or
following soft tissue injury or extensor tendon repair (Fig. 34-14).
3. Proximal interphalangeal joint flexion–extension splint: To localize

movements at the proximal interphalangeal joint, immobilization of
the proximal phalanx is necessary (Fig. 34-15). The outrigger rubber
band is adjusted to provide dynamic assistance and controlled
resistance to the middle phalanx, as per the needs. This splint is
advised after PIP joint arthroplasty or as a low-profile splint following
flexor or extensor tendon repair.
4. Finger trapper or buddy system splint: This is a simple but unique

dynamic splint which uses the active force of one digit to mobilize the
joints of the adjacent digit. This is advised as an assistive therapeutic
device to improve the ROM. It is used following soft tissue injury,
joint pathology, fracture of the phalanx or in ‘pain anxious’ patients
(Fig. 34-16).
5. Dynamic thumb splint: A dynamic thumb splint can be fabricated as

a low-profile splint which keeps the thumb in opposition, maintaining
the web space. It can be devised to mobilize MCP or IP joints of the
thumb by properly adjusting the outrigger with a rubber band.
6. Specially fabricated controlled movement dynamic splints (see Fig.

34-22).
FIG. 34-14 Dynamic MCP flexion/extension splint with outriggers.
FIG. 34-15 Dynamic PIP flexion–extension splint.

FIG. 34-16 Buddy splint in the treatment of fracture of the phalanx.
Lower extremity dynamic splints

Various types of orthoses like knee-foot-orthosis (KFO) and ankle-
foot-orthosis (AFO) are used to facilitate ambulation and functional
activities.
Common lower extremity splints
Static splints
1. Thomas static splint for lower extremity immobilization
2. Posterior knee splint to rest and maintain the knee in optimal

position
3. Splint to prevent contracture, known as posterior splint. It can be

made of POP cast
Dynamic splints
1. AFO (Fig. 34-17)
2. Toe pick-up orthosis
FIG. 34-17 Ankle-foot-orthosis (AFO).
Tendon injuries
A tendon is an important structure in the hand. Its basic function is to
transmit the tension developed by muscle. The muscle can thus act,
through the tendon, from a distance without increasing its bulk on the
joint. Its action is concentrated on a small area of bone and can be
applied to several joints.
Tendons have a great tensile strength. A tendon can elongate up to
10–15% of its original length. A force more than four times the greatest
isometric tension causes rupture of the tendon.
The tendon also protects the muscle during an unexpected strain by
the buffer action of its elasticity. The elastic fibres in the tendon have a
protective function by causing a gradual increase in tension, thus
absorbing the shock of contraction.
Injuries of a tendon result in loss of function of the involved
finger/thumb. A tendon rupture may occur in a closed injury or an
open injury or a penetrating injury. These injuries result from
domestic, agricultural or industrial accidents.
Tendon injuries will be discussed under the following headings:
A. Injuries of the flexor tendons
B. Injuries of the extensor tendons
Injuries of the flexor tendons

Applied anatomy of the flexor tendons (fig. 34-18)
Except thumb, each finger has two flexor tendons:
◼ Flexor digitorum superficialis (FDS)
◼ Flexor digitorum profundus (FDP)

FIG. 34-18 Diagrammatic representation of the anatomy of flexor tendons.

(A) The tendon of FDS dicussates to form a chiasma through which passes
the tendon of FDP. (B) Both the tendons are held together close to the
bones with the help of multiple pulleys.
Of these, FDS is superficial and divides into two slips before getting
inserted into the base of the middle phalanx on the volar aspect.
The FDP, a deeper tendon, passes through the divided tendons of
FDS and gets inserted into the base of the distal phalanx. This complex
arrangement of the tendons complicates the treatment of these
injuries; also these injuries are more common, most disabling and
often missed in the early stage.
◼ Injuries to the flexor tendons are much more common.
◼ Occasionally, old healed scars over the hand or the wrist could be
the cause of a tendon injury.
Muscular action
The FDS flexes the proximal interphalangeal joint (Fig. 34-19A),
whereas FDP flexes the distal interphalangeal joint (Fig. 34-19A and
B).
FIG. 34-19 (A) Test for the action of flexor digitorum superficialis tendon.
(B) Test for the action of flexor digitorum profundus tendon.
Diagnosis
On attempted active performance of the FDP, the affected digit
assumes an extended position at rest as compared to the other three
digits which, at rest, remain slightly flexed at the interphalangeal
joints.
The flexor tendons lie superficial in the palm as well as in the digits.
Therefore, any cuts or wounds over the volar aspect of the hand and
the wrist must be carefully examined for possible injury to the flexor
tendons.
Treatment
The treatment of flexor tendon injuries depends upon the following
factors:
1. Site of injury
For the purposes of treatment, the palmar aspect of the hand
is divided into five arbitrary zones (Fig. 34-20). The
treatment of a cut tendon varies in each zone.
Zone I: It extends from the tip of the finger to the middle of

the middle phalanx and contains the tendon of FDP only.
Cut injuries to the profundus tendon in this zone are rare

and, moreover, do not pose much problems since the flexor
digitorium sublimis tendon is intact and flexion at the PIP
joint is normal. Tenodesis of the DIP joint using the distal
end of the cut FDP tendon is performed without disturbing
the FDS tendon. Instead, one can do the arthrodesis of the
DIP joint. Alternatively, free tendon grafting can also be
done.
Zone II: This zone extends from the middle of the middle
phalanx to the distal palmar crease.
Also called no man’s land, this area has maximum number of

pulleys which normally prevent bowstringing of tendons
during flexion of the digit.
Zone III: It extends from the distal palmar crease to the

distal margin of the flexor retinaculum. Also called the
lumbrical zone, the cut tendons in this zone are sutured
primarily; however, some surgeons prefer to suture the
profundus tendon alone to avoid adhesions with the
sublimis tendon suture line.
Zone IV: This zone lies under the flexor retinaculum, under
the carpal tunnel. Both the flexor tendons can be sutured
primarily in this zone. Some surgeons, however, prefer a
secondary tendon graft to prevent crowding and
subsequent carpal tunnel syndrome.
Zone V: This zone is proximal to the wrist creases. Generally,

multiple tendons and nerves (median and/or ulnar) are cut.
All the tendons can be sutured primarily in this zone.
2. Duration of injury (i.e., whether a fresh or old injury)
(a) Fresh noncontaminated tendon injuries in zones I, III

and IV can be treated by primary tendon repair
(suturing):
Zone II injuries: Primary repair by suturing is done only on

the FDP tendon; simultaneous suturing of both FDP and
FDS within the flexor tendon sheath can result in
adhesions with loss of movements.
Or, first both the cut tendons are excised and a free tendon
graft is done to replace only the FDP tendon.
Zone V injuries: Although multiple involving tendons and

nerves can be treated by primary suturing.
(b) In old injuries a procedure of two-stage grafting is

adopted to overcome the hazards of fibrosis at the
tendon bed due to excessive tissue damage.
In the first stage of this procedure, a silastic smooth rod is

placed in the tendon bed and pulleys reconstructed, if
necessary. The wound is closed. Gradually, a thin sheath of
fibrous tissue forms around the silastic rod which acts as
the tendon sheath. Three months later a free tendon graft is
attached to one end of the silastic rod and the rod is pulled
out of the digit from the other end. Thus, the free tendon
graft replaces the silastic rod in the fibrous sheath.
3. Condition of the wound
FIG. 34-20 Five arbitrary flexor tendon zones.

In fresh injuries, if it is a clean-cut wound, not contaminated with
dirt, etc., primary repair/graft can be undertaken, whereas in cases
where the wound is contaminated with crushing of the surrounding
soft tissues, the repair/graft of the tendon is not undertaken. The
wound is dealt with first and the tendon reconstruction is left for a
later date.
Surgical approach of treatment
◼ Primary repair: Primary repair is indicated in clean-cut, fresh

wounds.
◼ Secondary repair: It is usually required in patients reporting late,

with severe injury including skin loss and wound contamination.
◼ Tendon transplant: It is done after failure of previous treatment.

Normally functioning tendons should be used for the transplant.
◼ Tendon graft: It is done in severe injury resulting in tendon loss.

Donor tendon is carefully selected to perform grafting, e.g., palmaris
longus and long toe extensor.
◼ Old tendon injury: The grating procedure is conducted in two stages:
◼ Stage 1: Siliastic rod is placed in the tendon and pulley

reconstruction is conducted. Slowly a fibrous sheath
develops over the siliastic rod.
◼ Stage 2: After 3–4 months, a free tendon graft is placed in

the sheath after removing the rod. Postoperatively, the
hand is immobilized in Jones position with a dorsal slab for
3 weeks.
A POP dorsal slab is applied for 3 weeks with the wrist and MCP
joints in 30 degrees flexion. Elastic traction is applied through finger
nails to keep the finger in flexion. The elastic traction, however, may
not be necessary in children.
Flexion at the MCP and IP joints is started after about 5 days.
The healing process of tendon injury, whether treated surgically or
conservatively, follows three distinct phases of wound healing (as
described earlier). Therefore, the standard basic principles of
physiotherapy must be observed meticulously during all three stages
of wound healing.
During the phase of inflammation, physiotherapy is directed

towards the following:
◼ Reduction of pain and oedema
◼ Prevention of infection
◼ Ensuring correct positioning of immobilization to facilitate

a single fibrous scar formation
◼ Improving circulation
During the phase of fibroplasia: Controlled movements or protected

early mobilization is initiated to maintain balance between
immobilization and mobilization. This helps in the following:
◼ Preventing adhesions (contracture) and stiffness of the

concerned joint
◼ Imparting tensile strength to the repaired tendon and scar
◼ Accelerating gliding of the repaired tendon with alternate

relaxation and stress with appropriate dynamic splint
During the phase of remodelling: During this phase, the cross-
linking of collagen molecule begins. Collagen fibres between the co-
opted tendon ends must organize in parallel alignment to improve
tensile strength, wherea s collagen fibres along the longitudinal
surface of the tendon should disorganize in a random orientation to
facilitate tendon glide further, controlled movements avoid
peritendinous scarring through maximal gliding, thus reducing
adhesion formation (Strickland and Glogovac, 1980). The exercise
programme is oriented
◼ To further improve the tensile strength of the repaired

tendon by aiming at accurate remodelling of the healing
tendons.
◼ To intensify active and passive mobilization for furthering

the range of joint motion, strength and endurance of the
repaired tendon.
◼ To bring functional restoration of the hand to the fullest

extent by introducing graded functional activities.
It is important to note the differences between the flexor and
extensor tendons for successful management.
The process of repair in flexor tendons is more rapid than in
extensor tendons due to the presence of synovial sheath in the flexor
tendons which provides synovial fluid nutrition, whereas extensor
tendon mechanism is extrasynovial.
The anatomical disposition and the strength difference between the
flexor and extensor groups should always be remembered and taken
care of during the management. Swan-neck deformity, Boutonniere
deformity, mallet finger or extensor lag needs careful monitoring.
Controlled mobilization with absolute precision in the
postoperative phase is the basis of restoration of hand function (Table
34-3).
Table 34-3
Postoperative Controlled Movement Procedures Following Flexor and Extensor Tendon
Repair
Postoperative Controlled Movement Procedures

Period
Day 4 to 2 Therapist-assisted passive flexion and extension movements
weeks
Weeks 3 and Active movement to the antagonistic muscle groups of the repaired tendon against the
4 resistance provided by the rubber band of the dynamic splint
Weeks 5 and Active movements, both flexion and extension, with proper stabilization
6
Weeks 7–12 Terminal ROM, strength and endurance exercise; functional movements, progressing to
power grips
Preoperative evaluation for injuries to the flexor and extensor

tendons
◼ Thorough evaluation of the hand is done.
◼ The complete restorative programme is explained to the patient.
◼ The exercise programme is demonstrated on the contralateral

normal hand.
◼ Fabrication of the dynamic splint is done.
Flexor tendon management (table 34-4)
During the phase of immobilization (1–3 days): The aim is to reduce

inflammation and pain, improve circulation, prevent infection and
ensure proper positioning of the repaired tendon to augment
healing without any stress.
◼ Pain is controlled by diapulse, TENS or any other suitable

modality.
◼ Oedema is controlled by vigorous movements to the

adjacent joints and the whole extremity, limb elevation,
retrograde massage and compressive dressing or
cryotherapy during the first 48 h.
◼ Circulation to the operated area is improved by active

movements to the adjacent digits, initially as small-range
relaxed passive movements, as the patient is apprehensive.
◼ Wound examination and proper wound care are of vital

importance to prevent infection.
Table 34-4
Specific Physiotherapy Measures at Various Periods of Healing Following Flexor
Tendon Repair
Period Following Tendon Repair Objective

Inflammatory phase: days 1–4 • Rest in optimal relaxed position (hand splint), measures to
prevent infection and formation of a single scar
• Measures to reduce inflammation, pain and oedema
• Measures to improve circulation
Fibroplasia phase: day 4 to 3 weeks • A specially designed dynamic dorsal splint is given
• Controlled passive mobilization is given to maximum ROM
twice a day
• It prevents tendon from getting adhered. Imparts and
improves tensile strength of the healing tendon
• Provides direction and guidance for remodelling and gliding of
the repaired tendon, preventing malalignment of newly laid
collagen
Early remodelling phase: weeks 3 • Active resistive extension against the resistance of a rubber
and 4 (early) band is encouraged, may be with required minimal manual
assistance if necessary
• It helps in correct early laying of intramolecular and
intermolecular collagen
• Allows extreme range for tendon guide along with inducing
relaxation to the repaired tendon
• By the end of 4 weeks, complete active extension of the joint
should be restored
(Test for the presence of extensor lag, if present, teach assisted active
exercise)
Late remodelling phase: weeks 5–6 • Terminal stage of collagen remodelling
(late or final collagen remodelling • Active full-ROM flexion and extension should be restored
stage) • Strengthening flexion–extension in full ROM furthers the
tensile strength of now matured collagen
Final restorative phase: 7–12 weeks • Introduce and quickly progress functional use
and further (if needed) • Increase vigourosity of all the types of exercise to achieve full
pain-free function including power as well as other grips
• Ensure the full return of the strength and extreme range of
flexion as well as extension
Caution
Use of heat or hydrotherapy (whirlpool) may increase pain and
hence is contraindicated.
Controlled mobilization (day 4 to 2 weeks): Precisely controlled

modes of mobilization techniques form the basis of physiotherapy.
◼ The patient is provided with flexion assist dorsal plaster of

Paris or thermostatic material dynamic splint (Fig. 34-21)
extending from the proximal forearm to beyond the
fingertips (Kleinert, Kutz & Cohen, 1975). The wrist is
positioned in 30–45 degrees of flexion with the MP joints in
0–20 degrees of flexion. This puts the repaired tendon in
ideal healing position. A rubber band connects the nail
loop to the wrist, which keeps the finger of the repaired
tendon in flexion, permitting resistive extension (Fig. 34-
22). Earley and Milward (1982) modified this dorsal splint
by using dorsal extension to the repaired digit only, thus
allowing freedom of movement to other digits.
◼ The standard basic principles of physiotherapy must be

observed meticulously during all three stages of wound
healing.
◼ Graduated passive flexion and extension of the PIP and

DIP joints of the involved digit are carefully carried out
twice a day. PIP and DIP extension is done only with
simultaneous flexion of MP joints. Flexion of PIP and DIP
joints is done only after maintaining MP joints in flexion to
prevent overstretching of the repaired tendon.
◼ Active extension is encouraged against the resistance
provided by rubber band within the confines of the splint.
This resistive extension induces reciprocal relaxation of the
digital flexors, besides providing graduated tension to the
remodelling of scar of the repaired tendon.
◼ It also facilitates tendon gliding by preventing adhesions.
◼ This dynamic dorsal splint needs to be worn for 24 h for a

period of 4 weeks.
◼ Graduated range of active flexion of the digits is initiated

with guidance, retaining the dorsal splint.
Weeks 3 and 4:
◼ Assisted exercises are discontinued, unless the patient has

developed an extension lag.
◼ Complete active extension of the IP joint should be

restored during this period.
FIG. 34-21 Flexion assist dorsal splint with palmar pulley system, provides
elastic traction to the tendon in the direction of flexion by a rubber band.
NH, nail hook; PP, palmar pulley; WST, wrist strap; RB, rubber band; FST,
forearm strap.
FIG. 34-22 Controlled mobilization of the repaired flexor tendon. (A)

Passive full-range flexion and extensions of the PIP and DIP joints. (B)
Passive full-range flexion and flexion of the PIP and DIP joints. (C) Active
full-range extension by detaching nylon band and attaching rubber band.
(D) Active band resistive extension against rubber band.
Caution
Simultaneous extension of the wrist, MCP and IP joints should never
be attempted.
Weeks 5 and 6:
◼ Rubber band traction is removed and the exercises are

intensified to regain maximum active range of flexion.
◼ Self-assisted full-ROM simultaneous passive flexion at the

MC, PIP and DIP joints is guided by using the normal
hand.
◼ If near-normal range of active flexion is restored,

sustenance of the digit in the position of maximal flexion is
introduced.
◼ Graded resistance to flexion is initiated.
◼ Light activities can be introduced carefully.
Weeks 7–12:
◼ All the modes of exercises are made vigorous.
◼ Isolated blocking exercises to encourage active isolated

flexion of the PIP and DIP joints should be initiated.
◼ Deep friction massage may be necessary over the scar, if

there is a tendency for scar adhesions.
◼ Functional use of the hand including power flexion

activities are introduced gradually.
◼ All the movements are allowed without splint.
◼ Full function should be restored in the repaired digit by 12

weeks.
Controlled mobilization steps following flexor tendon repair:
Step 1. Days 4–15: Passive flexion and extension assisted
Step 2. By 21 days: Active resistive extension against the

rubber bands
Step 3. By 6 weeks: Active flexion and extension of fingers

initiated
Step 4. By 7–12 weeks: Exercises to strengthen terminal ROM
to restore strong power grip
Step 5. By 12 weeks: Return of full hand function and that of

the repaired tendon
Injuries of the extensor tendons

These can occur anywhere between the fingertip and dorsum of the
forearm.
Diagnosis
Injury to the extensor tendon can be diagnosed by the patient’s
inability to extend the finger actively even after stabilization of the MP
joints, following an injury to the dorsum of the hand.
The extensor tendons in the hand are arbitrarily divided into the
following eight zones (Fig. 34-23):
◼ Zone I – DIP joint
◼ Zone II – Middle phalanx
◼ Zone III – PIP joint
◼ Zone IV – Proximal phalanx
◼ Zone V – MP joint
◼ Zone VI – Dorsum of hand
◼ Zone VII – Over the wrist joint
◼ Zone VIII – Distal forearm

FIG. 34-23 Eight arbitrary extensor tendon zones.
The diagnosis of a cut extensor tendon is easy as the patient cannot

actively extend the involved digit. Injuries of the extensor tendons are
usually associated with lacerations of the overlying skin or with
compound fractures of phalanges and/or metacarpals.
Treatment
A cut tendon in zones I and II results in a mallet finger, which is
discussed in Chapter 5.
Zone III and IV injuries result in a Boutonniere deformity which is
characterized by flexion at the PIP joint and hyperextension at DIP
joints (Fig. 34-24). The treatment of a Boutonniere deformity consists
of surgical repair of the tendon and immobilization of the corrected
finger in a splint for 3–4 weeks postoperatively.
FIG. 34-24 (A and B) Boutonniere deformity. R, Rupture of the central slip

of extensor tendon.
Zone V–VIII injuries, i.e., over the dorsum of hand and wrist, are
common and can be treated by the following methods (Table 34-5):
◼ Fresh injuries (within 3 weeks) can be repaired by tendon suture.
◼ Old injuries can be treated by one of the following methods:
◼ Tendon grafting
◼ Tendon transfer
◼ Attaching the injured tendon to the adjacent intact digital

extensor tendon
Table 34-5
Treatment of Extensor Tendon Injuries by Zones
Zone Region Deformity Treatment

I DIP jointmiddle Avulsion of the extensor tendon from • Immobilizing DIP joint in slight
and phalanx the distal phalanx with or without a hyperextension for 6 weeks
II bony chip (Mallet finger) • Open reduction and repair if
necessary
III PIP Avulsion of middle slip of extensor • Immobilizing finger straight for 3
and jointproximal expansion from the base of middle weeks
IV phalanx phalanx (Boutonniere deformity) (Fig. • Surgical open reduction repair of
34-24) the central slip or reattachment of the
avulsed tendon and immobilization
for 3–4 weeks
V MP joint • For fresh injuries of less than 3
and dorsum of hand weeks:
VIII wrist joint distal • Direct surgical repair
forearm • For late reporting injuries of more
than 3 weeks:
• Tendon grafting
• Tendon transfer or
• Attaching injured tendon to the
adjacent intact digital extensor tendon
A volar plaster slab is applied for 4 weeks with the wrist and finger in
extension. Finger mobilization is started after the removal of slab.
Spontaneous rupture of extenor pollicis longus tendon: Following
Colles fracture, the tendon of the extensor pollicis longus may get
frayed over the roughened area of the bone at the site of fracture. The
frayed tendon end makes direct end-to-end suture impossible. A
tendon transfer procedure is done.
The tendon of the extensor indicis proprius is divided at the level of
the neck of the metacarpal and re-routed towards the thumb and
sutured to the distal stump of the extensor pollicis longus tendon.
Simple laceration injuries treated by surgical repair do not pose
complex problems. They can be adequately managed by
immobilization of the wrist and digits in extension followed by
graded mobilization. Full function returns by 6–8 weeks.
Complex extensor tendon injuries with the involvement of
periosteum, adjacent soft tissues or extensor retinaculum invariably
result in adherent tendons restricting tendon glide, contracture, joint
stiffness or even extensor lag. Early controlled mobilization by slow
active assisted movements with appropriate immobilization can
prevent most of these complications (Evans, 1989).
Benefits of controlled early passive mobilization and stress to the
healing tendon:
◼ Promotes extrinsic and intrinsic healing.
◼ Encourages longitudinal reorientation of the adhesions.
◼ Enhances synovial diffusion to the healing tendon.
◼ Improves peritendinous vessel density and cellularity to the

repaired site.
◼ Facilitates tendon excursion and its tensile strength.
◼ Promotes metabolic activity.
However, the early return of full function requires certain

procedural norms. The most important is calculation of the angle of
stress.
Calculation of the angle of stress: Bunnell’s cadaver studies of
excursion (Boyes, 1970) provide data on the degree of excursion at the
MCP, PIP and DIP joints of the individual fingers and at CMC, MP
and IP joints of the thumb with the wrist joint in neutral position
(Table 34-6). The precise value for biomechanically sound excursion of
the tendon has to be in the range of 4–5 mm for extensor tendons.
From this, the exact angle of the joint needed for excursion of the
tendon can be calculated using the following formula:
Table 34-6
Excursions of the Extensor Tendons
Digit Extensor Digitorum Communis and Extensor Pollicis

Tendons
Wrist MCP PIP DIP
Index finger 38 15 2 0
Middle 41 16 3 0
finger
Ring finger 39 11 3 0
Little finger 20 12 2 0
Thumb 33 CMC (7) MP (6) IP (8)
Notes: MCP, metacarpophalangeal joint; DIP, distal interphalangeal joint; IP, interphalangeal
joint; PIP, proximal interphalangeal joint; CMC, carpometacarpal joint (Bunnell, reported in
Boyes, 1970).
Therefore, by applying this formula for MCP joint of the index

finger whose normal ROM is 85 degrees and the Bunnell’s value of
tendon excursion is 15 mm, the exact angle of the joint will be
For 5 mm excursion, it would be 5.66 × 5 = 28.30 degrees.
Design of dynamic splint: The dynamic splint is forearm-based with a
volar block which blocks any further flexion after the preset range.
The wrist joint is fixed in 40 degrees of extension. The dynamic
extension sling holds MCP, PIP and DIP joints in neutral position of
flexion and extension (Fig. 34-25).
◼ Controlled stress is applied in a graduated manner to the extrinsic

extensor tendons from the third or fourth postoperative day. The
patient is made to actively flex the digit at the MCP joint till the
finger touches the volar block of the splint, followed by relaxation so
that the extensor outrigger passively returns the digit to zero
position (Evans & Burkhalter, 1986). This exercise needs to be
repeated 10–20 times every hour.
◼ Gentle passive movements of each IP joint should be practised

regularly by holding the wrist joint and MP joints in maximum
extension. This is continued up to 3 weeks. After 3 weeks, the volar
block is discarded while the dynamic extension component of the
splint is retained.
◼ Graduated resistive range of flexion with controlled extension is

initiated and continued.
◼ By 6 weeks, the dynamic extension component is discontinued and

the exercises are made more vigorous.
◼ Graduated functional activities are encouraged and progressed to

powered and sustained grips. By 12 weeks, normal to near-normal
function should be restored.
FIG. 34-25 Dorsal forearm-based dynamic extension splint: with volar

block (VB) which permits only predetermined range of MCP flexion.
The physiotherapeutic regime after repair of extensor pollicis

longus tendon is also similar except that the dorsal dynamic traction
splint and a volar block are needed to keep the CMC, MCP and IP
joints of thumb in neutral position.
Prevention of common complications

The common complications like extensor lag, extension contracture
and swan-neck deformity should be identified early and prevented.
◼ Resting the digital joints at zero degree (static) prevents extensor lag.
◼ Motion of the MCP joints during the phase of healing reduces the
incidence of extensor lag.
◼ Maintaining collateral ligament integrity and stability prevents

contractures.
◼ Controlled intrinsic flexion promotes lymph and venous drainage.

It also improves local nutrition and reduces oedema and the chances
of developing contractures.
◼ Immobilization may be extended to 4–6 weeks if there is a tendency
for Boutonniere or swan-neck deformities. Intensive mobilization is
also postponed following injury to the PIP joint.
◼ Injury to the DIP joints may result in mallet finger due to distraction
of the terminal segment of extensor tendon and strong force of FDP.
This may need immobilization for 6–8 weeks.
Amputations: Amputation of the digits are on increase due to steep

rise in the RTAs all over. The wound should be carefully examined
after thorough irrigation. Depending upon the extent, the site and the
condition of the wound, amputation is to be planned observing the
general principles (Table 34-7).
Table 34-7
Amputation of Digit Management Procedure
Types and the Procedure

Level of Injury
Fingertip By full-thickness flap
amputation
Fingers with intact Closure of the stump after trimming of the bone ends
good length of the
stump
For thumb Try to save the length of the stump to the bone ends
Replantation of Severed digit can be replanted provided it is appropriately preserved and injury is
digits less than 6 h; it involves microsurgical techniques to repair and suture the arteries,
veins, nerves and tendons
Distal interphalangeal joints are never considered for replantations.
Replantation
Reattachment (replantation) of a completely amputated human limb
was successfully carried out for the first time by Malt and Meckhann
(1964). It is now being carried out routinely at some specialized
centres for reattachment of completely severed limbs/digits.
The amputated segment of the digit/limb should be preserved by
the method of dry cooling (Fig. 34-26). The indications for replantation
are as follows:
1. Clear-cut amputations
2. Duration of amputations not more than 4–6 h
3. Amputations distal to the DIP joint are not considered for

replantation
4. Age: below 55 years
FIG. 34-26 Dry cooling method to preserve amputated digit: the amputated
part (finger F in this case) is preserved in polythene bag which is sealed
and put in another bag containing ice cubes (IC).
Two teams of surgeons work simultaneously. One team works on

the amputated segment while the other on the proximal segment. The
vessels, nerves and tendons are identified and tagged for easy
identification (Fig. 34-27) for anastomosis later during the course of
surgery. The structures are then repaired in the following order:
1. The bones are shortened and fixed with screws/wires/plates, etc.
2. Repair (anastomosis) of arteries
3. Repair of veins
4. Repair of nerves
5. Repair of tendons
6. Cover/closure of the wound: the repair of nerves and tendons may

be left to be done at a later stage in some cases
FIG. 34-27 Tagging of vessels, nerves and tendons for easy identification.
After treatment
The part of the digit/limb is encased in a compressive dressing with
copious padding and a plaster slab is applied to support the limb. The
finger/toe tip is left open for frequent monitoring of circulation. The
part may be kept slightly elevated; however, it should be lowered if it
becomes pale due to arterial insufficiency. Mobilization of the part is
begun after about 3 weeks.
Properly controlled physiotherapy plays an important role in the
postoperative phase.
Careful monitoring and correct techniques are the basis of early
restoration of function following replantation. Before initiating
treatment, the physiotherapist must get acquainted with the type and
level of injury and the details of the surgery.
Early postoperative management (first 2 weeks):
◼ Proper positioning of the limb is ensured to protect the repair. The

limb is checked for correct position of elevation, which does not
exert any undue stress on the operated part. This will reduce
oedema and inflammation.
◼ Close monitoring of the fingertips for any change in colour,

indicating circulatory insufficiency is vital. Signs and symptoms of
infection should be checked repeatedly.
◼ Vigorous movements of the other parts of body and distant

segments of the limb, with proper support to the replanted area, are
useful to indirectly improve circulation to the replanted area.
Phase of restoration and re-education (3–5 weeks): This phase

begins after the dressings and cast are removed. The dressings are
removed by 2 weeks in replantation of the digits and after 4 weeks in
more proximal areas.
◼ A dynamic splint is applied with the wrist in slight dorsiflexion,

MCP joints in flexion and IP joints in slight flexion (Fig. 34-28).
Necessary modifications may be done to ensure optimal fitting
without any ill effects.
◼ Early gentle mobilization is begun in a small range with relaxed

passive movements. Application of controlled passive stress is of
vital importance. The stress should be applied giving due
consideration to the periods of recovery of various tissues as
follows:
Skin: The skin develops adequate tensile strength within 7–10

days to initiate stretching.
Vascular supply: It needs 14 days to heal (Prendergast, 1978).

Tight bandaging or cast blocks the healing of vessels.
Therefore, stretching is not initiated earlier than 2 weeks.
Nerves: Healing of nerves takes 3–4 weeks (Beasley, 1981).

The compression of a nerve or its overstretching blocks
regeneration. Therefore, care should be taken to avoid
compression as well as excessive stretching for 3–4 weeks.
Bones: The bony union can be confirmed by radiographic

investigations, for initiating mobilization or stretching.
Active movements: If wound healing is satisfactory, early

initiation of small-range gentle active movements is ideal.
Whirlpool: If the wound has loose necrotic tissue, it may need

debridement. Such wounds respond very well to whirlpool
treatment before debridement. The grafted skin should not
be treated by whirlpool to avoid skin maceration.
FIG. 34-28 Dynamic splint following replantation of digits: The dorsal

outrigger encourages active ROM of flexion.
Mobilization techniques
Grade I or grade II accessory and physiological movements by the
techniques of joint mobilization are useful, as they do not involve
stretch on the vessels or the nerves.
Care of other joints: Uninvolved proximal joints should be fully

stretched to prevent stiffness.
Splint modification: The splint may be modified to a dynamic one with

emphasis on MP joint flexion and joint extension to guide the
movements, e.g., outrigger extension assists the splint. This will
promote tendon gliding and early movements. This splint provides
resistance to the flexor tendons which can tolerate tension due to
their ability to heal before the extensor tendons. The extensors
remain relaxed. This provides reciprocal inhibition to the extensor
tendons facilitating the glide (Horovitz & Casler, 1986). Hand
should be exposed to early functional restoration first as an assisting
hand and later as a primary.
Progressive exercise: The exercise should be progressed to gain more

range and strength of the involved joints.
Sensory re-education: Sensory re-education should be begun by
adopting suitable techniques.
ADL training: Guided ADL training by using dynamic splint further

improves the tendon gliding. It should begin with easy, simple tasks
and movements, and progress gradually. To begin with, the
replanted arm should be used only as an assisting hand.
Resolution of oedema and scar adhesions: Intermittent compressive

techniques and vigorous active exercises are given to eliminate
oedema. Friction massage to the scar is useful in breaking adhesions.
Late phase of restoration (6–8 weeks): By this time, healing is

complete in the reconstructed soft tissues and bones. Therefore,
concentrated efforts to attain maximum return of function can safely
be started.
Vigorous procedures to improve ROM, strength, endurance, grip
and sensory re-education (if necessary) are to be emphasized. All
grades of joint manipulation and mobilization techniques as well as
PNF techniques are safe and effective at this stage provided the force
and resistance are monitored carefully. Special elaborate sessions
devoted to improve coordination, dexterity and skills should be
included.
Functional training should be oriented on the basis of job
requirements.
Acceptable function should return to the replanted hand by 16–20
weeks.
Caution
Maximum efforts are directed towards the reduction of postsurgical
oedema and infection. If not controlled, it may lead to a higher
incidence of stiff joints (Horovitz & Casler, 1986). Another important
aspect is scar remodelling by controlled stretch.
Burns of the hand

Most of the burns to the hand occur as a result of direct or indirect
contact with heat (Table 34-8).
Table 34-8
Burns: Types and Examples
Burns Examples
Flame Clothing catching fire
Scalds Contact with steam, hot water, etc.
Contact Hot press, bars, utensils during cooking, etc.
Flash Explosion causing a flash
Electrical Live AC or DC current
Chemical Dipping or applying concentrated acids or
alkalies
The burns of the hand may involve dorsal or the palmar aspect of
the hand, although dorsal burns are more common due to the reflex
action to protect face. All the groups may be affected, but children,
housewives, elderly persons, psychiatric and epileptic patients are
particularly at a risk.
Depending upon the degree of damage to the tissues, hand burns
are classified into the following three categories:
First-degree (grade I) burns: Only the dermis is involved. The free nerve
endings and sensory organs are intact. The wound is bright red or
glistening pink due to vasodilation.
Second-degree (grade II) burns: The dermis and epidermis are involved.
The hair follicles, sebaceous glands and sweat glands are spared.
The wound appears white due to interstitial oedema.
Third-degree (grade III) burns: There is destruction of dermis, epidermis

along with hair follicles, sebaceous glands and sweat glands. The
wound appears white or dark brown. There is extensive sensory
involvement and profuse oedema within 24 h.
Basic principles of management

1. Prevention of infection
2. Prevention of circulatory failure and control of oedema
4. Restoration of hand function
Prevention of infection
During acute phase, prevention of infection and control of pain are of
primary importance. Adequate measures are taken to clean and dress
the wound, removing slough and necrotic tissues, observing all the
aseptic measures. Anti-inflammatory drugs and antibiotics are given.
Enzymatic debridement and tangential excision may be needed.
Prevention of circulatory failure and control of oedema

Signs and symptoms of circulatory failure like paleness, cold and loss
of pulse should be monitored at regular intervals. Active exercises to
the joints adjacent to the site of burn and relaxed passive movements
within the limits of pain assist in controlling circulatory failure and in
preventing infection.
Control of oedema can be facilitated by the following measures:
1. Supporting the hand in elevation
2. Slow and graduated active intrinsic muscle pumping exercises

performed every hour
3. High-voltage pulsed current synchronized with active efforts
Prevention of deformity
Right from the beginning, the hand is immobilized, with the burnt
hand enclosed in a plastic bag or splint, in the optimum position of the
hand (Fig. 34-29, A–F). At a later stage, the splint is altered to a
dynamic splint with in-built mechanism to provide remodelling of the
scar tissue.
FIG. 34-29 Correct splinting to prevent expected deformity and provide

optimal immobilization following hand burns. DG, Dorsal PIP extension
gutter splint; VG, Volar PIP, DIP extension gutter splint; VAD, Volar anti-
deformity splint; WS, Web spacer splint; WSTIE, Web spacer-thumb and
index finger extension splint; LB, Long Banjo.
Common deformities and preventive splinting
1. Hyperextension at the MP joint with flexion at PIP joints: knuckle

bender splint
2. Boutonniere deformity: PIP–DIP joint extension gutter splint to

individual fingers
3. Mallet finger deformity: Simple splint maintaining extension at the

DIP joint
4. Swan-neck deformity, where hyperextension occurs at the PIP joint:

Simple splint preventing terminal extension of the PIP joint
5. Syndactyly, where there is a loss of digital web: This may occur as a

result of improper immobilization or due to contraction of the
adjacent wound; a splint maintaining an individual web space is
necessary
6. Palm cupping: The palmar arches of the hand may get contracted;
this needs low lying-load stress splint to flatten the palmar arch
Restoration of hand function

Exercises play a significant role in all the stages following burns. They
need to be properly planned and controlled to adequately meet the
demands of the individual patient.
Exercise procedures should be planned only after a thorough
evaluation. The management proceeds on the same lines as described
under hand injuries. However, hydrotherapy in the form of whirlpool
is extremely useful and a popular mode of management. It helps in
softening the wound, debridement, improving circulation, retaining
mobility, reducing oedema and hastening the process of healing.
Please ensure disinfecting the pool water before use.
Prevention of hypertrophic scars after burns: Precisely measured
pressure garments- Patients should start wearing gloves made up of
elasticated mesh material after 2 weeks of burn. These pressure gloves
need to be worn for 24 h of the day for 6–18 months (except brief
interval for washing). These pressurized gloves cause elongation of
the fibroplasts, thus preventing bumpy or raised scar tissue. It is well
monitored and retained till the hypertrophic scar tendencies are
overcome.
Occasionally, cortisone infiltration or surgery may be required to
cover the skin.
Caution
Even after healing, sensation may not be normal. Patient must be
warned not to cause direct friction, excessive pressure or any injury
to the new skin.
Infections of the hand

Acute infections of the hand need prompt diagnosis and management
lest the hand become stiff leading to permanent disability.
Even a trivial injury like scratch over the skin is adequate to result
in infection.
Even a pinprick injury is enough to cause serious infection. The
volar aspect of the palm and fingers is maximally used in the majority
of the functions of our daily routine. Therefore, it always remains
susceptible to injury. In the event of minor injury, we keep on using
the hand without protecting the wound; it welcomes pyogenic
bacteria causing infection and pus formation and leading to impaired
hand function.
Major causative microorganisms following open wounds

◼ Staphylococas aureus in about 60% of infections
◼ Streptococcus pyogenes
◼ Gram-negative bacilli
Common types of infections of the hand are as follows (Fig. 34-30):
1. Paronychia
2. Whitlow
3. Thenar space infection
4. Mid-palmar space infection
5. Infections of the tendon sheath (tenosynovitis)

FIG. 34-30 Common infections of hand. (A) Paronychia (P), Whitlow (W).
(B) Transverse section showing thinner space infection (TI), mid-palmar
space infection (MPI), flexor tendons (FT), metacarpal bones (MC). (C)
Tenosynovitis of flexor tendon sheaths: sheaths of the thumb and little
finger are longer and continue up to the radial and ulnar bursa respectively.
These infections are caused by pyogenic organisms (bacteria).

Minor injuries such as pricks, abrasions and cuts predispose the hand
to infection. The infection in the hand spreads to the tissue planes. If
not treated in time, it may involve the adjacent tissue planes.
Paronychia
Paronychia is a nail bed infection. It is the most common type of
infection. It starts in the nail bed on one side of the nail and may
spread around the nail to the other side or in rare instances to the pulp
space. The patient complains of pain, swelling and redness at the base
and on either side of the nail. The pain is generally severe. The
treatment consists of early drainage under cover of antibiotics.
Whitlow
Whitlow is a pulp space infection, also called Felon. The patient has
excruciating pain in the pulp of the finger which is also swollen, tense
and tender. The treatment is drainage of the abscess and appropriate
antibiotics.
Thenar space infection

The patient presents with swelling and pain in the radial half of the
palm. The swelling is more marked over the dorsum of the hand,
mainly due to the fact that lymphatics drain into the dorsum of hand.
The treatment is antibiotics and early drainage of pus.
Mid-palmar space infection

In the mid-palmar space infection, the ulnar half of the palm is
swollen, painful and tender. Drainage of pus and antibiotics is the
treatment.
Tenosynovitis
Infections of the tendon sheath are rare but may lead to necrosis of the
tendons and adhesions of the tendon sheath if not treated promptly.
Ulitmately, it may lead to permanent stiffness of the fingers. The
patient presents with a swollen finger with tenderness over the
tendon sheath.
A rare, but serious infection involves the flexor tendon sheaths and
hence adversely affects the function of the hand.
The flexor tendons of the hand are covered with fibrous and
synovial sheaths or bursae. They are organized into two groups, the
radial bursae and the ulnar bursae.
There exists a great variation in the arrangement of the synovial
tendon sheaths. The tendon sheaths of the index, middle and ring
fingers as well as the ulnar and radial bursae may be in contact with
each other increasing the susceptibility of spreading the infection.
Penetrating injuries to the tendon sheaths with a needle or sharp
object serve as entry point for S. aureus or Streptococcus pyogens.
Infection can spread by extension from the terminal pulp space.
Early detection
◼ Painful swelling through the entire length of infected finger
develops.
◼ There is marked tenderness localized over the flexor tendon sheath.
◼ Finger remains semiflexed, and passive extension is extremely

painful.
◼ In infection of the tensosynovitis of the little finger or to the ulnar

bursa, Kanavel sign’ is positive. A point of maximum tenderness is
present between two of the transverse palmar creases (Fig. 34-31).
◼ In infection at the radial bursa, excessive swelling is present over

the thumb and the thenar eminence.
FIG. 34-31 Web space infection – in the third web space (between middle
and ring fingers). Note the fixed separation of the fingers.
Treatment
Prompt drainage of pus under cover of antibiotics is instituted as its
treatment.
◼ Early acute inflammatory stage – rest is given with crepe bandage.
◼ A rigid thermoplastic or POP splint is given.
◼ Modalities like diapulse, ultrasound therapy, cryotherapy, TENS to

control pain and inflammation with hand in elevation are used.
◼ Gentle pain-free relaxed active movements with splint on are ideal.

◼ Isometrics with splint and pressing against the splint within pain-
free range are ideal.
◼ As the inflammation is reduced, relaxed passive ROM exercises

could be initiated with functional use of the hand.
◼ Deep friction massage across the affected tendons is very effective.
◼ By 2 weeks, the inflammation settles and vigourous exercise

procedure including regular functional use of the affected hand
should be initiated.
◼ Hydrocortisone infiltration is done.
◼ Rest is given in elevation and support.
◼ Intravenous antibiotics are administered.
◼ Surgical opening of the tendon sheath and irrigation are performed.
Complications
Suppurative or pyogenic tenosynovitis is a complicated problem as
pus formation occurs in the sheaths of the flexor tendons of thumb
and fingers; the built-up hydrostatic pressure of pus may block
circulation to the tendons. It results in extremely painful and stiff
fingers.
Under such circumstances, intramuscular injection of antibiotic is
advisable.
In traumatic tenosynovitis, tendons of the abductor pollicis longus
and extensor pollicis brevis may be involved with typical signs of pain
and stiffness over the anatomical snuff box.
Distinguishing signs (table 34-9)

The tendon sheath of the thumb, known as the radial bursa, extends
into the forearm.
Table 34-9
Distinguishing Characteristics in Tenosynovitis and Tenovaginitis
Tenosynovitis Tenovaginitis
Secretion of excessive synovial fluid in the Stenosis or thickening of the tendon sheaths
tendon sheaths
Swelling over the affected sheaths is soft The swelling is hard and tender to palpation
and tender
Excessive pain on attempted finger flexion The movements of thumb and/or wrist are extremely painful
movements
Intramuscular antibiotic injection is very Surgery – decompression of stenosed or thickened tendon
effective sheaths may be necessary
The flexor tendon sheath of the little finger opens into the ulnar
bursa.
The tendon sheaths of the index, middle and ring fingers extend
from finger top to the bases of the digits.
Pain at rest is the typical identifying feature of suppuration or pus
formation.
General principles of prevention of hand infections

Public awareness to the following facts:
◼ Even a small pinprick can cause serious infections leading to

impaired hand function.
◼ Educate on simple methods of initial wound care to prevent

bacterial invasion.
◼ Emphasize on educating the public on hygienic care while cutting

nails, etc.
◼ Dull pain progressing to intractable pain is a sure sign of pus

formation.
◼ Seek immediate medical assistance in the event of symptoms like

nagging pain, tenderness, swelling, redness or painful stiffness.
◼ Never attempt to treat yourself or seek cheap and easily available

treatment.
General principles of treatment
1. Rest and support in elevation
2. Systemic antibiotics in adequate dose and in an appropriate

combination using four antibiotics to prevent pus formation when
used within 48 h
3. Measures to reduce inflammation, pain and oedema
4. Measures to improve localized circulation
5. Protective immobilization
6. Drainage of pus: To ensure complete drainage of pus, certain factors

need to be strictly observed
◼ General anaesthesia (GA) or regional block is preferred to

local anaesthesia, which has a tendency to spread infection
by secreting excessive fluid to the already existing fluid.
◼ Application of tourniquet without exsanguination is

indicated to prevent spread of infection. Instead,
continuous well-supported elevation of hand is preferred.
Incision
◼ Incision should never cross the skin crease.
◼ It should not damage any important structure in the vicinity of the

abscess.
◼ Exploration should be wide enough for the complete evacuation of

pus.
◼ Wound is left partially open after ensuring complete removal of the

pus.
◼ Aftercare of the wound with regular dressing and monitoring

(check) is most important.
◼ Pus collected should be sent for culture and sensitivity to select

ideal combination of antibiotics.
◼ General principles of physiotherapy management in hand

infections.
Early acute stage:
◼ Rest with support in elevation is given.
◼ Rigid thermoplastic splint or POP slab is used.
◼ Suitable modality to reduce pain, products of

inflammation – like diapulse, US therapy, TENS or
cryotherapy – should be given.
◼ Providing active maximum ROM exercises to the

uninvolved fingers is very important to prevent stiff hand.
◼ Repetitive and sustained isometrics within the splint

should be encouraged with pain-free magnitude of force.
Late stage:
◼ Graduated repetitive mobilization should be started for

the involved finger.
◼ Relaxed, free, assisted movements to improve ROM to the

involved finger are begun.
◼ Functional use of the whole hand including diseased

finger is begun with soft spongy ball.
◼ As soon as inflammation and pain are settled, vigourosity

of exercise is progressed to the maximum.
◼ Concentrated exercises with hand dipped in disinfected

warm water are the best.
◼ Cyriax (1978) and Tidy (1968) advocated deep friction

massage across the affected tendons in tendon injuries,
when the wound is healed.
◼ Normal to near-normal hand function should be restored

within 4–6 weeks.
◼ Physiotherapy follows incision and drainage.
◼ Self-assisted ROM as well as muscle function exercises is

emphasized.
◼ Active holds in the maximally stretched position are

extremely useful in restoring hand function including the
involved digit.
◼ Exercise programme from early immobilization should be

progressed within a short duration by ensuring patient’s
own efforts at home within 6–8 weeks; normal restoration
of hand function should be restored.
Vasospastic diseases of the hand

Vasomotor instability precipitates vasospastic hand diseases like
reflex sympathetic dystrophy (RSD), Raynaud disease (RD) or
Raynaud phenomenon (RP).
Reflex sympathetic dystrophy

RSD may occur as a result of the following:
1. Repeated trauma to the dorsum of the hand, e.g., occupational,

truck drivers and chainsaw operators
2. Direct trauma, crush injuries, injuries to the nerves, Colles fracture

and cerebrovascular accidents (CVA)
3. Systemic disease
It is also called Sudeck dystrophy, complex regional pain syndrome

(CRPS). The exact aetiology is not known but it occurs due to
sympathetic disturbances.
Stagewise signs and symptoms (delp, 1986)

Stage 1
This stage may last up to 3–6 months.
◻ There is burning or aching pain with tenderness,

aggravated by movement or emotional stress
◻ Pitting oedema is observed
◻ Warm erythemic hand becomes cool and cyanotic with

excessive sweating
◻ Osteoporosis may set in

Stage II
This stage may also last for a period of 3–6 months.
◻ Pain and oedema continue, resulting in decreased joint

mobility (contractures).
◻ Muscles atrophy.
◻ Trophic changes like smooth and shiny skin, brittle and

grooved finger nails are seen.
Stage III
◼ There is diffuse marked osteoporosis.
◼ Ankylosis of the distal finger joints occurs.
◼ Intrinsic muscles atrophy, especially interossei.
◼ Pain during attempted movements continues.
Evaluation
A thorough evaluation is done to assess the nature of impairment.
Besides the usual strength and ROM, pain perception should be
evaluated on a 10 cm horizontal visual analogue scale (Scott and
Huskisson, 1976). Grip strength, finger dexterity and resting finger
temperature should be assessed before and after cold immersion. The
hand is kept immersed in cold water till the skin temperature reaches
13°C. Then it is removed from cold water noting the time taken to
reach the baseline temperature level. The test can also be done by 20 s
of ice-water bath (Porter et al., 1975). Volumetric measurements can be
used to assess the degree of oedema.
Investigations
X-ray shows patchy osteoporosis (Fig. 34-32); however, the diagnosis
is picked up on a bone scan (Fig. 34-33).
FIG. 34-32 CRPS: X-rays shows patchy osteoporosis of the left hand;
normal right hand for comparison.
FIG. 34-33 CRPS: bone scan—shows increased update on the left side.
Treatment
Medications are given to alter the circulatory disturbances. Chemical
sympathectomy in the form of stellate ganglion block may also be
done. Physiotherapy and exercises are continued despite pain.
Early detection of the symptoms like pain, oedema and digital skin
discolouration in suspected patients (e.g., Colles fracture, CVA) and
initiation of early treatment are of primary importance.
Control of pain
First priority in the treatment is to control pain by a suitable modality.
Prolonged heat, cold, high pulse rate (50–100 Hz) and narrow pulse
width (45–75 s) TENS, paraffin-wax bath, repeated gentle relaxed
passive movements and connective tissue massage are useful.
Intravenous injection of procaine and lidocaine, ganglion block, use of
corticosteroids and sympathectomy are the other measures.
Control of oedema
Methods like supported elevation, active movements, retrograde
massage, Jobst gloves and air splints are effective.
Splinting
At the initial stage, wrist stabilization is given to reduce pain and to
facilitate finger movement. Later on, a dynamic hand splint with
outrigger assists in providing resistance to finger flexion and assisting
extension.
Counselling
The long course of the disease with nagging pain causes emotional
imbalance and distress to the patient. Therefore, the therapist’s
counselling skill is an important aspect of the treatment.
Exercise programme
Well-planned graduated exercise programmes with functional use of
the hand are important.
Raynaud phenomenon
Primary RD: This has bilaterally symmetrical involvement without any
history of injury or associated disease. Emotional stress can
precipitate primary RD.
Secondary RD: This has a definite history of injury, extensive use of a
vibratory tool, prolonged exposure to cold, endocrine disease,
arterial disease, collagen disease, blood disorders or arterial
compression.
Signs and symptoms
◼ Pain
◼ Pallor and cyanosis
◼ Skin discolouration due to exaggerated vasoconstriction
Evaluation
Evaluation is done as described for RSD.
Treatment
◼ Electrically heated hand gloves are useful in maintaining hand

temperature.
◼ TENS has been reported to be effective in producing vasodilation

besides controlling pain.
◼ Pairing whole-body exposure to cold (0°C) and hands to warm

water (43°C) results in learned response (Jobe et al., 1982).
◼ Pendular rapidly swinging arm exercises with relaxation are useful

in improving blood flow to the hand. This occurs due to the
gravitational and centrifugal forces (Mc Intyre, 1978).
◼ Drugs to reduce sympathetic tone or to improve circulation are

effective.
Surgical management
◼ Vein grafts are used to bypass the thrombosed arteries (Wilgis,

1981).
◼ Digital artery sympathectomy (Flatt, 1980) or axillary

sympathectomy has been reported to be successful.
Arthritic hand
The hand may be affected by seven various types of joint affections.
Each type has its own differentiating characteristics to pinpoint the
arthritic class (Table 34-10).
Table 34-10
Postarthritis Typical Diagnostic Characteristics of Deformities at the Hand
Rheumatoid Osteoarthritis Lupus Psoriatic Reiter Gouty Arthritis Postparalytic

Arthritis Erythematosus Arthritis Syndrome Hand
• Swan- • Hard • Gross • • Triad of • Usually
neck round deformation of Deformities conjunctivitis attacks single
deformity: nodes, the are similar urethritis joint
Hyperextension Heberden metacarpophalangeal to those and • In acute stage,
of PIP joint and joints encountered synovitis the joint
with flexion Bouchard • Involvement of in • becomes
of the DIP nodes, are periarticular soft rheumatoid Synovitis swollen, red hot
joint: Due formed tissues and arthritis is and tender due
to rupture around tendons except asymmetrical to the deposition
of the volar the DIP, • It may involve unlike • Heel of monosodium
plate of the PIP joints the skin over the rheumatoid, pain, back urate crystal
PIP joint • nose involvement pain • Common site
• Degenerative of distal • Nail of involvement
Boutonniere destruction interphalangeal deformities is the first
deformity: of the joints • Attacks metatarsophalangeal
Flexion at joint (DIPs) is an young joint (Podagra)
the PIP cartilage identifying males; in >70% cases
joint: Due • feature commonly • Nodular
to the Formation • Always involves thickenings
rupture of of bony associated lower (tophi) may
the central spurs with extremities occur in tendon
extensor • typical skin • sheaths, bursae
expansion, Resulting lesions of Reversible and ear cartilage
resulting in in the psoriasis disease
flexion at limited • Pitting resolves
the PIP excursion and finger itself
joints of the nail •
• Trigger involved discolouration Symptoms
fingers joint/joints of
and/or arthritis
trigger in a single
thumb: Due or
to the multiple
formation joints
of nodules •
over the Multiple
tendons joint
• Unlar involvements;
deviation at attacks
MCP: Due spine,
to rupture resembles
of the ankylosing
collateral spondylitis
ligaments
•
Symmetrical
joint
swelling at
the MCP
and IP
joints due
to
inflammation
around the
joints
Jersey finger
Jersey finger is a deformity which is exactly the opposite of ‘mallet
finger’. In jersey finger deformity, the patient is unable to flex the DIP
joint due to the avulsion of a FDP from the point of its insertion due to
the direct hit to the fingertip (e.g., volleyball player).
Crush injuries
Crush injuries of the hand is an emergency situation with growing
number of industrial accidents, RTAs and machine tool accidents. The
incidence of crush injuries is on the rise. And considering the hand
being the most important functional asset, one must do full justice
before deciding its amputation.
One can prevent amputation with critical repetitive clinical
examination and proper care.
◼ What is the status of blood loss following an injury? If the blood

loss is absolute or irreversible, amputation is the only salvage
procedure.
◼ Examine the hand for the possibility of return of hand function.
◼ Can the residual intact finger/fingers compensate for the loss of

function due to an accident of the important five tissues: skin,
tendon, nerve, bone and joint?
◼ Permanent loss of neuronal and muscular function in adult will

require bionic arm with sensor, but otherwise amputation is the only
solution in adults.
◼ Salvage of the thumb is most important and should always be taken

care off.
Treatment of crush injuries

Step 1
◼ While covering wound with sterile dressing, hand should be

maintained in elevation to assist drainage of the waste products.
◼ Brief overall examination and care is done in general to check the

status of skin, damage to the bones, tendons and nerves; i.v. fluids
and antibiotics are started.
◼ Detailed examination of each tissue is conducted under GA or a

regional block in the OT after thorough debridement. This will help
in assessing the damaged tissues and extent of the damage and the
tissue loss. After this scrutiny, nonviable tissues are excised and
those which are viable are repaired as per each one’s required
procedure. If the damage is beyond repair, primary amputation is
unavoidable.
Note: Other soft-tissue lesions at the hand are covered in Chapter on
Regional Orthopaedic Soft Tissue Lesions.
Bibliography
1. Backhouse KM. Functional anatomy of hand. Physiotherapy.
1968;54:114.
2. Beasley RW. Hand injuries. Philadelphia: WB Saunders. 1981.
3. Bora FW, Richardson S, Black J. The biomechanical response
to tension in peripheral nerve. Journal of Hand Surgery (Am).
1980;5:21.
4. Boyes JH. Bunnell’s surgery of the hand. Philadelphia: JB
Lippincott Co. 1970.
5. Duncan RB. Basic principles of splinting the hand. Physical
Therapy. 1989;69:1104.
6. Earley MJ, Milward TM. The primary repair of digital flexor
tendons. British Journal of Plastic Surgery. 1982;35:133.
7. Evans RB. Clinical application of controlled stress to the
healing extensor tendon: a review of 112 cases. Physical Therapy.
1989;69:1041.
8. Evans RB, Burkhalter WE. A study of the dynamic anatomy of
extensor tendons and implications for treatment. Journal of Hand
Surgery (Am). 1986;11:744.
9. Hardy MA. The biology of scar formation. Physical Therapy.
1989;69:1014.
10. Horovitz ER, Casler PT. C. A. Moran Hand rehabilitation:
Clinics in physical therapy Replantation: current clinical treatment.
New York: Churchill Livingstone. 1986;91-116.
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An objective and standardised test of hand function. Archives of
12. Kleinert HE, Kutz JE, Cohen M. AAOS symposium on tendon
surgery in the hand Primary repair of zone 2 flexor tendon
lacerations. St Louis: Mosby Co. 1975.
13. Landmaster JMF, Long C. The mechanism of finger control,
based on electromyograms and location analysis. Acta
Anatomica. 1965;60:330.
14. Long C, Brown ME. Electromyographic kinesiology of the
hand muscles moving the long finger. Journal of Bone and Joint
Surgery. 1964;46(A):1983.
15. Lovett RW, Martin EG. Certain aspects of infantile paralysis
and the description of a method of muscle testing. Journal of the
American Medical Association. 1916;6:729.
16. Malt RA, Meckhann CF. Replanation of severed arms. Journal
of the American Medical Association. 1964;189:716.
17. Mason M, Allen H. The rate of healing tendons. Annals of
Surgery. 1941;113:424.
18. Merritt WH. L. J. Greenfield Complications in surgery and
trauma. Complications of hand surgery and trauma. Philadelphia:
JB Lippincott. 1984.
19. Prendergast K. J.M. Hunter L.H. Schneider E.J. Mackin J.A.
Bell Rehabilitation of the hand Therapist’s management of
mutilated hand. St Louis: Mosby Co. 1978.
20. Seddon H. (2nd ed.) Surgical disorders of the peripheral nerves.
New York: Churcill Livingstone. 1975.
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tendon repair in zone II: a comparison of immobilization and
controlled passive motion techniques. Journal of Hand Surgery
(Am). 1980;5:537.
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Orthopedic Clinics of North America. 1978;92:529.
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24. Wilgis E. Evaluation and treatment of chronic digital ischemia.
Annals of Surgery. 1981;193:693.
CHAPTER
35
Regional orthopaedic conditions at the hip
OUTLINE
◼ Hip joint
◼ Coxa vara
◼ Coxa valga
◼ Perthes disease
◼ Avascular necrosis
◼ Osteochondritis
◼ Rare hip pathologies
Hip joint
Applied anatomy
The hip joint is a true ball and socket joint which offers free mobility
during activities and stability during weight bearing. The all-
important mobility of this joint is secondary to stability as mobility
without stability is useless (Anson & McVay, 1971).
Stability to the hip joint is provided by the following structures:
2. Articular capsule and ligaments

3. Muscles
4. Atmospheric pressure
Bony configuration (fig. 35-1)

The ellipsoid shape of the femoral head fits tightly into the well-
formed hemispherical acetabulum. These two bony structures make a
stable ball and socket joint. The femoral neck has two angulations:
neck–shaft angle (normal value: about 135 degrees) and an angle of
anteversion which is about 10–20 degrees. The femoral anteversion
allows an extended range of flexion at the hip before the neck of the
femur impinges against the acetabular rim. The cartilage of the head
and the acetabulum, with collagen fibres, offers resistance to
mechanical stress. The presence of mucopolysaccharides offers a
shock-absorbing property apart from providing smooth surfaces for
joint movements (Warwick & Williams, 1973).
FIG. 35-1 Bony configuration of the hip joint, the only true ball and socket
joint.
Articular capsule and ligaments

The joint derives its strength from the thick articular capsule and
strong ligaments like the iliofemoral, pubofemoral, ischiofemoral and
the glenoid labrum.
Anteriorly the joint capsule is attached along the intertrochanteric
line, whereas posteriorly the capsule covers only the medial or upper
two-thirds of the neck. Thus, it falls short of the intertrochanteric crest.
Posteriorly, it has only a few longitudinally oriented ligaments. When
the hip is flexed and adducted, the posterior part of the head of the
femur is supported only by the capsule and not by the acetabulum.
Therefore, anteroposterior force on the distal end of the femur makes
the hip susceptible to posterior dislocation (Romains, 1972).
Muscles
Strong and heavy musculature provides protection and strength to the
hip joint. The tension in the iliopsoas and rectus femoris provides
anterior protection. The short lateral rotators offer protection
posteriorly. The obturator externus stabilizes inferiorly and
posteriorly while the gluteus medius and minimus protect the joint
laterally.
Flexion at the hip is produced primarily by the iliopsoas and
assisted by the straight head of the rectus femoris, sartorius and
pectineus.
Extension is produced by the gluteus maximus and assisted by
hamstrings. Hyperextension is checked by the iliofemoral ligament.
Abduction is produced by the gluteus medius and minimus and
assisted by the tensor fascia lata and sartorius. Excessive abduction is
checked by the pubo-femoral and iliofemoral ligaments and by the
tension in the adductor group of muscles. The gluteus medius and
minimus together are called the iliotrochanteric group of muscles. They
are instrumental in offering stability to the pelvis in standing on both
legs and especially during single leg balance. Weakness of abductors
dips the pelvis on the side opposite to the weak leg as it fails to
maintain the pelvis squared. This dipping of pelvis on the opposite
side of the standing leg is called positive Trendelenburg sign (Fig. 35-2).
It is positive in the following conditions: paralysis or paresis of hip
abductors, dislocation of the hip, congenital coxa vara, ununited
fracture of the neck of the femur and limb length shortening. It is
important to note that the force on the joint during standing on a
single leg is around 2.4 to 16 times the body weight (Paul, 1966;
Rydell, 1965).
FIG. 35-2 Trendelenburg sign. (A) Normal – the pelvis on the side
opposite to the normal leg is lifted upwards when standing on the normal
leg alone. (B) Positive – the pelvis on the side opposite to the affected
standing leg drops downwards when standing on the affected leg alone.
Medial rotation at the hip is produced by the anterior fibres of the

gluteus medius and minimus along with the tensor fascia lata.
Lateral rotation is principally produced by the obturators, gemelli
and quadratus femoris and assisted by the piriformis and gluteus
maximus.
Atmospheric pressure
The coverings of the joint and atmospheric pressure prevent any
communication with the exterior. They keep the joint surfaces
together and offer stability.
Blood supply
The hip joint and all its components receive rich blood supply through
the superior and inferior gluteal, circumflex, iliac and obturator
arteries.
Innervation: The pattern of innervation of the hip joint includes
branches from the femoral, obturator, accessory obturator and
superior gluteal nerves and the nerve to the quadratus femoris. The
joint receives its proprioceptive and pain fibres from the same nerves
which supply the muscles moving the joint and the overlying skin.
This explains the reflex spasm of the overlying muscles and the
referred pain to the adjacent skin in diseases of the joint (Hilton, 1971).
Compressive forces on the hip joint (fig. 35-3)

Since the hip is a principal weight-bearing joint, it is subjected to
tremendous forces in standing. When standing on one leg, the weight-
bearing femoral head is subjected to forces equal to about three times
the body weight (Paul, 1966; Rydell, 1966). These forces are produced
by the pull of the abductors and the body weight.
FIG. 35-3 Compressive forces (CF) and areas of tension (T) on the hip
joint.
Therefore, in abductor weakness, during the stance phase of the gait

cycle, the weak abductors fail to hold the pelvis squared, resulting in
downward tilt of the pelvis to the opposite side. This, in turn, results
in either a short swing phase on the normal side, or lurch on the side
of weakness. Compensatory gluteal lurch shifts the centre of gravity
lateral to the fulcrum, allowing gravity to substitute for the inefficient
hip abduction mechanism. Therefore, strengthening programmes for
the gluteus medius, gluteus minimus as well as the tensor fascia lata
are of importance in such cases.
In cases where the weak abductors cannot be strengthened, use of a
cane in the contralateral hand reduces forces on the affected hip joint
by 50%. This is achieved by transmission of the forces acting on the
hip to the cane through the lateral trunk flexors, shoulder depressors,
elbow extensors and wrist extensor muscles on the side of the cane.
Therefore, these muscles should be strengthened in the preambulatory
stage (Kessler & Hertlings, 1983).
While performing SLR in the supine position, the hip is subjected to
compressive forces greater than the body weight (Rydell, 1966). One
must remember this while initiating SLR exercises in patients with
internal fixation for hip fracture (Morris, 1971). This observation is
also applicable to initiation of strengthening programme at the hip.
The proximal end of the femur is positioned to provide maximal
compression and minimal tension and shear to combat the great
external load placed on it, like when on one limb stance. Thus,
compression becomes a maximal stress while tension and shearing are
minimal.
Therefore, if the proximal end of the femur or acetabulum develops
abnormalities like coxa valga or coxa vara, the uncontrolled external
forces may lead to problems such as subluxation or dislocation of the
hip joint, slipping of the epiphysis, osteoarthritis or even femoral
fractures.
In coxa valga, the angle between the femoral shaft and the neck is
greater than the normal (135 degrees). In paralysis of hip abductors or
spasticity of hip adductors, greater force is directed towards the upper
lip of the acetabulum. It increases the tendency towards subluxation
or dislocation (Fig. 35-4).
FIG. 35-4 (A) Coxa vara: decreased (less than 135 degrees) angle
between the neck and the shaft of the femur. (B) Coxa valga: increased
(more than 135 degrees) angle between the neck and the shaft of the
femur.
In coxa vara, the angle of inclination decreases from the normal

angle of 135 degrees. This gives rise to an increase in the bending
movement together with a more horizontal position of the neck;
putting excessive stress at the upper cortex of the neck, increasing the
shearing component at the capital femoral epiphysis and decreasing
the compressive component. This may predispose the patient to
fracture of the femoral neck or slipping of the epiphysis.
Increased compressive force may break down joint tissues and
predispose the patient to osteoarthritis. Reduction of bone strength
due to osteoarthritis or metabolic bone disease may contribute
towards fractures in geriatric patients (Mcleash & Charnley, 1970).
Therefore, a careful analysis of the factors involved in the
mechanics of hip joints play a prominent role in the planning and
implementation of the objective physiotherapy programme.
There is a definite link between the age group and the possibility of
a particular hip disorder (Table 35-1).
Table 35-1
Expected Hip Disorder as Related to the Age Group
Age Group Possible Disorder

(Years)
0–5 and 25–45 CDH or DDH
2–10 Perthes disease, transient
synovitis
2–18 Tuberculosis
6–12 Still disease
4–18 Infective arthritis
12–17 Slipped femoral epiphysis
22–55 Rheumatoid or osteoarthritis
45–70 Fracture of the femoral neck
Secondary bone tumours
Coxa vara
A decrease in the angle between the neck and the shaft of the femur
(normal about 135 degrees in adults and 150 degrees in children) is
called coxa vara. On the other hand, if the angle is more than the
normal values it is called coxa valga.
Coxa vara is of the following types:
1. Congenital (infantile)
2. Epiphyseal (slipped capital femoral epiphysis)
The change in the angle causes mechanical restriction of abduction

at the hip, shortening of the limb and a waddling gait.
Congenital (infantile) coxa vara

It is characterized by a triangular defect in the inferior portion of the
neck of the femur (as seen on an AP view X-ray of the hip) (Fig. 35-5)
(Wynne-Davis Fairbank, 1976). It is usually bilateral and may present
with pain and stiffness of the hip. On examination the greater
trochanter is overridden with resultant shortening of the limb. There
is limitation of rotation and abduction of the limb joint.
FIG. 35-5 Congenital coxa vara.
Treatment
Conservative: Conservative treatment has a very limited role in the
management of congenital coxa vara. Milder forms of deformity can
be treated by bed rest to relieve strain on the epiphysis; or it can be
treated by traction in abduction for 4–6 weeks followed by weight
relieving orthosis or POP for 12–18 months.
Surgical treatment
It is indicated in progressive or severe deformity. A corrective (valgus)
osteotomy is performed at the intertrochanteric level to increase the
neck–shaft angle. The osteotomy is generally fixed internally by a
plate and screws (Fig. 35-6). Postoperatively, a dressing is given for
about 2 weeks. Mobilization of the hip and non–weight-bearing crutch
walking can be started as soon as pain permits, while weight-bearing
is allowed after 2–3 months.
FIG. 35-6 Corrective valgus osteotomy for coxa vara. (A) Area of bony
wedge at the intertrochanteric region and (B) Fixation of the corrective
osteotomy by plate and screws.
Epiphyseal coxa vara or slipped capital femoral

epiphysis
A condition prevalent in adolescents, it is characterized by sudden or
gradual slip of the upper femoral epiphysis resulting in coxa vara (Fig.
35-7) due to strain on the growing bone.
FIG. 35-7 Slipped capital femoral epiphysis. (A) Normal position of the
epiphysis. (B) Posterior and downward slipping of the epiphysis.
Trauma and imbalance between growth and sex hormones have

been thought to be the causes of this condition.
This disorder is more common in males between the ages of 12 and
17 years. The child presents with pain in the region of the hip, and a
limp. However, initially, the clinical experiences increased tiredness
after walking a short distance or standing for some time. On
examination, the greater trochanter is at a higher level on the affected
side. Abduction, internal rotation and hyperextension are restricted at
the affected hip. A characteristic sign is external rotation of the limb
when the hip and knee are flexed.
X-rays: X-ray of the pelvis with both hips shows medial, inferior
and posterior displacement of the capital femoral epiphysis (Fig. 35-8).
FIG. 35-8 Slipped capital femoral epiphysis of right hip.
Treatment
In early cases with mild displacement of the capital epiphysis, the
epiphysis is fixed with Moore’s pins or screws under radiographic
control, without attempting reduction of the slip (Fig. 35-9).
FIG. 35-9 Slipped capital femoral epiphysis fixed with Moore’s pins.
The following procedures are performed in cases with marked

displacement of the epiphysis:
1. Open reduction: The slip is reduced by open reduction and fixed by

pins or screws.
2. Osteotomy of the neck of the femur: An osteotomy is performed at

the junction of the neck of the femur with the greater trochanter and a
wedge of bone is removed to achieve correction (Fig. 35-10).
The afore-mentioned procedures (1 and 2) carry a risk to the

femur (Duttire & Bentley, 1996).
3. Subtrochanteric osteotomy: In this procedure, the epiphyseal slip is

left as such and a corrective osteotomy is performed in the
subtrochanteric region to change the alignment to a certain extent (Fig.
35-11). It does, however, compensate to some extent for the deformity
and may, if done in the early stages, considerably improve the gait
and relieve symptoms (Griffith, 1991).
FIG. 35-10 Slipped capital femoral epiphysis—osteotomy performed

through the neck of femur, in two planes to normal relationship of the
epiphysis and neck of femur. (A) Preoperative, (B) Postoperative.
FIG. 35-11 Subtrochanteric osteotomy for slipped capital femoral

epiphysis. (A) BW, bony wedge for subtrochanteric valgus osteotomy; E1,
slipped epiphysis. (B) Restoration of epiphysis (E2) to normal position
following subtrochanteric valgus osteotomy.
◼ Strong vigorous active movement to the ankle and toes.
◼ Isometrics to be concentrated for the quadriceps and the glutei.
Mobilization
◼ Relaxed passive movements with emphasis on the hip abductors

and the internal rotators.
◼ Putting on weight-relieving orthosis, standing balance with PWB;

making sure that the correct level of pelvis is maintained.
◼ Re-education in walking to eliminate pelvis drop and waddling

gait.
◼ When present, the limb length disparity should be compensated.
Coxa valga
An increase in the neck–shaft angle of the femur is called coxa valga. It
is seen in poliomyelitis or other paralytic conditions and some
dysplasias.
Treatment
Corrective (varus) osteotomy is done at the intertrochanteric level.
The osteotomy is fixed internally with a plate (Fig. 35-12).
FIG. 35-12 Corrective varus osteotomy for coxa valga. (A) Area of bony
wedge at the intertrochanteric region for osteotomy. (B) Internal fixation of
the osteotomy by plate and screws.
Perthes disease (syn: Legg–calve–perthes

disease, coxa plana, pseudocoxalgia) (fig. 35-
13A)
Perthes disease is a disease of childhood characterized by avascular
necrosis of the femoral head. The exact cause is unknown. However, a
local disturbance of blood supply is thought to be the main causative
factor.
FIG. 35-13 Perthes disease: (A) Radiograph. (B) four grades of

progression: (I) appearance of cyst formation in the anterolateral aspect of
the femoral capital epiphysis; (II) involvement of about half portion of the
capital femoral epiphysis; (III) most of the capital femoral epiphysis (nearly
three-fourth) is involved and (IV) complete involvement of the capital
femoral epiphysis.
The epiphysis of the femoral head becomes necrotic and soft. There
occurs hypertrophy of the articular cartilage, particularly on the
medial side of the head of the femur, pushing the femoral head
laterally outside the lateral edge of the superior (weight-bearing) part
of the acetabulum (Fig. 35-14). In this state, it is susceptible to
deformation if subjected to the stresses of weight bearing. Although,
the disease is self-limiting in nature and the head revascularizes and
hardens again after sometime, it never regains the normal shape if
deformed. The whole process takes about 2–4 years.
FIG. 35-14 Perthes’ left hip. Note the fragmentation of the femoral head,
broadening of the femoral neck and part of the head of femur outside the
lateral edge of superior part of acetabulum.
It affects children between 5 and 10 years of age and may be

unilateral or bilateral. The child complains of pain in the hip and
walks with a limp. All movements of the hip are limited, especially
those of abduction and medial rotation.
Radiograph confirms the diagnosis (Fig. 35-13A) and shows the
stage of the disease (Grades I–IV) (Fig. 35-13B).
Treatment
1. When the hip is irritable (acute stage), the limb is immobilized in
skin traction. The hip is mobilized as soon as the pain and spasm
disappear.
2. In Grades I and II of the disease, no specific treatment is required;

however, the child is kept under observation (also called supervised
neglect).
3. In Grades III and IV of the disease, the goal of treatment is to

prevent the collapse/deformity of the femoral head. This happens
when the femoral head is subjugated to the stresses of weight-bearing
and muscular forces. When the head is not deformed, it is contained
inside the acetabulum by maintaining the hip in abduction. It can be
achieved by a plaster, splint, or by surgery (varus osteotomy of the
proximal femur or osteotomy of the pelvis).
4. In Grades III and IV of the disease, when the head is deformed, no

treatment is possible. Osteoarthritis of the hip will develop eventually,
which may need surgery in the form of total hip replacement.
Basic objective: Regaining the maximum possible range of motion at
the affected hip along with the strength to achieve physical
independence. The therapeutic approach has the following functions.
1. Reduction of muscular spasm, pain and inflammation: Muscular

spasm due to the disease process is the primary cause of pain and
deformity. It can be controlled by applying cryotherapy techniques or
moist heat with the leg maintained in traction and gentle active toe
and foot measurement with traction on.
2. Isometric painless contractions: Isometric painless contractions

should be taught for the hip extensors, abductors and quadriceps with
the leg in traction.
3. Intermittent compression of the joint: It can be achieved by early

slow relaxed passive movements. This helps in improving
nourishment of the joint cartilage, moulding the joint surfaces and
maintaining normalcy of the soft tissues (Ferguson, 1968; Petrie &
Bitenc, 1978).
4. Maintenance of the range of motion: The full range of movements

of hip extension, abduction and internal rotation is carried out and
measured at regular intervals. These movements usually get limited
due to the adaptive resting posture of the limb in flexion, abduction
and external rotation. This resting posture in one position can cause
adaptive shortening of the muscles and lengthening of the opposite
group of muscle in which the limb is kept, e.g. if limb is in flexed
position then the extensor group of muscles may get elongated.
Consequently, the flexor group of muscles will pull all the more
aggravating the flexion deformity (Kendall, McCleary, & Provance,
1993, pp. 334–335).
Earlier the mobilization, faster and better the results.
Reduction in the hip range of motion: Mainly in abduction,

flexion and internal rotation may lead to hypotrophy or
atrophy of the thigh muscles. The latter posture results due
to distension of the joint capsule following synovitis
(Eyring & Murray, 1964).
If the tendency for malpositioning of the limb persists, a

splint may be used to maintain the hip in abduction,
extension and internal rotation.
5. Prevention of contractures: The tendency to develop flexor

tightness and flexion contracture at the hip is common. This
complicates ambulation and the gait pattern when the child is allowed
to bear weight. Therefore, proper care is necessary to avoid flexion
contracture at the hip. Regular sessions of flexing the normal hip and
gently stretching the affected hip into extension are taught and
checked. This can be made effective by using the force of gravity and a
tolerable weight (Fig. 35-15). Frequent sessions of assisted prone lying
are also helpful in preventing flexion contractures at the hip.
6. Increase of muscle strength: As the pain and spasm reduce, active-

assisted, active or resisted exercises may be started depending upon
the degree of discomfort. The emphasis should be on the eccentric and
isometrics at the terminal range of movement to the abductors and
extensors of the hip, quadriceps and hamstrings, and dorsiflexors and
plantarflexors and intrinsic muscles of the foot.
7. Ambulation: Initially the child is not allowed weight bearing since

the leg may be immobilized in a POP cast or abduction splint.
Therefore, non–weight-bearing standing and walking are to be taught
in parallel bars. This could be progressed to a walker and then to
axillary crutches by using a special Synder sling. This allows non–
weight-bearing ambulation on the affected leg. All the basic methods
of ambulation with crutches and transfer activities are taught.
FIG. 35-15 Prevention of hip flexion contracture by sustained light weight.

Special braces for weight-bearing with hip containment
1. A special brace (Scottish Rite brace) allows flexion of the hip joint
while it is maintained in abduction.
2. The second method is the Petrie plaster method (Fig. 35-16). This
maintains the hip in 30 degrees of abduction and 20 degrees of
internal rotation, with 15 degrees of flexion at the knees.
FIG. 35-16 Broomstick plaster (Petrie).
Computerized gait analysis of a patient suffering from Perthes

disease reveals two distinct gait patterns.
1. This pattern corresponds well with the Trendelenburg pattern, i.e.,

pelvic drop to the swinging limb during single stance phase of more
than 4 degrees and maximum of more than 8 degrees.
Trunk lean in relation to the pelvis to the stance limb during

single stance phase of more than 5 degrees. Thin pattern
does not educe hip loading and femoral head coverage is
reduced, so should be treated during physiotherapy.
Hip adduction during single stance phase more than 9

degrees and maximum up to 11 degrees.
2. This gait pattern which is found in 36.4% of patients is characterized

by trunk lean of 3 degrees towards the stance limb. The pelvis is either
level or elevated on the swinging limb side. This leads to reduction of
abductor management and production of hip unloading effort; it
corresponds to the Duchenne gait pattern.
The child needs training in balanced standing, weight

bearing and ambulatory activities. Appropriate guidance
to the parents regarding support and assistance to the child
is a must during home ambulation.
On removal of the splint/POP cast/brace, active mobilization

is to be initiated. It is progressed from relaxed passive
movements to active resisted movements in stages.
Hydrotherapeutic pool exercises are very useful at this
stage.
Instructions regarding proper postural management to avoid

tightness or contractures of the susceptible muscle groups
need to be emphasized. Regaining full range of movements
at the knee is very important at this stage. Initial weight
bearing has to be assessed carefully for pain. If pain is felt
on weight bearing, ischial weight relieving brace may be
given.
In a short limb, weight bearing should be initiated with an

adequate shoe raise to avoid pain and excessive
compressive forces on the affected hip. Functional
positions like squatting on the floor, cross-leg sitting and
stair climbing should be initiated with enough support and
minimal discomfort. The assistive aids should be gradually
reduced. The total outcome of management depends upon
the course of the disease.
The importance of continuing regular resistive exercises to

the hip needs to be explained. Undue fatigue or straining
positions should also be discouraged, with proper
guidance for smooth rhythmic ambulation. These three
factors need to be educated keeping in view the possibility
of early osteoarthritis in the affected hip joint at a later date
(Somerville, 1971).
Physiotherapeutic management following surgery: Varus
derotation osteotomy of the femur is the usual surgical procedure. It
allows better containment of the femoral head within the acetabulum.
After surgery, the limb is immobilized in a hip spica for a period of
6 weeks and the physiotherapy is limited to:
1. Resistive toe movements and isometrics for the hip and knee
muscles inside plaster for the affected side.
2. Resistive full range movements for the contralateral knee, ankle and
toes with isometrics for the hip abductors and extensors.
Mobilization: After removal of hip spica, gradual mobilization of

the hip and knee is initiated with relaxed passive movements.
Continuous passive motion (CPM) equipment is very useful to initiate
the relaxed passive ROM exercises.
Mobilization, strengthening and ambulation are progressed as
described for conservative treatment.
Avascular necrosis (fig. 35-17)
Avascular necrosis (AVN) of the femoral head, also called
osteonecrosis, is caused by disruption of blood supply to the femoral
head.
FIG. 35-17 Avascular necrosis of bilateral femoral heads. Note the

sclerosis and deformation of the femoral head.
Aetiology
It can be caused due to injury to the hip joint or due to other causes.
1. Post-traumatic: Fracture of the femoral neck

◼ Dislocation of the hip
2. Nontraumatic: Steroid-induced
◼ Organ transplant
◼ Alcoholism
◼ Sickle cell disease
◼ Systemic lupus erythematosus (SLE)
◼ Postirradiation
3. Idiopathic
Clinical features
The patient presents with pain and limitation of movements at the
affected joint with a limp. In two-thirds of the cases, the disease is
bilateral. Initially, the patient has night pain aggravated by activity.
Later in the course of the disease, the pain is continuous, deep seated
and rather ill defined. On examination, there is limitation of
movements at the hip joint and internal rotation is painful.
Investigations
1. X-ray of the hip shows increased sclerosis, cyst formation and

deformation (in the later stages of the disease) of the femoral head
(Fig. 35-18). The disease can be staged radiographically (Ficat & Arlet,
1964) (Table 35-2).
2. MRI is the gold standard in the diagnosis of AVN with a sensitivity

and specificity of more than 98%.
FIG. 35-18 AVN of the femoral head right side. Note the sclerosis and
deformation of the head of femur.
Table 35-2
Stages of Osteonecrosis
Stage I X-rays normal

Biopsy positive
Bone scan may be positive
Stage II Bone quality abnormal (on X-
rays)
Bone outline intact
Joint space preserved
Stage Bone outline disrupted
III
Sequestrum formation
Joint space preserved
Stage Secondary osteoarthritis
IV
Treatment
The treatment, in a case of osteonecrosis, depends upon several factors
such as the patient’s age, stage of the disease, patient’s occupation and
life expectancy. However, the following procedures may be
performed, depending upon the merit of a particular case.
In the early stages of the disease
Core decompression of the femoral head: Raised intraosseous pressure is

reported to impair the vascularity of the bone leading to avascular
necrosis. Drilling the centre of the neck and head of the femur
decompresses the bone thereby decreasing the intraosseous
pressure. This procedure relieves pain and may arrest progression of
the disease (Fig. 35-19).
Core decompression and nonvascularized fibular bone grafting: In addition

to the operation of core decompression of the femoral neck and
head, a fibular graft is inserted into the hole thus drilled (Fig. 35-19).
This may provide support to the femoral head, prevent collapse and
help in the repair of the recipient bone.
FIG. 35-19 Avascular necrosis of the femoral head, treated by core

decompression and fibular grafting. The fibular graft is seen in place.
Core decompression and vascularized bone grafting
Vascularized fibular graft (with vascular anastomosis) provides
structural support and enhancement of vascularity in the recipient
area to promote healing.
In the late stage

An intertrochanteric valgus osteotomy is performed. This shifts the
area of weight bearing from the affected superolateral part of the
femoral head to other normal areas.
Revascularization, muscle and pedicle bone graft are the other
alternative procedures.
In the advanced stage of the disease

When significant collapse of the femoral head is present, associated
with secondary osteoarthrosis of the hip, total joint replacement is
indicated (Fig. 35-20).
FIG. 35-20 (A) Advanced case of avascular necrosis of the femoral head
with secondary osteoarthritis, seen on both sides and (B) treated by total
hip replacements on both sides.
The approach of physiotherapy depends upon the surgical procedure
adopted.
Non–weight-bearing phase: During the immediate postsurgical

phase, vigorous exercises to the ankle and foot, along with
isometrics to the quadriceps and hamstrings are begun. As the pain
reduces, isometrics to the glutei should be initiated.
Gentle mobilization in the form of relaxed passive

movements is initiated gradually and worked up to the
maximal pain-free range.
Isometrics with longer holds are important to minimize

muscle atrophy. Mobilization should be concentrated to
regain abduction and medial rotation as restriction of these
movements and muscle atrophy have been reported as
salient features following AVN.
Isotonic exercises including all movements at the hip are

initiated when good ROM returns and progressed to
isokinetic exercises.
Weight-bearing phase: Initially, weight bearing is taught in standing

with axillary crutches or a walker. Gradually, weight transfers on
one leg are taught. Four-point crutch walking is initiated to
minimize weight on the hip joints. As the pain is reduced, one
crutch should be discarded. Meanwhile the exercise programme to
the hip and knee is made progressive to improve strength and
endurance of the muscles at the hip and knee joints.
Once an acceptable gait and balance are achieved,

ambulation is progressed to two canes or a single cane
without compromising the pattern of gait.
Activities like supported squatting or cross-leg sitting should

be initiated with adequate support to avoid over-
stretching.
Adequate independence in functional activities should be

regained by 12–16 weeks. Physiotherapy following
osteotomy and total joint replacement is described under
the respective headings.
Osteochondritis
It is a noninfective and noninflammatory condition causing
disturbance of vascularity in the epiphysis or in the ossification
nucleus which may get softened and deformed.
Common sites of osteochondritis

◼ Head of femur (Perthes)
◼ Lunate (Kienbock disease) (Fig. 35-21)
◼ Vertebral epiphysis (Scheuermann disease)
◼ Tibial tubercle (Osgood–Schlatter disease)
◼ Lower end of femur (Osteochondritis dissecans)
◼ Elbow (Capitulum)
◼ Rarely Ankle (talus)

FIG. 35-21 Kienbock disease. Avascular necrosis of the lunate bone. Note
the collapse of the lunate (arrow).
Treatment
Treatment is on the same lines as avascular necrosis or Perthes
disease.
Rare hip pathologies

Irritable hip
History of mild trauma, limp and restriction of movements in a child
due to transient synovitis may cause irritable hip.
The patient presents with painful weight bearing while performing

movements of the hip joints.
It is treated with NSAIDs, rest and gentle traction till the diagnosis is
confirmed.
Dysplasia
The presence of excessive acetabular slope localizes the weight-
bearing forces on the central area of the femoral head.
Painful limp with movement restriction are the typical features.
Failure of conservative treatment may need surgical intervention to
improve the containment of the femoral head like Chiari’s osteotomy,
acetabular shelf operation or high femoral osteotomy.
Iliotibial tract syndrome

The iliotibial tract syndrome presents as pain over the upper part of
the lateral aspects of the thigh or at the lateral aspects of the knee with
occasional limp after excessive cycling. This condition is common
amongst young persons.
Examination of the spine, hip, knee or sacroiliac joints does not
reveal any positive findings. However, Ober’s test indicates selective
tightening of the iliotibial band. In this test, the affected thigh fails to
reach the horizontal plane when tested in a side lying position (Fig.
35-22). The tightening may be present in the vastus lateralis also,
which may result from the excessive lateral pressure syndrome.
FIG. 35-22 Ober’s test to detect tightening of the iliotibial tract. Thigh fails
to reach the horizontal plane when abduction is attempted following passive
adduction–extension and internal rotation.
Treatment
The basic approach of treatment is the regularly performed graduated
sustained stretching of the affected muscle.
1. Discontinue cycling.
2. Hydrocollator pack over the iliotibial band and vastus lateralis.
3. Ultrasonic exposure over the tender area.
4. Short but sustained sessions of iliotibial band stretching.
Wester and Beaton (1988) modified Ober’s test to achieve effective

stretching. It combines hip adduction, extension and lateral rotation
with knee flexion. This was done with a 10-second hold in the
maximally stretched position, six times a day.
Bibliography
1. Amtmann E, Kummer B. The stress of the human hip joint
magnitude and direction of the resultant force in the frontal
plane. Z Anat Entwick Gesch. 1968;127:286-374.
2. Anson BJ, McVay. (5th ed.) Surgical anatomy. Philadelphia: WB
Saunders Company. 1971;1089-1101.
3. Bombelli R. Osteoanthritis of the hip. New York: Springer. 1983.
4. Brinchmann P, Frobiu W, Hierholzer E. Stress of the articular
surface of the hip joint in healthy adult persons with idiopathic
osteoarthritis of the hip joint. Journal of Biomechanics,.
1981;14:149-156.
5. Duttire RB, Bentley G. Mercer’s orthopaedic surgery. London:
Arnold. 1996.
6. Eyring EJ, Murray WR. The effect of joint position on the
pressure of intra-articular effusion. Journal of Bone and Joint
Surgery. 1964;46(A):1235.
7. Ferguson AB. 3rd ed Orthopaedic surgery in infancy and
childhood. Baltimore: Williams and Wilkins Company. 1968;173-–
186.
8. Griffith MJ. G. Bentley R.B. Geer Rob and Smith’s operative
surgery, orthopaedics Slipped upper femoral epiphysis. London:
Butherworth-Heinemann. 1991;909-920.
9. Hilton J. 1950 E. W. Walls E. E. Phillip H Quoted in E.
Lachman, Studies in anatomy (2nd ed.) Rest and pain. New York:
Oxford University Press. 1971;319.
10. Kessler RM, Hertlings D. Management of common musculo-
skeletal disorders. Philadelphia: Harper and Row,. 1983;378.
11. Mcleash RD, Charnley J. Abduction forces in the one-legged
stance. Journal of Biomechanics. 1970;3:191-–209.
12. Paul JP. The biomechanics of the hip joint and its clinical
relevance. Proceedings of the Royal Society of Medicine,.
1966;59:943-–947.
13. Petrie J, Bitenc I. Abduction weight bearing treatment in Legg-
Perthes’ disease. The Journal of Bone & Joint Surgery.
1978;53(B):54.
14. Romains GJ. Cunningham’s textbook of anatomy. London: Oxford
University Press. 1972;172-663.
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persons. Acta Orthopaedica Scandinavica. 1966;88(Suppl):1.
16. Rydell N. R.M. Kenedi Forces on the hip joint:: Intravital
measurements in biomechanics and related bioengineering topics.
Oxford: Pergamon Press. 1965;351-–357.
17. Somerville EW. Perthes’ disease of the hip. The Journal of Bone
& Joint Surgery. 1971;53(B):639.
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Philadelphia: WB Saunders Company. 1973;446-567.
19. Wester B, Beaton P. Iliotibial tract syndrome. Physiotherapy.
1988;75(12):637.
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general affections of the skeleton. Edinburgh, London, New York:
Churchill Livingston. 1976.
CHAPTER
36
Regional orthopaedic conditions at the knee
OUTLINE
◼ Functional anatomy
◼ Examination of the knee
◼ Ligament injuries
◼ Arthroscopy and arthroscopic surgery
◼ Osteotomy around the knee
◼ Quadricepsplasty
◼ Chondromalacia patellae
◼ Osteochondritis dissecans
◼ Popliteal cysts
Functional anatomy
The knee is a modified hinge joint which plays an important role in
stabilizing the body in an erect posture. The osseous portions of the
knee include the femur, tibia, patella and fibula (Fig. 36-1). These
osseous portions together form two joints:
1. Tibiofemoral joint
2. Patellofemoral joint
FIG. 36-1 Knee joint. (A) Anteroposterior view. (B) Lateral view from
medical aspect. F, femur; T, tibia; P, patella; TCL, tibial collateral ligament;
PFJ, patellofemoral joint; Q, quadriceps; QFT, quadriceps femoris tendon.
The tibiofemoral joint is divided into the medial and lateral

compartments (Blackburn & Craig, 1980). The function of the knee
joint primarily depends upon its static and dynamic stability. The
knee derives its static stability from the ligaments, whereas the
dynamic stability is attained through the musculotendinous units and
their aponeuroses (McCluskey & Blackburn, 1980).
Static stability
The distal end of the femur has medial and lateral condyles. They are
convex from side to side and are separated by an intercondylar notch
in between. The proximal end of tibia has two condyles which are
concave from side to side and are separated by raised medial and
lateral intercondylar eminences or tibial spines. Therefore, convexities
of the condyles of the femur with the intercondylar notch are well
secured to the concavities of tibial condyles and tibial spine. This
offers static stability to the knee joint in extension. A thin fibrous
capsule, which is the largest synovial joint capsule in the human body,
provides an additional covering to the joint.
Dynamic stability
The basic frame for static as well as dynamic stability is provided by
the condyles of the femur and the tibia, strong ligaments, powerful
muscles and the medial and lateral menisci. Functions of the menisci
are as follows (Fig. 36-2):
1. They act as space occupying washers to maintain the joint space

and serve as shock absorbers against compressive forces (Grood,
1984), taking about 50–70% of the load across the knee.
2. They provide a concave surface over the convex tibial plateaus for
stable articulation with the femoral condyles. This improves joint
stability by decreasing the contact stress on the articular surfaces of
the knee (Grood, 1984; Manquet & Pelzer, 1977; Walker & Erkman,
1975).
3. They improve nutrition and lubrication of the articular cartilage by

spreading synovial fluid over it.
4. They bear weight and transmit between 50% and 70% of the load
applied across the joint.
5. They also facilitate rotation of the opposing articular surfaces of the

knee joint during locking and unlocking. To understand the
interaction between osseous and soft tissue components, in relation to
the dynamic stability, the knee is subdivided into:
(a) Medial compartment
(b) Lateral compartment
(c) Extensor apparatus

FIG. 36-2 Major knee ligaments and their attachments. LM, lateral
meniscus; ACL, anterior cruciate ligament; PCL, posterior cruciate
ligament; MM, medial meniscus.
Medial compartment
Ligaments: The medial meniscus is closely attached to the femur and

tibia by meniscofemoral and meniscotibial ligaments, respectively,
which lie deep to the tibial collateral ligament. Therefore, its motion
is less. The posterior cruciate ligament, ‘the main stabilizer’ of the
knee, consists of posteromedial and anterolateral fibre bundles.
During knee flexion, the anterolateral bundle is tense while in
extension, the posteromedial bundle becomes taut to prevent
posterior displacement of the tibia on the femur. However, they may
be torn on forceful hyperextension of the knee.
Muscles: The pes anserinus group consisting of the sartorius, gracilis

and semitendinosus provide medial stability because of their
anatomical disposition. The semimembranosus with its five
branches offers support to the posterior and posteromedial capsule,
medial meniscus and tibia. The muscular attachments to the medial
meniscus pull the medial meniscus posteriorly during flexion.
Lateral compartment
Ligaments: Like the medial meniscus, the lateral meniscus is also
closely attached by meniscofemoral and menisco-tibial lateral capsular
ligaments. The anterior third of the lateral capsule provides some
static support. The middle third of this lateral capsular ligament
provides support against anterolateral rotatory instability. The
posterolateral third of the lateral compartment is supported by the
arcuate complex. It consists of the arcuate ligament, fibular collateral
ligament, tendon of the popliteus and posterior third of the lateral
capsular ligament. The anterior cruciate ligament, also a part of the
lateral compartment, has two major fibre bundles, namely,
anteromedial and posterolateral. There is an intermediate bundle in
between these two bundles. The tension in the anterior cruciate
ligament provides stability to the knee as it moves from flexion to
extension. It also prevents anterior displacement of the tibia on the
femur.
Muscles
1. They provide force for the strong movements of the knee joint
2. They provide dynamic stability
3. They cause absorption of the weight-bearing forces as well as the

forces generated during activity
The muscular support is provided mainly by the iliotibial band,

iliotibial tract, biceps femoris and popliteus muscles. The popliteus
muscle, which originates from the lateral femoral condyle and is
inserted on the posterior medial edge of the tibia, reinforces the
posterior third of the lateral capsular ligament. The posterior third of
the lateral capsular ligament is responsible for internal rotation of tibia
during the initial flexion of the knee producing unlocking or ‘screw
home’ mechanism of the knee.
At the posterior compartment, the joint stability is mainly achieved
by thick and doubly strong posterior cruciate ligament.
Extensor apparatus
Its components are as follows:
1. Patella
2. A group of six extensor muscles and the quadriceps femoris tendon
3. Patellofemoral and patellotibial ligament (ligamentum patellae)
4. Patellar bursae and fat pads in the infrapatellar and suprapatellar

regions
5. Synovial membrane and capsule in the antero-medial and

anterolateral portions of the joint
The efficiency of the extensor mechanism largely depends upon the

unity and function of three structures, i.e., the patella, quadriceps
femoris and ligamentum patellae.
1. Patella: It provides dynamic stability to the knee joint during the

varied movements because of its shape and location.
2. Extensor group of muscles: The critical strength and support necessary

for the extensor mechanism are provided by the quadriceps
apparatus. The latter consists of the rectus femoris, vastus
intermedius, vastus lateralis, vastus medialis longus, vastus medialis
oblique fibres, articularis genu and the patellar ligament (patellar
tendon) (Fig. 36-3). The selective action of these attachments also
provides varying degrees of dynamic stability.
The knee joint is most stable when it is locked in full

extension by the action of the quadriceps femoris. The
active contraction of the quadriceps also controls the knee
in a position which is short of full extension. Thus the
efficiency of the extensor mechanism plays a vital role in
the stability of the knee.
3. Patellofemoral and patellotibial ligaments: Along with the thickened

extensor retinaculum, which covers the anterior portion of the knee, it
mainly offers stability to the patella.
4. Patellar bursae and fat pads: Prepatellar bursa, infrapatellar bursa,

along with the bursae at the anterior, medial and lateral portions of
knee and the infrapatellar fat pad provide ease of action to the
extensor mechanism by reducing friction. The prepatellar and
intrapatellar bursae are prone to inflammation.
5. Synovial membrane: The synovial membrane of the knee is developed

from three separate pouches (plica). The plica courses medially
beneath the extensor mechanism and runs distally across the medial
patellar border and medial femoral condyle, finally attaching to the fat
pad.
FIG. 36-3 Extensor group of muscles. RF, rectus femoris; VL, vastus
lateralis; VM, vastus medialis; VML, vastus medialis longus; VMO, vastus
medialis oblique; P, patella; LP, ligamentum patellae; TT, tibial tubercle.
Movements of the knee joint

The primary movements occurring at the knee joint are flexion and
extension. Besides these, a small degree of lateral and medial rotations
are also possible.
In extension: In extension of the knee, the lateral femoral condyle,
along with the lateral meniscus, moves around its axis, and becomes
close packed first. The medial femoral condyle, along with the
medial meniscus, starts rotating medially and moves backwards on
the tibia at least 30 degrees short of full extension. However,
maximum backward shift and rotation occurs during the terminal 10
degrees of extension with screw home mechanism which tightens
the ligaments and provides stability at the terminal range of
extension.
In flexion: When the knee is flexed from full extension, the opposite
movement takes place at the femoral condyles and their menisci.
The femur rotates laterally with the lateral meniscus moving
backwards on the tibia. However, these movements are completed
within the first few degrees of flexion (Barnett, 1953). The retraction
of the lateral meniscus and the lateral rotation of the femur are
brought about by popliteus which is attached to the lateral meniscus
and lateral femoral condyle (Last, 1950).
In rotation: During rotation, the menisci and femur move together in a

small arc. The tibia does not participate in this movement.
As the lateral meniscus is close to the vertical axis of rotation and is

loosely attached, it moves swiftly along with the lateral condyle.
Whereas, the periphery of the medial meniscus, which is closely
attached to the femur, moves with the femur; and its widely separated
anterior and posterior horns move with the tibia. Therefore, the
rotation of the femur causes more distortion of the medial meniscus,
making it more prone to injury (Last, 1950).
Role of iliotibial tract in stabilizing the knee joint
1. During standing, when the knee is in extended position and the

weight-bearing axis passes in front of knee joint, the taut iliotibial tract
maintains extended position without any muscular effort.
2. In walking or running, when the knee is flexed, the weight-bearing
axis falls in front of the iliotibial tract. It causes elongation of the
gluteus maximus which contracts powerfully as the movement
proceeds.
3. In rising from sitting position when the line of weight-bearing falls

behind the hip and knee, the gluteus maximus extends the hip. Later
on as the knee starts extending, the iliotibial tract provides the needed
support for the quadriceps to act optimally.
Locking and unlocking mechanism of the knee (fig. 36-4)

Locking mechanism: In the mechanisms of locking and unlocking, the
femoral condyles roll and glide over the articular surfaces of tibial
condyles.
FIG. 36-4 Locking and unlocking at the knee: MFC, medial femoral
condyle; LFC, lateral femoral condyle; P, patella; T, tibia; FL, fibula.
In the final stages of extension, the lower fibres of the vastus

medialis play a major role because:
1. The lower fibres of the vastus medialis originate from the adductor
magnus which is taut during extension.
2. They exert pull on the medial side of the patella which is pressed
firmly against the patellar surface of the femur. This indirectly results
in medial rotation of the femur. This medial rotation of the femur in
the terminal 15 degrees of extension tautens the forwardly directed
tibial collateral ligament and backwardly directed fibular collateral
ligament. The anterior cruciate ligament and the oblique popliteal
ligament also become taut. As a result the lower limb is converted into
a rigid pedestal.
Unlocking mechanism: At the commencement of flexion, the

popliteus muscle rotates the femur laterally over the articular surface
of the tibia by drawing the posterior horn of the lateral meniscus
backwards.
Locking (A): In a position of full extension with the foot firmly
placed on the ground, the knee joint gets rigidly locked in extension –
therapeutically the most important functional position of maximum
stability. It is masterminded by:
◼ Backward sliding of the medial condyle of the femur with sudden

medial rotation of the femur on the tibia
◼ Tautening of the anterior cruciate ligament, tibial and fibular

collateral ligaments, the oblique popliteal ligament and the posterior
part of the joint capsule
Unlocking: The knee begins to flex from the locked position by the
controlled action of the popliteus muscle bringing about lateral
rotation of the femur on the tibia (as evident from the near
superimposition of the femoral condyles (B).
The lateral rotation of the femur on the tibia continues as the
movement of knee flexion is continued further, evident from the
outline of the lateral femoral condyle and the intercondyler space (C).
The patella gradually rises higher on the patellar surface of the
femur as the knee assumes the position of extension.
Movements of the patellofemoral joint

There is no large excursion of the patella as it is fixed inferiorly by the
ligamentum patellae. Its apparent movement is only due to the
relative displacement of the femoral condyles. In full extension, the
lower part of the patella is above the joint line. In full flexion, it comes
to lie against the femoral condyles.
Muscles acting in movements of flexion and extension
Flexion: The principal muscles are the biceps femoris, semitendinosus

and semimembranosus. Assisted chiefly by the sartorius, gracilis
and popliteus, the gastrocnemius and plantaris also provide some
assistance.
Extension: The principal extensor of the knee is the quadriceps femoris.

It is assisted by the tensor fascia lata and the gluteus maximus via
the iliotibial tract.
Nerve supply: The nerve supply to the knee joint comes from the
genicular branches from the tibial and common peroneal nerves, the
obturator nerve, medial intermediate and lateral femoral cutaneous
nerves and the saphenous nerve via the patellar plexus.
Blood supply: The blood supply to the knee is by both the femoral and
popliteal arteries. Their branches form an anastomosis around the
knee joint and also supply the joint.
Examination of the knee

The history taking is as usual; however, a few additional points may
be noted. The symptoms of a knee disorder are pain, swelling,
haemarthrosis limitation of movements and occasionally deformity. In
case of a knee injury, there may be symptoms of locking of the joint or
a feeling of ‘giving way’ at the knee joint while walking or getting
down the stairs. The nature of pain can often give a clue to the
diagnosis (Table 36-1). Various postures of leg precipitating pain
should also be noted.
Table 36-1
Pain Characteristics and the Possible Lesions
1. Sharp catching pain Mechanical defect

2. Aching type pain with morning stiffness which eases with Degenerative changes
movements but gets worst with exertion
3. Night pain Degenerative changes, lateral cystic
cartilage, meniscal tear
4. Pain on weight bearing Mechanical or arthritic lesion
5. Pain while climbing up or down the steps or rising from chair Patellofemoral origin
6. Pain on twisting Meniscal origin
7. Pain over tibial tuberosity after exercise in young adults Osgood Schlatter disease
Inspection
The knee joint is inspected from all sides to note: attitude of the leg,
wasting of the quadriceps, any swelling around the knee joint and its
characteristics, and any anatomical deviations such as genu varum or
valgum.
The gait pattern is analysed in respect to the individual segments –
hip, knee, ankle and foot.
Palpation
The findings of inspection are confirmed by palpation. Note the skin
surface, temperature of the skin/swelling, sensibility, etc. Areas of
tenderness are identified. Swelling, if any, should be evaluated to
know whether it is a soft tissue swelling or a bony swelling or a joint
effusion. The type of swelling can give a clue to the diagnosis of the
possible lesion (Table 36-2).
Table 36-2
Type of Swelling and the Possible Lesions
Tense swelling within 2 h of injury Haemarthrosis

Effusion within 12–24 h Serous fluid effusion
Large blood strained effusion Anterior cruciate ligament lesion
Small effusion streaked with blood Meniscal lesion
Effusion associated with fever and general Infection with pus formation
illness
Hot, overall swollen joint Tuberculosis or pyogenic infection
Bony swelling Bone infection, tumour, cyst, exostosis or osteophytes at the
joint margin
Fluid within the joint Fluctuating effusion of blood, serous fluid or pus
Synovial thickening Nonfluctuating boggy or spongy swelling
Flexibility tests
Flexibility tests for lumbar spine, hip flexors, gastrosoleus,
hamstrings, quadriceps femoris, rectus femoris, tensor fascia lata,
iliotibial band, hip adductors and external and internal rotators are
essential. Decreased flexibility increases resistance to various
anatomical structures resulting in localized stress on the knee joint
and overuse syndrome, e.g., tight hamstrings increase patellofemoral
compressive forces because of passive resistance during the swing
phase of ambulation and running. Loss of extension by 15–25 degrees
and flexion possible up to 85–90 degrees, indicate capsular
involvement. Tight gastrosoleus leads to increased pronation of using
foot causing strain on the knee joint.
Examination of patella
The patella is examined for the presence of pain/tenderness, crepitus,
mobility and apprehension. Mobility is assessed by passively moving
the patella up and down the knee joint and also sideways.
Patellar apprehension test

An attempt is made to passively displace the patella laterally while
flexing the knee from full extension. The patient will become
apprehensive and will not allow further examination due to pain. This
test is positive when there is a tendency for patellar subluxation or
dislocation.
Tests for effusion in the joint

Accumulation of fluid due to irritation of the synovial membrane is
known as effusion; it could be serous, blood or pus. The suprapatellar
pouch is the common site of effusion. Effusion is detected by the
following three methods:
1. Patellar tap test (Fig. 36-5A and B)
2. Fluid displacement test (Fig. 36-5C)
3. Hydraulic impulse test (Fig. 36-5D)
FIG. 36-5 Patellar tap test. (A) Place the hand firmly about 15 cm above
the patella, slide it to the level of the upper patellar border and jerk the
patella downwards with the other hand. (B) Presence of click indicates
effusion. (C) Fluid displacement test. (D) Hydraulic impulse test.
All the three tests are based on passive displacement of the fluid in
the knee joint.
1. Patellae tap test: In the patellar tap test, the fluid is displaced from
the suprapatellar region to the knee joint by sliding the hand from a
point about 15 cm proximal to the superior border of the patella (Fig.
36-5A) towards the knee joint. The patella is then jerked quickly
downwards using finger tips (Fig. 36-5B). The patella strikes against
the anterior surface of the femoral condyles and bounces back into its
original position, which indicates effusion. In the fluid displacement
test, after evacuation of the suprapatellar pouch (Fig. 36-5A), firm
stroking is done alternately on the medial and then on the lateral
aspect of the joint (Fig. 36-5C), carefully watching the opposite side of
the joint for appearance of a bulge due to the displacement of fluid.
2. Fluid displacement test: In the hydraulic impulse test, one hand is
placed just over the suprapatellar pouch and the other over the front
of the knee joint just under the inferior border of the patella (Fig. 36-
5D). On applying pressure over the suprapatellar pouch towards the
joint, fluid displacement occurs from the suprapatellar pouch to the
main joint cavity which bulges with easily detectable hydraulic
impulse to the lower hand.
Range of motion
Active movements
Active ROM of the knee along with hip and ankle joints should be
recorded by goniometery. Presence of painful arc should be looked
for; it may be present in meniscal or articular deficiencies.
Passive movements
Passive movements put stress on the noncontractile structures like
ligaments, capsule and fascia, helping to identify the site and severity
of lesion in these tissues. It also helps in evaluating the degree of
accessary motion (joint play), the character of end feel and in
identifying the capsular pattern of knee joint restriction.
The pain and resistance sequence is also an important factor during
passive movement test:
◼ In acute injury, pain develops before resistance.
◼ In subacute conditions, pain and resistance occur simultaneously.
◼ In chronic conditions, resistance appears before pain.
◼ Pain in the direction opposite to the resisted movement implicates

contractile unit (musculotendinous). Passive range testing has to be
performed at the hip, knee and ankle joints, to detect any
abnormality.
Feel for crepitus in the knee joint while performing relaxed passive
movements. Also feel for crepitus at the patellofemoral articulation by
passive patellar movements from superior to inferior and from medial
to lateral directions with the knee joint in relaxed extension.
Resisted movements
Evaluation of the contractile unit is done by manual muscle testing
(MMT). The resistance is given in shortened range, mid-range and in a
stretched position of the muscle. Objective testing of the strength and
endurance is done by isokinetic dynamometer or isometric torque
evaluation.
Remember
Functional independence being most important, the quadriceps
group of muscles needs to be extensively tested for strength,
atrophy, reflex inhibition and function.
Specific passive tests

Certain specific passive tests provide useful clues to identify the
structures involved and also their degree of involvement, especially
the ligaments shown in Tables 36.3–36.5.
Table 36-3
Passive Tests and the Possible Lesions
Locking in flexion with passive extension not Bucket handle type of meniscal tear possible,
possible flexion may be free and full
Jamming in one position with occasional unlocking Loose body in the joint
Instability with a feeling of knee giving way during Patellar subluxation
straight running
Jerking instability, giving way during sporting Anterior cruciate ligament (ACL) lesion
activity with snapping back
Anterior instability ACL lesion
Posterior instability Posterior cruciate ligament lesion
Medial instability Medial collateral ligament lesion
Lateral instability Lateral collateral ligament lesion
Rotational instability Meniscal lesion
Table 36-4
Passive Integrity Test for Collateral Ligaments and Menisci
Test Findings Possible Inference
1. Final end feel (Marshall & Baugher, 1980) Intact ligament
2. Marked pain without opening up of the joint Incomplete rupture
3. (a) Mild pain with definite opening up of the joint
(b) Definite joint opening even with knee in extension (Smilie, Complete rupture
1978)
Site of Lesion Diagnostic Test
Anterior cruciate ligament Stabilized Lachman’s test
Posterior cruciate ligament Stress test with knee in extension
Medial or lateral collateral ligament Stress test with knee in slight
flexion
Menisci McMurray’s test
Table 36-5
Identification of Ligament Injury to the Knee
Knee Position at Ligaments Injured Test

Injury
Hyperextension Posterior cruciate Posterior drawer
Hyperflexion Anterior cruciate Posterior cruciate Anterior drawer Posterior drawer
Tibia in valgus Medial collateral Abduction in extension or 30 degrees flexion
Tibia in valgus and Medial collateral, meniscus and Abduction with knee in 30 degrees flexion
external rotation anterior cruciate anterior drawer in 15 degrees rotation
Tibia in varus and Lateral collateral, anterior cruciate Pivot shift Anterior drawer
internal rotation (anterolateral instability)
Tibia in varus and Lateral collateral posterior cruciate Reverse pivot shift
external rotation (posterolateral instability)
Tibia moving Anterior cruciate Lachman’s test Anterior drawer
forward on femur
Measurements
Real and apparent limb length is measured to rule out shortening.
Muscular atrophy
Circumferential measurements are done to evaluate wasting of the
thigh and leg muscles. These measurements are done at the following
sites, and compared with the normal side: (a) at the joint line, (b) 5 cm
proximal to the joint to assess effusion in the suprapatellar pouch, (c)
15–20 cm proximal to the joint line to evaluate wasting of the thigh
(quadriceps and hamstrings) muscles and (d) 15 cm distal to the joint
line to assess wasting of the leg (gastrosoleus) muscles.
Tests to evaluate the degree of deformity at knee
The knee should be evaluated for the deformity in weight-bearing
(e.g., standing) position by measuring with tape and goniometer.
Genu varum and valgum can also be measured by a measuring tape.
Measure the distance between the knee joints for genu varum and
between the medial malleoli for genu valgum. Measure the distance at
the centre points between the knee joints and the medial malleoli for
tibia vara. Angular measurements can also be done accurately with
the goniometer on weight-bearing radiographic film. Genu
recurvatum and flexion deformity are assessed with a goniometer in
weight-bearing on the affected limb alone (Fig. 36-6).
FIG. 36-6 Goniometric measurement of genu recurvatum (hyperextension)

is done with body weight on the leg to be tested.
Examination of the related joints

The related joints like the lumbar spine, sacroiliac, hip, superior tibio
fibular, ankle, subtalar and foot joints are carefully checked to rule out
lesions causing referred pain to the knee.
Neurological status
It may be necessary to conduct tests to assess cutaneous sensation in
the clinical dermatomes, the quadriceps reflex and the related muscle
strength.
Functional testing
The compensatory mechanisms, adopted by the patient to perform
various functions, should be observed and recorded. This will provide
a clue to the pathology of the knee problem. The activities to be tested
are squatting, cross-leg sitting, standing, standing on the affected leg
alone, brisk walking, stair climbing and descending and spot running.
The objective analysis of gait for individual segmental movements at
all the three weight-bearing joints is advisable. Activities like
sprinting, flexed knee hopping, figure-of-eight running and cross-over
running may be included (Davies & Malone, 1980) in the analysis,
especially in sports personnel.
Arnold’s test
It is a functional test to assess anterolateral rotary instability. The
examiner standing in front of the patient steps on his involved foot.
The patient rotates his upright torso of face about 90 degrees in the
opposite direction by crossing his good leg over the fixed one. The
symptoms of lateral pivot shift, with feeling of discomfort and the
sensation of knee ‘wanting to go out’ are felt (Arnold et al., 1979).
Passive tests for ligament injuries

Knee is a common site for ligament injuries. The three ‘C’s’, that is,
collateral, cruciate and cartilages (mensci) are the usual sites of injury.
Various types of passive stresses provide definite clues to diagnose
the injured ligament. The position of the knee joint during injury, the
direction and severity of stress can provide important clues to identify
the involvement of a particular ligament from amongst (A) collateral
ligament, (B) cruciate ligaments or (C) cartilages or menisci (Table 36-
5).
Ligament injuries
The injuries to the ligaments of the knee are classified into three
grades.
Grade I – Minimal tear
◼ Local tenderness+
◼ No instability
◼ Stress test causes pain
◼ Joint separation up to 5 mm
Grade II – Moderate tear
◼ Local tenderness ++
◼ Localized oedema +
◼ Minimal instability
◼ Stress test causes extreme pain
◼ Joint separation between 5 and 10 mm
Grade III – Complete tear
◼ Local tenderness +++
◼ Local oedema ++
◼ Marked joint instability
◼ Stress test causes excruciating pain

◼ Joint separation of 710 mm
Complete tear is invariably associated with additional cruciate

ligament injury thereby, increasing the degree of joint instability.
Medial (tibial) collateral ligament (fig. 36-7a)

Tenderness is maximum at the upper end near its attachment to the
medial condyle of the femur. The test for integrity of this ligament is
done by it valgus stress test with knee in full extension. If no
instability is detected the test is applied with knee in 30 degrees of
flexion. There is abnormal external rotation of it tibia with opening up
of knee joint on the medial side. This manoeuvre may cause severe
pain with or without opening up of knee joint medially. The end feel
at the terminal range during the manoeuvre may be soft or firm
(Marshall & Bangher, 1980). This test is positive in the tear of the
medial collateral ligament. This ligament mainly controls the external
rotation of the tibia on the femur. Considerable opening up of the joint
medially with excessive valgus indicates involvement of the posterior
cruciate along with medial collateral ligaments.
FIG. 36-7 Tests to assess the integrity of medial and lateral collateral
ligaments (MCL) and (LCL). (A) Valgus stress test for tear of the medial
collateral ligament: positive test may cause severe pain, excessive valgus
with opening up of the knee joint medially. (B) Varus stress test for tear of
the lateral collateral ligament causes severe pain on opening up of the joint
laterally.
Lateral (fibular) collateral ligament (fig. 36-7b)

In this injury, tenderness is felt over the fibular head or lateral joint
line. The varus stress is applied with knee in full extension, if no
lateral instability is detected, the test is applied with knee in 30
degrees of flexion. It will cause opening up of the lateral aspect of the
joint with pain. It will be positive in isolated tear of the lateral
collateral ligament. Excessive varus instability in knee extension as
well as flexion indicates involvement of the posterior cruciate
ligament as well. The presence of pain, status of the joint and
character of the end feel to be assessed carefully for a possible
diagnosis (Table 36-3). Complete rupture of the lateral collateral
ligament is very rare. When it occurs, it usually involves the capsule,
posterior cruciate ligaments and/or common peroneal nerve (Smillie,
1978).
Injuries to the cruciate ligaments

Injury to the anterior cruciate ligament results in undue anterior
mobility of the tibia while injury to the posterior cruciate ligament
produces excessive posterior mobility of the knee joint.
Anterior cruciate ligament: Injury to the anterior cruciate ligament

commonly results from a fall from height with the knee in flexion
and the body rotating on the stationary foot. This results in
abnormal internal rotation of it tibia. Similarly, hyperflexion or
hyperextension with internal rotation of the tibia can also produce it.
Abnormal anterior glide of the tibia on the femur is confirmed by
positive anterior drawer test (Fig. 36-8A) when anterior translation
of tibia of 6–8 mm occurs, which is associated with acute pain,
swelling and haemarthrosis of the knee.
Posterior cruciate ligament: The posterior cruciate ligament prevents

posterior displacement of the tibia on the femur. It occurs following
a direct blow to the front of the knee. It may be associated with
fracture of patella or even posterior dislocation of the hip. At 90
degree flexion of the knee, with foot resting on the treatment table,
the contour of the tibia looks concave because of the posterior
subluxation of the tibia (Fig. 36-8B).
FIG. 36-8 (A) Lachman’s test to assess integrity of anterior cruciate

ligament: The femur is held firm with one hand, the other hand grasps the
tibia with knee in 5–10 degrees of flexion and glides the tibia forwards on
the femur. Excessive anterior gliding indicates rupture of the anterior
cruciate. (B) Positive posterior cruciate integrity test: at 90 degrees of knee
flexon in supine position with foot resting on table: the contour of tibia (CT)
appears concave due to posterior subluxation of the left tibia, due to the
rupture of posterior cruciate.
The test is performed in the same position by stabilizing the foot.
The examiner grips the proximal end of the tibia (leg) with both hands
and glides it backwards over the femoral condyles (posterior drawer
test), and forwards (anterior drawer test). Excessive gliding
backwards is positive in posterior cruciate ligament tear while
anterior gliding of 6–8 mm indicates an anterior cruciate ligament
tear. Posterior subluxation or instability is the diagnostic sign for tear
of the posterior cruciate ligament.
Lachman test
This is a more specific test especially in an acute state, where the knee
cannot to be flexed to 90 degrees. The knee is held in 5–10 degrees of
flexion. The examiner, with one hand, stabilizes the femur firmly
while with the other he grasps the tibia and attempts to glide it
forward (anteriorly) on the femur. The tibia glides forwards
abnormally in cases of rupture of the anterior cruciate ligament (Fig.
36-8A). Excessive posterior subluxation of the tibia occurs in a case of
injury to the posterior cruciate ligament (Fig. 36-8B).
Stabilized lachman test (wroble & lindenfeld, 1988)

It is a modification of the original Lachman test. This test has the
ability to quantitate the amount of anterior translation of the tibia.
The patient is supine and the examiner stands on the side of the
knee to be tested. The examiner places his thigh with knee bent
beneath the patient’s thigh, just proximal to the metaphysis. Hand is
placed firmly so that the examiner’s thumb and the index fingers are
placed on the patient’s lateral and medial joint lines, respectively.
Using the other hand the examiner sequentially applies anterior and
posterior forces to the proximal tibia as is done in the regular
Lachman test.
When the posterior cruciate ligament is torn in association with the
medial or lateral ligaments, medial or lateral instability results with a
positive valgus or varus stress test, respectively, with the knee in full
extension.
In isolated medial or lateral collateral ligament tears, the medial or
lateral stress test will be positive in knee flexion and not in knee
extension. Forced hyper-extension of the knee may result in tear of the
posterior capsule followed by anterior and posterior cruciate ligament
tears (Kennedy et al., 1974).
Combined anterior cruciate and medial collateral ligament tears

Combined anterior cruciate and medial collateral ligament tears will
result in positive anterior drawer sign. The application of valgus stress
will produce much more opening on the medial side than when the
medial collateral ligament alone is torn.
Rotatory instability
Rotatory instability resulting in excessive external or internal rotation
of tibia may follow an injury. It could be:
◼ Anteromedial
◼ Anterolateral
◼ Posterolateral
Anteromedial instability
The tibia rotates and pops out anteriorly from the medial side. The
medial tibial condyle subluxates anteriorly. This type of injury is
precipitated by sudden external rotation of the tibia with the fixed
foot over the flexed knee and abducted thigh. The injury usually
involves the ACL, middle third of medial capsular ligament and
medial collateral ligament.
Anterolateral instability
A common athletic injury occurs when femur rotates laterally while
the tibia slides anteriorly and inside. The lateral condyle subluxates
anteriorly. The middle third of the lateral capsular ligament, the
arcuate complex and the posterolateral capsule may be involved.
Sudden internal rotation of tibia by a valgus force to the flexed knee
with fixed foot with femoral lateral rotation causes this injury.
Posterolateral instability
A sudden blow against the anterior tibia with leg externally rotated
and foot planted in a varus position causes this instability. The lateral
tibial condyle subluxates posteriorly. The posterior third of the lateral
capsule, the arcuate complex and the posterior cruciate ligament may
also be involved.
These rotatory instabilities can occur independently or in
combination.
Rotatory laxity causes marked instability in the knee joint severely
blocking functional activities and needing early surgical intervention.
Injuries to the menisci (semilunar cartilages)

Tear of the medial meniscus is the commonest injury (nine times out
of ten) due to its relative lack of mobility. The ratio of the
anteroposterior displacement of medial and lateral meniscus is 1 : 2
(Kapandji, 1970). It is produced by (a) sudden rotational force with the
knee in semiflexed weight-bearing position, (b) sudden twisting injury
to the knee while the foot is in contact with the ground, (c) a blow to
the flexed and rotated extremity or (d) sudden movement from the
hyperflexed to erect posture. The tear of the medial meniscus could be
of four types (Fig. 36-9). Injury to the medial meniscus may cause
concomitant injury to the medial collateral ligament and anterior
cruciate ligament (O’Donoghue, 1970).
FIG. 36-9 Meniscal tears. (A) Horizontal tear. (B) Bucket handle tear. (C)
Posterior horn tear. (D) Anterior horn tear.
Horizontal tear
Commonly occurs in patients over 50 years of age. It is produced as a
result of degenerative processes in both the menisci (Smillie, 1970);
with further degeneration, the peripheral border becomes adherent.
Therefore, the movement instead of occurring between the femur and
the meniscus or between the tibia and the meniscus, occurs in the
substance of the meniscus resulting in a horizontal tear (Fig. 36-9A).
Longitudinal tear (fig. 36-9b–d)

All the meniscal tears begin as a natural longitudinal tear. Depending
upon the site, it could be a ‘bucket handle’ tear, posterior horn tear or
anterior horn tear.
In the ‘bucket handle’ type of tear which is common, the tear
extends along the whole length of the meniscus but remains attached
at both ends. The centrally displaced fragment blocks the normal play
of the femoral condyle during the extreme range of extension, when it
needs maximum space. This produces apparent ‘locking’ in extension.
The posterior horn tear starts at the concave central border, but the
tag displaced centrally remains attached to the posterior horn.
The anterior horn tear appears at the anterior end of the concave
central border. Here also the tag produced remains attached.
Tear of lateral meniscus

The overall symptoms are similar to the medial meniscus tear. But the
pain and tenderness are felt over the antero-lateral aspect.
McMurray’s test confirms the site of lesion.
1. ‘Bounce home’ test for bucket handle type tear: The examiner holds the
patient’s heel cupping around it and passively extends the knee from
a fully flexed position of hip and knee in supine position. If the
extension is not complete or has a rubbery end feel with elastic
resistance to blocking full extension; it indicates bucket handle type of
meniscal tear (Figs 36-9B and 36.10).
2. McMurray’s test for pedunculated tag of meniscus: The test is
performed by producing internal rotation of the tibia and varus force
to the upper part of the leg while the knee is gradually extended for
lateral meniscus, and external rotation and valgus for the medial
meniscus. The patient lies in supine position with knee completely
flexed. Place the thumb and index finger along the joint line to detect
the ‘click’. The examiner medially rotates the tibia with a grasp at the
heel, and extends the knee from full flexion to extension maintaining
rotation. Loose (torn) fragment of the lateral meniscus will snap or
click with pain as the leg gets disengaged during extension. For
medial meniscus, perform the same test (Fig. 36-11) with the tibia
rotated laterally. Pain appearing during the first 30 degrees of
extension indicates the tear of the posterior horn whereas at 90
degrees or more indicates tear of the medial meniscus.
3. Apley’s grinding test: With the patient in prone position lying with
knee in 90 degree of flexion, vertical compression is applied to the
knee joint by pressing the foot downwards. The tibia is then rotated
either ways; pain with click localized to the joint line is elicited
indicating posterior horn meniscal lesions (Fig. 36-12A). The pain
and/or click is felt on the side of the torn meniscus. The same test is
performed with knee joint distraction (Fig. 36-12B), eliciting pain in a
ligament injury.
FIG. 36-10 Bounce home test or springy block: on passive extension of

knee from fully flexed hip and knee, a rubbery end-feel, blocking full
extension indicates bucket handle type of meniscal tear.
FIG. 36-11 McMurray’s test: Flex the hip and knee fully in supine position;
place the thumb and index finger on the medial and lateral joint lines.
grasping heel with the other hand, knee is gradually extended with (A)
external rotation of the tibia and valgus for medial meniscus and (B) internal
rotation and varus for the lateral meniscus. Pain and ‘click’ over the medial
or lateral joint line indicate medial or lateral meniscal tear, respectively.
FIG. 36-12 Apley’s grinding or compression, and distraction test. (A)
Compression or grinding test: on rotation of the tibia with vertical
downwards compression at the foot, pain is elicited to the side of the torn
meniscus due to compression. (B) Distraction test: same manoeuvre done
with vertical upward pull releases the meniscus but stretches the ligaments,
causing pain in a ligament injury.
When these tests are positive, the site and nature of the tear can be
confirmed by arthroscopy.
Other injuries
Traumatic effusion of the knee
In traumatic effusion, the patellar fossae on either side of the knee are
filled up. When swelling extends to the suprapatellar area, it assumes
the shape of an inverted horse shoe. The patella gets pushed away
from the articular surface of the femur because of this effusion.
Fibrosis of quadriceps femoris muscle

Fibrosis of the quadriceps femoris muscle may occur following an
intramuscular injection or may be congenital. There is limitation of
flexion at the knee as the fibrosed quadriceps muscle pulls the patella
upwards and locks the movement. This necessitates surgical release.
Overuse injuries
Activities repetitive in nature may produce injuries like ‘jumpers
knee’ or patellar tendinitis, iliotibial band friction syndrome, popliteus
tendinitis and pes anserinus bursitis.
In jumpers knee, the pain is situated at the patellar tendon which
increases with activities which load the quadriceps mechanism.
Iliotibial band crosses the lateral aspect of the knee to be inserted
into the Gerdy’s tubercle. Mechanical irritation occurs with repeated
flexion–extension movements. Tight iliotibial band or stress on the
lateral aspect may predispose this injury. Positioning the knee to 40
degrees of flexion in standing on the affected extremity produces pain.
Snapping at the iliotibial band may be noticed on flexion–extension of
the knee.
Popliteus tendinitis
The popliteus muscle prevents excessive internal rotation of the femur
as well as anterior displacement of the tibia. Injury to this muscle
results in pain on the lateral aspect of knee which is aggravated by
squatting or walking down the slope. The pain is usually felt by
internally rotating the femur on the weight-bearing leg. There may be
increased range of internal rotation with prolonged pronation of the
subtalar joint. The pes anserinus bursa prevents friction between the
tibia and pes anserinus tendons. Bursitis may occur as a result of
excessive knee flexion or extension. Resisted knee flexion with tibia
internally rotated causes pain on the medial aspect of the proximal
tibia.
Acute stage of injury
The main aim of physiotherapy in the acute stage is reduction of
1. Cryotherapy – Ice packs for 15 min every hour.
2. Modalities like diapulse, ultrasound therapy, interferential therapy

and TENS can be used.
3. Compressive or pressure bandage with limb in elevation.
4. Protection of knee from the position of stress.
5. Early initiation of isometrics for the quadriceps. They should be

done at least for 5 min every hour. Prevention of quadriceps wasting
and reflex inhibition is important. The isometrics, progressed slowly
to the maximum and sustained for 10–15 s, assist in strengthening the
quadriceps; whereas speedy isometrics help in resolution of oedema
and effusion.
6. When the leg is immobilized in a POP cast, vigorous movements to
the ankle and toes are important to prevent venous thrombosis and to
augment circulation. Static contractions to hamstrings and quadriceps
in the cast are encouraged. Attempt may be made to perform assisted
SLR, abduction of the hip and strong hip extension against the
resistance of the mattress.
7. If cast is not advised, a small range of self-assisted relaxed gentle

knee swinging could be initiated.
Subacute stage of injury

When the symptoms of the acute stage are reduced, mobilization is
initiated and progressed gradually along with strengthening exercises.
1. Initiate mobilization with the patient sitting at the edge of the bed
or table, injured limb fully supported by the sound limb. The patient
is guided to perform relaxed self-assisted small range of slow
rhythmic knee flexion and extension (Fig. 36-13). CPM is an ideal
mode of mobilization at this stage.
2. The range and power of quadriceps and hamstrings should be

recorded.
3. Passive exercise to be progressed to assisted active or active as early

as possible. Self-assisted relaxed passive stretching of knee flexion is
excellent for improving the ROM of flexion. Patient in supine or
sitting position slides the foot as far back as possible. Then the patient
plants the foot on the plinth and slowly moves forward over the
planted foot; the maximally achieved flexion is maintained. This can
be more effective if it succeeds the relaxed free heel-drag session.
4. Isometrics can be made self-resistive by the patient applying graded

resistance with hand. A soft roll is placed under the knee. The patient
carries out isometric quadriceps setting while resistance is applied by
hand, exerting pressure by the web between the thumb and the index
finger 5–7 cm proximal to the superior border of the patella. With
isometric contraction, the patella moves upwards. The patient resists
this movement with hand and then sustains the isometric hold by
continuously resisting upward pressure exerted by quadriceps with
the hand for 10–15 s. This can be made more effective by adding ankle
dorsiflexion with toes stretched in extension. We have found this to be
a very effective self-controlled isolated quadriceps exercise. It is also
well acceptable to the patient.
5. Relaxed knee swinging should be made speedy with increased arc

of movement to attain free mobility.
6. SLR – straight leg raising: It should be initiated as an assisted

movement. It could be made more effective by: (i) Slow repetitions
with self-generated intramuscular tension without the heel making
contact with bed. (ii) By adding weight: the weight or resistance
should be gradually progressive. Upper limit of resistance for the SLR
should be kept at 10–15 lb (4.5–6.8 kg) (Malone et al., 1980). SLR can
be modified to SLA or straight leg abduction. The advantages of these
two movements are that all the important muscle groups of the lower
limb are exercised at the same time. Due to sustained contractions in
all muscle groups, strength as well as endurance improves to a great
extent. This can be made objective by the patient keeping a record of
(the number of repetitions at a time) his active performance and
progress.
7. Knee flexion: Knee flexion exercises should be practised in prone

position as well as on a static bicycle. Speed, resistance and seat height
of the static bicycle should be properly adjusted so as not to overstrain
the knee. Begin with half circle of the pedal. The session should be for
15 min initially, increasing gradually to an hour.
8. Progressive resistive exercise (PRE): Gradual self-resistive exercise

with self-generated tension or graded resistance exercise with
De’lorme shoe or weight belts to be initiated.
9. Flexibility exercises: Flexibility exercises of static stretching using a

30-s hold, relaxing and performing five repetitions to hamstrings,
iliotibial band and gastrosoleus are important.
10. Vigorous programme: When the pain is minimal, ROM and swelling
are near normal. The endurance strengthening flexibility exercises are
made progressive by suitable techniques. Progress to guided prone-
kneeling, assisted squatting, stair climbing and descending and cross-
leg sitting.
◼ Graduated spot running and jogging to be initiated as

soon as the pain permits.
◼ Patients should be encouraged to begin aerobics and go

back to work with well learnt precautionary measures.
Advice on regular sessions of continuous halfway floor
squatting to be emphasized to keep fit and to prevent
recurrence of sprain (Fig. 36-14).
11. Isokinetic exercises: Isokinetic mode of exercise is effective in

improving strength, endurance and functional capacity of the
quadriceps and hamstrings. It assists in improving ROM due to the
physiological overflow. As the resistance is adjusted in relation to the
muscle force through ROM, it prevents excessive compression of the
joint. As the isokinetic provides fast contractile velocity, it improves
the control and coordination needed for smooth and speedy
movements in sports (Davies, 1988).
FIG. 36-13 Self-assisted rhythmic relaxed knee swinging, initiated in a

small ROM, progressed on achieving further relaxation. The affected knee
is relaxed and is rhythmically moved passively by the normal leg.
FIG. 36-14 Continuous halfway floor squatting provides an excellent

means of body weight resistive quadriceps exercise.
Specific programmes: Emphasizing specific areas in the schedule of

therapy is essential as per the diagnosis.
1. Extensor mechanism injury

(a) Heavy resistance quadriceps exercise should be done in
graduated steps to avoid irritation of the involved
tissues.
(b) Hamstrings stretching is necessary to prevent patellar

compression against the underlying bone.
(c) Resistance to SLR should be applied in the range of 10–

15 lbs.
(d) Activities like running, jogging and spot running

should be avoided (Malone et al., 1980).
2. Injuries to the menisci: Extra emphasis is necessary on:
(a) Terminal knee extension – progress from assisted to

resisted SLR is important.
(b) Gluteal muscles should be checked for weakness.
(c) Hamstrings stretching, repeated isometrics to the

quadriceps and free mobility are also important.
3. Injuries to the ligaments: Anterior subluxation of the tibia may be

noticed when there is combined anteromedial and anterolateral
instability on full ROM exercise. Similarly, posterolateral instability
may result in external rotation of the tibia. This can be avoided by
limiting the exercise to a safe range.
Caution
In combined anteromedial and anterolateral instability, full range
extension may cause anterior subluxation of the tibia. Therefore, full
arc of extension should be avoided while exercising. Posterolateral
instability will give rise to external rotation of the tibia against
posterolateral part of the capsule. Therefore, when there is
posterolateral instability, the knee should be exercised in an arc up
to 170 degrees or 10 degrees short of full extension.
Hamstrings and gluteal weakness may be present due to chronic

ligament instability. They need to be assessed and emphasized.
Chronic stage of injury

Even chronic ligament injuries respond favourably to the regime of
knee strengthening and hamstrings stretching exercises. However, the
knee should be well protected with a knee brace during strenuous
activities.
Patients with chronic ligament instability may show weakness of
hip muscles and hamstrings. This has to be tested and strengthening
exercises to these muscle groups are included in the therapy
whenever necessary.
Surgical treatment
Tears of the menisci: Torn meniscus is better excised. The operation of
meniscectomy can be performed by an arthrotomy of the knee or by
arthroscopic surgery.
Open meniscectomy: It is performed by doing an arthrotomy of the knee

joint. A compression bandage is given to the knee joint, after
operation. The bandage is removed after 2 weeks and the knee is
mobilized. Weight bearing, however, is started after 3–4 weeks, after
building up tone in the quadriceps muscle.
Arthroscopic meniscectomy: It is discussed elsewhere.
Treatment of ligament injuries

In partial rupture, when tense and painful haemarthrosis occurs,
aspiration of the fluid may be done. The knee is immobilized in a long
leg walking plaster for 4–6 weeks.
Static quadriceps setting and SLR are important during
immobilization.
Complete rupture of the collateral or cruciate ligaments requires
surgical repair or reconstruction. Acute injuries can be repaired
whereas chronic (old) injuries need surgical reconstruction using a
strip from fascia lata or ligamentum patellae. An above- knee plaster
cast is maintained for 4–6 weeks after which the knee is mobilized.
1. Postoperative programme for plica excision
1st day – Ankle circumduction.
2nd day –
(a) Simultaneous quadriceps and hamstrings isometrics are

very important and should be endured.
(b) Walking, gradual weight bearing with crutches.
5th day –
(a) Assisted SLR could be begun if not too painful.
(b) Hamstrings stretching sessions should be started.
2nd week –
(a) Active and active assisted flexion–extension exercises.
(b) Resistive hamstrings exercise to inhibit quadriceps

thereby allowing more flexion.
(c) Passive patellar mobilization.

Progress to resisted techniques.
2. Postoperative programme for proximal or distal extensor

reconstruction: Knee flexion exercise is very painful and should be
begun gradually with maximum relaxation.
Initiate flexion–extension (assisted) in cases of extensor

reconstruction. By 6 weeks, the patient should attain 90
degrees of knee flexion.
3. Postoperative programme for meniscectomies
(a) Same as 1., only straight leg raising should be started

right from day one.
(b) Hamstrings stretching to be begun a week or 10 days

following surgery.
(c) Bicycling, running by 1 month.
4. Postoperative programme following ligament repair: There is

usually a prolonged period of immobilization (about 6 weeks),
hence:
(a) Ankle movements, quadriceps and hamstrings

isometrics should be started in the cast.
(b) Non–weight-bearing crutch walking should be initiated

immediately.
(c) Assisted SLR may be begun after a week.
(d) Knee hinge cast (functional cast bracing) may be

applied after 10 days to allow small range of knee
flexion–extension.
(e) By 6 to 8 weeks, the cast is removed. Knee flexion–

extension exercises are made vigorous.
For posterolateral repairs, exercises are concentrated for

terminal extension, flexion to extension and SLR.
For anteromedial instabilities, knee extension exercises are

started.
Progress to graduated resistance for both the muscle groups.

For the first month, the resistance for quadriceps should
not be more than 5 lbs.
Passive extension should not be done as it may over-stretch

the surgical reconstruction.
Proper instructions and assistance are given for weight

bearing and gait training.
Caution
Isometric quadriceps contractions alone may produce a force which
draws out the tibia anteriorly in relation to the femur (develop
anterior drawer force). This is not advisable till the reconstructed
ligament is matured. Therefore, during the early stage following
ligamentous reconstruction, isometrics should be performed
simultaneously to the quadriceps as well as hamstrings and not to
the quadriceps alone (Yasuda & Saraki, 1987). This has to be done
with the knee held in 5 degrees of flexion. This procedure is
important, especially in anterior cruciate ligament reconstruction.
After ACL reconstruction surgery, there is disproportionate loss of
strength of the quadriceps. However, routine exercises for
quadriceps strengthening are contraindicated. They put excessive
stress on the reconstructed ACL. If at all, isolated quadriceps
isometrics is a must, they should be performed with the knee in 70
degrees of flexion, when the anterior drawer force on the tibia is
totally eliminated (Levy & Goldstein, 1987; Yasuda & Sasaki, 1987).
The knee ROM is therefore restricted to 30–90 degrees up to 4 weeks
after reconstruction.
Since the process of ligament reorganization is very slow,

these patients should be put on vigorous activities only
after a year. They may require 4–6 months to regain full
extension.
Utmost care is needed while teaching floor squatting and

cross-leg sitting.
All these patients should be warned to watch for a limp or an

increase in swelling. These signs indicate excessive strain
and should be avoided.
The hamstrings regain normal muscle power and endurance

sooner than the quadriceps mechanism. Therefore,
resistive quadriceps exercises (body resistive) need to be
continued for a long period (Fig. 36-14).
5. Postoperative programme for capsular repairs: Severe sprain to the

tibial collateral ligament may result in disorganization of the medial
meniscus, ACL and posterior medial capsule.
Immobilization is given for 3–4 weeks with the knee in 60

degrees of flexion and foot in internal rotation. Cast
bracing with de-rotation brace follows.
The most important aspect besides regular routine measures
is to regain terminal active extension of the knee (with
brace) through slow and controlled exercise. This is to
avoid knee instability at a later stage (Malone, 1988).
Weight bearing should be initiated only after regaining full

active knee extension.
Exercise programme should be submaximal to begin with,

progressing gradually to the maximum. The sequence will
be multiple angle isometrics, partial range isotonics and
isokinetics.
Adductor and internal rotation strengthening is important.
Maintaining foot with intoeing position is to be guarded

carefully.
Monitor correct proprioceptive activities to revitalize

mechanoreceptor unit.
The isokinetic protocol should be of gradually progressing

velocity spectrum from 30 to 300 degrees/s.
Following reconstruction or repair of the posterior cruciate

ligament, isometrics to the quadriceps need to be carefully controlled.
The usual tendency of pushing the knee posteriorly with isometric
efforts should be discouraged.
Arthroscopy and arthroscopic surgery

Arthroscope is a tubular endoscope through which the inside of a joint
can be visualized (Fig. 36-15). It is most commonly performed on the
knee joint. However, other joints like shoulder, elbow, wrist and ankle
can also be visualized with an arthroscope.
FIG. 36-15 Arthroscope.
Indications for arthroscopy

1. Recurrence of symptoms
2. Locked knee joint
3. In the diagnosis of internal derangements of the knee joint and

loose bodies, etc.
Arthroscopy is very useful in the diagnosis and assessment of

various knee disorders and internal derangements like tears of
menisci and cruciate ligaments. Apart from diagnosis, the arthroscope
is used for therapeutic purposes also. Nowadays, the various
structures in a joint can be operated upon without performing a
formal arthrotomy by inserting athroscopic fine instruments through
a second puncture in the joint. This arthroscopic surgery helps in
removal of torn or degenerated menisci and loose bodies from the
knee joint and even helps in the reconstruction of torn cruciate
ligaments.
Arthroscopic surgery (diagnostic as well as therapeutic) is
performed through one or two small puncture wounds in the skin.
Postoperatively, generally, a compression bandage is given for about a
week. The period of hospitalization is only a day or two. Therefore,
the greatest advantage of arthroscopy is rapid rehabilitation.
Mobilization and non–weight-bearing can be started within a week,
and full weight bearing in the second week.
Physiotherapy
The physiotherapeutic management depends upon the type of lesion
and the arthroscopic procedure which could be diagnostic or
therapeutic.
In a diagnostic arthroscopy, the programme of physiotherapy is
short and simple. It is basically directed to maintain and improve the
knee function. The basic principles of physical therapy are as follows:
1. Reduction of effusion
2. Quadriceps isometric contractions
3. Maintenance of full ROM
4. Relaxed knee swinging
5. Proper weight bearing and walking
Physiotherapy for arthroscopic surgery: As for any other surgical

procedures, the management falls into the following two distinct
phases.
This has a conditioning effect on the patients and shortens the period
of recovery. It consists of:
1. Teaching the exact technique of isolated, sustained isometric

submaximal contractions of the quadriceps to avoid atrophy and
reflex inhibition.
2. Relaxed speedy quadriceps settings to reduce effusion and oedema.
3. SLR to stabilize the knee.

4. Resistive exercise for hamstrings and gastrosoleus to increase the
posterior stability of the knee.
5. Relaxed coordinated knee swinging for the early return of knee

flexion ROM.
6. Single leg standing, balancing, weight transfers and gait training.
Postoperative physiotherapy regime

Zarins et al. (1985) divided the total period of recovery into the
following phases:
Phase I: Immediate postoperative period (3–5 days).
Phase II: Phase of early healing (5–15 days).
Phase III: Phase of late healing (15–21 days).
Phase IV: Phase of conditioning (3–5 weeks).
Phase V: Functional progression (6 weeks onwards).
Physiotherapeutic regime is elaborated in Table 36-6.
Table 36-6
Physiotherapeutic Programme (Phasewise) for Arthroscopy and Arthroscopic Surgery
Phase Physiotherapy Regimen

Preoperative 1. Explain and teach postoperative regime on the sound contralateral limb
(training) 2. Isolated quadriceps setting – speedy as well as sustained
3. Straight leg raising
4. Resistive hamstrings and gastrosoleus exercise
5. Relaxed and coordinated knee swinging
6. Instructions in balancing, weight transfer, supported weight bearing and gait
cycle (normal)
Phase I
Immediate 1. To reduce pain – Electrotherapeutic modality + Relaxation training
postoperative (3–5 2. To reduce effusion – Speedy quadriceps settings or electrical stimulation
days) under pressure bandage with the limb in elevation; resistive ankle, foot
movements and SLR
3. To prevent reflex inhibition – Sustained frequent isolated quadriceps setting
with hold for 6–10 s
4. Supported relaxed knee passive swinging in small range with normal
contralateral leg
Phase II
Early healing (5–15 Gradual but definite progression of earlier measures in Phase I + Add:
days) 1. Knee rachet, pedocycle or static exercise regime
2. Weight transfers
3. Supported or full weight-bearing ambulation
4. Knee ROM should be 90 degrees at least
Phase III
Late healing (15–21 1. Vigorous progressive resistive quadriceps exercise, supported and guided
days) functional positions
2. Floor squatting, cross leg-sitting and prone heel sitting (kneeling)
3. Standing on the affected leg alone, ambulation unsupported or with minimal
support, but no limp
4. Knee ROM should be around 120 degrees
Phase IV
Conditioning (3–5 1. High sitting speedy isotonic full ROM, relaxed knee swinging
weeks) 2. Progressive resistive quadriceps exercises
3. Balance activities – proprioception
4. Gait training
5. Return to work
Phase V
Functional 1. Spot running – by holding wall bars
progression(6 2. Straight jogging
weeks onwards) 3. Straight running
4. Jumping, hopping
5. Agility drills (e.g., figure-of-eight running)
6. Gradual return to sports
The modalities like cryotherapy, pulsed electromagnetic energy

(PEME), ultrasonics and TENS are valuable in reducing pain and
effusion.
Osteotomy around the knee

Osteotomy around the knee joint is done basically to correct acquired
genu valgum, varum or recurvatum deformities the causes of which
may be varied. Genu valgum may be congenital, due to rickets,
quadriceps insufficiency, idiopathic or degenerative arthritis. Genu
varum may be caused by rickets, Blount disease (an osteochondritis of
the upper tibial epiphysis) or osteoarthritis of the knee joint. Genu
recurvatum results from paralytic conditions such as poliomyelitis or
excessive spasticity of gastrosoleus.
In genu varum and valgum, the defect may be either in the femur,
tibia or both. Corrective osteotomy is, therefore, required in the distal
femur, or proximal tibia (Fig. 36-16) or at both these sites, as the case
may be.
FIG. 36-16 Corrective osteotomy at the proximal end of the tibia fixed by
staple (S).
Wedge osteotomy
1. Distal femoral osteotomy: It is also called supracondylar osteotomy
since it is done in the supracondylar region of the distal femur.
In children, the osteotomy is generally not fixed internally

and hence plaster cast immobilization is maintained
postoperatively for 6–8 weeks. In adults the osteotomy is
fixed internally with special plates and therefore, the
postoperative immobilization is for 8–10 days only after
which knee mobilization is started.
2. Proximal tibial osteotomy: As stated earlier, it is performed for

correction of genu recurvatum as well as for valgum/varum. Of these,
it is most commonly performed in osteoarthritis of the knee joint. It is
also termed as high tibial osteotomy (Fig. 36-16).
In osteoarthritis of the knee, varus or less commonly valgus

deformity causes abnormal distribution of body weight stress within
the joint. In genu varum, these stresses are concentrated medially and
vice versa. This leads to degenerative changes in that part of the joint
or it could be vice versa.
In osteoarthritis of knee, genu varum deformity is more common
with resultant degenerative changes in the medial compartment of the
knee joint. A valgus osteotomy is, therefore, a commonly performed
operation. In this operation, a wedge of bone is taken out from the
lateral cortex of tibia and the gap thus created is closed. The
osteotomy may be treated in a POP cylinder cast alone or fixed
internally with staples. After osteotomy, the weight-bearing axis shifts
laterally from the medial compartment of the knee joint and thus
helps in relief of pain.
The prerequisites of this operation (i.e., high tibial osteotomy):
1. Radiographically, only the medial (or less commonly, the lateral)

compartment of the knee joint should be involved. In other words, it
should not be a generalized (multicompartmental) osteoarthritis.
2. The patient should have at least 90 degrees of flexion at the knee

joint without any flexion deformity.
3. The patient should not preferably be obese.
The patient is given a POP cylinder cast or an above-knee plaster cast
after operation. The cast is maintained for a period of 6–8 weeks.
However, weight bearing causes compression at the osteotomy site
and helps in union of the osteotomy. Physiotherapy is started after
removal of the plaster. In cases where the osteotomy has been fixed
internally with staples, the POP can be removed after 4 weeks and
mobilization started.
This is a common procedure in osteoarthritic knee joints having severe
genu varum or genu valgum deformities with intense pain.
Preoperative phase
1. Accurate assessment of the degree of deformity, muscle strength,

endurance and ROM and functional status is done.
2. Anticipating the postoperative weakness and wasting, the

quadriceps should be trained for repeated isometric and resisted
exercises.
3. If genu valgum or varum is associated with flexion deformity at the

knee, long sessions of sustained low intensity stretching of the knee
with small weight are necessary.
4. If there is limitation of knee flexion, various mobilizing techniques

may be necessary to attain maximum range of knee flexion.
This programme of improving ROM and strength is especially

important where Benjamin’s procedure (1969) is to be performed as
this procedure involves simultaneous resection of the distal femur and
proximal tibia.
Postoperative phase
During immobilization: The leg is put in a posterior splint with

pressure bandage. Limb elevation with isometrics (speedy as well as
slow) should be initiated at the earliest. Strong resisted movements
are also given to the ankle, toes and hip. By 3–4 days, feeble
isometric contractions of the quadriceps should progress to strong
static contractions.
Standing on the normal leg can be initiated by the end of first

week.
In the second week, assisted straight leg raising (SLR)

exercise can be started safely and progressed to full range
active as well as resistive movement of SLR.
Partial weight bearing should be initiated first on double

axillary or elbow crutches. Axis of load-bearing should be
checked precisely during weight bearing. Appropriate
wedge in the shoe may be necessary to correct alignment of
the weight-bearing axis in the presence of ankle and foot
deformity.
During mobilization: Vigorous relaxed and graduated programme of

knee mobilization and strengthening is started after removal of POP
cast. Posterior half of the cast is applied during walking.
Alternatively, cast brace with mechanical joint may be applied. This
helps to initiate knee mobility and muscle strengthening procedures.
However, alignment of the axis of the orthotic knee joint to that of
the anatomical knee joint should be accurately checked before
initiating exercises and ambulation. In cases where some sort of
internal fixation has been used, the knee mobilization can be started
early. Mobilization can be started by CPM (continuous passive
motion) from the second postoperative day.
Optimal range of knee movements and quadriceps strength

should be attained by 6 weeks. Full weight bearing may be
initiated if the osteotomy has united by this time.
Vigorous training in functional activities should be initiated.
Correct knee sequence in gait training to be concentrated to
attain near normal gait pattern.
The patient should have strong and full range of knee

movements with total functional independence by 12
weeks.
Caution
Active isotonic exercises are not to be included during early
postoperative stage. When the cast is temporarily removed for
exercises, there is a danger of reaction to the arthritic changes within
the knee (Slocum et al., 1974). Relaxed passive movements are
employed as a procedure of mobilization of the knee.
Quadricepsplasty
In this procedure, the quadriceps muscle is lengthened by V–Y plasty
to achieve a functional range of knee flexion in a stiff knee. Stiffness of
knee is common after injuries, which are either close to the knee joint
or need prolonged immobilization, such as:
1. Fracture at the lower third of the femur.
2. Fracture of the femur associated with comminuted fracture of

patella.
3. Compound fracture of the femur with delayed union.
4. Infected wound around the knee joint, with skin loss.
It is also indicated in congenital contracture of the quadriceps.
Prerequisites for quadricepsplasty

1. Sound union of the fracture of the shaft of the femur.
2. Good power and endurance in the quadriceps mechanism.
3. The joint and articular surfaces must be in an ideal condition to

permit free movement after surgery.
4. The patient must be young and well prepared to take up the long
and painful exercise regimes.
The surgical procedure depends upon the causative factor of the

stiff knee.
If the cause of stiffness is intra-articular, then the following
operations are indicated:
◼ Bennett’s procedure: The tendinous rectus femoris insertion to the

upper border of the patella is divided by an inverted ‘V’ incision.
The limbs of the ‘V’ are extended to the lateral quadriceps
expansion. Intra-articular adhesions are divided by reflecting the
patella downwards. The quadriceps insertion is sutured with the
knee flexed to 90 degrees. The inverted ‘V’ incision is now converted
to an inverted ‘Y’ (Fig. 36-17). After wound closure, the knee is
bandaged in 90 degrees of flexion.
◼ Thompson’s operation: This is indicated when the knee ROM is

restricted due to adhesions both at the fracture site and the knee
joint.
A long anterolateral incision is made exposing the lower

two-thirds of the quadriceps and knee joint. The rectus
femoris is separated from the vastus mediu, intermedius
and lateralis, and the underlying adhesions are removed
from all these muscles and the patella. The knee joint is
opened and the lateral portions of capsule are separated
from the femoral condyles. The knee is manipulated to
attain maximum flexion. The muscles are loosely
approximated by intermittent sutures.
A pressure bandage is applied with the knee in flexion or
traction may be applied in a Thomas splint with Pearson
knee-piece for 3 weeks.
FIG. 36-17 Bennett’s procedure: quadriceps lengthening by ‘V-Y’ plasty:

conversion of inverted ‘V’ incision of rectus femoris (IV) tendon to inverted
‘Y’ (IY). (A) F, femur; P, patella; T, tibia; RF, rectus femoris; VI, vastus
intermedius with adhesions to the callus on femur, restricting the movement
of knee flexion. (B) Retraction of rectus femoris muscle by inverted ‘V’
incision (IV) to clear adhesions in the vastus intermedius, with knee in
extension. (C) Knee is flexed to the maximum and rectus femoris is stitched
as inverted ‘Y’ (IY).
Early mobilization to maintain the ROM achieved by surgery is the
most important aspect of physiotherapy.
1. Use of CPM (continuous passive motion) immediately after surgery

is ideal.
2. Self-assisted relaxed passive movements by using the contralateral

normal limb by the patient himself are initiated at the earliest.
3. TENS may be used along with exercises to reduce pain.
4. After removal of stitches, vigorous exercises are given at frequent

intervals to maintain or improve the ROM further.
Caution
The reflex inhibition of quadriceps, resulting in an extensor lag
needs to be taken care of from the early stage.
The ROM achieved following surgery should be maintained and
improved by repeated relaxed movements or else adhesions have a
tendency to reform.
5. Early institution and careful monitoring of isometrics to the

quadriceps are very important. Speedy as well as slow sustained
isometrics need to be emphasised to re-educate and strengthen the
quadriceps.
The rest of the regime follows on the same lines as described for
recurrent dislocation of the patella.
Chondromalacia patellae
It is a degenerative condition of the knee affecting the cartilage of the
patella in an otherwise fit person. There occurs fibrillation, fissuring,
erosion and softening of the articular cartilage of the patella (Fig. 36-
18). It gives rise to the following symptoms:
1. Pain arising from the posterior aspect of the patella.
2. The pain worsens with strong quadriceps contractions in actions

like descending stairs or getting up from squatting or from chair.
3. There is an associated symptom of the knee ‘giving way’ or

‘locking’.
4. The ROM at the knee is usually full.
5. There may be slight effusion and quadriceps atrophy.
6. Compression of the patella against femoral condyles causes pain.
7. Radiographs show osteoporosis. Anteroposterior striping is visible

on ‘skyline view’.
FIG. 36-18 Chondromalacia patellae: Skyline view of patella indicating

erosion of the articular cartilage of the patella.
The aetiology is unknown; however, mild repeated trauma,

inflammatory or metabolic joint disease may precipitate the condition.
Adolescents and young adults (age group 17–35 years) are
commonly affected, the incidence is however more common in
females.
Treatment
Conservative
It is effective in mild cases.
1. Initially, if too painful, the knee is immobilized in a POP cylinder

cast.
2. The exercise programme, then, includes:
(a) Gentle isometric quadriceps contractions.
(b) Assisted SLR.
(c) Strong hip, ankle and foot movements.
(d) Ambulation with shoe raise on the normal side, so as to

facilitate movement of the affected leg encased in a cast.
When treated without a plaster cast:
1. Avoid strenuous activities.
2. Isometrics to quadriceps with the knee in slight flexion to avoid

patellar movement, within the limits of pain.
3. Assisted SLR without hyperextension at the knee.
4. Relaxed passive or active knee swinging to maintain full ROM of

both flexion and extension.
5. Deep thermotherapy modality like pulsed short-wave diathermy or

ultrasonics may be given as an adjunct for pain relief.
6. Ambulation has to be properly controlled to avoid excessive

hyperextension of the knee; genu recurvatum has been reported as
one of the common features following chondromalacia patellae.
7. Exercise programme to be progressed to PRE as pain is reduced,

encouraging functional activities except squatting.
Injection therapy
Corticosteroid injections could be tried.
Surgery
Surgery is indicated only when the conservative treatment fails to
provide relief.
1. Arthrotomy: The affected area of articular cartilage is removed by

shaving and smoothening. This procedure has been reported to be
effective in very early cases of chondromalacia patellae.
2. Patellectomy: It is indicated when fragmentation and fissuring affects

an area of more than 1.3 cm in diameter, or erosion of the articular
cartilage and subchondral bone occurs.

A POP cylinder cast is applied after shaving of the articular surface.
The physiotherapy regime is the same as described for conservative
management with plaster cast. The only difference being that vigorous
exercises are delayed till soft tissue healing occurs.
For patellectomy, the physiotherapeutic management is the same as
described under the heading of patellectomy.
Caution
Keeping in view the common occurrence of genu recurvatum,
exercises putting extra strain on the posterior aspect of the knee
should be deferred, e.g.,
1. Single leg standing,
2. SLR in long sitting and

3. Excessive knee extension or heel strike stress at an early stance.
Osteochondritis dissecans
In osteochondritis dissecans, there is localized avascular necrosis of a
segment of the articular surface of the medial condyle of the femur.
It occurs usually in males during the second decade of life. The
predisposing factor may be an injury or impingement against the
tibial spine, resulting in thrombosis of the end artery leading to
necrosis. One segment of the subchondral bone becomes necrotic with
softening of the overlying cartilage. At a later stage, the fragment
separates as a loose body. This leaves a shallow cavity in the articular
surface which eventually is occupied by fibrocartilage (Fig. 36-19). The
precise cause is unknown.
FIG. 36-19 Osteochondritis dissecans: (A) NBAS: formation of necrotic

bony articular segment. (B) NBAS: separation of the bony fragment as a
loose body.
Initially, pain appears after exertion, with occasional effusion. The

range of motion at the knee joint is usually not affected. However,
sudden locking with sharp pain may occur if the loose body gets
lodged into the joint.
Treatment
Rest is given to the knee joint using a POP cast or a crepe bandage.
The patient is encouraged to do static quadriceps contractions, limb
elevation, and vigorous ankle and foot movements.
Before separation of the fragment, attempts may be made to
revascularize the interface by drilling into the underlying healthy
bone. When separation of the fragment occurs, the small fragment
may be removed by surgery or replaced in its position and fixed by a
steel pin or wire.
Rarely, it may affect the elbow joint (capitulum), the hip joint
(femoral head) or the ankle joint (talus).
Besides joint mobilization and improving the endurance of the
muscles around the knee, prevention of compressive forces on the
joint are of primary importance. Therefore, the patient must be guided
against undue weight bearing – postures and activities like stair
climbing and descending.
Complications: Osteoarthritis of the knee.
Popliteal cysts
Semimembranosus bursitis
The semimembranosus bursa which lies between the medial head of
the gastrocnemius and the semimembranosus may become a seat of
irritative bursitis. The bursa gets distended with fluid which develops
into an elongated fluctuant bursal swelling posteriorly between the
planes of these two muscles. A soft cystic swelling close to the medial
femoral condyle is formed.
Treatment
It usually does not require any specific treatment. However, if the
swelling becomes large and uncomfortable, excision of the sac
becomes necessary.
Baker’s cyst
Sometimes, herniation of the synovial cavity of the knee with a fluid-
filled sac may occur in the popliteal space. This sac extends backwards
and downwards at the posterior border of the popliteal space. A soft
palpable bulge is present which becomes more obvious on extending
the knee joint (Fig. 36-20). In rare cases, it may be situated at the upper
portion of the calf.
FIG. 36-20 Baker’s cyst (BC). Herniation of synovial cavity with a fluid-
filled sac in the popliteal space.
The precipitative factor is persistent synovial irritation and effusion

as occurs in osteoarthritis.
Treatment
The treatment is directed towards the underlying causative factor
responsible for the repetitive synovial irritation. However, an
excessively large Baker’s cyst may need excision.
The main principle of physiotherapy is directed towards the
reduction of excessive compressive or stretching forces over the
popliteal space.
The knee movements are guided without extreme flexion or
extension stretches.
Quadriceps strain
Rectus femoris is the commonest seat of strain in the quadriceps
muscle. The strain to this muscle results from a miskick, a sudden
forceful take off in sprint-start. Direct blow over the muscle belly may
also result in a strain.
As this muscle acts on both the hip and knee joints, the diagnostic
sign of strain is pain during the combination of hip flexion and knee
extension. In grades I and II strains, this combination of movement is
painful; however, weight bearing or level ambulation is not much
affected. In severe strain of grades III and IV, a gap is felt over the
muscle belly at about mid-thigh region and weight-bearing and
ambulation become impossible.
In rare cases, vastus medialis, vastus lateralis and vastus
intermedius may develop strain. Site of resistive extension provides
clues to the involvement of a particular muscle. Resisted knee
extension is extremely painful. Similarly, terminal range of knee
flexion is also painful due to stretching elongation of the strained
muscle.
Besides these sites, the quadriceps apparatus itself may be injured at
various sites by sudden knee flexion resisted by reflex quadriceps
contractions (e.g., when a person stumbles while going down in
steps).
The injury may occur at the upper pole of patella, through the
patella or at the attachment to the tibial tubercle.
Treatment
A complete rupture usually needs surgical intervention in the form of
suturing the avulsed quadriceps tendon. Milder varieties of strain
may be treated by a supportive bandage.
Following surgery, a POP cylinder is applied for 3 weeks followed
by posterior knee slab till the knee regains good range of flexion
(around 90 degrees).
1. Patients treated by conservative methods: Measures to reduce

inflammation and pain like ice massage, ice packs, limb elevation and
optimal resting position with suitable drug therapy are initiated.
Mild but frequent isometrics to the quadriceps are begun as

early as the pain permits.
Relaxed passive knee movements are begun by removing

bandage temporarily.
Properly controlled graded active-assisted, active free

exercises to improve the strength and endurance of the
quadriceps and hamstrings are of primary importance.
Terminal range of extension at the knee needs extra
attention to avoid extensor lag.
Graded weight bearing and gait training may be necessary to

avoid limp.
Exercises should be made vigorous to achieve full function

by 5–6 weeks.
2. Patients treated by surgery: It follows the same pattern as for

conservative treatment. Static quadriceps contractions should be
started at the earliest (5–6 days) inside the plaster cast. Self-assisted
SLR with limb in plaster cylinder should be initiated early.
Non–weight-bearing crutch walking without much jerk

should be initiated on the 2nd or 3rd day following surgery
and progressed to partial weight bearing by 3 weeks. Full
weight bearing can be started safely by 5–6 weeks.
On removal of the plaster cylinder, graded knee flexion–

extension exercises beginning with relaxed passive
movement should be started. As soon as knee flexion of
around 90 degrees is attained, knee-slab can be discarded.
If extensor lag is present, electrical stimulation synchronized

with voluntary quadriceps contractions may be needed
besides repeated isometrics to the quadriceps.
Progressive resistive exercises, guided squatting, cross-leg

sitting and gait training may be necessary.
Adequate knee function is achieved by 6–8 weeks. However,

sports should not be resumed before total conditioning is
achieved.
Hamstrings strain
The common site of hamstrings strain is at the fibular insertion of the
biceps femoris muscle. There is localized tenderness at this site;
resisted flexion and active full extension at the knee are extremely
painful. Knee may remain locked in slight flexion due to spasm in the
strained hamstrings. Many a times, there may be an associated injury
to the common peroneal nerve which should be examined carefully.
Weight bearing is uncomfortable in grades I and II strains, and is
impossible in grades III and IV strains. Ice massage or ice pack, rest in
optimal position, compression bandage and anti-inflammatory and
analgesic drugs constitute the treatment.
Well-controlled isometrics, though painful, should be started early
to both quadriceps and the hamstrings.
Self-assisted relaxed knee swinging should be initiated as early as
possible. However, weight bearing and strengthening exercise should
be progressed in grades to avoid excessive strain. PNF techniques are
ideal which should be done with controlled resistance without
causing pain in the hamstrings. In some patients, gait training may
become necessary.
Full function usually returns within 3 to 4 weeks.
Strained calf muscle

Strain in the calf muscle frequently occurs in athletes due to sudden
overstretching of the calf muscle. Pain and tenderness are present in
the calf rather than achilles tendon. Also, there is absence of a gap
which is the diagnostic feature of rupture of the tendoachilles.
Resisted plantar flexion is painful with loss of toe push off while
walking. Though painful, it is possible for the patient to stand on the
toes, raising heel from the ground.
Spontaneous relief occurs with local ice application, compression
bandage and avoiding overstretching activities along with medication.
Adequate functional recovery occurs within a week. However,
sportsmen should keep away from vigorous manoeuvres for at least 3
weeks.
Patellar tendinitis (jumper’s knee)

Repetitive microtrauma to the tendon-bone interface as in jumpers, is
the causative factor for patellar tendinitis. There is pain over the
inferior pole of patella.
On examination, tenderness is felt over bone – tendon interface
without swelling or instability.
During the acute phase, medication, rest, cryotherapy, diapulse or
ultrasonics is applied. Gentle isometrics to quadriceps are initiated.
Gradual mobilization of the knee is begun, when the pain and
tenderness are reduced.
Curwin and Stanish (1984) advocated the use of graduated eccentric
exercise to strengthen the quadriceps muscle – patellar tendon unit.
This is done to prepare the tendon for stresses. Improvement in the
eccentric work capacity has been found to be greatly rewarding in the
early resolution of pain and achieve full function (Jensen & Di Fabio,
1989). Passive stretching of the quadriceps and hamstrings muscles is
taught to the patients, along with other mobilizing and strengthening
procedures.
Prepatellar bursitis
The prepatellar bursa, which occupies a position just over the patella,
may get inflamed (Fig. 36-21). Occasionally, the bursa between the
ligamentum patellae and the upper part of the tubercle of tibia may be
the site of inflammation. The former is more common. Sustained
pressure of body weight due to frequent kneeling (occupational or in
handicapped persons who depend on knee walking) can also result in
prepatellar bursitis. Alternatively, a direct blow on the knee may
precipitate bursitis of these types.
FIG. 36-21 Bursae at the knee. SPB, suprapatellar bursa; PPB, prepatellar
bursa; IPB, infrapatellar bursa.
The patient presents with large rounded swelling over the patella.
The skin over the swelling may be red, stretched with rise in local
temperature. The swelling is tender and quadriceps activity may be
painful.
Treatment
1. Conservative
(a) Analgesic anti-inflammatory drugs.
(b) Rest in the crepe or pressure bandage.
(c) Avoiding kneeling, pressure positions and movements

at the knee.
(d) Limb elevation with sustained as well as speedy static

contraction of the quadriceps, within the limit of pain.
(e) Relaxed knee swinging in an available pain-free range

of flexion and extension.
(f) Electrical stimulation of quadriceps to avoid disuse

atrophy.
(g) Assisted SLR.
2. Surgery
Surgery may be necessary in patients nonresponsive to the

conservative treatment and with the bursa becoming
chronic and painful. The bursa is excised surgically.
Postoperatively, a pressure bandage is given for a period of
2–3 weeks.
1. Limb elevation, strong movements to the toes, ankle and hip.
2. By the end of 1 week when the soft tissues have healed, small range
isometrics to quadriceps within the painless range can be initiated.
3. Self-assisted relaxed passive knee swinging (flexion – extension) is
safe.
4. Gentle passive manoeuvres should be initiated to improve patellar

mobility.
5. Friction massage may be given around the patella.
6. Relaxed passive movements should be progressed gradually to

active-assisted, active and then to active-resistive movements.
7. Re-education in walking is essential to discourage the usual

tendency of walking with knee in flexion.
8. Body resistive quadriceps exercises (self-resistive) provide an

excellent means of strengthening quadriceps and mobilizing knee.
9. Guided functional positions could be initiated with least pain. The

patient should be back to normal activities by 4–6 weeks.
Plica syndrome
A fold in the synovial lining which arises from the undersurface of
vastus lateralis passes transversely to the medial wall of the medial
condyle of the femur and obliquely gets attached near the infra-
patellar fat pad. When it is injured (indirectly), it gets inflamed and
painful over an area medial to the patella. Pain is elicited after long
sitting or knee flexion movements as the plica is compressed between
the patella and the femoral condyle. At a later stage, plica becomes a
tough inelastic fibrotic band. The presence of this syndrome can be
confirmed by pain on medially displacing the patella with knee flexed
to 30 degrees. While performing active extension of the knee from
flexion, the patella skips or seems to jump between the range 60–45
degrees, as it passes over the plica. A false positive McMurray’s sign
may also be present.
Treatment
Conservative management includes routine knee rehabilitation
programme. Transverse friction massage over plica and sessions of
hamstrings stretching are important. In nonresponding cases,
arthrotomy or orthroscopic surgery to excise plica may be necessary.
The management will be on the same lines as described for
arthroscopy. Friction massage and hamstrings stretching are
important.
Arthroscopic surgery is minimally invasive. The patient is sent back
home the same day after surgery. There is generally no external
immobilization. Therefore, aggressive procedures in physiotherapy
can be initiated early. Thus, the return of function is much more rapid.
The improvement in strength and the adaptibility of the repaired
tissue to perform functional activities are the important aspects of the
therapy.
All the routine procedures of therapy can be included with
emphasis to regain terminal extension early.
Full weight can safely be started by 2 weeks following cast removal
(8 weeks since surgery). Light activities to be resumed by 3 months.
Genu valgum (knock knee)

Inward or medial angulation of leg over thigh at the knee joint is
termed as genu valgum or knock knee (Fig. 36-22A). In this condition,
a line drawn from the head of the femur to the middle of the ankle
joint passes lateral to the knee joint instead of passing through the
centre of the knee.
FIG. 36-22 (A) Genu valgum. (B) Genu varum.
It could be because of:
1. Rickets, producing curvatures in the femur or tibia.
2. Growth imbalance between the medial and lateral femoral

condyles. Rapid overgrowth of the medial condyle leads to knock
knee.
3. Muscular or ligamentous weakness at adolescent stage.
4. Muscular paralysis of semimembranosus, semitendinosus.
5. Fractures and injuries involving the knee joint.
6. Secondary to coxa vara, flat foot, OA knees or spinal curvatures.

As a consequence to the deformity, there is increased rotational or
posterior mobility at the knee.
Treatment
The knee is evaluated for the degree of deformity in the weight-
bearing position. Intermalleolar distance is noted which could vary
from 2 inches to 20 inches. The angle of genu valgum is measured
with a goniometer or using weight-bearing X-rays.
Any associated deformity is also evaluated.
Proper muscle chart and ROM measurements are recorded along
with the effect of the deformity on the overall functional status.
The cases are divided into two groups for the purposes of
treatment:
1. Those with negligible bony changes and
2. Those with marked bony changes.
The treatment is directed towards the causative factor. Specially

designed orthosis with lateral uprights and a broad knee strap to pull
the knee joint laterally is given. The patients are treated by corrective
osteotomy.
Cases treated conservatively: Correct method of applying orthosis,
weight transfers and proper ambulation is taught.
Following surgery:
1. Graded knee mobilization constitutes the major part of

physiotherapy. Knee mobilization should be initiated in a small range
as relaxed free movement, progressing gradually.
2. Thermotherapy adjunct should be used as a pain controlling

measure.
3. Strengthening exercises for the quadriceps, hamstrings and glutei

should be instituted.
4. When the patient is allowed to walk, weight transfer should be

done in stages till independent ambulation is achieved. Any tendency
for recurrence should be carefully observed and treated by orthosis.
Genu varum (bow legs)

In this condition, there is lateral angulation of the tibia in relation to
the knee. Thus, in standing with the feet together, the knees remain
wide apart (Fig. 36-22B).
It is usually bilateral. The main causative factor of this deformity is
early weight bearing, especially in children who are fat and heavy. In
adults, it could be due to osteoarthritis of the knee joints.
Pathology
In genu varum, there is lateral curvature of the shaft of the femur,
tibia as well as fibula, the maximum convexity being at the knee. In
bow legs, only the shafts of the tibia and fibula are bent with lateral
convexities. Internal rotation may be present at the hip joints with
knees in hyperextension. The muscles and ligaments on the lateral
aspect of the limb are stretched, whereas those of the medial aspect
are shortened. The child adopts waddling pattern of gait with toes
turned in and weight being borne on the lateral border of the feet.
Treatment
Mild cases: There occurs spontaneous improvement or full correction

as the child grows up to the age of 5 years.
Moderate cases: If the deformity persists, orthosis to pull the knee joints
medially (the reverse of the one prescribed for genu valgum) is
given.
Severe cases: Nonresponding cases are managed surgically by

corrective osteotomy.
It is on the same lines as detailed for the deformity of genu valgum.
However, it must be remembered that since this deformity is the
reverse of genu valgum, the therapeutic measures should be modified
accordingly.
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25. Zarins B, Boyle J, Harries BA. Knee rehabilitation following
arthroscopic meniscectomy. Clinical Orthopaedics. 1985;198:36.
CHAPTER
37
Regional orthopaedic conditions at the ankle

and foot
OUTLINE
◼ Plantar fasciitis and calcaneal spur
◼ Metatarsalgia
◼ Tarsal tunnel syndrome
◼ Injuries to the tendoachilles
◼ Tenosynovitis around the ankle
◼ Pes cavus (contracted foot)
◼ Hallux valgus
◼ Hallux rigidus
◼ Hammer toe
The ankle joint is a complex and fairly unstable joint which derives its
stability as well as the functional mobility required in ambulation,
sports, etc. from 26 bones (7 tarsals, 5 metatarsals and 14 phalanges
(Fig. 37-1)) which are held together by strong ligaments, muscles and
the spring-actioned foot arches.
FIG. 37-1 Bones and joints of the foot. CA, calcaneus; TA, talus; CUB,
cuboid; N, navicular; CUN, cuneiform; MT, metatarsals; PH, phalanges;
MTP, metatarsophalangeal joint; PIP, proximal interphalangeal joint; DIP,
distal interphalangeal joint.
Arches of the foot

1. Medial and lateral longitudinal arches extend between the
calcaneus and metatarsal heads.
2. Less defined transverse arch is located just posterior to the
metatarsal heads (Fig. 37-2).
These arches are formed by the interlocking of bones and the

following ligaments:
(a) Plantar aponeurosis, also known as plantar fascia
(b) Long and short plantar ligaments
(c) Plantar calcaneonavicular ligament
(a) Plantar aponeurosis: It is a thick band extending from the calcaneal

tuberosity to the toes. It forms a strong intermuscular septum between
the lateral, intermediate and medial plantar muscle groups. It has a
series of arches for the passage of the flexor digitorium longus and
brevis tendons.
(b) Long and short plantar ligaments: The long plantar ligament extends
from the plantar surface of the calcaneus to the cuboid and the bases
of the second to fifth metatarsals.
The short plantar ligament, which is deep to the long plantar

ligament, extends from the anterior tubercle of the
calcaneus to the plantar aspect of the cuboid.
These ligaments resist the flattening of the lateral

longitudinal arch of the foot.
(c) Plantar calcaneonavicular ligament: It extends from the

sustentaculum tali of the calcaneus to the plantar surface of the
navicular bone.
The ligaments are so arranged that they facilitate certain

movements while at the same time check excessive and
harmful joint movements.
FIG. 37-2 The arches of the foot. (A) Factors maintaining lateral
longitudinal arch. (B) Major gripping force of plantar surface tibialis
posterior.
Functions of the arches of the foot

1. These arches provide stability as well as mobility to body due to
their spring action with least expenditure of energy and thereby
prevent strain.
2. They also provide protection to the nerves, muscles and vessels of

the foot.
3. They protect the foot from sudden injuries or deforming forces.
4. They provide a base for the smoothness of dynamic weight-bearing

activities.
Ankle joint
The ankle joint is formed by the tibia, fibula and talus bones. The
distal articular surfaces of the malleoli and that of the tibia along with
the intervening strong tibiofibular ligament form a compact
semicircular bony fit over the dome-shaped superior articular surface
of the talus. It is called the ankle mortice (Fig. 37-3). An increase in the
distance between the tibia and the fibula in the ankle mortice, called
disruption of the ankle mortice, indicates a major injury to the ankle joint
(Fig. 37-4).
FIG. 37-3 Ankle mortice.

FIG. 37-4 Bimalleolar fracture of the ankle showing disruption of the ankle
mortice.
Structurally, the ankle joint has a strong (but susceptible to injury)

deltoid ligament medially and weaker lateral collateral ligament
laterally with its well protecting three bands (Fig. 37-5).
FIG. 37-5 Major ligaments of the ankle.
Muscles of the ankle joint

The muscles acting on the ankle joint are contained in three separate
compartments:
1. Anterior compartment
2. Posterior compartment
3. Lateral compartment
The anterior and posterior compartments are separated by an

interosseous membrane between the tibia and the fibula. The lateral
compartment is separated from the other two by a strong
intermuscular septum.
Anterior compartment muscles cross the ankle joint anteriorly and act
as dorsiflexors. The muscles of the anterior compartment (tibialis
anterior, extensor hallucis longus, extensor digitorum longus and
peroneus tertius) enter the foot under cover of the extensor
retinaculum and are innervated by the deep peroneal nerve. Since
these muscles cross the ankle joint anteriorly, they act as dorsiflexors
of the ankle joint.
Posterior compartment muscles consist of a superficial group of

gastrocnemius, soleus and plantaris and a deep group of popliteus,
flexor digitorum longus and flexor hallucis longus muscles.
Both the superficial and the deep groups of muscles are

innervated by the branches of the tibial nerve. The muscles
cross the ankle joint posteriorly and become plantar flexors
of the ankle.
Lateral compartment muscles are the peroneus longus and peroneus

brevis. The peroneus longus traverses the plantar aspect of the foot
and is inserted into the base of the first metatarsal, whereas the
peroneus brevis takes a direct course to the base of the fifth
metatarsal. Both these muscles are innervated by the superficial
peroneal nerve.
Joints of the foot

Subtalar joint
This joint is formed by the talus and the calcaneum. The main support
of this joint comes from the joint capsule and the strong interosseous
ligaments.
Eversion and inversion movements occur at the subtalar joint. Most
of the posterior compartment muscles and the tibialis anterior muscle
are invertors, whereas the lateral compartment muscles (peroneus
tertius and extensor digitorum longus) are evertors. The subtalar
motion of the extensor hallucis longus muscle, depending upon the
angulation of the subtalar axis, can do either inversion or eversion.
Transverse tarsal joint (midtarsal joint)

It is formed by the following two joints:
1. Talonavicular joint
2. Calcaneocuboid joint
Both these joints are supported by several ligaments. The muscles

crossing these joints act around a longitudinal as well as an oblique
axis. The movements at these joints are plantar flexion, dorsiflexion,
inversion, eversion, abduction and adduction. The joints receive a
‘shoe-string’ support from the crossing of the tendons of the tibialis
posterior and peroneus longus. The peroneus longus, with its action
of plantar flexion of the first metatarsal, plays an important role
during the terminal part of the stance phase of the gait cycle when the
body weight is being shifted to the forefoot.
Intertarsal joints
They are formed between the navicular, cuneiform and cuboid bones.
These joints allow gliding movement between the tarsal bones.
Tarsometatarsal joints
These joints are formed by all the metatarsal bones, articulating with
three cuneiform bones and the cuboid bone. The stability provided by
the three cuneiform bones to the second ray is important in the late
stance phase of the gait cycle when an increased load is transmitted
from the ground through the second metatarsal.
Metatarsophalangeal joints (MTP)

The metatarsal heads and proximal phalangeal bases form the
metatarsophalangeal joints. They allow the movements of
dorsiflexion, plantar flexion, abduction and adduction.
There are a number of plantar, dorsal and interosseous ligaments.
The movements of the toes are due to the action of various extrinsic
muscles originating proximal to the foot and inserting into the foot; as
well as intrinsic muscles originating and inserting within the foot.
Abductor hallucis, flexor digitorum brevis and abductor digiti
minimi form the first layer of the plantar intrinsic muscles.
The second layer is composed of the flexor hallucis, flexor
digitorum longus muscles, quadratus plantar and four lumbricals.
The third layer consists of the medial and lateral heads of the flexor
hallucis brevis muscle, adductor hallucis (oblique head) and flexor
digiti minimi brevis muscles.
The fourth layer is formed by the plantar and dorsal interosseous
muscles.
Innervation of the plantar intrinsic muscles is from the medial and
lateral plantar nerves.
Muscular representation of neurologic levels

The following muscles are recruited to test the integrity of the motor
supply at the neurologic level:
1. Tibialis anterior (L4)
2. Extensor hallucis longus and extensor digitorum longus (L5)
3. Gastrosoleus, peroneus longus and peroneus brevis (SI)
The same three levels are used for testing the sensory integrity:
1. Medial dorsal foot (L4)
2. Middorsal foot (L5)
3. Lateral dorsal foot (SI)
Vascular supply
The main blood supply of the ankle comes from (a) the anterior tibial
artery, the main artery of the anterior compartment, and (b) the
posterior tibial artery, the main artery of the posterior and lateral
compartments. These two arteries are formed by the division of the
popliteal artery. It supplies all the three compartments by sending
terminal branches to the foot.
Movements of ankle in relation to the movements of the

lower limb in gait cycle (mann, 1985)
Stance phase
1. Heel strike to midstance
(a) Lower limb medial rotation; ankle joint plantar flexion.
(b) Subtalar joint pronation
(c) Transverse tarsal joint free motion
2. Foot flat, midstance to heel raise
(a) Lower limb lateral rotation
(b) Ankle joint dorsiflexion
(c) Subtalar joint supination
(d) Transverse tarsal joint increasingly restricted motion
3. Heel raise to swing
◼ Ankle joint plantar flexion
Swing phase
1. Lower limb medial rotation
2. Ankle joint dorsiflexion
3. Subtalar joint pronation
4. Transverse tarsal joints free motion
Gait terminology
1. Stride: complete cycle of locomotory sequence of right

(Rt) plus left (Lt) steps.
2. Step length: The step length between right and left heel
strikes in a normal adult is nearly 80 cm.
3. Cadence: Rhythm of locomotion. In a normal adult, it is

101–120 steps per minute.
Range of motion: Average range of ankle movements during

normal walking:
1. Dorsiflexion – 9.6 degrees (Winter, 1987)
2. Plantar flexion – 19.8 degrees
3. Foot out toeing of 6.8 degrees (Murray et al., 1970).

Kayano (1986) found that the medial longitudinal arch lengthens
from the early stance to foot flat due to the vertical force of the body
weight. It then shortens as the body weight is decreased and there is
activation of the arch supporting muscles.
Direct loading to the foot during locomotion (gait cycle)

Vertical ground reaction force has been reported to be between 1.1
and 1.3 times the body weight (Cavangh et al., 1981). It was found to
be maximum just before foot flat and immediately following
midstance phase.
Pressure distribution studies during walking have shown that the
maximum pressure areas are the medial and lateral parts of the heel,
lateral border of the foot and the heads of the second to fifth
metatarsals (Fig. 37-6).
FIG. 37-6 Normal pressure distribution areas during walking cycle. (A) At
heel strike. (B) At midstance. (C) At toes off.
Forefoot is exposed to the heaviest mechanical stresses. For nearly

40% of each step, it carries the weight of all other parts of the body.
Both the compressive and shearing forces are taken up by the ball of
the foot and are transferred to the skeleton (Moller, 1979).
Ankle sprain
The ankle joint is fairly unstable and depends largely on the ligaments
for its stability. Therefore, it is highly susceptible to sprains.
The ankle sprain is of two types:
1. Pronation or eversion sprain
2. Supination or inversion sprain
Pronation or eversion sprain

It is caused by pronation or eversion of the foot combined with
internal rotation of the tibia on the fixed foot. This injury is serious as
it may cause a fracture along with tear of the deltoid ligament,
tibiofibular ligament and the interosseous membrane (Guise, 1976).
Following an injury, there will be swelling and tenderness directly
over the ligaments. Tenderness will be present below the medial
malleolus when the deltoid ligament is injured and over the anterior
aspect of the ankle when the anterior tibiofibular ligament and the
interosseous membranes are involved. All weight-bearing activities
are extremely painful. Passive movements which exert stress on a
particular ligament are painful whereas there will be hypermobility at
the joint in case of complete rupture of the ligament.
Treatment
When this injury involves diastasis of the distal tibia and fibula along
with complete tear of the deltoid ligament, anterior and posterior
tibiofibular ligaments and the interosseous membrane, the choice of
treatment is surgery to reduce diastasis and to remove interposed
segments of the medial deltoid ligament. Postoperatively, the limb is
immobilized in a plaster cast for 6 weeks.
Incomplete rupture of these ligaments can be treated
conservatively. The first priority is to reduce swelling and pain.
Immediate measures like ice application, limb elevation, compression
bandage and repeated toe movements are encouraged. Analgesic and
anti-inflammatory drugs are given to reduce pain and inflammation.
The limb is then immobilized in a plaster cast for a period of 4–6
weeks.
Mobilization is begun after removal of the cast and progressed
gradually to attain full function. It may take about 3 months to return
to normal activities and to sports by another 3 months.
Supination or inversion sprain

It is a common capsuloligamentous injury with a reported incidence
of about 85% of all ankle sprains (O’Donoghue, 1958). This injury
occurs as a result of sudden adduction–inversion force on the ankle.
The tibia rotates externally on the fixed foot with the foot going into
sudden inversion, which is compounded by the body weight. It causes
injury to the anterolateral part of the joint capsule, and one or all the
lateral ligaments (i.e., talofibular, anterior tibiofibular and/or
calcaneofibular).
When a sudden inversion force occurs with the ankle in
midposition of dorsi and plantar flexion, the injury involves the
talofibular ligament. Whereas, when the excessive inversion–
adduction movement is associated with forced plantar flexion, the
injury commonly involves the calcaneofibular ligament. This can be
identified by the site of pain and tenderness. Pain and tenderness over
the talus indicates injury to the talofibular ligament while the same
over the calcaneus indicates involvement of the calcaneofibular
ligament. The pain will increase with ankle adduction–inversion in
neutral in the former and adduction–inversion with plantar flexion in
the latter.
Tear or incomplete rupture

When the adduction violence is insufficient to rupture the lateral
ligaments, it results in strain or partial ruptures.
Tear of the anterior tibiofibular and talofibular ligaments can be
identified by the ‘anterior drawer’ test. Under local anaesthesia, the
heel is supported on a sand bag and downwards stress is applied on
the distal part of the tibia for 30 s, while the radiograph is being taken.
A gap of more than 6 mm between the talus and the tibia indicates
ligamentous instability (Fig. 37-7).
FIG. 37-7 Anterior drawer test for testing the integrity of the anterior
tibiofibular ligament. FS, forward stress on the heel; BS, backward stress
on the distal tibia.
A good range of passive dorsiflexion and plantar flexion at the

ankle joint is possible but attempted adduction in the neutral position
of the ankle and foot increases pain in cases of anterior talofibular
ligament injury.
The patient is able to take some weight on the affected limb though
with difficulty.
Complete rupture
Severe adduction–inversion force causes complete rupture of the
lateral ligament. The talus gets tilted medially in the tibiofibular
mortice. An anteroposterior radiograph is taken while adduction
stress is applied to the heel under local anaesthesia. This manoeuvre
causes medial tilt of the talus in the ankle mortice which if more than
20 degrees, confirms the diagnosis of a complete rupture.
The passive ROM of ankle dorsiflexion and plantar flexion is
relatively good and less painful but severe pain occurs when the ankle
is adducted with the foot in plantar flexion in cases of complete
rupture of the calcaneofibular ligament.
The patient is unable to take the body weight on the affected leg
and prefers to walk by hopping only on the sound limb.
Treatment
Cases of partial rupture are treated conservatively with
immobilization by strapping, daily open taping (Fig. 37-8) or by cast
brace. Those with complete rupture are treated with POP cast with or
without surgery. The surgery consists of repair or reconstruction of
the ruptured ligament.
1. Strapping: Strapping immobilization is given for 3 weeks. Partial

weight bearing is permitted after 3 days with crutches. But full weight
bearing is deferred till pain or limp disappears.
2. Daily open tapping: In this method, hydrotherapy in ice whirlpool is

given for 20–30 min followed by open taping for 4 days. Later on,
contrast hydrotherapy followed by closed taping is done. Closed
taping is done with the foot in maximum dorsiflexion and eversion
with knee flexed to 90 degrees to achieve maximum relaxation of the
gastrosoleus.
3. Cast brace technique: Cast brace allows early mobilization and weight
bearing. The brace is fabricated using synthetic materials.
The methods of daily taping and cast bracing allow early

mobilization and thus prevents disuse atrophy and
formation of adhesions. It has been reported that early
mobilization stimulates healing of the torn ligaments and
also improves strength of the ligaments, thus promoting
the strength and stability of the ankle joint (Clayton et al.,
1968; Tipton et al., 1965, 1970).
Strong toe movements, limb elevation, diapulse, pulsed

ultrasonics, cryotherapy by ice packs, ice massage or ice
immersion are effective in reducing pain, oedema and
inflammation. Immersion in ice cold water for 20 min at
50–60°F has been found to be more effective than heat or
contrast bath in reducing oedema (Barnes, 1979; Knight,
1978;Moore, 1977). Alternating cryotherapy (ice
immersion) with exercise is more effective. It consists of
numbing the ankle with cold immersion followed by
exercise.
4. Cases treated by plaster cast (with or without surgery): Cases with

complete rupture of the ligaments are treated by immobilization for 3–
4 weeks in a plaster cast or surgical repair of the torn ligaments.
FIG. 37-8 Open taping of the ankle.
The supportive treatment includes limb elevation, strong toe

movements, application of diapulse along with anti-inflammatory and
analgesic drugs. In cases treated conservatively, walking heel is
provided which facilitates early weight bearing with walking aid.
However, walking should not cause pain. Cases treated by surgery
need to continue non–weight bearing up to the time the operated
ankle is painful.
Mobilization
Early mobilization by relaxed passive movements in the maximum,
but pain-free range is ideal (Cyriax, 1978). The patient is taught the
correct technique of performing relaxed passive movements. The
movements should not be forcible to overstretch the fibrils that are
gaining longitudinal attachment within the healing breach; nor should
they be too gentle as to fail to disengage those fibrils that are gaining
abnormal transverse adherence.
Deep friction massage is also one of the effective procedures to
prevent or reduce adhesions.
Thermotherapy can be applied if there is no evidence of oedema. It
is helpful in increasing capillary permeability, promoting reabsorption
of the extravasated fluid and dissolution of the organized haematoma,
thus, helping early healing (Griffin & Karselis, 1978). However, heat
should not be used in the presence of haemorrhage.
Ultrasonics is especially beneficial in improving extensibility of the
reconstructed or injured ligaments.
Active and graduated resistive exercises should be started as early
as possible with emphasis on the muscle groups of the anterior and
lateral compartments. Intrinsics also need to be strengthened with
active slow circumduction and maximum isometric toe flexion. This
technique provides strong isometric contractions to the intrinsics
along with resistance to the other muscle groups of the ankle and foot.
Full weight bearing should be started after 6 weeks.
Re-education in foot placement, weight transfer and normal pattern
of gait can be assured by adequate aid and gait training.
On achieving proficiency in gait, vigorous regime of toe standing,
heel standing and walking, and speedy coordinated exercises like spot
jogging, running should be gradually initiated. This prepares the
patient to resume sports by 8–12 weeks.
Conditioning exercises are initiated so as to improve strength and
endurance of the peronei to prevent recurrence of the sprain.
Heel pain
Heel is the most common site of pain. Although it may also occur as a
result of subtalar joint disease, tendinitis, disease of the calcaneum,
retro-calcaneal bursitis or the inflammation of a fat pad, it commonly
occurs either due to plantar fasciitis or calcaneal spur (Fig. 37-9).
FIG. 37-9 Common causes of heel pain: STD, subtalar joint diseases; AT,
Achilles tendinitis; CD, diseases of calcaneum; RCB, retrocalcaneal
bursitis; FPI, fat pad inflammation; CS, calcaneal spur; PLF, plantar
fasciitis.
Plantar fasciitis and calcaneal spur

Heel pain, a common complaint, may arise from seven different
conditions. However, plantar fasciitis and development of a calcaneal
spur are common causes of heel pain (Fig. 37-9).
Plantar fasciitis
Plantar fascia extends from the plantar surface of the calcaneum (Fig.
37-9) to the metatarsal heads and supports the medial arch of the foot.
Summation of a series of microtrauma to the plantar fascia due to
sustained stress of weight-bearing hopping, jumping or running
results in plantar fasciitis.
During the first 15% of the gait cycle, the foot is subjected to
pressure as much as 120% of the body weight (Canningham, 1950).
This load on the foot is supported by the passive structures (bones
and ligaments) alone as the intrinsic muscles come into action only
around 30% of the gait cycle. Therefore, the maximum stress of the
body weight falls on the ligaments and plantar fascia. Significant
stress falls on the plantar fascia in stabilizing the foot from the heel
raise to the toe-off phase of gait again when the metatarsophalangeal
joints are extended (Hicks, 1954). Repeated stress of this nature causes
plantar fasciitis.
Pain is felt over the inner aspect of the sole or heel in all weight-
bearing situations. The pain is usually worst in the morning when the
patient steps down from the bed for the first time. On examination,
tenderness at the inner part of the calcaneus, the site of origin of the
plantar fascia, is seen. Pain is relieved as soon as weight bearing is
discontinued.
X-ray of the heel shows a bony spur in the calcaneum (Fig. 37-10),
which may not be of much significance.
FIG. 37-10 Calcaneal spur. Note the bony spur on the plantar surface of
the calcaneum.
Treatment
Soft cushion heel or silicon heel pads can be used inside the shoes
along with nonsteroidal anti-inflammatory drugs (NSAIDs). A local
steroid infection into the plantar fascia, at the tender sport can also
give relief from pain. However, the result may be unpredictable. It is
tempting to excise the body spur on the plantar aspect of the
calcaneum, as seen on the X-ray; however, it is generally not required.
Calcaneal spur
Continued overstrain of the plantar fascia results in stripping of the
periosteum from its origin at the calcaneus. The gap thus formed is
filled up by proliferation of bone, resulting in formation of a bony
spur to secure the detached attachment. Occasionally a bursa forms
over the bony spur which may get inflamed resulting in pain. Thus,
calcaneal spur is a late sequelae of plantar fasciitis. The calcaneal spur
may not always be painful. Once formed, this spur is permanent; and
attempts to remove it result in its recurrence.
Treatment
Analgesics and anti-inflammatory drugs are prescribed to reduce pain
and inflammation. Locally, heat modality may be used for relief of
pain. Local steroid injection may also be given but in rare instances, it
may cause degeneration tear/rupture of the tendoachilles.
The basic aim of treatment is to:
1. Reduce pain and inflammation by taking off the irritating focus of

the strain of weight bearing (e.g., heel raised walking while getting
down from bed in the morning or after long sitting).
2. Relieving strain from the fascia by providing an appropriate wedge

in the shoe. This helps in lessening the angle between the hindfoot
and the forefoot, and relaxes the fascia. It is done by adjusting the
height of the heel to a minimal level at which the pain disappears. The
UC-BL shoe insert has proved very effective. This shoe insert reduces
tension and constant irritation of the inflamed fascia and also provides
an alternative to elevate the foot arch (Campbell & Inman, 1974) (Fig.
37-11).
Elongated soft heel pad or well-padded medial arch support
covering the longitudinal arch is occasionally effective.
3. Faradism can be an effective measure to induce contractions in the

intrinsic muscles; improving their tone, power and circulation. Hard
shoes should be avoided. Small heel shoes help in transferring the
weight on toes, and can be used while the treatment is going on. After
that, the patient may return back to normal shoes.
4. Exercises to the intrinsic muscles in warm water in the morning

before initiating weight bearing are useful in lessening the morning
pain.
FIG. 37-11 ‘UC-BL’ shoe insert.
It must be emphasized that the patient performs these exercises for

several short sessions during the day.
Strengthening exercises to the intrinsic muscles, like sustained toe
curling, performed even with shoes on, provide an excellent technique
of resistive exercise. Sessions of holding the contracted position inside
the shoe several times a day are very effective, provided they are done
at frequent intervals within the level of discomfort.
Slow barefoot walking on the lateral border of the foot with
cupping of the foot by curling of toes is effective in moulding
longitudinal foot arch. It can be made effective by repeatedly doing
this exercise with the shoes on in standing, walking as well as sitting.
Sorbo rubber heel pad provides better relief in patients with
calcaneal spur.
Metatarsalgia
Normally only about one-third of the body weight falls on the forefoot
and that is distributed between the pads of the toes and
metatarsophalangeal joints. In metatarsalgia, pain occurs over the
plantar aspect of the foot when an excessive proportion of body
weight is taken up by the forefoot. The pain is felt under the
metatarsal heads and is relieved by resting the foot. Tenderness is felt
over the plantar aspect of the capsules of the metatarsophalangeal
joints.
It is common in the presence of the following factors:
1. Pesplantaris
2. Pescavus
3. Muscular weakness: Weakness in the short toe flexors due to

inactivity or immobilization can also give rise to metatarsalgia on the
initiation of sudden weight bearing.
4. Wearing high heels: This may also cause constant strain over the
forefoot giving rise to metatarsalgia. Therefore, while using high
heels, the surface where the heel rests should be horizontal so that the
major weight is transferred to the stable horizontal heel rather than to
the metatarsal heads (Fig. 37-12).
5. Tightness of plantar aponeurosis: Occasionally the digitation of
plantar aponeurosis gets shortened, pulling the metatarsal head
downwards. It causes curling of the toes. If not attended to, this may
cause shortening of the extensor tendons of the toes resulting in loss of
passive range of flexion at the metatarso-phalangeal joints. This
gradually results in hyperextension at the metatarso-phalangeal joint
with flexion at the interphalangeal joints (a deformity corresponding
to Volkmann’s ischaemic contracture of the hand). This is commonly
seen in rheumatoid arthritis. Correction of this deformity is possible
only with surgical release of the tight plantar aponeurosis and the
tendons of the extensor digitorum.
FIG. 37-12 Wedge to render heel horizontal to accept more pressure,

reducing tension on the metatarsal heads.
Treatment
1. Painful stage: Warm water bath, contrast bath, transcutaneous
electrical nerve stimulation (TENS), ultrasonics, diapulse or hot packs.
2. When associated with swelling: Suitable cryotherapy with leg in

elevation.
3. Speedy ankle and toe movements to reduce oedema and to improve

circulation.
4. Faradism under pressure (elastic bandage) with leg in elevation.
5. Faradic foot bath synchronized with voluntary intrinsic exercise.
6. Gradual re-education of walking with appropriate shoe wedge, pad

or metatarsal bar (Fig. 37-13).
FIG. 37-13 Metatarsal bar (MB).
Vigorous stress of weight bearing to be avoided but strengthening

exercises to intrinsics should be stepped up to avoid recurrence.
Morton’s metatarsalgia
In Morton’s metatarsalgia, there is sudden onset of pain with burning
sensation over the outer border of the forefoot and between the third
and fourth toes while walking. Pain subsides after rest and massage.
The causative factor is a thickened digital nerve (often a neuroma)
between the third and fourth metatarsal bones (Fig. 37-14). It is now
believed to be an entrapment neuropathy of the digital nerve
associated with thickened intermetatarsal bursa.
FIG. 37-14 Morton’s metatarsalgia. T, thickening of interdigital nerve

between the third and fourth metatarsal.
Treatment
Conservative treatment consists of altering the alignment of the
metatarsal heads by providing a small pad which elevates the heads
of the metatarsals. This prevents painful nipping of the digital nerve.
If conservative method fails to relieve pain, resection of the nerve
and/or neuroma offers total relief.
Tarsal tunnel syndrome

In this condition, pain, burning sensation or paraesthesia may occur in
the toes and sole of the foot in the distribution of the medial plantar
nerve. This occurs as a result of compression neuropathy of the medial
plantar nerve in the tarsal tunnel under the flexor retinaculum on the
medial aspect of the heel (Fig. 37-15). This situation is analogous to the
compression of the median nerve in the carpal tunnel at the wrist.
FIG. 37-15 Tarsal tunnel syndrome: Compression of the medial plantar

nerve (MPN) in the tarsal tunnel.
This compression neuropathy may be precipitated by previous
sprains, fracture, tenosynovitis of the tibialis posterior or flexor
hallucis longus tendons or exaggerated medial or lateral deviation of
the calcaneum.
Treatment
Surgical decompression of the tarsal tunnel by excising the flexor
retinaculum relieves the symptoms.
Nonoperative treatment includes steroid infiltrations at the
compression site, corrective orthosis, thermotherapy, ultrasonics and
TENS.
Injuries to the tendoachilles

The Achilles tendon is the strongest and thickest tendon in the body.
It is a fast-twitch and slow-twitch muscle and needs a correct balance
between the gastrocnemius and soleus for an individual to stand and
hop on the tip toe. In spite of being strong, the Achilles tendon is
susceptible to injury, especially at a site which is about 4–5 cm
proximal to the calcaneus. This is because of two factors. First, it
narrows considerably near its attachment to the calcaneus. Secondly,
it is a site of poor blood supply.
The common injuries to the Achilles tendon are as follows:
1. Tendinitis
2. Rupture
Tendinitis
The cause of tendinitis is usually a friction syndrome. The tendon is
constantly irritated due to the friction caused by the posterior shoe tab
in modern design shoes. It may also result from undue strain due to
overexertion.
There is localized tenderness, swelling or a nodule. Pain is present
on resisted plantar–flexion or tip-toe standing.
Treatment
Acute phase
1. Ice massage or ice pack.
2. Deep transverse friction massage, if not painful (Cyriax, 1978).
3. Pulsed ultrasonics (Dyson, 1989; Williams, 1976).
4. Diapulse.
5. Shock absorbing heel cushion or appropriate heel raise.
6. Gentle full range relaxed passive movements to the ankle and foot.
Resisted toe movements with the foot in neutral position.
7. Avoidance of weight-bearing or straining activities.
8. Non–weight-bearing exercises.
Subacute phase
1. Passive full range stretching to avoid adhesions.
2. Pulsed ultrasound (Dyson, 1989; Williams, 1976) to resolve

adhesions and to improve the tendon extensibility.
3. Gradual single-leg weight bearing to be initiated against wall bars

with knee in flexion to avoid undue stretching.
4. To be progressed to bilateral toe standing, jogging and spot

running.
5. Proper gait training.
Rupture of tendoachilles
It is a common injury in sports. It occurs as a result of sudden and
forceful dorsiflexion of the foot when the gastrocnemius is contracting
strongly. The rupture may also occur in the middle aged, about 4–5
cm proximal to its insertion. This area has decreased vascularity. The
rupture usually occurs in a degenerated tendon, with ragged margins
of ruptured ends. Walking is extremely painful with local swelling
and marked tenderness over the site of rupture.
Diagnosis
The diagnosis of rupture is ascertained by two tests.
Simmonds–thompson test (fig. 37-16)

The patient lies prone and the foot is supported in plantar–flexion; it is
then allowed to relax in dorsiflexion. The foot in the relaxed position
remains in a greater degree of dorsiflexion as compared to the
contralateral normal foot. The calf muscle is then squeezed, which
causes reflex contraction of the gastrocnemius producing plantar–
flexion on the normal side. However, the test is positive when the foot
instead of going in to plantar–flexion remains limp.
FIG. 37-16 Tendoachilles rupture: Simmonds–Thompson test: Squeezing

of both the calf muscles, the foot on the ruptured side (right) does not go
into plantar–flexion as the left.
Heel raise test

The patient fails to raise the heel from the ground in standing on the
affected leg alone.
Treatment
Conservative
The complete rupture of the Achilles tendon can be treated
conservatively. It needs above-knee plaster immobilization for a
period of 8 weeks with the knee in 30 degrees of flexion and in
equinus to allow close approximity of the ruptured tendon for
healing. After 8 weeks a high-heeled shoe is given for another 8
weeks.
Immobilization in equinus produces wasting of the soleus
(Haggmark & Eriksson, 1979) and long toe flexor muscles. Therefore,
the cast needs to be changed to gradually accommodate more and
more of dorsiflexion to avoid contracture and equinus deformity.
Alternatively, close POP can be avoided by taping the foot in
plantar–flexion and equinus by 30 mm (1.5 inch) heel raise or
removable cast.
Physiotherapy is limited to:
1. Strong toe movements, in elevation and resisted movements to the

muscles and joints free from casts
2. Diapulse over POP or cryotherapy in taping
Surgical treatment
Surgery can be done in fresh as well as old ruptures. A rupture with
clean edges may be sutured, whereas in a rupture with ragged ends,
accurate repair is not possible. In such cases, the tendon is repaired
using a strip from the proximal part of the tendon itself (Fig. 37-17).
Alternatively a strip from the fascia lata may be used. Postoperatively,
an above-knee plaster cast is given for a period of 6–8 weeks with the
foot in full equinus. Subsequently, a short-leg cast is given for 2–3
weeks with slight equinus.
FIG. 37-17 Tendoachilles rupture: tendon repair by using a strip from the
proximal part. STR, site of tendon repair.
Following surgery: Following surgery the leg is immobilized in an

above-knee light non–weight bearing cast for a period of 6–8 weeks.
Non–weight bearing ambulation with strong toe movements is given.
Diapulse may be useful when a short leg cast is given and vigorous
knee movements are begun.
Mobilization (after removal of the plaster)
1. Graduated, relaxed passive dorsiflexion is to be emphasized.

Mobilization of foot is initiated with strong toe flexion and
stabilization at the calcaneus.
2. Gradual partial weight bearing is begun with a heel raise of 15 mm

(3/4 inches) to avoid stress on the repaired tendon.
3. Whirlpool or warm bath provides an ideal medium for exercises at

this stage.
4. Ultrasonic and friction massage may be necessary when the

repaired tendon is shortened and surgical scar is adherent.
Rest of the therapeutic programme should be progressed as

described for tendinitis.
Tenosynovitis around the ankle

Occasionally, tenosynovitis may occur in the tendon sheaths of the
tibialis posterior, peroneus longus and long toe flexors. It is often
precipitated by the presence of degenerative changes, flat foot or
rheumatoid arthritis. The patient presents with pain, tenderness and
swelling along the affected tendons. Pain becomes severe when these
muscles are stretched by forced movements such as inversion or
eversion with foot plantar flexed. Excess of synovial fluid may be
demonstrated by milking the tendon sheaths proximally. Tenderness
is maximal behind the malleoli (Fig. 37-18).
FIG. 37-18 Tenosynovitis: maximal tenderness is felt behind the malleoli.
Treatment
◼ Symptoms are resolved with rest and immobilization in a below-
knee walking plaster.
◼ If symptoms persist on removal of the plaster, elastocrepe bandage

and ultrasonic therapy are effective.
◼ Some patients may need medial or lateral wedge in their footwear

to avoid excessive strain during weight bearing.
Talipes equinus
It is the commonest type of acquired foot deformity following
muscular imbalance. It is produced either due to the weakness or
paralysis of the dorsiflexors or spasticity in the plantar flexors. It may
occur as a result of improper foot positioning in bed-ridden patients.
It may be present in a case of unilateral limb length disparity where
the equinus is used as a compensatory mechanism to equalize the
limb length.
The deformity is at the ankle joint while the midtarsal joint is
normal. There is exaggeration of the longitudinal arch and broadening
of the heads of the matatarsals due to the constant pressure of body
weight on the forefoot as the heel is off the ground.
Pathology
There is stretching of the ligaments on the dorsum of the foot; with
shortening of the inferior-calcaneo-navicular or ‘spring’ ligament,
plantar fascia and other plantar ligaments. There is lengthening of the
anterior tibial group of muscles with shortening of the long toe
flexors, peroneus longus and especially tendoachilles.
Treatment
In early cases, the deformity can be corrected by manipulation. After
the manipulation, aluminium splint, Denis Browne splint, POP splint
or toe-pickup orthosis may be given.
Physiotherapeutic management after conservative treatment
1. Relaxed full range passive movement worked up to get maximum

dorsiflexion and its passive maintenance is important.
2. Whenever possible efforts should be made to get active contractions

in the anterior tibial group of muscles to strengthen them.
3. Gait training should be initiated with toe-pickup orthosis or BK

orthosis. Posterior splint should be applied during night and while
resting to avoid recurrence.
4. Assisted standing on the affected foot stretches the tight plantar
flexors with body weight.
Surgical treatment
Severe cases of fixed equinus deformity need surgical intervention.
The surgical procedures performed are as follows:
1. Tendon release: The plantar fascia and the tendoachilles are divided
and the foot is brought to the correct position. Following this,
immobilization in the posterior splint is done in paralytic cases,
whereas BK POP cast is applied in cases where spasticity of the
gastrocsoleus is the cause.
If equinus is associated with claw toes, division of flexors

and extensor tendons of toes may be necessary.
2. Triple arthrodesis: The principles of this operation as well as the

physiotherapy programme have been discussed elsewhere.
Physiotherapeutic management after surgery
1. During immobilization. The joints free from immobilization are

exercised vigorously.
2. Toe movements are encouraged with the operated leg in elevation.
3. Non–weight-bearing crutch walking could be begun immediately.
4. After removal of the plaster, maximum emphasis has to be placed

on controlled passive, active assisted and eventually active
dorsiflexion of the foot with toe extension.
5. When weight bearing is allowed, weight transfers, balance and gait

training (as described earlier) and other modes of ambulation are
taught. Initially the patient may need orthosis which, if possible,
should be gradually discarded when the active dorsiflexion control is
restored.
Pes cavus (contracted foot)

There is marked exaggeration of the longitudinal arch of the foot with
dropping of the tarsus. It may be associated with equinovarus or
calcaneal deformities (Fig. 37-19).
FIG. 37-19 (A) Pes planus (dropped medial longitudinal arch). (B) Pes
cavus (abnormally high longitudinal arch). (C) Pedoscopic prints: 1. Normal
foot, 2. Pes cavus, 3. Pes planus.
Paralysis of plantar flexors resulting in unopposed action of the

dorsiflexors gradually sets pes cavus. Weakness of the intrinsic foot
muscles, lumbricals and interossei could be the cause.
There is dropping of the anterior transverse arch. In case of
paralysis of intrinsic muscles, their stabilizing action is lost resulting
in uncontrolled action of the long toe flexors, which cause clawing of
the toes.
When the long toe flexors are paralysed, the anterior tibial muscles
exert excessive pull, resulting in raising of the anterior part of the
calcaneus and depression of the anterior transverse arch along with
hyperextension at the MTP and flexion at the IP joints (clawing) – Fig.
37-19B.
Treatment
Physiotherapy and special shoes can control the deformity in the early
stage. Neglected and severe cases need surgical intervention.
Surgical treatment
1. Steindler’s operation: All the muscles on the under surface of the

calcaneum along with the plantar fascia are divided. The divided
muscles slide forward and get attached to the bone distally. The cavus
position is thus corrected. A below-knee POP cast is applied in the
corrected position for 3–4 weeks.
2. Lambrinudi’s operation: This consists of the arthrodesis of the

interphalangeal joints to correct the clawing; the long toe flexors also
act at the metatarsophalangeal joints supporting the metatarsal heads.
Thus, the muscle power is redistributed in the foot. It is not done
when there is paralysis of the long toe flexors or when the
metatarsophalangeal joints are dislocated.
3. Fasciotomy: Plantar fascia is divided along with the tendons of the

extensor digitorum longus (when contracted). The foot is then
stretched, the deformity is corrected and immobilized in a plaster cast
for 3–4 weeks.
For conservatively managed cases
1. Pain to be controlled by a suitable pain-relieving

modality. Faradic foot bath and exercises under warm
water can be given.
2. A small sand bag is placed over the dorsum of the foot in

contact with the ground or by offering self-stretching by
placing the heel of the normal foot over the dorsum of
the deformed one. The weight of the sand bag or the
pressure of the normal foot offers relaxed passive stretch
to the contracted plantar fascia.
3. Movements of dorsiflexion combined with toe extension
have a stretching effect on the longitudinal arch. Resisted
toe extension is useful in preventing clawing of the toes.
4. Corrective shoes with soft padding are given to

encourage weight bearing over the arch.
For surgically managed cases
1. Exercises to the joints free from immobilization
2. On removal of the plaster: active exercises to the

metacarpophalangeal joints, ankle and foot.
3. Stretching sessions to flatten the longitudinal arch by

weight bearing and weight transfers to it.
4. If the surgical scar is painful, friction massage can be

helpful.
5. Re-education in ambulation.
Pes plannus (flat foot)

A foot deformity opposite to pes cavus. Here, the medial longitudinal
arch of the foot is dropped downward; thereby, there is a loss of the
spring action causing excessive stress over the whole foot during
every step.
Causes
Pott’s fracture, crushed injury to the calcaneum, laxity of ligaments
(deformity appear only on bearing weight), bony ankylosis
(talocalcaneal bar) result in a rigid flat foot remaining flat even during
non–weight bearing; sometimes, there are spasmodic reflex
contractions of the peronei (e.g., rheumatoid arthritis and
tuberculosis). This is known as a spasmodic flat foot.
It may be associated with valgus heel with partial subluxation and
eversion of a subtalar joint.
Symptoms
Except for the spasmodic variety, it is usually pain free. Later on
weight bearing becomes painful.
Treatment
For children younger than 3 years, initial stage C and E heel shoes
with medial arch support, and arch support in the footwear should be
used at home. Custom prothesis for age group between 3 and 10
years. At late stage, they will need well-moulded orthosis.
Physiotherapy
◼ Strengthening and endurances exercises to the intrinsics (in warm
water).
◼ Corrective gait training with orthoses and bearing weight on the

lateral border of the foot without orthoses.
◼ Repetitive toe curling even with shoes on (it provides resistance).
Surgery
Rarely performed procedures:
◼ Modified Hook–Miller’s procedure
◼ Durban’s flat foot plasty
◼ Triple arthrodesis
Hallux valgus
This deformity is characterized by abnormal abduction of the first
metatarsal with adduction of the phalanges. It is usually present
during early life but gets aggravated in later age (Fig. 37-20). Injury or
diseases like gout, arthritis or even bad footwear can precipitate this
condition.
FIG. 37-20 Hallux valgus. (A) Abnormal abduction of the first metatarsal.
(B) Hallux valgus deformity. (C) Corrective orthosis.
A false bursa may form over the first metatarsal head, which may
get thickened and enlarged. This is known as ‘bunion’. The articular
cartilage may get inflamed, eroded and atrophied. New bone
formation may take place on the medial side of the metatarsal head
(exostosis or spur). Tendon of the extensor hallucis longus is
shortened and displaced laterally. It acts with a mechanical
disadvantage, increasing the deformity. Intrinsic muscles, too, cannot
act effectively. These inadequacies result in dropping of the arch and
eversion of the foot.
Treatment
Mild cases are to be managed by physiotherapy and proper footwear.
Surgical treatment
Severe cases do not respond to conservative treatment and need
surgery.
1. Arthroplasty: The bunion and the exostoses are removed, shortened

and the soft tissues are divided. The joint is aligned in the maximally
corrected position.
2. Keller’s operation: Proximal two-thirds of the proximal phalanx are

removed with the bunion and the medial portion of the head of the
metatarsal (Fig. 37-21A).
3. Mayo’s operation: The head of the metatarsal is excised. Firm

dressings or plaster cast are given for 2–3 weeks following surgery.
Occasionally, traction may be applied through the pulp of the toe.
4. Arthrodesis: Arthrodesis of the metatarsophalangeal joint of the big

toe (Fig. 37-21B)
FIG. 37-21 Surgical procedures for hallux valgus. (A) Keller’s arthroplasty.
(B) Arthrodesis.
1. The patient is taught to carry out relaxed passive stretching of
abduction of the toe many times a day.
2. Straight inner border footwear with wedge in between the great toe
and the second toe greatly helps in maintaining constant abduction
stretch on the great toe. Night splint may be given.
The most important factor to be remembered with the splint

or the corrective shoe is that it must not exert any pressure
or friction over the medial aspect of the head of the first
metatarsal.
3. Strong active exercises are given for strengthening the lumbricals

and interossei.
4. Proper weight bearing: Weight bearing, which tends to be more on
the lateral aspect of the foot to avoid pressure and pain, should be
discouraged.
5. Faradic foot bath may be necessary to relieve pain, improve

circulation and induce contractions of the intrinsic muscles.
Physiotherapy following surgery: It follows the same course

as described earlier during immobilization. After the
removal of stitches:
1. The patient is trained in relaxed passive stretching of the

toe. It is advisable to put a soft cotton or foam wedge
between the great toe and the second toe.
2. Strong exercises are given to the intrinsic muscles of the

foot.
3. Active fanning of the toes in warm water with assisted

abduction of great toe is to be emphasized.
4. Faradic foot bath is useful in assisting active efforts.
5. Weight transfers, gait training and ambulatory activities

to be gradually added avoiding the limp.
Hallux rigidus
This deformity results in stiffness of the great toe at the
metatarsophalangeal joint.
Focal sepsis, direct injury to the great toe or tight footwear
precipitates rigidity. There is erosion of the cartilage with
inflammation of the synovial membrane. Spasm in the extensor
hallucis longus leads to shortening of the soft tissues leading to bony
ankylosis.
Stiffness of varying degrees with pain is the conspicuous feature.
The first phalanx may even be fixed in flexion (hallux flexus).
However, interphalangeal movement is not affected.
Treatment
Conservative
1. Thermotherapy modality with other measures should be used to

relieve inflammation.
2. Pressure relieving measures like metatarsal bar, soft sole and

modified footwear should be used.
3. Stress on the toe to be reduced by guiding modified gait with

minimum toe extension during the push off phase of gait. POP cast
may sometimes be necessary.
Surgical
◼ Excision arthroplasty of the proximal half of the first phalanx.
◼ Arthrodesis of first MTP joint.
1. Besides other routine postoperative measures, the

metatarsophalangeal joint of the great toe should be mobilized early.
2. Repeated active flexion–extension exercise in warm water restores

ROM early.
3. Exercising intrinsic muscles is important.
4. Proper gait training.

Hammer toe
In this condition, there is contracture in the second toe which could be
congenital or familial in origin. Tight shoes can also produce hammer
toe. It results in flexion deformity at the proximal interphalangeal joint
and flexion or extension at the distal interphalangeal joint. The long
extensor tendons are contracted along with the overlying skin (Fig. 37-
22).
FIG. 37-22 Hammer toe. Flexion deformity of the proximal interphalangeal

joint with compensatory hyperextension at the metatarsophalangeal and
distal interphalangeal joints.
Treatment
The toe is strapped to the neighbouring toes in the corrected position
with an adhesive plaster. Corrective splint during rest is necessary to
maintain small constant stretch. Relaxed passive stretching with axial
traction and its retention stretches the short muscles.
Surgical
Excision of the proximal interphalangeal joint corrects the deformity.
In severe cases, arthrodesis of the first interphalangeal joint is also one
of the surgical procedures adopted to manage severe cases of hammer
toe.
After the operation, immobilization is maintained for 4–6 weeks
after which weight bearing is permitted.
Mobilization and stretching of the metatarsophalangeal and
interphalangeal joints are encouraged. Following the procedure of
arthrodesis, other relevant joints are mobilized to the maximum.
Following all the procedures, adequate maintenance of correction,
along with other routine procedures are adopted till free and correct
function is achieved.
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CHAPTER
38
Yoga, yoga asanas and physiotherapy
OUTLINE
◼ Yoga and physiotherapy
◼ Genuine yoga
◼ Preventive and promotive aspects of yoga and yoga asanas
◼ Therapeutic benefits of yoga
◼ Preventive benefits of yoga
◼ Rationale of yoga and physiotherapy
◼ Yoga as applied to physiotherapy
Yoga and physiotherapy

Yoga
Yoga is a supreme harmonization of physical, vital, mental,
psychological and spiritual aspects of an individual. The basic aim of
genuine yoga is to acquire intelligent and absolute control of the mind
through self-development of physical and mental faculties. This
absolute harmony and coordination of mind and body, though based
upon physical exercises, breath and mind control, is primarily a
spiritual process. Thus, attainment of physical fitness through yoga
asanas and pranayama is just the initial two steps towards the path of
yoga sadhana.
Yoga is very ancient and the time of origin of its practice and
doctrine cannot be dated with accuracy. The word ‘yoga’ is mentioned
in the Rigveda and some of its methods are found in Vedic literature,
which dates back to thousands of years before Christ. One description
of yoga and its definition is found in the ancient Hindu epic, Bhagwat
Gita, which defines yoga as follows:
1. Samatvam yoga uchhayate – meaning, yoga is balance and harmony of

the mind and body
2. Yoga karmasu kaushalam – meaning, yoga is skill in work
Physiotherapy
Physiotherapy is the treatment of disease or its aftereffects by means
of various physical modalities like remedial exercises, heat
(thermotherapy), cold (cryotherapy), various modes of electrical
currents, water (hydrotherapy) and wax (wax therapy). The basic aim
of physiotherapy is to provide maximum possible physical
independence within the limits of the disease and disability. Of all the
modalities at hand, exercise forms the basis of physiotherapy for the
relief of symptoms and improvement of functions or functioning
capacity of the body.
The word exercise originated from the word ‘ex’ meaning out and
the word ‘ere’ derived from ‘arcere’ meaning to lock. Thus exercise
means to unlock or to free a part to move. The origin of exercise as a
therapeutic measure dates back to the prehistoric period. The earliest
writing on therapeutic exercises using various postures and
movements of the body is traced back to about 1000 years before
Christ in Cong Fou of Ancient China (Mac Auliffe, 1904). The fourth
volume of Atharvaveda of ancient India called Ayurveda recommended
remedial exercise and massage about 800 years before Christ (Guthrie,
1945).
In ancient Greece, interestingly enough, there existed a class of
gymnasts, besides philosophers and priest-physicians, who practised
medicine. They also studied the effects of diet and exercises (Littre,
1839).
The knowledge about the relationship between body movements
and muscles is found in a book on articulations by Hippocrates. In his
text, he also very often used the word exercise (Adams, 1849; Littre,
1839).
The theoretical benefits of yoga have resulted in its tremendous
attraction, wide appreciation and universal popularity, so much so
that practically every individual, at least verbally, praises yoga.
Innumerable yoga centres have come up within a short span. It is
being taught and practised at numerous yoga centres around the
globe. But how much of it is true or genuine?
Genuine yoga
There are four basic forms of yoga: Karma yoga, Jnana yoga, Bhakti
yoga and Raja yoga (Table 38.1). The first three forms trace their origin
to the Bhagwat Gita. The fourth form is the creation of the sage
Patanjali, the father of yoga sciences. He mentioned it in his Yoga
Sutras. Raja yoga has three components: Hatha yoga, mantra yoga and
laya yoga (Table 38.2). Hatha yoga itself is a scientific integration of
eight basic elements or steps, known as the eight limbs of the body of
yoga. As it is impossible for the human body to achieve control
without acquiring the control of its limbs (arms and legs), the body of
yoga also cannot achieve full control without the control of its eight
limbs or elements. These eight limbs are called astangas. Therefore,
genuine yoga is to acquire step-by-step mastery over all the astangas.
The objectives, requirements and composition of astangas are
presented in Table 38.3.
Table 38-1
Basic Forms of Yoga
Yoga
Karma Yoga (right attitude Jnana Yoga (pursuing Bhakti Yoga Raja Yoga (mastering
towards work) knowledge) (devotion) the mind)
Table 38-2
Components of Raja Yoga
Raja Hatha yoga Body and mind control

Yoga Mantra Recitation of mantras as an aid to meditation
yoga
Laya yoga Arousal of Kundalini by practice of hatha and mantra
yoga
Table 38-3
Basic Elements of Astangas
1. Disciplinary or moral restraints

Yama
2. Spiritual observances
Niyama
3. Movement and posture of the body for promotion of perfect health and to bring about
Asana harmony in the body
4. Rhythmic breathing or regulation of breathing process (control of bioenergy or prana)
Pranayama
5. Withdrawal of mind from external objects
Pratyahara
6. Concentration of mind on one object for a brief period (mental control)
Dharana
7. Meditation or concentration of mind on one object for a long period
Dhyana
8. Attainment of supreme harmony (between mind and body)
Samadhi
These astangas, or eight elements, which are the basic components of

complete yoga, are divided into two major stages:
1. Bahiranga or external yoga: This includes the first five elements.

Regular and disciplined practice of yama, niyama, asana and pranayama
is needed to attain the fifth element of pratyahara. Pratyahara or
abstraction is a phase of acquiring the highest control of the senses.
The void between the senses and the mind leads to the conquest of the
senses with total adjustment of one’s motivation, value judgement,
attitudes and behaviour. This minimizes the objective causes of
mental distractions and depravities. By the practice of external yoga,
an individual succeeds in freeing himself from the condition of
sensate and emotional servitude. The strict observance of these five
elements or Bahiranga yoga prepares the individual to be fit to
practise antarangas leading to samadhi.
2. Antaranga or internal yoga: Also known as Raja yoga, it leads

towards the achievement of the remaining three elements, namely
dharana, dhyana and samadhi. It represents a state of immaculate
consciousness. Samadhi is the final stage of supreme harmony, where
the individual remains unmoved (or still) by any sort of physical or
mental afflictions. Therefore, Patanjali aptly defined genuine yoga as
‘stilling of the modifications of consciousness’.
Second classification of yoga

The second classification of yoga is based on the principles of
preparing oneself physically and morally for the achievement of
supreme harmony.
1. Moral preparation through yama, niyama and pranayama
2. Physical preparation through asanas and pranayama
3. Real yoga through dharana, dhyana and samadhi
Therefore, yoga asanas and pranayama are two of the eight elements
of complete yoga. These two elements assist in acquiring physical
control. As these two elements are the important constituents of
physical or body control, it is important to know the detailed
methodology of asanas and pranayama.
Methodology of asanas (hatha yoga)

The yoga that deals with the physical aspect of the human body is
termed as hatha yoga. It represents the polarity in which all human
beings function. It consists of two basic principles, namely HA and
THA.
HA: It is an active or positive principle of existence and is
symbolized by sun, heat, light and creativity.
THA: It is an inactive or negative principle and is represented by
moon, cold, darkness and receptivity. A human being enjoys perfect
health only when there is equilibrium or balanced functioning of these
two polarities. Hatha yoga leads to the achievement of absolute control
over the body. Asanas, thus, have a dominant role to play in hatha
yoga.
Yoga asanas
Each asana is a series of scientifically developed slow, rhythmic and
graceful movements of various joints and muscles of the body aimed
at attaining a definite posture as related to that particular asana.
Asanas aim to acquire optimal physical conditioning with minimum
efforts. Smooth, rhythmic body movements are not possible without
perfect neuromusculoskeletal coordination and control.
Each asana has three stages.
Stage I
During this early stage, a particular asana is slowly and gradually
initiated from the fundamental starting position (e.g., supine lying,
sitting, standing, prone lying). From this fundamental position the
body is slowly moved towards the posture of that particular asana. It
must be progressed in graduated steps and not be proceeded beyond
the stage where even the slightest discomfort is felt.
Stage II
This stage represents static holding of the posture assumed during
stage I. However, this static brief holding should be a relaxed posture
not causing any strain on the body.
Stage III
This is a stage of graduated return of the body to its original starting
position. The gentle, rhythmic and dynamic reverse movements of the
various components of the body frame during stage I and its reflective
holding during stage II promotes harmonious equilibrium of the two
basic energies needed for the control of the body. The regular practice
of Hatha yoga results in a slim body (lissom), joyous face, sonorous
voice, sparkling eyes, positive good health, virility, exuberance of
vitality, radiance and purity of the nervous system (Yogendra, 1978).
Pranayama
Pranayama is based on the methodology of breathing to achieve
respiratory control. A single yogic breath has four units:
1. Puraka: Related to inhalation of oxygen to the fullest capacity of the

lungs
2. Kumbhaka: Refers to the steady state of holding air with full

distension of the lungs
3. Rechaka: Refers to the total exhalation of air emptying both lungs to

the maximum
4. Shunyaka: Holding the state of void or vacuum when air from the
lungs is totally expelled
To achieve effective breathing control, these four stages are

sequentially performed in a ratio of 10:20:10:10 s each. The ratio could
be 10:40:20 s when pranayama is performed with the first three units:
puraka, kumbhaka and rechaka leaving the fourth unit of shunyaka. Yogic
breathing carried out by this method tones up the intrathoracic and
intraabdominal viscera and the total respiratory system. The stage of
holding air with full distension of lungs (kumbhaka) has been given
more importance and its duration is double as compared to that of the
other stages.
Preventive and promotive aspects of yoga and

yoga asanas
Prevention of ill health or a disease is more logical than allowing it to
occur and then struggle to cure it. Yogabhyasa, that is, scientific
knowledge of yoga, kriyas and regular practice of asanas prepares an
individual’s body to an ideal state which not only prevents the disease
but also tunes the whole body system to a level that it can effectively
neutralize or fight back to reduce the impact of the disease, thereby
promoting its early resolution. Also, in yoga, one finds maximum
emphasis on body hygiene through strict body discipline and various
purificatory processes. This aspect is contributory in prevention of
disease.
The added advantage in the promotion of health through yoga is
that besides attaining physical fitness, it offers positive mental health.
The basic approach of yoga is through psychosomatics, so much so
that the term preferred to the therapeutic approach is yoga
psychosomatics.
The importance of positive mental health in any circumstances of ill
health need not be overstressed. In fact, medical science can never
boast of positive physical health without sound mental health.
Unfortunately, this important aspect, though accepted theoretically, is
generally overlooked in present therapeutic methods.
As yoga includes both these aspects, its integration is important in
prevention of the disease and promotion of the positive physical and
mental health. It therefore deserves a proud place in any health care
programme.
Yoga has a positive influence on both external and internal
functions of the body.
Promotion of external functions

For optimal physical functioning, the flexibility of joints, muscular
strength and endurance, and neuromusculoskeletal coordination are
important. The toning up of these body systems through yoga asanas
and pranayama improves the physiological functions of all the systems
and organs of the body.
Promotion of internal functions

Yoga provides efficiency in the functioning of the central nervous
system (CNS) and peripheral nervous system (PNS). The optimal
functioning of the ANS depends upon the degree of equilibrium of the
sympathetic and parasympathetic nervous systems. When there is
dominance of the sympathetic nervous system, it results in loss of
normal homeostatic condition of the body or optimal physiological
functioning of the body. Therefore, promotion of the parasympathetic
system or its dominance over the sympathetic system is important for
health. Influencing the functioning of higher nervous systems also
results in improved functions of the internal viscera including the
endocrine system. However, achieving such modifications in the
nervous system, which holds a master control over the functioning of
each and every living cell of the human body, needs genuine practice
of astangas, especially transcedental meditation (TM) (Anand, 1975).
The promotion of cellular health results in adequately meeting the
fundamental needs of the body, namely of nutrition and elimination.
Besides promotion of the circulatory and respiratory systems, it
improves the tone and elasticity of the musculoskeletal system. This
provides a higher anabolic ratio while accelerating the interchange of
products between blood and muscles.
Emotions, behaviour of the endocrine gland hormones and mental
health are deeply correlated with each other. By practising asanas,
bandhas and mudras regularly, physical and mental health are
maintained as the endocrine system is crucial in maintaining all levels
at the optimum. Some yogic practices, particularly uddiyan bandha,
kapal bhatic, nauli, dhanwasana, halasana and yogamudra, can alter
the menstrual cycle in women; therefore, they should practise them on
a mild scale and with careful observation.
Thus, these two elements of asanas and pranayama have a significant
role to play in the prevention of disease and promotion of positive
health.
Preventive and promotive aspects of

physiotherapy
The field of physiotherapy, which was primarily limited to
movements of joints following fracture or injury, has developed into a
medical speciality with wide horizons of its application. Besides its
therapeutic role, it has acquired a significant role in both aspects of
prevention, primary and secondary:
Primary prevention
Just like yoga asanas and pranayama, physiotherapy has several
systematically designed and scientifically proved procedures of
exercises which promote optimal physical fitness. Physical fitness
tones up all the systems and organs of the body to prevent disease,
facilitating the process of recovery.
◼ Prevention of cardiorespiratory diseases: prevention or control of

disease-prone risk factors like obesity, hypertension, diabetes and
dyslipidaemia
◼ Prevention of common musculoskeletal disorders like pain and/or

stiffness in the neck, shoulder, back and knees which have been the
source of discomfort and loss of productive working hours and
work efficiency
◼ Prevention of common sports injuries by conditioning specific

injury-prone areas
Secondary prevention
◼ Prevention of life-threatening cardiorespiratory and vascular
complications following major surgical procedures
◼ Prevention of secondary musculoskeletal complications following

injuries or diseases, burns, amputations, etc.
◼ Prevention of the recurrence of cardiovascular and

cardiorespiratory ailments by cardiopulmonary conditioning (as
detailed in Chapter 1) and also prevention of the recurrence of
common musculoskeletal disorders like pain and stiffness in the
neck, back, shoulder or knees and muscular atrophy and weakness
Therapeutic benefits of yoga

Hypertension
Reduction of systolic blood pressure from 150 to 140 mm Hg, and
reduction of diastolic blood pressure from 94 to 88 mm Hg was
reported in 22 hypertensive patients after TM.
The practice of shavasana also resulted in a significant reduction of
hypertension (Datey & Bhagat, 1975).
Exercise tolerance
Patients of coronary artery disease (CAD) with stable angina showed
improvement in exercise tolerance. Increase in the duration of
exercise, increase in maximum work load and delay in ST depression
in the ECG were reported in 10%, 15% and 15% of patients,
respectively.
Bronchial asthma
Spontaneous reduction in the rate of breathing from 13 to 10 and
reduction in the airway resistance were found in about 50% of
patients with bronchial asthma. The severity of symptoms was
reduced in as many as 75% patients (Wallace 1970; Wallace and
Benson, 1972).
Swami Anandananda and associates (1975) reported an
improvement in the lung function, pattern of breathing and even
harmonal homeostasis just by practising simple muscular exercises
(shukshma vyayam) with certain asanas in patients with mild-to-
moderate bronchial asthma. However, they concluded that yoga
cannot substitute drugs for emergencies like status asthmaticus.
Diabetes
Adult onset type diabetes, of less than 10 years’ duration, with a
fasting blood sugar of less than 250 mg%, and patients requiring less
than 40 units of insulin daily for control of their diabetes responded
favourably (Rugmini, 1975).
Low backache
Practising Konasana, Supta-vajrasana, Bhujangasana, Shalabhasana and
Chakrasana showed favourable response in patients suffering from low
back pain with improved functional capacity (Udupa, Singh &
Shettiwar, 1975).
Squatting posture gives excellent stretch for lower spine while
strengthening the muscles of legs and hips. It helps to open the lower
spine. People who squat often get less backache problems. However,
squatting should not be done for long periods.
Tachycardia, palpitation, nervousness, insomnia

All these symptoms and signs responded favourably to the regular
practice of asanas (Udupa, Singh & Shettiwar, 1975).
Preventive benefits of yoga

Physiological, biochemical and various all-round beneficial effects
have been reported by a number of studies in normal subjects
practising TM as follows:
Oxygen consumption and metabolic rate

Oxygen consumption reduced to the extent of 16–25% by regular
practice of TM for 40–60 min. Also the reduction in the metabolic rate
achieved after TM was found to be even more than that during the
state of deep sleep (Wallace, 1970).
Reduction in heart rate

Reduction in heart rate by 5 beats/min (from 71 to 66) was reported
during TM and it remained at that level up to 15 min after TM.
Perceptual motor performance

The speed and accuracy in performing complex perceptual motor test
improved in subjects practising TM.
Level of plasma cortisol and plasma prolactin

Level of plasma cortisol reduced by 25–30% and plasma prolactin
level was found to be increased in subjects practising TM (Jeving,
Wilson, Venderlaan & Levine, 1975). Blood lactate level dropped from
10 to 6 mg/100 mL (Wallace and Benson, 1972), all indicating a
profound state of muscular relaxation.
Besides these, other benefits in normal subjects are as follows:
1. Reversal of biological ageing as proved by the measurement of

auditory threshold, near point vision and systolic blood pressure
2. Improved athletic performance with reduction of heart rate
3. Feeling of restful alertness
4. Improved memory, intelligence, academic performance and

concentration
Therapeutic benefits of physiotherapy

Modern physiotherapy has a wide variety of specialized exercise
techniques, evolved and established through scientific research. The
specific technique of therapeutic exercises is planned after a thorough
clinical examination and investigations indicating the nature, degree
of involvement, and the prognosis of the disorder. It may be directed
toward the following:
1. To improve strength, endurance and flexibility of muscles
2. To facilitate neuromuscular coordination
3. To restore function or to provide maximum functional

independence within the limits of the disease and disability
(rehabilitation of physically handicapped patient)
4. To build up vicarious movements or trick movements to

compensate for the permanent loss of movements
5. To facilitate neuromuscular re-education through biofeedback or
synchronization of electrical stimulation with voluntary efforts and
specialized exercise techniques
6. To achieve cardiopulmonary conditioning to prevent as well as

control risk factors for CAD, hypertension, diabetes, obesity, etc.
7. To improve body balance and gait
8. To promote performance by leading to optimal physical fitness

through increase in functional capacity (VO2 max)
9. To prevent common sports injuries by conditioning of an athlete
10. To prepare for and facilitate child birth
11. To relieve pain and inflammation and to augment healing
12. To provide ergonomic advice with specific exercises, to prevent

common musculoskeletal ailments
13. To prevent postsurgical complications
14. To promote physical fitness for overall positive health benefits
15. To improve psychological status leading to positive thinking,

greater self-confidence, feeling of relaxation and wellness following a
session of exercise
Rationale of yoga and physiotherapy

Physiotherapy has its origin in yoga. The basic postures of the body
known as fundamental or starting positions for initiating therapeutic
exercise are same as the starting postures or asanas in yoga, e.g.,
tadasana corresponding to standing or shavasana corresponding to
supine lying (Figs. 38-1, 38-2).
FIG. 38-1 Tadasana, corresponds with the fundamental standing position.
FIG. 38-2 Shavasana, corresponds with the fundamental supine lying.
Similarly, many exercises resemble certain asanas (Figs. 38-3–38-10).

FIG. 38-3 Pawan muktasana, similar to low back stretch or knee–chest

position.
FIG. 38-4 Bhujangasana, similar to hyperextension stretch to the whole

spine.
FIG. 38-5 Paschimottasana, corresponds to spinal stretch in flexion along

with hamstrings stretch.
FIG. 38-6 Ardha halasana, similar to straight leg raising.

FIG. 38-7 Vrikshasana, similar to whole-body stretch.

FIG. 38-8 Gomukhasana, similar to shoulder stretch.
FIG. 38-9 Supta urdhwa hastasana, corresponds to arm stretching over

head in long sitting.
FIG. 38-10 Naukasana, similar to stretching of the whole spine and legs
together in hyperextension.
However, the basic difference is obvious when it comes to the

methodology of performance of the therapeutic exercise and yoga
asana.
In yoga asana, one assumes a definite posture of a particular asana
and holds that posture for a brief period and then returns back to the
starting position. Thus, the sequence of yoga asana is a slow, rhythmic
dynamic movement of the body progressing to a static state of holding
and again returning to the starting posture (dynamic-static hold-
dynamic), whereas in therapeutic exercise, the sequence, speed, groove
of the movement and arc of joint range vary as per the required effect
of exercise. Although the maximum emphasis is on dynamic exercises,
static exercises are used in physiotherapy to prevent painful joint
compression and disuse atrophy, to improve strength, endurance,
posture and to induce relaxation.
Similarly, exercises could be passive, assisted, active or even
resistive as against only dynamic and static in yoga. Thus, the mode of
therapeutic exercise is extremely variable and as such, there is no
generalization of exercises, rather the mode of exercise is planned on
an individual basis. The exercises are modified or progressed as per
the requirements of the patient’s condition.
This is not true with Hatha yoga. Although the asanas are more or
less based on scientific experimentation, they are limited to certain
body movements, postures and breathing and cleansing techniques
(kriyas). This has resulted in providing excellent general exercises with
flexibility to the whole body.
Yoga asanas, without integration of astangas or all the eight elements
of yoga, are excellent means of promoting flexibility to the joints and
soft tissues. They also help improve muscular strength, endurance,
controlled muscular actions, controlled breathing and relaxation. This
limits their application in patients with spinal cord injuries,
polyarthritis, severe physical handicap and neurological disorders.
The efficacy of exercising the whole body through asanas in a
specific localized disorder or dysfunction is not without doubt,
whereas advanced exercise techniques like proprioceptive
neuromuscular facilitation (PNF), biofeedback and self-controlled
movements in combination with a suitable electrotherapeutic
modality help to re-educate neuromusculoskeletal function.
Pranayama and yoga kriyas (or shat karmas), the procedures for
systemic purification, are, no doubt, excellent techniques to promote
respiratory and gastrointestinal systems on the whole. But various
methods of chest physiotherapy and postural drainage to eliminate
secretions from a diseased area of the lung are much more specific.
The slow, smooth and rhythmic movements of yoga asana leading
to a static relaxed posture aim at conservation of energy (prana). As
against this, in physiotherapy, the movements, although smooth and
rhythmic, are aimed at overloading or excessive expenditure of energy
(e.g., cardiorespiratory conditioning). The nature of movements in
restorative or re-educative therapies is not so vigorous but is dynamic
and repetitive.
Yoga as applied to physiotherapy

Yoga asanas can be applied effectively and to a very great advantage
with some modifications.
1. Shavasana is ideal for total relaxation of the body after continuous

exercise sessions or in patients where vigorous and strenuous
exercises are contraindicated.
2. Intermittent practice of TM is ideal for better concentration of mind

for all therapeutic exercise procedures and also in sensory, motor and
neuromuscular re-education procedures.
3. Intelligent integration of certain yoga postures and their suitable

modifications, like inhibitive procedures, facilitate movement control
by reduction of selective postures and postural attitudes. The effect of
asanas is more on the trunk portion of the body. These bring about
changes in the pressure in the internal cavities of the visceral organs,
though in physiotherapy, limb movements are also included, which
helps in increasing peripheral circulation also.
4. Pranayama and other cleansing kriyas can be added to chest

physiotherapy.
5. Modified asana postures can be effective in common

musculoskeletal dysfunction.
A number of studies have been reported on the therapeutic aspects

of yoga without due consideration in determining the base for
autonomic balance. Moreover, these studies have included only a few
elements of yoga like asanas and pranayama or meditation alone.
A study conducted with one or two elements out of eight elements
of yoga does not constitute genuine yoga. Therefore, concluding the
benefits of this partial yoga is also not justifiable.
Future studies should be conducted by integration of all the eight
elements of yoga. Who knows? Inclusion of astangas may even
promote healing or rejuvenation of the body systems (e.g., nervous
system) or the organs which are so far labelled as impossible in the
medical sciences.
Some precautions while doing yoga
◼ Do not force or strain. Pay special attention to your pain.
◼ Do not ignore or push through the pain. If pain becomes worse, the
muscle is already overstretched; hold the stretch where you are
comfortable.
◼ If pain decreases, you are doing yoga in a beneficial way.
◼ Pay attention to your breathing.
◼ Listen to your body. If something does not feel right for your back,
take rest.
◼ Remember to rest periodically in the midst of busy days.
◼ Try to increase the stretch time slowly.
◼ Stretch on a daily basis to prevent the muscles from tightening up.
◼ Deep relaxation in a simple technique but a powerful tool for

healing and taking away incapacitating back pain.
◼ One should take into account his or her limitations due to age, sex,
hyper- or hypotonic condition of the musculature rigidity or
flexibility of the joints and the purpose of practising asanas.
Therefore, asanas should never be done in a competitive spirit.
Conclusion
The science of yoga, which has a spiritual base, has tremendous
potential not only in health but in all spheres of life. It has excellent
dimensions as a preventive and promotive science for positive health
through asanas, pranayama and meditation. Its applicabilities remain
obscure due to the practice of only partial yoga.
Yoga teaching needs to be extensive which should include basic and
applied medical sciences like human anatomy, physiology,
kinesiology, biomechanics and pathology.
Intelligent integration of asanas, pranayama, kriyas and meditation
with physiotherapeutic procedures has a definite role to play in the
preventive, promotive and curative aspects of positive health.
Bibliography
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Yoga, Science and Man. 1975.
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shavasana. Seminar on Yoga, Science and Man. 1975.
5. GoseM. M.Anatomy and physiology of yogic practices.
6. Guthrie D. A History of Medicine, London. 1945.
7. Jeving R, Wilson AF, Venderlaan E, Levine S. Plasma prolactin
and cortisol during transcedental meditation. New York City: The
Endocrine Society Programme, 57th Annual Meeting. 1975.
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1839.
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10. Pandit Shiv Sharma. Yoga against spinal pain. New Delhi: B.I.
Publications. 1975.
11. Rugmini PS, Sinha RN. Seminar on Yoga, Science and Man
The effects of yoga therapy in diabetes mellitus. 1975.
12. Swami Anandanand & Varadani N. Seminar on Yoga, Science
and Man Therapeutic effects of yoga in bronchial asthma.. 1975.
13. Swami Shivananda. The science of pranayama. Rishikesh, India::
Divine Life Society. 1975.
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Science and Man Preliminary therapeutic trials of yogic
practices.. 1975.
15. Wallace RK, Benson. The physiology of meditation. Scientific
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proposed fourth state of consciousness (PhD Thesis). Department of
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17. Maharshi Ved. Vigyan Vidyapeeth. Yoga Asanas. Delhi, India:
SRM InternationalPublications:.
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Chapter 39
Sports medicine
Outline
◼ Incidence and broad classification of sports injuries
◼ Major causative factors
◼ Role of physiotherapy
◼ Prevention of injury
◼ Treatment of injury
◼ Training of an athlete
◼ Grooming of the specific athletic skill
Sports medicine has acquired the status of an independent

speciality of medical sciences. Its basic aim is to prepare and
educate an athlete to achieve the optimal physical efficiency
with safety.
Incidence and broad classification of sports

injuries
Rapid increase in the speed and the competitive nature of
sports have resulted in an increase in the incidence of sports
injuries. Williams reported as far back as 1979 an incidence
of sports injuries between 5% and 10% of the attendance at
the accident and emergency departments (Williams, 1979).
Except for sedentary games, the incidence of sports injuries is

predominant in the lower limbs, foot and ankle; injuries
alone account for about 80–82%.
Therefore, prevention as well as management of foot and

ankle injuries demands optimal care and competent
management.
Major causative factors
◼ Inadequate conditioning of the body particularly

cardiorespiratory and musculoskeletal systems
◼ Intermittent periods of lay off
◼ Overuse of a particular musculoskeletal complex related to

the requirements of individual sports (e.g., overhead
shoulder movement of a cricket bowler)
Broadly, sports injuries can be classified into two major

categories:
1. Traumatic, extrinsic or external injuries: These occur

mainly as a result of direct external trauma (e.g., direct hit
from an object used in a sport like cricket ball, or a fall).
Traumatic injuries are common in contact sports.
2. Nontraumatic, intrinsic or internal injuries: These occur as

a result of indirect internal trauma due to overuse of a
particular tissue which is subjected to stereotyped repetitive
movements in sports. The summation of a series of indirect
microtraumas results in internal tissue injury (e.g., tennis
elbow, tenosynovitis, stress fracture). Fortunately, the
majority of sports injuries are orthopaedic and
physiotherapy-related injuries which respond favourably to
adequate simple measures. A physiotherapist must be aware
of the injuries commonly met with in sports (Table 39-1).
Table 39-1
Regionwise Common Sports Injuries

Region Specification Cause Injury (Mode)
Head Head injury Direct violent Fracture/dislocation
blast of the cervical
spine
Neck Whiplash Direct/indirect Fracture/dislocation

violent jerky of the cervical
flexion– spine
extension
Burner and Direct trauma Forcing neck into

Stringer syndrome flexion and lateral
flexion nerve root
compression,
brachial plexus
lesion
Cervical sprains Indirect Posterior
and strains trauma longitudinal
following ligament is
jerky sudden commonly
neck involved
movement
Shoulder Fracture/dislocationDirect hit or Anterior

violent dislocation/fracture
indirect of the greater
trauma with tuberosity or neck
violent fall on are common
outstretched
hand
Recurrent anterior Indirect History of earlier
dislocation trauma, fall anterior dislocation
with arm in or defect in
abduction humeral head
and external
rotation
Dislocation of Direct: impact
acromioclavicular on the outer
joint side; indirect:
fall on
outstretched
hands
Bicipital tendinitis, Indirect due Repeated friction
Supraspinatus to repetitive causing rupture of
tendinitis, rotator movements the tendon or
cuff syndrome tendinitis
Fracture of the Direct fall on Fracture of the

clavicle the shoulder; clavicle (junction of
indirect fall middle and outer
on third)
outstretched
hand
Elbow Tennis elbow Indirect Tendinitis of
trauma due common elbow
to overuse of extensor origin
stressful
extension of
elbow
Golfer’s elbow Indirect Tendinitis of
trauma due common elbow
to overuse of flexor origin
repetitive
stressful
flexion of
elbow
Fracture/dislocationDirect Usually posterior
trauma, dislocation is
indirect common, fracture
violent fall on of coronoid process
the of ulna may occur
outstretched
hand with
elbow in
slight flexion
Wrist Carpal tunnel Indirect
syndrome injury, due to
overuse of
wrist joint
Hand Tenosynovitis Indirect, due Inflammation of
to overuse of the synovial lining
the wrist of flexor tendons of
joint; usually the wrist
occurs as a
result of
infection
Mallet finger Direct hit on Rupture of the
the tip of the extensor tendon
finger with
hard object
Fracture of the MP, Direct hit – Trauma
PID and DIP joints violent hit
over these
joints
Trunk Rib fracture Direct or
indirect
trauma
Intercostal strain Indirect Trunk twisting on
injury stationary feet
Abdominal sprain Indirect Overuse injury
injury
Low back pain Wrong Bony or soft tissue
postural strain, sprain
mechanism,
or postural
defect; loss of
joint
flexibility,
intervertebral
instability
Muscular
weakness,
tightness of
hamstrings or
hip flexors
Direct injury
to the back
Hip Hip joint pain Overuse, Training on hard
indirect surface
injury
Groin pain Overuse, Sudden external
indirect rotation with leg in
injury due to abducted position
adductor
strain
Thigh pain Direct blow Quadriceps muscle
or repeated contusion
adductor
strain
Tensor fascia strain Indirect Repetitive knee
overuse flexion–extension
syndrome or strain
friction
syndrome
Pyriformis Overuse
tightness syndrome
Pain – symphysis Overuse of Ligamentous strain
pubis adductors or
loosening of
symphysis
pubis
Knee Fracture patella Direct hit or Fracture of the
indirect patella
trauma due
to excessive
quadriceps
pull
Ligamentous Direct trauma Incidence of ACL
injuries causing injury is more
overstretching common
of the
ligaments
Meniscal injury Direct Tears, cysts or
twisting discoid menisci
injury to the
knee joint or
indirect
trauma
Chondromalacia Indirect Irritation of the
patellae overuse under surface of
injury patella
Patellar tendinitis Indirect
(Jumper’s knee) repetitive
trauma at the
tendon bone
junction or
hamstrings
tightness
Leg Calf strain Overuse Bracing lower leg
strain to calf against ground
muscle or reaction forces of
violent push landing
off thrust
Hamstring sprain Indirect Violent contraction
injury to the of hamstrings
hamstrings during push off
Shin soreness Indirect Repetitive shock

overuse absorptive stress
injury due to overuse
Ankle Inversion or Indirect Fall from height

and foot evertion strain injury due to and repetitive
with or without violent overuse
fracture inversion or
eversion with
ankle joint
relaxed in
plantar
flexion
Stress fracture of Indirect Hairline fracture of
tibia overuse the upper or lower
weight end of the tibia,
bearing fibula or metatarsal
injury bones
Fractures of the Indirect Weight bearing –
fifth metatarsal overuse results in–
injury to the Avulsion fracture
fifth of the base of the
metatarsal; fifth metatarsal
sudden
twisting of – Jones fracture
ankle in
inversion – Dancer’s fracture
March fracture A fatigue Fracture occurs at

fracture, the second or third
indirect metatarsal bones in
injury due to sustained standing
sustained
standing
Medial tibial stress Indirect Periosteum gets
syndrome injury due toinflamed over the
periosteal medial border of
inflammation the distal one-third
of tibia (shin
splints) due to
overuse
Anterior Overuse Excessive
impingement syndrome dorsiflexion of the
syndrome due to ankle joint results
repetitive in impingement of
excessive the anterior tip of
dorsiflexion the tibia on the
neck of the talus
Posterior Overuse Posterior tubercle
impingement indirect of the OS calcis
syndrome injury due to compresses the
repetitive synovial or
plantar capsular tissue
flexion against the tibia
due to repetitive
plantar flexion
Flexor hallucis Indirect Extreme repetitive
longus tendinitis overuse, plantar flexion
putting extra puts extra stress of
strain on dynamic
flexor hallucis stabilization of
longus medial foot and
ankle on flexor
hallucis longus
Injury or fracture Direct impact Impact of the foot
of sesamoid bone of the foot or on a hard surface
of great toe overuse with toes in
injury extension or
repetitive
microtrauma to the
foot; the fracture
may occur when
the proximal
phalanx of the first
MTP is jammed
into the dorsal
articular surface of
the metatarsal
head
Tenosynovitis Overuse Deep toe flexors,
causing tibialis posterior of
inflammation peronei are
of the commonly
synovial involved; overuse
lining of the results in synovial
fibrous inflammation
sheath of
deep toe
flexors
Note: It must be remembered that every speedy sport is

susceptible any type of neuromusculoskeletal injury.
The well-established role of physiotherapy as ‘only after
injury’ is incorrect. With rapid developments in the art and
science of physiotherapy, physiotherapy has great potential
to play a multifactorial role in the enhancement of all the
four major aspects of sports:
1. Prevention of injury
2. Treatment of injury
3. Training of an athlete
4. Grooming of the specific athletic skill
1. Prevention of injury
Preventing injury or ensuring early recovery is of primary

importance to any competitive sport or athletic event.
To prevent injury during the sport, the most important first
step is to conduct extensive physical examination with
objective evaluation of the physical adequacies required in
competitive sports, such as:
(a) Preexisting pathological deficiencies which are likely to

obstruct the efficiency of a sports person are detected (Table
39-2).
(b) The status of conditioning of the musculoskeletal

complexes predominantly involved in relation to the chosen
sport is examined.
(c) Exercise tolerance: A well-monitored exercise stress test

which provides normative data on the physical work
capacity (PWC) or aerobic capacity is inescapable.
(d) Before starting training on sport, overall physical fitness

of a sports person is assessed by a special fitness test (Table
39-3).
(e) Observation on the field: After selection for a particular

sport, the sport person is critically observed in a trial game
on the field for any abnormal attitudes and abnormal
mechanics, wrong postural attitudes, lack of speedy
coordination, etc. are recorded so that specialized training
can be given to correct them, especially on the field itself.
Table 39-2
Possible Pathological Deficiencies

Inadequacy of muscle Lack of strength, endurance
functions and flexibility
Limitation of a joint range of Due to soft tissue or skeletal
motion both active and pathology
passive
Static as well as dynamic Stable as well as instant
body balance regaining of equilibrium
Lack of movement Controlled – slow as well as
coordination between the speedy coordination of limb
body and the limbs movements
Lack of agility and speed For instantaneous position
changes while the body is in
motion
Table 39-3
Physical Fitness Test before Exercise Training and at Regular

Intervals
Ability to jump from the height of 1 m
Trail test to assess adequacy of strength, endurance,
flexibility, agility, neuromuscular coordination and balance
by the field test of a chosen sport
Presence of full passive ROM without any discomfort
Pain-free full active ROM against resistance
No limp during brisk walk, jogging or running
Full floor squats on both as well as on a single leg
Complete cross-legged sitting
Test for runners – ability to extend knee fully against the
resistance of 20 pounds, 10 times in <45 s
Test for contact sports: The same test as for runners, but
against the resistance of 45 pounds
On the basis of the data thus collected and the

musculoskeletal requirements of a chosen sport, a
comprehensive exercise prescription is formulated (e.g.,
improving the strength, endurance, flexibility and
coordination of the evertors of the ankle and foot will be
instrumental in preventing or in decreasing the gravity of the
commonly occurring inversion strain at the ankle joint).
Specific precautions to prevent injury
◼ Use adequate well-fitting protective aids (guards, helmets,

etc.).
◼ Comfortable light weight flexible footwear as per the

requirements of a particular sport (e.g., runner’s shoes
should have excessive cushioning to absorb the impact of the
ground reaction forces), excessive flexibility to toes, heel
wedge and 0.5 inch rocker under foot to facilitate toes-off.
◼ Do not undertake vigorous outdoor sports in extremely

high or low temperature or excessive humidity (e.g.,
temperature >42°C or 107°F, humidity close to 100% or
more).
◼ Lower extremity impact exercises should not be

performed on hard concrete surfaces or soft glossy surfaces.
The floor base should be tough.
◼ Initial phase of conditioning must have intermittent breaks

to prevent overuse injury.
◼ Appearance of pain or swelling during or following game
should not be overlooked. It may be a warning signal for
future capsulitis or arthritis.
◼ Using chewing gum during sports, a commonly seen

attitude which may cause asphyxia, should be stopped.
◼ Careful self-monitoring for adverse signs and symptoms

like dyspnoea, giddiness, excessive sweating, chest pain, or
angina should be taught, gradually tapering down the
intensity and never with an abrupt stop.
◼ Use protective guards even during the field trials.
2. Treatment of injury
Sports injury could be simple, just a contusion, sprain, strain,

open wound or a simple fracture. Although rare, the injury
could be cripping or even life-threatening in high-speed and
high-power contact sports, e.g., injury to the head, neck or
back. The treatment depends upon the gravity of the
structural involvement.
Fortunately, majority of sports injuries are simple in nature

and, therefore, can be managed effectively with appropriate
orthopaedic and physiotherapeutic procedures. As a rule of
thumb, the treatment begins by following the principles of
rest, ice, compression and elevation (RICE). On the whole,
the methods of treatment follow the same lines as described
in the chapters under respective headings. However, certain
modifications are needed due to the alterations in the
demands of an athlete.
Modifications in therapeutic approach
◼ The sports person needs 100% recovery in the shortest

possible period as compared to 60–80% recovery which may
be acceptable in an average individual, who only needs pain-
free activities for daily routine.
◼ Personally supervise and ensure that the basic principles

of early treatment with the concept of ‘RICE’ are adequate
and correct and are substantiated with anti-inflammatory
analgesics.
◼ Avoid detoning of the body, which sets in early and

progresses rapidly by rest and immobilization. Start early
vigorous exercise to the body parts free from immobilization,
avoiding stresses over the injured area.
◼ Begin early mobilization of the injured area by relaxed

passive movements strictly in a pain-free range to avoid
developing adhesions.
◼ Progress rapidly to the self-assisted active, and active

resistive mode with carefully graded resistance, to minimize
the loss of muscular strength or endurance.
◼ Instead of a regular routine of treatment of once a day or

on every alternate day, treat the injured athlete two to three
times a day.
◼ Maximum emphasis has to be given to improve the

psychological trauma of injury through an encouraging
psychophysiotherapeutic approach.
◼ Discourage early resumption of sport without physical
fitness test to avoid recurrence or breakdown and increased
morbidity.
Responsibilities of physiotherapist
The present trend of a physiotherapist accompanying a

sports team as a first-contact clinician, following an on-the-
field injury, has immensely increased the responsibility of a
physiotherapist. Therefore, he must have adequate
knowledge, experience and professional expertise of the
following:
(a) Emergency life-saving procedures like cardiorespiratory

resuscitation
(b) Ability to quickly diagnose the type, the structural

involvement and the gravity of injury
(c) Ability to take correct, on-the-spot decision on the

immediate management of an injured athlete
(d) Ability to decide whether an athlete urgently needs:
i. Orthopaedic consultation and care
ii. Hospitalization
iii. Investigative procedures like radiograph and blood test
iv. Just a simple conservative care

Initial diagnosis is made through critical clinical history and

physical examination of an injured athlete. If there is any
doubt about the diagnosis, a number of diagnostic modalities
could be used as and when required (Table 39-4).
Table 39-4
Diagnostic Procedures
For avulsion injuries or fractures
1.
Conventional
or plain
radiography
For ligament injury

2. Stress
radiography
It consists of injecting radiopaque contrast

3. material into the joint space followed by
Arthrography plane radiography; it is useful in detecting
soft tissue injury around the most susceptible
areas like knee, ankle, shoulder (e.g.,
ligament or meniscal injuries)
Three-dimensional spiral CT is particularly
4. beneficial in detecting skeletal imaging of
Computerized areas which are not readily accessible to
tomography conventional radiography like cervical spine,
(CT) pelvic, shoulder girdle.
It is useful in ruling out bone injury and in
5. detecting stress fractures and chronic
Radionuclide ligament injuries
imaging
(bone scan)
It has revolutionized the diagnostic

6. Magnetic procedures; it can give an exact picture of the
resonance location and extent of bone injury, bone
imaging bruises, all the types of soft tissue injuries like
(MRI) muscle, tendon, ligament as well as cartilage
It is an excellent investigative technique in

7. Diagnostic detecting the exact offending tissue inside the
arthroscopy joint and the degree of damage to it
After confirming the diagnosis, if suitable, conservative

measures like close reduction, immobilization and traction
may be adopted.
Surgical treatment
Arthroscopic surgery: Arthroscopy can be used as a tool to

conduct surgical procedures like meniscectomy, ligament
reconstruction, removal of osteophytes and biopsy. As it
does not involve large incisions, the period of recumbency
and the rate of healing are speedy and ideal for sports
injuries.
The other surgical procedures commonly used include

immediate soft tissue repair, reconstruction or suture.
Occasionally, fractures or other bone injuries may need
surgical interventions like open reduction or even internal
fixation.
Before resuming the sports, an athlete must undergo specific

fitness test (Table 39-5).
Table 39-5
Fitness Test before Resuming Sports after Injury

No tenderness over the injured site
No discomfort or pain during
• Resistive isometric as well as full-range isotonic

movement to the involved musculoskeletal complex
• Full range of passive movement in the event of fracture or

joint involvement
• While performing sport-related activities on the field
No limp while jogging or running

No comparable loss of timing of the injured limb when
injury involves upper extremity
Does not need any support or strapping except the one
needed to secure the dressing (Wright, 1981)
3. Training of an athlete
Remember, for peak performance, an athlete needs 100%

physical and mental fitness. With a sound background of
anatomy, physiology, kinesiology, biomechanics and day-to-
day experience in the management of injuries and above all
an exercise-oriented approach, the physiotherapist should be
able to give optimal performance fitness to the athlete.
Moreover, with frequent and longer sessions involved in the
therapy, the therapist can contribute significantly to boost
the morale of the athlete in terms of improving self-
confidence, self-awareness and a feeling of well-being.
Exercise training
Before initiating exercise training, an athlete must undergo a

thorough medical screening in and a test for physical fitness
(Table 39-5). A thorough medical screening of the athlete is
essential to rule out any contraindications for vigorous
sports. It consists of an evaluation by the following:
◼ Medical examination including history, physical

examination, laboratory investigations, radiograph – one
should also rule out risk factors for exercise or vigorous
sports such as cardiac or metabolic diseases
◼ Monitoring graded exercise tolerance (GXT) test or stress

test
◼ Evaluation of musculoskeletal system to detect any

pathological deficiencies by passive and passive accessory
joint movements, and strength and endurance tests (e.g., a
run of 2.4 km gives a time which correlates very well with
the aerobic capacity or endurance fitness)
◼ Sport-specific examination of the major parts of the body
involved in a particular sport
After these tests, a specific programme to develop the

efficiency of an athlete is formulated to enhance physical
fitness.
The physical fitness in an athlete is not limited only to a

strong body, it also needs optimal physical functioning of the
body. The required physical fitness is possible with the
highest degree of synchronized tuning of the
neuromusculoskeletal system. This is achieved by attaining
the maximal level of the following:
◼ Endurance
◼ Strength
◼ Power
◼ Flexibility
◼ Agility
◼ Coordination
◼ Reflex reactions
◼ Balance and equilibrium of the body
To improve the afore-mentioned aspects of physical fitness,

the exercise modes must be planned to meet adequately the
individual demands of each sport.
The basic components of the exercise training, in general, are:
(a) Endurance training
(b) Strength training
(c) Free weight training
(d) Agility training
(e) Speed, strength or power training
(f) Body stretches and relaxation techniques
(a) Endurance training: The performance of an athlete

greatly depends upon the maximum level of aerobic
capacity, physical work capacity or functional capacity
(VO2max) and anaerobic threshold (AT). The functional
capacity determines the rate at which oxygen is delivered to
the exercising muscles; the demand for which rapidly
increases with increase in the vigorousity of the game.
The important determinant of VO2max is the maximal cardiac

output (or Qmax) which denotes the volume of blood pumped
by the heart per minute. This depends upon the maximum
stroke volume (SVmax), which denotes the volume of blood
pumped with each heartbeat. Thus, increased stroke volume
results in an increase in cardiac output which, in turn, is
reflected by an increase in the functional capacity. Thus, the
major contribution to improve functional capacity, physical
or performance efficiency comes from cardiac output which,
in turn, depends upon the efficiency of the cardiorespiratory
system. Therefore, improvement of cardiopulmonary
conditioning (CPC) is the basic requirement of endurance
training. Endurance exercise training works on the principle
of overloading the physiologic systems of the body to a
definite predetermined range of exercise intensity or target
training range.
Besides improving maximum aerobic capacity (VO2max),

endurance exercise has the advantage of improving aerobic
threshold (AT) and improving the capacity of the athlete to
perform intense sport for a longer period. Endurance
training also enhances other basic physical requirements of
sports like agility, coordination and flexibility along with
balance and equilibrium (Fig. 39-1). In general, endurance
exercise training improves functions of the body systems and
organs besides offering safety from CHD, diabetes,
hypertension, hyperlipidaemia and obesity with
enhancement of the psychological status.
FIG. 39-1Role of endurance training in improving sport

performance.
Therefore, ideally, any exercise training should begin with

low-grade endurance training. The methodology and
contraindications of endurance training are included under
the heading of CPC in Chapter 1. However, the following
modifications are needed in the endurance training for an
athlete:
◼ The exercise programme for all the three phases of CPC,

i.e., warm-up, conditioning and cool-down, needs to be
formulated in such a way that it includes the movements
which are specific to a particular sport for which the athlete
is being trained.
◼ The aim of endurance training in an athlete is to improve
functional capacity and AT to the maximum for optimal
performance. It is achieved by faster increase in the intensity
component of exercise. Therefore, the intensity of exercise
training should be increased to reach the level of 85–90% of
VO2max at the earliest, of course with all the safety
precautions.
◼ The conditioning phase exercise scheme should include

exercise modes as per the needs of the sports, e.g., for the
sports needing explosive burst of energy, the conditioning
phases should be planned by using correct circuit weight
training (CWT) exercise which incorporates rapid bursts of
explosive energy during the particular forceful activity of the
sport (e.g., weightlifting, javelin throw).
For the sports needing sustained activity, the conditioning

phase exercise scheme should mimic the same movements
against resistance (e.g., long distance running, marathon).
(b) Strength training: To improve strength, the principle of

overloading the cardiorespiratory system through properly
graded progressive resistive exercise (PRE) is the rule of
thumb. It is achieved through the following major modes of
exercise:
(i) Bench press: Strengthens mainly deltoid, triceps and

pectoral muscles
(ii) Squat: For quadriceps, glutei and trunk extensors
(iii) Power clean: For strengthening the body’s major muscle

groups (i.e., upper extremities, lower extremities and trunk);
power clean is important to improve speed, coordination,
timing, balance as well as explosive power
(c) Free weight training: The great advantage of this

modality is that, besides strengthening the prime movers, it
strengthens the synergistic as well as stabilizer muscle
groups, tendons and ligaments. As it involves the need to
balance resistance during the movement which puts
overload on the ligaments and tendons, it improves their
excursion and tensile strength (e.g., weight training with
barbells or dumbbells), whereas strength training with
machines improves only the strength of the prime mover
muscle groups.
(d) Agility training: Agility training develops balance,

coordination and mobility at a faster pace. It includes specific
agility drills like jumping rope, combination of forward
running – turning, bending and running backwards. Two-leg
hop, one-leg hop, cross-over run are also extremely helpful
in improving overall agility in sports.
(e) Speed strength, or power training: It is also known as

polymetrics. It is the most important component of the sudden
burst of explosive power. It requires conditioning of the
neuromuscular system to react quickly and at the same time
forcefully during stretch-shortening actions. An athlete’s
speed, strength or power depends upon how fast the muscle
action switches from an eccentric contraction to a concentric
one. It can be achieved best by a series of progressive
exercises that will mimic principal movements involved in
relation to a particular sport. The exercise must be done fast
with sudden burst of energy.
Begin with speedy jumps, hops, bounds or running drills.

Progress gradually to against graded resistance by using
heavier objects than those used in a particular sport (e.g.,
using heavier bat in cricket). This has been proved by the
little master-blaster Sachin Tendulkar (who uses a heavy
bat).
Strength base for polymetrics is an ability to perform one

repetition maximum (1 RM) in the squat of one and a half
times the body weight.
(f) Body stretches and relaxation: Vigorous exercise should

be followed by slow body stretches during the cool-down
phase. This is followed by relaxation techniques.
Depending upon the specific requirements of the sport, the

modes of exercise are incorporated and emphasized in the
sessions of exercise training programmes. The guidelines
drawn by Kulund (1988) are extremely useful in formulating
the exercise training schedule to any sport (Table 39-6).
Table 39-6
Sport-Related Specific Exercise Training Programme

Sport Specific Needs Exercise Mode
High vertical Polymetrics with high pulls,
1. Basketball jump, wrist and power clean, squat, rope
hand strength, climbing, fingertip push ups
agility Various jumps like
backward, forward,
sideways, bench and rope
jumps
Trunk Bench press, squat, power
2. Field strengthening to clean, resistive trunk
events, shot use whole body twisting, trunk curls and
put, discus force to throw hyperextension
throw,
javelin
throw
Hammer Throwing action Mimicking throwing action

throw against pulley resistance
Body balancing Trampoline work
in space
Over 90% work is Arm exercise against
3. through arms resistance like hand pad
Swimming tube or float
Endurance Circuit weight training

(CWT) to improve
cardiovascular endurance
and body fitness
Short burst of High-intensity explosive
4. Football explosive energy burst exercise
for running,
blocking and
tackling
Strength Power training for hip,

especially at hips knee, ankle and foot
and legs
5. Short explosive General conditioning
Weightlifting bursts of energy
in arms to lift
Strength and Volume training rather than

power to pick up intensity training
weight and to lift
it overhead with
extra shoulder
external rotation
Phases of exercise training
Exercise training progresses through three phases:
Phase I: It is also called foundation phase. It involves

improvement in the basic physical fitness to reach
performance peak whenever necessary. Endurance or
conditioning exercise training includes exercise at low
intensity but with high repetitions.
Phase II: It is called preparatory phase. The aim is to improve

strength by hypertrophy of the maximally involved muscle
groups. It involves exercise at high intensity with low rate of
repetitions. During this, regular sessions of agility drills are
also included.
Phase III: It is a precompetition phase in which sport-specific

activities are performed against highest possible resistance
with further reduction in the repetitions.
Agility drills are also increased to reach a level of peak

performance.
Fitness test for returning to sports after injury: It is extremely

important to subject an athlete to a critical fitness test before
giving clearance to return to vigorous competitive sports.
The test includes the following:
◼ There should be no tenderness over the injured area
◼ Injured area should not hurt during:
◼ Normal daily activities
◼ Resistive movements to the involved musculoskeletal

components
◼ Passive full range of motion to the affected joint
◼ Ensure adequacy of strength, endurance, flexibility,

agility, coordination and balance of the muscles, tendons,
ligaments, bones and joints by short bouts of sports trial.
◼ Fitness test for runners: Ensure the ability to extend knee

with 20 lb × 10 in 45 s.
◼ For contact sports: Ensure the ability to lift 45 lb × 10 in

less than 45 s.
◼ The athlete with injury to the lower limb must not limp
while running.
◼ When injury is to the upper limb, there should be no

comparable loss of timing of that limb.
◼ The athlete has an ability to full squat on both the legs or
one leg and full press-up.
◼ The athlete does not need any support or strapping except

the one needed to hold on a dressing (Wright, 1976, 1981).
Before giving final clearance to the athlete to resume

vigorous sports, the fitness test should be given on the field
in the circumstances realistic to a particular sport with keen
observation of the injured area.
4. grooming of the specific athletic skill
Objective physiotherapeutic programme to enhance the specialized

skill of an athlete
The recent trend of identifying young talents and grooming

them for a particular skill opened up a new dimension to the
role of physiotherapy. Scientifically planned and properly
executed physiotherapy procedures have the potential to
contribute significantly in enhancing the specialized skill of
an athlete, as we suggested earlier (Joshi et al., 1987).
Methodology of objective physiotherapy
(a) To begin with, kinematics of the movements involved in

the specialized skill are recorded.
(b) Next, a critical analysis of the biomechanical and

musculoskeletal aspects involved in the specialized skill is
done.
(c) Then, on the basis of these evaluations, objective planning
is done by selecting suitable physiotherapeutic modalities to
enhance the specialized skill and given a trial.
(d) If found acceptable and beneficial, it should be continued

in a well-controlled manner over a period of time without a
break.
(e) Objective evaluation is done to assess the response of the

specialized training.
(f) If needed, suitable alterations are done and the

physiotherapeutic regime is continued.
To illustrate further, take an example of a youngster who has

been selected as a potential spin bowler in cricket.
The basic needs to enhance the skill of a spin bowler are as

follows:
1. To enhance the ability to spin a ball
2. To improve the ability to generate explosive force at the

shoulder girdle, shoulder joint and the upper back at the
time of delivering a ball
1. To augment the spin, the major requirement is to improve

mobility at the wrist, MP, PIP and DIP joints of the bowling
hand.
Earlier studies have proved that the mobility and dynamic

flexibility of musculoskeletal complexes are modifiable by
local warming or by low-volume cycloidal vibrations. Lately,
De Dyene, in 2001, has demonstrated the pathophysiology of
passive strength in augmenting the length of a
musculotendinous complex. On the basis of these findings,
we believe that properly formulated training in the following
sequential order could enhance mobility of the joints of wrist
and hand:
(a) Session of paraffin wax bath to wrist, thumb and fingers
(b) Followed immediately by mobilization procedures like

low-intensity sustained stretches to these joints
(c) Followed by a programme of dynamic flexibility work on

the field
When the force and coordination of wrist and fingers in

gripping and releasing the ball are adequate, excessive
mobility achieved through the sessions of specific
physiotherapy at the wrist and fingers will certainly enhance
the skill of a spin bowler. This has been amply proved by the
example of BS Chandrashekhar, famous Indian spin bowler
of the seventies. He could viciously spin the ball because of
the excessive mobility of forearm and wrist as a result of
post-polio residual paralysis.
2. The second objective of improving the ability to generate

effective explosive force at the time of delivering the ball can
be achieved through polymetric strength training mode. The
upper extremity PNF pattern of extension–adduction–medial
rotation, along with shoulder girdle protrusion and trunk
flexion with rotation over the contralateral leg, is ideal. This
pattern should be practised in standing against resistance by
pulley and weight system. This technique, besides
mimicking the exact pattern of movement during bowling,
provides excessive recruitment of the motor units to the
specific combination of the muscle groups involved in the
action of delivering a ball.
Explosive force at shoulder and upper trunk at the time of

delivering the ball from arm overhead to the angle of its
release is important. To achieve this, a technique of isometric
holds at an angle requiring maximum explosive force could
prove extremely effective.
Thus, critical analysis of the specialized skill and appropriate

selection and correct application of a physiotherapeutic
modality can enhance the performance of an athlete by
increasing the efficiency of the specific skill.
Bibliography
1. Joshi J B, Sherke V K, Dave PK. New objective
physiotherapy approach to develop individual skills of an
athlete. Physiotherapy J Ind Asso-Physiotherapists. 1987;(3):23-
26.
2. Kulund D N. The injured athlete . Philadelphia:

Lippincott. 1988.
3. Sperryn P N. Sports medicine. London: Butterworths. 1983.
4. Williams J G P. Injury in sports . Haywards Heath: UK:

Bayer UK Ltd. 1979.
5. Wright D. Testing for fitness. Physio. 1976;(62):260-265.
6. Wright D. T Eeilly Sports fitness and sports injuries

Fitness testing after injury. London: Faber and Faber. 1981.
Index
A
ABC of life support, 6, 6t, 21–23, 226t
Activities of daily routine (ADR), 1
Agility training, 621, 622
Achondroplasia, 419
Albers-Schonberg disease, See under Osteopetrosis
Amputations, 296–317
complications following, 316
foot, 299–305
indications, 296
Krukenberg, 297
level of, 299
lower extremity, 297–298
management,
of the stump, 301
physiotherapy, 300
postoperative, 299–300
prosthesis, 299
application and checking, 311–312
basic features, 305
bilateral, 308–309
instant, 313
lower limb, 306–308
methods of fabrication, 305
prescription, 305–306
re-education, 312–313
upper limb, 324
Syme’s, 298, 304, 306, 308
upper extremity, 205–207
Aneurysmal bone cyst, 219f, 267t, 268f
Ankle and foot, 210f, 383, 591–606
functional anatomy, 147
injuries to tendo-achilles, 212
metatarsalgia, 215
plantar fasciitis and calcaneal spur, 597–598
treatment, 212
sprain, 595–597
management, 212
pronation or eversion, 595
supination or inversion, 595
tarsal tunnel syndrome, 352, 599–600
tenosynovitis, 527, 549–550
Ankylosing spondylitis, 394–397, 400t, 485t
physiotherapy, 395–397
treatment, 395
Arachnoiditis, 503
Arnold’s test, 573
Arthritic hand, 553
Arthritis,
enteropathic, 371t, 397
juvenile, 371t, 389
osteoarthritis, 371–374
ankle, 383
cervical spine, 386, 396
elbow, 382–383
foot, 383
hand, 375, 383
hip, 375–376
knee, 375, 376–380
physiotherapeutic management, 378–380, 387–389
sacroiliac, 385
shoulder, 382
temporomandibular, 384, 386
treatment, 375, 387
wrist, 383
psoriatic, 389, 397, 554t
pyogenic, 247–249
physiotherapeutic management, 248
treatment, 247
rheumatoid, 385–389
physiotherapeutic management, 387–389
Still’s disease, 390–392
Arthrodesis, 270
ankle, 272
elbow, 270–272
extra-articular, 270–274
great toe, 272
hand, 272
hip, 272
intra-articular, 270
indications, 270
knee, 200
position of, 270–273
management, 273
shoulder, 270
spine, 272–273
subtalar, 272
wrist, 272
Arthrogryposis multiplex congenita, 421f
Arthroplasty, 270–293, 284f
ankle, 284f
elbow, 284
excisional, 286f
implant (total joint), 286
interpositional (fascial), 286
hand, 291–292
excisional (resection), 291
implant, 291
hip, 274
excisional (Girdlestone), 280
hemireplacement, 181, 274, 275
total hip replacement, 274–275, 277
knee, 281–283
total knee replacement, 281–282
shoulder, 284–285
wrist, 290–291
Arthroscopy and arthroscopic surgery, 580–581
Austin Moore prosthesis, 182f, 274f
Avascular necrosis, 83, 100, 136, 138, 563–565
Avulsion, 97–98, 145f, 179
hamstrings, 179
lesser trochanter, 274–275
rectus femoris, 278
sartorius, 278
Axonotmesis, 327
B
Baker’s cyst, 586
Barton’s fracture, 134–135
Bennett’s fracture dislocation, 142–143
Biceps brachii, 522–523
tendon, rupture, 274
Blood vessel injury, 44–45, 80
Bone, 25–29
blood supply of, 28
development and growth of long, 26–27
remodelling of, 27
structural and functional composition, 25–26
types of, 25
Bone metastasis, 266–269
Bone mineral density (BMD), 251, 257
Bone tumours, 260–269
benign, 260
characteristics of, 260
classification of, 260
diagnosis, 260
malignant, 260
management, 260
Brachial neuritis, 324
Brachial plexus injury, See Injury, brachial plexus
Burns of the hand, 547–548
Bursa injury, 35t, 45–46
Bursitis, 35t, 523, 525, 585–586, 587–588
olecranon, 44, 524, 526
prepatellar, 587–588
subacromial, 523, 523f
subdeltoid, 523
C
Calcaneal spur, 597–598
Calcaneovalgus deformity, 416
Calcium metabolism, 251
Calf muscle, 587
strain, 587
Card test, 330t
Cardiopulmonary conditioning (CPC), 9–14
integration of, 14
methodology and principles of, 9–14
Cardiopulmonary resuscitation (CPR), 21–23
basic principle of, 21
methodology of, 21–23
life support, 21–23
Caries sicca, 246
Carpal tunnel syndrome, 44, 339–341, 616–618t
Cerebral palsy, 222, 356t, 420
Cervical rib, 408
Cervical spine, 148–150, 227, 446, 451–452
osteoarthritis, 451–452
pain, high, 456–457
prolapsed disc, 484
Cervical spondylolisthesis, 455–456
Cervical syndrome, 446–451
treatment, 452
Charcoat’s joint, 399
Charnley’s compression device, 245
Chest physiotherapy, 14–21
Chondrodystrophy, See under Achondroplasia
Chondromalacia patellae, 584–585
Club hand, 403–404
Clutton’s joints, 249
Collateral ligament injuries of knee, 573
Colles fracture, 130–134
Congenital dislocation of hip, 408
treatment, 408
Congenital flat foot (vertical talus), 416–417
Congenital short femur, 412
Congenital talipes equino varus, 413–416
Connective tissue diseases, 398–399
Contracted fingers, 405
Coxa valga, 252–253
Coxa vara, 412, 558–560
acquired, 418
congenital, 558, 559f
D
Deformity, 401–421
acquired, 401
classification, 402
congenital, 402–412
management, 402
de Quervain’s disease, 527
Degenerative osteoarthritis, 496–497
Dennis Brown splint, 414–415
Dermatomyositis, 399
Diaphyseal aclasis, 420
Disaster management, 228–229
Dislocation, 89–90, 89f, 115–116, 176–179, 201
acromioclavicular joint, 89f
elbow, 115
hip, 176–179
complications, 178–179
congenital, See under Congenital dislocation of hip
posterior, anterior, central, 178–179t
knee, 201
patella, 200–201
acute, 199–200
recurrent, 200–201
shoulder, 92–96
recurrent anterior, 92–96
Dupuytren’s contracture, 418, 524
Dychondroplasia, 419
E
Ectrodactyly, 405
Egwa test, 330t
Epicondylitis (elbow), 524–526
medial (elbow), 525–526
treatment, 291
Epiphyseal coxa vara, 559–560
Epiphyseal injuries, 219
types, 219
Erb’s palsy, 323–324, 356t
Erythema nodosum, 399
F
Faber’s test, 472f
Facet joint arthritis, 498
Flat back, 445–446
Flutter device, 20
Foot drop, 332f, 350–352
Fractures,
ankle, 208–211
treatment, 208
Barton’s, 134–135
Bennett’s, 142–143
calcaneum, 213–214
capitulum, 106–108
cervical spine, 148–150
treatment, 150
clavicle, 86–88
complications, 87
coccyx, 175
Colles’, 130–134
treatment, 130
femur, 179
intercondylar, 194–196
neck, 179, 182f, 186
shaft, 190–193, 190f
supracondylar, 194, 196
trochanter, 186–189, 186f
general, 57–85
diagnosis of, 59
healing of, 59–62, 66t
in children, 62, 84, 218
treatment of, 62–77
types of, 57
healing, 59–62
humerus, 97–98, 112–113
greater tuberosity, 97–98
neck, 100
shaft, 102–105, 102f
single condyles, 113–115
supracondylar, 108–112, 108f
lunate, 137–139
complications, 138
treatment, 138
metacarpals, 140–142
metatarsals, 215
Monteggia, 128–129
olecranon, 116–117
patella, 196–199
pelvis, 173–175
phalanges, 143–144, 216
radius, 117–122
head, 117
neck, 117–122
radius and ulna, 125–128
ribs, 175
scaphoid, 136–137
complications, 136
treatment, 136
scapula, 88–89
Smith’s, 134
specific, 87
lower extremity, 160t, 179–189
pelvis, 173–175
spine, 147–165
upper extremity, 92, 160t
spinous process, 164–165
stress, 216
talus, 211–212
tarsal, bones, 214–215
thoracic and lumbar, 165f
tibia, 201–202
condyles, 201
shaft, 204f
tibia and fibula, 204–207
transverse process, 29
types, 595
compound (open), 359
simple (closed), 610
vertebra, 147–148, 151
treatment, 152–164
Froment sign, 331, 330t
Frozen shoulder, 513–516
G
Gaenslen’s test, 470
Gait, 171, 422–429
abnormalities, 429–430
evaluation, 427–429
kinematics of, 422
kinetics of, 423–424
phases of gait cycle, 424–427
training, 430–432
Gait training, 312–313, 417, 430–432
Galeazzi fracture, 129
Ganglion, 524
Genu valgum (knock knee), 588–589
treatment, 588
Genu varum (bow legs), 589
treatment, 589
Gibbus, 240f
Girdlestone (excisional) arthroplasty, 280
Glasgow coma scale (GCS), 227t
Golfer’s elbow, 525–526
Gomphosis, 29
Gonococcal arthritis, 249
Gout, 397–398
Greenstick fracture, 57, 126f, 218f
Guillain-Barre syndrome, 356t
H
Haemophilia, 392–394
Haemophilic arthropathy, 393
Hallux rigidus, 604–605
Hallux valgus, 604
treatment, 604
Hammer toe, 605
Hamstrings, 587
strain, 587
Hand, 510–528, 529–555
anatomy, 529–530
burns, 547–548
infections, 548–551
methods of evaluation, 531–532
replantation, 545–547
splints, 535–538
tendon injuries, 538–547
extensor tendons, 538
flexor tendons, 538–542
wound healing, 534
Harrison sulcus, 253, 253b
Heimlich manoeuvre, 15
Hitchhiker’s sign, 330t, 346
Hip, 556–566
applied anatomy, 556–558
avascular necrosis, 563–565
congenital, See under Congenital dislocation of hip
coxa valga, 560
coxa vara, 558–560
dislocation, See under Dislocation, hip
Perthes’ disease, 560–563
Horner’s sign, 320
Human skeleton, 25
Hurler’s syndrome, See under Gorgoilism
Hyperparathyroidism, 255–256
Hypoparathyroidism, 46
I
Iliotibial tract syndrome, 565–566
Infections of bones and joints, 230–250
hand, 548–551
osteomyelitis, 230–237
pyogenic arthritis, 247–249
skeletal tuberculosis, 237–247
Infective disease of the spine (caries spine), 240–244
Inflammation, 30–34
acute, 30–32
management, 31–32
signs, symptoms and pathology, 30
chronic, 32–34
management, 32–34
effects of, 31
progress of, 30
management of, 31–32
Infraspinatus tendinitis, 520–521
Injury, 30, 148–149, 179, 327–328
avulsion, lesser trochanter, 179
brachial plexus, 318–325
causes, 319
Erb’s palsy, 323–324
evaluation, 320
Klumpke’s paralysis, 324
postganglionic lesion, 319
preganglionic lesion, 319
cervical spine, 148–150
ligament, 39–41
rupture, 40–41
sprain, 40b
muscle and tendon, 36
complete rupture, 36, 40–41
contusion, 36–37, 44
partial rupture, 37
treatment, 38
nerve, 43
pelvis, 173–175
avulsion of hamstrings rectus femoris sartorius, 179
physiotherapeutic management, 173, 179
peripheral nerves, 110, 121, 326–353
axonotmesis, 327
classification, 327–328
compressive neuropathy, See under Neuropathy
neurotmesis, 327–328
neurapraxia, 327
soft tissue, 34–36
examination and evaluation, 35–36
synovial membrane, 41–42
Irritable hip, 565
Instant prosthesis, 313
J
Javelin throws, 616–618t, 621, 622t
Jercy finger, 553
Joint arthrodesis, 245
Joint manipulation, 74, 483, 547
Joints, 28
classification of, 28–29
functions of, 28
Jumper’s knee, 220, 587
Juvenile rheumatoid arthritis, 389
K
Kienbock’s disease, 138, 565
Klippel-Feil syndrome, 221, 408
Klumpke’s paralysis, 324
Knee, 567–590
arthroscopy and arthroscopic surgery, 580–581
chondromalacia patellae, 584–585
examination, 532
functional anatomy, 567–570
Lachman test, 575
ligament injuries, 573
McMurray’s test, 576
menisci injuries, 579
osteochondritis dissecans, 585
popliteal cyst, 585–589
traumatic effusion, 576
Krukenberg amputation, 297
Kypholordosis, 445
Kyphosis, 444–445
L
Lachman test, 572t, 575
Lasegue’s sciatic nerve test, 469
Legg-Calve-Perthes disease, 220, 560–563
Lesions of rotator cuff, 518–519
Levator scapulae syndrome, 457–458
Ligament injury, 40f, 574
Long head of biceps brachii (tendon), 522–523
Looser’s zone, 255
Lordosis, 445, 461, 479
Low back pain, 458–496, 503
aetiology, 462
disc lesion, 488–496
evaluation, 462
pathology, 462–474
physical examination, 467–468
physiotherapeutic management of chronic, 487–488
prevention, 504
role of physiotherapy, 504–507
thoracic origin, 503
treatment, 503
working diagnosis, 474
Lumbar canal stenosis, 497f
clinical features, 497
M
Madelung’s deformity, 403
Madura foot, 249
Mallet finger, 144–146
treatment, 145
Malunion, 121–122
Manipulation technique, 484, 498
March fracture, 216, 616–618t
Mask device, 20
McMurray’s test, 576
Mckenzie’s technique, 69
Meralgia paraesthetica, 352
Metabolic bone diseases, 251–259
hyperparathyroidism, 255–256
osteoporosis, 256–258
rickets and osteomalacia, 255
Metatarsalgia, 598–599
Monteggia fracture, 128f
Metatarsus adductus (metatarsus varus), 417–418
Mixed connective tissue disease, 399
Morton’s metatarsalgia, 599
Multiple myeloma, 264–265t, 265f
Muscle and tendon injury, 36–39
Musculoskeletal disorders, 47–54, 218–222
examination, 48–52
paediatric and adolescent, 220–222
pathology, 47–48
Musculotendinous complex injury, 46
Myositis ossificans, 110, 115, 421
progressive, 421
N
Nerve injury, 43
Neurapraxia, 327
Neurofibromatosis (von Recklinghausen’s disease), 441–442
Neuropathy, 2t
compressive, 340t
axillary nerve, 92
common peroneal nerve, 350f, 352
lateral femoral cutaneous nerve, 347
median nerve, 339
posterior tibial nerve, 348–349
radial nerve, 345–347
ulnar nerve, 343–345
Neurotmesis, 327–328
O
Ober’s test, 565–566, 566f
Ochsner’s pointing index text, 330f
Olecranon bursitis, 526
Ollier’s disease, See Dychondroplasia
Orthopaedic disorders, 1–2
traumatic, 1, 2t
nontraumatic, 1, 2t
Orthopaedic and physiotherapeutic evaluation, 3t
Orthopaedics and physiotherapy, 1f
goal and role of, 1
orthopaedic disorders, 1–2
Osgood-Schlatter disease, 220
Osteitis,
pyogenic, 452
Osteoarthritis, 371–374, 451–452
cervical spine, 452
Osteochondritis, 565
Osteochondritis dissecans, 585
Osteogenesis imperfecta, 418
Osteomalacia, 255
Osteomyelitis, 230–237
Osteotomy, 293–295
Osteopetrosis, 418–419
Osteoporosis, 256–258
P
Paget’s disease, 419–420, 497, 502
Painful arc syndrome, 516–518
Patellar tendinitis, 587
Paronychia, 549
Patellar tendon bearing (PTB) prosthesis, 307–308
Pen test, 330t, 331f
Peripheral nerve injuries, 327–328
classification, 327–328
Seddon’s, 327–328
Sunderland’s, 328
formation, 326
steps in evaluation and diagnosis, 328–339
structure, 326–327
Perthes’ disease, 560–563
Pes cavus, 602–603
treatment, 602
Phantom pain, 316
Physiotherapy, 4, 30, 52, 183, 192, 247, 269, 293, 300, 355, 395, 421, 487,
495, 520, 581, 623
chest, 14–21
management, 17–19
objectives of, 15
orthopaedic and cardiopulmonary conditioning, 9–14
planning of, 4–6, 7–8
preoperative, 7, 9, 15
role of, in total rehabilitation, 8
Pigeon chest, 253
Piriformis syndrome, 503
Plantar fasciitis, 597–598
Plica syndrome, 588
Poliomyelitis, 354
complications, 366
examination of patient, 355–356
history, 354
late effects, prevention of, 368–369
pathology, 354–355
prognosis, 358
surgery, 362–366
complications, 366
physiotherapy, 366–367
upper limb, 362–363
treatment, 363, 367
virology, 354
Polyarteritis nodosum, 399
Polydactyly, 405
Polymyalgia rheumatica, 399
Popliteal cyst, 585–589
Pott’s disease (spine), See under Tuberculosis, spine
Pott’s paraplegia, 241
Prepatellar bursitis, 587–588
Prolapsed cervical disc, 452
Prosthesis, 305–317
application and checking of, 311–312
basic features, amputations, 305
upper limb, 309–310
materials used for, 305
methods of fabrication, 305
prescription of, 305–306
re-education with, 312–313
Pseudogout, 398
Pseudohypertrophic muscular dystrophy, 420, 421t
Psychological upgrading, 268
Pulmonary embolism, 17
Pulled elbow, 115
Pyogenic arthritis, 247–249
Q
Quadriceps strain, 586–587
Quadricepsplasty, 583–584
R
Radioulnar synostosis, 403
Rare soft tissue syndromes, 46–47
Raynaud’s phenomenon, 553
Reflex sympathetic dystrophy (RSD), 83, 551
Reiter’s syndrome, 389, 397, 554t
Replantation, 545–547
Resection arthrodesis, 264, 266f
Rheumatoid arthritis, 385–389
Rickets, 251, 252–253, 253b
renal tubular, See under Fanconi’s syndrome
treatment, 255
Rickety rosary, 253, 253b
S
SACH (Solid ankle cushion heel) foot, 306
Scalenus syndrome, 455
Scheuermann’s disease, 503–507
Sciatica, 468, 497
Scoliosis, 435–436
complications, 436
indications, 440–442
Seddon’s classification of nerve injuries, 327–328
Senile osteoporosis, 257f, 257t
Sever’s disease, 221
Shoulder, 510–512
frozen, 513–516
functional anatomy, 433–435
infraspinatus tendinitis, 520–521
lesions of the rotator cuff, 518–519
long head of biceps brachii tendinitis, 522–523
painful arc syndrome, 516–518
subachromial bursitis, 523
subscapularis tendinitis, 521–522
supraspinatus tendinitis, 520
Side-swipe injury of elbow, 122–124
Sinding-Larsen-Johnson disease, 220
Sjogren’s syndrome, 399
Skeletal tuberculosis, 237–247
Smith’s fracture, 134
Soft tissue injuries, 35t
commonly involved, 34
examination and evaluation, 35–36
Spasmotic torticollis, 454
Spina bifida, 433–435
Splints, 535–538
hand, 535, 536
Spondylolisthesis, 455–456
cervical, 455–456
treatment, 456
lumbar, 498–502
clinical presentation, 499–500
diagnosis, 500
Spondylosis, 496–497
lumbar, 496f
Sports injuries, 615
role of physiotherapy, 615–623
orthopaedics, 615
preventive, 614
therapeutic, 619
training of an athlete, 620–623
agility, 622
endurance, 621
exercise training phase, 620–622
free weight, 621
grooming specific athletic skill, 623
relaxation, 622
strength, 622
Sports medicine, 615
Sprengel’s deformity, 221
Sprengel’s shoulder, 402f
Still’s disease, 390–392
Stress fracture, 216, 223
Stump bandages, 302f
Subdeltoid bursitis, 523–524
Subtalar joint, 214, 593–594
Sudeck’s osteodystrophy, 134
Sunderland’s classification, nerve injuries, 328
Suppurative tenosynovitis, 527
Swan-neck deformity, 387f, 389, 391t, 540, 545, 548, 554t
Syme’s amputation, See under Amputation, Syme’s
Syndactyly, 405
Synovitis, 42, 527
acute, 42
chronic, 42
Synovial membrane injury, 41–42
Systemic lupus erythematosus, 398
Systemic sclerosis (scleroderma), 399
T
Talipes, 413–418
congenital, equinovarus, See under Congenital talipes
equino varus
equinus, 413, 602
Tarsal tunnel syndrome, 352, 599–600
Tarsometatarsal joint, 594
Tendon injuries, 538–547
Tennis elbow, 524–525
Tenosynovitis, 35t, 42, 527, 549f, 601
Tenovaginitis, 527
Thenar space infection, 549
Thoracic outlet syndrome, 43, 319, 455
Tinel’s sign, 319f, 328t, 338
Tom Smith’s arthritis, 248–249
Torticollis, 406–408, 454, 512–513
acquired, 418, 512–513
congenital, 452
spasmodic, 454
Torus (buckle) fracture, 219
Total rehabilitation, 8
Traumatic effusion, knee, 576
Trendelenburg sign, 557f
Treponema pallidum, 249
Triage sort, 228
Trigger finger, 528
Tuberculosis, 237–247
skeletal, 237–247
spine, 240–244
complications, 242
Tumours, bone, 260, 261f
benign, 260
malignant, 264
primary, 264–266
secondary, 266–269
Turn-o-plasty, 150, 155f
V
Vertebrobasilar syndrome, 455
Vertebroplasty, 258
Vertical talus, See under Congenital flat foot
Volkmann’s ischaemic contracture (VIC), 110–111, 110f, 119, 599
von Recklinghausen’s disease, See under Neurofibroma
W
Web space infection, 550f
Wedge tarsectomy, 415
Wheaton brace, 414f
Whitlow, 549
Wind-swept deformity, 253
Wound healing, 533
Wrist disarticulation, 297f, 310
Wrist drop, 102, 330t, 332f, 346
Wrist sprain, 526
Y
Yoga, 607
and physiotherapy, 607
asanas, 607
as applied to physiotherapy, 614
genuine, 607
preventive aspects, 609–610
promotive aspects, 609–610
rationale of, 611–613
therapeutic benefits, 610

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Preface to the third edition

Preface to the first edition

1. Orthopaedics and physiotherapy

Physiotherapy as applied to orthopaedics

2. The bones and the joints

Soft tissue injury

5. Injuries around the shoulder

6. Injuries of the arm

7. Injuries of the elbow

8. Injuries of the forearm

9. Injuries of the wrist

10. Injuries of the hand

11. Injuries of the spine

12. Injuries of the pelvis

14. Injuries of the thigh

15. Injuries of the knee

16. Injuries of the leg

17. Injuries of the ankle and the foot

18. Common paediatric and adolescent musculoskeletal disorders and

19. Prevention of fractures

20. Emergency management of a polytrauma patient

21. Infections of the bones and joints

22. Metabolic bone diseases

23. Bone tumours

24. Arthrodesis, arthroplasty and osteotomy

Total hip replacement arthroplasty (thr)

Total knee replacement arthroplasty

26. Lesions of the brachial plexus

27. Peripheral nerve injuries

Brachial plexus lesions

Peripheral nerve injury

31. Locomotion and gait

Low back pain

33. Regional orthopaedic soft tissue lesions of the shoulder, elbow,

35. Regional orthopaedic conditions at the hip

36. Regional orthopaedic conditions at the knee

37. Regional orthopaedic conditions at the ankle and foot

38. Yoga, yoga asanas and physiotherapy

39. Sports medicine

RELX India Pvt. Ltd.

Copyright © 2017, by RELX India Pvt. Ltd.

No part of this publication may be reproduced or transmitted in any

Manager—Content Strategy: Nimisha Goswami

Dr Jayant Joshi left for his heavenly abode on 2 Februaruy

Preface to the third edition

It is indeed a pleasure to present the third edition of the book

Preface to the first edition

Physiotherapy has come of age and is now an integral part of

There are a large number of books on orthopaedics and

Therefore, a need was felt to bring out a book with an

Most of the chapters in this book start with a treatise on

We are grateful to Professor P Chandra and Professor PK

Kanchan Mittal, Superintendent of Physiotherapy, Department of

Orthopaedics and physiotherapy

Goal and role of both the sciences

FIG. 1-1 Goal and role of orthopaedics and physiotherapy.

Orthopaedic management provides the basic structural stability to the

1. Traumatic (Table 1-1) and