C

Carpal Tunnel Syndrome

(Adhesive) Capsulitis (Frozen Shoulder)

Adhesive Capsulitis is an insidious condition, characterized by fibrosis of the shoulder capsule and a progressive loss of shoulder range of motion in all directions(8). Adhesive capsulitis or "frozen shoulder" affects approximately 2% of the population(2). Of those affected, 70% are women and 20-30% will go on to develop symptoms in the opposite shoulder(1). Adhesive capsulitis occurs more frequently in diabetics and in persons over 40 years of age(3). Other factors may include trauma(3), immobilization(4), thyroid disease(5), autoimmune disease(6), stroke or myocardial infarction(7). It is characterized by pain and a progressive loss of active and passive range of motion in the shoulder.
Four stages are described in the literature:
1.Stage One, between 0-3 months: There is pain with active and passive motion, and limited motion in all directions.
2. Stage Two between 2-9 months: Known as the "Freezing" stage, this time period is marked by chronic pain with active and passive motion. There is significant limitation of motion in all directions.
3. Stage Three between 4-12 months: The "Frozen" stage exhibits significant limitation of motion in all directions, but minimal pain, except at end range of motion
4. Stage Four between 15-26 months: This "Thawing" stage presents with the gradual improvement in motion and minimal pain.
The goal of treatment is to decrease pain and inflammatory response, increase motion, and reestablish normal mechanics of the shoulder(1). A number of studies have found that physical therapy can be effective in the treatment of adhesive capsulitis(8-10). Physical therapy treatment may include exercise for range of motion, shoulder blade stabilization and joint mobilization.

Chondromalacia (Patello-Femoral Pain; Anterior Knee Pain)

This term is most often associated with the knee, but can also be associated with any joint that has articular cartilage. "Chondromalacia" is a Latin word meaning "cartilage softening" . "Chondromalacia" is a surgical determination, not a clinical one. Two common types of cartilage are: hyaline/articular and fibrocartilage. The former is a glistening, near friction-free surface that covers the ends of bones, allowing for smooth movement. The latter is a tougher type of cartilage, like the meniscus of the knee, which helps in stabilizing the joint. Chondromalacia is graded from I to IV, the latter implicating "bone on bone" wearing. A recent study (1) proved that one can have as much as a Grade III wearing without pain. So, pain is variable. The source of chondromalacia pain (2) is not the articular cartilage itself, but the thinning of it, which transfers loads onto the underlying subchondral bone, which is pain-sensitive.

Patello-Femoral pain is the most common of knee problems. This involves the joint between the knee cap(patella) and the thigh bone(femur). It is chronic, but usually only episodically painful. There is often no one trauma associated with it, just a sense of discomfort with fluctuations of pain over time. It is often associated with sub-optimal biomechanics around the knee cap and lower limb, but not always. When biomechanics are good, but there is PF pain, this may be due to a predisposition towards soft articular cartilage, which is poorly understood. Direct trauma to the knee cap can instigate PF pain and softening of the cartilage over time. Biomechanics are unalterable conservatively, but can be influenced by selective muscle stretching and strengthening exercises around the knee, pelvis, hip and foot. This helps to reduce the abnormal vector forces influencing the patella.
PF Pain is characterized by a poorly localized, deep aching under the patella, which often refers towards the front and inner aspects of the knee. Aggravating factors are: prolonged sitting, descending/ascending stairs or hills, and squatting. There is only rarely very mild swelling.
The treatment of PF Pain is conservative. This means seeking the advice of a Physical Therapist who will identify selective exercises to optimize lower limb mechanics. McConnell PF taping may also be indicated. Occasionally, modalities such as Ultrasound and Biofeedback may be helpful. The prescribed exercises are a life-long commitment, like brushing your teeth.
If conservative care of PF Pain fails, and the pain is significant, then the advice of a surgeon should be sought. But surgery is the last resort.
Other conditions such as patellar subluxation(partial dislocation) or dislocation often cause PF pain.

(Rotator) Cuff

One can strain ("Impingement"), partially or fully tear, or have a degenerative condition of the rotator cuff. The cuff comprises the conjoined tendons of four muscles that intrinsically stabilize the shoulder joint. Falling on an outstretched arm, overuse and the effects of aging are causative factors. Chronic imbalance amongst the muscles can produce pain over time. There is often difficulty raising the arm overhead. The diagnosis is usually clinical. It is a common condition after 40 years of age. If a specific tear is suspected by the surgeon, or pain persists despite diligent physical therapy, an MRI may be indicated. A rotator cuff strain is often point tender at the shoulder with possibly some referred pain into the upper arm. There is rarely numbness/tingling. A Physical Therapist can assess any influence on the pain pattern coming from the neck, which often refers pain to the arm. Pain with raising the arm especially overhead is classic. This condition can often lead to losing range of motion(ROM), which needs attention immediately. Treatment comprises the preservation of ROM, rebalancing of the four rotator cuff muscles(by selective stretches and strengthening exercises) and optionally, some modalities. Ideal posture is essential to rotator cuff health. Proper arm-shoulder blade mechanics during movement can be assessed by the therapist. Rehab is critical to avoiding recurrence or worsening of this commonly chronic problem.
Recalcitrant pathology should be assessed by a surgeon. The post-op rehab after a rotator cuff repair is lengthy and arduous. In most cases, the arm is kept in a sling for about 4-6 weeks, during which time only passive and limited movement is allowed. Only at about three months can strengthening exercises be started. The rehab should be closely monitored by the therapist.