Clinical Notes in Physiotherapy

✅ The descriptive terms "potential coper" and "potential non-coper" have been used to identify and classify those individuals early after ACL injury who are good versus poor candidates for nonoperative rehabilitation based on the results of an initial screening examination. Potential copers are described as having sufficient dynamic knee stability, the ability to compensate following injury, and good potential to return to preinjury, high-level activities following a course of nonoperative treatment. In contrast, potential noncopers are thought to have poor potential to return to preinjury activities following nonoperative treatment; these individuals typically have poor dynamic knee stability and are advised to consider surgical management. A study by Moksnes and associates evaluated both copers and noncopers after 1 year of intensive rehabilitation. For those not undergoing surgery, 19 of the 27 noncopers (70%) showed excellent knee function and were classified as true copers. In the coper group, 15 of 25 (60%) were true copers. The term "true copers" applies to individuals able to return to preinjury activity level 1 year after ACL injury with no episodes of the knee giving way during activities. The results suggest that the prognostic accuracy of the screening examination is poor and therefore support the importance of including all patients with ACL injury in intensive rehabilitation, not just those who initially meet the definition of coper.

✅ Several criteria have been described to select the appropriate candidate for a successful outcome with nonoperative treatment of ACL injury : ✔️ No evidence of joint effusion ✔️ Full passive knee joint ROM, as compared to the uninvolved knee ✔️ A quadriceps femoris maximal voluntary contraction force on the involved limb equivalent to 75% of that on the uninvolved limb ✔️ Tolerance for single-leg hopping on the involved limb without pain ✔️ No concomitant ligamentous or meniscal injury Once these criteria are met, the screening test is administered as described in table. Patients who pass the screening test are considered good candidates for nonoperative rehabilitation.

✅ Bunnel-Littler Test This test tests the structures around the metacarpophalangeal joint. The metacarpophalangeal joint is held slightly extended while the examiner moves the proximal interphalangeal joint into flexion, if possible. If the test is positive (which is indicated by inability to flex the proximal interphalangeal joint), there is a tight intrinsic muscle or contracture of the joint capsule. If the metacarpophalangeal joints are slightly flexed, the proximal interphalangeal joint flexes fully if the intrinsic muscles are tight, but it does not flex fully if the capsule is tight. The patient remains passive during the test. This test is also called the "intrinsic-plus test".

✅ Shoulder Abduction (Relief) Test This test is used to test for radicular symptoms, especially those involving the C4 or C5 nerve roots. The patient is sitting or lying down, and the examiner passively or the patient actively elevates the arm through abduction so that the hand or forearm rests on top of the head. A decrease in or relief of symptoms indicates a cervical extradural compression problem, such as a herniated disk, epidural vein compression, or nerve root compression, usually in the C4-C5 or C5-C6 area. Differentiation is by the dermatome (and possible myotome) distribution of the symptoms. This finding is also called Bakody's sign. Abduction of the arm decreases the length of the neurological pathway and decreases the pressure on the lower nerve roots. If the pain increases with the positioning of the arm, it implies that pressure is increasing in the interscalene triangle.

Evans outlined a second similar test. The seated patient abducts the arm to 90° with the elbow fully flexed. The arm is extended at the shoulder and then the elbow is extended. If radicular pain results, the test is positive (Bikele's sign). This test in reality is a modification of the ULNT4 done actively.

✅ Brachial Plexus Tension Test The sitting patient abducts the arms with the elbows extended, stopping just short of the onset of symptoms. The patient laterally rotates the shoulder just short of symptoms, and the examiner then holds this position. Finally, the patient flexes the elbows so that the hands lie behind the head. Reproduction of radicular symptoms with elbow flexion is considered a positive test. This test is similar to ULNT4 and stresses primarily the ulnar nerve and the C8 and T1 nerve roots.

✅ Scheuermann's Disease A disorder common in adolescents is Scheuermann's disease or juvenile kyphosis. The main radiologic sign is disk space narrowing, with anterior involvement being the greatest. This is typically evident between T3-T12, with at least three levels being involved as criteria for the diagnosis of Scheuermann's disease to be applied. Scheuermann's disease frequently leads to an anterior wedging of the vertebra. The most common area is between T10 and T12. Regularly, with the dramatic and adverse changes of thoracic kyphosis, there is a parallel development of scoliosis. Intervention cannot reverse the disorder, but it may be able to retard or prevent further exaggeration of the kyphosis. Treatment is directed at maintaining correct posture and performing extension exercises on a lifelong basis. Management of rotation dysfunction is directed at rotation exercises in sitting and extension in lying.

✅ Schmorl's Nodes Intraosseous herniations of nuclear material are known as Schmorl's nodes. They appear as extensions of disk material into the vertebral body, typically sorrounded by a rim of low signal intensity on T-1 weighted due to reactive sclerosis and may also display marrow edema if large. T-2 weighted images also demonstrate the schmorl's nodes typical of Scheuermann's disease. The disorder is typified by multiple small extrusions of nuclear material through the end plates into the vertebral bodies. While intrabody herniations may occur secondary to end plate weakness related to bone dysplasia, neoplasms, infections, or any process that weakens the endplate or the underlying bone, most intrabody herniations probably form after axial loading trauma, with preferential extrusion of nuclear material through the vertebral end plate rather than an intact and normal annulus fibrosus. It has been suggested that asymptomatic intrabody herniations may be traceable to a specific occurence of acute nonradiating low back pain in the patient's history, which supports the concept that intrabody herniations (Schmorl nodes) occur through sites of endplate fracture. While only approximately 50 percent of such positive findings are painful, a predisposition to disk degeneration in later life has been documented.