Clinical Notes in Physiotherapy

✅ Assessment and Treatment of Piriformis

Treatment for subacute stage : As acute pain subsides, succeeding treatments should be directed toward stretching the tight fascia. To stretch left tensor fasciae latae, have subject lie on right side with right hip and knee bent. Relax left leg on pillows between thighs and lower legs. Remove the pillows. Bend right hip and knee enough to flatten low back. Stabilize the pelvis firmly with one hand, draw the thigh slightly back and press gently (on thigh, not leg) downward toward the table. Stretching the muscles and fascia between the hip and knee. (The knee should not be allowed to rotate inward, and care should be taken to avoid strain at the knee joint.)

Treatment for acute stage : Heat may be applied to the lateral aspect of the thigh while the patient is in a position that gives in to the tightness. This is done by abducting the leg in either back-lying or side-lying. To support the leg in abduction in side-lying, firm pillows are placed between the thighs and lower legs, making sure that the foot is also supported. As soon as the patient can tolerate it, massage may be started. Massage should be firm but not deep. Massaging downward may be more effective than the usual upward stroke.

The mechanism by which the peroneal nerve is irritated in cases of tightness of the iliotibial band may be explained by the effect of pressure by the rigid bands of fascia or by the effects of traction on this part. The effect of traction is often seen in acute cases. With the patient side-lying and the affected leg uppermost, the mere dropping of the foot into inversion puts tension on the muscle and fascial band. Symptoms of nerve irritation in the area supplied by the peroneal nerve may be elicited by this simple movement of the foot.

✅ Tight Tensor Fasciae Latae and Iliotibial Band A condition sometimes mistakenly diagnosed as sciatica is that of pain associated with a tight tensor fasciae latae and iliotibial band. Pain may be limited to the area covered by the fascia along the lateral surface of the thigh or it may extend upward over the buttocks, involving the gluteal fascia as well. Painful symptoms may be limited to the area of thigh or may appear in the area supplied by the peroneal nerve.

✅ The quadriceps angle (Q angle or patellofemoral angle) is formed by a line drawn from the center of the patella proximally toward the anterosuperior iliac spine, and a second line drawn from the center of the patella distally toward the tibial tubercle with the foot in the subtalar neutral position and the knee extended (weight bearing). Normally the Q angle is 13 to 18 degrees (13 for males, 18 for females). An angle above 14 indicates a tendency toward less patellar stability. An angle above 18 is often associated with patellar tracking dysfunction, subluxating patella, increased femoral anteversion, or increased tibial torsion.

Lateral Scapular Slide Test : This test is used to determine the stability of the scapula during glenohumeral movements. The patient sits or stands with the arm resting at the side. The examiner measures the distance from the base of the spine of the scapula to the spinous process of T2 or T3 (most common), from the inferior angle of the scapula to the spinous process of T7-T9, or from T2 to the superior angle of the scapula. The patient is then tested holding two other positions; 45 degrees abduction (hands on waist, thumbs posteriorly) and 90 degrees abduction with medial rotation. In each position the distance measured should not vary more than 1 to 1.5 cm from the original measure.

✅ Scapular ptosis has been identified as a significant factor in the production of symptoms of TOS. Disuse of the shoulder because of pain or immobilization from any cause may result in atrophy of trapezius, levator scapulae, and rhomboids. This in turn will result in ptosis of the scapula.

توضیح تمرین : یک چوب یا عصا به دست بیمار می دهیم. در حالی که بیمار در وضعیت ساید قرار گرفته، شانه را به 10 درجه اکستنشن و اداکشن می برد. حتما باید ساعد بیمار در وضعیت سوپینیشن باشد تا شانه در اکسترنال روتیشن قرار گیرد. پرونیشن ساعد منجر به اینترنال روتیشن شانه شده و در این صورت لیگامان کوراکوهیومرال شل می شود. بیمار باید در این حالت یک حس کشیدگی در قدام شانه حس کند. چوبی که به دست بیمار می دهیم سه فایده دارد. اول اینکه فرد با لغزوندن دستش به سمت تخت می تواند کشش بیشتری را اعمال کند. دوم اینکه وضعیت ساعد رو در سوپینیشن حفظ می کند. سوم اینکه احتمال بروز خستگی بیمار را کمتر می کند (خستگی منجر به بروز حرکات تقلبی مثل چرخش شانه می شود) بیمار در ابتدا 5 دقیقه این وضعیت را حفظ می کند و بعد از 2 هفته می توانیم مدت تمرین را تا 15 دقیقه افزایش دهیم.

⚛ تمرین کشش وضعیتی لیگامان کوراکوهیومرال این تمرین که از مهمترین و موثرترین تمرینات در بیماران دچار فروزن شولدر است، با هدف کشش لیگامان کوراکوهیومرال و کپسول روتاتور کاف اینتروال انجام می شود. در MRI بیماران مبتلا به فروزن شولدر، ضخیم شدگی لیگامان کوراکوهیومرال و ابنرمالیتی روتاتور کاف اینتروال دیده می شود و یکی از فرضیات علت محدودیت اکسترنال روتیشن در این بیماران همین است. بنابراین این لیگامان در بیماران فروزن شولدر باید استرچ داده شود.

✅ EMG studies have confirmed that no one exercise isolates the action of the supraspinatus muscle from other rotator cuff or deltoid muscles. The supraspinatus muscle is effectively activated in both the "empty can" (humerus internally rotated) and "full can" exercises. It also contracts strongly with military press-up and horizontal abduction and external rotation exercises. These findings appear to give the therapist several choices for supraspinatus strengthening the supraspinatus. However, several authors have suggested that the "empty can" exercise (scapular elevation with internal rotation of the humerus) should not be used for shoulder rehabilitation, because it can cause impingement of the suprahumeral tissues, especially as the arm approaches and elevates above 90.