ANATOMY & SOFT TISSUE INJURY REVIEW

By Dr Simon Kaye, Sports Physician and General Practitioner

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ANATOMY & SOFT TISSUE INJURY REVIEW

by Dr Simon Kay

Are you seeing growing numbers of people with exercise related injuries? Help is at hand, with this informative and thorough guide to physical injuries of the joints and their surrounding tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals.

■ Back to basics revision of anatomy of each joint

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■ Includes 53 anatomy animations and video clips to bring the facts to life

■ Covers diagnosis and treatment options with background theory

InjuryRefresher_proofed AS.indd 1 11/07/2013 10:58 CONTENTS

■ Overview of diagnosis and treatment of sports injuries

■ Shoulder Joint and girdle ■ Elbow and Wrist ■ Ankle ■ Knee ■ Spine ■ Hip joint and pelvic girdle

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■ Provides tips for examination, learning exercises and highlights key points

■ Gives links to further reading ■ Useful for practitioners and those in training

SPORTS INJURIES DIAGNOSIS & TREATMENT

THE SHOULDER JOINT – ASSESSMENT AND DIAGNOSIS

BY DR SIMON KAY INTRODUCTION

The shoulder the most flexible joint of the body providing us with a wide range of motion of the upper limb as well as generating power movements like throwing, lifting and carrying. Unfortunately this mobility comes at the expense of instability and high injury potential. This article briefly reviews the anatomy and movements of the shoulder before going into a more detailed look at the diagnosis of injuries to the various soft tissue structures making up the shoulder girdle. We outline some simple assessment techniques with accompanying video footage, showing how each structure can be assessed and differentially diagnosed.

ANATOMY OVERVIEW

The shoulder or specifically the gleno-humeral (GH) joint, is one of five joints that make up the shoulder girdle. These joints are as follows: 1. gleno-humeral joint 2. acromioclavicular (AC) joint 3. coracoclavicular joint 4. scapulothoracic joint 5. sternoclavicular joint

The neutral position of the shoulder is with the arm at the side of the chest, neither externally or internally rotated, note that this isn’t the anatomical position (in which the shoulder is positioned in full external rotation).

SHOULDER MOVEMENTS Movement of the shoulder occurs in six ‘basic’ directions: flexion and extension (sagittal plane), abduction/adduction (coronal plane), and internal and external rotation (around axis of the humerus). The seventh movement is a ‘multiple’ movement called circumduction, which is a combination of all six ‘basic’ movements.

Rotation occurs primarily at the GH joint, the other

movements involve multiple joints in the shoulder depending on the degree of angulation from the vertical. For example during abduction from: n from neutral to 25-30 degrees, the majority of the movement is at the GH joint,

n from 30-90 degrees the movement is 2:1 ratio of GH movement to scapula-thoracic movement n after 90 degrees of abduction the clavicle comes into play

with the AC joint and sterno-manubrial movement to achieve 180 degrees of abduction

n From 150 degrees onwards and greater than 180 degrees, abduction/flexion is achieved with some thoracic rotation at T1-3.

ed with some thoracic rotation at

Observation from behind the patient demonstrates some of the changes in joint movements well.

ation from behind the patient demonstrates some of MUSCLE MOVEMENTS

Different muscle groups are involved in movement of the shoulder. Movement can roughly be divided into two gross areas:

1. Rotator cuff (RC) – the contractor/stabilising muscles of supraspinatus (SS), infraspinatus (IS), teres minor, and subscapularis (SSc)) (see Video 1)

2. Primary movers (PM) – pectoralis major, latissimus dorsi, deltoid, teres major,

pectoralis minor, biceps and triceps. These

muscles act mostly in a concentric/eccentric fashion, to move the humerus.

The RC muscles like close to the joint and surround it like an incomplete sleeve. Their job is to hold the humerus head against the glenoid fossa thus maintaining stability during shoulder movements. The rotator cuff muscles are are covered by the prime movers. The RC muscles act in a slow twitch contraction/ isometric fashion pulling the head of the humerus into the glenoid fossa, allowing the PM muscles to move the head of the humerus. The RC muscles shorten as the tendon is pulled medially under the acromium of the scapula. Rotation is effected by the rotator cuff with infraspinatus being responsible for external rotation and the subscapularis muscle responsible for internal rotation, in a concentric/ eccentric fashion (see Video 1). The accessory muscles of the scapula (trapezius, serratus anterior and posterior and levator scapulae) stabilise, rotate,

Following on our previous anatomy refresher articles covering the shoulder, knee, ankle and hip, Dr Simon Kay looks in this issue, at the joints of the wrist and elbow. We have grouped both anatomical regions together as they are so intimately related to each other.

BY DR SIMON KAY, GP

INTRODUCTION Considering how vital these two joints are to human development, i.e. hand- eye co-ordination and manipulation, it is surprising in a way that they are injured as little as they are.

online

The combination of the elbow, forearm and wrist allows both fine positioning of our hands, plus power grip. Perfection of a single function is not the hand’s role, use in a wide range of functions is, and with that in mind the elbow and wrist promote excellent positioning. Manipulation can be as fine as threading a needle, as mobile as combing our hair and as gross (in movement terms) as putting a shot.

ANATOMY OVERVIEW OF THE ELBOW The elbow consists of three joints: 1. the humero-ulna joint (a hinge joint) which consists of the articular facet of the humerus which articulates with the congruent surface on the ulna

2. the rotating humero-radial joint, allowing rotation of the radius longitudinally (pronation/supination) around the ulna

3. the radio-ulna joint which facilitates the rotating movement.

+ KEY POINT: OINT

Although three separate joints they are all

enclosed in the same capsule which can facilitate injection therapy (see figure 2).

Elbow movements

Movement of the true elbow joint occurs in one direction - flexion/extension

(sagittal plane) (Figure 3) via the humero- ulna joint.

The humero-radial joint which isn’t technically considered part of the true elbow joint, allows the hand to be turned around from front to back – supination (palm faces up) and pronation (palm faces the floor) (Figure 4a+b). The

ELBOW AND WRIST JOINTS

– AN INTRODUCTION TO ASSESSMENT AND DIAGNOSIS

SPORTS INJURIES REFRESHER ELBOW AND WRIST JOINT SPORTS INJURIES DIAGNOSIS & TREATME

SPORTS INJURIES DIAGNOSIS & TREATMENT

THE ANKLE JOINT – AN INTRODUCTION TO ASSESSMENT AND DIAGNOSIS

The ankle is the most commonly injured joint in the lower limb, the anterior talo-fibular ligament (the classic sprained ankle) is a relatively simple ligamentous injury but as the severity of inversion injury increases, the sub-talar joint and the mortice of the true ankle joint can be disrupted which can be as severe as any knee injury. We will consider the ankle, sub-talar joint and foot in this article.

BY DR SIMON KAY, GP

The function of the ankle and foot is to allow dissipation of force at heel strike and secondly to provide a rigid level to allow a stable and propulsive phase of gait during walking and running (see Box 1 for more information). As part of positioning the foot, the sub-talar joint allows for rough and uneven ground. Eccentric and concentric movements of the shin muscles are used to control the movements of the foot during pronation and supination. Excess pronation can put a strain on the invertors of the foot ie. tibialis anterior, when contracting eccentrically, to control the rate of pronation. This can cause trigger points to occur.

LEARNING EXERCISE n (kinaesthetic): Try examining an articulated foot which can be prised apart slightly, to fully appreciate the 3-D aspects of the subtalar joint.

The ankle consists of two main joints:

1. the ankle joint (similar to a mortice and tenon joint in woodwork) - consists of the articular facet of the talus (tenon) which articulates with the two congruent surfaces on the tibia and fibula (which form the mortice) 2. the complicated sub-talar joint

between the three inferior facets of the talus and the congruent facets on the calcaneum and cuboid bones.

Fibula

MOVEMENTS OF THE ANKLE

figures 3-5 for a description of the movements).

Movement of the true ankle joint occurs in one direction, plantar and dorsi-flexion (sagittal plane) (video 1). The three dimensions of the subtalar joint however allows for inversion and eversion (video 2) and pronation and supination (see Definitions box and figures 3-5 for a description of the

The movement of eversion and it’s counteracting movement of inversion allows the foot to take rough ground into account without putting excess

Calcaneus

Intermediate cuneiform

Medial cuneiform Navicular

ANATOMY OVERVIEW The knee consists of two joints: 1. the main joint - the tibio-femoral joint which consists of the facets of the tibia which articulate with the two congruent surfaces on the femur, cushioned and stabilised by two avascular structures, the mensici

BY DR SIMON KAY, GP Fifth

Proximal phalanx (5th toe)

metatarsal

Lateral cuneiform

Talus Cuboid

2. the patella-femoral joint - a joint between shallow V-shaped facets on the back of the patella which articulate only with the femoral trough. The patella essentially acts as a fulcrum for the quadriceps muscle, travelling in front of the knee and inserting into the tibia, making it mechanically more efficient. Note that the fibula pays no part in the articulation of the knee. The tibia is linked to the femur by

Calcaneus Tibia

two strong crossing ligaments – the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). Uncommonly for ligaments they have a good vascular supply. They are contained within the joint and covered by synovium. The ACL stops twist between the two bones and anterior glide of the tibia on the femur. The PCL also stops twist along with posterior glide of the tibia on the femur (see Online extras panel at the end of the article for videos).

Talus Navicular

The neutral and the anatomical positions of the knee are the same with the leg fully extended in a straight line.

MOVEMENTS OF THE KNEE Movement of the knee occurs in two main directions: n Flexion and extension (sagittal plane) n A small amount of rotation or twist. This rotation is to allow the knee to ‘unlock’ before flexion can occur.

SPORTS INJURIES DIAGNOSIS & TREATMENT

THE KNEE JOINT – AN INTRODUCTION TO ASSESSMENT AND DIAGNOSIS

Distal phalanx (5th toe)

Middle phalanx (5th toe)

The knee is the most commonly severely injured joint in the lower limb, like the shoulder mostly due to its relative instability. The function of the knee is to allow support of the body, propulsion, plus allowing positioning of the torso near the ground as in squatting and sitting. Propulsion can either be moving the body, as in walking and running or moving the foot allowing rapid acceleration of the foot as in kicking.

MUSCLE MOVEMENTS Different muscle groups are involved in movement of the knee.

1. Knee flexion - hamstring muscles ie. semi-tendinosus, semi-membranosus and biceps femoris with some help from the accessory muscle, popliteus, which unlocks the knee prior to flexion. 2. Knee extension - quadriceps muscles ie. rectus femoris, vastus lateralis, vastus medialis and vastus intermedialis. The gastrocnemius muscles also aid knee flexion when the foot is fixed. Man can stand straight upright on his legs because the facets of the tibia and femur lock to stabilise the joint in full extension, minimising muscle activity. Please note that hamstring injuries are not be addressed by this article (please refer to previous articles published in sportEX for this topic). Usually the pain from the muscle injury is more significant than the effect on knee flexion.

The stability of the knee joint is a due to the array of ligaments connecting the tibia and femur and the very strong muscles surrounding the joint which are activated in response to tensions within the ligaments. It is the ligaments which not only

hold the two bones together, but also tighten when they are stretched, firing off stretch receptors which allows

Femur

Patello- femoral joint

Tibio- femoral joint

BY DR SIMON KAY, GP INTRODUCTION

(behind patella)

The hip, mostly due to its stability is a rarely injured joint, at least acutely. With the recognition of femoro-

Fibula

acetabular impingement and of injuries to the sacro-iliac joint and surrounding muscles, the situation changes. Menisci The function of the hip is to allow support of the trunk on the limbs, particularly during locomotion. However a whole range of movements including standing, walking, running, jumping and kicking all involve the hip, to greater or lesser degrees depending on the amount of time that the hip bears all or multiples of bodyweight. For example whilst standing the hips will transmit appropriate muscle to avoid excess

movements of the prime movers slow BONES AND JOINTS

why arthritis occurs if a patient has be 400-500% of body weight. because the disarticulation and and the transfer of power to the leg through muscles from trunk to leg, means that if the hip wasn’t inherently stable, then disruption of the joint would occur far more often.

As in the shoulder, eccentric

The hip i.e. the femoro-acetabular joint is one of six joints that make up the hip girdle. The hip girdle consists of: 2 x femoro-acetabular (FA) joints 2 x sacro-iliac joints (SIJ) 1 x pubic symphysis

1 x lumbar-sacral junction The FA joint, although very stable

facets on an anatomical model of the human skeleton, to see how the faces lock under vertical downward pressure. N.B. the

LEARNING EXERCISE n (kinaesthetic): Look at the joint facets on an anatomical model eleton, to see

EARNING

anatomical position is with the rim of the pelvis tilted approximately 30 to the vertical and the femur slightly tilted anteriorly.

due to the high proportion of femoral head covered by the acetabulum, is further stabilised by a labrum of thick connective tissue, acting to further deepen the acetabulum (figs.1-2). The neutral position of the hip is with the neck of the femur projected slightly posteriorly and laterally from the acetabulum.

LIGAMENTS Tibia AMENTS

Whilst standing, the head of the femur is held tightly into the acetabulum by three key ligaments (fig.3):

1. Ischio-femoral ligament 2. Ilio-femoral ligament 3. Pubofemoral ligament.

the spinal reflexes to contract the approximately half the body-weight, however during running, hurdling or mo ement. This is the main reason jumping, the weight through the hip may a deficient ACL ligament after injury The transmission of huge weights, excess movement within the knee leads to minor trauma and ultimately osteoarthritis.

These ligaments tighten with the effect of gravity, allowing us to stand without a great use of muscle power. Although there is a large mass of muscle around the hip, the prime purpose of this muscle is for locomotion, not stability. Similarly the stability of the SI joints and the pubic symphysis relies on ligament strength and opposition of the joint facets.

Femur Ischium

Sacrum Ilium Acetabulum

Neck of the femur

HIP JOINT AND PELVIC GIRDLE – ANATOMY REFRESHER

The hip, mostly due to its stability, is a rarely injury joint, at least acutely. With the recognition of femero-acetabular impingement and injuries to the sacro-iliac joint and surrounding muscles, the situation changes. This article reviews the anatomy and function of the hip joint and follows the same format as previous articles in this series (see box at the end of the article for more information).

SPORTS INJURIES DIAGNOSIS & TREATMENT

THE SPINE – AN INTRODUCTION TO ASSESSMENT AND DIAGNOSIS

Pubis

This is the last in the series of injury refresher articles. Previously in this series we have covered the shoulder joint (issue 44), hip joint (issue 47), knee joint (issue 45), ankle joint (issue 46) and the elbow and wrist joints (issue 49). Although we have given this article the title of the spine it is more about the spine and associated muscle girdles.

Sacroiliac joint

Femero-

acetabular joint

Reviewing my own approach I have found that I have become more cosmopolitan, mixing various therapies in a pragmatic but difficult to ‘evidence’ approach. I make no apology for this, it is a practical, hands- on, primary care approach. It involves sports therapy, physiotherapy, manipulation, massage, mobilisations, acupuncture, myofascial theory, Mulligans techniques, podiatry and good old orthodox medicine. People, their spines and their sports, are so different that a truly holistic patient- based approach is, I believe, essential.

BY DR SIMON KAY, GP Pubic symphysis joint

INTRODUCTION The function of the spine is two-fold: 1) Protection of the spinal cord with distribution of the spinal nerve roots to their relative segments and limbs 2) Support of the trunk, upper limbs and skull on the pelvis and lower limbs, allowing locomotion and use of the arms. Most of the problems described below relate to the latter function.

ANATOMY The vertebrae are complex. From an embryological perspective, they develop from three centres which fuse between 8 and 15 years of age. The vertebrae are

divided into five sections, each of which is specialised to perform different roles: n Cervical n Thoracic n Lumbar n Sacral n Coccygeal.

Cervical

The cervical spine is designed to support the skull and allow positioning of the skull for purposes of good vision and hearing. The two uppermost cervical vertebrae have evolved anatomically differently, the body of the first vertebra (Atlas) has become separate from the first vertebral ring and has fused to the second vertebra