Tuesday, August 31, 2010

Shoulder joint functional alteration during arm elevation with impingement syndrome & latent trigger points

Justify FullShoulder elevation mechanics in impingement syndrome:

Both glenohumeral and scapulothoracic kinematics are altered during impingement syndrome. Normal & altered mechanics during shoulder elevation is discussed below.

Normal mechanics:

Functions of Trapezius muscle: Upper trapezius produces clavicular elevation and retraction. The middle trapezius is primarily a medial stabilizer of the scapula. The lower trapezius assists in medial stabilization and upward rotation of the scapula.

Functions of serratus anterior muscles: The middle and lower serratus anterior muscles produce scapular upward rotation, posterior tilting, and external rotation.

Pectoralis minor: The pectoralis minor is aligned to resist normal rotations of the scapula during arm elevation.

Rotator cuff: The rotator cuff is critical to stabilization and prevention of excess superior translation of the humeral head, as well as production of glenohumeral external rotation during arm elevation.

Alterations of shoulder muscle functions in impingement syndrome:

Alterations in activation amplitude or timing have been identified across various investigations of subjects with shoulder impingement. These include
1. Decreased activation of the middle or lower serratus anterior and rotator cuff,
2. Delayed activation of middle and lower trapezius
3. Increased activation of the upper trapezius and middle deltoid.

* Subjects with tight pectoralis minor exhibit altered scapular kinematic patterns similar to those found in persons with shoulder impingement.

Scapular tipping and serratus anterior muscle function are important to consider in the rehabilitation of patients with symptoms of shoulder impingement (3).

Impact of Latent myofascial trigger point in upward scapular rotator muscles (upper and lower trapezius and serratus anterior).

What are latent myofascial trigger points ?: These lesions are not pain producers but present as nodules in the muscle bulk. Commonly in shoulder upper and lower trapezius and serratus anterior hosting Latent Myofascial Trigger Points.

Lucas et al found presence of Latent Trigger Points in upward scapular rotators alters the muscle activation pattern during scapular plane elevation. This potentially predisposes to overuse conditions including impingement syndrome, rotator cuff pathology and myofascial pain.

Lucas et al found
1. In normal condition there is a relatively stable sequence of muscle activation.
2. The sequence is significantly different in timing and variability in the subjects with Latent Trigger Point group in all muscles except middle deltoid.
3. The Latent Trigger Point group muscle activation pattern under load was inconsistent, with the only common feature being the early activation of the infraspinatus.

Hence latent trigger points should be searched for treatment when it is even not producing non-segmental pain as it is known to produce.


1. Phadke V et al; Rev Bras Fisioter. 2009 Feb 1;13(1):1-9. (Scapular and rotator cuff muscle activity during arm elevation: A review of normal function and alterations with shoulder impingement.)
2. Lucas KR et al; Clin Biomech (Bristol, Avon). 2010 Oct;25(8):765-70. Epub 2010 Jul 27. (Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points.)
3. Ludewig PM et al;Phys Ther. 2000 Mar;80(3):276-91. (Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.)

Tuesday, August 24, 2010

Composition of different treatments in subacromion bursitis: Evidence from a recent study.

Tate AR et al recently tried to define the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome in a case series. 10 patients (age range, 19-70 years ware treated with a standardized protocol for 10 visits over 6 to 8 weeks.

More about this program:

1. Strengthening rotator cuff and scapular muscles (3-phase progressive strengthening program)
2. Manual stretching
3. Manual therapy aimed at thoracic spine (Both thrust and nonthrust manipulation)
4. Manual therapy aimed at and the posterior and inferior soft-tissue structures of the glenohumeral joint (Both soft & bony. Bony manipulation: Both thrust and nonthrust manipulation)
5. Other components of this program: Activity modification and a daily home exercise program of stretching and strengthening.

Result of this program: This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks and appeared to be successful in the majority of patients.

LEVEL OF EVIDENCE: Therapy, level 4.

Tate AR et al; J Orthop Sports Phys Ther. 2010 Aug;40(8):474-93. (Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series.)

Tuesday, August 17, 2010

Condensing osteitis of clavicle: Presenting with sternoclavicular pain & swelling

What is Condensing osteitis of clavicle?

Osteitis condensans of the sternoclavicular joint was first described by Brower et al in 1974 (5). Till 1989 only 16 cases ware reported in world medical literature (6).

Definition: Condensing osteitis of the clavicle is a benign idiopathic entity that is probably degenerative or mechanical in etiology manifesting by variably painful and tender swelling over the medial end of the clavicle.

There is no clinical or laboratory evidence of infection in all cases of Condensing osteitis.

Where else Condensing osteitis is also marked?

Condensing osteitis is also marked at ilium, and pubis (4).

The etiopathogenesis of this rare benign clinico-radiologic entity remains unknown (7). However Berthelot et al have proposed a pathogenic hypothesis for condensing osteitis of the clavicle, ilium, and pubis. According to their observation joint aspects spared by the sclerosis are covered with hyaline cartilage but occurs in bone overlaid by fibrocartilage.

Clinical features:
1. Pain at medial end of the clavicle or SC joint with shoulder joint movement specially with over head abduction or horizontal adduction.
2. Sex: Seen more in women of late child-bearing age.
3. Radiographs show sclerosis and slight expansion of the medial one-third of the clavicle.

Investigations: Radiologic, scintigraphic, and histologic features should be studied (2). Recognition of condensing osteitis of the clavicle may avoid the occasional unnecessarily aggressive diagnostic approach taken to search for a malignant tumor.

Radiological findings include sclerosis of the medial part of the clavicle and a normal sternoclavicular joint. Radiographic investigations reveal an increase in volume and a condensation of the median part of the clavicle, and scintigraphical studies revealed an intense incorporation of the radioisotope (7). According to Vierboom et al (9) magnetic resonance imaging is a useful non-invasive procedure for the diagnosis of condensing osteitis of the clavicle.

Diagnosis is usually confirmed by biopsy (5). Generally biopsy reveals an inflammatory exudate, and histochemical staining for Langerhans'-cell histiocytosis was negative (3). Histopathologic studies showed lamellar and spongious bone tissue, with a normal trabecular structure, although considerably thickened (7).

Differential diagnosis:
It can be mistaken for - Friedrich disease, bone island, osteoid osteoma, sternoclavicular osteoarthritis, and even a metastasis and osteosarcoma (2). Although malignant tumor of bone must be considered in the differential diagnosis, tests for a presumed primary malignant lesion are not recommended for most patients. It is recommended, however, that an excisional or (preferably) incisional biopsy be performed in all patients unless pain is insignificant and the clinical presentation strongly supports the diagnosis of condensing osteitis (1).
Shiv Sankar et al have suggested hypertrophic sclerosis causing painful enlargement of the medial end of the clavicle in isolation should be distinguished from condensing osteitis and chronic recurrent multifocal osteomyelitis.
However according to Baciu et al in the first place those concerning intra-sterno-clavicular hyperostosis, sterno-costo-clavicular arthrosis, chronic subacute osteitis, avascular necrosis of the clavicular epiphysis (Friedrich disease), and Tietze syndrome must be considered for differential diagnosis (7).

Treatment options:
Pain management can be challenging in these patients.Many patients who have slight pain do not need treatment. Anti-inflammatory medications are variably effective(1).

Multiple treatments have been described in the past including oral NSAIDS, physical therapy, radiation, surgical resection, and oral corticosteroids but have met with limited success. Galla et al described the novel utility of sternoclavicular joint steroid injections in treating a patient with Osteitis condensans of the clavicle after failed medical therapy. They also have advocated sternoclavicular joint injection under fluoroscopic guidance using a local anesthetic-corticosteroid injectate as a viable treatment option for pain associated with Osteitis condensans of the clavicle (5).Patients in whom the lesion is refractory respond well to excision of the medial one-third of the clavicle (1).

Course of the disease:
A report of self limiting nature of the disease is considered by Berthelot JM et al (4). According to a intermediate follow up (mean length of follow-up was 38 months - range, 9 to 77 months) by Sng KK et al (6) the severity of the pain appears to improve with time, although the clinical swelling over the medial clavicle does not resolve significantly.


1. Kruger GD et al; J Bone Joint Surg Am. 1987 Apr;69(4):550-7. (Condensing osteitis of the clavicle. A review of the literature and report of three cases.)
2. Greenspan A et al; AJR Am J Roentgenol. 1991 May;156(5):1011-5. (Condensing osteitis of the clavicle: a rare but frequently misdiagnosed condition.)
3. Shiv Shanker V et al; J Pediatr Orthop B. 1999 Jan;8(1):48-9. (Hypertrophic osteitis of the medial end of the clavicle.)
4. Berthelot JM et al; Pain Physician. 2009 Nov-Dec;12(6):987-90. Rev Rhum Engl Ed. 1995 Jul-Sep;62(7-8):501-6. (Osteitis condensans of the clavicle: does fibrocartilage play a role? A report of two cases with spontaneous clinical and roentgenographic resolution.)
5. Galla R et al; Pain Physician. 2009 Nov-Dec;12(6):987-90. (Sternoclavicular steroid injection for treatment of pain in a patient with Osteitis condensans of the clavicle.)
6. Sng KK et al; Ann Acad Med Singapore. 2004 Jul;33(4):499-502. (Condensing osteitis of the medial clavicle--an intermediate-term follow-up.)
7. Baciu CC et al; Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir. 1989 Sep-Oct;38(5):381-6. (Condensing osteitis of the middle third of the clavicle)
8. Noonan PT et al; Skeletal Radiol. 1998 May;27(5):291-3. (Condensing osteitis of the clavicle in a man.)
9. Vierboom MA et al; Ann Rheum Dis. 1992 Apr;51(4):539-41. (Condensing osteitis of the clavicle: magnetic resonance imaging as an adjunct method for differential diagnosis.)

Thursday, August 12, 2010

Coccygodynia (Tail bonepain): Causes

What is a dynia?

The "dynias" are a group of chronic, focal pain syndromes with a predilection for the orocervical and urogenital regions. They include glossodynia, carotidynia, vulvodynia, orchidynia, prostatodynia, coccygodynia, and proctodynia. In some cases, the dynias occur secondarily, but more often, despite an exhaustive evaluation, no etiology is found and in these remaining cases, the cause of the pain remains enigmatic. The controversy that surrounds this group of disorders, which ranges from questioning their existence to suggesting that they are purely psychosomatic, is counterbalanced by an extensive literature attesting to their organicity (1).

What is coccygodynia? & Causes of coccygodynia:

The three most common functional disorders causing anorectal and perineal pain are levator ani syndrome, coccygodynia and proctalgia fugax. However, Alcock's canal syndrome is also responsible for pain in these areas (3).
A review of Mayo clinic records Physical Medicine and Rehabilitation from 1970 through 1975 with pelvic floor myalgia (pyriformis syndrome, coccygodynia, levator ani spasm syndrome, proctalgia fugax, or rectal pain) is associated with poor posture, deconditioned abdominal muscles, and generalized muscle attachment tenderness. The most effective therapeutic regimen was a combination of rectal diathermy, Thiele's massage, and relaxation exercises (20).
Local pain in the area of coccyx (tail bone) is called coccygodynia. Chronic coccygodynia is a difficult problem diagnostically and therapeutically (2). According to Dr. Cyriax (Father of orthopedic medicine) there are 4 different causes of coccygodynia.
1. Trauma by direct blow to the coccyx
2. Sprain of sacro-coccygeal & Ilio-coccygeal ligament
3. Sprain of muscle fibers attached to the over lying sacro-coccygeal & Ilio-coccygeal ligaments

Coccyx disc disorder in common idiopathic coccygodynia: Coccygodynia are usually attributed to soft tissue injuries or psychologic disturbances. However Maigne et al (13) in 1994 has hypothesized that the source of coccygodynia as a lesion of the coccygeal disc. Basing on discography study Maigne et al (13) found Common coccygeal pain could come from the coccygeal disc in approximately 70% of cases.

True & pseudo coccygodynias: According to Traycoff et al (4) true coccygodynia consists of pain arising from the sacrococcygeal joint, whereas pseudococcygodynia consists of pain referred to but not arising from the coccyx. Coccygodnia can usually be distinguished from pseudococcygodynia by physical examination with the diagnosis being confirmed by injection of local anesthetic into the sacrococcygeal joint. The etiology of pain not relieved by intraarticular injection can be further defined by selective neuroblockade.

Differentiating traumatic and idiopathic coccygodynia:

Intercoccygeal angle: It is the angle between the first and last segment of the coccyx (11). According to Kim et al (11) intercoccygeal angle in the normal population is around 52.3 degrees. Intercoccygeal angle of the idiopathic (non-traumatic) coccygodynia is greater than that of the traumatic and normal population.Increased intercoccygeal angle can be considered a possible cause of idiopathic coccygodynia. The intercoccygeal angle was a useful radiological measurement to evaluate the forward angulation deformity of the coccyx.
According to Kim et al (11) the differences observed between traumatic & non-traumatic coccygodynia are
1. There is no difference between the traumatic and idiopathic coccygodynia groups in terms of age, male/female sex ratio, and the number of coccyx segments.
2. Significant differences between the traumatic and idiopathic coccygodynia groups are marked in terms of the pain score, the intercoccygeal angle, and the satisfactory outcome of conservative treatment.
a. If pain is compared in sitting then the pain in traumatic coccygodynia is more than non traumatic category.
b. If pain is compared on defecation then the pain in non traumatic coccygodynia is more than traumatic category.
c. Intercoccygeal angle is more in non traumatic coccygodynia than traumatic category.
d. Response to conservative treatment is better with non traumatic coccygodynia

Pregnancy & Coccygodynia: Coccygodynia appears to occur more in females. Coccydynia can result from a varying number of causes, parturition being one of them (6). Ryder et al (5) reviewed literature to find out coccydynia with specific reference to those cases of pregnancy and birth-related onset. They found there is little information about incidence, prevalence, pathophysiology, methods of differential diagnosis and efficacy of treatment for these women. No qualitative data from women with pregnancy or birth-related coccydynia were identified.
However according to a case report by Kaushal et al (6) strains and sprains of the ligaments attached to the coccyx is thought to be the usual cause for coccydynia occurring after childbirth, an intrapartum coccygeal fracture dislocation can result in the same. Similarly Jones et (12) reported a case of coccygodynia due to coccygeal fracture secondary to parturition.

Cyst in precoccygeal region as a cause of coccygodynia: Jaiswal et al in 2008 (7) reported for the first time a single case precoccygeal epidermal inclusion cyst presenting as a coccygodynia. This study suggests that patients with intractable coccygodynia should have a magnetic resonance imaging to rule out treatable causes of coccygodynia.
A few coccygodynia cases are attributed to so-called pericoccygeal glomus tumors. Pericoccygeal soft tissues normally contain numerous small glomus bodies and a larger one known as the glomus coccygeum, which can reach several millimeters in diameter. Most reported cases of alleged pericoccygeal glomus tumors represent normal, incidentally discovered coccygeal glomus bodies (14).
Intracoccygeal glomus tumor are also reported as a cause of coccygodynia. However, Pericoccygeal and intracoccygeal glomus bodies are normal findings in humans at all ages. They should not be mistaken for tumors, and their role in the pathogenesis of coccygodynia is questionable (14).
Ziegler et al (17) have reported a case of typical coccygodynia caused by a sacral nerve cyst. Relief of the pain by excision of the cyst occurred.
No case of arachnoid cyst causing coccygodynia has been found available in medical literature till Kepski A et al (18) reported a case of arachnoid cyst of cauda equina with severe chronic coccygodynia. Arachnoid cysts are often asymptomatic, by they may be responsible for coccygodynia and/or incomplete cauda equina syndrome (19).
Arachnoid cysts are called Tarlov’s cysts (perineurel meningeal cysts on the sacral nerve roots).It’s presence is suggested by the characteristics of the symptoms which are paroxysmal, exacerbated in standing position, relieved in dorsal position and revived by percussing the sacrum. Treatment is medical in most cases. The decision to operate depends on the persistence and intensity of pain and on whether signs of neurological defecit are present (19).
According to a single case study by Charpentier et al (21) ependymoma of the filum terminale caused the coccygodynia in that case. Similarly according to a single case study by Chateau et al (22) ependymoma of the filum terminale caused the coccygodynia in that case.

Association of depression with coccygodynia: Maroy B (15) investigated association of depression with coccygodynia in 1988. Out of 313 patients with signs of depression or spontaneous or evoked pain of coccygeal area were studied over six months. One hundred eighty (58 percent) had no spontaneous pain, 87 (28 percent) had moderate pain, and 46 (15 percent) a severe coccygodynia leading to consultation.

Association of jeans seam with coccygodynia: Stoshak ML (16) et al have tried to associate jeans seam with coccygodynia back in 1985.

Normal coccygeal movement during defecation don’t cause coccygodynia: Over view of coccygeal movement
An abnormal motion (laxity or hypermobility) of the coccyx that occurred in the sitting position and spontaneously was reducible when placed in the lateral decubitus position (13). According to a dynamic MRI study by Grassi R et al (2), coccyx is mobile during defecation and that it is possible to demonstrate coccygeal excursions by assessing the difference between its positions at maximum contraction and during straining-evacuation. This study also found there is no correlation between coccygeal movements and age, sex, parity, minor trauma and coccygodynia.
Dynamic radiography is a useful tool to differentiate posttraumatic from idiopathic coccygodynia (9).
Changes in post traumatic coccygodynia:
In an analysis of morphological changes associated with 23 different patients with post traumatic coccygodynia the following ware found by Brusko et al (8)
1. Coccyx cartilaginous tissue showed dystrophic changes of chondrocytes, destruction of the basic material with partial replacement of a fibrillar cartilaginous tissue with a hyaline cartilage were observed with a different degree of manifestation.
2. Vessels and sacrococcygeal nervous plexus were subjected to pathological changes.
3. Increased post-traumatic mobility, alterations in the process of ossification, deceleration of physiological joining of coccyx vertebras and sacrococcygeal joint alter biomechanical properties of coccyx at sitting.
Study by Brusko et also found that these above alterations lead to the long-lasting traumatization with degenerative - dystrophic changes, reinforcement of pain syndrome and manifestation of dysfunctions of organs of pelvis (8).

Coccyx instability following post traumatic coccygodynia:
Coccyx instability is a fairly common phenomenon after trauma to this area. Mouhsine et al reported 15 posttraumatic coccygodynia with instability which was diagnosed with dynamic lateral radiography and magnetic resonance imaging (MRI) (9). Doursounian et al between 1993 and 2000 surgically treated 61 patients with instability-related coccygodynia using a single technique. Twenty-seven patients had hypermobility of the coccyx and 33 subluxation. In all cases, the unstable portion was removed through a limited incision directly over the coccyx.

Complications of coccygodynia:
Complications of coccygodynia are not many however coccygodynia out of Coccygeal fracture dislocation may result in introital dyspareunia and tension myalgia of the pelvic floor. Pain from this lesion may become recurrently symptomatic (6).

1. Wesselmann U et al; Semin Neurol. 1996 Mar; 16(1):63-74. (The dynias)
2. Grassi R et al; Eur J Radiol. 2007 Mar;61(3):473-9. Epub 2007 Jan 16. Coccygeal movement: assessment with dynamic MRI.
3. Mazza L et al; Tech Coloproctol. 2004 Aug;8(2):77-83. (Anorectal and perineal pain: new pathophysiological hypothesis.)
4. Traycoff RB et al; Orthopedics. 1989 Oct;12(10):1373-7. (Sacrococcygeal pain syndromes: diagnosis and treatment.)
5. Ryder I et al; Midwifery. 2000 Jun;16(2):155-60. (Coccydynia: a woman's tail.)
6. Kaushal R et al; J Surg Orthop Adv. 2005 Fall;14(3):136-7. (Intrapartum coccygeal fracture, a cause for postpartum coccydynia: a case report.)
7. Jaiswal A et al; Singapore Med J. 2008 Aug;49(8):e212-4. (Precoccygeal epidermal inclusion cyst presenting as coccygodynia.)
8. Brusko AT, Fiziol Zh. 2004;50(6):114-7.( Morphofunctional changes of coccyx area in posttraumatic coccygodynia)
9. Mouhsine E et al; Spine J. 2006 Sep-Oct;6(5):544-9. Epub 2006 Jul 26. (Posttraumatic coccygeal instability.)
10. Doursounian L et al; Int Orthop. 2004 Jun;28(3):176-9. Epub 2004 Mar 13. (Coccygectomy for instability of the coccyx.)
11. Kim NH et al; Yonsei Med J. 1999 Jun;40(3):215-20. (Clinical and radiological differences between traumatic and idiopathic coccygodynia.)
12. Jones ME et al; Injury. 1997 Oct;28(8):549-50. (A case of coccygodynia due to coccygeal fracture secondary to parturition.)
13. Maigne JY et al; Spine (Phila Pa 1976). 1994 Apr 15;19(8):930-4. (Idiopathic coccygodynia. Lateral roentgenograms in the sitting position and coccygeal discography.)
14. Albrecht S et al; Surgery. 1994 Jan;115(1):1-6. (Intracoccygeal and pericoccygeal glomus bodies and their relationship to coccygodynia.)
15. Maroy B; Dis Colon Rectum. 1988 Mar;31(3):210-5. (Spontaneous and evoked coccygeal pain in depression.)
16. Stoshak ML et al; Pediatrics. 1985 Jul;76(1):138. (Jean seam coccygodynia.)
17. Ziegler DK et al; eurology. 1984 Jun;34(6):829-30. (Coccygodynia caused by perineural cyst.)
18. Kepski A et al; Neurol Neurochir Pol. 1978 Jan-Feb;12(1):109-12. (Arachnoid cyst of the cauda equina: a contribution to the etiology of coccygodynia)
19. Dehaine V et al; Rev Med Interne. 1990 Jul-Aug;11(4):280-4. (Coccygodynia disclosing Tarlov's cysts)
20. Sinaki M et al; Mayo Clin Proc. 1977 Nov;52(11):717-22. (Tension myalgia of the pelvic floor.)
21. Charpentier J et al; Rev Neurol (Paris). 1968 Feb;118(2):160-2. (Coccygodynia revealing an ependymoma of the filum terminale. Complete removal without sequelae)
22. Chateau R et al; Med Lyon. 1967 Apr 5;48(118):573-8. (Coccygodynia revealing a giant tumor of the cauda equine)

Interesting note by the author: The above picture of an MRI is taken in my center shows a coccyx fracture dislocation with no coccygodynia. The patient is a 32 year old lady.

Tuesday, August 3, 2010

Compensation for weak gluteus medius

1. Excessive lateral pelvic tilt (Trendelenburg):

Areas that may be affected due to compensation: Lumbar spine, sacroiliac joint (SIJ), greater trochanter bursa, insertion of muscle on greater trochanter, overactivity of piriformis and tensor fascia lata (TFL) .

2. Medial knee drift:

Areas that may be affected due to compensation: Lateral tibiofemoral compartment (via compression), patellofemoral joint, patella tendon and fat pad, pes anserinus, iliotibial band (ITB)

3. Lateral knee drift:

Areas that may be affected due to compensation: Medial tibiofemoral compartment (via compression), ITB, posterolateral compartment, popliteus

4. Same-sided shift of trunk (lateral flexion of trunk):

Areas that may be affected due to compensation: Lumbar spine (increased disc and facet joint compression), SIJ (increased shear)