Dr Satyajit Mohanty blogs

Lumbar facet pain (1): Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. However with invasive diagnostic technique the chance of false positive result may be up to 47% but these controlled diagnostic studies have shown the prevalence of lumbar facet joint pain in 27% to 40% of the patients with chronic low back pain without disc displacement or radiculitis. Facet joint surface area in LBA (2): Facet joint surface area is an important parameter for understanding facet joint function and pathology. Otsuka et al investigated lumbar facet joint surface area in relation to age and the presence of chronic low back pain. In this invivo study the following things are found: 1. The lumbar facet area was significantly greater at the inferior lumbar levels and a...

How facet joint pain manifests? Facet or zygapophysial joints are considered to be common sources of chronic spinal pain. In addition to causing localized spinal pain, facet joints may refer pain to adjacent structures. Cervical facet joint pain may radiate to the head, neck, and shoulders. Thoracic facets may produce paraspinous mid-back pain with neuralgic characteristics; and lumbar facet joints may refer pain to the back, buttocks, and proximal lower extremities. Referred pain may assume a pseudoradicular pattern, making the underlying diagnosis difficult to confirm, without the use of diagnostic blocks. Joint innervation: Facet joints are well innervated by the medial branches of the dorsal rami. Neuroanatomic, neurophysiologic, and biomechanical studies have demonstrated free and encapsulated nerve endings in facet joints, as well as nerves containing substance P calcitonin gene-related peptide; facet joint capsules contain low-threshold mechanoreceptors, mechanically sensitive n...

Clinical examination is not an efficient method of diagnosis of spine pain!!! Pain emanating from various structures of the spine is a major cause of chronic pain problems. Linton et al estimated the prevalence of spinal pain in the general population as 66%, with 44% of patients reporting pain in the cervical region, 56% in the lumbar region, and 15% in the thoracic region. Manchikanti et al reported similar results. Despite the high prevalence of spinal pain, it has been suggested that a specific etiology of back pain can be diagnosed in only about 15% of patients with certainty based on clinical examination alone (2). Prevalence of facet joint pain & Z joint pain: In the 1990s precision diagnostic blocks were developed, including facet joint blocks, provocative discography, and sacroiliac joint blocks. Facet joints have been implicated as a cause of chronic spinal pain in 15% to 45% of patients with chronic low back pain, 48% of patients with thoracic pain, and 54% to 67% of pat...

I. Introduction o other causes of anterior knee pain, besides primary PF pain o differential diagnosis may be more difficult than anticipated owing to interrelationships o realize that more than one problem may exist concurrently o a small acute injury may stir up an underlying mechanical anomaly that had previously been painfree; daily activity with a malalignment may be enough to perpetuate symptoms II. Plica o embryologically the knee is formed by the fusion of three synovial compartments and the intervening synovial tissues resorbed. The plicae are synovial remnants of these synovial tissues o intrapatellar plica (ligamentus mucosum) most common and runs parallel to the ACL; it has no clincial significance o suprapatellar second most common: acts as a tethering band in the superior portion of the quadriceps bursa and may separate it into two separate segments o medial plica least common, but probably produces the most symptoms; runs distally along the ...

Progressively Accelerating Cardiopulmonary Exertion (PACE) – A More Effective Alternative to Modern Exercise Prescriptions This following is an article from a news letter from Dr. Al Sears (USA) Ask a personal trainer, pick up a fitness magazine, or consult a medical organization and you will see the same fitness-training concepts. These modern exercise prescriptions will be cardiovascular endurance training (CVE) or “cardio” for short, “aerobic” exercises often given in hour-long group classes, and weight training on machines or with free-weights. These forms of exercise, while promoted by a majority of physicians and fitness professionals, fail to bring about the physiological adaptations necessary for a healthy and vital cardiopulmonary system and may leave patients at a heightened risk of mortality. The key failing of both cardiovascular endurance training and aerobics classes is the focus on exercise duration at the expense of intensity. In order to achieve the recommended duratio...

The sacrum weight transmission factors: The direction of the trabecular bone indicates the route of load transmission in the sacrum. From the various parts of the sacrum (body, facets, alae and laminae) distinct sets of trabeculae extend towards the auricular surface. L5-S1 weight transmission Weight transmitted from the fifth lumbar vertebrae to the sacrum is distributed in 3 separate components i.e. (a) Anteriorly- through vertebral bodies (b) Intermediately- through transverse elements (c) Posteriorly- through lumbosacral facet joints The posterior components of the fifth lumbar vertebra share greater proportion of load in comparison with the posterior elements of the upper lumbar vertebral levels. The forces acting on the body and articular facets, at the upper end of the sacrum, are ultimately transmitted through the two auricular surfaces with an appreciable part of the load passing directly from the transverse process of the fifth lumbar vertebra to the ala of the sacrum through...

I. Recent findings in DISH The diagnosis of DISH or Forestier's disease is based solely on radiographic abnormalities defined using the Resnick criteria. DISH is a condition characterized by calcification and/or ossification of soft tissues, mainly entheses, ligaments and joint capsules. Its prevalence increases with age and, therefore, DISH is a relatively common entity in the elderly. Witnessing the present increase in lifespan, obesity, DM and metabolic syndrome in the Western population, the prevalence of DISH should be expected to rise. Recent findings: Recent studies confirm that patients with DISH have a. Strong association with obesity: DISH patients have a greater body mass index, increased waist circumference b. Strong association with metabolic disturbances: DISH patients have disturbed lipid profile (dyslipidaemia), hypertension, , diabetes mellitus (DM), hyperuricaemia, metabolic syndrome and an increased risk for cardiovascular diseases. c. In addition, DISH ...

2 misconceptions about subacromial impingement & adhesive capsulitis Subacromial impingement (SI) syndrome is a painful condition that occurs during overhead activities as the rotator cuff is compressed in the subacromial space. Unrecognized secondary causes of subacromial impingement may lead to treatment failure. Posterior capsular tightness, believed to alter glenohumeral joint kinematics, is often cited as a secondary cause of SI. Karduna et al examined the effects of scapular orientation on clearance in the subacromial space in a cadaver study. Results from this study demonstrated no significant effect of posterior tilting and external rotation of the scapula but subacromial clearance was found to decrease with an increase in upward rotation, which is contrary to what was expected. These results suggest that changes in upward rotation observed in patients with impingement syndrome may serve to open the subacromial space. In adhesive capsulitis there is tightening of posterior...

According to Lin et al in persons with stiff shoulder a. A strong co-relationship is found between functional disabilities in a stiff shoulder and posterior shoulder tightness. The study also revealed significant relationship between functional disabilities and cross-chest adduction. b. There exists a significant relationship between internal rotation and posterior shoulder tightness. Similarly there is also a significant relationship of external rotation and anterior shoulder tightness. c. Further significant correlations between shoulder internal rotation and cross-chest adduction, shoulder external rotation and below-chest abduction are observed, indicating that internal and external rotations might be related to posterior and anterior shoulder stiffness. d. Below-chest abduction and cross-chest adduction were found to provide reliable data in shoulder stiffness & disbility. Reference: Lin JJ et al; Man Ther. 2006 May;11(2):146-52. Epub 2005 Aug 10. (Reliability and validity of...

Isolated shoulder internal rotation restrictions are rare clinical entities for physiotherapist to encounter in OPD set ups. According to cyriax J in a pan-capsular involvement there is more external rotation restriction than abduction restriction than internal rotation. This restriction pattern is called capsular pattern. So only limitation of internal rotation is attributed to involvement of structures other than capsule i.e. muscles & IDK (labrum problems) etc. A case in my clinic: A 42 year male reported with lateral arm pain. The patient has cervical spine involvement with Rt side rotation, side bend & back ward bending limited terminally but no ULTT tests ware positive. Both side levator scapulae ware tight. First 10 sitting ware spend to improve ROM & myofascial work to improve length of elevators of scapula without much avail. During the second 10 sitting it was found that shoulder IR/hand behind back is limited could reach maximum up to L3. No other shoulder tests ...

Authors such as McKenzie have emphasized distinct pain patterns attributable to mechanical & chemical origin within the scope of mechanical spinal disorders. It is easily understood that disc injury produces pain by mechanical effect. However, injured discs can produce chemical mediators of pain. Not only this, these chemical mediators can lead to degeneration of the disc itself. Interestingly biochemical events that occur with intervertebral disc degeneration and, in particular, the role of biochemical mediators of inflammation and tissue degradation have received sparse attention in the literature. Kang et al obtained herniated lumbar & cervical disc specimens from patients undergoing surgical discectomy for persistent radiculopathy. They found biochemical mediators of inflammation due to tissue degradation play a role in intervertebral disc degeneration and in the pathophysiology of radiculopathy. Herniated lumbar & cervical discs were producing spontaneously increased a...

This following technique is very effective in infra-patellar tendinitis. So may times it is associated with jumping injuries. The lesion: 1. Cause: It occurs nearly always as a result of overuse but occasionally over load is also responsible. 2. Site: Lies at the insertion of the tendon into the inferior pole of patella. The area is 1.5 cm long. How to identify it? 1. PROM- A full and painless ROM of knee. 2. No warmth or fluid is detected. 3. Resisted test- Resisted knee extension cause pain at the exact site. 4. Palpation- Tenderness is found at the insertion of the tendon into the patella. Patient cues: Supine lying with the knee fully extended and the quadriceps muscle relaxed. Therapist cues: Therapist arrange himself suitably facing the affected knee at the mid-thigh level. Stabilization of the upper pole of the patella (UE towards the head end of the patient): He presses downwards on the upper pole of the patella with the web of his ...

Crossed arm MFR is one of the most important myofascial release practiced today. Possible causes of the crossed arm stretch or bilateral rhomboids stretch leading to radiating pain in non-segmental pattern can be many. The possible explanations are 1. Each vertebra is connected on it’s sides to different muscles. Equal amount of pull keeps vertebral alignment normal. Normal alignment is required for normal functioning of spine during loaded phases. 2. Muscle and fascia are the active and passive tensors respectively. Both are structurally & functionally integrated. Increase in tension of active tensors can lead to increase tension of passive tensors and vice versa. Thus faulty tension transmission can affect function and later on dysfunction & derangement is produced. 3. One region of the spine is connected to the other end of the spine by nuraxis & through musculo-fascial system. Trespassing of the nuraxial system or contracture of the musculo-fascial system at on...

(Patellar distraction technique) It is now universally accepted that patellofemoral malalignment is the main cause of anterior knee pain. The most difficult question to researchers is what is the mechanism whereby patellofemoral malalignment produces pain? Currently, there are two theories one is the neural theory and the other is the mechanical theory. Both theories are not exclusive, but complementary (1). Development of Patella Baja (Infera) after knee trauma leading to altered knee mechanics & anterior knee pain: Patella Baja (Infera): Patella Baja refers to low lying patella in frontal plane as compared to normal. This condition develops following repetitive stress or knee traumas due to patellar tendon adhesion following the said two conditions. Patellar tendon adhesion leads to a decrease in the distance between inferior patellar pole to the tibial tuberosity, effectively creating patella infera. Effect on biomechanics: Patellar changes: 1. medial and distal translation o...

Introduction: Planter heel pain & posterior heel pain: Plantar heel pain is a symptom commonly encountered by clinicians. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain. HPT (heel pain triad): Labib et al described the heel pain triad (HPT). HPT is a combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome. They hypothesized that failure of the static (plantar fascia) and dynamic (posterior tibial tendon) support of the longitudinal arch of the foot has resulted in traction injury to the posterior tibial nerve, i.e., tarsal tunnel syndrome. When such a situation is present then all abnormalities i.e. plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome must be recognized and treated. Classification of ...

Pelvic floor dysfunction is a disorder predominantly affecting females. It is common and undermines the quality of lives of at least one-third of adult women and is a growing component of women's health care needs (2). The reported prevalence rates of pain within the pelvis range from 3.8% to 24% in women aged 15 to 73 years (3). Pelvic floor dysfunction affects women of all ages and is associated with functional problems of the pelvic floor. Pelvic floor dysfunction describes a wide range of clinical problems that rarely occur in isolation (2). Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inherent in achieving and promoting better health care services for women is the need for better collaborative approaches to care(2,3). There is a need to identify and develop comprehensive interdisciplinary, multi-professional strategies that improve the assessment and treatment of pelvic floor dysfun...