Osteoarthritis (OA) or degenerative joint disease (DJD)

• Chronic degenerative joint disease that causes the breakdown of cartilage, the protective tissue that cushions the ends of bones in joints
  • Characterized by articular cartilage with hypertrophy of subchondral bone and joint capsule of weight-bearing joints
  • Most common form of arthritis
  • Most common joints are cervical spine, lumbar spine, hips, knees, and great toe- weight-bearing joints

• Symptoms
  • Slow, progressive with pain, initial episode, and only presents when triggered by specific activity
    • Progressing to chronic with pain present with weight-bearing activities (including ambulation, standing, stair climbing)
  • Swelling in joints
  • Loss of range of motion of joints
  • Bony deformities can occur
• Diagnosis
  • Clinical presentation
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroids
  • Intra-articular injections into the joint space
• Physical therapy management
  • Joint mobility
  • Joint strengthening
  • Aquatic therapy
  • Aerobic/conditioning activities

Rheumatoid conditions

Rheumatoid arthritis (RA)

• Chronic autoimmune disease that causes inflammation and damage to the joints due to the overproduction of antibodies
  • Etiology is unknown, but it is thought to have genetic links
• Disease is characterized by times of exacerbation and remission
• Most common areas are hands, feet, cervical spine

• Symptoms (bilateral, symmetrical)
  • Joint pain, especially in the hands, feet, wrists, and knees
  • Swelling and stiffness in the joints
  • Fatigue
  • Fever
  • Deformities in the joints
• Diagnosis
  • Clinical presentation
  • X-ray imaging
  • Lab values
    • White blood cell count (WBC), erythrocyte sedimentation rate, rheumatoid factor
• Medical management
  • Antirheumatic medications
  • Immunosuppressive agents
  • Corticosteroid medications
• Physical therapy management
  • Management of pain and inflammation (during exacerbation phase)
  • Improve joint mobility and mechanics (during remission phase)
  • Resistance training (only during remission phase; contraindicated in exacerbation phase)

Psoriatic arthritis

• Chronic, inflammatory arthritis that often, but not always, occurs in people with the skin condition psoriasis
  • Autoimmune disorder
• Typically occurring in the axial skeleton and joints of the digits

• Symptoms
  • Joint pain
  • Swelling
  • Stiffness
  • Fatigue
  • Skin psoriasis
  • Changes in fingernails and toenails (discoloration)
  • Inflammation where tendons and ligaments attach to bone
• Diagnosis
  • Clinical presentation
  • Lab tests only to rule out rheumatoid arthritis
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Antirheumatic medications
  • Biological response modifier medications
• Physical therapy management
  • Improve joint mobility and mechanics
  • Joint protection strategies
  • Aquatic therapy
  • Aerobic/conditioning activities

Ankylosing spondylitis

• An autoimmune disease that causes inflammation and stiffness, primarily in the spine, and is notably more common in men. Men typically develop AS in early adulthood. It causes inflammation of the joints (vertebrae) and ligaments in the spine, leading to stiffness, pain, eventual fusion of the bones, and development of osteoporosis

• Symptoms
  • Mid and low back pain
  • Morning stiffness of the spine
  • Kyphotic deformity of the cervical and thoracic spine
  • Decreased lordosis in the lumbar spine
  • Degeneration of peripheral and costovertebral joints
• Diagnosis
  • Clinical presentation
  • Lab tests and bone scans show increased uptake in the anterior vertebrae
    • HLA-B27 antigen
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroid medications
  • Cytotoxic drugs
• Physical therapy management
  • Improve joint mobility and mechanics
  • Emphasis on spinal extension
  • Joint protection strategies
  • Freestyle swimming
  • Aerobic/conditioning activities
  • Activities to maintain respiratory function
  • Avoidance of high-impact sports, resistance activities, and repetitive bending

Gout

• Primary gout is a male genetic disorder in which uric acid changes into crystals and deposits in the peripheral joints

• Secondary gout affects all ages and genders with elevated uric acid in the blood secondary to other disease processes, primarily of the kidneys.

  • Characterized by elevated serum uric acid due to a disorder of purine metabolism

• Typically occurring in the knees and great toes

• Symptoms
  • Sudden onset of severe, intense pain in one or more joints, typically the big toe.
    • Pain may feel like burning, throbbing, or crushing
  • Significant swelling and redness in the affected joint
  • The joint may feel hot to the touch and tender to the slightest touch
• Diagnosis
  • Clinical presentation
  • Lab tests
    • Identify uric acid levels
• Medical management
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Colchicine medications
  • Corticosteroid medications
  • Allopurinol medications
  • COX-2 inhibitor medications
• Physical therapy management
  • Prescription of an assistive device as appropriate
  • Education on diet restrictions limiting consumption of red meats, dairy products, high-fat foods, and medication adherence

Tendonosis/tendopathy

• Tendon dysfunction caused by overuse or repetitive motions that put excessive stress on the tendon
  • Can also be caused by sudden trauma or age-related degeneration

• Symptoms
  • Pain is typically located over the affected tendon, often worse with activity.
  • Swelling present around the tendon.
  • Stiffness at the affected joint.
  • Weakness in the joint
• Diagnosis
  • Clinical presentation
    • Special tests specific to the joint
  • MRI
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
  • Corticosteroid medications
• Physical therapy management
  • Flexibility; joint mobilization
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Bursitis

• Inflammation of bursae due to overuse, trauma, gout, or infection

• Symptoms
  • Pain at rest
  • PROM and AROM presenting an empty end feel limited by pain (no capsular pattern)
  • Swelling of the joint area
  • Redness over the inflamed bursa
  • Warmth to the affected area may feel hot to the touch
  • Tenderness over the affected area when pressed
• Diagnosis
  • Clinical presentation
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy management
  • Flexibility; joint mobilization
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Myofascial pain syndrome

• Chronic pain condition that affects muscles and the tissue that surrounds them. Characterized by trigger points in muscles that cause pain when pressed
  • Can be caused by sudden overload, overstretching, and increased repetition
  • Types of trigger points
    • Active trigger points are tender to palpation and can cause referred pain
    • Latent trigger points are taut bands that can be transitioned to active trigger points

• Symptoms
  • Deep, aching, or throbbing pain that can be localized or widespread.
  • Tender knots in the muscles that cause pain when pressed.
  • Pain that radiates to other areas of the body, such as from the neck to the head or shoulder.
  • Headaches
  • Sleep disturbances
  • Postural changes
• Diagnosis * Clinical presentation
• Medical management
  • Dry needling
  • Corticosteroid injections
  • Analgesic injections
• Physical therapy management
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training
  • Dry needling

Complex regional pain syndrome (CRPS)

• Chronic pain condition characterized by persistent, severe pain; presentation of symptoms is disproportionate to the initial injury, thought to be caused by an abnormal response of the sympathetic nervous system to an injury.
  • Results in dysfunction of the sympathetic nervous system
  • Can be caused by trauma or have an unknown etiology
  • Types of complex pain syndrome
    • CRPS I- tissue injury with no nerve involvement
    • CRPS II- tissue injury with known nerve involvement

• Symptoms
  • Intense, burning, or throbbing pain that is disproportionate to the initial injury
  • Pain that worsens with movement or touch
  • Pain that may spread to other areas of the body
  • Allodynia (pain from normally non-painful stimuli, such as light touch or temperature changes)
  • Hyperalgesia (increased sensitivity to pain)
  • Hypersensitivity to heat and cold
  • Numbness, tingling, or prickling sensation
  • Changes in skin color, temperature, or sweating
  • Swelling
  • Joint stiffness
• Diagnosis
  • Clinical presentation
• Medical management
  • Sympathetic nerve block
  • Spinal cord stimulation
  • Intrathecal drug pumps
  • Antiseizure medications
  • Antidepressants
  • Corticosteroid medications
  • Opioid medications
• Physical therapy management
  • Patient education on diagnosis and prevention of exacerbating activities
  • Desensitization activities for return to normal function
  • Modalities for pain relief, such as TENS, avoid heat and cold therapies.

Muscle strains

• Injury to the muscle or tendon, the fibrous tissue that connects muscles to bones, causing an inflammatory response
  • Typically due to overuse or overstretching caused by forceful movement

• Symptoms
  • Sudden, sharp, or throbbing pain that worsens with movement
  • Inflammation and fluid buildup in the affected area
  • Discoloration of the skin due to blood vessel damage
  • Difficulty or inability to use the injured muscle
  • Restricted movement in the affected area
  • Feeling tight or sore when the muscle is stretched or contracted
  • Involuntary muscle contractions that can cause sudden pain
  • Pain when the injured muscle is touched or pressed
• Diagnosis
  • Clinical presentation
  • MRI, possibly
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy management
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Myositis ossificans

• Abnormal calcification within the muscle belly
  • Can be caused by direct trauma- hematoma causes calcification
  • Frequently located in the quadriceps or biceps

• Symptoms
  • Persistent, localized pain that worsens with activity
  • A firm, palpable lump or mass in the injured muscle
  • Limited range of motion
  • Warmth
  • Redness
• Diagnosis
  • Clinical presentation
  • X-ray imaging
  • CT scan
  • MRI
• Medical management
  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy management
  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Paget’s disease

• Chronic bone disorder characterized by abnormal bone remodeling
  • May be linked to viral infections

• Symptoms
  • Deep, aching pain in the affected bones, often worse at night or with activity.
  • Bowing of the legs or arms
  • Enlargement of the skull or jaw
  • Thickening of the bones in the spine or pelvis
  • Numbness, tingling, or weakness in the arms or legs
  • Headaches
  • Hearing loss
• Diagnosis
  • Clinical presentation
  • X-ray
  • Lab tests
    • Serum alkaline phosphatase and urinary hydroxyproline
• Medical management
  • Acetaminophen
  • Calcitonin
  • Surgery for bone deformities or joint replacements
• Physical therapy management
  • Joint protection strategies
  • Improve joint biomechanics
  • Aerobic capacity/conditioning

Osteoporosis

• ​​Bones become brittle and fragile from loss of tissue due to metabolic changes, resulting in bone mineral density loss
  • Affects women ten times more than men
    • Can be related to menopause (reduction in estrogen)
  • Common sites are the thoracic and lumbar spine, the proximal humerus, the proximal tibia, the pelvis, distal radius

• Symptoms
  • Bone fractures
  • Back pain
  • Loss of height
  • Brittle nails
  • Dental problems
• Diagnosis
  • Clinical presentation
  • CT scan
  • Dexa scan (bone density scan)
    • +1.0 or higher: Normal bone density
    • -1.0 to -2.5: Osteopenia (low bone mass)
    • -2.5 or lower: Osteoporosis (weak bones)
• Medical management
  • Calcium supplement
  • Vitamin D supplement
  • Estrogen - hormone replacement therapy
  • Calcitonin supplement
  • Bisphosphonate supplement
• Physical therapy management
  • Joint protection strategies
  • Improve joint biomechanics
  • Aerobic capacity/conditioning
  • Emphasize weight-bearing activities, such as walking, to help maintain bone density.
  • Aquatic therapy is not effective in maintaining bone density due to buoyancy.

Osteomyelitis

• Inflammation of the bone caused by infection

• Symptoms
  • Pain and tenderness in the affected bone
  • Swelling, redness, and warmth over the infected area
  • Drainage of pus from a wound or abscess
  • Limited range of motion in the affected joint
  • Fever and chills
  • Fatigue
  • Malaise
  • Loss of appetite
  • Weight loss
• Diagnosis
  • Clinical presentation
  • Bone biopsy
  • Lab tests
• Medical management
  • Antibiotics
  • Surgical debridement if necessary
• Physical therapy management
  • Joint protection strategies
  • Improve joint biomechanics

Somatic dysfunction

Somatic dysfunction is an impaired or altered function of the body’s framework, including muscles, joints, and fascia. It is commonly associated with pain, restricted movement, and abnormal tissue texture.

Diagnosed using the TART criteria

• Tissue texture changes
• Asymmetry
• Restriction of motion
• Tenderness

Below is a description of somatic dysfunction within each segment type:

Cervical somatic dysfunction

• Location: Affects the neck (C1-C7).
• Common causes:
  • Poor posture, whiplash, prolonged screen time, stress-related muscle tension.
• Symptoms:
  • Neck pain, stiffness, headaches, dizziness, reduced range of motion, and possible radiating pain to the shoulders or arms.
• Treatment:
  • Soft tissue mobilization, cervical manipulation, stretching, and postural correction exercises.

Thoracic somatic dysfunction

• Location: Affects the mid-back (T1-T12).
• Common causes:
  • Poor posture, kyphotic spine patterns, prolonged sitting, rib dysfunction, and respiratory issues.
• Symptoms:
  • Mid-back stiffness, difficulty taking deep breaths, rib pain, referred pain to the chest or upper back, and limited spinal rotation.
• Treatment:
  • Thoracic mobilization, rib articulation techniques, breathing exercises, and spinal extension exercises.

Lumbar somatic dysfunction

• Location: Affects the lower back (L1-L5).
• Common causes:
  • Heavy lifting, poor body mechanics, prolonged sitting, muscle imbalances, disc pathology.
• Symptoms:
  • Lower back pain, stiffness, restricted forward bending, muscle spasms, pain radiating to the hips or legs, and possible sciatic nerve involvement.
• Treatment:
  • Lumbar manipulation, core strengthening, stretching, and movement retraining.