thoughts on a case

[indytravl]

any thought on the following pt?

58 yom had CVA ~20y ago with L hemiparesis. uses SC & AFO. complains of L shoulder pain (has some subluxation), L knee pain (has genu recurvatum), & R elbow pain. He localizes distinctly to the elbow & there is a little bursitis. However he has full & painless ROM at the elbow but painful & limited active & passive abduction & flexion at the R shoulder (less than 90 degrees). external & internal rotation aren't painful and he denies any shoulder pain on palpation.

ideas?

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[Disciple]

The right shoulder pain may not have been apparent to the patient until you examined his shoulder.

Rotator Cuff Tendonitis(not-uncommon given his age)/Sub-acromial bursitis and adhesive capsulitis are two possibilities.

 

[indytravl]

yep, agree with the shoulder differential...was kind of looking for help on the elbow pain complaint. do you have ideas for that?
thank you

 

[indytravl]

sorry, forgot to include that stroke-affected side is L & uses cane on R. it's the right elbow that he's complainig aobut

 

[Disciple]

So you're convinced the pain is not due to the bursitis?

You may want to check for medial or lateral epicondylitis. Patients will sometimes localize the pain to "the elbow".

Also, check the insertion of the biceps tendon on the radius. Check the distal triceps as well. If the patient is leaning on a cane for support, then his triceps is under constant tension.

Barring trauma, medial/lateral collateral ligamentous injury or osteochondral injury are unlikely.

 

[indytravl]

triceps tendonitis seems likely. he's doing a little better on nsaid's. any other suggestions on activity modification? use of the cane is unavoidable in his situation. a strap around the triceps is a thought; where is it located/how is it positioned?

different stroke case. another relatively young guy also with foot drop, just fitted with an afo. now complains of excessive external rotation of the limb at hip on ambulation. I know that pediatric cases use a KAFO with straps to help with this. never actually seen one & would appreciate your thoughts on correction of this.

thanks

 

[SSdoc33]

KAFO with straps would be bulky and tedious and probably wouldnt be used. fix any alignment issues with the AFO (esp. pes planus) and strech hip esternal rotators while strengthening internal rotators.

 

[indytravl]

ok, thanks. stretching to avoid tight ext rotators pulling the hip around & strengthening int rotators to counter that tendency makes sense. correcting any pes planus? thinking it causes excessive supination leading to the hip ext rotation? how would that be corrected with the afo?

couple of other msk cases seeing later...

one of them is "spiral fracture of left tibia and left fibular fracture. surgical repair several years ago but has become more unstable". they're requesting a brace. if appropriate, would you use a hinged knee brace over a neoprene sleeve? what is a good resource for the differnet braces out there & what's appropriate for what?

the other one is "avulsion injury to ACL". shouldnt that be an ortho referral for repair & THEN rehab?

thank you

 

[SSdoc33]

pes planus cause internal rotation on the tibia, and external rotation of the hip. correcting this problem will decrease the hip ER. the AFO can be custom molded to support the arch.

 

[indytravl]

got it, thanks. what's a good source for similar clear biomechanics like you've just explained?