Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Idiopathic neck pain Download Section PDF Listen +++ Condition/Disorder Synonyms ++ Simple neck painNeck sprain/strainMechanical neck pain +++ ICD-9-CM Code ++ 729.1 Myalgia and myositis unspecified +++ ICD-10-CM Codes ++ M60.9 Myositis, unspecified M79.1 Myalgia +++ Preferred Practice Pattern ++ 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Connective Tissue Dysfunction1 +++ Key Features +++ Description ++ Neck pain from unknown causeNo underlying disease or specific disorderUsually acute Chronic, persistent, deep aching pains in muscle, non-articular in originUsually caused by sudden overload, overstretching, repetitive/sustained muscle activitiesPain associated with activities, generally relieved with restCan be in localized area affecting any muscle or fascia +++ Essentials of Diagnosis ++ Diagnosis made by clinical examination (generally palpation) with no medical diagnostic tests availableDifferentiated from fibromyalgia, as it can occur in a single area; fibromyalgia occurs in multiple locations, has specific tender points +++ General Considerations ++ Very common, affects most people in their lifetimesLatent trigger points are palpable, taut bands not tender to palpation, but may be converted into active trigger point +++ Demographics ++ In the US, 14.4% of general population suffers from chronic musculoskeletal pain421-93% of patients reporting regional pain have myofascial pain225-54% of asymptomatic individuals have latent trigger points2No racial differences in incidence of myofascial pain have been describedMyofascial pain affects men and women equallyLikelihood of developing active trigger points increases with age and activity levelSedentary individuals more prone to developing active trigger points than individuals who exercise vigorously on a daily basis +++ Clinical Findings +++ Signs and Symptoms ++ Muscle stiffnessHeadachesVertigoParesthesiasReferred painJoint stiffnessLimited range of motion (ROM)Acute painPain with palpation of the trigger pointDifficulty sleepingWeakness without atrophy may be seen when performing manual muscle testing +++ Functional Implications ++ Pain with standing, ambulation, ADLsLimited range of motionWeakness +++ Possible Contributing Causes ++ Improper postureEmotional/psychological stressAnxietyBehaviorTraumatic eventsImproper lifting, poor biomechanicsLack of activity, immobility (cast)Repetitive stressOverusePoor muscular or ligamentous supportObesityInflammatory conditions affecting ligaments, muscles, tendons +++ Differential Diagnosis ++ Herniated discFibromyalgiaRheumatoid arthritisComplex regional pain syndromeRadiculopathyLigamentous sprainMuscle strainPeripheral nerve impairmentThoracic outlet syndromeShoulder pathology with radiating pain patternSpinal tumorCarpal tunnel syndromeDegenerative disk diseaseArnold Chiari malformation +++ Means of Confirmation or Diagnosis +++ Imaging ++ Imaging not usually needed with non-specific neck pain unless warranted for differential diagnosisMRI helps to visualize compressed or inflamed nerve root in diagnosisX-ray/plain-film radiograph helpful if osteophyte located in intervertebral foramenCT to show herniation compressing the spinal canal/nerves6Electrodiagnostic/nerve conduction testing can help to determine specific impaired nerve function +++ Diagnostic Procedures ++ Palpation +++ Findings and Interpretation ++ Taut, fibrous band felt with palpation of the muscleLimited range of motion may be common findingPhysical examination cluster to rule in cervical radiculopathySpurling’s testRotation limited to ipsilateral sideUpper limb nerve tension testDiminished brachioradialis reflex +++ Referrals/Admittance ++ To psychologist for psychological counseling if appropriateTo dietitian to address obesity if appropriateTo massage therapist +++ Impairments ++ PainLimited function due reduced ROMMobilitySelf-careRole at home, school, work, in communityRecreation, leisure, sports +++ Intervention ++ Soft-tissue massage and joint oscillations to reduce pain or muscle guardingAddress biomechanical factors: improper posture, ergonomics, body mechanics during work and leisure Spray and stretch techniqueCryotherapy In acute cases within 24-72 hours of injury to alleviate pain, reduce inflammationCaution must be used; risk of decreasing flexibility or re-injuryThermotherapy: hot packs or whirlpool after initial inflammation subsides to increase circulation and relaxationHydrotherapyUltrasound to minimize scarring, stimulate tissue healing, increase circulation to the area, relax musculatureElectric stimulationMicrocurrent when inflammation is present and very acuteStimulates healing, decreases inflammationBiphasic/Russian when inflammation not acute, fatigue muscle to minimize contractures, re-educate muscleTranscutaneous electrical nerve stimulation (TENS) for symptomatic relief of painDesensitization of trigger point with manual pressureImplementation of strength, power, endurance exercisesRisk of decreasing flexibility and reinjuiryProgress from active-assistive to active to resistive exercises, then task-specific performance trainingPosture educationSitting: select appropriate ergonomic chair with low-back supportStanding: postureFunctional: proper body mechanicsMassageSlow, light percussion to increase circulation, flush lactic acid out of muscle tissuesEffleurage to relax musclesDeep-tissue when desensitizing trigger pointsJoint mobilizations to eliminate bony restrictions +++ Functional Goals ++ Patient will be able to sit with neutral cervical and thoracic spine posture for greater than 30 minutes with 0 out of 10 pain ratingPatient will be able to sit at work station and perform computer work for 45 minutes with 0 out of 10 pain ratingPatient will be able to rotate cervical spine 70 degrees so as to talk on the telephone with 0 out of 10 pain rating in neck/armDecrease inflammation to enable repetitive movementIncrease circulation to decrease inflammation and improve healing responseEducate patient on proper body mechanics, work area ergonomics, relaxation techniques +++ Prognosis ++ Very good, though may take several months to eliminate trigger pointsPain may recur if biomechanical causes not addressed +++ References ++1. The American Physical Therapy Association. Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction. Interactive Guide to Physical Therapist Practice 2003. DOI: 10.2522/ptguide.3.1_4. Accessed March 1, 2012. ++2. Eustice C. What Is Myofascial Pain? About.com Arthritis and Joint Conditions. http://arthritis.about.com/od/diseasesandconditions/a/myofascial_pain.htm Accessed October 20, 2011. +++ Additional Resources ++Draper DO, Prentice WE. Chapter 10. Therapeutic Ultrasound. In: Prentice WE, Quillen WS, Underwood F, eds. Therapeutic Modalities in Rehabilitation, 4e. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/8138751. Accessed March 11, 2012. ++Dutton M. Dutton's Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/685. Accessed March 11, 2012. ++Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/612. Accessed March 11, 2012. ++Goodman CC, Fuller KS. Pathology Implications for the Physical Therapist (3rd ed.). St. Louis, MO: Saunders Elsevier; 2009. ++Hall SJ. Basic Biomechanics, 4e. New York: McGraw-Hill; 2007. http://www.accessphysiotherapy.com/abstract/6060836#6060838. Accessed March 11, 2012. ++Hooker DN, Prentice WE. Chapter 5. Basic Principles of Electricity and Electrical Stimulating Currents. In: Prentice WE, Quillen WS, Underwood F, eds. Therapeutic Modalities in Rehabilitation, 4e. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed March 11, 2012. ++ICD10DATA web site. http://www.icd10data.com/Search.aspx?search=arnold+chiari+malformation&codebook=AllCodes. Accessed March 6, 2012. ++ICD9DATA web site. http://www.icd9data.com/. Accessed March 6, 2012. ++Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques (5 ed.). Philadelphia, PA: F.A. Davis Company; 2007. ++Malone DJ, Lindsay KB. Physical Therapy in Acute Care A Clinician's Guide. Thorofare, NJ: SLACK Incorporated; 2006. ++Malone TR, Hazle C, Grey ML. Imaging in Rehabilitation. New York: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/613. Accessed March 11, 2012. ++Martini FH, Timmons MJ, Tallitsch RB. Human Anatomy. San Francisco, CA: Pearson Education, Inc; 2009. ++Prentice WE. Chapter 16. Therapeutic Massage. In: Prentice WE, Quillen WS, Underwood F, eds. Therapeutic Modalities in Rehabilitation, 4e. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/8140838#8140936. Accessed March 11, 2012. ++Simons D, Travell J, Simons P. Travell & Simons’ Myofascial Pain & Dysfunction: the trigger point manual. Baltimore, MD: Williams & Wilkins; 1999. ++Soep JB. Chapter 27. Rheumatic Diseases. In: Hay W, Levin MJ, Sondheimer JM, Detering RR. CURRENT Diagnosis & Treatment: Pediatrics. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/6586584#6586588. Accessed March 1, 2012. ++Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52-62. [PubMed: 12544957] + Iliotibial band friction syndrome Download Section PDF Listen +++ Condition/Disorder Synonyms ++ Runner’s knee1Tensor fascia latae syndrome (TFLS)Iliotibial band friction syndrome (ITBFS) +++ ICD-9-CM Code ++ 728.89 Other disorders of muscle ligament and fascia +++ ICD-10-CM Code ++ M62.89 Other specified disorders of muscle +++ Preferred Practice Pattern ++ 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Connective Tissue Dysfunction2 +++ Key Features +++ Description ++ Repetitive stress injury due to friction between the IT band and lateral femoral condyle, occurring at approximately 30 degrees of knee flexionAcute inflammatory processUsually with genu varum and pronated feetFrequently develops in people with inadequate warm-up or stretching program before exerciseInflammation begins at IT band’s insertion and where friction develops between the IT band and lateral femoral condyle1Chronic inflammatory processBursitis that develops deep within the IT band as it crosses the lateral femoral condyleAssociated with leg-length discrepancies, tensor fascia latae contractures, excessive pronation, tight heel cords3 +++ Essentials of Diagnosis ++ Diagnosis usually made by clinical examinationHistory of poor training techniques1Progression of symptoms often associated with changes in training practice (e.g., increased running mileage or change in training surfaces, especially downhill running1)Pain from ITBFS so severe that activity must be discontinued +++ General Considerations ++ Most common overuse injury of the knee, especially in long-distance runnersThough most common in runners, may occur with any activity requiring constant knee flexion and extension1 +++ Demographics ++ Men and women equally affectedDistance runners, exacerbated with downhill runningCyclistsRepetitive knee flexion, extensionTraining on uneven terrain or graded slopesChange in Q-angle as a result of leg-length discrepancy +++ Clinical Findings +++ Signs and Symptoms ++ Pain along lateral aspect of knee, especially with repetitive knee motionPain may be diffuse and general at onset, becoming more specific and intense as ITBFS progresses Specific pain localized approximately 2cm above joint line over the lateral femoral condyle with knee flexed 30 degreesPain will radiate to lateral joint line and distally to proximal tibia1Pain typically begins after completion of activity, but may occur during activity or periods of rest as condition progresses4Crepitus upon palpation over lateral condyleSpecific swelling over lateral condyleIncreased pain after long periods of sitting +++ Functional Implications ++ Pain with running (especially on downhill terrain) and cyclingPain with walking and other activities that elicit knee flexion, especially as the condition persistsPain with sitting for prolong periods +++ Possible Contributing Causes ++ Biomechanical abnormalitiesLeg-length discrepanciesTensor fasciae latae contractureGluteus maximus contracturesHamstring and guadriceps tightnessGenu varumExcessive pronation leading to increased tibial torsionTight heel cordsHip abductor/multifidus weaknessPes cavusSudden change in training regimenPoor running or training techniquesIn cyclists, excessive bike-seat height or internal rotation of foot on the pedal +++ Differential Diagnosis ++ Biceps femoris tendinopathyDegenerative joint diseaseLateral collateral ligament sprainLateral meniscal tearMyofascial painPatellofemoral stress syndromePopliteal tendinopathyReferred pain from lumbar spineStress fractureSuperior tibiofibular joint sprain +++ Means of Confirmation or Diagnosis +++ Imaging ++ X-ray to rule out stress fractureDiagnostic ultrasound of IT band for fluid detection at insertion and pain siteMRI to demonstrate thickened IT band over lateral femoral condyles; will frequently detect a fluid collection +++ Findings and Interpretation ++ Increased pain when gait stride is lengthenedDevelopment of bursitis due to friction between IT band and lateral femoral condyle +++ Referrals/Admittance ++ To hospital for imaging, x-ray, MRITo physician for medicationAnti-inflammatoryCorticosteroid injectionTo surgeon for consult +++ Impairments ++ Antalgic gait secondary to gluteus-medius weakness, which increases thigh adduction and internal rotation of the leg at mid-stanceAntalgic gait secondary to increased knee pain with 30 degrees of knee flexionInability to sit for long periodsInability to run on a downhill gradeTrochanteric bursitis secondary to altered gaitLimitations in recreation, leisure, sports +++ Tests and Measures ++ Orthopedic tests considered positive if elicit pain or crepitus is feltOber’s testNoble compression testCreak test +++ Intervention ++ Rest, activity modification, address contributing factorsFor example, decrease running mileage, replace running shoes, change bike-seat position Avoid repetitive knee flexion/extension exercises initiallyInitial goal of alleviating inflammation Orthotics may reduce pronationAddress biomechanical factors contributing to the problemSurgical release of the posterior 2 cm of the IT band as it passes over the lateral epicondyle of the femurAddress swellingIceRest MassageUltrasoundOral anti-inflammatoryAddress painIceMassageIT band massage with foam rollerTransverse friction massage to increase responseElectrical stimulationUltrasoundAddress weakness, joint instabilityStrengtheningFour-way hip, straight-leg raisesGluteus mediusOther hip adductorsQuadriceps settingAddress lack of flexibilityStretching5Tensor fascia lataeIliopsoasHeel cordsAddress mobilizationPatellar mobilizationMedial glideMedial tipping of the patella with friction massage along lateral border6 +++ Functional Goals ++ Patient will be able to Initiate pain-free closed kinetic chain (CKC) exercises progressed through all planes of motion to be able to climb stairsPerform singe-leg mini squat on balance disc for 30 secondsMove pain-free through 30 degrees of knee flexion for pain-free sit-to-standResume prior exercise routine pain-free +++ Prognosis ++ Very good: most patients improve within 3-6 weeks with use of proper modalities, rehabilitative exercise, and activity modifications Surgical intervention should be considered for individuals who do not see improvement5 +++ References ++1. Prentice WE. Chapter 20. The Knee and Related Structures. In: Prentice W.E. Principles of Athletic Training: A Competency Based Approach, 14e. New York, NY: McGraw-Hill; 2010. ++2. The American Physical Therapy Association. Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction. Interactive Guide to Physical Therapist Practice 2003. DOI: 10.2522/ptguide.3.1_4. Accessed May 18, 2012. ++3. Hamilton N, Weimar W, Luttgens K. Kinesiology: Scientific Basis of Human Motion. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/618. Accessed May 18, 2012. ++4. Khaund RM, Flynn SH. Iliotibial band syndrome: A common source of knee pain. Am Fam Physician. 2005;71(8):1545-50. [PubMed: 15864895] ++5. Padua DA, Boling MC, Prentice WE. Chapter 21. Rehabilitation of Knee Injuries. In: Prentice W.E. Rehabilitation Techniques for Sports Medicine and Athletic Training, 5e. New York: McGraw-Hill; 2011. ++6. Kisner C, Colby L. Chapter 21. The Knee. In: Kisner C, Colby L. Therapeutic Exercises: Foundations and Techniques, 5e. Philadelphia, PA: F.A. Davis Company; 2007. +++ Additional Resources ++2012 ICD-10-CM. http://www.icd10data.com. Accessed May 18, 2012. ++2012 ICD-9-CM. http://www.icd9data.com. Accessed May 18, 2012. ++Anatomy and Physiology Revealed. McGraw-Hill. 2007. http://anatomy.mcgraw-hill.com/apt.html?login=1319025349139&system=Skeletal§ion=Dissection&topic=Femur&topicAbbr=Feb&view=Anterior%20and%20posterior&viewAbbr=Apo&catAbbr=Ske&grpAbbr=Fef&structure=Lateral%20condyle%20of%20femur. Accessed May 18, 2012. ++Draper DO, Prentice WE. Chapter 10. Therapeutic Ultrasound. In: Prentice WE, Quelled WS, Underwood F, eds. Therapeutic Modalities in Rehabilitation, 4e. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/8138751. Accessed May 18, 2012. ++Dutton M. Dutton's Orthopedic Survival Guide: Managing Common Conditions. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/612. Accessed May 18, 2012. ++Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/612. Accessed May 18, 2012. ++Polousky JD. Chapter 24. Orthopedics. In: Hay W, Levin MJ, Sondheimer JM, Detering RR. CURRENT Diagnosis & Treatment: Pediatrics. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/6585905#6585905. Accessed May 18, 2012. ++Prentice WE. Chapter 9. Cryotherapy and Thermotherapy. In: Prentice WE, Quillen WS, Underwood F, eds. Therapeutic Modalities in Rehabilitation, 4e. New York: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137995#8137995. Accessed May 19, 2012.