CASE PRESENTATION ON

RI TI S
A RT H
I A T IC
PS O R
&

JU R Y
I N
MCL
 PSORIATIC ARTHRITIS
 DEFINITION :
 Psoriatic arthritis is a
chronic disease characterized by an
inflammation of the skin(psoriasis) and
joints(arthritis).


 PSORIASIS is a common skin condition

affecting 2% of the caucasian
population in US, characterized by
patchy, raised, red areas of the skin
inflammation with scaling.
:Commonly affected areas and joints
 Background
 In 1964, the American Rheumatism
Association listed psoriatic arthritis as a
clinical entity.
 The high frequency of distal joint
involvement in psoriatic arthritis compared
with rheumatoid arthritis (RA) and arthritis
mutilans (as an unusual but characteristic
manifestation) has received special
attention.
 Psoriatic arthritis, a term used by the
American Rheumatism Association, is
widely accepted.
 Pathophysiology:
 Psoriatic arthritis is an autoimmune disease
with known human leukocyte antigen
(HLA)–associated risk factors.
 Psoriatic arthritis affects the ligaments,
tendons, fascia, and joints, and it
occasionally develops in the absence of
detectable psoriasis.
 Psoriatic arthritis may occur at higher
frequencies when skin involvement is
more severe, especially when pustular
psoriasis is present.
Race: Psoriatic arthritis is more common in white
persons than in persons of other races.

Sex: Men and women are affected equally;

however, if the subsets of psoriatic arthritis are
considered, male predominance occurs in the
spondylitic form, whereas female predominance
occurs in the rheumatoid form.

Age: Psoriatic arthritis characteristically develops

in persons aged 35-55 years, but it can occur in
persons of almost any age.
 What Causes Psoriatic Arthritis


 It
is not yet known what causes
psoriatic arthritis.
 However, hereditary factors,
environmental factors and
immunological factors play a role.
 Common sites
affected:

 Often affects the tips of the elbows, knees,

the scalp, the navel, and around the
genital areas or anus.
 Approx. 10% of the patients who have
psoriasis also develop and associated
inflammation of their joints.
oPsoriatic arthritis is systemic rheumatic disease that
can also cause inflammation in body tissues away from
the joints other than the skin such as in the eyes, heart,
lungs and kidneys.
 The following list details the 5 patterns of
psoriatic arthritis involvement:


Asymmetrical oligoarticular arthritis

Symmetrical polyarthritis
DIP arthropathy
Arthritis mutilans
Spondylitis with or without sacroiliitis.


 SIGNS AND SYMPTOMS
 In most patients, psoriasis preceds
the arthritis by months to years.

 Usually a few joints are inflamed at
a time.

 The inflamed joints become painful,
swollen, hot and red.

 Sometimes the swelling of entire digit gives the appearance of
sausage.

Nail lesion is another sign of psoriatic arthritis.

Joint stiffness is common,worse in early morning.

Inflammation of tendons and cartilage.

Pitting and ridges are seen in finger and toe nails.

 CASPAR
A large international study group recently
developed a simple and highly specific
classification known as CASPAR
(classification criteria for psoriatic
arthritis).



 The CASPAR criteria consist of established

inflammatory articular disease with at
least 3 points from the following features:


› Current psoriasis (assigned a score of 2)

› A history of psoriasis (in the absence of
current psoriasis; assigned a score of 1)
› A family history of psoriasis (in the absence of
current psoriasis and history of psoriasis;
assigned a score of 1)
› Dactylitis (assigned a score of 1)
› Juxtaarticular new-bone formation (assigned a
score of 1)
› Rheumatoid factor negativity (assigned a
score of 1)
› Nail dystrophy (assigned a score of 1)
DIAGNOSIS:

ØSkin and nail changes characteristic of psoriasis with

accompanying arthritic symptoms are hallmark of disease.

ØRheumatoid factor test is negative in all cases of psoriatic

arthritis.

ØX-ray may show characteristic damage to the larger joints

on either side of the body as well as fusion of the joints at the
ends of the fingers and toes.
Ø
ØMRI
ØCT SCAN
ØBIOPSY
DIFFRENTIAL DIAGNOSIS:

ANKYLOSING RHEUMATOID
SPONDYLITIS ARTHRITIS

GOUT REITER’S SYNDROME

OSTEOARTHRITIS SEPTIC ARTHRITIS

 TREATMENT
 NSAIDS
 Gold – inj.solganol, oral.auranofim
 Sulfasalazine
 Etretinate – Vit A derivative
 Ultraviolet light therapy

 Alternative treatment-
 # Homeopathy
 # Acupuncture
 # Chinese herbal medicines
 # western herbal medicines
 # Nutritional supplements
 # Physiotherapy
PROGNOSIS:
The following factors influence the degree of severity:
ØClinical subset (eg, arthritis mutilans, symmetric
polyarthritis)
Ø
ØEarly age of onset
Ø
ØSeverity of skin involvement
Ø
ØFamily history of arthritis
Ø
ØHLA marker: Patients with HLA-B39 and HLA-B27 in the
presence of HLA-DR7 are more likely to experience
disease progression, while those with HLA-B22 or HLA-
DQw3 in the presence of HLA-DR7 may be protected from
disease progression.
Ø
ØESR of greater than 15 mm/h.
 ASSESSMENT OF THE PATIENT

§Name of the Patient : Aman Chand

§Age : 27 years
§Sex : Male
§Address : Adarsh nagar, Amritsar
§Occupation : Student
§Date of assessment : 23-10-07
§Chief complaint : Pain in all joints of upper
and lower extremities
: Stiffness in all joints of
upper and lower extremities
:Difficulty in walking.
HOPI:
Patient was apparently normal 3 years back when he felt swelling in his
right feet. He took medication from a local healer for 3 months and got
temporary relief. He stopped medicine for two days and felt joint pain in
whole body. Pain was so severe that he became bed ridden within a
week. After one month he observed red pustules around the chest and it
gradually spread to whole body. Because of these problems he was
unable to do his daily functional activities. Further he had consulted in
jaipur and diagnosed with psoriasis. He continued taking medication for
one year but did not got satisfactory relief. After coming back to amritsar
he consulted to an ayurvedicpractitioner and taken herbal medicines for
the same problem. His skin condition improved but later he developed
arthritis and contractures mostly in hands and feet. Since one and half
months he is coming to health center for further treatment of the same.
PAIN ASSESSMENT:

Type- Dull aching

Nature- Intermittent

Provocative factors- Walking, other functional activities.

Palliative factor- Rest

Severity- On VAS scale

1 4 10
Past History: No h/o DM/HT/IHD

Past medical history: He tried different types of medication for 2-3

years. His problem started as a skin allergy when he had taken drugs
from the local healer.
No history of any other associated condition.

Personal history: No h/o of any addiction. Sleep, appetite, bowel and

bladder habits are normal.

Family history : Not significant

Socio-economic history : good

ON OBSERVATION:

Attitude : Upper limb- shoulder- protracted ( B/L)

- elbow- slightly flexed(B/L)
- wrist- ulnar deviation(B/L)
- finger – MCP & PIP flexion and ulnar
deviation(B/L)

: Lower limb – Hip- slightly flexed(B/L)

- Knee- slightly flexed(B/L)
- Ankle- slight plantar flexion(B/L)
- Toes- flexed(B/L)

DEFORMITY: Flexion deformity- Elbow, Wrist and Knee(B/L)

Varus &Pes planus – feet(B/L)
Skin changes: Scaly, dry and rough skin
: Nails are separated from nail bed.
: Black patches are seen around both the legs.

PALPATION: Temperature: slightly raised on dorsal aspect of hands

and feet.
: Tenderness- around the wrist joint( Grade 1)
: No obvious swelling is seen.

ON EXAMINATION:
SHOULDER RIGHT LEFT
1. RANGE OF MOTION:
Flexion 0-170⁰ 0-170⁰
Extension 0-20⁰ 0-20⁰
Abduction 0-100⁰ 0-100⁰
Lateral rotation painful Painful
Medial rotation 0-60⁰ 0-60⁰
ELBOW RIGHT LEFT

Flexion 10-135⁰ 10-135⁰

extension 135-10⁰ 135-10⁰

Supination Not possible Not possible

Pronation 0-80⁰ 0-80⁰

WRIST

Flexion 0-65⁰ 0-65⁰

Extension Not possible Not possible

Ulnar deviation 0-7⁰ 0-7⁰

Radial deviation Not possible Not possible

FINGERS RIGHT(⁰) LEFT(⁰)
MCP Flexion 30-80 30-90
Extension Not possible Not possible
PIP Flexion 25-90 25-100
Extension --------- -------
DIP Flexion 0-55 0-60
Extension ------- ------

THUMB
CMC Abduction 0-30 0-40
Flexion 0-10 0- 15
Extension -------- -------
MCP Flexion 0-15 0-20
Extension ------- -------
IP Flexion 0-70 0-70
Extension 0-10 0-10
LOWER LIMB:

RIGHT(⁰) LEFT(⁰)
HIP FROM FROM
KNEE
Flexion 10-120 10-125
Extension 120-10 125-10
ANKLE
Dorsi flexion 0-10 0-10
Plantar flexion 0-30 0- 30
Inversion 0-30 0-20
Eversion ------ ------
 MANUAL MUSCLE TESTING:

SHOULDER RIGHT LEFT HIP RIGHT LEFT

Flexors 4 4
Flexors 3+ 3+ Extensors 4 4
Extensors 3+ 3+ Abductors 4 4
Abductors 3 3 Adductors 4 4
Adductors 4 4 KNEE

ELBOW Flexors 4 4
Extensors 4 4
Flexors 4 4
ANKLE
Extensors 4 4
Dorsi flexors 3+ 3+
WRIST
Plantar 3+ 3+
Long flexors 3 3 flexion
Everters ------ ------
Long ------
extensors ------- Invertors -------- -------
GAIT ASSESSMENT: Antalgic

: Heel strike absent

: Stride length reduced

: short steps

: unable to walk 100 m constantly due to pain

and fatigue.

FUNCTIONAL ASSESSMENT : On FIMs scale 6

: Independent in all ADLs except

travelling
Investigations: Biochemical tests: CBC
: ESR
: Rh- factor
; urine analysis
X-ray
Biopsy of skin,muscle and tendon
Synovial fluid analysis
Genetic tests
PHYSIOTHERAPY MANAGEMENT

 Rest should be suggested till the

inflammatory changes subside.
 Paraffin wax bath
 Gentle mobilization of affected joints
and general mobility exercises.
 Splinting for prevention of deformities.
 Stretching exercises within limit.
 Home exercise program.
 SELF CARE :
 Maintain a healthy weight.
 Exercise regularly
 Use hot and cold packs
 Use of proper body mechanics
 Pace your self.


 PSYCHOLOGICAL COUNCELLING :
 Learn as much as you can about
psoriatic arthritis.
 Learn to manage stress.
 Maintain a long support system.
Medial Collateral Ligament
Strain (MCL Strain)
 Anatomy
 Ligaments are tough bands of
tissue that connect the ends
of bones together. The
collateral ligaments, located
on either side of the knee,
limit side to side motion of the
knee.
 The medial collateral ligament
(MCL) is found on the side of
the knee closest to the other
knee.
 MCL attaches above the joint
line of the knee on the medial
epicondyle of the femur and
 If an injury causes these
ligaments to stretch too
far, they may tear. The
tear may occur in the
middle of the ligament,
or where the collateral
ligament attaches to
the bone.

 If the valgus and external
rotation force from the
injury is great enough,
MCL may also be torn.

BIOMECHANICS OF THE KNEE
Axes of motion:

JOINT AXIS MOTION CLOSE-PACKED

tibio-femoral lateral flexion/extensio extension

longitudinal n
tibial rotation

patello-femoral
TIBIO-FEMORAL ARTHROKINEMATICS
Viewed in the sagittal plane, the femur's articulating surface is convex
while the tibia's in concave. We can predict arthrokinematics based on
the rules of concavity and convexity:
DURING KNEE EXTENSION DURING KNEE FLEXION

OPEN CHAIN CLOSED CHAIN OPEN CHAIN CLOSED CHAIN

TIBIA GLIDES FEMUR GLIDES TIBIA GLIDES FEMUR GLIDES

ANTERIORLY ON POSTERIORLY ON POSTERIORLY ON ANTERIORLY ON
FEMUR TIBIA FEMUR TIBIA

from 20o knee flexion to full extension from full knee extension to 20o flexion

Tibia rotates externallyFemur rotates Tibia rotates internallyFemur rotates

internally on stable externally on stable
tibia tibia
 CAUSES AND MECHANISM OF
INJURY
 The collateral ligaments can be torn in
sporting activities, such as skiing or
football. This usually occurs when the
lower leg is forced laterally.
 A blow to the outside of the knee while the
foot is planted can stress the MCL and
result in a tear of the ligament.

 Slipping on ice can cause the foot to move
outward, taking the lower leg with it. The
body weight pushing down causes an
awkward and unnatural force on the whole
leg.
 As a result, the MCL may be torn because
the force hinges the knee open, putting
stress on the MCL. MCL injuries also
sometimes happen in combination with
ACL tears.
 Older children are more likely to injure their
MCL than children who are younger than
age 12. Younger children more often break
the bone where the ligament attaches.
 The tearing of the lateral and
medial collateral ligaments
can be classified in three
categories:

 Grade I sprain: Ligament
stretch, pain along ligament.

 Grade II sprain: Partial tear,
mildly decreased stability .

 Grade III sprain: Complete
tear, significantly abnormal
stability
 SIGNS AND SYMPTOMES
 GRADE I : Local stiffness and/or point
tenderness along the medial aspect of the
joint line, but even during minor stiffness,
range of motion is still full.
 GRADE II : There is usually little instability,
 Swelling will be minimal unless the meniscus
or ACL has been torn. Moderate to severe joint
tightness
 GRADE III : Complete tear include a complete
loss of medial stability, minimum to moderate
swelling, immediate and severe pain followed
by a dull ache, severe loss of range of motion
due to effusion, and positive stress tests.
 Basic palpation and stress
testing of the knee
 INITIAL PHYSICAL EXAMINATION
 --Palpate for fluid on the knee, soft-tissue
swelling, and swelling in the joint.
 --Palpate all around the knee: the quadriceps
muscle and tendon, patellar tendon, hamstring
muscle and tendon, gastrocnemius muscle and
tendon, and collateral ligaments.
 -- Assess each muscle group from hip to foot
against gentle resistance.
 --Assess range of motion (ROM) of the hip joint.
 --Palpate all the way around joint line for
tenderness.
 -- Assess ROM of knee joint.
 SPECIFIC TESTS
 1. Böhler test
 With knee at 20 to 30 degrees
of flexion, apply valgus stress to
assess the integrity of the
medial collateral ligament
(MCL). Feel for laxity (gaping or
rocking), and note whether the
maneuver reproduces the pain.

 2 . Apley's Distraction
test :
 Apley’s Ditraction test
that flexes, internally rotates
the knee with distraction by
grasping ankle; aggrevates
pain at medial joint line.


3 . Valgus Challenge :
 Strain is applied to forleg
to stress the MCL. Laxity of
joint is noted.

  DIFFERENTIAL
DIAGNOSIS
DIAGNOSIS
 MRI > MRI is indicated for  Meniscal injury
imaging soft tissue.
 Pes anserine lesion

 Osteoarthritis

 Bone tumour

 Avulsion fracture
  Bursitis



 STRESS X-RAY
 PLAIN X-RAY > may be
required to rule out the
possibility that any
 TREATMENT
 Non-surgical Treatment :  Surgical Treatment :
 Initial treatments for a
collateral ligament injury
focus on decreasing pain
and swelling in the knee.
Rest and anti-inflammatory
medications, such as
aspirin, can help decrease
these symptoms.
 Physical therapy treatment
for swelling and pain
with the use of ice,
electrical stimulation,
and rest periods with
your leg supported in
elevation.
 Use of a functional brace
for athletes who intend
to return quickly to their
sport
 Chronic swelling or
instability caused by a
collateral ligament injury
may require a surgical
reconstruction.
 A reconstruction
operation usually
works by either
tightening up the
loose ligaments or
replacing the loose
ligament with a
tendon graft.

 REHABILITATION
 Minor sprains of either the MCL
should heal within four to six
weeks. Moderate tears should
rehabilitate within two months
and severe MCL tears require up
to three months.
 After a ligament repair, patient is
instructed to put little or no
weight on their foot when
standing or walking for up to six
weeks. Weight bearing may be
restricted for up to twelve weeks
 The first few physical therapy treatments are
designed to help control the pain and
swelling from the surgery.
 The goal is to regain full knee motion as
soon as possible.
 As the rehabilitation program evolves, more
challenging exercises are chosen to safely
advance the knee's strength and function.
Ideally, you will be able to resume their
previous lifestyle activities.
 When patients are well underway, regular
visits to the therapist's office will end. The
therapist will continue to be a resource,
but you will be in charge of doing your
exercises as part of an ongoing home
program.
 Case Study: MCL
reconstruction
 Name of the Patient : Makhan Singh
 Age : 27 years
 Sex : Male
 Address : Dharowali, Amritsar
 Occupation : kabaddi player
 Date of assessment : 23-10-07
 Chief complaint : Pain in Rt knee jton
medial aspect since 15 months.
 : Difficulty in playing kabaddi

 HOPI:
 Patient was apparantly alright 15 months
back, during playing kabaddi match he got
an injury in Rt knee joint.
 The injury occurred due to fall of another
player on outer aspect of his Rt knee when
he was running, followed by localized
swelling and tenderness.
 He was brought outside by other players and
RICE was applied onfield.
 On very next day, he consulted an orthopaedic
surgeon and there he was diagnosed as MCL
sprain
 POP was applied for 4 weeks but no relief was
there after the cast removal.


He undergone arthroscopy but again got no relief. One year
later he gone for MCL reconstruction on 18-07-07. Now he is
coming to health center for further physiotherapy since 3-10-
07.

PAIN ASSESSMENT:

Type: Dull aching

Nature: Intermittent
Provocating factors: Running, exertional activities
Relieving factors: Rest
Severity on VAS scale:

1 3 10
Past history: Patient complaints of sprain of same ligament two times
Earlier also and it was managed conservatively.
No h/o DM/HTN/TB.

Personal history: No h/o any addiction. Sleep, appetite,bowel and

bladder habits are normal.

Family history: Not significant

Socio-economic history: Good

ON OBSERVATION:

Attitude: Sitting- hip in 90⁰ flexion

- knee extended
- ankle in neutral.
Deformity: extension lag in right knee joint.

Muscle wasting: Slight muscle wasting is seen in right lower extremity.

Scar: Present on medial aspect of right knee.

Swelling: No obvious swelling is seen.

ON PALPATION:

Temperature: normal
Tenderness : absent
Scar : well healed, non adherent, mobile in all directions.
Crepitus: Absent
ON EXAMINATION:

1. RANGE OF MOTION:

HIP JOINT RIGHT LEFT

Flexion 0-110⁰ 0-110⁰
Extension 0-15⁰ 0-15⁰
Abduction 0-30⁰ 0-30⁰
Medial rotation 0- 30⁰ 0- 30⁰
Lateral rotation 0- 30⁰ 0- 30⁰
KNEE JOINT
Flexion 5- 135⁰ 5- 135⁰
Extension 135-5⁰ 135-5⁰
ANKLE JOINT
Dorsi flexion 0-20⁰ 0-20⁰
Plantar flexion 0-40⁰ 0-40⁰
Eversion 0-20⁰ 0-20⁰
Inversion 0-10⁰ 0-10⁰
MANUAL MUSCLE TESTING:
HIP JOINT RIGHT LEFT
Flexors 5 5
Extensors 5 5
Abductors 4 5
KNEE JOINT
Flexors 3+ 5
Extensors 4 5
ANKLE JOINT
Dorsi flexors 5 5
Plantar flexion 5 5
Everters 5 5
Invertors 5 5
GIRTH MEASUREMENT:

FROM THE RIGHT (cm) LEFT(cm) DIFFERENCE(c

BASE OF m)
PATELLA
AT 3 INCHES
(ABOVE) 46 48 2
AT 5 INCHES 52 53 1
AT 9 INCHES 61 63 2
FROM THE
APEX OF
PATELLA
AT 3 INCHES
(BELOW) 39 39.5 0.5
AT 5 INCHES 41 41.5 0.5
AT 7 INCHES 39 39 0
GAIT: Antalgic

FUNCTIONAL ASSESSMENT: ON FIMs scale- 7

: Difficulty in full squating, running and
playing sports.

INVESTIGATIONS: X-rays- A-P

- Lateral

: MRI

: Arthroscopy
Principles of management

After surgical intervention or acute injury or for chronic

conditions. Rehabilitation goals and interventions are

Full ROM
Good strength, stability, and flexibility
Bracing (and orthotic devices) as appropriate
Balance and gait training.


Physiotherapy management :
Pain relieving modalities :
SWD
Ultrasound
Progressive Resisted Exercises
ROM exercises
Open and close kinematic chain exercises for knee

 PHASES OF REHABILITATION
Days 1 to 3 : Rest from activity

 Acute phase: Protection of the site
 : RICE
 : ROM ex. For hip and ankle
 : NSAIDs
Day 4 -14 – Continue to rest the injured part completely

 Sub acute phase: Uses of crutches

 : Partial weight bearing
 : Use of CPM machine
 : Use of U.S. & PSWD
 : Achieve 90 degree flexion at the end of the
phase
Weeks 2-4: hinged knee brace should be worn at all
t im es

Early act ive rehabilit at ion phase: full weight bearing

: crut ches should be
abandoned lat er.
: gait t raining
: isom et ric quadriceps
: early propriocept ive
exercises
Week 4-6 : full ROM should be gained by t his st age.

Act ive rehabilit at ion phase : PRE

: st at ic cycling
: leg press/ squat s/ham
curls/quads ext ensions
: cont inue propriocept ive t raining
: hoping exercises should be
init iat ed.
Lat e act ive rehabilit at ion phase: Pain free act ive ROM
should be gained.
: Affect ed knee’s quads and
ham st ring should have 90% st rengt h of t he unaffect ed
knee.
: cont inue cycling wit h
increased resist ance.
: Init iat e st raight line running
, figure of 8 running wit h increasing no. of t urns.

Week 10+ : Hinged knee brace should be discarded.

Funct ional rehabilit at ion phase : PRE

: increase speed of running
and increase t urning angle t o 180 degrees.
: plyom et ric and agilit y
exercises.
: gradual ret urn t o sport s.
THANK
YOU…