Final Ortho 1/2 Alex/Josh/Erin

Implant and fixation choices for standard TKA

-Cemented, uncemented, or hybrid fixation -Metal-backed tibia or all-polyethylene tibia -Patella resurfacing or patella retaining -PCL or bi-cruciate substituting, PCL retaining, or mobile-bearing surfaces

You often find TPs _______the PSIS

Below

Hydrogel implants

Biocompatible, can be synthesized w/ a wide variety of mechanical and structural properties, characteristics similar to meniscus, proven durable in small animals

What causes FAI?

Bone overgrowth (spurs)

What surrounds the iliopsoas bursa?

Bounded by iliopsoas muscle/tendon anteriorly and the joint capsule posteriorly

Describe the MCL

Broadest structure of the medial aspect of knee, runs from adductor tubercle 3-4 cm below the crest of the tibial plateau, supercial + deep portions (deep portions have extensive attachment to meniscus and capsule, most taut w/ valgus force

Neurological pain

Burning, stabbing, itching, shooting, tingling, numbing, electrical

Describe the subtalar joint (talo-calcaneal)

Conversion of the rotation forces of LE, functionally linked to transverse tarsal joints

If an individual spends long periods of time at end range then the ligaments engaged in the elastic zone will have a plastic response - what is this called?

Creep

Metatarsals articulate w/ what?

Cuneiforms and cuboid

Closed pack position of the ankle

DF

What is the primary objective of an education session?

Decrease unnecessary fear

What is a directional preference?

Defined as a situation when movements in one direction improve pain and the limitation of ROM but may not centralize symptoms

What is a hip pointer?

Direct blow to the hip, lateral femoral cutaneous nerve (sensation to anterior lateral thigh), is compressed and could cause transient sensory changes

ACL is most taut in full ________

Extension

Disc patients feel better in____________

Extension

FABER

Flexion, abduction, ER

When is the PCl most taut? Most loose?

Flexion; extension

Common mechanisms of injury for cervical spine

Forward head w/ lift or twist or trauma (esp. in head forward posture)

ACL is taut in _______ ________________

Full extension

Over the door traction units

Generally not used anymore

3 categories of HRQL Questionnaires

Generic, Condition specific, Patient specific

Prevalence of LBP (Level II evidence)

Genetic component, inc. w/ leisure activities, smoking (don't heal very well, don't fight pain well), obesity, fear pain level, adolescence vs. adult same, most at risk - very active and sedentary

Generic

Good for anyone w/ any disability or condition

Condition specific

Good for patients w/ a specific condition

MTP joint of great toe

Grab base, anterior/posterior glide, medial/lateral glide, Turf tow injury, Need ~60 degrees of great toe extension, Compensate by ER at the hip joint

How to correct a lateral shift?

Grab pelvis, should into rib cage, and shift to opposite side, ask about leg symptoms, patient can perform by themselves using a wall; if it hurts more in their back, but makes their leg symptoms better - this is GOOD

S&Ss of Spondylolithesis

Grade 1+2: LBP and/or buttock and leg referred pain, feeling of instability w/ sudden movements, jarring movements, spine "give out", legs may buckle Grade 3+4: LBP, may be radicular signs into LE related to traction on lumbosacral nerve roots, pain paresthesia, numbness, muscle weakness, radicular signs may be unilateral or bilateral

Clinical presentation of internal snapping hip syndrome

Gradual onset, usually not associated w/ a traumatic event, may describe a painful sensation coming from deep within the anterior groin as the leg moves from flexion into extension or ER, snapping movement can produce an auditory clunk or click

Femoral head is removed but not _______________ _____________

Greater trochanter

CAM leads to _________between the 2 surfaces

Grinding

Tightness of what muscles are common at the hip?

Hamstrings, hip flexors

Pros/cons of ceramic ball w/ polyethylene liner

Harder than metal, don't scratch very much, less wear means less inflammations/bone loss, more expensive, in past ceramics were brittle and cracked, wear rate - 0.05 mm/year

Weakness of what muscles are common in the hip?

Hip ABD, gluteals

What does a lateral approach alter?

Hip ABD, which can result in weakness and may result in prolonged limping

What is known to predispose someone to labral tears?

Hip dysplasia (coxa valgus)

What can cause LE malaligment?

Hip excessive antiversion, excessive tibial torsion, excessive foot pronation (flat feet causing tibia to rotate medially)

All hip ligaments are taut w/ _____________

Hip extension

The use of traction dates back to _____________

Hippocrates

What does Gillet test test for?

Hypomobility of SIJ

Example of Step Deformity (EXAM)

If L5 vertebral body is anterior on S1, then L4 may feel more anterior (as L5 vertebral body slides anteriorly, the posterior arch and spinous process stays attached to S1), L4 feels deep b/c L4 has migrated anteriorly w/ L5 vertebral body (if L4 feels deep, then L5 is the problem)

Acute management of quad strain

If knee is left in ext the healing process will be slower and more painful b/c the quad will start to heal in a shortened position; knee should be flexed to avoid potential ms spasms, reduce hemorrhage, and minimize the risk of developing myositis ossificans

What is a precursor to hip OA?

If left untreated FAI will progress to labral tear, labral tear can lead to arthritis and DJD

Reason for symptoms

If the patient stands flexed to give more space for nerve roots- tends to over stress lumbar extensors which causes local lumbar spasm, if the patient stands in an extended position- tends to close IV foramen and impinge nerve roots, causing distal symptoms

Segmental lumbar musculature

In individuals w/o LBP, the TA and MF contracts prior to extremity movement to stabilize spine in preparation of movement, however in patients w/ LBP there is a delay in the onset of these muscles

Slump test

In sitting, bring their leg out and hold it there, have them slump down

Evidence for traction

Inconsistent outcomes among studies

Nucleus and inner annulus has no ____________

Innervation

What comes off and/or attaches to the medial epicondyle?

Insertion of adductor magnus at adductor tubercle, MCL

DD of snapping hip syndrome

Intra-articular hip disorders, trochanteric bursitis, iliopsoas bursitis, IT band syndrome

Describe reaming of the femoral canal

Intramedullary reaming (manually, robotically) rasp (sands down rough edges, used to size femur to accept the stem)

Closed pack of subtalar joint

Inversion (supination)

Motions at the subtalar joint

Inversion/eversion

Common accessory motion testing at hip

Lateral glide, lateral distraction, lateral distraction w/ combined movements, anterior glide, posterior glide

LCL is not connect w/ the _________

Lateral meniscus

What does the lateral condyle have to stabilize the position of the patella?

Lateral superior flair

What can cause lateral patellar compression syndrome?

Lateral tilted patella, hypomobility of patella, loss of patella mobility, excessive tightness of lateral retinaculum including distal attachment of IT band, atrophy of VMO (reflex inhibition)

___________meniscus moves more than the _____________meniscus

Lateral, medial

What muscle works to keep your pelvis more stable?

Latissimus dorsi

Side bend right - nucleus moves __________

Left

Install-salvati ration

Length of patella tendon (ligament) should be the same as the length of the patella top to bottom, if tendon is too long - patella alta, if too short - patella baja

Hallux rigidus

Loss of ROM in MTP joint

Manual techniques

Manual therapy, energy muscle technique, trust techniques (hard to focus on SI joint)

Interventions for acute LPB w/ mobility deficits

Manual therapy, exercise, patient education

Interventions for subacute LBP w/ mobility deficits

Manual therapy, exercise, patient education (focus on prevention and maintaining lifestyle)

Interventions for acute LBP, referred

Manual, exercise, exercise, traction, patient education, all to centralize symptoms

Interventions for chronic LBP, radicular

Manual, pain management

Interventions for subacute LBP, radicular

Manual, traction, nerve root mobilization

Do you have to manipulate to be a good PT?

Many highly effective PTs do not manipulate

Meniscal tears occur more often in men or women?

Men

Scour test

Move hip through ROM flexion/ADD and extension/ABD while adding compression, (+) test = reproduction of clicking or popping, if it hurts, then distraction should make it better

Risk factors for TKA

Multiple compartments are damaged due to arthritic changes, articular cartilage is damaged and is no longer able to absorb shock, previous injury, menisectomy, RA, fractures and congenital factors

Femoral neck fracture

Must repair or replace right away

Who should not be manipulated?

Near unhealed fractures, RA, pregnancy, osteoporosis, hypermobility in affected joints, unstable joints, unknown cause of symptoms, Down Syndrome (increased laxity)

Cervical

Neck Disability Index

What is a complication of a resurfacing anthroplasty?

Neck fracture

FABs of patients and health care providers have a ____________influence on LBP outcomes

Negative

Who is Robin McKenzie?

New Zealand PT, developed theory due to mistake by patient, developed theory based on patients' responses then wrote a book, no early research

Distraction

Nice to follow after a (+) scour test, 30 degrees of flexion and ABDuction w/ slight ER, if distraction relieves symptoms it helps confirm the hypothesis of hip OA, if test is painful, a capsular or ligamentous injury is possible

Is intermittent or static traction better?

No conclusive evidence to support one method being superior

Biggest reasons for concern

No h/o injury, no change in symptoms with changes in position or with activities, fever, chills, night sweats, unable to reproduce symptoms with physical examination

Bed traction

No longer use, very low-load (9-10 lbs), prolonged stretch (hours to days), costly for hospitals to have patient lie in bed (secondary complications)

Mortise (distal tibiofibular joint)

No muscular attachment to the talus

Quad strains are typically a ____-contact injury

Non

What test has a high level of diagnostic accuracy for a hip labrum tear?

None

Non-specific LBP

Not a homogeneous group, but consists of subtypes of patients who can be identified based on specific S&Ss

Peripheralizing

Not doing better

Frequency

Not supported by evidence, some authors report daily

Duration

Not supported by evidence, start w/ brief bout (5-10 minutes), relief of symptoms (leave same treatment time), partial relief (increased duration and/or frequency)

Sequestration

Nuclear material came completely through

Joint axis of talocrural joint

Oblique axis, through fibular malleoulus, body of talus and medial malleolus

Characteristics of pain

Onset - did it come on slowly? (CA) Suddenly, without mechanical event? (vascular) Does not change w/ position or activity? True constant pain? (does not vary w/ position or activity)

Clinical presentation of FAI

Onset of hip pain usually b/t ages 20-40 years; typically unilateral; typically aware of limited hip mobility long before pain begins

Contraindications for artificial disc replacement

Osteoporosis or osteopenia, scoliosis, instabilty

Total joint replacement is one of the most commonly performed and successful operations in orthopedics as defined by clinical_______________ and ____________survivorship

Outcomes; implant

Describe the medial meniscus

Oval or "C" shaped, wider posteriorly, attach to deep portion of the MCL, semimembranosis attaches to posterior horn

What attaches to the tibial tuberosity?

Patellar tendon

Sciatic nerve tension test

Patient is in supine, extend knee, flex hip, IR hip (tensioning nerve across the lateral part of the ischial tuberosity), DF ankle, if no change in symptoms have the patient flex cervical spine

Everter =

Pronator

Femoral nerve innervates the ______________

Quads

Individuals w/ lumbar injury show more postural sway and have ___________reaction times

Slower

Thessaly (meniscus)

Stand on one foot and rotate

Anti-inflammatory meds

Steroids, NSAIDS

Why manipulate?

To increase ROM, hypomobility due to capsule restriction, joint is blocked due to mechanical restriction (meniscus, disc), reflex inhibition of muscle spasm

Manual traction

Typically applied b/t 15-60 seconds, can be static or intermittent, monitor patient's reaction, can't control force exactly

Describe tibial torsion

Typically lateral torsion 20-30 degrees

Red flags S&S

sensory changes in the rectal, genital, genital region, changes in bowel and bladder control

Most susceptible athletes to spondylolysis

those who do frequent end range lumbar spine hyperextension: lineman in football, gymnasts, swimmers, wrestlers, volleyball, cheerleaders, weight lifters

normal mobility of spine

translation during flexion and extension 3-4.5mm or 9-15% of vertebral body width, rotation 15-25 degrees,

How much more translation or rotation before you have symptoms?

unanswerable- translation of vertebrae is no what matters when you are hypermobile, what matter is how much control you have of it with your muscles

How do you do core strengthening exercises for someone with spondylolisthesis?

utilizing a posterior pelvic tilt position, posterior pelvic tilt will lessen LS angle, strengthen abdominals and gluteals, tighter hamstrings will limit anterior tilt of pelvis,

Reason for anterior displacement in spondylolisthesis

vertebrae no longer attached posteriorly, sacral angle creates anterior sheer, supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to 'slide' anteriorly o the one below (creep).

Diagnosis of Spondylolysis

x-ray (oblique view), MRI, CT, Bone scan

Diagnosis for spondylolisthesis

xray, MRI, Bone Scan, increase in symptoms with hyperextension, pain with pressure on spinous processes, step deformity

What 3 things do you evaluate when looking at feet?

1) Arch - high, low, or middle 2) In WB, how do they hold their calcaneus 3) How do they hold their forefoot

Risk of vigorous exercise

1-1.5 million deaths per year

Risk of NSAID use

1-3% develop ulcers, long-term heavy use is kidney disease (7,600 deaths, 76,000 hospitalizations)

Ongoing impairments and functional deficits can be seen for as long as ____ years post THA

2

PCL is ____x as thick as the ACL (which is why it results in less injuries)

2

The presence of ___ or fewer findings was almost associated with failure to experience dramatic improvement

2

Describe the distal femur

2 WB condyles that are covered w/ articular cartilage, separated by the intercondylar notch (provides area for cruciate ligament to pass), trochlear groove (articulating surface w/ patella)

What should frequency and duration be?

2-3 times per week for 6 to 8 weeks depending on diagnosis

Normal hip extension

20 degrees

>______________discectomies are performed i the US per year

200,000

Roland-Morris Questionnaire

24 questions related to pain and function, 5 min to complete, 1 min to score, 0-24 (0 no pain and no functional limitations, 24 max pain and limitations), minimal detectable change (variable - 5 to 9), patient checks statement that applies to them, "because of my back pain...", designed to measure short term changes, short, simple, easy to understand, does not look at psychological or social, may be more sensitive in patients w/ lesser disability

Force of ____% of patients BW is sufficient enough to increase the length of the lumbar spine

25

Grade 2 Spondylolithesis

25-50%

Grade 2 for spondylolisthesis

25-50%

Rectus femoris is a _________ joint muscle and has a high % of type ____ fibers

2; II

The presence of at least ___ positive factors indicates a greater likelihood of responding to a stabilization intervention

3

Women are ____x more likely to have an ACL injury compared to men

3

Posterior surface of patella articulates w/ trochlear groove through facets ______,______, and ______

3, 5, 7

Minimally invasive incision length

3-4 inches

Normal translation during flexion/extension

3-4.5 mm or 9-15% of vertebral body width

Pincer occurs more often in whom?

3x more in females (ave. age 40)

Elongation of annular fibers by more than _____% will cause permanent damage to annular rings

4

The presence of ____out of 5 findings was strongly predictive of a dramatic response to the manipulation interventions

4

What is indicative for separation of facet joints and to increase foraminal space?

50-60% of patient's BW

Grade 3 Spondylolithesis

50-75%

Grade 3 for spondylolisthesis

50-75%

Grade 4 Spondylolithesis

75-100%

Grade 4 for spondylolisthesis

75-100%

Standard incision length

8-12 inches

Specificity for clicking w/ labral tears

85%

Posterolateral rotary instability

A direct blow to the anteromedial knee with the tibia in external rotation, Often occurs with concomitant ligamentous injuries making it difficult to detect/diagnose, Joint line tenderness with swelling in the posterolateral corner, Common fibular nerve injuries occur up to 30% of the time, Episodes of knee buckling during the stance phase of gate or with pivoting movements, Some patients present with unpredictable giving way without provocation or simply when just standing

Manipulation

A high velocity skilled movement done at a velocity that a patient cannot resist

Definition of manipulation/mobilization (Guide to PT Practice)

A manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small amplitude, high velocity therapeutic movement

Pubofemoral ligament is taut w/ ____________ and __________

ABD and ER

You can easily dislocate a newborn baby's hip - What positions are most stable and what should be avoided?

ABD and ER are most stable, you should not extend hips

During single leg support, your hip ______are firing

ABDuctors

Prevalence of GTPS

Affects 10 to 25 % of the general population Higher prevalence in runners, women, and between ages 40 - 60

Medial (deltoid) ligaments (all come off medial malleolus)

Anterior Talotibial Posterior Talotibial Calcaneotibial Tibionavicular

What is eversion or pronation supported by?

Anterior and posterior tibialis muscles and deltoid ligament

What is the preferred approach to THA today?

Anterior due to much smaller incision 3-4 inches

What direction does the ACL run?

Anterior medial on tibial plateau intercondylar eminence to posterior lateral on medial side of lateral condyle

Possible dysfunctions of SIJ

Anterior or posterior rotation, up slip or down slip, in flair, out flair, sacral tip (nutation or counternutation_, sacral obliquity

When in increased lumbar lordosis, the pelvis is ____________tilted and the __________ and __________ are tight

Anteriorly; hip flexors and spine extenders

Low early dislocation rate can be achieved using a __________________approach w/o restrictions

Anterolateral

Classification of instabilities - rotatory

Anteromedial, anterolateral, posterolateral, posteromedial

2 bands of the ACL

Anteromedial, posterolateral

Pincer can be due to increased acetabular ______________

Antiversion

Femoral retroversion

Anything less than the 15% of normal antiversion

Neutral zone (mid-range)

Area in range of motion segment where there is little resistance to motion; muscle function limits and stabilize motion segments in this area

What 2 states is it illegal to perform manipulations as PTs?

Arkansas and Washington

Patient education

Avoid forward flexion and sitting, maintain lumbar lordosis, avoid activities that peripheralize symptoms, may benefit from brace to maintain extended posture

Chronic LBP

Avoidance behaviors may become even more related to fear of continued pain and disability even after pain has become under control; can influence performance of functional tasks and can be a predictor of long term work disability

You want pt to maintain position for _______ after treatment

Awhile

Sensory innervation of joint capsule of the knee

Branches of femoral, saphenous, tibial, obturator, and fibular

Jefferson fracture

C1 vertebra

DF open chain

Convex on concave (anterior roll, posterior glide)

Slocum test for anterolateral rotary instability

Drawer test with tibia in IR

Posterior lumbar laminectomy

Due to diminished diameter of central canal cause by ligamentum flavum hypertrophy, facet hypertrophy, disc degeneration

Acute trochanteric bursitis

Due to trauma (fall or blow to lateral hip), pain, swelling, and warmth w/ palpation, motion may be limited

If patient cannot _______then nucleus has moved through rings and blocks motion

Extend

When is the LCL taut? Loose?

Extension; flexion

Lateral compartment musculature

Fibularis longus, fibularis brevis

Sports to avoid after TKA

Football, hockey, high-impact aerobics, jogging, parachuting, power lifting

For anterior labral tear, pain can occur where?

Groin (92%), anterior thigh (52%), labral hip (59%), buttock (38%)

Adolescent

Growing into their body, gain more control, improve balance and efficiency of movements, maturing of connective tissue

What is removed during a THA?

Head and neck of femur (loss of labrum), but not greater and lesser trochanter due to muscular attachment

What areas of the body should you examine when observing posture?

Head and neck, thoracic spine, shoulder girdle, lumbar spine, pelvis, knees, foot and ankle complex

Order of infant progression

Head control, prone on elbows, sitting, pull to stand, standing

DD of trochanteric bursitis

Hip pointer, ITBS, snapping hip syndrome, gluteus medius tendinopathy, meralgia paraesthetica

3 most common fractures in those w/ osteoporosis

Hip, colles, vertebral body

Examination of iliopsoas bursitis

Iliopsoas bursitis is often under diagnosed due to its unspecific symptoms, tenderness in femoral triangle, positive thomas test, active resistance of the iliopsoas is weak and/or painful

Disability

Impact on daily life, activity might cause pain and therefore harm, results in no activity, disuse atrophy, diminished strength and endurance, depression, injury result in pain experience, pain catastrophizing, pain perceive as threat, anxiety over pain and threat of pain, need to avoid pain, disability due to fear of pain

Functions of the meniscus

Improves articular congruency, distributes load during movement, reduces friction b/t femur and tibia, shock absorption, nutrition of articular cartilage, secondary restraint to tibial rotation

Examination of GTPS

In addition to pain along the posterior, lateral portion of the GT and pain w/ resisted hip ABD and/or ER, Trendelenburg test, FABER test, Ober's test, MRI can be effective to determine whether a patient is suitable for surgery

Rapid loading

Increased stiffness

Outer 1/3 of annular is ____________

Innervated

Accessory motion testing through the hip

It can be difficult to replicate accessory motions in the hip manually, common to use a mobilization belt when performing lateral glide

What does it mean if you extend the patients back and the local back pain goes away?

It is already centralized

Why is a posterior tilt important?

It will lessen LS angle (don't want them in extension)

Hamstring strains commonly occur w/ what action?

Kicking or running

What joint has the largest synovial capsule in the body?

Knee

LCL injuries may occur w/....?

Knee dislocation, distal IT band injury, popliteus rupture, posterolateral capsule injury, fibular nerve injury

Anterior drawer test

Knee is flexed, foot is flat on table; (+) test = tibia excessively translated anteriorly, mushy, empty end feel

Genu valgus

Knock knees, women tend to have a natural valgus

Dermatomes of the knee

L3-S2

90% of lumbar herniations occur @ ___-___ and ___-____

L4-L5, L5-S1

What is the most common level for spondylolysis? More common in males or females?

L5, more common in males

Manipulations show the best evidence for....

LBP (not radicular pain), cervical HA

Signs and symptoms of stenosis

LBP, pain and paresthesia in LEs, limited lumbar extension which may bring on distal symptoms, possible B&B changes (esp. central stenosis), posture (flexed in standing and walking), more common in older adults

What motion does the LCL, MCL, ACL, and PCL limit?

LCL - varus, MCL - valgus, ACL - anterior shear of tibia, PCL - posterior shear of tibia

Dislocation is _________99% of the time

Lateral

Is central or lateral stenosis more common?

Lateral

Most of the time, the bulge is __________to the nerve root

Lateral

Repair of meniscus

Lesion in vascular outer third, tear extending in central, relatively avascular third of meniscus of a young (<40-50 years) or physically active older adult (>50), restrictions on WB status (don't want to put compressive forces through the knee

Strong evidence exists that an inactive person will show ______ wear than in an active person with a THA, but exercise will decrease fall risk, ___________ bone density, and prosthesis fixation

Less, increase

Levels of Evidence - 2

Lesser quality diagnostic studies, prospective studies, or randomized control studies (weaker diagnostic criteria, reference standards, improper randomization)

Where does the iliopsoas attach to?

Lesser trochanter

Grade III Sprain

Ligament fibers are completely torn, there is pain during initial injury but then it subsides, tenderness may be present, lots of swelling, hemarthrosis may occur within 1-2 hour, feels unstable or gives out at certain times, rotational instability, end feel is empty

Grade II Sprain

Ligament fibers are partially torn w/ hemorrhaging, little tenderness and moderate swelling, joint may feel unstable or give out during activity, increased joint laxity yet there is still firm end point

How is knee stability maintained?

Ligaments, muscles, menisci, bony contours

Soft tissue treatment

Look for TPs, stretch what is tight (hip flexors, quadriceps, gluteals, TFL, piriformis, hip rotators

Loose pack and closed pack of talocrural joint

Loose packed - PF Closed packed - DF

Clinical findings of FAI

Loss of IR out of proportion w/ loss of movement at other positions (flexion and IR may be restricted when combined)

_______pressure does not produce the same effects (i.e. manual, self traction)

Low

Cervical pain can refer from...

Lung, liver, heart (usually L, can go into L jaw)

What is GTPS provoked by?

Lying on affected side but can also hurt lying on unaffected side, standing for a long time, sitting w/ legs crossed, climbing stairs, running or other high impact, repetitive activities

When the ACL is disrupted, the _______ provides most of the anterior stability

MCL

Clinical presentation of GTPS

Main symptom is pain and tenderness along the lateral thigh, pain may radiate down the thigh and buttocks, but rarely goes to the posterior thigh or distal to the knee, often described as aching but can be intense w/ strenuous activity, aggravated by passive, active and resisted hip ABD and ER

CAM occurs more in whom?

Males (ave. age 32)

What is infant hip dysplasia?

Malformation of the hip, can be either congenital or acquired, at risk for dislocation

PT and manipulations

Manipulation is used to break adhesions in the folds of the joint capsule and restore normal joint mobility, brings tissues into the plastic range of SS curve but not so forceful to cause failure, restore normal arthrokinematics, nutrition of articular cartilage

Best results are a combination of _____________ and _______________

Manipulation, exercise

__________therapy should not be considered a first-choice treatment

Manual

What do osteopaths do?

Manual medicine - many low and high velocity techniques, manipulate to restore normal range and quality of movement, break mechanical adhesions, stimulate proprioceptors to restore afferent and efferent balance, move synovial fluid - restore viscosity, improve local circulation and drainage, psychological - firm confident therapeutic touch

_____________ ___________techniques have been shown to inc. hip ROM and dec. pain in patients w/ hip OA

Manual therapy

Interventions for LBP

Manual therapy (thrust vs. non thrust), exercise (strength, endurance, stabilization), flexion exercises, extension exercises, nerve mobilization, traction, patient education, fitness exercises

Bone contusions (microtrabecular fractures)

May occur due to pressure on the knee w/ trauma, unlikely to significantly reduce function

Documentation applicable to goal setting

Measurable, functional, time elements

Oswestry scale

Measurement tool for patient satisfaction

The GRF falls __________ to the joint during a cutting maneuver

Medial

____________compartment of the knee is more likely to get osteoarthritic problems

Medial

_______femoral condyle goes down farther distally, therefore it wears out sooner

Medial

Where is the pes anserine located? What attaches there?

Medial tibia, gracilis, sartorius, semitendinosus

When are patients admitted to hospital before THA?

Morning of surgery

Pain after TKA

Most common complaint and mostly felt in whole knee, also behind patella, may affect sleep

Acute MOI for labral tear

Most commonly from a slipping or twisting injury w/ catching-type groin pain

Adult females have more __________ than males

Motion

Pregnant females have more _________than other females

Motion

Interventions for subacute LBP w/ coordination exercises

Neuromuscular reeducation, Manual , Exercise strength & endurance, Self acre training in mid range, Pain management

Facet injections

Non-operative alternative; analgesic effect; may last for several days, weeks, or months; also done @ epidural space to treat pain caused by nerve root irritation from HNP

In patients >60, labral tears are so common that it is a _________part of aging

Normal

Examination of MCL injury

Normally isolated swelling is seen on medial side of knee (may be minimal), palpation along the joint line may be tender, feel/hears "pop" or "snap", knee "stiffens up" within hours of injury, walking may be significantly limited, muscle guarding

Patient w/ severe pain and neuro deficits that are not relieved w/ changes in position are ________manual therapy candidates

Not

Nerve root compression results in...

Numbness/tingling, motor weakness, decreased deep tendon reflexes, decreased blood flow to nerve

Post op complaints

Over or underuse, pain, stiffness/rigidity

What are the two harnesses used for traction?

Pelvic belt and rib belt

Trendelenburg

Pelvis drops on the non-stance side (most everyone drops a few degrees, females more than males)

What is inversion or supination supported by?

Peroneus muscles and lateral ankle ligaments

SF-36 (Generic)

Physical and mental components score, subgroups - general health, physical functioning, role functioning, bodily pain, mental health, emotional functioning, vitality, social functioning

Supination

Plantar flexion, inversion, adduction

Mobile TKA

Polyethylene insert can rotate slightly, which gives the knee implant a more natural interface b/t the surface of the femoral component and polyethylene insert, both gliding and rotating motion can be done, since PE can rotate, contact w/ FC is more even, less stresses and wear

____________must unlock knee when knee is in full extension when moving into flexion

Popliteus

What are the 3 articulations of the ankle complex?

Proximal tibiofibular joint, distal tibiofibular joint, talocrural joint

Describe the proximal tibia

Proximally flared into two plateaus (condyles) that articulate with the femoral condyles, separated by intracondylar eminences (tibial spines), attachment of the cruciate ligaments and the menisci, both plateaus densely covered w/ articular cartilage

Posterior glide test

Pt is in prone, palpate PSIS, grab ASIS in front and lift up, this creates a shearing force

Long sitting test

Pt is lying in supine, check leg length, check ASISs, have patient sit up and check leg length again; if ASIS is down, acetabulum would be down and leg could appear longer, leg length should correct itself when patient sits up

Positional traction

Pt is placed in a position which causes gaping of a facet joint, intervertebral foramen, or reduces pressure on a nerve root, most common position is SL on non-involved side w/ towel roll or bolster under to create opening on contralateral side

Sacral compression

Pt is prone, PT applies a downward pressure to the superior portion of the sacrum and then the inferior portion of the sacrum

Anterior and posterior rotation

Pt is side lying, PT grasps the subjects ASIS w/ one hand and ischial tuberosity w/ the other and applies an anterior and posterior rotatory force

Approximation

Pt is side-lying, PT compresses into the subject towards the exam table

Gillet (stork) test

Pt is standing, one thumb on PSIS (on side you lift) and one thumb on sacrum around S2, PSIS should rotate backwards on side you lift

Who is most likely to benefit from traction?

Radicular symptoms from lateral stenosis

Coordination impairment signs + symptoms

Radicular weakness and lumbar spine stays stiff

Grade III strain (severe)

Ranges from >50% to complete rupture, both the ms belly and tendon may be involved, causes massive swelling and pain, significant weakness and loss of function

ACL injuries _______occur in isolation

Rarely

Failure to regain strength of the important trunk stabilizers may increase risk of _________________

Re-occurrence

Laminectomy

Removal of lamina

Spinal stabilization

Retraining appropriate activation of the TA and/or multifidus

Describe the LCL

Round cord like tissue, runs from lateral epicondyle area just above the groove for the popliteal tendon distally to attach on fibular head b/t tendons of biceps femoris, does NOT attach to meniscus or capsule, most taut w/ varus force

Examination of piriformis syndrome

Rule out lumbar spine, tender to palpation deep to gluteus maximus , pain and/or weakness with resisted hip abduction and external rotation, symptoms with the piriformis in a stretch position, Lasèque sign/Straight Leg Raise Test, positive for SLR will most likely be between 35-70 degrees, repetitive clamshells could cause symptoms

What anchors the meniscus to bone?

Sharpey's fibers

Lateral lurch

Shifts weight toward the weak or painful side

Minimally invasive TKA

Shorter incision, quad sparing, early, limited results: better ROM, less blood loss, shorter LOS

Primary restraint

Signifies the structure that is the major restraint to movement, ex: ACL - primary restraint to anterior translation of tibia

Patella baja

Sits low and is associated w/ diminished ROM esp. flexion and OA of PF joint

What is a posterolateral approach associated with?

Slightly higher risk of dislocation

How long does recovery from a hamstring strain typically take?

Sometimes weeks to a full year

What is a common symptoms of hamstring strains?

Sudden onset of pain in posterior thigh, may have an audible "pop"

Allograft

Taken from cadavers, slight risk for injection

Drehmann's sign

Unavoidable passive ER while performing hip flexion

Adult

Very dependent on body type and function

Grades of Recommendation - C

Weak evidence, a single level II study or support from level III or IV studies

What causes a sports hernia?

Weakening of the abdominal wall

How do you rotate pelvis back posteriorly?

Works glutes and hamstrings

Explain the centralization peripheralization phenomena.

Worse w/ flexion (peripheralize radicualr symptoms), better w/ extension (centralize peripheral radicular symptoms)

Examination findings

Worse w/ flexion and/or SB, worse w/ repeated flexion, better w/ extension or repeated extension, motions must be slow or you risk pinching bulging disc, nucleus moves like a very thick fluid

Diagnosis of pars fracture

X-ray (often oblique view, sometimes does not show), MRI, CT, bone scan

Diagnosis of Spondylolithesis

X-ray, MRI, Bone scan, increase symptoms w/ hyperextension (sometimes flexion as well), pain w/ pressure on spinous processes, Step Deformity

S&S of Spondylolysis

lower lumbosacral back pain and spasm, may have referred pain into buttocks or LE, often increases lordosis, tender with PA pressure to spinous processes

Meniscal allograft

Young/active patient who previously underwent total meniscectomy and now is symptomatic because of early osteoarthritic changes

What is pars interarticularis?

a bony isthmus between the superior and inferior facet joints of the spine

Intervention for spondylolisthesis:Grades 1&2

patient education to : avoid hyperextension, limit end ranges, especially heavy loads, proper lifting, bending, and sitting, often LS brace

what is key in order for muscle to control thing in the neutral zone?

proprioception

Prevalence of FAI

10-15% of population

Where can you palpate the rectus femoris?

AIIS

Where does the rectus femoris attach?

AIIS to tibial tubersoity via quad tenson

What are the parts of THA implants?

Acetabular cups, polyethylene liner, femoral head, neck, stem

Describe inserting the acetabular component

Acetabular shell is inserted (porous coated or cemented), a hard smooth plastic liner is inserted into the metal shell

Aquatic therapy

Benefits are pain control, ROM, stabilization

Genu varus

Bow legged, rare to see a true varus at the knee

Risk factors for hip dysplasia

Breach birth, infant held in hip adduction and extension

Primary piriformis syndrome

Caused by anatomical variation, <15% of all cases

Patients w/ labral tears typically complain of what?

Clicking, locking, or catching

Lateral stenosis occurs with ___________ and DJD

DDD

Gait observations

Dec. stance phase on involved side, dec. hip extension, Trendelenburg or lateral lurch

Adductor magnus helps __________the hip

Extend

Increased lumbar lordosis, lumbar spine is ___________________

Extended

Describe the posterior drawer test

Flex hip to 45 degrees, knees to 90 degrees, push knee posteriorly

FABER test

Flex, ABD, ER

Decreased lumbar lordosis, lumbar spine is __________________

Flexed

Gait - OA

Flexed hips, extended lumbar spine, shorter stride

Actions of TFL

Flexes, ABD, IR

Tibial portion of the sciatic nerve innervates the knee ____________ and ___________

Flexors and rotators

Adductors are __________when the hip is extended and _________when the hip is flexed

Flexors; extensors

Therapeutic Neuroscience Education

Focuses on the neurophysiology and the processing/representation of pain

What is myositis ossificans?

Formation of ectopic bone as a result of bleeding due to blunt trauma, x-rays show a calcium deposit 2-6 weeks post injury, pain, weakness, swelling, point tenderness, and dec. ROM

Popliteal (Baker's) cyst

Forms when a bursa swells w/ synovial fluid, results from chronic effusion and intra-articular lesions

During extension the menisci move _______________via attachments to the retinaculum

Forward (effect of quads)

Posterior superficial musculature

Gastrocnemius, soleus, plantaris

What are outcome measures designed to do?

Gauge treatment effectiveness and efficacy; looks at biopsycosocial effect of treatment; patient generated questionnaires

What is the most frequently strained muscle in the body?

Hamstring

Telescoping hip

Hip is flexed to 90 degrees, PT grasps lower leg and pulls hip anteriorly, feeling for excessive movement

Hx of manipulation

Hippocrates 3000 BC, bone setters 1871 (Hood), PTs in Sweden 1887, England 1899

Ortolani's sign and Barlow's test

Hips flexed, abducted and externaly rotated, you feel a click

McKenzie Method

History, examination, classification into syndromes, interventions based on syndrome, emphasized self treatment, therapists job is to guide treatment, patient education is emphasized, minimal hands-on treatment

Interbody cage

Hollow cylinders made of titanium, carbon, or bone filled w/ autogenous bone graft or a bone graft substitute and inserted b/t the bodies

Types of meniscal tears

Horizontal, radial (transverse), longitudinal (vertical), oblique, degenerative lesions

Interventions for grade I strains (mild)

Ice, being active, keeping moving

PT management of piriformis syndrome

If symptoms are due to a shortened, hypertonic piriformis, change the tone and increase mobility, Soft tissue techniques. PNF patterns, contract/hold relax techniques If the symptoms are due to a weak or inhibited piriformis, focus on strength (ABD and ER), Nerve glides - put patient in slumped position and have them do knee ext, or in supine (could add DF and ADD), McKenzie exercises. Lower trunk rotations - if really irritable at first, Bridge variations, Clamshells, Seated resisted ER, Quadruped fire hydrants, Theraband squats , Side steps, monster walks with theraband, Forward and lateral lunges

What is the largest bursa in the body? What is its purpose?

Iliopsoas bursa; reduces friction b/t anterior hip capsule and iliopsoas

Describe internal snapping hip syndrome

Iliopsoas tendon snaps over the head of the femur, iliopectineal eminence or lesser trohanter

How do cardiovascular exercises work?

Inc. blood flow and oxygenation, memory improves, focus and concentration improves, mood if affected, deeper breathing engages diaphragm and dec. accessory muscle activation

Prevalence of LBP and costs of treatment and lost work productivity continues to ___________

Increase

Stiffness/rigidity after TKA

Initially felt in morning, gradually increased to affect all activities

Days 1-6 following Lumbar Microdiscectomy

Initiate walking 1-3x per day as tolerated, become independent w/ bed mobility (sit to stand and toileting day 2), discharge from hospital 12-48 hours post op, protection of wound, limit bending and lifting, pain management, walking progression 5-10 minutes on level surface w/ minimal AD

Neuromuscular control

Injury to system, which can occur with traumatic spinal injury can result in diminished proprioceptive input and lead to further damage of passive restraint structures, diminished spinal stability

Interventions for hypomobility

Joint mobilization/manipulation, stretching, strengthening into a new range (elastic zone)

List some knee outcome measures

KOOS (knee disability and OA outcome scor), LE functional scale (FEFS), 6 minute walk test, TUG, VAS

Knee

KOOS, knee osteoarthritis outcome scor

Surgery

Laminectomy, foramenectomy

What will the "scotty dog" look like if there is a pars fracture?

Like the dog has a collar on

Cementless fixation

Liner consists of porous material compatible for bone growth, bone grows and secures liner in place, younger - less potential for cement to crack, more active, protected WB for 6-12 weeks, better for long-term fixation, longer recovery

Focus should be on ____load, ____ hold

Low, tonic

Pain past 70 degrees is most likely what?

Lumbar spine or SIJ, could be hip joint or articular in nature

Most patients are given a meaningless diagnosis such as ____________ ___________ or ___________ _____________

Lumbar strain; lumbar pain

Dysfunction syndrome

Mechanical deformation of soft tissue affect by adaptive shortening; results in loss of movement; pain w/ stress on shortened structures; intermittent pain; dec. ROM; name for the DIRECTION OF THE LOSS OF RANGE (typically extension)

If you fracture the femoral neck, what could be damaged?

Medial and lateral circumflex arteries, obturator artery

Where does the medial and lateral head of the gastroc originate?

Medial and lateral femoral condyles

Medial or lateral meniscus injury is more common?

Medial because it is attached to the MCL and is less mobile

Chondral injury

Occurs at the time of impact, chondral degradation is common years after an ACL injury

Step Deformity (EXAM)

One spinous process may appear to be anteriorly displaced over one below

What hip pathology is more common in older age?

Osteoarthritic changes

Examination of the low back

Outcome measures, measurements of lumbar ROM, centralization and peripheralization of symptoms, instability tests, straight leg test, slump test, trunk strengthening and endurance tests, fear avoidance questionnaire, pain assessment questionnaire

If you are suspecting a ligamentous injury, what do you always want to check first?

PCL

What attaches to the lateral meniscus?

PCL, popliteus, and posterior thickenings of the capsule

If the cauda equina is affected, there will be _____________ signs and possibly ______&________signs

PNS; bowel and bladder

SIJ tests w/ the highest level of reliability

Pain

Chronic LBP w/ movement coordination impairments and acute LBP w/ radiating pain

Pain occurs w/ sustained end range movements

Examination of LCL injury

Palpation could reveal tenderness over the posterolateral knee, no significant joint effusion (unless there is also a cruciate ligament or meniscal injury), varus stress test at 30 degrees of flexion

Examination of trochanteric bursitis

Palpation is the most provocative clinical test, Ober's test, MRI provides the most sensitive image

Interventions for Grades 1 and 2 Spondylolithesis

Patient education to avoid hyperextension, limit end range flexion (esp. w/ heavy loads), proper lifting, bending, sitting, often LS brace

What are some components of a post-op treatment program for the lumbar spine?

Patient education, exercise (spinal stabilization, strength, ROM, aquatic therapy, and cardiovascular), walking program, manual therapy, neural tissue mobilization, modalities

Craig's test

Patient is prone, bend knee, feel GT and feel for when it is most prominent

Ely's test for tight quad

Patient is prone, flex knee

Advantages of Unicompartmental arthroplasty

Preservation of ACL, smaller incision, less blood loss, lower morbidity, shorter recovery time, lesser bone removed

Femoral stem insertion

Press fit, cemented

A major part of pre op education should be dedicated to what?

Prevention of dislocation

Other variables important for predicting the outcome of stabilization treatment were a hx of _________________________ and _____________detected during segmental mobility testing

Previous episodes of LBP; hypermobility

Primary and secondary restrain for MCL

Primary - valgus force Secondary - Anterior knee stability

The initial goal of an acute episode is to ________pain and disability and progress the patient into stage II of treatment

Reduce

Unicompartmental arthroplasty

Replaces only damaged or arthritic parts in either compartments

Goals and advantages of artificial disc replacement

Replicate normal disc and joint biomechanics, reduce the forces transmitted to adjacent segments, improve disc height while maintaining structural integrity

Surfaces are covered w/ interlocking ___________and_______________

Ridges; depression (smaller in children and females, larger in males and post menopausal females)

If your left hip ABDuctors are weak, you will drop to the ___________side

Right

Risk w/ cervical manipulation goes up greatly when _________ is part of the manipulation (esp. in upper cervical spine)

Rotation

Neurological symptoms w/ patellofemoral disorders

Saphenous nerve neuralgia, CRPS

Reg flags S&Ss

Sensory changes in the rectal, genital region; changes in bowel and bladder

Coxa Varus

Shortening of abductors

Lachman's test

Slightly flex knee to 30 degrees, top hand on femur, bottom hand on tibia, quick pull w/ bottom hand, try to get an anterior pull with tibia; (+) test = do you feel laxity, does patient feel a difference from side to side

_________and________ are the the most prevalent early complaints

Stiffness & pain

Inc. in technology (MRI, bone scans, US, etc) have allowed for precise _____________ assessment

Structural

What nerve can be damaged w/ a hip pointer?

Superior cluneal nerve (folds over the top of iliac crest, you would lose sensation to the upper buttock region)

Ears of "scotty dog"

Superior facets

Grade 1 Spondylolithesis

Superior vertebrae migrates anteriorly 0-25% over the inferior vertebra

Symptoms of hamstring strain

Swelling and ecchymosis, pain w/ palpation, when there is a palpable defect - more severe injury, dec. AROM and PROM (SLR, 90-90 degree SLR, tripod sign)

Symptoms of a PCL injury combined w/ other ligamentous injuries

Swelling, bruising, anterior and posterior knee pain, a feeling of instability, limited ROM, difficulty walking

BW support treadmills may be more effective at restoring what?

Symmetrical gait

What 2 muscles attach to IT band?

TFL and glute max

Describe external snapping hip syndrome (most common)

TFL or glute maximus tendon as it inserts into IT band snaps over greater trochanter

What is traction?

Tensile force is applied manually, with a machine, or using patient's own BW and the force of gravity

Galeazzi sign

Test for infant hip dislocation, infant is supine w/ feet together on flat surface, femur will appear short on side of dislocation (femoral head is posterior to acetabulum)

Validity

Testing what you think you are testing

Thomas test

Tests for tightness of hip flexors

Annular rings are _____________anteriorly and _______________posteriorly

Thicker; thinner

Gravity assisted or inversion traction

Units available to general public

Osteoarthrosis will usually produce a ______________limited ROM

Universal

Laminotomy

Window is made into lamina

How do you rotate pelvis back anteriorly?

Work hip flexors

Intervention for spondylolisthesis once healed:

trunk strengthening, endurance, proprioception exercises

Q angle for males

14 degrees +/- 3

Normal hip drop

5-10 degrees

_____-_______ lbs during lumbar traction can reduce a disc prolapse, retracting the herniated discal material

60-120

TKAs are most performed on people ____-____ years old

60-80

Associated procedures w/ meniscal tears

ACL, PCL, articular cartilage repairs

Ischiofemoral ligaments is taut w/ ____________ and __________

ADD and IR

What are the 2 most common types of ACL reconstruction?

Autografts (patella bone and hamstring) and allografts (no consensus on which provides the most stability)

Precautions at 1-3 weeks

Avoid deep trunk flexion, high-velocity movements, valsalva, prolonged sitting

The hip angle normalizes w/ aging and weight _____________

Bearing

Clinical presentation of piriformis syndrome

Buttock pain that radiates to the posterior thigh and proximal lower leg . aggravated with prolonged sitting or walking, squatting, and positions that increase tension on the piriformis (hip adduction and IR) , pain decreases when lying down, bending the knee or when walking, knee flexion takes some tension off the nerve (not all patients can tolerate), isn't characterized by dermatome changes, myotome weakness, or diminished deep tendon reflexes, the patient may present with a limp when walking , knee flexed or when piriformis contracts it hurts , the patient may keep their leg in a shortened and externally rotated position while supine (splayfoot)

Upper extremity

DASH

When do patients start to ambulate after surgery?

Day of surgery or post op day 1, usually WBAT

You want to strengthen the ________stabilizers when you have weakness of the static stabilizers

Dynamic

Slow loading

Ligament deformation

MOI for disc

Often flexion or flexion w/ rotation

How can you rule out a stress fracture int he pelvis?

Patient is supine, SLR, then bend knee and flex more, sign of the buttock

Documentation of traction

Patient position, traction method, types of traction, magnitude of force, duration of traction, duration of hold/release periods, patient's symptoms before, during, after

CPR for stabilization

Patient's age >40 years old, average straight leg raise ROM >90 degrees, positie prone instability test, aberrant motions present in sagittal plane AROM

Goals of rehabilitation

Patients w/ acute symptoms are directions towards reducing pain and decreasing impairments; patients w/ chronic symptoms are less focused on pain and more focused on reducing anxiety and returning to participation in work, home, or athletic activities

Occurs when the pt reports the movement of pain from an area more proximal in the lumbar spine to an area more distal or lateral

Peripheralization

FABs result in...

Physical inactivity, reduced mental well being, assumption of sick roll, deterioration of family dynamics, dependence on medications, excessive utilization of medical services

Health Related Quality of Life (HRQL)

Physical, emotional, psychological, social

There is some evidence supporting manual therapy techniques directed toward the lumbar spine and SIJ as an effect _______-term intervention

Short

Patient selection for artificial disc replacement

Suffer from DDD, single level disease, failed conservative treatment

Injections treat ___________, not the __________

Symptoms; cause

Vascular pain

Throbbing, pounding, pulsating

Resting position of talocrural joint

10 degrees PF

Odd facet (or flexion facet)

Articulates only in full flexion (more medial)

Longitudinal (vertical) meniscal tears

Bucket handle tears (most likely to cause some type of catching or inability to get full knee extension or flexion), posterior horn or anterior horn tear

The medial plateau is ____shaped and the lateral plateau is ____ shaped

C; O

The annulus fibrosis has a ___________differentiation w/ nucleus when young

Clear

Where does the lower cluneal nerve come off?

Comes off the posterior femoral cutaneous nerve and goes up

Cauda Equina Syndrome

Compression of inflammation of the cauda equina results in paresthesia, anesthesia, paresis or paralysis, and possible B&B or genital dysfunction; nerve roots become chronically inflamed and adhere together

How do you perform inversion/eversion mobs on subtalar joint?

DF, shift calcaneus medially/laterally

Acute LBP w/ mobility deficits

Diminished ROM, pain worse w/ provocation of involved segments

MOI for PCL

Direct blow to front of tibia w/ knee flexed (most common), also forced hyperextension, can result from car accident in which posterior force is applied to tibia when the flexed knee hits dashboard

MOI of action for ACL injuries

Direct contact - 30% of cases Indirection contact - 70% of cases

MOI of quad contusion

Direct impact to muscle

What is a hip pointer?

Direct trauma to iliac crest

Posture w/ bulging disc

Disc occupies space and blocks extension, causing patient to flex

Pronation

Dorsiflexion, eversion, abduction

What are the menisci made of?

Fibrocartilaginous discs

What might the individual feel or hear after a MCL injury?

Immediate pain or feel/hear "pop"

Cons of minimally-invasive THA

Increased complications, smaller visual field/surgeon learning curve, skin integrity (greater risk for skin tears, infection), why fix what isn't broken?

Front feet of "scotty dog"

Inferior facets

Nerve roots are highly ______________ - react to compression

Innervated

Do you bear weight through the fibula?

Minimally

Females have a more ___________condylar notch

Narrow

Neck of "scotty dog"

Pars

To improve DF, what direction do you want to glide?

Posterior

What is the KT100 arthrometer?

Provides an objective measurement of anterior tibial translation, can be useful when pain and guarding preclude evaluation, can be used as part of the follow up exam after ACL reconstruction

Compression

Pt is supine, PT crossed their arms and pushes the ASISs away from the midline

Etiology of GTPS

Tendons of the gluteus minimus, medius and maximus and TFL attach directly or indirectly to the greater trochanter, the vastus lateralis increases the tension on the ITB because of its attachment to the greater trochanter, with hip flexion, the TFL pulls the ITB forward over the GT and with hip extension, the gluteus maximus pulls the ITB backwards over the GT, eventually the gluteus medius will tear from the repetitive friction, tightness of the ITB compresses and inflames the gluteal bursa; overuse and tightness of muscles that attach to the GT, contact sport or traumas

Cavitation

The cracking sound during a manipulation that is a result of...release of nitrogen gas within joint, breaking of adhesions within joint capsule, not necessary to attain improved movement

Are you better off with a vertical or transverse patella fracture?

Vertical b/c quad contracts and holds it together

You always want know _____ status from the surgeon

WB

What questions should you ask patients regarding their posture?

What does their job require? Do they sit most of the day? Do they stand most of the day? Do they walk most of the day? What leisure activities do they do? Does it require lifting, bending, and twisting? How often do they change their posture? How often do they reverse their posture?

Examination of lumbar stenosis

X-ray, MRI, CT scan, bone scan, EMG, NCV

Anterolateral rotary instability

ACL, LCL, posterolateral capsule, and arcuate complex

The classification system is intended for use in patients w/ _________LBP, however acuity is not strictly based on the total length of time the patient has had symptoms (based on severity of symptoms, goals, natural hx of condition)

Acute

Straights

All disease can be treated with manipulation, most everyone can and should have regular manipulation treatments to maintain normal health

All 4 ligaments of the knee are somewhat taut in what position?

All positions

For most people snapping hip syndrome is simple an _________________, however it may result in pain and weakness

Annoyance

Nucleus moves through torn ________ ________

Annular rings

Lateral ligaments

Anterior Talofibular (1st) Posterior Talofibular (3rd) Calcaneofibular (2nd)

What motion does the ACL resist?

Anterior shear of tibia on femur or posterior shear of femur on tibia , rotational shear in both directions

What surface of the patella is highly vascularized?

Anterior surface

Where does the vastus lateralis come off of?

Anterior surface of GT

ACl is a primary restraint to what action? Secondary restraint to what action?

Anterior tibial subluxation; rotation in both directions

Which direction does the acetabulum face?

Anterior, inferior, lateral

__________ make of 15% of reported cases and sports that involve repetitive end range hyperextension or hyperflexion w/ ABD and/or rotation - they are at risk for ___________tears

Athletes; labral

Reasons for PF pain w/o malalignment

Atraumatic PF OA, patella tendonitis, quadriceps tendonitis, IT band syndrome, prepatella bursitis, apophysitis (tendon attachment @ growth plate), bipartite patella (patella is split), oswood schlater's disease

Causes of lateral stenosis

Can be congenital, facet joint arthosis, loss of disc height, posterolateral bulge of IV disc or a growth within the IV foramen

Levels of Evidence - 3

Case controlled studies or retrospective studies

Levels of Evidence - 4

Case studies

Etiology of iliopsoas bursitis

Caused by RA, acute trauma, overuse, multiple mini-traumas caused by vigorous hip flexion and ext, when hip suddenly goes from flexion to hyperextension, there is tension that stretched the iliopsoas and the bursa, over time this can inflame the bursa

Chronic trochanteric bursitis (more common)

Caused by overuse (esp. cycling, running, swimming), results from repetitive compression and friction

Most common type of TKA

Cemented fixation- ambulating day 1 or 2, Cobalt-chromium alloy femur articulating with polyethylene tibial surface, All-polyethylene patella, Posterior cruciate substitution (Not enough evidence to say whether keeping or removing PCL is best)

Cemented vs. Cementless THA

Cemented technique: 98% survivorship @ 10 years, 93% survivorship @ 25 years Cementless technique: similar to above #'s for femoral component, and better w/ acetabular component at 15 year mark (now preferred method, especially in younger patients)

McKenzie also came up w/ the ________________phenomena

Centralization

The most important characteristic of patients likely to respond from specific exercise routines appears to be the presence of __________________

Centralization

The goal of treatment is to _________patient's symptoms and permit the patient to progress into another classification, most often a specific exercise or stabilization classification

Centralize

Effects of forward head posture

Cervical spine flexed, head on neck extended, all muscles of the subocciptal region are tight

What is snapping hip syndrome?

Characterized by a snapping sensation and/or audible "snap" or "click" in or around the hip when it is in motion

Pincer FAI

Characterized by bony growth on the superior-anterior aspect of the acetabulum, labrum is pinched b/t the prominent rim of the acetabulum and the superior-anterior head and/or neck of the femur

Legal issues of chiropractors

Chiropractic association believes that only chiropractors have been properly trained and that it should be illegal for any one else to perform the skill (it is in 2 states), chiropractors will perform modalities and exercise in the offices and wish to charge for PT services

How do you choose what position to place pt in?

Choice is related to being able to centralize or decrease symptoms

Pros/cons of metal ball w/ metal liner

Cobalt chromium alloy, more sizing options, allows for larger ball (more like natural joint, inc. ROM), fairly low wear rate, particles from wearing may cause inflammation, may perform better over long term, wear rate - 0.01 mm/year

Static tests

Compare relative positions of: ASISs, PSISs, iliac crests, pubic rami, depth of sacral sulcus, inferior angle of sacrum

What do patients typically complain of when they have lumbar spine hypomobility?

Complains of pain and stiffness, dull ache, may have LE referred signs, may have past h/o trauma, often unknown etiology, often sedentary, worsens with aging

Clinical findings for labral tear

Complaints of pain locking, catching, instability, giving way, and/or stiffness, anterior groin pain in 96-100% of cases, hip locking in 58% of cases, predisposing factor: coxa valga 87% of cases, c/o of clicking in the hip w/ (+) LR

Longitudinal tears are often ____, full thickness tears

Complete

Rotation - nucleus is ____________

Compressed

Provocation tests

Compression, distraction, knee to opp. shoulder, sheer, approximation, sacral compression, FABER, anterior and posterior rotation

Closed pack of subtalar joint

DF

Pre op education leads to what?

Decreased post op pain, medication use, LOS, and fear/anxiety

What should you do in preparation for traction?

Description of traction to patient, patient expectations, donn harness, position patient, explain/provide "kill" switch, set parameters, initiate treatment

Centralizing

Doing better

Most of the time, the _______ side of pelvis sits lower

Dominant

Precautions for anterior approach

Don't extend hip past neutral, no lying prone, do not ER or extend hip, do not perform bridging

L5 deramtome

Dorsum of the foot

Suitable but more risky

Downhill skiing, ice-skating, hunting, low-impact aerobics, volleyball, basketball, soccer, baseball

Slocum test for anteromedial rotary instability

Drawer test with tibia in ER

How does a quad strain occur?

Due to eccentric contraction or repetitive overloading during activity

The 2 most important factors for predicting success w/ manipulation are the _______ of symptoms and the lack of symptoms _____to the knee

Duration; distal

Correlation b/t medical imaging and LBP

False positive - 20-76% on subjects w/ no symptoms, 47% who had symptoms had positive findings (just b/c there is a positive finding does not necessarily mean the findings matches the patients complaints

Why are manipulations underutilized by PTs?

Fear of possible complications

Affective avoiders

Fearful and highly distressed, distorted significance of pain and condition of spine, will not attempt activities that might trigger pain, severely disabled, PTs need to address dysfunctional thinking, gradual exposure to fear activities

Prevalence of LBP (Level I evidence)

Females>males, inc. w/ aging, lower educational status, and jobs w/ higher physical demand

End plate

Fibrocartilage, serves as growth plate in child, transition point b/t body and disc, nutrition for disc from vertebral body

Where does the biceps femoris tendon insert?

Fibular head

How do you palpate the TFL?

Find ASIS and palpate just below it, attaches to IT band

How do you palpate the rectus femoris?

Find ASIS and slide ~ 1 inch distal and have patient extend knee

W/ meniscal tears, symptoms are frequently worsened by _______ and loading the knee

Flexing (squatting and kneeling are poorly tolerated)

PCL is most taut in ____________

Flexion

Common mechanisms of injury for lumbar spine

Flexion or flexion with rotation

Common mechanisms of injury for thoracic spine

Flexion w/ sustained flexion

Infant hips are most stable in what position?

Flexion, abduction, and ER

Motion detection tests

Forward flexion test, Gillet (Stork) test, long sitting test, posterior glide test

Chiropractors

Founded by David Palmer 1895, law of the nerve (relationship b/t nerves, muscles, joint, and general health), vertebrae can be subluxed, subluxation effects nerve and blood vessels at IV foramen (IV foramen is too small, this makes sense), impaired nerve function leads to disease, an adjustment or repositioning of subluxed vertebrae will release nerve and rehabilitate effected organs

Dengenerative meniscal tears occur most often in what decade of life?

Fourth and fifth decade

THA Indications

Fracture (due to fall), OA, RA, significant loss of function, failure of conservative treatment

Spondylolysis

Fracture of pars interarticularis, often begins w/ stress fracture, often caused by hyperextension trauma

What direction does the arcuate ligament run?

From fibular head it runs superior and medial

The goals for management for patients in stage II are more focused on improving more _______________abilities and avoiding ____________of symptoms

Functional; re-occurrence

Lumbar region can refer from...

GI, kidneys, bladder, uterus, ovaries, prostate, testicles

Proprioception treatment

Gait training (stride/step length, trunk rotation, arm swing), lumbopelvis stability, sit to stand correction, Trendelenburg correction, body supported gait training, aquatic therapy

How do you increase great toe extension?

Glide dorsally (concave on convex)

What is the most common injury in soccer?

Hamstring strain

What muscle group would you want to strengthen to prevent an ACL tear?

Hamstrings (prevent anterior translation)

Is taping beneficial? How do you perform taping?

Helps stimulate afferents; put ms in a slightly stretched position, origin to insertion (tends to come off in 24-48 hours)

Levels of Evidence - 1

High quality diagnostic studies, prospective studies, or randomized control studies

What structures in the posterolateral corner of the knee can affect rotatory stability?

IT band, biceps femoris tendon, lateral gastrocnemius, arcuate ligament, LCL, politeus tendon, popliteofibular ligament

Management of trochanteric bursitis

Ice, NSAIDS, activity mod, taping, e-stim, and possibly corticosteroid injection are used acutely to dec. pain, soft tissue and TP techniques to muscles attaching to GT, GM, and TFL, stretch hip flexors, ADD, IRs, strengthen hip ABD and ER, address leg length discrepancy

Etiology of hamstring strain

In the late swing phase, hamstrings are at their greatest length at this moment and generate max tension (contract eccentrically to decelerate flexion of the hip and ext of lower leg), strong hamstring contraction and quad relaxation is needed (lack of coordination results in hamstring tear)

What are some causes of patellofemoral pain w/ malalignment?

Inc. Q angle, lateral patellar compression syndrome, inadequate medial stabilizers, patella alta (too high), patella baja (too low), dysplastic femoral trochlea (if it is more shallow it can jump out of the groove)

Increased Q angle

Increased valgus, more likely to have an ACL, medial meniscus injury

Scarring from hamstring strains ____________risk of re occurrence

Increases

Risk factors for hamstring strains

Increases age (collagen is less elastic, mallard effect), hip flexor tightness (can cause inhibition of glute max), poor lumbopelvic control (anterior pelvic tilt), muscle fatigue, previous injury, overuse

Centralization was originally described by _______________ as occurring during lumbar movement testing when the patient reports the pain moves from an area more distal or lateral to a location more central or near midline position

McKenzie

Derangement dysfunction

Mechanical deformation caused by internal derangement (disc); constant or intermittent pain; certain motions cause either centralization or peripheralization of pain

Scoring for ODI

Min-disability: 0-20, patient education Mod disability: 20-40, problems w/ sitting, lifting, usually do well with conservative care Severe disability: 40-60, pain effects travel, personal care, sex, and sleep Crippling: 60-80, back pain effects all aspects of life 80-100 - bed bound or may be severely exaggerating symptoms

Who performs manipulations?

Osteopaths (a few MDs), chiropractors, PTs

What is the #1 intervention for poor proper?

Patient education

Femoral nerve tension test

Patient is in prone, passive extension of the hip (make sure to stabilize pelvis), then flex the knee and extend the hip, you can put patient in SL to help with passive movement

If sacrum is pushed to the left, it can put tension on _______________

Piriformis (can create symptoms that are radicular in nature)

Sciatica - always check the __________

Piriformis (could also be the superior and inferior gemellus)

What type of patient education should be performed prior to surgery?

Post op pain management, position restrictions, ambulation, rehabilitation progression

Buttock pain is associated w/ ____________labral tears and lumbar spine problems

Posterior

Ligaments of the SIJ

Posterior and anterior SI, interosseus, sacrotuberous, sacrospinous

Clinicians must take into account screening for medical ____flags and psychosocial ______flags in order to determine suitability for therapy

Red; yellow

What is GTPS?

Refers to chronic pain caused by a number of structures including trochanteric bursa, gluteus medius and minimus tendons and IT band, previously trochanteric bursitis was seen as main source of pain, but research now shows bursitis to be to be only component

Evidence based for outcome measures

Reliable and valid measurement tools, based on the opinion of effectiveness from the patient prospective

Goals of joint replacement surgery

Relieve pain, restore function and mobility

Discectomy and implantation of artificial disc

Removal of damaged disc, determination of correct implant size, verify size, correct placement and alignment by AP and lateral fluoroscopy and x-rays, insertion of endplates in the disc space followed by insertion of sliding core, final verification of the position of the implant

Goals of treatment

Restore mobility and function, decrease pain, avoid surgery, lack of literature on manual therapy and FAI

Sign of the buttock

Restriction of SLR concurrently with limited hip flexion and a non-capsular pattern of restriction of hip joint ROM

Clinical presentation of intra-articular snapping hip syndrome

Results from a sudden onset of snapping or clicking from a traumatic even to the hip capsule, sources of the snapping can come from intracapsular lesions, loose bodies in the acetabulum, a torn labrum, or idiopathic recurrent subluxation

S&Ss of quad strains

Same as HS strains, pain and weakness w/ resisted knee flexion, thomas test (kendal's test - modified thomas test that adds knee flexion)

Discs heal w/ ______ __________, making tissues less flexible

Scar tissue

LBP is generally_________

Self-limiting

What is joint distraction?

Separation of 2 articular surfaces, reduces compression on the joint surfaces and widens the intervertebral foramen

Hindfoot/rear foot

Talus and calcaneous, subtalar joint

Individuals who do not weight bear stay in coxa ____________

Valga

Most of the time a traumatic lesion is a _____ or a _________tear of meniscus

Vertical; longitudinal

Disc herniations are most commonly seen in what population?

Young adults

Spondylolysis occurs more in what population?

adolescent (athletic) and 2x more common in males than in female

why do patients with spondylolisthesis need to do proprioceptive exercises?

proprioception exercises (patients need to learn to feel where the limits are on their movements and be able to limit them during sports)

How can you clear the lumbar spine?

AROM, PROM w/ overpressures, quadrant positions, PA spring testing to lumbar spine, LLTT

AVN is fairly common in _______________

Childhood

Motions w/ males ______________@ puberty

Diminish

Where does the semimembranosus insert?

Medial posterior tibia

Chief complaints of meniscal tears

Pain w/ WB, locking and catching, episodes of giving way

Medial femoral condyle is ________AP

Smaller

Medical management of GTPS

Trochanteric bursectomy, IT band release, reduction-osteotomy of GT, glute med tendon repair, corticosteroid injections, platelet rich plasma injections

You are born w/ coxa _________

Valga (~170 degrees)

Up to ____% of patients can't be given a precise pathoanatomical diagnosis

90

Grade 4

A low velocity force (sustained or small amplitude) applied at end range

AVN of hip is due to injury of what arteries?

Circumflex

Motions of talocrural joint

DF/PF, small amount of ADD/ABD, inversion/eversion

Diastasis Pubic Symphasis

Separation of pubic symphysis, can occur w/ trauma, repetitive stress or postpartum

Always go into extension __________

Slowly (need to give them time to adjust to new position)

Xenograft

Taken from animals, bovine xenogratfs have been associated w/ high complication rate

grades 1 and 2 signs and symptoms are?

low back pain and or buttock and leg referred pain, feeling of instability with sudden movements, jarring movements, spine "gives out" legs may buckle

What are the 3 syndromes in the McKenzie classification system?

1) Postural 2) Dysfunction 3)Derangement

Nearly ____ will suffer from re-injury within the 1st year following a return to sport w/ subsequent injuries often being more severe that original ones (hamstring strains)

1/3

Coxa Vara

100 degrees

Sensitivity for clicking w/ labral tears

100%

Normal hip angle

125 degrees

Sickness Impact Profile (Generic)

136 items, 30 min to complete, physical tasks, psychosocial, emotional

Normal antiversion is ________degrees

15 (anything less is retroversion)

Normal rotation

15-25 degrees

Q angle for females

17 degrees +/- 3

Coxa Valgus

170 degrees

Posterior interbody fusion surgical procedure

1st a laminectomy is performed, next the posterior 2/3 of the disc is removed and an interbody graft is placed into the evacuated disc space, most surgeons use pedicle screws to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis

What % of people over the age of 70 suffer from hip OA?

20-30

What is a normal sacral angle?

20-30 degrees

Hip pain from FAI is more common in what age group?

20-40 years old

Par interarticularis may no reach maturity until age

25

Separation occurs w/ ______ of BW

25%

What should you start w/ at initial treatment?

25% of BW

What % of people have recurring episodes of dislocation?

30-50%

Risk of death w/ spinal surgeries are _________times greater

300

Arthritis affects over ____ million people in the US

32

Minimal Detectable Change for ODI

4-6 points, 10-15 points

Long-term risk of dislocation

4.8%, highest risk is 1st year after surgery

>_______ of all ACL ruptures have associated meniscal injuries

50

You need at least _____% of patient's BW to distract the lumbar facet joints

50

After THA through a posterolateral approach, how long are hip precautions continued for?

6 weeks (but may vary depending on surgeon)

Frequency of spondylolysis

6% of adult population w/ LB pain, 47% of adolescent population w/ LB pain, 2x more common in males than females, pars interarticularis may not reach bony maturity until age 25

Up to _____% of those who do recover are prone to reoccurrence

60

Effective separation is reported at _____-______ lbs

65-200

Mobilization

A low velocity skilled movement done at a velocity that a patient can resist

Care immediately after surgery

A suction drain may be used for 1-2 days after surgery, intravenous fluids & antibiotics, pain medication, compression stockings and blood thinners, hip precautions based on type of approach (may be kept for 6-8 weeks or longer, some surgeons leave precautions indefinitely)

What is a resurfacing arthroplasty?

A surface replacement preserves the head and neck of the femur and only removes the diseased portion, preserved portion is sculpted to accept a metal cap w/ a short stem, acetabulum is replaced by the same procedure in a THA

Subgroups

Acute LB pain with related referred symptoms Acute LB pain with radicular symptoms Subacute LB pain with referred symptoms Subacute LB pain with radicular symptoms Chronic LB pain with referred symptoms Chronic LB pain with radicular symptoms

Labral tears can be ________ or__________

Acute or chronic

What are the 2 types of trochanteric bursitis?

Acute, chronic

ACL neuromuscular prevention programs include what?

Balance training, jump training (landing w/ inc. flexion at the knee and hip), strengthening (emphasize proximal hip control through hip ABD, ER, and hamstrings), skill training (controlling body motions, esp. deceleration and pivoting maneuvers), movement education, agility training

Clinical presentation of BOTH hip OA and FAI

Both present w/ + tests for FABER and FADIR, both present w/ dec. hip flexion and IR, patients w/ hip OA often develop osteophytes and bony overgrowth of the acetabular rim and femoral head

Interventions for hypermobility

Braces or corsets, patient education (keep out of end range postures and activities), strengthening and endurance, proprioception exercises, spine and neutral exercises

McMurray's test (meniscus)

Bring patient into full end range knee flexion, ER - medial, IR - lateral and drop them down into extesion

Risks of manipulations

Cauda Equina Syndrome (1 in 100 million), cervical brain stem lesions and vertebral artery injury (3-6 per 10 million), HA, muscle soreness, fatigue

Ref flag conditions

Cauda Equina Syndrome, infection, spinal compression fractures, abdominal aneurysm

____________evidence as to whether obese patients have lower functional gains and higher complication rates

Conflicting

Grades of Recommendation - D

Conflicting evidence, high level studies disagree

Causes of central stenosis

Congenital narrowing, thickening of ligamentum flavum, bone spurs, central disc bulge, growth within central canal (tumor)

What motions occur at the talocrural joint?

DF and PF (sagittal plane - medial/lateral axis) ABD and ADD (transverse plane - vertical axis) Inversion and eversion (frontal plane - A/P axis)

Colles fracture (dinner fork deformity)

Distal fragment goes dorsally

Depth of sacral sulcus

Divot that is medial to PSIS

Interventions for acute LBP, radicular

Education to reduce nerve root symptoms, manual, traction, nerve root mobilization

Desired effects of traction on soft tissue

Elongation of spine increases the distance between vertebral bodies and facet joint surfaces to increase the length of soft tissue/ligaments, stretch occurs slowly

Male and female children have _______motion

Equal

Disadvantages of Unicompartmental arthroplasty

Error in proper placement of components, loosening, prosthetic wear, secondary degeneration of opposite compartment

Examination of Spondylolithesis

Lower quarter screen, palpation for step deformity, PA glides

Examples of soft tissue mobilizations

Muscle relaxation, massage, trigger point techniques (high volt estim through sound head), deep pressures, myofascial release

Quad strains typically occur where?

Muscle-tendon junction (distally to proximally and sometimes muscle belly itself)

Mobs to midtarsal joint

One hand on talus and calcaneus, one hand on cuboid and navicular

Clinical findings for a posterior impingement

Painful ER in full extension w/ leg hanging off the end of table and uninvolved leg flexed

FABER test

Passively position the hip in flexion, ABD, and ER, (+) test = pain, this test doesn't tell you where the problem is, it tells you where to look next (hip joint, labrum, SI joint)

What is the largest sesamoid bone in the human body?

Patella

Excessive antiversion

Patellas are facing medially, compensate w/ hip deep ERs (piriformis syndrome), risk for femoral acetabular impingement, associated w/ ACL injuries

Classification category does not describe a _________________condition such as HNP

Pathoanatomical

Posterior sag test/Godfrey sign

Position passively patient at 90 degrees of knee flexion (table top position), compare both sides, positive side you will see a sag at the tibial plateau

How does the trochanteric bursa sit?

Posterior and inferior to trochanter

Anteromedial rotary instability

Posterior horn of medial meniscus, oblique popliteal ligament, ACL, MCL

What direction does the PCL run?

Posterior lateral on tibial plateau to anterior medial on lateral side of medial condyle

What direction does the PCL resist?

Posterior shear of tibia on femur or anterior shear of femur on tibia, rotational shear in both directions, ER

3 plane articulations b/t talus and calcaneus

Posterior talocalcaneal (70% of articulating surface, independent joint capsule, concave talus on convex calcaneus), anterior and medial talocalcaneal (share a joint capsule w/ talonavicular joint, convex talus on concave calcaneus)

PCL is primary restraint to ________________ and secondary restrain to ________________

Posterior tibial translation; hyperextension and tibial rotation

What are the common approaches to THA?

Posterior, lateral, posterior-lateral (incision is lateral and slightly anterior to trochanter), anterior (preserves musculature - b/t fibers of sartorius and TFL)

During flexion the menisci move ____________ via the semimembranosis and lateral meniscus via popliteus

Posteriorly

Lesser trochanter faces _______________, when muscle shortens it allows you to ______________

Posteriorly; ER

When in decreased lumbar lordosis, the pelvis is ___________ tilted and the ____________ and ______________are tight

Posteriorly; gluteals and abdominals

Reasons for traumatic PF disease

Posttraumatic OA, quad tendon rupture, patella tendon rupture, avulsion of tibial tubercle, contusion

Distraction

Pt is supine, PT presses the ASISs toward the midline

Traction is effective to reduce __________ symptoms in the C-spine

Radicular

Hamstrings are often re-injured due to inadequate __________ and _____________return to activity

Rehab; premature

All tendons go under a____________ w/ synovial sheath when they cross your ankle

Retinaculum

Weeks 3-8 following Lumbar Microdiscectomy

Return to work and ADLs, adhere to surgeon guidelines for lifting and activity/sports, pt able to walk on level surfaces w/o restrictions, advance TA exercises, advance glute/bridging exercises, advance hip strengthening (esp. hip abductors), initiate nonimpact LE involved cardiovascular exercise (pool workouts, treadmill, elliptical, stationary bike)

Weeks 8-12 following Lumbar Microdiscectomy

Return to work without restrictions, objective measures improve, release to activity base on achievement of goals and MD clearance

ROM exercises/stretches

SKC, DKC, piriformis stretch, lower trunk rotations, hip flexor stretches, pelvic tilts

DD of piriformis syndrome

Si dysfunction, HNP, tumor, cyst (hematoma), FAI, tabeal tear, hip OA, spinal stenosis

Traumatic chondromalacia (formerly patellofemoral syndrome)

Sick cartilage, degenerative changes in cartilage on posterior side of the patella

Indications for lumbar fusion

Significant trauma, degenerative disc or joint disease, hypermobility (spondylolithesis), severe, disabling back and/or leg

Best results based on ________and not anatomical structures, as it is impossible to be sure what anatomical structures are causing pain

Signs and symptoms

Outcomes of artificial disc replacement

Similar to lumbar fusion w/ respect to functional outcomes and pain relief, further research needed to determine if disc replacement reduces rate of adjacent segment disease compared with fusions, disc replacement products are being developed for lateral or posterior approaches

Patella alta

Sits too high and is associated w/ subluxation/dislocation, OA of PF joint, and patella ligament ruptures

McKenzie Principles

Sitting causes lumbar spine to flex, stressing ligaments, and increasing disc pressure; dec. in lumbar ROM further influences poor posture; healing of a disc after injury results in adaptive shortening

Grade I strain (mild)

Small % (<20) of fibers are damaged, rarely influences the muscle's power and endurance, pain and sensitivity usually happen the day after the injury, C/O stiffness and minimal swelling on the back of leg, ROM minimally impaired and gait may be normal

Intermittent traction

Stimulation of mechanoreceptors through oscillations - stimulates the GTO which leads to muscle relaxation and spasm reductions (Gate Control Theory); brief intervals; "on/off" cycles; distraction, mobilization, stretching

Inverter =

Supinator

Complete meniscal tear

Tear runs through both the superior and inferior surfaces

What is the #1 sign of a pars fracture?

Tender w/ PA pressures to spinous processes

Clinical presentation of trochanteric bursitis

Tender w/ palpation to superior/posterior greater trochanter, symptoms may radiate laterally or posteriorly down the thigh, resisted isometrics may be strong and painful or weak and painful (hip ABD, ER), walking, running, esp. stairs are painful, difficulty laying on the affected side, sleep may be affected

Surgical fusion procedure

The basic lumbar fusion is posterolateral, incision is made over the operative levels, and the paraspinals are separated off the SP, lamina, and TP, retractors hold back muscles to expose the bone for fusion, a high-speed burr removes the TP and facets in preparation for bone graft, pedicle screws and interbody cage are inserted

Global lumbar musculature

The large lumbar erector spinae provide most of extensor force needed for lifting; rotation is a complex movement that requires co-contraction of several ms groups (erector spinae, transversospinalis, obliques); ms groups do not have a direct attachment to the lumbar spine and can't control the motion of individual segments

Secondary pirformis syndrome

The result of macrotrauma (fall or microtrauma from repetitive overuse)

Grades of Recommendation - E

Theoretical/foundational evidence animal or cadaver studies, conceptual models, base science

What do chiropractors claim?

They were the first to develop manipulation and that others are infringing on their scope of practice

What patient typically goes to in-patient rehab after a THA?

Those who are able to tolerate at least 3 hours of therapy a day and have a good chance of returning home, typically older patients w/o family support and patients w/ comorbid medical conditions

What patient typically goes to a SNF after THA?

Those who cannot tolerate 3 hours of therapy a day and are not at risk for medical instability

Most susceptible athletes to pars fracture

Those who do frequent end range lumbar spine hyperextension: linemen in football, gymnasts, swimming and diving, wrestling, volleyball, cheerleaders, weightlifters

Condylar TKA

Tibial component is topped w/ a flat metal piece that securely holds the polyethylene insert, when knee is in motion, the femoral component glides over the polyethylene, natural shape of condyle is not a perfect circle

Posterior deep musculature

Tibialis posterior, flexor digitorum longus, flexor hallucis longus

Tom Dick and A Very Nervous Harry

Tibialis posterior, flexor digitorum, artery, vein, nerve, flexor hallucis

What 2 joints make up the knee?

Tibiofemoral joint and patellofemoral joint

If butt raises off the table during Ely's test, what does this indicate?

Tight hip flexors

What can a positive FABERs test indicate?

Tight hip flexors, adductors, joint capsule

Possible reasons for hip hypomobility

Tight joint capsule, hip adductors, hip flexors

A hypomobile individual typically presents with the following:

Tight muscles, tight joints, flattened lumbar lordosis, spine flexion, feet more supinated, overall limited mobility in most joints

Men tend to have _________ligaments than females

Tighter

Emotional (increased sympathetic nervous system)

Tiring, agonizing, dreadful, unbearable

W/ a more central bulge, the patient tend shift _________side of bulge

Towards

Action of proximal tibia

Transfer weight across knee to ankle

Proximal tibiofibular joint

Transfers forces from biceps femoris & lateral collateral ligament to tibia (ant and post proximal TF ligaments)

Degrees of translation and rotation at joint

Translation - 0-4 mm Rotation - 0-5 degrees

Functions of the knee

Transmit loads, allows lengthening and shortening of LE, provides stability for WB, provides mobility for functional movement

The menisci are attached anteriorly via the _______________ligament

Transverse

Layers of the cervical region (superficial to deep)

Trapezius, splenius, erector spinae transversospinalis, subocciptals

Symptoms for a ___________meniscal lesion are produced by instability of the torn fragment

Traumatic

Weak hip ABDuctors results, results in a ________________gait

Trendelenburg

Uni space implant

Used for isolated medial tibiofemoral OA, metallic spacer that distracts the medial compartment and transfers load to lateral side, meant to replicate shape of medial meniscus, doesn't require bone cuts or component fixation, results in good relief of pain, minimally invasive, higher rate of implant failure due to medial overhang

Intervention for spondylolithesis

W/ fracture: often brace in neutral, avoid end ranges especially extension and rotation Once healed: trunk strengthening, endurance, proprioception exercises

Rehabilitation

WB status, hip strengthening (hip extension, ABD, knee ext), balance, ADLs, beware of orthostatic hypotension

What is the #1 activity recommended by surgeons and PTs following lumvar surgery?

Walking (to prevent blood clots)

What are signs of infection?

Warmness, redness, low grade fever

Causes of TJA failure

Wear of articular bearing surface, aseptic/mechanical loosening, osteolysis, infection, instability, per-prosthetic fracture, implant failure

Timing of TJR failure (later >5 years post op)

Wear of articular bearing surface, osteolysis, mechanical loosening, peri-prosthetic fracture

What is the #1 most important piece of information to know about patient after hip surgery?

What is their WB status

Spondylolysis

a fracture of the pars interarticularis (bt superior and inferior facet), often begins as a stress fracture, often caused by a hyperextension trauma (you compress facet and put extra force through pars)

Neutral Zone

area in range of motion segment where there is little resistance to motion, mid range, muscle function limit and stabilize motion segments in this area of range (muscle control things in neutral zone)

Spondylolisthesis

forward displacement of one vertebral body over another, most commonly occurs at L5, S1, Second most common is L4, L5

Mechanism of Injury for spondsylolysis?

hyperextension of the lumbar spine resulting in a repetitive loading of the facet joints and pars interarticularis, Pars ma be congenitally thinner or not completely formed

Intervention for spondylolisthesis with fracture:

often brace in neutral, avoid end ranges especially extension and rotation.

Grade 1 for Spondylolisthesis

superior vertebrae migrate anterior0-25% over the inferior vertebrae

Degrees of nutation and counternutation of sacrum

~0.5 degrees

Recommendation for conservative care (time frame)

6 months

Total costs associated w/ arthritis are over $____billion/year (including hospital and drug costs, rehabilitation costs, and lost productivity and work)

82

Clinical Prediction Rule for those most likely to improve w/ manipulation

82% show significant improvement when... Onset less than 16 days, no symptoms below knee, lumbar stiffness, hip IR <35 degrees

Bony lesions have been reported in _____-____% of ACL injuries

84-98 (often either lateral femoral condyle, lateral tibial plateau, or both due to compressive forces)

How do you measure the Q angle?

ASIS to mid patella, mid patella to tibial tubercle

Hybrid fixation

Acetabular cup (press fit, fixation screws), femoral stem (cemented)

Describe process of acetabular reaming

Acetabular cup is reamed into a hemisphere, cartilage is removed

Musculoskeletal S&Ss

Aching, dull, sore, stabbing, sharp

How are TKAs different these days?

Admitted morning of surgery, mobilize day of surgery or 1 day post op, usually WBAT, LOS <1-2 days

Cognitive Behavioral Therapy (CBT)

Aims to address fears related to movement, pathology, and function

Extension - nucleus moves _____________

Anterior

Which approach is more technically demanding?

Anterior

Closed chain - screw home mechanism

As knee extends femoral condyles rotate medially on fixed tibia; no muscle action necessary due to shape of joint

In the absence of ________ __________syndrome or significant neurological deficits, conservative care is advocated before recommending surgery

Cauda equina

Partial meniscal tear

Compromises 1 surface

Typical MOI for ACL injury is what time of movement?

Cut-and-plant movement or a sudden change in speed w/ the foot firmly planted

A traumatic meniscal tear is more likely to require surgery than a _________tear

Degenerative

What should the focus of any post op program be on?

Early activation of hip extensors, ABD, and knee extensors

High-speed activities (such as cutting or landing maneuvers) require ___________muscle action of the quads to resist further flexion

Eccentric

Indications for surgery

Failure of conservative treatment (4 weeks-6 months), unbearable pain, significant or increasing neurologic deficit, cauda equina syndrome (absolute indication)

Indications for TKA

Failure of conservative treatment (NSAIDS, activity modification, PT, bracing and orthotics), intractable pain w/ loss of function

Specific exercise

Flexion, extension, lateral shift patterns

Why should individuals who are hypomobile stretch?

For pain (rocking rhythmic), to warm tissue, to increase mobility, to increase strength, endurance, and stability into a new range, to maintain improvements over time

Acute LBP

For some individuals can be greatly heightened following an episode of acute, severe LBP; avoidance behaviors may persist long after the acute injury has resolved

Exercises should focus on _______________tasks such as lifting

Functional

Clinical presentation of external snapping hip syndrome

Gradual onset of snapping or pain laterally over the greater trochanter, usually not associated w/ a major traumatic event, observable and audible snap as patient flexes and extends the hip, may describe a sense that the hip is dislocating, may have coxa vara or a prominent greater trochanter

ALIF alone can't withstand the forces across the ______, so many collapse or don't fuse

Grafts (protected w/ posterior instrumentation)

An increase in the neutral zone requires what?

Greater muscle performance (strength, endurance, proprioception)

Outcome measure for THA

Harris hip score, FIM, Oxford hip score, WOMAC, SF-12, 12-item hip questionnaire, VAS, overall satisfaction

Secondary restraint

Has some significant function in resisting displacement but isn't the major restraint, ex: MCL - primary restraint to valgus force, but secondary restraint if you take it far enough

Quadriceps active test

Have patient actively fire quads and see degree of tibial movement

How can you tell the difference between neurogenic and vascular claudication?

Have patient ride a bike, sit up nice and straight, then ride bike again in a flexed forward position (if it is better flexed forward, it is probably neurogenic) - can also perform on a treadmill (walk on incline)

Slipped capital femoral epiphysis

Head separates from the neck, usually seen in obese adolescent males

Ilium surface

Hyaline and fibrocartialge

Sacral surface

Hyaline cartilage (1.5-3x thicker than the ilium)

Other less invasive options

Hyaluronic acid or cortisone injections, Uni Spacer implant, unicompartmental athroplasty

Abdominals, spine extensors, diaphragm and pelvis floor muscles make the trunk a semi-rigid cylinder and tighten the TL fascia and abdominal fascia - what is this effect called?

Hydraulic effect

Who is most likely to benefit from manipulations?

Hypomobile joints, those that did not respond to low velocity techniques, no radicular symptoms

As you age, your collagen tends to bind together and you become _____________; you lose ______, tissues become more brittle

Hypomobile; GAGS

If knee is unstable in full extension, it is suggestive of what?

LCL/PCL injury

Patient hx of disc problems

Many small bouts of LBP over many years, usually resolves on its own w/ rest, each time it gets a little worse, LBP, worse w/ sitting and bending, begins in 20s, eventually pain goes from back to back and buttock and down LE

Symptoms of an isolated PCL injury

Minimal pain, swelling, instability, and full ROM, may also have near-normal gait pattern

In hypermobile individuals, you either have too much ________ or not enough _____________

Mobility; control

Traditionally, ___________assessments and _________tests have been used to classify a patient as needing manual therapy

Mobility; special

What are the 4 basic categories used for patients w/ acute LBP?

Mobilizaation/manipulation, stabilization, specific exercise, traction

What can facilitate a deeper stretch prior to interventions for hypomobility?

Modalities - warm tissues stretch better (i.e. hot pack)

Interventions

Modalities to calm inflammation of SIJ capsule and ligaments, local muscle attachments, attempt to correct pelvic asymmetry, correct asymmetry of position of sacrum b/t iliums, SIJ support belts (good for hypermobile individuals)

MRA

More sensitive test for labral lesions than the standard MRI and would help rule out intra-articular injury prior to the more invasive arthroscopy

Do most people tend to have tibial antiversion or retroversion?

Most have retroversion because femur is rotated in (tibia is rotated out)

Differential diagnosis for FAI and labral tears

Muscle strain, contusion/hip pointer, dislocation or subluxation, osteitis pubis, trochanteric bursitis, stress fracture, infection, AVN, referred lumbosacral pain, cancer

W/o any ____________activity the lumbar spine is a highly unstable structure even under low loading

Muscular

Should you manipulate if you have radicular symptoms?

No

How long do non-constrained knee replacements last?

Not as long as other knee replacements

Clinical presentations of ACL injuries

Occurs after either a cutting maneuver, landing, or jumping, may be a audible pop, feeling of initial instability which may be masked later by extensive swelling, episodes of "giving way" especially on pivoting or twisting motions, initially injury is extremely painful, swelling may be immediate and extensive, but can be minimal or delayed, restricted movement, especially inability to fully extend

S&Ss of quad contusion

Pain, loss of function, decreased ROM, decreased strength, effusion

Exercise routines involving repeated movements into end-range spinal motion have been _____________ over the years

Popularized

Flexion - nucleus moves ___________

Posterior

What position does your foot and ankle need to be in to adapt for the shape of the floor?

Pronation

More abducted =

Pronator

Interventions for weeks 1-3

Prone press-ups to tolerance from slight flexion to neutral, prolonged prone ext 30 seconds to 2 minutes w/ pillow/cushion under stomach, treadmill w/ an initial goal of 5 minutes (progression to 30 minutes), aquatic therapy (once cleared by MD), cryotherapy post-therapy and prn for pain, review bed mobility, sit to sand, utilization of UE, LE nerve glides, TA activations, gluteal/hip strengthening

__________________ is key in order for muscles to control within this range (neutral zone)

Proprioception

Sheer

Pt in supine, PT flexes and abducts the hip, PT then compresses downward along the line of the femur attempting to create a shear force alone the SIJ

What is the patella held in place by?

Quadriceps mechanism (patella tendon and ligament)

What muscle group would you want to strengthen to prevent posterior translation?

Quads

Pros of minimally-invasive THA

Quicker recovery, cosmetic appearance, less perceived invasion of the body, patients are asking for MITHA

Interspinous decompression spaces

Separates the SP to relieve pressure, not indicated for stenosis > 2 levels, supraspinous ligament prevents backward migration, spacer only limits extension

What are the desired effects of joint distraction?

Separation of joint surfaces (OA, menisci, osteochondral fragments, portions of capsule that "catch" or impinge joints), increase joint mobility, increase proprioception (may contribute to pain modulation), nourish articular cartilage

When should you refer to a surgeon?

The patient fails to respond to PT, joint injection does not provide relief, MRA

When should SLRs be allowed?

When partial or full WB is permitted

Clinical presentation of labral tears of hip

"C" sign, deep ache w/ prolonged sitting or standing and hip flexion type movements

Etiology of snapping hip syndrome

5% of the population (higher prevalence b/t 15-40 years old), occurs more in females, typically an overuse injury, occurs in activities that involve repetitive hip flexion and extension (such as dance, soccer, gymnastics, and running)

_______% of cases (piriformis syndrome) are due to macrotrauma of the buttocks, leading to soft tissue inflammation and muscle spasms, with resulting nerve compression

50

During a step up, there is up to ____x the person's BW through the hip

6

Ratio of piriformis syndrome female to male

6:1

The lifetime prevalence of at least 1 episode of LBP is as high as _______%

80

What is the typical length of stay after a THA?

<5 days

How common is combined FAI?

>80% of cases according to some reports

Pars interarticularis ("scotty dog")

A bony isthmus b/t the superior and inferior facet joints of the spine

Grade 5

A high velocity, short amplitude force applied at end range

Standard ________ or__________view will not give you a great view of the hip

AP or lateral

Diastasis Recti

Abdominal separation

Etiology of quad strains

Acute - single event Chronic - result of repetitive micro trauma

Children w/ CP have a lot of tone in their hip_______________

Adductors

Requirements of proper posture

Adequate ROM, muscle length, muscle strength and endurance

Use of test

Administer at initial evaluation, as needed, and at discharge; establish a goal for change; document changes in chart

Evidence that low-stress ___________exercise may be effective in treatment for acute or chronic LBP

Aerobic

Signs of cancer

Age >50, unexplained weight loss, previous hx of cancer, no relief w/ treatment in last month

Degenerative tears are due to _______ as well as activity levels (long-term ________ forces)

Age; compressive

Disc function

Aide in mobility, restricts mobility, annulus acts as ligament, provide space b/t vertebra, keeps IV foramen open, acts as shock absorber, normally - even distribution of forces throughout disc

Classification of instabilities - straight

Anterior, posterior, medial lateral

What are the 2 bundles of the PCL?

Anterior-lateral, posterior-medial

What are the 2 bundles of the ACL?

Anterior-medial, posterior-lateral

Elastic Zone

Area of range in which there is substantial resistance to motion, end range, provided by ligments and tight musculature, facet joint capsules, disc

Elastic zone (end-range)

Area of range in which there is substantial resistance to motion; provided by ligaments and tight musculature, facet joint capsule, disc

Shape of talus

Articular surface (talar dome) is wider anteriorly than posteriorly (making DF most congruent)

Non-constrained knee replacement

Artificial components inserted into the knee are not linked to each other, rely exclusively on the body's muscles, ligaments, and tendons to keep kneecap in place, no stability built into system, most common type of knee replacement; used when the knee is highly unstable and the person's ligaments will not be able to support the other type of replacement (severely damaged knee), 2 pieces are connected w/ a hinge-like device that keeps the joint inline and helps support the patella's proper alignment

Open chain - screw home mechanism

As knee extends tibia rotates laterally in the last 30 degrees of motion; due to shape of joint surfaces, pull of quads and PCL

Posterolateral corner injury

Associated w/ rupture of one or both cruciate ligaments, failure to address instability of these corner structures increased the forces at the ACL and PCL graft sites and may predispose to failure of cruciate ligament reconstruction

DD of hamstring straings

Avulsion fx of ischial tuberosity, adductor strain, referred lumbosacral pain, piriformis syndrome, SI dysfunction, sciatica, hamstring tendinitis, ischial bursitis

Extension protocol

Begin in position of comfort (the way they came in the door but now supported in prone), slowly progress to extension w/ passive positioning (leave in positions for 5-10 minutes), progress to prone on elbows and prone press ups (slow), must do often at home and avoid all forms of flexion

S&Ss of recurrent subluxation

C/O of pain (difficult to localize), giving way (could also be meniscus or ligamentous injury), feeling of instability, pseudo locking, "something jumps in my knee", "something feels out of place"

Combined FAI

CAM and Pincer can occur together

If the spinal cord is affected, there will be ___________signs

CNS

Is a pars fracture unilateral or bilateral?

Can be either

Apley's test (meniscus)

Can be most painful, so do it last! patient is prone, compression and IR/ER of lower leg

Progression of degeneration

Can begin in teens (breakdown of innermost annular rings), fissures b/t annular rings, fissures across annular rings, nucleus bulging through fissures, outer rings bulge, nucleus protrudes through (radicular symptoms if on nerve root), sequestration of nuclear material

Diagnostic procedures - MRI

Can diagnose ligamentous injuries w/ an accuracy of 95% or better, will also reveal any associated meniscal tears, chondral injuries, or bone bruises

Symptoms of meniscal tears

Can result in locking of the joint (especially "bucket-handle tears"), "popping and locking" occur when torn part of meniscus moves under the femoral condyle, medial or lateral line joint pain may occur due to abnormal increase in tension on the joint capsule

Tibial plateau fractures

Cause my varus or valgus forces w/ axial loading, lateral tibial plateau fractures (Segond fracture) are most common

History of SIJ dysfunction

Cause?, trauma? (fall, lifting injury, MVA), unknown etiology?, symptoms (LBP or buttock pain), muscle spasms (LB, gluteals), sensory changes (not normally, but could irritate nerve root)

Intervention for posture syndrome

Change posture, patient education

What is piriformis syndrome?

Characterized by buttock or hip pain , Neuritis of the sciatic nerve

Nerve root can be ___________ irritated when in contact w/ nuclear material

Chemically

What is the main cause of GTPS?

Chronic friction of the glute medius tendon over GT (glute min and TFL can also be affected - friction of these tendons leads to a secondary inflammation of the bursa)

Describe the lateral meniscus

Circular or "O" shaped, less extensively attached to joint capsule, no attachment to LCL

As a child, hip joint relies heavily on the artery to the femoral head; Adults rely more on _______________ arteries

Circumflex

Neurogenic claudication

Compression of nerve roots results in: Antalgic gait, paresthesia, cramping of muscles in one or both LE with activities such as walking; tend to be in a more flexed position (open packed)

DF closed chain

Concave on convex (anterior roll and glide)

PF closed chain

Concave on convex (posterior roll and glide)

What are fear avoidance beliefs?

Concerns and fears about potential for physical activities to produce pain and further injury to the spine; result in heightened anxiety, an obstacle for recovery and potential disability

How are degenerative meniscal tears most treated?

Conservative treatment

Red flags w/ LBP

Constant pain not affected by positions or activity, over 50, h/o CA, failure of conservative intervention over 30 days, unexplained weight loss, no relief w/ rest

MOI for anterolateral rotary instability

Contact/Non-Contact , hyperextension with varus and IR stress, IR of tibia or ER of femur

MOI for anteromedial rotary instability

Contact/Non-Contact, flexed knee and valgus stress, ER of tibia or IR of femur

PF open chain

Convex on concave (posterior roll, anterior glide)

Exercises for Spondylolithesis

Core strengthening w/ proper posterior tilt, strengthen abdominals and gluteals, tighter hamstrings will limit anterior tilt of pelvis (maybe not stretch?), proprioception exercises, fine control pelvic tilts, pelvic clocks, spine neutrals, short range exercises, isometrics

The menisci are attached to the tibia via ___________ligaments

Coronary

Interventions

Correct lateral shift, posture, modalities, exercise, mobilization, traction, brace w/ extension

How do you know if treatment is successful?

Correction of alignment, symmetry of motion, relief of pain

Suitable sports and activity recommendations

Cycling, swimming, low-resistance rowing, walking, hiking, low-resistance weight lifting, ballroom dancing, square dancing

Clinical force _______ ________equal functional forces

DO NOT

Post op complications

DVT (swelling, change in temperature, pedal pulses, gold standard - Doppler), leg length discrepancy, infection, nerve palsy, dislocation

What is the role of pre-op education?

Dec post op pain, medication use, LOS, and fear/anxiety

Vascular claudication

Decreased circulation results in: antalgic gait, paresthesia, cramping of muscles in one or both LE w/ activities such as walking; might get referred to a Doppler; more common in older adults

________portions of the MCL have extensive attachment to the meniscus and capsule

Deep

What part of the MCL typically gets damaged first?

Deep part of ligament, which may lead to medial meniscal or ACL damage

Squat/sit-to-stand observations

Deep squat has evidence of validity in FAI, decreased WB on involved side

Paget's disease (osteitis deformans)

Deformation of bone due to re-absorption and formation of bone leading to a cycle of softening and thickening, deformity of vertebra leads to central or lateral stenosis or both, most common in older adults, congenital condition

Some individuals recover w/o intervention or recovery can be _______________

Delayed

Subtalar ligaments

Dense connective tissue structures, interosseous (talocalcaneal) and the cervical ligaments (functions to control extremes of ROM into inversion and eversion), easily scar w/ injury

What is the clinical prediction rule (CPR)?

Designed to assist in the classification process and improve decision making by using evidence to determine treatment strategies most likely to benefit patient w/ particular characteristics; multiple factors from a hx and exam to predict a priori which patients will most likely benefit from manipulation

Global patellar pressure syndrome

Develops secondary to localized trauma or immbolization, fibrosis of surrounding retinaculum, hypomobility of the patella medially, laterally, and superiorly, may result in patella baja

Both genders have __________motion w/ age

Diminished

Elderly

Diminished strength of spine extensors, degenerative disc and joint disease, posture becomes more flexed, forward head, increased thoracic kyphosis, flattened lumbar lordosis, may ambulate with flexed hips and knees, wider BOS, less energy efficient

Some patients will not centralize symptoms w/ movement, but do display a ________________preference

Directional

What is the gold standard for HNP surgery?

Discectomy (often done w/ laminectomy or laminotomy)

Types of decompression surgeries

Discectomy, laminotomy, laminectomy, foraminotomy

Coxa valga - increased risk of hip____________

Disclocation (femoral head is not well covered by acetabulum), worse w/ adductor spasticity

Misinformed avoiders

Discouraged, pain indicated harm and spine is vulnerable, hyper vigilant but will to try limited painful activates, mild to moderate disability, PTs need to challenge beliefs about importance of pain and restore confidence in spine

Learned pain avoiders

Discouraged, pain is benign, spine is sound but pain may be avoided, value of pain, must be avoided, mild to moderate disability, PTs need to utilize exercise and modalities to desensitize for pain

Children who never properly WB are much more likely to __________hips (CP)

Dislocate

Timing of TJR failure (early <10%)

Dislocation, infection, implant failure

Smith's fracture

Distal fragment goes palmarly

What are the desired effects of spine traction?

Distraction and separation of vertebral bodies, distraction and gliding of facet joints, tensing of ligaments and joint capsule, widening of the intervertebral foramen, stretching of the spine musculature

Precautions for posterior approach

Do not flex hip greater than 90 degrees, do not IR the hip beyond neutral, do not ADD past neutral

Fear Avoidance Beliefs (FAB) are derived from...

Emotionally based fears of pain and injury, information based beliefs about soundness of the spine, cause of spine degeneration, importance of pain

Effects of faulty posture

Energy insufficient, prolonged end range stresses, prolonged uneven loading of the IV discs, poor articular cartilage and disc nutrition, excessive lengthened or shortened muscles

What musculature is tight with hypomobile individuals?

Erector spinae, hamstrings, iliopsoas, rectus femoris

Loose pack of subtalar joint

Eversion (pronation)

Pronaton

Eversion is the main component, heel turns out, abduction is second component, foot points from midline, small component is DF

CAM FAI

Excessive "bump" in the superior-anterior femoral head-neck that results in an abnormal junction w/ the superior-anterior acetabular rim

What can cause an increased Q angle?

Excessive femoral antiversion, external tibial torsion, genu valgus, excessive pronation

Sponge effect

Exercise and loadbearing diffuses supply of nutrients and removes metabolic wastes

Levels of Evidence - 5

Expert opinion

Grades of Recommendation - F

Expert opinion, clinical experience

3 different movements are typically found to centralize symptoms: what are these?

Extension, flexion, side bending (lateral shift)

Total meniscectomy

Extensive damage to major portion of meniscus and it is determined to be unsalvageable

Recurrent subluxation is associated w/ what?

Extensor mechanism imbalance, dysplastic femoral trochlea, patellar tilt, LE malaligment

What are the 3 types of snapping hip syndrome?

External, internal, or intra-articular

Typical ACL injury occurs with the tibia ___________rotated and in 10-30 degrees of flexion w/ the knee in a __________position

Externally; valgus

What is FAI?

Extra bone causes abnormal contact and prevents the joints from moving smoothly during activity

What is a plica?

Extra fold in the joint capsule

Cruciate ligaments are _____-synovial but ______-articular

Extra; intra (between joint surfaces but not in the capsule)

What test would you perform for a suspected anterior femoroacetabular impingement?

FADIR test

Adolescents w/ anterior groin pain and (+) impingement tests have a 50% chance of ________

FAI

Foot and ankle

FAOS, foot and ankle outcome score

What is tight when there is lumbar spine hypomobility?

Facets/joint capsule, ligaments, muscles

Fat pad syndrome

Fat pad around patella tendon is inflamed

Etiology of trochanteric bursitis

Females> males (have wider pelvis), overweight, trauma, overuse of the muscles around the bursa, tight hip ADD, glute med tendinopathy, hip OA, rapidly increased running mileage, poorly cushioned shoes, excessive pronation, leg length differences (causes you to go into more adduction), ITBS, bacterial infection, RA, hip prosthesis

TKA components

Femoral component (strong polished metal - cobalt chrome), tibial component (proximal tibia is covered w/ metal tray, topped w/ a disk-shaped polyethylene insert, may be fixed, may rotate around a platform), patellar component (places posterior surface of the patella)

Non-musculoskeletal pain

Fever, chills, night sweats, N/V, unexplained weight loss, bilateral symptoms of paresthesia, SOB, excessive sweating, visual changes, skin lesions, GI changes, B&B changes, menstrual cycle changes

Red flags

Fever, chills, weight loss

New born/infant

Flexed posture in all regions of the spine, postural control goes cephalocaudal and proximal-distal, not yet developed cervical lordosis or lumbar lordosis, cervical lordosis comes first with child lifting head and gaining head control, lumbar lordosis comes with going prone on elbows, infant must establish proximal control before distal movements

Muscles in deep posterior compartment (medial to lateral)

Flexor digitorum longus, tibialis posterior, flexor hallucis longus

Patient specific

For a particular individual, patient is asked to select 5 main activates effected by back pain, rate ability 0-10 scale, 15 min

Spondylolithesis

Forward displacement of one vertebral body over another, most common is L5, S1 (second most common is L4, L5), occurs due to spondylolysis (pars fracture) or elongated pars interarticularis

Effects of long-term poor posture

Forward head, protracted scapula, increased lordosis, decreased lordosis, increased kyphosis, cox valgus or varus

Exercise based on what may be more effective than traditional exercise programs?

Functional activities

Thoracic spine and ribs can refer from...

Heart, stomach, kidney, gall bladder, appendix

Coxa vara is more likely in ___________individuals

Heavy

Mensci lose _____ and _____over time

Height, water

Facet orientation

Helps protect disc from excessive rotary forces; more rotation available when spine is in flexion

What are surgical treatment options for the hip?

Hemiarthroplasty, resurfacing arthroplasty, total joint arthroplasty

Pathologies possibly requiring surgery

Herniated nucleus pulposus, spinal stenosis, segmental instability, degenerative disease

Traction is not as effective when large _______________ fill spinal canal

Herniations

Talocrural joint design

Hinge joint w/ 1 degree of freedom, can withstand forces up to 450% of body weight, concave mortise (distal tibial and fibula) and convex talus

Problems following THA

Hip ABD weakness, muscle contracture, limb length difference, mal-alignment

When in doubt, someone w/ chronic hip pain would probably benefit from strengthening of what?

Hip ABD, ERs

MOI for labral tears

Hip extension and ER

Lateral pivot shift test

Hip flexed to 90, IR lower leg, drop patient down into extension

Mechanism of injury of pars fracture

Hyperextension of the lumbar spine resulting in a repetitive loading of the facet joint and pars interarticularis; pars interarticularis may be congenitally thinner or not completely formed

Changes in discs can lead to facet ______________

Hypertrophy; results in redirection of compressive loads to the posterior elements

Most common to be_______________in the lower lumbar spine

Hypomobile

Grade II strain (moderate)

Identified by a sudden "pop", about 50% of fibers torn, symptoms are acute pain, swelling, and a mild loss of function, gait will be impaired, pain w/ palpation or resisted knee flexion, could feel a breach in tendon

Use of an operating microscope

Inc. magnification and illumination, limits amt of tissue damage by working through a small exposure, minimizes blood loss and risk for infection, dec. length of stay in the hospital

Soft tissue stretching results in...

Inc. spinal ROM/joint mobility, dec. pressure on facet joints, discs, and nerve roots, inc. proprioceptive input

Weeks 1-3 following Lumbar Microdiscectomy

Inc. walking tolerance to 30 min w/o pain, no symptoms in LE, wound protection and complete closure, pain management PRN

Pre op exercise?

Inconclusive studies, improvement w/ pre-op function but not in immediate post op recovery, decrease LOS, or complications

Pros/cons of ceramic ball w/ ceramic liner

Incredibly low wear rate, very hard and strong, a wide range of sizing to meet patient specific needs, wear rate - 0.0001 mm/year

General criteria for home discharge include:

Independent ambulation farther than 150 ft on level indoor surfaces, adherence to hip precautions, achieving basic functional ADLs using adaptive equipment

What happens once it is really bad?

Individual is stuck in flexion and/or lateral shift, radicular symptoms

Healing scar is __________and must be mobilized to regain mobility

Inelastic

Post op complications

Infections (<5%), DVT, loosening of the prosthesis components, component misalignment and breakdown, nerve damage

What direction does the oblique popliteus ligament run?

Inferior medial to superior lateral

What direction does the popliteus run?

Inferior medial to superior lateral

What is nerve root compression caused by?

Inflammation, disc protrusion (typically posterior or posterolateral), bone spurs, narrowed foramen

Osteopaths

Initial theory by Andrew Still in 1870s, all disease is caused by dislocated bones, ligaments, or contracted muscles especially in spine, relief occurs due to release of pressure on blood supply to nerve roots, rule of the artery, similar educations to MDs (same rights and privileges)

Annulus tears from the ___________ _________

Inside out

What does ICF stand for?

International Classification of Function

Classification system uses information gathered from __________ and ___________exam to guide the management

Interview; physical

Pre-op for lumbar microdiscectomy

Introduction of neutral spine positioning and TA contractions, education on nature of surgical procedure, expected outcomes/timelines, precautions/contraindications, bending/lifting strategies, neutral spine/pelvic

Supination

Inversion is main component, heel turns in, adduction is second component, foot points toward midline, small component is PF

Special questions to ask during screening

Is pain aggravated by cough or sneeze? Did symptoms start gradually or suddenly? Leg cramps w/ walking? Is spine pain relieved w/ BM? (GI related) Any recent kidney or bladder infection? (UTIs can mask LBP) Do symptoms change with time of menstrual cycle? Any hx of osteoporosis? (possible fx) Any feelings of instability of the spine especially w/ lifting, twisting, bending, stairs? Smoke, drink, drugs? (smoking - decreased blood supply) Caffeine drinks? can cause dehydration (more cramps), stimulant can mask pain

Where are TPs on glute max often located?

Just below and lateral to PSIS

What comes off the lateral epicondyle?

LCL, lateral head of gastroc

What structures work together to stabilize the knee by restraining varus forces, tibial external rotation and posterior rotation?

LCL, popliteus tendon, popliteofibular ligament

Stability of the posterolateral corner of the knee is provided by what?

LCL, popliteus, and posterolateral capsule

Patients fitting a traction classification will most likely have symptoms that extend into the ____________, often distal to the knee

LE

Examination for spondylolisthesis

LQS palpation for step deformity PA glides

PF assessments

LQS, alignment, patella tracking (eyeball test), patella mobility (apprehension test), ballotment test (joint effusion), patella grinding/compression, quad strength, Q angle, VMO, foot alignment (standing), strength of hip ABD and ER (resisted clamshells), patella atla vs baja, McConnell test, Craig's test

Interventions for stenosis

LS bracing to avoid extension and support extensors, traction (mechanical or manual), low grade mobs, soft tissue mobs, patient education (position of relief, no heavy lifting or extending), position in flexion to relieve symptoms (flexion, SB away, rotate toward)

CAM results in impingement, wearing away of articular cartilage, and possible __________ tears over time

Labral

What hip pathology is more common middle age?

Labral tear

Over time, FAI can result in what?

Labral tears and articular cartilage breakdown

In a pincer FAI, what is the first structure to be effected?

Labrum (repetitive impact results in degeneration of labrum w/ bone spur formation on acetabular rim)

Contraindication for surgery

Lack of clear diagnosis, anatomic level of lesion or radiographic evidence; no attempt at non-operative treatment, medication contraindications (major comorbidities, unfavorable survival)

Why do some PTs not manipulate?

Lack of training, so skilled in low velocity that high velocity techniques are not needed, less need in areas other than OP ortho, only recently introduced in entry level programs

Toddler

Large lumbar lordosis, stand and ambulate with wide BOS, hold furniture, initially frequent falls, foot arches flat, genu varum

Surgical options

Lateral retinacular release, proximal realignment (VMO advancement - slide it more distally), distal realignment (Fulkerson - move attachment of patella ligament medially)

Where is Gerdy's tubercle located? What attaches there?

Lateral tibia, insertion of IT band

What is a Segond fracture?

Lateral tibial plateau fracture

Describe the trochlear groove

Lies superior to the medial and lateral condyles, articulation site for patella, lateral surface has an inc. height to prevent excessive lateral patella slide during active extension

Grade I Sprain

Ligament fibers are stretched but there is no tear, little tenderness and swelling, knee does not feel unstable or give out during activity, no increased laxity and there is a firm end feel

LQS findings

Limited and painful extension (radicular), possible painful flexion, SB toward (radicular), dermatomes, myotomes, reflexes

Hypomobility screen findings

Limited mobility in one or more planes of motion, limited mobility in one or more segments, may be hypermobile at others, may be hypomobile in other regions such as hips

Acrylic cemented fixation

Liner is permanently attached to the pelvis, >65 years old, low activity demand, tolerates small deviations from the operation, the bed cut for the prosthetic doesn't need to be very exact because the bone cement filler w/ level out all incongruities, can WB immediately after operation, later loosening

Signs and symptoms of pars fracture

Lower lumbosacral back pain and spasm, may have associated referred pain in buttock or LE, often increased lordosis, tender w/ PA pressure to spinous processes

_______provides the most sensitive view for dx hamstring strain

MRI

Static traction

May result in depression of monosynaptic response through prolonged stretch; higher forces; soft tissue stretching

Posture syndrome

Mechanical deformation of soft tissue results in postural stress; intermittent pain brought on by certain postures; symptoms are relieved w/ change in posture

Nerve root signs

Mechanical pressure of disc compressing nerve root, chemical irritation of nuclear material on nerve root

What is patellar tilt?

Medial retinaculum is overstretched and lateral retinaculum is too tight

The ______compartment is more likely to wear out, why?

Medial, less meniscus coverage over the tibia

Non-operative treatment

Medication (analgesics, NSAIDS), epidural/facet joint steroid injections (usually max 3), modified activity, bracing, PT

Who indicated the least satisfaction after surgery?

Men and those requiring revision

Etiology of meniscal tears

Meniscal tears are either due to an excessive force applied to a 'normal' meniscus or a normal force acting on a degenerative meniscus, most common MOI is a twisting motion on a semi-flexed knee in weight bearing, may also be associated with other ligamentous injuries, typically the ACL and the MCL

Forefoot

Metatarsals and phalanges, transmetatarsal, intermetatarsal, MTPs, and IPs

Stenosis is most commonly seen in what population?

Middle aged and up

Grades of Recommendation - B

Moderate evidence, a single strong evidence study or level II study support

PT management for GTPS

Modify activities (avoid lying/sleeping on affected area, no sitting w/ legs crossed), use of crutches if really painful, ice/heat, US, shock wave therapy, low evidence for iontophoresis, phonophoresis, TENS, soft tissue mobs/massage, TP therapy, foam roller to TFL, ITB, gluteals, vastus lateralis, stretching piriformis, qauds, TFL, strengthening hip ABD, ER, and knee ext, gait mechanics and pelvic stability

Coxa Valgus long-term effects

More likely to dislocate hips

Modalities

Most heat, Estim

MOI for MCL

Mostly occur after an impact on the outside of knee; w/ foot fixated to the ground, combined movement of flexion/valgus/tibial ER will place excessive tension on MCL

Studies have indicated that endurance, balance, and neuromuscular control may be more important than max ______strength for both prevention and rehabilitation

Muscle

Medical management of piriformis syndrome

NSAIDs, muscle relaxants and neuropathic pain medication, Ultrasound guided injections of anesthetics, steroids, and botulinum can serve both diagnostic and therapeutic purposes , Indications for surgical management include abscess, neoplasms, hematoma, and compression of the gluteal arteries, Surgical release of the piriformis tendon

How do you name a lateral shift?

Name it by which direction they are shifting towards (look @ shoulders)

Lateral stenosis

Narrowing of the intervertebral foramen affecting a nerve root

Foraminotomy

Narrowing of the intervertebral foramen leads to stenosis, goal is to take pressure off nerve roots, bone is cut or shaved away to open the foramen, may be done w/ removal of disc or lamina

Central stenosis

Narrowing of the spinal canal effecting the spinal cord or cauda equina

What is stenosis?

Narrowing of the spinal canal or intervertebral foramen

Mid foot

Navicular, cuboid, and 3 cunieforms, transverse tarsal joints, intertarsal joints

What is the most common application of traction?

Nerve root compression

What is the 1st tissue to be affected w/ compartment syndrome?

Nerves

Interventions for acute LBP w/ coordination deficits

Neuromuscular reeducation exercises, possible external supports to prevent end ranges, patient education (posture control, maintain lifestyle)

A combination of ACL, medial meniscus, and MCL is called what?

O'Donohue's or Terrible Triad

Who is most likely to have capsular component w/ FABER test?

OA (distraction can be very effective)

MOI for LCL

Occurs w/ varus stress, usually w/ contact, much less common than MCL injuries, usually respond well to conservative treatment

Single episode of patellofemoral subluxation/dislocation

Often associated w/ trauma, described as "pop" w/ dislocation and a second "pop" w/ relocation (w/ ext), high incidence of underlying misalignment

LQS findings

Often stands w/ reduced lumbar lordosis (more flexion), observe for atrophy or hypertrophy, limited AROM, overpressure only if no peripheral symptoms w/ AROM, perform dermatome and myotome scan, reflexes, gait (you will shorten stride on affected side due to tensioning on nerve), heel walking, toe walking, squat test, may or may not have a lumbar muscle spasm

What are predictors of overall satisfaction?

Older age, not living alone, worse pre op hip scale score, shorter LOS

Who reported greater reductions in pain after surgery?

Older patients, females, and patients w/o revisions

What are wind-swept hips (common in CP)?

One hip is abducted and ER, one hip is adducted and IR

Significant long-term impairment and disability (including pain) can continue for how long post TKA?

One year or more

What is a hemi-arthroplasty?

Only femoral side is replaced, but may not be efficient in pain relief

Ober's test

Originally designed for abductor muscle contracture, pain production or reduced ROM may be indicative, tight TFL will push into trochanter, make sure to stabilize pelvis, bring them into circumduction, then bring patient into ADD and extension

What can cause inadequate medial stabilization?

Overstretched retinaculum, under functioning VMO

What are some examples of passive mobility testing?

PA glides, PIVMs

Examples of joint mobs to lumbar spine

PA glides, side bending, rotation, combination of all 3

Management of quad contusion

PRICE, NSAIDS and analgesics, crutches if necessary, taping and wrapping, aspiration of hematoma, ROM exercises, knee flexion is typically last to return

Management of snapping hip syndrome

PRICE, NSAIDS, corticosteroids, lidocaine injections, stretching or TP release of iliopsoas or TFL, address hip muscle weakness, esp hip abductors, surgical lengthening of involved tendon

Management of iliopsoas bursitis

PRICE, NSAIDs, corticosteroid, or lidacaine injections, hip flexor stretching, hip rotator strengthening, bursectomy

PT management of hamstring strain

PRICE, modalities, taping, instrument assisted soft tissue mobs, dry needling, restore quad/hamstring strength ratio (focus on eccentrics once soreness is eliminated), BW hangs (eccentrically lowering), nordic HS curls, bridge variations, deadlift, kettlebell swing, flexibility, manually resisted hip ext or knee flex in prone, standing theraband flutter kicks, 2 or 1 leg stool scoots, forward or sideways 2 or 1 leg hops, 2 or 1 landing from a box

Post op PT implications following TKA

PRICE, pain control, compression garments, elevation, scar management once staples come out, patella mobility - glides, gentle rocking rhythmics

Management of quad strains

PRICE, taping for pain, proprioception, maybe swelling, gentle soft tissue mobs, IASTM, dry needling, quad setting, terminal knee ext in supine or standing, concentric/eccentric, manual, or theraband knee ext, standing hip flexion flutters w/ theraband, isometric wall sits, closed chain exercises, squats (2 or 1 leg), lunges, set ups, step downs (eccentric)

Referred pain

Pain from a lesion in one location that is experienced by the patient in another location, often pain is dull or achy, pain can refer from internal organs

Rehab

Pain management, control of joint effusion, knee ROM, normalize gait mechanics, flexibility of LE mm, foot alignment (orthotics or proper exercises), hip ABD and ER strength/control

Acute LBP w/ movement coordination impairments and acute LBP w/ radiating pain

Pain occurs w/ initial or mid range of active or passive movements

Subacute LBP w/ movement coordination impairments and acute LBP w/ radiating pain

Pain occurs w/ mid range or end range active or passive movements

Typical S&Ss of an adolescent athlete w/ a pars fracture

Pain w/ extension and palpation - need to have imaging performed

Clinical presentation of iliopsoas bursitis

Pain/tenderness is felt anteromedial aspect of the thigh, may have snapping sensation form front of hip, pain when passively going from extremes of flexion to extension and vice versa, pain worse w/ activity (esp walking or crossing legs), rest can relieve pain

What is trochanteric bursitis?

Painful and inflamed trochanteric bursa (in b/t greater trochanter and tendon of TFL), component of greater trochanteric pain syndrome, commonly results from friction of overlying IT band

Subluxation

Partial dislocation

Where is articular cartilage thickest in the body (4-5 mm)

Patella articulating surfaces

Examination of snapping hip syndrome

Patient hx - location of snap, timing of snap, duration of inset, pain and disability w/ activities Palpation - greater trochanter and the lateral border of glute max Observation - gait abnormalities, have pt demonstrate the snap Tests - ROM, MMT, muscle length Screen - lumbar spine and knee

Forward flexion test

Place thumbs on PSISs and have pt flex forward and look for movement of PSISs (can also perform in sitting)

Where does the plantaris muscle originate from?

Posterior lateral femoral condyle

Lateral shift

Posterolateral bulge blocks extension and side bending toward - causing patient to shift away or towards side of bulge (most of the time they will shift away)

Why do we need to recognize sources of non-musculoskeletal pain?

Practice w/o referral, recognize when it is outside our scope of practice

Surgical procedure for discectomy

Pre-op x-rays to identify appropriate level, 2-3 cm incision is made lateral to the SP on symptomatic side over the disc space, dissection is through erector spinae and transversospinalis groups (supraspinous, interspinous ligaments, and joint capsules are preserved), small metal tube is inserted under x-ray guidance, tube serves as a passage for the surgical tools so muscles aren't cut (in contrast to open discectomy), herniated disc is found w/ a tiny camera, ligamentum flavum may be removed or sparred, nerve root is retracted to expose the HNP, herniated nuclear material is then cleaned out w/ rongeurs (forceps)

What is the #1 predictor of an injury?

Previous injury

Primary and secondary restraint of LCL

Primary - varus force Secondary - anterior and posterior stress

Biomechanics of the PCL

Primary restrain for posterior tibial translation at 30 and 90 degrees of flexion

Biomechanics of the ACL

Primary restraint for anterior tibial translation, orientation of fibers also plays a role in high rate of injury

Newer machines allow a ____________increase in traction force after initiation

Progressive (can select the number of steps to achieve the full force and can also have regressive steps)

Knee to opposite shoulder

Pt is supine, PT brings one knee towards the subjects opposite shoulder

Positive SLR for piriformis syndrome will most likely be between 35-70 degrees, why?

Putting tension on the dura, which would most likely be lumbar spine (HNP)

Precautions for traction

RA (unstable C1-C2), Down Syndrome, cognitive impairment, claustrophobia, tumor, osteoporosis, can not tolerate supine or prone, pregnancy, dentures/TMJ dysfunction, hernia, systemic steroid use

Etiology of secondary piriformis syndrome

Results from macrotrauma, microtrauma, muscle spasms, and ischemic mass effect (hematoma), microtrauma may result from overuse during running or sports with repetitive hip rotation, i.e. tennis, SI joint pathology, "Wallet neuritis", Excessive hip adduction and internal rotation occurs during weight-bearing due to a weak gluteus maximus and/or gluteus medius (eccentrically contracting), this shifts a greater eccentric load to the piriformis muscle, perpetual loading of the piriformis through overlengthening and eccentric demand results in sciatic nerve compression or irritation

Benefits of good posture

Results in minimized abnormal forces on the body and energy efficiency of static and dynamic activities

Femoral antiversion

Rotation medially in shaft of bone (~15 degrees)

Control is best provided by...

Rotatories, multifidus, all abdominals (esp. TA)

Long right leg

SB to the right, rotated to the left (if it is more than 1/2 an inch, you probably need to adjust the shoe, not something in the shoe)

Controversy of SIJ

SIJ does not move, SIJ has such a small amt of motion that it does not cause pain, pain only results from severe trauma, pain is caused by strain of SIJ ligaments, pain is caused by hyper or hypomobility, pain is caused by joint that subluxes

Flexion exercises

SKC, DKC, sitting flexion, posterior pelvic tilts, spine neutral, rocking rhythmic exercises

What are some example of hip ABD exercises?

SL hip ABD, SL wall slides, SL hip lifts, side plank variations, step outs w/ or w/o theraband, hip hikes on stool, runner's pivot

Strengthening treatment

SL hip ABD, clamshells, prone/quadruped hip extension, bridge variations, squats, lunges, front/side step-ups

Where does the piriformis attach?

Sacrum anteriorly to GT

Bowel and bladder changes

Saddle numbness, rectal, genital region

In absence of primary restraint, ___________structures are put under larger tension to restrain the same force

Secondary

What is the acetabular component made of?

Shell is made of metal, plastic liner (load bearing, fits snugly inside shell)

McConnell test

Short squat, take thumb and push on outside of patella in medial direction, can also do taping technique

Should you have both knees done at the same time?

Short-term and long-term outcomes were equal by 12 weeks, except quad strength (equal by 52 weeks)

Shoulder

Shoulder pain and disability index

What are you palpating through to get to the SIJ?

Skin, fat, thoracolumbar fascia, thick tendon of erector spinae, multifidus, thoracolumbar fascia, lumbosacral ligament, joint space

Why are women at more risk for ACL injuries?

Smaller intercondylar notch, wider pelvis, greater Q angle, neuromuscular factors, hormonal variations may alter laxity of ligaments, females take longer for ADDs and ERs to fire

Who is most likely to get compartment syndrome?

Soccer players w/ no shin guards

What is the hip labrum made of? What is its purpose?

Specialized fibrocartilage; lines the acetabulum to increase its surface area, inc. joint stability, contributes to proprioceptive feedback, decreases the forces b/t the femoral head and acetabulum

Oswestry LBP Disability Index

Specific to LBP, measure patients perceived level of disability, takes 5 min, 10 questions w/ 6 answers per question, each answer assigned a value (0-5), x 2 for percentage score, may be more sensitive in patients w/ severe disability

Classification category is intended to direct clinician to a ________ ______ of management

Specific type

Interventions for Grades 3 and 4 Spondylolithesis

Spinal orthosis, often require surgery (if radicualr symptoms are present), realignment and fusion

When can patients resume sexual relations?

Standard is 1-3 months

What positions put the most pressure on the discs?

Standing flexion w/ weights and sitting in forward flexion

Genu recavatum

Standing with knees hyperextended

Apply harness in ___________ or lying. Loops should maintain a __________pull

Standing; posterior

Research says that _________tests are unreliable

Static

What makes of the femoral components?

Stem (made of metal - usually titanium), head (made of either cobalt chrome or ceramic)

Tests for sciatic nerve

Straight leg test, sciatic LLTT, slump test, stealth slump test

What are the 2 schools of though of chiropractors?

Straights and Mixers

High compliance groups have greater improvements in what?

Strength, walking speed, functional outcome scores, recommend HEP 3x/week

What can a radiograph differentiate a hamstring strain from?

Stress fx

Intervention for dysfunction syndrome

Stretch into direction of limitation, avoid bad postures, patient education

Derangement dysfunction intervention

Stretch into direction that causes centralization, avoid direction of peripheralization, after disc healing stretch into the direction of limitation, patient education

Manual therapy techniques include...

Stretching of muscles of the hip joint, traction of the hip, traction manipulation of the hip

Grades of Recommendation - A

Strong evidence, supported by level I studies

Support for the McKenzie Method

Studies by Nachemson and Anderson showed changes in pressure w/ the IV disc w/ changes in posture; numerous studies have looked at reliability of method and others at effectiveness; effective for acute discs (not so much for degenerative discs)

Anterior interbody fusion procedure

Subcutaneous tissue and rectus abdominis are retracted, done w/ retroperitoneal approach, an anterior discectomy and bone graft are done, EO, IO, and TrA are divided, neurovascular and visceral structures are moved out of the way (genitofemoral nerve, psoas muscle, aorta and vena cava, sympathetic chain, iliac vessels)

The proposed mechanisms for disc realignment include...

Suction due to decreased intra-discal pressure, pulling displaced disc pieces back to center, tensing PLL pushing any posteriorly displaced material anteriorly towards original position

Common mechanisms of quad strains

Sudden deceleration of leg (kicking), violent contraction of quad (sprinting), rapid deceleration of an overstretched ms (by quick change in direction)

What portions of the capsule form the suprapatellar pouch?

Superior and anterior

More adducted =

Supinator

It is recommended that exercises be started with the patient in ____________

Supine

What position should you place patient in?

Supine, prone, some table allow SB, increased hip flexion (to 90 degrees) causes greater separation of posterior structures

Describe the meniscus blood supply

Supplied by medial and lateral geniculate arteries, only 10% to 30% of peripheral medial meniscus and 10% to 25% of lateral meniscus receive direct blood supply, remaining portion receives nourishment from synovial fluid via diffusion

Are manipulations for PTs supported?

Supported by the Orthopedic Section of the APTA, American Association of Orthopedic Manual Physical Therapists

What is the collagen fiber orientation of the menisci?

Surface layers - random orientation, inferior layers - circumferentially "hoop strength", tie fibers - radially oriented

Inspection of meniscal tears

Swelling, stands w/ knee partially flexion, quad atrophy (chronic), joint line tenderness, terminal extension may be blocked, end feel - springy if knee is locked, limb girth measurement (reduced quad girth), balance and proprioception testing

Partial meniscectomy

Symptomatic displaced tear in older inactive individual, tear in central avascular third

CPR for manipulation

Symptoms less than 16 days; at least 1 hypomobile segment; at least 1 hip w/ less than 35 degrees of motion; no symptoms distal to the knee; less than 19 points on FABQ

Distal tibiofibular joint

Synarthrosis, dense irregular CT, ant and post proximal TF ligaments and interosseous membrane, not a synovial joint

______________(such as Gore-Tex) are also used for ACL reconstruction

Synthetics

T/F Patient education has been shown to reduce the use of narcotics and hospital length stay

T

T/F: In degenerative meniscal tears, the patient may not have a "click" upon examination since tears are often multiple frays rather than large tears

T

T/F: Symptoms of degenerative meniscus are the same as traumatic meniscus

T

Autograft

Taken from the patient's own body and include portions of the patellar tendon, IT band, semitendinosus tendon, gracilis tendon

Subtalar neutral

Talus and calcaneus in a straight line

Arthroscopic debridement

Tear of the labrum is only part of the pathology, labrum may be a source of the pain, debridement of the labrum w/o addressing the reason for impingement will lead to poor surgical outcome

What are your supinator muscles of the foot (inverters)?

Tibialis anterior and posterior

Anterior compartment musculature

Tibialis anterior, ext digitorum longus, ext hallucis longus, fibularis tertius

What shape is the patella?

Triangular, frontal plane (wider proximal base and a distal apex), transverse plane (broader anteriorly and posterior apex)

Tarsal canal (tunnel)

Tunnel running between the subtalar articulations, divides the subtalar joint into 2 separate joint cavities, lateral opening known as the sinus tarsus

Nucleus pulposus

Type 1 and 2 collagen; more ground substance, hydrophilic (70% in adult, 90% in child), sits more posterior within annulus

What is the annulus fibrosis made of?

Type 1 collagen - resists tensile forces w/ alternating crossing pattern

Non-musculoskeletal warning signs

Unable to find comfortable position, pain is unaltered by position, pain is worse at night, feelings of fatigue, symptoms are associated w/ GI, genitourinary, cardio, respiratory, etc.

What is meralgia paresthetica?

Underwear is too tight and compressed the lateral femoral cutaneous nerve

What are the types of patella fractures?

Undisplaced, transverse, lower or upper pole, comminuted undisplaced, comminuted displaced, vertical, osteochondral

Patient hx - red flags

Unknown etiology, no h/o trauma, significant past systemic illness, family hx of systemic illness

Muscle energy techniques

Use bodies muscles to reposition bones; if pelvic innominate is posteriorly rotated what muscle do we have to rotate it back anteriorly?, if anterior, what muscle to rotate back posteriorly?

FADIR test

Used to assess FAI, esp. anterior/superior labrum, passively move the hip into flexion, ADD, and IR, (+) test = hip or groin pain, Sn = 0.95

Mixers

Used to treat musculoskeletal pain due to hypomobility, muscle spasm, correct alignment, relieve pressure on nerves

Anterior interbody fusion

Uses same principles of disc excision and interbody bone grafting

Describe intra-articular snapping hip syndrome (least common)

Usually due to tear of cartilage and/or loose body within the hip joint, may cause the hip to "lock up"

Is high impact aerobics and jogging recommended following THA?

Usually not

You have more coxa ___________ when you are born

Valga (changes as we WB)

Can load the ACL in a more _______position

Valgus

When does the MCL become taut?

Valgus force, extension and looser in flexion

Special test for MCL injury

Valgus stress at 20-30 degrees of flexion

Medial meniscus injury is associated w/ a ______________force and lateral meniscus injury is associated w/ a ____________force

Valgus; varus

Describe the vascularization of the menisci

Vascularization along the periphery via capsular attachments, inner borders are avascular; red zone (best), red/white, white (no blood supply)

Anterior displacement occurs due to...

Vertebra no longer attached posteriorly, sacral angle created anterior sheer, supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to "slide" anteriorly on the one below (creep)

ACL/PCL has a _________orientation in extension and a more ____________orientation in flexion

Vertical; horizontal

Arthroscopic microdiscectomy

Very common, less morbidity and an earlier hospital discharge compared w/ standard discectomy

Re-occurrence of LBP

Very common, not predictable as to how often or severity of next occurrence, more common w/ hx of re-occurrence excessive spine mobility, more likely to become chronic w/ symptoms BK, depression, fear of reinjuries, high pain levels

FABs of HC providers

Very similar to that of patients, low expectations for patients, recommend avoidance of activities that "might" bring on symptoms, recommend limiting activity levels

What is the shape of the menisci?

Wedge shaped to improve joint congruency, improve joint stability, and maintain joint space

Questions typically asked on HRQL Questionnaires

What can they do or not do? How often can they do them? Level of difficulty perform them?

What do patients want to know?

What is going on, how long will recovery take, how can they help themselves, what will the clinician do for them

When you do typically get central LBP?

When the outer rings bulge because they are innervated

Contraindications to traction

Where motion is contraindicated (fx, hypermobility, dislocated joint), uncontrolled HTN if using inversion table, if traction peripheralizes symptoms, immediately post-surgery of spine, (+) vertebral artery sign

Methods before McKenzie

Williams flexion exercises (1930s); open the IV foramen to relieve nerve root compression - lordosis was bad; promote flattened lordosis postures; brace into flexion; bed rest; disc dynamics were no understood esp. nucleus within annulus;

When in side lying, what direction do men and women side bend toward?

Women SB toward the opposite side they are lying on (curvature to same side) due to wider hips, men SB toward the same side they are lying on (curvature to opposite side) because they have wider shoulders

Diagnostic imaging for labral tears

X-rays and MRI are often inconclusive for detecting intra-articular pathologies; gold standard - MRA

Can US diagnose a hamstring strain?

Yes, relatively cheap and has the ability to image muscles dynamically

What population is a resurfacing arthroplasty good for?

Younger patient w/ better bone stock

Intervention for hypermobile patient

braces or corset, patient education( KEEP OUT OF END RANGE POSTURES), Strengthening and endurance exercises, proprioception exercise, spine neutral exercises (make pt realize when they are at mid rang and can they hold it and do other things?)

Exercises for pt with spondylolisthesis

core stability, spine neutral, isometrics, short range exercises (strength and endurance), proprioceptive exercises (pelvic clocks)

If an individual spends long period of time at end range then the ligaments engaged in the elastic zone will have a plastic response which causes what?

creep this causes elongation increasing the size of the elastic zone leading to instability unless a sufficient amount of muscle control is attained

grades 3 and 4 signs and symptoms

in addition to low back pain there may be radicular signs into LE related to traction on lumbosacral nerve root, pain, parasthesia, numbness, muscle weakness, radicular symptoms unilateral or bilateral ( could be putting traction on cauda equina)

Step Deformity

one spoons process may appear to be anteriorly displaced over one below, if L5 vertebral body is anterior on S1 and L4 may feel more anterior, as L5 vertebral body slides anteriorly the posterior arch & spinous process stays attached to S1, L4 feels deep because L4 has migrated anteriorly with L5 vertebral body. If L4 feels deep problem is at L5

Injury to your neuromuscular system, which can occur with traumatic spinal injury can result in diminished_________ input and lead to further damage of passive restraint structures

proprioception

increase in neutral zone means

requires greater muscle performance (strength, endurance, proprioception)

Muscle control is best provided by

rotatories, multifidus, all abdominals especially transfer abdomens

Interventnion for spondylolisthesis: Grades 3&4

spinal orthosis, grades 3&4 especially those with radicular signs often require surgery, realignment and fusion

Spondylolisthesis occurs due to to

spondylolysis (pars fracture) or elongated pars interarticularis