Lower Ortho Exam 1 (Labs)

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Hip Flexion-Extension

(120°-0-20°)

Eccentric strengthening of the anterior tibialis

(Kern-Steiner, 2003): hold a pencil in your curled toes and move your ankle up and down for thirty seconds to one minute, moving through as much of the range of motion as possible.

Anterior Talofibular Ligament (ATF)

(lateral) most commonly sprained ligament

Cephalad movement of the fibula on the tibia.

-evert -palpate fib head -feel fib go up

1st MTP abduction goni

Hip adduction goni

20 Fulcrum- ASIS, Proximal-horizontal line to other ASIS, Distal- midline of patella

1st MTP flexion goni

1st MTP extension goni

MMT Tibialis Anterior

Dorsiflexes and inverts Patients supine with ankle off table, put ankle in dorsiflexion and inversion, stabilize ankle, apply pressure into plantarflexion and eversion and have patient resist. Patient goes up and in PT pushes down and out "dont let me pull you down and out"

MMT extensor hallucis longus

Extend the big toe Longus goes to distal part Brevis attaches proximally

Forefoot-Strike Wear Pattern

Focused outsole wear over mid and forefoot No visible heel wear Wrinkling of midsole in mid and forefoot

Prognosis: MCL injuries

Grade I MCL injuries are usually able to return to play by an average of 10.6 days post injury. Grade II injuries return as early as 3-4 weeks. However, it might be 3 months after injury before most return to their preinjury activity level. Isolated grade III MCL complex injuries might be treated conservatively, but if other structures are involved (e.g., ACL) they will likely undergo surgery. Isolated Grade III it may take 2 to 4 months to return to competition. Those that underwent surgery may take 6-9 months before return to play.

Nonoperative Management Maximum Protection Phase

If possible, examine before effusion sets in. Utilize cold and compression with rest and elevation. Teach protected weight bearing with use of crutches and partial weight bearing as tolerated. Teach safe transfer activities to avoid pivoting on the involved extremity. Initiate quadriceps-setting exercises. The knee may not fully extend for end- range muscle-setting exercises, so begin the exercises in the range most comfortable for the patient. As the swelling decreases, initiate ROM within tolerance.

Good - 4-/5

In the against-gravity position, holds against moderate resistance, then gives way in an eccentric contraction.

Dynamic Internal & External Rotatory Impingement Tests

Internal - Passively flex hip to 90 then take hip though arc of adduction and IR External - Passively flex hip to 90, then take hip though arc of aBduction and ER No known sensitivity or specificity -trying to impinge -more static

knee - lateral aspect

LCL illiotibial band fibular head

MMT lateral hamstrings

Lateral hamstrings: externally rotate tibia Lateral hamstrings: biceps femoris

What are the potential causes of excessive pronation?

Limited dorsiflexion Weak intrinsic foot muscles Weak supinators Weak fibularis longus (wait isn't that a pronator? Supports longitudinal arch - see discussion below.) Weak quadriceps Weak hip abductors and external rotators

MMT medial hamstrings

Medial hamstrings: internally rotate tibia, if they try to externally rotate it shows lateral are stronger Medial hamstrings: semitendinosus and semimembranosus

Subtalar Joint Distraction Direction of force:

Navicular and calcaneus moves away from the Talus. Notice the hand and body positions are basically the same as the talocrural distraction technique except the therapist right arm in the picture is now on the navicular versus the talus in the talocrural mobilization. Once again, the therapist uses their body weight for the mobilization. -have their knee on you -sit on chair and have their knee bent

Zero 0/5

No contraction or movement felt or seen.

inhibition of Tensor Fascia Lata (TFL):

Note: for demonstration purposes, the tape is applied over clothing in the image at right; obviously when using therapeutically, you will apply directly to skin. Using an I-strip of tape, anchor it with no tension just inferior to (not on) the ASIS and perpendicular to the muscle fibers of the TFL. Place about 75% stretch on the tape and pull it posteriorly, adhering the tape to the skin as you go, using the last inch to anchor, with no tension.

LE Deep Tendon (myotatic) Reflex Assessment: Patellar Achilles'

Patellar [L4] Achilles' [S1]

MMT: Plantarflexors

Plantar flexors as a group (sitting and standing heel-rise test) -dont let me dorsiflex

Soft-Tissue Palpation (cont.) of knee posterior

Posterior Aspect -Baker's Cyst -Popliteus -Medial and Lateral Heads of Gastrocnemius Biceps femoris lateral side Semitendinous on top of membranous on medial side

Interphalangeal Joints Rotation Direction of force:

Stabilize proximal portion of joint with one hand. The other hand is on the distal part of the joint to perform the maneuver. Move the distal part of the joint in a rotatory fashion.

Posterior Labral Test

Step 1: Flex, Add, IR Step 2: Arc into ABd & ER Step 3: Move into Ext (+) pain or click reproduction

Taping at Distal Iliotibial Band:

This technique is similar to use of the counterforce straps used by runners. Anchor the end of an I-strip with no tension medial to the distal IT-band and approximately 1 inch proximal to the lateral femoral condyle. Place about 90 percent stretch on the tape and pull it laterally, smoothing it over the IT-band and moving posteriorly over the biceps femoris. Be careful to place the tape over the muscular portion of the distal biceps femoris and not over its tendon. Anchor with no tension in the region of the popliteal fossa.

Interphalangeal Joints Medial and Lateral Tilting

This tilting of the phalanx must occur over a fulcrum that you created on the opposite side.

Subtalar Joint

a joint in the ankle found between the talus and calcaneus

Hip Scour test:

assesses for hip joint pathology such as arthritis, osteochondral defects, avascular necrosis, acetabular defects, and/or labral tears. With the patient supine, the therapist passively flexes the patient's hip to 90 degrees, and the knee to 90 degrees. The therapist then compresses the femur into the acetabulum, then slowly moves into a clockwise or counterclockwise movement, "scouring" the acetabulum with the femoral head. Pain is a positive finding... and typically hip pain manifests itself as anterior groin pain. -hands can go around patella and go in circles -with popping could be a labral tear, cam, impingement -push down and go all around

fibularis longus insertion

base of 1st metatarsal and medial cuneiform

deltoid ligament prevents

eversion

MMT extensor digitorum longus and brevis

extension of lesser toes, & try to push toes down Patient supine with ankle off table, have them extend toes 2-5, stabilize ankle, use thenar eminence to push toes into flexion. -she also does flick test

To facilitate a weak muscle: taping

• Apply tape with light to moderate tension/25-50% stretch from origin to insertion to the target muscle when it is passively elongated

Trace 1/5

In the gravity-lessened position / horizontal plane, visible or palpable muscle contraction without movement of the segment.

Figure 8 Tape:

One optional method to quantify the amount of edema is the Figure 8 method. A tape measure is placed around the ankle, crossing over the navicular tuberosity, the tip of the lateral malleolus, the tip of the medial malleolus, and the base of the fifth metatarsal, forming a figure 8. (Malliaropoulos 2009)

Ankle Joint Functional Assessment Tool

Scoring for each of the 12 items is 0-4 in descending order. 48 points total, lower score = greater instability This questionnaire has been designed to give your therapist information as to how your ankle problems have affected your functional ability.

Mulligan Techniques to Restore Plantarflexion and Dorsiflexion:

these techniques work well with patients who have acquired a positional fault at the talocrural joint, which may present as a lateral ankle sprain. MWM (mobilization with movement) 5-10 reps

Top Tier Tests of SFMA: Active Cervical Flexion Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please bring your chin down to your chest with your body upright." Can't touch sternum with chin

Ankle Dorsiflexion-Plantarflexion

(20°-0-50°)

Calcaneal Inversion-Eversion

(20°-30° inversion to 5°-10° eversion)

First MTP Flexion-Extension

(30°-0-70°) Sport activities need >90° degrees DF

Ankle Inversion-Eversion

(35°-0-15°)

Hip Abduction-Adduction

(40°-0-20°)

Hip Medial-Lateral rotation

(45°-0-45°)

Femoral Antetorsion

(8°-15° of femoral internal rotation)

Resisted exercise with theraband:

(your therapist will provide you with an elastic band or tubing for this exercise.) Tie a knot in the band and place it in a door that is securely shut. Put your foot inside the loop and move your step away from the door until the band it taut. Slowly move your foot out and hold, feeling the band provide resistance to your movement. Repeat. Change the position of the band so that you move it in the opposite direction.

Waldron's Test

- helps to confirm chondromalacia patella or similar causes of anterior knee pain from patella contact pressure Subject is standing. The examiner palpates the patella while the athlete performs several deep knee bends or squats in a slow or controlled manner. The examiner also watches the tracking of the patella. Results: Pain and crepitus occur simultaneously for Chondromalacia Patella. The patella may deviate to the side of pain. Correlates: Chronic synovitis, Plical irritation, Chondral defects

how to grade reflexes

-0 = no response -1+ = sluggish or diminished -2+ = active or expected response (normal) -3+ = slightly hyperactive -4+ = brisk, hyperactive with intermittent clonus

Dermatomes of the lower extremity

-L1 -L2 -L4 -L5 -S1

lateral aspect of knee

-Lateral Tibial Plateau -Lat. Femoral Condyle -Head of Fibula -Gerdy's Tubercle Gerdys tubercle - top of lateral portion of tibial plateu - iliotibial band - don't let me pull leg in - activate TFL, glut max, hamstrings

Bony Landmarks medial aspect of knee

-Medial Tibial Plateau -Med. Femoral Condyle -Medial Joint line

Various Syndesmotic injury testing:

1) External rotation stress test (Kleiger test) 2) Squeeze test 3) Point test 4) dorsiflexion 5) Heel thump test 6) Crossed-leg test 7) clunk test (side-to-side text - explained earlier in handout) 8) One-legged hop test (Caution - only use if all the other tests are negative to rule out since this might cause further seperation, should be able to do 10 times without significant pain)

Posterior Glide of hip

1) Position the patient with their trunk resting on the table and thigh over the edge. 2) The clinician stands on the lateral side of the patient's thigh. (If needed, a belt can be placed around the clinician's shoulder and under the patient's thigh to help hold the weight of the lower extremity.) 3) Using one hand, the clinician grasps the patient's lower leg. The other hand of the clinician is placed anteriorly on the proximal thigh of the patient, just below the inguinal canal. Keeping the arms stiff, use your legs to lift the distal end of the thigh while applying force through the proximal hand in a posterior direction. -helps with hip flexion

1. A 30-year-old male has a goal of walking without knee pain and returning to play occasional recreational rounds of golf. He currently has dysfunctional but non-painful single limb stance as well as dysfunctional and painful deep squat and bilateral multi-segmental rotation. Further examination reveals decreased knee flexion mobility (90 degrees), decreased hip ER bilaterally, weakness in his quadriceps and gluteal musculature, and limited pronation on the involved side. He is 4 weeks s/p partial medial menisectomy. a. What interventions are appropriate at? i. 4-6 weeks postoperatively

1. Advanced activities such as plyometrics, maximum effort isokinetic training, and simulated high-demand functional activities can be initiated as early as 4 to 6 weeks or 6 to 8 weeks postoperatively with emphasis on reestablishing normal mechanics in movement.

1. Begin muscle-setting exercises, SLRs, active knee ROM, and weight bearing as tolerated. Full weight bearing is usually achieved by 4 to 7 days, and at least 90° of knee flexion (so this person is way behind) and full extension are attained by 10 days. Closed-chain exercises and stationary cycling a few days after surgery, or as pain and weight bearing status allow, with the goal of regaining dynamic strength and endurance.

Progress to Functional Training

1. Develop activity-specific exercises and drills that replicate the demands of the individual's outcome goals.

What hip exercises could be used to prevent genu valgus and hip adduction?

1. Open chain a. Clams, hip abduction 2. Closed chain a. Bridges, Monster walks, step up-down.

1. 22-year-old male s/p Right Allograft ACL reconstruction with lateral meniscal debridement 6 weeks ago. He has not participated in a rehabilitation program to this point, FWB, no crutches. He tore his ACL playing soccer. No other pertinent PHM. He is in good physical health (6'1", 200 lbs) and goes to the gym 4 times weekly (currently only doing UE lifting). Socially: Single, lives on the second floor of his parents' house (approximately 13 stairs), and a college student. Meds: Naproxen 2 tablets, BID last week due to right knee discomfort, otherwise no other meds. Currently not wearing a brace but supposed to obtain one this week. CC: Right knee fatigues by the end of the day or after standing for several hours. Scored a 5 on the lateral step down test on the right and difficulty maintaining unilateral stance on right for great than 15 seconds. ROM (supine): end feels normal i. Controlling pain and swelling through proper intermittent activity and continued prevention of dependent limb position. List a couple methods:

1. keep leg out of dependent position, keep elevated when in bed, encourage ROM, may need NSAIDS.

1. minimum protection of the knee is necessary, but full, pain-free, active knee ROM and a normal gait pattern should be achieved before progressing to high-demand exercises. Resistance training, endurance activities, bilateral and unilateral closed-chain exercises, and proprioceptive/balance training to develop neuromuscular control can all be progressed rapidly.

sway back posture

A long outward curve of the thoracic spine with a backward shift of the trunk starting from the pelvis -posterior pelvis tilt -rounded shoulders -head forward

Alternate Methods of Distraction at knee Direction of force:

Tibia moves away from the Femur at a right angle. -the second one is like Apleys test (meniscal)

Posterior Glide Direction of force:

Tibia moves posterior on Femur parallel to tibial plateau. -work toward end range -used to increase flexion

alternate positions for Lachman Test/Test for the Anterior Cruciate Ligament:

Alternate positions: 1) pt's thigh supported on examiner's thigh; 2) pt's thigh supported by table, with lower leg off table and knee flexed 15-20 degreed; 3) patient seated with knee flexed 15-20 degrees and lower leg supported by examiner; 4) the pt is prone with knee flexed 15-20 degrees; examiner pushes the tibia anteriorly (down toward the table). Again, the hamstrings must be relaxed. -push tib back then pull quick jerk up and forward -close to joint line -relaxed hamstrings Psychometrics: established by Scholten, et al. (2003) in a meta analysis. Sensitivity: 63 - 93% Specificity: 55 - 99% Additional psychometrics (Cooperman, et al., 1990): Sensitivity: 71 - 77% Specificity: 46 - 57% Positive predictive value: .47 - .54 Negative predictive value: .70 - .82

Anterior Glide - Prone of the hip

Although this picture from Dutton 2017 does not show it. It would be best to: 1) Position the patient with their trunk resting on the table and thigh over the edge. 2) The clinician stands on the lateral side of the patient's thigh. (If needed, a belt can be placed around the clinician's shoulder and under the patient's thigh to help hold the weight of the lower extremity.) 3) Using one hand, the clinician grasps the patient's lower leg. The other hand of the clinician is placed posteriorly on the proximal thigh of the patient, just below the buttock. Keeping the arms stiff, use your legs to lift the distal end of the thigh while applying force through the proximal hand in an anterior direction. -helps with hi extension -with belt - supine and put ti over your shoulder

To enhance circulation/reduce bruising and edema:• taping

Apply fanned tape with none to light tension/0-25% stretch to the injured tissue with the skin passively stretched/joint near end of range of motion. Tape fans can be criss-crossed to form a mesh. Tape will pucker when skin/joint is returned to resting position. Theoretically, this puckering lifts the skin and enhances microcirculation in the lymphatic system.

taping To decrease spasm/inhibit a tight muscle:

Apply tape with minimal tension/stretch from insertion to origin to the target muscle when it is passively (and gently) elongated OR Apply tape with moderate tension/50% stretch perpendicular to the fibers of the muscle (similar to bowstringing technique) "Bridge" trigger points by applying tape around them to divert tension caused by force transmission

Craig's Test / Ryder's Test / Test for Femoral Torsion:

Assess the amount of torsion. Align the greater trochanter in the lateral most position so that it is parallel with the plinth. Goniometer Alignment 1) SA: perpendicular or parallel to ground. 2) F: long axis of femur. 3) MA: Aligned with tibia. Correlates within 4 degree of radiographic measurements in children Average angle of torsion · Children 4-7 y/o, 23-26 degrees · Femoral torsion is complete between 8 and 16 years of age Adults 8-15 degrees

knee extension goni

Axis: Lateral Epicondyle of Femur Stationary Arm: Greater Trochanter Moving Arm: Lateral Malleolus Standard ROM: 0-10* hyperextension Standard End-Feel: Firm Stabilization: Hip if needed to maintain neutral position

Babinski reflex

in response to the sole of the foot being stroked, a baby's big toe moves upward or toward the top surface of the foot and the other toes fan out (adults do opposite) -in adult if abduct and extend the test is positive and is an issue

Metatarsophalangeal joint mobility:

Check for loss of metatarsophalangeal extension and mobilize (via distraction and oscillation, or via stretching) into greater extension.

Alternate Test for the A.T.F. / The Anterior Drawer Test:

Checks the A.T.F. (anterior talofibular ligament) by sliding the talus forward from the ankle mortise. With the patient supine, position the foot over the edge of the table and grasp the calcaneus. Gently grasp the tibia and fibula (avoid compressing the mortise) and pull the calcaneus (and thus the talus) forward. Pain along the course of the A.T.F. and/or laxity as compared to the opposite side indicates a positive test. No psychometric information available on this test. -basically anterior glide of calcaneus in neutral

Criteria for stopping a single leg heel-rise:

Client requests Heel-rise less than 50% of maximal range Excessive trunk lean Excessive balance support (more than a finger) Client flexes their knee

strains

overstretching and tearing a muscle 1. strong and painful (exercise induced, grade 1 strain, mild grade II strain) 2-21 days recovery 2. weak and painful (moderate grade II strain, severe grade III strain) 3-12 weeks recovery 3. weak and painless (grade III strain) 7 weeks to 6 months

MMT Lumbricals of toes

Flexion of toes 2-5 at MTP joints Extension of toes 2-5 at IP joints

Elusive Popliteal Pulse

Fortunately in the majority of sites where we wish to determine the existence of an arterial pulse the vessel is near both to the surface and to the underlying bone. Thus the detection bf the carotid, subclavian, brachial, radial, femoral, and foot pulses is easy. It is not so with the popliteal pulse. It is often essential to know whether the popliteal pulse is present or absent-for example, to distinguish a block of the lower femoral artery from one of the popliteal artery-yet many students, some of them postgraduate, have been heard to say that they have never felt it. R. Ger' points out that the lower half of the popliteal artery is nearest to bone and skin as it lies behind the head of the tibia, and that this should be the standard point for palpating it. In fact there are three methods of palpating this artery, and the clinician may have to try them all before being sure that the pulse is absent. The commonest method is to grasp the upper end of the tibia with both hands-thumbs in front, fingers behind-with the knee slightly flexed. If the fingers are then moved from side to side they slip over the neurovascular bundle, which, once identified, can be fixed between the fingertips and compressed back against the bone. Occasionally it is easier to feel the artery higher up, behind the lower end of the femur, by hyperextending the knee joint with one hand pushing backwards on the patella, and placing the fingers of the other hand between the popliteal fossa and the bed. Both of these methods may be ineffectual in an obese person. Probably the best and most certain way to feel the popliteal pulse is to have the patient in the prone position. The whole length of the popliteal fossa can then be palpated with the tips of the fingers of both hands. A pulse that cannot be felt in this way is surely absent. As with all clinical techniques, success comes from constant practice and, in the matter of palpating the popliteal pulse, self-discipline. A quick feel behind the knee is of no value. The approach must be slow, deliberate, and painstaking.

Instructions for assessing the strength of the gastrocnemius and soleus muscles.

Given that these postural control muscles typically have significant strength, even a moderate decrease in force could still result in a high grade using modified Lynch / Lovett. For these two muscles, we'll use the standing one-leg heel-rise test and the scale below, which is based on number of heel rises the person can perform or resistance. A successful heel-rise is considered when the patient is able to achieve the maximal range, the test is terminated and heel-rises are not counted if they are unable to achieve 50% of the maximum range or they exhibit excessive leaning, use more than a single finger for balance, or flex their knee Criteria for stopping a single leg heel-rise: Client requests Heel-rise less than 50% of maximal range Excessive trunk lean Excessive balance support (more than a finger) Client flexes their knee

Patrick or FABERE Test/Hip-Sacroiliac Screening Test:

Have the patient lie supine and place the foot of his involved side on his opposite knee. The hip joint is now Flexed, ABducted, and Externally Rotated. In this position, inguinal pain is a general indication that there is pathology in the hip joint or surrounding muscles. If the patient complains of increased pain posteriorly, there may be pathology in the sacroiliac joint. Again, anterior hip/groin pain would continue to indicate hip involvement. Psychometrics: Inter-rater reliability is 92.31% (Kikmeyer, Van der Wurff, Aufdemkampe, & Fickenscher, 2002). Certain properties established by Dreyfuss et al (1996), and others by Slipman et al (1998). Sensitivity: 69% Specificity: 16% (Dreyfuss, et al, 1996) Positive predictive value: 0.75 (Slipman, et al, 1998) -cross knee over and push down on opposite ASIS

Lateral Tilt of the Knee:

Impose a valgus stress for a lateral tilt. Be sure to control the internal rotation component of the femur.

Medial Tilt of the Knee: Direction of force:

Impose a varus stress for a medial tilt. Be sure to control the external rotation component of the femur.

Fair + 3+/5

In the against-gravity position, holds against only minimal resistance, then completely gives way.

fracture physical exam

Ottawa knee rules (any one of the following positive) 55 years old or older Isolated tenderness of patella Tenderness to proximal head of fibula Inability to flex 90 degrees Inability to WB for 4 steps both immediately and in ER/office

Manual therapy for hallux valgus:

Manual therapy for hallux valgus: gently stroke with your knuckles between the first and second metatarsals (both dorsal and plantar aspects) to loosen the adductor hallucis, or have the patient roll a small rubber ball (about a half inch diameter) between the dorsum and plantar aspect of the foot. Perform soft tissue release by pulling along the great toe, moving it away from the valgus position by moving the great toe medially. Passively glide the metatarsals up and down, as well as into rotation. Manual therapy for hallux valgus: grasp the great toe at the proximal phalanx and slightly distract and rotate it (either clockwise or counterclockwise, whichever feels better to the patient). While maintaining the traction, move the toe into extension; progress from passive motion to having the patient assist by using the extensor hallucis longus.

Hip extension- goni

Mean value: 20 Fulcrum: Greater trochanter of femur Stationary arm: Lateral midline of pelvis (mid axillary line) Moving arm: Lateral epicondyle of femur

Ankle Dorsiflexion- goni

Mean value: 20 Fulcrum: Lateral aspect of lateral malleolus Stationary arm: Lateral midline of fibula (head of fibula for reference) Moving arm: Parallel to lateral aspect of fifth metatarsal

Hip Internal Rotation- goni

Mean value: 45 Fulcrum: Anterior aspect of patella Stationary arm: Perpendicular to floor Moving arm: Anterior midline of lower leg- between two malleoli

MMT Gastrocnemius

O: Medial & Lateral Condyles of femur I: Calcaneus via Achilles tendon Action: -Plantar flexion of foot at ankle -Flexes the leg at the knee joint *Test - Standing* Client stabilizes themselves with a hand on the table. Test is to rise up onto toes - Test one side at a time Have patient standing one testing foot, knee extended, using therapist hands for support, have them go into heel raises. Test the right leg by picking up left leg and hold onto the PT for support Criteria for stopping a single leg heel-rise(Lundsford & Perry, 1995; Jan, et al, 2005): The person wants to stop the test Heel-rise less than 50% of maximal range Excessive trunk lean Excessive balance support (more than a finger) The person flexes the knee Standing 20 - 25 single leg heel-rises N (5) 15 single leg heel-rises G (4) Unable to do 1 Heel-rise from neutral: apply resistance using Kendall's method Max resistance F (3) Full ROM with no resistance P (2) Incomplete ROM T (1) No muscle activity (Zero) 0 (0)

Oblique trunk flexors (left internal and right external obliques): MMT

Oblique trunk flexors (left internal and right external obliques): the person is supine with hands clasped behind the head, an assistant stabilizes the person's legs on the table. To test these muscles, the therapist passively places the person in trunk flexion with left rotation and asks the person to hold that position.(3 sec) (To test right internal and left external oblique muscles, rotate the person's trunk to the right.) Arm position determines grading Normal: the patient can hold the test position with hands clasped behind head. Good: the patient can hold the test position with arms folded across chest. Fair+: the patient can hold the test position with arms extended forward. Fair: the patient can hold the trunk in enough flexion and rotation that the right shoulder blade is off the table. Bring left shoulder up the right hip - stabilize legs Bring right shoulder up to left hip Remember that left trunk rotation uses left internal oblique and right external oblique

Test for Rigid or Supple Flat Foot:

Once the patient has been determined to have a flat foot, the patient is then placed in sitting, with the foot dangling. The patient then slightly plantarflexes the foot (keeping the toes relaxed), and the examiner compares the degree of arch noted in stance versus the arch now produced in sitting. If a greater arch is noted in sitting, the patient has a supple flat foot. If the arch remains absent or does not change with slight plantarflexion in the sitting position, the flat foot is designated as rigid. No psychometric information available on this test.

MMT Iliopsoas

Only muscle that can flex the hip past 90 Attaches from proximal femur up into spine and does hip flexion If it is weak, they will substitute with rectus femoris and will lean back Have them hold on to the end of the table

Meniscal physical exam

Palpation: tender at tibial plateau Hx & PE: Delayed minimal to moderate joint effusion PE: (+) McMurray, Thessaly Other: potential motion loss, Varied dysfunction/pain with squat, Single leg stance

Lateral Pivot Shift Test for Anterolateral Knee Instability

Patient is supine with the hip flexed to 30 degrees and slight abduction. The lower leg near the ankle is grasped with the examiner's distal hand, maintain 20 degrees of internal tibial rotation. Allow knee to sag into full extension. The proximal hand grasps the lateral portion of the leg at the level of the superior tibiofibular joint, increasing the force of internal rotation. Maintain internal rotation, apply a valgus force with the proximal hand to the knee while it is slowly passively flexed. If the tibia's position on the femur reduces as the knee is flexed in the range of 30 to 40 degrees or if there is an anterior subluxation felt during extension, the test is positive for a tear of the ACL, posterolateral capsule, arcuate ligament complex, or the IT band. Caution: meniscal involvement, limited range of motion, and muscle guarding may produce false-negatives. -internal rotation, let leg drop

Talocrural Distraction Manipulation

Patient position - Supine with ankle off table, non-treatment limb is bent with foot on plinth Therapist position and technique · Grasp the patient's foot with both hands. · Small or ring fingers lie just below the neck of the talus. · Both thumbs provide firm pressure to the mid forefoot from the plantar surface. · Manipulation technique o Engage the barrier with ankle slightly plantar flexed with distraction § Slightly Evert & DF forefoot to fine-tune the barrier. § Use body weight and scooping motion with hands to apply a HVLA thrust in a caudal and DF direction.

MMT of extensor hallucis brevis

Patient supine with ankle off table, have them extend big toe, stabilize ankle, push toe into flexion. For brevis, put big toe mid extension, grab the metatarsal and apply a plantar flexion pressure while patient resists.

MMT flexor hallucis longus/brevis

Patient supine with ankle off table, have them flex big toe, stabilize ankle, push toe into extension.

MMT flexor digitorum longus

Patient supine with ankle off table, have them flex toes 2-5, stabilize ankle, hook around toes, pull toes into extension. Flex toes and plantarflex foot

Rotation of the Tibia: Direction of force:

Rotatory forces are applied at the distal end of the tibia.

any excessive navicular drop from side to side with the marching? Find subtalar neutral in standing. Mark the most prominent lateral portion of the navicular and measure how far below the medial malleolus. Have them march in place. At the bottom of the march where they lose most of their arch have them stop. Then repeat finding the most prominent lateral portion of the navicular and measure how far below the medial malleolus. Navicular drop test > 10 mm neutral to standing = excessive

Scoring- Pronation: >9 mm - Neutral: 5-9 mm- Supination: <5 mm

SFMA

Selective Functional Movement Assessment

Fundamental Movement Tests of SFMA

Selective Functional Movement Assessment Active Cervical Flexion Active Cervical Extension Active Cervical Rotation with Side- Bending UE Pattern 1 - Medial Rotation & Extension UE Pattern 2 - Lateral Rotation & Flexion Multi-segmental Flexion Multi-segmental Extension Multi-segmental Rotation Single leg stance Arms Down Deep Squat

Typical Pain Sites of the Knee

Sinding-Larsen-Johansson (SLJ) syndrome is pain at the bottom of the kneecap (patella). It is caused by swelling and irritation of the growth plate there. A growth plate is a layer of cartilage near the end of a bone where most of the bone's growth happens. Thickening of medial side: medial collateral ligament Up from fibular head thickening: lateral collateral ligament (sit cross legged) Internal rot tibia: pushed med menisus forward

Active Lachman test: (for ACL)

pt supine with knee supported by examiner's thigh in 15-20 degrees of flexion. Examiner stabilizes the pt's distal tibia and asks the pt to actively contract the quadriceps. Examiner observes pt's proximal tibia for signs of anterior displacement.

Subtalar Joint Rocking Direction of force:

Talus glides posteriorly over the calcaneus. The talus will glade down and back over the calcaneus. Top hand on the talus and lower hand at the base of the calcaneus. Your hands should slide across each other. This is a small movement. -sort of ant/post -slide toward each other -grab talus and navicular -grab calcaneus

Second-degree MCL sprain).

The incidence of medial (tibial) collateral ligament (MCL) lesions is 7.9% of all athletic injuries. MCL injuries can be seen in both contact and noncontact sports when valgus stress is applied to a flexed knee. Additional mechanisms of injury include an external rotation pivoting injury, a blow to the anterolateral knee, and frank knee dislocation. Concomitant injuries to associated structures about the knee (eg, ligaments, menisci) are frequent and increase in likelihood with increasing severity of the sprain.

Test for the Deltoid Ligament / Eversion Stress Test:

With the patient in the same position as the test for the calcaneofibular ligament, and with the hands in the same location on the calcaneus and tibia-fibula, apply a direct eversion stress. The test is positive if a noticeable gap is produced inferior to the medial malleolus as compared to the opposite side. No psychometric information available on this test. -do it from calcaneous and support the foot

Plantar fasciitis:

With the patient long sitting or in prone, place first metatarsal into flexion and allow the tissues to relax; move thumbs up and down the long arch of the foot and along the great toe, pulling it slightly into abduction (left). Roll knuckles along the longitudinal arch (below). distal to proximal attaches to 1st metatarsal -put them in plantarflexion

The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome:

With the patient sitting, the examiner maximally dorsiflexes the ankle, everts the foot, and extends the toes maintaining the position for 5 to 10 seconds, while tapping over the region of the tarsal tunnel to determine if a positive Tinel sign is present or if the patient complains of local nerve tenderness. tibial N + A with tom dick and harry

Anterior and Posterior movement of the fibula on the tibia.

surround the fibula -see if it wiggles

Apprehension Test/Test for Patellar Stability:

With the patient supine and relaxed, gently push the patella laterally. The test is positive if the patient expresses a sensation of instability, expresses apprehension ("it feels like its going to dislocate again"), or if the patient actually contracts the quadriceps to prevent further lateral displacement. Psychometrics: Sensitivity: 39% (Malanga, Andrus, Nadler, & McLean, 2003). -most people dislocate laterally

Hughston Plica Test:

With the patient supine, flex the pt's knee with the palm of your hand pressing the patella medially, and your fingers of the same hand applying pressure over the medial femoral condyle, then passively flex and extend the knee. A popping, clicking, or pain over the medial condyle, usually between 45-60 degrees knee flexion is a positive test. In many patients, an inflamed plica is palpable over the medial femoral condyle. No psychometric information available on this test. plica: extra synovial thickening, medial more

"Cuboid Whip" or Cuboid Manipulation.

The manipulation begins with the patient in the prone position and the knee flexed to approximately 70-90 degrees with the ankle near neutral. Interlock the fingers over the dorsum and position the thumbs on the plantar aspect of the cuboid. The manipulation is performed by moving the knee into extension and plantar flexing the foot while maintain the above positions of the hands. The knee is passively extended as the ankle is plantar flexed with slight supination of the subtalar joint. A thrust force is applied through both of the thumbs on the plantar aspect of the cuboid.

Test for Plantar Fascitis:

The patient is supine with the knee extended. The therapist maximally dorsiflexes the patient's foot while simultaneously dorsiflexing the digits, especially the hallux. The therapist palpates at the medial and lateral calcaneal tubercles with the other hand. Pain along the region of the fascia represents a positive test. No psychometric information available on this test.

Functional Hallux Limitus test:

This is a two step test designed to compare the amount of motion at the 1st MTP when it is unloaded vs loaded. 1) Begin with the person in a long sit position, the foot in a relaxed position, and examine how much passive extension (DF) of the 1st MTP is available (normally 70-90 degrees) 2) Load the 1st metatarsal as it would be in stance (towards the dorsal surface of the foot) and recheck the PROM available at the 1st MTP. It should be about 1/3 of the unloaded ROM. No clinometrics. Dutton (2020), states 60 degrees is needed for walking and over 90 degrees for running, squatting, and some dance maneuvers

"Bounce Home" Test/Test of the End-Feel of the Knee that Lacks Full Extension:

With the patient supine, relax the muscles around the knee. Place one or both hands on the heel of the patient's foot and passively flex the knee to about 15 degrees. Ensuring that the musculature is still relaxed, let the knee passively extend (or "bounce" home), and palpate the end-feel as it does so. A rubbery end-feel would indicate meniscus, a "mushy" end-feel would indicate joint effusion. No psychometric information available on this test.

The heel thump test:

Syndesmotic injury testing: The examiner holds the patient's leg with one hand and with the other hand applies a gentle but firm thump on the heel with the fist. This force is applied at the center of the heel and in line with the long axis of the tibia. Pain experienced at the distal tibiofibular syndesmosis suggests the presence of injury.

External rotation stress test:

Syndesmotic injury testing: The examiner stabilizes the leg with 1 hand and applies an external rotation load to the foot, with the ankle in neutral dorsiflexion/plantar flexion. it will hurt if positive

Interphalangeal Joints Anterior and Posterior Glide Direction of force:

Stabilize proximal portion of joint with one hand. The other hand is on the distal part of the joint to perform the maneuver. Move the distal part of the joint at a perpendicular angle.

Midtarsal Joint Anterior - Posterior Glide Direction of force:

Stabilize the navicular with the proximal hand, and then move the metatarsal anterior or posterior with the distal hand in relation to the navicular.

Subtalar Joint Medial and Lateral Tilting of the Calcaneus Direction of force:

Stabilize the talus then invert (medial tilt) and evert (lateral tilt) the calcaneus on the talus.

Anterior Labral Test

Step 1: Flexion, Abd, ER Step 2: Arc into Add & IR Step 3: Move into Ext, maintain Add & IR (+) pain or click reproduction -dynamic

cuboid groove

Strain/itis/osus of peroneus tendon -fibularis longus goes through cuboid groove

Neutral Wear Pattern

Tend to wear most heavily along lateral aspect of heal Even wear along the remainder of the outsole No excessive midsole wrinkling or tilt

Test for the Anterior Talofibular Ligament:

The A.T.F. is located at the sinus tarsi, the depression on the lateral aspect of the ankle. The evaluator palpates this ligament while inverting and plantarflexing the foot/ankle. Pain along the course of the ligament and/or laxity as compared to the opposite side indicates a positive test. No psychometric information available on this test.

Noble Compression Test/ Test for Iliotibial Band Friction Syndrome:

The affected limb's hip and knee are passively flexed to 90 degrees. The examiner applies pressure with the thumb over the IT Band proximal to the lateral femoral condyle. The patient then actively (some say this motion should be done passively by the examiner) extends the hip and knee. At approximately 30 degrees of flexion (0 degrees being a straight leg), if the patient complains of severe pain over the lateral epicondyle, the test is positive. No psychometric information available on this test. -squeeze over lateral femoral condyle and striaghten knee

Foot Taping Techniques Plantar Fasciitis - Option 1

The ankle should be in a slightly supinated position with the ankle near zero degrees of dorsiflexion. 1. Apply a strip of Cloth tape in a circumferential fashion at the level of the metatarsal heads (Do not make this too tight otherwise it will be uncomfortable in standing) 2. Next start a strip of tape along the lateral aspect of the plantar surface at the 4th and 5th metatarsal head, apply it diagonally across the sole, around the heel, along the lateral border of the foot and ends on the metatarsal strip; 3. The third and fourth strips are started at the lateral aspect of the metatarsal strip and carried around the heel and end on the metatarsal strip near the base of the great toe. 4. End with another metatarsal heads circumferential strip 5. Some will add strips to support the medial longitudinal arch (blue dotted arrows) a. beginning at the base of the 5th metatarsal b. proceed medial across the metatarsals proceeding up and over the navicular c. then continue filling in the rest of the medial longitudinal arch

Foot Taping Techniques Plantar Fasciitis - Option 2

The ankle should be in a slightly supinated position with the ankle near zero degrees of dorsiflexion. 1. First, a "U" anchor is placed around the heel from the lateral to medial border at the metatarsal heads. Although not shown here some will begin with a circumferential metatarsal heads anchor. 2. Then link the anchors by using tape strips beginning at the 5th metatarsal and coming medial across the metatarsal strips up and over the navicular, and then continue to filling in the rest of the medial longitudinal arch. This picture shows the person beginning at the calcaneus and moving towards the metatarsal heads. Some begin proximal to the metatarsal heads and proceed in a stepwise fashion to the calcaneus. Either method is fine. 3. Repeat both anchoring strips a. First, the "U" anchor around the heel from the 1st to the 5th metatarsal heads. b. Finally, a circumferential metatarsal heads anchor (note the picture shows the tape being applied tape proximal to metatarsal heads - should be applied around the metatarsal heads).

Test for the Anterior Tibiofibular Ligament / Side-to-side Test

The anterior tibiofibular ligament is the ligament that maintains the dome-shape of the mortise. Gently grasp the talus, avoiding compression/squeezing together of the mortise, then attempt to translate the talus from side to side. There should be minimal translation from side to side, and the test is positive if the talus translates greater in one direction than the other does. Again, compare to the opposite ankle. No psychometric information available on this test. translate talus and calcaneus

Test for Calcaneofibular Ligament / Talar Tilt or Inversion Stress Test:

The calcaneofibular ligament is located laterally and stabilizes the ankle against direct inversion. With the patient sitting in a comfortable position, place the ankle in neutral (i.e.: 90 degrees, directly between dorsiflexion and plantarflexion). Grasp the calcaneus with one hand and the tibia-fibula with the other and apply a direct inversion stress. The test is positive if the talus tilts out from the lateral malleolus. Compare to the opposite ankle. No psychometric information available on this test. -do it from calcaneous and support the foot

The Royal London Hospital Test for Tendonopathy

The clinican palpates several centimeters proximal to the Achilles tendon insertion for local tenderness with the ankle either in neutral position or with slightly plantar flexion. The tenderness to palpation decreases significantly or disappears completely with ankle dorsiflexion. You must palpate in the same area, do not follow the local area of swelling as the patient dorsiflexes. In the picture to the left the person is palpating just below the superior aspect of the lateral malleous. This position (just below the superior aspect of the lateral malleolus remains the same with the foot resting in neutral-slightly plantar flexed (position 1) or when the patient actively dorsiflexes (position 2). Do not attempt to follow the swelling if tendonopathy is suspected. Tendonopathy = Less painful/tender to palpation when the foot is fully dorsiflexed. Dorsiflexion may increase the pain with tendonopathy (moves distally with the tendon) but when palpating at the same point the pain should lessen to palpation because the swelling has moved more caudal. Reported Sensitivity 0.54, Specificity 0.91 from Maffuli, et al., (2003). Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med, 13(1), 11-5.

greatest holistic approach for the common impairments - plank was the correct answer. Common reasons for ankle sprains include the _________________ including trunk stabilization. - Reason for a bonus

whole kinetic chain

The squeeze test:

The examiner cups both hands around the distal tibia and fibula and imposes compression in a progressively more forceful manner. The test is repeated at progressively more proximal locations. Pain experienced at the distal tibiofibular syndesmosis is a positive test result. Syndesmotic injury testing:

Tibial Sag (Godfrey) sign:

The patient is in the drawer position (hip flexed to 45 deg and knee flexed to 90 deg). Traditionally done with the patient supine, hips flexed to ninety, knees flexed to ninety, and heels supported on a stool or by the clinician. The position of the proximal tibia is noted. If the PCL is torn, the tibia will drop (sag) posteriorly relative to the femoral condyles. If the PCL is intact, the tibia will remain in neutral position. If the tibia sags then perform the Quadriceps Active Test. The patient performs a gentle isometric quadriceps contraction, watch the proximal end of the tibia, if the sag reduces it is positive (Dutton, 2013, p. 874 reports sen 54-98%, spec 97%) Tibial Sag Sign Psychometrics: established by Rubinstein, et al. (1994) in a comparative study of 31 patients, with a mean age of 27. Sensitivity: 79% Specificity: 100% -if tib sags back- PCL could be torn

Posterior Drawer Test/Test for the Posterior Cruciate Ligament:

The patient is supine with the hip flexed to 45 degrees, the knee flexed to 90 degrees, and the foot flat on the table. Use both hands to grasp the tibia medially and laterally, with thumbs anterior over the joint line. Take up the slack and move the tibia backward on the femur. Palpate the end-feel and compare to the opposite PCL. The test is positive if there is excessive posterior translation of the tibia on the femur without a ligamentous end-feel. Psychometrics: established by Rubinstein, et al. (1994) in a comparative study of 31 patients, with a mean age of 27. Note: the authors found frequent false negatives of this test in acute situations. Sensitivity: 90% Specificity: 99% -your thigh on their foot -push back for PCL (PCL is 50% stronger) -pull forward for ACL -there should not be lots of movement

Test for Flat or Pronated Foot:

The patient is tested in stance with the feet about six inches apart, thus fully weight bearing on the feet. The examiner observes the medial aspect of the foot, noting the degree of arch. The examiner then palpates the apex of the medial malleolus, the most medial aspect of the navicular, and the plantar aspect of the first metatarsophalangeal joint. The navicular should lie on a line (also known as the Feiss line) drawn between the apex of the medial malleolus and the plantar aspect of the first M-T-P joint. If the navicular falls below this line, the patient has a flat or pronated foot. No psychometric information available on this test. -medial malleolus -1st MTP -navicular tuberosity (take note of how much this falls)

Clunk (Cotton) Test:

The person is prone and the examiner stabilizes lower leg then everts the calcaneous. A clunk is positive for syndesmosis injury. Syndesmotic injury testing could feel a clunk

Talocrural Joint Anterior & Posterior Glides Direction of force:

The therapists' body leans away from the patient to provide distraction. Then the therapist using their body weight glides the talus anteriorly or posteriorly. -neutral dorsiflexion -if cant do it in ant position, go underneath to pull calcaneous up

Testing the Trunk Muscles.

Therapists should realize that testing the trunk muscles is not a common assessment, however they must have an understanding of how to test and grade the strength of these muscles when it is appropriate that they do so. Trunk muscles to test: Trunk extensor groups Quadratus lumborum Oblique trunk flexors "Upper and Lower" abdominals Trunk extensor group (erector spinae, latissimus dorsi, quadratus lumborum, trapezii): the patient is prone, hands clasped behind the head, therapist stabilizes the patient's legs firmly on the table. The therapist asks the patient to extend his back, lifting his chest and off the table as high as possible. If the patient can perform this maneuver through the entire range of back extension, the strength grade is normal. The therapist determines weakness if the patient cannot perform the movement, nor can the patient hold the position of back extension when passively placed there by the therapist. Kendall proposes that the therapist classify any weakness as "slight, moderate, or marked" This is not a true maximal strength test, but a test to examine if they enough strength to counteract gravity, which is not enough (in my opinion) to perform ADLs. It is probably best to look at endurance and strength testing since these are postural muscles. How long can you hold it? 30 seconds, 60 seconds, 2 minutes? Don't go longer than 2 minutes

gastroc and soleus testing what is good ?

There is considerable disagreement about the number of heel-rises that represents normal recommend 25 as normal for males and females between the ages of 20-59 and Jan, et al., states that those who do not exercise regularly, males above 60, and females above 40 are unlikely to achieve 20 repetitions (2005). It may be better to record the number they can achieve and compare it to the uninvolved side. Standing 10 single leg heel-rises N (5) 5 single leg heel-rises G (4) Unable to do 1 Heel-rise from neutral (Lundsford & Perry - suggest as slightly different criteria our Fair is their Poor) Max resistance F (3) Full ROM with no resistance P (2) Incomplete ROM T (1) No muscle activity (Zero) Z (0)

Develop a weight bearing exercise for someone when trying to do a calf raise (without a ball between the heel) that rolls to the outside of their foot (uncontrolled supination at end range). Hint: Try to incorporate what you have already done.

They need to incorporate an exercise that activates the fibularis longus. Calf raises with TheraBand maintained under 1st metatarsal. Have them do the exercise properly and then allow them to roll the foot outward while doing the exercise and the TheraBand should pop up (reason for the hand across chest to protect face from TheraBand when it pops up) - This is a good exercise for those with inversion control issues.

General instructions for SFMA:

They should remove their shoes. Tell them to perform the exercise after the instructions. Instruct them, if any of the movements reproduces their symptoms or pain please let you know. If they do any of the movements incorrectly, correct and have them repeat with cueing at your discretion.

Anterior Glide at knee Direction of force:

Tibia moves anterior on Femur parallel to tibial plateau. -sort of like lachmans (for ACL) -used to increase extension -do glides at end range

Distraction at knee Direction of force:

Tibia moves away from the Femur at a right angle. -make sure to stabilize femur -grab ankle - lean with body weight down

Trendelenburg Test/ Gluteus Medius Test:

This procedure evaluates the strength of the gluteus medius muscle on the stance side. Stand behind the patient and observe the dimples overlying the posterior superior iliac spines. Normally, when the patient bears weight evenly on both legs, these dimples appear level. Then ask the patient to stand on one leg. If he stands erect, the gluteus medius muscle on the stance side should contract as soon as the opposite leg leaves the ground, and should elevate the pelvis on the unsupported side. This elevation indicates that the gluteus medius muscle on the supported side is functioning properly (negative Trendelenburg sign). If the pelvis on the unsupported side remains in position or actually drops, the gluteus medius on the stance side is either weak or non-functioning (positive Trendelenburg sign). "A pelvic on femoral angle with ≤83° angle criteria with specified time duration of 30 s was used as a positive sign." (Reiman, et al., 2015, p.1) "Diagnostic accuracy: Sensitivity (SN) 55%, specificity (SP) 70%, positive likelihood ratio (+LR) 1.83 and negative likelihood ratio (−LR) 0.82. Special note: Monitor for patient compensating by leaning their trunk to avoid having pelvis drop. Leaning compensation constitutes a positive test as well. Background: Generally considered a physical performance test of hip strength, this test has also been utilized for assessment of gluteal tendinopathy with a positive test being reproduction of spontaneous pain within 30s on involved leg compared with the contralateral leg during single leg stance." (Reiman, et al., 2015, p.1)

Taping to Pull Distal Fibula Posteriorly:

This technique is a variation of Mulligan's method to address lateral ankle sprains by facilitating posterior glide of the fibula. Cut an I-strip of tape and anchor (25% tension) just anterior to the distal fibula. Place about 75% tension on the rest of the tape and pull posteriorly, laying the tape down and spiraling around the distal leg. (Once you begin spiraling around the leg, decrease your tension to about 25%.)

Taping to Support the Navicular and/or Posterior Tibialis:

This technique is useful with people who excessively pronate. Cut two I-strips. Place the ankle in slight inversion and about 5 degrees of dorsiflexion. Anchor the first strip of tape (no tension) just behind the tuberosity of the fifth metatarsal. Lay the tape down over the sole of the foot with no tension, moving medially to capture the navicular (as you cover the navicular, place about 80 - 90% tension on the tape), pull upward and anchor the tape over the anterior distal tibia, spiraling posteriorly as needed. (Once you begin spiraling around the leg, decrease your tension to about 25%.Repeat with the second strip, laying it down so that about half of the tape overlaps the first strip.

trunk extensors mmt

Trunk extensor group (erector spinae, latissimus dorsi, quadratus lumborum, trapezii): the person is prone, hands clasped behind the head, therapist stabilizes the person's legs firmly on the table. The therapist asks the person to extend his back, lifting the chest and off the table as high as possible. If the person can perform this maneuver through the entire range of back extension, the strength grade is normal. (AROM=PROM and hold 3 sec) The therapist determines weakness if the person cannot perform the movement, nor can the person hold the position of back extension when passively placed there by the therapist. Kendall proposes that the therapist classify any weakness as "slight, moderate, or marked" -lay on stomach and lift up , stabilize their legs

Distraction/Inferior glide of hip

Two different ways of doing a similar technique. 1. Use your body weight (don't sit on the plinth as in the picture from Dutton), 2. keep your arms stiff, 3. shoulder against their posterior thigh, 4. and shift posteriorly from your hips and legs. This will generate the force you need to distract and inferiorly glide the hip. -could also do lateral distraction -with belt -close to ASIS -put it around your belt and use it to pull them -hands near ASIS and overlap hands -have them relax

Longitudinal Arch Angle (Feiss line):

Used to assess risk for development of medial tibial stress syndrome or plantar faciitis Description: The angle formed by 1 line projected from the midpoint of the medial malleolus to the navicular tuberosity in relation to a second line projected from the most medial prominence of the first metatarsal head to the navicular tuberosity. Method: With the patient standing with equal weight on both feet, the midpoint of the medial malleolus, the navicular tuberosity, and the most medial prominence of the first metatarsal head are identified using palpation and marked with a pen. A goniometer is then used to measure the angle formed by the 3 points with the navicular tuberosity acting as the axis point.

Inhibition of Quadratus Lumborum:

Using an X- strip of tape, anchor the middle of the tape (the uncut portion) with no tension, placing it in the center of the QL and in line with the muscle fibers. Place about 75% tension on the 'arms' of the tape and lay each end of the X down moving at a diagonal from the center piece of tape. Use no tension on the last 1" of the arms of the X to anchor.

Inhibition of Muscles along the Iliotibial Band:

You can use three or four Y-strips of tape (depending on length of the person's femur). You may use this technique to inhibit either the biceps femoris (pictured at right) or the vastus lateralis. Use the first inch of tape (the base of the Y) as the anchor (no tension). Pull the first of the two arms of the tape forward (75-90% tension) and anchor, then do the same with the second. NOTE: if the person has an active trigger point, tape in such a manner that the trigger point is between the two arms of tape (refer to image at right). This will take some load off that part of the muscle and the trigger point as well. Apply the other Y-strips as above, overlapping the arms with the superior and inferior Y-strips, as pictured. For vastus lateralis, the base of the Y will be anchored on that muscle with the two arms moving posteriorly toward the biceps femoris. Note: You may also use this technique to inhibit the adductors as well as treat trigger points in that group of muscles.

Inhibition of Muscles along the Iliotibial Band

capsular pattern for knee is

a gross limitation of flexion and slight limitation of extension & ratio of knee flex:ext is 10:1 (Dutton, 2020, p.936). For every 5 degree loss of extension you will see an approximate 45-60 degree loss of flexion.

talocrural joint

a joint in the ankle found between the tibia, fibula, and talus

anterior tibiofibular ligament

a ligament that connects the tibia to the fibula in front of the ankle

Apley's Compression Test/Test for Menisci:

a non-specific test for involvement of the menisci that does not differentiate medial meniscus from lateral meniscus. With the patient prone, flex the knee to 90 degrees. Compress the joint through the long axis of the tibia, and then internally and externally rotate the tibia. The test is positive for a meniscal tear if pain is elicited, or if a pop or click is noted. Psychometrics: established by Fowler & Lubliner (1989) in a systematic review. Sensitivity: 16% Specificity: 80% -distract and twist -compress and twist

Neuromuscular control.

a. Neuromuscular control is compromised when stabilizing muscles fatigue. Emphasize neuromuscular reeducation (proprioceptive training) with stabilization, acceleration, deceleration, and perturbation training in weight-bearing positions. Begin with low-intensity, single-plane movements and progress to high-intensity, multiplane movements.

posterior medial shin splints - what causes it?

accepted Weak fibularis longus as that is a possibility (exam was adjusted). Recognize tight gastrocnemius is the more likely cause.

The ___________ is the ligament that maintains the dome-shape of the mortise.

anterior tibiofibular ligament

A patient with a first-degree sprain presents

with tenderness over the MCL but no instability.

Knee bracing

can be used for patients with acute PCL injuries, severe MCL injuries, or PLC injuries. Functional bracing with the use of a hinged knee brace allows early ROM while protecting the knee from a further valgus blow. Level of evidence from CPG = F

Midtarsal adduction test is performed to implicate ___________. There are no psychometrics for this test. Stabilize the subtalar joint with the proximal hand and adduct the forefoot with the distal.

cuboid syndrome

Midtarsal supination test is performed to implicate _________. There are no psychometrics for this test. Stabilize the subtalar joint with the proximal hand and supinate the forefoot with the distal.

cuboid syndrome

Palpate over the dorsolateral aspect of the cuboid bone will elicit pain in __________. It is located proximal to the tuberosity of the 5th metatarsal and distal to the peroneal tubercle.

cuboid syndrome

clonus reflex

extensor plantar response primitive reflex rhythmic muscle contraction and relaxation during stretch reflex (foot tapping motion) -quick stretch of gastroc - lots of beats mean positive

what attaches to the fifth metatarsal?

fibularis brevis

MMT tensor fasciae latae

flexes, abducts, and medially rotates thigh

Deltoid ligament of ankle

formed by Anterior tibiotalar, tibiocalcaneal, posterior tibiotalar, and tibionavicular ligaments provides medial support,,,,,resist eversion of the talus

Prehension exercises with toes:

gather items of uniform size (such as marbles or cotton balls) and place them in an area near the inside of your foot. Using your toes, pick up one item at a time and place it in an area on the other side of your foot. Move all items from one side, then to the other. To make more difficult, use items of varying size.

American Medical Association classification, an injury is defined by the amount of joint line opening:

grade I, <5 mm of medial joint line opening; grade II, 5 to 10 mm of joint line opening; and grade III, >10 mm of joint line opening. More than 7 mm of laxity isthought to signify the potential for additional injury to other structures (Marchant, 2011). Since most are not able to judge the exact mm of movement, the term degree is usually used and defined below.

MMT Hip Medial Rotators Hip medial rotator group: tensor fascia lata, gluteus minimus, anterior fibers of gluteus medius

have patient seated with legs over side of table, go through their full range of internal rotation then come off the end range just a bit, stabilize knee, apply pressure to bring the patient into neutral. Put a pad under the knee

A second-degree sprain, there is

increased valgus laxity, but a firm end-point still exists. This level of damage is purported to result in 5° to 15° of valgus instability at 30° of flexion,with a definite endpoint, no instability with knee extension, and no rotational instability. (Marchant, 2011)

Sprain:

injury to a ligament Grade 1: pain, mild swelling, no laxity, no instability, Grade 2: pain and laxity (definitely at 30 degrees - maybe or maybe not at 0 degrees) Grade 3: no pain, laxity and instability (may or may not Grade I Sprain: 10 days- 2 weeks (10.6 days) Grade II Sprain: 2-5 weeks up to 2 months Grade III Sprain: 7 weeks to 18 months Avulsion: 6-8 weeks

calcaneofibular ligament

intrinsic ligament located on the lateral side of the ankle joint, between the calcaneus bone and lateral malleolus of the fibula; supports the talus bone at the ankle joint and resists excess inversion of the foot

what things effect the cuboid?

inversion sprain weight (obesity) overpronation affects cuboid

Anterior Drawer Test/Test for the Anterior Cruciate Ligament:

less sensitive than the Lachman test, due to the potential for the fibers of the Iliotibial Band, which run parallel with the fibers of the ACL, adding to the stability of the joint in the test position (may give you a false negative test!). The patient is supine with the hip flexed to 45 degrees, the knee flexed to 90 degrees, and the foot flat on the table. Use both hands to grasp the tibia medially and laterally, with thumbs anterior over the joint line. Take up the slack and move the tibia forward on the femur. Palpate the end-feel and compare to the opposite ACL. The test is positive if there is excessive anterior translation of the tibia on the femur without a ligamentous end-feel. Caution: In a knee with a torn PCL, the tibia may have passively shifted posteriorly, giving the evaluator a false sense of anterior instability when doing the anterior drawer test. Be sure and check the starting position of the tibia! Psychometrics: established by Scholten, et al. (2003) in a meta analysis of six studies of this test. Sensitivity: 62% Specificity: 88% -stabilize foot -push posterior (PCL) and anterior(ACL) -just like posterior drawer test but move anterior

which is longer - medial or lateral femoral condyle?

medial femoral condyle is 1.7 cm longer A-P than lateral

remember waiting until you are pain free to advance will be too slow for most and you can still advance exercises as long as it is

minimal and there are few symptoms the next day. If they are they are having minimal pain, even with ADLs you likely can begin plyometrics.

Medial Soft Tissue of knee

nMedial Aspect -MCL -Pes Anserinus Insertion (Sartorius, Gracilis, Semitendinosus) Pes Anserinus --> sartorius, gracilis, semitendinousus (say grace before supper) Couple fingers in medial from tibial tuberosity (gracilis, don't let me pull foot out)- down further on tibia

neuroma

nerve tumor

· Anterior border of knee

o Bone § Tibial tuberosity § patella · odd facet · Ballottement of patella - Why do you get the tapping sensation? normally patella is in close contact with femur unless there is swelling, then farther away so as you push it to the femur you get a tapping sensation. · Moderate effusion test. Proximal hand 10cm above patella, maximally extend knee, distal index and thumb at joint line, proximal hand pushes fluid down to patella, if effusion is present feel it at distal hand. · Minimal effusion - start from the distal and medial border of the knee - stroke superiorly along the medial aspect of the patella about 10 cm above to midline of thigh - repeat 2-3 times. Immediately repeat on the lateral side. If the medial side begins to fill with fluid there is effusion. § tibial plateau § tibia tuberosity o Ligament o Tendon or other § patella tendon § suprapatellar (quadriceps) tendon § Bursae · subcutaneous infrapatellar · deep infrapatellar · prepatellar · suprapatellar

Hip Accessory Motions

o Distraction/Inferior glide o Posterior glide (occurs with flexion and internal rotation) o Anterior glide (occurs with extension and lateral rotation) o Superior glide (occurs with adduction)

Lachman Test/Test for the Anterior Cruciate Ligament:

of the tests of the ACL, this is the most sensitive. With the patient supine, grasp the femur with one hand and slightly externally the lower extremity. Grasp the tibia with the other hand, flex the knee to 15-20 degrees, and, ensuring that the hamstrings are relaxed, briskly pull the tibia forward on the femur. Palpate the end-feel and compare to the opposite extremity. The test is positive if there is excessive anterior translation of the tibia on the femur without a ligamentous end-feel. -this is the gold standard -put your thigh under their knee -push tib back then pull quick jerk up and forward -close to joint line -relaxed hamstrings

"The criteria for returning to training and competition include being

pain-free with full ROM, no instability on clinical examination, and muscle strength comparable with the uninjured side. Most clinicians want to see the strength of the quadriceps and hamstrings strength at least 90% of contralateral side." (Kim, et al., 2016, p.683)

Tarsal Tunnel Syndrome

painful foot disorder caused by compression of the posterior tibial nerve as it passes through the ankle -medial side

Direct myofascial trigger point release associated with Achilles tendonitis:

perform in standing. Identify the active trigger points, and "load" the fascia in all three planes (superior-inferior, medial-lateral, clockwise - counterclockwise), and have the patient actively plantarflex by raising their heels off the floor. As the patient slowly lowers back to the floor, a release typically occurs.

Soft tissue release along the myofascial meridians:

performing soft tissue mobilization along the plantar fascia, then extending upward through the gastroc-soleus, then the hamstrings, all the way up to the pelvis

1st MTP Adduction Goniometry

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Anterior and Anterolateral Ligaments: Anterior Talofibular, Calcaneofibular, Posterior Talofibular

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Anterior and Anterolateral Tendons: Fibularis longus tendon, fibularis brevis, extensor digitorum

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Anterior and Anterolateral bones and articulations: lateral malleolus, cuboid, tuberosity of 5th ray, Peroneal trochlea also known as the peroneal pulley - splits the brevis and longus tendon

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Anterior and Anteromedially Bones and articulations: MTP joints, Metatarsals, Cuneiforms, Navicular, Navicular tuberosity, Sustentaculum tali, Medial malleolus

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Anterior and Anteromedially Ligaments: Deltoid and Spring (Calcaneonavicular) ligament

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Anterior and Anteromedially Other Structures: dorsal pedal and posterior tibial arteries

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Anterior and Anteromedially Tendons: Posterior tibialis, Anterior tibialis, Extensor halliucis longus

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Cervical Spine Measurements goniometry

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Cervical Spine Measurements inclinometer

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Cervical Spine Measurements tape measurements

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Thoracolumbar Measurements goniometry

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McMurray Test for meniscal pathology:

pt supine; examiner grasps the pt's femur with one hand and the tibia with the other, and passively fully flexes and extends the pt's knee to relax the muscles around the joint. To check the medial meniscus: examiner fully flexes pt's knee while externally rotating the tibia; examiner then applies a valgus stress to the knee while extending the knee. To check the lateral meniscus: same starting position but the examiner internally rotates the tibia and applies a varus stress to the knee while extending the knee. The test is positive when a pop or click is palpable / audible within the joint along with pt report of reproduction of symptoms, or if there is a catch in the movement of the knee. Psychometrics: established by Stratford & Binkley (1995) and Evans, Bell, & Frank (1993). Evans, et al. (1993): Sensitivity: 16% Specificity: 98% Positive predictive value: .83 Negative predictive value: .65 Stratford & Binkley (1995): Positive predictive value: .81 Negative predictive value: .56 -flex to extend

MMT Adductors

pull legs apart Have the patient lying on side, lift both legs off table then separate thighs, therapist applies downward pressure on table leg and upward pressure on sky leg. Swap sides and repeat. (laying in side figure 4) roll them on side, have their leg in extension, put one leg over the other and let bottom leg adduct, then see how much range they have, see if they can hold it, see if they have full ROM, apply graded pressure resistance - could also have two legs in air pushing them opposite directions (top leg push in air, bottom leg push to table)

Overall, you did well with the tendinopathy questions so congratulations. I did notice a few had trouble with the patellar tendinopathy question where they were doing jumps, every other day, but having 6 out of 10 pain with significant symptoms the next day. They key to that question is that they needed more ______

rest. Remember part of tissue loading with tendinopathy may require up to a 72-hour period of rest from strenuous loading if they are continuing to have significant symptoms from the previous day. - Reason for a bonus

1. A 68-year-old female is having difficulty walking for prolonged periods as well as getting up/down out of low chairs. She reports bilateral knee stiffness and pain that is worse in the mornings when she wakes up or after sitting for prolonged periods. If she moves her knees, the stiffness usually resolves fairly quickly. She has a dysfunctional and painful squat and is unable to perform single limb stance at all. She walks with antalgic gait demonstrating decreased tibial advancement in mid-stance and late heel off in terminal stance as well as a mild lateral trunk lean to the left in mid-stance. Further examination reveals decreased patellofemoral and tibiofemoral mobility bilaterally, weakness in her gluteal musculature, decreased DF bilaterally with left worse than right, observable bony changes at bilateral knees, and decreased strength in bilateral quadriceps. i. Home exercise programs

should consist of safe to improve muscle performance, ROM, and endurance.

Ankle pumps:

sitting or standing such that you can freely move your ankle, gently bend your ankle up and down "pumping" it so that you point your foot downward, then upward. Move as far as you can in both directions. Do on both sides. Stretching Exercises for the Ankle and Foot

Ankle alphabet:

sitting or standing such that you can freely move your ankle, use your foot to trace the letters of the alphabet in the air. Make your letters big and emphasize moving your ankle in as many directions as possible. Do on both sides. Stretching Exercises for the Ankle and Foot

Gastrocnemius / soleus stretch:

stand facing a wall with the leg you are going to stretch extended behind you. Position your foot so that your toes point toward the wall and your heel isn't turned in or out. Create a slight arch in your foot (supinate it to make it more rigid), lean forward, bending at your ankle and not allowing your heel to rise. Feel the stretch in the your calf muscles and hold for 30 seconds. To stretch the soleus muscle, bend your knee and lean forward at your ankle, again not allowing your heel to rise. Repeat to the other side. Stretching Exercises for the Ankle and Foot

MMT popliteus

start with foot facing out and have them bring it in internal rotation and flexor of the knee O: lateral epicondyle of femur I: tibia

Test for Minor Joint Effusion (sweep test):

tests for minor swelling within the joint capsule. With the patient supine and knee relaxed, place the web space of your hand superior to the patella and "milk" the fluid downward and distally. Maintain the pressure superiorly. If there is minor joint effusion, two bulges will appear on either side of the patellar ligament, which will move laterally with pressure applied medially, and vice versa. If there is no movement of the fluid with the application of medial or lateral pressure, the edema is extracapsular. No psychometric information available on this test. -swelling will lift patella

Patellofemoral Grinding Test/Clarke's Sign:

tests for patellofemoral pain syndrome (PFPS) and evaluates the articular surface of the patella. The patient is supine, with a towel roll under the knee, flexing it approximately 5 degrees (if the knee is fully extended, the test may pinch the superior joint capsule). Cup the superior pole of the patella and stabilize it by moving it distally. Have the patient contract his/her quadriceps and allow the patella to glide underneath your hand (don't change the pressure of your hand, however). The test is positive if the patient reports excessive pain with the maneuver. Some degree of discomfort with this maneuver is common. No psychometric information available on this test. -press patella down, have them contract thigh

Quadratus lumborum:

the patient is prone with the test leg abducted about 20 degrees; the therapist applies resistance in the form of traction at the distal leg (near the ankle). The patient elevates the pelvis on that side, or works to "make the leg shorter" by hiking the pelvis on that side. Kendall advises against giving a specific grade to this muscle, instead, therapists should simply qualify it as strong or weak

Abdominals (biasing "lower" abdominals, external obliques):

the patient is supine with arms folded across the chest, low back flat on the table, the patient then slowly lowers both legs from the vertical (90 degree angle). The angle between the extended legs and the table noted at the moment that the low back arches determines the strength grade (see figure with grading scale from Kendall, et al., page 213).

Abdominals (biasing "upper" abdominals, rectus abdominis and internal oblique muscles):

the patient is supine, legs extended, back flat. Grading is based on hand/arm position and ability to perform both the trunk-curl phase and the hip flexion phase. The therapist should not stabilize the patient's legs until the person begins the hip flexion phase of the sit up. Normal: with hands clasped behind head, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Good: with arms folded across the chest, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Fair+: with arms extended forward, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Fair: with the arms extended forward, the patient can perform a trunk curl, but cannot maintain it when attempting to enter the hip flexion phase (typically only able to clear the shoulder blades from the table) (Kendall, McCreary, Provance, Rodgers, & Romani, 2005, p. 203).

Tom, Dick and Harry

tibialis posterior, flexor digitorum longus, flexor hallucis longus

A third-degree sprain has no end-point to

valgus stress. The terms "grade" and "degree" are often incorrectly used interchangeably.

Test for Length of the Quadriceps:

with the patient side-lying, place the femur in neutral (0 degrees ab/adduction) and passively flex the knee. Knee flexion less than 140 degrees with a muscular end-feel indicates tight quadriceps. To differentiate rectus femoris tightness from that of the vastus medialis, intermedius, and lateralis, flex the hip slightly, while keeping the knee fully flexed. If you no longer get a muscular end-feel, it was the rectus that was tight. If you continue to appreciate the same quality of end-feel, the other three quadriceps are tight.

Test for Length of the Gluteus Maximus:

with the patient sitting, achieve and maintain an anterior pelvic tilt (keep your hand at the patient's lower back to monitor). Adduct the patient's legs (the patient can do actively, or you can perform passively); stop if you begin to lose the anterior pelvic tilt or get a muscular end-feel. Note the position of the femur: if the patient cannot achieve a neutral position (0 degrees adduction), the patient likely has a tight gluteus maximus, which will manifest as a return to abduction and external rotation when you release the femur.

Top Tier Tests of SFMA: Multi-segmental Flexion Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please bend down and try to touch your toes." (Note: knees straight) Can't touch toes and return to standing Less than 70 degrees Sacral Angle No posterior weight shift (T-L junction over foot) Non-Uniform spinal curve

Bilateral Adductor Test

"Patient position: Patient is supine with bilateral legs extended. Clinician position: Standing at patient's bilateral feet, directly facing patient. Movement: Patient is asked to contract maximally both adductor muscles simultaneously, thereby attempting to bring bilateral legs together. Assessment: Reproduction of patient's concordant pain is considered a positive test. Diagnostic accuracy: SN 54%, SP 93%, +LR 7.7 and -LR 0.49.32 Special note: Monitor for compensations of patient grabbing onto table and/or bending knees. Background: As with the other sports related chronic groin tests, adduction contraction elicits stress across the common origin of the adductor muscles on the pubic symphysis region." (Reiman, et al., 2015, p.5) -resist it

Patellar-pubic percussion test

"Patient position: Supine, bilateral legs extended. Clinician position: Standing at the side of the leg to be tested. Movement: Clinician places a stethoscope over the pubic tubercle of the patient. Clinician taps the patella of patient's leg being assessed and qualitatively reports the sound. A tuning fork has also been used in place of tapping Assessment: A positive test is diminished percussion noted compared with contralateral side. Pooled diagnostic accuracy: SN 95%, SP 86%, +LR 6.11, −LR 0.07 Special note: Clinician must ensure that stethoscope is placed firmly over pubic tubercle and lateral to the pubic symphysis joint (on the side ipsilateral to side being tested). Background: The sound produced with either tapping or the tuning fork is dampened with the fracture/stress fracture." (Reiman, et al., 2015, pp.3-4) -if you suspect stress fracture -see if you hear vibration -with fracture you would not hear sound -vibrate over knee

Top Tier Tests of SFMA: Multi-segmental Extension Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please keep your hands above your head and reach back as far as you can." (Note: knees straight) ASIS doesn't clear the toes Can't maintain greater than 170 degrees of shoulder flexion Spine of scapula doesn't clear heels Non-Uniform spinal curves

Top Tier Tests of SFMA: Active Cervical Extension Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please look up to the ceiling." Unable to have the vertical line of the face become parallel or within 10 degrees of parallel to the horizontal line of the floor or ceiling.

Top Tier Tests of SFMA: Multi-segmental Rotation Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please place your hands by your side and rotate your entire body Right/Left trying to look behind you while keeping your feet still." Pelvis rotation less than 50 degrees Trunk/shoulder less than 50 degrees more than pelvis Spinal/Pelvic deviation Loss of body height with rotation Excessive knee flexion

Knee Flexion-Extension

(135°-0-10°)

Tibial Torsion

(15°-30° outward toeing)

Eccentric strengthening of the anterior tibialis / Wall exercise

(Duncan, 1990): Stand with your back to the wall... about one foot away. Lean back, maintaining a straight trunk. As you lean back, be sure the movement occurs at your ankles, and try to get as close to the wall as you can without touching it. If you touch the wall, pull yourself forward using the muscles on the front of your ankle.

"Short foot" exercise

(Kern-Steiner, 2003): Start with the foot resting on the floor, either full or partial weight bearing. Raise the longitudinal arch of the foot by shortening your foot, being careful not to curl your toes.

Self mobilization of metatarsals

(Kern-Steiner, 2003): start on your hands and knees, with your knees about hip width apart, directly under your hips. Bend your ankles and tuck your toes under. Gently rock your feet from side to side over the metatarsal heads. Stretching Exercises for the Ankle and Foot

Standing heel raises

(Kern-Steiner, 2003): this strengthens the gastrocnemius and soleus muscles. Stand with a support nearby for balance, but use it only as needed. Slowly raise your heels while maintaining a neutral position of your foot (ie: avoid pronation/supination by not allowing your arch to flatten or raise).

Manual therapy for shin splints

(Kern-Steiner, 2003): treat the muscle in a shortened position. Find the area(s) of restriction and perform gentle myofascial stretching by applying pressure in parallel with the muscle fibers as the patient plantar-flexes and dorsiflexes the foot; progress to performing the same stretching as the patient performs ankle circles clockwise, then counter-clockwise. Regardless of the origin of the shin splints, treat anterior, medial/posterior, and lateral compartments. -sometimes posterior tib - decelerator of pronation

Rocking - quadruped position

(Sahrmann, 2002, p. 437): Start on your hands and knees with your feet pointing away from your body, knees a few inches apart. The center of your hips should be over your knees, your shoulders centered over your hands, and your spine straight. Begin with your hips at 90-degree angles. (Figure a). Keeping your spine straight, rock backward toward your heels by moving at your hip joints. Think about aiming your buttocks toward the ceiling as you move (Figure b). Hold for 20 seconds, repeat 5 times. Stretching Exercises for the Ankle and Foot

FAIR test (Flexion, Adduction, and IR) FADIR

- Symptomatic leg in 60 to 90 degrees of flexion in the hip and 90 degrees knee flexion. The examiner's hand stabilizes the hip and the other hand performs a horizontal adduction on the lateral side of the knee until there is are symptoms or motion stops due to firm endfeel. From https://www.physio-pedia.com/Piriformis_Test Sensitivity = .88 -LR = .14 Specificity = .83 +LR = 5.2 -stretching piriformis and ex rotators

Stinchfield Maneuver

- possible OA, labral, or SI Active SLR to 30 degrees Clinician resists hip flexion (+) pain reproduction -lift leg up and dont let me push it down

Soft-Tissue Palpation Anterior Aspect of knee

-Rectus Femoris -Vastus Lateralis -Vastus Medialis Obl. -Quadriceps Tendon -Pre-patella Bursa -Patellar Tendon -Tibial Tubercle

Anterior Glide - Supine of hip

1. Create a fulcrum with your elbow (Left elbow in this picture is on the plinth). In this picture the therapist's left arm is on the medial side of the person's thigh with the left hand at the gluteal fold. a. Squeeze the person's thigh into your side with the inside arm (Left arm in this picture) 2. The right hand (in this picture) comes into support the left hand. 3. Stiffen both arms The drop your body weight and use the elbow as a fulcrum to deliver the force to the hip joint. -helps with hip extension -if limited ROM -elbow becomes teeter totter -tuck thigh between body -gluteal line and brace elbow on table

1. Focus? Flexibility and activation a. 4 way SLR - 30 seconds progressing to 1 minute each way b. Bilateral Heel-toes raises with knees slightly bent on foam cushion (issued to client) - 30 seconds progressing to 1 minute - BID c. Sitting rolling a ball under foot in a cross pattern to increase proprioception - 30 seconds progressing to 1 minute - BID d. Standing Hamstring curls - 30 seconds progressing to 1 minute - BID

Scoring SFMA 4 categories

1. Functional Nonpainful (FN) 2. Functional Painful (FP) 3. Dysfunctional Painful (DP) 4. Dysfunctional Nonpainful (DN)

1. High-impact weight-bearing activities such as jogging or jumping, if included in the program, should be added and progressed cautiously to prevent articular damage. Improper lower extremity alignment during weight bearing, such as valgus collapse and/or pelvic drop should be corrected prior to advancing with plyometric and high-impact activities.

1. 22-year-old male s/p Right Allograft ACL reconstruction with lateral meniscal debridement 6 weeks ago. He has not participated in a rehabilitation program to this point, FWB, no crutches. He tore his ACL playing soccer. No other pertinent PHM. He is in good physical health (6'1", 200 lbs) and goes to the gym 4 times weekly (currently only doing UE lifting). Socially: Single, lives on the second floor of his parents' house (approximately 13 stairs), and a college student. Meds: Naproxen 2 tablets, BID last week due to right knee discomfort, otherwise no other meds. Currently not wearing a brace but supposed to obtain one this week. CC: Right knee fatigues by the end of the day or after standing for several hours. Scored a 5 on the lateral step down test on the right and difficulty maintaining unilateral stance on right for great than 15 seconds. ROM (supine): end feels normal i. What are the key exercise components for someone after an ACL surgery?

1. Plyometrics 2. Strength 3. Balance 4. Stretching 5. Agility

improve Cardiopulmonary Conditioning

1. Utilize a program that is consistent with the patient's goals, such as biking (begin with a stationary bike), jogging (begin with walking on a treadmill), using a ski machine, or swimming.

"lower" abdominals (special test)

Abdominals (biasing "lower" abdominals, external obliques): the person is supine with arms folded across the chest, low back flat on the table, the patient then slowly lowers both legs from the vertical (90 degree angle). The angle between the extended legs and the table noted at the moment that the low back arches determines the strength grade. -leg lowering phase: bring their legs up, suck belly button up and in, have thumb on ASIS, or lower back -fail test once ASIS moves

Kinesio taping has four major effects:

Activates endogenous analgesic system: Provides sensory stimulation to skin receptors during movement Supports muscle: Elastic properties of tape replicate and enhance muscle function; improves muscle contraction and/or relaxation (depending on application of tape); appears to influence golgi tendon organs Removes congestion/edema of tissues: Stimulates mechanisms that facilitate movement of lymphatic and interstitial fluids by lifting skin and facilitating tissue pumping with movement Corrects joint problems: By helping to improve mal-alignment, can provide support to joint structures, enhances kinesthetic awareness

Posterior Glide with Hip flexed of hip

Although this picture from Dutton 2017 does not show it. It would be best to: 1) Position the patient with their trunk resting on the table and pelvis close to the edge of the table. 2) The clinician stands on the lateral side of the patient's thigh. 3) Both hands should be on the thigh (I prefer to have both of my hands near the knee). 4) Keeping the arms stiff and the person's thigh close to your body, 5) Then drop your body weight to deliver the posterior glide to the hip.

Bony Landmarks of knee

Anterior Aspect - Tibial Tubercle Patella -Superior Patellar Border -Inferior Patellar Border -Around Periphery w/ knee relaxed -Around Periphery w/ knee in full extension

Distal Tibiofibular Joint Anterior and Posterior Glide Direction of force:

Anterior glide of the fibula on the tibia (far left picture). A posterior glide is performed the same way, except the positions of the hands are on the opposite side of the malleoli as shown in the picture on the right. -the tibia and fibula separate when you dorsiflex -fibula moves posterior with supination and moves anterior with pronation -gran medial malleous

Four optional movement tests of SFMA (normally do for athletes) : Plank with a twist - tests for dynamic stability of core Patient Instructions: Limitation:

Assume down plank position resting on elbows with trunk straight" "Rotate the whole body ninety degrees as one unit, keeping the trunk, pelvis, and legs straight. You should be facing straight to the side and maintaining a side- plank position on one elbow and the nonweight bearing arm is resting on your top hip. Return to the starting position and repeat to the other side. Unable to achieve side plank position Unable to control shoulder or pelvis Unable to stabilize scapula

Ottawa Ankle Rule (positive if one is present with acute ankle pain)

Bone tenderness along the distal 6 cm, posterior edge of the tibia or tip of the medial malleolus, OR Bone tenderness along the distal 6 cm, posterior edge of the fibula or tip of the lateral malleolus, OR Bone tenderness at the base of the fifth metatarsal, OR Bone tenderness at the navicular bone, OR An inability to bear weight both immediately and in the emergency department for four steps.

Taping for Edema/Contusion at the Knee:

Cut two fanned pieces of tape, each with about five "fingers" and a one-inch base. Place the knee in maximal flexion. You will lay down the fingers with no tension, so place your anchor (also with no tension) such that the ends of the fingers cover as much of the edematous area/contusion as possible. Typically, the anchors are more proximal and the "fingers" are more distal. Place the first fan down on the skin, then do the same with the other piece, criss-crossing the fingers to forma mesh configuration. Once both tape fans are placed and the person extends the knee, the tape "fingers" should pucker/wrinkle somewhat. In theory, this puckering lifts the skin and enhances local circulation of blood and lymph.

Fat Pad Taping

Correcting Patella Tilt (some include this correction with the taping technique and some don't) (-slight knee flexion -lateral to medial) ---Begin lying on your back, with the knee slightly bent, but completely relaxed and a foam roller or rolled up towel under the knee. Holding both ends of a line of tape, place it firmly down onto the top of the knee cap so the top third to half of the knee cap is covered by the tape (figure 2). This technique is designed to tilt the patellar so the top half of the knee cap moves towards the thigh bone, with the lower half subsequently moving further away from the shin bone, reducing compression of the patella on the fat pad. Repeat this process 1 - 3 times depending on the amount of support required. Medial Sling (pull inferior to superior) ---begin lying on your back, with the knee slightly bent, but completely relaxed and a foam roller or rolled up towel under the knee. Begin this taping technique by fixating the tape approximately 3 - 5 cm directly below the patella and following the black arrow in a diagonal line towards the lower aspect of the inner thigh (figure 3). Using your thumb, pull the soft tissue of the lower thigh towards the tape starting point to increase tension on the tape. Conclude this taping technique by following the white arrow and attaching the tape to the lower aspect of the inner thigh as demonstrated. Repeat this process 1 - 3 times depending on the amount of support required. lateral Sling (This will limit ability to squat -then put luko tape on top) ---Begin lying on your back, with the knee slightly bent, but completely relaxed and a foam roller or rolled up towel under the knee. Begin this taping technique by fixating the tape approximately 3 - 5 cm directly below the patella and following the black arrow in a diagonal line towards the lower aspect of the outer thigh (figure 4). Using your thumb, pull the soft tissue of the lower thigh towards the tape starting point to increase tension on the tape. Conclude this taping technique by following the white arrow and attaching the tape to the lower aspect of the outer thigh as demonstrated. Repeat this process 1 - 3 times depending on the amount of support required. Use peptobismol if someone has allergy Will prevent patella form going laterally a little

Arc Test to distinguish Tendonopathy from Paratendonitis

Distinguishing a swelling in the tendon (tendonopathy) from paratendonitis. A swelling in the tendon will move with passive (or active - test is done passively) dorsiflexion (Arc test), while a paratendonous swelling does not move. The arc sign for tendonopathy is a palpable tendon nodule that moves during plantar- and dorsiflexion of the foot. Reported Sensitivity 0.52, Specificity 0.83 from Maffuli, et al., (2003). Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med, 13(1), 11-5. -the swelling arc -swelling will move if tendonis -if it doesnt move then it is paratendinous

Ely's Test/Femoral Nerve Stretch Test:

Evaluates irritation of the femoral nerve via stretching of the nerve. The patient is prone on the table. Flex the knee to 90 degrees or greater then passively extend the hip. Anterior and/or medial thigh pain is positive for femoral nerve irritation. No psychometric information available on this test. -peripherial symptoms down thigh -length of rectus femoris

Over-Pronation Wear Pattern

Excessive wear along medial outsole Excessive wrinkling of the medial midsole Medial tilt

MMT Gluteus Medius

Have patient lying on the side their not being tested on, flex legs at the knee, make sure shoulder and hip are in line, grab testing leg and bring it into extension and slight external rotation (toes to ceiling), use other hand to stabilize at the hip, have them hold leg in the position then apply downward pressure on either thigh or ankle adjusting amount of pressure depending on location. Hip abductor PROM, AROM, MMT See range passively, then see if patient can match it actively Palpate the muscle the whole time for the muscle tone Stabilize with one hand and resistance in the other superior gluteal nerve, testing posterior fibers, side lying bring leg and toes up and out, want external rotation, support at knee, don't let them roll back, side lying, keep the toes up too, apply pressure at knee down and in, want them to keep the external rotation, you can bend bottom leg, bring toes and legs up and back

MMT hip lateral rotators Hip lateral rotator group: piriformis, quadratus femoris, obturatur internus and externus, superior and inferior gemelli

Have patient seated with legs over side of table, go through their full range of external rotation then come off the end range just a bit, stabilize knee, apply pressure to bring patient into neutral. "dont let me pull your leg out"

Good 4/5

In the against-gravity position, holds against moderate resistance (muscle may shake, but does not give)

Normal 5/5

In the against-gravity position, holds against strong resistance; "muscle rebound" present.

Good + 4+/5

In the against-gravity position, holds against strong resistance; no "muscle rebound"

Poor + 2+/5

In the against-gravity position, moves through 1/3 of the range of motion.

Fair - 3-/5

In the against-gravity position, moves through 2/3 of the range of motion.

Fair 3/5

In the against-gravity position, moves through the entire range of motion, no resistance.

Poor - 2-/5

In the gravity-lessened position / horizontal plane, moves through 1/3 to 2/3 of the range of motion.

Poor 2/5

In the gravity-lessened position / horizontal plane, moves through the entire range of motion.

Dorsiflexion WB Lunge

Initial position: The great toe is 10 cm from the wall, the subject attempt to touch their knee to the wall keeping the knee in a line over their second toe and the heel on the ground. They can use two fingers with each hand to maintain contact with the wall for balance. Depending if the subject can touch the wall with their knee as instructed (keeping the knee in a line over their second toe and the heel on the ground) the will then progress 1 cm either towards the wall (if they are unable to achieve the first position) or away from the wall if they able to complete the first position. They will continue in 1 cm increments either getting closer to the wall until they are successful or away from the wall until they cannot maintain the knee over the second toe or the heel does not remain on the ground. The last successful trial is their weightbearing DF in a lunge position. This could be measured with a goniometer or inclinometer.

Instruct the patient in exercises designed to improve cardiopulmonary function. It is also proposed that aerobic exercise be used to improve pain and treat underlying depression and anxiety that may be comorbidities in OA. The choice of exercise should have low impact on the joints, such as walking, biking, or swimming. Avoid activities that cause repetitive intensive loading of the joints, such as jogging and jumping.

Joint position sense may be impaired. Nontraditional forms of exercise, such as tai chi, have been found to be effective for improving balance in patients with OA.

Arch restoration exercise

Kern-Steiner, 2003): place a 1.5 - 2 inch diameter rubber ball under your foot, just at the base of your metatarsal heads (the "toe knuckles" on the bottom of your foot). Gently curve your foot so that it creates an arch in your foot and hold this position for 30 seconds to a minute. Repeat to other side. Stretching Exercises for the Ankle and Foot

calcaneonavicular ligament

Ligament inserting on the calcaneus and the navicular; supports the arch and limits abduction of the foot. spring ligament

Knee Flexion- goni

Mean value: 135 Fulcrum: Lateral epicondyle of femur Stationary arm: Greater trochanter Moving arm: Lateral malleolus

hip External Rotation- goni

Mean value: 45 Fulcrum: Anterior aspect of patella Stationary arm: Perpendicular to floor Moving arm: Anterior midline of lower leg- between two malleoli

Hip abduction- goni

Mean value: 45 Fulcrum: Anterior superior iliac spine (ASIS) of extremity being measured Stationary arm: Imaginary horizontal line extending from one ASIS to the other Moving arm: Anterior midline of femur- midline of patella

Ankle Plantarflexion- goni

Mean value: 50 (sitting or laying prone) Fulcrum: Lateral aspect of lateral malleolus Stationary arm: Lateral midline of fibula (head of fibula for reference) Moving arm: Parallel to lateral aspect of fifth metatarsal

Medial and Lateral patellar glide

Medial and Lateral gliding of the patella. -very similar to apprehension sign

Delayed joint effusion (>48 hrs.) is most likely attributable for which of the following injuries?

Meniscal injury is the primary cause, but I saw many choose osteochondritis articular fracture due to blunt trauma - This was probably not specified enough in lecture, but you would have immediate effusion if there was enough blunt trauma to cause an articular fracture. Since this was not specified in lecture, I gave credit for this answer.

Modified Thomas Test

Modified Thomas Test: This utilizes the same patient position as for the Thomas Test, but in addition, the patient scoots down the table until his knee are approximately four inches over the edge. Have the patient perform maneuver for the Thomas Test. If the thigh rises off the table, attempt to flex the knee on that side. If the knee flexes easily, the tight hip flexor is the iliopsoas (positive. test for iliopsoas). If you are unable to flex the knee, or resistance is felt, the rectus femoris is tight (positive test for rectus femoris. If the LE abducts and/or IR to gain hip extension then it is more likely the TFL. A goniometric measurement can be obtained by measuring the amount of hip extension.

Distal Intermetatarsal Joints Anterior and Posterior Glide Direction of force:

Move one metatarsal (head) anterior then posterior on the adjacent metatarsal. -distract first

Distal Intermetatarsal Joints Rotation Direction of force:

Move one metatarsal in a rotatory fashion on the adjacent metatarsal.

MMT Soleus

O: Soleal line of post. tibia & prox. 1/3 of fibula I: Calcaneus via Achilles tendon Action: Plantar flexion of foot at ankle (prime mover) *test - prone* -Client's knee is flexed to 90 degrees; pressure is against the calcaneus, pulling the heel in a superior direction (as if dorisflexing the ankle - hook)

MMT posterior tibialis

PF and inversion Goes behind medial malleolus Plantarflexor and inverter Resistance is up and out Patient supine with ankle off table, put ankle in plantarflexion and inversion, stabilize ankle, apply pressure into dorsiflexion and eversion and have patient resist. "dont let me pull you up and out"

Alternate testing of quadratus lumborum for strength and flexibility

PURPOSE To test the quadratus lumborum muscle. PATIENT POSITION The patient is side lying, resting the upper body on the elbow. EXAMINER POSITION The examiner is positioned so as to observe for altered mechanics. TEST PROCEDURE To begin, the patient is side lying with the knees flexed to 90°. The examiner asks the patient to lift the pelvis off the examining table and straighten the spine. The weight of the body is supported by the forearm and elbow proximally and the lateral knee distally. If the patient can do the first test easily, the test can be made more difficult by having the patient keep the legs straight and then lift the knees and pelvis off the examining table with the feet as the base, so that the whole body is straight. INDICATIONS OF A POSITIVE TEST The patient should not roll forward or backward when doing the test. The examiner times how long the patient can hold the position without cheating. The test is graded as described in Table 8-5. Normal: 5 Able to lift the pelvis off the examining table and hold the spine straight (10- to 20-second hold) Good: 4 Able to lift the pelvis off the examining table but has difficulty holding the spine straight (5- to 10-second hold) Fair:3 Able to lift the pelvis off the examining table but cannot hold the spine straight (<5-second hold) Poor: 2 Unable to lift the pelvis off examining table

Use of Cuboid whip (manipulation) for Cuboid syndrome

Palpate over the dorsolateral aspect of the cuboid bone will elicit pain in cuboid syndrome. It is located proximal to the tuberosity of the 5th metatarsal and distal to the peroneal tubercle. Midtarsal adduction test is performed to implicate cuboid syndrome. There are no psychometrics for this test. Stabilize the subtalar joint with the proximal hand and adduct the forefoot with the distal. Midtarsal supination test is performed to implicate cuboid syndrome. There are no psychometrics for this test. Stabilize the subtalar joint with the proximal hand and supinate the forefoot with the distal. "Cuboid Whip" or Cuboid Manipulation. The manipulation begins with the patient in the prone position and the knee flexed to approximately 70-90 degrees with the ankle near neutral. Interlock the fingers over the dorsum and position the thumbs on the plantar aspect of the cuboid. The manipulation is performed by moving the knee into extension and plantar flexing the foot while maintain the above positions of the hands. The knee is passively extended as the ankle is plantar flexed with slight supination of the subtalar joint. A thrust force is applied through both of the thumbs on the plantar aspect of the cuboid.

Fulcrum Test

Patient position: Sitting on side of table with legs off the edge of the table. Patient leans back on bilateral hands. Clinician position: Standing or kneeling to the side of the leg to be tested. Movement: Clinician places one forearm under patient's thigh to be tested. Clinician arm is used as a fulcrum under the thigh and is moved from the distal to the proximal thigh as gentle pressure is applied to the dorsum of the knee with the opposite arm. Assessment: A positive test is reproduction of patient's concordant discomfort/sharp pain, usually accompanied by apprehension. Diagnostic accuracy: SN 93%, SP 75%, +LR 3.7, −LR 0.09; SN 88%, SP 13%, +LR 1.0, −LR 0.92." -for stress fractures -make fulcrum and push on distal end - it will hurt proximal -for cross country, band, military

To support joints/ligaments and to correct posture:• taping

Place the part into the desired resting position and apply tape with greatest tension (full stretch) in line with the structure(s) that you wish to support.

MMT: Fibularis Longus & Brevis

Plantarflexion and eversion patient supine with ankle off table, put ankle in 1⁄2 plantarflexion and full eversion, stabilize ankle, apply pressure into dorsiflexion and inversion and have patient resist. Use hand scale for foot muscles PT pulls foot up and in (dorsiflexion and inversion) " don't let me up pull your foot up and in" Grade 0: No contraction is felt in the muscle 1: Feeble contraction in muscle belly or tendon is palpated (trace) 2: Muscle moves part through a small arc of motion (1/4) 3: Muscle moves part through a moderate arc of motion (half) 4: Muscle moves part through an almost complete arc of motion (3/4) 5: Muscle moves part through complete arc of motion 6-7: Moves part through complete arc of motion, holds against slight pressure (minimal resistance) 8-9: Same as above, but holds against moderate pressure 10: Same as above, but holds against maximum pressure

Quadratus lumborum mmt

Quadratus lumborum: the person is prone with the test leg abducted about 20 degrees; the therapist applies resistance in the form of traction at the distal leg (near the ankle). The person elevates the pelvis on that side, or works to "make the leg shorter" by hiking the pelvis on that side. Kendall advises against giving a specific grade to this muscle, instead, therapists should simply qualify it as strong or weak -it hikes the hip, have them lift the hip up and don't let me pull down

What are some procedures that might assist someone whose symptoms are related to excessive pronation, loss of medial longitudinal arch? a. Passive mechanisms (Flexibility)

Soft tissue, joint capsule issues 1. Stretching gastrocnemius-soleus in sub-talar neutral 2. Posterior glide of talus 3. Anterior-Posterior glide of the tibiofibular joint Taping (an upcoming lab) iii. Footwear 1. Shoe type 2. Lacing - tighter lacing should provide more support if lacing is too loose. See Asics supplementary handout. (we can try different lacing patterns when we examine shoes) 3. orthotics

Improve Muscle Performance

Strength and endurance - Initiate isometric quadriceps and hamstring exercises, and progress to dynamic strength and muscular endurance training. Quadriceps strength is important for knee stability. Utilize both open-chain and closed-chain resistance. Open-chain resistance has been shown to be more effective for increasing quadriceps strength than closed-chain single-leg squat in patients with an ACL injury. Progress closed-chain exercises using partial squats, step-ups, leg press, and heel raises. Reinforce quadriceps contractions with high-intensity electrical stimulation if there is an extensor lag.

Interphalangeal Joints Distraction Direction of force:

Stabilize proximal portion of joint with one hand. The other hand is on the distal part of the joint to perform the maneuver.

Four optional movement tests of SFMA (normally do for athletes) : Single-leg hop for distance - tests for strength, power, and control Patient Instructions: Limitation:

Stand on one leg and hands on hips. Hop as far forward as possible. Land on bend knee and hold for 2-3 seconds. Repeat other side. Measure distance from heel to heel. Compare distances. Unable to land hop without moving foot or losing balance. Unable to keep hands on hips. Unable to hold 2-3 seconds.

Design another weight bearing exercises that incorporate LE control with single limb support that incorporates eccentric and concentric control.

Step down - Step up .i. Start with something accomplishable, even if it is 2" step. ii. The key is to make sure alignment there is good alignment of the knee over the second toe with ascension and decension.

Thessaly's test for Meniscal Tear

Support the patient while the patient stands on one foot. Instruct the patient to rotate their body and thigh several times in each direction with the knee flexed at 20 degrees. Joint-line discomfort is indicative of meniscal injuries. sensitivity 90.3%, specificity 97.7%, PPV of 98.5%, NPV of 86.0%, positive likelihood ratio of 39.3, negative likelihood ratio of 0.09, diagnostic accuracy -clicking, similar to labral -can have them toe touch -body weight involved -if they have a neg test- very unlikely they have it

The crossed-leg test:

Syndesmotic injury testing The patient sits in a chair, with the injured leg resting across the knee of the uninjured leg. The resting point should be at approximately mid calf. The patient then applies a gentle force on the medial knee of the injured leg. Pain experienced in the distal syndesmotic area suggests the presence of injury.

The point test:

Syndesmotic injury testing: The examiner applies pressure in a progressively more forceful manner directly over the anterior aspect of the distal tibiofibular syndesmosis. Pain with palpation suggests the presence of an injury.

Talocrural Joint Distraction Direction of force:

Talus and calcaneus moves away from the Tibia. -have their knee on you -distract with both hands -make sure their knee is bent -distract then lean

Matles Test for Achilles Tendon Rupture

The patient lies prone with the foot over the edge of the plinth. They are asked to actively flex their knee to 90 (test uninvolved first). If there is no tear in the Achilles the foot should remain slightly plantar flexed. If there is a tear in the Achilles tendon, gravity will cause the foot to dorsiflex or approach a neutral position of the ankle. Sensitivity 0.88, Specificity 0.85, PPV 0.92 (Dutton, 2012, p.987)

Test for Achilles Tendon Rupture / Thompson Test:

The patient may be tested prone, or kneeling in a chair with the feet over the edge. While the patient is relaxed, gently squeeze the calf. A positive test is indicated by the absence of plantarflexion when the muscle is squeezed and is indicative of a ruptured Achilles tendon. -when you squeeze it- the foot should plantarflex Psychometrics: established by Mafulli (1998) in a study of 174 patients who were treated for Achilles tendon ruptures. Sensitivity: 96% Specificity: 93% Positive predictive value: .98 Negative predictive value: 1

Taping to Facilitate Vastus Medialis Obliquus (VMO) and/or Pull Patella Medially:

This technique uses a Y-strip, however the arms of the Y are placed in a curved fashion. Begin with the knee flexed. Anchor the base of the Y over the middle to distal half of the VMO (no tension), then lay down the arms of the Y (up to 50% tension) along the VMO, anchoring one arm at the superior- medial pole of the patella and the other arm over the inferior-medial pole. You may find that placing the anchors over a greater portion of the patella may be useful. If you note rotation of the patella, you can add varying degrees of tension on the arms of the Y to counteract the unwanted rotation.

Inhibition of Gastrocnemius and/or Soleus:

This technique uses two Y-strips, positioned such that their bases are parallel to the muscle fibers and anchored (no tension) over the medial and lateral bellies of the gastrocnemius (or the medial and lateral portions of the soleus). Place between 75- 90% tension on the arms of the Y's and smooth them over the muscle, anchoring them with no tension. If you tape both the gastrocnemius and the soleus, you may find that an I-strip for the soleus is more useful for people with smaller calf muscles.

Use resistance exercises, within the tolerance of the joint, as part of the patient's exercise program. Avoid deforming forces and heavy weights that the patient cannot control or that cause joint pain. Adaptations include the use of multiple-angle isometrics in pain-free positions, applying resistance only through arcs of motion that are not painful, and use of a pool to decrease weight-bearing stresses and improve functional performance. This person appears to be deconditioned with weak core, hip, and ankle musculature. Often a key are exercises that reduce the knee adduction moment,

1) Describe the grades of strain & expected return to play time frames - hamstrings

a. Hamstring strain injuries are commonly classified according to the amount of pain, weakness, and loss of motion, resulting in grades of I (mild), II (moderate), or III (severe). b. The greater the deficit with maximal hip flexion active knee extension test (MHFAKE) compared to the other side, the longer the return to play. (Martin, et al., 2022) i. Done with maximal hip flexion and the subject actively extending as far as possible. Compare to the other side 1. Grade I injury had less than a 15° deficit and required 25.9 days of rehabilitation. 2. Grade II injury exhibited a 16° to 25° deficit and required 30.7 days of rehabilitation. 3. Grade III injury demonstrated a 26° to 35° deficit and required 75.0 days of rehabilitation 4. MHFAKE test found the injured limb to have a mean ± SD deficit of 12.8° ± 6.8° when compared to the uninjured side. ii. FYI, some only refer to this as the Active Knee Extension Test (AKE).

1) Describe the typically mechanism of injury for a hamstring strain

a. Mechanisms i. Often results from a sprinting activity (e.g., track, football, soccer, rugby) or extreme stretching (dancers, yoga), but could occur from lifting or slipping or some activity that requires sudden control of movement that involves that hamstring. ii. Terminal swing when the limb is decelerating to contact the ground is believed to be one of the primary times this injury occurs. The musculotendon unit of the biceps femoris is most commonly injured. 1. Why is this important to understand? a. If the mechanism occurred during sprinting, the rehabilitation must contain high eccentric loading upon return to running. b. If the mechanism involves dancing this often involves simultaneous hip flexion and knee extension with the hamstrings on an extreme stretch and the rehabilitation will eventually need to incorporate those maneuvers. c. Both mechanisms will follow a similar rehabilitation plan, but the dancer may take longer depending on the degree of strain to get back to their extreme ranges.

1) Discuss the pertinent anatomy, where the tears typically occur, and show how to locate common sites of injury.

a. The hamstrings can be divided into 2 groups, the medial (inside) and lateral (outside) groups. The medial group is made up of the semimembranosus and semitendinosus. The lateral group consists of the biceps femoris (long and short head). i. Biceps femoris is the most commonly strained muscle of the hamstring complex (53%). Only the long head extends the hip and it is innervated by tibial portion of the sciatic nerve. The fibularis (peroneal) division innervates the short head. ii. Semimembranosus. Originates at the ischial tuberosity beneath the semitendinosus and inserts onto the medial tibial condyle, posterior oblique ligament, arcuate ligament, and posterior joint capsule. The semimembranosus is innervated by the tibial division of the sciatic nerve. iii. Semitendinosus. Originates at the ischial tuberosity by a conjoint tendon with the biceps femoris and inserts as part of the pes anserinus on the superior and medial aspect of the tibia. The semitendinosus is innervated by the tibial division of the sciatic nerve. b. They are diarthoidial (cross two-joints). c. The origin or insertion, muscle tendon or muscle belly are common places for strains.

1) What are their factors that will affect the progression? hamstring strain

a. age, health, smoking, nutrition, and intramuscular tendon or aponeurosis and adjacent muscle fibers (biceps femoris during high-speed running) typically require a shorter convalescent period than those involving a proximal free tendon (purely tendinous - no muscle fascicles) of the semimembranosus (during dance and kicking). b. events that result in extreme and forceful hip flexion with the knee fully extended (e.g., water skiing), and often require operative intervention with extensive postsurgical rehabilitation. c. The greater the area injured will likely take longer to rehabilitate d. It has been reported that "...the more proximal the site of maximum pain, the greater the time needed to return to preinjury level. (Heiderscheit, 2010, p. 68)

Midtarsal Joint

calcaneocuboid and talonavicular

MMT Sartorius

criss cross apple sauce muscle do the opposite

The calcaneofibular ligament is located laterally and stabilizes the ankle against

direct inversion.

for joint mobs, what order should you typically do them in?

distract, A/P glide, rotate

MMT abductor hallucis

dont let me push your big toe in

Seasmoid bones of foot- where are they?

head of 1st metatarsal

MMT Gluteus Maximus

heel to ceiling push their leg down Hip extensor Have patient lying prone, flex the knee, bring leg up into slight extension, have them hold that position then apply downward pressure while they resist. Have the knee bent to eliminate the hamstrings See passive range, active range

1. A 15-year-old female has anterior knee pain with running and going up/downstairs. Her deep squat was dysfunctional and painful with increased knee valgus, decreased depth of squat, a forward trunk lean, and weight-bearing over her toes. She also has a dysfunctional and non-painful single limb stance. You find that she has poor core stability, weakness in her gluteus maximus and medius, tightness and soft tissue restrictions in her quadriceps, and is generally hyper-mobile. a. What are methods to examine these deficits?

i. SFMA ii. Lateral step down iii. Front step down

i. controlled step up and step downs would be important ii. closed chain Hip abductor & extensor exercises are essential iii. core stability

Medial border of knee

o Bone § adductor tubercle (site for attachment of distal part of adductor magnus and uppermost part of MCL) § medial condyle § tibial plateau o Ligament § MCL · superficial (posterior oblique ligament), deep band continuation of capsule and blend with meniscus, anterior fibers tense in flexion o Tendon or other § Pes anserinus attachment § medial meniscus § medial inferior genicular artery

· Lateral border of knee

o Bone § lateral epicondyle § tibial tubercle (Gerdy's) § head of fibula o Ligament § Fibular collateral ligament o Tendon or other § TFL insertion · Gerdy's tubercle, lateral border of patella, posteriorly biceps femoris tendon, and with aponeurotic expansion from VL. § popliteus tendon § Common peroneal § Arcuate-ligament complex · biceps femoris tendon, ITB, popliteus tendon

Functional Strength? (Maybe Strength in a Weight Position) foot and ankle

photo

Plantar surface: Calcaneus, plantar aponeurosis, Abductor halliucis, Sesamoids of 1st ray

photo

Posteriorly: Gastrocnemius, Soleus, Achilles' tendon, Calcaneus, calcaneal bursae (a), retrocalcaneal bursae (b)

photo

Thoracolumbar Measurements inclinometer

photo

Thoracolumbar Measurements tape measurements

photo

Caudal and Cephalad gliding of the patella, respectfully

photo hands gliding along surface

ankle eversion goni

photo (15 degrees - between malleloi moving: second metatarsal stationary tibia)

ankle inversion goni

photo (35 degrees - between malleloi moving: second metatarsal stationary tibia)

Arch restoration exercises with mp flexion

place a 1.5 - 2 inch diameter rubber ball under your foot, just at the base of your metatarsal heads (the "toe knuckles" on the bottom of your foot). Gently curve your foot so that it creates an arch in your foot and hold this position for 30 seconds to a minute. Hold this, then flex metatarsal phalangeal joints while manually maintaining a transverse arch. Repeat to other side. Stretching Exercises for the Ankle and Foot

Four Optional Movement Tests of SFMA

plank with a twist single-leg squat in-line lunge with lean, press, lift single-leg hop for distance

shortening the stride or using a cane might be appropriate. More cushioning shoes could potentially have an impact.

Oblique trunk flexors (left internal and right external obliques):

the patient is supine with hands clasped behind his head, an assistant stabilizes the patient's legs on the table. To test these muscles, the therapist passively places the patient in trunk flexion with left rotation and asks the patient to hold that position. (To test right internal and left external oblique muscles, rotate the patient's trunk to the right.) Arm position determines grading (Kendall, McCreary, Provance, Rodgers, & Romani, 2005, p. 186): Normal: the patient can hold the test position with hands clasped behind head. Good: the patient can hold the test position with arms folded across chest. Fair+: the patient can hold the test position with arms extended forward. Fair: the patient can hold the trunk in enough flexion and rotation that the right shoulder blade is off the table.

Towel scrunches:

this exercise focuses on using intrinsic and extrinsic toe flexors and extensors. Place a towel on the floor and move your foot to the edge. Use your toes to pull the edge of the towel under your foot. Keep "scrunching" the towel until you can't move it any more. Smooth it out and repeat. Placing the towel on a smooth surface is easier than on a carpeted one.

Ankle strengthening using the Biomechanical Ankle Platform System (BAPS):

this exercise requires a BAPS board or similar device. Choose the appropriate size sphere to place onto the bottom of the platform (larger is more difficult). Balance on the board, then slowly shift your weight and move your ankle such that you move the edge of the platform to the floor. Move the platform from left to right, then front to back, then clockwise and counterclockwise.

Varus Stress Test/Test for Lateral Collateral Ligament:

with the patient supine, slightly flex the knee to 20-30 degrees (this is the "true test" for single-plane instability of the LCL), and with one hand on the medial aspect of the thigh and the other laterally over the tibia, apply a varus stress. Compare the degree of gapping to the opposite LCL and palpate end-feel. Be sure to prevent hip rotation. The test is positive if there is a gapping of the lateral aspect of the joint space that is greater than the opposite LCL, if the tibia and femur "clunk" together when released or if there is pain along the course of the ligament. If the test is positive, assess the degree of sprain and then perform the same maneuver in full extension and compare findings Psychometrics: established by LaPrade & Terry (1997): Positive predictive value: .67 Negative predictive value: 1.00 -hold foot with elbow -both hands on knee both sides -have thigh supported -test at 30 degrees and 0 degrees (0 degrees should be way tighter)

Valgus Stress Test/Test for Medial Collateral Ligament:

with the patient supine, slightly flex the knee to 20-30 degrees (this is the "true test" for single-plane instability of the MCL), and with one hand on the lateral aspect of the thigh and the other medially over the tibia, apply a valgus stress. Compare the degree of gapping to the opposite MCL and palpate end-feel. The test is positive if there is a gapping of the medial aspect that is greater than the opposite MCL, if the tibia and femur "clunk" together when released, or if there pain along the course of the ligament. If positive, assess the degree of sprain. If test is positive, perform the same maneuver with knee in full extension and compare finding Psychometrics: established by McClure, Rothstein, & Riddle (1989): Inter-rater reliability: .16 -hold foot with elbow -both hands on knee both sides -have thigh supported -test at 30 degrees and 0 degrees (0 degrees should be way tighter)

Test for Length of the Hamstrings / 90-90 test.

with the patient supine. passively flex the patient's hip to 90 degrees, and the knee to 90 degrees. Passively extend the knee, while keeping the hip at 90. Stop when you appreciate a noticeable muscular end-feel and/or when the pelvis begins to tilt posteriorly. A goniometric measurement for knee extension is obtained

Posterior border of knee

·o Bone o Ligament (need a very thin person to palpate, then it is still difficult to distinguish isolated structures) § PCL attachment to tibia is located medial to the popliteal artery and either between or under the tendon of the semimembranosus. The meniscofemoral ligament (ligament of Wrisberg) is also located here slightly lateral to the attachment of the PCL. PCL is attachment is tender to palpation normally. § oblique popliteal ligament - thickening of posterior capsule - reinforces lateral capsule and has attachments to semimembranosus & popliteal tendons - limits anteromedial rotation o Tendon or other § biceps femoris § semimembranosus · Deep to the semitendinosus on both medial and lateral side, you will find the deeper parts of the semimembranosus. § semitendinosus · This is usually the more superficial round tendon initially felt when palpating the posterior aspect on the medial side of the knee. § Gracilis (adduction) § Sartorius (abduction) § Gastrocnemius · medial - deep and medial to fossa · lateral - deep and medial to biceps § popliteal artery · typically felt just below the crease of the knee more towards the midline on the medial side at the tibial plateau § common fibular nerve § Tibial

Selective Functional Movement Assessment Active Cervical Flexion

□ Can't touch sternum to chin □ Non-uniform spine curve □ Excessive effort and/or lack of motor control

Selective Functional Movement Assessment Multi-segmental Flexion

□ Cannot touch toes □ Sacral angle <70 degrees □ Non-uniform spine curve □ Lack of posterior weight shift □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment Active Cervical Rotation with Side- Bending

□ Chin/Nose not in line with mid-clavicle □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment UE Pattern 1 - Medial Rotation & Extension

□ Does not reach inferior angle of scapula □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment UE Pattern 2 - Lateral Rotation & Flexion

□ Does not reach superior angle of scapula □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment Single leg stance

□ Eyes open <10 seconds □ Eyes closed < 10 seconds □ Loss of Height □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment Arms Down Deep Squat

□ Hips do not break parallel □ Cannot reach fists to ground within footprint □ Loss of sagittal plane alignment: Right____Left_____ □Excessive effort, weight shift, or motor control

Selective Functional Movement Assessment Active Cervical Extension

□ Not within 10 degrees of parallel □ Non-uniform spine curve □ Excessive effort or lack of motor control

Selective Functional Movement Assessment Multi-segmental Rotation

□ Pelvic Rotation < 50 degrees □Torsos Rotation < 50 degrees □ Excessive effort, appreciable asymmetry, or lack of motor control

Selective Functional Movement Assessment Multi-segmental Extension

□Upper extremity does not achieve or maintain 170 □ ASIS does not clear toes □ Spine of scapula does not clear heels □ Non-Uniform spine curve □ Excessive effort and/or lack motor control

MCL physical exam

Palpation: Careful palpation along the course of the ligament is necessary. Tenderness over the adductor tubercle or proximal medial tibia may indicate injury at the origin or insertion sites of the ligament. Additionally, pain over the medial joint line may indicate an associated medial meniscus tear or chondral injury. Special Tests: The crucial test for MCL injury is gentle 1) valgus stress testing with the knee in 30° of flexion and at 0°. 2) rotatory instability. Knee flexed to 90°, the tibia is externally rotated. When the knee is externally rotating in flexion, the collateral ligaments are tightened while the cruciates are relatively lax. Pain along the medial side of the joint indicates injury to the MCL complex.

Hip flexion - goni

Mean value: 120 Fulcrum: Greater trochanter Stationary arm: Lateral midline of pelvis (mid axillary line) Moving arm: Lateral epicondyle of femur

Top Tier Tests of SFMA: Arms Down Deep Squat Patient Instructions: Limitation:

"Please start by placing feet close together and toes pointing forward." "Make a fist and place your arms at your side. Hold this position and squat down as far as you can towards the floor." (Note: subject should squat back and down, not over toes.) Caution- There are discrepancies about how this is describe, some do it with feet shoulder with apart, fist go between legs. Hips do not break parallel Cannot reach fists to ground within footprint Loss of sagittal plane alignment: Right____ Left _____ Excessive effort, weight shift, or motor control

Top Tier Tests of SFMA: Single Leg Stance (eyes open, then closed) Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "1. Lift your Right/Left leg so that your hip and knee make 90 degree angles. Please hold this for 10 seconds. 2. Now lift your leg to the same 90 degree position and then close your eyes. Hold this position for 10 seconds." 3. Now swing the limb from flexion to extension continuously for 10 seconds. Eyes open unable to stand less than 10 seconds Eyes closed unable to stand less than 10 seconds Loss of position of non-stance limb Unable to maintain stance foot position

Top Tier Tests of SFMA: Active Cervical Rotation with Side- Bending Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Please turn your head as far as you can to the right/left and then bend down and touch your chin towards your collarbone." (Note: Avoid shoulder elevation) Can't touch chin to midclavicular region (Note: Avoid shoulder elevation)

Top Tier Tests of SFMA: UE Pattern 1 - Medial Rotation & Extension Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Take your Right/Left arm and reach behind your back and aiming to touch the bottom of your opposite shoulder blade." (Note: scapular dyskinesis) Can't touch contralateral scapula

Top Tier Tests of SFMA: UE Pattern 2 - Lateral Rotation & Flexion Patient Instructions: Limitation:

"Stand in a tall position with feet together and toes pointing forward." "Take your Right/Left arm and reach up and behind your head towards the top of your opposite shoulder blade." (Note: scapular dyskinesis) Can't touch contralateral scapula

Soft tissue releases for Achilles tendonitis

(Kern-Steiner, 2003): beginning with the plantar fascia and working your way over the calcaneus and up through the calf (release in line with the muscle fibers, using the heel of your hand and thumbs). You may treat the gastrocnemius and soleus in prone (resting position, left), in quadruped (shortened position, below left), and with the patient standing performing a calf stretch(this is active) (lengthened position). -compare to other side gastroc-planatarflex- ask them to dorsiflex

Anterior and Anterolateral • Sinus Tarsi.

"The sinus tarsi is visible as a concave space between the lateral tendon of the EDL muscle and the anterior aspect of the lateral malleolus. The origin of the EDB is at the level of this tunnel. Tenderness with palpation of the sinus tarsi is considered one hallmark clinical sign of subtalar joint inflammation."

Great toe abduction

(Kern-Steiner, 2003): this exercise strengthens the abductor hallucis muscle. Lying on your back with your legs straight, bring the bones of your inner ankles together, keeping your big toes separated by an inch or so. Concentrate on bringing your big toes together by contracting the muscle on the inner part of your foot (the abductor hallucis). Think about spreading your toes apart, emphasizing the big toe. Don't allow your big toe to flex (a common substitution). Variation: if the above exercise is too difficult, passively take your big toe out to the side and concentrate on holding it there. Feel the muscle on the inner part of your foot, and try to make it contract. Sometimes stroking the muscle or applying pressure to it helps it to contract.

Squat:

(emphasize ankle movement) stand with equal weight on both feet, and slowly bend your ankles, knees, and hips while keeping your heels on floor. Try to assure that you bend at all three joints, and that your knee stays in line with your second toe (Sahrmann, 2002, p. 268). Repeat. Stretching Exercises for the Ankle and Foot

1. 22-year-old male s/p Right Allograft ACL reconstruction with lateral meniscal debridement 6 weeks ago. He has not participated in a rehabilitation program to this point, FWB, no crutches. He tore his ACL playing soccer. No other pertinent PHM. He is in good physical health (6'1", 200 lbs) and goes to the gym 4 times weekly (currently only doing UE lifting). Socially: Single, lives on the second floor of his parents' house (approximately 13 stairs), and a college student. Meds: Naproxen 2 tablets, BID last week due to right knee discomfort, otherwise no other meds. Currently not wearing a brace but supposed to obtain one this week. CC: Right knee fatigues by the end of the day or after standing for several hours. Scored a 5 on the lateral step down test on the right and difficulty maintaining unilateral stance on right for great than 15 seconds. ROM (supine): end feels normal i. Activation/Strength/Cardiovascular (how do you accomplish these three in a short period of time?)

1. Circuit training (90 seconds each, 3 circuits - 21 minutes total) a. Unilateral stance bent knee with body blade b. Lateral step-up-down c. Wall slides d. Repetitive Skater Pose or golfer pick up Ex- unilateral stance with slight knee flex 2. Cardiovascular a. Circuit training b. Cycling - 25-30 minutes 3. Reactive neuromuscular training? a. Previous exercises are examples b. Lunges with theraband resisting hip abduction and external rotation

Scoring SFMA what are the categories?

1. Functional Nonpainful (FN) :Unrestricted mobility without symptoms or pain 2. Functional Painful (FP) :Unrestricted mobility that reproduces primary or secondary signs or symptoms, which includes pain 3. Dysfunctional Painful (DP) :Restricted mobility (limited range, stability, or symmetry) that reproduces primary or secondary signs or symptoms, which includes pain 4. Dysfunctional Nonpainful (DN) :Restricted mobility (limited range, stability, or symmetry) that is symptom free

i. Single-leg hamstring bridge test in athletes. Single-leg bridge scores are a predictor for hamstring strains. (Dutton, 2020, p.190; Freckleton, et al., 2014) - Faculty: Have them do this test and record the number for each side.

1. Lie down on the ground with one heel on a box (measuring 60 cm high) 2. Test leg positioned in approximately 20° knee flexion. 3. Cross arms over the chest and push down through the heel to lift their bottom off the ground. 4. Advise them the aim of the test is to do as many repetitions as possible until failure. 5. Essential that each trial has the participant touching their bottom onto the ground, without resting, and then extending the hip to 0°. The non-working leg is held stationary in a vertical position to ensure that momentum was not gained by swinging this leg. 6. When the correct form is lost, one warning is given and the test ceases at the next fault in technique. 7. Reliable (intratester intraclass correlation coefficient (ICC) =0.77-0.89, intertester ICC=0.89-0.91). 8. A score less than 20 repetitions for Rugby players are considered poor, 25 average and greater than 30 good. On average, Rugby players who sustained hamstring injuries in this study were close to or below the 'poor' level.

1. 22-year-old male s/p Right Allograft ACL reconstruction with lateral meniscal debridement 6 weeks ago. He has not participated in a rehabilitation program to this point, FWB, no crutches. He tore his ACL playing soccer. No other pertinent PHM. He is in good physical health (6'1", 200 lbs) and goes to the gym 4 times weekly (currently only doing UE lifting). Socially: Single, lives on the second floor of his parents' house (approximately 13 stairs), and a college student. Meds: Naproxen 2 tablets, BID last week due to right knee discomfort, otherwise no other meds. Currently not wearing a brace but supposed to obtain one this week. CC: Right knee fatigues by the end of the day or after standing for several hours. Scored a 5 on the lateral step down test on the right and difficulty maintaining unilateral stance on right for great than 15 seconds. ROM (supine): end feels normal i. Flexibility: restoring normal ROM is an important goal but should recover quickly once appropriate flexibility and cardiovascular exercises are engaged (at 3 weeks it is common to have between 100-120 degrees of flexion, at 6 weeks it is common to have 135 degrees of knee flexion. Full extension and at least 90 degrees of knee flexion are expected within 1-2 weeks)

1. Passive extension: Heel props, prone hangs, hamstring and gastroc stretching 2. Knee Flexion stretching - active-passive, Stationary bike 3. Patellar glides

1. Patients who have undergone partial meniscectomy must be cautioned not to progress themselves too quickly. An accelerated progression of exercise can cause recurrent joint effusion and may damage articular cartilage.

Homan's Sign / Sign of Deep Vein Thrombosis:

1. observe 2. palpate calf 3. dorsiflex foot A comparison of findings with the patient's medical history is very important when attempting to rule-in or rule-out D.V.T.. With the patient supine or sitting, the examiner (1) observes the lower extremities, noting redness, edema, and an increase in warmth of one calf versus the other; the examiner (2) palpates slowly but deeply, along the calf; the examiner (3) gently (but completely) passively dorsiflexes the foot. If any of the three tests is positive, the examiner must rule out between pathology of the gastroc-soleus muscles versus D.V.T.. If two of the three tests are positive (especially if redness or warmth of the calf is noted), the patient should be immediately sent to a physician for further evaluation. Therapists are urged to err on the side of caution when D.V.T. is suspect with a gastroc/soleus strain dorsiflexion will feel better - with a DVT dorsiflexion will not feel better

Under-Pronation Wear Pattern

Excessive wear along lateral outsole Excessive wrinkling of lateral midsole Lateral tilt

Midtarsal Joint Rotation Direction of force:

Hands are in same position as previous picture. The navicular is stabilized and the metatarsals are rotated around the longitudinal axis of the foot.

MMT: hamstrings as a group

Have patient lying prone, flex the knee, stabilize hip, pull knee into extension while they resist. Hamstrings as a group: laying prone, heel ceiling, little below 90 degrees, pull down on ankle , knee flexed hand on knee, stabilize at the knee Medial hamstrings: internally rotate tibia, if they try to externally rotate it shows lateral are stronger Lateral hamstrings: externally rotate tibia

Ober's Test/ Test for Shortening of the liotibial Band:

Have the patient lie on his side with his involved leg uppermost. Be sure the patient does not move the pelvis forward or backward. Abduct the leg as far as possible, flex the knee to 90 degrees, then extend the hip. Slowly release the patient's leg. If the iliotibial band is normal, the patient's thigh should drop to the adducted position. If there is a shortening of the fascia lata or iliotibial band, the thigh remains abducted when the leg is released (positive test). Hip Adduction is measured goniometrically if a deficit is present. ASISs for Stationary Arm, fulcrum at the ASIS of LE being measured, Movable Arm aligned with femur.

The 97% Miracle Technique for Dorsiflexion Loss Mulligan Techniques

Have the patient stand with their involved foot on a low chair. Place a strap around yourself and the posterior aspect of the patient's distal tibia and fibula, about 4 cm superior to the insertion of the Achilles tendon. Place the web spaces of both hands on the talus, as close to the joint as possible, but be sure you are not on the tibia or fibula. Slightly push posteriorly on the talus with your hands. Pull the tibia and fibula forward with the strap as the patient flexes forward over the involved foot, maintaining the posterior glide of the talus with your hands There should be no pain with this technique, and you may find that you need to slightly change the direction of pull on the strap to achieve this. Repeat the maneuver five to ten times (p. 106). -stabilize talus posteriorly -wrap belt around you -push posterior and inferior on talus -have him lean forward -roll and glide of talus: posterior

What are some procedures that might assist someone whose symptoms are related to excessive pronation, loss of medial longitudinal arch? Active mechanisms (Activation & Strengthening)

Intrinsic tripod exercise (short foot exercise), see exercise sheet for other short foot exercises (towel, marbles) ii. Arch lift with TheraBand - A type of short foot exercise 1. Arch lift while the 1st MTP remains in contact with the ground. a. The key is to concentrate on the arch and shorten the length of the foot by raising the arch. Picture shows foot up on a stool. Intrinsic + fibularis longus control with hip external rotation/abduction activation 1. Place Theraband under the 1st MTP, then loop theraband around the outside of the knee and then the person provides resistance with the opposite hand. In the example with the left foot the person will ultimately adjust the resistance with the right hand. 2. Keep 1st MTP on ground. 3. Slight hip Abduction with ER while maintaining 1st MTP on ground and medial longitudinal arch. 4. Why does this activate the fibularis longus and why is it important in someone excessive pronation? a. Anatomy The fibularis longus muscle is innervated by the superficial fibular nerve (L5, S1). Proximally: Head of fibula, proximal 2/3 of lateral surface of fibula, intermuscular septa iii. Distally: Medial cuneiform bone, 1st metatarsal bone Why? Although it may seem counter intuitive to activate a pronator. The fibularis longus shortens the arch, stabilizing the 1st metatarsal with a plantarflexion force, it reinforces the longitudinal and transverse arch, and helps to control the dorsiflexor component of pronation. v. Calf raises with ball. - See if you can do 25 The key is to maintain pressure on the ball with the concentric and eccentric portions of the heel raises.

Four optional movement tests of SFMA (normally do for athletes) : In-line lunge with lean, press, and lift - test for ability to control deceleration and direction Patient Instructions: Limitation:

Stand erect with feet together and arms out to the side along a reference line. Part 1: Assume the lunge position: o Keeping the chest up and pelvis level, Step forward along the reference line so that lower leg is vertical with the ground. The thigh should remain over the second toe. The front leg is the leg that is being tested. o Then lower the back knee almost to the floor, again keeping trunk upright. • Part 2: shift weight onto front leg o Keep arms out to side, bed through hips keeping the trunk straight, pelvis facing forward, and stance knee over the second toe. • Part 3: Lift the rear leg o Keeping the trunk over the forward leg (knee is bent), lift the rear leg straight so the trunk and rear leg are aligned. Hold for 5 seconds and return to starting position. • Repeat on other side. Stance knee does not stay over base of support (over foot). Unable to keep trunk and pelvis level or forward facing. Unable to shift weight properly or maintain proper spine, leg, or arm positions. Toeing out or excessive pronation Heel on stance limb does not remain in contact with the ground. Cannot maintain position for 5 seconds.

Four optional movement tests of SFMA (normally do for athletes) : Single-leg squat - tests for dynamic stability of LE Patient Instructions: Limitation:

Stand with your feet together, feet pointing forwards, with arms and hands staying at the sides of your body. The squatting limb's (stance limb) knee should go over the second toe and the heel should remain on the ground during the single- leg squat. Keep your body upright as you reach out with one leg as far as possible, lightly touch the ground with that reaching limb for 1 second, and return to the starting position. Measure the distance Hands do not remain at sides Difference of less than 4 cm between limbs should be noted Unable to achieve 60 degrees of knee flexion from neutral position Trunk lean in any direction Lower leg does not go over second toe Stance knee does not stay over base of support (over foot). Unable to keep trunk vertical and lumbar spine in neutral. Toeing out or excessive pronation Heel on stance limb does not remain in contact with the ground. Hips do not remain level.

Stretching and joint mobilization. Use stretching and joint mobilization techniques to increase mobility. Teach the patient self-stretching/flexibility exercises and the importance of movement through the full available ROM to counteract the developing restrictions.

Windlass Test for Plantar Fasciitis:

The test is performed in 2 positions: non-weight bearing and weight bearing. Non-weight bearing: With the patient sitting, the examiner stabilizes the ankle joint in neutral with 1 hand placed just behind the first metatarsal head. The examiner then extends the first metatarsophalangeal joint, while allowing the interphalangeal joint to flex. Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient's pain is reproduced. Weight bearing: The patient stands on a step stool and positions the metatarsal heads of the foot to be tested just over the edge of the step. The subject is instructed to place equal weight on both feet. The examiner then passively extends the first metatarsophalangeal joint while allowing the interphalangeal joint to flex. Passive extension (ie, dorsiflexion) of the first metatarsophalangeal joint is continued to its end of range or until the patient's pain is reproduced. -effects of plantar fasciitis - load the foot - more loaded when weight bearing - when weight bearing there should be less range

hamstrings grades

a. Grade 1 i. Usually a mild strain where cramping or tightness may be felt. Often there is some pain when the muscle is stretched or palpated. Key findings: Gait appears normal, but there is a pain with extreme range of a straight-leg raise. ii. Recovery: 5 days-4 weeks (depending on recurrence and ability to perform a sports specific program pain free). b. Grade 2 i. This grade usually is associated with more marked, instant, pain causing immediate cessation of activity. Athletes often describe a "ping" feeling, like a rubber band has snapped. This is confirmed again with palpation and stretch/contraction pain. There may be signs of swelling and often delayed bruising in and around the area. Key findings: antalgic gait or gait with a flexed knee. Resisted knee flexion and hip extension are both painful and weak. ii. Recovery: 4-6 weeks c. Grade 3 i. This is a complete rupture and is quite rare. Usually associated with a slip or fall into a splits position or jerking movement (often with water skiing). There will be immediate loss of strength. Pain is usually present, but not always. There will be a palpable area of swelling and a depression where there is a tear. Key findings: may requires the use of crutches for ambulation. In severe cases, ecchymosis, hemorrhage, and a muscle defect may be visible several days post injury. ii. Recovery: Complete tears may require surgical reattachment followed by a 3-6 month specific rehabilitation program

1) What are the primary components of examination for an acute hamstring strain injury and how would they present?

a. Observation: ecchymosis, visible deformity b. Physical exam is more to determine the location and severity of the injury than its presence. Based on the History you should have had a high suspicion of a hamstring injury. c. Strength - multiple test positions may be necessary due to the bipartite nature of the muscles and that they cross two joints i. Prone with knee flexed at 15 degrees and 90 degrees (some suggest at 45 degrees too). Try to bias medial and lateral hamstrings ii. Check for weak gluteals d. ROM (acutely, pain will limit these motions) i. Passive SLR to 80 degrees of hip flexion ii. Sitting should be able to actively straighten the knee to 20 degrees shy of neutral iii. 90/90 e. Palpation i. location ii. presence/absence of a palpable defect in the musculotendon unit f. Functional examination & outcomes i. SFMA & LEFS as examples g. Provocation tests

1) Describe the typical presentation of injury for a hamstring strain

a. Presentation: i. sudden onset of posterior thigh pain resulting from a specific activity ii. occurrence of an audible pop will signify a potential Grade III tear (proximal>distal tendons)-usually will not be able to continue to play iii. If proximal tendon is involved, it may hurt to sit

The 100% Miracle Technique for Plantarflexion Loss" Mulligan Techniques

at talocrural joint Have the patient lie on a plinth with the knee of the involved side flexed to about 90 degrees and the heel of the foot on the surface of the plinth. The therapist stands at the end of the plinth, facing the patient. Place the hypothenar border of your right hand just proximal to the joint line and wrap your thumb and fingers insecurely around the leg. You will deliver posterior pressure evenly on both the tibia and fibula with this hand. Place the web space of your left hand over the talus. Your thumb and index fingers should slope slightly distally so that they lay just below each malleolus. Stand in a lunge position with your right elbow locked, and using your body weight, glide the tibia and fibula posteriorly as far as you can. This locks the ankle joint. Without releasing the glide on the tibia and fibula, glide the talus anteriorly with your left hand. Have the patient slightly plantarflex the ankle. If the patient has discomfort, slightly alter the direction of your force until it goes away. Perform between five and ten repetitions (Mulligan, 1999, p. 105). -actively plantarflex -roll and glide of talus: anterior -stabilize posterior -heel on ground but foot not

"upper abdominals" (special test)

biasing "upper" abdominals, rectus abdominis and internal oblique muscles): the person is supine, legs extended, back flat. Grading is based on hand/arm position and ability to perform both the trunk-curl phase and the hip flexion phase. The therapist should not stabilize the person's legs until the person begins the hip flexion phase of the sit up. Normal: with hands clasped behind head, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Good: with arms folded across the chest, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Fair+: with arms extended forward, the patient can perform a trunk curl and maintain this position while flexing the hips, ending in a long-sitting position. Fair: with the arms extended forward, the patient can perform a trunk curl, but cannot maintain it when attempting to enter the hip flexion phase (typically only able to clear the shoulder blades from the table) Keep elbows out and chin can be tucked Doing a basic sit up

Moderate Protection (Controlled Motion) Through Return to Activity Phases - As swelling decreases, examine the patient for impairments and functional losses. Initiate joint movement and exercises to improve muscle performance, functional status, and cardiopulmonary conditioning.

i. Improve Joint Mobility and Protection 1. Joint mobility. a. Use supine wall slides, patellar mobilizations, and stationary cycling; encourage as much movement as possible. Unless there has been an extended period of immobilization, there should be minimal need to stretch contractures. 2. Protective bracing. a. Bracing may be necessary for weight-bearing activities to decrease stress to the healing ligament or to provide stability when ligament integrity has been compromised. Bracing can be one of two types: (1) range-limiting postoperative type braces that are used to protect healing tissues and discontinued during later phases of rehabilitation or (2) functional braces that are used during advanced rehabilitation and upon return to functional activities. The patient must be advised to modify activities until appropriate stability is obtained.

i. Includes teaching the patient about the disease of OA, how to protect the joints while remaining active, and how to manage the symptoms. ii. Adaptive or assistive devices, such as a raised toilet seat, cane, or walker, may be needed to decrease painful stresses and maintain function. Shock-absorbing footwear may decrease the stresses in OA of the knees. iii. Symptom management—early stages. Pain and feelings of "stiffness" are common complaints during the early stages. Pain usually occurs because of excessive activity and stress on the involved joint and is relieved with rest. Brief periods of stiffness occur in the morning or after periods of inactivity. This is due to gelling of the involved joints after periods of inactivity. Movement relieves the stasis and feelings of stiffness. Help the patient find a balance between activity and rest and correct biomechanical stresses in order to prevent, retard, or correct the mechanical limitations.

i. Likely osteoarthritis

List the factors that can predispose someone to a hamstring strain or re-injury

i. Previous hamstring injury (Parish, 2016; [recent hamstring injury] Martin, et al., 2022) ii. Degenerative joint disease of lumbar spine - pain in lumbar results in restricted lumbar ROM which restricts hamstring flexibility iii. reduced extensibility of the musculotendon unit, iv. weakness in the muscle, v. coordination issues or improper movement activities for the task vi. inadequate warm up vii. fatigue viii. Modified Thomas test (quadriceps flexibility). Reduced quadriceps flexibility (<50 degrees of knee flexion) is an independent predictor of time before sustaining a hamstring injury. (Dutton, 2020, p.190) ix. Ankle dorsiflexion lunge. Reduced ankle dorsiflexion on the contralateral leg is an independent predictor for lower limb/back injury and/or hamstring injury. (Dutton, 2020, p.190) x. Although not specific to a hamstring strain, decreased hip ER is a risk factor for an adductor strain (Dutton, 2020, p.190) xi. Single-leg hamstring bridge test in athletes. Single-leg bridge scores are a predictor for hamstring strains. (Dutton, 2020, p.190; Freckleton, et al., 2014) - Faculty: Have them do this test and record the number for each side. i. Inadequate rehabilitation from previous hamstring injury that did not specifically include eccentric exercises (Martin, et al., 2022) ii. During gait, causes of excessive knee flexion and inadequate knee extension include inappropriate hamstring activity, knee flexion contracture, soleus weakness, and excessive ankle plantar flexion b. It is estimated that "...one-third of the hamstring injuries will recur with the greatest risk during the initial 2 weeks following return to sport." (Heiderscheit, 2010, p. 67)

1. A 17-year-old basketball player has a goal of returning to basketball. He is unable to perform a functional squat at all and unable to maintain a split tandem stance. Further examination reveals impairments at the knee including swelling/joint effusion, decreased patellar mobility, knee ROM from 5-70 degrees, (+) Thomas test, inability to fully weight-bear through the involved LE (Full weight bearing is allowed), antalgic gait, and decreased quadriceps activation. He is 2 weeks s/p ACLR. a. What are components of a PRE?

i. Quad sets at Zero, some recommend also at 60 and 90 degrees ii. Closed chain terminal knee extension iii. Straight leg raise (brace locked at 0 degrees extension); progress to 4-way SLR iv. Isometrics; progress to mini-squats and leg press (brace at specified degrees) v. heel toe raises vi. Single limb balance -ankle pumps --> eventually go to heel raises -quad sets --> straight leg raise

i. There are a variety of exercises that could be used, but he is behind in ROM, effusion management, and weight bearing. ii. restoring normal ROM (at 3 weeks it is common to have between 100-120 degrees of flexion, and he should of had full extension and at least 90 degrees of knee flexion within 1-2 weeks) 1. Passive extension: Heel props, prone hangs, hamstring and gastroc stretching (avoid stretching hamstrings for approximately 6 weeks if hamstring graft) 2. Flexion: wall slides, heel slides, Stationary bike (may need 100 degrees before can do a successful circle) 3. patellar glides -needs improvement - should have 90 degrees by 2 weeks- he is behind on flex/extend Exercises: -heel slides with a ball under foot (very minor) - can hold thigh -passive ROM -prone hangs (start with foot and ankle) - or prop heel on something to let gravity take over

i. There is no need for an extended period of maximum protection following arthroscopic partial meniscectomy because there is little soft tissue trauma during surgery. Moderate protection is warranted for approximately 3 to 4 weeks. All exercises and weight-bearing activities should be pain free and progressed gradually during the first few postoperative weeks.

i. keep leg out of dependent position, keep elevated when in bed, encourage ROM, may need NSAIDS. -ice, elevation, small motion, rest, taping -grade 1 and 2 mobilizations of patella

i. small obstacle [foam cup] to emphasize hip and knee flexion in conjunction with ankle dorsiflexion) ii. Weight shifting -teach him how to use crutches and work with his brace? -stand on good leg and go forward and back to practice weight transfer -then switch legs if able to -tape on the ground

Proprioceptive assessment is warranted if the

joint capsule and/or ligaments have been injured (such as with a dislocation or sprain) or are otherwise involved. Assess proprioception, the patient's eyes are closed and the therapist uses the thumb and index finger to grasp the segment. The therapist then moves the segment into different positions and asks the patient to recreate the position at each joint with the opposite side. Use as few contact points as possible to position the body segment. At best, this a screening test; if you note deficits, conduct further neurological testing to assess other potential neurological deficits. Include outcome measures that decreased proprioception should effect (e.g., using the Balance Error Scoring System to assess static balance).

Test for Major Joint Effusion:

major joint effusion is indicated by a "ballotable" patella. The patient is supine, and the knee relaxed. The therapist pushes the patella downward (ballots the patella) with the palm of the hand, then releases the pressure, but doesn't move the hand. The test is positive for major joint effusion if the patella springs up "like a cork on water" due to increased joint capsule pressure secondary to edema. No psychometric information available on this test.

MMT Quadriceps Femoris

put a towel under their thigh, have the straighten knee, test at 30 degrees so you aren't getting screw home, push down (quadriceps - vastus intermedius, vastus lateralis, vastus medialis, rectus femoris)

Tripod stance:

stand with equal weight on both feet and distribute it such that you bear your weight equally through the following three points on each foot: - through the middle of your heel - through the base of the joint of your big toe - through the base of the joint of your little toe This produces a "tripod" for each foot. Practice this throughout your day. Stretching Exercises for the Ankle and Foot

"Norwegian pump" technique:

this is an excellent technique for Grade I and mild Grade II strains, or for more severe ones that are three to four weeks post occurrence. With the patient prone, palpate with one hand for myofascial restrictions (areas of greater tension in the muscle) in the gastroc-soleus. Once you've located these, gently apply downward pressure into the restriction with the base of your hand (thenar eminences). This "loads the fascia." While maintaining this pressure, gently dorsiflex the foot with your knee (the patient is completely passive in this technique). Once you get to the end of dorsiflexion, release the pressure on the restriction, move to another one, load the fascia, and passively dorsiflex the foot again. Repeat this as necessary. -it is passive -therapist dorsiflexes the foot

Unilateral stance:

work on strengthening the muscles around your ankle by standing on one leg for thirty seconds to one minute. Once this becomes easy, progress to raising your heel, balancing on your forefoot and toes.

________ has proprioceptive nerve endings & absorbs 90% of the tibial anterior translation (no matter the degree of knee flexion). Only 50% as strong as PCL

· ACL

medial tibial plateau

· Medial tibial plateau concave A-P, Lateral is convex A-P. Both concave M-L · medial tibial plateau is articulation area is 50% larger and 3x thicker than lateral

Lower Ortho Exam 1 (Labs)

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