MSK Exam 2: LE
1. Restoring knee flexion -functional use - What is the minimal amount of knee flexion needed for daily activities?
- use it or lose it -Post-TKA: commonly have to undo years of altered movement patterns -120 dg = minimal amount of knee flexion needed for daily activities
3. Restoring knee extension: Functional use - What is the goal of this phase? - What is common? - How can you provide cues to enhance motor learning for recovery of knee ext?
- use the new ROM functionally goal: carryover to GAIT (motor learning) -quad avoidance common -ie. terminal knee extension = use quad to straighten -put X with tape on back of knee...when they go into more ext tape pulls on skin for tectile cue
2. Restoring Knee extension: PROM/stretching - What technique is effective for stretching? - What is autogenic inhibition? - How do you increase a superior patellar glide?
- use your tricks - low load, long duration stretching (ie. strech out strap, bag hang, prone hang--knee cap off of table) *contract relax (contract quad and relax and immediately go into knee ext), autogenic inhibition (put them into knee ext, do hamstring contract and then relax and go further into extension) -Quad set facilitating superior patellar glide
Trendelenberg test - What is the clinical presentation of a weak glut med? - What is a positive test?
- Weak glut med will lead to contralateral hip drop Test = SLS for 30 sec Positive test = if reproduces lateral hip pain - Indicative of greater trochanteric pain syndrome/glut med weakness *can have pain w/o pelvis drop*
Objective measures: Accessory motions - When will the sense of stability be impacted? - Which would you want to test for each joint? What motion will this facilitate?
- any time there is effusion in the joint it will impact sense of stability 1. TCJ: Distraction, anterior (facilitate PF), posterior (facilitate DF) - sagittal plane 2. STJ: Distraction, medial (facilitate eversion), lateral (facilitate inversion) - can assess response to pain for unloading, but not a lot of motion 3. TTJ: Dorsal, plantar -medial & lateral side of foot 4. MTP - Similar to fingers - concave prox, convex MT head *joint you're most concerned about*
Avascular necrosis - What is the sign that's seen on the MRI?
- blood supply to hip is part of synovial system -any jt effusion in hip can compromise blood supply.... -crescent line
Current theory: Loading in PFPS - Load ratio: What's predictive of injury risk? - What is different about PFPS?
-not fact -recent evidence correlates -premise = load homeostasis -increase in load without opportunity for adaptation result in symptoms (non-specific) -spikes in training loads are predictive of injury risk (acute load = ok, but there is a fine line where it then changes over to injury if workload too much) *PFPS = ONE OF THE ONLY CASES WHERE EVEN IF THEY DONT OBJECTIVELY PRESENT WITH WEAKNESS, TRY TO STRENGTHEN*
Subjective Exam: Suggesting SIJ Dysfunction - When is pain relieved typically compared to hip jt? - What are common pt complaints indicating SIJ Dysfunction? - Typical MOI(s)?
-pain relief while standing is a statement about SIJ symptoms that is useful in diagnosing SIJ dysfunction (usually reverse for CFJ) -common complaints: 1. pain rolling in bed, sit to stand or other transitional movements 2. pain initiating L-spine flexion 3. pain at heel strike, one leg stand, ascending & or descending stairs 4. Pt choosing asymmetrical sitting posture MOI may be helpful -unexpected step down -fall onto hip (especially with feet fixed) ie. skis, bike
Special tests: Foot squeeze (Morton's) test - What is a positive test? - Where is it most commonly?
-peripheral nerve in webspace.... compression through forefoot 2nd-3rd, 3rd-4th MTP Positive test = Reproduces Sx
Subjective for foot/ankle - What is different for the onset of pain of plantar fasciitis & arthrosis? - How do you measure effusion at the ankle?
-plantar fasciitis= most painful event is stepping out of bed -arthrosis = better with rest, increase with activity -effusion: circumferential
Legg-Calve-Perthes Syndrome - How does this present? Does this follow a capsular pattern? - Prognosis different for certain ages?
-presents as a capsular pattern
Accessory motions - Why don't we use traction for the hip?
Because of the deep configuration of this joint, traction applied perpendicular to the treatment plane causes lateral glide of the superior, weight-bearing surface. To obtain separation of the weight-bearing surface, a caudal glide is used.
Hip arthroscopy: Phase 4 - Return to running & sport - What needs to be considered before return to play is considered? - What tests should be done to confirm return to sport?
Before return to play (RTP) is considered... 1. Full ROM in all planes 2. Cardiovascular endurance consistent with the sport Functional tests: 1. Y-balance test within 4 cm limb to limb comparison anterior reach, 6 cm posteromedial and posterolateral reach 2. Single leg hop for distance, triple hop for distance, and triple crossover hop for distance - at least 90% limb symmetry 3. Single leg squat, double leg squat, drop vertical jump (to look at quality of mvmt)
Pro tips
Begin your movement observation before the patient knows you're examining them "See what they own, not what they rent" Save the tests you expect to be most painful for the end of the exam Never rely on a single test - look for clusters, patterns
Alignment: - Relaxed calcaneal stance
Bisect the calcaneus and the distal 1/3rd of the lower leg (not the calf muscle mass) Do NOT be fooled by the line of the Achilles 1. Find inferior border of calcaneus...don't be biased by achilles...bisect the calcaneus & leg
Hip arthoscopy: Phase 3 - Return to pre-injury function - What are the 4 Tx priorities? What are the precautions?
1. Fully restore hip muscle strength 2. Improve balance, proprioception 3. Improve cardiovascular status 4. Precautions: avoid forced aggressive stretching, aggressive hip flexor strengthening, and contact activities - Generally weeks 9-12
Alignment: 1st ray position/mobility - How is this graded? - What does this tell you?
1. Grasp the 1st ray between thumb and fingers (lumbrical grip) 2. Stabilize rays 2-5 with the other hand 3. Examine position (DF'd, PF'd neutral) 4. Apply a dorsal and plantar force to the 1st ray to determine mobility 5. Typically considered normal or hypomobile
ROM endfeels - Knee extension vs. knee flexion
1. Knee extension - firm or possibly boney - springy = meniscal tear/loose body 2. Knee flexion - firm or soft tissue approx. (calf hitting ham) 3. What structures can contribute to loss of knee ext?
PROMS
1. Knee outcome survey - what Sx do you have when doing stairs.... 2. IKDC Subjective form - surgeons use majority of time, lengthy 3. Knee Osteoarthritis Outcomes Survey (KOOS) - degenerative painful conditions - 5 different scale....QOL, sports & recreation 4. Tegner or Marx for activity - specific for sport population, measure of activity of person - Marx = cutting & pivoting component 5. TSK-11 or ACL-RSI for fear/confidence (ACL) -used to be back outcome - affects how pain is affecting them -not a great measure of psycho. of pain - ACL-RSI = more specific to fear/confidence in knee.....sending ppl out to sports but not psychologically ready
Test Clusters for SIJ Dysfunction???? 1. Laslett's 2. Van der Wurff's
1. Laslett's - thigh thrust, compression/gapping, sacral thrust 2. Van der Wurff's - Gaenslen's (passive physiologic nutation/counternutation)
Heel pain - What are the 2 conditions?
Calcaneal bone spurs Plantar fasciitis
Plantar Fasciitis - Which population is at risk? - What to check for? - What do you need to rule out?
Can affect sedentary as well as active people More common in middle aged individuals Obesity can contribute to symptoms Prolonged standing and walking (occupational hazard) May occur after acute injury (e.g. stepping on hard object) ? Loss of elasticity of heel pad *Biomechanical issues: high arch (pes cavus) or low arch (pes planus) both at risk* -Lose extensibility as we age WHAT TO CHECK FOR: 1. Short calf muscles 2. Excessive rear-foot motion 3. Or rigid varus hindfoot place stress on PF 4. Weakness of intrinsic foot muscles (need to r/o inflammatory conditions, stress fx, nerve entrapment, tumors- rare, infection, fat pad syndrome)
Accessory Motion: STJ - Medial glide - What motion does this facilitate?
Can also be performed in prone - Restricted = loss of eversion Stabilize distal to the malleoli
Achillies tendinopathy - Invervention
1. Reduce activity- address training errors.. 2. Stretching of gastroc/soleus complex 3. Strengthening 4. Manual techniques 5. Correcting lower extremity asymmetries 6. Correct shoe wear 7. Orthotics if indicated 8. Modalites- laser and ionto- see CPG
Hip Tx--Manual therapy: Non arthritic intra-articular hip pain - What are the 3 priorities of treatment? - Any contraindications?
1. Restore motion: joint mobs 2. Decrease pain 3. Improve nutrient imbibition for articular cartilage--avoid end range movements (should be avoided when cam or pincer lesions are present ie. post op cases w/inflexibility & pain) *Contraindicated in cases of structural instability (hypermobile)*
Hip Special Tests: Anterior labrum test - What position do you start the leg in? What is a positive test?
1. Start in flexion, ER, ABD, apply axial load & sweep --> IR, ADD & ext positive = pain
Objective measures 2 - Effusion: How do we measure?
1st picture = congestive heart failure 2 = capsular effusion
Lateral hip pain - During which movement does this hurt? Where can it radiate? - Which movements usually provoke pain?
Lateral aching with lying on involved side, can radiate to knee *+ pain with palpation or stretching of ITB across greater trochanter with hip adduction, or at extremes of IR/ER* *+ pain with resisted hip abduction, ER, extension* Short hip adductors Remove causative factors ITB/TFL influences
Arthritic hip pain
ICD 10 & ICF
Accessory motion testing: Proximal tibiofibular jt
Patient: knee flexed to 80-90 dg, ankle in neutral Therapist: stand at the patient's feet Direction: anterolateral & posteromedial
THA (or THR): Treatment - Which approach is the most typical? - What are 3 Tx priorities? - What are some outcome measures?
Precautions or no precautions - typical = lateral approach - prosthetics now *1. Early weight bearing and mobilization* *2. Restore strength* *3. Restore proprioception* - Interventions not specified - appropriate load? *Need to load tissue for functioning* Outcome measures: - ROM, functional patient-reported outcome measures vs strength, movement and performance-based outcome measures 1. Harris Hip Score 2. Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) 3. SF-36 *All patient reported functional outcomes...doesn't explain quality of mvmt or strength*
Posterior glide - What motions would this help?
Purpose: to increase flexion & IR -ischial tubs right on end of bed, belt will take up weight of leg and bring into loose packed position (Open-packed position = 30˚ flexion, 30˚ ABD, and slight ER) -hand has to be close to femoral head Force = lateral & posterior
Hip Special Tests: Quadrant & Scour - What is a positive test?
Quadrant = testing 4 quadrants of the hip (position) Scour = axial loud & sweep Flex the knee and axially load the femur Sweeping compression and rotation from ER/ABD to IR/ADD positive test = non-specific, could be intra-articular pain
Posterior hip pain: less common....
Spondyloarthropathies (Ank Spond, Reiter's - reactive arthritis, Psoriatic arthritis, Inflamm bowel disease) Malignancy Bone and joint infection
Accessory Motion: STJ - Distraction - Where are you stabilizing/moving?
Stabilize talus, grab calcaneus STJ distraction can be performed in prone or sidelying
Special tests: Laxity - Patellar Apprenhension - What position do you start in? - What is a positive test?
Test for Patellar lateral instability (MPFL) • Supine 20-30 degrees • GENTLY glide patella laterally (don't dislocate it) • Positive: Apprehension NOT pain
Hip Special Tests: FAIR test - What is this testing for? - What is a positive test?
Test movement: Flexion, adduction, internal rotation to detect compression of sciatic nerve by piriformis ms. -clinically, add resistance Positioned: supine or sidelying + result: if FAIR mvmt elicits pain in location of sciatic nerve and piriformis (ie. burning...) Sn = 0.88 Sp = 0.83
Anterior Drawer - What is a positive test? - What is the problem with this test compared to Lachman's?
Tests ACL integrity • 90 degrees • Pull tibia anteriorly • Positive: No endpoint • High false negatives due to hamstrings • SNout: 40% SPin: 97%
Cuboid manipulation 2
*exert pressure in dorsal direction* swing into PF & supi
Hip Tx post-operative: phases - What are they the same as? - What must be worked on first before strengthening distally?
*follows same principles of intra-articular lesions* 1. Acute - joint/tissue protection 2. Restore ROM and proximal strength and NM control 3. Restore full strength proximal --> distal 4. Restore full tissue capacity-->return to activities/participation/sport *ROM and proximal control must be established prior to progressing to distal dynamic strengthening*
Important subjective info - What is the MOST important info the pt can give you? - Nature of pain - What Sx indicate a loose body? What about instability?
*location- superficial and distal = easy to locate*
Patellofemoral pain syndrome - Strength: Where are their deficits?
- plenty of evidence -have less quad and hip strength
Special test: Tinel sign - What does this test for? - What is a positive test?
- Palpate VAN - Tests for Tarsal tunnel syndrome Positive test: concordant symptoms, tingling
SIJ special tests: - SIJ gapping - What is a positive test? - What direction is the load you are applying?
-ventromedial load through ilium -vertical sacrum, can put pillow between knees -use body weight -gapping of posterior aspect of SIJ - Want to hold for a couple of minutes + = pain provocation
Foot & Ankle Management: - Inversion ankle sprain theory
ATFL is strong enough that it pulls fibular anteriorly during inversion sprain - ankle sprain might not be a ligamentous injury but also a positional fault of the distal fibula anteriorly
Achillies tendinopathy
Acute irritation of healthy tendon involves inflammation of the paratenon- can be visualized and palpated *easy to spot & feel* - tissue that is degenerated = avascular & mushy
Objective Examination Tests for the Hip: - What the accessory motion we want to examine? Muscle length tests? - What are the special tests
Accessory motion tests (caudal glide, ant/post glide) Muscle length tests (Thomas, Ober, SLR, 90/90--review Kendall for these) Special tests: 1. Trendelenberg 2. Quadrant/scour 3. Labrum (anterior and posterior) tests 4. FADIR
Palpation
Achilles tendon, Calcaneus Lateral malleolus, FL, FB tendons, ATFL, CFL, PTFL Sinus tarsi- concave space between lateral mal and lateral tendon of EDL Cuboid Base of 5th met
Inversion sprain- Associated injuries - Syndesmosis - Acute period: How does this differ from ankle sprains?
Acute: NWB 4-6 weeks, gradual return to WB -Tx is different once syndesmosis is involved, recovery is 2x that of a 3rd dg ankle sprain
Achilles cross fiber massage
After locating the most painful site in the tendon, the therapist grasps that part of the tendon between thumb and index finger. Exert just enough pressure so that mild pain occurs and can be easily tolerated. Move hand ant to post, taking the skin around the Achilles tendon so that friction is applied transversely to fibers. General guidelines: 2-3 minutes for acute, up to 10-15 minutes for chronic Achillodynia
Posterior ankle/foot pain - Sever's disease
Apophysitis of the calcaneus, (Osgood Schlatter syndrome of the foot)
Palpation skills
Bony landmarks: - ASIS, pubic symphysis, iliac crest - PSIS, sacral sulcus (put thumb medial to PSIS and see how deep you go), iliac crest, ischial tuberosity, greater trochanter, SIJ Bursae (difficult to palpate unless inflamed) - Greater trochanter or gluteal, psoas, ischial Ligaments - Sacrotuberous, sacrospinous Muscles - adductor longus, sartorius, rectus femoris, rectus abdominus, TFL gluteals, hamstrings, erector spinae, quadratus lumborum
Accessory motion: TCJ - Posterior glide - What motion does this facilitate?
Convex talus moving under the concave tibia and fibula - Restricted = loss of DF Open Packed = 10 dg PF
Accessory Motions: TTJ- Calcaneocuboid - Plantar glide - What does this motion facilitate?
Distal concave cuboid moving on proximal convex calcaneus - Loss of dorsal glide = loss of "plantar flexion"
Accessory Motion: TTJ: Talonavicular - Dorsal glide
Distal concave navicular moving on proximal convex talus -Facilitates DF
Patellar instability: Dx + Non-op management - How is it Dx? - What are the 2 priorities for non-op management? What angle to you want to strengthen the patella in?
Dx = Xray sunrise view Non-op management 1. Quad strengthening - avoid OKC 0-45 dg, want to strengthen with patella in trochlea groove 2. Bracing -prevent patella from moving laterally
Special tests: Syndesmosis - Squeeze test - What is a positive test?
Examiner applies a manual squeeze @ midcalf, pushing the fibula into the tibia Proximal force causes distal pain Positive test: concordant symptoms
Hip Tx--Strengthening - Excessive hip ER ROM associated with.... -Exessive hip IR ROM associated with... - How do we treat this impairment? - Which motion weaknesses are associated with labral tears?
Excessive hip ER ROM has been shown to be associated with weakness in hip IR's Excessive hip IR ROM has been shown to be associated with weakness in hip ER's *Recommendation that asymmetrical hip strength should be addressed* Hip abduction and rotation weakness has been associated with labral tears
Talocrural PF
F- lateral malleolus SA- mid line lateral leg, fibular head MA- 5th metarsal
Taping of patella: 1. First technique: When do you use? 2. Second technique: When do you use?
First technique: 1. 1 layer for skin protection, second layer for changing mvmt pattern 2. Condyle to condyle - Start w/o tension, then apply medial glide & increase tension & end w/o tension - If this doesn't decrease pain, try lateral OR superior glide as long as person isn't unstable - Want to tape right on top of patella so that when stands up, its still on the patella *Make sure for person to perform painful activity and then come back to see if it worked...if not then readjust* Second technique: 1. Used after mobilizations - Try superior glide for pain reduction (if they are hypo-mobile superiorly) - Don't have to do the horizontal taping superior to the knee in picture
PF taping
Go medial to lateral for the stripes
Hip arthroscopy: Phase 2 - Return to FWB - What are the 3 main goals of this phase? - What strengthening should you be working on? - What is the duration of this phase?
Goals: continued tissue protection, restore full ROM and normal gait patterns *Strengthening: emphasis on gluteus medius (to avoid trendelenberg, will stress labrum)* - incorporate more functional movements (i.e. single leg stance w/isometrics) Generally weeks 4-8
Lateral ankle sprains - What is the greatest risk factor for an ankle sprain? - What are the 3 Grades?
Greatest risk factor for ankle sprain is a previous ankle sprain Grade I: sprain of anterolateral structures, may not test (+) for laxity Grade II: total rupture of ATFL, sprain or partial tear of CFL Grade III: total rupture of ATFL and CFL, possible sprain or partial tear of PTFL and anterior inferior tibiofibular ligament (syndesmosis)
SIJ/pelvic ring stabilization - What pattern is displayed to create compression at the SIJ? How is this different than control groups (with no SIJ pain)?
In control subjects, onset of IO and multifidus occurred before initiation of weight transfer In SIJ pain subjects, onset of IO, multifidus and glut max was delayed on symptomatic side Onset of biceps femoris was earlier Onsets were different between symptomatic and asymptomatic sides *Criss cross activation that can create compression at the SIJ*
Ottawa rules for x-ray of knee, ankle, foot - Which spots at the foot & ankle require a referral for x-ray for fracture? - Tx for ligamentous injury? - Rule out a complete tear of ligaments?
Inability to bear weight upon initial examination = order to rule out fracture
Patient-reported outcome measures (PROMs)
Lower Extremity Functional Scale (LEFS) http://www.rehab.msu.edu/_files/_docs/LEFS.pdf Foot and Ankle Ability Measure (FAAM) https://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Foot%20and%20Ankle%20Ability%20Measure.pdf -mostly used by surgeons Foot Function Index http://www.nsoplb.com/uploads/article_documents/footfunctionindex.pdf
Special tests: Navicular drop - What does this determine?
Measure the difference in the height of the naviculum in NWB, then in WB
Palpation of foot - Get straight what is medial & lateral!!
Medial malleolus, sustentaculum tali, Naviculum, medial and lateral talar head PT, FDL, FHL, Posterior tibial artery Deltoid ligament Cuneiforms, metatarsals- shafts and heads 1st MTP joint
ACL injuries: Response to injury - Explain the Rule of 1/3s - Can you return to sports w/o an ACL? - Which population are non-op worth? - Can you prevent an ACL tear?
Rule of 1/3rds.... 1. Coper- torn ACL and can return to normal fxn when swelling goes down 2. Potential coper- tear ACL with extended non-op rehab can return to sports on short term basis 3. Non-coper- torn ACL & havng giving ways with normal ADL's - US surgeons don't really pay attention to this - absolutely can return to sports w/o ACL (important for cutting & pivoting sports not running on treadmill or spinning) Non-op: older, less active or willing to mitigate activity Reconstruction: younger, active Braces don't prevent ACL tears - People respond differently to surgery
Inversion sprain= Associated injuries 1. Soft tissue injuries 2. Nerve injuries 3. Ligamentous injuries
Soft tissue injuries - sinus tarsi syndrome, impingement syndromes (bony or soft tissue), tendon disorders (peroneal tears, peroneal dislocation/subluxation--snapping ankle, tenosynovitis) Nerve injuries - superficial peroneal nerve, sural, complex regional pain syndrome (CRPS) type I (post-trauma, PNS/CNS allodynia & inflammation) Ligamentous injuries - bifurcate, calcaneocuboid, and/or cuboideometatarsal ligaments, syndesmosis
Hip Special Tests: Posterior labrum test - What position do you start in? What's a positive sign?
Start in flexion, IR, ADD --> finish in extension, ER, ABD -positive = pain
Hip MWM's - Which motions can you assist with? - What are you looking for while performing this?
Therapist placement: stand on the same side as the hip you are treating. Place the seat belt in the groin, close to the joint line. Stabilize the ilium with the arm tucked into the belt, elbow against the abdomen. Pt position: supine, hip and knee at 90 Mobilization: laterally glide femur with AAROM hip flexion, or internal rotation -looking for a measureable difference: in pain relief AND ROM
Talocrural joint
Therapist: in front of pt with web space on ant talus, belt on hips Pt position: standing with foot on chair, belt 4 cm above Achilles insertion (towel for comfort) Mobilization: Glide tibia and fibula anteriorly with belt while stabilizing talus. Pt actively lunges fwd DF'ing ankle Useful for restoring Talocrural DF *Hand placement = on top of talus* go back & down w/force -high reps bc immediate change
Hip Tx--Post-operative conditions - What are the 4 types of hip arthroscopy?
Total hip arthroplasty Hip arthroscopy - Labral repair - Acetabular rim resection - Femoral head - osteochondroplasty
Superficial peroneal nerve - What are common n. conditions associated with this n? - How do we test for this? - How do we treat?
Traction neuropathy Compression neuropathy SLR with ankle plantarflexed and inverted Rx with nerve mobilization
Radiographs of the hip
bone spurs = intra-articular
Objective measures - What does effusion indicate? What does edema indicate? - How can we look at this clinically? What is a positive test?
effusion = intra-articular swelling edema = swelling of interstital tissues (extra-articular) - can look at this clinically Modified stroke/sweep test: 1. Pocket on medial side of the knee will disappear 2. Sweep the side (medial sulcus) of the swelling...pushes fluid upwards into super-patellar pouch area of the jt 3. Go to lateral side and the push medially (ie. sulcus will fill it again if swelling is intra-articular) *Can determine if swelling in the jt*
Objective measures for swelling - Where are other common areas of swelling? Which population is prone to swelling here? - If examining fluid from swollen joint, what will cue you to think an acute injury vs. chronic? - For determination of a fracture, what procedural intervention is used?
good reliability for fluctuations in swelling (can increase of degress Tx progression) other areas of swelling = prepatellar bursa (common in wrestlers or direct blow to the knee)...localized swelling in bursa & nothing in medial/lateral areas similar to olecranon bursa & will look like big balloon when swollen 1. knee aspiration = fluid is blood if it's acute injury (risk. vs reward) 2. chronic problem/cartilage problem...fluid will be yellow (ie. OA or degenerative meniscal tears or chronic synovitis) -for determination of fracture: will aspirate the knee & let it sit....if it has globules sitting on top then fat globes coming from bone marrow bc can't tell on xray
SIJ AP shear/thigh thrust - What is a positive test?
ie. Ostagaard -axial load through femur to then thrust-->shearing motion between ilium & sacrum -hand on sacrum + = pain provocation
Post inversion sprain - What can happen with an inversion sprain at PTFJ & DTFJ?
if ATFL strong enough with inversion spirain, can pull distal fibula anteriorly and inferiorly...shifts prox tib fib inferior and posterior (rotation around an oblique axis) if this happens, *can compression common peroneal n.* Proximal tib-fib - locking or hypermobility
Palpation - What is the difference between the MPFL & plica?
medial + lateral jt line = lteral to patellar tendon - lateral jt line = figure 4 position -pes= follow hamstring tendon on the medial side - medial patellofem. ligament -- near femur slide into medial patellar groove, fibers run perp. to patella -plica = extra synovium, runs parallel medial to patella, snaps back + forth
PCL injuries - What is the most common MOI? - What's the gold standard of Dx? - Do they require surgery? - What do you want to avoid after PCL?
not very common MRI gold standard MOI = Dashboard injury- direct blow to flexed knee (ie. car accidents) Most (isolated) do not require surgery 1. Avoid allowing tibia to sag posterior early after injury and/or reconstruction...reverse ACL brace to hold up tibia -usually just allograft reconstruction, doesn't play as big of a role in ADL's 2. Avoid HS contractions
Posterior rotation of ilium on sacrum - What motion is this facilitating at the sacrum? - What is a positive test?
nutation: posterior rotation of the ilium with anterior rotation of sacrum - place *bottom leg in extension* and block with knee and push ASIS posteriorly -hold onto ASIS, iliac crest, ischial tuberosity -can place pillow between you and patient - positive test = pain *force couple with hands*
Patellofemoral jt - What is the open packed position? - What motion does a superior glide facilitate? - Inferior? - Medial? - Lateral? - Medial tilt - Lateral tilt
open packed position= full extension -some people might do in 20-30 dg bc joint space is tighter here 1. superior glide: - webspace of thumb -keep fingers on top to make sure that patella stays level -facilitates extension 2. inferior glide -facilitates flexion 3. medial - facilitates flexion 4. lateral - facilitates extension 5. medial tilt---not for trying to improve motion -based on movement of head of the patella -place hand laterally & push medially 6. lateral tilt -for treatment, usually wouldn't have leg in full extension
Hip Special Tests: Fulcrum test - What does this test for? - What is the downside to using this test?
positive = pain reproduced indicative of femoral stress fx Sn = 100% *Sp= 100% (0%)*
Hip Special Tests: FADIR - What is a positive test?
positive test = reproduction of groin pain - indicative of mechanical impingement (FAIR) or labral pathology -if bony lesion in acetabulum or neck/head --> this position can be provocative (ie. pinching or groin pain) *if retroverted, anterior rim will hurt*
Trimalleolar fracture
posterior = posterior aspect of tibia
Special tests: Laxity - Modified stroke/sweep - What is this testing for? - Grading scale
pushing fluid superomedial Test for presence of knee joint effusion • Sweep fluid superiorly out of medial sulcus • Sweep inferiorly on lateral side and watch for return of fluid to medial sulcus • Scale: • None • Trace- partially fills sulcus • 1+ fills sulcus • 2+ fills sulcus, returns without inferior sweep • 3+ can't milk out of sulcus, ballotted *can't use circumferential at the knee--this is the test for that*
Bony impingement- ATTCS or PTTCS - What would you want to do to treat this?
w/DF, no room for tib to go can also happen posteriorly *if bony block, would want to distract or glide posterior but DF probably wont change* Anterior tibiotalur compression syndrome
Objective measures: - What should you check all major jt and soft tissue structures for? (5) - What is the goal of all objective measures?
• Check major joints and soft tissue structures for: 1. Pain/tenderness 2. Diffuse tenderness and tender/trigger points 3. Abnormal texture/tone (muscle bulk) 4. Abnormal structure/ alignment 5. Can be used to assess treatment response and guide treatment *must reproduce pts Sx!!!!*
Alignment observation
• Frontal • Genu varum/valgum • Patella • Q angle • Sagittal • Recurvatum • Posterior • Foot IR/ER
Posterior sag - What is a positive test?
• Tests PCL integrity • Supine 90/90 • Positive: Tibia sags posteriorly
Plantar Fasciitis - What is the function? - What are the different phases of gait? - How do you unload the PF? - How does this create the secondary condition for the heel?
Function: - During standing and wt bearing, the PF plays a major role in supporting the body wt (by virtue of it's attachments along the longitudinal arch) Assumes different roles during different phases of gait: 1. Toe-off: windlass effect helps to promote the arch and a more rigid foot for propulsion due to orientation of the insertion on the medial aspect of the calcaneus 2. Heel spur is there bc plantar fascia is pulling on it....it will grow back if it's removed surgically 3. Unload PF by creating more length through posterior chain (ms, heel cord & PF)
ACL injuries: Reconstruction vs. repair - Allograft vs. Autograft... Which tendons do they typically use? - Outcomes after ACLR: What is shown to improve outcomes post-op the best? Likelihood to return to function? Return to sport? Second Injury? - OA development & ACL tear - What are predictors of poor outcome after ACLR?
Reconstruction: make a new ligament (repair = fixing what is already there) - allograft = usually achilles or post tib (cadaver) - autograft = BPTB, hamstrng, quad tendon (hamstring & patellar tendon are the best) Outcomes after ACLR: - Prehab improves post-op outcomes - Function: ~70% return to "normal" function - Sports: 65% return to sports within 2 years of surgery - Second Injury: 30% if under 25 yo and returning to sport ~ 50% develop OA within 20 years, Surgery does NOT prevent OA development....outcome is the same if you don't get surgery *Poor quad strength and loss of knee ext predict poor outcomes after ACLR*
Movement System: 3 Functional tests for the foot & ankle
Single leg stance - eyes open, eyes closed, firm surface, unstable surface (ICF category- impairment of body function- proprioception) Hop (ICF category- measurement of activity limitation- jumping) - lateral hop for distance (3 consecutive hops= total distance) - Side hop (timed hop 30 cm back and forth for 10 reps) Star excursion or Y balance test
Special tests: Forced DF - What does this test for? - What is a positive test?
Tests for anterior impingement Examiner stabilizes the distal tibia and applies a forceful DF motion Positive test: Anterolateral ankle pain
1. Restoring knee extension: Jt mobilizations - Where in the range should you mobilize?
Treat the accessory motion impairments 1. Mobilization at or near end range - Move further into range as mobility improves - Stretch in between bouts - Don't forget about the screw home mechanism *move the knee further into extension with improvements ie. mobilize for 30 seconds, continue to push them into extension
Accessory motions: TTJ- Calcaneocuboid - Dorsal glide - What motion does this facilitate? - What is this good to use for?
Use hypothenar eminence & push on cuboid dorsally Distal concave cuboid moving on proximal convex calcaneus - Loss of dorsal glide = loss of "dorsiflexion" -good for inversion injury (lateral foot pain).. cuboid goes into plantar flexion
Ways to increase DF
Using a rocker board to develop control of ankle motions with the patient sitting. When both feet are on the board, the normal foot can assist the involved side. With only the involved foot on the board, the activity is more difficult.
Meniscus tear: Degenerative - Is surgery effective? - What does research show is most effective?
*Any surgical procedures done to meniscal tear = not effective* -No difference in outcomes with sham surgery for degenerative, also with exercise therapy = no differences *Shouldn't be scoping degenerative tear unless mechanical symptoms...even if you do scope, you won't get any better outcomes than just did rehab alone*
SIJ clinical wisdom - Pain where often indicates SIJ dysfunction? - Which sports are prone to SIJ injury? - What pain pattern would lead you to think it's SIJ?
*Buttock pain initiating hip or LSP motion especially reciprocal or asymmetrical motions is often SIJ* *Buttock pain with "one legged" sports (hurdles, high jump, pole vault, soccer, cricket fast bowler, football/rugby kicker ...) suggests SIJ however, r/o labral tear* Recent pregnancy warrants special attention to SIJ Pain walking, and eased with 10 + mins sitting, - be suspicious of SIJ (BUT don't forget spinal stenosis) Always remember that NIGHT pain unchanged by your objective examination tests or by any positional or movement changes strongly suggests a non musculoskeletal origin (red flag, seriously consider referring for further evaluation)
Prone Hip jt PA (anterior) glide - When is this position indicated to use?
*If the patient is not comfortable with the legs off the end of the table* Block the ipsilateral ASIS with a sandbag or towel Support the thigh Therapist stands on opposite side Direct force anterolateral *can always use belt to support leg* -prompt him to contract when moving through the range...CAREFUL to not give lumbar extension
Multi-ligament injuries at tib-fem jt - What is the typical MOI for this? - What is the biggest concern with this injury? - How is this typically treated? - How are the outcomes?
*MOI = dislocation* - Concern for neurovascular injury - Surgery is typically staged to reduce risk of arthrofibrosis - Individualized rehab protocols - Generally poor outcomes
PFPS: Orthotics - What does the research say?
*PT + orthotics better than PT alone (only 12 week follow up)* -If single leg squat pain decreases with orthotics, use it
Knee OA Tx - What are the 5 options?
*READ CPG's for specific exercises* HA = jt lubricant debridement - getting away from this bc outcomes are worse joint replacement = still considered a salvage procedure...to get rid of pain to function and maintain healthy lifestyle (not to return back to normal process) -unilateral = if lateral side is pristine but medial side is damaged -TKA = expensive, but most effective
Prone dial test - What does this test for? - What is a positive test? - What if PCL torn? - What if PLC torn?
*Tests PCL and PLC* • Prone 30 degrees, tibial ER. Flex knees to 90 • Positive: Greater than 10 degree side to side difference • If PCL is torn: Greater ER at 90 (goes into slack the more ext you go into) • If PLC is torn: Greater ER at 30 PCL = taught w/ more knee flexion
Hip joint alternate PA (anterior glide): alternative side lying - Why would you use this position over others?
*for patient if not comfortable with prone* Patient Side lying, hips flexed comfortably and well supported.. Therapist Standing behind patient. Procedure Proximal hand stabilises pelvis at ASIS Distal hand pushes in anterior direction against posterior aspect of greater trochanter Indications Increase hip joint extension and external rotation Notes Use when patient can not lie prone Stronger treatment grades are difficult in this position Effective position for pain relief treatment grades
Movement system- active tests in standing - Unilateral toe raises: What does this assess? - Bilateral squat: What does this assess for? - Unilateral squat: When would you use this? What is a "positive result"?
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Medial Ankle Pain: Tarsal Tunnel syndrome - How can this happen? What physiologically is going on? - What are common Sx? When are Sx the worst? What needs to be ruled out?
- *Entrapment neuropathy of the tibial nerve as it passes through the anatomic tunnel between the flexor retinactulum and the medial malleolus* Can be post-traumatic (malleolus fx), neoplastic, inflammatory, result of rapid weight gain, fluid retention, abnormal foot and ankle mechanics Dx based on history and clinical exam *Sx:: poorly localized pain and or burning sensation/paresthesia at the medial plantar surface of the foot, worse after activity, end of the day, (need to r/o plantar fasciitis)*
Femoro-acetabular impingement (FAI) - What are the 3 classifications? - Who are most prone to specific classification? - Which is the most common?
- *abnormal bony contact between femur & acetabulum which leads to labral tears, articular caritilage damage, pain & eventual arthrosis* - NON-capsular pattern even though intra-articular 1. Cam type -decreased femoral head-neck offset, "bump" - SCFE - femoral neck fracture - idiopathic, developmental, genetic... - young, active males 2. Pincer Type Retroversion of acetabulum Middle-aged Females (prevalence 19% vs 15% male) Crushing injury to labrum 3. Mixed Type Most common
Valgus 0/30: With & w/o ER - What does the ER test? - What is a positive test? - What are the 3 grades?
- 0 tests integrity of the whole joint - 30 tests MCL - *Provide varus THEN valgus force* • Add tibial ER to test POL (posteromedial corner), better to grab malleolus • Positive: No or Spongey endpoint • Grade I - Normal endpoint, No laxity, pain • Grade II- Normal/spongey endpoint, increased laxity, pain • Grade III- No endpoint, +/- pain
Lateral ankle pain- Inversion sprain 1. Inflammatory phase - Time frame? - What modalities can be done? - What motions to avoid?
- 0-4 days *RICE, cross fiber (CFM) or deep friction massage to prevent ligament contraction & decrease pain* *Oscillatory joint mobilization* (AP mobs) has demonstrated statistical improvement in ROM *Avoid forced DF and inversion* Protected motion - *Early weight bearing with support* - *Bracing based on strong evidence--anything to protect lateral structures*
Lateral ankle sprain- Inversion sprain 3. Early Remodeling Phase - When does balance improve?
- 11-21 days *Continue manual therapy for pain free joint mobilizations, neuromuscular/sensorimotor rehabilitation* Static to dynamic Simple to complex Firm, immobile support to soft, mobile support *Balance improves after 4 weeks of training (quicker than strength improvements)*
Lateral Ankle Pain - Inversion sprain 2. Proliferation phase - Time frame - When do encourage walking? - Treatment methods?
- 4-11 days *Avoid max DF and inversion past neutral, start with functional rehabilitation* CPG: Progressive loading/sensorimotor training - strong evidence *In grade II and III lesions: taping or bracing x 6 weeks* *Encourage normal walking within 1-2 weeks*
Loose knee problems
- ACL, MCL, PCL, multi-ligament -LCL isn't very common
ACL injuries - When does effusion occur? - What immediately happens? Clinical presentation? - Reason why not walk on torn ACL? - What are the 2 presentations of instability?
- Acute effusion (blood) within 2 hours *important to ask when during subjective* -immediate quad inhibition -pain, loss of motion, flexed knee gait (feel unstable & nervous about full extension bc tibia goes anteriorly--co-contraction of quads & hams to maintain this position, adding a loss of compression to the joint), loss of proprioception -reason why not walk on torn ACL--can have another episode of instability then can damage meniscus Instability - giving way: pt feels the bones shift resulting in exacerbation of pain and effusion -pseudo buckle: caused by quad weakness up & down stairs
Non-arthritic hip pain - What does the evidence say about treatment?
- All expert opinion...quality is so low.... -part of the reason = looking at diachotomous (yes or no) for OA, but looking at radiographic evidence BUT non-arthritic hip pain
Painful knee problems: 1. Meniscus injuries - What is the typical MOI? - When is effusion typically seen? - What is the common pt complaint? - What is the gold standard of diagnostic imaging? - Why is surgery typically performed? What types of tears is this done for? What does this predispose a pt to? - Bucket handle - Explain the "zones"
- Can occur acutely or degeneratively MOI = deep squat or pivoting, pop Common complaint = Pain with stairs, mechanical symptoms (clicking, popping, catching) - Effusion: 12-24hrs after injury - MRI gold standard *Surgery: primarily for mechanical symptoms (NOT PAIN)* 1. Repair: only works in red zone 2. Excision for tears not in the red zone -even trimming down = can lead to OA bucket handle: trying to go into extension and it becomes locked red zone = decent blood supply red-white = will still stitch and hope it heals white zone = wont heal
Structural instability - What is this defined as? - How can it happen? - What are factors that relate to structural instability? Common in which population? - What is the future impact of femoral version?
- Extra hip mobility that causes pain with or without signs of hip joint unsteadiness - May be traumatic, atraumatic, or secondary to bony or soft tissue abnormality Factors related to structural instability = 1. Shallow acetabulum (acetabular dysplasia--poor alignment/shape) 2. Excessive femoral anteversion. Structural instability due to dysplasia is thought to be more common in female sex. Femoral version (excessive ante or retroversion may place an individual at risk for labral injury and increase risk for developing hip OA) *both of these require nms to be more active & have better control*
Accessory motion: Tib-Fem joint - Posterior glide - What motion does this facilitate?
- Facilitates flexion For mobilizations, can lift the leg up to 90 dg supine, grasp leg and push posteriorly - ER or IR the foot and then perform mobilization
Hip arthroscopy: Phase 4 - Return to running - How do the motor learning principles apply? - Duration of phase?
- Faded feedback = motor learning - Start running in alter G machine--then advance to treadmill *Have to establish proximal control before distal strengthening* - Duration = 16-32 weeks
Accessory Motion testing: Tib-Fem jt - Anterior glide prone & supine - What motion does this facilitate? - What is the open packed position?
- Helps facilitate knee extension - Open packed position = 20-30 dg knee flexion 1. Prone -towel under thigh proximal to patella -dont use thumbs 2. Supine: -slide towel distal down -push quad posterior - if want to make more aggressive, move towel down under foot...remember ER happens w/lock in home so put more force on the medial side prone *recommended for Tx purposes*
Hip Tx: Joint mobilizations w/movement (MWM) - How is jt accessory motion testing generally performed? - What is the purpose of jt accessory motion/mobs versus MWM? - When is it indicated to use? What are you looking for after its performed? How long is the suggested duration?
- Joint accessory motion testing = generally performed in the open packed position - Can be performed anywhere in the available joint motion - i.e. if want to increase hip flexion ROM, perform posterior glide at end of range MWM - Used to increase painfree motion throughout the range - Principle = jt mob in open pack position and sustained while pt moves through available ROM - The glide / joint mobilization is not released until the joint is back at the open pack position. - When to use: pain reduction & increase jt ROM...looking for an immediate change in pain and ROM after MWM Duration: Repeat 6-10 times. - i.e. painful ROM, take through the range...find where it's painful and do the mobs while the person is actively doing the movement....ideally looking for a reduction in pain -also, lateral glide & assist into IR & ER
Resisted hip abduction - What does this test for? What is a positive test? How many degrees should the leg be in?
- MMT for hip abductors -hip positioned at full extension & 50 dg abd with other leg bent positive test = pain provocation - SIJ dysfunction
Alignment: sagittal plane - Normal knee patellar alignment - Patella baja vs. alta: How does this affect the lever arm?
- knee extension & its effect up the chain patellar position: can't really see clinically so xray normal knee = longer lever arm = produce more torque 1. Baja = Decreased lever arm, have quad weakness forever...patellar tendon rupture can cause this 2. Alta = tend to see patellar instability, doesn't sit in groove
Articular cartilage injuries - What is the common MOI? - What is the original cartilage replaced by? - Explain the 5 grades - What imaging would you want to use? When would you want to use a different modality?
- MOI: kissing lesion or shear during instability event same thing as OA -hyaline cartilage usually lines, replaced by fibrocartilage • ICRS Grading: • Grade 0- normal • Grade I- superficial fissures • Grade II- partial thickness • Grade III- full thickness • Grade IV- into subchondral bone *Can see displaced on x-ray....Non-displaced need MRI to see*
Alignment of foot - Arch height/Feiss Line - What is the norm? - Where are the axes?
- Measures flat foot/high arch foot in WB Norm = 130-150 dg Landmarks 1. Axis at navicular tuberosity 2. Moving arm at medial malleolus 3. 1st metatarsal head
LQS - What is the purpose? - Which roots contribute to pain at the LE?
- Neurological status -central (everything and below) vs. nerve root (that level only) vs. peripheral (doesn't follow an exact dermatomal pattern) - L3, L4 (sometimes L2) for contributions of pain *assess don't assume, horses before zebras*
PFPS: - What does evidence NOT support for treating PFPS?
- No evidence to support 1. ultrasound 2. lumbar manipulation (theorized that weakness was coming from L3-L4 root, but its not contributor in patellofemoral pain syndrome) 3. NMES 4. Dry Needling
Hip Tx: Neuroms training - What do pts w/labral tears present with clinically? Which neuroms training technique should be used?
- Pts w/labral tears= present with worse balance in the affected leg compared to unaffected leg *Recommend proprioception balance testing as a noninvasive means to assess for hip labral tears* *Due to the proprioceptive capabilities of the acetabular labrum, it has been suggested that neuromuscular re-education may play a beneficial role in dynamic stabilization of the hip* -proprio training/dynamic stabilization = beneficial
Knee OA - What are common pt complaints? - Where is the location most commonly? What does this cause? Why?
- Stiff, then loosens up, then stiff/painful - Mechanical symptoms - Most common in medial compartment - varus deformity d/t shortening on medial side - No cure *load doesn't necessarily mean development of OA--evidence doesn't show that* -varus deformity and medial lesion, they know if they repair it, it wont do well...will cut tibia and restructure it in valgus position so GRF is lessened (high tibial osteotomy)
Special tests: Lateral ligament tests of the ankle -Anterior Drawer - Which ligament does this test? - What is a positive test? - What is the open-packed position of the TCJ? - What to do if someone has tight gastroc's?
- Tests ATFL integrity (Inversion sprain) 1. TCJ in open packed position (10 dg PF) 2. Stabilize Tib Fib distal to malleoli 3. Apply anterior glide to the calcaneus NOT DF Positive test: Pain at ATFL, laxity compared to opposite side -pt with tight gastroc, flex the knee or get bolster
Special tests: Navicular Drop - What does this test? - What is considered normal?
- Tests midtarsal pronation - Mark the naviculum in NWB Measure the drop of the naviculum in WB using an index card 1. Normal = 5-9mm drop 2. Excessive pronation > 10 mm drop 3. Supinated foot < 4 mm drop
Patellofemoral pain syndrome - What does this describe? - What are the 2 parts of this complex issue?
- broad term = ie. subacromial pain Complex issue: 1. Proximal biomechanics - Hip add, IR, pelvic drop - Hip weakness/tightness 2. Distal biomechanics - foot pronation, tibial IR -source of pain may involve multiple structures & highly controversial
Lateral hip pain - Greater trochanteric bursitis/gluteal tendinopathy-- How to distinguish between the 2? Peak incidence age? What conditions are these common with? How can a bursa become inflammed? - Bursa vs. tendon: How do you differentially Dx? When is pain felt more?
- bursa & tendon pathologies Greater trochanteric bursitis/gluteal tendinopathy (cannot distinguish between the two....) Peak incidence 40-60yo Common in arthritic conditions, fibromyalgia, LLD, females> males Bursa can become inflamed via friction, trauma *Bursa vs tendon?* Diff dx: Passive motion, stretching, compression - bursa Active motion, muscle activation - tendon Palpation?? Bursa = stretch ms over bursa and passively move pt through motion & reproduces their pain... Tendon: active motion and reproduces pain (contractile)
SIJ special tests: - FABER/Patrick - What constitutes a positive test?
- can provoke pain for SIJ or hip *non-specific* + = pain provocation...need to ask for pain where??? if in hip, + for that joint
Labral tears - What are the 2 types of tears? - Where is the most common site of injury?
- commonly in superior region--increased mechanical demand 1. vertical, traumatic -more common posterior 2. Horizontal, degenerative - detachment of labrum from articular cartilage at transition zone
Management of the stiff knee: Restoring knee flexion - How is this comparable to knee ext? - What commonly happens w/jt mobility?
- easier to restore than extension same principles of knee extension for warm up & jt mobilization Common to improve joint mobility and then muscle length becomes the biggest limiter of motion, then back to joint, then back to soft tissue..... *always be reassessing*
Tib-Fem joint: Distraction
- grab proximal at malleoi and provide distraction force
Hip Pain: OA w/ mobility deficits (intra-articular) - Where can the pain be? - Location of pain - Quality - Intensity
- hip jt proper (femoroacetabular articulation or Coxa femoral joint) - OA of the hip - 55+ yo, insidious onset common, but minor/major trauma can contribute - exception = major accidents (mtn biking, skiing early in life) Location: pain can vary in site & nature: buttock, groin, thigh, knee Quality: dull ache to sharp, stabbing, *C-sign accompanied by 3D limit & capsular pattern* Intensity: pain related to activity, can last several hours post activity...relieved by rest
Assessing movements - How should we test a runner with patellofemoral pain?
- just bc we have functional tests to provoke pain & why that's occurring....need to do the activity that is reproducing his pain (ie. runner with patellofemoral pain should put them on a treadmill for 20 minutes)
Screening algorithm for the knee
1. Are they apprpriate for PPT? 2. Is it a knee problem? 3. Classify as loose, stiff or painful knee 4. Tissue irritability isn't as prevalent as the shoulder.... so Intra or extra articular problem
Patellar instability: Surgical Management - What is the surgery of choice?
- lots of surgeries = none of them work well 1. MPFL reconstruction- surgery of choice, better outcomes but still not great 2. Lateral release (on its way out)--cut lateral retinaculum to keep patella from being pulled laterally 3. Trochlear Chondroplasty 4. Proximal-Distal realignment -advance VMO to patella - medialize tibial tubercle (correct Q angle)
Subjective exam: Suggesting Hip Jt Dysfunction - What PMHx may clue you into labral tear? Which sex is more common? - What may anterior hip/groin pain indicate? - What Sx are associated with hip jt dysfunction?
- mechanism (or not) of injury -PMH of hip dysplasia--may predispose person to labral tear -Sx of people w/labral tears: more common in females than males - anterior hip/groin pain--CFJ or anterior labral tear -*mechanical symptoms of clicking, locking or catching, giving way (clicking most consistent clinical Sx)*
Developmental Dysplasia of hip (DDH) - What are the 4 degrees of severity? Does this follow a capsular pattern?
- non-capsular pattern
Hip capsular pattern - Why is it not clear? - What is the pattern?
- not clear bc a lot of guarding that can occur w/hip jt limitations *capsular pattern: flexion > IR > ABD* -what is reliable is some sort of 3D limitation to indicate intra-articular problem (OA)
Recognition of DVT - Why is it an emergency? - When Sx would elicit strong suspicion of a DVT?
- old test = Homan's--DF the ankle - DVT = emergency...can go into lungs and present as pulmonary embolism - Refer for doppler ultrasound - Well's clinical prediction rule (CPR): 1. Bedridden for >3 days 2. Swollen leg compared to asymp. leg 3. Tenderness of deep venous Sx (tenderness along popliteal fossa, center of posterior calf & anterior thigh/groin) 4. Active cancer 5. Pitting edema 6. Paralysis/paresis/immobilization of LE
Special tests: Patellofemoral - Which way will it dislocate? Which tests is used for apprehension? What ligament does this test?
- really just accessory motion testing Laxity - MPFL (apprehension), will be lateral dislocation, will NOT reproduce pain - Med/Lat tilt - IR/ER - A/P Tilt Pain -lateral step down: can measure angle when they develop pain or reps and where the location of pain was
Mats fav study - What's the most painful part of the knee? Least painful?
- retro patellar surface = no pain *cartilagenous structures = no pain, most painful = infra-patellar fat pad & jt capsule*
ACL treatment
- selective ms response to perturbation - have to percieve the motion and activate muscles *Trying to reduce co-contraction & increase NMS control* RTS = return to sport - doesn't appear to last after they have had surgery....mat's paper didn't show any effects with this after ACL surgery
Hip Tx: Cardiorespiratory training - What activities can mitigate pain with labral tears?
- swimming, cycling (can be irritating for hip/labral tears bc bony alignment), elliptical
Lateral ankle pain: Inversion sprain 4. Late Remodeling Phase - Time frame - How can we test improvements?
-- 3-6 weeks -Sensorimotor training, return to activity/sport *Intensive strengthening of peroneals to create greater passive stiffness through hypertrophy (minimum 6 months)* Jogging, jumping, hopping Star excursion or Y-balance tests - effective in training and for dynamic assessment of lower extremity function *helps ID pt's limitations* Can wear protective device for up to one year
Postural screen - How do test for anteversion? What are the norms for this?
-Want to know if there is an retroversion/anteversion -coxa valga & vara -palpate for most lateral point of greater trochanter while rotating the hip & then measures Normal anteversion = 15 dg Excessive anteversion = > 15 dg Retroversion = 5 dg...presents as out-toeing -presents as in-toeing if excessive
Special tests: Laxity - Varus 0/30 - What is this assessing for? - Why do you close before you open? - What is a positive test? - What are the 3 different grades?
-assessing for end-feel of ligament (should snap like tugging on a string that's tied to something) -if ligamentous disruption, knee might not be in proper resting position (ie. ACL, tibia could be more forward on...this is why you close before you open) - C-cup grip on distal leg *palpate lateral side, watch for hip rotation* - 0 tests integrity of the whole joint - 30 tests LCL *Provide valgus THEN varus force (close before opening* • Positive: No or Spongey endpoint Grade I - Normal endpoint, No laxity, painful Grade II- Normal/spongey endpoint, increased laxity, painful Grade III- No endpoint, increased laxity +/- pain
Tx of LCPS - Group 1: What should you do? - Group 2: Less than 7 yo, greater than 7yo - Group 3+4 = less than 4 yo, greater than 7 yo
-beyond 7yo, surgery emminent
Hip strengthening: Theraband 4-way - What is the benefit with using these?
-can be used for NWB -bent knee fall out
Hip pain - What 2 divisions is it classified into?
1. Arthritic pain 2. Non-arthritic pain: intra-articular, extra-articular
Special tests of the Foot & Ankle: Ligaments (laxity) - Lateral & Medial ligament tests - What will an unstable ankle to medially?
1. Lateral ligament tests - Anterior drawer - Medial talar tilt (inversion stress--ATFL & CFL) 2. Medial ligament tests - Lateral talar tilt (eversion stress) - i.e. unstable ankle will invert & over correct into excessive eversion
Extra-articular hip problems: anteror hip pain 1. Adductor ms strain: Most commonly caused by which movements? Which sports particularly? Risk factors? S/Sx? Where the range can specific ms be located for causing pain? 2. Osteitis pubic/pubic symphysitis
-common 1. Adductor ms strain - most frequent cause of muscular induced groin pain - caused by fatigue or abduction overload during running, jumping, twisting activities, combined with ER of the leg, common in soccer and hockey players (strong eccentric adductor ms contraction during these sports) Risk factors- imbalance in ms strength and length between ab and adductors.... Signs/symptoms- pain with palpation of adductor tendons and or insertion site, Pain in groin with quick start/stopping motion Swelling *Pain with passive abduction or resistance to adduction (0 degrees gracilis, 45 degrees adductor longus and brevis, 90 degrees pectineus)* 2. Osteitis pubis/Pubic symphysitis
Posterolateral & posteromedial corner - What does this help contribute to at the knee?
-contribute to rotational stability at the knee left = posterolateral semimembranosus attaches to MCL
SIJ Special tests: - SIJ compression - What direction is the load you're applying? - Supplemental material to use? - What is a positive test?
-dorsolateral load through both ilia (posterior aspect) -pillow under legs to un-weight lumbar spine -pad ASIS's with towels bc can be sensitive/ticklish -crossing arms bc want pressure dorsolateral - Want to hold for a couple of minutes + = pain provocation
PFPS -taping & bracing
-effective at reducing pain to work on strengthening -does change alignment or contact area -no long term benefits
Special test: Tinnel - What is a positive test?
-for tarsal tunnel on medial side.... roof is flexor retinaculum.... posterior tibial nerve, vein, artery and flexor digitorum tendon and posterior tib tendon -pain + paresthesia = positive test
Hip mobility vs. stability - What do hip mobility limitations often lead to? - What is the priority of the GHJ? How is stability provided? - What is the priority of the CFJ? How is stability provided?
-hip mobility limitations often lead to increased lumbar movement -comparisons between the GHJ & CFJ 1. GHJ priority = mobility -stability provided neuroms system 2. CFJ priority = stability - stability provided by bony architecture, capsuloligamentous structures, NS
Objective measures: Accessory motion - What is a measure and what is a Sx? - What is important to tie back to accessory motion testing? Give an example.
-laxity is a measure -instability is a Sx -dont forget patella - Do accessory motion findings correlate with ROM? If you find stiffness, it must be correlated with ROM (if don't have ROM loss, dont need to treat the stiffness) ie. superior glide to improve knee ext -can do mobilization if can't find out where contracture is coming from and then re-measure ROM
Knee anatomy - What are the 2 joints? - Congruency? - Compartments
-little bony congruency -tibiofemoral jt & patellofemoral jt -proximal tibulofibular jt tends to affect ankle than the knee compartmentalized--medial, lateral & anterior
Hip Tx--Stretching: Intra-articular pain - Which pt's won't benefit from stretching?
-patient who display a limited ROM w/a hard bony end feel may not benefit from stretching, particularly if stretching aggravates the pt's pain*
Anterior rotation of ilium on sacrum - What motion is this facilitating on the sacrum? - What is a positive test?
-pull top of iliac crest toward you -pushing up with sacrum with hand -flexion of bottom leg postive test = pain *force couple with hands*
Hip pain: Intra-articular - mobility deficit 2 - Where in the range is pain usually felt? - What is common after inactivity? - How is OA confirmed? What indicates a substantial loss of cartilage? - What are 2 predictors for OA? - What does the evidence show to delay/prevent OA?
-stiffness after inactivity common -impaired function/ADL's -*loss of IR, abduction and/or flexion (capsular pattern), + pain at end range* -confirmed by radiograph (jt space of 2.5mm or less indicates substantial loss of cartilage, osteophytes, sclerosis)...radiograph severity may not match clinical findings -OA development predictor = BMI & genetics -we can't predict progression of OA, address the deficits, evidence shows *strengthening*, can delay or fully prevent OA
Hip Tx--Conservative management - What are the 4 stages of Tx of intra-articular lesions (i.e. labral tear, chondral lesions, loose bodies, FAI)?
1. Acute - joint/tissue protection *Weight bearing restrictions* - Reducing levels of physical activity and restricting athletics - Avoid passive movements of the hip that reproduce pain or exacerbate symptoms 2. Restore ROM and proximal strength and NM control 3, *Restore full strength proximal--> distal* -runners & cyclists = strong arms & legs but usually weak glutes and core 4. Restore full tissue capacity--> return to activities/participation/sport
Exam/Medical referred pain screening - Intugementary? - Spine: What clinical presentation should tell you pain isn't coming from posterior knee? - Hip--Where does pain commonly refer to? - Vascular? - Systemic? What is the clinical presentation
1. Bone/soft tissue tumors 2. Spine - anterior knee pain vs. L3 dermatomal pattern - posterior knee pain vs. neural tension/sciatica (ie...no MOI, insidious onset and pain with activity= not posterior knee) 3. Hip - commonly refers to medial thigh/knee (SCFE) 4. Vascular - DVT post knee surgery 5. Systemic - Lyme's (insidious onset of pain & swelling w/o MOI...shouldn't have pain & swelling without MOI) - RA and other inflammatory disorders
1. Chondral lesions--what is it? Which population is this most likely to be expressed? Most common MOI? How is it confirmed? 2. Loose bodies--What can this contribute to?
1. Chondral lesions : Little is known about the prevalence of isolated chondral lesion *focal loss of cartilage on the articular surfaces*, rare - Hip pain in younger, more active individuals *Traumatic injury pattern involving acute overloading through impact sustained by a blow to the greater trochanteric region has been described* - Confirmed by arthroscopic findings 2. Loose bodies - small fragments of bone or cartilage within the joint can disrupt joint function and contribute to hip pain -can give way in the LE
Special tests: Ligaments (laxity) - Which structure is varus testing for? - What dg are the ACL/PCL on slack?
1. Collaterals • Varus 0/30 ---testing LCL - 30 dg = ACL, PCL on slack & jt capsule on slack....mostly testing LCL or MCL - 0 dg = testing everything & if laxity here then know that it's a big problem bc may have vascular injuries 2. Valgus 0/30 w/ER - can measure posteromedial corner *if testing at 0 dg, testing everything (close packed position of tibofemoral jt)* 2. Cruciates • Lachman (gold standard, pure ACL) • Anterior Drawer: pure ACL, (limited in # of false negatives, can be firing hams) • Pivot Shift (ACL + rotation) • Posterior Drawer (PCL) • Dial Test (PCL & posterolateral corner difference)
Generally can't go wrong with these 3 things...
1. Education 2. Exercise 3. Weight loss
Avascular necrosis.... - What are the 4 types?
1. Emboli 2. Osteopenia w/microfractures 3. Multifactorial 4. Idiopathic
Special tests: Syndesmosis - What is a high ankle sprain?
1. External rotation stress (Kleiger) test 2. Squeeze test (medial + lateral squeeze on proximal tib-fib) 3. Palpation (Point) test 4. Forced DF: i.e. high ankle sprain....above TCJ. Mtn bikers, hikers....
Inversion sprain- Associated injuries - Extra-articular vs. intra-articular: What are examples of each?
1. Extra-articular - Avulsion- fibula, lateral talar process, posterior talar process or os trigonum, base of 5th met, anterior calcaneal process 2. Intra-articular: - Osteochondral lesions of the talar dome (accessory bone in back of ankle) - Distal tibial loose bodies - Synovitis of the tibiotalar, talocrural and midtarsal joints
Knee OA TX - What 2 exercises need to be focused on? - Which type of exercises require the most (to the least) amount of force on the knee? - How much weight loss = 30 lbs reduction in JRF?
1. Hammer the quads 2. Promote strength/movement with less "pounding" -walking 2-3x BW - elliptical = 75% BW - bike = 50% BW -aquatics -weight loss: 10 lbs gets you 30 lb reduction
READ THE CPG's - What are common non-arthritic intra-articular structure defects? - What is structural instability? - What are common non-arthritic extra-articular structure defects?
1. Hip pain with mobility deficits - OA 2. Generalized hip pain - Non-arthritic hip pain- intra-articular structures 1. FAI 2. Labral tears 3. Chondral lesions 4. Ligamentous teres tears 5. Structural instability- excess motion that causes pain, with or without symptoms of hip joint unsteadiness (acetabular dysplasia, excessive femoral anteversion) Non-arthritic hip pain- extra-articular structures 1. Gluteal bursitis 2. Gluteal tendinopathy 3. Nerve entrapments - piriformis syndrome, hamstring syndrome 4. Snapping hip (psoas, ITB)
Plantar Fasciitis - Common objective findings
1. History of pain and tenderness on the plantar medial aspect of the heel 2. Worse during initial weight bearing in the morning 3. Can have a throbbing or burning quality 4. Often unilateral 5. + short Achilles 6. + pain with stretch of PF- evert calcaneus and dorsiflex great toe
Less common anterior hip problems: 1. Iliopsoas tendopathy = Which tests are provocative? 2. Stress fractures = Which sites are more prone to fracture? 3. Rectus femoris tendopathy = Which tests are provocative? 4. Rectus abdominis ms strain = Which tests are provocative? What is this a result of? What to beware of in this situation? 5. Sports Hernia = When does this happen? When does the pain occur? Where does it typically radiate to?
1. Iliopsoas tendopathy - *groin pain w/resisted hip flexion and resisted ER, but no pain with resisted hip adduction)*; pain distal to inguinal ligament, and medial to sartorius 2. Stress fracture (neck of femur, pubic ramus) 3. Rectus femoris tendopathy - *most painful groin pain with resisted knee extension in neutral hip position in prone, resisted hip flexion w/mild to mod. pain)*; pain at ASIS, or just distal, c/o groin pain with sprinting or lifting the knee, -Inguinal hernia 4. Rectus abdominus ms strain- occurs with strong contraction, moved from short to lengthened position, usually resulting from inadequate ab strength or technique during sports; r/o internal organ pathology (MD), can lead to hernia.... 5. Sports hernia- weakening of ms or tendons of lower abdominal wall, no palpable hernia, pain during sports, twisting during single leg stance, pain radiates to adductor region, difficult for pt to pinpoint, increased intra-abdominal pressure increases pain
Clinical Reasoning - What are the 2 main questions to ask when interpreting objective measures at the foot & ankle? - If the most painful test were the following where would this indicate the problem area is: Resisted, stretch, tension/compression, compression?
1. Is there a limit of motion? 2. CP vs. NCP What is the most painful test? 1. Resisted - Muscle, tendon 2. Stretch - Tenosynovium 3. Tension and/or compression - Nerve 4. Compression - Bursa
Lateral hip pain: less common - Lateral cutaneous nerve to thigh entrapment: AKA? - What is the clinical presentation? Sx? When are Sx the worst? - What is the Tx?
1. Lateral cutaneous nerve to the thigh entrapment (meralgia parasthetica); sensory changes in lateral thigh and lateral knee, local and referred pain, can produce debilitating symptoms when severe - Sx: *burning, people who work with heavy belt around their waist, overweight* Pts c/o burning, coldness, lightning type pain, deep ms ache, tingling, anesthesia. May have local hair loss Symptoms worse when hip is extended (prone lying or standing), sitting may relieve or exacerbate... Conservative rx- analgesics, NSAIDS, wt loss
Hip arthroscopy: Phase 1 - Joint protection - How long does this phase last? - What happens with effusion in the joint space?
1. Limited weight bearing, limited ROM 2. Diminish pain 3. Prevent muscle inhibition: when inflammation & jt effusion present, ms inhibition (can't do quad set if post knee surgery & swollen) 4. Protect repaired tissues 5. Generally weeks 1-4, in some cases 1-6
Hip: Phases of gait - Loading Response: - Midstance: what ms is working to control hip extension? -Propulsion: What combination of movement does this consist of?
1. Loading response - heel strike -eccentric activity -gravitational forces 2. Midstance - moving towards extension - concentric adductor magnus to contrl hip extension 3. Propulsion *extension, adduction, IR* -basic clinical exam may be negative for pain provocation---may need provocative activity prior to exam
CAUTIONS - What can the MCL/LCL present as?
1. MCL & LCL can be intra-articular or extra-articular depending on if superficial or deep fibers are involved - if deep, wont see anything superficial but will see effusion 2. *No effusion in jt if capsule is torn* 3. Save the tests you expect to be positive for the end of the exam, you will likely muck up everything you do after 4. Never rely on a single test is possible
Important subjective info: MOI - What does a pop usually indicate? - Swelling: 0-2 hrs you should be thinking about which structures.... 12-24 hrs? - Instability: Pseduo vs. Giving way?
1. MOI 2. Pop? plus pain + swelling = ligamentous until proven otherwise 3. Swelling? - 0-2 hrs...thinking about bleeding....fracture/dislocation, ACL, PCL - 12-24 hrs...thinking cartilage (less blood supply) ie. meniscus, articular cartilage 4. Instability? Giving way episodes - Pseudo-buckling--ie. wobbling, related to weakness, quads - Giving way = feel shift in knee where tibia slides forward, accompanied by a fall & increased swelling
Special tests: Cartilage - What is the cluster for meniscus testing? - What Sx may indicate intra-articular cartilage damage?
1. Meniscus: all 3 can be cluster of test - Medial jt line (the best of the 3) - Thessaly - McMurray 2. Articular - Mechanical Sx: when lesion of intra-articular cartilage & engages in jt, can get locking, abnormal end feel
Meniscus injuries: Repair - Limitations for non-op or excision? - What are the surgical precautions post-surg? - Outcomes?
1. No major limitations for non-op or excision (patient tolerance) 2. *Limited WB for 4-6 wks, limit loaded deep flexion depending on repair location* 3. Outcomes: Meniscal injury associated with future OA...redistribution of forces around the knee jt, will change loading pattern
SIJ/pelvic ring stabilization - Explain how stabilization is achieved at the SIJ. - Which muscles are active during weight bearing? - Explain hydraulic amplification.
1. Oblique course between gluteus maximus, TLF and Lat dorsi...all fibers perpendicular to SIJ orientation 2. On landing (WB), ipsilateral glut max fires with contralateral lat dorsi resulting in dynamic stabilization 3. Hydraulic amplification = contraction of erector spinae/multifidus dilate posterior layer of TLF 4.Increased intra-abdominal pressure further stabilizes the spine *co contraction of lat dorsi with contralateral glut max....transverse abdominis, erector spinae, multifidus recruitment*
Accessory motions: Hip joint distraction (caudal glide) - What is the open packed position of the hip? - What conditions would you use this accessory motion testing for
1. Open-packed position = 30˚ flexion, 30˚ ABD, and slight ER 2. Place belt below ASIS, but above greater trochanter....can also put belt around ankle (make sure it's above malleoli) to really use body weight (around hips NOT back) 3. allow a few minutes to relax ie. use for hip OA, stiff hip conditions for pain relief -intra-articular problem = 3D limitation (not specific) *Make sure to test the other side to determine if its hyper or hypomobile or normal*
Objective measures: ROM - If you do PROM in prone, what info is this telling you? - What is the most important motion to gain after surgery/injury? - If ACL re-injury is a worry, what would you want to be most careful with?
1. PROM in supine, sometimes prone (can give you info about quad limiting motion, functionally can sit on the ground a lot) - towel under heel for ext *knee ext is most important thing to get back after surgery or injury...dont want to get 0, want to get what the other side is at* - if ACL re-injury is a worry, then would want to be careful about ROM for knee ext 2. AROM supine, sometimes seated 3. Relationship of active vs. passive vs. pain vs. end feel 4. Capsular pattern: intra-articular vs. extra-articular 5. Context matters in ROM (ie. knee flexion) - Athlete/runner: a few dg loss of ROM can have substantial impact - Basic ADL's: a few dg of loss of ROM unlikely
Craig's test - What is this used to measure? Where are the measuring points? What are the norms? - What will this information guide you to try to answer during the clinical exam?
1. Palpate greater trochanter & feel for greater trochanter to be in most lateral position 2. Measure angle between tibial shaft and most vertical position w/goni Normal anteversion = 10-15 degrees Excessive anteversion = >15 degrees Retroversion = <10 degrees -can be difference in flexion & extension... bc of the way it's seated in acetabulum -measuring bc you want to inform if it's truly coming from bone...if so, we can't treat... if ms, then we can
Special test for PFPS: - Lateral step down test - What are you looking for?
1. Perform lateral step down 2. Assess pain: # of reps or degree of knee flexion 3. Perform taping technique 4. Repeat step down to see if pain reduces - interpretation...if taping reduced pain use taping as an adjunct
Posterior hip pain: Less common 1. Piriformis syndrome: When is pain felt? When is it decreased? What is the clinical presentation? Which special tests can you use to confirm? Which ms are typically weak? 2. Hamstring syndrome: Where does it get entangled? Which population is it seen in frequently? Where is the pain localized to? When is pain increased? Which position is painfree?
1. Piriformis syndrome : radiating sciatic pain in buttock when walking, sitting decreases pain, SLR/slump usually positive, decreased ROM and + pain with hip adduction and IR, + FABER, FAIR test, weak glute med, max, biceps femoris, LLD short leg... 2. Hamstring syndrome: sciatic nerve entrapment via fibrous band from biceps femoris at the ischial tub. Seen frequently in active people, runners - Pain localized to IT, increased pain w/sitting, resisted end range knee flexion w/hip flex to 90 degrees, (90/90 position).... *resisted knee flex w/hip extended is painfree*
Post-traumatic Knee OA - What happens to the knee after an ACL tear? - Which population of individuals are prone to OA? - If load = tissue repair, then what would be true?
1. Shifts contact points in the knee after ACL tear 2. Cartilage that isn't used to this load is now getting loaded--> lead to OA 3. Association of recreational running & competitive running with hip & knee OA--runners dont tend to get higher rates of OA than more sedentary people 4. If it was all about loading, people who are doing running should have more OA than sedentary people which isnt the case
Hip arthroscopy: Phase 1 - Joint protection - Which 3 modalities to use?
1. Specific ROM restrictions: lateral approach is 90 dg flexion, 30 dg abduction, 0 dg extension 2. Manual therapy (soft tissue mob) & PROM 3. Isometric: to load, ms inhibition *respect principles of management at stage, can be as creative as you want to*
Examination of the Foot - Medical/referred pain screening - Spine: Which roots can contribute pain to the foot? - Vascular: What to be concerned about? - Systemic diseases?
1. Spine- any radicular symptoms don't have to follow the entire dermatome - L4-5 dermatome/myotome -heel pain 2. Vascular - DVT 3. Systemic - Ankylosing spondylitis, Reiter's syndrome (reactive arthritis)
Foot & Ankle Pathology - Staged approach for ankle disorders: What are the 3 stages? - What are the capsular patterns for the subtalar and talocrural joint?
1. Stiff ankle - post trauma or post immobilization, CP vs NCP (TCJ, STJ, MTJ, 1st MTP) 2. Loose ankle - Ankle instability, post inversion sprain - Giving way and then pain 3. Painful ankle - tendinopathy, synovitis (macro or micro trauma), loose body (pain & then gives way), Achilles pain, Heel pain Capsular Pattern Subtalar = inversion > eversion Talocrural jt = PF > DF
Patellofemoral pain syndrome: Treatment - Strengthening: OKC v. CKC - What should be guiding treatment? - What other impairments might increase PFPS?
1. Strengthening of hips & quads = 44-90% decrease in pain - Quads: Progress motion and resistance - Open chain: start at 90 work towards 10 - Closed chain: start at 10 work towards 90 (increasing moment arm) - Hip abductors reduced pain, but doesn't change kinematics *Irritability guides treatment:* • 5/10 pain and below - Pain during exercise = ok, but dont want ppl to have Sx throughout the day (ie back off Tx plan) -higher load training had greater reduction of Sx Determine if flexibility or coordination impairments are present and use critical thinking to judge whether they are contributory or not • DF ROM • Pronation • Manage load (running injuries)
How to measure quad strength: - What is the best way? Good? - False positives: How does this change your Tx method? - If ACL injury, how should you test?
1. best = dyno 2. good = compare 1RM side to side - *Done in 60-90 dg knee flex...for ACL re-construction, try to avoid 0-45 bc range = most strain* 3. leg press = false positive bc can cheat - if know that gives high false positives, then overestimate the improvement in strength
Knee: Subjective exam - MOI - Impairment - Pain: LQDIP--What is anterior knee pain usually associated with? Pain at the joint line indicates? Posterior knee? Explain a Baker's cyst. What is the main difference between quality of pain between intra-articular vs. extra? - What does jt effusion indicate?
1. chief complaint/MOI 2. impairment/function/disability 3. pain LQDIP - location: anterior knee pain = usually tendinopathy (not intra-articular), joint lines = intra-articular, posterior knee pain can be both intra & extra articular (Baker's cyst = secondary problem...swelling from the jt) - quality--intra articular = achy where anterior knee pain = sharp - duration - intensity/irritability - pain hx -P1, P2, P3.... - effusion (ie. swelling in the joint capsule) vs. edema (extra-articular)? helpful for differential Dx...if have acute injury, how long did it take for swelling to occur? - aggrevating factors, alleviating factors -patient goals
Hip presentation - Referred pain: Which is easier to locate? What are the challenges with determining where the pain comes from? - What is the function of the hip in weight bearing? Which phases of gait? - What is the hip???
1. referred pain: proximal, deep vs distal, superficial - point to me where you have pain (communicate clearly with pt) -challenges = convergence, innervation density (i.e. more proximal & deep = lots of convergence on dorsal horn) -overlapping dermatomes -children: thigh & knee pain 2. function in wt bearing - loading response -midstance -propulsion -what is the hip? L-spine, SIJ, CFJ, thigh, buttocks
Pelvic ring stabilization: SIJ belt - Where should the belt be applied? - What should you do if pain is felt with the belt on? - When should the belt be worn? - When is wearing this belt indicated?
Apply the belt in supine or sitting just above greater trochanters *Belt needs to be tight* If pain provoked with belt, try mobilization/manipulation 1st Wear: - During pain provoking activities (some sources: 23hrs/day, up to six months) for pelvic ring stabilization exercises during early phases of rehabilitation *Indicated if 1. ASLR test is positive 2. Reciprocal leg activities or pelvic torsion activities provoke pelvic ring pain*
Acute Intra-articular pathology: Arthogenic inhibition - Why does this happen? - Explain the graphs.
Arthrogenic inhibition: trying to contract both quads but can only contract one...we need to wake this ms up as quickly as possible to restore neuroms control -quads become inhibited can affect both sides *Mechanism unclear but may be due to a change in the jt receptors * i.e., has been recreated with saline injection...but it doesn't happen to the other side graphs: top = normal quad looks like this -volitionally can use 95% of what the ms true power is, so can do MVIC and then add 120 V stim to see what's left to activate - both graph= increase towards the end is the inhibition of the power left in the ms
Through the lifespan: AVN - Legg-Calve-Perthes Ds: Who does it effect? How does this present clinically? - DDH - SCFE: What is it? More common in which population? How does this present clinically?
Avascular necrosis femoral head - seen in children and adults *Legg-Calve-Perthes Disease - in children 3-10yo child presents w/ groin, ant. thigh or knee pain, and antalgic gait* - Developmental dysplasia of the hip (DDH) *Slipped capital femoral epiphysis: femoral head slides off femoral neck, more common in adolescent boys 13-15yo, associated with young men who are overweight and underdeveloped, c/o significant groin pain, valgus at the knee*
Tx of non-arthritic hip pain - What activities should be avoided?
Avoid activities that consistently place the hip joint in positions that create the impingement effect 1. end-range flexion, internal rotation, and in some cases abduction 2. Activity modification: sleeping, sitting work and fitness activities need to be assessed. May need higher seat during work or cycling (hips higher than knees to avoid excessive hip flexion) 3. Manual therapy and stretching to increase ROM (avoiding end range irritating positions***) 4. Strengthening 5. Neuromuscular reeducation
Accessory motion: STJ - Lateral glide - What motion does this facilitate?
Can also be performed in side lying - Restricted = loss of inversion
Posterior ankle/foot pain: Achilles tendinopathy - Location of pain? - What is the dominant pain? When is it the worse? - What will happen in the morning? - Which population is this common in? - What are common clinical findings?
Can be insertional (at tendon bone interface) or non insertional (proximal to the tendon insertion on the calcaneus) *Dominant pain = At posterior aspect of the heel, exacerbated by activity* May have swelling and stiffness (morning) Common in runners *Often pronated feet, + pain with palpation, gastroc tightness (or excessive length), STJ ROM +/-,pain with RI, decreased posterior tib strength*
Post Inversion General Management Suggestions - What is important to not do? - Bracing vs. surgery: When are they appropriate?
Careful functional diagnosis of possible complications after inversion trauma followed by appropriate Rx Neuromuscular training, peroneal hypertrophy *Do NOT overtrain!* *Fatigue, exhaustion leads to decreased proprioceptive mechanisms* Brace for functional instability Surgery of mechanical instability
Posterior Ankle/Foot Pain - PTTCS - Clinical findings? - Management?
Clinical findings: 1. Hx of plantarflexion trauma or chronic forced plantarflexion in people with os trigonum or abnormally long lateral tubercle 2. Pain with passive plantarflexion 3. Passive DF can also be painful d/t stretch on irritated posterior capsule and fat pad Management: restrict PF via brace or tape, local injection, occasionally surgery is indicated *diff than capsular pattern....pain will be more globally in TCJ*
Inversion sprain- Associated injuries - Sinus Tarsi Syndrome - What are clinical findings? - What do pts with this feel like? - Non-invasive & invasive Tx
Clinical findings: *anterolateral activity-related pain, prolonged peroneal reflex time d/t gamma motor neuron suppression8 *Consequence - "feeling of instability" though joints found to be stable* Management: Sensorimotor reactivation Invasive anesthetic management - Injection - RFTC (radiofrequency thermocoagulation) or RFA (radiofrequency nerve ablation) of the lateral terminal branch of the deep peroneal nerve
Posterior hip pain - Where is pain commonly referred from? - Hamstring ms strain: Where is it most commonly strained? Contributing factors to injury? - Hamstring tendinopathy microtrauma--When is pain felt? - Ischial bursitis: AKA? Which population is more prone to this?
Common - referred pain from L-spine, SIJ 1. Hamstring ms strain- most commonly strained ms of the hip (biceps femoris) usually during eccentric phase of ms use Contributing factors- prior ham injury (loss of extensibility and eccentric strength), DDD of L- spine; anterior pelvic tilt, LLD (shorter leg tighter hams); ms imbalances, decreased flexibility, fatigue 2. Hamstring tendinopathy microtrauma = + pain w/resisted knee flexion with hip in the flexed or extended position 3. Ischial bursitis- "Weaver's Bottom"- chronic compression or direct trauma, thinner individual, females> males, cyclists
Inversion sprain: Associated injuries - Cuboid syndrome: What common causes this problem? - Contributing factors?
Common but poorly recognized Calcaneal cuboid joint is usually very mobile but can be repetitively subluxed and become locked or hypomobile Mechanisms unclear - cuboid is thought to evert while the calcaneus is inverted Contributing factors: overuse, weight gain, training on uneven surfaces, pes planus, lateral ankle sprain
1st MTP - Distraction, Dorsal & Plantar - What do the dorsal & plantar glides facilitate?
Concave proximal phalanx moving on convex MT head Loss of dorsal glide associated with extension loss. Loss of plantar glide associated with flexion loss
Hip arthroscopy - What are the four phases of repair/treatment?
Considerable variability around the country (weight bearing, bracing, etc) Four phases: 1. Joint protection 2. Return to full weight bearing 3. Return to pre-injury function 4. Return to running and sport
Accessory motion: TCJ - Anterior glide: Which motion does this facilitate?
Convex talus moving under the concave tibia and fibula Restricted = loss of PF Stabilize tib/fib and right on talus....adjust so in 10 dg PF!! MAKE SURE in open packed position
SIJ/pelvic ring stabilization - What are the 4 educational recommendations?
Education recommendations: 1. Avoid static posture > 30 minutes 2. Avoid sitting on affected buttock 3. Avoid sitting with legs crossed 4. Avoid unipodal standing
Joint mobilizations of Hip Tx: 2. Supine caudal glide of hip joint: Direct technique - What direction is the force? - Why is this method superior to the indirect technique? Why would you want to use this technique over the others?
Direction of force = inferior lateral *directly targetting the hip vs the other distraction* *Would use this technique to provide treatment since will be holding for longer duration*
Transverse tarsal joint--Talonavicular - Plantar glide
Distal concave navicular moving on proximal convex talus Facilitates PF
Alignment of foot - Arch linge/Feiss line: What does it measure? - Tibial torsion: What does this finding inform you of? - Relaxed calcaneal stance: What does this info tell you? - 1st ray position/mobility
Feiss line: measures flat foot to high arch foot Tibial torsion: in adults, might explain what you see posturally involved....ie. if someone is overpronating is it coming from the hip or the knee? - can't manage, structural finding Relaxed calcaneal stance: Valgus/varus alignment of the calcaneus and valgus/varus alignment of the forefoot (over-pronated or over-supinated/high arch foot?)
Posterior tib tenosynovitis - Common clinical findings? - What will the intervention look like?
Findings may include: 1. Short gastroc/soleus complex 2. Weak posterior tibialis (or poor endurance) 3. + pain with resisted PF and inversion 4. Tenderness with palpation along the tendons course 5. May have visible swelling Intervention depends on the cause of the symptoms May include stretching, tendon gliding, strengthening, orthotics, icing, casting
Hip strengthening: Side lying hip abduction +/- hip lateral rotation
Flex lower leg 45° at the hip and 90° at the knee for stability Monitor pelvic rotation Raise upper leg ~30o keeping trunk, pelvis and heels aligned Knee and toes pointing straight ahead (abductors as a group) Knee and toes pointing toward ceiling (hip external rotation) to bias to PGM
Management of the stiff knee: Restoring Knee extension - Sample Tx: What should you address?
Get knee extension back ASAP sample Tx: 1. warm up: to increase tissue extensibility, active warm-up 2. jt mobilizations 3. PROM/stretching 4. functional use Warm up: if active warm-up is not possible then consider..... (i.e. MCL)...*heat & thermal ultrasound*
Ankle Special tests: Thompson's - What does this test for?
Grab the gastroc muscle belly - Eccentric lengthening followed by quick concentric Positive test = if foot DOESNT plantar flexes - If it doesn't, then achilles tendon rupture
MCL injuries: Management 1. Grade 1 2. Grade 2 + 3 = What is the focus here? - Surgery: When is it done? Why is it staged?
Grade I: Brace limiting valgus, *early ROM* (1-2 week out of sport injury, mostly just pain) Grade II + III - Brace limiting valgus - *Limit extension to 30 degrees...more tension through MCL if continue to extend through 30 degrees...hope that it heals in shortened position* - Quadriceps strengthening - Lateral movement last to return - Surgery: Usually only done if not isolated - *Staged: repair MCL ASAP, repair ACL a month or 2 later* - Repair of both MCL and ACL at same time = arthrofibrosis (angry joint that loses ROM--kind of like frozen shoulder)
Sever's disease - Which population is affected? - What do they clinical present with? - What's the treatment?
History: usual age 8-13 yo Short heel cord, tendency toward in-toeing and forefoot varus (pronation) Treatment: Stretching, heel lift, rest from stressful pain provoking activities Return to play criteria: no edema, full painfree ROM, normal strength and normal painfree functional tests - hop, run, cutting Heel lifts Progressive heel cord stretching Calf and foot intrinsic strengthening
Patellofemoral pan syndrome - Flexibility (ITB), patellar tracking, Q-ankle - What are the 2 myths of patellar tracking?
ITB - pulls retinaculum laterally, patellar tracking- can be lateral Mechanics of patella don't change so it doesn't make sense that lateralization is the problem....happens frequently to asymptomatic people *Lateralization of patella= doesn't change from pre to post treatment but pain does* Myth = strengthening of VMO pulls the patella medially - VMO atrophy not more prevalent in PFPS - cant isolate VMO
Accessory motion: TCJ - Distraction - What is the open packed position of TCJ? - What 2 things are you looking for during accessory motion testing?
Loose packed position = 10 dg PF - if slipping down the table, use jt mob belt What are you looking for with accessory motion testing: 1. Hyper/Hypo or normal mobility? 2. Is there any pain?
ITB friction syndrome - Which population is this most common in? - Quality of pain? - When does it develop during exercise? - How will you make your Dx? - What are 4 treatment priorities?
Increased friction of ITB sliding over bony prominences of knee -common in runners -primarily pain, burning -develops during run & progresses..once stop and relax it stops *Hx and palpation will make Dx* Treatment: 1. Reduce inflammation 2. Stretch ITB if possible 3. Consider hip capsule/glut med 4. Load tolerance *Study cut ITB and hip abduction didnt get much better---majority from limitation in motion occurred at hip capsule* ie. foam roller, doesn't create any change to tissue itself but does decrease pain
Hip Tx--Manual therapy: hip spine syndrome - What do intra & extra articular hip problems concurrently exist with? - LBP often presents with which motion limitation? How should we Tx this? Why?
Intra- and extra-articular hip problems existing concurrently with spinal stenosis....Often difficult to differentiate what is symptomatic Patient's with lumbar spine pain often present with hip extension motion limits Treatment: *Mobilize hip extension to off-load the lumbar spine* -LBP pts: screen for sufficient hip extension ROM bc when trailing, will have to get extension from lumbar spine
Anterior Hip Girdle pain -Ankylosing spondylitis: Who does it affect? What happens physiologically? When is the pain? Common Sx? Clinical presentation? What to focus on during Tx?
Intra-abdominal pathology Spondyloarthropathies- 1. Ankylosing spondylitis - affects 1-3/1000 people, males > females, 15-40yo, *human leukocyte antigen (HLA-B27) association* Involvement of ALL, and ossification of intervertebral disk, thoracic facet, costovertebral, manubriosternal jts (check chest expansion!), progressed to whole spine and hips, causing fixed flexed posture Sx: Pts c/o back pain at night, awake with back pain and stiffness, c/o hip pain and stiffness Clinical presentation: Inspection reveals flat lumbar spine, decreased side-bending, *capsular pattern at the hip* Rx: maintain mobility of joints to prevent stiffening- positioning exercises in spine and hip/knee extension, breathing exercises, prone lying 3 times/day, swimming
Surgical management of particular defects - Intra-articular injection: What are the purposes for use of these? - Biologic injections: Give examples of 3. - Chondroplasty: Which type of lesions are these used for? - Microfracture: Which type of lesions are these used for? How does this result in new cartilage? -Fibrin adhesives: What are these used for? How are the results? - ACT: Describe the process? How are the results? - Bone grafting: Which type of lesions are these used for? How are the results?
Intra-articular injection - diagnostic and therapeutic Biologic injections - hyaluronic acid (viscosupplementation), PRP, stem cell Chondroplasty - for partial thickness lesions, debridement Microfracture - for focal full-thickness lesions, new cartilage develops from "super clot" Fibrin adhesives - for arthroscopic repair, initial results promising, small # of reported outcomes Autologous chondrocyte transplantation (ACT) - extract viable chondrocytes, cultured in a lab, re-implant in 2nd surgical procedure, initial results promising Bone grafting - for large full-thickness lesions, requires hip dislocation, results improving, greater morbidity as a result of surgical dislocation and autologous donor site
Hip pain: intra-articular lesion - Labral tears - What are the 3 common MOI? - What is the likely MOI for younger and older adults? - What Sx are most commonly associated w/labral tears? - Where is the most vulnerable part of the labrum? - How will this clinically present?
Labral tear-direct trauma, twisting motions, sports, OR not associated with any known trauma or event... - Acute trauma or insidious onset (74% not associated with any specific event).... 1. Young person with twisting injury (forceful rotation while hip is in hyper extended position) 2. Older person with hx of hip dysplasia or result of repeated pivoting /twisting - Most common cause of mechanical hip symptoms (catching/locking/pinching) - Found to be the cause of groin pain in >20% of athletes presenting with groin pain -most vulnerable in superior part of labral *will present as Non-capsular pattern even though it's intra-articular*
Cuboid Syndrome - What injury usually triggers this? - What do pts commonly complain of? - Common signs: - Intervention:
Lateral mid foot pain after inversion is resolved Localized near 4th and 5th metatarsals at the dorsal aspect of the cuboid or calcaneocuboid joint May feel like the pt is "walking with a small stone in the shoe" Common signs: possible forefoot valgus, pronated foot, tight peroneus longus Intervention: manipulation (Cuboid whip), stretching, taping and/or plantar padding
Considerations for Ankle/Foot Management - Lateral ankle pain - Medial ankle pain - Anterior ankle pain - Posterior ankle pain
Location! Lateral ankle pain - post inversion (grades, syndesmosis, bifurcate ligament, cuboid syndrome), peroneal tendinopathy, snapping ankle Medial ankle pain - Tarsal tunnel (T, D, VAN, H), periostitis post inversion injury, post tib tendinopathy, subtalar joint (synovitis, arthritis) Anterior ankle pain - anterior tibiotalar compression syndrome (ATTCS), sinus tarsi, syndesmosis, capsular impingement, talocrural joint* - These Sx are secondary to inversion like trauma Posterior pain - posterior tibiotalar compression syndrome (PTTCS), Sever's disease, Achilles tendinopathy, calcaneal bursitis Heel pain, plantar fasciitis (medial heel)
ACL injuries: - What is the gold standard for diagnostics? - What is the most common MOI? Are all torn this way? - What are 2 risk factors?
MOI: plant, cut, pop (planted foot w/valgus force) -70-80% are non-contact..suggestive of neuroms control (NMC) -MRI= gold standard Dx -Risk factors 1. Family history/genetics 2. Increased post-tibial slope (less bony stability biomechanics) decrease core/hip strength -can happen when switching surfaces (ie. turf to grass)
MCL injuries - What is the most common MOI? What happens if the force is great enough? - How is the healing potential? - What are the long-term outcomes like for Grade 1 + 2? - Grade 3 = How are the outcomes? What is common secondary to this? - What is the gold diagnostic standard? What is common to see here?
MOI: valgus blow to knee, pop not as common if valgus force great enough, can also get ACL & PCL -excellent blood supply and healing potential Grade 1 + 2 = excellent long term outcomes Grade 3= isolated = excellent outcomes - 80%combined cruciate injury -avulsions uncommon (femoral side if they do) MRI = gold standard, also see *bone bruising (ie. kissing lesion) from femoral condyles smashing together after MCL tear*
Slipped Capital Femoral Epiphysis (SCFE) - Which populations are most likely to have? Age? Race? Gender? - What predicts a contralateral slip? - Does this present as a capsular pattern?
Male: female = 2:1 African American: Caucasian 4:1 Hispanic: Caucasian 2:1 Male 13-15 years / Female 11-15 years Puberty Obesity 30% chance of occurrence on the other side Age(<11yrs, 4mos) predicts contra slip for boys Prognosis better when acute - early identification is important *Capsular pattern*
Stiff Knee problems: Knee OA - What are the 2 influences that causes this to develop? - How should the x-ray be taken? - What starts to occur outside of the tibia? When then happens?
Most common joint affected - Degeneration of the articular cartilage - Post-traumatic OA - We don't understand the pathogenesis - Biomechanics? yes - Metabolic/physiologic? yes *Take x ray at 20 dg flexion bc want to know what it looks like during function activity* *Spurs start to occur on outside of tibia.....MCL & ACL get more lax (less stretched), responds by adding more bone on the side to help with bony stability*
Hip or SIJ? How do we decide? - Where does posterior hip pain commonly come from? - How is CFJ pain perceived? - Loss of hip ROM in capsular pattern suggests.....?
Most often primary hip (CFJ) pain is perceived as inguinal or groin pain Posterior hip pain is often referred from LSP (L-spine) Pain sitting - be suspicious of LSP, don't ignore ischial bursa *Loss of hip ROM in capsular pattern suggests CFJ* Capsular pattern must make sense! (no trauma, history of dysplasia...unexplained capsular pattern = red flag) -younger people w/traumatic event = might see capsular pattern
Tendon management: Transverse friction/cross fiber massage (TFM) - What is the difference in response between tendinopathy vs. bursitis? - How long should you do this for?
Move the ms in one direction -not massage, soft tissue mobilization -if expect tendinopathy, can do massage and ask if increase or decrease or stay the same....it wont hurt anymore if tendinopathy... -if it's bursitis, this will make them feel worse
Managing arthogenic inhibition - What is the best outcome for restoring quad strength & gait pattern? - What is the con to this technique?
NMES for the quad NMES + volitional exericse is the best outcomes for restoring quad strength & gait pattern NMES- literature is different on the dosage, doesn't work well for ms that isn't inhibited
PF Tx
Night splinting Orthotics Taping (shown to significantly decrease pain in comparison to heel cups and steroid injection) Heel cups (supports fat pad) Stretching/strengthening Deep friction massage Cortisone injection Iontophoresis
Articular cartilage injuries: Non-op management & surgery - Non-op: How would you treat? What would this Tx look like? (refer to earlier slides) - Surgery: What are the 4 types?
Non-op management: Treat like OA • Surgery: 1. Debridement: shave off pieces causing mechanical symptoms 2. Microfracture: fracturing the bone for healing factors to stimulate....does ok short term, long term outcomes bad 3. OATS: will fill hole with plug from opposite side of leg, outcomes still aren't great 4. ACI/MACI - 2 stage procedure -debridge the lesion, place chondrocytes to try and hold them in there in hopes of regrowth -or take chondrocytes out, artificially created and then placed back in
Hip versions - Normal - Anteversion - Retroversion
Normal = 15 dg Anteversion = greater than 15 (in-toeing) Retroversion = less than 15 (out-toeing) picture = incorrectly labeled
Objective measures - What is the first thing you look for? - What does a callus tell you? - Valgus deformity of 1st MTP: How does this happen? - What does a severe foot/ankle injury look like?
Observations/Inspection 1. Calleous = increased load and increased shearing 2. Valgus deformity = hallux needs to DF/extension & bc its abducted you get shearing over medial border of the toe....may have decreased extension so want to measure 1st MTP extension Bottom pic = effusion vs edema in tissues....when injury is more severe will see effusion around ankle and pitting edema into the dorsum of foot
Patellofemoral pathology: Anterior knee pain - What will happen with a patellar fracture? A dislocation? - What will pt's complain of?
Pain around or behind the patella - Only patellar fracture will cause substantial effusion - Patellar dislocation: Soft tissue bleed but not effusion Patient complaints: 1. Pain with stairs, squatting, running, jumping 2. *Pain with prolonged sitting, goes away with change in knee angle*
Medial Ankle pain: Tarsal tunnel syndrome - What is the pain usually described as? What special test is positive? - What parts of your clinical exam will stick out? - Intervention?
Pain described as burning, tingling, cramping Possible (+) Tinel's sign Pain with passive dorsiflexion or eversion Varus or valgus deformity of the heel, Weakness or wasting of foot intrinsic muscles *Normal neurologic examination* Intervention: Orthoses for foot abnormality, strengthening of foot intrinsic muscles to support MLA, wt loss, heel lift to decrease tension on tibial nerve, cortisone injection, surgery *heel lift = bandaid--short term use & weaning away unless structural difference*
Objective examination (suggesting SIJ dysfunction) - Which part of the subjective portion is most useful in dx SIJ dysfunction? - Objectively, what is useful? What isn't?
Pain location descriptions most useful in diagnosing SIJ dysfuntion (Freburger & Riddle, 2001): *No LSP pain Pain below L5 Pain in PSIS region Pain in groin* SIJ Pain provocation tests are useful, symmetry and movement tests are not (Freburger & Riddle, 2001): Patrick/FABER Palpation of sacral sulcus (deeper on affected side) Posterior shear/Thigh thrust Resisted hip abduction Iliac compression Iliac gapping ASLR
Meniscus Cluster Test 1: Medial jt line - What is a positive test? - What must the Hx suggest?
Palpate medial joint line...pain = positive test • History must suggest meniscal injury • Indicative of Medial meniscus tear -if you have a strong suspicion of MCL tear, only do this test
Special Tests: subtalar joint neutral (STJN)
Palpate the medial and lateral talar head Grasp the 5th metatarsal and passively invert/evert the forefoot to find the neutral position (both medial and lateral aspects are palpated equally) Look for the relationship between the forefoot and subtalar jt - ie. use your index finger horizontally at the forefoot and vertically at the rearfoot and they should be exactly perpendicular
Cuboid manipulation
Patient is prone, knee flexed to 70 dg and ankle near neutral. Knee is passively extended as the ankle is PF'd with slight supination. A thrust force is applied using both thumbs on the plantar aspect of the cuboid
Active SLR (ASLR) - What is a positive test? What does this indicate is physiologically going on?
Patient performs ASLR; if pain and compensatory movements noted; therapist provides compression to pelvic ring. If ASLR improves with compression, this indicates poor motor control of pelvic ring stabilizers -can also use belt distal to ASIS *tight* and then perform SLR, and will be less painful -instability of dynamic stabilizers to hold pelvic ring IF HIP is the problem = negative test IF SIJ is the problem = positive test
Special tests- Syndesmosis (high ankle sprain) - External rotation stress (kleiger) test - What is a positive test? - What question do you need to ask?
Patient supine, knee flexed to 90 dg ??Hold ankle in neutral and ER the lower leg...hold leg neutral and ER at the calcenuous?? Positive test: concordant symptoms Don't stabilize too low (false neg) *Pt needs to point to where the pain is....pain needs to be near anterior/medial*
Articular cartilage injuries: Post-op management ctnd - What is key? - What type of forces should be avoided? - What is a common place for injuries? How does this happen?
Post-op management: Highly individualized based on procedure, location of defect *Communication with surgeon key* *Underloading just as deleterious as overloading (accelerated NWB protocols post surgery)* - Avoid shear -Lateral femoral condyle = most common place for injuries, can also be caused by retropatellar dislocation
Posterior Ankle/Foot pain - What are the 4 conditions?
Posterior tibiotalar compression syndrome (PTTCS) Sever's disease Achilles tendinopathy Calcaneal bursitis
ACL Injuries - Management 1. Can you prevent ACL tear? 2. How to prep for surgery? 3. What are the 4 main things you want to work on?
Prevention NM training = 50% reduction in risk 1. Reduce pain 2. Decrease swelling 3. Restore ROM 4. Restore quad activation -NMES- combined with exercise, dosage -neuroms training *Need to restore before surgery bc will increase outcomes of the surgery...if you let the knee "quiet down" first where you get rid of effusion and restore ROM, then people tend to do better*
Therapeatuc exercise principles
Proximal control first Lumbopelvic and pelvic girdle ("belly and butt") Distal strength Appropriate loading - task specificity Progression/regression
Joint mobilizations for hip Tx: 3. Supine hip joint lateral distraction/glide - When would you use this as a Tx method? What does it treat?
Purpose: 1. Remove compression of head of femur in acetabulum 2. Treat joint pain and general mobility How to perform: 1. Place hip in loose packed position. 2. Fasten a seatbelt around therapist's hips and patient's groin (be as close to the joint line as possible).--use towel around inner thigh 3. Apply a lateral distraction force by leaning backwards using the seatbelt to create force. 4. Stabilize pelvis using fixation on opposite ASIS (ie. see picture....may also use a belt fixed to the table) OR lateral hip & thigh instead
Joint mobilizations for Hip Tx 1. Supine caudal glide of hip joint: Indirect technique - What is the purpose of this? What conditions does this treat? - Explain the 2 different techniques to perform this joint mobilization.
Purpose: 1. Remove compression of head of femur in acetabulum 2. Treat joint pain and general mobility *Would use this technique for someone with knee pain* Joint mobilization 1. Place hip in loose packed position (30 flexion, slight ER, 30 dg abd, prop hip up with pillow to help with this position) - Grasp around femoral epicondyles with both hands (or use a seatbelt) and apply a longitudinal distraction force by leaning backwards. -oscillations or prolonged hold OR 2. Use medial and lateral malleoli as bony contacts, with or without a seatbelt - Belt needs to be above the malleoli (or at) bc doing ankle distraction if it's below - Make sure seatbelt is around your butt NOT your low back
Anterior glide OR prone hip jt PA (anterolateral glide) - What motions would this help assist with?
Purpose: Increase extension & ER Force = anterior & lateral push Open packed position: Open-packed position = 30˚ flexion, 30˚ ABD, and slight ER - To improve jt motion, Tx can be delivered at end of physiological motion *ALWAYS COMPARE TO OTHER SIDE TO ASSESS HYPER/HYPO-MOBILE OR NORMAL* Procedure Distal hand holds knee and lower leg Proximal hand on posterior proximal thigh close to joint Apply anterior-lateral glide through proximal hand - block ASIS w/towel, could support quad w/pillow
Supine hip joint AP posterior glide - What movements does this increase?
Purpose: Increases flexion and IR Patient Supine, hips at end of plinth, opposite hip flexed and held by patient Therapist 1. Standing on medial side of thigh to be treated (between patient's legs) 2. Use belt on your shoulder and patient's thigh to support hip in loose packed position (30o F, 30o Abd, slight ER). Procedure Distal hand under belt and distal thigh Proximal hand on anterior proximal thigh close to joint Apply posterior LATERAL force through proximal hand *Keep elbows extended and knees flexed To improve joint motion, treatment may be delivered at the end of physiological motion*
General management for knee conditions - What is most important to knee function? - What should the paramount priorities when treating the knee? - How can we determine when to progress someone?
QUADS are king *Quadriceps strength is related to knee function* *Restore full symmetrical knee ROM even though it might not be WNL* *3 degree loss of ext = OA* *Restore neuromuscular control* • Criterion-based progression: • Use OBJECTIVE data to determine when ready to progress from early (healing--want no pain & full ROM first) to middle (normal function--full strength, ROM and no pain) to late phases of rehab! -time doesnt equal restore back to injury (ie. 6 months to recover isn't for everyone)
Objective measures: Ms performance - What do resisted isometrics tell you? - Prone limitations in muscle length?
Resisted isometics - minor = strong + painful - major = weak + painful - nerve injury = weak & painless MMT - almost useless for quads - HHD, %RM, Biodex SLR - with/without lag? Muscle length - Quad - HS -supine vs prone....prone limitation = probably quad limiting vs. if it was the joint it wouldn't matter if prone or supine
SI jt dysfunction - What are the 3 broad categories it falls under? - What mechanically may be causing Sx? What might the pain also be a secondary result of?
SIJ dysfunction falls into 3 broad categories: 1. Hypermobility 2. Hypomobility 3. Inflammation (ankylosing spondylitis, infection ...) The precise etiology of SIJ pain is uncertain. Possibly torsion between ilia and sacrum causing stress on surrounding ligaments *The mechanical changes may also cause a secondary inflammation component to the pain*
Dont forget about
Stretching Decreased hamstring muscle length? Decreased hip flexor muscle length (one and two joint)? Lateral hip musculature Functional training/gait/balance Closed chain functional exercises that can help strengthen hip musculature? Know how to progress these exercises to increase degree of difficulty
Inversion sprain: Associated injuries - Snapping ankle: How does this occur? - How can this be seen?
Superior peroneal retinaculum rupture & peroneals sublix The patient is asked to actively, with minimal force, plantarflex, abduct, and pronate the foot while the examiner gently brings the foot into dorsiflexion The peroneals can be seen to sublux over the lateral malleolus - only a problem if its painful
Alignment: Tibial torsion - Why would you want to test for this?
Supine...contract quad and line femoral condyles up with goniometer horizontally at the foot In toeing also due to anteversion at the hip Want 15 dg of tibial torsion developmentally Ie. find toe-in on initial exam...if give a bunch of ER exercise and not benefit then maybe something else is going on...might be d/t tibial torsion
Objective measures: ROM - What are the capsular patterns of the talocrural joint & subtalar jt? - Which position would you want to measure the TCJ? STJ? - How much big toe extension do you functionally need?
TCJ capsular pattern = PF > DF STJ capsular pattern = Inversion (supination) > Eversion (pronation) -happens earlier in the range
What are some functional tests recommended for hip mobility deficits?
TUG 6 minute walk test 4 square test Single leg stance time 30 second chair sit to stand Step test *may need to maximally load the region to provoke the pt's Sx or to see mvmt breakdown--larger force needed for MMT*
Special tests- Syndesmosis (high ankle sprain) - Point test
Tenderness to palpation at the syndesmosis or patient points to it
Achilles tendinopathy - What does a tendon usually?
Tendinosis - non-inflammatory Can have fatty deposits in the tendon, can have mucoid degeneration- normal white glistening appearance is lost- tendon becomes grayish or brown
Management of soft tissue - What are the main priorities for treatment?
Tendons: peroneals, posterior tib, Achilles, FHL, to name a few... Ligaments: ATFL, CFL, PTFL, bifurcate lig... *Pain reduction: CFM, Isometric loading, tendon gliding* *Remodeling: progressive loading* *Sensorimotor reactivation*
Medial Ankle Pain: Posterior tib tenosynovitis - Where are common pain complaints localized to? - What is this commonly associated with? - Which population of pts is this typically seen in?
Tenosynovial sheath can become inflammed and if untreated can rupture Complex disorder of the hind foot *Pain at medial foot/leg - can be at any of the following- proximal to malleolus, distal to medial malleolus at the navicular region, at the musculotendinous origin (medial shin splints)* May be associated with pes planus Seen frequently in joggers, dancers, ice skaters
Special tests: Thompson's - What is this used for? - What is a positive test?
Tests Achilles tendon integrity Examiner squeezes the patient's calf *Positive test: Nonresponse - no plantar flexion*
Special tests: Lateral ligament test - Medial talar tilt (inversion stress) - Which ligaments does this test? What direction is the force you're applying? - What is a positive test?
Tests CFL and ATFL integrity Stabilize just proximal to the malleoli, grasp the calcaneus, and apply inversion stress Positive test: Pain in the lateral ankle, laxity compared to the opposite side
Medial ligament tests: Lateral talar tilt (eversion stress) - Which ligaments is this testing? - What is a positive test?
Tests Deltoid ligament integrity Stabilize just proximal to the malleoli, grasp the calcaneus, and apply eversion stress Positive test: Pain in the medial ankle, laxity compared to the opposite side
Special tests: Foot squeeze (Morton's) test - What is a positive test? - What supports this Dx?
Tests for Morton's neuroma Apply a medial/lateral squeeze force to the forefoot Positive test: concordant symptoms, numbness, toe pain Tenderness between the metatarsals supports Dx
Hip Tx: Hip MWM flexion & adduction
Therapist placement: stand to side and inferior to treatment hip. Belt in groin. Mobilize lateral and inferiorly with AAROM flexion and adduction. -PROM --> AAROM-- have the pt help you get further in the range with AROM
1st MTP ext
Therapist: stabilize distal 1st MT Mobilization: Glide proximal 1st phalanx medially Patient: extends 1st MTP while therapist applies OP Useful for restoring 1st MTP extension Tape in place 70 dg of toe ext needed 4 push off or glide medially for hallux valgus (the pt can apply overpressure if really lacking extension) To tape...make sure to not cut off blood supply , make sure to pat dry with a towel (not heat resistent ) for hallux valgus--ie breast cancer sign
prox tib-fin
Therapist: stand on side of pt with heel of hand on post-lat fibular head Pt position: standing with foot on chair Mobilization: Posteromedial to anterolateral with patient actively flexes knee Useful for lateral knee pain esp with squatting or stepping Tape in place mobilize with left hamd, tape w right Pain with full knee flexion...HS attach to head to fibula 1. Anterior glide while have the pt lunge forward into a chair—looking for immediate relief
Hip TX + mob= Side lying posterior rotation ilium on sacrum - When do use? - Why is the lower leg maintained in extension? - How do you perform?
When to use: SIJ pain provocation/alleviation - can be used clinically during tx (if it alleviates pain) of posterior hip and SIJ pain and dysfunction (e.g. SIJ pain at end range hip flexion) The lower leg is maintained in extension to create anterior rotation (counter rotation) which helps to stabilize the non tested ilium and pelvic ring Patient Side lying, bottom hip and knee extended Therapist Standing facing patient Caudal leg on plinth to maintain patient's leg in extension Procedure Flex patient's top hip and knee Therapist's (caudal side) forearm under patient's shin, (caudal side) hand on patient's top ischial tuberosity Therapist's (cranial side) hand on patient's ASIS Posteriorly rotate the top ilium using both hands
PFPS - Muddy waters
associated with depression, fear-avoidance & anxiety -may be a psychosocial component to their pain
Patellar instability - What is the difference between a subluxation & dislocation? - What is the most common direction it goes in? - Causes of dislocation?
common problem -sublux: quick out and back -dislocation: out and stays out until reduced *slowly bring them back into extension and it will slowly pop back into place* - most common laterally d/t morphology of the trochlea Common causes: 1. Patella alta 2. Shallow groove 3. Hyper-laxity
Quad strength testing - What is the problem with hand dynamometry? - What's wrong with doing a leg press?
false + = big problem leg press = false positives....can cheat with glutes as opposed to knee ext or handheld dyno
Tib-Fem joint: Rotation
grab tibia near joint line for treatment, have them rest leg on shoulder for more control -take up slack of skin
SLR - What does unable to lift tell you? - What must you do prior to testing?
knee = fully extended & locked out -if can, knee gets bend....not bc ROM issues its from quad weakness or inhibition ie. patellar tendon rupture along with rupture & swelling & pain with palpation, do SLR test and will confirm suspicions
Special tests: STJ neutral (STJN) 1. What will happen to a pronated foot in NWB (forefoot AND calcaneus)? 2. What will happen in WB (forefoot & calcaneus)
not necessarily important for management, but will explain why something else is occurring
Hip arthroscopy: Criteria to advance - What are the 4 stages?
pain = guides how people progress early on -proximal control, no compensatory mvmts (ID'ing these separates us from everyone else)
1. Restoring knee flexion -PROM/stretching
prone = getting more quad then sitting yoga= having them go into internal rotation
SIJ/Pelvic ring stabilization - Activation of transversus abdominis has showed what effect at the SIJ?
pt's w/o LBP selected to ensure optimal pattern of muscle contraction could be attained. SIJ laxity was measured through color doppler *Transverse abdominis contraction increased SIJ stiffness to a significantly greater degree than the general abdominal exercise pattern (p = 0.02)* -stiffer = more vibration through SIJ
Lachman - What is this testing for? - What position? - What is a positive test?
• Tests ACL integrity • 20-30 degrees of knee flexion • Stabilize femur, pull tibia anteriorly • Positive: No endpoint • Gold standard clinical test -thumb along patellar tendon -use lever...stabilize femur with hand, c grasp around tibia, leg under femur -go posterior then anterior (close then open)
Pivot shift - What does this test? - What is a positive test?
• Tests ACL/rotary laxity • Full extension, apply valgus load, flex up to 40 degrees • Positive: Subluxation and reduction of tibia on femur...would feel relocation • Difficult to get on a conscious patient (guarding)
Posterior drawer - What are common causes for PCL rupture? - What is a positive test?
• Tests PCL integrity • 90 degrees • Push tibia posteriorly • Positive: No endpoint common cause = car accidents, falling on flexed knee
Meniscus Cluster Test 2: McMurray - What does this test for? - What is a positive test?
• Tests meniscus • Passively flex knee in supine with ER and IR - Bring the knee into flexion, IR and bring through the range of flexion (Lateral meniscus) - Bring the knee into flexion, ER and bring through range of flexion (medial meniscus) • Positive: joint line pain, mechanical symptoms
Meniscus Cluster Test 3: Thessaly - What does this test? - What is a positive test?
• Tests meniscus • Patient in unilateral stance, flex to 20, rotate body internally and externally • Positive: reproduces joint line pain/mechanical symptoms