Final Ortho 1/2 Alex/Josh/Erin
Implant and fixation choices for standard TKA
-Cemented, uncemented, or hybrid fixation -Metal-backed tibia or all-polyethylene tibia -Patella resurfacing or patella retaining -PCL or bi-cruciate substituting, PCL retaining, or mobile-bearing surfaces
You often find TPs _______the PSIS
Below
Hydrogel implants
Biocompatible, can be synthesized w/ a wide variety of mechanical and structural properties, characteristics similar to meniscus, proven durable in small animals
What causes FAI?
Bone overgrowth (spurs)
What surrounds the iliopsoas bursa?
Bounded by iliopsoas muscle/tendon anteriorly and the joint capsule posteriorly
Describe the MCL
Broadest structure of the medial aspect of knee, runs from adductor tubercle 3-4 cm below the crest of the tibial plateau, supercial + deep portions (deep portions have extensive attachment to meniscus and capsule, most taut w/ valgus force
Neurological pain
Burning, stabbing, itching, shooting, tingling, numbing, electrical
Describe the subtalar joint (talo-calcaneal)
Conversion of the rotation forces of LE, functionally linked to transverse tarsal joints
If an individual spends long periods of time at end range then the ligaments engaged in the elastic zone will have a plastic response - what is this called?
Creep
Metatarsals articulate w/ what?
Cuneiforms and cuboid
Closed pack position of the ankle
DF
What is the primary objective of an education session?
Decrease unnecessary fear
What is a directional preference?
Defined as a situation when movements in one direction improve pain and the limitation of ROM but may not centralize symptoms
What is a hip pointer?
Direct blow to the hip, lateral femoral cutaneous nerve (sensation to anterior lateral thigh), is compressed and could cause transient sensory changes
ACL is most taut in full ________
Extension
Disc patients feel better in____________
Extension
FABER
Flexion, abduction, ER
When is the PCl most taut? Most loose?
Flexion; extension
Common mechanisms of injury for cervical spine
Forward head w/ lift or twist or trauma (esp. in head forward posture)
ACL is taut in _______ ________________
Full extension
Over the door traction units
Generally not used anymore
3 categories of HRQL Questionnaires
Generic, Condition specific, Patient specific
Prevalence of LBP (Level II evidence)
Genetic component, inc. w/ leisure activities, smoking (don't heal very well, don't fight pain well), obesity, fear pain level, adolescence vs. adult same, most at risk - very active and sedentary
Generic
Good for anyone w/ any disability or condition
Condition specific
Good for patients w/ a specific condition
MTP joint of great toe
Grab base, anterior/posterior glide, medial/lateral glide, Turf tow injury, Need ~60 degrees of great toe extension, Compensate by ER at the hip joint
How to correct a lateral shift?
Grab pelvis, should into rib cage, and shift to opposite side, ask about leg symptoms, patient can perform by themselves using a wall; if it hurts more in their back, but makes their leg symptoms better - this is GOOD
S&Ss of Spondylolithesis
Grade 1+2: LBP and/or buttock and leg referred pain, feeling of instability w/ sudden movements, jarring movements, spine "give out", legs may buckle Grade 3+4: LBP, may be radicular signs into LE related to traction on lumbosacral nerve roots, pain paresthesia, numbness, muscle weakness, radicular signs may be unilateral or bilateral
Clinical presentation of internal snapping hip syndrome
Gradual onset, usually not associated w/ a traumatic event, may describe a painful sensation coming from deep within the anterior groin as the leg moves from flexion into extension or ER, snapping movement can produce an auditory clunk or click
Femoral head is removed but not _______________ _____________
Greater trochanter
CAM leads to _________between the 2 surfaces
Grinding
Tightness of what muscles are common at the hip?
Hamstrings, hip flexors
Pros/cons of ceramic ball w/ polyethylene liner
Harder than metal, don't scratch very much, less wear means less inflammations/bone loss, more expensive, in past ceramics were brittle and cracked, wear rate - 0.05 mm/year
Weakness of what muscles are common in the hip?
Hip ABD, gluteals
What does a lateral approach alter?
Hip ABD, which can result in weakness and may result in prolonged limping
What is known to predispose someone to labral tears?
Hip dysplasia (coxa valgus)
What can cause LE malaligment?
Hip excessive antiversion, excessive tibial torsion, excessive foot pronation (flat feet causing tibia to rotate medially)
All hip ligaments are taut w/ _____________
Hip extension
The use of traction dates back to _____________
Hippocrates
What does Gillet test test for?
Hypomobility of SIJ
Example of Step Deformity (EXAM)
If L5 vertebral body is anterior on S1, then L4 may feel more anterior (as L5 vertebral body slides anteriorly, the posterior arch and spinous process stays attached to S1), L4 feels deep b/c L4 has migrated anteriorly w/ L5 vertebral body (if L4 feels deep, then L5 is the problem)
Acute management of quad strain
If knee is left in ext the healing process will be slower and more painful b/c the quad will start to heal in a shortened position; knee should be flexed to avoid potential ms spasms, reduce hemorrhage, and minimize the risk of developing myositis ossificans
What is a precursor to hip OA?
If left untreated FAI will progress to labral tear, labral tear can lead to arthritis and DJD
Reason for symptoms
If the patient stands flexed to give more space for nerve roots- tends to over stress lumbar extensors which causes local lumbar spasm, if the patient stands in an extended position- tends to close IV foramen and impinge nerve roots, causing distal symptoms
Segmental lumbar musculature
In individuals w/o LBP, the TA and MF contracts prior to extremity movement to stabilize spine in preparation of movement, however in patients w/ LBP there is a delay in the onset of these muscles
Slump test
In sitting, bring their leg out and hold it there, have them slump down
Evidence for traction
Inconsistent outcomes among studies
Nucleus and inner annulus has no ____________
Innervation
What comes off and/or attaches to the medial epicondyle?
Insertion of adductor magnus at adductor tubercle, MCL
DD of snapping hip syndrome
Intra-articular hip disorders, trochanteric bursitis, iliopsoas bursitis, IT band syndrome
Describe reaming of the femoral canal
Intramedullary reaming (manually, robotically) rasp (sands down rough edges, used to size femur to accept the stem)
Closed pack of subtalar joint
Inversion (supination)
Motions at the subtalar joint
Inversion/eversion
Common accessory motion testing at hip
Lateral glide, lateral distraction, lateral distraction w/ combined movements, anterior glide, posterior glide
LCL is not connect w/ the _________
Lateral meniscus
What does the lateral condyle have to stabilize the position of the patella?
Lateral superior flair
What can cause lateral patellar compression syndrome?
Lateral tilted patella, hypomobility of patella, loss of patella mobility, excessive tightness of lateral retinaculum including distal attachment of IT band, atrophy of VMO (reflex inhibition)
___________meniscus moves more than the _____________meniscus
Lateral, medial
What muscle works to keep your pelvis more stable?
Latissimus dorsi
Side bend right - nucleus moves __________
Left
Install-salvati ration
Length of patella tendon (ligament) should be the same as the length of the patella top to bottom, if tendon is too long - patella alta, if too short - patella baja
Hallux rigidus
Loss of ROM in MTP joint
Manual techniques
Manual therapy, energy muscle technique, trust techniques (hard to focus on SI joint)
Interventions for acute LPB w/ mobility deficits
Manual therapy, exercise, patient education
Interventions for subacute LBP w/ mobility deficits
Manual therapy, exercise, patient education (focus on prevention and maintaining lifestyle)
Interventions for acute LBP, referred
Manual, exercise, exercise, traction, patient education, all to centralize symptoms
Interventions for chronic LBP, radicular
Manual, pain management
Interventions for subacute LBP, radicular
Manual, traction, nerve root mobilization
Do you have to manipulate to be a good PT?
Many highly effective PTs do not manipulate
Meniscal tears occur more often in men or women?
Men
Scour test
Move hip through ROM flexion/ADD and extension/ABD while adding compression, (+) test = reproduction of clicking or popping, if it hurts, then distraction should make it better
Risk factors for TKA
Multiple compartments are damaged due to arthritic changes, articular cartilage is damaged and is no longer able to absorb shock, previous injury, menisectomy, RA, fractures and congenital factors
Femoral neck fracture
Must repair or replace right away
Who should not be manipulated?
Near unhealed fractures, RA, pregnancy, osteoporosis, hypermobility in affected joints, unstable joints, unknown cause of symptoms, Down Syndrome (increased laxity)
Cervical
Neck Disability Index
What is a complication of a resurfacing anthroplasty?
Neck fracture
FABs of patients and health care providers have a ____________influence on LBP outcomes
Negative
Who is Robin McKenzie?
New Zealand PT, developed theory due to mistake by patient, developed theory based on patients' responses then wrote a book, no early research
Distraction
Nice to follow after a (+) scour test, 30 degrees of flexion and ABDuction w/ slight ER, if distraction relieves symptoms it helps confirm the hypothesis of hip OA, if test is painful, a capsular or ligamentous injury is possible
Is intermittent or static traction better?
No conclusive evidence to support one method being superior
Biggest reasons for concern
No h/o injury, no change in symptoms with changes in position or with activities, fever, chills, night sweats, unable to reproduce symptoms with physical examination
Bed traction
No longer use, very low-load (9-10 lbs), prolonged stretch (hours to days), costly for hospitals to have patient lie in bed (secondary complications)
Mortise (distal tibiofibular joint)
No muscular attachment to the talus
Quad strains are typically a ____-contact injury
Non
What test has a high level of diagnostic accuracy for a hip labrum tear?
None
Non-specific LBP
Not a homogeneous group, but consists of subtypes of patients who can be identified based on specific S&Ss
Peripheralizing
Not doing better
Frequency
Not supported by evidence, some authors report daily
Duration
Not supported by evidence, start w/ brief bout (5-10 minutes), relief of symptoms (leave same treatment time), partial relief (increased duration and/or frequency)
Sequestration
Nuclear material came completely through
Joint axis of talocrural joint
Oblique axis, through fibular malleoulus, body of talus and medial malleolus
Characteristics of pain
Onset - did it come on slowly? (CA) Suddenly, without mechanical event? (vascular) Does not change w/ position or activity? True constant pain? (does not vary w/ position or activity)
Clinical presentation of FAI
Onset of hip pain usually b/t ages 20-40 years; typically unilateral; typically aware of limited hip mobility long before pain begins
Contraindications for artificial disc replacement
Osteoporosis or osteopenia, scoliosis, instabilty
Total joint replacement is one of the most commonly performed and successful operations in orthopedics as defined by clinical_______________ and ____________survivorship
Outcomes; implant
Describe the medial meniscus
Oval or "C" shaped, wider posteriorly, attach to deep portion of the MCL, semimembranosis attaches to posterior horn
What attaches to the tibial tuberosity?
Patellar tendon
Sciatic nerve tension test
Patient is in supine, extend knee, flex hip, IR hip (tensioning nerve across the lateral part of the ischial tuberosity), DF ankle, if no change in symptoms have the patient flex cervical spine
Everter =
Pronator
Femoral nerve innervates the ______________
Quads
Individuals w/ lumbar injury show more postural sway and have ___________reaction times
Slower
Thessaly (meniscus)
Stand on one foot and rotate
Anti-inflammatory meds
Steroids, NSAIDS
Why manipulate?
To increase ROM, hypomobility due to capsule restriction, joint is blocked due to mechanical restriction (meniscus, disc), reflex inhibition of muscle spasm
Manual traction
Typically applied b/t 15-60 seconds, can be static or intermittent, monitor patient's reaction, can't control force exactly
Describe tibial torsion
Typically lateral torsion 20-30 degrees
Red flags S&S
sensory changes in the rectal, genital, genital region, changes in bowel and bladder control
Most susceptible athletes to spondylolysis
those who do frequent end range lumbar spine hyperextension: lineman in football, gymnasts, swimmers, wrestlers, volleyball, cheerleaders, weight lifters
normal mobility of spine
translation during flexion and extension 3-4.5mm or 9-15% of vertebral body width, rotation 15-25 degrees,
How much more translation or rotation before you have symptoms?
unanswerable- translation of vertebrae is no what matters when you are hypermobile, what matter is how much control you have of it with your muscles
How do you do core strengthening exercises for someone with spondylolisthesis?
utilizing a posterior pelvic tilt position, posterior pelvic tilt will lessen LS angle, strengthen abdominals and gluteals, tighter hamstrings will limit anterior tilt of pelvis,
Reason for anterior displacement in spondylolisthesis
vertebrae no longer attached posteriorly, sacral angle creates anterior sheer, supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to 'slide' anteriorly o the one below (creep).
Diagnosis of Spondylolysis
x-ray (oblique view), MRI, CT, Bone scan
Diagnosis for spondylolisthesis
xray, MRI, Bone Scan, increase in symptoms with hyperextension, pain with pressure on spinous processes, step deformity
What 3 things do you evaluate when looking at feet?
1) Arch - high, low, or middle 2) In WB, how do they hold their calcaneus 3) How do they hold their forefoot
Risk of vigorous exercise
1-1.5 million deaths per year
Risk of NSAID use
1-3% develop ulcers, long-term heavy use is kidney disease (7,600 deaths, 76,000 hospitalizations)
Ongoing impairments and functional deficits can be seen for as long as ____ years post THA
2
PCL is ____x as thick as the ACL (which is why it results in less injuries)
2
The presence of ___ or fewer findings was almost associated with failure to experience dramatic improvement
2
Describe the distal femur
2 WB condyles that are covered w/ articular cartilage, separated by the intercondylar notch (provides area for cruciate ligament to pass), trochlear groove (articulating surface w/ patella)
What should frequency and duration be?
2-3 times per week for 6 to 8 weeks depending on diagnosis
Normal hip extension
20 degrees
>______________discectomies are performed i the US per year
200,000
Roland-Morris Questionnaire
24 questions related to pain and function, 5 min to complete, 1 min to score, 0-24 (0 no pain and no functional limitations, 24 max pain and limitations), minimal detectable change (variable - 5 to 9), patient checks statement that applies to them, "because of my back pain...", designed to measure short term changes, short, simple, easy to understand, does not look at psychological or social, may be more sensitive in patients w/ lesser disability
Force of ____% of patients BW is sufficient enough to increase the length of the lumbar spine
25
Grade 2 Spondylolithesis
25-50%
Grade 2 for spondylolisthesis
25-50%
Rectus femoris is a _________ joint muscle and has a high % of type ____ fibers
2; II
The presence of at least ___ positive factors indicates a greater likelihood of responding to a stabilization intervention
3
Women are ____x more likely to have an ACL injury compared to men
3
Posterior surface of patella articulates w/ trochlear groove through facets ______,______, and ______
3, 5, 7
Minimally invasive incision length
3-4 inches
Normal translation during flexion/extension
3-4.5 mm or 9-15% of vertebral body width
Pincer occurs more often in whom?
3x more in females (ave. age 40)
Elongation of annular fibers by more than _____% will cause permanent damage to annular rings
4
The presence of ____out of 5 findings was strongly predictive of a dramatic response to the manipulation interventions
4
What is indicative for separation of facet joints and to increase foraminal space?
50-60% of patient's BW
Grade 3 Spondylolithesis
50-75%
Grade 3 for spondylolisthesis
50-75%
Grade 4 Spondylolithesis
75-100%
Grade 4 for spondylolisthesis
75-100%
Standard incision length
8-12 inches
Specificity for clicking w/ labral tears
85%
Posterolateral rotary instability
A direct blow to the anteromedial knee with the tibia in external rotation, Often occurs with concomitant ligamentous injuries making it difficult to detect/diagnose, Joint line tenderness with swelling in the posterolateral corner, Common fibular nerve injuries occur up to 30% of the time, Episodes of knee buckling during the stance phase of gate or with pivoting movements, Some patients present with unpredictable giving way without provocation or simply when just standing
Manipulation
A high velocity skilled movement done at a velocity that a patient cannot resist
Definition of manipulation/mobilization (Guide to PT Practice)
A manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small amplitude, high velocity therapeutic movement
Pubofemoral ligament is taut w/ ____________ and __________
ABD and ER
You can easily dislocate a newborn baby's hip - What positions are most stable and what should be avoided?
ABD and ER are most stable, you should not extend hips
During single leg support, your hip ______are firing
ABDuctors
Prevalence of GTPS
Affects 10 to 25 % of the general population Higher prevalence in runners, women, and between ages 40 - 60
Medial (deltoid) ligaments (all come off medial malleolus)
Anterior Talotibial Posterior Talotibial Calcaneotibial Tibionavicular
What is eversion or pronation supported by?
Anterior and posterior tibialis muscles and deltoid ligament
What is the preferred approach to THA today?
Anterior due to much smaller incision 3-4 inches
What direction does the ACL run?
Anterior medial on tibial plateau intercondylar eminence to posterior lateral on medial side of lateral condyle
Possible dysfunctions of SIJ
Anterior or posterior rotation, up slip or down slip, in flair, out flair, sacral tip (nutation or counternutation_, sacral obliquity
When in increased lumbar lordosis, the pelvis is ____________tilted and the __________ and __________ are tight
Anteriorly; hip flexors and spine extenders
Low early dislocation rate can be achieved using a __________________approach w/o restrictions
Anterolateral
Classification of instabilities - rotatory
Anteromedial, anterolateral, posterolateral, posteromedial
2 bands of the ACL
Anteromedial, posterolateral
Pincer can be due to increased acetabular ______________
Antiversion
Femoral retroversion
Anything less than the 15% of normal antiversion
Neutral zone (mid-range)
Area in range of motion segment where there is little resistance to motion; muscle function limits and stabilize motion segments in this area
What 2 states is it illegal to perform manipulations as PTs?
Arkansas and Washington
Patient education
Avoid forward flexion and sitting, maintain lumbar lordosis, avoid activities that peripheralize symptoms, may benefit from brace to maintain extended posture
Chronic LBP
Avoidance behaviors may become even more related to fear of continued pain and disability even after pain has become under control; can influence performance of functional tasks and can be a predictor of long term work disability
You want pt to maintain position for _______ after treatment
Awhile
Sensory innervation of joint capsule of the knee
Branches of femoral, saphenous, tibial, obturator, and fibular
Jefferson fracture
C1 vertebra
DF open chain
Convex on concave (anterior roll, posterior glide)
Slocum test for anterolateral rotary instability
Drawer test with tibia in IR
Posterior lumbar laminectomy
Due to diminished diameter of central canal cause by ligamentum flavum hypertrophy, facet hypertrophy, disc degeneration
Acute trochanteric bursitis
Due to trauma (fall or blow to lateral hip), pain, swelling, and warmth w/ palpation, motion may be limited
If patient cannot _______then nucleus has moved through rings and blocks motion
Extend
When is the LCL taut? Loose?
Extension; flexion
Lateral compartment musculature
Fibularis longus, fibularis brevis
Sports to avoid after TKA
Football, hockey, high-impact aerobics, jogging, parachuting, power lifting
For anterior labral tear, pain can occur where?
Groin (92%), anterior thigh (52%), labral hip (59%), buttock (38%)
Adolescent
Growing into their body, gain more control, improve balance and efficiency of movements, maturing of connective tissue
What is removed during a THA?
Head and neck of femur (loss of labrum), but not greater and lesser trochanter due to muscular attachment
What areas of the body should you examine when observing posture?
Head and neck, thoracic spine, shoulder girdle, lumbar spine, pelvis, knees, foot and ankle complex
Order of infant progression
Head control, prone on elbows, sitting, pull to stand, standing
DD of trochanteric bursitis
Hip pointer, ITBS, snapping hip syndrome, gluteus medius tendinopathy, meralgia paraesthetica
3 most common fractures in those w/ osteoporosis
Hip, colles, vertebral body
Examination of iliopsoas bursitis
Iliopsoas bursitis is often under diagnosed due to its unspecific symptoms, tenderness in femoral triangle, positive thomas test, active resistance of the iliopsoas is weak and/or painful
Disability
Impact on daily life, activity might cause pain and therefore harm, results in no activity, disuse atrophy, diminished strength and endurance, depression, injury result in pain experience, pain catastrophizing, pain perceive as threat, anxiety over pain and threat of pain, need to avoid pain, disability due to fear of pain
Functions of the meniscus
Improves articular congruency, distributes load during movement, reduces friction b/t femur and tibia, shock absorption, nutrition of articular cartilage, secondary restraint to tibial rotation
Examination of GTPS
In addition to pain along the posterior, lateral portion of the GT and pain w/ resisted hip ABD and/or ER, Trendelenburg test, FABER test, Ober's test, MRI can be effective to determine whether a patient is suitable for surgery
Rapid loading
Increased stiffness
Outer 1/3 of annular is ____________
Innervated
Accessory motion testing through the hip
It can be difficult to replicate accessory motions in the hip manually, common to use a mobilization belt when performing lateral glide
What does it mean if you extend the patients back and the local back pain goes away?
It is already centralized
Why is a posterior tilt important?
It will lessen LS angle (don't want them in extension)
Hamstring strains commonly occur w/ what action?
Kicking or running
What joint has the largest synovial capsule in the body?
Knee
LCL injuries may occur w/....?
Knee dislocation, distal IT band injury, popliteus rupture, posterolateral capsule injury, fibular nerve injury
Anterior drawer test
Knee is flexed, foot is flat on table; (+) test = tibia excessively translated anteriorly, mushy, empty end feel
Genu valgus
Knock knees, women tend to have a natural valgus
Dermatomes of the knee
L3-S2
90% of lumbar herniations occur @ ___-___ and ___-____
L4-L5, L5-S1
What is the most common level for spondylolysis? More common in males or females?
L5, more common in males
Manipulations show the best evidence for....
LBP (not radicular pain), cervical HA
Signs and symptoms of stenosis
LBP, pain and paresthesia in LEs, limited lumbar extension which may bring on distal symptoms, possible B&B changes (esp. central stenosis), posture (flexed in standing and walking), more common in older adults
What motion does the LCL, MCL, ACL, and PCL limit?
LCL - varus, MCL - valgus, ACL - anterior shear of tibia, PCL - posterior shear of tibia
Dislocation is _________99% of the time
Lateral
Is central or lateral stenosis more common?
Lateral
Most of the time, the bulge is __________to the nerve root
Lateral
Repair of meniscus
Lesion in vascular outer third, tear extending in central, relatively avascular third of meniscus of a young (<40-50 years) or physically active older adult (>50), restrictions on WB status (don't want to put compressive forces through the knee
Strong evidence exists that an inactive person will show ______ wear than in an active person with a THA, but exercise will decrease fall risk, ___________ bone density, and prosthesis fixation
Less, increase
Levels of Evidence - 2
Lesser quality diagnostic studies, prospective studies, or randomized control studies (weaker diagnostic criteria, reference standards, improper randomization)
Where does the iliopsoas attach to?
Lesser trochanter
Grade III Sprain
Ligament fibers are completely torn, there is pain during initial injury but then it subsides, tenderness may be present, lots of swelling, hemarthrosis may occur within 1-2 hour, feels unstable or gives out at certain times, rotational instability, end feel is empty
Grade II Sprain
Ligament fibers are partially torn w/ hemorrhaging, little tenderness and moderate swelling, joint may feel unstable or give out during activity, increased joint laxity yet there is still firm end point
How is knee stability maintained?
Ligaments, muscles, menisci, bony contours
Soft tissue treatment
Look for TPs, stretch what is tight (hip flexors, quadriceps, gluteals, TFL, piriformis, hip rotators
Loose pack and closed pack of talocrural joint
Loose packed - PF Closed packed - DF
Clinical findings of FAI
Loss of IR out of proportion w/ loss of movement at other positions (flexion and IR may be restricted when combined)
_______pressure does not produce the same effects (i.e. manual, self traction)
Low
Cervical pain can refer from...
Lung, liver, heart (usually L, can go into L jaw)
What is GTPS provoked by?
Lying on affected side but can also hurt lying on unaffected side, standing for a long time, sitting w/ legs crossed, climbing stairs, running or other high impact, repetitive activities
When the ACL is disrupted, the _______ provides most of the anterior stability
MCL
Clinical presentation of GTPS
Main symptom is pain and tenderness along the lateral thigh, pain may radiate down the thigh and buttocks, but rarely goes to the posterior thigh or distal to the knee, often described as aching but can be intense w/ strenuous activity, aggravated by passive, active and resisted hip ABD and ER
CAM occurs more in whom?
Males (ave. age 32)
What is infant hip dysplasia?
Malformation of the hip, can be either congenital or acquired, at risk for dislocation
PT and manipulations
Manipulation is used to break adhesions in the folds of the joint capsule and restore normal joint mobility, brings tissues into the plastic range of SS curve but not so forceful to cause failure, restore normal arthrokinematics, nutrition of articular cartilage
Best results are a combination of _____________ and _______________
Manipulation, exercise
__________therapy should not be considered a first-choice treatment
Manual
What do osteopaths do?
Manual medicine - many low and high velocity techniques, manipulate to restore normal range and quality of movement, break mechanical adhesions, stimulate proprioceptors to restore afferent and efferent balance, move synovial fluid - restore viscosity, improve local circulation and drainage, psychological - firm confident therapeutic touch
_____________ ___________techniques have been shown to inc. hip ROM and dec. pain in patients w/ hip OA
Manual therapy
Interventions for LBP
Manual therapy (thrust vs. non thrust), exercise (strength, endurance, stabilization), flexion exercises, extension exercises, nerve mobilization, traction, patient education, fitness exercises
Bone contusions (microtrabecular fractures)
May occur due to pressure on the knee w/ trauma, unlikely to significantly reduce function
Documentation applicable to goal setting
Measurable, functional, time elements
Oswestry scale
Measurement tool for patient satisfaction
The GRF falls __________ to the joint during a cutting maneuver
Medial
____________compartment of the knee is more likely to get osteoarthritic problems
Medial
_______femoral condyle goes down farther distally, therefore it wears out sooner
Medial
Where is the pes anserine located? What attaches there?
Medial tibia, gracilis, sartorius, semitendinosus
When are patients admitted to hospital before THA?
Morning of surgery
Pain after TKA
Most common complaint and mostly felt in whole knee, also behind patella, may affect sleep
Acute MOI for labral tear
Most commonly from a slipping or twisting injury w/ catching-type groin pain
Adult females have more __________ than males
Motion
Pregnant females have more _________than other females
Motion
Interventions for subacute LBP w/ coordination exercises
Neuromuscular reeducation, Manual , Exercise strength & endurance, Self acre training in mid range, Pain management
Facet injections
Non-operative alternative; analgesic effect; may last for several days, weeks, or months; also done @ epidural space to treat pain caused by nerve root irritation from HNP
In patients >60, labral tears are so common that it is a _________part of aging
Normal
Examination of MCL injury
Normally isolated swelling is seen on medial side of knee (may be minimal), palpation along the joint line may be tender, feel/hears "pop" or "snap", knee "stiffens up" within hours of injury, walking may be significantly limited, muscle guarding
Patient w/ severe pain and neuro deficits that are not relieved w/ changes in position are ________manual therapy candidates
Not
Nerve root compression results in...
Numbness/tingling, motor weakness, decreased deep tendon reflexes, decreased blood flow to nerve
Post op complaints
Over or underuse, pain, stiffness/rigidity
What are the two harnesses used for traction?
Pelvic belt and rib belt
Trendelenburg
Pelvis drops on the non-stance side (most everyone drops a few degrees, females more than males)
What is inversion or supination supported by?
Peroneus muscles and lateral ankle ligaments
SF-36 (Generic)
Physical and mental components score, subgroups - general health, physical functioning, role functioning, bodily pain, mental health, emotional functioning, vitality, social functioning
Supination
Plantar flexion, inversion, adduction
Mobile TKA
Polyethylene insert can rotate slightly, which gives the knee implant a more natural interface b/t the surface of the femoral component and polyethylene insert, both gliding and rotating motion can be done, since PE can rotate, contact w/ FC is more even, less stresses and wear
____________must unlock knee when knee is in full extension when moving into flexion
Popliteus
What are the 3 articulations of the ankle complex?
Proximal tibiofibular joint, distal tibiofibular joint, talocrural joint
Describe the proximal tibia
Proximally flared into two plateaus (condyles) that articulate with the femoral condyles, separated by intracondylar eminences (tibial spines), attachment of the cruciate ligaments and the menisci, both plateaus densely covered w/ articular cartilage
Posterior glide test
Pt is in prone, palpate PSIS, grab ASIS in front and lift up, this creates a shearing force
Long sitting test
Pt is lying in supine, check leg length, check ASISs, have patient sit up and check leg length again; if ASIS is down, acetabulum would be down and leg could appear longer, leg length should correct itself when patient sits up
Positional traction
Pt is placed in a position which causes gaping of a facet joint, intervertebral foramen, or reduces pressure on a nerve root, most common position is SL on non-involved side w/ towel roll or bolster under to create opening on contralateral side
Sacral compression
Pt is prone, PT applies a downward pressure to the superior portion of the sacrum and then the inferior portion of the sacrum
Anterior and posterior rotation
Pt is side lying, PT grasps the subjects ASIS w/ one hand and ischial tuberosity w/ the other and applies an anterior and posterior rotatory force
Approximation
Pt is side-lying, PT compresses into the subject towards the exam table
Gillet (stork) test
Pt is standing, one thumb on PSIS (on side you lift) and one thumb on sacrum around S2, PSIS should rotate backwards on side you lift
Who is most likely to benefit from traction?
Radicular symptoms from lateral stenosis
Coordination impairment signs + symptoms
Radicular weakness and lumbar spine stays stiff
Grade III strain (severe)
Ranges from >50% to complete rupture, both the ms belly and tendon may be involved, causes massive swelling and pain, significant weakness and loss of function
ACL injuries _______occur in isolation
Rarely
Failure to regain strength of the important trunk stabilizers may increase risk of _________________
Re-occurrence
Laminectomy
Removal of lamina
Spinal stabilization
Retraining appropriate activation of the TA and/or multifidus
Describe the LCL
Round cord like tissue, runs from lateral epicondyle area just above the groove for the popliteal tendon distally to attach on fibular head b/t tendons of biceps femoris, does NOT attach to meniscus or capsule, most taut w/ varus force
Examination of piriformis syndrome
Rule out lumbar spine, tender to palpation deep to gluteus maximus , pain and/or weakness with resisted hip abduction and external rotation, symptoms with the piriformis in a stretch position, Lasèque sign/Straight Leg Raise Test, positive for SLR will most likely be between 35-70 degrees, repetitive clamshells could cause symptoms
What anchors the meniscus to bone?
Sharpey's fibers
Lateral lurch
Shifts weight toward the weak or painful side
Minimally invasive TKA
Shorter incision, quad sparing, early, limited results: better ROM, less blood loss, shorter LOS
Primary restraint
Signifies the structure that is the major restraint to movement, ex: ACL - primary restraint to anterior translation of tibia
Patella baja
Sits low and is associated w/ diminished ROM esp. flexion and OA of PF joint
What is a posterolateral approach associated with?
Slightly higher risk of dislocation
How long does recovery from a hamstring strain typically take?
Sometimes weeks to a full year
What is a common symptoms of hamstring strains?
Sudden onset of pain in posterior thigh, may have an audible "pop"
Allograft
Taken from cadavers, slight risk for injection
Drehmann's sign
Unavoidable passive ER while performing hip flexion
Adult
Very dependent on body type and function
Grades of Recommendation - C
Weak evidence, a single level II study or support from level III or IV studies
What causes a sports hernia?
Weakening of the abdominal wall
How do you rotate pelvis back posteriorly?
Works glutes and hamstrings
Explain the centralization peripheralization phenomena.
Worse w/ flexion (peripheralize radicualr symptoms), better w/ extension (centralize peripheral radicular symptoms)
Examination findings
Worse w/ flexion and/or SB, worse w/ repeated flexion, better w/ extension or repeated extension, motions must be slow or you risk pinching bulging disc, nucleus moves like a very thick fluid
Diagnosis of pars fracture
X-ray (often oblique view, sometimes does not show), MRI, CT, bone scan
Diagnosis of Spondylolithesis
X-ray, MRI, Bone scan, increase symptoms w/ hyperextension (sometimes flexion as well), pain w/ pressure on spinous processes, Step Deformity
S&S of Spondylolysis
lower lumbosacral back pain and spasm, may have referred pain into buttocks or LE, often increases lordosis, tender with PA pressure to spinous processes
Meniscal allograft
Young/active patient who previously underwent total meniscectomy and now is symptomatic because of early osteoarthritic changes
What is pars interarticularis?
a bony isthmus between the superior and inferior facet joints of the spine
Intervention for spondylolisthesis:Grades 1&2
patient education to : avoid hyperextension, limit end ranges, especially heavy loads, proper lifting, bending, and sitting, often LS brace
what is key in order for muscle to control thing in the neutral zone?
proprioception
Prevalence of FAI
10-15% of population
Where can you palpate the rectus femoris?
AIIS
Where does the rectus femoris attach?
AIIS to tibial tubersoity via quad tenson
What are the parts of THA implants?
Acetabular cups, polyethylene liner, femoral head, neck, stem
Describe inserting the acetabular component
Acetabular shell is inserted (porous coated or cemented), a hard smooth plastic liner is inserted into the metal shell
Aquatic therapy
Benefits are pain control, ROM, stabilization
Genu varus
Bow legged, rare to see a true varus at the knee
Risk factors for hip dysplasia
Breach birth, infant held in hip adduction and extension
Primary piriformis syndrome
Caused by anatomical variation, <15% of all cases
Patients w/ labral tears typically complain of what?
Clicking, locking, or catching
Lateral stenosis occurs with ___________ and DJD
DDD
Gait observations
Dec. stance phase on involved side, dec. hip extension, Trendelenburg or lateral lurch
Adductor magnus helps __________the hip
Extend
Increased lumbar lordosis, lumbar spine is ___________________
Extended
Describe the posterior drawer test
Flex hip to 45 degrees, knees to 90 degrees, push knee posteriorly
FABER test
Flex, ABD, ER
Decreased lumbar lordosis, lumbar spine is __________________
Flexed
Gait - OA
Flexed hips, extended lumbar spine, shorter stride
Actions of TFL
Flexes, ABD, IR
Tibial portion of the sciatic nerve innervates the knee ____________ and ___________
Flexors and rotators
Adductors are __________when the hip is extended and _________when the hip is flexed
Flexors; extensors
Therapeutic Neuroscience Education
Focuses on the neurophysiology and the processing/representation of pain
What is myositis ossificans?
Formation of ectopic bone as a result of bleeding due to blunt trauma, x-rays show a calcium deposit 2-6 weeks post injury, pain, weakness, swelling, point tenderness, and dec. ROM
Popliteal (Baker's) cyst
Forms when a bursa swells w/ synovial fluid, results from chronic effusion and intra-articular lesions
During extension the menisci move _______________via attachments to the retinaculum
Forward (effect of quads)
Posterior superficial musculature
Gastrocnemius, soleus, plantaris
What are outcome measures designed to do?
Gauge treatment effectiveness and efficacy; looks at biopsycosocial effect of treatment; patient generated questionnaires
What is the most frequently strained muscle in the body?
Hamstring
Telescoping hip
Hip is flexed to 90 degrees, PT grasps lower leg and pulls hip anteriorly, feeling for excessive movement
Hx of manipulation
Hippocrates 3000 BC, bone setters 1871 (Hood), PTs in Sweden 1887, England 1899
Ortolani's sign and Barlow's test
Hips flexed, abducted and externaly rotated, you feel a click
McKenzie Method
History, examination, classification into syndromes, interventions based on syndrome, emphasized self treatment, therapists job is to guide treatment, patient education is emphasized, minimal hands-on treatment
Interbody cage
Hollow cylinders made of titanium, carbon, or bone filled w/ autogenous bone graft or a bone graft substitute and inserted b/t the bodies
Types of meniscal tears
Horizontal, radial (transverse), longitudinal (vertical), oblique, degenerative lesions
Interventions for grade I strains (mild)
Ice, being active, keeping moving
PT management of piriformis syndrome
If symptoms are due to a shortened, hypertonic piriformis, change the tone and increase mobility, Soft tissue techniques. PNF patterns, contract/hold relax techniques If the symptoms are due to a weak or inhibited piriformis, focus on strength (ABD and ER), Nerve glides - put patient in slumped position and have them do knee ext, or in supine (could add DF and ADD), McKenzie exercises. Lower trunk rotations - if really irritable at first, Bridge variations, Clamshells, Seated resisted ER, Quadruped fire hydrants, Theraband squats , Side steps, monster walks with theraband, Forward and lateral lunges
What is the largest bursa in the body? What is its purpose?
Iliopsoas bursa; reduces friction b/t anterior hip capsule and iliopsoas
Describe internal snapping hip syndrome
Iliopsoas tendon snaps over the head of the femur, iliopectineal eminence or lesser trohanter
How do cardiovascular exercises work?
Inc. blood flow and oxygenation, memory improves, focus and concentration improves, mood if affected, deeper breathing engages diaphragm and dec. accessory muscle activation
Prevalence of LBP and costs of treatment and lost work productivity continues to ___________
Increase
Stiffness/rigidity after TKA
Initially felt in morning, gradually increased to affect all activities
Days 1-6 following Lumbar Microdiscectomy
Initiate walking 1-3x per day as tolerated, become independent w/ bed mobility (sit to stand and toileting day 2), discharge from hospital 12-48 hours post op, protection of wound, limit bending and lifting, pain management, walking progression 5-10 minutes on level surface w/ minimal AD
Neuromuscular control
Injury to system, which can occur with traumatic spinal injury can result in diminished proprioceptive input and lead to further damage of passive restraint structures, diminished spinal stability
Interventions for hypomobility
Joint mobilization/manipulation, stretching, strengthening into a new range (elastic zone)
List some knee outcome measures
KOOS (knee disability and OA outcome scor), LE functional scale (FEFS), 6 minute walk test, TUG, VAS
Knee
KOOS, knee osteoarthritis outcome scor
Surgery
Laminectomy, foramenectomy
What will the "scotty dog" look like if there is a pars fracture?
Like the dog has a collar on
Cementless fixation
Liner consists of porous material compatible for bone growth, bone grows and secures liner in place, younger - less potential for cement to crack, more active, protected WB for 6-12 weeks, better for long-term fixation, longer recovery
Focus should be on ____load, ____ hold
Low, tonic
Pain past 70 degrees is most likely what?
Lumbar spine or SIJ, could be hip joint or articular in nature
Most patients are given a meaningless diagnosis such as ____________ ___________ or ___________ _____________
Lumbar strain; lumbar pain
Dysfunction syndrome
Mechanical deformation of soft tissue affect by adaptive shortening; results in loss of movement; pain w/ stress on shortened structures; intermittent pain; dec. ROM; name for the DIRECTION OF THE LOSS OF RANGE (typically extension)
If you fracture the femoral neck, what could be damaged?
Medial and lateral circumflex arteries, obturator artery
Where does the medial and lateral head of the gastroc originate?
Medial and lateral femoral condyles
Medial or lateral meniscus injury is more common?
Medial because it is attached to the MCL and is less mobile
Chondral injury
Occurs at the time of impact, chondral degradation is common years after an ACL injury
Step Deformity (EXAM)
One spinous process may appear to be anteriorly displaced over one below
What hip pathology is more common in older age?
Osteoarthritic changes
Examination of the low back
Outcome measures, measurements of lumbar ROM, centralization and peripheralization of symptoms, instability tests, straight leg test, slump test, trunk strengthening and endurance tests, fear avoidance questionnaire, pain assessment questionnaire
If you are suspecting a ligamentous injury, what do you always want to check first?
PCL
What attaches to the lateral meniscus?
PCL, popliteus, and posterior thickenings of the capsule
If the cauda equina is affected, there will be _____________ signs and possibly ______&________signs
PNS; bowel and bladder
SIJ tests w/ the highest level of reliability
Pain
Chronic LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ sustained end range movements
Examination of LCL injury
Palpation could reveal tenderness over the posterolateral knee, no significant joint effusion (unless there is also a cruciate ligament or meniscal injury), varus stress test at 30 degrees of flexion
Examination of trochanteric bursitis
Palpation is the most provocative clinical test, Ober's test, MRI provides the most sensitive image
Interventions for Grades 1 and 2 Spondylolithesis
Patient education to avoid hyperextension, limit end range flexion (esp. w/ heavy loads), proper lifting, bending, sitting, often LS brace
What are some components of a post-op treatment program for the lumbar spine?
Patient education, exercise (spinal stabilization, strength, ROM, aquatic therapy, and cardiovascular), walking program, manual therapy, neural tissue mobilization, modalities
Craig's test
Patient is prone, bend knee, feel GT and feel for when it is most prominent
Ely's test for tight quad
Patient is prone, flex knee
Advantages of Unicompartmental arthroplasty
Preservation of ACL, smaller incision, less blood loss, lower morbidity, shorter recovery time, lesser bone removed
Femoral stem insertion
Press fit, cemented
A major part of pre op education should be dedicated to what?
Prevention of dislocation
Other variables important for predicting the outcome of stabilization treatment were a hx of _________________________ and _____________detected during segmental mobility testing
Previous episodes of LBP; hypermobility
Primary and secondary restrain for MCL
Primary - valgus force Secondary - Anterior knee stability
The initial goal of an acute episode is to ________pain and disability and progress the patient into stage II of treatment
Reduce
Unicompartmental arthroplasty
Replaces only damaged or arthritic parts in either compartments
Goals and advantages of artificial disc replacement
Replicate normal disc and joint biomechanics, reduce the forces transmitted to adjacent segments, improve disc height while maintaining structural integrity
Surfaces are covered w/ interlocking ___________and_______________
Ridges; depression (smaller in children and females, larger in males and post menopausal females)
If your left hip ABDuctors are weak, you will drop to the ___________side
Right
Risk w/ cervical manipulation goes up greatly when _________ is part of the manipulation (esp. in upper cervical spine)
Rotation
Neurological symptoms w/ patellofemoral disorders
Saphenous nerve neuralgia, CRPS
Reg flags S&Ss
Sensory changes in the rectal, genital region; changes in bowel and bladder
Coxa Varus
Shortening of abductors
Lachman's test
Slightly flex knee to 30 degrees, top hand on femur, bottom hand on tibia, quick pull w/ bottom hand, try to get an anterior pull with tibia; (+) test = do you feel laxity, does patient feel a difference from side to side
_________and________ are the the most prevalent early complaints
Stiffness & pain
Inc. in technology (MRI, bone scans, US, etc) have allowed for precise _____________ assessment
Structural
What nerve can be damaged w/ a hip pointer?
Superior cluneal nerve (folds over the top of iliac crest, you would lose sensation to the upper buttock region)
Ears of "scotty dog"
Superior facets
Grade 1 Spondylolithesis
Superior vertebrae migrates anteriorly 0-25% over the inferior vertebra
Symptoms of hamstring strain
Swelling and ecchymosis, pain w/ palpation, when there is a palpable defect - more severe injury, dec. AROM and PROM (SLR, 90-90 degree SLR, tripod sign)
Symptoms of a PCL injury combined w/ other ligamentous injuries
Swelling, bruising, anterior and posterior knee pain, a feeling of instability, limited ROM, difficulty walking
BW support treadmills may be more effective at restoring what?
Symmetrical gait
What 2 muscles attach to IT band?
TFL and glute max
Describe external snapping hip syndrome (most common)
TFL or glute maximus tendon as it inserts into IT band snaps over greater trochanter
What is traction?
Tensile force is applied manually, with a machine, or using patient's own BW and the force of gravity
Galeazzi sign
Test for infant hip dislocation, infant is supine w/ feet together on flat surface, femur will appear short on side of dislocation (femoral head is posterior to acetabulum)
Validity
Testing what you think you are testing
Thomas test
Tests for tightness of hip flexors
Annular rings are _____________anteriorly and _______________posteriorly
Thicker; thinner
Gravity assisted or inversion traction
Units available to general public
Osteoarthrosis will usually produce a ______________limited ROM
Universal
Laminotomy
Window is made into lamina
How do you rotate pelvis back anteriorly?
Work hip flexors
Intervention for spondylolisthesis once healed:
trunk strengthening, endurance, proprioception exercises
Q angle for males
14 degrees +/- 3
Normal hip drop
5-10 degrees
_____-_______ lbs during lumbar traction can reduce a disc prolapse, retracting the herniated discal material
60-120
TKAs are most performed on people ____-____ years old
60-80
Associated procedures w/ meniscal tears
ACL, PCL, articular cartilage repairs
Ischiofemoral ligaments is taut w/ ____________ and __________
ADD and IR
What are the 2 most common types of ACL reconstruction?
Autografts (patella bone and hamstring) and allografts (no consensus on which provides the most stability)
Precautions at 1-3 weeks
Avoid deep trunk flexion, high-velocity movements, valsalva, prolonged sitting
The hip angle normalizes w/ aging and weight _____________
Bearing
Clinical presentation of piriformis syndrome
Buttock pain that radiates to the posterior thigh and proximal lower leg . aggravated with prolonged sitting or walking, squatting, and positions that increase tension on the piriformis (hip adduction and IR) , pain decreases when lying down, bending the knee or when walking, knee flexion takes some tension off the nerve (not all patients can tolerate), isn't characterized by dermatome changes, myotome weakness, or diminished deep tendon reflexes, the patient may present with a limp when walking , knee flexed or when piriformis contracts it hurts , the patient may keep their leg in a shortened and externally rotated position while supine (splayfoot)
Upper extremity
DASH
When do patients start to ambulate after surgery?
Day of surgery or post op day 1, usually WBAT
You want to strengthen the ________stabilizers when you have weakness of the static stabilizers
Dynamic
Slow loading
Ligament deformation
MOI for disc
Often flexion or flexion w/ rotation
How can you rule out a stress fracture int he pelvis?
Patient is supine, SLR, then bend knee and flex more, sign of the buttock
Documentation of traction
Patient position, traction method, types of traction, magnitude of force, duration of traction, duration of hold/release periods, patient's symptoms before, during, after
CPR for stabilization
Patient's age >40 years old, average straight leg raise ROM >90 degrees, positie prone instability test, aberrant motions present in sagittal plane AROM
Goals of rehabilitation
Patients w/ acute symptoms are directions towards reducing pain and decreasing impairments; patients w/ chronic symptoms are less focused on pain and more focused on reducing anxiety and returning to participation in work, home, or athletic activities
Occurs when the pt reports the movement of pain from an area more proximal in the lumbar spine to an area more distal or lateral
Peripheralization
FABs result in...
Physical inactivity, reduced mental well being, assumption of sick roll, deterioration of family dynamics, dependence on medications, excessive utilization of medical services
Health Related Quality of Life (HRQL)
Physical, emotional, psychological, social
There is some evidence supporting manual therapy techniques directed toward the lumbar spine and SIJ as an effect _______-term intervention
Short
Patient selection for artificial disc replacement
Suffer from DDD, single level disease, failed conservative treatment
Injections treat ___________, not the __________
Symptoms; cause
Vascular pain
Throbbing, pounding, pulsating
Resting position of talocrural joint
10 degrees PF
Odd facet (or flexion facet)
Articulates only in full flexion (more medial)
Longitudinal (vertical) meniscal tears
Bucket handle tears (most likely to cause some type of catching or inability to get full knee extension or flexion), posterior horn or anterior horn tear
The medial plateau is ____shaped and the lateral plateau is ____ shaped
C; O
The annulus fibrosis has a ___________differentiation w/ nucleus when young
Clear
Where does the lower cluneal nerve come off?
Comes off the posterior femoral cutaneous nerve and goes up
Cauda Equina Syndrome
Compression of inflammation of the cauda equina results in paresthesia, anesthesia, paresis or paralysis, and possible B&B or genital dysfunction; nerve roots become chronically inflamed and adhere together
How do you perform inversion/eversion mobs on subtalar joint?
DF, shift calcaneus medially/laterally
Acute LBP w/ mobility deficits
Diminished ROM, pain worse w/ provocation of involved segments
MOI for PCL
Direct blow to front of tibia w/ knee flexed (most common), also forced hyperextension, can result from car accident in which posterior force is applied to tibia when the flexed knee hits dashboard
MOI of action for ACL injuries
Direct contact - 30% of cases Indirection contact - 70% of cases
MOI of quad contusion
Direct impact to muscle
What is a hip pointer?
Direct trauma to iliac crest
Posture w/ bulging disc
Disc occupies space and blocks extension, causing patient to flex
Pronation
Dorsiflexion, eversion, abduction
What are the menisci made of?
Fibrocartilaginous discs
What might the individual feel or hear after a MCL injury?
Immediate pain or feel/hear "pop"
Cons of minimally-invasive THA
Increased complications, smaller visual field/surgeon learning curve, skin integrity (greater risk for skin tears, infection), why fix what isn't broken?
Front feet of "scotty dog"
Inferior facets
Nerve roots are highly ______________ - react to compression
Innervated
Do you bear weight through the fibula?
Minimally
Females have a more ___________condylar notch
Narrow
Neck of "scotty dog"
Pars
To improve DF, what direction do you want to glide?
Posterior
What is the KT100 arthrometer?
Provides an objective measurement of anterior tibial translation, can be useful when pain and guarding preclude evaluation, can be used as part of the follow up exam after ACL reconstruction
Compression
Pt is supine, PT crossed their arms and pushes the ASISs away from the midline
Etiology of GTPS
Tendons of the gluteus minimus, medius and maximus and TFL attach directly or indirectly to the greater trochanter, the vastus lateralis increases the tension on the ITB because of its attachment to the greater trochanter, with hip flexion, the TFL pulls the ITB forward over the GT and with hip extension, the gluteus maximus pulls the ITB backwards over the GT, eventually the gluteus medius will tear from the repetitive friction, tightness of the ITB compresses and inflames the gluteal bursa; overuse and tightness of muscles that attach to the GT, contact sport or traumas
Cavitation
The cracking sound during a manipulation that is a result of...release of nitrogen gas within joint, breaking of adhesions within joint capsule, not necessary to attain improved movement
Are you better off with a vertical or transverse patella fracture?
Vertical b/c quad contracts and holds it together
You always want know _____ status from the surgeon
WB
What questions should you ask patients regarding their posture?
What does their job require? Do they sit most of the day? Do they stand most of the day? Do they walk most of the day? What leisure activities do they do? Does it require lifting, bending, and twisting? How often do they change their posture? How often do they reverse their posture?
Examination of lumbar stenosis
X-ray, MRI, CT scan, bone scan, EMG, NCV
Anterolateral rotary instability
ACL, LCL, posterolateral capsule, and arcuate complex
The classification system is intended for use in patients w/ _________LBP, however acuity is not strictly based on the total length of time the patient has had symptoms (based on severity of symptoms, goals, natural hx of condition)
Acute
Straights
All disease can be treated with manipulation, most everyone can and should have regular manipulation treatments to maintain normal health
All 4 ligaments of the knee are somewhat taut in what position?
All positions
For most people snapping hip syndrome is simple an _________________, however it may result in pain and weakness
Annoyance
Nucleus moves through torn ________ ________
Annular rings
Lateral ligaments
Anterior Talofibular (1st) Posterior Talofibular (3rd) Calcaneofibular (2nd)
What motion does the ACL resist?
Anterior shear of tibia on femur or posterior shear of femur on tibia , rotational shear in both directions
What surface of the patella is highly vascularized?
Anterior surface
Where does the vastus lateralis come off of?
Anterior surface of GT
ACl is a primary restraint to what action? Secondary restraint to what action?
Anterior tibial subluxation; rotation in both directions
Which direction does the acetabulum face?
Anterior, inferior, lateral
__________ make of 15% of reported cases and sports that involve repetitive end range hyperextension or hyperflexion w/ ABD and/or rotation - they are at risk for ___________tears
Athletes; labral
Reasons for PF pain w/o malalignment
Atraumatic PF OA, patella tendonitis, quadriceps tendonitis, IT band syndrome, prepatella bursitis, apophysitis (tendon attachment @ growth plate), bipartite patella (patella is split), oswood schlater's disease
Causes of lateral stenosis
Can be congenital, facet joint arthosis, loss of disc height, posterolateral bulge of IV disc or a growth within the IV foramen
Levels of Evidence - 3
Case controlled studies or retrospective studies
Levels of Evidence - 4
Case studies
Etiology of iliopsoas bursitis
Caused by RA, acute trauma, overuse, multiple mini-traumas caused by vigorous hip flexion and ext, when hip suddenly goes from flexion to hyperextension, there is tension that stretched the iliopsoas and the bursa, over time this can inflame the bursa
Chronic trochanteric bursitis (more common)
Caused by overuse (esp. cycling, running, swimming), results from repetitive compression and friction
Most common type of TKA
Cemented fixation- ambulating day 1 or 2, Cobalt-chromium alloy femur articulating with polyethylene tibial surface, All-polyethylene patella, Posterior cruciate substitution (Not enough evidence to say whether keeping or removing PCL is best)
Cemented vs. Cementless THA
Cemented technique: 98% survivorship @ 10 years, 93% survivorship @ 25 years Cementless technique: similar to above #'s for femoral component, and better w/ acetabular component at 15 year mark (now preferred method, especially in younger patients)
McKenzie also came up w/ the ________________phenomena
Centralization
The most important characteristic of patients likely to respond from specific exercise routines appears to be the presence of __________________
Centralization
The goal of treatment is to _________patient's symptoms and permit the patient to progress into another classification, most often a specific exercise or stabilization classification
Centralize
Effects of forward head posture
Cervical spine flexed, head on neck extended, all muscles of the subocciptal region are tight
What is snapping hip syndrome?
Characterized by a snapping sensation and/or audible "snap" or "click" in or around the hip when it is in motion
Pincer FAI
Characterized by bony growth on the superior-anterior aspect of the acetabulum, labrum is pinched b/t the prominent rim of the acetabulum and the superior-anterior head and/or neck of the femur
Legal issues of chiropractors
Chiropractic association believes that only chiropractors have been properly trained and that it should be illegal for any one else to perform the skill (it is in 2 states), chiropractors will perform modalities and exercise in the offices and wish to charge for PT services
How do you choose what position to place pt in?
Choice is related to being able to centralize or decrease symptoms
Pros/cons of metal ball w/ metal liner
Cobalt chromium alloy, more sizing options, allows for larger ball (more like natural joint, inc. ROM), fairly low wear rate, particles from wearing may cause inflammation, may perform better over long term, wear rate - 0.01 mm/year
Static tests
Compare relative positions of: ASISs, PSISs, iliac crests, pubic rami, depth of sacral sulcus, inferior angle of sacrum
What do patients typically complain of when they have lumbar spine hypomobility?
Complains of pain and stiffness, dull ache, may have LE referred signs, may have past h/o trauma, often unknown etiology, often sedentary, worsens with aging
Clinical findings for labral tear
Complaints of pain locking, catching, instability, giving way, and/or stiffness, anterior groin pain in 96-100% of cases, hip locking in 58% of cases, predisposing factor: coxa valga 87% of cases, c/o of clicking in the hip w/ (+) LR
Longitudinal tears are often ____, full thickness tears
Complete
Rotation - nucleus is ____________
Compressed
Provocation tests
Compression, distraction, knee to opp. shoulder, sheer, approximation, sacral compression, FABER, anterior and posterior rotation
Closed pack of subtalar joint
DF
Pre op education leads to what?
Decreased post op pain, medication use, LOS, and fear/anxiety
What should you do in preparation for traction?
Description of traction to patient, patient expectations, donn harness, position patient, explain/provide "kill" switch, set parameters, initiate treatment
Centralizing
Doing better
Most of the time, the _______ side of pelvis sits lower
Dominant
Precautions for anterior approach
Don't extend hip past neutral, no lying prone, do not ER or extend hip, do not perform bridging
L5 deramtome
Dorsum of the foot
Suitable but more risky
Downhill skiing, ice-skating, hunting, low-impact aerobics, volleyball, basketball, soccer, baseball
Slocum test for anteromedial rotary instability
Drawer test with tibia in ER
How does a quad strain occur?
Due to eccentric contraction or repetitive overloading during activity
The 2 most important factors for predicting success w/ manipulation are the _______ of symptoms and the lack of symptoms _____to the knee
Duration; distal
Correlation b/t medical imaging and LBP
False positive - 20-76% on subjects w/ no symptoms, 47% who had symptoms had positive findings (just b/c there is a positive finding does not necessarily mean the findings matches the patients complaints
Why are manipulations underutilized by PTs?
Fear of possible complications
Affective avoiders
Fearful and highly distressed, distorted significance of pain and condition of spine, will not attempt activities that might trigger pain, severely disabled, PTs need to address dysfunctional thinking, gradual exposure to fear activities
Prevalence of LBP (Level I evidence)
Females>males, inc. w/ aging, lower educational status, and jobs w/ higher physical demand
End plate
Fibrocartilage, serves as growth plate in child, transition point b/t body and disc, nutrition for disc from vertebral body
Where does the biceps femoris tendon insert?
Fibular head
How do you palpate the TFL?
Find ASIS and palpate just below it, attaches to IT band
How do you palpate the rectus femoris?
Find ASIS and slide ~ 1 inch distal and have patient extend knee
W/ meniscal tears, symptoms are frequently worsened by _______ and loading the knee
Flexing (squatting and kneeling are poorly tolerated)
PCL is most taut in ____________
Flexion
Common mechanisms of injury for lumbar spine
Flexion or flexion with rotation
Common mechanisms of injury for thoracic spine
Flexion w/ sustained flexion
Infant hips are most stable in what position?
Flexion, abduction, and ER
Motion detection tests
Forward flexion test, Gillet (Stork) test, long sitting test, posterior glide test
Chiropractors
Founded by David Palmer 1895, law of the nerve (relationship b/t nerves, muscles, joint, and general health), vertebrae can be subluxed, subluxation effects nerve and blood vessels at IV foramen (IV foramen is too small, this makes sense), impaired nerve function leads to disease, an adjustment or repositioning of subluxed vertebrae will release nerve and rehabilitate effected organs
Dengenerative meniscal tears occur most often in what decade of life?
Fourth and fifth decade
THA Indications
Fracture (due to fall), OA, RA, significant loss of function, failure of conservative treatment
Spondylolysis
Fracture of pars interarticularis, often begins w/ stress fracture, often caused by hyperextension trauma
What direction does the arcuate ligament run?
From fibular head it runs superior and medial
The goals for management for patients in stage II are more focused on improving more _______________abilities and avoiding ____________of symptoms
Functional; re-occurrence
Lumbar region can refer from...
GI, kidneys, bladder, uterus, ovaries, prostate, testicles
Proprioception treatment
Gait training (stride/step length, trunk rotation, arm swing), lumbopelvis stability, sit to stand correction, Trendelenburg correction, body supported gait training, aquatic therapy
How do you increase great toe extension?
Glide dorsally (concave on convex)
What is the most common injury in soccer?
Hamstring strain
What muscle group would you want to strengthen to prevent an ACL tear?
Hamstrings (prevent anterior translation)
Is taping beneficial? How do you perform taping?
Helps stimulate afferents; put ms in a slightly stretched position, origin to insertion (tends to come off in 24-48 hours)
Levels of Evidence - 1
High quality diagnostic studies, prospective studies, or randomized control studies
What structures in the posterolateral corner of the knee can affect rotatory stability?
IT band, biceps femoris tendon, lateral gastrocnemius, arcuate ligament, LCL, politeus tendon, popliteofibular ligament
Management of trochanteric bursitis
Ice, NSAIDS, activity mod, taping, e-stim, and possibly corticosteroid injection are used acutely to dec. pain, soft tissue and TP techniques to muscles attaching to GT, GM, and TFL, stretch hip flexors, ADD, IRs, strengthen hip ABD and ER, address leg length discrepancy
Etiology of hamstring strain
In the late swing phase, hamstrings are at their greatest length at this moment and generate max tension (contract eccentrically to decelerate flexion of the hip and ext of lower leg), strong hamstring contraction and quad relaxation is needed (lack of coordination results in hamstring tear)
What are some causes of patellofemoral pain w/ malalignment?
Inc. Q angle, lateral patellar compression syndrome, inadequate medial stabilizers, patella alta (too high), patella baja (too low), dysplastic femoral trochlea (if it is more shallow it can jump out of the groove)
Increased Q angle
Increased valgus, more likely to have an ACL, medial meniscus injury
Scarring from hamstring strains ____________risk of re occurrence
Increases
Risk factors for hamstring strains
Increases age (collagen is less elastic, mallard effect), hip flexor tightness (can cause inhibition of glute max), poor lumbopelvic control (anterior pelvic tilt), muscle fatigue, previous injury, overuse
Centralization was originally described by _______________ as occurring during lumbar movement testing when the patient reports the pain moves from an area more distal or lateral to a location more central or near midline position
McKenzie
Derangement dysfunction
Mechanical deformation caused by internal derangement (disc); constant or intermittent pain; certain motions cause either centralization or peripheralization of pain
Scoring for ODI
Min-disability: 0-20, patient education Mod disability: 20-40, problems w/ sitting, lifting, usually do well with conservative care Severe disability: 40-60, pain effects travel, personal care, sex, and sleep Crippling: 60-80, back pain effects all aspects of life 80-100 - bed bound or may be severely exaggerating symptoms
Who performs manipulations?
Osteopaths (a few MDs), chiropractors, PTs
What is the #1 intervention for poor proper?
Patient education
Femoral nerve tension test
Patient is in prone, passive extension of the hip (make sure to stabilize pelvis), then flex the knee and extend the hip, you can put patient in SL to help with passive movement
If sacrum is pushed to the left, it can put tension on _______________
Piriformis (can create symptoms that are radicular in nature)
Sciatica - always check the __________
Piriformis (could also be the superior and inferior gemellus)
What type of patient education should be performed prior to surgery?
Post op pain management, position restrictions, ambulation, rehabilitation progression
Buttock pain is associated w/ ____________labral tears and lumbar spine problems
Posterior
Ligaments of the SIJ
Posterior and anterior SI, interosseus, sacrotuberous, sacrospinous
Clinicians must take into account screening for medical ____flags and psychosocial ______flags in order to determine suitability for therapy
Red; yellow
What is GTPS?
Refers to chronic pain caused by a number of structures including trochanteric bursa, gluteus medius and minimus tendons and IT band, previously trochanteric bursitis was seen as main source of pain, but research now shows bursitis to be to be only component
Evidence based for outcome measures
Reliable and valid measurement tools, based on the opinion of effectiveness from the patient prospective
Goals of joint replacement surgery
Relieve pain, restore function and mobility
Discectomy and implantation of artificial disc
Removal of damaged disc, determination of correct implant size, verify size, correct placement and alignment by AP and lateral fluoroscopy and x-rays, insertion of endplates in the disc space followed by insertion of sliding core, final verification of the position of the implant
Goals of treatment
Restore mobility and function, decrease pain, avoid surgery, lack of literature on manual therapy and FAI
Sign of the buttock
Restriction of SLR concurrently with limited hip flexion and a non-capsular pattern of restriction of hip joint ROM
Clinical presentation of intra-articular snapping hip syndrome
Results from a sudden onset of snapping or clicking from a traumatic even to the hip capsule, sources of the snapping can come from intracapsular lesions, loose bodies in the acetabulum, a torn labrum, or idiopathic recurrent subluxation
S&Ss of quad strains
Same as HS strains, pain and weakness w/ resisted knee flexion, thomas test (kendal's test - modified thomas test that adds knee flexion)
Discs heal w/ ______ __________, making tissues less flexible
Scar tissue
LBP is generally_________
Self-limiting
What is joint distraction?
Separation of 2 articular surfaces, reduces compression on the joint surfaces and widens the intervertebral foramen
Hindfoot/rear foot
Talus and calcaneous, subtalar joint
Individuals who do not weight bear stay in coxa ____________
Valga
Most of the time a traumatic lesion is a _____ or a _________tear of meniscus
Vertical; longitudinal
Disc herniations are most commonly seen in what population?
Young adults
Spondylolysis occurs more in what population?
adolescent (athletic) and 2x more common in males than in female
why do patients with spondylolisthesis need to do proprioceptive exercises?
proprioception exercises (patients need to learn to feel where the limits are on their movements and be able to limit them during sports)
How can you clear the lumbar spine?
AROM, PROM w/ overpressures, quadrant positions, PA spring testing to lumbar spine, LLTT
AVN is fairly common in _______________
Childhood
Motions w/ males ______________@ puberty
Diminish
Where does the semimembranosus insert?
Medial posterior tibia
Chief complaints of meniscal tears
Pain w/ WB, locking and catching, episodes of giving way
Medial femoral condyle is ________AP
Smaller
Medical management of GTPS
Trochanteric bursectomy, IT band release, reduction-osteotomy of GT, glute med tendon repair, corticosteroid injections, platelet rich plasma injections
You are born w/ coxa _________
Valga (~170 degrees)
Up to ____% of patients can't be given a precise pathoanatomical diagnosis
90
Grade 4
A low velocity force (sustained or small amplitude) applied at end range
AVN of hip is due to injury of what arteries?
Circumflex
Motions of talocrural joint
DF/PF, small amount of ADD/ABD, inversion/eversion
Diastasis Pubic Symphasis
Separation of pubic symphysis, can occur w/ trauma, repetitive stress or postpartum
Always go into extension __________
Slowly (need to give them time to adjust to new position)
Xenograft
Taken from animals, bovine xenogratfs have been associated w/ high complication rate
grades 1 and 2 signs and symptoms are?
low back pain and or buttock and leg referred pain, feeling of instability with sudden movements, jarring movements, spine "gives out" legs may buckle
What are the 3 syndromes in the McKenzie classification system?
1) Postural 2) Dysfunction 3)Derangement
Nearly ____ will suffer from re-injury within the 1st year following a return to sport w/ subsequent injuries often being more severe that original ones (hamstring strains)
1/3
Coxa Vara
100 degrees
Sensitivity for clicking w/ labral tears
100%
Normal hip angle
125 degrees
Sickness Impact Profile (Generic)
136 items, 30 min to complete, physical tasks, psychosocial, emotional
Normal antiversion is ________degrees
15 (anything less is retroversion)
Normal rotation
15-25 degrees
Q angle for females
17 degrees +/- 3
Coxa Valgus
170 degrees
Posterior interbody fusion surgical procedure
1st a laminectomy is performed, next the posterior 2/3 of the disc is removed and an interbody graft is placed into the evacuated disc space, most surgeons use pedicle screws to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis
What % of people over the age of 70 suffer from hip OA?
20-30
What is a normal sacral angle?
20-30 degrees
Hip pain from FAI is more common in what age group?
20-40 years old
Par interarticularis may no reach maturity until age
25
Separation occurs w/ ______ of BW
25%
What should you start w/ at initial treatment?
25% of BW
What % of people have recurring episodes of dislocation?
30-50%
Risk of death w/ spinal surgeries are _________times greater
300
Arthritis affects over ____ million people in the US
32
Minimal Detectable Change for ODI
4-6 points, 10-15 points
Long-term risk of dislocation
4.8%, highest risk is 1st year after surgery
>_______ of all ACL ruptures have associated meniscal injuries
50
You need at least _____% of patient's BW to distract the lumbar facet joints
50
After THA through a posterolateral approach, how long are hip precautions continued for?
6 weeks (but may vary depending on surgeon)
Frequency of spondylolysis
6% of adult population w/ LB pain, 47% of adolescent population w/ LB pain, 2x more common in males than females, pars interarticularis may not reach bony maturity until age 25
Up to _____% of those who do recover are prone to reoccurrence
60
Effective separation is reported at _____-______ lbs
65-200
Mobilization
A low velocity skilled movement done at a velocity that a patient can resist
Care immediately after surgery
A suction drain may be used for 1-2 days after surgery, intravenous fluids & antibiotics, pain medication, compression stockings and blood thinners, hip precautions based on type of approach (may be kept for 6-8 weeks or longer, some surgeons leave precautions indefinitely)
What is a resurfacing arthroplasty?
A surface replacement preserves the head and neck of the femur and only removes the diseased portion, preserved portion is sculpted to accept a metal cap w/ a short stem, acetabulum is replaced by the same procedure in a THA
Subgroups
Acute LB pain with related referred symptoms Acute LB pain with radicular symptoms Subacute LB pain with referred symptoms Subacute LB pain with radicular symptoms Chronic LB pain with referred symptoms Chronic LB pain with radicular symptoms
Labral tears can be ________ or__________
Acute or chronic
What are the 2 types of trochanteric bursitis?
Acute, chronic
ACL neuromuscular prevention programs include what?
Balance training, jump training (landing w/ inc. flexion at the knee and hip), strengthening (emphasize proximal hip control through hip ABD, ER, and hamstrings), skill training (controlling body motions, esp. deceleration and pivoting maneuvers), movement education, agility training
Clinical presentation of BOTH hip OA and FAI
Both present w/ + tests for FABER and FADIR, both present w/ dec. hip flexion and IR, patients w/ hip OA often develop osteophytes and bony overgrowth of the acetabular rim and femoral head
Interventions for hypermobility
Braces or corsets, patient education (keep out of end range postures and activities), strengthening and endurance, proprioception exercises, spine and neutral exercises
McMurray's test (meniscus)
Bring patient into full end range knee flexion, ER - medial, IR - lateral and drop them down into extesion
Risks of manipulations
Cauda Equina Syndrome (1 in 100 million), cervical brain stem lesions and vertebral artery injury (3-6 per 10 million), HA, muscle soreness, fatigue
Ref flag conditions
Cauda Equina Syndrome, infection, spinal compression fractures, abdominal aneurysm
____________evidence as to whether obese patients have lower functional gains and higher complication rates
Conflicting
Grades of Recommendation - D
Conflicting evidence, high level studies disagree
Causes of central stenosis
Congenital narrowing, thickening of ligamentum flavum, bone spurs, central disc bulge, growth within central canal (tumor)
What motions occur at the talocrural joint?
DF and PF (sagittal plane - medial/lateral axis) ABD and ADD (transverse plane - vertical axis) Inversion and eversion (frontal plane - A/P axis)
Colles fracture (dinner fork deformity)
Distal fragment goes dorsally
Depth of sacral sulcus
Divot that is medial to PSIS
Interventions for acute LBP, radicular
Education to reduce nerve root symptoms, manual, traction, nerve root mobilization
Desired effects of traction on soft tissue
Elongation of spine increases the distance between vertebral bodies and facet joint surfaces to increase the length of soft tissue/ligaments, stretch occurs slowly
Male and female children have _______motion
Equal
Disadvantages of Unicompartmental arthroplasty
Error in proper placement of components, loosening, prosthetic wear, secondary degeneration of opposite compartment
Examination of Spondylolithesis
Lower quarter screen, palpation for step deformity, PA glides
Examples of soft tissue mobilizations
Muscle relaxation, massage, trigger point techniques (high volt estim through sound head), deep pressures, myofascial release
Quad strains typically occur where?
Muscle-tendon junction (distally to proximally and sometimes muscle belly itself)
Mobs to midtarsal joint
One hand on talus and calcaneus, one hand on cuboid and navicular
Clinical findings for a posterior impingement
Painful ER in full extension w/ leg hanging off the end of table and uninvolved leg flexed
FABER test
Passively position the hip in flexion, ABD, and ER, (+) test = pain, this test doesn't tell you where the problem is, it tells you where to look next (hip joint, labrum, SI joint)
What is the largest sesamoid bone in the human body?
Patella
Excessive antiversion
Patellas are facing medially, compensate w/ hip deep ERs (piriformis syndrome), risk for femoral acetabular impingement, associated w/ ACL injuries
Classification category does not describe a _________________condition such as HNP
Pathoanatomical
Posterior sag test/Godfrey sign
Position passively patient at 90 degrees of knee flexion (table top position), compare both sides, positive side you will see a sag at the tibial plateau
How does the trochanteric bursa sit?
Posterior and inferior to trochanter
Anteromedial rotary instability
Posterior horn of medial meniscus, oblique popliteal ligament, ACL, MCL
What direction does the PCL run?
Posterior lateral on tibial plateau to anterior medial on lateral side of medial condyle
What direction does the PCL resist?
Posterior shear of tibia on femur or anterior shear of femur on tibia, rotational shear in both directions, ER
3 plane articulations b/t talus and calcaneus
Posterior talocalcaneal (70% of articulating surface, independent joint capsule, concave talus on convex calcaneus), anterior and medial talocalcaneal (share a joint capsule w/ talonavicular joint, convex talus on concave calcaneus)
PCL is primary restraint to ________________ and secondary restrain to ________________
Posterior tibial translation; hyperextension and tibial rotation
What are the common approaches to THA?
Posterior, lateral, posterior-lateral (incision is lateral and slightly anterior to trochanter), anterior (preserves musculature - b/t fibers of sartorius and TFL)
During flexion the menisci move ____________ via the semimembranosis and lateral meniscus via popliteus
Posteriorly
Lesser trochanter faces _______________, when muscle shortens it allows you to ______________
Posteriorly; ER
When in decreased lumbar lordosis, the pelvis is ___________ tilted and the ____________ and ______________are tight
Posteriorly; gluteals and abdominals
Reasons for traumatic PF disease
Posttraumatic OA, quad tendon rupture, patella tendon rupture, avulsion of tibial tubercle, contusion
Distraction
Pt is supine, PT presses the ASISs toward the midline
Traction is effective to reduce __________ symptoms in the C-spine
Radicular
Hamstrings are often re-injured due to inadequate __________ and _____________return to activity
Rehab; premature
All tendons go under a____________ w/ synovial sheath when they cross your ankle
Retinaculum
Weeks 3-8 following Lumbar Microdiscectomy
Return to work and ADLs, adhere to surgeon guidelines for lifting and activity/sports, pt able to walk on level surfaces w/o restrictions, advance TA exercises, advance glute/bridging exercises, advance hip strengthening (esp. hip abductors), initiate nonimpact LE involved cardiovascular exercise (pool workouts, treadmill, elliptical, stationary bike)
Weeks 8-12 following Lumbar Microdiscectomy
Return to work without restrictions, objective measures improve, release to activity base on achievement of goals and MD clearance
ROM exercises/stretches
SKC, DKC, piriformis stretch, lower trunk rotations, hip flexor stretches, pelvic tilts
DD of piriformis syndrome
Si dysfunction, HNP, tumor, cyst (hematoma), FAI, tabeal tear, hip OA, spinal stenosis
Traumatic chondromalacia (formerly patellofemoral syndrome)
Sick cartilage, degenerative changes in cartilage on posterior side of the patella
Indications for lumbar fusion
Significant trauma, degenerative disc or joint disease, hypermobility (spondylolithesis), severe, disabling back and/or leg
Best results based on ________and not anatomical structures, as it is impossible to be sure what anatomical structures are causing pain
Signs and symptoms
Outcomes of artificial disc replacement
Similar to lumbar fusion w/ respect to functional outcomes and pain relief, further research needed to determine if disc replacement reduces rate of adjacent segment disease compared with fusions, disc replacement products are being developed for lateral or posterior approaches
Patella alta
Sits too high and is associated w/ subluxation/dislocation, OA of PF joint, and patella ligament ruptures
McKenzie Principles
Sitting causes lumbar spine to flex, stressing ligaments, and increasing disc pressure; dec. in lumbar ROM further influences poor posture; healing of a disc after injury results in adaptive shortening
Grade I strain (mild)
Small % (<20) of fibers are damaged, rarely influences the muscle's power and endurance, pain and sensitivity usually happen the day after the injury, C/O stiffness and minimal swelling on the back of leg, ROM minimally impaired and gait may be normal
Intermittent traction
Stimulation of mechanoreceptors through oscillations - stimulates the GTO which leads to muscle relaxation and spasm reductions (Gate Control Theory); brief intervals; "on/off" cycles; distraction, mobilization, stretching
Inverter =
Supinator
Complete meniscal tear
Tear runs through both the superior and inferior surfaces
What is the #1 sign of a pars fracture?
Tender w/ PA pressures to spinous processes
Clinical presentation of trochanteric bursitis
Tender w/ palpation to superior/posterior greater trochanter, symptoms may radiate laterally or posteriorly down the thigh, resisted isometrics may be strong and painful or weak and painful (hip ABD, ER), walking, running, esp. stairs are painful, difficulty laying on the affected side, sleep may be affected
Surgical fusion procedure
The basic lumbar fusion is posterolateral, incision is made over the operative levels, and the paraspinals are separated off the SP, lamina, and TP, retractors hold back muscles to expose the bone for fusion, a high-speed burr removes the TP and facets in preparation for bone graft, pedicle screws and interbody cage are inserted
Global lumbar musculature
The large lumbar erector spinae provide most of extensor force needed for lifting; rotation is a complex movement that requires co-contraction of several ms groups (erector spinae, transversospinalis, obliques); ms groups do not have a direct attachment to the lumbar spine and can't control the motion of individual segments
Secondary pirformis syndrome
The result of macrotrauma (fall or microtrauma from repetitive overuse)
Grades of Recommendation - E
Theoretical/foundational evidence animal or cadaver studies, conceptual models, base science
What do chiropractors claim?
They were the first to develop manipulation and that others are infringing on their scope of practice
What patient typically goes to in-patient rehab after a THA?
Those who are able to tolerate at least 3 hours of therapy a day and have a good chance of returning home, typically older patients w/o family support and patients w/ comorbid medical conditions
What patient typically goes to a SNF after THA?
Those who cannot tolerate 3 hours of therapy a day and are not at risk for medical instability
Most susceptible athletes to pars fracture
Those who do frequent end range lumbar spine hyperextension: linemen in football, gymnasts, swimming and diving, wrestling, volleyball, cheerleaders, weightlifters
Condylar TKA
Tibial component is topped w/ a flat metal piece that securely holds the polyethylene insert, when knee is in motion, the femoral component glides over the polyethylene, natural shape of condyle is not a perfect circle
Posterior deep musculature
Tibialis posterior, flexor digitorum longus, flexor hallucis longus
Tom Dick and A Very Nervous Harry
Tibialis posterior, flexor digitorum, artery, vein, nerve, flexor hallucis
What 2 joints make up the knee?
Tibiofemoral joint and patellofemoral joint
If butt raises off the table during Ely's test, what does this indicate?
Tight hip flexors
What can a positive FABERs test indicate?
Tight hip flexors, adductors, joint capsule
Possible reasons for hip hypomobility
Tight joint capsule, hip adductors, hip flexors
A hypomobile individual typically presents with the following:
Tight muscles, tight joints, flattened lumbar lordosis, spine flexion, feet more supinated, overall limited mobility in most joints
Men tend to have _________ligaments than females
Tighter
Emotional (increased sympathetic nervous system)
Tiring, agonizing, dreadful, unbearable
W/ a more central bulge, the patient tend shift _________side of bulge
Towards
Action of proximal tibia
Transfer weight across knee to ankle
Proximal tibiofibular joint
Transfers forces from biceps femoris & lateral collateral ligament to tibia (ant and post proximal TF ligaments)
Degrees of translation and rotation at joint
Translation - 0-4 mm Rotation - 0-5 degrees
Functions of the knee
Transmit loads, allows lengthening and shortening of LE, provides stability for WB, provides mobility for functional movement
The menisci are attached anteriorly via the _______________ligament
Transverse
Layers of the cervical region (superficial to deep)
Trapezius, splenius, erector spinae transversospinalis, subocciptals
Symptoms for a ___________meniscal lesion are produced by instability of the torn fragment
Traumatic
Weak hip ABDuctors results, results in a ________________gait
Trendelenburg
Uni space implant
Used for isolated medial tibiofemoral OA, metallic spacer that distracts the medial compartment and transfers load to lateral side, meant to replicate shape of medial meniscus, doesn't require bone cuts or component fixation, results in good relief of pain, minimally invasive, higher rate of implant failure due to medial overhang
Intervention for spondylolithesis
W/ fracture: often brace in neutral, avoid end ranges especially extension and rotation Once healed: trunk strengthening, endurance, proprioception exercises
Rehabilitation
WB status, hip strengthening (hip extension, ABD, knee ext), balance, ADLs, beware of orthostatic hypotension
What is the #1 activity recommended by surgeons and PTs following lumvar surgery?
Walking (to prevent blood clots)
What are signs of infection?
Warmness, redness, low grade fever
Causes of TJA failure
Wear of articular bearing surface, aseptic/mechanical loosening, osteolysis, infection, instability, per-prosthetic fracture, implant failure
Timing of TJR failure (later >5 years post op)
Wear of articular bearing surface, osteolysis, mechanical loosening, peri-prosthetic fracture
What is the #1 most important piece of information to know about patient after hip surgery?
What is their WB status
Spondylolysis
a fracture of the pars interarticularis (bt superior and inferior facet), often begins as a stress fracture, often caused by a hyperextension trauma (you compress facet and put extra force through pars)
Neutral Zone
area in range of motion segment where there is little resistance to motion, mid range, muscle function limit and stabilize motion segments in this area of range (muscle control things in neutral zone)
Spondylolisthesis
forward displacement of one vertebral body over another, most commonly occurs at L5, S1, Second most common is L4, L5
Mechanism of Injury for spondsylolysis?
hyperextension of the lumbar spine resulting in a repetitive loading of the facet joints and pars interarticularis, Pars ma be congenitally thinner or not completely formed
Intervention for spondylolisthesis with fracture:
often brace in neutral, avoid end ranges especially extension and rotation.
Grade 1 for Spondylolisthesis
superior vertebrae migrate anterior0-25% over the inferior vertebrae
Degrees of nutation and counternutation of sacrum
~0.5 degrees
Recommendation for conservative care (time frame)
6 months
Total costs associated w/ arthritis are over $____billion/year (including hospital and drug costs, rehabilitation costs, and lost productivity and work)
82
Clinical Prediction Rule for those most likely to improve w/ manipulation
82% show significant improvement when... Onset less than 16 days, no symptoms below knee, lumbar stiffness, hip IR <35 degrees
Bony lesions have been reported in _____-____% of ACL injuries
84-98 (often either lateral femoral condyle, lateral tibial plateau, or both due to compressive forces)
How do you measure the Q angle?
ASIS to mid patella, mid patella to tibial tubercle
Hybrid fixation
Acetabular cup (press fit, fixation screws), femoral stem (cemented)
Describe process of acetabular reaming
Acetabular cup is reamed into a hemisphere, cartilage is removed
Musculoskeletal S&Ss
Aching, dull, sore, stabbing, sharp
How are TKAs different these days?
Admitted morning of surgery, mobilize day of surgery or 1 day post op, usually WBAT, LOS <1-2 days
Cognitive Behavioral Therapy (CBT)
Aims to address fears related to movement, pathology, and function
Extension - nucleus moves _____________
Anterior
Which approach is more technically demanding?
Anterior
Closed chain - screw home mechanism
As knee extends femoral condyles rotate medially on fixed tibia; no muscle action necessary due to shape of joint
In the absence of ________ __________syndrome or significant neurological deficits, conservative care is advocated before recommending surgery
Cauda equina
Partial meniscal tear
Compromises 1 surface
Typical MOI for ACL injury is what time of movement?
Cut-and-plant movement or a sudden change in speed w/ the foot firmly planted
A traumatic meniscal tear is more likely to require surgery than a _________tear
Degenerative
What should the focus of any post op program be on?
Early activation of hip extensors, ABD, and knee extensors
High-speed activities (such as cutting or landing maneuvers) require ___________muscle action of the quads to resist further flexion
Eccentric
Indications for surgery
Failure of conservative treatment (4 weeks-6 months), unbearable pain, significant or increasing neurologic deficit, cauda equina syndrome (absolute indication)
Indications for TKA
Failure of conservative treatment (NSAIDS, activity modification, PT, bracing and orthotics), intractable pain w/ loss of function
Specific exercise
Flexion, extension, lateral shift patterns
Why should individuals who are hypomobile stretch?
For pain (rocking rhythmic), to warm tissue, to increase mobility, to increase strength, endurance, and stability into a new range, to maintain improvements over time
Acute LBP
For some individuals can be greatly heightened following an episode of acute, severe LBP; avoidance behaviors may persist long after the acute injury has resolved
Exercises should focus on _______________tasks such as lifting
Functional
Clinical presentation of external snapping hip syndrome
Gradual onset of snapping or pain laterally over the greater trochanter, usually not associated w/ a major traumatic event, observable and audible snap as patient flexes and extends the hip, may describe a sense that the hip is dislocating, may have coxa vara or a prominent greater trochanter
ALIF alone can't withstand the forces across the ______, so many collapse or don't fuse
Grafts (protected w/ posterior instrumentation)
An increase in the neutral zone requires what?
Greater muscle performance (strength, endurance, proprioception)
Outcome measure for THA
Harris hip score, FIM, Oxford hip score, WOMAC, SF-12, 12-item hip questionnaire, VAS, overall satisfaction
Secondary restraint
Has some significant function in resisting displacement but isn't the major restraint, ex: MCL - primary restraint to valgus force, but secondary restraint if you take it far enough
Quadriceps active test
Have patient actively fire quads and see degree of tibial movement
How can you tell the difference between neurogenic and vascular claudication?
Have patient ride a bike, sit up nice and straight, then ride bike again in a flexed forward position (if it is better flexed forward, it is probably neurogenic) - can also perform on a treadmill (walk on incline)
Slipped capital femoral epiphysis
Head separates from the neck, usually seen in obese adolescent males
Ilium surface
Hyaline and fibrocartialge
Sacral surface
Hyaline cartilage (1.5-3x thicker than the ilium)
Other less invasive options
Hyaluronic acid or cortisone injections, Uni Spacer implant, unicompartmental athroplasty
Abdominals, spine extensors, diaphragm and pelvis floor muscles make the trunk a semi-rigid cylinder and tighten the TL fascia and abdominal fascia - what is this effect called?
Hydraulic effect
Who is most likely to benefit from manipulations?
Hypomobile joints, those that did not respond to low velocity techniques, no radicular symptoms
As you age, your collagen tends to bind together and you become _____________; you lose ______, tissues become more brittle
Hypomobile; GAGS
If knee is unstable in full extension, it is suggestive of what?
LCL/PCL injury
Patient hx of disc problems
Many small bouts of LBP over many years, usually resolves on its own w/ rest, each time it gets a little worse, LBP, worse w/ sitting and bending, begins in 20s, eventually pain goes from back to back and buttock and down LE
Symptoms of an isolated PCL injury
Minimal pain, swelling, instability, and full ROM, may also have near-normal gait pattern
In hypermobile individuals, you either have too much ________ or not enough _____________
Mobility; control
Traditionally, ___________assessments and _________tests have been used to classify a patient as needing manual therapy
Mobility; special
What are the 4 basic categories used for patients w/ acute LBP?
Mobilizaation/manipulation, stabilization, specific exercise, traction
What can facilitate a deeper stretch prior to interventions for hypomobility?
Modalities - warm tissues stretch better (i.e. hot pack)
Interventions
Modalities to calm inflammation of SIJ capsule and ligaments, local muscle attachments, attempt to correct pelvic asymmetry, correct asymmetry of position of sacrum b/t iliums, SIJ support belts (good for hypermobile individuals)
MRA
More sensitive test for labral lesions than the standard MRI and would help rule out intra-articular injury prior to the more invasive arthroscopy
Do most people tend to have tibial antiversion or retroversion?
Most have retroversion because femur is rotated in (tibia is rotated out)
Differential diagnosis for FAI and labral tears
Muscle strain, contusion/hip pointer, dislocation or subluxation, osteitis pubis, trochanteric bursitis, stress fracture, infection, AVN, referred lumbosacral pain, cancer
W/o any ____________activity the lumbar spine is a highly unstable structure even under low loading
Muscular
Should you manipulate if you have radicular symptoms?
No
How long do non-constrained knee replacements last?
Not as long as other knee replacements
Clinical presentations of ACL injuries
Occurs after either a cutting maneuver, landing, or jumping, may be a audible pop, feeling of initial instability which may be masked later by extensive swelling, episodes of "giving way" especially on pivoting or twisting motions, initially injury is extremely painful, swelling may be immediate and extensive, but can be minimal or delayed, restricted movement, especially inability to fully extend
S&Ss of quad contusion
Pain, loss of function, decreased ROM, decreased strength, effusion
Exercise routines involving repeated movements into end-range spinal motion have been _____________ over the years
Popularized
Flexion - nucleus moves ___________
Posterior
What position does your foot and ankle need to be in to adapt for the shape of the floor?
Pronation
More abducted =
Pronator
Interventions for weeks 1-3
Prone press-ups to tolerance from slight flexion to neutral, prolonged prone ext 30 seconds to 2 minutes w/ pillow/cushion under stomach, treadmill w/ an initial goal of 5 minutes (progression to 30 minutes), aquatic therapy (once cleared by MD), cryotherapy post-therapy and prn for pain, review bed mobility, sit to sand, utilization of UE, LE nerve glides, TA activations, gluteal/hip strengthening
__________________ is key in order for muscles to control within this range (neutral zone)
Proprioception
Sheer
Pt in supine, PT flexes and abducts the hip, PT then compresses downward along the line of the femur attempting to create a shear force alone the SIJ
What is the patella held in place by?
Quadriceps mechanism (patella tendon and ligament)
What muscle group would you want to strengthen to prevent posterior translation?
Quads
Pros of minimally-invasive THA
Quicker recovery, cosmetic appearance, less perceived invasion of the body, patients are asking for MITHA
Interspinous decompression spaces
Separates the SP to relieve pressure, not indicated for stenosis > 2 levels, supraspinous ligament prevents backward migration, spacer only limits extension
What are the desired effects of joint distraction?
Separation of joint surfaces (OA, menisci, osteochondral fragments, portions of capsule that "catch" or impinge joints), increase joint mobility, increase proprioception (may contribute to pain modulation), nourish articular cartilage
When should you refer to a surgeon?
The patient fails to respond to PT, joint injection does not provide relief, MRA
When should SLRs be allowed?
When partial or full WB is permitted
Clinical presentation of labral tears of hip
"C" sign, deep ache w/ prolonged sitting or standing and hip flexion type movements
Etiology of snapping hip syndrome
5% of the population (higher prevalence b/t 15-40 years old), occurs more in females, typically an overuse injury, occurs in activities that involve repetitive hip flexion and extension (such as dance, soccer, gymnastics, and running)
_______% of cases (piriformis syndrome) are due to macrotrauma of the buttocks, leading to soft tissue inflammation and muscle spasms, with resulting nerve compression
50
During a step up, there is up to ____x the person's BW through the hip
6
Ratio of piriformis syndrome female to male
6:1
The lifetime prevalence of at least 1 episode of LBP is as high as _______%
80
What is the typical length of stay after a THA?
<5 days
How common is combined FAI?
>80% of cases according to some reports
Pars interarticularis ("scotty dog")
A bony isthmus b/t the superior and inferior facet joints of the spine
Grade 5
A high velocity, short amplitude force applied at end range
Standard ________ or__________view will not give you a great view of the hip
AP or lateral
Diastasis Recti
Abdominal separation
Etiology of quad strains
Acute - single event Chronic - result of repetitive micro trauma
Children w/ CP have a lot of tone in their hip_______________
Adductors
Requirements of proper posture
Adequate ROM, muscle length, muscle strength and endurance
Use of test
Administer at initial evaluation, as needed, and at discharge; establish a goal for change; document changes in chart
Evidence that low-stress ___________exercise may be effective in treatment for acute or chronic LBP
Aerobic
Signs of cancer
Age >50, unexplained weight loss, previous hx of cancer, no relief w/ treatment in last month
Degenerative tears are due to _______ as well as activity levels (long-term ________ forces)
Age; compressive
Disc function
Aide in mobility, restricts mobility, annulus acts as ligament, provide space b/t vertebra, keeps IV foramen open, acts as shock absorber, normally - even distribution of forces throughout disc
Classification of instabilities - straight
Anterior, posterior, medial lateral
What are the 2 bundles of the PCL?
Anterior-lateral, posterior-medial
What are the 2 bundles of the ACL?
Anterior-medial, posterior-lateral
Elastic Zone
Area of range in which there is substantial resistance to motion, end range, provided by ligments and tight musculature, facet joint capsules, disc
Elastic zone (end-range)
Area of range in which there is substantial resistance to motion; provided by ligaments and tight musculature, facet joint capsule, disc
Shape of talus
Articular surface (talar dome) is wider anteriorly than posteriorly (making DF most congruent)
Non-constrained knee replacement
Artificial components inserted into the knee are not linked to each other, rely exclusively on the body's muscles, ligaments, and tendons to keep kneecap in place, no stability built into system, most common type of knee replacement; used when the knee is highly unstable and the person's ligaments will not be able to support the other type of replacement (severely damaged knee), 2 pieces are connected w/ a hinge-like device that keeps the joint inline and helps support the patella's proper alignment
Open chain - screw home mechanism
As knee extends tibia rotates laterally in the last 30 degrees of motion; due to shape of joint surfaces, pull of quads and PCL
Posterolateral corner injury
Associated w/ rupture of one or both cruciate ligaments, failure to address instability of these corner structures increased the forces at the ACL and PCL graft sites and may predispose to failure of cruciate ligament reconstruction
DD of hamstring straings
Avulsion fx of ischial tuberosity, adductor strain, referred lumbosacral pain, piriformis syndrome, SI dysfunction, sciatica, hamstring tendinitis, ischial bursitis
Extension protocol
Begin in position of comfort (the way they came in the door but now supported in prone), slowly progress to extension w/ passive positioning (leave in positions for 5-10 minutes), progress to prone on elbows and prone press ups (slow), must do often at home and avoid all forms of flexion
S&Ss of recurrent subluxation
C/O of pain (difficult to localize), giving way (could also be meniscus or ligamentous injury), feeling of instability, pseudo locking, "something jumps in my knee", "something feels out of place"
Combined FAI
CAM and Pincer can occur together
If the spinal cord is affected, there will be ___________signs
CNS
Is a pars fracture unilateral or bilateral?
Can be either
Apley's test (meniscus)
Can be most painful, so do it last! patient is prone, compression and IR/ER of lower leg
Progression of degeneration
Can begin in teens (breakdown of innermost annular rings), fissures b/t annular rings, fissures across annular rings, nucleus bulging through fissures, outer rings bulge, nucleus protrudes through (radicular symptoms if on nerve root), sequestration of nuclear material
Diagnostic procedures - MRI
Can diagnose ligamentous injuries w/ an accuracy of 95% or better, will also reveal any associated meniscal tears, chondral injuries, or bone bruises
Symptoms of meniscal tears
Can result in locking of the joint (especially "bucket-handle tears"), "popping and locking" occur when torn part of meniscus moves under the femoral condyle, medial or lateral line joint pain may occur due to abnormal increase in tension on the joint capsule
Tibial plateau fractures
Cause my varus or valgus forces w/ axial loading, lateral tibial plateau fractures (Segond fracture) are most common
History of SIJ dysfunction
Cause?, trauma? (fall, lifting injury, MVA), unknown etiology?, symptoms (LBP or buttock pain), muscle spasms (LB, gluteals), sensory changes (not normally, but could irritate nerve root)
Intervention for posture syndrome
Change posture, patient education
What is piriformis syndrome?
Characterized by buttock or hip pain , Neuritis of the sciatic nerve
Nerve root can be ___________ irritated when in contact w/ nuclear material
Chemically
What is the main cause of GTPS?
Chronic friction of the glute medius tendon over GT (glute min and TFL can also be affected - friction of these tendons leads to a secondary inflammation of the bursa)
Describe the lateral meniscus
Circular or "O" shaped, less extensively attached to joint capsule, no attachment to LCL
As a child, hip joint relies heavily on the artery to the femoral head; Adults rely more on _______________ arteries
Circumflex
Neurogenic claudication
Compression of nerve roots results in: Antalgic gait, paresthesia, cramping of muscles in one or both LE with activities such as walking; tend to be in a more flexed position (open packed)
DF closed chain
Concave on convex (anterior roll and glide)
PF closed chain
Concave on convex (posterior roll and glide)
What are fear avoidance beliefs?
Concerns and fears about potential for physical activities to produce pain and further injury to the spine; result in heightened anxiety, an obstacle for recovery and potential disability
How are degenerative meniscal tears most treated?
Conservative treatment
Red flags w/ LBP
Constant pain not affected by positions or activity, over 50, h/o CA, failure of conservative intervention over 30 days, unexplained weight loss, no relief w/ rest
MOI for anterolateral rotary instability
Contact/Non-Contact , hyperextension with varus and IR stress, IR of tibia or ER of femur
MOI for anteromedial rotary instability
Contact/Non-Contact, flexed knee and valgus stress, ER of tibia or IR of femur
PF open chain
Convex on concave (posterior roll, anterior glide)
Exercises for Spondylolithesis
Core strengthening w/ proper posterior tilt, strengthen abdominals and gluteals, tighter hamstrings will limit anterior tilt of pelvis (maybe not stretch?), proprioception exercises, fine control pelvic tilts, pelvic clocks, spine neutrals, short range exercises, isometrics
The menisci are attached to the tibia via ___________ligaments
Coronary
Interventions
Correct lateral shift, posture, modalities, exercise, mobilization, traction, brace w/ extension
How do you know if treatment is successful?
Correction of alignment, symmetry of motion, relief of pain
Suitable sports and activity recommendations
Cycling, swimming, low-resistance rowing, walking, hiking, low-resistance weight lifting, ballroom dancing, square dancing
Clinical force _______ ________equal functional forces
DO NOT
Post op complications
DVT (swelling, change in temperature, pedal pulses, gold standard - Doppler), leg length discrepancy, infection, nerve palsy, dislocation
What is the role of pre-op education?
Dec post op pain, medication use, LOS, and fear/anxiety
Vascular claudication
Decreased circulation results in: antalgic gait, paresthesia, cramping of muscles in one or both LE w/ activities such as walking; might get referred to a Doppler; more common in older adults
________portions of the MCL have extensive attachment to the meniscus and capsule
Deep
What part of the MCL typically gets damaged first?
Deep part of ligament, which may lead to medial meniscal or ACL damage
Squat/sit-to-stand observations
Deep squat has evidence of validity in FAI, decreased WB on involved side
Paget's disease (osteitis deformans)
Deformation of bone due to re-absorption and formation of bone leading to a cycle of softening and thickening, deformity of vertebra leads to central or lateral stenosis or both, most common in older adults, congenital condition
Some individuals recover w/o intervention or recovery can be _______________
Delayed
Subtalar ligaments
Dense connective tissue structures, interosseous (talocalcaneal) and the cervical ligaments (functions to control extremes of ROM into inversion and eversion), easily scar w/ injury
What is the clinical prediction rule (CPR)?
Designed to assist in the classification process and improve decision making by using evidence to determine treatment strategies most likely to benefit patient w/ particular characteristics; multiple factors from a hx and exam to predict a priori which patients will most likely benefit from manipulation
Global patellar pressure syndrome
Develops secondary to localized trauma or immbolization, fibrosis of surrounding retinaculum, hypomobility of the patella medially, laterally, and superiorly, may result in patella baja
Both genders have __________motion w/ age
Diminished
Elderly
Diminished strength of spine extensors, degenerative disc and joint disease, posture becomes more flexed, forward head, increased thoracic kyphosis, flattened lumbar lordosis, may ambulate with flexed hips and knees, wider BOS, less energy efficient
Some patients will not centralize symptoms w/ movement, but do display a ________________preference
Directional
What is the gold standard for HNP surgery?
Discectomy (often done w/ laminectomy or laminotomy)
Types of decompression surgeries
Discectomy, laminotomy, laminectomy, foraminotomy
Coxa valga - increased risk of hip____________
Disclocation (femoral head is not well covered by acetabulum), worse w/ adductor spasticity
Misinformed avoiders
Discouraged, pain indicated harm and spine is vulnerable, hyper vigilant but will to try limited painful activates, mild to moderate disability, PTs need to challenge beliefs about importance of pain and restore confidence in spine
Learned pain avoiders
Discouraged, pain is benign, spine is sound but pain may be avoided, value of pain, must be avoided, mild to moderate disability, PTs need to utilize exercise and modalities to desensitize for pain
Children who never properly WB are much more likely to __________hips (CP)
Dislocate
Timing of TJR failure (early <10%)
Dislocation, infection, implant failure
Smith's fracture
Distal fragment goes palmarly
What are the desired effects of spine traction?
Distraction and separation of vertebral bodies, distraction and gliding of facet joints, tensing of ligaments and joint capsule, widening of the intervertebral foramen, stretching of the spine musculature
Precautions for posterior approach
Do not flex hip greater than 90 degrees, do not IR the hip beyond neutral, do not ADD past neutral
Fear Avoidance Beliefs (FAB) are derived from...
Emotionally based fears of pain and injury, information based beliefs about soundness of the spine, cause of spine degeneration, importance of pain
Effects of faulty posture
Energy insufficient, prolonged end range stresses, prolonged uneven loading of the IV discs, poor articular cartilage and disc nutrition, excessive lengthened or shortened muscles
What musculature is tight with hypomobile individuals?
Erector spinae, hamstrings, iliopsoas, rectus femoris
Loose pack of subtalar joint
Eversion (pronation)
Pronaton
Eversion is the main component, heel turns out, abduction is second component, foot points from midline, small component is DF
CAM FAI
Excessive "bump" in the superior-anterior femoral head-neck that results in an abnormal junction w/ the superior-anterior acetabular rim
What can cause an increased Q angle?
Excessive femoral antiversion, external tibial torsion, genu valgus, excessive pronation
Sponge effect
Exercise and loadbearing diffuses supply of nutrients and removes metabolic wastes
Levels of Evidence - 5
Expert opinion
Grades of Recommendation - F
Expert opinion, clinical experience
3 different movements are typically found to centralize symptoms: what are these?
Extension, flexion, side bending (lateral shift)
Total meniscectomy
Extensive damage to major portion of meniscus and it is determined to be unsalvageable
Recurrent subluxation is associated w/ what?
Extensor mechanism imbalance, dysplastic femoral trochlea, patellar tilt, LE malaligment
What are the 3 types of snapping hip syndrome?
External, internal, or intra-articular
Typical ACL injury occurs with the tibia ___________rotated and in 10-30 degrees of flexion w/ the knee in a __________position
Externally; valgus
What is FAI?
Extra bone causes abnormal contact and prevents the joints from moving smoothly during activity
What is a plica?
Extra fold in the joint capsule
Cruciate ligaments are _____-synovial but ______-articular
Extra; intra (between joint surfaces but not in the capsule)
What test would you perform for a suspected anterior femoroacetabular impingement?
FADIR test
Adolescents w/ anterior groin pain and (+) impingement tests have a 50% chance of ________
FAI
Foot and ankle
FAOS, foot and ankle outcome score
What is tight when there is lumbar spine hypomobility?
Facets/joint capsule, ligaments, muscles
Fat pad syndrome
Fat pad around patella tendon is inflamed
Etiology of trochanteric bursitis
Females> males (have wider pelvis), overweight, trauma, overuse of the muscles around the bursa, tight hip ADD, glute med tendinopathy, hip OA, rapidly increased running mileage, poorly cushioned shoes, excessive pronation, leg length differences (causes you to go into more adduction), ITBS, bacterial infection, RA, hip prosthesis
TKA components
Femoral component (strong polished metal - cobalt chrome), tibial component (proximal tibia is covered w/ metal tray, topped w/ a disk-shaped polyethylene insert, may be fixed, may rotate around a platform), patellar component (places posterior surface of the patella)
Non-musculoskeletal pain
Fever, chills, night sweats, N/V, unexplained weight loss, bilateral symptoms of paresthesia, SOB, excessive sweating, visual changes, skin lesions, GI changes, B&B changes, menstrual cycle changes
Red flags
Fever, chills, weight loss
New born/infant
Flexed posture in all regions of the spine, postural control goes cephalocaudal and proximal-distal, not yet developed cervical lordosis or lumbar lordosis, cervical lordosis comes first with child lifting head and gaining head control, lumbar lordosis comes with going prone on elbows, infant must establish proximal control before distal movements
Muscles in deep posterior compartment (medial to lateral)
Flexor digitorum longus, tibialis posterior, flexor hallucis longus
Patient specific
For a particular individual, patient is asked to select 5 main activates effected by back pain, rate ability 0-10 scale, 15 min
Spondylolithesis
Forward displacement of one vertebral body over another, most common is L5, S1 (second most common is L4, L5), occurs due to spondylolysis (pars fracture) or elongated pars interarticularis
Effects of long-term poor posture
Forward head, protracted scapula, increased lordosis, decreased lordosis, increased kyphosis, cox valgus or varus
Exercise based on what may be more effective than traditional exercise programs?
Functional activities
Thoracic spine and ribs can refer from...
Heart, stomach, kidney, gall bladder, appendix
Coxa vara is more likely in ___________individuals
Heavy
Mensci lose _____ and _____over time
Height, water
Facet orientation
Helps protect disc from excessive rotary forces; more rotation available when spine is in flexion
What are surgical treatment options for the hip?
Hemiarthroplasty, resurfacing arthroplasty, total joint arthroplasty
Pathologies possibly requiring surgery
Herniated nucleus pulposus, spinal stenosis, segmental instability, degenerative disease
Traction is not as effective when large _______________ fill spinal canal
Herniations
Talocrural joint design
Hinge joint w/ 1 degree of freedom, can withstand forces up to 450% of body weight, concave mortise (distal tibial and fibula) and convex talus
Problems following THA
Hip ABD weakness, muscle contracture, limb length difference, mal-alignment
When in doubt, someone w/ chronic hip pain would probably benefit from strengthening of what?
Hip ABD, ERs
MOI for labral tears
Hip extension and ER
Lateral pivot shift test
Hip flexed to 90, IR lower leg, drop patient down into extension
Mechanism of injury of pars fracture
Hyperextension of the lumbar spine resulting in a repetitive loading of the facet joint and pars interarticularis; pars interarticularis may be congenitally thinner or not completely formed
Changes in discs can lead to facet ______________
Hypertrophy; results in redirection of compressive loads to the posterior elements
Most common to be_______________in the lower lumbar spine
Hypomobile
Grade II strain (moderate)
Identified by a sudden "pop", about 50% of fibers torn, symptoms are acute pain, swelling, and a mild loss of function, gait will be impaired, pain w/ palpation or resisted knee flexion, could feel a breach in tendon
Use of an operating microscope
Inc. magnification and illumination, limits amt of tissue damage by working through a small exposure, minimizes blood loss and risk for infection, dec. length of stay in the hospital
Soft tissue stretching results in...
Inc. spinal ROM/joint mobility, dec. pressure on facet joints, discs, and nerve roots, inc. proprioceptive input
Weeks 1-3 following Lumbar Microdiscectomy
Inc. walking tolerance to 30 min w/o pain, no symptoms in LE, wound protection and complete closure, pain management PRN
Pre op exercise?
Inconclusive studies, improvement w/ pre-op function but not in immediate post op recovery, decrease LOS, or complications
Pros/cons of ceramic ball w/ ceramic liner
Incredibly low wear rate, very hard and strong, a wide range of sizing to meet patient specific needs, wear rate - 0.0001 mm/year
General criteria for home discharge include:
Independent ambulation farther than 150 ft on level indoor surfaces, adherence to hip precautions, achieving basic functional ADLs using adaptive equipment
What happens once it is really bad?
Individual is stuck in flexion and/or lateral shift, radicular symptoms
Healing scar is __________and must be mobilized to regain mobility
Inelastic
Post op complications
Infections (<5%), DVT, loosening of the prosthesis components, component misalignment and breakdown, nerve damage
What direction does the oblique popliteus ligament run?
Inferior medial to superior lateral
What direction does the popliteus run?
Inferior medial to superior lateral
What is nerve root compression caused by?
Inflammation, disc protrusion (typically posterior or posterolateral), bone spurs, narrowed foramen
Osteopaths
Initial theory by Andrew Still in 1870s, all disease is caused by dislocated bones, ligaments, or contracted muscles especially in spine, relief occurs due to release of pressure on blood supply to nerve roots, rule of the artery, similar educations to MDs (same rights and privileges)
Annulus tears from the ___________ _________
Inside out
What does ICF stand for?
International Classification of Function
Classification system uses information gathered from __________ and ___________exam to guide the management
Interview; physical
Pre-op for lumbar microdiscectomy
Introduction of neutral spine positioning and TA contractions, education on nature of surgical procedure, expected outcomes/timelines, precautions/contraindications, bending/lifting strategies, neutral spine/pelvic
Supination
Inversion is main component, heel turns in, adduction is second component, foot points toward midline, small component is PF
Special questions to ask during screening
Is pain aggravated by cough or sneeze? Did symptoms start gradually or suddenly? Leg cramps w/ walking? Is spine pain relieved w/ BM? (GI related) Any recent kidney or bladder infection? (UTIs can mask LBP) Do symptoms change with time of menstrual cycle? Any hx of osteoporosis? (possible fx) Any feelings of instability of the spine especially w/ lifting, twisting, bending, stairs? Smoke, drink, drugs? (smoking - decreased blood supply) Caffeine drinks? can cause dehydration (more cramps), stimulant can mask pain
Where are TPs on glute max often located?
Just below and lateral to PSIS
What comes off the lateral epicondyle?
LCL, lateral head of gastroc
What structures work together to stabilize the knee by restraining varus forces, tibial external rotation and posterior rotation?
LCL, popliteus tendon, popliteofibular ligament
Stability of the posterolateral corner of the knee is provided by what?
LCL, popliteus, and posterolateral capsule
Patients fitting a traction classification will most likely have symptoms that extend into the ____________, often distal to the knee
LE
Examination for spondylolisthesis
LQS palpation for step deformity PA glides
PF assessments
LQS, alignment, patella tracking (eyeball test), patella mobility (apprehension test), ballotment test (joint effusion), patella grinding/compression, quad strength, Q angle, VMO, foot alignment (standing), strength of hip ABD and ER (resisted clamshells), patella atla vs baja, McConnell test, Craig's test
Interventions for stenosis
LS bracing to avoid extension and support extensors, traction (mechanical or manual), low grade mobs, soft tissue mobs, patient education (position of relief, no heavy lifting or extending), position in flexion to relieve symptoms (flexion, SB away, rotate toward)
CAM results in impingement, wearing away of articular cartilage, and possible __________ tears over time
Labral
What hip pathology is more common middle age?
Labral tear
Over time, FAI can result in what?
Labral tears and articular cartilage breakdown
In a pincer FAI, what is the first structure to be effected?
Labrum (repetitive impact results in degeneration of labrum w/ bone spur formation on acetabular rim)
Contraindication for surgery
Lack of clear diagnosis, anatomic level of lesion or radiographic evidence; no attempt at non-operative treatment, medication contraindications (major comorbidities, unfavorable survival)
Why do some PTs not manipulate?
Lack of training, so skilled in low velocity that high velocity techniques are not needed, less need in areas other than OP ortho, only recently introduced in entry level programs
Toddler
Large lumbar lordosis, stand and ambulate with wide BOS, hold furniture, initially frequent falls, foot arches flat, genu varum
Surgical options
Lateral retinacular release, proximal realignment (VMO advancement - slide it more distally), distal realignment (Fulkerson - move attachment of patella ligament medially)
Where is Gerdy's tubercle located? What attaches there?
Lateral tibia, insertion of IT band
What is a Segond fracture?
Lateral tibial plateau fracture
Describe the trochlear groove
Lies superior to the medial and lateral condyles, articulation site for patella, lateral surface has an inc. height to prevent excessive lateral patella slide during active extension
Grade I Sprain
Ligament fibers are stretched but there is no tear, little tenderness and swelling, knee does not feel unstable or give out during activity, no increased laxity and there is a firm end feel
LQS findings
Limited and painful extension (radicular), possible painful flexion, SB toward (radicular), dermatomes, myotomes, reflexes
Hypomobility screen findings
Limited mobility in one or more planes of motion, limited mobility in one or more segments, may be hypermobile at others, may be hypomobile in other regions such as hips
Acrylic cemented fixation
Liner is permanently attached to the pelvis, >65 years old, low activity demand, tolerates small deviations from the operation, the bed cut for the prosthetic doesn't need to be very exact because the bone cement filler w/ level out all incongruities, can WB immediately after operation, later loosening
Signs and symptoms of pars fracture
Lower lumbosacral back pain and spasm, may have associated referred pain in buttock or LE, often increased lordosis, tender w/ PA pressure to spinous processes
_______provides the most sensitive view for dx hamstring strain
MRI
Static traction
May result in depression of monosynaptic response through prolonged stretch; higher forces; soft tissue stretching
Posture syndrome
Mechanical deformation of soft tissue results in postural stress; intermittent pain brought on by certain postures; symptoms are relieved w/ change in posture
Nerve root signs
Mechanical pressure of disc compressing nerve root, chemical irritation of nuclear material on nerve root
What is patellar tilt?
Medial retinaculum is overstretched and lateral retinaculum is too tight
The ______compartment is more likely to wear out, why?
Medial, less meniscus coverage over the tibia
Non-operative treatment
Medication (analgesics, NSAIDS), epidural/facet joint steroid injections (usually max 3), modified activity, bracing, PT
Who indicated the least satisfaction after surgery?
Men and those requiring revision
Etiology of meniscal tears
Meniscal tears are either due to an excessive force applied to a 'normal' meniscus or a normal force acting on a degenerative meniscus, most common MOI is a twisting motion on a semi-flexed knee in weight bearing, may also be associated with other ligamentous injuries, typically the ACL and the MCL
Forefoot
Metatarsals and phalanges, transmetatarsal, intermetatarsal, MTPs, and IPs
Stenosis is most commonly seen in what population?
Middle aged and up
Grades of Recommendation - B
Moderate evidence, a single strong evidence study or level II study support
PT management for GTPS
Modify activities (avoid lying/sleeping on affected area, no sitting w/ legs crossed), use of crutches if really painful, ice/heat, US, shock wave therapy, low evidence for iontophoresis, phonophoresis, TENS, soft tissue mobs/massage, TP therapy, foam roller to TFL, ITB, gluteals, vastus lateralis, stretching piriformis, qauds, TFL, strengthening hip ABD, ER, and knee ext, gait mechanics and pelvic stability
Coxa Valgus long-term effects
More likely to dislocate hips
Modalities
Most heat, Estim
MOI for MCL
Mostly occur after an impact on the outside of knee; w/ foot fixated to the ground, combined movement of flexion/valgus/tibial ER will place excessive tension on MCL
Studies have indicated that endurance, balance, and neuromuscular control may be more important than max ______strength for both prevention and rehabilitation
Muscle
Medical management of piriformis syndrome
NSAIDs, muscle relaxants and neuropathic pain medication, Ultrasound guided injections of anesthetics, steroids, and botulinum can serve both diagnostic and therapeutic purposes , Indications for surgical management include abscess, neoplasms, hematoma, and compression of the gluteal arteries, Surgical release of the piriformis tendon
How do you name a lateral shift?
Name it by which direction they are shifting towards (look @ shoulders)
Lateral stenosis
Narrowing of the intervertebral foramen affecting a nerve root
Foraminotomy
Narrowing of the intervertebral foramen leads to stenosis, goal is to take pressure off nerve roots, bone is cut or shaved away to open the foramen, may be done w/ removal of disc or lamina
Central stenosis
Narrowing of the spinal canal effecting the spinal cord or cauda equina
What is stenosis?
Narrowing of the spinal canal or intervertebral foramen
Mid foot
Navicular, cuboid, and 3 cunieforms, transverse tarsal joints, intertarsal joints
What is the most common application of traction?
Nerve root compression
What is the 1st tissue to be affected w/ compartment syndrome?
Nerves
Interventions for acute LBP w/ coordination deficits
Neuromuscular reeducation exercises, possible external supports to prevent end ranges, patient education (posture control, maintain lifestyle)
A combination of ACL, medial meniscus, and MCL is called what?
O'Donohue's or Terrible Triad
Who is most likely to have capsular component w/ FABER test?
OA (distraction can be very effective)
MOI for LCL
Occurs w/ varus stress, usually w/ contact, much less common than MCL injuries, usually respond well to conservative treatment
Single episode of patellofemoral subluxation/dislocation
Often associated w/ trauma, described as "pop" w/ dislocation and a second "pop" w/ relocation (w/ ext), high incidence of underlying misalignment
LQS findings
Often stands w/ reduced lumbar lordosis (more flexion), observe for atrophy or hypertrophy, limited AROM, overpressure only if no peripheral symptoms w/ AROM, perform dermatome and myotome scan, reflexes, gait (you will shorten stride on affected side due to tensioning on nerve), heel walking, toe walking, squat test, may or may not have a lumbar muscle spasm
What are predictors of overall satisfaction?
Older age, not living alone, worse pre op hip scale score, shorter LOS
Who reported greater reductions in pain after surgery?
Older patients, females, and patients w/o revisions
What are wind-swept hips (common in CP)?
One hip is abducted and ER, one hip is adducted and IR
Significant long-term impairment and disability (including pain) can continue for how long post TKA?
One year or more
What is a hemi-arthroplasty?
Only femoral side is replaced, but may not be efficient in pain relief
Ober's test
Originally designed for abductor muscle contracture, pain production or reduced ROM may be indicative, tight TFL will push into trochanter, make sure to stabilize pelvis, bring them into circumduction, then bring patient into ADD and extension
What can cause inadequate medial stabilization?
Overstretched retinaculum, under functioning VMO
What are some examples of passive mobility testing?
PA glides, PIVMs
Examples of joint mobs to lumbar spine
PA glides, side bending, rotation, combination of all 3
Management of quad contusion
PRICE, NSAIDS and analgesics, crutches if necessary, taping and wrapping, aspiration of hematoma, ROM exercises, knee flexion is typically last to return
Management of snapping hip syndrome
PRICE, NSAIDS, corticosteroids, lidocaine injections, stretching or TP release of iliopsoas or TFL, address hip muscle weakness, esp hip abductors, surgical lengthening of involved tendon
Management of iliopsoas bursitis
PRICE, NSAIDs, corticosteroid, or lidacaine injections, hip flexor stretching, hip rotator strengthening, bursectomy
PT management of hamstring strain
PRICE, modalities, taping, instrument assisted soft tissue mobs, dry needling, restore quad/hamstring strength ratio (focus on eccentrics once soreness is eliminated), BW hangs (eccentrically lowering), nordic HS curls, bridge variations, deadlift, kettlebell swing, flexibility, manually resisted hip ext or knee flex in prone, standing theraband flutter kicks, 2 or 1 leg stool scoots, forward or sideways 2 or 1 leg hops, 2 or 1 landing from a box
Post op PT implications following TKA
PRICE, pain control, compression garments, elevation, scar management once staples come out, patella mobility - glides, gentle rocking rhythmics
Management of quad strains
PRICE, taping for pain, proprioception, maybe swelling, gentle soft tissue mobs, IASTM, dry needling, quad setting, terminal knee ext in supine or standing, concentric/eccentric, manual, or theraband knee ext, standing hip flexion flutters w/ theraband, isometric wall sits, closed chain exercises, squats (2 or 1 leg), lunges, set ups, step downs (eccentric)
Referred pain
Pain from a lesion in one location that is experienced by the patient in another location, often pain is dull or achy, pain can refer from internal organs
Rehab
Pain management, control of joint effusion, knee ROM, normalize gait mechanics, flexibility of LE mm, foot alignment (orthotics or proper exercises), hip ABD and ER strength/control
Acute LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ initial or mid range of active or passive movements
Subacute LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ mid range or end range active or passive movements
Typical S&Ss of an adolescent athlete w/ a pars fracture
Pain w/ extension and palpation - need to have imaging performed
Clinical presentation of iliopsoas bursitis
Pain/tenderness is felt anteromedial aspect of the thigh, may have snapping sensation form front of hip, pain when passively going from extremes of flexion to extension and vice versa, pain worse w/ activity (esp walking or crossing legs), rest can relieve pain
What is trochanteric bursitis?
Painful and inflamed trochanteric bursa (in b/t greater trochanter and tendon of TFL), component of greater trochanteric pain syndrome, commonly results from friction of overlying IT band
Subluxation
Partial dislocation
Where is articular cartilage thickest in the body (4-5 mm)
Patella articulating surfaces
Examination of snapping hip syndrome
Patient hx - location of snap, timing of snap, duration of inset, pain and disability w/ activities Palpation - greater trochanter and the lateral border of glute max Observation - gait abnormalities, have pt demonstrate the snap Tests - ROM, MMT, muscle length Screen - lumbar spine and knee
Forward flexion test
Place thumbs on PSISs and have pt flex forward and look for movement of PSISs (can also perform in sitting)
Where does the plantaris muscle originate from?
Posterior lateral femoral condyle
Lateral shift
Posterolateral bulge blocks extension and side bending toward - causing patient to shift away or towards side of bulge (most of the time they will shift away)
Why do we need to recognize sources of non-musculoskeletal pain?
Practice w/o referral, recognize when it is outside our scope of practice
Surgical procedure for discectomy
Pre-op x-rays to identify appropriate level, 2-3 cm incision is made lateral to the SP on symptomatic side over the disc space, dissection is through erector spinae and transversospinalis groups (supraspinous, interspinous ligaments, and joint capsules are preserved), small metal tube is inserted under x-ray guidance, tube serves as a passage for the surgical tools so muscles aren't cut (in contrast to open discectomy), herniated disc is found w/ a tiny camera, ligamentum flavum may be removed or sparred, nerve root is retracted to expose the HNP, herniated nuclear material is then cleaned out w/ rongeurs (forceps)
What is the #1 predictor of an injury?
Previous injury
Primary and secondary restraint of LCL
Primary - varus force Secondary - anterior and posterior stress
Biomechanics of the PCL
Primary restrain for posterior tibial translation at 30 and 90 degrees of flexion
Biomechanics of the ACL
Primary restraint for anterior tibial translation, orientation of fibers also plays a role in high rate of injury
Newer machines allow a ____________increase in traction force after initiation
Progressive (can select the number of steps to achieve the full force and can also have regressive steps)
Knee to opposite shoulder
Pt is supine, PT brings one knee towards the subjects opposite shoulder
Positive SLR for piriformis syndrome will most likely be between 35-70 degrees, why?
Putting tension on the dura, which would most likely be lumbar spine (HNP)
Precautions for traction
RA (unstable C1-C2), Down Syndrome, cognitive impairment, claustrophobia, tumor, osteoporosis, can not tolerate supine or prone, pregnancy, dentures/TMJ dysfunction, hernia, systemic steroid use
Etiology of secondary piriformis syndrome
Results from macrotrauma, microtrauma, muscle spasms, and ischemic mass effect (hematoma), microtrauma may result from overuse during running or sports with repetitive hip rotation, i.e. tennis, SI joint pathology, "Wallet neuritis", Excessive hip adduction and internal rotation occurs during weight-bearing due to a weak gluteus maximus and/or gluteus medius (eccentrically contracting), this shifts a greater eccentric load to the piriformis muscle, perpetual loading of the piriformis through overlengthening and eccentric demand results in sciatic nerve compression or irritation
Benefits of good posture
Results in minimized abnormal forces on the body and energy efficiency of static and dynamic activities
Femoral antiversion
Rotation medially in shaft of bone (~15 degrees)
Control is best provided by...
Rotatories, multifidus, all abdominals (esp. TA)
Long right leg
SB to the right, rotated to the left (if it is more than 1/2 an inch, you probably need to adjust the shoe, not something in the shoe)
Controversy of SIJ
SIJ does not move, SIJ has such a small amt of motion that it does not cause pain, pain only results from severe trauma, pain is caused by strain of SIJ ligaments, pain is caused by hyper or hypomobility, pain is caused by joint that subluxes
Flexion exercises
SKC, DKC, sitting flexion, posterior pelvic tilts, spine neutral, rocking rhythmic exercises
What are some example of hip ABD exercises?
SL hip ABD, SL wall slides, SL hip lifts, side plank variations, step outs w/ or w/o theraband, hip hikes on stool, runner's pivot
Strengthening treatment
SL hip ABD, clamshells, prone/quadruped hip extension, bridge variations, squats, lunges, front/side step-ups
Where does the piriformis attach?
Sacrum anteriorly to GT
Bowel and bladder changes
Saddle numbness, rectal, genital region
In absence of primary restraint, ___________structures are put under larger tension to restrain the same force
Secondary
What is the acetabular component made of?
Shell is made of metal, plastic liner (load bearing, fits snugly inside shell)
McConnell test
Short squat, take thumb and push on outside of patella in medial direction, can also do taping technique
Should you have both knees done at the same time?
Short-term and long-term outcomes were equal by 12 weeks, except quad strength (equal by 52 weeks)
Shoulder
Shoulder pain and disability index
What are you palpating through to get to the SIJ?
Skin, fat, thoracolumbar fascia, thick tendon of erector spinae, multifidus, thoracolumbar fascia, lumbosacral ligament, joint space
Why are women at more risk for ACL injuries?
Smaller intercondylar notch, wider pelvis, greater Q angle, neuromuscular factors, hormonal variations may alter laxity of ligaments, females take longer for ADDs and ERs to fire
Who is most likely to get compartment syndrome?
Soccer players w/ no shin guards
What is the hip labrum made of? What is its purpose?
Specialized fibrocartilage; lines the acetabulum to increase its surface area, inc. joint stability, contributes to proprioceptive feedback, decreases the forces b/t the femoral head and acetabulum
Oswestry LBP Disability Index
Specific to LBP, measure patients perceived level of disability, takes 5 min, 10 questions w/ 6 answers per question, each answer assigned a value (0-5), x 2 for percentage score, may be more sensitive in patients w/ severe disability
Classification category is intended to direct clinician to a ________ ______ of management
Specific type
Interventions for Grades 3 and 4 Spondylolithesis
Spinal orthosis, often require surgery (if radicualr symptoms are present), realignment and fusion
When can patients resume sexual relations?
Standard is 1-3 months
What positions put the most pressure on the discs?
Standing flexion w/ weights and sitting in forward flexion
Genu recavatum
Standing with knees hyperextended
Apply harness in ___________ or lying. Loops should maintain a __________pull
Standing; posterior
Research says that _________tests are unreliable
Static
What makes of the femoral components?
Stem (made of metal - usually titanium), head (made of either cobalt chrome or ceramic)
Tests for sciatic nerve
Straight leg test, sciatic LLTT, slump test, stealth slump test
What are the 2 schools of though of chiropractors?
Straights and Mixers
High compliance groups have greater improvements in what?
Strength, walking speed, functional outcome scores, recommend HEP 3x/week
What can a radiograph differentiate a hamstring strain from?
Stress fx
Intervention for dysfunction syndrome
Stretch into direction of limitation, avoid bad postures, patient education
Derangement dysfunction intervention
Stretch into direction that causes centralization, avoid direction of peripheralization, after disc healing stretch into the direction of limitation, patient education
Manual therapy techniques include...
Stretching of muscles of the hip joint, traction of the hip, traction manipulation of the hip
Grades of Recommendation - A
Strong evidence, supported by level I studies
Support for the McKenzie Method
Studies by Nachemson and Anderson showed changes in pressure w/ the IV disc w/ changes in posture; numerous studies have looked at reliability of method and others at effectiveness; effective for acute discs (not so much for degenerative discs)
Anterior interbody fusion procedure
Subcutaneous tissue and rectus abdominis are retracted, done w/ retroperitoneal approach, an anterior discectomy and bone graft are done, EO, IO, and TrA are divided, neurovascular and visceral structures are moved out of the way (genitofemoral nerve, psoas muscle, aorta and vena cava, sympathetic chain, iliac vessels)
The proposed mechanisms for disc realignment include...
Suction due to decreased intra-discal pressure, pulling displaced disc pieces back to center, tensing PLL pushing any posteriorly displaced material anteriorly towards original position
Common mechanisms of quad strains
Sudden deceleration of leg (kicking), violent contraction of quad (sprinting), rapid deceleration of an overstretched ms (by quick change in direction)
What portions of the capsule form the suprapatellar pouch?
Superior and anterior
More adducted =
Supinator
It is recommended that exercises be started with the patient in ____________
Supine
What position should you place patient in?
Supine, prone, some table allow SB, increased hip flexion (to 90 degrees) causes greater separation of posterior structures
Describe the meniscus blood supply
Supplied by medial and lateral geniculate arteries, only 10% to 30% of peripheral medial meniscus and 10% to 25% of lateral meniscus receive direct blood supply, remaining portion receives nourishment from synovial fluid via diffusion
Are manipulations for PTs supported?
Supported by the Orthopedic Section of the APTA, American Association of Orthopedic Manual Physical Therapists
What is the collagen fiber orientation of the menisci?
Surface layers - random orientation, inferior layers - circumferentially "hoop strength", tie fibers - radially oriented
Inspection of meniscal tears
Swelling, stands w/ knee partially flexion, quad atrophy (chronic), joint line tenderness, terminal extension may be blocked, end feel - springy if knee is locked, limb girth measurement (reduced quad girth), balance and proprioception testing
Partial meniscectomy
Symptomatic displaced tear in older inactive individual, tear in central avascular third
CPR for manipulation
Symptoms less than 16 days; at least 1 hypomobile segment; at least 1 hip w/ less than 35 degrees of motion; no symptoms distal to the knee; less than 19 points on FABQ
Distal tibiofibular joint
Synarthrosis, dense irregular CT, ant and post proximal TF ligaments and interosseous membrane, not a synovial joint
______________(such as Gore-Tex) are also used for ACL reconstruction
Synthetics
T/F Patient education has been shown to reduce the use of narcotics and hospital length stay
T
T/F: In degenerative meniscal tears, the patient may not have a "click" upon examination since tears are often multiple frays rather than large tears
T
T/F: Symptoms of degenerative meniscus are the same as traumatic meniscus
T
Autograft
Taken from the patient's own body and include portions of the patellar tendon, IT band, semitendinosus tendon, gracilis tendon
Subtalar neutral
Talus and calcaneus in a straight line
Arthroscopic debridement
Tear of the labrum is only part of the pathology, labrum may be a source of the pain, debridement of the labrum w/o addressing the reason for impingement will lead to poor surgical outcome
What are your supinator muscles of the foot (inverters)?
Tibialis anterior and posterior
Anterior compartment musculature
Tibialis anterior, ext digitorum longus, ext hallucis longus, fibularis tertius
What shape is the patella?
Triangular, frontal plane (wider proximal base and a distal apex), transverse plane (broader anteriorly and posterior apex)
Tarsal canal (tunnel)
Tunnel running between the subtalar articulations, divides the subtalar joint into 2 separate joint cavities, lateral opening known as the sinus tarsus
Nucleus pulposus
Type 1 and 2 collagen; more ground substance, hydrophilic (70% in adult, 90% in child), sits more posterior within annulus
What is the annulus fibrosis made of?
Type 1 collagen - resists tensile forces w/ alternating crossing pattern
Non-musculoskeletal warning signs
Unable to find comfortable position, pain is unaltered by position, pain is worse at night, feelings of fatigue, symptoms are associated w/ GI, genitourinary, cardio, respiratory, etc.
What is meralgia paresthetica?
Underwear is too tight and compressed the lateral femoral cutaneous nerve
What are the types of patella fractures?
Undisplaced, transverse, lower or upper pole, comminuted undisplaced, comminuted displaced, vertical, osteochondral
Patient hx - red flags
Unknown etiology, no h/o trauma, significant past systemic illness, family hx of systemic illness
Muscle energy techniques
Use bodies muscles to reposition bones; if pelvic innominate is posteriorly rotated what muscle do we have to rotate it back anteriorly?, if anterior, what muscle to rotate back posteriorly?
FADIR test
Used to assess FAI, esp. anterior/superior labrum, passively move the hip into flexion, ADD, and IR, (+) test = hip or groin pain, Sn = 0.95
Mixers
Used to treat musculoskeletal pain due to hypomobility, muscle spasm, correct alignment, relieve pressure on nerves
Anterior interbody fusion
Uses same principles of disc excision and interbody bone grafting
Describe intra-articular snapping hip syndrome (least common)
Usually due to tear of cartilage and/or loose body within the hip joint, may cause the hip to "lock up"
Is high impact aerobics and jogging recommended following THA?
Usually not
You have more coxa ___________ when you are born
Valga (changes as we WB)
Can load the ACL in a more _______position
Valgus
When does the MCL become taut?
Valgus force, extension and looser in flexion
Special test for MCL injury
Valgus stress at 20-30 degrees of flexion
Medial meniscus injury is associated w/ a ______________force and lateral meniscus injury is associated w/ a ____________force
Valgus; varus
Describe the vascularization of the menisci
Vascularization along the periphery via capsular attachments, inner borders are avascular; red zone (best), red/white, white (no blood supply)
Anterior displacement occurs due to...
Vertebra no longer attached posteriorly, sacral angle created anterior sheer, supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to "slide" anteriorly on the one below (creep)
ACL/PCL has a _________orientation in extension and a more ____________orientation in flexion
Vertical; horizontal
Arthroscopic microdiscectomy
Very common, less morbidity and an earlier hospital discharge compared w/ standard discectomy
Re-occurrence of LBP
Very common, not predictable as to how often or severity of next occurrence, more common w/ hx of re-occurrence excessive spine mobility, more likely to become chronic w/ symptoms BK, depression, fear of reinjuries, high pain levels
FABs of HC providers
Very similar to that of patients, low expectations for patients, recommend avoidance of activities that "might" bring on symptoms, recommend limiting activity levels
What is the shape of the menisci?
Wedge shaped to improve joint congruency, improve joint stability, and maintain joint space
Questions typically asked on HRQL Questionnaires
What can they do or not do? How often can they do them? Level of difficulty perform them?
What do patients want to know?
What is going on, how long will recovery take, how can they help themselves, what will the clinician do for them
When you do typically get central LBP?
When the outer rings bulge because they are innervated
Contraindications to traction
Where motion is contraindicated (fx, hypermobility, dislocated joint), uncontrolled HTN if using inversion table, if traction peripheralizes symptoms, immediately post-surgery of spine, (+) vertebral artery sign
Methods before McKenzie
Williams flexion exercises (1930s); open the IV foramen to relieve nerve root compression - lordosis was bad; promote flattened lordosis postures; brace into flexion; bed rest; disc dynamics were no understood esp. nucleus within annulus;
When in side lying, what direction do men and women side bend toward?
Women SB toward the opposite side they are lying on (curvature to same side) due to wider hips, men SB toward the same side they are lying on (curvature to opposite side) because they have wider shoulders
Diagnostic imaging for labral tears
X-rays and MRI are often inconclusive for detecting intra-articular pathologies; gold standard - MRA
Can US diagnose a hamstring strain?
Yes, relatively cheap and has the ability to image muscles dynamically
What population is a resurfacing arthroplasty good for?
Younger patient w/ better bone stock
Intervention for hypermobile patient
braces or corset, patient education( KEEP OUT OF END RANGE POSTURES), Strengthening and endurance exercises, proprioception exercise, spine neutral exercises (make pt realize when they are at mid rang and can they hold it and do other things?)
Exercises for pt with spondylolisthesis
core stability, spine neutral, isometrics, short range exercises (strength and endurance), proprioceptive exercises (pelvic clocks)
If an individual spends long period of time at end range then the ligaments engaged in the elastic zone will have a plastic response which causes what?
creep this causes elongation increasing the size of the elastic zone leading to instability unless a sufficient amount of muscle control is attained
grades 3 and 4 signs and symptoms
in addition to low back pain there may be radicular signs into LE related to traction on lumbosacral nerve root, pain, parasthesia, numbness, muscle weakness, radicular symptoms unilateral or bilateral ( could be putting traction on cauda equina)
Step Deformity
one spoons process may appear to be anteriorly displaced over one below, if L5 vertebral body is anterior on S1 and L4 may feel more anterior, as L5 vertebral body slides anteriorly the posterior arch & spinous process stays attached to S1, L4 feels deep because L4 has migrated anteriorly with L5 vertebral body. If L4 feels deep problem is at L5
Injury to your neuromuscular system, which can occur with traumatic spinal injury can result in diminished_________ input and lead to further damage of passive restraint structures
proprioception
increase in neutral zone means
requires greater muscle performance (strength, endurance, proprioception)
Muscle control is best provided by
rotatories, multifidus, all abdominals especially transfer abdomens
Interventnion for spondylolisthesis: Grades 3&4
spinal orthosis, grades 3&4 especially those with radicular signs often require surgery, realignment and fusion
Spondylolisthesis occurs due to to
spondylolysis (pars fracture) or elongated pars interarticularis
