MSK II Spring

stabilizers of PF joint

quads joint surface retinaculum and capsule

diagnosis of labral

radiograph hip arthro (gold standard) MRI not so good MRA perferred option 70-90% accuracy distingishes hip capsule form labrum and outlines it

compartment syndrome diagnosis

radiograph followed by MRI needle manometer above 27.5 mm Hg after 1 min of exerisce *** exercise testing to recreate symptoms Muscle hardness, muscle hernia after exercise, absence of pain at rest, identical pain pattern are all predictive clinical findings

radiographs for and MR for?

radiographs = angles MR arthro = assess labrum and articular cartialge

hamstring syndrome

rare semi mem semi tend long head of biceps femoris fibrous band may project from biceps insertion which can surround sciatic nerve and this entrapment and sx lead to hamstring syndrome In hamstring syndrome, the tendons attached to the sits bones become inflamed and form bands of tissue that can surround the sciatic nerve.

tendon ruptures: quad and patellar MOI, who, tx

rare, associated with patellar fx or systemic comorbid that weaken tendons MOI: Sudden quadriceps contraction in slight flexion Sprinting, impulsion, jumping, descending stairs More often in middle age individuals ~40 yo Diagnosis: Inability to extend the knee Treatment: Surgical repair

sx for peripheral vs avascular tears

reapir - periph partial menisectomy - avascular poor results with reapir

short foot exercise

recruits abductor hallicus to slow MLA lowering*** 4 weeks pull met heads back toward the heel without curling toes passive modeling, active assitive then active modeling

menisci fxn

reduce compresssive stress of TF joint protects articular cartilage by deforming peripherally stabilize lubricate proprioception guides knee arthrokin

MCL tx

rehab same as ACL

torsion angle "-version"

relative rotation between shaft and neck of femur

HS sx and post op rehab

release

causes of sesamoiditis

repetative loading

adductor strain who does it affect and MOI

repetative stress males 20-50 ice hocket, soccer more common in preseason *noncontact, overuse* strength imbalance between propulsive and stabilizing msucles may cause strain (they decelerate the stabilize the limb so strains can happen when the amount of eccentric force the adductors are attemping use to decelerate the leg) ADDUCTOR LONGUS INJURIED MOST COMMONLY aka adductor weakness can cause this bc cant widthstand the stress that is put on it delayed abdominal recruitment is also a risk factor

chronic ankle instability MOI

repetitive bouts of inversion or PF/INV sprains NM control, prop, strength, balance, joint lax, joint restrictions*, synovial changes

achilles tendinopathy/rupture MOI

repetitive stress/increased training sudden violet DF, landing on PF foot, pushing off forefoot while extending knee Mid portion: micro trauma and altered loading leading to progressive tendon degeneration with end result of larger diameter, loss of parallel collagen structure, addition of fatty infiltrate Insertional: potentially increased strain and decreased stiffness of tendon Degenerative tendinopathy most common histological finding in spontaneous ruptures

ACL fxn and mechanism of injury

resist excessive knee extension anterior translation of tibia (anterior roll and slide) posterior translation of femur (anterior roll and posterior slide) resists extremes of varus, valgus, and axial rotation MOI: large valgus force with foot planted, large axial rotation with foot planted, combo of above with knee in full extension, severe hyper extension of knee

chronic ankle instability S/S

sensation of giving way frequent non traumatic rolling pain laterally or dorsally decreased night throbbing, increased morning stiffness as compared to acute 40% LAS develop CAI

what angle of knee flexion/ext in open chair will ACL recieve max stress?

short arc quads find this answer

short plantar ligament

short foot when she talked about it class thats why you need to keep the big toe down

lisfranc tx if stable

short leg cases 4-8 weeks Bilateral heel raises in standing Bilateral heel raise, single leg eccentric lower Single leg heel raise from standing Bilateral leaning heel raises Bilateral leaning heel raises, single leg eccentric lower Single leg leaning heel raises Single leg triple extension heel raises Mini‐tramp low impact exercises (1:2 work:rest ratio)‐ Bilateral 2‐legged jumps in place ‐ 1/4 turns in place (2 legs) ‐ 1/2 turns in place (2 legs) ‐ Jog in place ‐ 3 hops uninvolved, 1 hop involved ‐ 2 hops uninvolved, 2 hops involved ‐ 1 hop uninvolved, 3 hops involved Agility ladder‐ Various 2 foot sagittal, frontal and transverse plane patterns ‐ "Hopscotch" to involved side (2 feet to 1 foot) Single leg A/P hops in place (all in place hops 1:2 work:rest ratio) Single leg M/L hops in place Single leg transverse plane hops in place Single leg hops in agility ladder, multi‐plane

how to differentiate hamstring syndrome and tendinopathy

similar location tendinopathy is NOT provoked with sitting or neural dynamic testing **** pain with resisted knee flexion in both hip flexion and extension not just at 90 hip flexion and knee extended (and DF) like for hamstring syndrome

PT for dislocation

simple = AROM/PROM after closed is okay to weight bear but with open have to ask physician

what dislocations have best prog

simple and anterior

sx for OA

total joint arthro: Greater pain and disability Fewer co-morbidities Less troublesome joints OA over inflammatory arthritis No difference in outcomes regarding weight Higher likelihood of surgical complications

what does the tibia do

transfer weight across knee and ankle

what do hip dislocations happen from

trauma high energy MVA fall from a height athletic injury

cuboid syndrome MOI

traumatic PF/INV sprain or overuse Disruption of congruency of the calcaneocubiod joint by trauma or incorrect training (Theory) fibroadipose synovial folds or "foot labra" which can restrict motion or become impinged

labrum is what, blood supply, nerve endings?

triangular fibrocartilage attached to majority of acetabular rim blends with transverse ligament contunuation of articular cartilage blood supply from capsule to outer 1/3 of labrum free nerve endings found here in anterior and superior portion

hyperextensioninjury of MTP

turf toe repetitive extension of the 1st ray running jumping flexible footwear Injury or sprain of plantar structures of the 1st ray Plantar plate Collateral ligaments FHB tendon Sesamoids and ligaments

TC joint what type, ROM and accessory motion

uniaxial hinge joint talus and malleoli ROM: 20-0-50 sagittal plane DF/PR anterior glide of talus with PF posterior glide of talus with DF

athletic pubalgia clinical presentaion

unilateral lower abdomen and anterior groin pain, may radiate to the perineum, inner thigh, and scrotum lots are bilateral I/M deep throbbing pain worse with sit ups, coughing, or sneezing long standing history of symptoms pain easily returns with return to sport*** tenderness at or above pubic tubercle painful hip adduction and hip flexion VALSALVA hurts limited hip IR, ER and abduction ROM

PCL O&A

Origin: anterolateral aspect of the medial femoral condyle. Insertion: Posterior intercondylar area of tibia `

ACL O&I

Origin: medial and anterior aspect of the tibial plateau Insertion: medial wall of the lateral femoral condyle

gluteal tendinopathy

excessive hip adduction may compress the glut min and med tendons against the greater trochanter leading to tendinopathy/tears aka from genu valga aka weak gluts ONE OF THE BIGGEST CONTRIBUTORS TO GTPS

who gets cuboid syndrome

excessive pronators bc longer lever arm of peroneus longus midtarsal instab obesity footwaer

iliofemoral limits

extension, ER

center-edge anlge (angle of wiberg)

extent to which acetabulu m covers femoral head in frontal plane

acetabular anteversion angle

extent to which acetabulum surrounds femoral head in transverse plane

extravascular vs intra when do they happen

extra = trauma aka fx or surgery, obesity bc takes up room, high alcohol intake or steroids, chemotherapy or radiation intra = occlusion via thrombus, lipids, sickle cells, or coag disorders

other tx of AVN

extracorpeal shock wave (promotes osteoblastic activity) hyperbaric oxygen therapy (restores tissue oxygenation) *biphosphonates* PT just as effective as core decompression

who has higher lifetime risk of OA

female

MTSS who does it affect

female over training over pronate increased hip ER/IR ROM

tibial stress fx who does it affect

female triad runners over training

who gets PTTD

females overweight

who does it happen to

females associated with incrase in activity, altered training military amenorrhea

sites of attachment for the collateral ligaments

femoral EPIcondyles

turf toe tx

firmer footwear to decrease stress on plantar structures grade 1 orthotic grade II grade III boot PROGRESSION back to play

MCL what does it attach to

flat and broad reinforced by medial patellar retinaculum and medial capsule deep part attaches to the medial meniscus

TF flex/ext degrees and axis

flex 130-150 ex 0-+5 migrating axis of rotation average axis is close to the lateral epicondyle of the femur

femoroacetabular impingement syndrome limits what

flexion and IR

ischiofemoral limits

flexion, IR, extension

positive impingement tests

flexion, add, IR test (FADIR) rule OUT flexion, IR test rule OUT

sx for GTPS

for tendon tears IT band decompression bursectomy glutean tendon reconstruction or repair

itis or osis

found to be a degernative process without inflamm fasciosis = denoting a pathological state

do you want the angles to be big or small

generally bigger angles are worse because it can cause impingement

what does GTPS include

glut med.min tendinopathies glut med/min tears trigger points external snapping hip syndrome bursitis two or more of these are often seen concomitantly

SI joint

goes 3x10 vertical area inferior to PSIS also groin and thigh but usually local SI ligament can refer all the way into the lower leg

cruciate ligaments blood supply, stability, resistance to what motions

good blood supply multiplanar stability (resists all extremes) most resistance to anterior posterior motion GUIDE THE ARTHROKIN OF KNEE provide proprioceptive feedback

PCL tx

good intrinsic healing ability if isolated conservative can work HAMSTRING STRENGTHENING return slowly as it creates posterior tibial translation

ACL tx

grade I & II with low level active lifestyle, conservative grade III repair, reconstruction (tx of choice) -autograft is preferred bc it is from you (improve return to sport and decreased risk of rupture)

what type of mobilization is best for GTPS

grade IV immediately reassessed hip extension and abduction stregnth allows you to load more during therapy and increase strength

PTTD tx

greater improvements in pain and fxn early stage PTTD with eccentrics than concentrics or orthosis and stretching alone HIP STRENGTHENING Strengthening of tibialis posterior, tibialis anterior, gastroc and soleus combined with foot bracing over 10 PT visits lead to 89% satisfaction in grade 1 or 2 PTTD home and center based forms of rehab are equally effective

diganosis of piriformis syndrome

hard bc no widely accepted definition not a clear understanding o why happened and not good validated diagnositic criteria diagnosis of exclusion have to rule out other causes special tests not validated no sens or spec

true radic

hard neuro signs: myotomal weakness dermatomal N/T dimished reflexes must have all three to be a true radic!

getting out of a car is what diagnosis

hip

compartment syndrome special tests

hop test/heel slam test UNSUPPORTED tuning fork SNOUT

causes of labral tears

hyperabduction, hyperext, hyperflex, dislocation developmental dysplasia degernative laxity bony abnormalities idiopathic (microtrauma)

ACL instability patho

hyperexcitability of nociceptive pathways and trigger flexor withdrawal reflex more readily and promote sensation of instability and giving way during walking or pivoting

PCL MOI

hyperflexed or hyperextened and then a force is put on the proximal tibia High energy "Dashboard" injury Fall onto hyper-flexed knee Sudden violent knee hyperextension Twice as strong as the ACL Much less frequently torn mid portion tears more common

surgical management of stress fx when to do it

if complete fx tension incomplete fxs compression fx if fail conservative tx percutaneous screw fixation

tx of AP

if high level athlete, conservative tx is recommended

PCL sx

if increased AP lax >8mm functional limitations graft types: Bone patellar tendon bone Autograft Good healing Multiple strand hamstring tendon Allograft Good graft strength Achilles tendon Allograft Minimal donor morbidity

collateral ligaments fxn and what do they resist

limits excessive frontal plane motion in full extension MCL resists valgus and LCL resists varus secondary fxn to resist extreme knee extension tertiary fxn to resist extreme tibial ER and IR when partially flexed (limited)

ligamentum teres limits

limits extreme ROM

who gets metatarsalgia

long second met pes cavus bunion/hallux valgus

MRI vs physical exam for rupture

look at positive calf squeeze test, decreased resting tension, and palpable defect MRI still gold standard but this was very close

prehab

low quality evidence may be effectiveup to 3 month decreasein post op strength asymm no sig dif in pain and fx

labral tear prognosis

lower rate of hip survival post arthroscopy due to older age, microfx of acetabulum, joint space of <2mm, leads to higher conversion to THA repair has better outcomes than debridement and less conversion to THA

bending is from what diagnosis

lumbar

other causes of sciatic symptoms

lumbar disc, fact, muscles * SI joint * hip joint * thrombosis renal sttones endometriosis tumors hematomas fibrosis Aneurysm of inferior gluteal artery Myositis ossificans Fracture of ischial tuberosity Fracture of femoral neck

articular surface of acetabulum is called what

lunate and is lined with articular cartilage

if suspect AVN what do you do

make sure they have imaging and see their physician can do conservative for early stages

managment of instability

make up laxity with strength eccentricl control muscle control in NORMAL range may undergo an osteotomie idk why

who do meniscus tears happen to

males 20-29 occur with ACL posterior horn mostly injuried and msotly in women

who does athletic pubalgia happen to

males 22-30 prevalent in kicking athletes soccer, ice hocket, football more common in high level athetes

mortons neuroma tx

manual therapy address reason for abnormal plantar stress metatarsal pad capsaicin injection?

plantar fascia tx

manual therapy of TC, ST, TMT strengthen: Tibialis posterior, fibularis longus, tibialis anterior, quadriceps femoris, glute med, hip external rotators stretching for short term releif

ACL diagnosis

MRI (mid portion tear most common) xray for joint arthroscopy gold standard

imaging for meniscus

MRI SPIN AND SNOUT poor detection of posterior horn knee artho gold stand

PCL diagnosis

MRI best radiographs arthroscope

imaging for adductor straing

MRI or US

patellar tendon where does it originate

apex and goes until the tibial tuberosity

achilles tendinopathy/rupture special tests

arc sign SPIN calf squeeze/thomposon test SPIN/SNOUT

complications of dislocations

avascular necrosis less likely if reduced in <6 hours OA nerve injury het oss

hallux valgus tx

distraction lateral glide Found self-lateral mobilization DECREASED valgus angle

hallux rigidus tx

distraction and extension subatalar and talocrural mob sesamoid mob large toe box rocker bottom shoes

SLR subtypes

TED (tib ev df) PIP (peroneal inv pf) SID (sural inv df)

IT band etiology friction vs compressoin vs inflamm

"Friction syndrome": During repetitive motions at knee Friction as ITB passes ant/post over lateral femoral epicondyle "Compression Syndrome" Deep, lateral structures of knee Fat pad Highly innervated and vascular Connective tissue Chronic Inflammation of the bursa

tarsal tunnel

"Tom" "Dick " "Bloody Nervous" "Harry"

positive special tests with instab

+dial test +abduction hyperextension ER test +prone instab test +hyperextension ER test LOOKING FOR ANTERIOR HIP PAIN

femoral anteversion

10-15

coxa vara angle

105

angle of inclination

125

coxa valga angle

140

normal anteversion

15

STJ axis of motion

16 degree off sagittal plane 42 degrees off transverse plane

baxters neuropathy

1st Branch of the lateral plantar nerve, lies deep to the abductor hallicus and FDB, and travels superficial to the quadratus plantae along medial calcaneus Often seen concurrently with Fat Pad Atrophy and PF Cadaveric Studies: Demyelination of the lateral plantar nerve and perineural fibrosis

1. What bones make up the first ray?

1st met, Medial cuneiform, proximal/distal phalanx

sesamoiditis

2 sesamoids embedded in FHB tendons like PF syndrome part of plantar plate of first ray articulate with MT head

femoral head covered how much

2/3 if sphere covered with articular cartilage

STJ ROM and accessory motion

20-0-10 frontal plant INV/EV total of 30 deg 8-12 deg supination and 4-6 deg of pronation for normal gait calcaneus glides laterally with INV calcaneus glides medially with EV concave calcaneus

loose pack of PF

20-30 degrees knee flexion where dislcoations occur

labral tear who gets it

22-55% in those with hip or groin pain commonly asymptomatic 94% of cadavers at 78 had tears 73% asymptomatic YOUNG FEMALES atheltes with sustained hip flexion, rotation, extreme hip ROM (baseball)

ACL tears secondary injury

23% of athletes <25 y/o who return to sport sustain a second ACL injury doesnt specify a side can be either early in return to play contralateral injury > ipsilatearal graft failure more often in females graft failure bc age, high risk, incomplete healing, inadequate rehab

who is affected by FAI

25-50 hockey, soccer, football males (combined and cam) females (pincer)

calcaneal stress fx

2nd most common location of foot stress fracture 1st - metatarsals Commonly seen in skeletally mature athletes, military trainees, elderly with osteopenia Repetitive overload and inability of bone formation to match resorption X-Rays often NEG early Sensitivity: Initial 10% F/U 50% MRI*

who does AVN affect what age and what gender

30-50 males can be bilateral hip replacements are indicated when this is found

excessive anteversion

35 toe will go in as a compensation

why is the squeeze test in hook lying

45 degress hip flexion has been shown to recruit highest adductor ACTIVITY on EMG although most force produced at 0 degrees 45 gets all of them except pectineus which needs to be at 90 degrees

functional knee ROM gait, stairs, sit to stand, in and out of bath

60 flex 80 flex 90 flex 135 flex 110 = rehab joal

retroversion

5 toe will go out

ACL injuries contact vs non, who does it affect

70 non 30 contact females (although men have a higher absolute risk) military, prof, amateur athletes

ACL reconstruction outcomes

81% of athletes able to return to some level of sport 65% of athletes returned to their preinjury sport level 55% of athletes returned to competitive sport Increasing odds to return to sport.... Limb-to limb symmetry - hop test Younger age Males Fear of reinjury negatively influences recovery Better recovery found in those with: Higher self-efficacy Higher optimism Positive coping strategies Athletes who returned to sport: Higher preoperative motivation Positive perception

tx of adductor strain

83% self resolve within a week

PFOA risk factors

>40 obesity prev ACL injury

metatarsalgia

A collection of pathologies causing overload and pain in the forefoot Etiology: Primary - intrinsic abnormalities of metatarsal anatomy and the relationship between metatarsals and the rest of the foot Secondary - Changes to forefoot anatomy via disease or trauma Iatrogenic - reconstructive procedure to foot

ITB tx

ACITIVTY MODIFICATION

ACL tear and osetoarthritis

ACL reconstruction could not prevent OA the menisci was found to be the most important predictor of the development of OA The prevalence of osteoarthritis after an ACLR: Significantly increased with time Positively correlated with longer chronicity of ACL tear at the time of surgery 3 fold increase in OA following ACL injury treated with reconstruction No difference in graft type used Stronger risk factor with meniscus resection Low risk of evolution of OA But mild signs of joint degeneration were reported so MAYBE lol carol would say yes

diagnosis of AVN

AP and frog leg radiograph not sensitive for early detection MRI best

TC joint lateral ligs resistance

ATFL: resist inversion and anterior glide of talus CFL: resists inversion PTFL: limits talus posterior glide and inversion

PCL post op rehab

Active Flexion allowed 6 weeks post operative reconstruction Prone passive flexion or supine passive flexion Prevent posteriorly directed force Non weight bearing or partial weight bearing initially Or weight bearing in full extension Hamstring and quadriceps co-contraction exercise Minimize posterior shear force With these two playing together will minimize shear Contrindicated for PCL repair Mini squats mini leg press Quads anterior translate after 70 degrees is a posterior translator no idea what shes talking about 30-60 degrees something

fxn of foot

Acts as a support base that provides the necessary stability for upright posture with minimal effort Provides flexibility to adapt to uneven terrain Provides mechanism for rotation of the tibia and fibula during stance phase of gait Acts as a lever for push off propulsion

acute lateral ankle sprain tx

Acute/Protected Motion Phase: Early WB with support (Strong Evidence) *Lace up > tape or immobilization - no more than 4-6 weeks* Manual therapy - lymphatic drainage, soft tissue/joint mobilization (Moderate Evidence) Manual therapy + therapeutic exercise Physical agents - cryotherapy (Strong), electrotherapy (Conflicting), low-level laser (Conflicting) not ultrasound (Strong) Cryotherapy + therapeutic exercise Therapeutic exercise (Strong) Progressive loading/Sensorimotor Training Phase: Manual therapy - MWM, graded mobilization for DF AROM, proprioception and WB tolerance (Strong) Therapeutic exercise - Supervised single limb balance activities on unstable surface (Weak) Sport-specific progressive loading - reduce risk for recurrence (Weak)

sever's disease (calcaneal apophysitis)

Adolescents, young athletes Overuse or repetitive stress of an open epiphyseal plate Closes around 13 y/o females, 15 y/o males 4 Proposed Mechanisms: Increased tension of Achilles tendon complex due to rapid growth spurts* during puberty Strain caused by hard strikes to the heel in children with high arches, or flat feet Mechanical disruption caused by microtrauma Obesity Other considerations: Overuse (new sport, new season) in high impact sports (jumping/running)* Improper footwear Running on hard surfaces

snapping hip syndrome

Aka Coxa saltans Audible or palpable snap with movement Can be painful or not

Greater throchanteric pain syndrome

Aka greater trochanteric bursitis May not have inflammation though of the bursa Gluteal tendons are more commonly affected

ottawa ankle/midfoot rules

An X-ray is indicated if there is pain in the malleolar zone and: 1. Bone tenderness specific to -Distal 6cm of posterior edge or tip of lateral malleolus -Distal 6cm posterior edge or tip of medial malleolus 2. Inability to weight bear immediately following the injury and during exam A foot X-ray is indicated if there is pain in the midfoot zone and: 1. Bone tenderness specific to -Base of 5th -Navicular 2. Inability to weight bear immediately following the injury and during exam (must be able to take 4 steps)

anterior and posterior meniscus horns

Anterior horn: receives fibers from ACL Posterior horn: receives fibers from PCL

osgood schlatters disease

Apophyseal osteochondrosis tibial tuberosity micro-alvulsions and secondary ossification Adolescents F: 8-12 y/o M: 10-15 y/o Clinical findings: Anterior knee pain Pain with jumping, kneeling Enlarged tibial tuberosity Decreased quad length Painful quad strength testing Treatment: RICE Activity modification/limitation Oral inflammatory meds Knee brace Stretching/strengthening During maturation, the cartilage cells of proximal tibial tuberosity migrate distally. With increased stress by the quads, micro-avulsions occur and secondary ossification. These bone fragments get reabsorbed and incorporated into the tibial tuberosity forming an enlarged tuberosity.

non op management of meniscus

Asymptomatic tears Older patients (68-90% prevalence meniscus lesions of patients with OA) (Englund et al 2008) Pt's at high surgery risk Tear Type: (Cole 1999) Partial thickness splits STABLE full thickness vertical or oblique tears Short radial or minor inner rim tears Degenerative tears in OA (no mechanical symptoms) Stable tears with inability to displace central portions

ankle OA presenation

May develop slowly over time and result in intermittent flare Deep, intermittent, ache with sharpness during aggravating activity HEAT HELPS * stiffness morning, throb evening

PCL presenation

Body Chart: Posterolateral knee pain Pain over proximal fibular head and lateral joint line Reports of functional instability Knee "giving way" into hyperextension with graded walking and stairs Gait: varus thrust with extension

lisfranc presentation

Bruising/swelling and deep sharp/aching pain at midfoot/TMT joint SL raise hurts

medial meniscus

C shaped larger radius thin peripheray external border attaches to MCL** NOT attached to ACL/PCL** less mobile: injuried x2 more frequenty

why use a CT vs MRI for hip dislocation

CT is used post reduction to assess the intracapsular anatomy MRI is for osteonectrosis and labral tears

MCL diagnosis

Clinical Diagnosis Location of pain Mechanism of injury r/o other ligamentous injury Valgus stress test MRI When clinical diagnosis is inconclusive Grades tear

PT tx

Conservative: Activity modification (Relative Rest) Exercise Eccentric loading vs Isometris vs Heavy Slow Resistance (HSR) Quadriceps strengthening Flexibility: Quadriceps and Hamstrings Friction massage Better outcomes than traditional treatment Pharmacotherapy NSAIDs Short-term Iontophoresis Injections surgery rarely required (tenotomy) reduce risk with: Improve kinetic chain function Perform eccentric exercise Correct landing patterns Minimize valgus force

hoop stress

Conversion of axial load into tensile strain through INTACT longitudinal collagen fibers, depends on intact anterior and posterior attachments.

fx imaging and ottawa knee rules

Diagnosis of fracture CT Radiograph Ottawa Knee Rules One or more in acute knee injury -- Age >55 y/o Isolated tenderness of patella Tenderness of head of fibula Inability to flex 90 degrees Inability to weight bear 4 steps *Negative result is associated with a fracture probability of <1.5%

metatarsalgia presenation and MOI

Foot trauma, surgery or slow progression over time Superficial sharp, sometimes aching pain at MTP

lateral ankle sprain presenation

Deep/superficial sharp/achy pain with ecchymosis and swelling Pain commonly lateral, dorsal stiffness pain AM*** throbbing PM****

pros and cons to THA posterior and anterior approach

DAA may be better in immediate short term No significant functional differences long term Approach should be based on patient factors, surgeon preference and experience SHORT TERM DO STRENGTHEING OF QUADS AND HAMS

9. Your new ankle evaluation is complaining of lateral ankle pain as well as minor posterior knee soreness after playing pick-up basketball. You begin watching them on the treadmill and notice that they demonstrate minimal knee hyperextension and whole foot ER on the painful side. You suspect to find limitation in ankle ___________.

DF

mortons neuroma presentaion

Deep, intermittent, forefoot burning/cramping/tingling/sharp pain affecting the 2nd and 3rd met spaces prolonged standing/walking

cuboid syndrome presenation

Deep, intermittent, localized sharp, sometimes aching pain along lateral foot with TTP potentially at peroneus longus PROPULSION PAIN

fx s/s

Difficulty with weight bearing* Decreased ROM Persistent pain History of trauma Joint Effusion

MTSS presentation

Diffuse, dull, aching, superficial (>5cm) pain over distal 1/3 of posteromedial tibia Pain with exertion that eases - eventually pain does not ease

5. During midstance, while the foot translates to pronation, what three kinematic motions do the stance hip produce? ____________, _____________ & ____________

During midstance, while the foot translates to pronation, what three kinematic motions do the stance hip produce? Flexion, Adduction & IR

meniscus fxn

During walking, compression 2.5-3 x BW, over 4 TIMES in stair navigation, menisci TRIPLE the contact...significantly reducing pressure on artic cartilage Circular orientation of meniscus designed to absorb "circumferential hoop stress" : compressive forces absorbed as circumferential tension throughout EACH menisci

achilles tendinopathy tx

Eccentric loading in midportion: 45 X 2 X 7 X 12 (Strong evidence) 3x15 2 times a day 7 days a week for 12 weeks Bad side is behind so its okay Manual therapy (Expert opinion) Low-level laser (Moderate) Iontophoresis with dexamethasone (Moderate) Stretching to increase DF (Weak) Foot orthoses (Weak) Taping (Expert opinion) Heel lift (Conflicting) Not using night splint (Weak) *Performing to neutral may be more effective in IAT (insertional) (45 X 2 X 7 X 12) 67% satisfaction vs 32%* Isometrics (PF) increase tendon stiffness in healthy patients - how about irritable IAT with decreased stiffness? Do-as-tolerated eccentric program past neutral did not lead to lesser improvement with mid portion tendinopathy (as many as can up to that amount) Balance training on impaired side mid portion

haglunds deformitiy (retrocalcaneal exostosis)

Enlargement of the heel at the Achilles Tendon insertion 40-60 y/o, Females > Males Unknown aetiology, suggested higher risk in those with high arch, tight Achilles Tendon, or a genetic predisposition, repetitive stress May be associated with Achilles tendinitis or retrocalcaneal bursitis

Snapping hip presentation

External - superficial lateral hip pain Pain with hip flexión and extension Internal - deep, anterior groin pain Snaps with flexión, abduction, ER to extension addiction IR movement Bc iliopsoas sits on the outside in flexión and moves in with extension

Who does snapping hip happen to

Females Adolescence and young adults Dancers martial arts gymnast runners

what is plantar fascia

Fibrous aponeurosis Proximal Attachment: Plantar medial aspect calcaneal tuberosity Divides into 5 'slips' Distal Attachment: Proximal Phalanges (MTP), surrounding dermis, transverse metatarsal ligaments, and flexor tendon sheaths Lacks elasticity, maximal elongation of only 4% of total length

Tx of snapping hip

Flexibility/stretching Eccentric control

lisfranc injury MOI

Forceful ER and pronation of foot/fall onto maximally plantar-flexed foot/direct crush injury Disruption of the capsuloligamentous or bony structures of the midfoot leads to varying degree of TMT separation

compartment syndrome

Forefoot running with increased step rate (180 steps per minute) to decrease eccentric activity of the anterior musculature need to change running habits

functional examples of OA

Functional examples: hip OA (tying shoes, crossing legs). Knee OA: shoewear (heels), stairs, squatting/kneeling

ankle sprain grading

Grade I: No ligamentous instability (talar tilt, anterior drawer) Little or no ecchymosis, no functional loss Grade II: Positive anterior drawer, negative talar tilt Ecchymosis, swelling, point tenderness, some loss of function Grade III: Near total loss of function Positive anterior drawer and talar tilt Diffuse swelling and ecchymosis, extreme point tenderness

plantar fasciosis presentation

Gradual onset Local pain at medial calcaneal tubercle Pain with 1st steps in AM, after period of inactivity, prolonged standing, activity dependent (sport/work) Improves with brief periods of activity, rest, light stretching Usually worsens by the end of the day Recent increase in activity levels (change in work or sport demands) DECREASED DF!!! FAT PAD ATROPHY!!!

ACL presenation

HEMARTHROSIS 0-12 hours after injury, cant see joint lines instability, giving out

IT band presenation

Lateral Knee pain superior to lateral joint line May report snapping/clicking h/o repetitive activity Pain worsens with increased activity (initially) Pain with walking/sitting (chronic) Nature: sharp/burning pain/tenderness 2-3cm superior to lateral joint line

copers vs noncopers

copers - ACL deficient, resume without instab, adapters and modify their activity level noncopers - require reconstruction bc recurrent giving way episodes in ADLs

fun fact

Homo Sapiens developed 2 tibial insertions of lateral meniscus: anterior and posterior 2° habitual full extension movements of the knee during stance and swing phases of walking Reduce AP movement of LM and reinforce knee extension stability necessary for bipedalism

grades of adductor strain

I • Pain, minimal loss of strength and minimal restriction of motion II • Tissue damage that compromises strength of muscle, but not complete loss of strength/function III • Complete disruption of muscle tendon unit, complete loss of function (refer for imaging)

GTPS presentation

I/M, superficial lateral hip, thigh, buttock pain if have lower leg pain more likely a trigger point pain may be dull, achy, sharp, or lancing hard to lay on affected side, SLS, walking running, stairs may have just INITIATED or INCREASED activity or falls weakness of hip abductors may have TRENDELENBERG or lateral lurch compensation

what is in this corner and fxn

ITB, biceps femoris, FCL, popliteus, popliteofibular ligament, lateral gastroc, lateral joint capsule, coronary ligament, and oblique popliteal ligament helps PCL especially in 30 degrees knee flexion; stability of knee in <45 degrees flexion Studies have reported that these structures work together to stabilize the knee by restraining varus, external rotation and combined posterior translation with external rotation to it. The function of the PCL is to prevent the femur from sliding off the anterior edge of the tibia and to prevent the tibia from displacing posterior to the femur. aka makes sure it doesnt go into hyperexension****

tarsal tunnel syndrome presenation

Idiopathic or following trauma Space occupying lesion Burning sensation or pain at medial heel and/or plantar surface of the foot WB, prolonged standing NIGHT PAIN****

convex vs concave rule

If the moving joint surface is CONVEX, sliding is in the OPPOSITE direction of the angular movement of the bone. If the moving joint surface is CONCAVE, sliding is in the SAME direction as the angular movement of the bone.

Internal snapping hip

Iliopsoas tendón over iliopectinal eminence or femoral Head Caused by bony ridge at eminence, cyst, or acetabular prosthesis Pain again due to inflammation of bursa

windlass effect

Important for Toe-Off Phase in Gait 1st MTP Extension increases tensile plantar fascia forces Elevates the Medial Longitudinal Arch Increases foot stability Rigid column for effective push off/propulsion in gait

4. In closed chain supination you will expect the calcaneus to ___________ while the talus _________ & __________.

In closed chain supination you will expect the calcaneus to Invert while the talus Dorsiflexes & Abducts.

meniscus kinematics

In knee flexion/extension: convex femoral condyle roll on tibial plateau FLEXION LM/MM move postero-lateral. decrease contact area EXTENSION LM/MM move anterior ROTATION LM/MM follow femoral condyles

high ankle sprain presenation

Intermittent, generalized, deep, aching pain in lower anterior leg Out of proportion to apparent injury Difficulty with pushing off stiffness in morning, throb at night

patellar tendinopathy guidelines

Isometric loading - found decreased patellar tendon pain for 45 min after exercise way of loading musculotendinous unit when pain provoked with isotonic exercises Isotonic loading - initiated when can be performed with minimal pain restore muscle bulk and strength heavy slow resistance methodology applied here performed 10-60 deg of knee flexion and progress towards 90 deg - remember the relationship between quad force and patellar tendon load (greater at 90 deg of knee flexion) Then begin to reintroduce energy storage loading - plyometrics, jumping, etc. and return to sport

ACL psychometric questionnaires

Knee symptoms/function: KOOS, LEFS Activity Level: Marx Activity Rating Scale Tegner Scale Psychosocial factors: Tampa Kinesiophobia Scale SF-12 General Health questionnaire PHQ-9 Depression screen

6. Your 45-year old weekend warrior comes in complaining of "shin splints" with burning pain down across his distal, medial R shin after he sits for a prolonged period of time after running. You remember your anatomy, and develop an additional hypothesis that his ___________ nerve root may be irritated and a lumbar screen/exam may be necessary.

L4

PCL tx non surg vs surg

LE strengthening Quads, hamstrings, gastrocs, popliteus Hip/lumbopelvic stabillization Neuromuscular Re-education Controlling varus and tibial ER Grade III and greater Surgical intervention depends on structures involved anatomic repairs or reconstructions of the PLC structures be performed Goal: stable, well-aligned knee restore the preinjury kinematics of the knee Improved outcomes for isolated PCL surgery <3 weeks of injury

foot outcome measures

LEFS Foot and Ankle Ability Measure Victorian Institute of Sports Assessment Star Excursion Balance Test - demonstrates deficits and improvements with training in CAI Single Leg Hop Test

what does manual therapy do for an ACL tear

LOCALLY Increase knee joint mobility Decrease pain Facilitate nociceptive processing DISTALLY Improve muscle activation Decrease pain

MOI meniscus

MOSTLY NON CONTACT. Sudden acceleration/deceleration in conjunction with change in direction (rotation). Meniscus gets trapped between tibia and femur tear. In jumping sports, vertical sports + varus/valgum moments

gait

Load Response Ankle - Dorsiflexion Subtalar - Supination Mid-stance Ankle - Neutral Subtalar - Pronation Terminal Stance Ankle - Dorsiflexion Subtalar - Pronation -> Supination Pre-swing Ankle - Plantarflexion Subtalar - Supination Great toe - Extension

assocaited injuries with ACL

MCL tear meniscal terrible triad = acl, mcl, and meniscus bone bruise (tibia and femur collide on lateral femoral condyle or lateral tibial plateu)

more fxn

Mechanoreceptors transduce mechanical deformation into electric neural signals. Meniscus can detect proprioceptive info in the knee, thus playing an important role in the sensory feedback mechanism of the knee. Partial menisectomy pts had a sig loss off JP sense at knee flexion angles 60-75 deg at 2 yr follow up

External snapping hip syndrome

Most common IT band or anterior aspect of glut max moving over greater greater trochanter Caused by tight or thick structures or Coxa vara Pain is due to inflammation of trochanteric bursa

plantar fasciosis

Most common foot condition diagnosed and treated accounting for 8% of injuries Ages 40-60, or younger in runners

are corticosteroids recommended for plantar fasciosis?

NO bc PF rupture and fat pad atrophy

stress fx tx

NWB/boot if pain with walking*** cross training/low impact loading RTS after 10-14 days pain free full unrestricted sport 12-13 weeks ISOMETRICS FOR BONE STRENGTH IN CORTICAL AREAS PRONE TO STRESS

MTSS tx

No clinical significance between pain medication, rest only, walking cast and calf stretching only orthosis not supported CALF MUSCLE TRAINING RUNNING RETRAINING

early ACL reconstruction vs rehab with option for surgery

No differences between groups in: Patient-reported outcomes Activity level Radiographic incidence of OA in the surgical knee

When do surgery for snapping hip

No relief in 3-6 months Z Plasty Tendon release Causes abduction and flexión weakness

lateral meniscus

O shaped smaller radius thick periphery external border attaches to lateral capsule*** attached to ACL/PCL***

post op consideration

OA 50% Tiobiofemoral contact area dec by ~50% Removal of 15-34% inc contact pressure by >350% Total lateral menisectomy results in 45-50% dec in total contact area and 235-335% inc in peak local contact pressure

piriformis tx controversion

OFF LOAD, dont stretch bc already in an elongated position and it is encroaching on the nerve and causing symptoms

OA presenation

PAIN DURING ACTIVITY ABSENSE OF WARMTH AND WEIGHT LOSS FEVER AND SWEAT

labral tx PT

PT has not been shown to be effective however work on dynamic hip control like SLS, will help with pain

FHL presenation

Pain anywhere along distribution (n= 88) Posteromedial ankle (n= 40) Plantar heel pain (n= 23) Midfoot pain (n= 22) Multiple locations (n=16) All patients had pain at FHL Limited 1st MTP DF with ankle DF (n=30)

PT presenation

Pain localized to inferior pole of patella Load-related pain Increases with demands knee extensors Rarely pain in resting state "Warm-up" phenomenon Dose dependent pain Shallow squat<deep squat Stiff-knee vertical jumping-landing strategy

mortons neuroma MOI

Pathological changes leading to intraneural fibrosis ie MTP joint instability or thickened transverse met ligament compressing interdigital nerve Acute DF injury to forefoot or chronic compressive load

tx of AVN surgery

core decompression (take out necrosis) osteotomies (offload necrosis) femoral resurfacing arthroscopy (put cap on head) THA (most reliable!!! later stages)

TF accessory motions

Plantar Flexion: - Caudal, posterior migration of fibula - Lateral malleolus rotates medially - Approximation of TC joint Dorsi Flexion: - Cephalad, anterior migration of fibula - Lateral malleolus rotates laterally - Accommodates wider portion of talus Supination: - Fibula glides distally and posteriorly (goes with the motion) Pronation: - Fibula glides proximally and anteriorly

8. Your 75-year-old with DM2, PVD and a history of MI shows up for their first visit post-operatively after tibial ORIF. Along with observation, palpation and swelling measurements, you want to check that their peripheral vascular structures are intact so you check their pulse at the __________ artery and the ___________ artery.

Posterior Tibial Artery artery and the Dorsal Pedal Artery.

When walking my patient with weakness/pain in her RLE who requires supervision where should I be standing to appropriately guard this patient?

Posterolateral on the R with hands in guarding position

ACL stages of rehab

Pre-operative -Effusion reduction, normalize gait, strength, and muscle activation Post-operative -Same as above -Regaining knee extension ROM! Progressive limb loading Unilateral load acceptance sport specific task retraining Unrestricted sport specific training ** Critical that pain and joint effusing are monitored!!

DVT risk factors

Previous DVT or PE ago over 55-60 years active cancer/cancer treatment Oral contraceptives Prolonged Immoblity/bed rest Recent surgery

ankle OA MOI

Previously acute on chronic change in ankle joint structure or mechanics leading to repetitive cartilage degeneration Osteochondral defect with traumatic sprain Combination of biologic, mechanical and structural factors

PTTD presenation

Progressive increased pain at medial ankle, mid foot or medial calf after prolonged or increase frequency loading Intermittent, superficial, sharp pain with potential deep aching pain walking, heel raise, and toe walking hurts first steps hurt??

cam impingement

early contact DUE TO osseous deromities of femoral head-neck junnction pistol grip deformitiy where there is less concavity of the neck laterally or anteriorly/superiorly

posterior tibial tendon dysfunction aka tendinopathy MOI

Proximal and distal myotendinous junction most susceptible to damage shifting load to midsubstance causing micro tears and collagen disruption

vascularity

RED ZONE: outer, vascular WHITE ZONE: inner, avascular, aneural RED-WHITE ZONE: between red + white

what is GTPS analogous to

RTC syndrome

positive tests for labral patho

RULE OUT thomas test = high sens and spec for labral tears ??? + = deep click or clunk +twist test = groin pain, apprehension, gross ROM limitations this is a bad notecard i know sorry just this one

PCL presentation

Rarely hear 'pop' at injury Posterior knee pain Instability and discomfort Aggravation with kneeling or decelerating Minimal pain with knee extension Increased pain past 90 degrees of flexion Possible lack in knee flexion by 10-20 degrees Minimal swelling compared to ACL rupture Instability may or may not be present

PFPS pos special tests

patellar compression (clarkes) eccentric step test patellar apprehension test SPIN

stress fx special test

patellar-pubic percussion test RULE OUT

who gets hamstring syndrome

preceded by a hamstring injury (may have frequency injuries here) sprinters, runner, jumpers hx of LBP 20-40

MCL presenation

Well localized medial knee pain Local tissue swelling No large joint effusion Medial knee bruising Instability less common May report medial knee "pop" at time of injury Higher grade sprains Presence of locking/catching concurrent meniscus tear

who gets tarsal tunnel syndrome

pregnant people

7. Because of your clever anatomy professor's acronyms, you easily recall that these 5 structures sit in the tarsal tunnel: ___________, ___________, _____________, _________ & __________

Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis longus, Posterior Tibial Artery/Vein & Tibial Nerve

exercise therapy vs arhtroscopic partial meniscectomy

Reduction in pain after arthroscopy is short lived (< 1 year) (thorlund et al 2015) Improved results in active population with lower BMI Exercise therapy resulted in improved quad strength Supervised PT should be considered as an option for pts with knee pain and known degen meniscus tears!

indications for surgery

Repair results support favorable success at extended follow-up rates in > 70-90% pt's (Belzer et al 1993) Improved outcomes with meniscal repair than menisectomy

patellar tendinopathy (PT) MOI and risk

Repetitive eccentric loading Risk Factors Weight BMI Leg length difference Foot arch height Quadriceps flexibility Vertical jump performance

LCL presenation and special tests

Reports of 'popping' sensation at injury Moderate lateral joint line pain Minimal to moderate effusion Instability may or may not be present Painful knee ROM pos varus stress test extension = multiple structures 30 deg flexion = isolated LCL

TIBIAL PLATEUA FX

SCHATZKER FX TYPES I-IV I-III LOW ENERGY IV-VI HIGH ENERGY

tarsal tunnel syndrome intervention

STM to surrounding muscles motor control of pronation*** neural mobs

peripheral nerves: saph, common peroneal, superficial fib, tibial

Saphenous Nerve Common Peroneal Nerve Superficial Fibular (Peroneal) Nerve - TKA Tibial Nerve Nature: Burning, numbness, tingling

osteochondritis dissecans all info

Separation of subchondral bone from the articular surface affecting articular cartilage Localized necrosis of the subchondral bone Later revascularizes and reossifying of bone No h/o trauma 12-20 y/o athletic males c/o joint pain; antalgic gait Swelling or locking if loose bodies present Non operative treatment (Yoshida 1998) Activity modification Immobilization Weight bearing restrictions Operative treatment Fixation Rehabilitation Restrictions Weight bearing ROM Seperation of subchondral bone from the articular surface may affect the artiicular cartilage and cause joint pathology Fragment of bone may detach and become loose body with in joint space The knee is not the only joint affected but it is the most common - medial femoral condyle

what functional tests will PT have pain with

Single leg declining squats Stairs Jumping/hopping

positive special tests PLC

Special tests: Posterolateral drawer test, dial test, ER recurvatum test, varus stress test, reverse pivot shift test

grading of ligament tears

Sprains/Tears: Grade I (stretch) Grade II (partial tear) Grade III (full thickness/rupture)

How many bursae and where

Sub glut med Sub glut max (trochantieric) Sub glut min TFL is also right there

diagnosis of sesamoiditis

Subjective will drive this Change in activity level Repetitive loading activities Phase of gait that is painful Type of footwear Objective Exam Increased lateral foot loading/gait analysis Painful and limited MTP ROM Decreased MTP PF strength Pain at plantar first metatarsal head

haglunds deformitiy (retrocalcaneal exostosis) presenation

Subjective: Pain at posterior heel, worse after period of rest Painful with shoe wear (rubbing, compression) Pain with plantarflexion, or activities like running, jumping Objective: Observation: Bump at posterior calcaneous, limping, swelling Painful direct palpation Management: Heel pads Shoe changes Stretching Plantarflexor strengthening

severs diseease

Subjective: Non-radiating pain and tenderness in one or both heels Recent increase or change in activity or sport participation Worse with running, jumping Objective: + Calcaneal Squeeze test Pain with direct compression Absent swelling, erythema Imaging not necessary but may be indicated to rule out other pathology like stress fracture, bone cyst, etc Management: Activity modification Protected WB (boot) for 4-8 weeks Return to activities once tenderness resolves LE strengthening and stretching of hamstrings and gastroc to reduce tension at the heel Return to sport in 4-8 weeks NEEDS TO BE MANAGED ASAP AS THEY GROW, NEED TO TAKE A BREAK

fat pad atrophy clinical presenation

Subjective: Deep, non-radiating pain at the central weight-bearing part of the calcaneal tuberosity, progressive worsening with increased WB activities Objective: Observation - Asymmetry, Gait Palpation: TTP central calcaneal tuberosity Unable to elicit symptoms with ROM, MMT, Neural Provocation Management: NSAIDs Padded shoes Heel cups Customized orthotics Corticosteroids and surgery is not recommended

baxters neuropathy presentation

Subjective: Dull pain 4-5 cm anterior to the posterior aspect of the heel, burning may radiate distally to lateral plantar foot. Pain and stiffness in AM Objective: Painful palpation Pain with stretch of Abductor Hallicus, shortening of foot flexors Hindfoot valgus, Posterior tibialis deficiency + Percussion Diminished sensation over lateral plantar foot Management: Manual Therapy, Orthoses for hindfoot position. Strengthening of Posterior Tib, change in running posture

calcaneal stress fx presenation

Subjective: Pain during weightbearing activities, night pain, changes in exercise or activity, pain is intense, diffuse posterior superior heel pain medial and lateral Objective: + Calcaneal Squeeze test Pain with direct compression Bruising/swelling Management: Activity modification Protected WB (Boot/Cast) for 4-8 weeks Return to activities once tenderness resolves

achilles tend/rupture presenation

Superficial, localized intermittent sharp/aching pain at insertion or between 2-6cm proximal to insertion Rupture may or may not be painful

aggravating knee factors

Terminal knee flexion/extension Weight bearing - standing/walking Kneeling Squatting Descending vs ascending stairs Prolonged sitting Running Jumping Cutting/pivoting

ankle OA sx

arthrodesis: Ankle positioned in neutral DF and 5 degrees hind foot valgus with screws and plates Decreased stride length, cadence and foot/ankle ROM during gait 10.3% revision rate Lower health care cost total ankle arthroplasty: increased AROM, decreased pain higher cost and revision rate

piriformis syndrome presentation

buttock pain pain aggravated on siiting external tenderness near the greater sciatic notch any PS sign - pain with increased PM tension ??? may also have paresthesias into posterior thigh, lower leg, foot

2. The talocrural joint is supported by the ____________, ____________ & __________ laterally and the ___________ medially

The talocrural joint is supported laterally by the ATFL , PTFL & CFL and the Deltoid ligament medially.

Diagnosis of snapping hip and pos tests

Through clinical exam Positive obers (IT) Positive Thomas test (internal) Can use US

tarsal tunnel syndnrome MOI

Tibial nerve compression/entrapment neuropathy in tarsal tunnel stemming from post-traumatic, biomechanical or inflammatory conditions

shaft of femur anatomy

anterior convexity to bear greater loads

lateral ankle sprain pos special tests

anterior drawer test for ATFL

risk factors for IT band syndrome

Training errors -Change in routine -Increased mileage -Hill running Downhill Running Excessive genu varum Increased hip adduction + knee IR Weak hip abductors

meniscus differential

Twisting injury Tearing sensation at time of injury Delayed effusion (6-24 hours post injury) History of "catching" or "locking" ✪ Pain with forced hyperextension ✪ Pain with maximum flexion ✪ Pain or audible click with McMurrays ✪ Joint line tenderness ✪ Discomfort or a sense of locking or catching in knee over the medial or lateral joint line during the Thessaly Test (performed at 5° or 20°of knee flexion

PFOA tx

prioritize nonpharm unless longer than 9 months of conservative then both are the same

stress fx tx

WB restiction when pain with WB improves, can progress to closed chain acitivty if no progress after 6 weeks, repeat imaging

imaging

WB xray or MRI heel spur but might be in flexor digitorum not the plantar fascia imaging not indicated except in cases where paients fail to improve

warm up phenomenon

Warm up phenomenon - improves with repeated loading but may be increased pain the day after

sesamoiditis tx

Weight-bearing modification: CAM boot Orthotic shoe Rocker bottom shoe Sesamoid/metatarsal pad Activity modification Metatarsal pad Manual therapy sesamoid mob

labral tear presentation

anterior hip and groin pain!!! if dont have this RULE OUT deep dull ache, sharp at end ROM mechanical symtpoms- click lock give out may hear pop hurts with walking, running, pivot, prolonged sitting NIGHT PAIN!!! rotation ROM deficits most pain with flex, add, IR global hip weakness

lateral and medial condyles articulate with

tibial plateus

imaging PLc

XR: fibular fx, lateral capsule avulsion, lateral joint space widening MRI: integrity of PLC

3. You will expect, on average, up to ________ degrees of DF and _________ degrees of plantar flexion, with _________ degrees of inversion and _________ degrees of eversion.

You will expect, on average, up to 20 degrees of DF and 50 degrees of plantar flexion, with 20-35 degrees of inversion and 10-15 degrees of eversion.

labral sx and contraindications

arthroscopy (persistant pain conserv doesnt work) contraindications for arthro: hip fusion cellulitis severe acetabular dysplasia femoral neck stress fx AVN advanced joint degen labral debridment labral repair (anchors sutures, used more often) labral recontstruction (form IT band)

FAI can damage what

articular cartilage and labral structures can contribute to OA and labral tears

high ankle sprain sx

screw fixation arthrodesis arhtroscopic debridement

TF ER/IR

at 90 degrees knee flex = 40-45 2:1 ratio of external to internal rotation maximally restricted with full knee extension combo of femoral and tibial rotation

posterolateral corner injury moi

athletic trauma, mvc, falls anteromedial blow to knee hyprextension tibial ER w partially flexed knee

who does lisfranc happen to

athletics MVA shorter second met adding pressure to midfoot

patellofemoral dislocations who does it affect and what is it and how does it happen

athletics, often <20 non contact knee flexion and valgus moment injury to medial patellofemoral ligament displaced laterally diagnosis = xray or CT for displacement, MRI for cartilage and ligament integ tx = sx if fx and conserv if no fx (bracing)

FAI presentation

anterior lateral hip/groin, medial thigh "C sign" I/M deep ache, sharp with activity prolonged sitting >90 degrees, sit to stand transition, pivoting with sports/gettingout of car/crossing legs FLEXION/IR HURTS less pelvic recline during squat aka sit in an anterior pelvic tilt which predisposes them to impinge then the femur and everything else cant move anymore to squat lower so have to flex at your spine and get the WINK so if situation and fixed more into a posterior tilt then wont impinge as early and back will not have to flex

PFOA presenation

anterior or retropatellar knee pain worse with loading crepitus enlargement of the joint * knee extensor weakness hip extensor and abductor weakness decreased knee FLEXION and or EXTENSION INACTIVITY IRRITATES IT**** SO DOES EXCESSIVE LOADING aka can do swimming, biking better after hot shower no excessive movement or inactivity

pubofemoral limits

abduction, extension, ER

pincer impingement

abnormal contact of head and acetabular rim DUE TO acetabular osseous abnormalities or overcovergae increased center-edge angles (coxa profunda, acetabular protrusion) decrease in acetabular anteversion angles (acetabular retroversion)

what causes PFPS

abnormal patella tracking laterally poor hip control (knee valgus) increased foot pronation hamstring weakness/tightness tight ITB or TFL overtraining

PFPS tx

activity mod quad strengthening increases PFJ contact area and decreases pain***

acute vs chronic ACL injury and risk of meniscus

acute increased likelihood tear LM chronic increased tear MM

ideal repair tear

acute, vertical, longitudinal tear in peripheral 1/3 of a young + stable knee

closed chain WB what adductor is recruited

adductor magnus

adduction and abduction muscle balance

adductors 78% of abduction strength in injuried players 17x more likely to strain if adductor strength is <80% of abductor strength

surgical intervention for adductor strain

after 6 months fail tx adductor tenotomy good results for pain releif but ppl become weak 76% return to sport

patellar tendinopathy who gets it

aka jumpers knee young males prolonged absense from sports

WB lung test

aka lung wall test ankle DF restriction or ankle stiffness

avascular necrosis of femoral head

aka osteonecrosis results in osteocyte death, fx, and collapse of artcular surface commonly affects TMJ, humeral head, knee, ankle most common in femoral head

hip OA +

compression trendelenburg crepitus

types of tx

compression = inferomedial neck, minimal risk of displacement, CONSERVATIVE TX happens in young and healthy adults tension = superolateral neck, increased risk for displacement can progress to nonunion or AVN...MOST REQUIRE SX, common in elderly

who does PFPS affect

both sedentary and active women

hallux valgus MOI and who does it affect

bunion females more than males Medial drift of 1st metatarsal head Lateral drift of proximal phalanx

hip what type of joint

ball and socket synovial joint

what is the vascular supply to the femoral head

basicervical extra cap ring (circumflexx) subsynovial intraart ring lateral epiphyseal vessels obturator artery

combo cam and pincer

both majority of cases people can have this without pain and it is NOT considered FAI

patellar concave convex

convex anterior convex posterior in the middle concave on the sides of the posterior sits on concave intercondular groove and the convex facets

lateral column

calcaneus, cuboid rays 4-5

abnormal PF mechanics excessive knee valgus/IR

causes increased Q angle and lateral force on the patella "bowstrining of patella" pull of the IT band and lateral patellar retinacular fibers contibute more to the bowstringing may predispose factor to patellofemoral joint pain or lateral patellar dislocations

patellofemoral OA where does it affect and who

chondral wear is most prevalent in the lateral patellar facet female age greater than or equal to 55-60

athletic pubalgia

chronic lower abdomen and groin pain that may occur in athletes and non athletes aka sports hernia but falling out of favor bc true hernia is usually not present

PT diagnosis

clincally MRI r/o others US strucute, neovasc, and tendon chagnes can be improvement of symtpoms despite no change in imaging

diagnosis of GTPS

clinical exam imaging used for more persistent symptoms radiographs to rule out other pathology MRI is primary means to evaluate GTPS US can also work

tx of hip dislcoation relocated

closed reduction for simple open reduction for unstable arthroscopy for when its really messed up

high ankle sprain who does it happen to

collision sports wearing rigid boots pes planus

high ankle sprain MOI

combined ankle DF and foot ER on lower leg tearing of syndesmosis (anterior and posterior tibiofibular ligaments) alone due to trauma or in addition to lateral or medial lig stress/damage

tx of GTPS

cotricosteriod injection (short term) AVOID STRETCHING bc most likely due to strength deficit control abduction moments

AVN pathophys

cut off supply increase in osteoclastic activity thinning of tabeculae weakening

what surfaces are bad for ACL and risk factors

dry, cold, turf vs rubber during menstrual cycle fatigue ankle DF limitations

what can hip instability present as

dislocations, subluxations, microinstabilty

nondisplaced lisfranc

d=

MOI MCL

deceleration on a fixed foot or a sudden change in direction knee valgus and tibial ER combined with knee flexion lateral force applied to the outer knee breaststroke microtrauma

who ruptures

decreased PF strength increased foot pronation, obesity, drugs

when is the MCL in danger of injury and which part

deep full extension i.e. valgus stress over a planted foot in extension

hamstring syndrome presentation

deep aching pain at ischial tub radiate to posterior thigh less often the leg paresthesia stretching is aggravataing tends to LINGER may feel "weakness" pain with resisted knee flexion (may worsen with ankle DF) SLP and slump positive

capsule of hip is

deep and embedded with ligaments, more anterior forms a ring around the base of the femoral neck

hip instab presentation

deep pain with extreme ROM in groin butt and lateral thigh apprehension clicking locking catching giving out they have increased hip PROM but its painful they feel like their hip needs to be stretched but then they have their foot over their head so might not be the case also they have varying pain

femoral neck stress fx presentation

deep, anterior hip/groin aching pain...may radiate to knee, lateral hip indsidious pain with WB!!! pain with sinlge leg hop PAINFUL ROM END RANGE

deep squat and PF

deeper squat requires force of the quads and the greater the joint force between the patella and femur

movement impairment syndrome

diagnosis based on dysfunctional/faulty movement patterns which turn into pain named for direction that is dysfunctional aka anterior femoral glide syndrome limited posterior glide??? long and weak psoas muscle altered firing of gluts and hams leads to excessive anteriortranslation of femoral head with hip flexion = impingement and anterior hip pain aka hamstring pull the lower leg more than the psoas and that lever creates the excessive anterior glide

diagnosis of athletic pub

diagnosis of exclusion, clinically radiograph rules out other strong relationship betweeen AP and FAI MRI for msucular pathology US can help too

LCL MOI

direct load to anteromedial knee while in full extension varus or adduction moment non contact = adduction, flexion, ER

fx MOI both

direct trauma Patella Compression Fall Dashboard injury Eccentric motion High impact jumping Tibial plateau Axial loading Falls Skiing Direct contact Lateral contact injury Soccer

what causes piriformis syndrome

direct trauma over use hypertrophy shortening of the muscle infection anatomic variance

fx tx

immobilization and WB restriction conserv surg = ORIF

labrum fxn

increases articular surface by 22% and acetabular volume by 33% transfers load and stabilizes hip seals hip joint with negative intra-art pressure reduces stress on cartilage assists in stability with extreme hpi ROM and loading ie. ER and anterior translation

MOI athletic pubalgia

insidious acute is less common and occurs with trunk hyperextension or hip hyperabduction

femoral neck stress fx (insufficency vs fatigue)

insuff: normal stress applied to abnormal bone (osteoporosis) fatigue: excessive stress to normal bone (overuse)

what in the knee allows for passage of the cruciate ligaments

intercondylar notch

lisfranc sx

internal fixation removed 3-5 months later

acute/subacute lateral ankle sprain MOI

inversion/PF usually ATFL last would be PTFL

associated injuries with dislocations

ipsilateral knee sciatic/peroneal nerve femoral head/neck acetabulum

MCL sx

isolated tears are not required sx bc high vascularity and intact ACL resists valgus motion will still exhibit continued functional instability if combined with ACL, treat medial tear first then ACL reconstruction 5-7 weeks after that

pos special tests meniscus

joint line tenderness SPIN mcmurrays SPIN apleys SNOUT barely thessaly SPIN **CLINICAL BOTTOM LINE: MM: Thessaly LM: Thessaly, McMurray, Joint Line Tenderness based on sesn and spec

who gets mortons neuroma

joint mobility female 6th decafe junction between fixray 3 and mobile ray 4-5 ***

OA severity scale

too much emphasis on osteophytes and not all OA has osteophytes

what is best predictor of OA

joint space narrowing in radiograph normal 3-5 mm <2.5mm: mod, <1.5mm: severe Reduction >0.5 is a clinically relevant finding No conclusive findings on FAI as a predisposing factor to OA

knee outcome meansures

knee outcome survey knee injury and osteoarthritis outcome score lower extremity functional scale patient specific functional scale

positive special tests

lachmans test SPIN/SNOUT pivot shift test SPIN anterior drawer with >5 mm anterior tibial translation for complete tears SPIN/SNOUT

ACL MOI

landing form jump decel or accel motions with noncontact valgus load near full extension

sx of AP

laparoscopic mesh open repair adductor release when both pubalgia and FAI is corrected with surgery 90% RTSport

antagonistic relationship of quads and ACL

last 50-60 degrees of knee extension, quads pull the tibia anteriorly and ACL becomes taut and limits this extension the greater the quads torque the more force palced through the ACL

ACR guidelines is best for what stages

lateer

support of talocrural joint

lateral - ATFL, PTFL, CFL medial - deltoid ligament

what happens when they fail to identify this

leads to PCL graft failures long term instab

lateral collateral ligament

least common of all knee ligament injuries rarely isolated often injured with posterolaterl corner structures sports or car

what contributes to hip instab

ligamentous injury (microtrauma) labral tear developmental hip dysplasia (lack of coverage for femoral head) connective tissue disorders (ED, marfan, downs) gymnasts martial arts

metatarsalgia tx

limited evidence for maual therapy address cause of abnormalplantar stress

hallux rigidus presenation

limits DF and extension Pain and decreased ROM at the 1st MTP Imaging showing degeneration Decreased stance time/early foot-off during gait Antalgic gait

CAI tx what does manual therapy do

manual therapy: Improved short term dynamic balance, DF ROM and Foot and Ankle Ability Measure (FAAM) following AP TCJ mobilization X 2 weeks Improved dynamic balance, DF AROM and Cumberland Ankle Instability Tool (CAIT) immediately and 6 months post MWM X 3 weeks Acute changes in landing kinematics - reduced PF at initial contact after 3 AP mobilizations Thrust AP TCJ - immediate improvement in functional measures including Y balance

PF path of contact

max contact at 90 and 60 degrees of knee flexion in full extension the patellar rests on the suprapatellar fat pad

LF special tests

mid foot squeeze test piano key test

ligament tear types

mid substance and avlusion (from insertion)

cuboid syndrome special tests

midfoot accessory mobility midtarsal adduction/supination tests

FHL rx

mobilization short term immob

cuboid syndrome tx

mobilizations including tarsal consider prox and distal tib/fib joint**

knee arhtroscopy

most common despite accumulating evidence suggesting little benefit

hip joint pain

most commonly groin and buttock pain than in low back pain patients

patellofemoral pain syndrome

most commonnly reported condition of the LE peripatellar knee pain

medial collateral ligament

most frequently injured ligament of the knee (typ isolated tears) ACL and MCL is the most common multilig injury

why does athletic pubalgia happen

muscle imbalance between adductors and abdominal musculature at pubic aponeurosis pubic symphysis acts as fulcrum abdominals are more commonly injured secondary to weakness

diagnosing FAI

must have clinical signs, symptoms, AND imaging to diagnose • Symptoms: hip pain, clicking, catching, stiffness, or giving way • Clinical signs: restricted ROM, positive impingement test • Radiological findings: cam or pincer morphology on plain radiographs

midfoot pathology special tests

navicular drop test tinels sign DF/EV test SLR

HS tx

neural mobs possible pelvic floor training

mortons neuroma sx

neuroma excision good outcomes

sx vs conservative

no diff in QOL sx better pain levels

early vs delayed surgery

no difference in Laxity Instability ROM Muscle strength Patient-reported outcomes Return-to-sport levels Postoperative complications

tx of FAI

no evidence for definitive tx bump up chair offload structures fix firing patterns of posterior chain (hamstring vs glut max)

does the fibula have a function at the knee?

no expect for attachment site for muscles

positive special tests for IT band

nobles compression test (not validated) pain reproduced at 30 degrees knee flexion obers test hip weakness (inconclusive)

what about the fibula

non weight bearing bone helps maintain aligment of the tibia attachment site for bicceps femoris and LCL

apex of patella top or bottom

top

chronic exertional compartment syndrome presenation and who does it happen to

occurs at a specific time/distance of exercise completely normal at rest men

posterior cruciate ligament tear

often goes undiagnosed MVCs and athletics not usually seen in isolation

what is a ray

one metatarsal and it's associated set of phalanges first ray = first MT and medial cuneiform *** also consider: 2 sesamoids in the FHB tendons Plantar plate Ligamentous attachments

compartment syndrome sx

open fasciotomy (WBAT and ankle AROM immediately) 20% reop rates with 13% complication

ITB sx

open surgical relesae ITB zlength ITB bursectomy

sx for FAI

osteoplasty osteotomy labrum can be reconstructed

medial tibial stress syndrome MOI

overuse associated with running/walking

IT band friction syndrome

overuse in atheltic pop distance runners and cyclists* impingement zone 30 degree knee flexion *** ITB compress fat pad, bursae, and connective tissue

piriformis syndrome

pain caused by impingement of the sciatic nerve by the piriformis muscle, causing buttock pain, sciatica or both only 6-8% of cases with sciatic symptoms MORE RARE

diagnosis of adductor strain

pain on palpation groin pain with resisted adduction = clinical definition

ACL resconstruction and when do people retear

patellar (extensor weakness, anterior knee pain) semitendinosis (flexor weakness, IR weakness in extension) gracilis tendon revascularization occurs at 3-8 weeks retear around 8 weeks because feel good and over do it complete by 12 collagen produection over 1 year called ligamentation when the characterisitcs resember graft after 1 year

positive special tests PFOA

patellar compression (clarkes) eccentric step test patellar apprehension test

hallux rigidus (OA of first MTP) who does it affect

patients >50 males bilateral progressive

flexor hallicus longus tendinopathy who does it happen to

peak force during terminal stance ballet dancers bc FHL stabilizing the whole time may mimic: PTTD Plantar fascial pain Sesamoid pathology Turf toe

adductor strain (muscles and fx)

pectineus adductor longus brevis and magnus gracilis obturator exernus adduct thigh in open chain *stabilize LE to perturbations in closed kinetic chain*

achilles rupture sx

percutaneous or open repair NWB case x4 weeks boot x 4 weeks similar outcomes with conservative

PFPS presentation

peripatellar crepitus mild swelling after activity patellar lateral tilt ROM WFL hypomobile medial patellar glide hurts with sitting "movie goers knee" running ascending and descending stairs* squatting* kneeling

who gets plantar fasciosis

pes planus aka pronation decreased DF in hindfoot BMI footwear training errors

ray =

phalanges, MT, and articulating cuneiform

sx of PS

piriformis release

spring ligament

plantarcalcaneonavicualar ligament

high ankle sprain tx

possible immobilization compression, elevation in acute when there is less discomfort then can progress to ambulation training unstable surfaces, perturb agility, plyos

positive special tests PCL

posterior (tibial) sag sign SPIN SNOUT posterior drawer SPIN SNOUT active quadriceps SPIN SNOUT

hip dislocations which way to they happen and with what motions

posterior 90% flexion, adduction and IR anterior 10% extension abduction ER

hip dislocation presentation

posterior dislocation leg will be flexed, adducted, and have a shorted limb can palpate femoral head in buttock antioer dislocation leg will be extended, ER, and abducted can palpate femoral head in femoral trianlge

parts of deltoid lig

posterior tibiotalar tibionavicular tibiocalcaneal

lateral ankle sprain who does it affect

ppl with decreased DF FEMALE

PCL general rehab goals

progressive weight bearing prevention of posterior tibial subluxation strengthening of the quadriceps muscles

PCL fxn and MOI

resists extreme knee flexion posterior translation of tibia (posterior roll, posterior slide) anterior translation of femur (posterior roll, anterior slide) resists extreme varus, valgus, and axial rotation MOI: falling on fully flexed knee (tibia hits the ground) dashboard injury (posterior force of tibia on femur) large axial rotation or valgus-varus force with foot planted and knee flexed seere hyperextension of knee (gapping of posterior joint)

why is first ray important

rigid level during WB forward propulsion and stability

ankle OA tx

rocker bottom shoe, AFO 6-weeks of isometric, resistive, closed kinetic chain and proprioceptive therex or hyaluronic acid injection improvements at 12 months

LCL what does it attach to

round and strong from epicondyle to fibula DOES NOT ATTACH TO THE LATERAL MENICUS

tissue layers of abdominal wall from outside to inside

skin fascia external oblique and fascia internal oblique and fascia transversus abdominus muscle and fascia transversalis fascia with the peritoneum conjoint tendon = fascia of internal oblique and TA inguinal canal houses spermatic cord in males and round ligament in females *pubic apineurosis = confluence of fibers from rectus, conjoint tendon, and external oblique continuous with origin of adductor and gracilis muscles*****

what happens to the patella during knee flexion and extension

sliding motion between posterior surface and intercondylar groove used to increase the internal moment arm of the quads at the knee EXTENDS *

AVN clinical presentation

slient hip in early stages sudden, severe onset latera pain in deep groin can radiate to butt thigh knee and lower leg vague, mechanical, throbbing I/M PAIN WITH WB!!! rom limitations (flex, IR, abduction) painful log rolling test!!!

risk factors of FAI

slipped femoral epiphysis legg calve perthes congen hip dys femoral neck fractures previous hip sx

tx of PS

soft tissue mob weak hip abductors (causes excessive eccentric loading of the piriformis) strengthen hip ER, extensor, and abductors reduced adductor/IR moment

HAS

squeeze test SPIN pain out of proportion to injury SPIN DR/ER test SNOUT syndesmosis tenderness SNOUT

how does intercondylar groove stabilize the patella

steeper slope of lateral facet keeps in groove

tibial stress fracture MOI

sudden build up of training gradual onset of sharp, localized pain commonly at distal third of tibia Accelerated bone remodeling in response to repetitive submaximal stresses Fatigue fracture vs insufficiency: abnormal repetitive load upon normal bone

chronic exertional compartment syndrome MOI

sudden build up of training in younger pop fullness, cramping with or without paraesthesias and weakness in the peripheral nerve distribution With exertion, intracompartmental volume increases in conjunction with increased pressure Critical level leads to compromised vascular profusion leading to tissue ischemia, metabolic accumulation and pain Anterior and deep posterior compartments most common

tibiofibular joint

superior - plane synonvial joint, articulates with posterolateral aspect of tibial condyle inferior - synarthrosis (fixed) , refinforced by posterior tibfib ligaments

what types of tears are the most common

superior, anterior tears

who does hip dislocations happen to

young population (16-40 years old) common in males

labrum

surrounds acetabular rim medially blends with capsule laterally

PT progrnosis FAI

symptom reduction for up to 2 years 5 years for surgery

subtalar joint (STJ)

synovial joint calcaneus and talus 3 facets: Anterior - Convex Talus Middle - Convex Talus Posterior - Concave Talus SHIP IN THE WAVE pronation of heel is coutnerbalanced by supination of the transverse tarsal joint supination of the heel is counterbalanced by pronation of the transverse tarsal joint

CAI special tests

talar tilt SPIN anterior drawer

medial column

talus, navicular and rays 1-3

plantar fasc special tests

tarsal tunnel negative windlass positive longtidudinal arch angle

screw home mechanism

terminal knee extension requires 10 degrees of ER coupling of ER and knee extension to maximize contact area of the knee = stability dependent on: shape of medial femoral condyle passive tension of ACL lateral pull of quads OKC: tibia rotates ER on femor CKC: femur rotates IR on tibia to unlock: ER of femur or IR of tibia driven by popliteus

mortons neuroma special tests

thumb index finger squeeze SPIN/SNOUT mulders click SPIN

adductor strain clincial presenation

usually acute can become chronic superficial aching medial thigh groin swelling pain with adduction

positive special tests MCL

valgus stress test (at 30 deg knee flexion - islolated MCL injury In extension - likely concurrent ACL injury Soft end feel - likely Gr III tear)***** Sensitivity: 86% (Harilainen 1987)

extensor lag

weak quads cant get fulll extension actively but have full PASSIVE swelling/effusion can increase liklihood of extensor lag may be due to reflexibely inhibiting the neural activaton of the quads or inflamm-induced flexor withdrawal

menisci

wedge/crescent shaped semicir firbocart dics covers 2/3 of tibial plataeu anchored by anterior and posterior horns fibrillar componenets: collagen and elastin transform articular suface to shallow groove for larger convex femoral condyesl

sesamoid fx

weight distribution through the first ray like the patella mechanical advantage for FHB (pulley) stability of the first ray main WB force when elevated onto toes *****

can we prevent sprains?

weight loss external bracing neuromuscular retraining, balance mechanical support or proprioceptive feedback (not sure how it helps but is one of those)

hip dislocation simple vs complex

without fracture (simple) with fracture of femoral head, neck, or acetabulum

who does GTPS affect

women higher in post menopause common in those 40-60 higher incidence in those with lower back pain, knee pain, and obesity

manual therapy for total hip arthro revision? WHY

yes Not just peripheral changes Spinal and supraspinal pathways involved in patient responses to MT

can leg pain come from the back even when there are no back symptoms?

yes in chronic cases you may see more leg pain and not so much from the back

does the tibia have condyles?

yes but is also called the tibial plateu this "intercondylar region" allows for cruciate ligaments and menisci to attach

who do you see atraumatic hip instability with

young females in athletics gynmasts