MSK 1 Exam 3
Type I Salter-Harris Growth Plate Injury
repeated trauma or mechanical stresses and possibly hormonal issues
LCL S&S based on degrees of sprain etiology
etiology: blow to the medial knee S&S: 1st degree sprain: Varus stress painful with no increased mobility 2nd degree sprain: Pain with varus stress and moderate increase mobility 3rd degree sprain: Ligament ruptured -no pain -significant increased mobility with varus stress
coxa plana
flat femoral head
Main M/T injured in hip tendinopathy
hamstring (most common) strain would be more in the middle of the belly, tendinopathy would be more in towards the ischial tub at the attachment PSOAS strain in mid belly or tendon Adductor mms
pes cavus
high arch
A hypomobility may need to be __________, a hypermobility will likely need to be __________
manipulated; stabilized (internally or externally)
Etiology of MCL Sprains The injury is usually caused in one of several classic ways:
-In collision sports the ligament can be damaged when an opponent applies a force to the outside aspect of the leg. -The medial ligament can be damaged if the cleats get caught in turf and the player tries to turn to the side, away from the planted leg. -A VALGUS stress with or without a combined rotational stress to the knee most commonly causes this injury. -The foot or lower leg is usually held in a fixed position, and the upper leg and body moves or twists in relation to the lower leg. -The MCL may also be injured in conjunction with tears of the ACL, PCL, and/or lateral complex. -Deceleration injury where the eccentric load is beyond the control of the person (change in direction), especially at the hip.
Myelocele
-Spine and dura fail to close over the neural tube - Spinal cord and nerve roots are completely exposed/ infection may result in death
Meniscal Injury MOI
-Sports related, usually involving damage due to rotational force with varus / valgus stress -The foot is planted and the femur is flexed and internally rotating -A varus force applied may lead to a lateral tear -A valgus force may tear the medial meniscus
Phase II: Revascularization
Blood supply returns Bone deposition occurs and dead epiphysis becomes revascularized Pathologic fracture Symptoms are present Radiographic exam shows fragmentation Doctor makes diagnosis Biological plasticity Treatment by splinting/bracing May have flattening of femoral head indicating coxa plana. S/sx: Pain, limited hip ABD. Flex and IR. Atrophy thigh mm Imaging: Coxa Plana
Risk of surgery with meniscal injury
Can accelerate degenerative processes to the subchondral cartilage of the knee
How many classical motions make up one tri-planar motion?
3
How many planes of the body are there?
3
What is the maximum number of cortisone injections that a patient should have in one year?
3-4. Not to exceed 4
Scoliosis exam mm length
Check hip flexors and lumbar myofascia
Stability of the knee joint depends on:
Collateral Ligaments: -MCL opposing abduction / valgus forces -LCL opposing adduction / varus forces The cruciate ligaments which are extracapsular but intraarticular: -ACL and PCL bracing against excessive P/A and A/P translations respectively
Best Exam step to determine DJD
Combining special tests with classical and accessory ROM rather than just one specific test
Common Tendinopathies in the hip
Commonly proximal HS, rec fem, and iliopsoas Could be any tendon in the hip MSTT, MLT
Why are there 2 patterns for the hip by 2 different authors?
Difficult to isolate different motions of the hip since the capsule is so deep and complex. You can find different patterns. You are responsible for knowing which capsular pattern is coming from which author.
Main attachment point between 2 vertebral bodies
Disc. Main support for static ability
If the knee is in genu valgus, in what position is the femur?
Femoral IR There are several different sources of anterior knee pain. As a therapist, you must play detective! You must search and find in order to find the impairments that are causing the anterior knee pain.
What must you do when it comes to a tendinopathy? (Important)
Find the root cause
Hip tendinopathy
Hip joint sprains and muscle strains usually are overruse injuries resulting from repetitive microtrauma Intervention depends on correct identification of the injured tissue ex of hip jt sprains and hip muscle strains:
Reflexes: Hyper? Hypo? Upper motor neuron lesion?
Hyper: nerve irritation Hypo- nerve compression Babinksi and Hoffman's sign for upper motor neuron lesion Can have positive myotome(s) or dermatome(s) or Reflex(es) OR any combination
IF the ratio was identified as 2:0 this would indicate what about the medial and lateral calcaneal arc glides?
IF the ratio was identified as 2:0 this would indicate the Medial calcaneal arc glide is normal, while the Lateral calcaneal arc glide is limited (hypomobile).
Can we as PTs get rid of DJD?
No, but we can treat them and help them to minimize the effects of condition.
Trochanteric Bursitis
PFC, PFT important (go through 18 step outline) Patient education, activity modification Treat surrounding impairments
Trochanteric Bursitis Exam Findings
PFC= Best
Laminotomy with discectomy
Patient positioned prone 90/90 Muscles and fascia incised and pulled to the side Ligamentum flavum removed/lamina partially removed/ epidural fat removed Nerve root pulled medially Anulus cut (window) Remaining nucleus removed Nerve root released, subcutaneous fat placed where ligamentum flavum was Closure
TL Right rotation and SB arthrokinematics
RIGHT rot: Ipsilateral: Post motion (facet gapping) Contralateral: Ant motion (facet compression) RIGHT Sideb: Ipsilateral- post/inf motion (facet compression) Contralateral: Ant/sup motion (facet gapping)
Supine examinations
ROM Hip flexion Hip rotation Can be done prone or sitting which have been shown to have good intertester reliability [22]
Cram's Test
Raise leg to the point of symptoms and putting pressure directly on tibial n in popliteal fossa.
What two categories can these tendinopathies fall into?
Reactive or Degenerative.
Total knee replacement recent advances
Recently, there has been an increase in unicompartmental total knee replacements. This means that only one side of the knee is replaced (medial or lateral) and the other side has normal bone/cartilage preserved. There are also minimally invasive surgeries (smaller incisions), gender specific knees and surgeries that are computer assisted. The type of surgery performed and specific prosthesis used will depend on the patient needs and surgeon preference. Complications As with any surgery there is a chance of infection, DVT and pulmonary embolism.
The primary classical motions we can influence clinically at the Talocrural joint are those within the ______________ plane and ____________ plane
Sagittal plane (Dorsiflexion and Plantarflexion); Frontal plane (Eversion and Inversion)
Characteristics of normal movement
Takes place smoothly regardless of speed Range is full according to body type Pain free Muscles are of normal strength Passive range is greater than active range
T/F: meniscal injuries may be managed conservatively
T:
T/F: Stenosis happens in elderly
T: degenerative changes osteophytes/narrowing of foramen where nerve root is exiting. Nerve root gets caught
Nature of TL spinal segments when compared to cervical:
TL carries more of the body weight so they are larger and the disks are larger to absorb more weight
T/F: There will not be any change in sensation with metatarsalgia
TRUE With a metatarsalgia there will not be any change in sensation since there is no nerve involvement. The only symptoms will be pain over the metatarsal heads.
What is the achilles tendon susceptible to?
The Achilles tendon is a tissue that is susceptible for tendinitis, tendinosis and rupture. Tendonitis is most commonly related to an acute condition while a tendinosis is most commonly related to a chronic injury. By now you should be able to differentiate between an itis versus an osis.
anterior longitudinal ligament
connects anterior surfaces of adjacent vertebral bodies Strengthens disc anteriorly
There is a higher incidence of DJD and capsular tightness with-
hip dysplasia and leg length asymmetry (usually on the side of the longer leg). Hip dysplasia is the medical term for a hip socket that doesn't fully cover the ball portion of the upper thighbone. This allows the hip joint to become partially or completely dislocated. Most people with hip dysplasia are born with the condition.
Posterior longitudinal ligament
strengthens disc posteriorly
L5 nerve root will be affected by stenosis at which foramen?
L5/S1
Injury to the anterior tibio-fibular ligament is commonly referred to as a....
"high ankle sprain"
Scoliosis non-operative treatment
- Exercise alone will not halt the progression of a scoliosis or correct a 20- 40 degree curve - For curves less than 20 degrees, exercise may be beneficial. Coordinative exercises for trunk extension/rotation and mobility exercises towards the convexity may be beneficial. - For children with curves of 20-40 degrees with 2 or more years of anticipated skeletal growth, spinal braces combined with exercise can reduce the curve and prevent it from increasing
PCL injury interventions
- PRICE method several times a day - control pain and swelling. - Patients with grade I and grade II injuries can bear weight as tolerated immediately, though some may require axillary crutches initially. - Long leg brace are recommended for only severe grade III injuries with other associated ligamentous laxity - Functional electrical stimulation (FES) may be used to stimulate the quadriceps muscle, - Hamstring and hip strengthening, also quadriceps strengthening (eg, quadriceps sets, straight leg raises, hip abduction/adduction, multiangle quadriceps isometrics). - Postoperatively, it is very important to control pain and swelling through the use of cold therapy, compression, and elevation. -the patient may bear weight as tolerated on the operated limb with the use of 2 crutches and a long leg brace. - Patellar mobility is important - ROM should be initiated (0-90°), emphasizing full passive knee extension. Other examples of exercises that may be initiated include quadriceps sets, ankle pumps, straight leg raises, and upper body strengthening.
Signs and symptoms of PCL Injury
- Symptoms of disability consistent with loss of function for personal professional and recreational requirements -Minimal to no pain - Usually full or functional range of motion (ROM) - Contusion over the anterior tibia - Posterior tibial sag - Posterior sag sign during extension - Findings of the posterior drawer test
Impairments that a patient with a disc dysfunction may have include the following:
-A protective scoliosis (i.e. lateral shift) -Limited AROM -Positive neurological signs in corresponding dermatome and/or myotome -Limited neural mobility -Tight hamstrings and piriformis -Distraction decreases symptoms -Compression/quadrant increases symptoms -Tenderness in lumbar paraspinals, quadratus lumborum and posterior lateral hip muscles on side of involvement -Decreased function and endurance
Hip surgery complications
-Femoral stem loosening -Femoral fx -DVT/Pulmonary Embolus -Infection -Metal sensitivity -Nerve damage -Repetitive dislocations
MCL sprain S&S
-With a first degree sprain there will be pain at the site of the damage with touch or valgus stress . -stressing the ligament with a valgus force (when the knee is slightly bent and the shin is moved out in relation to the thigh) is painful. -In the case of a second degree sprain, the pain is more severe when touched and when the ligament is stressed. -there will usually be swelling of the knee joint, but this may take 24 hours to appear. In the case of a third degree sprain, where the ligament is ruptured, the pain is excruciating initially. With this injury the knee joint is unstable and activity cannot be continued. - there will be a bleed and an inflow of fluid into the joint. Because the capsule surrounds the joint it is damaged as well, this fluid may leak out and swelling may not be evident.
If there are 3 planes of the body, and 3 classical motions required for each tri-planar motion, then this means there MUST be ____ movement from each of the different planes required to make up the 3 motions of pronation and supination.
1
Scoliosis goals of treatment
1) To prevent the progression of a mild scoliosis 2) To correct and stabilize a more severe scoliosis The key is early detection via screenings to prevent mild scoliosis from becoming severe.
Lateral bunion
A lateral bunion is identical to a medial bunion in regards to pathology but is instead located on 5th metatarsal and is sometimes referred to as a tailor's bunion.
Unhappy triad
ACL, MCL, medial meniscus tear.
The patient may then gradually be progressed with.... What should emphasis be on?
AROM and PROM exercises through a restricted, pain-free range. The emphasis should be focused on not allowing the ankle to move into the extreme ranges of the classical motion responsible for the original injury For example: If the patient sustained a plantarflexion and inversion ankle sprain, you would caution the movement into plantarflexion and inversion as this would be at risk of applying a tensile load to the injured ATFL
Leg length - true leg length
ASIS to medial or lateral malleolus can measure individual segments medial malleolus to med. jt. line [tib/fib] Lateral joint line to gr. trochanter [femur] Greater trochanter. to iliac crest [pelvis &/or fem. neck angle] Leg lowering test (Kendall page 155) [26] Leg lowering test modification Functional testing - timed trunk curl
Stabilizing exercises for laxity
Active single to chest/ Active double knee to chest (lower abdominals) Recommended Dosage 60% 1 RM Bridge/ Bridge with Knee Extension (Lumbar extensors and Gluteus Maximus) Recommended Dosage 75% of 1 RM Kneeling/ Kneeling with Forward Lean (Lumbar extensors and Gluteus Maximus) Recommended Dosage 60- 75% of 1 RM Walk Backs (Bias Trunk Extensors)/ Walk Forward (Bias Trunk Flexors) Recommended Dosage 60% 1 RM Trunk Flexion/ Trunk Extension Recommended Dosage 60% 1 RM Diagonal Patterns: Trunk Flexion with Rotation/ Trunk Extension with Rotation Recommended Dosage 60% of 1 RM
Primary patient population for osteochondrosis
Active young males. and it is not uncommon for the onset of these symptoms to follow a 'growth spurt' Contraction of the quadriceps muscle creates a traction force that stresses this area, and the patient will frequently complain of pain with athletic activities, such as running and jumping.
Acute vs chronic compartment syndromes
Acute - secondary to trauma Chronic - secondary to overuse. Commonly exercise induced
Slipped Capital Femoral Epiphysis (SCFE)
Adolescent disorder more common in males. Femoral head slips in posterior direction. Potential causes: Faulty growth plate, growth spurts, high BMI
How to determine if pes planus is structural or functional?
Again we must determine if it is structural or functional using the same methods described with pes cavus. That being, AROM and PROM classical.
How long should the ankle be immobilized with a sprain?
Approximately 6-12 weeks, or until the tissue is perceived to have finished with the Maturation (Remodeling) phase of healing.
How can the diagnosis of chondromalacia be confirmed?
Arthroscopic observation or radiograph. There are no good clinical tests for this.
How are fractures treated by MD?
As stated, fractures will be treated with a cast, brace, ORIF or EF. Once these devices are removed, the patient will then come to rehab to increase range of motion, strength, proprioception and return to functional activities.
When do your disks fill up with fluid the most?
At night when you are gravity eliminated
popliteus tendinopathy vs. Semimembranosus tendinopathy
Both occur on posterior medial knee. Seen primarily in runners associated with running downhill or long distance runners. Pain tends to be on post med knee and does involve IR of tibia. Running downhill creates IR and eccentric load on popliteus and semimembranosus Difference between the two is what is the hip doing? Bc hamstring is 2 joint, you can use clinical exam to differentiate involvement at the hip. If no hip involvement takes place, then it is probably an issue of the popliteus. - difficult to palpate bc of close tissue proximity.
Types of Meniscal Injuries
Complete tear Partial Circumferential tear Bucket handle tear Complete tear with detached fragments Complete tear with flap Torn flapVertical tear https://orthop.washington.edu/patient-care/articles/sports/torn-meniscus.html
supraspinous ligament
Connects tips of spinous processes L3/L4 and then erector spinae tend to provide support Supraspinous ends at L3
What is a bi-malleolar fracture?
Consists of both the medial and lateral malleolus. May be susceptible to avulsion fractures, fracture secondary to impact and/or fracture associated with a dislocation.
Which tendinopathy would you want to apply eccentric loading?
Degenerative
History questions specific to the lumbar spine
Do you have any tingling in the saddle region? Do you have any loss of bowel or bladder control? Do you note a change in symptoms it you hold your breath and strain (Valsalva)?
Why is patellofemoral syndrome not a tissue specific impairment?
Does not specifically target the tissue that is the cause of the problem
When considering the statement directly previously, what potential findings would be identified during Exam Step #7 (PFC)?
Edema and/or effusion. Since the ATFL is extra-articular it has the potential of presenting with edema. Since it blends with the joint capsule it has the potential of presenting with effusion. Warmth may also be identified based on the phase of healing. An acute phase of healing would present with warmth due to the vascular response of that phase of healing
Almost all disc buldges are medial. T/F
FALSE Almost all disc bulges are lateral to the nerve root with the patient leaning AWAY from the side of pain. However, it is possible to get a bulge that is medial to the nerve root
DJD/OA: Exam and treatment
Exam: Gradual onset, WB pain, compression pain Tx: Conservative, surgical hip resurfacing- can provide relief before hip replacement in hip resurfacing the surface of the jt is replaced with metal and the femur is preserved.
PCL Physical exam and management: Special tests
Excessive posterior translation Special tests positive: Posterior Draw, Sag, Godfrey 90/90 We want to promote anterior translation by strengthening the QUADS mainly.
T/F: ATFL is an intraarticular ligament
F The ATFL is an extra-articular ligament that blends with the joint capsule in the ankle.
If you rotate to the R and feel pain on the R, the facet is the issue. T/F
F Type 1 tensile collagen issue, joint capsule or ligamentous issue. Bc joint capsule is stresses when gapped If there was pain on the L, it would be a facet cartilage issue
TL Flexion and extension arthokinematics
Flexion: Bilaterally superior/anteriorly (up and forward) Ext: Bilaterally inferior/posterior (down and back)
Capsular pattern of the knee
Flexion>ext Because it is a hinge joint. Extension is the greatest limitation functionally. W/o extension, you cannot ambulate at all. If they have at least 105 degrees, they can do almost anything they need to.
T/F: You cannot have 2 motions in the same plane
T This would result in literally no movement for that plane
Rehab - as per physician - S/p Laminotomy with Discectomy
Gentle movement starting with pelvic rocking Hip range of motion and neural mobility exercises Walk on the treadmill Stabilization for abdominal, lumbar spine musculature Back school/ work hardening Backward bending contraindicated
Grades of Ligamentous Injury
Grade 1 - minimal fiber tearing, no increased motion noted with stress testing, painful with stress test. Grade 2 - moderate fiber tearing, increased motion noted with stress testing, painful with stress test. Grade 3 - complete fiber tearing, no end-feel noted with stress testing, non-painful with stress test
There are three (3) grades of injury for a sprained ligament. What are they and what do they represent?
Grade 1 sprain is an overstretch of a ligament Grade 2 sprain is a partial tear of a ligament Grade 3 sprain is a complete tear of a ligament
Corrective treatments triplanar motions
Hardest to go from flexion and rotation and go into extesion
What would we find present with each grade?? In other words, what are our findings?
Grade 1: Would present with pain and NO laxity Grade 2: Would present with pain and laxity Grade 3: Would present with NO pain and laxity
Which joint does hindfoot pronation and supination occur at?
Gross movement occurs as a unit between the talocrural and subtalar joint When we reference the hindfoot, we are referencing both of these joints collectively
Supportive treatments
HEP mimicing clinical treatments Follows corrective Utilize theraband/theratube for similar exercises with HEP Utilize home gym access, weights, and gravity resistance
Hallux rigidus can lead to what?
Hallux rigidus can lead to a hallux valgus, but does not have to. A hallux valgus can be present without a prior hallux rigidus
Hammer toes vs claw toes
Hammer toes are from an uncertain etiology and associated with contractures to the tendons of the foot. A contracture of the extensors occurs at the MTP pulling it into extension and a contracture of the flexors occurs at the PIP pulling it into flexion. Claw toes are often seen with pes cavus and considered to be a neurological condition. Hyperextension is present at the MTP with flexion of the PIP and DIP.
Ankle/Foot is divided into three (3) primary sections:
Hindfoot (aka Rearfoot) Midfoot Forefoot
Reactive vs Degenerative Tendinopathies
If the condition is of the reactive nature, then you want to eliminate the stressor and allow the tissues to heal. Then progress to light loading activities. If it is of the degenerative nature, you actually want to increase the load to the tendon with eccentric exercises and transverse friction massage. Dutton describes the protocol originally proposed by Stanish et al. (pg. 1057) Additionally, ultrasound and shockwave therapy have been found beneficial when degenerative.
what will happen up the kinetic chain of the foot and ankle if the hindfoot is supinating?
If the hindfoot is supinating the ankle and midfoot are also supinating, while the forefoot will pronate.
If joint capsule hypomobility was present at the TMT, what would the ratio look like?
If there is a joint capsule hypomobility, this would be indicated by two '0' within the ration (i.e. 0:0).
Disc dysfunction treatments
In order to treat a patient with this dysfunction we treat the impairments. So if there are tight muscles present we stretch, if there is tenderness in muscles massage, moist heat, electrical stimulation or ultrasound can work, limited neural mobility will be treated with neural mobilizations. The decreased ROM will be treated with ROM exercises. If distraction decreases the symptoms then that becomes a treatment. You can do mechanical traction as discussed in more detail in the modalities course or you can do positional distraction. Distraction will decrease the pressure on the nerve root which will in turn decrease many of the patient's symptoms.
MCL tear intervention
In the acute stage, regardless of the grade of injury, the first course of action should be to follow the PRICE protocol (Protection, rest, ice, compression and elevation). So the knee should be wrapped with a compression bandage, ice placed on it while it is in an elevated position. If medication has been prescribed by the medical doctor, it should be taken for pain relief and anti-inflammatory effects. PT progresses as the stages of condition allow. Therapy should focus on providing stability to the medial aspect of the knee with outside supports if necessary and the use of dynamic muscular control. If the injury is a grade 3, the treatment of choice is surgery to repair the damaged ligament.
Patellar Tendinopathy
Involves common extensor mechanism of the LE You may often come across this and can fall under tendonitis and tendonosis. Causes: Sport related like jumping, squatting, or running. Consider potential impact the kinetic chain and mm imbalance can have. ex: Tight hamstring can cause excessive strain to extensor mechanism. Issue can be related to mm extensibility, strength, and joint mobility. At the apex of patella at proximal insertion, the tendon will be tender to touch. Can also be related to trauma
we need to identify where the impairments of excessive or limited pronation/supination is occurring within the ankle/foot. Once we identify where we need to figure out why this impairment is occurring. When doing so, consider these questions:
Is there a hypomobility or hypermobility? Is there a muscle strength problem or a muscle length problem?
Special test used attempting to identify the ACL (tissue). Positive?
Lachman's test The positive finding for the Lachman's test is the presence of Laxity (specific finding). Pain is contributing finding, not the primary finding.
MCL healing capacity
Large blood supply and large capcity to heal. Treated conservatively
Osteochondrosis Examples
Legg-Valve Perthes Osgood-Schlatter's Disease Sever's Disease Kienbock's Disease Panner's Disease
Ligamentous laxity/postural back pain
Lig laxity is very common due to poor posture or long positions for long periods of time which typically puts spine in more flexion stretching out the posterior structures.
Which meniscus has a much higher incidence of injury than the other?
Medial meniscus has a much higher incidence of injury than the lateral meniscus which may be attributed to the coronary ligaments and attachments to the capsule.
Different Types of Braces for scoliosis
Milwaukee Brace - Typically used - worn 23-24 hours/day Research indicates that progression of deformity can be halted in 70% of mild to moderate curves Up to 50% correction can be attained in some cases Some curves progress despite bracing and require surgery Some curves corrected or halted with use of a brace may regress and require surgery Boston Brace- Molded plastic jacket eliminate metal suprastructure and can be hidden by clothes
Intersegmental control of spinal segments are most controlled by what mm?
Multifidi bc they have direct attachments to the segments. 1-2 levels in the spine but some can go up to 5 segments in the lumbar spine.
Scoliosis exam strength
Muscles weak on the convex side Weak abdominals Trunk extensors weak
Is there a signficant difference in the collagen in the spine and extremity?
NO! Type 1 collagen- STRETCH- mm, tendons, ligs, capsule, annulus Type II collagen- COMPRESSION- facet cartilage/nucleus of disk
Will JUST having the pt sit and lift confirm a disc issue?
NO!!! This is why we do the 18 steps!! This just refers to history of pain with sitting and lifting
Nonstructural scoliosis
Nonstructural type can be reversed by addressing the underlying cause (leg length, poor postural habits, disc bulge).
types of meniscal tears
Normal, bucket handle, flap tear, transverse tear, torn horn tear
Clinically, how can you tell the difference between a structural hallux valgus and a functional hallux valgus?
PROM Classical: If you can passively re-align the joint it is a positional hallux valgus. If you cannot re-align the joint it is a structural hallux valgus.
Biases ATFL
PROM accessory
What is osteochondrosis of the tibial tubercle commonly misdiagnosed as?
Patella tendinopathy or patellar femoral pain syndrome
Phase Progression of Osteochondrosis
Phase I: Necrosis Phase II: Revascularization Phase III:Bone Healing Phase IV: Residual Deformity
Angle of torsion
Position of neck and head of femur in relation to the condyles. Retroversion and anteversion
2 Categories of DJD/OA
Primary(more generalized that affects the hands, thumb, spine, hips, and knees or WB joints) and secondary which occurs after injury or repetitive inflammation in the joint or a result of another condition like bleeding in the joint. Not established whether or not DJD leads to tight capsule
Menisci function
Primary: Pressure distribution Secondary: Shock absorption Meets a rounded femur with a flattened tibia so the pressure is evenly distributed
During forward bending look for:
Reversal of lumbar curve is normal Does the patient exhibit deviation to one side? Sudden shake, catch, or hitch may be indicative of instability
What causes tear of menisci?
Rotational force with varus/valgus stress or squatting. Twisting on semi-flexed knee. Varus or valgus force. Pop, click, giving away=symptoms
ACL position
Runs from antero-medial direction and dives superiorly-posteriorly onto the femur
LCL anatomy
Runs from superior aspect of medial epicondyle of the femur and attaches to tip of fibular head. Figure 4 position is the best to palpate following fibular head onto joint line small and rope-like
Special Tests (lumbar spine)
SLR - compare to sitting (45 degree difference is a yellow flag -refer to Waddell's Signs) - 80 DEGRESS is considered WNL SLR lower slightly dorsiflex foot (decreases tension on HS & tensions sciatic nerve)
Scoliosis examination (active movements)
Side bending limited to the side of the convexity Thoracic rib hump remains in FB if structural Erector spinae prominent on convex side of lumbar spine due to rotation that brings the transverse processes back on the convex side
Grades of mm strain generalized
Slight limit in strength and ROM. Pain 2- Symptoms worsen 3- complete tear
How do patients function with joint degeneration? In other words, do they experience pain, or are they able to function normally?
Some patients function fine and others have more issues. Imaging doesn't coorelate with functional loss
Nachemson's Disc Pressure Studies
Standing 100% Supine 20% Forward Bending 150% Forward bending with weight 220% Sitting 140% Sitting and lifting weight 275% Sit ups 210% Supine with legs supported 35%
______________________ can also be incorporated under controlled circumstances
Strengthening, balance and return to functional activities may also be incorporated under controlled circumstances. Meaning, you as the therapist are controlling what specific exercises can be incorporated without causing further harm.
Superficial, intermediate, and deep spinal muscles
Superficial layer: Lats, traps, rhomboids, levator, glut max Intermediate layer: Iliocostalis, longissimus, spinalis; Run up and out and SB and rotate to same side Deep layer: Transverse spinalis, multifidus, rotators; Run up and in and SB to same side and rotate away -Multifidus primary segmental stabilizer -Psoas -Quadratus Lumborum -Abdominals
If the hindfoot is pronating, then the forefoot be _____________, and the midfoot will do what?
Supinating; follow the hindfoot into pronation
Closed pack positions of the midfoot and hindfoot
Supination Closed pack position is the most stable position and allows for the hindfoot to act as a stable base on which to land.
Bones in the Hindfoot (aka rearfoot)
Talus Calcaneus
Morton's Metatarsalgia vs. Morton's Neuroma
The distinction between these two dysfunctions is in their name. Metatarsalgia is pain over the metatarsals from any cause while a neuroma is a bundle of nerves that is causing the pain.
What are the two main areas in the lumbar spine where stenosis can occur?
The first is the intervertebral foramen where the nerve roots exit, and the second is the central canal where the spinal cord is located.
Fasciotomy
The main difference is that if it is an acute situation, the patient must be seen immediately by medical personnel in order to remove the swelling in the area. This is conducted by a fasciotomy. A fasciotomy (aka fasciectomy) is a surgical procedure that involves the surgeon cutting the skin and fascia over the compartment in order to relieve the pressure that is building up. This is vital in order to restore circulation and prevent tissue necrosis in compartment syndrome.
Treatment for Ligamentous laxity/postural back pain
The main focus of treatment is postural education, taping for biofeedback, lumbar stabilization exercises focusing on the abdominals (transversus abdominus) and mulitifidus. Conditioning exercises are also helpful.
Glut min and med strain
The mechanism of injury can be a fall, overuse (refer to elbow unit for discussion on overuse!) or prolonged weight bearing on one lower extremity. More often, middle aged women will be impacted by a glut med/minimus strain as they take up a new exercise program.
What other impairment can cause similar symptoms to the ones above?
The other impairment that can cause similar symptoms is an entrapment of the interdigital nerve. This nerve can get entrapped at the metatarsal heads and cause a change in sensation between the webspaces and tenderness to palpation between the metatarsal heads.
Lateral Foramenal Stenosis
The patient is typically an elderly male or female who has had a gradual onset of pain over a period of time. The pain can be located in the lumbar spine, buttocks and/or lower extremity. Typically paresthesias are noted in the lower extremity and the pain is increased with backward bending and/or sidebending to the affected side.
Why is knowing the components of the different sections of the foot so important?
The reason is due to the fact we do not commonly reference motion at each individual joint like we do for the shoulder, knee, hip, etc. Instead, we more commonly use the tri-planar terms of pronation and supination to define the gross movement occurring at each section of the ankle/foot.
What motions will be occurring up the kinetic chain with hindfoot supination?
The tibia should be externally rotating causing the knee to externally rotate, leading to increased genu varum, resulting in abduction and external rotation of the femur.
Total Knee Replacement Components
There are typically three components inserted into the knee during a TKA - femoral, tibial and patellar component. The femoral component is usually made of cobalt/chrome metal and is cemented into the femur. The tibial component is chrome or titanium with a plastic insert for the tibial condyles. The patellar component is usually a plastic cap.
Trochanteric Fracture
These fractures are extra-capsular and tend to be severely comminuted. If you are the first person to come upon this type of fracture, the lower extremity will be externally rotated and will appear shortened. You will notice swelling of the surrounding soft tissue. As with most fractures in the hip region, the patient population is elderly females for reasons discussed previously.
Those that use the term ER and IR are referencing what? ABD and ADD?
Those that use the term ER and IR are referencing the movement that occurs within the sagittal plane. Those that use the term ABd and ADd are referencing the appearance of movement towards or away from the midline of the lower leg.
What are four (4) possible end-feels for classical dorsiflexion following immobilization for a distal tibia and fibula fracture?
Tight capsule Tight muscle Adhesion Swelling
Treatment for growth plate conditions
Treatment involves decreasing the aggravating factors that usually includes a period of 'forced rest' for a couple of weeks and correction of any contributing factors.
Total Knee Replacement
Total knee arthroplasties (total knee replacements) have been performed since the 1970's. As the population ages, the frequency and number of TKA per year is increasing. The average age of the patient who undergoes a TKA is 70 years old, females tend to have the surgery more than males and about 1/3 of the patients are obese. A TKA is performed when the pain in the knee joint is interfering with the patient's functioning. The goal of surgery is to relieve pain and improve function. Pain in the knee may be due to OA, DJD, RA, avascular necrosis or infection.
Recall, there can be three (3) different directions of a fracture. They are:
Transverse Oblique Spiral
Patellar tendinopathy physical exam- management
Transverse friction, shockwave, ultrasound, address underlying impairments Management: also consider 50% 1 RM exercise to control inflammation
Treatment for medial bunion
Treatment for a medial bunion involves addressing and treating the impairments that are found in the examination. If the exostosis impairs functioning, then surgery may be required to remove this.
Tri-malleolar fracture
Tri-malleolar fractures occur less often than the other two malleolar fractures. Consists of both the medial malleolus, lateral malleolus, and the posterior aspect of the distal tibia. May be susceptible to avulsion fractures, fracture secondary to impact and/or fracture associated with a dislocation.
Patient complaints associated with a disc dysfunction
Typically the patient will complain of pain that radiates below the knee, and that their symptoms are worse in sitting (again think back to Nachemson's study). Standing and walking will decrease their symptoms. A cough or sneeze will increase the pain in their back and down the leg.
Does immobilization mean NWB? Why or why not?
Understand though, immobilization does not mean non-weight-bearing. In fact, allowing a patient to gradually progress in weight-bearing following the ligament sprain assists with maintaining proprioception and the muscular pumping thereby reducing swelling. Immobilization of the ankle and progressive weight-bearing can be incorporated together.
Medial meniscus is more prone to disruption due to what types of forces?
Valgus and torsional forces
What happens when the MTP is extended during gait?
When the MTP is extended during gait it pulls on the plantar fascia which will then pull the rearfoot into more supination which is the closed pack position of the rearfoot. This is a rigid position that is needed at toe off (push off). Lack of MTP extension can lead to plantar fasciitis as one of many types of dysfunctions.
hemangioma
a benign tumor made up of newly formed blood vessels
The disk and ligamentous structures are 70-90% water which makes them a ____________ system
hydraulic
ACL injuries physical exam and management
instability physical exam- joint ROM related to swelling or pain (PROM accessory) -picks up increased anterior translation Special tests: Stable Lachmans, Pivot shift, or Anterior Drawer.
Bones of the forefoot
metatarsals and phalanges
Osgood Schlatter's disease
osteochondrosis (apophysitis) of the tibial tubercle
Intracapsular (knee)
patella- is going to be imbedded within the capsule itself but not intraarticular
Sindig-Larson-Johansson syndrome
apophysitis of inferior pole of patella
Developmental Dysplasia of the Hip (DDH)
Occurs anytime between birth through infancy Sequence of events of repetitive dislocation or subluxation of hip. F affected 8x>M
Why is IR and ER hard to assess clinically? Give 2 reasons
1) The degrees of motion are the smallest in comparison to those that occur in the sagittal and frontal planes. As physical therapists we may have greater benefit by directing attention to the limitations found in the other planes, and by doing so the amount of rotation may be corrected in conjunction with those limitations found in the sagittal and frontal planes 2) We do not teach rotation of the talus or rotation of the calcaneus in lab due to the difficulty in accurately assessing how much rotation there is, or should be. Think of it like this...how would you successfully grab the talus and rotate it without any other motions.
Best exam step to determine if mm strain is present
MSTT grade 1: strong and painful Use them on any mm in the body Grade 2: Weak and painful Grade 3: Weak and painless bc the mm fibers are no longer in tact
What are three possible complications from a posterior fracture dislocation?
Avascular necrosis, sciatic nerve damage, post traumatic DJD.
Acute phase/early subacute interventions
Acute phase/early sub acute phase goals are to reduce swelling and spasm 50% 1 RM Vascular Exercise: 31+ reps or minutes of exercise WITHOUT fatigue or increased pain - Inner to Mid Range - 3-6x/Day or more
coxa vara, valga, and plana
Angle formed by neck and shaft of femur Coxa Vara: Develops, rarely congenital. Makes limb seem shorter. Passive abd of hip. Angle less than 120 degrees, genu valgus Coxa Valga: Angle > 135 Genu Varus- knees will be bow-legged. Moment arm for abd mms are decreased. Makes limb seem longer. Inc stress on medial knee. Coxa Plana: Flat Femoral head
Why will backward bending and sidebending increase the patient's symptoms in lateral foramenal stenosis?
Backward bending and sidebending to the affected side will decrease the intervertebral foramen, if the foramen is already narrowed by osteophytes adding the backward bending and sidebending will further decrease the space and put further pressure on the nerve root.
Phase IV: Residual Deformity
Bone healing becomes complete Shape of epiphysis is fixed Joint function may be limited Degenerative joint disease may ensue Defrormity present (epiphysis shape fixed) Cartilage initially normal
Phase III:Bone Healing
Bone resorption stops Bone deposition continues Biological plasticity is still present Final shape of epiphysis is forming Still biological plasticity to some extent. Final shape of epiphysis emerging.
Corrective tx exercises LB pain
Bridging; progression with one leg in the air Pt kneeling with a forward lean stance for glut max and LB mms Walk back exercise with pulley pulling the trunk into flexion with pulley on one side of the body to bias leg rotators Pulley on L to bias R rotators (engaging extensors) Pt standing with back to pulley walking out to bias the flexors, lower abs. Pulley on L side of pt to activate rotators Pulley on L to bias R rotators PROGRESSION: ROM! Pt in flexed position moving into extension with pulley on L shoulder. Using extensors. Pulley below her squatting up Same but pulley above biasing obliques and transverse abdominis Rotation exercises with pulley- biasing the multifidi (and obliques)
Subjective evaluation and history of lumbar spine
Demographics/vitals Symptom, location, type, intensity Better/worse PMH/PSH Functional limitations Red flags- (screen for non MS origin s/s)- MAKE A HYPOTHESIS!
Degenerative Disc Disease (DJD)
DJD can occur in the spine just like it can in the peripheral joints. Osteophytes form within the intervertebral foramen narrowing the space available for the nerve roots causing nerve root irritation. If there is stenosis at the L4/L5 intervertebral foramen the L4 nerve root will be affected.
A tight capsule often presents with-
DJD, however it has not been established whether DJD/OA leads to capsular tightness or whether capsular tightness leads to DJD/OA.
What is the most serious issue with compartment syndrome?
Either way they are a serious problem because of the potential for neurovascular compromise. The pain related to compartment syndromes is more of a pressure building up in the lower leg and at times a patient with compartment syndrome will not feel specific pain. Instead we find impairments of decreased sensation and decreased pulse.
In the lower extremity what muscles typically get weak?
Glutes (med/min, max), quads, posterior tib, anterior tib
Common muscles that are strained
Gluteus Medius/min Adductors Hamstrings
Besides a hypomobility, what other impairments can cause a functional hallux valgus?
Hypermobility Effusion Edema Muscle weakness Muscle Tightness
Causes of PFS (Patellofemoral Pain Syndrome)
Hypermobiltiy: There are three main structural impairments that will result in a hypermobility of the patellofemoral joint. These include genu valgum which will cause increased lateral mobility of the patella as well as increasing the Q angle. A small lateral femoral condyle will also increase lateral movement of the patella... As will patella alta. These three structures will cause the patella to "track" or move more laterally which will result in anterior knee pain. Hypomobiltiy: Soft tissue around the knee can cause a hypomobility of the patellofemoral joint. The patella will not move as much as it should which will cause anterior knee pain. A tight lateral retinaculum, tight ITB and tight quads are all potential sources of hypomobility.
When can the joint not be loaded and unloaded?
If a tight capsule is present It probably stays more in a loaded position, which places abnormal stress on the articular cartilage causing degeneration. We need to be able to go through a full range of motion at the hip in order to have proper nutrition.
If anterior compartment syndrome was a traumatic onset, what must take place?
If it was a traumatic onset this patient will need to be referred to an MD immediately due to the fact the pressure will likely continue to increase. If the cause was due to tissue specific impairments (i.e. weak muscle, tight muscle, tight joint capsule, etc.) you must address these.
How do you score the Oswestry?
In order to score the Oswestry, you will add up all the checked boxes. The first line in each section is a 0 progressing down to a 5 as the last line in each section. The total score is then divided by 50 (the total points possible) and multiplied by 100 to get a percentage. The goal is to get the score to decrease as the patient progresses with therapy.
What are a few things that we as PTs can do for a patient that may delay the need for a total joint replacement?
Manual therapy to increase the capsule extensibility, stretching any tight muscles, strengthening any weak ones, addressing gait deviations with the use of an assistive device
What are six tissue impairments that can cause anterior knee pain
Muscle weakness, Muscle tightness, edema/effusion, tendinitis/osis, hypermobility, hypomobility (need to make specific by adding the muscle, location, or tissue at fault) These impairments can be located at the knee, but they don't have to be. Chris Powers is a researcher out of USC who is looking at the effect of hip strength on anterior knee pain. He has found that weak hip abductors and external rotators causes more genu valgus which then causes anterior knee pain. If the hip muscles are strengthened the genu valgus resolves and the knee pain goes away. So the moral of the story is to search and find - above and below the location of the pain - for the impairment.
Would you defer MLT and/or MMT in the presence of a complete tear of the Achilles tendon?
No. Due to the MSTT findings you may proceed with both MLT and MMT. Both of these exam steps would assist you in confirming a complete tear of the Achilles tendon. MLT - would present with excessive length into dorsiflexion MMT - would present with 0/5 grade specific to the gastroc/soleus
T-L/S Ligament-Capsule Sprain/Strain RIGHT Exam
Painful Movement Pattern: -ENDRANGE All motions - Worst end range LEFT SB/FLEXION (Gapping of facet joint) -pain unilateral
Positional distraction
Positional Distraction is using the position of the patient to cause a distraction or opening of the intervetebral foramen to decrease the pressure on the nerve root. The patient will lie with the involved side up (see image below). A pillow or bolster is placed under the unaffected side in order to cause more sidebending away from the side of pain. The patient's knees and hips are flexed up to approximately 90 degrees in order to cause forward bending of the lumbar spine which will also open the intervetebral foramen. The patient in the image below has a left sided problem.
Pott's fracture-dislocation
Pott's fracture-dislocation is a general term used to refer to any fracture around the foot/ankle that concurrently has a dislocation
Synovitis of the knee: Signs and symptoms and tx
S&S: -Gradual onset of swelling (6-12 hours to develop) -Warm joint -Min/mod limited joint ROM with ability to assess (may or may not be pain limited) - Usually a dull ache into the joint when the capsule is distended TX: - Rest from provoking activities - PRICE
Hemarthrosis of the knee: Signs and symptoms and tx
Signs & Symptoms: -Rapid onset of swelling (1-2 hours to develop) -Hot joint -Mod/Severe limited joint ROM with inability to assess (very painful) -More severe pain because the knee is very inflamed Treatment of Hemarthorsis: -Rest -Support -Aspiration by Medical Doctor -PRICE
T/F: Posterior Talo-Fibular ligament is rarely injured. MOI? Does it blend with the joint capsule like the ATFL?
TRUE The posterior talo-fibular ligament (PTFL) is not injured nearly as often as the ATFL and/or CFL. In fact, injury to the PTFL is rather rare. In fact, the PTFL plays a minimal role in stabilizing the ankle when the ATFL and CFL are intact. This means, if injury to the PTFL was to occur it will likely be due to failure of the ATFL and CFL, which would then call on the demand of the PTFL. Due to this, an isolated injury to the PTFL is rare. The primary MOI to the PTFL is when the ankle is forced into external rotation usually with some degree of plantarflexion. The PTFL also blends with the joint capsule at the ankle. NOTE: Often times with an injury to the lateral ligaments there is also damage to the peroneal tendons.
The ______________ muscle has fibers that blend/attach to the medial meniscus while the __________ muscle has fibers that blend/attach to the lateral meniscus
semimembranosus popliteus
Imhibition
The uptake of nutrients in the nucleus of the disc. Enters through the intervertebral body and is pressed out with WB activities.
Ratio of movement with accessory mobility at the TMT
This normal ration should be a 1:1 ratio of movement for the Plantar-to-Dorsal glides. This means, assuming everything is normal, there SHOULD BE the same amount of Plantar glide as there is for the Dorsal glide.
Treatment for functional pes cavus? Structural?
Treatment for functional pes cavus would be to improve the tissue specific impairments causing the high arch (i.e. stretch tight muscles, manipulation tight joint capsules, etc.). Treatment for a structural pes cavus would be shock absorbing shoe inserts.
convex
curved outward
Meniscus most important function
distribution of weight bearing forces (most important function), increase in joint congruency - which aids in stability. They also act as secondary restraints to knee motion, and act as a shock absorber. They also function to aid in joint lubrication
What are the expected clinical findings in case of gluteal tendinopathy?
pain with contraction of the gluteal muscles, pain with lengthening of the muscles, point tenderness
Treatment for Bursitis
Initially the focus of treatment must be on decreasing the inflammation within the bursa. After the inflammation is decreased you must determine why the bursa was irritated and treat the impairments you find in your examination. There could be a muscle imbalance present which led to the bursitis, in which case you would stretch the tight muscles and strengthen the weak ones. If the bursitis was due to a tight capsule then you would need to perform manipulations into the direction of the restriction. You should analyze the patient's weight bearing related to the muscles stresses on the leg either a cane (or crutch) on the contralateral side may be advisable to decrease the weight bearing and therefore, decrease the muscle pull on the bursa.
PCL (posterior cruciate ligament)
"dashboard injury" PCL injuries are not as common as ACL injuries. Injury most often occurs when a force is applied to the anterior aspect of the proximal tibia when the knee is flexed. A PCL tear can result in varying degrees of disability, from no impairment to severe impairment. The primary function of the PCL is to prevent posterior translation of the tibia on the femur. The PCL also plays a role as a central axis controlling and imparting rotational stability to the knee. This injury has received little attention in the past, compared with the ACL; however, this emphasis on the ACL has stimulated increased interest in the treatment of PCL injuries. Controversy regarding treatment exists in the literature, with recommendations supporting both operative and non-operative therapy.
Mensical Injuries Signs and Symptoms
-Acute joint line pain may be described -Joint effusion gradually develops -The experience of locking of the knee (between 20-45 degrees) -Complaint of sensations of giving way (buckling) -The patient may have difficulty extending the knee fully -Full flexion, as in squatting, may be painful or impossible -Positive special tests may include McMurray test and Apley's Compression Test
Signs and symptoms of ACL sprains
-Inability to ambulate (especially with MCL and meniscal tears) -A rotational instability and a feeling of the knee "giving way." -With a second degree sprain, the pain is more severe when stress tested -With a third degree sprain, the pain may be less severe as no tension can be developed over the ruptured ligament. -Effusion (dependent on location of tear) -Minimal to significant hemarthrosis -Usually incomplete functional range of motion (ROM) primarily with extension. The level of limitation will correlate with amount of effusion and / hemarthrosis.
Occulta
-No external manifestation -Least serious -10 % of the population -Rarely associated with neurological deficit - External signs may be a patch of hair, pigmented area a or hemangioma are present - There may be neurologic deficit at birth or it may develop as the child grows
MOI of PCL ruptures
-Patients typically report falling on flexed knee or sustaining a direct blow to the anterior aspect of tibia. - forced hyperflexion - Motor Vehicle Accident (MVA) - "dashboard" injury - when the passenger or driver's knee/tibia is forcefully hit and displaced backwards by the dashboard. - Fall onto tibia - where the tibia is forced posteriorly.
Impairments associated with Lumbar sprain/strain/synovitis
-Posture will be guarded -Limited ROM in all directions - Quadratus lumborum and posterior lateral muscles are typically tighter on the involved side - Tenderness and/or increased tone in the lumbar paraspinals, quadratus lumborum and posteriorlateral hip muscles on the affected side - decreased strength and endurance - no neurological signs
Meningocele
Form of spina bifida - Meniges extrude through the defect in the neural arches forming a meningocele containing CSF and some nerve roots covered by skin There may be neurologic deficit at birth or it may develop as the child grows
Iliac Crests/ASIS/PSIS (Standing versus Sitting)
1) Iliac crests are unlevel in standing and Greater trochanters are unlevel standing = leg length discrepancy; and, the I.C should be level in sitting 2) Iliac crests unlevel standing and Greater trochanters are level standing = pelvic asymmetry; and the I.C will be unlevel in sitting
Waddell's Behavioral signs for yellow flags
1) Inappropriate overreaction - this is the "drama queen", the patient will overreact and have inappropriate reactions to your questions and tests 2) Simulated axial compression - you will apply an axial load through the head and cervical spine. This should not cause any pain in the lumbar spine or LE - if it does this is a positive sign. There may be symptom reproduction in the cervical spine. 3) Simulated rotation - you will rotate the patient through the hips and LE not through the spine. This should not cause any pain in the lumbar spine as you are not moving the lumbar spine. If the patient complains of pain in the lumbar spine this is a positive sign. 4) Regional weakness disturbance - this is weakness that does not follow a specific myotome or muscle group; the whole leg might be weak, this would be a positive sign 5) Regional sensory disturbance - this is sensation loss that does not follow a dermatome; the whole leg might be numb - this is a positive sign 6) Distracted SLR - a regular straight leg raise can cause pain in the lumbar spine and LE, in order to check if this is true you can have the patient do a SLR in another position without telling him that you are doing a SLR test. For example you can ask the patient to sit on the edge of the table and extend the knee in order to check quad strength, but this is also a straight leg raise - just in a different position. If a regular straight leg raise causes pain but a distracted SLR does not - that is a positive sign. 7) Superficial tenderness to palpation - this is tenderness to very light touch - it should not be painful in a normal individual 8) Non-anatomic tenderness to palpation - this is tenderness that does not correspond to an anatomical structure
It is necessary to rule out three things when examining the spine:
1) Is there a non-mechanical (systemic) problem? This is called a red flag and is something that we as physical therapists cannot treat. The patient must be referred back to the medical doctor. Some examples of systemic problems are cancer or a dysfunction of an internal organ (stomach, intestine, kidney, gallbladder, etc). 2) Are there neurological signs? Is there weakness in a myotome? Sensation loss in a dermatome? Decreased reflexes? Any of these would point towards nerve root involvement. 3) Are there psychosocial issues? This is called a yellow flag - it does not necessitate a referral back to the medical doctor, but is something that we should be aware of. In order to determine if there is a psychosocial issue, Waddell's Behavioral Signs are used as well as a variety of questionnaires.
Grades of tear for mm strain
1-3 much like ligament sprain 1: Minimal tearing of ligament fibers 2: Moderate tearing of ligament fibers 3: Complete tear- no stress no pain You can clinically tell difference through special tests or PROM accessory for ligaments, and through MSTT for mm strain.
What are the four (4) ligaments that make the deltoid ligament complex?
1. Anterior tibiotalar ligament 2. Tibiocalcaneal ligament 3. Posterior tibiotalar ligament 4. Tibionavicular ligament
Different severities of scoliosis
10 degrees - WNL General population, no treatment needed 10- 20 degrees - mild scoliosis 20- 40 degrees - moderate scoliosis Early structural changes 40-50 degrees - severe scoliosis Significant rotational deformity of the vertebrae and ribs Associated with pain and DJD in adults 60 - 70 degrees Significant cardiopulmonary changes Decreased life expectancy
MCL Sprain S&S based on degree
1st degree: (Sprain) Valgus stress painful, NO increase in mobility 2nd degree: Partial tear. Valgus stress painful and moderate increase in mobility 3rd Degree sprain: Complete tear. Ligament ruptured. No pain with valgus stress and unstable knee.
How many degrees of MTP extension is needed for walking? Running?
65 degrees of MTP extension is needed for walking, while 85 degrees is needed for running.
Medial Bunion
A medial bunion is the prominence of the metatarsal head at the first MTP. This occurs when exostosis and a callus form over the medial aspect of the metatarsal head.
Why is a fracture easier to rehab? How is it treated by a physician?
A fracture is a lot easier to rehabilitate because of the management of the fracture. A fracture is either casted or surgically repaired with either an open reduction internal fixation (ORIF) or and external fixation (EF). These patients don't commonly come in to physical therapy due to the fixation and will primarily follow up with their physician until the fracture is healed. Once the fracture is healed they will then present to physical therapy for us to treat the tissue specific impairments that are now present.
What is harder to rehab: a fractured bone or a sprained ligament?
A sprain. Bones will eventually heal with equal, if not more, strength than it previously had prior to the fracture. As compared to a ligament sprain. That ligament sustained a load within the Plastic Region of the Stress-Strain curve and will have permanent deformation.
Hallux rigidus
A stiffness or hypomobility of the first MTP joint. This is most often a chronic condition with decreased range of motion in MTP extension.
What is paramount to resolution of growth plate conditions?
A thorough examination and specific flexibility exercises are paramount to resolution. In addition, patient/family education is important as this condition may reappear at the next 'growth spurt'. Recurrent or severe cases of this condition will lead to permanent structural changes of an enlarged tibial tubercle.
The anterior compartment contains: (nerve, artery, mms)
Nerve: Deep peroneal nerve Vascular: Anterior tibial artery and vein Muscles: Anterior tibialis, extensor hallucis longus and extensor digitorum longus
Positive exam findings in osteoarthrosis/osteoarthritis/DJD
A/PROM Classical PROM accessory- quality, quantity, and change in symptoms MLT MMT Special Tests Movement Analysis- not going to be diagnostic or best step but if someone has degenerative issues, watching their gait can show you a lot of information Imaging*- will 100% be positive. You are not doing this in the clinic
ALL grades result in what? In other words, what do they have in common?
All Grades result in an over-stretch of the ligament. When this occurs, the ligament may never have normal length again. Instead, it may have some additional length associated with it.
Progression for standing exercises (or regression to sitting)
All are same but seated
Impairments associated with Ligamentous laxity/postural back pain
Lumbar ROM is usually OK, although there may be pain at end range with stretching Hip musculature may be tight
Do we as physical therapists treat fractures?
No. As physical therapists we treat the tissue specific impairments that result from the fracture and/or the result from the fracture being immobilized or being repaired surgically. For examples, capsule hypomobilities, tight musculature, weak musculature, etc
Osgood-Schlatter's Disease
Osteochondrosis of the knee. Especially the tibial tuberosity
Clinically, how would you be able to tell the difference between a structural versus a functional high arch?
AROM and PROM classical. If the arch can be corrected, it is a functional high arch. If the arch remains the exact same with classical motions, it is a structural high arch.
Can you flex and extend your elbow at the exact same time and create movement?
Absolutely not (Lol)
Components of hip joint in a THR
Acetabulum shell with liner Femoral head with stem Uncemented (Pressfit) vs. Cemented Healing considerations
mms that are strained with eccentric load
Adductors and hamstrings Ballistic force like kicking a soccer ball, athletes.
Total knee replacement considerations
After surgery the patient will present with decreased quad strength and decreased ROM. It is our job to gradually increase ROM and strength in order to return the patient to functional activities. The stronger the patient and the better the ROM before surgery, the better the outcomes after surgery (usually!).
Treatment for Lateral Foraminal Stenosis
Again we will treat the impairments that are present. So if there are tight muscles, we need to stretch them. If there is decreased strength we need to strengthen; walking is a great exercise for patients with back pain who have decreased endurance. If there are positive neurological signs and if distraction decreases symptoms then the distraction becomes the treatment. Limited neural mobility is treated with neural mobilizations.
Treatment for Lumbar sprain/strain/synovitis:
Again, just like everything we have talked about so far we will treat the impairments that are present. The following picture is a good general ROM exercises to assist with vascularity for the lumbar spine and decrease pain. Lower Trunk Rotation Recommended Dosage 50% of 1 RM
What else can make the Achilles tendon more prone to tendon rupture?
Another item to be aware of with a tendon rupture in this area is if there have been any cortisone injections in this area. Cortisone will make the tissue more brittle and decrease the integrity of the collagen thus increasing the chance for a tendon rupture.
Backward bend annulus flattens anteriorly
Annulus bulges posteriorly Facets move back and down Nucleus deforms slightly anterior Foramen closes Abdominals and hip flexors elongate Anterior longitudinal ligament becomes taught
What happens to annulus during flexion or SB?
Annulus bulges to side of sidebending Annulus flattens on opposite side Facet slides up on opposite side Facet slides down & compresses on same side
Forward bend annulus compresses/bulges anteriorly
Annulus flattens posteriorly Nucleus deforms slightly posterior Facets slide up and forward Foramen opens Back extensors elongate Posterior ligaments become taught
End feel for anteversion and retroversion
Ante: Normal cartilage end feel with ER (pt will appear to lack ER) Retro: Normal cartilage end feel with IR (pt will appear to lack IR)
The most commonly injured ligament of these three is the.... What is its function and MOI? When does the MOI occur?
Anterior Talo-fibular (ATFL). Its primary responsibility is preventing excessive anterior translation of the talus on the tibia/fibula. The mechanism of injury (MOI) for the ATFL is excessive ankle plantarflexion with coupled inversion. In this position the ATFL has the greatest amount of strain applied to it. This MOI most often occurs during the transition between loading-to-unloading or unloading-to-loading of the foot with the ground. During this transition the muscles are trying to control acceleration and deceleration forces as the body transitions over the foot/ankle.
3 main compartments of the lower leg:
Anterior compartment Lateral compartment Deep posterior compartment
What is the specific nerve located within each compartment of the lower leg?
Anterior- Deep fibular Lateral- superficial fibular N Deep posterior- Tibial N
What are three complications that can occur following a femoral neck fracture?
Avascular necrosis, a non-union, post-traumatic DJD in a younger patient.
How can you differentiate a tendonitis/osis and a muscle strain?
Ask the patient where the pain is following an MSTT.
Fractures that can occur at the malleoli:
Avulsion fracture - secondary to the attaching ligaments pulling on the malleolus during an inversion and/or eversion sprain. This results in a portion of the bone being fractured off rather than the ligament rupturing. Stress fracture - excessive ground reaction forces delivered through the bone create a mild fracture line within the bond. This fracture line is commonly referenced as a "hair-line" fracture Fracture secondary to impact - an outside force contacts the bone resulting in a direct fracture. Fracture associated with a dislocation - traumatic ligamentous disruption results in abnormal and excessive arthrokinematic movements around the ankle resulting in the forces being transmitted through the bone.
Additional considerations regarding Posture
Axial Compression (yellow flag refer to Waddell's Signs) Review job site (work station and computer) Active Movement
The deep posterior compartment contains: What is the compartment syndrome also known as?
Nerve: Posterior tibial nerve Vascular: Posterior tibial artery and vein; and the Peroneal artery and vein Muscles: Posterior tibialis, flexor hallucis longus and flexor digitorum longus Aka: Posterior Tibial (Exertional) Compartment Syndrome
Location of MCL
Broad and flat ligament that extends below the level of the tibial tubercle The middle portion (1/3) sits right at joint line, proximal 1/3 is right at the area of adductor tubercle and distal 1/3 is just blow the level of tibial tubercle
Late Sub Acute/ Settled/ Chronic Phase Goals
Build Co-ordination/endurance of postural/tonic mm. (multifidii) 60% 1 RM 25-30 Reps; 1-2x/day Build Endurance/Strength of Prime mover/phasic mm (gluteus max)- and glut med 75% of 1 RM 15-20 Reps; Every other day Begin Inner to mid range progressing to outer range
Settled/Chronic Phase Goals Lumbar spine
Build Strength of Prime Mover/Phasic mm 80% 1 RM 8-12 reps; every 2 days Functional exercises Build Power of Prime Mover/ phasic mm 90% a RM 4-6 Reps; every 3 days Functional/Plyometric Exercise
Patellar tendinopathy: physical exam
Can be diagnosed clinically and does not REQUIRE imaging, but can be picked up. T2 MRI- example in ppt indicating swelling Clinical exam: Contract it, touch it, and lengthen the area (as any other tendinopathy) 1) MSTT (strong and painful with knee ext or hip flexion) 2) MMT 3) MLT- tight quads or mms imbalance of gastroc or hamstrings 4) Palpation for C- Inflammatory, warmth, redness and swelling PFT- tenderness to touch at inferior pole of patella
Causes of DJD/osteoarthritis
Causes are not known but contributing factors can include joint injury, too much stress, increasing age, overweight.
Uncemented vs Cemented Hip replacement
Cemented THA use polymethylmethacrylate (PMMA) to function as a grout, producing an interlocking fit between cancellous bone and prosthesis. Uncemented hips rely on biological fixation of bone to a surface coating on the prosthesis.
What is a uni-malleolar fracture?
Consists of either malleoli, but only one is fractured. May be susceptible to avulsion fractures, stress fractures, fracture secondary to impact and/or fracture associated with a dislocation.
Lateral compartment contains: MOI?
Nerve: Superficial peroneal nerve Vascular: none Muscles: Peroneus longus and peroneus brevis This compartment syndrome is commonly due to direct trauma to the area and is not commonly associated with overuse. If it is an acute situation, the patient should be referred out to medical personnel for a fasciotomy.
Craig's Test
Craig's test (also called Ryder Method) is used to determine the amount of anteversion or retroversion. The patient will lay prone with the knee flexed. The greater trochanter is palpated for the position of the most amount of prominence which is also where the trochanter is parallel to the table. Once this position is found the angle between the shaft of the tibia and perpendicular to the floor is determined. If the angle is larger than approximately 15-18 degrees there is more anteversion present (the hip will be in more internal rotation). If the angle is less than approximately 5-8 degrees there is more retroversion present (the hip will be more neutral or externally rotated).
The two capsular patterns of the hip
Cyriax - gross limitation of flexion, abduction, medial rotation and extension (FAME) with slight limitation of lateral rotation Kaltenborn - limitation of medial rotation, extension, abduction and flexion (MEAF) with slight limitation of lateral rotation (more common in WB position)
Capsular Pattern of the hip
Cyriax- FAME: Flexion, medial rotation, ext Kaltenborn- MEAF: Medial rotation, ext, abd, flexion Both present with slight limitation lateral rotation
Method to decrease impact forces on hip joint
Shoe inserts shock absorption
If a compartment does not have an artery within it, what finding would you use in replace of the vascular finding?
NeuroMUSCULAR: Neuro - identify the specific location of impaired sensation related to the specific nerve within each compartment Muscular - identify weakness of the muscles located within that specific compartment
Degenerative Disc Disease (DDD)
DDD is the degeneration of the intervertebral disc. Over time the nucleus loses its ability to absorb water and as a result becomes more fibrous. The consistency of the disc of a 70 year old person is often compared to crab meat! Due to the loss of water, the disc space narrows and the superior vertebrae slides down and back on the vertebrae below it. This will narrow the central canal and the intervertebral foramen.
Pes Anserine Tendonitis
Could be a tendonitis or osis Any condition that promotes and genu valgus force can cause elongation of these tendons: Gracilis, semitendinosis, sartorius. lack of femoral ER or excessive IR can cause stress. Found in people with larger q angle bc it stretches hip adductors and ERs. Tendons insert into the tibial tuberosity Management: Deg- load Retractive- regress stress and move back into activity Must address the impairments that are creating prob. mm imbalance, mm strength, mm extensibility, mm control
What will motions will be occurring up the kinetic chain if the hindfoot is pronating?
The tibia should be internally rotating causing the knee to internally rotate, leading to increased genu valgum, resulting in adduction and internal rotation of the femur.
There are many things that can cause plantar fasciitis, including:
Excessive hindfoot pronation Excessive hindfoot supination Weakness of surrounding musculature Tightness of surrounding musculature Poor footwear Excessive time spent on feet Decreased dorsiflexion Heel spurs may be a potential cause of plantar fasciitis, however just because heel spurs are present doesn't mean the patient will have plantar fasciitis, and just because the patient has plantar fasciitis doesn't mean that they will have heel spurs.
T/F: Pronation and supination are classical motions. Why or why not?
F You must first recall the terms pronation and supination are tri-planar terms and are NOT a classical motion. -A classical motion is ONE specific direction of movement (i.e. flexion, extension, abduction, adduction, external rotation, internal rotation, dorsiflexion, plantarflexion). -A tri-planar motion requires THREE different classical motions referenced above in order to produce one gross movement.
Eccentric loading should create a large amount of pain with tendinopathy: T/F
F Min/mod
T/f: Patella is intraarticular
F- intracapsular
T/F: Disc absorbs shock
F: It disperses it
Disc injuries are common in elderly: T/F
F: Usually a bending and twisting motion or some sort of injury
SP moves superior. T/F
F: moves inferior to protect SC from injury
T/F: Medial tibial stress syndrome is a type of compartment syndrome
FALSE
T/F: Calcaneofibular and ATFL injuries go hand in hand. You cannot injure the Calcf. without first injuring ATFL If it can be injured alone, how does this injury occur? If it is injured along with ATFL, how does this occur?
FALSE It is possible to injure the CFL only without involvement of the ATFL. This type of MOI is a pure inversion force. As compared to the ATFL requiring plantarflexion and inversion. The CFL ligament is extra-articular only.
T/F: Ligament injuries usually occur similarly for each patient and can all be treated in simple ways. Will also heal completely
FALSE When it comes to a ligament injury not all patients will receive the same immobility. Some patient's may not even receive any type of brace or support. The management alone makes it easier to rehab a fracture. In addition, once a ligament is torn it will never be the same. Aside from surgical intervention to replace the ligament, it is rare for the two torn ends to come back together and form a "normal" ligament.
T/F: As PT's, we DO treat a pronated or supinated foot.
FALSE A pronated and supinated foot is only an appearance, that being, the appearance of either a flat foot (pronated) or a high arch foot (supinated). Think of it like this: We treat what we feel, not what we see. Pronation and supination ARE NOT tissue specific impairments. Something is causing the foot to have excessive/limited pronation or supination. It is that "something" we must identify and treat.
T/F: We will be using the same concept of tissue specific impairments in the spine
FALSE In the lumbar and cervical spine we will not be using the concept of tissue specific impairments. It is much more difficult to get tissue specific in the spine. We will focus on general impairments instead.
What happens to annulus and facets during rotation?
Facets gap on side rotating toward Facets compress on side rotation away from Annular rings tighten causing shear and compression on disc
T/F: Damage to peroneal tendons is rare with a lateral ligament injury
False!! It is COMMON
Injury to Anterior tibio-fibular ligament is common- T/F MOI?
False... It is rare This injury is rare in comparison to the ATFL and CFL. The primary MOI is forced dorsiflexion and external rotation of the ankle while in weight bearing. The anterior talar dome is wider than the posterior talar dome. This means with ankle dorsiflexion the talus rolls and glides posteriorly wedging the wider, anterior aspect of the talar dome between the medial and lateral malleoli. Once this occurs the external rotation creates a greater pressure on to the tibia and fibula causing the distal tib-fib joint to spread resulting in injury to the anterior tibio-fibular ligament.
Management of different grades of sprain
Grade 1: Managed conservatively Grade 2: Managed conservatively but increased motion at the joint Grade 3: Can also (sometimes) be managed conservatively Grade 4: Person may need a reconstruction Overall management: STRENGTH of hamstring muscles to prevent excessive anterior translation is crucial Glut med/min, abductors and ER are also very important to prevent valgus and IR of the tibia relative to femur.
In the lower extremity what muscles typically get tight?
Hamstring, hip flexors, adductors, gastrocs Kinetic Chain Abnormalities The entire kinetic chain can be affected by the muscle imbalances, structural problems or soft tissue restrictions we have discussed. The typical presentation at the knee is genu valgus.
MOST commonly strained mm at the hip
Hamstrings As with the adductors, a strain of the hamstrings typically occurs during an eccentric contraction most often at end range hip flexion with full knee extension. Also, like the adductors, hamstring strains have a prolonged recovery period and are often reinjured. Multiple factors have been attributed to hamstring strains such as prior injury, advanced age, insufficient warm up and muscle imbalances in the pelvis and lower extremity to name a few.
What is the single best examination step and finding to identify a compartment syndrome of the lower leg?
NeuroVASCULAR: Neuro - identify the specific location of impaired sensation related to the specific nerve within each compartment Vascular - identify the specific pulse that is impaired for each specific artery within each compartment
Scoliosis Operative treatment
Harrington Rods are used for curves over 40 degrees or predicted to be over 40 degrees. The surgery is typically performed after the growth spurt and can correct the curve up to 50%. The surgery will give a stable spine with decreased pain level. The patient may be placed in traction prior to surgery and may need to wear an appliance post-surgery. They are typically out of bed the following day. Various restrictions may apply for sitting/standing etc.
IF the ratio was identified as 3:1 this would indicate what about the medial and lateral calcaneal arc glides?
IF the ratio was identified as 3:1 this would indicate the Medial calcaneal arc glide is excessive (hypermobile), while the Lateral calcaneal arc glide is normal.
if a hypermobility were present at the TMT, what would the ratio look like?
If a hypermobility were present, this would be indicated by a '2' within the ratio (i.e. 2:1)
If an adhesion or restriction in one direction were present at the TMT, what would the ratio look like?
If there is an adhesion or restriction in one direction, this would be indicated by a '0' within the ratio (i.e. 1:0).
SCFE: What if it is unstable? What are the complications?
If unstable, surgical intervention. If stable, conservative management (e.g. limitation of actvity and casting) might be recommended but less likely. Complications: Long term degenerative OA, AVN of the femoral head, Chondrolysis (7-10%): acute cartilage necrosis, deformity, limb length discrepancy
When will disc patients have the most pain?
In the morning bc their is too much fluid and pressure on the nerves.
Sitting while lifting a weight will increase/decrease discal pressure?
Increase the MOST at 275%
The worse the curve is, the more likely it is going to do what? What is the prognosis?
Increase. An important factor is the amount of growth that the child has left to go though. That means that a 10 year old with a 15 degree curve has a worse prognosis than a 15 year old with a 15 degree curve
ACL
Injury to the ACL most often occurs as a result of sport related activities that place stress on the knee joint as in cutting or jumping activities. Ruptures of the ACL may occur as a result of a direct blow to the knee with the foot planted. More often, however, they are the result of a non-contact twisting injury associated with hyperextension or varus/valgus stress to the knee The ACL is the primary (85%) restraint to limit anterior translation of the tibia. The greatest restraint is in full extension. The ACL is composed of densely organized, fibrous collagenous connective tissue that attaches the femur to the tibia. The ACL is composed of 2 groups, the anteromedial and posterolateral bands. During flexion the anterior band is taught while the posterior is loose; during extension, the posterolateral band is tight, while the anterior band is loose.
Trochanteric Bursitis and the 18 steps
Intake Forms Assessment: Pain in lateral hip that may radiate to the knee, some amount of disability reported on LEFS Initial Observation Nothing significant. History: Insidious onset and gradual onset, pain increases with stair climbing and laying on affected side. Night pain when rolling onto opposite side Systems Review: n/a Screening: n/a Structural Inspection: There can be a variety of structural deviations that may lead to bursitis, but just because a patient has bursitis, doesn't mean that you can say for sure that there is some type of structural deviation present Palpation for Condition: Swelling, with possible warmth, palpated over the bursa in the lateral hip region AROM: Pain with abduction, external rotation and extension due to contraction of muscles to perform these actions will compress the bursa; adduction, internal rotation and flexion will be painful as the patient moves into these motions and the muscles are pulled tight across the inflamed bursa (muscles located ontop of bursa) PROM: PROM Classical: pain with adduction, internal rotation and flexion; moving into these directions will pull muscles tight over top of the bursa. PROM Accessory: negative MSTT: False positive of strong and painful for abductors, ER and extensors due to contraction of the muscle over the bursa MLT: False positive Ober's test pain due to lengthening of TFL/ITB over irritated bursa False positive because it is the bursa and not the mm. Resisted abduction would cause pain. MMT: Pain with contraction of muscles that cross the bursa see MSTT. Do not perform if false positive MSTT. Special Tests: None specific to bursitis Neurovascular: Nothing significant. Palpation for tenderness: Pain over bursa on posterior lateral aspect of hip Movement analysis: Pain with stair climbing, pain with lying on affected side, pain with crossing legs Diagnostic imaging: none given Evaluation/Diagnosis/Prognosis: Swelling end feel
Is stabilization or increasing ROM easier to do?
It is a lot easier to increase range of motion for a joint that is too tight, but it is a lot harder to stabilize a joint that is moving too much
What is important to determine with a high arch?
It is important to determine if the high arch is structural or functional.
T/F: Only certain bones in the body can be fractured because some bones aren't susceptible
It is important to understand any bone of the body can be fractured if it sustains a great enough force applied to it. The reality is though certain bones within the body have the tendency to fracture more than others.
Reactive condition would be related to what? Tendonosis or itis?
Itis
Treatment for central spine stenosis
Just like we talked about earlier, we will be treating the impairments that we find!. Commonly, the hip abductors/extensors, gastroc, quadriceps, and back extensors will need to be strengthened. Further, endurance training for ambulation will usually be necessary. Aquatic physical therapy is generally a good modality for these patients, as the buoyancy of the water will unweight the spine. Further, pool exercises usually can be performed for a longer time than land based exercises and thus can increase endurance.
T/f: ACL is intraarticular
Kind of. It is intraaricular but a large part of it is extra-articular
Which meniscus is more mobile and less likely to be injured?
Lateral
During rotation look for:
Look at spinous processes - they should rotate to the opposite side Spine should gradually side bend to the opposite side (simulated/yellow flag - refer to Waddell's Signs)
Incorrect posture from lateral view
Lordosis/anterior pelvic tilt (APT) or flat back/posterior pelvic tilt (PPT)
Impairments for Lateral Foraminal Stenosis
Lordotic posture Limited backward bending and sidebending towards with pain radiating into LE Positive neurological signs in the corresponding dermatome and/or myotome Limited neural mobility Tight hamstrings and piriformis Distraction decreases symptoms in LE Compression/quadrant increases symptoms in LE Tenderness on side of involvement in lumbar paraspinals, quadratus lumborum, posterior lateral hip muscles) Decreased strength, endurance, function
Lumbar and Lumbosacral plexus
Lumbar: Ventral Rami L1-L4 Lumbosacral: Post rami L4-S3
Injury to what tissues at the knee will result in synovitis?
MCL, meniscus, anteromedial fibers of ACL
Best step to determine tendon tissue reactivity
MLT PROM classical PFT
What examination steps and findings would indicate a complete tear of the Achilles tendon?
MSTT: Weak and painless plantarflexion
What is medial tibial stress syndrome? How does it compare to a compartment syndrome?
MTSS is not a compartment syndrome. It is tibial periosteitis at the attachment of either the posterior tibialis or the medial attachment of the soleus. It is a very local pain on the distal posterior-medial border of the tibia. It is much more focal and painful than that of compartment syndromes. Again, treatment is to address the impairments that you find. First the swelling must be decreased and the aggravating activity stopped while you treat any muscle weakness, tightness or joint mobility problems.
Anterior Lumbar Fusion
May require a vascular or general surgeon Does not denervate posterior structures Indications (lateral foraminal stenosis, central spine stenosis, Spondylolysthesis, failed laminotomy with discectomy Patient is side lying with knees pulled toward the chest Aorta is retracted (sympathetics, arteries, veins and lymphatics must be avoided Annulus is cut anterior/laterally and disc removed Vertebral endplate is decorticated Iliac bone graft is inserted into the disc space which restores the lateral foramen and central spine canal
Anatomy of Meniscus
Medial: Attached to joint capsule, MCL, semimembranosus (external attachments) and medial tibial condyle via coronary ligament Lateral: Attaches to tibia, capsule and coronary but not LCL. Popliteus tendon attaches to lateral meniscus. Attachments will promote movement. Except for the anterior horn, the menisci are floating.
Is chondromalacia a tissue specific impairment? Why or why not?
No because it does not identify the impairment. All you know is the tissue involved. There are several causes for this... which would make up the tissue specific impairment.
What can prevent nutrition from entering the joint?
No loading and unloading, tight capsule, stresses on the joint. This leads to degeneration Anything that decreases ROM increases compressive forces, so as a PT we can stretch tight mms and manipulate the tigh capsule
Menisci biomechanics
Menisci are relatively free floating to allow sliding. EXT knee- slide anteriorly and vice versa. only about 6 mm of motion at Medial and 12mm at lateral meniscus
Knee Meniscal Injury Interventions
Nearly 1/3 of tears can be managed by conservative intervention. Non-operative rehabilitation is similar in principle to the protocol that follows meniscectomy -End range ext and flex (ROM important) -consider entire kinetic chain -Cryotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) play a very important role in the management of swelling, hence you need consult from a physician. Maintenance of ROM of the knee is important, as are muscular strength and endurance. On page 1053-54 in Dutton, you will find a post-operative protocol for a meniscal repair. As a supplement, you may refer to Hertling and Kessler pages 523-524 to review the management of acute and chronic tears, coronary ligament tears and surgical repairs.
The fracture is the cause of the fall rather than the result of it. What does this mean?
More often than not, the statement above is true when we are referencing a fracture of the femoral neck and/or tuberosities. A rotational force is applied to the femur as the patient turns to do something and it is this rotational force that causes the femur to fracture. For example, an elderly woman standing by her sink turns to put something into a drawer and falls. The result is a hip fracture. The rotational force is sufficient to cause the fracture because the patient typically will have osteoporosis. Remember that osteoporosis causes the bones to become weak and brittle, decreasing the amount of force required causing a fracture. Assuming our bones are strong and healthy, you or I would not have any problem turning while our foot is planted on the ground. However, that simple action in someone with osteoporosis may cause the femur to fracture either at the neck or trochanters. The patient will then fall down since the lower extremity can no longer support the weight of their body on the fracture.
Total Hip replacement (THR/THA)
More than 300,000 THRs per year in US Average pt= age 66 F>M Females have higher risk of implant failure and 2 times the amount of complication Relieve pain, improve function= Modest Activity participation
THR approaches
Most common is posterolateral then there is... -ant minimal incision- results in less blood loss and smaller scar but can take longer in surgery since its harder to do. Minimally invasive aren't often done Outcome considerations
Landmarks for the Posture/standing test of the lumbar spine
Navicular tubercles/medial malleolus Fibular heads Greater trochanters (GT) Iliac Crests (IC)/ASIS/PSIS Observe for any lateral shift or scoliosis
ACL Sprain Intervention
Non-Operative Intervention: -Rule out other potential dysfunctions -Initial intervention should involve controlling swelling -Gentle massage. -PRICE and Immobilization -Functional electrical stimulation may be used to stimulate the quadriceps muscles. -Initiate motor control exercises such as Quads sets and Straight Leg Raising. -Gentle PROM and progress as tolerated -Progress closed chain activities as tolerated Many of these interventions can also be used before a surgery. Post-Operative intervention will utilize a protocol by the surgeon
Anteversion/Retroversion
Normal Anteversion: 8-15 degrees towards IR Excessive ant: >15 degrees IR with craigs test (decreased PROM classical ER with normal cartilage end feel) Retroversion- less than 8 degrees (decreased PROM classical IR with normal cartilage end feel) Hip jt PROM accessory= normal capsule
Coxa Vara/Valga
Normal angle between neck and shaft of femur= 125 degrees Coxa Vara: <125 degrees (shaft angles medially) Coxa Valga: > 125 degrees (shaft angled laterally) Consider the kinetic chain
What will the end-feel be for PROM external rotation with anteverted hip?
Normal cartilage it is normal for that person so bony block would not be appropriate as it implies an abnormal condition.
Normal "version" for the femur
Normal version is a slight amount of anteversion of the femur which is then compensated for by the natural external torsion that is present in the tibia. This keeps our feet facing forward.
Where do knee tendinopathies commonly occur?
Occur more commonly in the patella tendon, quad tendons, and any of the hamstring tendons Additionally, you can develop this condition to the popliteus or pes anserine tendons.
Hip Impingement
Occurs do to abnormal rubbing of the femoral head or the acetabular socket which can result in damage to the hip joint causing premature hip DJD or osteoarthritis Damage can occur through cartilage or labral tear which is the ST bumper on the socket
SCFE: Where does it commonly occur
Often occurs in L hip and 20% of cases occur bilaterally. Child has high BMI: key factor Klines line used to determine how much displacement has occured Type 1 Salter Harris growth plate injury
T/F: Laxities can be easily stabilized. Why?
Once a laxity always a laxity. It is difficult to stabilize laxities. At the ankle there is not a single muscle that attaches to the talus, so there isn't one particular muscle that can be used to stabilize that area. Instead, we must rely on the muscular support and stability of ALL the muscles in the area.
What happens to proprioception when a ligament is torn? What can this cause?
Once a ligament is torn the proprioception will be decreased. Decreased proprioception places the patient at increased risk of having another ankle sprain and damaging more ligaments. Ligament injuries should be immobilized as soon as they happen in order to promote healing of the ligament. The sooner the ankle can be immobilized the better the chance of the ligament healing with some degree of scar tissue.
In the lower leg there is an increased incidence of what type of fractures? Why?
Open fractures This is because of the close proximity of the bone to the overlying skin and the fact there is not a lot of soft tissue that surrounds the tibia and fibula. Often times healing can be slow with lower leg fractures, especially when there is a severe disruption of the periosteum.
Degenerative condition would be related to what? Tendonosis or itis?
Osis
Individuals that commonly have osteochondrosis
Osteochondroses are seen in children and rarely, if ever, occurs in adulthood. Although it is most specific to children there could be long-term results that could affect adulthood. Therefore, if an osteochondrosis is suspected or identified it must be treated accurately.
Sever's Disease
Osteochondrosis of foot. (specifically the calcaneal tuberosity)
Legg-Valve Perthes
Osteochondrosis of the hip (especially the femoral head) Most common. 4 times for frequent in boys and girls.
Clinically, how can you tell the difference between a metatarsalgia and an interdigital nerve entrapment?
PFT: Pain is specific to between the metatarsals with interdigital nerve entrapment and specific to the metatarsal heads with metatarsalgia Neuromuscular: Decreased sensation in the webspace of the toes with the interdigital nerve entrapment, normal sensation with the metatarsalgia
What are the three (3) best examination steps and findings to differentiate an ATFL sprain from a peroneal strain?
PROM accessory: Laxity would be present P/A talar glide, but normal mobility if it was the peroneals. MSTT. If the peroneals are involved then the findings would present as strong and painful. If only the ATFL were injured the findings would be strong and painless. PFT: Pain with accurate palpation to each tissue would be provoked.
The primary reason for a patient needing a total joint replacement?
Pain Just because the radiograph or MRI shows significant degeneration of the joint, that alone is not a reason for a total joint replacement. Many patients can function perfectly fine with a lot of degeneration, while others have major functional limitations with what appears to be a small amount of degeneration.
T-L/S RIGHT Facet Cartilage Exam
Painful Movement Pattern: Type 2 collagen pathology so with compression +EXTENSION Ipsi SB/opp rotation Pain on RIGHT
Lateral Foraminal Stenosis Exam
Painful movement pattern: +EXTENSION Ipsi SB Radicular sx (due to nerve involvement) Neuro? -myotomes -dermatomes -reflexes
L/S Disc degeneration Exam
Painful movement pattern: - + EXTENSION -WB activities - improved with sitting/flexion - Referred Sx are central and into buttock - no radicular symptoms involved - Bilateral pain bc brain can't really tell the difference Osteophytes bc of shearing motion
L/S disc herniation/Prolapse Exam
Painful movement pattern: -+ FLEXION -seated activities -improved with walking/movement -Unilateral or bilateral symptoms -pain -neuro? (myo/derm/reflexes) - Is it the disc? -SLR and Cram's Test Look at radiology last to not be biased
Treatments for Lumbar issue/ low back pain
Palliative/prep: 1)ST 2) Gd I/II non thrust manipulation 3) Thrust manipulation (if necessary) 4) Taping 5)50% 1 RM exercise 6) Physical agents (sparingly)- hot packs, cold packs (can increase BF), and estim (Be careful with estim with inflammation) primary modality for pain is exercise
Patellofemoral pain syndrome What is it? Symptoms?
Patellofemoral syndrome (PFS) is a generic name for anterior knee pain. It is a catch all phrase that really doesn't tell us much other than the location of the pain. Think about the impingement syndrome we talked about in the shoulder... even though we had a general diagnosis we still needed to find out what is causing it. Same thing with PFS - we have to figure out what is causing the anterior knee pain. There are some classic symptoms that are associated with PFS. These include anterior knee pain, pain with sitting, pain with descending stairs and a gradual onset of pain.
What is Plica? How is it diagnosed and treated?
Plica is an embryological tissue that develop early on and then forms into the capsule of the knee. These are usually asymptomatic. Unless there is trauma or irritation to them. Think of biting your cheek... and for the next week, you continually bite that same spot because it is inflamed and irritated. Once the inflammation is resolved, you no longer have a problem. Plica acts the same way. These will mimic meniscal lesions and can be treated conservatively. However, there is controversy in the literature about how to diagnosis. This should be a condition that is arrived upon when all other clinical exams are negative (ie, meniscal tests are negative). If conservative management fails, then they can perform a plicectomy to remove the irritated tissue. Then, you can resume physical therapy to progress the patient back to their activities.
If the hindfoot is pronating the ankle and midfoot will do what?
Pronate while the forefoot supinates
If the knee is in genu valgus, in what position are the hindfoot and ankle joint?
Pronation
Loose pack position of the midfoot and hindfoot. What does loose pack position allow the foot to do?
Pronation of the hindfoot and midfoot is the loose pack position of these sections. Loose pack position allows the foot to accommodate to the ground and any uneven surfaces.
During movement look for:
Range of motion Ease of performance (quality) Smoothness of curves and symmetry Note symptoms and location
Sitting exams
Recheck iliac crest heights Neurological - reflexes (patellar L4/ Achilles S1) Marked differences are significant Minor differences may be due to poor muscle relaxation Sensation - light touch, sharp dull (most accurate) Motor signs- marked differences are more valid Babinski -check with knee extended [12,13] yellow flag Regional motor and sensory findings suggest yellow flag (refer to Waddell's Signs)
MOI of ACL Sprains
SPORTS RELATED MECHANISM - ACL tears occur with or without contact, and with the knee in any position from flexed to fully extended. - The most common contact mechanism of injury is the valgus-abduction injury without contact also hyperextension (ACL and PCL) Non contact injury: Demographic, MOI, concomitant injury. More common in females (7-10x more susceptible) usually it is a deceleration injury with a big eccentric load to change direction. Distinct pop
Exercise progressions VASCULAR
Same rotation but with a pulley or band hooked on to the side and attached to pt legs when rotating Pulley attached to pts hips
Scoliosis
Scoliosis is the lateral curvature of the spine accompanied by rotational deformity. It is a deformity rather than a disease which can lead to structural abnormalities of the vertebrae, thoracic cage and pelvis. It can be either structural or nonstructural.
Sever's Disease
Sever's disease is an osteochondrosis of the calcaneus. More specifically, it is at the location of the Achilles tendon where it directly attaches to the calcaneus. This osteochondrosis is specific to children and is the most common cause of heel pain in children. Progression of this pathology follows the normal process of osteochondrosis.
What type of injury will result in hemarthrosis?
Severe damage that results in bleeding in the joint
What are Shin Splints? By now you might be thinking how do shin splints fit into this picture?
Shin splints are a general term for any type of lower leg pain. So, pretty much anything we have talked about so far could fall into the general diagnosis of shin splints. Think back to patellofemoral syndrome - it was a general term for anterior knee pain, same thing here.
What can a medial bunion occur secondary to?
Shoe attire causing excessive forefoot compression Associated with a hallux valgus Related to instability at the first TMT (The instability at the first TMT will cause the metatarsal shaft to rotate allowing the metatarsal head to become more prominent.)
Rehab - as per physician - S/p Anterior Fusion
Similar to the above will likely have to wait until fusion occurs before rehab Must be careful with active movement lumbar
What can we do about tight muscles or capsule at the hip?
Stretch those tight muscles and manipulate that tight capsule. Another thing that will help decrease compressive forces (although it will not affect ROM) is a shoe insert. The Shiba article that is recommended for this unit discusses the use of various types of shoe inserts to decrease compressive forces. Polymeric foam rubber was the type of insert that was the most effective, decreasing compressive forces up to 11%.
The above answer means that the midfoot is also moving back into what?
This means the midfoot is also moving back into supination. Again, supination of the hindfoot and midfoot is the closed pack position of these sections and required in order to have a stable structure to push off from and therefore propel the body forward.
Treatment and potential complications of Posterior Fracture-Dislocation
Tx: Closed reduction, ORIF Potential complications: AVN, sciatic N, post traumatic DJD
Structural scoliosis
Structural scoliosis is an irreversible curvature with fixed rotation of the vertebrae toward the convex side. It can occur in infants and juveniles, but typically occurs in adolescent females at approximately age 10. It begins painlessly and slowly and may not be noticed until a 30 degree curve has developed. Radiographic diagnosis is performed using the Cobb method (greatest angle toward concavity).
Scoliosis examination (structure)
Structure: - "Rib Hump" evident on the side of the convexity due to rotation of the vertebrae and ribs, anterior rib cage prominent of the side of the concavity - S curve typically L lumbar / R thoracic (named by the side of the convexity) - Un level shoulders - Scapula prominent on the side of the convexity - Pelvic obliquity may appear as a leg length
Deltoid Ligament MOI Due to its broad attachment to the medial mall, what injury commonly takes place?
The deltoid ligament complex is on the medial side of the ankle and composed of four (4) different ligaments. Each of these ligaments blend with one another creating a ligamentous complex. The primary MOI consists of forced eversion to the ankle. Due to the deltoid ligaments all blending together, they collectively create a broad ligamentous attachment to the medial malleolus. Due to this broad attachment it is common for the medial malleolus to result in an avulsion fracture due to the deltoid pulling on it rather than the ligament tearing.
During sidebending look for:
Symmetry of curve Flattened areas Sharp angulation- can use tape measure for quantification
What are the five (5) best examination findings to confirm a capsular pattern restriction at the hip?
You should be getting very familiar with this question by now You should understand the connection between AROM, PROM classical and PROM accessory related to a tight joint capsule You should know what pieces of information (data) are needed from AROM, PROM classical and PROM accessory and WHY this information is needed.
How do you differentiate which mms are involved in a knee tendinopathy?
You will need to use contraction of muscles at the hip and knee to differentiate between what muscles may be involved. The same exam step findings exist at the knee as previously discussed in the upper extremity. MSTT= best exam step
Central Spine Stenosis Patient complaints?
Stenosis of the central spine is caused by the same things that cause lateral foraminal stenosis - DDD and DJD. The central canal narrows and pressure is placed on the spinal cord. If it narrows so much that the cauda equina is compressed, the patient will likely complain of saddle paresthesia and loss of bowel/bladder control. The patient will also likely complain of burning paresthesia in the bilateral calves with short bouts of walking (5-10 minutes) due to pressue on the cauda equina. This is called neurogenic claudication.
When the foot initially contacts the ground (heel strike) the hindfoot is in.....
Supination This occurs in the very short transition before the ground reaction forces have an impact on the motion of the hindfoot. This means the midfoot is also moving into supination.
Exercises LB pain VASCULAR
Supine moving legs to the L and R rotating the spine with knees and hips flexed. Dec pain and inc BF. Active single knee to chest (don't pull with arms) Bringing both knees to chest is a progression Active SLR - mobilization to sciatic nerve or stretching tight HS
Articulation between the forefoot and midfoot why is it included as the forefoot?
TMT joint The reason it is included as the forefoot is due to the fact we more commonly reference movement of the distal segment on the proximal segment. Therefore, we are referencing movement of the metatarsal on the tarsals.
Most common and strongest graft
Taking middle 1/3 of the patellar tendon bc they are going to chip away part of the inferior pole and the tibial tubercle they can also take portion of gracilis and semitendinosis as a hamstring graft. Preference depends on physician and where they feel most comfortable harvesting.
Functional Index for lumbar spine
The Oswestry is a functional index for the lumbar spine. It is used as an objective measure to monitor and assess the patient's ability to perform certain functional activities. The patient fills this out during the initial eval and again at re-eval and discharge. See the file in the file library.
What is the annulus made of? What is its function?
The annulus is 6-10 concentric rings that have an alternating oblique orientation (see the image below). The outer annulus is usually injured first rather than the interior annulus which is suggested in many medical artist drawings. The injury to the disc starts on the outer aspect and works its way inwards towards the nucleus. The outer annulus has a neurovascular supply and thus can heal.
The bicycle test
The bicycle test is performed with the patient riding a stationary bike. The patient is instructed to ride in an upright posture until their symptoms come on. The time when symptoms begin is noted. The patient is then asked to repeat the test with a forward bent posture to open the intervertebral foramen and central canal. The time to symptom onset is again noted. If the symptoms took longer to present with the patient forward bent then it is neurogenic claudication; if the symptoms presented the same amount of time then the cause is vascular claudication.
In what position is the calcaneofibular ligament injured? MOI?
The calcaneofibular ligament (CFL) is also injured with inversion, but not with the plantarflexion. When considering a progression of injury and forces, when a patient sustains a plantarflexion and inversion ankle sprain the toes are on the ground, but the heel is not. This results in the foot/ankle "rolling" outward causing damaging to the ATFL primarily. The forces applied to the foot eventually result in the lateral aspect of the entire foot coming back into contact with the ground. Once this occurs the primary force is inversion, which now leaves the CFL susceptible for injury. At this point, the ATFL has already been injured.
When examining for growth plate conditions, what should we consider?
The growth plate part of the contractile unit (mm, tendon, attachment site to bone, and growth plate) The growth plate represents the 'weak link' in the contractile unit for the younger population.
How does hyper and hypomobiltiy cause anterior knee pain?
The impairments discussed above that cause hyper and hypomobility of the patellofemoral joint cause anterior knee pain because of increased compression of the lateral aspect of the patellofemoral joint. Muscle Imbalance as a cause of PFS Muscle tightness and muscle weakness often occur together with one muscle group getting tight and the antagonist getting weak. Your movement Science class will discuss more about the specifics of this.
Most commonly sprained ligaments in the body
The lateral ligaments of the ankle are the most commonly sprained ligaments in the entire body. The lateral ligaments consist of: Anterior Talo-fibular ligament (ATFL) Calcaneofibular ligament (CFL) Posterior Talo-fibular ligament (PTFL)
Coxa Valga
This is when the shaft of the femur is angled laterally (valgus). The angle between the neck of the femur and the shaft of the femur is greater than approximately 125 degrees. Keep these structural deformities in mind as we work our way down the kinetic chain in the upcoming units. What is happening here at the hip will affect the knee as well as the foot and ankle. The opposite is also true, what happens in the foot and ankle will affect the hip.
Posterior Fracture-Dislocation MOI
The most common mechanism of injury is a dashboard injury where the dashboard of a car hits the femur while the patient is seated with the lower extremity flexed, adducted and internally rotated (a little flexed too). This type of injury is a medical emergency because of the blood vessel damage resulting in decreased blood supply to the femoral head. The dislocation must be reduced within eight hours in order to decrease the risk of complications. If there is only a dislocation and no fracture then treatment is simply reducing the dislocation. However, if there is a fracture and a dislocation then an ORIF is performed. Fracture of acetabulum. intrascapular fx
How does the nucleus recieve its nutrition?
The nucleus is hydrophilic and receives its nutrition through imbibition. The disc will imbibe water when compression is relieved such as when lying down and the fluid is gradually expressed/dispersed through the day when compressed. The nucleus will "move" with different actions of the lumbar spine. This is actually more of a deformation of the nucleus in a certain direction.
Impairments with central spine stenosis
The patient may have a lordotic posture. However, many patients have a flat/straight lumbar spine or stand forward bent, as this compensation will decompress the spinal cord/nerves and decrease their symptoms. There will be lower extremity weakness and lumbar spine muscle weakness. There is also decreased functional abilities and decreased endurance.
What type of patient education can you provide the patient for their pain sleeping/laying on the involved side?
The patient should lay on the opposite side. However, since many patients are used to sleeping facing a particular direction within their room, you can tell them to make the bed with the head and foot of the bed reversed. This way when they lay on the opposite hip they will still be facing the same side of the room.
Ligamentous laxity/postural back pain: Pt symptoms? How does this occur?
The patient who has this dysfunction complains of an aching pain with prolonged sitting or standing due to poor postural habits. The patient will change positions frequently for relief of symptoms; they can't sit still. The patient will also "crack" their back frequently for temporary relief of symptoms. This relief is temporary because the "crack" is the synovial fluid changing from a liquid to a gas and then back to liquid. Since gas takes up more space than liquid the capsule will expand. As the capsule expands the GTO's are fired which are inhibitory to the muscles surrounding the joint. The muscles will then relax and decrease the patient's pain. However the patient is now more susceptible to further injury because the muscles are relaxed.
Coxa Vara
This is when the shaft of the femur is angled medially (varus). The angle between the neck of the femur and the shaft of the femur is less than approximately 125 degrees.
Fryette's Laws
The rules that govern spinal motion (arthrokinematics) I: SB/rot opposite when spine in neutral II: SB/rot same side when the spine in extension or flexion originally III: Spinal motion in one plane will limit motion in other planes.
What is the spinal motion segment? What does it consist of? What are its 3 main functions?
The spinal motion segment is the basic functional unit of the spine. It is made up of the two adjacent halves of the vertebrae, the interposed disc, facet joints and all the supporting ligaments, muscles, blood vessels and neural structures. When naming the spinal motion segment we refer to it by the two adjacent halves, i.e. L3/L4 segment. It has three main functions: weight bearing, protection of the spinal cord and to allow for motion.
MCL
The superficial MCL has demonstrated provisions to restrain valgus loads at all degrees of knee flexion. It also provides restraint to anterior tibial translation when the anterior cruciate ligament is injured. The superficial MCL acts as a primary restraint to external rotation of the tibia. The static restraints of the medial knee are the superficial MCL and the joint capsule, including the deep MCL and the Posterior Cruciate Ligament.
What are the transverse plane motions? Why were they not mentioned in the previous chart?
The transverse plane motions of External rotation and Internal rotation were not directly referenced above. This is due to the fact the amount of motion (in degrees of movement) for rotation is the least amount of movement as compared to what occurs in the Sagittal and Frontal planes. Due to this, some authors consider the amount of rotation to be "clinically insignificant". This does not mean external and internal rotation do not occur and we as physical therapists should not consider it clinically. We must know ER and IR occur individually at each section of the foot and at each articulation.
The treadmill test
The treadmill test is similar except that the patient is walking on a treadmill rather than riding a bike. The patient will walk on a level incline until the time of symptom onset is noted. The patient then walks on an incline to cause a forward bending posture. Again the time to symptom onset is noted. Similar to the bike test, if the symptoms took longer to present with the forward bent position then it is neurogenic claudication. If the symptoms took the same amount of time then it is vascular claudication.
Femoral Neck Fracture
These fractures are the most problematic of all fractures everywhere in the body. 95% of fractures are displaced. They are intracapsular so there is no obvious swelling - although there is bleeding within the joint capsule. Most often femoral neck fractures are displaced. The patient population usually affected with these fractures is again elderly females because of the osteoporosis. Treatment for a femoral neck fracture is varied. If the bone is not too osteoporotic an ORIF may be attempted. However, if the bone is very osteoporotic then a hemiarthroplasty will be performed. Rehab will then progress after the arthroplasty.
MOI Anterior Compartment Syndrome
This compartment syndrome is commonly due to direct trauma to the area. For example, being kicked in the anterior tibia during sports or hitting the anterior tibia against something (i.e. motor vehicle accident). It can also be exercise induced when the muscles responsible for dorsiflexion become weak and/or the posterior musculature becomes tight. This muscle imbalance causes the anterior tibial musculature to work too hard causing swelling and possible inflammation. If this swelling continues to build up within the small amount of space availability in the compartment, it will place direct pressure nerves, arteries and veins. Intervention for anterior compartment syndrome is to first identify the cause.
Posterior Tibial (Exertional) Compartment Syndrome MOI?
This compartment syndrome relates to the muscles in the posterior compartment being overused. They are commonly weak or quickly fatigued. When this occurs the activities of running/walking may create an exertional compartment syndrome. This leads to onset of swelling and possible inflammation in the deep posterior compartment causing pressure on the nerve, arteries and veins. Recall: A weak muscle can be due to direct tightness, or simply be weak. This is true for all muscles and all compartment syndromes. In order to treat this compartment syndrome, you must first decrease the swelling and then identify the aggravating activity. Once you identified you will need to address the strength deficits and potential of tight muscles being present. You must also identify if there is a mobility impairment of the midfoot or hindfoot that may be leading to certain muscles becoming tight or weak.
ITB friction syndrome What is it? What must you look at as a contributing cause?
This condition occurs when there is increase pressure to the lateral aspect of the lateral epicondyle of the femur. There is increase tension in the TFL, which then translates into increase pressure. This condition is not reserved only for runners, although a large percentage of those with this are regular runners. You must look at kinetic chain, as this is often a contributing cause. Likewise you may need to look at running shoes used for patterns or even have the patient run to check out their running mechanics. This condition is often best treated by multi-nodal approach.
What types of patients is an achilles tendon injury most common in?
This happens most often in middle aged men and is common with running, sports or simply stepping wrong.
What injury most commonly causes a buldge/herniation?
This injury most often involves a combination of lifting and twisting. Think back to the pressure studies by Nachemson - lifting increased the pressure in the disc. When someone twists only 50% of the fibers of the annulus will resist the rotation based on the oblique orientation of the rings of the annulus.
What causes lumber sprain/strain/synovitis?
This injury results from an awkward movement, over stretch, fall or trauma such as a motor vehicle accident. There is pain initially with the injury although it typically worsens over the next few days. The pain is usually unilateral and stays in the lumbar spine; the pain may radiate to the buttocks or posterior thigh.
Posterior Fracture-Dislocation
This is a dislocation of the femoral head in the posterior direction. The fracture is of the acetabulum.
Lumbar compression fracture
This is a fracture of the vertebral body secondary to a compressive force. It typically occurs in the thoracic or lumbar spine in a person who falls on their buttock in the flexed position. In those predisposed (osteoporosis), it may take a relatively minor slip to cause a fracture. Usually results in a stable fracture. An unstable fracture will need bracing or surgical stabilization.
Anterior Fracture-Dislocation
This is a rare injury that occurs as a violent injury resulting from excess extension, abduction and external rotation. There can be a dislocation by itself or a fracture and a dislocation. The chances of avascular necrosis and sciatic nerve damage are less with an anterior dislocation. The main complication is post traumatic DJD.
What is the treatment strategy for a capsular pattern restriction?
This is another topic with which you should be very familiar by now You should understand how to apply the concepts of clinical management (i.e. tissue reactivity, subject reactivity, phases of healing, functional goals and categories of intervention) to a capsular pattern restriction
Retroversion
This is the exact opposite of anteversion. This patient will stand with the toes pointing out (again if no other compensations). They will have increased external rotation but will lack internal rotation.
spina bifida
This is the incomplete bony closure of one or more of the posterior neural arches. It typically occurs in the lumbosacral region which is usually the last part of the vertebral column to close. It is the most common congenital deformity of the spine. The most significant aspect of the abnormality is not the bony defect, but the neurological deficit that may be associated due to incomplete development of the spinal cord. Neurologic deficits may range from mild weakness, imbalance and sensory deficits to complete parapalegia and/or bowel and bladder incontinence. You will learn much more about this in the child development and neurological courses. There are three main types of Spina Bifida: Occulta, meningocele and myelocele
The amount of movement for the Medial and Lateral glides of the talus is referenced as a ratio of movement. What is this ratio and what does it mean?
This normal ratio of movement is 1:1 for Medial-to-Lateral talar glides. Meaning, there is an equal amount of movement that should normally be found for both the Medial talus glide and the Lateral talus glide. Meaning, if the Medial talus glide is moving a normal equivalent of 1 ratio, than the Lateral talus glide would also be moving a normal equivalent of 1 ratio. IF the ratio was identified as 1:0 this would indicate the Medial talus glide is normal, while the Lateral talus is glide is limited (hypomobile). IF the ratio was identified as 2:1 this would indicate the Medial talus glide is excessive (hypermobile), while the Lateral talus glide is normal.
The amount of movement for the Medial and Lateral arc glides of the calcaneus is what and why?
This normal ratio of movement is 2:1 for Medial arc glide-to-Lateral arc glide. • Meaning, there is normally more movement with a Medial calcaneal arc glide than there is with a Lateral calcaneal arc glide. This directly correlates with calcaneal inversion being approximately 2x greater than calcaneal eversion. Meaning, if the Medial calcaneal arc glide is moving a normal equivalent of 2 ratio, than the Lateral calcaneal arc glide would be moving a normal equivalent of 1 ratio.
What are potential complications following a fracture of the distal tibia and fibula?
Tight joint capsule Tight muscle Weak muscle Pitting edema Soft tissue contracture Vascular compromise Nerve pathology
Treatment for trochanteric fracture
Treatment for a fracture of the trochanteric region is typically ORIF as there is good union in this area and the fracture is outside of the joint capsule, meaning that the articular surfaces are not affected. The patient is usually WBAT within a few weeks. GOOD UNION. Rehab will progress from there with gait training, range of motion and strengthening according to what impairments are discovered during the evaluation.
Why do you think there are two different capsular patterns? (At the hip)
Two different authors/clinicians and the anatomy of the hip makes it difficult to isolate the capsule due to the bony structure and the muscular and ligamentous support of the joint.
Outcomes and interventions for femoral neck fracture
Tx: ORIF and hemiarthroplasty (poor blood supply in femoral neck) Outcomes: AVN, Nonunion, DJD. Overall outcomes are not too good with a femoral neck fracture. Approximately 50 % of the patients will have unsatisfactory results. There is a thin persiosteum with poor blood supply in that area which inhibits good healing. Also when there is bleeding in the joint, the blood vessels are compressed which further compromises blood flow needed for healing.
Most common type of malleolar fracture?
Uni-malleolar
Only malleolar fracture that is susceptible to stress fracture:
Uni-malleolar
There are three (3) types of malleoli fractures. They are:
Uni-malleolar fracture Bi-malleolar fracture Tri-malleolar fracture
How do we fix the laxity?
We trigger dynamic stabilizers which are mms. We would strengthen the multifidi The multifidi are like the rotator cuff of the spine in regards to the fact that it helps stabilize and coordinates the spine. So coordination and strength training both will be needed.
When a disc bulges, it is typically in which direction and why?
When a disc bulges, it typically will bulge in a posteriorlateral direction because the posterior longitudinal ligament is directly posterior preventing the disc from bulging in that direction. However, even though it will bulge posteriorlateral the bulge itself can be either medial or lateral to the nerve root.
Similarity between Cyriax and Kaltenborn
You can see that both have slight limitations of lateral (external) rotation, but that is where the similarities end.
How can you tell if the bulging is medial or lateral to the nerve root?
You can tell if it is medial or lateral to the nerve root based on which way the patient leans or says alleviates their symptoms. A disc bulge that is LATERAL to the nerve root will cause the patient to shift/lean AWAY from the side of pain. However a disc bulge that is MEDIAL to the nerve root will cause the patient to shift/lean TOWARDS the side of pain.
Phase I: Necrosis
Zero blood supply (blood vessel damage) Osteocytes and bone marrow die Radiographic exam is negative "Quiet Period"- unremarkable on plain film radiograph Child is symptomless
a joint gets its nutrition through-
a cyclical loading and unloading This is needed at the hip joint in order to provide adequate nutrition to the articular cartilage
The component motions that occur at the Meta-Tarso-Phalangeal (MTP) are.....
a plantar glide (posterior) for toe flexion and a dorsal glide (anterior) for toe extension. There is no clear ratio of movement referenced for the MTP joint. Determination of normal, hypermobile and/or hypomobile requires bilateral comparison.
Deep spine muscles of TL spine
abdominals and deep LB mms and Latissimus --> Forms corset around the spine to provide support
Plantar Fasciitis
an inflammation of the plantar fascia on the sole of the foot
Postural back pain
back pain that is the result of poor postural habits that place stress on the ligaments and muscles of the spine. A lumbar sprain/strain/synovitis is a mechanical injury to the muscles and/or ligaments of the spine.
A patient who has a disc dysfunction (bulge/herniation) has had a long history of what?
back pain with each episode getting worse.
MCL vs LCL management
basically the same for collateral ligs Dynamic muscular control: Cannot control the knee at the knee. Hip impairments and Doot/ankle impairments External Support Clinical management decision making- look at the demands the patient requires and what kind of stresses will occur based on activities they participate in. conservative management and progression through stages. Clinical signs and symptoms related to joint stability to rule in or rule out surgery
2nd most common type of malleolar fracture
bi-malleolar
When we reference the hindfoot (rearfoot) we are discussing which joint(s)?
both the talocrural and subtalar joints collectively. To state it another way, the talocrural and subtalar joints together make up the hindfoot (rearfoot).
Tendinopathies at the hip. Which tendons are commonly involved? Best exam steps?
can involve any muscle, however most commonly the proximal insertion of the hamstrings, the rectus femoris and the iliopsoas are involved. As previously discussed, tendinopathies can be reactive or degenerative. A reminder that the best examinations will be MSTT, MLT and palpation for tenderness. Remember that if the MSTT is painful then MMT is not performed as the results will be invalid due to pain and there is possibility of causing more damage to the muscle by asking for a maximal muscle contraction.
S/S of meniscal tear
clicking, popping, catching, or giving away within joint in a loaded or WB position.
Adductor or Groin Strain
common injury at the hip. The adductors typically involves are the adductor longus and magnus. A groin strain can take a long time to resolve and may result in long standing problems at the hip. Typically the adductors are injured when there is a strong eccentric contraction such as with soccer players kicking the ball.
ligamentum flavum
connects the laminae of adjacent vertebrae
interspinous ligament
connects the spinous processes of adjacent vertebrae
If pt goes from standing to supine, what will happen to pressure on disk
decrease by 80% to a 20%
What is the specific artery located within each compartment of the lower leg?
deep posterior- posterior tibial A&V and Peroneal A&V Lat- NONE Anterior- anterior tibial A
In order to know what nerve root is affected we will be testing what? What are they?
dermatomes and myotomes Dermatomes: L2 - anterior or lateral thigh L3 - medial knee L4 - medial anterior tibia L5 - medial malleolus or dorsal web space of Hallux S1 - lateral malleolus/foot Myotomes L1-L2 - hip flexors L3-L4 - quads L4 - tibialis anterior L5 - EHL S1 - FHL/peroneals S2 - hamstrings/gastroc Reflexes L3/L4 Patellar S1 Achilles
pes planus
flat foot
With stenosis, if the L4/L5 foramen is stenotic, which nerve root would be affected?
if the L4/L5 foramen is stenotic, then the L4 nerve root would be affected because it exits in that foramen. Remember that in the lumbar spine the nerve roots exit below the level for which they are named (i.e. below the vertebral body with the same name). So in order to affect the L5 nerve root, stenosis would have to be at the L5/S1 foramen.
The positional relationship between the disc and the nerve roots is important for what reason? How do they exit in the lumbar spine?
in order to know what disc is affecting what nerve root. Generally, discs lie below the corresponding nerve root. So that means that since the L4 nerve root exits below the L4 vertebral body the L4/L5 disc sits below where the L4 nerve root exits. Therefore, the L4/L5 disc would impinge on the L5 nerve root. The L5/S1 disc would impinge on the S1 nerve root. See the image below, a cross-section of the lumbar spine indicating where the nerve roots exit in relationship to the discs.
How much will forward bending decrease/inc disc pressure?
inc to 150% with weight to over 200 %
Sitting will inc/dec discal pressure?
increase to 140 percent
Why is it important to have full ROM at the MTP?
it is needed for a normal gait pattern
Chondromalacia
just what the two parts of the word indicate - softening of the cartilage. It too is often overused as a diagnosis. It can cause anterior knee pain and may be diagnosed as PFS rather than the medical diagnosis of chondromalacia.
Deltoid ligament complex is on the ____________ side of the ankle and consists of ___ ligaments
medial; 4
The incongruity of the articular surfaces comprising the knee joint demands the need for the integrity of what?
menisci and collateral and cruciate ligaments. Muscles and their tendons are also involved in stability of the knee. The muscles function primarily in motion and reinforcement of the ligaments. Excessive joint motion that exceeds the physiological joint range of motion occurs at the expense of ligamentous resistance.
What makes up the forefoot?
metatarsals and phalanges Metatarsal 1,2,3 articulate with cuneiforms while 4 and 5 articulate with cuboid
What does stenosis mean?
narrowing. Osteophytes, compression
Bones of the midfoot
navicular, cuboid, cuneiforms
What makes up the midfoot? Articulations?
navicular, cuboid, cuneiforms Navicular has primary articulation with talus cuboid has primary articulation with calcaneus
Best exam findings for growth plate conditions
pain with contraction of the quadriceps (could be AROM, MSTT, or MMT depending upon the severity of the condition), pain with lengthening of the quadriceps (A/PROM knee flexion, prone knee flexion, or Thomas Test MLT), and pain with palpation along the tibial tubercle or inferior pole of the patella.
Osteochondrosis
pathology that is not specific to the hip alone Epiphyses disorder. Children 3-10 years and more common in males than females and more common in LE. Idiopathic, genetic, trauma and possibly effusion. Is self limiting the term "Osteochondrosis" is more of an umbrella term that encompasses many other diagnostic names. An osteochondrosis involves the epiphyses of bone and any epiphyses could be affected.
Pt with excessive anteversion
patient who has excessive anteversion may walk with their toes pointing in (this is if there are no compensations elsewhere in the kinetic chain). When performing classical PROM, the patient will appear to have increased internal rotation and appear to lack external rotation. Think of it this way... upon observation the patient's femurs look more internally rotated and thus when examining the amount of internal rotation it is increased. They lack external rotation because of the twist in the femur.
The component motions that occur at the Tarso-Meta-Tarsal (TMT) joint
plantar glide (posterior) for forefoot pronation and a dorsal glide (anterior) for forefoot supination.
popliteus tendinopathy vs. Semimembranosus tendinopathy physical exam- management
popliteus is deeper than semimemb. Semimemb is a very wide and thin mm that inserts medially onto tibia. can contract hamstring to differentiate. Palpation isn't a good exam step for this. Management: Degenerative- loading reactive- remove load and progressively bring them back into activities
With forward bending the nucleus will deform ___________ and with backward bending it will deform _______________
posteriorly; anteriorly Because the part that is under less compression will imbibe more fluid
Pes planus is often referred to as a __________________ foot
pronated foot. NOTE: This is NOT the same as a foot moving into the motion of pronation. A pronated and a supinated foot are simply a visual appearance of the foot's structure. It does not indicate movement. While pronation and supination are tri-planar motions that absolutely indicate movement.
If the hindfoot is supinating, then the forefoot will be __________, and the midfoot will do what?
pronating; and the midfoot will follow the hindfoot into supination
As the patient transitions from heel strike through the loading response to midstance, the hindfoot will do what?
reach its maximal amount of pronation This means the midfoot is also moving into pronation
There will be moments in your career when a patient presents with no specific tissue injury, but instead has complaints related to what? What must we assess?
related to an impairment of excessive mobility or limited mobility of a joint. These impairments can influence the kinetic chain and predispose a patient to complaints in other areas of the body than the specific location of impairment. In these instances we must be able to examine the entire kinetic chain and intervene by either stabilizing/supporting (strengthening and/or bracing) the locations of excessive mobility, or mobilizing the locations of limited mobility.
Anterior cervical fusion
removing disc tissue pressing on a nerve in the neck, inserting a piece of bone between the vertebrae, and fusing this area with plates and screws. Skeletal System
What does a compartment syndrome result from? What else does it cause?
results when there is increased pressure within a closed location (compartment). This increased pressure within the compartment will eventually apply pressure directly on the neurovascular structures and muscles that are located within that specific compartment. Compartment syndromes can be either acute or chronic
PCL position
starts medially and dives laterally on the posterior side
Pes cavus is often referred to as a _____________ foot
supinated foot. NOTE: This is NOT the same as a foot moving into the motion of supination.
Interventions for a tendon tear in the Achilles tendon
surgery followed by immobilization to allow for complete healing of the tendon. The patient will then need rehab after the cast/walking boot is removed. Therapy will consist of addressing the impairments that are present such as decreased range of motion and strength. Gait training will also be necessary.
Lumbar micro discectomy
surgery is performed to remove the portion of a herniated disc that is irritating or inflaming the nerve root.
What makes up the hindfoot? Articulations?
talus and calcaneus Joints: talocrural and subtalar subtalar: Below talus, articulation between talus and calcaneus
Growth plate conditions: Given the frequency of this condition following a period of rapid growth, the MLT are often positive for tightness, which can increase what?
tensile force on the tibial tubercle growth plate or inferior pole of the patella.
Following midstance the patient will transition through.....
terminal stance to heel off and toe off (aka push-off). At push off the hindfoot will move back into supination.
How does the Achille's tendon rupture?
the Achilles tendon most often ruptures when there is sudden passive dorsiflexion with resisted plantarflexion. Stated another way, the patient is performing a concentric contraction when there is an eccentric force applied to the Achilles tendon. This results in a rupture.
The spinal nerve root exits the intervetebral foramen and divides into what?
the anterior and posterior primary rami. The anterior primary ramus proceeds to the lumbar and sacral plexus giving sensory and motor innervation to the lower extremities. The posterior ramus provides innervation to the posterior structures such as the facet joints, ligaments and muscles. The structures on the posterior aspect are innervated by 2-3 different levels.
There are two tests that help to differentiate neurogenic from vascular claudication:
the bicycle test and the treadmill test.
Minimally invasive THR
uses the same prosthesis you saw in the video, but the incision is much, much smaller only a few inches long compared to maybe 12 inches with a regular THR. The literature is mixed on the outcomes of a mini THR compared to a regular THR. Some articles indicate that there is less blood loss, less damage to surrounding tissues and fewer complications with a mini THR, while other articles indicate no difference. Regardless it is something you will see out there in the clinic. Keep your eye on the literature to see which type of surgery prevails - or is it surgeon preference?
Vascular claudication causes similar symptoms but the problem is what?
vascular not neural
Anything that decreases the range of motion will do what to the hip?
will increase compressive loads on the hip (tight capsule or tight muscles)
Where is the change in sensation in Morton's Neuroma?
with a neuroma there is a change in sensation in the webspace of the toes. There will also be tenderness to palpation between the metatarsal heads over the neuroma