Lower Ortho Exam 1

ischemia

Lack of blood supply

Lateral Sprains •Mechanism:

PF-Inversion

the great adapter

ankle

genu valgus

knock knees

Gerdy's tubercle

where IT band inserts

Syndesmotic TightRope

•Control swelling •Walking Day 4 •Running Day 8 •3-4 weeks return to play

femoral torsion

Rotation of Femur (upper leg)

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee things they recommend not doing

TENS is not recommended

Halux Valgus

excessive valgus stress at the great toe

Forefoot varus deformity / Corrected with foot orthosis that incorporates a _________ wedge

medial forefoot

Forefoot varus, continued... •The therapist can eliminate the need for compensation by supporting the deformity with an orthosis that incorporates a __________

medial forefoot wedge. Forefoot varus deformity corrected with foot orthosis

•Abnormal supination is also known as

pes cavus, high-arched foot, and supinated foot.

•Abnormal pronation of the foot is also called

pes planus, flatfoot, low-arched foot, valgus foot, pronated foot, and calcaneovalgus foot. This problem may be the result of bony abnormalities of the ankle, STJ, or the MTJ; soft tissue abnormalities such as a tight Achilles tendon, which will cause talar plantarflexion; from trauma; from ligamentous laxity; or as compensation for abnormalities extrinsic to the foot

Achilles Tendon Tear and Repair

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Because of the additional compensatory pronation, the foot may still be relatively mobile during push-off.

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Forefoot varus deformity compensated by STJ pronation

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Hammer-Claw Splints

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Neurologic Referral/radiation posterior

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Uncompensated forefoot varus in stance what does it look like?

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achilles tendinopathy exercises

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ankle exercises

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anterior ankle palpation

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evaluate shoe wear patterns

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foot palpation 1

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foot palpation 2

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surgical fixture of ankle fracture

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systems review TABLE 20-5 Medical Screening Questionnaire for the Knee, Leg, Ankle, and Foot Region

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2021 Lateral Ankle Ligament Sprains: Clinical Practice Guidelines

photo -acute lateral ankle sprain vs chronic ankle instability

more achilles tendon treatment

photo •Surgical (do it sooner rather than later) -Ideally done within 1 week of rupture -Detail outline of rehab in Maxey & Magnusson

During the gait cycle, the tibiofemoral joint reaction force has two peaks: Tibiofemoral joint reaction forces ___________to five to six times body weight for running and stair climbing, and eight times body weight with downhill walking.

the first immediately following initial contact (two to three times body weight) and the second during preswing (three to four times body weight). increase

•Subtalar Neutral:

the position where the STJ is neither pronated nor supinated. It is the standard position in which therapists examine the foot. 42 degrees up and 16 degrees in

...and, because pronation is associated with internal tibial rotation,

the q-angle changes during the gait cycle, with possible effects on patellofemoral mechanics

•The traditional 5 P's of acute ischemia in a limb are not clinically reliable and manifest only in the late stages of compartment syndrome

-pain, -paresthesia, -pallor, -pulselessness, -Paralysis

tibial torsion

twisting of the tibia

Gastroc Strain (which head normally?) signs and symptoms

•Usually at medial head •Signs & Symptoms -Immediate pain -Loss of function -Localized swelling -Bruising -Potential palpable defect -Pain with RROM &/or stretch

Neurologic Referral/radiation anterior

Dermatomes - need to know dermatomes, myotomes, DTRS

"Short Foot" exercise (Intrinsic strengthening)

Draw arch of foot up and keep metatarsal on ground Posture Tri-pod Ex

Common Recommendations for supinators Foot mechanics: Foot shape: Shock absorption in stride: Recommended shoe last: Recommended type of shoe:

Foot mechanics: Excessive outward roll Foot shape: Medium to high arch Shock absorption in stride: Poor Recommended shoe last: Curved Recommended type of shoe: Cushioning

Common Recommendations for neutral feet Foot mechanics: Foot shape: Shock absorption in stride: Recommended shoe last: Recommended type of shoe:

Foot mechanics: Normal - the lateral of midline of heel through push off over 1-2 MTP. Foot shape: Neutral Shock absorption in stride: Good Recommended shoe last: Semi-curved Recommended type of shoe: Stability provided they don't over pronate

Physical Performance Measures from Principles of Human Movement (for ankle) -name 2

Forward Step-Down Test •Hip adduction •Dynamic Q-angle - knee valgus angle Drop Jump Test Looking for excessive pronation, if feet land same time

Trimalleolar Fracture

Fracture of the posterior portion of the tibia and the medial and lateral malleoli Fractured medial and lateral malleolus and posterior tibia

•Osteochondritis Dissecans

Fragment of cartilage and underlying bone is detached from articular surface. -Loose body in joint •Joint mouse signs and symptoms -Mild/mod effusion -Episodes of locking Joint mouse- loose body, cartilage and bone free floating fragment Don't cram and force it if it is catching and locking

Closed Chain Biomechanics in the Lower Extremity: Move one Segment, and the Others are Affected Anterior pelvic tilt; Anterior nutation of innominte Internal rotation of the hip Internal femoral rotation Slight knee flexion Internal tibial rotation pronation this is a functionally ______________ leg

Functionally Shorter leg

West Point Ankle Sprain Grading System Locations of tenderness: ATFL Swelling and ecchymosis: Slight local Weight-Bearing ability: Full or partial Ligament Damage: Stretched Instability: None

Grade I ATFL=anterior talofibular lig.

West Point Ankle Sprain Grading System Locations of tenderness: ATFL, CFL Swelling and ecchymosis: Moderate local Weight-Bearing ability: Difficult without crutches Ligament Damage: Partial tear Instability: None or slight

Grade II ATFL=anterior talofibular lig. CFL=calcaneofibular lig.

West Point Ankle Sprain Grading System Locations of tenderness: ATFL, CFL PTFL Swelling and ecchymosis: Significant diffuse Weight-Bearing ability: Impossible without pain Ligament Damage: Complete tear Instability: Definite

Grade III ATFL=anterior talofibular lig. CFL=calcaneofibular lig. PTFL=posterior talofibular lig.

Blood and Nerves of knee Sensory innervation primarily _______

L3-5

Historical Clues to Knee Injury Diagnoses Medial blow to the knee

LCL tear

Knee Stability - Capsule and Reinforcing ligaments Region of the Capsule: Lateral Connective Tissue Reinforcement: Muscular-Tendinous Reinforcement:

Lat. collateral lig. Lat. patellar retinacular fibers Iliotibial band Biceps femoris Tendon of the popliteus Lat. head of the gastrocnemius

Lateral Longitudinal Arch

Lateral arch supported by bony architecture

•Purpose of Menisci:

Load transmission, shock absorption, joint lubrication, joint stability, proprioception, and helps guide movements.

- usually an avulsion fracture

Lower pole fracture of patella

how to read Brannock Device

MAKE SURE TO READ NUMBERS THAT ARE RIGHT SIDE UP TO THE FITTER NOT THE NUMBERS THAT ARE UPSIDE DOWN 1ST MPJ

Historical Clues to Knee Injury Diagnoses Lateral blow to the knee

MCL tear

Measuring Tibial Varus The normal tibia exhibits a ________° varus angle

Measure: Align one arm of the goniometer in line with the middle of the anterior tibia and the other perpendicular to the floor. The normal tibia exhibits a 4-6° varus angle in the frontal plane, relative to the ground (slight bow leg).

Knee Stability - Capsule and Reinforcing ligaments Region of the Capsule: Medial Connective Tissue Reinforcement: Muscular-Tendinous Reinforcement:

Medial patellar retinacular fibers (aka medial patellofemoral lig.) Medial collateral lig. Thickened fibers posterior-medially (aka posterior-medial capsule or the posterior oblique lig.) Expansions from the tendon of the semimembranosus Tendons of the sartorius, gracilis, and semitendinosus

Fibula Fractures

Occur following direct blow. These fractures heal well and rapidly. Upper fibular fractures (at the neck and upper shaft) may occur with severe rotary ankle injuries, where the tibial malleolus is fractured and the fibula fractures as part of this rotary fracture-dislocation of the ankle. The treatment based on management of the ankle fracture dislocation - internal fixation is required. Can still walk many times with fibula fracture (10% weight bearing) Fibular nerve goes right behind it

knee overview

One of the most commonly injured joints 3 distinct articulating surfaces 2 joints within one joint capsule •Some include tibiofibular joint as part of the knee joint BUT it is not part of the knee joint capsule. Femur is 25% of your overall height The surface area of the medial tibial plateau is approximately 50% greater than that of the lateral, and its articular surface is three times thicker. Patella is a sesamoid bone and embedded in tendon of quadriceps muscle. •It protects your femur and from trauma & improves the moment arm of the quadriceps Largest synovial capsule in your body, anteriorly 2 finger widths above patella, posteriorly origins of gastrocnemius, and then down to the edges of tibial plateau •Cruciate ligs are intra-articular but extra-capsular

open chain -- is talus and forefoot stable or mobile? closed chain -- is talus and forefoot stable or mobile?

Open Chain -- (Talus is stable) forefoot is mobile Closed Chain -- (Talus is mobile) forefoot is stable

Treatment for Ankle Sprains Phase I

PRICEDEM, Temporary Stabilization Limit weight bearing AROM exercises 30 reps, QID (pain free) Core strengthening QID - 4 times a day BID - 2 times a day Not time based but activity based- once you are able to do it you can go on to next phase

Subtalar Neutral

Palpate the talus, inverting and everting foot so talus produces even pressure under index finger and thumb "Pt supine with the feet hanging off of table. Therapist grasps the patient's foot over the fourth and fifth metatarsal heads, using the thumb and index finger of one hand. Therapist palpates both sides of the head of the talus on the dorsum of the foot with the thumb and index finger of the other hand. Therapist then gently, passively dorsiflexes the foot to point of resistance. While the therapist maintains the dorsiflexion, he/she passively moves foot to supination (talar head bulges laterally) and pronation (talar head bulges medially). If the foot is positioned so that the talar head does not appear to bulge to either side, the subtalar joint will be in its neutral non-weight-bearing position. This supine test position is best for determining the relation of the forefoot to the hindfoot."

knee overview info

Patella with femur Femur with tibia on both sides Medial tibial plateau is larger than lateral - screw home mechanism Patella is sesamoid bones Capsule goes above patella 3 distinct articulating surfaces 2 joints within one joint capsule

Knee Stability - Capsule and Reinforcing ligaments Region of the Capsule: Anterior Connective Tissue Reinforcement: Muscular-Tendinous Reinforcement:

Patellar tendon Patellar retinacular fibers Quadriceps

when early stance pronation is excessive ...

Push-off occurs on a relatively mobile foot If excessive, supination never gets reached so then you have a mobile foot

Forefoot varus deformity compensated by _______

STJ pronation retards midstance/terminal stance supination

hamstring info

Scarring and fatty deposits can occur with significant strain - then tissue isn't quite as good as it was before

DVT

Score ≤ 0 probability of DVT = 3% Score = 1 or 2 probability of DVT = 17% Score = 3 probability of DVT = 75%

SFMA Need to be good at this and know it by heart

Selective Functional Movement Assessment 1. forward bending 2. backward bending 3. rotation 4. single leg stance 5. shoulder mobility 6. squatting 7. C-spine patterns

Effects of Aging on Muscle Senescence sarcopenia ________% loss Decrease in muscle __________ Type _____ affected greater than Type ___ Age-related muscle fiber loss can be reversed in some with proper training

Senescence sarcopenia 20-25% loss (Senescence- getting older) Decrease in muscle volume Type IIa affected greater than Type I Age-related muscle fiber loss can be reversed in some with proper training As you get older you lose muscle mass- type 2 loses quicker (Fast twitch) most effected by aging

Patellar Fractures

Stellate fracture - multi-fragmented fracture usually the result of falling onto a flexed knee. (Stellate - they will fixate it Screws and cables) Transverse fracture - patella receives a relatively minor blow while the quadriceps is strongly contracting a separation of the superior and inferior fragments. Lower pole fracture - usually an avulsion fracture Vertical fracture - usually occurs from an indirect blow (kick) to patella

Causes of LE Pain and/or Dysfunction name two major forms

Systemic •Cancer •Vascular •Urogenital (-Kidneys, UIT, STDs, endometriosis, BPH) •Infectious or Inflammatory conditions •Metabolic diseases •Diabetes •Other Neuromusculoskeletal •Fracture •OA •Inflammation - Bursitis, synovitis, tendonitis •Hernia •Labral or cartilage tear •Hip dysplasia •Slipped capital femoral epiphysis •Disc disease •Muscle strain and/or trigger points •Trauma •Nerve compression •Other

Talar tilt test

Talar tilt test to assess subtalar joint laxity

Q-angle

The angle between the line of quadriceps force and the patellar tendon.

Review of Systems

Therapists should review the patient's general health and investigate the presence of signs or symptoms in each of the major body systems. •The systems that therapists should review as a routine part of any patient examination are: -Allergic and immunological system -Cardiovascular/pulmonary: assessment of heart rate, respiratory rate, blood pressure, and edema. -Endocrine -Gastrointestinal -Head, eyes, ears, nose, throat -Hemapoietic system: assess bleeding tendencies, easy bruisability, lymph node enlargement -Integumentary system: assessment of skin integrity, skin color, and presence of scar formation. -Musculoskeletal system: assessment of gross symmetry, gross range of motion, gross strength, height, and weight. -Neuromuscular system: a general assessment of gross coordination of movement (eg, balance, locomotion, transfers, and transitions). -Psychological: communication ability, affect, cognition, language, and learning style, consciousness, orientation, expected emotional/behavioral responses; and learning preferences. -Urogenital •clients sometimes have difficulty talking about certain areas or their memories may not provide the full details. Make sure to interview but also look at the forms they fill out

Example of Lateral Ligament Repair Rehabilitation Protocol

Week: 1-4 Orthosis/Progression to next phase: Short-leg cast Cleared by Physician to begin rehab Interventions: Progressing from NWB to TTWB to FWB Week: 4-6 Orthosis/Progression to next phase: Ankle support orthosis Cleared by Physician to begin rehab (some in cast for 6 weeks) No increase in pain, no loss of ROM, improved tolerance to WB Interventions: Increase ROM (avoid inversion), proprioception, normalize gait, cardiorespiratory fitness, patient education Week: 6-8 Orthosis/Progression to next phase: PRN orthosis No increase in pain, no loss of ROM, improved progress in therapy Interventions: Begin light strengthening and ROM all directions, balance board, pool running and light jumping, treadmill, stationary bike Week: 8-10 Orthosis/Progression to next phase: Good progression, Normal ROM, normal strength Interventions: Pain-free weight resistance, lunges with caution, progress to activity specific drills Week: 11-18 Orthosis/Progression to next phase: Ankle support orthosis Initially when returning to sport or PRN with new activities Interventions: Plyometrics, trampoline hopping, figure 8, slide board, lateral shuffles Don't memorize this be able to use them Early on avoid inversion and plantarflexion Spelling the alphabet with ankle

Talocrural what is the shape?

a carpenter's mortise joint Tenon is the male end. Mortise is the female end of the joint.

•Crepitus

a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone.

Hallux Valgus: Exercises & Orthosis

abduction of big toe

Hallux Valgus: Exercises to strengthen the ____________

abductor hallucis

Intrinsic muscles of the foot are important for the arches

abductor hallucis flexor digitorum brevis abductor digiti minimi lumbricals quadratus plantae

bunion causes

abnormal enlargement of the joint at the base of the big toe •Causes -Poor fitting shoes •Too tight •Toe box too short -Activities •Ballet -Excessive pronation Poor fitting shoes can do it too Causes adduction of all your toes and can give you a bunion

Lower Extremity Bone Development: Hip •Normal compressive forces help form the ____ and _______ to create stable hip joint

acetabulum and femoral head/neck

Quick Review How is the height of medial longitudinal arch elevated?

action of gastroc, tibialis posterior, and peroneus longus rearfoot supination midfoot supination forefoot pronation tensioned spring ligament tensioned plantar aponeurosis metatarsophalangeal extension

Ottawa Ankle Rules Reported to have a 97.6% Sensitivity

ankle or foot x ray is required if any one of the following features are present: 1. bone tenderness along the distal 6 cm, posterior edge of the tibia or tip of medial mallelous 2. bone tenderness along the distal 6 cm, posterior edge of the fibula or tip of lateral mallelous 3. bone tenderness at the base of the fifth metatarsal 4. bone tenderness at the navicular bone 5. an inability to bear weight for 4 steps, both immediately following injury and at time of examination Palpation Helps determine if radiograph is needed or not If all of these are absent then you can say that they don't need an x ray

4 ligaments that make the deltoid ligament where is the deltoid ligament?

anterior tibiotalar ligament tibionavicular ligament tibiocalcaneal ligament posterior tibiotalar ligament medial side of ankle

•Menisci move with __________ and ____________ with knee extension and flexion respectively

anteriorly & posteriorly •Anteriorly with knee extension due in part of contracting quads •Posteriorly with knee flexion in part due to contraction of semimembranosus and popliteus.

Frontal plane projection angle (FPPA) & Lateral step down

avoid valgus

genu recurvatum

bending backward (knee hyperextension)

hemarthrosis

blood within a joint

Genu varus

bow legged

Contusions related factors:

bruises Mild, moderate, severe Intramuscular vs. intermuscular related factors: Direct blow, associated with increasing muscle trauma and tearing of fiber proportionate to severity

when you rupture a muscle/tendon you often see a _________

bulge

Heel Height

can help equinus or cause it Need an elevated heel with equinus heels can cause you to lose dorsiflexion if always in heels

Strains Third degree (severe):

complete tear; may require aspiration; may require surgery

coxa varus

decreased angle of inclination less than 125 degrees

medial ligaments of the ankle

deltoid ligament spring ligament Deltoid - very strong Spring ligament (plantar calcaneonavicular lig) deltoid ligament 1 and 2: Ant/post tibiotalar 3: Tibiocalcaneal 4. tibionavicular

fibula fractures Styloid process -

direct blow or avulsion - Hamstring (biceps femoris tendon) - lateral (fibular) collateral ligament

Muscle actions extensor digitorum longus fibularis tertius

dorsiflexion eversion

Muscle Actions extensor hallucis longus tibialis anterior

dorsiflexion inversion

Neuromotor control/balance/proprioception balance error scoring system (BESS) errors:

errors: hands lifted off illiac crest opening eyes step, stumble, or fall moving hip into more than 30 degrees of flexion or abduction lifting forefoot or heel remaining out of testing position for more than 5 seconds

healing rates for specific soft tissues muscles exercise induced grade 1 grade 2 grade 3

exercise induced: 24-48 hrs grade 1: 2-21 days grade 2: 20-90 days grade 3: 50-180 days

Antetorsion Children 4-7 y/o - ________degrees Femoral torsion is complete between_____ and ________ years of age Adults ________ degrees

femoral neck rotated forward Children 4-7 y/o - 23-26 degrees Femoral torsion is complete between 8 and 16 years of age Adults 8-15 degrees

•when menisci Rotation they follow the _________

femur

•Menisci follow _________ with rotation (moves with ______ for rotation, moves with _______ for flex and extension)

femur (moves with femur for rotation, moves with tibia for flex and extension) •ER of tibia = medial meniscus displaces posteriorly and later displaces anteriorly

the ankle and foot anatomy

fibula tibia talus calcaneous talocalcaneal joint navicular cuboid transverse tarsal joint

-Although I only provide 1/10 of PF power, I help stabilize the calcaneocuboid joint, plantar flex the 1st ray, support the medial longitudinal arch. Who am I?

fibularis longus

Running involves both a stance phase (30%) and a swing phase (70%), with increased speed showing an increase in the swing to the stance ratio. Running also involves a _______ phase, during which there is no foot contact with the ground and potential energy is greatest, and which comprises 30% of the running cycle

float

why is it Important for fibula and tibia to separate?

for talus to move

Closed Chain Biomechanics in the Lower Extremity: Move one Segment, and the Others are Affected Posterior pelvic tilt; Posterior nutation of innominte external rotation of the hip external femoral rotation knee extension external tibial rotation supination this is a functionally ______________ leg

functionally longer leg

healing rates for specific soft tissues ligaments grade 1 grade 2 grade 3 (extracapsular) grade 3 (intracapsular)

grade 1: 10 days - 2 weeks grade 2: 3 weeks - 5 months grade 3 (extracapsular): 7 weeks- 1 year grade 3 (intracapsular): 4-24 months

subchondral sclerosis

hardening of the bone just below the cartilage surface

healing rates for specific soft tissues Ligament (strains) Grade I _________ wks Grade II _________ months Grade III Extracapsular_______ year Intracapsular ______ months

healing rates for specific soft tissues Ligament Grade I 10 days - 2 wks Grade II 3 wks - 5 months Grade III Extracapsular 7 wks - 1 year Intracapsular 4 - 26 months

Chronic plantar fasciitis can lead to formation of _____________

heel spurs. Plantar Fasciitis is the most common injury seen among long distance runners. It is very painful and can be chronic, extending over several years. The heel spur does not cause the plantar fasciitis, the fasciitis causes the heel spur. Taping for plantar fasciitis- if it helped then you know should use taping, foot orthoses, night splints, stretching

Baker's cyst

herniation of posterior joint capsule through defect in the semimembranosus fascia associated with medial meniscus tear •Symptoms •A feeling of fullness or a lump behind the knee •Knee pain •Stiffness or tightness at the back of the knee •Swelling in your knee and lower leg Baker's cyst -posterior rupture of synovial membrane Don't dry needle it- popping it doesn't help Can be surgically removed

hamstring strain -location important - rule of thumb -> the ____________ the strain, the longer the rehab

higher

Comparison of open and closed chain Subtalar Joint Movement what does the talus do in closed chain?

in closed chain, the talus is mobile and it does the opposite movement from the rest of the foot

coxa valga

increased angle of inclination greater than 125 degrees

Tibial Tubercle Fractures Conservative treatment is recommended for fractures with minimal or no displacement. Displaced fractures best managed by ____________

internal fixation.

•Cruciate ligs are

intra-articular but extra-capsular

The ___________________ is the longest of all the ligaments of the tarsus. It is attached behind to the plantar surface of the calcaneus in front of the tuberosity, and in front to the tuberosity on the plantar surface of the cuboid bone, the more superficial fibers being continued forward to the bases of the second, third, and fourth metatarsal bones. This ligament converts the groove on the plantar surface of the cuboid into a canal for the tendon of the fibularis longus. Deep to this ligament is the short plantar ligament. The long plantar ligament separates the two heads of the quadratus plantae muscle.

long plantar ligament A little more support on lateral than medial

The _________________ is a long ligament on the underside of the foot that connects the calcaneus with the cuboid bone.

long plantar ligament (long calcaneocuboid ligament; superficial long plantar ligament)

The greater the degree of coxa valga, the __________ the resulting limb length.

longer

Ischemia-reperfusion

loss and restoration of blood flow •Ischemia results in depletion of intracellular energy stores, which, after reperfusion will generate toxic oxygen radicals. •Results in cascade of activation of leukocytes/platelets, inflammatory mediators, calcium influx, disruption of cell membrane, and fluid transudation •All culminate in excess fluid formation

is the lateral of medial meniscus more likely to be injured?

medial (3x more likely to be injured)

chopart joint

midtarsal joint

Strains First degree (mild):

minimal structural damage; minimal hemorrhage; early resolution

Skeletal Development in Children •Deformities of the skeleton can lead to abnormalities in__________ and decreased __________ in functional activities

movement participation

foot and ankle osteology

navicular cuboid cuniforms (3) metatarsals seasmoid bones proximal, middle, distal phalanx

pes planus classification pes cavus classification

navicular drop test > 10 mm neutral to standing = excessive look at photo

Optimal Postural Alignment

nearly straight line from ankles to hips to shoulders to ears Not everyone has the same perfect posture since everyone is different

Exercise-Based Knee & ACL Injury Prevention

need to do it preseason and season

Forefoot Valgus Gait Pattern

normal pronation early resupination late pronation at weight transfer

The Subtalar Joint •Axis: This axis is a single _________ axis

oblique •Because the joint's axis is oblique, we observe a component of subtalar motion no matter which of the three reference planes (sagittal, frontal, or transverse) that we use as our point of view. •The axis may be a line that connects the points at which the talus contacts the navicular anteriorly and the calcaneus inferiorly.

talus is stable in (open chain or close chain?)

open chain

Pronation open chain Calcaneous: Talus: Forefoot: closed chain Calcaneous: Talus: Forefoot:

open chain Calcaneous: everts Talus: stable Forefoot: abducts and dorsiflexes closed chain Calcaneous: everts Talus: adducts and plantarflexes Forefoot: stable

Supination open chain Calcaneous: Talus: Forefoot: closed chain Calcaneous: Talus: Forefoot:

open chain Calcaneous: inverts Talus: stable Forefoot: adducts and plantarflexes closed chain Calcaneous: inverts Talus: abducts and dorsiflexes Forefoot: stable

The _______________ is a common accessory bone of the foot that usually ossifies and fuses with the talus between the ages of 8-11 as a secondary ossification center. If the os remains unfused it is termed __________

os trigonum os trigonum - calcaneous small part separates in younger people who are growing quickly Testing of it is nut cracker - plantarflex hard - squeeze little bone can be accessory bone

Metatarsalgia

pain of the metatarsals •Signs & symptoms -Pain over metatarsal heads or at MTP joints •Contributing factors -Abnormal foot mechanics •Morton's foot - short 1st metatarsal compared to 2nd metatarsal - may lead to increased weight bearing through 2nd metatarsal head •Hypermobile foot •Pes cavus •Tight Achilles -Improper shoe wear •High heels -Other •Excessive weight gain, neurogenic, vascular, RA •Treatment -Metatarsal pads (proximal to metatarsal head) -Increase flexibility of Achilles -Proper shoe wear -Mobilization & Manipulation (metatarsal whip) RA Transverse metatarsal arch has fallen

tarsal tunnel syndrome symptoms, signs and treatment

painful foot disorder caused by compression of the posterior tibial nerve as it passes through the ankle •Symptoms: -vague pain in the sole -burning or tingling -increase with activity, especially standing and walking for long periods. -Reduced by rest -Numbness and weakness become present as it progresses •Signs -Hx & PE -Tinel's (if inflamed) -NCV •Treatment -PRICED -Address cause •Overpronation •Decreased medial arch •Weak posterior tib •Tight flexor retinaculum -Surgery

Strains Second degree (moderate):

partial tear; large spectrum of injury; significant early functional loss

The Middle Child aka Knee basic osteology

patella lateral/medial condyle intercondylar notch medial/lateral joint compartment

The upper fibula, and especially the neck fractures, may be associated with a _____________ nerve palsy. leads to

peroneal (fibular) - neuropraxia with a foot drop - variable recovery time

CPG Interventions for meniscus

photo

Callus Formation overview

photo

Fallen metatarsal arch

photo

The _________________ is a ligament on the bottom of the foot that connects the calcaneus to the cuboid bone. It lies deep to the long plantar ligament.

plantar calcaneocuboid ligament (short calcaneocuboid ligament; short plantar ligament)

85% - 95% of all ankle sprains involve some ____________ of the ankle and ______________ of the foot.

plantar flexion inversion two ligaments commonly torn: -anterior talofibular ligament -calcanofibular lisamen

Forefoot Valgus •Forefoot valgus can occur with or without a ____________________!

plantarflexed first ray

muscle action fibularis brevis fibularis longus

plantarflexion eversion

Muscle Actions tibialis posterior flexor digitorum longus flexor hallucis longus achilles tendon

plantarflexion inversion

foot supination

plantarflexion, adduction, inversion Soups -you add plants to it

A person excessively pronates and has demonstrates a loss of medial longitudinal arch during standing and with heel rise during terminal stance on the right compared to the left. This is most likely due to a tear in the;

posterior tibialis TOM dick and harry

functionally shorter leg goes with pronation or supination of foot?

pronation

compensated Forefoot varus Because of the compensatory pronation relatively late in stance, the foot may still be _______

relatively mobile during push-off.

pes anserinus

sartorius, gracilis, semitendinosus

Distal Tibiofibular Joint •During dorsiflexion this syndesmosis joint _____________ 1-2 mm at the distal end while allowing the fibula to glide sightly cephalically.

separates The distal tibiofibular joint is a synarthrodial joint formed by joining of the convex medial surface of the distal fibula, with the concave fibular notch of the tibia -close to the foot

Patella is a ___________ bone and embedded in tendon of quadriceps muscle. •It protects your femur and from trauma & improves the moment arm of the quadriceps

sesamoid

Metatarsal Pads

singular pads located on the plantar surfaces of the metatarsal areas of shoes -used to redistribute pressures away form the metatarsal head Proximal to the heads of the metatarsals - to support transverse metatarsal arch - can make them out of foam pads

Uncompensated Forefoot Varus STJ motion

slowed ST pronation no STJ motion though remaining phases

Shoe Shape: The Last

straight semi-curved curved

Alignment from a Soft Tissue Perspective-Muscle strength Short muscles may be relatively ___________ compared to antagonist and vice versa

strong

•Did you know if you combine me with the posterior capsule, I become the posterior oblique ligament (POL)? what am i?

superficial medial collateral ligament

Plantarflexed First Ray. Intrinsic deformity of the first ray consisting of the first metatarsal and the medial cuneiform where it is in plantarflexion. A fixed plantarflexed first ray causes a rapid transfer of weight laterally and abnormal STJ ___________

supination. Abnormal Foot Supination due to compensation

The distal tibiofibular joint is a _________________ joint formed by joining of the convex medial surface of the distal fibula, with the concave fibular notch of the tibia

synarthrodial

•The ___________________ is often also injured with an eversion force. If the tibia and fibula spread on the talus, the ankle mortise is disrupted and the ankle can become very unstable. It is also not unusual to see an associated fibula fracture with an eversion mechanism.

syndesmosis ligament/joint

The remaining 5%-15% of all ankle sprains consist of a _________ or ______________ sprain, which are often the result of an outside force such as being fallen on from the outside.

syndesmosis or eversion

what takes longer to heal normally? lateral ankle sprain or syndesmosis sprain?

syndesmosis sprain " syndesmosis sprain can take anywhere up to 2-20 times more time than that of a lateral ankle sprain to recover." (p.1095)

Transverse Tarsal Joint what two joints is it made of?

talonavicular and calcaneocuboid joint •Axes of Rotation -Oblique -Longitudinal Allows the foot to adjust for the uneven surface

Plantar Fasciitis (Plantar Heel Pain) •Differential Dx:

tarsal tunnel or may be a symptom of a systemic disorder (RA, gout, etc)

lisfranc joint

tarsometatarsal joint

Medial Longitudinal Arch The arch is significant because, in theory at least, it provides a structure which eliminates

tensile stresses in spanning an open space. All the forces are resolved into compressive stresses. This is useful because several of the available building materials such as stone, cast iron and concrete can strongly resist compression but are very weak when tension, shear or torsional stress is applied to them. By using the arch configuration, significant spans can be achieved. This is because all the compressive forces hold it together in a state of equilibrium. This even applies to frictionless surfaces. However, one downside is that an arch pushes outward at the base, and this needs to be restrained in some way, either with heavy sides and friction or angled cuts into bedrock or similar.

Point test

tests for Syndesmotic injury examiner applies pressure in a progressively more forceful manner directly over the anterior aspect of the distal tibiofibular syndesmosis. pain with palpation suggests presence of injury

Squeeze Test

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

external rotation stress test

tests for Syndesmotic injury examiner stabilizes the leg with 1 hand and applies an external rotation load to the foot with the ankle in neutral dorsiflexion/plantarflexion

Anterior knee pain: evidence-based interventions

this is the black hole •Variety of different conditions (see CPG) •Quadriceps strengthening •Biomechanics training •Motor control & Balance •Hip Abductor/ER/ glutes(extension) strengthening •Soft tissue mobility/flexibility

extrinsic and intrinsic muscles of foot working

this raises the arch

weight bearing between tibia and fibula

tibia: 90-95% fibula: 5-10%

Medial Tibial Stress Syndrome aka

tibial periostitis

•Tibial Torsion: twisting of the tibia in the __________ plane

twisting of the tibia in the transverse plane Should have a little bit of external tibial torsion If knees are towards each other -it is typically from the hip

Lateral Ligament Repair of Ankle using Gould modified Broström Technique

two suture anchors placed at the footprint of the ATFL(anterior talofibular) and CFL(Calcanofibular) insertion site. a third suture is placed 1 cm above ATFL insertion site to reinforce the repair.

Movement Screening

used to evaluate the presence of muscle imbalance watch out because People train around their weaknesses

•Normally a physiological ________ (_______ degrees) exists at the knee. -Angle < 165 degrees = genu valgus -Angle > 180 degrees = genu varum

valgus 170 - 175

•Tightening of the plantar fascia as a result of hallux dorsiflexion (tightens fascia and elevates arch)

windlass mechanism

Plantar Fascitis Stretch

working on dorsiflexion supporting the subtalar joint in a neutral or slightly supinated position enhances ankle-talocrural joint dorsiflexion

are ankle and foot problems common?

yes very Magee (2008) states that 80% of the general population has foot problems.

Agility

• Cutting, changing directions, changing speed of movement

Muscle Strains of knee •Mechanism of injury (MOI) - 2 common mechanisms

• maximum contraction before the muscle is ready (concentric) •force generated exceeds the muscle's ability to withstand such a force (eccentric)

Patellar/Quadriceps tendinopathy

•"Jumper's knee" •MOI -Microtrauma •Repetitive eccentric loading -rigid surface •Rapid change in training -Frequency -Intensity -From one method to another •Improper mechanics •Poor base strength of quads

Static and Dynamic Musculoskeletal Assessment of the Lower Quarter Ideal alignment facilitates __________

•"The ideal alignment of the body may not be attainable in every respect, but it is the standard toward which efforts to attain it are directed" •"Ideal alignment facilitates optimal movement... the more ideal the alignment of the skeletal segments, the more optimal the performance of the controlling elements such as the muscle and nervous systems. •Similarly, if alignment is ideal, there is less chance of causing microtrauma to joints and supporting structures"

Prepatellar Bursitis

•"housemaid" aka "carpenter's knee" •MOI -Repetitive friction or pressure •Kneeling •Repeated blows -Wound/Infection -Direct blow •Signs & Symptoms -Pain -Swelling -Warmth -Decreased ROM Due to an infection Bursa issue Key is to get the swelling down

Ankle & Foot Injuries Epidemiology and Impact:

•1/5 of the joint injuries occur at the ankle. •Over 3 million US ER visits attributed to ankle/foot injuries. •Approximately 55% of patient who experience an ankle sprain do not seek help from a health care professional.

ACL

•2 bundles •Anteriomedial (AM) •Posteriolateral (PL) •tensile strength of the ACL = knee collaterals, but 1/2 of PCL •forcing the ACL > 5% beyond resting length may result in rupture •Tension •full extension, both bundles are under tension •PL limits anterior translation of the tibia at 0-30 degrees •Max tension with full knee extension •60-90 degrees of flexion, PL lax allowing rotation •AM primarily resists anterior translation of the tibia and undergoes less change in length throughout the range of knee motion •AM under maximum tension between 45 and 60 degrees of knee flexion •Secondary restraint to valgus and varus angulation when knee fully extended. Some state at 30 degrees the ACL resists knee IR>ER. (Physiopedia contributors, August 28th, 2019) •Femoral footprints •Full knee extension femoral insertions nearly vertical with AM more cephalic (don't need to know) •90 degrees of flexion they are horizontal to each other Think of the bundles like a peppermint Strong but not as strong as PCL Limits anterior tibial translation

Cancer

•2nd leading cause of death in US •Tumors of the lower extremity can initially mimic common musculoskeletal •Less than 1% of all adult malignancies are of bone & soft tissue (sarcomas); soft tissue (87%) and bone (13%), more than half of those occur in the lower extremity. •Pathology •Age 50 years or older •History of Cancer •Unrelenting Night Pain •Unexplained weight loss/gain •Malaise/fatigue •Worsening or unresolved pain at 4 weeks

Calcaneal Apophysitis (Sever's Disease)

•8-12 year olds •Accounts for about 8% of overuse injuries in children & adolescents •Bone growth is faster than muscle tendons can lengthen results in a traction apophysitis •Direct or microtrauma to the growth center of the posterior calcaneus •Other Possible Factors -hard playing surfaces -shoes - poorly padded -Cleats -poor support -cavus type foot -tight Achilles and or plantar fascia •Treatment (expect return to activity in 2 wks to 2 months) -NSAIDS -Reduce activity -Flexibility (as symptoms decrease, increase DF without causing symptoms) -Shoe wear •get out of cleats •shock absorbent heel pads •orthotic or heel stabilizers or heel cup -in resistant cases immobilization for 4 - 6 weeks may be needed Os good slaughters Growing quickly

Cumberland Ankle Instability Tool

•9-item questionnaire, 0 to 30 score (30 is best) •No instability ≥ 28 •Scores ≤ 27 have an increasing level of functional instability of ankle •Scores of 22-24 have a likelihood ratio of 7.7 for instability. •Scores < 22 the likelihood ratio for functional ankle instability increases to 21.52. Document this

Stress Fractures

•95% of all stress fractures occur in the LE in the athletic population -Training and/or forces exceed repair phase -Muscle imbalances -Tibial & fibular stress fx accounts for > 50% •Symptoms -Gradual onset over a 2-3 week period -Initially pain with activity relieved by rest -Progress to pain for several hours after activity, may get worse at night -Swelling may occur after activity •Signs -Localized tenderness (medial aspect of tibia or 2-3 inches superior to fibular malleolus) -WB may or may not be painful -Percussion sign (tap on the bone) -US over site - pain continues 1-2 hours after US -May not be visible on radiographs for 2-8 weeks after injury In people who do lots of activity Cross country, military, band members Hard to diagnose

Rearfoot Anatomy •Sinus tarsi

•A "tunnel" that is filled with the attachments of several ligaments

Lisfranc Injury

•A fracture and or dislocation at the tarsometatarsal joint. •It is named after a surgeon in Napoleon's cavalry who originally described them. •At that time, the most common mechanism of injury was getting a foot caught in a stirrup. •Now, they are most often seen in patients after a motor vehicle accident and in mountain bikers who get their feet caught in the pedal clips. Bball or football - gets stepped on then move, horseback riders

LE Compartment Syndrome Presentation & Diagnosis

•Acute -Pain is disproportionate to the injury; progressive; not relieved by morphine; spontaneous at rest; and worsened by passive stretching of the involved muscles -Involved compartment may also be palpably tense, have signs of numbness, pulselessness, partial paralysis, and paleness. •Chronic -Tightness, pain, burning, or numbness related to physical activities. -Involved compartment may also be palpably tense, •Less likely to have signs of numbness, pulselessness, weakness, and paleness than acute. -Improvement in symptoms with rest. •The traditional 5 P's of acute ischemia in a limb are not clinically reliable and manifest only in the late stages of compartment syndrome -pain, -paresthesia, -pallor, -pulselessness, -Paralysis •Diagnostically needles/catheters are often used -Traditionally, absolute measures were used to guide therapy; •> than 30 mmHg in the compartment, within 30 mmHg of the diastolic blood pressure, and for pressures within 30 mmHg of the patient's mean arterial pressure •Compartment syndrome occasionally develops at lower tissue pressures in hypotensive patients •Imaging Studies -MRI T2 may show increased signal intensity in an entire compartment -Computed tomography scanning is useful if pelvic or thigh compartment syndrome is suspected. -Lower extremity venous Doppler or arterial ultrasonography (US) is performed as needed to address possible DVT or arterial occlusion. •US alone is not useful in making the diagnosis of CS.

Symptom sources by LOCATION

•Anterior - Anterior knee pain (e.g., chondromalacia, fat pad irritation), bursitis, Tibial apophysitis (Osgood-Schlatter's disease), patellar tendinitis (Jumper's knee), intra-articular dysfunction, OA, plica, fracture, soft tissue referral, neurologic referral, surgical pain, Patellar subluxation or dislocation •Medial - meniscus, MCL, DJD, pes anserine bursitis, intra-articular dysfunction, plica, soft tissue referral, OA, neurologic referral •Lateral - Meniscus, LCL, ALL, DJD, iliotibial band friction syndrome, fibular head dysfunction, fracture, intra-articular dysfunction, soft tissue referral, neurologic referral •Posterior - hamstring injury, tear of posterior horn of medial or lateral meniscus, Baker's cyst, intra-articular dysfunction, neurovascular injury (popliteal artery or nerve), soft tissue referral, neurologic referral

Compartments of the LE

•Anterior compartment -Dorsiflexion muscles of the ankle and foot •Tibialis anterior •Extensor digitorum longus •Extensor hallucis longus •Peroneus tertius -Anterior tibial artery - Commonly injured in lateral tibial plateau fractures -Deep peroneal nerve - Provides sensation to the first dorsal web space •Lateral compartment -Peroneus brevis and peroneus longus (that is right, I said peroneus not fibularis) - Plantar flexor and evertor muscles of the foot -Superficial peroneal nerve - Provides sensation to the dorsum of the foot •Deep posterior compartment -Plantar flexor and phalangeal flexor muscles •Tibialis posterior •Flexor digitorum longus (FDL) •Flexor hallucis longus -Posterior tibial and peroneal arteries -Posterior tibial nerve - Provides sensation to the sole of the foot •Superficial posterior compartment -Plantar flexor muscles of the foot •Gastrocnemius •Plantaris •Soleus -Sural nerve - Provides sensation to the lateral aspect of the foot and distal calf

Menisci Ligaments

•Anterior transverse aka Transverse genicular or intermeniscal or menisomeniscal ligament is attached anterior aspect of menisci. It is absent in 25% of population. •Coronary ligaments connects the meniscus peripherally to the tibia •The ligament of Humphrey (anterior meniscofemoral ligament), runs anteriorly to the PCL and inserts on the posterior aspect of the lateral meniscus. •The ligament of Wrisberg (posterior meniscofemoral ligament) runs posteriorly to the PCL to insert either into the superior/lateral aspect of the tibia, the posterior aspect of the lateral meniscus, or the posterior capsule. •Meniscofibular ligament •Oh, and there are bunch more Lots of ligaments Ligament of humphery - anterior (h before w) Ligament of wrisburg - posterior

Osgood-Schlatter's

•Apophysitis of the tibial tuberosity -Partial avulsion of patellar tendon off of insertion •Active 9-16-year-olds are the ones commonly affected. •Usually runners, basketball players, and jumpers. •More common in males (3-7 times) than females. •Most patients have symptom resolution in 12-24 months Partial avulsion of patellar tendon off of insertion With kids who do plyometrics Males more than females Modified activities - avoiding high energy jumping Bump below knee

Support of Transverse (Metatarsal) Arch

•Arch supported by 1.Bones 2.Ligaments and capsule 3.Tension of tibialis posterior and peroneus longus Wrap over and create and x which provides lots of arch support fibularis longus and tibialis posterior are the dynamic duo

Tibial Plateau Fractures associated with MOI signs and symptoms

•Associated with -ACL injury -MCL or LCL injury -Meniscus injury -Articular Cartilage injury •MOI -Vertical stress on a flexed knee -Force to the lower leg while in varus/valgus position •Signs & Symptoms -Swelling/Effusion -Unable to weight-bear -Stiffness Soccer, kick boxing

Strengthening Component of knee

•Balance between the hamstring and quad muscles •Recommended that the hamstrings be 60 - 80% as strong as the quads •Work on the hip muscles to stabilize knee and control knee

Patella

•Base (top) •Apex (bottom) •Anterior surface •Posterior articular surface •Articular cartilage is up to 5mm thick; thickest in the body •Vertical ridge •Lateral, medial, and "odd" facets

Treatment •Acute to Sub-acute to Chronic

•Based on healing times •Based on function/movement Patients think things are linear - they are not They will have good days and bad days Sometimes you will decline a little

Fitting Shoes Properly

•Because your feet may vary in size, ask the salesperson to measure the length and width of each of your feet. •Your feet expand when bearing weight, so stand while your feet are being measured. •Because swelling during the course of the day can enlarge your feet, have your feet measured at the end of the day. (when buying new pair of shoes do it at the end of the day because your feet are more swollen) •The shoes you buy should be fitted to your longer and wider foot. Although the toe box should be spacious, too much space can cause the feet to slide around in the shoes, possibly causing blisters or abrasions. -Widest part of foot = widest part of shoe -Allow ~ 1/2" front and top •Shoes should be fitted carefully to your heel as well as your toes. Check to make sure your heel does not slip out of the back of the shoe. •Walk around in the shoes to make sure they fit well and feel comfortable. •Don't select a shoe by size alone. A size 10 in one brand or style may be smaller or larger than the same size in another brand or style. Buy the shoe that fits well. •Select a shoe that conforms as closely as possible to the shape of your foot. •Have your feet measured regularly. Their size may change as you grow older. •If the shoes feel too tight. don't buy them. There is no such thing as a "break-in period." With time, a foot may push or stretch a shoe to fit. But this can cause foot pain and damage. •If one of your feet is considerably larger than the other, an insole can be added to the shoe on the smaller foot. •Fashionable shoes can be comfortable, too.

TKA (total knee arthroplasty) Condition specific rehab

•Beneficial in decreasing pain and improving function •Indication: •Radiographic advanced arthritis •Failed conservative management: therapy, activity modification, assistive device use, medication, weight loss •Rehabilitation •Prevent infection •Prevent DVT •Manage pain and scarring •Early ROM (Post-op ROM determined by pre-op ROM) •Restore normal gait •Address impairments: strength, balance, ROM

Common Injuries to knee

•Bone •Articular •Muscle/Tendon •Other Structures

Heterotrophic Ossificans

•Bone formation at an abnormal site -Usually in soft tissue •Myositis Ossificans Progressive -Genetic •Neurogenic Heterotrophic Ossificans -Traumatic spinal cord injury •Traumatic Myositis Ossificans -Direct blow or muscle tear Calcium lays down Exercising beyond capabilities Began to lay down bone Not super common

Observation & Posture

•Braces •Assistive Devices •Asymmetry •Discoloration •Swelling •Incisions •Gait •Transfers •Willingness/Ability to move •Genu Varus/Valgus •Bony enlargement •Foot/Ankle/Hip

Normal Subtalar joint pronation (closed chain)

•Calcaneus everts at initial contact. •Talus adducts and plantar flexes •Tibia follows talus so that it rotates internally while knee flexes. •STJ pronation causes MTJ axes to become parallel, making foot flexible and adaptable to different surfaces. •STJ pronation functionally shortens the LE, assisting in shock absorption.

Cuboid Syndrome

•Causes - speculative -Subluxation of cuboid -Abnormal pull of peroneus longus -Some report increased pronation as a factor or symptom •Symptoms -Lateral midfoot pain -Feels like they are walking on pebbles -Unable to run, jump, or cut -Palpable tenderness to plantar aspect of foot over calcaneocuboid joint •Rx -Devo - Ah, whip it good (cuboid whip?) •Some prefer the cuboid squeeze - same end position as the whip, wait for tissues to relax then use thumbs to relocate cuboid -Low-Dye taping to maintain arch for 1-2 weeks -Soft tissue mobilization - peroneals and long dorsiflexors Feels like on a rock

-A focal area of damage to only the articular cartilage

•Chondral lesion

Chondral-Osteochondral Lesions (Defects)

•Chondral lesion -A focal area of damage to only the articular cartilage •Osteochondral Fracture -Fracture of the bone near the sight of joining with articular cartilage •Osteochondritis Dissecans -Loss of blood flow to subchondral bone leading to separation &/or instability of a segment of cartilage and it may be free movement within the joint space

Lower Extremity Bone Development: Hip •Clinical tests & Interventions

•Clinical tests & Interventions -Craig's test -Hip joint ROM -Positional or surgical depending on problem and level of function

•CONTACT INJURIES/DIRECT BLOWS:

•Commonly cause injury to: collateral ligaments, patellar dislocation, epiphyseal fractures in children with open growth plates •Valgus forces are more common than varus-directed forces •Blow to lateral aspect of knee resulting in stretch injury to soft tissues of medial knee (MCL more prone to injury than LCL) Harder to get hit on medial knee

Brannock Device

•Compare the arch length to the heel-to-toe length. •Generally you'll use the larger of the two measurements as the correct shoe size. •If the arch length and heel-to-toe length are the same, this will be the shoe size. •If the heel-to-toe length is larger than the arch length, then fit to the heel-to-toe size. •If arch length is larger than heel-to-toe, then fit to arch length. Where the metatarsal head is and the foot length

What do people do? Rearfoot Varus (compensated and uncompensated)

•Compensated - Foot adapts to the ground to meet the requirements of gait (usually pronates) •Uncompensated - regardless, the alignment, the foot does not adapt or come to the ground. Uncompensated you remain in the position and don't adapt to the ground

Rearfoot Varus...

•Compensation (via pronation) retards supination during midstance/terminal stance, and is thus unacceptable. •Without supination, the subtalar joint and the midtarsal joints are not rigid for push-off. Hand is on lateral side of foot

Patellar subluxation/dislocation: surgery?

•Conservative •Older •1st time dislocation •Surgical •Younger •Recurrent dislocations •Continued c/o instability •Mal-alignment •Co-morbid Injuries Most of the time will not do surgery

Achilles Tendon Tear Treatment

•Conservative (non-surgical candidate) -Casted in an equinus position (10-20 PF) -10-30 % rerupture -Expect decreased maximum function •Surgical (do it sooner rather than later) -Ideally done within 1 week of rupture -Detail outline of rehab in Maxey & Magnusson

Collateral ligament injury: evidence-based interventions

•Conservative management (Potential exceptions: MLIK (Multiple-Ligament-Injured Knee); significant rotational instability (corner injuries)) •Decrease swelling/pain •Early ROM •WB advanced as tolerated •Avoid valgus/varus stresses •Biomechanical considerations •Strengthening •Balance & Motor control

Prevention is the real key (ACL) •Contact vs. non-contact

•Contact vs. non-contact •~80% non-contact (soccer, basketball, skiing, etc.) •~20% contact (football, ice hockey) •Non-contact - usually with landing, rapidly stopping, cutting or change in direction •Altered biomechanical and neuromuscular patterns •Female athletes have 3.5 x risk of non-contact injury compared to males Primarily a noncontact injury

Posterior Tibial Tendonitis Treatment

•Control the inflammation -PRICED -Pulsed US •Reduce the stress -Orthotics •Heel wedge initially if lack of functional DF •Address abnormalities -Immobilization may be necessary -Proper foot wear •Flexibility -Achilles, 1st MTP, joint mob as indicated of the ankle-foot complex -Soft Tissue mobilization, Friction massage •Strengthening -Progress to closed chain & eccentric strengthening -Controlled landing for a higher surface -Sidestepping and cariocas away from involved LE •Proprioception -Wobble board in both directions

Compartment syndrome

•Critical pressure increase within a compartment leading to a decline in perfusion to the tissue within that compartment •Pain within a compartment at the same time, distance, or intensity of exercise/activity •Pain increases with continued activity until patient must cease activity •Pain resolves with rest •5 P's: Pain, Pallor, Paresthesia, Paralysis, Pulselessness

Chronic Ankle Instability •Exam - Outcome Measure

•Cumberland Ankle Instability Tool •Identification of Functional Ankle Instability

Compartment Syndrome

•Defined as increased tissue pressure contained in a nonexpansile space •Raised pressure within a closed fascial space reduces capillary perfusion, placing the enclosed structures at risk •Most commonly observed after acute injury or ischemia in upper and lower extremities -Other variants do exist: abdominal, epidural, CHI, and glaucoma •Two types of compartment syndrome exist: Acute and chronic. -Acute compartment syndrome (majority of cases) is related to a type of trauma occurring to the involved compartment -Chronic compartment syndrome, known as exertional compartment syndrome, is associated with small injuries to the body or continual loading of a limb related to physical activity

Rehabilitation LE Compartment Syndrome (post-fasciotomy and non-surgical conservative)

•Depends on the reason for onset of symptoms (tibial fracture vs exertional) -limited weight bearing on the involved limb, use of an assistive device as needed, -flexibility and range of motion exercises, -weight resistive exercises, -stretches, -soft tissue mobilization, -and modifying certain activities of the patient

Plyometrics

•Designed to produce fast, powerful movements, and improve the functions of the nervous system •Examples: squat jumps, drop jumps, bounding •Has been shown to be one of the most effective tools to reduce non-contact ACL injuries

Achilles Tendinopathy

•Dutton states, "most common overuse injury of LE...2.35 per 1000 in the adult population" •5-18% of all running injuries Umbrella term Common overuse injury Poor condition with the tendon

ACLR: rehab considerations (anterior cruciate ligament reconstruction)

•Early WB (isolated ACLR) •Early ROM (Especially extension ---- What is limiting motion?) •Limit early OKC (open kinetic chain) RROM •Core & NM Control •Progressive interventions related to impairments

AROM/PROM/RROM of knee

•End Feel •Overpressure Capsular Pattern -- Flexion limited greater than extension (5 to 1 ratio)

Plantar Fasciitis (Plantar Heel Pain)

•Etiology -Multifactorial -Decrease PF strength -Obesity -Antetorsion -Decreased DF -Over pronation -Pes cavus -Improper shoe wear -Overtraining -Occupational •Signs & symptoms -Pain upon initial weight-bearing -Pain at medial calcaneal tubercle -Pain with prolonged weight-bearing or increased activity (e.g., running or stair climbing) -Pain with DF, which is further exacerbated with 1st MTP DF •Great toe DF range is often limited to less than 90 degrees -Rest relieves symptoms •Differential Dx: tarsal tunnel or may be a symptom of a systemic disorder (RA, gout, etc)

Under-Pronation Wear Pattern

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

Over-Pronation Wear Pattern

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

Other Tendonitis (FHL - flexor hallicus longus)

•FHL -Presents similar to posterior tibialis •Treat in a similar fashion except limit hallices extension

Infection

•Fever •Chills •Night sweats •Nausea or Vomiting •Recent history of cold or flu-like symptoms •Open wound or recent open trauma •Redness •Warmth •IVDU (IV drug use - dirty needles)

Red-Flags

•Fevers, chills, night sweats •Recent unexplained weight changes -CHF, CA, Thyroid, GI, DM •Malaise or fatigue •Unexplained n/v •Quadrilateral paresthias •SOB •Dizziness after a recent trauma or associated with neck movements •Cancer -Persistent pain at night -Unwarranted fatigue •Cardiovascular -SOB (shortness of breath) -Dizziness -Pain or heaviness in Chest -Discolored or painful feet especially with elevation -Swelling (no hx of trauma) •GI/GU -Frequent or severe abdominal pain or N/V -Unusual menstrual irregularities -Bladder function changes •Misc -Fever or night sweats -Emotional disturbances -Swelling or redness at any joint (no hx trauma) •Neurological -Changes in hearing or vision -Changes in swallowing or speech -Fainting spells (drop attacks) -Changes in balance or coordination

Pathologies with FF Valgus

•Fibularis longus and Brevis Tendinopathy •Haglund's deformity •Stress fractures •Plantar fasciitis (length issue) •Knee medial compartment degeneration, stress fractures, SI pain, lumbar pain.

Common pathologies Uncompensated FF varus

•Fibularis longus tendinopathy •5th ray stress fractures •Jones fractures (base of 5th) Jones fracture - shaft of metatarsal

Treatment •F.A.S.T. Approach

•Flexibility/Mobility •Activation •Strength/Stability •Training Movement Patients think things are linear - they are not They will have good days and bad days Sometimes you will decline a little

Achilles tendinopathy: treatment

•Focus for the therapist are the causes! -Decreased DF, overpronation, etc •Acute -PRICED •Immobilization may be required (e.g.., cam boot) •Modalities (pulsed US) -Heel wedge, Prevent increase PF •Rehabilitative phase -Some suggest a 12-week program, include manual therapy -Progress to eccentrics with the knee bent and straight •Heel drop down ex •3 set of 15 reps with body weight TID -"Dutton, start with isometric contractions to reduce pain, and progress to heavy slow resistance training, slowly increasing load and speed -In the past, eccentric contractions were widely used. However, some state that there is not any difference in the benefits between the use of isolated eccentric or concentric contractions -Final stage should closed chain challenges and incorporate activity specific ex •Figure 8 running, one-legged hop, carioca, wobble board -CPG: eccentric exercise or a heavy-load slow-speed (concentric/eccentric) exercise program, to decrease pain and improve function for patients with midportion Achilles tendinopathy without presumed frailty of the tendon structure. Level A Heel wedge could help Isometrics are a good place to start with load tolerance

Forefoot-Strike Wear Pattern

•Focused outsole wear over mid and forefoot •No visible heel wear •Wrinkling of midsole in mid and forefoot 80% of runners are heel-strikers Only 20% are midfoot strikers

An intrinsic deformity that occurs when the forefoot is pronated with respect to the rearfoot when the foot is maintained in subtalar neutral.

•Forefoot Valgus.

Talipes Equinovarus (TEV) (AKA Clubfoot)

•Forefoot curved medially, hindfoot in varus, equinus of the ankle, small calcaneus •Congenital clubfoot caused by restricted positioning in utero •Genetic influence is suggested •Bilateral in half of the cases •Often associated with myelomeningocele(spina bifida) or arthrogryposis

intrinsic deformity where the forefoot is supinated with respect to the rearfoot when the foot is in subtalar neutral.

•Forefoot varus:

Anterior Knee Pain

•Formerly Patellofemoral Joint Syndrome (PFJS) •"black hole of orthopedics" •Potential multiple sources of pain -Anterior synovium -Retinaculum -Fat pad -Joint capsule -Referred from quadriceps -NOT patellofemoral joint surfaces •Signs & Symptoms -Diffuse pain •With prolonged sitting •With knee flexion •With RROM knee extension •Poor mechanics So many things that can contribute to it

Red Flag Screening for knee: concrete

•Fracture •Ottawa Knee Rules •Cancer •Infection •Septic Arthritis •Osteomyelitis •DVT •Compartment Syndrome •Vascular Claudication

Training movement Training

•Fundamental vs Complex Movement •Forced Use Paradigm - putting the body in a position so they are forced to use the affected part •Uses the whole body or body segment •Upright in a functional position •Closed chain •Challenging and intense •Reactive Neuromuscular Training •Motor Learning Start simple then complex Forced Use Paradigm - forcing to use it Reactive Neuromuscular Training -having then react to something with good neuromuscular control

Lower Quarter Assessment & Screening

•Gait •Posture •SMFA •Clearing the Lumbar Spine •Neural Examination -Myotome -Dermatome -DTRs -Proprioception as needed -Adverse Neural Tension as needed •Special Tests

ACL Prevention Program

•Goal: decrease the number of ACL tears •Improve neuromuscular control and train proper movement patterns •Gain biomechanical efficiency and accuracy of movement •Enhance dynamic strength and muscle endurance of the trunk, hip and knee •Training session replaces the traditional warm-up of practice •Education for players on strategies to avoid injury •completed PRIOR TO and DURING sport season •3 times per week x 20-30 min each session

Presentation: Achilles tendinopathy

•Gradual onset of pain •In the early stages pain decreases as exercise continues. As the pathology progresses, pain increases with activity throughout duration of exercise. •Pain in the morning upon waking in the inflammatory stage •Swelling may be present 2-3 cm proximal to the calcaneous •May be insertional tenderness only or more typically 2-6 cm proximal the distal insertion •Decreased PF strength/endurance •ARC test (poor sensitivity 0.52, good specificity 0.83, Inter-tester reliability 0.55-0.72) -Tendonopathy = swelling in the tendon will move with the DF -video above -Paratendonitis = swelling does not move with DF •Royal London Hospital Test (poor sensitivity 0.54, good specificity 0.91, Inter-tester reliability 0.63-0.73) -Positive when tenderness occurs 3 cm proximal to the Calcaneus with slight PF -Pain with palpation decreases with active DF Can happen at insertion but more typical above If it moved- with tendon If didn't move- with paratendon

: a deformity of the great toe in which the metatarsophalangeal joint is enlarged and permanently laterally displaced.

•Hallux valgus HAV- hallucus abductus valgus

gait analysis of underpronation, normal pronation, overpronation

•Have the patient walk about 15-20 meters away from you •Observe from behind: -Location of heel strike -Foot motion during single-leg stance phase -Part of the foot with which they push off

Yellow Flag Screening

•Hip Referral •Neurologic referral/radiation •Psychosocial factors

Clinical Exam of the Ankle

•History is always good! -Don't immediately focus on the injury & forget to do a proper systems review •Chief complaint -Have patient point to the area with one finger •They may complain of an "ankle sprain" while pointing elsewhere e.g.. 5th metatarsal fracture -What happened? -Which way did it bend? -Could you walk? -How much swelling/ecchymosis (bleeding)? -When did it happen? -What have you done for it? -Have you sprained it before? •Onset -Acute, chronic, overuse, single event •Characteristics •Past Medical History •Activity History •Functional tests & Outcome Measures -Self-report measures •The Ankle Joint Functional Assessment Tool •The Foot Function Index •Lower Extremity Functional Scale -Physical Performance •SFMA •Agility Testing •Forward Step-Down Test (PHM) •Jump Down Test (PHM)

Special tests of knee •Plica

•Hughston Plica

compensated Rearfoot Varus, continued... what type of device could help

•In addition to an arch support providing subtalar neutral, therapists can temporarily support the deformity using a medial heel wedge or an orthosis with a medial heel wedge, while prescribing exercises to strengthen the muscles that provide the sling support for this problem.

#3 Forefoot Valgus - (with a plantarflexed first ray)

•In forefoot valgus (A), the plane of metatarsal heads is everted in relation to the rearfoot when the STJ is in neutral. Left lateral Right medial

#2 Forefoot Varus

•In forefoot varus (A), the plane of metatarsal heads is inverted in relation to the rearfoot's plane when the subtalar joint is neutral. Hand on lateral side

Compensated forefoot valgus (plantarflexed 1st ray)

•In stance, the calcaneus inverts. •The subtalar joint supinates to get the 5th metatarsal phalangeal joint to the ground.

Uncompensated Forefoot Valgus

•In uncompensated forefoot valgus therapists must provide orthotics that support the subtalar joint in neutral and provide a lateral forefoot post that supports the deformity permanently. •In the case of a plantarflexed first ray, the orthotic may include a 1st metatarsal cut out for the first met head (Lateral wedge with a cut out)

Uncompensated Rearfoot Varus

•In uncompensated rearfoot varus, the rearfoot remains in its inverted position, despite the weightbearing status.

Subacute treatment

•Increase ROM •Active Movements •Joint Mobilization/Manipulation (Grade III, IV, V) •Stretching •Soft Tissue Mobilization •Dry Needling •Increase Strength •Progressive resistance •Concentric vs. Eccentric •Isolation vs. Integration •Neuromotor Control •Joint Position Sense •Balance

Clinical Signs of forefoot valgus

•Increased GRF through the 1st metatarsal head. •Increased lateral weight-bearing through the metatarsal heads. •The leg pivots on the 5th ray at heel-rise. •A bunion like callus forms under the 1st and the 5th metatarsal heads.

How are pressures on the foot distributed during gait?

•Initial contact is slightly lateral to the heel in supination. •Pronation occurs immediately with loading for shock absorption. •The outer, more rigid border of the foot maintains the weight bearing (5th ray) through mid stance. •Weight progresses on the 5th ray through heel rise. •Weight is then transferred toward the medial side of the foot. •During push-off the weight usually stays at the ball of the foot and the first ray.

Patellar subluxation/dislocation: evidence-based interventions

•Initial period of long leg brace •Decrease swelling •Progressive ROM (Flexion) •Quadriceps strengthening •Biomechanical considerations

Extremity Examination Checklist

•Inspect skin for color, scratch marks, inflammation, track marks, bruises, heat, or other obvious changes •Observe for hair loss or hair growth •Observe for asymmetry, contour changes, edema, obvious atrophy, fractures or deformities; measure circumference if indicated •Assess palpable lesions •Palpate for temperature, moisture, and tenderness •Palpate pulses •Palpate lymph nodes •Check nail bed refill (normal: capillary refill time under 2-3 seconds for fingers and 3-4 seconds for toes) •Observe for clubbing, signs of cyanosis, other nail bed changes •Observe for peripheral vascular disease ; listen for femoral bruits if indicated; test for thrombophlebitis •Assess joint ROM and muscle tone •Perform gross MMT (gross strength test); grip and pinch strength •Sensory testing: light touch, vibration, proprioception, temperature, pinprick •Assess coordination (UEs: dysmetria, diadochokinesia; LEs: gait, heel-to-shin test) •Test deep tendon reflexes

Clinical Exam of Ankle

•Inspection & Palpation: -Most helpful during the acute phase -Remember your anatomy! If not, look it up! -Palpate the structures you know •Boney prominences •Ligaments •Tendon insertions •Check Range of Motion -Accessory motion prn •Neurovascular status •Gait •Ligamentous testing •Strength •Special testing as needed -Joint and condition specific -Agility (if appropriate) -stone bruise

The Patient Interview

•Intake forms cannot replace the expertise of clinicians. •The primary goals of the interview are to understand; -the origin of the patient's problem -the impact of the problem on the patient's life -and to determine the existence of red flags and/or comorbid conditions. •Communication is a skill that we often take for granted. •Listening requires active participation and paying attention to verbal & nonverbal cues. •Can you recognize and guide the conversation as it requires?

#1 - Rearfoot varus

•Inverted calcaneous compared to the leg •Normal alignment (left) compared to uncompensated rearfoot varus. The calcaneus (and forefoot) are inverted when the subtalar joint is neutral.

Activation Treatment

•Isometric Muscle Activation •Neuromuscular Electrical Stimulation (NMES) •Dry Needling •Isolated Active Movements Muscle activation

The Patient Intake

•It is a screening form designed to elicit pertinent information. •They are reliable and valid methods for gathering information.

Contributing factor to knee pain?

•Knee -Genu varus or valgus -genu recurvatum (tight soleus, limited ankle ROM, ligamentous laxity) ---Muscle imbalance -Tibial torsion -Contusion -OA -Hip •Weak hip abductors (increased Q angle) •Antetorsion (increased Q angle) •Limb length changes (coxa valga or varus •Ankle -Low or high arch -Foot or toe deformity -Weak muscle

Special tests of knee •ACL

•Lachman's •Anterior Drawer •Pivot-Shift

Uncompensated rearfoot varus' effect on gait

•Lack of motion at the subtalar joint. •Excessive shear through the midtarsal joint. •Marked decreased shock absorption.

__________ meniscus more mobile than medial, more circular, and covers about 70-80% of _______ tibial plateau. It can move about 11mm due in part to pull of popliteus

•Lateral moves with popliteus

Osteology: Distal Femur

•Lateral and medial condyles •Lateral and medial epicondyles •Intercondylar notch •No articular cartilage •Trochlear (intercondylar) groove •Lateral and medial facets (for the patella) •Patella may have up to 7 facets •Lateral and medial grooves (lateral is steeper adding to patellar stability) •Popliteal surface Cartilage behind patella is thickest in the body

Special tests of knee

•Ligamentous •ACL •Lachman's •Anterior Drawer •Pivot-Shift •MCL •Valgus Stress •LCL •Varus Stress •PCL •Posterior Drawer •Sag Sign •Meniscus •McMurray •Apley Compression •Thessaly •Patella •Apprehension •Plica •Hughston Plica

Mechanisms of Recurrent Ankle Sprains

•Ligaments healed in lengthened position •Less tensile strength than normal •Muscular weakness - incomplete rehab -Although I only provide 1/10 of PF power, I help stabilize the calcaneocuboid joint, plantar flex the 1st ray, support the medial longitudinal arch. Who am I? fibularis longus •Tibiofibular instability •Hereditary hypermobility •Loss of proprioception •Undiagnosed cuboid subluxation, subtalar instability, or other disorder •Functional instability (loss of ankle kinematics) •Some propose weak core trunk muscles

Skeletal Development in Children •Influences begin in-utero -Factors that can contribute to prenatal boney deformity:

•Limited space for fetus to move, including pregnancies with multiples •Decreased amniotic fluid •External forces from tightly stretched uterine and abdominal walls

Function of Foot During Stance Phase •Loading response phase: •Terminal stance phase:

•Loading response phase: mobility to adapt the ground(become flexible and adapt - supinated then immediate pronate) •Terminal stance phase: stability to provide propulsion (supinated)

LOCIDAA

•Location: •Potential source of symptoms or area of referral •Onset: •Potential type of injury/pathology •Characteristics: •Potential type of tissue that is the source of pain •Intensity: •A benchmark for comparison •Duration: •Information for staging and irritability •Aggravating Activities: •Potential source of symptoms and potential treatment options •Alleviating Activities: •Potential source of symptoms and potential treatment options

Emergency Situations

•Loss of Bowel/Bladder Control •Unable to weight bear or severe pain after a fall •Painful swelling in an extremity •This is not an inclusive list

Outcome measures for LE

•Lower Extremity Functional Score (LEFS) •Knee Injury and Osteoarthritis Outcome Score (KOOS) •Western Ontario and McMasters University Arthritis Index (WOMAC) •International Knee Documentation Committee (IKDC) Subjective Knee Form •Global Rating of Change (GROC)

Iliotibial Band "Friction" Syndrome - Not really a friction syndrome, but a compression issue MOI

•MOI -Overuse •Repetitive knee bending -Tightness of TFL / ITB -Running on uneven surfaces •Crown of road •Down hill -Faulty biomechanics Lateral knee pain is often this More of a compressive syndrome Pain over lateral femoral condyle

ACL Injuries MOI

•MOI -Plant and cut -Rapid deceleration -Hyperextension -Stiff-leg landing -Contact Could also happen when you land stiff legged

Pes Anserine Bursitis

•MOI -Repetitive overuse •Semitendinosus •Gracilis •Sartorius -Direct blow •Signs & Symptoms -Pain -Tenderness with palpation -Localized swelling -Gait dysfunction -Decreased muscle strength -Decreased ROM •R/O adverse neural tension/neural involvement -Infrapatellar branch of Saphenous nerve Bicycling Repetitive injuries

Patellar subluxation/dislocation MOI

•MOI -Usually, non-contact •Pivoting •Twisting •Cutting -Valgus stress with strong quadriceps contraction -Anatomical predisposition •Bony anomalies Very painful Contact or noncontact Usually dislocated laterally

Flexibility/Mobility Treatment

•Manual Therapy •Joint mobilization •Soft tissue techniques •Mobilization with Movement (MWM) •Manipulation •Dry Needling •Exercise •Stretching --Low load, Long duration --Contract-Relax Stretching - low load, long duration

Interventions you will learn to apply to the LE

•Manual Therapy Techniques -Soft tissue techniques •Bowstringing •Myofascial release -Joint mobilization and manipulation •Taping -Kinesiotaping -Athletic taping •Neural mobilization •Apply your knowledge of therapeutic exercise (Incorporate what you are learning from Dr. Williams) -FAST (flexibility activation strength training) & FITT-VP •Stretching •Impairment & functional based interventions •Motor facilitation •NMES (neuromuscular electrical stem) •Dry needling

What does research say about ACL prevention programs

•Mattu, et al. (2022) most recent literature review found that ACL prevention programs were effective in reducing non-contact ACL injuries by 64% (IRR = 0.36 (95% CI: 0.18-0.70)). A multi-faceted exercise program is recommended, pre-season, and in sessions should contain at least three exercise types to reduce ACL injury risk. "Individual exercises should be related to the high-risk movements within each specific sport. P.17" Feedback on techniques is critical. •Plyometrics •Strength •Balance •Stretching •Agility •Lim et al. 2011 & Gilchrist et al. support that pre-session and in-session training helps to reduce ACL injury. A prevention program done right makes a difference Plyometrics Strength -most bang for buck (but want to do at least 3) Preseason and in season

Special tests of knee •Meniscus

•McMurray •Apley Compression •Thessaly

Patellar Tendon Rupture MOI

•Mechanism of Injury -Usually, a deceleration force •Landing off balance from jump •Stepping in a hole •Previous tendon pathology

Focused History Questions

•Mechanism of Injury •Helps predict injured structure •Helps direct rehabilitation •Acute •Contact or noncontact injury? •If contact, what part of the knee was contacted? •Anterior blow? •Valgus force? •Varus force? •Was foot of affected knee planted on the ground?

Collateral Ligament Injuries MOI

•Mechanism of Injury (MOI) -Medial •Valgus force with foot fixed •Valgus, ext. tibial rotation force -Skiing -Lateral •Varus force with foot fixed •With other ligament tears

_________ meniscus more firmly attached to tibia (3x more likely to be injured) than the other, crescent or U-shaped, covers about 50% of ______ tibial plateau and moves posteriorly about 5mm by pull of semimembranosus

•Medial moves with semimembranous

Clinical Signs for compensation of rearfoot varus

•Medial bunion from excess pressure •"Hammer Toes" (Hammer toes- flexion at pip and extension at dip) •"Medial heel callus" or bump due to the pressure of the heel against the shoe Callus pattern on metatarsal heads....

pain monitoring model

•Minimal pain is acceptable and potentially necessary for proper loading for tendinopathy. •Mild (0-3) pain (avoid discomforting or distressing pain) with exercises loading is acceptable and should resolve within 24 hours. •If you are doing "heavy" loading of the tendon, then up to 3 days rest may be necessary for proper recovery. •Return to energy storing activities when pain is 2/10 or less with ADLs Try to work in the 2-5 level of pain Should be a low level of pain before you start exercise Tendon recovery 24-72 hours

Meniscus: surgery?

•Most likely no benefit to patients with degenerative tears •Conservative •Delayed symptom onset •Minimal swelling/effusion •Full ROM with pain only at end range flexion •Surgical •Immediate symptom onset and unable to continue with activity •Locking of knee •Associated ACL tear •Failure of up to 6 weeks of conservative management Not every tear needs to be repaired

Achilles Rupture

•Most likely to occur in the middle-aged athlete with peak incidence occurring in the early 40s •Etiology is multifactorial •Three activities primarily associated with the rupture -At push off -Sudden DF with FWB during fall -Violent DF with jumping from higher surfaces •Symptoms -Arrrgh! Mommy •Immediate pain -Difficulty walking -Often an audible "snap" -Swelling -Palpable defect •Clinical tests -Positive Thompson test •Low sensitivity 40% (Dutton, 2017, p.1132-1133) -Palpation and visualization of defect -Matles test - Client prone, active knee flexion to 90, if foot DF or goes to neutral it is (+). 88% sen, 85% spec (Dutton, 2017, p.1133) - not state in 2020 version

ACL Tears Condition specific rehab

•Most require surgery •Pre-op: •Decreased effusion/inflammation •Full ROM (focus on extension) •Normalize Gait •Increase Quad activation

Palpation of knee

•Muscles •Quadriceps •Hamstrings •Gastrocnemius •Adductors •Tendons •Quad •Patellar •Biceps Femoris •Semitendinosus/Semimembranosus •Bone •Tibial Tubercle •Femoral Condyles •Patella •Fibular Head •Gerdy's Tubercle •Joint •Joint Line •Effusion •Surrounding swelling (edema) MCL/LCL

Osteoarthritis: Treatments that are not EBP

•NOT = knee arthroscopy, ultrasound, hot packs, ice packs, magnet bracelets, copper (these are not EBP) 2009 and 2013 RCTs concluded that magnets or copper devices did not appear to have any meaningful therapeutic effect, beyond that of a placebo on people with OA or RA respectively. Smith, et al., 2013 meta-analysis supports this position regarding OA.

CPG Component 5: Intervention Strategies Nonacute: Diagnostic Indicators

•No redness, warmth, and swelling •>3 mo in duration •Pain after the onset of or after completing higher-level activity (ie, jumping and running) •Findings/interventions -Tendon pain with palpation, with or without presence of nodules - Mechanical loading exercises: eccentric, concentric/eccentric, or heavy load and slow speed -Abnormal biomechanical findings -Target lower extremity impairments that may lead to abnormal kinetics and/or kinematics -See acute for other findings/interventions

Arthrology & Arthrokinematics of knee

•Normal alignment is slight genu valgum 170-175 degrees •Screw-home mechanism •Shape of medial femoral condyle •Tension in ACL •Lateral pull of quads •Roll & Glide occur in SAME directions •Menisci move with anteriorly & posteriorly with knee extension and flexion respectively •Anteriorly with knee extension due in part of contracting quads •Posteriorly with knee flexion in part due to contraction of semimembranosus and popliteus. •Menisci follow femur with rotation (moves with femur for rotation, moves with tibia for flex and extension) •ER of tibia = medial meniscus displaces posteriorly and later displaces anteriorly

knee -Angle < _______ degrees = genu valgus -Angle > ______ degrees = genu varum

•Normally a physiological valgus (170 - 175 degrees) exists at the knee. -Angle < 165 degrees = genu valgus -Angle > 180 degrees = genu varum

Interdigital Neuroma (Morton's)

•Not truly a neuroma - more likely a fibrosis condition due to compression •Tenderness in the web spaces •Lateral compression of the forefoot increases symptoms •Tinel's ? •Causes -Typical cause is improper shoe wear •poorly cushioned and or tight shoes, high heels •pronation - nerve gets pinched between the heads of the 3rd and 4th metatarsals and the base of the proximal phalanx of the 3rd & 4th toes •hard surfaces •leg length discrepancy •Rx -Shoes with increased shock absorption -MET pads -Wider shoe -Hard and soft tissue mobilization -NSAIDS -Surgery

Patient Education for osteoarthritis

•OA diagnosis, prognosis, and the risks and benefits of treatment options •weight loss •exercise flexibility

Risk factors of osteoarthritis

•Older age •Gender Women more likely •Obesity -Weight & Endocrine response resulting in inflammation •Joint injuries •Repeated stress on the joint •Genetics •Bone deformities •Certain metabolic diseases -diabetes and hemochromatosis

-Fracture of the bone near the sight of joining with articular cartilage

•Osteochondral Fracture

-Loss of blood flow to subchondral bone leading to separation &/or instability of a segment of cartilage and it may be free movement within the joint space

•Osteochondritis Dissecans

Palpation of knee other

•Other •ITB (iliotibial band) •Popliteal pulse •Pes Anserine •Warmth Trigger points refer to the knee

Retrocalcaneal Bursitis -Treatment

•PRICED •Heel lift •Potentially open backed shoe

Osteoarthritis symptoms

•Pain -Initially dull and aching pain at the end of the day or after prolonged periods of standing or walking. -Progression is signified by pain and stiffness on rising in the morning, which eases with activity or rest, and a limitation of movement in a capsular pattern. -With inactivity -Worse with cold, trauma, fatigue •Swelling •Crepitus •Stiffness -Progression to ROM loss -Worse in the morning •Deformity •Instability •Loss of function Pain initially in morning - then feels better in the day - feels bad at end of day

Retrocalcaneal Bursitis -Signs and symptoms

•Pain anterior to Achilles tendon •Swelling is often present •Two finger squeeze test anterior to Achilles tendon and just superior to its distal insertion •Pain with passive DF

Uncompensated Rearfoot Varus - what are the other clinical signs?

•Peroneus brevis tendinopathy •Stress fractures (lack of shock absorption) •Haglund's deformity •Medial knee compartment pain and degeneration •Stress fractures up the kinetic chain

Plantar Ligaments name the two •Provide structural stability to the _____________________ of the foot

•Plantar Ligament -Long -Short (plantar calcaneocuboid ligament) •Provide structural stability to the lateral column of the foot

Anterior knee pain: evidence-based interventions plica

•Plica •Quad strengthening & stretching •Avoid repetitive activities/pressure •Biomechanics training

Special tests of knee •PCL

•Posterior Drawer •Sag Sign

Nerves of knee •Sensory innervation primarily L3-5

•Posterior tibial N to posterior capsule, associated ligaments, most of the internal structures, and even the infrapatellar fat pad. •Obturator nerve medial and posterior-medial side of capsule •Femoral nerve to the anterior medial and anterior-lateral portions of capsule

Other non-specific clinical signs of compensated rearfoot varus

•Posterior tibial tendon dysfunction or tibial tendinopathy •Plantar fasciitis •Achilles tendinopathy •Shin splints •Patello-femoral syndrome, ITB syndrome, greater trochanteric pain syndrome.

Sesamoiditis potential causes and treatment

•Potential causes -Impact -Overpronation -Great toe injury •Treatment -Acute •Reduce inflammation •Reduce stress -Limit hallices DF -Metatarsal pad placed proximal to 1st & 2nd metatarsal head

Hamstring strains: prevention & interventions

•Preventions •"Level B evidence...Nordic hamstring exercise, plus other components of warm-up, stretching, stability training, strengthening, and functional movements •Factors related to prolonged recovery: •Injury involving proximal free tendon •Smaller distance between tear and ischial tuberosity •Greater cross-sectional area of tear •Early •avoidance of isolated resistance •motor control within symptom free ROM •Lumbopelvic isometrics •Begin with functional strengthening/activities in transverse/frontal planes followed by sagittal plane •Eccentric activities beginning in mid-range and gradually progressing to end ROM •Avoid open chain stretching initially •Later stages •progressive agility and trunk stabilization exercises •running program that involves acceleration and deceleration phases, with progressive increases in speed and distance as tolerated. If tendon is injured takes more time to heal Very extreme one

Osteoarthritis primary vs secondary

•Primary or idiopathic (you don't know why it occurred) •Secondary (something happened) -Infection -Dysplasia -Trauma -AVN (avascular necrosis) •Disparity between -stress applied -vs strength of articular cartilage (is affected by many numbers) This is not always due to wear and tear Could get bone cysts

Meniscus: post-op rehab considerations

•Progressive ROM •Progressive WB (Repair = period of NWB) •Strength training: quadriceps & hamstrings •Quadriceps endurance Flexibility, activation, strength stability

Strength/stability treatment

•Progressive Resistive Exercises •Balance and Neuromotor Control Activities •Core Stability

Acute Treatment

•Protection of healing tissue •External Support •Bracing, Assistive Device, etc. •Post-surgical •Weight-bearing, Motion, or Muscle Activation restrictions •Adaptations of Exercise •Pain control •Modalities •Joint Mobilization (Grades 1 & 2) •Active & Passive Movement •Isometrics •Minimize Disuse Sequelae •Isometric Muscle Contraction •Active-Assistive/Active Movements •Adaptations of Exercise •Cardiovascular Endurance •Education •Pain •Surgery/Injury •Rehabilitation Process •Address Psychosocial Factors •Fear-Avoidance •External Locus of Control •Catastrophizing

Menisci

•Purpose: Load transmission, shock absorption, joint lubrication, joint stability, proprioception, and helps guide movements. •Medial meniscus more firmly attached to tibia (3x more likely to be injured) than the lateral, crescent or U-shaped, covers about 50% of medial tibial plateau and moves posteriorly about 5mm by pull of semimembranosus •Lateral meniscus more mobile than medial, more circular, and covers about 70-80% of lateral tibial plateau. It can move about 11mm due in part to pull of popliteus •Rotation they follow the femur •Ligaments (see next slide) Distribute loads, joint stability, proprioception, guide movement Lateral one moves better Medial one attaches to MCL? Medial menisus moves with semimembranous

Excessive pronation in early stance may relate to the foot's structure.

•Push-off occurs on a relatively mobile foot •One reason for excessive pronation is due to compensate for "intrinsic foot deformities"

Why land with knee bent?

•Quad muscles works to extend the knee region - also pulls the lower leg bone forward (tibia) relative to the upper leg bone (femur) •ACL prevents this forward movement of the tibia •Hamstring muscles work to bend the knee and pull the tibia backward (works with the ACL) •Hamstring allows the muscles to absorb the force when landing and supports the ACL •Landing with knee bend causes less stress at the ACL and allow muscles to absorb the force

Rearfoot Varus Possible compensations...

•Rearfoot - usually the foot compensates with pronation to get the heel on the ground •Forefoot - Subtalar joint and midtarsal joint supinate or pronate to get the entire foot to the ground. •Sometimes if the foot does not adapt, the body must, and we see deviations further up the kinetic chain.

An intrinsic deformity where the calcaneus is everted relative to the lower leg when the foot is in subtalar neutral position.

•Rearfoot Valgus.

intrinsic deformity whereby the calcaneus is inverted relative to the lower leg when the foot is in subtalar neutral.

•Rearfoot varus:

ACLR (anterior cruciate ligament reconstruction) ACL Surgery (ACLR) rehab

•Reconstruction vs Repair •Graft choice •Autograft •Patellar tendon (bone-tendon-bone [BTB]) •Hamstrings •Allograft •Complications •Cyclops lesion (portion of the ligament has thickened) •Re-tear •Infection •Osteoarthritis (Associated with decreased ROM) After surgery - more likely to have OA

Muscle Strains of knee •Majority of strains involve muscles that cross 2 joints name 3

•Rectus femoris •Hamstrings •Gastroc• Need to get treated right away Muscle begins to retract

CPG Component 5: Intervention Strategies Acute: Diagnostic Indicators

•Redness, warmth, and swelling •≤3 mo in duration •High levels of pain limiting low-level activity (ie, walking) •Findings/interventions -Pain and inflammation - Iontophoresis, Other modalities -Loss of motion - Stretching, Joint and/or soft tissue mobilization -Painful motion - Rigid taping, Other range-of-motion protective treatment (ie, bracing) -Include patient education and counseling (activity modification, modifiable risk factors, course of recovery)

Interventions for Pronated Feet

•Reduce stress on inflamed structures •Strengthen the muscles that support the arch •Correct biomechanical dysfunction •Proprioception training •Modalities and soft tissue techniques •Shoe inserts and modifications

Uncompensated forefoot varus' effect on gait

•Reduced ability to absorb shock. •Reduced limb rotation. •Difficulty adapting to uneven surfaces. •Maintained lateral weight-bearing.

The Referral Process

•Referral the patient back to the physician or other health care provider may be necessary. You may want to call and ask the physician how they want to handle the situation. Either way you must communicate with the referring practioner: -Describe the problem and the observed cluster of signs & symptoms: Do not suggest a medical diagnosis. -Provide written documentation, a short summary of your evaluation, and a list of concerns or red flag signs and symptoms with the following comment: •These do not seem consistent with a neuromuscular or musculoskeletal and seek their input. •What do you think? Keep your questions open-ended •Emergency situations require emergency action.

Selective Functional Movement Assessment (SFMA)

•Regional Interdependence •Looks for patterns within tests •Direct to further testing -find the weak link

Evaluating for Syndesmotic injury how long does it take to recover?

•Rehab - mean is 55 days •46.4 days return to play •Dutton (2020), states ..." syndesmosis sprain can take anywhere up to 2-20 times more time than that of a lateral ankle sprain to recover." (p.1095)

Inflammatory Mediators

•Released from ischemic skeletal muscle •Produce local and systemic effects -Local: increase capillary permeability, activate coagulation cascade to produce more tissue damage -Magnitude of systemic response depends on amount of muscle mass involved

Meniscus: surgical options

•Repair vs Partial Meniscectomy

Physical Performance Measures in Ther Ex (for ankle)

•Running -40-meter run time -Figure 8 (cones 3-5 meters apart) •Hopping -Single-limb hop for distance -Triple hop -Crossover hop -Stair hop -Side to side hop •Start Excursion Balance Test •Agility T-Test •Y-Balance

Multiple Ligament Injured Knee (MLIK)

•Rupture of 2 or more knee ligaments •Increased likelihood of rotary instability •Concern re: neurovascular involvement •May be more likely to develop arthrofibrosis and prolonged dysfunction All types of instability

Patellar Tendon Rupture signs and symptoms

•S & S -Inability to extend knee -Significant swelling -Pain -High riding patella •Patella alta -R/O (rule out) patellar dislocation Higher patella

Iliotibial Band Friction Syndrome signs and symptoms

•S & S -Pain over lateral femoral epicondyle -Crepitus -Localized swelling -Pain with running

Patellar/Quadriceps tendonopathy signs and symptoms

•S & S -Pain with deceleration •jumping -Quadriceps weakness -Palpable tenderness -Tendon crepitus

Patellar subluxation/dislocation signs and symptoms

•S & S -Sensation of knee "going out" -Intense pain with effusion -Inability to actively flex knee •Laterally displaced patella -Significant soft tissue damage -Deformity -Often reduces on its own with extension of the knee •Must R/O (rule out) fracture and knee dislocation

Contribution from adjacent structures

•SFMA •dont forget to Screen joint above/below •AROM/PROM •Overpressures Screen above and below and potential additional factors

How do we Distinguish? (what is happening to our patient?)

•Screen for medical conditions •Red flags in the history -Previous cancer -Unusual weight loss or gain -Previous surgeries -Medications •Long-term use of steroids •Excessive use to dull pain •Constitutional signs or symptoms -Fever, chills, fatigue, swollen joints, etc •Physical Exam -Pain with weight bearing -Antalgic or ataxic gait -Noncapsular pattern -Hard, immovable lymph nodes -Vascular signs or symptoms -Sensation or other neurological findings •Diminished or hyperactive DTRs -Special tests •McBurney's •Blumberg's sign - Abd. Rebound tenderness •Log-rolling test - -Synovitis = pain at extremes of rotation. Significant hip trauma or septic hip joint potentially causes pain with minimal rotation. •Unable to change their symptoms with mechanical examination or change in position.

Selective Functional Movement Assessment (SFMA)

•Seven Basic Movements -Cervical Spine -UE movement pattern -Multi-segmental •Flexion •Extension •Rotation -Single-leg stance with knee lift -Arms down deep squat •Four Optional Movements -Plank with a twist -Single-leg squat -In-line lunge with lean, press, and lift -Single-leg hop for distance

•Screw-home mechanism is based on what 3 things?

•Shape of medial femoral condyle •Tension in ACL •Lateral pull of quads femur - internal rotation tibia - external rotation

LCL

•Simple - one band? Dutton states 3 bands •Well, there is a proposal 6 types of the LCL - say it isn't so •Resists varus moments at all knee angles •Resist tibial ER from 0-30 degrees- it does resist IR too but to a lesser degree •ALL? - Anterolateral ligament •Currently it is being debated if it is a ligament or a thickening of the anterolateral capsule.(more anterior than LCL for lateral stabilization) (Andrade et al., 2019) Complicated There are variations in the LCL Red muscle is popliteaus GT is gerdys tubercles - iliotibial band attaches there

Sinus Tarsi Syndrome

•Sinus tarsi syndrome develops from excessive motions of the subtalar joint that results in •Injury to interosseous talocalcaneal and cervical ligaments •Subtalar joint synovitis •Infiltration of fibrotic tissue into the sinus tarsi space Inflammation of cervical ligament and other ligament Due to subtalar instability Provide stability Sinus tari means tunnel

Subtalar Joint Ligaments

•Sinus tarsi syndrome develops from excessive motions of the subtalar joint that results in •Injury to interosseous talocalcaneal and cervical ligaments •Subtalar joint synovitis •Infiltration of fibrotic tissue into the sinus tarsi space

Measuring Width on Brannock Device

•Slide heel firmly to back of Brannock device. •Slide the width bar firmly to the edge of the foot for thin foot and lightly for wide foot. •Locate the shoe size (as determined in step four) on the movable width bar and view the width measurement indicated by the properly determined shoe size. •If the shoe size falls between widths, choose a wider width for a thick foot, a narrower width for a thin foot.

Anterior knee pain: evidence-based interventions compressive syndromes

•Soft tissue mobility •Joint mobilization •Taping? •Avoid OKC(open kinetic chain) 0-30 & CKC >60 - it probably matters more about initially being relatively pain free with the exercise

Risk Factors for Stress Fractures

•Some combination volume, intensity, and surface in training •menstrual disturbances •caloric restriction •decreased bone density •muscle weakness •leg-length differences •lower dietary calcium intake •less oral contraceptive use •decreased testosterone level in male endurance athletes -female athlete triad

# 4 Rearfoot Valgus

•Some say this does not clinical exist unless there is a structural deformity. Likely would see a rearfoot valgus with Charcot foot deformity

Ankle & Foot Injuries Most ankle injuries fall into these basic categories :

•Sprains •Strains •Contusions •Degenerative conditions •Fractures

Tendon Load Management

•Stage 1: Isometrics are used to manage patients with high levels of pain irritability (typically 1-2 weeks) - Flexibility issues are initiated during this stage, •Stage 2: Isotonic concentric and eccentric maneuvers (Heavy Slow Resistance - about 3 seconds per phase, which totals about 6 seconds each rep) progressing to; •Stage 3: Energy-Storage exercises (hops, acceleration [sprinting or deceleration, cutting]) and then; •Stage 4: A progressive return to sport. Return to sport is often recommenced when full training is tolerated without symptom provocation for 24-hours after a load test, such as the single-leg decline squat and any power and endurance deficits have been resolved. Great way to introduce load

Other functional testing

•Stair Ascension/Descension •Sport Specific Movements •Video analysis

Meniscus: evidence-based interventions

•Strengthening: musculature crossing knee (Especially quadriceps) •Avoid deep squatting, kneeling, twisting, pivoting, repetitive bending, running (compression + shear) •Balance & Motor Control •LE Biomechanics

Shock Absorption and Mobility Unlocking mechanism

•Subtalar pronates 1.Talus adducts and plantarflexes 2.Calcaneaus everts 3.Tibia internally rotates •Transverse tarsal joint UNLOCKS •Provides MOBILITY to adapt various terrains and shock absorption

•Subtalar pronation causes the MTJ axes to become ___________ •Subtalar supination causes the MTJ axes to become ____________

•Subtalar pronation causes the MTJ axes to become more parallel. •Subtalar supination causes the MTJ axes to become non-parallel

Stability Locking mechanism

•Subtalar supinates 1.Talus abducts and dorsiflexes 2.Calcaneus inverts 3.Tibia externally rotates •Transverse tarsal joint LOCKS •Provides STABILITY for Propulsions

Reverse anterolateral drawer test

•Supine, knee flexed & heel fixed on plinth •10-15 degrees PF •Support the foot by grasping the 1st metatarsal then cup the lateral side of the foot with tips of fingers touching 1cm proximal to tip of fibula. •Other hand uses the base of the palm to produce a posterior tibial translation parallel with articular surface of talus. •Sensitivity greater than the ADT & ALDT •--push the tibia back, stabilize foot

Focal articular cartilage injuries

•Surgical Options •Microfracture •Osteochondral Autologous Transplantation Surgery (OATS) - the photo •Mosaicplasty •Rehab Considerations •Initial NWB •Progressive WB

Neutral Wear Pattern

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

Ankle Fracture

•Tender over the fibula •Often unable to bear weight •Medial tenderness, widened mortise = unstable fracture The mortise should have same distance Crack in fibula

Anterior knee pain: evidence-based interventions tendinopathy

•Tendinopathy •Isometrics to Eccentrics

Uncompensated Rearfoot Varus - what are the clinical signs?

•The calcaneus remains inverted •Weight is forced laterally on the entire foot. •This causes increased shearing laterally, as well as on the 4th and 5th metatarsal heads, because the foot is in an unstable position.

Orthotic for compensation of Forefoot Valgus

•The compensation makes the foot less stable during preswing and push-off and, over time, produces joint laxity and pain. •Therapists can eliminate the need for compensation by supporting the deformity with an orthosis that incorporates a lateral forefoot wedge.

•Blood supply of knee

•The femoral artery and the popliteal artery are primarily responsible for the knee. There six branches are known as the genicular arteries and the recurrent branch of anterior tibial artery.

The Physical Examination

•The intake form and the interview help to structure the physical exam. •How irritable the condition is or not will often determine how much force is needed to reproduce their symptoms •An emerging picture of one or more disorder should begin to form. Exam is based on the interview Interview is the most important part

ankle and foot arthrology (joints) •The major joints of the ankle and foot are the ___________, __________, and __________ joints. The________ is mechanically involved with all three of these joints.

•The major joints of the ankle and foot are the talocrural, subtalar, and transverse (midtarsal) tarsal joints. The talus is mechanically involved with all three of these joints.

Compensated Forefoot Varus

•The person compensates (B) by pronating the STJ during midstance and terminal stance to allow the first metatarsal to contact the ground. •The calcaneus everts and the subtalar joint pronates to get the 1st MTP to the ground. Looking at left foot

Forefoot Valgus, compensation

•The person compensates (B) by supinating the STJ during midstance then pronating during terminal stance.

"Bottom up:" foot position influences behavior of proximal joints

•The subtalar joint pronates rapidly during loading response... •then "recovers," supinating through midstance and terminal stance. •The subtalar joint reaches its neutral position by heel off (during terminal stance; 35 to 40 percent of gait cycle).

Synovial plica

•Thickening of synovial membrane •Normal anatomical variant •MOI -Overuse •Repetitive bending/straightening -Direct trauma -Biomechanical abnormalities •S & S -Anterior knee pain •Kneeling, squatting, prolonged sitting -Tenderness •Medial femoral condyle -Clicking, popping, locking (pseudo), focal swelling •R/O medial meniscus injury More common medially Calm it down - make sure structures are flexible

Accessory Motions of knee

•Tibiofemoral •Tibiofibular •Patellar

Causes of Pain/Dysfunction to knee

•Traumatic vs Overuse •Mechanical vs Chemical •Regional Interdependence

Educating Patient's about Plantar fasciitis

•Understanding the condition -PF is the most common cause of heel pain in the US, affects > 2 million people. -Conservative tx is successful up to 90% of time. -Most symptoms resolve in a year regardless of intervention •What is it? -PF is a degeneration of the plantar fascia as a result of repetitive microtears of the fascia that lead to an inflammatory reaction •Cause? -multifactorial, with abnormal biomechanics and delayed healing are likely contributors •Treatment -Stretching, orthotics (over the counter), night splint, alter risk factors, control inflammation -Expect significant pain reduction in the next 1-3 weeks, with continued resolution over 2-3 months They are not alone

Bursae of the knee

•Up to 11 common bursae Don't need to know all these names but think of common problems

Special tests of knee •MCL

•Valgus Stress

Special tests of knee •LCL

•Varus Stress

Example of ACL Injury Prevention Program: Basic Components

•Warm-Up (~2 min): increase core temp, increase heart rate, and circulation throughout the musculature •Stretching (~2 min): either dynamic (stretching while moving) or static (stationary/traditional stretching) •Strengthening (~4min): focus on the hip region and the thigh regions •Plyometrics (~4 min): jumping, landing, ballistic movements •Agility (~4 min): cutting, changing directions

Onset of Symptoms

•Was onset of symptoms sudden? •NO •Gradual onset of symptoms •Does pt. have overuse condition or a chronic condition (e.g., tendinitis, bursitis, arthritis)? •YES •Was onset of symptoms related to an injury? •NO •Rapid onset, non-traumatic injury •Does pt. have acute inflammatory condition (i.e., tendinitis, bursitis, strain)? •YES •Did the injury involve direct contact? •NO •Rapid onset, non-contact injury •Does the pt. have a traumatic condition (i.e., sprain, strain, subluxation, dislocation, fracture)? •Think ACL INJURY any time you have a patient with a significant NON-CONTACT injury with foot planed on the ground (foot planted then knee twisted or body changed direction, felt a pop, immediate swelling, could not continue playing) •YES •Rapid onset, non-contact injury •Does the pt. have a traumatic condition (i.e., sprain, strain, subluxation, dislocation, fracture)?

Swelling After Injury?

•Was there swelling associated with this injury •YES •How soon did the swelling develop? •Within 24 hours •Hemarthrosis associated with ligament, meniscal, or osteochondral injury •Intra-articular injury •More than 24 hours •Reactive synovitis associated with trauma or overuse condition •More likely extra-articular •Swelling is not a distinctive term •Edema (bone or soft tissue) •Joint effusion

Posterior Tibial Tendonitis

•Who -Dancers, joggers, ice skaters, increased BMI, over pronators •Contributing factors -Poor flexibility •Short triceps surae complex •Shortened posterior tibialis (pes cavus) -Weak musculature •posterior tibialis •Flexor hallucis longus and flexor digitorum (work with post. Tib. As dynamic stabilizers of longitudinal arch) -Alignment abnormalities that lead to over pronation -Training conditions (poor foot wear, over training, training surface) •Signs & Symptoms -Painful during or limited heel off -Over pronation -Pes planus -MMT: weak & painful -Pain in 3 locations •Distal to malleolus near navicular •Proximal to malleolus (medial) •Musculotendinous origin (Medial Shin Splints)

Windlass Mechanism

•Windlass: tightening of a rope or cable •Tightening of the plantar fascia as a result of hallux dorsiflexion (tightens fascia and elevates arch) Mechanism whereby tension in plantar aponeurosis raises foot arch Dorsiflex first mtp the planatarfascia gets tight Brings the heel closer to metatarsal heads- supports arch, makes it a more rigid

MCL

•Yes, I have two bands too •Superficial •Longer than you think, just below adductor tubercle to 6 cm below joint line •Tightest with knee extension •Did you know if you combine me with the posterior capsule, I become the posterior oblique ligament (POL)? •Deep •Blend with capsule and meniscus •Anterior fibers tighter in knee flexion - opposite for posterior fibers •I also help prevent tibial ER •biomechanics •There is often a bursa between the two bands Superifical and deep bands Superficial one is broad Prevents tibial external rotation

PCL

•Yes, I have two bundles too •Anterolateral (AL) •Tightest in flexion •Posteromedial (PM) •Tightest in extension •biomechanics •50% thicker and 2x as strong as my cousin ACL •minimizes posterior tibial displacement (95%) •Secondary restraint to tibial ER at 90 degrees Under tension most of the time in extreames of the range Stops posterior displacement of tibia Instraartucialar but extracapsular

OsteoarthritisX-ray changes

•joint space narrowing •subchondral sclerosis •osteophytes •cysts You get narrowing in the joint space subchondral sclerosis Whitening

Jumping Technique •Land:

•on the balls of the feet •knees flexed (initially ~ 20 deg and then bend to about 40 deg) - Simple cue to land "softly" has been shown to decrease force at the ACL •chest over the knees •avoid excessive movement of the knee upon landing (inward or forward) - keep knee over the middle of the foot •Keep hips straight - don't turn out hips •Equal weight on the right and left To land properly Balls of feet, softly Don't want to have valgus when you jump

Medial Tibial Stress Syndrome

•or tibial periostitis •Basically posteromedial shin splints with a more focal and painful periosteal inflammation -Near origin of posterior tibialis & medial soleus •Treatment involves is similar to posterior tibial tendonitis •Differential Dx includes: tibial stress fx, compartment syndrome, posterior tibial tendonitis

_________ is a quality of structures that maintain their integrity due primarily to a balance between tension and compression

"Tensegrity" or "tension integrity,"

"The body seeks balance... and while the body may not be symmetrical, it is in balance" "Tensegrity" or "tension integrity,"

"Tensegrity" or "tension integrity," is a quality of structures that maintain their integrity due primarily to a balance between tension and compression "Many individuals train around a pre-existing problem or simply do not train their weaknesses during strength and conditioning (fitness) programs." -Many individuals only train their strengths

The anterolateral drawer test (ALDT)

(anterior drawer test [ADT] combined with inversion, internal rotation, and adduction of the forefoot).

Exercise-induced muscle injury related factors:

(delayed muscle soreness) related factors: Increased activity Unaccustomed activity Excessive eccentric work Viral infections Muscle cell damage

Matles Test for Achilles Tendon Rupture

(patient prone with foot over edge of plinth. Patient actively flexes their knee to 90, if there is no tear in the Achilles the foot should remain slightly plantar flexed. If there is a tear in the Achilles, gravity will cause the foot to DF or approach a neutral position of the ankle)

•Infrapatellar (Hoffa's) fat pad

- An extrasynovial tissue, due to location and metabolic properties of adipose tissue, may influence the synovial membrane, and potentially considered a morpho-functional unit. •Innervation: "Nerve fibers from the posterior tibial nerve" •"Biomechanical: promotes synovial fluid distribution absorbing loads of the knee joint" •"Biochemical: secretes proinflammatory mediators (i.e. adipokines, interleukins) and growth factors showing endocrine-paracrine and autocrine-like activity on the cartilage and synovial membrane" Fat pad behind patella is important Metabolic structure Helps with distribution of synovial fluid Biomechanical and biochemical

Symptom sources by LOCATION •Anterior

- Anterior knee pain (e.g., chondromalacia, fat pad irritation), bursitis, Tibial apophysitis (Osgood-Schlatter's disease), patellar tendinitis (Jumper's knee), intra-articular dysfunction, OA, plica, fracture, soft tissue referral, neurologic referral, surgical pain, Patellar subluxation or dislocation

Symptom sources by LOCATION •Lateral

- Meniscus, LCL, ALL, DJD, iliotibial band friction syndrome, fibular head dysfunction, fracture, intra-articular dysfunction, soft tissue referral, neurologic referral

Symptom sources by LOCATION •Posterior

- hamstring injury, tear of posterior horn of medial or lateral meniscus, Baker's cyst, intra-articular dysfunction, neurovascular injury (popliteal artery or nerve), soft tissue referral, neurologic referral

Symptom sources by LOCATION •Medial

- meniscus, MCL, DJD, pes anserine bursitis, intra-articular dysfunction, plica, soft tissue referral, OA, neurologic referral

Morton's foot

- short 1st metatarsal compared to 2nd metatarsal - may lead to increased weight bearing through 2nd metatarsal head can lead to Metatarsalgia

•All 3 - takes a lot of force (ATFL, CFL, and PTFL)

-"An inability to bear weight or the presence of severe pain and rapid swelling indicates a serious injury such as a capsular tear, fracture, or grade III ligament sprain." -Fractures must be ruled out, especially with the skeletally immature population.

ACL Injuries signs and symptoms

-"Pop" -Often not associated with external trauma -Rapid effusion •Hemarthrosis -Restricted movement -Feelings of instability -Giving way or buckling -(+) Lachman, Anterior Drawer, Pivot Shift Variety of mechanisms Nice ACL vs torn one - lots of vasculature

PCL Injuries signs and symptoms

-"Pop" -Vague knee pain -Giving way or buckling -Variable swelling (delayed) -Unable to fully extend -Pain with prolonged sitting, going up/down stairs/hills, &/or jumping -(+) posterior drawer test, posterior sag sign, dial test Lots of swelling

Hamstring Strain signs and symptoms

-"pop" with sudden sharp pain -"tightness" -localized swelling -bruising -location important - rule of thumb -> the higher the strain, the longer the rehab -pain with resisted knee flex and passive stretch -palpable tenderness -potential palpable defect Lots of bruising the higher the strain, the longer the rehab - if it is towards ischial tuberosity - longer recovery

ankle overview

-28 bones -55 articulations -30 synovial joints -Forces at talocrural during walking reach 120% of body weight & 275% while running (Significantly greater forces while running at talocrural joint) -1.5-3 times your body weight is exerted at the talocrural joint during heel strike while running - A 150-180lb person is estimated to absorb 63.5-76.2 tons while walking a mile and 110-121.5 tons if running a mile

Hallux Conditions •Hallux valgus

->20 degrees (normally expect 8-20 degrees) -Congruous or Pathological

-A typical Q-angle (with the knee extended) is ______ degrees for men, and ________ degrees for women ->_____ degrees may increase chances of patellar tracking issues.

-A typical Q-angle (with the knee extended) is 13 degrees for men, and 18 degrees for women - >18 degrees may increase chances of patellar tracking issues.

Lower Extremity Bone Development: Hip •Muscle pulls

-Active pull of the muscles while the infant and child are moving influences bony development -Abnormal muscle pull or bony torsion

•Two types of compartment syndrome exist: Acute and chronic.

-Acute compartment syndrome (majority of cases) is related to a type of trauma occurring to the involved compartment -Chronic compartment syndrome, known as exertional compartment syndrome, is associated with small injuries to the body or continual loading of a limb related to physical activity

PCL Injuries MOI

-Anterior force with knee flexed •Fall with ankle plantarflexed -Hyperflexion -Severe hyper-extension With direct blow Contact injury Takes force to cause Car wreck (tibia hits dash board) Stepping in hole

Achilles Tendinopathy •Training Variables

-Anthropometric variables •Pes cavus -Lack of regular stretching -Fatigue -Muscular weakness resulting in more than usual eccentric work -Hill running -Fast running -Improper shoes Spiked shoes

Achilles Rupture •Symptoms

-Arrrgh! Mommy •Immediate pain -Difficulty walking -Often an audible "snap" -Swelling -Palpable defect -a divet

Achilles Rupture •Three activities primarily associated with the rupture

-At push off -Sudden DF with FWB during fall -Violent DF with jumping from higher surfaces

Abnormal Pronation •Causes:

-Bony abnormalities of the ankle, STJ, or the MTJ -Soft tissue abnormalities such as a tight Achilles tendon, ligamentous laxity, and/or weak extrinsic or intrinsic musculature or as compensation for extrinsic abnormalities to the foot such as; femoral antetorsion or internal tibial torsion Effects the whole chain not just the foot

Ankle Sprain Treatment •Grade III

-Casting or bracing are required -Likely will require >6 weeks before return to full function •Proprioceptive training and Eccentric strengthening is essential -May take 1-4 years before symptom free

Skeletal Development in Children •Forces that influence bone development in young children: name two

-Compressive forces: weight bearing and muscle pulls •Asymmetrical forces can result in asymmetrical growth at the epiphyseal plate -Shear forces: muscle pulls •Results in torsional or twisting forces in bones

Chronic Ankle Instability •Treatment

-Conservative 2-3 months •Phase I-IV •Leg brace, taping, or orthotic support -Surgery •Overall success rates for surgery >80%

Hallux Conditions •Hallux Limitus/Rigidus

-DF of big toes is limited •Arthritis •Anatomical abnormality - index plus forefoot •Pronation •Trauma -Test: quick scan - standing see if they can just lift their big toe without lifting the others. Should be greater than 10 degrees of DF. <10 degrees is considered limited -Treatment: rest, PRICED, shoe modification (larger toe box - rocker bottom), joint mobilization, exercise, corticosteroid injection, surgery •Don't forget to include: Sesamoid mobilization, flexor hallicis strengthening, cues to push through hallicis with gait

Posterior Tibial Tendonitis •Who

-Dancers, joggers, ice skaters, increased BMI, over pronators

Cuboid Syndrome •Rx

-Devo - Ah, whip it good •Some prefer the cuboid squeeze - same end position as the whip, wait for tissues to relax then use thumbs to relocate cuboid -Low-Dye taping to maintain arch for 1-2 weeks -Soft tissue mobilization - peroneals and long dorsiflexors

Traumatic Myositis Ossificans

-Direct blow or muscle tear •Bone formation at an abnormal site -Usually in soft tissue •Signs & Symptoms -Previous muscle strain or direct blow with significant bruising -Pain with palpation of muscle -Pain with activation of muscle -Restricted ROM

•Anterior compartment of LE

-Dorsiflexion muscles of the ankle and foot •Tibialis anterior •Extensor digitorum longus •Extensor hallucis longus •Peroneus tertius -Anterior tibial artery - Commonly injured in lateral tibial plateau fractures -Deep peroneal nerve - Provides sensation to the first dorsal web space

Rearfoot Varus, continued... •This person compensates (B) by

-Everting the calcaneous -And pronating the subtalar joint to allow the medial heel to hit the ground.

Evaluating for Syndesmotic injury •Mechanism of injury

-Forced DF -Forced eversion

Skeletal Development in Children •Growth and resultant shape of the skeleton are affected by:

-Genetics -Nutrition -Mechanical forces

•Typical Single Ligamental Grading System Edema and ecchymosis are often present (caused by tearing of the vasculature); the person is able to ambulate with stability.

-Grade I:

•Typical Single Ligamental Grading System

-Grade I: Edema and ecchymosis are often present (caused by tearing of the vasculature); the person is able to ambulate with stability. -Grade II: Edema and ecchymosis are more extensive. The person may or may not be able to complete what they were doing when injured (be it ADL, Work, or Leisure, i.e., basketball player may be able to finish the game). -Grade III: Edema and ecchymosis are more diffuse than the previous grades; the person is typically unable to weight bear, the joint is grossly unstable, the foot usually drops and supinates (with lateral ankle sprains). Possible to have an isolated Grade III, but more likely several are involved.

•Typical Single Ligamental Grading System Edema and ecchymosis are more extensive. The person may or may not be able to complete what they were doing when injured (be it ADL, Work, or Leisure, i.e., basketball player may be able to finish the game).

-Grade II:

•Typical Single Ligamental Grading System Edema and ecchymosis are more diffuse than the previous grades; the person is typically unable to weight bear, the joint is grossly unstable, the foot usually drops and supinates (with lateral ankle sprains). Possible to have an isolated Grade III, but more likely several are involved.

-Grade III:

Hallux Conditions •Turf toe

-Hyperextension sprain typically with a compressive load (less often due to hyperflexion injury) •Varus or valgus stresses may have been imposed •Capsule can be torn •Sesamoid fractures can occur •Cartilage damage -Dutton states that 50% of the athletes may continue to have unresolved symptoms even 5 years later. -Treatment: PRICED, limit DF, motion and resistance as soon as symptoms allow, may need limited WB, could be out of sports participation for up to 6 weeks. Modified shoe. Grade I - can play as symptoms allow, Grade II out of play 3-14 days, Grade III sprain - up to 6 weeks out of play. Needs 90 DF before returning to play. Non-athletes need 75 decrees of 1st MTP DF for normal walking.

Lower Quarter Assessment & Screening •What should it accomplish?

-Identify movement patterns (Regional Interdependent Modeling) •Expected range but painful •Altered range -Painful -Nonpainful »At risk for injury -Identifies which altered movement require the greatest scrutiny during the examination -Identify difficulty with exercises or activities -Link movement errors to corrective exercise (program design) -A standardized approach to allow comparison from baseline measurement and across populations

Tendinopathy: Update on Pathophysiology •Potential Predisposing Factors

-Increased BMI, LDL -Meds: corticosteroids, statins & Fluoroquinolones (antibiotic) -Poor regulation of substance P and prostaglandin E2 can be damaging in overuse situations (may lead to a central sensitization component)

Chondral-Osteochondral Lesions (Defects) MOI

-Internal trauma •Plant and cut to opposite side -intercondylar eminence impacts posterolateral corner of medial femoral condyle -External trauma •Direct blow -Fall with knee flexed -Injury to weight-bearing surface of femoral condyle

Cuboid Syndrome •Symptoms

-Lateral midfoot pain -Feels like they are walking on pebbles -Unable to run, jump, or cut -Palpable tenderness to plantar aspect of foot over calcaneocuboid joint

Lateral Sprains exams

-Ligaments (ATFL, CF, PTFL) -PROM - PF/Inv painful -A/RROM - DF/ever painful -Anterior Drawer •Dimple sign (1st 48hrs)

Plantar Fasciitis (Plantar Heel Pain) •Etiology

-Multifactorial -Decrease PF strength -Obesity -Antetorsion -Decreased DF -Over pronation -Pes cavus -Improper shoe wear -Overtraining -Occupational

Tibial Tubercle Fractures

-Occur far more commonly in children and adolescents, but still uncommon -Two common mechanism -1) violent knee flexion with quad contraction (e.g., landing from a jump) -2) powerful contraction of quads with fixed foot (e.g., jumping - too many box jumps) -The Ogden and Murphy classification system use 5 categories with subcategories A & B to indicate displacement and commination

Achilles Tendinopathy •More popular proposed mechanisms:

-Overpronation -Decreased dorsiflexion -Weak PF -Altered blood supply -Improper training

Educating Patient's about Plantar fasciitis •What is it?

-PF is a degeneration of the plantar fascia as a result of repetitive microtears of the fascia that lead to an inflammatory reaction

Ankle Sprain Treatment Grade 1

-PRICEDEM -Brace for 10-14 days (stirrup brace or similar) when performing athletic events, average return to full activities in 11 days is expected. -Rehab: peroneal strengthening and proprioceptive training (•Eccentric strengthening is essential) -Educate that it may take several month to regain full ligamental stability

Lateral Sprains what will be painful with PROM and what will be painful with AROM/RROM

-PROM - PF/Inv painful -A/RROM - DF/ever painful

Collateral Ligament Injuries •Signs and Symptoms

-Pain •Along course of ligament -Variable joint line laxity -Stiffness -Gait deviations -Swelling •Minimal to moderate -(+) valgus/varus stress tests •0 and 30 degrees (at both degrees)

LE Compartment Syndrome Presentation & Diagnosis •Acute

-Pain is disproportionate to the injury; progressive; not relieved by morphine; spontaneous at rest; and worsened by passive stretching of the involved muscles -Involved compartment may also be palpably tense, have signs of numbness, pulselessness, partial paralysis, and paleness.

Plantar Fasciitis (Plantar Heel Pain) •Signs & symptoms

-Pain upon initial weight-bearing -Pain at medial calcaneal tubercle -Pain with prolonged weight-bearing or increased activity (e.g., running or stair climbing) -Pain with DF, which is further exacerbated with 1st MTP DF •Great toe DF range is often limited to less than 90 degrees -Rest relieves symptoms

Chondral-Osteochondral Lesions (Defects) •Some common symptoms include:

-Pain, especially with weight bearing -Tenderness -Joint instability -Decreased mobility -Catching or locking sensation -Swelling / hemarthrosis (blood within a joint)

Posterior Tibial Tendonitis •Signs & Symptoms

-Painful during or limited heel off -Over pronation -Pes planus -MMT: weak & painful -Pain in 3 locations •Distal to malleolus near navicular •Proximal to malleolus (medial) •Musculotendinous origin (Medial Shin Splints)

Screening for Red Flags & Comorbitities •The three primary methods for obtaining information are:

-Patient Intake, -the Interview, -and the Physical Examination. •No one question, examination technique, sign, or symptom can definitively rule something in or out.

Achilles Tendinopathy •Types

-Peritendinitis •Inflammation in the tissue surrounding the tendon •Often 2 - 6 cm above insertion •Possible crepitus with long standing injury (paratenon with fibrin exudate) -Peritendinitis with tendinosis -Tendinosis •Focal areas of tendon degeneration •Weekend warrior -Tendinopathy - "...nonrupture injury in the tendon or paratendon that is exacerbated by mechanical loading."

lateral compartment of leg

-Peroneus brevis and peroneus longus (that is right, I said peroneus not fibularis) - Plantar flexor and evertor muscles of the foot -Superficial peroneal nerve - Provides sensation to the dorsum of the foot

•Deep posterior compartment of LE

-Plantar flexor and phalangeal flexor muscles •Tibialis posterior •Flexor digitorum longus (FDL) •Flexor hallucis longus -Posterior tibial and peroneal arteries -Posterior tibial nerve - Provides sensation to the sole of the foot

•Superficial posterior compartment of LE

-Plantar flexor muscles of the foot •Gastrocnemius •Plantaris •Soleus -Sural nerve - Provides sensation to the lateral aspect of the foot and distal calf

Evaluating for Syndesmotic injury •Tests for injury to the syndesmosis

-Point test -The Squeeze test -External rotation test -One-legged hop test -Dorsiflexion -Clunk test (side-to-side test)

Posterior Tibial Tendonitis •Contributing factors

-Poor flexibility •Short triceps surae complex •Shortened posterior tibialis (pes cavus) -Weak musculature •posterior tibialis •Flexor hallucis longus and flexor digitorum (work with post. Tib. As dynamic stabilizers of longitudinal arch) -Alignment abnormalities that lead to over pronation -Training conditions (poor foot wear, over training, training surface)

Achilles Rupture •Clinical tests

-Positive Thompson test •Low sensitivity 40% -Palpation and visualization of defect -Matles test - Client prone, active knee flexion to 90, if foot DF or goes to neutral it is (+). 88% sen, 85% spec (Dutton, 2017, p.1133) - not state in 2020 version

Ankle Sprain Treatment •Grade II

-Possible Cam Walker Boot or Bracing for several weeks -PRICED, rehab as previously described •Proprioceptive training and Eccentric strengthening is essential -Typically, able to return to full function in 2-6 weeks -May require brace or taping for sports for 6 months

"Shin Splints" Tibial Stress Syndrome •Anterolateral

-Pretibial muscles (TA, EHL, EDL) •Hard surfaces •Poor heel cushioning •Imbalance between pretibial and triceps surae (gastric soleus complex) -Symptoms typically at HS or swing phase

"Shin Splints" Tibial Stress Syndrome •Posteromedial

-Primarily related to overpronation -Symptoms exacerbated in late stance -May lead to medial tibial stress syndrome

Chronic Ankle Instability •Subjective c/o (complaints of)

-Repeated episodes of giving way, -frequent sprains, -unreliable ankle, -unable to run or run on uneven surfaces, -difficulty cutting or jumping, -tenderness, -weakness, -and/or recurrent swelling.

Alignment from a Soft Tissue Perspective •Muscle length

-Short muscles that are stiff/tight -Short muscles that are hypertonic Hypertonicity: a condition in which the nerve input to a muscle is increased, resulting in greater resting tone. -Long muscles (prolonged elongated position, injurious strain, sustained stretching) or due to reciprocal inhibition. Reciprocal inhibition: reflex action that occurs when an active muscle suppresses the antagonist

•Retrocalcaneal Bursitis

-Signs and symptoms •Pain anterior to Achilles tendon •Swelling is often present •Two finger squeeze test anterior to Achilles tendon and just superior to its distal insertion •Pain with passive DF -Treatment •PRICED •Heel lift •Potentially open backed shoe

Other Tendonitis (tibialis anterior)

-Similar complaints as posterior tibialis except location of pain •Treatment similar to post tibialis with more emphasis on triceps surae flexibility

•Forefoot varus

-Some state that it is the leading cause of abnormal pronation -Abnormal STJ and midtarsal pronation occurs as a result of trying to bring the 1st ray to the ground -Prolonged pronation from mid-stance to pre-swing -retards midstance/terminal stance supination (less rigid foot) Try to bring first metatarsal to the floor

Educating Patient's about Plantar fasciitis •Treatment

-Stretching, orthotics (over the counter), night splint, alter risk factors, control inflammation -Expect significant pain reduction in the next 1-3 weeks, with continued resolution over 2-3 months

Cuboid Syndrome •Causes - speculative

-Subluxation of cuboid -Abnormal pull of peroneus longus -Some report increased pronation as a factor or symptom

Meniscal injuries signs and symptoms

-Sudden locking, catching -Localized joint line pain -Giving way or buckling -Delayed mild/mod effusion -Pain with weight-bearing -Pain on hyperflexion/squatting -(+) McMurray's test, Thessaly's test Meniscus is not well vascularized Bucket handle tear probably needs to be repaired

Osgood-Schlatter's •Signs & Symptoms

-Tender "bump" below the knee -Pain with extension RROM -Pain during rigorous activity •Jumping •Deep knee bends •Weight-lifting

Tendonopathy and Paratendonitis = swelling in the tendon will move with the DF -video above = swelling does not move with DF

-Tendonopathy = swelling in the tendon will move with the DF -video above -Paratendonitis = swelling does not move with DF If it moved- with tendon If didn't move- with paratendon

Tendinopathy: Update on Pathophysiology •Tendon characteristics & symptoms

-Thicker, but less ability to store energy (bad collagen not good) -stress shielding-uneven distribution of forces -Morning stiffness or delayed onset of pain may indicate return of inflammation and need to decrease strain -May take 36-78 hours after activity before there is increased collagen deposits (learn about this later) Left is good looking collagen, right they are not aligned well

Typical Ligamental Grading Scale •Lateral Ankle Sprains Isolate or combination?

-This grading system fails to characterize ankle injuries involving 2 or more ligamentous structures and excludes consideration of non-ligamentous injuries.

Muscular Support Medial Arch

-Tibialis anterior tom dick and harry -Tibialis posterior tendon -Flexor digitorum longus -Flexor hallucis longus -Other muscles that are important: abductor hallucis, flexor digitorum, interossi, and maybe fibularis longus Tom dick and harry for medial side

LE Compartment Syndrome Presentation & Diagnosis •Chronic

-Tightness, pain, burning, or numbness related to physical activities. -Involved compartment may also be palpably tense, •Less likely to have signs of numbness, pulselessness, weakness, and paleness than acute. -Improvement in symptoms with rest.

Meniscal injuries MOI

-Twisting -Pivoting -Plant & Cut -Poor technique or Deep squatting -Injury to related structures •MCL, ACL -Degeneration Bad squatting form 45-64 65-84 more common As we get older it is more common

Plantar Fasciitis (Plantar Heel Pain) Treatment

-Typically does not resolve quickly -Reduce the pain & inflammation -Decrease the stresses imposed on the tissues •Night splint •Orthotics (i.e., heel wedge) -Strengthening •Muscles that support the arch of the foot •Intrinsic strengthening -Towel curls -Pick-up marbles -Toe taps •Don't forget to address proximal areas of weakness (e.g.., Hip Abductors) -Flexibility •Triceps Surae •PF stretching -Rolling foot over a tennis ball -Rolling foot over a frozen plastic bottle •Friction massage at insertion -Training issues •Running constantly around a track in one direction photo: Thickening of plantar fascia

Tendinopathy: Update on Pathophysiology •Development of tendinopathy

-a single event or a more typical a series of sub-acute injuries that have a cumulative inflammatory effect -chronic cycle of microscopic injury and incomplete healing -small chance NSAIDS may reduce repair of tendon-to-bone attachment -suddenly increasing loading after inactivity can cause tendon injury - weekend warrior

Thompson Test (Ankle)

-assess Achilles tendon tear -pt lying prone on exam table with feet dangling off, knee and ankle at 90 degrees- squeeze grastrocnemius muscle positive: no plantar flexion normal: plantar flexion

•Anterior ankle bursitis

-figure skaters, hockey -Runners who tie their shoelaces too tight? -can also get bursitis near malleoli -use donut pads

Educating Patient's about Plantar fasciitis •Cause?

-multifactorial, with abnormal biomechanics and delayed healing are likely contributors

FIFA 11+

-running exercises -strength, plyometrics, balance -running exercises "Teams that performed the "11+" regularly at least twice a week had 37% fewer training injuries and 29% fewer match injuries. Severe injuries were reduced by almost 50%." Good program that has been used a while, not just for soccer

Hamstring Strain MOI

-sudden maximal contraction (concentric) •sprinter's push leg out of blocks •jumper's plant leg -rapid eccentric contraction to decelerate limb •sprinter in full stride

Proximal Tibiofibular Joint stability provided by (5 things)

1. Ligaments 2. Joint capsule 3. Interosseous membrane 4. Popliteus tendon 5. Biceps femoris •Synovial Joint (2 flat or slightly oval surfaces) •Allows little gliding movement •1-3 mm

Medial (tibial) collateral Primary Restraints Secondary Restraints

1. valgus and lateral rotation of the tibia 2. AP translation of the tibia on the femur

Lat. (fibular) collateral Primary Restraints Secondary Restraints

1. varus and lateral rotation of the tibia 2. AP translation of the tibia on the femur

Ottawa Knee Rules

1.55 years old or older 2.Isolated tenderness of patella 3.Tenderness to proximal head of fibula 4.Inability to flex 90 degrees 5.Inability to WB for 4 steps both immediately and in ER/office If you don't have these(and younger than 55) you can be fairly certain you don't have a fracture

Measuring tibial torsion

1.Align the femoral condyles in the frontal plane 2.Identify the tibiofibular joint axis 3.Measure angle between two The normal tibial torsion angle in older children and adults is 15 to 30 degrees of out-toeing Less than 15 degrees suggests medial tibial torsion, greater than 30 is external tibial torsion.

Toe Deformities

1.Claw toes 1.weak lumbricals & interosseus muscles 2.Pes cavus 3.Fallen metatarsal arch 4.Neurological problems 2.Hammer toes 1.Interosseus muscles 2.Hereditary 3.Poorly fitting shoes 4.Hallux valgus 3.Mallet toes 1.ill fitting or poorly designed shoes Hyperextension of the MTP pulls the plantar plate distally leaving the head of metatarsal less protected during weight bearing

ACL = knee collaterals, but _____ of PCL

1/2

Ankle Joint Functional Assessment Tool (AJFAT) self report measures

12 item tool to ID ankle instability Higher the score the more difficult of a time they are having

healing rates for specific soft tissues ligament graft

12 weeks -28 months

Excessive anteversion more than ______degrees Excessive anteversion with "in toeing"

15 this photo is 35 degrees

The normal tibial torsion angle in older children and adults is ________ degrees of out-toeing Less than _______ degrees suggests medial tibial torsion, greater than ______ is external tibial torsion.

15 to 30 Less than 15 degrees suggests medial tibial torsion, greater than 30 is external tibial torsion.

The surface area of the medial tibial plateau is approximately _____% greater than that of the lateral, and its articular surface is three times thicker.

50

Localization of Achilles tendinopathy: (A) midportion and (B) insertional.

55-65% are located 2-6 cm proximal to the insertion of the tendon on the calcaneus

healing rates for specific soft tissues bone

6-8 weeks

Fig. 2. Anterolateral talar palpation (ATP) test.

A and B: ATP—searching for instability by visual inspection and thumb palpation of the talar anteriorization. C and D: radiographic image of the test.

Traditional anterior drawer test (ADT).

A and B: traditional anterior drawer test -searching for instability by visual and hand proprioception. C and D: radiographic image of maneuver. "train up the chain"

hammer toes

A flexion deformity of the distal interphalangeal joint of the toes.

Antalgic Gait

A persons manner of walking that develops as a way to avoid pain while walking, "limping'

Intra-articular but Extra-capsular?

ACL and PCL Red outline is synovial joint

Historical Clues to Knee Injury Diagnoses Acute swelling

ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation

Historical Clues to Knee Injury Diagnoses Knee "gave out" or "buckled"

ACL tear, patellar dislocation, instability, joint effusion

intervention strategies for for Lateral ankle sprain and Chronic ankle instability

Always try to motivate the person Rocking and trying to maintain balance is the proprioceptive proprioception for chronic

Medial Longitudinal Arch what is it supported by?

An arch of the foot running from the heel to the big toe on the inside of the foot. Medial arch is supported by bony architecture

-PRICEDEM -Brace for 10-14 days (stirrup brace or similar) when performing athletic events, average return to full activities in 11 days is expected. -Rehab: peroneal strengthening and proprioceptive training (•Eccentric strengthening is essential) -Educate that it may take several month to regain full ligamental stability

Ankle Sprain Treatment Grade 1

-Possible Cam Walker Boot or Bracing for several weeks -PRICED, rehab as previously described •Proprioceptive training and Eccentric strengthening is essential -Typically, able to return to full function in 2-6 weeks -May require brace or taping for sports for 6 months

Ankle Sprain Treatment •Grade II

-Casting or bracing are required -Likely will require >6 weeks before return to full function •Proprioceptive training and Eccentric strengthening is essential -May take 1-4 years before symptom free

Ankle Sprain Treatment •Grade III

4 Primary Ligaments of the knee

Anterior cruciate Posterior cruciate Medial (tibial) collateral Lat. (fibular) collateral

Knee Stability - Capsule and Reinforcing ligaments Region of the Capsule: Posterior-lateral Connective Tissue Reinforcement: Muscular-Tendinous Reinforcement:

Arcuate popliteal lig. Lateral collateral lig. Popliteofibular lig. Tendon of the popliteus

Guiding Concepts of Musculoskeletal (Orthopedic) Assessment and Rehabilitation

Assessment •Understand your patient (occupations, environments/contexts) •Understand typical posture and movements/biomechanics •Understand the mechanism of injury (formulate a diagnosis) Rehabilitation •Understand and apply knowledge of soft and hard tissue healing •Manage inflammation and pain (modalities, meds, application of protection/rest as needed) •Gain Range of Motion at the joint(s) •Gain muscle length and strength / restore normal posture •Gain normal movement (movement re-education) •Address return to function/occupations through exercise, activity, and adaptation (if needed)

Segond Fracture

Avulsion fracture of the lateral tibial condyle at the site of attachment of the iliotibial band on Gerdy's tubercle. It is often associated with anterior cruciate ligament (ACL) injury -Occurs with severe rotary stress and concurrent ACL disruption. -Potential avulsion of the ALL

Axis of rotation of ankle inclined slightly ________ and _________ from lateral to medial malleoli

Axis of rotation inclined slightly medially and superiorly from lateral to medial malleoli

Subtalar Joint (Non-weight-bearing) calcaneous pronation calcaneous supination

Calcaneus: pronation Eversion (Primary; max 12.5°) Abduction (Primary) Dorsiflexion (small) Calcaneus: supination Inversion (Primary; max 22.6°) Adduction (Primary) Plantarflexion (small)

Common Causes of Knee Pain by Age Group

Children and adolescents Patellar subluxation Tibial apophysitis (Osgood-Schlatter lesion) Jumper's knee (patellar tendonitis) Referred pain: slipped capital femoral epiphysis, others Osteochondritis dissecans Adults Patellofemoral pain syndrome (chondromalacia patellae) Medial plica syndrome Pes anserine bursitis Trauma: ligamentous sprains (anterior cruciate, medial collateral, lateral collateral), meniscal tear Inflammatory arthropathy: rheumatoid arthritis, Reiter's syndrome Septic arthritis Older adults Osteoarthritis Crystal-induced inflammatory arthropathy: gout, pseudogout Popliteal cyst (Baker's cyst) These are most common but could be in different age groups

Transverse Joints AKA ___________ which two joints make it?

Chopart joint Talonavicular Joint and Calcaneocuboid Joint Each joint surface has concave and convex curvature

Functionally shorter leg

Closed Chain Biomechanics in the Lower Extremity: One Segment Moves and the Others are Affected pronation Internal tibial rotation Slight knee flexion Internal femoral rotation Internal rotation of the hip Anterior pelvic tilt; anterior nutation of innominate

Arthro-kinematics of ankle

Convex on concave - opposite directions Dorsiflexion: posterior glide, forward roll plantarflexion: anterior glide, posterior roll

Coxa Valgus example

Coxa Valga: a neck-shaft angle of the femur that exceeds 125 degrees in adults or 150 degrees in newborns. The greater the degree of coxa valga, the longer the resulting limb length. Frontal view an 8 y/o with Morquio's syndrome (genetic disorder). This radiograph of the femor reveals enlarged acetabular cavities with rough margins, as well as poorly formed femoral epiphyses and widened femoral necks with coxa valga.

Coxa Vara example

Coxa Vara: a decrease in the neck-shaft angle of the femur, resulting in an angle less than 125 degrees. The greater the degree of coxa vara (or the closer this angle approaches 90 degrees) the shorter the length of the limb. This radiograph is a frontal view of a child with coxa vara of the R LE. Notice the relative elevation of the greater trochanter and how the epiphyseal cartilage plate approaches vertical.

Treatment for Ankle Sprains Phase III criteria goals and description of interventions

Criteria: Ambulates FWB no Pain (may still need brace or heel lift) description of interventions: Unilateral balance training Progress to single heel raises Treadmill - progress to fast walking Eccentrics & Planks QID - 4 times a day BID - 2 times a day Not time based but activity based- once you are able to do it you can go on to next phase

Treatment for Ankle Sprains Phase II criteria goals and description of interventions

Criteria: PWB with assistive dev., Decrease in pain/ swelling Goals: Normal AROM, FWB without pain, increased proprioception description of interventions: Low level balance training Low level Theraband strengthening (no pain) Cardiovascular - 30 minutes of stationary cycling Core strengthening QID - 4 times a day BID - 2 times a day Not time based but activity based- once you are able to do it you can go on to next phase

Treatment for Ankle Sprains Phase IV criteria goals and description of interventions

Criteria: Pain free unilateral heel raises description of interventions: Jog to run progression Cutting maneuvers Sports specific training QID - 4 times a day BID - 2 times a day Not time based but activity based- once you are able to do it you can go on to next phase

Quad Strain signs and symptoms

- pain with resisted knee extension and passive stretch -swelling - location - palpable defect -muscle spasm

Distal Tibiofibular Joint Ligaments name 3

1. Interosseous ligament 2. Anterior (distal) tibiofibular ligament 3. Posterior (distal) tibiofibular ligament

Anterior cruciate Primary Restraints Secondary Restraints

1. anterior translation and medial and lateral rotation of the tibia on the femur 2. valgus and varus of the tibia

Posterior cruciate Primary Restraints Secondary Restraints

1. posterior translation and medial rotation of the tibia on the femur 2. valgus and varus of the tibia

when kids should start walking

12-15 months

•Normal knee alignment is slight genu valgum ________ degrees

170-175

MCL Grade: II Treatment & Healing: Return to Sport?

3-4 weeks before decent Ligamental strength 3-4 weeks, ~3 months before preinjury status

healing rates for specific soft tissues tendonitis

3-8 weeks

Leg Length Inequality •_______ cm or greater difference in leg length •Causes include:

2.5 •Causes include: -trauma -congenital -neuromuscular -acquired diseases -infections causing physeal growth arrest -tumors -vascular disorders Could be a tibial component

•Assessment of a syndesmosis sprain will be difficult for the initial ____________. If the ankle is quite swollen and edematous assessment of a syndesmosis sprain may be difficult until the pain and swelling have isolated to individual areas or x-rays show some spreading of the ankle mortise.

24 to 48 hours

Femur is ______% of your overall height

25

healing rates for specific soft tissues lacerations

50-180 days

Osteoarthritis

A chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of bone at the joint margins (osteophytes) and capsular fibrosis Osteoarthritis (OA) the most common form of arthritis, Estimated to affect 302 million people worldwide, Leading cause of disability among older adults, The knees, hips, and hands are the most commonly affected appendicular joints. Any injury to a joint can lead to OA Wearing away of articular cartilage Bone remodels and makes spurs around there in attempt to stabilize

Historical Clues to Knee Injury Diagnoses Noncontact injury with "pop"

ACL tear

•60-70% of all ankle sprains involve the _______________.

ATFL ATFL=anterior talofibular lig.

•20% of all ankle sprains involve ________ and __________ - ________ and __________ are tender to palpation with lateral sprains.

ATFL & CFL ATFL=anterior talofibular lig. CFL=calcaneofibular lig.

Medial Malleolus Fracture

Avulsion fractures normally happen with younger people off deltoid ligament as they are growing fast

Recurvatum

Bending backward, as in knee hyperextension Weakness at the quads, something at ankle, tight gastric?

healing rates for specific soft tissues Bone _______ weeks

Bone 6 - 8 weeks

Lower Extremity Bone Development: Knee •Typical development -Birth: _______ normal in newborns and non-walking infants -1-2 years old: reach ________ alignment -2-4 years old: progress toward ________ (compensate with intoeing) -By 11 years old: ________ has decreased to an average of 5-6 degrees

Bowlegged, normal, knock kneed, normal •Typical development -Birth: genu varum normal in newborns and non-walking infants -1-2 years old: reach neutral alignment -2-4 years old: progress toward genu valgum (compensate with intoeing) -By 11 years old: genu valgum has decreased to an average of 5-6 degrees

Hallux Valgus: Manual Therapy

But once its gotten bad there isn't much you can do -might need surgery Look at flexion of the mtp

Talocrural Capsular pattern: Plantar flexion loss greater than dorsiflexion where is the capsule thin? and where is it reinforces?

Capsular pattern: Plantar flexion loss greater than dorsiflexion The capsule is thin anteriorly & posteriorly. It is reinforced laterally and medially by collateral ligaments.

asking the patient about knee problem

Chief Complaint •What complaints does the patient have? -Locking? -Giving way? -Swelling? -Crepitus? -Catching? -Stiffness? Focused History Questions •Onset of Pain -Date of injury or when symptoms started •Was there a history of previous injury? •YES •Is this the same injury as before? •NO •Different injury •YES •Possible reoccurrence •Was the initial injury treated? •NO •How did the symptoms resolve? •YES •What was the treatment? •What was the effect of that treatment?

Menisus injury

Don't force it if locked catching and locking

Fractures about the knee Salter-Harris Classification (9 types, but only 5 are common) is used for fractures of the epiphyseal plate or growth plate of the long bones

Don't memorize this but be aware of it and it is often used with epiphyseal plates with long bones Slip (separated or straight across Above (away or above the physis) Lower (below the epiphysis) Through Everything Rammed (crushed)

Uncompensated Rearfoot Varus - what happens?

Don't pronate very much, foot is rigid and not flexible a lot of the time lack of subtalar motion

Talocrural Closed packed position:

Dorsiflexion

foot pronation

Dorsiflexion, abduction, eversion

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee recommendations

Exercise, self-efficacy, weight loss, tai chi, cane, orhtosis, brace, oral NSAIDS is recommended Know these recommendations for OA

Strains degrees and related factors

First degree (mild): minimal structural damage; minimal hemorrhage; early resolution Second degree (moderate): partial tear; large spectrum of injury; significant early functional loss Third degree (severe): complete tear; may require aspiration; may require surgery related factors: Onset at 24-48 hours after exercise Sudden overstretch Sudden contraction Decelerating limb Insufficient warm-up Lack of flexibility Increasing severity of strain associated with greater muscle fiber death, more hemorrhage, and more eventual scarring Steroid use or abuse Previous muscle injury Collagen disease

Common Recommendations for overpronators Foot mechanics: Foot shape: Shock absorption in stride: Recommended shoe last: Recommended type of shoe:

Foot mechanics: Excessive inward roll Foot shape: Flat foot to low arch Shock absorption in stride: Good Recommended shoe last: Straight Recommended type of shoe:Motion Control

can pain refer to different areas?

Hip can refer up to lumbar spine to the ankle Lumbar spine can refer all the way down the leg

a condition in which the nerve input to a muscle is increased, resulting in greater resting tone.

Hypertonicity:

kinesiopathologic model of movement system

Improper movement leads to pain Sometimes hypermobility can cause pain also hypomobility -dont memorize but be aware

Osteoarthritis info

Increased stress •increased load •BW or activity •decreased surface area for joint loading •Varus knee - medial compartment •Valgus knee - lateral compartment Weak cartilage •age •stiff •soft (chondromalacia) •abnormal bony support -AVN Low-grade synovial inflammation (15-20 yrs) •Immune response -Macrophages release inflammatory molecules -Triggers extracellular matrix degrading enzymes -Abnormal response from chondrocytes -All of this contributes to the cartilage damage and bone alterations There is an immune response The reasons why it is more complicated than stress

•Plantarflexed First Ray.

Intrinsic deformity of the first ray where it is in plantarflexion.

Jones vs Ballerina

Jones = Fracture of the base of the fifth metatarsal, at least 1.5 cm. distal to the metatarsal styloid. Avulsion of 5th tuberosity "Ballerina" = proximal tip of 5th tuberosity (fibularis brevis connects here)

effects of aging Ligament Decrease in ____,_____,_____, and ______ Ligament & bony insertion _______ _______&_______ properties decline

Ligament Decrease in mass, stiffness, strength, and viscosity Ligament & bony insertion weakens Biochemical & mechanical properties decline

healing rates for specific soft tissues Ligament Graft _____ weeks -______months

Ligament Graft 12 weeks -28 months

foot arthrology 1

Lisfranc- tarsometatarsal joint chopart- midtarsal joint

healing rates for specific soft tissues Muscle Exercise Induced 24 48 hrs. Grade I ______ days Grade II ________ days Grade III _______ days

Muscle Exercise Induced 24 48 hrs. Grade I 2-21 days Grade II 20-90 days Grade III 50-180 days

Normal anteversion is _______ degrees Retroversion- less than _______ degrees Excessive anteversion more than ______degrees

Normal anteversion is 8-15 degrees Retroversion- less than 8 degrees Excessive anteversion more than 15 degrees

Condition specific rehab - osteoarthritis

OA: exercise, self efficacy, tai chi Unloader knee brace -This helps with OA a lot -Provides relief to allow them to walk

Knee Stability - Capsule and Reinforcing ligaments Region of the Capsule: Posterior Connective Tissue Reinforcement: Muscular-Tendinous Reinforcement:

Oblique popliteal lig. Arcuate popliteal lig. Popliteus Gastroc., semimembranosus

Calcaneal Stress Fracture

Occurs due to repetitive trauma and is characterized by sudden onset in plantar-calcaneal area Bone scan

Achilles tendinopathy

Overuse injury resulting from repetitive microtrauma and accumulative overloading of the tendon -Decreased DF, overpronation, etc

Historical Clues to Knee Injury Diagnoses Fall onto a flexed knee

PCL tear

MCL Grade: I Treatment & Healing: Return to Sport?

PRICEDem Temporary immobilization? WB ASAP w/n tol. return to sport: 10.6 days

outcome measures for Lateral ankle sprain and Chronic ankle instability

Pain scale is important

•5 P's:

Pain, Pallor, Paresthesia, Paralysis, Pulselessness

Pediatric genu varum Pediatric genu valgum

Pediatric genu varum - bowlegged Pediatric genu valgum-knock kneed

Pump Bumps (Haglund Syndrome)

Poor fitting shoes, bump is frequently a bone spur Usually don't go away

If you do have it, they do surgery, and open it up LE Compartment Syndrome

Post-Fasciotomy

Lateral ligaments of the ankle

Posterior and anterior talofibular Calcanofibular ligament - Dorsiflexion and inversion Anterior talofibular lig - plantarflexion, inversion Bifurcate ligament Interosseous ligament Tunnel - sinus tarsi- provides stability to subtalar joint Lateral collateral ligament : anterior talofibular posterior talofibular calcaneofibular

PRICEDEM

Protect Rest Ice Compression elevation Drugs Early motion

Osteology of Proximal Tibia and Fibula

Proximal Fibula -Head Proximal Tibia -Medial (larger and concave) and lateral (flatter) condyles -Intercondylar eminence (with tubercles) -Anterior intercondylar area -Posterior intercondylar area -Tibial tuberosity -Soleal line

Feiss Line

Purpose: Assesses the amount of pronation Method: Mark medial malleolus, navicular tuberosity, * 1st MTP joint. Assess marks in weightbearing. Positive Test: Navicular drop during WB 1st deg. = falls 1/3 of distance to floor 2nd deg. = Falls 2/3 of distance to floor 3rd deg. = Navicular rests on floor Lateral most point of mtp, navicular head, bottom of medial malleolus navicular drop test > 10 mm neutral to standing = excessive

Heel Drop

Raise the heel, leaving the ball of the foot on the floor and drop on the heel of the same foot Getting the tendon used to handling loads Knee straight (gastco) and bent (soleus)

foot arthrology 2

Rearfoot, midfoot, forefoot

reflex action that occurs when an active muscle suppresses the antagonist

Reciprocal inhibition:

Chronic treatment

Return to Function •Cardiovascular Endurance •Muscle Power (Plyometrics and Functional strengthening) •Movement Re-education •Activity Tolerance

what should patients do if they have osteoarthritis?

STAY ACTIVE AND EXERCISE. If you have hip or knee osteoarthritis, exercise and physical activity may not only help improve your joint pain but can also boost your overall health and quality of life. Physical activity can be as simple as walking (A), biking, or water exercises (B). Strength training is critical to improving your function (C). Consult your physical therapist to design the right program for you. Physical exercise helps Need to get moving- does not have to be high impact

- multi-fragmented fracture usually the result of falling onto a flexed knee.

Stellate fracture of patella

#5 Equinus

Structurally plantarflexed •When the ankle's passive dorsiflexion is limited, the cause can be structural (bony and fixed or rigid) or "functional," related to shortened soft tissue. •Soft tissue shortening usually involves the heelcord or the plantarflexion muscles.

Joint: Metatarso-phalangeal Structure: Axis: Motion:

Structure: biaxial(condylar) Axis and motion: Lateral (Flexion and extension) Anterior-posterior (Abduction and adduction)

Joint: Tarso-metatarsal Structure: Axis: Motion:

Structure: gliding joints Axis: n/a Motion: glide aka lisfranc joint

Joint: interphalangeal Structure: Axis: Motion:

Structure: uniaxial Axis: lateral Motion: Flexion and extension (NO ab,add)

The Subtalar Joint •Close packed position :

Supination

MCL Grade: III Treatment & Healing: Return to Sport?

Suspect other injuries Isolated Grade III = 2 to 4 months, surgery = 6-9 months

Proximal Tibiofibular Joint •_________ Joint (2 flat or slightly oval surfaces) •Allows little _________ movement •1-3 mm

Synovial gliding

effects of aging Tendon _________ decreases _______ & _______ Decrease in ______ & ________ Rapid _______ or _______ more likely to cause damage

Tendon Crimp decreases(Your collagen is crimped- makes elastic barrier to help absorb stress) Weaker & Stiffer Decrease in cellular & vascular (Achilles tendon rupture typically happen in 40 yr olds, decreased crimp, vascularity --> think they are 20 yr old) Rapid force or releases more likely to cause damage

healing rates for specific soft tissues Tendon Tendonitis ______wks Lacerations ______ days

Tendon Tendonitis 3-8wks Lacerations 50 - 180 days

•The "Q" angle:

The angle between the line of quadriceps force and the patellar tendon. the tendons of the quadriceps femoris and the patellar tendon form an angle with the center of the patella. -A typical Q-angle (with the knee extended) is 13 degrees for men, and 18 degrees for women ->18 degrees may increase chances of patellar tracking issues.

angle of inclination what is normal?

The angle between the shaft and the neck of the femur in the frontal plane; normally 125 degrees. 125 degrees is normal Over 125 is coxa valga Under 125 is coxa vara Angle of inclination (frontal plane): the angle between the anatomic axis of the femur (the shaft) and the axis of the femoral neck, determined by radiographic examination. In the newborn, this angle is approximately 150 degrees, decreasing with weight bearing as the child matures. The average angle of inclination for adults is 125 degrees

MIDTARSAL JOINT (TRANSVERSE TARSAL OR CHOPART JOINT) The joint only ________ or _______

The joint only pronates or supinates. •This joint has an oblique and a longitudinal axis. These axes do not necessarily correspond to talo-navicular or calcaneo-cuboid articulations. •Moreover, the joint is functionally uniaxial, not biaxial.

Educating Patient's about Plantar fasciitis •Understanding the condition

They are not alone -PF is the most common cause of heel pain in the US, affects > 2 million people. -Conservative tx is successful up to 90% of time. -Most symptoms resolve in a year regardless of intervention

Muscular & Ligamental Support of Lateral Arch

The peroneus tertius is absent in 5% to 17% of the human white population. Conclusion: This study shows that subjects without peroneus tertius are not at higher risk for an ankle ligament injury. In addition, subjects without peroneus tertius do not exhibit decreased eversion or dorsiflexion strength. Fibularis Brevis goes to tuberosity of 5th metatarsal

Hallux Valgus & Bunion

The word bunion is from the Latin "bunion," meaning enlargement.

Treatment of Knee Injuries

Theres always some overlap 1. acute 2. subacute 3. chronic flexibility/mobility activation strength/stability training movement

Ankle dislocation with no fractures.

This takes a high degree of trauma and force. In this case this was generated as the result of a high flip off of a trampoline and impact with the ground. The ankle was in a plantar flexion and inverted position upon impact. This was an open dislocation.

•Internal tibial torsion versus femoral antetorsion

Tibial medial torsion --> knees pointing straight ahead (with toes in) Femoral antetorsion --> knees pointing inward (with toes in)

- patella receives a relatively minor blow while the quadriceps is strongly contracting a separation of the superior and inferior fragments.

Transverse fracture of patella

functionally longer leg goes with pronation or supination of foot?

supination

Coxa vara vs coxa valga

Vara - "femur angle" is <120 Valga - > 135 *smaller angle gets the shorter name*

- usually occurs from an indirect blow (kick) to patella

Vertical fracture of patella

Pediatric Fractures

Weak spot in Bone, including Ligament! Epiphyseal plates are where you are worried about kids injuries

The greater the degree of _______ (or the closer this angle approaches 90 degrees) the shorter the length of the limb.

coxa vara

Typical Bony Alignment and Related Deviations of the Lower Half of the Body

coxa vara/valga; femoral torsion Q-angle genu varus/valgus; recurvatum tibial torsion rearfoot/forefoot varus/valgus Halux valgus & hammer toes

stone bruise

heel contusion

Special tests of knee •Patella

•Apprehension

Subtalar joint (STJ) movement during gait cycle

•pronates during loading response •supinates throughout midstance and terminal stance. •reaches neutral position by heel off