04 PT 250 Ortho. kulinskin imran

NOT STUDIED ch 17

-Arch deformaties (Pes planus and Pes avus) 252 -morton neuroma (plantar interdigital neuroma) 253 -Hallux Valgus -Lesser toe deformities (hammer toes mallet toes, and claw toes) 254 -Common mobilization techniques for the ankle, foot and toes. 255 -Ankle mobilization 256

Intervertebral Disc pathology

-Common expression used "Slipped disk", the disk does not slip from within confines of the vertebral bodies. -2 Terms applied interchangibalyy 1) disk bulge 2) Herniated Nucleus Pulposus. ---Disk Bulge: the nucleus puposus is within the annulus. ---Disc protrusion: 1)Type I: peripheral annular bulge 2)Type II: localized annular bulge ---Herniated Nucleus Pulposus (HNP) classification 1) Disc protrusion: bulges agains intact nucleus 2) Extruded disc: extending through the annulus but contained within the PLL. 3) Sequestrated disc: free within the spinal canal. -Age related degenerative changes: 1) decreased hydration, bochemical change in glycoaminoglycans of the nuceleus, 3) increases in collagen --Patient examination: Peripheralization or centralization of symptoms 1)peripheralizatoin: symptoms are felt further down the leg 2) Centralization: (McKenzie): phenomenom whereby, result of certain repetitive movements or the adoption of certain positions, radiating pain that originating from the spine and refereed distally. IS MADE TO MOVE AWAY FROM THE PERIPHERY AND TOWARD THE MID_LINE OF THE SPINE. 1)==Spondylolysis: bone defect (stress fx, fracture) in the pars interarticularis of the posterior element of the spine. 2)==Spondylolisthesis: slippage or migration of the vertebrae over an inferior vertebra as a result of bilateral defect in the pars interarticularis. (5 classes pg 327) --Grades of spondylolisthesis/rehab: >grade I 0-25: may not experience significant symptoms. >grade II 25-50, >grade III 50-75, >grade IV 75-100%. --Symptoms Spondylolisthesis report pain with extremes of lumbar motion, especially extension (pain usually follows belt line.) Rehabilitation SPONDYLOLISTEHESIS: grade I-II: avoid ballistic lumbar extension as well as vertical loading while seated or standing to minimize anterior sheering forces on the spine. in addition, abdominal strengthening exercises, neutral spinal stabilizatoin exercises (controlled lumbar extension strengthening, isometrics, and rectus/oblique strengthening while in the neutral spine position and strengthening exercises for the trunk and LE are encouraged. PAIN and MM SPASM are addressed by DR: mm relaxers, NASID and PT by agents (heat, ice, US and E-stim) to alleviate acute pain and swelling. HALLMARK: application of abdominal and paravertebral mm strengthening exercises to provide dynamic support of spine during activity and AVOIDENCE of extreme lumbar Extension. SURGERY: is usually for grade III, IV which compress the root and cause neurological signs. Rehabilitation: immobilizaton until solid bone union is radiologically confirmed, lumbosacral orthosis to not permit lumbar extension during immobilizatoin, perform rudimentary ROM and strengthenitng for UE/LE (ankle pump, quadriceps sets, and knee ROM), once bone healing confirmed gradual program of abdominal strengthening (from isometrics to concentric and eccentric abdominal contractions), lumbar ROM , general conditioning, and progressive return to function is advocated. 3) LUMBAR SPONDYLOSIS:(Osteoarthritis of the spine/DJD) Is the narrowing of the spinal canal which constricts and compresses spinal roots. ( associated with aging. associated with decrease in joint height or degenerative process.). Pt. may have forward flexed trunk posture and lean forward may feel better and reduce LE pain. >classification as 1) RADICULAR ACHE into thigh less frequent into calf. 2) Paresthesisas into the LE 3) Disturbance in motor function --Rehabilitation may include education in reinforcing proper postures, body mechanics, and lifting techniques. SItting/sleeping changes, general conditioning and weight management programs. Subjects with stenosis experienced greater improvement in pain and recovery at 6wk with manual therapy, exercise and walking vs subject who performed routing flexion exercise and walking.

microsructure of muscle

-Connective tissue layers 1)Epimysium: surrond mm and continuous with muscles and tendons. 2)Perimysium: surounds mm group of fibers (aka: faciculus) 3)Endomysium: surround each mm fiber. mm fiber(mm cell) further divides into myofibril and myofilaments.

Fibrocartilage Vs Articular cartilage

-Fibrocartilage cartilage: (meniscus/labrum): -Articular cartilage: (Hyeline),

Cartilage Healing ch 10 Zones type II collagen

-Gliding Zone (superficial): decreased metabolic activity, function Vs. Sher -Transitional Zone (middle): increased metabolic activity, function vs. compression. -Radial Zone (deep): increased collagen size, function vs. compression. -Tidemark: undulation barrier, function vs shear -Calcified Zone: hydroxyapatite crystals, Function Anchor.

Hemiarthroplasty of the HIP

-Indication: severe femoral head fracture (used to eliminate pain and improve function). only femoral head is replaced because Pt. has health acetabulum cartilage.

Joint mobilization (before and after )

-Pain level: change by 2 levels -Joint ROM -begin and end with grade I/II oscillations.

ACL Anterior Cruciate Ligament injury Rehabilitation

-Resists anterior tibia translation on the femur. Prevents HYPEREXTENSION & extreme varus, valgus, & rotation. *Cruciate=Intracapsular structures cause joint effucion -TEST (2): (test the degree of anterior translation of tibia relative to stabilized femur) 1) Lachman Examination: sup/knee flex 25-30degree, 1 hand stabilized distal femur, other hand ant/pos displaces the tibia (note the amt of tibial translation) 2) Anterior Drawer test: Knee to 90 degree, grasp proximal tibia w/ (B) hands & provide anterior directional force. if tibia translates forward against stabilized femur then ACL considered injured) -Surgical Repair: 1)Autograft reconstruction:(gracilis tendon, facscia lata, smitendinosus tndon, and quadriceps mm tendon but bone-patellar tendon-bone (BPTB) common) --HEALING AUTOGRAFT: 1) 6-8wk Avascular Necrosis, gradually looses strength and is very fragile. (No excessive load and forces) 2)Slowly revascularizes at approximately 3 months tensile strength is less than 50% of original, may take up to a year to mature and may never reach original strength. -POST-OP Rehabilitation: designed to protect graft, decrease pain & swelling. increase joint motion, strength & endurance (local &aerobic endurance). MAX 1st day-6wk: joint protected range limiting hinge brace, cryotherapy, elevation, use of compession wrap limits swelling, Early AROM is essential component (patellar motion must be an immediate goal for restoring knee motion) Gentle patellar stretches (pt perform 2-3x day, full knee extension next (passive prone/ supine), CPM (maintain regular articular surface/evacuate joint hemiarthrosis & aid in prevention of joint contracture), encourage quad control and hamstring co-contractions of quad/ham (standing curls/supine leg curl IF BRACE USED!), Ther ex: that do not strain ACL: iso ham contraction at 15, 30, 60, 90), iso. quad contraction at 0,90, simultaneous ham/quad contraction at 60/90, active flex/ext motion of knee from 90 to full extension, & passive flex/ext of knee w/o mm contraction. Four way (hip flex/ext/abd/add) and calf strengthing stationary bike are encouraged. -MAX-TO-MOD: ROM from 0 ext to 120 flex, FWB,w/normal gait, quariceps/hamstring control, controlled pain/swelling, & min 6 w/k post surgery. MOD 7-12wk: CKC( motion in one joint produced motion in the other in a predictable manner), CKC are progressive proprioceptive tasks (stimulate afferent nural input system) begin w/bracing to protect the healing graft. (Brace removal criteria: Pt. demonstrates confidence, mm control & stability w/ prior consultancy w/ PT.) leg press ckc exercise in short arch motion w/brace, progressiv ROM as tolerated, standin wall slides(brace & tibia kept vertical), short -arc step-up (quad control/strength) Biofeedback can be used for proper quad firing pattern. Stationary cycling progressed w/added time/resistance used early for ROM and later stages for endurance.stair steppers & inclined walking(if resistance is modified/controlled initially to allow for protected joint motion). Patient is encouraged to maintain patellar, ham, quad stretching exercises; normal gait mechanics and general fitness program of strength and endurance activites. -MOD-TO-MIN: Full ROm (flex,ext, and patellar mobility), normalized FWB gait and removal of brace as indicated, improved quad/ham strength, continued pain/ swelling control, & min 12-13 w/k post surgery. MIN 12-24 wk to return to activity: return to more normalized activites, isolated knee ligament test (lachmans/ADT * pivot shift test), are peformed at the PT/Dr. discretion. progression to more challenging exercises & quantify the clinical results of surgery. isokinetic testing by PT/DR., more progressive proprioceptive exercises when clinical testing demonstrated improved strength, neuromusular control, & stability of ligament (balance board, mini trampoline to challenge mechanoreceptor system). standing knee extension w/ resistance by elastic tubing is excellent CKC exercise to encourage quad. control in more functional position. POOL RUNNING PROGRAM progressing to a straight line program can start late in this stage. Plyometrics exercises for individuals returning to athletic activities. bilateral ballistic movements, progressing to unilateral movment. Progressive strengthening of entire LE including isokinetic velocity spectrum training and isotonic ecentric quad strengthening. Rehab after ACL reconstruction envolves entire body not just affected limb. Nonoperative ACL: MAX: 2-4wk, MOD: 3-12 wk, & MIN: 10-16wk

Glueteal mm strengthening

-Side-lying abducntion: (glut med 43%) -Side bridngin:(glut med 74%) -(B) LE bridging: (glut med:28%,max 27%, ham 35%) -single LE bridging: (glut med 47%) Standin hip abd (glut med 33%)

Plantar Fasciitis (hel spur syndrome)

-chronic inflammation of the plantar aponeurosis, w/ or w/o associated calcaneal heel spur. Described as microtrauma leading to injury, attempted repair, and chronic imflammation. Most authors believe that this pathology can be degenerative as well as inflammatory in nature, depending on the cronicity of the pathology. -70% of patients with PF have heel spur on xray. -C/O pain along the medial border of calcaneus on the plantar surface. Pain is worse in the morning when foot contact the floor getting out of bed. -Intervention: reduce tension on plantar fascia (calf, sloeus, great toe and plantar fascia stretching) strengthening focus on intrinsic musculature (towel grabs) manual pressure release by rolling can under foot. if treatment not successful and MD will suggest splint at night (foot plantar flexes and stretches fascia). if symptoms persist MD may do a surgical intervention (fascia release or remove spur).

MCL Medial Collateral Ligament injuries Rhabiliation

-common injury seen in knees from valgus stress to the knee, patient may feel or hear a pop but most common feel tearing or pulling on the medial aspect of knee. pt. will often present w/ swelling, more severe will present w/ecchymosis, walk w/ limp very hesitation to full extend knee b/c increased stress&pain. Grade III MCL also associated with ACL. MCL & medical meniscus are attached to one another in the knee. *UNHAPPY TRIAD: combination of MCL/ACL/Medial meniscus. -TEST: 1) Valgus Stress Test:supine, Dr. side of affected leg,knee flexed to 30 degree, distal medial knee firmly grasped, other hand applied lateral valgus stress to proximal joint. gap or open compared to opposite side. -Rehabilitation: grade I-III can be treated non operatively pt initially present w/ brace, crutches, & hinged brace to decrease valgus stress & rotational forces. MAX: decrease inflammation, Restore ROM, increase quad tone. (Knee ROM exercises, quadriceps setting & multiplane straight leg raise w/o creating valgus stress. progress to FWB 1-2wk from injury as pain & quad strength allows. MOD: (starts at 2wk): same goals 1) restore ROM, 2) progress strength to the affected limb, 3) continue protection of involved tisue 4) continue use of antiinflammatory modalities as needed. CKC should be progressed as mentioned earlier from bilateral to unilateral and from sagital to frontal to transverse plane in nature. if patient achieves full ROM w/o increased level of pain or struggly w/FWB reevaluation by PT is advised. If gait mechanics exist and strength and ROM allow, a running progress may be started as early as 6 weeks from injry. PLYOMETRIcS strengthening may start at the same time and progress to different planes discussed previously. General return to sport will happen 8-12 wk from injury. FUNCTIONAL BRACE may be suggested to protect injured MCL when returning to sport is prermitted.

Muscle strainLumbar spine

-mm Strain: ----Mechanism of injury: sudden, violent contraction (attempt to lift heavy object), rapid stretching, combines lumbar ext/rotation (torque), eccentric loading and repetitive overuse.

Anticoagulant

-prevents clotting of blood (oral injectable IV), Warfarin (Coumadin), herpin, lovenox (don't need to check PT-INR) -1.9-2.9: normal Ortho patient -3.0-3.9: proceed w/ therapy but don't progress -4.0-4.9: Bed exercise only- no resistance >5: bed rest- no exercise *PT-INR (Prothrombin time- international rating): Hi=blood to thin ===== LOW=Blood to0 thick

LIGAMENT RAPIR KEY CONDITIONS

1: torn ends must be in contact 2: progressive/controlled stress must be applied to the tissue to orient scar tissue formation 3: ligament must be protected from excessive forces during the remodeling process

Bursitis

inflammation of the bursa from excessive friction causes decreased ROM. (Bursa: sacks that sit between mm and bone)

Knee ligament Sprain degree Grade

-Grade I: minimal pain, min/no swelling, no loss of joint function, & no clinical/functional instability. -Grade II: partial loss of fiber continuity, few fibers torn, Mod pain/swelling, some loss of function/stability. -Grade III (RUPTURE): entire ligament fibers completely torn, PROFOUND pain, intense swelling, loss of joint function, & instability.

Ligament sprainLumbar spine

-Ligament Sprains: ----Anterior longitudinal ligament (ALL): Runs anteriorly along vetebral body blending w/ annulus ----Posterior longitudinal ligament (PLL): runs posteriorly along vetebral body within vertebral canal (weaker than ALL) ----ligamenum flavum (LF):lies within verteral canaal and connects the lamina on the vertebral arch of adjacent vertibare. ----interspinous ligament (ISL): between spinous process weaker than ALL, PLL, & LF. ----supraspinous ligamnet (SSL): attatches tip of spinous process to the net spinous process from C7-to the sacrum. -Lumber Ligament Mechanism of injury: sudden violent force or from repeated stress

joint mobilization effects

-Neurophysiological: stimulate -mechanoreceptors to decrease pain, affect mm spasms and mm guarding. -Nociceptive: increase position awareness/ motion because of afferent nerve impulses. -Nutritional:synovial fluid movement, improve nutrition exchange due to joint selling and immobilization. -Mechanical: improve mobility of hypo-mobile joint( decrease adhesion, loosen connective tissue)

Legg-Calve-Perthes Disease LCP (AKA: Coxa Plana)

-Non-inflammatory self limiting syndrome, when femur head is flattened at WB surface resulting in disruption of blodd supply (AVN). 4-8 y/o

Patellofemoral pathologic conditionas

-Patella alta: patella superior than normal( excessive ham tightness). Test for ITB/rectus femoris. -Q-ANGLE (Quadriceps angle) standing: ASIS-AXIS OF PATELLA (middle), tibial tuberosity. 1) increased q angle can affect tracking in flexion/ext and pain. Miserable malalignment syndrom: combined femoral antiversion, squinting patella(facing each other), external tibial torsion and foot pronation). NEED TO FINISH PG 279-281)

mm fiber types

-Type 1:RED, Slow Twitch, oxidative fibers(presence of myoglobin and O2 binding protein): adapted to continous aerobic exercise, fatigue resistance, (ex; soleus, spine, postural mm) -Type 2: WHITE, Fast Twitch, glycolytic fibers (anaerobic activities; usemyosin heavy chain (MHC) protein complex), fibers are differentiated by there resistance to fatigue,

Ligament ch 8

Primarily type I fiberoblast, extracellular matrix and varying amount of elastin

Grades of joint mobilization

-Grade I: treat pain (25% ROM), small amplitude oscillation only at the beginning of range, (used daily), -Grade II: treat pain (50% ROM) large amplitude movement from beginning to midrange. (used daily), -Grade III: joint restriction, large amplitude motion midrange to available endrange. (75% ROM) 3/4 /wk. -Grade IV: Joint Restriction, small amplitude oscillation (100% ROM) 3/4 /wk, at the end of available joint ROM. -Grade V: High velocity trust of small amplitude at the end of available ROM

TOTAL HIP REPLACEMENT THR

-Indication: RA, OA (both femoral head/acetabulum), Osteonecrosis, fracture, juvenile RA (most common THR in adolescents), Pain, Reduced ambulation, significant alterations in ADL's) Rehab up to 4 months -Complications: -Noncimented (antalgic gait b/c of pain), Thromboembolic Disease (DVT, PVT). -Precautions: --Posterior, posteriolateral, lateral: Avoid hip IR, Flex past 90, combined (flex, IR, & ADD for 4 months post surgery). -- Anterior: AVOID Combined Hip ext/ER. -MAX: ankle pump (B), iso quad set, glut set, active knee flexion. (Contralateral: active SLR, quad sets, ham sets, ankle pump, full knee & hip mobility exercise. transfer/bed mobility, (TDWB/PWB: crutches/walker), 3wk gradually progress. -MOD: starts (when patient is able to improved quadriceps control, active knee flexion, reduced pain, compliance w/ all precautions and exercises, ind. bed mobility/transfer and improved gait.). challenging exercises to approximate functional activities. -Semirecumbant theraband- light resistance exercises for quad strength. can be used to strengthen ham and quads. -Standing: stress active hip motion (straight plain no combination) and strengthening. -Aerobic fitness: recumbent bucket seat bicycle ergometer or a UBE -CEMENTED 3-8 weeks: Closed-chain functional activities. as directed by DR. (ex: sit-stand w/ elevated seat, partial supported knee bends( con/ecc quad control), weight shifting exercises, treadmill walking, mini step-ups, and standing resisted hip and knee extension. -UNCEMENTED (2-3wk longer than cemented 5-10wk): however standing straight plain (hip ext,flex, abd, add, allowed 3-8wk) MIN 12-16 wks:Dr. may elect to discontinue THR precautions. classically characterized as return to normal gait pattern w/0 AD & by instruction in balance, coordination, proprioception(SLS (Eyes open/eyes closed), SLS on mini trampoline/balance board), & advance CKC functional activities that duplicate ADL's .

Skeletal mm ch 11

-Musculotendinous Junction: transition zone between mm and tendon. -tendo-osseous junction: attatchment between tendon and bone.

Muscle strain degree

AKA: mm tear (ex: pulled hamstrings "hammy") -First Degree: tear of few mm fiber, minor mm weakness, none to minor loss of function, minor pain and min/none swelling -Second Degree: tear of approximately half of mm fibers, significant (moderate) mm weakness, loss of function, pain, and noticeable degree of swelling. -Third Degree: tear (rupture) of the entire mm, major loss of function &weakness, NO PAIN (B/C Nerve damaged), SIGNIFICANT amount of swelling.

Deltoid ligament Sprain AKA: Eversion Sprain AVOID: Dorsiflexion/EVERSION

AVOID: EVERSION/Dorsiflexion -Isolated sprains deep/superficial layer of deltoid ligament are rare (3-5% of all ankle sprains)). important to recognize that complete deltoid ligament rupture occur in combination w/ ankle fx. -Rehabilitation: NWB for 6wk/s (Begin total body fitness program) then progressive WB and PT. primarily joint protection and use of semirigid orthosis. Ice, compression and elevation assist w/ pain and swelling. progressive strength follow 3 phases. isometric exercises, latex ruber band strengthening, AROM (carfull to avoid unwanted stresses), & progressive WB are added as tolerated.

Cortical Bone Vs. Trabecular bone

Cortical Bone (Compact Bone): dense in appearance & is subjected to bending, torsion and compressive forces less than 30% porosity. Trabecular Bone ( 50-90% porosity) structure and less dense.

Nerve injuries classifiction & causes Neurapraxia Axonotmesis Neurotmesis

-Neurapraxia: temporary loss of motor and sensory function. Reduction in nerve conduction at the site of injury, usually to compression. (reversible if cause is removed and recovery in wk/months 6-8wk) -Axonotmesis: schwann cells/ myelin sheath, epinurium intact, the perineurium and endoneurium damage occurs. functional Recovery w/o surgery may occur. -Neurotmesis: entire nerve trunk is transected/ruptured. total loss of nerve connection requires surgery. * nerve usually fails to conduct impulses related to motion (first), proprioception touch, temp, and pain (last). Recovery occurs in reverse order.

Bone cells

-Osteocyte: are obsteoblast that are embedded within newly formed mineralized bone matrix (90% of mature skeletal tissue. -Osteoblast: form bone matrix (osteoid) and synthesize type I collagen. -Ostoclast: form acidic enzyme lowering, lowering the PH and causing bone resorption to reabsorb bone.

General terms pharmacodynamics

-Pharmacodynamics: the medication does in the body. -Adverse Drug Reactions (ADR): side effects. -Window: minimum concentration needed to show drug effectiveness. -Duration of action: length of time active in body. -Mechanism of action: biochemical interaction through which a drug substance produces its pharmacological effect. -Prophylaxis: use of antibiotics to reduce infection. -Analgesic: any drug that reduces pain (ex: opiods, acetaminophen & anti-inflammatory agents)

Fracture Classification

-Site of Injury: area of insult to bone (ex: epiphyseal fracture/ intraarticular fracture, diaphyseal (shaft) fracture) proximal/middle/distal portion of bone. -Extend of Injury: complete (transverse the bone entirely) or incomplete (ex: hairline cracks or greenstick fracture. -Configuration of direction of abnormality: Direction of the fracture, ( transverse (fracture line goes straight across (horizontally), oblique fracture (crosses bone diagonally). Spiral torsion or spiral fracture trough bone, impacted fracture long-axis compression injury, & Comminuted when more than two fragments are present. - Relationship of fracture fragments to each other: displaced, non-displaced, angulated, twisted, rotated, or overriding (Ex: Avulsion fracture: bone is pulled away via tendon or mm attachment). -Relationship of fracture fragment to the environment: open( compounded fx) or closed (simple) -Complications: resulting in delayed union, non-union, & malunion of fracture fragments

Direct (external) Vs indirect (internal)

-Supraphysiologic load: greater than mm tissue tolerance (volent or excesive mm stretch combined with eccentric mm contraction. -Subfailure load: that is experienced for prolonged period of time. -Direct (external) mechanism injury: external force applied to the body results in a trauma (ex: contusion (blunt trauma), deep laceration (sharp implement). -Indirect (internal) mechanism injury: independent of applied external force. result of either supraphysiologic load (ex: violent/excessive mm stretch with eccentric mm contraction). or repeated insult (overuse injury) without allowing tissue time to recover .

Patella Glide

caudal glide: inferior force cephalic glide: superior force lateral glide: lateral force Medial glide: Medial force Rotational:

THERAPY FOR ACUTE, SUBACUTE, CHRONIC

-ACUTE(0-6days): PRICE (Protection, Rest, Ice (20min for every 30 min/hr, Compress, elevate), if severe emergency room. -ACUTE (up to 6 days): control or reduce effects of inflammation, decrease pain, initiate controlled movement to resolve pain, initiate controlled movement to restore ROM, and reduce the loss of mm strength. GOALS: -Facilitate healing of Inj. tissue: ultrasound & cryotherapy. -Control/reduce inflammation: ultrasound, cryotherapy & massage -Decrease pain: ultrasound, cryotherapy, massage, joint mobilization. -Restore ROM: PROM (manual or self techniques), AAROM (self techniques), massage, & Joint mobilization. -Strengthening: isometric exercises. *HEP, assess the effect of treatment, discontinue treatment that do no impact patient recovery, and treatment that worsen patient state should be discontinue. Subacute (3days to 3weeks): Restore full/PROM, initiate mm strengthening, continue to address residual swelling, reduce pain, and initiate functional movement tasks. Primary goals PROM, AAROM exercise are prescribed as tolerated, pt. progressed to AROM techniques and static stretch (30 sec hold). Strengthening 15-20reps of 1 to 2 sets per exercise. -CHRONIC (12-18 months):Collagen aligns to stress applied. should be functional in nature and account for type of fibers (type I mm fiber: trained endurance training strategies)/ (Type II mm fiber: strength training) Plyometrics/power training must be initiated if functionally necessary once patient is pain free. ***ECCENTRIC EXERCISES FOR: tendinopathy, tendinosis (at the achilles tendon or patellar tendon)

Osteoarthritis (OA) HIP

-Characteristics: Pain/functional limitations -GOAL: Minimizing symptoms, min disability, & reducing risk of disease progression. Add. goals: mod activities, maintenance of ROm , instruction on proper diet/weight control, proper footwear, AD if appropriate. -Therapy: gait & balance training(proprioception/ balance/ strength impairments), manual therapy techniques distraction (pain relief/improve mobility/function w mild hip OA), flexibility/strengthening and endurance. Psoas mm group: assessed for lack of flexibility. Gluteus medius for weakness.

Pubalgia

-Characterized by causing chronic pain in public tubercle & Inguinal region. Lower abdominal pain during exertion and no pain at rest. pain noted unilaterally but possible bilaterally. -Therapy: Stretching of traditionally tight( psoas major/adductor mm groups) & Strengthening of weak (gluteal mm) ofter indicated as long as pain free.

Osteitis Pubis

-Characterized by pain and erosion of public symphysis. Pain in pubic region radiatigin laterally across the anterior hip (aggrevated by striding, kicking, or pivoting) -Therapy addressing primary dysfunction, where mm imbalance, joint mobility dysfunction or some other cause.

Hip fractures

-Comorbidities: Patient mental Status (healing diabetic, COPD, pagets disease (bone healing compromised) -Post-op Complication: Avascular necrosis (AVN), malunion or nonunion, DVT- PVT. •Co-morbidities and patient mental status may also influence rehab approach (Age, COPD, mental, smokers, alcohol users, malnutrition)

Precaution/contraindication

-Contraindication: acute inflammation, advanced osteoporosis, ligamentous rupture, herniated disk w/never compression, bone disease, fx, congenital bone deformities, hyper-mobility, interrupt healing process, mm guarding, joint replacement, pregnancy (3-9 mts). -Precautions: early stage osteoporosis, flu (active infection), poor general health, pregnancy (relaxin after 1st trimester), severe scoliosis (spinal), patient inability to relax.

Operative management of AC pathology

-Debridement: Arthroscopy lavage or debridement: temporary benefit because of lack of true inflammation response. -Microfracture: surgically abrading or fracturing multiple small holes down to bone to cause bleeding and start the heling process. SHOWN TO PROVIDE SHORT TERM functional RELIEF. -Arthroscopic osteochondral autografts: bone and cartilage taken from other part of the bone to replace nonviable cartilage that is removed. -Autologous Chndrocyte Implantation ACI: 2 procedures. Harvest AC from (superomedial edge of trochlea or lateral edge of intercondylar notch), sent to lab and chondrocytes are separated/cultured and multiplied. 6-18 weeks implantation is secured by fibrin glue.

Fracture Complications

-Delayed Union: dynamic biologicial repair process occurs slower than expected. Brashear and Raney malunion can be detected if firm callus is not formed with in 20 weeks (tibia/femur fx) and 10 weeks (humerus). -Nonunion: healing process have stopped. Can occur when there is a significant and severe associates soft tissue trauma, poor blood supply, and infections. -Malunion: healing process results in non-anatomical position. caused by ineffective immobilization and failure to maintain immobilization for adequate period of time.

Cartilage Injuries

-Erosion and degeneration: causes degenerative joint Disease (DJD), related joint instability, blunt trauma, repetitive overloading and immobilization. -Degeneration events are Fibrillation or fraying, Blistering, and splitting/clefting/fissuring.

PCL Posterior Collateral Ligament injury Rehabilitation

-Fall on HYPERFLEXED knee results in posterior translation of tibia on the femur, dashboard injury from MVA. -ACUTE: Pt. will often not report feeling a pop or tear. Pt. have mild to mod. knee effusion, a slight limp, pain in back of the knee & often lack full flexion of the knee. CHRONIC: diability having difficulty doing things such as walking up/down inclines secondary to increased tibial movement on the femur. -TEST: 1) Posterior Drawer Test: supine, knee flexed to 90, + test is when the tibia sags relative to femur. 2) Godfrey tibial sag test: HIP 90 & knee 90 hlf to observe affected lim to translate sublux or sag posteriorly. -Surgical: autograft (BPTB, ham/quad tendon) -Post-OP rehabilitation: Day one crutched, hinge locked in full ext., PWB to FWB 4-6wk MAX (0-6wk): early: quad setting, multiplane straign leg raise, patella mob. & ROM exercise to gain full ext..,minimizing full knee flexion from 60-90 is necessary early rehabilitation to protect the healing PCL graft. Generally full knee flexion ROM can be achieved by 2 months of surgery. AVOID HAM iso at greater than 30 degree have shown to increase strain on PCL. MOD&MIN (6-12/wk/surgery): SIMILAR TO POST OF ACL in terms of GOAL and TIME FRAME, Return to sport can be 6-0 months post surgery --NON OPERATIVE: Pt. w/ isolated grade I & II PCL tears. Pt may present with knee immobilizer or hinged knee brace, along with crutches, decreasing inflammation, maintaining quad tone & restoring knee ROM. exercises include isometrics, multiplane SLR & ROM. CKC strengthening begins 2-4 wks as swelling, pain & ROM improves.

Clinical application of rehabilitation techniques during

-Immobilization period: non immobilized structers should be exercised through the period (ex: LE straightening and endurance ;staionary cycle, treadmill and leg extension for UE fx) -Isometric mm contraction for injured area are designed to minimize mm atrophy. - cast brace serve as weight in the beginning (AROM) but ankle weights can be used later in the rehab (should be applied superiorly in the beginning) - Electrical muscle stimulation: holes made in the cast to place electrodes. but controversial. -CPM GOALS: improve overall fitness, promote motion on unmobilized joints, minimize mm atrophy, maintain/improve strength, protect healing structure, teach safe and effective transfers and gait activities. After immobilzation - progressive exercises must be directed cautiously 1-Thermal agents to promote various thermal agents. 2-Strengthening: systematically progress through isometrics, concentric and eccentric resistance, isokinetics, and CKC resistance exercises 3-Balance, Coordination and Proprioceptive exercises: included during the post immobilization. 4:Cardiopulmonary: Stationary Cycle ergometer, UBE's, stair climbers, and treadmills used to enhance fitness during and after immobilization.

Proximal Femoral Osteotomy

-Indication: DJD is excessive resulting in hip pain associated w/ subchondral bone erosion, cartilage fibrillation, fissuring & hip joint incongruity. -Goal: reduce pain and improve function by significantly changing angle of femoral neck to expose health cartilage. THERAPY: MAX(1st day): , quad setting exercie, glute sets, ankl pumps and gentle AROM. -WB: 8-12wk crutches (TDWB/PWB & NWB) STRICTLY ENFORMCED. surgical incision healed/ Pt. allowed pwb (underter treadmill or unweighting device used for gait mechanics) -RADIOLOGICAL confirms secure bone healing: isotonic knee extension, leg curls, & standing hip abd, add, flex, ext, strengthening using system/wall pulleys, lighter thera-band , ankle weighs. -Closed Chain: extreme caution should be taken, to minimize joint compressiove loads. (Limited ROM leg press FWB, as healing progresses mini step-ups, shor-arc wall squats, treadmill walking.

Strains (mm Strains)

-Initial: 20min cold pack 3-5x daily, compression, avoiding activities that exacerbate/interfere with healing process. Sleep: Supine with pillow under (B) knees. Pain free knee extension/ leg flexion (to align collagen fibers). FOLLOW MM TISSUE HEALING.

Fracture Fixation

-Internal: anatomic fixation of bone results in primary repair or direct cortical reconstruction -Bone Plate: stripping the periosteum where screws and plates are to be fixed. (devascularizes periosteum blood supply) -Intermedullary Rod:medullary canal must be reamed to allow for proper anatomical placement of rod. (LE diaphsyseal fx: femur, tibia removed 1-2 years) -Tension Wire: platella fx. and olecranon fx. -External: cast, traction, splints, and braces. Risk of infection or further fracture: pins used to immobilize the fx but used to hold in rigid alignment (fiberglass casts, plaster casts, hinged-plaster casts, and adjustable range hinge. (Less Rigid: periosteal bridging callus, More rigid: Primary cortical healing.)

Radiculopathy

-Mechanical compression or inflammation of a nerve root that causes neurological symptoms in LE. -Symptoms: pain, numbness, tingling, weakness, burning, or paresthesisas (is a sensation of tingling, tickling, pricking, or burning of a person's skin) frequently called sciatica or a pinched nerve. However TRUE Radiculopathy often involves more than pain/paresthesias often involves change in reflexes, strength loss in a myotomal distribution, and sensory loss in a dermatomal distribution. Test: 1) Straight leg raise test: pt supine, leg passively raised w/ knee completely extended.

Fibrocartilage: type I collagen

-Menisci: c shaped fibrocartilage tissue, dissipates extreme compression, shock absorber, limites knee hyperextension and function in joint lubrication/nutrition. -Glenoid labrum of shoulder & Acetabular labrum of hip: increased congruency and as an anchor point for other structure.

Ficrocartilage injuries

-Menisci: injury occurs through trauma or degeneration -Tear: in <40 young adults through combination of compression, torque, acceleration or decelleration. (running, jumping, twisting, and dynamic change in direction activities) -Degeneration: 40> older adults. no sudden trauma injury complication of pain and dysfunction. -Glenoid labrum of shoulder: direct trauma or repetitive stress. Detachment of Anterior-inferior labrum (bankart lesion) by anterior shoulder dislocation. 'Long head biceps tendon (LHBT) attach to superior labrum, anterior to posterior tear (SLAP) lesions from repetitive stress from biceps tendon from repetitive throw. -Acetabular labrum of hip:repetitive bony contact seen in femoractabular impingement (FAI). labrum can become torn or detached over time as femur repetedly makes contact during deep hip flexion or internal rotation.

Mobilization Vs Manipulation

-Mobilization: Pain (gate theory) and increase ROM (less pain), applied in motion light enough that patient can stop the motion. -Manipulation: Passive: increase joint ROM, sudden forceful thrust beyond patient control. Joint to endrange/high velocity/quick thrust audible pop. -Traction: pulling joint away from ones articular surface.

Pain Nociceptive Pain Neuropathic pain

-Nociceptive Pain: pain from actual tissue damage. (may be inflammatory or noninflammatory) -inflammatory pain: pain from inflammation (corticosteroids, non-steroidal anti-inflammatory drugs, or cyclooxygenase-2 (COX-2) inhibitors. -Neuropathic pain: Pain from damage or disfunction of nerves. (nerve compression, fibromyalgias, diabetic neuropathy, postherpetic nuralgia, spinal cord injury, and phantom pain.) -TREATING: by drugs that sow or block nerve conduction. (ex: anti-depresents, Anticonvulsant, Topical products (ex: lidocaine patch, capsaicin cream) and opiod analgesic (ultra). Acute: following injury and disappears after healing. Chronic: remains after normal time expected for healing which is presumed to be 3 months.

End feel

-Normal (3): 1)Bone to Bone end-feel: sudden, hard, nonyielding sensation felt at the end of ROM. 2)Soft-tissue approximation: "yielding compression" typically encountered with knee or elbow flexion. 3)Hard or springy-tissue stretch: characteristic feature is "elastic resistance" or "rising tension" -Abnormal (6): 1)Muscle Spasm: pain accompanied by a sudden halt of movement. 2) Internal Derangement (springy block): full motion is limited by a soft or springy sensation occasionally accompanied by pain 3) Empty end feel: limited by significant pain without mm spasm 4)Loose end-feel: joint hyper-mobility, w/ no resistance felt at the end ROM(significant joint looseness) 5)Capsular end-feel: related to capsular resistance, normal tissue stretch but elastic resistance before the normal ROM. 6)Boggy: soft, mushy; joint effusion

Medial Tibial Stress Syndrome MTSS: ( Shin Splints should be disregarded) Medical EMERGENCY to cut fascia to relieve pressure and left open to heal

-Overuse injury of the lower leg involving the distal third of the posterior medial border of the tiba have historically been referred to as shin splints. Mechanism of Injury: micro-tears of periosteum, overuse commonly happen after changes in training - increasing running speed/distance -running on, hard/angled surfaces, overuse can also occur from running in flimsy footwear from soles that wear out --Medial Tibial Stress Syndrome: severity of pain with activity Pg. 250 -Grade I: pain experienced AFTER activities (muscle soreness/inflammation) *Treatment: CP, NSAIDs, rest, gradual stretching/strengthening -Grade II: pain DURING and AFTER activities but DOES NOT LIMIT ABILITY TO PERFORM (mild-mod inflammation) *Treatment: CP, NSAIDs, rest, gradual stretching/strengthening -Grade III: pain BEFORE, DURING, AFTER activity and limits activity (significant inflammation and bone microfractures) *Treatment: stretch gastroc, soleus -Grade IV: pain SIGNIFICANT and CANNOT PERFORM ACTIVITY *Treatment: deviations in the foot that may require orthotics, change footwear as suggested.

Ligament Phase of Healing 4 Phases

-Phase I: (immediate to 2 days) Hemostasis/Degeneration: Tissue retracts and hematoma forms between the damaged end of tissue PHASE I & 2 Take 2 days -Phase II: Inflammation: 3-14 days (extremely potent chemical mediators of vasodialation released/cell wall permiability and pain inresponse to fibrin clot formation (Prostaglandins, histamine, bradykinins, & serotonin are sendt to trauma site to increase capillary permeability and profusion dilation of blood vessel). Causing the migration of polymorphonuclear cells and lymphocytes to initiate ingestion (phagocytosis) of bacteria and dead tissue (main cells: neutrophils, lymphocytes (monocytes =>macrophages => as they become phagocyts) -Phase III: Proliferation/migration: (14-60 days/Several Weeks): fibroblast rapidly synthesize new extracellular matrix (with high concentration of water, GAGs, and relatively weak/fragile immature type III collagen.). over Several WEEKS the the concentraction of Type 3 collagen decrease and Type I collagen are laid down and align to appropriately applied stress. -Phase IV: Remodeling/degeneration: (60-360 daysLastal YEAR OR MORE). the hallmark of phase IV is collagen organization and increase in tensile strength of repair tissue. (UP TO A YEAR THE TENSILE STRENGTH MAY ONLY REACH 50-70% of original) (knee and ankle highest in tendon sprain, MCL 25-40%. *** High dense fibrous tissue (tendon/ligament) Frequent, intensity & duration exercises. Tissue subjected to repeated COMPRESSION respond by synthesizing larger and greater amount of proteoglycans than those tissue exposed to tension loads.

Terms joint mobilization

-Physiological Movement: voluntary movement(concentric/eccentric, flex/ext, etc.) -Accessory movement: within joint/surrounding tissue (ligament, joint capsule) -Component motion: accompanies motion/not voluntary. -Joint Play: motion occurs within joint (determined by joint laxity. -Thrust: high velocity, short amplitude motion (snap adhesions, stimulate joint. (beyond scope of practice).

Rehabilitation Fracture

-Program is Highly individualized. high mortality rate. -MAX (1-21 days):site protected, pain and swelling reduced & isometric exercises, gentle protected ROM, and limit WB begins. USUALLY TDWB, TTWB allowed 2nd day -Ther. EX.: Ankle pump (B), gluteal sets, heel slides, hip abd/add, supine IR/ER) must be SUBMAX. Must be submax and progress as patient tolerates. -NO NO: combined diagonal or rotary forces (cause hardware loosening. (pg 299-300 19.5 figure) !!NO ACTIVE SLR, Supine hip bridge FIRST 6-8 weeks. WB increased from radiography confirmation by Dr. Closed chain functional added as FWB is achieved. (TherEX: Step up, partial wall squats to regain con/eccent control of quads/hip flex, bike ergometer used early as patient tolerate sitting depending on ROM/Precautions) -MOD (3-6wks post surgery): Ther EX: standing position strengthening (proper movement pattern), advance exercise using cable system, lower lels of thera-band or ankle weights. initialtion of limited ROM leg presses can commence. - advnace (6-8 weeks):normalizing gait mechanics & reducing use of AD, treadmill can be used step cadence and stride length adjusted, to enhance gait and provide stimulus of greate hip and quad strength. (ACTIVE PATIENTS: more advance hip strengthening and endurance.)

Ankle/foot & toes ATFL, Fibulocalcaneal, and Posterior talofibular

-ROM dorsi: 20, plant: 50, inver: 35, ever: 15 (FUNCIONAL: min. of 35 of DF and 30 of PF) -Loose: 10PF mid between INV/EV. -Closed: EVERSION Classification: Lateral Inversion Sprain: grade I:single ligament rupture (anterior talofibular ligament) ,II: double ligament rupture (anterior talofibular ligament & fibulocalcaneal ligament), & III all 3 ligaments ruptured (ATFL, Fibulocalcaneal, and Posterior talofibular)

Opioid (Analgesics )

-SIDE EFFECTS: NAUSEA/VOMITING, allergic reaction, sedation, drowsiness, DIZZINESS, constipation, HYPOTENSION/ORTHOSTATIc hypotension, slowed hear rate/respiration, impaired judgement, physical dependence, and addiction. -Chemically related to Opium (ex: morphine, xycodone, hydrocodone, and codine) -Work within CNS to block the transmission of pain and create feeling of euphoria. -Reduce patient safety and increase risk of falls & injury.

Cocyooxygenase-2 inhibitor (Prescription only)

-Side effect: less Gi distress than NSIDS -COX2: causes pain and inflammation. (ex: celecoxib (Celebrex) -COX2 inhibitor: same as NSAIDs but reduced side effects. inhibits the production of prostaglandins but does not inhibit Cox-1 (allowing fewer bleeding/stomach related side effects). age 65 or over w/bleeding disorders

Non-steroidal Anti-inflammatory Drugs

-Side effects: GI distress/bleeding (urine, stool, vomit, broken blood vessels in eyes) - mechanism of action: inhibition of prostaglandins and cocylooxygenase type 1 and cox-2 -OTC(asprin, ibuprofen, naproxen, and ketoprofen) -Very effective in inflammatory pain:( RA, carpal tunnel syndrome, acute gout, lateral (tennis)/medial(golf) epicondylitis & Bursitis). Not appropriate for Pt. w/ uncontrolled hypertension, CHF, kidney disease, stomach ulcers, bleeding disorders, alcoholism and anticoagulants (varfarin).

Corticosteroids injection

-Side effects: edema, insomnia, risk of infection, mm atrophy, GI distress, glaucoma, mood changes, increase appetite, increase osteoporosis risk, increase blood glucose for diabetic patient. POWERFUL ANTI-INFLAMMATORY/ immunosuppressant effects. Naturally by adrenal glands, regulates metabolism of carbohydrate, fats, proteins, immune function, wound healing, and other. Used in : OA, Carpal tunnel syndrome, acute gout, lateral/medial epicondylitis, bursitis and systemic lupus erythmatosus (SLE) Effects: start 24-72 hrs to 8-10 week. beginning should limit the use of limb. no more than 3/year

Articular Cartilage Lesion

-Surgery: making hole in subchondral bone and letting it bleed to form fibrocarliginous clot, graft harvested from NWB surface and strategically placed in the lesion. -REHABILITATION: NWB 2-8wk, hing brace locked in extension or allowing 20 flex. protect healing tissue, patellar mobilization, min. joint swelling, restore ROM, & begin iso exercises. Stationary bike, w min resistance or UBE. 8-10 wk: should be FWB/relatively limp free. exercise progress from (B) to Unilateral. 2-6 wk patient should have normalized gait, full ROM, and within 90% strength of unaffected limb. SPORTS6-12months: 6 months skating/cycling, 8 months agility pool running begins, 12 months tennis/basketball.

Tendon injury classification (pg 161 11-3) • Tendinitis • Tendinosis • Peritenonitis: • Tenosynovitis: • Tenovaginitis:

-Tendonitis: Acute injury to the tendon with associated inflammatory response -Tendinosis: not associated with inflammatory (CHRONIC) -Peritenonitis: inflammation of the peritenon only -Tenosynovitis: inflammation of tendon synovial membrane. -Tenovaginitis: inflamed, thickened tendon sheath.

Tendon pathologies Tendonitis Tendinopathy Tendinosis

-Tendonitis: acute, injury of tendon associated with inflammatory response. Patient presents with inflammation (pain, warmth, swelling, redness) often describes performing an unfamiliar, repetitive activity from 1 day to a week before seeking medical attention. -Tendinopathy: Pt. presents tendon injury with lack of inflammatory response. ( common locations: achiles tendon, quadriceps tendon, and supraspinatus tendon) -Tendinosis: chronic tendon injury at a cellular level.

Meniscus Injuries:

-ZoneI: elect non surgical, ZoneII: may heal b/c of partial vascular zone, Zone III: nonvascular does not heal requires surgery. -TEST: 1) Apley compression & distraction test (determine if injury is ligamentous or maniscal): 2) McMurray test (used to reproduce symptoms of torn maniscus): 3) Bounce home test (determine if torn maniscus is preventing knee extension): 4) The Thessaly test (MOST ACCURATE clinical test to determine maniscus tear) -Surgery criteria: symptoms affect ADL's/work/sport, positive clinical examination finding, not responding to nonsurgical approach, & absent of other causes of pain identified in clinical examination. SURGERY TYPES: 1) Subtotal or partial meniscectomy ( recommended when repair is not feasible) REHABILITATION: reducing inflammation, normalize patella mobility & progressing full ROM as soon as possible. PWB from 1-14 days, progressive stretching & early strengthening exercises about 2 weeks after surgery, progress to mutiplane OKC &CKC strengthening and stationary bicycle. Athletes low level plyometrics and running start aprox. 6-8wk post surgery, return to competition 2-4 months. 2)Meniscal Repair: greater potential for repair when 1)repair involves lateral meniscus, 2) injuries are acute, 3) repair are performed with ACL reconstruction. REHABILITATION: isolated meniscus, MAX: (0-6wk) protective WB use brace locked into extension & restricted ROM to 90 flex. Delayed FWB status until 4-6wk avoid vertical compression forces into the repaired tissue. EXERCISE include patellar mobility, knee rom limited to 90 flex., quad setting, SLR, & gait training. MOD: (4-6wk) begin when allowed FWB status, (B) CKC strength, to SL as tolerated, & stationary bicycling progress to WB cardio elliptical & stair climbing. CKC should be progressed with caution (progressing CKC within a pool reduces compression through the knee due to boyancy of the patient. MIN: depends on prior level and goals. Patient should demonstrate Full ROM, normal gait mechanics, gairly good strength compared to uninvolved LE. light plymetrics (jump rope introduce impact before progressing to higher level plyometrics). 3)Meniscal transplantation (meniscal allograft): when surgical indicated are adhered provides excellent results in pain & improved function. Rehabilitation: conservative approach is recommended, NWB post op with limited ROM of 0-90 flexion. postoperative will vary but closely resemble MENISCAL REPAIR. most surgeries will provide program that allows running 4-6wk, and full activities at 6-9 months.

Compartment Syndrome

-defined as either acute or chronic elevated tissue pressure within closed facial space, resulting in occlusion of vessels and compromised neuromuscular function. -ACUTE (CONSIDERED MEDICAL EMERGENCY): most commonly associated with tibial fx, direct trauma to the area, mm rupture, mm hypertrophy, and circumferential burns. -Symptoms Acute clinical: pain, palpable swelling or tensensess, and paresthesias. skin warm shinny and tense, passive stretch of lower leg mm may produce pain. -CHRONIC (AKA: exertional cmpartment syndrome or exercise-induced compartment syndrome), mm contactions and exertion have been shown to increase in mm size leading to increase intracompartmental pressure resulting in ischemia and reduced neuromuscular function. -Symptoms Chronic: dull aching pain within mm during and after long-term exercise. paresthesias also may develop as syndrome progress. Exercise inducing Compartmental syndrome are (anterior and deep posterior compartments) -Anatomy: 4 compartments divided by nonyielding fascia: 1) Anterior compartment:(tibialis anterior, ANTERIO TIBIAL artery & vein and foot/toe extensor mm) 2) Lateral compartment: ( SUPERFICIAL PERONEAL nerve & short/long peroneal mm) 3) Superficial Posterior compartment: (soleus mm, and plantaris/gastrocnemius tendons). 4) Deep posterior compartment:( posterior tibialis mm, proneal artery/vein, TIBIAL nerve, POSTERIOR TIBIAL artery & vein.) -INTERVENTIONS: ACUTE: treated with surgical procedure called: fasciotomy. when nerve and mm ischemia last longer than 12 hrs, severe, and irreversble damage occurs. if ischemia can be reduced in less than 4 hours usually no permanent damage occurs. *fasciotomy is designed to relieve intracompartmental pressr by opening/ releasing fascial compatment. ice and elevation is used immediately after surgery to reduce swelling. walking as tolerated & active/passive gentle ROM of ankle/knee are begun 2 days after surgery. PT: early ROM is crucial inorder to prevent contractures, ice and elevation continued post exercise. General conditioning can begin single-leg ergometer or UBE. once pt shows improved motion/reduced pain/swelling light resistance exercise bein for involved leg. light resistance should be encouraged because heavy resistance leads to hypertrophy is CONTRAINDICATED after fasciotomy for acute compartment syndrome. -INTERVENTIONS: CHROMIC: are similar to acute however chronic do not always represent a surgical emergency. conservative management should include relative rest, Anti-inflammatory drugs, stretching and strengthening of the involved mm, and foot orthotic device (if appropriate) subcutaneous fasciotomy used when symptoms affect function.

Achilles Tendinopathy

-overuse injury resulting from repetitive microtrauma and accumulative over loading of the tendon. -primary localized pain at the midportion, distal third and insertion of the calcaneus.( should be distinguished from retrocalcaneal bursitis and haglund disease). -Rehabilitation: most cases managed conservatively w/ physical agents, oral medications, relative rest, and progressive exercises. initial use ice massage or ice packs for 15-20 min 3-5x daily. DR: NSAID to help reduce swelling and pian. All aggresive motion MUST be stopped (ex; athlete who runs must stop running temporarily until symptoms subside). program of aerobic exercise using stationary bicycle or swimming program can take the place or running program. sometimes a small felt heel lift can be placed in everyday shoes to help reduce stress (can be removed as sx subside, should reduce gradually to avoid returning of sx). Ultrasound can reduce pain and assist w/ collagen syntheis (generally can be used immediatel befor exercise). Flexibility therex used to increase DF motion and Reduce effects of scarring in prolonged cases of achilles tendinopathy. initially actie DF and towel strecthes are grenerally added as pain allows. ice massage/packs before stretching/strengthening. standin heel cord strecthes as soon as twel stretches do not cause pain or swelling. AVOID: balstic motions. hold stretch for 10-30 sec. standing heel cord stretch performed small block to produce DF motion. Soleus stretch on wall preferred. strengthening exercises often prove very beneficial for patient. Safe and effective program focuses on Limited ROM & submaximal exercises. ECCENTRIC STRENGTHENING exercises when strengthening soleus-gastroc mm group, standin heel raises are preferred form of exercise that produce excellent clinical outcomes following 12wk program for achilles tendinopathy. Pt. have been reported to return to running 12 wk. daily ecc. training is a safe activity w/o any evidence of adverse effects. SEVERE cases may be rigid casted for 10 days. IN GENERAL : general body fitness program. Aerobic fitness can be achieved w/ UBE, seated bicycle ergometer w/ seat height corrected to avoid PF or a swimming program. Upper/ lower body strenth & stretching exercise encouraged as long as tedon suffers no undue stress or pain.

Adhesive Capsulitis (Frozen Shoulder)

-results in loss of ROM due to soft tissue contractures. 40-60 female, pt. w/ diabetes have increased incidence of Adhesive Capsulitis. show posterior Capsular pattern: loss of ER ROM greater than, ABD, IR, Flexion. -Characterized by decreased shoulder ROM, Pain, inflammation, fibrous synovial adhesion, and reduction of the joint cavity. -PRIMARY Idiopathic frozen shoulder: Spontaneous onset w/o cause. -Secondary ahesive capsulitis: generally occurs after trauma or immobilization. •Signs & Symptoms: localized pain often extends down the arm, stiffness, night pain, restricted ROM. initially pain occurs both during rest and during activity. As condition progresses pain subsides and disappears spontaneously -Rehabilitation: ACUTE: Focusses on controlling pain and inflammation/ judicious ice, heat, US, phonophoresis and infrared. The stimulation of pain free motion and relaxation of mm guarding of GH joint, cervical area, and scapulothoracic mm, passive, active, and active assisted motion must occur within pain free ROM to stimulate removal of metabolic waste, increase blood flow, and assist in reduction of edema in local tissues. Both wand/rope/pulley systems can be used early to perform slow and controlled, pain-free ROM. For severely restricted GH joint specific joint mobilization techniques may be utilized to modulate pain and reduce mm guarding. The scapula must be free from restrictions while shoulder attempts to regain shoulder motion and function to normalize scapulohumeral rhythm. Before normalizing motion specific strengthening activities should be accomplished to avoid developing faulty shoulder mechanics. -When Pt. demonstrates improved GH motion, and appropriate scapulohumeral rhythm: strengthening exercises can begin for the deltoid, scapular mm, rotator cuff, and upper arm mm. Strengthening submax to maximal isometrics before theraband or dumbell for concentric & eccentric a comprehensive series of RC exercises and scapular stabilization exercises can be encouraged as early as pain and motion allows. Normalized function can be achieved by having Pt. perform CKC exercise with proprioception (balance board, slide boards, and plyoball) in a sequential, orderly fashion once sufficient strength improved motion and scapulohumeral rhythm activities focus on purposeful functional movements that duplicate ADLs. KEY: pain control, restoration of motion, and improved function must be reinforced continually to encourage compliance w/HEP and the avoidance of positions that may exacerbate pain and mm guarding.

HIP SPECIAL TEST:

1) Patrick or Faber Test (SI joint dysfunction/ hip pathology), (figure 4) ---This test is indicative of illipsoas, ascroliac, or hip abnormalities. ---positive if there is noted pain in the back or the tested limb or if the tested limb remains in a plane above the opposite limb. This may indicate tightness of the hip flexors, adductors or joint capsule of the hip. 2)Thomas Test (+RECTUS FEMORIS, ITB, TFL, Sartorius tightness) --(tight 2 joint)Rectus Femori: <80 degree knee flex/ pos thigh touches table. -- (tight 1 joint) iliopsoas: pos thigh no touching table. -Sartorius: 3 combination of (hip abd, flex, er & knee flex) 3)Ely's Test (Knee) (RECTUS FEMORIS TIGHTNESS, Pt. flexes hip when PTA flexes knee) --Patient prone, passively flex knee -- + hip flexion occurs simultaneously with knee flex and may be indicative of a RECTUS FEMORIS TIGHTNESS. 4)Piriformis Test (OBERS Test) ( PAIN/Tightness PIRIFOMIS TIGHTNESS/ SCIATIC NERVE COMPRESSION tingling) --Patient sidelying with test leg positioned towards the ceiling and hip flexed 60 degree. Therpaist places one hand on pelvis and the other hand on the knew. While stabilizing pelvis. The therapist applies downward (adduction) force on the knee. -- + = pain and tightness, and may be indicative of PIRIFORMIS or compression on the sciatic nerve caused tingling. 5)Tripod sign (Hamstring tightness test) -- Pt. sitting with the knees flexed to 90 degree over edge of table, holding front of the table and sitting erect (allow hip to anterior pelvic tilt). Therapist passively extends one knee. -- + = hamsting tightness. 6) 90-90 SLR Test ( hamstring tightness knee flex greater 20 degrees) -- patient lying supine with the hip and knees flexed to 90degress. Therapist instructs patient to alternately extend each knee as much as possible while maintaining the hip in 90 flexion -- + knee remains 20 degrees or more flexed. 7) • Craigs Test (Antiversion extraversion (toed-in IR, toed-out ER) - Prone with the knee flexed to 90 degrees. Therapist palpates Greater trochanter, and then measure angle - + the angle measured in outside the normal range of 8-15 degrees, Less than 8 exclusively less, More then 15 8) Hip scouting Test oLABRUM TEARS/pinched labrum: (PAIN or reproduction of symptoms at the hip indicative of defect in the articular cartilage of the femur or acetabulum) - Patient supine. Therapist pulls flexed the patients hip & knee. Therapist applies downward pressure along the femoral shaft while repeatedly externally & internally rotating the hip with multiple angles of flexion. o+ = 9)Trendelenburg Sign(hip abductor weakness glut med) ---Stand for 10 seconds and if the opposite hip drops then its positive trendelemburg. --- + perform STANDING abduction exerises (theraband: eccentric/concentric control).

Chronic ligament instabilities

10-30% of patient have chronic symptoms of weakness, swelling, pain, and joint instability after inversion sprain. 2 types of instabilities associated with chronic ankle sprain: MECHANICAL & FUNCTIONAL. 1)Mechanical instabilities: (laxity of ankle ligaments w/ mechanical instability surgery may be necessary to stabilize the ankle joint. -Rehabilitation: commonly rehabilitation involves some form of ankle immobilization for aproximately 2-6 w/k depending on surgery. Passive DF, PF after immobilization. general full body fitness and proximal leg strengthening and proprioception exercise is vital throughout rehab. -Primary delayed repair or Anterior reconstruction: have longer immobilization time (ligament is surgically shortened and reinserted (imbricated). the progression of rehab is same as w/ tenodesis. active/pasive ROM, control of swelling and pain, isometcic and manual resistive exercises (AVOID PF and INV.) theraband and isotonic exercise and isometric are used. Generally proprioceptive exercises are used extensively. SLS exercises, balance board activities, mintrampoline exercise and heel walking exercise are part of the moderate to minimum protection phase. IN ALL CASES JOINT PROTECTION (tape, brace, or hinged orthosis is rudimentary but critical princpal throughout rehab. 2) Functional Instability: subjective feeling of giving way w/o affective ligament laxity. Can involve host of factors including strength, proprioception, and ligament stability. Bracing is important. -Rehabilitation: CKC resistance exercises, proprioception meneuvers, dynamic muscular exercises (con/ecc loads) and bracing for support. SL support proprioception exercises w/ external resistance provide dynamic support and balance training. balance board activities, hel-toe walking, and minitrampoline exercises for ankle through all phases for functional ankle instability.

Chapter 20 Lumbar/ Thoracic / carvical spine

33 vertebral disks (Cervical 7, Thoracic 12, Lumbar 5, sacral 5, coccyx 4) -Direction of motion is determined by the orientation of the facets. Cervical: increased Rotation (horizontal facet) Thoracic: increased Flex/Ext (vertical), suppot upper body weight and dispate compressive loads with minimal production of mm torque. standig 100%, supine 25%, side-lying 75%, standing&bending forward 150%, supine w/ knee flexed 35%, seated in a flexed position 85%, bending forward in a flexed position 275% of body weight. DISC: ----Outer wall: Annulus 12-18 concentric rings: stability, enhanced movement between vertebral bodies & minimal shock absorption(greater shock absorption comes form vertebral body). ----Inner: Nucleus Pulposus: transmit forces, equalizes stress and promotes movement. -Spine mm: ----Dorsal/paravertebral mm: semispinalis, splenius, multifidi, rotatores, interspinales & intertransversarii. -----More superficial: illiocostalis, longissimus & spinalis ------Anterior positional: rectus abdominis, interna/external obliques, and transverse abdominis. Ligament support: Anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), ligamenum flavum (LF), interspinous ligament (ISL), and supraspinous ligamnet (SSL)

Muscle & Tendon Healing process/ tissue healing time

ACUTE: can last up to 6 day if continually stressed --Immediate- 48hrs: Rupture of blood and lymphatic vessels , coagulation (clot formation), vasodilation, immediate swelling (cellular exudate fill the site). Hallmark signs of inflammation experianced (redness (rubor), swelling (tumor), heat or warmth (calor) and pain (dolor). chemical mediators attracted to control inflammatory process. -Day 2-4: decrease in inflammation decrease in clot size (resorption), -(SUBACUTE: early as 3 days to 3weeks): increase in granulation tissue, repair process initiated, angiogenesis (developing new blood supply) -Day 4-21: initiation of fibroplasia (scar formation) fibroblastic activity, growth of scar ceases at the end of the phase. CHRONIC: fiber aligned along the line of stress can occur for 12-18 months after original injury. -day 21-60: Remodeling of scar, collagen thickens and strengthens.

Ankle Fractures & stress Fracture pg 247-250

Ankle Fractures: treated based on MD direction for bone healing. Classifications: know it but be familiar and rehab approach -MAX Protection Phase: restricted WB (TTWB), pain/edema management. ROM may be allowed if motion does not stress the fracture site (DO NOT INVERT/EVERT), keep at sagittal plane, MRE's, toe pickups, towel crunches -MOD Protection Phase: progression is at the direction of MD, seated DF with heel on floor (limits eccentric control of coming down), thera-bands, seated weight shifting, seated proprioception (balance boards) -MIN Protection Phase: return to function (CKC), balance, sagittal planes, frontal, then transverse -STRESS FRACTURE: Mechanism of Injury: result of increasing amount/intensity of activity too rapidly, normal usage if bones have been weakened by osteoporosis or other disease, occur WB bones of the foot and lower leg, most commons sites are second and third metatarsals of foot then heel (calcaneus), fibula, navicular if in "no man's land" (no vascularity) or base of 5th metatarsal there is a higher risk for delayed union/non thus immobilization for 6-8 weeks Not at Risk: not on no man's land rest, modalities for pain and swelling, LE strength and stretching avoid aerobic activities that cause impact on foot (stepper, treadmill) until healed PRECAUTION/CONTRAINDICATION

Edema Vs Effusion

Both are swelling --Edema: Extravascular swelling (outside of joint) --Effusion: Intravascular swelling (inside of joint)

SOFT TISSUE INJURIES OF THE HIP

Bursitis: 1)TROCHANTERIC Bursitis: --CAUSE: excessive compression & repeated friction from IT band. --Therapy: initially relieve pain and inflammation (RICE/Antiinflammitory med). STRETCH: soft tissue of lateral thigh (TFL, Illiotibial band)/ also flexibility of (hip ER, quads, flexors) is important. STRENGTHENING: hip abductor is important to establish mm balance (partial squats, leg press, & hip abd). Endurance: UBE, treadmill, or stair climbing if not painful. US & Hydrotherapy also may help acute phase. 2)Ischial Bursitis (Wavers botom): contusion (bruise damaged blood vessels)/ extended period of sitting. pain over Ischial tuberosity. --Therapy: padded cushion, stretch hams and mm) 3) Illiopectineal Bursitis: tightness of the iliopsoas alone and in conjunction w/ excessive hip extension, passive hip flexion/add end range. --Therapy: thermal agents, stretching and strengthening (Stretching os Psoas mm stop if pain excerbates such activity), Strengthening: of quad, stretching: hamstring, ITB, hip add,and begin aerobic as long as symptoms do not increase)

joint mobilization ch 15

Cave on vex: same direction Vex on cave: opposite direction

Lateral ankle sprain AKA: Inversion Sprain AVOID: PF/INV Anterior talofibular ligament, Fibulocalcaneal, and Posterior talofibular

Classification: Lateral Inversion Sprain: grade I:single ligament rupture (anterior talofibular ligament) ,II: double ligament rupture (anterior talofibular ligament & fibulocalcaneal ligament), & III all 3 ligaments ruptured (ATFL, Fibulocalcaneal, and Posterior talofibular) -95% of ankle sprains. and 14-25% of all sports injuries -Mechanism: PF/INV (Does not require large motions and most cases foot is unloaded) -TEST: 1)Anterior Drawer test: RELAXED! seated/semirecumbent, knee 90 flex, ankle slight PF. positive if excess forward or anterior motion if the ATFL is torn. 2) Talar Tilt Test (inversion stress test) calcaneofibular ligament: maximal ankle ligaments taken to inversion stress. RELAXED! seated/semirecumbent, knee 90 flex, ankle slight PF. Gradual stress by exertion of constant pressure over the lateral aspect of the foot and ankle, until maximal inversion is reached. Rehabilitation: I&II treated non operation and supervised rehabilitation program. ACUTE: RICE: to minimize intense inflammatory response, hemorrhage, swelling, pain and cellular metabolism. Most effective way to reduce swelling is to COMPRESS and ELEVATE (ex: ACE WRAP). MAX: (AVOID: PF/INV !!! cause disruption of healing process) RICE 3-5x daily, ice for 15-20min every 1-2hour interval. immobilization/ joint protection(by commercial appliances, tape, casting and braces DR discretion), most commonly plastic shell brace w/air bladder or a leather semirigid ankle support. WB/ ambulation W/AD are left at the Pt. tolerance usually WBAT. AROM should be cautiously applied. Isometric (DF & EVE 2-3 sets of 10 reps, 10 sec hold). Proximal leg strengthening (leg extension, ham curls, hip abd/add and hip ext) and general full-body conditioning throught out the rehabilitation course. MAX-MOD: bear weight on injured limb w/o crutches, perform all ROM and ISO w/0 complain of pain & control the swelling. MOD: RICE, FWB & ligament support( brace/ tape). Concentric/eccentric progressive exercises initiated (theraband/ankle weight), heel cord STRETCH (towel stretch, wall stretch or prostretch) and standing toe and heel raises. Gradually INV & PF added as pain allows. stationary bicycle W/SEAT lowered slightly to encourage more neutral ankl position instead of PF position. Proprioception initiated, limb protection must be encouraged, balance on injured limb on flat surface is slowly progressed to balance board, & then minitrampoline. MOD-MIN: Pt. can perform all resistive exercises (ankle weight, W/O pain or limping and swelling is reduced), MIN: PT SHOULD PERFORM TAPING OR WEAR SEMIRIGID BRACE DURING RUNNING ACTIVITES. New collagen formation allows for normalized stress from 4-8weeks after injury at this point more functional activities are allowed including (straight-line jogging, large figure of eight running, jumping drills, and cutting activites. MIN DOE NOT APPLY REMOVING ALL PROTECTIVE DEVICES, maturation of ligament can take up to 6-12 months. * PROGRESSION to phases depends on pain, swelling, and irritation. GRADE III joint protection lasts longer set by DR. TABLE : 17-1 MAX: RICE< Electrical galvanic stimulation (EGS), WBT, joint protection (plastic, hinged orthosis, tape, air cast, semirigid brace), AROM (DF and EVERSION), isometric exercises, and general fitness exercise) MOD:RICE, FWB, Con/ecc contractors (later rubberband, ankle weight), continued joint protection, hell cord stretching, stationary cycling, proprioception exercise, general fitness exercise, avoid unwanted stresses (INV & PF) MIN: JOINT PROTECTION DURING ACTIVITIES (Running, jumping, plyometrics, proprioception exercise, general fitness exercises, isotonic & isokinetic exercises.

Glenohumeral joint instability and dislocation DISLOCATIONS: Anterior shoulder AVOID shoulder ABD & ER. Posterior shoulder AVOID (ABD & IR)

Dislocation/subluxation (partial dislocation) of the GH joint frequently occurs after direct trauma with arm abd, elevated and IR (posterior dislocation). Anterior dislocation greater than posterior. -Shoulder instability can be defined as multidirectional, wherein humeral head may sublux and dislocate anteriorly, inferiorly and posteriorly 1)Bankart lesion(Labrum injuries can occur if forces are great enough to dislocate the humerus from its confines within the glenoid cavity.): defined as an AVULSION of the scapule and glenoid labrum off the anterior rim from traumatic anterior dislocation. 2) Hill-Sachs lesion: (humerus is subjected to injury result of anterior shoulder instability): compression or impaction fracture of the posteriolateral aspect of the humeral head. NON OPERATIVE shoulder dislocation (anterior & posterior): protection 4-6w/k , all mechanism of dislocation are avoided and sometimes immobilization is needed for healing. Management of pain with NSAIDs, Analgesics, ice packs, electrical stimulation or other physical agents such as US, and infrared. IMMOBILIZATION: hand, wrist and elbow must receive active motion and strengthening exercises that do not compromise the shoulder and general conditioning program of strengthening, flexibiility and endurance activites. Anterior shoulder *subluxation: AVOID shoulder ABD& ER. -Pre-functional phase: begins w/ manual control ROM, active assistive strengthening for elevation and assisted ROM exercise to help Pt. regain motion if lengthy period of immobilization was warranted. initial strengthening begins w/submax isometric exercises that can be safely started when patients shoulder is place in neutral humeral position (1)Isometric shoulder ABD/ADD, (2)IR/ER, and (3) elevation and extension can be performed at a pain free level. once pt can demonstrate an increase from submaximal iso contractions to near-maximal contractions, progressive IR & ER can begin with affected shoulder in minimal degree of abduction. When pain are reduced and intensity and quality of mm contractions are improved, the patient may increase ROM activities in forward elevation, extension, scapular mobility and IR & ER and abductoin. -Return to function activities anterior (AVOID: combines Shoulder ABD & ER.) some authors state to avoid extremes of shoulder ABD, & ER should be avoided for 3 months. HALLMARK of return to function after anterior shoulder dislocation or subluxation is progressive strengthening of the rotator cuff, anterior shoulder mm, and scapular stabilizers w/ particular attention to eccentric strengthening of the posterior RC (infraspinatus and tere minor) -synchronous shoulder motion, or scapulohumeral rhythm must be addressed before and throughtout recovery from a shoulder dislcoation (2:1 ration: for every 2 degree of GH the scapula should upwardly rotate 1 degree. FROM CLASS: • Non-operative management: 6 weeks of immobilization, pain and edema management, AROM to hand writs and elbow and strengthening that does not compromise the shoulder. • Shoulder ABD and ER must be AVOIDED!!!, submax isometric with arm IR and Abducted with immobilization. • After immobilization: ROM ex as tolerated, Codmans ex( joint nutrition), active assistive strengthening, flex and cable pulley, once max isometric are pain free begin theraband PREs for IR & ER with elbo at the side (shoulder adducted), wand, pulley, good arm help the weak arm. As pain decreases and quality of mm contraction improves progress ROM activities to include flex, ext, scap mobility, IR, ER, abd. • Moderate: progressive strengthening with theraband and cuff weight of RC, scap stabilization, emphasis on eccentric strengthening of posterior RC mm (infraspinatus, and teres minor) UBE, CKC activities. • Avoid ER and abd with anterior dislocation in MAX/MOD. • Caution: avoid anterior translation of humeral head until minimal protection phase, some ex many. • Focus on proper scapulohumeral rhythm is essential to prevent abnormal scapular and humeral movement during strengthening. Abnormal movement can result in impingement. • Minimum (final stage): focus on functional motions, proprioception and dynamic joint

HIP chapter 19

Flex: 120, Ext: 30, ABD: 45, ADD: 30 ER: 45, IR: 45 -Loose: 30flex, 30abd, slight ER -Closed: Full EXT, IR

Ligament tear grades (3)

Grade I: microscopic tearing of ligament w/o producing joint laxity II: tearing of some ligament fibers w/ moderate joint laxity III: completer rupture w/ profound joint laxity (only 15%)

BONE ch 9 LAWS

Hueter-volkmann Law: compression and tensile forces applied to physeal growth plates. Compression forces limit bone growth, whereas tensile stress stimulates growth. Wolfs Law: intermittent physiologic loads applied to bone stimulate adaptive response, removal of mechanical stresses have opposite effect.

Bone Phases of fracture repair healing

I: Inflammation/ hematoma formation (0-24-48 hours): fibrin clot formation, increased inflammation to the a hematoma forms and begins the process of clot formation. Callus forms, which is early precursor to mature calcified bone formation. II: Chondrocyte Formation: chondrocytes form a V-shaped wedge of tissue between fracture ends of bones (Type I & II cartilage). III: Cartilage & calcification (starts 2 weeks): gradual decline in proliferative cell activity and in increase in chondrocyte deposition and release of proteolytic enzymes. lamellar bone is dependent to revitalization (vascularity) of injured bone to form into its natural state. (angiogenesis (neovasculariztion) is critical for delivering O2, nutrients, inflammatory cells, and fibrolblasts to stimulate and support the healing fracture) IV: Cartilage removal (starts 4-6 weeks): Primary cortical healing (hard callus) forms with anatomic alignment and fragment apposition, immobilization and appropriately applied progressive stress. V: Bone formation (): VI: Bone Remodeling ( several years to complete, strongly influenced by wolff's law): -0-24-48 hours inflammatory response to injury same as soft tissue. characterized by blood clotting, and fibroblast/osteoblast proliferation. -2 days after fracture: circulation increases and peaks at approximately 2 weeks. -2weeks scarring/callus formation are detected. -2-4 w/k: hinge brace to allow motion within limit. -several years to complete, strongly influenced by wolff's law

ligament Healing therapeutic consideration phases

Immediate-Phase I: Hemostasis/ Degeneration: Non WB/WBAT, RICE, pain management (TENS, oral IV analgesics), CPM, & contralateral exercises as tolerated. DAY 3-14 Phase II Inflammation: progressive WB, Continue RICE, Active progressive motion, continue ligament protection, Active resistance exercise. ( cycling for motion) isometric exercise progression, ESTIM, initiate multiangle static holds ( isometrics) avoid excessive motion. Day 14-60 Phase III Proliferation/migration:Full WB continue RICE, low load static stretch if needed, heat if needed, isokinetic w continuous ligament protection, eccentric isotonic exercise, progressive concentric isometric, (Hydrotherapy: swimming), progressive cycling, initiate closed kinetic exercise. Day 60-360 Phase IV Remodeling/degeneration: Prolonged low load static stretch, progressive advanced isokinetic and isotonic exercise, cycling (stair climbs), Proprioception and balance, coordination excise. Advance KC exercise, progress to plyometric exercise (jogging, running, jumping, maintain joint protection with functional bracing as needed.

Total Shoulder Arthroplasty

Indications: w severe four part fracture of the proximal humerus, AVN of humeral head, osteoporosis, rheumatoid Arthritis, and advanced osteoarthritis, the proximal humerus may be replaced w/ prosthesis or Total shoulder arthroplasty. immobilization may be as long as 4-6 wk Reverse total shoulder replacement: reverse total shoulder replacement is used for people who have completely torn rotator cuffs with severe arm weakness, the effects of severe arthritis and rotator cuff tearing (cuff tearing arthropathy), had a previous shoulder replacement that failed. • In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and plastic socket is attached to the upper arm bone, • Revers TSA: can not do IR, no Horizontal adduction, can not lift more than a coffee cup, and longer recover time, NO Active IR until 3 months. • Traditional restricted by ER and Abd ( ER is avoided because of surgical approach) • Always place towel roll under to keep elbow at the mid axial line.

Total knee replacement, TKA

Knee Arthroplasty: eliminate/reduce pain & improve functional activities. osteoarthritis (DJD) or RA. 1)unicompartmental (medil/laterl), 2) bicompartmental (both laterl/medial), 3)tricompartmental (medial/lateral/patellofemoral compartment) pain and dysfunction. Rehabilitation: post op uses compression dressing w/ knee immobilizer in full extension, limb elevated 30-40 degree to minimize swelling and prevent knee flexion contracture. Max: reducing unwanted stress that my loosening prothesis, stimulate mm strength, increasing ROM, and reducing pain/swelling. Quad/glut/ham isometrics, ankle pumps, active assisted straight leg raise, short-arc terminal knee extension & knee flexion ROM exercises. CPM may help in regaining knee flexion however other authors suggest PT w/0 cpm result in same function/ROM post surgery. KNEE IMMOBILIZER CAN BE REMOVED to perform supine heel slides, and supine hip & knee flexion exercises, supine wall slides & active assisted wall slides can be added as pain allows. As surgical incision heals the patella should be mobilized in a caudal (inferior)-cephalic (Superior) motion to reduce patelofemoral adhesions. PWB gait with walker or cruthces within days after surgery. -PRIMARY GOAL: restore ROM -SECONDARY GOAL: restore strength (quad strength is highly correlated with functional performance. -Elderly: to demonstrate reduced cardio fitness and should start general cardio program as soon as tolerate, early single leg stationary cycling or UBE. Swimming programs may be more appropriate than Open or CKC resistance exercises. GREATEST amt. of function gained first 3 months but can expect improvements up to 1 year. page 289 table 18-1

mm intervention

NO COOK BOOK, therapy must be based on the individual patient and there needs. PT based on tissue injured, severity, current stage of healing, pt. musculoskeletal exam, the patients short and long term goals.

Osteoporosis

Osteoblast (boneformation) activity is surpassed by osteoclast (bone resorption) activity. Created weaker bones and increase rate of fracture. Causes:( multifactorial), hormonal changes after menopause, prolonged immobilization, diseases, and prolonged steroid administration. women greater. Age 40 y/o cortical bone loss. because of lowered estrogen loss of bone is 2-8% annually. Poor absorption of calcium leads to decreased mineralization called osteomalacia cause: calcium deficient diet, accelerates calcium loss and malabsorption of calcium (FEMORAL NECK FRACTURE MOST COMMON IN OSTEOMALACIA Pt.)

Stimulation of fx repair

PTA:CLINICAL - Electromagnetic field application and low-intensity ultrasound 30 mW/cm2) for 20 min/day has shown to reduce the fracture union time. (this process stimulates chondro/osteoblast. Increasing blood blow and enhancement of greater mechanical and histologic influence on enchondral and periosteal bone healing. OTHER BY DR/Surgeon -Bone grafts: used to fill osseous defects and stabilize fx. -Bone autograft: take from same person (iliac crest to transpose to lumbar spine for fusion. -Bone allograft: taken from same species -Passive osteoconduction: auto/allograft support the existing structure and to allow growth of host tissue. -Osteoinduction: graft bone becomes revascularized with stimulation and trasportaton of osteoblast.

Shoulder ch 21 Gelnohumeral Joint

ROM: Flex: 180, EXT: 60, abd: 180, ADD:0, ER: 90 IR: 70 LOOSE: 55 abd, 30 hor-add CLOSED: abd & lateral rotation functional: flex 150, abd 150, IR (spinoius process level), ER (spinous process level) Capsular pattern: loss of shoulder ER grater than ABD-IR-FLEX

Rotator Cuff (RC) Tears & Rehab after subacromial Decompression with or w/o RC repair 352

Rotator Cuff (RC) Tears: acute trauma or chronic degenerative pathology. • calcified as partial thickness or full thickness tear, size of tear, small: less than 1cm medium: less than 3cm Large: more than 5cm. Surgical Management of shoulder impingement or RC Tear. • Subacromial decompression: done wit no RC tear 1. coracoacromical ligament tresection 2. anterior acromioplasty 3. excision of outer age of the clavicle 4. osteotomies of glenoid and or acromion 5. Acromionectomy o ...or more than over of the above surgeries may be performed -if RC is torn they will repair it and perform subacromial decompression. -Rehab with subacromial decompression and or RC repair of small tears is similar to the pro=op approach over time for healing of soft tissue and bone must be allowed. If RC tear 1-5 cm there must be longer protection time. Rehab after subacromial Decompression with or w/o RC repair 352 1) Phase I: acute or max protection phase 1-6 wk: ISOMETRIC pain management, immobilization- length depends on the extent of tissue damage, Codman pendulum exercises, isometric for decompression and RC repairs (less than 1 cm)- should abd, ER, IR, Elbow flex, should flex with pain decrease, AAROM ex-pulley in pain free range. 2)Phase II: Moderate or fibroblastic phase (7-12wk): Dedicated isolated strength progressive ROM activities( caution with repetitive flex ana abd), MRE in pain free range, theraband PRE's, concentric and eccentric PREs with dumbbells focusing on scap stabilization, pain management prn. 3)Phase III: Minimal protection phase, remodeling phase (12-21wk): Triplainer movement/activity specific movement demonstrate mobility without pain and good motor control: begins when pt can demonstrate mobility without sx and increase strength, progressive strengthening, stabilization, strengthening, gradual return to normal activities. (UBE: backward: easier and less pain—ROM/endurance) Ex: have the electrician perform, body blade multiplane 2min in each plane, • Exercises in all phases: forward flex, scaption, prone horiz abd, scap ex (see pre-op ex) ER. (abd, IR/ER for the rotator cuff). • Repair of large RC tears require longer immobilization and more PROM, generally NO AROM or strengthening for 12-26wk, After surgery patient be put in a sling, airplane splint or abd pillow, rehab for larger tears will generally follow a MD protocol based on surgical procedure.

Acetominophen (OTC) (safest over the counter non-inflmmatory condition drug)

Side effect-Cause liver toxicity -Reduce fever and analgesic. Noninflammatory conditions( headache, toothache, sinus pain, back pain, osteoarthritis, and may other)

Fibrocartilage Zones system

This system is used to evaluate the injury to see if it can be healed by "inflammatory response mechanism and/or if there is a need for sutures or excision of meniscus. -Zone 1: Both portion of the meniscus are torn within the vascularized periphery; RED ON RED -Zone 2: one porn torn within vascular and other portion is within avascular region; RED ON WHITE -Zone 3: there is no blood supply on either side; WHITE ON WHITE. LABRAL INJURIES TO HIP AND SHOULDER are similar to WHITE ON WHITE injury to meniscus. laberal attatchement are RED ON WHITE, and usually respond well to surgical intervention.

Non operative management of AC patology

Tibiofemoral articular cartilage defect: Limited weight bearing can decrease pain and swelling. Reduce vertical compression loads (stair climbing, squats, and walking). patient maintain strength throught isometric exercise or limited open kinetic chain (OKC) resistance exercises. -Patelofemoral Articular Cartilage disease: Vertical loading do not negatively affect function. Full ROM knee extension may produce symptoms of pain, swelling, and crepitus (noise, grinding, and cracking). limited ROM exercises do not produce pain & crepitus -Glucosamine (4-8wks) and chondroitin sulfate (3-6month) supplement: reestablishing the water content of articular cartilage matrix. 500mg/3xdaily. -hyaluronic acid injection: reduces pain and inflammation, replenishing decreased volume of hyaluronic acid, and stimulating intrinsic synovial synthesis of hyaluronic acid. injected 1xweek for 3weeks.

Pharmacokinetics

describe what body does to medication. 1)Absorption: medication into bloodstream 2)Distribution: movement from bloodstream to various parts of the body. 3)Metabolism: (metabolite by product of medication): usually happens in the liver but can be or Enzymatic process in the kidney, lungs, and bloodstream. 4)Exertion: half life: amt. of time it takes for reduction of drug concentration in body by half.. Duration of action: length of time active in body.

Maniscus injury 274

• Menisci are composed of fibrocartilage -Function of meniscus: Increase joint stability, Shock absorption, Load transmission, Reduces Friction, Control Motion. -5 types of meniscus injuries 274 o horizontal tear (common in older population) o Longitudinal tears (younger): bucket handle tear o Degenerative tears o Flap tears : catching(feel something gets caught) o Radial Tears

Contusion mm muscle

-bruise damaged blood vessels (subcutaneous tissue of illiac creast (aka: hip pointers) -Therapy: MAX: PRICE, PWB, Crutches, compression wrap, until tissue healing has completed. -strengthening & stretching of the hip commnce after soft tissue heals and pain is in control. MOD: US, Hydrotherapy, ESTIM, phonophoresis or iontophoresis to help control pain.

ACHILLES TENDON RUPTURE.

-sudden eccentric/concentric contraction of gastrocnemius-soleus( 3-4 cm proximal to insertion) -TEST (1): Thompson test: lies prone, w/ entire LE (knee to foot) exposed, gastroc is squeezed to observe if there is any PF is non the test is positive. -Intervention: no-operative are immobilized for 8 weeks and have rerupture rate of 8-39 percent, have greater loss of strength/power/endurance compared to surgical. SURGICAL 0-5% rerupture. 1) NONSURGICAL Rehabiliation: -Immobilization: instructed on general body conditioning program: noninvolved limb (quad, ham, gastro/soleus) are vigorously strengthened and Involved LE thigh and ham should be strengthened. Aerobic exercise is also encouraged, staionary bik using one limb, UBE are safe cardio. -POST-CAST REMOAL: thermal agens (moist heat pre flexibility/ROM) and if pain present use of cold whirlpool or ice packs w/compression can be applied. Initially do what they can tolerate. DF/PF motion is an exceedingly slow process post cast removal gentle DF/PF are initiated immediately. Use of small hell life to minimize stress work for 3-4wk and gradually reduced in size every 2 weeks. progressive AROM is essential for return to function. progressive latex band DF/PF encouraged as pain allows. proprioception employed early depending on pt tolerance( begin in seated position and progress). RERUPTURE usually occurs within 4 weeks after immobilization. MAX: avoid sudden forceful PF/DF. as motion increases gradually CKC resistive ex. based on pt ROM, pain/swelling and length of time after cast removal. Seated stationary cycling used for aerobic fitness, ROM and local mm endurance (seat must be adjusted to avoid excess PF or DF. . stepup can be used with heel lift to encourage eccentric loading. WB PF can be added after sucessfully completing ROM and strength exercise program w/o complications: standing PF (instruct pt to gradually raise on toes using primarily uninvolved limb and lower using both feet), adding a small blod of wood to increae DF stress and motion, & seted calf raises w/ modified leg extension machine. * PTA reasses Pt. ROM, strength, pain, and swelling & modification are necessary if Pt. is having undue pain with any phase of program. isokinetic testing for PF, DF, ROM, strength, power and local mm endurance are generally reserved for MIN phase but isokinetic strengthening exercises can be employed early if done at high speed. 2)OPERATIVELY/Surgical Repair : very variable depending on the procedure performed, depending on surgeon-surgeon and patient to patient. Pt. having different immbilization/wb restrctions, WB, ROM, initiation of strengthening are determined by Physician. -Generally rehab post surgery follows criteria based rehabilitation program described previously. strengthening early as 2-4 wk postimmobilization. Generally most patients are able to return to full activity within 6-9months.

Subacromial Rotator cuff impingement

-tendons of the RC are crowded, buttressed, or compressed undero coracoacromical arch , resulting in mechanical stress, wear, and friction. -PRIMARY Impingement: MECHANICAL COMPRESSION of the RC tendons primarily the supraspinatus tendon as it passes under the coracoacromial ligament. -Secondary Impingement: GH INSTABILITY: that creates reduced subacromial instability creates a reduced subacromial space b/c the humeral head elevates and minimizes the area under the coracoacromical ligament resulting from impairment of mm coordination and WEAKNESS of SCAPULAR STABILIZERS. -AGE RELATED CAUSES: bony osteophystes under anterioinferior acromion. 1) Anatomic Crowding: reduced available space under shoulder. 2) Watershed zone/critical zone/critical portion: an area just proximal to the insertion on the greate tuberosity is hypovascular and is referred to as the (watershed zone), occurs from repeated Abd/Add which compromises blood supply. -Stages of impingement (3 stages) -Stage 1: usually <25 y/o , reversible lesion, clinical feature are edema and hemorrhage, pain is worse w/shoulder abduction greater than 90. -Stage 2: usually 25-40 y/0, irreversable from long term repeated stress, causing suprapinaus tendon, biceps, and subacromial bursa to become fibrotic. pain primary that occurs with daily activities, Frequently cause patient difficulty at night. -Stage 3: >40 y/o, tendon degeneration, rotator cuff tear, and rotator cuff ruptures. associated with history of repeated shoulder pain and dysfunction, as well as significant mm weakness & atrophy. -TEST: 1) Neer painful Arc Test: (impingement of supraspinatus and long head of biceps (90-120 deg) & Acromioclavicular joint involvement (170-180)). Arm fully pronated and placed in forced flexion- Trying to impinge subacromial structures with humeral head- Pain is positive test Neer's Impingement test. 2) Hawkins-Kennedy Test: Arm is forward flexed to 90 degrees, then forcibly internally rotated- Trying to impinge subacromial structures with humeral head- Pain is positive test 3) Drop Arm Test: Patient is sitting or standing with the involved arm fully abducted Patient then slowly lowers the arm back to their side. + unable to slowly lower UE and/or has significant pain. 4) Empty can test: supraspinatus test: Patient stands with both shoulders abducted to 90°, horizontally adducted 30°, and internally rotated so the patient's thumbs face the floor Examiner resists the patient's attempts to actively abduct both shoulders + TEST: Weakness and/or report of pain Positive Test Implications Involvement of the supraspinatus muscle and/or tendon -REHABILITATION: -Secondary Impingement: Requires first the scapulothoracic mm be strengthened and stabilized before specific RC mm weakness can be addressed. Scapulothoracic mm (serratus anterior, upper, middle and lower trapezius, levator scapulae, and rhomboid mm). comprehensive -Nonoperative Treatment -Phase I Pre-functional: above 90 degrees pain free and no shoulder compensation. Starts with Modification of activities b/c activities are made worse at 80-90 degrees, NSAIDS and therapy agents ICE Pack, Ultrasound, pharmacophoresis (iontophoresis/ phonophoresis) and IR laser application. Stretching exercises, encourage nonballistic, slow, controlled, pain-free motion less than 80-90 of elevation. Capsular stretches have been shown to increase motion and assist surrounding mm to assist in shoulder elevation in all planes. Posterior capsular tightness stretches (1) shoulder abduction across the ches and internal shoulder rotation are used to overcome capsular tightness and use of sleeper stretch has been reported. the use of anterior shoulder stretch have been reported to prepare tri-plane overhead motion. Straightening: scapular stabilzatoin and light rotator cuff strengthening. CKC loading such as wall push-ups. CKC exercise will provide co-contraction and triplane stabilization w/ lower mm contraction load than OKC. OKC Progression criteria: Pt. demonstrates improved motion and can do ADLs without pain can begin prone extension to hip, side-lying external rotation and scaption elevation w/o pain are RC recritment exercises. Specific RC exercises should focus on supraspinatus mm, RC mm are effectively strengthened by arm elevation in transverse plane, shoulder elevation w neutral rotation in the plane of scapular, prone Horizontal shoulder abduction with external rotation and seated press ups. -Phase II Return to function: progress with advance scapular stabilization exercises via increasing resistance while using OKC exercises. Electromyographic studes have shown 4 basic scapular stabilization exercises for upper middle and lower trap, levator scapula, rhomboid major/minor, pectoralis major and middle/lower serratus anterior mm (1)rowing, (2)scapular plane elevation (scaption), (3)press ups, & (4) push-ups followed by scapular probation. Phase II to III criteria: strength improves and when motion increases. -Phase III return to activity: functional recover is slow and must be done cautiously; overhead activities are introduced incrementally as patient is able to demonstrate pain free motion and the ability to perform strengthening activities. SURGICAL MANAGEMENT: when PT fails to provide long tern relief and rotator cuff tears (neers stage III impingement, tendon degeneration and cuff tears), Surgical intervention can include 1) subacromial decompression (SAD), acromioplasty, distal clavicule exision (DCE). SURGICAL RC REHABILITATION: -SAD: closely paralled to nonoperative, however time must be allowed for bone and tissue to heal. page 252-253)