FINAL EXAM KRS 415

Subtalar Joint

- Articulation between calcaneus and talus - Triplanar joint (plane type) Movement 1) Inversion - Eversion 2) AP glide 3) Medial- Lateral Glide - Cannot Assess #2 and #3

Anterolateral Ligament (ALL)

- Assists LCL against the varus force - Prevents anterolateral subluxation

Plantar fasciitis

- Common in athletes and nonathletes. - Catchall term used for pain in proximal arch and heel. Etiology. - Increased tension and stress on fascia (particularly during push-off of running phase) - Change from rigid supportive footwear to flexible footwear - Poor running technique - Conditions include leg length discrepancy, excessive pronation, inflexible longitudinal arch, and tight gastrocnemius-soleus complex. - Running on soft surfaces with shoes that have poor support. - Dehydrated and not warmed up = not elastic Sign and symptoms - Pain in anterior medial heel - Increased pain in morning, lessens after first few steps - Increased pain with forefoot dorsiflexion. Management - Extended treatment (8 -12 weeks). - Orthotic therapy is very useful (soft orthotic with deep heel cup). - Simple arch taping and using night splint to maintain a position of static stretch. - Vigorous Achilles tendon stretching and exercises that increase great toe dorsiflexion. - NSAIDs and occasionally steroidal injection

peroneus tendon dislocation

- Inversion sprain - Overuse

Adolescents/pediatric injuries to the pelvis/hip

- Legg-Calve-Perthes Disease (LCPD) - Slipped Capital Femoral Epiphysis (SCAFE)

Lateral Collateral Ligament (LCL)

- Provides lateral stability of the knee - Resist to the varus stress

Prevention of Ankle Injuries

- Strengthening the musculatures - Neuromuscular Control and Balance (More important than stretching musculature) - Trains the nerve that innervates the muscle - Taping and Bracing

Legg-Calve-Perthes Disease (LCPD)

- The hint with this is to look at age since S & S is vague Etiology: - Idiopathic avascular necrosis (unknown cause) of the femoral head in the pediatric population. - 4-10 y/o in boys, more often than in girls by a ratio of 4:1 Signs & Symptoms: - pain in the groin may be referred to the abdomen or knee - Limping - limited hip ROM, especially in ABD and IR. Management: - Could be complete bed rest - Special brace to avoid direct weight bearing on the hip - Surgical intervention for older patients

Understand the screw-home mechanism. What would happen at the terminal knee extension and why? What muscle unlocks it?

- Tibia externally rotates as it reaches to the full extension due to the difference in size of medial condyle and lateral condyle. - ER of tibia "locks" the leg in straight position - During weight bearing (Closed-kinetic chain), tibia does not move thus femur internally rotates to "lock" the joint - To "unlock" the joint, tibia must internally rotate (OKC) or femur externally rotates (CKC) - This "unlocking" is done by popliteus m.

Knee Joint

- condyloid type synovial joint Movement = Flexion and Extension (140 degree total), with internal/external Rotation

What is Trendelenburg's test?

A test that shows whether you have a weak gluteus medius. Patient stands on one leg and if opposite pelvic drops, it is a positive Trendlenburg test.

What is the correct order of tendons running behind the medial malleolus from most anterior to most posterior? A) Tibialis posterior - Flexor Digitorum Longus - Flexor Hallicis Longus B) Tibialis posterior -Flexor Hallicis Longus - Flexor Digitorum Longus C) Flexor Hallicis Longus - Tibialis posterior - Flexor Digitorum Longus D) Flexor Digitorum Longus - Flexor Hallicis Longus- Tibialis posteri

A) Tibialis posterior - Flexor Digitorum Longus Tom Dick and Harris (and means artery)

Avulsion fractures

ASIS - Sartorius AIIS - Rectus Femoris Ischial tuberosity - Hamstrings

Cause of graft failure ACL

Age - Under 20yo vs Over 20yo: 3x higher risk - Under 20yo vs Over 30yo: 4x higher risk - Under 20yo vs Over 40yo: 8x higher risk - Biological sex: mixed findings - Participation in pivoting and cutting sports: 4x higher - Technical errors: tunnel malpositioning - 22%-79% of failure cases - Missed concomitant lesions (i.e. meniscus injury, MCL)

ACL - evaluative tests

Anterior Drawer Test Sensitivity: 0.41 Specificity: 0.95 Lachmann's Test Sensitivity: 0.68 Specificity: 0.94

Autograft vs Allograft

Autograft: Graft of tissue from one point to another of the same body Allograft: A tissue grafted from a donor like a cadaver

Jones Fracture Which muscle has a distal attachment on the base of the fifth metatarsal? A) Peroneus longus B) Peroneus brevis C) Tibialis Anterior D) Achilles tendon

B

Types of autograft

BPTB - Bone-patellar tendon-bone Advantage: -Stabilization occurs faster (6-8 weeks) - Putting a Filling in a hole Disadvantage: - Huge scar formation - Not ideal for those who use jumping activities ST Graft (hamstring tendon) Advantage - Minimal scar - Not invasive - Perfect for those who do jump activities - No bony tissue attached to it - 3 months to regenerate Disadvantage - 8-12 weeks to heal

Severe case of Inversion Sprain

Bimalleolar fracture (aka: Pott's fracture) : avulsion of lateral malleolus and medial malleolus fracture - Repetitive ankle sprain will lead to Rotary ankle instability

Medial Longitudinal Arch

Components: calcaneus, talus, navicular, 3 cuneiforms, 1-3 metatarsals. Talar head is the keystone (highest point) - Dynamic control by tibialis anterior, tibialis posterior, peroneus longus, Flexor hallucis longus, intrinsic muscles - Passive support by plantar fascia, long plantar ligament, short plantar ligament, plantar calcaneonavicular (Spring) ligament

Coxa Vara vs Coxa Valga

Coxa Vara: Abnormal decreased angle of inclination - decrease joint stability Coxa Valga Abnormally increases the angle of inclination - increase forces on hip

Meniscus injury - Mangement

Depends on the location of the tear and the type of tear. - does not have a lot of blood circulation

Compartment syndromes (acute vs chronic)

Etiology - Acute compartment syndrome - Occurs secondary to direct trauma - Medical emergency Acute exertional compartment syndrome - Evolves with minimal to moderate activity Chronic compartment syndrome - Symptoms arise consistently at certain point during activity Signs and Symptoms - Complain of deep aching pain & tightness due to pressure and swelling - Reduced circulation and sensation of foot occurs - Intracompartmental measures further define severity - Must be recognized and treated early Management If severe acute or chronic case, may present as medical emergency that requires surgery to reduce pressure or release fascia - RICE, NSAID's and analgesics as needed - Under acute and exertional cases pressures will be monitored and surgical needs will be dependent on findings - Following surgical release patient may not return to activity for 2-4 months - In chronic conditions management is initially conservative - Fasciotomy may be necessary if conservative measures fail

Heel contusion

Etiology - Caused by sudden starts, stops or changes of direction, irritation of fat pad - Pain on the lateral aspect due to heel strike pattern. Sign and Symptoms - Severe pain in heel and is unable to withstand stress of weight bearing - Often warmth and redness over the tender area Management - Reduce weight bearing for 24 hours, RICE and NSAID's - Resume activity with heel cup or doughnut pad ( not rlly effective) after pain has subsided (be sure to wear shock absorbent shoe)

Stress fracture

Etiology - Common overuse condition, particularly in those with structural and biomechanical insufficiencies - Runners tends to develop in lower third of lower leg (dancers middle third) - Often occur in unconditioned, non-experienced individuals - Often training errors are involved - Component of female athlete triad Signs and Symptoms - Pain more intense after exercise than before - Point tenderness; difficult to discern bone and soft tissue pain - Bone scan results (stress fracture vs. periostitis) Management - Discontinue stress inducing activity 14 days - Use crutches for walking - Weight bearing may return when pain subsides - Cycling before running - After pain free for 2 weeks patient can gradually return to running - Biomechanics must be addressed

Jone's fracture - SPECIFIC location and the cause of surgical intervention

Etiology - Fx at base of fifth metatarsal Sign and symptoms - Immediate swelling and pain over fifth metatarsal - High nonunion rate and course of healing is unpredictable Management - Crutches with no immobilization, gradually progressing to weight bearing as pain subsides - May allow athlete to return in six weeks - If nonunion occurs, internal fixation may be required. - No blood flow goes in there hence poor healing - Bone-growth stimulators have also been suggested

Pump Bump aka Retrocalcaneal Bursitis

Etiology - Inflammation of bursa beneath Achilles tendon - Result of pressure and rubbing of shoe heel counter - Chronic condition that develops over time; may take extensive time to resolve; exostosis may develop (Haglund's deformity) Sign and Symptoms - Pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of the heel cord Management - RICE and NSAID's used as needed, ultrasound can reduce inflammation - Routine stretching of Achilles, heel lifts to reduce stress, donut pad to reduce pressure - Possibly invest in larger shoes with wider heel contour

Meniscus injury

Etiology - Medial meniscus is more commonly injured -why? - Also more prone to disruption through torsional and valgus forces - Most common MOI is rotary force w/ knee flexed or extended - Tears may be longitudinal, oblique or transverse - Twisting motion Signs and symptoms • Effusion developing over 48 to 72 hour period. •Joint line pain and loss of motion. • Intermittent locking and giving way. • Pain with squatting. • Portions may become detached causing locking, giving way, or catching within the joint. • If chronic, recurrent swelling or muscle atrophy may occur.

Osteochondritis dissecans

Etiology - Occurs in superior medial articular surface of the talar dome. - One or several fragments of articular cartilage, with underlying. subchondral bone, partially or completely detached and moving within the joint space. - Mechanism may be single trauma or repeated traumas. Signs and symptoms. - May complain of pain and effusion with signs of atrophy. - May also be catching, locking, or giving way. Management - Diagnosis through X-ray or MRI. Incomplete and nondisplaced injuries can be immobilized with early motion and delayed weight bearing. • If fragments are displaced, surgery is necessary. • Surgery will minimize risk of nonunion.

Achilles tendon rupture

Etiology - Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension - Commonly seen in athletes > 30 years old but Can be observed at any age Generally has history of chronic inflammation Signs and Symptoms - Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides - Point tenderness, swelling, discoloration; decreased ROM - Obvious indentation and positive Thompson test - Occurs 2-6 cm proximal to the calcaneal insertion Management - Stabilize the joint in PF position!! - surgical repair for serious injuries (return of 75-80% of function) - Non-operative treatment consists of RICE, NSAID's, analgesics, and a non-weight bearing cast for 6 weeks, followed up by a walking cast for 2 weeks (75-90% return to normal function) - Rehabilitation lasts about 6 months and consists of ROM, PRE and wearing a 2cm heel lift in both shoes

Medial Collateral Ligament Injury (MCL)

Etiology - Result of a severe blow from lateral side (valgus force) - Non-contact mechanism - Often sprained with ACL tear - "unhappy triad" = ACL, MCL, and Medial meniscus tear - In reality, ACL, MCL, and Lateral meniscus tear often occurs. S&S Grade I - Little or no joint effusion - Some joint stiffness and point tenderness on femoral end of MCL Grade II - Complete tear of deep capsular ligament and partial tear of superficial layer of MCL - No gross instability; laxity at 30 degrees of flexion - Pain at full extension and full flexion Grade III -Complete tear - Complete loss of medial stability - Minimum to moderate swelling - Positive valgus stress test both @0 & 30 degree Management: - Avoid full extension bc it tenses the MCL - Avoid Full flexion bc it stretches the MCL MCL /ACL tear • Avoid flexion/extension ( 2 weeks) • Decrease swelling • gradually regain ROM

Lateral Collateral Ligament Sprain (LCL) Sprain

Etiology - Result of a varus force, generally w/ the tibia internally rotated - If severe enough damage can also occur to the cruciate ligaments, ITB, and meniscus, producing bony fragments as well

Sever's disease aka Apophysitis of the Calcaneus

Etiology - Traction injury at apophysis of calcaneus, where Achilles attaches Sign and Symptoms - Pain occurs at posterior heel below Achilles attachment in children and adolescent athletes - Pain occurs during vigorous activity and ceases following activity Management - Best treated with ice, rest, stretching and NSAID's - Heel lift could also relieve some stress

Quad strain

Etiology • Eccentric contraction of quads = hip extension + knee flexion Signs and Symptoms - Pain at the injury site - Pain with AROM MMT 3-4/ 5

Iliotibial band friction syndrome (Runner's knee or Cyclist's knee)

Etiology • General expression for repetitive and overuse conditions attributed to malalignment and structural asymmetries. Signs and symptoms. • IT band friction syndrome. • Irritation at band's insertion: Commonly seen among individuals who have genu varum or pronated feet. Management. • Correction of malalignments. • Ice before and after activity. • Utilize proper warm-up and stretching techniques. • Avoidance of aggravating activities. • NSAIDs and orthotics.

Patellar Tendinitis (Jumpers/Kickers knee)

Etiology • Jumping or kicking: Placing tremendous stress and strain on patellar or quadriceps tendon. • Sudden or repetitive extension. Signs and symptoms. • Pain and tenderness at inferior pole of patella. • 3 phases: Pain after activity, pain during and after, and pain during and after (possibly prolonged). Management. • Ice, phonophoresis, iontophoresis, ultrasound, and heat. • Exercise. • Patellar tendon bracing. • Transverse friction massage.

Cuboid subluxation

Etiology : lateral slip of the foot - Pronation and trauma injury - Often confused with plantar fasciitis - Primary reason for pain is stress on long peroneal muscle with a foot in pronation Sign and Symptoms - Displacement of cuboid causes pain along 4th and 5th metatarsals and over the cuboid - May refer pain to heel area and pain may increase following long periods of weight bearing - FEELS LIKE TINY STONES IN THEIR SHOES Management - Dramatic results may be obtained with jt. Mobilization - Orthotic can be used to maintain the position of cuboid

Tarsal tunnel syndrome - know the specific sequence of tendons running at the tarsal tunnel

Etiology. - Any condition that compromises tibialis posterior, flexor hallucis longus, flexor digitorum, and tibial nerve artery or vein. - May result from a previous fracture, tenosynovitis, or acute trauma. Sign and symptoms. - Pain and paresthesia along medial and plantar aspect of foot and may result in motor weakness and atrophy. - Increased pain at night with positive Tinel's sign

Acute patella subluxation or dislocation

Etiology. • Deceleration with simultaneous cutting in opposite direction (valgus force at knee). • Quad pulls the patella out of alignment. • Some individuals may be predisposed. • Repetitive subluxation will stress medial restraints. Signs and symptoms. • Subluxation, pain and swelling, restricted ROM, palpable tenderness over adductor tubercle. •Result in total loss of function. Management. • Reduction is performed by flexing hip, moving patella medially, and slowly extending the knee. • Following reduction, immobilization for at least 4 weeks with use of crutches and isometric exercises during this period. • After immobilization period, horseshoe pad with elastic wrap should be used to support patella.

Hamstring strain

Etiology: - Eccentric contraction of the hamstrings - Hip flexion + knee extension - Leg length discrepancy (one leg bigger than the other) - Glut max firing delay - Muscular tightness - Hamstring to Quadriceps Ratio (HQ ratio) = 6-7: 10 - reinjury rate high - eccentric --> concentric Happens in the middle or heel contact when running Management: Grade 1 - POLICE, NSAIDs, and gradual ROM, isometrics, PRE. Grade 2 & 3 - Do not stretch the muscle until the inflammatory phase subsides. Progressive rehabilitation exercises

Patellofemoral stress syndrome

Etiology: - Result of lateral deviation of patella while tracking in femoral groove. - Tight structures, pronation, increased Q angle, and insufficient medial musculature Signs and symptoms - Tenderness of lateral facet of patella and swelling associated with irritation of synovium. - Dull ache in center of knee. - Patellar compression will elicit pain and crepitus. - Apprehension when patella is forced laterally. Management - Correct imbalances (strength and flexibility). - McConnell taping. - Lateral retinacular release if conservative measures fail

Chondromalacia patella

Etiology: - Softening and deterioration of the articular cartilage. - Undergoes three stages. 1) Swelling and softening of cartilage. 2) Fissure of softened cartilage 3) Deformation of cartilage surface. - Often associated with abnormal tracking. - Abnormal patellar tracking may be due to genu valgum, external tibial torsion, foot pronation, femoral anteversion, patella alta, shallow femoral groove, increased Q angle, and laxity of quad tendon. Signs and symptoms: - Pain with walking, running, stairs and squatting. - Possible recurrent swelling and grating sensation with flexion and extension. - Pain at inferior border during palpation. Management: - Conservative measures - RICE, NSAID, isometrics, and orthotics to correct dysfunction • Surgical possibilities. - Altering muscle attachments. - Shaping and smoothing of surfaces. - Drilling. - Elevating tibial tubercle.

Sciatica aka piriformis syndrome

Etiology: The sciatic nerve can be irritated by a herniated disc in the low back, direct trauma, or compression under the piriformis muscle (piriformis syndrome). Signs and Symptoms: - depends on where the pain is coming from.

Hip joint sprain

Etiology: a violent twisting, an impact force delivered by another participant, forceful contact with another object, a situation in which the foot is firmly planted and the trunk is forced in an opposite direction. S&S: inability to circumduct Management: r/o fx, POLICE, NSAIDs, and analgesics

Slipped Capital Femoral Epiphysis (SCAFE)

Etiology: - Posteroinferior displacement of the femoral head boys between 9-15 y/o ( no in between) who are tall and thin or obese. Idiopathic (could be the effect of the growth hormone) ¼ of the cases are bilateral (slightly older) Signs and Symptoms: sudden Acute or insidious onset hip and knee pain during PROM and AROM Limited ABD, FLEX, and IR Limp Management: minor- conservative treatment major - corrective surgery Femoral head slips off on the epiphysial plate. wont be able to walk

Contusion (aka Hip Pointer)

Etiology: Contusion of iliac crest or abdominal musculature and most frequent S&S - Pain, spasm, transitory paralysis of soft structures - Decreased rotation of trunk or thigh/hip flexion

Femoral neck stress fracture

Etiology: Rare injury, could happen to the endurance athletes MOI: overuse - More likely in females who are amenorrheic. Signs and symptoms: - onset occur several weeks after increasing the intensity of training. - pain in the groin, anterior thigh, which increases during activity and may persist after. - Positive Trendelenburg's sign

Hip dislocation

Etiology: Rarely occurs in sport Risk: AMV accident, Hx of hip replacement surgery • Result of traumatic force directed along the long axis of the femur (posterior dislocation w/ hip flexed and adducted and knee flexed) - i.e. hitting the knees to dashboard S&S - Flexed, Adducted and internally rotated hip Management - Time Sensitive and requires immediate medical care (blood and nerve supply may be compromised) - Contractures may further complicate reduction • 2 weeks immobilization and crutch use for at least one month

Femoral Fracture

Etiology: rare in the adolescents, more often in middle-age patients, common in elderly with osteoporosis. - A significant trauma is necessary to cause a femoral fracture in adolescents - The prognosis depends on the location of the injury and the degree to which the blood supply is compromised. - Fx across the epiphysis have the highest likelihood of developing avascular necrosis. - not alot of bloid flow to femoral head

Center of Pressure

Excessive pronation - Forefoot and rearfoot varus due to over prontation • Subtalar joint will remain in pronation for 55% to 85% of stance phase • Major cause of stress injuries • Results in loose foot, allowing for more midfoot motion, compromising first ray and attachment of peroneus longus • Negative effect on pulley mechanism of cuboid relative to peroneal, decreasing stability of first ray • Causes more pressure on metatarsals and increases tibial rotation at knee • less powerful and less efficient force produced • Result in 2nd metatarsal stress fracture, plantar fasciitis posterior tibialis tendinitis, Achilles tendinitis, tibial stress syndrome and medial knee pain Excessive Supination - forefoot valgus •Causes foot to remain rigid decreasing mobility of the calcaneocuboid joint and cuboid •Results in increased tension of peroneus longus and decreased mobility in first ray causing weight absorption on 1st and 5th metatarsals and inefficient ground reaction force absorption •Limits internal rotation and can lead to inversion sprains, tibial stress syndrome, peroneal tendonitis, IT-Band friction syndrome and trochanteric bursitis

Varus Stress Test

FOR LCL

Femoral neck anteversion vs retroversion

Femoral anteversion - legs forward in Femoral Retroversion - legs pointed out

Pes Planus pes Cavus

Flat foot High Arch foot

FIR TEST

Flexion Internal Rotation Test No adduction - Positive: groin pain, locking, clicking, or catching sensation indicating injury to the labrum. Sensitivity (True positive rate): 0.96 Specificity (True negative rate): 0.17

FABER test (Patrick's test)

Flexion- Abduction-External Rotation Test - positive tests produce pain, locking, clicking, or catching indicating injury to the labrum. Sensitivity (True positive rate): 0.94 Specificity(True negative rate): 0.08

FADDIR Test

Flexion- Adduction-Internal Rotation Test - positive tests produce pain, locking, clicking, or catching indicating injury to the labrum. Sensitivity (True positive rate): 0.94 Specificity(True negative rate): 0.08 94% accurate 8% doesnt mean anything

HIP Normal ROM

Flexion: 120° Extension: 30° Abduction: 40° Adduction: 30° External Rotation: 45° Internal Rotation: 45°

Leg length discrepancy measurements

General population: more than 1 inch • Athletic population: as little as 1/8 inch (3mm) can be problematic • X-ray is the most valid measurement Anatomical/TRUE = d/t shortening of the femur or lower leg Functional: 1) d/t pelvic tilt 2) d/t genu valgum or genu varus

Inversion Ankle Sprain Grade II + III

Grade II ankle inversion sprain / Partial Tear of the ATL/CFL S&S; - moderate pain and disability, bear weight is difficult - Popping sound - Point tenderness at - ATFL and or CFL - Edema, Discoloration - Joint laxity - Use crutches for 5-10 days - Progressive resistance exercise - Recovery: 2-6 weeks Grade III ankle inversion sprain Dislocation, complete rupture Subluxation of the joint - Significant pain i- mpossible to bear weight = immobilization for 10 days followed by 3-6 weeks of WB boot - Surgical option - Swelling - Joint laxity which leads to rotary ankle instability

Basic Anatomy of the hip joint.

Hip Joint: Synovial Joint - Ball & Socket type Acetabulum - Much deeper compared to the glenoid cavity Femoral head - ⅔ of the head is covered by the acetabulum rim Prioritize the stability over the mobility. Shallow acetabulum = dysplasia (1:1000)

Femoroacetabular impingement (FAI) Syndrome S&S and Management

Initial Signs and Symptoms: - Slow-onset persistent groin pain - Positive FADIR + FABERtest (aka. positive impingement sign) -Clicking, catching, locking, stiffness -Increases pelvic posterior tilt Management: 1. Conservative treatment (PT) - flexibility exercises, work on the external rotators of the hip, & core. because there is an increase in posterior tilit of the pelvis because of the pain so they tilt it. Train to keep it neutral 2. Surgical treatment - arthroscope 3. - Importance of the capsular closure (particularly the iliofemoral ligament

Knee Joint Ligaments

Intracapsular: - Synovial layer of the medial collateral ligament (MCL) - Anteior cruciale ligament (ACL) - Posteior Cruciale Ligament (PCL) Extracapsular: - Fibrous layer of Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL)

Inversion vs Eversion

Inversion: the plantar surface of the foot is facing inward Eversion: facing outward

ACL - MOI, signs and symptoms,

MOI: - Caused by direct contact or a noncontact mechanism - Noncontact mechanisms are 80% more likely to cause an ACL injury - Noncontact injury occurs when A) Athlete is decelerating from a jump or running B) Foot contacts the ground with the heel or in a flatfoot C) WB creates an axial force with the knee near full extension and in knee valgus D) Axial and valgus forces with quad contraction produces anterior shear and internal rotation subluxation of tibia on the femur. S&S: •A loud "POP" •Intracapsular swelling •Pain level varies by individuals • Often describe pain on the lateral knee area •Knee being "loose" - Swelling makes test diffucult to do. - Golden hour for test is 0-1 after injury bc no swelling

Posterior Cruciate Ligament (PCL) injury

MOI: - Most at risk during 90 degrees of flexion - Fall on bent knee is most common - Can also be damaged as a result of a rotational force -Sometimes referred to as a "dashboard injury" - flexed knee of car driver or passenger hits the dashboard swelling in the popliteal fossa • Laxity w/ posterior sag test Signs and Symptoms • Feel a pop in the back of the knee • Tenderness and relatively little swelling in the popliteal fossa - laxity w/ posterior sag test Management - Grade I & II Non-operative rehab of grade I and II injuries should focus on quad strength - PCL has better healing property than ACL (Middle genicular a.) only artey that goes into capsule - Concurrent injuries to the other structures (i.e. meniscus) requires surgery - 6 weeks of immobilization in extension w/ full weight bearing on crutches - ROM after 6 weeks and PRE at 4 month

Quadriceps contusion management

Management: Early termination of exercise, compression, and continuous passive ROM. Grade 1 = a superficial intramuscular bruise Grade 2 = unable to flex the knee more than 90° Grade 3= Knee flexion ROM is 90-45° with an obvious limp Grade 4 = major disability, split of the fascia, allowing the muscle to protrude. (Knee flexion ROM 45° >)

High ankle sprain aka Syndesmotic Sprain

Mechanism: DF & External Rotation of the foot Damaged Structure: Distal tibiofibular lig. & syndesmosis membrane Signs and Symptoms Severe pain, loss of function; passive external rotation and dorsiflexion cause pain Pain is usually anterolaterally located Management - Difficult to treat and may requires months of treatment - Same course of treatment as other sprains, however, immobilization and total rehab may be longer - Surgery may be required (if the gap between tibia and fibula is greater than 2mm in stress x-ray)

Eversion sprain (10% of ankle sprains)

Mechanism: Eversion Structures damaged: Deltoid Ligament (medial)

Inversion Ankle Sprain + Grade I

Mechanism: PF and Inversion Structures damaged: ATFL, PTFL (rare), and Calcaneofibular ligament (CFL) Grade I ankle inversion sprain / Minor Tear TFL S&S; - mild pain and disability, able to bear weight - Point tenderness at ATFL and or CFL - No joint laxity - POLICE for 30-60 minutes every 2 hours for 1-2 days - Recovery: 7-10 days

Medial ligaments vs lateral ligaments

Medial Ligaments (Deltoid Ligament): Comprised of anterior tibiotalar, posterior tibiotalar, tibionavicular, and tibiocalcaneal ligaments. - Provides stability to the inner side of the ankle joint. Lateral Ligaments: Three Main Ligaments:Anterior Talofibular Ligament (ATFL)Calcaneofibular Ligament (CFL)Posterior Talofibular Ligament (PTFL) - resist excessive inversion (rolling outward) of the ankle.

Meniscus

Medial Meniscus (MM) - C-shaped - covers about 50% of the medial plateau - Firmly attached to the MCL - Immobile - Only about 5mm AP translation Lateral Meniscus (LM) - O-shaped? - covers about 59% of the medial plateau - More movable - about 11mm Poterior translation during the knee flexion

MTSS - new discovery

Medial Tibial Stress Syndrome (MTSS) Etiology - Pain in anterior portion of shin (usually Medial) - Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome - Accounts for 10-15% of all running injuries, 60% of leg pain in athletes - Caused by repetitive microtrauma - Weak muscles, improper footwear, training errors, varus foot, tight heel cord, - hypermobile or pronated feet and even forefoot supination - Either stress fractures or exertional compartment syndrome

Meniscus Repair vs meniscectomy

Meniscus repair = suture - keeps most meniscus tissue - maintains cushion and congruency - makes joint more stable - No gradual weight-bearing for 1 month - 6 weeks - Limited activity until healed Meniscectomy = - removal of damaged meniscus tissue - Lose 20% of meniscus - Lose cushion for joint - Makes joint unstable - Similar to a labrum tear - Able to bear weight instantly - Risk of developing osteoarthritis meniscus= cushion

Popliteus

O: Lateral condyle of the femur I: Posterior surface of the medial tibia A: Internal rotation of the tibia & Knee flexion N: Tibial nerve

Injuries common in adolescents/pediatric populations

Osgood-Schlatter disease and Larsen-Johansson disease. Etiology: - Osgood-Schlatter disease (overworking of quads/ bad hamstrings) is an apophysitis occurring at the tibial tubercle. - Begins cartilagenous and develops a bony callus, enlarging the tubercle - Resolves with aging. - Common cause = Repeated avulsion of patellar tendon. Larsen-Johansson ( less frequent) is the result of excessive pulling on the inferior pole of the patella

Foot alignment

Over-pronation Forefoot varus Rearfoot varus Oversupination Forefoot Valgus

ACL - Management/ different surgical options,

POLICE; use of crutches - If only partial tear = no surgery - If complete tear = surgical intervention is recommended if the patient wish to be active Surgery options: - Autograft - Allograft

What type of shoes are good for pronation/supination

Pronators :a rigid shoe is recommended •Supinator: more flexible footwear with increased cushion

Ottawa ankle rule

Screening for the need of xray 1) Bony tenderness/pain at zone A-D 2) Or inability to bear weight for 4 steps both at the time of injury and at ER (2 steps each foot)

Tools to assess Balance

Star Excursion Balance test - Lower quarter Y balance test

Concept of Pronation vs Supination

Supination = Rigid Inversion (at subtalar joint) + Foot ADD + Ankle PF Pronation = Supple (soft) Eversion + Foot ABD + Ankle Df Navicular Drop Test Overpronation= flat foot/ pes planus High Arch- over supintation/ pes clavus

Ligamentous Test

Talar Tilit for CFL Anterior Drawer Test for ATFL

LisFranc injuries

Tarsometatarsal fracture/dislocation Etiology. - Occurs when foot hyper-plantar flexed with foot already plantar flexed and rearfoot locked resulting in dorsal displacement of the proximal end of the metatarsals. Sign and Symptoms - Pain and inability to bear weight, swelling and tenderness localized on dorsum of foot - Possible metatarsal fractures, sprains of 4th and 5th tarsometatarsal joints, may cause severe disruption of ligaments Management - Key to treatment is recognition (refer to physician), realignment and maintaining stability - Generally requires open reduction with fixation - Complications include metatarsalgia, decreased metatarsophalangeal joint ROM and long-term disability

ACL - prevention

Training program which include flexibility, agility, strengthening, plyometric, and balance exercises.

Anterior Cruciate Ligament (ACL)

Two bundles: - Anteromedial Bundle (AM) - Posterolateral bundle (PL) Function- to stop excessive - Anterior translation of Tibia on the femur - IR of tiba (valgus) - Hyperextension

Medial Collateral Ligament (MCL)

Two layers Superfical: Fibrous, extracpasular Deep - Synovial intracapsular

Gait cycle

Two phases Stance phace starts with initial contact of the heel on the ground and ends with toe-off Swing represents the time between toe=off and the subsequent initial contact Stance Phase: - Accounts for 60% of gait cycle - Involves weight bearing in closed kinetic chain - Five periods: - Initial contact (double limb support) - Loading response (double limb support) - Midstance (single limb support) - Terminal stance (single limb support) - Pre-swing.

Femoroacetabular impingement (FAI) Syndrome Types/Risk factors

Type: Cam lesion - bone deformity at the femoral head-neck junction (Superior-anterior area) Pincer lesion - extra bone extends out over the normal rim of the acetabulum. Mixed- combination of Cam and Pincer Risk Factor: 1. - Caucasian 2. - Family History of FAI 3. - Hx of Legg-Calve-Perthes disease (LCPD), Slipped capital femoral epiphysis (SCFE), developmental dysplasia (DDH) 4. - Competing in high-intensity sports during adolescence

Valgus force vs Varus force and associated injuries.

Valgus Force: - ACL - MCL - Meniscus - Acute patella subluxation or dislocation Varus Force: - LCL

Angle of inclination

an angle between the long axes of femoral neck and femoral shaft

Valgus Stress Test

for MCL

Posterior Drawer test

for PCL Sensitivity 0.90 Specificicifty 0.99

ACL - risk factors

intrinsic factors- 1) Gender 2) The shape of femoral notch 3) ACL size and laxity 4) Malalignments (Q-angle) 5) Faulty biomechanics 6) Muscular imbalance Quad 100 % Hamstring:70-80% extrinsic factors- 1) Conditioning / fatigue 2) Skill acquisition 3) Playing style 4) Equipment 5) Preparation time

Why more inversion sprain than eversion?

lateral ligaments are weaker than (medial ligaments). - Everyday activities and sports involve the foot turn inward (inversion). The structure of the ankle joint allows for more natural inward movement. - more ROM than eversion

ACL - rehab post ACLR

• Protection of the graft for the first 8 weeks (BPTB) and 12 weeks (ST) is crucial. • Initially, the terminal knee extension ROM must be regained as soon as possible to stimulate the VMO ( vastus medialis obliquus) • Strengthening - Hamstrings, Quad, hip abductors, Core • Proprioception - Balance exercises • Plyometrics - hopping, jumping, • Sports specific movement