4 - OA OF LL Flashcards
Main joints affected by OA in LL
- Hip joint
- Knee joint
- Ankle joint (talocrural joint)
- Subtalar joint
- First metatarsophalangeal joint (MTP)
- Midfoot joints
Classifications of OA
Primary & secondary
Table
Pathophysiology of OA
Mechanism understanding still poor:
- Failure of chondrocytes to control degradation & repair of cartilage
- Chondropathy (articular cartilage changes)
- Cartilage softening, thinning
- Loss of cartilage & attempts for regeneration
Hip OA:
- assessment
- diagnosis
- outcome measures
- physical tests
Assessment
- Subjective
- Objective
Diagnosis
- Based on clinical findings
- Imaging not first line of diagnosis
Outcome measures:
- Pain
- WOMACs subscale
- BPI
- VAS
- Activity limitations
- HOOS
- LEFS
- HHS
Physical tests
- Reduced passive hip ROM (particularly internal rotation < 25°)
- Scour test (labral stress test, AVN, arthritis)
- Pain with active hip extension
- Lateral pain on active hip flexion
- If > 4/5 tests positive, high chance of hip osteoarthritis present
Knee OA:
- assessment
- diagnosis
- outcome measures
- Observation
- physical tests
Assessment
- Subjective
- Objective
Diagnosis
- Based on clinical findings
- Imaging not first line of diagnosis
- Xray: joint space narrowing, bone osteophytes, bone sclerosis
Outcome measures
- Pain
- VAS
- BPI
- Activity limitations
- KOOS
- WOMAC
LEFS
Observation
- Swelling
- Deformities
- Muscle atrophy
- Scars
- Gait pattern
Physical tests
- Reduced passive knee ROM: extension > flexion
- Squatting aggravates symptoms
- General objective Ax: AROM, PROM, muscle strength, muscle length, knee structures
Consequences of articular cartilage loss in OA
Image
Potential predictors of fall & fractures in people with knee/hip OA classified into ICF domains
Table
Load distribution in foot during normal gait:
- load distribution
- why it matters in OA
Load distribution in normal foot
- Heel (rearfoot): more or less 60% of initial load
- Midfoot: transmits load forward, supports arch
- Forefoot (especially 1st met head): push-off via big toe bears peak pressure
- Subtalar & talonavicular joints help adapt to ground surfaces
Why it matters in OA
- Altered gait → abnormal joint loading
- Compensations stress other joints
- Poor shock absorption increases OA progression in overloaded joints
Joint specific overview of foot & ankle OA
Table
Clinical evaluation
- history
- physical examination
- gait analysis
- ROM
Outcome measures: tool & use
Table
Ankle OA:
- etiology
- classification
- treatment
Etiology
- Post-traumatic ankle OA, representing 75-80% of all cases. Traumatic event fractures in ankle region (malleolus, distal tibia, talus…) being responsible for 62% of cases
- 16% due to chronic ligament instability, particularly those affecting lateral collateral ankle ligament
- 7-9% of cases being idiopathic OA
- 13% secondary to other causes (rheumatoid arthritis, hemochromatosis, hemophilia or
osteonecrosis)
Classification
Takakura
Table
Treatment
Image classification:
Management of OA:
- general explanation
- exercise
- weight management
- info & support
- manual therapy
- devices
- do not offer
- pharmaco management
Table
Management of OA:
- key point
Image
Management of OA:
- strength
- flexibility & balance
- aerobic exercise / activity
- surgical management
Strength
- Body weight
- Resistance bands
- Weights
Flexibility & balance
- ROM exercises x5-10 / day AM or PM
- Stretching exercises x3-5 / week, 15-30 sec hold
Aerobic exercise / activity
- 150 mins of moderate exercise per week
- 10 min intervals/day
- Moderate talk test intensity
- X 2-3 / week
- 8-10 reps, start with 1 set & increase
- Resistance: sufficient to challenge muscle in pain free ROM
Surgical management of foot OA
- Midfoot fusion used to treat joint pain caused by midfoot arthritis or in some cases, severe
injury to ligaments that creates instability in arch
Management of OA:
- hind foot fusion / subtalar fusion
Table
Weight bearing progression
Table
Rehabilitation phases:
- fusion protocol
- TAR protocol
Table
Hallux rigidus:
- description
- treatments
HALLUX RIGIDUS
- Common & disabling arthritis of 1st MTP joint
- Characterized by:
o Degenerated cartilage
o Large osteophytes
o Joint stiffness
- Conservative treatments:
o Activity modification
o Supportive footwear & orthotics
o NSAID’s & steroid injections - Surgical options:
o Hemi-arthroplasty: promising for advanced cases
o Arthrodesis (fusion): gold standard for advanced hallux rigidus
Lisfranc injuries:
- description
- epidemiology
- mechanism
- clinical presentation
- Involves displacement or dislocation of metatarsal bones from tarsal bones, particularly as it
relates to second tarsometatarsal joint & Lisfranc ligament
Epidemiology - Injuries to Lisfranc joint can be categorized as caused by either low or high energy incidents
- Injuries can be caused by either direct or indirect trauma
- Men are 2 to 4 times more likely to suffer Lisfranc joint injury
- Most common complication => post-traumatic arthritis of joint
Mechanism
Image
Clinical presentation
- Swelling of foot / ankle
- Bruising of foot / ankle
- Pain usually in middle part of foot
- Widening of midfoot area
- Large bump on top midfoot area
- Not being able to put any weight on injured
Differential diagnosis to Lisfranc injury includes midfoot sprain, metatarsal fracture, cuboid
fracture, posterior tibialis tendon dysfunction & compression injuries to navicular
Lisfranc injuries:
- diagnostic procedures
- Special tests
- management
- PT management
Diagnostic procedures
- Patients will typically present reduced or non-weight-bearing
- MOI
- May present acutely, but delayed presentation not unusual as patient may well self-care for
sprain
- Bruising to sole of foot common & considered strong indicator of Lisfranc injury, but not
always present
- Tenderness over base of 1st & 2nd metatarsal & medial cuneiform suspicious
Special tests
- Pronation-abduction test
- Lisfranc joint squeeze test
- Piano hey test
- Pain or palpable click indicative of injury
Management
- Dislocation less than 2 mm, fracture can be managed with casting for 5 weeks non-weightbearing
- In majority of cases, early surgical alignment of bone fragments to original anatomical
position (open reduction) & stable fixation indicated
- When Lisfranc injury characterized by significant displacement of tarsometatarsal joint,
nonoperative treatment often leads to severe loss of function & long-term disability
secondary to chronic pain, sometimes to planovalgus deformity & OA
PT management
- Essential to prevent post-traumatic OA
- Restore midfoot stability
- Reduce long-term disability
Structured rehab plan improves functional outcomes, promotes safe return to activity, &
minimizes chronic pain & gait disturbances
Table with phases
Differential diagnosis OA & RA
Table
Basic of PT for knee OA
Table
