AT2 - Common Lower Limb Conditions and Treatments

Question 1

S&S: Meniscus injury

Answer 1

MOI: Acute tear associated w/ mechanism involving twisting w/ foot anchored (may describe a tearing sensation), degenerative lesions occur w/ minimal trauma, pain levels vary considerably, swelling may be delayed 6+ hours, can report “clicking”, “grinding”, etc., more severe injuries, indicated by more severe symptoms and (if acute) can be associated w/ other injuries (e.g. ACL tear), intermittent locking may result from torn flap impinging btw articular surfaces, may unlock spontaneously w/ clicking sensation. P/E: Change of direction tasks, deep squat problematic, pain & restriction @ EOR F/E of knee, magnitude of lost ROM depends on injury severity, AROM=PROM, Tibiofemoral joint PAM positive, Special test (McMurray’s test) positive, varus/valgus may produce pain due to compression on injured side of knee, Joint line tenderness

Question 2

S&S: knee OA

Answer 2

Hx: Knee pain and at least 3 of the following 6 features: Age >50yo (some suggest 38yo), Morning stiffness <30mins, Crepitus on active joint movement, Bony tenderness, Bony enlargement, No palpable warmth.
P/E: Pain – including risk of nociplastic pain, Reduced function, Joint stiffness (i.e. PAMs) and reduced ROM (AROM=PROM), Muscle weakness (i.e. quadriceps atrophy and dynamometry findings), Joint effusion and limb deformity visible during observation, May have Hx of previous joint injury or surgery, Can be related to family history

Question 3

S&S: Patellofemoral pain

Answer 3

MOI/HX: ONLY IF NO OTHER DIAGNOSIS. Typically insidious onset but may be present secondary to acute traumatic episode (e.g. falling on knee) or another knee injury/surgery (e.g. ACL tear), Hx often includes some recent change/increase in extrinsic PFJ loading factors, Diffused ache exacerbated by PFJ loaded activities e.g. stairs, running, Sometimes aggravated by prolonged sitting, Pain during activity typically worsens over time vs “warming up” and getting better until end of activity (like tendinopathy), A Hx of crepitus may be reported.
P/E: Best test to identify PFP is pain during activities (i.e. squatting, stairs, prolonged sitting) and pain during isometric quadriceps contraction, Single leg squat, jump, lunge commonly assessment movements (link to pt specific aggravating activities), Often allows identification of intrinsic PFJ loading factors, Manual/cueing to address movement issues alleviates pain, Knee flexion increases PFJ compression and pain, active extension loading can cause pain response via quad contraction and associated PFJ loading (esp. if done in knee flexion), Weakness of key lower limb muscles (quadriceps hip ER/abd, ext, lumbopelvic, ankle stabilisers), Patella glides may demonstrate restriction in lateral knee structures, Exclusion of other more discrete pathologies via special test (e.g. meniscal injury), Small effusion may be present

Question 4

S&S: Patella dislocation

Answer 4

MOI/Hx: Pts will report sensation of slippage/giving way/pop, along w/ strong pain,
P/E: Swelling and tenderness at patella present, Quad contraction (i.e. IMT or active extension) painful, Passive knee extension often comfortable due to de-loading of PFJ, Patella lateral glide should provoke apprehension in patient, Similar predisposing factors to PFP condition (i.e. abnormal patella position, etc.)

Question 5

S&S: MCL injury

Answer 5

Hx of valgus stress incident, often w/ reported instability, Commonly occur w/ ACL injury,
P/E: Likely to have loss of ROM at end ranges (AROM=PROM), Valgus stress test positive, Local tenderness at site of MCL, Swelling dependent on severity

Question 6

S&S: ACL injury

Answer 6

Hx of change of direction or landing or similar injury incident, Audible pop, crack, or feeling of something going out and then going back, Extreme pain first few minutes, unable to continue activity, swelling (usually), Reports of knee instability if able to continue activity, Commonly occur with MCL and/or medial meniscus injury,
P/E: Reduced ROM, general tenderness (esp. at joint line), Lachmans and anterior draw test positive, Scans (i.e. MRI) recommended for detecting secondary injuries

Question 7

S&S: PCL injury

Answer 7

Mechanism usually a direct blow to anterior tibia w/ knee flexed (i.e. another athlete, equipment or ground), Can also result from hyperextension injury,
P/E: Mild-moderate effusion, posterior knee pain, Pain with knee flexion ROM or activities, Positive posterior drawer test

Question 8

S&S: LCL injury

Answer 8

Hx typically involves an injury/incident that included knee varus, extension and rotation forces, Usually injured with other structures as described for posterolateral corner injury,
P/E: Pain, swelling and instability reported, Varus stress test positive

Question 9

S&S: Patella tendinopathy

Answer 9

Hx: Increase in jumping workload,
P/E: Possible decreased strength of quads, Possible significant increased strength of quads, Decreased ankle DF, Pain over inferior pole of patella, Agg. by decline squats and energy storage activities (stretch shortening cycle), Possible increased thickness of tendon, Normal PFJ mechanics with minimal impact of PFJ taping

Question 10

S&S: Quadriceps tendinopathy

Answer 10

Hx: Increase in deep weighted squats,
P/E: Possible decreased strength of quads, Decreased ankle dorsiflexion, older & weightlifter. Pain over superior lateral margin of patella, Agg. by deep squats, Pain on resisted quadriceps contraction

Question 11

S&S: Biceps femoris tendinopathy

Answer 11

Hx: Excessive acceleration and deceleration, Frequently associated w/ stiffness of lumbar spine and decreased torso/pelvis control, Recent increases in workload, high prevalence in cyclists/runners.
P/E: pain in posterior lateral corner of knee, pain settles after activity and post exercises, Morning stiffness of posterior lateral knee during walking and F/E, Pain on resisted flexion

Question 12

S&S: Quadriceps muscle strain

Answer 12

Hx: Most common in rec fem, risk factors include fatigue, weakness, muscle imbalance, sprinting/kicking sports, etc.Athlete reports sudden pain in anterior thigh w/ explosive muscle action.
P/E: Local pain/tenderness on palpation, Pain on resistance (IMT), Pain on stretch (flexion), Possible parasthesia if femoral nerve involved

Question 13

S&S: Hamstring muscle strain

Answer 13

Hx: Most common biceps femoris, Type 1 sprinting related, Type 2 stretching related. Sudden onset of moderate to severe pain, reports difficulty ambulating.
P/E: Haematoma (bruising), Focal tenderness, Reduced stretch, Reduced and pain contraction, Difficulty with ambulation/propulsion tasks

Question 14

S&S: Posterolateral corner injury

Answer 14

MOI/Hx: Mechanisms of injury can include varus forces, extension forces, posterior translation of tibia on femur, hyperextension forces, and rotation of tibia on femur.
P/E: MILD GRADE: Mild varus force (usually isolated LCL injury), Minimal/no swelling, Tenderness over LCL, Varus stress test – pain but no laxity. MODERATE GRADE: Moderate varus force and possible rotatory (PLC likely and possibly LCL), Significant swelling may be present, Marked tenderness of LCL, lateral joint line, Varus stress test – pain and some laxity, Maybe reduced range at EOR, Possible side-to-side instability in ext. SEVERE GRADE: Large varus and posterior force (multiple structures injured), Variable pain over LCL (no connected fibres), Significant feelings of instability in extension, Difficulty walking on uneven ground or up/down stairs, Varus stress test – large laxity, no end feel, +/- pain, Dial test positive, Often reduced range at EOR, Possible foot drop (common peroneal nerve irritation), Often difficult calf raise and reduced knee flexion strength, Possible secondary ankle pain

Question 15

S&S: ITB friction syndrome

Answer 15

Hx: Increased hip/femoral IR and hip adduction, Decreased strength/endurance of lower limb muscles (hip abd, knee F/E), Poor hip control of eccentric abduction in stance and loading, Recent changes in workload.
P/E: Ache over lateral knee, Pain aggravated by running or cycling, Tenderness over lateral femoral condyle +/- crepitus and local swelling, Possible pain on repeated flexion/extension/Ober’s test, Significant weakness of hip abductors, knee flexors/extensors

Question 16

RED FLAGS: Children & teens

Answer 16

referral from the hip (when in doubt check the hip - paediatric hip?), Osgood-Schlatter’s (causes painful lump below the patella, pain common in front of knee)

Question 17

RED FLAGS: Tumour

Answer 17

past Hx of cancer, age >50yo, unexplained weight loss, pain at rest, unexplained deformity, mass or swelling, non-mechanical pain

Question 18

RED FLAGS: Infection

Answer 18

(osteomyelitis): red skin, fever, systemically unwell, compromised immune system

Question 19

RED FLAGS: Fracture

Answer 19

high force injury with significant pain that doesn’t change/respond the way we would expect.
OTTAWA KNEE RULE: an x-ray is indicated if the patient has any of the following features: Age >55 years, Inability to weight bear > steps on initial presentation, Isolated tenderness of the patella or fibula head, Inability to flex to 90 degrees

Question 20

MANAGEMENT: Meniscal injury - indicators of surgery

Answer 20

Some factors that may indicate surgery will be required include: Severe twisting injury, athlete is unable to continue playing, Locked knee or severely restricted ROM, Positive McMurray’s test (palpable clunk), Pain on McMurray’s test with minimal knee flexion, Presence of associated ACL tear, Little improvement of clinical features after 3-6 weeks of non-surgical treatment

Question 21

MANAGEMENT: Meniscal injury - Phase 1 (1 week)

Answer 21

Education and goal setting, Control swelling, Gentle ROM exercises (pain guided), Isometric strength knee flexors/extensors (including targeted VMO), Hip and calf strengthening exercises as able, Progress to full WB and normal walking gait, Maintain fitness (light biking may be possible with restricted ROM)

Question 22

MANAGEMENT: Meniscal injury - Phase 2 (2 weeks)

Answer 22

Swelling should be eliminated, ROM can progress to targeting residual stiffness, Quad/hamstring progress to through ROM (e.g. leg press, etc.) and functional actions (e.g. lunge, squat, etc.), Hip and calf strengthening exercise – progress functionality (e.g. deadlift, single leg calf raise), Progress walking and biking activity (consider swimming), Balance and proprioceptive exercises

Question 23

MANAGEMENT: Meniscal injury - Phase 3 (2-3 weeks)

Answer 23

Develop endurance and power capabilities in lower limb muscles, Balance and proprioceptive exercises should progress to jump/land/agility, Progress to running straight and then lateral, etc., Restricted sport specific exercises as able (if relevant)

Question 24

MANAGEMENT: Meniscal injury - Phase 4 (3-5 weeks)

Answer 24

Continued, gradual return to full sport training participation and then match/competition

Question 25

MANAGEMENT: Meniscal injury - long term considerations

Answer 25

There is a significant increase for developing OA after traumatic meniscus tear – therefore we need to promote the importance of healthy lifestyles and ongoing exercise to promote knee health

Question 26

MANAGEMENT: Knee OA - 1st and 2nd line treatments

Answer 26

The core treatments agreed upon are education and weight management, as well as structured land-based exercise programs (e.g. strengthening, cardio, balance, and/or mind-body exercises like yoga or tai chi). First line treatments: Topical NSAIDs (not long-term paracetamol use), Physiotherapy. Second line treatment (persisting symptoms): Oral meds, Intra-articular corticosteroids injections, Intra-articular hyaluronic acid.

Question 27

MANAGEMENT: Knee OA - conservative

Answer 27

Patient-specific management – guided by assessment findings, support sustainability of exercise/physical activity participation, Gait aids, braces, orthotics, footwear, Self-pain management strategies
LONG-TERM PHYSIOTHERAPY MANAGEMENT
Be goal specific – develop a plan and work towards the patient’s goals, Help the patient access home supports, health programs, sustainable forms of exercise, and any necessary care related to comorbidities, Work with MDT i.e. medical team, nurses, OTs, dieticians, GP and encourage ongoing physio

Question 28

MANAGEMENT: Knee OA - post-op

Answer 28

DAY ONE: Pain and swelling management, DVT prophylaxis, Chest physio, Knee ROM and isometric strength, Bed, gait mobility and walking/transfers, Ankle/hip ROM and strength work if able
POST SURGERY MANAGEMENT – BEYOND DAY ONE
Progress ROM exercise from pain guided to stiffness targeted, Progress strength from isometric quad to functional exercise (e.g. STS reps) and bed exercises to standing exercises, Progress from walking frame to crutches/stick and trial up/down stairs, Facilitate general increase in independence with ADLs

Question 29

MANAGEMENT: Patellofemoral pain

Answer 29

Education: especially to address aggravating activities, training adjustments, etc. Strategies: to address local tissue based problems at the knee (e.g. exercise). Consideration: of other joints (ankle and hip) and management of them. Exercise: a cornerstone of PFP management, usually involving exercises like below:
- QUADRICEPS RETRAINING Some patients may have difficulty activating VMO, Feedback can be used to address this i.e. EMG, palpation, imagery during prescription of quadriceps exercise
- HIP MUSCLE RETRAINING Retraining hip abductors, external rotators and extensors is thought to stabilise the lateral pelvis and to control internal hip rotation and adduction
- FUNCTIONAL EXERCISES Step up/down, single leg squat/jump, etc., Prescription needs to focus on appropriate knee position and provide suitable cue to help the patient with this, e.g. mirror feedback
- OTHERS Coordination and balance training, Strengthening/endurance building for lower limb and trunk muscles
- ADDITIONAL PHYSIO OPTIONS Technique training, Taping and bracing to support patella position, Orthotics, supportive footwear, Manual therapy to restricted lateral and anterolateral knee structures, Self-pain management options

Question 30

MANAGEMENT: Patella dislocation

Answer 30

most first-time traumatic patella dislocations are treated non-operatively, however surgery is more likely to be recommended if: Presence of an osteochondral fractures, Substantial disruption of stabilising structures, Lateral subluxation of patella, Multiple dislocations, or Not improving with appropriate rehabilitation. The aim of patella dislocation rehabilitation is to restore normal range of knee motion and quad function. Some important strategies include VMO strengthening and stretching of the lateral structures when tight, and improving trunk, pelvic and foot/ankle stability to control the knee’s position. Bracing does not prevent instability but can manage symptoms. The rehabilitation of patella dislocations is similar to PFP rehab.

Question 31

MANAGEMENT: ACL

Answer 31

Arthroscopic ACL reconstruction is the surgical Rx of choice, with other options including a tendon (patella or hamstring) autograft (typically ipsilateral) or an allograft (from cadaver). Each option introduces potential complications including PFP/hamstring strain risk and/or infection risk. Systematic review data favours autograft. The Multicentre Orthopaedic Outcomes Network (MOON) ACL rehabilitation guidelines are based on systematic reviews of level 1-2 evidence (RCTs and synopses of RCTs). The key components of rehabilitation include: Early weightbearing and motion, No postoperative bracing, Progressive exercise program, Limited open chain activities in first 6 weeks, Inclusion of substantial proprioceptive and balance training elements

Question 32

MANAGEMENT: ACL - rehab Phase 1 (2 weeks)

Answer 32

Education and goal setting, Control and eliminate swelling (cryotherapy and compression), Self-pain management strategies as needed (e.g. cryotherapy, TENS), Gentle ROM exercises (pain guided) – restore knee extension, Isometric strength knee flex/extensors (including targeted VMO), Hip and calf strengthening exercise as able, Progress to full WB and normal walking gait

Question 33

MANAGEMENT: ACL - rehab Phase 2 (2-12 weeks)

Answer 33

ROM can progress to targeting residual stiffness, including hyperextension, Quad/hamstring progress to through ROM (e.g. leg press, etc.) and functional actions (e.g. lunge, squat, etc.), Hip and calf strengthening exercises progress to functionality (e.g. deadlift, single leg calf raise), Progress walking, Biking activity to build fitness, Balance and proprioceptive exercises

Question 34

MANAGEMENT: ACL - rehab Phase 3 (3-6months)

Answer 34

Develop endurance and power capabilities in lower limb muscles, Balance and proprioceptive exercises should progress to jump/land/agility, Progress to running straight and then lateral, etc., Restricted sport specific exercises as able (if relevant), Swimming with light kicking

Question 35

MANAGEMENT: ACL - rehab Phase 4 (6-12months)

Answer 35

Continued, gradual return to full sport training participation and then match/competition

Question 36

MANAGEMENT: MCL - overview

Answer 36

typically these are treated non-surgically with a hinged brace (4-6 weeks in brace for mild injury, 8-12 weeks for mod-severe injury). There is no difference in outcomes for surgery vs non-surgery. The key points of rehabilitation include: Education, activity modification, goal setting, Pain and swelling management, Gentle ROM exercises within brace limits, -10 to 30 degrees extension, 90-100 degrees flexion limit for 2-4 weeks, Progressive exercise program similar to other knee ligament injuries, Early motion and muscle reactivation, Balance and normal gait, Early strengthening and coordination, Advanced strengthening and coordination (including jump/land), Plyometrics and agility, Sports-specific training (if relevant).

Question 37

MANAGEMENT: MCL - mild tear

Answer 37

PHASE 1 (0-1/52) AIMS: Control swelling, ROM 20-100+ degrees, Quads and hamstrings strength
PHASE 2 (1-2/52) AIMS: ROM 10-120+ degrees, Light jogging, Continue strength focus
PHASE 3 (2-4/12) AIMS: Full ROM, strength, squat, Return to running/restricted sports drills
PHASE 4 (3-6/12) AIMS: As above, Sport specific drills, Graduated return to training and sport

Question 38

MANAGEMENT: MCL - mod-severe tear

Answer 38

PHASE 1 (0-4/52) AIMS: Control swelling, WBAT, ROM 30-100+ degrees, hinged knee brace, Quads and hamstrings strength
PHASE 2 (4-6/52) AIMS: FWB, Eliminate swelling, Full ROM and continue strength work
PHASE 3 (6-10/12) AIMS: Full ROM, strength, squat, Return to running and restricted sports drills
PHASE 4 (8-12/12) AIMS: As above, Sport specific drills, Graduated return to training and sport

Question 39

MANAGEMENT: LCL injury

Answer 39

isolated LCL injury is rare, usually injured in combination with other structures. Rehabilitation approach is similar to MCL injury, with surgical consideration, including: Education, activity modification, goal setting, Pain and swelling management, Gentle ROM exercises within brace/surgeon limits, Progressive exercise program.

Question 40

MANAGEMENT: PCL injury

Answer 40

typically these are managed non-surgically, unless a multi-ligament injury or poor response to initial rehab. Severe injuries (grade 3) are immobilised in extension for the first 2 weeks in a Rebound/Jack brace to provide PA tibial support. Surgical reconstruction via autograft or allograft tissue (similar to ACL). PCL graft healing times are greater than ACL so return to full WB is delayed. Approx. 50% of patients return to sport at the same/higher level, 33% at a lower level. Again, the exercise program for rehabilitation for PCL is similar to other major knee injuries (6-9mths duration, but this is highly variable pt to pt), apart from the following key differences:prone, passive knee bend ROM early, ROM limits from knee flexion as PCL strain increases over 90 degrees flexion, Avoid hyperextension, Avoid early, isolated hamstring exercises.

Question 41

MANAGEMENT: Tendinopathies

Answer 41

Rx depends on competition/in season workload and aims of Rx, usually confined in season to: Managing workload, Maintaining strength/improving strength as able, Isometric exercises for pain relief, Working on the kinetic chain, Correcting biomechanical factors, Soft tissue therapy, And avoiding overly heavy eccentric, power, energy storage exercises – the athlete already does these!

Question 42

MANAGEMENT: Muscle strains

Answer 42

the rehabilitation for muscle strains follows the principles of soft tissue healing (inflammatory, proliferation and remodelling stages). Rx can involve some form of resistance training quite early, as well as sport specific training – this ensures our rehabilitation is complete and targeted for the athlete and their sport. Patients are more likely to get recurrent muscle strains if they have a Hx of muscle strains (quads/hamstrings). Prevention for muscle strains key tips: Stretching does not reduce the risk of exercise related injury (more in Sem D), Nordics are part of, but not all of, the program for hamstring strength, It should be relevant to the athlete’s functional requirements (strength, power, endurance, acceleration, deceleration, endurance of power activities, jumping, kicking, change of direction, etc.), It should be consistent as the most benefits of exercise are seen when it is maintained, and the most risk comes when exercise follows an on/off pattern.

Question 43

MANAGEMENT: ITB friction syndrome

Answer 43

we look at mechanical factors vs workload factors to see what is feasible to change. We need to: Manage deficiencies in the kinetic chain (is there a problem at the hip/ankle that needs to be addressed?), Manage workload (realistic expectations of what is feasible to achieve in a week), Build up towards a goal

Question 44

ROM EXERCISES

Answer 44

Impairment: Reduced ROM
Common cause: Pain & swelling, joint stiffness, reduced muscle/tendon extensibility
Focus: Maximise EOR time (>5-10 min/day)
Sets/reps: High sets and reps/hold time to achieve EOR goal
Frequency: Multiple times per day
Recovery time: N/A unless managing pain
Load: Add resistance to increase stretch force (overpressure) not to make movement harder
Additional: High pain (set pain limit), acute muscle injury (passive or active assisted movement), 2 joint muscle restriction (2-joint stretch positioning), tendinopathy (avoid tendon compression)

Question 45

ENDURANCE EXERCISES

Answer 45

IMpairment: Reduced muscle endurance
Common cause: Pain, deconditioning
Focus: Moderate load w/ high volume or static hold
Sets/reps: 3+ sets, 15-25+ reps, >5min hold
Frequency: 4+ /week
Recovery time: 1-2 min
Load: 50-60% 1RM, >16-20 RPE
Additional: Joint injury (isometric), reactive tendinopathy (isometric), muscle function (iso, con or ecc)

Question 46

STRENGTH EXERCISES

Answer 46

Impairment: Reduced muscle strength
Common cause: Pain, deconditioning
Focus: High load with low reps
Sets/reps: 3 sets or more, 6-8 reps
Frequency: 2-3 times per week
REcovery time: 2min or more
Load: >80% 1RM, >16-20 RPE
ADditional: Joint injury (isometric), muscle function (i.e. isometric, concentric and/or eccentric)

Question 47

STABILITY/CONTROL EXERCISES

Answer 47

Impairment: Reduced movement control or muscle activation
COmmon cause: Pain, weakness, reduced ROM, disuse
Focus: Low-mod load, high volume, correct movement/activation
Sets/reps: Similar to endurance (3+ sets, 15-25+ reps, >5min hold)
Frequency: Daily
Recovery time: 2 min or more
Load: Low load, challenging but not to the point of lost control (e.g. RPE 14)
ADditional: Biofeedback/cueing needed, pain impacts motor control so less desirable to work into pain

Question 48

RED FLAGS: Avascular necrosis

Answer 48

Hip pain for more than 6 weeks with normal hip radiograph, patients presenting with hup pain and risk factors including: Previous unilateral AVNFH, Alcohol excess, High exposure to steroid therapy, Immunologic therapy, Chemotherapy, Sickle cell disease and other coagulopathies, HIV, Recent pregnancy

Question 49

S&S: Avascular necrosis

Answer 49

Death of bone tissue due to lost microcirculation – subchondral bone collapses leading to progressive secondary arthritis. This is a rare condition, more common in men, with increased risk of developing after NoF #.
P/E: Pt reports pain in groin, gluteal area, or proximal femur, Pain worsens with WB, Reduced hip AROM + PROM, May report night pain

Question 50

S&S: Paediatric hip

Answer 50

This is a common cause of pain in the hip, groin, knee and lower leg – if you have any suspicions, or are in doubt, screen the hip for children! Common conditions in children that refer lower and look like other conditions include Perthes Disease and SCFE.
P/E: Mild hip discomfort, Decreased AROM/PROM at hip, Limping while walking, Muscle weakness

Question 51

S&S: Perthes disease

Answer 51

typically occurring in children 4-10 years old, in boys more so than girls. This is another necrotic disease, and can be unilateral or bilateral necrosis of the femoral head due to circulation problems with the femoral head.
P/E: Minor ache in thigh, groin or knee, May be limited hip ROM abduction, IR and/or flexion, NEED TO REFER FOR IMMEDIATE EMERGENCY MANAGEMENT

Question 52

S&S: Slipped Capital Femoral Epiphysis

Answer 52

this is the most common hip disorder amongst children aged 9-16 years, which results from a weakened proximal femoral physis. This leads to posterior/medial translation of epiphysis relative to the metaphysis. The aetiology is multifactorial, including: Bone morphology predisposition, Obesity, Chronic kidney disease, Post-radiation therapy, Thyroid problems.
P/E: May be sudden onset or more commonly gradual progression of symptoms, Limping child (BIG FLAG), Leg shortening and ER of the limb, Reduced IR, flexion, or abduction, REFER FOR IMMEDIATE ASSESSMENT AND MANAGEMENT

Question 53

S&S: Femoroacetabular impingement (FAI)

Answer 53

this is a pathological mechanical process where morphological abnormalities of the acetabulum and/or femur combined with vigorous hip motion (flexion + IR) damages the soft tissue structures within the hip joint. This is more common in males, and has two main types: 1) Cam and 2) Pincer.
P/E: Pain in impingement positions (flexion, IR, adduction), FADIR/Hip quadrant test positive

Question 54

S&S: Labral tear

Answer 54

these are common in athletes – 22% of groin pain athletes have labral tears, and 55% of patients with hip pain have labral tears. There is also a high prevalence of labral tears in the older, asymptomatic population. Pre-existing FAI increases the risk of labral tears as higher shear forces as present. Can result from gradual onset or trauma,
P/E: Locking, clicking, catching and giving way, Pain location usually anterior hip or groin region (some may report posterior pain), FADIR and FABER tests – high sensitivity, low specificity, MRI investigation may help Dx

Question 55

S&S: Hip OA

Answer 55

Pain (including risk of nociplastic pain) – pain typically described as dull, aching pain that becomes constant, with short episodes of intense, unpredictable, emotionally draining pain,
P/E:Reduced function (i.e. lying on side, walking, stairs, etc.), Reduced ROM (AROM=PROM) + crepitus and joint stiffness, Muscle weakness (i.e. gluteal atrophy and dynamometry findings), Biomechanical changes over time due to pain/reduced muscle function, May have history of previous hip joint injury or surgery (i.e. FAI, arthroscopy)

Question 56

S&S: Greater trochanter pain syndrome

Answer 56

previously, this was only known as trochanteric bursitis or ITB syndrome, but is now thought that tendinopathies, muscle tears, and bursitis co-exist and is generally known as greater trochanter pain syndrome.
Hx of activity overuse, sudden fall, prolonged weight bearing on one leg, Middle aged women unaccustomed to exercise, Difficult to sleep on affected side, Pain crossing legs or sitting for long periods.
P/E: Tenderness on palpation, Abductor muscle weakness common, Positive resisted external rotation – derotation test

Question 57

S&S: Adductor-related groin pain

Answer 57

most common longstanding and acute groin injury.
P/E: Tender adductor longus tendon, Pain on resisted adduction

Question 58

S&S: Pubic-related groin pain

Answer 58

there is no data on how common this is, and there are no particular diagnostic tests. The presence of bone marrow oedema on MRI is often an indicator of bone stress but not necessarily a pathology

Question 59

S&S: Iliopsoas-related groin pain

Answer 59

this is the second most common injury in the groin, often from overuse. It is poorly localised ache at the anterior aspect of the proximal thigh (can be more laterally located). It is often differentiated from hip-related groin pain. Iliopsoas tenderness,
P/E: Pain on resisted hip flexion, Pain on stretching hip flexors, Thomas test (restricted and painful)

Question 60

S&S: Inguinal-related groin pain

Answer 60

This is caused by herniation of the bowel into the inguinal canal. Acute (direct trauma) or insidious onset (end of activity),
P/E: Aggravated by increasing intra-abdominal pressure or sudden movement, Palpable/obvious swelling

Question 61

S&S: Referred pain

Answer 61

this comes from nerve irritation, and the pain refers down into the groin area. Commonly irritated areas include: SIJ, Thoraco-lumbar spine, Radicular pain T12, L1, Peripheral nerves (iliohypogastric, ilioinguinal, genitofemoral)

Question 62

MANAGEMENT: Hip OA

Answer 62

Patient education (moderate evidence): Explaining Dx, pain education, self-management strategies, Advice re: activity modification (i.e. sitting, sleeping, etc.), Importance of sustainable exercise and managing body weight
Gait and balance training (weak evidence): Provide functional, gait and balance training, Include appropriate use of gait aids, Target patient-specific activity limitations
Manual therapy (weak evidence): Consider manual therapy procedures to provide short-term pain relief and improve hip mobility and function in patients, Base decisions on reassessment findings
Surgical option (moderate evidence): Pooled results from 20 trials suggest that THR improves QoL, pain and physical function (up to 7 years post-surgery) compared to pre-op, Patient satisfaction is favourable, The 10 year implant survival of cemented THR is 94% in patients 65-74 and 96% in patients aged 75+

Question 63

MANAGEMENT: Post-op THR

Answer 63

the critical components of physiotherapy for post-op THR include: Education, pain management, Bed mobility, walking, transfers (bed, chair), stairs, Exercises (ankle pump, hip ROM, quad/glute strength, squats, balance), Chest physiotherapy to prevent respiratory complications. We also need to be careful of hip precautions (first 6 weeks post-op).

Question 64

MANAGEMENT: Post-op THR - posterior precautions

Answer 64

No hip flexion > 90 degrees, no crossing the legs, no internal rotation

Question 65

MANAGEMENT: Post-op THR - lateral precautions

Answer 65

Same as posterior, but additional no active hip abduction due to mm incision

Question 66

MANAGEMENT: Post-op THR - anterior precautions

Answer 66

No extreme hip extension with external rotation

Question 67

MANAGEMENT: FAI/Labral tear - general

Answer 67

Education re: avoiding position of impingement, Modify daily aggravating activities (i.e. sitting height, increase ER, avoid extremes of ROM) and sporting activity (i.e. change playing position/time), Increase controlled hip ROM/decrease muscle spasm, Manual therapy (soft-tissue and joint mobilisation), Improve hip joint neuromotor control (deep stabilising muscles), Integrate ROM/stability into functional activities

Question 68

MANAGEMENT: FAI/Labral tear - Phase 1 strengthening

Answer 68

Deep hip stabiliser retraining: Educate re: role, location and action of the deep hip stabiliser muscles, Facilitate independent contraction of deep hip stabiliser muscles, Graded progression (i.e. resistance, reps, speed, balance, functional)

Question 69

MANAGEMENT: FAI/Labral tear - Phase 2 strengthening

Answer 69

Gluteus maximus retraining: Due to its insertion in the proximal femur it can control femoral head position during hip extension (unlike hamstrings) i.e. resist anterior translation that stresses anterior structures, Educate re: role, location and action of gluteal muscles, facilitate independent contraction and progressively strengthen

Question 70

MANAGEMENT: FAI/Labral tear - Phase 3 strengthening

Answer 70

Generalised strengthening: Ensure good deep hip stabiliser and gluteal activation maintained, Restore strength, endurance and proprioception to the levels needed for pt to return to desired level of function

Question 71

S&S: Lateral ankle sprain

Answer 71

Injury event often relates to activities requiring rapid change of direction, uneven surfaces, or landing on someone else’s foot, Common sports involved: basketball, volleyball, netball, football, Pain likely worst at anterolateral ankle if isolated AFTL sprain, Sometimes crack or tear sensation reported, P/E: Degree of swelling, bruising and disability indicates severity. AROM=PROM, all movements likely painful due to inflammation, but inversion worst due to greatest stretching of injured ligaments (+PF for ATFL), Can weight-bear, often anatalgic (limping gait), Observation of inflammation signs, Palpation – tenderness worst of over involved ligaments at joint line, Anterior drawer and talar tilt test positive for pain and laxity

Question 72

S&S: Talar dome lesion

Answer 72

talus osteochondral lesion is a cause of residual pain after ankle sprain, and is the separation of the articular cartilage fragments from the talus +/- subchondral bone. This occurs in 10% of ankle sprains. Usually it occurs when there is a compressive component to the ankle sprain injury (e.g. when landing from a jump). Most commonly occurs in the superomedial corner of the talar dome.
P/E: This is often missed early, and the patient will represent later with unremitting ankle aching and locking/catching despite appropriate ankle sprain treatment. It is challenging to Dx early after injury due to general ankle tenderness and lack of ROM. Tenderness of the talar dome can be investigated with the patient’s foot PF at 35 degrees to rotate the talus out of the ankle mortise

Question 73

S&S: AITFL/High ankle sprain

Answer 73

presenting with usually more pain and disability than a typical lateral ankle sprain. Swelling is less marked, but bruising is more proximal. The MOI is due to external rotation of the foot with axial compression, hyperdorsiflexion force, or abduction force. The more proximal the pain, the greater the lesion will be.
P/E: We also need to palpate the medial ankle to check if the deltoid ligament is involved also (due to MOI). Palpation findings notable over AITFL and/or PITFL, DF positions uncomfortable due to anterior talus promoting separation of distal syndesmosis, Pain provoked in lunge, step downstairs, Cross-legged position (where tib/fib is squeezed high up leg) generates separation forces and is provocative of pain, External rotation test most helpful in Dx AITFL sprain

Question 74

S&S: Medial ankle sprain

Answer 74

Hx: Forced eversion injury – direct trauma to lateral ankle,
P/E: Swelling and pain on palpation of medial ligament, Lateral talar tilt test positive (reverse of lateral ligament test), High sensitivity for MRI

Question 75

S&S: Lisfranc ankle sprain

Answer 75

A Lisfranc sprain MOI can be direct (crush injury) or indirect (axial force while foot is PF and rotated, backwards fall with foot trapped, or fall onto point of toes). There may also be a concurrent metatarsal fracture.
P/E: Midfoot pain and difficulty weightbearing, Pain aggravated by forefoot weightbearing, Feels pain on push-off phase of running (and possibly walking too), Unable to run on toes, calf raise also provocative of pain, Tenderness on the dorsal midfoot, Bruising and swelling are also likely, Pain with combined eversion and abduction of forefoot, Neurovascular exam to check dorsalis pedis compromise, XR, CT and MRI can all assist with diagnosis

Question 76

S&S: 5th metatarsal/Jones #

Answer 76

this is a fracture of the diaphysis of the 5th metatarsal. This can be caused by a traumatic onset (inversion + PF injury) or an overuse stress fracture (more common). Non-union may occur in this type of fracture due to the blood supply of the region

Question 77

S&S: Weber/Lateral ankle #

Answer 77

WEBER A: Distal tip of lateral malleolus, Possible medial malleolus involvement (usually stable). WEBER B: Possible involvement of syndesmosis joint, May significantly involve medial structures. WEBER C: Proximal to ankle, Usually involving tibiofibular injury, Often medial injury also

Question 78

S&S: Medial tibial stress syndrome

Answer 78

Common running injury, Patient presents with diffused pain along posterior medial border of tibia, Worse at beginning of activity, better with increased activity.
P/E: Tender posterior-medial shin, Muscle imbalance in leg and thigh, May also find: Rearfoot pronation, Decreased dorsiflexion, Decreased hallux extension, Poor hip ER/Abd control, Calf muscle imbalance, Decreased quads/hamstring strength

Question 79

S&S: Navicular stress #

Answer 79

High risk # due to blood supply issues for bone, Insidious onset (can be support by MRI).
P/E: Poorly localised midfoot ache associated with activity, Pain at the N-spot (proximal dorsal portion of the navicular) – ALWAYS assume stress fracture until proven otherwise

Question 80

S&S: Anterior impingement

Answer 80

when additional soft tissue or bony tissue is trapped between the talus and the tibia during maximum dorsiflexion – common in repeated dorsiflexion athletes (e.g. footballers, gymnasts, ballet), May follow ankle sprain (particularly anterolateral sprains).
P/E: Begins as vague discomfort at anterior ankle, Pain becomes sharp and localised esp. during dorsiflexion, Worse with activity with potential loss of take-off during acceleration, Ankle stiffness into dorsiflexion, Tenderness along the anterior margin of the talocrural joint (+/- palpable spurs), Special test – lunge (most localised pain), Investigates – weightbearing x-ray in PF and DF

Question 81

S&S: Posterior impingement

Answer 81

impingement of the posterior talus against the tibia in extreme plantarflexion. Os trigonum or prominent posterior talus can predispose posterior impingement, Common in sports requiring maximum plantarflexion (e.g. ballet, gymnastics, football, fast bowling), Can occur secondary to acute forceful hyper-plantarflexion.
P/E: Pain on active and passive plantarflexion and local tenderness

Question 82

S&S: Calf strain

Answer 82

patient will complain of acute pain with a stabbing/tearing sensation when injury occurred. Mechanism of injury is rapid acceleration or deceleration,
P/E: May be painful to ambulate, Limited power, Tender over muscle strain site, Possible skin discolouration +/- swelling, Pain on contraction and stretch

Question 83

S&S: Achilles tendinopathy

Answer 83

common in runners, as well as sports involving running and jumping – mid-portion tendinopathy is common, and it can also be at the enthesis (insertion point). This is almost always related to relative training workload. Achilles tendinopathy usually occurs in active 35+ year olds, especially 30s and 40s. Forceful calf contractions (usually eccentric) can completely tear through the tendon. Pt will report feeling like they’ve been hit by something in Achilles region with a loud “bang”. Obvious limp but may still be able to walk. Excessive training or sudden increases in training (strong evidence for this), relative weakness in plantarflexion strength, Reduced dorsiflexion range, Reduced knee flexor strength, High central adiposity (men), or peripheral adiposity (women), Increased BMI, high cholesterol, diabetes, Genetics, Exposure to fluroquinolones.
P/E: C/O of pain on activities that involve energy storage and release, Localised pain, point tenderness, Tenderness/thickening in mid portion of Achilles, Uniformly grossly swollen in acute episodes (swollen nodules in degenerated tendons at insertion), Reduced strength and power of gastroc and/or soleus, Hx of overload (degenerated tendons will react with relatively minor loads)

Question 84

S&S: Tibialis posterior tendinopathy

Answer 84

an overuse type injury (especially from running or walking), and is most often seen in middle-aged women.
P/E: Excessive rearfoot pronation, Medial ankle pain, behind the medial malleolus extending to the navicular, Pain and weakness on resisted inversion, Pain on heel raise (no rearfoot inversion)

Question 85

S&S: Plantarfasciopathy

Answer 85

usually affects very physically active people or those with standing occupations. This affects the enthesis (origin point) of the plantar fascia at the medial calcaneal tuberosity. Dynamically the plantar fascia provides stability to the foot via the “Windlass” mechanism. In late stance, as the heel lifts, passive dorsiflexion of the MTP joints produces increased tension in the plantar fascia, resulting in arch elevation and midfoot stability. Standing work/training volume, FHL flexibility and strength, No association with foot alignment

Question 86

S&S: Plantar heel pain

Answer 86

Gradual onset of inferior medial heel pain, First step pain – morning pain or after prolonged rest,
P/E: Pain on prolonged standing, Palpation of medial calcaneal tuberosity is definitive objective sign

Question 87

S&S: Inflammatory arthritis/gout

Answer 87

joint pain without an acute injury, often related to an increased use of diuretics. Typically it will affect the PIP of the big toe, and the Dx depends on demonstration of uric acid crystals in the synovial fluid

Question 88

S&S: Complex regional pain syndrome

Answer 88

potential to follow and complicate acute ankle injuries – this is considered to be caused by a change in sympathetic nerve function.
P/E: increased pain, swelling, hot/cold skin, localised sweating, discolouration, and hypersensitivity

Question 89

EXERCISE EVIDENCE: Stretching

Answer 89

For improving range at the foot/ankle, overall evidence for stretching is low, however ankle DF flexibility programs can be effective in the short-term. Addition of foam rolling can increase short-term extensibility, but detraining happens quickly after discontinuation of stretching

Question 90

EXERCISE EVIDENCE: Balance/proprioception

Answer 90

it is also important to consider balance and proprioception in treatment, which is supported by ankle and foot strength. More complex exercises are less beneficial on average, but can be individually useful when specified

Question 91

EXERCISE EVIDENCE: PF strengthening/power

Answer 91

we need to develop speed and endurance in plantarflexor muscles – which should progress to speed, plyometric and functional training.

Question 92

EXERCISE EVIDENCE: Foot strengthening

Answer 92

the intrinsic foot muscles are the main local stabilisers of the foot, and are key in supporting the foot arch, providing flexibility and stability, and absorbing shock. Early activation/learning exercises include: short foot exercise, towel curl, and ES. We can incorporate short foot into other exercise (e.g. single leg deadlift, balance, etc.). Heel raises with foot muscle bias can be important for foot strength. The short-foot exercise has been seen to correct static foot alignment and improved foot kinematics during gait – for runners specifically, the short foot exercise increased intrinsic foot muscle volume and propulsive forces in runners

Question 93

MANAGEMENT: Lateral ankle sprain

Answer 93

For management of lateral ankle ligament sprains, we need to remember POLICE – protection, optimal loading, ice, compression, elevation. We shouldn’t be afraid of loading the ankle as long as the patient can WB. We also need to address impairments at the ankle, commonly: Swelling, ROM at DF and subtalar movements, Secondary deconditioning, Kinetic chain weaknesses, Proprioception. Recurrent ankle sprains are common, particularly in the next 6-12 months. Patients can RTS when functional exercises can be performed without pain during or after. For prevention of possible recurrent sprains, we can use taping/bracing or neuromuscular training – for most effective results taping/bracing for 6-12 months. Taping options include: stirrups, figure 6s, figure 8s, reverse 6s, heel locks, modified heel locks, low dye, calcaneal slings, and combinations of these

Question 94

MANAGEMENT: Syndesmosis

Answer 94

If management is not progressing the way we expect then we need to re-evaluate and consider if we have missed a subtle secondary injury – such as a syndesmosis injury. STABLE: Managed with CAM boot 4-6 weeks, Usually requires prophylactic taping following removal of boot, Usually double the amount of rehab as ankle sprains (~ 12 weeks). UNSTABLE: Surgical stabilisation of inferior tibiofibular joint, Post-surgical rehabilitation usually the same amount of time (~ 12 weeks)

Question 95

MANAGEMENT: Medial ankle sprains

Answer 95

beware of the increased likelihood of fractures – but these are treated the same as lateral ankle sprains, but will likely take double the amount of time to heal also (~ 12 weeks). Common secondary complications from medical ligament sprains include tibialis posterior tendinopathy and FHL (flexor hallucis longus) tendinopathy.

Question 96

MANAGEMENT: Lisfranc sprains

Answer 96

LOW GRADE: NWB in CAM for 6/52, Followed by ankle mobilisation and strengthening, Recovery 3-4 months w/ good prognosis.
HIGH GRADE: Surgical fixation required, If frank diastasis, early recognition leads to good outcomes

Question 97

MANAGEMENT: Weber/Lateral ankle #

Answer 97

STABLE: Can be managed conservatively with 6 weeks immobilisation followed by rehabilitation.
UNSTABLE/MULTIPLE STRUCTURES/COMPLICATED FRACTURE: Often requires surgical fixation
Followed by 3-6 months rehabilitation

Question 98

MANAGEMENT: Talar dome lesions

Answer 98

Stage 1 and 2 are managed non-surgically. Grade IIa, III or IV lesions are managed surgically. NON-SURGICAL: Avoid painful activities, Encourage to pedal an exercise bike with low resistance, Progress ROM without significant loading to promote articular cartilage healing as early as possible, If there is pain or S/O clicking, locking, giving way beyond 2-3 months conservative Mx, then ankle arthroscopy is indicated to remove or fixate loose bodies. SURGICAL: Arthroscopic removal of fragments and drilling of the fracture bed down to bleeding bone, After treatment of osteochondral lesions a comprehensive rehabilitation program is required

Question 99

MANAGEMENT: 5th metatarsal/Jones #

Answer 99

we need to distinguish between acute avulsion fractures and often present chronic fractures. Management will often depend on the location of the fracture and the mechanism of injury. Surgical fixation is much more common, but can be managed with CAM boot PWB/NWB. Often these injuries re-occur and surgical options fail – these injuries almost always require a surgical opinion

Question 100

MANAGEMENT: Navicular stress #

Answer 100

6-8 weeks boot NWB, 6 weeks progressive WB, Progressive restoration of range, strength and exposure to training, Often requires another 3-4 months of rehabilitation following NWB period
Readily reoccurs and may require surgical opinion (screw or osteotomy)

Question 101

MANAGEMENT: Medial tibial stress syndrome

Answer 101

there is currently no conclusive evidence to manage this condition (due to poor research, poor understanding of pathology, poor consideration of all factors, and central sensitisation after chronic issues develop). Ice/heat, Compression, Iontophoresis, Massage, Taping, Orthotics, Rest, Prolotherapy such as PRP injections CAN HELP

Question 102

MANAGEMENT: Anterior impingement

Answer 102

CONSERVATIVE: Heel lifts, Improving ROM with manual therapy, Avoiding aggravating activities, NSAIDs, Taping or orthoses. SURGICAL: May require removal of exostoses (bony spurs)

Question 103

MANAGEMENT: Calf strains

Answer 103

progressive strengthening program using multiples of bodyweight is the best rehabilitation for this condition. We progress to power work, sport specific skills and then develop some sport specific endurance. The most power in ambulation is generated from the calf complex, and athletic activity usually involves power. We need to train for long term function as the most common risk factor for a second calf injury is the first calf injury

Question 104

MANAGEMENT: Achilles tendinopathy

Answer 104

involves the altering of loading of the Achilles tendon irrespectively – can be eccentric or heavy slow load. A study looking at the effectiveness of heavy slow loading vs eccentric loading found that both groups improved in all pain and function measures at 12 weeks, and these were maintained at 52 weeks – no difference btw groups. Patients were more satisfied with the HSL and had higher compliance with the exercise program. We also need to ensure that we continue to load to required capacity. Secondary management for Achilles tendinopathy: Address the kinetic chain: DF range and knee extension strength, Manage workload of the patient, Avoid: resting completely, relying on passive treatments, stretching tendons, injection therapies

Question 105

MANAGEMENT: Tibialis posterior tendinopathy

Answer 105

there is limited evidence for specific interventions, however some management strategies include: soft tissue therapy, footwear, controlled strengthening, AVOIDING steroid injections, and potentially surgery.

Question 106

MANAGEMENT: Plantarfasciopathy

Answer 106

different treatment methods are used: 1) self massage, ice or heat are common but have mixed results, 2) minimise aggravating activities, 3) orthotics with conflicting evidence, 4) advice on footwear with limited evidence, and 5) strengthening the lower limb with developing evidence. High load strength training has been found to have better outcomes for strength at 3 months, but has no significant difference at 12 months

Question 107

MANAGEMENT: Gout

Answer 107

primarily managed pharmacologically by a rheumatologist with urate-lowering medications and NSAIDs during flare-ups. Can also be managed non-pharmacologically through weight loss and diet

Question 108

MANAGEMENT: Complex regional pain syndrome

Answer 108

difficult to manage – needs to be referred to pain specialised clinics