Chapter 11 MSK LE Flashcards
what is the MOI of hip injuries
twisting, kicking, rapid acceleration adn decelleration
who is more at risk of hip injuries, males or females
males
what are some risk factors that increase the incidence of hip injury
-history of previous hip or groin injury
-age
-BMI inc or dec
-ecreased hip ABD and tROM loss,
-strength deficits between abd and add
-difference in hip ext strength bilaterally
according to the 2015 consensus statement on hip and groin pain what are the classifications
hip joint
adductor
public bone stress injry
iliopsoas/abdominal wall issue
**HIP/JOINTmost common
___% of athetes show findings of
FAI
7/10 young patients with hip fractures have had previous existing signs or symptoms of
osteoporosis
pediatric hip fractures are most often caused by
MVA
what are risks and possible bad things associated with pediatric hip fractures
failure of physeal plate to close, AVN, chondrolysis
what is the risk of acetabular fracture
AVN of femoral head
what kind of sports get pelvic fractures
high speed, such as motor sports
what are S+S of atraumatic bone stress injures
hip thigh groin pain, worse with activity relieved with rest
what are some risk factors or things that can lead to stress injuries
training intensity, surface changes, diet, female sex and triad, biomechanics with landing
how to best idenify a bone stress
MRI
what are tests to look for stress fractures in the hip and groin
FABER, flamingo and fulcrom test
femur stress fractures are likely associated with coxa ____, and happen at the _____ of the femur
vara,
neck of femur
what types and locations of stress fractures in the femur require surgical fixation
high stress at the head or the lateral side of the femoral neck (because this is the tension side)
what side of the femoral neck is the low risk femur fracture
the medial side of the femoral neck, and this can be NWB/PWB
what two things have been shown to speed up the bone healing
pulsed ultrasound and e-stim
what ages are chondral injuries common
14-25
where do apophyseal injuries happen
at the immature bone-tendon attachment
signs of apophyseal injury
pain and tenderness at apophysis, painful stretching and strengthening, and swelling.
RTP following apophyseal injury
~3 months
avulsion sites
ASIS (sartorius) , AIIS (RF), iliac crest (TFL, abdominals), ischial tuberosities (HS), LT (iliopsoas), pubis ramus (adductors)
management of acute avulsion fracture WB status
TTWB for 1-2 months
role of the labrum
absorption, joint stability and nutrition
what is the most common intra-articular hip pathology
labrum
labral tears are common in hips with coxa ___, femoral and acetabular _____, and ____ center edge angle
vara, retroversion, increased center edge angle
s+s of labral tear
anterior groin, hip pain or butt pain with clicking, locking or giving way
MOI of anterior vs posterior labral tearing
anterior: twisting or pivoting, posterior from a direct blow posteriorly, usually with dislocations.
traumatic vs atraumatic labral tears
traumatic, from a rapid twist, pivot or fall. atraumatic from cumulative microtrauma
tests for labral tears
FADIR, flex-IR test, posterior impingement test
difference between cam and pincer type
cam is a fat femoral neck, pincer is an overgrown acetabular rim
what is a pistol grip deformity
from a cam lesion where the femoral head and neck are fat at the junction
where are cam and pincer more common
cam in athletes due to repetitive stresses causing over growth
pincer in middle age active females
when to suspect FAI
painful clicking, locking, giving way, lateral/post hip pain, groin pain with pivoting, rotational movements, hip in flex/add/IR
pain worse with prolonged sitting, standing waking.
C sign
special tests for FAI
FADIR, FABER, modified Thomas test, Flex-IR test, resisted SLR and log roll
which test has sensitivity of 100% for FAI/labral tears
flexion IR test
dx of fai best done with
MRI
non-op FAI management
avoid aggravating positions, core strength, avoid end range movements
what things may cause structural instability in the hip
shallow acetabulum, excessive acetabular ante/retroversion, inferior acetabulum insufficiency, neck/shaft angle >140 degrees
focal rotary instability can be seen in
kicking repeated forceful rotation such as ballet, golf, martial arts,
which ligament is often involved in the abnormal loading of the anterosuperior labrum with focal rotary instability
iliofemoral
what is the most common position of hip dislocations
posteriorly, with a big posterior force in the flex/add position.
atraumatic instability signs and symptoms
coxa___
locking, giving way, clicking and c/o pan in the hip. hip dysplasia s+s on imaging and caxa valga.
tests for instability in the hip
pain with FABER, FADIR, AB-HEER (abd, ext and ER apprehension), hip IR less than 30 degrees at 90 degrees hip flexion
what ligament is affected in those with anterior capsule instability
ligamentum teres
what are the actions that cause a hip flexor tendinopathy
kicking or decelerations and eccentric contractions
severe injuries which lead to swelling can lead to what kind of palsy
femoral nerve palsy
most common muscles injured in the thigh
hamstrings
what are some things associated with prolonged recovery from a hamstring pull
ROM deficits with the hip flex to 90, over 1 day being unable to ambulate without pain, greater than 1 week from injury to consultation, stretching type injuries, participating in rec sports, and increased pain
what is the strongest predictor of adductor pain
previous adductor injury
adductor MOI
running, jumping twisting with hip ER,
which adductor most commonly involved
adductor longus
predictive things for adductor strains
add/abd weakness imbalance, hip/abd muscle imbalance,
how long for rehabb
4-8 weeks
what is the LSI of strength that they say you need
70%
where does AP-sports hernia affect
Rectus abdominus and hip adductors
in sports hernia ___ is strong and ___ is weak
strong adductors and weak abdominals
s+s of sports hernia
twisting, kicking lateral movements and change direction pain, insidious onset of pain, deep groin/lower abdomen, worse with resisted sit ups, sprinting cutting pain with adductor testing,
non-op PT for sports hernia
6-8 weeks, with strength, flexiblity, NM control…
what is the surgical option for sports hernia
abdominal wall repair with bilateral adductor tenotomy.
how long after sports hernia repair can PT start
4 weeks
how does sports hernia rehab start
light PREs (progressive resistance exercises) adductor strengthening, propriocetion and coordination,
when can add and abdominal pres be added after Sports hernia repair
6 weeks
what is the difference between intra-articular and extra-artcular snapping hip
intra: labral tears, chondral injuries, ligamentum teres…
extra: have internal and external snapping hip
internal snapping hip is AKA
coxa saltans interna
iliopsoas over the iliopectineal eminence or the femoral head
tests for coxa saltans interna
Thomas test for tight iliopsoas, positive active iliopsoas snapping testing, glute med weakness
external snapping hip AKA
coxa saltans externa from the ITB or Glute max over the greater trochanter.
tests for external snapping hip
thightness in the ITB obers test, positive bike test
what is overactive and what is underactive in external snapping hip
TFL overactive and glute max underactive
what type of eccentric training is needed for external snapping hip
eccentric glute muscles
what are the 3 stages and considerations for hip rehab
protective phase, rehabilitation phase and functional phase
what is it about non contact injuries to the ACL
there is a strong quad contraction on the knee extended with some valgus, which created a IR of the femur on the tibia
what are some criteria to be able to get surgery for your ACL
full ROM, walking ok, minimal swelling,
what parts of the patellar tendon and hamstring are used for ACL
central third, or distal hamstring
what is the avg return to running post ACl as per textbook
12 weeks
RTP following ACL-R as per textbook
9-12 months
what kind of tibial rotation can cause MCL injury
twisting and a tibial lateral rotation
where are the different tissues (deep and superficial) layers of the MCL most often injured
in extension, the whole ligament is messed up
in 20+ degrees flexion, usually just the superficial tissue
grades of MCL injury
grade I: pain with palpation to medial joint line, no instability, minimal swelling,
grade II 1+: 0-5 mm laxity, with an end feel
grade II 2+: 6-10 mm laxity, end feel harder to ID
grade III: no end feel
grade II or more injuries should be managed how
in a locked slight flexion brace around 20-25 degrees
RTP for MCL injuries grade I vs II
I: within 7-10 days
II: up to 3 weeks
what is the PLC
the posterolateral complex made up of the posterior joint capsule, LCL, popliteus tendon and the popliteofibular ligament.
what are some clinical findings/exams to clue into a PLC injury
-laxity posteriorly with varus testing
-laxity with dial test
-laxity with ER recurvatum test of Hughston test
what is the dial test
increased ER of the tibia noted while prone with knee flex at 30 than 90 degrees flexion
tests for PCL injury
posterior sag sign and posterior drawer test/clancy step off test
what is the largest concern with PCL injury
tibial lag sign
post op PCL… WB status and bracing
in full extension brace for 4-6 weeks, can WB if knee extended
when can you do HS exercises following PCL-R
6-8 weeks
what are risk factirs for Patellofemoral dislocation
-inc Q angle,
-female, wider pelvis,
-shallow femoral groove,
-flat lateral sulcus,
-high riding patella,
-ligamentous laxity,
-pronated feet and
-vastas medialis weakness
do pronated or supinated feet leave you more prone to patellofemoral dislocation
pronated
which way does a patella usually dislocate
laterally
what way do you move the knee to relocate a dislocated patella
move it from flex to ext and that should reduce it.
what is ruptured in most lateral patella dislocations
MPFL
how long do you immobilize following dislocation of patella
3-4 weeks
what kind of brace helps the knee after initial immobilization in patella dislocation
lateral buttress
can you do QS right after patella dislocation
yes
how many ligaments need to be disrupted to have a tibiofemoral disloaction
3+
what are things to be mindful of with tibiofemoral dislocation
distal pulses, sensation, vascular supply due to popliteal artery, peroneal and tibial nerve
how long do you immobilize after tibiofemoral dislocation
in full extension for 4 weeks
what muscle is important to strengthen for tibiofemoral dislocation
vastas medialis oblique, as that is the only medial dynamic stabilizer.
what provides blood supply to the meniscus
the medial and lateral genicular arteries
where the is meniscus red zone
THE OUTER PORTION OF THE
white zone is the _____1/3
inner
s+s of meniscus tear
pain, twisting, giving way, locking, catching sensation,
test for meniscus tear
joint line tenderness, McMurrays, Apleys
partial meniscectomy WB status ?
RTP?
as soon as feel comfortable, and RTP in 6-8 weeks.
meniscus repair WB? bracing? ROM limitations
either PWB or FWB, and first 6 weeks, ROM limited to 90 flexion.
RTP following meniscus repair
16-20 weeks
what are the grades of chondral injuries/lesions
grade 1: softening and swelling of cartilage
grade 2: fissuring and fragmentation of less than 1/2 inch in diameter
grade 3: fissuring and fragmentation greater than 1/2 inch in diameter
grade 4: cartilage eroded down to subchondral bone
what location is the most common for OCD
the lateral portion of the medial femoral condyle
what kind of view can you see an OCD lesion on
a notch view
following OCD lesion surgery WB status? and early activities?
early quad sets, and usually WB status is restricted for first 4-6 weeks.
patellofemoral pain is characterized by
pain int he anterior knee which is inc with compression of the patella against the femur.
peak prevelance of PFPS
12-17 years old
what are some anatomical risk factors of PFPS
anteversion of the hip and trochlear or patellar dysplasia
when moving from ext to flexion, the patella has to translate…
has to translate medially as it enters the trochlear groove, around 20-30 degrees knee flexion, then will follow groove and translate laterally.
what kind of things compound tracking issues
patella alta, baja, laterall pressure syndome
PFPS is increased with what tasks
squatting, climbing stairs, kneeling.
what could lateral PFPS mean
excessive lateral pressure syndrome or small nerve endings.
what could medial PFPS mean
medial plica, stretchng of retunaculum.
what could inferior pain with PFPS mean
patella tendinitis, fat pad
what could retropatella PFPS mean
chondromalacia or articular cartilage
what does a laterall tilted patella mean in full extension
tightness in the fibers of the retinaculum.
how can you assess retinaculum with patella mobility
patella mobs in slight knee flexion.
what is normal amount of tilting that should be able to occur medially at the patella
15 degrees past neutral, into medial position
what kind of foot and tibia position can lead to tracking patella issues
pronated foot and tibial IR/MR
who benefits more from orthotics
older folks, while younger do better with exercises
taping and orthotics are good for those with what kind of structural things
excessive foot pronation
what can inhibit quad firing which leads to atophy
pain
why is intra-artcular swelling bad
becuse it can irritate the synovium and create articular cartilage issues
whats better? ice alone or ice with compression
ice with compression for knee injruies
cartilage procedures have what kind of WB restrictions
NWB for 6 weeks
what is a fully extended knee gait pattern caled
quad avoidance gait pattern
why is it a good idea to start balance exercises of 30 degrees knee flexion
becuase you get a co-contraction of quad to HS
what kind of things do you need to do to get cleared for RTP
strngth within 10%, OKC testing (to isloate issues) CKC chain testing too
jump assessment
which is the actual most important part of jump testing assessments
the landing ecentric phase tells us the most.
what are jump height cut offs for men and women
(and single hop too)
jump men: 90-100% their height
women: 80-90% height
(single HOP: men: 80-90%, women 70-80%)
what is a good LE test for RTP
LEFT lower extremity functional test with 15 conditions on a 30-10ft diamond.
