Common Orthopedic Conditions/Sports Injuries

Question 1

Legg-Calve-Perthes Disease

Answer 1

• —Degeneration of femoral head from â blood supply (osteonecrosis of capital femoral epiphysis)
• 2-4 year progression seen mainly in 4-8 yo
• Affects one hip mainly in males
• Limp
  
  • Pain in hip, groin, medial thigh, knee
• ROM into hip Abd and IR
• • Trendelenburg
• —Leg length discrepancy
• —Tends to eventually heal but à degen. arthritis

—

Question 2

LCPD PT

Answer 2

—Hip ROM measurements in all planes taken and repeated often

—Emphasize ROM of hip in all directions especially IR and Abd

—Orthosis possible to maintain femoral head in contact with acetabulum

—Teach donning/doffing (“A” frame, Toronto brace)

—Gait train with orthosis

—

Question 3

LCPD Med Mgmt

Answer 3

• —Pain management (medications)
• —Decrease weight bearing
• —Joint protection
• —Natural course of revascularization
• —If severe with destruction of femoral head à surgical intervention

Question 4

SCFE

Answer 4

—Femoral head slides off the femoral neck due to slipping of femoral epiphysis

• —Preadolescence and early teens (think growth spurt) boys > girls
• —Limp
  
  • Pain in groin, buttock or thigh (acute onset follows trauma)
  • Also associated with obesity and weakness of growth plate
• • Trendelenburg
• Dec ROM into hip Abd and IR
• ***If patient is only able to flex the hip if also externally rotating
  
  • VERY characteristic

Question 5

SCFE Med Mgmt

Answer 5

• —Surgical pinning (stabilization) soon after diagnosis
• Once diagnosis made, no weight bearing as it can lead to osteonecrosis

Question 6

Congenital Dysplasia of Hip (CDH)
Developmental Dysplasia of Hip (DDH)

Answer 6

Acetabulum and femoral head not aligned normally—subluxed or dislocated

—Left hip > right hip (intrauterine positioning?)

—Girls > boys (maternal hormone?)

—Abnormal growth of hip

—Dec. ROM

—Leg length difference

—Uneven skin folds (thigh and gluteal)

—Antalgic gait

Question 7

Higher risk—so screen (if…)

Answer 7

Breech position (HF with KE)

—First born especially if large

—Torticollis

—Metatarsus adductus

—Oligohydramnios

—Family history

-Cultural differences in carrying infants: In a sling in hip flexion and wide abduction on mom’s hip or back vs swaddled for first few months

Question 8

Hip dysplasia Med Mgmt

Answer 8

Test for hip instability: at birth and infancy

— Barlow (stress test): adduction and compression

—Ortolani (reduction): distraction and abduction

—Conservative management—bracing (Pavlik)

• —If optimal position of femoral head and acetabulum maintained, femoral head and femoral anteversion can remodel
• —If bracing not successful, may need traction f/b closed reduction and spica cast

—After 2 years old—surgery (open reduction) if needed

Question 9

Hip Dysplasia PT Intervention

Answer 9

• —Improve ROM of HF, HAbd, and IR
• —ER to neutral only
• Orthoses
  
  • Pavlik harness
    
    • —Infants 0-9 months
    • Promotes gradual, dynamic reduction
    • Requires reliable caregiving
    • Places child in HF, Abd and neutral rotation

Question 10

—If excessive genu valgum:

Answer 10

Anterior knee pain

—Patellofemoral instability

—Circumduction gait

—Difficulty running

—

*Staple medial femoral growth plate

Question 11

Flat foot

Answer 11

• —“normal” for first 2 years
  
  • Arch not developed yet due to ligamentous laxity
  • —Fat pad under medial longitudinal arch (up to 5 years)
  • Lack of neuromuscular control
  • May take several years to develop arch
• Weight bearing allows ligaments to stretch and allow mild subluxation of tarsal bones
  
  • Obesity plays a factor

Question 12

Clubfoot:
Congenital talipes equinovarus

Answer 12

• —Common congenital deformity
• Forefoot adductus
• Hindfoot varus
• Ankle equinus
• —Changes in talus, tarsal bones, navicular —— ligament and joint changes—–hypoplastic muscles with shortness of foot and small calf

Question 13

Other MS Abnormalities with idiopathic clubfoot

Answer 13

—Tibial shortening

—Internal tibial torsion

—Increased hip IR

—–—If due to merely intrauterine positioning, tend to be more mild and respond well to intervention

Question 14

Clubfoot PT Intervention

Answer 14

• —Correct deformity
• Retain mobility and strength
• Plantigrade positioning with normal load-bearing area
• Serial casting- if flexible
  
  • Correct cavus first, rotating foot from under talus, then correct equinus
  • May require achilles lengthening

Question 15

Scoliosis

Answer 15

• Lateral curvature of spine
  
  • Neuromuscular
  • Orthopedic
  • Congenital
  • Poor posture
  • Idiopathic—usually noted around time of adolescent growth spurt (girls > boys)
• Named for:
  
  • direction of convexity
  • Type and number of curve (“s” or “c”, single or double)
  • Section of vertebral column
• Postural asymmetries:
  
  • One shoulder higher than the other
  • Pelvic obliquity
  • Leg length difference
  • Prominent ribs/rib hump on one side

Question 16

Scoliosis Medical Management

Answer 16

• —Cobb angle
• Brace (20-40°)
• Surgery (>40°)

Question 17

Blount Disease

Answer 17

• —Abnormal development of the tibial epiphyseal plate à altered growth of tibia (bowing)—-irreversible pathologic change
• Tibia vara and torsion
• Delayed ossification of medial epiphysis and metaphysis of proximal tibia
• —Boys > girls
• —Increases with obesity

—

Question 18

Blount disease Medical Management

Answer 18

• Osteotomy to realign tibia
• Disruption of growth plate
• Limb lengthening

Question 19

Osteonecrosis:

Answer 19

• —Group of diseases of kids in which localized tissue death (necrosis) occurs f/b regeneration of healthy bone tissue
• During years of rapid growth, blood supply to epiphyses may be compromised à necrotic bone (typically near joints)

Question 20

Osgood Schlatter Disease

Answer 20

—Non-articular osteochondrosis at tibia

—Occurrence more frequent at times of rapid growth

—Activity related pain and inflammation at anterior knee

—Repetitive traction of patellar tendon on tibial tubercle on apophysis (ossification center)

—Tender to the touch at tibial tubercle

Question 21

OSD PT Intervention:

Answer 21

—Tends to be self limiting (related to growth)

—Ice, NSAIDs, modify activity

—Stretch hamstrings, quads

Question 22

Scheuermann Disease

Answer 22

• —Physeal Osteochondrosis at intervertebral joints (endplates)
• —Anterior vertebral body wedging— kyphosis during growth spurt

Question 23

Discoid Lateral Meniscus

Answer 23

—Snapping Knee

—Central area of lateral meniscus is filled in rather than “C” shape

—Possible limited ROM, locking, quad atrophy, pain, effusion

—May require arthroscopic surgery if ”symptomatic”

Question 24

Sever Disease

Answer 24

—Calcaneal apophysitis—heel pain

—Overuse syndrome caused by repetitive microtrauma at insertion of Achilles tendon at calcaneal apophysis

—Predisposing factors:

-—Gastroc/soleus tightness with tension at Achilles

—-Cavus or planus foot type à hard heel strike

—-Infection, trauma

—-obesity

Question 25

Sever Disease Intervention

Answer 25

• —Typically self limiting (closure of growth plate)
• Ice, heel cups, heel lifts, stretching
• Reduce activity if necessary
• —Proper foot wear for activity

Question 26

Sports Injuries

Answer 26

—Most common anatomic location is lower extremity (particularly knee and ankle)

—>50% of sports injuries are from overuse

—ACL injuries

—-In skeletally immature athletes, males> females

—-In skeletally mature athletes, females>males

Question 27

Growth Factors (and overuse)

Answer 27

Growing articular cartilage has low resistance to repetitive loading àmicrotrauma to cartilage or underlying growth plate

—Growing articular cartilage has low resistance to shear, particularly at elbow, knee, ankle

—Apophysitis is common– point of attachment of tendon to bone and represents an ossification center

—Increased tension at attachment sites à detachment of the structure at the apophysis (avulsion fracture)

—Longitudinal bone growth adds stress: musculotendinous structures tighten and lose flexibility (major at growth spurts)

—Biomechanical properties of bone: less cartilaginous and stiffer with growth à decrease in resistance to impactà buckling or bowing

—With growth spurt, ligaments stronger than growth plateà fx growth plate (Salter-Harris classification)

—Increased tension at attachment sites à detachment of the structure at the apophysis (avulsion fracture)

Question 28

Snapping Hip

Answer 28

—Overuse injury in athletes with a rotational component like gymnastics, dancing, sprinters

—Irritation of iliotibial band moving over the greater trochanter with hip movement

OR

—Tenosynovitis of the iliopsoas tendon near its femoral insertion

—Treat with rest, activity modification, stretching, strengthening, modalities

—

Question 29

Hip Pointer

Answer 29

—Iliac crest contusion mainly from a driving blow from a helmet

—Overlying muscle with subperiosteal hematoma

—RICE and padding

—Modalities, soft tissue work and stretching may be indicated if not resolved with above

Question 30

Avulsion Fractures

Answer 30

• —Forceful contraction or excessive stretch of muscle originating from involved apophysis (sprinting, jumping, soccer, football, weight lifting)
• Anterior-superior iliac spine
  
  • Origin of sartorius
• Ischium
  
  • Origin of hamstrings
• Lesser trochanteric spine
  
  • —Insertion of iliopsoas
• Anterior-inferior iliac spine
  
  • Origin of rectus femoris
• Iliac crest
  
  • Abdominal insertion

—

Question 31

Little League Shoulder

Answer 31

—Common in young pitchers and catchers

—Injury of proximal humeral growth plate secondary to a rotatory torque

—Limit throwing and rotational activities

—Strengthen parascapular and core muscles

—Don’t return to sports until all pain subsided

Question 32

Little League Elbow

Answer 32

—Extreme valgus stress placed on epicondyles during the acceleration of pitching

—Separation of of medial condyle with hypertrophy, irregularity, fragmentation, and avulsion

—Compressive load in lateral joint between radial head and capitellum àà

—–osteochondritis of capitellum

—–Avascular necrosis of radial head

—RICE to progression to full mobility/strength

—May have to alter throwing mechanism