Exam 2 Flashcards
What System should be considered when doing a system review?
(hip)
Urogenitial
- The Kidneys can refer to the lateral hip
- We may need to perform Kidney percussion test
When screening the hip, what vascular conditions should we look out for?
Avascular Necrosis / Osteonecrosis
- They may complain of a dull ache or throbbing pain in the groin, lateral hip or buttock
- Pain with ambulation, abduction and IR/ER
Pediatric Disorders
What is Legg-Calve-Perthes Disease?
When the Femoral Head temporarily loses blood supply
- This is idiopathic
- More common in overweight adolescents
- Hx of recent growth spurt or trauma
Legg-Calve-Perthes Disease, what can be observed and what may we find objectively?
- Limp is observed
- Pain in Hip, Groin, Thigh or Knee that worsens with activity
- Limited flexion, abduction and IR
What is Slipped Capital Femoral Epiphysis?
- Anterior displacement of the Femoral Neck
- Male > Females; 2-13 years old
- Gradual onset of groin, medial thigh and knee pain
With Slipped Capital Femoral Epiphysis, what can be observed?
- Limited abduction and extension ROM
- Short limb, antalgic gait
What is Congenital Hip Dysplasia?
- Hips that are “unstable”, malformed, subluxated, or dislocated
- Infants, Female > Male
- Short limb
- Associated with torticollis
- Hip position flexed and abducted
- May be a breech birth
- Galeazzi, Ortolani and Barlow signs
What types of infections should be considered with Red Flag considerations?
(hip)
- Septic Arthritis
- Osteomyelitis, espeically those patients who’ve had an acute trauma or who are post-op
Which Cancers are local to the hip?
- Osteoid Osteoma
- Colon Cancer
Which Neurologic conditions should be considered with Hip red flags?
- Cauda Equina Syndrome
- Guillain-Barre Syndrome
- MS
- ALS
What are the Red Flags associated with Colon Cancer?
- Age > 50
- Bowel Disturbances (e.g., rectal bleeding or black stools)
- Unexplained weight loss
- Hx of colon cancer in the family
- P! unchanged by positions or movement
What are the Red Flags with Osteonecrosis/Avascular Necrosis of the Hip?
- Hx of long-term corticosteroid use
- Hx of avascular necrosis of the contralateral hip
- Trauma
What is referred pain?
- Pain that is perceived at a different location than in source
- When determining probable hypothesis, somatic and visceral referred pain must be considered
Where can the Hip refer pain to?
Pretty much anywhere in the LE
- Most commonly to the buttock
- Also the groin and thigh
- Less commonly to the lower leg, dorsum of foot, and plantar heel
What can refer pain to the Hip?
Lumbar
- Somatic referral, commonly refers pain to the hip
- Must be considered as a source of hip pain
What muscles are a source of LE Pain?
- Gluteal musculature can and do develop myofascial trigger points
- Glute Medius, Glute Minimus, TFL, Deep Hip Rotators: Down to LE
What may you hear during the Subjective Hx with these patients?
(Hip w/ mobility def.)
- Insidious onset of stiffness and global pain
- Typically pain and stiffness worsens over time
- Worse in morning and with prolonged positioning, eases with movement
- Reports limited ROM eventually resulting in activity limitations and participation restrictions
- Aggravating Factors: Endrange hip motions; IR and Flex tend to be most provocative
What Objective Finding may you find with these patients?
(Hip w/ mobility def.)
- Limited AROM and PROM; if mobility deficits are a result of a joint integrity deficit than a capsular pattern may be present
- Possibly impaired joint integrity/mobility
- Possibly limited muscle length
What is the Prognosis for Hip P! with Mobility Deficit?
- Dependent upon integrity of joint
- Mobility deficits typically improve with interventions targeting joint mobility and pain control, if needed
What interventions are typically done with Hip P! and Mobility Deficit pts?
- Mobility/ROM exercises
- Manual Therapy
- Functional Optimization
If a Patient is in the Acute stage of condition, what should we the PTs do?
- These pt may require symptom modulation approach depending upon severity and irritability; also may present with somatic referred pain
If a patient is in the Subacute stage of condition, how may a patient present?
- The patient may begin to present with indications of movement and coordination impairments as mobility increases and motor control is impaired due to prolonged lack of mobility
If a patient is in the Chronic stage of healing, what do we, the PTs, do in this stage?
- Continue to address endrange mobility deficits, continue to improve movement and coordination impairments, and work towards functional optimization
What are the Primary S/S of Symptomatic Hip OA?
- Joint pain, joint stiffness, and activity associated limitations/participation restrictions
With Symptomatic Hip OA, what are the 4 diagnostic critera (CPG)?
- Moderate anterior or lateral hip pain with weight-bearing activities
- Morning stiffness lasting less than 1 hour in duration
- Hip IR < 24 degrees or Hip IR and Flexion 15 degrees less than the asymptomatic hip
- Increased Pain with passive Hip IR
-P! may be felt in the butt, groin, thigh or knee. Can be a dull to sharp and stabbing pain
Flexion and IR are most common losses of motion (Capsular Pattern)
What is the Sutlive et al. Diagnosis Criteria for those with Hip OA? (5)
- Self-reported squatting as an aggravating factor
- Scour test with adduction causing groin or lateral pain
- Active hip flexion causing lateral pain
- Active hip extension causing hip pain
- Passive hip internal rotation less than or equal to 25°
What Outcome Measures should be completed with patients with Symptomatic Hip OA?
- Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
- Hip Disability and Osteoarthritis Outcome Score (HOOS),
- Harris Hip Score (HHS)
- Lower Extremity Functional Scale (LEFS
Patients with Symptomatic Hip OA, what other test and measures should be done during the Examination?
- Balance performance and activities that predict risk of falls should be measured
(Berg, Timed Single Leg Stance Test) - Use FABER (Patrick’s) Test, Assess hip PROM, Assess hip muscle strength
What intervention should be done to those patients with Symptomatic Hip OA?
- Manual therapy: thrust and non-thrust, and soft-tissue mobilization. As hip motion improves add exercise.
- Individualized flexibility, strengthening, and endurance exercises to address identified impairments of body function
- Bracing should not be used as an initial intervention
- Clinicians should collaborate with physicians and dieticians to support weight reduction in individuals with hip OA who are overweight or obese
What type of patients typically get diagnosed with Femoracetabular Impingement (FAI)?
Young and Middle-aged adults
What may cause Femoracetabular Impingement (FAI)?
- Morphology variations of the hip joint
- Cam
- Pincer
- Combined: both Cam and Pincer (likely to be the most common category)
- Results in abnormal bony contact
Patients with Femoracetabular Impingement (FAI), what motions do they typically feel pain? What are some reports we may hear from the patient that have FAI?
- Typically during endrange hip motions, especially rotation, and hip flexion positions
- Can report clicking, catching, locking, giving way
What Examinations should be done with those patients with Femoracetabular Impingement (FAI)?
Patients may be (+) with Scour, FABER, FADIR, and Posterior Impingement Test
Patients with Femoracetabular Impingement (FAI) may lead to what other hip injuries?
Labral tears, and chondral damage due to altered loading of the femoroacetabular joint
What are some risk factors for Hip OA?
- Family Hx
- Obesity
- Hypermobility of the joint
How can you differentially diagnose between Hip OA and RA?
Sx that include prolonged morning stiffness (>1 hour) should raise suspicion of inflammatory arthritis such as RA
With Femoracetabular Impingement (FAI), what is Cam Impingement?
An abnormality of the femur due to boney overgrowth of the Femoral Neck
- This deformity causes abnormal contact between the femur and the acetabulum, particularly when hip flexion is combined with adduction and IR
- The Cam impingement has been implicated in the etiology of Anterosuperior labral and chondral lesions
With Femoracetabular Impingement (FAI), what is Pincer Impingement?
This is caused by a boney abnormality of the acetabulum due to an increase in the size of the acetabular rim, effectively creating a deeper hip socket
What are some Common Clinical Findings with FAI?
- Primary Sx is motion related (rotation activities) or position related (hip flexion positions) pain in the hip or goin
- Pain described as aching or sharp and typically located in the anterior hip/groin and/or lateral hip/trochanteric region
- Anterior hip pain is Agg by prolonged sitting and is reproduced with the FADIR test
- Common finding is a limitation of hip IR (< 20°) and a decrease in hip flexion and hip abduction
What may you hear in the Subjective Exam with those patients with Hip P! with Muscle Function Impairments?
- Chief complaints of hip pain and weakness
- Descriptor: Often sharp, possibly pinching
What is the MOI with those patients with Hip P! with Muscle Function Impairments?
Acute or Chronic; often repetitive stress or eccentric loads
What is the Primary Agg and Ease Factors with those patients with Hip P! with Muscle Function Impairments?
Agg
loading of specific contractile tissue
Ease
Rest and support
What may you find Objectively with those patients with Hip P! with Muscle Function Impairments?
- PROM > AROM
- Tender To Palpate (TTP) of involved musculature
- Pain with loading of involved musculature through PROM/MLTs and AROM/MMTs
- Associated mobility deficits and muscle performance impairments may be present of surrounding structure
This can be due to joint dysfunction and the muscles over compensate (Bray Clinical Pearl)
What is the Prognosis for these patients?
(Hip w/ muscle function impairment)
- Likely to be favorable
- Dependent upon structures involved and severity of condition
- Minimum of 12 weeks until full return to function
- Further improvement may take up to 24 weeks
- Referral is recommended for patients whose symptoms remain unacceptable
What is the PT focus with patients in the Acute Stage of condition?
Often a symptom modulation and reduction of tissue loading
approach; may present with somatic referred pain
What is the PT focus with patients in the Subacute Stage of condition?
Addressing muscle performance impairments; may present
similar to a movement and coordination impairments condition
What is the PT focus with patients in the Chronic Stage of condition?
Muscle performance impairments need to be continued to be addressed ultimately focusing on functional optimization
What interventions are done to those patients with Hip P! with Muscle Function Impairment?
- Reduction of tissue loading
- Graduated rehabilitation
- Manual therapy for symptom modulation and associated mobility deficits
- Regional interdependence
- Education
What is Greater Trochanteric Pain Syndrome (GTPS)?
This isn’t just bursitis, also found to include Gluteal Medius/Minimus Tendinopathy/Tears, and external coxa saltans (snapping hip syndrome) or ITB friction syndrome at the hip
- Predominantly occurs in females between 40 and 65 years-old
What is a common subjective report with patients with Greater Trochanteric Pain Syndrome (GTPS)?
Typically presents with:
- lateral thigh, groin and gluteal pain, especially when lying on the side at night,
- sitting and during prolonged standing
- walking and climbing up and down stairs
- It may also radiate distally to theknee and the lower leg
What interventions can be done for those patients with Greater Trochanteric Pain Syndrome?
- Should utilize conservative case since greater than 90% of cases respond; impairment-based approach
- Eccentric exercises are should be considered due to tendinopathic component
- Corticosteroid injections could be considered to provide short-term pain relief
- Orthotics may be prescribed if there is a biomechanical fault in the kinetic chain
- Surgical options (bursectomy, gluteal tendon repair, ITB lengthening, trochanteric reduction osteotomy) for persistent conditions exist but have low methodological quality research to support their use
With Hip Region Muscular Strains, what are common muscular strains?
Gluteus medius, Adductors, iliopsoas, Rectus Femoris, Rectus Abdominis and hamstrings are most common
- Muscle induced groin region pain typically due to adductor strain (Adductor longus, Adductor Magnus)
With Hip Region Muscular Strains, what are common objective findings?
- PROM > AROM
- TTP of involved structures
- Pain with loading of involved musculature through PROM/MLTs and AROM/MMTs
What are the Characteristics of Hamstring Strains?
- Most common strained muscles of the Hip
- Typically a grade 2 strain
- Usually due to a sudden eccentric load (sudden change in direction, acceleration or deleceration)
- High recurrence rate
- Prolonged recovery
- Should use a holistic approach to consider contributing factors
With Hamstings strains, what are common examination findings?
This is digital lecture
Posterior thigh pain during activity with reproduction of Sx with muscle lengthening, activiation, and palpation along with a loss of function
What should be assessed with Hamstring Strains?
- Assess Knee Flexor strength with Dynamometer
- Assess hamstring length with hip flexed at 90° using an inclinometer
What Interventions can be done with Hamstring Strains?
- Eccentric training added to stretching, strengthening, stabilization and progressive running programs
- Trunk stabilization and progressive agility training
- Neural tissue mobilization
- Therapeutic modialities to control pain and swelling in acute stage of healing
Which hamstring is the most commonly strained?
Bicep Femoris
How can a hamstring injury to the Semimembranosus and its proximal free tendon occur?
During slower speed activities such as a dance and yoga
Hamstring injuries and/or tears typically occur during what movements?
They occur in the end-range hip flexion with knee extension stretching movements
What are Clinical findings associated with Hamstring Injuries?
(Book)
- The patient reports distinctive MOI with immediate p! during sprinting or decelerating quickly. In acute cases, they may report a “pop”or tearing sensation
- Tenderness elicited with passive stretching of the hamstrings (hip flexion and knee extension)
- Altered gait mechanics
- Posterior Thigh pain, often near butt, worsens with resisted knee flexion and/or hip extension
- Tenderness to palpate, generally located at ischial tuberosity but may also be at belly and distal attachment
- Positive special test specific for hamstring injuries
With Hamstring Strains, what is Grade 1?
Gait appears normal, but there is pain with the extreme ranges of a straight-leg raise
With Hamstring Strains, what is Grade 2?
Antalgic gait or gait with a flexed knee. Resisted knee flexion and hip extension are both painful and weak
Antalgic Gait: Abnormal pattern of walking secondary to pain that ultimately causes a limp, whereby the stance phase is shortened relative to the swing phase
With Hamstring strains, what is Grade 3?
Usually requires the use of crutches for ambulation. In severe cases, ecchymosis, hemorrhage, and a muscle defect may be visable several days post-injury
What Subjective findings may you find with this Diagnosis?
(Hip w/ Movement Coordination def.)
- MOI can be either traumatic or atraumatic
Traumatic
- Reports of traumatic dislocation or subluxation
- 90% of dislocations or subluxations are posterior
- Immediatly after dislocation, the LE is usually held in Adduction, IR and Flexion
Atraumatic
- Insidious onset of Anterior hip or groin pain
- No motion loss, but excessive motion especially ER and Extension
- Reports popping, locking or snapping Sx are common
- May have a Hx that involed repetitive forceful activities, especially activities involving rotation
What may you find during the Physical Examination with this Diagnosis?
(Hip w/ Movement coord def.)
- No restrictions in AROM or PROM, but excessive motion may be present
- MLTs may or may not be impaired
- MMTs may be impaired:
-Hip Abductors
-Deep Hip ERs - Joint Integrity Test
-Hypermobility is typical - Additional Test
-(+) Dial, FABER, FADIR, Scour, Resisted SLR - Palpation
What are the Prognostic Factors for Traumatic MOI?
- The direction of dislocation
- Time to reduction of dislocation
- Age
What are the Prognostic Factors for Atraumatic MOI?
- Etiology
- Age
- Activity level
What interventions can be done for Movement Coordination?
Sx Modulation
- Manual Therapy
- Dry needling
Motor control and stabilization
- Core and lumbar stability exercises
- Hip abduction/ER strengthening
- Single limb exercises focusing on motor control and stability
Functional Optimization
- Continue to focus on strength and stability
- Exercise should match sport/activity: Movement patterns, speed, energy system, intensity, muscle performance goal
What are the Characteristics of Hip Dysplasia?
- More common in females than males
- Decreased coverage of the acetabulum
- Can be congenital or acquired
- Dx via radiograph, MRI or CT
- Should be considered in athletes who benefit from increased motions such as dancers
-Up to 89% of professional ballet dancers have hip dysplasia or borderline hip dysplasia
congenital (present at birth) or acquired (develops later in life)
What may you find in the Examination with those with Hip Dysplasia?
- Typically presents as Deep Anterior Groin Pain
Test and measures that will indicate hip dysplegia
- AROM/PROM (limited IR and Excessive ER is common)
- MLT
- Joint integrity (Hypermobile)
- Additional Orthopedic Test
-Apprehension with Long Axis distraction and improvement with Axial loading is a sign of instability
Any personal or familial Hx of connective tissue disorders may also be a consideration
What are common treatments for Hip Dysplegia?
Conservative Treatment
- Activity modification and/or brief period of rest
- Strengthening of the Hip Flexors, Abductors, Short ERs, Core and Low Back muscles
- Proprioception training should be included due to joint hypermobility
Corticosterioid injection should be considered
Surgical Intervention
If conservative treatment fails
- This procedure depends on the degree of instability
What are the Characteristics of Hip Labral Tears?
The prevalence of labral tears with mechanical hip pain can be as high as 90%
- The cause of groin pain in more than 20% of athletes
- Tears can be degenerative, dysplastic, traumatic or idiopathic
-Degeneration tears can also be associated with inflammatory arthropathies
- Common MOI is Mechanical impingement and instability
What are the 2 most common patient scenarios for Hip Labral Tears?
- Younger patient with a twisting injury to the hip, usually an external rotation force in a hyperextension position
- Older patient with a history of dysplegia or repeated pivoting/twisting motion
What may you find in the Examination with those with Hip Labral Tear?
Test and measures that stress the labrum
- AROM/PROM
- MLT
- Joint integrity
- Additional Orthopedic Test
Hip IR with overpressure and FABERs test show the highest sensitivity for identifying a labral tear
What are common treatments for Hip Labral Tear?
Conservative Treatment
- Activity modification
- Improve the force-producing capacity and control of hip musculature
- 12 weeks or more is recommended
Corticosterioid injection should be considered
Surgical Intervention
If conservative treatment fails
- Labral debridment
- Labral repair
- Labral reconstruction
What is the Most Common Type of Hip Labral Tear?
Radial Flap
- Radial flap labral tears are related to damage to the free margin of the labrum and therefore form a radial flap
What is a Type 1 Hip Acetabular Labral Tear?
A detachment of the labrum from the articular cartilage surface.
- These tears tend to occur at the transition zone between the fibrocartilaginous labrum and the hyaline articular cartilage. They are perpendicular to the articular surface and in some cases, extend to the subchondial bone
What is a Type 2 Acetabular Labral Tear?
Consist of one or more cleavage planes variable depth within the substance of the labrum
In other words, when 1 or 2 splits/separations of the labrum are torn either shallow or deep. Seen with MRI
What may you find in the Hx with a patient with a Hip Labral tear?
- Sx are usually mechanical: Buckling, catching, twinges, clicking, locking, instability and painful clicking.
- May or may not be a hx of trauma
- The injury is caused by the hip joint being stressed while in rotation
- The pain is mainly in the anterior groin (most commonly), but can be in the lateral or posterior thigh and/or medial knee region
- Activities that involve forced adduction of the hip joint in association with rotation in either direction tend to Agg the pain
From book, bolded was also in digital lecture
What are the Subjective finding for those patients with Hip P! with Radiating pain?
- Insidious, gradual onset
-Traumatic MOI - Sitting and/or standing for prolonged periods could be an aggravating factor
- Reports of neuropathic pain symptoms
What are common Physical Examination findings for Radiating Pain?
- Neurologic exam may or may not be normal
- Restrictions in AROM or PROM will vary
- MLT may or may not be impaired
- MMT may be impaired
-Based on etiology and compensations - Joint integrity testing
-May be Hypomobile - Additional Orthopedic Test
- Palpations
Keep in mind that, Mobility deficits may cause radiating pain
What are Prognostic Factors for Radiating Pain?
- Etiology
- Concomitant Low back pathology
- Age
- Severity
- Social Determinants of Health
What Interventions can be done with Radiating Pain?
Sx Modulation
- Manual Therapy
- Dry Needling
- Modalities
- Static Stretching
Movement Control
- Core and Lumbar Stability
- Hip Musculature strengthening
- Neurodynamics
Functional Optimization
- Continue to focus on strength and stability
- Education on how to avoid recurrence
What are the Characteristics of Piriformis Syndrome?
- Several etiologies:
-Hypertrophic piriformis
-Anatomical variance
-Overuse - More common in middle-age patients
- More common in females than males
What may you find during the Examination of Piriformis Syndrome?
- Reports of deep buttock pain
- May or may not have radiating pain
Test and Measures that will indicate Piriformis Syndrome
- Neurologic Exam
- AROM/PROM
- MLT/MMT
- Additional Orthopedic Test
- Palpation
What Interventions can be done with Piriformis Syndrome?
Conservative Treatment
- Manual Therapy
- Dry Needling
- Static stretching
- Neurodynamics
- Strengthening of Hip musculature and core and back stabilzers
Various injections may be considered depending on severity
Surgical Treatment
What are the effects that Coxa Valga has on the Hip?
- Alters the orientation of joint reaction forces
- Hip Abductors are shortened, putting them at a disadvantage and causes them to contract more vigoroously to stabilize the pelvis, increaseing JRF
- Increases overall length of the LE, impacting the kinetic chain
What are the effects that Coxa Vara has on the Hip?
- Increases downward shear forces on femoral head
- JRF are decreased as the greater trochanter is displaced laterally and superiorly, increasing the pull angle and the hip abductor lever arm
- There may be an increase of incidence of epiphyseal plate damage with the increased shearing and torsional forces
What type of collagen are the Meniscus made of?
Type 1 and 2
With Meniscus Injuries, What is the MOI?
Traumatic: Weight bearing with rotation - twisting injury
- Soccer, Rugby
-Audible pop or click at time of injury
-Tearing sensation
Degenerative: Repetitive flexion with loading
- Work related kneeling or squatting
- Climbing more than 30 flights of stairs per day
Pt. with Meniscus injuries, what would we find in the Subjective Hx?
- Delayed effusion (6-24 hrs post injury)
Chief Complaint
- Catching or clicking of the knee with movement; Doesn’t matter if P! is involved
What are the Agg/Ease with Meniscus injuries?
Agg:
- P! with end range knee flexion
- P! with knee hyperextension
- P! with knee rotation/pivoting
- Swelling and stiffness in the acute stages of the injury
Ease
- Rest
What may we find in the Physical Examination with Meniscus Injuries?
Palpation for condition; AROM; Palpation for tenderness
Palpation for Condition
- (+) Modified stroke test for effusion
AROM
- P! with maximum knee flexion
- P! with forced hyperextension
Palpation for Tenderness
- Joint line tenderness
With Meniscus injuries, what Special Test would you expect to find to be (+)?
Meniscal Lesion Test
- (+) McMurray test with pain or audible click
- (+) Thessaly test at 20° knee flexion with pain, sense of locking or catching (This is often the go-to)
- (+) Apley’s Compression Test
With Meniscus Injuries, during the Physical Examination, what Physical Performance Measure can we do?
Activity Limitations
- 30 sec chair-stand Test
- Stair-climb Test
- Timed Up and Go Test
- 6 min Walk Tests
Return to Activity or Sports
- Single Leg Hop Test
We won’t use these in the Acute or Subacute Stage of Healing
What are the Clinical Findings for Meniscus Injuries?
- Twisting Injury
- Tearing sensation at time of injury
- Delayed Effusion (6-24 hrs post-injury)
- Hx of catching or locking
- P! with forced hyperextension
- Joint Line Tenderness
- P! with maximum passive knee flexion
- P! or audible click with McMurray’s Test
- P! with Thessaly’s Test at 20° knee flexion
What is the Prognosis for Meniscus Injuries?
- Dependent on type and severity of meniscal tear
- Joint mobility
- LE strength
- Goals and level of function
What are the Clinical Findings during the Physical Examination for Articular Cartilage Injuries?
- Acute Trauma with hemarthosis (0-2 hrs)
- Associated with Osteochondral Fx
- Insidious onset aggravated by repetitive impact
- Intermittent pain and swelling
- Hx of “catching” or “locking”
- Join line tenderness
With Mobility Impairments, what are the Interventions you should do in the Acute Stage for Non-surgical patients?
- Pain and Sx modulation - education
- Progressive knee ROM
- Progressive weight bearing
- Progressive return to activity
- Progressive strength training to knee and hip muscles
- Neuromuscular electrical stimulation
With Mobility Impairments, what are the Interventions you should do in the Subacute Stage for Non-surgical patients?
- Progressive knee ROM
- Progressive weight bearing
- Progressive return to activity
- Progressive strength training to knee and hip muscles
- Neuromuscular electrical stimulation
With Mobility Impairments, what are the Interventions you should do in the Chronic Stage for Non-surgical patients?
- Progressive knee ROM
- Progressive return to activity
- Progressive strength training to knee and hip muscles
- Neuromuscular electrical stimulation
- Proprioceptive training
What motions does the MCL limit?
Valgus and ER
What motions does the LCL limit?
Varus and ER
What motions does the ACL limit?
Anterior Translation and IR
What motions does the PCL limit?
Posterior Translation and IR
With this patient population, what may you hear in the Subjective Hx?
(Knee movement coord)
- Sx onset is linked with trauma
- “Pop” heard or felt at time of injury
- hemarthrosis with 0 - 12 hrs post injury
- Describes sense of knee instability (“Gives out”)
- Stiffness and pain
With these patients, what is the MOI?
Deceleration, cutting or valgus motion
With these patients, what are some Clinical Findings during the Examination?
(Palpation, AROM, MMT, Proprioception, Movement Analysis)
- Palpation for Condition: Effusion
- AROM: Decreased knee flexion/extension
- MMT: Decreased quads/hamstrings strength
- Proprioception: Single balance impaired
- Movement Analysis: Compensatory Strategies
With these patients, what may you find during Ligament Integrity Test?
- Excessive tibiofemoral laxity with cruciate/collateral ligament integrity tests
What test(s) are done to test the integrity of the ACL?
- Anterior Drawer
- Lachman Test (Best, however hardest)
- Lateral Pivot Shift Test
What test(s) are done to test the integrity of the MCL?
Valgus stress test
What test(s) are done to test the integrity of the LCL?
Varus stress test
What test(s) are done to test the integrity of the PCL?
- Posterior Sag Test
- Posterior Drawer Test
With these patients, during the examination, what Impairment Measures can be done?
- Star Excusion Balance Test
- Single Leg Hop for Distance
- Crossover Hop Test for Distance
- Triple Hop Test for Distance
- 6 Meter Hop for Time
Not in Acute or Subacute Stage of Healing
What is the prognosis for these patients?
- Dependent on type and severity of ligamentous injury
- Joint mobility
- LE strength
- Movement co-ordinations
- Psychosocial status
- Surgical intervention
- Goals and level of function
With Interventions, what is done with Early Rehabilitation Strategies?
(knee with mob def)
- Edema Management - Cryotherapy
- Progressive Early ROM
- Progressive Early Weight Bearing
- Neuromuscular Electrical Stimulation
- Bracing Support
- Strengthening Quads, Posterior Lower Kinetic Chain
With Interventions, what is done with Early-Late Rehabilitation Strategies?
Therapeutic Exercise
- Optimal ROM, strength, flexibility
- Addressing impairments with foot/ankle, hip and trunk regions
Neuromuscular Re-Education
- Field/Court sports performance
Education/Counselling Strategies
- Activity modification, return to sport readiness, and whether or not surgery is required
With this, what is the age range that this occurs, with the highest prevalance?
12 to 19 years old
This is not a self-limiting condition
What is the MOI for these patients?
(Patellofemoral syndrome)
Insidious onset
- Gradual onset of Sx
Where would these patients feel the pain?
(Patellofemoral syndrome)
- Retro patellar or Peripatellar pain
- Pain quality poorly described
Retro patellar refers to pain arising from pressure on the back of the patella
What are the Agg/Ease factors for these patients?
(Patellofemoral syndrome)
Agg
- Squatting
- Ascending/Descending stairs
Ease
- Decrease load/rest
With these patients, what are Objective Findings that you may see?
(Patellofemoral syndrome)
- Reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting
- (+) Patellar Tilt Test
- Exclusion of other possible sources of Anterior Knee Pain
With these patients, what Objective Findings would we see with Patellofemoral pain with Muscle Performance Deficits?
(Patellofemoral syndrome)
- HipSIT: Hip Stability Isometric Test
- LE Strength Decreased:
-Hip Abductors
-Hip ERs
-Quads
-Hamstings
The HipSIT test evaluates the strength of the hip posterolateral stabilizers in a position that favors greater activation of the Glute Max and Med and lower activation of the TFL. (positioned in 45° hip flexion and 90° knee flexion in sidelying)
With these patients, with objective findings, what test can we do for Overuse/Overload? What would it reproduce?
- Eccentric Step-down Test
- Reproduction of Anterior Knee Pain
If there is an absence of increased load from the subjective Hx and they are complaining of the peri/retropatellar knee pain what can the primary impairment be related to? How can this be identified, what test?
Patellofemoral Pain with Movement Coordination Deficit
Can be identifed by:
- Dynamic valgus on lateral step down Test
- Frontal plane valgus during single leg squat Test
With Patellofemoral pain with Mobilty Deficits, what Objective Finds would we see?
AROM
- Hip IR and ER limited
We would do Foot Mobility Testing
Hypomobility
- Patellar Tilt Test of Lateral Pateller Retinaculum
MLTs
- Hamstrings - SLR
- Gastroc
- Soleus
- Quads
- IT : Ober’s Test
With these patients, what would be done for Interventions?
(Patellofemoral syndrome)
- Exercise therapy with combined hip and knee targeted exercises
- Patellar taping
- Foot orthoses - short-term use
- Patellar Mobilizations with exercise
- Lower limb stretching
- Patient education
- Run gait rand movement retraining
With these patients, what Interventions do we not do?
- EMG based biofeedback to Medial Vastii
- Visual feedback
- Dry needling
- Biophysical Agents:
-Ultrasound, Cryotherapy, Phonphoresis, Lontophoresis, Laser
-Electrical Stim
What is Sinding-Larson-Johansson Syndrome and Osgood-Schlatter Disease?
- Sinding-Larson-Johansson Syndrome: An apophysitis of the inferior pole of the patella
- Osgood-Schlatter Disease: An apophysitis of the tibial tuberosity
Both occur in skeletally immature individuals, especially those involved in sports requiring repetitive-loaded knee flexion.
-P! is usually reported using the knee in athletics,cycling or resisted knee extension activities.
-The involved area is tender and usualy prominent on physical exam
Pg. 988
What is Turf Knee/Wrestler’s Knee?
This is an injury to the soft tissue overlying the knee. Its caused by a shearing mechanism within the subcutaneous tissues
- This injury usually responds well to rest and avoidance of the aggravating trauma
During the Review of Systems and Systems Review, what can cause pain at the foot?
- Neighboring joints
- Non MSK conditions
With the Medical Screen, what are the systemic conditions we should look out for?
- Peripheral Artery Disease (PAD)
- Peripheral Neuropathy
- Gout
- Compartmental Syndrome (Anterior Compartment Syndrome)
- Deep Vein Thrombosis
With the Medical Screen, what fractures should we look out for?
- Fibular Shaft
- Malleolar Fracture (Uni-, Bi-, and Tri-)
- Talus
- Calcaneus
- 5th Metatarsal
Med Screen
With Peripheral Artery Disease, what are the Risk Factors? What can cause this?
This is a slow progressing circulatory disorder
Risk Factors
- Modifiable: CAD, DM, Smoking, Obesity, High cholesterol, Physical inactivity
- Non-Modifiable: Age > 50, Male, Postmenopausal Female, Family Hx of HTN, and High Cholesterol
Causes
- Atherosclerosis, Acute Trauma to Vessels, infection
What are the S/S of Peripheral Artery Disease?
- Asymptomatic
- Intermittent Claudication (Diff Dx: Neurogenic Claudication)
- Trophic Changes
-Hair loss, shiny skin, thick nails - Cool skin temp.
- Weak/absent pulse
- Slow or nonhealing wounds
- Slow capillary refill
What is typically done during the Peripheral Arterial Disease Physical Examination?
Ankle-Brachial Index
- Ankle SBP / Arm SBP
-≤0.90 = PAD (Diagnostic criteria)
Med Screen
What are the Risk Factors for Peripheral Neuropathy?
- Age > 55
- Type 1 and 2 DM
- Chemotherapy
- Long-term Alcohol consumption
- Meds:
-HIV/AIDS
-Fluroquinolones (antibiotic)
With Perihpheral Neuropathy, what can a Sensory Neuropathy increase risk of?
Risk of minor cuts going unnoticed
- Infecion, unhealing ulcers
With Perihpheral Neuropathy, what can a Motor Neuropathy increase risk of?
Risk of muscle imbalances and atrophy
With Perihpheral Neuropathy, what can a Autonomic Neuropathy increase risk of?
Leads to decreased sweating and sebaceous oil production
- Dry, cracked skin
What is typically done during the Peripheral Neuropathy Physical Examination?
Test Sensation
- Light touch or monofilament, pin-prick, vibration with 128Hz tuning fork
-DM - Vibration and monofilament
When to do which tests:
Light Touch = Nerve Irritation
Sharp/Dull = Sensation issues
With Peripheral Neuropathy, what can be done as Interventions?
- Daily feet washing in warm water
-Do no soak feet - Daily inspection for cuts, bruises, blisters, calluses and swelling
-Mirror training as indicated - Regular nail inspection and trimming
- Avoid walking barefoot/socks
- Daily exercises that minimize impact forces
-Bike, swimming - Smoking cessation
Med Screen
What is Gout?
Acute Inflammatory Arthritis
- Accumulation of monosodium urate crystals in synovial fluid
- Affects one joint at a time
- 1st MTP most common
With Gout, what are the S/S?
- Severe joint pain
- Warmth and Redness
- Difficulty weight bearing and walking
- Symptoms resolve within 2 weeks
With Gout, what are the Risk Factors?
- Male
- Age > 40
- High-Purine diet
- Family Hx of gout
- Hx of flare ups
Med Screen
What is Compartment Syndrome?
Compartmental Increase in tissue pressure due to sustained exercise resulting in pain
- Pain associated with affected compartment
With Compartment Syndrome, what are the effects with exercise?
Pain increases with heavy exercise and ceases when activity is stopped
- Exercise increases interstitial fluid combined with limited expanding fascia
- Increase intramuscular pressure results in capillary collapse, hypoxia and cell death
With Compartment Syndrome, what are the 5 Ps?
- Pain (Disproportionate)
- Paralysis
- Paresthesia
- Pallor
- Pulselessness
With Compartment Syndrome, what happens if the Anterior Compartment is affeected?
Emergent Fasciotomy required
Med Screen
What is Deep Vein Thrombosis? Which DVT is the most life threatening
Blood Clot of the Venous System
- Proximal = Popliteal or Thigh Veins
- Distal = Calf Veins
Proximal DVT is most life threatening
- Pulmonary Embolism
What are the Risk Factors for DVT?
- Age > 60
- Bed Rest
- CHF
- Indwelling Catheters
- Long-distance travel
- Major trauma/surgery
- Obesity
- Smoking
- Hx of stroke
- Pregnant and post-partem
- African Amercian
Also drugs: Contraceptive agents, hormone replacements in post-menopaual women, antidepressants, glucocorticoids steroids
What are the S/S of DVT?
- Acute calf pain and/or tenderness
- Swelling with pitting edema
- Increased skin temp
- (+) Homan’s Sign
- Calf redness/discoloration
- Superficial venous distention or cyanosis
What is the Clinical Descision Rule for OP Suspected Proximal DVT?
If ≥ 2, Refer to imaging
With DVTs, what are the Non-Pharmacological Interventions?
Reverse effects of immobilization
- Ankle/foot exercises and compression stockings
With DVTs, what are the Surgical Interventions?
Inferiro Vena Cava Filters (Greenfield)
- Anticoagulation therapy is contraindicated, not tolerated well or failed
With Fractures, what will be found in the Systems Review?
- Pain, swelling, obvious deformity, acute trauma/MOI
- Immediate and continuous inability to bear weight
- Nocturnal Pain
- Gross Pain with ankle valgus and tenderness to distal fibula
-Distal Fibular fracture
What are the Ottawa Ankle Rules for the foot/ankle?
Ottawa ankle rules for ankle x-rays, are indicated to rule out an ankle fracture when there is bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia and an inability to bear weight immediately after injury.
What is a Unimalleolar Fracture?
Most common ankle fracture
- Below talocrural joint is the most stable
What is a Bimalleolar Fracture?
This is a fracture of both fibular and tibia
- MOI: Severe Pronation, Abduction, ER force
What is a Trimalleolar Fracture?
Fracture of Medial, Lateral, and “Posterior” Malleoli
- MOI: Abduction and Severe ER force
What is a Fibular Shaft Fracture?
- Direct blow/trauma; Forced soleus muscle contraction
- Stress fracture from running
What is a Talus Fracture?
- Fx of the head, neck or body of talus
- MOI: High-energy axial load with foot in PF or excessive DF
What is the MOI of Calcaneal Fracture? How is it tested?
Older individual- Jumping/landing on calcaneous
- Calcaneus squeeze test
What is the 5th Metatarsal Fracture? What are the 3 zones?
Most Fractured Metatarsal of the foot
- MOI: Foot forcible twisted or rolled inwards
3 Zones:
- Tuberosity Avulsion
- Jones Fracture
- Stress Fracture
What is Plantar Fasciitis?
Heel pain that results from pathology
- A painful condition due to repetitive overload of the tissue
Most common condition treated by healthcare providers
What is the most common location for those with heel pain due to Plantar Fasciitis?
At the insertion of the Central Band of the Plantar Fascia at the Medial Plantar Tubercle of at the medial heel
- less commonly individuals may present with the pai located along the mid portion of the central band, just prior to its splitting into the 5 slips that go to the toes
What are the Risk Factors for those with Plantar Fasciitis?
- BMI > 30
- Mechanical Overload
-Running
-Prolonged standing activities - Abnormal foot posture
- Decreased ankle DF
What is the DD for Plantar Fasciits?
- Inflammatory Spndyloarthropathy
- Fat Pad syndrome
-Calcaneal stress fracture - Tumors
- Infection
- Primary Neuropathic mechanisms
-S1 Radiculopathy
-Tarsal tunnel syndrome
-Lateral Plantar nerve impingement
With patients with Plantar Fasciitis, what may you hear in the history?
- Plantar heel pain
-1st step after inactivity or with prolonged weight bearing - Recent increase in physical activity/demand
With patients with Plantar Fasciitis, what may you find in the Obervation?
- Abnormal foot posture (Foot Posture Index -6)
-Supination/Pronation/Weak foot intrinsics - Leg Length Discrepancy
With patients with Plantar Fasciitis, what may you find in the ROM Testing?
- A/PROM limited DF
-limited 1st MTP extension - Mid-Range Isometric Testing
-Strong/Pain-Free
With patients with Plantar Fasciitis, what examination findings may you find with palpations?
- Localized pain at medial plantar tubercle of calcaneus
- Midportion of central band
With patients with Plantar Fasciitis, what examination findings may you find with Special Test?
- (+) Windlass Test
- (-) Neuro Finding
-Tinel’s at Tarsal Tunnel
-DF-Eversion Test
What can be done for interventions for Plantar Fasciitis?
Strong Evidence
- Therapeutic Exercise
-Plantar Fascia Specific Stretch
-Gastroc/Soleus Stretch - Manual Therapy
- Taping
- Night Splints
Moderate Evidence
- Low level laser
- Dry needling
- Strengthening/Neuromuscular re-education
With these patients, what may you find in the history?
(Ankle mob def)
- Insidious onset or prior trauma
-Rotational injury - Limited motion, stiffness, and pain
- Gradually worsening
Patients with ankle/foot mobility deficits, what will you find during the Physical Examination?
- Limited A/PROM
- Hypomobility
- Abnormal pronation/supination foot posture
- Muscle performance (Strength/endurance/power)
What are some areas that a person can get OA in the Foot/Ankle?
- Ankle
- Midfoot
-2nd Cuneform-Metatarsal
-Talo-navicular
-Naviculo-cuneiform
-1st cuneiform-metatarsal - Forefoot
-1 MTP
When considering Ankle/Foot OA, what should we rule out?
- Red Flags
- Sx from neighboring body regions
-Lumbar P! with radiating p!
-Hip and knee
-Neurologic (SLR/Slump Test)
What are significant Exam findings we will see with Ankle/Foot OA?
- Transient Morning stiffness
- Pain worse at beginning and end of physical activity
- AROM = PROM
- Hypomobility w/ crepitus/grinding with joint mobility test
-Hard End-feel - (+) Grind Test
What is Tarsal Coalition?
An Autosomal Dominant trait disorder, that results in the congenital fusion of 2 or more bones in the hind or mid foot
- Most Common
-Calcaneonavicular and Talocalcaneal Coalition
What are the Risk Factors of Tarsal Coalition?
- Male
- Age
-8-12 Calcaneonavicular coalition
-12-16 talocalaneal coalition
Those patient with tarsal coalition, what may we hear in the history?
- Vague pain
-Mid/Hind foot - Hx of Ankle sprains
- Sx exacerbated with activities of Athletic training
Those patient with tarsal coalition, what may we find in ROM Testing?
- A/PROM limited (especially to the affected articulations)
Those patient with tarsal coalition, what may we find in Joint Integrity Testing?
Hypomobility or Fusion (Hard end-feel)
What is Hallux Limitus/Rigidus? What is the difference between them?
A degenerative disorder resulting in loss of sagittal plane ROM, in particular DF
- Hallux Limitus = Chronic Hypomobility
- Hallus Rigidus = Auto-fusion of 1st MTP
@ least 45-60° extension needed for gait
What are the Risk Factors for Hallux Limitus/Rigidus?
- Abnormal pronated foot posture
- 1st ray hypomobility
- Family hx
- Obesity
- Improper footwear
The first ray is a single foot segment consisting of the first metatarsal and first cuneiform bones
With those patients with Hallux Limitus/Rigidus what are may we find during the exam?
- Decreased P! motion of 1st MTP
-Decreased tolderance to wearing constrictive footwear and performing heel raises - Reports of swelling, pain with walking/running uphill, climbing stairs, during gait push off
With those patients with Hallux Limitus/Rigidus what are some Key Findings during the Examination?
- Limited and painful 1st MTP ROM
- Decreased accessory mobility of 1 ray
- Painful palpation of osteophytes on dorsal aspect of 1st MTP
For Special Test
- Axial Grind test for articular cartilage involvement
What is Hallux Valgus?
This is a deformity of the 1st Metatarsophalangeal joint
- This results in medial deviation of the 1st metatarsal, with simultaneou lateral deviation of the proximal phalanx
What are the Prevalence/Risk factors for Hallux Valgus?
Prevalence
- Women > Men
- Women ages 18 - < 65
Risk Factors
- Obesity
- Tight foot wear/high heels
Individuals with Hallus Valgus tend to develop what?
A Bunion on the medial side of the first MTP jont
Those patient with Hallux Valgus, what are common findings during the examination?
(Posture, ROM, jt integ)
Posture
- Abnormal pronated foot posture
- Great toe valgus deformity
- bunion
ROM
- Limited 1st MTP
- Limited ankle DF
Joint integrity/mobility test
- 1st MTP hypomobile
- Midfoot and rearfoot limitations
What is Hammer Toe?
When there is Mild Extension of the MTP and Hyperflexion of the PIP
What is Mallet Toe?
When there is Normal MTP and PIP; Hyperflexion of DIP
What is Claw Toe?
When there is Hyperextension of MTP; Hyperflexion of PIP and DIP
With Mobility Deficity, what are Intervention Strategies?
Manual Therapy:
- Joint mobs
Theraeutic Exercise
- Stretching, strength, endurance, power
- Address abnormal foot posture
Adaptive and assistive technology
- Taping/orthotics/bracing
-Promote normal foot posture
-Reduce stress to affected area
What is the goal for treatment for Tasal Coalition?
To reduce stress in the foot, relax the fibularis muscles and support the foot with orthotics and exercise
With Tarsal Coalition, what may you find in the Physical Examination?
- Limited or no subtalar motion compared to the other foot
- Occasional tight fibularis muscle. Spastic fibularis has been reported
What will you typically hear in the Hx of those patients with this impairment?
- Insidious onset
- Localized pain and swelling
- Pain worse at the beginning and end of physical activity
- Morning stiffness and pain (Worse after activity)
- Relief when stopping painful activity
What is Achilles Tendinopathy?
This is activity-limiting pain located at midportion or insertion of achilles tendon
- Those with midportion achilles pain present with Sx with pain localized between 2-6cm from calcaneal insertion
- Those with Insertional achilles pain present with Sx with pain located within 2cm of insertion
What are the Risk Factors of Achilles Tendinopathy?
- 30-50 years old
- Male
- Sport-specific activities (Rock climbing, soccer, running)
Others:
- Obesity, rigid footwear, prior injury, decreased PF strength, history of fluroquinolones
With the DD of Achilles Tendinopathy, what are Red Flags to look out for?
- Compartment Syndrome
- Deep Vein Thrombosis
- Vascular Insufficiency/Claudication
With the DD of Achilles Tendinopathy, what are the Neuromusculoskeletal Disorders that should be considered?
- Acute Achilles Rupture
-Sensation of “pop” at time of injury
-(+) Thomas Test - Plantar fasciitis
- Lumbar Radiculopathy
- Retrocalcaneal bursitis
With Achilles Tendinopathy, what are Key Objective Findings during the Physical Examination?
- (+) Palpation
-This will help with the Midportion vs. Insertional - (+) Arc Test
- (+) Royal London Hospital Test
- Insertional Tendinopathy may present with Haglund’s deformity
What is the Prognosis for those with Achilles Tendinopathy?
- For Runners:
-Mean time = 82 days of recovery
-May be longer with worse initial Sx - For Elite Male soccer players
-Mean 23 missed days
-Has high recurrence rate
What is Tibialis Posterior Tendinopathy?
A continuum of disorders due to dysfunction of posterior tibialis muscle-tendon unit
- Dutton Def.: A complex disorder of the hind foot, beginning with synovitis, followed by tendinosis, which can potentially culminate in a rupture
What are the Risk Factors for Tibialis Posterior Tendinopathy?
- Middle-aged female (< 40)
- Obesity
- HTN
- DM
- History of steriod use
- Prior trauma
What is the DD for Posterior Tibialis Tendinopathy?
- Lumbar Radiculopathy
- Tarsal Tunnel Syndrome
- Medial Tibial Stress Syndrome
- Flexor Hallucis Longus Tendinopaty
- Medial Ankle Sprain
What is Stage 1 of Tibialis Posterior Tendinopathy?
Weakness, mild swelling, medial ankle/foot pain
What is Stage 2 of Tibialis Posterior Tendinopathy?
Tibialis Posterior Degeneration resulting in lengthening
- Impingement of lateral structures (subtalar joint or calcaneofibular ligament)
- Rearfoot valgus/forefoor abduction {which are associated with an abnormal pronated foot posture}
What is Stage 3 of Tibialis Posterior Tendinopathy?
- Severe medial and lateral pain
- Rearfoot and forefoot abnormal postures become rigid
What is Stage 4 of Tibialis Posterior Tendinopathy?
- Posterior Tibialis Tendon rupture
With Tibialis Posterior Tendinopathy, what is Progressive Collapsing Foot Deformity?
- Progressive loss of Medial Longitudinal arch
-Flexible -> Rigid - Causes Pes Planus
-Abnormal pronated foot posture - Due to Excessive medial ankle/foot tensile loading
With Tibialis Posterior Tendinopathy, what is the Etiology of Progressive Collapsing Foot Deformity?
- Posterior tibialis tendon rupture
- Arthritic changes
- Neuromuscular dysfunction
- Post-traumatic changes
With Tibialis Posterior Tendinopathy, what will you find in the physical examination?
- (+) Muscle performance test and measures
- Single limb heel raise
- P! with palpation at:
-Distal to medial malleolus
-Proximal to medial malleolus
-At muscuolotendinous proximal or distal attachent - Limited DF w/ A/PROM
- Limited talocrural joint
- Outcomes
-Foot Posture Index > 4
What is Medial Tibial Stress Syndrome?
Aka Shin Spints
Posteromedial Tibial Pain that aggravated by activity
- Mostly affects running athletes
What are the two Etiologies liked to the development of Medial Tibial Stress Syndrome?
(Shin Splints)
- Fasciotomy of the insertion sites for muscles like:
-Tibialis Anterior
-Soleus
-Deep Plantar Flexor Muscles - Bony stress injury due to injury of bone formation and resoption of the tibial complex due to repetitive microtrauma
What are the Risk factors for Medial Tibial Stress Syndrome?
Shin splints
- Females
- Obesity
- Abnormal Pronation foot posture
- Greater than normal Hip ER and ankle PF
- Small Q-angle
With Medial Tibial Stress Syndrome, what Differential Diagnosis should we consider?
Red Flags
- Compartment Syndrome
Neuromusculoskeletal Conditions
- Lumbar Radiculopathy
- Tarsal Tunnel Syndrome
- Tendinopathy/Muscle strain
-Tib anterior/posterior, flexor digitorum longus, flexor hallucis longus
With Medial Tibial Stress Syndrome, what would we find in the physical examination?
- Localized pain
-Distal 1/3 of tibia - AROM and Mid-range isometric testing
-DF combined w/ inversion = Tib. Anterior
-PF combined w/ eversion = Deep plantar flexor muscles - Limited ankle DF
-AROM, PROM, and joint mobility testing
Patients with Muscle Performance Deficits, what can be done in terms of interventions during the Acute/Protective Phase?
- Reduce loading
-Limit participation in Agg activities
-Boots, rigid taping, orthotic/wedges - Treat pain and Sx
-Iontophoresis w/ dexamthasone (More for Midportion achilles tendinopathy) - Normalize surrounding mobility and muscle performance (Above and below)
Patients with Muscle Performance Deficits, what can be done in terms of interventions during the Non-Acute stage?
- Continue to address any continued pain/symptoms
- Provide mechanical loading in line of stress
-Achilles tendon
-Fibularis Longus
-Posterior Tib. - Address abnormal pronation/supination foot posture
- Functional training of entire kinetic chain
Patients with Muscle Performance Deficits, Achilles Tendinopathy, what can be done in terms of interventions during the Non-Acute stage?
- Midportion Teninopathy
-Either Eccentric or Heavy load/slow speed (concentric/eccentric) - Insertional Teninopathy
-Benefits from eccentrics in limited ROM
With Ankle/Foot pain with radiating pain, what will we hear in the Hx?
- Sensory Changes
-Shooting, burning, cramping, hyperestesia, paresthesia, anesthesia - Motor Changes
-Weakness paralysis
With Ankle/Foot pain with radiating pain, what is the MOI?
- Direct Trauma
- Insidious
With Ankle/Foot pain with radiating pain, what will we find in the Physical Exam?
(+) Neuromuscular finding
- Segmental vs Peripheral sensation and/or motor changes
- Neural tension/provication
What are the Characteristics of Fibular Nerve Entrapment?
This is the most common compressive neuropathy of LE
- Sx can originate of the Common Fibular or either the Superficial/Deep after the split (Presentation differ)
- Fibular Nerve entrapment has been associated with Surgical interventions, including TKA and High Tibial/Fibula Osteotomies and Knee Dislocations
- Number 1 Cause of Foot Drop
What are the Risk Factors for Fibular Nerve Entrapment?
- Prolonged Crossed Leg Posture
- Recent Weight Loss (~24 lbs)
- Diabetes Mellitus
During the Hx, what may we hear with Patient that are sufforing from Sensory Disturbances from the Common Fibular Nerve?
Disturbances of the entire anterior and lateral leg, dorsum of foot, web spaces of 1st - 5th toes
During the Hx, what may we hear with Patient that are sufforing from Sensory Disturbances from the Superficial Fibular Nerve?
Disturbances of the Distal 1/3 of the lateral lower leg, dorsum of the foot, web spaces of 2nd - 4th toes
During the Hx, what may we hear with Patient that are sufforing from Sensory Disturbances from the Deep Fibular Nerve?
Disturbances of the web space between the 1st and 2nd toes
During the Hx, what may we hear with Patient that are sufforing from Motor Disturbances from Fibular Nerve Entrapment?
- Drop Foot
- Decreased Balance
Those patients with Fibular Nerve Entrapment, what may we find during the Muscle Performance Testing?
Mid-Range Isometric Testing
- Weak and Pain-free
MMT
- Weak to motor innervation
Those patients with Common Fibular Nerve Entrapment, what are common exam findings?
- (+) Tinels at Fibula Neck
- (+) SLR w/ PF and Inversion
Those patients with Superficial Fibular Nerve Entrapment, what are common exam findings?
3 Tests
-Resisted DF and Eversion w/ palpation
-Passive PF and Inversion
-Passive Inversion w/ Tinel’s along course of nerve (5 in proximal to lateral malleolus)
- SLR w/ PF and Inversion
Those patients with Deep Fibular Nerve Entrapment, what are common exam findings?
- Tinels at anterior Tarsal Tunnel w/ ankle in PF and Inversion
- SLR w/ PF and Inversion
What is the Prognosis with Fibular Nerve Entrapment?
- Conservative Treatment First
-Deep Fibular N. > Superficial Fibular N. - Surgery if conservative fails
What is Tarsal Tunnel Syndrome?
This is Compression of the Tibial N. at Medial Ankle
2 Types:
- Proximal Tarsal Tunnel Syndrome
- Distal Tarsal Tunnel Syndrome
What are the Risk Factors for Tarsal Tunnel Syndrome?
- Age 25-50
- Trauma
- Repetitive Stress
-Pronation and Ankle DF - Rheumatoid Arthritis
- DM
With Tarsal Tunnel Syndrome, what are the DD that we must consider?
- Plantar Fasciitis
- Lumbosacral Radiculopathy
- Morton’s Neuroma
- Tendinopathies
-Tib. Posterior
-Flexor Hallucis Longus - Medial Tibial Stress Syndrome
- Systemic Disease (Gout, RA)
- Tumor
With Tarsal Tunnel Syndrome, what is the most common site of Entrapment?
Beneath the Flexor Retinaculum, before it splits into its medial and lateral plantar branches
What are the Primary Complains with those with Tarsal Tunnel Syndrome?
Vague pain and/or Neuropathic Sx to the regions of the Medial Malleolus; Medial Arch; Plantar foot and toes
With Tarsal Tunnel Syndrome, what are the Exam Findings we’ll see?
- (+) Dorsiflexion-Eversion Test
- (+) Tinel’s Sign
What is Distal Tarsal Tunnel Syndrome?
This is a compression syndrome of the Distal branches of the tibial nerve. Either the Medial or Lateral Plantar Nerves can become compressed
- When the Medial Plantar Nerve is implicated this is knowns as Joggers Foot
- When the Lateral Plantar Nerve is implicated this is known as Baxter’s Foot
With Distal Tarsal Tunnel Syndrome, what is Joggers Foot?
Compression of the Medial Plantar Nerve
This occurs due to compression in 1 or 2 sites:
- 1st site: Between the Fascia of the Abductor Hallucis and Quadratus Plantae Muscles
- 2nd site: Within the Tarsal Tunnel, Under the Knot of Henry, which is the place that the tendons of Flexor Hallucis Longus and Flexor Digitorum Longus cross in the Flexor Retinaculum
With Distal Tarsal Tunnel Syndrome, what is Baxter’s Nerve?
Compression of the Lateral Plantar Nerve, more specifically the first branch of the Lateral Plantar N.
- This is Primarily a Motor Nerve (supplying innervation to Abd Digiti Minimi (Sensory to periosteum of the calcaneus and long plantar lig.)
Compression can occur at:
- 1st site: Between the Fascia of the Abductor Hallucis and Quadratus Plantae Muscles
- 2nd site: Between Flexor Digitorum Brevis and Calcaneus
What are the Primary Complains with those with Joggers Foot (Med. Plantar N.)?
Vague pain worse with activity
- 1st - 3rd toes, medial heel, medial arch
What motions compress the Medial Plantar Nerve under Abductor Hallucis M?
Heel Raises and Ankle Eversion
With what population will you see Jogger’s Foot (Med. Plantar N.) more often?
- Long Distance Runners or those individuals that perform a lot of repetitive loading through their heels
-They may display abnormal pronated foot postures, like hyper-pronation, rearfoot valgus or pes planus with associated abnormal running mechanics
What are the Primary Exam Findings with Baxter’s Nerve (Lateral Plantar N.)?
- Chronic medial heel pain without sensory disturbances
(Due to compression of the 1st branch) - Pain to deep palpation to abductor hallucis, this radiates proximal and/or distal
- (+) Tinel’s sign at Abductor hallucis
- Abductor Digiti Minimi weakness (In advanced cases)
With the Prognosis of Tarsal Tunnel Syndrome, what is the difference between Surgical Management with Proximal and Distal Tarsal Tunnel Syndrome?
Proximal Tarsal Tunnel Syndrome
- Outcomes are best if they are provided before Sx have been present for a year
- These have the best outcomes when the cause of the neuropathy is entrapment due to space-occupying lesion
Distal Tarsal Tunnel Syndrome
- Outcomes are not as good, therefore recommended to hold off of surgery as long as possible
What are the Risk Factors for Morton’s Neuroma?
- Middle-aged women
- Runners, dancers
- Narrow shoes
- Abnormal foot postures/mechanics
What is Morton’s Neuroma?
This is a mechanical entrapment of one of the interdigital nerves in the foot
- The nerves develop non-neoplastic fibrotic or degenerative lesions that results in forefoot pain and disability
- Typically affects the 3rd digitial nerve (between 3rd and 4th toes); followed closely by the 2nd digital nerve (between the 2nd and 3rd toes)
Whats the DD for Mortons Neuroma we should consider?
- Lumbar, hip, knee referral
- Tarsal Tunnel Syndrome
- OA
- MTP Strain
- MTP Synovitis
- Stress Fx
With Morton’s Neuroma, what will we hear in the Hx?
- Plantar forefoot pain
- Worse with activity; better with rest
-P! with Weightbearing - Worse when wearing tight/narrow shoes
With Morton’s Neuroma, what will we find in the Physical Examination?
ROM
- P! MTP extension
Joint Integ. and Mobility
- MTP dorsal glide hypermobility
Muscle Performance
- Intrinsic Muscle strength deficits
Special Test
- (+) Squeeze test with Mulder’s Sign
What are the Intervention Strateiges for Radiating Pain?
- Activity Modification
- Braces, Orthotics, Taping, Footwear
- Soft tissue mobilizations
- Joint mobs/manipulations
- Therapeutic exercise and/or neuromuscular re-education
-Address abnormal ankle/foot posture/mechanices
-Improve ankle/foot stability
What are the Intervention Strateiges for Tarsal Tunnel?
Tarsal Tunnel has the largest cross section area when the ankle is in a neutral position (slight PF, midway bewteen inversion and eversion)
- So braces and supports that help maintain an ankle neutral position are recommended strategies for Proximal Tarsal Tunnel Syndrome
- For Distal Tarsal Tunnel Syndrome, Heel Pads may protect the medial and lateral plantar nerves from excessive compressive forces
What are the Intervention Strateiges for Morton’s Neuroma?
- Changes to wider shoes with improved shock absoprtion
- Metatarsal pads proximal to symptomatic area
With Movement Coordination Impairments, what will we hear in the Hx?
- Recent Trauma
-MOI: Inversion, Eversion, Rotational Injury - Pop or Snap
- Localized Pain
With Movement Coordination Impairments, what will find with Joint Integrity and Mobility?
This will depend on the severity of the injury
- Grade 1: Pain with normal mobility
- Grade 2: Pain with hypermobility
- Grade 3: Pain-Free with Hypermobility
With Ankle Sprains, what are common sports that deal with Ankle Sprains?
- Basketball
- Football
- Soccer
With Ankle Sprains, what are the Risk Factors?
{Intrinsic vs Extrinsic Factors}
Intrinsic Factors
- Age 15-19
- Female
- Body Composition (Lower body mass)
- Physical Fitness (Weak Hip Abd and ER strength)
- Limited ankle DF
Extrinsic Factors
- Specific sports (Indoor and court sports
- Level of competition
With Ankle Sprains, what is the DD that we should consider?
Fx including Avulsion Fx’s
- Ottowa Ankle Rules
- Malleolar Fx
- Fibular
- Talar Fx
Tendinopathy
- Fibularis Longus/Brevis
- Posterior Tib.; Flexor Hallucis Longus; Flexor Digitorum Longus
Neuropraxia
- Posterior Tib. N.
With Lateral Ankle Sprains, what will we find in the Physical Exam?
Observation
- If acute = Redness, warmth, swelling
ROM
- A/PROM = P! Inversion and PF
- Limited DF
Resistive
- Strong and Painless
Joint Integ.
- Anterior Talar Glide
-Normal or hypermobile
-Painless or painful
- Hypomobile Posterior Glide w/ associated loss of DF
With Lateral Ankle Sprains, what will we find with Palpation and Special Test??
Palpation
- Painful and tenderness over affected ligament(s)
Special Test
- (+) Anterior Drawer
- (+) Talar Tilt
With Medial Ankle Sprains, what will we find in the Physical Exam?
Observation
- If acute = Redness, warmth, swelling
ROM
- A/PROM = P! Eversion
Resistive
- Strong and Painless
Joint Integ.
- Talar Glides
-Normal or hypermobile
-Painless or painful
- Hypomobile Posterior Glide w/ associated loss of DF
With Medial Ankle Sprains, what will we find with Palpation and Special Test??
Palpation
- Painful and tenderness over affected ligament(s)
Special Test
- (+) Kleiger (ER) Test
With High Ankle Sprains, what will we find in the Physical Exam?
Observation
- If acute = Redness, warmth, swelling
ROM
- A/PROM = P! DF and combined DF and Eversion
Resistive
- Strong and Painless
Joint Integ.
- Distal Tibiofibular Accessory Motion
-Pain
-Talar Glides
- Normal and Painless
With High Ankle Sprains, what will we find with Palpation and Special Test??
Palpation
- Painful and tenderness over affected ligament(s)
Special Test
- (+) Kleiger (ER) Test
- (+) Squeeze Test
What is the Prognosis of Ankle Sprains?
- Lateral Ankle Sprain, have High Recurrence Rates
- High Ankle Sprains, take 2-20 times longer
- Severity of Injury, West Point Ankle Sprain Grading System
What are Lisfranc Complex Injuries?
Injury to the Tarsometatarsal Articuations
- This can range from a Grade 1 sprain to a dislocation
Lisfranc Ligament Proper is a group of 3 ligaments located between the medial cuneiform and second metatarsal
What is the MOI for Lisfrac Injuries?
- Axial Load through supinated foot
- MVA, fall from height (greater than 3 meters), sport injuries
- More common with males
What is the DD of Lisfranc Injuries that we should consider?
- Midfoot Fx
- Cuboid Fx
- Navicular Compression Injury
- Tibialis Posterior Tendon Dysfunction
Rare:
- Dorsal Pedal injury
- Deep Fibular nerve injury
With Lisfranc Injuries, what may we Observe during the physical examination?
- Swelling and Pain in midfoot
- Difficulty walking/weightbearing
- Gap Sign {Visable separation between the first and second matatarsals in weight bearing}
-Plantar Ecchymosis
With Lisfranc Injuries, what may we find during the physical examination?
Joint Mob./Integrity
- Painful mobility testing
- Mobility differences
Palpation
- Localized tenderness to affected structures
What is the Prognosis for Lisfrac Injuries?
Mild Injuries
- 4-6 weeks
- Return to sport = longer
NFL Players
- 27 weeks post-injury
Surgical Repair
- If unstable and if the gap sign is > 2 mm
What is Turf Toe?
This is a Hyperextension Injury to the 1st MTP
- Most commonly occurs when the running athlete’s shoe sticks to the ground when trying to stop
What are the Risk Factors for Turf Toe?
- Running sports with stops and starts
- Collision sports
- Flexible footwear
-Artificial Turf - > 78° of 1st MTP Extension
What is the DD of Turf Toe we must consider?
- Gout
- Sesamoidits
- Morton’s Neuroma
- Metatarsalgia
With Turf Toe, what will we find during the Physical Examination?
Observation
- Swelling and Eccymosis
ROM
- Limited and painful 1st MTP (due to muscle guarding)
Joint integ. and Mobility
- Painful accessory motion
- Hypermobility in more severe injuries
Palpation
- Localized pain
Gait
- Painful push-off
What is the Prognosis for Turf Toe?
- Conservative Mangagement indicated
- Return to running/sport-specific activities
-2-6 weeks - Goals:
-1st MTP Extension = 60°
-Painfree heel raises
What is the treatment approach during the Inflammatory Phase of Healing?
- Protect injured tissue
-Boots, braces, rigid taping, ADs - ROM in pain-free directions and ranges
- Maintain ROM and muscle performance to surrounding regions
What is the treatment approach during the Proliferation/Repair Phase of Healing?
- Controlled ROM
-Optimal loading - Therapeutic exercise
What is the treatment approach during the Remodeling/Maturation Phase of Healing?
- Progressive exercise program to include entire kinetic chain
- Return to running and sport specific activities
