Exam 2 Flashcards
Hilton’s Law
the nerve supplying the muscles extending directly across and acting at a give joint also innervate the joint
What are the ABC’s of imaging in regards to the hip?
- Neck-shaft angle (femoral antero-/retroversion)
- Bone disease
- Joint spaces (cortical bone)
How much joint space loss is clinically significant in the hip?
.5mm
Red Flags for Systemic Origins of Hip and Groin Pain
- spinal metastases
- primary bone tumors (ie Ewing’s sarcoma)
- iliopsoas abscess
- pelvic inflammatory disease (PID)
- Crohn’s disease
- Reiter’s syndrome/ankylosing spondylitis
- arterial insufficiency
- kidney stoes
What are possible musculoskeletal diagnoses for hip and groin pain?
- hernia
- trochanteric bursitis/snapping hip
- sciatic disorder/radiculopathy
- piriformis syndrome
- SI joint pathology
- iliac apophysitis
- fractures (avulsion, metastatic, stress)
What are two ways to categorize hip pathologies?
- age/lifespan
- mechanism of injury
Hip disorders under the age of 18 years
- congenital hip dislocation (birth - 6 mos.); 28-48 (bi-modal distribution)
- transient synovitis/Perthes disease (males: 3-10)
- Tuberculosis (3-18)
- Still’s disease (JRA); 6-13
- infective arthritis (4-18)
- slipped capital femoral epiphysis (male: 8-12)
Hip disorders over the age of 18 years
- ankylosing spondylitis (18-38: age at onset)
- Reiter’s syndrome
- pelvis inflammatory disease and low back strain (19-52)
- rheumatoid arthritis and secondary OA (24-55)
- primary OA, femoral neck fractures, and 2˚ bone tumors
Risk factors for the development of congenital hip dislocation
- positive family history
- breech presentation at birth
- congenital postural deformities
- persistent click in a stable hip
- births by c-section
- fetal growth retardation
Risk factors for the development of congenital hip dislocation
- positive family history
- breech presentation at birth
- congenital postural deformities
- persistent click in a stable hip
- births by c-section
- fetal growth retardation
Signs of congenital hip dislocation
- Galeazzi sign
- Barlow’s test
- passive dislocation
- Ortolani manuever
What are the methods of CHD treatment?
- Frejka pillows
- Pavlik harness
Shenton’s line
smooth curve line from medial edge of femur continuing upward along inferior edge of pubis
Nelaton’s line
line drawn from ischial tuberosity to ASIS of same pelvis; indicates hip dislocation or coxa vara
Bryant’s triangle
- vertical line perpendicular from ASIS to examination table
- horizontal line from tip of greater trochanter perpendicular to vertical line above
- indicates congenital hip dislocation or coxa vara
Late CHD treatment
- osteotomies (salter, chiari, and giant shelf)
- arthrodesis
- total hip arthroplasty
Adolescent hip conditions
- slipped capital femoral epiphysis
- Legg-Calves-Pethes disease
- acquired (ie fractures)
Slipped Capital Femoral Epiphysis
- often in males 12-15 years of age
- slippage of femoral capital epiphysis off the femoral neck
- main complaint of groin pain (intermittent and gradual)
- limited IR and adduction
Treatment for slipped capital femoral epiphysis
- surgical treatment
- stabilize epiphysis on femoral neck
- strong screw fixation thru femoral neck to affix femoral head
Signs and Symptoms of Legg-Calves-Perthes disease
- pain in the hip with common referral to the thigh and knee
- Trendelenburg gait
- Limited hip ROM (esp IR and ABD)
What are the four LCP classification systems?
- Waldenström
- Catterall
- Salter & Thompson
- Herring
Treatment for Legg-Calves-Perthes disease
- surgical: osteotomy
- conservative: bracing/casting, pain-free ROM, isometric strengthening
Acquired adolescent hip injuries
- apophysitis
- fracture
*potential sites include the ASIS, ischial tuberosity, and severe HS tear
Signs and symptoms of acquired adolescent hip injuries
- pain
- swelling
- point tenderness
- recent growth spurt
- significant increase in level of activity or participation
Treatment for acquired adolescent hip injuries
- surgical in rare cases
- physical therapy aimed at strengthening, cautious stretching, modalities, and functional progression
Types of traumatic hip dislocations
- posterior without fracture
- posterior with fracture
- anterior
- anterior with fracture
- central fracture dislocations
Mechanism of injury for posterior hip dislocation without fracture
- force along femoral shaft with hip in flexion/adduction
- dashboard or fall on flexed knee
*Rads exhibit femoral head above acetabulum
Treatment of posterior hip dislocation without fracture
- emergent situation
- closed reduction with brief anesthesia
- Goal: minimize femoral head and neck vessel trauma
Posterior hip dislocation with fracture
- 50% with posterior dislocation fracture the posterior acetabular lip
- surgical indications: remove loose bony fragments, restore joint stability, and congruity
- accurate reduction
Complications following posterior hip dislocation with and without fracture
- avascular necrosis of femoral head and neck
- sciatic nerve lesion (peroneal > tibial nerve division)
- DJD (late)
Mechanism of injury for anterior hip dislocation without fracture
- violent injury forces hip into ext, abd, and ER
- mush less common
- rads show femoral head below the acetabulum
- closed reduction
- complications include neurovascular compromise (NAVL)
Anterior hip dislocations with fracture
- fracture of femoral head
- closed reduction
- complications include DJD, aseptic necrosis, and recurrent dislocations
Mechanism of injury for central fracture-dislocations
-severe blow to lateral hip (i.e. MVA); drives head of femur into acetabular wall
Treatment for central fracture-dislocations
- closed reduction with continuous traction
- possible THR or acetabular replacement
- Post-traumatic DJD is a potential “late” complication
What are the two types of femoral stress fractures?
- fatigue - repetitive prolonged stress on otherwise normal bone
- insufficiency - normal stresses on abnormal bone
What are the two types of stress fractures?
compression and distraction
What are the three sites for compression stress fractures?
- calcaneus
- medial tibial plateau
- mid-tibia
What are the four sites for distraction stress fractures?
- metatarsal shaft
- femoral neck
- pars interarticularis (lumbar spine)
- pubic ramus
What is the continuum of events resulting in stress fracture?
- causal event, “training error”
- pain after exercise, relieved by short rest
- tolerable pain during exercise, more marked with exercise, relieved with longer rest
- intolerable pain during and after exercise, partially relieved by long rest
- constant pain, no relief with rest
Signs and symptoms of a femoral stress fracture
- point tenderness
- soft tissue swelling
- palpable callus (occurs with healing; only palpable on femoral shaft)
- antalgic gait
- FABER’s test
- femoral bending test (shaft)
- may have + heel pounding test
- radiographs
- bone scan
Treatment for a femoral stress fracture
- crutches
- bed rest
- surgical nailing
- endoprosthesis; THA
- physical therapy
Trochanteric bursitis
- hx of overuse or change in training
- increased pain with stairs
- preceded by low grade LBP
- insidious onset
- pseudo-radicular symptoms
Physical findings of trochanteric bursitis
- normal back exam
- site of tenderness (may decrease w/ spread of stimulus)
- pain with resisted hip abduction
- hip abductor weakness
- Ober’s sign (IT band tightness)
Treatment of trochanteric bursitis
- ice
- iontophoresis
- NSAIDs
- NMES to gluteals
- US
- IT band stretching (PT and pt.)
- gluteal strengthening (≤ 3 wks.)
- external rotator strengthening (≤ 3 wks.)
Ischiogluteal bursitis
hx of prolonged sitting (driving, bleachers, etc.)
Physical exam findings of ischiogluteal bursitis
- normal low back exam
- full hip ROM
- (-) neurotension signs, but pain referred down the leg
- pain relieved with standing
Treatment for ischiogluteal bursitis
- modalities (ionto, US, ice)
- doughnut cushion
- stretching and strengthening as indicated
Piriformis Syndrome
- insidious onset
- may have radicular-type symptoms
Physical findings of piriformis syndrome
- normal back exam
- tight hip IR
- site of tenderness
- (+) piriformis sign
- (+) FADER test
Treatment for piriformis syndrome
- modalities
- hip stretching
- PNF techniques
Meralgia Parasthetica
usually following surgery; scar begins to encircle the lateral femoral cutaneous n. resulting in pain; cicatrix
Snapping Hip Syndrome
generally involved IT band over greater trochanter, but may also involve the iliopsoas tendon
the iliopsoas tendon shifts laterally in relation to the center of the femoral head during hip flexion, then shifts medially in relation to the center of the femoral head during hip extension
Etiology of snapping hip syndrome
- loose bodies
- hip subluxation
- synovial chondromatosis
- osteocartilaginous exostosis
Clinical signs and symptoms of snapping hip syndrome
- insidious onset
- painful popping of the hip
- audible click
- palpation unremarkable
Treatment for snapping hip syndrome
- restore normal ROM and strength
- activity modifications
- appropriate flexibility exercises
Femoral acetabular impingement
occurs when there is decreased joint clearance between the femur and acetabulum; can be cam or pincer impingement; associated with onset of hip OA
Similar impingement noted after THA
Cam Impingement
occurs when the femoral head has abnormally large radius - leads to loss of normal spherical junction between femoral head and neck; abnormal contact between femur and acetabulum with flexion, add, and IR; implicated in loss of antero-superior labral and chondral lesions; more common in young athletic males (22-42 yoa.)
Pincer Impingement
occurs when there is abnormal acetabulum with increased overcoverage; general (coxa profunda) or local anterior (acetabular retroversion); persistent abutment of femoral head into acetabulum postero-inferior chondral lesions; more common in middle-aged athletic women
Exam findings of femoral acetabular impingement
- (+) Fair test
- Log-roll test
- Cross-over sign on rads
Hip Degeneration
- neoplasm
- arthritis
Causes of hip degeneration
- idiopathic
- post-traumatic degeneration
- avascular necrosis
- long-term steroid use
- familial
Radiographic findings of hip degeneration
- narrowing joint space
- osteophyte formation
- subchondral cysts
Signs and symptoms of hip degeneration
- decreased hip ROM
- impaired gait
- sleep difficulties
- difficulty with active hip flexion
- general hip weakness
- groin pain
- (+) hip scouring and distraction
- adduction test (3 zones)
Treatment for hip degeneration
- NSAIDs
- physical therapy - joint mobs
- activity modification
- THA/THR
Surgical approaches for THA
- posterior
- lateral
- anterolateral
- transtrochanteric
- straight anterior
Materials used for THA
cemented: strong adhesive - methyl methacrolate; allows for early weight bearing
porous-coated: in-growth of bone to adhere; may require initial weight bearing limitations; Wolff’s law
THA Intra-Operative Complications
- anaphylactic reaction to cement
- DVT
- respiratory complications
- loss of blood
- inadvertent femoral shaft fracture
THA “Early” Complications
- ectopic classification
- dislocation of hip
- wound infection, DVT
- leg-length inequality
- femoral/sciatic nerve injury (usually fibular)
THA “Late” Complications
- aseptic loosening
- sepsis
- dislocation
- femoral fracture
- heterotopic ossification
- chronic pain
Post-Op THA Treatment
- mobility - determine weight bearing status; appropriate assistive device
- therapeutic exercise - muscle setting exercises, isometrics, ankle pumps, SLR
- Patient education - hip precautions (motions to avoid), ADL modifications, adaptive equipment
What are the components of functional stability at the knee?
- passive ligamentous restraints
- joint geometry
- muscular restraints
- joint compressive forces
What is the joint geometry like in the knee?
- medial compartment: convex femoral condyle articulates with concave tibial plateau
- lateral compartment: convex femoral condyle articulates with convex tibial plateau
What are the arthrokinematics like in the knee during flexion to extension?
135-75: rolling & gliding
75-20: gliding
20-ext: rolling
*Minimize rotation by staying in the 90˚ to 30˚ range
What dictates ligamentous insertions in the knee?
Burmester curve: ligaments become less effective in different parts of the range
Medial Collateral Ligament
- has both deep & superficial components
- intimate meniscal attachment
- posterior femur to anterior tibia
- taut in extension; lax in flexion
- prevents valgus & helps control ER
Lateral Collateral Ligament
- cord-like
- anterior femur to posterior fibula
- taut in extension - lax in flexion
- limits varus & ER
Cruciate Ligaments
- intra-articular but extrasynovial
- components wind and unwind
- named for TIBIAL attachment
- poor vascularity
- limit A-P but also IR
Anterior Cruciate Ligament
- APEX (anterior-posterior & external attachment)
- meniscal attachments
- limits hyperextension & guies tibial extension
- anterior band is tightest in flexion; posterior band is tightest in extension
Posterior Cruciate Ligament
- PAIN
- shorter and stronger than ACL
- lateral meniscus attachment
- guides tibia in flexion
- binds on ACL in internal rotation
- anterior bulk is tightest in flexion; posterior band is tightest in extension
Ligaments of Wristberg and Humphries
assist the PCL in its function
Menisci
- poor vascularization
- increase joint congruency
- limits abnormal motion
- travel with tibia d/t attachment w/ bone (roots)
- transversal coronary ligaments
Medial Meniscus
- C-shaped
- posterior 1/3 attached to MCL
- posterior horn to semimembranosus
- anterior horn to ACL
Lateral Meniscus
- O-shaped
- weak capsular attachment
- ligaments of Wristberg/Humphries
- popliteus attachment
- mobile attachment: moves 2x as much as medial meniscus (.5 inch)
What are the associated structures of the knee?
- synovium (plica)
- bursae
- fat pads
ACL vs. PCL MOI
- ACL: rotation (IR) AND anterior problem
- PCL: straight posterior problem
ACL vs. PCL problems
- ACL: giving way - instability
- PCL: pain (anterior vs. medial)
ACL vs. PCL loading
- ACL: greater load in flexion; HS are important
- PCL: greater load in extension; quads are important (do not work terminal extension or heavy CKC exercises)
Current trends in ACL reconstruction
- earlier “full” motion and weight bearing but aware of constraints
- ACL emphasis is to CKC - multiple joint rehab but still having an integrative approach
- final return is “function +” - not only a single piece of data (about 9 mos.)
Muscle Response Time During Activity
- slow: up to 1/2 sec (muscles respond = dynamic stab)
- fast: 200-500 msec. (muscle training for dynamic stab)
- sudden: < 150 msec. (no muscle response = static stab)
Weel 1 - ACL Reconstruction
- possible extension brace
- avoid anterior translation
- partial/protected weight bearing
- get extension (some hyper if equal to other side)
- turn on the quads
- assisted ROM/AROM
- ice to control hemarthrosis
- E-stim if inhibition is great
- patellar mobility
Week 2-4 ACL Reconstruction
- AAROM/AROM: 0-90-120
- ice
- progressive weight bearing and gait - partial then full
- free brace as able if using (quad activation - able to absorb - prevent chronic effusion)
Weeks 4-8 ACL Reconstruction
- cycle with seat down slightly
- FWB out of protection - must have normal responses
- Hip extension (knee flexed & extended); prone curls (not if HS graft)
- water walking - not swimming
- balance work
Weeks 8-16 Reconstruction
- push higher velocities
- functional CKC emphasis
- tubing co-contraction is a great adjunct
- submaximal at multiple velocities - often mid ROM emphasis - watch out for maximal - open chain full extension
Weeks 16+ ACL Reconstruction
- functional progression
- forward & backward running on ball of foot
- keep the knee flexed during functional activities
- knee & hip flexion - avoid valgus
- return 9+ mos
Why should you not allow resistive work for 4 weeks following meniscus repair?
trying to protect the meniscus repair
What are the different layers of the cartilage and bone?
- gliding zone
- transitional zone
- radial zone
- tidemark
- calcified zone
- subchondral bone
What are the 16 critical characteristics of the knee?
- protrusion of femoral condyles = 2
- convex curvature of two condyles = 2
- position of ligament attachment points = 2
- concave curvature of two tracks = 2
- position of ligament attachment points (tibia) = 2
- position of ligament attachment points (ACL) = 2
- Length of ACL = 1
- position of ligament attachment points (PCL) = 2
- Length of PCL = 1
16 TOTAL
Surgical or Rehabilitation Complications: Loss of Motion
- Goal: 95˚-100˚ flexion; 0˚ extension or hyperextension
- prolonged stretch/low load
- contract-relax
- manipulation (with/without anesthesia)
- patellar mobilization; tibiofemoral joint mobs
What is the relationship between a flexion contracture, patellofemoral pain, and quad weakness?
- flexion contracture > 5˚ - 24% of patients
- patellofemoral pain present in 19%
- quad weakness (< 80% of normal present in 65% of pts.)
Patellofemoral scar adherence
- infrapatellar contracture syndrome (IPCS)
- mobilize - superior/inferior; medial-lateral
Surgical Complications: Anterior Knee Pain
- increased patellofemoral reaction forces; graft site pain
- treatment (back off)
- iontophoresis
- ice
- quad sets; CKC exercises
- joint mobs
Surgical Complications: Loss of strength
- tourniquet palsy
- neurogenic inflammation
- CRPS (RSD)
- muscle inhibition
Treatment options: patience (3-6 mos.); high amplitude muscle stimulation; EMG biofeedback training; axial loading (CKC exercise)
Surgical Complications: Effusion
- effect on proprioception, muscle function
Treatment: NSAIDs; ice; high-voltage pulsed current; CPM; submaximal isokinetic training
How long does it take for reaction time to return in patients following TKA or LE fracture?
8 weeks
IT Band Friction Syndrome
- affects men > women
- common in people ages 20-40
- training errors: increased mileage; excessive speed work
- hard running shoe
- road camber
- wet pavement surface
IT Band Friction Syndrome: Predisposing factors
- variation in IT band width
- downhill running
- slower running with increased knee flexion at footstrike
Special tests for ITBS
- Noble compression
- Ober’s test
Treatment of ITBS
- palliative (modalities) - caution with US
- stretching
- orthotics
- biomechanical examination
- stop all running for a period of time
Patellofemoral Pain Syndrome
- one of the most common knee problems
- defined as retropatellar or peripatellar pain
- not necessarily “chondromalacia” (actual cartilage damage)
Patellofemoral Pain Syndrome: Contributing Factors
- chronic overuse and overload to joint (most common)
- single-traumatic event (rare)
- excessive foot pronation
- excessive hip IR
- muscular dysfunction - weak quads and/or hip abductors
Signs and Symptoms of Patellofemoral Pain Syndrome
- inferomedial patellar facet pain
- pain up and down stairs
- pain with prolonged sitting
- higher incidence in females
- patellofemoral crepitus
*rarely have joint effusion
Special tests for Patellofemoral Pain Syndrome
- Grind test
- Clarke sign (Chandelier sign)
- Q-angle
- A-angle
- Step-up test
- McConnell test
Patellofemoral Pain Syndrome: Initial Phase
- activity modification
- NSAIDs/modalities
- patellar taping and bracing
Patellofemoral Pain Syndrome: Reactivation Phase
- patellar taping
- patellar mobilization
- soft tissue mobilization (IT band; lateral retinaculum)
- quadriceps strengthening (OKC: avoid excessive ext; CKC: avoid excessive flex)
- hip strengthening (hip extensors, ERs, abductors)
Patellofemoral Pain Syndrome: Maintenance Phase
- normalize gait mechanics
- orthotic management for subtalar joint pronation
- comprehensive home program
Plica Syndrome
- thin wall of fibrous tissue
- remnants of 3 knee cavities during fetal development
- located near medial femoral condyle
- problem only if the synovial sac becomes inflamed
Plica Syndrome: Treatment Options
- NSAIDs
- surgical excision (arthroscopy)
- physical therapy
- “benign neglect”
- modalities
- ice
- quadriceps strengthening
- lower extremity flexibility
*All exercises must be performed in the pain-free range
Pes Anserinus Bursitis Causes
- tight HS may cause increased pressure over the bursa
- direct trauma
- possible irritation from over pronation during running
Pes Anserinus Bursitis
- more prevalent in women
- age (post-menopausal; 50-59)
- exercise-induces (weight reduction)
Pes Anserinus Bursitis Treatment
- rest
- ice
- NSAIDs
- injection
- PT
Pre-Patellar Bursitis
- results from constant friction that irritates the bursa
- inflamed bursa becomes fluid filled
- constant kneelers
- direct blow
- MVA
- patients with RA or gout
Pre-Patellar Bursitis Signs and Sx
- pain with activity
- rapid swelling over the patella
- warmth and tenderness over the bursa
Pre-Patellar Bursitis Treatment
- rest
- activity modification
- ice
- NSAIDs
- PT
- aspiration
- surgical excision
Baker’s Cyst
- popliteal cyst
- fluid-filled bursa located in the posterior knee (light diffusion test)
- associated with OA and RA
Baker’s Cyst Treatment
- rest
- elevation
- ice
- NSAIDs
- aspiration
- corticosteroid injection
- surgical excision
Femoral Shaft Fracture
- fall with the foot in a fixed position in combination with a twisting force
- MVA
- middle 1/3 most common site
- patient unable to lift leg
Femoral Shaft Fracture Treatment
- fixed traction
- skeletal traction (closed reduction)
- ORIF with Kuntscher intramedullary nail
- Exercises: glutes, quads, HS setting; AROM, ankle pumps
Femoral Condyle Fracture
- direct injury
- fall from a height
- may have associated intra-articular ligamentous injury
- hemarthrosis
- unable to move knee 2˚ to pain
- radiographs - “Y” or “T” fracture
Femoral Condyle Fracture Treatment
- skeletal traction (closed reduction)
- 6 weeks CPM (CWB)
- ORIF if skeletal traction fails
- exercises: glutes, quads, HS sets; ankle pumps
Tibial Spine Fracture
- hyper-extension injury
- unable to move knee
- flexed position
- knee effusion
*Requires tunnel view on radiograph
Tibial Spine Fracture Treatment
- ORIF
- closed reduction
Tibial Plateau Fracture
- direct blow
- fall from a height
- commonly to lateral side “bumper fracture”
- knee in extension and slight varus
- common among 50-60 years of age (women > men)
- joint effusion
- patient unable to bend or lift knee
- radiographs; CT is preferred method
What are three options for treatment of a tibial plateau fracture?
- skeletal traction (6 wks), non-weight bearing (12 wks)
- casting, non-weight bearing (12 wks)
- ORIF - plate/screws, weight bearing per MD order
Segond Fracture
- avulsion of the lateral tibial plateau
- indicative of an ACL tear
- MOI: knee flexion in combination with IR
- radiographs: seen only on A-P view and tunnel view
Patellar Fracture
- direct blow: fall, MVA, avulsion with landing/leaping
- swelling
- unable to move knee
Patellar Fracture Classifications
- non-displaced
- comminuted non-displaced
- transverse
- inferior or superior pole
- comminuted displaced (stellate)
- vertical
- osteochondral
Patellar Fracture Treatment
- conservative or surgical
- AROM
- joint mobilization: patellar, tibiofemoral
- quadriceps re-education
- cautiously stretch in the prone position
Osteochondritis Dissecans
- young men
- usually well-muscled
- traumatic/atraumatic
- presentation
- medial meniscus tear is a differential diagnosis
- Wilson test
Treatment for pediatric/adolescent knee conditions
- activity modification
- NSAIDs
- modalities if age appropriate
- strengthening
- stretching
Knee Osteoarthritis
- medial compartment is most commonly affected
- collapse of medial compartment may result in varus deformity
- accompanying knee flexion contracture
- pain brings patients to the physician
Knee Osteoarthritis Clinical History
- usually insidious
- pain ranges from aching to sharp
- increased pain with activity
- night pain at severe stages
- increased knee stiffness
- difficulty with ADLs
Knee Osteoarthritis Management
- NSAIDs
- steroid injections
- “Synvisc” injections
- Assistive device for weight bearing
- Activity modification
- unloading brace (only is uni-compartmental)
- PT (hip and quad strengthening; hip and patellar mobilizations)
Powell’s Angle
- coxa valga: < 125-130˚; associated with knee varus
- coxa vara: > 125-130˚; associated with knee valgus
What are the five types of meniscus tears?
- vertical longitudinal
- oblique
- horizontal cleavage
- radial
- degenerative
What is the breakdown of ankle sprains?
- inversion = 85%
- eversion = 5%
- syndesmosis = 10%
Inversion ankle sprain
- increased supination moment at the subtalar joint
- center of pressure medial to subtalar joint axis
- excessive inversion and internal rotation of the rearfoot
- more laterally deviated subtalar joint axis leads to predisposition to recurrent sprains
- medial displaced COP increased the supination moment arm
*Some pts. may even tear the peroneus longus & brevis
Eversion ankle sprain
- stepping on an object, fall in a hole, or related to kicking in soccer
- excessive eversion with DF
- disruption of deltoid ligament
- commonly results in an avulsion fracture of the medial malleolus
Syndesmotic ankle sprain
- high ankle sprain
- hyper PF
- excessive leg ER on fixed foot
- DF and eversion in combination with tibial internal rotation
- often shows little associated swelling
Special tests for ankle sprains
- anterior drawer
- tilt test
- eversion stress test
- squeeze test
- External rotation test (Kleiger test)
Mechanical instability
- pathologic laxity
- limited DF
- Inability to reach closed packed position during stance
- predisposes subtalar joint to inversion and IR
- fibula position - ant. and inf. position limits DF
- slackness of ATFL
- Synovial hypertrophy or degeneration
Functional instability
- feeling of ankle giving way
- loss of neuromuscular control
- proprioception
- mm weakness
- muscle reaction time
- posture control
What two components are lost in an ankle sprain?
elasticity and negative pressure
How should pressure be applied for an ankle sprain?
continuous, focal, and circumferential
Clinical observations following an ankle sprain
- muscle atrophy
- ambulation pattern
- prolonged recovery time
- preliminary EMG findings
- leg denervation
Treatment for ankle sprains: inflammatory phase
- 0-5 days
- PRICE
- gentle ROM
- pain control
- isometric strengthening
- flexibility (calf & HS)
Treatment for ankle sprains: proliferative phase
- 5-21 days
- gait normalization
- strength restoration
- stabilometry
- balance and postural control
- power and endurance
Treatment for ankle sprains: maturation phase
- > 21 days
- functional progression
- SAID principle
- protection w/ bracing and taping
Ankle sprain radiology
- anteroposterior
- lateral
- mortise (special view) - A-P view in 15-20˚ tibial IR
Charcot-Marie-Toothe disease
- inherited degenerative disorder affecting the central and peripheral nervous system
- characterized by muscle atrophy and proprioception deficits
- autosomal dominant trait
*Can be neural and/or muscular
What is the pattern of muscle wasting observed in Charcot-Marie-Toothe disease?
intrinsic foot muscles > fibular group > posterior “lower” leg
Clinical signs and symptoms of CMT disease
- excessive force from antagonist muscle
- claw toe
- cavus foot (forefoot equinus)
- rearfoot varus
- insidious onset in late childhood or adolescence
- increased arch height (difficulty fitting shoes)
- toe deformities
- “stork legs” deformity
- general foot weakness
- unsteady gait
- ankle instability
- wasting of foot intrinsic musculature
- cramping associated with progressive muscle wasting
- pain at rest d/t mm wasting
Plantar fasciitis etiology (over-pronation)
- excessive stretch of plantar fascia
- inadequate toe-off
- inefficient use of windlass mechanism
Plantar fasciitis etiology (under-pronation)
- increased tension
- analogous stretch on a bow string
- inability to dissipate GRF
- calcaneal fat pad atrophy
Tarsal Tunnel Syndrome
- most common ankle nerve entrapment
- entrapment of posterior tibial nerve or branches within the tarsal tunnel
Clinical signs and symptoms of tarsal tunnel syndrome
- dysethesia in plantar aspect of foot
- (+) tinel’s sign
- complain of plantar foot pain but not tender to palpation
- EMG documentation
Treatment of tarsal tunnel syndrome
- NSAIDs
- local corticosteroid injections
- orthotics to limit excessive pronation (reduces nerve tension)
- surgical release
Morton’s Neuroma
- commonly seen in women ages 25-50
- ? as to etiology resulting from women’s shoe wear
- irritation of digital nerves between metatarsal interspace
Clinical signs and symptoms of Morton’s neuroma
- burning sensation
- commonly between the 3rd and 4th metatarsals
- pain with weight bearing
- night pain
- (+) Morton’s test - “foot squeeze”
Management of Morton’s neuroma
- improve foot and ankle flexibility
- address inflammation
- increase interspace (metatarsal pad, shoes with wide toe box, accommodative orthosis)
Retrocalcaneal bursitis
- excessive pronation
- windshield wiper effect
- irritation from improper shoe fit
Management of retrocalcaneal bursitis
- modalities to address inflammation
- proper shoe wear
- calf stretching
- biomechanical control if indicated
Achilles tendinits
- paratenon to allow maximal gliding action
- poor blood supply
- repetitive lengthening and shortening increases tendon loads
- results in microtrauma and inflammation
Clinical presentation of achilles tendinitis
- tendon pain
- tenderness
- thickened tendon
- painful ROM
Treatment of achilles tendinitis
- NSAIDs
- ice
- rest
- heel lift
- stretching
- CKC modalities
Clinical presentation of achilles tendon rupture
- feeling of being kicked in back of ankle
- audible “pop”
- swelling
- palpable defect
- unable to palpate tendon
- (+) Thompson’s test
Treatment of achilles tendon rupture
- long-term immobilization - serial casting in increased amounts of DF
- surgical repair and immobilization
- PT following immobilization and surgery
- evidence for early tendon loading
Clinical examination of foot & ankle fractures
- severe pain (usually)
- extreme edema
- discoloration
- limb position
- reluctant to move
- inability to bear weight
Ottawa Ankle Rules
- pain in the malleolar zone
- bone tenderness in the posterior half of the lower 6 cm of the fibula or tibia
- inability to bear weight immediately after injury
- 5th metatarsal or navicular bone tenderness
Stress fractures of the foot & ankle
- soleus syndrome
- 2nd and 3rd metatarsals (March fracture)
- calcaneal (marching, running)
Ottawa Knee Rules
Imaging is indicated if any of the following are positive:
- age 55 years or older
- isolated tenderness of patella
- tenderness at head of fibula
- instability to flex 90˚
- inability to bear weight both immediately & in the ER for 4 steps
Catterall classification of Legg-Calve-Perthes disease
Stage 1: bone resorption changes visible in the anterior aspect of the epiphysis and metaphysis visible in osteonecrosis of the femoral head; no sclerosis
Stage 2: further bone resorption with slight femoral head collapse in the anterior aspect of the femoral head; sclerosis
Stage 3: almost entire femoral head involved in collapse with characteristic head within head appearance; sclerosis
Stage 4: complete collapse of femoral head with flattening and formation of dense sclerosis; additional metaphyseal changes may be visible; sclerosis and posterior remodeling
