Final Exam questions! Flashcards
1
Q
What extra-articular structures can be a source of symptoms around the hip?
A
- Gluteus Medius
- Gluteus Minimus
- Adductor longus
2
Q
What must be “ruled out” for patients with hip area symptoms?
A
Lumbar spine and SIJ
3
Q
What are the clinical sets for HIP OA?
A
- Provocation of symptoms (increased pain)
a. Hip pain
b. Age > 50 y/o
c. Hip > or equal 15 degrees
d. Pain with hip IR
e. Hip morning stiffness < or equal 60 min - Decreased mobility (Loss of ROM)
a. Hip pain
b. Age > 50 y/o
c. Hip IR < 15 degrees
d. Hip FLEX < or equal to 115 degrees
4
Q
What is Legg-Calve-Perthes disease?
A
Idiopathic avascular necrosis of the femoral head in children
5
Q
What are the broad clinical trajectories of pain for patients with Hip OA?
A
- Mild pain throughout
- Moderate pain with increased in pain
- Moderate pain with decreased in pain
- Severe pain throughout
6
Q
What are the performance based measures of physical function for hip OA? (Name the recommended measures first)
A
- Sit to stand with 30 second chair stand test
- 4x10m fast paced walk test (walking short distances)
- Stair negotiation
- TUG (ambulatory transitions)
- 6MWT (aerobic capacity/ walking long distances)
7
Q
Interventions for patients with Hip OA?
A
- Exercise and manual therapy
a. Manual therapy effective for pain and self-reported function
b. Exercise effective for physical performance - Aquatic therapy
8
Q
Define “cam type” FAI
A
Changes in the sphericity of the femoral head and loss of normal narrowing at femoral head-neck junction
9
Q
Define “pincer type” FAI
A
Global over-coverage of the femoral head (coxa profunda or deep acetabulum), local over-coverage of the femoral head (anterosuperior overcoverage at roof of acetabulum) or changes in the orientation of acetabulum (retroversion of acetabulum)
10
Q
What is FAI syndrome?
A
Preferred term to describe patients who have triad of symptoms, clinical signs, and imaging findings needed to diagnose this disorder
11
Q
What is the most common location of symptoms for FAI?
A
Groin area
a. But can also see symptoms in LATERAL hip, ANTERIOR thigh, buttocks, knee, and low back
12
Q
What tests can commonly provoke symptoms for patients with FAI?
A
- Anterior Impingement tests (FADIR)
- Passive OP into IR in 90 degrees of flexion
- IR in prone
- FABER test
- Sinchfield test (resisted hip flexion)
- Modified Thomas test
- Log roll rest (passive supine rotation test)
13
Q
What interventions will you utilize for patients with FAI?
A
Inferior and lateral glides of the hip (combined with physiological flexion or IR in 90 degrees of flexion) AND strengthening exercises of the hip
14
Q
What characterizes lateral hip pain/ greater trochanteric pain syndrome?
A
Pain and tenderness in lateral hip/ greater trochanter region
15
Q
What tests are used to differentiate lateral hip pain?
A
- Resisted ABD - assess for lag sign
- Sustained single leg stance for 30s (low load)
a. Single leg hop (high load) - Resisted external de-rotation test
- FABER test
- TTP (anterior, lateral, and/or posterosuperior) of the greater trochanter
16
Q
What functional movements are unlikely to be seen from patients with lateral hip pain/ greater trochanteric syndrome?
A
Unlikely to have limitations with:
- Hip flexion and IR
- Hip Ext
- FABER position (no lack ROM) *
*However, FABER pain can indicate lateral hip pain.
17
Q
What interventions utilized for patients with lateral hip pain?
A
Piriformis stretching and gluteal/thigh strengthening
18
Q
What muscle injury could be contributing to pain for patients with groin pain not related to hip OA or FAI?
A
- ADductor mm.
- Iliopsoas mm.
- Rectus femorios m.
+ or - lower abdominal mm. and pubic symphysis problems
19
Q
What clinical tests are utilized for extra-articular problems of the hip?
A
- ADductor Squeeze test
- Single ADductor test
- Bilateral ADductor test
- Resisted ADD in greater ABD
- ADD squeeze (0 degrees of hip flexion)
- Passive ADD stretch
- ADD palpation
20
Q
Which muscle undergoes the greatest amount of stretch-related mechanical load during terminal swing?
A
long head tendon of Biceps Femoris m.
21
Q
If patient reports sudden onset of posterior thigh symptoms related to rapid hip flexion/ knee extension (ie. dancing or kicking) will more likely have injury to what tendon?
A
Proximal free tendon of the Semimembranosus mm.
22
Q
What are common provocation tests for hamstring injuries?
A
- Puranen-Orvara Test - standing HS stretch
- Bent-knee stretch test involving max hip Flex followed by knee Ext - tests contractile loading
- Modified bent-knee stretch test involving faster speed of knee extension
- Supplement these tests with isometric testing of knee flexion in PRONE
- Slump testing for nerve sensitivity - it is warranted for HS injuries
23
Q
Besides the clinical sets, what other comparable findings can help clinically diagnose HIP OA?
A
Hip IR ROM > or equal 15 degrees compared to non-involved hip or hip IR < 24 degrees (sitting)
24
Q
What are interventions for hamstring injuries?
A
- Eccentric loading in lengthened positions (ie single-leg deadlifts)
- Trunk exercises
- Agility drills
25
What are interventions for proximal hamstring tendinopathy?
1. Isometric contractions in lower angles of hip FLEXION for analgesic effect and avoidance of compression
2. Load in shortened position
3. Nerve gliding exercise in slump position
26
What are the primary risk factors for Development of Dysplasia of the Hip (DDH)?
1. Female
2. Breech presentation
3. Family history of DDH
27
What intervention is utilized for patients with Legg-Calve-Perthes Disease?
Maintain good ROM and obtain/maintain good containment of the femoral head in the acetabulum to allow the femoral head to remodel into a spherical shape
28
What is a SCFE?
Slipped Capital Femoral Epiphysis
1. Posterior and inferior slippage of the proximal femoral epiphysis on the metaphysis (femoral neck)
29
What are the risk factors for SCFE?
1. Obesity
2. Endocrine disorders
3. Renal Failure
4. Previous radiation therapy (childhood cancers)
30
Define Tibio-femoral OA.
Characterized by focal areas of loss of articular cartilage, hypertrophy of bone, and thickening of the joint capsule
31
What are the clinical diagnosis criteria for tibio-femoral OA?
1. Knee pain on most days of month
2. Crepitus
3. Morning stiffness < 30 min
4. > 50 y/o
5. Bony enlargement of knee on examination
6. Bony tenderness of knee on examination
7. No palpable warmth
32
Where do symptoms commonly occur on patients with tibio-femoral OA?
Common in medial compartment of the knee (but both medial and lateral may be involved).
Increased frequency of medial compartment may be related to normal knee alignment, in which 60% of WB force go through this part)
33
True or False? Changes in knee alignment increases risk of developing tibio-femoral OA.
FALSE. It does not increase risk of developing tibio-femoral OA.
However once OA is present, changes in knee aligment may be related to progression
34
Pts with isolated patello-femoral OA more likely to have what symptoms?
1. Coarse crepitus
| 2. Pain with patellar compression
35
Pts with combined tibio-femoral OA more likely to have what symptoms?
1. Impairments with knee EXT strength
2. Greater impairments in Knee Flex ROM
3. Greater difficulty descending stairs
36
Which knee misalignment is more common in pts with patello-femoral OA?
Valgus misalignment
37
What are some knee OA interventions?
1. Emphasize restoring knee extension with EXT + PA mobs
2. Encourage to lose weight
3. Exercise and manual therapy are effective in improving pain and self-reported function
a. Exercise should address hip strengthening (quads), and hip musculature along with aerobic and functional training (balance/ proprioception)
4. Lateral wedge insoles w/ subtalar strapping for medial compartment tibio-femoral OA
5. Patellar taping
38
What factors amplifies the forces to the ACL?
Knee Flexion + IR + Valgus + Increased Quad activation + reduced activation of the Hamstrings
39
What physical exam findings would you utilize to diagnose for ACL injury?
1. (+) Lachman's test = increased laxity
2. (+) Pivot shift Test = Anterolateral sublux (Lateral tibia subluxes ANT) ; detects rotatory instability
3. (+) Anterior Drawer Test = increased laxity
4. Loss of EROM knee EXT
40
What is the terrible triad?
Injury to the ACL along with injury to MCL and medial menisci
41
What are the ACL conservative treatment interventions?
1. Reduce quad dominance pattern
| 2. Restore knee EXT
42
What would increase your suspicion of a Grade I MCL injury?
1. Trauma by external force to lateral leg OR rotational trauma AND
2. Pain with valgus stress testing in 30 degrees flexion
43
What would increase your suspicion of a Grade II MCL injury?
1. Trauma by external force to lateral leg OR rotational trauma AND
2. Pain with valgus stress testing in 30 degrees flexion AND
3. Laxity with valgus stress testing in 30 degrees flexion
44
Why do ligament testing of varus/ valgus in 20- 30 degrees of flexion?
To take out the anterior cruciate ligaments of the knee during testing.
45
How are MCL injuries treated conservatively?
1. Restore ROM
2. Strengthening
3. Progressive return to functional activities
46
How is a grade III MCL treated?
Treated with a brace for ~6 weeks to prevent valgus stress
47
What physical findings/ tests would you utilize for a PCL injury?
1. Posterior drawer test = increased laxity
2. Quadriceps active test = increase tibial displacement with sliding of foot
3. Posterior sag sign
48
How are PCL injuries treated conservatively?
1. Focus on Quad muscle performance
| 2. CKC exercises to decrease Posterior shear forces with hamstring activation
49
How is a grade III PCL injury treated?
Immobilized in full knee extension for the first 2-4 weeks.
| Isolated hamstring exercises are avoided - especially OKC exercises
50
What clinical findings are useful to increase suspicion of a meniscal injury?
1. MOI
2. Pattern of effusion (6-24 hours)
3. History of catching, locking, and giving way
4. Pain with MAX flexion (squat w/ heels off ground)
5. Pain with forced Hyperextension
6. McMurray's test (+)
7. Joint line pain
8. Joint line tenderness
51
What is the non-surgical treatment precaution to be monitored for patients with meniscal injuries?
An MD exam is warranted or meniscectomy repair is needed if 1 or more of the signs are present:
1. Block motion (FLEX or EXT)
2. Episodes of giving way
3. Reactive synovitis following WB
52
What clinical features distinguish articular cartilage injury from meniscal?
Articular cartilage injuries have an effusion pattern consistent with hemoarthrosis and a rapid onset of bleeding ~2-4 hours
53
What are different surgical interventions for patients with articular cartilage injuries?
1. Microfracture surgery (fibrocartilage)
2. Matrix-induced Autologous (allograft) Chrondrocyte Implantation (MACI)
3. Osteochondral Autologous (allograft) Transplant System
54
What are the time frames of rehab after a microfracture surgery?
Initial phase (0-8wks): Protect the clot. TTWB, NWB flex/ext cycles, maintenance of patellar mobility, Aquatic therapy
Weeks 9-16: Begin WBAT; focus on restoring muscle performance. Inclined treadmill walking initiated ~12wks (5-10 min w/ increases in 5 min increments or as tolerated)
>17 weeks: continue progression of WB, strengthening, and functional activity
(Wait for jumping, cutting, and pivoting until ~6-9 months)
55
What is the rehab protocol for MACI?
Progressively increase PWB immediately post-op to FWB at ~6-8 weeks
56
What is OCD?
Osteochondritis Dissecans
Localized idiopathic change in subchondral bone that involve varying degrees of osseous resorption, collapse, and support of overlying articular cartilage
57
What is the most common area of lesions for patients with OCD?
Lesions most commonly found on the postero-lateral aspect of medial femoral condyle; most easily seen w/ a notch view on radiographs
58
What are the non-operative treatment for OCD?
Period of restricted WB +/- immobilization for healings
59
What is a risk factor for PFPS?
Decreased knee extension strength
60
What are PFPS interventions?
1. Multi-modal in nature to address relevant local (knee, patella, quad strength), proximal (hip mm. strength) and distal (ankle mechanics and mobility) impairments
2. Quad strengthening
a. OKC useful earlier to address impairments in force production
b. CKC to closely replicate function later in rehab
3. Hip strengthening (ABD/ ER)
4. Patellar taping
61
What is the overall goal of the interventions for PFPS?
The aim is to increase capacity to tolerate load
62
What structure(s) is(are) injured with patellofemoral instability?
Lateral subluxation
Injury to medial patellofemoral ligament
63
How are patellofemoral instabilities treated?
Period of immobilization in 20 degrees knee flexion to allow healing and it engages patellar in trochlea groove.
Aim is to restore knee EXT ROM and strengthening
64
What is the main area of symptom(s) for patients wtih Iliotibial Band Syndrome?
Lateral femoral epicondyle
65
How is ITBS mostly aggravated?
Most symptomatic is in ~30 degrees of knee flexion with excessive compression of ITB against underlying lateral femoral epicondyle
66
Why is downhill running more aggravating for patients with ITBS?
Due to the increased knee flexion at foot contact. This increases forces required to decelerate forward momentum.
67
What physical findings will be useful to diagnose ITBS?
1. Pain with palpation of lateral femoral epicondyle
2. Reproduction of pts. symptoms with Noble compression test near 30 degrees of knee flexion
3. Ober's and modified Thomas test to build a clinical case for diagnosis for ITBS
68
What should you consider assessing with ITBS?
Consider assessment of patellar mobility (medial tilt/ glide); explore in different angles of knee flexion
69
Where are symptoms localized with patellar tendinopathy?
Localized to patellar tendon (often inferior pole). Could have anterior knee pain
70
What interventions are utilized for patellar tendinopathy?
1. Combined concetric/ eccentric training
2. Decline squatting used to increase loading of patellar tendon
3. Start with isometric loading (initially for analgesics) and progress to isotonic loading (heavy and slow resistance)
71
Why do we need to stay below 60 degrees of knee flexion with decline squatting?
To avoid excessive patellofemoral load. When under 60, you are loading the patellar tendon more.
72
Define Osgood Schlatter's Disease.
Irritation of proximal tibial apophysis in children. Symptoms localized to the tibial tubercle
73
What intervention is utilized for Osgood Schlatter's Disease patients?
Relative rest w/ appropriate LE strengthening (esp. Quads) and stretching
74
What is the kinematic mechanism of injury for lateral ankle sprains?
Hindfoot Internal Rotation, Ankle Inversions in Plantarflexion, Forefoot Adduction
75
What ligament(s) is/are injured with a lateral ankle sprain?
Primarily anterior talofibular ligament but the calcaneofibular ligament is sometimes involved
76
What is the kinematic mechanism of injury for posterior talofibular ligament injury?
Significant Dorsiflexion, Foot External Rotation, and Pronation (IR of lower limb on planted foot)
77
What do you need to consider as potential involvement for pts with lateral ankle sprains?
Subtalar joint as some patients experience lateral ankle instability and have subtalar joint instability
78
Describe the grading criteria for a Grade I ankle sprain.
1. No loss of function
2. Negative Anterior drawer test
3. Negative talar tilt test
4. Little or no ecchymosis
5. No point tenderness
6. <5 degree loss in total active ROM
7. Swelling < 0.5 cm
79
Describe the grading criteria for a Grade II ankle sprain
1. Some loss of function
2. Positive Anterior drawer test
3. Negative talar tilt test
4. Ecchymosis present
5. Point Tenderness
6. 5 - 10 degree loss in total active ROM
7. Swelling > 0.5 cm but < 2.0 cm
80
Describe the grading criteria for a Grade III ankle sprain
1. Near total loss of function
2. Positive Anterior drawer test
3. Positive talar tilt test
4. Ecchymosis present
5. Extreme point tenderness
6. > 10 degree loss in total active ROM
7. Swelling > 2.0 cm
81
Why would a patient have medial symptoms with a lateral ankle sprain?
This may be related to impingement of the medial talus against the medial malleolus during inversion. Contact compression and bruising rather than a medial/ deltoid ligament injury
82
What main criterias are useful for diagnosing lateral ligament injury of the foot?
1. Pain with palpation of Anterior talofibular ligament
2. Lateral ecchymosis
3. Positive Anterior drawer test
83
What is important to test for all patients with lateral ankle sprains?
Balance testing
84
Describe the Ottawa Ankle rules
1. Pt within 10 days s/p ankle injury
2. Pain in the malleolar zone PLUS
3. Unable to bear weight for 4 steps immediately after injury and at the time of clinical assessment OR
4. Bone tenderness at posterior edge or tip of either malleolus
85
Describe the Ottawa Foot rules
1. Pt within 10 days s/p ankle injury
2. Pain in midfoot zone PLUS
3. Unable to bear weight for 4 steps immediately after injury and at the time of clinical assessment OR
4. Bone tenderness at navicular or base of 5th metatarsal
86
What are interventions for lateral ankle sprains?
1. Early WBAT supplemented with functional bracing
2. POLICE
3. Manual therapy and stretching recommended to restore ankle ROM
4. Therapeutic exercise addresses balance/ proprioceptive impairments
5. MWM for talocrural DF in WB
87
Describe the Brostrom Procedure
Primary repair of ATFL +/- calcaneofibular ligament
88
What structure(s) are injured with an ankle syndesmosis?
Anterior inferior tibio-fibular ligament
May be associated with deltoid ligament involvement or fracture of distal fibula
89
What is the common MOI of an ankle syndesmosis?
Involves ER of the foot on the tibia with hyper-dorsiflexion (Foot in WB + DF + tibial IR)
90
What clinical tests are utilized to determine an ankle syndesmosis?
1. Palpation over distal tibio-fibular ligaments
2. External rotation test
3. Squeeze test
91
What group of tests will help diagnose best for an ankle syndesmosis?
1. Inability to single-leg hop on toes 10x without pain
2. Syndesmosis tenderness
3. Reproduction of symptoms with DF/ ER test
4. Reproduction of symptoms with squeeze test
92
What interventions are utilized for ankle syndesmosis?
1. POLICE
2. Manual therapy, ther-ex, and balance/ neuromuscular retraining
a. Progress WBAT as increased healing time than lateral inversion sprain
3. Circumferential taping above distal AITFL joint
93
True or False. Recovery time for ankle Syndesmosis injuries are 4x longer than for lateral ankle sprains.
TRUE
94
Where are symptoms located with plantar heel pain?
On the medial side of the plantar surface of the heel where the central band of the plantar fascia attaches to the medial plantar tubercle of the calcaneus
95
How is a heel fat pad issue different from plantar heel pain?
Changes in the viscoelastic properties of the heel fat pad, in which it reduces its ability to dissipate the compressive forces applied during gait.
Typically, heel fat pad issues typically most tender with palpation on the plantar aspect of the calcaneus
96
What are the symptom presentations that would be present with a patient that has plantar heel pain?
1. Symptom aggravated with first steps when getting up in the morning or after periods of inactivity
2. Symptoms return/ increase after prolonged WB
3. Onset of symptoms related to increase in WB activities
97
What are the risk factors for plantar heel pain?
1. Increased BMI
2. Reduced ankle DF
3. Prolonged WB during daily activities
98
What physical findings will help determine plantar heel pain?
1. Pes planus or pes cavus
2. Pain with palpation of proximal attachment at medial plantar tubercle of calcaneus
3. Reduced active and passive DF ROM
4. Reproduction of sxs with tarsal tunnel syndrome test (DF + EV + toe extension in 90 degrees of knee flexion)
5. Reproduction of sxs with Windlass test (toe extension)
99
What can be done with structural differentiation when assessing nerve sensitivity for patients with plantar heel pain? and Why?
Adding knee and hip movements to DF + EV + toe extension changes strain on the nerve structures but not on the plantar fascia
100
What are interventions for plantar heel pain?
1. Stretching plantar fascia and Achilles tendon
2. Taping calcaneus toward inversion to support medial longitudinal arch
3. Custom foot orthoses
4. Impairment based manual therapy
5. Incorporate high-load progressive resistance training
6. Night Splints
7. Nerve gliding and deep tissue
101
What structure if irritated within the mid-substance region of achilles tendinopathy presents as more of a typical inflammatory response with pain?
Paratenon
102
What physical findings will help determine achilles tendinopathy?
1. Pain +/- decreased function/ performance with calf-raise activities
2. Royal London Test
3. Palpate for tendon thickening that moves with the tendon with active DF/ PF
4. Palpate for fine crepitus
5. Impairments in talocrural and subtalar mobility
6. Potential nerve sensitivity in SURAL nerve
103
What interventions are useful for patients with achilles tendinopahty?
1. Eccentric training: combine concentric/ eccentric training
2. Alfredson protocol
104
What test can you use to determine an Achilles tendon tear?
Thompson test
105
What is the common area of symptom for patients with Medial Tibial stress Syndrome?
Pain occurs along Posteromedial aspect of the medial 1/3 to distal 1/3 of the tibia. Diffused tenderness > 5 cm
106
What are competing differential diagnoses along with medial tibial stress syndrome?
1. Exertional compartment syndrome: deep posterior compartment
a. requires elevation for relief of sxs
2. Tibial Stress Fracture: localized tenderness (2-3 cm)
107
What is the likely cause for MTSS?
Changes in regional bone density; bone resportion greater than bony formation
108
What are the BIGGEST risk factors for MTSS?
1. Pronated foot
| 2. Excessive increases in weekly running distances > 30%/ wk
109
What are the interventions for MTSS?
1. Relative rest with gradual build up to activity level
2. Impairment based
3. Shock-absorbing insoles have potential for benefits
110
What are avulsion fractures?
Due to tensile loading of bone from an attached structure
111
What are impaction fractures?
Due to compression forces with axial loading
112
Define a Lisfranc joint?
Articulation between 1st and 2nd metatarsals and 1st and 2nd cuneiforms
113
What is associated with Hallux Abducto Valgus deformity?
1. Pronated foot type, reduced ankle DF mobility, and possibly high-heel shoe wearing
2. Consider genetic factors, metatarsal morphology and 1st Ray hypermobility
114
Moderate/ severe HAV more likely to have:
1. Pronated foot type
2. Greater impairments in force production and greater toe flexion/ ABD
3. Place less pressure on medial foot during gait (medial side less efficient to WB)
4. Greater medial-lateral postural sway (medial side less tolerant to WB)
115
Describe the deformity of HAV?
1. Compromise of the MCL at the 1st MTP joint and medial sesamoid
2. Head of 1st MT drifts medially on the sesamoid
3. Proximal phalanx starts to move into valgus position, additionally there are changes in angle of pull of extensor and flexor hallicus longus tendons which exacerbates valgus deformity
4. 1st MTP joint will rotate medially, and this reduces ability to effectively WB and push off of 1st ray
116
What are interventions for HAV?
1. 1st MTP mobilization
2. Exercise
3. Balance and proprioception training
4. Orthotics
5. Promote restoration of WB through medial foot
6. Address DF restrictions with stretching
117
What are weight bearing options to challenge hip abductors/ external rotator muscle function?
Single-leg squat and a ' medial reach ' of the uninvolved limb during a Star Excursion Balance Test (SEBT)
