Final Exam: Wrist & Hand, UE, and LE Flashcards
How many bones are in the wrist and hand?
28 bones
What bones are in the proximal carpal row?
-Scaphoid
-Lunate
-Triquetrum
-Pisiform
What bones are in the distal carpal row?
-Trapezoid
-Capitate
-Hamate
What structure is between the ulna and the proximal carpal row? What structure is it similar to?
-Triangular fibrous cartilage complex
-Structurally and functionally similar to a meniscus
What two tendons is the anatomical snuff box between? What artery runs through the snuff box?
-Between extensor pollicis brevis and longus
-Radial artery
What are wrist flexion ROM norms?
80-90
What are wrist extension ROM norms?
70-90
What are radial deviation ROM norms?
15
What are ulnar deviation ROM norms?
30-45
What are the major ligaments at the wrist?
-Radio-ulnar ligaments strengthen capsule anteriorly and posteriorly
-Carpal ligaments
-Ulnar collateral
-Radial collateral
What movement at the wrist tightens the anterior capsule?
Supination
What movement at the wrist tightens the posterior capsule?
Pronation
What is the functional splint position of the hand?
-Wrist in 20-30 degrees of extension and slight ulnar deviation
-Fingers in 45 degrees of MCP flexion, 15 degrees of PIP and DIP flexion
-Thumb in 45 degrees of abduction
What is the open pack position of the distal radio-ulnar joint?
5-10 degrees of supination
What is the open and closed pack position between the radius and ulna and the proximal carpal row?
-Open: neutral and slight ulnar deviation
-Closed: full extension with radial deviation
What are questions to ask a patient with a wrist or hand injury?
-When and how trauma occurred
-Position of wrist and hand at time of trauma
-“popping” or “clicking”
-Past behavior of wrist, hand, or finger deformities
In the presence of trauma, what is the most common cause of radial side wrist/hand pain?
Scaphoid fracture
In the absence of trauma, what is the most common cause of radial side wrist/hand pain?
DeQuervain’s tenosynovitis
What is the most common cause of wrist/hand pain on the posterior side?
-Radial carpal athritis
-Ganglion cyst
What is the most common cause of wrist/hand pain on the ulnar side?
Tear of the triangular fibrocartilage complex (TFCC)
What is the most common cause of wrist/hand pain on the anterior side?
-Carpal tunnel
-Ganglion cyst
-Formation of tenosynovitis
What are common orthopedic conditions of the wrist?
-Carpal tunnel syndrome
-De Quervain tenosynovitis
-Fracture of the distal radius
-Fracture of the scaphoid
-Gamekeeper’s thumb
-OA of the thumb CMC joint
-Flexor digitorum profundus avulsion
-Trigger finger
-Mallet finger
-Boutonniere deformity
-Swan neck
What is carpal tunnel syndrome?
-Compression of the median nerve that occurs under the transverse carpal ligament at the wrist
-Can also be associated with pregnancy, diabetes, trauma,
or tumors in the carpal tunnel
What are the subjective findings of carpal tunnel syndrome?
-Complaints of numbness in the median nerve distribution, primarily the tips of the first 3 fingers
-Complaints of pain in the forearm and wrist
-Symptoms may awaken the patient from sleep
-Activities involving wrist flexion are uncomfortable
What are the objective findings of carpal tunnel syndrome?
-Thenar atrophy may be present
-+ Phalen
-+ Tinel
-+ Carpal tunnel compression test
What imaging might be done if carpal tunnel syndrome is suspected?
-Radiograph to rule out bony causes
-EMG or nerve conduction studies to rule out other conditions
What are possible interventions for carpal tunnel syndrome?
Splinting, especially at night
What is De Quervain tenosynovitis? What is it caused by?
-Inflammation of the extensor and abductor tendons of the thumb
-Caused by repetitive or unaccustomed use of the thumb
What are the subjective findings of De Quervain tenosynovitis?
-Wrist pain on the radial side
-Difficulty with grasping and gripping
What are the objective findings of De Quervain tenosynovitis?
-Possible swelling at the radial styloid process
-Palpation elicits pain at the side of the retinaculum at the radial styloid
-+ Finkelstein’s
-+ WHAT test
-+ Eichoff
What are possible interventions for De Quervain?
-Reduce inflammation, prevent adhesions from forming, and prevent recurring tendonitis
-Splint the thumb (spica splint)
-Steroid injections made directly into the fibrous sheath of the first dorsal compartment
-Electrotherapeutic and thermal modalities to help decrease inflammation
-Gentle AROM for short periods
-Grasping and releasing of small objects emphasizing a wide variety of prehensile patterns
What is the prognosis for De Quervains?
-Patients who receive treatment within 6 months of developing the condition have an excellent prognosis
-90% of non-severe cases may expect relief with conservative care
What are the different types of distal radius fractures?
-Colles
-Smith
-Barton
-Chauffeurs
-Die-punch
What is a Colles fx?
-Most common type of distal radius fracture
-Distal radius fracture fragment is tilted upward or dorsally
What is a Smith fx?
-Opposite of Colles
-Distal fragment is tilted downwardly or volarly/palmarly
What is a Barton fx?
-Intra-articular fracture associated with subluxation of the carpus, along with displaced fragments of the radius
What is a Chauffeurs fracture?
Oblique fracture through the base of the radial styloid
What is a Die-punch fx?
Depressed fracture of the articular surface opposite the lunate or scaphoid bone
What are subjective findings of fracture of the distal radius?
-Acute pain, tenderness, swelling, and deformity of the wrist
-Hx of falling onto an outstretched hand or arm
What are the objective findings of fracture of the distal radius?
-Swelling, deformity, and discoloration around the distal radius
-May have associated skin injury and bleeding
-May have decreased sensation in the median, radial, or ulnar nerve distribution
-May have decreased circulation to the hand
What are possible interventions for fx of the distal radius?
-Conservative care can begin while the fx is immobilized and involves AROM of the shoulder, elbow, and fingers
-Finger exercises must include isolated MCP flexion, complete flexion and intrinsic fisting
-After immobilization, extension and supination commonly limited and need to be mobilized
-Wrist ext. exercises are performed with the fingers flexed
-PROM performed according to MD protocol
What is the prognosis of a distal radius fx?
-Typically an uncomplicated course
-Occasional malunion or post-traumatic wrist arthritis can occur
What patient population is a fx of the scaphoid most common in?
-Most common in young male adults
-Diagnosis often delayed or missed
What is the most commonly fractured carpal bone? Why?
-Scaphoid is the most commonly fractured carpal bone
-Because it spans the distal and proximal rows of the carpals and consequently is more vulnerable to FOOSH injuries
What are the subjective findings of a scaphoid fx?
-Hx of a FOOSH
-Complaints of dorsal wrist pain, especially with any type of wrist motion or activity such as gripping
-Tenderness over the anatomical snuffbox
What are the objective findings of scaphoid fx?
-Palpation over the anatomic snuff box markedly tender
-Decreased AROM of the wrist
-Decreased grip strength
-Normal neuro exam
What is a clinical pearl for the scaphoid?
When wrist pain is severe, snuff box or dorsal wrist tendonitis is dramatic, and the ROM of the wrist has been decreased by 50%, you should suspect a scaphoid fx, lunate dislocation, or carpal avascular necrosis
What are confirmatory tests for scaphoid fx?
-Axial compression of the thumb along its longitudinal axis, which translates force directly along the scaphoid and elicits pain if there is a fx
-Often not visible on PA and lateral radiographs, but can get a scaphoid view (clenched fist with wrist in ulnar deviation)
What are possible interventions for scaphoid fx?
-No agreement on optimal position for immbolization
-Current management is immobolization in a long-arm or short-arm thumb spica cast
-Following immobilization, capsular pattern of the wrist will dominate
-AROM, PROM, and gentle stretching
What is Gamekeeper’s thumb?
-Injury to the ulnar collateral ligament of the thumb
-Whether by injury or repetitive use, disrupted ligament can lead to instability of the MCP joint and decreased functioning in both pinching and opposition involving the thumb
What are the subjective findings of Gamekeeper’s thumb?
-Pain and swelling along the ulnar side of the thumb MCP joint
-Complaints of pain, weakness, or loss of stability
What are the objective findings of Gamekeeper’s thumb?
-Local tenderness and swelling with palpation along the ulnar side of the MCP joint of the thumb
-Pain or excessive motion with valgus stress test of the ulnar collateral ligament
-Impaired MCP joint flexion and extension, especially when acute and swollen
-Decreased pinching strength resulting from instability or acute pain
What are confirmatory special tests for Gamekeeper’s thumb?
-Valgus stress test in full extension
-Valgus stress test at 30 degrees of MCP flexion
What are possible interventions of Gamekeeper’s thumb?
-Grade I and II tears are treated with immbolization in a thumb spica cast for 3 weeks, with 2 additional weeks of splinting
-AROM of flexion and extension begins at 3 weeks progressed to strengthening by 8 weeks
-NO abduction stress to the MCP joint for 6 weeks
-Grade III tears are treated with surgery
What patient population is OA of the thumb most common in?
-More common in women than in men, and usually occurs after 40 years of age
-Prior fractures or other injuries to the joint may increase the likelihood of developing this condition
What are subjective findings of thumb OA?
-Pain with activities that involve gripping or piching, such as turning a key, opening a door, or snapping your fingers
-Loss of strength in gripping and pinching activities
-An aching discomfort after prolonged use
What are objective findings of thumb OA?
-Swelling and tenderness at the base of the thumb
-An enlarged, “out of joint” appearance
-Development of a bony prominence or bump over the joint
-Limited motion in all planes
What are the surgical options for thumb OA after conservative management has failed?
-Ligament reconstruction
-Ligament reconstruction and tendon interposition
-Total joint arthroplasty
-Arthrodesis (fusion)
What is the ligament reconstruction surgery for thumb OA? What are pros and cons?
-Stabilizes the CMC joint by removing the damaged ligament and replacing it with a piece of the patients wrist flexor tendon
-Pros: most people with very early OA experience good to excellent pain relief
-Cons: does not repair damaged cartilage or bone
What is the ligament reconstruction surgery and tendon interposition (LRTI) for thumb OA? What are pros and cons?
-LTRI is the most commonly performed surgery for thumb OA
-Arthritic joint surfaces are removed and replaced with a cushion of tendon that keeps the bones separated
-Surgeons remove all or part of the trapezium bones
-Helps adults with moderate to severe arthritis with pain and difficulty pinching or gripping
-Pros: removing trapezium eliminates possibility of arthritis returning
-Cons: lengthy and painful recovery
What is the total joint arthroplasty surgery for thumb OA? What are pros and cons?
-Total joint replacement
-Replaces joint with an artificial implant
-Pros: thumb arthroplasty is less invasive because there is no grafting
-Cons: spacers have high complication rates for some patients
What is the arthrodesis surgery for thumb OA? What are pros and cons?
-Eliminates pain by fusing the bones in the joint together
-Surgeons create a socket by hollowing out the thumbs metacarpal bone and then shaping the trapezium into a cone that fits into the socket
-A metal pin holds bones together to maintain proper alignment
-Pros: a stable, pain-free thumb that can grasp and pinch
-Cons: high complication rate, can damage nearby joints, and causes loss of ROM in CMC
What is flexor digitorum profundus avulsion? What is the mechanism of injury?
-Avulsion of the FDP can occur in any digit, but most commonly the ring finger
-Usually occurs when a hyperextension stress is applied to a flexed finger such as when an athlete grabs an opponents jersey
-Often misdiagnosed as a sprained or “jammed” finger
-FDP is anatomically weaker in the middle finger
What are the subjective findings of flexor digitorum profundus avulsion?
Hx of trauma involving the digit
What are the objective findings of flexor digitorum profundus avulsion?
-Specific testing of the isolated DIP joint flexion in all digits reveals the involved digit
-Inability to flex DIP, while PIP is held in extension
-Tenderness along the flexor
What are possible interventions for flexor digitorum profundus avulsion?
Primarily surgical
What is the prognosis for flexor digitorum profundus avulsion?
Depends on acuteness of the diagnosis, rapidity of surgical intervention, and level of tendon retraction
What is trigger finger? What fingers are most effected? What is the cause?
-Inflammation of the 2 flexor tendons of the finger, which become thickened and narrowed as they cross the MCP head in the palm, causing a painful snapping
-Thumb, long, and ring fingers most commonly affected
-Cause is idiopathic
What are the subjective findings of trigger finger?
-Complaints of a painful finger or loss of smooth motion (catching) of the finger when gripping or pinching
-May be complaints of painful nodule in the distal palm usually at the level of the distal flexion crease
What are the objective findings of trigger finger?
-Local tenderness with palpation at the base of the finger, directly over the tendon as it courses over the metacarpal head
-May palpate crepitus or a moving nodular mass
-Pain typically aggravated by stretching the tendon into extension or by resisting the action flexion isometrically
-Clicking or locking with active flexion may or may not be present
-Full flexion of the finger may not be possible
What are possible interventions for trigger finger?
-Goals are to reduce swelling and inflammation in the flexor tendon sheath and to promote smooth movement of the tendon
-Corticosteroid injections into the flexor sheath now considered the treatment of choice
What is the prognosis of trigger finger?
-Spontaneous long-term resolution of trigger finger is rare
-Patient with recurring tenosynovitis or mechanical locking need to evaluate their work and recreational habits
-Surgical release of the trigger finger is reserved for recalcitrant cases (uncooperative)
What is Mallet finger?
-Deformity of a finger causes when the extensor tendon is damaged (DIP)
-Finger/DIP unable to extend
-Also called “baseball” finger
What is the mechanism of injury of Mallet finger?
-When a ball or object strikes the tip of the finger or thumb
-The force damages the thin tendon that straightens the finger
What is the treatment for Mallet finger?
-Surgery with Mallet splint for 6-8 weeks
-OR extension block k-wire for 4 weeks
What is the Mallet splint?
-Splint that allows the tendon to return to normal length
-If the finger is bent during these weeks, the healing process must start all over again
When is surgery performed for Mallet finger?
Surgery is performed within a week to reattach the tendon
What is the prognosis of Mallet finger?
Will recover completely with surgery
What is Boutonniere deformity?
-Injury to the tendons that straightens the PIP joint of the finger
-PIP of the injured finger will not straighten, while the DIP bends back
What happens if Boutonniere deformity is not treated promptly?
The deformity may progress, resulting in permanent deformity and impaired functioning
What is the mechanism of injury of Boutonniere deformity?
-Generally caused by a forceful blow to the top side of a flexed PIP joint of a finger
-Also can be caused by a cut on the top of the finger which can sever the central slip (tendon) from its attachment to the bone
-Could also be caused by arthritis
What are the symptoms of Boutonniere deformity?
-The finger at the PIP cannot be straightened and the fingertip cannot be bent
-Swelling and pain occur and continue on the top of the middle joint of the finger
What is non-surgical treatment of Boutonniere deformity?
-Splint
-Applied to the finger at the PIP joint to straighten it
-Keeps the ends of the tendon from separating as it heals
-Also allows the end joint of the finger to bend
-Splint is worn for 6 weeks, and after 6 weeks may still have to wear it at night
What is a Swan neck deformity? What is the cause?
-PIP of a finger is extended more than normal while the DIP is flexed
-Caused by a weakness or tearing of the ligament and tendon
What are the treatment options for Swan neck deformity?
-Treatment varies!
-Splint/brace
-Surgery
-Replace the joint
What are the 4 joints at the shoulder?
-Sternoclavicular
-Acromioclavicular
-Glenohumeral
-Scapulothoracic
How much of the humeral head is in contact with the glenoid?
-25% humeral head in contact with glenoid
-75% in contact with labrum
What is the most commonly dislocated joint in the body? Why?
-GHJ
-It lacks bony stability
What is the GHJ composed of?
-Fibrous capsule
-Ligaments
-Surrounding muscles
-Glenoid labrum
What muscles form part of the capsule?
-The rotator cuff
-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor
What is joint approximation and what is it typically used for?
-Compression of a joint surface
-Used to promote reflexive stability, often used with weight bearing activities
-Thought to stimulate type 1 receptors and facilitate postural stabilizers
What is joint centration achieved by?
Achieved by the combined neuro-motor tasks of:
-Stabilization
-Dissociation
What is the self perpetuating pattern of movement dysfunction?
Any stressor to the nervous system, including acute and repetitive trauma, emotional stress, can up-regulate the sympathetic nervous system and pain which alter movement strategies that further increase dysfunction
What are local vs global muscles?
-Local: involved in joint stabilization; oxidative
-Global: movers; aerobic
Which of the rotator cuff muscles is the only one that pulls the humeral head posteriorly? Why?
Subscapularis, because internal rotation causes a posterior glide of the humerus
What is closed pack position of the GHJ?
90 degrees of abduction and full ER
What is open pack position of the GHJ?
55 degrees abduction, 30 degrees horizontal adduction
What is the capsular pattern of the GHJ?
-ER
-Abduction
-IR
What are special questions for the shoulder that a PT should ask the patient?
-Feeling of instability
-Popping, catching, painful popping
-Tingling
-Night time awakening
-Trouble lifting, reaching, etc.
What does night time awakening suggest for the shoulder?
Internal derangement
What are common causes of shoulder injuries?
-Traumatic
-Sports
-Overuse
-Insidious onset
What are the 3 types of Kibler classification for scapular dyskinesis?
-Type 1: inferior medial border
-Type 2: Medial border off ribs
-Type 3: elevated superior border
What is Kibler Type 1 scapular dyskinesis? What muscles are tight? Which are weak?
-Inferior medial border more prominent
-Anterior tilt of scapula
-Coracoid process often TTP
-Tight: pec minor, biceps SH
-Weak: lower trap, lats, serratus anterior
What is Kibler Type 2 scapular dyskinesis? What muscles are tight? Which are weak?
-Entire medial border off ribs
-Points glenoid fossa anteriorly
-Weak serratus anterior and lower traps
What is Kibler Type 3 scapular dyskinesis? What muscles are tight? Which are weak?
-Superior border of the scapula is elevated
-Usually with adhesive capsulitis
-Tight: upper trap
-Weak: lower trap
What level of the spine is the acromion at?
C7
What level of the spine is the medial portion of the spine of the scapula at?
T3
What level of the spine is the inferior border of the scapula at?
T7
What are common causes of shoulder pain that do not originate from the shoulder joint?
-C-spine nerve impingement
-Peripheral nerve entrapment
-Diaphragm irritation
-Intrathoracic tumors
-Gallbladder problems
-Myocardial ischemia
-Pancoast tumor
What are common shoulder orthopedic conditions?
-Acromioclavicular joint separation
-Adhesive capsulitis
-Biceps tendonitis
-Glenohumeral joint instability
-Glenohumeral joint OA
-Impingement syndrome
-Rotator cuff tear
-SLAP lesion
-Thoracic outlet syndrome
What is the mechanism of injury of acromioclavicular joint separation? What patient population is it more likely in?
-Commonly occurs in men and younger people
-Usually caused by a traumatic event such as FOOSH or direct blow to the anterior shoulder that results in AC joint ligament tears
-4-5x more prevalent than SC injuries
What are the 6 types of AC joint separation?
-Type I: AC joint ligaments are partially or completely disrupted
-Type II: AC joint ligaments are torn and coracoclavicular ligaments are partially disrupted
-Type III: coracoclavicular ligaments are completely disrupted
-Types IV-VI: uncommon; periosteum of the clavicle or deltoid/trap muscle are also torn
What are the subjective findings for AC joint separation?
-Relief reported with cradling the involved arm
-Localized pain over the AC joint
-Pain when lifting the arm
What are the objective findings for AC joint separation?
-Patient supports the arm in adducted position
-Swelling at the ACJ
-Pain is consistently aggravated by passively horizontally adducting arm
-+ cross body test
-+ AC resisted extension test
What are the interventions for ACJ injury?
-Acute: protection and rest
-Sub-acute: strengthening of surrounding muscles
What is frozen shoulder? What are the two types?
-Adhesive capsulitis of the shoulder
-Characterized by progressive and painful loss of active and passive ROM that follows capsular patterns
-Primary: idiopathic
-Secondary: traumatic or related to a disease process
What are the subjective findings of frozen shoulder?
-Diffuse aching at the shoulder
-Difficulty sleeping on the involved side
-Difficulty dressing and grooming
What are the objective findings of frozen shoulder?
-Insidious onset of severe shoulder pain
-Shoulder stiffness with markedly reduced external rotation
-Negative radiographic findings
-Varies according to stage
-Inability to elevate shoulder
-ER, abduction, IR limited
-Restriction of anterior and inferior glide of the GHJ
-Negative neuro tests
-Pain at end range of shoulder motions
What are the stages of adhesive capsulitis? How long does each stage last?
-Prefreezing: 1-3 months
-Freezing: 3-9 months
-Thawing: 9-14 months
What are possible interventions for frozen shoulder?
-Patient education
-NSAIDs
-Steroid injection
-PT: ROM, joint mobilizations, pain management
What is the prognosis of frozen shoulder?
18 months to 3 years- some patients may never get back to their PLOF
What are three pathological disorders that can cause biceps tendonitis?
-Inflammatory/degenerative conditions
-Instability of the biceps tendon such as subluxation or dislocation of the tendon
-SLAP (superior labrum anterior or posterior) lesion
What is the mechanism of injury for biceps tendinopathy and SLAP lesions?
-FOOSH
-Traction mechanism: eccentric firing of the biceps muscle that causes injury to the superior labrum complex
-Peel-back: the arm is abducted and maximally externally rotated and the twisting of the biceps tendon may result in the “peel-back” of the anchor and its subsequent gradual or acute detachment from the superior glenoid
What are the subjective findings of biceps tendonitis?
-Diffuse and vague pain in the anterior shoulder or over the bicipital groove
-Painful AROM of shoulder flexion
What are the objective findings of biceps tendonitis?
-Tenderness over bicipital groove
-Possible loss of shoulder ROM
-May have painful arc
-Pain with resisted elbow flexion
-+ speeds test
-+ Yergason test
What are possible interventions for biceps tendonitis?
-Acute phase: pain and inflammation management
-Subacute phase: AROM exercises and early strengthening
-Phase 3: strengthening with emphasis on enhancing dynamic stability
-Phase 4: return to sport or high workloads
What are the different types of glenohumeral joint instability?
-Anterior inferior
-Multidirectional
-Posterior
-Inferior
What is TUBS?
-Instability caused by a Traumatic event, is Unidirectional, associated with a Bankart lesion, often requires Surgery
-TUBS= traumatic, unidirectional, bankart, surgery
What is AMBRI?
-Atraumatic, Multidirectional, may be Bilateral, best treated by Rehabilitation, Inferior capsular shift is the surgery performed if rehab fails
-AMBRI= atraumatic, multidirectional, bilateral, rehabilitation, Inferior capsular shift surgery
What is the most common type of shoulder dislocation?
Anterior
What are the subjective findings of glenohumeral joint instability?
-Complaints of looseness of the shoulder or a “noisy” shoulder
-May or may not have a history of trauma
-Patients with anterior instability typically describe the sensation of the shoulder slipping out of joint when the arm is abducted and ER
-Tend to support arm in neutral position
-Patients with multidirectional instability may have vague symptoms, but tend to be activity related
What are the objective findings of glenohumeral joint instability?
-+ Sulcus sign
-Variable degrees of crepitation or popping
-Apprehension in extreme ROM such as IR and ER
-Generalized ligamentous laxity
-+ apprehension test
-+ surprise test
-+ posterior instability tests (Jerk)
What are possible interventions for glenohumeral joint instability?
-Rotator cuff strengthening
-Shoulder stability exercises
What is OA in the shoulder typically a result of?
Usually a long term consequence of trauma such as dislocation, fx, large RC tears
What are the subjective findings of shoulder OA?
-Gradual onset, deep-seated shoulder pain and stiffness
-Worst pain is typically in the posterior aspect
-Progressive loss of ROM
-Hx of trauma to the shoulder
What are the objective findings of shoulder OA?
-Forward humeral head, protracted scapula
-GH joint line tenderness
-Swelling around the joint
-Decreased active and passive ROM
-Crepitation with circumduction may or may not be present
-Radiographs will show joint space narrowing
-May have pseudolaxity
What are possible interventions for shoulder OA?
-Improve GHJ flexibility
-RC strengthening
What is subacromial pain syndrome (SAPS)?
-Mechanical impingement of the rotator cuff between the coracoacromial arch and the humeral head
-Anything that decreases the volume of this space can cause impingement
-Hypertrophy of the AC joint secondary to OA can also cause impingement
What are the 3 different types of acromions? Which is most likely to cause SAPS?
-Type 1: flat 17% of people
-Type 2: curved 43% of people
-Type 3: hooked 40% of people
What are the contents of the coracoacromial tunnel?
-Supraspinatus tendon
-Long head of biceps tendon
-Subacromial/subdeltoid bursa
-Coracohumeral ligament
What is subacromial decompression (SAD) and distal clavicular resection (DCR) surgery?
It is where the surgeons shave down part of the clavicle that can be causing impingement as well as some of the subacromial arch
What are the subjective findings of SAPS?
-Pain felt down the lateral aspect of the upper arm near the deltoid insertion, over the anterior proximal humerus, or in the periacromial area
-Functional loss of the shoulder attributable to pain, stiffness, weakness, and catching, especially when the arm is in flexion and IR
-Difficulty sleeping on the involved side
-Pain provoked by everyday activities such as putting on a coat, pouring coffee, etc.
What is stage I SAPS?
-Tenderness at supraspinatus insertion and anterior acromion
-Painful arc
-Weakness at 90 degrees abduction and flexion
What is stage II SAPS?
Physical exam reveals crepitus or catching at 100 degrees of elevation and restriction of PROM
What is stage III SAPS?
-Atrophy of the infraspinatus and supraspinatus
-More limitation in AROM than PROM compared to the other stages
What are the possible interventions for SAPS?
-Strengthen RC
-IR and ER isometrics initially
-Address strength deficits
What is a rotator cuff tear?
-Can be acute/traumatic or chronic/degenerative
-Described by size, location, direction, and depth
-Tears are usually longitudinal
-Occur in critical zone (avascular) situated at the anterior portion of the cuff within the subacromial space between the supraspinatus tendon and coracohumeral ligament
-Uncommon before age 40 unless associated with trauma
What are the subjective findings of a rotator cuff tear?
-Significant weakness and pain with activities that involved abduction and ER
-Localized pain over the upper back, deltoid, shoulder, and arm
-A popping sensation may be present
What are the grades of rotator cuff tears?
-Small: < 1cm
-Medium: 1-3 cm
-Large: 3-5 cm
-Massive: > 5cm
What are the objective findings of rotator cuff tears?
-May reveal muscle asymmetry or atrophy
-Pain located at the greater tuberosity
-Loss of PROM and AROM
-+ special tests
-Weakness
-Massive tears present with sudden profound weakness
What are the diagnostic tools for rotator cuff tear?
-Special tests: drop arm, empty can, lift off test, ER lag sign
-Medical imaging
What are possible interventions for rotator cuff tears?
-Small or partial tears: intervention is directed toward strengthening the rotator cuff and scapular stabilizers
-Full thickness tears usually require surgery followed by PT
What is the criteria for operative interventions for rotator cuff tears?
-Patient younger than 60 years old
-Failure to improve after conservative regimen of at least 6 weeks
-Presence of a full thickness tear, either clinically or by imaging
-Patient’s need to use the involved shoulder in a vocation or an avocation
-Ability or willingness of the patients
What are the rotator cuff repair options? Which option leads to better tendon healing?
-Single row, double row, suture bridge, or transosseous repairs are all commonly performed
-Double row tends to repair more of the tissue back to the humeral insertion point which has led to better tendon healing
What are possible post-operative rotator cuff repair complications? How can these be avoided?
-Re-tear rates range anywhere between 25-70% of the time
-Those that do fail or re-tear do so within the first 3-6 months
-Avoiding early motion protects the surgical site
What percent muscle activation level must a post-operative RCR patient stay below?
Below 15% for 6 weeks post-op
What should be the protocol for the first 2 weeks following RCR?
Strict immobilization for 2 weeks, such as a sling
What is the strength of a RCR at 6 weeks post-op? What about at 12 weeks?
Only about 19-30% strength of normal and 29-50% at 12 weeks
When can AAROM be performed post RCR?
7 weeks
What is a SLAP lesion?
-Superior labral anterior posterior (SLAP) lesion
-Involve an injury to the superior glenoid labrum and the biceps
-Several injury mechanisms speculated- range from single traumatic to repeptitive microtraumatic injuries
What is the mechanism of injury of a SLAP lesion?
Typically results from FOOSH, sudden deceleration or traction forces such as catching a falling object, or chronic anterior or posterior instability
What are the subjective findings of SLAP lesions?
-History of trauma or overuse
-Complaints of pain and/or instability with overhead activities and symptoms of painful clicking, catching, or locking
What are the objective findings for a SLAP lesion?
-Symptoms very similar to those of instability and rotator cuff tears
-Positive findings of pain or clicking with maneuvers that place tensile or torsional load on the biceps, thereby stressing the loose anchor of the biceps-superior labrum complex
What are confirmatory special tests for SLAP lesions?
-O’Brien’s active compression
-Compression rotation test
-Crank test
-Biceps load II (or I)
-Kim test
-Jerk test
What are possible interventions for SLAP lesions?
-Conservative interventions should address the underlying hypermobility
-Dynamic stabilization exercises of GHJ
What is the prognosis for SLAP lesions?
-If conservative management fails, diagnostic arthroscopy is recommended
-Studies of surgical labral repairs are generally good to excellent in terms of returning patients to their prior level of activity
What is thoracic outlet syndrome (TOS)?
-Clinical syndrome characterized by symptoms attributable to compression of the neural or vascular anatomic structures (brachial plexus, subclavian artery or vein) that passes through the thoracic outlet
-Bony boundaries of the thoracic outlet include the clavicle, first rib, and scapula
What patient population is TOS more common in?
More common in women with onset of symptoms between 20-50 years old
What are the subjective findings of TOS?
-Symptoms are often vague and variable, chief complaint is diffsue arm and shoulder pain especially above 90 degrees of elevation
-Potential symptoms include pain localized in the neck, face, UE, chest, shoulder, and axilla
-Could have UE paresthesias, numbness, weakness, heaviness, fatigability, swelling
-Neural compression symptoms occur more frequently
What are the objective findings of TOS?
-Swelling or discoloration of the arm
-Auscultation may reveal the presence of bruits (abnormal sound/murmur) especially when doing provocative measures during special tests
-Difference in distal pulses compared to opposite side
-+ special tests
What trunk of the brachial plexus is most commonly effected by TOS? What specific symptoms would this cause?
-Lower trunk, which is made up of C8 and T1 nerve roots
-Supplies sensation to 4th and 5th digits, so there may be symptoms in those fingers
What are confirmatory special tests for TOS?
-Adson vascular test
-Allen pectolaris minor test
-Costoclavicular test
-Roos test
-Hyperabduction maneuver
-Passive shoulder shrug
What are possible interventions for TOS?
-Correction of postural abnormalities of the neck and shoulder girdle
-Pec minor release/stretches
-Strengthening of scapular muscles
-1st and 2nd rib mobilizations
What is the prognosis for TOS patients?
50-90% of patients with TOS respond rapidly to conservative interventions and regain normal, pain-free function of the UE
What is the criteria for surgical interventions for TOS?
-Failure to respond to conservative intervention within 4 months
-Signs of muscle atrophy
-Intermittent paresthesias being replaced by sensory loss
-Pain becoming incapacitating
What are the most common surgical interventions for TOS?
-Depression of the scalene muscles and resetting of the 1st rib
-Removal of the cervical rib (if present)
-Removal of the clavicle
-Severing of the pec minor
-Transection of the subclavius muscle above the coracoid ligament
What are the upward rotators of the scapula?
-Upper trap
-Serratus anterior
-Lower trap
What are the downward rotators of the scapula?
-Rhomboids
-Levator scapulae
-Pectoralis minor
What are the 3 articulations at the elbow?
-Humeroradial
-Humeroulnar
-Proximal radioulnar
What is the open and closed pack positions of the humeroulnar joint?
-Open: 70 degrees of flexion and 10 degrees of supination
-Closed: maximum extension and supination
What is the capsular pattern of the humeroulnar joint?
-Flexion > extension
What is the open and closed pack positions of the humeroradial joint?
-Open: extension and supination
-Closed: 90 degrees of flexion and 5 degrees of supination
What is the capsular pattern of the humeroradial joint?
There is none
What is the open and closed pack positions of the proximal radioulnar joint?
-Open: 70 degrees of flexion and 35 degrees of supination
-Closed: 5 degrees of supination
What is the carrying angle of the elbow? What is the normal carrying angle?
-The angle between the humerus and ulna
-10-15 degrees
What is the normal end feel of the humeroulnar joint?
-Flexion: soft tissue
-Extension: bony
What is the normal end feel of the radioulnar joint?
-Supination: capsular
-Pronation: bony
What are the major ligament of the elbow? What motions do they restrict?
-Ulnar collateral ligament (UCL): resists valgus stress
-Radial collateral ligament: resists varus stress
-Annular ligament: supports radial head
What are the 2 bands of the UCL? Which band is more important? When is each band taut?
-Anterior and posterior bands
-Anterior band is more important as it resists valgus stress
-Anterior band: taut from 0-70 degrees of flexion
-Posterior band: taut between 60-120 degrees of flexion
How much stability does the radial collateral ligaments provide to the lateral elbow?
-RCL provides 30-50% stability
-Boney structures provide the other 50-70% of stability
What is the “4th” joint of the elbow?
The interosseous membrane between the ulna and radius
What is the most common diagnosis for lateral elbow pain?
Lateral epicondylalgia
What is the most common diagnosis for medial elbow pain?
-Medial epicondylalgia
-UCL sprain
-Ulnar nerve compression
What is the most common diagnosis for posterior elbow pain?
-Olecranon bursitis
-Triceps tendinosis
-Valgus extension overload (VEO)
What is the most common diagnosis for cubital fossa elbow pain?
-Tear of the brachialis
-Biceps brachii tear
What are common orthopedic conditions of the elbow?
-OA
-Fracture of the radial head
-Olecranon bursitis
-Biceps tendon rupture
-Triceps tendon rupture
-Lateral epicondylalgia
-Medial epicondylaglia
-UCL tear
-“Little league elbow”
What patient population is elbow OA most common in?
Most common in men ages 40-60 with a history of strenuous work, throwing sports, or trauma
What are the subjective findings of elbow OA?
-Pain, stiffness
-Mechanical locking
-Deformity
What are the subjective findings of elbow RA?
Pain and swelling
What are the subjective findings for septic arthritis of the elbow?
-Acute and severe pain, stiffness, and warmth
-Swelling
-Effusion
-Fever, chills, malaise
What is septic arthritis?
A painful joint infection that occurs when bacteria, viruses, or fungi invade a joint’s tissues and fluid
What are the objective findings for elbow RA?
-Joint swelling
-Rheumatoid nodules over the olecranon and extensor surface of the forearm
-Tenderness
-Joint instability
What are the objective findings of elbow OA?
-Joint line tenderness
-Reduced ROM
What are the objective findings of septic arthritis of the elbow?
Severely painful and restricted ROM in the presence of significant effusion and warmth
What are possible interventions for OA of the elbow?
-Rest
-NSAIDs
-Gentle stretching
-Activity modification
What are possible interventions for RA of the elbow?
-Intra-articular corticosteroid injection
-PT
-Splints
What is the primary indication for total elbow arthroplasty?
-Patients with RA with advanced joint destruction and severe limitations
-Patients with OA with severe limitations and/or pain
What is the mechanism of injury for a fracture of the radial head?
-Usually from a FOOSH
-Force of impact transmitted up the hand through the wrist and forearm to the radial head
What are the 4 types of radial head fractures?
-Type I: non-displaced or minimally displaced fx
-Type II: displaced more than 2 mm at the articular surface
-Type III: severely comminuted (bunch of pieces) fx of the radial head and neck
-Type IV: associated with ulnohumeral dislocation
What are the subjective findings of a radial head fracture?
-Complaints of pain and swelling over the lateral aspect of the elbow
-Loss of elbow motion related to pain inhibition and joint diffusion
What are the objective findings of a fracture of the radial head?
-Palpate carefully and feel for deformity at radial head
-Assess neurovascular function for all nerves of the forearm and hand
-Tender over the lateral aspect of the elbow joint
-Passive forearm pronation/supination is typically limited and may have palpable crepitus
-AROM and PROM with flexion and extension may be limited
What are confirmatory tests for radial head fracture?
-Patient history and physical exam findings
-Radiographs
What are possible interventions for type I radial head fx?
-Sling or splint initially
-Early AROM as soon as pain allows
-Strengthening begins at 3 weeks
What is the rule of 3’s for type II radial head fx?
-Non-surgical is considered if the fx involves less than 1/3 of the articular surface
-Less than 30 degrees of angulation
-Displacement is less than 3mm
What are the possible interventions for type III radial head fx?
-Surgical excision of bone fragments or internal fixation
-Rehab after fixation usually lasts 12 weeks
-Do NOT begin AAROM pronation/supination until week 6
What is olecranon bursitis?
-Inflammation of the bursa located between the olecranon process of the ulna and the overlying skin
-Easily bruised through direct trauma or irritated through repetitive weight bearing
What patient population is olecranon bursitis most common in?
-Students and wrestlers
-Athletes who play basketball, football, indoor soccer, and hockey in which the potential for falling and striking an elbow on hard playing surfaces is high
What are the subjective findings of olecranon bursitis?
-Complaints of pain and swelling that can be gradual as in chronic cases or sudden acute injury
-Patients often note decreased ROM or an inability to don a long-sleeved shirt
What are the objective findings of olecranon bursitis?
Swelling over the olecranon process that can vary in size from a slight distention to a mass as large as 6cm
What is a sign of infection with olecranon bursitis?
Redness and heat
What are confirmatory special tests for olecranon bursitis?
-Lab eval of the bursal aspirate
-Aspiration also helps reduce the level of discomfort and restriction of movement
-Cell count, gram stain, and crystal analysis to differentiate between traumatic, infection, or gout
What are possible interventions for olecranon bursitis?
-RICE
-Early motion
-Infected bursa needs prompt medical attention
What is the mechanism of injury of a biceps tendon rupture?
Involve a sudden contraction of the biceps against a significant load with the elbow in 90 degrees of flexion
What population is biceps tendon ruptures most common in?
Most commonly occurs in muscular males in their 50’s
What is the subjective findings of biceps tendon ruptures?
-Sharp, tearing pain concurrent with an acute injury
-Patient often describes loss of strength in activities involving elbow flexion and supination
What are the objective findings of biceps tendon rupture?
-Ecchymosis in antecubital fossa
-Visible deformity (full rupture)
-Loss of strength in elbow flexion
-Loss of forearm supination strength
What are the possible treatment options for biceps tendon rupture?
-Most active individuals have a repair
-If older, they usually do not repair it
What is the mechanism of injury of a triceps tendon rupture?
Occurs when a deceleration force occurs during elbow extension or with an uncoordinated contraction of the triceps muscle against the flexing elbow
What are the objective findings of a triceps tendon rupture?
Commonly has loss of elbow extension strength and an inability to extend overhead against gravity
What are possible treatment options for triceps tendon rupture?
-Surgical repair indicated with complete rupture
-Partial tear can be treated conservatively with immobilization for 3 weeks then gradual progression of ROM and strength
What is lateral epicondylalgia?
-Pathological condition of the common extensor muscles at their origin on the lateral humeral epicondyle
-Specifically involves the tendons that control wrist extension and radial deviation resulting in pain on the lateral side of the elbow
-Affects between 1-3% of the population
What population is lateral epicondylalgia most common in?
-Occurs most commonly between the ages of 35-50
-Seldom seen in those less than 20 y.o.
-Usually effects the dominant arm
What is the mechanism of injury of lateral epicondylalgia?
-Repetitive grasping with wrist extension
-Participants of tennis, baseball, racquetball, etc.
Which tendon is the most commonly effected in lateral epicondylalgia?
Extensor carpi radialis brevis
How can you differentiate between extensor carpi radialis brevis and longus when someone has lateral epicondylalgia?
-Resisted wrist extension with elbow flexed and then with the elbow straight
-ECRB will hurt the same with both
-ECRL will hurt more with elbow straight
What is a grade 1 lateral epicondylalgia?
-Injury probably inflammatory
-Not associated with pathologic alterations
-Likely to resolve
What is a grade 2 lateral epicondylalgia?
-Injury associated with pathologic alterations such as tendinosis or angiofibroblastic degeneration
-This stage most commonly associated with sports related overuse injuries
-Within the tendon, there is fibroblastic and vascular response (tendinosis) rather than an inflammatory response
What is a grade 3 lateral epicondylalgia?
Injury is associated with pathologic changes and complete structural failure (partial tears)
What is a grade 4 lateral epicondylalgia?
-Macroscopic tears
-Associated with other changes such as fibrosis, matrix calcification, and hard osseous calcification
-May be related to use of cortisone
What are the subjective findings of lateral epicondylalgia?
-Complaints of diffuse achiness and morning stiffness of the elbow
-Reports of localized tenderness over the lateral aspect of the elbow
What are the objective findings of lateral epicondylalgia?
-Tenderness usually over the ECRB and ECRL
-AROM usually painless
-PROM into wrist flexion with forearm pronated and elbow extended can be painful
-Resisted tests typically reproduce symptoms especially wrist extension and radial deviation
What are the 5 types of tendon lesions for lateral epicondylalgia?
-Type 1: lesion at origin of ECRL
-Type 2: insertion of ECRB
-Type 3: pain at the radial head
-Type 4: ECRB muscle belly strain
-Type 5: inflammation at the origin of the extensor digitorum
What are the confirmatory special tests for lateral epicondylalgia?
-Cozen’s
-Mill’s
-Maudley’s
What are possible interventions for lateral epicondylalgia?
-Wrist strengthening
-Radial head mobs
-Brace?
-Corticosteroid injections
-Manual therapy
What percent of patients with lateral epicondylalgia improve within a year?
80%
What is medial epicondylalgia?
-Tendinopathy at the attachment of the flexor or pronator muscles at the medial humeral epicondyle
-Mechanism related to overuse
How common is medial epicondylalgia compared to lateral epicondylalgia?
Only 1/3 as common as lateral epicondylalgia
Which tendon is most commonly affected with medial epicondylalgia?
Pronator teres
What are the subjective findings of medial epicondylalgia?
-Complaints of pain along the medial elbow
-History of unaccustomed repetitive lifting, tooling, hammering, or sports activities involving tight gripping
-Reports of increased pain with active wrist flexion and pronation
What are the objective findings of medial epicondylalgia?
-TTP about 5 mm distal to medial epicondyle
-Pain elicited on resisted wrist flexion and pronation
-Pain at extremes of passive wrist extension, supination, and ulnar deviation
What are possible interventions for medial epicondylalgia?
-Conservative intervention has 90% success rate
-Initially rest and activity modification
-Restore ROM, strength, and flexibility after acute phase
-Strengthening program progresses to include concentric and eccentric
How do you know when to progress exercises with medial epicondylalgia?
-When no pain at rest, start more intense stretching
-When no pain with stretching, start resistance training
What is the mechanism of injury of an ulnar collateral (medial) ligament tear?
-Chronic attenuation of valgus and ER forces
-FOOSH
-Baseball throwing, football throwing, tennis serve, etc.
What structure is also commonly injured with a UCL tear?
-Irritation of the ulnar nerve
-Symptoms of ulnar neuritis may be present
What are the subjective findings of UCL tear?
Complaints of medial elbow pain at the ligaments origin or insertion
What are the objective findings of UCL tear?
-Tenderness with palpation along UCL
-Tenderness over the ulnar nerve and a + Tinel sign
-Possible loss of terminal elbow extension
-+ valgus stress test
-MRI
What are possible interventions of UCL tear?
-Early symptoms of UCL injury include rest and activity modification for 2-4 weeks
-Strengthening and stretching
-Initial emphasis on isometrics
When is surgery indicated for UCL tears?
-Competitive throwing athletes
-Pt’s involved in heavy manual labor
What is little league elbow? What patient population does it occur in?
-Apophysitis of the medial epicondyle or injury to the UCL
-Osteochondritis dissecans of the capitulum
-8-15 year olds
What are the subjective findings of little league elbow?
-Medial elbow pain
-Decreased throwing effectiveness and distance
-Swelling
-Occasional flexion contractures
What is used to diagnose little league elbow?
-MRI
-Radiographs
-Physical exam
What is the mechanism of injury of little league elbow?
-During cocking and acceleration phase of pitching
-Valgus stress
-Shearing forces in the posterior elbow
-Compression along the lateral elbow
What is median nerve entrapment?
-Entrapment of the median nerve from the pronator teres muscle
-Also know as pronator teres syndrome
What is the subjective findings of pronator teres syndrome?
-Insidious pain felt on the anterior aspect of the elbow, radial side of the palm, and the palmar side of the 1st, 2nd, and 3rd digits
What are the objective findings of pronator teres syndrome?
-Pressure over the pronator teres 4cm distal to cubital crease with concurrent resistance against pronation, elbow flexion, and wrist flexion
-Pain with resisted pronation
-Pain with resistance of the long finger flexors
-+ pronator teres syndrome test
What are the possible interventions for pronator teres syndrome?
-Responds well to activity modification
-Rest, NSAIDs, ice
-Restore flexibility and strength of wrist flexors and forearm pronators
-Manual techniques to break up adhesions
How many bones are there in the foot? How many synovial joints are there?
-28 bones
-30 synovial joints
-55 articulations
What is the function of the foot and ankle?
Convert the rotational movements that occur with weight bearing activities into sagittal, frontal, and transverse movements
What joint sustains the greatest load per surface area in the body?
The ankle joint
What are peak weight bearing forces through the ankle during walking and running?
-Walking: 120%
-Running: 275%
What are the three subdivisions of the foot?
-Rearfoort/hindfoot
-Midfoot
-Forefoot
What does the rearfoot/hindfoot consist of?
-Tibia
-Fibula
-Calcaneus
-Talus
What does the midfoot consist of?
-Navicular
-Cuboid
-3 cuneiforms
What does the forefoot consist of?
-14 bones of the toes
-5 metatarsals
What are common ankle disorders?
-Ankle sprains/instability
-Osteochondritis Dissecans of talus
Where do most of ankle sprains occur?
85% of ankle sprains occur on the lateral ankle
What ligament is involved in 60-70% of all ankle sprains?
Anterior talofibular ligament (ATFL)
What ligament is involved 20% of the time when the ATFL is sprained?
Calcaneofibular ligament (CFL)
What is the sequence of tears for ankle sprains?
- ATFL
- Anterolateral capsule
- Distal tibiofibular ligament
- CFL
- Posterior talofibular ligament
Why might someone with a lateral ankle sprain experience medial ankle pain?
Due to bone bruising of the talus at the time of injury
How long do bone bruises typically take to heal?
6 months or more
What grades of sprains are there?
-Grade I: 1-24% is torn
-Grade II: 25-99% torn
-Grade III: 100% torn
What is a high ankle sprain?
-High ankle sprains occur when the syndesmosis is stretched and torn
Other structures that can be torn include:
-Anterior inferior tibiofibular ligament
-Posterior inferior tibiofibular ligament
-The transverse ligament
What is the typical mechanism of injury for high ankle sprains?
External rotation or dorsiflexion as these motions can cause the distal tibia and fibula joint to separate
What is the recovery time of a high ankle sprain compared to a lateral ankle sprain?
A high ankle sprain usually takes twice as long to recover from
What is the mechanism of injury for a lateral ankle sprain?
Inversion and plantarflexion
What is a medial ankle sprain? How common is it?
-Injury to the deltoid ligament
-Less common than lateral ankle sprains
-Usually due to trauma
What is the mechanism of injury for a medial ankle sprain?
Excessive eversion and dorsiflexion
What are the Ottawa ankle rules?
-After traumatic incidents or injuries
An ankle X-ray is required if there is any pain in the malleolar zone and any of these findings:
-Bone tenderness at lateral malleolus
-Bone tenderness at medial malleolus
-Inability to weight bear both immediately and in the ER/office
What are the Ottawa foot rules?
A foot X-ray is required if there is pain in the midfoot zone and any of these findings:
-Bone tenderness at navicular bones
-Bone tenderness at base of the 5th metatarsal
-Inability to weight bear both immediately and in ER
How should you treat an ankle sprain during the acute stage?
-Minimize effusion
-Promote early protected motion
-Early supported/protected WBAT
-Cryotherapy
-Compression
-Elevation
-Ankle pumps in free range
How should you treat an ankle sprain during the subacute stage?
-Begin dynamic balance and proprioceptive exercises
-Open chain resistive exercises
-Stationary bike
How should you treat an ankle sprain during the advanced healing stage?
-Restore normal ROM
-Normalize gait
-Pain-free with full weight bearing
-Functional activities
-Enhanced proprioception
What is chronic ankle instability (CAI)? How can it be diagnosed?
-Repeated acute inversion ankle sprains
-Initial sprain being more than 12 months ago
-Frequent episodes of ankle sprains, reports of “giving way”, chronic ankle weakness
-Presentation with pain and instability
-Diagnosis: tenderness, + anterior drawer
What are treatment options for CAI?
-Conservative: PT, splints
-Balance and strength training
-Surgical: repair or reconstruction
What is osteochondritis dissecans of the talus? What is it caused by?
-Fracture of the joint surface (cartilage that can also damage the bone)
-Usually effects the domes of the talus
-Can break off into fragments
-Caused by torsional stress through either impact or cyclical loading and usually follow a twisting injury
What is the clinical presentation of osteochondritis dissecans? How is it diagnosed?
-Persistent pain and swelling with stiffness
-Diagnosis: tenderness, diffuse swelling (needs imaging)
How is osteochondritis dissecans treated?
-Non-displaced lesions are treated with rest and cast immobilization
-Displaced lesions require arthroscopic removal
What are the 4 grades of osteochondritis dissecans?
-Grade I: subchondral impaction
-Grade II: partly detached fragment
-Grade III: non-displaced free fragment
-Grade IV: fragment with 180° shift
What are the most common ankle tendon disorders?
-Tibialis posterior
-Peroneal tendons
-Achilles tendon
What is the origin of the posterior tibial tendon? What is the insertion?
-Origin: posterior surface of tibia
-Insertion: 3 cuneiforms, base of 2-4 metatarsals, cuboid, and navicular tubercle
What is the function of the tibialis posterior?
-Plantar flexion and inversion
-Stabilizes the medial longitudinal arch
What are common pathologies of the posterior tibialis tendon?
-Tenosynovitis
-Incomplete tear
-Complete disruption
What is tenosynovitis?
Inflammation of the tendon sheath
What patient population is posterior tibialis tendon dysfunction most common in?
-Younger patients with inflammatory arthropathy/traumatic rupture
-Older, typically female patient with degenerative tears (knee valgus, over pronation)
What are the subjective findings of a patient with posterior tibialis tendonitis?
-Insidious onset of pain
-Pain felt in one of 3 locations: distal to medial malleolus in area of navicular, proximal to medial malleolus, at the musculotendinous origin or insertion
-Swelling on the medial aspect of the ankle
What are the objective findings with posterior tibialis tendonitis?
-Swelling and tenderness posterior and inferior to the medial malleolus, along the course of the tendon, and at its insertion into the navicular
-Medial arch is decreased or completely flattened
-Heel shows increased valgus
-Pain on resisted ankle PF and inversion
What are some treatment options for posterior tibialis tenosynovitis?
-Rest
-NSAIDs
-Short leg walking cast
-Orthoses
-Steroid injection in tendon sheath
-Synovectomy
What are some treatment options for incomplete tear of the posterior tibialis?
Repair or augmentation with either FDL or FHL
What are some treatment options for complete tear of the posterior tibialis?
-Repair in traumatic cases in young patients
-Tendon transfer with medial calcaneal displacement osteotomy and subtalar/triple arthrodesis (fixed hindfoot)
What are the origins and insertions of the peroneus longus and brevis?
-Origin: fibula and interosseus membrane
-Insertion: Base of I & V metatarsals respectively
What are common pathologies of the peroneal tendons?
-Tenosynovitis
-Sprain/subluxation
What are symptoms of peroneal tendon dysfunction?
-Pain in the outer part of the ankle or just behind the lateral malleolus
-Pain worsens with activity and eases with rest
What is non-surgical treatment options for peroneal tendon dysfunction?
-Rest
-Short leg walking cast
-Lateral heel wedge
-PT
-NSAIDs
-Cortisone injection
What are surgical options for peroneal tendon dysfunction?
-Tenosynovectomy and repair of split
-Stabilization of dislocating tendons by groove deepening, peroneal retinaculum reconstruction, and bone blocks
What is achilles tendinosis?
There will be clinical inflammation but objective pathologic evidence for cellular inflammation is lacking
What is achilles tendonitis?
-Peritendinous inflammation
-Seen in adults in their 30s-40s
-Most commonly affects runners
What are the two types of achilles tendon dysfunction?
-Non-insertional: occurs proximal to retrocalceneal bursa, generally responds well to non-operative treatment
-Insertional: tenderness is localized to calcaneal tendon insertion, more difficult to treat
What are the subjective findings of achilles tendonitis?
-Gradual onset of pain and swelling in the Achilles tendon
-Exacerbated by activity
-Some patients will present with pain and stiffness along the achilles tendon when rising in the morning
What are the objective findings of achilles tendonitis?
-Tenderness & warmth to palpation along tendon
-Decreased active and passive dorsiflexion
-Gait may include: antalgia, premature heel off, leg may be held in ER
What are the conservative treatment options for achilles tendonitis?
-Rest
-Ice
-PT: eccentric loading, correction of lower chain asymmetries
-Orthoses
What are the surgical treatment options for achilles tendonitis?
-Achilles tendon decompression and debridement if unrelieved by 6 months of conservative measures
-90% will have significant relief of symptoms
What are the three types of Achilles tendonitis? How much activity should be reduced with each type?
-Type I: pain is only experienced after activity; reduce activity by 25%
-Type II: pain that occurs both during and after activity but does not affect performance; reduce activity by 50%
-Type III: pain during and after activity that does affect performance; temporarily discontinue activity
What does current evidence suggest is a good treatment plan for achilles tendonitis?
-12 week eccentric program
-Knee bent and knee straight
-To floor level for insertional tendonitis
-Below floor level for non-insertional
What is the mechanism of injury of achilles tendon rupture? What patient population is this most common in?
-Loading on a dorsiflexed ankle with the knee straight or repeated microtrauma
-Consider systemic conditions such as gout, hyperparathyroidism, or previous steroid injections
-Commonly affects young and middle aged athletes
Approximately how long does it take to recover from an achilles tendon rupture?
6-8 months
What are the subjective findings for achilles tendon rupture?
-Feels like being kicked or shot in the leg
-Mechanism: eccentric loading, sudden unexpected dorsiflexion, or direct blow
What are the objective findings for achilles tendon rupture?
Positive Thompson’s test
What is non-operative treatment options for achilles tendon rupture?
-Non-op is indicated in older adults with minimally displaced ruptures
-Serial casting over 10-12 weeks
What is operative treatment options for achilles tendon rupture?
-Repair is indicated in younger patients with clinically displaced ruptures
-Surgery followed by casting regime
What are possible complications of achilles tendon ruptures?
-Wound healing
-Sural nerve damage
-Possible DVT
What are the rates of return to pre-injury level of activity with achilles tendon ruptures?
-Non-operative: 69%
-Operative: 83%
What are the rates of patient satisfaction with achilles tendon ruptures?
-Non-operative: 66%
-Operative: 93%
What are the rates of re-rupture with achilles tendon ruptures?
-Non-operative: up to 33%
-Operative: 2-3%
What is the most common cause of heel pain? What is often associated with this condition?
-Plantar fasciitis
-Heel spurs often associated
What are causes of plantar fasciitis?
-Obesity
-Excessive walking/sporting activity
-Tight plantar fascia & flattening of the arch
What are treatment options for plantar fasciitis?
-Orthoses
-PT
-Injections
-NSAIDs
-In rare cases, surgical release
What are the subjective findings in plantar fasciitis?
-Hx of pain and tenderness on the plantar medial aspect of the heel
-Pain with first steps in the morning
-Pain worsens with activity
What are objective findings with plantar fasciitis?
-Localized pain on palpation along the medial edge of the fascia or at the origin on the anterior edge of calcaneus
-Positive Windlass test
What is the prognosis for plantar fasciitis?
90% who undergo a conservative intervention improve significantly within 12 months
What is retrocalcaneal bursitis?
Inflammation of the retrocalcaneal bursa (subtendinous) or the subcutaneous calcaneal bursa
What are the causes of retrocalcaneal bursitis?
-Repetitive trauma from shoe wear and sports
-Gout, RA, and ankylosing spondyloarthropathies
-Bursal impingement between the Achilles tendon and an excessively prominent posterior-superior aspect of the calcaneus
What are the subjective findings of retrocalcaneal bursitis?
-Posterior ankle pain
-Pain with walking
What are the objective signs of retrocalcaneal bursitis?
-Tenderness
-Lump
-Inflammation
What is the conservative treatment of retrocalcaneal bursitis?
-PT
-Appropriate shoe wear
-Injection
What is the surgical intervention for retrocalcaneal bursitis?
-Resection of Haglund deformity (removal of calcaneal superoposterior prominence, aka “pump bump”)
-Excision of the painful bursa and tendon debridement
What are the most common foot disorders?
-Hallux valgus
-Pes planus (“flat foot”)
-Metatarsal stress fracture
-Morton neuroma
-Tarsal coalition
-Turf toe
-Tarsal tunnel
-Cuboid syndrome
What is hallux valgus (“bunion”)?
-Lateral deviation of great toe
-1st MTP joint and proximal phalanx deviated laterally
-Angle between 1st ray and phalanges greater than 20 degrees
What is the etiology of hallux valgus?
-Familial
-Inappropriate footwear/toe box
-Flat feet
-Long first ray
-Incongruous 1st MTP joint articular surface
-Metatarsus primus varus
-RA
What can hallux valgus cause in the other toes?
Can cause hammer toes (especially in the 2nd toe)
What are signs of hallux valgus?
-Bunion and inflammed overlying bursa and skin
-Valgus and pronation deformity of hallux
-Painful callus on 2nd toe
-Transfer metatarsalgia/thickened skin over MT heads
What are conservative treatment options for hallux valgus?
-Properly fitted, low heeled stiff-soled shoes
-Wide square toe box
-Toe portion stretched to accommodate bunion
-Extra depth shoe to accommodate dorsiflexed 2nd toe
-Splint that separates 1st and 2nd toe
-Silicone bunion pad for pressure relief
-Acute pain management
What are surgical treatment options for hallux valgus?
-Bunionectomy
-Correction of the joint angle
What is pes planus/flat foot?
-Disappearance of the medial longitudinal arch when weight bearing
-Can be flexible (99%) or rigid (1%)
How can you distinguish between flexible or rigid pes planus?
-Jack test
-Toe raise test (if calcaneus does not move into inversion then it is rigid)
What is the etiology of rigid pes planus?
Congenital vertical talus & tarsal coalition
What is tarsal coalition?
-Bones can fuse together
-Can happen between calcaneo-navicular or talocalcaneal
-Can be bony, cartilaginous, or fibrous
What are symptoms of rigid pes planus?
-Foot pain
-Difficulty walking on uneven surfaces
-Foot fatigue
-Peroneal spasm
What is the treatment for rigid pes planus?
-Surgical resection of connecting bar & soft tissue interposition, subtalar arthrodesis, triple arthrodesis
-4-6 weeks of cast immobilization post surgery
What are the most common metatarsal stress fractures?
2nd and 3rd metatarsals most frequently injured
What causes stress fractures?
-Develops after cyclical submaximal loading
-Running on hard surfaces, improper shoes, sudden increase in jogging distances
What are the subjective findings with metatarsal stress fractures?
-Pain and swelling on weight bearing
-Hx of sudden increase in activity, change in running surface, prolonged walking
What are the objective findings for a metatarsal stress fracture?
-Swelling
-Ecchymosis (bruising)
-Tenderness over fractured metatarsal
-May not show on radiographs for 2-3 weeks
What is a Morton’s neuroma?
-Mechanical entrapment of the interdigital nerve
-Not a true neuroma, but rather a perineural fibrosis of the common digital nerve as it passes between metatarsal heads
What is the etiology of Morton’s neuroma?
-Trauma
-Ischemia
-Entrapment
What are the subjective findings of a Morton’s neuroma?
-Symptom of shooting/constant pain on walking
-Pain relieved by rest and removal of footwear
-Clinical sign of third/second cleft tenderness and palpable click on metatarsal squeeze
What patient population is a Morton’s neuroma most prevalent in?
Women are 8-10x more likely to have this condition
Between what digits is a Morton’s neuroma most common?
Between digits 3-4
What is non-operative treatment for Morton’s neuroma?
-Metatarsal pad
-Orthoses
-Injection
-Supportive shoes with wide toe box or shoes with heels more than 2 inches high
What are operative treatments for Morton’s neuroma?
-Excision
-Compression dressing and post-op shoe is placed on the foot
-Dorsal approach allows for immediate weight bearing and suture removal after 2 weeks (plantar approach delays by 2 more weeks)
What is tarsal tunnel?
Entrapment neuropathy of the posterior tibial nerve as it passes between the flexor retinaculum and the medial malleolus
What are the subjective findings for tarsal tunnel?
-Onset may be acute or insidious
-Patient reports poorly localized burning sensation or pain and paresthesia at the medial plantar surface of the foot
-Worse after activity and worse at the end of the work day
What are the objective findings for tarsal tunnel?
-Positive tinel sign
-Pain with passive dorsiflexion or eversion
-Decreased 2 point discrimination on the plantar aspect of the foot
-Varus or valgus deformity of the heel
-Weakness of foot intrinsics with sustained PF of the toes
What are treatment options for tarsal tunnel?
-Local corticosteroid injections
-Orthoses
-Strengthening of foot intrinsics to restore medial longitudinal arch
What is Turf Toe?
Sprain of 1st MTP joint of the great toe
What is the mechanism of injury for turf toe?
Most commonly occurs with hyperextension and varus/valgus stress of the 1st MTP joint
What are the subjective findings with turf toe?
-Complaints of red, swollen, stiff 1st MTP joint
-Joint may be tender on plantar and dorsal surface
-May have limp and may be unable to run or jump
-Hx of a single DF injury or multiple injuries to great toe
What are objective findings of turf toe?
Pain with ligamentous stability testing
What are the grades for turf toe?
-Grade I: minor stretch to soft tissues; little pain or swelling
-Grade II: partial tear of the capsulo-ligamentous structures; moderate pain and swelling, ecchymosis
-Grade III: complete tear of the plantar plate with severe swelling, pain, ecchymosis, inability to weight bear
What is treatment for Turf toe?
-Rest, ice, compression, elevation
-NSAIDs
-Toe tapes to limit DF
-Grade I: return to activities as soon as symptoms allow
-Grade II: 3-14 days of rest
-Grade III: 6 weeks rest from sport
What is cuboid syndrome?
-Disruption of the structural congruity of the calcaneo-cuboid joint complex
-Often misdiagnosed
-Lack of valid and reliable diagnostic tests
How common is cuboid syndrome?
Relatively uncommon (less than 3%) after a lateral ankle sprain
What is the important anatomy of the cuboid?
-The keystone of the lateral column of the foot: concave cuboid rests of convex navicular and lateral cuneiform
-Cuboid is the only mid-tarsal that articulates with the navicular
-Peroneus/fibularis longus slings laterally and inferiorly into a fibrous-osseus tunnel in the plantar aspect of the cuboid
What is the etiology of cuboid syndrome?
-The degree and direction of the force of the peroneus with sudden inversion of the foot causes a medial and inferior glide of the cuboid
-Cuboid subluxes medially and inferiorly
-Disruption of cuboid ligaments occurs
What are objective signs of cuboid syndrome?
-Persistent and localized pain over the cuboid following an inversion sprain
-Pain with toe off during gait
-Inability to perform plyometrics
-Pain radiating along the medial arch and/or the length of the 4th metatarsal
-Limited and painful DF, INV, EV localized to CC joint
-Painful dorsal glides of the cuboid
What are the recommended treatments for cuboid syndrome?
-Cuboid whip (Grade V)
-Cuboid squeeze
-Mobs with movement
-Retraining of the intrinsics of the foot to ensure stable midfoot
-Rehab of whole kinetic chain
-Peroneal & gastroc stretches
What shoe type do people with flat feet need? Why?
-Motion control/stability shoes
-They are over-pronated which “unlocks” the midfoot and does not allow for much stability
What shoe type do people with neutral feet need? Why?
-Neutral shoes
-They have neutral feet therefore do not require special shoes
What shoe type do people with high arches need? Why?
-Cushion shoes
-They are over-supinated and cannot move into pronation to absorb shock during gait
What is joint stability dependent upon in the knee?
-Static restraints of the joint capsule, ligaments, and menisci
-Dynamic restraints of the lower limb muscles
What is one of the most commonly injured joints in the body? Why?
-The knee
-Because the tibia and femur are nearly flat so there is less stability at the joint surfaces
How much internal tibial rotation should occur at the knee joint?
30-40°
How much external tibial rotation should occur at the knee joint?
20-30°
What are the 4 main ligaments of the knee?
-ACL
-PCL
-MCL
-LCL
What movements does the MCL and LCL restrict?
-MCL: restricts valgus force and external tibial rotation
-LCL: restricts varus force and external tibial rotation
What are the smaller ligaments of the knee joint?
-Coronary ligament
-Transverse ligament
-Meniscofemoral (deep MCL)
-Arcuate ligament
-Oblique popliteal ligament
What are some special characteristics of the patella?
-Sesamoid bone (largest in the body)
-5 facets: superior, inferior, lateral, medial, and odd
-During flexion to extension, different parts of the patella articulate with the femoral condyles
What is the purpose of the patella?
-Increase the leverage of torque of quads by increasing distance from the axis of motion
-Provide bony protection to distal joint surface of femoral condyles when knee is flexed
-Prevent damaging compression forces on the quadriceps tendon with resisted knee flexion such as squats
What facets of the patella are in contact with the femur at different degrees of knee flexion?
-0 degrees: no contact
-15-20 degrees: inferior pole
-45 degrees: middle pole
-90 degrees: all facets (NOT odd)
-Full flexion: odd facet and lateral aspect
What activities increase the patellar loading?
-Walking: 0.5x BW
-Cycling: 1.5x BW
-Up stairs: 3.3x BW
-Down stairs: 5x BW
-Jogging: 7-8x BW
-Deep squatting: 20x BW
-Jumping: 20x BW
What are the biomechanics of the superior tib-fib joint?
-Simple synovial joint
-Oriented anterior-lateral, and posterior-medial
-Closed pack: weight bearing during dorsiflexion
What are the ligaments of the superior tib-fib joint?
-Anterior and posterior tib-fib ligament
-Interosseous membrane
What are some key mechanical symptoms to ask a pt about their knee?
-Locking or catching
-Popping
-Giving way
-Pain with stairs
-Difficult walking around corners
What are the 5 Ottawa Knee Rules? What are they used for?
-Age > 55 or < 18
-Unable to walk
-TTP on patella
-TTP on fibular head
-Unable to flex to 90 degrees
-Used to determine if someone needs an X-ray
What are common orthopedic conditions of the knee?
-ACL tear
-PCL tear
-Collateral ligament strain
-Baker’s cyst
-Medial gastroc strain
-Meniscal tear
-Osgood Schlatter’s Disease
-Patellofemoral pain syndrome
-Plica syndrome
-Prepatellar bursitis
-Iliotibial band syndrome
-Patellar dislocation
-Osteoarthritis of the knee
What are the secondary restraints of the ACL?
Internal and external rotation in the NWB knee
What are the subjective findings for ACL tears?
-Risk of injury 2-8x more in women
-Twisting or hyperextension of the knee
-Sensation of their knee “popping” or “giving out”
-Pain and immediate dysfunction
-Instability in the involved knee and inability to walk without assistance
-Immediate swelling
What are the objective findings for ACL tears?
-Large hemarthrosis
-Pain
-Positive special tests for anterior stability
-Involvement of other knee structures
What is the prognosis for an ACL tear?
-Not usually an isolated injury
-Post-op: 8-12 months until full activity
What is an “autograft” vs an “allograft”?
-Autograft: using your own tissue (HS tendon)
-Allograft: using tissue from a cadaver
What is the rejection rate for ACL allografts?
25% rejection rate
What are the pros of using allografts?
-Lack of harvest morbidity
-Less trauma and quicker surgery
-Decreased post op pain
-Easier and early rehab
-Lack of limit to the size of graft
What is the load to failure of the native ACL? What about in ACL autografts?
-Native ACL: 1,725-2,160 N of force
-HS tendon: 2,640 N
-Patellar tendon: 1,580 N
-Quad tendon: 2,185 N
What is the rate of contralateral ACL injury after one ACL injury?
13%
What are the major goals of ACL rehab?
-Gain good functional stability
-Repair muscle strength
-Reach the best possible functional level
-Decrease the risk for re-injury
-Closed and open kinetic chain exercises
What is the general time frame for return to sport post ACL repair/reconstruction?
-Minimum of 6 months, but better to wait 7-10 months
-Generally, light jogging can be started around 4-5 months
How many patients return to sport after ACL repair/reconstruction?
-81% return to some form of sport
-65% return to pre-injury level of activity
-55% return to competitive sports
What is the strongest and largest ligament in the knee?
PCL
What percent of outpatient knee injuries are PCL?
3%
What is the mechanism of injury of PCL tears?
-Often not an isolated injury and other ligaments will be injured or there will be a fx
-“Dashboard injury”
-Direct blow to the anterior tibia or a fall onto the knee w/ the foot in a plantar flexed position
What are special tests for PCL tears?
-Posterior drawer
-Sag sign
What are the subjective findings for collateral ligament sprains?
-Localized swelling or stiffness
-Medial or lateral pain and tenderness
-Most patients are able to ambulate after an acute collateral ligament injury
What are the objective findings for collateral ligament sprain?
-Tender to palpation along its entire course
-MCL may have isolated tenderness at most proximal or distal end
-Positive varus or valgus stress tests
-Laxity in full extension indicates a more extensive injury
What is the most common mechanism of injury for MCL sprains?
Contact/hit on the outside of the knee with a planted foot
What are the different grades of MCL sprains?
-Grade I: pain but no laxity on valgus stress test
-Grade II: laxity only present at 30 degrees
-Grade III: severe laxity at full extension
What is the prognosis for MCL injuries?
-Grade I: 10 days
-Grade II: 3-4 weeks low end
-Grade III: 6-8 weeks
What should be the focus of treatment for MCL sprains?
-With proper rehab, even a full tear can be healed without surgery
-Initially should be focused on controlling edema and slowly progress to improving ROM
What is a Baker’s cyst?
-Abnormal collection of synovial fluid in the fatty layers of the popliteal fossa
-Most common synovial cyst in the knee
What are the subjective findings for Baker’s cyst?
-Complaints of tightness/swelling behind the knee or pain down the back of the leg
-No history or trauma
What are the objective findings Baker’s cyst?
-Pt prone & leg fully extended, an oblong mass is palpable and visible in the medial popliteal fossa
-Active knee flexion may be limited by 10-15 degrees with a large cyst
What are interventions for Baker’s cyst?
-RICE
-For large cysts that interfere with knee function= aspirate
Why are doctors cautious with aspirating a Baker’s cyst?
Due to risk of intra-articular infection
What is the mechanism of injury of a medial gastroc strain?
-Typically results from an acute, forceful push-off with the foot joint in activities such as hill running, jumping, or tennis
-Also from increased volumes of running load, acceleration and deceleration as well as during fatiguing conditions of play or performance
What are subjective findings of medial gastroc strain?
-Complaints of pulling or tearing sensation in the calf (think velcro)
-May hold ankle in PF to avoid placing tendon on the injured muscle
What are the objective findings of medial gastroc strain?
-TTP and swelling over medial gastroc
-Pain aggravated with passive DF
-Inability to perform a single-leg toe raise
-Negative Thompson test
-Peripheral pulses intact
What is the grading for a medial gastroc strain?
-Grade I: little to no loss of strength, less than 10% of fibers disrupted
-Grade II: clear loss of strength, 10-50% of fibers disrupted
-Grade III: more than 50% of fibers disrupted, pain, swelling, tenderness, and bruising
What are interventions for medial gastroc strain?
-Acute: control pain and inflammation
-Gentle AROM & PROM
-Once painfree with symmetrical ROM & strength, full activities can be resumed
-Stretching and strengthening should be continued for several months to overcome increased risk for re-injury
What is the most common cause of mechanical symptoms of the knee?
Meniscal tear
What is the mechanism of injury for a meniscus tear?
-Usually occur when the patient attempts to turn, twist, or change direction when weight bearing
-Also can occur from contact to the lateral or medial aspect of the knee
How do patients with meniscal tears have pain if there are no pain fibers in the menisci?
The tearing and bleeding into the peripheral attachments as well as traction on the capsule that causes production of pain
What are the subjective findings with meniscal tears?
-Reports of significant twisting injury to the knee
-Hx of popping, swelling, or clicking
-Pain along the joint line, particularly with twisting or squatting activities
What is the function of the menisci?
-50% load transmitted in extension
-85% load transmitted at 90 degrees flexion
How much of a pressure increase is there with resection of a meniscus?
Resection of 15-34% increases pressure by 350%
What is the average excursion of the medial and lateral meniscus with knee flexion?
-Medial: 5.2 mm
-Lateral: 11 mm
What are the objective findings for a meniscal tear?
-Tenderness over the medial or lateral joint line
-Some degree of effusion
-Forced flexion and circumduction of the tibia frequently elicit pain
What are the 4 main intervention approaches for meniscal tears?
-Rehab
-Menisectomy
-Meniscus repair
-Allograft transplantation
What is Osgood Schlatter’s disease? When does it occur?
-Osteochondritis of inferior patella, tibial tuberosity, or tibial tubercle traction apophysitis
-A form of periostitis of the tibial apophysitis type that manifests as a partial avulsion of the tibial tuberosity with subsequent osteonecrosis of the fragmented bone
-Occurs during growth spurts
What are the subjective findings of Osgood Schlatter’s?
-Gradually increasing pain and swelling below the involved knee
-Involvement in sporting activities that involve running
What are the objective findings of Osgood Schlatter’s?
-Prominence over the tibial tubercle
-Mild swelling may be evident
-Pinpoint tenderness over the tibial tuberosity
-PROM reveals limitation of knee flexion
-AROM is painful at end ranges
-Resisted knee extension typically reproduces the pain
-Flexibility testing may reveal adaptive shortening of the HS, quads, and calf muscles
What is the prognosis of Osgood Schlatter’s?
Self-limiting and spontaneously remitting over a period of 6-24 months as the tibial tubercle ossifies
What is patellar tendonitis? What is the mechanism of injury?
-Inflammation of the patellar tendon at the inferior pole of the patella or at its insertion at the tibial tubercle
-Overuse condition frequently associated with eccentric overloading during deceleration activities
What are the subjective findings for patellar tendonitis?
-Hx of jumping or kicking sports
-Anterior knee pain
-Pain noted immediately at the end of exercise of following sitting that has been preceded by exercise
-Pain with sitting, squatting, or kneeling
-Pain with climbing or descending stairs, jumping, or running
What are the objective findings of patellar tendonitis?
-Localized tenderness at either the inferior pole of the patella, tibial tubercle, or both
-AROM typically normal
-Pain with passive hyperflexion of the knee
-Pain with resisted knee extension
What are the 3 stages of intervention for patellar tendonitis?
- Relative rest from aggravating activities
- Regaining pain-free motion, flexibility of quads and HS, and exercises focusing on pain-free quad strengthening
- Gradual resumption of the activities that causes the symptoms
What is the prognosis for patellar tendonitis?
Usually self-limiting and responds to rest, stretching, eccentric strengthening, and bracing
What is patellofemoral pain syndrome?
Common disorder that is diagnosed on the presence of anterior or retropatellar knee pain associated with prolonged sitting or with weight bearing activities that load the PF joint (squatting, kneeling, running, and stairs)
What are the subjective findings of patellofemoral pain syndrome?
-Reports of anterior knee pain with going up or down stairs
-Instability of patella with activities
-Usually no hx of trauma and swelling is uncommon
-More common in female than in male patients
What are the objective findings for patellofemoral pain syndrome?
-May see valgus alignment of knees, femoral anteversion, and abnormal tracking
-Quad weakness
-Generalized laxity of patellofemoral ligaments
-Hip weakness
-Poor eccentric quad control in weight bearing
-Positive Clarke’s sign
-Positive apprehension test
What is the plica?
A normal fold in synovium
What is plica syndrome?
Plica that becomes inflamed and thickened from trauma or overuse and may interfere with normal joint motion
What are subjective findings of plica syndrome?
-Insidious onset of knee pain, but can be related to fall or injury
-Activity-related aching in the anterior or anteromedial aspect of the knee
-May be painful snapping or popping
What are the objective findings for plica syndrome?
-Tenderness according to the location of the symptomatic plica
-May be able to reproduce the snapping or popping at 60° of knee flexion with passive extension
What are interventions for plica syndrome?
-Stretching of the quads, HS, and gastroc
-Strengthening
-Ice
-Patellar bracing
-NSAIDs
-Altered sports training schedule
-Surgical if conservative fails
What is prepatellar bursitis?
When the prepatellar bursa becomes inflamed or infected as a result of trauma to the anterior knee such as a direct blow or from chronic irritation from kneeling or hyperextension
What are subjective findings for prepatellar bursitis?
Complaints of knee swelling and knee pain just over the front of the knee
What are the objective findings for prepatellar bursitis?
-Swelling directly over the inferior portion of the patella
-Palpation reveals bursal sac tenderness or bursal sac thickening
-Normal AROM of the knee
What are interventions for prepatellar bursitis?
-Decrease inflammation using cryotherapy
-Patient education on activity modification
-Stretches if there is adaptive shortening of quads, HS, or IT band
What is the prognosis for prepatellar bursitis?
-50% of traumatic bursitis resolves spontaneously
-10% progresses to chronic bursitis and may require bursectomy
What is iliotibial band tendonitis/friction syndrome?
-Excessive friction between iliotibial band (ITB) & lateral femoral condyle
-Common in runners and cyclists
What are subjective findings of iliotibial band friction syndrome?
-Pain at lateral knee
-Progresses to pain immediately with activity
What are the objective findings of iliotibial band friction syndrome?
-Tender at lateral femoral condyle
-Soft tissue swelling & crepitus
-Positive ober’s and/or noble’s compression test
What are interventions for iliotibial band tendonitis/friction syndrome?
-Relative rest
-Ice
-NSAIDs
-Stretching
-Cortisone
-PRP
What is the prognosis for ITB friction syndrome?
-Long recovery!!!
-Improves with rest
Who is most at risk for patellar dislocation or instability?
-Young active patients at highest risk (13-20)
-Common in football and basketball
-More common in women than in men
How common is recurrent patellar dislocation?
Recurrence is common, especially if initial dislocation is before the age of 15
What is the mechanism of injury of patellar dislocation?
Indirect trauma most common; strong quad contraction while leg is in valgus w/ foot planted
What are the subjective findings of patellar dislocation?
-Feel a “pop” and immediate pain
-Obvious knee deformity
-Painful, difficult to bend knee
-May spontaneously relocate
What are the objective findings of patellar dislocation/instability?
-Laterally shifted patella
-Swelling
-Positive patellar apprehension test
What are interventions for patellar dislocation/instability?
-NSAIDs
-Ice
-Patellofemoral knee brace (rigid)
-PT: ROM, quad strengthening, e-stim
-Surgery for recurrent instability
What is the prognosis for patellar dislocation/instability?
Recurrent instability is common but rehab is very useful
What compartment of the knee is most frequently involved with OA?
Medial compartment
What are the subjective findings for knee OA?
-Insidious onset of pain
-Pain with weight bearing
-May have complaints of buckling, locking, or giving way
-Difficulty climbing or descending stairs
-Increased stiffness in AM
What are the objective findings for knee OA?
-Angular deformity through the knee
-Effusion
-Diffuse tenderness along the joint lines
-Loss of AROM in a capsular pattern
What is the prognosis for knee OA?
-Progressive condition
-Can somewhat control symptoms and progression with meds, shoe inserts, strengthening, and bracing
-Severe functional limitations and pain at rest or at night may indicate need for surgery
What are the 4 stages of OA?
-Stage I: doubtful
-Stage II: mild
-Stage III: moderate
-Stage IV: severe
What is the evidence for clinical diagnosis of knee OA?
-Age > 50
-Stiffness > 30 min
-Crepitus
-Bony tenderness
-Bony enlargement
-No palpable warmth
-If greater than 3, sensitivity is 0.95, specificity 0.69
What is involved in the management of knee OA?
-Weight loss
-Exercise program
-Ambulatory AD
-Insoles
-Unloader knee braces
What medications are there to help manage OA?
-Glucosamine/chondroitin sulfate
-Acetaminophen
-NSAIDs
-Cox-2 inhibitors
-Intraarticular injections (glucocorticoids, hyaluronic acid)
Who is a candidate for unicompartmental knee replacement?
-Arthritis in only 1 compartment
-Used in either young or old patient
-Ligaments intact
-No systemic disease
-Weight < 200#
-Dependent on occupation
What are the advantages of unicompartmental knee replacements?
-Better kinematics as cruciate ligaments are retained
-Better ROM
-Better function, especially stairs
-Pain relief is better
-Less frequent and severe complications
-More rapid recovery
-Lower cost
What is the surgical procedure for a TKA?
-Resurface all three surfaces: tibia, femur, patella
-Components fixed to bone with “cement”
-Traditional approach has 20-30cm incision
What is the different between standard TKA and mini/Q-S TKAs?
-Standard: 20-30cm incision
-Mini: 12-14 cm incision, quad snip
-Q-S: 7-10 cm, no quad snip
What is the benefit of minimally invasive (mini and Q-S) TKAs?
-Earlier mobilization
-Less pain
-Cost
-Shorter hospital stay
-Quicker rehab
-Less blood loss
What is the pattern of the trabeculae in the proximal femur?
-Horizontal and vertical patterns that cross over each other
-There is a zone of weakness where there is no trabeculae in the inferior portion of the neck of the femur
What is the capsular pattern of the hip?
-Flexion
-Abduction
-Medial rotation
How many bones make up the hip joint?
-4 bones
-Pubis
-Ilium
-Ischium
-Femur
How many Newton pounds does it take to dislocate the hip?
400
What is the vascularity of the femoral head?
-Ligamentum teres (1/3 supply)
-Circumflex artery
-Superior & inferior gluteal arteries
What is the labrum?
Fibrocatilaginous tissue that increases the joint congruency and stability
What are the 4 major ligaments of the hip?
-Anterior iliofemoral “Y” ligament
-Pubofemoral
-Posterior ischiofemoral
-Ligamentum teres
What motions does the ligamentum teres restrict?
At 90 degrees of hip flexion it limits IR & ER
What are the flexors of the hip?
-Iliacus
-Psoas
-TFL
-Rectus femoris
-Sartorius
-Adductor longus
-Pectineus
What are the extensors of the hip?
-Glute max
-Hamstrings
-Adductor magnus
What are the abductors of the hip?
-Glute med
-TFL
-Superior glute max
-Glute min
What are the adductors of the hip?
-Adductor group
-Pectineus
-Gracilis
-Pectineus
What are the medial rotators of the hip?
-No pure rotator
-TFL
-Glute minimus
-Glute medius anterior fibers
-Adductor group
-Semimembranosus/tendinosis
What are the lateral rotators of the hip?
-Obturator internus/externus
-Gemelli
-Quadratus femoris
-Piriformis
-Glute max
-Posterior fibers of glute med
-Biceps femoris
What is normal hip extension ROM?
10-15 degrees
What is normal hip abduction ROM?
30-50 degrees
What is normal hip adduction ROM?
25-30 degrees
What is normal hip external rotation ROM?
40-60 degrees
What is normal hip internal rotation ROM?
30-40 degrees
What is the normal angle between the femoral neck and shaft?
125 degrees
What is coxa vara?
-Decreased angle between the femoral neck and shaft
-105 degrees
-More horizontal
What is coxa valga?
-Increased angle between the femoral neck and shaft
-140 degrees
-More vertical
Does coxa vara or valga put someone at higher risk of fx?
Coxa vara because now there is an increased load on the neck of the femur
What complications can occur from having coxa valga?
-Increased stress across joint surfaces due to more vertical femoral neck
-Increases overall length of LE
-Decrease physiologic angle at knee
-More likely to get FAI
What complications can occur from having coxa valga?
-Results in increased downward shear forces of the femoral head
-Reduces compressive forces but increase shear and torsional forces at the femoral head/neck junction
-More likely to fx
What is femoral anteversion?
-Increased anterior angle between neck and shaft of femur in the transverse plane
-Anterior orientation of the femoral neck
-Results in more hip IR
What is femoral retroversion?
-Increased posterior angle between neck and shaft of femur in the transverse plane
-Results in more hip ER
-Out toeing gait
What are common orthopedic conditions of the hip?
-Avascular necrosis of the femoral head
-Legg-Calve Perthes Disease
-Slipped capital femoral epiphysis (SCFE)
-Stress fracture of the femoral neck
-Hamstring strain
-Hip adductor tendinopathy
-OA of the hip
-Snapping hip
-Trochanteric bursitis
-Hip labral tears
What occurs during avascular necrosis of the femoral head?
Variable areas of dead trabecular bone and bone marrow extending to and including the subchondral plate
What are the subjective findings of avascular necrosis of the femoral head?
-Pain in the groin, can radiate to the lateral hip, knee, or buttocks
-“Throbbing and deep”
-Most often pain is intermittent and gradual onset
-Antalgic shift
What are common risk factors for avascular necrosis of the femoral head?
-Cumulative corticosteroid total dose
-Alcohol use
-Systemic lupus
-Sickle cell disease
-Trauma
-Cancer
What are objective findings for avascular necrosis of the femoral head?
-Usually painful ROM, especially IR
-Patients have pain with attempted SLR
-Antalgic gait
What is used to diagnose avascular necrosis?
Imaging
What interventions are available for avascular necrosis?
Surgery
What is the prognosis for avascular necrosis of the femoral head?
-Success is related to the stage at which care is initiated
-Complication of AVN include incomplete fx and superimposed degenerative arthritis
What is Legg-Calve-Perthes Disease?
-Idiopathic osteonecrosis of the femoral head in kids aged 4-10 years
-Children are usually malformed with less blood
-The speculated cause is localized manifestation of generalized disorder of the epiphyseal cartilage in the proximal femur
-Unilateral in 90% of patients
Who is at higher risk of Legg-Calve-Perthes disease?
4x more common in boys
What are subjective findings in Legg-Calve-Perthes?
-Vague ache in the groin that radiates to the medial thigh and inner aspect of the knee
-Muscle spasm
What are objective findings of Legg-Calve-Perthes?
-Limp
-Dragging of the leg
-Atrophy of thigh muscles
-Child may be small for their age
-Positive trendelenburg
-Out-toeing of the involved LE
-Decreased abduction and IR
-May be a hip flexion contracture
What is used to diagnose Legg-Calve-Perthes?
-Imaging
-AP and frog-lateral radiographs of the pelvis
What are interventions for Legg-Calve-Perthes?
-For children less than 6 years old and minimal capital femoral epiphysis and normal ROM, physical exams and radiographs every 2 months
-More severe cases would likely be treated with surgery
What is slipped capital femoral epiphysis (SCFE)?
-Displacement of the femoral head through the epiphysis that typically occurs during the adolescent growth spurt
-Femoral head remains in acetabulum and neck is displaced anteriorly
-Most common disorder of the hip in adolescents
What are the subjective findings for slipped capital femoral epiphysis (SCFE)?
-Pain exacerbated by activity
-Hx of groin pain or medial thigh pain
-May be mild weakness in the leg
-May be no hx of trauma, can be as minimal as turning over in bed
What are the objective findings for slipped capital femoral epiphysis (SCFE)?
-Limp
-Decreased ROM
-The involved extremity may be 1-3 cm shorter
What is the only pediatric disorder that causes greater loss of IR when hip is moved into a flexed position?
Slipped capital femoral epiphysis (SCFE)
What are risk factors for slipped capital femoral epiphysis (SCFE)?
-Obesity
-Male
-Greater involvement with sports activities
What is used to diagnose slipped capital femoral epiphysis (SCFE)?
-Radiographs
-IR with hip flexed to 90 degrees
What are interventions for slipped capital femoral epiphysis (SCFE)?
-Relief of symptoms
-Containment of the femoral head
-Restoration of ROM
-Surgical fixation
What is the mechanism of injury for a stress fracture of the femoral neck?
-Results from accelerated bone remodeling in response to repeated stress
-Occurs commonly in military recruits and athletes, especially runners
Where does a stress fracture of the femoral neck typically occur in older people? What about in younger people?
-Older: superior side of the femoral neck
-Younger: inferior side of the femoral neck
What are subjective findings of stress fractures of the femoral neck?
-Onset of hip pain, often associated with recent change in training or change in training surface
-Pain in the deep thigh
-Pain usually occurs with weight bearing or at the extremes of hip motion
What are the objective findings of stress fractures of the femoral neck?
-Physical exam usually negative
-May be empty end feel or pain at end ranges of IR & ER
What special tests can help diagnose stress fractures of the femoral neck?
-Resisted straight leg raise + for pain
-Auscultory patellar-pubic test +
-Fulcrum test + for pain
-Radiographs
What are interventions for stress fractures of the femoral neck?
-Surgically for all tension-side fx
-Bed rest or complete NWB
What is a hamstring strain?
-Strain or rupture of 1 or more HS muscles
-Usually takes place during eccentric loading
What are the key subjective findings for a HS strain?
-Distinct mechanism of injury w/ immediate pain during full stride running or while decelerating quickly
-May hear a “pop”
-Posterior thigh pain, worsened with knee flexion
What are objective findings for a HS strain?
-TTP
-Tenderness reported with passive stretching
-Pain with resisted knee flexion
What are rehab timelines for the 3 grades of HS strain?
-Grade I: continue activities
-Grade II: 5-21 days
-Grade III: 3-12 weeks
What is the most common adductor pathology?
Hip adductor tendinopathy
What is the most common cause of groin pain?
Adductor strain or tendinopathy
What is the mechanism of injury for hip adductor tendinopathy?
-Constant exposure to repetitive loading with activities that involve twisting and turning
-Other theory is muscular imbalance of the combined action of the muscles stabilizing the hip joint
What are the subjective findings for adductor tendinopathy?
-Twinging or stabbing pain in the groin area with quick starts and stops
-Edema or ecchymosis
-Symptoms are aggravated with running, especially directional changes, kicking, SL exercises, cutting, and lunges
What are the objective findings for adductor tendinopathy? What degree of hip flexion targets which muscles?
-Pain with passive abduction
-Pain with resistance
-TTP
-0 degrees: gracilis
-45 degrees: add. longus
-90 degrees: pectineus
What are interventions for adductor tendinopathy?
-RICE in acute stage
-Hip adductor isometrics
-Graded resistive program
What is the prognosis for adductor tendinopathy?
Most patients fully recover fully or only have minimal pain with high intensity activities
What are subjective findings with hip OA?
-Insidious onset of pain
-Progressively worsens with activity
-Painful, limping gait
-Physical activity may induce bouts of pain that last several hours
-May have difficulty climbing stairs & putting on socks
What are objective findings for hip OA?
-Early signs include restriction of IR, abduction, or flexion and pain at end range
-Scour +
-FABER may be +
What are interventions for hip OA?
-Relieving symptoms, reduce risk of progression
-Education
-Modalities
-Swimming or cycling
-Reduction in BW
-Walking stick
-Joint mobs
-Stretches
-Hip strengthening
What is snapping hip?
-Characterized by a snapping or popping sensation that occurs as tendons around the hip move over bony prominences
-Internal: iliopsoas snapping over structures deep to it
-External: snapping of ITB pr glute max over greater trochanter
-Intra-articular: synovial chondromatosis, loose bodies, fracture fragments, and labral tears
What are subjective findings of snapping hip?
-Complaints of snapping or popping localized to greater trochanter
-Snapping cause by subluxation of the iliopsoas tendon
-May be complaints of pain associated with the snapping if the trochanteric bursitis is inflammed
What are objective findings for snapping hip?
-IT band can be felt subluxing
-Snapping of the iliopsoas tendon may be palpated
-Obers may be +
-Thomas may be +
What are interventions for snapping hip?
-Improve muscle length
-Correct strength imbalances
What is the prognosis for snapping hip?
Responds well to conservative management
What are the subjective findings with trochanteric bursitis?
-Lateral thigh, groin, or gluteal pain
-Pain when lying on involved side
-Pain usually worse when rising from a seated or recumbent position
What are objective findings of trochanteric bursitis?
-TTP
-Pain will get much worse with STM
-Resisted abd, ER, or ext painful
-Tightness of hip adductors
-Obers test +
What are interventions for trochanteric bursitis?
-Stretching lateral thigh soft tissues
-Flexibility of ER
-Hip abd strengthening
-Establishing muscular balance
-Orthotics
What is the prognosis for trochanteric bursitis?
-Responds well to conservative measures
-Corticosteroid injection may help
What is the etiology of hip labral tears?
-Trauma
-FAI
-Capsular laxity or hip hypermobility
-Dysplasia
-Degeneration
-Often goes undiagnosed for extended periods of time
What are the subjective findings of labral tears?
-Anterior hip or groin pain
-Often mechanical symptoms of clicking, locking, or giving way
What are the objective findings of hip labral tears?
-FADIR +
-Anterior or posterior labral tear tests +
What are interventions for hip labral tears?
-PT/conservative management: limit pivoting motions, strengthen inhibited muscles, assess foot motion
-Arthroscopic debridement of tear
What is femoral acetabular impingement (FAI)?
-Abnormal bony prominences on the neck of the femur or acetabular rim due to contact between the femoral head-neck junction and the acetabular rim
-Impingement occurs with combined movements, usually flexion and IR or ER
-Prolonged impingement can lead to damage to the labrum and subchondral bone
What is FAI a precursor to?
OA and labral tears
What can PTs do to manage FAI?
-Restore mobility and function
-Decrease pain
-Correct muscular imbalances
-Avoid surgery
What is the prevalence of FAI?
-More common in 20-40 y.o.
-Athletes make up 15% of reported FAI cases
-Sport with repetitive end range hyperextension or hyperflexion combined with abduction at an increased risk for labral tears
What are the two types of FAI?
-CAM
-Pincer
What is CAM FAI?
-Aspherical femoral head
-Bony prominence at anterolateral head-neck junction
-Impinges on the rim of the labrum
-Leads to superior OA
-More common in young athletic males
-FADIR +
What is pincer FAI?
-Over-coverage of femoral head by the acetabulum which impinges on the neck of the femur
-Leads to posterior inferior or central OA
-Middle aged females more common
-Hip extension + ER will be painful
What percent of patients with FAI have both CAM and pincer impingement?
86%
What are common symptoms with FAI and/or labral tears?
-Anterior groin pain
-The C sign
-Described as dull and aching
-Pain is worse with prolonged sitting
-Occasional sharp catching pain with activity
-Increase symptoms with flexion, adduction, and internal rotation
-May limp
What activities should patients with FAI avoid?
-End range flexion, adduction, and internal rotation
-Treadmill running as it encourages internal rotation
-Upright cycling
-Sitting with hips flexed and neutral spine for long periods of time
What surgical options are there for FAI and/or labral tears?
-Arthroscopic repair
-Trimming of bony rim
-Severe cases may require open operation with larger incision
What is Duprytrens disease? What patient population is it more common in? What is the cause?
-Fibroproliferation disease of the palmar fascia
-Often self limiting
-Male > female
-Genetic and environmental
-Usually not treated by PT
What are the typical treatments for Duprytrens contractures?
-Limited evidence for PT
-Surgical approaches such as collage-nase clostridium histolyticum
-Injection and manipulation
-Needle aponeurectomy
-Percutaneous
-Needle fasciotomy
-Fasciectomy
