Final Exam: Wrist & Hand, UE, and LE

Question 1

How many bones are in the wrist and hand?

Answer 1

28 bones

Question 2

What bones are in the proximal carpal row?

Answer 2

-Scaphoid
-Lunate
-Triquetrum
-Pisiform

Question 3

What bones are in the distal carpal row?

Answer 3

-Trapezoid
-Capitate
-Hamate

Question 4

What structure is between the ulna and the proximal carpal row? What structure is it similar to?

Answer 4

-Triangular fibrous cartilage complex
-Structurally and functionally similar to a meniscus

Question 5

What two tendons is the anatomical snuff box between? What artery runs through the snuff box?

Answer 5

-Between extensor pollicis brevis and longus
-Radial artery

Question 6

What are wrist flexion ROM norms?

Answer 6

80-90

Question 7

What are wrist extension ROM norms?

Answer 7

70-90

Question 8

What are radial deviation ROM norms?

Answer 8

15

Question 9

What are ulnar deviation ROM norms?

Answer 9

30-45

Question 10

What are the major ligaments at the wrist?

Answer 10

-Radio-ulnar ligaments strengthen capsule anteriorly and posteriorly
-Carpal ligaments
-Ulnar collateral
-Radial collateral

Question 11

What movement at the wrist tightens the anterior capsule?

Answer 11

Supination

Question 12

What movement at the wrist tightens the posterior capsule?

Answer 12

Pronation

Question 13

What is the functional splint position of the hand?

Answer 13

-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

Question 14

What is the open pack position of the distal radio-ulnar joint?

Answer 14

5-10 degrees of supination

Question 15

What is the open and closed pack position between the radius and ulna and the proximal carpal row?

Answer 15

-Open: neutral and slight ulnar deviation
-Closed: full extension with radial deviation

Question 16

What are questions to ask a patient with a wrist or hand injury?

Answer 16

-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

Question 17

In the presence of trauma, what is the most common cause of radial side wrist/hand pain?

Answer 17

Scaphoid fracture

Question 18

In the absence of trauma, what is the most common cause of radial side wrist/hand pain?

Answer 18

DeQuervain’s tenosynovitis

Question 19

What is the most common cause of wrist/hand pain on the posterior side?

Answer 19

-Radial carpal athritis
-Ganglion cyst

Question 20

What is the most common cause of wrist/hand pain on the ulnar side?

Answer 20

Tear of the triangular fibrocartilage complex (TFCC)

Question 21

What is the most common cause of wrist/hand pain on the anterior side?

Answer 21

-Carpal tunnel
-Ganglion cyst
-Formation of tenosynovitis

Question 22

What are common orthopedic conditions of the wrist?

Answer 22

-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

Question 23

What is carpal tunnel syndrome?

Answer 23

-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

Question 24

What are the subjective findings of carpal tunnel syndrome?

Answer 24

-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

Question 25

What are the objective findings of carpal tunnel syndrome?

Answer 25

-Thenar atrophy may be present -+ Phalen -+ Tinel -+ Carpal tunnel compression test

Question 26

What imaging might be done if carpal tunnel syndrome is suspected?

Answer 26

-Radiograph to rule out bony causes -EMG or nerve conduction studies to rule out other conditions

Question 27

What are possible interventions for carpal tunnel syndrome?

Answer 27

Splinting, especially at night

Question 28

What is De Quervain tenosynovitis? What is it caused by?

Answer 28

-Inflammation of the extensor and abductor tendons of the thumb -Caused by repetitive or unaccustomed use of the thumb

Question 29

What are the subjective findings of De Quervain tenosynovitis?

Answer 29

-Wrist pain on the radial side -Difficulty with grasping and gripping

Question 30

What are the objective findings of De Quervain tenosynovitis?

Answer 30

-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

Question 31

What are possible interventions for De Quervain?

Answer 31

-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

Question 32

What is the prognosis for De Quervains?

Answer 32

-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

Question 33

What are the different types of distal radius fractures?

Answer 33

-Colles -Smith -Barton -Chauffeurs -Die-punch

Question 34

What is a Colles fx?

Answer 34

-Most common type of distal radius fracture -Distal radius fracture fragment is tilted upward or dorsally

Question 35

What is a Smith fx?

Answer 35

-Opposite of Colles -Distal fragment is tilted downwardly or volarly/palmarly

Question 36

What is a Barton fx?

Answer 36

-Intra-articular fracture associated with subluxation of the carpus, along with displaced fragments of the radius

Question 37

What is a Chauffeurs fracture?

Answer 37

Oblique fracture through the base of the radial styloid

Question 38

What is a Die-punch fx?

Answer 38

Depressed fracture of the articular surface opposite the lunate or scaphoid bone

Question 39

What are subjective findings of fracture of the distal radius?

Answer 39

-Acute pain, tenderness, swelling, and deformity of the wrist -Hx of falling onto an outstretched hand or arm

Question 40

What are the objective findings of fracture of the distal radius?

Answer 40

-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

Question 41

What are possible interventions for fx of the distal radius?

Answer 41

-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

Question 42

What is the prognosis of a distal radius fx?

Answer 42

-Typically an uncomplicated course -Occasional malunion or post-traumatic wrist arthritis can occur

Question 43

What patient population is a fx of the scaphoid most common in?

Answer 43

-Most common in young male adults -Diagnosis often delayed or missed

Question 44

What is the most commonly fractured carpal bone? Why?

Answer 44

-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

Question 45

What are the subjective findings of a scaphoid fx?

Answer 45

-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

Question 46

What are the objective findings of scaphoid fx?

Answer 46

-Palpation over the anatomic snuff box markedly tender -Decreased AROM of the wrist -Decreased grip strength -Normal neuro exam

Question 47

What is a clinical pearl for the scaphoid?

Answer 47

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

Question 48

What are confirmatory tests for scaphoid fx?

Answer 48

-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)

Question 49

What are possible interventions for scaphoid fx?

Answer 49

-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

Question 50

What is Gamekeeper's thumb?

Answer 50

-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

Question 51

What are the subjective findings of Gamekeeper's thumb?

Answer 51

-Pain and swelling along the ulnar side of the thumb MCP joint -Complaints of pain, weakness, or loss of stability

Question 52

What are the objective findings of Gamekeeper's thumb?

Answer 52

-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

Question 53

What are confirmatory special tests for Gamekeeper's thumb?

Answer 53

-Valgus stress test in full extension -Valgus stress test at 30 degrees of MCP flexion

Question 54

What are possible interventions of Gamekeeper's thumb?

Answer 54

-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

Question 55

What patient population is OA of the thumb most common in?

Answer 55

-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

Question 56

What are subjective findings of thumb OA?

Answer 56

-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

Question 57

What are objective findings of thumb OA?

Answer 57

-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

Question 58

What are the surgical options for thumb OA after conservative management has failed?

Answer 58

-Ligament reconstruction -Ligament reconstruction and tendon interposition -Total joint arthroplasty -Arthrodesis (fusion)

Question 59

What is the ligament reconstruction surgery for thumb OA? What are pros and cons?

Answer 59

-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

Question 60

What is the ligament reconstruction surgery and tendon interposition (LRTI) for thumb OA? What are pros and cons?

Answer 60

-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

Question 61

What is the total joint arthroplasty surgery for thumb OA? What are pros and cons?

Answer 61

-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

Question 62

What is the arthrodesis surgery for thumb OA? What are pros and cons?

Answer 62

-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

Question 63

What is flexor digitorum profundus avulsion? What is the mechanism of injury?

Answer 63

-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

Question 64

What are the subjective findings of flexor digitorum profundus avulsion?

Answer 64

Hx of trauma involving the digit

Question 65

What are the objective findings of flexor digitorum profundus avulsion?

Answer 65

-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

Question 66

What are possible interventions for flexor digitorum profundus avulsion?

Answer 66

Primarily surgical

Question 67

What is the prognosis for flexor digitorum profundus avulsion?

Answer 67

Depends on acuteness of the diagnosis, rapidity of surgical intervention, and level of tendon retraction

Question 68

What is trigger finger? What fingers are most effected? What is the cause?

Answer 68

-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

Question 69

What are the subjective findings of trigger finger?

Answer 69

-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

Question 70

What are the objective findings of trigger finger?

Answer 70

-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

Question 71

What are possible interventions for trigger finger?

Answer 71

-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

Question 72

What is the prognosis of trigger finger?

Answer 72

-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)

Question 73

What is Mallet finger?

Answer 73

-Deformity of a finger causes when the extensor tendon is damaged (DIP) -Finger/DIP unable to extend -Also called "baseball" finger

Question 74

What is the mechanism of injury of Mallet finger?

Answer 74

-When a ball or object strikes the tip of the finger or thumb -The force damages the thin tendon that straightens the finger

Question 75

What is the treatment for Mallet finger?

Answer 75

-Surgery with Mallet splint for 6-8 weeks -OR extension block k-wire for 4 weeks

Question 76

What is the Mallet splint?

Answer 76

-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

Question 77

When is surgery performed for Mallet finger?

Answer 77

Surgery is performed within a week to reattach the tendon

Question 78

What is the prognosis of Mallet finger?

Answer 78

Will recover completely with surgery

Question 79

What is Boutonniere deformity?

Answer 79

-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

Question 80

What happens if Boutonniere deformity is not treated promptly?

Answer 80

The deformity may progress, resulting in permanent deformity and impaired functioning

Question 81

What is the mechanism of injury of Boutonniere deformity?

Answer 81

-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

Question 82

What are the symptoms of Boutonniere deformity?

Answer 82

-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

Question 83

What is non-surgical treatment of Boutonniere deformity?

Answer 83

-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

Question 84

What is a Swan neck deformity? What is the cause?

Answer 84

-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

Question 85

What are the treatment options for Swan neck deformity?

Answer 85

-Treatment varies! -Splint/brace -Surgery -Replace the joint

Question 86

What are the 4 joints at the shoulder?

Answer 86

-Sternoclavicular -Acromioclavicular -Glenohumeral -Scapulothoracic

Question 87

How much of the humeral head is in contact with the glenoid?

Answer 87

-25% humeral head in contact with glenoid -75% in contact with labrum

Question 88

What is the most commonly dislocated joint in the body? Why?

Answer 88

-GHJ -It lacks bony stability

Question 89

What is the GHJ composed of?

Answer 89

-Fibrous capsule -Ligaments -Surrounding muscles -Glenoid labrum

Question 90

What muscles form part of the capsule?

Answer 90

-The rotator cuff -Supraspinatus -Infraspinatus -Subscapularis -Teres minor

Question 91

What is joint approximation and what is it typically used for?

Answer 91

-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

Question 92

What is joint centration achieved by?

Answer 92

Achieved by the combined neuro-motor tasks of: -Stabilization -Dissociation

Question 93

What is the self perpetuating pattern of movement dysfunction?

Answer 93

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

Question 94

What are local vs global muscles?

Answer 94

-Local: involved in joint stabilization; oxidative -Global: movers; aerobic

Question 95

Which of the rotator cuff muscles is the only one that pulls the humeral head posteriorly? Why?

Answer 95

Subscapularis, because internal rotation causes a posterior glide of the humerus

Question 96

What is closed pack position of the GHJ?

Answer 96

90 degrees of abduction and full ER

Question 97

What is open pack position of the GHJ?

Answer 97

55 degrees abduction, 30 degrees horizontal adduction

Question 98

What is the capsular pattern of the GHJ?

Answer 98

-ER -Abduction -IR

Question 99

What are special questions for the shoulder that a PT should ask the patient?

Answer 99

-Feeling of instability -Popping, catching, painful popping -Tingling -Night time awakening -Trouble lifting, reaching, etc.

Question 100

What does night time awakening suggest for the shoulder?

Answer 100

Internal derangement

Question 101

What are common causes of shoulder injuries?

Answer 101

-Traumatic -Sports -Overuse -Insidious onset

Question 102

What are the 3 types of Kibler classification for scapular dyskinesis?

Answer 102

-Type 1: inferior medial border -Type 2: Medial border off ribs -Type 3: elevated superior border

Question 103

What is Kibler Type 1 scapular dyskinesis? What muscles are tight? Which are weak?

Answer 103

-Inferior medial border more prominent -Anterior tilt of scapula -Coracoid process often TTP -Tight: pec minor, biceps SH -Weak: lower trap, lats, serratus anterior

Question 104

What is Kibler Type 2 scapular dyskinesis? What muscles are tight? Which are weak?

Answer 104

-Entire medial border off ribs -Points glenoid fossa anteriorly -Weak serratus anterior and lower traps

Question 105

What is Kibler Type 3 scapular dyskinesis? What muscles are tight? Which are weak?

Answer 105

-Superior border of the scapula is elevated -Usually with adhesive capsulitis -Tight: upper trap -Weak: lower trap

Question 106

What level of the spine is the acromion at?

Answer 106

C7

Question 107

What level of the spine is the medial portion of the spine of the scapula at?

Answer 107

T3

Question 108

What level of the spine is the inferior border of the scapula at?

Answer 108

T7

Question 109

What are common causes of shoulder pain that do not originate from the shoulder joint?

Answer 109

-C-spine nerve impingement -Peripheral nerve entrapment -Diaphragm irritation -Intrathoracic tumors -Gallbladder problems -Myocardial ischemia -Pancoast tumor

Question 110

What are common shoulder orthopedic conditions?

Answer 110

-Acromioclavicular joint separation -Adhesive capsulitis -Biceps tendonitis -Glenohumeral joint instability -Glenohumeral joint OA -Impingement syndrome -Rotator cuff tear -SLAP lesion -Thoracic outlet syndrome

Question 111

What is the mechanism of injury of acromioclavicular joint separation? What patient population is it more likely in?

Answer 111

-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

Question 112

What are the 6 types of AC joint separation?

Answer 112

-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

Question 113

What are the subjective findings for AC joint separation?

Answer 113

-Relief reported with cradling the involved arm -Localized pain over the AC joint -Pain when lifting the arm

Question 114

What are the objective findings for AC joint separation?

Answer 114

-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

Question 115

What are the interventions for ACJ injury?

Answer 115

-Acute: protection and rest -Sub-acute: strengthening of surrounding muscles

Question 116

What is frozen shoulder? What are the two types?

Answer 116

-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

Question 117

What are the subjective findings of frozen shoulder?

Answer 117

-Diffuse aching at the shoulder -Difficulty sleeping on the involved side -Difficulty dressing and grooming

Question 118

What are the objective findings of frozen shoulder?

Answer 118

-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

Question 119

What are the stages of adhesive capsulitis? How long does each stage last?

Answer 119

-Prefreezing: 1-3 months -Freezing: 3-9 months -Thawing: 9-14 months

Question 120

What are possible interventions for frozen shoulder?

Answer 120

-Patient education -NSAIDs -Steroid injection -PT: ROM, joint mobilizations, pain management

Question 121

What is the prognosis of frozen shoulder?

Answer 121

18 months to 3 years- some patients may never get back to their PLOF

Question 122

What are three pathological disorders that can cause biceps tendonitis?

Answer 122

-Inflammatory/degenerative conditions -Instability of the biceps tendon such as subluxation or dislocation of the tendon -SLAP (superior labrum anterior or posterior) lesion

Question 123

What is the mechanism of injury for biceps tendinopathy and SLAP lesions?

Answer 123

-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

Question 124

What are the subjective findings of biceps tendonitis?

Answer 124

-Diffuse and vague pain in the anterior shoulder or over the bicipital groove -Painful AROM of shoulder flexion

Question 125

What are the objective findings of biceps tendonitis?

Answer 125

-Tenderness over bicipital groove -Possible loss of shoulder ROM -May have painful arc -Pain with resisted elbow flexion -+ speeds test -+ Yergason test

Question 126

What are possible interventions for biceps tendonitis?

Answer 126

-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

Question 127

What are the different types of glenohumeral joint instability?

Answer 127

-Anterior inferior -Multidirectional -Posterior -Inferior

Question 128

What is TUBS?

Answer 128

-Instability caused by a Traumatic event, is Unidirectional, associated with a Bankart lesion, often requires Surgery -TUBS= traumatic, unidirectional, bankart, surgery

Question 129

What is AMBRI?

Answer 129

-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

Question 130

What is the most common type of shoulder dislocation?

Answer 130

Anterior

Question 131

What are the subjective findings of glenohumeral joint instability?

Answer 131

-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

Question 132

What are the objective findings of glenohumeral joint instability?

Answer 132

-+ 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)

Question 133

What are possible interventions for glenohumeral joint instability?

Answer 133

-Rotator cuff strengthening -Shoulder stability exercises

Question 134

What is OA in the shoulder typically a result of?

Answer 134

Usually a long term consequence of trauma such as dislocation, fx, large RC tears

Question 135

What are the subjective findings of shoulder OA?

Answer 135

-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

Question 136

What are the objective findings of shoulder OA?

Answer 136

-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

Question 137

What are possible interventions for shoulder OA?

Answer 137

-Improve GHJ flexibility -RC strengthening

Question 138

What is subacromial pain syndrome (SAPS)?

Answer 138

-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

Question 139

What are the 3 different types of acromions? Which is most likely to cause SAPS?

Answer 139

-Type 1: flat 17% of people -Type 2: curved 43% of people -Type 3: hooked 40% of people

Question 140

What are the contents of the coracoacromial tunnel?

Answer 140

-Supraspinatus tendon -Long head of biceps tendon -Subacromial/subdeltoid bursa -Coracohumeral ligament

Question 141

What is subacromial decompression (SAD) and distal clavicular resection (DCR) surgery?

Answer 141

It is where the surgeons shave down part of the clavicle that can be causing impingement as well as some of the subacromial arch

Question 142

What are the subjective findings of SAPS?

Answer 142

-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.

Question 143

What is stage I SAPS?

Answer 143

-Tenderness at supraspinatus insertion and anterior acromion -Painful arc -Weakness at 90 degrees abduction and flexion

Question 144

What is stage II SAPS?

Answer 144

Physical exam reveals crepitus or catching at 100 degrees of elevation and restriction of PROM

Question 145

What is stage III SAPS?

Answer 145

-Atrophy of the infraspinatus and supraspinatus -More limitation in AROM than PROM compared to the other stages

Question 146

What are the possible interventions for SAPS?

Answer 146

-Strengthen RC -IR and ER isometrics initially -Address strength deficits

Question 147

What is a rotator cuff tear?

Answer 147

-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

Question 148

What are the subjective findings of a rotator cuff tear?

Answer 148

-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

Question 149

What are the grades of rotator cuff tears?

Answer 149

-Small: < 1cm -Medium: 1-3 cm -Large: 3-5 cm -Massive: > 5cm

Question 150

What are the objective findings of rotator cuff tears?

Answer 150

-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

Question 151

What are the diagnostic tools for rotator cuff tear?

Answer 151

-Special tests: drop arm, empty can, lift off test, ER lag sign -Medical imaging

Question 152

What are possible interventions for rotator cuff tears?

Answer 152

-Small or partial tears: intervention is directed toward strengthening the rotator cuff and scapular stabilizers -Full thickness tears usually require surgery followed by PT

Question 153

What is the criteria for operative interventions for rotator cuff tears?

Answer 153

-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

Question 154

What are the rotator cuff repair options? Which option leads to better tendon healing?

Answer 154

-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

Question 155

What are possible post-operative rotator cuff repair complications? How can these be avoided?

Answer 155

-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

Question 156

What percent muscle activation level must a post-operative RCR patient stay below?

Answer 156

Below 15% for 6 weeks post-op

Question 157

What should be the protocol for the first 2 weeks following RCR?

Answer 157

Strict immobilization for 2 weeks, such as a sling

Question 158

What is the strength of a RCR at 6 weeks post-op? What about at 12 weeks?

Answer 158

Only about 19-30% strength of normal and 29-50% at 12 weeks

Question 159

When can AAROM be performed post RCR?

Answer 159

7 weeks

Question 160

What is a SLAP lesion?

Answer 160

-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

Question 161

What is the mechanism of injury of a SLAP lesion?

Answer 161

Typically results from FOOSH, sudden deceleration or traction forces such as catching a falling object, or chronic anterior or posterior instability

Question 162

What are the subjective findings of SLAP lesions?

Answer 162

-History of trauma or overuse -Complaints of pain and/or instability with overhead activities and symptoms of painful clicking, catching, or locking

Question 163

What are the objective findings for a SLAP lesion?

Answer 163

-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

Question 164

What are confirmatory special tests for SLAP lesions?

Answer 164

-O'Brien's active compression -Compression rotation test -Crank test -Biceps load II (or I) -Kim test -Jerk test

Question 165

What are possible interventions for SLAP lesions?

Answer 165

-Conservative interventions should address the underlying hypermobility -Dynamic stabilization exercises of GHJ

Question 166

What is the prognosis for SLAP lesions?

Answer 166

-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

Question 167

What is thoracic outlet syndrome (TOS)?

Answer 167

-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

Question 168

What patient population is TOS more common in?

Answer 168

More common in women with onset of symptoms between 20-50 years old

Question 169

What are the subjective findings of TOS?

Answer 169

-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

Question 170

What are the objective findings of TOS?

Answer 170

-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

Question 171

What trunk of the brachial plexus is most commonly effected by TOS? What specific symptoms would this cause?

Answer 171

-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

Question 172

What are confirmatory special tests for TOS?

Answer 172

-Adson vascular test -Allen pectolaris minor test -Costoclavicular test -Roos test -Hyperabduction maneuver -Passive shoulder shrug

Question 173

What are possible interventions for TOS?

Answer 173

-Correction of postural abnormalities of the neck and shoulder girdle -Pec minor release/stretches -Strengthening of scapular muscles -1st and 2nd rib mobilizations

Question 174

What is the prognosis for TOS patients?

Answer 174

50-90% of patients with TOS respond rapidly to conservative interventions and regain normal, pain-free function of the UE

Question 175

What is the criteria for surgical interventions for TOS?

Answer 175

-Failure to respond to conservative intervention within 4 months -Signs of muscle atrophy -Intermittent paresthesias being replaced by sensory loss -Pain becoming incapacitating

Question 176

What are the most common surgical interventions for TOS?

Answer 176

-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

Question 177

What are the upward rotators of the scapula?

Answer 177

-Upper trap -Serratus anterior -Lower trap

Question 178

What are the downward rotators of the scapula?

Answer 178

-Rhomboids -Levator scapulae -Pectoralis minor

Question 179

What are the 3 articulations at the elbow?

Answer 179

-Humeroradial -Humeroulnar -Proximal radioulnar

Question 180

What is the open and closed pack positions of the humeroulnar joint?

Answer 180

-Open: 70 degrees of flexion and 10 degrees of supination -Closed: maximum extension and supination

Question 181

What is the capsular pattern of the humeroulnar joint?

Answer 181

-Flexion > extension

Question 182

What is the open and closed pack positions of the humeroradial joint?

Answer 182

-Open: extension and supination -Closed: 90 degrees of flexion and 5 degrees of supination

Question 183

What is the capsular pattern of the humeroradial joint?

Answer 183

There is none

Question 184

What is the open and closed pack positions of the proximal radioulnar joint?

Answer 184

-Open: 70 degrees of flexion and 35 degrees of supination -Closed: 5 degrees of supination

Question 185

What is the carrying angle of the elbow? What is the normal carrying angle?

Answer 185

-The angle between the humerus and ulna -10-15 degrees

Question 186

What is the normal end feel of the humeroulnar joint?

Answer 186

-Flexion: soft tissue -Extension: bony

Question 187

What is the normal end feel of the radioulnar joint?

Answer 187

-Supination: capsular -Pronation: bony

Question 188

What are the major ligament of the elbow? What motions do they restrict?

Answer 188

-Ulnar collateral ligament (UCL): resists valgus stress -Radial collateral ligament: resists varus stress -Annular ligament: supports radial head

Question 189

What are the 2 bands of the UCL? Which band is more important? When is each band taut?

Answer 189

-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

Question 190

How much stability does the radial collateral ligaments provide to the lateral elbow?

Answer 190

-RCL provides 30-50% stability -Boney structures provide the other 50-70% of stability

Question 191

What is the "4th" joint of the elbow?

Answer 191

The interosseous membrane between the ulna and radius

Question 192

What is the most common diagnosis for lateral elbow pain?

Answer 192

Lateral epicondylalgia

Question 193

What is the most common diagnosis for medial elbow pain?

Answer 193

-Medial epicondylalgia -UCL sprain -Ulnar nerve compression

Question 194

What is the most common diagnosis for posterior elbow pain?

Answer 194

-Olecranon bursitis -Triceps tendinosis -Valgus extension overload (VEO)

Question 195

What is the most common diagnosis for cubital fossa elbow pain?

Answer 195

-Tear of the brachialis -Biceps brachii tear

Question 196

What are common orthopedic conditions of the elbow?

Answer 196

-OA -Fracture of the radial head -Olecranon bursitis -Biceps tendon rupture -Triceps tendon rupture -Lateral epicondylalgia -Medial epicondylaglia -UCL tear -"Little league elbow"

Question 197

What patient population is elbow OA most common in?

Answer 197

Most common in men ages 40-60 with a history of strenuous work, throwing sports, or trauma

Question 198

What are the subjective findings of elbow OA?

Answer 198

-Pain, stiffness -Mechanical locking -Deformity

Question 199

What are the subjective findings of elbow RA?

Answer 199

Pain and swelling

Question 200

What are the subjective findings for septic arthritis of the elbow?

Answer 200

-Acute and severe pain, stiffness, and warmth -Swelling -Effusion -Fever, chills, malaise

Question 201

What is septic arthritis?

Answer 201

A painful joint infection that occurs when bacteria, viruses, or fungi invade a joint's tissues and fluid

Question 202

What are the objective findings for elbow RA?

Answer 202

-Joint swelling -Rheumatoid nodules over the olecranon and extensor surface of the forearm -Tenderness -Joint instability

Question 203

What are the objective findings of elbow OA?

Answer 203

-Joint line tenderness -Reduced ROM

Question 204

What are the objective findings of septic arthritis of the elbow?

Answer 204

Severely painful and restricted ROM in the presence of significant effusion and warmth

Question 205

What are possible interventions for OA of the elbow?

Answer 205

-Rest -NSAIDs -Gentle stretching -Activity modification

Question 206

What are possible interventions for RA of the elbow?

Answer 206

-Intra-articular corticosteroid injection -PT -Splints

Question 207

What is the primary indication for total elbow arthroplasty?

Answer 207

-Patients with RA with advanced joint destruction and severe limitations -Patients with OA with severe limitations and/or pain

Question 208

What is the mechanism of injury for a fracture of the radial head?

Answer 208

-Usually from a FOOSH -Force of impact transmitted up the hand through the wrist and forearm to the radial head

Question 209

What are the 4 types of radial head fractures?

Answer 209

-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

Question 210

What are the subjective findings of a radial head fracture?

Answer 210

-Complaints of pain and swelling over the lateral aspect of the elbow -Loss of elbow motion related to pain inhibition and joint diffusion

Question 211

What are the objective findings of a fracture of the radial head?

Answer 211

-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

Question 212

What are confirmatory tests for radial head fracture?

Answer 212

-Patient history and physical exam findings -Radiographs

Question 213

What are possible interventions for type I radial head fx?

Answer 213

-Sling or splint initially -Early AROM as soon as pain allows -Strengthening begins at 3 weeks

Question 214

What is the rule of 3's for type II radial head fx?

Answer 214

-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

Question 215

What are the possible interventions for type III radial head fx?

Answer 215

-Surgical excision of bone fragments or internal fixation -Rehab after fixation usually lasts 12 weeks -Do NOT begin AAROM pronation/supination until week 6

Question 216

What is olecranon bursitis?

Answer 216

-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

Question 217

What patient population is olecranon bursitis most common in?

Answer 217

-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

Question 218

What are the subjective findings of olecranon bursitis?

Answer 218

-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

Question 219

What are the objective findings of olecranon bursitis?

Answer 219

Swelling over the olecranon process that can vary in size from a slight distention to a mass as large as 6cm

Question 220

What is a sign of infection with olecranon bursitis?

Answer 220

Redness and heat

Question 221

What are confirmatory special tests for olecranon bursitis?

Answer 221

-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

Question 222

What are possible interventions for olecranon bursitis?

Answer 222

-RICE -Early motion -Infected bursa needs prompt medical attention

Question 223

What is the mechanism of injury of a biceps tendon rupture?

Answer 223

Involve a sudden contraction of the biceps against a significant load with the elbow in 90 degrees of flexion

Question 224

What population is biceps tendon ruptures most common in?

Answer 224

Most commonly occurs in muscular males in their 50's

Question 225

What is the subjective findings of biceps tendon ruptures?

Answer 225

-Sharp, tearing pain concurrent with an acute injury -Patient often describes loss of strength in activities involving elbow flexion and supination

Question 226

What are the objective findings of biceps tendon rupture?

Answer 226

-Ecchymosis in antecubital fossa -Visible deformity (full rupture) -Loss of strength in elbow flexion -Loss of forearm supination strength

Question 227

What are the possible treatment options for biceps tendon rupture?

Answer 227

-Most active individuals have a repair -If older, they usually do not repair it

Question 228

What is the mechanism of injury of a triceps tendon rupture?

Answer 228

Occurs when a deceleration force occurs during elbow extension or with an uncoordinated contraction of the triceps muscle against the flexing elbow

Question 229

What are the objective findings of a triceps tendon rupture?

Answer 229

Commonly has loss of elbow extension strength and an inability to extend overhead against gravity

Question 230

What are possible treatment options for triceps tendon rupture?

Answer 230

-Surgical repair indicated with complete rupture -Partial tear can be treated conservatively with immobilization for 3 weeks then gradual progression of ROM and strength

Question 231

What is lateral epicondylalgia?

Answer 231

-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

Question 232

What population is lateral epicondylalgia most common in?

Answer 232

-Occurs most commonly between the ages of 35-50 -Seldom seen in those less than 20 y.o. -Usually effects the dominant arm

Question 233

What is the mechanism of injury of lateral epicondylalgia?

Answer 233

-Repetitive grasping with wrist extension -Participants of tennis, baseball, racquetball, etc.

Question 234

Which tendon is the most commonly effected in lateral epicondylalgia?

Answer 234

Extensor carpi radialis brevis

Question 235

How can you differentiate between extensor carpi radialis brevis and longus when someone has lateral epicondylalgia?

Answer 235

-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

Question 236

What is a grade 1 lateral epicondylalgia?

Answer 236

-Injury probably inflammatory -Not associated with pathologic alterations -Likely to resolve

Question 237

What is a grade 2 lateral epicondylalgia?

Answer 237

-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

Question 238

What is a grade 3 lateral epicondylalgia?

Answer 238

Injury is associated with pathologic changes and complete structural failure (partial tears)

Question 239

What is a grade 4 lateral epicondylalgia?

Answer 239

-Macroscopic tears -Associated with other changes such as fibrosis, matrix calcification, and hard osseous calcification -May be related to use of cortisone

Question 240

What are the subjective findings of lateral epicondylalgia?

Answer 240

-Complaints of diffuse achiness and morning stiffness of the elbow -Reports of localized tenderness over the lateral aspect of the elbow

Question 241

What are the objective findings of lateral epicondylalgia?

Answer 241

-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

Question 242

What are the 5 types of tendon lesions for lateral epicondylalgia?

Answer 242

-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

Question 243

What are the confirmatory special tests for lateral epicondylalgia?

Answer 243

-Cozen's -Mill's -Maudley's

Question 244

What are possible interventions for lateral epicondylalgia?

Answer 244

-Wrist strengthening -Radial head mobs -Brace? -Corticosteroid injections -Manual therapy

Question 245

What percent of patients with lateral epicondylalgia improve within a year?

Answer 245

80%

Question 246

What is medial epicondylalgia?

Answer 246

-Tendinopathy at the attachment of the flexor or pronator muscles at the medial humeral epicondyle -Mechanism related to overuse

Question 247

How common is medial epicondylalgia compared to lateral epicondylalgia?

Answer 247

Only 1/3 as common as lateral epicondylalgia

Question 248

Which tendon is most commonly affected with medial epicondylalgia?

Answer 248

Pronator teres

Question 249

What are the subjective findings of medial epicondylalgia?

Answer 249

-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

Question 250

What are the objective findings of medial epicondylalgia?

Answer 250

-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

Question 251

What are possible interventions for medial epicondylalgia?

Answer 251

-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

Question 252

How do you know when to progress exercises with medial epicondylalgia?

Answer 252

-When no pain at rest, start more intense stretching -When no pain with stretching, start resistance training

Question 253

What is the mechanism of injury of an ulnar collateral (medial) ligament tear?

Answer 253

-Chronic attenuation of valgus and ER forces -FOOSH -Baseball throwing, football throwing, tennis serve, etc.

Question 254

What structure is also commonly injured with a UCL tear?

Answer 254

-Irritation of the ulnar nerve -Symptoms of ulnar neuritis may be present

Question 255

What are the subjective findings of UCL tear?

Answer 255

Complaints of medial elbow pain at the ligaments origin or insertion

Question 256

What are the objective findings of UCL tear?

Answer 256

-Tenderness with palpation along UCL -Tenderness over the ulnar nerve and a + Tinel sign -Possible loss of terminal elbow extension -+ valgus stress test -MRI

Question 257

What are possible interventions of UCL tear?

Answer 257

-Early symptoms of UCL injury include rest and activity modification for 2-4 weeks -Strengthening and stretching -Initial emphasis on isometrics

Question 258

When is surgery indicated for UCL tears?

Answer 258

-Competitive throwing athletes -Pt's involved in heavy manual labor

Question 259

What is little league elbow? What patient population does it occur in?

Answer 259

-Apophysitis of the medial epicondyle or injury to the UCL -Osteochondritis dissecans of the capitulum -8-15 year olds

Question 260

What are the subjective findings of little league elbow?

Answer 260

-Medial elbow pain -Decreased throwing effectiveness and distance -Swelling -Occasional flexion contractures

Question 261

What is used to diagnose little league elbow?

Answer 261

-MRI -Radiographs -Physical exam

Question 262

What is the mechanism of injury of little league elbow?

Answer 262

-During cocking and acceleration phase of pitching -Valgus stress -Shearing forces in the posterior elbow -Compression along the lateral elbow

Question 263

What is median nerve entrapment?

Answer 263

-Entrapment of the median nerve from the pronator teres muscle -Also know as pronator teres syndrome

Question 264

What is the subjective findings of pronator teres syndrome?

Answer 264

-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

Question 265

What are the objective findings of pronator teres syndrome?

Answer 265

-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

Question 266

What are the possible interventions for pronator teres syndrome?

Answer 266

-Responds well to activity modification -Rest, NSAIDs, ice -Restore flexibility and strength of wrist flexors and forearm pronators -Manual techniques to break up adhesions

Question 267

How many bones are there in the foot? How many synovial joints are there?

Answer 267

-28 bones -30 synovial joints -55 articulations

Question 268

What is the function of the foot and ankle?

Answer 268

Convert the rotational movements that occur with weight bearing activities into sagittal, frontal, and transverse movements

Question 269

What joint sustains the greatest load per surface area in the body?

Answer 269

The ankle joint

Question 270

What are peak weight bearing forces through the ankle during walking and running?

Answer 270

-Walking: 120% -Running: 275%

Question 271

What are the three subdivisions of the foot?

Answer 271

-Rearfoort/hindfoot -Midfoot -Forefoot

Question 272

What does the rearfoot/hindfoot consist of?

Answer 272

-Tibia -Fibula -Calcaneus -Talus

Question 273

What does the midfoot consist of?

Answer 273

-Navicular -Cuboid -3 cuneiforms

Question 274

What does the forefoot consist of?

Answer 274

-14 bones of the toes -5 metatarsals

Question 275

What are common ankle disorders?

Answer 275

-Ankle sprains/instability -Osteochondritis Dissecans of talus

Question 276

Where do most of ankle sprains occur?

Answer 276

85% of ankle sprains occur on the lateral ankle

Question 277

What ligament is involved in 60-70% of all ankle sprains?

Answer 277

Anterior talofibular ligament (ATFL)

Question 278

What ligament is involved 20% of the time when the ATFL is sprained?

Answer 278

Calcaneofibular ligament (CFL)

Question 279

What is the sequence of tears for ankle sprains?

Answer 279

1. ATFL 2. Anterolateral capsule 3. Distal tibiofibular ligament 4. CFL 5. Posterior talofibular ligament

Question 280

Why might someone with a lateral ankle sprain experience medial ankle pain?

Answer 280

Due to bone bruising of the talus at the time of injury

Question 281

How long do bone bruises typically take to heal?

Answer 281

6 months or more

Question 282

What grades of sprains are there?

Answer 282

-Grade I: 1-24% is torn -Grade II: 25-99% torn -Grade III: 100% torn

Question 283

What is a high ankle sprain?

Answer 283

-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

Question 284

What is the typical mechanism of injury for high ankle sprains?

Answer 284

External rotation or dorsiflexion as these motions can cause the distal tibia and fibula joint to separate

Question 285

What is the recovery time of a high ankle sprain compared to a lateral ankle sprain?

Answer 285

A high ankle sprain usually takes twice as long to recover from

Question 286

What is the mechanism of injury for a lateral ankle sprain?

Answer 286

Inversion and plantarflexion

Question 287

What is a medial ankle sprain? How common is it?

Answer 287

-Injury to the deltoid ligament -Less common than lateral ankle sprains -Usually due to trauma

Question 288

What is the mechanism of injury for a medial ankle sprain?

Answer 288

Excessive eversion and dorsiflexion

Question 289

What are the Ottawa ankle rules?

Answer 289

-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

Question 290

What are the Ottawa foot rules?

Answer 290

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

Question 291

How should you treat an ankle sprain during the acute stage?

Answer 291

-Minimize effusion -Promote early protected motion -Early supported/protected WBAT -Cryotherapy -Compression -Elevation -Ankle pumps in free range

Question 292

How should you treat an ankle sprain during the subacute stage?

Answer 292

-Begin dynamic balance and proprioceptive exercises -Open chain resistive exercises -Stationary bike

Question 293

How should you treat an ankle sprain during the advanced healing stage?

Answer 293

-Restore normal ROM -Normalize gait -Pain-free with full weight bearing -Functional activities -Enhanced proprioception

Question 294

What is chronic ankle instability (CAI)? How can it be diagnosed?

Answer 294

-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

Question 295

What are treatment options for CAI?

Answer 295

-Conservative: PT, splints -Balance and strength training -Surgical: repair or reconstruction

Question 296

What is osteochondritis dissecans of the talus? What is it caused by?

Answer 296

-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

Question 297

What is the clinical presentation of osteochondritis dissecans? How is it diagnosed?

Answer 297

-Persistent pain and swelling with stiffness -Diagnosis: tenderness, diffuse swelling (needs imaging)

Question 298

How is osteochondritis dissecans treated?

Answer 298

-Non-displaced lesions are treated with rest and cast immobilization -Displaced lesions require arthroscopic removal

Question 299

What are the 4 grades of osteochondritis dissecans?

Answer 299

-Grade I: subchondral impaction -Grade II: partly detached fragment -Grade III: non-displaced free fragment -Grade IV: fragment with 180° shift

Question 300

What are the most common ankle tendon disorders?

Answer 300

-Tibialis posterior -Peroneal tendons -Achilles tendon

Question 301

What is the origin of the posterior tibial tendon? What is the insertion?

Answer 301

-Origin: posterior surface of tibia -Insertion: 3 cuneiforms, base of 2-4 metatarsals, cuboid, and navicular tubercle

Question 302

What is the function of the tibialis posterior?

Answer 302

-Plantar flexion and inversion -Stabilizes the medial longitudinal arch

Question 303

What are common pathologies of the posterior tibialis tendon?

Answer 303

-Tenosynovitis -Incomplete tear -Complete disruption

Question 304

What is tenosynovitis?

Answer 304

Inflammation of the tendon sheath

Question 305

What patient population is posterior tibialis tendon dysfunction most common in?

Answer 305

-Younger patients with inflammatory arthropathy/traumatic rupture -Older, typically female patient with degenerative tears (knee valgus, over pronation)

Question 306

What are the subjective findings of a patient with posterior tibialis tendonitis?

Answer 306

-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

Question 307

What are the objective findings with posterior tibialis tendonitis?

Answer 307

-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

Question 308

What are some treatment options for posterior tibialis tenosynovitis?

Answer 308

-Rest -NSAIDs -Short leg walking cast -Orthoses -Steroid injection in tendon sheath -Synovectomy

Question 309

What are some treatment options for incomplete tear of the posterior tibialis?

Answer 309

Repair or augmentation with either FDL or FHL

Question 310

What are some treatment options for complete tear of the posterior tibialis?

Answer 310

-Repair in traumatic cases in young patients -Tendon transfer with medial calcaneal displacement osteotomy and subtalar/triple arthrodesis (fixed hindfoot)

Question 311

What are the origins and insertions of the peroneus longus and brevis?

Answer 311

-Origin: fibula and interosseus membrane -Insertion: Base of I & V metatarsals respectively

Question 312

What are common pathologies of the peroneal tendons?

Answer 312

-Tenosynovitis -Sprain/subluxation

Question 313

What are symptoms of peroneal tendon dysfunction?

Answer 313

-Pain in the outer part of the ankle or just behind the lateral malleolus -Pain worsens with activity and eases with rest

Question 314

What is non-surgical treatment options for peroneal tendon dysfunction?

Answer 314

-Rest -Short leg walking cast -Lateral heel wedge -PT -NSAIDs -Cortisone injection

Question 315

What are surgical options for peroneal tendon dysfunction?

Answer 315

-Tenosynovectomy and repair of split -Stabilization of dislocating tendons by groove deepening, peroneal retinaculum reconstruction, and bone blocks

Question 316

What is achilles tendinosis?

Answer 316

There will be clinical inflammation but objective pathologic evidence for cellular inflammation is lacking

Question 317

What is achilles tendonitis?

Answer 317

-Peritendinous inflammation -Seen in adults in their 30s-40s -Most commonly affects runners

Question 318

What are the two types of achilles tendon dysfunction?

Answer 318

-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

Question 319

What are the subjective findings of achilles tendonitis?

Answer 319

-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

Question 320

What are the objective findings of achilles tendonitis?

Answer 320

-Tenderness & warmth to palpation along tendon -Decreased active and passive dorsiflexion -Gait may include: antalgia, premature heel off, leg may be held in ER

Question 321

What are the conservative treatment options for achilles tendonitis?

Answer 321

-Rest -Ice -PT: eccentric loading, correction of lower chain asymmetries -Orthoses

Question 322

What are the surgical treatment options for achilles tendonitis?

Answer 322

-Achilles tendon decompression and debridement if unrelieved by 6 months of conservative measures -90% will have significant relief of symptoms

Question 323

What are the three types of Achilles tendonitis? How much activity should be reduced with each type?

Answer 323

-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

Question 324

What does current evidence suggest is a good treatment plan for achilles tendonitis?

Answer 324

-12 week eccentric program -Knee bent and knee straight -To floor level for insertional tendonitis -Below floor level for non-insertional

Question 325

What is the mechanism of injury of achilles tendon rupture? What patient population is this most common in?

Answer 325

-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

Question 326

Approximately how long does it take to recover from an achilles tendon rupture?

Answer 326

6-8 months

Question 327

What are the subjective findings for achilles tendon rupture?

Answer 327

-Feels like being kicked or shot in the leg -Mechanism: eccentric loading, sudden unexpected dorsiflexion, or direct blow

Question 328

What are the objective findings for achilles tendon rupture?

Answer 328

Positive Thompson's test

Question 329

What is non-operative treatment options for achilles tendon rupture?

Answer 329

-Non-op is indicated in older adults with minimally displaced ruptures -Serial casting over 10-12 weeks

Question 330

What is operative treatment options for achilles tendon rupture?

Answer 330

-Repair is indicated in younger patients with clinically displaced ruptures -Surgery followed by casting regime

Question 331

What are possible complications of achilles tendon ruptures?

Answer 331

-Wound healing -Sural nerve damage -Possible DVT

Question 332

What are the rates of return to pre-injury level of activity with achilles tendon ruptures?

Answer 332

-Non-operative: 69% -Operative: 83%

Question 333

What are the rates of patient satisfaction with achilles tendon ruptures?

Answer 333

-Non-operative: 66% -Operative: 93%

Question 334

What are the rates of re-rupture with achilles tendon ruptures?

Answer 334

-Non-operative: up to 33% -Operative: 2-3%

Question 335

What is the most common cause of heel pain? What is often associated with this condition?

Answer 335

-Plantar fasciitis -Heel spurs often associated

Question 336

What are causes of plantar fasciitis?

Answer 336

-Obesity -Excessive walking/sporting activity -Tight plantar fascia & flattening of the arch

Question 337

What are treatment options for plantar fasciitis?

Answer 337

-Orthoses -PT -Injections -NSAIDs -In rare cases, surgical release

Question 338

What are the subjective findings in plantar fasciitis?

Answer 338

-Hx of pain and tenderness on the plantar medial aspect of the heel -Pain with first steps in the morning -Pain worsens with activity

Question 339

What are objective findings with plantar fasciitis?

Answer 339

-Localized pain on palpation along the medial edge of the fascia or at the origin on the anterior edge of calcaneus -Positive Windlass test

Question 340

What is the prognosis for plantar fasciitis?

Answer 340

90% who undergo a conservative intervention improve significantly within 12 months

Question 341

What is retrocalcaneal bursitis?

Answer 341

Inflammation of the retrocalcaneal bursa (subtendinous) or the subcutaneous calcaneal bursa

Question 342

What are the causes of retrocalcaneal bursitis?

Answer 342

-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

Question 343

What are the subjective findings of retrocalcaneal bursitis?

Answer 343

-Posterior ankle pain -Pain with walking

Question 344

What are the objective signs of retrocalcaneal bursitis?

Answer 344

-Tenderness -Lump -Inflammation

Question 345

What is the conservative treatment of retrocalcaneal bursitis?

Answer 345

-PT -Appropriate shoe wear -Injection

Question 346

What is the surgical intervention for retrocalcaneal bursitis?

Answer 346

-Resection of Haglund deformity (removal of calcaneal superoposterior prominence, aka "pump bump") -Excision of the painful bursa and tendon debridement

Question 347

What are the most common foot disorders?

Answer 347

-Hallux valgus -Pes planus ("flat foot") -Metatarsal stress fracture -Morton neuroma -Tarsal coalition -Turf toe -Tarsal tunnel -Cuboid syndrome

Question 348

What is hallux valgus ("bunion")?

Answer 348

-Lateral deviation of great toe -1st MTP joint and proximal phalanx deviated laterally -Angle between 1st ray and phalanges greater than 20 degrees

Question 349

What is the etiology of hallux valgus?

Answer 349

-Familial -Inappropriate footwear/toe box -Flat feet -Long first ray -Incongruous 1st MTP joint articular surface -Metatarsus primus varus -RA

Question 350

What can hallux valgus cause in the other toes?

Answer 350

Can cause hammer toes (especially in the 2nd toe)

Question 351

What are signs of hallux valgus?

Answer 351

-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

Question 352

What are conservative treatment options for hallux valgus?

Answer 352

-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

Question 353

What are surgical treatment options for hallux valgus?

Answer 353

-Bunionectomy -Correction of the joint angle

Question 354

What is pes planus/flat foot?

Answer 354

-Disappearance of the medial longitudinal arch when weight bearing -Can be flexible (99%) or rigid (1%)

Question 355

How can you distinguish between flexible or rigid pes planus?

Answer 355

-Jack test -Toe raise test (if calcaneus does not move into inversion then it is rigid)

Question 356

What is the etiology of rigid pes planus?

Answer 356

Congenital vertical talus & tarsal coalition

Question 357

What is tarsal coalition?

Answer 357

-Bones can fuse together -Can happen between calcaneo-navicular or talocalcaneal -Can be bony, cartilaginous, or fibrous

Question 358

What are symptoms of rigid pes planus?

Answer 358

-Foot pain -Difficulty walking on uneven surfaces -Foot fatigue -Peroneal spasm

Question 359

What is the treatment for rigid pes planus?

Answer 359

-Surgical resection of connecting bar & soft tissue interposition, subtalar arthrodesis, triple arthrodesis -4-6 weeks of cast immobilization post surgery

Question 360

What are the most common metatarsal stress fractures?

Answer 360

2nd and 3rd metatarsals most frequently injured

Question 361

What causes stress fractures?

Answer 361

-Develops after cyclical submaximal loading -Running on hard surfaces, improper shoes, sudden increase in jogging distances

Question 362

What are the subjective findings with metatarsal stress fractures?

Answer 362

-Pain and swelling on weight bearing -Hx of sudden increase in activity, change in running surface, prolonged walking

Question 363

What are the objective findings for a metatarsal stress fracture?

Answer 363

-Swelling -Ecchymosis (bruising) -Tenderness over fractured metatarsal -May not show on radiographs for 2-3 weeks

Question 364

What is a Morton's neuroma?

Answer 364

-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

Question 365

What is the etiology of Morton's neuroma?

Answer 365

-Trauma -Ischemia -Entrapment

Question 366

What are the subjective findings of a Morton's neuroma?

Answer 366

-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

Question 367

What patient population is a Morton's neuroma most prevalent in?

Answer 367

Women are 8-10x more likely to have this condition

Question 368

Between what digits is a Morton's neuroma most common?

Answer 368

Between digits 3-4

Question 369

What is non-operative treatment for Morton's neuroma?

Answer 369

-Metatarsal pad -Orthoses -Injection -Supportive shoes with wide toe box or shoes with heels more than 2 inches high

Question 370

What are operative treatments for Morton's neuroma?

Answer 370

-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)

Question 371

What is tarsal tunnel?

Answer 371

Entrapment neuropathy of the posterior tibial nerve as it passes between the flexor retinaculum and the medial malleolus

Question 372

What are the subjective findings for tarsal tunnel?

Answer 372

-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

Question 373

What are the objective findings for tarsal tunnel?

Answer 373

-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

Question 374

What are treatment options for tarsal tunnel?

Answer 374

-Local corticosteroid injections -Orthoses -Strengthening of foot intrinsics to restore medial longitudinal arch

Question 375

What is Turf Toe?

Answer 375

Sprain of 1st MTP joint of the great toe

Question 376

What is the mechanism of injury for turf toe?

Answer 376

Most commonly occurs with hyperextension and varus/valgus stress of the 1st MTP joint

Question 377

What are the subjective findings with turf toe?

Answer 377

-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

Question 378

What are objective findings of turf toe?

Answer 378

Pain with ligamentous stability testing

Question 379

What are the grades for turf toe?

Answer 379

-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

Question 380

What is treatment for Turf toe?

Answer 380

-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

Question 381

What is cuboid syndrome?

Answer 381

-Disruption of the structural congruity of the calcaneo-cuboid joint complex -Often misdiagnosed -Lack of valid and reliable diagnostic tests

Question 382

How common is cuboid syndrome?

Answer 382

Relatively uncommon (less than 3%) after a lateral ankle sprain

Question 383

What is the important anatomy of the cuboid?

Answer 383

-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

Question 384

What is the etiology of cuboid syndrome?

Answer 384

-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

Question 385

What are objective signs of cuboid syndrome?

Answer 385

-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

Question 386

What are the recommended treatments for cuboid syndrome?

Answer 386

-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

Question 387

What shoe type do people with flat feet need? Why?

Answer 387

-Motion control/stability shoes -They are over-pronated which "unlocks" the midfoot and does not allow for much stability

Question 388

What shoe type do people with neutral feet need? Why?

Answer 388

-Neutral shoes -They have neutral feet therefore do not require special shoes

Question 389

What shoe type do people with high arches need? Why?

Answer 389

-Cushion shoes -They are over-supinated and cannot move into pronation to absorb shock during gait

Question 390

What is joint stability dependent upon in the knee?

Answer 390

-Static restraints of the joint capsule, ligaments, and menisci -Dynamic restraints of the lower limb muscles

Question 391

What is one of the most commonly injured joints in the body? Why?

Answer 391

-The knee -Because the tibia and femur are nearly flat so there is less stability at the joint surfaces

Question 392

How much internal tibial rotation should occur at the knee joint?

Answer 392

30-40°

Question 393

How much external tibial rotation should occur at the knee joint?

Answer 393

20-30°

Question 394

What are the 4 main ligaments of the knee?

Answer 394

-ACL -PCL -MCL -LCL

Question 395

What movements does the MCL and LCL restrict?

Answer 395

-MCL: restricts valgus force and external tibial rotation -LCL: restricts varus force and external tibial rotation

Question 396

What are the smaller ligaments of the knee joint?

Answer 396

-Coronary ligament -Transverse ligament -Meniscofemoral (deep MCL) -Arcuate ligament -Oblique popliteal ligament

Question 397

What are some special characteristics of the patella?

Answer 397

-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

Question 398

What is the purpose of the patella?

Answer 398

-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

Question 399

What facets of the patella are in contact with the femur at different degrees of knee flexion?

Answer 399

-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

Question 400

What activities increase the patellar loading?

Answer 400

-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

Question 401

What are the biomechanics of the superior tib-fib joint?

Answer 401

-Simple synovial joint -Oriented anterior-lateral, and posterior-medial -Closed pack: weight bearing during dorsiflexion

Question 402

What are the ligaments of the superior tib-fib joint?

Answer 402

-Anterior and posterior tib-fib ligament -Interosseous membrane

Question 403

What are some key mechanical symptoms to ask a pt about their knee?

Answer 403

-Locking or catching -Popping -Giving way -Pain with stairs -Difficult walking around corners

Question 404

What are the 5 Ottawa Knee Rules? What are they used for?

Answer 404

-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

Question 405

What are common orthopedic conditions of the knee?

Answer 405

-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

Question 406

What are the secondary restraints of the ACL?

Answer 406

Internal and external rotation in the NWB knee

Question 407

What are the subjective findings for ACL tears?

Answer 407

-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

Question 408

What are the objective findings for ACL tears?

Answer 408

-Large hemarthrosis -Pain -Positive special tests for anterior stability -Involvement of other knee structures

Question 409

What is the prognosis for an ACL tear?

Answer 409

-Not usually an isolated injury -Post-op: 8-12 months until full activity

Question 410

What is an "autograft" vs an "allograft"?

Answer 410

-Autograft: using your own tissue (HS tendon) -Allograft: using tissue from a cadaver

Question 411

What is the rejection rate for ACL allografts?

Answer 411

25% rejection rate

Question 412

What are the pros of using allografts?

Answer 412

-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

Question 413

What is the load to failure of the native ACL? What about in ACL autografts?

Answer 413

-Native ACL: 1,725-2,160 N of force -HS tendon: 2,640 N -Patellar tendon: 1,580 N -Quad tendon: 2,185 N

Question 414

What is the rate of contralateral ACL injury after one ACL injury?

Answer 414

13%

Question 415

What are the major goals of ACL rehab?

Answer 415

-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

Question 416

What is the general time frame for return to sport post ACL repair/reconstruction?

Answer 416

-Minimum of 6 months, but better to wait 7-10 months -Generally, light jogging can be started around 4-5 months

Question 417

How many patients return to sport after ACL repair/reconstruction?

Answer 417

-81% return to some form of sport -65% return to pre-injury level of activity -55% return to competitive sports

Question 418

What is the strongest and largest ligament in the knee?

Answer 418

PCL

Question 419

What percent of outpatient knee injuries are PCL?

Answer 419

3%

Question 420

What is the mechanism of injury of PCL tears?

Answer 420

-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

Question 421

What are special tests for PCL tears?

Answer 421

-Posterior drawer -Sag sign

Question 422

What are the subjective findings for collateral ligament sprains?

Answer 422

-Localized swelling or stiffness -Medial or lateral pain and tenderness -Most patients are able to ambulate after an acute collateral ligament injury

Question 423

What are the objective findings for collateral ligament sprain?

Answer 423

-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

Question 424

What is the most common mechanism of injury for MCL sprains?

Answer 424

Contact/hit on the outside of the knee with a planted foot

Question 425

What are the different grades of MCL sprains?

Answer 425

-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

Question 426

What is the prognosis for MCL injuries?

Answer 426

-Grade I: 10 days -Grade II: 3-4 weeks low end -Grade III: 6-8 weeks

Question 427

What should be the focus of treatment for MCL sprains?

Answer 427

-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

Question 428

What is a Baker's cyst?

Answer 428

-Abnormal collection of synovial fluid in the fatty layers of the popliteal fossa -Most common synovial cyst in the knee

Question 429

What are the subjective findings for Baker's cyst?

Answer 429

-Complaints of tightness/swelling behind the knee or pain down the back of the leg -No history or trauma

Question 430

What are the objective findings Baker's cyst?

Answer 430

-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

Question 431

What are interventions for Baker's cyst?

Answer 431

-RICE -For large cysts that interfere with knee function= aspirate

Question 432

Why are doctors cautious with aspirating a Baker's cyst?

Answer 432

Due to risk of intra-articular infection

Question 433

What is the mechanism of injury of a medial gastroc strain?

Answer 433

-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

Question 434

What are subjective findings of medial gastroc strain?

Answer 434

-Complaints of pulling or tearing sensation in the calf (think velcro) -May hold ankle in PF to avoid placing tendon on the injured muscle

Question 435

What are the objective findings of medial gastroc strain?

Answer 435

-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

Question 436

What is the grading for a medial gastroc strain?

Answer 436

-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

Question 437

What are interventions for medial gastroc strain?

Answer 437

-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

Question 438

What is the most common cause of mechanical symptoms of the knee?

Answer 438

Meniscal tear

Question 439

What is the mechanism of injury for a meniscus tear?

Answer 439

-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

Question 440

How do patients with meniscal tears have pain if there are no pain fibers in the menisci?

Answer 440

The tearing and bleeding into the peripheral attachments as well as traction on the capsule that causes production of pain

Question 441

What are the subjective findings with meniscal tears?

Answer 441

-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

Question 442

What is the function of the menisci?

Answer 442

-50% load transmitted in extension -85% load transmitted at 90 degrees flexion

Question 443

How much of a pressure increase is there with resection of a meniscus?

Answer 443

Resection of 15-34% increases pressure by 350%

Question 444

What is the average excursion of the medial and lateral meniscus with knee flexion?

Answer 444

-Medial: 5.2 mm -Lateral: 11 mm

Question 445

What are the objective findings for a meniscal tear?

Answer 445

-Tenderness over the medial or lateral joint line -Some degree of effusion -Forced flexion and circumduction of the tibia frequently elicit pain

Question 446

What are the 4 main intervention approaches for meniscal tears?

Answer 446

-Rehab -Menisectomy -Meniscus repair -Allograft transplantation

Question 447

What is Osgood Schlatter's disease? When does it occur?

Answer 447

-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

Question 448

What are the subjective findings of Osgood Schlatter's?

Answer 448

-Gradually increasing pain and swelling below the involved knee -Involvement in sporting activities that involve running

Question 449

What are the objective findings of Osgood Schlatter's?

Answer 449

-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

Question 450

What is the prognosis of Osgood Schlatter's?

Answer 450

Self-limiting and spontaneously remitting over a period of 6-24 months as the tibial tubercle ossifies

Question 451

What is patellar tendonitis? What is the mechanism of injury?

Answer 451

-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

Question 452

What are the subjective findings for patellar tendonitis?

Answer 452

-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

Question 453

What are the objective findings of patellar tendonitis?

Answer 453

-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

Question 454

What are the 3 stages of intervention for patellar tendonitis?

Answer 454

1. Relative rest from aggravating activities 2. Regaining pain-free motion, flexibility of quads and HS, and exercises focusing on pain-free quad strengthening 3. Gradual resumption of the activities that causes the symptoms

Question 455

What is the prognosis for patellar tendonitis?

Answer 455

Usually self-limiting and responds to rest, stretching, eccentric strengthening, and bracing

Question 456

What is patellofemoral pain syndrome?

Answer 456

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)

Question 457

What are the subjective findings of patellofemoral pain syndrome?

Answer 457

-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

Question 458

What are the objective findings for patellofemoral pain syndrome?

Answer 458

-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

Question 459

What is the plica?

Answer 459

A normal fold in synovium

Question 460

What is plica syndrome?

Answer 460

Plica that becomes inflamed and thickened from trauma or overuse and may interfere with normal joint motion

Question 461

What are subjective findings of plica syndrome?

Answer 461

-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

Question 462

What are the objective findings for plica syndrome?

Answer 462

-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

Question 463

What are interventions for plica syndrome?

Answer 463

-Stretching of the quads, HS, and gastroc -Strengthening -Ice -Patellar bracing -NSAIDs -Altered sports training schedule -Surgical if conservative fails

Question 464

What is prepatellar bursitis?

Answer 464

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

Question 465

What are subjective findings for prepatellar bursitis?

Answer 465

Complaints of knee swelling and knee pain just over the front of the knee

Question 466

What are the objective findings for prepatellar bursitis?

Answer 466

-Swelling directly over the inferior portion of the patella -Palpation reveals bursal sac tenderness or bursal sac thickening -Normal AROM of the knee

Question 467

What are interventions for prepatellar bursitis?

Answer 467

-Decrease inflammation using cryotherapy -Patient education on activity modification -Stretches if there is adaptive shortening of quads, HS, or IT band

Question 468

What is the prognosis for prepatellar bursitis?

Answer 468

-50% of traumatic bursitis resolves spontaneously -10% progresses to chronic bursitis and may require bursectomy

Question 469

What is iliotibial band tendonitis/friction syndrome?

Answer 469

-Excessive friction between iliotibial band (ITB) & lateral femoral condyle -Common in runners and cyclists

Question 470

What are subjective findings of iliotibial band friction syndrome?

Answer 470

-Pain at lateral knee -Progresses to pain immediately with activity

Question 471

What are the objective findings of iliotibial band friction syndrome?

Answer 471

-Tender at lateral femoral condyle -Soft tissue swelling & crepitus -Positive ober's and/or noble's compression test

Question 472

What are interventions for iliotibial band tendonitis/friction syndrome?

Answer 472

-Relative rest -Ice -NSAIDs -Stretching -Cortisone -PRP

Question 473

What is the prognosis for ITB friction syndrome?

Answer 473

-Long recovery!!! -Improves with rest

Question 474

Who is most at risk for patellar dislocation or instability?

Answer 474

-Young active patients at highest risk (13-20) -Common in football and basketball -More common in women than in men

Question 475

How common is recurrent patellar dislocation?

Answer 475

Recurrence is common, especially if initial dislocation is before the age of 15

Question 476

What is the mechanism of injury of patellar dislocation?

Answer 476

Indirect trauma most common; strong quad contraction while leg is in valgus w/ foot planted

Question 477

What are the subjective findings of patellar dislocation?

Answer 477

-Feel a "pop" and immediate pain -Obvious knee deformity -Painful, difficult to bend knee -May spontaneously relocate

Question 478

What are the objective findings of patellar dislocation/instability?

Answer 478

-Laterally shifted patella -Swelling -Positive patellar apprehension test

Question 479

What are interventions for patellar dislocation/instability?

Answer 479

-NSAIDs -Ice -Patellofemoral knee brace (rigid) -PT: ROM, quad strengthening, e-stim -Surgery for recurrent instability

Question 480

What is the prognosis for patellar dislocation/instability?

Answer 480

Recurrent instability is common but rehab is very useful

Question 481

What compartment of the knee is most frequently involved with OA?

Answer 481

Medial compartment

Question 482

What are the subjective findings for knee OA?

Answer 482

-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

Question 483

What are the objective findings for knee OA?

Answer 483

-Angular deformity through the knee -Effusion -Diffuse tenderness along the joint lines -Loss of AROM in a capsular pattern

Question 484

What is the prognosis for knee OA?

Answer 484

-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

Question 485

What are the 4 stages of OA?

Answer 485

-Stage I: doubtful -Stage II: mild -Stage III: moderate -Stage IV: severe

Question 486

What is the evidence for clinical diagnosis of knee OA?

Answer 486

-Age > 50 -Stiffness > 30 min -Crepitus -Bony tenderness -Bony enlargement -No palpable warmth -If greater than 3, sensitivity is 0.95, specificity 0.69

Question 487

What is involved in the management of knee OA?

Answer 487

-Weight loss -Exercise program -Ambulatory AD -Insoles -Unloader knee braces

Question 488

What medications are there to help manage OA?

Answer 488

-Glucosamine/chondroitin sulfate -Acetaminophen -NSAIDs -Cox-2 inhibitors -Intraarticular injections (glucocorticoids, hyaluronic acid)

Question 489

Who is a candidate for unicompartmental knee replacement?

Answer 489

-Arthritis in only 1 compartment -Used in either young or old patient -Ligaments intact -No systemic disease -Weight < 200# -Dependent on occupation

Question 490

What are the advantages of unicompartmental knee replacements?

Answer 490

-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

Question 491

What is the surgical procedure for a TKA?

Answer 491

-Resurface all three surfaces: tibia, femur, patella -Components fixed to bone with "cement" -Traditional approach has 20-30cm incision

Question 492

What is the different between standard TKA and mini/Q-S TKAs?

Answer 492

-Standard: 20-30cm incision -Mini: 12-14 cm incision, quad snip -Q-S: 7-10 cm, no quad snip

Question 493

What is the benefit of minimally invasive (mini and Q-S) TKAs?

Answer 493

-Earlier mobilization -Less pain -Cost -Shorter hospital stay -Quicker rehab -Less blood loss

Question 494

What is the pattern of the trabeculae in the proximal femur?

Answer 494

-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

Question 495

What is the capsular pattern of the hip?

Answer 495

-Flexion -Abduction -Medial rotation

Question 496

How many bones make up the hip joint?

Answer 496

-4 bones -Pubis -Ilium -Ischium -Femur

Question 497

How many Newton pounds does it take to dislocate the hip?

Answer 497

400

Question 498

What is the vascularity of the femoral head?

Answer 498

-Ligamentum teres (1/3 supply) -Circumflex artery -Superior & inferior gluteal arteries

Question 499

What is the labrum?

Answer 499

Fibrocatilaginous tissue that increases the joint congruency and stability

Question 500

What are the 4 major ligaments of the hip?

Answer 500

-Anterior iliofemoral "Y" ligament -Pubofemoral -Posterior ischiofemoral -Ligamentum teres

Question 501

What motions does the ligamentum teres restrict?

Answer 501

At 90 degrees of hip flexion it limits IR & ER

Question 502

What are the flexors of the hip?

Answer 502

-Iliacus -Psoas -TFL -Rectus femoris -Sartorius -Adductor longus -Pectineus

Question 503

What are the extensors of the hip?

Answer 503

-Glute max -Hamstrings -Adductor magnus

Question 504

What are the abductors of the hip?

Answer 504

-Glute med -TFL -Superior glute max -Glute min

Question 505

What are the adductors of the hip?

Answer 505

-Adductor group -Pectineus -Gracilis -Pectineus

Question 506

What are the medial rotators of the hip?

Answer 506

-No pure rotator -TFL -Glute minimus -Glute medius anterior fibers -Adductor group -Semimembranosus/tendinosis

Question 507

What are the lateral rotators of the hip?

Answer 507

-Obturator internus/externus -Gemelli -Quadratus femoris -Piriformis -Glute max -Posterior fibers of glute med -Biceps femoris

Question 508

What is normal hip extension ROM?

Answer 508

10-15 degrees

Question 509

What is normal hip abduction ROM?

Answer 509

30-50 degrees

Question 510

What is normal hip adduction ROM?

Answer 510

25-30 degrees

Question 511

What is normal hip external rotation ROM?

Answer 511

40-60 degrees

Question 512

What is normal hip internal rotation ROM?

Answer 512

30-40 degrees

Question 513

What is the normal angle between the femoral neck and shaft?

Answer 513

125 degrees

Question 514

What is coxa vara?

Answer 514

-Decreased angle between the femoral neck and shaft -105 degrees -More horizontal

Question 515

What is coxa valga?

Answer 515

-Increased angle between the femoral neck and shaft -140 degrees -More vertical

Question 516

Does coxa vara or valga put someone at higher risk of fx?

Answer 516

Coxa vara because now there is an increased load on the neck of the femur

Question 517

What complications can occur from having coxa valga?

Answer 517

-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

Question 518

What complications can occur from having coxa valga?

Answer 518

-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

Question 519

What is femoral anteversion?

Answer 519

-Increased anterior angle between neck and shaft of femur in the transverse plane -Anterior orientation of the femoral neck -Results in more hip IR

Question 520

What is femoral retroversion?

Answer 520

-Increased posterior angle between neck and shaft of femur in the transverse plane -Results in more hip ER -Out toeing gait

Question 521

What are common orthopedic conditions of the hip?

Answer 521

-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

Question 522

What occurs during avascular necrosis of the femoral head?

Answer 522

Variable areas of dead trabecular bone and bone marrow extending to and including the subchondral plate

Question 523

What are the subjective findings of avascular necrosis of the femoral head?

Answer 523

-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

Question 524

What are common risk factors for avascular necrosis of the femoral head?

Answer 524

-Cumulative corticosteroid total dose -Alcohol use -Systemic lupus -Sickle cell disease -Trauma -Cancer

Question 525

What are objective findings for avascular necrosis of the femoral head?

Answer 525

-Usually painful ROM, especially IR -Patients have pain with attempted SLR -Antalgic gait

Question 526

What is used to diagnose avascular necrosis?

Answer 526

Imaging

Question 527

What interventions are available for avascular necrosis?

Answer 527

Surgery

Question 528

What is the prognosis for avascular necrosis of the femoral head?

Answer 528

-Success is related to the stage at which care is initiated -Complication of AVN include incomplete fx and superimposed degenerative arthritis

Question 529

What is Legg-Calve-Perthes Disease?

Answer 529

-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

Question 530

Who is at higher risk of Legg-Calve-Perthes disease?

Answer 530

4x more common in boys

Question 531

What are subjective findings in Legg-Calve-Perthes?

Answer 531

-Vague ache in the groin that radiates to the medial thigh and inner aspect of the knee -Muscle spasm

Question 532

What are objective findings of Legg-Calve-Perthes?

Answer 532

-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

Question 533

What is used to diagnose Legg-Calve-Perthes?

Answer 533

-Imaging -AP and frog-lateral radiographs of the pelvis

Question 534

What are interventions for Legg-Calve-Perthes?

Answer 534

-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

Question 535

What is slipped capital femoral epiphysis (SCFE)?

Answer 535

-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

Question 536

What are the subjective findings for slipped capital femoral epiphysis (SCFE)?

Answer 536

-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

Question 537

What are the objective findings for slipped capital femoral epiphysis (SCFE)?

Answer 537

-Limp -Decreased ROM -The involved extremity may be 1-3 cm shorter

Question 538

What is the only pediatric disorder that causes greater loss of IR when hip is moved into a flexed position?

Answer 538

Slipped capital femoral epiphysis (SCFE)

Question 539

What are risk factors for slipped capital femoral epiphysis (SCFE)?

Answer 539

-Obesity -Male -Greater involvement with sports activities

Question 540

What is used to diagnose slipped capital femoral epiphysis (SCFE)?

Answer 540

-Radiographs -IR with hip flexed to 90 degrees

Question 541

What are interventions for slipped capital femoral epiphysis (SCFE)?

Answer 541

-Relief of symptoms -Containment of the femoral head -Restoration of ROM -Surgical fixation

Question 542

What is the mechanism of injury for a stress fracture of the femoral neck?

Answer 542

-Results from accelerated bone remodeling in response to repeated stress -Occurs commonly in military recruits and athletes, especially runners

Question 543

Where does a stress fracture of the femoral neck typically occur in older people? What about in younger people?

Answer 543

-Older: superior side of the femoral neck -Younger: inferior side of the femoral neck

Question 544

What are subjective findings of stress fractures of the femoral neck?

Answer 544

-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

Question 545

What are the objective findings of stress fractures of the femoral neck?

Answer 545

-Physical exam usually negative -May be empty end feel or pain at end ranges of IR & ER

Question 546

What special tests can help diagnose stress fractures of the femoral neck?

Answer 546

-Resisted straight leg raise + for pain -Auscultory patellar-pubic test + -Fulcrum test + for pain -Radiographs

Question 547

What are interventions for stress fractures of the femoral neck?

Answer 547

-Surgically for all tension-side fx -Bed rest or complete NWB

Question 548

What is a hamstring strain?

Answer 548

-Strain or rupture of 1 or more HS muscles -Usually takes place during eccentric loading

Question 549

What are the key subjective findings for a HS strain?

Answer 549

-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

Question 550

What are objective findings for a HS strain?

Answer 550

-TTP -Tenderness reported with passive stretching -Pain with resisted knee flexion

Question 551

What are rehab timelines for the 3 grades of HS strain?

Answer 551

-Grade I: continue activities -Grade II: 5-21 days -Grade III: 3-12 weeks

Question 552

What is the most common adductor pathology?

Answer 552

Hip adductor tendinopathy

Question 553

What is the most common cause of groin pain?

Answer 553

Adductor strain or tendinopathy

Question 554

What is the mechanism of injury for hip adductor tendinopathy?

Answer 554

-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

Question 555

What are the subjective findings for adductor tendinopathy?

Answer 555

-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

Question 556

What are the objective findings for adductor tendinopathy? What degree of hip flexion targets which muscles?

Answer 556

-Pain with passive abduction -Pain with resistance -TTP -0 degrees: gracilis -45 degrees: add. longus -90 degrees: pectineus

Question 557

What are interventions for adductor tendinopathy?

Answer 557

-RICE in acute stage -Hip adductor isometrics -Graded resistive program

Question 558

What is the prognosis for adductor tendinopathy?

Answer 558

Most patients fully recover fully or only have minimal pain with high intensity activities

Question 559

What are subjective findings with hip OA?

Answer 559

-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

Question 560

What are objective findings for hip OA?

Answer 560

-Early signs include restriction of IR, abduction, or flexion and pain at end range -Scour + -FABER may be +

Question 561

What are interventions for hip OA?

Answer 561

-Relieving symptoms, reduce risk of progression -Education -Modalities -Swimming or cycling -Reduction in BW -Walking stick -Joint mobs -Stretches -Hip strengthening

Question 562

What is snapping hip?

Answer 562

-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

Question 563

What are subjective findings of snapping hip?

Answer 563

-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

Question 564

What are objective findings for snapping hip?

Answer 564

-IT band can be felt subluxing -Snapping of the iliopsoas tendon may be palpated -Obers may be + -Thomas may be +

Question 565

What are interventions for snapping hip?

Answer 565

-Improve muscle length -Correct strength imbalances

Question 566

What is the prognosis for snapping hip?

Answer 566

Responds well to conservative management

Question 567

What are the subjective findings with trochanteric bursitis?

Answer 567

-Lateral thigh, groin, or gluteal pain -Pain when lying on involved side -Pain usually worse when rising from a seated or recumbent position

Question 568

What are objective findings of trochanteric bursitis?

Answer 568

-TTP -Pain will get much worse with STM -Resisted abd, ER, or ext painful -Tightness of hip adductors -Obers test +

Question 569

What are interventions for trochanteric bursitis?

Answer 569

-Stretching lateral thigh soft tissues -Flexibility of ER -Hip abd strengthening -Establishing muscular balance -Orthotics

Question 570

What is the prognosis for trochanteric bursitis?

Answer 570

-Responds well to conservative measures -Corticosteroid injection may help

Question 571

What is the etiology of hip labral tears?

Answer 571

-Trauma -FAI -Capsular laxity or hip hypermobility -Dysplasia -Degeneration -Often goes undiagnosed for extended periods of time

Question 572

What are the subjective findings of labral tears?

Answer 572

-Anterior hip or groin pain -Often mechanical symptoms of clicking, locking, or giving way

Question 573

What are the objective findings of hip labral tears?

Answer 573

-FADIR + -Anterior or posterior labral tear tests +

Question 574

What are interventions for hip labral tears?

Answer 574

-PT/conservative management: limit pivoting motions, strengthen inhibited muscles, assess foot motion -Arthroscopic debridement of tear

Question 575

What is femoral acetabular impingement (FAI)?

Answer 575

-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

Question 576

What is FAI a precursor to?

Answer 576

OA and labral tears

Question 577

What can PTs do to manage FAI?

Answer 577

-Restore mobility and function -Decrease pain -Correct muscular imbalances -Avoid surgery

Question 578

What is the prevalence of FAI?

Answer 578

-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

Question 579

What are the two types of FAI?

Answer 579

-CAM -Pincer

Question 580

What is CAM FAI?

Answer 580

-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 +

Question 581

What is pincer FAI?

Answer 581

-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

Question 582

What percent of patients with FAI have both CAM and pincer impingement?

Answer 582

86%

Question 583

What are common symptoms with FAI and/or labral tears?

Answer 583

-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

Question 584

What activities should patients with FAI avoid?

Answer 584

-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

Question 585

What surgical options are there for FAI and/or labral tears?

Answer 585

-Arthroscopic repair -Trimming of bony rim -Severe cases may require open operation with larger incision

Question 586

What is Duprytrens disease? What patient population is it more common in? What is the cause?

Answer 586

-Fibroproliferation disease of the palmar fascia -Often self limiting -Male > female -Genetic and environmental -Usually not treated by PT

Question 587

What are the typical treatments for Duprytrens contractures?

Answer 587

-Limited evidence for PT -Surgical approaches such as collage-nase clostridium histolyticum -Injection and manipulation -Needle aponeurectomy -Percutaneous -Needle fasciotomy -Fasciectomy