HSS final Flashcards
muscle strain mechanism of injury
most common in two joint muscles when they are max elongated during quick powerful contractions and quick eccentric contractions (eg hamstrings decelerating leg)
grades of muscle strain: severity, presentation and common length of recovery
I
II
III
grade I- minimal damage to single muscle (>5%), generally 2-3 weeks recovery
minimal loss of strength and motion
grade II- more extensive but not completely ruptured
generally 2-3 months before a complete return to athletics
significant loss of strength and motion. These injuries may require
Grade III: Complete rupture of a muscle or tendon
These can present with a palpable defect in the muscle or tendon
generally need surgery
what is most important in R.I.C.E.?
ice most important to slow cell metabolism and stop 2 edema
2 edema => losing proteins
general rehab principles
- rice
- protection
- AROM
- flexibility => lengthen motion
- strengthening
myositis ossificans
heterotropic ossification (bone growth) in muscle after injury to muscle, usually from direct blow in contact sports
most common in thigh and quads
4 common overuse injuries
- patella tendinitis
- PFPS
- ITB syndrome
- plantar fascitis
7 treatment progressions for overuse injuries
- determine cause during eval
- activity modification
- NSAIDs
- therapeutic modalities
- flexibility
- strength
- return to sport
ACL injury- who is it most common in? why?
most common in women > men because wider pelvis => increased flexion and tibial torsion
ACL anatomy
2 bands and when they are taut
- anteromedial - taut in flexion
2. posterolateral- taut in extension
ACL function (4)
- mechanoreceptors for proprioception
- prevents forward translation of tib on femur
- checks IR
- checks hyperextension
ACL biomechanics during…
active knee ext (OKC)
tibial rotation
active knee extension (60-0): increased anterior translation
tibial rotation: ACL stress increases as tibal rotation increases
ACL mechanism of injury (3)
- hyperextension
- varus/ valgus force
- rotation
unhappy triad of knee injury**
ACL
MCL
medial meniscus
laxity vs. instability
instability is pts subjective complaint
laxity- measurable
functional progression (of all knees) (6)
- quad control
- ROM
- normalize gait
- ascend stairs
- descend stairs
- running => return to sport
when are muscles the strongest?
how does this affect our stair rehab?
- muscles are strongest when slightly stretched
- going up stairs everything is slightly stretched (hips, knees gluts all bent/ stretched) so easier than going down stairs which is all quads
PCL anatomy
2 bands and when they are taut
- anterolateral band (bulk) - taut in flexion
2. posteromedial band - taut in extension
PCL function (3)
- prevents posterior tib displacement on femur
- resists ER
- resists valgus/varus
PCL biomechanics
strength vs. ACL
what puts force on PCL
- 2x strength of ACL
2. loading the hamstring at 12-100 degrees (walking)
PCL mechanism of injury (3)
- A/P force on flexed knee (w/ or w/o rotation)
- rotatry force with valgu/ varus
- hyperextension
ACL rehab OKC vs. CKC
no stress on ACL during CKC squat
**no OKC resisted for 3m p/o
PCL rehab
most important to work on
what to absolutely not ever work on***
- focus on QUAD strengthening
2. no strengthening at deep flexion angles and NO OKC hamstrings
early WB status p/o
ACL repair
PCL repair
ACL: >50% PWBAT => no crutches
PCL: TTWB/PWB up to 6 weeks
MCL anatomy
3 bands
- superficial
- deep
- posterior oblique
MCL function (2)
- primary restrain to valgus force (lat -> medial)
2. restraint to ER
MCL mechanism of injury (2)
- valgus or varus force
2. rotation force with fixed leg
MCL biomechanics
when is it taut
- taut throughout ROM but increases as knee approached full extension
meniscus anatomy
medial
lateral
vascularity
medial- oval or C shape, larger than lateral
lateral- circular or O shape, greater mobility
vascularity- outer 1/3 from capsule and synovial attachements
meniscus function (4)
- to distribute weight bearing loads
- increase joint congruency (increase stability)
- limit abnormal motions
- improve articular nourishment
meniscus biomechanics
moves with ….
in extension
in flexion
- moves with tibia, pushed by femur
- extension => ant and medial
- flexion => post and lateral
meniscus mechanism of injury (2)
- rotation with foot planted in ground
2. degenerative lesion
rehab following meniscal repair (surgery)
protective phase
RTS
- 4-6 weeks = protection phase:
limit ROM < 90
WBAT w/ brace locked in extension - RTP - 4 months
Patellofemoral
purposes of patella (2)
articular surfaces
contact area
- patella protects and increases movement arm for quad tendon
- posterior fact divided into 7 articular surfaces
- contact area- starts at 15deg flexion and moves proximally w/ increased flexion
factors affecting patella alignment (7)
- increased Q angle
- patella alta
- excessive pronation
- tight lateral structures
- decreased flexibility
- VMO insufficiency
- proximal weakness/ imbalance
PFPS (dx/ presentation/ causes) 4
- excessive lateral tracking
- excessive compressive forces “chondromalacia” = everything is tight
- patella tendinitis
- fat pad irritation (dances with lots of hyper extension)
compartment syndrome
def
where we usually see it
def: increased pressue w/i fixed osseofascial compartment causing compression of muscular and neurovascular structures
can occur in any compartment but most often seen in lower leg
acute compartment syndrome
common cause
how do it present?
does anything increase pain?
how is it confirmed
treatment
- *considered a medical emergency
1. from direct trauma/ fracture
2. presents with pain, tightness and swelling
3. decreased pedal pulses/ sensory changes
4. pain with passive stretch
confirm dx by intercompartmental pressure measurements
relieved by emergency fasciotomy
chronic compartment syndrome
symptoms
most common compartments (2)
treatment
activity related symptoms
most common compartments:
anterior
deep posterior
low success with conservative treatment => surgery
acute exertional compartment syndrome
when does it occur
etiology
occurs during intense, repetitive exercise, most frequently long distance runners… repetitive muscle contraction or acute trauma causes muscles to swell
etiology: tissues can’t expand to alleviate pressure, nerves and BV compressed => ischemia (pain) and sensory disturbances
increase P => decrease venous flow => increased capillary leakage => decreased arterial flow
poor biomechanics that can lead to compartment syndrome (4)
- overstriding
- increased heel strike
- increased pronation
- weak hip or core muscles causing increased ground reaction forces
clinical presentation of compartment syndrome (5)
- aching, burning or cramping in affected compartment
- tightness
- numbness or tingling
- weakness
- foot drop in severe cases
pain pattern of compartment syndrome (3)
dx - how and normal and abnormal #s
- several minutes to come on
- progressively worsens
- stops 15-30 minutes after cessation of exercise
dx:
use needle catheter to measure pressure in compartment immediately after intense exercise
normal 0-10mm Hg
dx: > 35mm Hg post exercise
conservative management of compartment syndrome (5)
- activity modification => cross training
- deep soft tissue massage
- myofascial release
- new shoes/ orthodics
- work on gait deficiencies
achilles tendon rupture
who is affected most? age/ gender
cause
- males > females
- age > 35
from sudden acceleration or deceleration
achilles tendon rupture conservative treatment (3) vs. surgical options (3)
conservative treatment:
long immobilization- case 4-6 weeks
higher re-injury rate
100% strength return unlikely
surgical options:
primary repair
percutaneous repair
reconstruction
achilles tendon rupture rehab overview (3) what don't we do? main focus (2)
- protect repair
- active ROM
- gradual strengthening/ avoid high loads
** don’t stretch** focus on gait and strength*
ankle sprains
most common ligament sprains and how we do it
anterior talo-fibular ligament
sprained by PF then inversion
ankle sprains mechanism of injury
lateral sprain
medial sprain
synedsmosis
lateral: PF/ inversion/ ER
medial: PF/ eversion/ valgus stress
syndesmosis: fixed foot with tib IR/ high valgus force
how much DF do we need for normal gait?
10 degrees
plantar fascitis
common pt population
pain presentation (2)
what increases pain?
some causes (5)
common in middle aged women and young male runners- very common w/ obesity
presents with pain in proximal arch and heel
pain with toe/ forefoot DF
WB increases tension
running increases WB 2x
some causes: leg length discrepancy pes cavas excessive pronation of subtalar joint increased flexibility of longitudinal arch gastroc/ soleus tightness
turf toe- what is it?
treatment (3)
- hyperextension of MTP of great toe
treatment:
activity modification
flat insoles - to help with push off
taping
general RTP guidelines
- full ROM
- flexibility meets demands of sport
- lack of apprehension w/ sport specific movements
- quality of movements
- muscle strength >85-90% unaffected limb
SAID principle
Specific
Adaptation to
Imposed
Demands
that which is used developes, that which is not used wastes away
what do i need to walk?
muscle control
mobility
hip
knee
ankleneuromuscular quad control to do straight leg raise w/o quad lag**
mobility:
hip
flex 20 deg
ext 20 deg
knee
0-60
ankle
DF -10 deg
PF - 20-30 deg
arthrogenic muscle inhibition
when it happens/ why
describe 5 steps of cycle
happens after injury, as a protective mechanism quad shuts down
- knee injury => (2) effusion => (3) quad inhibition => (4) loss of knee extension => (5) antalgic gait => knee effusion etc
3 basic quad re-training modalities/ exercise
e-stim (NMES and russian)
quad sets
SLR
terminal knee ext
knee ROM needed to ride a stationary bike
short-crank
full crank
short crank: 85-90
full crank: 110-115
when can i walk up steps
muscle control (2)
mobility
hip
knee
ankleneed concentric quad strength (double leg squat) and ability to stand on one leg
mobility
hip
flex 30-40
ext 5
knee
0-100
ankle
DF -20
common compensations for not using quads on stairs (2)
use railing
lean back/ trunk tilt
when can i walk down steps
muscle strength needed (2)
ROM
hip
knee
ankleeccentric quad control (on knee press) and ability to stand on one leg
ROM
hip
flex 60-65
ext 5
knee
0-100
ankle
DF- 25 deg
when can i do leg press?
ROM
progression from 2 legs -> 1 leg (weight guidelines)
need full ext -> 100 deg flex
“rule of 60” progress from 2 legs -> 1 leg use 60% of wt
Open chain vs. closed chain exercises
closed chain kinetics have… (4)
- decreased posterior shear forces
- decreased tibiofemoral shear
- decreased patellofemoral stress
- decreased patellofemoral contact stress per unit at 0-53 degree of flexion
(increased patellofemoral contact stress 53-90 degrees)
OKC safe zone post op
ACL
PCL
ACL: 90-30 deg knee flexion
PCL: 0-60 deg knee flexion
same as both ACL/PCL CKC
CKC safe zone post op
ACL
PCL
ACL safe zone: 0-60 deg knee flexion
PCL safe zone: 0-60 deg knee flexion
(same as OKC PCL p/o)
when can i use an elliptical?
6 inch step-up with controlled alignment (starting on 8 inch step up)
the 4 local core stabilizing muscles
- transverse abdominals
- pelvic floor muscles
- diaphragm
- multifids
function of core interesting notes from a study
provide stable base in preparation or anticipation of trunk and extremity movements => feed forward
studies show people with low back pain activate core after movement
6 global movers of the spine
- rectus abdominus
- external obliques
- psoas muscls
- latissimus
- spinal extensors
- QL
pelvic neutral (whats aligned)
both ASIS with pubic symphysis (while lying supine)
how to cue pt to get into neutral spine
4 steps/ things to activate (do)
- pelvic floor activation (“muscles to stop peeing”)
- transverse abdominus (tighten to put on tight pants)
- diaphragmatic breathing w/ emphasis on expanding rib cage and back
- activate multifids (bulge lateral to spinous processes)
correct activation of core muscles for hip extension (4)
- transverse abs (and pelvic floor)
- multifids
- glutes
- hamstrings
in there is an injury in glutes u will see hamstrings bulge then move
postural progression of exercises (6)
- lying down
- quadruped
- seated
- half kneel
- kneel
- standing
stages of motor control (4)
- mobility
- stability
- controlled mobility
- skill
aquatic therapy - what % of bdy wt is eliminated when water is up to... pubic symphysis umbilicus xyphoid C7
pubic symphysis - 40% bdy wt is supported
umbilicus - 50% bdy wt
xyphoid - 60% bdy wt
C7 - 90% bdy wt
