LE Pathology Flashcards
what are the s/s of OA?
stiffness following inactivity (am) is often the 1st symptom
pain unrelated to imaging present in buttock, groin, thigh, knee
pain not proportionate with radiograph
pain subsequent to exercise may persist
loss of motion in capsular pattern (IR>ext>abd) with capsular end feel
what is the end feel with OA?
capsular
what is the capsular pattern of OA in the hip?
IR>ext>abd
what would radiographs of hip OA find?
<2.5 mm Jt space
osteophyte formation
subchondral bone sclerosis and cysts
whiter appearance of bone
(radiographs lack sensitivity)
what are the hip tests for hip OA?
femoral grind (Scour)
flexion abd ER (FABER) test
what are the interventions for hip OA?
educate and modify ADLs
regular and controlled loading interspersed w/rest (or useful avoidance) is encouraged
ROM and prolonged stretching (FABER)
PREs
manual therapy
why do we do ROM and prolonged stretching (FABER) for hip OA intervention?
for generalized capsular tightness to dispurse WB forces through more of the jt
why do we do PREs for hip OA intervention?
to strengthen the muscular around the jt to add stability around the jt
why do we do manual therapy for hip OA intervention?
to reduce capsular tightness
what is the progression of interventions in hip OA?
start with isometrics, mid-range, straight plane, OKC and move towards full range, triplanar, and CKC
what is the pathogenesis of congenital hip dysplasia?
in utero, subluxation may occur that results in a flattened posteriomedial femoral head, anteversion, and shallow acetabulum
when the femoral head dislocated and rests on the iliac crests in congenital hip dysplasia, what can happen?
a false acetabulum can form around the femoral head
t/f: prolonged and repeated dislocation of the femoral head in congenital hip dysplasia may cause greater incidence of hip OA
true
congenital hip dysplasia is also called what?
developmental dysplasia of the hip (DDH)
t/f: early diagnosis of congenital hip dysplasia is crucial?
true
what are the diagnostic tests for congenital hip dysplasia
Barlow (pop out) and Ortolani (pop back in) tests
what are the signs of congenital hip dysplasia?
gluteal fold height differences, knee height differences, decreased amount of hip abduction
what are the abnormal gait patterns of congenital hip dysplasia?
toe walking, in-toeing/out-toeing gait
what are the interventions for congenital hip dysplasia?
reduce the hip
Pavlick harness uses flexion and free abduction to produce effective reduction in 90% cases
how does the Pavlick harness work in congenital hip dysplasia?
it uses flexion and free abduction to produce effective reduction in 90% cases
how long does the Pavlick harness have to be worn?
3-6 months of continuous wear
if the Pavlick harness is ineffective, what may be done for congenital hip dysplasia?
skin traction, closed reduction, spica cast
t/f: congenital hip dysplasia puts pts at risk for THA later in life
true
what is a SCFE?
when the femoral neck slips up off the femoral head
what is the epidemiology and pathogenesis of SCFE?
most common disorder of the hip in adolescents
girls 12 yo, boys 14 yo
displacement of the femoral neck from the capital femoral epiphysis
coxa valga of the developing femur produces shear forces
injury occurs from innocuous causes
neck migrates up and out as the head remains in the acetabulum
neck fuses with the capital epiphysis toward the end of adolescence
injury in SCFEs occur from what causes?
innocuous causes
45% of pts with SCFE have what as the initial symptom?
knee or lower thigh pain
t/f: radiographs, physical exam, and symptoms are used to determine if the hip is stable or unstable in SCFE
true
intervention for SCFE focuses on what?
symptom relief, containment of femoral head, and restoration of ROM
what are the interventions for SCFE?
traction for days to weeks
PWB
NSAIDs
what is the etiology of Legg-Calve-Perthes disease?
avascular necrosis - trauma resulting in ischemia
idiopathic osteonecrosis - atraumatic mechanical interruption of femoral head circulation associated w/ETOH and steroid use
t/f: LCPD produces osteochondritis dissicans (damage to jt surface)
true
what is LCPD?
damage to vascular supply that may occur at birth
t/f: 70-90% of LCPD pts are pain-free regardless of intervention
true
what is the emphasis of treatment in LCPD?
containment of the femoral head and avoiding collapse
what does the Scottish Rite brace do for LCPD?
holds the femur in abduction w the ability to flex
what are the s/s of LCPD?
pain in groin, buttock, and proximal thigh
exacerbated by WB
non-capsular loss of motion
antalgic gait
radiographic evidence shows coxa magna (enlarged femoral head) and demineralization
what is the intervention for LCPD?
surgical intervention is usually done (hip resurfacing vs THA)
t/f: 70-80% of LCDP progress to collapse of the femoral head
true
what are the 2 types of FAIs?
CAM and pincer
what is a CAM lesion?
overgrowth of the femoral head
what is a Pincer lesion?
overgrowth of the acetabulum
what are the symptoms of an FAI?
anterior hip/groin pain
pain with flexion, active SLR
intra-articular jt sounds
what are the signs of an FAI?
decreased flex, abd, and rotation
MR arthrogram (70-91% accurate)
what is the pathophysiology of acetabular labral tears?
chondrocyte proliferation of labral fibrocartilage at the border of the defect
increased microvascularity at the base of the tear adjacent to the bone insertion
osteophyte/stress that caused the tear may cause bone irritation and growth
labrum becomes detached or torn from the acetabulum
what is the most common cause of hip dysfunction in young, active populations?
acetabular labral tears
what are the anatomical features of type 2 acetabular labral tears?
variable depths w/in substance of the labrum
what is the cause of groin pain in >20% of athletes?
acetabular labral tears
what is the most common location for acetabular labral tears?
anterior>posterior>superior (lateral)
what is the etiology of acetabular labral tears?
degenerative, dysplastic, traumatic, idiopathic
how are acetabular labral tears diagnosed?
torsional forces in WB
pain in the groin, trochanteric region, buttock w/flexion and rotation (likely IR)
sharp pain w/clicking, catching, locking (FAI usually doesn’t click)
what are the anatomical features of type 1 acetabular labral tears?
detachment of the labrum from the cartilage at the transition zone, which may extend to subchondral bone
what causes reproduction of pain with anterior labral tears?
abd, ER, flexion TO add, IR, ext
t/f: acetabular labral tears are confirmed by arthrography, MRI w/contrast
true
what causes reproduction of pain with posterior labral tears?
add, IR, flexion TO abd, ER, ext
what are the interventions for acetabular labral tears?
bed rest w/traction
NSAIDs
protected WB phase
arthroscopy w/labral resection or reattachment
what is the second most frequent cause of lateral hip pain?
greater trochanteric bursitis
where would a pt be tender if they had greater trochanteric bursitis?
with direct palpation over the GT
greater trochanteric bursitis would cause weakness of what muscle groups?
abductors and ERs
what is the cause of greater trochanteric bursitis?
direct trauma or repeated friction
greater trochanteric bursitis would cause tightness of what muscle group?
adductors
what would cause pain with greater trochanteric bursitis?
stretching the ITB into add, ER, IR
resisted abd, ext, ER
t/f: greater trochanteric bursitis is associated with LBP
true
t/f: greater trochanteric bursitis may cause Trendelenburg gait
true
what is the intervention for greater trochanteric bursitis?
stretch the TFL/ITB
phonophoresis, iontophoresis
transverse friction massage (TFM)
glut med, ER PREs
correction of biomechanical causes anywhere along the chain (likely overpronation)
patellofemoral pain syndrome (PFPS) makes up __% of outpatient visits and __% of all knee pathologies
5.4, 25
PFPS is the most common in what population?
ectomorphic female athletes
what is the etiology of PFPS?
muscles imbalances
inflammation
instability
anatomic variance
LE alignment
foot contributions
hip contributions
what anatomic variances are associated with PFPS?
femoral condyle dysplasia, patellar congruence, patellar position
what is the most common cause of mechanical knee pain?
meniscus injuries
what % of >45 yo have asymptomatic meniscus tears?
16-36%
what motions cause reproduction of pain with meniscus tears?
turning, twisting, or change of direction in WB
what causes meniscal injuries?
medial or lateral contact w/foot planted
t/f: aging leads to delamination of the menisci
true
why does edema produces symptoms in meniscus tears?
from increased pressure in the knee jt
which meniscus is more frequently injured?
the medial meniscus
what are the symptoms of meniscus injuries?
swelling, popping, clicking, catching at the jt line
locked in flexed position (bucket handle)
pain with flexion and WB
(+)McMurray, (+)Appley, and (+)Thessaly
tender medial jt line
what are the surgical interventions for meniscus injuries?
menisectomy (inner third)
meniscus repair (peripheral)
allograft transplantation
the ACL controls what forces?
anterior translation and rotation
are ACL injuries 2-8x more common in males or females
females
what are the intrinsic factors of ACL injuries make females more at risk?
females have narrower intercondylar notches causing impingement of the ACL in full ext
females are more likely to have LE malalignment (knee valgus)
females are more likely to have generalized jt laxity
female hormones estrogen, estradiol, relaxing lead to lig laxity in women
women have smaller ACLs
strength and recruitment
what are the extrinsic factors that lead to ACL injuries?
abnormal quad to HS ratio (5:3) makes the quads pull more on the tibia forward
altered neuromuscular control
playing surface
playing style
shoewear
almost all ACL tears are what kind of tears?
complete midsubstance tears
what is the terrible triad?
ACL, MCL, and meniscal injury together
when there is an ACL tear, __% of the time, it involves the terrible triad
49
t/f: cartilage degeneration is progressive due to altered proprioception and kinematics
true
what are the mechanisms of injury for the ACL?
sudden deceleration
abrupt change in direction
foot planted
valgus forces (72% non contact)
full ext w/ER of the femur on a fixed tibia (ski boot, turf)
extreme hyperext or hyper flex
what are the s/s of an ACL injury?
“pop” at the time of injury
giving away
hemarthrosis (immediate swelling)
quad atrophy
(+)ant drawer, (+)Lachman (+)KT- 1000 findings
rotatory instability: AMRI, ALRI, PMRI, PLRI
(+)MRI (not sensitive for discrimination bw partial and complete tears)
what are the post-surgical management principles for ACL injuries?
consult w/the surgeon for the latest protocol
understand potential risk factors of gait disruption
control pain and edema
utilize locked brace early during some PREs
respect healing constraints
emphasize early restoration of ROM (esp ext)
emphasize CKC
emphasize HS recruitment
focus on fxn
how long will an ACL injury typically take to heal?
at least 6 months for the tendon to become more like a ligament
what are the types of bursitis?
superficial and deep infrapatellar bursitis
prepatellar bursitis (housemaid’s knee)
superficial pes anserine bursitis
MCL bursitis
what is superficial and deep infrapatellar bursitis?
inflammation from mechanical irritation or direct trauma
what is prepatellar bursitis (housemaid’s knee)?
recurrent trauma
often from kneeling too much
easily observable
what is superficial pes anserine bursitis?
swimmer and runners
medial knee pain
tibia in ER
what is MCL bursitis?
deep to the MCL
often misdiagnosed
palpable mass and tender w/ER and IR of the tibia
what are the interventions for bursitis?
correct malalignment
correct mechanics
stretching
strengthening
surgical resection
what is another name for patellar tendonitis?
jumper’s knee
what causes patellar tendonitis?
eccentric overload
where is a pt with patellar tendonitis tender?
at the tibial insertion site or mid substance
t/f: patellar tendonitis is often self-limiting and will get better with rest
true
what are some interventions for patellar tendonitis?
RICE
tendon strap during activity
TFM
correct malalignment (ankle often not DF enough)
what is the most common overuse injury (esp runners)
ITB friction syndrome
what causes ITBFS?
repeated friction of the ITB at 30 deg knee flex
why does downhill walking often make ITBFS worse?
bc it required knee flexion >30 deg
t/f: ITBFS is better with faster speeds
true
where is a pt with ITBFS tender?
over Gurdy’s tubercle
what are the s/s of ITBFS?
structural/functional malalignment
weak abductors/ERs
(+) Ober, (+) Noble
what tests would be positive with ITBFS?
Ober and Noble
______ instability and ________ instability can cause recurrent ankle sprains
mechanical, functional
what % of ankle sprains involve the LM projecting more distally and a stronger deltoid lig
85%
what lig is involved in 60-70% of all ankle sprains?
ATF lig
what % of ankle sprains involve the ATF and CF ligs?
20%
what % of ankle sprains are midsubstance tears?
86%
what % of ankle sprain are avulsion fxs?
14%
what is the sequence of events in lateral ankle sprains?
ATF–>anterolateral capsule–> CF–>PTF–>LM avulsion–>MM or talar neck compression fx
with forced DF, what ankle sprain is likely?
tib fib syndesmosis sprain
with forced PF, what ankle sprain is likely?
ant capsule sprain
with inversion and PF, what ankle sprain is likely?
lat ankle sprain
what is a grade 1 ankle sprain?
min edema
localized tenderness over the ATF
a grade 1 ankle sprain takes ____ b4 return
12 days
what is a grade 2 ankle sprain?
localized edema
localized tenderness over ATF
begin to see fxnal problems
a grade 2 ankle sprain takes ____ b4 return
2-6 weeks
what is a grade 3 ankle sprain?
edema
ecchymosis
a grade 3 ankle sprain takes ____ b4 return
> 6 weeks
what % of grade 3 ankles sprains are surgery free 1-4 years post injury
25-60%
what are the sn and sp of ankle sprains if an exam is performed within 48 hrs of injury (better if delayed 4 days)?
84% and 96%
what are the s/s of a lat ankle sprain?
edema and hematoma suggests rupture
TTT over ATF
(+) ant drawer
what are the interventions for lateral ankle sprains?
control edema
early, supported WB (taping and bracing)
proprioceptive training
OKC to CKC using non-dominant to dominant plane (sag to frontal)
multiplane fxnal training
plyometrics
sport-specific training
what % of obese males will get plantar fasciitis?
40%
what % of obese females will get plantar fasciitis?
90%
jobs that require what activities, put pts at risk for plantar fasciitis?
prolonged walking/standing
what is more common, acute or chronic plantar fasciitis?
chronic
what biomechanical factors pose risk for plantar fasciitis?
pes cavus, pes planus, over pronation, weak foot intrinsics, and hallux rigidus/limitus
what % of pts with plantar fasciitis have it in both feet?
15-30%
what are the symptoms of plantar fasciitis?
AM pain (first few steps after waking up or after inactivity)
GS tightness in 78%
TTT med calc tubercle
pain with great toe extension
presence of heel spurs
HAV
what often leads to HAV (hallux abductor valgus (HAV)?
overpronation and medial foot stress
what are the interventions for plantar fasciitis?
low dye taping
orthotics
night splints
TFM
calf stretching
great toe mobility
NSAIDs
foot intrinsic PREs
iontophoresis/phonophoresis
injection
surgery (release PF)
t/f: night splints are a long-term intervention for plantar fasciitis
false, they are for short term use
what is the most common overuse syndrome of the lower leg?
Achilles tendonopathy
what tendinopathy accounts for 5-18% of all running injuries?
Achilles tendonopathy
t/f: Achilles Tendonopathy is associated with Hagland’s deformity and Sever’s disease
true
what is a Hanglund’s deformity?
tension of the Achilles tendon on the calcaneus causes irritation of the insertion and bone over growth (“pump bump”) over the posterior heel
what is Sever’s disease?
Haglund’s deformity in children
what is the etiology for Achilles tendonopathy?
largely biomechanical having to do with eccentric loading which increases w/overpronation
what actions may cause Achilles tendonopathy?
rupture from push off, sudden DF in WB, or forceful DF
what are interventions for Achilles tendonopathy?
correct biomechanical contributions, RICE in acute phase, TFM, stretching, eccentric training
what are the symptoms of tibialis posterior tendinopathy?
navicular pain, pain proximal to medial malleolus, and medial shin pain
pain with PF, inversion
TTT over medial ankle
what causes tibialis posterior tendinopathy?
overpronation, change in direction, tight GS complex, weak PT
what do we treat for tibialis posterior tendinopathy?
inflammation, biomechanical contributions, impairments
what is the too many toes sign?
a sign of tibialis posterior tendinopathy where there is too much foot abduction
what is tarsal tunnel syndrome?
peripheral neuropathy of the tibial nerve bw the flexor retinaculum and medial malleolus
involves the tibial nerve including terminal branches med/lat plantar nerves
what test would be positive with tarsal tunnel syndrome?
Tinel
what 2 things may contribute to tarsal tunnel syndrome?
accessory FDL and over pronation
what are interventions for tarsal tunnel syndrome?
orthotic w/rearfoot control
proper footwear
PREs for inverters
injection
surgical release
what is the Lauge-Hansen Classification system?
a way to classify about 95% of all ankle fxs
what is the Salter-Harns Growth Plate Classification system?
a way to classify ankle fxs in younger pts
what is a type 1 fx in the Salter-Harns Growth Plate Classification system?
an epiphyseal fx across the epiphyseal plate
what is a type 2 fx in the Salter-Harns Growth Plate Classification system?
a fx across the epiphyseal plate and triangle of the shaft that’s attached to it proximally
what is a type 3 fx in the Salter-Harns Growth Plate Classification system?
a fx through the epiphysis that extends into the epiphyseal plate
what is a type 4 fx in the Salter-Harns Growth Plate Classification system?
a fx of the epiphysis and shaft crossing the epiphyseal plate for a portion and some of the metaphysis
what is a type 5 fx in the Salter-Harns Growth Plate Classification system?
damage to the epiphyseal plate w/o a fx
what is a Jones fx?
avulsion fx of the 5th metatarsal
how may a Jones fx occur?
when rolling over the lateral ankle
what is the MOI for stress fxs?
overuse
what are the symptoms of a stress fx?
point tenderness over the fx
(+)US test - pain with US over the fx
(-) x-ray initially
(+) bone scan
what is a March fx?
2nd metatarsal fx
what is the ratio of males to females for Morton’s neuroma?
1:9
what is Morton’s neuroma?
compression of the interdigital nerve (usually bw the 3-4 metatarsals)
what may occur as a result of Morton’s neuroma?
perineural fibrosis, demyelination, endoneurial fibrosis
what are the symptoms of Morton’s neuroma?
pain and tingling in the forefoot
tenderness bw met heads plantarlly
pain with compression pof the forefoot
(+) Tinel, (+)EMG/NCV
what test would be positive with Morton’s neuroma?
(+) Tinel
(+) EMG/NCV
what are the interventions for Morton’s neuroma?
wider shoes
orthotics w/metatarsal pad
NSAIDs
interspace injection
surgery (last resort)
