LL MSK Pathologies Flashcards
Pathology of GTPS
Compressive forces cause impingement of bursa and glute tendons onto the greater trochanter by the ITB
Compression increased by weak hip adductors - hip joint ABD causes overstretching of ITB leading to compression and lateral pelvic tilt to contralateral side
Prevalence ACL sprains/tears
- ACL tear > common than PCL because ACL more vulnerable - has thinner fibre bundles and smaller attachment
- ACL most commonly injured in 15-25 age group participating in pivoting sports;
- Women > men
- Other structures are commonly involved in ACL tears: Meniscal tears, Articular cartilage damage, MCL injury, Bone bruising, (O’Donaghue unhappy triad = sprain injury thought to most likely injure the 3 structures: ACL, L meniscus, MCL)
Define Greater Trochanteric Pain Syndrome (GTPS)
Attributable (caused) to tendinopathy of gluteus medius and/or minimus +/- bursal pathology.
GTPS is a common cause of lateral hip pain
Prevalence of Ankle LCL sprains
More common than deltoid ligt sprain
Usually after traumatic event/acute presentation - occurs due to an inversion type injury
Common in teens-40s
Management of Posterior Tibial Tendon Dysfunction
- Rest
- Orthotics (conservative)
- Rehab
- Surgery but not recommended for elderly, obese patients as not necessary; young adult athletes may require surgical opinion
Treatment outcome: can be poor if not treated correctly.
Types of Apohysitis
Osgood Schlatter Disease = Apophysitis occurring at tibial tubercle
Sinding-Larsen-Johansson Syndrome = Apophysitis occurring at patella tendon attachment at apex of patella
Sever’s Disease = Apophysitis occurring at Achille’s tendon attachment on the middle facet of the calcaneus
Meniscal Anatomy
Menisci situated between corresponding femoral condyle and tibial plataeu Meniscofemoral ligaments (Humphrey and Wrisberg), attach the meniscus to the femur. The menisci are attached to each other via the transverse ligament. The horn attachments connect the tibial plateau to the meniscus. Lateral meniscus is more mobile than the medial meniscus as there is no attachment to the LCL or joint capsule Medial meniscus is more commonly injured because it is attached to the medial joint capsule and deeper fibres of MCL and therefore less mobile
General factors influencing PFP (AKP)
Split into two categories and assess for both; if structural
look at what we can do. Obviously can’t treat structural except with orthoses but can alter functional problems. Think of training errors
Functional:
Muscle length/strength
Stability
Proprioception
Structural:
Bony alignment
Patella shape
Trochlear shape
Foot position
Management of Meniscal Injuries
Previous sole treatment involved surgically removing meniscal tears. However, discovered this results in the gradual development of osteoarthritis of the knee OR those already w/ OA = it is associated w/ increased risk of progression of OA of the knee
Hence, the current management strategies in repairing meniscus-related lesions is to maintain the tissue intact whenever possible by conservative treatment
Causes of AVN of femur
The femoral head receives its blood supply through the neck of femur. Fractures across this zone may cause a loss of this supply leading to tissue death; Femoral neck # -> AVN to femur
Trauma causes - # femoral neck, # dislocated hip, surgery around hip
Non-trauma causes (affects both hips bilaterally)- prolonged use of corticosteroids (management of asthma), XS alcohol
Risk factors of Plantar Fasciitis
Obesity/overweight
Flatfoot
High arch
Reduced dorsiflexion
DM
RA - connective (soft) tissue disease hence effecting soft tissues
Prevalence of AKP
More common in adolescence (teens); may be seen in older ages
What are the lateral supporting structures of the knee
Anterolateral stabilisation = LCL, ITB, Joint capsule
Posterolateral stabilisation = Popliteal, biceps femoris, lateral head gastrocnemius tendons + various other structures
Pathology of Meniscal Injuries
Usually involves components of flexion and rotational forces under compression e.g. twisting, squatting or cutting manoeuvres (football).
If patient describes pain during these movements look for in an assessment:
Joint line tenderness
Joint effusion - swelling
Define Jones #
Fracture to the base of the 5th metatarsal
Polzer Classification = split into 2: Metaphyseal Fracture, Meta-diaphyseal Fracture
Lawrence and Botte classification = split into 3 = Zone 1 (Tuberosity Avulsion #), Zone 2 (Jones #), Zone 3 (Diaphyseal stress #)
Stress # for female athletes
Female athletes developing Relative Energy Deficiency Syndrome (REDS)/ Female Athlete Triad
Risk factors: in teens-20s, High levels of exercise and eating insufficient nutrients to accommodate exercise levels, increasing risk of lowering BMD thus greater risk of stress #
Signs: Low body fat, menstrual cycle stopped/dysfunctional, Previous #, high levels of exercise
Risk factors of Hip Impingement
Repetitive hip motion
High levels sports
Pediatric diseases (slipped/# epiphyseal (growth) plate)
Femoral neck #
Previous hip surgery
MOI of PCL strains/tears
MOI =Posterior force to the proximal tibia.
If combined with a rotational force injury to P-L complex can occur
Mainly from car accidents - knee hits dashboard resulting in neck of femur # and/or subluxation of the hip joint; PCL rupture/strain tends to be overlooked due to the more severe injuries
Pathology of Patella tendinosis
Alterations to Tendon cell population – increased number of tenocytes, increased tenoctye metabolism, increased immature tenocytes, increased rates of apoptosis, immunoactive cells.
Disorganisation of collagen, reduction type I collagen, disorganised areas with higher concentrations of immature collagen bundles (increased type III).
Ground substance changes– PG and GAG content alters, increased H2O, chemical alterations – substance P, Glutamate and lactate.
Neovascularization – influx of blood vessels into the anterior surface and mid substance this is associated with various nerve fibres ingrowing into the tendon
Define Avascular Necrosis (AVN)
AVN is condition in which there is loss of blood supply to the bone. Bone is living tissue, hence loss of blood supply, means bone death. If bone death progresses, leads to bone collapse
Prevalence of Avulsion Injuries
May not be able to surgically repair tendons that have avulsion injuries for a prolonged period
More common in adolescents involved in sports because the tendons are stronger than apophyses (where tendon attached to bone) - because in adolescents bone have yet to fully ossify
Clinical Presentation of AKP
Complaint of ‘deep ache in front of knee’ ○ Aggs = when patellofemoral joint lowered; deep knee flexion
○ Eases = with rest
○ localised tenderness around medial extensor retinaculum + lateral knee pain
○ haemarthrosis
recurrent dislocation likely: 15-44%
Pain is the main symptom all patients experience; syndrome indicates presence of other common conditions: Tightening of muscles anterior/posterior to knee causing a change to knee biomechanics, creating pain.
Altered alignment
Superior/inferior migrated patella
Direct trauma
Overuse - jogging/overweight
HPC: Dislocation: patella slipped out and had to be manually relocated
Subluxation: patella slipped out and spontaneously relocated
Clinical presentation of patient with GTPS
Age 40-60
Female - more common due to biomechanics - females have larger pelvic width w/ greater prominence of trochanters, which is associated w/ greater stretching of ITB as it passes over greater trochanter
Post-menopause
Lower femoral neck shaft angle - increases compression of gluteus medius tendon over greater trochanter
Increased BMI
Systemic factors?
Explain Pincer-type FAI
Result of excess acetabular coverage of the femoral head.
Over coverage can be either:
□ Global (coxa profunda) - due to deepened acetabulum
OR
□ Focal anteriorly (acetabular retroversion) - due to altered orientation of acetabulum
Results in abutment of the femoral head neck junction against the acetabular rim pressing upon the labrum, in turn causing damage to articular cartilage (chondral injuries)
Picked up on AP viewing (radiographic imaging) looking at lateral center edge angle = x>40o
Prevalence of Meniscal Injuries
Meniscus lesions most common intra-articular knee injury - injuries inside knee joint capsule
Most common in athletic young patients - sports-related injuries take >1/3 of all cases
Old adults meniscal tear may be caused by degeneration of the joint - may come about by a gradual or sudden onset
Medial injured more frequently 5:1 ratio to lateral
81% meniscal tears are located posteriorly.
Often associated with ACL tears (60% of cases)
Most patients do not require a MRI scan - if they do = 95% cases picked up; 5% not picked up
Define Patellofemoral Joint Pain
AKA Anterior Knee Pain (AKP) - Umbrella term to cover pain over the anterior of the knee joint
Indicates no distinction can be made to a specific structure
PFJ disorders:
○ Patella femoral pain syndrome ○ Mal-tracking ○ Dislocation ○ Chondromalacia patella
○ Patella tendinosis
○ Prepatellar bursitis
Clinical presentation of ankle LCL sprains
PC:
Pain/tenderness, swelling local to lat ligt. Esp. ATFL and/or bruising - in more mod-severe cases (ATFL>CFL>PTFL)
Aggravated - Walking or running over uneven ground, Turning sharply, Landing on inverted ankle
Severe/Moderate tears Grade II-III pain on WB, walking and most movements of the ankle
HPC/Previous episodes:
Traumatic = specific injury involving ankle inversion (MOI)
Sudden onset
Can be recurrent
SQs:
Giving way
Swelling- onset or recurrent
Walking over uneven ground
SH:
Sport involving rotation/turning eg. football, rugby, hockey!
Special tests: Anterior drawer test = ATFL injury
Talar tilt test = CFL injury (+ve)
Muscle spasm
Inability bear weight - may indicate # present
Ottawa ankle rules - used to determine if a X-ray is necessary:
Look for pain on weight-bearing at the distal end of fibula and posterior edge of L malleolus and likewise pain on distal 2-3” tibia just proximal to M malleolus
Look for pain on navicular and 5th MT and inability to weight-bear
Site of symptoms may not be diagnostic – multitude of other injuries such as peroneal tendon strains, neural irritation, OCDs, syndesmotic ligament tears, osteochondral lesions of the talus, occult stress fractures, synovitis, adhesions, intra-articular loose bodies, chronic instability, anterolateral impingement, and peroneal tendon pathology
Signs of Hip Dysplasia in infants
limping when first walking or one hip is less flexible when changing baby
Prevalence of PCL strains/tears
Up to 60% of PCL tears have associated posterolateral complex injuries
PCL tears account for up to 40% of ligament injuries in acute haemarthrosis
Meniscal injury with PCL injury is uncommon
Types of Hip Impingement
CAM-type Femoral Acetabulum Impingement (FAI)
Pincer-type Femoral Acetabulum Impingement (FAI)
Mixed FAI - some patients exhibit both impingements
Symptoms of Hip Impingement
Sitting cross legged is difficult or painful
Difficulties putting socks and shoes (52%)
Unable to sit for period of time (23%)
Slight or more severe limp (65%)
Adductor related symptoms
Walking long distance painful and pain doesn’t disappear straight away with rest
Significant pain after sports activities
> 40% buttock / low back pain
4 radiographic stages of maturation of apophysis
- Cartilaginous (0-11 years)
- Apophyseal (11-14 years)
- Epiphyseal (14-18 years), during which the epiphysis and apophysis coalesce
- Bony (> 18 years)
Difference in signs of quadriceps tendon and patella tendon ruptures
Patella tendon rupture also seen by patella gliding more superior than normal
Define Hip Dyplasia
Hip socket (acetabulum) does not cover femoral head fully causing hip joint to be partially/completely dislocated
Pathology of Hip Impingement
• Pathophysiology of FAI is unclear - brought by bony deformities from birth/developmentally acquired through overuse, causing repetitive abutment and wear of articular cartilage (chondral injuries)
Explain CAM-type FAI
Caused by an irregular osseous prominence of the proximal femoral neck or head-neck junction.
Cam impingement can become symptomatic in physically active young males (athletes)
Bony protrusion located at the anterosuperior aspect of the femoral head-neck junction
Picked up on Dunn view (radiographic imaging) looking at alpha angle = 90o flexion & 20o ABD
Risk factors of babies acquiring Hip Dysplasia
Born in breech position; foot deformities
Prevalence of Jones #
Patient (and clinician) often don’t realise fracture has occurred
May have sprained ankle - pain at LCL but also # 5th MT w/out knowing
Affects base of 5th MT, maybe peroneal swelling, often misdiagnosed as insertional tendinitis.
Can indicate vitamin D deficiency
Pathology of ACL sprains/tears
Intra-articular (good blood supply); extrasynovial structure.
Proximal part has greater vascularity.
Comprised of 2 bundles = Anteromedial (AMB); posterolateral (PLB).
○ AMB restrains anterior tibia translation at > 45 of knee flexion
○ PLB shown to be more important restrain toward full extension.
Substantial number of partial tears (difficult to diagnose) progress to complete tears with a higher rate of meniscal and cartilage injuries
ACL rupture = bleeding occurs (hemarthrosis) - large swelling, typically a couple hours from onset
Meniscal Vascularisation
Meniscal vascularisation refers to blood supply to meniscus
Healing capacity is directly related to the blood circulation of each region of the menisci
Though fully vascularized at birth, the blood vessels in the meniscus recede during maturity. In adulthood vascularisation appears to subside
Red-red region (outer border) contains the overwhelming majority of blood vessels = vascularised
White-white region (inner border) - is avascular
White-red region holds attributes of both regions; separates both regions
Symptoms of PCL strains/sprains
- Mild to moderate swelling - mimicking ACL due to synovial damage
- Positive posterior drawer test/sag sign
- Often asymptomatic or may have vague symptoms of pain in posterior aspect of knee
- Pain on kneeling.
Types of Snapping Hip Syndrome
Internal - caused by iliopsoas over iliopectinal eminence, paralabral cysts
External - caused by ITB “snapping” over greater trochanter OR proximal hamstring tendon rolling over ischial tuberosity, TFL OR glut max over the greater trochanter
Define Snapping Hip Syndrome (Coxa Saltans)
Clinically characterised by a audible and palpable ‘snapping’ sensation heard/felt during hip movement
Prognosis of MCL injuries
The majority of athletes who sustain an MCL injury will achieve their pre-injury activity level with non-operative treatment
However those w/ combined injuries, such as ACL injury w/ MCL injury may require surgical intervention
Prognosis of damage to lateral supporting structures of the knee
Damage is rare = injuries frequently combined w/ cruciate ligt tears or damage to medial stabilising structures
Although damage is less common - damage may be more disabling
Define Avulsion Injuries
Joint capsule, ligt or muscle attachment site fall of bone, usually taking fraction of bone with it
Diagnosis of Stress #
- Early diagnosis is difficult because - Plain radiograph could only be positive in less than 10% of cases.
- Hence for early signs MRI is the gold standard test looking for bone marrow oedema.
- Physiotherapists should have high index of clinical suspicion in athletes presenting history of gradual onset of symptoms VS sudden onset (traumatic #)
Clinical presentation of Plantar Fasciitis
PC:
Pain affecting the heel, worse in the morning and after weight-bearing all day
Symptom location - Medial origin of medial band of plantar fascia; Medial calcaneal tubercle attachment of PF
HPC:
Onset gradual over weeks/months
May be associated with traumatic incident to PF
FSH:
Sport or job that involves weight bearing
SQs:
P&Ns or Numbness
24 hour aggs
First few steps am, or after prolonged rest
Running, dancing, jumping, prolonged standing/walking
Test - Palpation with twisting motion to MCT will cause discomfort and pain; palpation during ext of toes - put plantar aponeurosis on a stretch
Define Apophysitis
XS or repetitive traction in adolescence may result in micro-trauma and chronic irritation causing thickening and pain of the apophysis
Common in paediatric patient aged between 12-16 years - tend to be sport individuals
Symptoms of AVN
Symptoms may include stiffness in the hip, night pain, limp, pain in the groin, buttocks, front of thigh.
Define a osteochondral defect
An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone
What are the Medial supporting knee structures
Static stabilizers:
○ Superficial MCL
○ Deep MCL or medial capsular ligament
○ Posterior oblique ligament (expansion of semimembranosus tendon)
Dynamic stabilizers:
○ Semimembranosus
○ Quadriceps
○ Pes anserinus
MCL is the primary restraint against valgus (ABD) stress
Define Plantar Fascitis
Traditionally ‘inflammation of the plantar aponeurosis’
Currently, syndrome that may comprise more than 1 condition
Pathology of Hip Dysplasia
Superior surface of hip joint covered in hyaline cartilage that gradually hardens into bone, if femoral head is not seated firmly into acetabulum the socket will not fully form around femoral head becoming too shallow -> XS movement in hip joint -> partial/complete dislocation of hip joint
Physiotherapy management of ankle LCL sprains
treat same as soft tissue injury: Reduce swelling (ICE, PRICE, PROTECT)
Functional treatment (More effective in short and long term than immobilisation):
Proprioception exercises - those w/ proprioceptive rehab and strengthening of the evertors (peronei) have lower risk of recurrence
Ankle exercises + external support (semi-rigid brace, tubigrip, tape etc)
OMs - reduced swelling, return to work and sport, increased ankle stability
Immobilisation is still considered an option when pain is severe and patients are unable to WB in the absence of a #
Other: Surgery - may increase stability and speed up return to sport but balanced against risks of surgery.
Ice - unlikely to be effective
US - unlikely to be effective PSWD - unknown effectiveness
MWM’s- significant increases in ROM DF immediately post treatment in sub-acute (1-12 weeks) ankle sprains
Meniscal Injury Classification
- Vertical longitudinal
a. Occur between fibres on outside of meniscus
b. Biomechanics of knee may not always be disrupted; may be asymptomatic - Vertical radial
a. Disruption of fibres on outside of meniscus
b. May occur from a twist from joint = bucket handle tear - very unstable tears causing mechanical problems like ‘true’ locking of the knee
c. Affects meniscus ability to absorb femoral load
d. Not able to fully repair because it affects fibres in white-white region as well - Horizontal
a. Splits meniscus into upper and lower parts
b. Usually mechanically stable but may give rise to a flap tear
c. Can be asymptomatic - Oblique
a. May give rise to a flapped tear - mechanically unstable and associated w/ mechanical symptoms
b. Often requires re-section to prevent tear-flap from getting caught during flexion - Complex / degenerative
a. Associated with two or more types of tears
b. More common in elderly and associated w/ OA w/in knee joint
Diagnosis of Hip Dysplasia
On X-ray looking at Center edge angle:
25-40 = normal
25-30 = borderline dysplasia
<20 = dysplasia
<16 = almost certainly will develop OA
Management of Jones #
Usually repairs on its own with immobilisation (air cast) but sometimes requires surgical fix if union doesn’t occur
Recovery 4-16 weeks dependent on intervention
Treatment plan is debatable depending on classification used
Define a chondral defect
A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones).
Prevalence of Hip impingements
Radiographic findings consistent with FAI and dysplasia were common and were not associated with the presence of OA
Diagnosis of labral tears
Standard MRI only has 35% sensitivity (detection) and accuracy in detecting labral pathology.
Sensitivity and accuracy can be improved to reach up to 90% using contrast (fills tear in capsule thus easier to identify)
Prevalence of labral tears
Associated with chondral injuries = injury to articular cartilage; hip dysplasia
Causes of Osteochondral defect
Can occur acutely or develop as a result of several chronic conditions including:
○ Separation of the osteochondral fragment caused by an acute traumatic injury or as the end result of an unstable fragment in osteochondritis dissecans (small segments of bone begins to separate due to lack of blood supply)
○ Acute osteochondral impaction of the bone with resultant contour deformity.
○ A collapse of the subchondral bone in a subchondral insufficiency fracture (SIF) or avascular necrosis (AVN) or a bone collapse uncovering a large subchondral cyst (can occur from OA)
Prevalence of Plantar Fasciitis
Common foot disorder - 15% of all foot pathologies (Hyland et al, 2006)
Very common in sports injuries and sedentary population
Often misdiagnosed (sinus tarsi syndrome)
Prevalence of Hip Dysplasia
More common in babies and girls
Define Hip Impingement
Pathological hip condition characterised by abnormal contact between acetabulum & femoral head-neck junction
Pathology of subchondral cyst
The synovial fluid intrusion theory -proposes that articular surface defects and increased intra-articular pressure allow intrusion of synovial fluid into the bone, leading to formation of cavities.
The bone contusion theory - according to which non-communicating cysts arise from subchondral foci of bone necrosis that are the result of opposing articular surfaces coming in contact with each other
Prevalence of Posterior Tibial Tendon Dysfunction
Posterior tibial tendon dysfunction typically occurs in obese, middle-aged women with up to 10% prevalence in this group.
Conditions such as diabetes, hypertension, obesity, previous surgery, foot/ankle trauma and steroid use is found in up to 60% of patients.
Define Apophysis
A normal developmental outgrowth of a bone, which fuses later in adult development
Found where major tendons and ligaments attach to bone, e.g. the tibial tubercle apophysis is an insertion for the patellar tendon
Clinical Presentation of Posterior Tibial Tendon Dysfunction
Typically present with pain along posterior medial malleolus extending to the navicular
May have lowered medial longitudinal arch - flat foot if tendon is ruptured/dysfunctional
Test: tiptoe single phase support = Clinician stands behind - observe calcaneus (heel) turns inwards as they raise their tiptoes - observation of high foot varus (ADD) - If tendon is ruptured this is not observed
What pathologies can inhibit the knee extensor mechanism
Quadriceps or patella tendon rupture
OR
Patellar tendinosis shows similiar symptoms
Define labral tears
Tears of the acetabular labrum
Causes of labral tears
The majority are not associated with a specific event or cause but most commonly is the result of repetitive stress (loading) irritating the hip
End range motion in position of hyperabduction, hyperextension, hyperflexion and external rotation contributes to labral tears
High risk: athletes in football, ice hockey, rugby, golf, balle, long distance running
Prevalence of Stress #
Common among joggers and runners
Metatarsals & tibia = most common # sites
Estimated 1% # at femoral neck - Early recognition is required to prevent progression of # of femoral neck because if it becomes displaced -> avascular necrosis of femur
Symptoms of femoral neck stress # = Exertional groin pain, worsening on exercising; pain at full hip ROM
Clinical presentation of Meniscal Injuries
- H/O loaded twisting/ squatting
- catching
- locking (knee gets stuck)
- acute block to extension (locking)
- effusion developing over 24 hours
- joint line tenderness
- +ve clinical tests
a. McMurray’s
b. Apley’s
MOI of ACL ruptures
MOI: Injury on external rotation femur, Usually non-contact injury with h/o sudden deceleration and change of direction with fixed foot. Also hyperextension injury
Clinical features of ACL rupture
- Knee buckles/GW - Knee will buckle leading to the inability to stand and continue sport or activity without the knee GW again
- Unable to stand/WB
- Audible ‘Pop’
- Immediate swelling- haemarthrosis (within 2hrs) - swelling occurs rapidly due to the damage to the synovium (remember intra-articular but extra-synovial)
- a sense of disruption or that the knee ‘came apart’; h/o giving way
- Inability to resume sport
- Pseudo-locking/loss of extension-ACL stump
- Positive Lachman’s test/anterior drawer test - Lachman’s more sensitive and specific
Pathology of PCL sprain/rupture
Larger than ACL
Secondary restraint to external rotation
Intracapsular but extrasynovial
MOI of MCL/LCL sprains
Usually a varus/valgus contact force ie. direct blow to the knee Can also occur as a result of a varus or valgus blow to the foot.
With or without a rotation force
Prevalence of MCL/LCL sprains
MCL most commonly injured structure in knee > common than LCL
Characteristic instability caused by MCL/LCL injury is opening of medial /lateral joint space
Can occur in isolation or in conjunction with injuries to the cruciate ligaments, menisci or bone depending on position of knee and size of force
MOI of posterolateral corner injury
Direct blow to antero-medial tibia in an extended knee
Fall onto a flexed knee
Non-contact hyperextension injuries
Clinical Presentation of posterolateral corner injuries
Pain in the postero-lateral corner of the knee
Peroneal nerve symptoms
Associated ligament pathology
Positive posterolateral drawer testing - Coupled testing should include the dial test, passive extension and external rotation, screen LCL and both cruciates
Prognosis of posterolateral corner injuries
Damage is rare = injuries frequently combined w/ cruciate ligt tears or damage to medial stabilising structures
Although damage is less common - Due to nature of association with other tissue effects can be devastating on that persons sport
Management of Plantar Fasciitis
85% cases respond to conservative treatment alone; 15% require surgery
Taping – many different techniques described for PF
Medial arch support for the overpronated foot
Correction of calcaneal valgus
Effectiveness unknown
Stretching of PF, hamstrings, and calf muscles - 72% improved with stretching alone which increased to 88% with heel insert. 256 subjects with heel pain over 8 weeks
Strengthening of tibialis post, intrinsics may be beneficial but lack of evidence
Other:
US
Medial arch support Rest Phonophoresis /iontophoresis Ice/compression to reduce inflammation
Subtalar joint accessory mobilisations Heel pad
*Steroid injection-may be harmful risk of rupture.
NSAID’s Acupuncture Heat
Common LL #s
NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress #
Management of LL #s
Aim - stabilise #, Restore Function
- Gait-re-ed - use of parallel bars, zimmer frames, crutches
- ROM - try maintain as much in early stages
- Strength - After consolidation - WB activity, progressive strengthening
- Pain relief
Common LL muscle injuries
Hamstrings>Calf>Groin>Quads
MOI of muscle injuries
Sport/activity dependent
Proximal muscles MOI - high speed contractions usually kick in during high level activities
Distal muscles MOI - can be lower speed contraction as they are active during all levels of activity.
Hamstring strain management
- POLICE - activity modification
- Early load - 2-3 days in elite sports
- Length of muscle (ROM/stretch) - prevent scar tissue formation in shortened state
- Strengthen - early as best stimulus for recovery via mechanotherapy.
- Pain relief if needed - heat/cold therapy, walking aids, medication.
Groin strain causes
Adductors, Iliopsoas, Rectus Femoris affected
Causes:
- Inflammation from overuse of muscle/tendon
- Direct trauma/Biomechanical
- Inflammation, pain on movement/contraction, loss of function/weakness
- Visible/palpable defect (if grade III tear)
Achilles tendon rupture/calf injuries MOI
Extension of knee with DF (all eccentric PF work) followed by push off
Clinical presentation of Achilles tendon rupture
Resting position in knee flex/ext - more DF
Lack of or reduced End feel and increased ROM DF
Tendon palpation
Visibility of tendon rupture - as a dip
Positive Squeeze/Thompson test
Define Perthes Disease
Avascular necrosis of the femoral epiphysis (head)
Prevalence of Perthes Disease
Self limiting with revascularisation occurring within 2-4 years. Femoral head may remain deformed resulting in OA. Cause unknown.
Median age onset – 6 years (2-12 years)
Male:Female = 4:1
Clinical presentation of Perthes disease
knee pain only and a limp - need to assess the hip in these cases
Adults especially with alcohol problems (Bilateral symptoms) - assess hip
Management of Perthes disease
Management:
Reduce WB and rest - allow to recover
Define Slipped Femoral Epiphysis (SFE)
disorder of adolescents in which the growth plate is damaged and the femoral head moves (“slips”) with respect to the rest of the femur. The head of the femur stays in the acetabulum while the rest of the femur is shifted
Clinical presentation of SFE
Age 10-17 in males, 8-15 in females
Presents with pain- maybe in hip/groin, thigh or knee (can present with just knee)
Differentiate between SFE and Perthes with age and x-ray.
Pain initially then limp progressing onto leg length differences in severe cases.
Common LL pathologies
Sprains (ligs):
- Knee (ACL/PCL, MCL/LCL)
- Ankle sprains low (LLS – ATFL and CFL) and high (syndesmosis injuries)
Adolescents:
- OGS, SLJ’s, Perthe’s, SFE’s (Slipped Femoral Epiphysis), Sever’s
Bone:
- Stress #s
- # s - # NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress
Vascular:
- Arterial = PVT, arterial entrapment
- Venous = DVT
Muscle/Tendon:
- Tendinopathies – Gluteal, Achilles, Plantarfascia and PTTD. Tendon rupture (Achilles)
- Muscle Strains - hamstring>calf>groin>quads
Joint:
- Degenerative - OA – HIP>Knee> Ankle, Joint replacements
- Inflammatory
- Traumatic
- Joint disorders – FAI,PFPS, meniscal tears
