LL MSK Pathologies

Question 1

Pathology of GTPS

Answer 1

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

Question 2

Prevalence ACL sprains/tears

Answer 2

• 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)

Question 3

Define Greater Trochanteric Pain Syndrome (GTPS)

Answer 3

Attributable (caused) to tendinopathy of gluteus medius and/or minimus +/- bursal pathology.
GTPS is a common cause of lateral hip pain

Question 4

Prevalence of Ankle LCL sprains

Answer 4

More common than deltoid ligt sprain
Usually after traumatic event/acute presentation - occurs due to an inversion type injury
Common in teens-40s

Question 5

Management of Posterior Tibial Tendon Dysfunction

Answer 5

1. Rest
2. Orthotics (conservative)
3. Rehab
4. 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.

Question 6

Types of Apohysitis

Answer 6

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

Question 7

Meniscal Anatomy

Answer 7

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

Question 8

General factors influencing PFP (AKP)

Answer 8

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

Question 9

Management of Meniscal Injuries

Answer 9

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

Question 10

Causes of AVN of femur

Answer 10

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

Question 11

Risk factors of Plantar Fasciitis

Answer 11

Obesity/overweight
Flatfoot
High arch
Reduced dorsiflexion
DM
RA - connective (soft) tissue disease hence effecting soft tissues

Question 12

Prevalence of AKP

Answer 12

More common in adolescence (teens); may be seen in older ages

Question 13

What are the lateral supporting structures of the knee

Answer 13

Anterolateral stabilisation = LCL, ITB, Joint capsule

Posterolateral stabilisation = Popliteal, biceps femoris, lateral head gastrocnemius tendons + various other structures

Question 14

Pathology of Meniscal Injuries

Answer 14

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

Question 15

Define Jones #

Answer 15

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 #)

Question 16

Stress # for female athletes

Answer 16

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

Question 17

Risk factors of Hip Impingement

Answer 17

Repetitive hip motion
High levels sports
Pediatric diseases (slipped/# epiphyseal (growth) plate)
Femoral neck #
Previous hip surgery

Question 18

MOI of PCL strains/tears

Answer 18

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

Question 19

Pathology of Patella tendinosis

Answer 19

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

Question 20

Define Avascular Necrosis (AVN)

Answer 20

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

Question 21

Prevalence of Avulsion Injuries

Answer 21

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

Question 22

Clinical Presentation of AKP

Answer 22

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

Question 23

Clinical presentation of patient with GTPS

Answer 23

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?

Question 24

Explain Pincer-type FAI

Answer 24

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

Question 25

Prevalence of Meniscal Injuries

Answer 25

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

Question 26

Define Patellofemoral Joint Pain

Answer 26

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

Question 27

Clinical presentation of ankle LCL sprains

Answer 27

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

Question 28

Signs of Hip Dysplasia in infants

Answer 28

limping when first walking or one hip is less flexible when changing baby

Question 29

Prevalence of PCL strains/tears

Answer 29

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

Question 30

Types of Hip Impingement

Answer 30

CAM-type Femoral Acetabulum Impingement (FAI) Pincer-type Femoral Acetabulum Impingement (FAI) Mixed FAI - some patients exhibit both impingements

Question 31

Symptoms of Hip Impingement

Answer 31

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

Question 32

4 radiographic stages of maturation of apophysis

Answer 32

1. Cartilaginous (0-11 years) 2. Apophyseal (11-14 years) 3. Epiphyseal (14-18 years), during which the epiphysis and apophysis coalesce 4. Bony (\> 18 years)

Question 33

Difference in signs of quadriceps tendon and patella tendon ruptures

Answer 33

Patella tendon rupture also seen by patella gliding more superior than normal

Question 34

Define Hip Dyplasia

Answer 34

Hip socket (acetabulum) does not cover femoral head fully causing hip joint to be partially/completely dislocated

Question 35

Pathology of Hip Impingement

Answer 35

• 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)

Question 36

Explain CAM-type FAI

Answer 36

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

Question 37

Risk factors of babies acquiring Hip Dysplasia

Answer 37

Born in breech position; foot deformities

Question 38

Prevalence of Jones #

Answer 38

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

Question 39

Pathology of ACL sprains/tears

Answer 39

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

Question 40

Meniscal Vascularisation

Answer 40

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

Question 41

Symptoms of PCL strains/sprains

Answer 41

* 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.

Question 42

Types of Snapping Hip Syndrome

Answer 42

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

Question 43

Define Snapping Hip Syndrome (Coxa Saltans)

Answer 43

Clinically characterised by a audible and palpable 'snapping' sensation heard/felt during hip movement

Question 44

Prognosis of MCL injuries

Answer 44

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

Question 45

Prognosis of damage to lateral supporting structures of the knee

Answer 45

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

Question 46

Define Avulsion Injuries

Answer 46

Joint capsule, ligt or muscle attachment site fall of bone, usually taking fraction of bone with it

Question 47

Diagnosis of Stress #

Answer 47

* 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 #)

Question 48

Clinical presentation of Plantar Fasciitis

Answer 48

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

Question 49

Define Apophysitis

Answer 49

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

Question 50

Symptoms of AVN

Answer 50

Symptoms may include stiffness in the hip, night pain, limp, pain in the groin, buttocks, front of thigh.

Question 51

Define a osteochondral defect

Answer 51

An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone

Question 52

What are the Medial supporting knee structures

Answer 52

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

Question 53

Define Plantar Fascitis

Answer 53

Traditionally ‘inflammation of the plantar aponeurosis’ Currently, syndrome that may comprise more than 1 condition

Question 54

Pathology of Hip Dysplasia

Answer 54

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

Question 55

Physiotherapy management of ankle LCL sprains

Answer 55

``` 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

Question 56

Meniscal Injury Classification

Answer 56

1. Vertical longitudinal a. Occur between fibres on outside of meniscus b. Biomechanics of knee may not always be disrupted; may be asymptomatic 2. 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 3. 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 4. 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 5. Complex / degenerative a. Associated with two or more types of tears b. More common in elderly and associated w/ OA w/in knee joint

Question 57

Diagnosis of Hip Dysplasia

Answer 57

On X-ray looking at Center edge angle: 25-40 = normal 25-30 = borderline dysplasia \<20 = dysplasia \<16 = almost certainly will develop OA

Question 58

Management of Jones #

Answer 58

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

Question 59

Define a chondral defect

Answer 59

A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones).

Question 60

Prevalence of Hip impingements

Answer 60

Radiographic findings consistent with FAI and dysplasia were common and were not associated with the presence of OA

Question 61

Diagnosis of labral tears

Answer 61

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)

Question 62

Prevalence of labral tears

Answer 62

Associated with chondral injuries = injury to articular cartilage; hip dysplasia

Question 63

Causes of Osteochondral defect

Answer 63

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)

Question 64

Prevalence of Plantar Fasciitis

Answer 64

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)

Question 65

Prevalence of Hip Dysplasia

Answer 65

More common in babies and girls

Question 66

Define Hip Impingement

Answer 66

Pathological hip condition characterised by abnormal contact between acetabulum & femoral head-neck junction

Question 67

Pathology of subchondral cyst

Answer 67

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

Question 68

Prevalence of Posterior Tibial Tendon Dysfunction

Answer 68

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.

Question 69

Define Apophysis

Answer 69

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

Question 70

Clinical Presentation of Posterior Tibial Tendon Dysfunction

Answer 70

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

Question 71

What pathologies can inhibit the knee extensor mechanism

Answer 71

Quadriceps or patella tendon rupture OR Patellar tendinosis shows similiar symptoms

Question 72

Define labral tears

Answer 72

Tears of the acetabular labrum

Question 73

Causes of labral tears

Answer 73

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

Question 74

Prevalence of Stress #

Answer 74

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

Question 75

Clinical presentation of Meniscal Injuries

Answer 75

1. H/O loaded twisting/ squatting 2. catching 3. locking (knee gets stuck) 4. acute block to extension (locking) 5. effusion developing over 24 hours 6. joint line tenderness 7. +ve clinical tests a. McMurray’s b. Apley’s

Question 76

MOI of ACL ruptures

Answer 76

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

Question 77

Clinical features of ACL rupture

Answer 77

1. Knee buckles/GW - Knee will buckle leading to the inability to stand and continue sport or activity without the knee GW again 2. Unable to stand/WB 3. Audible ‘Pop’ 4. Immediate swelling- haemarthrosis (within 2hrs) - swelling occurs rapidly due to the damage to the synovium (remember intra-articular but extra-synovial) 5. a sense of disruption or that the knee ‘came apart’; h/o giving way 6. Inability to resume sport 7. Pseudo-locking/loss of extension-ACL stump 8. Positive Lachman’s test/anterior drawer test - Lachman's more sensitive and specific

Question 78

Pathology of PCL sprain/rupture

Answer 78

Larger than ACL Secondary restraint to external rotation Intracapsular but extrasynovial

Question 79

MOI of MCL/LCL sprains

Answer 79

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

Question 80

Prevalence of MCL/LCL sprains

Answer 80

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

Question 81

MOI of posterolateral corner injury

Answer 81

Direct blow to antero-medial tibia in an extended knee Fall onto a flexed knee Non-contact hyperextension injuries

Question 82

Clinical Presentation of posterolateral corner injuries

Answer 82

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

Question 83

Prognosis of posterolateral corner injuries

Answer 83

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

Question 84

Management of Plantar Fasciitis

Answer 84

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

Question 85

Common LL #s

Answer 85

NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress #

Question 86

Management of LL #s

Answer 86

Aim - stabilise #, Restore Function 1. Gait-re-ed - use of parallel bars, zimmer frames, crutches 2. ROM - try maintain as much in early stages 3. Strength - After consolidation - WB activity, progressive strengthening 4. Pain relief

Question 87

Common LL muscle injuries

Answer 87

Hamstrings\>Calf\>Groin\>Quads

Question 88

MOI of muscle injuries

Answer 88

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.

Question 89

Hamstring strain management

Answer 89

1. POLICE - activity modification 2. Early load - 2-3 days in elite sports 3. Length of muscle (ROM/stretch) - prevent scar tissue formation in shortened state 4. Strengthen - early as best stimulus for recovery via mechanotherapy. 5. Pain relief if needed - heat/cold therapy, walking aids, medication.

Question 90

Groin strain causes

Answer 90

Adductors, Iliopsoas, Rectus Femoris affected Causes: 1. Inflammation from overuse of muscle/tendon 2. Direct trauma/Biomechanical 3. Inflammation, pain on movement/contraction, loss of function/weakness 4. Visible/palpable defect (if grade III tear)

Question 91

Achilles tendon rupture/calf injuries MOI

Answer 91

Extension of knee with DF (all eccentric PF work) followed by push off

Question 92

Clinical presentation of Achilles tendon rupture

Answer 92

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

Question 93

Define Perthes Disease

Answer 93

Avascular necrosis of the femoral epiphysis (head)

Question 94

Prevalence of Perthes Disease

Answer 94

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

Question 95

Clinical presentation of Perthes disease

Answer 95

knee pain only and a limp - need to assess the hip in these cases Adults especially with alcohol problems (Bilateral symptoms) - assess hip

Question 96

Management of Perthes disease

Answer 96

Management: Reduce WB and rest - allow to recover

Question 97

Define Slipped Femoral Epiphysis (SFE)

Answer 97

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

Question 98

Clinical presentation of SFE

Answer 98

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.

Question 99

Common LL pathologies

Answer 99

**Sprains (ligs):** 1. Knee (ACL/PCL, MCL/LCL) 2. Ankle sprains low (LLS – ATFL and CFL) and high (syndesmosis injuries) **Adolescents:** 1. OGS, SLJ’s, Perthe’s, SFE’s (Slipped Femoral Epiphysis), Sever’s **Bone:** 1. Stress #s 2. #s - # NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress # **Vascular:** 1. Arterial = PVT, arterial entrapment 2. Venous = DVT **Muscle/Tendon:** 1. Tendinopathies – Gluteal, Achilles, Plantarfascia and PTTD. Tendon rupture (Achilles) 2. Muscle Strains - hamstring\>calf\>groin\>quads **Joint:** 1. Degenerative - OA – HIP\>Knee\> Ankle, Joint replacements 2. Inflammatory 3. Traumatic 4. Joint disorders – FAI,PFPS, meniscal tears