MSK Flashcards

Question

Describe how you would do the ULTT for each nerve?

Answer 1

Median 1 - ULNT 1 -Shoulder depression, abduction, supination, wrist and finger extension, elbow extension Median 2 - ULNT 2 -Shoulder depression, shoulder lower abduction, forearm supination, wrist and finger extension, elbow extension Radial - ULNT 3 -Shoulder depression and abduction (10 degrees), forearm pronation, wrist flexion and ulnar deviation, finger and thumb flexion, elbow extension Ulnar - ULNT 4 -Shoulder depression and abduction, forearm pronation, wrist extension and radial deviation, and finger extension, elbow flexion

Answer 2

Stenosis - unload the nerve - SLF and rotation away, flexion based exercises, traction -Can also floss / tension Disc - graduated retraction, then add extension when ready being careful not to make things worse -The UCS in to flexion - no discs so don’t worry, LCS in to extension

Answer 3

Erb- Duchenne’s Palsy -C5/C6 injury -Shoulder and elbow effected, not hand -Elbow extension, shoulder internal rotation, forearm pronation -Sensation - limited on deltoid area and along radial side -From traumatic birth traction of head when shoulder gets stuck Klumke’s Palsy -C8/T1 -Present with Horner’s syndrome - drooping eyelids (ptosis) and small pupils (miosis) -Effects the forearm, wrist and hand - elbow flexion, forearm supination, wrist and MCP extension, finger flexion -Sensation on ulnar side of forearm and hand -Hyperabduction injury on birth or grabbing something and hanging off of it

Answer 4

Pain with extension, SLF (ipsilateral) and rotation (ipsilateral) - all compression stress May refer to neck or scapula Direction of Cx is 45 degrees towards eyes - able to get more rotation Tested using coupled or combined movements Physiological coupled - SLF and rotation to same side Can use manual therapy of either because they are the same arthrokinematics Non-physiological coupled - SLF and rotation to opposite side - more provocative

Answer 5

Compression of vertebral artery = decrease BF to brain Dizziness Drop attacks Dysarthria Dysphagia Diplopia Nausea Nystagmus Other neurological signs

Answer 6

Vertebral artery (cervical quadrant) test Bring patient in to extension and SLF holding for 10-30 sec The into ipsilateral rotation holding for 10-30 sec Dizziness or nystagmus = +ve on contralateral side artery is being compressed *keep eyes open*

Answer 7

Accessory nerve (CNXI) Branches of cervical plexus C2,C3

Answer 8

Can be congenital or acquired -Congenital - unknown etiology - trauma during birth or positioning in utero -Positional plagiocephaly - flattened head cause of positioning - change positions or wear a helmet (cranial remodeling orthosis) Primarily tightness of SCM causing ipsilateral SLF and contralateral rotation -Cause and decrease AROM and PROM the opposite way Postural education, stretch muscles and strengthening opposite side for treatment

Answer 9

Upper cross syndrome Weak - lev scap and upper trapezius, DNF Tight - pects and lower trapezius and lev scap Chin poking leads to tight upper extensors and lower flexors which lead to weak DNF Puts more stress on posterior structures (discs and facet) *good alignment when sitting at desk* Interventions - stretch tight muscles, strengthening of weak ones, appropriate positioning

Answer 10

Excessive motion between two adjacent vertebrae Due to joint damage, muscle weakness, fracture, dislocation, ligament damage Caused by trauma, long term corticosteroid use, congenital or secondary to other conditions (RA,OA, downs syndrome) *DO NOT MOBILIZE OR MANIPULATE

Answer 11

Severe headaches especially with movement Fear to movement head or neck especially in to flexion Dizziness Pupil dysfunction Nystagmus Lip or facial paraesthesia Lump in thorat Nausea/committing Severe muscle spasm Soft end feel *may have SCI S + S as well

Answer 12

Anterior shear or sagittal stress test Test: anterior ligaments and capsular tissues How: stabilize at TP below, anterior force on adjacent vertebrae above through SP or posterior arch (lamina) Positive: excessive motion or S + S Lateral flexion alar ligament stress test Test: contralateral alar ligaments How: stabilize C2 at SP and lamina, side flexes C1 and head Positive: excessive side flexion Lateral (transverse) shear test Test: lateral ligaments and capsular tissues How: radial aspect of one hand on one vertebrae, other side radial aspect of one hand on another vertebrae and push together Positive: excessive motion or symptoms of instability, SC or vascular pathology Sharp purser test Test: Determine subluxation between C1 (atlas) and C2 (axis) - potentially torn transverse ligament as stops C1 moving forward on C2 in flexion How: Hand on forehead and thumb on C2, patient to flex forward and to push forehead back Positive: head slide backwards during the movement, potential clunk Cervical flexion-rotation test Test: Determines C1/C2 dysfunction or CGH How: full Cx flexion then rotate to right and left Positive: increased or decreased ROM 45 UCS rotation = C1/C2 dysfunction or headaches = CGH

Answer 13

Inner unit muscles - attach segmental - postural control, not that strong but have good endurance DNF, deep neck extensors and SOM Global muscles - strong but don’t have good endurance *if IUM are weak or inhibited by pain then the global muscles take over to work but they are not meant for that task* This leads to segmental instability - aberrant movements between segments and causing pain Strength DNF - coordination and timing, analgesic effect

Answer 14

Craniocervical flexion test Use blood pressure cuff - inflate to 20mmHg, continue to add by 2’s if patient successful. See if they can perform upper cervical flexion and hold is for 10 sec getting it up to 22mmHg Most can get it up to 26mmHg Positive: unable to get to 26mmHg, hold it, raise pressure in small increments, uses compensatory patterns (using superficial neck muscles - SCM, extends the head)

Answer 15

Costochondral Costovertebral Facet joints Transitional vertebrae Thoracic rib motion Pump handle action- ribs 1-6 - up and forward Bucket handle action - ribs 7- 10 - lateral and forward Caliper action - ribs 8-12 - lateral

Answer 16

From external auditory meatus Acromion Greater trochanter Posterior to patella Anterior to lateral malleolus

Answer 17

Round back -Entire spine is kyphosis - decreased pelvic inclination (20 degrees) with thoracolumbar and thoracic kyphosis -Associated with FHP and rounded shoulders Scheuermann’s disease -Uneven growth = excessive wedge shape increasing kyphosis -Typically T10-12 -Rare congenital and/or degenerative weakening of vertebral end plate -Most common deformity in adults, 2nd decade, “growing pains” Hump back -Gibbus (localized, sharp, posterior angulation) in Tx caused by structural deformity (e.g., anterior wedging) due to fracture, tumour or bone disease -May or may not have pelvic inclination Flat back -Decrease pelvic inclination and decrease curve in Tx - mobile though Dowager’s hump -Increased kyphosis, typically postmenopausal OP with older women creating anterior wedge fracture across several vertebrae (result from trunk flexion) -Happens in upper and middle Tx, decreases height

Answer 18

Posture education Extension approach Stabilization exercises Stretching as needed Mobilization as needed * DO NOT JOINT MANIPULATE AND AGGRESSIVE MOBILIZATION IN SCHEUERMANN’S DISEASE AND DOWAGER’S HUMP*

Answer 19

Secondary to OP, F>M (post-menopause), 60-70 yo Most common in thoracolumbar region, typically anterior vertebral body (wedge shaping) Causes - falls, trauma, trunk flexion Increased kyphosis (multiple fractures = increase)

Answer 20

Posture education Extension approach Stabilization exercises Scapular stabilization exercises Weight bearing activity and exercises Light mobilizations as needed with precautions JOINT MANIPULATIONS AND AGGRESSIVE MOBILIZATION, TRUNK FLEXION EXERCISES ARE CONTRAINDICATED*

Answer 21

Named based on the direction of the convexity, and level of apex -If two - minor and major names -Cobb angle - >10 is significant, <10 is not Non-structural -Based on muscle guarding or spasm, nerve irritation, inflammation, postural, leg length discrepancy -LLD - if R higher- pelvis, sacrum, Lx all shift to R then thoracic shifts to L in order to compensation. Adducted on R, abducted on L - more stress on hip joints -Easy to correct once you know the difference -Adam’s test - disappears with forward flexion Structural -Due to the bony structures - congenital or acquired -Severe (>60 degrees) - cardiopulmonary system compromised -Rotation of vertebrae is towards the convexity, creates a rib hump -This is palpable along back, might be confused with SP -If severe = razor back spine -Can’t fix bones but can manage that non-structral doesn’t exacerbate structural

Answer 22

Posture education Stretch concavity Strengthen convexity Stabilization exercises Scapular stabilization exercises Mobilization as needed Bracing as needed - boston, milwaukee Surgery if severe

Answer 23

AKA shingles Viral infection of nerve causing skin rash along the typical dermatomal pattern (stripe like in Tx, just on one side) May be with fever

Answer 24

Right Liver and gallbladder - right neck and shoulder, right upper quadrant Appendix - right lower quadrant Left Lung and diaphragm - left neck and shoulder Heart - Left chest and arm and between scapula Pancreas - left upper quadrant Center Stomach - center of chest and back Small intestine - center of abdominal area Colon - center of groin area Both Kidney - left and right lower quadrants and upper legs Bladder - lower groin, inner legs

Answer 25

5 vertebrae 5 spinal nerves coming out below 5 discs -Thicker anterior - why lumbar lordosis -Posterolateral weaker - that is why it herniations here -Also not posterior cause of the posterior longitudinal ligament Motion segment - disc + above and below vertebrae

Answer 26

Dermatomes - same procedure as cervical -L4 - patella, and to great toe -L5 - plantar and dorsal digits, lateral ankle -S1 - 5th digit Myotome - same procedure as cervical -L1/L2 - hip flexion -L3 - knee extension -L4 - Ankle DF -L5 - Great toe extension -S1 - PF, hip extension and eversion at ankle -S2 - PF, hip extension and knee flexion Reflexes - same procedure as cervical (and same rating) -L3/L4 - patella -L4/ L5 - tibialis posterior -L5/S1 - medial hamstring -S1/S2 - lateral hamstring -S1/S2 - achilles UMN - same as cervical spine as this doesn’t change

Answer 27

Slump - get patient to slump down and tuck chin then passively extend their unaffected leg, then their affected If no symptoms - add DF If symptoms - ask them to lift head without moving from slump Positive - symptoms become worse with DF, or better when lifting head indicated neural tension/restriction of lumbosacral roots or dura/neural tissues *If symptoms at any stages - don’t add movements SLR - testing unaffected side first, add medial rotation and adduction, then flex at hip, if pain/tightness lower slightly until disappears, then DF or flex patient’s neck to see if symptoms or reproduced ROM - 35-70 = sciatic nerve -Before 35 - slack taken up -35- under tension -60-70 sciatic roots tense over disc ->70 - pain is likely MSK (hamstring stretch) Further stress nerves -SID - sural, inversion, DF -TED - tibial, eversion, DF -PIP - peroneal, inversion, PF Crossover sign - if when doing unaffected side they feel it in affected - suggests a large disc bulge as pulling the nerves into the disc Sign of the buttock - do after SLR - go to point of restriction then back off, add knee flexion and see if can get further hip flexion Positive - hip flexion does not increase - pathology behind hip joint (bursitis, tumour, abscess) - refer to GP Bow-string test - SLR produces symptoms, slightly flex the patient’s knee (20 degrees) to reproduce symptoms, pushing then in to popliteal area Positive - reproduces radicular symptoms, pressure or tension on sciatic nerve

Answer 28

Narrowing of the central canal (central stenosis) or lateral canal (lateral stenosis) which may compress the nerve roots or spinal cord Onset is insidious and usually >60 Due to osteophytes, spondylosis, ligament thickening May result in neurogenic claudication - neural leg pain Better with flexion, worse with extension

Answer 29

IC is similar leg pain symptoms but more to do with the use of muscles. Increase pain leads to increase activity and it is relieved by rest *see chart to differentiate between NC and IC * Use bicycle test as main measure to differentiate the two

Answer 30

Flexion based exercises initially and positioning (e.g., z-posture) Avoid aggravating movements Surgical management - laminectomy

Answer 31

Disc herniations posterolateral - due to PLL and weak annulus fibrosis, may compress nerve root Typically acute onset, 30-50 Levels -Protrusion -Prolapse -Extrusion -Sequestration Happens with flexion MOI, hurts in flexion, better in extension Worse in morning - due to larger disc = more herniation, worse with cough, sneeze, Valsalva May present with lateral shifting away from bulge (named based on the shoulders shift)

Answer 32

Postero-lateral bulge -Extension based exercises with progressions -Lumbar roll to promote extension when sitting Lateral bulge -Shift back towards the affected side Anterior bulge -Happens when bulge comes out anteriorly - less common, but there is no spinal nerves but the disc has nociception therefore can still feel pain -Flexion based exercises May be painful initially but complete entire set to evaluate the effect CENTRALIZATION is the priority Green (centralized or with an increase in pain), yellow (no change), red (no change and increase pain and peripheralized) Avoidance of aggravating movements and positions Surgical - laminectomy, discectomy

Answer 33

The nucleus goes up or down, typically from a compression force, which goes through the cartilaginous end plate and vertebral body Typically in higher lumbar levels

Answer 34

Lower cross syndrome Tight hip flexors, hamstrings, ES Hamstrings tight from trying to correct pelvis and compensating for glutes Weak glutes and core Anteriorly rotates the pelvis = more lumbar lordosis Intervention Strengthening weak, stretch tight

Answer 35

Degenerative changes within spinal motion segment Increase incidence with age, typically around >50, insidious Loss of disc height, approximation of vertebrae (initially unstable because ligaments longer = more laxity, then becomes stiff), degeneration of plates, fibrotic in discs, osteophyte formation Presents with loss of lordosis - results in increased stiffness, muscle spasms and back pain (Ache) Worse with prolonged flexion, specifically load. Better unloaded, position changes and gentle movement

Answer 36

Syndrome cause by facet - worse with compression of facet joints May refer to low back, glutes, hips, groin, thighs (not below knees) Coupled movements -Flexion - SLF and rotation to same side -Extension - SLF and rotation to opposite sides Non-physiological coupled - the opposite of this

Answer 37

Quadrant Test -Patient extended Lx and side flexes and rotates to side of pain -If increase - indicate facet involvement

Answer 38

Flexion based exercises and positioning Avoidance of aggravating movements and positions

Answer 39

Excessive motion between two vertebrae Can be ligament damage, fracture, dislocation,muscle weak, joint damage, poor neuromuscular control May be caused by trauma, long term corticosteroid use, congenital or secondary to other conditions Do not mobilize or manipulation Control system (CNS), active system (muscles and neural control) and passive system (bones and ligaments) Intervention = inner unit core stability training

Answer 40

Inner unit muscles - stabilizers - timing and endurance is important Transverse abdominis, PF muscles, diaphragm, lumbar multifidus Neurophysiological connected - meaning that they all fire at once, anticipatory before movement Often weak, trouble with timing - leads to aberrant movement and increased recruitment of global muscles to maintain stability Active muscle systems -Local and global - see chart in book

Answer 41

H and I (*start with pain free direction first) -If two positive - hypomobility -If one positive - instability -as the first movement providing stability for the second movement if this is the one that is unstable -direction of instability is based on the first movement Prone segmental instability test -Upper body prone, legs on floor -PA by therapist, if pain - lift legs - not present, then need core strengthing/stability exercises

Answer 42

TA isolation Make sure deep tension, no bulge 2 inch medial to ASIS, 1 inch inferior - then draw in abdomen and hold for 10 secs May coactivate with multifidus and PF muscles and progress to sitting / standing Correct -Normal, relaxed breathing -Slow, inward movement of lower abdomen -Deep tension under palpated area Incorrect - global muscle use -No movement of lower abdomen -Rapid contraction and/or tremor -Visible contraction -Swelling or bulging -Upper abs and rib cage movement -Breathing - unable to relax abdomen, holding breath -Spinal movement - PPT or APT, flex or extension of spine Multifidus Lateral to both sides of lower lumbar SP - contract for 10 secs - swell muscle, pushing fingers away May coactivate with TA or PF muscles PF Contract PF, stop urine from flowing, NO peri-anal or glute gripping Diaphragmatic Breath through belly, not chest Progression Isolate inner unit Train inner unit Maintain control of inner unit while training outer unit Integrate into function

Answer 43

Spondylolysis - fracture of one pars articularis - no slippage Spondylolisthesis - fracture of two and get anterior slippage -Traumatic - from trauma -Isthmic - repetitive micro trauma - common in L5/ S1 (excess movement of L5, carry weight of body, angulation is greatest) -Degenerative - degenerative changes - decrease joint space, increased laxity and risk of slippage -Dysplastic (congenital) - defect in formation of vertebrae -Pathological - secondary to another disease process or treatment Retrolisthesis - fracture of two and get posterior slippage

Answer 44

1 - <25 2 - 25-50 3- 50-75 4 - >75 5 - 100 *4 and 5 - need fixation, others core stability exercises

Answer 45

Hyperlordotic Pain with hyperextension Tight hamstrings Scotty dog with collar or decapitation Step deformity maybe S + S of central and lateral stenosis

Answer 46

Inner core stability Education - avoid aggravating movements Spinal fusion surgery *don’t manipulate

Answer 47

Max protection - Patient education -Expectations -No heavy lifting >10 pounds for up to 3 months -Signs of inflammation and infection -No getting incision wet (1 to 2 weeks) -Surgeons guidelines --Based on preference and surgery dependent - no rotation and avoid hyperflexion/extension Bed mobility Exercise - walking, gentle exercise C/I - extension exercises for laminectomy Moderate and minimum Scar tissue mobilization Progressive stretching and joint mobilization - grade I or II for pain relief Exercise - walking, strengthening - start with inner unit then progress C/I - joint manipulation at level of spinal fusion, extension exercises

Answer 48

CES -Below L1 - variable nerve root damage -Flaccid paralysis -LMN injury - areflexic B + B and sacral anesthesia -Leaking but don’t notice as don’t know when it is full -Emergency Malignancy -Spinal pain common- -Age >50 -Previous history of cancer -Unexplained weight loss -Constant unrelenting pain -Pain unrelieved by rest -Pain worsens at night -Failure to improve with conservative therapy (1 month)

Answer 49

A; Draws scapula anterolaterally, Suspends scapula on thoracic wall, Rotates scapula (draws inferiorly angle laterally) N: Long thoracic nerve (C5- C7) (SALT)

Answer 50

A: Shoulder joint: abduction of arm, stabilization of the humeral head in the glenoid cavity N:Suprascapular nerve (C5, C6)

Answer 51

A: Flexion and supination of the forearm at the elbow joint, weak flexor of the arm at the glenohumeral joint N: Musculocutaneous nerve (C5- C6)

Answer 52

A: Shoulder joint: Arm external rotation; Stabilizes humeral head in glenoid cavity N: suprascapular nerve (C5, C6)

Answer 53

A: Shoulder joint: Arm external rotation, arm adduction; Stabilizes humeral head in glenoid cavity N: Axillary nerve (C5, C6) *can be injuried with axillary nerve damage from shoulder dislocation

Answer 54

A; Shoulder joint: Arm internal rotation Stabilizes humeral head in glenoid cavity N: Upper and lower subscapular nerves (C5 - C6)

Answer 55

A: Clavicular part: flexion and internal rotation of the arm, Acromial part: abduction of the arm beyond the initial 15° Spinal part: extension and external rotation of the arm. N: Axillary nerve (C5, C6)

Answer 56

Sternoclavicular joint - attaches shoulder to axial skeleton, ligaments very strong, more likely to fracture clavicle Acromioclavicular joint - attached scapula to axial skeleton Glenohumeral joint -ER>abduction>IR - closed packed -30 degrees flexion, 60 degrees abduction, internal rotation - loose packed Scapulothoracic joint - false joint since no capsule and no bony articulation

Answer 57

Borders -Anterior - pect minor, coracoid process, clavicle -Posterior - scapula, UFT -Medial - 1st rib, scalenes -Lateral - axilla Content -Brachial plexus -Subclavian artery -Subclavian vein

Answer 58

Diagnosis of exclusion - results from compression of nerve or vascular structures in outlet Types Neurogenic (True TOS) -From anatomical anomaly - compression of nerve Non specific (symptomatic) neurogenic -Most common, diagnosis of exclusion - nothing shows up on scan, muscle atrophy or anatomical anomaly -Maladaptive postures - tight scalenes or pect minor Vascular - arterial -Compression of subclavian artery from anatomical anomaly -Worse with upper arm movements Vascular - vein -Does not typically result in TOS complaints - result of another cause (thrombus)

Answer 59

Neurogenic -Tingling, numbness, paraesthesia -Harder fine movements -Weak grip strength Vascular - artery -Cold and pale -Decrease pulses -Rapid fatigue of limb -Lower BP on affected side Vascular - vein -Mottled skin, blueish -Painful swelling in arm F>M, onset 20-50 - neuro most common Involves C8,T1 (ulnar nerve distribution) Athletes with abduction and external rotation

Answer 60

Congenital anatomical anomaly Inflammation or scar tissue Hypertrophy of scalenes, pect minor, subclavius Pressure Posture Overhead movements Trauma Thrombus (vascular TOS) Pancoast tumor

Answer 61

1. Scalenus anterior syndrome Compress = interscalene triangle - between scalene anterior and medius (SUPRACLAVICULAR) 2. Costoclavicular syndrome Compress = costoclavicular space - between clavicle and 1st rib (subclavicular) 3. Hyperabduction syndrome Compress - axillary interval - under coracoid process and behind pect minor (infraclavicular) 4. Cervical rib syndrome

Answer 62

Adson’s Allen’s Costoclavicular syndrome Halstead Wright test *above are all vascular and have to do with different positioning and decreasing the pulse* Roos - opening and closing hands - see why they stop Shoulder girdle passive elevation - do to patient and see if they get decrease in symptoms

Answer 63

The AC joint separation - the ligaments that hold the joint together (AC and coracoclavicular) Etiology -Downward pressure on acromion, or fall on acromion -Fall on outstretched hand or elbow

Answer 64

Step deformity -Distal end of clavicle raises -Grade III separation -Torn deltoid and trapezius also possible Pain with -Horizontal adduction - compressing together -Elevation - causes posterior rotation of clavicle -HBB - causes anterior rotation of clavicle Tenderness and swelling Horizontal adduction or cross body test Stress view xray - provide traction (inferior pressure) to see if there is separation

Answer 65

Grade 1 (SPRAIN) - no separation, capsule intact Grade 2 (SUBLUXATION) - increased AC joint spacing Grade 3 (DISLOCATION) - torn AC and coracoclavicular ligaments, joint surfaces not in contact

Answer 66

Direction - anterior, posterior, inferior, multidirectional Degree - subluxation, dislocation Etiology - traumatic, atraumatic Timing - acute, recurrent Epidemiology - M, <30

Answer 67

Shoulder dislocation - separate of humerus from scapula, common (and common anterior - for MSK) Shoulder subluxation - incomplete dislocation

Answer 68

Traumatic - direct, indirect -Most common abduction, ER -Stability provide - subscapularis, GH ligaments, long head biceps -Anterior dislocation injuries - subscapularis, long head of biceps, GH ligaments, anterior capsule, anterior glenoid labrum Atraumatic - general laxity lead to instability *surgery - only if recurrent - tighten subscap - no stretching or resisted activities

Answer 69

Feeling of slippage with pain or insecurity with certain activities Pain or apprehension when approaching extreme ROM Decrease ROM - acute Increase ROM - chronic Normal on clinical examination - more apparent after repeated activities with fatigue Atrophy due to disuse (chronic) Sulcus sign - multidirectional instability, loss of muscle control, groove inferior/lateral of acromion

Answer 70

Axillary nerve injury - deltoid or teres minor Axillary artery Brachial plexus - posterior cord especially Bankart lesion - anterior dislocation = labrum damage Hill-Sach’s lesion - damage to posterolateral humerus (indentation) as humeral head is compressed against anterior-inferior glenoid rim

Answer 71

AMBRI - born loose -Atraumatic, multidirectional, bilateral, rehab, inferior capsule shift if surgery required TUBS - torn loose -Traumatic, unidirectional, bankart, surgery

Answer 72

Anterior instability Crank, apprehension test with relocation Apprehension release (surprise) Load and shift test Posterior instability Posterior apprehension test Load and shift test Jerk test Inferior and multidirectional instability Sulcus sign Feagin test - push inferior with their hand on your shoulder

Answer 73

Bankart Anterior-inferior of labrum From anterior dislocation, common from overhead sports S + S Clicking and/or popping Diffuse shoulder pain Worse with HBB Weakness and instability SLAP Superior labrum anterior, posterior Long head of biceps attaches to superior labrum - can tear if forceful, shoulder can become unstable From -Repetitive throwing and overhead activity -Deceleration when throwing -Direct trauma -FOOSH -Traction injury (to biceps) in inferior direction S + S Clicking and/or popping GIRD - internal rotation deficit Pain with overhead activity (elevation) and lying on affected side Loss of strength and endurance in RC and scapular stabilization “Dead arm”

Answer 74

Clunk test Active compression test of O’brien - SLAP Biceps load test

Answer 75

Idiopathic - pain with more decrease ROM in capsular pattern from dense adhesions and capsular thickening F>M, 40-60 yo, non-dominant shoulder, increased with diabetes

Answer 76

1 - primary - idiopathic 2- secondary - other conditions *high correlation with psychosocial issues

Answer 77

Progressive ROM restriction in capsular pattern Hard with HBB, HBH, overhead Reverse scapulo-humeral rhythm (normal is 1:2, this is 2:1) Trick movements General muscle weakness and poor endurance

Answer 78

1 Pain starts, increased with movement, present at night Loss of ER <3 months 2 - Freezing More intense pain, restricted ROM in all directions 3-9 months 3 - Frozen Pain only with movement Hard capsular end feel - significant adhesions Restricted ROM in all directions with increased scapula compensation movements Atrophy of deltoid, RC, biceps, tricpes 9-15 months 4 - Thawing Minimal pain Increased ROM 15-24 months

Answer 79

Increased pressure on structures under a narrowed sub-acromial space Subacromial bursa Supraspinatus tendon Long head biceps tendon Coracoacromial ligament Joint capsule

Answer 80

Primary - congenital or degenerative Secondary - abnormal force coupling action - muscle imbalance and abnormal movement patterns (scapula or GH) -Secondary after instability (loose anterior capsule) -From tight pect minor (anterior tip), weak LFT (less post tilt), winging of scapula (internal rotation of scapula), kyphotic posture (no posterior tilt since blocked by ribs) Calcific tendinitis - typically supraspinatus

Answer 81

Pain arc (60-120) Pain - with overhead, anterior lateral shoulder, not below elbow, no pain at rest TOP - SSp, LHB, bursa Revered scapula-humeral rhythm Decreased HBB or HBH Pain and weakness on resisted abduction and ER Anterior-superior placed HH at rest Decreased posterior-inferior glide

Answer 82

Hawkins kennedy Neers Scapular assist - help scapula move

Answer 83

Tendonitis - inflammation Tendinosis - chronic degenerative changes without inflammation Tenosynovitis - inflammation of synovium Tendon rupture - tendon rupture

Answer 84

Pain with muscle contraction TOP

Answer 85

Biceps -Speed -Yergasons Supra -Drop arm -Empty can Subscap -Belly press -Lift off -Internal rotation lag sign Infra -Infraspinatus test -Lateral rotation lag sign Teres minor -Hornblower’s sign

Answer 86

Abnormal movement -Static - structural deformity, winging at rest -Dynamic - winging with movement Long thoracic nerve Serratus anterior weakness Other causes

Answer 87

Wall or floor push up Scapular load test Punch out test

Answer 88

Ulnohumeral joint Ulnar / Medial collateral ligament Trochlea and coronoid process Radiohumeral joint Radial / lateral collateral ligament Capitulum and radius Proximal radioulnar joint Head of radius with notch on ulna Annular ligaments holds together

Answer 89

NORMAL: female 10-15, male 5-10 (a little valgus) Excessive cubitus valgus: 30 Cubitus varus: -5 Gun stock deformity: -15

Answer 90

Grade I - no laxity, pain and inflammation Grade II - moderate swelling, ecchymosis and pain. Increased ligament laxity but still firm end feel Grade III - severe swelling, ecchymosis and pain. Gross laxity present. No end feel noted.

Answer 91

Fan shape - anterior, posterior and transverse portions Resists valgus

Answer 92

Valgus stress (chronic or acute - FOOSH with elbow stressed or forced ER) S + S -Pain, TOP -Joint effusion -Instability with valgus stress -Limited ROM -May have heard audible pop Special test Valgus stress test

Answer 93

Activity modification Correcting faulty technique Decrease pain Decrease swelling Bracing (medial strapping of elbow) Strengthening (focus on forearm flexors and pronators) Restore ROM Surgical - ligament reconstruction (take from other tendon typically hamstring) Immobilize to 90 degrees elbow flexion, neutral pro/sup = stiff especially in to elbow extension

Answer 94

Posterior Most common, ulna and radius (distal segment) moves posterior MOI: FOOSH *often involves disruption of UCL and RCL *often involves fracture of coronoid process or radial head Major complications from impairment of vascular supply (CHECK DISTAL PULSES) Anterior Distal segment moves anterior MOI: High energy trauma (MVA) Lateral Distal segment moves lateral MOI: humerus moves medial Medial Distal segment moves medial MOI: humerus moves lateral Divergent Ulna and radius move apart MOI: driving force inferiorly

Answer 95

Sublux radial head - commonly young children Longitudinal traction force with wrist in pronation S + S Child doesn’t move arm Arm is held at side in slight flexion Interventions Reduction of subluxed radial head Hyper pronation Supination / flexion maneuver Compressive manipulation on radius with arm in supination

Answer 96

Inflammation of bursa (fluid filled sac between bones, ligaments or tendons) Etiology Trauma Pressure - chronic Infection *more at risk if RA/gout* S + S Swelling, TOP Redness Interventions Activity modification, ice, compression, decrease swelling Medical - NSAIDs, corticosteroid injection, aspiration (drain excess fluid), antibiotics (if infected), bursectomy (if repeated bursitis or antibiotics don’t work)

Answer 97

Degenerative changes to wrist extensor tendons inserting into lateral epicondyle CEO Most common ECRB Etiology (>35 years olds) Repetitive use E.g., people that do extension/pro/sup all day Poor technique Heavy racquet Heavy ball Small grip *Load> person’s capacity to recover = degeneration of tendon Load = capacity = no degeneration Decrease BS also limits someone’s ability to recover S + S Aching pain - down to proximal forearm - insidious onset TOP near lateral epicondyle Pain with resisted wrist extension and/or gripping Pain with stretching of wrist extensors Decreased wrist extension or grip strength Special test Maudsleys - resisted D3 Cozen - resisted wrist extension Mill’s - passive wrist flexion

Answer 98

Cervical radiculopathy C5, C6 Radial nerve entrapment Musculocutaneous nerve tunnel syndrome Supraspinatus referral Radial head fracture Radiohumeral synovitis

Answer 99

Activity modification Counterforce brace Stretching Strengthening - eccentric Mobilization DTFM Pain modalities Medical - NSAIDs, corticosteroids

Answer 100

Degenerative changes to wrist flexors tendons inserting into medial epicondyle CFO Most common pronator teres and FCR Etiology (>35 years olds) Repetitive use S + S Aching pain - down to proximal forearm - insidious onset TOP near medial epicondyle Pain with resisted wrist flexion and/or gripping Pain with stretching of wrist flexors Decreased wrist flexion, pronation or grip strength Special test Medial epicondylitis (golfers elbow test) - reverse mills - passive wrist extension Resisted wrist flexion Resisted pronation

Answer 101

Activity modification Stretching Strengthening - eccentric Mobilization DTFM Pain modalities Medical - NSAIDs, corticosteroids

Answer 102

Median (C6-C8, T1) -Humerus supracondylar process syndrome - ENTRAPPED - under the ligament of struthers (anomaly) -Pronator syndrome - ENTRAPPED - between heads of pronator teres (does not lose innervation though) -Anterior interosseous nerve syndrome - between heads of pronator teres ---Occurs with forearm fracture ---Pinch deformity - can’t go tip to tip, pulp to pulp ---Just the motor - FPL, lat ½ of FDP and pronator quadratus ---Branch of median nerve Ulnar (C7, C8, T1) -Cubital tunnel syndrome - ENTRAPPED - cubital tunnel between two heads of FCU -More stress on nerve if more valgus or shallow tunnel -Special tests - cubital tunnel compression test, tinnel’s test at the elbow, elbow flexion test -Interventions ---Nerve mobilization ---Medial - NSAIDs, corticosteroids, ulnar nerve transposition surgery - reposition the bitch Radial (C5-C8, T1) -Posterior interosseous nerve (a branch) ENTRAPPED ---Two head of supinator in arcade of Frohse (anomaly) ---Entrance of radial tunnel anterior to radial head ---Near brachioradialis and ECRL ---Between ulnar half of ECRB tendon and fascia ---At distal border of supinator *may mimic tennis elbow* -Superficial branch of radial nerve -ENTRAPPED - under tendon of brachioradialis -*common with fractures mid-humerus - doesn’t affect triceps -Interventions ---Mobilization ---Medial - NSAIDs, corticosteroids, radial tunnel release surgery

Answer 103

Phalanges - Distal, Proximal and Middle MC Carpals - scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate Radius Ulna Joints DIP PIP MCP CMC Midcarpal Intercarpal Radiocarpaul Distal radioulnar *there is no ulnocarpal joint because the TFCC (triangular fibrocartilage complex) articulates with ulna and triquetrum

Answer 104

Distal radial fracture where the fragment moves more dorsally -SMITH'S fracture - the distal segments moves more anterior Complications -Compression neuropathy (commonly median nerve) -CRPS -Arthritis From FOOSH - with wrist extended -SMITH’s - with wrist flexed -More common in osteoporotic women - because they have a weak radius therefore it is the first thing to give) S +S -“Dinner fork” deformity -Dorsal wrist pain and TOP -Swelling - which may cause the compression of the median nerve -May have bruising or paraesthesia -Difficulty lifting or grasping Interventions -Medical - immobilization (either stable in cast (thumb spica), or unstable/displaced in ORIF) -PT - mobilization, strengthening -In cast - move everything above and below - NO PRO/SUP - makes sense cause radius moves around ulna = pain and delayed healing

Answer 105

Chronic pain disorder caused by SNS malfunction and is characterized by pain out of proportion to original injury Types I - injury to tissue - also known as regional sympathetic dystrophy (RSD) II - injury to nerve - also known as causalgia Unknown etiology - association with injury to affected area, F>M S + S Severe pain (burning) Sensory abnormalities -Allodynia - pain response to non-painful stimuli -Hyperalgesia - exaggerated response to stimuli Abnormal blood flow (vasomotor changes) and sweating (sudomotor changes) Abnormal motor function - weakness and poor coordination and stiffness Trophic changes -Color changes -Temperature changes -Edema -Shiny tight skin -Abnormal hair and nail growth Late stages may develop OP

Answer 106

Stage 1 - acute / reversible - days to weeks Characteristics - pain, hyperhidrosis, warmth, erythema, rapid nail growth and edema VASODILATION PHASE Stage 2 - dystrophic or vasoconstriction (ischemic) stage - 3 months lasting 3-6 months Characteristics - burning pain, sympathetic hyperactivity, hyperesthesia exacerbated by cold weather, mottling and coldness, brittle nails and OP VASOCONSTRICTION PHASE - *careful with OP* Stage 3 - Atrophic stage - 6 months to a year and lasts for months or years Characteristics - pain decreases or becomes worse, severe OP, muscle wasting, contractures CHRONIC PHASE - *careful of OP*

Answer 107

Education Mobility - early AROM, tendon gliding, nerve mobilization Encourage ADLs Compression loading Distraction Desensitization Edema control - Elevate, compression, retrograde massage Modalities - TENS, US, ice Mirror therapy Aerobic activity

Answer 108

Increased pain Cast tightness Cast looseness Changes in skin colour / sensation - CRPS, nerve/blood vessel compression Increase swelling DO Maintain ROM above and below Check skin integrity above and below Check capillary refill Education - reduce swelling warning signs / precautions Remove tight jewelry DONT Stick something inside case Get cast wet

Answer 109

Fracture of scaphoid - common, from FOOSH or MVA. Common in young males Complications Avascular necrosis Radial artery branch affected - no longer supplies blood, bone cause disintegrate Nonunion of fracture Arthritis S + S Radial sided pain Tenderness and swelling in anatomical snuffbox (EPL, EPB), scaphoid in floor Pain with longitudinal compression of thumb - pushing in to scaphoid Interventions Immobilization - stable (cast - thumb spica), unstable/displaced - ORIF Non - union - bone graft, avascular necrosis - vascular graft PT - mobilization and strengthening

Answer 110

Inflammation in sheath (synovium) of ABL and EPB - compression between sheath and radial styloid process Etiology Chronic overuse - repetitive wrist (ulnar deviation) and thumb movements Direct trauma - to radial styloid process S + S Radial side wrist pain Tenderness and swelling Wrist with wrist and thumb movements - contraction and stretching of APL and EPB May have crepitus Special tests - Finklestein’s Interventions PT Activity modification Cryotherapy Splinting (thumb spica) Gradually stretching and strengthening (as tolerated) Medical NSAIDs Corticosteroid injections * Surgical release

Answer 111

Tear to TFCC on ulnar side of wrist TFCC - transmits and distributes load, stabilizes area (therefore causes radius to bear more load) Etiology Compressive loads to wrist - while in ulnar deviation - degenerative or traumatic Distal radial - ulnar fracture S + S Ulnar side wrist pain Tenderness and swelling over dorsal ulnar aspect of wrist CLICKING with wrist movements - HALLMARK Pain with (or resisted) wrist extension and ulnar deviation Special tests TFCC load test - compressive load with ulnar deviation with flexion/extension Press test - pushing up in chair Interventions Activity modification Bracing (widget - two straps) Cryotherapy Progressive strengthening and mobility exercises when able to tolerated *after extension period of immobilization Medical management -NSAIDs, Corticosteroid injection, Surgery

Answer 112

Median nerve 2 lumbricals - 1 and 2 Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Ulnar nerve Lumbrical 3 and 4 Hypothenar muscles -Abductor digiti minimi -Opponens digiti minimi -Flexor digiti minimi -Palmaris brevis Interossei muscles -PAD DAB -Palmar - adductor -Dorsal - abductor Adductor pollicis brevis Radial nerve Brachioradialis Extensors Supinator Triceps and anconeus

Answer 113

Median Ape hand - thumb in same plane, stuck in adduction - no other thumb movements Lower level lesion Hand of benediction - cannot flexion digits 1-3, so when make a fist those digits remain (ONLY SEE WITH FIST) High level lesion Ulnar Claw hand - hyperextension of MCP, flexion of digits 4 and 5 Radial Wrist drop - cannot extend wrist or MCP

Answer 114

Compression medial nerve as through carpal tunnel (made by flexor retinaculum and carpal bones) Contents FDP, FDS, FPL Median nerve Etiology Typically insidious onset, F > M Repetitive hand movements Vibrations Associated conditions -RA and other inflammatory conditions -Colles’ fracture -Lunate subluxation - encroach on space -Hypothyroidism - fluid retention -Pregnancy - 2nd trimester - fluid -DM - fluid -Obesity - fluid and tissue larger

Answer 115

S +S Paresthesia and pain in median nerve distribution Worse with sustained or repetitive wrist movements Nocturnal numbness and pain Relieved by “flicking” Weakness and clumsiness in hand - decrease grip strength and frequently dropping objects Severe - atrophy and thenar eminence and lumbricals 1 and 2 Special tests Tinel’s test Phalen’s test - reverse prayer Reverse Phalen’s - Prayer Carpal compression test Resisted APB - only one exclusively innervation by median nerve ULTT median nerve Nerve conduction velocity test Electromyography (EMG) Interventions Activity modification Splinting in neutral Mobility techniques Nerve mobilization Tendon gliding exercises Joint mobilization Improve muscle performance (no symptoms) Gentle multi-angle muscle setting Progress to resistance and endurance Fine-finger dexterity Medial - NSAIDs, corticosteroids, carpal tunnel release surgery

Answer 116

Post-operative management Immobilized 7-10 days in slight extension Splint removed during surgery cannot do active flexion past neutral or use finger flexors with wrist flexion for first 10 days Pillar pain = pain in thenar and hypothenar eminences Max protection Patient education Wound management Control of edema Control of pain Active tendon/nerve gliding Upper extremity exercises Finger and thumb movements Wrist extension Active radial and ulnar deviation Pronation and supination Elbow and shoulder movements Moderate and minimum Suture removed post op 10-12 Return to full activity by 6 - 12 weeks Residual impairments -Weakness -Sensory deficits -Persistent edema -Limited ROM -Hypersensitivity -Pain Scar tissue mobilisation Progressive stretching / joint mobilisation Progressive strengthening -Isometrics - 4 weeks -Grip and pinch - 6 weeks Dexterity exercises Sensory reeducation

Answer 117

Nerve compression in more than one place for same nerve Proximal compression increases vulnerability at distal point

Answer 118

Compression of ulnar nerve as it passes through Guyon’s canal - between pisiform and hook and hamate Etiology Trauma - FOOSH with or without hamate fracture Chronic pressure Space occupying lesion Extended use of crutches Higher risk of cyclist, baseball catches, karate players and use of jack hammers S +S Pain and paresthesia in ulnar nerve distribution Motor weakness of muscles innervated by ulnar nerve Decreased grip strength Fatigue with repetitive or sustained activities Severe - claw hand and atrophy of hypothenar eminence Special tests Froment’s sign - pinch paper and pull away - need to use adductor pollicus and if not then go in to thumb flexion instead Guyon canal compression test Tinel’s test over guyon’s canal ULTT ulnar nerve Nerve conduction velocity test Interventions Activity modification Cock up splint - into extension Ergonomic and padded equipment Frequent changes of hand positions Nerve mobilization Medical - NSAIDs, corticosteroid injections, guyon’s canal release

Answer 119

Sprain of ulnar collateral ligament - occurs with valgus force of MCL joint (seen in gamekeepers, skiers, volleyball players) S +S Pain and tenderness at base of thumb on ulnar side of MCP Pain with movement - worse with abduction and extension Decreased pinch and grip Swelling and dislocation at base of thumb Special test Thumb UCL laxity or instability test- valgus stress test Interventions Acitvity modification Splint MCL in slight flexion Gentle ROM as tolerated Strengthening Medical - surgical repair - complete or displaced avulsion fracture

Answer 120

CMC OA - common Etiology Repetitive movement Joint injury F>M, advanced age S + S Pain at base of thumb Worse at night, changes in weather and with overuse Tenderness at CMC Decreased pinch and grip strength Muscle wasting at thenar eminence (disuse) Possible instability (sublux or dislocation) Lead to hyperextension deformity of MCP Special tests Grind test - compression with rotation Interventions Activity modification Splinting Larger grip handles AROM within limits Strengthening Medical - NSAIDs, corticosteroids, 1st CMC arthroplasty (replaced trapezium with something else / arthrodesis (fuse bones)

Answer 121

Dupuytren’s contracture - of palmar fascia Fixed in flexion of MCP and PIP, usually D4 and D5 Skin is adherent to the fascia Splint in extension after release Trigger finger Thickening of flexor tendon sheath (Notta’s nodule) Tendon sticking, catching or locking when flexing More common D3-D4 Associated with RA Mallet finger Flexion of DIP at rest Rupture or avulsion of extensor tendon at insertion in distal phalanx Splint DIP for 6-8 weeks Bouchard nodes OA enlargement of PIP on dorsal Heberden nodes OA enlargement of DIP on dorsal Swan neck deformity (RA) Boutonniere deformity (RA) Ulnar drift (RA)

Answer 122

Acetabulum -Ischium -Ilium -Pubis Femur Labrum - suction, and capsule also help support Hard to dislocate unless deformity, extreme force or poor stability from passive and active structures Ligaments (*strong) -Ischiofemoral -Iliofemoral -Pubofemoral -Ligamentum teres

Answer 123

Frontal plane -Normal: 120-135 -Coxa valgus - >135 ---Creates varus at the knees -Coxa vara- <120 ---Creates valgus at the knees Transverse plane -Anteverted - femoral moved anteriorly, creates internal rotation force at foot ---Associated with W sitting - already in the position, greater BoS -Retroverted - femoral head moves posteriorly, creates external force at foot -*doesn’t mean someone has pain, just different body mechanics acting on joint - might need to have variations in how they do things

Answer 124

Degeneration of articular cartilage and subchondral bone = narrow joint space, bone on bone (no articular cartilage) and osteophyte formation Etiology Unknown Risk factors Non- Modifiable -Age -Genetics -Gender (F>M) -Congenital malformation Modifiable -Obesity -Abnormal repetitive stress -Trauma -Joint mechanics (may or may not be able to modify)

Answer 125

S + S Pain around hip, groin, glutes, thigh, back or knee Pain with weight bearing Decrease pain in loose packed position (30 flexion, 30 abduction, slight ER) Stiffness Firm capsular end feel, limited ROM Capsular pattern - flexion, abduction, IR Initially lose IR, then hip is fixed in adduction (no abduction), no IR or extension past neural and limitation in hip flexion to 90 Decrease muscle stretch Limited functional abilities (PROGRESS to this) STS Walking on uneven surfaces Difficulty with ADLs Decrease walking distance Decrease time in standing Special tests 1. Scour - in to flexion and adduction May also be iliopsoas, pectineus, TFL, sartorius pain as well if +ve 2. FABER or Patrick’s Decrease ROM, knee isn't parallel or lower = hip pathology, SIJ, iliopsoas spasm 3. Hip quadrant - flexion adduction without scouring +ve if pain

Answer 126

Education -Safe ambulation -Minimize aggravating activities Decrease pain -Grade I or II mobilizations -Assistive device for ambulation -LLD - shoe lifts -Modify chairs and commodes -Modalities Increase ROM -ROM exercises -Grade III or IV mobilizations -Stretching if chronic Strengthening -OKC first then progress to CKC -Hip strengthening as tolerated

Answer 127

Replacement of the femoral head and acetabulum Indications Severe hip pain, loss of function, decrease QoL associated with OA, RA, AS, avascular necrosis with failure of conservative treatment Nonunion fracture, instability or deformity of hip Bone tumours Failure of previous joint reconstruction surgery Preoperatively Examine patient’s status Education - operative procedures, post-operative precautions and rationale Functional training for early post-op days and exercises Criteria for discharge

Answer 128

Posterior / posterolateral Keep - Glute med and TFL Cut - Glute max and tendon, posterior capsule, small ER and piriformis, interval between glute max and medius Good for gait, bad for dislocation and subluxation in post-op Lateral Keep - NOTHING Cut - glute med, min, TFL, vastus lateralis, capsulotomy Bad recovery in gait and weakness of hip abductors, possible pelvic obliquity Anterior Keep - ALL Cut - (move sartorius and rectus femoris out of way), anterior capsulotomy WBAT immediately, good recovery, good gait

Answer 129

Intra-operatively Malpositioning Femoral fracture Nerve injury Peroneal division of sciatic - most common = drop foot Also superior gluteal or obturator or femoral nerve LLD - either prosthesis not in place or dislocated Early post- op DVT Infection Wound healing problems Pneumonia - HAP, immunity decreased Dislocation of prosthetic joint Late post - op Prosthesis doesn’t fit - mechanical loosening, atraumatic wearing out

Answer 130

Posterior / posterolateral No flexion past 90 degrees -Pay attention for STS No internal rotation past neutral -Pay attention for pivoting when walking - turn towards the sounds leg No adduction past neutral -Pay attention for transfer Anterior/anterolateral and direct lateral No flexion past 90 degrees No adduction past neutral No external rotation No hip extension No hip abduction (resisted or antigravity) if muscles cut 6 - 8 weeks No combined movements of FABER *less precautions that are more natural so that is why better for patient’s with dementia*

Answer 131

Max Prevent complications Ankle pumps, deep breathing and secretion clearance Reduce risk of complications education (precautions, safe bed mobility, transfers, S + S of infection) Prevent muscle atrophy Isometric quads, hip extensors and hip abductors (if not cut) Regain active mobility and control AAROM / AROM in ranges CKC weight shift, balance, heel raises, mini squats Achieve independent functional mobility Bed mobility STS Transfer training Ambulation with assistive device Stairs training Moderate Continue Minimal Continue - resume return to spots - avoid high intensity/ impact sports with slippery surfaces

Answer 132

Fracture of the hip - majority in elderly women (>75 years old) Extracapsular Intracapsular -Risk of avascular necrosis -Not congruent - wears out acetabulum -Delayed healing -Non-union Etiology Falls Decreased walking speed and balance- more likely to fall sideways on the hip Decreased muscle strength and flexibility Poor vision Cognitive decline Medications Osteoporosis Sudden twisting motion of LE

Answer 133

S + S Pain in groin or hip AROM or PROM of hip Pain with LE weight bearing LLD LE assumed ER and abduction position Intervention Surgery ORIF - younger people Hemiarthroplasty - just femur and if acetabulum in good shape THA

Answer 134

Minimize adverse effects of bed rest -Bed mobility, transfers, ambulative with assistive device (walker), deep breathing and coughing, LE edema control Exercise program - ROM, strengthening, balance

Answer 135

Severe pain increasing with weight bearing or hip movement Shortening that was not immediately present Positive trendelenburg on involved side that doesn’t resolve Damage to superior gluteal nerve Lurching gait - getting CoG over stance leg Persistent external rotation

Answer 136

Sciatic Entrapped from piriformis Obturator Uterine pressure and damage during labour Femoral Fracture of upper femur or pelvis, reduction of congenital dislocation or pressure during a forceps labor and delivery

Answer 137

Modified thomas test Iliopsoas or rectus femoris - hip stays flexed, bent knee and if continues then rectus femoris TFL and sartorius - if abducted - if in external rotation - sartorius, if internal - TFL Ely’s test Prone, flex knee - if hip flexes = rectus femoris tightness Ober’s test Tight ITB Piriformis test Sidelying, forward flex (60-90) and adduct the hip 90/90 SLR More accurate than just SLR (isolating hamstrings) In reverse table top and straight the leg

Answer 138

General instability resulting in increased risk of hip fractures, common in infants (F>M) Etiology Genetics F>M - gender First born Breech birth Narrow uterus Tight swaddling Signs and symptoms Asymmetry (if unilateral) -LLD or gluteal folds Hip abduction limitations Hip clicks *diagnosis through US, not XRAY

Answer 139

Barlow’s maneouver Hip adduction with a posterior force - +ve if sublux or dislocation Ortolani maneouver Hip flexed to 90 then abduction with anterior force - +ve if click when hip reduces

Answer 140

Pavlik’s harness - in flexion and abduction (*avoid extension and adduction) Hip spica - if severe instability or above doesn’t work - more fixed Closed reduction - if didn’t catch it soon enough Open reduction - if tissue is stopping it

Answer 141

Avascular necrosis of femoral head due to interruption of blood supply (etiology unknown but risks factors - trauma, infection, family Hx, low birth weight) Children 2-15 (common 4-8) S + S Limp of insidious onset +ve trendelenberg Pain aggravated by activity and relieved by rest Pain in hip which may refer to anteromedial thigh or knee Decreased hip ROM (especially abduction, internal rotation) *XRAY - flattened femoral head, if not - MRI or bone scan Interventions Petrie’s cast - in abduction Low impact, strengthening, ROM, reduction of weight bearing if pain is severe, hemiarthroplasty *heals fairly well since young*

Answer 142

Fracture through growth plate (physis) causing slippage of end of femur (metaphysis) Shaft moves anterior (and external rotated), head moves posterior Seen in adolescent M>F Etiology Obesity Family history Endocrine disorders S + S Pain in hip or anterior thigh Pain with activity ROM limitations - flexion, abduction, IR Limp present Interventions - surgery - same rehab as ORIF Get screw through but don’t change the femoral head cause more risk for avascular necrosis

Answer 143

Medial (C-shaped - thicker anterior / posterior) and lateral (O-shaped) meniscus -Thicker on peripheries -Vascular on lateral ⅓ - easier to heal, avascular on inner 2/3s - harder to heal, get surgery -Attach to tibia by coronary ligament and to each other by transverse ligament During flexion, the meniscus both move posterior but the lateral meniscus moves more (10mm) the medial moves less (2mm) making the lateral one less prone to injury -Lateral meniscus is less prone to injury because ot this and because it is attached to less structures Lateral meniscus - attaches to PCL and tendon of popliteus through capsular connections Medial meniscus - attached to ACL, MCL (terrible triad), PCL, semimembranosus -Because of semimem - if eccentric contraction can disrupt the meniscus Roles -Increase congruency -Shock absorber -Lubrication and nutrition of joint -Improve weight distribution -Reduce friction -Aid ligaments and capsule preventing hyperextension

Answer 144

Typically occurs in vascular region Etiology Occurs with shearing / twisting forces Compression with hyperflexion (>90 degrees) common MOI Early flexion = anterior, deep flexion = posterior Internal rotation = lateral, external rotation = medial Also think of femur - if internal rotation when cutting = external rotation of tibia so medial meniscus tear S + S Swelling, joint line tenderness “Locking” if bucket handle tear, need an external force to unlock it This and osteocondritis dyskinesis - bones get caught Clicking noise with movement Knee “gives way” - because of swelling - quads because inhibited Loss of ROM “Springy block” - bucket handle tear instead of soft tissue approximation Types of meniscal tears Posterior tear -Most common - hyperflexion and compression Transverse tear -Common in lateral meniscus, and associated with ACL injuries Longitudinal tear Bucket handle tear -Longitudinal tear but a inner edge flips up getting caught in intercondylar notch -Medial meniscus tear - associated with ACL injuries -*refer to surgery*

Answer 145

Special tests Mcmurrys - deep flexion with external (medial) or internal (lateral) rotation into extension - can also add a varus/valgus force Apley’s - compression/ distraction in prone Thessalys - twist in SLS Bounce home test - extension and test end feel Interventions Physio - decrease swelling, increase ROM, strengthening Medical Meniscal repair -WBAT in extension ->90 flexion in 4-6 weeks -WB in flexion >90 3-4 months -No pivoting or cutting 3-4 months Partial or total meniscectomy -Recovering easier - RTW in 5-7-days, sport in 3-6 weeks -Focus on decrease swelling, improve ROM and gait -More prone to OA - redistribute load

Answer 146

Grade I - stretching ligament with minimal disruption of fibers Grade II - tearing 50% of ligament fibers; small hematoma; hemarthrosis may be present Grade III - complete tear and separation of ends, hematoma and hemarthrosis -Hemarthrosis - more likely in those with hemophilia and on anticoagulants (get greater ROM limitation, increased warmth/bruising

Answer 147

Runs back, up and lateral (BUL) - from medial tibial condyle to lateral femoral condyle Two bands Anterior medial - taut in flexion - more tested with anterior drawer Posterolateral - taut in extension - more tested with lachman’s Resists anterior drawer, medial rotation of tibia and valgus/varus on tibia Epidemiology - F>M - hormones and q-angle Etiology Excessive anterior translation of tibia Contact -A valgus force from lateral side of knee -Terrible triad - ACL,MCL,medial meniscus Non-contact -Pivoting or cutting - ER of tibia, or internal rotation of tibia or femur with planter foot -Rapid deceleration - because quads working eccentric - pull tibia forward -Forceful hyperextension - cause of contraction of quads S + S Hear audible pop or snap, tearing sensation Pain Contrast, throbbing, aching Increased with movement or weight bearing Hemarthrosis Joint effusion Knee “giving out” or feelings of instability - because of swelling inhibiting quads or because of actual instability Limited ROM

Answer 148

Special tests Anterior drawer -More in flexion -Check for muscle guarding from hamstrings that won’t let you pull it forward -Check for PCL tear as might feel like excessive motion but is because just sitting more posterior -Posterior sag sign or Godfrey’s (that is at 90-90) Lachman’s -More in flexion Pivot - shift -In flexion when supine, anterior force on the calf then in to extension - about 20-30 degrees of flexion the ITB will kick in and pull the tibia and you can see the reduction Interventions Strengthening (CKC because OKC) Decrease pain/ swelling Bracing Crutches if necessary Proprioception Restore ROM Surgical - ACL graft Autograft - you are donor -Gracilis / semitendinosus ---Don’t use semimembranosus because of the attachment to the medial meniscus ---Issues with strengthening of hamstrings - is a dynamic stabilizes so prevents the tibia from going anteriorly - prone to more tears -Patellar tendon graft ----Harder to strengthening quads - more at risks for PFPS Allograft - other donor

Answer 149

Tibiofemoral joint -Meniscus -Cruciate ligaments - support anterior/posterior direction -Collateral ligaments - supports medial/ lateral direction Patellofemoral joint Superior tibiofibular joint

Answer 150

Goes from tibial lateral plateau to the medial femoral condyle Resists posterior translation, medial rotation of tibia and valgus/varus force on tibia Stronger and thicker than ACL - less likely to tear Etiology Posterior translation of tibia on femur (typically knee flexion) Dashboard injury Fall on knees in hyperflexion Sudden forceful hyperflexion or hyperextension S + S Pain Contrast, throbbing, aching Increased with movement, especially kneeling or stairs Hemarthrosis Joint effusion Limited ROM in acute stage Increased passive extension ROM Genu recurvatum (knees hyperextended on observation) Have functional instability - so less likely to come to clinic cause don’t notice it as much

Answer 151

Special tests Posterior drawer Posterior sag sign Godfrey test Interventions Strengthening Decrease pain/ swelling Bracing Proprioception Restore ROM Surgical - ACL graft Autograft - you are donor Gracilis / semitendinosus Patellar tendon graft Allograft - Achilles tendon

Answer 152

Two layers - superficial (just attaches to capsule) and deep (attaches to capsule and medial meniscus) Restrains valgus, lateral rotation of tibia and anterior/posterior tibial translation All fibers taut in extension -Anterior - more taut in flexion -Posterior - more taut mid range Etiology Valgus force (with or without compression) S + S Pain Contrast, throbbing, aching Increased with movement, especially kneeling or stairs Joint effusion Pay report knee “giving out” or feelings of instability Limited ROM

Answer 153

Special tests Valgus stress test - if full extension = capsule, so want 20-30 degrees of flexion Interventions Strengthening Decrease pain/ swelling Bracing - not in full extension due to MCL taut Proprioception Restore ROM Surgical - not usually done, because of attachment to capsule - has good blood supply and therefore can heal conservatively

Answer 154

Round, cord like - lateral epicondyle of femur to fibular head Restrains valgus, lateral rotation of tibia and anterior/posterior tibial translation All fibers taut in extension, lose in 30 degrees flexion (so when testing don’t go past this) Can feel in figure 4 position Etiology Varus force (with or without rotation) S + S Pain Contrast, throbbing, aching Increased with movement, especially kneeling or stairs Joint effusion Pay report knee “giving out” or feelings of instability Limited ROM

Answer 155

Special tests Varus stress test When doing this compress medial side - so pain there might be a meniscus injury Interventions Strengthening Decrease pain/ swelling Bracing - not in full extension due to MCL taut Proprioception Restore ROM Surgical - not usually done

Answer 156

Degeneration of articular cartilage and subchondral bone leading to joint space narrowing, rubbing of bone on bone leading to osteophyte formation Etiology Non-modifiable -Age -Gender (F>M) - hormonal, weight distribution, body shape (q-angle) -Genetics -Congenital malformation Modifiable -Obesity -High impact activities -Inactivity -Muscle weakness - rely on passive structures -Trauma -Decreased proprioception - not optimal loading -Joint mechanics (may or may not be able to modify) S + S Insidious onset Morning stiffness (<30 mins) - if >1 hour it is more likely inflammatory (RA) Pain with activity - worse with weight bearing, squatting, stairs, static postures, rissing after sitting, excessive activity (e.g., walking), fall in barometric pressure Joint line tenderness Decreased ROM / strength / function Bony enlargement Crepitus Muscle atrophy, swelling, warm knee, feelings instability (decrease joint space = ligaments lax or quad inhibition), genu varum or valgum Imaging Decreased joint space Osteophyte formation

Answer 157

Interventions Muscle strengthening Low impact exercises Decrease pain and swelling Increase ROM (continuous passive motion machine - post -op) Improve function Assistive device for ambulation if needed Bracing if needed (unloader) Weight loss Surgical Aspiration Injections - hyaluronic acid (component of synovial fluid), corticosteroids Arthroscopic debridement Proximal tibial osteotomy (closing wedge varus - take out piece, opening wedge valgus - put in piece) Partial (hemi) knee replacement - unicompartmental OA TKR - 90 degrees required by 6 weeks or manipulation under anesthetic required

Answer 158

Diffuse pain around knee cap from abnormal patellar tracking causing increased contact pressure on posterior surface of patella against the femur Diagnosis made on history and physical exam Chondromalacia patella - progression - degeneration of patella articular cartilage Epidemiology - F>M

Answer 159

Extrinsic - sudden or drastic changes in training regime Intrinsic - abnormal patellar tracking (normally 60-90 degrees most contact, at 20- contact at apex, 90- contact at base, odd facet - side of patella - likely irritated and painful) Increased Q angle Measured from ASIS to mid patella, and mid patella to tibial tubercle Angle of quad muscles and patellar tendon - represents angle of force of the quads If increase in q-angle = larger bias to lateral quads = patella tracks more lateral Q- angle in females 15-18, males 12-15 Q-angle <12: patella alta (high sitting patella) Q-angle >18: patella baja (low sitting patella), genu valgum, subluxing patella - since pull patella laterally out of trochlea, PFPS Muscle and fascial tightness ITB tightness - lateral tracking Patella retinaculum tightness (especially laterally) Ankle PF tight (tight calves) → decrease ankle DF, subtalar pronation (not proper push offs), increased tibial IR (tibial torsion) - changes q-angle since tibial tubercle has changes, changes pull of quads Hip muscle weakness Weakness in hip abductors and ERs may results in adduction of the femur and valgus at the knee and possibly IR of femur Glute med weakness = TFL compensation and overuse = increase femoral internal rotation Glute med - abduction, external rotation and extension TFL - abduction, internal rotation and flexion *changes q-angle, TFL pulls it in to internal rotation or makes ITB more taut - patella track in different way VMO insufficiency Disuse or inhibition (because of joint swelling and pain) Weakness or poor timing of VMO = lateral drifting of patella Lax medial retinaculum

Answer 160

S + S Insidious onset (can be traumatic too) Anterior knee pain Pain with activities - prolonged knee flexion (theater/movie sign), loaded knee flexion/extension “Buckle” or “give way” - inhibited quads Crepitus PF joint pain, swelling and tenderness - common in retropatellar area Special tests Clarke’s sign (patellar grind test) - proximal patella with webspace - contract quads McConnels tests - resisted isometrics in 30,60,90 - if pain, add medial glide - if goes away = PFPS Step - up test Eccentric step test (step-down test) See if goes in to dynamic valgus Special tests for swelling Brush tests Patellar tap test Interventions Reduce activity involving high or prolonged loads Bracing or taping to prevent/limit lateral tracking Lateral retinaculum stretch VMO training Glute medius strengthening Arch support and foot intrinsic training Treat underlying cause(S) Surgical - lateral retinacular release (poor outcomes), Fulkerson’s procedure (distal realignment - changing tibial tubercle to decrease q-angle-change pull of quads)

Answer 161

Impingement of infrapatellar fat pad (Hoffa’s pad) from patella - occurs at 20 degrees knee flexion Etiology Patella alta -High sitting patella - apex touching fat pad at joint line Genu recurvatum -Hyperextended, go into inferior patellar tilt, apex tilts backwards into joint to cause irritation Inferior patellar tilt -See above Anterior pelvic tilt -More likely to go into hyperextension - see above Knee hyperextension injury (sudden onset) -Irritation S + S Anterior inferior knee pain Pain with extension activities (difficult from PFPS - since hurts with flexion), prolonged standing, stairs Tenderness on Hoffa’s fat pad - joint line near outside of patella Puffy appearance below patella “Camel sign” - two humps (patella and inflamed bursa) Special tests Hoffa’s Test - palpate then go from flexion to extension - fat pad goes anterior - compressed into fingers (20 degrees knee flexion) Interventions Decrease inflammation Decrease aggravating activities Taping (tape base to tilt inferior apex of the patella off fat pad) Address muscle imbalances Surgical - partial or full removal of fat pad

Answer 162

Irritation to the plica (commonly medial plica) that causes inflammation of synovial sack where the area of the plica becomes thicker - this may catch between patella and femur causing further irritation and inflammation Plica - fold of synovial membrane - embryological remnant S + S Intermittent anteromedial knee pain Pain with prolonged standing, squatting, sitting, stairs Tenderness on plica - medial side Audible clicking or snapping Knee may give way, present with pseudo-locking (not real, just catching), catching Special tests Hughston’s plica test Mediopatellar plica test Patellar bowstring test Interventions Decrease inflammation Decrease aggravating activities Taping to offload plica Address muscle imbalance and possible patellar tracking Surgical - partial or full removal of plica

Answer 163

Sublux - partially out, dislocation - completely out (lateral more common) Etiology Decelerated lateral cut- eccentric quads with planted foot = hip internally rotated, foot externally rotated - quads pull patella laterally and over the lateral femoral condyle Increased likelihood of dislocation with decelerated lateral cut and external valgus force Increased likelihood -Shallow groove -Patella alta -Increased q - angle -Foot pronation Post TKR Previous subluxation S + S Audible popping noise Severe pain and immediate swelling Apprehension Knee extension relocates typically and reduces pain Knee not feeling secure and slips out of place Hypermobile patella Tenderness on medial border Special tests Fairbank’s apprehension test - lateral glide, patient shows apprehension Interventions Early: Immobilization (zimmer splints) - 3-6 weeks Decrease inflammation Crutches until full extension can be obtained Normalize gait Isometrics and ROM exercises - OKC not CKC Later: Progress to CKC - emphasis on VMO and gluteus medius Patellar bracing Surgical - medial retinaculum tightening, lateral retinaculum release, Fulkerson’s procedure

Answer 164

Degenerative injury to patellar tendon causing pain in infrapatellar region of knee - NOT inflammatory Etiology Jumping sports and activities Repetitive overloading - typically eccentric quads Increased risk in those with patella alta S + S Pain with quadriceps contraction Worse with jumping, squatting, resisted knee extension Decrease pain with compression over patellar tendon TOP Localized swelling, quadricep weakness Interventions Manage pain and swelling Patellar tendon strap - force going through wider surface Avoid overloading quadriceps Progressive loading → return to activity Eccentric quadricep contraction - realign collagen

Answer 165

Traction apophysitis of tibial tuberosity Apophysis - bony tubercle arising as a result of secondary ossification Apophysitis - inflammation /irritation of apophysis *also sinding - larsen johansson - same but the inferior pole of patella Overuse injury in growing adolescents - M>F Etiology Repeated tension on growth plate of tibia Growth spurt - bones grow fast then muscles, so muscles traction Increase incidence in sports with running and jumping (quad contraction) S + S Pain with quad contraction over tibial tuberosity Worse with quad activation Decrease with compression over patellar tendon Pai with pressure of tibial tubercle (kneeling) Increased prominence of tibial tubercle (remains in adulthood) Interventions Manage pain and swelling Decrease parameters of aggravating activity Patellar tendon strap

Answer 166

Lateral knee pain - from irritation of structures from repeated knee flexion / extension - ITB frictions over lateral epicondyle ITB goes over lateral femoral epicondyle around 30 degrees Brought on by inflammation of ITB and underlying bursa Etiology Repetitive knee flexion / extension - e.g., sports like running/cycling Rapid increase in training volume Precipitating factors TFL/ITB tightness -Weak gluteus medius → TFL overactivity Genu varum -Increase distance of ITB Tibial IR (increase tension for ITB) -Further from gurdy’s tubercle (insertion) S + S Lateral knee pain Increase pain with repetitive knee flexion / extension Pain decreases with rest Special tests Noble compression test - compress lateral with extension, Pain at 30 degrees = +ve Obers test Thomas Test - test for ITB Interventions Decrease pain Avoid aggravating activity TFL/ITB stretches / ST

Answer 167

Fluid filled sac providing cushion, has synovial fluid reduces friction Etiology Trauma Sustained pressure Overuse and chronic friction Inflammatory conditions Infections S + S Joint stiffness Decreased ROM Warmth Pain with movement and pressure May present as visible bump *infection S + S - fever, red, warm, swollen Common Pes anserine - between sartorius, gracilis, semitendinosis Prepatellar Superficial infrapatellar Deep infrapatellar Interventions Manage pain and inflammation Avoid aggravating activities Stretching / ST mobilization putting pressure on bursa Surgical - aspiration corticosteroid injection, bursectomy

Answer 168

Excess fluid behind knee (between semimem and medial gastroc) which can rupture and produce pain and swelling in calf Etiology Intra-articular knee pathology, increases synovial fluid in knee which spills in to bursa May occur in children idiopathically S + S Swelling in popliteal fossa Visible lump Joint stiffness Decreased ROM Warmth Pain - worse with movement, knee extension and standing Interventions Manage pain and inflammation Avoid aggravating activities Compression sleeve Self limiting - will resolve on own Surgical - aspiration, corticosteroid injection, excision of cyst, arthroscopy and debridement of articular pathology

Answer 169

Cracks from articular cartilage and subchondral bone due to avascular necrosis Patella or femoral trochlea Pain, swelling, crepitus May cause catching and locking if caught Worse with squatting, walking, descending stairs

Answer 170

Formation of bone instead muscle-tendon unit, capsule, ligamentous structure Calcification may occur following injury (i.e.,. Bruising forms to bone) Commonly quads (also brachialis) MASSAGE, PASSIVE STRETCHING AND RESISTED EXERCISE IS C/I*

Answer 171

Inferior tib fib -AITFL, PITFL, interosseous, inferior transverse Talocrural -Lateral - ATFL, PTFL, CFL -Medial - deltoid Subtalar -Medial / lateral talocalcaneal ligament

Answer 172

Inversion sprain - tearing ligaments on the lateral aspect of ankle (ATFL, CFL, PTFL) Etiology Traumatic - PF and inversion Landing on uneven surface, running on uneven ground Increased incidence with weak peroneal or ankle instability PF and inversion (ATFL), neutral inversion (CFL), DF and inversion (PTFL) S + S Acute onset swelling/inflammation - warmth, bruising Lateral ankle pain - worse with inversion and weightbearing Antalgic gait TOP Instability Decreased proprioception Special tests Anterior drawer test Talar tilt Other - ankle lunge test (KTW), proprioception, strength Interventions Manage pain and swelling Bracing / taping Crutches Strengthening Proprioception Restore ROM - mobilizations, AROM, PROM Cross friction massage

Answer 173

See chart in book

Answer 174

Eversion sprain - tearing ligaments on the medial aspect of ankle (anterior tibiotalar, posterior tibiotalar, tibiocalcaneal, tibionavicular Due to strength of deltoid - associated with avulsion fracture Les common due to fibular blocking movement, strength of medial ligaments Etiology Traumatic Eversion Jumping and landing on uneven surface Running and cutting S + S Acute onset swelling/inflammation - warmth, bruising Medial ankle pain - worse with eversion and weight bearing Antalgic gait TOP Decreased proprioception Special tests Anterior drawer test Talar tilt External rotation stress test (Kleiger) - for high ankle sprains but if feel pain on medial side - splaying of the mortise Other - ankle lunge test (KTW), proprioception, strength Interventions Manage pain and swelling Bracing / taping Crutches Strengthening Proprioception Restore ROM - mobilizations, AROM, PROM Cross friction massage

Answer 175

Tearing of syndesmotic ligaments connecting tib-fib (inferior transverse, AITFL, PITFL, interosseous membrane / ligament) Associated with deltoid ligament injuries or fracture of the fibula/ medial malleolus Etiology Traumatic External rotation Hyper-DF S + S Acute onset swelling/inflammation - warmth, bruising Anterior ankle pain - worse with external rotation and weight bearing Antalgic gait TOP over syndesmosis and interosseous membrane Decreased proprioception May present with widening of mortis on imaging Special tests External rotation stress test (Kleiger) - for high ankle sprains - splaying of the mortise since wider anterior Squeeze test - pain, in weightbearing and do this adds stability and may get increased DF Other - ankle lunge test (KTW), proprioception, strength Interventions Manage pain and swelling Bracing / taping Crutches Strengthening Proprioception Restore ROM - mobilizations, AROM, PROM Cross friction massage

Answer 176

Ottawa ankle rules - referred for radiographic imaging Bony tenderness along 6cm of posterior edge of lateral malleolus Bony tenderness along 6 cm posterior edge of medial malleolus Bony tenderness at base of 5th MT (from peroneal brevis maybe) Bony tenderness of navicular Inability to weight bear immediately after injury and for 4 steps during initial evaluation

Answer 177

Degenerative changes to achilles tendon - may lead to thickening if chronic Classification Insertional - <2cm from calcaneal insertion Midsubstance - 2-6cm from calcaneal insertion Etiology Extrinsic Sudden and drastic changes in training regime - FOOT WEAR Intrinsic Age - reduced ability to recover, natural degeneration Decreased DF - excess stress on DF Foot pronation (static or dynamic) Weight gain S + S Insidious onset Morning stiffness Decreased ankle DF Decrease strength in PF Pain Increased with active/resisted PF, passive DF or weight bearing Decrease pain with walking about or applying heat TOP Antalgic gait Thickening of achilles tendon Retrocalcaneal exostosis -Excess bone - called pump bump, haglund deformity or achilles heel bone spur -Can lead to retocalcaneal bursitis May present with crepitus Interventions Avoid aggravating activities Eccentric exercises for PF (heel drops) Increasing shoe heel height and progressively decreasing heel height Stretching of PF Manage pain Taping Night splint Manage inflammation if paratenonitis or retrocalcaneal bursitis is present

Answer 178

Full grade III tear (~2-6cm proximal to calcaneal insertion) Epidemiology: M>F, athletes in 30s-40s Etiology Direct trauma (direct blow / cut) Rapid and forceful concentric contraction Eccentric overload Corticosteroid use - weakens connective tissue - more likely to rupture S + S Audible snap / tear Swelling Warmth, bruising Obvious limp - because no PF Palpable gap Gross decrease in strength in PF Present with pain Special tests Thompson’s test - squeeze calf, ankle in PF Interventions PT (conservative) -Cast immobilization in max PF (4 weeks) then gradually progress for 4 weeks reduced DF -Crutches NWB -Progressive ROM and strengthening exercise following -Proprioception exercises -*higher risk of re-rupturing Surgical management -Rupture repair (suturing) -Immbolization post-op same as conservative approach - strength and ROM may be difficult to regain -*higher risk of complications but less likely to re-rupture

Answer 179

Traction apophysitis in calcaneal insertion of achilles tendon Epidemiology - overuse injury in children, ages 7-10 Etiology Repeated tension on growth plate of calcaneus Growth spurt - bone growing faster than muscle Over-pronation - increase stretch of tendon Increase incidence in sports that involve running / jumping (especially hard surfaces) S + S Heel pain (posterior plantar side) Worse with calf use - walking, running, jumping May present with antalgic gait Pain with pressure over medial and lateral calcaneus in area of growth plate May present with decreased passive DF ALREADY on stretch and inhibited by pain Interventions Manage pain Decrease parameters of aggravating activity Foot orthotics Stretching Heel lifts - decrease stress of tendon

Answer 180

Umbrella term = pain along medial border of the tibia synonymous with medial tibial stress syndrome (MTSS) Classification -Periostitis -Stress fracture -Compartment syndrome *please ses chart for comparison* Stress - remains same pain wise Compartment - as use it, more pain - stops rapidly Periostitis - initially worse, then better, then worse once stopped

Answer 181

Inflammation of the periosteum- surrounds bone - chronic pulling (traction) by the muscles connected with repeated activity Anterior shin splints -Overuse of tib ant, EHL, EHL -Pain over proximal ⅔ of anterolateral aspect of tibia -Pain with resisted DF and passive PF Posterior shin splints -Overuse of tib post -Pain over the distal ⅓ of posteromedial aspect of tibia -Pain with acitve supination and with passive DF and eversion Etiology Sudden and drastic change in training regime Over -pronation - tib post on stretch Muscle dysfunction Fatigue Decreased flexibility S + S Gradual onset Diffuse pain - increases with activity, decreases or disappears with warming up and rest Diffuse TOP Interventions Avoid aggravating activities Manage inflammation and pain Taping - approximate muscles towards bone Orthotics Stretching and ST mobilization Strengthening (graduated with an eccentric focus) Walk-run program Address alignment and biomechanical issues

Answer 182

Overuse injury from repetitive loading leading to microdamage Etiology Sudden and drastic change in training regime Cavus foot - increased arch, not as much shock absorption Over pronation Overall limb and foot alignment - overload it LLD - overloading one side S + S Gradual onset Focal pain - present with activity and rest, remains constant or slightly increases with activity, worse at night, worse with impact activities TOP Special tests Stress fracture test (turning fork vibration) - irritate fracture Interventions Initial period of rest Avoidance of aggravating activities Crutches if needed Gradual progressive loading - Wolfe’s law -bone adapts to demand Walk-run program *get bone scan not an XRAY*

Answer 183

Increase pressure within fascial compartments of LL - decreased BF, decreased tissue perfusion, increase ischemia, pain and permanent damance Chronic exertional compartment syndrome - increased pressure within fascial compartment due to increased activity (increased muscle pump, increased BF = increased pressure) Compartments Anterior -Muscles - EHL, EDL, tib ant, peroneous tertius -Nerves - deep peroneal nerve (foot drop = no DF) -Cutaneous - webbing between 1st and 2nd digit Lateral -Muscles - peroneous brevis and longus -Nerve - superficial peroneal nerve (stuck in inversion since no eversion) -Cutaneous - dorsum of foot, except webbing of 1st and 2nd digit Posterior superficial -Muscles - gastroc, soleus, plantaris -Nerve - Sural - purely sensory -Cutaneous -posterior lateral aspect of leg and lateral foot and 5th digit Posterior deep -Muscles - tib post, FHL, FDL, popliteus -Nerve - tibial (does motor of above too) -Cutaneous - plantar aspect of the foot Etiology - unknown S + S Gradual onset Diffuse pain - severe cramping, increased with activity, decreased or disappears with rest (significant in minutes) Severe cramping Tightness sensation May present with motor weakness, altered or absent sensation, vascular S + S Special tests Compartment pressure (gauge) test - before, after exercise Pulse palpation MMT - strength Sensory testing - peripheral nerve testing - see if alterations Interventions PT - rest, ST mobilization Surgical - interosseous membrane release (fasciotomy)

Answer 184

Compression of posterior tibial nerve through tarsal tunnel (post to medial malleolus) - created by bone and flexor retinaculum Contains -Tib post -FDL -Posterior tibial artery and vein -Tibial nerve -FHL -TOM DICK and A VERY NERVOUS HARRY S + S Pain and paresthesia -burning , electric shock nerve pain -Plantar surface of foot -Increased with weight bearing, activity -Decreased with rest May present with swelling in the feet Special tests Tinel’s sign at ankle

Answer 185

*see picture in book*

Answer 186

Rearfoot Talus Calcaneus Midfoot Cuneiform Cuboid Navicular Forefoot Phalanges Metatarsals

Answer 187

-Club foot -Pes Cavus -Pes Planus -Hallux rigidus -Hallux valgus -Claw toe -Hammer toe -Mallet toe

Answer 188

Club foot Congenital deformity, etiology unknown - genetics or environment or intrauterine malpositioning Most common is congenital talipes equinovarus (CTEV) Congenital - from birth, talipes - foot and ankle, equinovarus - horse like and in varus Ankle - PF, rearfoot - varus, midfoot - adduction and supination *foot in in PF and turned inwards* Can be rigid (can’t move, complicated surgery) and flexible (can move a lot - serial casting gradually) During gait walking on edge laterally of foot and the heels are off the ground Pes cavus Longitudinal arches are accentuated with abnormally short muscles on the sole of the foot Leads to rigid foot with poor ability to adapt to stress and absorb shock (similar to stress #/ shin splints, causes plantar fasciitis, heel stress #) Pes planus Medial longitudinal arch is reduced Can cause no other problems Can lift arch and see if it changes the pain Hallux rigidus Extension of great toe is limited due to OA of MTP Hallux valgus Great toe deviations medially (along with MT head) Causes - tight pointed shoes, hereditary factors Bunion = medial side callus, thickened bursa and exostosis (bone) Can use toe wedge, change footwear, intrinsic foot exercises, mobilization or get fusion, osteotomy Claw toe Hyperextension of MTP and flexion of PIP and DIP PIP and MTP get callus formation Hammer toe Extension of MTP and flexion of PIP (DIP may be flexed, neutral or extended) Callus at PIP Mallet toe Flexion of DIP Callus at DIP or tip of toe *all three hereditary, poor shoes, muscle imbalance - common in RA*

Answer 189

Overuse injury of plantar fascia leading to pain at medial tubercle of the calcaneus (attachment), and it also attaches at metatarsal heads During great toe extension (heel/toe off) - plantar fascia tightens to bring bones together to lift the medial longitudinal arch - creates rigid foot ready for push off Etiology Pes planus -Increased strain trying to maintain arch- already stretched, stretching further Pes cavus -Short and thick - trying to pull against tightness Excessive walking or running -load> capacity to recover = degeneration Prolonged weight bearing -Load for long time Obesity -Load > capacity to recover Decreased ankle DF -Compensate during push off for pronation or hyperextension of 1st toe to push off = further stretching Tight calf muscles -Same as above Non-supportive footwear -Excess stress Special tests Windlass Test - standing on step and PT extends great toe - pain at insertion of calcaneus S + S Insidious onset Worse in morning and may decrease with activity Increased pain when activity is recommenced after period of inactivity tender on medial calcaneal tubercle which may extended into medial longitudinal arch Antalgic gait - less / no toe off, no heel contact

Answer 190

Interventions Activity modification ST mobilization or stretching- plantar fascia / calf Strengthening - intrinsic foot muscles Taping Orthotics, insoles, heel pad Night splints / Strassberg sock (DF over night - on stretch) Cryotherapy - decrease inflammation and analgesic Iontophoresis - medication given through electrodes Extracorpeal shock wave therapy Medical - NSAIDs, corticosteroids (inflammation and to wear down connective tissue so it eventually just breaks), plantar fasciotomy Ddx Fat pad contusion -High impact on heel - increase heel strike - common with fat pad atrophy (posterior-lateral of heel) Calcaneal stress fractures -Common with pes cavus - heel strike hurts Lateral plantar nerve entrapment - most common -Extension of posterior tibial nerve -Presents with pain - do S + S, SLR with tibial nerve stress, with head movements -Similar Rx

Answer 191

Thickening of fibrous tissue leading to entrpaemtn of digit nerve of foot (usually 3rd and 4th between MT) Etiology Narrow shoes High heels (MTP in extension, balls drop) Metatarsal injury - # = ossification encraoching Dropped transverse arch - all bones closer together *more common in RA * Special tests Morton’s test - press together MT heads S +S Pain between MT heads May have associated paraesthesia Worse with walking (especially push off), running and with high heeled or narrow shoes (compression of MT heads) Interventions Activity modification Changes in footwear Orthotics Cryotherapy Plantar metatarsal padding Strengthening - intrinsic foot muscles Medical - corticosteroid injections Surgical excision of nerve

Answer 192

Sprain of 1st MTP due to hyperextension injury combined with compression loading Etiology Flexible footwear Artificial turf Decreased ankle DF - compensate with hyperextension of toe Decreased MTP ROM - taut ligaments - more strain S + S Pain, swelling, plantar tenderness at 1st MTP Decrease ROM Worse with extension Interventions Activity modification Cryotherapy Taping Stiff soled shoes Medical - NSAIDs

Answer 193

Indications ROM limitations -Adaptive muscle shortening -Adhesions -Contractures -Scar tissue formation Preventable structural deformity due to restricted movements Component of sport to increase performance or reduce risk of injury Potentially reduce post-exercise soreness Contraindications Bony block limiting ROM Recent fracture or incomplete bone union Evidence of acute inflammation or infection Sharp acute pain with muscle elongation Hematoma Hypermobility Functional muscle shortening

Answer 194

Passive, assisted (something helps), active PNF - need normal innervation and voluntary control -Hold relax - isometric contraction -Contract relax - concentric contraction Incorporating into regular basis is most effective way to gain ROM

Answer 195

Sagittal (runs anterior to posterior) - separates R and L - like flexion/extension (abduction/adduction for thumb) Coronal (separates anterior / posterior) - separates front and back - like abduction / adduction (flexion/extension for thumb) Transverse - separates in upper and lower - rotational movements, supination/pronation

Answer 196

Physiological Movements Done actively by the patient Accessory Movement Cannot be actively performed by the individual Component movements - motions that accompany physiological movements (but not voluntary) -Scapular movements, clavicular movements Joint play - motions that occur between joint surfaces - describe distensibility of capsule (hypo/hypermobility, normal, doing traction, compression, distraction, glide spine)

Answer 197

Physiological movements that occur between segments (bones) End feel Normal -Bone to bone -Soft tissue approximation -Tissue stretch Abnormal -Abnormal capsular - frozen shoulder -Springy block - meniscus tear -Muscle spasm -Empty - can’t get to the end range -Abnormal bone to bone

Answer 198

Accessory movements that occur between joint surfaces Types of movement -Slide - one point of one meets new point on other - e.g., tires sliding to a stop -Roll - new point on one meet new point on another - tires moving normally -Spin - doesn’t move, same surfaces but spins -Traction -Distraction - pulling at a right angle -Compression *in periphery - name based on the distal segment, in spine - named based on the vertebrae above compared to the one below Direction of movement

Answer 199

Concave (distal) on convex - moves in SAME direction -E.g., MCP flexion = anterior, extension = posterior Convex (distal) on concave - moves in OPPOSITE direction -E.g, GH abduction - inferior, adduction - superior, flexion = posterior, extension = anterior, external rotation = anterior, internal rotation = posterior Rule of same different same as you name joints going down

Answer 200

Indications Pain, muscle guarding, spasm Reversible joint hypomobility Positional faults, subluxations Progressive limitation -frozen shoulder - need to maintain ROM Functional immobility - isn’t moving (cast) - regain ROM Contraindications Hypermobility Joint effusion Inflammation Precautions Malignancy Bone disease Unhealed fracture Excessive pain Hypermobility in associated joints Total joint replacements Weakened connective tissue Systemic connective tissue diseases Elderly individuals with weakened connective tissues

Answer 201

Freddy Kaltenborn - sustained glides grades I (loosen - small distraction, pain), II (tighten - small amplitude - distraction/glide - tighten tissue around joint, joint sensitivity, helps with pain, maintain joint play), III (large amplitude - distraction or glide to stretch joint capsule and periarticular structures - helps increase joint play) Geoffrey Maitland - oscillatory glides - grades I (small - pain and spasm), II (large - pain and spasm), III (large - regain ROM), IV (small - regain ROM), V (small - high velocity thrust) Brain mulligan - MWM (sustained glides with movements) Sustained accessory glide during active or passive physical movement by patient Comparable sign - determine effectiveness Accessory - pain free OP - pain free Improve comparable sign Failure to improve - something fucked up Parameters Type Direction Grade Speed (Hz) - how many pushes per sec (2Hz = 2 pushes per sec) Time (reps / sets)

Answer 202

Consider - needs (stairs, environment), abilities (physical - strength, balance, energy expenditure or psychological - cognitive), preference Help - increase support, stability, confidence (decrease fear of falling)

Answer 203

Pain, weakness, limited PROM Decreased strength / endurance Impaired motor control, balance Unstable structures Fear of falling Open wounds on WB surface (increase chance of infection)

Answer 204

NWB - affected limb bearing no weight in any circumstance -ONLY CRUTCHES AND STANDARD WALKER TTWB - toe touch weight bearing - foot may touch for balance only (<20%) PWB - prescribed based on percentage of weight that can be applied (25%, 50%) - -Use two bathroom scale method (or limb load monitor, heel sensors) WBAT - as much weight as comfortable FWB - no restrictions, no gait aid necessary *increase in weight bearing - progression, bone adapts to stress - Wolfe’s law

Answer 205

Advantages - max support/stability, initiate gait training, assistive gait device measurement Disadvantages - no portable, expensive

Answer 206

Advantage - high stability , wide BoS, functional mobility, unloads limb NMB, TTWB, PWB, WBAT, FWB Disadvantage - high energy expenditure, no stairs, difficult to transport

Answer 207

add a storage attachment, glides or platform - e.g., weightbearing through forearm

Answer 208

Advantage - high stability , wide BoS, functional mobility, unloads limb, can collapse easily TTWB, PWB, WBAT, FWB (NOT NWB LIKE STANDARD) Disadvantage - low mobility, high energy expenditure, no stairs

Answer 209

Advantages - increased mobility, good stability, unload a limb PWB, WBAT, FWB Disadvantages - not for NWB, no stairs

Answer 210

Advantages - promotes upright posture , less energy expenditure than standard Disadvantages - no stairs

Answer 211

Advantages - high mobility, WBAT or FWB, sit to rest (main reason - CRT or endurance issues) Disadvantages - low stability, no stairs, no turning if issues

Answer 212

Advantages - high mobility, used to unload limb, stairs, wide selection of gait patterns NWB, TTWB, PWB, WBAT Disadvantages - low stability, good balance and upper body/trunk strength, high energy expenditure, risks of brachial plexus or radial nerve compression injury (crutch palsy), temporary use only

Answer 213

Estimate height of crutches -Height markers -ATNR method (sitting) -From folding arm to the extended arm -Axillary fold to a spot 6-8 inch lateral to heel of shoe Estimate height of handles -Measure axillary fold to greater trochanter -Measure bottom of shoe to greater trochanter Confirm fit in functional standing -Tip 2 inch lateral, 6 inch anterior to 5th digit -2 fingers between axilla and axillary pad -Hand grips at wrist crease, ulnar styloid, greater trochanter (elbows 20-30 degrees flexion)

Answer 214

Advantages - high mobility, used to unload limb, stairs, wide selection of gait patterns, no risks of brachial plexus injuries or radial nerve compression, allows for release of handgrips for functional activities NWB, TTWB, PWB, WBAT Disadvantages - low stability, good balance and upper body/trunk strength, high energy expenditure, good coordination *mostly for those long term use of crutches that need just a little stability* (SB, CP - grade II GMFCS)

Answer 215

Handgrips -2 inch lateral, 6 inch anterior -Hand grips at wrist crease, ulnar styloid, greater trochanter (elbows 20-30 degrees) Cuff -Proximal 1/3rd forearm, 1-⅕ below olecranon or elbow cuff -Squeeze together or pull apart for proper fit (partial contact but not binding

Answer 216

Advantages - good stability, use when stability is needed but only one UE can be used, unload limb PWB, WBAT or FWB Disadvantages - low mobility, high energy expenditure, cannot be used on most stairs

Answer 217

Advantages - high mobility, good stability, unload limb, stairs WBAT or FWB Disadvantages - minimal balance deficits, slower gait pattern

Answer 218

Advantages - high mobility, unload limb, stairs, lower energy expenditure WBAT or FWB Disadvantages - minimal balance deficits, low stability

Answer 219

Weight bearing capacity of device (standard - <300 pounds, bariatric >300 pounds) Handgrip placement - *wearing shoes Elbows in 20-30 degrees of flexion Estimate using -Greater trochanter to heel -Wrist crease in standing -Ulnar styloid process -Height markings on device Confirm in functional standing -Tips of cane or crutches slight forward (4-6 inches) and to the side (2 inches) -Feet within box of walker

Answer 220

Gait belt -Secure when seated, usually at midsection or high if physical condition or patient’s size (breasts, incision) -Hold with supinated grip Stand posterior and to the side (which they are most likely to fall - weaker or side they lean to) Maintain broad BoS in staggered stance

Answer 221

-see image in book

Answer 222

STS Scoot to edge, flat feet, extend restricted leg out Lean over CoM over BoS -*for posterior or posterolateral - do not - just lean back because don’t want hips to go over 90 degrees of flexion Push up stable surface -Do not push up or pull up on stable surface Once standing - grab device Stand to sit Back legs up against chair, reach back and extended weight bearing restrictions, slow descent Turning Turn towards unaffected then can progress With posterolateral turn towards unaffected Use multiple slow steps progress to pivot Stairs Good up, bad down - device moves with affected LE - guard most likely to fall Initially step to then progress to step through Use handrails (no bilateral if device) - use on affected side

Answer 223

Inspect device regularly Replace rubber tips when signs of excessive wear Avoid slippery surfaces Beware of ice and snow - may need ice picks on tip in winter