MSK Pathology Flashcards
Degenerative joint disease (DJD) Degenerative osteoarthritis (OA)
Degeneration of articular cartilage with hypertrophy of subchondral bone and joint capsule of weight-bearing joints
Meds: corticosteroids, NSAIDs, glucocorticoid injections, acetaminophen (mild pain)
Diagnostic tests: plain film (diminished joint space, decreased height of articular cartilage, osteophytes) and lab tests (rule out RA)
PT GOALS:
joint protection strategies
Ankylosing spondylitis
Marie-Strumpell disease, Bechterew’s disease, rheumatoid spondylitis
Progressive inflammatory disorder that initially affects the axial skeleton
Initial onset before 4th decade; men 3x more
First sx = mild and low back pain, morning stiffness and sacroilitis (3+ months duration)
Leads to kyphotic deformity of CS/TS and decreased lumbar lordosis
Degeneration of peripheral and costovertebral joints in advanced stages
Meds: NSAIDs, corticosteroids, cytotoxic drugs, tumor necrosis factor inhibitors
Diagnostic tests: HLA-B27 antigen
PT GOALS:
flexibility exercises
relaxation activities–breathing strategies
Gout
Genetic disorder of purine metabolism –> elevated serum uric acid (hyperuricemia) which forms crystals that deposit in peripheral joints (knee/great toe) and other tissues (kidneys)
Meds: NSAIDs, COX-2 inhibitors, colchicine, corticosteroids, ACTH, allopurinol, probenecid and sulfinpyrazone
Diagnostic tests: lab tests identify monosodium rate crystals in synovial fluid and/or connective tissue samples
PT GOALS:
pt education for injury prevention
Psoriatic arthritis
Chronic, erosive inflammatory disorder (digits and axial skeleton) associated with psoriasis
Meds: acetaminophen, NSAIDs, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), biological response modifiers (BRMs)–Enbrel
Diagnostic tests: lab tests rule out RA
PT GOALS:
joint protection strategies
Rheumatoid Arthritis (RA)
Chronic systemic disorder in a symmetrical pattern of dysfunction in synovial tissues and articular cartilage of hands, wrists, elbows, shoulders, knees, ankle and feet
Women 2x more than men
**MCP/PIP: panes formation (inflamm granulation tissue covering joint surface), ulnar drift, volar subluxation of MCP
**swan neck and boutonniere deformity, Bouchard’s nodes (excess bone formation on dorsal PIP)
JRA: onset
Osteoporosis
Metabolic disease that depletes bone mineral density/mass predisposing individual to fracture
Women 10x > men
Common fracture sites: TS/LS, femoral neck, proximal humerus/tibia, pelvis, distal radius
Primary = decreased estrogen production
Senile = decreased bone cell activity due to genetics or acquired abnormalities
Meds: calcium, vitamin D, estrogen, calcitonin, and biophosphonates
Diagnostic tests: CT, single and dual photon absorptiometry
PT GOALS:
joint/bone protection strategies
Osteomalacia
Decalcification of bones due to vitamin D deficiency
Sx: severe pain, fractures, weakness, deformities
Meds: calcium, vitamin D, vitamin D injections (calciferol–vitamin D2)
Diagnostic tests: plain film, lab tests, bone scan, bone biopsy
PT GOALS:
joint/bone protection strategies
Osteomyelitis
Inflammatory response within bone caused by infection (staphylococcus aureus)
Children and immunosuppressed adults (male)
Meds: antibiotics, proper nutrition, surgery if spreads to joints
Diagnostic tests: lab tests (infection), bone biopsy
PT GOALS:
joint/bone protection strategies and cast care
Arthrogryposis multiplex congenita
Congenital deformity of skeleton and soft tissues limiting joint motion and “sausage-like” appearance of limbs; normal intelligence
Diagnostic tests: plain films
PT GOALS:
joint/bone protection strategies
pt education regarding adaptive devices
flexibility exercises
Osteogenesis imperfecta
Inherited disorder (autosomal dominant) leading to abnormal collagen synthesis creating imbalance between bone deposition and reabsorption Cortical and cancellous bone become thin leading to fractures/deformity of WB bones
Meds: calcium, vitamin D, estrogen, calcitonin and biophosphonates
Diagnostic tests: bone scan and plain film, serological testing
PT GOALS:
joint/bone protection strategies
Osteochondritis dissecans
Separation of articular cartilage from underlying bone (osteochondral fracture) usually medial femoral condyle near intercondylar notch or humeral capitellum
Surgery indicated if displaced
Diagnostic test: pain film or CT scan
PT GOALS:
joint/bone protection strategies
flexibility exercises
Myofascial pain syndrome
“Trigger point”: focal point of irritability within a muscle; taut, palpable band within muscle
Active = tender, referral pattern of pain when provoked
Latent = palpable taut bands, not tender, can become active
Onset: sudden overload, overstitching and/or repetitive/sustained muscle activities
Medical intervention: dry needling, injection of analgesic, corticosteroid
PT GOALS:
flexibility exercises
manual therapy: soft tissue, jt mobs, “spray and stretch” technique, dry needling, modalities and manual pressure
strength, power and endurance exercises
Tendonosis/Tendonopathy
Common tendon dysfunction (supraspinatus, common extensor tendon of elbow, patella, Achille’s tendon)
Histological charac: hypercellularity, hypervascularity, no inflammatory infiltrates, poor organization/loosening of collagen fibrils
Meds: acetaminophen, NSAIDs, and/or steroid injection
Diagnostic tests: possibly MRI
PT GOALS: flexibility exercises manual therapy: soft tissue and joint mobs endurance and strengthening (ECCENTRIC) modalities pt education for IADLs
Bursitis
Inflammation of bursa due to overuse, trauma, gout or infection
S/S: pain with rest, limited motion due to pain (non-capsular pattern)
Meds: acetaminophen, NSAIDs, and/or steroid injection
PT GOALS: flexibility exercises manual therapy: soft tissue and joint mobs modalities pt education for IADLs
Muscle strains
Inflammatory response within muscle due to micro tearing of musculotendinous fibers
Pain and tenderness within muscle
Meds: acetaminophen and/or NSAIDs
Diagnostic tests: MRI if necessary
PT GOALS: flexibility exercises manual therapy: soft tissue and joint mobs modalities pt education for IADLs
Myositis ossificans
Painful condition of abnormal calcification within muscle belly (quadriceps, brachial and biceps brachii) due to direct trauma leading to a hematoma and calcification
**Can be induced by early mobilization and stretching
Meds: acetaminophen and/or NSAIDs
Surgery: if nonhereditary and after maturation of the lesion (6-24 months) when lesions interfere with joint movement or impinge on nerves
Diagnostic tests: plain films, CT scan or MRI
PT GOALS:
flexibility exercises
manual therapy: soft tissue and joint mobs
NOTE: avoid aggressive soft tissue/massage techniques which may worsen condition
Complex regional pain syndrome (CRPS)
Dysfunction of SNS: pain, circulation and vasomotor disturbances
CRPS I: frequently triggered by tissue injury; its with above sx but no underlying nerve injury
CRPS II: same sx but clearly associated with a nerve injury
Medical intervention: sympathetic nerve block, surgical sympathectomy, spinal cord stimulation, intrathecal drug pumps
Meds: topical analgesics, anti seizure drugs, antidepressants, corticosteroids and opioids
Long term changes: muscle wasting, trophic skin changes, decreased bone density, decreased proprioception, loss of muscle strength from disuse and joint contractors
PT GOALS: pt education for injury prevention/reduction desensitization activiies flexibility exercises TENS for pain relief
Paget’s disease
osteitis deformans
Metabolic bone disease involving abnormal osteoclastic and osteoblastic activity leading to spinal stenosis, facet arthropathy and possible spinal fracture
Unknown etiology: possibly viral infection and/or environmental
Meds: acetaminophen, calcitonin and etidronate disodium (limit osteoclastic activity)
Diagnostic test: plain film, lab tests (increased serum alkaline phosphatase and urinary hydroxyporline)
PT GOALS:
joint/bone protection strategies
Idiopathic scoliosis
Structural: irreversible lateral curvature of spine with a rotational component
Nonstructural: reversible lateral curvature of spine without rotational component and straightening as individual flexes spine
Intervention (structural): bracing and possible surgery (Harrington rods placement)
45 deg: surgery
Diagnostic test: plain film (full-length Cobb’s method), CT scan and/or MRI to rule out associated conditions
PT GOALS:
flexibility exercises
application/pt education with orthoses
Torticollis
Spasm and/or tightness of sternocleidomastoid
SB toward and rotation away from affected SCM
Meds: acetaminophen, muscle relaxants and/or NSAIDs
PT GOALS:
flexibility exercises
manual therapy: soft tissue, joint mobs
Glenohumeral Subluxation and Dislocation
95% in anterior-inferior direction: when abducted UE is forcefully ER causing tearing of the inferior GH ligament, anterior capsule and occasionally glenoid labrum
Posterior dislocation: horizontal add and IR
Complications:
Hill-Sachs lesion: compression fracture of posterior humeral head
SLAP lesion: tearing of superior glenoid labrum from anterior to posterior
Bankart’s lesion: avulsion of anteroinferior capsule and ligaments associated with glenoid rim
Bruising of axillary nerve
Following surgical repair: AVOID apprehension position (flexion>90, horiz abd>90, ER to 80)
Diagnostic tests: plain film, CT scan, MRI
Meds: acetaminophen, NSAIDs
PT GOALS:
joint mobs
exercise focused on regaining scapulothoracic, GH stabilization and muscular re-ed
Instability (Shoulder)
Traumatic: young throwing athletes
Atraumatic: congenitally loose connective tissue around shoulder
Popping/clicking and repeated dislocation/subluxation of shoulder
Unstable injuries require surgery
Meds: acetaminophen, NSAIDs
PT GOALS:
return of function without pain
POST SURGERY:
Sling 3-4 wks
After 6 wks: sports-specific training
Full fitness: 3-4 months
Labral Tears
Superior: toward the top of glenoid socket
Inferior: toward bottom of glenoid socket
SLAP: tear of rim above middle of socket that may also involve biceps tendon
Bankart’s lesion: tear of rim below middle of glenoid socket
S/S: Pain cannot be localized Pn incr with OH activities or arm behind back Weakness Instability Pn on resisted flexion of biceps Tenderness over front of shoulder
Diagnostic tests: MRI arthrogram, “gold” standard: arthroscopic surgery
Meds: acetaminophen, NSAIDs
POST SURGERY:
Sling 3-4 wks
After 6 wks: sports-specific training
Full fitness: 3-4 months
Thoracic Outlet Syndrome (TOS)
Compression of neuromuscular bundle (brachial plexus, subclavian A/V, vagus and phrenic nerves and sympathetic trunk)
Common areas of compression: Superior thoracic outlet Scalene triangle Between clavicle and first rib Between p. minor and thoracic wall
Surgery: remove cervical rib or release anterior and/or middle scalene
Diagnostic tests: plain film, MRI, EMG
Special tests: Adson’s, Roo’s, Wright, Costoclavicular
Meds: acetaminophen, NSAIDs
PT GOALS:
Postural re-ed
Manipulations (first rib)
Acromioclavicular and Sternoclavicular joint disorders
MOI: fall onto shoulder with UE add OR collision with another individual in a sporting event
Acute phase: UE pos. in neutral in a sling; AVOID shoulder elevation
Diagnostic tests: plain film
Special tests: Shear test
Meds: acetaminophen, NSAIDs
PT GOALS:
manual therapy: soft tissue, joint mobs
Subacromial and Subdeltoid Bursitis
Subacromial and sub deltoid bursae (may be continuous) have close relationship to RC tendons–susceptible to overuse
Impinged under acromial arch
Meds: acetaminophen, NSAIDs
Rotator Cuff Tendonosis/Tendonopathy
Relatively poor blood supply near insertion of muscles makes them more susceptible
Mechanical impingement of distal attachment of rotator cuff on anterior acromion and/or coracoacromial ligament with repetitive overhead activities
Diagnostic test: MRI
Special tests: Supraspinatus tet, Neer’s impingement test
Meds: Acetaminophen, NSAIDs
Impingement Syndrome
Soft tissue inflammation of shoulder from impingement against acromion with repetitive overhead AROM
Diagnostic tests: arthrogram or MRI
Special tests:
Neer’s impingement test
Supraspinatus test
Drop arm test
Surgical repair: AVOID shoulder elevation >90
Meds: acetaminophen, NSAIDs
PT GOALS:
restoration of posture
joint mobs
Internal (Posterior) Impingement
Irritation between the RC and greater tuberosity or posterior glenoid and labrum
Overhead athletes
Pain in posterior shoulder
Special test: Posterior internal impingement test
Meds: acetaminophen, NSAIDs
PT GOALS:
joint mobs
Bicipital Tendonosis/Tendonopathy
Inflammation of long head of biceps
Mechanical impingement of proximal tendon between anterior acromion and bicipital groove of humerus
Diagnostic test: MRI
Special test: Speed’s test
Meds: acetaminophen, NSAIDs
Proximal humeral fractures
Fall onto an outstretched UE among older osteoporotic women
Diagnostic test: plain film
Meds: acetaminophen, NSAIDs
PT GOALS:
joint mobs
early PROM to prevent capsular adhesions
Adhesive capsulitis
Frozen shoulder
Restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule due to disuse or repetitive microtrauma
*Capsular pattern: ER > abd & flex > IR
Common with diabetes mellitus
Meds: acetaminophen, NSAIDs
PT GOALS:
joint mobs
Elbow Contractures
Loss of motion in capsular pattern (flex>ext)
Loss of motion in non capsular pattern: loose body, ligamentous sprain and/or CRPS
Meds: acetaminophen, NSAIDs
PT GOALS:
joint mobs
soft tissue techniques
splinting (for capsular restrictions)
Lateral Epicondylosis/Epicondylopathy
Chronic degenerative condition of ECRB at its proximal attachment on lateral epicondyle
Onset is gradual with repetitive wrist extension or strong grip with wrist extended
RULE OUT involvement/relationship to cervical spine condition
Special test: Lateral epicondylitis test
Meds: acetaminophen, NSAIDs
PT GOALS: ECCENTRIC exercise joint mobs education regarding prevention modalities counterforce bracing to reduce forces on ECRB
Medial Epicondylosis/Epicondylopathy
Degenerative condition of the pronator teres and flexor carpi radials tendons at their attachment to the medial epicondyle of the humerus
Overuse with strong hand grip and excessive pronation of the forearm
Special test: medial epicondylitis test
PT GOALS: ECCENTRIC exercise joint mobs education regarding prevention modalities
Distal Humeral Fractures
Complications: loss of motion, myositis ossificans, malalignment, neuromuscular compromise, ligamentous injury, CRPS
Supracondylar fractures: examine quickly for neuromuscular status (radial nerve involvement) may lead to Volkmann’s ischemia; youth: growth plate; high incidence of malunion
Lateral epicondyle fractures: young people, require ORIF to ensure alignment
Diagnostic test: plain film
Meds: acetaminophen, NSAIDs
PT GOALS:
pain reduction, reduce inflammation
flexibility exercises
Osteochondrosis of humeral capitellum
Osteochondritis dissecans: central and/or lateral aspect of capitellum or radial head
- Osteochondral bone fragment becomes detached from articular surface forming a loose body in the joint
- Repetitive compressive forces between radial head and humeral capitellum
- 12-15 years old
Ulnar collateral ligament injuries
Repetitive valgus stresses to medial elbow with overhead throwing
S/S:
pn along medial elbow at distal insertion of lig
paresthesias in ulnar nerve distribution
Diagnostic test: MRI
Special test: medial ligament instability test, Tinel’s sign
Meds: acetaminophen and NSAIDs
PT GOALS:
initial: rest and pain management
later: strength elbow flexors, taping
Ulnar nerve entrapment
Direct trauma at cubital tunnel
Traction due to laxity at medial elbow
Compression due to thickened retinaculum
Hypertrophy of flexor carpi ulnaris muscle
Recurrent subluxation or dislocation
DJD affecting cubital tunnel
S/S: medial elbow pain, paresthesias in ulnar distribution
Diagnostic test: EMG
Special Test: Tinel’s sign
Meds: acetaminophen, NSAIDs, Neurontin
PT GOALS:
early: rest, avoiding activities, modalities, soft tissue
neurodynamic mobilization
protective padding and night splints
Median nerve entrapment
Pronator teres muscle and under superficial head of flexor digitorum superficial with repetitive gripping activities
S/S: aching pain with weakness of forearm muscles
Diagnostic test: EMG
Special Test: Tinel’s sign with paresthesias in median nerve distribution
Meds: acetaminophen, NSAIDs, Neurontin
PT GOALS:
early: rest, avoiding activities, modalities, soft tissue
neurodynamic mobilization
protective padding and night splints
Radial nerve entrapment
Distal branches (posterior interosseous nerve) within radial tunnel (radial tunnel syndrome) due to overhead activities and throwing
S/S:
lateral elbow pain that can be confused with lat epicondylitis
pain over supinator muscle
paresthesias in radial nerve distribution
Diagnostic test: EMG
Special Test: Possible Tinel’s sign
Meds: acetaminophen, NSAIDs, Neurontin
PT GOALS:
early: rest, avoiding activities, modalities, soft tissue
neurodynamic mobilization
protective padding and night splints
Elbow dislocations
Posterior: position of olecranon relative to humerus; cause avulsion fractures of medial epicondyle due to pull of MCL
Posterolateral: most common due to elbow hyperextension from a FOOSH
Anterior/radial head: 1-2%
Complete dislocation: UCL will rupture, possible rupture of anterior capsule, LCL, brachialis muscle, and/or wrist flex/ext mm
S/S: rapid swelling, severe elbow pain and deformity with olecranon pushed posterior
Diagnostic tests: plain film
Meds: acetaminophen and NSAIDs
PT GOALS:
initial: reduction of dislocation
if stable: initial phase of immobilization
if not stable: surgery
Carpal tunnel syndrome
Repetitive stress syndrome
Compression of median nerve at carpal tunnel of wrist due to inflammation of flexor tendons and/or median nerve
Occurs with repetitive wrist motions or gripping, pregnancy, diabetes and RA
*RULE OUT cervial spine dysfunction, TOS or peripheral nerve entrapments
Diagnostic test: EMG
S/S:
exacerbation of burning, tingling, pins/needles
numbness in median nerve distribution at night
Long term: atrophy/weakness of thenar mm and lateral 2 lumbricals
Special test: Tinel’s sign, Phalen’s test
Meds: acetaminophen and NSAIDs
PT GOALS:
joint mobs
soft tissue
DeQuervain’s tenosynovitis
Inflammation of extensor policies brevis and abductor policies longus tendons at first dorsal compartment due to microtrauma or swelling during pregnancy
Diagnostic test: MRI
S/S:
pain at anatomical snuffbox
swelling
decreased grip and pinch strength
Special test: Finkelstein’s test
Meds: acetaminophen and NSAIDs
PT GOALS:
joint mobs
soft tissue
Colles’ fracture
Most common, due to a FOOSH
Immobilized 5-8 wks
Complication of median nerve compression with excessive edema
“Dinner fork” deformity: dorsal or posterior displacement of radius, with a radial shift of wrist and hand
Diagnostic test: plain film
Complications: decreased motion, grip strength, CRPS, carpal tunnel syndrome
Meds: acetaminophen, NSAIDs
PT GOALS:
early: normalizing flexibility
joint mobs
soft tissue
Smith’s fracture
Distal fragment of radius dislocates in a volar direction causing a “garden spade” deformity
Diagnostic test: plain film
Meds: acetaminophen and NSAIDs
PT GOALS:
early: normalizing flexibility
joint mobs
soft tissue
Scaphoid fracture
Most commonly fracture carpal bone; FOOSH in a younger person
Diagnostic test: plain film
Complications: avascular necrosis of proximal fragment of scaphoid due to poor vascular supply
Immobilized 4-8 weeks
Meds: acetaminophen and NSAIDs
PT GOALS:
early: maintenance of flexibility in distal/proximal joints while UE is casted
later: strength, stretching, soft tissue/joint mobs
Dupuytren’s contracture
Banding on palm and digit flexion contractors due to contracture of plamar fascia that adheres to skin
Men > women
Contractures:
MCP and PIP of 4th/5th digits (nondiabetics)
MCP and PIP of 3rd/4th digits (diabetics)
Meds: acetaminophen and NSAIDs
PT GOALS:
flexibility and splints
post-surgery: wound management, edema control and progression of exercise
Boutonniere deformity
Rupture of central tendinous slip of extensor hood following trauma or with RA
MCP extension
DIP extension
PIP flexion
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
splinting or taping
Swan neck deformity
Contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons following trauma or with RA
MCP flexion
DIP flexion
PIP extension
Diagnostic test: plain film
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
splinting or taping
Ape hand deformity
Thenar much wasting with 1st digit moving dorsally until it is in line with second digit due to median nerve dysfunction
Diagnostic test: EMG
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
splinting or taping
Mallet finger
Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digits due to trauma forcing distal phalanx into flexion
DIP flexion
Diagnostic test: MRI
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
splinting or taping
Gamekeeper’s thumb
Sprain/rupture of UCL of MCP joint of 1st digit leading to medial instability of thumb due to a fall while skiing when increasing forces are placed on thumb through ski pole
Immobilized 6 weeks
Diagnostic test: MRI
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
splinting or taping
Boxer’s fracture
Fracture of neck of 5th metacarpal due to a fight or punching a wall in anger/frustration
Casted 2-4 weeks
Diagnostic test: plain film
Meds: acetaminophen and NSAIDs
PT GOALS:
edema management
flexibility
Avascular necrosis (AVN) of the hip Osteonecrosis
Impaired blood supply to femoral head
Hip ROM decreased in flexion, IR, abd
Diagnostic test: plain film, bone scans, CT and/or MRI
S/S:
pain in groin/thigh
tenderness with palpation at hip joint
coxalgic gait
Meds: acetaminophen and NSAIDs
**corticosteroids are contraindicated
PT GOALS:
joint/bone protection
post-surgery: flexibility, strength, gait training
Legg-Calve-Perthes disease
Osteochondrosis
2-13 years old (avg age = 6 years)
Males 4x > females
Psoatic limp due to weakness of psoas major: affected LE moves into ER, flex, add
Gradual onset of “aching” at hip, thigh, knee
AROM limited: abd and ext
Diagnostic test: MRI (positive bony crescent sign–collapse of subchondral bone at femoral neck/head)
Meds: acetaminophen and NSAIDs
PT GOALS:
joint/bone protection
post-surgery: flexibility, strength, gait training
Slipped capital femoral epiphysis
Males: 10-17 y/o (avg age = 13)
Females: 8-15 y/o (avg age = 11)
Males 2x > females
AROM limited in abd, flex and IR
Vague pain at knee, thigh, hip
Chronic: Trendelenburg sign
Diagnostic test: plain film (positive displacement of upper femoral epiphysis)
Meds: acetaminophen and NSAIDs
PT GOALS:
joint/bone protection
post-surgery: flexibility, strength, gait training
Femoral anteversion
25-30 deg or more anteversion leads to squinting patellae and toeing-in
Coxa Vara and Coxa Valga
Coxa vara: 125 deg
Both can result from necrosis of femoral had with septic arthritis
Diagnostic test: plain film
Trochanteric bursitis
Inflammation of deep trochanteric bursa from a direct blow, irritation by ITB and biomechanical or gait abnormalities causing repetitive microtrauma
Common with RA
AROM vs PROM and resistive tests
Meds: acetaminophen and NSAIDs
Iliotibial band tightness/friction disorder
Tight ITB, abnormal gait pattern leads to inflammation of trochanteric bursa
Special test: Noble compression test, Ober’s test
Meds: acetaminophen and NSAIDs
PT GOALS: reduce pain/inflammation with modalities correct muscle imbalances joint mobs gait training/patient education
Piriformis syndrome
ER of hip can become overworked with excessive pronation of foot causing abnormal femoral IR
Tightness/spasm can compress sciatic nerve or lead to SIJ dysfunction
Diagnostic test: possible EMG
S/S: restriction in IR pain with palpation of piriformis referral of pain to posterior thigh weakness in ER, + piriformis test uneven sacral base **RULE OUT lumbar spine and/or SIJ
Meds: acetaminophen, NSAIDs and Neurontin
PT GOALS: pain reduction with modalities correct muscle imbalances patient education orthotic device for feet
ACL laxity leads to…
anterior instability
PCL laxity leads to…
posterior instability
ACL and MCL laxity leads to…
anteromedial rotary instability
ACL and LCL laxity leads to..
anterolateral rotary instability
PCL and MCL laxity leads to…
posteromedial rotary instability
PCL and LCL laxity leads to..
posterolateral rotary instability
Classification of ligament injury
First degree: little or no instability
Second degree: minimal to moderate instability
Third degree: extreme instability
“Unhappy triad”
Injury to MCL, ACL and medial meniscus
Results from a combination of valgum, flexion and ER forces applied to knee when foot is planted
Knee Ligament Injury
Diagnostic test: MRI
Special tests: Lachman’s, anterior drawer, collateral ligament instability tests, pivot shift, posterior sag test, posterior drawer test, reverse Lachman
Meds: acetaminophen and NSAIDs
PT GOALS:
reduce pain/inflammation with modalities
correct muscle imbalances
joint mobs
Mensical Injuries
Combination of forces: TF joint flexion, compression and rotation placing abnormal shear stress on meniscus
S/S: lateral and/or medial joint pain effusion joint popping knee giving way during walking limitation of knee joint joint locking
Diagnostic test: MRI
Special tests: McMurray, Apley
Meds: acetaminophen and NSAIDs
PT GOALS:
reduce pain/inflammation with modalities
correct muscle imbalances
Patella alta
Patella tracks superiorly in femoral intercondylar notch, may lead to chronic patellar subluxation
Positive camel back sign: 2 bumps over anterior knee instead of one
Diagnostic test: plain film including “sunrise” view
PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping
Patella baja
Patella tracks inferiorly in femoral intercondylar notch, leads to restricted nee extension with abnormal cartilaginous wearing–> DJD
Diagnostic test: plain film including “sunrise” view
PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping
Lateral patellar tracking
Could result if increased “Q-angle” with tendency for lateral subluxation or dislocation
Diagnostic test: plain film including “sunrise” view
PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping
Patellofemoral pain syndrome (PFPS)
Abnormal patellofemoral tracking ends to abnormal patellofemoral stress
May be related to chorndromalacia patellae and/or patella tendonitis
Diagnostic test: MRI
Meds: acetaminophen and NSAIDs
PT GOALS: patellofemoral taping patella mobilization correct muscle imbalances DO NOT USE: quad sets, single-leg raise flexion, isolated quads exercises
Patellar tendonosis/tendonopathy
“Jumpers knee”
Degenerative condition of patellar tendon (deep aspect)
Related to overload and/or jumping activity and interrelated to patellofemoral dysfunction
Meds: acetaminophen, NSAIDs, corticosteroid
Pes anserine bursitis
Due to overuse or contusion
*Differentiate from tendonitis
AROM vs PROM and resistive tests
Meds: acetaminophen, NSAIDS and corticosteroids
Osgood Schlatter disease
Mechanical dysfunction leading to traction apophysitis of tibial tubercle at patellar tendon insertion
Diagnostic test: plain film (irregularities at epiphyseal line)
Meds: acetaminophen and NSAIDs
early flexibility is important in prevention
PT GOALS:
modify activities to decrease excessive stress
Genu varum and valgum
NORMAL tibiofemoral shaft angle: 6 deg valgum
Genu varum: excess medial tibial torsion “bow legs”; excess medial patellar positioning and pigeon-toed orientation of feet
Genu valgum: excess lateral tibial torsion “knock knees”; excess lateral patellar positioning
Diagnostic test: plain film
PT GOALS:
decreased loading at knee
Femoral condyle fracture
Medial femoral most often involved
Trauma, shearing, impacting, avulsion forces
MOI: fall with knee subjected to shearing force
Diagnostic test: plain film unless complex fracture (CT)
Meds: acetaminophen and NSAIDs
PT GOALS:
return to function without pain
Tibial plateau fracture
MOI: valgum and compression forces when knee is in a flexed position
Often occurs with MCL injury
Diagnostic test: plain film unless complex fracture (CT)
Meds: acetaminophen and NSAIDs
PT GOALS:
return to function without pain
Epiphyseal plate fracture
MOI: weight bearing torsional stress
More frequent in adolescents
Diagnostic test: plain film unless complex fracture (CT)
Meds: acetaminophen and NSAIDs
PT GOALS:
return to function without pain
Patella fracture
MOI: direct blow to patella due to fall
Diagnostic test: plain film unless complex fracture (CT)
Meds: acetaminophen and NSAIDs
PT GOALS:
return to function without pain
Anterior compartment syndrome (ACS)
Increased compartmental pressure resulting in a local ischemic condition due to direct trauma, fracture, overuse and/or muscle hypertrophy
Sx (chronic or exertion): produced by exercise or exertion = deep, cramping feeling
Sx (acute): produced by sudden trauma causing swelling within compartment
**Acute ACS = medical emergency and requires immediate surgical intervention with fasciotomy
Anterior tibial periostitis
Shin splints
Musculotendinous overuse condition
3 common etiologies:
abnormal biomechanical alignment
poor conditioning
improper training methods
Muscles involved: anterior tibialis and extensor hallucis longus
Pain elicited with palpation of lateral tibia and anterior compartment
Meds: acetaminophen and NSAIDs
PT GOALS:
correct muscle imbalances
flexibility
Medial tibial stress syndrome
Overuse injury of posterior tibias and/or medial soles resulting in periosteal inflammation at the muscular attachment due to excess pronation
Pain elicited with palpation of distal posteromedial border of tibia
Meds: acetaminophen and NSAIDs
PT GOALS:
correct muscle imbalances
flexibility
Stress fracture
Overuse injury resulting in microfracture of the tibia (49%) or fibula (10%)
3 common etiologies:
abnormal biomechanical alignment
poor conditioning
improper training
Diagnostic test: plain film and bone scan
Meds: acetaminophen and NSAIDs
PT GOALS:
correct muscle imbalances
flexibility
Ankle ligament sprains (lateral)
95% of sprains: foot is plantarflexed and inverted
Grade I: no loss of function, minimal tearing of ATFL
Grade II: some loss of function, partial disruption of ATFL and calcaneofibular ligg
Grade III: complete loss of function, complete tearing of ATFL and calcaneofibular ligg with partial tear of posterior talofibular lig
Diagnostic test: MRI
Special test: anterior drawer and talar tilt
Meds: acetaminophen and NSAIDs
PT GOALS:
reduce pain/inflammation with modalities
correct muscle imbalances
joint mobs
Achilles’ tendonosis/tendonopathy
Degenerative condition of Achille’s tendon
Special test: Thompson’s test
Meds: acetaminophen, NSAIDs and corticosteroids
Fractures of foot and ankle
Unimalleolar: medial or lateral malleolus
Bimalleolar: medial and lateral malleoli
Trimalleolar: medial and lateral malleoli and posterior tubercle of distal tibia
Diagnostic test: plain film
- *Growth plate fractures are a concern since bone growth can be affected
- Types III and IV fractures and Salter Harris classification are of most concern with high complication rate
Meds: acetaminophen and NSAIDs
PT GOALS:
return of function without pain
correct muscle imbalances
early PROM to prevent capsular adhesions
Tarsal tunnel syndrome
Entrapment of posterior tibial nerve or one of its branches within the tarsal tunnel due to over/excess pronation, overuse problems (tendonitis of long flexor and post tib) and trauma
S/S: pain, numbness, paresthesias along medial ankle to plantar surface of foot
Diagnostic test: EMG
Special tests: Tinel’s sign at tarsal tunnel
Meds: acetaminophen, NSAIDs and Neurontin
PT GOALS:
foot orthoses
neurodynamic mobilization
Flexor hallucis tendonopathy
Acute stage: tendonitis
Can be chronic tendonosis
Common in ballet dancers
Meds: acetaminophen, NSAIDs and corticosteroids
Pes cavus
Hollow foot
Genetic predisposition, neurological disorders resulting in muscle imbalances and contracture of soft tissues leading to decreased ability to absorb forces through foot
Deformity: Increased height of longitudinal arches Dropping of anterior arch Metatarsal heads lower than hind foot PF and splaying of forefoot Claw toes
PT GOALS:
patient education: limit high impact sports, proper footwear, orthosis fitting
Pes planus
Flat foot
Genetic predisposition, muscle weakness, ligamentous laxity, paralysis, excessive pronation, trauma or disease (RA) leading to decreased rigid level for push-off
*Normal in infant/toddler feet
Deformity: reduction in height of medial longitudinal arch
PT GOALS:
pt education: proper footwear and orthotic fitting
Talipes equinovarus
Clubfoot
Postural: intrauterine malpositioning
Talipes equinovarus: abnormal development of head and neck of talus due to heredity or neuromuscular disorders (spina bifida)
Postural deformity: foot is in….
plantarflexion
inversion
adduction
Talipes equinovarus deformity: 3 components
(1) plantarflexion at talocrural joint
(2) inversion at subtler, talocalcaneal, talonavicular and calacaneocuboit joints
(3) supination at midtarsal joints
PT GOALS:
manipulation followed by casting/splinting
talipes equinovarus requires surgery to correct deformity followed by casting/splinting
Equinus
Congenital bone deformity, neurological disorders (CP), contracture of gastrocnemius and/or soleus, trauma or inflammatory disease
DEFORMITY: plantarflexed foot
Compensation secondary to limited dorsiflexion includes subtalar or midtarsal pronation
PT GOALS:
flexibility exercises
joint mobs
Hallux valgus
Biomehcanical malalignment (excess pronation), ligamentous laxity, heredity, weak muscles, tight footwear
DEFORMITY: metatarsal and base of proximal 1st phalanx move medially; distal phalanx moves laterally
NORMAL metatarsophalangeal angle: 8-20 deg
PT GOALS:
early orthotic fitting and patient education
later: surgery
Metatarsalgia
Mechanical=tight triceps surae group and/or Achille’s tendon, collapse of transverse arch, short first ray, pronation of forefoot
Structural=changes in transverse arch leading to vascular and/or neural compromise of forefoot tissues
Pain at 1st/2nd metatarsal heads after long periods of weight bearing
Meds: acetaminophen, NSAIDs, and neurontin
PT GOALS: correction of biomechanical abnormalities modalities to decrease pain orthotics pt education on footwear
Metatarsus adductus
Congenital, muscle imbalance or neuromuscular disease (polio)
DEFORMITY OBSERVED:
Rigid=medial subluxation of tarsometatarsal joints; hind foot valgus with navicular lateral to head of talus
Flexible=adduction of all 5 metatarsals at the tarsometatarsal joints
PT GOALS:
strengthening
regaining proper alignment (orthotics)
Charcot-Marie-Tooth Disease
Peroneal muscular atrophy that affects motor and sensory nerves
Initially lower leg and foot, progresses to hands and forearm
Diagnostic test: electrodiagnostic
Meds: acetaminophen, NSAIDs, neurontin
PT GOALS:
prevent contractures/skin breakdown
pt education regarding braces/assistive devices
Plantar fascitis
Chronic irritation of plantar fascia from excess pronation, Limited ROM of 1st MTP and talocrural joint, Tight triceps surae, Acute injury from excessive loading of foot, Rigid cavus foot
Differentiate from tarsal tunnel syndrome by a negative Tinel’s sign
Meds: acetaminophen, NSAIDs, corticosteroid
PT GOALS: proper mechanical alignment modalities to reduce pain/inflammation flexibility of plantar fascia for pes caves foot flexibility exercises for triceps surae joint mobilization night splints strengthen invertors pt education regarding footwear/orthotics
Rearfoot varus
Abnormal mechanical alignment of tibia, shortened rearfoot soft tissues or malunion of calcaneus
DEFORMITY: rigid inversion of calcaneus while subtalar joint is in neutral
PT GOALS:
proper mechanical alignment
improve flexibility
orthotic fitting and pt education (footwear/orthotics)
Rearfoot valgus
Abnormal mechanical alignment of knee (genu valgum) or tibial valgus
DEFORMITY: eversion of calcaneus with neutral subtalar joint
*Increase mobility of hind foot, fewer MSK problems develop than with rearfoot virus
PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics)
Forefoot varus
Congenital abnormal deviation of head and neck of talus
DEFORMITY: inversion of forefoot when subtalar joint is neutral
PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics)
Forefoot valgus
Congenital abnormal development of head and neck of talus
DEFORMITY: eversion of forefoot when subtalar joint is neutral
PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics)
Spondylolysis
Spondylolisthesis
Congenitally defective pars interarticularis
SPONDYLOLYSIS: fracture of pars interarticularis with positive “Scotty dog” sign on oblique x-ray of spine
SPONDYLOLISTHESIS: ant or post slippage of one vertebra on another following B fracture of pars interarticularis
Diagnostic test: plain film (oblique and lateral views)
Special tests: Stork tests
Meds: acetaminophen, NSAIDs, corticosteroids, muscle relaxants, trigger point injections
PT GOALS: joint mobilization dynamic stabilization (abdominals) AVOID extension and other postures that add stress pt education braces
Spinal or intervertebral stenosis
Congenital narrow spinal canal or IV foramen, coupled with hypertrophy of spinal lamina and ligamentum flavum or facets due to age-related degenerative process leading to vascular and/or neural compromise
S/S: B pain/paresthesia in back, buttocks, thighs, calves and feet Pain dear in flexion, Incr in ext Pain incr with walking Pain relieved with prolonged rest
Diagnostic test: plain film, MRI, CT scan, myelography
Meds: acetaminophen, NSAIDs, corticosteroids, muscle relaxants, trigger point injections
PT GOALS: joint mobs flexion based exercise AVOID extension Manual therapy: traction
Internal disc disruption
Internal structure of disc annulus is disrupted; external structures remain normal (most common in LS)
S/S:
constant deep achy pain increased with movement
referred pain to LE
Diagnostic test: CT discogram or MRI
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids
PT GOALS:
joint mobs
pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc.
spinal manipulation may be CONTRAINDICATED
Posterolateral bulge/herniation
Most common disc disorder of LS because:
(1) post disc narrower in height than ant
(2) post long leg not a s strong in LS
(3) post lamellae of annulus is thinner
Overstitching and/or tearing of annular rings, vertebral endplate and/or ligg from high compressive forces or repetitive microtrauma leads to loss of strength, radicular pain, paresthesia and inability to perform ADLs
Diagnostic test: MRI
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids
PT GOALS:
promote dynamic stability
positional gapping x 10 min
pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc.
manual and/or mechanical traction
**spinal manipulation may be CONTRAINDICATED
Central posterior bulge/herniation
More common in CS than LS
Overstitching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (PLL) from high compressive forces and/or long-term postural malalignment leads to loss of strength, radicular pain, paresthesias, inability to perform ADL, compression of spinal cord
Diagnostic test: MRI
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids
PT GOALS:
promote dynamic stability
positional gapping x 10 min
pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc.
manual and/or mechanical traction
**spinal manipulation may be CONTRAINDICATED
Degenerative joint disease (DJD)
Normal aging process due to WB properties of facets and IV joints leads to bone hypertrophy, capsular fibrosis, hypermobility or hypomobility of joint and proliferation of synovium
S/S:
reduction in mobility of spine
pain, loss of strength and paresthesias
possible impingement of assoc. nerve root
Diagnostic test: plain film
Special test: LS quadrant test
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids
PT GOALS:
promote dynamic stability
joint mobs
spinal manipulation
Facet entrapment
acute locked back
Abnormal movement of fibroadipose meniscoid in facet during extension (from flexion)
Meniscoidal does not properly re-enter joint cavity and bunches up becoming a space-occupying lesion which distends capsule and causes pain
Flexion is most comfortable and extension increases pain
Special tests: LS quadrant test
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids
PT GOALS:
positional facet joint gapping and/or manipulation
Acceleration/deceleration injuries of cervical spine
“Whiplash”
Excess shear and tensile forces are exerted on cervical structures (facets/articular processes, facet jt capsules, ligg, disc, ant/post mm, fx to odontoid/spinous processes, TMJ, sympathetic chain ganglia and spinal/cranial nn)
S/S:
EARLY=H/A, neck pn, decr flexibility, reversal of LCS lordosis and decr in UCS kyphosis, vertigo, change in vision/hearing, irritability to noise/light, dysesthesias of face/BUE, nausea, diff swallow, emotional lability
LATE=chronic head/neck pain, limited flexibility, TMJ dysfunction, limited ADL too, disequilibrium, anxiety, depression
Clinical findings: postural changes, excess mm guarding with soft tissue fibrosis, segmental hyper mobility, gradual development of restricted segmental motion cranial to caudal
Diagnostic test: plain film, CT and/or MRI
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids
PT GAOLS: spinal manipulation correct muscle imbalance joint mobs manual and/or mechanical traction (CS at 15 deg flexion)
Hypermobile spinal segments
Abnormal increase in ROM at a joint due to insufficient soft tissue control
Diagnostic test: plain film (flex/ext views)
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, sclerosing agents, corticosteroids
PT GOALS: pain reduction modalities passive ROM passive stabilization (corsets, splints, casts, tape and collars) correct muscle imbalance pt education
Sacroiliac joint (SIJ) conditions
Need to closely examine BOTH LS and SIJ
Diagnostic test: plain film and possible MRI, occasionally double blind injections
Special tests: Gillet’s test, IPSI anterior rotation test, Gaenslen’s test, Long-sitting (supine to sit) test, Goldthwait’s test
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids
PT GOALS: spinal manipulation (SIJ gapping) correct muscle imbalances joint mobs pt education SIJ belts
Repetitive/cumulative trauma to back
Disorders of nerves, soft tissues and bones precipitated/aggravated b repeated exertions or movements of back
Vocational factors: physically heavy static work postures, lifting, frequent bending/twisting, repetitive work and vibration
PT GOALS:
focus on prevention
pt education
Bone tumors
Primary: multiple myeloma, Ewing’s sarcoma, malignant lymphoma, cohondrosarcoma, osteosarcoma and chondromas
Metastatic: primary sites in lung, prostate, breast, kidney and thyroid
S/S: pain unvarying and progressive, not relieved with rest or analgesics more pronounced at night
Diagnostic test: plain film, CT and/or MRI, lab tests
Visceral tumors leading to LBP
Esophageal cancer: radiating pain to back, pain with swallowing, dysphagia, weight loss
Pancreatic cancer: deep, gnawing pain that may radiate from chest to back
Diagnostic test: plain film, CT and/or MRI and lab tests
Gastrointestinal conditions leading to LBP
Acute pancreatitis: mid-epigastric pain radiating through to back
Cholecystitis: abrupt, severe abdominal pain and RUQ tenderness, N/V, fever
Diagnostic test: plain film, CT and/or MRI and lab tests
Cardiovascular and pulmonary conditions leading to LBP
Heart and lung: chest, back, neck, jaw and UE
Abdominal aortic aneurysm (AAA): nonspecific lumbar pain
Diagnostic test: plain film, CT and/or MRI and lab tests
Urological and gynecological conditions leading to LBP
Kidney, bladder, ovary and uterus reer to trunk, pelvis and thighs
Diagnostic test: plain film, CT and/or MRI and lab tests
Temperomandibular joint conditions
S/S: joint noise (click, pop, crepitation) joint locking, limited flexibility lateral deviation of mandible during depr/elev decreased strength/endurance of mm tinnitus, H/A, forward head posture pain with mandible movement **CS must be thoroughly examined**
3 diagnostic categories
(1) DJD (OA or RA in TMJ)
(2) myofascial pain: most common, discomfort or pain in mm controlling jaw/neck/shoulder
(3) internal derangement of joint: dislocated jaw, displaced articular disc or injury to condyle
- -Causes: trauma, congenital, abnormal fun
Diagnostic test: plain film and/or MRI
Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids
PT GOALS: postural re-ed modalities biofeedback joint mobs pt education night splints
