MSK Practical Flashcards
Observation Questions
-prefering to sit, stand or move
-changing position often
-ADL assistance
-visible discomfort
-observations match Hx
-eye contact
When to Scan
- No obvious MOI
- Proximal Cause for Distal S/s
- Non-mechanical sounding Sx
LQ Scan
- Vitals***
- Observation: posture, plumb line
- Gait: look for gross abnormalities
- Functional MMts: squats***
- Balance Testing***
- Clear the spine**
- SI Joint Provocation**
- Myotomes: include functional testing (heel and toe walking)
- Dermatomes
- DTR: patellar, med hamstring, achilles
- UMN Testing: Babinski, clonus***
- Neurodynamic Testing: SLR, slump test**
- LE ROM: FABER, flx, DF/PF, toe flx/ext
- Pulses (optional)
- Lymph Nodes (optional)
Physical Examination Components
- Pt Hx
- Systems Review
- Observation
- Scanning Exam (if needed)
- AROM>PROM>RROM & Flexibility
- Muscle
- Joint Play
- Palpation
- Special Tests
Normal End Feels
Bony/Hard: bone on bone
-elbow ext
-hard ending
-no joint play
Elastic: muscle tendon unit
-stretches with recoil
-wrist flextion causing finger flexion
-muscle adhesions= passive stretch
Soft: soft tissue
-elbow flexion
Capsular: produced by capsule or ligaments
-with pain= 1-2 Oscillation
-Adhesions= 3 sustained and 3-4 oscillation mobilization
Abnormal End Feels
Springy: articular surface
-rebound sensation
-knee flexion with displaced meninscus
Boggy: viscous fluid in joint
-squishy sensation
-blood in joint or sepsis
Spasm: reactive muscle reaction
-unyielding spasm
-recent trauma or tear
-no joint play
Empty: pain stops you
-no joint play if with assessment
Grade I Oscillatory Mobilization Grades
-small amplitude
-0-25%
-beginning of available joint play
-Pain
-acute stage
Grade II Oscillatory Mobilization Grades
-large amplitude
-25-75%
-middle joint play
-acute and sub acute stage
-pain
Grade III Oscillatory Mobilization Grades
-large amplitude
-50-100%
-end of joint play
-joint adhesions
-Subacute and chronic stages
Grade IV Oscillatory Mobilization Grades
-small amplitude
-75-100%
-end of joint play
-intense
-joint adhesion
-chronic stage
Grade V Oscillatory Mobilization Grades
-high velocity low amplitude thrust
-quick movement that exceeds resistance
-100+%
-Subacute to chronic stages
Grade I Sustained Mobilization Grades
-loosen to neutralize joint pressure
-no stress on capsule
-decrease compression
-used with gliding motion
Grade II Sustained Mobilization Grades
-take up slack to separate joint surfaces
-eliminate joint play
-determine joint sensitivity
Grade III Sustained Mobilization Grades
-stretch
-large distraction w/ 6 sec hold
-increase mobility
-treat hypomobility
-joint adhesions
Oscillatory Joint Mobilizations
-pain dominant
-III-IV for stiffness
Contraindications for Manual Therapy
-infection
-Fever
-Cancer
-Acute Circulatory Condition
-Open Wound
-Fracture
-Hematoma
-Advanced DM
-Hypersensitivity
-Abnormal Endfeel
-RA
-Cellulitis
-Constant, Severe pain
-Extensive radiation of pain
-Condition not evaluated
Precautions for Manual Therapy
-Joint effusion or inflammation
-RA (non-exacerbation)
-Osteoporosis
-Pregnancy (over spine)
-Dizziness
-Steroid or anti-coagulant
Examination to Treatment w/ Mobilizations
- Baseline Assessment
-pain, s/s, ROM, Strength - Determine Grade
-impairment, stage, irritability - Contraindications and Precautions
- Take up Slack
-assess joint play - Arthrokinemattics and Pt Position
- Only 1 Surface Moves
- Re-assess after Treatment
-pain, s/s, ROM, Strength
Convex on Concave
-roll and glide in opposite direction
-pt move with glide
Concave on convex
-roll in glide in same direction
-pt move with glide
Joint Play (Spine)
-Hypomobile, Normal, Hypermobile
-Only skip if they have normal, pain free motion
- Know joint surface shape
- Determine hand placement
3.Grade Motion compared to other side and expected motion - Assess Pain/no pain and mobility
Neurodynamic Mobility Exam
-Subjective (Pain, spasms, paresthesias)
-Observation
-Palpation
-ROM
-Resisted testing
-Nerve provocation test
3 Signs of a Positive NTPT
- Reproduces Pt s/s
- Movement of distant body part causes responses
- Test differences from L to R
Straight Leg Raise
-test for sciatic n
- actively raise leg
- passively raise leg
- DF
- Pt lift head
Pain in 0-30: acute/severe MSK
Pain in 30-70: nerve issue
Pain >70: not positive
Crossed SLR sign: opposite s/s, disc protrusion
Sensitizers:
-Tibial: DF > Eversion > Toe Ext
-Sural: DF > Inversion
-Common fib: PF > Inversion
Slump Test
-test neuromobility
- Hands behind back
- Head and neck flexed
- Lumbar flx
- Straighten knee
- overpressure
- DF of ankle
- Pt moves head
Indication for Neurodynamic Mobilizations
-Neurological s/s
-Antalgic Postures
-Active or passive mmt Dysfunction
-Tenderness to palpation over superficial neural tissues
Contraindications for Neurodynamic Mobilizations
-Recent repair
-Malignancy
-Active Inflammatory Disorders
-Acute Inflammatory Demyelinating Disorders
Precautions for Neurodynamic Mobilizations
-irritable conditions
-SC signs
-Nerve root signs
-Severe night pain w/ no Dx
-recent paresthesia or anesthesia
-Mechanical spine pain w/ peripheralization s/s
Neurodynamic Mobilization Techniques: Tension
-load opposite ends of nerve
-both “on” or “off”
-when glides no longer help
ex: head flx and ankle DF, the head ext and ankle PF
Neurodynamic Mobilization Techniques: Gliding
-load one end of nerve while relieving stress on opposite end
- 1 “on” and 1 “off” then switch
ex: head flx and ankle PF, the head ext and ankle DF
Neurodynamic Mobilization Techniques: Stretching
-load opposite ends of nerve and hold
-7-30s
-both “on” or “off”
-most agressive
ex: head flx and ankle DF (hold), the head ext and ankle PF (hold)
LBP Subjective Hx
Pain: location/movement, MOI/onset, time, description, behavior, intensity, better/worse, 24h bahavior
Pt Demopgraphics: age, race, hobbies, work, participation, impact of s/s, psychosocial considerations
General Health: Prior Hx, Co-morbidites, surgeries, Pregnancies, Medications
Red Flag Qs: Neural involvement, fracture, infection, cancer (Constant pain, intense pain, weight loss), AAA
Lumbar ROM Values
Flexion: 70-90
Extension: 40-50
Rotation: 20-40
LSB: 25-35
Evaluation Steps of LBP
- Subjective Hx
- Scan/Not (neuro, no MOI, not MSK)
- Observation
- ROM
- Strength
- Special Tests
- Repeated Measures (if needed)
Piriformis Syndrome
-Dx of exclusion
S/s:
-hx of trauma so SIJ or glute
-pain around SIJ or piriformis
-worse with lifting, sitting
-palpable tension
-+ SLR
-(+) provocation pain
-(+) LE paresthesias
-Glute atrophy
End Plate Fx S/s
-trauma or MOI
-Acute pain
-(-) SLR
-(+) compression test
Internal Disc Disruption S/s
-separation of inner layers
-LBP or referred hip pain
-(-) SLR
Disc Protrusion/Prolapse S/s
-contained
-some AF and PLL intact
-LBP or referred hip
-pain with cough or sneeze
-(-) SLR
Disc Extrusion of Sequestration S/s
-uncontained
-LBP
-Pain with cough/sneeze
-True Sciatica (radicular pain)
-(+) SLR
Spinal Stenosis S/s
-narrowing spinal canal (vascular or neurogenic)
-congenital development or acquired
S/s: butt pain, limping, lack of sensation, dec walking ability
Central:
-spinal canal dec
-claudication, butt pain
Lateral:
-narrowing of facets
-can impinge nerve roott
Facet Dysfunction S/s
-hypomobility at a facet joint
S/s:
-localized pain
-specific AROM deficits
-hyper mobility at another level
Tx:
-manual therapy > mobility > strengthening
Lumbar Instability S/s/Tx
-loss of passive restraints to movement
-lack of NM control
S/s:
-catching in back
-inconsistent symptoms
-(+) Prone instability
Tx:
-strengthening/stabilization
-recurrence is common
Manual Therapy Classification
CPR:
-No sx distal to knee
- <16 days (acute/subacute)
-FABQ score <19 (fear avoidance beliefs)
-1 hypomobile segment
-1 hip >35deg internal rotation (loss of ER)
Tx:
-HVLAT
-ROM
Stabilization Classification
CPR:
- <40 yrs old
- Post parum/SLR >91 deg (flexible)
- Instability catch or aberrant movements during flx/ext
-(+) Prone instsbility test
-Postpartum:
(+) posterior pelvic pain provocation, ASLR, mod Trendelenburg
OR
Pain w/ palpation of long dorsal SI ligament or pubic symphysis
Tx:
-isolated contraction of deep stabilizers (TA, Multifidi)
-Strengthen large spinal stabilizers (ES, Obliques)
-Hooklying to Side Plank
Extension Direction-Specific Classification
CPR:
-Sx distant to Butt
-Sx centralize with extension
-sx peripheralize with flexion
-directional preference for extension (standing/walking)
Tx:
-End range exetnsion
-mobilize to promote extension
-Avoid flexion
Flexion Direction-Specific Classification
CPR
- >50yrs
-Directtional preference for flexion
-Lumbar Spinal stenosis
Tx:
-mobilize or manip spine
-strength and flexibility exercises
-body weight supported treadmill
Lateral Shift Direction-Specific Classification
CPR
-visible frontal plane shift
-directional preference for lateral translation movements
Tx:
-exercises to correct shift (manual glide from PT or leaning on walls)
-traction
Traction Classification
CPR
-Sx decrease w/manual or auto traction
don’t respond to anything else
*(+) Crossed SLR *
Peripheralization of multipple directions
Joint Manipulation Contraindications
-Serious pathology
-fracture*
-lack of skill
-Ligament rupture*
-No working hypothesis
-Worsening neuro function*
-Unremmitting night pain*
-Severe multi directional spasms
-UMN Lesions*
SIngle Limb Stance (SLS)
Note:
-abnormal postural sway
-assistance
-Sx
-side ot side diff
-(+) Trendelenberg Sign
-Poor balance (<30s)
Single Limb Squat
Note:
-depth
-assistance
-Sx
-side ot side diff
-(+) Trendelenberg Sign
-Poor balance (<30s)
Functional Tasks
-Lifting
-Squatting
-Bending
-Twisting
-assess quality and duration of movement prior to pain
Repeated Movements Testing
-Radiating S/s ONLY
Extension: 80%
-prone to standing
-10 reps
-want centralization
Flexion:
-Supine to standing
-10 reps
-want centralization
Sorenson Test
-muscle endurance and strength test
-stopped at 4 mins if continue
5: hands across chest 20-30s)
4: Hands at side (15-20)
3: Hands at siide (10-15)
2: Hands at side (1-10)
Dynamic Abdominal Endurance Test
-muscle endurance and strength test
5: hands behind neck (20-30s)
4: Hands crossed on chest (15s)
3: Arms straight (10-15)
2: Hands straight toward knees (1-10)
1: Unable to raise more than head
Flexibility Tests
-Psoas
-Rec Fem
-Piriformis (>90 IR)
-Hamstring
Prone Knee Bend
-Neuroprovocation Test
-tests femoral nerve
- Pt prone
- PT papssively flexes knee
- (+)= S/s 80-100 degs
- (-)
- Absense of s/s
-<80 deg knee joint dysfunction
->100 deg RF or spine dysfunction
Spinal Joint Play
-hypo, hyper, normal
Central (CPA):
-palpate SPs
-pisiform and push
-INCLUDE SACRUM
Unilateral (UPA):
-palpate opposite TP
-Thumbs and push
Prone Instability Test
-when you suspect instability
-hypermobile joint play
- Pt in prone with legs off
- Relaxed, PT push on symptomatic joint segments
- if painful, have Pt lift legs and push again
-(+): pain gets better - Repeat on each hypermobile section from joint play
Stoop Test
-for intermittent claudication****
-bike or walking
- Start upright and time until Sx occur
- Stoop until Sx occur
(+): Sx improve w Stopped posture (takes longer to produce)
Waddell’s Test
-for non-organic Sx
-need 3 or +/5
- Stimulation
-gently compress head, Pt response
-trunk rotation at hips, Pt response - Regional
-sensory weakness or weakness in whole area and not pattern - Tenderness
-superficial brush on skin in non-surgical area - Distraction
-look for inconsistencies
-SLR: distraction no response, response when brought to their attention
-Bending
-Limping - Over-Reaction
-less reliable
Sidelying Lumbar Gapping
- Pt Sidelying
- Palpate L5-L4
- Flex sup leg until movement at L5
- Rotate Arm/trunk until Movement at L3
- Rotate in opposite directions
add HVLAT for manipulation
Million Dollar Roll
1.Pt Supine
2.Banana shape with Pt on outside of curve
3.Roll trunk toward PT
4.Place resistance on opp ASIS
5. Rote in opposite directions
add HVLAT for manipulation
Lumbar Gapping MET
- Pt Sidelying
- Palpate L5-L4
- Flex sup leg until movement at L5
- Rotate Arm/trunk until Movement at L3
- Rotate in opposite directions
- Have Pt try to unwind against PT
-hold for 6 sec, relax, go further
Opening Restriction MET
Opening on down side
- Pt Sidelying
- Palpate L5-L4
- Flex BOTH legs until movement at L5
- Rotate Arm/trunk DOWN until Movement at L3 (flexion bias)
- Lift BOTH legs
- Ask Pt to gently push into hands
-hold for 6s, relax, go further
Closing Restriction MET
Closing on up side
- Pt Sidelying
- Palpate L5-L4
- Flex SUP leg until movement at L5
- Rotate Arm/trunk UP until Movement at L3 (extension bias)
- Lift SUP leg
- Ask Pt to gently push into hands
-hold for 6s, relax, go further
-might not be great IR
Adduction Isometric for Anterior pelvic/SIJ Pain MET
-Pt in hooklying
-PT pushes against medial knees to resist add the switch to resisit abduction (can use chest)
-Pt pushes against for 3 seconds 3x
Possible LBP DDx
-Instability (Stabilization)
-Hypomobility (Manual Therapy)
-Piriformis Syndrome
-Disc Pathology
-Spinal Stenosis
-Foraminal Stenosis
-Facet Dysfunction
Subjective Hx of SIJ Dysfunction
-Fortin Sign: pain over PSIS**
-Pain with transitional movements**
-Pain with SLS activities**
-Pain at end range of Active SLR
-Prolonged sitting/standing
-(-) Neuro
-No s/s below knee
SIJ Joint Diagnoses: Hypomobility
Innominate Rotation
-anterior rot on one side and posterior on the other
-ASIS OR PISIS different heights and superficialness
Upslip
-ASIS, PSIS, ISCH tub ALL up on one side
-leg forced up
Downslip
–ASIS, PSIS, ISCH tub ALL down on one side
-rare
-leg pulled down
Pubic Lesion
-superior or inferior
Tx:
-manual
-core exercises
MOI:
-unilateral forces
-falls
-back lifting
-swinging
SIJ Joint Diagnoses: Joint Arthritis (Sacroilitis)
S/s:
-pain in post sacrum or groin
-radiating into thigh
-increase SLS pain
-Turning in bed pain
-lumbar extension painful
-(+) SI stress tests
-(+) Compression test with SI Belt
Tx:
-NSAIDs, ice, core exercises and LE exercises
SIJ Joint Diagnoses: Pelvic Girdle Instability
-suspect hypermobility or nothing from other tests
Form Closure:
-assessed 1st with ASLR
-passive stability malfunction (joint shape, ligaments, bony stability)
-Tx: SI Joint compression belt
Force Closure:
-assessed 2nd with ASLR
-active stability malfunction (muscles and fascia)
-Tx: core stabilization exercises
SIJ Joint Diagnoses: Piriformis Syndrome
S/s:
-persistent low back pain into butt and thigh
-(+) pain provocation of piriformis
-(+) pain w/ sitting or squatting
-persistent hip ER
-Difficuly lying
-(+) LE paresthesias
Tx: manual, stretching, core exercises
Evaluation Order of SIJ Dysfunction
- Do Hip and/or Lumbar Exam
- Confirm Presence of SIJ dysfunction with Provocation
- Determine side of Hypomobiltiy (mobility/functional tests)
- Determine Pathology
- Determine if Form or Force are a component
- Select Intervention (treat lumbar or hip dysfunction first, then SIJ hypomobility first)
Lumbar Disc Joint Clearing Tests
(+) pain with coughing and sneezing
Decreased pain with walking
Lumbar Spine Joint Clearing Tests
(-) pain with coughing and sneezing
(+) pain with extention or flx
(+) pain with PA joint glides
Hip Joint Clearing Tests
(+) Trendelenburg signs
(+) Pain or decreased ability to squat
(+) Sign of buttock test
SI Joint Clearing Tests
(+) Fortin’s Sign
(+) Joint gapping or compression tests
(+) TTP at SI ligs
(+) Pain/weakness with SLS
Mobility Exercises (SIJ)
-foam roll
-AROM
-Stretches
Stability Exercises (SIJ)
-AROM
-Spinal Stability
-Pelvic Floor Strength**
-Glute Strength**
SI Belt Application
- Pt flexes hip and crease is where bottom of belt will go
- Middle seam goes in mid back
- Pull belt traps snugly
- Pt exercises or performs ADLa for s/s reduction
belt goes on skin
Possible SIJ DDx
-Hypomobility
-Joint Arthritis
-Pelvic Girdle Instability
-Piriformis Syndrome
SIJ Provocation/Stress Tests
-statistically the best
-reproduce pain
-FABER
-Distraction
-Compression
-Thigh Thrust
-Sacral Thrust
-Gaenslen’s Test
SIJ Alignment/Positional Tests
-Questionable reliabiliy/validity
-Iliac Crest Height
-ASIS Height
-PSIS Height
-Isch Tub Height
Mobility/Functional Tests
-questionable reliability/validity
-More movement=Hypomobile segment
-Standing Flexion Test
-Seated Flexion Test
-Stork Gilet Marching
-Supine to Long Sit Test
Evaluation Order of SIJ Dysfunction
- Do Hip and/or Lumbar Exam
- Confirm Presence of SIJ dysfunction with Provocation
- Determine side of Hypomobiltiy (mobility/functional tests)
- Determine Pathology
- Determine if Form or Force are a component
- Select Intervention (treat lumbar or hip dysfunction first, then SIJ hypomobility first)
Fortin’s Sign
-pain localized with one finger over PSIS
->2 times
Primary SI Gapping (Distraction) Test
-provocation tests
-anterior SI joint stress test
-push on ASISs
(+) Reproduction of s/s
Primary SI Compression Test
-provocation tests
-in sidelying press down on hip
-painful side up
(+) Reproduction of s/s
Sacral Thrust Test (PA Glide)
-provocation tests
-Palapate sacrum
-apply force downward over S3
-repeat multiple times (<6)
(+) Reproduction of pt pain over SIJ or posterior ligs
Gaenslen’s Test
-provocation tests
-Thomas Test position, testing leg down
-flex non-testing leg and assess s/s
-PT presses top leg into flx and bottom into ext
(+) reproduction of pt pain at SIJ or pubic symphysis
FABER Test
-provocation tests
-pt supine, PT on ipsi side of leg
-hip in flx, ER, abduction
-press into contra ASIS and knee
(+) reproduction of pt pain at posterior pelvis or butt
Thigh Thrust Test
-provocation tests
-PT on contra side of testing leg
-PT hand under sacrum
-Pt hip flx and adducted
-PT pushes hip past sacrum
(+) reproduction of pt pain at SIJ
(+) SIJ Dysfunction CPR
- Compression
- Distraction
- Sacral Thrust*
- Gaeslen Test
- Thigh Thrust
3 or more/5 (+) = dysfunction
(-) SIJ Dysfunction CPR
- Compression
- Distraction
- FABER*
- Gaeslen Test
- Thigh Thrust
3 or less /5 (+) = no dysfunction
Pubic Stress Test for Anterior Pain
-provocation tests
-PT uses heel of hand 1 superior aspect of pubic ramiu and 1 hand at inferior
-slow downward opposite pressure
-switch sides
(+) reproduction of pain over pubic symphysis or anterior pelvis
Sign of Buttock Test
-provocation tests
-sign of serious pathology (hip absess, fracture, infection, cancer)
-nerve on slack and pain still there
- Passive SLR (+)
- Return to neurtral and bend hip and knee
- Passive bent leg raise (+) and same ROM
Alignment Palpation Sites
-ASIS
-PSIS
-Pubic Tubercle
-Sacral Base Depth
-Inferior Lateral Angle
-Isch tubs
Seated Flexion Test
-Mobility/functional test
-Pt seated
-PSIS found then Pt bends over
-PSISs should move superiorly equally
-rules out Leg length diff or hamstring tightness**
(+) Don’t move equally, affected (hypomobile) side moves more than unaffected
Long Sitting (Suine to sit) Test
-Mobility/functional test
-Pt supine
-palpate medial malleoli on both ankles
-Pt sits up, Med mals should come down equally
(+) malleoli don’t move equally
longer limb= posterior innominate
Shorter limb= anterior innominate
Standing Flexion Test
-Mobility/functional test
-Pt standing
-PSIS found then Pt bends over with knees extended
-PSISs should move superiorly equally
(+) Don’t move equally, affected (hypomobile) side moves more than unaffected
Gillet’s (Stork) Test
-mobility/functional test
-Pt in standing with testing leg down and opp hip flexed
-P palpates PSIS and contra sacrum
-Pt flexes opp hip
-PSIS should move inferiorly to sacrum
(+) PSIS doesn’t move inferiorly to sacrum (hypomobile) OR causes SI joint pain
Active SLR Test
Form Closure Test
Step 1. Pt actively lifts leg
(+) reproduces SIJ pain OR abberant movements during
1 must be positive to move on to 2 and 3
Step 2: PT compresses pelvis laterally and Pt lifts leg
(+) Pt has less pain OR fewer abberant movements
-Tx: SI compression belt
Step 3: Pt contracts core then lifts leg
-PT can reisist contra shoulder to help
(+) Pt can perform ASLR with less pain OR few abberant movements
Tx: stabilization exercises
Sidelying SI Gapping Manipulation
- Pt sidelying with hips flexed 90 deg, shoulders stacked ( PT behind pt)
- Pt rotated by pulling “table arm” across Pt
- Pelvis remains stable with PT hand
- Pt then rotated more to take up slack while pushing hip medially
- Quick thrust to manip,
Long Axis Traction Manipulation (SI)
-2 person technique
-Pt prone with legs off table in closed packed (ext, abd, IR)
-PT grabs affected LE and lifts up and out
-other PT stabilizes sacrum
-PT takes of slack on leg then quickly pulls
Prone Sacral PA Mobilization
-Palapate sacrum
-assess glide of sacrum
-apply force downward over base (counternutated) or apex (nutated)
Prone Joint Mobilization to Restore Anterior Innominate Rotation
-Pt prone with unaffect LE relaxed or off table
-PT extends affected legwhile stabilizing ipsi PSIS
-Mobilize joint into anterior rotation if stuck in posterior
-maintain extension
Supine w/ Hip Flexed and Extended Isometric Hold MET
-Pt supine with hips and knees flexed
-PT puts hand on ipsi knee and contra posterior thigh
-Simultaneously push into flexion and extention
-Pt reissts for 6 sec
-Resist flexion: brings pelvis ant
-Resist extension: brings pelvis post
brings both sides closer together
Hip Joint (OP/CP)
-synovial joint
-Designed for stability and less mobility
-Convex head of femur and concave acetabulum
-Femoral head faces Medially, anteriorly, superiorly
Resting Position: Flx 30, Abd 30, Slight ER
Closed Packed: Full ext, IR, ABD
Capsular Pattern: Flx, Abd, IR (sometimes IR first)
Normal ROM Hip
Flx: 110-120
Ext: 10-15(20)
IR: 30-40
ER: 40-60
Abd: 30-50
Add: 25-30
Arthrokinematics of Hip
Flexion: sup spin, post glide
Extension: inf spin, ant glide
Abd: inf glide, med glide
Add: sup glide, lat glide
IR: posterior glide
ER: anterior glide
Legg-Calve-Perthes
Age: 2-13yrs
-avascular necrosis
-Males >
S/s:
-gradual onset, ache in hip, thigh, knee
Observation:
-short limb
-higher g troch
-quad atrophy
-adductor spasm
-antalgic gait
ROM:
-limited abduction
-ext
Intervention:
-ROM and positioning
Slipped Femoral Capital Epiphysis
Age: 10-17 yrs males, 8-15yrs female
-ice cream falling off cone
-Male>
S/s:
-gradual onset
-vague pain in knee, suprapatellar, thigh and hip
Observation:
-short limb, usually obese, quad atrophy
-adductor spasm
-hip abducted and ER
ROM:
-limited IR, abd, flex
Gait: antalgic acutely, Trendelenburg chronically
Altman’s Clinical Criteria (Hip)
-do you have hip OA?
- Hip pain
- IR <15deg
- Pain with IR
- Morning stiffness up to 60min
- Age >50yrs
Sutlive CPR
-what are the odds you have hip OA
3/5 present= 68%
4/5 present= 91%
- Self-reported squatting is aggravating
- SCOUR test w/ ADD causes groin or lat hip pain
- Active hip flx causes lat pain
- Active hip ext causes hip pain
- Passive hip IR less than or equal to 25deg
Hip OA
->50yrs
-hip pain
Observation:
-decreased stance time
-morning stiffness
-painful squatting
ROM:
-Dec IR
-Decreased >2 planes of motion
-flex causes latt pain
Osteitis Pubis/ Symphysiolysis
-inflammation of pubic tubercles
-during surgery or pregnancy
ITB Syndrome
-gradual onset; overuse
-Ober’s test
S/s:
-lat hip, thigh, knee pain
-snapping IT band over greater troch
Tx:
-activity modification
-stretching
-footwear
Trochanteric Bursitis
-pain over greater troch w/ resisted abd
-pain on greater troch
Meralgia Paresthesia
-Brittany spears
-gradual onset, obese, pregnancy
S/s:
-pain and paresthesia of ant lat thigh
-lateral femoral cutaneous
Tx: Nerve glides
Gluteus Med Tendinopathy/Tear
-post menopausal, >50yrs
-Aggravating factors: stair climbing and sleeping on side
-muscle wasting
Diffx:
-troch bursitis
-hip OA
Testing Cluster:
-FABER
-external de-rotation tests
-palpation of glute med
-SLS
-Load dependent pain
Tx:
1. isometrics
2. Isotonics
3. Energy Storage
4. Sport Specific
Femoroacetabular Impingement
-FAI, labral pathology
Cam Impingement:
-related to femoral head and neck morphology
-early contact
-damages labrum
Observations: Anteversion, coxa vara
Pincer Impingement:
-acetabular abnormalities
Observations: retroversion
Pain locations:
-Anterior-medial: flx/IR positioning
-Posterior: flx/abd/ER positioning
(ischtub pain)
Femoral Neck Stress Fracture
-not on Xray
-unable to passively rotate hip
-Patella Percussion Test
ROM: cannot passively rotate hip
Avascular Necrosis
-30-50yr
-Male>
S/s:
-50% sharp pain, 50% intermittent
-Limp gait
ROM:
-decreased
Degenerative Join Disease
->40yr
-Female>
-insidious onset, pain with weight-bearing
Observation:
-often obese
-joint crepitus
-muscle atrophy of glutes
ROM: limp
Radiographic: increased density, osteophytes
Hip Subjective Hx
-H/o LBP
-Hip problems as a child
-Clicking/popping/catching (w/ or w/o pain)
-OA
-Surgical Hx
Examination Order of Hip
- Hx
- Observation
- Gait/Squat/SLS
- Scan/Not
- Hip ROM > Back ROM > Knee ROM
- MMT
- Flexibility
- Joint Play
- Palpation
- Special Tests
Possible DDx of Hip
-OA
-Avascular Necrosis
-Degenerative Joint Disease
-Legg-Calve-Perthes
-SCFE
-Stress Fx
-FAI
-Bursitis
-Muscle Lesion
-Glute Med Lesions
Long Axis Hip Manipulation (Hip)
-Open pack: 30 flx/ 30 abd/ ER
-pull on leg
targets entire capsule
Inferior Glide Mobilization
-Open pack
-for loss of flx
- Pt in supine, hip flx
- PT on table, leg over shoulder
Anterior Glide Mobilization
-Open pack
-loss of extension
- Pt prone, leg in ext and abd (other leg off table if needed)
- PT hand on isch tub and lift knee up
- Push on isch tub
- Progress with more hip ext and knee flx
Lateral Glide Mobilization
-Open Pack
-lack of ADD
- Pt in supine, knee flexed 30
- PT pulls down and out laterally (can use belt or hands)
- Can add more ADD during progression
Progression: AP Lat Mobilization
Observations of Hip Pain
-discomfort
-Antalgic gait
-foot drop
-Stand in OPP
-Weight shifts
-leg length discrepancy
Hip Joint Clearing Tests
-(+) Trendelenburg
-(+) Inability or pain with squat
-(+) Sign of buttock
FABER Test
-provocation tests
-pt supine, PT on ipsi side of leg
-hip in flx, ER, abduction
-press into contra ASIS and knee
(+) reproduction of pt ain at posterior pelvis or butt
Sign of Buttock Test
-provocation tests
-sign of serious pathology (hip absess, fracture, infection, cancer)
-nerve on slack and pain still there
- Passive SLR (+)
- Return to neurtral and bend hip and knee
- Passive bent leg raise (+) and same ROM
Hip ROM/MMT Directions
-Flx/Ext
-Abd/ADD
-IR/ER
AROM > Overpressure > PROM
all must be measured
test back and knee
Hip Flexibility Tests
-Ober’s
-Modified Thomas
-Elys
-Piriformis
-Hamstrings
Joint Play: Long Axis Distraction (Hip)
-Open pack: 30 flx/ 30 abd/ ER
-pull on leg to assess joint
- Pt supine, flx/abd/ER
- PT holds above talocrural
targets entire capsule
Joint Play: Posterio-Inferior Glide
-inferior/posterior capsule
-for loss of flx
- Pt in supine, hip flx
- PT on table, leg over shoulder
- PT scoops and pulls out and down
Joint Play: Anterior Glide (Hip)
-target anterior capsule
-loss of extension
- Pt prone, leg in ext and abd (other leg off table if needed)
- PT hand on isch tub and lift knee up
- Push on isch tub
Joint Play: Lateral Traction
-Open Pack
-targets lateral capsule
- Pt in supine, knee flexed 30
- PT pulls inferolateral
- Can add more ADD during
Labral Special Tests
- Fitzgerald Test
- FADIR Test
- Hip Quadrant
- Hip Scour
- FABER
Capsular Tightness Special Test
-FABER
Fitzgerald Test
-anterior labral tear
- Pt in supine
- PROM from FABER to Ext/Add/IR
(+): reproduces s/s w/ or w/o click
Quadrant Test
-FAI or Labrum
- Pt in supine
- PT PROM from FADIR to FABER
(+): reproduces s/s w/ or w/o click
FADIR Test
-FAI or Labrum
- Pt in supine
- PT PROM into flx/add/IR
(+): reproduces s/s w/ or w/o click
Hip Scour Test
-FAI, Labrum, acetabular dysfunction
- Pt in supine
- PT hugs knee and PROM from FADIR to FABER WITH COMPRESSION
- Can scallop for specific areas
(+): reproduces s/s w/ or w/o click
FABER/Pattrick Test
-impingement, SIJ, capsular tightness
- Pt in supine
- PT PROM into flx/abd/ER
(+): reproduces s/s in ant hip or posterior hip
Craig’s Test
-femoral anteversion/retroversion
- Pt in prone
- Move into IR/ER until Greater troch is parallel to table (most into hand)
- Measure ROM
-normal 10-15 IR
(+):
->15: anteverted
~10 IR: Normal
-<10: retroverted
Patellar Pubic Percussion Test
-fx oof the hip or femur
- Stethoscope over pubic symphysis
- Tap on Patella on affected sound and compare
(+): diminished sound on involved side
Posterio-Inferior Mobilization w/ Belt
-inferior/posterior capsule
-for loss of flx
- Pt in supine, hip flx
- PT stands with belt at hips
- PT pulls out and down
- Add more flexion to progress
AP w/ Lateral Mobilization
-progressive mobilization
-more aggressive lat mobilization
-add adduction and IR (piriformis stretch position)
-target posterio-lateral capsule, ADD ROM
-use when (+) FABER, quadrant, or SCOUR
PA Hip Mobilization w/ ABD and ER
-progressive mobilization
-target ER and ABD ROM
-use when (+) FABER
- Pt prone with hip flexed and abducted off of bed (progress to more ER)
- PT mobilize into ER
Hip IR Mobilization
-progressive mobilization
-target posterior capsule and IR ROM
- Pt prone in IR
- PT maintains IR while mobilizing contra pelvis
Causes of knee injuries
- Sprains, strains, tendinopathies
- Contusions
- Meniscal or ligamentous
Tibio-Femoral: Open Packed Position
25 deg of flexion
Tibio-Femoral: Closed Packed Position
Extension
Tibio-Femoral: Capsular Pattern
Flexion > Extension
Open Chain Arthokinematics
-Rolling and gliding same
Closed Chain Arthrokinematics
-Rolling and gliding opposite
Acute Knee Injuries
-ligaments
-Instabilities
-Meniscal and articular cartilage injuries
Chronic Knee Injuries
-instabilities
-OA
-Patellofemoral pain
-Patellar Tendonopathy
Valgus Force
-MCL
-ACL
-Med Meniscus
-Posteriormedial capsule
Hyperextension Injury
-ACL
-Sometimes PCL
-Meniscus
Flexion w/ Posterior Translation
-PCL
Varus Force
-LCL
-Posterolateral capsule
-PCL
ACL Tears
MOI:
Contact: hyperext, valgus force
Non-contact: deceleration valgus force near extension (cutting, popping)
S/s:
-hear/ feel a pop
-rapid swelling
-knee gives away
-loss of end range ext
Tests:
-Lachman’s
-Anterior Drawer
-6m Single Limb Timed Test
PCL Tear
MOI:
-trauma with posterior tibial shear in flx or hypertext
-dashboard injury, sudden stopping
S/s:
-bruising or abrasion on tibia
-loss of knee extension
-localized knee posterior pain with kneeling or decelerating
Tests:
-Posterior Drawer
-Posterior Sag Sign
-Valgus Stress at 0 Deg
MCL Tear
MOI:
-traumatic valgus force
-rotational trauma
S/s:
-normal ROM
-painful palpation
-medial knee pain
Tests:
-Valgus Stress Test 20-30 deg flx
heals well on it’s own
LCL Tear
MOI:
-traumatic varus force
S/:
-swelling over LCL
-pain over LCL
-lack of LCL
Tests:
-Varus Stress at 30 deg flx
Anteromedial Instabiltiy
-anterior and ER force
-MCL, Medical Meniscus, ACL
MOI:
-valgus force and tibial ER
-anterior sublux of medial tibial plateau
Tests:
-Anterior Drawer with ER
Anterolateral Instability
-anterior and IR force
-ACL, LCL, Lateral mensiscus, ITB
MOI:
-valgus force and tibial IR
-anterior sublux of lateral tibial plateau
-ACL tear
Tests:
-Anterior Drawer Test with IR
-Pivot shift
Posteromedial Instability
-Posterior and IR force
-valgus force
-PCL, MCL, Medial meniscus, Semimembranosis, ACL
MOI:
-force into extension and tibial IR
-valgus movement
Tests:
-Hughston’s Posteriormedial Drawer (posterior drawer with IR)
Posterolateral Instability
-posterior and ER force
-Varus force
-PCL, LCL, Biceps femoris
MOI:
-laxity of PCL in addition to other structures
-tib posterior and ER
Tests:
-Dial Test/PLR Tests
-Posterolateral Drawer
-Reverse Pivot Shift
Posterolateral Corner Injury
MOI:
-direct varus hit to tibial on an extended knee
-posterior force on flexed knee with tibial ER
-chronically after trauma to ACL or PCL
S/s:
-varus thrust gait
-posterolateral instability
-knee giving way
-common fib irritation
Meniscal Injuries (MOI & CPR)
MOI:
-twisting
-valgus/ hyperextension force
CPR:
-catching or locking
-joint line tenderness
-twisting MOI
-pain with knee hyperextension or max flx
-pain or click w/ McMurrays test
> 4 positive
Patellofemoral Pain Syndrome
MOI:
-trauma
-overuse
-patellar tracking
-muscle imbalance
Observations:
-dec quad strength, flexibility, coordination of quads
-over-pronation
-patellar position
-weight-bearing pain
-pain after sitting, squatting
Tx:
-hip strengthening
-quad strengthening
Possible Knee DDx
-Cruciates
-Collaterals
-OA
-Patellar Tendinopathy
-PFPS
Patellar Tendinopathy
-pain on tendon
-overuse common in jumping and running
Observation:
-pain with loading
-pain on tendon
Tx:
-load on tendon
-quad eccentrics
Subjective Hx
-MOI
-pain/location/changes/time of day
-Swelling
-Noise
-Locking
-Giving out
-length of symptoms
Rule out Non-MSK
PAD: claudication, cook extremities, decrease filling time
DVT: pain, warmth, swelling
Compartment Syn: swelling, absent pulses, neuro
Septic Arthritis: pain, swelling, infection signs
Cellulitis: skin warmth, redness, rash
Ottawa Knee Decision Rule
- > 55
- Tenderness at head of fib
- Tenderness at Patella
- Inability to flex knee 90
- Inability to WB 4 steps
(+) 2/5= need imaging
Knee Observations
-abrasion, bruising, atrophy, swelling
-LE rotation
-knee position
-flx or hyperextensionon
-tibial torsion
-foot position
Knee Joint ROM
-Flex (0-140) then Ext (0-15)
-AROM > Over > PROM
Knee MMT
-knee flx/ext
-Hip ROM
-Ankle DF and PF
Flexibility Tests
-Ober’s
-Modified Thomas
-Prone Rectus (ELy)
-Gastroc Length
-Hamstring Length
Joint Play/Mobilization: Knee Extension
Ext: ant roll AND glide (concave on convex)
- Pt supine (prone if dec ext)
- Towel under tibia
- Push femur posteriorly
OR
-Push tibia ant if in prone w/ knee flx
Mob:
-ad ER
Joint Play/Mobilization: Knee Flexion
Flex: Post roll and glide
- Pt supine (sitting if distracting or dec)
- PT supporting femur
- PT Push tibia posteriorly
Mob:
-Ad IR
Joint Play/Mobilization: Patellar Sup/Inf Glide
Crab hand: tiny
Bear Claw: big
- Pt in supine, slightly flexed
- Move patella up and down
Joint Play: Patellar Medial/Lateral Glide
Claw hand
- Pt in Supine, slightly flexed
- Move patella side to side
Joint Play: Proximal Tibiofibular Joint
-use if lacking last bit of flexion and has pain at fib head
-or frequent ankle sprains
AP Glide:
1. Pt supine in hooklying
2. Push posteriorly
PA Glide: treat in this position
1. Pt in quadruped
2. Push anteriorly
Knee Exam Order
- Subjective Hx (MOI and pain description)
- Observation
- ROM (knee, hip, ankle)
- MMT (knee, hip, ankle)
- Joint Play
- Palpation (or before joint play)
- Special Tests
Ligament Special Tests
ACL: Lachman, anterior drawer, pivot shift
PCL: Posterior Drawer, Posterior sag, valgus at 0
MCL: valgus stress test at 20
LCL: Varus stress test at 20
Instability Special Tests
AMRI: Anterior drawer + ER
ALRI: anterior drawer + IR, pivot shift
PMRI: Posterior drawer + IR
PLRI: Posterior drawer + ER, reverse pivot shift, dial test
Meniscus Special Tests
McMurray, Thessaly, Apley
Patellar Special Tests
Patellar Grind Test
Patellar Apprehension
Lachman Test
ACL
-less flx than Anterior drawer
- Pt supine, knee flexed slightly
- PT stabilizes femur and pulls tibia ant
- 1-2 reps
Anterior Drawer Test
ACL
-more flx ~ 60
- Pt supine with knee flexed 60
- PT sits on foot
- Pull tibia anteriorly
Posterior Drawer
PCL
-more flx ~ 60
- Pt supine with knee flexed 60
- PT sits on foot
- Find norm of tibia
- Push tibia posteriorly
Posterior Sag Sign
PCL
- Pt supine
- PT flexes knee and hip ot 90 passively and looks for sag of tibia
Valgus Stress Test
PCL (0 deg) , MCL (20 deg)
- Pt supine w/ leg at 0 then 20 deg flexion
- PT outside of leg holding medial tibia and lateral thigh (take up slack)
- PT provides valgus stress
Varus Stress Test
Cruciates (0 deg), LCL (20 deg)
- Pt supine w/ leg at 0 then 20 deg flexion
- PT inside of leg holding lateral tibia and medial thigh (take up slack)
- PT provides varus stress
Anterior Medial Rotary Instability Special Test
Anterior Drawer w/ ER
Anterior Lateral Rotary Instability Special Test
anterior drawer + IR
Posterior Medial Rotary Instability Special Test
Posterior drawer + IR
Posterior Lateral Rotary Instability Special Test
Posterior drawer + ER
Posterorlateral Instability Reverse Pivot Shift
PLRI
- Pt supine
- PT flexes knee to 90 while ER tibia (check for medial sublux
- PT slowly extends knee while adding valgus stress (reduction at full extension)
McMurrays Test
-Meniscus
-NWB
-tells you which one is involved
-provocative
Medial:
1. Pt supine at 90/90
2. PT palpates or watches medial joint line
2. PT passively flexes knee
3. PT puts tibia into ER while extending knee
Lateral:
1. Pt supine at 90/90
2. PT palpates or watches lateral joint line
2. PT passively flexes knee
3. PT puts tibia into IR while extending knee
Apley’s Test
-Meniscus test
-NWB
Distraction:
1. Pt prone with knee bent
2. PT stabilizes femur with leg
3. PT ER then distracts, IR then distracts
Better: meniscus
Worse: Ligament
Compression:
1. Pt prone with knee bent
2. PT stabilizes femur with leg
3. PT ER then comrpesses, IR then compresses
Worse: Mensicus
Thessaly’s Test
-meniscus
-WB test
-5 deg of knee flx, then 20 deg
- Pt stands on one leg with leg bent 5/20 with PT support
- PT askes Pt to twist from side to side
(+): clock, pop, or reproduction of pain
Patellar Apprehension
-lateral patellar subluxation
- Pt supine with leg off of plinth slightly flexed ~15
- Pt foot on PT leg
- PT lateral mobs patella
(+): Pt feels apprehensive about it subluxing
Patellar Grind Test
-Chondromalacia, PF dysfunction
- Pt supine in full knee ext
- PT uses web space to push superir patella down
- Pt then contracts quad
(+): reproduction of patients pain
Altman’s Criteria for Knee OA
- Knee Pain
- > 50
- Knee Crepitus
- Palpable bony enlargement
- Bony tenderness
- Morning stiffness <30mins
- No warmth
Tibialis Posterior Action
- Plantarflexes
- Invert foot
- Supports medial longitudinal arch
Ottawa Ankle and foot Fracture rules
Midfoot zone Rules:
-Inability to bear weight
-tenderness to base of 5th MT
-Tenderness to navivular
Malleolar zone rules:
-inability to bear weight
-tenderness to lateral malleolus
-tenderness to medial malleolus
High Ankle Sprain
- at Tibiofibular syndesmosis
-interosseous membrane
-anterior talofibular lig
-during ER and DF
Subtalar Joint in Gait
Loose Adaptor (swing): sup/pro/sup
Initial contact to loading response: sup to pro
Shock Absorber (weight acceptance): pronation
Midstance: pro to sup
Rigid Level (midstance to toe off): supination
Preswing to initial: sup to pro
Pes Cavus
-high arch
-supinated
-decreased shock absortion
-ankle sprains common
Pes Planus
-low arch
-decreaed rigid lever
-pronated
-hallux valgus
Tarsal Tunnel
-tibial nerve > medial and lateral plantar nerves
Anterior Ankle Nerves
-deep peroneal/fibular nerve
-goes to between big and 2nd toe
-common site for retinaculum compression
Lateral Ankle Nerves
-superficial peroneal/fibular
-can be stretched by ankle sprain
Compartment Syndrome
-tissue pressure increased by trauma
-muscle and nerve ischemia
S/s:
-swelling
-Pain
-no pulses
Tx:
-fasciotomy
-rest (for developing)
Achilles Tendinopathy
S/s:
-pain at junction, tendon, at bony insertion
Tx:
-eccentric loading
-heavy load, low speed
-stretching
-patient education
Posterior Tibialis Tendon Dysfunction
-degenerative and progressive condition
S/s:
Observation: loss of arch height, abduction
Mobility: limited and/or painful PF
Functional: abnormal gait, decreased push off, pain with WB or single leg balance
Strength: weak and painful SL heel raise, weakness with inversion and PF
Cuboid Subluxation
-almost always plantar subluxation
-lateral ankle sprain
-COG in front of midtarsals
-“i feel like there’s a rock in my shoe”
Tx:
-Cuboid Whip
-Cuboid Squeeze
Possible Ankle/Foot DDx
-Cuboid subluxation
-Planar fascitis
-Post Tib Tendon
-Achilles Tendonopathy
-Lateral Ankle Sprain
-Medial Ankle Sprain
-High Ankle Sprain
-Stress Fx
Windlass Effect
-plantar fascia slack until ext of big toe during push off
- Check arch
- Lift big toe and check for arch
Order of Foot/Ankle Exam
Pt Hx
Observation
Scanning Exam
Palpate**
ROM
Flexibility
MMT
Joint Play
Special Tests
Subjective Hx Foot/Ankle Specific
-Activities?
-Flat feet or high arches
-Types of shoes
-Pop?
-Child bracing?
-Surgeries?
-OA?
Palpation (Ankle)
-Achilles tendon
-Calcaneus
-Great Toe/phalanges
-Cuneiform
-Navicular
-Malleoli
-Deltoid ligament
-ATFL
-Shin
-Fibulari
Foot/Ankle ROM
DF/PF: 20/50
Sup/Pro: 45-60/15-30 (measure at top of ankle)
Inv/Env: 20/10 (measure calcaneus)
Great toe Ext/Flx: 70/45
Foot/Ankle MMT
-Gastroc/Soleus
-Tib ant/post
-Fibulars
-Hallucis Flex/ext
-Foot Intrinsics
Joint Play: Proximal Tibio-Fibular
-AP glide or PA
-Lacking last ext or flx
Knee Joint:
-Flx: anterior
-Ext: posterior
Ankle Joint:
-DF: ER
-PF: IR
Joint Play: Distal Tibio-fibular
-AP and PA
-For lacking DF
- Pt supine, foot PF
- Stabilize tibia and mobilize fibula
Joint Play: Talocrual PA Glide
-improve PF
- Pt prone, slightly PF
- PT stabilizes Tibia
- Anterior mob through calcaneus
Joint Play: Talocrual AP Glide
-improve DF
- Pt supine, slightly PF
- PT stabilizes tibia
- Posterior mob through anterior talus
Joint Play: Subtalar Medial Glide
-improve eversion
- Pt sidelying
- Push medially
Joint Play: Subtalar Lateral Glide
-improve inversion
- Pt sidelying
- Push laterally
Joint Play: MTP and IP Dorsal Glide
-Distraction
-Extension
- Stabilize distal MT
- Mobilize dorsally
Joint Play: MTP and IP Plantar Glide
-Flexion
- Stabilize distal MT
- Mobilize plantarly
High (Syndesmotic) Ankle Sprain Special Tests
-Fibular translation test
-External Rotation test
Lateral Ankle Special Tests
-Anterior Talus Displacement- Anterior Drawer
-Lateral Ligament Integrity - Medial Talar Tilt
Anterior Ankle Impingement Special Tests
-Forced Dorsiflexion Test
Midtarsal Joint Pronation Special Tests
-Navicular Drop Test
-Feiss Line
Achilles Tendon Integrity Special Tests
-Thompson Test
FIbular Translation Test
-high ankle sprain
- Pt supine
- PT mobs tibia and fibula
(+): ROS and/or increased displacement
External Rotation Test
-high ankle sprain
- Pt supine; knee flexed to 90
- PT ER and DF ankle
(+): ROS or excessive movement
Anterior Drawer (Ankle)
-stress ATFL
-Lateral ankle sprain
- Pt supine in PF
- PT give anterior glide of talus and calcaneus
(+): Excessive translation
Medial Talar Tilt Stress Test
-stress CFL
-lateral ankle sprain
- Pt supine, foo in neutral
- PT stabilizes malleoli med mobilization at calcaneus
(+): excessive laxity
Forced Dorsiflexion Test
-anterior ankle impingement
- Pt supine, knee flexed
- PT stabilizes distal tibia
- Forceful DF
(+): ROS
Ankle Joint Mobs/Manips
-open packed positions
Proximal and Distal Tibiofibular Joint
Talocrual Joint
Cuboid (whip/squeeze)
Forefoot Joints Mobs
Cuboid Manip/Mob
- Pt prone
- Foot in PF, INV, ADD
- PT thumb over thumb on plantar surface of cuboid
- Sharp Whip motion or squeeze
AP with Progressive DF
-talocrual mobilization
-go the end range
- Pt in long sitting
- PT Stabilize tibia
- PT Mobilize in AP direction while using high to increase
Mobilization with Movement: DF at TC
- Pt in squat or lunge
- AP mob at talus under tibia
OR
PA mob at distal tibia with belt - During squat or lunge to increase
