Musculoskeletal LE Flashcards
ACL Sprain– Grade III
- Peak incidence 14-29 y/o
- Loud pop or feeling as if the knee buckled
- Special Tests: Anterior drawer, Lachman, Lateral pivot shift test
- 2/3 times there will also be a meniscus tear
- CKC exercises are considered more desirable than OKC since they minimize anterior translation of the tibia.
- Return to PLOF 4-6 months.
Achilles Rupture
- Occur most frequent when pushing off WB extremity with extended knee, unexpected DF WB, or rapid eccentric contraction of the PF
- Highest incidence of rupture age 30-50 y/o, males, h/x of corticosteroid use, participate in recreational activities
- swelling over distal tendon, snap or pop, severe pain
- Special Test: Thompson test
- Non-surgical: serial casting ~10 weeks, heel lift for 3-6 months (with minimal stress placed on it). Greater incidence of rerupture
- Surgical intervention: cast or brace is required for 6-8 weeks.
- PT for both starts after cast (or brace) is removed
- Should return to PLOF 6-7 months
Achilles Tenonditis
- Repetitive overuse ; microscopic tears of collagen fivers.
- Typically in the avascular zone 2-6 cm above the insertion point.
- Cause:
o Change in training intensity or faulty technique
o Limited flexibility and strength
o Pts with pronated or cavus foot - S&S: aching or burning in the posterior heel, tenderness of the Achilles, pain with increased activity, swelling and thickening of in the tendon area, m weakness due to pain and morning stiffness.
Severs disease
Calcaneal apophysitis
- stretching of the gastroc and soleus
- heel wedge to decrease traction at the achilles insertions
Anterior Compartment Syndrome
- Pressure in the anterior compartment of the lower leg increases secondary to swelling.
- Causes occlusion of blood flow leading to ischemia and necrosis
- Caused by traumatic injury
- Medical emergency.
- Anterior compartment includes: tibialis anterior, extensor hallicus longus, extensor digitorum longus, and peroneus tertius muscles.
Exertional Compartment Syndrome
It is anterior compartment syndrome brought on by exertion.
The signs of compartment syndrome include: pain, paralysis, paresthesia, pallor, and diminished pulses.
From question: pn is relieved after activity stops, skin is swollen, shiny. Has decreased 2 pt discrimination.
Congenital Hip Dysplasia
- Malalignment of the femur within the acetabulum
- Hip abduction with tightness and apparent femoral shortening of the involved side
- Special test: Ortalania, Barlow, diagnostic US
- Harness, bracing, splinting, traction
- Surgical intervention followed by subsequent pplication of hip spica if conservative treatment fails
Congenital Limb Deficiencies
- Longitudinal limb deficiencies: reduction or absence of an element(s) within the long axis of the bone
- Transverse limb deficiencies: developed to a particular level beyond which no skeletal elements exist.
Legg – Calve- Perthes Disease
- AVN
- Held in ER, Flexion, adduction
- Limp
- limited motion of abduction and extension
- Males > Female
- Ages 2-13 y/o
- self-limiting.
- smaller stature and leg length discrepancies
- Degeneration of the femoral head due to a disturbance in the blood supply (avascular necrosis)
- Self limiting and has 4 stages (condensation, fragmentation, re-ossification, remodeling
- Etiology – trauma, genetic predisposition, synovitis, vascular abnormalities, infection
- S&S – pain, decreased ROM, antalgic pain, + Trendelenburg
- Treatment – primary focus is to relieve pain. PT for stretching, splinting, AD training, aquatic therapy, traction, exercises. Potentially orthopedic and surgical involvement.
Slipped Capital Femoral Epiphysis (SCFE)
- most common hip disorder in adolescents
- femoral head displaced posteriorly and inferiority which can cause AVN
- Males > Females (2x)
- Males: 10-17 (13 y/o)
- Females: 8-15 (11 y/o)
- Held in ER
Loose ROM in flexion, abduction, and IR
-XR
Medial collateral Ligament Sprain (MCL)
- From contact or noncontact, fixed foot, tibial rotation injury associated with valgus force and ER tibial rotation
- Valgus stress test
- Surgery is rarely required since the MCL is well vascularized.
- S&S – inability to fully extend and flex the knee, pain and significant tenderness along medial aspect of knee, possible decrease in strength, and potential loss of proprioception.
- More severe swelling may indicate a meniscus tear or cruciate tear
- May wear full length knee immobilizaer or hinge brace
- PT – ROM and light resistive exercises focusing on quads (ISOM or CKC)
- Don’t massage proximal attachment of the MCL for potential bony disruption.
- Return to PLOF in 4-8 weeks.
Meniscus Tear
- Medial meniscus is more common. Incidence increases with ACL deficiency.
- Mechanism – fixed foot rotation with WB on flexed knee
- Joint line pain, swelling, catching or locking, feelings of instability
- Special tests – McMurray, Apleys compression test, Thessaly, bounce home test,
- Outer 1/3 is vascularized and may sponstaneously heal.
- Inner 2/3’s may require surgery
Myositis Ossificans
- Calcification of the muscle typically after neglecting to properly treat a muscle strain or contusion.
o Failing to apply cold after injury or applying heat after injury, or intense therapy or massage too soon after injury - Bone will begin to grow 2-4 weeks after injury and will mature within 3-6 months
- S&S (initial) – pain with functional activities, stiffness and pain after prolonged rest. Swelling, tenderness, and bruising possible.
- S&S (progressed) – noticeable hard lump in m belly, increase in pain, decrease in ROM that had previously been improving.
Osgood Schlatter Disease
- Traction apophysitis on tibial tuberosity. Self limiting.
- Young athletes typically
- S&S: point tenderness of over patella tendon, antalgic gait, pain with increasing activity
- Typically reproduced with resisted knee extension and alleviated with rest or activity restriction
- Will typically have tight hip and knee muscles (especially the quads)
- PT – icing, flexibility, eliminate activities that place strain on the patella tendon such as squatting, running, or jumping.
Osteoarthritis
- Degeneration of articular cartilage. Subsequent deformity and thickening of the subchondral bone.
- Most common joints are the hands (DIP and PIP) , hips, and knee
- Men>women up to age 55 years old; however after this age it is more common in women.
- S&S: gradual onset pain; increased pain after exercise, increased pain with weather changes, enlarged joints, crepitus, stiffness (morning), limited joint ROM, deep and aching joints Heberden’s nodes, and Bouchard’s nodes
Herberden’s nodes
- Women not men
- Palpable osteophytes in the DIP
Osteochondritis Dissecans
- Subchondral bone and its associated cartilage crack and separate from the end of the bone
- Severe cases: bone may actually detach from the surrounding area and float freely inside the joint.
- S&S: pain with functional activities, joint popping or locking, weakness, swelling, and decreased ROM.
Osteeogenesis Imperfecta
- Connective tissue disorder affects the formation of collagen during the bone development
- Etiology:
o It is genetic inheritance with type I & IV autosomal dominant traits
o Types II and III autosomal recessive - S&S: pathological fx, osteoporosis, hypermobile joints, bowing of the long bones, weakness, scoliosis, impaired respiratory function.
Osteogenesis Imperfecta Types
Type 1 - mildest form. Normal growth and appearance. Fx frequency ceases after puberty
Type II - most SEVERE. Child dies in utero (or early childhood)
Type III - sig. growth retardation, progressive deformities, fx, osteoporosis, triangular face, blue sclera, significant limitations with functional mobility.
Type IV - MILDER. Mild to mod fragility and osteoporosis. Shorter stature, blowing of long bones, barrel rib cage, possible hearing loss, brittle teeth. Near normal life expectancy.
Osteomyelitis
- Infection in the bone mostly commonly from staphylococcus aureus microbe.
- S&S: Fever and chills; pain, edema, and erythema
- Those at risk: weakened immune system, diabetes, sickle cell disease, elderly or undergoind hemodialysis.
- Bone biopsy for definite diagnosis
Patellofemoral Syndrome
- Abnormal tracking on the patella typically pulled too laterally during knee extension
- Can cause chondromalacia patella (softening of the articular cartilage of the patella)
- More in females; older population due to OA.
- Decreased quads strength, decreased LE flexibility, patellar instability, increased tibial torsion or femoral anteversion
- Increased risk – growth spurt, running that have increased their training/mileage, overweight individuals
- Other associated factors – patella alta, insufficient lateral femoral condyle, weak VMO, excessive pronation, excessive knee valgus, tightness (iliopsoas, hamstrings, gastrocnemius, vastus lateralis)
- S&S – anterior knee pain, pain with prolonged sitting, swelling, crepitus, pain when ascending and descending stairs.
- Special tests – Clarke’s sign
- Treatment – LE strengthening should emphasize quad and VMO (OKC and CKC), stretching (hamstrings, ITB, TFL, and rectus femoris)
Piriformis Syndrome
- Compression or irritation to the proximal sciatic nerve due to piriformis muscle inflammation, spasm, or contracture. (the nerve passes inferior to the muscle)
- Diagnosis of exclusion since it presents nearly identical to L5-S1 radiculopathy (which is from herniated disk or stenosis).
- S&S:
o mid-buttock pain that progresses to radicular complaints. May have hip, coccyx, or groin pain.
o Typically exacerbated by prolonged sitting and activities that combine medial rotation and adduction.
o Pain reproducible with palpation and positioning in flexion, adduction and medial rotation (FADIR) - PT: thermal modalities, soft tissue mobilizations, stretching, hip joints mobs, m energy, strain-counter-strain techniques.
- As symptoms decrease start strengthening the piriformis and surrounding muscles.
Posterior tibial tenosynovitis
- inflammation of the posterior tibial tendon
- Experience symptoms inferior to the medial malleolus
- posterior tib helps to support the arch
- With this condition it can progress to where the arch of the foot can become flattened.
- More common with pronation.
Plantar Fasciitis
- Inflammation of the plantar fascia at the proximal insertion on the medial tubercle of the calcaneus.
- Factors that contribute: excessive pronation during gait, tightness of the foot and calf, obesity, and having a high arch.
- 40-60 y/o
- From acute injury from excessive loading of the foot OR chronic irritation from excessive amount of pronation or prolonged duration of pronation.
- S&S: tenderness at the insertion, heel spur, pain worse in morning or after inactivity, difficulty with prolonged standing, pn with walking barefoot.
o Can also radiate proximally up the calf or distally to the toes - PT – stretching, massage/manual, night splinting, activity modification, orthotics/shoe modification. Once out of acute phase incorporate foot intrinsics and extrinsic exercises.
PCL Sprain
- MOI – landing on tibia with flexed knee or hitting knee on dashboard during MVA.
- S&S – may have had audible “pop”, swelling, pain, may feel that the femur is sliding off the tibia (may feel the instability with walking and pain with descending stairs or squatting), but may be asymptomatic
- Special tests – posterior drawer, posterior sag sign, quadriceps active drawer test
- PT – reduce swelling, regain full ROM, strengthen
- Strengthening exercises that place a posterior shear force on the knee (OKC hamstring exercises) should be avoided to let the ligament heal.
- If surgery is performed hamstring exercises to often avoided for minimum of 6 weeks.
PCL prevents posterior translation of tibia on femur
Talipes Equinovarus
- “clubfoot” heel pointing downward and forefoot turning inward
- Seen with spina bifida and arthrogryposis
- Forefoot in adduction, varus positioning of hindfoot, and equinus at ankle
- Medical management shortly after birth and includes splinting and serial casting
Tarsal Tunnel Syndrome
- Compression of the tibial nerve as it passes through the tarsal tunnel (located posterior to the medial malleolus)
- S&S: paresthesias in foot (sometimes mistaken as plantar fasciitis), antalgic gait, m atrophy, light touch and temp sensation diminished
- Rest alleviates but doesn’t resolve
- Diagnosis with EMG or NCV
See more with “flat feet” or pronation since this increases pressure on the tunnel region often resulting in nerve compression
Peroneal tenosynovitis
- inflammation of the peroneal tendons.
- Peroneus longus and brevis are located posterior to the lateral malleolus and are the structure more typically associated with activities requiring repetitive ankle motion that results in overuse, trauma or recurrent ankle sprains.
- Supinated gait places additional stress on the peroneal tendons within the groove behind the lateral malleolus.
Total Hip
- Cemented – WBAT
- Cementless and hybrid fixation rely on bone growth – PWB or NWB for up to 6 weeks.
- Primary indication for cementless fixation is a young, active individual (<65)
- Average lifespan is 15-20 yrs of a hip.
- Complications – DVT, infection, PE, heterotopic ossification, femoral fx, dislocation, and neurovascular injury
Posterior dislocation of the hip
- typically occurs with MVA or fall
- more common than anterior
- severe groin and lateral hip pain
- leg is shortened, and held flexed, and adducted, and IR
pg. 251 Dutton
Anterior dislocation of the hip
- typically from forced abduction
- Groin pain and tenderness
- Superior-anterior (pubic) dislocation – leg is extended and ER
- inferior-anterior (obturator) dislocation – thigh is abducted, ER, and flexion.
pg. 251 Dutton
Immediate and severe swelling following a knee injury would most likely indicate damage to the:
ACL
The medial inferior genicular artery runs through the anterior cruciate ligament (ACL). As a result, tearing of the ACL often produces hemarthrosis of the knee joint.
What medical condition would likely result in a decreased percentage of the femoral head being within the acetabulum?
Congenital hip dysplasia (aka developmental dysplasia)
Where does a patient with Achilles tendonitis typically experience the most pain and swelling?
proximal to the insertion on the calcaneus
A patient with Achilles tendonitis will typically experience a gradual onset of pain and swelling localized 2-3 centimeters above the tendon’s insertion on the calcaneus. Morning stiffness or pain at the start of activity are also classic signs associated with Achilles tendonitis.
What is the goal of therapeutic intervention associated with developmental dysplasia of the hip?
- internal fixation
- enlarging and deepening the acetabulum
- replacing the femoral head
- compensating for a leg length discrepancy
enlarging and deepening the acetabulum
Developmental dysplasia of the hip is characterized by malalignment of the femoral head in the acetabulum. Enlarging and deepening the acetabulum can allow for a more stable articulation between the two structures. If conservative treatment for this condition is not successful, surgical management may be indicated.
The majority of congenital limb deficiencies are caused by:
- genetics
- infection
- maternal drug exposure
- inadequate blood supply
genetics
The majority of congenital limb deficiencies are idiopathic or genetic in origin. The remaining options represent possible etiologies for congenital limb deficiencies, but they are not as common as genetics.
What type of meniscal tear is described as a vertical longitudinal tear displaced into the intercondylar notch?
bucket handle
A bucket handle tear often occurs in an area of good blood supply and are often associated with anterior cruciate ligament injuries.
A surgically repaired medial meniscus tear would prevent a person from participating in competitive athletics for approximately how many months?
4-6 months
Which type of osteogenesis imperfecta is characterized by a child having normal or near normal growth with the frequency of fracture ceasing after puberty?
type 1
Orthopedic condition often caused by staphylococcus aureus microbe
osteomyelitis
orthopedic condition resulting in inadequate collagen production
osteogenesis imperfecta
Q angle
measure from midpatella to ASIS and to tibial tubercle
Norms:
Male - 13 deg
Female - 18 deg
Excessive q angle can lead to pathology
