Musculoskeletal LE Flashcards
1
Q
ACL Sprain– Grade III
A
- 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.
2
Q
Achilles Rupture
A
- 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
3
Q
Achilles Tenonditis
A
- 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.
4
Q
Severs disease
A
Calcaneal apophysitis
- stretching of the gastroc and soleus
- heel wedge to decrease traction at the achilles insertions
5
Q
Anterior Compartment Syndrome
A
- 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.
6
Q
Exertional Compartment Syndrome
A
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.
7
Q
Congenital Hip Dysplasia
A
- 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
8
Q
Congenital Limb Deficiencies
A
- 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.
9
Q
Legg – Calve- Perthes Disease
A
- 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.
10
Q
Slipped Capital Femoral Epiphysis (SCFE)
A
- 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
11
Q
Medial collateral Ligament Sprain (MCL)
A
- 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.
12
Q
Meniscus Tear
A
- 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
13
Q
Myositis Ossificans
A
- 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.
14
Q
Osgood Schlatter Disease
A
- 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.
15
Q
Osteoarthritis
A
- 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
16
Q
Herberden’s nodes
A
- Women not men
- Palpable osteophytes in the DIP
17
Q
Osteochondritis Dissecans
A
- 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.
18
Q
Osteeogenesis Imperfecta
A
- 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.
19
Q
Osteogenesis Imperfecta Types
A
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.
20
Q
Osteomyelitis
A
- 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
21
Q
Patellofemoral Syndrome
A
- 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)
22
Q
Piriformis Syndrome
A
- 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.
23
Q
Posterior tibial tenosynovitis
A
- 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.
24
Q
Plantar Fasciitis
A
- 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.
25
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
26
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
27
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
28
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.
29
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
30
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
31
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
32
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.
33
What medical condition would likely result in a decreased percentage of the femoral head being within the acetabulum?
Congenital hip dysplasia (aka developmental dysplasia)
34
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.
35
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.
36
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.
37
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.
38
A surgically repaired medial meniscus tear would prevent a person from participating in competitive athletics for approximately how many months?
4-6 months
39
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
40
Orthopedic condition often caused by staphylococcus aureus microbe
osteomyelitis
41
orthopedic condition resulting in inadequate collagen production
osteogenesis imperfecta
42
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
43
What structures are most likely to be damaged with TKA sx?
Peroneal nerve is most common neurologic complication -- causing foot drop (innervates the DF)
Superficial femoral and popliteal vessels are among the vascular structures at greatest risk.
44
Ely's test
* To assess rectus femoris flexibility
* Pt prone; passively flexion knee
* Results (+) – If you see excessive anterior pelvic tilt or hip flexion on the same side- tight rectus femoris. – compare to the unaffected side.
45
Ober's test
o To assess TFL flexibility
o Pt in side-lying; flex the knee
o Stabilize the iliac crest bring the test-leg into abd/extension.
o Slowly lower the leg
o Results: (+) – If the leg doesn’t lower past neutral -tight TFL
only flex the knee to 45 deg. If flexing more...more looking at femoral nerve.
46
Piriformis test (muscle length)
* pt in S/L with test leg toward ceiling and hip flexed to 60*.
* Therapist places one hand on pelvis and other on knee.
* While stabilizing pelvis, applies a downward (adduction) force to the knee
* (+) = pain or tightness. May be indicative of piriformis tightness or compression on the sciatic nerve.
47
Modified Thomas
o To identify presence of hip flexion contracture or tightness of TFL
o Have patient sitting at end of the table
o Instruct them to lay back and hold the non-test leg into chest
o Push the test-leg femur down onto table
o Results:
(+) if there is inability to achieve full hip extension
If the femur cannot lay flat on table > tight hip flexors
If the knee goes into extension > tight rectus femoris
If the hip moves into abduction > tight TFL
Thomas test is they are supine and just pull knee to chest.
48
Tripod sign
* pt in sitting with knees flexed to 90.
* Therapist passively extends one knee
* (+) = tightness in hamstring or extension of the trunk on order to limit the effect of the tight hamstrings.
49
90-90 SLR test
* pt in supine and asked to stabilize the hips in 90* flexion and knees relaxed.
* pt ACTIVELY extends te knee as much as possible while maintaining 90* hip flexion.
* (+) = knee remaining in 20* or more flexion and is indicative of hamstring tightness
50
Barlow's test
* pt is supine in hips flexed to 90* and knees flexed.
* each hip is tested individually
* stabilize the emur and pelvis with one hand and the other hand moves the test leg into adduction.
* A posteriorly directed pressure is then applied through the knee
* (+) = clunk and may be indicative of hip being dislocated.
Pediatric hip test
51
Ortolani's test
* supine with hips flexed to 90* and knees flexed
* therapist grasps legs so their thumbs are along pts medial thigh and fingers are on lateral thighs toward buttocks.
* Therapist abducts hips and gentle pressure is applied to the greater trochanters until resistance is felt at ~30*
* (+) = click or clunk and may be indicative of dislocation being reduced.
52
Anterior labral tear
* pt in supine in figure 4 position ( F, ABD, ER)
* Therapist moves the hip into extension, IR, and adduction
* (+) = presence of pain and/or click
* used for diagnosing anterior labral tear, though may also be indicative of iliopsoas tendonitis or anterior-superior impingement
53
Craigs test
* Prone with knee flexed 90 deg
* Palpate the greater trochanter while IR/ER to find the most lateral portion of the greater trochanter
* Measure the angle
* Results:
(+) an angle >25 deg - suggests femoral anteversion (IR)
(+) an angle <15 deg - suggests femoral retroversion (ER)
Normal anteversion (IR) for adults = 8-15 deg
54
FABER (Patrick's test)
* Screening for hip, lumbar, or SI joint dysfunction
* Flexion, abduction, ER (“Figure 4 position”) and then loading it. Stabilize the opposite ASIS (Anterior side is stretching & Posterior is compression)
* Results:
(+) Pain in groin/anterior hip – ilipsoas and/or intraarticular hip pathology
(+) Pain in posterior hip joint – ligament teres injury or posterior impingement
55
Quadrant scouring test (Hip Scour)
* end range flexion then adduction full range…then compress through femur
* while holding compression move from adduction to abduction.
* Not a very specific test. (+) – reproduction of symptoms
* Could be from: Articular surface (acetabulum), labrum (impingement), synovium (hip joint capsule), insertion of TFL and sartorius, iliopsoas muscle, provoke nerve, pectineus, adductor longus, femoral neck.
- Scorebuilders says indicative of pathologies such as arthritis, avascular necrosis or osteochondral defect
56
Trendelenburg test
* standing on 1 leg fro ~10 sec
* (+) = drop of the pelvis of the unsupported side and may be indicative of weakness of the glut med on the supported side
57
Piriformis syndrome test
* Piriformis is an ER until 90* where it switches to an IR
* Full flexion, adduction, and ER to stretch piriformis
* Resisted IR (to maximize compression of the piriformis on to the sciatic nerve)
* Results:
o (+) = reproduces the patient’s sciatic symptoms.
o If they have piriformis syndrome they will also have a (+) SLR.
58
Sign of the Buttock
* Perform a SLR test; If a limitation is present, flex the knee and flex the hip again
* Results:
o (+) if hip flexion does not increase when the knee is flexed
o To identify the presence of a lesion or pathology within the buttock (ischial bursitis, abscess, neoplasm)
59
Gluteal bursa test
o Both are stretching to get compression.
o Bring hip into flexion, add, ER
(+) = pain provoked due to gluteus medius bursitis
o Repeat with flexion, adduction, IR
(+) = pain provoked with this test is gluteus maximus bursitis.
60
Iliopectineal bursa test
o Between pubic symphysis and AIIS.
o Hip hyperflexion and ER
The iliopsoas attached at lesser trochanter will hit the bursa.
61
Stinchfield's Test
* Doesn’t tell you what structure but an idea of the area of the pain generator
* SLR at about 30* flexion (pt holds it there) and then resist flexion.
* (+) = reproduction of symptoms
o Groin or anterior thigh – symptomatic hip structural issue
o SI or lumbar spine or buttock -- Iliacus and psoas are attached to lumbar region
62
Fulcrum test
o To assess for presence of stress fx of the femoral shaft
o Pt. sitting over edge of table
o Place hand under distal femur and apply downward pressure on the top of the knee
o Results:
(+) sharp pain or apprehension
63
Anterior Drawer
* Position: supine with 90° of knee flexion. Therapist sitting on lateral aspect of foot.
* Therapist: Wrap hands around proximal calf musculature with thumbs at tibial plateau. Pull anteriorly
* Positive:
Looking for greater motion (from unaffected side)
Soft-end feel
* Problem with test:
PCL or posterior corner deficiency may demonstrate as increased motion due to starting in a more posterior inclined position.
64
Drawer test with ER and IR
* Performed same as above however with foot IR and then ER.
* IR → ACL, posterior lateral corner, PCL
* ER → ACL, stressing the posterior medial side of the knee.
65
Lachman’s test
* 30° of knee flexion.
* Prop distal test femur on therapist thigh. Stabilize distal thigh without compressing the hamstrings (which would give a sense of false integrity).
* Grasp distal femur with proximal hand and proximal tibia with distal hand.
* Pull anteriorly on tibia and then push posterior on the tibia.
* Assessing the anterior translation of the tibia on the femur (testing for the ACL). Should be firm end-feel
o Best performed immediately after injury and not 1-2 hours later (due to swelling)
(+) indicated by excessive anterior translation of the tibia on the femur with diminished or absent end-point and may be indicative of ACL injury
66
Valgus test of the knee
* Place one hand on lateral side of knee and grasp distal tibia/fibular with other hand.
* Place in 30° flexion and apply valgus load (make sure it is valgus load and not IR/ER of hip or further knee flexion)
* Tests the integrity of the SMCL (quality, quantity, and provocation)
67
Varus test of the knee
* Place in 30* knee flexion
* Proximal hand above joint line at the femur. Distal hand lateral aspect of lower leg
* Testing mainly the LCL
68
Posterior Sag (Godfrey) Sign
* Test for PCL
* Position: hips and knees at 90° with therapist supporting legs
* Therapist: Looking at contour of tibial plateaus/tuberosities as they relate to the joint line.
o To further delineate: ask pt to contract hamstrings slightly (this will pull tibia posterior) to exaggerate response.
* Positive: Tibia will sag posterior (tibial tuberosity will be less visible) → insufficient PCL
69
Pivot-Shift Test
– for anterior lateral rotatory instability
o Position: in knee extension in supine
o Therapist: distal hand on tibia giving valgus load and IR (will bring lateral tibial plateau forward if unstable); start to flex knee without rotating femur.
o At ~90° it will relocate in position.
o Can perform starting at flexion and it will relocate at extension.
70
RROM at 0-120° - for suspected patellofemoral joint pathology
* Proximal hand under distal femur to stabilize; distal hand on distal tibia/fibula.
* Apply resistance to ISOM knee extension. Repeat in 30°, 60°, 90°, and 120°.
* Stresses the patellofemoral interface in different angles.
* Positive: Pain.
o If they have an anterior horn lesion it would likely also be positive. But would typically use a different test.
71
Eccentric step test
* Pt standing on 6” step and step off with uninvolved LE.
* Positive: reproduction of the patellofemoral pain.
* May also assess stance leg for Trendelenburg and excessive valgus angle at the knee.
72
Zohler Sign
– pain provocation of chondromalacia or symptomatic posterior surface of the patella.
* Classic Zohler sign is painful for those who don’t have patella issues. This is why knee is flexed.
* Pts knee is flexed to 30° and therapist supports it.
* Stabilize the superior border of the patella. Have them engage in a quad set.
o Compression of the superior border causes compression of patella into femur.
* Positive: pain provocation indicating patellofemoral issues
73
Waldron test
* Have patient do a single leg squat while holding onto therapist. Therapists hand on over the patellar surface to feel for any crepitus
o The posterior aspect of patella is compressed and gliding along femoral groove.
For patellofemoral issues
74
McMurray's Test
- for provoking the posterior horn of the meniscus
- Start in flexion and move into knee extension and ER/IR of
IR -- captures lateral posterior horn
ER -- captures the medial posterior horn
(+) = click or pronounced crepitation felt over the joint line and may be indicative of a posterior meniscal lesion.
75
Apley's Test
- for meniscal lesion
- pt prone with knee flexed
- stabilize distal femur and distract lower leg and ER/IR lower leg. Repeat with compressed
(+) = more painful with compressed IR/ER or clicking
76
Thessaly Test
-- meniscal test (doesn't tell location)
- Stand on 1 leg and flex knee to 5 deg first then~20 deg and rotate medial and lateral (holding onto therapist for balance). Perform 3 times each.
(+) = joint line discomfort or catching or locking in the knee...positive for meniscal tear
First perform on the unaffected
77
Steiman's test
-- anterior horn of the meniscus
- Supine with knee flexed 60-90 deg.
- Grasp knee with both hands with thumbs over anterior medial joint space with ipsilateral thumb over the most painful region and contralateral thumb to reinforce it.
- Move from flexion to extension
(+) = pain is provoked by pressure with knee in extension but disappears ~30-40 deg of knee flexion.
78
Noble Compression Test
- for ITB friction syndrome
- lay on side (with back to you) with knees flexed to 90 deg
- hold pressure at the lateral femoral condyle
(+) = around 30 deg would be the most taunts compression of the IT band over the lateral femoral condyle. This is where the most painful production of symptoms would be.
79
Clarke's sign
- supine with knees extended.
- Applies pressure distally with web space of the superior pole of the patella.
- Pt then contracts the quads while therapist maintains pressure on the patella
(+) = failure to complete the contraction without pain and may be indicative of patellofemoral dysfunction.
80
Patellar apprehension test
- Supine with knee extended
- Therapist places both thumbs on the medial border of the patella and applies a lateral directed force.
(+) = look of apprehension or attempt to contract the quads in an effort to avoid subluxation and may be indicative of patellar subluxation or dislocation
81
Testing the ATFL (anterior talofibular ligament)
Full PF and inversion
82
Testing the CFL (calcaneofibular ligament)
aka talar tilt test
10 deg of PF and inversion
83
Testing the PTFL (posterior talofibular ligament)
DF/Inv
84
Testing the anterior tibiotalar/navicular ligaments
full PF and eversion
85
Testing the tibiocalcaneal ligaments
10 deg PF and eversion
86
Testing the posterior tibiotalar ligaments
DF and eversion
87
Anterior drawer (ankle)
* Helps assess the motion of the talus on the tibia and checking what the ATF protect.
* Position: seated on edge of mat with knee flexed.
* Therapist: stabilize the tibia; grasp the pts calcaneus and position foot in 10-20° PF
o OKC: Stabilize the distal tibia; Grasp calcaneus and translate forward
o CKC: place foot on table to help stabilize distal segment and apply posterior force on the tibia.
* (+) If laxity → will have more motion but will also have some rotation
88
Windlass Test
* Purpose: Suspected plantar fasciitis
* In bipedal standing therapist passively extend the 1st metatarsal.
* Results:
o (+)- pain along the medial longitudinal arch.
89
Navicular drop test
* Assess the degree to which the talus plantar flexion in space on the calceus that has been stabilized by the ground, during subtalar joint pronation.
* Naviculum -- PF and invert to find posterior tib tendon. Points pretty close to it and there is a tuberosity
* Draw a circle around the tuberosity.
* Pt in a sitting position resting on the ground in a NWB position.
* Measure distance between navicular tuberosity and the floor in the
o In the subtalar neutral position → Want equal presentation of the tibial tubercles.
* Have pt stand
o Measure the navicular tuberosity to the floor
(+) = If there is change greater than 10mm suggests excessive medial longitudinal arch collapse of abnormal pronation.
90
Thompson Test
* Purpose: To determine Achilles tendon rupture
* Pt prone with foot off the edge of the table
* While grasping the midbelly of the calf, squeeze the calf.
* Results:
o (+) – if the foot fails to PF when the squeeze is applied
91
External Rotation test (Kleiger)
* Purpose:
o general test to implicate the syndesmosis if pain is produced over anterior or posterior tibiofibular ligaments and the interosseous membrane.
o Also used for integrity of the medial ligament of the ankle complex. (deltoid ligament)
* Sitting with legs over edge of mat ~90° knee flexion.
* Stabilize lower leg and grasps foot and externally rotates it.
* Results:
o (+) – pain experienced at the anterolateral aspect of the distal tibiofibular syndesmosis for syndesmosis injury
o (+) – pain on medial aspect of ankle and/or displacement of talus from medial malleolus may indicate a tear of the medial (deltoid) ligament
92
Cotton Test (used for chronic conditions)
* Pt supine with foot over edge of mat.
* One hand stabilizes distal leg and other grasps heel and moves calcaneus laterally.
* (+) – clunk can be felt as talus hits the tibia and fibula if there has been a significant mortise widening.
93
Syndesmosis Squeeze Test (for acute conditions)
* Pt supine or side-lying
* Clinician squeezes the lower 1/3 of leg at point just above the ankle.
* Results
o (+) – pain in distal 1/3 of leg may indicate a compromised syndesmosis (high ankle sprain) if the presence of tibia and/or fibula fracture, calf contusion, or compartment syndrome has been ruled out.
94
Buerger’s Test
* Pt supine
* Clinician elevates the pts leg to ~45° and maintains it there for at least 3 mins.
* Results:
o (+) - Blanching of the foot is positive for poor arterial circulation, especially if when the pts sits with legs over the end of the bed it takes 1-2 mins for the limb color to be restored.
95
Tinels sign for posterior tibial nerve
* Posterior tibial nerve may be tapped behind the medial malleolus.
* Tingling or paresthesia with this test is considered a positive finding.
96
Mortons test
* Pt supine
* Clinician grasps the foot around the met heads and squeeze the heads together.
* Results:
o (+) – reproduction of pain with this maneuver indicated the presence of a neuroma or stress fracture.
3rd and 4th toes is the morton's neuroma
97
External snapping hip
* Pain/snapping sensation over the lateral hip when running
* Cause is the ITB rubbing on the greater trochanter.
* Occurs more with some IR.
98
Internal snapping hip
Iliopsoas
- slips on the lesser trochanter (or anterior acetabulum)
- most common cause
- more common going into extension with some abduction and ER (~45 deg)
Iliofemoral ligament
- slips and rides over the femoral head
- occurs at the same position as listed above.
99
If you have a Trendelenburg what is an orthopedic condition it could elude to you having?
Labral tear
This causes hip instability which would result in weak glut med or unstable hip on the stance side.
100
What other conditions would likely accompany talipes equinovarus
Tibial shortening
Decreased external tibial torsion
Increased internal hip rotation on the affected lower extremity
101
What are the grades of lateral ankle sprains?
o 1 – Stretch of the lateral ligament complex with no macroscopic tear or joint instability, little swelling or tenderness
o 2 - Partial tear of the lateral ligament complex with mild joint instability, moderate intra- capsular swelling and tenderness, and some loss of ROM and joint function
o 3 - Complete rupture of the anterior talofibular ligament, calcaneofibular ligament, and capsule with mechanical joint instability; severe intra/extra-capsular swelling, ecchymosis, tenderness and inability to weight-bear.
o High ankle sprain - Partial tear of the syndesmosis, creating generalized swelling and tenderness throughout the ankle joint complex; inability to bear weight, severe ecchymosis, and mortise widening.
102
Where does the tibialis anterior refer pain?
anterior lower leg and medial dorsum of the foot to the hallux (great toe)
103
Where does the peroneus longus refer pain?
Superolateral aspect of the lower leg
104
Where does the peroneus brevis refer pain?
lower lateral leg, over lateral malleolus and lateral aspect of the foot.
105
Where does the tibialis posterior refer pain to ?
posterior leg, achilles tendon, heel, and sole of foot.
106
When does an ACL graft reach it weakest point?
approx. 6 weeks post surgery.
