Musculoskeletal pathologies

Question 1

Achilles tendonitis

Answer 1

repetitive overuse disorder. The tendon is most often impacted in an avascular zone located 2 to 6 cm above the insertion.

Etiology: repetitive overload of the Achilles tendon often caused by changes in training intensity or faulty technique. Patients with limited flexibility and strength in the gastroc and soleus complex and patients with a pronated or cavus foot are at increased risk.

S/S: aching or burning in the posterior heel, tenderness of the tendon, pain with increased activity, swelling ans thickening in the tendon area, muscle weakness due to pain, morning stiffness.

Tx: initially RICE, non-steroidal anti-inflammatory meds (NSAIDS), and analgesics as needed. A heel lift and cross training may be used to limit the amount of tensile loading through the tendon Prevention includes heel cord stretching exercises, use of appropriate soft-soled foot wear, eccentric strengthening of the gastroc and soleus, and avoiding sudden changes in training intensity.

Question 2

Adhesive capsulitis

Answer 2

results in loss of ROM in both active and passive shoulder motion due to soft tissue contracture. The condition is caused by adhesive fibrosis and scarring between the capsule, RC, subacromial bursa, and deltoid.

Etiology: onset may be related to a direct injury to the shoulder or may begin insidiously. Peak incidence occurs in individuals between 40 and 60 years of age with females being affected more than males. Patients with DM have an increased incidence of adhesive capsulitis. The condition is self-limiting and typically resolves in one to two years, although some have residual loss of motion.

S/S: insidious onset of localized pain often extending down the arm, subjective reports of stiffness, night pain, restricted ROM in the capsular pattern.

Tx: focus of tx is increasing ROM with GH mobilization, ROM exercises, and palliative modalities. The therapist and pt should avoid overstretching and elevating pain since this can result in further loss of motion. Surgical options include suprascapular nerve block and closed manipulation under anesthesia.

Question 3

Anterior cruciate ligament (ACL) sprain

Answer 3

ACL runs from the anterior intercondylar area of the tibia to the medial aspect of the lateral femoral condyle in the intercondylar notch. The extent of the sprain is classified according to the extent of ligament damage. A grade I sprain involves microscopic tears of the ligament, while a grade III sprain indicates a completely torn ligament.

Etiology: noncontact twisting injury associated with hyperextension, varus or valgus stress to the knee. An ACL sprain often involves injury to other knee structures such as the medial capsule, medial collateral ligament and menisci.

S/S: pt may report a loud pop or feeling the knee is giving way or buckling, followed by dizziness sweating and swelling. Special test involve the anterior drawer test, Lachman test, and lateral pivot shift test

Tx: initially RICE, NSAIDs, and analgesics as needed. Conservative tx includes LE strengthening exercises emphasizing the quads and the HS. Surgery is often warranted for a complete ACL tear (grade III). Surgery most often consists of intra-articular reconstruction using the patellar tendon, iliotibial band or HS tendon. A derotation brace may be beneficial for a pt with an ACL deficient knee, however, it has limited benefit for a patient following surgical reconstruction.

Question 4

Congenital hip dysplasia

Answer 4

also known as developmental dysplasia, is a condition characterized by malalignment of the femoral head within the acetabulum. The condition develops during the last trimester in utero.

Etiology: cultural predisposition, malposition in utero, environmental and genetic influences.

S/S: asymmetrical hip abduction with tightness and apparent femoral shortening of the involved side. Testing for this condition may include the Ortolani’s test, Barlow’s test, and diagnostic ultrasound.

Tx: the focus of treatment is dependent on age, severity, and initial attempts to reposition the femoral head within the acetabulum through the constant use of a harness, bracing, splinting, or traction. Open reduction with subsequent application of a hip spica cast may be required if conservative treatment fails. PT may be indicated after cast removal for stretching, strengthening, and caregiver ed.

Question 5

Congenital limb deficiencies

Answer 5

malformation that occurs in utero , secondary to an altered developmental course. Classified as longitudinal or transverse. A longitudinal limb deficiency refers to a reduction or absence of an element or elements within the long axis of the bone. A transverse limb deficiency refers to a limb that has developed to a particular level beyond which no skeletal elements exist.

Etiology: the majority are idiopathic or genetic in origin. Other possible etiologies include poor blood supply, constricting amniotic bands, infection, and maternal drug exposure

S/S: structural or acquired abnormality of a limb, phantom limb pain

Tx: focus on symmetrical movements, strengthening, ROM, and WB activities, and prosthetic training when appropriate.

Question 6

Congenital toricollis

Answer 6

also known as wry neck, is characterized by a unilateral contracture of the SCM muscle. Condition often identified within the first 2 months of life.

Etiology: cause is unknown, however is may be associated with malpositioning in utero and birth trauma

S/S: lateral cervical flexion to the same side as the contracture, rotation towards the opposite side, and facial asymmetries

Tx: initially treatment is conservative with emphasis on stretching, AROM, positioning, and caregiver education. Surgical managment is indicated when conservative options have failed and the child is over 1 year of age. A surgical release followed by PT may be indicated for ROM and proper alignment.

Question 7

GH instability

Answer 7

excessive translation of the humeral head on the glenoid during active rotation. Instability involves varying degrees of injuries to dynamic and static structures that contain the humeral head within the glenoid. Subluxation refers to joint laxity, allowing for more than 50% of the humeral head to passively translate over the glenoid rim without dislocation. Dislocation is the complete seperation of the articular surfaces of the glenoid and the humeral head. Approx. 85% of dislocations detach the glenoid labrum (Bankart lesion)

Etiology: combo of forces stress the anterior capsule, GH ligament, and RC, causing the humerus to move anteriorly out of the glenoid fossa. An anterior dislocation is the most common and is usually associated with shoulder abd and ER.

S/S:
Subluxation: feeling the shoulder “popping” out and back into place, pain, paresthesias, sensation of the arm feeling “dead”, positive apprehension test, capsular tenderness, and swelling
Dislocation: severe pain, paresthesias, limited ROM, weakness, visible shoulder fullness, arm supported by contralateral limb

Tx: initial immobilization with a sling for 3 to 6 weeks. RICE and NSAIDS. Following immobilization, ROM and isometric strengthening should be initiated followed by progressive resistive exercises emphasizing the IR and ER, as well as the large scapular muscles.

Question 8

Impingement syndrome

Answer 8

Often caused by repetitive microtrauma from upper extremity activity performed above the horizontal plane. Throwing, swimming, and racquet sports are particularly susceptible

Etiology: caused by the humeral head and the associated RC attachments migrating proximally and becoming impinged on the undersurface of the acromion and the coracoacromial ligament.

S/S: discomfort or mild pain deep within the shoulder, pain with overhead activities, painful arc of motion (70-120° abduction), positive impingement sign, tenderness over the greater tuberosity and the bicipital groove.

Tx: initially RICE, NSAIDs, and activity modification. Once tolerated, treatment includes RC strengthening and scapular stability exercises. Long-term prevention includes continued strengthening of the RC and scapular stabilizers, along with improved biomechanics related to sport-specific or relevant work activities.

Question 9

Juvenile RA

Answer 9

the most common chronix rheumatic disease in children and presents with inflammation of the joints and CT. Classification of JRA includes systemic, polyarticular, and oligoarticular.

Etiology: exact etiology is unknown, however, it is theorized that an external source such as a virus, infection, or trauma may trigger an autoimmune response producing JRA in a child with a genetic predisposition.

S/S: Systemic JRA occurs in 10-20% of cases and presents with acute onset, high fevers, rash, enlargement of the spleen and liver, and inflammation of the lungs and heart. Polyarticular JRA accounts for 30-40% of cases and presents with high female incidence, significant rheumatoid factor, and arthritis in more than four joints with symmetrical joint involvement. Oliogoarticular (pauciarticular) JRA accounts for 40-60% of cases and affects less than 5 joints with asymmetcial joint involvement.

Tx: pharmacological management to relieve inflammation and pain through NSAIDs, corticosteroids, antirheumatics, and immunosuppresive agents. PT management includes passive and active ROM, positioning, strengthening, splinting, endurance training, WB activities, postural training, and functional mobility. Pain management using paraffin, US, warm water, and cryotherapy. Surgical intervention may be indicated secondary to pain, contractures or irreversible joint damage.

Question 10

Lateral Epicondylitits

Answer 10

irritation or inflammation of the common extensor muscles. Throwing sports commonly involved.

Etiology: condition is caused by eccentric loading of the wrist extensors resulting in microtrauma. Can be caused by a tennis raquet with strings too tight or a handle too small. Common among individuals age 30-50 y/o

S/S: pain present immediately anterior or distal to the lateral epicondyle of the humerus. Pain worsens with reps and wrist /

Tx: initially RICE, NSAIDs, and activity modifications. PT should attempt to increase strength, flexibility, and endurance of the wrist extensors. A step placed 2 to 3 inches distal to the elbow joint can reduce muscular tension placed on the epicondyle.

Question 11

Legg-Calve-Perthes disease

Answer 11

characterized by degeneration of the femoral head due to disturbance in the blood supply (avascular necrosis). Disease is self limiting, and has 4 stages: condensation, fragmentation, re-ossification, and remodeling

Etiology: trauma, genetic predisposition, synovitis (inflammation of the synovial membrane), vascular abnormalities, infection

S/S: pain, decreased ROM, antalgic gait, positive Trendelenburg

Tx: Primary focus is to relieve pain, maintain the femoral head in the proper position, and improve ROM. PT may be required intermittently for stretching, splinting, crutch training, aquatic therapy, traction, and exercise. Orthotic devices and surgical intervention may be indicated.

Question 12

Medial collateral ligament sprain (MCL)

Answer 12

runs from slightly above the medial femoral epicondyle to the medial aspect of the shaft of the tibia. An MCL sprain often involves injury to the other knee structures such as the ACL or medial meniscus.

Etiology: contact or noncontact, fixed foot, tibial roational injury associated with a valgus force and external tibia rotation can damage the MCL. This injury is often associated with activities such as football, skiing, and soccer.

S/S: knee pain, swelling, antalgic gait, decreased ROM, feeling of instability. Valgus stress test can be used to assess the integrity of the MCL.

Tx: initially RICE, NSAIDs, and analgesics as needed. Conservative treatment includes decreasing inflammation, protecting the knee joint and ligament, and strengthening exercises as tolerated. Strengthening exercises gradually become more aggressive. Surgery is rarely necessary since the MCL is well vascularized.

Question 13

Meniscus tear

Answer 13

medial and lateral menisci are attached to the proximal surface of the tibia. Menisci are thick at periphery and thinner at their internal unattached edges. Medial menisus more commonly injured than the lateral because it is less mobile due to its attachment to the joint capsule. Medial meniscus tears increases with ACL deficiency. Definitively diagnosed by MRI or arthroscopy.

Etiology: usually associated with fixed foot rotation while WB on a flexed knee (compresses and twists)

S/S: joint line pain, swelling, catching or locking, special tests include Apley’s compression test, bounce home test, and McMurray test.

Tx: initially RICE, NSAIDs, and analgesics as needed. Palliative modalities and strengthening exercises. Surgery ranging from a partial menisectomy to a meniscal repair often warranted for active individuals. Meniscal tears are usually performed on tears on the outer edges of the meniscus due to the increased vascularity.

Question 14

Osgood-Schlatter disease

Answer 14

known as traction apophysitis is a self-limiting condition that results from repetitive traction on the tibial tuberosity apophysis.

Etiology: condition is caused by repetitive tension to the patellar tendon over the tibial tuberosity in young athletes. Can result in a small avulsion of the tuberosity and subsequent swelling.

S/S: point tenderness over the patella tendon at the insertion on the tibial tubrecle, antalgic gait, pain with increasing activity.

Tx: focused on education, icing, flexibility, and eliminating activities that place strain on the patella tendon such as squatting, running, or jumping.

Question 15

OA

Answer 15

chronic disease that causes degeneration of the articular cartilage, primarily in WB joints. Any joint may be involved, however, the most commonly affected sites include the hands and WB joints such as the hips and knees.

Etiology: cause is unknown. Typically appears during middle age and affects nearly all individuals to some extent by age 70. OA is more common in men up to age 55, but then it is more common in women. Risk factors include obesity, fx, or other joint injuries, and occupational overuse.

S/S: gradual onset of pain, increased pain after exercise, increased pain with weather changes, enlarged joints, crepitus, stiffness, limited joint ROM, Herberden’s nodes and Bouchard’s nodes. Blood test are not helpful in diagnosing OA, although radiographs may show diminished joint space or spurs.

Tx: goal is to decrease pain, promote joint function, and protect the joint. Acetominophen, NSAIDs, and corticosteroids. Viscosupplementation through a series of injections of hyaluronic acid into the knee with the goal to improve lubrication, reduce pain, and increase ROM. PT tx includes PROM and AROM, heating and cooling, pt ed, exercises, TENS, energy con, weight loss, body mechanics, joint protection, and bracing.

Question 16

Osteogenesis imperfecta

Answer 16

a CT disorder that affects the formation of collagen during bone development. There are 4 classifications of osteogenesis imperfecta that vary in severity.

Etiology: genetic inheritance

S/S: pathological fractures, osteoporosis, hypermobile joints, bowing of the long bones, weakness, scoliosis, impaired respiratory function

Tx: caregiver ed on proper handling and facilitation of movement. PT focus on AROM emphasizing symmetrical movements, positioning, functional mobility, fx management, and the use of orthotics.

Question 17

Patellofemoral Syndrome

Answer 17

general term describing pain or discomfort in the anterior knee. Condition often termed chondromalacia pain patella, which refers to softening of the articular cartilage of the patella.

Etiology: repetitive overuse disorder resulting from increased force at the patellafemoral joint. Factors associated with increased patellofemoral forces include decreased quad strength, decreased LE flexibility, patellar instability, increased tibial torsion or femoral anteversion. Factors that increase risk: females, individuals experiencing a growth spurt, runners who increased their mileage, and overweight individuals.

S/S: anterior knee pain, pain with prolonged sitting, swelling, crepitus, pain with stairs.

Tx: depends on the suspected cause. Possible options include: palliative modalities, LE flexibility exercises, medial patella glides, biofeedback, and patella taping, LE strengthening should emphasize the quads and in particular the vastus medialis oblique, while minimizing patellar compressive forces.

Question 18

Plantar Fasciitis

Answer 18

inflammation of the plantar fascia. Fascia is designed to provide support to the arch.

Etiology: often associated with acute injury from excessive loading of the foot or chronic irritation from an excessive amount of pronation. age 40-60 y/o

S/S: tenderness as the insertion of the plantar fascia, presence of a heel spur, pain is worse in the morning or after periods of prolonged inactivity, difficulty with prolonged standing, pain when walking in bare feet.

Tx: initially RICE, NSAIDs, and analgesics. A heel cup, massage using a tennis ball, medial longitudinal arch taping, and joint mobes may be helpful. Prevention includes heel cord stretching, soft-soled footwear, and avoiding sudden changes in the intensity of training. Orthotics to minimize hyperpronation.

Question 19

Posterior cruciate ligament (PCL)

Answer 19

runs from the posterior intercondylar area of the tibia to the lateral aspect of the medial femoral condyle in the intercondylar notch.

Etiology: most common cause of injury is landing on the tibia with a flexed knee or hitting a dashboard in a MVA with a flexed knee. Isolated PCL tears are not common and usually occur with ACL, MCL, LCL, and/or menisci tears.

S/S: pt report feeling femur is sliding off the tibia. Swelling and mild pain may be present, but often the pt is asymptomatic. Special test: Posterior drawer test, and posterior sag sign

Tx: initially RICE, NSAIDs, and analgesics as needed. PT tx includes LE strengthening and functional progression. Surgical tx can occur, however, the procedure is not as evolved as the procedure for the ACL. If surgery is performed isolated HS exercises are often AVOIDED for a min of 6 weeks.

Question 20

RA

Answer 20

systemic autoimmune disorder of unknown etiology. Chronic inflammatory reaction of the synovial tissues of a joint that results in erosion of cartilage and supporting structures within the capsule. Onset may initially occur at any joint , but it is common in the small joints of the hands, feet, wrists, and ankles. Periods of exacerbation and remission. RA dx based on clinical presentation, the presence of blood rheumatoid factor, and radiographic changes.

Etiology: unknown cause. 1 to 2% of US pop affected. Women affected 3 times more and the most common age of onset falls between 40-60 y/o.

S/S: onset may be gradual or immediate, symmetrical involvement, pain and tenderness of affected joint morning stiffness, warm joints, decrease in appetite, malaise, increased fatigue, swan neck deformity ( DIP flexion, PIP hyperextension), boutonniere deformity (DIP extension and PIP flexion), low grade fever

Tx: goal is to reduce inflammation and pain, promote joint function, and prevent joint destruction and deformity. NSAIDS may be used and corticosteroids may be used in acute flares or when NSAIDs aren’t working. Disease modifying antirheumatic meds (DMARs) are slow acting and take weeks or months to become effective, however, they have the ability to slow the progression of joint destruction and deformity. PT interventions include PROM, AROM, heating and cooling, splinting, pt ed, energy con, body mechanics, and joint protection techniques.

Question 21

RC tear

Answer 21

RC can be torn due to an acute traumatic incident or as a result of chronic degenerative pathology. Patients 50 y/o and up are particularly susceptible. RC tears are classified as partial or full thickness.

Etiology: intrinsic factors associated with RC tear include impaired blood supply to the tendon, resulting in degeneration. Extrinsic factors include trauma, repetitive microtrauma, and postural abnormalities.

S/S: arm positioned in IR and adduction, point tenderness at the greater tubercle and acromion, marked limitation in shoulder flexion and abduction, with upper trap recruitment evident, increased tone in anterior shoulder structures.

Tx: RICE, NSAIDs and analgesics. Primary focus of therapy is to prevent adhesive capsulitis and strengthen upper extremity musculature. Following surgery the pt will be immobilized in a sling, amount of time depends on size of the tear and surgery, large tear is usually 4 to 6 weeks of immobilization. PT begins with PROM and gradually moves to AAROM. Active motion and isometrics begin once approved by the surgeon. Return to functional activities requiring dynamic overhead movements occurs in 9-12 months.

Question 22

Scoliosis

Answer 22

lateral curvature of the spine. Condition is most often quantified using the Cobb method with a standing radiograph. Scoliosis is often classified as functional, neuromuscular, or degenerative. Functional scoliosis results from abnormalities in the body that indirectly impac the spine (leg length discrepancy, muscle imbalance, poor posture). This type of scoliosis is often referred to as nonstructural scoliosis since the curves are flexible and can be corrected with lateral bending. Neuromuscular scoliosis results from developmental pathology resulting in alterations in spinal structure. Often seen in pts with CP or marfan syndrome. Degenerative scoliosis occurs due to the normal aging process and is facilitated by changes such as osteophyte formation, bone demineralization, and disk herniation. Neuromuscular and degenerative scoliosis are considered to be forms of structural scoliosis since the curves are inflexible.

Etiology: typically idiopathic. Commonly diagnosed between 10 and 13 y/o. Girls and boys have similar risk of developing a mild curve (10° or less), however, girls have significantly greater risk of developing a curve greater than 30°.

S/S: shoulder level asymmetry with or without the presence of a rib hump. pain isn’t associated with the curve itself but can occur as a result of abnormal forces placed on surrounding tissues.

Tx: based on magnitude of curve and degree of progression. If the curve is not progressing generally no formal action is taken. PT tx includes muscle strengthening and flexibility exercises, shoe lifts and bracing. A spinal orthosis is often warranted with a curve that ranges between 25 and 40°. Surgical interventin may be warranted for curves greater than 40°.

Question 23

Talipes Equinovarus

Answer 23

also known as clubfoot. Deformity characterized by the heel pointing downward and the forefoot turning inward.

Etiology: cause is unknown, theories include familial tendency, positing in utero or ovum defect. Condition accompanies other deformities such as spina bifida and arthrogyposis (congenital joint contracture in 2 or more joints).

S/S: adduction of the forefoot, varus positioning of the hindfoot, and equinus in the ankle

Tx: splinting and serial casting shortly after birth. Goal is to restore proper positioning of the ankle and foot.

Question 24

total hip arthroplasty

Answer 24

cemented = immediate WB, non-cemented may = PWB or NWB at first

Etiology: common pathologies include OA, RA, osteomyelitis, and avascular necrosis.

S/S: prior to surgery there is severe pain with WB, instability or ROM limitation.

Tx: initially PT focuses on decreasing inflammation and allowing tissues to heal, adherence to hip precautions minimizing atrophy, and regaining full PROM.

Question 25

Anterolateral approach

Answer 25

access through interval between TFL and glute med.

Precautions: avoid flexion greater than 90°, ER, adduction, and extension

Question 26

Direct lateral approach

Answer 26

this approach leaves the posterior portion of the glute med attached to the greater troch. It requires longitudinal division of the TFL and the vastus lateralis, along with a release of the anterior portion of the glute med. Since the posterior soft tissues and capsule are left intact, the approach minimizes the probability of dislocation and may be ideal for noncompliant pts.
Hip precautions: avoid flexion greater than 90°, extension, ER, and adduction

Question 27

Posterolateral

Answer 27

splitting the glute max . The short ERs are released and the hip abd are retracted anteriorly. Maintains the integrity of the glute med and vastus lateralis. Most commonly used procedure but with a high post-surgical dislocation rate.
Precautions: avoid hip flexion greater than 90°, IR, and adduction

Question 28

TKR

Answer 28

Etiology: common associated conditions include OA and osteomyelitis
Tx: initially decrease inflammation and allow tissues to heal. Knee flexion requires a min of 90° for ADLs and 105° to rise comfortably from sitting.

Question 29

Laminectomy

Answer 29

usually performed in the presence of a disk protrusion or spinal stenosis. A complete laminectomy involves removal of the entire lamina, the SP, and the associated ligamentum flavum. A partial laminectomy involves the removal of only one lamina. In cases where a complete laminectomy is performed the vertebral segment will be much less stable than when a partial laminectomy is performed.

Rehab: likely restrictions on how much weight can be lifted post surgery. May also be restrictions on AROM especially extension. PTA should emphasize proper body mechanics and posture.

Question 30

Spinal fusion

Answer 30

surgical considerations: indicated in the presence of axial pain with unstable spinal segments, advanced arthritis, or uncontrolled peripheral pain. Bone is harvested from the patient’s body and used to fuse two vertebrae together. Because a fusion creates immobility at one spinal segment, it can inherently lead to hypermobility at adjacent segments, which can hasten degeneration.

Rehab considerations: may be restrictions on AROM espec bending and twisting. Early therapy included bed mob and transfers. Bracing may be used to help pts comply with movement precautions (more likely to be used when the surgeon did not use instrumentation for stabilization). Formal outpatient therapy does not usually occur until approximately 6 weeks after surgery. If instrumentation is used therapy will usually begin sooner and be more aggressive. Emphasis should be placed on proper body mechanics and posture, as well as core stabilization.

Question 31

Total shoulder arthroplasty

Answer 31

Surgical considerations: replaces both the glenoid and the humeral head. (shoulder hemiarthroplasty replaces only one component). All surgeries (including rTSA) involve an anterior surgical approach in which the suscapularis is detached.

Rehab considerations: pt will be immobilized in a sling for several weeks. Protocols vary widely but there will likely be some movement precautions for a period of time (6 to 8 weeks).

Question 32

Subacromial depression

Answer 32

surgical considerations: surgery performed when cases of shoulder impingement have not responded to conservative treatment. The approach can be open (deltoid is detached) or mini-open (deltoid is split), or arthroscopic. Procedure could involve acromioplasty, bursectomy, removal of distal clavicle, and release of the coracoacromial ligament

Rehab considerations: A sling will only be used for 1 to 2 weeks since no repair has been performed. Early treatment focuses on pain control and gentle ROM, with strength training beginning later. If a deltoid repair was performed, passive extension is avoided initially to prevent stress on the repair site. Tx should focus on interventions to reduce the occurrence of impingement (posture, strengthening scapular upward rotators). Full recovery is expected.

Question 33

RC repair

Answer 33

Surgical considerations: graded according to depth (partial vs full) and according to width. Small partial-thickness tears may only require debridement; all others likely require a repair. surgery usually arthroscopic, but may need open or mini-open approach.

Rehab considerations: pt will be immobilized in a sling for several weeks, and the sling may have an abduction pillow attached to it. Therapy usually includes PROM and AAROM initially then progresses to strengthening. Precautions usually no AROM, lifting, or WB through the arm for several weeks. Depending on which muscle is repaired, there may be ROM precautions, if deltoid repair was performed , passive extension is avoided initially to prevent stress on the repair site.

Question 34

Shoulder stabilization surgeries

Answer 34

Surgical considerations: capsular shift procedure is performed in the presence of chronic shoulder instability. The process involves tightening the joint capsule by cutting the capsule and overlapping the ends to reduce capsular redundancy. There is also an electrothermally assisted capsular shift procedure in which thermal energy is used to shrink and tighten the capsule. The portion of the capsule tightened depends on the direction of instability. Labral repair may also be performed since labral tears often accompany dislocation. A Bankart repair involves a repair of the anterior labrum. A SLAP repair involves a repair of the superior labrum. These procedures are often performed arthroscopically, though can also be done as an open procedure. If the procedure is open then the subscap may need to be detached.

Rehab considerations: If the anterior capsule was affected then the pt will usually utilize a normal sling. They should avoid positions of ER, extension, and hor abd. They should also avoid resisted IR if the subscap was detached during surgery. If the posterior capsule was affected the patient would be immobilized in the “hand shake” position with the shoulder in neutral rotation. The pt should avoid positions of IR, flexion, and hor add. AROM can begin soon after surgery. Therapists should not wait for full ROM before beginning strengthening exercises and should not be overly aggressive in getting full motion early. If a SLAP repair has been performed, the pt should avoid contracting or stretching the biceps since the biceps is attached to the superior labrum.

Question 35

Hip ORIF

Answer 35

Surgical considerations: proximal hip fx commonly occur in the femoral neck of in the intertrochanteric region. Femoral neck fx are intracapsular and may lead to a disruption of the blood supply. Because of this nonunion and ostronecrosis are more common with these fractures. Intertrochanteric hip fx are extracapsular and therefore foes not affect the blood supply. Fixation usually occurs with the use of plates and screws or an intramedullary nail. For older pts THA is often considered. The surgery is always an open procedure. Depending on the approach, the TFL, glute med, and vastus lateralis may be affected.

Rehab considerations: new surgical advances now allow for early WB, though WB restrictionswill be based on age, location of fx, and bone quality. Early rehab consists of ambulation and ROM. Isotonic strengthening is usually postponed until the muscles have been given a chance to heal.
SIGNS OF FIXATION FAILURE: persistent thigh or groin pain , a leg length discrepancy that was not present initially, positioning the limb in ER, or a Trendelenburg sign that does not improve with strengthening.

Question 36

Surgeries to fix focal cartilage defects.

Answer 36

Osteochondral autograft transplantation is a procedure in which cartilage is harvested from several NWB surfaces to form a plug that can fill the chondral defect. Autologous chondrocyte implantation is a procedure in which healthy cartilage is harvested and cultured so it will grow , then later implanted into the cartilage defect.

Rehab considerations: likely WB restrictions. Dependent upon the size and location of the lesion. Adherence to WB precautions is critical. Pt will often be in a brace that is initially locked into extension. ROM progression will also vary depending on the size and location of the lesion. In general, larger lesions require a slower progression.

Question 37

ACL reconstruction

Answer 37

Surgical considerations: generally perfomed arthroscopically. Use of an autograft is preferred over an allograft. A bone-patellar tendon-bone graft is considered the gold standard. Because it uses bone-to-bone healing. Use of the gracilis and/or semitendinosus is also common, however, the fixation is not as strong since it uses tendon-to bone healing

Rehab considerations: protocols vary widely, but there is generally some period of immobilization with a hinge brace (initially locked in extension) in addition to WB precautions. The brace is unlocked when the pt demos good quad control. ROM interventions should place an emphasis on achieving full knee extension early. Strengthening exercises can occur soon after surgery and typically includes isometric quad strengthening, HS strengthening, and closed-chain exercises. Open-chain exercises between 0-45° of flexion should be avoided since they place excess stress on the graft site. Patients receiving a bone-patellar tendon-bone graft may experience anterior knee pain and should be cautious with quad strengthening. Likewise, those receiving a HS graft should be cautious with flexion. Graft tissue is most vulnerable 6-8 weeks after surgery. As the tendon transforms into ligamentous tissue, it actually becomes weaker before it gets stronger. Failure generally happens around that time secondary to poor compliance. Graft maturation has been shown to be at 100% around 12 to 16 months post-op, however, most protocols allow return to sports at around 6 months. Criteria to return to sport include: no pain or effusion, full ROM, no instability, quad strength 85-90% of the opposite leg, HS strength that is 90-100% of the opposite leg, and functional test (single leg hop) that is 85-90% of the opposite leg.

Question 38

PCL reconstruction

Answer 38

Surgical: injuries to PCL are much less common than ACL. If PCL injury occurs in isolation, surgery may not be needed. Surgery is indicated if pain and/or instability do not improve with therapy.

Rehab: in general same protocol as ACL. However, progression with WB and with exercise tends to be more gradual. Therapist should choose exercises that will limit posterior sheer forces within the knee. Repetitive knee flexion should also be avoided.

Question 39

Surgeries for meniscal injuries

Answer 39

surgical considerations: generally performed arthroscopically. Can be dealt with in two ways, either partial menisectomy in which the torn piece of meniscus is removed, usually used for older individuals when the tear occurs in the inner two-thirds of the meniscus where the healing capacity is poor, or repair of the meniscus in which the tear is sutured, this option is more likely to be chosen in younger patients or when the tear is in the outer third of the meniscus.

Question 40

Surgeries for meniscal injuries

Answer 40

surgical considerations: generally performed arthroscopically. Can be dealt with in two ways, either partial menisectomy in which the torn piece of meniscus is removed, usually used for older individuals when the tear occurs in the inner two-thirds of the meniscus where the healing capacity is poor, or repair of the meniscus in which the tear is sutured, this option is more likely to be chosen in younger patients or when the tear is in the outer third of the meniscus.

Rehab: depends on whether or not the meniscus was repaired. Following a meniscus repair, there will likely be WB restrictions in addition to bracing. There will also likely be limitations on ROM , specifically with flexion. Following a partial menisectomy, the pt is full WB without the use of a brace. There are no rehab restrictions and recovery time is significantly quicker.

Question 41

Lateral ankle reconstruction

Answer 41

surgical considerations: commonly performed secondary to a complete tear of the anterior talofibular ligament or calcaneofibular ligament or secondary to chronic ankle instability. There are two methods and both are open. The first method involves repair of the torn ligaments in which they are sutured back together. The second method involves harvesting of an autograft (usually the peroneus brevis) to replace the torn ligaments. The second option is usually performed when the original ligaments cannot be repaired due to deterioration. The surgery may also include arthroscopy or subchondrol drilling since a high percentage of unstable ankles have chondral lesions within the joint.

Rehab: protective cast often used for a short period of time (one week) , then they are placed in a walking boot for several weeks, followed by a brace. Initially the pt is NWB while in the protective cast , which is progressed to PWB and FWB once in the walking boot. Easly rehab focuses on increasing the pt’s ROM while still protecting the tissues. Caution should be taken while ranging the ankle into inversion since this will stress the repaired tissues. Bracing may be required long term if the pt plans to return to sports or higher level activities.

Question 42

Achilles tendon repair

Answer 42

surgical considerations: surgery is performed on active patients. Generally arthroscopic, with the torn tendon being sutured back together. Augmentation with the use of a graft (flexor hallucis longus, peroneus brevis, plantaris) may be needed for the repair instead of suturing together the original tendon.

Rehab: pt will likely be casted with the ankle in slight PF. additionally the pt will be NWb for the first several weeks. Eventually pt placed in a cast with neutral ankle position, and allowed PWB. Recent push for immediate PWB and neutral cast due to studies saying this leads to better outcomes. During the healing process caution should be taken with exercises that stretch the achilles or require active PF.