Optimising Function - MSK Flashcards
What are some lower limb red flags?
Sudden onset without obvious cause
Night pain
History of malignancy
Unplanned/unexpected weight loss
Night sweats
Appetite loss
Malaise
Fever without cause
Inability to weight bear
Fractures/Acute trauma
Dislocation/Tendon ruptures
Pins and needles/Altered sensation (Cauda Equina)
DVT (Wells Score)
Infection
What are the key myotomes for the lower limb?
L2 Hip flexion
L3 Knee extension
L4 Ankle dorsiflexion
L5 Big toe extension
S1 Ankle plantarflexion
S2 Knee flexion
Reflexes: L2/3/4 for patella and S1 for Achilles
What is the slump test?
Once in a slumped position, actively extend leg and complete extension passively
Positive only if pain shoots beyond the knee
Tightness behind the knee is normal
If severe or back pain increases, muscular de-conditioning is likely
When the knee is extended, flexion at the neck exacerbates sciatic pain, while extension relieves it
What are the warning symptoms for cauda equina?
Loss of feeling/pins and needles between inner thighs or genitals
Numbness in or around back passage and buttocks
Altered feeling when using toilet paper to wipe
Increased difficulty when trying to urinate
Increasing difficulty in controlling urine flow
Leaking urine
Not knowing when your bladder is full or empty
Inability to stop bowel movement
Loss of sensation when bowels open
Loss or change in sensation during sex
Change in ability to achieve an erection or ejaculation
What are the warning symptoms for cauda equina?
Loss of feeling/pins and needles between inner thighs or genitals
Numbness in or around back passage and buttocks
Altered feeling when using toilet paper to wipe
Increased difficulty when trying to urinate
Increasing difficulty in controlling urine flow
Leaking urine
Not knowing when your bladder is full or empty
Inability to stop bowel movement
Loss of sensation when bowels open
Loss or change in sensation during sex
Change in ability to achieve an erection or ejaculation
What is lateral hip pain - Greater Trochanteric Pain Syndome 0 GTPS?
Overuse/mechanical overload due to bursitis often caused by tendonopathy of the glute med/min
Presentation: lateral hip pain, tender on palpation, specifically near the greater trochanter . Pain on resisted abduction.
Aggregating: prolonged sitting, climbing stairs, lying on affected side, high impact activity, crossed leg sitting, pain on non painful side of leg falls into adduction
Gluteal tendonopathy is the main cause of pain and leads to inflammation at the bursa
Diagnosis: FADER, OBER and FABER, trendelburg sign, Single leg stand 30s produces pain
Management:
Strengthening of weak hip abductors
Education
Local corticosteroid injection
Medication
Weight reduction
Surgery only if the management has failed
What is a hip flexor tendonopathy?
Pain usually come on with increase in load/training regime
Microtrauma caused to the associated tendon due to chronic overuse or injury.
Presentation: increasing pain at the site of the affected tendon. Reduced function/range of motion usually into hip extension and decreased exercise tolerance. Often localised pain - severe or sharp but can become dull. Intermittent groin pain described as a deep ache
Usually pain is load dependant/worsens with activity. Symptoms often worse with kicking or deep hip flexion. Can lead onto hip bursitis.
Diagnosis: increase tenderness with deep palpation of iliopsoas muscle - particularly around the insertion onto the lesser trochanter . Passive hip extension pain. Active/resisted hip flexion is painful. Thomas Test.
Management: eccentric exercises to promote collagen fibre cross-link formation and tendon remodelling/repair . Isometric exercises for pain modulation. Corticosteroid injections only for short term outcome/pain management.
Discuss hip fractures? Neck of femur (NOF) fracture.
Onset: usually trauma - fall
Eitiology: classed as an intrascapular fracture. Can have extracapular too (outside of capsule so better outcomes as less affects blood supply)
Presentation: dull ache in groin or hip. External rotation of affected leg. Stiffness, bruising and swelling around the affected leg. Shortening of affected leg. Inability to weight bear.
Diagnosis: history, physical exam, X0ray/MRI/CT.
Management: surgery, weight bearing/walking on the day after surgery. Regular PT review (daily), rehab (strength, balance, ROM).
Discuss knee osteoarthritis.
Usually chronic/long term (gradual onset)
Eitiology: change in shape/structure of the joint. Cartilage thins and becomes rougher. Not all patients with OA are symptomatic.
Presentations: pain and stiffness within the joint. Morning stiffness lasts less than 30 minutes. Swelling. Pain with prolonged sitting/resting. Pain when going down the stairs/walking. Knee can lock or give way. Loss of ROM.
Features: Bakers cyst (fluid filled swelling - small tear in the joint capsule)
Diagnosis: X ray and blood tests. Pain on joint line and palpation. Joint enlargement/swelling. Grade 0-4.
Management: exercises. Education, weight loss, steroid injections, NSAIDs, analgesia, surgical intervention.
Discuss ligamentous injuries/meiscus tears
Onset - trauma, twisting. Usually after cutting manoeuvres/ SLS or jump and land
Eitiology - ACL stops anterior translation of the tibia over the femur
Presentation: audible crack/pop. Initially feeling of instability. Episodes of giving way. Extreme pain (ititially). Reduced ROM (extension). Muscle weakness.
Diagnosis: MRI, Anterior Draw/Lachman test/Pivot Shift, Subjective history
Management: Conservative vs surgical, strength and conditioning, ROM, advice and education
Discuss anterior knee pain/patella tendinopathy/ Recurrent patella dislocations (patella alta).
Gradual or acute onset
Presentations: varying array of symptoms, crepitus, pain, instability, worsens with stairs, squatting, running
Diagnosis: subjective and objective (rarely pain at rest). Instant pain with loading. Dose dependant pain (load/range).
Management: strengthening program. ISOMETRIC then ECCENTRIC then CONCENTRIC. Not NSAIDs as negative effect on soft tissue healing.
Patella alta is a high riding patella.
Discuss stress fractures of the ankle
Usually due to repetitive loading such as running and marching or a sudden change in activity demands
Due to an imbalance of bone remodelling. Fatigue vs insufficiency. Stress reaction and fracture.
Presentation: pain tends to develop and worsen over weeks. Localised pain and tenderness. Worse on weight bearing. Swelling and present.
Other features: vitamin D deficiency, diet and recovery.
Diagnosis: MRI - acute. Bone scan - X-ray secondary
Management:
Initial phase of off loading (6/52)
Maintain fitness (cross training)
Pacing and strengthening
Discuss plantar fascia patchy/plantar heel pain
Can present as an overuse injury due to micro tears (runners)
Primarily a degenerative process, micro tears, chronic degermation of the fascia
Presentation: sharp localised heel pain that worsens with load/weight bearing. Initial pain on loading and then eases. Pain reduces with moderate activity but then worsens later in the day due to prolonged activity. At its worst pain can present at night and rest.
Diagnosis: tenderness around the plantar feel area (sometimes around the medial calcaneal tuberosity). Reduced dorsiflexion. Subjective history (antalgic gait). Positive windlass test.
Management: ice massage/elevation. Cushioned shoes/Arch support. Stretching. Analgesia. Weight loss. Cross training/load management.
Discuss Achilles tendonopathy
Gradual onset. Repetitive stress/loading. Weakened/deconditioned tendon
Eitiology: repetitive micro trauma active — inflammatory
Tendon disrepair if not offloaded and allowed to recover
Degenerative tendinopathy — poor prognosis
Presentations: pain in the back of heel
Warmth and tenderness along TA. Swollen and thickened TA. Clicking/rubbing of tendon on movement. Morning pain - stretch through range.
Diagnosis: rupture - Thompson test. TA tears grades 1-3.
Management: supportive helped shoes/heel lift. Pacing. Strengthening. Pain activity ladder.
Discuss ankle sprains
Onset: inversion (lateral) sprain. Rapid shift in center of mass - ankle goes out forth goes in
Ethology - healing process - 3 phases: inflammatory, proliferation, remodelling
Presentation - pain of WBing. Tenderness over palpation of joint/ligaments. Bruising/swelling. Limited ROM/instability.
Diagnosis - grading 1-3. Anterior draw, posterior draw and Tatar tilt special tests
Management: decrease pain and swelling (analgesia/PRICE). Strengthening/ROM. PEACE and LOVE.
What are some common ligaments on the lateral aspect of the ankle?
Posterior talofibular ligament
Anterior talfibular ligament
Calcaneofibular ligament
Discuss the stages of a hip assessment
Objective assessment
Postural exam, hip height
Back extension, flexion, lateral flexion
PROM and ACROM Knee flexion
PROM and AROM External and internal rotation of hip, over pressure
PROM and AROM Abduction and abduction, over pressure
Strength for knee flexion, abduction, internal and external rotation
Palpate in and around the hips
Move patient onto front and then perform hip extension, apply over pressure. AROM and PROM.
Discuss a full assessment of the knee
Observation
Palpation of the knee In extension and flexion
Knee flex, extension - and hip, with int and external rotation
Anterior draw for ACL
Test for MCL and LCL
Knee strength
Discuss the steps of an ankle assessment
Observation
Palpate the ankle, and up the calves too - with bent and straight leg
Toe extension and flexion, over pressure
Internal rotation, over pressure
External rotation, over pressure
Strength for these movements
What is the anterior draw test of the ankle?
Detect laxity for anterior talo-crural joint laxity after inversion trauma
Knee joint slightly flexed in supine
Fixate tibia and draw the food anteriorly under the ankle
Or slightly flexed foot and fixate. Push tibia posteriorly.
Describe the Talar tilt test
To assess integrity of anterior and posterior talo fibulae ligament, calcaneofibular ligament and deltoid ligaments
Sitting, knee off the table
Foot into plantar flexion
Grab calcaneous and perform inversion
To test calcaneo-fibular ligament, bring foot into anatomical position, then bring foot into inversion and eversion (stresses deltoid ligament)
To stress posterior talo-fibular ligament bring foot into dorsiflexion and perform the same movement again.
What is the Thompson squeeze test?
For achillies tendon rupture
Prone, feels off of the bed
Squeeze the calf and observe plantar flexion at the ankle
Discuss Tinel’s Sign for ankles?
For peripheral nerve injury
Tap anterior to medial malleolus
Tap behind the medial melleleous
Tingling and parenthesis felt dismally is a positive sign
Describe the management for osteoarthritis
Exercise - therapeutic exercise. Advise that it may initially cause pain but long term adherence will benefit the joints, reduce pain and improve function
Weight management - improve function and decrease pain
Information and support
Only consider manual therapy for hip and knee, alongside therapeutic exercise.
Do not offer: acupuncture, dry needling, electrotherapy, treatments, insoles, braces, tape, splints or supports routinely.
What are the Ottawa ankle rules?
Ankle:
X-ray only required if:
- bone tenderness at Posterior edge or top of lateral melleolus
OR
- bone tenderness at posterior edge or tip of medial malleolus
OR
- inability to weight bear both immediately and in ED (4 steps)
Foot:
X-ray only required if:
- bone tenderness at base of 5th metatarsal
OR
- bone tenderness at navicular
OR
- inability to weight bear both immediately and in ED (4 steps)
What is the McMurrays test?
Physical exam to help diagnose a torn meniscus
Patient lies on their back with knee and hip fully bent
Practitioner rotates the patients leg whilst extending the knee. Positive test indicated by a thud or click.
What is the anterior draw test for the knee?
Assesses the stability of the knee’s anterior cruciate ligament (ACL).
Patient supine and bends knee to 90 degrees.
Practitioner sits on the patients foot
Practitioner wraps their hands around the back of the patients knee, places their thumbs on the front of the kneecap, and pulls the knee forward.
Practitioner rotates the patients foot to a different direction and pulls forward again.
What is the posterior draw test for the knee?
Assess for posterior cruciate ligament tears
Supine. Practitioner applies a force in the posterior direction to the proximal tibia.
Looks similar to anterior (force in the opposite direction).
What is the thesseleys test for the knee?
Can help to diagnose a torn meniscus in the knee.
Patient stands on one leg with their foot flat on the ground. Examiner supports them. The patient then rotates their knee and body internally and externally three times.
Positive test result is indicated by pain or a feeling of catching or locking in the knee, or a popping sound.
What is the Thompson test for the ankle?
Physical exam to help diagnose an Achilles tendon rupture
Calf squeeze test
What is the syndesmosis test?
A physical exam that helps diagnose a syndesmosis sprain in the ankle.
The examiner squeezes the tibia and fibula together above the injury. Pain in the area of the distal tibia fibulas and interosseous ligaments indicates a positive test.
Test for high ankle sprain.
What is FABERS test?
Asseses pathologies at the hip
Flexion, abduction, external rotation
Test is positive if it reproduces the patients pain or limits their range of movement. Low back pain indicates SI joint pathology, while pain in the anterior groin indicates intraarticular hip pathology.
What is FARDIRS test?
For the hip. Helps diagnose hip joint issues, such as femoroacetabular impingement (FAI) or labral tears.
Flexion, abduction, internal rotation
Positive test is when the patient experiences pain in the groin or anterolateral hip during the test.
Describe the 5 tests for the sacroiliac joint?
Gaenslen - looks like Thomas test. Apply pressure to extended hip and flexed hip. Positive = reproduction of their symptoms
Thigh thrust - hip flexed and pressure down
Distraction - posterior directed force to both anterior superior iliac spines
Compression - patient in side, hip and knees flexed to approximately right angles. Apply force vertically downward on uppermost iliac crest.
Sacral thrust - force is vertically downward on center of sacrum
What are upper limb tension tests?
Used for suspected cervical radicular syndrome.
ULTT A: median nerve, anterior interosseous nerve, nerve roots C5-C7
- depress shoulder, laterally rotate shoulder, supinate forearm, extend fingers and extend elbow until symptoms provoked (can laterally flex neck to the opposite side too).
ULTT 2/B: stresses median nerve, ancillary nerve, musculocutaneous nerve
- depress shoulder, abduction arm to 10 degrees, flex elbow, extended fingers (same as above except elbow stays next to waist). To confirm findings, you can create slack by flexing elbow and laterally flex neck.
ULTT 3/C: stresses radial nerve. Depress shoulder, bring arm to 10 degrees of flexion, 10 degrees abduction, pronate forearm, flex fingers and the extend the elbow. Until symptoms are provoked.
ULTT4: stresses the ulnar nerve and nerve roots C8 - T1. Bring arm into 90 degrees of abduction, pronate forearm, extend fingers and go into lateral rotation, and bring fingers towards ear. Until symptoms provoked.
All considered positive if reproduce patient symptoms. Marked differences between each side.
What is the straight leg test?
Test for lumbar radicular syndrome
Hip flexion in supine whilst maintaining full knee extension
Positive test = shorting pain down the leg is reproduced, usually below 60 degrees.
Test places tension on the sciatic nerve.
What are whiplash associated disorders?
Rapid/excessive hyperflexion or hyperextension of the neck causing damage to spinal structures
Presentation: acute/sharp pain, excessive movement aggravating, ice/heat/.rest eases
Patients can be very protective and guarding. Severe causes may struggle with dizziness, double vision, loss of balance, and nausea.
Management:
Education/Reassurance. Exercises - ROM and/or strengthening (isometrics). Ice/heat. TENS. Manual therapy. CBT is appropriate.
What is cervical spondylosis?
Degenerative changes to the spinal structures (most typically the intervertebral discs and facet joints).
Presentations: dull, fairly constant spine. Aggravated by excessive movement.
Imaging is not neccessary.
More severe cases can progress to radiculopathy and/or myelopathy.
Management: education/reassurance. Exercises. Ice/heat. Manual therapy.
