Pathologies of MSK Flashcards
What can also help achilles tendonitis?
Iontophoresis with dexamethasone
heel lift
What should you avoid when treating achilles tendonitis?
complete rest
night splints
elastic taping
Shoulder mobility/stretching exercises are most effective when combined with what in frozen shoulder?
corticosteroid injection
Peak incidence of frozen shoulder is
40-60 y/o females with diabetes
When does frozen shoulder resolve on its own?
1-2 years
What is a unique way to know it is frozen shoulder?
capsular pattern of restriction
What should you avoid in frozen shoulder treatment?
overstretching
What is the surgical method for treating frozen shoulder?
suprascapular nerve block and closed manipulation
What grade is an ACL considered completely torn?
III
What are some signs that an ACL has torn?
loud pop or feeling like the knee is giving way or buckling followed by dizziness, sweating and sweling
When is surgery required for an ACL tear?
III tear
Types of reconstruction for ACL?
IT band, patellar tendon, hamstring tendon
When is congenital hip dysplasia developed?
last trimester in utero
What are some signs and symptoms of congenital hip dysplasia?
asymmetrical hip abd with tightness and apparent femoral shortening of the involved side.
Testing for congenital hip dysplasia?
ortolani’s or barlow’s tests
diagnostic US
Treatment for congenital hip dysplasia?
constant use of harness, bracing, splinting or traction. Open reduction with subsequent application of hip spica cast if conservative treatment fails. PT after cast removal for stretching, strengthening, and caregiver education.
Congenital limb deficiencies are classified as..
longitudinal or transverse
Longitudinal limb deficiency refers to
reduction or absence of an element or elements within long axis of bone
Transverse limb deficiency refers to
limb that has developed to a particular level beyond which no skeletal elements exist.
Treatment of congenital limb deficiencies
symmetrical movements
strengthening
ROM
WB
prosthetic training
Congenital torticollis is from contracture unilaterally from which muscle?
When is it identified?
SCM
first 2 months of life
Presentation of congenital torticollis?
lateral cervical flexion to the same side as contracture and rotation toward the opposite side
facial asymmetries
Treatment of congenital torticollis?
surgical management when conservative treatment has failed and child is over one year of age. surgical release followed by PT
Subluxation is when there is
more than 50% of the humeral head translating over the glenoid rim without dislocation
what percentage of dislocations detach the glenoid labrum aka Bankart lesion?
85
What causes GH instability?
forces stress the anterior capsule and it moves anteriorly out of the glenoid fossa
anterior is most common and assoc with abd and lateral rotation (ER)
Treatment for GH instability
sling for 3-6 weeks
strengthening IR, ER, scaps
Impingement syndrome in shoulder
repetitive microtrauma from UE above horizontal plane
Painful arc is
70-120 degrees abduction
Systemic JRA is
least common
high fevers, rash, enlargement of spleen and liver, inflammation of lungs and heart
Polyarticular JRA is
more common than systemic
high female incidence
significant RA factor
arthritis in 4+ joints with symmetrical joint involvement
Oligoarticular JRA is
most common
affects less than 5 joints with asymmetrical involvement
How to treat JRA
paraffin, US, warm water, cryotherapy, surgical intervention when indicated secondary to pain or if there are contractures
Lateral ankle sprain ligaments most frequently affected
anterior talofibular
calcaneofibular
How are lateral ankle sprains done?
inversion stress to ankle
What should you avoid in treating lateral ankle sprains?
US in acute ankle sprains
bracing/taping as a standalone treatment in chronic lateral ankle sprains
tennis elbow cause
eccentric loading of the wrist extensor muscles: extensor carpi radialis brevis
Most common ages for tennis elbow
30-50
Treatment for tennis elbow
strap placed two to three inches distal to elbow joint
Legg-Calve-Perthes disease is
degeneration of femoral head due to disturbance in blood supply (avascular necrosis)
Four stages of Legg-Calve-Perthes disease
condensation
fragmentation
re-ossification
remodeling
A sign of LCP
trendelenburg
Treatment of LCP
stretching, splinting, crutch training, aquatic therapy, traction and exercise. Orthotic devices and surgical intervention maybe
MCL sprain in knee is often associated with
ACL or medial meniscus
Is surgery required for MCL?
rarely since its well vascularized
Medial or lateral meniscus more common injury?
Why?
medial
less mobile due to attachment to joint capsule.
Medial meniscus injuries increase over time because
of ACL deficiency
Signs and symptoms
catching or locking sensation
Meniscal repairs are usually done
on the outer edges due to increased vascularity
Osgood-schlatter disease is aka
and it is..
traction apophysitis
repetitive traction on the tibial tuberosity apophysis
Osgood-schlatter disease results in
small avulsion of tuberosity and subsequent swelling
Signs and symptoms of osgood-schlatter disease
point tenderness over patella tendon and at the insertion on tibial tubercle, antalgic gait, pain with increasing activity
Avoid for treatment for hip OA
bracing
tens unit or other e-stim
avoid in knee OA
lateral wedge insoles or patellofemoral braces
elastic taping
footwear modifications
interferential e-stim
US
Osteogenesis imperfecta
affects formation of collagen during bone development
How is osteogenesis imperfecta gained
genetic inheritance with types I and IV considered dominant and types II and III recessive
Signs and symptoms of osteogenesis imperfecta
pathological fxs
bowing of the long bones
impaired respiratory function
Treatment of osteogenesis imperfecta
AROM emphasizing symmetrical movements
positioning
functional mobility
fracture management
orthotics
w/c training sometimes
Patellofemoral syndrome
chondromalacia patella
softening of articular cartilage of patella
How is patellofemoral syndrome formed?
decreased quad strength
decreased LE flexibility
patellar instability
increased tibial torsion or femoral anteversion
What to avoid in patellofemoral syndrom?
manual therapy as a standalone intervention
knee orthoses, braces and straps
electromyography-based feedback for VMO
visual feedback for correcting leg alignment
biophysical agents-US, cryotherapy, phonophoresis, iontophoresis, e-stim
Plantar fasciitis is caused by
excessive amount of pronation or prolonged duration of pronation in ages 40-60 mostly
Treatment for plantar fasciitis
heel cup to cushion heel
taping/foot orthoses to support medial longitudinal arch
soft-soled footwear and avoiding sudden changes in intensity of training
PCL tears are how common
not
Signs and symptoms of PCL tear
feeling like femur is sliding off tibia
often asymptomatic
Treatment for PCL tear
surgical can occur but not evolved enough.
If they do, hamstring is used and isolated hamstring exercises are avoided for 6 weeks
RA is
inflammation of synovial tissues which results in erosion of cartilage and supporting structures
How many people have RA
1-2 women 3x more than men and 40-60 y/o
Signs and symptoms of RA
symmetrical involvement
decreased appetite, malaise, swan neck deformity in hands, boutonneire deformity
swan neck deformity
DIP flexion
PIP hyperextension
boutonniere deformity
DIP extension
PIP flexion
Patients who are 50+ are susceptible to what
RTC tears due to degenerative pathology
small RTC tear
large
1 cm
5 cm
Primary focus of therapy in a RTC tear is
preventing adhesive capsulitis and strengthening UE
Large tear requires how many weeks
6-8 of immobilization
Return to dynamic functional activities with OH movement
9-12 months
Scoliosis is quantified using the
Cobb method with X ray
Scoliosis is classified 3 ways
functional, neuromuscular, degenerative
functional scoliosis is from
abnormalities from the body that indirectly impact the spine like leg length discrepancy, muscle imbalance, poor posture
nonstructural scoliosis since curves can be corrected
Neuromuscular scoliosis is from
developmental pathologies resulting in alterations within the structure of the spine
cerebral palsy or Marfan syndrome
Degenerative scoliosis is from
normal aging that causes osteophyte formation, bone demineralization and disc herniation
Neuromuscular and degenerative scoliosis are considered forms of
structural scoliosis since curves are inflexible and do not reduce with lateral bending
Diagnosis of scoliosis ages
10-13
mild curve
10 degrees or less
girls have a significantly higher risk of acquiring a curve greater than
30 degrees
How to spot scoliosis
shoulder level asymmetry with or without presence of rib hump.
pain is not typically associated rather it is a result of abnormal forces
If the curve is not progressing…
no formal action is taken
PT helps with
shoe lifts and bracing among regular stuff
Spinal orthosis warranted if curve is between
25-40 degrees
surgical intervention is required for curves
greater than 40 degrees
Talipes Equinovarus is aka
clubfoot
clubfoot is characterized as
heel pointing downward and forefoot inward
clubfoot is associated with
neuromuscular abnormalities like spina bifida and arthrogryposis
Signs and symptoms of clubfoot
adduction of forefoot
varus positioning of hindfoot
equinus at ankle
Treatment of club foot
medical management begins shortly after birth and includes splinting and serial casting.
failed management or severe involvement may require surgical intervention and subsequent casting
THA cementing allows
WBAT immediately
Cementless and hybrid fixation requires
bone growth and dictates PWB or NWB initially
Anterolateral approach THA
between TFL and glute med
Abductors are released to dislocated anteriorly
precautions: extension, ER, adduction
Direct lateral THA
leaves posterior portion of glute med attached to trochanter
longitudinal division of TFL and vastus lateralis with anterior portion of glute med
minimizes dislocation risk
precautions: flexion beyond 90 degrees, extension, ER, adduction. glute med repair avoid abd for 6-8 weeks
Posterolateral THA
splits glute max and short ER are released and hip abductors are retracted
maintains integrity of glute med and vastus lateralis muscles. femur is dislocated posteriorly. Most common approach.
precautions: hip flexion over 90, adduction, IR
THA lasts
15-20 years
Complications for THA
DVT
infection
pulmonary embolus
heterotropic ossification
femoral fxs
dislocation
neurovascular injury
Precautions for THA lasts
1-3 months
TKA three types
unicompartmental
bicompartmental
tricompartmental
Unicompartmental TKA
medial or lateral joint surface
Bicompartmental TKA
entire surface of femur and tibia
Tricompartmental TKA
femur, tibia and patella
TKA constraints
unconstrained
semiconstrained
fully constrained
unconstrained TKA
usually a unicompartmental arthroplasty
no inherent stability and relies on soft tissue integrity for stability
semiconstrained TKA
some degree of stability without compromising mobility
most common
fully constrained TKA
most stability and restricts one or more planes of motion
results in greater implant stress and higher likelihood of implant problems
TKA length
15-20 years
Most common fixation of TKA
cemented
Complications of TKA
DVT
infection
pulmonary embolus
fibular nerve palsy
restricted ROM
periprosthetic fxs
chronic joint effusion
Knee flexion for ADLS
for STS
90
105
Laminectomy done when
disc protrusion or spinal stenosis
complete laminectomy
removal of entire lamina, spinous process and ligamentum flavum
partial laminectomy
one lamina
Restrictions on what after laminectomy
weight lifted
active motions especially extension
How is a spinal fusion usually done
bone grafts from iliac crest
cervical fusion done which kind of approach and lumbar fusion is done in what kind of approach
anterior
posterior
Spinal fusion leads to
hypermobility at adjacent segments and will hasten onset of degeneration
Restrictions for spinal fusion
lifting, active motion-bending or twisting
If surgeon does not use instrumentation for spinal fusion then what is more likely to be used
brace
OP PT does not occur with spinal fusions until
6 weeks
If instrumentation is used in spinal fusion therapy can
begin sooner and progressed more aggresively
SA replaces
glenoid and humeral components
hemi-SA
only one component
What kind of approach for TSA?
anterior
cuts into subscapularis
Avoid what movements after TSA
extension and ER to protect healing of subscapularis muscle
resisted IR
Subacromial decompression is open and what muscle is detached
mini open is when…
deltoid
deltoid is only split
Subacromial decompression involves
acromioplasty
bursectomy
removal of distal clavicle (when degenerated)
release of coracoacromial ligament
Recovery from subacromial decompression
rapid
sling only 1-2 weeks
if delt was performed, passive extension is initially avoided
RTC small partial thickness tears only require
debridement
Shoulder stabilization strategies surgically
capsular shift
Capsular shift involves
tightening of joint capsule by cutting it and overlapping the ends to reduce capsular redundancy
Other options for capsular tightening of shoulder
electrothermal
shrinks and tightens the capsule
Anterior is the most common type of stability so..
anterior portion is tightened
What also happens with capsular shift
labral repairs
Bankart requires repair of
anterior labrum
SLAP requires repair of
superior labrum
If labrum repairs are done openly ….
subscapularis may need to be detached
When having a shoulder stabilization surgery and the anterior portion was utilized, what kind of sling and what positions should be avoided?
normal sling
ER
extension
horizontal adduction
resisted IR if subscapularis was detached
When having a shoulder stabilization surgery and the posterior portion was utilized, what sling and what positions should be avoided?
hand shake position with shoulder in neutral
IR
Flexion
horizontal adduction
SLAP avoid
bicep contracting or stretching as it is attached to superior labrum
Femoral neck fractures that are intracapsular may lead to…
which leads to nonunion and ____ is found more with these fractures
disruption of blood supply to femoral head
osteonecrosis
Intertrochanteric hip fractures are ___ and do not affect blood supply. ____ _____ is more of a problem with these since fixation need is greater.
extracapsular
implant failure
HIP ORIF is always
open
Which muscles are affected with hip ORIF?
TFL, glute med, vastus lateralis
If the fracture site of a hip is intracapsular a _____ will be performed.
capsulotomy
With hip ORIF, new advances in surgery have allowed early…..
_____ strengthening is postponed until muscles have been given a chance to heal.
weight bearing
isotonic
Fxs of greater trochanter will affect which muscle? While fxs of lesser trochanter will affect which muscle?
glute med
iliopsoas
Signs of fixation failure in hip ORIF
persistent thigh or groin pain, leg length discrepancy that was not present initially, positioning the limb in ER, trendelenburg sign that does not improve with strenghtening.
Surgeries to fix articular cartilage defects
microfracture procedure using an awl to penetrate subchondral bone which causes an ingrowth of fibrocartilage
osteochondral autograft transplantation: harvested from NWB surfaces to form a plug in the chondral defect
autologous chondrocyte implantation: grow healthy cartilage (MACI)
In ACL is autograft or allograft preferred?
autograft
Which graft is considered the gold standard in ACL repair? Why?
bone-patellar tendon-bone graft
uses bone-to-bone healing and considered stronger with good fixation
What is another common fixation for ACL?
gracilis and/or semitendinosus but its not as strong since it uses tendon-to-bone healing.
What exercises should be avoided between 0-45 degrees initially after ACL repair? Those with bone patellar tendon bone graft may experience ____ knee pain and should be careful with quad strengthening. Hamstring graft should be care with ____ exercises. Graft tissue is most vulnerable ___-___weeks after surgery. Graft becomes weaker before it gets stronger. Graft maturation is 100% around ____-____months.
open chain
anterior
flexion
6-8
12-16
What are the criteria for return to sport after ACL?
no pain or effusion
full ROM
no instability
quad strength 85-90% of opposite leg
hamstring strength that is 90-100% opposite leg
functional testing that is 85-90% opposite leg
Grafts for PCL and rehab are the same as ..but progression for PCL is….and exercises should…
ACL
slower/more gradual
limit posterior shear forces within knee. Repetitive knee flexion should be avoided
Surgical choice for meniscectomy usually for older individuals
partial and when tear is in the inner 2/3 of the meniscus where healing is poor
Surgical choice for meniscus usually for younger
repair
outer third of meniscusd
Rehab after meniscus surgery restrictions on
flexion
Rehab after partial meniscectomy pt is ___ without use of brace
WB no restrictions and recovery is quicker
Lateral ankle reconstruction is done secondary to
complete tear of anterior talofibular ligament or calcaneofibular ligament or chronic ankle instability
Two methods for lateral ankle reconstruction
1: repair where they are sutured
2: harvesting autograft from fibularis brevis to replace the ligaments
second option for lateral ankle reconstruction is used when
original ligaments cannot be repaired due to deterioation
Rehab progression for lateral ankle reconstruction
protective cast for one week
walking cast or boot for several weeks followed by a brace
PT not immediately after surgery. Focus on not ranging too much into inversion.
Grafts used in achilles tendon repair
flexor hallucis longus
fibularis brevis
plantaris
Rehab progression with achilles tendon repair
casted in slight PF initially
NWB first several weeks
cast or boot with ankle in neutral and PWB
