Exam 1: LE Flashcards
(319 cards)
1
Q
How many bones are there in the foot? How many synovial joints are there?
A
-28 bones
-30 synovial joints
-55 articulations
2
Q
What is the function of the foot and ankle?
A
Convert the rotational movements that occur with weight bearing activities into sagittal, frontal, and transverse movements
3
Q
What joint sustains the greatest load per surface area in the body?
A
The ankle joint
4
Q
What are peak weight bearing forces through the ankle during walking and running?
A
-Walking: 120%
-Running: 275%
5
Q
What are the three subdivisions of the foot?
A
-Rearfoort/hindfoot
-Midfoot
-Forefoot
6
Q
What does the rearfoot/hindfoot consist of?
A
-Tibia
-Fibula
-Calcaneus
-Talus
7
Q
What does the midfoot consist of?
A
-Navicular
-Cuboid
-3 cuneiforms
8
Q
What does the forefoot consist of?
A
-14 bones of the toes
-5 metatarsals
9
Q
What are common ankle disorders?
A
-Ankle sprains/instability
-Osteochondritis Dissecans of talus
10
Q
Where do most of ankle sprains occur?
A
85% of ankle sprains occur on the lateral ankle
11
Q
What ligament is involved in 60-70% of all ankle sprains?
A
Anterior talofibular ligament (ATFL)
12
Q
What ligament is involved 20% of the time when the ATFL is sprained?
A
Calcaneofibular ligament (CFL)
13
Q
What is the sequence of tears for ankle sprains?
A
- ATFL
- Anterolateral capsule
- Distal tibiofibular ligament
- CFL
- Posterior talofibular ligament
14
Q
Why might someone with a lateral ankle sprain experience medial ankle pain?
A
Due to bone bruising of the talus at the time of injury
15
Q
How long do bone bruises typically take to heal?
A
6 months or more
16
Q
What grades of sprains are there?
A
-Grade I: 1-24% is torn
-Grade II: 25-99% torn
-Grade III: 100% torn
17
Q
What is a high ankle sprain?
A
-High ankle sprains occur when the syndesmosis is stretched and torn
Other structures that can be torn include:
-Anterior inferior tibiofibular ligament
-Posterior inferior tibiofibular ligament
-The transverse ligament
18
Q
What is the typical mechanism of injury for high ankle sprains?
A
External rotation or dorsiflexion as these motions can cause the distal tibia and fibula joint to separate
19
Q
What is the recovery time of a high ankle sprain compared to a lateral ankle sprain?
A
A high ankle sprain usually takes twice as long to recover from
20
Q
What is the mechanism of injury for a lateral ankle sprain?
A
Inversion and plantarflexion
21
Q
What is a medial ankle sprain? How common is it?
A
-Injury to the deltoid ligament
-Less common than lateral ankle sprains
-Usually due to trauma
22
Q
What is the mechanism of injury for a medial ankle sprain?
A
Excessive eversion and dorsiflexion
23
Q
What are the Ottawa ankle rules?
A
-After traumatic incidents or injuries
An ankle X-ray is required if there is any pain in the malleolar zone and any of these findings:
-Bone tenderness at lateral malleolus
-Bone tenderness at medial malleolus
-Inability to weight bear both immediately and in the ER/office
24
Q
What are the Ottawa foot rules?
A
A foot X-ray is required if there is pain in the midfoot zone and any of these findings:
-Bone tenderness at navicular bones
-Bone tenderness at base of the 5th metatarsal
-Inability to weight bear both immediately and in ER
25
How should you treat an ankle sprain during the acute stage?
-Minimize effusion
-Promote early protected motion
-Early supported/protected WBAT
-Cryotherapy
-Compression
-Elevation
-Ankle pumps in free range
26
How should you treat an ankle sprain during the subacute stage?
-Begin dynamic balance and proprioceptive exercises
-Open chain resistive exercises
-Stationary bike
27
How should you treat an ankle sprain during the advanced healing stage?
-Restore normal ROM
-Normalize gait
-Pain-free with full weight bearing
-Functional activities
-Enhanced proprioception
28
What is chronic ankle instability (CAI)? How can it be diagnosed?
-Repeated acute inversion ankle sprains
-Initial sprain being more than 12 months ago
-Frequent episodes of ankle sprains, reports of "giving way", chronic ankle weakness
-Presentation with pain and instability
-Diagnosis: tenderness, + anterior drawer
29
What are treatment options for CAI?
-Conservative: PT, splints
-Balance and strength training
-Surgical: repair or reconstruction
30
What is osteochondritis dissecans of the talus? What is it caused by?
-Fracture of the joint surface (cartilage that can also damage the bone)
-Usually effects the domes of the talus
-Can break off into fragments
-Caused by torsional stress through either impact or cyclical loading and usually follow a twisting injury
31
What is the clinical presentation of osteochondritis dissecans? How is it diagnosed?
-Persistent pain and swelling with stiffness
-Diagnosis: tenderness, diffuse swelling (needs imaging)
32
How is osteochondritis dissecans treated?
-Non-displaced lesions are treated with rest and cast immobilization
-Displaced lesions require arthroscopic removal
33
What are the 4 grades of osteochondritis dissecans?
-Grade I: subchondral impaction
-Grade II: partly detached fragment
-Grade III: non-displaced free fragment
-Grade IV: fragment with 180° shift
34
What are the most common ankle tendon disorders?
-Tibialis posterior
-Peroneal tendons
-Achilles tendon
35
What is the origin of the posterior tibial tendon? What is the insertion?
-Origin: posterior surface of tibia
-Insertion: 3 cuneiforms, base of 2-4 metatarsals, cuboid, and navicular tubercle
36
What is the function of the tibialis posterior?
-Plantar flexion and inversion
-Stabilizes the medial longitudinal arch
37
What are common pathologies of the posterior tibialis tendon?
-Tenosynovitis
-Incomplete tear
-Complete disruption
38
What is tenosynovitis?
Inflammation of the tendon sheath
39
What patient population is posterior tibialis tendon dysfunction most common in?
-Younger patients with inflammatory arthropathy/traumatic rupture
-Older, typically female patient with degenerative tears (knee valgus, over pronation)
40
What are the subjective findings of a patient with posterior tibialis tendonitis?
-Insidious onset of pain
-Pain felt in one of 3 locations: distal to medial malleolus in area of navicular, proximal to medial malleolus, at the musculotendinous origin or insertion
-Swelling on the medial aspect of the ankle
41
What are the objective findings with posterior tibialis tendonitis?
-Swelling and tenderness posterior and inferior to the medial malleolus, along the course of the tendon, and at its insertion into the navicular
-Medial arch is decreased or completely flattened
-Heel shows increased valgus
-Pain on resisted ankle PF and inversion
42
What are some treatment options for posterior tibialis tenosynovitis?
-Rest
-NSAIDs
-Short leg walking cast
-Orthoses
-Steroid injection in tendon sheath
-Synovectomy
43
What are some treatment options for incomplete tear of the posterior tibialis?
Repair or augmentation with either FDL or FHL
44
What are some treatment options for complete tear of the posterior tibialis?
-Repair in traumatic cases in young patients
-Tendon transfer with medial calcaneal displacement osteotomy and subtalar/triple arthrodesis (fixed hindfoot)
45
What are the origins and insertions of the peroneus longus and brevis?
-Origin: fibula and interosseus membrane
-Insertion: Base of I & V metatarsals respectively
46
What are common pathologies of the peroneal tendons?
-Tenosynovitis
-Sprain/subluxation
47
What are symptoms of peroneal tendon dysfunction?
-Pain in the outer part of the ankle or just behind the lateral malleolus
-Pain worsens with activity and eases with rest
48
What is non-surgical treatment options for peroneal tendon dysfunction?
-Rest
-Short leg walking cast
-Lateral heel wedge
-PT
-NSAIDs
-Cortisone injection
49
What are surgical options for peroneal tendon dysfunction?
-Tenosynovectomy and repair of split
-Stabilization of dislocating tendons by groove deepening, peroneal retinaculum reconstruction, and bone blocks
50
What is achilles tendinosis?
There will be clinical inflammation but objective pathologic evidence for cellular inflammation is lacking
51
What is achilles tendonitis?
-Peritendinous inflammation
-Seen in adults in their 30s-40s
-Most commonly affects runners
52
What are the two types of achilles tendon dysfunction?
-Non-insertional: occurs proximal to retrocalceneal bursa, generally responds well to non-operative treatment
-Insertional: tenderness is localized to calcaneal tendon insertion, more difficult to treat
53
What are the subjective findings of achilles tendonitis?
-Gradual onset of pain and swelling in the Achilles tendon
-Exacerbated by activity
-Some patients will present with pain and stiffness along the achilles tendon when rising in the morning
54
What are the objective findings of achilles tendonitis?
-Tenderness & warmth to palpation along tendon
-Decreased active and passive dorsiflexion
-Gait may include: antalgia, premature heel off, leg may be held in ER
55
What are the conservative treatment options for achilles tendonitis?
-Rest
-Ice
-PT: eccentric loading, correction of lower chain asymmetries
-Orthoses
56
What are the surgical treatment options for achilles tendonitis?
-Achilles tendon decompression and debridement if unrelieved by 6 months of conservative measures
-90% will have significant relief of symptoms
57
What are the three types of Achilles tendonitis? How much activity should be reduced with each type?
-Type I: pain is only experienced after activity; reduce activity by 25%
-Type II: pain that occurs both during and after activity but does not affect performance; reduce activity by 50%
-Type III: pain during and after activity that does affect performance; temporarily discontinue activity
58
What does current evidence suggest is a good treatment plan for achilles tendonitis?
-12 week eccentric program
-Knee bent and knee straight
-To floor level for insertional tendonitis
-Below floor level for non-insertional
59
What is the mechanism of injury of achilles tendon rupture? What patient population is this most common in?
-Loading on a dorsiflexed ankle with the knee straight or repeated microtrauma
-Consider systemic conditions such as gout, hyperparathyroidism, or previous steroid injections
-Commonly affects young and middle aged athletes
60
Approximately how long does it take to recover from an achilles tendon rupture?
6-8 months
61
What are the subjective findings for achilles tendon rupture?
-Feels like being kicked or shot in the leg
-Mechanism: eccentric loading, sudden unexpected dorsiflexion, or direct blow
62
What are the objective findings for achilles tendon rupture?
Positive Thompson's test
63
What is non-operative treatment options for achilles tendon rupture?
-Non-op is indicated in older adults with minimally displaced ruptures
-Serial casting over 10-12 weeks
64
What is operative treatment options for achilles tendon rupture?
-Repair is indicated in younger patients with clinically displaced ruptures
-Surgery followed by casting regime
65
What are possible complications of achilles tendon ruptures?
-Wound healing
-Sural nerve damage
-Possible DVT
66
What are the rates of return to pre-injury level of activity with achilles tendon ruptures?
-Non-operative: 69%
-Operative: 83%
67
What are the rates of patient satisfaction with achilles tendon ruptures?
-Non-operative: 66%
-Operative: 93%
68
What are the rates of re-rupture with achilles tendon ruptures?
-Non-operative: up to 33%
-Operative: 2-3%
69
What is the most common cause of heel pain? What is often associated with this condition?
-Plantar fasciitis
-Heel spurs often associated
70
What are causes of plantar fasciitis?
-Obesity
-Excessive walking/sporting activity
-Tight plantar fascia & flattening of the arch
71
What are treatment options for plantar fasciitis?
-Orthoses
-PT
-Injections
-NSAIDs
-In rare cases, surgical release
72
What are the subjective findings in plantar fasciitis?
-Hx of pain and tenderness on the plantar medial aspect of the heel
-Pain with first steps in the morning
-Pain worsens with activity
73
What are objective findings with plantar fasciitis?
-Localized pain on palpation along the medial edge of the fascia or at the origin on the anterior edge of calcaneus
-Positive Windlass test
74
What is the prognosis for plantar fasciitis?
90% who undergo a conservative intervention improve significantly within 12 months
75
What is retrocalcaneal bursitis?
Inflammation of the retrocalcaneal bursa (subtendinous) or the subcutaneous calcaneal bursa
76
What are the causes of retrocalcaneal bursitis?
-Repetitive trauma from shoe wear and sports
-Gout, RA, and ankylosing spondyloarthropathies
-Bursal impingement between the Achilles tendon and an excessively prominent posterior-superior aspect of the calcaneus
77
What are the subjective findings of retrocalcaneal bursitis?
-Posterior ankle pain
-Pain with walking
78
What are the objective signs of retrocalcaneal bursitis?
-Tenderness
-Lump
-Inflammation
79
What is the conservative treatment of retrocalcaneal bursitis?
-PT
-Appropriate shoe wear
-Injection
80
What is the surgical intervention for retrocalcaneal bursitis?
-Resection of Haglund deformity (removal of calcaneal superoposterior prominence, aka "pump bump")
-Excision of the painful bursa and tendon debridement
81
What are the most common foot disorders?
-Hallux valgus
-Pes planus ("flat foot")
-Metatarsal stress fracture
-Morton neuroma
-Tarsal coalition
-Turf toe
-Tarsal tunnel
-Cuboid syndrome
82
What is hallux valgus ("bunion")?
-Lateral deviation of great toe
-1st MTP joint and proximal phalanx deviated laterally
-Angle between 1st ray and phalanges greater than 20 degrees
83
What is the etiology of hallux valgus?
-Familial
-Inappropriate footwear/toe box
-Flat feet
-Long first ray
-Incongruous 1st MTP joint articular surface
-Metatarsus primus varus
-RA
84
What can hallux valgus cause in the other toes?
Can cause hammer toes (especially in the 2nd toe)
85
What are signs of hallux valgus?
-Bunion and inflammed overlying bursa and skin
-Valgus and pronation deformity of hallux
-Painful callus on 2nd toe
-Transfer metatarsalgia/thickened skin over MT heads
86
What are conservative treatment options for hallux valgus?
-Properly fitted, low heeled stiff-soled shoes
-Wide square toe box
-Toe portion stretched to accommodate bunion
-Extra depth shoe to accommodate dorsiflexed 2nd toe
-Splint that separates 1st and 2nd toe
-Silicone bunion pad for pressure relief
-Acute pain management
87
What are surgical treatment options for hallux valgus?
-Bunionectomy
-Correction of the joint angle
88
What is pes planus/flat foot?
-Disappearance of the medial longitudinal arch when weight bearing
-Can be flexible (99%) or rigid (1%)
89
How can you distinguish between flexible or rigid pes planus?
-Jack test
-Toe raise test (if calcaneus does not move into inversion then it is rigid)
90
What is the etiology of rigid pes planus?
Congenital vertical talus & tarsal coalition
91
What is tarsal coalition?
-Bones can fuse together
-Can happen between calcaneo-navicular or talocalcaneal
-Can be bony, cartilaginous, or fibrous
92
What are symptoms of rigid pes planus?
-Foot pain
-Difficulty walking on uneven surfaces
-Foot fatigue
-Peroneal spasm
93
What is the treatment for rigid pes planus?
-Surgical resection of connecting bar & soft tissue interposition, subtalar arthrodesis, triple arthrodesis
-4-6 weeks of cast immobilization post surgery
94
What are the most common metatarsal stress fractures?
2nd and 3rd metatarsals most frequently injured
95
What causes stress fractures?
-Develops after cyclical submaximal loading
-Running on hard surfaces, improper shoes, sudden increase in jogging distances
96
What are the subjective findings with metatarsal stress fractures?
-Pain and swelling on weight bearing
-Hx of sudden increase in activity, change in running surface, prolonged walking
97
What are the objective findings for a metatarsal stress fracture?
-Swelling
-Ecchymosis (bruising)
-Tenderness over fractured metatarsal
-May not show on radiographs for 2-3 weeks
98
What is a Morton's neuroma?
-Mechanical entrapment of the interdigital nerve
-Not a true neuroma, but rather a perineural fibrosis of the common digital nerve as it passes between metatarsal heads
99
What is the etiology of Morton's neuroma?
-Trauma
-Ischemia
-Entrapment
100
What are the subjective findings of a Morton's neuroma?
-Symptom of shooting/constant pain on walking
-Pain relieved by rest and removal of footwear
-Clinical sign of third/second cleft tenderness and palpable click on metatarsal squeeze
101
What patient population is a Morton's neuroma most prevalent in?
Women are 8-10x more likely to have this condition
102
Between what digits is a Morton's neuroma most common?
Between digits 3-4
103
What is non-operative treatment for Morton's neuroma?
-Metatarsal pad
-Orthoses
-Injection
-Supportive shoes with wide toe box or shoes with heels more than 2 inches high
104
What are operative treatments for Morton's neuroma?
-Excision
-Compression dressing and post-op shoe is placed on the foot
-Dorsal approach allows for immediate weight bearing and suture removal after 2 weeks (plantar approach delays by 2 more weeks)
105
What is tarsal tunnel?
Entrapment neuropathy of the posterior tibial nerve as it passes between the flexor retinaculum and the medial malleolus
106
What are the subjective findings for tarsal tunnel?
-Onset may be acute or insidious
-Patient reports poorly localized burning sensation or pain and paresthesia at the medial plantar surface of the foot
-Worse after activity and worse at the end of the work day
107
What are the objective findings for tarsal tunnel?
-Positive tinel sign
-Pain with passive dorsiflexion or eversion
-Decreased 2 point discrimination on the plantar aspect of the foot
-Varus or valgus deformity of the heel
-Weakness of foot intrinsics with sustained PF of the toes
108
What are treatment options for tarsal tunnel?
-Local corticosteroid injections
-Orthoses
-Strengthening of foot intrinsics to restore medial longitudinal arch
109
What is Turf Toe?
Sprain of 1st MTP joint of the great toe
110
What is the mechanism of injury for turf toe?
Most commonly occurs with hyperextension and varus/valgus stress of the 1st MTP joint
111
What are the subjective findings with turf toe?
-Complaints of red, swollen, stiff 1st MTP joint
-Joint may be tender on plantar and dorsal surface
-May have limp and may be unable to run or jump
-Hx of a single DF injury or multiple injuries to great toe
112
What are objective findings of turf toe?
Pain with ligamentous stability testing
113
What are the grades for turf toe?
-Grade I: minor stretch to soft tissues; little pain or swelling
-Grade II: partial tear of the capsulo-ligamentous structures; moderate pain and swelling, ecchymosis
-Grade III: complete tear of the plantar plate with severe swelling, pain, ecchymosis, inability to weight bear
114
What is treatment for Turf toe?
-Rest, ice, compression, elevation
-NSAIDs
-Toe tapes to limit DF
-Grade I: return to activities as soon as symptoms allow
-Grade II: 3-14 days of rest
-Grade III: 6 weeks rest from sport
115
What is cuboid syndrome?
-Disruption of the structural congruity of the calcaneo-cuboid joint complex
-Often misdiagnosed
-Lack of valid and reliable diagnostic tests
116
How common is cuboid syndrome?
Relatively uncommon (less than 3%) after a lateral ankle sprain
117
What is the important anatomy of the cuboid?
-The keystone of the lateral column of the foot: concave cuboid rests of convex navicular and lateral cuneiform
-Cuboid is the only mid-tarsal that articulates with the navicular
-Peroneus/fibularis longus slings laterally and inferiorly into a fibrous-osseus tunnel in the plantar aspect of the cuboid
118
What is the etiology of cuboid syndrome?
-The degree and direction of the force of the peroneus with sudden inversion of the foot causes a medial and inferior glide of the cuboid
-Cuboid subluxes medially and inferiorly
-Disruption of cuboid ligaments occurs
119
What are objective signs of cuboid syndrome?
-Persistent and localized pain over the cuboid following an inversion sprain
-Pain with toe off during gait
-Inability to perform plyometrics
-Pain radiating along the medial arch and/or the length of the 4th metatarsal
-Limited and painful DF, INV, EV localized to CC joint
-Painful dorsal glides of the cuboid
120
What are the recommended treatments for cuboid syndrome?
-Cuboid whip (Grade V)
-Cuboid squeeze
-Mobs with movement
-Retraining of the intrinsics of the foot to ensure stable midfoot
-Rehab of whole kinetic chain
-Peroneal & gastroc stretches
121
What shoe type do people with flat feet need? Why?
-Motion control/stability shoes
-They are over-pronated which "unlocks" the midfoot and does not allow for much stability
122
What shoe type do people with neutral feet need? Why?
-Neutral shoes
-They have neutral feet therefore do not require special shoes
123
What shoe type do people with high arches need? Why?
-Cushion shoes
-They are over-supinated and cannot move into pronation to absorb shock during gait
124
What is joint stability dependent upon in the knee?
-Static restraints of the joint capsule, ligaments, and menisci
-Dynamic restraints of the lower limb muscles
125
What is one of the most commonly injured joints in the body? Why?
-The knee
-Because the tibia and femur are nearly flat so there is less stability at the joint surfaces
126
How much internal tibial rotation should occur at the knee joint?
30-40°
127
How much external tibial rotation should occur at the knee joint?
20-30°
128
What are the 4 main ligaments of the knee?
-ACL
-PCL
-MCL
-LCL
129
What movements does the MCL and LCL restrict?
-MCL: restricts valgus force and external tibial rotation
-LCL: restricts varus force and external tibial rotation
130
What are the smaller ligaments of the knee joint?
-Coronary ligament
-Transverse ligament
-Meniscofemoral (deep MCL)
-Arcuate ligament
-Oblique popliteal ligament
131
What are some special characteristics of the patella?
-Sesamoid bone (largest in the body)
-5 facets: superior, inferior, lateral, medial, and odd
-During flexion to extension, different parts of the patella articulate with the femoral condyles
132
What is the purpose of the patella?
-Increase the leverage of torque of quads by increasing distance from the axis of motion
-Provide bony protection to distal joint surface of femoral condyles when knee is flexed
-Prevent damaging compression forces on the quadriceps tendon with resisted knee flexion such as squats
133
What facets of the patella are in contact with the femur at different degrees of knee flexion?
-0 degrees: no contact
-15-20 degrees: inferior pole
-45 degrees: middle pole
-90 degrees: all facets (NOT odd)
-Full flexion: odd facet and lateral aspect
134
What activities increase the patellar loading?
-Walking: 0.5x BW
-Cycling: 1.5x BW
-Up stairs: 3.3x BW
-Down stairs: 5x BW
-Jogging: 7-8x BW
-Deep squatting: 20x BW
-Jumping: 20x BW
135
What are the biomechanics of the superior tib-fib joint?
-Simple synovial joint
-Oriented anterior-lateral, and posterior-medial
-Closed pack: weight bearing during dorsiflexion
136
What are the ligaments of the superior tib-fib joint?
-Anterior and posterior tib-fib ligament
-Interosseous membrane
137
What are some key mechanical symptoms to ask a pt about their knee?
-Locking or catching
-Popping
-Giving way
-Pain with stairs
-Difficult walking around corners
138
What are the 5 Ottawa Knee Rules? What are they used for?
-Age > 55 or < 18
-Unable to walk
-TTP on patella
-TTP on fibular head
-Unable to flex to 90 degrees
-Used to determine if someone needs an X-ray
139
What are common orthopedic conditions of the knee?
-ACL tear
-PCL tear
-Collateral ligament strain
-Baker's cyst
-Medial gastroc strain
-Meniscal tear
-Osgood Schlatter's Disease
-Patellofemoral pain syndrome
-Plica syndrome
-Prepatellar bursitis
-Iliotibial band syndrome
-Patellar dislocation
-Osteoarthritis of the knee
140
What are the secondary restraints of the ACL?
Internal and external rotation in the NWB knee
141
What are the subjective findings for ACL tears?
-Risk of injury 2-8x more in women
-Twisting or hyperextension of the knee
-Sensation of their knee "popping" or "giving out"
-Pain and immediate dysfunction
-Instability in the involved knee and inability to walk without assistance
-Immediate swelling
142
What are the objective findings for ACL tears?
-Large hemarthrosis
-Pain
-Positive special tests for anterior stability
-Involvement of other knee structures
143
What is the prognosis for an ACL tear?
-Not usually an isolated injury
-Post-op: 8-12 months until full activity
144
What is an "autograft" vs an "allograft"?
-Autograft: using your own tissue (HS tendon)
-Allograft: using tissue from a cadaver
145
What is the rejection rate for ACL allografts?
25% rejection rate
146
What are the pros of using allografts?
-Lack of harvest morbidity
-Less trauma and quicker surgery
-Decreased post op pain
-Easier and early rehab
-Lack of limit to the size of graft
147
What is the load to failure of the native ACL? What about in ACL autografts?
-Native ACL: 1,725-2,160 N of force
-HS tendon: 2,640 N
-Patellar tendon: 1,580 N
-Quad tendon: 2,185 N
148
What is the rate of contralateral ACL injury after one ACL injury?
13%
149
What are the major goals of ACL rehab?
-Gain good functional stability
-Repair muscle strength
-Reach the best possible functional level
-Decrease the risk for re-injury
-Closed and open kinetic chain exercises
150
What is the general time frame for return to sport post ACL repair/reconstruction?
-Minimum of 6 months, but better to wait 7-10 months
-Generally, light jogging can be started around 4-5 months
151
How many patients return to sport after ACL repair/reconstruction?
-81% return to some form of sport
-65% return to pre-injury level of activity
-55% return to competitive sports
152
What is the strongest and largest ligament in the knee?
PCL
153
What percent of outpatient knee injuries are PCL?
3%
154
What is the mechanism of injury of PCL tears?
-Often not an isolated injury and other ligaments will be injured or there will be a fx
-"Dashboard injury"
-Direct blow to the anterior tibia or a fall onto the knee w/ the foot in a plantar flexed position
155
What are special tests for PCL tears?
-Posterior drawer
-Sag sign
156
What are the subjective findings for collateral ligament sprains?
-Localized swelling or stiffness
-Medial or lateral pain and tenderness
-Most patients are able to ambulate after an acute collateral ligament injury
157
What are the objective findings for collateral ligament sprain?
-Tender to palpation along its entire course
-MCL may have isolated tenderness at most proximal or distal end
-Positive varus or valgus stress tests
-Laxity in full extension indicates a more extensive injury
158
What is the most common mechanism of injury for MCL sprains?
Contact/hit on the outside of the knee with a planted foot
159
What are the different grades of MCL sprains?
-Grade I: pain but no laxity on valgus stress test
-Grade II: laxity only present at 30 degrees
-Grade III: severe laxity at full extension
160
What is the prognosis for MCL injuries?
-Grade I: 10 days
-Grade II: 3-4 weeks low end
-Grade III: 6-8 weeks
161
What should be the focus of treatment for MCL sprains?
-With proper rehab, even a full tear can be healed without surgery
-Initially should be focused on controlling edema and slowly progress to improving ROM
162
What is a Baker's cyst?
-Abnormal collection of synovial fluid in the fatty layers of the popliteal fossa
-Most common synovial cyst in the knee
163
What are the subjective findings for Baker's cyst?
-Complaints of tightness/swelling behind the knee or pain down the back of the leg
-No history or trauma
164
What are the objective findings Baker's cyst?
-Pt prone & leg fully extended, an oblong mass is palpable and visible in the medial popliteal fossa
-Active knee flexion may be limited by 10-15 degrees with a large cyst
165
What are interventions for Baker's cyst?
-RICE
-For large cysts that interfere with knee function= aspirate
166
Why are doctors cautious with aspirating a Baker's cyst?
Due to risk of intra-articular infection
167
What is the mechanism of injury of a medial gastroc strain?
-Typically results from an acute, forceful push-off with the foot joint in activities such as hill running, jumping, or tennis
-Also from increased volumes of running load, acceleration and deceleration as well as during fatiguing conditions of play or performance
168
What are subjective findings of medial gastroc strain?
-Complaints of pulling or tearing sensation in the calf (think velcro)
-May hold ankle in PF to avoid placing tendon on the injured muscle
169
What are the objective findings of medial gastroc strain?
-TTP and swelling over medial gastroc
-Pain aggravated with passive DF
-Inability to perform a single-leg toe raise
-Negative Thompson test
-Peripheral pulses intact
170
What is the grading for a medial gastroc strain?
-Grade I: little to no loss of strength, less than 10% of fibers disrupted
-Grade II: clear loss of strength, 10-50% of fibers disrupted
-Grade III: more than 50% of fibers disrupted, pain, swelling, tenderness, and bruising
171
What are interventions for medial gastroc strain?
-Acute: control pain and inflammation
-Gentle AROM & PROM
-Once painfree with symmetrical ROM & strength, full activities can be resumed
-Stretching and strengthening should be continued for several months to overcome increased risk for re-injury
172
What is the most common cause of mechanical symptoms of the knee?
Meniscal tear
173
What is the mechanism of injury for a meniscus tear?
-Usually occur when the patient attempts to turn, twist, or change direction when weight bearing
-Also can occur from contact to the lateral or medial aspect of the knee
174
How do patients with meniscal tears have pain if there are no pain fibers in the menisci?
The tearing and bleeding into the peripheral attachments as well as traction on the capsule that causes production of pain
175
What are the subjective findings with meniscal tears?
-Reports of significant twisting injury to the knee
-Hx of popping, swelling, or clicking
-Pain along the joint line, particularly with twisting or squatting activities
176
What is the function of the menisci?
-50% load transmitted in extension
-85% load transmitted at 90 degrees flexion
177
How much of a pressure increase is there with resection of a meniscus?
Resection of 15-34% increases pressure by 350%
178
What is the average excursion of the medial and lateral meniscus with knee flexion?
-Medial: 5.2 mm
-Lateral: 11 mm
179
What are the objective findings for a meniscal tear?
-Tenderness over the medial or lateral joint line
-Some degree of effusion
-Forced flexion and circumduction of the tibia frequently elicit pain
180
What are the 4 main intervention approaches for meniscal tears?
-Rehab
-Menisectomy
-Meniscus repair
-Allograft transplantation
181
What is Osgood Schlatter's disease? When does it occur?
-Osteochondritis of inferior patella, tibial tuberosity, or tibial tubercle traction apophysitis
-A form of periostitis of the tibial apophysitis type that manifests as a partial avulsion of the tibial tuberosity with subsequent osteonecrosis of the fragmented bone
-Occurs during growth spurts
182
What are the subjective findings of Osgood Schlatter's?
-Gradually increasing pain and swelling below the involved knee
-Involvement in sporting activities that involve running
183
What are the objective findings of Osgood Schlatter's?
-Prominence over the tibial tubercle
-Mild swelling may be evident
-Pinpoint tenderness over the tibial tuberosity
-PROM reveals limitation of knee flexion
-AROM is painful at end ranges
-Resisted knee extension typically reproduces the pain
-Flexibility testing may reveal adaptive shortening of the HS, quads, and calf muscles
184
What is the prognosis of Osgood Schlatter's?
Self-limiting and spontaneously remitting over a period of 6-24 months as the tibial tubercle ossifies
185
What is patellar tendonitis? What is the mechanism of injury?
-Inflammation of the patellar tendon at the inferior pole of the patella or at its insertion at the tibial tubercle
-Overuse condition frequently associated with eccentric overloading during deceleration activities
186
What are the subjective findings for patellar tendonitis?
-Hx of jumping or kicking sports
-Anterior knee pain
-Pain noted immediately at the end of exercise of following sitting that has been preceded by exercise
-Pain with sitting, squatting, or kneeling
-Pain with climbing or descending stairs, jumping, or running
187
What are the objective findings of patellar tendonitis?
-Localized tenderness at either the inferior pole of the patella, tibial tubercle, or both
-AROM typically normal
-Pain with passive hyperflexion of the knee
-Pain with resisted knee extension
188
What are the 3 stages of intervention for patellar tendonitis?
1. Relative rest from aggravating activities
2. Regaining pain-free motion, flexibility of quads and HS, and exercises focusing on pain-free quad strengthening
3. Gradual resumption of the activities that causes the symptoms
189
What is the prognosis for patellar tendonitis?
Usually self-limiting and responds to rest, stretching, eccentric strengthening, and bracing
190
What is patellofemoral pain syndrome?
Common disorder that is diagnosed on the presence of anterior or retropatellar knee pain associated with prolonged sitting or with weight bearing activities that load the PF joint (squatting, kneeling, running, and stairs)
191
What are the subjective findings of patellofemoral pain syndrome?
-Reports of anterior knee pain with going up or down stairs
-Instability of patella with activities
-Usually no hx of trauma and swelling is uncommon
-More common in female than in male patients
192
What are the objective findings for patellofemoral pain syndrome?
-May see valgus alignment of knees, femoral anteversion, and abnormal tracking
-Quad weakness
-Generalized laxity of patellofemoral ligaments
-Hip weakness
-Poor eccentric quad control in weight bearing
-Positive Clarke's sign
-Positive apprehension test
193
What is the plica?
A normal fold in synovium
194
What is plica syndrome?
Plica that becomes inflamed and thickened from trauma or overuse and may interfere with normal joint motion
195
What are subjective findings of plica syndrome?
-Insidious onset of knee pain, but can be related to fall or injury
-Activity-related aching in the anterior or anteromedial aspect of the knee
-May be painful snapping or popping
196
What are the objective findings for plica syndrome?
-Tenderness according to the location of the symptomatic plica
-May be able to reproduce the snapping or popping at 60° of knee flexion with passive extension
197
What are interventions for plica syndrome?
-Stretching of the quads, HS, and gastroc
-Strengthening
-Ice
-Patellar bracing
-NSAIDs
-Altered sports training schedule
-Surgical if conservative fails
198
What is prepatellar bursitis?
When the prepatellar bursa becomes inflamed or infected as a result of trauma to the anterior knee such as a direct blow or from chronic irritation from kneeling or hyperextension
199
What are subjective findings for prepatellar bursitis?
Complaints of knee swelling and knee pain just over the front of the knee
200
What are the objective findings for prepatellar bursitis?
-Swelling directly over the inferior portion of the patella
-Palpation reveals bursal sac tenderness or bursal sac thickening
-Normal AROM of the knee
201
What are interventions for prepatellar bursitis?
-Decrease inflammation using cryotherapy
-Patient education on activity modification
-Stretches if there is adaptive shortening of quads, HS, or IT band
202
What is the prognosis for prepatellar bursitis?
-50% of traumatic bursitis resolves spontaneously
-10% progresses to chronic bursitis and may require bursectomy
203
What is iliotibial band tendonitis/friction syndrome?
-Excessive friction between iliotibial band (ITB) & lateral femoral condyle
-Common in runners and cyclists
204
What are subjective findings of iliotibial band friction syndrome?
-Pain at lateral knee
-Progresses to pain immediately with activity
205
What are the objective findings of iliotibial band friction syndrome?
-Tender at lateral femoral condyle
-Soft tissue swelling & crepitus
-Positive ober's and/or noble's compression test
206
What are interventions for iliotibial band tendonitis/friction syndrome?
-Relative rest
-Ice
-NSAIDs
-Stretching
-Cortisone
-PRP
207
What is the prognosis for ITB friction syndrome?
-Long recovery!!!
-Improves with rest
208
Who is most at risk for patellar dislocation or instability?
-Young active patients at highest risk (13-20)
-Common in football and basketball
-More common in women than in men
209
How common is recurrent patellar dislocation?
Recurrence is common, especially if initial dislocation is before the age of 15
210
What is the mechanism of injury of patellar dislocation?
Indirect trauma most common; strong quad contraction while leg is in valgus w/ foot planted
211
What are the subjective findings of patellar dislocation?
-Feel a "pop" and immediate pain
-Obvious knee deformity
-Painful, difficult to bend knee
-May spontaneously relocate
212
What are the objective findings of patellar dislocation/instability?
-Laterally shifted patella
-Swelling
-Positive patellar apprehension test
213
What are interventions for patellar dislocation/instability?
-NSAIDs
-Ice
-Patellofemoral knee brace (rigid)
-PT: ROM, quad strengthening, e-stim
-Surgery for recurrent instability
214
What is the prognosis for patellar dislocation/instability?
Recurrent instability is common but rehab is very useful
215
What compartment of the knee is most frequently involved with OA?
Medial compartment
216
What are the subjective findings for knee OA?
-Insidious onset of pain
-Pain with weight bearing
-May have complaints of buckling, locking, or giving way
-Difficulty climbing or descending stairs
-Increased stiffness in AM
217
What are the objective findings for knee OA?
-Angular deformity through the knee
-Effusion
-Diffuse tenderness along the joint lines
-Loss of AROM in a capsular pattern
218
What is the prognosis for knee OA?
-Progressive condition
-Can somewhat control symptoms and progression with meds, shoe inserts, strengthening, and bracing
-Severe functional limitations and pain at rest or at night may indicate need for surgery
219
What are the 4 stages of OA?
-Stage I: doubtful
-Stage II: mild
-Stage III: moderate
-Stage IV: severe
220
What is the evidence for clinical diagnosis of knee OA?
-Age > 50
-Stiffness > 30 min
-Crepitus
-Bony tenderness
-Bony enlargement
-No palpable warmth
-If greater than 3, sensitivity is 0.95, specificity 0.69
221
What is involved in the management of OA?
-Weight loss
-Exercise program
-Ambulatory AD
-Insoles
-Unloader knee braces
222
What medications are there to help manage OA?
-Glucosamine/chondroitin sulfate
-Acetaminophen
-NSAIDs
-Cox-2 inhibitors
-Intraarticular injections (glucocorticoids, hyaluronic acid)
223
Who is a candidate for unicompartmental knee replacement?
-Arthritis in only 1 compartment
-Used in either young or old patient
-Ligaments intact
-No systemic disease
-Weight < 200#
-Dependent on occupation
224
What are the advantages of unicompartmental knee replacements?
-Better kinematics as cruciate ligaments are retained
-Better ROM
-Better function, especially stairs
-Pain relief is better
-Less frequent and severe complications
-More rapid recovery
-Lower cost
225
What is the surgical procedure for a TKA?
-Resurface all three surfaces: tibia, femur, patella
-Components fixed to bone with "cement"
-Traditional approach has 20-30cm incision
226
What is the different between standard TKA and mini/Q-S TKAs?
-Standard: 20-30cm incision
-Mini: 12-14 cm incision, quad snip
-Q-S: 7-10 cm, no quad snip
227
What is the benefit of minimally invasive (mini and Q-S) TKAs?
-Earlier mobilization
-Less pain
-Cost
-Shorter hospital stay
-Quicker rehab
-Less blood loss
228
What is the pattern of the trabeculae in the proximal femur?
-Horizontal and vertical patterns that cross over each other
-There is a zone of weakness where there is no trabeculae in the inferior portion of the neck of the femur
229
What is the capsular pattern of the hip?
-Flexion
-Abduction
-Medial rotation
230
How many bones make up the hip joint?
-4 bones
-Pubis
-Ilium
-Ischium
-Femur
231
How many Newton pounds does it take to dislocate the hip?
400
232
What is the vascularity of the femoral head?
-Ligamentum teres (1/3 supply)
-Circumflex artery
-Superior & inferior gluteal arteries
233
What is the labrum?
Fibrocatilaginous tissue that increases the joint congruency and stability
234
What are the 4 major ligaments of the hip?
-Anterior iliofemoral "Y" ligament
-Pubofemoral
-Posterior ischiofemoral
-Ligamentum teres
235
What motions does the ligamentum teres restrict?
At 90 degrees of hip flexion it limits IR & ER
236
What are the flexors of the hip?
-Iliacus
-Psoas
-TFL
-Rectus femoris
-Sartorius
-Adductor longus
-Pectineus
237
What are the extensors of the hip?
-Glute max
-Hamstrings
-Adductor magnus
238
What are the abductors of the hip?
-Glute med
-TFL
-Superior glute max
-Glute min
239
What are the adductors of the hip?
-Adductor group
-Pectineus
-Gracilis
-Pectineus
240
What are the medial rotators of the hip?
-No pure rotator
-TFL
-Glute minimus
-Glute medius anterior fibers
-Adductor group
-Semimembranosus/tendinosis
241
What are the lateral rotators of the hip?
-Obturator internus/externus
-Gemelli
-Quadratus femoris
-Piriformis
-Glute max
-Posterior fibers of glute med
-Biceps femoris
242
What is normal hip extension ROM?
10-15 degrees
243
What is normal hip abduction ROM?
30-50 degrees
244
What is normal hip adduction ROM?
25-30 degrees
245
What is normal hip external rotation ROM?
40-60 degrees
246
What is normal hip internal rotation ROM?
30-40 degrees
247
What is the normal angle between the femoral neck and shaft?
125 degrees
248
What is coxa vara?
-Decreased angle between the femoral neck and shaft
-105 degrees
-More horizontal
249
What is coxa valga?
-Increased angle between the femoral neck and shaft
-140 degrees
-More vertical
250
Does coxa vara or valga put someone at higher risk of fx?
Coxa vara because now there is an increased load on the neck of the femur
251
What complications can occur from having coxa valga?
-Increased stress across joint surfaces due to more vertical femoral neck
-Increases overall length of LE
-Decrease physiologic angle at knee
-More likely to get FAI
252
What complications can occur from having coxa valga?
-Results in increased downward shear forces of the femoral head
-Reduces compressive forces but increase shear and torsional forces at the femoral head/neck junction
-More likely to fx
253
What is femoral anteversion?
-Increased anterior angle between neck and shaft of femur in the transverse plane
-Anterior orientation of the femoral neck
-Results in more hip IR
254
What is femoral retroversion?
-Increased posterior angle between neck and shaft of femur in the transverse plane
-Results in more hip ER
-Out toeing gait
255
What are common orthopedic conditions of the hip?
-Avascular necrosis of the femoral head
-Legg-Calve Perthes Disease
-Slipped capital femoral epiphysis (SCFE)
-Stress fracture of the femoral neck
-Hamstring strain
-Hip adductor tendinopathy
-OA of the hip
-Snapping hip
-Trochanteric bursitis
-Hip labral tears
256
What occurs during avascular necrosis of the femoral head?
Variable areas of dead trabecular bone and bone marrow extending to and including the subchondral plate
257
What are the subjective findings of avascular necrosis of the femoral head?
-Pain in the groin, can radiate to the lateral hip, knee, or buttocks
-"Throbbing and deep"
-Most often pain is intermittent and gradual onset
-Antalgic shift
258
What are common risk factors for avascular necrosis of the femoral head?
-Cumulative corticosteroid total dose
-Alcohol use
-Systemic lupus
-Sickle cell disease
-Trauma
-Cancer
259
What are objective findings for avascular necrosis of the femoral head?
-Usually painful ROM, especially IR
-Patients have pain with attempted SLR
-Antalgic gait
260
What is used to diagnose avascular necrosis?
Imaging
261
What interventions are available for avascular necrosis?
Surgery
262
What is the prognosis for avascular necrosis of the femoral head?
-Success is related to the stage at which care is initiated
-Complication of AVN include incomplete fx and superimposed degenerative arthritis
263
What is Legg-Calve-Perthes Disease?
-Idiopathic osteonecrosis of the femoral head in kids aged 4-10 years
-Children are usually malformed with less blood
-The speculated cause is localized manifestation of generalized disorder of the epiphyseal cartilage in the proximal femur
-Unilateral in 90% of patients
264
Who is at higher risk of Legg-Calve-Perthes disease?
4x more common in boys
265
What are subjective findings in Legg-Calve-Perthes?
-Vague ache in the groin that radiates to the medial thigh and inner aspect of the knee
-Muscle spasm
266
What are objective findings of Legg-Calve-Perthes?
-Limp
-Dragging of the leg
-Atrophy of thigh muscles
-Child may be small for their age
-Positive trendelenburg
-Out-toeing of the involved LE
-Decreased abduction and IR
-May be a hip flexion contracture
267
What is used to diagnose Legg-Calve-Perthes?
-Imaging
-AP and frog-lateral radiographs of the pelvis
268
What are interventions for Legg-Calve-Perthes?
-For children less than 6 years old and minimal capital femoral epiphysis and normal ROM, physical exams and radiographs every 2 months
-More severe cases would likely be treated with surgery
269
What is slipped capital femoral epiphysis (SCFE)?
-Displacement of the femoral head through the epiphysis that typically occurs during the adolescent growth spurt
-Femoral head remains in acetabulum and neck is displaced anteriorly
-Most common disorder of the hip in adolescents
270
What are the subjective findings for slipped capital femoral epiphysis (SCFE)?
-Pain exacerbated by activity
-Hx of groin pain or medial thigh pain
-May be mild weakness in the leg
-May be no hx of trauma, can be as minimal as turning over in bed
271
What are the objective findings for slipped capital femoral epiphysis (SCFE)?
-Limp
-Decreased ROM
-The involved extremity may be 1-3 cm shorter
272
What is the only pediatric disorder that causes greater loss of IR when hip is moved into a flexed position?
Slipped capital femoral epiphysis (SCFE)
273
What are risk factors for slipped capital femoral epiphysis (SCFE)?
-Obesity
-Male
-Greater involvement with sports activities
274
What is used to diagnose slipped capital femoral epiphysis (SCFE)?
-Radiographs
-IR with hip flexed to 90 degrees
275
What are interventions for slipped capital femoral epiphysis (SCFE)?
-Relief of symptoms
-Containment of the femoral head
-Restoration of ROM
-Surgical fixation
276
What is the mechanism of injury for a stress fracture of the femoral neck?
-Results from accelerated bone remodeling in response to repeated stress
-Occurs commonly in military recruits and athletes, especially runners
277
Where does a stress fracture of the femoral neck typically occur in older people? What about in younger people?
-Older: superior side of the femoral neck
-Younger: inferior side of the femoral neck
278
What are subjective findings of stress fractures of the femoral neck?
-Onset of hip pain, often associated with recent change in training or change in training surface
-Pain in the deep thigh
-Pain usually occurs with weight bearing or at the extremes of hip motion
279
What are the objective findings of stress fractures of the femoral neck?
-Physical exam usually negative
-May be empty end feel or pain at end ranges of IR & ER
280
What special tests can help diagnose stress fractures of the femoral neck?
-Resisted straight leg raise + for pain
-Auscultory patellar-pubic test +
-Fulcrum test + for pain
-Radiographs
281
What are interventions for stress fractures of the femoral neck?
-Surgically for all tension-side fx
-Bed rest or complete NWB
282
What is a hamstring strain?
-Strain or rupture of 1 or more HS muscles
-Usually takes place during eccentric loading
283
What are the key subjective findings for a HS strain?
-Distinct mechanism of injury w/ immediate pain during full stride running or while decelerating quickly
-May hear a "pop"
-Posterior thigh pain, worsened with knee flexion
284
What are objective findings for a HS strain?
-TTP
-Tenderness reported with passive stretching
-Pain with resisted knee flexion
285
What are rehab timelines for the 3 grades of HS strain?
-Grade I: continue activities
-Grade II: 5-21 days
-Grade III: 3-12 weeks
286
What is the most common adductor pathology?
Hip adductor tendinopathy
287
What is the most common cause of groin pain?
Adductor strain or tendinopathy
288
What is the mechanism of injury for hip adductor tendinopathy?
-Constant exposure to repetitive loading with activities that involve twisting and turning
-Other theory is muscular imbalance of the combined action of the muscles stabilizing the hip joint
289
What are the subjective findings for adductor tendinopathy?
-Twinging or stabbing pain in the groin area with quick starts and stops
-Edema or ecchymosis
-Symptoms are aggravated with running, especially directional changes, kicking, SL exercises, cutting, and lunges
290
What are the objective findings for adductor tendinopathy? What degree of hip flexion targets which muscles?
-Pain with passive abduction
-Pain with resistance
-TTP
-0 degrees: gracilis
-45 degrees: add. longus
-90 degrees: pectineus
291
What are interventions for adductor tendinopathy?
-RICE in acute stage
-Hip adductor isometrics
-Graded resistive program
292
What is the prognosis for adductor tendinopathy?
Most patients fully recover fully or only have minimal pain with high intensity activities
293
What are subjective findings with hip OA?
-Insidious onset of pain
-Progressively worsens with activity
-Painful, limping gait
-Physical activity may induce bouts of pain that last several hours
-May have difficulty climbing stairs & putting on socks
294
What are objective findings for hip OA?
-Early signs include restriction of IR, abduction, or flexion and pain at end range
-Scour +
-FABER may be +
295
What are interventions for hip OA?
-Relieving symptoms, reduce risk of progression
-Education
-Modalities
-Swimming or cycling
-Reduction in BW
-Walking stick
-Joint mobs
-Stretches
-Hip strengthening
296
What is snapping hip?
-Characterized by a snapping or popping sensation that occurs as tendons around the hip move over bony prominences
-Internal: iliopsoas snapping over structures deep to it
-External: snapping of ITB pr glute max over greater trochanter
-Intra-articular: synovial chondromatosis, loose bodies, fracture fragments, and labral tears
297
What are subjective findings of snapping hip?
-Complaints of snapping or popping localized to greater trochanter
-Snapping cause by subluxation of the iliopsoas tendon
-May be complaints of pain associated with the snapping if the trochanteric bursitis is inflammed
298
What are objective findings for snapping hip?
-IT band can be felt subluxing
-Snapping of the iliopsoas tendon may be palpated
-Obers may be +
-Thomas may be +
299
What are interventions for snapping hip?
-Improve muscle length
-Correct strength imbalances
300
What is the prognosis for snapping hip?
Responds well to conservative management
301
What are the subjective findings with trochanteric bursitis?
-Lateral thigh, groin, or gluteal pain
-Pain when lying on involved side
-Pain usually worse when rising from a seated or recumbent position
302
What are objective findings of trochanteric bursitis?
-TTP
-Pain will get much worse with STM
-Resisted abd, ER, or ext painful
-Tightness of hip adductors
-Obers test +
303
What are interventions for trochanteric bursitis?
-Stretching lateral thigh soft tissues
-Flexibility of ER
-Hip abd strengthening
-Establishing muscular balance
-Orthotics
304
What is the prognosis for trochanteric bursitis?
-Responds well to conservative measures
-Corticosteroid injection may help
305
What is the etiology of hip labral tears?
-Trauma
-FAI
-Capsular laxity or hip hypermobility
-Dysplasia
-Degeneration
-Often goes undiagnosed for extended periods of time
306
What are the subjective findings of labral tears?
-Anterior hip or groin pain
-Often mechanical symptoms of clicking, locking, or giving way
307
What are the objective findings of hip labral tears?
-FADIR +
-Anterior or posterior labral tear tests +
308
What are interventions for hip labral tears?
-PT/conservative management: limit pivoting motions, strengthen inhibited muscles, assess foot motion
-Arthroscopic debridement of tear
309
What is femoral acetabular impingement (FAI)?
-Abnormal bony prominences on the neck of the femur or acetabular rim due to contact between the femoral head-neck junction and the acetabular rim
-Impingement occurs with combined movements, usually flexion and IR or ER
-Prolonged impingement can lead to damage to the labrum and subchondral bone
310
What is FAI a precursor to?
OA and labral tears
311
What can PTs do to manage FAI?
-Restore mobility and function
-Decrease pain
-Correct muscular imbalances
-Avoid surgery
312
What is the prevalence of FAI?
-More common in 20-40 y.o.
-Athletes make up 15% of reported FAI cases
-Sport with repetitive end range hyperextension or hyperflexion combined with abduction at an increased risk for labral tears
313
What are the two types of FAI?
-CAM
-Pincer
314
What is CAM FAI?
-Aspherical femoral head
-Bony prominence at anterolateral head-neck junction
-Impinges on the rim of the labrum
-Leads to superior OA
-More common in young athletic males
-FADIR +
315
What is pincer FAI?
-Over-coverage of femoral head by the acetabulum which impinges on the neck of the femur
-Leads to posterior inferior or central OA
-Middle aged females more common
-Hip extension + ER will be painful
316
What percent of patients with FAI have both CAM and pincer impingement?
86%
317
What are common symptoms with FAI and/or labral tears?
-Anterior groin pain
-The C sign
-Described as dull and aching
-Pain is worse with prolonged sitting
-Occasional sharp catching pain with activity
-Increase symptoms with flexion, adduction, and internal rotation
-May limp
318
What activities should patients with FAI avoid?
-End range flexion, adduction, and internal rotation
-Treadmill running as it encourages internal rotation
-Upright cycling
-Sitting with hips flexed and neutral spine for long periods of time
319
What surgical options are there for FAI and/or labral tears?
-Arthroscopic repair
-Trimming of bony rim
-Severe cases may require open operation with larger incision
