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1
Q

Leg-Calve-Perthes

A
  1. AVN of the Femoral Head
  2. MOI: unknown
  3. Hx: 4-10 y/o; 4:1 males; 20% bil; pain in groin, thigh or knee; insidious onset usually with limp (worse w/ activity)
  4. PEx: no int/ext hip rotation; pain w/ motion; hip or knee/thigh pain; Trendelenburg gait
  5. Dx: increased radio density (sclerotic line); flattening of head
  6. Tx: conservative with rest, crutches, PT; containment of head in acetabulum with cast/brace; surgery for severe cases
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2
Q

Slipped Capital Femoral Epiphysis (SCFE)

A
  1. Hx: 10-14 y/o; males; 50% bil; insidious onset w/ hip, groin, thigh, knee pain; obese male, delayed development usually
  2. PEx: spasm, synovitis, reduced ROM; observe ext rotation w/ hip flexion; radio (frog-leg view) shows medial hip dislocation (grade I (50%))
  3. Tx: surgical reduction
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3
Q

Trochanteric Bursitis

A
  1. MOI & Hx: tight IT band; runner w/ trochanteric pain during flexion & extension (increased w/ coxa varum); commonly due to overuse; pain may radiate to groin and/or lateral thigh (1/3 of Pts)
  2. PEx: lay on unaffected side, flex hip w/ leg extended (decubitis pos.); produces aching pain over lateral hip; pain reproduced with ext rotation and abduction and resisted abduction; ITB tightness may be present; positive OBER TEST (decubitis pos. with leg up, lower knee to table to assess ITB tightness)
  3. Tx: modify activity; ITB stretching; steroid injection
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4
Q

Avulsion Hip Fractures (ASIS)

A
  1. Hx: sudden contraction of sartorius; forced contraction w/ knee flexed & hip extended (before a kick); ant lateral thigh parasthesias
  2. PEx: P.O.P @ ASIS; localized tenderness and swelling; flexion & abduction provokes symptoms; pain against hip flexion w/ knee extension; displacement of ASIS in radio
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5
Q

Avulsion Hip Fractures (AIIS)

A
  1. Hx: forced contraction “kicking;” groin pain
  2. PEx: P.O.P @ AIIS; pain against hip flexion w/ knee extended; localized tenderness and swelling; active flexion provokes symptoms
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6
Q

Ischial Tuberosity Fracture

A
  1. Hx: strong hamstring contraction w/ hip flexed and knee extended (hurdles); sudden pain in buttocks, “can’t go on;” difficulty sitting
  2. PEx: hip flexion w/ knee extended reproduces symptoms; P.O.P @ ischial tuberosity; pain w/ straight leg raise and resisted knee flexion
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7
Q

Hamstring Strain

A
  1. Hx: tight, poor warm-up, fatigue; fast contraction, extension of knee; (baseball and track)
  2. PEx: pain w/ resisted knee flexion; P.O.P @ muscle belly; visible or palpable knot
  3. Tx: NSAIDs; PRICE; weight bearing as tolerated; e-stim; stretching bil; pool running; isokinetic strengthening
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8
Q

Piriformis Syndrome

A
  1. Benchwarmer’s Syndrome
  2. Hx: trauma, prolonged sitting, overuse; dull ache in mid-buttocks; pain walking up stairs (from swelling or compression of sciatic n.)
  3. PEx: P.O.P along m.; pain w/ flexion, adduction, internal rotation; may hold leg in ext rotated pos., esp. if in spasm; may have Trendelenburg gait
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9
Q

Iliopsoas Tendonitis/Bursitis

A
  1. Snapping Hip Syndrome
  2. MOI: acute trauma; overuse from repetitive hip flexion
  3. Hx: groin pain worse w/ activity; “snapping” w/ hip flexion
  4. PEx: pain w/ resisted hip flexion; P.O.P over pubic ramus, lateral to neurovascular bundle
  5. Tx: steroids (usually oral); NSAIDs; modify activty; strength/stretch exercises; e-stim
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10
Q

Avulsion Hip Fractures (General)

A
  1. Rapidly growing males w/ mm. stronger than growth plates
  2. Ballistic loading w/ eccentric contracture
  3. D/Dx: muscle strain or contusion
  4. Dx: radiographs
  5. Tx: PRICE; crutches; stretch/strengthening after 2 weeks; return to activity w/ return of strength & function
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11
Q

O’ Donahue’s Triad

A
  1. ACL
  2. MCL
  3. Medial Meniscus
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12
Q

ACL Injury

A
  1. Limits ant. tibial displacement and int. rotation
  2. Female>Male; teens, 20s; sports
  3. MoI: cutting-deceleration-hyperextension (stop & turn in); most non-contact
  4. 60% have O’Donahue’s Triad; 50% have subchondral bone injury
  5. Hx: effusion & tenderness (near patellar tendon); decreased stability
  6. Complications: DJD; decreased stability increases reinjury; long rehab w/ surgery
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13
Q

Anterior Drawer Sign

A
  1. For Dx of ACL injury
  2. supine; knee @ 90 flex; grab leg at prox tibia and pull towards you
  3. 50% false negative
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14
Q

Lachmann’s Test

A
  1. For Dx of ACL Injury
  2. supine; knee @ 15 flex; grab leg at prox tibia and pull towards you
  3. can standardize w/ machine; >3mm
  4. 5-10% false negative
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15
Q

PCL Injury

A
  1. Limits post. tibial displacement and ext. rotation
  2. Less common than ACL; auto accidents #1 cause; sports due to direct blow to prox tibia or hyperextension
  3. Hx: might have “pop;” no edema until 48 hrs; may WB; reluctant to extend knee
  4. PEx: popliteal tenderness; stability (much more than ACL injury)
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16
Q

Sag Test

A
  1. For Dx of PCL injury
  2. supine; thighs @ 90 flex, knees @ 90 flex; support at ankle
  3. sag at tibial plateau sinks below patella –> +
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17
Q

Posterior Drawer Sign

A
  1. For Dx of PCL injury

2. supine; knee @ 90 flex; grab leg at prox tibia and push away from you

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18
Q

MCL Injury

A
  1. deep layer is thickened capsule; major medial stabilizer
  2. football & skiing; involve blow laterally
  3. Hx: very painful increase over time; feel/hear “pop;” knee stiffens up w/in hrs; partial tear more painful
  4. PEx: medial edema/minimal effusion; medial ecchymosis after 24hrs; medial instability when stressed @ 20 flex
  5. DDx: epiphyseal fracture (peds)
  6. Tx: I&II-knee brace hinged w/ locked pos.; III-cast immobilization of primary repair
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19
Q

MCL Injury Grades

A
  1. medial instability when stressed @ 20 flex
  2. Grade I - no opening at medial joint
  3. Grade II - opens w/ firm end point
  4. Grade III - opens w/ soft end point
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20
Q

LCL Injury

A
  1. very rare
  2. from major trauma with knee dislocation
  3. major vascular injury; cruciate & common fib n. damaged
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21
Q

Meniscus Injury

A
  1. fibrocartilage; redistributes pressure
  2. MoI: WB injury; medial-involving cutting; lateral-involving rotation while squatting
  3. Hx: “snap or pop;” may lock right away
  4. PEx: medial or lateral joint line; meniscal impingement tests
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22
Q

Meniscal Tears

A
  1. Bucket Handle: medial more common; prone to locking; younger athletes
  2. Flap: may start as bucket handle; impingement but not locking
  3. Transverse
  4. Torn Horn
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23
Q

Degenerative Meniscal Tears

A
  1. older athletes (>40y/o)

2. minimal trauma; joint line pain w/ activity; recurrent effusions; minimal impingement episodes; can’t squat

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24
Q

McMurray Test

A
  1. provocative meniscal impingement test
  2. supine; knee @ 90 flex & ext rotated
  3. extend leg on thigh w/ varus stress while palpating medial joint line
  4. pain w/ audible/palpable click –> +
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25
Apley Compression Test
1. provocative meniscal impingement test 2. prone; knee @ 90 flex 3. compress leg toward knee while rotating foot ext 4. pain elicited --> +
26
Patella Injury
1. tendency to displace laterally; femoral trochlea restricts lateral movement; females>males 2. Hx: knee flexed @ 20-40 w/ quads contracting; foot ext rot (cutting); "ripping tearing grinding;" immediate effusion; immediate disability 3. PEx: large, tense painful effusion; pain @ retinac + vastus medialis; cannot extend knee past 10-15; medial ecchymosis 12-18hrs 4. Tx: immoblize @ 10 flex & PRICE 48hrs, remove immobilizer to begin ROM exercise; isometric quad contractions; e-stim over vastus medialis m. (2hrs/day); w/ motion, D/C brace for patellar stabilizer 3-6 months
27
Fulkerson Classification
``` 1. For PFD Type I-subluxation Type II-subluxation & tilt Type III-tilt Type IV-no malalignment ```
28
Patella Femoral Dysfunction
1. 25% of all athletes; females>males 2. Patellalgia, ant knee pain, chondromalacia patella, patellar compression syndrome 3. associated w/ partially/compensated FF varus, flex FF valgus, comp congenital gastroc equinas, comp transverse plane deformity 4. PEx: note position
29
Chondromalacia Patella
I-softening/degeneration of AC II-Cleaving of AC III-Cleaving and fronds of AC IV-wearing away of AC to subchondral bone
30
Patella Biomechanics
1. trochlea engaged @ 20-30 flex 2. increases knee extension force by 50% 3. Walking = 0.5 x BW 4. Stairs = 3.3 x BW 5. Squatting = 6 x BW
31
Q-Angle
1. line from ASIS to central patella & line from central patella to tibial tuberosity 2. 14-males; 17-females
32
Plica
1. redundant fold of synovial lining of knee; tears at femoral condyles 2. Hx: gradual onset; "theatre sign;" "pop" during extension if fibrosed; buckling if entrapped
33
ITB Syndrome
1. associated w/ tight ITB; genu varum, runner's varus; causes lateral knee pain 2. Ober's Test
34
Stress Fractures
1. inability to withstand repetitive non-violent force; often due to muscle fatigue 2. 95% in LE; account for 10% of running injuries; women>men; women w/ amenorrhea, low estrogen, more bil stress fractures 3. Hx: tenderness; pain w/ WB; reproduce pain w/ inciting activity; may see slight edema 4. Dx: x-ray (14-21 day rule) 5. Tx: decrease activity; change activity; foot wear; orthoses; immobilization 6. 1st most common met; lateral mall>medial mall
35
Posterior-Medial Shin Splints
1. MoI: overuse of TP m.; due to increased velocity of pronation; eccentric contraction after HS (STJ moments highest) 2. Hx: medial shin pain
36
Anterior-Lateral Shin Splints
1. most common 2. MoI: overuse of TA m.; due to increased velocity of ankle joint DFion; eccentric contraction after heel contact (ankle joint moments highest) 3. Hx: anterior-lateral shin pain
37
Shin Splints
1. Poss. MoI: shoes, running surface, tight opposing m. groups, weak m. groups, running variations, foot morphology 2. Hx: diffuse pain late in workout; more localized as gets worse; not tender on WB; can palpate area of tenderness; running in place hurts 3. Tx: decreased activity; substitute activity; orthoses/shoes; stretch/strengthen; phys therapy
38
Chronic Compartment Syndrome
1. acute is medical emergency 2. MoI: due to high pressures in fascial boundaries causing ischemia; increased pressure due to increased m. volume and intra/extracellular fluid accumulation during activity 3. Hx: dull, achy, stabbing pain along lower limb; preceived m. tightness or fullness; eventually have neurological symptoms; pain subsides after activity (longer activity, longer pain); ant + deep post most affected 4. PEx: have pt exercise; P.O.P along compartment; herniation in 20-60%; decreased neurological sensation + parasthesias 5. Dx: compartment pressures (pre-exercise-15; 1 min post-exercise->30; 5-10min post-exercise-15) 6. Tx: **decreased activity; substitute activity; orthoses/shoes; phys therapy; surgical decompression
39
Achilles Tendonitis
1. 18% of runners exhibit signs 2. poss. due to excess mileage, improper training, inadequate shoes, tight post m. group, excessive pronation 3. Insertional (involves tendon/bone interface, often associated w/ haglund's deformity) v. non-insertional (proximal to insertion) 4. Tx: Binnell Surgery; 1/8" heel lift or medial wedge; achilles tendonitis walking boot; orthoses/shoes; stretching in non-acute cases; ultrasound
40
Non-Insertional Achilles Tendonitis
1. middle-aged weekend athletes; male>female 2. involves avascular zone 2-6cm prox to insertion 3. Hx: pain worse in AM and w/ activity 4. PEx: localized tenderness + crepitus; palpable knot; x-ray may show calcification; Thompson test (squeeze calf, failure to PF --> +)
41
Insertional Achilles Tendonitis
1. overuse enthesopathy 2. often associated w/ retrocalcaneal bursitis; chronic inflammation often results in calcification 3. laterally-seen w/ varus deformities; medially-seen w/ over pronation 4. PEx: erythema + edema; P.O.P @ insertion; worse after exercise; palpable mass post lateral calcaneus; x-ray show some degree of haglund deformity and poss. spur
42
Posterior Tibial Tendonitis (PTTD)
1. linked to excessive pronation; females>males 2. insertional usually occurs @ navicular tub.; acc. navicular often present 3. crepitation w/ motion; pain w/ active/passive everision; pain against eversion resistance; pain w/ heel raise (or weakness); no calcaneal inversion w/ heel raises
43
Peroneal Tendonitis
1. often seen after periods of inactivity followed by intensive workout 2. Brevis-pain @ base of 5th met; Longus-pain @ cuboid area (DDx cuboid syndrome-subluxed) + base of 1st met, 2nd cune; both-pain post to lateral mall
44
Extensor Tendonitis
1. often in skating + skiing 2. weakness of ant compartment and/or tight post compartment 3. ankle joint exhibits rapid PF ("foot slap"); excessive pronation plays a role 4. Tx: modify activity; substitute activity; stretch/strengthen; ultrasound/phonophoresis; soft/rigid orthoses therapy
45
Ankle Sprains
1. PF/Inv-15% of sports injuries 2. Dx: anterior drawer; radio (stress test-10-20: ATFL; >20: ATFL + CFL); squeeze test (compress midcalf-tests tib/fib syndes) 3. Ottawa Ankle Rules 4. Tx: Acute phase (0-3days)-reduce edema, pain, spasm, cryotherapy, compression, elevation, exercise (NWB); Subacute phase (3d-3w): mobility, contractures, strength, proprioception, contrast baths + cryo, air cast, partial/full WB activities, exercise; Repairative phase (3w-3m): full function + return to sport, spot icing, brace, tape, orthoses
46
Ankle Sprain Grades
1st degree-strength?;splint? 2nd degree-stable; functional impairment; some joint laxity; splint + rehab indicated 3rd degree-unstable; repair; BK cast
47
Anterior Drawer Ankle Test
1. supine; hand on tibia and hand on post calcaneus and pull up 2. 4-5mm dev: ok; 8-10mm dev: ATFL; 11-15mm dev: ATFL, CFL, PTFL
48
Turf Toe
1. sprain of 1st MTPJ 2. commonly occurs while wearing flexible shoes on surface like artificial turf; usually caused by hyperextension force 3. Tx: PRICE; avoid WB 2-4d; recovery is 3-4weeks
49
Effects of Immobilization
1. Muscle: reduced size, force, and lengthening; increased CT 2. Articular Cartilage, Bone: decreased mass, volume, strength 3. Ligaments: decreased tensile strength (reduces more even after post-immobilization)
50
Musculoskeletal Impairments
1. Pain 2. Muscle Weakness 3. Decreased Muscle endurance 4. Limited ROM 5. Faulty Posture 6. Muscle Imbalance 7. Joint Hypermobility 8. CT Disorders
51
Interventions to Impaired Mobility
1. ROM 2. Self-stretching 3. Neuromuscular Facilitation and Inhibition Techniques: inhibition of short mm. 4. Muscle Energy Techniques: designed to lengthen muscle + mobilize joint 5. Joint Mobilization/Manipulation 6. Soft Tissue Mobilization 7. Neural Tissue Mobilization
52
SAID Principle
Specific Adaptation to Imposed Demands
53
"Conventional" Approach to post-op rehab of achilles tendon repair
0-4weeks: BK cast (15-30 PFed) @4weeks: begin WB in walking cast or functional brace (limiting DFion to neutral) 6-8weeks: CAM brace; begin AROM
54
Early Remobilization Approach to post-op rehab of achilles tendon repair
0-2weeks: WB as tolerated; AROM limited (15-30 PFed) Brace or splint while WB until 6-8weeks 6-8weeks: progress to 10 DFion
55
Therapeutic Modalities in Inflammatory Stage
1. Minimize secondary injury 2. Decrease inflammatory response 3. Limit edema 4. control pain 5. decrease functional loss
56
Therapeutic Modalities in Proliferative Stage
1. Increase tissue perfusion 2. Increase metabolic rate 3. Control pain 4. Decrease functional loss 5. begin ROM progressive strengthening exercises
57
Therapeutic Modalities in Maturation Stage
1. Optimize alignment of collagen fibers 2. Control pain 3. Decrease functional loss 4. Treat decreased muscle performance
58
Thermotherapy Effects
1. Hemodynamic: increase blood flow 2. Neuromuscular: increased nerve conduction velocity; increased pain threshold (spinal gating mechanism) 3. Metabolic: increased rate of enzymatic reactions (13% per degree) 4. Increased Collagen Fiber Extensibility
59
Thermotherapy Uses
1. Pain control 2. increased ROM and decreased joint stiffness 3. accelerated healing 4. gating of pain transmission 5. decreased muscle spasm 6. reduced ischemia
60
Contraindications & Precautions of Thermotherapy
``` Contraindications 1. acute injury/inflammation 2. hemorrhage 3. Thrombophlebitis 4. Malignancy 5. pregnant Precautions 1. impaired circulation 2. poor thermal regulation 3. edema 4. cardiac insufficiency 5. metal ```
61
Hot Packs
1. require coupling medium (towels) | 2. treatment time: 10-30 min
62
Ultrasound
1. frequency greater than 20kHz | 2. treatment area 4 times surface area of soundhead
63
Nonthermal Effects of US
Increased... 1. intracellular calcium: increased protein synthesis 2. skin and cell membrane permeability 3. mast cell degranulation 4. histamine release 5. macrophage responsiveness 6. fibroblast activity: protein synthesis
64
Clinical Applications of US
1. soft tissue shortening 2. pain control 3. dermal ulcers 4. surgical skin incisions 5. tendon injuries 6. resorption of calcium deposits 7. bone fractures 8. plantar warts

Sports Medicine (1 decks)

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