MEDEX FINAL EXAM FINAL. USE THESE

The “inside out” concept of joint stability applies to the hip. The three layers: 1) the boney congruency and fit of the femoral head into the acetabulum; 2) the strong layer of ligaments surrounding the joint; and 3) the layer of muscles including the deep hip rotators and gluteals, together there layers make the hip  an extremely stable but mobile joint.

The key assessment components include: 1) understand the related  anatomy and pathology; 2)  get a good history and  don't chase the symptoms; 3) think and assess function; 4) select appropriate activities; and 5) listen…the client will tell you what is wrong and needs attention if you listen closely.

MedXPROs provide safe and effective exercise for clients after rehabilitation services are completed. Also, communicate effectively with medical professionals, progress and manage clients to successful outcomes.  Document and report your outcomes and provide lifestyle education to your clients.

The MedXPROs scope of practice includes: 1) Fitness assessments; 2) strength, cardiovascular and flexibility training; 3) functional conditioning; 4) aquatic exercise; 5) weight reduction management;  6) lifestyle education and 7) specialty training including Pilates, Yoga, etc

Red flags include: 1) radiating pain; 2) numbness/tingling; 3) loss of range of motion; 4) loss of function; 5) swelling; 6) nite pain; 7) chest pain/shortness of breath; 8) open wounds and 9) abnormal vital signs. These indicate either refer back to the medical professional or proceed with exercise using caution.

Medical exercise training (MET) is the development and implementation of safe and effective exercise and conditioning programs for clients with medical conditions. MET utilizes exercises as the sole modality to manage medical conditions. Every MES must have a sound background in anatomy, pathology, kinesiology, exercises physiology and biomechanics. These are the medical exercise sciences. MET is not designed to take the place of services provided by licensed medical professionals such as physical or occupational therapists, physicians, nurses or chiropractors.

There are 4 types of joint receptors in the body. The type 1 receptors are found in the joint capsule. Type 2 receptors are found in the deep in the joint capsule. Type 3 receptors are found in the ligaments. Type 4 receptors, pain or nocioceptors, are found in the joint capsule, fat pads and ligaments. The signal of the type 3 receptors reaches the brain before those of the type 4 receptors. This is the “gate theory” of pain management.

Prolonged use of NSAIDs may lead to GI distress. Whenever taking NSAIDs, make the client does so with food in their stomach.

Wolff’s Law simply says by applying resistive training, both muscle and connective tissue are strengthened. But each tissue has a physiologic limit. If exceeded this results in injury, rupture, tear, etc.

Connective tissue structures include: 1) fascia; 2) cartilage; 3) ligaments; 4) adipose tissue; 5) tendon; 6) blood vessels; 7) dermis; 8) bone; and 9) joint capsule.

The inflammatory process begins with trauma or degeneration. The injury or degeneration causes damage to the blood vessel. Blood vessel damage causes hemorrhage. The hemorrhage causes a change in protein permeability. The hemorrhage releases enzymes which will cause vasoconstriction followed shortly by vasodilation. Substances such as histamine, prostaglandins and bradykinin cause vasodilation in the area of the injury. This process leads to the swelling in and around the damaged or injured area.

The six keys to medical exercise program design include: 1) clear understanding of anatomy and pathology; 2) recognize contraindicated exercises/activities; 3) assess key areas using appropriate assessment techniques; 4) incorporate indicated exercises/activities; 5) understand progression guidelines and goals leading to a positive outcome; 6) use a protocol based approach to MET.

Each of the six keys positively impacts the client and the MET program. Understanding the related anatomy/pathology of the condition is essential. Without understanding the anatomy/pathology of the condition you are training the client in the dark. Recognize contraindicated exercises avoided causing the client more pain or exacerbating the condition further. Assessing the key areas and using the key techniques is important to produce a positive outcome. Recognizing indicated exercises and incorporating these into the MET is important to obtain a positive outcome. Establish appropriate goals and use a protocol-based approach are the final components in developing a successful MET program. These six together are essential to MET.

The four joints which are part of the shoulder complex include: 1) the gleno-humeral joint (shoulder mobility); 2) scapula-thoracic joint (stability for overhead activities); 3) acromio-clavicular joint and 4) the sterno-clavicular joint.

There are 3 degrees of movement in the shoulder: abduction-adduction; flexion-extension; internal rotation – external rotation.

The rotator cuff is made up of the: 1) supraspinatus; 2) teres minor; 3) infraspinatus and 4) subscapularis.

The C5 myotome include: deltoid and biceps.

The C6 dermatome includes the thumb side of the hand and forearm.

The ligaments damaged in the anterior shoulder dislocation include: inferior  gleno-humeral ligament; middle gleno-humeral ligament and superior gleno-humeral ligament.

Within the subacromial space you will find the subacromial bursa, the supraspinatus tendon, and the biceps tendon.

• Gleno-humeral joint – shoulder dislocation
• Acromio-clavicular joint – ac joint separation
• Scapulo-thoracic joint – winging scapula
• Sterno-clavicular joint – arthritis or subluxation

With shoulder impingement the subacromial spaces diminishes to 7mm or less.

With impingement syndrome the structured damaged include subacromial bursa, supraspinatus tendon, and biceps tendon.

Other conditions similar to impingement are ac joint separation and bicipital tendinitis.

Usually the proximal portion of the biceps is involved.

AC joint separation is associated with pain with overhead activities above 135 degrees and heavy lifting.

The client will report having no pain with sleeping on the shoulder at night.

The ratio should be rotator cuff exercises 2 to deltoid exercises 1. The ratio is 2:1.

The primer set is used to warm-up the rotator cuff or posterior shoulder girdle prior to deltoid or pectoralis exercise. The engaged the rotator cuff to pull the humeral into the glenoid and the posterior shoulder girdle to stabilize the scapula.

Axial distraction is the medical term for the opening of the gleno-humeral joint or the pendulum exercise.

The humeral head is forced out of the gleno-humeral joint usually due to a fall on an outstretched arm. The gleno-humeral ligaments are damaged. The key ligament damaged is the inferior gleno-humeral ligament. The rotator cuff may be damaged with the dislocation. Occasionally nerves or blood vessels may be damaged with a shoulder dislocation.

The shoulder capsule begins to deteriorate. These leads to the capsule adhering to itself. The capsule sticking to itself causes the freezing of the shoulder. The shoulder thaws with time. Usually the frozen shoulder lasts 14 months.

The frozen shoulder results in lack of movement. Over time this may weaken the rotator cuff. Strengthening of the cuff as the client gradually regains motion will hasten functional return.

The inferior gleno-humeral ligament is the key stabilizer in the shoulder.

The glenoid fossa is deepened by the labrum. The labrum makes the shoulder more stable.

3 key exercises following the shoulder dislocation include seated pushups, rotator cuff strengthening and limited ROM chest flyes.

The primary indicator for a TSR is loss of function. Trauma, arthritis and/or multiple dislocations lead to severe gleno-humeral damage and eventually replacement. Pain, limited ROM and weakness equals loss of function.

The most crucial factor in TDR recover is the return of strength in the rotator cuff.

A medical clearance is required for use of the pendulum after the surgical repair of the rotator cuff.

Fair strength is the ability to move the extremity through the full range of motion against gravity and return it to the start position without assistance.

The carpal bones include the: 1) scaphoid; 2) lunate; 3) triquetral; 4) pisiform; 5) trapezium; 6) trapezoid; 7) capitate and 8) hamate.

The wrist flexors include the flexor carpi radialis, flexor carpi ulnaris, flexor digitorium profundus/superficialis and palmaris longus.

Wrist extensors include the: Extensor Digitorum, Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis, Extensor Carpi Ulnaris, Extensor Indicis, Extensor Digiti Minimi, Entensor Pollicis Longus and Extensor Pollicis Brevis

Interrosseous Membrane attaches between the ulna and radius.

The median nerve passes beneath the transverse carpal ligament to enter the hand.

The collective name for the small ligament structures along the medial aspect of the elbow is “deltoid ligament”.

The ulnar nerve innervates the flexor carpi ulnaris and flexor digitorum profundus.

Layperson’s terms for medial and lateral epicondylitis include Golfer's Elbow and Tennis Elbow respectively.

The MET criteria to begin training a client with medial epicondylitis are: 1) medical clearance; 2) minimal swelling and pain (< 4 on pain scale); 3) full ROM; 4) full upper extremity motor function and 5) sensation intact

The MET criteria for lateral epicondylitis are: 1) medical clearance; 2) minimal swelling and pain (<4 on pain scale); 3) full hand motor function and 4) sensation intact.

Numbness and tingling in the IV and V digits indicate involvement of the ulnar nerve.

Goals for carpal tunnel syndrome include: 1) improve and maintain wrist & hand strength/ROM; 2) strengthen forearms (pronation/supination); 3) stretch anterior shoulder girdle; and 4) strengthen posterior shoulder girdle. The criteria for carpal tunnel are: 1) fair grip and wrist strength; 2) minimal pain (<4 on pain scale); 3) medical clearance and 4) if the client is prescribed a brace, it is worn during the session.

Carpal tunnel will cause numbness and tingling along the distribution of the median nerve. The median nerve is a branch off the brachial plexus. Thoracic outlet syndrome may produce similar symptoms as carpal tunnel due to the compression of the brachial plexus. Because the median nerve is a branch off the brachial plexus, compression of it will produce carpal tunnel like symptoms.

The median nerve innervates the thumb, index finger, middle finger, and lateral aspect of the ring finger, flexor retinaculum, transverse carpal ligament, and the flexor tendons.

The vertebral foramen houses the spinal cord. The vertebral foramen is formed by the posterior arch of the vertebrae and the vertebral body. The intervertebral foramen is formed but the articulation of the inferior articular process of the superior vertebrae and the superior articular process of the inferior vertebrae below and the posterior wall of the vertebral body. The spinal nerve passes through the intervertebral foramen.

The spinal motion segment includes the vertebra above, the vertebra below, the disc in between and the posterior articular structures. The spinal motion segment is the basic unit of spinal motion.

In spinal extension the facet joint closes, the intervertebral foramen closes, and the nucleus moves anteriorly.

During spinal flexion the nucleus moves posteriorly, the intervertebral foramen opens and the facet joint opens.

The facets are formed by the inferior/superior articular processes. The facets control motion in the spine. They prevent excessive extension, side bending and rotation. The facet joints are covered with cartilage and are highly susceptible to injury and damage.

The intervertebral end plate is made of fibrocartilage, which is not durable and the most often damaged structure in the spine. Damage to the intervertebral end plate may lead to arthritic changes and will inhibit the movement of nutrients through the end plate and into the disc.

The anterior longitudinal ligament is a strong band that covers the anterior surface of the vertebrae. It runs the length of the spine. This limits extension and supports intervertebral discs. The posterior longitudinal ligament is found along posterior aspects of the vertebrae within the vertebral canal and extends along the posterior surfaces of the vertebral bodies within the spinal canal. It minimally prevents hyperflexion of the vertebral column and serves as a reinforcement to prevent posterior spinal disc herniation. It narrows at points along the posterior aspect of the vertebral body, so it does not fully prevent disc herniations.

Degenerative joint disease will lead to spinal stenosis. Spinal stenosis is a result of damage to the intervertebral end plate and facet joints, causing narrowing of the both the intervertebral and vertebral foramina. Spinal arthritis is known as “DJD”.

The disc herniation occurs when the annular fibers are torn, and a portion of the nucleus migrates through tears (herniates) in the annulus. Disc herniations usually occur because of multiple tears over an extended period. Disc herniations usually do not occur due to one activity. It's imperative the disc herniation client refrain from repetitive spinal flexion and sitting as both cause the disc to move posteriorly and compressing the nerve root.

The question asks about motor control not strength. Lower extremity motor control is important criteria for lumbar clients. Long term DJD or disc herniations may cause nerve compression. This may lead to impaired motor function. Loss of motor function in the lower extremities may be an indication for surgical intervention. Significant weakness in the quads, hip adductors, tibialis anterior and extensor digitorium longus indicate loss of motor control with a long-term lumbar disc herniation or nerve root compression.

Lateral stenosis involves compression of a nerve root as it exits the intervertebral foramen. Lateral stenosis usually presents with unilateral back and/or leg pain distributed along with dermatome of the compressed nerve root. Central stenosis is narrowing of the vertebral foramen and compression of the spinal cord. This may occur at any level of the spine. Central stenosis may present as low back and bilateral leg pain with prolonged standing or walking which is eliminated with sitting or spinal flexion.

Lumbar extension reduces sciatica because the movement pushes the disc anteriorly relieving compression of the nerve posteriorly.

Higher disc pressure is associated with sitting. Sitting and spinal flexion significantly increase disc pressure. Supine lying significantly reduces disc pressure and minimizes pain.

Managing a spinal disc herniation requires these 3: 1) spinal stabilization based on finding and maintaining neutral spine; 2) cardiovascular training and 3) lower extremity strengthening. These are essentials for all lumbar conditions not just herniation.

Spondylolisthesis usually occurs with forced and traumatic spinal extension. This is often seen with football linemen. The forced extension fractures the posterior arch of the vertebrae. This then allows the vertebrae to translate forward and possibly compress the spinal cord and/or spinal nerves.

The most common mechanism of injury with the lumbar disc herniation is via spinal flexion with uncontrolled rotation. These two movements place maximal tension on the annular fibers. The uncontrolled rotation is the “triggering” force that tears the annulus.  Usually a series of annular tears result in the actual herniation at a later point when the client is lifting and twisting.

Extreme or forced hyperextension of the spine results in fracture of the posterior vertebral arch.

The MET criteria for the spondylolethesis client include: 1) full LE motor control and function; 2) full bowel and bladder control; 3) medical clearance; 4) slippage less than 5 mm; and 5) pain less than 4 on 1-10 scale

There are a significant number of conditions that may cause sciatica including: disc herniation, spondylolethesis, DJD, facet joint syndrome, SI joint dysfunction, lateral stenosis, central stenosis, and piriformis syndrome. Other conditions are injection, cancerous lesion, avascular necrosis, etc.

Laminectomy is indicated with disc herniation, nerve root compression, DJD. Nerve root compression is the primary reason for lumbar laminectomy. Laminectomy is performed after all conservative measures have been exhausted and the client makes little progress.

Patient is gowned. 2. IV line is started. 3. Once under anesthesia, a urinary catheter is inserted. 4. Hair may be clipped off the surgical site. 5. On the operating table, the patient is either positioned on the side or stomach. 6. Anesthesiologists constantly monitor HR, BP, breathing, and O2 sat during surgery. 7. Skin of the surgical site is cleaned with an antiseptic solution. 8. Surgeon makes an incision over the selected vertebra. 9. Surgeon then separates muscle tissue. 10. Surgeon remove lamina to ease the compression on nerves. (May involve removing bone spurs/growths or removing all or part of the disc). 12. Incision is closed with surgical staples or stitches. 13. Sterile bandage or dressing will be applied.

The MET criteria for laminectomy: 1) full LE motor control and function; 2) full bowel and bladder control; 3) medical clearance; 4) slippage < 5mm; 5) pain <4 on 1-10 scale.

Spinal fusion indications included failed back surgery; severe spinal instability; severe trauma; severe degenerative arthritis. There are numerous reasons for spinal fusions.

Same procedures as seen in the laminectomy. The surgeon removes the intervertebral disc between affected vertebrae. 7. Bone chips are then packed between the vertebrae. 8. Hardware is used to fusion the vertebral segments. 9. Surgeon close incisions with surgical staples or sutures.

Immobilization of the client will happen for first 2-4 weeks. Muscle activation of the trunk musculature is then introduced with neutral spine techniques. Functional capacity is improved along with overall leg strength. It is important to emphasize spinal stabilization while managing client.

Ankylosing spondylolitis (AS) is a painful inflammatory condition which begins with fusion at the SI joints and works its way superiorly in the spine. AS is usually seen in adult males of Eastern European descent. The fusion positions the spine in flexion. Clients with long-term AS have a severe forward bent posture.

To manage scoliosis, begin by looking at the C's not the S. Manage the spine in sections. Begin at the inferior portion of the spine and work superiorly. 2. Stretch the concave component using a fulcrum to stretch the client. 3. Strengthen the convex areas as the muscles in these areas need strengthening.  4. Start with the lower "C": Any functional changes that are made in the inferior "C" will be seen the superior "C". 5: Rinse and repeat….stretch and strengthen over and over again.

Piriformis syndrome is usually associated with SI joint dysfunction. The fallacy is piriformis syndrome is simply a dysfunction of the muscle. With piriformis syndrome look for SI joint involvement. If the piriformis syndrome is chronic refer to a DO for SI adjustment. Several conditions look like piriformis syndrome including sciatica, lateral stenosis, disc herniation and SI joint dysfunction.

The MET goals for the piriformis client are: 1) establish stretching program; 2) correct sacral fault; 3) improve hip strength; and 4) improve functional capacity.

The primary signs and symptoms of cervical disc herniation are localized pain the cervical spine as well as pain radiating down the arm, numbness and tingling and muscle weakness. The pain and other symptoms occur along the dermatome and myotome distribution pattern of the nerve root being compressed.

The MET criteria for the cervical disc herniation client include: 1) No radiating pain (< 4 on pain scale; 2) no numbness and tingling; 3) full UE motor function; 4) No headaches; and 5) clearance from MD, DC or RPT

The most common radiculopathy occurs at C5-C6, followed by C6-C7. These are the two most common locations for radiculopathy in the neck. Radiculopathy also commonly referred to as compressed nerve. Radiculopathy can result in pain (radicular pain), weakness, numbness, or difficulty controlling specific muscles.

Each cervical nerve root has a sensation and muscle distribution pattern known respectively as the dermatome and myotome. The pain patterns associated with these will produce radiating pain, numbness/tingling, weakness in the muscles in the dermatome/myotome.  It’s important to know which nerve roots are affected as well as clearance from the physician. This makes the MET program much more effective.

Management of cervical spine herniation begins with controlling inflammation; 2) limit c-spine motion to avoid painful ranges; 3) as often as possible decompress the segment; 4) remember surgical intervention is an option after conservative measures have been exhausted.

Avoid excessive cervical flexion; increase cervical spine stability and strength; teach how to decompress C-spine.

With cervical disc herniation clients, the assessment should include: 1) c-spine ROM exam; 2) check UE strength and neuro testing; 3) check sensation in the UE; and 4) check ROM and function in the UEs.

Obtain a thorough medical history from the client prior to beginning the spinal screening.

The two are very similar. The “straight leg raise” test (SLR) is a simple test to check possible nerve root compression or disc herniation in the lumbar spine. The test is performed with the client supine and passively lift the leg into hip flexion while maintaining knee extension and the ankle in neutral position. LaSegue's Sign is performed in the same method as the SLR. LaSegue’s differs by maintaining ankle dorsiflexion, which creates more tension in the sciatic nerve and the lower extremity. Both tests determine if a nerve root compression or disc herniation is present. LaSegue’s is the more sensitive test.

The Thomas Test assesses the IT band, the psoas, the sartorius, and the rectus femoris.

The Ober Test assesses the IT band.

Patrick’s/Faber test assesses the hip capsule for flexibility.

Leg length discrepancies are seen in the femur and/or the tibia.

The ligamentum teres attaches from the femoral head into the acetabulum. Its primary function is proprioception. Degeneration will cause a decrease in proprioception and stability in the hip.

The osseous or boney structures that form the ball and socket of the hip are the femoral head which inserts into the “acetabulum”. The acetabulum is covered with hyaline cartilage. The joint has boney congruency which contributes to hip stability.

Think of the three layers of hip stability from the “inside out”. The layers begin with the boney congruency found with the articulation of the femoral head and acetabulum; the second layer is ligamentous. The strong ligaments of the hip, which have calcium deposits are very strong. Finally, the muscles including the deep hip rotators and the gluteals are the final muscle layer. These 3 give the hip enormous mobility and stability.

Deep rotators or the deep 6 include the: 1) Piriformis; 2) Quadratus Femoris; 3) Obturator Internus; 4) Obturator Externus; 5) Gemellus Superior; and 6) Gemellus Inferior. They are located deep to the gluteus maximus and attach to the greater trochanter. These originate on the pelvis or sacrum They all laterally rotate the hip.

The greater trochanter is a major muscle attachment landmark for the deep rotators and gluteals. Removal of the greater trochanter due to surgery or injury would cause a huge loss in function due to reattachment of muscle tendons to different sites. This is due to the change in the length tension ratio with the change of attachment.

The major ligaments of the hip include the: 1) iliofemoral ligament; 2) ischiofemoral ligament; and 3) the pubofemoral ligament.

Three degrees of freedom at the hip mean the ability to move the hip in 3 planes of movement. These degrees include flexion/extension, internal/external rotation and abduction/adduction.

As osteoarthritis develops in the hip the attachment of the ligamentum teres to the acetabulum is destroyed. This results in primarily the loss of proprioception along with a slight loss of stability.

The procedures used to assess the arthritic hip include: 1) Faber Test; 2) Thomas Test and 3) Ober Test.

The strong boney congruence in the hip is responsible for its stability. As the acetabulum lining and the femoral head deteriorate their congruence decreases. This increases with time and arthritic changes. Eventually the hip become unstable and increasing pain. Also, muscle strength and joint stability decreases.

Common reasons for hip replacement under 55 include trauma or disease related situations. High doses of steroids due to cancerous lesions or organ transplants are often reasons for hip replacements under 55.

There is a network of blood vessels supplying blood to the femoral head. Fracture of the femoral head will rupture the blood vessels. The loss of the vascular flow will result in tissue death due to lack of blood supply or avascular necrosis.

There are two surgical approaches to hip replacement: 1) posterior approach (the most common) and 2) the anterior approach becoming more popular. The contraindicated movements for the posterior approach are hip flexion beyond 90 degrees, adduction across the midline and hip internal rotation. The anterior approach contraindications are exact opposite. Avoid hip extension, hip abduction and hip external rotation.

Key exercises for the total hip replacement clients may vary depending on the equipment available. Hip extension, hip abduction and activities to increase overall leg strength in the involved extremity.

Hip resurfacing requires minimal bone loss and minimal ligament involvement. After surgery there is faster recovery and quicker return to full function. There is less possibility of co-morbidity since this procedure involves limited hospital stay or may be performed on an outpatient basis.

The Thomas Test assesses the hip flexor, knee extensors and the IT band.

The client is positioned on the table seated on the very edge. The ischial tubs are on the table. The client brings one knee to the chest and then reclines on the table. The leg in held in the chest. The opposite leg is free on the table. Review the leg’s positioning on the table specifically the assess the rectus femoris, psoas, It band and the sartorius.

The Faber test assesses the hip capsule for flexibility and is best used to assess arthritic changes.

A positive Trendelenburg Sign indicates weakness of the gluteus medius.

Performing the Ober test in a client with greater trochanteric bursitis would cause pain. The test positioning requires the client to lay on the side which compresses the trochanteric bursa.

The two joints making up the knee are the patella-femoral joint and the tibio-femoral joint. Pathologies in the patella-femoral joint include patella-femoral syndrome. At the tibio-femoral joint: they are ligament sprains of the ACL, PCL, MCL, and LCL along with the meniscus tears.

Contributions of the ligaments to knee stability include: ACL = 84-88%; MCL = 4-6%; LCL = 1%;

The menisci are primarily avascular. Only the outer portion or periphery of the menisci are vascular.

ACL ruptures occur with the knee is in a more extended position while a rotary force is applied.

PCL ruptures usually occur with a knee in flexion position with an anterior blow to the tibia.

Retro-patella contact shifts superiorly as the knee flexes from 0 - 135º.

The Q-angle is measured by extending a line from the anterior superior iliac spine to the center of the patella, and then from the center of the patella through the tibial tubercle. The angle between the two lines is the Q-angle.  Normal Q-angle ranges are: Men - 10-12º & Women - 15-18º

Genu Valgus is knocked kneed or when the angle at the knee is increased. This creates a more severe Q-Angle. Genus Varus is the opposite when the knees are bowed. This is known as "bowed legs”. The Q-angle is higher with genu valgus. The Q-angle could be negative with genu varus.

The screw home mechanism is slight rotation of the tibia at the end of knee extension. It is due to the size difference in the femoral condyles. The medial condyle is the larger condyle.

ACL ruptures occur when the foot is planted, the knee is in extension, and there is rotary force applied to the knee.  The force results in rupture of the ACL. The client will feel or hear a pop or snap. Swelling occurs within hours. Blood is present in the joint fluid when the physician examines the joint.

The ACL contributes as much 88% of knee stability. This has a big impact on active clients and/or athletes. Without knee reconstruction there is an 87% chance the client will damage the meniscus with intense physical activity. Meniscal tears lead to arthritic changes in the knee with time.

The terrible triad which is the rupture of the ACL and MCL and tear of the medial meniscus. This is an extremely unstable knee. These knees require reconstruction.

The two most common knee reconstruction grafts are the patellar tendon graft and the hamstring graft. The patella tendon graft is taken from a cadaver or the client’s opposite knee or a cadaver. The graft is 110% stronger than original ACL. Patella tendon grafts should begin physical therapy within 7-10 days of surgery. Hamstring grafts are not as strong (79 – 82% of ACL strength) but with these grafts do not require immediate physical therapy.

Knee swelling results in quad atrophy as well as reduced muscle fiber recruitment of the vastus medialis (VM) including the vastus medialis oblique (VMO). Knee swelling will cause VM and VMO reduced firing which can lead to maltracking of the patella and patella-femoral syndrome.

Surgical reconstruction of the PCL is extremely difficult due to the location of the ligament at the posterior edge of the tibial plateau. Recent advances with robotics have increased the surgical repositioning and success of PCL reconstruction.

During healing of the MCL and LCL sprains both require avoidance of specific movements. The MCL sprains should avoid the last 5 degrees of knee extension. The LCL sprains should avoid full knee flexion. These restrictions are temporary until the ligament has healed.

The two pathologies are similar. The quadriceps tendon rupture occurs above the patella. The quadriceps tendon rupture occurs below the patella. Both are caused by a fall on a fully flexed knee.

The 3 primary factors with patella-femoral syndrome (PFS) are: 1) weak vastus medialis and vastus medialis oblique; 2) tight IT band; and 3) strong vastus lateralis.

Larger Q-angles significantly increase the possibilities of lateral tracking of the patella. The lateral tracking of the patella will eventually cause wear and damage to the retropatella surface. This results in damage to the hyaline cartilage along the retropatella surface. Damage to the cartilage and wear of the retropatella surface results in pain, swelling and inhibition of the quadriceps.

The menisci are shock absorbers and reduce friction in the knee. Meniscal tears, with time, become more severe. The tear continues to wear, even with surgery. The wear comes from normal activities and sports after injury. Arthritic changes develop and become more severe over time. If the arthritic changes become severe enough, the client will experience swelling, pain and quadriceps inhibition. They will begin to lose function of the knee. Eventual loss of function will require a joint replacement.

The primary indication for total knee replacement is loss of function. TKR is usually a voluntary procedure. Usually the client has severe arthritic changes or some major pathology leading to the replacement. Pain, swelling, loss of range of motion alone are not reasons for knee replacement. But the combination of these results in lost function. This is the indication for the total knee replacement.

Usually total knee replacements allow about 110 to 120 degrees of knee flexion.

The anterior drawer test assesses the integrity of the ACL. It should be used to determine if the ACL is intact. Only medical professionals should perform the anterior drawer test.

Lachman’s test allows assessment of ACL integrity while eliminating hamstring involvement. Lachman’s should be used whenever the hamstrings are influencing the anterior drawer test. Only medical professionals should perform the Lachman’s test.

Both tibial and femoral discrepancies result in leg length discrepancies. Either tibia or femur length may have a discrepancy.

Hip flexor tightness is indicated when the free leg demonstrates hip flexion when correctly positioned with the Thomas Test. The femur instead of being flat on the table will show hip flexion.

During the Ober Test a tight IT band will show as inability for the top foot to touch the surface the client is laying on.

There is 1 degree of movement in the ankle – dorsiflexion and plantarflexion

The ankle mortis is a bony arch deep in the ankle formed by the articulation of the medial malleolus of the tibia and the lateral malleolus of fibula. These sit on top of the talus. The fit of the talus into the arch formed by the tibia and fibula is the mortis. The calcaneous sits below the talus. Hyaline cartilage covers the talus well as the inner portion of the medial and lateral malleoli.

The ligaments along the lateral aspect of the ankle include: 1) anterior talo-fibular ligament; 2) posterior talo-fibular ligament and 3) the calcaneo-fibular ligament.

Collectively the ligaments along the medial aspect of the ankle are known as the deltoid ligament.

The peroneus longus and brevis both are ankle evertors.

The nerves of the foot include the tibial nerve, deep peroneal nerve, medial plantar nerve, lateral plantar nerve, rural nerve, intermediate dorsal cutaneous nerve, and medial dorsal cutaneous nerve.

The most common fracture site in the ankle is the lateral malleolus.

Most often damaged ligaments in the ankle are the anterior talo-fibular and the calcaneo-fibular ligaments.

The MET criteria for the ankle fracture client include: 1) minimal pain (< 4 on pain scale); 2) independent ambulation; 3) medical clearance from surgeon is surgery performed; and 4) ability to wiggle the toes.

The assessment to look at ankle ligament stability is the anterior drawer test. This assesses the anterior talo-fibula and calcaneo-fibular ligament.

Middle aged males are the usual clients sustaining Achilles tendon ruptures.

For the ankle sprain the 3 essential exercises are: 1) seated calf raises: 2) standing calf raises; and 3) eversion strengthening.

The anterior drawer assesses the integrity of the anterior talo-fibular ligament, which is the most often injured ligament in ankle sprains. To perform the anterior drawer, the client sits on table with the legs hanging off unsupported. The examiner stabilizes the lower leg (tibia and fibula) just above the ankle with one hand. The other hand cupped around the heel of the foot, the examiners sharply pulls the rear hand forward, looking for a "hard end feel”. This indicate stability in the anterior talofibular ligament. This should only be performed by a medical professional.

Thompson’s Test is used for clients with potential Achilles tendon rupture. The test is performed with the client in a prone position. The MES grips and squeezes the meaty superior gastronemius/soleus complex. Look for slight plantar flexion. An intact Achilles tendon is indicated by slight plantar flexion. No movement indicates a tear of the Achilles. Also, a noticeable divot may be noticed along the posterior aspect of the Achilles complex.

Homan’s Sign looks for possible blood clots from thrombophlebitis, a condition characterized by the formation of blood clots in the veins. Clients will complain of tightness or stiffness in the calf area. The risk of thrombophlebitis is higher after a recent surgery. Perform the test with the client supine while the examiner moves the foot into forced dorsiflexion. If the client experiences significant pain or discomfort along the posterior aspect of the calf, they should be referred to their physician or surgeon to be evaluated for the presence of blood clots.

The anterior drawer test in the ankle assesses the anterior talo-fibular ligament and to a lesser degree the calcaneo-fibular ligament.

Thrombophlebitis is characterized by the presence of blood clots. Blood clots develop in blood vessels.  Symptoms that include localized pain, possibly swelling and redness. The risk of thrombophlebitis increases with recent surgery.

Complications from diabetes include: stroke, kidney dysfunction, cardiovascular disease, neuropathy, and amputation.

The primary risk factors for diabetes include overweight (fat deposits in the abdominal region and apple shape), sedentary lifestyle, and family history.

Insulin is produced by cells in the pancreas - the Islets of Langerhan. Type 1 diabetes, these cells are destroyed and unable to produce insulin. Insulin is required to allow blood glucose to enter cells to support the essential maintenance and function of cells. If glucose cannot get into the cells, then there is systemic and connective tissue deterioration with time. Excessive glucose in the blood stream binds to hemoglobin causing oxygen depletion. Type 2 diabetes, insulin is produced, but because of lifestyle consequences, the body becomes resistant to insulin, and glucose cannot get into the cells, and increases its presence in the bloodstream. Exercise has an insulin like affect on the body.

Symptoms associated with diabetes include: blurred vision, nausea, vomiting, abdominal pain, polyuria (production of abnormally large volumes of dilute urine), glycosuria (excess sugar in the urine), hyperventilation, central polydipsia (abnormal great thirst), polyphagia (excessive hunger and eating). Symptoms more prominent in Type 1 are weight loss, lethargy  and smell of acetone on the breath.

Management of diabetes includes: oral hypoglycemic drugs to reduce blood glucose levels; Insulin to allow glucose to enter the cells (administered by needle, pump, or pen); exercise and diet. Exercise significantly assists with control blood glucose levels. Surgery may be indicated for complications resulting from unsuccessful medical management such as neuropathy.

The typical diabetic client presents with central obesity, high BP, high triglycerides, low HDL, insulin resistance, sedentary lifestyle. Later complications may include tissue slow to heal, deterioration of tissue, foot blisters, and reduced sensation in fingers and toes.

Neuropathy is nerve damage caused by lack of cell maintenance and breakdown of neurons due to lack of glucose reaching the cells. This may result in lack of sensation into fingers and toes.

MET criteria for diabetic clients include: 1) medical clearance from physician; 2) ability to self-monitor blood glucose; 3) acceptable BP values; 4) blood glucose values between 90-240 mg/dl (communicate with physician for acceptable values)

Start each session with a blood glucose check. This should fall between 100-240 mg/dl. Have a snack or juice available during the session. Engage the large muscle groups during long duration and low intensity exercise.



Type 1 - 50-60% Vo2 max, 5-7 days a week, 20-30 mins

Type 2 - 50-60% Vo2 max, 4-5 days a week, 40-60 mins

Diabetic exercise precautions include: 1) check blood glucose before exercise; 2) long warm up before exercise; 3) use RPE scale for exercise intensity; and 4) check feet periodically for blisters.

Medical complications associated with hypertension include: 1) kidney dysfunction; 2) cardiovascular disease; 3) cerebrovascular accident; 4) heart attack; and 5) congestive heart failure (with pitting edema).

Risk factors associated with hypertension include: 1) genetics; 2) age; 3) race; 4) unhealthy diet; 5) physical inactivity; 6) obesity; 7) excessive alcohol; 8) tobacco consumption; and 9) diabetes.

Essential hypertension is of unknown cause. Secondary hypertension is a result of a diagnosed medical condition such as pregnancy, hypothyroidism, renal failure.

Common complications associated with hypertension include: CVA/stroke; elevated blood sugar levels; hypertensive retinopathy; myocardial infarction (heart attack); congestive heart failure; and chronic renal failure.

Due to increased blood pressure, greater effort is required to pump blood in the hypertensive client. This eventually leads to greater stress on the heart, particularly the left ventricle. The muscle wall of the left ventricle becomes thinner and weaker, wearing with time, becoming over worked and resulting in an enlarge heart. This sequela results in congestive heart failure. The most common symptom is pitting edema in the ankles.

Management of hypertension begins with diet and exercise strategies. If blood pressure measures are still elevated, then medications are administered beginning with diuretics. If blood pressure is still not controlled, then beta blockers are applied. These are followed by calcium channel blockers and finally treated with ACE inhibitors. Lifestyle changes rather than medications are the optimal choice.

Exercise precautions include: 1) long warmup with prior to exercise; 2) use RPE (beta blockers may affect HR); 3) check BP before each session (160/100 or less for cardiovascular exercise/180/85 for resistance training); 4) terminate session if BP exceeds 220/110 or greater than 20 point drop in SBP; and 5) establish safe BP levels via communication with MD.

The MET criteria for the hypertensive client is pretty simple: 1) medical clearance from treating physician; 2) check BP 160/100 or less; 3) no unstable angina or arrhythmias; and 4) they are being managed medically. Medical clearance is necessary to determine if the client is appropriate for exercise. Blood pressure should be checked prior to each session. No client shall enter the MET program with unstable angina or arrhythmias. These two are beyond the scope of MET management. Finally, every hypertensive must have ongoing supervision of a MD, DO, PA or RN-P.

Begin each session with BP check. Should be 160/100 or less (or the established level from MD). Training should follow a low intensity and long duration program at 40-65% intensity, 30-60min, 4-5 days a week. For resistance training, use 30-50% of 1 rep max, BP 180/105 or less (level determined by MD). Exercise should not exceed 10-15reps, 30-45sec with 60 sec rest, light resistance-high reps, 10-12 exercises max, and use RPE.

Systolic blood pressure is pressure when the heart is pumping. The diastolic is the pressure when the heart is at rest. The difference between the two is pulse pressure.

There are two types of cerebrovascular accident. The hemorrhagic stroke is associated rupture of a blood vessel and HTN. The ischemic stroke results in blockage of blood vessels and is associated with diabetes.

Hemiparesis means weakness on one side of the body. Hemiplegia is a greater loss of strength to the point of paralysis on one side of the body. In strokes motor function is always affected on the opposite or contralateral side of the body as the ruptured artery in the brain.

Flaccidity is the loss of muscle tone after stroke. There seems to be a greater number of inhibitory cells which have survived the stroke. These cells inhibit movement.

Spasticity is an increase in muscle tone on the opposite side of the stroke. There seems to be a greater number of faciliatory cells which have survived the stroke. Spasticity is increased involuntary muscle tone after stroke. This may lead to flexor or extensor synergies.

The physical characteristics after stroke include loss of motor function and skills on contralateral side of the body due to hemiparesis or hemiplegia. Motor function is affected on the opposite side of the body as the stroke. Motor function may be impaired with increased muscle tone (spasticity) or decreased muscle tone (flaccidity).

There may be visual field deficits. Cranial nerves including the optic nerve, the hypoglossal nerve are affected on the same side as the stroke. Other characteristics may include bowel/bladder dysfunction. Speech limitations and/or cognitive limitations.

The middle cerebral artery is most associated with stroke. The middle cerebral artery is a branch off the Circle of Willis. Rupture or occlusion causes loss of blood supply to large area of the brain causing tissue death or infarction. Motor function on the contralateral side of the stroke and cranial nerve function on the ipsilateral side of the stroke are affected.

CVA exercise precautions include checking BP and/or blood glucose prior to each session. The BP should be less than 160/100 or the established level from MD. If diabetic, blood glucose levels should be between 90-240 mg/dL.

Don't provoke or try to work through spasticity. Avoid objects in the palm of hand. These will cause the flexor synergy and closure of the hand. Avoid unwanted movements. If aberrant movements occur terminate the activity/exercise and move to another region and begin exercise. Train proximal to distal as proximal stability gives distal mobility. Start with core, shoulder, and pelvic girdles.

Multiple sclerosis is a slow progressive disorder of the CNS in which the destruction and deterioration of the myelin sheaths causes scaring. This impairs nerve impulses diminishing neurological control of bowel/bladder, motor control, vision deficits, GI dysfunction, gait and balance dysfunction, and body temperature regulation.

Multiple sclerosis has many symptoms. These include spasticity, weakness, contractures, easy fatigue, paresthesia, double vision/diplopia, gait ataxia, intermittent tremor, difficulty regulating changes in temperature, and loss of bowel bladder control.

Located deep in the brain, cells of the substantia nigra, a part of the basal ganglia, which produce dopamine, are destroyed. Dopamine is a neurotransmitter which controls movement and coordination. Without dopamine we see tremors, rigidity, shuffling gait, bradykinesia, forward tilt of trunk, balance dysfunction, and speech impairment. The client may also have bowel/bladder dysfunction and visual field deficits. These components result in limited movement, balance dysfunction and other neurological characteristics.

Osteoarthritis begins with the breakdown of articular cartilage. This may be result of trauma/injury or aging (wear and tear). Cartilage damage leads to Inflammation of the synovial membrane, swelling and pain which causes muscle inhibition and limited ROM leading to decreased strength and joint changes. The degenerative cascade of arthritic changes begin in the joint and with time, wear (mother nature), gravity, weight gain, inactivity, and smoking, lead to severe OA including bone spurs and pain.

NSAIDS (nonsteroidal anti-inflammatory drugs) are used to manage and decrease pain and inflammation, thereby increasing mobility. NSAIDS may cause GI discomfort requiring the client to eat prior to taking the NSAID. Common NSAIDs include Naprosyn, Voltaren, etc

Hip - strengthen deep hip rotators, directly adjacent to the joint, and gluteals. Use gentle distraction techniques (stretching only). Improve overall leg strength. Avoid prolonged postures (especially hip flexion which increases compression of the femoral head in the acetabulum).


Knee - avoid high impact/compression. Recruit VM, strengthen quads and adductors. Check for PFS (stretch ITB).

Shoulder - work in limited and pain free ROM. Strengthen rotator cuff and posterior shoulder girdle. Improve stability with seated pushups/small movement. Use PNF for mobility, stability (allows shoulder to move in normal patterns/planes for functional activities).

Connective tissue structures include: 1) ligaments; 2) synovial membrane; 3) tendons; 4) fatty tissue; 5) bone; 6) blood vessels; 7) cartilage and 8) joint capsules.

OA - bone spurs with localized deterioration of the joint due to injury, wear and tear of cartilage and bone. Usually unilateral, with hips, knees, and low back mostly affected. Managed with exercise, NSAIDs, TJR.

RA - autoimmune disease with systemic destruction of connective tissue by enzymes release by the synovium affecting joints throughout the body. Usually bilateral affecting the small joints of hands, elbows, wrists, cervical vertebra mostly affected.

Connective tissue structures are subject to deterioration by RA which affects the cardiovascular system and other organs as well. RA affected joints are more sensitive to activity than osteoarthritic joints. Limit reps and sets, give plenty of rest between sets and at least 2 days between sessions. Overworking causes more deterioration and pannus in the joint worsening the condition. RA is managed with NSAIDs, corticosteroids, gold salts, splints, and braces.

Common fractures sites associated with osteoporosis include: 1) thoracic vertebrae; 2) distal radius and 3) femoral head.

Cortical bone is compact dense bone which forms the outer protective shell of bone. Cortical bone makes up 80% of skeletal mass. Cortical bone is found in the shafts of long bones. Trabecular or cancellous bone is the inner spongy bone which gives bone its resiliency. Trabecular bone is the inner framework of bone. It’s more affected with osteoporosis and more more susceptible to fractures  as the disease progresses.

There are many conditions which could fall in the same category as fibromyalgia. The fibromyalgia diagnosis requires the have 11 of the 18 common trigger points, no positive findings on medical testing; at least 3 months history of body pain, and a history of trauma. Many FM clients are treated by multiple practitioners. These are common characteristics of fibromyalgia.

There is no cure for FM but exercise can improve and maintain function. Changes are seen in type I and II muscle fibers, although mostly in type II resulting in decreased muscle fiber size, atrophy, and weakness; changes in contraction time; reduced mitochondria levels; loss of dynamic joint stability, and constant pain.

Characteristics associated with FM include persistent ache, non-restorative sleep, fatigue, morning joint stiffness, subjective swelling, paresthesia, numbness, tingling, nausea, and menstrual problems.

MET guidelines for FM include: 1) low intensity exercise at 50% of IRM; 2) emphasize stability training of the core, pelvic and shoulder girdles in existing ranges; 3) incorporate stretching to maintain, not increase range; 4) incorporate and prioritize cardiovascular training to increase VO2 max; 5) do not ask how the client feels. Instead focus on function….. "What have you done since your last session”?

10 Points of the musculoskeletal Screening: 1. Posture; 2. Active Shoulder Range of Motion; 3. Anterior Shoulder Flexibility; 4. Cervical ROM; 5. Resisted Internal/External Rotation; 6. Full Knee Extension; 7. Resisted Knee Extension and Flexion; 8. Knee to Chest; 9. Hamstring Flexibility; and 10. Balance

The medical history interview should be conducted verbally prior to screening or assessing the client. This allows the MES to identify red flags and determine if the client is appropriate to begin MET. The MES must explain to the client that they need to get as much information as possible to develop a program that is effective and safe.

• Cervical Spine Oswestry used to assess cervical conditions and dysfunction.
• Functional scale for the ankle used to assess for an ankle fracture.
• Functional status index used to assess neuro, senior and other clients.
• Harris Hip Scale used to assess function in clients with hip disorders
• Lysholm’s knee scale is used to assess an ACL reconstruction
• Lumbar Oswestry Scale used to assess lumbar conditions and post-surgery outcomes.
• Functional Shoulder Strength Scale used to assess shoulder function with a wide range of conditions.
• Tinetti gait and balance scale is used to assess a gait and balance capabilities.
• Functional Scale for Ankle Assessment used to assess ankle and some foot function.

Functional assessment scales (FSAs) will become important to the medical exercise profession in the future to validate the use of exercise is managing medical conditions to positive outcomes. FSAs provide a snapshot of the client’s function capacity at the beginning, middle and end of MET services. Functional assessment scales will MedXPROs the ability to better estimate the number of sessions and outcomes for future clients. These will become a more useful tool at MET becomes more widely used.

The 7 keys are: 1) have a passion for medical exercise  and managing the MET client; 2) Seek medical exercise education rather than fitness based education; 3) develop a MET marketing plan; 4) become part of the local medical community; 5) Establish referral relationships with medical professionals; 6)  become the fitness and exercise expert in your community; 7) develop Multiple Streams of Income coming into your practice.

Proximal = in proximity to or closer to

Distal = distant or further away from

• S- Supraspinatus
• I- Infraspinatus
• T- Teres Minor
• S- Subscapularis