-
Hip joint
(talk about joint- stability, size)
most stable
largest
-
Lesions of the hip are detected during what type of activity?
walking/ weight bearing
-
Where do lesions of the lumbar refer to?
lumbar spine, SI, anterior thigh and knee
-
What type of joint is the hip?
multiaxial ball and socket
-
what structures form the acetabulum?
ilium, ischium, pubis
-
3 ligaments that support the hip
iliofemoral (strongest ligament)
ischiofemoral
pubofemoral
-
The ligaments tighten in ______ and also ______rotation
extension
internal rotation
-
Resting/loose pack position of the hip
30d flexion
30d abduction
slight ER
-
forces on the hip:
during standing
.3 times body weight
-
forces on the hip:
standing on 1 limb
2.4-2.6 times body weight
-
forces on the hip:
walking
1.3-5.8 times body weight
-
forces on the hip:
walking on stairs
3 times body weight
-
forces on the hip:
running
4.5 + times body weight
-
neck shaft angle for a 1 yr old
148d
-
neck shaft angle for an adult
120-125d
-
neck shaft angle larger than 120-125d is termed....
coxa valga
-
neck shaft angle smaller than 120-125 is termed....
coxa vara
-
normal anteversion (femoral condyle axis/femoral head axis) of hip is _____at birth
30d
-
normal anteversion (femoral condyle axis/femoral head axis)of the hip is ______ for an adult
8-15d
-
muscles of the hip
glute max, glute med, glute min, piriformis
-
where is the trochanteric bursa?
over greater trochanter beneath glute max
-
Is congenital hip dysplasia more common in girls or boys and when is it more common?
more common in girls
during infancy
-
presence of snapping is termed_____
coxa saltans
-
How do you get snapping of the hip?
explain in detail about iliopsoas,
iliopsoas tendon slips over the osseous ridge of the lesser trochanter or anterior acetabulum
-
How do you get internal snapping of the hip?
iliofemoral tendon rides over femoral head which occurs at 45d when hip goes from flexion to extension
-
How do you get external snapping of the hip?
Tight IT band or glute max tendon slides over the greater trochanter occurs during hip flexion and extension and is made worse if hip is in MR
-
How do you get intra-articular snapping of the hip?
acetabular labral tears or loose bodies-patient complains of sharp pain into the groin and anterior thigh, especially on pivoting movements
clicking heard and felt when patient is adducted and LR
-
Dermatomes
- L1= groin
- L2= medial thigh
- L3=medial patella
- L4=medial malleolus
- L5=top of foot
- S1=lateral border of foot
- S2=behind knee
-
Myotomes
- L2=hip flexion
- L3=knee extension
- L4=dorsiflexion
- L5=great toe extension
- S1=ankle PF and eversion
- S2=knee flexion
-
Reflexes
patellar tendon = L4
achilles S1
-
hip issues and gait
painful hip is shorter on stance
stiffness causes trunk rotation
B hip flexor tightness increases lordosis
-
AROM of LE
flexion
extension
abduction
adduction
ER
IR
- flexion=100-120
- extension 10-15
- abduction-30-50
- adduction=30
- ER=40-60
- IR=30-40
-
End feels of hip movements
flexion
extension
abduction
adduction
ER
Ir
- flexion-tissue approximation or tissue stretch
- extension-tissue stretch
- abduction-tissue stretch
- adduction-tissue approximation or tissue stretch
- ER-tissue stretch
- IR-tissue stretch
-
capsular pattern of the hip
flexion, abduction, and MR order may vary
-
rectus femoris length test
supine, 1 leg over edge of table, flex other to chest
look for extension of lower leg at the knee joint
-
Ober's test
sidelying, extend and abduct upper leg, lower leg and test, leg remains abducted
tight TFL/ITB
-
ROM needed for tying shoes
120d of flexion
-
ROM needed for sitting
112d of flexion
-
ROM needed for stooping
125d flexion
-
ROM for squatting
115 flexion
20 abd
20d IR
-
ROM needed for ascending stairs
67d flex
-
ROM needed for descending stairs
36d flex
-
ROM for putting foot on opposite thigh
120 d flex
20 abd
20 ER
-
ROM needed for putting on pants
90 flex
-
Craig/Ryder test
prone, knee flexed to 90d
rotate hip until greater trochanter is parallel with table
estimate angle of leg with the vertical hip anteversion/ MR of femur
-
hip scourer
hip flexed 90d
pressure down thru femur
look for pain
-
piriformis special test
sidelying
hip flexed to 60d, flex at the knee and push hip into adduction
look for pain/parasthesia-compression of sciatic nerve
hold for 60secs, goal is reproduce radiating symptoms
-
sign of the buttock
SLR supine
if limitation-bend knee
look for instability to increase in flexion= serious pathology of hip
-
true hip pain is referred to where?
groin, but also ankle, knee, lumbar spine and SI joint
-
inguinal ligament
runs from ASIS to symphysis pubis
-
sciatic nerve
under piriformis or between ischial tuberosity and greater trochanter
-
General info about Legg-Calve-Perthes Disease
what does it lead to later? who it affects? causes?
-self limiting
-often leads to severe DJD later in life
-affected children between 2-12 most commonly in boys (4 to 1 ratio)
-causes: metabolic bone disease, thrombotic vascular insults, trauma, infection
-
Clinical presentation of Legg-Calve-Perthes
-child 2-12
-gradual onset of pain, increase with activity
-aching sensation in groin, thigh, knee
-limited PROM abduction and IR
-antalgic gait
-decreasing leg length
-
interventions for Legg-Calve-Perthes
-skin traction
-bracing (abduction)
-PT for strengthening and gentle ROM
-
General info on Slipped Capital Femoral Epiphysis
when it occurs? what happens? what happens to growth plates and what causes it? what happens to femoral head during weight bearing? cause?
-occurs during adolesence
-epiphysis slips from its normal position on the femur makes the growth plate become disorganized as fibrous tissue increases
femoral head displaces inferiorly and posteriorly during weight bearing
idiopathic
-
clinical presentation of capital femoral epiphysis
-2 to 1 ratio boys to girls
-boys 10-17 girls 8-15
-75% of cases occur with obese children with delayed maturation
-usually vague pain, can be in hip but also common in knee
-ROM limited in IR, abd and flex--ext may be increased
-position of comfort-flex, ER, abd
-
interventions for capital femoral epiphysis
surgery, bracing
seen in PT for ROM and strengthing
-
Trochanteric bursitis
pain over lateral hip and occasionally down the lateral thigh to the knee when the IT band rubs over the trochanter
-
psoas bursitis
-pain in groin or anterior thigh and possible into the patellar area
-aggravated during activities requiring excessive hip flexion
-
ischiogluteal bursitis
pain is experienced around the ischial tuberosities, especially when sitting, occasional sciatica if inflammation affects nearby sciatic nerve
-
impairments/problems with bursitis
-pain when involved overlapping muscle contracts when stretched
-gait deviations
-imbalance in muscle flexibility and strength
-decrease muscular endurance
-
management of bursitis (acute)
-rest
-ice, other anti-inflam tx
-
management of bursitis (subacute and chronic)
-stretching (psoas and ITB)
-strengthening and endurance training (isometics, controlled WB exercise, biking walking)
-functional activities
-
etiology of piriformis
-sciatic nerve passes deep
-entrapment results in sensory changes along lateral and posterior portion of the leg and dorsal/plantar surface of the foot
-progressive weakness in hamstring, portion of the adductor magnus and other muscles of the leg and foot can develop
-
common impairment/problems with piriformis syndrome
-exacerbated with sitting
-complain of deep buttock pain, radiating pain down leg
-often confused with radiating pain from a lumbar problem; when x-rays, MRI's are negative patient is dismissed as all in youre head
-
management of piriformis (acute)
rest, ice, and other anti-inflam treatments
-
management of piriformis (subacute/chronic)
-ultrasound
-soft tissue mobilization to piriformis
- -stretching of piriformis
- stretch as many times a day
- piriformis is an ext, abd, ER until 90d then changes to IR
- -stretch/strengthen may be muscle imbalance due to
- tight ITB, hamstrings, weak adductors
-
knee joint is _______ (size)
largest
-
what type of joint is the knee?
modified hinge
-
femoral condyles are ________concave/convex?
convex
-
medial tibial plateau is _______concave/convex?
concave (slightly)
-
lateral tibial plateau is _______concave/convex?
concave in the front
convex in the sagittal
-
does the medial or lateral condyle project more anteriorly?
lateral to prevent subluxing
-
normal Q angle for men? for women?
men 13d
women 18d
-
how many facets does the patella have? name them!
3
lateral, medial, odd (medial side of patella)
-
lateral and medial facets are sub divided into proximal, middle and distal pairs for a total of how many facets?
7
-
name quad muscles:
rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
-
what is the function of the VMO?
pull patella medially to prevent from subluxing laterally
-
what muscles is affected first with knee joint effusion?
VMO
-
name the hamstrings muscles:
biceps femoris, semitendinosus, semimembranosus
-
name the hamstrings muscles that are lateral? that are medial?
lateral-biceps femoris
medial-semitendinosus, semimembranosus
-
what makes up the pes anserine? where is it?
sartorious, gracilis, semitendinosus
located on medial aspect of tibia
has bursae that is commonly irritated
-
popliteus muscle-where is it? what does it do?
crosses behind knee, lateral aspect of femur to medial tibia
helps with the screw home mechanism
-
what does the gastroc do?
flexes the knee in open chain
-
describe the medial meniscus
C shaped, thicker posteriorly,
large and skinny
-
describe the lateral meniscus
O shaped, same thickness throughout
short and fat
-
how are the menisci attached to the tibia?
by coronary ligaments
-
how much motion does the lateral meniscus have?
10 mm
-
how much motion does the medial meniscus have?
2 mm
-
meniscus moves ______with knee flexion
meniscus moves _______with knee extension
posterior (flexion)
anterior (extension)
-
what is the medial meniscus attached too?
MCL, semimembranosus, ACL
-
what is the lateral meniscus attached to?
popliteus tendon and PCL
-
what is the function of the menisci?
shock absorption, depress weight, make joint surfaces more congruent
-
Collateral ligament facts
tight in extension, loose in flexion
tight in ER of tibia
-
MCL resists _____forces
valgus
-
LCL resists _____forces
varus
-
MCL connects to....?
medial meniscus and semimembranosus
-
LCL connects to....?
biceps femoris
-
attachments of ACL
starts posterior/lateral on femur
courses anterior/medial to attach on tibia
-
when is ACL most taut?
throughout entire knee motion
-
has how many bands? name them!
3 bands
anteromedial
posterolateral
intermediate
-
When is the anteromedial portion of the ACL tight?
during knee flexion, somewhat in extension too
-
when is posterolateral portion of ACL tight?
knee extension
-
when is the ACL at its "loosest"?
30-60d
-
is it vascularized and innervated?
YES
-
ACL tigthens in MR/LR?
MR
-
PCL attachments
starts anterior/medial on femur and attaches posterior/lateral on tibia
-
is the PCL vascularized and innervated?
YES
-
Arcuate ligament complex...what does it do? what is it?
-strengthens the posterior lateral capsule
-Y shaped band of deep capsular fibers that attach distally to the fibular head, fanning proximally over the posterior capsule and a portion of the popliteal tendon
-
Posterior oblique popliteal ligament--what does it do? what is it? what does it limit?
-supports the posterior-medial capsule
-an expansion of the semimembranosus tendon
-limits anterior-medial instability
-
Joint capsule- what is it? where does it go? what does it contain?
-like a cylinder with a posterior invagination
-courses around the ACL/PCL
-has up to 3 folds called plicas
-
patellar tendon.....is it a tendon or a ligament?
TENDON
-
patella alta
patellar tendon too high, more than 20% longer , more likely to have problems with instability
-
patella baja
patellar tendon too low, 80% or less length of patella, some say more likely to have compressive disorders
-
Iliotibial tract...what is it? what does it attach to?
-fascia lata of the thigh that arises from the TFL and tendon of glute max
-attaches to lateral condyle of tibia, and vastus lateralis and lateral patellar retinaculum
-
Screw-home mechanism with flexion
tibia IR and femur ER
-
screw home mechanism with extension
tibia ER and femur IR
-
screw home mechanism with extension (incorporating menisci)
tibia moves anterior, menisci move anterior too
-
screw home mechanism with flexion (incorporating menisci)
tibia moves posterior, menisci move posterior too
-
which way does the medial meniscus go when the femur IR on the tibia
with IR of the femur on the tibia the medial meniscus goes POSTERIOR
-
which way does the lateral meniscus goe when the femur IR on the tibia
with IR of the femur on the tibia the lateral meniscus goes ANTERIOR
-
during flexion/extension menisci travel with ______
TIBIA
-
during rotation menisci travle with _______
FEMUR
-
ER tightens which ligaments?
COLLATERALS
-
IR tightens which ligaments?
CRUCIATES
-
Resting/loose pack of the knee
25d flexion
-
Closed pack position of the knee
full extension, LR of the tibia
-
capsular pattern of the knee
flexion then extension
-
hyperextension stretches out which ligament?
ACL
-
isolated medial rotation of the tibia results in what?
ACL tear
-
dashboard affects which ligament?
PCL
-
Valgus, anterior forces of the tibia and forced ER of the tibia affects what and is called what?
MCL, ACL, medial meniscus
Terrible Triad
-
hyperflexion results in what?
meniscal injury
-
if you hear clicking what does that suggest?
patellofemoral issue
-
"pop" at the time of accident suggests
ACL tear
-
theatre sign
pain with prolonged sitting with knee flexed
suggest patellofemoral problems
-
joint locking suggests
meniscal tear
-
Osgood- Schlatters
enlarged tibial tuberosity
-
-
-
MR of the tibia on the femur (knee flexed to 90) ROM
20-30d
-
LR of the tibia on the femur (knee flexed to 90d) ROM
30-40d
-
end feels:
flexion
extension
MR of tibia
LR of tibia
patellar movements
- flexion=tissue approximation
- extension=tissue stretch
- MR of the tibia=tissue stretch
- LR of the tibia=tissue stretch
- patellar movements=tissue stretch all directions, should not translate laterally more than 1/2 of its body width without tilting or rotating
-
who do you do a ligament screen on?
EVERYONE!
-
valgus stress test at 0d extension 30d flexion =
MCL
-
varus stress test at 0d extension and 30d flexion =
LCL
-
Lachman's/ Anterior Drawers =
ACL
-
-
one plane medial tests which ligament?
MCL
-
one plane lateral tests which ligament?
LCL
-
one plane anterior tests which ligament?
ACL
-
one plane posterior tests which ligament?
PCL
-
Anteromedial rotary tests which ligaments?
MCL first than ACL
-
Anterolateral rotary tests which ligaments?
ACL, LCL
-
Posteromedial rotary tests which ligaments?
PCL, MCL
-
Posterolateral rotary tests which ligaments?
LCL, PCL
-
anteromedial rotary tests is called?
Slocum
-
anterolateral rotary test is called?
pivot shift
-
posteromedial rotary test is called?
hughston's posteromedial drawer
-
posterolateral rotary test is called?
external rotation
recurvatum
-
describe the posterior drawer test
patients lies supine knee bent to 90d
thumbs on jt line
push posterior on tibia
looking for increase in posterior motion
-
describe the lachman's test
anterior drawer in 15-30d flexion
patient sitting c leg rest on examiners knee
examiner stabilizes with hand and forearm
-
describe the slocum test
15d of lateral rotation
do anterior drawer test
motion occurs mostly on medial side showing anterior medial instability
-
describe the lateral pivot shift
knee extended or slightly flexed, medial rotation of tibia
apply valgus/forward pressure at the proximal tibia then flex the knee
-
clunk from lateral pivot shift is what?
reduction of tibia (tibia going back in place)
occurs at 30d of flexion
-
reduction from lateral pivot shift is what?
occurs because at 30d of flexion ITB drops below the center of rotation of the knee and then jerks the tibia posteriorly back in place
-
describe hughston's posteriomedial drawer test
tibia slightly medial rotated
push tibia posterior
if there is a lot of movement it suggests PCL,MCL,ACL tears
-
describe external recurvatum test
patient lies with legs extended
grasp big toes and lift legs
if knee hyperextends and tibia rotates laterally suggests LCL PCL tears
-
describe anterior drawer test
junk test
one plane anterior
suggest ACL but can be false due to help from collaterals
-
describe the McMurray test for medial meniscus
knee in full flexion, ER tibia, valgus pressure at knee extend knee
-
describe the McMurray test for the lateral meniscus
knee in full flexion, IR of tibia, varus pressure at knee then extend knee
-
swelling within 1-2 hours suggests?
think blood which suggests ligament tear, osteochondral fracture or peripheral meniscus tear, doughy feel, hot joint
-
swelling within 8-24 hours suggests?
think synovial fluid, suggest joint irritation, fluctuating or boggy feeling
-
describe plica syndrome
irritated soft tissue medial to knee
capsular
presents like patellofemoral issue
occurs from repetitive motions
-
describe the brush test
start medial to inferior patella, brush up 2-3 times, then start lateral and brush down lateral aspect
positive sign is a wave of fluid going back to medial area
-
describe the McConnell Test
isometric contraction of quads at 0, 30, 60, d 10 secs each
-compare pain level to same contraction with slight medially directed pressure on the lateral edge of the patella
-if less pain, patellar tracking problem (lateral) indicated
-
what is the Q angle?
measure by ASIS thru midpoint of patella and tibial tubercle through midpoint of patella
-
describe the apprehension test
knee at 30d flexion, examiner pushes patella laterally
quad will fire and patient will be apprehensive for tendency of patella to dislocated laterally
-
describe the noble compression test
supine, flex knee to 90d
pressure applied to lateral femoral condyle or 1-2 cm proximal to it, thumb and knee passively extended
-at 30d short of full extension, patient will complain of pain
-
you palpate the jt line for what kind of injury?
meniscal tears
-
palpating patella facet
relaxed quads, push patella medially and laterally to check for tenderness
-
palpating suprapatellar pouch
proximal to base of patella
lift skin with thumb and finger
feel for thickness, tenderness or nodule
-
palpating MCL
medial to tibiofemoral joint, feel for tenderness
-
palpating pes anserinus
medial and distal to tibial tuberosity, check for tenderness
-
etiology of symptoms of Anterior knee pain (patellofemoral issue)
-direct trauma
-imbalance of soft tissues aligning the patella in the trochlear groove and influencing patellar tracking
-increasing Q angle
-insufficient VMO muscle
-
common impairments/problems with anterior knee pain
(9)
1. weakness, inhibition or poor recruitment or timing of VMO
2. outstretched medial retinaculum
3.tight lateral retinaculum, IT band, or facial structures around the patella
4. decreased medial glide or medial tipping of the patella
5. pronated foot
6. pain on palpation
7. tight gastroc, hamstring, or rectus femoris
8. irritated patellar tendon or subpatellar fat pad
9. pain with long term sitting (theatre sign)
-
Management of anterior knee pain (acute)
-modalities, rest, protection, gentle submax multi angle isometrics
-
management of anterior knee pain (subacute)
mobile the patella
friction massage
medial tipping of the patella
patellar taping
stretch of IT band
strengthen VMO
-
what does taping of the patella allow for?
more vigorous exercise
pain relief so you can exercise them
-
what are the exercises that strengthen the VMO
-quad sets
-SLR
-SAQ
-weight bearing terminal knee ext
-squat
-lunge
-
management of anterior knee pain (remodeling stage)
functional activities
increase resistance
activity specific drills
-
mechanisms of injury of meniscal tears
-medial more commonly injured
-often foot fixed on ground and femur is IR or ER
-
common impairments/problems of meniscal tears
joint locking
pain along joint line
knee effusion/swelling
-
describe a bucket handle tear
longitudinal
loose, not attached to tibial plateau so you can pick it up like a bucket handle
-
describe a radial meniscal tear
perpendicular to edge
-
non-operative management of meniscal tears
- reduction of loose body
-general open and closed chain exercises to improve strength of leg musculature
-weight bearing may be limited for some time to aid in healing of meniscus
-
non-operative management of MCL/LCL strains
general open and closed chain exercises to improve strength of leg musculature
limit medial and lateral stress/rotational stress
avoid varus/valgus functional activities
-
post-operative management of an ACL tear
often in slight flexion
sometimes none at all
-
how strong is the ACL? before you tear it...
tear comes from 652 lbs or more
graft is equal or better
-
what weight do you pull out the ACL?
230lbs- bone tendon bone
this is your worry initially
6 weeks bone plug healed
-
what makes the tibia not slide forward?
ligaments
hamstrings
meniscus/joint geometry
weight bearing
-
maximum protection phase of ACL: (5)
1. RICE
2. gentle isometric contraction of quads and hams
3. patellar glides
4. ambulation weight bearing varies some full
5. ROM
-
moderate and minimal protection phase of the ACL
-advancement and vigorousness of ROM and strengthening exercise, increasing intensity of closed chain rehab
-
precautions of ACL tears
-terminal knee extension in open chain will cause anterior translation of tibia
-closed chain provides more stability via joint compression and firing of hamstrings
-graft is at its weakest at approx 6 wks
-
what % of the population have foot complaints?
80%
-
general functions of the foot (4)
-acts as a support base with minimal muscular effort
-mechanism for rotation of the tibia/fibula during stance
-flexibility to adapt to uneven terrain, and shock absorption
-acts as a lever at push off
-
rearfoot/ hindfoot bones in foot
talus and calcaneus
-
forefoot bones of the foot
navicular, cuboid, 3 cuneiforms
-
talocrural joint (ankle joint) characteristics
-uniaxial, modified hinge, synovial joint
-talus, medial and lateral malleolus
-much more mobile while in PF
-
medial ligament in foot:
-deltoid
-medial collateral ligament
-
superficial medial ligaments in foot: what are they and what do they do?
tibionavicular
tibiocalcanean
posterior tibiotalar
**resist talar abduction
-
deep medial ligaments in the foot: what do they do? what are they?
anterior tibiotalar
**resist lateral translation and lateral rotation of the talus
-
anterior talofibular ligament: medial/lateral? what does it do?
lateral
resists excessive inversion
often sprained 1st
-
posterior talofibular ligament: medial/lateral? what does it do?
lateral
resists DF,adduction, MR and medial translation of the talus
-
calcaneofibular ligament: medial/lateral? what does it do?
lateral
resists inversion
sprained 2nd
-
subtalar joint
articulation between the talus and calcaneous
-
midtarsal joint
combination of 2 joints: calcaneo-cuboid and the talo navicular
-
talocrural joint resting pack, closed pack, capsular pattern
resting/loose pack: 10d PF, neutral inversion/eversion
closed packed: maximum DF
capsular pattern: PF, DF
-
normal transmalleolar angle
12-18d
-
normal toe out angle
5d as a child
12-18d as an adult
-
foot loading during gait: walking, running, jumping
walking- 1.2 x body weight
running- 2 x body weight
jumping- (2 feet) 5 x body weight
-
arches of the foot maintained by:
-wedging of the interlocking tarsal and metatarsal bones
-tightening of ligaments of the plantar aspect of the foot and plantar fascia
-instrinsic and extrinsic muscles and tendons of the foot
-
medial arch is made up of:
calcaneus, the talus, the navicular, the three cuneiforms, and the 1, 2, 3, metatarsals
-
lateral longitudinal arch is made up of:
calcaneus, the cuboid, and the 4, 5 metatarsals
-
transverse arch is made up of
cuneiforms, the cuboid, and the five metatarsal bases.
-
line of Feiss is made up of what?
medial malleolus, navicular, 1st metatarsal head should be in line with weight bearing
-
Anterior tarsal tunnel contents
-deep peroneal nerve passes under the extensor retinaculum
-motor loss-extensor digitorum brevis
sensory-small triangular area between the first and second toes
-
tarsal tunnel contents:
medial malleolus, calcaneus, and talus on one side and the deltoid ligament on the other
-tibial nerve passes through
-pain and paresthesia into the sole of the foot
-
biomechanics of the foot: heel strike
name foot position and ankle postions
foot: supination-->pronation
ankle: moving into PF
-
biomechanics of the foot: flat foot
name foot position and ankle position
foot: pronation
ankle: PF to DF
-
biomechanics of the foot: midstance
name foot positon and ankle positon
foot: neutral
ankle: 3d DF
-
biomechanics of the foot: heel off
name foot position and ankle position
foot: supination
ankle: 15d DF
-
biomechanics of the foot: toe off
name the foot position and ankle position
foot: supination
ankle: 20d PF
-
where do sprains most generally occur?
in PF inverted and adducted
-
high heeled shoes contribute to what condition?
heel cord tightening
-
swelling above lateral malleolus suggests?
fibular fracture or disruption of syndesmosis
-
swelling posterior to lateral malleolus suggests?
peroneal retinacula injury
-
swelling distal lateral malleolus suggests?
inversion ankle sprain
-
asymmetrical calf bulk could suggest?
peripheral nerve or nerve root involvement
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what is a pump bump and what does it suggest?
build up of bone and callus on posterior calcaneus
results from pressure on heel
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lateral malleoulus extends farther ______
medial malleolus extends farther _______
distally
anteriorly
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what are bone spurs? how do you get them? where do they commonly occur?
abnormal bone growth
get them from irritative lesion, overuse, trauma or excessive pressure
occur at the dorsal aspect of the tarsometarsal joint, head of the 5th metatarsal, calcaneus, insertion of plantar fascia, superior aspect of navicular bone
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hallux valgus: what is it?
-medial deviation of the head of the first metatarsal bone in relation to the center of the body and lateral deviation of the head in relation to the center of the foot
-as metatarsal bones move medially, the base of the proximal phalanx is carried with it
-phalanx pivots around the adductor hallucis muscle
-bunion-combination of callus, thickened bursa and exostosis
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hallux rigidus is what?
extension of big toe is limited
causes: OA of the 1st MTP joint, abnormally long 1st metatarsal bone, pronation of the forefoot or trauma
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describe claw toe:
hyperextension of the MTP and flexion of the proximal and distal IP
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describe hammer toe:
extension of the MTP and flexion of the proximal IP, distal can vary
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describe mallet toe:
flexion of the distal IP
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-
-
-
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how many degrees of DF does it take to DESCEND stairs?
20d DF
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what does walking require of the foot?
10d DF
20-25d PF
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describe the test for tibial torsion
supine, align femoral condyles parallel with floor and have patient contract quad to hold
-look at angle formed from malleoli and floor
norms can be 12-30d
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describe the anterior drawer sign of the foot
patient lies supine, examiner stabilizes the tibia and fibula, holds the patients foot in 20d of PF and draws the talus forward in the ankle mortise
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describe Thompson's test
patient prone, with feet over edge of table
squeeze calf muscle and foot should PF if the Achilles Tendon is intact
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describe Tinel's test of the foot:
tap the front of the ankle (joint line) for the anterior tibial branch of the deep fibular nerve
-posterior tib nerve may be impinged as it passes behind the medial malleolus
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if there is extracapsular edema what does that suggest?
on one side of the Achilles tendon
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if there is intracapsular edema what does that suggest?
on both sides of the Achilles tendon
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where is the anterior talofibular ligament?
horizontal, small palpate very close to anterior aspect of lateral malleolus
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where is the calcaneal fibular ligament?
tip of laterally malleolus down and back at approximately 45d stress with calcaneal inversion
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inversion/lateral ankle sprain characteristics
95% of all ankle sprains are lateral
most common ligament is the anterior talofibular ligament
next most common is calcaneal fibular ligament
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eversion/medial ankle sprains
greater likelihood of avulsion or fracture of medial malleolus with severe eversion stress
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grade 1 ankle sprain
microscopic tearing of the ligament with no loss of function
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grade 2 ankle sprain
partial disruption or stretching of the ligament with some loss of function
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grade 3 ankle sprain
complete tearing of the ligament with complete loss of function
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acute management of ankle sprains
PRICE
crutches and splint if severe
submax multi angle isometrics
cross friction massage
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subacute management of ankle sprains
cross friction massage to affected ligaments
grade 2 mobilization for pain relief and to maintain motion
gentle AROM and PROM
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chronic management of ankle sprains
isometric to isotonic progression of lower extremity musculature
proprioceptive and balance training
endurance and activity specific exercise
may need to protect joint during vigorous activity
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plantar fascitis general info
pain usually along the plantar aspect of the heel where plantar fascia inserts on the medial tubercle of the calcaneus
excessive pronation of the subtalar joint predisposes the foot to abnormal forces and irritation of the plantar fascia
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common symptoms of plantar fascitis
severe pain on plantar surface of the foot, near calcaneus that is especially severe in AM upon waking
activities that cause stress to the plantar fascia will reproduce pain
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management of plantar fascitis
ice
cross friction to plantar fascia
stretching
stretching of gastroc
management of pronation
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etiology of tarsal tunnel syndrome (what nerve is entrapped?)
posterior tibial nerve or one of its branches (medial or lateral plantar nerve) trapped within the tunnel posterior to medial malleolus
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what are the structures passing through the tarsal tunnel?
long flexor tendons and their sheaths, posterior tibialis tendon, and tibial nerve artery and vein
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causes of tarsal tunnel?
chronic tendinitis, old fractures, anatomic anomalies in the area, excessive pronation
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what does over pronation do to tarsal tunnel syndrome?
causes stress to the musculature and cause an inflammatory process that decreases space in tunnel
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common symptoms/findings of tarsal tunnel
sensory changes to plantar surface of the foot and toes and dorsum of distal phalanges
pain on plantar surface of foot, palpation negative
weakness and postural changes of the foot may occur
positive tinnel over tunnel
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management of tarsal tunnel
therapy is effective if cause is inflammation
use anti-inflams
gradually progress to stretching, isometric to isotonic
manage pronation
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describe shin splints
junk term for any pain posteromedial, anteromedial, or medial lower leg pain
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what can cause shin splints?
myositis, periositis, inflammation of the interosseous membrane or tendinitis
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Medial Tibial Stress Syndrome and its general info
most common form of shin splints
tibial periostitis at the fleshy origin of the posterior tibialis muscle or medial aspect of the soleus
tender to the medial tibial border above the ankle
resisted foot inversion/plantar flexion is painful
often hyperpronators
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managements of MTSS (acute)
cross friction massage
sub max, multi angle iso
AROM in pain free range
protect joint
control improper biomechanics as needed
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management of MTSS (subacute/chronic)
correct abnormal foot alignment
stretch tight structures, often gastroc
progress isometric to isotonics and fxnal exercises
increase endurance
stress proper warm up, cool down and gradual increase of offending activity
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general info of a tibial fracture
failed adaptation to stress on the bone
accelerated osteoclastic remodeling progressing to a complete fracture
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signs and symptoms of a tibial fracture
pain during weightbearing activity that slowly resolves with rest--progresses to severe pain with weightbearing activity that does not totally dissipate with rest
-night pain common
callus forms=positive X ray
bone scan most useful- look for increased uptake
US over site painful
pain with vibratory fork
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treatment of tibial fractures
modified rest pool exercise cycling or other decreased weight bearing exercise
educate on appropriate training technique and foot wear
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how long does the average tibial stress fracture take to heal?
8-12 weeks
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what is exertional compartment syndrome?
raised pressure within a closed osteofacial compartment that compromises the circulation and function of tissues within the compartment
-
what are common causes of exertional compartment syndrome?
fracture
acute/chronic overuse
anti-coagulants worsen this
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what are the 5 P's of exertional compartment syndrome?
1-pain
2-pressure
3-pulse
4-paresthesia
5-palsy
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hallmark findings of exertional compartment syndrome
persistent progressive pain beyond what would be expected from a strain or contusion
swollen, tense compartment
pain with muscular stretch
paresthesia
decrease muscle action
increase compartment pressure
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if you have pressure of over 70 mmHg that suggests what?
lower extremity compartment syndrome
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if pressure difference is 30 mmHg from DIASTOLIC BP that suggests what?
acute compartment syndrome
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Anterior compartment
lateral surface of tibia
anterior intermuscular septum
interosseous membrane
most common compartment affected, 45% of syndromes
-
Lateral compartment
between anterior and posterior intermusclar septum
anterior surface of fibula
10%
-
posterior compartment
tibia
interosseous membrane
fibula
posterior intermuscular septum
40% deep, 5% superficial
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muscles in anterior compartment and nerve that innervates them
tibialis anterior
extensor hallucis longus
extensor digitorum longus
fibularis tertius
deep fibular nerve innervates
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muscles in the lateral compartment and the nerve that innervates them
fibularis longus
fibularis brevis
superficial fibular nerve
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muscles in the superficial posterior compartment and the nerve that innervates them
gastroc
soleus
plantaris
tibial nerve innervates them
-
muscles in the deep posterior compartment and the nerve that innervates them
tibialis posterior
popliteus
flexor digitorum longus
flexor hallucis longus
tibal nerve innervates them
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severe pain increases with activity and then decreases with rest (20min or so) describes what condition?
exertional compartment syndrome
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no pain at rest: stress fractures will do what?
continue to hurt
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pain with warm up: shin splints will often have ______ pain with warm up
decrease
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exertional compartment syndrome is often confused with MTSS...how is MTSS different?
MTSS has tenderness to posterior medial tibia, not common in compartment syndrome
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no pain with vibratory testing so what condition has a positive sign of this?
stress fracture
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management of overuse injuries (acute)
protect...decrease activity
anti-inflam (ice, iontophoresis)
RIE do not use compression
control of biomechanic faults
-
management of overuse injuries (once symptoms have evolved)
stretching of involved musculature
sub-max, multi-angle isometrics, progressed to isotonic
gradual return to activity
-
describe subtalar neutral
not pronated or supinated
point of positon that the head of the talus cannot be palpated or is felt to extend equally at the medial and lateral borders of the talonavicular joint
-
closed chain PRONATION of the subtalar joint
calcaneus everts
talus rotates down and in
IR of tibia
knee flexion
floppy foot
-
closed chain SUPINATION of the subtalar joint
calcaneus inverts
talus rotates up and out
ER of tibia
knee extension
rigid foot
-
7 criteria for normal foot function during latter part of the mid stance gait
- 1-metatarsals lie in the transverse plane
- 2-plantar surface of the calcaneus is in the transvere plain
- 3-subtalar joint is neutral
- 4-midtarsal joint is locked in its maximum position of pronation
- 5-subtalar joint, ankle joint and knee joint lie in transverse plane
- 6-significant rotational or torsional influences are present
- 7-distal 1/3 of the leg is in sagittal plane
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during rearfoot varus what happens?
pronate more
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during forefoot varus what happens?
big toe in air, talus, navicular twisted, pronate late and over pronate
-
during rearfoot varus and forefoot varus what happens?
flat feet, look like they walk on medial malleolus
-
during forefoot valgus (rigid)/ rigid plantarflexed 1st ray what happens?
big toe down, really high arch, forces into supination
-
posting deformities
arch was NOT meant to be a weightbearing structure
generally post 40-60% of the deformity
rigid to semi-rigid
4-6d varus deformity norm
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