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Orthopedic Condition Lumbar Spine: •
Hx, A/P Movements, Neurological, Palpation Acute trauma or microtearing, localized pain aggravated by movements. Rest relieves, stiffness follows immobility • Poor motor control (QOL), pain with active movement • Negative for neurological signs & sx • Local tenderness, may spill over to other segments, UNILATERAL • Gradual onset or acute overload. Pain patterns consistent with trigger point referred pain zones (RPZ). Referred aching pain, sometimes parasthesias. Stretching muscle or active contraction aggravates. Pattern Varies; referred TP zones • Negative for Neurological signs & sx • Palpable jump sign and TP bands • Special Tests: anything that stretches muscle may elicit pain; SLR, FABER + muscle length tests • Factors that underlie muscle strain may also predispose MPS • Sudden onset; gross trauma or micro trauma, aggravated by ALL movements; loss may be severe. Relieved by rest, stiffness after • Active/Passive Extension is PAINFUL • Protective muscle spasm and guarding. Point tenderness • Special Tests may be (+) due to high level of irritability • May be progression of facet joint sprain • Scleratogeneous referred pain patterns can mimic nerve root sx • Positional Relief: FLEXION • Quadrant Test, Stork Standing, Farfan’s Rotation Indicators: • (+) Response to intra-articular injection • Localized, unilateral pain; no referral below knee • Pain relief with medial branch blocks • Reproduce pain with unilateral pressure over Zygo Jt or Transverse Proc • Lack of radicular features • Pain relieved with flexion, increased with ext/ipsilat rot/ Lateral bend • Unilateral muscle spasm over affected ZJ • Phase I: Hypomobility; early cartilage degen. In ZJ’s, disc degeneration • Phase II: Hypermobility; ZJ subluxation & HNP • Phase III: Fixed hypomobility; osteophytes, lateral & central stenosis • Disc space narrowing, loss of disc integrity, disc prolapse/bulging • Protrusion: nucleus migrates to periphery thru torn inner fibers, causing AF to bulge. Extrusion: nucleus
Facet Joint Sprain
Facet Joint Syndrome
Zygohypophyseal Joint Pain (ZJP)
Degenerative Joint Disease (DJD): Arthrosis, Spondylosis Herniated Nucleus Pulposis
increased intradiscal pressure. NTT reproduces LBP NR involvement: most common cause of lumbar radiculopathy syndrome. Global loss of both P/A mobility in phase III Neurological: (+) dermatomal sensory loss! SLR. (+) Gowers Sign (walk up legs c arms). (+)Quadrant. aberrant trunk mvmnts. Phase III of degenerative process. bending. instability may be significant muscle guarding. coughing Peak Age: 20-45. May present with bizarre symptoms. L5-S1 Lesion will affect S1 NR.• • • • • • • • Lumbar Instability Syndrome • • • • • Lateral Stenosis • • • • • Central Stenosis Spondylolisthesis • • • • has escaped outer fibers of AF but maintains continuity with central mass of NP. hypermobility with PIVMT (+) Prone Lumbar Instability Test Clinical Prediction Rules refer to Lumbar spine mgmt PowerPoint Spine STABILIZATION exercises Depends on phase of degenerative process. (-) Neurological. Postural correction and ergonomic corrections! Usually Hx of LBP. Phase II. esp supraspinatus ligament. protective mm guarding & tenderness. (CommonL5/S1) . Pain with sustained postures Limited ROM in multiple directions. Mean age = 41years Extension and ipsilateral LB loss. above or below knee. POC directed @ impairment/functional loss. Slump tests may be (+). usually LBP unless sequestrated. better w/repeat ext. L5/S1 Flexion postures aggravate. and/or leg pain. Loss of ext. Centralization phenomena. rotating. Phase II. local pain. Sequestration: nucleus loses continuity with central mass. (+) Quadrant Episodic LBP. extension relieves Without NR involvement: unilateral. L4/5. Common Levels. Male: Female = 3:2. Nerve Root Compression L4-L5 Lesion will affect L5 NR. then leg pain only. Quadrant Test (+) Joints tender to palpation. Catch Sign. Lateral shift possible. pain with fwd flex. Ely’s Tests Anterior slippage of one disc on another. Mean Age 64 years Loss of extension ROM (+) Motor &/or sensory neurological signs (+) Quadrant. Unilateral peripheral pain. extension aggravates. (+) Neuro & NTT. PLL is torn and material escapes into central canal. lifting. large lesions will affect multiple levels Usual activity is reported as MOI. implementing jt protection strategies. Lateral shift may be present. tissues may be thickened. intermittent leg pain w/wo LBP. Flexion relieves pain. unless sequestered. Bilateral Leg Sx! Intermittent Claudication. Phase III more constant often w/o LBP. stabilization program for phase II.
• Neurological. ischial tuberosities. ABD and IR movements limited 10-16y. Presents with aching pain @ lateral hip & palpatory tenderness. Stork Standing. mild hip flexion contracture. humeral epicondyles. Flexion-Distraction. quadriceps atrophy. or hamstring dominance in hip ext mvmnt Hamstring Strain . & shoulders • Nocturnal Pain. limited abd and ext. LOCAL Weakness. ABD and flexion ROM. Leg length defecit. Female:Male = 8:1 Can ride superior. L>R 3:1. PAINFUL limp is characteristic. loss of flexibility. LBP. Iliopectineal: Ant groin pain. failure of anterior column 2. Flexion often relieves. ant & post joint capsule is tender. Compression.5/1. • Spondylosis – Pars Defect. Morning Stiffness. 2-12yrs Often is self-limiting. Unilateral 50-80% of cases. Ischiogluteal Non-Sciatic buttock & posterior thigh pain. leg pain in severe cases. • Flexion and Ext painful when active. Progressive disorder of unknown cause. Cauda Equina signs when severe • (+) Step Sign. Asymmetrical peripheral arthritis 4 Main Types: 1. or completely out of the joint. most common hip disorder of adolescence Physical signs include: limited IR. Leg Length Discrep up to 1inch. endochondral ossification defect of femoral neck Angle of inclination <120 degrees! Painless limp. Symptomatic with grades 2-4. failure of anterior column Fractures 3. iliac crests. most common. pain with AROM flexion. hormonal. anterior and posterior columns • Hip: Congenital Hip Dysplasia • • • • • Coxa Vara • • • • Legg-Calve Perthes (Pediatric Condition) • • Slipped Capital Femoral Epiphysis • • Bursitis • • • • Malformation. excessive lordosis.o. begins as underlying avascular necrosis of secondary epiphyses of head of femur.000 Births. non-capsular pattern of movement loss. genetic. small % have Hx of trauma.Insidious. antalgic or trendelenberg gait Deep Trochanteric: Subgluteus Medius. compensated gait. mechanical 1. So pt needs to IR to bring head back into socket. presenting s&sx Surgical intervention in <110 degrees Osteochondral Condition. progresses cranialward Ankylosing Spondylosis • Pain in heels. Femoral Anteversion-Head of femur ant. Fracture-Dislocation. Burst. involved anterior and posterior columns 4. pain with PROM in ext + IR. • Fusion begins caudally. ZJ. and costovertebral joints. Affects SI.
especially flexion. Sartorius. Idiopathic form occurs primarily in males 30-50. proximal femoral shaft. DJD. followed by lesser troch. rectus femoris Sportsman Hernia: abdominal distal insertion (inguinal) Most common disease affecting hip. or knee. Muscle Piriformis Syndrome • • . Non specific. Fulcrum test Terminal phase of conditions that impair blood supply to femoral head (superior lateral aspect) including Fx of proximal femur (especially displaced). atrophy of glute max and med. Alcoholism.Other Muscle Injuries • • • • • • Osteoarthritis • • • • Labral Tear • • • Fractures • • • Stress Fracture • • • Avascular Necrosis • • • Transient Synovitis • • • Nerve Entrapment • Chronicity is common. Male:Female = 4:1 Sudden onset of pain & stiffness Most common hip disorder causing a limp in children. micro trauma (degenerative) S&S: Sensation of locking or catching. sciatic nerve is compressed at tendinous origin of Biceps Femoris “Deep Gluteal Syndrome” Prevalent in runners due to repetitive hip ER. ant hip tenderness. trauma. IR ROM limited. ant thigh. osteophytes. general systems failure 2o to immobilization Insidious onset of deep hip pain. Limited in extension and IR (mild) Meralgia Paraesthesia: Femoral Nerve. females. iliopsoas. limb assumes position of ER Complications of hip fx most troublesome of all fx: Avascular necrosis. self-limiting inflammation of the synovium. decompression sickness. Acute groin pain. Sickle Cell Anemia. limited ROM. subchondral sclerosis Cause: Sports injury (rotation on WBing limb). nonunion. Generally acute or insidious onset Pain in hip. thigh. knee and groin Loss of IR most sensitive ROM measure Physical signs include capsular pattern of ROM defecits. Steroid Use. numbness. tingling anterior thigh Hamstring Syndrome. Can refer pain to knee or groin.25% of running injuries Femoral neck common. anterior hip pain. 15% males >60 years Correlated with hip retroversion. 1. “Internal Snapping” Commonly in >60 age group. pain posterior to greater troch. Dislocation. SCFE. (+) axial compression. 25% females. can take up to 6 months to heal Adductor Strain: adductor longus most common Groin Strain: adductors. 50% bilaterally. Femoral neck common.
includes semimembranosus or medial gastroc bursa. Patellar Tendinitis Point tenderness. Laxit with varus stress @ 0o or 30o of flexion 6. swelling. containing inflammatory response. superficial or deep infrapatellar Baker’s Cyst. quad atrophy Tx directed at controlling loading. Palpatory medial joint line tenderness 6. Laxity with valgus stress @ 30o flexion 4. usually medial. Knee ROM WNL 5. Varus Trauma 2. and quadriceps Movement Impairments • • • • Knee • • • Bursitis • Patellar Tendinitis • • • • • • Collateral Ligament Injuries • Plica Syndrome • • • . Pain with varus stress @ 0o or 30o of flexion 5.injured by varus stress. rarely isolated injury due to attachments S&Sx: MOI. Jumper’s Knee. medial capsule and ACL LCL. (+) Modified stroke test/Bulge sign Clinical Dx: LCL Sprain: 1. may radiate to post thigh w or w/o LE parasthesias Symptoms aggravated by sitting or WBing activities. Trauma to lateral knee or rotational trauma 2. Short or Stiff/ Weak Abdominals Dominant TFL Weak Glutes Osgood Schlatter’s = children. chronic overuse. Quadricep tendinitis. LCL region 3. Palpatory tenderness @ LCL 4. becomes TAUT during knee flexion Trauma. any form of synovial herniation or bursistis of post knee. S&Sx: LOCAL pain and swelling MCL. instability Most injuries managed conservatively Clinical DX: MCL Sprain: 1. Runs medial surface of the synovial capsule to the infrapatellar fat pad.• • may be short/stiff Buttock pain.injured by valgus stress w knee ext or flexed <90o usually accompanied by damage to medial meniscus. LOCAL pain and swelling. Pain with valgus @ 30o flexion 3. pain with resisted extension or PROM flexion. Synovial membrane of semitendinosus sheath or post joint capsule. Localized effusion. (+) Modified Stroke Test/Bulge Sign Plica = ext of synovial membrane. crepitus. correcting underlying impairments Pre-patellar Bursitits=housemaid’s knee. joint line tenderness.
crepitus. LOCALIZED posterior knee pain with kneeling or deceleration 3. MOI consistent with ACL injury 2. Unhappy Triad Reconstruction generally a prerequisite before returning to sports Risk Factors (Non-Contact) 1. MOI consistent with PCL injury 2. Hearing or feeling a POP at time of injury 3. Strong quad activation during eccentric loading conditions Clinical DX: ACL Tear 1. Narrow femoral notch width 4. compression. and locking Partial Menisectomy and direct repair are surgical procedures of choice Traction apophysitis or epiphysitis of the tibial tubercle Direct trauma usually precipitates. Loss of end-range knee extension 5. swelling. effusion. 6m SL Hop Test 80% or less uninvolved side 7. (+) Lachman’s/Pivot Shift Tests 6. Hemarthrosis 0-2 hrs after injury 4. Sx: medial pain. and rot. Meniscus fails to follow Longitudinal Tear = Bucket Handle Tear S&Sx: joint line pain. resulting in shear stress to fibrocartilage. Increased joint laxity 5. 80% or more MV quad defecit Anteromedial blow to a flexed knee. (+) Sag Sign 5. 80-85%. clicking. Increased BMI 2. Pre-ovulatory phase of menstrual cycle 6. Loss of knee extension ROM Most commonly due to force movements of flexion. or fall onto knee accompanied by hyperextension. MCL& Arcuate ligament complex tears often accompanyleading to PLRI Clinical Dx: PCL Tear 1. then chronic irritation occurs from traction forces of the patellar tendon Benign osseous tumor forms S&Sx: local pain and bony swelling. (+) Posterior Drawer @ 90o 4. 30- Anterior Cruciate Ligament (ACL) • • • Posterior Cruciate Ligament (PCL) • • Meniscal Injuries • • • • Osgood Schlatter Disease • • • • • • Osteochondritis Dessicans (OCD) . pain with resisted knee extension In growing bones boys>girls Osteochondral fracture/intra-articular fragment of articular cartilage and underlying bone Medial femoral condyle most common. (+) Modified Stroke Test 6. CONTACT vs non-contact injuries.• • • • weakness predispose. Shoe surface interaction (increase coefficient of friction) 3.
Most common. Px good. S&Sx: knee pain & stiffness. and patellar instability CP consists of softening. ice. and proliferation of new bone in the joint margins. severe radiographic changes. Uncommon. Muscle atrophy & muscle activation underlie impairments Femoral Condyle. increased q angle. failed conservative management. difficult to dx. avulsion. occurs in teenagers. post-operative rehab is not adequate in many cases. distal tibia.caused by impact. Uncommon. poorly localized aching pain. effusion or bony swelling. ORIF. or shearing forces. Type IV: fx extends from jt surface through epiphysis. pain w WBing & rotational movements. shallow patellar groove. Px good. locking or “giving way” sensations Activity modification for 6-12wks. Px poor. interrupts bone development. quad weakness. Closed reduction.caused by direct blow.000 May be 2o to avulsion of PCL or direct trauma S&Sx. ORIF. radiographic evidence Indications for TKR: severe pain. fibrillation & degeneration of undersurface of patella. general rehab. Patellar tendinitis (jumpers knee) chondromalacia patellae (CP) patellar malalignment. Requires surgery. swelling. into metaphysis. significant loss of function. epiphyseal plate & metaphysis. 30-60 cases per 100. occurs in older children Type III: fx extends in epiphysis. internal fixation with bone graft Type I: complete seperation of epiphysis. Most common tx is ORIF Patella. children Type II: fx extends along epiphysis. sclerotic changes in the subchondral bone.• • • • • • • • Osteoarthritis (OA) • • • • 40% bilateral Male: Female = 3:1.combination of valgus & compressive stress with knee flexed. decreased ROM. insufficiency of VMO. Occurs in newborns. associated with shear injury. px poor. with internal fixation Epiphyseal Plate-hyperextension or torsional weight bearing movement Tibial Plateau. and is associated with altered patellar biomechanics Incidence is higher in physically active individuals Direct trauma. intra articular. residual quad strength impairments and functional deficits. Tx involves closed reduction or open. return to function Deterioration of cartilaginous surfaces of the joint. interrupts bone development Type V: compression injury w/o displacement. or abnormally Fractures • • • • • • Patellofemoral Pain Syndromes • • • Patellar Instability . Outcomes for TKA: self-report pain and function improve.
loading at growth plate Ankle and Foot • • Equinus Deformity • • • • Pes Cavus • • • • Pes Planus • • • • Hallux Valgus • • • • • • • Achilles Tendinopathy • • • • • • • • • Sever’s Disease . most common mechanism is combination of planting foot & ext rotating femur as knee is flexed.secondary ossification center @ growth plate Excessive tension. Soft tissue adaptations “rigid foot” – therefore susceptible to injury. ligament laxity. strengthening (ECCENTRIC) Occurs in 8-12 y.• positioned patella. paralysis. US. Begins as paratenonitis. or supination. LIMITED DF <10o can be 2o to immobilization Caused by contracture of gastrocnemius. Medial deviation of head of the 1st metatarsal in relation to the center of the body Increase in metatarsalphalangeal angle Callus formation (medial aspect of met head) + thickened burse + exostosis = BUNIONS! Must be surgically managed Posterior heel pain. prescription of heel pad inserts. neurological condition (spina bifida). inflammatory disease or deformity of talus May lead to rocker-bottom foot. Subluxation/dislocation can occur. decreased length of tendon.o’s Sport Participation Chronis Heel Pain Apophysis. Structural impairment. stretching exercises. forefoot is lower in relation to hindfoot. congenital deformity-most common form=talipes equinovarus Congenital. or associated with clubfoot. may be congenital or result of trauma (fx of calcaneus). 2nd most common in basketball. excessive pronation Clubfoot. swelling. Associated with pronated foot Rigid (congenital) or acquired/flexible Loss of longitudinal arch. ice. excessive pronation. muscle imbalance. prone to inversion sprains More common.degenerative thickening of paratnon without inflammation Tendon gliding mechanism is impaired Area most susceptible is Avascular zone – insertion of midsubstance into calcaneous Tx. Thickest. strongest tendon in body Subject to shear and compressive stress S&Sx: post heel pain. muscle weakness. soleus or achilles tendon Can also be caused by trauma. most common form of tendonitis/osis in runners. additional stress up the chain d/t no absorption of ground reaction forces. Longitudinal arches are accentuated.
therefore affecting running Tibial stress fx. Sprain of plantar capsule and lateral collateral ligament complex MOI involves hyperextension of big toe. Predisposed for future injury I (Mild). 10-30% chronic mechanical instability. tenderness over anterolateral capsule. calf & PF stretching. III (severe). secondary heel spur disorder may develop due to periosteal failure S&Sx: plantar/heel pain. severe pain. footwear. Idiopathic compartment syndrome Exercise induced pain secondary to repeated loading Target musculotendinous unit Anterolateral (TA. pain with passive toe extension Tx. diffuse swelling. taping. If PTFL is torn=ankle DISLOCATION. marked degeneration and lengthening of tendon. 2575% of fibers torn. part of CL. MT. inability to WB grade 3+ ant drawer with + sulcus sign. Restricted ROM. ecchymosis. Instability mild or absent. EDL) Posteromedial (TP) medial tibial stress syndrome of posterior tibial SS I: Mild Weakness. tarsal/metatarsal fx Increased pressure within one or more of the . orthotics Chronic Leg Pain. Swelling may become more diffuse within a few days. point tenderness-medial calcaneal tubercle. pronated or cavus footpredisposes Microtears of origin of plantar fascia at medial calcaneal tuberosity Common in running sports. pain upon first arising. point tenderness.• • Plantar Fascitis • • • • • Shin Splints • • • • Posterior Tibial Tendon Dysfunction (PTTD) • • • • • • Ankle Sprain • • Sprain of 1st MTP/ Turf Toe • • • • Fractures Compartment Repetitive Stress Injury. common in football. some difficulty with FWB II (Moderate). >75% fiber diruption. US. complete rupture of ATFL. little to no hemorrhage. lax Significant short term & potential long term impairment of push-off. soccer. hemorrhage. distal fibular fx. Ionto–dexameth acetic acid. Mild swelling. <25% fiber disruption of ATFL and stretching of intact fibers. Rapid onset of swelling. ankle fx. inability to raise on toes. tenderness at anterolateral ankle. normal tendon length II: hindfoot eversion. EHL. Tx considerations: address structural impairments. complete tear of ATFL and capsule. no forefoot deformity. along with capsule. localized swelling. calcaneal fx. orthotics. eccymosis. ATFL and CFL. forefoot abduction and lowering of MLL III: Progression of stage II with fixed deformity. distal tibial fx. ECCENTRIC strengthening exercises Most frequently injured joint in athletes. rupture of CFL.
Exercise will increase muscle volume. EDL. or compression near fibular head Sensory loss associated with both proximal and distal lesions – lateral leg and dorsum of foot. sural nerve Anterior Compartment. post tibial nerve Superficial Posterior-gastroc. Contents: tibial nerve. motor weakness of intrinsics.RA. • anatomical compartments of the leg. abductor hallicis Commonly injured in ant compartment syndrome and ant tarsal tunnel syndrome Compression can also be caused by trauma. a ganglion or pes cavus Weakness of: tib ant. peroneus tertius possible Drop foot. tendons of FHL. Compromises circulation and tissue function within that space Chronic form due to repetitive loading or microtrauma associated with physical activity. EHL. d/t tight shoes. tight shoes. direct blow) or from entrapment as it passes over the popliteus and under soleus = popliteal entrapment syndrome Injury to proximal nerve can result in inability to PF and invert foot. hallux. Roof is flexor retinaculum. sensory loss in thong space of 1st/2nd toes Injury associated with lateral ankle sprain. steppage gait. EDL. Later.Peroneus long&brev. post tibial artery & vein. trauma. ant tibial artery and vein. soleus. case.FHL. and medial foot. and medial calcaneus. entrapment 4-5 inches above lateral malleolus. Interdigital neuroma secondary to injury to one of . TP. weakness of foot EVERSION and ankle instability. and loss of sensation on sole of foot Tarsal Tunnel Syndrome can also affect the nerve Entrapment neuropathy of the tibal nerve Floor of tunnel is medial talus. FDL. inflammation secondary to tendosynovitis and venous thrombosis Excessive pronation can also cause stretch to tibial nerve and lead to TTS Other causes. deep peroneal nerve Can be injured secondary to trauma (knee dislocation. rapid weight gain .• • • Syndrome • • • • • Tibial Nerve • • • • • • Tarsal Tunnel Syndrome • • • • • • Deep Peroneal Nerve • • • Superficial Peroneal Nerve • • Morton’s Neuroma. common and superficial peroneal nerves Deep Posterior. peroneal artery and vein. sustentaculum tali. cysts. fluid retention S&Sx: pain and hyper/hypoesthesia in sole of foot. Motor loss with proximal lesion. thus stretching the compartment margins Lateral. EHL.tib ant. post tib artery/vein. MTP flexion. flex abd/add toes. and tib post Idiopathic in 50% of cases. FD.
More frequent in women Pain on lateral aspect of forefoot associated with WBing .• Interdigital Neuritis • • the digital nerves Most often involves digital nerve between 3rd and 4th toes.
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