Review for Ortho Exam and Practical #2
Orthopedic Condition
Lumbar Spine:
 Acute trauma or microtearing, localized pain aggravated by
Muscle Strain
Myofascial Pain
Facet Joint Sprain
Facet Joint Syndrome
Indicators:
Zygohypophyseal Joint Pain
(ZJP)
Degenerative Joint Disease
(DJD): Arthrosis, Spondylosis
Herniated Nucleus Pulposis
Hx, A/P Movements, Neurological, Palpation
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
 (+) 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 has escaped outer fibers of AF but
maintains continuity with central mass of NP. Sequestration: nucleus
loses continuity with central mass. PLL is torn and material escapes into
central canal.
 Nerve Root Compression  L4-L5 Lesion will affect L5 NR, L5-S1
Lesion will affect S1 NR, large lesions will affect multiple levels
 Usual activity is reported as MOI; increased intradiscal pressure;
bending, lifting, rotating, coughing
 Peak Age: 20-45, Male: Female = 3:2. Common Levels; L4/5, L5/S1
 Flexion postures aggravate, extension relieves
 Without NR involvement: unilateral, local pain. Loss of ext, pain with fwd
flex, better w/repeat ext. Lateral shift may be present. (-) Neurological,
protective mm guarding & tenderness. (+)Quadrant, NTT reproduces LBP
 NR involvement: most common cause of lumbar radiculopathy
syndrome. Unilateral peripheral pain, above or below knee, usually LBP
 unless sequestrated, then leg pain only. Centralization phenomena,
unless sequestered. Lateral shift possible, (+) Neuro & NTT, (+) Quadrant
 Episodic LBP, and/or leg pain. Pain with sustained postures
 Limited ROM in multiple directions, aberrant trunk mvmnts, (+)
Gowers Sign (walk up legs c arms), Catch Sign, hypermobility with PIVMT
Lumbar Instability Syndrome
 (+) Prone Lumbar Instability Test
 Clinical Prediction Rules refer to Lumbar spine mgmt PowerPoint
 Spine STABILIZATION exercises
 Depends on phase of degenerative process. Phase II; intermittent leg pain
w/wo LBP. Phase III more constant often w/o LBP. Mean age = 41years
 Extension and ipsilateral LB loss. Phase II; instability may be
significant muscle guarding. Global loss of both P/A mobility in phase III
 Neurological: (+) dermatomal sensory loss!
Lateral Stenosis
 SLR, Slump tests may be (+), Quadrant Test (+)
 Joints tender to palpation, tissues may be thickened, esp
supraspinatus ligament. POC directed @ impairment/functional loss,
implementing jt protection strategies, stabilization program for phase II.
 Postural correction and ergonomic corrections!
 Usually Hx of LBP, Phase III of degenerative process. Bilateral Leg Sx!
Intermittent Claudication, May present with bizarre symptoms. Flexion
relieves pain, extension aggravates. Mean Age 64 years
Central Stenosis
 Loss of extension ROM
 (+) Motor &/or sensory neurological signs
 (+) Quadrant, Ely’s Tests
 Anterior slippage of one disc on another. (Common- L5/S1)
 Insidious, small % have Hx of trauma. Symptomatic with grades 2-4.
LBP, leg pain in severe cases.
Spondylolisthesis
 Flexion and Ext painful when active, Flexion often relieves.
 Neurological; Cauda Equina signs when severe
 (+) Step Sign, Stork Standing.
 Spondylosis – Pars Defect. Affects SI, ZJ, and costovertebral joints.
 Fusion begins caudally, progresses cranialward
 Pain in heels, ischial tuberosities, iliac crests, humeral epicondyles, &
Ankylosing Spondylosis
shoulders
 Nocturnal Pain, Morning Stiffness. Asymmetrical peripheral
arthritis
4 Main Types:
1. Compression; failure of anterior column
Fractures 2. Burst; failure of anterior column
3. Flexion-Distraction; involved anterior and posterior columns
4. Fracture-Dislocation; anterior and posterior columns
Hip:
 Malformation; genetic, hormonal, mechanical
 1.5/1,000 Births, Unilateral 50-80% of cases, L>R 3:1, Female:Male = 8:1
Congenital Hip Dysplasia  Can ride superior, or completely out of the joint.
 Femoral Anteversion-Head of femur ant. So pt needs to IR to bring head
back into socket.
 Progressive disorder of unknown cause; endochondral ossification
defect of femoral neck
 Angle of inclination <120 degrees!
Coxa Vara
 Painless limp, Leg length defecit, limited abd and ext, mild hip flexion
contracture, excessive lordosis, presenting s&sx
 Surgical intervention in <110 degrees
Legg-Calve Perthes  Osteochondral Condition; begins as underlying avascular necrosis of
(Pediatric Condition) secondary epiphyses of head of femur; 2-12yrs
 Often is self-limiting, PAINFUL limp is characteristic, ant & post joint
 capsule is tender, ABD and IR movements limited
 10-16y.o.  most common hip disorder of adolescence
Slipped Capital Femoral
 Physical signs include: limited IR, ABD and flexion ROM, quadriceps
Epiphysis
atrophy, Leg Length Discrep up to 1inch, antalgic or trendelenberg gait
 Deep Trochanteric: Subgluteus Medius, most common. Presents with
aching pain @ lateral hip & palpatory tenderness, non-capsular pattern
of movement loss.
Bursitis
 Iliopectineal: Ant groin pain, compensated gait, pain with PROM in ext +
IR, pain with AROM flexion.
 Ischiogluteal
 Non-Sciatic buttock & posterior thigh pain; LOCAL
 Weakness, loss of flexibility, or hamstring dominance in hip ext
Hamstring Strain
mvmnt
 Chronicity is common, can take up to 6 months to heal
 Adductor Strain: adductor longus most common
Other Muscle Injuries  Groin Strain: adductors, iliopsoas, Sartorius, rectus femoris
 Sportsman Hernia: abdominal distal insertion (inguinal)
 Most common disease affecting hip. 25% females, 15% males >60 years
 Correlated with hip retroversion, pain posterior to greater troch, ant
thigh, knee and groin
Osteoarthritis  Loss of IR most sensitive ROM measure
 Physical signs include capsular pattern of ROM defecits, atrophy of glute
max and med.
 Can refer pain to knee or groin; osteophytes, subchondral sclerosis
 Cause: Sports injury (rotation on WBing limb), trauma, micro trauma
(degenerative)
Labral Tear  S&S: Sensation of locking or catching, limited ROM; especially flexion,
anterior hip pain.
 “Internal Snapping”
 Commonly in >60 age group, females. Femoral neck common.
 Acute groin pain, ant hip tenderness, limb assumes position of ER
Fractures
 Complications of hip fx most troublesome of all fx: Avascular necrosis,
DJD, nonunion, general systems failure 2o to immobilization
 Insidious onset of deep hip pain. 1.25% of running injuries
Stress Fracture  Femoral neck common, followed by lesser troch, proximal femoral shaft.
 IR ROM limited, (+) axial compression, Fulcrum test
 Terminal phase of conditions that impair blood supply to femoral
head (superior lateral aspect) including Fx of proximal femur (especially
displaced), SCFE, Dislocation, Alcoholism, Sickle Cell Anemia, Steroid Use,
Avascular Necrosis decompression sickness.
 Idiopathic form occurs primarily in males 30-50, 50% bilaterally,
Male:Female = 4:1
 Sudden onset of pain & stiffness

 Most common hip disorder causing a limp in children. Non specific;

Transient Synovitis self-limiting inflammation of the synovium.
 Generally acute or insidious onset
 Pain in hip, thigh, or knee. Limited in extension and IR (mild)

 Meralgia Paraesthesia: Femoral Nerve; numbness, tingling anterior thigh

Nerve Entrapment  Hamstring Syndrome; sciatic nerve is compressed at tendinous origin of
Biceps Femoris

Piriformis Syndrome
 “Deep Gluteal Syndrome”
 Prevalent in runners due to repetitive hip ER. Muscle may be short/stiff
 Buttock pain, may radiate to post thigh w or w/o LE parasthesias

Movement Impairments
Knee
Patellar Tendinitis
Bursitis
Collateral Ligament Injuries
Plica Syndrome
Anterior Cruciate Ligament
(ACL)
 Symptoms aggravated by sitting or WBing activities.
 Short or Stiff/ Weak Abdominals
 Dominant TFL
 Weak Glutes
 Osgood Schlatter’s = children, Jumper’s Knee, Quadricep tendinitis,
Patellar Tendinitis
 Point tenderness, swelling, pain with resisted extension or PROM
flexion, crepitus, quad atrophy
 Tx directed at controlling loading, containing inflammatory response,
correcting underlying impairments
 Pre-patellar Bursitits=housemaid’s knee, superficial or deep infrapatellar
 Baker’s Cyst; any form of synovial herniation or bursistis of post knee;
includes semimembranosus or medial gastroc bursa. Synovial membrane
of semitendinosus sheath or post joint capsule.
 S&Sx: LOCAL pain and swelling
 MCL- injured by valgus stress w knee ext or flexed <90o usually
accompanied by damage to medial meniscus, medial capsule and ACL
 LCL- injured by varus stress; rarely isolated injury due to attachments
 S&Sx: MOI, LOCAL pain and swelling, joint line tenderness,
instability
 Most injuries managed conservatively
 Clinical DX: MCL Sprain:
1. Trauma to lateral knee or rotational trauma
2. Pain with valgus @ 30o flexion
3. Laxity with valgus stress @ 30o flexion
4. Knee ROM WNL
5. Palpatory medial joint line tenderness
6. (+) Modified stroke test/Bulge sign
 Clinical Dx: LCL Sprain:
1. Varus Trauma
2. Localized effusion, LCL region
3. Palpatory tenderness @ LCL
4. Pain with varus stress @ 0o or 30o of flexion
5. Laxit with varus stress @ 0o or 30o of flexion
6. (+) Modified Stroke Test/Bulge Sign
 Plica = ext of synovial membrane; usually medial.
 Runs medial surface of the synovial capsule to the infrapatellar fat pad,
becomes TAUT during knee flexion
 Trauma, chronic overuse, and quadriceps weakness predispose.
 Sx: medial pain, swelling, clicking.
 CONTACT vs non-contact injuries; Unhappy Triad
 Reconstruction generally a prerequisite before returning to sports
 Risk Factors (Non-Contact)
1. Increased BMI
2. Shoe surface interaction (increase coefficient of friction)
3. Narrow femoral notch width
4. Increased joint laxity
5. Pre-ovulatory phase of menstrual cycle
6. Strong quad activation during eccentric loading conditions
 Clinical DX: ACL Tear
 1. MOI consistent with ACL injury
2. Hearing or feeling a POP at time of injury
3. Hemarthrosis 0-2 hrs after injury
4. Loss of end-range knee extension
5. (+) Lachman’s/Pivot Shift Tests
6. 6m SL Hop Test 80% or less uninvolved side
7. 80% or more MV quad defecit
 Anteromedial blow to a flexed knee, or fall onto knee accompanied by
hyperextension.
 MCL& Arcuate ligament complex tears often accompany-leading to PLRI
 Clinical Dx: PCL Tear
Posterior Cruciate Ligament 1. MOI consistent with PCL injury
(PCL) 2. LOCALIZED posterior knee pain with kneeling or deceleration
3. (+) Posterior Drawer @ 90o
4. (+) Sag Sign
5. (+) Modified Stroke Test
6. Loss of knee extension ROM
 Most commonly due to force movements of flexion, compression, and rot.
resulting in shear stress to fibrocartilage. Meniscus fails to follow
Meniscal Injuries  Longitudinal Tear = Bucket Handle Tear
 S&Sx: joint line pain, effusion, crepitus, and locking
 Partial Menisectomy and direct repair are surgical procedures of choice
 Traction apophysitis or epiphysitis of the tibial tubercle
 Direct trauma usually precipitates, then chronic irritation occurs from
traction forces of the patellar tendon
Osgood Schlatter Disease
 Benign osseous tumor forms
 S&Sx: local pain and bony swelling, 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; 80-85%. 30-40% bilateral
Osteochondritis Dessicans  Male: Female = 3:1, 30-60 cases per 100,000
(OCD)  May be 2o to avulsion of PCL or direct trauma
 S&Sx; poorly localized aching pain, swelling, pain w WBing &
rotational movements, locking or “giving way” sensations
 Activity modification for 6-12wks, ice, general rehab, return to function
 Deterioration of cartilaginous surfaces of the joint, sclerotic changes
in the subchondral bone, and proliferation of new bone in the joint
margins.
 S&Sx: knee pain & stiffness, effusion or bony swelling, decreased
ROM, quad weakness, radiographic evidence
Osteoarthritis (OA)  Indications for TKR: severe pain, significant loss of function, severe
radiographic changes, failed conservative management.
 Outcomes for TKA: self-report pain and function improve; post-
operative rehab is not adequate in many cases; residual quad strength
impairments and functional deficits. Muscle atrophy & muscle activation
underlie impairments
Fractures  Femoral Condyle- caused by impact, avulsion, or shearing forces. Most
common tx is ORIF
 Patella- caused by direct blow. Tx involves closed reduction or open, with
internal fixation
 Epiphyseal Plate-hyperextension or torsional weight bearing movement
 Tibial Plateau- combination of valgus & compressive stress with knee
flexed. Requires surgery; internal fixation with bone graft

 Type I: complete seperation of epiphysis, associated with shear injury.

Closed reduction, Px good. Occurs in newborns, children
  Type II: fx extends along epiphysis, into metaphysis. Most common, Px
good, occurs in older children
 Type III: fx extends in epiphysis, intra articular. Uncommon, distal tibia.
ORIF, occurs in teenagers.
 Type IV: fx extends from jt surface through epiphysis, epiphyseal plate &
metaphysis. ORIF, px poor, interrupts bone development
 Type V: compression injury w/o displacement. Uncommon, difficult to
dx. Px poor, interrupts bone development.
 Patellar tendinitis (jumpers knee) chondromalacia patellae (CP) patellar
malalignment, and patellar instability
Patellofemoral Pain
 CP consists of softening, fibrillation & degeneration of undersurface of
Syndromes
patella, and is associated with altered patellar biomechanics
 Incidence is higher in physically active individuals
 Direct trauma, increased q angle, insufficiency of VMO, shallow
patellar groove, or abnormally positioned patella.
Patellar Instability
 Subluxation/dislocation can occur, most common mechanism is
combination of planting foot & ext rotating femur as knee is flexed.
Ankle and Foot
 Structural impairment, LIMITED DF <10o can be 2o to immobilization
 Caused by contracture of gastrocnemius, soleus or achilles tendon
Equinus Deformity  Can also be caused by trauma, inflammatory disease or deformity of talus
 May lead to rocker-bottom foot, excessive pronation
 Clubfoot; congenital deformity-most common form=talipes equinovarus
 Congenital, neurological condition (spina bifida), muscle imbalance, or
associated with clubfoot.
 Longitudinal arches are accentuated, forefoot is lower in relation to
Pes Cavus
hindfoot.
 Soft tissue adaptations
 “rigid foot” – therefore susceptible to injury; prone to inversion sprains
 More common, may be congenital or result of trauma (fx of calcaneus),
muscle weakness, ligament laxity, paralysis.
 Associated with pronated foot
Pes Planus
 Rigid (congenital) or acquired/flexible
 Loss of longitudinal arch, additional stress up the chain d/t no absorption
of ground reaction forces.
 Medial deviation of head of the 1st metatarsal in relation to the center
of the body
 Increase in metatarsalphalangeal angle
Hallux Valgus
 Callus formation (medial aspect of met head) + thickened burse +
exostosis = BUNIONS!
 Must be surgically managed
 Posterior heel pain, most common form of tendonitis/osis in
runners, 2nd most common in basketball.
 Thickest, strongest tendon in body
 Subject to shear and compressive stress
 S&Sx: post heel pain, swelling, decreased length of tendon, excessive
pronation, or supination.
Achilles Tendinopathy  Begins as paratenonitis- degenerative thickening of paratnon without
inflammation
 Tendon gliding mechanism is impaired
 Area most susceptible is Avascular zone – insertion of midsubstance into
calcaneous
 Tx; stretching exercises, prescription of heel pad inserts, ice, US,
strengthening (ECCENTRIC)
Sever’s Disease  Occurs in 8-12 y.o’s
 Sport Participation
  Chronis Heel Pain
 Apophysis- secondary ossification center @ growth plate
 Excessive tension, loading at growth plate
 Repetitive Stress Injury, pronated or cavus footpredisposes
 Microtears of origin of plantar fascia at medial calcaneal tuberosity
 Common in running sports, secondary heel spur disorder may develop
Plantar Fascitis due to periosteal failure
 S&Sx: plantar/heel pain, pain upon first arising, point tenderness-medial
calcaneal tubercle, pain with passive toe extension
 Tx; Ionto–dexameth acetic acid, MT, calf & PF stretching, taping, orthotics
 Chronic Leg Pain, Idiopathic compartment syndrome
 Exercise induced pain secondary to repeated loading
Shin Splints  Target musculotendinous unit
 Anterolateral (TA, EHL, EDL)
 Posteromedial (TP) medial tibial stress syndrome of posterior tibial SS
 I: Mild Weakness, no forefoot deformity, normal tendon length
 II: hindfoot eversion, forefoot abduction and lowering of MLL
Posterior Tibial Tendon  III: Progression of stage II with fixed deformity, marked degeneration
Dysfunction (PTTD) and lengthening of tendon.
 Tx considerations: address structural impairments, US, footwear,
orthotics, ECCENTRIC strengthening exercises
 Most frequently injured joint in athletes, 10-30% chronic mechanical
instability. Predisposed for future injury
 I (Mild); <25% fiber disruption of ATFL and stretching of intact fibers.
Mild swelling, point tenderness, little to no hemorrhage, some difficulty
with FWB
 II (Moderate); complete rupture of ATFL, part of CL, 25-75% of fibers
torn, along with capsule. Restricted ROM, localized swelling, eccymosis,
Ankle Sprain hemorrhage, tenderness at anterolateral ankle. Swelling may become
more diffuse within a few days. Instability mild or absent, inability to
raise on toes.
 III (severe); complete tear of ATFL and capsule, rupture of CFL. >75%
fiber diruption. If PTFL is torn=ankle DISLOCATION. Rapid onset of
swelling, diffuse swelling, severe pain, ecchymosis, tenderness over
anterolateral capsule, ATFL and CFL, inability to WB grade 3+ ant drawer
with + sulcus sign.
 Sprain of plantar capsule and lateral collateral ligament complex
st  MOI involves hyperextension of big toe, common in football, soccer, lax
Sprain of 1 MTP/ Turf Toe
 Significant short term & potential long term impairment of push-off,
therefore affecting running
 Tibial stress fx, distal tibial fx, distal fibular fx, ankle fx, calcaneal fx,
Fractures
tarsal/metatarsal fx
 Increased pressure within one or more of the anatomical
compartments of the leg.
 Compromises circulation and tissue function within that space
 Chronic form due to repetitive loading or microtrauma associated
with physical activity.
 Exercise will increase muscle volume, thus stretching the compartment
Compartment Syndrome margins
 Lateral- Peroneus long&brev, common and superficial peroneal nerves
 Deep Posterior- FHL, FD, TP, post tibial artery & vein, peroneal artery
and vein, post tibial nerve
 Superficial Posterior-gastroc, soleus, sural nerve
 Anterior Compartment- tib ant, EHL, EDL, ant tibial artery and vein,
deep peroneal nerve
Tibial Nerve  Can be injured secondary to trauma (knee dislocation, 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,
flex abd/add toes, 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, sustentaculum tali, and medial calcaneus.
Roof is flexor retinaculum.
 Contents: tibial nerve, post tib artery/vein, tendons of FHL, FDL, and
tib post
 Idiopathic in 50% of cases, d/t tight shoes, case, cysts, inflammation
Tarsal Tunnel Syndrome
secondary to tendosynovitis and venous thrombosis
 Excessive pronation can also cause stretch to tibial nerve and lead to TTS
 Other causes; trauma, rapid weight gain ,RA, fluid retention
 S&Sx: pain and hyper/hypoesthesia in sole of foot, hallux, and
medial foot.
 Later, motor weakness of intrinsics, MTP flexion, abductor hallicis
 Commonly injured in ant compartment syndrome and ant tarsal tunnel
syndrome
 Compression can also be caused by trauma, tight shoes, a ganglion or pes
Deep Peroneal Nerve
cavus
 Weakness of: tib ant, EDL, EHL, peroneus tertius possible
 Drop foot, steppage gait, sensory loss in thong space of 1st/2 nd toes
 Injury associated with lateral ankle sprain, entrapment 4-5 inches above
lateral malleolus, or compression near fibular head
 Sensory loss associated with both proximal and distal lesions –
Superficial Peroneal Nerve
lateral leg and dorsum of foot.
 Motor loss with proximal lesion, weakness of foot EVERSION and
ankle instability.
 Interdigital neuroma secondary to injury to one of the digital nerves
Morton’s Neuroma,  Most often involves digital nerve between 3rd and 4th toes.
Interdigital Neuritis  More frequent in women
 Pain on lateral aspect of forefoot associated with WBing