PHYSICAL REHABILITATION Midterms

Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders

Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

Date: March 23, 2023

REHABILITATION OF LOWER LIMB MUSCULOSKELETAL TROCHANTERIC BURSITIS
DISORDERS
 Seen in elderly
 Manifests as pain in the lateral thigh
PIRIFORMIS SYNDROME  Sx:
o Pseudoradicular pattern with pain extending to the
 Due to Sciatic Nerve compression of an inflamed piriformis lateral aspect of lower limb and into the buttocks
o Agur: 87 % of patients have Sciatic Nerves passing o Manifests when lower ext. is placed in ext. rotation
under the Piriformis and abduction
o Dysesthesias, Buttock pain and tenderness of the o Direct palpation or deep pressure applied to posterior
Piriformis as main complaint and superior to the greater trochanter will reproduce
o Symptoms arise during sitting and lower limb pain
exertion  Functional biomech. Deficits:
 May include Piriformis, Gluteal Muscles, gemelli, quadratus o Shortening of the tensor fascia lata, rectus femoris,
lumborum, sacroiliac ligaments hamstrings and weakness of the adductors
 Biomechanical deficits  Functional adaptations
o Tight piriformis and external rotators o Increased hip ext. rotation
o Hip abductor weakness
o Sacroiliac joint hypomobility/hypermobility Treatment
 Functional adaptations
o Ambulating with an externally rotated thigh  Stretching and strengthening ex. to restore flexibility and
o Shortened stride length balance
o Functional limb length shortening  Steroid injections
 Heating modalities
 Check of lumbar spine if all fails

ISCHIAL BURSITIS

 Not common
 Also known as the weaver’s bottom or tailor’s bottom
 Due to friction and trauma after prolonged sitting
 Seen also with adolescent runners usually in conjunction
with ischial apophysitis
 S/Sx:
o Pain during uphill running
o Pain distributed at the posterior aspect of the thigh
o Pain activated by hamstring muscles

Treatment

Treatment  Modification of activity

 Avoid use of toe clips
 NSAIDs o Toe clips increase activation of Hamstrings
 Stretching exercises of the piriformis and associated  PRICE
external rotators  Steroid Injection under fluoroscopy
 Correct sacral and pelvic abnormalities
 Exercises AVASCULAR NECROSIS OF THE FEMORAL HEAD
o Pelvic tilt
o Strengthening ex to hip ext. rotators, piriformis  Note pain on joint loading with no apparent source of pain
 Evaluate the spine  Due to problems in Blood supply
SNAPPING HIP SYNDROME  Diagnostics:
o MRI
 Iliotibial band snapping is the common cause o Plain films-become (+) in later stages
 Loose bodies, labral tears and osteochondritis dessicans are  Poor outcome
other causes
Treatment
Treatment
 Surgery-THRA
 Stretching exercises
 Myofascial release QUADRICEPS STRAIN
 Evaluation of intraarticular pathology by MRI or CT scan if it
persists  Strain: due to musculotendinous unit overload
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(Forayo, L | Salvador, K)
 PHYSICAL REHABILITATION Midterms
Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders
Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

 Football, soccer, rugby players are prone to it  Grading of the severity of contusion
 Strain injuries are grades as: o Flexion of less than 45 deg. Indicates severe injury
o First degree (mild): o 45-90 deg. Indicates moderate injury
 Overstretching with minimal disruption of o Greater than 90 deg. Indicates mild injury
musculotendinous unit integrity.
 Less than 5 % fiber disruption Treatment
 Patient experiences soreness with motion but
has only minimal strength loss  Thigh should be bandaged/wrapped in a maximally
o Second degree (moderate): tolerated knee flexion
 An actual but incomplete tear of the muscle  Crutch walking is advised
 (+) Bleeding with hematoma formation  NSAIDs
 Muscle strength is compromised  Do not aspirate hematoma
o Third degree (severe):
 Icing for the acute phase
 Complete rupture  Heating modalities after 48 hours
 Muscle function is lost
 Scar mobilization
 Avulsion injuries are included in this category
 Aerobic exercises
 Rectus Femoris is most often affected
 Closed Kinematic Chain exercises
o Check for tightness by using Ely’s test
 S/Sx:
MYOSITIS OSSIFICANS TRAUMATICA
o Pain on deep palpation or passive stretch
o Swelling, discoloration
o Palpable mass in the zone of injury  Most common in Football or rugby
 Quadriceps as the most common site of involvement
 Functional Biomech. Deficits
 Like Heterotrophic ossification
o Tightness or weakness of the quadriceps
 Usually resolves when it occurs at the belly of the muscle
o Hamstring tightness
 S/Sx:
o Lack of warm up
o Local pain
o No stretching
o Warmth
o Overtraining
o Tenderness
o Usually nonspecific
Treatment
o Becomes evident in 3 weeks in plain films
o Triple phase bone scan/ultrasonography can detect it
 PRICE earlier
 NSAIDs
 Pain limited stretching
Treatment
 scar mobilization
 Strengthening ex
 NSAIDs
o Start isometrics then progress to PRE’s then to full
 Mature MOT can be surgically excised
weight bearing exercises
o Usually reserved for patients who have lost the range
of motion persisting 6 to 12 months
QUADRICEPS TENDON RUPTURE
ANTERIOR COMPARTMENT SYNDROME
 Represents an extreme form of overload
 A result of the repeated quadriceps strain injuries
 Palpably tense thigh
 Occurs mostly in the elderly population
 Decreased sensation in front of the thigh or in the
saphenous nerve or both
Treatment
 (+) pallor, decreased quadriceps strength

 Incomplete tears
Treatment
o Conservative
o Splinting
 Surgery
o Protected crutch ambulation
o Rehabilitation of other muscles
ADDUCTOR STRAIN
 Complete tears
o surgery
 Common in soccer, kicking sports, horseback riding,
gymnastics and ice hockey
QUADRICEPS CONTUSIONS
 Due to tensile overload or repetitive mechanism
 S/Sx:
 Characterized by:
o Medial thigh and groin pain worsened by abduction
o Capillary rupture
 Biomech. Deficits
o Edema
o Loss of adductor and psoas flexibility
o Inflammation
o Loss of external rotation of femur
o Bleeding
o Hamstring tightness
 The more relaxed the quads, the greater the injury
o Gluteus Medius weakness
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(Forayo, L | Salvador, K)
 PHYSICAL REHABILITATION Midterms
Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders
Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

 Functional adaptations o Ecchymosis

o Shortened stride with less crossover o tenderness
o Attempt to maintain a relatively internally rotated
position of the femur Treatment

Treatment  PRICE
 Crutch or cane walking
 PRICE  NSAIDs
 NSAIDs  Stretching programs
 E. S.-inferential current  Scar mobilization
 Surgery for complete rupture  Aerobic exercises
 Use of neoprene sleeve to keep muscles warm
 Rehabilitation:
o Stretching program for adductors, gluteals, external MERALGIA PARESTHETICA
rotators
o Closed kinematic Chain exercises  Pain and dysesthesias in the lateral thigh caused by
entrapment of the lateral femoral cutaneous nerve
OSTEITIS PUBIS  No resulting motor deficit
 May be due to obesity, pregnancy or a tight lumbar corset
 Pain in the groin or symphysis pubis or sudden hip hyperextension
 Seen in cross country skiers
 Diagnostics: Treatment
o Radiographs and bone scan
o Reveal periosteal reaction, demineralization and
 Weight reduction
sclerosis
 Vitamin B
 Avoidance of tight clothing
 Local injections
 Amitriptyline
 Carbamazepine

PATELLOFEMORAL PAIN SYNDROME

 Most common knee problem

 Seen also in runners
 Factors that predispose to this condition:
o Patella alta
Treatment o Increased Q angle
o Femoral anteversion
 Rest for 1 to 2 months o Excessive pronation
o Upper limb strengthening exercises  S/Sx:
o Lower limb exercises should start once tenderness o Worsened during knee flexion:
disappears  Pain
 Crepitus
HAMSTRING STRAIN  Swelling
o Theater sign-Achy anterior knee pain worsened by
squatting or prolonged sitting
 Most common
 Biomechanical deficits:
 Short head of the biceps femoris is involved
o Medial quadriceps insufficiency
 Occurs at high running speeds
o Inflexibility of the lateral retinacula
 Hurdlers and football punters are at risk
o Gluteus Medius and hip ext. rotator weakness
 Biomechanical deficits
(increases stress on the P-F jt)
o Decreased knee extension
o Imbalance of hip ext. and int. rotators
o Reduced hamstring to quadriceps strength ratio
o Excessive pronation
o Increased hip flexion
 Functional Adaptation
 Causes:
o Knee flexion contracture
o Insufficient warm ups
o Altered stride
o Flexibility imbalance
 Functional adaptations
o Shortened walking or running stride length
 S/Sx:
o Pain at the posterior thigh with the onset of a
popping sensation
o (?) palpable mass

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(Forayo, L | Salvador, K)
 PHYSICAL REHABILITATION Midterms
Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders
Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

 Housemaid’s knee
 Due to effusion of the subcutaneous bursa of the knee
 Pain reproduced by direct pressure on the knee

Treatment

 Stretching of quadriceps, hamstrings and triceps surae

 Icing

Management ANTERIOR CRUCIATE LIGAMENT INJURIES

 PRICE  A disabling event

 Stretching ex.  S/sx:
 Strength training o Audible pop and hyperextension or rotation of the
 Foot orthosis knee
 Patella taping o Hemarthrosis
 CKC o Clicking or locking might mean an associated meniscal
tear
ILIOTIBIAL BAND SYNDROME  Diagnostics:
o Anterior drawer’s test
 Painful sensation when the ITB slides back and forth over  Has technical limitations
the lateral femoral condyle as the knee flexes and extends  An associated meniscal tear can cause a “door
 Risk factors: jam”
o Limb length discrepancies  Hamstrings might interfere with the test
 False (+) with presence of PCL
o Running on beveled surfaces
o Lachman’s test
o Tibia vara
o Pivot shift test
o Foot hyperpronation
 Indicates anterolateral rotatory instability
 Diagnostics:
 Represent increased risk for cartilaginous injury
o Noble compression test
o Arthroscopy
o MRI
Treatment
Treatment
 ITB, hip flexors, gluteus max stretches
 Correction of forefoot pronation
 Swimming  Reduction of joint swelling through Icing
 Strengthening ex of hip adductors, gluteus max, Tensor  Prehabilitation
Fascia Latae o Stretching exercises
o Strengthening ex of quadriceps and hamstrings
o Protected weight bearing
PES ANSERINUS BURSITIS
o Avoid hyperextension of knee
 Surgery
 Pes Anserinus bursae separates the conjoined tendons of
o Patellar tendon grafts commonly used
semitendinosus, semimembranosus, sartorius and gracilis
 Post op rehabilitation (Week 1-4)
muscle from MCL and the Tibia
o Gradual PROME’s
 Commonly seen in women with heavy thighs and OA of the
knee o Control effusion
 Also seen in patients with direct trauma to the knee e. g. o Soft tissue mobilization
soccer players o Electrical Stim. To quadriceps
 Patients complain of pain at the inferior of the  Post Op rehab. (week 1 – 4)
anteromedial surface of the knee during stair ascent o Knee immobilizer for 1st post op week to avoid
 Diagnostics: persistent extension block
o May reproduce pain during flexion/extension while o Stationary cycling with no resistance
holding the knee in internal rotation o CKC exercises
o Crutch walking with partial weight bearing to affected
Treatment limb
 Rehabilitation (2nd month up)
o Cardiovascular fitness and improve quadriceps and
 Steroid injection
hamstring strength
 Stretching of adductors and hamstrings
o Improve proprioception
 Add padded protection of the knee
o Agility drills
o May need functional brace with a derotation
PREPATELLAR BURSITIS
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 PHYSICAL REHABILITATION Midterms
Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders
Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

POSTERIOR CRUCIATE LIGAMENT INJURIES o rehabilitation

 Occurs with direct trauma forcing the tibia posteriorly MENSICAL INJURIES
 S/sx:
o Vague  Common in both sport and industry
o Less pain  Semilunar cartilage tears are common
o Less hemarthrosis  Due to forceful rotation of the lower limb with foot firmly
 Physical Examination and Diagnostics: placed on the ground
o Reverse Lachman’s test  Physical Examination:
o MRI o Effusion within 24-48 hours
o CT o Sensation of giving way or mechanical locking
o Pain intensity depends on the severity of the tear
Treatment o (+) McMurray’s test
 Diagnostics:
 Aggressive stretching and Strengthening exercises o MRI
 Icing
 CKC exercises Treatment
 Agility drills
 May return to full activity in 2 months  Dependent on the severity
 Pain control and reduction of effusion
MEDIAL COLLATERAL LIGAMENT INJURIES  Arthroscopy if patient is unable to bear weight at 2-3 days
post injury
 Common  Surgery
o Grades of damage: o Tries to preserve most of the cartilage
 Grade 1- mild o Meniscal repair
 Grade 2- moderate  Non-surgical:
 Grade 3- Severe o Hamstring and ITB stretching
o CKC ex
Grade I o Hydrotherapy
 Post Op rehab:
 Pain on palpation o Return to weight bearing once pain subsides
 No valgus instability o Avoid deep squats for 6 months
 Treatment: o Strengthening ex
o PRICE
o NSAIDs ANKLE SPRAIN
o Locked brace in a few days
o Proprioceptive drills and strengthening ex  Occur when foot and ankle are plantar flexed
 Anterior Talo Fibular Ligament (ATFL) is injured with
Grade II combined inversion-plantarflexion
 Calcaneo fibular ligament (CFL) injures with increased
 Inability to fully extend the knee because of pain and inversion
inflammation  Posterior Talofibular Ligament (PFTL) injures with further
 Mild to moderate instability increased inversion and posterior displacement of the talus
 (+) swelling and hemorrhage  Classes:
o Grade I (Mild)
 Extracapsular MCL are ruptured
 Treatment:  minor ligament disruption
o PRICE  no signs of instability
o Grade II (Moderate)
o Knee orthosis to limit last 20 to 30 deg. Ext.
 near complete disruption with macroscopic
o After 1st week: limited arc ROM (20 to 70 deg.)
tearing and swelling
o Early mobilization within pain free limits
 (+) moderate functional loss and with mild to
o FWB at the end of first mo.
moderate instability
o Hip girdle ms. Strengthening ex
o Grade III (Severe)
o Proprioceptive drills, carioca drills
 complete rupture with swelling/discoloration
 loss of function
Grade III  limited weight bearing tolerance
 reduced stability
 Hemarthrosis  Physical Examination:
 Due to rupture of the MCL fibers o Ant. Drawer test
 Unstable to valgus stress in both extension and flexion o Talar tilt test
 Treatment: o Clunk test
o Surgery o Squeeze test
o Lifestyle modification o Eversion test
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 PHYSICAL REHABILITATION Midterms
Lesson 2.2 Rehabilitation of Lower Limb Musculoskeletal Disorders
Dr. JOEL T. ARETA, PTRP, DPARM, FPARM

Treatment

 PRICE
 Ankle pumping exercises
 Alphabet writing ex.
 Gastrocsoleus complex stretching ex
 Proprioceptive exercises
 Cycle exercises
 Drills

PLANTAR FASCIITIS

 Due to traction induced microtears of the plantar fascia

 Tenderness at the heel area

Treatment

 PRICE
 Plantar fascia stretches
 Stretching ex.
 Taping
 Foot orthoses

MORTON’S NEUROMA

 Entrapment of the digital nerves of the foot

 Exacerbated by tight footwear

Treatment

 Foot orthoses
 Footwear modification
 Corticosteroid injection
 excision

REFERENCE/S:

 Dr. Areta’s Asynchronous Lecture

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