m3

MSK LE Study Guide 1

Low back pain Dermatomes
- Largest outpatient population served L1 Inguinal crease
by PT L2 Medial Thigh
- Most common cause of disability L3 Medial Knee
worldwide L4 Medial Malleolus/Great Toe
- 85% of LBP can’t be reliably L5 Dorsum of Foot
attributed to a specific disease S1 Lateral Foot
LBP in primary care: S2 Postero-medial Thigh or S2- Medial
Cancer 0.7% aspect of the posterior calcaneus
Compression fracture 4% Myotomes
Spinal infection 0.01% L1-2 Hip Flexion
Ankylosing spondylitis 0.3-0.5% L3 Knee Extension
Spinal stenosis 3% L4 Ankle Dorsiflexion
Symptomatic herniated disc 4% L5 Great Toe Extension
Flexion S1 Plantar Flexion or Eversion
Cauda equina 0.04%
- Iliopsoas S2 Knee Flexion
Extension
- Glut max and hamstrings
Abduction Hip Differential Diagnosis based
- gluteus medius, gluteus minimus, and TFL; the piriformis, Conditions mimic mechanical LBP- cauda on Age
sartorius, and superior fibers of the gluteus maximus equina, cancer, infection, fracture
Adduction Age Condition
- These muscles are the adductor longus, adductor brevis, adductor Mechanical and non-mechanical LBP may
magnus, gracilis, and pectineus 0- 2 Congenital dislocations; septic arthritis
coexist
External rotation
- the piriformis. the gemellus superior and inferior. the obturator 4- 8 LCPD (Perthes Disease)
internus and externus. the quadratus femoris. Goals for Screening
Internal rotation Identify those with a high 9- 15 SCFE; Apophysitis (stress fractures?)
- Obturator, gemellus, pectineus, Anterior fibers of gluteus min probability of a serious medical
Knee flexion condition causing LBP or LE pain 14- Osteochondritis Dissecans, Overuse
Knee extension Coexisting, unrelated health 25 Injuries, Strains, Osteitis Pubis
condition
30- Rheumatoid Arthritis; AVN
50

55+ DJD and Hip Fractures

 Inflammatory back pain Red Flag Conditions
LBP is leading symptoms in spondyloarthropathies
Abdominal Aortic aneurysm Cauda Equina Syndrome

4/5 features (95% Age < 40 years of age
sens; 85% spec) Duration of back pain > 3
months
Insidious onset
Morning stiffness
Back pain tends to get
worse in the second half
of the night
Wake up with pain or
stiffness
Improves with exercise
Signs: Signs and symptoms:
Pulsating mass/bruit Insidious onset of LBP/LE pain
Symptoms: Sensory and motor impairment and bowel
Can be symptomatic or bladder dysfunction
May sense throbbing when lying Causes:
down Herniated disc (1-2%)
Sudden onset of back pain Trauma
Excruciating midline pain in low Post-op complication
back, mid-abdominal or mid Stenosis
scapular region Space occupying lesion
Risk Factors: History factors for CES
Males > 55 y/o
Tobacco use
Family history
CAD/cholesterol
Clinical Exam:
Abdominal
palpation/auscultation can detect
most large AAA’s
US and CT: 100% sensitive and
specific

Spinal infections Spinal Malignancy

Category 1: Category 2: Category 3:
- Bacterial infection of the disc Malignant neoplasms
Factors Factors that Factors that and surrounding tissue Occur in less than 1% of patients with LBP
that require subjective require further - Incidence of lumbar spinal Early detection and treatment is important
require questioning, physical testing infection= 0.01% to prevent the spread
immediate examination and and differential - Tenderness during spine Cancer of the breast, lung and prostate are the
medical treatment analysis palpation is a sensitive clinical most- commonly associated with pony
attention measure metastases
Category 1 examples - MRI gold standard Symptoms
Infection (rapid onset, leading to fever, malaise, severe lbp Clinical signs of infection: - Insidious onset,
Pulsatile abdominal masses (AAA) Temperature >100* F - Constant non-mechanical pain
Cauda equina syndrome (CES) BP >160/95 mm Hg - No relief with bedrest
Neoplasm - Unexplained weight loss
Resting pulse > 100 bpm
Upper lumbar disc herniation (younger populations)
Resting respiration > 25 bpm
Patterns of symptoms not compatible with mechanical pain
Progressive neurological deficit Fatigue
Fractures Elevated lab values (ESR,
C-reactive protein, WBC)

Pathologies
CONDITION SUBJECTIVE OBJECTIVE INTERVENTIONS
EXTRA ARTICULAR:
HIP BURSITIS -
ISCHIAL Direct trauma or movement in sitting
position (rowing, biking)
HIP BURSITIS -
ILIOPECTINEAL Anterior hip pain, difficult to differentiate
from hip flexor strain

Direct trauma or repetitive friction from IT Manage with RICE

band over greater trochanter during hip Sharp pain (acute) that progresses to dull
flex/ext ache with activity (chronic) Address biomechanical factors
HIP BURSITIS - Can progress to “snapping hip syndrome”
Pain with lying on involved side, walking, - rest, ice, load modification
TROCHANTERIC
Inflammation of bursa between the greater and stairs
US/Shockwave therapy?
trochanter & ITB
Corticosteroid Injections?
Women > Men
Iliopsoas snapping hip may or may not be Iliopsoas tendon tender to palpation NSAIDs
painful
Pain with resisted hip flexion Address muscle imbalances
- Greater incidence in ballet dancers
- Stretching, strengthening
- Most common cause of groin pain in Movement from FABER position into
runners extension, adduction, and IR often
- Anterior groin pain with elicits a palpable snap Manual therapy
SNAPPING HIP extending the hip from - Pss soft tissue
SYNDROME flexed position - Anterior glides of the hip
 Imaging US-guided injection with lidocaine and corticosteroid
can provide relief
•US may show tendinopathy, bursitis
•Dynamic US to see tendon snapping - Predicts the response to surgical release
- 80% success with arthroscopic release

- External coxa saltans less common
- Thickened IT band or glut max
tendon snapping over greater
trochanter
- Often have spinal or other hip
disorders causing gait alterations
- May also have bursitis
Iliotibial
Band/Gluteus
Max Snapping
More common in middle-aged women and
Hip
runners
Pain with direct compression of the
trochanteric bursa
Treatment example:
- Core stabilization training, hip muscle
rebalance, functional movement retraining
Rest
Ober test + for IT band tightness
NSAID
Snapping can be elicited in side lying with
Stretching
hip flexion/ext and IR/ER
Manual therapy?
Biomechanical factors
Corticosteroid injection
- Femoral add/IR, pronation
For symptoms > 6 months with failed conservative
Gait may reveal gluteal weakness management surgical IT band release or debridement
results in good outcome at 1 year

Gluteal tendons analogous to rotator cuff of shoulder Treatment

Tendinitis to tendinosis - Physical therapy addressing hip impairments
- Corticosteroid injection
More common in women
GLUTEUS - Endoscopic repair
MEDIUS/ Examination
MINIMUS
INJURY - Dull lateral hip pain
- Focal tenderness at gluteal insertion
- Weak hip abduction
Provocative tests
- Pain with one-leg stance for 30 seconds
Sciatic nerve compression by the piriformis May have leg pain in sciatic nerve distribution ● NSAIDs
muscle ● Muscle relaxants
Numbness or weakness rare, SLR negative
● Physical therapy addressing muscle imbalances
Caused by: Sitting worsens the pain, walking relieves pain
● Hip mobilizations
- Piriformis hypertrophy or spasm Tenderness at greater trochanter and piriformis ● Myofascial release
 PIRIFORMIS - Muscular fibrosis following trauma
INJURY - Sciatic nerve emerges from greater
sciatic notch below piriformis
- Anatomy is variable
Nerve can split above the piriformis
Branches can emerge above, through (12%), or
below muscle
Significant cause of groin pain in athletes
Higher incidence in:
- Hockey, soccer, and rugby
- Adductor weakness,
abductor–adductor imbalance, or
decreased preseason hip ROM
ADDUCTOR - Poor core stabilization/functional
STRAIN movement control
Origin of adductor longus at pubic
symphysis has small tendon predisposing
area to strain
Disabling lower ab and inguinal pain
MOI: trunk extension & thigh abduction
injury to insertion of abs on pubic bone
- Gilmore's groin: tears in the external
ATHLETIC
PUBALGIA oblique aponeurosis and conjoined
SPORTS HERNIA tendon
GILMORE'S
Risk factors:
GROIN
SPORTS HERNIA - Sports requiring repetitive twisting
and turning of the thigh and trunk
- Muscle imbalance abdominals &
adductors
- Inflammation around the pubic
symphysis
- Common among athletes, pregnant
women, pelvic trauma, or pelvic
OSTEITIS PUBIS
surgery.
Mechanism of Injury:
Pain with FAIR test (flexion to 600, adduction ● TS and LS mobility
and IR in sidelying) with or without resisted ● Core stabilization
abduction
Present with aching groin or medial thigh •RICE
pain
•PT focus on flexibility and core strengthening
Tenderness to palpation •Preseason adductor strengthen & hip ROM
May relate a specific incident •Injection helpful
•Surgical repair for diagnosed tears
Adductor weakness
Abductor–adductor imbalance
Athletic Pubalgia/Sports Hernia-Exam & Rx NSAIDs
•Pain with activity, resolves with rest - RICE
- Physical therapy
•Tenderness around the conjoined tendon,
Core and hip strength for imbalances
pubic tubercle, inguinal canal
•Aggravated by ballistic movements Surgical repair of posterior inguinal wall
–Coughing, sneezing, sit-ups, sprints, or Good outcomes: return to full activity 2-6 months
kicking
•Pain with sit-ups, hip adduction, or Valsalva
- Diagnosis determined by history and
NSAIDs
physical examination
- Tenderness pubic symphysis Physical therapy for 6-8 weeks
- Pain with resisted adductor testing - Address muscle imbalances hip and core
- hypermobility/instability pubic - Adductor stretching
symphysis - Proprioceptive retraining
Cortisone injections Brace/Belt
 - Overuse/shear injury pubic
symphysis
10-14 years of age

SLIPPED Displacement of epiphysis from its normal position

CAPITAL Antalgic gait, LE in ER, limited IR and abd
EPIPHYSIS More common in males

INTRA ARTICULAR:
LEGG CALVES - 5-10 years of age
Limp, pain in groin or hip, ROM loss in abd and IR
PERTHES - Osteochondrosis of femoral head
DISEASE
Degenerative vs traumatic Generally gradual onset vs. acute trauma
Groin pain with/without click Dull and/or sharp groin pain

Clicking hip: +LR of 6.7 Worse with activity, walking, and sitting

Risk factors for labral tears 50% report catching or painful clicking

- Perthes' disease May have Trendelenburg gait or limp

- Previous trauma Often positive impingement sign (FADIR)
- Slipped capital femoral epiphysis
FABER painful or restricted
LABRAL TEARS - Femoroacetabular impingement
(FAI) Relief with an intra-articular injection
- Repetitive pivoting or hip flexion

Clicking – is a consistent finding

Hockey, football, soccer, ballet, or running
Tests
Suspected anterior:
- Flexion abd er moved to
Ext/ADD/IR
Suspected posterior:
- Flex/ADD/IR, moved to
Ext/ABD/ER
Phase 1: Maximum Protection: 0 weeks to 3 weeks Phase 3: Strengthening: Unspecified timeline-
● Pain control progress as tolerated
● Education in trunk stabilization ● Advanced sensory motor training
 ● Correction of abnormal joint movement ● Sport-specific functional progression
Phase 2: Controlled stability: Begins at 3 week ● Reassess ROM, strength, flexibility, pain,
Labral Tear special tests, and level of function
● Muscular strengthening
TREATMENT
● Recovery of normal ROM
● Sensory motor training
Phase 4: Return to sport: 6 months

LABRAL T EARS

•Young Male patients with hip pain, •Sharp groin pain with flexion and IR Stage 1
Middle active age females- more common? •Lateral or posterior pain with ER, - Decrease joint stress
stair-climbing and prolonged sitting - Education re: basic biomechanics to reduce
•Reduced ROM in flexion & IR
•Difficulty squatting or with lateral and symptom aggravation
•Repetitive microtrauma - Use of assistive device
cutting movements.
•Increased incidence of early OA
•Significantly limited flexion and IR Stage 2:
•Etiology
FEMOROACETAB •Positive impingement test occurs with groin - Progress ROM, avoid end range hip F/ER
ULAR •Abnormal acetabulum pain at 90 of flexion with IR (FADIR) - Manual therapy – anterior / posterior 111
IMPINGEMENT - Progress hip abduction/ adduction and rotator
•Abnormal femur •Pain or asymmetry with FABER strengthening
•Increased stress •Conservative management should be - Avoid sitting low chairs
•Two types considered before surgery - Cardiovascular activity: upright bike,
swimming flutter kick
- Pincer (acetabular) ♀
- Cam (femoral) ♂ Stage 3:
•Mixed – 86 %
- Progress strengthening
- Progress functional training
Pincer type of FAI - Increase activity load
Middle aged women
Ballet dancers - Progress neuromuscular retraining
Acetabular abnormality Overcoverage Focal Surgery!
articular damage
Posterior inferior cartilage abrasion Improve clearance for hip ROM
•Relieve femoral head abutment on the acetabular rim
Cam Type FAI
Younger males •Open treatment: hip dislocation & osteoplasty
Primary femoral abnormality Possible
adaptation to activity, ie sports.
–Longer recovery time, delayed recovery
Loss of normal concavity Etiology Growth
abnormality of the capital femoral epiphysis •Arthroscopic osteoplasty for both cam and pincer
SCFE impingement has good results
LCPD
Femoral head jams into acetabulum
Shear forces on labrum
Diffuse articular damage
Hip Fractures
Hip Fractures Treatment Complications Post ORIF
Fractures and Surgical Weight-Bearing
Options - Avascular Necrosis Type Procedure Status

- Infection Femoral Neck Hemiarthroplasty WBAT

- ORIF
- Arthritis ORIF
- External Fixators Displaced Fracture Depends on
- Dislocation (garden 3 and 4) stability of surgical
- Arthroplasty
- Coxa Vara or Valgus fixation
- Hemiarthroplasty
- Mal-Reduction or Nail Penetration
- Non-surgical Femoral Neck Hemiarthroplasty WBAT
ORIF
Physical Therapy Management Garden type I Undisplaced Depends on
- Incomplete fracture with valgus Impacted Fracture stability of surgical
(garden 1 & 2) fixation
During Immobilization impaction
- Mobility depends on stability of Garden type II Intertrochanteric Pins, screws, side Depends on degree
- Complete fracture without plates of fracture
fracture undisplaced/displac stabilization, pt
displacement
ed 2 part fracture frailty, immobility
- WB status (assistive devices) Garden type III or 3 part fracture risks
- Complete fracture with partial
- Maintain cardiovascular fitness, displacement of the fracture Subtrochanteric Blade plate ORIF Delayed until
Screws fracture heals
motion and strength in uninvolved fragments Simple, Intramedullary nail
Garden type IV fragmented, or
joints
- Complete fracture with total comminuted
- ADL’s displacement allowing the femoral
head to rotate back to an anatomical
- Monitor casts, fixators or surgical
position
incisions
nondisplaced, Garden I and II
Post Immobilization Stage
displaced Garden III and IV fractures.
- Improve ADL’s
- Restore ROM Stable - Fractures with an intact
- Restore strength posteromedial cortex
- Gait training
 - Balance Unstable - Fractures with comminution of
- Function the posteromedial cortex, fractures with
diaphyseal extension
Number 1 risk factor of falling is fear of
falling

Hip Differential Diagnosis based on Age

Age Condition

0- 2 Congenital dislocations; septic arthritis

4- 8 LCPD (Perthes Disease)

9- 15 SCFE; Apophysitis (stress fractures?)

14- 25 Osteochondritis Dissecans, Overuse Injuries, Strains, Osteitis Pubis

30- 50 Rheumatoid Arthritis; AVN

55+ DJD and Hip Fractures

Red flags?

CONDIT SUBJECTIVE OBJECTIVE INTERVENTIONS

ION
- Injury of the elderly (osteoporosis) - ORIF with various nails and screws
Fractures
- Blood supply compromised because fracture is intracapsular - Hemiarthroplasty vs. Total hip
of the replacement (THR)
- Healing is less certain, avascular necrosis (AVN) may occur
Femoral - Very few patients return to full mobility following this injury Mortality is high (20-25%)
Neck - Cause is usually a trivial fall or stumble (trip on rug)
(intracapsu - Up to 40-50% over age 80
lar) Rehabilitation needs to take place early
(open reduction internal fixation)
Intertrocha Better prognosis than intracapsular fractures Type 1: stable non displaced
nteric - Do not have to worry about blood supply
fractures Type 2: unstable displaced
being compromised as much
Type 3: Unstable oblique non displaced
Younger age group
Most common rx = ORIF Type 4: Unstable non displaced and
fracture extends into femoral shaft
Older patients ORIF,
- (if older) nails and plates, screws

Subtrochan A; Most stable, low Risk

teric D & C: Comminuted
Fractures
E: Unstable, highest complication risk

Stress Risk Factors Symptoms Management

Fractures - Female Gender - Exercise induced deep hip pain
- Dysmenorrhea - (+) Pain w/ single leg hop test - Female Athlete Triad
- Overuse (+)Patellar pubic percussion test - Nutrition consult
- Smoking (+)Fulcrum test - Counseling consult
- Steroid use - Can occur in males
Fatigue Fractures - Physical therapy for biomechanical
- Normal bone w/ abnormal stress
contributions
Insufficiency Fractures
- Relative rest
- Abnormal bone w/ normal stress
Location
- Femoral Neck
- pubic rami
- acetabulum
- femoral head
Pelvic Mechanism of Injury: Stable (1 side of ring) Methods of Reducing and Stabilizing
Fracture - Ilium, pubic rami, avulsion, stress
- Compression (Blunt Trauma), e.g., ORIF
high-speed collision, fall, direct blow Unstable (2 sides of ring) External Fixators
Most Common injury sites - Compression Fractures - Spica Cast
- Vertical Shear - Traction
- Anterior pubis - Hinge - External fixation
- Anterior Ischium - Lateral

Associated Risks:
- Damage to overlying blood vessels and
adjacent organs resulting in peritonitis,
sepsis, infection, hemorrhage, shock

Possible Risks from Pelvic Fractures

- Rupture of major arteries (femoral artery)
- Neurological damage (sacral plexus)
- Sacroiliac injury or pain
- Hip joint disruption
- Damage to genitourinary structures

Hip MOI: Fracture Dislocation of the Hip

Dislocation - Fracture of the acetabulum occurs as the hip dislocates
- Compression trauma: Blunt force to bent
knee when hip is flexed (e.g.,MVA, fall - Treatment by reduction of the fracture with traction and rest for 12 weeks
while climbing). - May be prone to re-dislocation due to poor alignment of the acetabular component
- Rotational trauma: Severe internal rotation
of thigh with hip partially flexed (e.g.,
Avascular Necrosis
release of ski binding when skier initiates - Avascular Necrosis of the Femoral Head
turn)
- Blood supply to the femoral head is compromised
Most common injury site
- Common complication following hip dislocations, fractures, and chronic synovitis
- Posterior dislocation (may have “rim
fracture” of acetabulum) - Often necessitates a hip replacement
Associated Risks
 - Damage to sciatic nerve, compromise of
blood supply to head of femur

Avulsion MOI:
Fracture - Violent contraction or tractioning of the
muscle
Common sites:
- ASIS, AIIS, lesser trochanter, and ischial
tuberosity
Signs and symptoms:
- pain at time of injury, bony tenderness,
muscle bulging away from the attachment,
and swelling

Degenerati Develop secondary to repetitive trauma, age, acute “Patients with nonoperative treatment
ve Hip injury following hip fracture were associated with
Changes - Arthritis substantially higher complication and
- Osteochondritis Dissecans mortality compared with patients who were
- Avascular necrosis treated operatively”
- Femoroacetabular Impingement (FAI)

HIP OA Degenerative Joint Disease Signs/Symptoms Conservative Management

- Progressive deterioration of the articular Minimize Pain and Inflammation

- Anterior groin pain
cartilage with osteophytes - Stiffness after prolonged rest - NSAIDs
- Can be primary (idiopathic) - Decreased ROM in extension, IR, and - Physical therapy
- Can be secondary (traumatic) or loss of end range flexion - Manual therapy!
- Result of congenital abnormalities that alter - Antalgic gait and pain with ADLs - Exercise-ROM, strength
biomechanics - Heat
- Coxa vara Altman - Glucosamine and Chondroitin Sulfate?
- Leg length discrepancy - Traction
- hip pain and hip IR less than 15 and
- LCP, SCFE
flexion less than 115 Patient Education
- AVN
- FAI - OR
- Activity Modification
- painful IR
- Cane Unloading
- older than 50
- morning stiffness that goes away after 60
minutes

CPG Criteria for Hip OA

- Hip IR less than 24*…..or
- Hip IR and flexion less than 15 less
than non-painful side
- Increased hip pain with passive hip IR
- Moderate anterior or lateral hip pain
during weight bearing activities
- Morning stiffness less than one hour after
waking (LESS THAN 60 MINS)

FABER and Scour

Total Hip Arthroplasty & Rehabilitation
Charnley THA

Sir John Charnley introduced the

- THA worldwide in 1960s

25-year follow-up of 1689 patients (2000 arthroplasties) who had Charnley THA between 1969 and 1971:

- 461 patients still living

 - 77.5% free of reoperation
- 80.9% free of revision or removal of the implant for any reason
- 86.5% free of revision or removal for aseptic loosening

Total Hip Arthroplasty (THA)

Indications Contraindications
- OA - Infection.
- Inflamed synovium (RA) - Injured or non-functional hip muscles
- Nonunion hip fractures - Neuromuscular disease
- Avascular Necrosis - Skeletally immature
- Congenital hip dysplasia - Poor quality bone
- Slipped capital femoral epiphysis - Poor skin coverage around the hip joint

1970s Then Now

•Admitted 1-2 days before surgery •Admitted morning of surgery

•Bedrest 2-3 days post-op •Mobilize day of surgery or POD 1

•Partial weight bearing •Usually WBAT

•LOS 17 days •LOS < 5days

Standard THA
Standard total hip arthroplasty

- Incision > 10 cm

Posterolateral approach

- Return to normal abductor strength and ambulation is faster

- Higher rates of dislocation
Anterior lateral

- Allows immediate normal ROM

- Lower risk dislocation
- Higher revision rates
- Higher risk complication

Lateral & transtrochanteric approaches

- Higher rates of post op limp due to gluteal nerve injury or avulsion of gluteal flap

Cemented vs. Cementless

Cemented technique:
- 98% survivorship of implant at 10 years
- 93% survivorship of implant at 25 years
Cementless technique:
- Similar to above numbers for femoral component, and better with acetabular component at 15 year mark
Cementless technique is now preferred method, especially in younger patients

In the old days: NWB &/or PWB

Now: WBAT/FWB

Rationale:

- NWB and TDWB produces greater joint pressure than FWB

- FWB does not adversely affect bone ingrowth or prosthetic stability

THA Precautions
(Posterior Approach)

● Don’t cross your legs or ankles

● Don’t raise knee above hip
● Don’t bend at the waist > 90°
● No ER if anterior approach
 ● No IR if posterior approach
● Don’t sleep on side or without pillows between your knees

Complications
DVT (8% to 70%)
- Prophylactic anticoagulants
Device failure
Leg length discrepancy
Component malalignment
Infection
Improper implant fixation to surrounding bone
Nerve palsy
Prosthetic hip dislocation

Are Hip Precautions Necessary?

499 patients s/p THA via anterolateral approach
No post-operative restrictions
3 dislocations within 6 weeks post-op (0.6%)
Stable hip achieved after closed reduction
Low early dislocation rate can be achieved using anterolateral approach without restrictions

Cumulative Long-term Risk of Dislocation

Retrospective study
- 5459 patients s/p Charnley THA between 1969 and 1984 routinely followed until revision or death
- 4.8% dislocated
Highest risk in first year s/p surgery
- Usually hip precautions for 3 months
Patients at highest risk:
 - females, those with dx of osteonecrosis of femoral head, acute fx, or nonunion of proximal part of femur
Late Dislocation
- 15964 pts s/p THA between 1969 & 1995
- 32% of the dislocated hips first dislocated 5 or more years after primary THA (median 11.3 yrs)
Late dislocations associated with:
- long-standing problem with prosthesis, trauma, neurologic decline, polyethylene wear, or combination
No randomized controlled trials have been done to determine the most effective rehab protocol

No prospective studies have determined the advantage of inpatient rehab post THA

No specific data on the type and duration of ROM restrictions

What We Do Know
Ongoing impairments and functional deficits for as long as 2 years post THA
Of 67 patients treated with unilateral THA (original and revised) who presented for rehab with problems 6-9 weeks to one year post-op…
•47% hip abductor weakness
•28% muscle contracture
•13% limb length difference
•12% malalignment

Weight Bearing and Postural Stability Exercises

Trudelle-Jackson & Smith, 2004:
- 34 subjects who had undergone THA 4-12 months previously; 28 completed the study
- 8 week intervention: experimental group rec’d strength & postural stability exercises; control group rec’d basic isometric & AROM
- Exercise program emphasizing weight bearing & postural stability significantly improved muscle strength, postural stability &
self-perceived function

Home Programs
 - Low resistance strengthening hip flex/ext/abd
Patients s/p THA > 1.5 years
- 30 min walking every day
Compared 12-week home program
Greater improvement in Exercise high compliance group :
- Exercise-low compliance
- Strength on operated side
- Exercise high compliance (most success group)
- Fast walking speed
- Control group
- Functional score on Harris Hip Score
HEP
Recommend HEP 3x/week for training effect
- Hip flexion ROM

THA Rehab
Phase I Rehab Exercises (0-3 weeks)

- Gait Training - Prone Lying

- Quad Sets and/or Terminal Knee Extension - Prone Hamstring Curls
- Gluteal Squeezes - Reclined Sitting Knee Extension
- Heel Slides - SLR????
- Supine Abduction/Adduction AROM
More stressful to hip than walking

THA Education

Phase I Education
- Use of Abduction Pillow
- Bed Transfer Methodologies
- WB Instructions
- Breathing Exercises
- Awareness of DVT (ankle pumps)
- Commode/Chair Transfers
- ADLs
Phase II Rehab Exercises (4-6 weeks)
- Supine Hip Lift (SLR)
- Make it functional!
- Standing Hip Lift
- Standing Hip Abduction
- Standing Hip Extension
- Partial Squats
- Hip Extensor Stretch
Phase III Rehab Exercises (6-12 weeks)
- Side Lying Hip Adduction
- Prone Hip Extension
- Step Ups
- Calf Raises
- Proprioceptive and Balance
activities
- Supine Hip Flexor Stretch
- Bike
When Can Patients Resume Sexual Relations After THA?
67% of the 254 surgeons surveyed recommended waiting 1 to 3 mos. follow ing THA

30% would allow within first 4 weeks

5 safe positions for men and 3 for women were approved by 90% surgeons

Minimally-invasive THA
General definition: incision < 10 cm
Strict definition: Single incision (1-MITHA) Two incisions (2-MITHA)
- incisions that do not involve - Modification of old approach - New approach
cutting muscles or tendons »E.g., top half of post-lat or ant-lat - Use intermuscular planes to access
approach joint

- May be less cutting of

muscles/tendons, or not

Indications:
Birmingham Hip •Physically active
Resurfacing •Under 60 years of age
•Hip OA, dysplasia or AVN
•Bone quality strong enough to support the implant.
 KNEE
MCL Medial Collateral Ligament Injuries MCL Testing
- Most common mechanism is blow to lateral knee with Valgus Stress Test
valgus force 2 positions:
- May also be injured by non-contact and/or rotational - Full extension
stresses - Laxity indicates possible sprain of MCL, cruciates, and medial capsule
At full extension: - 25°-30°flexion
- MCL, joint capsule and pes anserine tendons resist valgus - Laxity indicates isolated MCL sprain
force
At 20-30 degrees flexion Apley’s Distraction test
- MCL is primary restraint to valgus force
Valgus Stress Test
Anteromedial Rotatory Instability Test
Medial Collateral Ligament Injuries- Rehab Palpate MCL
Most MCL injuries managed nonoperatively
Has good blood supply
Low ROM during healing to create optimal environment –
bracing/immobilization
Tend to lose extension if not careful!
Loss of extension because of hamstring contracture and quadriceps
inhibition.
30

MCL Repair (rarely done)

LCL Lateral Collateral Ligament Injuries
- Rarely an isolated injury
- Frequently also injures posterolateral corner of knee
Blow to medial knee:
- varus stress

IR of tibia may also contribute

May also injure cruciates and capsule
Rule out peroneal nerve injury
Poor blood supply
- doesn’t heal well and may need surgical repair

Varus Stress Test

- 2 positions:
- Full extension laxity indicates LCL, cruciate, or lateral capsule pathology
- 25°-30°flexion laxity indicates isolated LCL sprain
- Apley’s Distraction test - COMMENT
- ACL taut in maximal extension

ACL
● Origin posteromedial aspect of lateral femoral condyle
● Insertion anterior intercondylar eminence of the tibia
Size 33mm length (average) 11 mm diameter (average)

Anterior Cruciate Ligament Injuries

- Most injuries are non-contact rotational forces
- Tibia displaced anteriorly on femur, rotational stress
(cutting) or hyperextension
- May be isolated but may also injure other structures (joint -
capsule, menisci, MCL)
ACL
MOI and Findings History and demographics
Mechanism of Injury
 - Hyperextension Anterior Cruciate Ligament Injuries
- Past
Unhappy Triad - often treated surgically dependent upon activity and/or level of
● Valgus Stress performance
● MCL - autografts (patellar tendon, hamstrings)
● Medial meniscus - allografts (cadavers)
● ACL - Return to sport slower DH Skiing eg. - 2 years (CHANGE w/
RESEARCH)
Subjective and Objective Findings
- Often note a “pop” or state “knee gave way” > Females
- Immediate swelling typically present and significant - Females with significant numbers of non-contact ACL injuries vs. males
- “Partial tears” typically treated as complete tears due to - Females also typically have narrower intercondylar notches than males
changes in ability of ligament to respond to stresses placed - Hormonal changes during menstrual cycle may increase risk of injury –
upon it with activity lax ligaments
(9 to 14 days)

Female Athlete Considerations

● Increase Susceptibility to ACL Injury
● Anatomical Differences
● Wider pelvis
● Increased flexibility
● especially extension
● Narrower femoral notch
● Less developed thigh muscularly

Predisposing Risk Factors TESTS

Extrinsic and Intrinsic factors Anterior Drawer Testing
● Sport-specific activities - Hip flexed to 45° with knee at 90 °
● Athletic skill - Foot stabilized and neutral
● Shoe/surface - Hamstrings must be relaxed
● Muscle strength - Fingers at jointline parallel to patella tendon
● Coordination - Anterior force applied
● Pronation
● Joint laxity Lachman’s test
● Limb alignment - Femur stabilized with knee slightly flexed
● Small intercondylar notch - Anterior force applied to tibia
● Small ACL - Hands placed at tibial tuberosity and proximal to femoral condyles
 ● Genu recurvatum
● Anterior pelvic tilt Pivot Shift Test
● Anteverted hip - Subluxing the tibia on the femur 2° to torn ACL
● Menstrual cycle - IR, axial loading, and valgus stress on knee during flexion

ACL Surgery Surgical Approaches

- If you have a torn ACL is surgery required?
- How are decisions made? ACL Bone-Patella-Bone Graft
Normal ACL Rupture force needed = 2500N
Pre-operative Physical Therapy
- Knee needs to recover from injury
- Surgery too soon = arthrofibrosis risk (6month) BTB Graft
- Goals pre-op Patellar tendon graph
- Regaining full ROM Force needed to rupture = 2977 N
- Normalize swelling
- Good quad contraction HS Graft
- Faster recovery of ROM and quad strength following Force needed to rupture = 4590 N
surgery
ACL Bone-Patella-Bone Graft
Operative Patellar tendon (bone-tendon-bone)
● ACL Grafts Pros
● Autografts ● bone to bone healing
● gold standard of repairs
● Ipsilateral patellar tendon
● good size graft
● Contralateral patellar tendon Cons
● Shelbourne ● anterior knee pain and patellar tendonitis
● Hamstring/gracilis ● significant quadriceps atrophy
● risk of patellar fracture
● Quadriceps tendon
● Fulkerson ACL Hamstring Graft
● Allografts (cadaver) Pros
- Very strong if doubled or quadrupled
● Patellar tendon
Cons
● Achilles tendon - May result in permanent decrease in hamstring strength 5-10%
● Iliotibial band (dancers, skaters)
● Anterior tibialis
 Graft healing Pattern
- @ 6 weeks graft shows signs of avascular necrosis (weak!)
- 8-10 weeks tissue begins to revascularize

The Rehabilitative Process Closed Kinetic Chain Exercises (Move)

Quad Dominant
CKC ● Wall Squats
- More functional ● Leg Press
- More effective in improving function ● Lateral Step-ups
- Increase joint compressive forces ● Front Squat
- Promote co-contractions Hamstring Dominant
- Minimize translatory stresses on the ligaments ● Retrograde Stair Master
- Less shear force on ACL when performed in 0 – 600 angle ● Multi Position Lunge
- May encourage a co-contraction of the hamstrings ● Forward Step-ups
● Straight Leg Dead Lifts
Quad/Ham Co-contraction
● Fitter
● Slide Board
● Vertical Squat (0-45)

Open Kinetic Chain Exercises (Move)

OKC
- Knee Extension
- Greater shear force on ACL when performed in 0 – 300; <
- ACL is loaded when the knee angle is less than 50-80 degrees
shear at 600-900
(peak at ~ 30 – 0 degrees).
- Result in no co-contraction
- PCL is loaded at higher angles (greatest at ~ 90)
- Anterior shear with final 30 degrees of extension
- Knee Flexion
- Exercises
- Only the PCL is loaded (peak force at ~ 90 degrees)
- ACL is not loaded during OKC flexion activities

Pre-Operative Phase
Goals:
● Full ROM (extension)
● Minimal swelling
● Mental preparation
● Near full strength
● Rationale
● Arthrofibrosis
Phase 3
Muscle Strength and Control
9 weeks to 4 months
Goals:
● Increase quadriceps, hamstrings,
gluteal and core strength using
advanced dynamic exercises
● Improve proprioception and balance
● Aerobic activity for 20-30 minutes per
day, 3-4 times per week
BANFF ACL Management Phases
Phase 1
Early Post Op
1-3 weeks
Goals:
● Reduce inflammation and swelling –
cold therapy unit/ elevation
● Range of Motion: 0° to ≥ 110° by end
of 3rd week post-operative – ankle
pumps/ AAROM
● Quadriceps muscle activation
Phase 4
Strength, Agility and Plyometrics
3 months – 12 months
Goals:
● Increase agility using pivoting and
jumping activities
● Commence jogging and running drills
● Maximize quadriceps, hamstrings, hip
and core strength with functional
exercises
Phase 2
Muscle Strength and Core Stability
3-12 weeks
Goals:
● Manage pain and swelling
● Range of Motion: 0°-135° (or near
full range) by week 12
post-operatively
● Able to perform a straight leg raise
● Full weight bearing with normalized
gait
● Using stationary bike in daily exercise
program
● Increase bilateral leg strength and
core control
Phase 5
Sport Readiness
5 months – 12 months +
Goals:
● Sport specific proprioception and
agility
● Progressive plyometric exercises
● Return to sport specific training
 Knee extension is of primary importance post ACL surgery for efficient heel striking in walking
- Step ups/step down:
- Dynamic quad strengthening of quadriceps. And has an eccentric portion in step down. Fx for single leg stance and for stairs.
Starting really slow, a tiny step since 6 weeks is the weakest.
- Sit to stands:
- Fx to progress to squat, facilitates co-contraction of hamstrings and quads and with terminal knee extension in standing
- Standing, banded side steps:
- Weight bearing and strengthening of glut mid and med to assist with pelvic stability and reduced trendelenburg

● One of the strongest ligaments in the body

PCL Sprains
● Prevents posterior translation of tibia on femur
● Very rarely injured in athletics Observation: Effusion
● Most common mechanism is knees hitting dashboard in MVA (posterior force on tibia)
Palpation: May have pain
Etiology posterior knee
● Most at risk during 90 degrees of flexion (hit dashboard in MVA)
● Fall on bent knee is most common mechanism AROM: May have full painfree
● Can also be damaged as a result of a rotational force or hyperextension range

PROM: extension may be

Signs and Symptoms
painful
● Feel a pop in the back of the knee
PCL ● Tenderness and relatively little swelling in the popliteal fossa Resistive: Negative
● Laxity w/ posterior sag test
● Posterior Cruciate Ligament Sprain Special Tests: Posterior drawer, sag
sign

Management PCL Testing

Posterior Drawer
Grades I & II ● Knee flexed to 90°and hip to 45°
- RICE ● Posterior force applied to tibia
- Non-operative rehab of grade I and II injuries should focus on quad strength, avoid ● Increased posterior translation= (+) test
open chain hamstring work Godfrey’s (Sag) Sign
- Closed chain and functional rehab as per ACL rehabilitation ● Knees flexed to 90° bilaterally
● Observe level of anterior tibia
Grade III ● (+) test if sag sign present
- may need bracing or surgery, but usually do fine…
 PCL Post-surgical Rehabilitation Low Impact Aerobics (walking, swimming)
- Full Range of Motion by 8 weeks (0-135) 9-12 weeks
- Full Weight Bearing around the 7 week mark - Running at 6 months post-op
Strengthening Exercises which include:
- Quad Sets and SLR immediately post-op Return to Sports/Functional Activities ~ 7-12
- Limited Arc Quad (0-60/0-90) through rehabilitation months
- Closed Kinetic Chain exercises at 5-6 weeks - What are some of the considerations for
- OKC Hamstring Exercises? returning to sport?

Bony Knee Pathologies

Ottawa Knee Rules and Salter Harris classification

Salter-Harris Classification of Epiphyseal Complex

Fractures

Type I fracture through the physis

(widened physis)

Type II fracture partway through the

physis extending up into
metaphysis

Type III fracture partway through the

physis extending down into the
Distal Femur Fracture
epiphysis
4% of femur fractures
Mechanism Type IV fracture through the metaphysis,
- MVA or fall physis, and epiphysis can lead
Condylar (intraarticular) to angulation deformities when
Intercondylar healing
Supracondylar
Type V crush injury to the physis
Femoral MOI: Surgery: Prognosis
Condylar - Axial loading with valgus or varus stress - Hemarthrosis - Moderate for femoral
Fracture Symptoms: - Conservative or ORIF depends condylar fractures
- Unable to WB upon stability - 14% recover full quad
- Pain over distal femur strength
- 20% have residual knee
Supracondylar, intercondylar or condylar. stiffness 1 year after injury

Patellar Info: Physical Therapy Treatment

Fracture - Largest sesamoid bone - With closed reduction, similar - Nondisplaced transverse
- Almost all intra-articular to other knee fractures, limit fractures with intact
- Transverse most common 50-80% knee flexion for 4-6 weeks extensor mechanism
- Be careful for PROM and AROM knee flexion - Knee immobilizer 6
MOI: ORIF weeks, PWB
- Direct blow to patella, knee hyperflexion, contraction of the - AROM and sub-max crutches
quadriceps muscle. isometrics post-op - May displace and
Symptoms: - Gait training (may be PWB need ORIF
- Pain, swelling, crepitus & pain extending the knee. 6-8 weeks) - Displaced fractures, or
- Displaced, transverse fractures result in an inability to SLR - Because they do not disrupted extensor
Radiographs: want to do knee mechanism
- sunrise view to see fx flexion and extension - May need ORIF or
- Bipartite patella common - Start as PWB, WBAT, partial or total
- Accessory bone superior lateral FWB patellectomy

Bipartite Patella vs. Fracture

- Smaller side on sunrise view
of patella has a not fully
fused fracture line that
won’t heal because they had
it when they were younger

Tibial MOI: Information: Management:

Eminence - Direct blow to proximal tibia with knee flexed or - Most common 8-14 years old Nonoperative treatment for
Fractures hyperextension with varus or valgus stress - Often misdiagnosed as ACL non-displaced
- Mechanism can be the same for ACL rupture - Immobilization for 4-6 wks.
- But injury is more like an avulsion fracture as opposed ORIF for displaced fractures
to a ligament tear - Physical Therapy
Tibial Information: Management: Prognosis:
Tubercle - Common in adolescents and in females. - Nonoperative treatment for - Good for tubercle fractures
Fractures MOI: non-displaced
- Sports involving jumping - immobilization for 4-6 Surgery:
- Typical for younger individuals weeks. - Usually treated with ORIF
- Displaced fractures. - Commonly fixated with
- ORIF screws, occasionally wires
- Must be very careful with WB are used
and quad contractions until
bony union

Tibial Information: Complications Goal:

Plateau - Compression fracture of proximal tibia - Popliteal artery injury - stable, aligned, mobile knee
- Lateral tibial plateau (55-70%) > medial - Peroneal nerve injury to minimize risk of OA
Fractures
- Common to have ligament damage Management:
- Many Intra-articular - Non-displaced Prognosis
- 8% of fx’s in elderly - immobilized 4-6 wks - Moderate
- Normal slope of 10 degrees ant to post - Displaced fractures > 3mm - 14% recover full quad
MOI: - ORIF strength
- Caused by impaction of the femoral condyle into the tibial - May need bone - 20% residual knee stiffness
plateau grafting at 1 year

Segond Information: MOI: Radiograph

Fracture - Bony avulsion of lateral tibial plateau - Usually Varus stress w/ ACL - lateral capsule sign
- Site of attachment of LCL disruption association
- Pathognomonic with ACL disruption - Site of LCL avulses off the
- A pathognomonic sign is a particular sign whose plateau
presence means, beyond any doubt, that a particular
disease is present.

Dislocation Information: Management: Bracing:

of the - Patella usually dislocates laterally. - Radiographs - Set at 0 degrees initially
Patella - More common in adolescents - Knee immobilizer with ambulation
- Girls > boys - Lateral buttress pad
MOI: Treatment Prognosis
- Twisting injury, valgus load or a direct blow 1. No studies on PT after patellar - 30-50% have long-term
Complications: dislocation instability or pain
- May have osteochondral fracture. 2. PWB with crutches
 - May reduce spontaneously or require sedation and reduction 3. RICE
- Can lead to recurrent dislocation 4. McConnell taping
5. E-stimulation for activation of
quad
6. Quad strengthening
- With rapid management,
70% of patients will have a
painless, stable knee
- Of the remaining 30%:
- 50% have
reasonable function
- 50% have
chronically unstable
and painful knee

Knee/Tibio Information: Complications: Management:

femoral - Described based on displacement of tibia on femur - Neurovascular bundle - Knee immobilizer
- Most common is anterior injuries - Long rehab to return
Dislocation
- May be fractures of tibial spine or tip of fibula - 10% with normal function
- Disrupts cruciate/collateral ligaments pulse - May have instability
- Posterior with direct trauma - Peroneal nerve - Most need reconstruction
- dorsum
sensory,
dorsiflex
- Post tibial nerve
- plantar
sensory,
plantarflex
- Concern about Popliteal artery
and nerve

Complications of Knee Fractures Goals of Fracture Treatment Physical Therapy Fracture Care
1. Atrophy (quads!) - Restore the patient to optimal - Movement and muscle
2. Joint stiffness functional state contraction around fracture
3. Arthritis (if intra-articular) - Prevent fracture and soft-tissue dependent upon stability
4. Other injuries, often missed until PT starts! complications - Stable vs. unstable fractures
5. Shock
- Get the fracture to heal, and in - Always consult physician
6. Fat emboli (femoral shaft fx)
a position which will produce - Stability of fracture
7. Avascular necrosis (condylar)
8. Quad tendon ruptures
optimal functional recovery - Precautions
9. Patellar instability (patellar fx) - Rehabilitate the patient as - Motions allowed
10. Damage to popliteal fossa structures early as possible
 Rehabilitation in Immobilization Stage Rehabilitation in Mobilization Stage
- Patient is commonly immobilized - If a clinical and/or radiographic bony union is present
- May only see patient one time Assess
1. Impairments in body function/structure
Minimize the effects of immobilization by: 2. Activity limitations
- Patient education! 3. Participation limitations
- Maintain cardiovascular fitness Provide
- Upper body ergometer 1. Patient education
- Maintain uninvolved joints and extremities 2. Manual therapy
- Provide means of safe mobility 3. Therapeutic exercise
- Prevent respiratory complications and decubiti a. Aerobic, strengthening, stretching
4. NM reeducation/Proprioception
5. Function!!!

Osteoarthr Epidemiology ACR Diagnostic Criteria for Knee Intervention and

itis of the ● 10th largest contributor to disability OA (1986) Management
○ Doubled in the last decade - Joint symptoms and signs
Knee
● > 60 years old associated with defective
Physical Therapy
○ 13% women integrity of articular cartilage
- Therex
○ 10% men and changes in underlying
- Manual Therapy
● > 70 years old motion at bone margins
- Patient Education
○ 40% of people
Weight loss
● Only 15% of patients with radiographic findings are Focus on clinical exam plus;
- Knee bracing?
symptomatic Presence of 3 of the following:
- NSAIDs?
- Age >50 years old
- Glucosamine and
Clinical Symptoms - Morning stiffness <30 minutes
Chondroitin?
- Symptoms gradual and variable - Joint crepitus on active motion
Exercise
- Knee stiffness-improved with movement - Bony tenderness
- Strengthening exercises
- Can be worse during or after activity - Bony enlargement
- Aerobic fitness
- Swelling - No palpable warmth of
- Balance training
- Symptoms after prolonged sitting/resting synovium
- Yoga/tai chi
- Symptoms are activity dependent - Sensitivity 95%, Specificity
- Worse w/ more activity 69%
Primary Examination
- No underlying cause - Observation
- Wear and tear, age, heredity, lifestyle, obesity? - ROM
- Gait
Secondary - Neuro Screen
- Post traumatic/surgical - Strength Testing
- Malposition - Functional/Performance
- Scoliosis Testing
- Avascular necrosis - Impairments proximal and
distal
Radiographic Findings
- Joint space narrowing (stage 1 typical)
- Bone spur formation
- Subchondral sclerosis
- Subchondral cysts
- ROM problems usually start at stage 3
- Stage 4 is bone on bone
Total Knee Arthroplasty & Rehabilitation

TKA:
1970s
- Admitted 1-2 days before surgery
- Bedrest 2-3 days post-op
- POD 3
- Ambulation with knee splint begun
- POD 7
- Knee ROM begun POD 7
No discharge until knee flex = 90

Present
- Admitted morning of surgery
- Mobilize day of surgery or POD 1
- WBAT (usually
- LOS < 5days
- CPMs placed in post-op?
Contraindications TKA Complications
1. Inflammatory Arthritis ● Periprosthetic failure
2. Obese patients ○ Femur 1-2%
3. Knee flexion contraction > 15* ○ Tibia 0.5-1.0%
4. Knee flexion < 90* ● Aseptic loosening
5. > 20* correction needed ● Wound complications
6. PF arthritis ● Periprosthetic joint infection (1-2%)
7. Ligamentous instability
What Is the Evidence Related to TKA & Rehab?
Cemented TKA ● 20-30% slower walking speed
● 650,000 TKA’s are performed each year in U.S. ● 50% slower stair climbing speed
● 3.48 million TKAs per year by 2030 ● 52% have functional limitations
● Cemented TKA is current gold-standard ● 22% without knee problems
● 10-14 year survival rate of 94-98% ● 75% have difficulty with stairs
● Cobalt-chromium alloy femur articulating with standard ● Peak recovery 2-3 yrs after TKA
polyethylene tibial surface is most common ● Rapid decline in function after that

TKA Options Management and Rehabilitation APTA Clinical Practice

- Not enough evidence to say whether keeping or removing Guidelines 2020:
PCL is best ● Pre-op exercise and education program
- Recent literature synthesis suggests that resurfacing the ● CPM device
patella probably improves outcomes and pain-free function ● Cryotherapy
● Physical activity
● Motor function training
● Postop knee ROM exercises
● Immediate post op knee flexion recommendations
● NMES
● Strengthening

TKA Treatment Protocols

 Soft Tissue Knee Pathologies

Physical Exam
- “Pain Diagram”
- Patient to identify the painful area

General Phases of Healing- Connective Tissue

● Inflammation (hours to days)
● Repair (days to weeks)
● Remodeling (months)

General Principles for Treatment

What are the considera/ons for treatment in each phase?
- Pain Control, Inflammatory Control, ROM, Strength:
Maximum Protection Phase: Inflammatory
Moderate Protection Phase: Repair
Minimum Protection Phase: Remodeling

Patellar Tissue: Prepatellar, Suprapatellar, Infrapatellar Symptoms

bursitis - Inflammation and swelling of the prepatellar bursa
Cause and Contributing Factors: MOI:
- Direct trauma - May result from trauma or repetitive compression (carpet and tile
- IT Band or Pes Anserine Friction workers) AROM and PROM flexion limited
- High BMI
Resistive testing
Interventions: - negative
- Remove provocative position
Mobility – Joint Play testing
- Improve joint mechanics
- normal
- Consider draining if no progress
Treatment
- Avoid kneeling or other offending activities
- Modalities for pain and swelling
- Medical management may include aspiration, anti-inflammatory
meds
- May start ROM and strengthening once significant swelling subsides
Pes Anserine Cause: Interventions
bursitis - Usually caused by repetitive motion or overuse • Modalities for pain and inflammation
• Soft tissue mobilization
Clinical Findings:
- Inflammation of bursa between pes anserine group and • Gentle stretching
MCL/medial tibia
• Avoid repetitive motion and resisted hamstring
• AROM and PROM knee extension may be painful • May start strengthening once pain and swelling subside
• Resistive hamstring, sartorius or gracilis may be painful • Correct biomechanical factors such as muscle imbalances, excessive
• May have tightness of hamstrings and/or adductors foot pronation, assess for precipitating factors, load, activities -
LOOK ABOVE AND BELOW KNEE!
Cyclist
- Bike fit
- Knee position on upstroke
- Substantial change in training

Runners vs Walkers
- Hip weakness
- Hip ROM/joint mobility
- Shoes: type, age, orthotics
- Running surface/change in training

Popliteal cyst • Posteromedial knee

(Baker’s cyst) • Semimembranosus bursa Interventions:
- RICE:
• May be indicative of some intra-articular pathology
- rest, ice, compression, elevation and appropriate exercise
• Common post surgically - Modalities:
- pulsed ultrasound, Hi- volt electrical stimulation, IFC, etc…
• Associated with arthritis
- Activity modification
Causes:
- Repetitive knee flexion
- Post surgical response
Patellar • Tendinitis Tendinopathy
tendonitis / reserved for tendon injuries that involve acute injuries accompanied Cause:
tendinopathy by inflammation: should NOT utilize eccentric exercises!!! - Can occur with overuse and/or eccentric activity
Clinical Findings:
(jumper's • Tendinosis/opathy - AROM knee extension painful
knee) the suffix "osis" implies a pathology of chronic degeneration - PROM negative except with acute or highly irritable
without inflammation - Resistive knee extension painful
• Tendinosis is an accumulation over time of microscopic - Point tenderness and possibly warmth with palpation patella tendon
injuries that don't heal properly. - Associated findings: hip weakness, core instability, decreased quads
• Inflammation involved in the initial stages of the injury strength and flexibility
Interventions
• Inability of the tendon to heal perpetuates the pain and
- Physical agents to manage pain/ inflammation for tendinitis
disability
- Activity modification
Tendinitis =
- Straps/ taping/ knee sleeves
- Inflammation of the patellar tendon.
- Cross friction massage once beyond inflammatory phase
Tendinopathy =
- Gentle stretching – quads,
- degeneration of tendon
- Address flexibility issues in hip/ hamstrings
Commonly seen in athletes who jump or decelerate frequently
- Progressive loading – exercise therapy / eccentric exercise
progressions and functional activities

Patellar • I: Pain after activity All stages should progress progress through progressive tendon loading
tendinitis • II: Pain during and after activity exercises:
tendinopathy • III: Pain leading to functional disability/constant
pt 2 Stage I
- Prognosis is good for return in 3-6 weeks
- Activity modification of offending activity only
- More aggressive stretching early
Stage II
- Prognosis for return: 5-10 weeks
- Usually requires a period of abstinence from all impact and high
velocity eccentric loading
-
Stage III
- Prognosis is guarded: may require surgical consult/intervention if fails
to have improvement after
- 8 weeks of conservative treatment (may have extensive necrotic
tissue)
- Modification of all eccentric loading activities can be helpful
(including basic ADLs-stairs, squating, sitting, etc)
Osgood-Schla • Traction of patellar tendon on immature bony anatomy Interventions:
tter’s • Develop pain and inflammation at tendon bone interface • Rest/activity modification (patient and presentation specific)
• Skeletally immature (12-16 y.o) • Gentle stretching of extensor mechanism/quadriceps
• Correction of muscle imbalances and alignment issues
• Modalities for pain/inflammation as indicated

Sinding-Lars Similar to Osgood-Schlatterʼs disease,
en-Johansson - but occurs at either superior or inferior pole of patella
Disease
Can be very debilitating to active adolescents – conservative
management can take significant period of time
Pain relief – interventions, gentle AROM, modalities…US?
Activity modification
- avoid kneeling, squatting, jumping, stair climbing
• Off load with crutch use
• Address lower extremity flexibility and strength imbalances

Fat Pad
Irritation

Hamstring Similar history to patellar tendinitis but associated with more

Tendinitis hamstring dominant activities.
• Eccentric deceleration with running; aggressive cycling,
etc.
• Treat as per patellar tendinitis

• Clinical story – NYC marathon

Plica History Plica Stutter Test

- Synovial thickening present in ~ 50% population - Observe: “jumping” movement of patella at 45 to 60 degrees of knee
 - A synovial fold can be present medial or lateral, and frequently flexion from sitting position
courses up and over patella Interventions
- Can present like PFPS – (Patient story) - Modalities for pain and inflammation
- Usually patient has pain medially May occur with overuse or - Avoid heavy WB activities
trauma Also may report snapping or popping - Correct muscle imbalances
Symptoms - Stretching and strengthening (pain free)
- May notice some swelling or inflammation - Correction of faulty movement patterns or muscle length/strength
- AROM extension may be painful imbalances
- PROM negative - May require surgery to excise synovial thickening
- Resistive knee extension may hurt at 30 degrees
- Pain with medial glide of patella
- May palpate thickened area medial to patella
- Special tests include Stutter and Hughstonʼs plica tests

Quadriceps • Differentiating between a strain and a contusion is important!

Treatment
Strain • Ice, compression, elevation
or • Contusions occur as a result of a direct blow
Quadriceps • High volt galvanic stimulation
• Strains occur via indirect trauma (pulled muscle)
Contusion • Crutches if severe
• Contusions can lead to compartment syndromes or myositis
• Gentle stretching (active stretching/ROM first)
ossificans
• Progress to more vigorous stretching aUer 7-10 days
Contusion • Strengthening when 120 flexion pain free, isometrics to PREʼs in
• Direct trauma to quadriceps pain free range
• May note swelling, heat and palpable hematoma • May aspirate if severe

• AROM and PROM knee flexion painful (>90 degrees severe, 45- • Gradual progressive return to activity
90 moderate, <45 mild)
• Resistive knee extension painful

Myositis - Myositis ossificans literally means inflammation of muscle Risk Factors

Ossificans leading to bone formation. - Limited knee range of mo/on
- Myositis ossificans has been reported in 9% to 20% of all cases - Previous quad contusion
of quad contusions. - Treatment for a quad contusion that was delayed more than 72 hours
- Knee effusion (swollen knee)
- Injury sustained in contact sports
 - When the quadriceps muscles bleed, a cascade of cellular
responses can occur, causing heterotopic bone forma/on –
secondary too much load too soon
ITB - Results from friction between IT band and lateral femoral
Syndrome condyle during repetitive knee flexion/extension activities
- Usually overuse combined with alignment issues
- May complain of popping or crepitus
- Pain over lateral knee and condyle
- Frequently seen in runners
- Can be very painful with sharp, stabbing type pain.
Clinical Findings
- May note tight ITB in stance, genu varum, or excessive
pronation or supination
- AROM knee flexion may be painful (ITB passes anterior to
condyle at 30 degrees flexion)
- PROM, resistive and mobility testing negative
- Tender to palpation lateral femoral epicondyle
- Positive Noble compression test
- Positive Ober test and weak gluteus medius
Hamstring Pathomechanism
Strains - Complexity of hamstring and quadriceps functioning together
while crossing 2 joints
- Musculotendinous region is generally involved
- Often resulting in some degree of swelling, depending on
severity of injury
Treatment goals:
- The treatment plan should include liming swelling and bleeding;
minimizing the amount of scar formation; and preserving the
elasticity, contractility, and strength of the injured and uninjured
muscle 'tissue.
- Many authors advocate keeping the knee flexed to 120 degrees for the
first 24 hours after a deep thigh contusion
Interventions
- Correct muscle imbalances and foot mechanics (orthotics); modify
training/activity
- Stretching ITB? Vs. TFL!
- Patellar mobs (medial glide and tilt); proximal tibiofibular
manipulation
- Soft tissue mobilization
- Iontophoresis
- NSAIDs/direct analgesic/corticosteroid injection
- In chronic cases may require surgery (lateral release vs window
procedure)
Hamstring Stair physical impairment measures
- Knee flexor strength – with handheld dynamometer
- Hamstring Strength Testing
- Mobility/ ROM – assess hamstring length by measuring knee
extension deficit with hip flexed to 90 degrees using inclinometer
 MOI Grade I injury
• Quick explosive contraction often in transition from eccentric to - may result in no lost time micro tear
concentric part of knee motion Grade II injury
• Other factors - could result in 5-12 days loss of participation tear into muscle tone
• Muscle imbalances, fatigue, running posture, gait, leg length Grade III
discrepancy, decreased ROM, muscle innervation - could require missing 3-12 weeks complete tear muscle tone
Evaluation
● Inspection: Look for obvious defect, swelling, ecchymosis
Patient should be able to perform functional activities pain free and have
● AROM: knee flexion painful
completed full strengthening/ eccentric, plyometric, and function specific
● PROM: may be painful into knee extension
training regimen
● Resisistive: knee flexion painful
● Palpation: local pain in muscle belly, musculotendinous jxn or
tendon

Patellofemora • Presence of retropatellar or peripatellar pain

l Pain
Syndrome • Reproduction of retropatellar or peri-patellar pain during
squatting

• Reproduction of pain with functional activities that load the

patellofemoral joint in a flexed position such as stair climbing,

Exclusion of all other conditions causing anterior knee pain

Impairment/ Function Based Classification Subcategories

● Overuse/ overload
● Muscle performance deficits
● Movement coordination deficits
PFP Interventions = Multi Modal Rx Approach
● Mobility impairments – Hypermobile/ Hypomobile Exercise therapy
- targeting posterolateral hip musculature and knee musculature (NWB
Movement Pattern Analysis knee extension, WB squats)
Patellar taping
Single Leg Squat Test
- initial 4 weeks for Pain reduction PFP Knee orthoses/ bracing = not
Overall impression across trials
recommended Foot orthoses 4-6 weeks w/ exercise therapy
Trunk posture Biofeedback = not recommended
Pelvis in space Running gait retraining
Hip joint position DN/ Dry Needling = not recommended Acupuncture for P relief
Knee joint position - Manual therapy w/ exercise
- Biophysical agents (US, iontophoresis, laser) = not recommended
 Isolated hip exercises
Decreased pain in 4-6 weeks
Improved func/on and decreased femoral IR with mo/on
Improved hip muscle strength

Patellar Management/ Interventions: Patellar Bracing

Dislocation ● R/O fracture ● Function to position center the patella on the femur
● Knee immobilizer 1-6 weeks ● Less intensive than taping
● Reduce inflammation ● Also used for patellar instability
● Restore ROM ● May help to hold the train on the track
● Strengthen quads, hamstrings, hips
● Brace if unstable
● Subluxation treated as patellofemoral pain while being aware of
instability
○ Repeated subluxation/dislocation may require surgical
intervention to repair the MPFL and/or advance the
VMO

◤━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━◥
Meniscal and Articular Injuries
Function of Meniscus: Enhance joint congruity, shock absorber
Meniscus Anatomy Vascular Zones
- Comprised of wedge-shaped fibrocartilage Red-red zone Red-white zone White-white zone
Lateral Meniscus Medial Meniscus
Outer 1/3 of Middle 1/3 may have Inner 1/3 has no
More circular and mobile More crescent, attached to meniscus has good healing potential blood supply, won’t
MCL potential to heal heal
- Highest
- Valgus force can
amount of
cause MCL and
blood supply
medial meniscus - Greater
injury probability
of repair
Microanatomy Mechanism of Injury
Central part of meniscus - Forced rotation while flexing/extending knee
- No blood supply - Usually closed chain
- No nerve supply - Forced tibial ER usually injures medial meniscus
- No lymphatic supply - Forced IR commonly injures lateral meniscus
- Fibrochondrocytes surrounded by extracellular matrix - May hear a “pop”
- May cause instability in knee
Meniscal Tears History - Slow onset effusion
Acute Chronic

Often sudden onset & associated with People older than 50 may not have
twisting injury - especially in people injury – Degenerative tears associated
less than 40 with mild arthritis
- May hear a pop

- Pain worse with movement, better at rest (loading meniscus)

- May have collateral or cruciate ligament injury
- May complain of “locking” (can’t flex or extend knee)- flat tear or
bucket handle tear
- Joint line tenderness compared to opposite side
- Almost always an effusion acutely (slower than ACL)
Squatting Mechanism
Past 90 degrees- roll and glide of femur resting over tibia
Deep squat removes stress off meniscus

Objective Findings Cutting Mechanism

- Effusion/edema Knee valgus stress, lateral compartment torsioned, longitudinal tear
- AROM and PROM may be limited
- Squatting difficult and painful- consistently
- Resistive testing negative (except acute)
- Tender joint line to palpation
 Physical Exam
The Four Hallmark objective exam findings are:
1. Joint Line tenderness – good sensitivity (versus contralateral side)
2. Mild to Moderate Effusion that occurs over 1-2 days
3. Positive entrapment test – McMurray’s, Apley’s, Thessaly test or Squat
4. Quad shutdown and atrophy over first week or two following injury

Types of Tears
Longitudinal Bucket-handle Oblique Complex Radial Horizontal

- Typical of the third decade Frequent in Generally Typically produced by repeated Usually originate from the free Degenerative lesions involving
-Most frequent meniscal medial meniscus between 1/3 knee trauma side of the periphery meniscus intramural portion
injury back and
1/3 middle
of the
meniscus
Healing Prognosis
Good Prognosis Poor Prognosis
- Younger patient (under 35)
- Peripheral damage
- Longitudinal tear
- Short tear
- Acute injury
- Stable knee
Meniscal Tear Treatment
● Pain may improve with
- Temporary change in activity
- Older patient - Nonsteroidal anti-inflammatory medications
- Central damage ● If it does not heal, swelling & pain persist, may need surgery
- Complete tear ● Partial meniscectomy: Cut out tear and smooth surfaces
- Bucket handle tear ● Complete meniscectomy: Remove entire meniscus
- Chronic injury ● Repair: If in vascular zone, the surgeon will try repair. This is
- Unstable knee always preferable but the rehab is longer (up to 6 months to return
to sport).
 Meniscectomy (partial or full) Meniscal Repair

Traumatic lesion within the vascular zone

● Removal and debridement of tear • Intact peripheral circumferential fiber and minimal damage to the meniscus body
● PWB 1-4 days • Longer than 8 mm
● Flexibility and ROM • NWB for 1-3 wks (may have brace)
- A/PROM Stretches (Heat after acute stage) – Patella Mobs - Depending on the tear, may be NWB longer
- Bike • ROM limited to 0 – 90
– Wall slides - Patella Mobs, general flexibility
– Seated knee bends - QS, SLR, OKC for ancillary muscles
– Focus on hamstrings • PWB for 3–6 wks
• Stationary bike, pool
Rehabilitation
• RICE, edema and pain control Post-op Meniscal Rehab Considerations
• Quad sets (E-stim), Hamstring sets Proactive approach
• SLR, SAQ - Protected arcs of motion
• Hamstring curls - Varus-valgus stress
• Weight shifts - Rotational torque
• Bike (AAROM to AROM)
• Maintain cardiovascular fitness

Protocol FWB 3 - 6 wks Strengthening Protocol

FWB 1-3 wks
• Mini squats – double leg then single leg
• Leg press light weight, < 90 degrees
• Wall sits at 45 and 60 degrees
• Lunge
• Step-up > Lateral step-up > Step-down
• Sit-to-stand and functional exercises
• Proprioceptive retraining
• Functional Exercises
6 weeks – 8 weeks
- gradual progression of CKC exercises
- Proprioception drills
- SAQ, Mini Squats, Step downs/ups
- Treadmill
8 weeks – 10 wks
- Enhanced proprioception
- 1st phase functional activities if at 80%
10 – 12 weeks
- Return to activity
 Articular Cartilage Injury
Symptoms
- Pain any location of knee
- Locking or catching
- Recurrent swelling
Treatment
- Untreated injuries may progress to arthritis
- Traditional treatment
- Debridement, drilling
- New treatment- autologous cartilage cell transplantation
Inflammatory Phase
( days up to 1- 1-2 weeks)
Increased blood flow into area after acute
response to fracture
Hematoma forms
Osteoclastic activity removes damaged bone
Growth factors stimulate fibroblasts,
osteoblasts at site
X-ray : fracture line becomes more visible as
necrotic tissue is “removed”
Maximum protection phase: (6 weeks)
distinctions – cast vs ORIF
Edema management
ROM/ Strength
Gait training
Autologous Cartilage Cell Transplantation
- 2 surgeries, 1 open, 1 arthroscopic
- Biopsy cartilage
- Cartilage cells grown and multiplied
- Cartilage defect cleaned out, cells injected and covered
with a patch
FOOT AND ANKLE
Reparative Phase Remodeling
(up to several months) (months to years)
Soft fibrous callus forms initially followed by Immature bone is replaced by organized
a hard callus mature bone
Osteoblasts are responsible for mineralizing Fracture line disappears
soft callus causing...hard callus to form Process begins during reparative phase
Hard callus is considered immature
bone…stable compared to soft callus but
weak compared to mature bone
X-ray: fracture line begins to disappear
PT Management Principles:
Moderate protection phase: (6 weeks) Minimal protection/return to activity (12 weeks +)
Stability modifications, ROM progressions,
Strength, Gait training, Functional training
 Fracture Complications
Complications include:
- Non-union
- Joint stiffness
- Infection
- Extensive soft tissue damage
- Compartment syndrome
- Leg length differences

Post Surgical Considerations

- ORIF

Risk factors for infection:

- Male
- Diabetes
- Smoking
- Immunosuppressant use
- Time to wound closure
- Wound location

DVT

Tibial Shaft Fractures Tibial Shaft Complications include:

● May result from trauma, either direct or indirect and may be - Non-union
closed or open - Joint stiffness
● Fibula fractured by same mechanisms - Infection
● May also occur as a result of repetitive stress - Extensive soft tissue damage
● Fracture types include transverse, spiral and butterfly - Compartment syndrome
Reduced and retained closed via: - Leg length differences
- Long leg cast with knee in slight flexion and ankle in neutral
- Rigid external fixators Fibular Fractures
ORIF Fibula bears 8% of the body weight
- using intramedullary rods, plates and screws - Isolated fibular fractures rarely have complications
- Treated with boot or short leg cast
ORIF includes Rush rods and plates and screws
- May have avulsions that are treated as ankle sprains
Ankle Fractures

Malleolar Fractures
- Common MOI = foot planted with external force applied Unimalleolar Fractures- Medial
- Unimalleolar Isolated medial fracture (nondisplaced)
- Bimalleolar (Pott’s fracture) - NWB x3 weeks, f/u after 1 week
- Trimalleolar (Cotton fracture) - weight bearing increased over next 3-5 weeks • if very
- Bimalleolar and Trimalleolar usually involve syndesmosis active may ORIF initially
- Vertical compression (Pilon)

Unimalleolar Fractures Bimalleolar Fractures- Management

Lateral - disruption of two elements of the ring
- Any avulsion <3 mm in size can be treated as an ankle sprain - ortho consult
- May see “push-off” or avulsion injuries medially - management controversial (ORIF vs closed reduction
and close f/u)
Danis-Weber Classification
- Three fracture types, defined by the location of the Pott’s Fracture
fibular fx - fx dislocation of the foot from forces eversion
a. Below the tibiotalar joint
b. At the level of the tibiotalar joint
c. Above the tibiotalar joint Trimalleolar Fracture (Cotton’s Fracture)
Management
Type A (below tibiotalar joint) What is the third malleolus?
- no medial tenderness - posterior articular margin of the malleolus
- Walking cast - disruption of three parts of the ring
- f/u 1week to ensure no displacement (medial/lateral/posterior)
- NWB x 3weeks then WB for 3-5 weeks - ortho consult
- medial tenderness (check mortise for displacement) - ORIF

Type B and C (at or above the tibiotalar joint)
- Orthopedic consult ?ORIF
- Type B : 50% associated with tibiofibular disruption
(syndesmosis and/or anterior tibiofibular ligament)
Malleolar Fractures Complications
- Syndesmosis injury
- Sprains and dislocations
- OA if mortise alignment changed
- Chronic swelling
- Joint stiffness in foot, ankle, knee
 - After pain free for 2 weeks athlete can gradually return
to running

Pilon Fractures Osteochondritis Dissecans

Mechanism - Segment of articular and subchondral bone separates
- axial compression from surrounding bone and loses its blood supply.
- usually comminuted and displaced with extensive soft - Osteochondritis dissecans can involve the bone and
tissue swelling cartilage of virtually any joint
- look for associated injuries - Fracture at the superomedial corner of the talar dome.
- calcaneus, femoral neck, acetabulum, lumbar vertebrae Within this defect are osteochondral fragments, made up of
Management articular cartilage and its underlying subchondral bone.
- Very unstable, require ORIF

Tillaux Fracture (Pediatric) Treatment consists of: protected immobilization of the joint and
SH type III of the lateral tibial epiphysis NSAIDs
- extreme eversion and lateral rotation - Surgery may be required to remove the intra-articular
- adolescence loose body and/or correct the resulting degenerative changes.
- medial aspect of epiphysis is closed
- fracture of the lateral aspect and into joint PT Management
Management - ORIF Immobilization phase:
- Gait training
Stress Fracture of Tibia or Fibula - Cast care
Etiology - Transfers
- Common overuse condition, particularly in those with - Maintain cardiovascular fitness and strength of rest of
structural and biomechanical insufficiencies body
- Runners tends to develop in lower third of leg, dancers Mobilization phase:
middle third - Assist chondral surface- high reps low load ther-ex
- Often occur in unconditioned, non-experienced individuals
- Female athletes Talar Fractures
Signs and Symptoms - Relatively rare
- Pain more intense after exercise than before - Poor blood supply= high incidence of AVN
- Point tenderness; difficult to discern bone and soft - Can be major/minor
tissue pain - MOI requires large amount of force
- Bone scan results (stress fracture vs. periostitis) - Most commonly fx talar neck (50%)
Management - Can also have fx’s of head, body, and chip fractures of
- Discontinue stress inducing activity 14 days lateral or medial process
- Use crutch for walking if pain
- Cycling before running
 - Joint stiffness, loss of motion
- Osteoarthritis

Calcaneal Fractures
Major Talar Fractures Framework – Cancellous bone that reacts like eggshell with
- Neck, head, body (& lat process) compression, can be severely comminuted
- Talar neck fractures = 50% – Extraarticular: 25-35%
Hawkins type I: – Anterior process, tuberosity, medial process,
- non displaced + no joint involvement sustenaculum tali, and body
Type II: – If not displaced nor involving subtalar jt may treat with
- displaced with subluxation or dislocation of the subtalar joint compressive dressings/casting
BUT ankle joint is OK (AVN = 20-50%) – Intraarticular: posterior facet involved
Type III: – Commonly with falls from a height
- Type II +dislocation of ankle joint – >50% associated with other extremity or spinal
Type IV: fractures
- Type III + talar head dislocation (AVN = 80-100%) – Can be disabling:
• 7% are bilateral
Treatment Framework • 20%unabletoreturntowork
- Talar body fracture: if non-displaced-BK non-weight – Reduced and retained closed via cast or splint NWB 4
bearing cast x 6-8 weeks weeks f/b boot allowing only PF/DF until bony union at 8-12
- Talar head fracture: if non-displaced-BK walking cast X weeks
6-8 weeks VS NWB – ORIF f/b cast may include screws, bone grafts or triple
- Type I=NWB BK casting x 8-12 weeks arthrodesis of talus, calcaneus, navicular
- Type II = closed reduction with traction + plantar
flexion and BK casting vs ORIF Complications
- Type III/IV=ORIF – Pain
- Ortho should be involved in all cases! – Joint stiffness with decreased inv/eversion
– Spontaneous ankylosis
– Other fractures (vertebral compression fx)
Minor Talar Fractures Framework – OA requiring fusion
- Minor avulsion fractures of neck, body, and lateral – Weakness of plantar flexors
process are treated with a boot, crutches and ortho follow-up – Leg length discrepancy
- Osteochondral fractures of talar dome- NWB short leg – Tenosynovitis of peroneals, PT, FHL, FDL
cast for up to 3 months with ortho follow up
Talar Fracture Complications Midfoot Fractures
- Avascular necrosis secondary to disruption of the - Navicular
nutrient arteries - Cuboid
- Soft tissue and skin damage - Lisfranc
 - r/o accessory bone
Metatarsal Fractures
Navicular Fractures
- Most common midfoot fracture but still rare
- Treatment
• Non-displaced: short-leg walking cast 6 weeks
• Displaced: ortho for possible surgery
Cuboid Fractures
- Treat as per navicular fractures
- Rule out Lisfranc injury
Lisfranc Joint
- Articulations of metatarsals 1-3 with the cuneiforms and
metatarsals 4 & 5 with the cuboid
- Metatarsal bases of digits 2-5 are joined by strong ligaments
- Missed in ED 20-25% of time
Treatment- Framework
What to look for on an x-ray
- Normally, medial aspect of metatarsals 1-3 should align
with medial borders of cuneiforms
- Metatarsals should be aligned dorsally with tarsals on
lateral view
- Medial 4th metatarsal should align with medial cuboid
- Any fracture or dislocation of the navicular or
cuneiforms or widening between metatarsals 1-3
- Proximal 2nd metatarsal fx is pathopneumonic
Jones Fracture = base 5th metatarsal
Treatment
- Consult orthopaedics
- May try closed reduction with traction but post
reduction displacement of >2mm or tarso-metatarsal
angle> 15 degrees requires surgery
- Commonly leads to OA
Forefoot Fractures
- Metatarsal
- Phalangeal
- MOI: trauma, stress or rotation
- Common location for stress fractures, may take 2-8
weeks to show up on x-ray
- Jones fracture: base of 5th between diaphysis and
metaphysis, prone to non-union
- Avulsion fractures of peroneus brevis are slow healing
- Reduction and retention
- Closed if undisplaced, short leg cast for 3-4 weeks f/b
stiff soled shoe
- ORIF with pins, wires or screws may be necessary if
fracture is displaced, or in case of Jone’s fx or peroneus
brevis avulsion (don’t heal well)
- Complications: stiffness, pain, altered foot mechanics,
non-union
- Nondisplaced or min displaced fractures of metatarsal
2-4 • treated with stiff shoe, casting, or brace.
- Non displaced 1st metatarsal
- treated with NWB short leg cast or walking boot
- Displaced 1st or 5th metatarsal fracture may require
ORIF
- Metatarsal base fracture
- r/o LisFranc injury
- Treatment: non displaced treated with NWB short leg
cast x 6-8 wks
- Displaced ORIF
- High risk non-union
Phalangeal Fractures
- Nondisplaced digits 2-5 treat with buddy tape
- Can also buddy tape non- displaced phalange 1 but may
need walking cast for pain control
- Residual displacement, intraarticular, comminution may
be treated with ORIF
 Foot and Ankle Soft Tissue

Calcaneal Apophysitis (Sever’s Disease)

Etiology Pathology Signs & Symptoms Management

- Commonly seen in skeletally immature
- Direct trauma (repetitive heel strike
during weight bearing activities)
- Repetitive traction through Achilles
tendon
- Inflammation of the Apophysis
of the calcaneus
- Apophysis may fragment
- Antalgic gait: heel pain during
running/walking
- Swelling -Localized
pain/tenderness
- Positive active/passive ROM test
for tight Achilles tendon
- Restricting DF by elevating heel
– Will resolve when apophysis closes
- Modification of activity level -Walking boot
6-8 weeks
– Sometimes stretching indicated- consult MD.

Morton’s Neuroma
Etiology Pathology Signs & Symptoms Management

- Direct trauma
- stretching of plantar structures during
hyperextension of the MP joint
- sprint starts
- recovery from jump
- Tight shoes, lateral compression of met heads
and interdigital nerves
– Splayed toes & pronated foot
Localized thickening medial
plantar and lateral plantar nerves,
most commonly between 3rd and
4th metatarsals
- Cramp-like pain during running
- Tingling/numbness in lateral
third and medial 4th toes
- Pain relief on removal of shoe
and/or pressure
- Point tenderness -Callus
– Positive
compression test
– Positive sensory test
- Relieve pressure via a cutout
- Gastroc stretching
- Orthotics, inserts or arch taping
- Metatarsal pad
- Shoes with wide toe box
- Corticosteroid injection
– May need to be surgically excised, but run
the risk of a “stump” neuroma

Tarsal Tunnel Syndrome (tibial neuritis)

• Entrapment posterior tibial nerve in flexor retinaculum and osseous tunnel behind medial malleolus (analogous to carpal tunnel)
• Tarsal tunnel contains
– Tibialis posterior tendon
– Flexor digitorum longus
– Tibial artery and veins
– Tibial nerve
– Flexor hallucis longus
Etiology
- Indirect trauma: repetitive heel
strike during running on hard
surfaces, poor fitting shoes
-Overpronation
- Forces transmitted to tarsal
tunnel
Compartment Syndrome
Etiology
- Acute: direct blow to the leg
(emergency!!!!)
– Chronic: Overuse, muscle
hypertrophy, poor biomechanics
Pathology
Compression or entrapment of the
tibial nerve (or medial and lateral
plantar nerves) in the
posteromedial compartment of the
ankle
Pathology
Compartment syndromes can
occur in any compartment of the
lower leg (anterior, posterior,
lateral, and deep posterior)
Signs & Symptoms
-localized swelling
-pain medial ankle and heel
-positive sensory test (medial
heel)
-positive motor test (flexion of
toes)
-positive Tinel’s sign
- may have positive neural tension
Signs & Symptoms
- Weakness
- Paresthesia
- Observation and
palpation reveals swelling
and/or tautness in
involved compartment
- AROM painful when
muscles in that
compartment contract
(anterior = ant tib)
- PROM may be painful
when fascia of
compartment is stretched
- Resistive painful with
contraction of involved
compartment, may have
foot drop
- May have sensory
involvement
Management
- Correct biomechanics, shoe
wear, etc
- Anti Inflammatory (US, ice may
be sensitive)
- Non-weight bearing/ or altered
participation
- Orthotics - if indicated to
prevent pronation
- Decompression - surgical if
indicated
Management
- Acute: medical emergency and
may require surgery to
decompress fascia
- NEVER apply a compressive
wrap - Chronic: may have
limited success with icing,
stretching, soft tissue work,
addressing biomechanics
- If conservative treatment fails,
may require surgery
 Anterior Compartment Syndrome
• Increased pressure within anterior compartment – traumatic or exertional
• Traumatic – bleeding from direct blow to compartment
• Exertional – can be acute or chronic due to volumetric changes in muscle tissue

Overuse Syndromes
• Predisposing factors include poor foot biomechanics, muscle imbalances, leg length discrepancies, and previous injury
• Precipitating factors include overuse, training errors, poor footwear, hard surfaces
• Shin splints is a wastebasket term, and may include injuries to ant and posterior tibialis, peroneals, FDL and FHL, periostitis, stress
fractures and compartment syndromes

Shin Splints
Etiology Pathology Signs & Symptoms Management

- Muscle strains - Inappropriate footwear, - Activity induced leg pain - Rice

- Repetitive microtrauma repetitive strain, muscle
- Accounts for 10-15% weakness and malalignment /
of all running injuries foot pronation
- Training or working on hard
surfaces
- Training errors
- Tight gastroc/soleus
- Hypermobile feet or pronated
feet
- Supinated feet
- Tibialis anterior - Modalities
- Tibialis posterior - Activity modification
- Peroneals - Correction of abnormal
biomechanics (orthotics)
-Tightness/tenderness, throbbing along border
- Ice massage to reduce pain and
of tibia that comes on with activity and settles
inflammation
with rest - Flexibility program for
-Excess stretching (traction) of soft tissues gastroc-soleus complex
structures along the shin bones (tibia and - Strengthening
fibula) - taping / orthotics

Medial Tibial Stress Syndrome

Observation Signs & Symptoms Management

- Periostitis of the attachment of the tibialis
posterior or medial soleus
- Commonly associated with overpronation
- AROM may be painful with PF and inversion
- Resistive testing painful with PF/inversion
- Tenderness along medial border of tibia
- Four grades of pain - Control biomechanics and inflammation
1. Pain after activity - US and heat in chronic stages?
2. Pain before and after activity and not - Orthotics and/or taping
affecting performance - Patient education on training (<10% increase
3. Pain before, during and after activity, duration per week)
affecting performance - Eccentric strengthening post tib and soleus
4. Pain so severe, performance is - Gastroc/soleus stretching
impossible
 Anterolateral Shin Splints
Etiology Observation
- Periostitis or tenosynovitis of tibialis
anterior, extensor digitorum or EHL
- Usually related to sudden increase in
activity or poor shock absorption
Tibialis Posterior Strain/Tendinitis
Etiology Observation
- Repetitive Stress, pes planus, hypermobile
forefoot
- Irritation can occur at insertion on
navicular or in sulcus behind medial
malleolus
- Pain during walking/running
Peroneal Tendinitis
Etiology
- Irritation can occur in sulcus behind lateral
malleolus or at cuboid secondary to friction
or overuse
- May have past history of inversion sprains
- Can rupture the retinaculum that holds
peroneal tendons behind malleolus
(subluxing peroneal tendons)
- Observation may reveal cavus foot
- AROM dorsiflexion painful
- PROM painful into plantarflexion
- Resistive painful with dorsiflexion and
inversion
- Palpable tenderness along anterolateral tibia
- Swelling
- AROM painful with plantarflexion and
inversion
- PROM painful with eversion
- Resistive testing painful with inversion
- Palpation: point tender on post tib tendon
Observation
- May have history of running on
slanted surfaces, or supinated feet
- AROM eversion painful
- PROM inversion painful
- Resistive testing painful with eversion
(tendons may sublux)
- Palpation tender over peroneal
tendons
- Special tests may reveal ankle
instability
Management
- Control biomechanics and inflammation
- US and heat in chronic stages
- Orthotics and/or taping
- Patient education on training
- Eccentric strengthening anterior tibialis, EDL,
EHL
- Gastroc/soleus stretching
Management
- Control biomechanics and inflammation
- US and heat in chronic stages
- Orthotics and/or taping
- Patient education on training
- Cross friction massage
- Eccentric strengthening post tib when painfree
with palpation
- Gastroc/soleus stretching
Management
- Control biomechanics and inflammation
- US and heat in chronic stages
- Orthotics and/or taping, horseshoe pad
- Patient education on training
- Cross friction massage
- Eccentric strengthening peroneals when
painfree with palpation
- Gastroc/soleus stretching
 Peroneal Tendon Subluxation
• Due to sudden, forceful PF/inversion which ruptures retinaculum
• May visibly/palpably move from behind lateral malleolus – become DF instead of normal PF
• Local inflammatory symptoms at site of injury
• May require surgical intervention

Achilles Tendinitis
Etiology Observation Management

- Inflammatory condition involving
tendon, sheath or paratenon
- Tendon is overloaded due to
extensive stress
- Presents with gradual onset and
worsens with continued use
- Decreased flexibility exacerbates
condition
- Aggravated by running, jumping, etc
- Tenderness over tendoachilles
- Bursa between achilles tendon and calcaneus
(retrocalcaneal bursa) may be inflamed
- Tight gastroc/soleus complex and abnormal foot
pronation
- Hypovascular zone 2-6cm from insertion
- Point tenderness
- May present with crepitus to palpation or ROM
testing
- AROM plantarflexion painful
- PROM dorsiflexion may be painful
- Tight gastroc/soleus
- Resistive painful and possibly weak with
plantarflexion
- Resistant to quick resolution due to slow
healing nature of tendon
- Must reduce stress on tendon, address
structural faults
- Use antiinflammatory modalities and
medications
- US and heat in chronic stages
- Orthotics, taping, heel lifts to decrease stress
- Patient education on training
- Cross friction massage may help break down
adhesions
- Strengthening must progress slowly
- Progress to eccentric strengthening
gastroc/soleus
- Gastroc/soleus stretching

Tendinosis vs Tendinitis
• Tendinitis is a self-limiting condition that takes only a few weeks resolve
• Tendinopathies often prove recalcitrant to treatment and may take months to resolve
– May require eccentric program and XFM
– Cyst-like ultrasonographic abnormalities in tendons are indications for surgery
– After surgery, return to sport takes a minimum of 4-6 months, not all patients do well

The Alfredson Protocol Exercises

• Eccentric exercise
– 3X15 reps
– Twice daily
 Retrocalcaneal/Retroachilles Bursitis
Etiology Signs & Symptoms Management

- Repetitive dorsiflexion/plantar flexion
of the ankle with friction/traction
exerted through the Achilles tendon-
Direct pressure from shoe
- Inflammation of the retrocalcaneal bursa
- May have callus formation “pump bump”
- Localized swelling and warmth
- Tenderness to palpation
- Pain with active/passive ROM
- Use anti-inflammatory modalities and
medications
- Address shoewear (loose heel counters)
- US and heat in chronic stages
- Orthotics, taping, heel lifts to decrease stress
- Patient education on training
- Soft tissue massage
- Gastroc/soleus stretching

Achilles Tendon Rupture Plantar Fasciosis

- Avascular zone of tendon just proximal to calcaneal insertion point • Microtrauma/inflammation at the insertion of the plantar fascia into
- Chronic degeneration due to inflammatory condition/irritation contribute to the calcaneus
tissue weakness – risk for rupture • Can develop bony exostosis (calcaneal spur), but present in 30%
• Forceful, sudden contraction is most common mechanism of injury and removal rarely improves symptoms
• Corticosteroid injection risk factor • ***Pain in heel which is worse with first few steps in the morning
• Commonly seen in 30-40 y.o. males when fascia is more inflexible
• May report sudden audible pop • Tight gastroc-soleus complex
• Palpable and/or visible defect in tendon • Excessive pronation which lengthens the fascia
• Altered gait pattern – unable to push off • Caused by overuse such as prolonged standing or walking,
• Swelling and ecchymosis overtraining
• Ability to PF with secondary muscles, but significantly weaker than • Flat shoes with poor arch support or shock absorption
normal Signs & Symptoms
• Positive Thompson test – History: repetitive stress, morning pain, on feet
• Most treated surgically followed by neutral cast or boot for 6 weeks – Overpronation OR cavus foot, may have “toe-out”
Treatment Post-surgical – Swelling
- In a boot, traditionally NWB to PWB for up to 6 weeks- recent research – A/PROM Localized pain and tenderness during great toe
showing good results with immediate WB in functional boot/brace in PF extension
positions. – Resistive testing negative
– Point tender at calcaneal insertion
Gentle progressive ROM Progressive strengthening from
– Tightness of gastroc/soleus
Joint mobilizations isometrics to theraband to weight bearing
Heel Spurs
Gentle progressive stretching to function
• As you push off, your plantar fascia is put on stretch, overpronation
E-Stim to facilitate strengthening Proprioceptive and functional retraining
causes arch to collapse and plantar fascia to lengthen
• Accounts for 9% of running injuries
Ankle Sprains

Most common athletic injury • Lateral ankle sprains • Syndesmosis ankle sprains
• Most caused by excessive – Least stable in “loose – “high ankle sprain”
inversion packed position” – PF with Ankle Anatomy
– Injury to lateral inversion • 3 main ligaments on the
supporting ligaments – Progression of tissue outside of the ankle
• Most treated nonoperatively damage with severity from • Anterior Talofibular
• Risk Of Ankle Injuries By ATF to CF to PTF • Calcaneofibular
Sport • Medial ankle sprains • Posterior Talofibular
– Basketball 45% – Less common due to • High ankle sprain includes
– Soccer 31% decreased eversion ROM Anterior Tibiofibular ligament
– Volleyball 25% and bony architecture
– Football 10-15%

Lateral Ligament Instability Anterior Drawer Alternate- ATFL

• ATFL – resists inversion in plantarflexion- stress with
anterior drawer stress test
• CFL – resists inversion in neutral or dorsiflexion- assess
with talar tilt
• PTFL - resists posterior and rotatory subluxation of the
talus
• If performed less than 48 hours after injury, sensitivity
is 0.71 and specificity is 0.33
• If performed 4 to 5 days post-injury sensitivity is 86%
and specificity is 74%

Talar Tilt- CFL

• Grasp foot and stabilize tibia and fibula, then adduct and invert the calcaneus into varus
• Deltoid ligament examined by abducting and everting the calcaneus into a valgus position
• A positive test will result in laxity and/or pain.
• Compare to opposite side
• 5°greater than opposite side or 10 degree absolute value suggest CFL damage
Special Tests
• Anterior Drawer +, Talar Tilt –
– Most likely isolated ATFL injury (60-70% of all inversion injuries)
• Anterior Drawer –, Talar Tilt +
– Most likely isolated CFL injury (10% of all inversion injuries)
• Both the Anterior Drawer and Talar Tilt +
– Most likely ATFL/CFL injury (accounts for 20% of inversion injuries)
Lateral Ankle Sprain Sequela
• Impingement of medial joint capsule/ligaments
• Peroneal tendon strain/rupture
• Medial malleolar “push-off” fracture
• Avulsion fracture of 5th metatarsal or lateral malleolus
• Talus/ankle mortise chondral lesions
• Superficial branch of peroneal nerve injuries

First Degree Sprain

• Signs and symptoms
• Acute ankle pain, may hear pop
• Little loss of function or ROM (full inversion may be painful), no laxity, Mild tenderness
• Little or no bruising or swelling
• Management
• RICE for 1-2 days; limited weight bearing initially and then aggressive rehab
• Tape may provide some additional support
• Return to activity in 7-10 days

Second Degree Sprain

• Moderate to marked tear of ligament
– Severe ankle pain
– Feeling of popping or tearing
– Extreme tenderness
– Loss of function, painful A/PROM
– Increased laxity but good end point
– Generalized swelling
– Bruising soon after injury
– Limited ability to weight bear

Nonsurgical Treatment
• Grades 1 and 2
– PRICE, range-of-motion exercises, WBAT
– Neuromuscular training – peroneal muscle and proprioceptive training
• Grade 3
– Should they be immobilized?
Functional Treatment: 3 Phases Medial Eversion Sprain
3 phases: • Commonly seen in wrestlers
1. PRICE protocol is initiated within 24 hours of injury • 10% of sprains vs. 70-80% lateral
2. Exercises to restore motion and strength start within 48 to 72 • Deltoid Ligament
hours of injury • 75% of ankle fractures occur on medial side
3. Endurance training, sport-specific drills, and training to – Avulsion fracture of medial malleolus
improve balance – Bimalleolar (Pott’s) fracture
– Talus/ankle mortise chondral lesions
Third Degree Sprain
• Complete tear of ligament Eversion Ankle Sprains
– Severe or no ankle pain • Etiology (Represents 5-10% of all ankle sprains)
– Feeling of popping or tearing - Bony protection and ligament strength decreases likelihood
– Sometimes a sensation of the joint dislocating of injury
– Severe tenderness - Eversion force resulting to damage of deltoid and possibly fx
– Loss of function of the fibula
– Positive Anterior Drawer and Talar Tilt tests - Due to severity of injury, it may take longer to heal
– Immediate, generalized swelling - Foot that is pronated, hypermobile or has a depressed medial
– Immediate bruising longitudinal arch is more predisposed to eversion sprains
– May not be able to bear weight
Management Medial Ankle Sprains
- RICE, X-ray per Ottawa rules - Typically present with localized point tenderness and
- May need splint or brace, rarely a boot swelling over deltoid ligament
- Isometrics - ROM/strength deficits per mechanism of injury and tissue
- ROM, PRE and balance exercise once immobilization involved
discontinued - Positive eversion (talar tilt) stress test
- Manual therapy Management
- Surgery may be warranted to stabilize ankle due to increased - Follows the same course of treatment as inversion sprains
laxity and instability - Grade 2 or 3 may have considerable instability and weakness
Grade III Management in medial longitudinal arch resulting in pronation and fallen
- RICE for at least first 72 hours; PWB with crutches, arch
progressing to weight bearing as tolerated when pain High Ankle Sprain/Rotation Dorsiflexion Sprain
subsides ● Injury to anterior tibio-fibular ligament and/or syndesmosis
- Taping may provide support during early stages of walking (1-11% of ankle sprains)
and running ● Hyperdorsiflexion (snowboarding)
- May have chronic instability with injury recurrence ● Rotation and plantarflexion
- Must retrain proprioception to prevent against re-injury ● Takes longer to heal because every time the individual steps
the distal tib/fib joint spreads and ligament is re-irritated.
 Syndesmosis Sprains
Etiology Signs & Symptoms Management

- Much more debilitating and difficult - Severe pain, loss of - Difficult to treat and may requires months of treatment
recovery process versus med/lat injuries function; passive external - Same course of treatment as other sprains, however, immobilization
- Pain with DF/ER due to wider anterior rotation and dorsiflexion and total rehab may be longer
dome of talus spreading distal tib-fib joint cause pain Treatment
- Must rule out involvement of fibular - Pain is usually Acute – RICE, protect ankle, crutches (if unable to walk painfree), isometrics
fracture due to common mechanism anterolaterally located in immobilization device, contrast baths, horseshoe pads
- Proximal 1/3 of fibula fracture • Subacute-
(Maisonneuve) from rotational stress that - Retromassage
can cause syndesmosis injury - Ultrasound, laser
- Average recovery time of 55 days - Electrical stimulation (IFC, TENS)
- Taping or elastic bandage
- Active range of motion exercises
- Isometrics to gentle PRE’s theraband
Chronic (healed)
- Strengthening exercises
- Thermal modalities and joint mobs if stiffness
- Balance and agility exercises
- Train functionally for final goal of rehab

Foot and Toe Pathologies

● Many foot/toe injuries/conditions relative to either biomechanics at the foot or as compensation for abnormal biomechanics elsewhere in
the lower extremity
Great Toe Injuries
MP Joint Sprain Hallux Valgus Hallux Rigidus

- Aka “turf toe” - Aka “bunion” Ankylosis (joint fusion)

- Typically associated with - Atypical for traumatic onset
hyperextension

Metatarsal/Phalangeal Injuries
Metatarsal fractures Metatarsal stress fractures Avulsion fractures Phalangeal fractures

Traumatic, “false joint” “march” fractures most common at base of 5th metatarsal
Bunions (Hallux Abductovalgus)
Etiology Management

- Overpronation causes increased stress to big toe - Ice

- Bone becomes irritated and a bump forms - Orthotics to control pronation?
- Aggravated by tight shoes - Wider shoes, motion control shoes
- Family History - Bunion pads
- surgery

Metatarsalgia
Etiology Signs & Symptoms Management

- poor calf flexibility, pes cavus - Pain bearing weight on ball of foot - Rest, walking boot
- fallen metatarsal arch due to pronation - flattened transverse arch - X-ray vs walking boot
- training errors
- Morton’s toe (long 2nd MT) or other
atypical conditions of foot

Metatarsalgia and Stress Fractures

• Caused by high impact exercise, poor shoes, overpronation
• Treat with ice, arch supports, ibuprofen, padding, shoes with forefoot padding
• Physical therapy
• Walking boot