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107 Cards in this Set
- Front
- Back
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In an open chain knee extension, what direction does the tibia move? |
Ventral glide and lateral rotation at the end of extension |
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In a closed chain knee extension, what direction does the femur move? |
Dorsal glide and medial rotation at end |
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In the screw home mechanism, what locks first? |
Lateral condyles and ACL |
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Normal Range Knee flexion |
0-135 or 0-140 |
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What direction does the tibia glide in open chain knee flexion? |
Dorsal glide and medial rotation |
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What is maximal newborn knee extension? |
15-20 degrees (reach 0 by age 2) |
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What change in knee ROM is observed in the elderly? |
Not much change, small decrease in extension and flexion |
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What is the knee ROM needed for gait? |
0-60 |
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What is the knee ROM needed for stairs and chair? |
0-90 |
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What is the knee ROM needed for full ADLs? |
5/10 - 115 |
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What areas can refer pain to the knee? |
- Hip L3 (anterior-medial) - Lumbar spine L4-5 (Anterior- lateral) - Sacrum S1-2 (Posterior) |
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In what areas may swelling occur in the knee? |
- Suprapatellar bursa - Capsule - Prepatellar bursa - Infrapatellar bursa |
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What types of swelling may be observed in the knee (temporally/regionally)? |
- Immediate swelling - Immediate diffuse swelling - Gradual swelling over several days |
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What muscles might affect mechanics of the knee if they are tight? |
1. hip flexors - shorter stride length in extension 2. hamstrings - shorter stride length in flexion 3. gastrocnemius and soleus - lacking full dorsiflexion, would pick up foot early 4. TFL |
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Causes of osteoarthritis |
Aging Trauma Repetitive abnormal stress Obesity Developmental disorder Disease |
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Degenerative changes with osteoarthritis |
Articular cartilage breakdown/loss Capsular fibrosis (stiffness) Osteophytes Occur in sites of most loading(superior acetabulum) |
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HIP OA symptoms |
Groin pain Referred pain to knee (L3 dermatome) Stiffness Antalgic gait (gluteus medius) Limited hip extension, hip IR, flexion (can lead to LBP, knee stress) Muscle weakness (quads, glute med, glute max) |
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Clinical prediction rule for Hip OA |
1. Pain with squatting 2. Pain with active hip flexion 3. +SCOUR test in adduction (pain) 4. Pain active hip extension 5. Passive IR <= 25 degrees 3 out of 5 = 68% likelihood 4 out of 5 = 91% |
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When is faulty contractile tissue painful? |
- resisted isometric contraction - active motion using muscle (there could also be stress on joint or stretch on capsule that would cause pain) - active and passive motion in direction opposite to ms function (due to stretch. be aware that stretching a ligament could hurt too) |
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With which motion would faulty contractile tissue not be painful? |
Passive motion in same direction as muscle function |
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When is faulty inert tissue painful? |
- Active motion in same direction (could also be antagonist ms and tendon being stretched) - Passive motion in same direction - Joint play testing |
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When is faulty inert tissue not painful? |
Resisted isometric contraction |
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What points to inert tissue (joint surface, capsule, ligament) involvement? |
- Restriction and pain in joint play - Restriction in passive ROM - Pain with active and passive motion in same direction - No pain with resisted isometric contraction |
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What things point to contractile tissue involvement? |
- No restriction with joint play - Restriction with passive ROM - Pain with active motion in agonist direction - Pain with passive motion in antagonist direction - No pain with passive motion in agonist direction |
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What is a capsular pattern and what are its causes? |
What: Pattern of restriction in more than one motion Why: - Diffuse intra-articular inflammation - Fibrosis of entire capsule |
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Knee capsular pattern |
Flexion limited more than extension |
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Inert Tissues |
Bone Ligaments Periosteum Bursa Joint capsule Synovium Meniscus |
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In differential diagnosis, note on active movements: |
- WHEN and Where during each movement pain occurs - Whether movement INCREASES intensity and quality of pain - REACTION of patient to pain - AMOUNT of observable restriction - PATTERN of movement - RHYTHM and QUALITY of movement - Movement of ASSOCIATED joints - Willingness of patient to move part - Any LIMITATION and its nature |
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Abnormal end feels |
Muscle spasm Capsular Bone to bone Empty Springy block |
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Noncapsular patterns |
Movement in one direction limited (e.g. impingement) Internal derangement (e.g. meniscus) Extra-articular lesion (e.g. adhesions) |
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Sensory scan involves: |
Differentiating b/w nerve root symptoms and peripheral nerve symptoms |
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Similarities between peripheral nerve and nerve root lesions |
Symptoms: Paresthesia, muscle weakness, pain |
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Differences between peripheral nerve and nerve root lesions |
- Pattern of weakness - Peripheral nerve lesion obvious right away while nerve root lesion takes up to 5 sec to develop(?) - sensation: sensory distribution (PN) vs dermatome (NR) - motor control: muscle distribution (PN) vs myotome (NR) - inert tissue: joint distribution (PN) vs sclerotome (NR) |
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Dermatome |
Area of skin innervated by same segmental segment |
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Sclerotome |
Deep somatic tissues innervated by same segmental segment |
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Referred pain principles |
1. Pain is referred segmentally 2. Pain doesn't cross midline. If bilateral has central cause. 3. More superficial tissue - less likely to refer 4. Pain is usually referred distally 5. Increase injury -> increased referred pain |
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Causes of osteoarthritis |
- Aging - Trauma - Repetitive abnormal stress - Obesity - Developmental disorder - Disease |
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Degenerative changes seen in OA |
- Articular cartilage breakdown/loss - Capsular fibrosis (stiff!) - Osteophytes - Occur in sites of most loading (eg superior acetabulum) |
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Hip OA symptoms |
Groin pain Referred pain to knee (L3 dermatome) Stiffness Antalgic gait (gluteus medius) Limited hip extension, hip IR, flexion - can lead to LBP, knee stress Muscle weakness (quads, glute med, glute max) |
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Clinical prediction rule OA |
- Pain with squatting - Pain with active hip flexion - + SCOUR test in adduction (pain) - Pain active hip extension - Passive IR <= 25 3 out of 5 = 68% likelihood 4 out of 5 = 91% likelihood |
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Functional limitations |
- Sit to stand - Walking - Stairs - Squatting - In/out of car or shower - Dressing (socks, shoes, pants) |
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Surgical options for THA |
Traditional (15-25 cm incision) - more stressful to soft tissues. Posteriolateral, lateral, anterior or transtrochanteric approach. Minimally Invasive (1 or 2 mini-incisions <10 cm) - Less trauma to soft tissues. Posterior, anterior, or lateral approach. |
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Posterior approach THA - procedure and advantages |
- Glute max divided, several ERs and post capsule released - Capsule and ERs later repaired - Most common approach - Excellent surgical visualization - NO damage to abductors |
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Anterior approach THA - characteristics |
- No muscles are cut - Access hip between TFL and RF - Newer in US - Much smaller window for surgeon |
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Acute care for THA |
-Typical hospitalization 2-5 days - begin PT day of or day after THA (1-2x/day) - abduction pillow in supine and SL - No pillow under knee/thigh - Emphasis on early movement - Ambulation - WBAT or PWB depends on surgical approach - Education on dislocation precautions - All precautions/restrictions will depend on type of surgery and info from surgeon |
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Dislocation precautions THA posterior approach |
No IR > neutral No adduction > neutral No flexion >90 ADLs to avoid: crossing legs sitting low soft chairs/toilets pivoting on and toward operative LE sleeping without abd pillow donning shoes/socks traditional way |
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Dislocation precautions THA anterior approach |
No ER> neutral No extension > neutral No flexion > 90 Avoid combine flx,abd,ER Might not be able to do antigravity abd 6-8 wks ADLs to avoid: crossing legs large steps with ambulation (use step to gait) pivoting on and away from operative LE |
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Acute care exercises THA |
Ankle pumps Deep breathing Safe bed mobility and transfers Submax isometrics - quads, hip ext, hip abd Resistance exercise for intact LE and UEs Ambulation with AD Stairs with AD AAROM of hip in protected ranges AROM knee flx/ext Gravity eliminated hip abd, maybe clams Standing hip flx/ext of operative LE Weight shifting, mini squats Heel raises |
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Discharge criteria |
Achieve independent functional mobility: - bed mobility - sit to stand/ stand to sit - transferring - ambulation w/ AD - stairs w/ AD - maintain precautions with ADLs |
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Hip Dysplasia signs in babies |
- Asymmetrical thigh or gluteal folds - LLD - Restricted hip abd - Special tests (Ortolani and Barlow) - Radiographs, ultrasound |
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Treatment for Hip Dysplasia |
- Pavlik Harness - Short leg hip spica cast - Surgery |
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Hip Dysplasia signs in babies (5) |
- Asymmetrical thigh or gluteal folds - LLD - Restricted hip abd - Special tests (Ortolani and Barlow) - Radiographs, ultrasound
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Treatment for Hip Dysplasia (3) |
- Pavlik Harness - Short leg hip spica cast - Surgery
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Legg-Calve-Perthes Disease: Cause and Characteristics |
Avascular necrosis occurs - blood supply temporarily interruped to femoral head, bone dies and can deform. - typically in children 4-10, especially in physically active, athletic, shorter children, and 4x more common in boys - worse in ages >= 10 (will develop degenerative arthritis) - Need blood work and radiographs to diagnose - can be self healing, or may need intervention |
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LCPD symptoms |
- Intermittent Limp (abductor lurch), especially after exertion, often insidious - Mild, intermittent pain in anterior thigh, knee - limited hip ROM (abd, IR) - quad atrophy - adduction/flexion contracture |
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Treatment for LCPD |
- Surgery or brace to position femoral head in abd/IR - PT: Education about brace/crutch use Activity modification Reduce pain (heat, ice, e-stim) Restore ROM (AROM, PROM, stretching) - focus on hip adductors, IRs, ERs, flexors (10-30 sec hold as tolerated) Prevent dislocation Strengthen (isometric, progress to low resist) - Isometrics all in hip neutral - Isotonics: 10-15 reps, 2-3 sets Balance and gait training - Balance Narrow BOS (no prolonged U stance) - Use of AD walking, stairs, progress to no AD and walking on uneven surface
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Slipped Capital Femoral Epiphysis - Cause, risk, treatment, complications |
Cause - instability in proximal femoral growth plate Risk - age 10-16, 2x in boys, 2.5-3x in black and hispanic children, obesity. Treatment: Surgical fixation Complications: Can result in avascular necrosis |
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Radiographic findings in SCFE |
Femoral head displaced posteriorly and inferiorly in relation to femoral neck. Femoral head w/in acetabulum |
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SCFE signs and symptoms |
- Hip, medial thigh, and/or knee pain - Insidious onset limp, toe out gait - Reduced ROM hip - LE held in passive ER - May have inability to weight bear (if unstable) - W/ passive hip flex, LE with ER and abd - Decreased and painful IR |
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SCFE Treatment |
- Immediate internal fixation surgery - Crutches 6-8 weeks (PWB) - Physical therapy |
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PT for SCFE |
- Crutch training (includes stair navigation) - Reduce pain (ice, heat, e-stim) - ROM: stretches, PROM, joint mobs hip and spine - Aquatic or AlterG exercise - Strengthening (isometric, progress to resisted and body weight) - proprioception - balance - return to sport drills 3-6 months post op |
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Femoracetabular impingement cause |
Pincer - acetabular rim overhang Cam - femoral head bony deformity, not round
-> cause excessive friction on labrum, resulting in intra-articular pain and risk of tear |
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Causes of FA Impingement/Labral tear |
- Trauma - Capsular laxity - Hip dysplasia - Bony deformities - Hip OA - Sports with alot of hip rotation: golf, soccer, hockey, ballet, yoga (laxity) |
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FAI and impingement symptoms |
- Deep groin pain, "C" sign - Anterior or medial thigh pain to knee - Puttock pain - posterior invovlement (less common) - Clicking, locking, catching, giving way - Pain with flexion, pivoting motions - Sharp pain with motion, dull ache at rest or with lower intensity activity - Functional limitations: walking, stairs, running, sitting, pivoting, in/out of car |
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Evaluation for subtalar degenerative arthritis |
- swelling in hindfoot - WB and NWB - PROM - ... |
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FAI and impingement symptoms |
- Deep groin pain, "C" sign - Anterior or medial thigh pain to knee - Buttock pain - posterior invovlement (less common) - Clicking, locking, catching, giving way - Pain with flexion, pivoting motions - Sharp pain with motion, dull ache at rest or with lower intensity activity - Functional limitations: walking, stairs, running, sitting, pivoting, in/out of car |
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Treatment of subtalar degenerative arthritis |
Conservative: - NSAIDs, corticosteroids, cryotherapy, PT modalities (us, LLLT, interferential electrical stimulation, iotophoresis), activity modification, footwear modification - Orthotic and bracing (acquired flatfoot deformity).... Surgery: - joint sparing - if min degen changes. - joint sacrificing - advanced STJ arthritis, arthrodesis |
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STJ Osteochondral injury definition |
injuries to articular surface of talar dome in ankle joint (aka OCD = osteochondritis dessecans; transchontral fracture) Typically associated with extreme inversion sprains |
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Hip Dysplasia Signs in Babies |
- Asymmetrical thigh or gluteal folds - LLD - Restricted hip abduction - Special tests: Ortolani (abduction and anterior force elicits sensation of hip reducing) and Barlow (adduction and posterior force detects unstable hip) - Radiographs, ultrasound |
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Hip Dysplasia Treatment in babies |
- Pavlik Harness - Short leg hip spica cast |
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Hip Dysplasia Symptoms in teenagers and young adults |
- Hip pain with walking, limp - Pain in groin (also in lateral or posterior) - Starts as mild pain and gets progressively worse, especially with activity - Clicking, popping - Radiographs needed to dx - Can lead to labral tears and early OA |
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Treatment for Hip Dysplasia in teenagers and young adults |
- May need surgery - May do PT |
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PT for hip dysplasia |
- Soft tissue mobilization - PROM, active and passive stretching (pain free) - Postural and LE alignment - Strength focuses on hip abduction and external rotation - Heel lift for LLD - Education on energy conservation, appropriate use of heat and ice, non-impact exercise, may have to avoid golf/bowling/rowing/road cycling/tennis/yoga |
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Differential Dianosis for labrum |
- Hip flexor or groin strain - will be TTP, painful with cx - Iliopsoas bursitis - will be TTP - Osteitis pubis - TTP in pubic symphysis - Hip OA - age, activtiy, amount of stiffness in hip - Hernia (inguinal or femoral) - pain into scrotum, abdomen, sometimes palpable - L1, L2, L3 radiculopathy - non-tender in hip, elicit pain with lumbar motions - Stress fracture - very similar symptoms, imaging, pt history - SCFE - age - LCPD - age |
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Treatment for Hip labral tear |
- May ultimately need surgery but conservative treatment first - Emphasize correct hip alignment - Strengthening of abductors, ERs, extensors, abs - Flexibility of tight structures - careful with hip flexors, anterior capsule, hamstrings, lumbar ES - Avoid hip flexion from extended position - avoid painful motions such as rotation w/ load - Use caution with all hip joint mobs |
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Muscle strain or overuse stages |
1. Acute (<72 hrs) - PRICE, AAROM, NSAIDs 2. Subacute (10 days - 6 weeks) - heat, massage, AROM, Isometrics 3. Late subacute: isometrics painfree, gentle stretch, isotonics (eccentric), aerobics 4. Chronic (95% ROM, 75% strength): balance, agility, jogging, light sport specific drills 5. Chronic (95% strength): maintenance program for stretching, strengthening maintenance, return to sport, warm-up before activity |
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Causes of Muscle/Tendon Injuries |
- Repetitive strain - Trauma - Reduced flexibility - Fatigue - Inadequate rest between activity
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Signs of FAI (anterior involvement) |
1. + SCOUR 2. + FADIR 3. + FABER 4. Pain with supine active hip flexion 5. No palpable pain 6. Tight hip flexors and lumbar extensors 7. Weak glutes and abdominals |
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DD labral tear and hip flexor or groin strain |
Strain will be TTP, painful with cx and stretch |
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DD labral tear and L1,2,3 radiculopathy |
radiculopathy - pain with lumbar motions |
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Treatment for FAI or Labral tear |
Conservative first: - emphasize good hip alignment - Strengthen abductors, external rotators, extensors, abdominals - increase flexibility of tight structures while avoiding compromising positions - do soft tissue mobilization and foam rolling on hip flexors, hamstrings - No hip flexion from extended position - Caution with all hip joint mobilizations May ultimately need surgery |
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Signs/symptoms of muscle strain/overuse |
1. Pain with contraction or stretch 2. Antalgic gait with shorter stance on painful side 3. Palpable divot in muscle 4. Tender to palpation |
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Treatment acute muscle strain (<72 hrs) |
PRICE, AAROM, NSAIDs |
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Treatment Subacute muscle strain (10-days - 6 weeks) |
Heat, massage, AROM, Isometrics |
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Treatment late subacute muscle strain |
Isometrics pain free, gentle stretch, eccentric isotonics, aerobics |
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Treatment chronic muscle strain (95% ROM, 75% strength) |
Balance, agility, jogging, light sports specific drills |
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Treatment Chronic muscle strain (95% strength) |
Maintenance, return to sport, warm up before activity |
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Manual treatment muscle strain |
Soft tissue massage, cross friction massage to promote fiber mobility and linear scarring |
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Symptoms of Gluteus Med/Min Tendonitis |
- Lateral hip pain, TTP - Pain with rolling in bed, sidelying, sitting with crossed legs, stairs - low endurance when walking - "hip hanging" stance - LLD |
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Treatment Glute Min/Med Tendonitis |
- Cross friction massage to tendon - stretch ITB, glute med, min - Hip abductor/ER strengthening - isometric, eccentric, then concentric/eccentric - Core and pelvic stability - Gait retraining - Ice, ultrasound, kinesiotape, heel lift |
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Adductor Tendonitis symptoms |
- pain in groin - pain with hip flexion, adduction - pain with running, worsens with sprinting - Tender to palpation |
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Who gets adductor tendonitis? |
- common in runners, horseback riding, hockey - can accompany hernia, osteitis pubis - usually a result of overuse or previous groin strain |
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Who gets glute med/min tendonitis? |
- more common in women than men - common in older adults - usually a result of trendelenburg gait causing repetitive strain - may also have trochanteric bursitis |
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What is the treatment for adductor tendonitits? |
- Cross friction massage - adductor, hip flexor stretching - strengthening of adductors, flexors, abductors, external rotators - improve pelvic and LE alignment |
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What arteries are at risk of disruption in proximal and midshaft tibial/femoral fractures? |
Popliteal artery Posterior tibial artery Fibular artery Anterior tibial artery |
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Treatment for proximal and midshaft tibial/femoral fractures (3 options) |
- closed reduction with LL cast, progressing to short cast (common in children since their strong periosteum means less displacement - closed reduction with external skeletal fixation - ORIF with or without cast |
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Mechanism of injury of Fractures of distal leg and ankle |
Foot pushed into abduction and external rotation, causing: - shearing injury to lateral malleolus - avulsion injury to medial malleolus via deltoid ligament - shearing injury to posterior malleolus |
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Treatment for malleolar fx |
Closed reduction and cast 6-8 weeks (NWB at least 4 weeks) |
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Bimalleolar Fx/Trimalleolar Fx Treatment |
Usually treat with open reduction internal fixation and cast 8-12 weeks (LL or SL 1 mo NWB, SL 1-2 mo PWB) |
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What ligaments are usually sprained or ruptured in an ankle inversion injury? |
- anterior talofibular ligament - calcaneofibular ligament - posterior talofibular ligament If forefoot also inverted: - dorsal calcaneocuboid ligament - peroneus tertius |
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What ligaments are usually involved in an ankle eversion injury? |
- deltoid ligament - anterior inferior tibiofibular ligament and/or interosseus membrane involved if in a lot of dorsiflexion ("high ankle sprain") |
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These symptoms are consistent with what pathology?
Swelling localized over sinus tarsi Stiffness in morning that eases with activity Pain in medial or lateral hindfoot Exacerbation with WB Limited ROM
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Symptoms of STJ DJD |
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Imaging for STJ Osteochondral injury |
X-ray (bone) MRI - most sensitive - (bone, cartilage, ligament) |
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Causes of STJ Osteochondral injury |
chronic instability traumatic event |
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Symptoms of STJ Osteochondral injury |
Prolonged pain Swelling Catching/grinding Stiffness Instability Arthrosis if displaced fragment interferes w/ joint movement |
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Causes of tarsal coalition |
- developmental - infection - arthritis - injury to area |
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Most common hip strains are |
hip flexor, adductor, hamstring due to dominance of these mucles and weakness in glute max, min, and med |
