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Achilles Tendon Rupture
- rupture 1-2 inches above tendon insertion on calcaneus
- degenerative changes, impaired bloodflow, repetitive microtrauma
- push off through WBing extremity, unexpected DF, forceful eccentric contraction
- 30-50 yo, weekend warriors
- positive Thompson Test, palpable defect, swelling, pain and weakness with PF, x-ray can rule out avulsion fractures
- serial casting for ~ 10 weeks with heel lift
- ROM, stretching, icing AD, gait training strengthening
- previous level of function within 6-7 months
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Adhesive Capsulitis
- inflammation and fibrotic thickening of anterior joint capsule of shoulder
- primary (spontaneously occurring), secondary (underlying condition)
- middle age females, DM, hypothyroidism, immobilization, reflex sympathetic dystrophy
- restricted AROM and PROM, ROM initially restricted by pain, then ROM restricted by capsular stiffness (ER, abduction, IR)
- NSAIDs, corticosteroids, heat/ice, joint mobs, strengthening
- spontaneous recovery 1-2 years
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ACL sprain
- ACL extends from anterior intracondylar region of the tibia to medial aspect of the lateral femoral condyle in the intracondylar notch
- injury from: hyperflexion, rapid deceleration, hyperextension or landing unbalanced
- risk factors: muscle strength, joint laxity, Q angle, narrow intercondylar notch
- unhappy triad: ACL, MCL, medial meniscus
- patellar tendon most common graft
- improve ROM, control edema, pain modulation, then start with closed chain activities
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Bicipital Tendonitis
- inflammatory process of long head of bicep in the bicipital groove
- repititive overhead motion damage the cells and don't give time for the tendon to heal
- MRI can detect it but usually not done unless not responded to conservative treatment
- deep ache directly on top and in front of shoulder
- Speeds and Yeargesons' test
- goal: relieve pain, reduce inflammation (ionto, phono), regain full ROM, strengthen affected muscule groups
- average of 6-8 weeks of therapy
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Carpal Tunnel
- carpal tunnel: transverse carpal ligament, scaphoid tuberosity, trapezium, hook of hamate & pisiform, volar radiocarpal ligament
- entraps:median nerve, 4 flexor digitorum profundus tendons, 4 flexor digitorum superficialis tendons, flexor pollicis longus tendon
- edema, inflammation, fibrosis cause compression
- repetitive use, RA, pregnancy, diabtetes, trauma, tumor, hypothyroidism, 35-55, women
- night pain, weakness, thenar muscle atrophy (abductor pollicis brevis), decreased grip strength, clumsiness, decreased wrist mobility
- Tinel's sign, phalens test, EMG
- corticosteroid injections, splinting, carpal mobilization, gentle stretching
- decrease in symptoms generally in 4-6 weeks
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Tunnel of Guyon Compression
- inflammation of ulnar nerve, between hook of the hamate and pisiform
- parathesis along ulnar distribution, atrophy of hypothenar musculature
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Congenital Torticollis
- unilateral contraction of SCM- ipsi SB contra rotation
- usually treated for 12-24 before considering surgery
- stretching program and proper handling
- 85-90% respond to conservative treatment
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Duchenne Muscular Dystrophy
- progressive neuromuscular degenerative disorder
- fat and connective tissue replace muscle
- X-linked recessive, only males affected
- waddling gait, proximal muscle weakness, clumsiness, toe walking, excessive lordosis, pseudohypertrophy of calf, gowers sign
- EMG to examine nerve activity within muscles
- maintain function of unaffected musculature for as long as possible
- death usually by teens or young 20s
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Lateral Epicondylitis
- repeated overuse of wrist extensors, especially extensor carpi radialis brevis, but also include extensor carpi radialis longus, extensor digitorum, extensor carpi ulnaris
- 30-40's, men, backhand in tennis
- pain along lateral aspect of elbow, sometimes into dorsum of hand, pain increases with wrist flexion and elbow extension or resisted extension and radial deviation
- Cozens, Mills, lateral epicondylitis (middle finger)
- protect, rest, ice, compression, elevation, NSAIDs, resting splints, stretching and strengthening- as pt progresses introduce resistive, isokinetic, and sport specific exercises
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MCL Sprain
- connects medial epicondyle of femur to medial tibia, resisting medial directed force
- direct blow to lateral surface of knee- contact activities
- inability to fully extend and flex knee, pain along medial aspect of knee, possible strength decrease, slight ot moderate swelling
- valgus stress test in full extension and 30' flexion
- unhappy triad: ACL, MCL, medial meniscus
- RICE
- grade II should return to previous level of function within 4-8 weeks
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Osteoarthritis
- degenerative, chronic disorder resulting in biochemical breakdown of articular cartilage in synovial joints
- primary OA (aging process), secondary OA (younger individuals)
- generally in DIP, PIPs, thumbs, knees, hips, spine, morning stiffness, deep and aching jt pain exacerbated by prolong activity and use
- can be seen on X-ray
- NSAIDs, acetaminophen or glucocorticoid intra-articular injections
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Osteogenesis Imperfecta
- affects all connective tissue's collagen-producing genes in the body so all bones and all forms of connective tissue are compromised
- four different types: type 1 is the mildest 1/2 are community ambulators, Type 2 is the worst, type III 1/4 are household ambulators, type IV are1/4 community ambulators
- improve optimal bone mass and muscle strength to prevent fractures and deformities, parent handling and positioning techniques
- strong predictor of a child's ability to ambulate is their ability to sit by 10 months
- skin biopsy will determine type of OI, x-rays and bone scans can show old fractures
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Patellofemoral Syndrome
- abnormal tracking of the patella between the femoral condyles causing damage to articular cartilage
- gradual onset of anterior knee pain, exacerbated by compressive forces (stairs, jumping) and prolonged static positioning
- Imaging not commonly used, but X-ray to rule out other conditions
- Clark's sign (hold down patella and contract quads- inability or pain)
- control edema, stretching strengthening (HS, ITB, TFL, rec fem), improve ROM, activity modification
- previous function within 4-6 weeks
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Plantar Fasciitis
- inflammation of tough connective tissue supporting arch of foot
- chronic overuse from repetitive stretching from excessive pronation
- due to same origin on medial tubercle of calcaneus- abductor hallucis, flexor digitorum brevis, and quadratus plantae may also become inflamed and irritated
- severe pain first standing up in the morning, can radiate proximally or distally, increased with prolonged activity, or when resumes Wbing position after being non WBing, tighteness of achilles tendon
- EMG to rule out nerve root entrapment
- corticosteroid injections, non WBing endurance activities, stretching program of Achilles, ongoing strengthening
- total resolution of symptoms may be up to 12 months, often reoccurs
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Tarsal Tunnel Syndome
- tibial nerve passes between the medial malleolus and calcaneus
- pain experienced with WBing but not direct palpation
- numbness, buring pain, tingling, parasthesia
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Rotator Cuff Tendonitis
- repetitive overhead activities causes impingement from weak supraspinatus unable to adequately depress HH in the glenoid fossa during elevation so humerus translates superiorly
- supraspinatus most commonly affected
- 25-40 years old
- difficulty with overhead activities, presence of painful arc (60-120 degrees), pain increases at night
- MRI can be used to show tendonitis but rarely used due to cost
- empty can, Neer, Hawkins Kennedy
- acute therapy: cryotherapy, activity modification, ROM, rest then strengthening
- prior level of function after 4-6 weeks of treatment
- for full rotator cuff tear, can take upwards of 6 months
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Scoliosis
- lateral curvature of the spine
- 12-14 year old, typically rotation occurs toward the side of convexity
- non-structural scoliosis is a REVERSIBLE curve caused from poor posture, leg length, etc
- structural scolisosis is NOT reversable due to congenital, musculoskeletal, neuromuscular reasons (CP, muscular dystrophy, congenital defect)
- X rays taken from anterior and lateral view standing up and bending over
- <25' should be monitored, 25-40 can have spinal orthosis, >40 probably need surgery.
- at skeletal maturity if curve is >50 will most likely continue to progress
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Spondylolisthesis
- forward slippage of one vertebral body with respect to the vertebral body below
- spondylolysis is a defect in the pars interarticularis
- pain is the most common symptoms, palpable step off, HS tightness, lumbar spasm, trunk shortening, gait abnormalities
- most common for degenerative spondylolisthesis is L4-L5
- X rays with lateral & anteroposterior view, or an oblique view to view scottie dog with collar for spondylolysis
- activity modification, patient education, bracing, therapeutic stretching, want exercises to reduce stress with spinal extension, possible bracing
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Temporomandibular Joint Dysfunction
- complex joint- condylar, hinge, synovial
- inflammation and muscle spasm surrounding the joint produces symptoms
- 20-40 year olds, women
- clicking or popping with motion at TMJ, pain, muscle spasm, limited/abnormal jaw motion, HA, tinnitus
- NSAIDs, muscle relaxants, avoid teeth grinding, posture retraining, moist heat, US, estim, joint mob, ROM
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Myofascial pain dysfunction syndrome
- nonarticular disorder that affects area surrounding the TMJ
- grinding and jaw clenching increase tension in muscles of mastication and create spasm
- can mimic TMD, but differential diagnosis will rule out TMJ involvement
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Osteosarcoma
- primary bone tumor- accounts for 15-20% bone tumors, highly malignant
- usually affects bones with an active growth phase and located in the metaphysis
- primary or secondary cancers, young children, most often in long bones
- risk factors for secondary: pagets, osteoblastoma, giant cell tumor, chronic osteomyelitis
- survival rate is 70-80% 5 year cure rate
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Ewing's Sarcoma
- malignant nonosteogenic primary bone tumor that infiltrates the bone marrow
- usually affects people under 20 yo
- extremely malignant with high frequency of metastasis
- requires aggressive treatment- amputation and chemo
- 5 year survival rate 70%
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Amputation from Arteriosclerosis Obliterans
- PVD that produces thickening, hardening and narrowing/occlusion of arteries
- results in ischemia, ulceration and may become necrotic, gangrenous and require amputation
- risk factors: age, DM, male, HTN, high serum cholesterol and LDL, smoking, impaired glucose tolerance, obesity, sedentary
- doppler, MRI, arteriography can examine degree of blood flow
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Glenohumeral dislocation
- excessive translation of HH on glenoid during active rotation
- 85% of dislocations detach the glenoid labrum (Bankart lesion)
- anterior dislocation most common from shoulder abduction and lateral rotation
- subluxation (laxity) vs. dislocation (visible shoulder fullness, popped out)
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Medial Epicondylitis
- repeated microtrauma to the flexor carpi radialis and/or humeral head of pronator teres
- pain with resisted wrist flexion and resisted pronation, point tenderness over medial epicondyle
- don't want to immobilize, but counter force bracing may be good
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Meniscus Tear
- Medial and lateral mensci are attached to proximal surface of tibia
- medial more common than lateral
- MRI can be used to diagnose
- occurs fom fixed foot rotation while WBing on a flexed knee
- joint line pain, swelling, catching, or locking sensation
- meniscal repairs generally performed on out edges due to increased vascularity (red/red zone)
- Apleys (prone), bounce home (flexion then passive extension), McMurrys (supine)
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Osgood Schlatter Disease
- repetitive traction on tibial tuberosity apophysis
- young athletes
- point tenderness over the patellat at tibial tubercle, antalgic gait, pain with increasing activity
- icing, flexibility exercises, eliminate activities that put strain on patella tendon (squatting, running, jumping)
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PCL Sprain
- runs from posterior intercondylar area of tibia to lateral aspect of medial femoral condyle
- landing on tibia with a flexed knee or hitting a dashboard with flexed knee
- isolated PCL tears, not common
- swelling and mild pain may be present, but often asymptomatic, knee extension often limited from effusion
- posterior sag test, posterior drawer
- if have surgery: avoid isolated HS exercises for minimum of 6 weeks
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Osteomyelitis
- inflammatory response within bone caused by an infection
- common in kids and immunosuppressed adults
- surgery may be indicated if infection spreads
- medical treatment consists of antibiotics
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Osteochondritis Dissecans
- separation of articular cartilage from underlying bone
- usually involves medial femoral condyle
- surgery required if fracture is displaced
- plain X-ray or CT scan can show it
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Bursitis
- inflammation of bursa secondary to overuse, trauma, gout, infection
- PROM/AROM limited due to pain, not in capsular pattern
- flexibility exercises to maintain ROM, soft tissue massage/mobs, heat/ice/hydrotherapy for pain reduction
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Complex Regional Pain Syndrome
- reflex sympathetic dystrophy
- related to trauma- results in dysfunction of SNS including pain, circulation and vasomotor disturbances
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Ulnar Collateral Ligament Sprain
repetitive valgus stresses to medial elbow with overhead throwing
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DeQuervains Tenosynovitis
- inflammation of extensor pollicis brevis and abductor pollicis longus at first dorsal compartment
- repetitive microtrauma
- imaging not necessary but could do MRI
- pain at snuff box, swelling, decreased grip and pinch strength, positive finkelsteins
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Colles Fracturs
- most common wrist fractures resulting from FOOSH
- immobilized 5-8 weeks
- complication of median nerve compression can occur
- dinner fork deformity- dorsal or posterior displacement of distal fragment of radius
- loss of motion, decreased grip strength, CRPS, carpal tunnel
- smiths fracturs is similar to colles but distal fragment of radius dislocates in volar direction- garden spade deformity
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Piriformis Syndrom
- external rotator of hip that can be overworked with excessive foot pronation causing abnormal IR of hip
- can result in compression of sciatic nerve
- restriction in IR, pain with palpation of piriformis muscle, referral of pain to posterior thigh, weakness in ER- positive piriformis test, uneven sacral base
- rule out invovlement of lumbar spine and SI joint
- reduce pain, joint oscillations, correction of muscle imbalances, flexibility exercises
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Anterior Compartment Syndrome
- increased compartmental pressure resulting in local ischemic condition
- caused by direct trauma, fracture, overuse, muscle hypertrophy
- acute- swelling within compartment- medical emergency requiring fasciotomy
- chronic- deep, cramping feeling
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