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. What would you like to do?
(talk about joint- stability, size)
Lesions of the hip are detected during what type of activity?
walking/ weight bearing
Where do lesions of the lumbar refer to?
lumbar spine, SI, anterior thigh and knee
What type of joint is the hip?
multiaxial ball and socket
what structures form the acetabulum?
ilium, ischium, pubis
3 ligaments that support the hip
iliofemoral (strongest ligament)
The ligaments tighten in ______ and also ______rotation
Resting/loose pack position of the hip
forces on the hip:
.3 times body weight
forces on the hip:
standing on 1 limb
2.4-2.6 times body weight
forces on the hip:
1.3-5.8 times body weight
forces on the hip:
walking on stairs
3 times body weight
forces on the hip:
4.5 + times body weight
neck shaft angle for a 1 yr old
neck shaft angle for an adult
neck shaft angle larger than 120-125d is termed....
neck shaft angle smaller than 120-125 is termed....
normal anteversion (femoral condyle axis/femoral head axis) of hip is _____at birth
normal anteversion (femoral condyle axis/femoral head axis)of the hip is ______ for an adult
muscles of the hip
glute max, glute med, glute min, piriformis
where is the trochanteric bursa?
over greater trochanter beneath glute max
Is congenital hip dysplasia more common in girls or boys and when is it more common?
more common in girls
presence of snapping is termed_____
How do you get snapping of the hip?
explain in detail about iliopsoas,
iliopsoas tendon slips over the osseous ridge of the lesser trochanter or anterior acetabulum
How do you get internal snapping of the hip?
iliofemoral tendon rides over femoral head which occurs at 45d when hip goes from flexion to extension
How do you get external snapping of the hip?
Tight IT band or glute max tendon slides over the greater trochanter occurs during hip flexion and extension and is made worse if hip is in MR
How do you get intra-articular snapping of the hip?
acetabular labral tears or loose bodies-patient complains of sharp pain into the groin and anterior thigh, especially on pivoting movements
clicking heard and felt when patient is adducted and LR
- L1= groin
- L2= medial thigh
- L3=medial patella
- L4=medial malleolus
- L5=top of foot
- S1=lateral border of foot
- S2=behind knee
- L2=hip flexion
- L3=knee extension
- L5=great toe extension
- S1=ankle PF and eversion
- S2=knee flexion
patellar tendon = L4
hip issues and gait
painful hip is shorter on stance
stiffness causes trunk rotation
B hip flexor tightness increases lordosis
AROM of LE
- extension 10-15
End feels of hip movements
- flexion-tissue approximation or tissue stretch
- extension-tissue stretch
- abduction-tissue stretch
- adduction-tissue approximation or tissue stretch
- ER-tissue stretch
- IR-tissue stretch
capsular pattern of the hip
flexion, abduction, and MR order may vary
rectus femoris length test
supine, 1 leg over edge of table, flex other to chest
look for extension of lower leg at the knee joint
sidelying, extend and abduct upper leg, lower leg and test, leg remains abducted
ROM needed for tying shoes
120d of flexion
ROM needed for sitting
112d of flexion
ROM needed for stooping
ROM for squatting
ROM needed for ascending stairs
ROM needed for descending stairs
ROM for putting foot on opposite thigh
120 d flex
ROM needed for putting on pants
prone, knee flexed to 90d
rotate hip until greater trochanter is parallel with table
estimate angle of leg with the vertical hip anteversion/ MR of femur
hip flexed 90d
pressure down thru femur
look for pain
piriformis special test
hip flexed to 60d, flex at the knee and push hip into adduction
look for pain/parasthesia-compression of sciatic nerve
hold for 60secs, goal is reproduce radiating symptoms
sign of the buttock
if limitation-bend knee
look for instability to increase in flexion= serious pathology of hip
true hip pain is referred to where?
groin, but also ankle, knee, lumbar spine and SI joint
runs from ASIS to symphysis pubis
under piriformis or between ischial tuberosity and greater trochanter
General info about Legg-Calve-Perthes Disease
what does it lead to later? who it affects? causes?
-often leads to severe DJD later in life
-affected children between 2-12 most commonly in boys (4 to 1 ratio)
-causes: metabolic bone disease, thrombotic vascular insults, trauma, infection
Clinical presentation of Legg-Calve-Perthes
-gradual onset of pain, increase with activity
-aching sensation in groin, thigh, knee
-limited PROM abduction and IR
-decreasing leg length
interventions for Legg-Calve-Perthes
-PT for strengthening and gentle ROM
General info on Slipped Capital Femoral Epiphysis
when it occurs? what happens? what happens to growth plates and what causes it? what happens to femoral head during weight bearing? cause?
-occurs during adolesence
-epiphysis slips from its normal position on the femur makes the growth plate become disorganized as fibrous tissue increases
femoral head displaces inferiorly and posteriorly during weight bearing
clinical presentation of capital femoral epiphysis
-2 to 1 ratio boys to girls
-boys 10-17 girls 8-15
-75% of cases occur with obese children with delayed maturation
-usually vague pain, can be in hip but also common in knee
-ROM limited in IR, abd and flex--ext may be increased
-position of comfort-flex, ER, abd
interventions for capital femoral epiphysis
seen in PT for ROM and strengthing
pain over lateral hip and occasionally down the lateral thigh to the knee when the IT band rubs over the trochanter
-pain in groin or anterior thigh and possible into the patellar area
-aggravated during activities requiring excessive hip flexion
pain is experienced around the ischial tuberosities, especially when sitting, occasional sciatica if inflammation affects nearby sciatic nerve
impairments/problems with bursitis
-pain when involved overlapping muscle contracts when stretched
-imbalance in muscle flexibility and strength
-decrease muscular endurance
management of bursitis (acute)
-ice, other anti-inflam tx
management of bursitis (subacute and chronic)
-stretching (psoas and ITB)
-strengthening and endurance training (isometics, controlled WB exercise, biking walking)
etiology of piriformis
-sciatic nerve passes deep
-entrapment results in sensory changes along lateral and posterior portion of the leg and dorsal/plantar surface of the foot
-progressive weakness in hamstring, portion of the adductor magnus and other muscles of the leg and foot can develop
common impairment/problems with piriformis syndrome
-exacerbated with sitting
-complain of deep buttock pain, radiating pain down leg
-often confused with radiating pain from a lumbar problem; when x-rays, MRI's are negative patient is dismissed as all in youre head
management of piriformis (acute)
rest, ice, and other anti-inflam treatments
management of piriformis (subacute/chronic)
-soft tissue mobilization to piriformis
- -stretching of piriformis
- stretch as many times a day
- piriformis is an ext, abd, ER until 90d then changes to IR
- -stretch/strengthen may be muscle imbalance due to
- tight ITB, hamstrings, weak adductors
knee joint is _______ (size)
what type of joint is the knee?
femoral condyles are ________concave/convex?
medial tibial plateau is _______concave/convex?
lateral tibial plateau is _______concave/convex?
concave in the front
convex in the sagittal
does the medial or lateral condyle project more anteriorly?
lateral to prevent subluxing
normal Q angle for men? for women?
how many facets does the patella have? name them!
lateral, medial, odd (medial side of patella)
lateral and medial facets are sub divided into proximal, middle and distal pairs for a total of how many facets?
name quad muscles:
rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
what is the function of the VMO?
pull patella medially to prevent from subluxing laterally
what muscles is affected first with knee joint effusion?
name the hamstrings muscles:
biceps femoris, semitendinosus, semimembranosus
name the hamstrings muscles that are lateral? that are medial?
what makes up the pes anserine? where is it?
sartorious, gracilis, semitendinosus
located on medial aspect of tibia
has bursae that is commonly irritated
popliteus muscle-where is it? what does it do?
crosses behind knee, lateral aspect of femur to medial tibia
helps with the screw home mechanism
what does the gastroc do?
flexes the knee in open chain
describe the medial meniscus
C shaped, thicker posteriorly,
large and skinny
describe the lateral meniscus
O shaped, same thickness throughout
short and fat
how are the menisci attached to the tibia?
by coronary ligaments
how much motion does the lateral meniscus have?
how much motion does the medial meniscus have?
meniscus moves ______with knee flexion
meniscus moves _______with knee extension
what is the medial meniscus attached too?
MCL, semimembranosus, ACL
what is the lateral meniscus attached to?
popliteus tendon and PCL
what is the function of the menisci?
shock absorption, depress weight, make joint surfaces more congruent
Collateral ligament facts
tight in extension, loose in flexion
tight in ER of tibia
MCL resists _____forces
LCL resists _____forces
MCL connects to....?
medial meniscus and semimembranosus
LCL connects to....?
attachments of ACL
starts posterior/lateral on femur
courses anterior/medial to attach on tibia
when is ACL most taut?
throughout entire knee motion
has how many bands? name them!
When is the anteromedial portion of the ACL tight?
during knee flexion, somewhat in extension too
when is posterolateral portion of ACL tight?
when is the ACL at its "loosest"?
is it vascularized and innervated?
ACL tigthens in MR/LR?
starts anterior/medial on femur and attaches posterior/lateral on tibia
is the PCL vascularized and innervated?
Arcuate ligament complex...what does it do? what is it?
-strengthens the posterior lateral capsule
-Y shaped band of deep capsular fibers that attach distally to the fibular head, fanning proximally over the posterior capsule and a portion of the popliteal tendon
Posterior oblique popliteal ligament--what does it do? what is it? what does it limit?
-supports the posterior-medial capsule
-an expansion of the semimembranosus tendon
-limits anterior-medial instability
Joint capsule- what is it? where does it go? what does it contain?
-like a cylinder with a posterior invagination
-courses around the ACL/PCL
-has up to 3 folds called plicas
patellar tendon.....is it a tendon or a ligament?
patellar tendon too high, more than 20% longer , more likely to have problems with instability
patellar tendon too low, 80% or less length of patella, some say more likely to have compressive disorders
Iliotibial tract...what is it? what does it attach to?
-fascia lata of the thigh that arises from the TFL and tendon of glute max
-attaches to lateral condyle of tibia, and vastus lateralis and lateral patellar retinaculum
Screw-home mechanism with flexion
tibia IR and femur ER
screw home mechanism with extension
tibia ER and femur IR
screw home mechanism with extension (incorporating menisci)
tibia moves anterior, menisci move anterior too
screw home mechanism with flexion (incorporating menisci)
tibia moves posterior, menisci move posterior too
which way does the medial meniscus go when the femur IR on the tibia
with IR of the femur on the tibia the medial meniscus goes POSTERIOR
which way does the lateral meniscus goe when the femur IR on the tibia
with IR of the femur on the tibia the lateral meniscus goes ANTERIOR
during flexion/extension menisci travel with ______
during rotation menisci travle with _______
ER tightens which ligaments?
IR tightens which ligaments?
Resting/loose pack of the knee
Closed pack position of the knee
full extension, LR of the tibia
capsular pattern of the knee
flexion then extension
hyperextension stretches out which ligament?
isolated medial rotation of the tibia results in what?
dashboard affects which ligament?
Valgus, anterior forces of the tibia and forced ER of the tibia affects what and is called what?
MCL, ACL, medial meniscus
hyperflexion results in what?
if you hear clicking what does that suggest?
"pop" at the time of accident suggests
pain with prolonged sitting with knee flexed
suggest patellofemoral problems
joint locking suggests
enlarged tibial tuberosity
MR of the tibia on the femur (knee flexed to 90) ROM
LR of the tibia on the femur (knee flexed to 90d) ROM
MR of tibia
LR of tibia
- flexion=tissue approximation
- extension=tissue stretch
- MR of the tibia=tissue stretch
- LR of the tibia=tissue stretch
- patellar movements=tissue stretch all directions, should not translate laterally more than 1/2 of its body width without tilting or rotating
who do you do a ligament screen on?
valgus stress test at 0d extension 30d flexion =
varus stress test at 0d extension and 30d flexion =
Lachman's/ Anterior Drawers =
one plane medial tests which ligament?
one plane lateral tests which ligament?
one plane anterior tests which ligament?
one plane posterior tests which ligament?
Anteromedial rotary tests which ligaments?
MCL first than ACL
Anterolateral rotary tests which ligaments?
Posteromedial rotary tests which ligaments?
Posterolateral rotary tests which ligaments?
anteromedial rotary tests is called?
anterolateral rotary test is called?
posteromedial rotary test is called?
hughston's posteromedial drawer
posterolateral rotary test is called?
describe the posterior drawer test
patients lies supine knee bent to 90d
thumbs on jt line
push posterior on tibia
looking for increase in posterior motion
describe the lachman's test
anterior drawer in 15-30d flexion
patient sitting c leg rest on examiners knee
examiner stabilizes with hand and forearm
describe the slocum test
15d of lateral rotation
do anterior drawer test
motion occurs mostly on medial side showing anterior medial instability
describe the lateral pivot shift
knee extended or slightly flexed, medial rotation of tibia
apply valgus/forward pressure at the proximal tibia then flex the knee
clunk from lateral pivot shift is what?
reduction of tibia (tibia going back in place)
occurs at 30d of flexion
reduction from lateral pivot shift is what?
occurs because at 30d of flexion ITB drops below the center of rotation of the knee and then jerks the tibia posteriorly back in place
describe hughston's posteriomedial drawer test
tibia slightly medial rotated
push tibia posterior
if there is a lot of movement it suggests PCL,MCL,ACL tears
describe external recurvatum test
patient lies with legs extended
grasp big toes and lift legs
if knee hyperextends and tibia rotates laterally suggests LCL PCL tears
describe anterior drawer test
one plane anterior
suggest ACL but can be false due to help from collaterals
describe the McMurray test for medial meniscus
knee in full flexion, ER tibia, valgus pressure at knee extend knee
describe the McMurray test for the lateral meniscus
knee in full flexion, IR of tibia, varus pressure at knee then extend knee
swelling within 1-2 hours suggests?
think blood which suggests ligament tear, osteochondral fracture or peripheral meniscus tear, doughy feel, hot joint
swelling within 8-24 hours suggests?
think synovial fluid, suggest joint irritation, fluctuating or boggy feeling
describe plica syndrome
irritated soft tissue medial to knee
presents like patellofemoral issue
occurs from repetitive motions
describe the brush test
start medial to inferior patella, brush up 2-3 times, then start lateral and brush down lateral aspect
positive sign is a wave of fluid going back to medial area
describe the McConnell Test
isometric contraction of quads at 0, 30, 60, d 10 secs each
-compare pain level to same contraction with slight medially directed pressure on the lateral edge of the patella
-if less pain, patellar tracking problem (lateral) indicated
what is the Q angle?
measure by ASIS thru midpoint of patella and tibial tubercle through midpoint of patella
describe the apprehension test
knee at 30d flexion, examiner pushes patella laterally
quad will fire and patient will be apprehensive for tendency of patella to dislocated laterally
describe the noble compression test
supine, flex knee to 90d
pressure applied to lateral femoral condyle or 1-2 cm proximal to it, thumb and knee passively extended
-at 30d short of full extension, patient will complain of pain
you palpate the jt line for what kind of injury?
palpating patella facet
relaxed quads, push patella medially and laterally to check for tenderness
palpating suprapatellar pouch
proximal to base of patella
lift skin with thumb and finger
feel for thickness, tenderness or nodule
medial to tibiofemoral joint, feel for tenderness
palpating pes anserinus
medial and distal to tibial tuberosity, check for tenderness
etiology of symptoms of Anterior knee pain (patellofemoral issue)
-imbalance of soft tissues aligning the patella in the trochlear groove and influencing patellar tracking
-increasing Q angle
-insufficient VMO muscle
common impairments/problems with anterior knee pain
1. weakness, inhibition or poor recruitment or timing of VMO
2. outstretched medial retinaculum
3.tight lateral retinaculum, IT band, or facial structures around the patella
4. decreased medial glide or medial tipping of the patella
5. pronated foot
6. pain on palpation
7. tight gastroc, hamstring, or rectus femoris
8. irritated patellar tendon or subpatellar fat pad
9. pain with long term sitting (theatre sign)
Management of anterior knee pain (acute)
-modalities, rest, protection, gentle submax multi angle isometrics
management of anterior knee pain (subacute)
mobile the patella
medial tipping of the patella
stretch of IT band
what does taping of the patella allow for?
more vigorous exercise
pain relief so you can exercise them
what are the exercises that strengthen the VMO
-weight bearing terminal knee ext
management of anterior knee pain (remodeling stage)
activity specific drills
mechanisms of injury of meniscal tears
-medial more commonly injured
-often foot fixed on ground and femur is IR or ER
common impairments/problems of meniscal tears
pain along joint line
describe a bucket handle tear
loose, not attached to tibial plateau so you can pick it up like a bucket handle
describe a radial meniscal tear
perpendicular to edge
non-operative management of meniscal tears
- reduction of loose body
-general open and closed chain exercises to improve strength of leg musculature
-weight bearing may be limited for some time to aid in healing of meniscus
non-operative management of MCL/LCL strains
general open and closed chain exercises to improve strength of leg musculature
limit medial and lateral stress/rotational stress
avoid varus/valgus functional activities
post-operative management of an ACL tear
often in slight flexion
sometimes none at all
how strong is the ACL? before you tear it...
tear comes from 652 lbs or more
graft is equal or better
what weight do you pull out the ACL?
230lbs- bone tendon bone
this is your worry initially
6 weeks bone plug healed
what makes the tibia not slide forward?
maximum protection phase of ACL: (5)
2. gentle isometric contraction of quads and hams
3. patellar glides
4. ambulation weight bearing varies some full
moderate and minimal protection phase of the ACL
-advancement and vigorousness of ROM and strengthening exercise, increasing intensity of closed chain rehab
precautions of ACL tears
-terminal knee extension in open chain will cause anterior translation of tibia
-closed chain provides more stability via joint compression and firing of hamstrings
-graft is at its weakest at approx 6 wks
what % of the population have foot complaints?
general functions of the foot (4)
-acts as a support base with minimal muscular effort
-mechanism for rotation of the tibia/fibula during stance
-flexibility to adapt to uneven terrain, and shock absorption
-acts as a lever at push off
rearfoot/ hindfoot bones in foot
talus and calcaneus
forefoot bones of the foot
navicular, cuboid, 3 cuneiforms
talocrural joint (ankle joint) characteristics
-uniaxial, modified hinge, synovial joint
-talus, medial and lateral malleolus
-much more mobile while in PF
medial ligament in foot:
-medial collateral ligament
superficial medial ligaments in foot: what are they and what do they do?
**resist talar abduction
deep medial ligaments in the foot: what do they do? what are they?
**resist lateral translation and lateral rotation of the talus
anterior talofibular ligament: medial/lateral? what does it do?
resists excessive inversion
often sprained 1st
posterior talofibular ligament: medial/lateral? what does it do?
resists DF,adduction, MR and medial translation of the talus
calcaneofibular ligament: medial/lateral? what does it do?
articulation between the talus and calcaneous
combination of 2 joints: calcaneo-cuboid and the talo navicular
talocrural joint resting pack, closed pack, capsular pattern
resting/loose pack: 10d PF, neutral inversion/eversion
closed packed: maximum DF
capsular pattern: PF, DF
normal transmalleolar angle
normal toe out angle
5d as a child
12-18d as an adult
foot loading during gait: walking, running, jumping
walking- 1.2 x body weight
running- 2 x body weight
jumping- (2 feet) 5 x body weight
arches of the foot maintained by:
-wedging of the interlocking tarsal and metatarsal bones
-tightening of ligaments of the plantar aspect of the foot and plantar fascia
-instrinsic and extrinsic muscles and tendons of the foot
medial arch is made up of:
calcaneus, the talus, the navicular, the three cuneiforms, and the 1, 2, 3, metatarsals
lateral longitudinal arch is made up of:
calcaneus, the cuboid, and the 4, 5 metatarsals
transverse arch is made up of
cuneiforms, the cuboid, and the five metatarsal bases.
line of Feiss is made up of what?
medial malleolus, navicular, 1st metatarsal head should be in line with weight bearing
Anterior tarsal tunnel contents
-deep peroneal nerve passes under the extensor retinaculum
-motor loss-extensor digitorum brevis
sensory-small triangular area between the first and second toes
tarsal tunnel contents:
medial malleolus, calcaneus, and talus on one side and the deltoid ligament on the other
-tibial nerve passes through
-pain and paresthesia into the sole of the foot
biomechanics of the foot: heel strike
name foot position and ankle postions
ankle: moving into PF
biomechanics of the foot: flat foot
name foot position and ankle position
ankle: PF to DF
biomechanics of the foot: midstance
name foot positon and ankle positon
ankle: 3d DF
biomechanics of the foot: heel off
name foot position and ankle position
ankle: 15d DF
biomechanics of the foot: toe off
name the foot position and ankle position
ankle: 20d PF
where do sprains most generally occur?
in PF inverted and adducted
high heeled shoes contribute to what condition?
heel cord tightening
swelling above lateral malleolus suggests?
fibular fracture or disruption of syndesmosis
swelling posterior to lateral malleolus suggests?
peroneal retinacula injury
swelling distal lateral malleolus suggests?
inversion ankle sprain
asymmetrical calf bulk could suggest?
peripheral nerve or nerve root involvement
what is a pump bump and what does it suggest?
build up of bone and callus on posterior calcaneus
results from pressure on heel
lateral malleoulus extends farther ______
medial malleolus extends farther _______
what are bone spurs? how do you get them? where do they commonly occur?
abnormal bone growth
get them from irritative lesion, overuse, trauma or excessive pressure
occur at the dorsal aspect of the tarsometarsal joint, head of the 5th metatarsal, calcaneus, insertion of plantar fascia, superior aspect of navicular bone
hallux valgus: what is it?
-medial deviation of the head of the first metatarsal bone in relation to the center of the body and lateral deviation of the head in relation to the center of the foot
-as metatarsal bones move medially, the base of the proximal phalanx is carried with it
-phalanx pivots around the adductor hallucis muscle
-bunion-combination of callus, thickened bursa and exostosis
hallux rigidus is what?
extension of big toe is limited
causes: OA of the 1st MTP joint, abnormally long 1st metatarsal bone, pronation of the forefoot or trauma
describe claw toe:
hyperextension of the MTP and flexion of the proximal and distal IP
describe hammer toe:
extension of the MTP and flexion of the proximal IP, distal can vary
describe mallet toe:
flexion of the distal IP
how many degrees of DF does it take to DESCEND stairs?
what does walking require of the foot?
describe the test for tibial torsion
supine, align femoral condyles parallel with floor and have patient contract quad to hold
-look at angle formed from malleoli and floor
norms can be 12-30d
describe the anterior drawer sign of the foot
patient lies supine, examiner stabilizes the tibia and fibula, holds the patients foot in 20d of PF and draws the talus forward in the ankle mortise
describe Thompson's test
patient prone, with feet over edge of table
squeeze calf muscle and foot should PF if the Achilles Tendon is intact
describe Tinel's test of the foot:
tap the front of the ankle (joint line) for the anterior tibial branch of the deep fibular nerve
-posterior tib nerve may be impinged as it passes behind the medial malleolus
if there is extracapsular edema what does that suggest?
on one side of the Achilles tendon
if there is intracapsular edema what does that suggest?
on both sides of the Achilles tendon
where is the anterior talofibular ligament?
horizontal, small palpate very close to anterior aspect of lateral malleolus
where is the calcaneal fibular ligament?
tip of laterally malleolus down and back at approximately 45d stress with calcaneal inversion
inversion/lateral ankle sprain characteristics
95% of all ankle sprains are lateral
most common ligament is the anterior talofibular ligament
next most common is calcaneal fibular ligament
eversion/medial ankle sprains
greater likelihood of avulsion or fracture of medial malleolus with severe eversion stress
grade 1 ankle sprain
microscopic tearing of the ligament with no loss of function
grade 2 ankle sprain
partial disruption or stretching of the ligament with some loss of function
grade 3 ankle sprain
complete tearing of the ligament with complete loss of function
acute management of ankle sprains
crutches and splint if severe
submax multi angle isometrics
cross friction massage
subacute management of ankle sprains
cross friction massage to affected ligaments
grade 2 mobilization for pain relief and to maintain motion
gentle AROM and PROM
chronic management of ankle sprains
isometric to isotonic progression of lower extremity musculature
proprioceptive and balance training
endurance and activity specific exercise
may need to protect joint during vigorous activity
plantar fascitis general info
pain usually along the plantar aspect of the heel where plantar fascia inserts on the medial tubercle of the calcaneus
excessive pronation of the subtalar joint predisposes the foot to abnormal forces and irritation of the plantar fascia
common symptoms of plantar fascitis
severe pain on plantar surface of the foot, near calcaneus that is especially severe in AM upon waking
activities that cause stress to the plantar fascia will reproduce pain
management of plantar fascitis
cross friction to plantar fascia
stretching of gastroc
management of pronation
etiology of tarsal tunnel syndrome (what nerve is entrapped?)
posterior tibial nerve or one of its branches (medial or lateral plantar nerve) trapped within the tunnel posterior to medial malleolus
what are the structures passing through the tarsal tunnel?
long flexor tendons and their sheaths, posterior tibialis tendon, and tibial nerve artery and vein
causes of tarsal tunnel?
chronic tendinitis, old fractures, anatomic anomalies in the area, excessive pronation
what does over pronation do to tarsal tunnel syndrome?
causes stress to the musculature and cause an inflammatory process that decreases space in tunnel
common symptoms/findings of tarsal tunnel
sensory changes to plantar surface of the foot and toes and dorsum of distal phalanges
pain on plantar surface of foot, palpation negative
weakness and postural changes of the foot may occur
positive tinnel over tunnel
management of tarsal tunnel
therapy is effective if cause is inflammation
gradually progress to stretching, isometric to isotonic
describe shin splints
junk term for any pain posteromedial, anteromedial, or medial lower leg pain
what can cause shin splints?
myositis, periositis, inflammation of the interosseous membrane or tendinitis
Medial Tibial Stress Syndrome and its general info
most common form of shin splints
tibial periostitis at the fleshy origin of the posterior tibialis muscle or medial aspect of the soleus
tender to the medial tibial border above the ankle
resisted foot inversion/plantar flexion is painful
managements of MTSS (acute)
cross friction massage
sub max, multi angle iso
AROM in pain free range
control improper biomechanics as needed
management of MTSS (subacute/chronic)
correct abnormal foot alignment
stretch tight structures, often gastroc
progress isometric to isotonics and fxnal exercises
stress proper warm up, cool down and gradual increase of offending activity
general info of a tibial fracture
failed adaptation to stress on the bone
accelerated osteoclastic remodeling progressing to a complete fracture
signs and symptoms of a tibial fracture
pain during weightbearing activity that slowly resolves with rest--progresses to severe pain with weightbearing activity that does not totally dissipate with rest
-night pain common
callus forms=positive X ray
bone scan most useful- look for increased uptake
US over site painful
pain with vibratory fork
treatment of tibial fractures
modified rest pool exercise cycling or other decreased weight bearing exercise
educate on appropriate training technique and foot wear
how long does the average tibial stress fracture take to heal?
what is exertional compartment syndrome?
raised pressure within a closed osteofacial compartment that compromises the circulation and function of tissues within the compartment
what are common causes of exertional compartment syndrome?
anti-coagulants worsen this
what are the 5 P's of exertional compartment syndrome?
hallmark findings of exertional compartment syndrome
persistent progressive pain beyond what would be expected from a strain or contusion
swollen, tense compartment
pain with muscular stretch
decrease muscle action
increase compartment pressure
if you have pressure of over 70 mmHg that suggests what?
lower extremity compartment syndrome
if pressure difference is 30 mmHg from DIASTOLIC BP that suggests what?
acute compartment syndrome
lateral surface of tibia
anterior intermuscular septum
most common compartment affected, 45% of syndromes
between anterior and posterior intermusclar septum
anterior surface of fibula
posterior intermuscular septum
40% deep, 5% superficial
muscles in anterior compartment and nerve that innervates them
extensor hallucis longus
extensor digitorum longus
deep fibular nerve innervates
muscles in the lateral compartment and the nerve that innervates them
superficial fibular nerve
muscles in the superficial posterior compartment and the nerve that innervates them
tibial nerve innervates them
muscles in the deep posterior compartment and the nerve that innervates them
flexor digitorum longus
flexor hallucis longus
tibal nerve innervates them
severe pain increases with activity and then decreases with rest (20min or so) describes what condition?
exertional compartment syndrome
no pain at rest: stress fractures will do what?
continue to hurt
pain with warm up: shin splints will often have ______ pain with warm up
exertional compartment syndrome is often confused with MTSS...how is MTSS different?
MTSS has tenderness to posterior medial tibia, not common in compartment syndrome
no pain with vibratory testing so what condition has a positive sign of this?
management of overuse injuries (acute)
anti-inflam (ice, iontophoresis)
RIE do not use compression
control of biomechanic faults
management of overuse injuries (once symptoms have evolved)
stretching of involved musculature
sub-max, multi-angle isometrics, progressed to isotonic
gradual return to activity
describe subtalar neutral
not pronated or supinated
point of positon that the head of the talus cannot be palpated or is felt to extend equally at the medial and lateral borders of the talonavicular joint
closed chain PRONATION of the subtalar joint
talus rotates down and in
IR of tibia
closed chain SUPINATION of the subtalar joint
talus rotates up and out
ER of tibia
7 criteria for normal foot function during latter part of the mid stance gait
- 1-metatarsals lie in the transverse plane
- 2-plantar surface of the calcaneus is in the transvere plain
- 3-subtalar joint is neutral
- 4-midtarsal joint is locked in its maximum position of pronation
- 5-subtalar joint, ankle joint and knee joint lie in transverse plane
- 6-significant rotational or torsional influences are present
- 7-distal 1/3 of the leg is in sagittal plane
during rearfoot varus what happens?
during forefoot varus what happens?
big toe in air, talus, navicular twisted, pronate late and over pronate
during rearfoot varus and forefoot varus what happens?
flat feet, look like they walk on medial malleolus
during forefoot valgus (rigid)/ rigid plantarflexed 1st ray what happens?
big toe down, really high arch, forces into supination
arch was NOT meant to be a weightbearing structure
generally post 40-60% of the deformity
rigid to semi-rigid
4-6d varus deformity norm
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