602 Graduate AT Test #2

Evaluation Process

H istory

O bservation

P alpation

S pecial tests

Skills Needed to Solve Problems

Ability to read

Speak the language

Accept the feedback

Understanding the Problem

• what is the primary tissue affected? How does it heal? What factors affect healing?

• What are the secondary tissues affected? Is it necessary?

• What differential diagnoses are possible?

• What are the consequences of a misdiagnosis? Do I need to refer?

Devise and Carry Out a Plan

• immediate management and treatment

• Rehabilitation

• Prevention of re-injury

Types of Therapeutic Modalities

Thermal

Electric

Mechanical

Cryotherapy - how cold and how deep?

Depends on

Cold medium

Length of exposure

Conductivity of area being cooled

Physiological effects of cold - Circulatory Theory

Decreased tissue temp → vasoconstriction and decreased capillary permeability → decreased fluid entering the tissues → prevented swelling

Physiological Effects of cold - metabolism theory

Limit secondary injury

Secondary Injury

• decreased oxygen = cell death (hypoxia)

• Decreased blood supply = decreased oxygen = cell death (ischemia)

• Hypoxia/ischemia causes dead cells to release enzymes from the lysosomes which break down the cell walls of neighboring cells

• Damaged cell walls cannot maintain an osmotic balance = cellular edema (bursting)

• Results in increased H+ (acidosis) in the exudate = increased injury to surrounding cells

• Cycle results in injury to surrounding healthy cells (secondary injury)

Secondary Injury: Cryotherapy

Cold decreases metabolic demands of the cell = cell lives longer with less oxygen

This results in the cell remaining intact = less exudates and edema

Pressures

Capillary Oncotic Pressure

Tissue Hydrostatic Pressure

Capillary Hydrostatic Pressure

Tissue Oncotic Pressure

Physiological Effects of Cold

Decreased permeability

• Decreased protein loss into tissue

• Decreased tissue Oncotic pressure

Decreased spasm

• could improve ability to stretch

Decreased pain

• decreases excitability of free nerve endings

Decreased muscle inhibition

Effects of Heat

• increased blood flow (vasodilation)

  • Decreased pain from ischemia

• Increased extensibility of tissue

• Decreased joint stiffness

Electrotherapy

Electricity affects tissues by

• mechanical effects

• Chemical effects

• Magnetic effects

• Thermal effects

Motions of the Ankle

Pronation

• dorsiflexion, eversion, external rotation (flexible)

Supination

• plantar flexion, inversion, internal rotation (rigid & stable)

Heel Bruise

MOI - impact

S&S - pain on heel strike or weight bearing

Heavily vascularized and innervated

Easy to bruise, shows @ fatty layer

Could be mistaken for plantar fascia

Can last weeks/months if not treated

Hurt it and then NOTHING for a few days (itis)

Longitudinal Arch Injury

MOI: High impact with hard surface usually in early season

S&S - pain during running and jumping

Plantar Fasciitis

MOI: repeated microtrauma during loading

S&S: onset of pain usually just anteromedial to calcaneus, pain most intense on 1st step in AM

Midfoot sprain (Lis Franc)

• 1st tarsometatarsal joint (between 1st and 2nd metatarsal bases and 1st cuneiform)

• Mech - Load and rotate w/o support - fast

• For surgical fix = how much gap. Fixed with screws

Great Toe Sprain (Turf toe)

• MOI - hyperextension from a non-yielding source

• S&S - pain at metatarsal phalageal joint, exacerbated during push off

• Problem @ volar plate, fibrocartilage in plantar surface

• Management: steel shanks and REST

Jones Fracture (5th metatarsal)

MOI - avulsion (pulled on by fibularis brevis) during sudden inversion, stress from tape or shoe

S&S - sever pain over 5th metatarsal head, pain during inversion or resisted eversion

Metatarsal Stress Fx (marching Fx)

Usually 2nd/3rd/4th metatarsal shaft

MOI: long distance runner changing surfaces combined with foot structure problem

• tibialis posterior eccentrically controls pronation

Stress Fracture Continum

Bone gets irritated (bad shoes & no rest) → stress response → stress fracture

Pes Cavus with Clawfoot

Flexion at PIP joint

MOI: Genetic, associated with excessive supination

S&S: plantar pain, callus formation, Achilles tightness

Manage: Achilles stretching (increases flexibility of arch) and orthotic

Concave vs Convex

Concave = shortened and stronger

Convex = lengthened and weaker

Hallux Valgus (Bunion

MOI: structural Valgus deformity of 1st metatarsophalageal joint

S&S: excessive callus formation, swelling and hardening of bursae, tenderness

• caused by pointy shoes

• Can cause neuroma between metatarsal

Prevention: foot intrinsic exercises, toe separator, wide toe box shoes

Interdigital Neuroma (Morton’s neuroma)

MOI: compression of nerve between metatarsal heads, fallen metatarsal arch

S&S: burning, paresthesia and intermittent pain

Nerves need space of NO stress to regenerate

Great use for tear drop pad

Exostoses (Heel spur)

MOI: often associated with plantar fasciitis (gets pulled on)

S&S: point pain at base of calcaneous

Tx: stops whats pulling on it, prevent dorsiflexion, likely to come back when shaved

Bone Pain

Bones are a neural, periosteum is what hurts when bone is injured

Retrocalcaneal Bursitis

MOI: chronic condition caused by rubbing the heel against a hard surface (shoe)

S&S: local pain & swelling, burning or itching.

Bursa

= synovial with endothelial tissue

Gets less slippery and provides less space, can lead to hardening

Sever’s Disease (apophysitis)

MOI: traction (over time) to the calcaneal tuberosity (lays down the bone)

S&S: pain during vigorous activity, subsides thereafter

Starts in puberty, rest while young to have better results later

Intrinsic & Extrinsic Muscles

Intrinsic = inside a joint LOCAL STABILIZERS

Extrinsic = over multiple joint GLOBAL STABILIZERS

Joints of Foot/Ankle

Subtalar joint = inversion/eversion

Talocrural = plantar/dorsi flexion

Ankle uses foot to help stabilize

Why medial ankle sprains are less common?

MOI = less common to stress medial side

Distal lateral malleolus = acts as a block - more likely to be fractured

Strength of deltoid ligament = so strong !!!

** Medial injury has bigger consequences. Foot gets loaded differently

Grades of Ankle Sprains

1st = microtrauma, some pain, minimal swelling, no loss of function

2nd = incomplete microtrauma, pain, moderate loss of function, swelling, slight instability

3rd = complete microtrauma, pain, loss of function, severe instability

Lateral Ankle Sprain

MOI: inversion (often combined with plantar flexion)

S&S: depends on grade, pain in sinus

Most common joint injury, most common seen injury in ER, most athletes have chronic problems for 2 years after injury

NOT BENIGN

Other effects of lateral ankle sprain

Inhibits dorsiflexion

• most stable ankle position

• Affects patterns @ knee & hip

Medial/Eversion Ankle Sprain

5-10% of ankle sprains

MOI: forced eversion - foot pronation more susceptible

S&S: pain on weight bearing, may result in some pronation, more navicular drop

Usually comes with trauma

TX: boot w/ medial arch support

Syndesmotic/High Sprain

MOI: forced dorsiflexion and external rotation

S&S: severe pain and loss of function especially during external rotation and/or dorsiflexion

Hard because repeat MOI when you walk

Anterior tibiafibular tears ALSO

Ankle Fx

• Tibial (stress fractures)

• Fibular

• Avulsion (ex. Jones)

  • Muscular

  • Ligamentous

• Calcaneal (severs

• BIGGEST CONCERN IS TALAR DOME

Achilles Tendon Strain

MOI: sudden dorsiflexion (forceful)

S&S - sudden pain on mechanism, extreme weakness

Adapts to load

More worried about chronic inflammation

Achilles Tendonitis

MOI: repetitive stress, gradual onset

S&S: pain with plantar flexion, decreased dorsiflexion ROM, stiffness, crepitus

Inflamed = decreased blood supply, synovial is INFLAMED

Achilles Tendon Rupture

MOI: sudden forceful plantar flexion from a dorsiflexed position, secondary to chronic problems

S&S: someone “kicked” or “shot” me, sudden pain, can’t plantar flex, step deformity

Peroneal Tendon Subluxation

MOI: planting and forceful lateral movement

S&S: snapping sensation over lateral malleolus during activity, will progress to include tendonitis

Retinaculum is GONE

Dynamic Stability

Magnitude, timing, pattern

Patellar Cartilage

Does have innervation/is sensitive

Patella femoral syndrome

MCL

Has 3 bands, can withstand Valgus force 3 ways

Rotary Stability

Stability in all 3 planes

Menisci

Medial is tethered, gets injured more because it is LESS mobile

Lateral is more mobile and does not get injured as often

Knee Ligamentous Injuries

1st = microtrauma, some pain, minimal swelling, no loss of function

2nd = incomplete microtrauma, pain, moderate loss of function, swelling, slight instability

3rd = complete macro trauma, pain, loss of function, severe instability

MCL Injury

Not benign

MOI: Valgus force, often in a slightly flexed position, sometimes associate3d with cruciate ligament and/or meniscus damage

S&S: palpable medial pain, pain w/ Valgus force, extra capsular swelling

• could wreaking meniscus

• Weakens rotary stability

• Patellar tracking problems

• Consequential muscle inhibition (adductors/quad/glute med/etc.)

LCL Injury

MOI: Varus force (less common)

S&S: palpable lateral pain, extra capsular swelling, laxity with some flexion

** check for common fibular nerve

Has lots of innervation and could restful in drop foot

PCL Injury

MOI: force to tibia when knee is flexed, landing on tibial tuberosity w/ flexed knee

S&S: “pop” to the back of the knee, minor swelling in popliteal fossa

ACL Injury

MOI (contact): lower leg is externally rotated, foot is fixed, and a blow to the knee (impact on front w/ hyperextension)

MOI (non-contact): deceleration, stop, cut (change direction [extension, external rotation, valgus]) - position of NO return MORE COMMON

S&S: sometimes “pop”, feeling of giving away, intracapsular swelling, pivot shift

Could catch femoral condyle, bruise it, and affects articular cartilage

Mechanical Lesions

MOI: weight bearing, combined w/ rotary force, squatting, cutting

S&S: gradual effusion, joint line point tenderness, locking or giving away, pain on squatting

TX: if person has time leave it alone and let it rest

• consider vascular/neural supply

Knee Joint Plica

• Plica are a synovial fold (from embryo leftover)

MOI: medial fold will sometimes become thick and nonpliable - from blunt force or twisting mechanism

S&S: snapping during knee ROM, pain ascending and descending stairs

Osteochondritis dissecans

Happens in 11-16 y/o

Detachment of dead bone w/ articular cartilage

MOI: degeneration associated with injury or genetics, usually the lateral portion of the medial femoral condyle

S&S: intracapsular swelling, aching, recurrent swelling, catching or locking, quad atrophy

Manage: in youth, immobilization to allow for healing. Need to be non-weight bearing if caught early, if not JOINT REPLACEMENT

Infrapatellar Fat Pad Injury

MOI: becomes the wedged between the patella and tibia

S&S: swelling, weakness, anterior knee pain, stiffness

Prepatellar Bursitis

MOI: contact to the anterior portion of the knee

S&S: swelling directly over the patella, itching or burning sensation

Patellar Subluxation/Dislocation

Almost always lateral

Predispositions: wide pelvis, genu Valgus, shallow femoral grooves, flat femoral condyle, shallow femoral grooves, high riding patella, weak and lax VMO, foot pronation

Patellafemoral stress syndrome

MOI: lateral deviation of the patella tracking in the femoral groove (intrinsic & extrinsic risk factors)

S&S: swelling, lateral patellar tenderness, dull ache under patella, pain with compression of the patella

• could lead to chondromalacia patella

Osgood Schlatter (Apophysitis)

MOI: tension to the tibial tuberosity during growth (avulsion)

S&S: abnormally large tibial tuberosity, pain during kneeling, running and jumping

Patellar Tendonitis

MOI: forceful repetitive knee extension during running and jumping

S&S: pain after activity, pain during and after activity, pain during and prolonged after w/ crepitus

IT band friction syndrome

MOI: genu varum, tight IT band

S&S: referred pain to the lateral and anterior portion of the knee