5 - LE Advances Ortho Issues (copy)

Iliotibial (IT) band syndrome

• IT band becomes thickened and irritated as it rubs along the lateral knee or the greater trochanter

• Patient complains of pain along the lateral leg. It is often accompanied by clicking and popping in the hip and knee

• Contributing factors: poor foot support, sudden increase in volume and intensity of training, running on unlevel surfaces

What type of interventions are used for IT band syndrome?

• Modalities for pain and inflammation

• Strengthening of hip musculature

• Soft-tissue mob

• Examination of running mechanics

• Education on activity mods (training parameters, change in surfaces)

What special test is used for IT band syndrome?

Ober test

Acetabular Labral Tears and Femoroacetabular Impingement Syndrome (FAI)

• Both pathologies present with anterior hip and groin pain and are most likely to occur in young athletes due to high velocity twisting and turning. They will have a gradual reduction in hip motion and strength

• Patients with labral tears will also complain of clicking, locking and/or giving way of the hip.

How are Acetabular Labral Tears and Femoroacetabular Impingement Syndrome treated?

• Typically with arthroscopic surgery

• Protocol:

  • Patient education to avoid painful positions. No hip flexion greater than 90 dg, no Ext past neutral and not ER beyond 20-25 dg

  • TTWB for several weeks. o Gradual progression for AAROM to AROM around weeks 4-5

  • Emphasis on lumbopelvic and hip strengthening and control to reduce shear forces during progressions.

  • Sport specific activities do not typically begin before week 12.

Patellofemoral Pain Syndrome

• Patients will present with retropatellar and peripatellar pain. Repetitive knee flexion and extension exercises tend to elicit pain. Common complaints is pain with descending steps

• Risk factors: Increased Q angle, hyperpronation, obesity

What interventions are used for patellofemoral pain syndrome?

• During acute phase, OKC exercises should be performed between 30 – 90 dg knee flexion and CKC exercises should be performed between 20 dg knee flexion to full extension

• Exercises should not increase pain

• Main focus of interventions should include strengthening of the quadriceps, hip external rotators, hip abductors and hip extensors. Stretching of the IT band

• Assessment of mechanics during activities causing pain (ex: squatting, landing, descending steps) should be performed. Check for excessive valgus motion and hip IR

• Muscle balance between the vastus lateralis and the VMO is essential. CKC exercises are key to VMO activation.

Meniscal Tears

• Location and size of the meniscal tear will greatly influence treatment options.

• Outer tears are more likely to heal that inner tears due to vascularization.

• Tears can occur due to acute injury, chronic degenerative changes or joint laxity.

• Patients present with tenderness on palpation of the joint line, limited motion at end range knee flexion and/or extension. Locking, clicking and giving way of the knee are common.

What special tests are used to diagnose for meniscal tears?

McMurray, Apley and Thessaly Tests

What interventions are used to treat meniscal tears?

• Modalities for pain, inflammation and weakness (NMES)

• AROM and stretching to regain motion. Strengthening of the quadriceps, hamstrings and gastrocnemius

• Progression to exercises improving dynamic control of the knee (unstable surfaces).

• Surgery is common.

Osgood-Schaltter’s disease

• Traction apophysitis affecting the tibial tuberosity • Common cause of adolescent anterior knee pain. Pain is described as a dull ache at the tibia tubercle that increases with activity and decreases with rests. Onset coincides with growth spurts. The length of the connective tension is not matching the bone growth

• Repetitive jumping and sprinting cause small avulsion fractures where the patellar tendon inserts.

How is Osgood-Schlatter’s disease treated?

• Athletic activities will need to be significantly limited until healing of the area occurs

• After healing occurs, PT treatment should focus on hamstring and quadriceps stretching and pain-free strengthening of the quadriceps.

Plantar fasciitis

One of the most common causes of foot pain that can occur in both active and sedentary populations

• Used to be seen as an inflammatory condition, but current information indicates it is more of a degenerative process.

• Patients complain of sharp pain at the proximal attachment on the plantar side of the calcaneus. Pain is typically worst with the first few steps

• Lack of ankle DF and excessive pronation are leading contributors.

What interventions are used to treated plantar fasciitis?

• Stretching and soft tissue mobilization of the gastrocnemius/soleus complex (triceps surae)

• Manual therapy to increase ankle DF 

• Night splints. Orthotic device or taping to support medial longitudinal arch

• Low-level LASER for pain reduction • Strengthening of foot instrinsics

• Patient education about footwear

• Appropriate support, rotate shoes often, avoid walking barefoot. Rocker bottom shoes may be recommended in some situations

• Patient education about weight reduction for patients who are obese

Posterior tibialis tendon dysfunction

• Inflammation and deterioration related to overpronation, weakness of foot intrinsics, hip extensor and hip abductors

• Patients present with pain and tenderness posterior to the medial malleolus and the medial longitudinal arch

• Patients report decreased balance and decreased ability to walk longer distances.

What interventions are used to treated posterior tibialis tendon dysfunction?

• Gastrocnemius and soleus stretching

• Eccentric strengthening of the posterior tibialis, anterior tibialis, and fibularis muscles

• Orthotics to support the medial longitudinal arch

• Strengthening and motor control activities for hip extensors, abductors and external rotators.

Tarsal Tunnel Syndrome

Entrapment neuropathy of the tibial nerve as it passes through the tunnel between the flexor retinaculum and the medial malleolus.

• Causes: Excessive pronation or abnormal structure (varicose vein, arthritic spur, cyst) in the area of the tarsal tunnel.

• Patient present with pain and/or altered sensation on the medial side of the ankle and the bottom of the foot. Symptoms increase with weightbearing

What interventions are used to treated tarsal tunnel syndrome?

• Rearfoot wedge orthotic to limit excessive pronation

• Tibial nerve glides

• Stretching of the gastrocnemius/soleus complex

• Strengthening of the tibialis posterior and the foot intrinsic.

Achilles tendinopathy

Inflammation or deterioration of the Achilles tendon

• Patients present with pain in the area, limited ankle DF. Prolonged standing, walking and running increase pain. Decreased ability to perform or tolerate single leg heel raises

• Cause: Decreased ankle dorsiflexion ROM, abnormal foot mechanics, gastrocsoleus weakness, excessive running or improper alterations in training patterns, obesity

What interventions are used to treat Achilles tendinopathy?

• Iontophoresis or low-level LASER for pain

• Stretching and soft tissue mobilization to the gastrocnemius/soleus

• Joint mobilization to increase ankle DF.

• Eccentric strengthening of the ankle PF.

What special tests are used to diagnose Achilles tendinopathy?

Thompson's test (if ruptured)