Unit 1A - LE Ortho

Hip Joint Hypomobility: Non-operative Management

• Etiology: Common causes include Osteoarthritis (OA), Rheumatoid Arthritis (RA), and aseptic necrosis.

• Common Impairments:

  • Pain located in the groin, along the anterior thigh, and the knee.

  • Stiffness occurring after periods of rest.

  • Limited motion with a firm capsular end-feel.

    • The initial limitation is typically in Internal Rotation (IR).

    • In advanced stages, the hip is fixed in adduction, with no IR or extension past neutral ($0^{\circ}$), and only approximately $90^{\circ}$ of flexion.

  • Asymmetry in Weight-Bearing (WB), antalgic gait, and decreased step length/stance duration on the affected side.

  • Increased mechanical forces on the lumbar spine due to limited hip extension, often leading to Low Back Pain (LBP).

  • Lack of full knee extension during standing or gait, secondary to hip extension limitations.

  • Impaired balance and postural control.

• Activity Limitations:

  • Early Stages:

    • Progressive pain with WB and walking

    • Increased pain at the end of the day following repetitive lower extremity (LE) activities.

      • Pain may interfere with work or routine activities requiring WB.

    • Progressive Degeneration:

      • Difficulty rising from a chair, walking long distances or on uneven surfaces, negotiating stairs, and squatting.

      • Limitations extend to bathing, toileting, and dressing (e.g., putting on pants or socks).

• Phases of Rehabilitation:

  • Protection Phase

    • Focuses on

      • Patient education

      • Decreasing pain at rest and with WB activities

      • Decreasing the effects of stiffness

      • Maintaining available Range of Motion (ROM).

  • Controlled Motion and Return to Function Phases

    • Focuses on

      • Progressively increasing joint accessory motion and soft tissue mobility

      • Improving joint tracking and pain-free motion

      • Improving muscle performance in supporting muscles, balance, and aerobic capacity.

Nonarthritic Hip Pain and Piriformis Syndrome

• Nonarthritic Hip Pain Etiology:

  • Extra-articular:

    • Musculotendinous (MT)

      • Caused by overuse or trauma to MT units or bursae.

      • This results from excess strain during muscle contraction or repetitive use without rest.

  • Intra-articular:

    • Femoroarticular Impingement (FAI) syndrome.

• Common Impairments (Nonarthritic):

  • Pain, gait deviations, imbalance in muscle flexibility and neuromuscular control, and decreased muscular endurance.

• Phases of Management for Nonarthritic Pain:

  • Protection Phase:

    • Patient education

    • Controlling inflammation

    • Promoting healing

    • Developing support in related areas.

  • Controlled Motion Phase:

    • Remodeling muscle/tendon scars via cross-fiber massage

    • Exercises to balance hip muscle length and strength

    • Developing cardiopulmonary and muscular endurance

  • Return to Function Phase:

    • Progression of closed-chain and functional training, specificity training for return to work/sport, and plyometric training.

• Piriformis Syndrome:

  • Mechanism:

    • Decreased hip abductor and extensor weakness

      • Results in hip adduction and internal rotation during functional activities.

      • Can cause the piriformis to overuse, leading to secondary sciatic nerve compression.

    • Management:

      • Strengthening and functional retraining of the gluteus maximus and medius

        • Corrects faulty movement patterns and alleviate symptoms.

Hip Fracture Post-Operative Management (ORIF)

• Prevalence: Most prevalent in the elderly population. In the US, the majority of patients are over $75$ years old, and $75\%$ are women.

• Acute Signs of Fracture: Groin or hip pain, pain with active (AROM) or passive (PROM) hip motion, and pain with WB. The affected LE typically appears shorter and is positioned in external rotation (ER).

• Non-operative Management: Sometimes the only option for specific patients; involves bedrest and traction until healing occurs.

• ORIF Weight-Bearing: Status varies from Non-Weight-Bearing (NWB) to Toe-Touch Weight-Bearing (TTWB) to Weight-Bearing As Tolerated (WBAT).

• Exercise Progression:     * Maximum Protection Phase: Follows protocol similar to Total Hip Arthroplasty (THA).     * Cautions: Straight Leg Raises (SLR) should be avoided or used cautiously as they have a long lever arm that creates high rotational loads on the fracture site. Abductor and adductor contractions can place significant stress on subtrochanteric fractures.     * Moderate and Minimum Protection Phases: Focus on strengthening, functional control, and increasing the level of functional activities.

Pediatric Hip Conditions: Legg-Calve-Perthes Disease

• Definition: A noninflammatory, self-limiting syndrome affecting children between $2$ and $12$ years of age.

• Pathology: The femoral head becomes flattened at the weight-bearing surface due to avascular necrosis. It can heal with or without treatment, but may lead to incongruous joint surfaces and advanced Degenerative Joint Disease (DJD).

• Management Goals:     * Maximum Protection: Reduce pain and dysfunction. Use traction to reduce load and restore abduction motion.     * Surgical/Orthotic Goal: Keep the femoral head seated in the acetabulum by maintaining abduction.     * Interventions: Abduction orthosis, ROM exercises for knee flexion/extension, hip internal rotation (IR), hip abduction, and hip extension.

Knee Joint Hypomobility: Non-operative Management

• Etiology: Osteoarthritis (OA), Rheumatoid Arthritis (RA), or acute trauma.

• Impairments:     * Generally, there is a greater loss of flexion than extension.     * Joint effusion often forces the knee into a position of approximately $25^{\circ}$ of flexion for comfort.     * Pain occurs during motion, WB, and gait, interfering with Activities of Daily Living (ADL).     * Difficulty controlling WB during tasks involving flexion: sit-to-stand, stairs, squatting, and rising from the floor.

• Phases of Management:     * Protection Phase: Control pain, protect the joint, maintain mobility via PROM/AROM, Grade $I$ or $II$ joint distraction, and anterior/posterior (A/P) glides. Prevent patellar adhesions using quadriceps sets specifically for patellar mobility during immobilization.     * Controlled Motion and Return to Function: Continued use of Assistive Devices (AD) and elevated seats to reduce mechanical stress. Focus on increasing joint play/ROM, muscle performance, and cardiopulmonary endurance.

Patellofemoral Dysfunction: Non-operative Management

• Patellofemoral Pain Syndrome (PFPS) Categories:     1. Local Factors: Related to the knee joint itself.     2. Distal Factors: Related to the foot (e.g., flexible pronated foot).     3. Proximal Factors: Related to the hip and pelvis (e.g., weak hip abductors, ER, or extensors).

• Common Impairments: Pain, crepitus, altered alignment, weak quadriceps, and decreased flexibility in the Tensor Fasciae Latae (TFL), hamstrings, quadriceps, and gastrocnemius/soleus. Decreased medial gliding or tipping of the patella is common.

• Activity Limitations: Pain with ADLs and Instrumental ADLs (IADLs). Inability to maintain a prolonged flexed knee position, referred to as the "Theater Sign."

• Management:     * Protection Phase: Muscle setting in pain-free positions, hip strengthening in NWB positions, and foot orthoses if applicable.     * Controlled Motion/Return to Function: Flexibility exercises, patellar mobilizations, taping, and neuromuscular control. Caution: Progressing beyond $60^{\circ}$ of flexion increases compressive loads significantly.

Knee Ligament Injuries: Management and Rehabilitation

• Ligaments: Anterior Cruciate Ligament (ACL), Posterior Cruciate Ligament (PCL), Medial Collateral Ligament (MCL), Long Collateral Ligament (LCL).

• Signs of Injury: Immediate swelling if blood vessels are torn; otherwise, swelling appears several hours later. The knee may give way during WB. Pain on testing suggests an incomplete tear; instability suggests a complete tear.

• Anterior Cruciate Ligament (ACL):     * Anatomy: Originates anterior to the tibial eminence and moves postero-laterally to insert on the inner part of the lateral femoral condyle.     * Function: Prevents hyperextension and rotational movement.     * Demographics: Females tear ACLs more frequently than males.     * Tests: Lachman test, Anterior drawer test.

• Medial Collateral Ligament (MCL):     * Cause: Valgus force applied to the knee with the foot fixed.     * Laxity Grading: Grades $1$, $2$, or $3$ based on valgus stress testing.

• Posterior Cruciate Ligament (PCL):     * Function: Restricts posterior tibial translation.     * Cause: Trauma, motor vehicle accidents (MVA), or hyperextension (often concurrent with ACL injury).     * Tests: Posterior drawer test, Godfrey posterior tibial sag test, Active quadriceps drawer test.

Non-operative Ligament Rehabilitation (Table 21.4 Overview)

• Weeks 1-3 (Max Protection): Goals are to protect healing tissue, prevent reflex inhibition, and decrease effusion/pain. Interventions: PRICE, protective bracing, crutches, PROM/A-AROM, patellar mobilization (Grades $I$/$II$), and muscle setting.

• Weeks 3-6 (Moderate Protection): Goals are full pain-free ROM, restoring strength, and normalizing gait. Interventions: PRE, closed-chain strengthening, LE flexibility, and aerobic/endurance training (bike, pool).

• Weeks 8+ (Minimum Protection): Goals are increasing power, endurance, and neuromuscular control. Interventions: Advance PRE and closed-chain exercises, perturbation training, and skill-specific drills.

Post-Operative ACL Reconstruction (Rehab and Precautions)

• Phases (Table 21.5):     * Max Protection (Day 1 - Week 4): ROM goal is $0-110^{\circ}$. Gait training with crutches ($75\%$ WB to WBAT). Interventions include ankle pumps, SLRs, and multiple-angle isometrics.     * Moderate Protection (Weeks 4-10): Goals are full pain-free ROM and $4/5$ MMT. Interventions include single-leg balance, BOSU, and stationary cycle.     * Min Protection (Weeks 11-24): ROM is full; goal is $75\%$ strength of the uninvolved side. Interventions include plyometrics, agility drills, and return-to-run progression.

• Exercise Precautions (Box 21.10):     * Progress more gradually for hamstring tendon grafts vs. bone-patellar tendon-bone grafts.     * Closed-Chain: Avoid quadriceps strengthening between $60-90^{\circ}$ of flexion. Ensure knees do not move anterior to toes during squats to minimize tibial shear.     * Open-Chain: Avoid resisted knee extension (short-arc quads) between $45^{\circ}$ and full extension for at least $6-12$ weeks. Do not apply resistance to the distal tibia during quad strengthening.

• Return to Activity Criteria: No pain/effusion, full active ROM, quad strength $85-90\%$ of contralateral side, hamstring strength $100\%$, and H/Q ratio $> 70\%$. Must have a negative pivot shift and $< 3\,mm$ difference on arthrometer.

Post-Operative PCL Reconstruction

• Ambulation Criteria (Box 21.12): No pain/effusion, full active extension (no lag) on SLR, flexion $0-90^{\circ}$, and quad strength $70\%$ or $4/5$.

• Precautions (Box 21.13):     * Limit knee flexion repetitions to minimize graft abrasion.     * Reverse gravity for flexion: Perform seated to let gravity flex the knee while hamstrings remain inactive.     * During squats, avoid excessive trunk flexion (activates hamstrings) and avoid flexion past $60-70^{\circ}$.     * Postpone prone/standing active knee flexion (hamstring curls) for $6-12$ weeks; postpone resistance machines for $5-6$ months.     * Avoid downhill inclines and rapid deceleration with planted feet.

Meniscus Injuries: Management and Repairs

• Mechanism: Femur-on-tibia rotation during WB with a fixed foot (e.g., getting out of a car, sudden deceleration with change of direction).

• Tests: Apley’s compression, McMurray, Steinman, and Thessaly tests.

• Non-operative: Presents with knee locking or catching. A "springy" end feel is noted with passive extension.

• Post-Op Precautions (Box 21.15):     * Progress more gradually for central zone repairs vs. peripheral zone repairs.     * Report any "clicking" sensation immediately.     * Bike seat height: Keep high to limit flexion.     * WB Squats/Lunges: No flexion beyond $45^{\circ}$ for $4$ weeks, or beyond $60-70^{\circ}$ for $8$ weeks.     * Leg Press: Postpone until week $8$ (set range $0-60^{\circ}$).     * Hamstring curls: Postpone until week $8$.     * Deep squats/lunges/pivoting: Avoid for $4-6$ months.     * Running: Avoid for $5-6$ months.

MPFL Repair or Reconstruction (Table 21.3)

• Max Protection (Weeks 1-4): Focus on pain/edema control. Knee ROM goal: $0-90^{\circ}$ by end of week $4$. Interventions include superior/inferior patellar mobilization (Grades $I$/$II$) and NMES over the VMO.

• Moderate Protection (Weeks 4-8): Gain full active extension (no lag) by week $6$. ROM goals: $120^{\circ}$ by week $6$ and $135^{\circ}$ by week $8$. Interventions include proprioceptive training and stationary cycling.

• Minimum Protection (Weeks 8-12+): Target is $75\%$ muscle strength. Includes agility drills and walk/jog progression starting at week $10$.

Foot and Ankle Arthrodesis (Fusion)

• Indications: Debilitating pain during WB, instability, deformity, or failed total ankle arthroplasty.

• Contraindications: Vascular impairment or infection. Relative: Uncontrolled Diabetes Mellitus (DM) or tobacco use.

• Common Types:     * Tibiotalar: Fuses talus to tibia at $0^{\circ}$ dorsiflexion and $5-10^{\circ}$ ER. Provides stability but alters gait speed/biomechanics.     * Hindfoot: Eliminates pronation/supination. Types: Talocalcaneal, talonavicular, or Triple (talocalcaneal, talonavicular, and calcaneocuboid).     * First Toe: Provides pain relief; allows for push-off even if toe does not touch ground.     * IP Joints: Typically for hammer toes ($2-3$).

• Complications: Nonunion (most common), nerve damage/neuromas, and delayed wound healing.

• Post-Op Timeline: NWB cast for $4-8$ weeks. Walking boot for another $6-8$ weeks. Full Weight-Bearing (FWB) attained by $12-16$ weeks.

Ankle and Foot Pain Conditions

• Plantar Fasciitis: Pain at the medial tubercle of the calcaneus. Pain is worst after rest (initial steps) and returns with prolonged activity. Causes: High BMI, poor footwear, or abnormal arch. Management includes intrinsic muscle strengthening (towel gathering, picking up marbles).

• Bursitis (Hip/Knee):     * Trochanteric (Hip): Lateral hip pain, discomfort standing "hipshot."     * Psoas: Groin/anterior thigh pain.     * Ischiogluteal (Taylor or Weaver’s Bottom): Pain when sitting.     * Prepatellar (Knee): "Housemaid’s knee."     * Infrapatellar: "Parson’s knee."

• Osgood-Schlatter Disease: Localized pain/edema at the tibial tuberosity (patellar tendon insertion). Manage with knee immobilizer and gentle stretching; progress to cycling/swimming.

Ankle Sprains and Achilles Rupture

• Ankle Inversion Sprains: Mechanism is plantar flexion, inversion, and adduction. Grades: $1^{st}$ (single ligament), $2^{nd}$ (double), $3^{rd}$ (three lateral ligaments torn).

• Deltoid Ligament Sprain: Rare ($3-5\%$ of sprains); usually involves fracture.

• Achilles Tendon Rupture:     * Mechanism: Sudden eccentric-concentric contraction. $50\%$ involve degenerative changes.     * Sign: Visible gap in distal third; positive Thompson test.     * Rehab (Early Case): WBAT in orthosis (plantarflexion or neutral) by weeks $1-2$. Wean to shoes with bilateral heel lifts ($1-1.5\,cm$) at weeks $6-8$. Discontinue lifts by week $10$.     * Precautions (Box 22.7): No unilateral WB until pain-free FWB is possible. Limit dorsiflexion to $10^{\circ}$ beyond neutral until week $8$. Full symmetry by week $12$. Unilateral heel raises postponed until weeks $10-12$.

Other Musculoskeletal and Neurological Conditions

• Anterior Compartment Syndrome: Increased pressure occluding blood flow. Signs: Tightness over tibialis anterior, shiny skin, paresthesia.

• Myositis Ossificans: Calcification in muscle due to untreated strain/contusion. Presents as a hard lump.

• Osteochondritis Dissecans: Subchondral bone fragment breaks away due to blood flow issues; causes joint popping.

• Osteogenesis Imperfecta: Avoid rotational forces and long lever arms during exercise.

• Talipes Equinovarus (Clubfoot): Adduction of forefoot, varus hindfoot, equinus ankle. Ponseti method involves serial casting ($3-6$ long-leg casts).

• Tarsal Tunnel Syndrome: Tibial nerve compression on the medial ankle. Symptoms: Paresthesia/numbness (mistaken for Plantar Fasciitis), antalgic gait, positive Tinel’s sign, and trophic skin changes.