Untitled Quiz

Lower Quadrant Conditions

• Readings: Andrews, Harrelson, Wilk. Physical Rehabilitation of the Injured Athlete, 4th Ed, Saunders 2012

Objectives

• Objective 1: Injury Assessment

  • Injury assessment is the act of assessing, appraising, and evaluating.
  • It also involves classifying people or things.

• Objective 2: Injuries of the Lower Quadrant

  • This objective focuses on examining conditions of the hip.

Mechanisms of Injury

• Strain
• Rupture
• Fracture
• Avulsion Fracture
• Ligament Sprains
• Overuse
• Underuse

Clinical Assessment

• Clinical Assessment (Starts at clinic)
  • Environment: Controlled
  • Emergency cleared
  • Decisions to make: Further medical attention, tests, orthopaedic consult, orthotics, or bracing.
• Clinical Assessment (Needs of rehabilitation)
  • Determine athlete's goals
  • Determine therapists goals
  • Return athlete to daily living activities and competition.
• Clinical Assessment (Components):
  • History
  • Observations (includes reflexes, sensation, etc.)
  • Rule outs
  • Functional assessment
  • Special tests
  • Palpation
• Documentation Format: SOAP

Field Assessment

• Field Assessment:
  • Observe mechanism of injury.
  • Environment: Uncontrolled
  • May need to assess within rules of the game
  • Primary Survey (ABC)
  • Secondary Survey
  • Components: History (H), Observations (O), Palpations (P), Stress/Special tests (S)

HOPS Assessment

• History:

  • Primary complaint
  • Mechanism of injury (if not seen)
  • Areas & nature of the pain
  • Functional ability ("I can't feel my fingers")
  • Symptoms associated with injury
  • Previous history of injury
  • Ask relevant, NON-LEADING questions (open-ended), listen attentively
  • Allow athlete to describe injury

• Observations:

  • Survey entire injured area
  • Look for obvious signs of injury
  • Note general body alignment
  • Observe functional abilities
  • Inspect injured area
  • Be alert for signs of trauma
  • Watch athlete's face and/or eyes
  • Compare bilaterally

• Palpation:

  • Avoid unnecessary pain.
  • Ensure injured area is relaxed
  • Demonstrate care.
  • Encourage cooperation.
  • Start away from the site of injury, moving toward the injured area.

• Palpation Key Information:

  • Areas/pain/tenderness
  • Deformity
  • Distal circulation, skin temperature, muscle spasm
  • Swelling
  • Crepitus
  • Sensory function

• HOPS Assessment Palpation (Additional Info):

  • What do you feel? (crepitus, bogginess, etc.)

• HOPS Assessment Stress Testing:

  • Determine nature of injury
  • AROM
  • PROM
  • RROM
  • Specials

Stress Testing

• Begin testing carefully, slowly and gently.
  • First assess the uninjured structures bilaterally.
  • Increase testing intensity as tolerated.
  • Explain procedure to the athlete, promote trust and cooperation.
• Always Begin with Functional Testing.
  • Active, passive and resisted ROM.
• Active Testing: Take note of quality and quantity of movement in the pain-free range; address most painful ranges.
• Passive Testing: Therapist moves the joint through its full, pain-free range of motion.
• Resisted Testing: Strong, static isometric voluntary muscle contraction with joint in neutral position, athlete meets resistance.
  • Evaluate on a 0-5 grading scale; consider possible attributing factors (Upper motor neuron lesion, Injury to peripheral nerve, Pathology at NMJ, Injury to muscle itself).

Hips

• Common Hip Injuries
  • Hip Flexor Strains
  • Adductor Strains
  • Piriformis Syndrome
  • Osteoarthritis of the Hip
  • Labral Tears
  • Femoroacetabular Impingement

Knee

• Knee Movements: flexion (range 0–135°), extension (0–15°), medial rotation (20–30°), lateral rotation (30–40°).

• MCL Sprain

  • Symptoms: based on severity, pain, instability, swelling, discoloration, disability.
  • Treatment: acute stages-immobilization (Zimmer splint, crutches, PIER), healing stages-CKC exercises (as soon as weight-bearing, NMES with CKC squats @ 30°), strengthen adductors to help re-enforce joint stability.
  • Grades vary from small tear showing stability (Grade 1) to complete tear and instability (Grade 3).

• LCL Sprain

  • Symptoms: sharp lateral pain, subtle instability, non impressive swelling
  • Treatment: acute immobilization; healing stages-CKC exercises, NMES with CKC squats @ 30°, strengthen adductors to help re-enforce joint stability.

• ACL Sprain

  • Symptoms: pop/snap, pain, effusion/hemarthrosis (often immediate), patient c/o instability, tender anterior tibial plateau, limited ROM.
  • Treatment: PIER, immobilize knee, crutches, referral to orthopaedic surgeon for further management, hamstring strengthening is key. Post-op treatment; bracing for RTS recommended for first year post-op

• PCL Sprain

  • Symptoms vary.
  • Treatment: assess posterior instability, acute treatment as per ACL, re-establish quad strength/function (60% body weight goal), proprioception exercise.

• Meniscus Tears

  • Symptoms: knee swelling (synovial irritation), occasional “giving way”, pain on same side as injury (joint line), Recurrent swelling with use, positive McMurray’s test, recurrent “clicking”, quads wasting, unable to perform bilateral deep squat, locking.
  • Treatment (immediate): Do NOT force a locked knee into extension, PIER, NWB, refer to consult; Treatment (surgical): Arthroscopy, day surgery (patient walks out of hospital), 10-14 days post-op possible to RTP, treat for swelling and strengthen around joint.

• Patellofemoral Pain Syndrome (PFPS):

  • Causes: Patellar malalignment, congenital abnormalities, wide hips/Q-angle, knee malalignment (bowlegged), muscle imbalances (tight lateral structures, weak medially)
  • Treatment: depends on the cause, strengthen weakness, stretch tightness, hip strengthening, foot alignment.

• True Chondromalacia Patella:

  • Treatment: Find the cause, treat the cause, increase patellar mobility, restore quads synchronicity, restore knee mechanics, strengthen quads, stretch lateral compartment, correct foot biomechanics, and educate.

• Patellar Tendonitis (“Jumper's Knee”):

  • Causes: repetitive or eccentric knee extension activities (running, jumping) location: between inferior pole of patella and tibial tubercle
  • Stages of Pain: 1) After activity, 2) During and after activity, 3) During and after activity (performance affected)
  • Treatment: PIER immediately after activity, rehab (massage, stretch), tape, brace.

• Osgood-Schlatter Disease:

  • Cause: Apophysitis of tibial tubercle, traumatic fracture. excessive pull of patellar tendon on tibial tuberosity before bony closure.
  • Symptoms: Pain on direct pressure (kneeling), pain on active use (climbing stairs, running, jumping), pain extreme at end range of extension; Enlarged tibial tubercle, age 10-15 males, 8-13 females, bilateral (25-30% of the time)
  • Treatment: Time, stretching, gradual strengthening, straps.

• Bursitis Around the Knee:

  • Types: Suprapatellar, prepatellar, superficial infrapatellar, deep infrapatellar, and pes anserine.
  • General Mechanisms: Direct Blow (repeated or single), friction, poor biomechanics.
  • Treatment: PIER, rest (use may irritate condition), Protective padding (donut), Stretch structures over top of bursa, Open space around bursa.

• Ilio Tibial Band Friction Syndrome:

  • Etiology: Lean individuals, varus knee(malalignment), precipitated by contusion, continuous running, training errors, banked surfaces, running downhill, increased training.
  • Signs/Symptoms: ↑ pain as activity time ↑, tender epicondyle (2-3 cm above lateral joint line), Crepitus with flex/extn; Stair climbing aggravates; Resisted knee flexion=no pain.
  • Treatment: PIER, address mechanics, good warm up/stretches, gradual RTP, stop if pain returns

• Strains of the Lower Leg:

  • Tibialis Anterior: improper footwear, down hill running, poor warm-up, poor arch support, anterior compartment syndrome

  • Peroneal Strain: Usually secondary; inversion ankle sprain, need to be strengthened in inversion sprain rehab

  • Gastrocnemius Strain: caution necessary; rupture, chronic irritation, poor warm-up stretching, running uphill/poor footwear. Slow return.

  • "Shin Splints":

    • Symptoms: Anterior compartment. tibialis anterior tendinosis, Posterior Compartment, tibialis posterior tendinosis; running on hard surfaces, too much too soon, poor arch support, muscle imbalance, poor mechanics of running.
    • Pathology (underlying cause): inflammation of muscle belly, tearing of muscle from bone, tear in interosseous membrane.
    • Treatment: Rest, change activity, footwear change, stretch, gradually strengthen

• Lateral Ankle Sprain:

  • MOI: rolling of the ankle; inversion. Often coupled plantar flexion, landing from a jump, cutting, uneven ground.
  • Symptoms: Instability (grade dependant), pain with inversion and plantar flexion, swelling, discoloration, positive anterior drawer test
  • Treatment: Keep ankle joint in neutral position to shorten ligaments, PIER, open gibney, crutches (high grade), X-ray, strengthen peroneal group.

• Achilles Tendonitis:

  • MOI: ↓flexibility, foot type (pes planus vs pes cavus), new footwear, changes in training schedules, ↑ mileage, hill training.
  • Treatment: find the cause, rest, friction/ultrasound for adhesions, heel lift for shoe, taping, gradual stretching and strengthening, eccentrics.

• Plantar Fasciitis:

  • Symptoms: Point tender medial side of calcaneous, localized pain, stiff in the AM, swelling, unable to walk on toes, pain ↑ with passive toe extension.
  • Treatment: PIER (rest, ice), X-ray, ultrasound, stretch Achilles, proper footwear, tape, orthotics, heel cup, balance pelvis, roll/massage tendon.