EHR520 Weeks 5 - 10

Functional Anatomy and Rehabilitation of the Vertebral Column

Vertebral Column Structure

• Consists of Cervical spine (C1-C7), Thoracic spine (T1-T12), Lumbar spine (L1-L5), Sacrum (S1-S5), and Coccyx
• Components: Intervertebral discs (shock absorbers), Ligaments (stability), Muscles (movement), Spinal cord, nerve roots, and peripheral nerves

Functional Anatomy and Biomechanics

• Movements: Flexion, lateral flexion, extension (limited), and rotation
• C3-L5: Transverse and spinous processes (attachments for ligaments and muscles)
• Articular processes

Intervertebral Discs (IVDs)

• Contain nociceptive fibers, contributing to pain
• Both IVDs and facets can contribute to pain

Muscles of the Back

• Superficial: [list of muscles]
• Deep: [list of muscles]
• Anterior Trunk: [list of muscles]
• Trunk: [list of muscles]

General Rehabilitation Considerations

• Exercise rehabilitation should be commenced early
• Includes posture, stability, flexibility, strength, and endurance exercises
• Posture examination: Standing and sitting posture
• Include body mechanics/ADLs (e.g., picking up objects from the floor, sit to stand)
• Gait examination: ROM, strength, special tests, palpation, outcome measures

Rehabilitation Techniques

• Soft Tissue Mobilisation: used to release trigger points in muscles, providing pain relief
• Flexibility Exercises: generally held for 30 seconds or more, repeated several times daily, to restore muscle imbalances, improve posture, and regain lost joint ROM
• Posture, Core, and Stabilisation Exercises: core (lumbo-pelvic-hip complex) provides spinal stability, increases intra-abdominal pressure, and involves transverse abdominis, multifidus, pelvic floor, and diaphragm

Disc Lesions and Radiculopathy

• L4/5 IVD and L5/S1 IVD
• Treatment: use of extension exercises, flexibility, strengthening exercises, and pelvic-neutral exercises

Facet Injuries

• Can be difficult to identify
• Often require investigative skills to identify
• Facet impingement and positional dysfunction: facet restriction can occur from an impingement following a traumatic event

Upper and Lower Crossed Syndromes

• Feature a cross-pattern arrangement of weak and tight muscles
• Upper Crossed Syndrome: forward head, upper cervical lordosis, thoracic kyphosis, protracted and winged scapulae, and internally rotated or abducted shoulders
• Lower Crossed Syndrome: excessive anterior pelvic tilt, hyperextension of the knees, and hip flexor tightness
• Treatment: patient education, postural changes, soft-tissue treatments, correction of muscle imbalances with flexibility and strengthening exercises

Sprains and Strains

• Signs and symptoms: tenderness on palpation, painful during contraction
• Treatment: REST, ice, compression, elevation, and rehabilitation exercises

Functional Anatomy and Rehabilitation of the Pelvis and Hip

Functional Anatomy and General Considerations

• The pelvis is composed of the left and right hemipelvis, joined at the pubic symphysis and sacroiliac joints (SIJs)
• The lumbopelvic-hip complex includes the spine, pelvis, and hips, with each segment influencing the other in terms of alignment and function
• The pelvis can tilt anteriorly or posteriorly, affecting the position of the hips and lumbar spine
• A total of 4-6 degrees of movement is possible at the SIJs, which can become hyper- or hypomobile

Sacroiliac Stabilization

• Sacroiliac stabilization is important for the transmission of forces through the kinetic chain and prevention of back and pelvic pain
• Three components of sacroiliac stabilization: form closure (anatomical stability of pelvic ring), force closure (muscles provide stability), and neuromotor control (proper activation and sequential recruitment of muscles)
• Ligament sprain compromises form closure, and focus is on improving force closure through strengthening and activation exercises to re-establish lumbopelvic-hip stability

The Core

• The core consists of inner (deep) core muscles (transverse abdominis, diaphragm, multifidus, and pelvic floor) and outer core muscles (erector spinae, rectus abdominis, external oblique, gluteal muscles, and thoracolumbar fascia)
• Core instability is linked to knee injuries, ankle sprains, and patellofemoral pain syndrome
• Hip muscles not only provide hip motion but also influence pelvis and trunk motion

Pelvic Neutral

• Pelvic neutral serves as a platform for lumbopelvic-hip stability and extremity performance
• The pelvis is stable when it is in pelvic neutral, which minimizes injury risk and optimizes load transfer
• Maintaining pelvic neutral in all activities is important for optimal function

Combining Local and Global Core Muscles

• Abdominal hollowing facilitates transverse abdominis and multifidus activation, but does not activate outer core muscles
• Abdominal bracing activates outer core muscles, and progressive exercises should be incorporated into functional activities

Pathological Sacral Alignment – Movement Tests

• Investigation of the sacroiliac region should include posture, alignment, and lumbar spine range of motion
• Tests for sacroiliac joint dysfunction include the standing forward-bend test, seated forward-bend test, kinetic test (Gillet test), and others

Here are the study notes for the text:

Functional Anatomy and Rehabilitation of the Knee and Thigh

Introduction

• Knee injuries are common and can cause significant functional limitations
• Knee joint is a complex structure that relies on sound function for daily activities such as walking, standing, and sitting
• Need to examine the entire kinetic chain to understand knee injuries, as restrictions or weakness in surrounding joints can contribute to knee pain

Knee Structure

• Tibiofemoral joint: concave tibial platform and convex femur
• Knee joint capsule surrounds the joint and merges with collateral ligaments
• Collateral ligaments provide medial, lateral, and rotational stability
• Cruciate ligaments provide anterior-posterior and rotational stability
• Medial and lateral meniscus cushion the joint, deepen the socket, and provide joint congruity
• Screw-home mechanism occurs in the last 30° of extension, where the tibia rotates laterally and the femur rotates medially

Patellofemoral Joint

• Patella sits in the femoral groove and glides superiorly during knee extension and inferiorly during knee flexion
• Patella stability is maintained by static (femoral groove, patellofemoral ligaments) and active (quadriceps) structures
• Quadriceps angle (Q-angle) is the angle formed by a line from the ASIS to the middle patella and a line from the middle patella to the tibial tuberosity

Factors Affecting Post-Injury Strength

• Oedema shuts down quadriceps function and is proportional to the quantity of fluid
• Pain can cause reflex inhibition and reduced muscle output
• Ambulation can cause weakness and bad habits to develop

Ligament Sprains

• Most knee ligament injuries result from an external force
• Anterior cruciate ligament (ACL) sprains are common, particularly in females
• Signs and symptoms of a grade 3 ACL rupture include a "pop" sound, immediate disability, knee instability, rapid swelling, and a positive anterior drawer test
• Treatment for ACL sprains includes PRICER, definitive diagnosis, arthroscopic examination, and reconstruction surgery

Posterior Cruciate Ligament (PCL) Sprain

• Mechanisms include external force and hyperextension
• Signs and symptoms include a "pop" sound, tenderness in the popliteal area, laxity in the posterior "sag" drawer, and rapid swelling
• Treatment includes PRICER, definitive diagnosis, arthroscopic examination, and reconstruction surgery

Collateral Ligament Sprains (MCL and LCL)

• Mechanisms include external force and rotation
• Non-surgical treatment includes bracing, crutches, active ROM exercises, and strength training

Meniscal Injuries

• Mechanisms include rotation while weight-bearing on the leg
• Signs and symptoms include severe pain, loss of movement, and peripheral tears
• Treatment includes conservative management vs. surgical repair/meniscectomy

Patellofemoral Pain Syndrome (PFPS)

• Mechanisms include lateral tracking of the patella, tight hamstrings, and excessive foot pronation
• Signs and symptoms include tenderness over the lateral facet of the patella, swelling, stiffness, and crepitus
• Treatment includes strengthening the VMO, adductors, and abductors, improving core strength, and stretching hamstrings and ITB

Iliotibial Band (ITB) Syndrome

• Mechanisms include postural problems, tight quads, and hip flexors
• Signs and symptoms include sharp stabbing pain over the lateral knee area
• Treatment includes addressing predisposing factors, training volume, posture education, flexibility and strength exercises, and corticosteroid injection

Patellar Tendinopathy (Jumper's Knee)

• Mechanisms include sudden or forceful repetitive knee extension
• Signs and symptoms include pain and tenderness at the inferior pole of the patella
• Treatment includes ice, correcting muscle strength and flexibility imbalances, eccentric strength training, and corticosteroid injection

Quadriceps Contusion ("Corky")

• Mechanisms include direct blow to the thigh
• Signs and symptoms include pain, loss of function, stiffness, and weakness
• Treatment includes PRICER, gentle passive stretching, and surgical intervention in extreme cases

Knee Osteoarthritis

• Characterized by a breakdown of articular cartilage, inflammation, narrowing of the joint space, and osteophyte formation
• Treatment includes normalizing biomechanics, increasing physical activity levels, reducing body mass if overweight or obese, pain medication, corticosteroid injection, and total joint replacement

Knee - Special Tests

• Patellar Grinding Test
• Anterior Draw Test
• Posterior Draw Test
• Valgus Stress Test
• Varus Stress Test
• Apley's Test
• McMurray's Test

Functional Anatomy and Biomechanics of the Ankle and Foot

• The lower leg consists of the tibia, fibula, and four muscle compartments.
• The tibia has a proximal tibiofemoral joint and tibial tuberosity (patella tendon), and a distal talocrural (ankle) joint that allows for plantarflexion and dorsiflexion.
• The subtalar joint, located between the talus and calcaneus, enables pronation and supination.
• Supination involves foot adduction, plantarflexion, and inversion, while pronation involves foot abduction, dorsiflexion, and eversion.

Muscle Function

• There are 12 extrinsic and 11 intrinsic muscles of the lower leg and foot.

Common Structural Deformities

• Pes Cavus: an abnormally high longitudinal arch, resulting in a rigid foot position with limited force absorption, increasing the risk of stress fractures and overuse injuries.
• Pes Planus: an abnormally low longitudinal arch, which may be rigid or flexible, and can cause little supination during gait, placing rotational stress on the hip, knee, plantar fascia, and Achilles tendon.

Ankle Ligament Sprains

• Ankle ligament sprains are one of the most common sports injuries, with a high risk in jumping sports (e.g., basketball, netball, volleyball) and running, especially on rough or uneven surfaces.
• Early treatment enhances recovery time.
• The most common mechanism of injury is inversion and plantarflexion.
• The ligaments commonly sprained are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament.
• Grading of ankle ligament sprains:
  • Grade I: stretching of the anterior talofibular ligament, with mild pain and disability, and no loss of function.
  • Grade II: tearing of the anterior talofibular ligament, with a tearing sensation, diffuse swelling, and point tenderness.
  • Grade III: severe pain, diffuse swelling, and tenderness over the entire lateral ankle, with all three ligaments torn.

Lateral Ankle Sprains

• Treatment for Grade I sprains:
  • PRICE (protection, rest, ice, compression, and elevation)
  • Gentle ROM exercises
  • Gradual weight-bearing
  • Taping
  • Rehabilitation exercises
• Treatment for Grade II sprains:
  • PRICER (protection, rest, ice, compression, elevation, and rehabilitation)
  • X-ray
  • Crutches
  • Air cast or camboot
  • PF/DF exercises
  • ROM and proprioceptive exercises
  • 1-2 weeks of resumed weight-bearing
  • Taping
  • Graduated rehabilitation
• Treatment for Grade III sprains:
  • PRICER
  • Short walking cast for 4-6 weeks
  • Similar to Grade II but with a longer healing time
  • Problems can remain for 8-10 months
  • Or surgery due to severe laxity and instability

Medial Ankle Sprains

• Medial ankle sprains are less common (<10% of ankle sprains) and often occur due to pronated or hypermobile feet.
• Mechanism of injury: usually ankle eversion.
• Signs and symptoms: pain, inability to weight-bear, and 2nd and 3rd degree sprains can cause significant instability.

Syndesmosis Sprain

• Syndesmosis sprains occur between the tibia and fibula, including the anterior talofibular ligament, posterior talofibular ligament, and interosseous membrane.
• Signs and symptoms: tenderness and swelling at the junction of the tibia and fibula, pain on weight-bearing, and talus may slip laterally and be unstable.

Gastrocnemius Strain

• Medial head at the musculotendinous junction is the most common site of injury.
• Mechanism of injury: quick starts and stops during sports (e.g., tennis, squash).
• Signs and symptoms: sudden pain in the calf, difficulty walking, especially on toes, local tenderness, and swelling.
• Treatment: PRICE, AROM/gentle stretches, and rehabilitation exercises to prevent scarring and repeated rupture.

Soleus Strain

• Signs and symptoms: pain located deep in the calf, pain triggered by tiptoe walking, bruising may appear on the medial border of the tibia, and deep local tenderness over the injured area.
• Treatment: PRICE, AROM/gentle stretches, and training the muscle to pain threshold with increasing load.

Achilles Tendinopathy

• Causes: overuse, prolonged and repeated stress, increased mileage, poor shoes, uneven surfaces, and pes cavus.
• Prevention: warm-up and stretching of both gastrocnemius and soleus, good quality training and competition shoes, and heel wedge if tension is felt in the Achilles tendon.
• Signs and symptoms: pain and swelling, crepitus felt over the tendon, erythema, weakness in plantarflexion, restricted dorsiflexion, and point tenderness.

Medial Tibial Stress Syndrome (MTSS)

• Also known as "shin splints" or "exercise-related leg pain."
• Causes: malalignment of the foot or lower leg, muscle fatigue, overuse stress, and sudden changes in training habits.
• Signs and symptoms: tenderness over the middle to distal medial margin of the tibia, pain occurring after activity, pain affecting performance, and local inflammation.
• Treatment: rest and ice-massage, taping, alternate heat and cold, stretching gastrocnemius, soleus, and deep PF's, aquatic rehabilitation, and orthotics.

Plantar Fasciitis

• One of the most common foot injuries, affecting the plantar aponeurosis, a thick fibrous band covering the plantar surface of the foot.
• Causes: pes cavus, pronated feet, increased mileage, poor shoes, and restricted dorsiflexion.
• Signs and symptoms: heel pain under load, morning stiffness, tenderness on pressure, pain if standing on tiptoes or heels, and sometimes heel spurs form.
• Treatment: rest and ice in acute stages, crutches to decrease load, tape to unload, checking shoes, and self-massage.