Hip OA and THA Surgical Approaches

Hip OA

• Motions affected by hip osteoarthritis include ER, IR, flexion, extension, abduction, and adduction.
• All movement at the hip joint is affected by hip OA

Surgical Approaches for THA

• Posterior or posterolateral approach involves splitting the gluteus maximus along muscle fibers
• The posterior approach also moves the short external rotators off the femur
• Direct lateral approach involves longitudinal division of the tensor fascia latae
• For the direct lateral approach, up to one half of the proximal insertion of the gluteus medius is released
• Splitting the vastus lateralis is also part of the direct lateral surgical approach
• The anterolateral approach uses an incision centered over the greater trochanter
• During the anterolateral approach, the IT band is split
• Also during the anterolateral appraoch, the anterior 1/3 of the glut medius and minimus are detached from their insertion
• The anterior approach utilizes an incision made lateral and distal to the ASIS
• None of the muscles are detached during the anterior approach
• The rectus femoris and sartorius are retracted medially for exposure to the joint when using the anterior approach
• The transtrochanteric approach requires an osteotomy of the greater trochanter at the insertion of the gluteus medius and minimus

Hip Replacement Precautions

• Posterior/Posterolateral approach precautions include avoiding hip flexion past 90 degrees, adduction, and internal rotation beyond neutral
• Additional precautions for the posterior approach: do not cross legs, keep knees slightly lower than hips when sitting
• More precautions for posterior approach: avoiding bending the trunk over legs when rising or dressing, ascending stairs with the sound leg first, and descending with the involved leg first
• Patients need to sleep supine with an abduction pillow after a posterolateral hip replacement
• Anterior/anterolateral/direct approach precautions include avoiding hip hyperextension past 90 degrees
• Lateral approach precautions: avoid hip extension, adduction, and external rotation past neutral
• More precautions for lateral approach: avoid combined hip flexion, abduction, and external rotation, do not cross the legs
• Early ambulation precautions for the lateral approach include avoiding hyperextension and potentially needing a step-to pattern
• Transgluteal approach precautions involve avoiding hip adduction past neutral
• Additional precautions for the transgluteal approach: no active/antigravity hip abduction for 6-8 weeks unless approved, no weight-bearing exercises on the operative side
• More precautions for the transgluteal approach: do not cross legs, and sleep supine with an abduction pillow

Transitioning from Max Protection to Controlled Motion Post-THA

• Criteria to progress from the max protection phase to the controlled motion phase includes pain-free ambulation with or without an assistive device
• Criteria also calls for functional ROM and strength of the operated hip
• Independence in ADL

Exercise Progression After a Hip ORIF

• The primary emphasis for acute phase ORIF treatment is on restoring ROM of the involved hip
• Also important to develop balance and strength of the uninvolved hip to facilitate ambulation during the acute phase
• Low-intensity resistance exercise of the operated hip may be delayed until weeks 4 to 6 in the acute phase
• Acute phase for ORIF includes ankle pumping and deep breathing exercises to help prevent vascular and pulmonary complications
• Isometric exercises of the hip and knee muscles on the affected leg are also indicated during the acute phase
• During the subacute and return to function phases, emphasis is increasing strength and functional control of the involved LE
• Increasing patient's level of functional activities is a focus of the subacute phase

Bursitis of the Hip

• Trochanteric bursitis is the inflammation of the trochanteric bursa
• Pain is experienced over the lateral hip, possibly down the lateral thigh to the knee when the IT band rubs the greater trochanter from trochanteric bursitis
• Discomfort may be experienced with the affected hip elevated and adducted and the pelvis dropped on the other side from trochanteric bursitis
• Ambulation and climbing stairs aggravate trochanteric bursitis
• Psoas bursitis is the inflammation to the psoas bursa
• Individuals with Psoas bursitis experience pain in the groin or anterior thigh, maybe to the patellar area
• Activities requiring repetitive hip flexion aggravate psoas bursitis
• Ischiogluteal bursitis, also known as tailor's or weaver's bottom, involves pain around the ischial tuberosity, especially when sitting
• Sciatica may occur if the adjacent sciatic nerve is irritated from swelling with ischiogluteal bursitis

Actions That Aggravate Bursitis

• Ambulation and climbing stairs aggravate trochanteric bursitis.
• Activities requiring repetitive hip flexion aggravate psoas bursitis.
• Sitting irritates ischiogluteal bursitis

Pelvic Tilt Differences

• Neutral pelvic tilt exhibits a balanced pelvic angle, natural lumbar curve, balanced core/glutes, and an upright, stable posture
• Anterior pelvic tilt has the front of the pelvis dipping forward and tightened hip flexors and back, while the abs and glutes are weak
• Posture is characterized by an arched low back and protruding stomach from anterior pelvic tilt
• Posterior tilt involves the front of the pelvis lifting and the back dropping, a flattened lumbar curve, and tight glutes/hamstrings
• The posture associated with posterior pelvic tilt is a tucked pelvis and flat low back

Joint Mobs for the Hip

• Hip Distraction is indicated for general mobility.
• Posterior Glide can improve flexion and IR.
• Anterior Glide can improve extension and ER.

Special Tests for the Hip

• The Ely Test assesses rectus femoris tightness
• In the Ely Test, the patient is prone, and the examiner passively flexes the knee
• A positive Ely Test is indicated if the hip on the same side rises off the table
• The Ober Test assesses IT band and TFL tightness
• The patient is sidelying, and the examiner abducts/extends the leg, then lowers it
• A positive Ober Test occurs if the leg remains elevated and doesn't drop
• The Piriformis Test assessses for piriformis syndrome/sciatic nerve irritation
• The hip is flexed, adducted, and internally rotated
• A positive Piriformis Test involves pain or numbness in the buttock or down the leg
• The Thomas Test assesses for iliopsoas or hip flexor tightness
• The patient is supine, and pulls one knee to the chest, keeping the opposite leg flat
• A positive Thomas Test involves the opposite leg lifting off the table
• The 90-90 SLR Test assesses for hamstring tightness
• The patient is supine with hips/knees at 90 degrees, then attempts to extend the knee
• A positive 90-90 SLR Test involves the knee not being able to extend within 20 degrees of full extension
• The Tripod Sign assesses hamstring tightness
• The examiner passively extends the knee while the patient is sitting
• a leaning back or propping up with hands indicates a positive test
• The Craig's Test assesses for femoral anteversion or retroversion
• The hip is internally/externally rotated when the patient is prone until the greater trochanter is most lateral
• A positive Craig's test involves an abnormal rotation angle
• Patrick's (FABER) Test assesses for hip or sacroiliac (SI) joint pathology
• The patient is supine, puts the leg in a figure-4 position, pushes the knee and opposite ASIS
• A positive FABER Test involves pain in the groin or SI region
• The Trendelenburg Test assesses for weak gluteus medius/hip abductor weakness
• The patient stands on one leg
• The pelvis dropping on the opposite side indicates a positive Trendelenburg Test

Expected Knee Flexion ROM After TKA

• Max protect: ROM goals unspecified
• Mod protect: 110 degrees flexion
• Min protect: ROM goals unspecified

ACL Surgery Exercise Progression

• The main goal to progress from Max to Mod ACL post-op is full active knee extension
• To progress from Mod to Min post-op, goals should include
  • At least 110 degrees knee flexion
  • Quad strength is about 50-60% compared to the contralateral side
• To progress from Mod to Min protection phase
  • Full active knee ROM
  • At least 75% strength of knee musculature compared to the contralateral knee
  • Achieving a hamstring/quad ratio of >65%
• The goal of the Min protection phase of progression is to achieve eccentric training and advanced closed-chain strengthening
• Another key goal of the min protection phase is to achieve advanced neuromuscular balance and agility training

Exercise Precautions After ACL Repair

• The progression of resistance training should be more gradual for a hamstring tendon graft
• Knee flexor strengthening should be progressed cautiously if there's a hamstring graft
• Knee extensor strengthening should be progressed cautiously if there is a patellar tendon graft
• When squatting in closed chain training, ensure proper form
• Avoid closed chain strengthening of the quads between 60-90 degrees of knee flexion
• Initially place resistance above the knee for open chain training
• Avoid resisted open-chain knee extension for at least 6 weeks

ACL Injury Signs and Symptoms

• Frequent episodes of "giving way" during ADLs
• Positive pivot-shift test indicating rotational instability
• "Popping" sound injury
• Rapid swelling
• Positive Lachman's anterior drawer tests

The "Unholy Triad" or "Terrible Triad"

• Refers to injury to the ACL, MCL, and medial meniscus

Patellofemoral Dysfunction Impairments

• Pain in the retropatellar region
• Pain along the patellar tendon or subpatellar fat pads
• Patellar crepitus; swelling or locking of the knee
• Altered lower extremity alignment, specifically increased hip adduction and internal rotation
• Dynamic knee valgus during weight-bearing activities
• Weakness of hip abductors, external rotators, and/or extensor muscles
• Weakness and atrophy of the quadriceps
• Overstretched medial retinaculum
• Restricted lateral retinaculum, IT band, or fascial structures around the patella
• Decreased medial gliding or medial tipping of the patella
• Pronated foot

Knee Q Angle

• The Q-angle is formed by two intersecting lines: one from the ASIS to the mid-patella and the other from the tibial tubercle through the mid-patella
• A greater Q-angle suggests greater lateral bowstring forces on the patella

Gait Impairments from Knee Muscle Problems

• Quadriceps control the amount of knee flexion during initial contact and loading response, and extends the knee toward midstance
• If quadriceps function is impaired, the patient will lurch their trunk anteriorly during initial contact to stabilize the joint
• The trunk will move the trunk center of gravity anterior to the knee flexion/extension axis if the quadriceps are impaired
• Hamstrings primarily decelerate and control knee extension during terminal swing
• Loss of Hamstring function = knee snapping into extension prior to initial contact
• The soleus helps limit the amount of knee flexion during preswing
• A loss of function in the soleus can lead to compensatory hyperextension of the knee during pre-swing
• Loss of heel rise during preswing, resulting in a lag or slight dropping of the pelvis on are other potential side effects to impaired soleus function
• The gastrocnemius provides posterior support to the extended knee at the end of loading response
• Loss of Gastrocnemius function = hyperextension of the knee, as well as loss of propulsion from plantarflexion during preswing or push-off

Meniscus Tears

• Injuries occur during femur on tibia rotation during weight bearing when the foot is firmly fixed on the ground

Knee Ligament Special Tests

• The Anterior Drawer Test assesses ACL integrity
• The patients knee is at 90° in the test and the examiner pulls the tibia forward
• Excessive forward movement of the tibia indicates a positive test
• The Posterior Drawer Test assesses PCL integrity, with the patients knee at 90° and the examiner pushing the tibia backward
• Excessive posterior movement reveals a positive test
• The Lachman Test assessses ACL integrity, conducted with the knee at 20-30° flexion and the tibia pulled anteriorly
• A Soft/mushy end-feel or excessive anterior translation indicates a positive test
• The Pivot Shift Test assesses ACL and anterolateral rotary instability
• The examiner places the knee in extension, applies a valgus force + internal rotation as the knee is flexed
• Tibia shifts or "clunks" at ~30° flexion indicates ACL instability
• The Posterior Sag Sign assesses PCL injury, tested with the hips and knees at 90°
• A test results in Posterior sag of tibia compared to the femur if they have a PCL injury
• The Valgus Stress Test assesses MCL integrity, performed at 0° and 30° flexion
• Apply valgus (inward) force to the knee
• Pain or gapping on medial side with either force indicates an MCL problem
• The Varus Stress Test assesses LCL integrity, also performed at 0° and 30° flexion
• Pain or gapping reveals a lateral side injury

Special Tests for Meniscus Tears

• The Apley's Compression tests are used to assess for meniscal tears
• The test is performed prone, with the knee at 90°, and axial load + rotation is applied to the knee.
• An Apley's test is positive if it results in pain, clicking, or restriction with compression
• The McMurray Test also looks for this issue
• With the patient supine, the examiner fully flexes the knee, rotates the tibia, and extends the knee.
• A positive test can elicit joint line pain
• The Thessaly Test assesses for meniscal tears
• The patient stands on one leg, flexes the knee ~20°, and rotates the body side to side
• Presence of joint line pain, catching, or locking indicates a meniscal issue on the knee

Assessing Effusion

• Palpate the Medial and Lateral joint lines to find a joint line tear location
• Joint swelling is a general term for tests detecting fluid in the joint capsule
• A minimal effusion can be assessed with the Brush Method
• Sweep fluid medially to laterally around the patella in this test
• The Patellar Tap Method allows the examiner to assesses for the presence of a large effusion
• Knee is extended, and then they push down on the patella after milking fluid toward it

Tibiofemoral Mobilizations

• A distraction targets pain and enhances general mobiility.
• A Posterior Glide increases flexion.
• An Anterior Glide increases joint extension.
• A Distal Glide enhances regular flexion.
• A Proximal Glide enhances regular joint extension.
• A Medial or Lateral Glide enhances patellar mobility.

Windlass Mechanism

• During push-off in gait, the foot plantarflexes and supinates and the MTP joints extend
• This increases the tension placed on the plantar aponeurosis, increasing the arch

Triplanar Motions of the Foot and Ankle

• Pronation is a combination of dorsiflexion, eversion, and abduction.
• Supination is a combination of plantarflexion, inversion, and adduction

Gait Control and Muscle

• Dorsiflexors counter plantarflexion and control lowering of the foot to the ground during initial contact and loading response
• Keeps the foot from plantar flexing during the swing phase
• Plantarflexors eccentrically control the rate of forward movement of the tibia while in stance
• Following 40% of the midstance cycle, concentric contraction occurs to initiate plantarflexion for push-off
• Contraction of the peroneus longus muscle in late stance phase facilitates weight shifting from the lateral to medial side of the foot
• Tibialis anterior helps control the pronation force on the hind foot
• Tibialis posterior helps control the pronation force along the medial longitudinal arch during loading
• Intrinsic muscles support the transverse and longitudinal arches

Total Ankle Arthroplasty Indications

• End-stage ankle arthritis that has failed conservative measures
• Sufficient ligament integrity for ankle stability
• Low to moderate physical demands
• A flexible deformity which can be passively corrected to neutral
• Adequate vascular flow

Return to Weight Bearing after TAR

• In most cases, full weight-bearing is achieved 6 weeks post-surgery.

Ligaments Involved in Ankle Sprains

• Most common ankle sprain caused by inversion stress can result in partial or complete tear of the anterior talofibular ligament (ATFL) and often the calcaneofibular ligament
• Significant inversion stress is required to tear the posterior talofibular ligament

Ankle Sprain Healing

• Progress strengthening exercises by adding elastic resistance to foot movements in long sitting
• Progress neuromuscular reeducation to improve balance, coordination, stability, and neuromuscular response to full weight bearing
• Incorporate movement patterns: add forward/backward walking and cross over side steps with resistance
• Utilize unstable surfaces- incorporate the BOSU, BAPS board, or mini trampoline
• Train with weight bearing activities

Signs and Symptoms of Achilles Rupture

• Pain, swelling, palpable defect, and significant plantarflexion weakness at the time of a complete rupture
• Clinical examination indicative of Achilles tendon rupture includes an abnormal Thompson Squeeze Test
• Decreased ankle resting is a common sign
• Palpable defect in the Achilles

Achilles Tendon Repair Post-Op

• Re-establish independent ambulation and functional mobility through gait and transfer training; emphasize WB restrictions
• Maintain ROM of non-immobilized joints by performing AROM of the hip, knee, and toes of the operated side while wearing the immobilizer
• Prevent reflex inhibition of immobilized muscle groups by beginning submaximal, pain-free muscle setting exercises
• Prevent joint stiffness and soft tissue adhesions in the operated foot and ankle by initiating ROM exercises in protective ranges
• Restore balance reactions in standing by performing weight-shifting activities in bilateral stance while wearing a protective orthosis.
• Maintain cardiopulmonary fitness using an upper extremity ergometer. After 2 weeks initiate exercise bike with the protective orthosis & minimal resistance

Arthrodesis Indications

• Debilitating pain
• Severe articular degeneration caused by arthritis
• Marked instability or stiffness unresponsive to conservative management
• Deformity of the ankle, foot, or toes from congenital anomalies, neuromuscular disorders, or arthritis
• Osteonecrosis of the talus
• A salvage procedure after a failed TAA

Definitions of Tendinopathy

• Tendinopathy is the umbrella term for a disorder of the tendon.
• Tendinosis describes long-standing, chronic, degenerative tendons that lack inflammatory mediators or cells.
• Tendonitis is an acute inflammatory process in the tendon.
• Tenosynovitis is the inflammation of the tendon's synovial sheath.

Shin Splint Impairments

• Pain with repetitive activities, palpation of the involved site, stretches of the involved musculotendinous unit, resistance of the involved muscle
• Pain upon initial weightbearing and with prolonged weight-bearing
• Muscle length/strength imbalances, particularly involving the gastrocnemius-soleus group
• Abnormal foot posture
• Decreased tolerance of standing
• Decreased distance or tolerance of ambulation

DVT Clinical Features

• Unilateral leg swelling
• Pain or tenderness
• Warmth and redness or discoloration of the skin

Ligament Special Tests for the Ankle

• The Anterior Drawer Test assessses tibiofibular integrity
• The test is performed with the patient seated with foot in slight plantarflexion, stabilizing tibia and pulling the calcaneus forward
• Excessive anterior translation of the talus indicates ATFL sprain
• The Talar Tilt Test assessses joint instability
• The test requires the patient being either seated or supine
• The therapist stabilizes the lower leg, grasps the calcaneus and inverts or everts the foot to test for ligament impairments

Joint Mobilization for talocural joint

• A distraction (perpendicular to joint) with prone reduces pain
• Medial or Lateral Glide in frontal plane improves inverion and eversion
• Proximal Glide in sagittal plane improving dorsiflexion
• Distral Tibiofibular and tibiofibular (anterior) improves dorsiflexion