Orthopedic Conditions & Interventions: Week 1

• Core practice and assessment notes for a range of orthopedic conditions

Common Conditions

• Achilles tendinopathy is one condition
• Lateral ankle sprain is another condition
• Plantar fasciopathy
• Medial tibia stress syndrome
• Patellofemoral Pain Syndrome (PFPS)
• Patellar Tendon (PT)
• Knee Osteoarthritis (OA)
• Fat pad impingement
• Iliotibial Band Syndrome (ITBS)
• Femoroacetabular Impingement (FAI)
• Hip OA
• Gluteus medius/minimus tendinopathy

Week 1: Intervention Strategies

• Optimal intervention involves gathering highest quality evidence
• Clinical experience guides decisions when evidence is lacking
• The absence of evidence doesn't negate the possibility of something being effective
• Intervention selection considers impairments, how to address them, and prior successful approaches
• Understanding how a professional therapist functions is important
• Patients' perceptions of their issues is important
• How the problem impacts patients' lives should be taken into account
• Consider how patient lifestyle affects their issues
• Clinical reasoning should include pathophysiology
• Conditions vary regarding prognosis and healing times

Tissue Healing Times

• Skin: 3 days to 2 weeks
• Tendon: 2-12 weeks
• Muscle: 3 weeks - 3 months
• Bone: 6-8 weeks
• Ligament: 6-12 weeks
• Fibrocartilage (meniscus, TFCC, TMJ): 8-12 weeks
• Articular cartilage (inside all joints): 3-6 months
• Nerve: 2-5mm/day (several months to over a year)

Medical/Biological Model

• Musculoskeletal (MSK) injuries, pain, and impairments are often linked to structural or organic pathology
• Addressing pathology should alleviate symptoms

Biopsychosocial Model

• Biological factors are worth studying and practicing
• Behaviors, thoughts, and feelings also influence physical state
• A biopsychosocial approach enables a more individualized therapy strategy

Biopsychosocial Question Examples

• Questions can address worries, sleep, stress, perceived cause, and expectations

Mechanotransduction

• A biological process converts mechanical load into cellular responses that lead to structural tissue changes

Mechanotherapy

• Therapeutic exercise supports beneficial tissue adaptations such as repair and remodeling

Steps of Exercise Defined

• Mechanocoupling is loading the trigger requiring exercises to be performed
• Physical load provides perturbation, causing cells that make up the tissue to be impacted
• Achilles tendon receives a tensile load when performing exercises
• Cell-to-cell communication allows distribution of the message the tendon has experienced a load
• Effector cell response allows activation of new proteins to address the work that has been done
• An increase in Insulin Growth Factor (IGF) helps with cellular proliferation, tendon stiffness, and matrix remodeling
• Maximizing effects in tendons involves high-intensity muscle contractions

Envelope of Function

• Ability of tissues to deal with loading should determine the exercise approach
• Too little loading causes deconditioning
• Zone of supraphysiologic overload will result in muscle adaptation
• Loading in a zone of structural failure leads to damage

Assessing Envelope of Function

• Envelope of function can be assessed with strength, ROM, and functionality tests such as walk distance or hopping

Manual Therapy

• Manual therapy can alter pain sensation
• Manual therapy can change muscle activation
• Manual therapy can improve joint ROM
• The effects are temporary, so it should be an adjunct, not a stand-alone treatment

Manual Therapy Function

• Manual therapy provides a complex neurophysiological response from peripheral/central NS
• Mechanical stimulation, such as pushing on joints, triggers afferent neurons in skin, joints and muscles
• This leads to various responses like pain inhibition, neuromuscular inhibition, or facilitation

Use of Manual Therapy

• Manual therapy is useful if passive movement is limited by pain/stiffness
• Interventions should aim to decrease pain while reassessing post-treatment
• Interventions should aim to decrease stiffness while reassessing post-treatment

Maitland Grading System

• Grade I: Small amplitude movement at the beginning of ROM
• Grade II: Large amplitude movement within available ROM
• Grade III: Large amplitude movement reaching the end of ROM
• Grade IV: Small amplitude movement at the very end of ROM
• Grade V: Manipulation

Contraindications for Manual Therapy

• Absolute contraindications include high risk of deleterious consequence
• Examples include open wound/infection, osteoporosis, or disc herniation
• Relative contraindications involve possibility of deleterious consequence
• Examples include old/young age and history of cardiovascular disease (CVD)

Heat vs. Cold

• Heat reduces muscle spasm
• Cold can increase stiffness but provides analgesia

Ankle Sprain Treatment (ATFL)

• Decreased ROM can be addressed with AP glide, ankle alphabets, P/AROMs
• Decrease proprioception with DL stance, tandem stance, and SL stance
• Address ATFL laxity with strength exercises (resisted PF/df with TheraBand) and education
• Weight-bearing difficulty can be addressed with crutches, boot, or tape
• Pain and swelling can be managed with RICE (Rest, Ice, Compression, Elevation)

Week 2: Tendinopathy Characteristics

• Tendons connect muscle to bone
• Tendons produce joint movement
• Tendons maintain joint position
• Tendons optimize distance between muscle belly and joint

Tendinopathy Pain

• Tendinopathy has Localized pain that can be pointed to with a finger (except glute med/min)
• Provoked by loading, with more load causing more pain
• Tendinopathy has latency periods and feels worse after 24 hours
• Absence of load results in no pain

Healthy Tendon Structure

• Healthy tendons tend to be highly organized
• Contains collagen fibrils embedded in extracellular matrix with small proteoglycans
• Sparse neurovascular structures provide supply

Tendon Continuum Breakdown

• Normal tendon adapts to appropriate loading and strengthening
• Excessive load plus intrinsic/extrinsic risk factors can lead to reactive tendinopathy
• Reactive tendinopathy has increased proteoglycans and collagen, resulting in a thickened, swollen appearance
• Tendon dysrepair has separation and disorganization causing neovascular ingrowth
• Degenerative tendinopathy arises with cell death, disorganization, and degenerative patches
• Tendons can move up and down through this continuum, especially if recognized early on

End-Stage Tendinopathy

• End-stage tendinopathy shows minimal inflammation with degenerative pathology
• Collagen is disrupted with disorganized appearance similar to mucoid degeneration
• Presence of rounded nuclei with fewer tenocytes
• Neural and vascular Ingrowth is common

Tendinopathy Costs

• It effects 28 million Americans per year
• Has a $30 billion cost in USA

Achilles Tendinopathy Demographics and Risks

• Achilles tendinopathy affects athletes and older or sedentary patients
• Most common lower limb tendinopathy is gluteal
• Most common upper limb tendinopathy is the rotator cuff
• A mismatch of load vs capacity can lead to too much load for the tendon to handle

Achilles Tendinopathy Outcome Measurements

• VISA-A
• NRS
• MMTs/IMTs
• Functionality tests like calf raises
• ROM
• Patient-Specific Functional Scale (PSFS)

Achilles Tendinopathy Treatment

• Manual therapy gives short term relief and impacts when combined with progressive rehab for tendon and kinetic chain
• Manual therapy alone is not enough
• A structured loading program is beneficial
• Heavy slow resistance training (HSR) or eccentric exercises show positive results
• Both improve pain and function, but there's little impact between them based on VISA-A
• HSR has better compliance but requires gym equipment
• Isometric Calf Raises, Strength Exercises, and Functional Strength Exercises are examples that can be employed
• The kinetic chain must be developed through hamstring/glut strengthening/activation during rehab

Achilles Tendinopathy Exercise

• Isometric holds for static calf raises
• Strength exercises such as calf raises
• Functional strength exercises such as lunges up onto toes
• Speeds exercises are pogo jumps and fast calf raises
• Develop the kinetic chain

Achilles Tendinopathy Stage 4 - Return to Sport

• Eliminate all stage 3 exercises in favor of stage 4 training
• All exercises should be sport specific
• In a return to run program, ensure pain free walking before running with walking implemented using the 10% rule up to twice weekly

Achilles Tendinopathy Guidance

• Relative rest and activity modification can help reduce aggravating activities
• Pain when running = load mismatch that require a reduction in load
• Using a Traffic light system to control pain can include up to 5/10
• There should be no pain after 24 hours as well as no impact after exercising

Achilles Tendinopathy Special Considerations

• Insertional concerns occur in only 25% of cases with tenderness or pain in insertion of the tendon
• Patients must be put at ease and engaged by showing that the pain will get bette
• This ensures that the patient isn't scared of rupture and continues exercises needed for improvement

Peter Malliaris Achilles Tendinopathy Review -

• Reviewed through patient's Visual Analogue Scale and questionnaire, and level of disability
• Finding's include:
• -Graded exposure exercises can be a lot more helpful than strictly eccentric ones
• -Starting slow progressive exercises are beneficial (isometric, isotonics, plyometrics)
• -As load gradually increases on the tendon, encourage patient's to continue exercises
• -Education will play a large role to manage recurrence and recovery

Isometric Exercise for Tendinopathy

• Can reduce pain as effectively as isotonic loading

Isotonic Exercise for Tendinopathy

• Engage through full RoM to allow for confidence so symptoms can be improved
• Can be used with Alfredson or heavy resistances as a means of help

Implementing Stretch-Shorten Cycles

• Slowly incorporating loading on top of normal cycles while resting days in between helps create improvement
• Always implement less resistance to keep flare ups to a minimal

Lateral Ankle Injuries: Management

• Ice, Compression, Elevate for effective initial responses to injury
• Prevent weight bearing activites and showers/hot water

Managing Pain/Swelling to restore ROM

• Take NSAIDs to reduce pain related stiffness
• Always focus on exercises that keep weight minimal, stretch easily, and allow continuous cycles without pain

CAI Clinical Implications and Recommendations

• CAI results in patient's loading the foot in a irregular pattern that increases the risk of future injury
• Center of gait becomes more lateral, so try to cue patients through the "center of feet" to promote regular pattern
• Exercises allow proprioception
• Manual therapy can be combined for better ROM and pain relief

Plantar Fasciitis

• Most commonly apparent in factory workers and older runners
• Traffic light method ensures a balance between pain and rehab
• If pain worsens up to 24 hours you must provide activity and resting adjustments (FFI)

Treatments for Plantar Fasciitis

• Heavy load (windlass) shoes/inserts are more useful opposed to stretching
• Find proper way to load patient with orthotics that better their movements

Manual Therapy

• Not as effective as more efficient treatments (stretching), and is prioritized less

MTSS

• Overuse injury resulting in pain which surpasses Osteoblast activity
• Proper education is useful for rehabilitation, proper loading, and rest

MTSS Treatment

• Strengthen hip through ERs+ABDs , and ensure more flexible foot movements
• Modify activity to ensure slow and steady recovery and incorporate better movements

MTSS Return To Running Guide

• Slowly promote muscle strength with proper form while progressively loading muscles every couple days
• Be sure patient form is correct and aligned to prevent further degradation

Rehabilitation Frameworks

• Frameworks (ROAST, PAASS) help to evaluate rehabilitation in the form of pain, swelling, and movement. Follow through on sport specific tasks

PEACE and LOVE Framework

• Framework emphasizes short term exercises while slowly easing into longer activities
• Always provide short term exercises with a gradual climb

Insidious Knee Injuries w/ PFP

• Greater population of females, high reoccurrence rates, poorly defined pain, rapid development
• Pain is worsened during weight bearing exercises
• Strengthening core is important for pain management (coupled with a gradual return to exercise and activity)

Pain Progression w/ exercises

• Slow and steady progression is prioritized
• Non Weight baring: free movement where specific body part isn't restrained
• WB: specific body part on the patients are fixed and they provide the action

Treatments for Knee Complications

• Combining hip and proper alignment are the most beneficial processes
• Strengthening knee will help restore natural stability and reduce pain

Tendinopathy

• More often more common in younger males due to higher volume of activity, or late tendon maturation
• Localized pain is often found in lower part of patella that has a load-response
• Often free of rest, warm up can help reduce pain short term

Common Impairments

• Lack of quad/glute control (hip abduction)
• Decrease in lower limb flexibility which prevent activation of proper muscles
• Excessive foot pronation

PT Treatment

• Education and proper rehabilitation time frames
• Passive treatments have low value to ensure strengthening of proper supporting muscles

3 Stages (Isometric, Isotonic, Energy Loading)

• Quad Isolation: 5 sets for 45 seconds

• Slow adjustments in angles to increase comfort

• If there's muscle vibration then the load is too aggressive on the patient

• Proper posture adjustment will allow kinetic chain strengthening along with strength training

• Increase progressive loads while using low tolerance when necessary

What to do after Isometric and Isotonic exercises

• Ensure proper strength so exercises and load aren't too heavy
• After performing these exercises you can do sets of 8 at patients 150% Body Weight, or symmetrically
• Slowly add volume to exercise to ensure safety
• Always look for abnormalities (tight muscles, incorrect form), and promote movement to reduce restrictions
• Always address concerns like proper landing and imbalances to prevent problems
• The most important detail is slow and steady progress

Considerations for Knee and Hip OA patients

• Ensure proper encouragement, reasurrance, and to keep them comfortable, and don't use certain equipment so that the exercise is less of an inconvenience
• Focus on land-based kinetic and neuromusclar movements that warm up their lower body

Reduce Swollen Fat Pads

• Limit activities that may cause inflammation, find alternatives if available
• Offload weight bearing activities
• Reduce elevation can also alleviate pressure

Iliotibial Band (ITB) Syndromes

• Inflamattion caused by constant flexion of knee for long periods of time
• Treat by loading and proximal trunk/hip to release pressure of areas where pain occurs in alignment with proper gait

Femoroacetabular ITB

• Only present in young males with deformity in femoral head (CAM shape)
• Alpha (lateral) angle > 55 is indicative of CAM deformity which can be evaluated with imaging
• Also often come together with hip rotation, OA, and pain

Hip OA Management

• Non-surgical and surgical methods don't restore back to perfect levels (can still have an issue)
• Exercise and movements can allow for proper function

Treatment for Joint Complications and Exercises

• Can be addressed with lower limb strength kinetic movements that gradually increase
• Also proper patient positioning, balance of load, and activity, and the right equipment usage

Glut Med/Min Tendinopathy

• Mostly caused by aging women with symptom's like night, hip pains
• Can be tested through SLS
• Compression is a massive factor! Do not lie on effected area or cross the leg over it in order to prevent the stretch from occurring
• Load Management can be tested (LEAP study)
• Don't promote extreme ranges with hip adduction and flexion or stretching could cause injury
• Gradually increase volume and tempo for best results