Conditions of the Lower Quadrant PDF

Conditions of the Lower Quadrant Readings: Andrews, Harrelson, Wilk. Physical Rehabilitation of the Injured Athlete, 4th Ed, Saunders 2012 Objectives: 1. An overview of injury assessment 2. Examination of conditions of the hip. Objective 1: Injury Assessment the act of...

Conditions of the Lower Quadrant Readings: Andrews, Harrelson, Wilk. Physical Rehabilitation of the Injured Athlete, 4th Ed, Saunders 2012 Objectives: 1. An overview of injury assessment 2. Examination of conditions of the hip. Objective 1: Injury Assessment the act of assessing; appraisal; evaluation the classification of someone or something Mechanisms of Injury: Strain Rupture Fracture Avulsion Fracture Ligament Sprains Overuse Underuse Clinical Assessment Begins moment athlete enters clinic Controlled environment Emergency cleared Decisions to make: Further medical attention Tests Orthopaedic consult Orthotics or bracing Clinical Assessment Determine the needs of rehabilitation Athlete’s goals Therapists goals Return athlete not only to activities of daily living but competition as well Clinical Assessment Components: History Observations Rule outs (includes reflexes, sensation, etc.) Functional assessment Special tests Palpation Documentation follows SOAP format Field Assessment Observed mechanism of injury UNCONTROLLED environment May need to assess within rules of the game Primary Survey (ABC) Secondary Survey Field Assessment H: history O: observations P: palpations S: stress/special tests 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 (“snap”, “pop” sounds) Previous history of injury Ask relevant, NON-LEADING questions (open-ended) LISTEN attentively Allow the athlete to describe the 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 causing unnecessary pain Ensure the injured area is relaxed Demonstrate care Encourage cooperation To begin palpations, start AWAY from the area of injury and move TOWARDS the lesion site Includes bony and soft tissue palpation Compare the both sides (start on injured or non-injured side first?) Palpation Information gained: Area(s) of pain and point tenderness Deformity Distal circulation, skin temperature, muscle spasm Swelling, crepitus Sensory function HOPS Assessment Palpation: What do you feel? (crepitus, bogginess, etc.) Stress Testing: Determine the nature of the injury AROM PROM RROM Specials Stress Testing Begin slowly and gently Stress the UNINJURED structures first Compare bilaterally Increase intensity as tolerated Explain what you are doing, talk to your athlete Promote cooperation and trust Stress Testing ALWAYS begins with Functional Testing Functional testing consists of Active, Passive and Resisted ROM Active ROM ALWAYS takes place first Stress Testing - Active When performing the Active testing, take note of both the quality and quantity of movement in the pain-free ranges Address the most painful ranges last Stress Testing - Passive Completed by the therapist to assess the joint’s inert tissues Best performed with the athlete relaxed and the injured area well supported Therapist attempts to move joint through the full, pain-free range of motion Challenges? What are you feeling for? Stress Testing - Resisted Consists of a strong, static isometric voluntary muscle contraction Must be done with joint in neutral position (minimizes stress on inert tissues) Athlete is instructed to “meet my resistance”, not to “over-power me” Evaluated on a grading scale 0-5 Muscle weakness may be attributed to: Upper motor neuron lesion Injury to the peripheral nerve Pathology at the NMJ Injury to the muscle itself Objective 2: Injuries of the Lower Quadrant Common Hip Injuries  Hip Movements Flexion Extension Abduction Adduction Circumduction Hip Flexor Strains Psoas Major Iliacus Rectus Femoris Pectineus Rectus Femoris Two joint muscle Midbelly tear May have palpable divot Painful movements… Pectineus Most under diagnosed flexor strain Action: flexes, adducts and internally rotates hip Adductor Strain More severe strains tend to be at proximal attachment MOI: Violent external rotation with leg abducted Overextension via violent stretch or contraction Overuse Piriformis Syndrome MOI: Prolonged sitting/overuse Sudden ↑ in activity Buttock trauma Direct trauma, hemorrhage or spasm of piriformis puts pressure on sciatic nerve Piriformis Syndrome S/S and Tx Signs and Symptoms: Treatment: Numbness/tingling in ↓ muscle spasm (ice) buttock, post. thigh, down Stretch piriformis to relieve leg stress on nerve Point tenderness upon Correct mechanics of palpation of muscle pelvis! Active & resisted ER = painful Passive IR = reproduction of tingling Osteoarthritis of the Hip Articular cartilage degeneration Bone on bone Osteophyte formation Potential causes: Uneven distribution of weight Biomechanical dysfunction Previous trauma Overweight Age Genetics Treatment: - Corticosteroid, HA injections - Therapy to maintain function and stability - Total/partial replacement Labral Tears Ring of cartilage outlining hip socket Causes: Trauma Anatomical defect Overuse in extreme ROM Symptoms: Pain in the hip or groin, often made worse by long periods of standing, sitting or walking or athletic activity A locking, clicking or catching sensation in the hip joint Stiffness or limited range of motion in the hip join Treatments: Anti-inflammatories Therapy to restore stability Corticosteroid injection Surgery Femoroacetabular Impingement occurs when the femoral head (ball of the hip) pinches up against the acetabulum (cup of the hip) Causes: Kicking, swinging leg, squatting, trauma Symptoms: Pain in the groin during or after activity or when sitting for long periods of time Difficulty flexing the hip beyond a right angle Hip stiffness Trouble going up stairs Limping A loss of balance Treatment: corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, rest and surgery Conditions of the Knee Joint Knee Movements Flexion (0 to 135°) Extension (0 to 15°) With the knee flexed: Medial Rotation (20-30°) Lateral Rotation (30-40°)  MCL Sprain Blow to lateral aspect of knee with foot planted Knee joint forced into valgus; twisting, cutting, rotation with foot flexed Symptoms: Will be based on severity Pain Instability Swelling Discolouration 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 LCL Sprain Forceful varus stress with internally rotated knee Isolated sprains uncommon in most sports except wrestling Direct blow to medial aspect of femur with knee flexed Symptoms: Sharp, lateral pain Instability may be subtle Swelling neither immediate nor impressive; if present, localized over ligament and tracks distally 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  ACL Sprain Rapid change in momentum or direction (cutting): Sudden forcible internal rotation of femur on fixed tibia while knee is abducted (valgus) and flexed Forced hyperextension of knee with internal rotation of tibia on femur (MCL)—terrible triad Violent force from behind with foot fixed, driving the leg forward on the thigh ACL: S/S “Pop” or “snap” sensation, knee goes “out” Pain may be minimal to severe, transient or constant Described as being “deep in the knee” Effusion/hemarthrosis usually present unless capsule torn; 24 hours (often immediate) Patient c/o instability Tenderness anterior tibial plateau ROM limited ACL: Treatment PIER, immobilize knee Crutches Referral to ortho necessary Hamstring strength is key to rehab Post-op treatment dependant on surgeon’s protocol Bracing for RTS recommended for first year post-op PCL: MOI Sudden forcible external rotation of femur with foot fixed while knee adducted & flexed Forcible displacement of tibia backwards on femur while knee flexed Fall on flexed knee with force on upper end of tibia Relatively uncommon in sports, knee hyperextension is most common or dashboard injury in MVA Treatment: MUST accurately assess posterior instability Acute treat as per ACL Re-establish quads strength/function to overpower action of hamstrings Quad strength goal = 60% body weight Proprioception  Meniscus Tears 80% of all meniscus tears = medial side Foot fixed, weight-bearing, medial rotation of femur on tibia, valgus force to knee (includes MCL) Poor blood supply except at MCL attachment (↑ chance of healing here) Symptoms: Knee swelling (synovial irritation) Occasional “giving way” Pain on same side as injury, joint line Recurrent swelling with use Quads wasting Positive McMurray’s test (65-75% tears) Recurrent “clicking” with use Unable to perform bilateral deep squat Locking – 1 solid lock usually = surgery Meniscus: Treatment Immediate: Surgical: Do NOT force a locked knee into Arthroscopy extension Day surgery: patient walks out of PIER hospital NWB and refer to consult 10-14 days post-op possible to RTP but potential complications Treat for swelling and strengthen around the joint Patella Femoral Pain Syndrome (PFPS) Term used until knee viewed internally Includes several syndromes causing pain in anterior aspect of knee Causes: Patellar malalignment Congenital abnormalities in patella (too small, too large etc.) Wide hips/Q-angle Knee malalignment (bowlegged etc.) Muscle imbalance (tight lateral structures, weak medially) Treatment: Depends on cause Stretch tightness Strengthen weakness Hip strengthen Foot alignment True Chondromalacia Patella “Sick cartilage of the patella” True degeneration in articular cartilage of patella Term can ONLY be applied post-surgically Treatment: FIND THE CAUSE, TREAT THE CAUSE ↑ patellar mobility Restore quads syncronicity Restore knee mechanics Strengthen quads Stretch lateral compartment Correct foot biomechanics Educate PIER Patellar Tendonitis – “Jumper’s Knee” Repetitive or eccentric knee extension activities (running, jumping) Between inferior pole of patella and tibial tubercle Tenderness, Stages of Pain 1.After activity 2.During and after activity 3.During and after activity (performance affected), P constant,  risk of rupture PIER after activity, rehab (massage, stretch), tape, brace Osgood Schlatter’s Disease Apophysitis of tibial tubercle MOI: Traumatic fracture or avulsion fracture of tib tub epiphysis Excessive constant forceable pull of patellar tendon on tib tub before bony closure (most common) Avascular disturbance of growth centre Osgood Schlatter’s Disease Growth plate inflammation around tibial tuberosity. S/S: Pain on direct pressure (kneeling) Pain on active use (climbing stairs, running, jumping) Pain extreme end range of extension Enlarged tibial tubercle 3x more common in males Age 10-15 males, 8-13 females Bilateral 25-30% of the time Treatment: Time Stretching Gradual strengthening Wraps, straps Bursitis Around the Knee Suprapatellar Bursa Pre Patellar Bursa Superficial Infra Patellar Bursa Deep Infra Patellar Bursa Pes Anserine Bursa Bursitis Around the Knee General Mechanisms: General S/S: Localized swelling, Direct Blow (repeated, tenderness one time) Warm, red, spongy Friction Hx overuse, trauma Crepitus with mvmt Poor Biomechanics ↓ ROM Rebound pain with mvmts Night pain Bursitis Around the Knee General 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: MOI: Lean individuals Over-use irrititation of ITB Varus knee (malalignment) over lateral epicondyle of Precipitated by contusion femur in flexion and Continuous running extension Training errors Bursitis or irritation of ITB Banked surfaces itself Running downhill Increased training Ilio Tibial Band Friction Syndrome S/S: Treatment: ↑ pain as activity time ↑ PIER Pt. tender over epicondyle (2- Address mechanics 3cm above lateral joint line) Good warm-up, stretches Crepitus with flex/extn Gradual RTP Stair climbing aggravates Stop activity if pain returns Resisted knee flexion = no pain Strains of the Lower Leg Tibialis Anterior Gastrocnemius strain Improper footwear Caution necessary or could lead to Down hill running rupture Poor warm-up Chronic irritation can = calcification Poor warm-up and stretching, running Poor Arch support uphill, poor footwear can cause this Anterior Compartment Syndrome Slow return to activity Peroneal Strain Usually secondary to an inversion ankle sprain Need to be strengthened in inversion sprain rehab “SHIN SPLINTS” 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 Inflammation of the muscle belly Tearing of the muscle from bone (creates a periostitis) Tearing of interosseous membrane Prevention the key Treatment: Rest, change activity Footwear change Stretch, strengthen gradually Lateral Ankle Sprain Anterior Talo-Fibular Ligament (ATFL) Calcaneo-Fibular Ligament (CFL) Posterior Talo-Fibular Ligament (PTFL) MOI: “Rolling” of the ankle; inversion Often coupled with plantar flexion (landing from a jump) Cutting, uneven ground Lateral Ankle Sprain con’t. S/S: Treatment: Instability (grade dependant) Keep ankle joint in neutral position Pain with Inv and PF to shorten ligaments Swelling PIER Discolouration Open gibney Positive anterior drawer test Crutches (higher grade) X-ray Strengthen peroneal group Achilles Tendonitis Gastrocnemius, Soleus, Plantaris MOI: Ankle plantar flexors ↓ flexibility Foot-type: pes planus vs. pes cavus New footwear Changes in training schedules ↑ mileage ↑ hill training Achilles Tendonitis Treatment: Prevention: FIND THE CAUSE Gradually increase activity Rest Proper time and progression of Frictions/Ultrasound for adhesions warm-up Heel lift for shoe ↑ Flexibility of G-S complex Taping Proper footwear Gradual stretching, strengthening, Recognition of early signs eccentrics Plantar Fascitis high arched, rigid foot OR flat foot Prolonged pronation – excessive motion Footwear Training habits Partial/complete tear of ligament Plantar Fascitis Signs/Symptoms: Treatment: Point tender, medial side of PIER (REST, ICE) calcaneous X-ray Localized pain (origin) Ultrasound Stiff in AM or after inactivity Stretch Achilles Swelling/inflammation Proper footwear Tape Unable to walk on toes Orthotics, heel cup Pain ↑ with passive toe extension Balance Pelvis Roll/massage tendon