Summary, all lecture PDF

Preview

Summary

Condition Presentation Examination Pathophysiology ManagementAcute ankleinjuryAnterior talofibular ligament sprain: Pain, swelling, TOP, possibleecchymosis just ant & inf to lateralmalleolus Aggravated by weight bearing andcombined inversion and plantar flexion Complete tear may be pa...

Description

Condition Acute ankle injury

High ankle sprain/ syndesmotic

Presentation Anterior talofibular ligament sprain:  Pain, swelling, TOP, possible ecchymosis just ant & inf to lateral malleolus  Aggravated by weight bearing and combined inversion and plantar flexion  Complete tear may be painless

   

MOI = external rotation of foot upon leg or hyperdorsiflexion Pain is focal above the ankle joint Less significant swelling Poor tolerance of WBing

MOI = compression + shearing Persistent ache at rest May present with swelling Poor tolerance of Wbing or compression or loading Later:  Fails to resolve as normal ankle sprain  Slow recovery (>6weeks)  Persistent swelling

Talar Dome injury

   

Calf Strain

  

Athletic population 40-60 yo – sedentary + unaccustomed load Sudden sever pain in leg (kicked sensation)

Examination Supination grading  Grade 1: Partial tear ATFL  Grade 2: complete ATFL + partial CFL  Grade 3: Complete ATFL + CFL +/- PTFL  This indicates severity

TOP proximally over the anterior TF ligament  TOP proximal along interosseous membrane Ortho  ER/ Squeeze  Persistent effusion  TOP over talar dome  Altered joint mobility  Reduced or increased depending upon original mechanism  Compression or shearing recreate pain 

  

TOP medial or lateral belly Bruising on observation Pain on toe raise, push-off muscle stretch

Pathophysiology MOI  85% are supination mechanism: Inversion, Plantarflexion, Adduction  10% syndesmottic sprains: DF, Eversion  5% medial complex sprains: DF, Eversion

Management

ROM, reduce pain and swelling, protection  Patient education  Limited Wbing for period  Long term – manual therapy Medical referral Imaging  Plain film  Ct  Bone scan

  

SPRICEMM Graduate rehabilitation Address predisposing factors

Achilles tendon-opathy



    

Achilles Rupture

Plantar Fasciitis

Dull non-radiating ache around the heel or lower calf – could be insertional, mid or both Aggravated by load Eased by rest Morning stiffness Insidious onset May have acute overload

Ultimate end-stage of tendonopathy Partial/full Acute trauma:  Sharp pain – feeling of being kicked or shot  Hx of long standing degenerative tendonopathy  Previous rupture  Popping or snapping at time of injury  

    

Gradual onset of burning pain/ache in proximal MLA Common in running athletes: Unaccustomed load or increase? AM stiffness and pain on WB Aggravated: Wbing (running, walking) Can have acute onset

MOI: Local and uniform tendon thickening  Training regime (load, pattern,  TOP – achilles, or insertion technique)  Fx: heel raise recreates, jog,  Surface jump, hop  Imaging: US/MRI LE mechanical faults:  Lack of DF  Poor gluteal function  Poor LP control  Swelling of the calf Functional critical test:  Inability to heel raise  Push off affected in gait ROM: Loss of AROM in PF. Increased PROM DF compared to other side  Palpation of gap or step or loss of contour  Thompson test  Fx: avoid loading through 1st MTP with heel raise and pain on SL/DL heel raise  ROM: Loss of 1st MTPJ extension (length of PF)  Pain on DF (Windlass mechanism)  Local, mild swelling  Palpation: local TOP (medical calcaneal tubercle. Also local thickening of palpation or crepitus 



 

   

Grade 3 tears in isolation restricted bracing for 2-3 weeks, gradual weight bearing, rehab Grade 2 tears 2 weeks of hinged bracing, and rehab Grade 1 tear rehab.

Surgery or conservative Immobilised post op for 12 weeks Immobolised 6-8 weeks if conservative Rehab – ROM, strength and coordination

Rest: Unload from exacerbating exercise  NSAIDs or local steroid injection  EPA if acute Taping: Variety of techniques, Heel raise, Orthotics Correct lower limb mechanics:  Gastroc and Soleus length  Strengthen Plantar flexors  Improve rear and midfoot mobility 

Medial Tibial Stress syndrome (Shin splints)

Stress fracture

Pain @ attachment of posterior compartment muscles of tibia: Most commonly posterior tibialis  Intrinsic factors: o Excessive or uncontrolled pronation o Muscle tightness (PFs) o Running technique  Extrinsic factors o High or unaccustomed load o Hard training surfaces o Poor footwear Gradual onset:  Increased unaccustomed load  Deep, nagging pain with exercise  Pain @ rest also well localised pain 

TOP:  Medial border of tibia (~6cm region at the junction proximal 2/3 and distal 1/3 of medial tibial crest  Tibialis posterior +/-medial border of soleus

Can also occur:  Anterolateral  Posteromedial Usually due to:  Eccentric overuse leading to an inflammatory musclotendinous injury

TOP is point tenderness on shaft/site Imaging  Early–ve  Late +ve n BS+ve 

  



   

Sever’s Disease     

Distal symmetric polyneuropathy





Active Child 7-15 years Pain @ achilles insertion Posterior inferior heel pain n Absent when child wakes Similar presentation to OSD Aggravated by Wbing, running or jumping



Decreased distal deep tendon reflexes, as well as pain, dysethesia, or paresthesia in the feet or toes Vibration and light touch usually absent



   



Excess pronation & tight plantarflexors Limp on Gait pattern TOP @ insertions of tendons Limited DF on ROM Imaging – traction spur on XR Retrograde axonal degeneration = distal to proximal distribution Electromyography studies and biopsy confirm diagnosis

   



Acquired immunodeficiency syndrome, alcohol/drug abuse, carcinoma, diabetes mellitus, kidney failure, malnutrition



Usually self resolving after skeletal maturity Guide participation in sports by severity Could be painful to continue, but not necessarily cause more harm Address muscle imbalance

Confirm Can require 3/12 rest (protective footwear) Reviewing intrinsic and extrinsic factors Consider low load bearing exercise Tends to be self limiting (few weeks to 2 months) Rest May need to address lower limb mechanics Consider reloading principles Treat underlying pathology

Compartment syndrome

Anterior compartment:  Early signs of paresthesia and  Weakness of the foot and toe hypesthesia in the anterior lower leg and dorsal foot dorsiflexion muscle groups Distal deep compartment:  Followed by significant pain,  Weakness of foot plantarflexormassive edema, ecchymoses, invertors and toe flexors muscle groups ST tenderness, erythema and Lateral compartment: palpable warmth  Weakness of foot plantar flexors pulses and capillary refill evertor muscle group usually normal until pressure Posterior compartment: increase to severe injury level  Weakness of the plantar flexors and toe flexors

 Superficial Peroneal Nerve entrapment

Sural Nerve entrapment



Tibial Nerve  entrapment (tarsal tunnel  syndrome) Anterior ankle  impingement

Pain, paresthesia, dysesthesias, or numbness on the antero-lateral lower leg and dorsum of the foot Pain, paresthesia or hypesthesias along the posterior calf, posterolateral ankle and dorsolateral foot

Pain, paresthesia or hypesthesias along the post. calf, medial ankle and plantar surface of the foot Motor symptoms less common Pain in the anterior ankle during dorsiflexion activities



 

 PF and foot inversion are often aggravating factors  + ve tinels sign  foot eversion weakness  + ve tinels sign  No motor involvement (sensory afferent only nerve)



 Pain aggravated by weight bearing and compression of the nerve, relieved by rest  +ve tinels  Ankle may be tender on palpation if osteophytes present on talus or tibia  Decreased talor glide  +ve ankle impingement







Spontaneous in patients with diabetes mellitus Usually results from trauma Altered vessel perfusion and edema result in increase intercomparmental pressure that disrupts oxygen diffusion and results in ischemia traumatic or idiopathic entrapment



Medical emergency and requires immediate surgical decompression



Ankle sprains, stretch injury, Achilles injury, trauma, ganglionic cyst compression, calcaneal fx SOL, fx, calluses, arthritis, osteophytes, edema, bursitis, tendonitis Compression of osseous or ST structures; meniscoid lesion of organized scar tissue from repeated strains



conservative or surgery to release entrapment sire radiculopathy must be ruled out Conservative or surgical to release entrapment site Radiculopathy must be ruled out





   

Conservative or surgical to release entrapment site Radiculopathy must be ruled out Conservative Arthroscopic debridement in case of recalcitrant symptoms and disability

Bursitis



Pain, palpable warmth, TOP and some swelling of the medial and lateral aspects of the Achilles (retrocalcaneal bursa) or just posterior to Achilles tendon insertion (subcutaneous bursa)

Gout



Severe pain, edema, warmth, erythema and very localized tenderness, Typically: the 1st metatarsophalangeal joint, talocurial, calcaneal and tarsals of the instep Systemic findings: fevers, chills, malaise, sweating





Ankle OA

 

Hallucal Sesamoid Disorders

 

Freiberg’s  (AVN of the 2nd /3rd metatarsal  head) Hallux Rigidus (1st MTP OA)

 

 Tenderness on firm palpation of bursa  Retrocalcaneal bursitis may have associated prominent posterosuperior calcaneal tuberosity  Pain provoked by hard movements or may follow alcohol abuse, dehydration, trauma, surgery, septic arthritis, protein fasting, excessive purine ingestion, allopurinaol or uniosuric agents  Reduced ROM  Hard end-feel, crepitus  Increase pain and stiffness in the morning and prolonged static postures  Dorsiflexion of the first metatarsophalangeal joint  Bone scan to confirm



Trauma, systemic disease, biomechanical or structural factors

 

Activity modification Conservative care



Sustained hyperuricemia levels lead to deposition of monosodium urate crystals in and around tendons and joints M>F 8:1 Primary or secondary to conditions that affect the intraarticular environment Fracture can occur with direct trauma, an avulsion, or repetitive trauma

 

Anti-inflams Colchicine in those with normal liver function Preventative treatment should be taken to control uric acid levels in diet and medication in individuals with chronic gout Physical therapy Corticosteroid injections Total joint arthroplasty

Pain and tenderness, edema over the 2nd and thirds metatarsal heads F>M

 MC the 2nd metatarsal head (75%)  Bone scan or xray to confirm



Osteochondrosis with AVN that follows repetitive trauma



Pain, edema, and tenderness at the 1st MTP Gait abnormality: a decrease terminal stance phase and rolling the foot into supination

 Decrease ROM  Possible bony promimence with redness  Pain on MTP extension



Results from degenerative changes

   

Pain with localized tenderness at the involved joint, Pain onset is gradual, symptoms are worse with exercise and weight bearing Pain and TOP of involved sesamoid

 





  

 



Immobilization, protective weight bearing, Recalcitrant pain and disability may require surgical excision Immobilization is primary treatment Surgical debridement for advanced cases Physical therapy Footwear modification Orthose Surgery: wedge osteotomy

Hallux Valgus

  

Hammer Toe Deformity



Longitundinal Arch Strain





Morton’s Neuroma

Calcaneal branch neurodynia (tibial nerve branch) Deep Peroneal nerve entrapment

 

 

 Medial pain, edema, redness,  May seen point deformity tenderness of the hallux (lateral deviation of the hallux at the MTP) Metatarsalgia pain Difficult wearing tight/desired footwear  Adventitious bursa may develop  Pain, redness, tenderness, blister  May have hx of subungual formation/presence of corn or callus hematomas as a result of  formation repetitive trauma



 

PIP flexion with DIP extension Resulting from repetitive trauma Prolonged weight bearing that results in ligament sprain or muscle fatigue

 

Thickening and fibrosis of the interdigital nerve: MC in the 3rd intermetatarsal space

 

 

Physical therapy Footwear modification Orthose Surgery: to reduce deformity Physical therapy Surgery if intolerable pain/biomechanics Physical therapy Activity/footwear modification Anti-inflams Stretching/strengthening musculature

Pain on the plantar aspect of the foot,  primarily along the medial aspect of the foot  History/ signs of: Excessive foot pronation, pes cavus, pes planus or excessive ligament laxity

Aggravated by weight bearing and dorsiflexion Alleviated by plantar flexion and rest



Sharp/burning forefoot pain or numbness that may be generalized or in the distribution of a specific digital nerve



Pain with compressive footwear and weight bearing on metatarsal heads during walking, standing, or active ankle dorsiflexion



Local medial heel pain, located inferior & posterior to the tarsal tunnel. Valgus hindfoot posture is common

 

TOP Increased with weight bearing neural tension testing with ankle in dorsiflexion and foot eversion



compression or tension due to SOL, fx, calluses, arthritis, osteophytes, edema, bursitis, tendinitis, accessory bones

 

physical therapy surgery to release entrapment site

ankle plantarflexion or inversion may increase symptoms anteriolateral ankle pain or weakness of dorsiflexion



extensor retinaculum is the most common site of entrapment. Other sites: tight showlaces, anterior compartment synd

 

Physical therapy Surgery to release entrapment site





Abductus deformity with associated cartilage damage within the 1st MTP

pain, numbness, dysesthesia, and/or paraesthesia at the first dorsal web space of the foot







   

 

Corticosteroid injection Orthose/footwear/activity modification Gentle exercise Address strength deficits

Condition Rib Fracture

Presentation         

Pleurisy

        

GORD

     

Usually involves a blunt traumatic incident Or fall onto chest Mc: is posterior lateral Maybe pathological Chest wall pain Pain on breath or guarded respiration Observation (bruising, swelling, noticable defect). Palpation (elicit pain, palpable step) AP pressure will often recreate the pain, avoid pressing through the site Sharp stabbing pain Pain may be constant or intermittent SOB Aggravated by: Deep inspiration, Movements, Coughing May be tender to palpation of the chest wall Constitutional signs Pleural rub on auscultation Blood tests – infection? Chest X-ray “heart burn” in anterior chest near lower sternum Sour taste and difficulty swallowing. Can be described as a lump in the throat. Pain can radiate and simulate MI Pain on swallowing, nausea, vomiting, coughing. (Large meals + lying down) Symptoms may be aggravated by bending forward or lying down.

Examination   

Oblique films PA chest for co-existing pneumothorax May not be evident on radiographs until callurs formation occurs.

Pathophysiology

Management     

  

 

 

Kinesiotape (or supportive taping techniques). Minimise movement – bone healing times. If suspect multiple fractures refer for medical evaluation. Or if suspicious of visceral involvement, then also refer. Gradual stretching and active ROM exercises later in the remodelling process. Refer for medical evaluation Small effusions are managed conservatively Large are likely treated with thoracentesis

Refer for medical evaluation. May be able to give some advice regarding postures and eating habits. o Eating smaller meals o More frequent meals, o Going to bed on an empty stomach o Avoid large amounts of caffeine, chocolate, alcohol Antacids, OTC H2 antagonists Proton pump inhibitors

Vertebral Osteomyelitis

      

Pain in the neck or back (persistent) with anterior chest pain. Other constitutional symptoms and signs. Aggravated by any movement of the spine Severe cases may present with neurological signs WARNING: can be a delay in onset of condition and presentation of S/Ss. Percussion over involved segment elicits tenderness Fever is often absent

 

Blood Tests: CRP and ESR. Imaging: plain film, MRI or CT

Refer

Condition Lateral Epicondylalgia

Presentation 

 

Cervical Radiculopathy

Median Nerve peripheral neuropathy Lateral nerve roots = C5-C7 Medial nerve roots = C8 & T1

Pain and point tenderness over the lateral epicondyle (common ECRB) Pain can refer to the wrist and hand. At risk populations: amateur tennis player, repetitive manual tasks. 30-55 years

C6  Pain in neck, shoulder, medial border of scapula.  Radial side upper arm and forearm pain.  Thumb and index finger Sensory:  thumb, index and lateral hand/forearm DTR (biceps/brachioradialis) diminished or absent Muscles innervated:  biceps brachii  brachialis/brachioradialis  deltoid  Pec major  supinator  ECRB/ECRL  Non-localised pain in the anterior forearm  Weakness of muscles associated with median nerve (FDP, FCU, Pronator quadrat)  Numbness in the median nerve distribution Proximal entrapment  Non localized aching pain in the anterior forearm and TOP Supracondylar tunnel entrapment  Deep pain in suprcondylar tunnel (supracodylar process, medial epicondyle, ligament of struthers)

Examination

Pathophysiology

Reproduced by:  Gripping or manual tasks that require manipulation of the hand  Resisted wrist extension and passive wrist flexion Grip force is reduced when compared to the other arm. C8  Pain in neck and scapula  Medial aspect of upper arm and forearm  Fourth and fifth fingers Sensory:  fourth, fifth fingers and medial aspect of forearm.  DTR = Triceps Muscles innervated:  flexor group: FDS/FDP/FPL/FCU  Extensor Group: ECRB/ED/EDM/ECU  Triceps  Palmaris longus  Must rule out C6 radiculopathy  NTPT: base test  History of repetitive resisted pronation and supination 

Management Outcome measures: PFGS  Manipulative therapy  Therapeutic exercise program  Taping techniques (offloading)  MFR  Activity modification  SLGWPFG (sustained lateral glide with pain pre grip strength)