Foot,Leg and Ankle, Knee, Shoulder, Elbow, Spine

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Function of the Foot and Ankle

act as a lever to propel the body forward

ROM @ Talocrural Joint

@ minimum 50 degrees of plantarflexion and 20 degrees of dorsiflexion before starting activities

Function of Subtalar Joint

supination, pronation

Posterior Superficial Muscles

gastroc, soleus

Function of Posterior Superficial Muscles

concentric pushoff

Posterior Deep Muscles

Tiblialis posterior, flexor digitorum longus, flexor hallicus longus

Function of Posterior Deep Muscles

inversion

Lateral Muscles

Peroneals

Function of peroneals

eversion, stabilize @ subtalar joint

Function of Peroneus Longus

stabilizes 1st joint during pushoff

Anterior Muscles

anterior tibialis, EDL, EHL, peroneus tertius

Function of Anterior muscles

prime dorsiflexors, eversion

Best Strengthening Exercise for lower leg and ankle

therabands

Most Injuries occur in the ____ compartment

anterior

"Foot Slap" gait

inability to control eccentric movement during gait

Common Abnormalities

over pronation/supination

Over Pronators are susceptible to:

stress injuries, plantar facitis, bunions, stress fx of 2nd MT, medial knee probs

Over Supinators are susceptible to:

inversion ankle sprains, calcaneal fx, lateral knee probs

Largest Inhibitor of Ankle ROM

pain and inflammation

ROM exercises for ankle

ABC's, balance board, towel stretch

Proprioception exercises for ankle

stork stand

Conditioning exercises for ankle

water workouts, UBE, fwd/bkwd movements, hop on one leg

Achilles Tendon Rupture

Most significant lower leg injury. Common in older population and "weekend warriors". Inability to push off during gait

Return Time for Achilles Tendon Rupture

6 months (aggressive), 9 months (conservative)

Most Common Ankle Sprain

Inversion

Plantar Faciitis Return Time

8-12 weeks

Worst type of shoes to wear

cleats b/c they offer no support

What type of Joint is the Knee

hinge joint

Screw Home Mechanism

ext rot of tibia, int rot of femur to provide full knee ext

Function of the Knee

midpoint of kinetic chain of LE, provides stability in weight bearing, mobility during locomotion

Knee is unstable during ____ movements

rotational and lateral

MCL function

stability vs. valgus forces, prevent excessive ext rot forces (tight in flexion, loose in ext)

LCL function

stability vs. varus forces (loose in flexion, tight in ext)

True/False: LCL is more commonly injured than MCL

False

ACL function

prevents anterior translation of tibia, prevents ext rot of knee (tight in extension, loose in flexion)

True/False: HS work to support the ACL in preventing anterior translation of the tibia

True

PCL function

main stabilizer of knee, prevents posterior translation of tibia (some portion tight throughout ROM)

True/False: The quads work to support the PCL

True

Menisici function

provide cushioning and space in between tibial plateau and femoral condyles, help distribute ground reaction forces in WB

More commonly injured meniscus

medial, b/c majority of weight is placed on medial femoral condyle in WB, and MCL partially attached to meniscus so there is less movement

Largest sesamoid bone in body

patella

Patella function

lengthens lever arm of quads increasing force output, distributes compression forces on quads tendon during knee flexion, protects patellar tendon against frictional forces

True/False: Baby's are born with patellas

False

OKC exercises for the knee

increased tibial translation, rectus activity, shear forces, patellar compression

CKC exercises for the knee

dynamic stability, joint compression, vasti muscle stimulation

True/False: SLR are the only OKC exercises that are ok to have patient to perform post-op

True

MOI for an ACL sprain

cutting and jumping

During an ACL sprain the tibia ____ rotates and the femur ____ rotates

externally, internally

True/False: Males are more likely to sprain their ACL than females

False

True/False: A person needs their ACL to function properly

False

What are the 4 options for ACL reconstruction?

patellar tendon graft, semitendinosus graft, allograft, double bundle graft

What is an allograft?

tendon taken from a cadaver (usually an achilles tendon)

When is a patellar tendon graft used during an ACL surgery?

when dealing with large individuals

When is a semitendinosus graft used during an ACL surgery?

volleyball, soccer players

When is an allograft used during an ACL surgery?

usually the 2nd-3rd surgery

Of the 4 techniques of ACL surgery, which is the newest?

double bundle graft

Which graft has the highest failure rate of the 4 techniques?

allograft

True/False: ACL surgery is needed for 2nd degree and partial tears

False

How long should rehabilitation be for non-operative ACL patients?

3-4 months

Non-Operative ACL rehab structure

WB ASAP, aggressive CKC strengthening, increase HS strength, increase stability

True/False: degeneration occurs with each ACL surgery

True

How long should rehabilitation be for post-op ACL patients?

8-9 months conservatively, 4-6 months accelerated

True/False: Doctors have no problem signing off on accelerated rehab for post-op ACL patients

False

Post-Op Timeline

early tensile strength, graft necrosis: 6 weeks, revascularization: 8-16 weeks, remodeling: over 4 months

When is the ACL graft most likely to fail?

week 6-8, during graft necrosis, b/c patient is becoming more functional

Rehab protocol for months 2-4 for post-op ACL should focus on...

HS strength and forward movements

How long does the remodeling phase last?

up to 2 years

Rehab protocol beyond 4 months for post-op ACL should focus on...

agility

Why is there a 3-4 week period btwn dx and surgery date for a torn ACL?

get rid of inflammation, possible pre-op PT

#1 goal for acute post-op ACL patients

control inflammation (cryo-cuff, compressions wrap)

Conservatively, how long should you wait before taking the patients crutches away for ACL?

2 weeks normally, up to 6 weeks if severe

When should patient start working on ROM post-op?

immediately (24-48 hrs ideally), want 110 degrees by day 10-14

What motion do we want to attain more than anything else

knee extension

During the strengthening phase, what exercises should be avoided?

any exercises that put stress on the graft or produce shear forces (kicking)

True/False: CV fitness should not begin until the remodeling phase of rehab

false, it should be worked in throughout the entire rehab process

Before return to activity what does the patient need to achieve?

85-100% strength ratio (quads-HS) bilaterally, stability, confidence in their own knee

MOI of a PCL sprain or tear

fall with knee flexed to 90 w/ posterior force on tibia

How long does the rehab for a PCL last?

9-12 months (aggressively)

When should the patient have surgery for a meniscal injury?

only if there is a physical restriction (locking/catching)

What are some surgical options for a partially torn meniscus?

partial menisectomy, meniscal repair (suture the piece back down)

How long does rehab last for a partial menisectomy?

2 weeks

How long does rehab last for a meniscal repair?

4-6 weeks

Static stability of the shoulder comes from ____

non-contractile tissues

4 ligaments of the sternoclavicular joint

Ant/post sternoclavicular, costoclavicular, intraclavicular

True/False: The sternoclavicular is the only true articulation between the trunk and the UE

True

The scapulothoracic joint plays a big role in ____

shoulder movement

Ligaments of the acromioclavicular joint

acromioclavicular and coracoclavicular ligament

The shoulder sacrifices stability for ____

mobility

Group I Dynamic stabilizers of the shoulder

originate on the axial skeleton and attach to humerus. Latissimus dorsi and pec major.

Group II Dynamic stabilizers of the shoulder

scapular origin. deltoid, teres major, rotator cuff muscles

Static Stabilizers of the shoulder

glenohumeral ligaments, joint capsule, labrum

3 glenohumeral ligaments

anterior, posterior, inferior glenohumeral ligaments

Anterior glenohumeral ligament limits ____

ext, ABD, ER

Posterior glenohumeral ligament limits ___

ext, ER

Inferior glenohumeral ligaments limits ___

ABD, ext, ER

The most stress is placed on the shoulder in ____

ABD, ext rot and ext

Scapulohumeral Rhythm

0-30: no scapular movement, 30-90: scapula abd and upwardly rotates 1 degree for every 2 degrees of humeral elevation, >90: 1:1 ratio

True/False: Shoulder immobilization is not preferred because we don't want scar tissue to build up.

False

SLAP lesions are more likely to occur with ___ dislocations

posterior

Bankhart lesion

injury to inferior GH ligament

Hill Sachs lesion

cartilagenous damage to the head of the humerus

What is the reoccurence rate of shoulder dislocations?

85-90%

Rehab progression (conservative)

for 1st time dislocations (12 weeks).

What position needs to be avoided during rehab?

ABD, ext rot, ext

Phases of Rehab

Phase I: Protective Phase, Phase II: Motion Intensive, Phase III: Strength and Neuromusc. Function, Phase IV: Functional Progression

Conservative Phase I: Protective Phase (weeks 1-3)

pain management, PROM (<90), isometrics. Patient will be in sling anytime outside of PT.

Conservative Phase II: Motion Intensive (weeks 4-6)

AAROM, CKC activities, begin PNF by week 6.

Conservative Phase III: Strength and Neuromuscular Control (weeks 7-9)

eccentric rot cuff, stabilization (scapular, rhythmic), core, OKC, PNF (overhead)

Conservative Phase IV: Functional Progression

endurance, sport specific

Surgical Intervention for Shoulder

(7-10 months total) repetitive trauma loosens structures. patient compliance is critical (will be in sling for 4-6 weeks)

Surgical Phase I: Protective Phase (weeks 1-6)

PROM (1-3), AAROM (4-6), shoulder shrugs, wrist and elbow at side. ROM <90

Surgical Phase II: ROM intensive (weeks 7-12)

restore full ROM, isotonics, begin ABD/ext/ext rot. rhythmic stab, PNF and OKC's by week 12

Surgical Phase III: Strengthening Phase (weeks 12-24)

advanced strengthening, endurance, neuromusc control, plyos. (sedentary individuals should be fully functional)

Surgical Phase IV: Functional Activity (for athletes)

functional activities, throwing progressions

Shoulder Impingement

compression of supraspinatus, subacromial bursa, and long head of biceps tendon

MOI of Shoulder Impingment

repetitive overhead activities

Rehab Shoulder Progression

reduce p!, address biomechanics, CV fitness, stabilize/strengthen, NM control

Adhesive Capsulitis

decreased GH motion with restricted elevation and ER

MOI of Adhesive Capsulitis

inidious. capsule becomes thick and fibrotic

Ligaments of the Elbow

radial collateral, ulnar collateral, annular

Which elbow ligament is more commonly damaged?

UCL

Function of the annular ligament

support and hold in head of radius

Joint Motion of the elbow

145 flex, 90 pron/sup

What major structures run through the elbow?

ulnar, median, radial nerves and brachial artery

Osteochondritis Dessicans

loose bodies in the joint from repetitive compressive forces

What is the only difference between osteochondritis dessicans and Panners Disease

Panner's disease occurs in children <10 y/o

MOI of elbow UCL injuries

valgus stress/ hyperextension (especially with OH throwing)

What surgery is associated with UCL injuries?

Tommy John's Surgery

Nerve Entrapment occurs ___

secondary to other injury.

Ulnar Nerve entrapment

most common nerve entrapment because of easy access. Caused by direct trauma which leads to traction

Median Nerve entrapment

caused by compression

Radial nerve entrapment

caused by the lateral head of the triceps

Which way does the elbow more commonly dislocate?

posteriorly, because of the bony structure

MOI of elbow dislocations?

FOOSH

What are the most common elbow pathologies seen in the clinical setting?

medial/lateral epicondylitis

What is the RTA time for post-op elbow reduction?

12 weeks

MOI of medial/lateral epicondylitis

repetitive microtrauma to wrist flexors or extensors

cervical and lumbar vertebrae tend to move___

anteriorly and laterally

Ligaments of the spine

ALL, PLL, interspinus, supraspinus, transverse, sacral ligaments

The ALL restricts ___

extension

The PLL restricts ___

flexion

Disc problems in the LB tend to occur____ and ___ in the C-spine

posteriorly, anteriorly

An indication for joint mobs is ___

pain at specific joint that increases with activity and has decreased motion

What should be avoided if the patient is diagnosed with spondylolysis/spondylolisthesis?

hyperextension, manipulation

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