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
Posterior Superficial Muscles
Function of Posterior Superficial Muscles
Posterior Deep Muscles
Tiblialis posterior, flexor digitorum longus, flexor hallicus longus
Function of Posterior Deep Muscles
Function of peroneals
eversion, stabilize @ subtalar joint
Function of Peroneus Longus
stabilizes 1st joint during pushoff
anterior tibialis, EDL, EHL, peroneus tertius
Function of Anterior muscles
prime dorsiflexors, eversion
Best Strengthening Exercise for lower leg and ankle
Most Injuries occur in the ____ compartment
"Foot Slap" gait
inability to control eccentric movement during gait
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
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
Plantar Faciitis Return Time
Worst type of shoes to wear
cleats b/c they offer no support
What type of Joint is the Knee
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
stability vs. valgus forces, prevent excessive ext rot forces (tight in flexion, loose in ext)
stability vs. varus forces (loose in flexion, tight in ext)
True/False: LCL is more commonly injured than MCL
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
main stabilizer of knee, prevents posterior translation of tibia (some portion tight throughout ROM)
True/False: The quads work to support the PCL
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
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
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
MOI for an ACL sprain
cutting and jumping
During an ACL sprain the tibia ____ rotates and the femur ____ rotates
True/False: Males are more likely to sprain their ACL than females
True/False: A person needs their ACL to function properly
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?
True/False: ACL surgery is needed for 2nd degree and partial tears
How long should rehabilitation be for non-operative ACL patients?
Non-Operative ACL rehab structure
WB ASAP, aggressive CKC strengthening, increase HS strength, increase stability
True/False: degeneration occurs with each ACL surgery
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
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...
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
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?
How long does rehab last for a meniscal repair?
Static stability of the shoulder comes from ____
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
The scapulothoracic joint plays a big role in ____
Ligaments of the acromioclavicular joint
acromioclavicular and coracoclavicular ligament
The shoulder sacrifices stability for ____
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 ___
Inferior glenohumeral ligaments limits ___
ABD, ext, ER
The most stress is placed on the shoulder in ____
ABD, ext rot and ext
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.
SLAP lesions are more likely to occur with ___ dislocations
injury to inferior GH ligament
Hill Sachs lesion
cartilagenous damage to the head of the humerus
What is the reoccurence rate of shoulder dislocations?
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
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
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?
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
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?
What are the most common elbow pathologies seen in the clinical setting?
What is the RTA time for post-op elbow reduction?
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 ___
The PLL restricts ___
Disc problems in the LB tend to occur____ and ___ in the C-spine
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?