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FF Valgus

heel strike: excessive supination
midstance: inadequate/no pronation
heel rise: inverted or may be everted

RF Varus

heel strike: early and excessive pronation
midstsance: increased IR

RF Valgus

heel strike: abducted RF
midstance: no supination
heel rise: no supination

FF Varus

heel strike/Wt acceptance: early and excessive pronation
midstance: increased IR
heel rise: increased IR

Common causes of excessive STJ pronation

o Compensation for limited DF
o Excessive tibial varum
o Achilles tightness
o Weakness of peroneus longus or ankle/STJ invertors, arch laxity
o Increased LE IR secondary to femoral anteversion or strong IRs

Ottowa Ankle Rules

• Unable to bear weigh for 4 steps plus tenderness at any of:
o Posterior edge/tip of lateral malleolus
o Base of 5th metatarsal
o Posterior edge/tip of medial malleolus
o Navicular

• Talipes Equinovarus

o Birth deformity - large spectrum of severity
o Adduction/inversion of FF & MF, calcaneal varus, fixed equinus
o Postural and congenital
o PT intervention:
 Achilles stretching
 Manipulations
 Serial casting then abduction bar

o FF Valgus

 Callous on 1st & 5th met heads
 Muscle fatigue
 Lateral knee strain
 Inversion sprains (because you are in a supinated position)

o RF Varus

 Callous on 4th & 5th met heads
 Haglands deformities
 HAV

o RF Valgus

 Medial ankle pain
 Muscle fatigue
 HAV

o FF Varus

 Callous 2,4,5
 Muscle fatigue
 4th, 5th hammer toes
 HAV
 Plantar fascitis

Equinas

• Minimum of 10° DF needed for gait
• With equinas, at 50-60%, STJ & MTJ pronate to give more DF
• Causes: muscular, congenital, osseous, acquired
• Gait: excessive and early pronation, little to no supination
• Rx: heel lift, surgery, stretching

overuse syndromes

o Shin splints, stress fx, compartment syndromes, chondromalacia, IT band friction syndrome

Shin splints

 Periostitis vs tendonitis
 Overuse & biomechanical factors
 Muscle imbalance
• Tx based upon accurate dx
• Rest, activity modification
• Biomechanical eval and adjustment
• Modalities, stretching to posterior muscles and strengthening anterior

stress fracture

 Usually metatarsals or tibia
 Sometimes difficult to differentiate from shin splints
 Dx: x-ray, repeat x-ray, bone scan

exertional compartment syndrome

 Exercise induced pain in lower leg at specific compartments
 Cramping, burning, tightness, aching
 Growing evidence for conservative tx vs surgery
 Diff diagnosis: periostitis, stress fx, vascular/neural entrapment
 ACUTE COMPARTMENT SYNDROMES ARE A MEDICAL EMERGENCY

gastroc/soleus pathologies

• Calf strain/tear, plantaris tear/strain
o Resembles achilles rupture symptoms
o Sudden onset of pain
o Supportive tx with heel lift
o Gradual ROM, stretching

achilles tendon rupture

o Sudden onset, characteristic hx, positive Thompson test
 Chronic tendonopathy or acute injury
 Age >30
 Sudden snap
 Positive Thompson, hyperdorsiflexion, palpable defect
 Diff diagnosis: tendinopathy, avulsion fx, calf strain, nerve entrapment
o Surgical repair superior to conservative tx
 Casted 6-10 weeks, rehab traditional or accelerated (early ROM, stretching, strengthening)
 Full strength in 12 months

achilles paratenonitis/tendinosis

o Diff diagnosis: bursitis, radiculopathy, nerve entrapments
o Paratenonitis: inflammatory process limited to paratenon
 Modalities, limit activity, stretching impairments addressed and gradual return to activity
o Tendinosis: non-inflammatory, intratendon mucoid degeneration, vascularity changes, low level chronic pain, fewer effusions and crepitus, tendon thickening and irregular structure
 Eccentric strengthening, address impairments and biomechanical factors

plantar fascitis

o AM pain, limited gait mechanics, pain provoked with palpation and DF of great toe
o Stretching very effective with soft orthotic and night splint
 95% recover with conservative tx - can take up to a year
 surgery = last resort, high complication rate...wait 12-18 mos
o Associated factors: obesity, pes planus, pronation, cavus feet, tight gastroc

Morton's neuroma

o Interdigital neuroma
 Local tenderness btwn met head, pain on compression
 Relieved with injection, sometimes accommodative orthotic helpful

metatarsalgia

o Painful met head
 Local tenderness, often aggravated by cavus foot or high heeled footwear
 Accommodative orthotic: soft with MT pad or cutout

calcaneal

o Extra or intraarticular
o Fx of the body are the result of a large compressive force
o Conservative vs surgical based on factors such as configuration, displacement, soft tissue involvement
o NWB during initial phase
o Lose significant STJ ROM - may lead to STJ fusion

talus

o Mostly intraarticular due to large amt of cartilage
o Osteochondral lesions as a result of forces with fx or sprains

forefoot

o Nondisplaced 2-5: tape and WBAT
o Nondisplaced 1: NWB x 2 weeks
o Displaced: must be accurately reduced
o Nondisplaced 5: jones fx = base of 5th met and avulsion fx of tuberosity - can extend into proximal diaphysis - high incidence of nonunion

phalanges

o Tape immobilization and protected WB

ankle

o Classification: lateral, medial, bimalleolar, trimalleolar
 Lateral: surgery with static or dynamic incongruency only - all others have good results with closed reduction
 Bimalleolar: usually require ORIF
 Trimalleolar: involvement of the posterior lip of the tibial plafond - usually require ORIF
 All require 4-6 of NWB
 Rehab problems: limited CKC DF, weakness, gait deficits

diabetic neuropathy

• Risk factors
o Sensory
o Microvasculature changes
o Anatomical changes: 1st met and ankle mobility, achilles and plantar fascia thickness
• Can lead to amputation if not dx and tx

hallux valgus

• Causative factors
o Biomechanical, acquired, genetic, arthritic, neuromuscular, traumatic
• Etiology
o Increase Im angle (most common reason)
o Stretching and loosening of medial sesamoid ligaments
o Bowstring affect of long tendons
o Pronatory forces
• Surgery: pain free, congruent jt, IM angle < 10, good ROM (60 degrees), cosmetic
o Arthroplasty, capsule/tendon balance procedure, arthrodesis, implant, osteotomy
• Rehab
o Edema control
o ROM restoration: early in soft tissue and implant procedures (2-4 weeks), later in osteotomies (4-6 weeks)
o Strength restoration: estim
o Gait training: platform shoe for r2-4 weeks depending upon procedure and healing

bunnionette deformity

o Prominence of lateral 5th met
o Often associated with pronation

tibial n entrapment, tarsal tunnel syndrome

• Entrapment or compression of the posterior tibial nerve, medial and lateral plantar nerves
• Occurs in the flexor retinaculum or canal created by the retinaculum
o Popliteal entrapment also possible
• Initial sensory involvement (sole of foot, lateral heel), later motor involvement (PF, INV, toe AB/AD)
• Etiology: unknown, systemic, trauma, biomechanics, gout

Jogger's foot

• Burning pain in the heel and aching in the arch
• DD: plantar fascitis, neuropathy, radiculopathy

proximal nerve entrapments

• Sural nerve btwn 2 heads of gastroc
• Common peroneal between fibular head & peroneus longus
• Tibial nerve as it passes through soleus

posterir tibial tendonosis

• Intrinsic failure of tendon
o Common in middle aged females and people with a longstanding flatfoot deformity
o Chronic tenosynovitis, attenuation of tendon
• Symptoms: pain, swelling, hx of flat feet, limited sports, recreation, ADL
• Dx: clinical exam presents with pain and weakness during contraction, loss of inversion with single limb heel raise in complete rupture, x-ray, MRI
• 3 stages
• Tx: immobilization 6-8 weeks, footwear modifications, orthotic, AFO, achilles stretch with foot in supination, stretching to invertors, muscles of arch, hip extensors, abductors, mostly eccentric

ankle sprain

• Protocol
o Acute phase (1-7 days) - protection, ice, support, appropriate WB
o Sub-acute phase (1-8 days) - modalities, progressive WB, pain free ROM, strengthening and begin proprioceptive exercises
o Rehab phase (1-3 weeks) - progression of strengthening and proprioceptive activities
o Return to activities (2-6 weeks) - jog, sprint, figure 8, etc

syndesmosis injury

• Often occurs with injured deltoid ligament and fibular fx
• Point tenderness, inability to WB
• Partial tear treated with removable cast/boot for 6 weeks with PWB
• Full tear ligament suture and tib-fib fixation
• Progress to aggressive ROM and rehab as ankle sprains after healing (6-8 weeks)

idiopathic toe walking

• Heel toe pattern by 2 years
• Strong link to hx of one or both parents
• Tx: based upon age and if there is a tendon contracture
o <3-4 & minimal contracture: conservative treatment of stretching, maybe serial casting
• DD: MD, CP, developmental delay

sever's disease

• Calcaneal apophysitis
o Activity related pain over posterior calcaneus, pain with DF, tenderness
o Middle years of childhood (6-12)
o Tx: gentle calf stretching, activity modification, orthotic

kohler disease

• Osteonecrosis of navicular
o Often 4-5 y/o
o Painful asymmetric gait, decreased PF strength, tenderness
o DD: Lisfranc injury, stress fx, midfoot sprain
o Self-limiting condition: activity modification, arch support, orthotic therapy, gentle stretching and gait training

tarsal coalition

• Complete or partial union of 2 tarsal bones
• Usually calcaneus and navicular or talus and calcaneus
• Pain and decreased ROM, sometimes initiated by trauma, confirmed by x-ray
• Usually conservative tx: orthotic, activity modification, anti-inflammatory modalities, medication

Stress sharing

• Casts
• Rods & nails
o Callous formation, rapid secondary bone healing
o Femoral & tibial shaft fxs
• Butress plates
o Used with lag and wood screws, create anatomic reduction
o Tibial plateau fxs, pt usually NWB
• Pins, wires, & screws
o Provide partial immobilization
o Threaded or non-threaded
o WB often delayed
o Ankle & patella
• Compression screws
o Delayed WB
o Fragments drawn together through the lag effect of the screw
• Sliding hip screw & plate
o Limited WB
o Proximal femoral fxs, usually intertrochanteric
• External fixator
o Maintains fx alignment & length while allowing pt to be mobile
o Used on any long bones, often with open fxs

stress shielding

 Transfers stress to device
 No motion, primary bone healing without callous
 Heals slower, requires secondary support
 Examples:
• Compression plates
o Usually UE but also used in LE
o Allow anatomic reduction & fixation of fx
o Long period of NWB to prevent hardware failure due to primary bone healing which is slow

compound/open

complete break of the bone with protrusion of the bone through the skin
o Amount of soft tissue injury influences rehab outcome
o May have neuro-vascular compromise
o Fx can be simple or communited, contamination can be little to severe

general femur fracture rehab guidelines

o PWB or WBAT in stable fx and fixation in stress sharing devices
o NWB in compression plate, unstable fxs
o Early AAROM and isometrics
o Avoid stress through the fx site
o Avoid rotation and torsion with ROM & ambulation

femoral stress fractures

o Due to repeated stress or compromised BMD
o Can develop into complete and displaced Fx
o Cc: sudden hip pain usually due to change in training intensity, distance, surface
o Signs: pain in thigh, inguinal region, groin > lateral
o Physical exam: empty/painful end feel at end range ER/IR, pain with resisted ER

femoral neck fractures

o 4 levels from incomplete to completely displaced
o Screw/ screw & plate fixation
o Non or minimally displaced fx may being WBAT immediately post-op
o Displaced fxs often have disruption of blood supply  hip prosthesis or THR
o Early PWB or WBAT ambulation for stable fxs
o Delayed or NWB ambulation for unstable fxs or if ORIF instead of prosthesis/THR
o Bone healing: 12-16 weeks

intertrochanteric fractures

o Orthopedic tx objective: restore shaft angle and inclination angle
o Dynamic hip screw w/ stable fixation and WBAT
o Bone healing: 12-15 weeks
o Rehab:
 Angular mvmt caused by WB initially limited
 Often remain as TTWB or NWB until healing is demonstrated (8-12 weeks)
 Psoas sometimes left free if lesser troch can't be sufficiently reduced  limited hip flexion
 Length of hip abductors may be changed based upon type of reduction  affects gait
 Set lower expectations for these fxs

sub trochanteric fractures

o Between lesser troch & proximal 1/3 of femur
o Bone healing: 12-16 weeks
o Intermedullary rod & locking screws/sliding hip screw
 Fixation strength allows early WB
 Blood supply not disrupted - improved results

femoral shaft fracture

o Diaphyseal fx
o Femoral rod & locking screws - sometimes compression plate if extension into articular area
o Nail may be statically or dynamically locked
o PWB to WBAT if stable
o Healing time: 12-16 weeks

supracondylar fracture

o Extra or intraarticular, uni or bicondylar with or without displacement
o Usually a 95° dynamic compression screw & plate
 Stress sharing unless rigidly fixed (stress shielding)
 Used at distabl femoral fxs which are difficult to stabilize
o Bone healing: 12-16 weeks
o Fixation can either be stable or not - dictates WB

patella fracture

• Patella fx
o Displaced or nondisplaced
o Transverse, longitudinal, or comminuted
o Extra-articular involve the poles and are usually 2° to avulsion
o Tx goal: alignment & stability
o Bone healing: 8-12 weeks
o PWB or WBAT while in immobilizer
o Criteria to determine surgery:
 Fx displacement > 3-4 cm
 Loss of ability to extend knee
 Tension band wiring superior to other methods

tibial plateau fracture

o Proximal tibia to articular surface
o Split, depressed or split depression involving 1 or both condyles
o Bone healing: 10-12 weeks
o Typically NWB for 12 weeks
o Early limited ROM - no varus/valgus stress

tibial shaft fracture

o Tx objective: restore anatomy including length
o Bone healing: 10-12 weeks
o NWB - PWB based upon fixation & stability

tibial osteotomies

o Indications: varus knee deformities with unicompartmental disease and remaining cartilage
o Preferred method: lateral closing wedge
o NWB-PWB initial stages to GWB 3-6 weeks after radiographic union
o Knee ROM initially and progress to OKC quad & LE strengthening as healing occurs

tibial plafond fracture

o Plafond = horizontal WB surface of distal tibia
o High energy fxs of the distal WB surface of the tibia
o Malleolar fxs may or may not involve the plafond
o NWB for 8-16 weeks
o PWB 6-8 weeks with minimally displaced fxs
o No ankle ROM until 4+ weeks
o Bone healing: 6-8 weeks

ankle fractures

• Bimalleolar, trimalleolar, or lateral/medial malleolar
• Can also have dislocation
• NWB 6-12 weeks followed by PWB until 8-12 weeks
• ROM at 6 weeks

TKA

• Implant and fixation devices
o Cemented, uncemented or hybrid
o Metal backed tibia or all polyethylene tibia
o Metal backed patella or all polyethylene patella
o Patella resurfacing or patella retaining
o PCL or bicruciate substituting, PCL retaining or mobile bearing surfaces
• Complications: infection, instability, malalignment, stiffness, RSD, patella malalignment, DVT

lateral ligament reconstruction and repari

• Lateral ligament reconstruction & repair
o Surgery only indicated when functionally unstable & exhibiting mechanical instability & unresponsive to conservative tx
o Brostrom - direct repair
o Reconstructive tenodesis
 Evans - limits ankle INV
 Watson-jones - limits INV & reconstructs the ATF ligament
 Christman-snook - reconstruct the ATF & calcaneofibular ligaments

rehab of ankle soft tissue procedures

o Week 1: cast/splint with limited WB
o Week 2: short leg walking case/brace - WBAT
o Controlled ROM until week 4-6 - avoid INV
o Isometric strengthening progressing to isotonic at week 4-6

peroneal tendon repair/stabilization

o Direct repairs, retinaculum reconstruction, bone block, groove deepening
o Limit A/PROM DF initially to reduce risk of peroneal sublux

arthrodesis (fusion)

o Tibiotalar, subtalar, midfoot
o Position of function = neutral at tibiotalar and subtalar joints
o NWB initially, motion allowed based upon fused areas & goals of rehab

guidelines hip, ankle, patella, tka

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