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62 terms

ortho ah

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
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
o RF Valgus
Medial ankle pain
Muscle fatigue
o FF Varus
Callous 2,4,5
Muscle fatigue
4th, 5th hammer toes
Plantar fascitis
• 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
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
o Painful met head
Local tenderness, often aggravated by cavus foot or high heeled footwear
Accommodative orthotic: soft with MT pad or cutout
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
o Mostly intraarticular due to large amt of cartilage
o Osteochondral lesions as a result of forces with fx or sprains
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
o Tape immobilization and protected WB
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
• 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
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
• 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