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Ortho Practical Study GuideLower Extremity:Muscle Strain and/or TendinitisPt PresentationResult of trauma or overuse. Pt may move stiffly/tentativelyTenderness directly over the tendon Dec ROM/StrengthPain: Acute- Intense/sharp. Chronic-Dull/achy Swelling of the tendon Pain with AROM and PROM (if stretched) Isometrics should be strong & painful (unless a considerable tear-weak and painful) Can be present in any muscle/tendonHip musclesQuadricepsHamstringsAchilles tendonAnkle Evertors/InvertorsInterventionsFor Pain: Modalities: Cryotherapy, Gentle strengthening, massage, PROM, Jt mobsAnitinflammatoriesFor ROMStretching, MobsContract Relax/Hold RelaxFor functionPractice functional task! For StrengthWeights/TBand3 Sets of 10 (should be fatigued by the 3rd set) Work concentrically first then eccentrically later on in rehabPatient EducationPosture Correct technique with functional activityPatella TendonitisPt PresentationUsually overuse injury. Risk factors: high intensity/frequency physical activity, being overweight, tight leg muscles (quads and hams), Misalignment of your leg, patella alta, muscular imbalance, poor VMO activationPain with palpationPain with jumping, going up/down stairs, squatting activities InterventionsFIX THE CAUSE!!!!For pain:Modalities- CryotherapyAnitinflammatoriesGentle strengthening, massage, PROM, Jt mobsFor ROM:Stretching, MobsFor StrengthWeights/TBand/Kinetron 3 Sets of 10 (should be fatigued by the 3rd set) For functionPractice functional task! Patient EducationPosture Correct technique with functional activity*****AVOID DEEP SQUATTING/LUNGES, ISOMETRICS, JUMPING Piriformis SyndromePt Presentation:Caused by localized trauma or overuseButtock, groin, hip , and disc type symptomsWorse with prolonged sitting, sitting on hard chairsPain with resisted hip ER, passive hip flex & IRLocalized tenderness to deep palpationMay have pain with SLR (especially if IR)InterventionsFor Pain:ModalitiesMassageFor ROMContract Relax/Hold RelaxStretchingStrengthStrengthen ER—PNF, Tband(sitting)Side/lying Hip ABDPatient EducationAvoid prolonged sitting; sitting on hard surfaces Avoid hills, uneven terrain, banked trackPatellofemoral Dysfunction Pt PresentationRisk factors includeLarger Q anglePoor VMO control, strength & recruitmentTight Lateral Retinaculum and/or ITbandIncrease femoral anteversionPatella alta/bajaShallow intercondylar facets/deformed patellar facetsSymptoms includeNon-localized anterior knee painCrepitusGiving way sensationUsually insidious onset Pain with going down stairsPain/stiffness with prolonged sittingPossible inc swellingPossible Surgical InterventionsPatella shavingChrondoplasty of patella or femoral articulating surfacesPatellar realignment PatellectomyInterventionsBracing: Minimizes lateral patellar subluxation, minimizes patellar dislocation, improves tracking**, dec pain**, warms the jtOrthotics- improve LE biomechanicsPes Planus: Prevents overpronation, IR of tibia/femur**Pes Cavus: Provides broader base of supportPatella Taping: Realignment, dec pain**Strengthening: Quad strengthening- painfree range with isometrics and eccentric contractions. Add/IR to “isolate” VMOSide-lying ADD, Wall squats with ball, Step up/downs, Stretching- of tight lateral structures, hams, gastrocPatellar MobsImprove recruitment timing: particular strengthen exercises, e-stimIce, Anti-inflammatory drugsPatient Education- avoid activities that make it worse** AVOID DEEP SQUATS, LUNGES, STAIRSMeniscal Repair/MenisectomyPt presentationVMO AtrophyPain with/without swellingGiving wayLocking/UnlockingJt Line tenderness Blocking at end range+ Special tests: McMurray, Apleys, Anderson Medial-Lateral GrindJoint EffusionPartial Menisectomy: Early progression of WB & Rom. Limitations to strengthening at certain ranges. Pt. response guides speed of RehabMeniscal Repair Interventions** Delayed Progression of WB & ROM—depends on protocol but usually 4-8 weeksDuring WB exercise do not go pass 45 flex for 4 weeks and 70 for 8 weeks. (puts posterior translation forces on repaired meniscusLess aggressive strengtheningROMCPM is prescribed at surgeons discretion. Begin AAROM and AROM day 1 post op. Knee flex is restricted by brace. Heel slides**Postpone leg press machine and hamstring curls until about 8 weeks**Avoid twisting motions during WB activities**Acutely- avoid TKE if ant horn, full flex if post hornPAINModalitiesPatellar MobsStrength/Activation of MusclesQuad sets4-way SLRHeel Raises- Begin B (must be PWB+), then progress unilateralIsometrics Open chain knee ext/flex in sitting position T/Bands Glut/Add sets Neuromuscular Control, Proprioception, and BalanceMini-squatsWall-slidesTrunk stabilization exercisesProgress to perturbation training, partial lunges, step ups/downsFlexibilityStretch hams, PFProgress to IT Band, Rectus (after full knee flex with hip flex is achieved) Cardiopulmonary functionUBE Progress to stationary bike, pool-walking9-12 weeks: treadmillLast progression is return-to-activity phaseACL ReconstructionPt PresentationHemarthrosisPainDec ROMDiminished voluntary quad activationMay have protective braceAmbulation with crutchesInterventionsREHAB BEGINS IMMEDIATELYPainModalities, Antiinflammatories controversy ROMCPM Ankle PumpsPatellar MobsHeel slidesPROM/AAROM. Progress to AROM ** AVOID ATKE (but want PTKE)StrengthQuad, hams, hip abd/add sets4-way SLR- Being AAROM AROM Hamstring curlsPRE open chain/ close chain activitiesMake sure resistance is above knee until knee control is established** Avoid resisted open-chain knee ext between 45 and 15Stepping with elastic bandMake sure to keep knee slightly bentNeuromuscular Control, Proprioception, Dynamic stabilityBegin with trunk/LE stab exercises standing. Progress to mini-squats, weight-shifting, stepping and marching mvts, partial lunges (Begin Bilateral then progress unilateral)Add stationary cycling, seated leg press at 3-4 weeksGait training Practice ambulation- emphasis on symmetrical alignment, step length, and timingGradually discontinue protective bracing—use functional braceAerobic conditioningSwimming, treadmill, or continue stationary cycling (inc duration and speed)Activity-Specific trainingIntegrate simulated functional activitiesMCL Tears with/without RepairPt Presentation Mostly seeing with ACL & Medial Meniscus tearBuckling Pain Slight swellingDec ROM/StrengthDec stability/Inc LaxityIntervention** AVOID VALGUS STRESS, A/P TKE, ADD WITH FORCE DISTAL TO KNEE !!!Rehab similar to ACL Reconstruction!LCL Tears with/without RepairPt PresentationPain Dec ROM/StrengthDec stability/Inc LaxityIntervention***AVOID VARUS STRESS AND ABD WITH FORCE DISTAL TO KNEE!Rehab similar to ACL ReconstructionSpine:Discectomy and/or Spinal FusionCervicalPt Presentation : Usually have surgery due to redicular symptoms 2 DDD, HNP, etcDec ROM/StrengthPoor PostureSensation lossInterventions**AVOID JT MOBS, EXCESSIVE STRETCHIGSubmax Resistance-Cervical , UE, & GrippingPROM AAROM AROMRROMWeights, PREs, T-Band, Finger Ladder, PulleysMassageChin TucksArm BikeLumbarPt PresetationSimilar to CervicalInterventionsMassageBridgingPelvic tilts/Abdominal HallowLog Rolling- ** AVOID TWISTING MOVEMENTSSKCDKCDead Bug: Supine/quadrupedStretch quads, hams, gastrocPNF4 Way SLRAbs -CrunchesPhysioBallBounceMarchingLean BacksKnee extPelvic ClockScoliosisPt PresentationDec ROMStretch weaknessDec FlexibilityPoor PostureDec cardiopulmonary FunctionMay have NR Irritation alsoInterventionUsually 2 something else-Fix thatBracingOrthoticsSurgeryStretchConcave sideStrengthenConvex sideROM Strain: Cervical/LumbarPt PresentationDec ROMPoor PostureDec StrengthPain: Dull AchingInterventionCervicalChin TucksAROMIsometricsUT StretchArm BikeShoulder PREsCorner Pec StretchMassageModalities: If acute: ice. If chronic: US, Hot PackTBand- Scap RetractionLumbarAROMIsometricsProne ExtAbs/ Core StabilityPelvic TiltsModalitiesPt EducationDisc DerangementPt Presentation Shooting radiating painParaesthesiasPossible + SLR, Slump testDec ROMDec StrengthPain worse walking up hillsInteventionPostural CorrectionsPt EducationTractionManipulation McKenzie ExercisesCore stability: pelvic tilts, SKC, Dead Bug, Physio BallLumbar Spinal StenosisPt PresentationParaesthesias: numbness, tingling, heavy feeligWorse standing, walking (going down hill)Intermittent claudicationInterventionNSAIDS, CorticosteroidsCore Stability: Pelvic tilts, SKC, Dead Bug, Physio Ball, BridgingLumbar BraceSurgerySI DysfunctionPt PresentationInc pain with walking (heel strike and b4 toe off)Hip ext is most painfulRadicular symptomsCan be post(bone) or ant (ligs)InterventionIf hypomobile: Mobilize, Muscle EnergyIf hypermobile: SI belt ................
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