Ortho Practical Study Guide

Lower Extremity:

Muscle Strain and/or Tendinitis

  • Pt Presentation

Result of trauma or overuse.

Pt may move stiffly/tentatively

Tenderness directly over the tendon

Dec ROM/Strength

Pain: 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/tendon

Hip muscles

Quadriceps

Hamstrings

Achilles tendon

Ankle Evertors/Invertors

  • Interventions

For Pain:

  • Modalities: Cryotherapy,
  • Gentle strengthening, massage, PROM, Jt mobs
  • Anitinflammatories

For ROM

  • Stretching, Mobs
  • Contract Relax/Hold Relax

For function

  • Practice functional task!

For Strength

  • Weights/TBand
  • 3 Sets of 10 (should be fatigued by the 3rd set)
  • Work concentrically first then eccentrically later on in rehab

Patient Education

  • Posture
  • Correct technique with functional activity

Patella Tendonitis

  • Pt Presentation

Usually 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 activation

Pain with palpation

Pain with jumping, going up/down stairs, squatting activities

  • Interventions

FIX THE CAUSE!!!!

For pain:

  • Modalities- Cryotherapy
  • Anitinflammatories
  • Gentle strengthening, massage, PROM, Jt mobs

For ROM:

  • Stretching, Mobs

For Strength

  • Weights/TBand/Kinetron
  • 3 Sets of 10 (should be fatigued by the 3rd set)

For function

  • Practice functional task!

Patient Education

  • Posture
  • Correct technique with functional activity

*****AVOID DEEP SQUATTING/LUNGES, ISOMETRICS, JUMPING

Piriformis Syndrome

  • Pt Presentation:

Caused by localized trauma or overuse

Buttock, groin, hip , and disc type symptoms

Worse with prolonged sitting, sitting on hard chairs

Pain with resisted hip ER, passive hip flex & IR

Localized tenderness to deep palpation

May have pain with SLR (especially if IR)

  • Interventions

For Pain:

  • Modalities
  • Massage

For ROM

  • Contract Relax/Hold Relax
  • Stretching

Strength

  • Strengthen ER—PNF, Tband(sitting)
  • Side/lying Hip ABD

Patient Education

  • Avoid prolonged sitting; sitting on hard surfaces
  • Avoid hills, uneven terrain, banked track

Patellofemoral Dysfunction

  • Pt Presentation

Risk factors include

  • Larger Q angle
  • Poor VMO control, strength & recruitment
  • Tight Lateral Retinaculum and/or ITband
  • Increase femoral anteversion
  • Patella alta/baja
  • Shallow intercondylar facets/deformed patellar facets

Symptoms include

  • Non-localized anterior knee pain
  • Crepitus
  • Giving way sensation
  • Usually insidious onset
  • Pain with going down stairs
  • Pain/stiffness with prolonged sitting
  • Possible inc swelling

Possible Surgical Interventions

  • Patella shaving
  • Chrondoplasty of patella or femoral articulating surfaces
  • Patellar realignment
  • Patellectomy

Interventions

  • Bracing: Minimizes lateral patellar subluxation, minimizes patellar dislocation, improves tracking**, dec pain**, warms the jt
  • Orthotics- improve LE biomechanics
  • PesPlanus: Prevents overpronation, IR of tibia/femur**
  • PesCavus: Provides broader base of support
  • Patella Taping: Realignment, dec pain**
  • Strengthening: Quad strengthening- painfree range with isometrics and eccentric contractions. Add/IR to “isolate” VMO
  • Side-lying ADD, Wall squats with ball, Step up/downs,
  • Stretching- of tight lateral structures, hams, gastroc
  • Patellar Mobs
  • Improve recruitment timing: particular strengthen exercises, e-stim
  • Ice, Anti-inflammatory drugs
  • Patient Education- avoid activities that make it worse

** AVOID DEEP SQUATS, LUNGES, STAIRS

Meniscal Repair/Menisectomy

  • Pt presentation

VMO Atrophy

Pain with/without swelling

Giving way

Locking/Unlocking

Jt Line tenderness

Blocking at end range

+ Special tests: McMurray, Apleys, Anderson Medial-Lateral Grind

Joint Effusion

  • Partial Menisectomy: Early progression of WB & Rom. Limitations to strengthening at certain ranges. Pt. response guides speed of Rehab
  • Meniscal Repair Interventions

** Delayed Progression of WB & ROM—depends on protocol but usually 4-8 weeks

  • During WB exercise do not go pass 45 flex for 4 weeks and 70 for 8 weeks. (puts posterior translation forces on repaired meniscus

Less aggressive strengthening

ROM

  • CPM 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 horn

PAIN

  • Modalities
  • Patellar Mobs

Strength/Activation of Muscles

  • Quad sets
  • 4-way SLR
  • Heel Raises- Begin B (must be PWB+), then progress unilateral
  • Isometrics
  • Open chain knee ext/flex in sitting position
  • T/Bands
  • Glut/Add sets

Neuromuscular Control, Proprioception, and Balance

  • Mini-squats
  • Wall-slides
  • Trunk stabilization exercises
  • Progress to perturbation training, partial lunges, step ups/downs

Flexibility

  • Stretch hams, PF
  • Progress to IT Band, Rectus (after full knee flex with hip flex is achieved)

Cardiopulmonary function

  • UBE
  • Progress to stationary bike, pool-walking
  • 9-12 weeks: treadmill

Last progression is return-to-activity phase

ACL Reconstruction

  • Pt Presentation

Hemarthrosis

Pain

Dec ROM

Diminished voluntary quad activation

May have protective brace

Ambulation with crutches

  • Interventions

REHAB BEGINS IMMEDIATELY

Pain

  • Modalities, Antiinflammatories controversy

ROM

  • CPM
  • Ankle Pumps
  • Patellar Mobs
  • Heel slides
  • PROM/AAROM. Progress to AROM
  • ** AVOID ATKE (but want PTKE)

Strength

  • Quad, hams, hip abd/add sets
  • 4-way SLR- Being AAROM AROM
  • Hamstring curls
  • PRE open chain/ close chain activities
  • Make sure resistance is above knee until knee control is established
  • ** Avoid resisted open-chain knee ext between 45 and 15
  • Stepping with elastic band
  • Make sure to keep knee slightly bent

Neuromuscular Control, Proprioception, Dynamic stability

  • Begin 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 weeks

Gait training

  • Practice ambulation- emphasis on symmetrical alignment, step length, and timing
  • Gradually discontinue protective bracing—use functional brace

Aerobic conditioning

  • Swimming, treadmill, or continue stationary cycling (inc duration and speed)

Activity-Specific training

  • Integrate simulated functional activities

MCL Tears with/without Repair

  • Pt Presentation

Mostly seeing with ACL & Medial Meniscus tear

Buckling

Pain

Slight swelling

Dec ROM/Strength

Dec stability/Inc Laxity

  • Intervention

** AVOID VALGUS STRESS, A/P TKE, ADD WITH FORCE DISTAL TO KNEE !!!

Rehab similar to ACL Reconstruction!

LCL Tears with/without Repair

  • Pt Presentation

Pain

Dec ROM/Strength

Dec stability/Inc Laxity

  • Intervention

***AVOID VARUS STRESS AND ABD WITH FORCE DISTAL TO KNEE!

Rehab similar to ACL Reconstruction

Spine:

Discectomy and/or Spinal Fusion

  • Cervical

Pt Presentation :

  • Usually have surgery due to redicular symptoms 2 DDD, HNP, etc
  • Dec ROM/Strength
  • Poor Posture
  • Sensation loss

Interventions

  • **AVOID JT MOBS, EXCESSIVE STRETCHIG
  • Submax Resistance-Cervical , UE, & Gripping
  • PROM AAROM AROMRROM
  • Weights, PREs, T-Band, Finger Ladder, Pulleys
  • Massage
  • Chin Tucks
  • Arm Bike
  • Lumbar

Pt Presetation

  • Similar to Cervical

Interventions

  • Massage
  • Bridging
  • Pelvic tilts/Abdominal Hallow
  • Log Rolling- ** AVOID TWISTING MOVEMENTS
  • SKCDKC
  • Dead Bug: Supine/quadruped
  • Stretch quads, hams, gastroc
  • PNF
  • 4 Way SLR
  • Abs -Crunches
  • PhysioBall
  • Bounce
  • Marching
  • Lean Backs
  • Knee ext
  • Pelvic Clock

Scoliosis

  • Pt Presentation

Dec ROM

Stretch weakness

Dec Flexibility

Poor Posture

Dec cardiopulmonary Function

May have NR Irritation also

  • Intervention

Usually 2 something else-Fix that

Bracing

Orthotics

Surgery

Stretch

  • Concave side

Strengthen

  • Convex side

ROM

Strain: Cervical/Lumbar

  • Pt Presentation

Dec ROM

Poor Posture

Dec Strength

Pain: Dull Aching

  • Intervention

Cervical

  • Chin Tucks
  • AROM
  • Isometrics
  • UT Stretch
  • Arm Bike
  • Shoulder PREs
  • Corner Pec Stretch
  • Massage
  • Modalities: If acute: ice. If chronic: US, Hot Pack
  • TBand- Scap Retraction

Lumbar

  • AROM
  • Isometrics
  • Prone Ext
  • Abs/ Core Stability
  • Pelvic Tilts
  • Modalities
  • Pt Education

Disc Derangement

  • Pt Presentation

Shooting radiating pain

Paraesthesias

Possible + SLR, Slump test

Dec ROM

Dec Strength

Pain worse walking up hills

  • Intevention

Postural Corrections

Pt Education

Traction

Manipulation

McKenzie Exercises

Core stability: pelvic tilts, SKC, Dead Bug, Physio Ball

Lumbar Spinal Stenosis

  • Pt Presentation

Paraesthesias: numbness, tingling, heavy feelig

Worse standing, walking (going down hill)

Intermittent claudication

  • Intervention

NSAIDS, Corticosteroids

Core Stability: Pelvic tilts, SKC, Dead Bug, Physio Ball, Bridging

Lumbar Brace

Surgery

SI Dysfunction

  • Pt Presentation

Inc pain with walking (heel strike and b4 toe off)

Hip ext is most painful

Radicular symptoms

Can be post(bone) or ant (ligs)

  • Intervention

If hypomobile: Mobilize, Muscle Energy

If hypermobile: SI belt