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					       Pathology                            History/ MOI
                             33% of ppl age 63-94 have it, 80% is medial
                             compartment, risk factors include obesity,
                             age, female gender, OA at other sites, prev
                             knee trauma. Symptoms =pain with
        Knee OA              activity & stiffness




                             Traumatic injury/ blow to knee OTAWA
                             KNEE RULES: age>55, inability to bear wt (4
     Knee Fracture           steps) immediately after injury or at first
                             visit
                             Pt reports popping/clicking/catching in
                             knee

     Meniscal Tear



                             Typically secondary to acute trauma, but
                             may be chronic or assoc with infection
Patellar Bursitis (supra-,
      pre-, infra-)



                             Commonly seen in athletes who jump or
                             decelerate frequently, pn in area of
                             patellar tendon usually after activity,
  Patellar Tendonitis        sometimes during activity
   (Jumper's Knee)




                             May complain of popping or crepitus, pain
                             over lateral knee and condyle, frequently
   IT Band Syndrome
                             seen in runners
             Usually c/o anterior knee pn, pn with stair
             ascent/descent, "moviegoer's" sign, giving
             way of knee secondary to pn

  PFPS




             Most common mechanism is blow to
             lateral knee with valgus force, may also be
             injured by non-contact and/or rotational
MCL injury   stresses




             Rarely an isolated injury, most common
             mechanism is blow to medial knee
             imparting varus stress, internal rotation of
LCL injury   tibia may be secondary contributor to LCL
             injury

             Most common mechanism is knees hitting
             dashboard in MVA (posterior force on
             tibia), fall on bent knee, can also be
             damaged as a result of a rotational force or
             hyperextension, pt reports feeling a pop in
PCL injury
             the back of the knee
             MOI: usually rotational force with foot
             planted. Often note a “pop” or state “knee
             gave way”, immediate swelling typically
             present and significant, inability to
             continue playing



ACL injury
            Physical Exam Findings                                 Rule Out
Signs =joint line or condylar tenderness,     Because of older age, CA should be ruled out.
effusion, crepitus, decreased ROM, angular    Assess for hip OA.
deformity. Diagnosis usually based on
decreased joint space shown on an x-ray. CPR:
at least 3 are met to establish diagnosis of
knee OA: 1. age >50 2. stiffness >30 min 3.
crepitus 4. bony tenderness 5. bony
enlargement 6. no palpable warmth


OTAWA KNEE RULES: isolated patellar              Otawa knee rules are highly sensitive so if
tenderness, tenderness of the fibular head,      they are negative, one can rule out fracture
inability to flex knee to 90 deg.


Joint line tenderness, mild to moderate          May want to rule out ACL or MCL injury since
effusion that occurs over 1-2 days, quad         they often occur together. Also R/O plica
inhibition and atrophy over 1st-2nd week after   irritation bc of similar hx reports of
injury, may be unable to perform squat, (+)      snapping/popping
McMurray's, (+) Apply's Compression

Girth measurment, may have (+) floating          R/O fx with any acute trauma, R/O infection
patella or (+) stroke sign                       by vitals and hx




patellar tendon TTP, may feel warm, defer        R/O PFPS because of report of ant knee pn
patellar reflex testing if too tender




(+) Ober's, (+) Noble's                          R/O lateral meniscus injury, LCL injury, maybe
                                                 biceps femoris due to fibular head
                                                 attachment
may have (+) clark's test, (+) McConnell test, This is a "dump" diagnosis, so you may come
patellar tracking abnormalities, weak hip mm to this conclusion after ruling out many other
(esp ER and ABD), assess alignment both static hypotheses.
and dynamic (during gait), asses foot
pronation (medial collapse), q-angle, assess
mm length of hamstrings, quads, and gastrocs.
Defer patellar reflex if too tender



(+) Valgus stress test at 30 deg, may also be + a R/O fx with Otawa knee rules, assess for
0 deg but must be + at 30 to tell you its MCL, meniscal involvement bc of MCL attachment
medial knee pain, usually immediate swelling to medial portion
with ligamentous injuries, could have (+)
appley's distraction but this test is not specific
to which ligament is injured

(+) Varus stress test at 30 deg, may also be + at   Must consider lateral joint capsule and
0 deg but must be + at 30 deg to tell you its       cruciate ligament injury based on mechanism,
LCL, lateral knee pn, usu immediate swelling,       must rule out peroneal nerve injury, R/O fx
could have (+) appley's distraction but this test   with otawa knee rules
is not specific to which ligament is injured

Tenderness and relatively little swelling in the R/O fx with otawa knee rules, rarely an
popliteal fossa, (+) sag sign, (+) posterior     isolated injury so assess other ligaments and
drawer (be aware of false neg due to starting menisci
position of knee), knee effusion, extension
may be painful
(+) Lachman's, (+) anterior drawer, (+) pivot        Rule out a potential patella tendon rupture
shift if rotational anteriorlateral instability is   through observing ability to perform straight
present, document swelling, document ROM,            leg raise, sometimes ACL injury is
ability to initiate quad contraction                 accompanied by MCL and meniscus injury so
                                                     assess these also.
                     PT Treatment
Manual therapy along entire chain, ROM exercises,
stretching (hams, quads, calves), strengthening
(quads, hips), activity mod, cardio (Deyle article)




RED FLAG: refer to physician for x-ray
NOTE: only one of the otawa rules must be met to
necessitate an x-ray




Modalities for pain and swelling, gentle stretching,
avoid repetitive knee flexion and extension, may start
strengthening once pain and swelling subside, correct
biomechanical factors such as muscle imbalances,
excessive foot pronation


Modalities for pain and inflammation, activity
modification (may be able to cycle), cho-pat straps or
knee sleeves may help, cross friction massage, gentle
stretching, start eccentric program once resistive is
negative for pain, progress to plyometrics and activity
specific exercises (General Rehab for knee
inflammatory conditions)


Correct muscle imbalances and foot mechanics
(orthotics), stretching ITB and patellar mobs (medial),
soft tissue massage
Basically treat the impairments: Stretch what is tight,
strengthen what is weak, and assess any
biomechanical issues that you observe during your
eval




Usually non-operative, bracing/ immobilization is
crucial, tend to lose extension quickly so may
immobilize in extension




Has poor blood supply –doesn’t heal well and may
need surgical repair




Management of Grades I & II: RICE, non-operative
rehab of grade I and II injuries should focus on quad
strength, avoid open chain hamstring work, closed
chain and functional rehab as per ACL rehabilitation
Post Surgical Repair: Full ROM by 8 wks, full wt
bearing at 7 wks, Quad sets, SLR, CKC exercises at 5-6
wks, running at 6 mo, return to sport at 7-12 mo.
Pre-operative PT: Focus on regaining full ROM and
good quad contraction, edema reduction
(compression, motion), knee needs to recover from
trauma of injury prior to surgery, or risk of
arthrofibrosis increases. Patients that regain good
quad control, normalize swelling and ROM have faster
recovery of ROM and quad strength following surgery
Potential Copers:
1. < 1 episode of giving way
2. > 80% 6m timed hop test
3. > 80% KOS ADL subscale
4. > 60% Global Rating of Knee Function
Post Surgery: Focus on achieving full extension and
regaining quad strength, OCK exercises should be
implemented later in rehab
       Pathology                        History/ MOI

                         Most often MOI is PF with inversion
                         Grade I: ATFL, Grade II: ATFL + CF, Grade
                         III: ATFL + CF + PTFL , pts with pes cavus
                         are at greater risk




  Lateral Ankle Sprain




                         MOI: forced eversion, Foot that is
                         pronated, hypermobile or has a depressed
                         medial longitudinal arch is more
  Medial Ankle Sprain
                         predisposed (pes planus), Injury Is to the
                         Deltiod Ligament

                         Injury to anterior tibio-fibular ligament
                         and/or syndesmosis, MOI:
                         Hyperdorsiflexion (snowboarding),
                         common with "boot" sports like
High (Syndesmosis) Ankle
                         snowboarding, skiing, hockey where ankle
         Sprains
                         motion is limited; sometimes caused by
                         rotation and plantarflexion
                            Tenderness at fascial insertion onto medial
                            tubercle of calcaneus, symptoms often
                            worst during initial steps after prolonged
                            inactivity, usu these pts have a job where
                            they are on their feet a lot, may have an
                            increase in activity in their hx, may be
      Plantar Faciitis      heavier, may be a runner




                            Often 2º age-related collagenous fat pad
                            degeneration, can also result from
                            calcaneal trauma with resultant bleeding
                            into fad pad. MOI: Acute contusion: fall
                            from height onto feet, repetitive mild
                            contusions: eg. gymnastic vaults or
    Fat Pad Syndrome
                            landings in stocking feet or slippers,
                            excessive body weight, poorly cushioned or
                            worn shoes, sudden shift to hard training
                            surfaces, c/o diffuse heel pn



                           Overuse conditions traditionally diagnosed
                           as achilles tendinitis are more likely
                           tendinoses
                           Achilles tendinitis:inflammation of the
                           paratenon/outer layer of the tendon
                           Achilles tendinosis:involves loss of collagen
                           continuity & intratendinous degeneration
                           rather than inflammation, tendonosis is
                           much more common than tendonitis.
                           Acute Symptoms:Tenderness 2-6 cm above
                           calcaneal insertion (region of relative
Achille's Tendon Pathology hypovascularity), crepitus, pain with AROM
                           PF or PROM DF, pain with running or stair
                           a/descent. Chronic Symptoms: Nodular
                           swelling, potential for partial tear.
                           Underlying Factors: Sudden increase in
                           frequency, intensity or duration of
                           exercise, pes cavus foot/tight achilles, pes
                           planus foot/excessive pronation: repetitive
                           stretch on medial achilles.
                          Pain posterior to calcaneus & deep to
                          achilles tendon. Potential cause: repetitive
                          contact between bursa & calcaneal bone
Retrocalcaneal Bursitis   spur. Potential underlying factors:
                          excessive pronation, rigid/cavus foot


                          Entrapment of posterior tibial
                          neurovascular bundle (tibial nerve or
                          med/lat plantar nerves) as it passes
                          posterior to medial malleolus. Causes:
                          Increased compressive forces within tunnel
                          2º: trauma to calcaneus, talus, or medial
                          malleolus, excessive pronation or pes
Tarsal Tunnel Syndrome    planus, esp. when combined with weight
                          gain, tightly laced shoes or tightly fastened
                          ski boots, localized edema or inflammation,
                          space occupying lesion (eg. tumor). C/O:
                          Plantar foot paresthesias, pn



                          Pathology: Localized thickening medial
                          plantar and lateral plantar nerves, most
                          commonly between 3rd and
                          4thmetatarsals Etiology: direct trauma
                          (stretching of plantar structures during
                          hyperextension of the MP joint (sprint
                          starts, recovery from jump), tight shoes,
Morton's (Interdigital)
                          lateral compression of met heads and
     Neuroma
                          interdigital nerves, splayed toes &
                          pronated foot. Symptoms: Cramp-like pain
                          during running, tingling/numbness in
                          lateral third and medial 4th toes, pain relief
                          on removal of shoe and/or pressure.
                          Condition marked by progressively
                          increasing diffuse pain: along middle &
                          distal thirds of posteromedial tibia,
                          frequently along soleus or tibialis posterior
                          tendons, frequently occurs in runners or
                          jumpers. Potential Underlying Causes:
                          Continuous pull of tibialis posterior or
                          soleus along attachment to medial tibial
  Medial Tibial Stress
                          border when countering excessive
Syndrome (shin splints)
                          pronation (soleus acts to stabilize foot &
                          invert heel), running on balls of feet:
                          increases work performed by tibialis
                          posterior, cavus foot secondary to
                          decreased shock absorption capability




                          Cause: Activity (eg. running, extended
                          marching) that causes
                          intermittent/transient increase in
                          intracompartmental pressure of leg.
                          Symptoms: onset at specific duration or
                          distance during exercise (exercising muscle
                          volume may increase by 20%), symptoms
        Transiet
                          subside with rest/cessation of activity
  (chronic/exertional)
Compartment Syndrome




                          Results from significant lower extremity
                          edema and/or significant increase in
                          intracompartmental pressures within
                          unyielding compartments. Causes: Trauma-
 Acute Compartment
                          fractures, burns, blunt trauma to leg.
 Syndrome (MEDICAL
                          Marked increase in training parameters for
    EMERGENCY)
                          specific activity (eg. unaccustomed forced
                          march or long run)
                                                                      Rule Out
            Physical Exam Findings

(+) Anterior Drawer (ATFL), (+) talar tilt (CF),     Rule out fx: otawa ankle rules (only one
figure of 8 girth measurement should be taken        rule needs to be met to necesitate x-ray)
, ROM assessed, do not have pt toe walk due          1. tenderness upon palpation to posterior
to instability in PF, no PF+INV in neuro screen,     6cm of medial or lateral malleoli 2.
may find superficial peroneal nn involvement         Tenderness upon palpation of navicular or
Grade I: Mild sx, no functional loss /instability,   base of 5th metatarsal 3. inability to wt
recovery time avg: 8 days (range: 2-10 days),        bear 4 steps immediately after injury or in
CLINICAL POINT: rare in PT clinic; typically self-   ER; With inversion sprain, always palpate
treat                  Grade II: Moderate            up the shaft of the fibula to check for
functional loss, may have “walked it off”,           concominant proximal fx of fibula
diffuse swelling/tenderness, recovery time           (Maisonnueve fx)
avg: 20 days (range: 10-30 days)
CLINICAL POINT: most common in PT clinic
Grade III: Unstable, multi-ligamentous sprain
with anterior capsular involvement, unable to
fully bear weight, diffuse edema/tenderness
medially & laterally, frequent concomitant
fracture, ortho intervention often required,
recovery average: 40 days (range: 30-90 days)




Present with localized point tenderness and          Rule out fx with otawa ankle and foot
swelling over deltoid ligament, ROM/strength         rules, commonly there will be an avulsion
deficits per mechanism of injury and tissue          fracture before injury to the ligament
involved, (+) Eversion stress test (DF +             occurs due to the strength of the deltoid
eversion)                                            ligament

(+) tib fib squeeze, (+) DF External Rotation        Rule out fx with otawa ankle and foot
Stress test, would not have pt doing any heel        rules, palpate up the shaft of the fibula to
walking due to the DF component, defer               check for concominant proximal fx of
clonus testing                                       fibula (Maisonnueve fx, usu in proximal
                                                     1/3)
Usu have decreased DF, usu pes planus, (+)   Rule out stress fx if increase in activity is
Windlass test, TTP at medial tubercle of     in hx. (calcaneal squeeze, bump test,
calcaneal tuberosity, position of comfort is metatarsal loading (1-3)
slight PF because fascia is on slack. Other
Physical Exam Components to be included:
navicular drop test, single limb heel raise,
observe for too many toes, DF AROM, PROM,
jt accessory mobility - AP talocrual, AP/PA
distal tib/fib, hip abduction STR




(+) bump test with diffuse pn, TTP around        Rule out fx with calcaneal squeeze test
entire heel-not local, aviod barefoot heel       and otawa rules (prob just the wt bearing
walking with this pt-may be tolerable with       part for this pt), also bump test: if pn is
shoes on, may have a secondary dx of plantar     local= suspect fx, if pn is diffuse= suspect
faciitis and rule that out with windlass test.   fat pad syndrome
Assess gastroc/soleus fexibility, achilles




Toe walking & Heel raise (pn level noted for     Rule out achille's tendon rupture:
test/retest), palpation of gastroc/soleus and    Frequently in males > 30 years old,
achille's for tenderness, swelling, and temp.    especially w/ history of recurrent achilles
Assess length of gastroc/ soleus, A/PROM of      tendinopathy, sensation of being kicked in
DF and PF, may do figure of 8 if swelling is     back of leg, may occur during running,
present. Defer clonus testing.                   jumping, sudden achilles stretch, requires
                                                 orthopedic consult—splint ankle in
                                                 plantarflexed position to approximate
                                                 ends of achilles, observe toe walking for
                                                 plantar flexion weakness or combined
                                                 INV/PF, do not allow weight bearing
                                                 through upper extremities when checking
                                                 plantar flexion strength in standing. (+)
                                                 Thompson test, at 90/90 in prone, foot
                                                 will hang in DF instead of slight PF. Rule
                                                 out retrocalcaneal Bursitis (differential
                                                 dx)
Achilles may be painless, TTP over bursa,       Differential dx: achilles
Haglund's deformity (caused by: continual       tendinitis/tendinosis
pressure of heel counter vs. calcaneus or could
be congenital), palpation/length assessment of
achille's, gastroc, soleus


Burning, N&T & pain in medial ankle and/or         Differential dx: Morton's Neuroma (so
plantar foot, (+) Tinels to tibial nerve with      perform metatarsal squeeze, striping,
simultaneous ankle DF/EV & toe extension           and/or interdigital compression/ shearing
held for 5-10 seconds (can straighten the leg if   to r/o). Because of nn involvement, need
having trouble reproducing symptoms- may           to rule out back for radiculopathy. Pay
turn into a modified slump test to stretch that    close attn to your neuro screen if you
nn), MMT changes (rare), foot neuro screen is      suspect this.
crucial




Point tenderness over neuroma (usu bt 3 & 4), Differential dx: Tarsal tunnel (do tinnels
callus, (+) compression test may have            to r/o), lambar radiculopathy r/o (same as
(clicking), (+) striping, (+) interdigital       above)
compression, (+) interdigital shearing (+)
sensory test- this is from the notes but I'm not
sure exactly if this is dermatomes or what??
Pain may be reproduced with active                 R/O fibular stress fx
contraction or passive stretch of soleus, tibialis
posterior or tibialis anterior muscle, diffuse
symptoms (unlike focal symptoms of stress
fracture). Assess toe walking, gastroc/soleus
strength and flexibility, post tib strength with
MMT and heel raise




Motor strength, neurovascular status              R/O stress fx of fibula or tibia, Differential
generally intact (unless patient in later stages dx: medial tibial stress syndrome
of gradually progressive, chronic syndrome),
Clinical exam may be unremarkable unless
patient has just completed exacerbating
activity--if so, have patient return to clinic in
exercise gear to reproduce symptoms,
perform pre-exercise neuro screen & lower
extremity girth measurement, then have
patient perform offending exercise near the
clinic until symptoms appear, immediately
upon appearance of symptoms, patient should
return to clinic for post-exercise neuro screen
and girth measurement



4 “Ps”:                                            Do not rely on pulses for this dx, their
1. Pain                                            absence may come later in the
2. Pallor                                          progression.
3. Paresthesia (paralysis)
4. Pulse (diminished/absent)
trophic changes (skin discoloration, shiny
presentation), muscle weakness, Symptoms
progress rapidly!!
                    PT Treatment

Rearfoot distraction only if: swelling is minimal,
ligaments are intact (so only Grades I and II, must
have an endfeel on both ligament tests), and
decreased ROM particularly DF. ABC's with a
precaution not to go into excessive PF or Inversion.
Stretching, BAPS board, RICE, strengthen evertors,
treat jt hypomobility with mobs if pt has pes cavus




Follows the same course of treatment as inversion
sprains, grade 2 or 3 may have considerable
instability and weakness in medial longitudinal arch
resulting in pronation and fallen arch


DF ROM frequently limited in
rehab to avoid further stress on mortise/tibiofibular
ligaments, recovery often requires > 6 mos
Gradual stretching of plantar fascia (ICW friction
massage), gastroc/soleus stretch, (plantar fasciial
more effective than gastroc/soleus stretching for
pain severity, ADL limitations & overall patient
satisfaction), night splints, iontophoresis may
provide short term relief, advice to lose wt if
indicated, using a golf ball or coke can in morning for
cross friction massage ( but this is not supported by
evidence). Addressing impairments such as
decreased DF, weakness of foot intrinsics, weakness
of Post Tib, Per. long.


Activity modification, doughnuts, cushioned heel
cups or heel pads, basket weave or similar fad pad
containment taping, footwear with increased
cushioning, cushioned, semi-rigid orthosis, assess any
impairments found in PE




Acute Tx: Rest/ice/ analgesics progressing to NSAIDs,
bilateral heel lifts or orthoses, stretching (painfree
ROM only). Chronic Tx: Focus on restoration of
collagen integrity rather than inflammation, Address
training protocol errors: Sudden initiation of
sprinting, jumping, or hill runs. Footwear
interventions: Proper running shoe type (& possible
orthosis) for excessive pronators or supinators,
frequent replacement of footwear (6 months or 4-
600 miles for running shoes), constant heel height in
all shoes throughout day: heel lift in training shoes if
adamant about wearing high heels. General: Focus
on eccentric strengthening of achille's
(gastroc/soleus), address any impairments found in
PE like pes cavus or plantus
Doughnut to cushion bursal contact with shoe,
footwear change to decrease pressure of heel
counter against bursa, orthoses PRN, ice & NSAIDS,
Protective horseshoe or cutout padding for
Haglund's Deformity.


Non-surgical measures addressing underlying source
of compression (changes in training protocol,
footwear specific for foot type, orthoses, weight
loss). Address any impairments found in PE




Relieve pressure via a cutout, gastroc/soleus
stretching, orthotics, inserts or arch taping,
metatarsal pad or bar, shoes with wide toe box
Relative rest, then gradual, controlled progression in
training frequency, duration, intensity, referral as
necessary to primary care to address menstrual cycle
irregularities & potential nutrition-related issues,
proper running shoe type (per individual foot type) &
possible orthotic intervention, aircast to unload bone
at site of inflammation, addressing muscle
strength/length deficits per objective exam findings,
frequent directional changes on track, roadside
changes while running to avoid effect of road
angulation




Increase flexibility of muscles in involved
compartment, increase muscular endurance by
gradual increase in activity duration (progress from
duration insufficient to cause symptoms), training
surface change from hilly to level surface courses,
footwear appropriate for individual foot type




Emergency Action: Remove all bandages, wraps,
plaster or other forms of external compression, Do
NOT elevate beyond horizontal (potential decrease
in arterial pressure & further compromise in capillary
filling), Do NOT place in dependent position
(potential increase in compartmental pressures),
Notify physician ASAP & monitor until he/she
assumes care of patient
              KNEE
Lachman's              Sensitive & Specific
Posterior Drawer       Sensitive & Specific

Anterior Drawer        Specific
Pivot Shift            Specific
McMurray's             Specific
Appley's Compression   Specific

Valgus Stress Test     Sensitive
Varus Stress Test      Sensitive (low .25)
Otawa Knee rules       Sensitive
CPR for knee OA        Sensitive
           ANKLE
Thompson Calf Squeeze      Sensitive & Specific




Anterior Drawer            Sensitive
Otawa Ankle & Foot Rules   Sensitive

				
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