Review for Ortho Exam and Practical #2

Orthopedic Condition Hx, A/P Movements, Neurological, Palpation

Lumbar Spine:
• Acute trauma or microtearing, localized pain
aggravated by movements. Rest relieves, stiffness
follows immobility
Muscle Strain • Poor motor control (QOL), pain with active movement
• Negative for neurological signs & sx
• Local tenderness, may spill over to other segments,
UNILATERAL
• Gradual onset or acute overload. Pain patterns
consistent with trigger point referred pain zones
(RPZ). Referred aching pain, sometimes parasthesias.
Stretching muscle or active contraction
aggravates. Pattern Varies; referred TP zones
Myofascial Pain • Negative for Neurological signs & sx
• Palpable jump sign and TP bands
• Special Tests: anything that stretches muscle may elicit
pain; SLR, FABER + muscle length tests
• Factors that underlie muscle strain may also predispose
MPS
• Sudden onset; gross trauma or micro trauma,
aggravated by ALL movements; loss may be
severe. Relieved by rest, stiffness after
Facet Joint Sprain • Active/Passive Extension is PAINFUL
• Protective muscle spasm and guarding. Point
tenderness
• Special Tests may be (+) due to high level of irritability
• May be progression of facet joint sprain
• Scleratogeneous referred pain patterns can mimic nerve
Facet Joint Syndrome root sx
• Positional Relief: FLEXION
• Quadrant Test, Stork Standing, Farfan’s Rotation
Indicators:
• (+) Response to intra-articular injection
• Localized, unilateral pain; no referral below knee
• Pain relief with medial branch blocks
Zygohypophyseal Joint • Reproduce pain with unilateral pressure over Zygo Jt or
Pain (ZJP) Transverse Proc
• Lack of radicular features
• Pain relieved with flexion, increased with ext/ipsilat rot/
Lateral bend
• Unilateral muscle spasm over affected ZJ
• Phase I: Hypomobility; early cartilage degen. In ZJ’s,
disc degeneration
Degenerative Joint • Phase II: Hypermobility; ZJ subluxation & HNP
Disease (DJD): • Phase III: Fixed hypomobility; osteophytes, lateral &
Arthrosis, Spondylosis central stenosis
• Disc space narrowing, loss of disc integrity, disc
prolapse/bulging
Herniated Nucleus • Protrusion: nucleus migrates to periphery thru torn
Pulposis inner fibers, causing AF to bulge. Extrusion: nucleus
 has escaped outer fibers of AF but maintains continuity
with central mass of NP. Sequestration: nucleus loses
continuity with central mass. PLL is torn and material
escapes into central canal.
• Nerve Root Compression  L4-L5 Lesion will affect L5
NR, L5-S1 Lesion will affect S1 NR, large lesions will
affect multiple levels
• Usual activity is reported as MOI; increased intradiscal
pressure; bending, lifting, rotating, coughing
• Peak Age: 20-45, Male: Female = 3:2. Common Levels;
L4/5, L5/S1
• Flexion postures aggravate, extension relieves
• Without NR involvement: unilateral, local pain. Loss of
ext, pain with fwd flex, better w/repeat ext. Lateral shift
may be present. (-) Neurological, protective mm
guarding & tenderness. (+)Quadrant, NTT reproduces
LBP
• NR involvement: most common cause of lumbar
radiculopathy syndrome. Unilateral peripheral pain,
above or below knee, usually LBP unless sequestrated,
then leg pain only. Centralization phenomena, unless
sequestered. Lateral shift possible, (+) Neuro & NTT, (+)
Quadrant
• Episodic LBP, and/or leg pain. Pain with sustained
postures
• Limited ROM in multiple directions, aberrant trunk
mvmnts, (+) Gowers Sign (walk up legs c arms), Catch
Lumbar Instability
Sign, hypermobility with PIVMT
Syndrome
• (+) Prone Lumbar Instability Test
• Clinical Prediction Rules refer to Lumbar spine
mgmt PowerPoint
• Spine STABILIZATION exercises
• Depends on phase of degenerative process. Phase II;
intermittent leg pain w/wo LBP. Phase III more constant
often w/o LBP. Mean age = 41years
• Extension and ipsilateral LB loss. Phase II; instability
may be significant muscle guarding. Global loss of both
P/A mobility in phase III
Lateral Stenosis • Neurological: (+) dermatomal sensory loss!
• SLR, Slump tests may be (+), Quadrant Test (+)
• Joints tender to palpation, tissues may be
thickened, esp supraspinatus ligament. POC
directed @ impairment/functional loss, implementing jt
protection strategies, stabilization program for phase II.
• Postural correction and ergonomic corrections!
• Usually Hx of LBP, Phase III of degenerative process.
Bilateral Leg Sx! Intermittent Claudication, May
present with bizarre symptoms. Flexion relieves pain,
Central Stenosis extension aggravates. Mean Age 64 years
• Loss of extension ROM
• (+) Motor &/or sensory neurological signs
• (+) Quadrant, Ely’s Tests
Spondylolisthesis • Anterior slippage of one disc on another. (Common-
L5/S1)
 •Insidious, small % have Hx of trauma. Symptomatic
with grades 2-4. LBP, leg pain in severe cases.
• Flexion and Ext painful when active, Flexion often
relieves.
• Neurological; Cauda Equina signs when severe
• (+) Step Sign, Stork Standing.
• Spondylosis – Pars Defect. Affects SI, ZJ, and
costovertebral joints.
• Fusion begins caudally, progresses cranialward
Ankylosing Spondylosis • Pain in heels, ischial tuberosities, iliac crests, humeral
epicondyles, & shoulders
• Nocturnal Pain, Morning Stiffness. Asymmetrical
peripheral arthritis
4 Main Types:
1. Compression; failure of anterior column
2. Burst; failure of anterior column
Fractures
3. Flexion-Distraction; involved anterior and posterior
columns
4. Fracture-Dislocation; anterior and posterior columns
Hip:
• Malformation; genetic, hormonal, mechanical
• 1.5/1,000 Births, Unilateral 50-80% of cases, L>R 3:1,
Congenital Hip Female:Male = 8:1
Dysplasia • Can ride superior, or completely out of the joint.
• Femoral Anteversion-Head of femur ant. So pt needs
to IR to bring head back into socket.
• Progressive disorder of unknown cause; endochondral
ossification defect of femoral neck
• Angle of inclination <120 degrees!
Coxa Vara • Painless limp, Leg length defecit, limited abd and ext,
mild hip flexion contracture, excessive lordosis,
presenting s&sx
• Surgical intervention in <110 degrees
• Osteochondral Condition; begins as underlying
avascular necrosis of secondary epiphyses of head of
Legg-Calve Perthes femur; 2-12yrs
(Pediatric Condition) • Often is self-limiting, PAINFUL limp is characteristic,
ant & post joint capsule is tender, ABD and IR
movements limited
• 10-16y.o.  most common hip disorder of
adolescence
Slipped Capital
• Physical signs include: limited IR, ABD and flexion ROM,
Femoral Epiphysis
quadriceps atrophy, Leg Length Discrep up to 1inch,
antalgic or trendelenberg gait
• Deep Trochanteric: Subgluteus Medius, most common.
Presents with aching pain @ lateral hip & palpatory
tenderness, non-capsular pattern of movement loss.
Bursitis
• Iliopectineal: Ant groin pain, compensated gait, pain
with PROM in ext + IR, pain with AROM flexion.
• Ischiogluteal
Hamstring Strain • Non-Sciatic buttock & posterior thigh pain; LOCAL
• Weakness, loss of flexibility, or hamstring
dominance in hip ext mvmnt
 • Chronicity is common, can take up to 6 months to heal
• Adductor Strain: adductor longus most common
• Groin Strain: adductors, iliopsoas, Sartorius, rectus
Other Muscle Injuries
femoris
• Sportsman Hernia: abdominal distal insertion (inguinal)
• Most common disease affecting hip. 25% females, 15%
males >60 years
• Correlated with hip retroversion, pain posterior to
greater troch, ant thigh, knee and groin
Osteoarthritis • Loss of IR most sensitive ROM measure
• Physical signs include capsular pattern of ROM defecits,
atrophy of glute max and med.
• Can refer pain to knee or groin; osteophytes,
subchondral sclerosis
• Cause: Sports injury (rotation on WBing limb), trauma,
micro trauma (degenerative)
Labral Tear • S&S: Sensation of locking or catching, limited ROM;
especially flexion, anterior hip pain.
• “Internal Snapping”
• Commonly in >60 age group, females. Femoral neck
common.
• Acute groin pain, ant hip tenderness, limb assumes
Fractures position of ER
• Complications of hip fx most troublesome of all fx:
Avascular necrosis, DJD, nonunion, general systems
failure 2o to immobilization
• Insidious onset of deep hip pain. 1.25% of running
injuries
Stress Fracture • Femoral neck common, followed by lesser troch,
proximal femoral shaft.
• IR ROM limited, (+) axial compression, Fulcrum test
• Terminal phase of conditions that impair blood supply
to femoral head (superior lateral aspect) including Fx
of proximal femur (especially displaced), SCFE,
Dislocation, Alcoholism, Sickle Cell Anemia, Steroid Use,
Avascular Necrosis
decompression sickness.
• Idiopathic form occurs primarily in males 30-50, 50%
bilaterally, Male:Female = 4:1
• Sudden onset of pain & stiffness
• Most common hip disorder causing a limp in
children. Non specific; self-limiting inflammation of
Transient Synovitis the synovium.
• Generally acute or insidious onset
• Pain in hip, thigh, or knee. Limited in extension and
IR (mild)
• Meralgia Paraesthesia: Femoral Nerve; numbness,
tingling anterior thigh
Nerve Entrapment • Hamstring Syndrome; sciatic nerve is compressed at
tendinous origin of Biceps Femoris

Piriformis Syndrome • “Deep Gluteal Syndrome”

• Prevalent in runners due to repetitive hip ER. Muscle
 may be short/stiff
• Buttock pain, may radiate to post thigh w or w/o
LE parasthesias
• Symptoms aggravated by sitting or WBing
activities.

Movement • Short or Stiff/ Weak Abdominals

Impairments • Dominant TFL
• Weak Glutes
Knee
• Osgood Schlatter’s = children, Jumper’s Knee,
Quadricep tendinitis, Patellar Tendinitis
• Point tenderness, swelling, pain with resisted
Patellar Tendinitis extension or PROM flexion, crepitus, quad atrophy
• Tx directed at controlling loading, containing
inflammatory response, correcting underlying
impairments
• Pre-patellar Bursitits=housemaid’s knee, superficial or
deep infrapatellar
• Baker’s Cyst; any form of synovial herniation or
Bursitis bursistis of post knee; includes semimembranosus or
medial gastroc bursa. Synovial membrane of
semitendinosus sheath or post joint capsule.
• S&Sx: LOCAL pain and swelling
• MCL- injured by valgus stress w knee ext or flexed <90o
usually accompanied by damage to medial meniscus,
medial capsule and ACL
• LCL- injured by varus stress; rarely isolated injury due to
attachments
• S&Sx: MOI, LOCAL pain and swelling, joint line
tenderness, instability
• Most injuries managed conservatively

• Clinical DX: MCL Sprain:

1. Trauma to lateral knee or rotational trauma
Collateral Ligament 2. Pain with valgus @ 30o flexion
Injuries 3. Laxity with valgus stress @ 30o flexion
4. Knee ROM WNL
5. Palpatory medial joint line tenderness
6. (+) Modified stroke test/Bulge sign

• Clinical Dx: LCL Sprain:

1. Varus Trauma
2. Localized effusion, LCL region
3. Palpatory tenderness @ LCL
4. Pain with varus stress @ 0o or 30o of flexion
5. Laxit with varus stress @ 0o or 30o of flexion
6. (+) Modified Stroke Test/Bulge Sign
Plica Syndrome • Plica = ext of synovial membrane; usually medial.
• Runs medial surface of the synovial capsule to the
infrapatellar fat pad, becomes TAUT during knee
flexion
• Trauma, chronic overuse, and quadriceps
 weakness predispose.
• Sx: medial pain, swelling, clicking.
• CONTACT vs non-contact injuries; Unhappy Triad
• Reconstruction generally a prerequisite before returning
to sports

• Risk Factors (Non-Contact)

1. Increased BMI
2. Shoe surface interaction (increase coefficient of
friction)
3. Narrow femoral notch width
4. Increased joint laxity
Anterior Cruciate 5. Pre-ovulatory phase of menstrual cycle
Ligament (ACL) 6. Strong quad activation during eccentric loading
conditions

• Clinical DX: ACL Tear

1. MOI consistent with ACL injury
2. Hearing or feeling a POP at time of injury
3. Hemarthrosis 0-2 hrs after injury
4. Loss of end-range knee extension
5. (+) Lachman’s/Pivot Shift Tests
6. 6m SL Hop Test 80% or less uninvolved side
7. 80% or more MV quad defecit
• Anteromedial blow to a flexed knee, or fall onto
knee accompanied by hyperextension.
• MCL& Arcuate ligament complex tears often accompany-
leading to PLRI
• Clinical Dx: PCL Tear
Posterior Cruciate 1. MOI consistent with PCL injury
Ligament (PCL) 2. LOCALIZED posterior knee pain with kneeling or
deceleration
3. (+) Posterior Drawer @ 90o
4. (+) Sag Sign
5. (+) Modified Stroke Test
6. Loss of knee extension ROM
• Most commonly due to force movements of flexion,
compression, and rot. resulting in shear stress to
fibrocartilage. Meniscus fails to follow
Meniscal Injuries • Longitudinal Tear = Bucket Handle Tear
• S&Sx: joint line pain, effusion, crepitus, and locking
• Partial Menisectomy and direct repair are surgical
procedures of choice
• Traction apophysitis or epiphysitis of the tibial
tubercle
• Direct trauma usually precipitates, then chronic irritation
Osgood Schlatter occurs from traction forces of the patellar tendon
Disease • Benign osseous tumor forms
• S&Sx: local pain and bony swelling, pain with resisted
knee extension
• In growing bones  boys>girls
Osteochondritis • Osteochondral fracture/intra-articular fragment of
Dessicans (OCD) articular cartilage and underlying bone
• Medial femoral condyle most common; 80-85%. 30-
 40% bilateral
• Male: Female = 3:1, 30-60 cases per 100,000
• May be 2o to avulsion of PCL or direct trauma
• S&Sx; poorly localized aching pain, swelling, pain
w WBing & rotational movements, locking or
“giving way” sensations
• Activity modification for 6-12wks, ice, general rehab,
return to function
• Deterioration of cartilaginous surfaces of the
joint, sclerotic changes in the subchondral bone, and
proliferation of new bone in the joint margins.
• S&Sx: knee pain & stiffness, effusion or bony
swelling, decreased ROM, quad weakness, radiographic
evidence
• Indications for TKR: severe pain, significant loss of
Osteoarthritis (OA)
function, severe radiographic changes, failed
conservative management.
• Outcomes for TKA: self-report pain and function
improve; post-operative rehab is not adequate in many
cases; residual quad strength impairments and
functional deficits. Muscle atrophy & muscle activation
underlie impairments
• Femoral Condyle- caused by impact, avulsion, or
shearing forces. Most common tx is ORIF
• Patella- caused by direct blow. Tx involves closed
reduction or open, with internal fixation
• Epiphyseal Plate-hyperextension or torsional weight
bearing movement
• Tibial Plateau- combination of valgus & compressive
stress with knee flexed. Requires surgery; internal
fixation with bone graft

• Type I: complete seperation of epiphysis, associated

Fractures with shear injury. Closed reduction, Px good. Occurs in
newborns, children
• Type II: fx extends along epiphysis, into metaphysis.
Most common, Px good, occurs in older children
• Type III: fx extends in epiphysis, intra articular.
Uncommon, distal tibia. ORIF, occurs in teenagers.
• Type IV: fx extends from jt surface through epiphysis,
epiphyseal plate & metaphysis. ORIF, px poor, interrupts
bone development
• Type V: compression injury w/o displacement.
Uncommon, difficult to dx. Px poor, interrupts bone
development.
• Patellar tendinitis (jumpers knee) chondromalacia
patellae (CP) patellar malalignment, and patellar
instability
Patellofemoral Pain
• CP consists of softening, fibrillation & degeneration
Syndromes
of undersurface of patella, and is associated with altered
patellar biomechanics
• Incidence is higher in physically active individuals
Patellar Instability • Direct trauma, increased q angle, insufficiency of
VMO, shallow patellar groove, or abnormally
 positioned patella.
• Subluxation/dislocation can occur, most common
mechanism is combination of planting foot & ext rotating
femur as knee is flexed.
Ankle and Foot
• Structural impairment, LIMITED DF <10o can be 2o
to immobilization
• Caused by contracture of gastrocnemius, soleus or
achilles tendon
Equinus Deformity • Can also be caused by trauma, inflammatory disease or
deformity of talus
• May lead to rocker-bottom foot, excessive pronation
• Clubfoot; congenital deformity-most common
form=talipes equinovarus
• Congenital, neurological condition (spina bifida),
muscle imbalance, or associated with clubfoot.
• Longitudinal arches are accentuated, forefoot is
Pes Cavus lower in relation to hindfoot.
• Soft tissue adaptations
• “rigid foot” – therefore susceptible to injury; prone to
inversion sprains
• More common, may be congenital or result of trauma (fx
of calcaneus), muscle weakness, ligament laxity,
paralysis.
Pes Planus • Associated with pronated foot
• Rigid (congenital) or acquired/flexible
• Loss of longitudinal arch, additional stress up the chain
d/t no absorption of ground reaction forces.
• Medial deviation of head of the 1st metatarsal in
relation to the center of the body
• Increase in metatarsalphalangeal angle
Hallux Valgus
• Callus formation (medial aspect of met head) +
thickened burse + exostosis = BUNIONS!
• Must be surgically managed
• Posterior heel pain, most common form of
tendonitis/osis in runners, 2nd most common in
basketball.
• Thickest, strongest tendon in body
• Subject to shear and compressive stress
• S&Sx: post heel pain, swelling, decreased length of
tendon, excessive pronation, or supination.
Achilles Tendinopathy
• Begins as paratenonitis- degenerative thickening of
paratnon without inflammation
• Tendon gliding mechanism is impaired
• Area most susceptible is Avascular zone – insertion of
midsubstance into calcaneous
• Tx; stretching exercises, prescription of heel pad
inserts, ice, US, strengthening (ECCENTRIC)
• Occurs in 8-12 y.o’s
• Sport Participation
Sever’s Disease • Chronis Heel Pain
• Apophysis- secondary ossification center @ growth plate
• Excessive tension, loading at growth plate
 • Repetitive Stress Injury, pronated or cavus
footpredisposes
• Microtears of origin of plantar fascia at medial calcaneal
tuberosity
• Common in running sports, secondary heel spur disorder
Plantar Fascitis may develop due to periosteal failure
• S&Sx: plantar/heel pain, pain upon first arising, point
tenderness-medial calcaneal tubercle, pain with passive
toe extension
• Tx; Ionto–dexameth acetic acid, MT, calf & PF stretching,
taping, orthotics
• Chronic Leg Pain, Idiopathic compartment
syndrome
• Exercise induced pain secondary to repeated
loading
Shin Splints
• Target musculotendinous unit
• Anterolateral (TA, EHL, EDL)
• Posteromedial (TP) medial tibial stress syndrome of
posterior tibial SS
• I: Mild Weakness, no forefoot deformity, normal
tendon length
• II: hindfoot eversion, forefoot abduction and lowering of
Posterior Tibial Tendon MLL
Dysfunction (PTTD) • III: Progression of stage II with fixed deformity,
marked degeneration and lengthening of tendon.
• Tx considerations: address structural impairments, US,
footwear, orthotics, ECCENTRIC strengthening exercises
• Most frequently injured joint in athletes, 10-30%
chronic mechanical instability. Predisposed for future
injury
• I (Mild); <25% fiber disruption of ATFL and stretching of
intact fibers. Mild swelling, point tenderness, little to no
hemorrhage, some difficulty with FWB
• II (Moderate); complete rupture of ATFL, part of CL, 25-
75% of fibers torn, along with capsule. Restricted ROM,
localized swelling, eccymosis, hemorrhage, tenderness
Ankle Sprain
at anterolateral ankle. Swelling may become more
diffuse within a few days. Instability mild or absent,
inability to raise on toes.
• III (severe); complete tear of ATFL and capsule, rupture
of CFL. >75% fiber diruption. If PTFL is torn=ankle
DISLOCATION. Rapid onset of swelling, diffuse swelling,
severe pain, ecchymosis, tenderness over anterolateral
capsule, ATFL and CFL, inability to WB grade 3+ ant
drawer with + sulcus sign.
• Sprain of plantar capsule and lateral collateral ligament
complex
Sprain of 1st MTP/ Turf • MOI involves hyperextension of big toe, common in
Toe football, soccer, lax
• Significant short term & potential long term impairment
of push-off, therefore affecting running
• Tibial stress fx, distal tibial fx, distal fibular fx, ankle fx,
Fractures
calcaneal fx, tarsal/metatarsal fx
Compartment • Increased pressure within one or more of the
 anatomical compartments of the leg.
• Compromises circulation and tissue function
within that space
• Chronic form due to repetitive loading or
microtrauma associated with physical activity.
• Exercise will increase muscle volume, thus stretching
the compartment margins
Syndrome
• Lateral- Peroneus long&brev, common and superficial
peroneal nerves
• Deep Posterior- FHL, FD, TP, post tibial artery & vein,
peroneal artery and vein, post tibial nerve
• Superficial Posterior-gastroc, soleus, sural nerve
• Anterior Compartment- tib ant, EHL, EDL, ant tibial
artery and vein, deep peroneal nerve
• Can be injured secondary to trauma (knee dislocation,
direct blow) or from entrapment as it passes over the
popliteus and under soleus = popliteal entrapment
syndrome
Tibial Nerve
• Injury to proximal nerve can result in inability to
PF and invert foot, flex abd/add toes, and loss of
sensation on sole of foot
• Tarsal Tunnel Syndrome can also affect the nerve
• Entrapment neuropathy of the tibal nerve
• Floor of tunnel is medial talus, sustentaculum tali, and
medial calcaneus. Roof is flexor retinaculum.
• Contents: tibial nerve, post tib artery/vein,
tendons of FHL, FDL, and tib post
• Idiopathic in 50% of cases, d/t tight shoes, case, cysts,
inflammation secondary to tendosynovitis and venous
Tarsal Tunnel thrombosis
Syndrome • Excessive pronation can also cause stretch to tibial
nerve and lead to TTS
• Other causes; trauma, rapid weight gain ,RA, fluid
retention
• S&Sx: pain and hyper/hypoesthesia in sole of foot,
hallux, and medial foot.
• Later, motor weakness of intrinsics, MTP flexion,
abductor hallicis
• Commonly injured in ant compartment syndrome and
ant tarsal tunnel syndrome
• Compression can also be caused by trauma, tight shoes,
a ganglion or pes cavus
Deep Peroneal Nerve
• Weakness of: tib ant, EDL, EHL, peroneus tertius
possible
• Drop foot, steppage gait, sensory loss in thong
space of 1st/2nd toes
• Injury associated with lateral ankle sprain, entrapment
4-5 inches above lateral malleolus, or compression near
fibular head
Superficial Peroneal
• Sensory loss associated with both proximal and
Nerve
distal lesions – lateral leg and dorsum of foot.
• Motor loss with proximal lesion, weakness of foot
EVERSION and ankle instability.
Morton’s Neuroma, • Interdigital neuroma secondary to injury to one of
 the digital nerves
• Most often involves digital nerve between 3rd and
4th toes.
Interdigital Neuritis
• More frequent in women
• Pain on lateral aspect of forefoot associated with
WBing