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Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems Medical Screening

for the Knee, Leg, Ankle or Foot Region


Condition Fractures1-4 Red Flag Data obtained during Physical Exam Joint effusion and hemarthorsis Bruising, swelling, throbbing pain, and point tenderness over involved tissues Unwillingness to bear weight on involved leg Unilaterally cool extremity (may be bilateral if aorta is site of occlusion) Prolonged capillary refill time (>2 sec) Decreased pulses in arteries below the level of the occlusion Prolonged vascular filling time Ankle Brachial index < 0.90 Calf pain, edema, tenderness, warmth Calf pain that is intensified with standing or walking and relieved by rest and elevation Possible pallor and loss of dorsalis pedis pulse History of blunt trauma, crush Severe, persistent leg pain that is intensified with injury - or stretch applied to involved muscles Recent participation in a rigorous, Swelling, exquisite tenderness and palpable unaccustomed exercise or tension/hardness of involved compartment training activity Paresthesia, paresis, and pulselessness History of recent infection, surgery, Constant aching and/or throbbing pain, joint or injection swelling, tenderness, warmth Coexisting immunosuppressive May have an elevated body temperature disorder History of recent skin ulceration or Pain, skin swelling, warmth and an advancing, abrasion, venous insufficiency, irregular margin of erythema/reddish streaks CHF, or cirrhosis Fever, chills, malaise and weakness History of diabetes mellitus Red Flag Data obtained during Interview/History History of recent trauma: crush injury, MVA, falls from heights, or sports injuries Osteoporosis in the elderly Age > 55 years old History of type II diabetes History of ischemic heart disease Smoking history Sedentary lifestyle Co-occurring intermittent claudication Recent surgery, malignancy, pregnancy, trauma, or leg immobilization

Peripheral Arterial Occlusive Disease5-9

Deep Vein Thrombosis10,11,17

Compartment Syndrome12-14

Septic Arthritis15

Cellulitis16

References: 1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-794. 2. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2002;68:2413-2418. 3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman. J of Bone Joint Surg. 2003;85:820-824. 4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments. Injury. 2004;35:443-461. 5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. Journal of Clinical Epidemiology. 1997;50:659-668. 6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158:1357-1364. 7. Halperin, JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303-11. 8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182. 9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ. 1996;313:1440-79. 10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in outpatients. Amer J Med. 2003;115:436-440. 11. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome. Pain Res Manag. 2001;6:200-203. 12. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-104. 13. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup. Postgraduate Medicine. 1999:105. 14. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder. Orthop Trauma. 2002;16:572-577. 15. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 16. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections. Am Fam Physician. 2002; 66:119-124. 17. Riddle DL, et al. Diagnosis of lower-extremity deep vein thrombosis in outpatients with musculoskeletal disorders: a national survey study of physical therapists. Phys Ther. 2004; 84 (8): 717-728.
Robert Klingman PT, Joe Godges PT KP SoCal Ortho PT Residency

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE


NAME: ________________________________________ Medical Record #: _________________________ DATE: _____________

Yes 1. Have you recently experienced a trauma, such as a vehicle accident, a fall from a height, or a sports injury? 2. Have you recently had a fever? 3. Have you recently taken antibiotics or other medicines for an infection? 4. Have you had a recent surgery? 5. Have you had a recent injection to one or more of your joints? 6. Have you recently had a cut, scrape, or open wound? 7. Do you have diabetes? 8. Have you been diagnosed as having an immunosuppressive disorder? 9. Do you have a history of heart trouble? 10. Do you have a history of cancer? 11. Have you recently taken a long car ride, bus trip, or plane flight? 12. Have you recently been bedridden for any reason? 13. Have you recently begun a vigorous physical training program? 14. Do you have groin, hip, thigh or calf aching or pain that increases with physical activity, such as walking or running? 15. Have you recently sustained a blow to your shin or any other trauma to either of your legs?

No

Joe Godges DPT

KP SoCal Ortho PT Residency

Normal Gait Mechanics


Normal Gait Patterns Have Two Major Periods: 1. Double Limb Support: a) weight loading b) weight unloading 2. Single Limb Support: a) stance phase of ipsilateral side b) swing phase of contralateral side

DOUBLE LIMB SUPPORT WEIGHT UNLOADING: Phases: Trailing foot is rolling off floor when heel rises when 1st MTP rolls off floor Pre-Swing Max. plantarflexion (20 o) Flexes to approx. 40o Flexes to approx. 0o (neutral) Less anterior rotation Begin anterior elevation Aligned towards wt. loading leg

Terminal Stance: Pre-Swing:

Joint Motions: Ankle Knee Hip Pelvis Trunk

Terminal Stance Heel rise Full extension Max. extension (20o) Relative anterior rotation Posterior depression Aligned between legs

WEIGHT LOADING: Phases:

Weight is transferred to contralateral leg Initial Contact: Loading Response: when heel contacts floor when sole of foot contacts floor

Joint Motions Ankle Knee Hip Pelvis Trunk

Initial Contact Neutral Knee extended Flexed 25o Level Aligned between legs

Loading Response Plantarflexes 10o Knee flexes 15o Stable 25o flexion Relative abduction Lateral drop to swing leg Aligned towards wt. bearing leg

Joe Godges DPT

SINGLE LIMB SUPPORT

Body is aligned over the stationary foot Contralateral leg is off the floor

STANCE PHASE: Joint Motions Ankle Knee Hip Pelvis Trunk

(Initial Mid-Stance, Mid-Stance, Late Mid-Stance) Initial Mid-Stance Slight plantarflexion Slight flexion Flexed, Relative adduction Late Mid-Stance Max. dorsiflexion (10 o) Extended Extended, Relative adduction

10o

Lateral drop to swing leg, externally rotated Toward stance leg Away from stance leg Trunk rises in an arc over the stationary foot

SWING PHASE: Sub Phases:

Leg shortens via hip and knee bend to simplify floor clearance Initial Swing: big toe leaves ground Mid-Swing: contralateral leg is at high point mid-stance Terminal Swing: leg reaching forward for next floor contact Initial Swing Plantarflexed Max. flexion (60 o) Flexion, Relative abduction Mid-Swing Neutral Flexion Max, flexion (25 o) Max. abduction (10o) Terminal Swing Neutral Max. extension (0o) Flexion, Relative abducted

Joint Motions Ankle Knee Hip Pelvis Trunk

Lateral drop to swing leg, medial rotated Aligned over stance leg

Pathway of Center of Gravity Sagittal Plane: Rhythmical up and down motion Highest point: Over extended single leg (MSt) Lowest point: Double limb support (PSw/LR) Vertical displacement of 4-5 cm. (sinusoidal wave) Frontal Plane: Rhythmical side-to-side motion Most lateral point: Mid-Stance C. O. G. swings laterally in as arc over the stationary foot Lateral displacement of 4-5 cm. (sinusoidal wave)

References: Greenman PE. Clinical aspects of sacroiliac function in walking. Manual Medicine. 1990;5:125130. Koerner I. Observation of Human Gait. Edmonton, Alberta, Canada: University of Alberta; 1986. Observational Gait Analysis. Downey, CA: Rancho Los Amigos Research and Education Institute; 1993. Perry J. Gait Analysis. Normal and Pathological Function. Thorofare, NJ: Slack; 1992.

Joe Godges DPT

Critical Events During Gait


Joint 1st MTP Midtarsal: Calcaneocuboid Sagittal Plane 65o extension at PSw Control of Abduction at TSt PF of 1st Ray at TSt/PSw (Peroneus Longus) Oblique MT Jnt Axis stability at TSt Control of Eversion at MSt (Tib Ant and Tib Post) Longitudinal MT Jnt Axis stability at TSt 4-6o eversion at IC/LR 10o-20o DF at TSt Control of DF (tibial advancement) after MSt (Gastroc. and Soleus) Control of flexion at LR (Quadriceps and VMO) o 0 extension at TSt 60o flexion at ISw Produce full ext. at TSw Control of flexion at LR (Hip extensors) 20o extension at TSt Patellar Medial Glide Frontal Plane Transverse Plane

Talonavicular

Subtalar Ankle

Knee

Hip

Control of lateral pelvic tilt at MSt (Hip Abductors)

Common Lower Extremity Musculoskeletal Impairments Associated With Gait Deviations Joint ROM/Muscle Length Deficits
1st MTP Dorsiflexion Talocalcaneal Eversion Talocrural Dorsiflexion Tibiofemoral Extension Tibiofemoral Flexion Patellofemoral Medial Glide Hip Extension

Motor Control/Strength Deficits


Tibialis Anterior Tibialis Posterior Peroneus Longus Gastrocnemius/Soleus Quadriceps/VMO Gluteus Medius/Minimus Gluteus Maximus

Joint Hypermobility/Instability
Calcaneocuboid/Oblique MTJA Talonavicular/Longitudinal MTJA

Joe Godges DPT

1 Foot Capsule Disorders "Midtarsal Joint Capsulitis" ICD-9-CM: 845.11 Sprain of tarsometatarsal joint

Diagnostic Criteria History: Arch area pain - medial or lateral Pain worse with single limb support phase of gait Recent strain or repetitive use Pain at end range of one or more of the following accessory movement tests (dorsal glide or plantar glide of the distal bone on a stabilized proximal bone): Lateral Foot Calcaneus Cuboid Navicular/3rd Cuneiform Cuboid

Physical Exam:

Medial Foot Talus - Navicular Navicular - 1st Cuneiform

Talus - Navicular Accessory Movement Test Cues: Patient sits on edge of table to allow knee flexion Proximal forearm rests on tibia, index finger metacarpal (MCP) stabilizes dorsal surface of talus, PIP and DIP stabilize talus using sustentaculum tali of calcaneus Distal index finger MCP provides the planter glide and PIP and DIP provide the dorsal glide of the navicular Alter forearm/upper extremity angle to align force with the "treatment plane" (move the navicular with a glide parallel to the plane of the talonavicular joint) Determine symptom response, available motion, and end feel

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Navicular - 1st Cuneiform Accessory Movement Test Cues: Proximal MCP, PIP, and DIP stabilize navicular Distal MCP, PIP, and DIP move 1st cuneiform Determine symptom response, available motion, and end feel

Calcaneus - Cuboid Accessory Movement Test Cues: Calcaneus rests on stabilizing hand which rests on table, outside hand grabs cuboid Thumb on plantar surface, index and/or middle finger on dorsal surface of cuboid "Up and out, down and in" - using a straight plane, translatory force (in line with the "treatment plane") Determine symptom response, available motion, and end feel

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Navicular/3rd Cuneiform - Cuboid Accessory Movement Test Cues: Inside hand now stabilizes navicular and 3rd cuneiform (Thumb on plantar surface, index and middle finger on dorsal surface) Move cuboid "up and out, down and in"

"Hallux Rigidus" ICD-9-CM: 735.1 Hallux rigidus

Diagnostic Criteria History: off") Physical Exam: Limited motion of 1st metatarsophalangeal (MTP) extension Pain at end range of extension ROM Limited MTP accessory movements - especially volar glide Stiffness Pain with barefoot walking - symptoms worse at pre-swing ("toe-

1st MTP Extension ROM Cues: Depress 1st metatarsal plantarly, extend proximal phalanx of big toe dorsally Measure angle of metatarsal shaft to proximal phalanx. Normal ROM is 65 degrees
Joe Godges PT, Robert Klingman PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

1st MTP Accessory Movement Test Dorsal Glide of Proximal Phalanx Cues: Loose pack position is 10 degrees of dorsiflexion "Bunch Skin" Glide parallel to articulating surface of the proximal phalanx Compare with opposite side for normal amount of movement (if the opposite side has normal range of motion) Determine symptom response at end range

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Hallux Rigidus
ICD-9: 735.1 Description: Hallux rigidus is considered a progressive disorder of the 1st MTP joint marked by pain, decreased dorsiflexion, and degenerative changes in the joint. Etiology: Hallux rigidus can be caused by osteoarthritis, repetitive trauma, or anatomic abnormalities of the foot. Patients with hallux rigidus present with complaints of pain localized at the first MTP joint and/or joint stiffness. These symptoms can be insidious or as the result of an injury. The pain associated with this condition is often noted with increased activities that require a patient to extend the first MTP joint as in squatting, jumping, kicking, and dancing. Another cause of symptoms is shoes that irritate the soft tissues at the subcutaneous bony prominences and shoes such as high-heels that require extended amounts of time in MTP extension and MTP jamming. According to the Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel, the hallmark of hallux rigidus is the typical dorsal bunion caused by both the proliferative disease and the flexion at the first MTP joint. This position of hallux equinus results in retrograde elevation of the metatarsal and the uncovering of the dorsal portion of the articulation. Dorsiflexion is generally limited because of abutment of the articular surfaces of the phalanx and metatarsal head, and motion is painful with/without crepitus. The patient will generally walk with an antalgic gait, which can lead to problems in other joints of the foot. Radiographic findings are consistent with those of osteoarthrosis. The division of hallux rigidus into stages is based on the progression of osteoarthrosis. A patient with stage I may present with little or no radiographic joint changes and a patient with stage IV will demonstrate severe end-stage arthrosis. The majority of the medical literature acknowledges these 4 stages; however, Magee divides hallux rigidus into two categories: acute and chronic. The following lists describe the signs and symptoms associated with both the stage divisions and the acute/chronic divisions. The stages are taken from J Foot Ankle Surg. 42(3):124-36. 2003. Stage I: Stage of Functional Limitus Hallux equinus/flexus Plantar subluxation proximal phalanx Metatarsus primus elevatus Joint dorsiflexion may be normal with nonweightbearing, but ground reactive forces elevate the first metatarsal and yield limitation No degenerative joint changes noted radiographically Hyperextension of the hallucal interphalangeal joint Pronatory architecture Stage II: Stage of Joint Adaptation Flattening of the first metatarsal head Osteochondral defect/lesion Cartilage fibrillation and erosion Pain on end ROM Passive ROM may be limited Small dorsal exostosis
Joe Godges PT, Robert Klingman PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

6 Subchondral eburnation Periarticular lipping of the proximal phalanx, the first metatarsal head, and the individual sesamoids

Stage III: Stage of Established Arthrosis Severe flattening of the first metatarsal head Osteophytosis, particularly dorsally Asymmetric narrowing of the joint space Degeneration of articular cartilage Erosions, excoriations Crepitus Subchondral cysts Pain on full ROM Associated inflammatory joint flares Stage IV: Stage of Ankylosis Obliteration of joint space Exuberant osteophytosis with loose bodies within the joint space or capsule <10 ROM Deformity and/or misalignment Total ankylosis may occur Inflammatory joint flares possible Local pain is most likely secondary to skin irritation or bursitis caused by the underlying osteophytosis The following classification is taken from: Magee DJ. Orthopedic Physical Assessment: Acute (adolescent) Primarily in young people with long, narrow, pronated feet Boys > girls Constant, burning, throbbing, or aching pain and stiffness come on quickly Palpable tenderness over MTP joint 1st metatarsal head may be elevated, large, and tender Antalgic gait Chronic Primarily in adults Men > women Frequently bilateral Usually result of repeated minor trauma leading to osteoarthritic changes Stiffness gradually develops and the pain persists

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention Approaches / Strategies If the patient chooses to first attempt conservative/non-surgical treatment it is essentially the same for stages I-IV (along with acute and chronic). This is an inflammatory joint disorder so the most important thing is to reduce inflammation and not aggravate the condition. Stage I-IV (non-surgical) Goals: 1) decrease inflammation and pain 2) restore ROM 3) if conservative treatment does not work, but patient is unwilling to have surgery it is important to teach patient how to manage pain and function with decreased 1st MTP motion Physical Agents: phonophoresis/iontophoresis, US, NSAIDS, steroid injection, grade I-II joint mobs for pain relief, rest, ice, whirlpool, HVGC External Devices: Orthoses, shoe modifications to limit extension at 1st MTP Therapeutic Exercises: painfree AROM or passive ROM exercises Re-Injury Prevention Instruction: Temporarily cease/reduce aggravating activities.

When conservative treatment does not reduce the impairments and the patient is not willing to live with hallux rigidus there are several surgical options. If the patient is in stage I or II they are usually good candidates for joint-salvage procedures. These include cheilectomy, metatarsal astronomy, phalangeal osteotomy, and chondroplasty. If the joint has progressed to stage III or IV often a joint destructive procedure if appropriate. These include resection arthroplasty, implant arthroplasty, and arthrodesis. The two procedures that are utilized most often are cheilectomy and arthrodesis. While individual surgeons have slightly different protocol for post-surgical treatment, there are general guidelines that most surgeons request. Post-Surgical Management Guidelines taken from J Bone Joint Surg. 85A(11):207287.2003. Cheilectomy: Passive ROM exercises are begun within 10 days post-operatively. Aggressive stretching is allowed as pain and swelling subside. Weight bearing as tolerated is allowed following surgery with the patient wearing a stiff-soled postoperative shoe. Final stages of rehab include teaching the patient a normal, functional gait pattern. Arthrodesis of the 1st MTP Joint: The foot is placed in a stiff-soled postoperative shoe after surgery, and weight-bearing on the heel and the lateral aspect of the involved foot is permitted. The first ray remains unweighted until there is radiographic evidence of a fusion.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Selected References Andrews JR. Harrelson GL, Wilk KE. Physical Rehabilitation of the Injured Athlete, 2nd Edition. Philadelphia, PA: W.B. Saunders; 1998. Brotzman SB. Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby; 1996. Coughlin MJ, Shurnas PS. Hallux Rigidus Grading and Long-Term Results of Operative Treatment. J Bone and Joint Surg. 2003;85A(11):2072-87. Donatelli R, Wooden MJ. Orthopaedic Physical Therapy, 2nd Edition. Churchill Livingstone; 1994. Feltham GT, Hanks SE, Marcus RE. Age-based outcomes of cheilectomy for the treatment of hallux rigidus. Foot Ankle Int. 2001;22(3):192-7. Haddad SL. The use of osteotomies in the treatment of hallux limitus and hallux rigidus. Foot Ankle Clin. 2000;5(3):627-61. Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus. Foot Ankle Int. 2001;22(6):462-70. Makwana NK. Osteotomy of the hallux proximal phalanx. Foot Ankle Clin. 2001;6(3):455-71. Nawoczenski D. Nonoperative and Operative Intervention for Hallux Rigidus. J Orthop Sports Phys Ther. 1999;29(12):727-735. Notni A, Fahrmann M, Fuhrmann RA. Early results of implantation of an unconstrained metatarsophalangeal joint prosthesis of the firs toe. Z Orthop Ihre Grenzgeb. 2001;139(4):326-31. Schwetzer ME, Maheshwari S, Shabshin N. Hallux valgus and hallux rigidus: MRI findings. Clin Imaging. 1999;23(6):397-402. Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br. 2001;83(5);706-8. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Mendicino RW, Couture SD;. Diagnosis and Treatment of First Metatarsophalangeal Joint Disorders. Section 2: Hallux Rigidus. J Foot Ankle Surg. 2003; 42(3):124-36.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Posterior Medial Calf

Posterior Lateral Calf

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10 Impairment: Limited Ankle Dorsiflexion Limited Inferior Tibiofibular Accessory Movements

Fibular Posterior Glide Cues: Stabilize the tibia by 1) resting in on the treatment table, and 2) using the thenar eminence of one hand to stabilize the medial malleolus Slightly internally rotate the tibia (to line up the treatment plane perpendicular to gravity) Posteriorly glide the fibula using the thenar eminence of the other hand (catch the skin on the anterior aspect of the ankle to provide a firmer grip on the fibular)

Fibular Anterior Glide Cues: Position the patient prone with feet of the edge off the table - but keep the distal tibia on the table Stabilize the tibia with one hand - internally rotate it a bit Glide the fibula anteriorly The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 158, 1989

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11 Impairment: Limited Ankle Dorsiflexion Limited Talar Posterior Glide

Talar Posterior Glide Cues: Stabilize tibia with one hand - cushion the Achilles tendon with your fingers between the tendon and the table Contact the talus with a V formed between your thumb and your index finger metacarpal head Posteriorly glide the talus using a weight shift from the lateral side of the table The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 154, 1989

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

12 Impairment: Limited Ankle Dorsiflexion Limited Talar Posterior Glide

Talar Posterior Glide MWM Cues: Stand facing the patient Place a towel pad between the Achilles tendon and the table Grasp the calcaneus with the palm of one hand and the talus with the web space of the other hand Elicit active dorsiflexion Maintain the dorsiflexion with pressure from your abdomen Relax the dorsiflexors Glide the talus and calcaneus posteriorly - using a slight knee bent Maintain the posterior glide of the calcaneus and again elicit active dorsiflexion take up the slack with your abdomen Repeat the posterior glide of the talus and calcaneus Again, relax the dorsiflexors Repeat the sequence several times The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 96-97, 1995

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

13 Impairment: Limited and Painful Talocrural Dorsiflexion

Ankle Dorsiflexion MWM Cues: Position the patient standing on a secure treatment table with the patient using a wide base of support and another person or a stationary object for balance assist Using a belt, glide the tibia and fibular anteriorly Match the anterior glide with an equal and opposite posteriorly glide on the talus using a dummy thumb and thenar eminence If the opposing forces are balanced the patient remains stable Attempt to keep the midtarsal joint in the supinated position Sustain both glides and midtarsal supination while the patient actively dorsiflexes (by shifting weight forward and bending the involved knee) The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 96-98, 1995

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

14 Impairment: Limited and Painful Talocrural Plantarflexion

Ankle Plantarflexion MWM Cues: Position patient supine with a partially flexed knee Glide the tibia and fibula posteriorly with one hand Grasp the talus with the web space of your other hand Sustaining the posterior glide, roll the talus anteriorly as the foot is actively and/or passively plantar flexed The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 95-96, 1995

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

15 Impairment: Limited Ankle Plantarflexion Limited Talar Anterior Glide

Talar Anterior Glide Cues: Stabilize the tibia with one hand - use your fingers as a pad between the anterior tibia and the table Glide the calcaneus (and, thus, also the talus) anteriorly using a weight shift from the lateral side of the involved ankle The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 155, 1989

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

16 Impairment: Limited Subtalar Eversion Limited Calcaneal Lateral Glide

Calcaneal Lateral Glide Cues: Position the patient lying on the involved side with the involved heel off the side of the treatment table Stabilize and pad the lateral malleolus against the table with one hand Mobilize either 1) the posterior talocalcaneal, or 2) the anterior talocalcaneal joint(s) with the thenar eminence of the other hand - use a weight shift from the end of the table The procedure is contrary to convex - concave principles but the consensus of the foot nerds of Southern California (including myself) is the lateral glides work best for restoring calcaneal eversion (probably because the talocalcaneal joint surfaces are more planar than spheroid)

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

17 Impairment: Limited Navicular Plantar Glide (at the talonavicular joint)

Navicular Plantar Glide Cues: Flex the knee and stabilize the calcaneus and, thus, also the talus, on a wedge Slightly internally rotating the limb and placing a finger under the medial side of the talus provides additional stabilization Contact the navicular with the index finger metacarpal head and mobilize the navicular plantarly Be sure that your mobilization is parallel to the treatment plane Modifications of this procedure can be used for any of the tarsal plantar glide mobilizations (i.e., stabilize the dorsal surface of the proximal bone on a wedge and mobilize the distal bone plantarly) The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 148, 1989

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

18 Impairment: Limited Cuboid Dorsal Glide (at the calcaneocuboid joint)

Cuboid Dorsal Glide

Cues: Position the patient prone with the dorsal lateral surface of the calcaneus on the wedge Slight internal rotation of the tibia provide additional calcaneal stabilization Contact the cuboid with either 1) the head of the index finger metacarpal, or 2) a dummy thumb under the mobilizing thenar eminence The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremities

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Ankle Muscle Power Deficit "Achilles Tendinitis" ICD-9-CM: 726.71 Achilles bursitis or tendinitis

Diagnostic Criteria History: Gradual onset of aching in of Achilles tendon - may be able to identify a recent increase in activity Symptoms worse with activity Swelling 1 2 inches above Achilles tendon insertion Palpable tenderness of Achilles tendon 1 2 inches above Achilles tendon insertion

Physical Exam:

Posterior Calcaneal Bursitis ICD-9-CM: 726.73 Calcaneal spur

Diagnostic Criteria History: Posterior heel pain and swelling Irritated by pressure (e.g., from shoe) Tender bump on posterior aspect of calcaneus reproduces pain complaint

Physical Exam:

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Achilles Tendinitis/Tendonosis
ICD-9: 726.71 achilles bursitis or tendinitis Description: Repetitive strain injury to the Achilles tendon typically producing posterior ankle inflammation and pain. Etiology: Inflammation of the Achilles tendon and calcaneal insertion as well frequently the retrocalcaneal bursa. Generally the result of over-use activities such as running or jumping, repetitive over-stretching and/or a biomechanically deficient foot conditions such as pes cavus and varus heels. In contrast, tendonosis involves a slow onset with chronic and recurrent responses where the tendon may never regain its former structure, and is always sensitive to load. Tendonosis includes intratendonous degeneration commonly due to aging, microtrauma over a prolonged period, or vascular compromise. Collagen disorganization, focal necrosis and calcification (may never regain normal structure, making it always sensitive to load).

Misconception Tendonopathies are self-limiting conditions that take only a few weeks to resolve Imaging techniques (MRI, ultrasound, etc) can predict prognosis Cyst-like abnormalities found with ultrasound are indications for surgery Surgery provides fast recovery of symptoms in almost all patients

Evidence Based Finding Tendonopathies are often recalcitrant to treatment and may require months to resolve Imaging does not predict prognosis; it adds to the chance of a tendonopathy Dx, but does not prove it Surgery should be based on clinical grounds;cyst-like ultrasound findings can be asymptomatic After surgery, return to sport takes at least 4-6 months. Not all do well.

Acute Stage / Severe Condition Focal palpatory pain and swelling 4 to 5 cm proximal to insertion Possible palpable tissue disruption Pain with resisted plantarflexion; especially with walking and running Pain at end range dorsiflexion Decreased plantarflexion strength

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Sub Acute Stage / Moderate Condition As above with the following differences: Possible increased ankle stiffness Compensatory gait pattern Progressive tendon nodular thickening Increased retrocalcaneal bursa pain

Settled Stage / Mild Condition Limited ankle dorsiflexion Residual nodule thickening Pain response limited to forceful loading (i.e., running or jumping) or static overstretching such as maintained squat position (e.g., baseball catcher position)

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease swelling and pain Limit aggravating causes Physical Agents Ultrasound/ phonophoresis Electrical stimulation Heat or ice (contrast bath) Therapeutic Exercises Gentle mobility exercises to maintain ankle range of motion (avoiding end range dorsiflexion) Strengthening exercises for the foot intrinsic muscles External Devices (Taping/Splinting/Orthotics) Heel lifts and orthotics where indicated Re-injury Prevention Instruction Instruct patient in appropriate exercises, stretches, application of ice and heat and instruct in the use of lifts and orthotics

Sub-Acute Stage / Moderate Condition Goals: Restore normal, pain free motion Normalize biomechanics for standing and walking tasks Approaches / Strategies listed above Manual Therapy May begin gentle soft tissue mobilization techniques to the Achilles tendon and surrounding tissues (e.g., soleus myofascia, ankle retincula) where indicated Therapeutic Exercises Progressive strengthening activities. In cases where tendonosis is likely, increase tissue thickness and strength, with eccentric loading. Proprioceptive training Progressive stretching techniques

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Settled Stage / Mild Condition Goal: Allow patient to return to most normal activities including community ambulation, unlevel surfaces and stairs without pain Approaches / Strategies listed above Functional Training Introduce inclined walking, light jogging and gentle jumping activities

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to unrestricted sport or work activity Therapeutic Exercises Review desired activity and progress to ballistic activity specific exercises. Patient Education/Ergonomics Instruction Educate patient to recognize signs and symptoms of recurrent tendinitis. Issue final home exercise and stretching program to prevent recurrence.

Selected References Anderson DL, Taunton JE, Davidson RG. Surgical management of chronic Achilles tendonitis. Clin J Sport Med. 1992; 2 (1): 38-42 Khan KM, Cook JL, Taunton JE, et al. Overuse tendonosis, not tendonitis: a new paradigm for a difficult clinical problem. The Phys and Sport Med. 2000; 28 (5) Knight C, Rutledge C, et al. Effects of superficial heat, deep heat and active exercise warm-up on the extensibility of the plantar flexors. Phys Ther. June 2001 Galloway M, Jokl P, Dayton O. Achilles tendon overuse injuries. Clin Sports Med. Oct 1992 pp 771-82 Mercier, L. Practical Orthopedics 3rd ed. Mosby Year Book, St. Louis, 1991 Nielson-Vertommmen SL, Taunton JE, Clement DB. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis. Clin J Sport Med. 1992; 2 (2) : 109-113. Sammarco, J. Rehabilitation of the Athletes Foot and Ankle. Mosby Year Book, St. Louis, 1995 Scioli M. Achilles tendinitis. Orthop Clin North Am. Jan 1994 pp 177-82

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Retrocalcaneal Bursitis
ICD-9: 726.73 calcaneal spur

Description: Inflammation, hypertrophy, and adherence of the bursa and surrounding tissue located between the insertion of the Achilles tendon and the calcaneus producing posterior heel pain, which is often most severe in the morning or when just starting to walk
Etiology: Inflammation of the calcaneal bursae is commonly caused by repetitive overuse and cumulative trauma, as seen in runners wearing tight-fitting shoes. Additional causes of retrocalcaneal bursitis include: direct trauma, rheumatoid arthritis, and biomechanical abnormalities such as rearfoot varus, rigid plantar flexed first ray, and Haglunds deformity. Physical Examinations Findings (Key Impairments)

Acute Stage / Severe Condition Antalgic gait pattern Swelling, redness, and warmth of the posterior heel (pump bump) Positive two-finger squeeze test (positive = pain when applying pressure both medially and laterally with two fingers superiorly and anterior to the insertion of the Achilles tendon) Pain with dorsiflexion and plantarflexion

Careful examination can help the clinician distinguish whether the inflammation is posterior (superficial) to the Achilles tendon (within the subcutaneous bursa) or anterior (deep) to the Achilles tendon (within the subtendinous bursa). Differentiating Achilles tendonitis from bursitis may be impossible. At times, the two conditions coexist. Isolated subtendinous bursitis is characterized by tenderness that is best isolated by palpating just anterior to both the medial and lateral edges of the distal Achilles tendon. Insertional Achilles tendonitis is notable for tenderness located slightly more distally, where the Achilles tendon inserts on the posterior calcaneus. A patient with plantar fasciitis has tenderness along the posterior aspect of the sole, but should not have tenderness with palpation of the posterior heel.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 A patient with a complete avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon, weakness in plantarflexion, and positive Thompson test on physical examination.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Sub-Acute Stage / Moderate Condition As above along with the following: Pain during passive end-range dorsiflexion Pain during terminal stance of gait Pain with tight-fitting shoes

Settled Stage/Mild Condition Pain with running or other athletic activities Limited ankle dorsiflexion

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9 Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Decrease swelling and pain. Limit aggravating causes. Physical Agents Ice (The patient should be instructed to ice the posterior heel and ankle to reduce inflammation and pain. Icing can be performed 15-20 minutes at a time, several times a day during the acute period.) Ultrasound/ phonophoresis Iontophoresis Electrical stimulation Contrast baths Therapeutic Exercises Gentle mobility exercises to maintain ankle range of motion (avoiding end range dorsiflexion) External Devices (Taping/Splinting/Orthotics) Heel lifts and orthotics where indicated Re-injury Prevention Instruction Instruct patient in appropriate exercises, stretches, and application of ice Use of and open-backed shoe or a better-fitting shoe may relieve the pressure of the affected region Immobilization (consider if above is not effective) Walking boot Cast for 4-6 weeks

Sub-Acute Stage / Moderate Condition Goal: Restore normal, pain free motion Normalize biomechanics of gait Approaches/ Strategies listed above Manual Therapy May begin gentle soft tissue mobilization techniques to the Achilles tendon and surrounding tissues (e.g., soleus myofascia, ankle retincula) where indicated Therapeutic Exercises Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous bursa Ballistic stretches should be avoided to prevent clinical exacerbation.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10

Re-injury Prevention Instruction Changing footwear may be the most important treatment for calcaneal bursitis. Inserting a heel cup within the shoe may help raise the inflamed region slightly above the restricting heel counter of the shoe. If this approach is implemented, a heel cup also should be placed in the other shoe to avoid introducing a leg length discrepancy.

Settled Stage / Mild Condition Goal: Return to most normal pain free activities including ambulating over uneven surfaces and short community distances Approaches/ Strategies listed above Functional training: Heavy-load eccentric calf muscle training Re-injury Prevention Instruction Avoid footwear that fits excessively tight or causes excessive friction at the posterior heel

Note: If chronic pains persists and conservative treatment is unsuccessful, patient may consider ultrasound-guided cortisone injection or surgery

Intervention for High Performance/High Demand Functioning in Workers and Athletes Goal: Return to desired recreational or occupational level of activity Functional training: light jogging Patient education/Ergonomic instruction Instruct patient in signs and symptoms to prevent re-injury Review home exercise program to prevent recurrence

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11

Selected References Alfredson H, Pietila T, Jonsson P, et al. Heavy-load eccentric calf muscle training for treatment of chronic Achilles tendinosis. Am J Sports Med. 1998; 26(3): 360-366. Retrieved January 28, 2004, from the MD Consult database. Cunnane G, Brophy DP, Gibney RG, et al. Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound. Sem Arth Rheum. 1996; 25(6): 383-389. Foye P., Nadler SF. Retrocalcaneal bursitis. (2003, August 12). Retrieved January 21, 2004, from eMedicine database. Mazzone MF. Common conditions of the Achilles tendon. Am Fam Physician. 2002; 65(9):1805-1810. Retrieved January 28, 2004, from the MD Consult database. Myerson MS, McGarvey W. Disorders of the insertion of the Achilles tendon and Achilles tendonitis. J Bone Joint Surg. 1998; 80A(12): 1814-1824. Paavola M, Kannus P, Paakkala T, et al. Long-term prognosis of patients with Achilles tendinopathy: an observational 8-year follow-up study. Am J Sports Med. 2000; 28(5): 634-642. Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. Am J Sports Med. 2002; 30(2): 287-305. Schepsis AA, Wagner C, Leach RE. Surgical management of Achilles tendon overuse injuries: a long-term follow-up study. Am J Sports Med. 1994; 22(5): 611-619. Stephens M. Haglunds deformity and retrocalcaneal bursitis. Orthop Clin North Am. 1994; 25(1): 41- 46.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Ankle Movement Coordination Deficit "Lateral Ankle Sprain" ICD-9-CM: 845.02 Sprain of calcaneofibular ligament

Diagnostic Criteria History: Inversion sprain Swelling Pain If chronic - instability Antalgic gait Lateral ankle effusion Tender anterior talofibular ligament and possibly also the calcaneofibular lig. Pain reproduced with inversion stress (usually worse with plantarflexion and inversion) If severe sprain, or recurring sprains - laxity with anterior drawer

Physical Exam:

Anterior Talofibular Ligament Cues: 1 = Lateral malleolus (fibula); 2 = Anterior talofibular lig.; 3 = Calcaneofibular ligament Locate lateral malleolus - palpate anteriorly and slightly inferiorly Palpate using graduated pressure to avoid inadvertent further injury

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Inversion Stress Test (Talar Tilt)

Cues: Apply graduated force to avoid inadvertent injury Slightly reproduce reported pain complaint (must not assume all lateral ankle pain/effusion is from anterior talofibular and/or calcaneofibular ligament tears). If not symptomatic with gentle inversion consider tarsal or metatarsal fracture, or inferior tibiofibular syndesmosis sprain

Anterior Drawer

Anterior Drawer

Cues: Either (1) Stabilize tibia and fibula and pull calcaneus and talus anteriorly, or (2) Bend knee to 90 degrees, place calcaneus on table and hold ankle in about 10 degrees of plantar flexion push tibia and fibula posteriorly to create a relative anterior glide of talus

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Lateral Ankle Sprain


ICD-9: 845.02 sprain of calcaneofibular ligament Description: Lateral ankle sprains are usually caused by an inversion and plantar flexion injury, followed by ankle swelling and decreased function. After the initial recovery from a lateral ankle sprain, some patients exhibit residual pain that limits their activities. Also, some patients are prone to reinjure the ankle. This re-injury predisposition is thought to be caused by neuromuscular deficits following the sprain that result in functional instability. Etiology: With an inversion force of foot, there is injury to anterolateral capsule, anterior talofibular ligament, and anterior tibiofibular ligament about 40% of patients will have this injury type. As the inversion force progresses, the calcaneofibular ligament is injured as well. In about 58% of cases, there will be a tear of both the anterior talofibular ligament and the calcaneofibular ligament. Finally, in a small number of cases (3%), there will be tears of the above two ligament and the posterior talofibular ligaments.

Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition Severe swelling (more than 4 cm about the fibula) Severe ecchymosis Loss of function and motion (patient is unable to bear weight or ambulate) Positive anterior drawer test Inversion will bring on pain and apprehension Tenderness over Anterior Talofibular Ligament, Calcaneofibular Ligament, and Posterior Talofibular Ligament Possible anterior shift/displacement of lateral malleolus

Sub Acute Stage / Moderate Condition Moderate pain and swelling Mild to moderate ecchymosis Some loss of motion and function (patient has pain with weight-bearing and ambulation) Mild to moderate instability (mild positive anterior drawer) Pain with inversion Mild to moderate tenderness with swelling/effusion over the lateral malleolus

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Settled Stage / Mild Condition Mild tenderness and swelling Slight or no functional loss (patient is able to bear weight and ambulate with minimal pain) No mechanical instability (negative anterior drawer test) Slight to no apprehension when taken into inversion

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Limit effusion Reduce pain and protect from further injury Prevent movement induced inflammatory reactions Physical Agents Cryotherapy / Ice Electrical stimulation Therapeutic Exercises Gentle, active dorsiflexion and plantarflexion in painfree ranges Progress to ankle pumps, ankle circles, and ankle alphabet Note: In grade III and severe grade II injuries, AROM exercises for inversion and plantar flexion should be limited until tenderness over the ligament decreases in order to avoid disrupting healing structures. Towel stretch for the calf myofascia Pain free-isometrics strengthening exercises all directions Towel toe curls Note: Early Mobilization of joints following ligamentous injury actually stimulates collagen bundle orientation and promotes healing, although full ligamentous strength is not reestabilished for several months. Limiting soft-tissue effusion speeds healing. External Devices (Taping/Splinting/Orthotics) Fit patient with knee support if pain relief requires temporary use of an external device Compression ankle strapping An ankle brace, such as air cast splint, or a walking boot Re-injury Prevention Instruction Crutch walking for 2-3 days depending on grade of sprain Wear a brace or have ankle taped when doing activities that have high incidence of ankle injuries. Wear correct footwear for each sport Be aware of uneven terrain, potholes, and high curbs Turn a light on at night when out of bed Watch out for slippery floors

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Sub Acute Stage / Moderate Condition Goals: Decrease and eliminate pain Increase pain-free range of motion Limit loss of strength and proprioception Approaches / Strategies listed above Manual Therapy Manual joint mobilization if dorsiflexion or eversion range of motion is limited Therapeutic Exercises Progress active dorsiflexion / plantarflexion and eversion and inversion in painfree ranges add resistance of tolerated (e.g., with rubber tubing or gravity via toe raises) Initiate proprioceptive exercises, such as single leg standing, seated BAPS board progressing to standing BAPS board type exercises

Settled Stage / Mild Condition Goals: Regain full pain-free motion Regain normal strength Regain normal proprioception Approaches / Strategies listed above Therapeutic Exercises Gradual return to sport activities through use of functional progression, such as activity-specific exercise for example: Running in pool, swimming Gradual progression of functional activities Pain free hopping on both legs progressing to single leg Stand on toes and hop on toes Step up / over / forward / sideways on high step pain free Begin stairmaster, treadmill, biking Initiate running when fast pace walking is pain free Figure 8s, cross-over walking Jump rope Ball on wall Weight bearing wobble board Heel raises External Devices (Taping/Splinting/Orthotics) Reinjury is common with ankle sprains; so external bracing is recommended and can include taping, lace-up braces, and air splints

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention for High Performance / High Demand Functioning with Workers or Athletes Goals: Return to desired occupational or leisure time activities Prevention of recurring injury Approaches / Strategies listed above Therapeutic Exercises Progress functional activies related to desired sport activity for example: Walk-jog, 50/50 backwards, forwards, patterns, circles Jog-running, backwards, forwards, patterns Jumping rope single limb Figure 8s, cross-over running Improve strength and endurance through use of progressive resistive training Consider early mobilization with the movitated athlete. However, when choosing the specific intervention strategy, consider the patients activity level, age, goals for recovery, degree of injury, previous history of injury, and general motivation. Selected References Wolfe MW, Uhl ML, Mccluskey LC. Management of Ankle Sprains. American Family Physician 2001; 63: 93-104 Young CC. Ankle Sprain. EMedicine Journal 2002; (1) 3 Hammer WI. Functional Soft Tissue Examination and Treatment By Manual Methods. 2nd ed. Aspen Publishers, Inc. Gaithersburg, Maryland. 1999 Renstrom, PA. Persistently Painful Sprained Ankle. J Am Acad Orthop Surg 1994;2(5):270-280. Hertel, J. Functional instability following lateral ankle sprain. Sports Med. 2000;29(5):361-71. Hertel, J; Denegar, CR; Monroe, MM; and Stokes, WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc 1999;31(11):1501-8. Seto, JL; and Brewster, CE. Treatment approaches following foot and ankle injury. Clinics in Sports Medicine. 1994;13(4):695-719. Mascaro, TB; and Swanson, LE. Rehabilitation of the Foot and Ankle. Orthopedic Clinics of North America. 1994;25(1):147-160.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Limited and Painful Ankle Inversion

Distal Tibiofibular MWM Cues: Glide the fibula posteriorly on a stable tibia Sustain the posterior glide while the patient actively inverts his/her foot As always: 1) alter the direction and amplitude of the glide to achieve painfree active motion, 2) repeat movement several times (sets of ten) 3) add overpressure, if indicated, at the end of available painfree active movement The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 98-100, 1995

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Ankle Nerve Disorder Tarsal Tunnel Syndrome ICD-9-CM: 355.5 Tarsal tunnel syndrome

Diagnostic Criteria History: Medial foot pain Paresthesias Numbness Symptoms reproduced with tibial nerve tension test Symptoms reproduced with palpation/provocation of tibial nerve in tarsal tunnel

Physical Exam:

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Tibial Nerve Tension Test Cues: SLR to first resistance Full dorsiflex and evert the ankle and foot. Assess symptom reproduction/elimination with alteration to hip flexion

Provocation of Tibial Nerve in Tarsal Tunnel Cues: Determine ability to reproduce symptoms Remember Tom, Dick, an" Harry T = Tibialis Posterior D = Flexor Digitorum Longus A = Posterior Tibial Artery N = Posterior Tibial Nerve H = Flexor Hallucis Longus

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Tarsal Tunnel Syndrome


ICD-9: 355.5 tarsal tunnel syndrome Description: An extrinsic or intrinsic compression neuropathy of the posterior tibial nerve or one of its branches. Patients with TTS often report 1) burning pain in the heel and medial arch and/or plantar aspect of the foot, 2) tightness, swelling, and fullness in the medial portion of the foot, and 3) sensory disturbances including burning, tingling, and numbness. Pain located around the ankle and extending to the toes is increased with walking and is relieved by rest. Nerve conduction tests demonstrate a time delay across the tarsal tunnel area. EMG may demonstrate fibrillation potential and positive sharp waves in tibial innervated muscles. MRI showed TTS abnormality 88% of time. Positive tinels sign is a common finding. Mixture of corticosteroids and local anesthetics may be injected for pain relief. Foot taping and the use to orthotics may be used to reduce pressure on the nerve. If all other treatment fail, surgery (tarsal tunnel release) may be necessary to alleviate pain. There is another less common type TTS, anterior tarsal tunnel syndrome, which entraps the deep peroneal nerve. Etiology: Any lesion that occupies space within the tarsal region may cause pressure on the nerve and subsequent symptoms. Examples of intrinsic factors include ganglions, tenosynovitis, lipomas, varicose veins, fibrosis, and synovial hypertrophy. Extinsic factors may also place trauma and tension across the flexor retinaculum. Examples include bone fracture, hypertrophic flexor hallucis tendon, or pronation and subtalar eversion, which can stretch the flexor retinaculum and cause a narrowing of the tunnel. Half of the patients who present with tarsal tunnel syndrome relate a history of a previous sprain or ankle fracture. Other causes may include repetitive stress with activities, flat feet, and excess weight.

Physical Examination Findings (Key Impairments) Acute Stage/ Severe Condition Tenderness over the nerve at the tarsal tunnel Positive Tinel sign (percussion over the flexor retinaculum of the tarsal tunnel) Diminution of two point discrimination and hypothesisas to pin prick With prolonged, extreme compression, nerve demyelination with Wallerian degeneration may take place with numbness, muscular weakness, and atrophy

Sub Acute Stage/ Moderate condition As above: Now when less acute, signs of coexisting foot disorders may be revealed, For example: Tight Achilles tendon Increased hind foot valgus and the appearance of too many toes sign Weak or absent inversion of the heel

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Loma Linda U DPT Program

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Rear foot valgus/calcaneous eversion Depressed medial longitudinal arch Inability to do unilateral heel raises Gait lacks effective push-off

Settled Stage/ Mild condition As above with the following differences Resolving symptoms Decreased paresthesia and pain Improved pain-free soft-tissue motion along the course of the tibial nerve Improved strength of tibialis posterior Improved functional activity tolerance; standing and walking

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention Approaches / Strategies

Acute Stage/ Severe Condition Goal: Reduce pain and inflammation and tissue stress Physical Agents Ice Contranst baths Pulsed ultra sound/ phonophoresis with 0.5 percent hydrocortisone or 2.5 percent lidocane ointment Iontophoresis Interferential current therapy Orthotics or Taping University of California Berkeley Laboratory (UCBL) orthosis to improve hind foot alignment Ankle braces, controlled ankle motion (CAM) walkers Plantar arch taping to reduce tissue stress Medial Heel Wedge or Heel Seat may assist by inverting the heel and removing traction from tibial nerve Advise regarding footgear, such as the use of wider shoes, may be beneficial Therapeutic Exercise Calf stretching exercises Nerve mobility exercises Manual Therapy Soft tissue mobilization to fascial of myofascial tissues suspected of creating the entrapment Neural mobilization

Sub Acute Stage/ Moderate Condition Goal: Restore muscle strength and flexibility As above with following differences Therapeutic Exercise Posterior tibialis strengthening exercise

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Settled Stage/ Mild Condition Goal: Normalize strength, flexibility, and restore lower extremity functional mobility As above with following differences Therapeutic Exercise Posterior tibialis strengthening exercise in weight bearing.

Selected References Daniels TR, Lau JT, Hearn TC. The Effects of Foot Position and Load on Tibial Nerve Tension. Foot Ankle International. 1998 Feb; 19(2); 73-8 Meyer J, Kulig K, Landel R. Differential diagnosis and treatment of subcalcaneal heel pain: a case report. Journal of Orthopaedic & Sports Physical Therapy. 2002; 32(3):114-124. Kinoshita M MD, Okuda R MD, Morikawa J MD, Tsuyoshi J MD, Abe M MD. The dorsiflexion test for diagnosis of tarsal tunnel syndrome. Journal of Bone & Joint Surgery. 2001;83A(12):1835-1839. Romani W, Perrin DH, Whiteley T. Tarsal tunnel syndrome: Case study of a male collegiate athlete. Journal of Sport Rehabilitation. 1997;6:364-370. Patla CE, Abbott HJ. Tibialis posterior myofascial tightness as a source of heel pain: diagnosis and treatment. Journal of Orthopaedic & Sports Physical Therapy. 2000;30(10):624-632. Geideman WM MD, Johnson JE MD. Posterior tibial tendon dysfunction. Journal of Orthopaedic & Sports Physical Therapy. 2000;30(2):68-77 Kupper, BC. Tarsal tunnel syndrome. Orthopaedic Nursing. 1998;17(6):9-16.

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Loma Linda U DPT Program

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1 Foot Pain "Pronatory Disorder" ICD-9-CM: 734 Flat foot (pes planus-acquired)

Diagnostic Criteria History: Physical Exam: Aching in arch of foot - worse after prolonged weight bearing Excessive pronation at loading response and mid-stance (talonavicular joint) terminal stance (calcaneocuboid) joint Delayed or absent mid-tarsal or forefoot supination (normal = supination begins immediately following loading response) Inability to form rigid arch with lower external rotation when weight bearing or with full calcaneal inversion when non weight-bearing

Tibial Internal Rotation Normal Foot Pronation

Tibial External Rotation Normal Foot Supination Cues: Pronatory disorder - foot remains pronated with tibial external rotation
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Longitudinal Mid Tarsal Joint Axis Mobile with Calcaneal Eversion

Longitudinal Mid Tarsal Joint Axis Rigid with Calcaneal Inversion Cues: Grasp navicular and 1st cuneiform Supinate and pronate wrist to provide inversion and eversion motion - compare mobility with full calcaneal eversion and full calcaneal inversion Normal - LMTJ axis becomes relatively rigid with full calcaneal (subtalar) inversion

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Oblique Mid Tarsal Joint Axis Mobile with Calcaneal Eversion

Oblique Mid Tarsal Joint Axis Rigid with Calcaneal Inversion Cues: Grasp cuboid Move cuboid parallel to the plantar surface of the foot to provide adduction and abduction motion - compare with full calcaneal eversion and full calcaneal inversion Normal - OMTJ axis becomes relatively rigid with full calcaneal (subtalar) inversion

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Loma Linda U DPT Program

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Pronatory Disorder
ICD-9: 734 flat foot (pes planus-acquired) Description: Excessive pronation is defined as pronation that occurs for too long a time period or of too great an amount. The subtalar joint is the most common location of this excessive motion. The loss of a normal medial longitudinal arch will be evident and may result in a talonavicular subluxation throughout the stance phase of gait. Etiology: A pronatory disorder may be caused by congenital, neurological, and/or acquired factors. The etiology of acquired factors will be discussed here, as the congenital and neurological causes are listed under a different ICD9 diagnosis. Acquired factors resulting in excessive pronation can be divided into extrinsic and intrinsic causes. Extrinsic causes are a result of factors outside the foot/ankle complex such as the lower leg or knee. Gastocsoleus tightness, femoral anteversion, tibial internal rotation, and postural deformities are examples of extrinsic factors. Intrinsic causes of pronatory disorders are located within the foot and ankle region. These causes are usually fixed deformities of the subtalar joint, the midtarsal joints, and the first ray. It is common to see forefoot valgus (abduction), calcaneal eversion, a flattened medial longitudinal arch, midfoot ligament laxity, talar subluxation, posterior tibial tendon dysfunction, and plantarfascia rupture. A combination of extrinsic and intrinsic factors often results in excessive compensatory subtalar joint pronation. This compensatory motion may produce various soft tissue stresses resulting in pain, inflammation, and/or tissue deformity.

Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition Excessive pronation (navicular drop) at mid-stance and terminal stance Forefoot valgus, subtalar pronation, and calcaneal eversion deformities are common Limited ankle dorsiflexion and excessive calcaneal eversion are common. Weak ankle plantar flexors, ankle/foot inverters (tibialis posterior) and ankle/foot everters (peroneus longus - aka fibularis longus), and intrinsic pedal musculature (abductor hallucis) are common. Excessive midtarsal motions (hypermobile talonavicular, calcaneocuboid articulations, and excessive first ray dorsiflexion). Palpable tenderness of the peroneal tendons, tibialis posterior tendon, tarsal ligaments, and talonavicular and calcaneocuboid articulations Other dysfunctions in the lower kinematic chain (i.e. knee, hip) are commonly associated with excessive subtalar pronation.

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5 Sub Acute Stage / Moderate Condition The above impairments may be present however with less severe functional limitations.

Settled Stage / Mild Condition The above impairments may be present however with less severe functional limitations.

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Loma Linda U DPT Program

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6 Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Restore pain free performance of daily activities Physical Agents Ultrasound Phonophoresis Electrical Stimulation Ice Manual Therapy Joint mobilization for restricted accessory movements associated with talocrural dorsiflexion and talocalcaneal eversion Soft tissue mobilization for restricted posterior calf myofascia Therapeutic Exercises Strengthening exercises for weak calf muscles and foot intrinsics Stretching for tight calf muscles Instruct in exercises and functional movements to maintain the improvements in mobility gained with joint and soft tissue manipulations External Devices (Taping/Splinting/Orthotics) Anti-pronation type taping procedures In-shoe orthotics to stabilize the hindfoot and medial longitudinal arch Re-injury Prevention Instruction Proper footgear and/or inserts to limit pronation

Sub Acute Stage / Moderate Condition Goals: Restore pain free performance of functional activities Improve foot proprioception/afferent activity Normalize ankle and foot mobility and strength Approaches / Strategies listed above Neuromuscular Re-education Training for neutral foot position with daily activities including single leg standing activities with/without unstable surfaces or visual cuing

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Settled Stage / Mild Condition Goal: Return patient to prior level of function or desired functional goals Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises include exercises that address impairments of the pelvis, hip, and knee which may be associated with excessive pronation, such as weak hip abduction and external rotation Neuromuscular Re-education Progress neutral foot position training External Devices (Taping/Splinting/Orthotics) Consider foot orthotic prescription/fabrication

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired work or sport specific activity levels Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises include exercises/activities that challenge the patient with work related or sport specific demands addressing strength, flexibility, proprioception and endurance.

Selected References Bennett JE, Reinking MF, Pluemer B, Pentel A, Seaton M, Killian C. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001;31(9):504-510. Boerum DH, Sangeorzan, BJ. Biomechanics and pathophysiology of flat foot. Foot Ankle Clin N Am. 2003(8):419-430. Donatelli R. Orthopaedic Physical Therapy. Second Edition. Churchill Livingstone inc. 1994. Donatelli R. Normal biomechanics of the foot and ankle. J Orthop Sports Phys Ther. 1985;7(3):91-95. Elftman NW. Nonsurgical treatment of adult acquired flat foot deformity. Foot Ankle Clin N Am. 2003(8):473-489.

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8 Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M. Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 2003;42(6):327333. Glasoe WM, Yack HJ, Salzman CL. Anatomy and biomechanics of the first ray. Physical Therapy. 1999;79(9):854-859. Greisberg J, Hansen ST, Sangeorzan B. Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int. 2003;24(7):530-534. Hintermann B, Boss A, Shfer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med. 2002;30(3):402-409. Holmes CF, Wilcox D, Fletcher JP. Effect of a modified, low-dye medial longitudinal arch taping procedure on the subtalar joint neutral position before and after light exercise. J Orthop Sports Phys Ther. 2002;32(5):194-201. Imhauser CW, Abidi NA, Frankel DZ, Gaven K, Siegler S. Biomechanical evaluation of the efficacy of external stabilizers in the conservative treatment of acquired flatfoot deformity. Foot Ankle Int. 2002:22(8):727-737. Munn J, Beard DJ, Refshauge KM, Lee RYW. Eccentric muscle strength in functional ankle instability. Med Sci Sports Exerc. 2003;35(2):245-250. Nakamura H, Kakurai, S. Relationship between the medial longitudinal arch movement and the pattern of rearfoot motion during the stance phase of walking. J Phys Ther Sci. 2003;15(1):1318. Ogon, M. Does arch height affect impact loading at the lower back level in running? Foot Ankle Int. 1999;20(4):265-269. Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot: Clinical Biomechanics. Vol. 2. 1997. Shrader JA, Siegel KL. Nonoperative management of functional hallus limitus in a patient with rheumatoid arthritis. Physical Therapy. 2003;83(9):831-843. Snook AG. The relationship between excessive pronation as measured by Navicular drop and isokinetic strength of the ankle musculature. Foot Ankle Int. 2001;22(3):234-40. Staheli L, Chew D, Corbett M. The Longitudinal Arch. A survey of eight hundred and eightytwo feet in normal children and adults. J Bone Surg. 1987;69a:426-428. Vicenzino B, Griffiths SR. Effect of antipronation tape and temporary orthotic on vertical navicular height before and after exercise. J Orthop Sports Phys Ther. 2000;30(6):333-9. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatments for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989;71(6):80010.
Joe Godges PT, Robert Klingman PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

SUMMARY OF ANKLE AND FOOT DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES


DISORDER Ankle & Foot Mobility Deficits Midtarsal Joint Capsulitis HISTORY Arch area pain Recent strain or repetitive wt. bearing Sxs worse w/ SLS or prolonged wt. bearing Stiffness Pain at toe-off phase of gait Gradual onset of Achilles area aching Sxs worse with activity Posterior heel pain Swelling Irritated by pressure, i.e., from a shoe Inversion stress Swelling Pain If chronic instability PHYSICAL EXAM SR w/: End range accessory motion Test of one or more of the midtarsal articulations ROM deficit: 1st MTP extension Pain at end range of 1st MTP ext. Limited MTP accessory movements Swelling 1-2 inches above Achilles insertion SR w/palpation of tendon in same area Swelling near Achilles insertion SR w/provocation of insertion on posterior aspect of calcaneus Antalgic gait Lateral ankle effusion SR w/: Palpation of lateral ligaments Inversion stress May have laxity w/anterior drawer PT MANAGEMENT Joint Mob (to specific hypomobility) Ther Exs (Stretch/strengthen related muscles) Taping/footgear/orthotics Joint Mob Ther Exs Patient Ed: Proper footgear Activity modification Proper footgear and/or heel lift Calf stretching Strengthening esp. eccentric Physical agents (Ice, US, Phono, Ionto) Activity and Shoe Modifications P.R.I.C.E. Instructions Physical agents (Ice, E. Stim,) Friction massage Inferior Tib-Fib Mobs Proprioceptive Training Calf stretching Functional Strengthening Rx entrapment (STM/JM to Med. Ankle and Foot) Tibial Nerve Mob (PROM and AROM Exs) Joint mob/manip (to hypermobile of subluxed tarsal articulations) Ther Exs (stretch shortened and strengthen weak myofascia of LE) Taping Proper footgear or orthotics

Ankle & Foot Mobility Deficits Hallux Rigidus Ankle Muscle Power Deficits Achilles Tendinitis Ankle Muscle Power Deficits Posterior Calcaneal Bursitis Ankle Movement Coordination Deficit Lateral Ankle Sprain

Ankle & Foot Radiating Pain Tarsal Tunnel Syndrome Foot Pain Pronatory Disorder

Medial foot pain Paresthesias Numbness Aching in arch of foot Sxs worse after prolonged weight bearing

SR w/: Tibial Nerve bias LLTT Provocation of Tibial Nerve in Tarsal Tunnel Excessive pronation at LR, MSt, or TSt Deficient Midtarsal supination or Forefoot eversion at TSt Inability to form arch w/tibial external rotation and calcaneal inversion

Joe Godges DPT

KPSoCal Ortho PT Residency

Achilles Tendon Repair and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The poorest blood supply to the Achilles tendon is in the central part of the tendon approximately 2 to 6 cm proximal to the calcaneal insertion which may account for the fact that most of the ruptures occur in this area. Pathogenesis: Tendons rupture when the mechanical loads exceed the physiologic capacity of the tendon. The physiologic capacity of the Achilles tendon may be compromised by intrinsic factors such as hypovascularity, repetitive microtrauma and the associated inflammation and degeneration, endocrine function and nutrition. Extrinsic, mechanical forces may also exceed the physiologic capacity of the Achilles tendon, such as when 1) an individual forcefully pushes off the forefoot while extending the knee (e.g., when cutting, sprinting or jumping), 2) an individual experiences a sudden dorsiflexion with full weightbearing (e.g., a slip, fall, or sudden deceleration), or 3) an individual experiences violent dorsiflexion when jumping from a height and landing on a plantar-flexed foot. Epidemiology: Achilles tendon ruptures are one of the most frequently ruptured tendons about 40% or all tendon ruptures are of the Achilles. Most Achilles tendon ruptures occur in male, recreational athletes between the ages of 30 and 40 years. Athletic activities that require sudden acceleration or deceleration are most likely to cause a rupture. Ruptures not attributed to athletic activity are usually caused by falls or stumbles that also produce sudden acceleration and deceleration movements. Diagnosis Most patients describe a pop as though someone has shot them in the back of the ankle Palpable defect in the tendon between 2 to 6 cm proximal to the calcaneus Positive Thompsons test Radiographs rule out bony injury MRI can be helpful in demonstrating the presence, location, and severity of the tear(s)

Nonoperative Versus Operative Management: Surgical repair is typically recommended for patients who expect to return to relatively high functional activities required of recreational athletics. Surgical repairs allow quicker mobilization and return to activity thus lessening the deleterious effects on prolonged cast immobilization with the ankle in a plantarflexed position. The main surgical risk is wound infection and breakdown, which can be a distrastrous complication because soft tissue coverage can only be resolved with vascularized flaps and a reconstructive tendon procedure will likely be required. Indications for nonoperative management include patients with poor wound healing potential (e.g., those with moderately severe diabetes), concomitant illnesses, a sedentary lifestyle or lower functional/athletic goals. The prolonged cast immobilization required of nonoperative management promotes the

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2 following common problems associated with immobilization: muscle atrophy, joint stiffness, cartilage atrophy, degenerative arthritis, adhesion formation, and deep venous thrombosis. The average re-rupture rate is about 18% in nonoperative patients compared with approximately 2% in operatively treated patients. Surgical Procedure: Surgery is usually performed about one week after rupture. This delay allows consolidation of the tendon ends, making the repair technically easier. Various suture techniques have been described to approximate the ruptured ends of the tendon. Augmentations using either the plantaris tendon or gastrocnemius fascia flaps have also been described. Mandelbaum et al promotes the use of a Krackow modified suture technique to provide a stronger fixation thus, allowing an accelerated rehabilitation emphasizing early motion, weight bearing and conditioning in motivated, higher-level athletes. Neglected acute ruptures or reruptures may require reconstruction using endogenous materials (e.g., fascia lata, peroneus brevis transfer) or exogenous materials (e.g., carbon fiber, Marlex mesh, Dacron vascular graphs, polypropylene braid). Preoperative Rehabilitation Further injury protection using a splint or cast with the ankle in about 20o or plantarflexion Instruction in use of crutches to maintain the desired non-weight bearing or partial weight bearing status Instructions/review post-operative rehabilitation plan

POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Mandelbaum, Gruber, and Zachazewski. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Phase I for Traditional Immobilization and Rehabilitation: Weeks 1-4 Goals: Control edema and pain Protect repair Minimize deconditioning Intervention: Cast with ankle in plantarflexion Elevation and ice Instruct and monitor non-weight-bearing crutch ambulation General cardiovascular and muscular conditioning program

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Phase II for Traditional Immobilization and Rehabilitation: Weeks 5-8 Goals: Control any residual symptoms of edema and pain Continue to protect repair Progressive weightbearing status Minimize deconditioning Intervention: Re-casted with ankle in neutral dorsiflexion Elevation and ice Instruct in progressive weight-bearing, as allowed, using the appropriate assistive devices and encouraging normal gait mechanics Modify/progress cardiovascular and muscular conditioning program

Phase III for Traditional Immobilization and Rehabilitation: Weeks 9-16 Goals: Normal gait mechanics Limit scar tissue adhesions Full range of motion (ROM) Improve strength of all ankle and foot musculature Modify/progress cardiovascular and muscular conditioning program Intervention: Gait training use a the appropriate height heel lift, if necessary, to attain normal loading response and stance phase mechanics Soft tissue mobilization to hypomobile tissue in superficial fascia near surgery site and to shortened posterior calf myofascial Joint mobilization to hypomobile accessory motions of the talocrural, talocalcaneal, and mid-tarsal articulations Progressive passive stretching to painfree tolerance Active range of motion (AROM) exercises, isometric exercises, progressing to resisted exercises using tubing or manual resistance to all weakened ankle and foot musculature Modify/progress cardiovascular and muscular conditioning

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Phase IV for Traditional Immobilization and Rehabilitation: Weeks 17-20 Goals: Normal gait mechanics for walking and running on level surfaces Symmetric ankle mobility and single-leg proprioception Improved ability to perform repeated single leg heel raises Initiate sport-specific or job-specific skill development Intervention: Continue intervention strategies listed in Phase III as indicated by remaining impairments Progress stretching exercises to initiate body weight stretching over incline or wedge Progress resistive exercises to body weight exercises such as repeated heel raises (if no increase in symptoms occurs with previous exercises) Progress proprioceptive and balance training to include pertabative surfaces (such as a wobble board) or advanced single-leg balance activities Near the end of phase IV, begin running progression and/or sport-specific or job-specific skill development

Phase I for Early Motion and Rehabilitation: Day 1-7 Goals: Prevent wound complications Control edema and pain Active dorsiflexion to 5o 50% of active plantar flexion (compared to opposite side) Intervention: Instruct in surgical site protection Elevation and ice Toe curls, ankle pumping (full active dorsiflexion and plantar flexion out of splint - by day 3) Instruct and monitor non-weight-bearing crutch ambulation

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Phase II for Early Motion and Rehabilitation: Weeks 2-8 Goals: Active dorsiflexion to 0o by week 4 Active dorsiflexion to +5o by week 8 Full weight bearing beginning on day 14 Normal gait mechanics on level surfaces without brace by end of week 8 Initiate progressive resistive training program for the gastrocnemius-soleus complex Intervention: Pool therapy walk or run under full buoyancy conditions (non-weight bearing only), heel raises in chest deep water after Week 5 Ankle AROM (out of splint) exercises Initiate gentle passive dorsiflexion stretching with towel or strap after Week 3 Initiate gentle, painfree, weight-bearing dorsiflexion starting at Week 5 Gait training wearing protective splint with weight bearing to tolerance until Week 5 Gait training out of walking splint to painfree tolerance starting at Week 5 Painfree resistive ankle exercises using elastic tubing or band Initiate double-leg heel raises at Week 5 Initiate single-leg heel raises in chest-deep water after Week 5 Initiate submaximal isokinetic dorsiflexion and plantarflexion emphasizing endurance Cardiovascular conditioning on stationary bicycle to painfree tolerance using walking splint until Week 5 without splint to painfree tolerance starting at Week 5 Resistive exercises for unaffective muscle groups

Phase III for Early Motion and Rehabilitation: Weeks 9-20 Goals: Normal gait mechanics for all activities of daily living Normal ankle and foot ROM Ability to perform repeated single-leg heel raises Fast walking, progressing to slow jogging, progressing to sport-specific or job specific skill development all to painfree tolerance Intervention: Continue intervention strategies listed in Phase II as indicated by remaining impairments Pool therapy walking, gentle hopping and jumping in waist deep water Gait training progress to treadmill walking on level surfaces and later on a slight incline, gradual progressing to jogging if symptom free and progress to skiping, hopping, and easy jumping after Week 17. Careful not to progress gait or sport specific training too soon and accentuate the risk of re-rupture. Progress submaximal isokinetic dorsiflexion and plantarflexion emphasizing endurance After Week 17, develop and individualized strength and flexibility program to address

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6 remaining impairments on the involved and uninvolved lower extremities. Then, gradually initiate a functional training program leading toward the ability to perform the desired sport-specific or job-specific skills.

Selected References: Mandelbaum B, Gruber J, Zachazewski J. Achilles Tendon Repair and Rehabilitation. In Maxey L, Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, Mosby, 2001. Certi R, Steen-Erik C, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21:791-799. Curwin S. Tendon injuries. Pathology and Treatment. In Zachazewski JE, Magee DJ, Quillen WS, eds., Athletic Injuries and Rehabilitation. Philadelphia, WB Saunders, 1996. Kannus P, Jozsa L. Histopathological changes preceding spontaneusos rupture of a Achilles tendon. J Bone Joint Surg. 1991;73A:1507-1525. Lagerrgren C, Lindholm A. Vascular distributon in the Achilles tendon. an arteriographic and microangiographic study. Acta Chir Scand. 1958;116:491-495. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. a new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995;23:392-95.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Ankle Open Reduction Internal Fixation


Surgical Indications and Considerations Anatomical Considerations: Damage to neurovascular and tendonous structures must be considered with ankle fractures. Medially, the posterior tibial artery, tibial nerve, posterior tibial and flexor tendons, and deltoid ligament are subject to trauma. Laterally, the peroneous longus/brevis tendons, lateral collateral ligaments, superficial peroneal nerve and sural nerve are potentially at risk. Pathogenesis: Ankle fractures result from similar mechanisms as ankle sprains. For example, an inversion injury may result in a medial malleolus fracture as well as a sprain of the lateral collateral ligaments. In contrast, an eversion injury may fracture the lateral malleolus and sprain the medial deltoid ligament. Ankle fractures are based on the classification system developed by Lauge-Hansen in 1948. The classification system has five groups of ankle fractures and is dependent on the foot position and direction of force when the injury occurred. It also indicates the injured structures. Since the mechanism of injury for ankle sprains and fractures is virtually the same, ankle sprains that do not respond to conservative treatment after 4 to 5 weeks should be reevaluated for a fracture. Lauge-Hansen Classification (Lesic & Bumbasirevic) Type of Fracture Stage Injured Structures Supination-adduction 1 Avulsion fracture of the lateral malleolus Supination-adduction 2 Vertical fracture of the medial malleolus Supination-eversion 1 Lesion of the anterior tibiofibular ligament Supination-eversion 2 Oblique fracture of the lateral malleolus Supination-eversion 3 Posterior malleolus fracture or rupture of the posterior tibiofibular ligament Supination-eversion 4 Fracture of the medial malleolus or rupture of the deltoid ligament Pronation-abduction 1 Transverse avulsion fracture of the medial malleolus Pronation-abduction 2 Rupture of tibiofibular ligaments Pronation-abduction 3 High transverse bending fracture of the lateral malleolus Pronation-eversion 1 Rupture of deltoid ligament or avulsion fracture of the medial malleolus Pronation-eversion 2 Failure of the anterior tibiofibular ligament Pronation-eversion 3 Oblique or spiral fibular fracture Pronation-eversion 4 Disruption of the posterior tibiofibular ligament or fracture of the third metatarsal Pronation5 Pilon fractures stages 1/3 dorsiflexion

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Epidemiology: Ankle fractures are one of the most common injuries in the lower extremity occurring at a rate of 107 fractures per 100,000 persons per year. Young athletic males and middle age women are most commonly affected. Talus fractures represent 3% of foot fractures and tend to be associated with high-energy traumas such as a fall from a height or a motor vehicle accident. Eversion fractures are the most common whereas pronation-dorsiflexion (pilon) fractures are the rarest but more severe. Diagnosis: Physical Examination: Acute trauma Pain with weight bearing Local tenderness Instability Obvious swelling- Ankle effusion of 13 mm or more has been shown to be indicative of a fracture with an 82% predictive value. Radiological Examination: Plain film radiographs using a minimum of three views (anterior-posterior, lateral and mortise view with the foot internally rotated 15o) are used. Magnetic Resonance Imaging may be utilized if ligamentous, tendon or chondral lesions are suspected. Computed tomography is also used in complex fractures to better identify fracture comminution and displacement as well as soft tissue injury. The following radiological criteria are used to assess ankle integrity: The medial joint space measures less than 4 mm. There is less than 5 mm of interosseous clear space. The anterior tibial tubercle and fibula overlap at least 10mm. Normal talcrural angle is 83o + 4o 0o of talar tilt allowing for 5o of difference between the two joints. The tibiotalar line must pass through both the center of the tibia and the talus on anteriorposterior and lateral views. Nonoperative Versus Operative Management: Nonoperative versus operative treatment depends on the type of fracture (displaced versus nondisplaced), skin integrity, circulation status as well as the patient's age and current health. Stable, nondisplaced fractures are typically treated conservatively with immobilization. Some displaced fractures may undergo closed reduction under general or spinal anesthesia if possible. Some indications for conservative treatment include: peripheral vascular disease, peripheral neuropathy, diabetes mellitus, poor health, age, sedentary lifestyle, open wounds, infections, paraplegia, and debilitated mental status (i.e. ability to maintain weight-bearing status post-operatively). The patient is typically nonweight-bearing in a cast for 3-4 weeks and may then be weight-bearing as tolerated or partial weight-bearing in a walking cast for another 8-12 weeks depending on the stability of the fracture. Open reduction internal fixation is indicated in unstable, displaced fractures especially if the talus is subluxed. Pronation type fractures are typically treated with open reduction and internal fixation whereas supination/eversion type fractures can be treated either conservatively or surgically with about equal results.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Fractures and dislocations should be reduced as quickly as possible to prevent circulatory impairments and neuropraxia. Swelling and inflammation severely limit reduction. Depending on the extent of the fracture, pins, screws, plates and intramedullary nails and rods are used to secure the fracture site(s). The surgical approach depends on the location of the fracture.

POSTOPERATIVE REHABILITATION

Phase I: Weeks 1-4 Goals: Decrease pain and edema Protect surgical repair Maintain/improve general cardiovascular and muscular fitness Intervention: Ice and elevation Gait train nonweight-bearing with crutches/front wheeled walker. Step/stair training as needed Immobilize with below-the-knee plaster cast with ankle in neutral General cardiovascular and total body strengthening program

Phase II: Weeks 5-10 Goals: Control pain and edema Protect surgical repair Gradually progress weight-bearing status Increase ankle plantarflexion/dorsiflexion range of motion Maintain/improve general cardiovascular and muscular fitness Intervention: Ice and elevation Continue gait training as weight-bearing status changes (walking cast to short leg walking brace) with assistive device as needed Compression garments as needed to control edema Begin active and passive ankle dorsiflexion and plantarflexion General cardiovascular and total body strengthening program

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase III: Weeks 10-14 Goals: Control edema Full ankle range of motion Normalize gait Increase strength Maintain/improve general cardiovascular and muscular fitness Intervention: Ice and elevation Continue range of motion exercises adding ankle inversion/eversion Lower extremity stretching focusing on the gastrocnemius/soleus complex (may begin with passive seated towel stretch and progress to standing) Begin ankle/foot strengthening (begin with isometric progressing to isotonic with theraband to standing ankle dorsiflexion/plantarflexion) Scar mobilization and desensitization Joint mobilization to decrease capsular tightness General cardiovascular and strengthening program

Phase IV: Week 14-24 Goals: Increase ankle muscle strength/endurance Increase balance/proprioception/neuromuscular control Maintain/improve general cardiovascular and muscular fitness Begin sport/job specific activities Normalize gait/running on varied surfaces Intervention: Continue to progress lower extremity stretching and strengthening Balance/proprioception exercises on varied surfaces/conditions (single leg stance/tandem, compliant/noncompliant surface, eyes open/closed) Gait training/running on varied surfaces and inclines General cardiovascular and strengthening program Sport/job specific skill training

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References: Bernier J, Sieracki K, Levy L. Functional rehabilitation of the ankle. Athletic Therapy Today. 2000;23:38-44. Hannu L, Teppo J, Seppo H, Markku N, Kimmo V, Markku J. Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. JBJS. 2003;85:205-215. Lesic A, Bumbasirevic M. Ankle fractures. Trauma. 2004;2(1). Nilsson G, Nyberg P, Ekdahl C, Eneroth M. Performance after surgical treatment of patients with ankle fractures 14-month follow-up. Physiotherapy Research International. 2003;8:6982. Prentice W. Ankle fractures and dislocations. In Malinee V, Reed S, eds., Rehabilitation Techniques. Boston, McGraw-Hill, 1999.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Talar Fracture Repair and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The talus is made up of a body (consisting of a dome, central portion, a lateral process, and a posterior process. Along with that is the talar neck and head. There are no tendons attached to the talus, it is held by ligamentous as well as bony structures. It articulates with the tibia, medial and lateral malleoli, calcaneus, and the navicular bone. The talus has a rich vascular network made up of three main arteries, the posterior tibial artery, anterior tibial artery, and peroneal artery. Pathogenesis: Decreased osteoblast activity in the bone makes it become weak to stresses placed on it. Strong axial and shear forces accompanied with activity or trauma can cause bones in the body to break. Therefore talar fractures usually occur with a severe impact like trauma to an either dorsiflexed foot or with an increased load on a hyper-plantar flexed foot. Examples range from involvement in a motor vehicle accident to forces produced by ballerinas while dancing. Epidemiology: Talar fractures are quite rare, they account for about 0.14% - 0.32% for all fractures throughout the body. Of all foot fractures talar fractures make up about 3-5%, but they can be underreported. Roughly about 50% of the fractures of the talus involve the talar neck. Fractures of the main portion of the talar body and of the talar head are uncommon. Fractures of the talar dome, lateral process, and posterior process occur primarily in young athletes. But other talar fractures can occur at any age, primarily from a motor vehicle accident or a fall from a height. Diagnosis: Chronic ankle pain and non-union can be present after an undetected fracture that is misdiagnosed as a chronic ankle sprain. Patient may complain of chronic hindfoot pain. Possible tear of lateral collateral ligament or injury to flexor hallucis longus. Plain radiographs of the foot and ankle are use to diagnose a talar fracture. A CT Scan is used to evaluate displacement of the bone and plan for surgery. MRI and CT are used to diagnose clinically occult fractures.

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Hawkins Classification of Talar Neck Fractures Radiographic findings Type I Type II Nondisplaced fracture line Displaced fracture, plus subluxation or dislocation of subtalar joint Displaced fracture, dislocation subtalar AND tibiotalar joints Displaced fracture and disruption of talonavicular joint Risk of AVN* 0-13% 20-50%

Type III

69-100%

Type IV

high

*AVN=Avascular necrosis

Nonoperative vs. Operative Management: There is a general consensus that dislocated talar fractures should be operated on. The collapse rate of the talus has been shown to be lowered due to surgical intervention. Surgical repair allows better healing and decreases the chance of any further complications such as avascular necrosis or severe arthrosis of the ankle. Immediate reduction of fracture dislocations is essential to preserve blood supply to the talus and to also avoid secondary soft tissue edema. Unlike non-operative treatment it also permits early mobilization of the joint. Indications for non-operative treatment are used solely for undisplaced talar fractures. If stable fixation with surgical treatment is not used than prolonged immobilization of the ankle is used. A non-weight bearing status is usually preferred. Due to the long term immobilization of the ankle significant problems can arise such as secondary arthrosis, muscle atrophy, and cartilage atrophy (with 2/3 of the bone surface being covered by cartilage).

Surgical Procedure: According to both Kundel and Frawley et al careful closed fracture reduction should be attempted as early as possible during assessment in the emergency room. Most of the blood supply runs along the neck of the talus, with the neck being the most common fracture site. Immediate reduction of fracture dislocations is vital to maintain blood supply to the talus and therefore the antero-medial approach is usually preferred. The approach goes from the navicular to the medial malleolus between the tibialis anterior and the tibialis posterior tendons. K-wire transfixation of a mobile fragment can be used to maintain the reduction during the insertion of usually 2 titanium screws. Open reduction along with stable internal fixation of a talar fracture can speed along recovery. Earlier motion is then achieved leading to increased weight bearing status as well as preservation of the blood supply to help with healing and postoperative rehabilitation.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Preoperative Rehabilitation: Immobilization of ankle with temporary splint or cast before surgery is performed in the emergency room. Instruction in assistive device for ambulation while maintaining a non-weight bearing status. Instruction and review of post-operative rehabilitation.

POSTOPERATIVE REHABILITATION Phase I for Early Motion and Rehabilitation: Week 1-6 Goals: Initiate early active motion Control edema and pain Maintain motion of affected/unaffected joints in the foot Intervention: Surgical scar protection Mobilization to ankle/foot to increase joint mobility Elevation with intermittent ice compression Active ROM exercises (i.e. ankle pumps) to increase circulation to the foot and promote cartilage healing PROM to joints of the ankle/foot (increase ROM, control pain, once edema is lowered) Instruction in non-weight bearing crutch ambulation

Phase II for Early Motion and Rehabilitation: Weeks 6-8 Goals: Partial weight bearing Prevention of necrosis of the talus Continue with joint mobilization in Phase I as needed Increase AROM to 50-75% of normal Intervention: Initiate instruction in partial weight bearing restriction with crutch ambulation. Patient performing PROM exercises actively to ankle. Aquatic therapy ambulation in waist to chest high water (partial wt. bearing). Instruction in donning and doffing walking boot. Pain free open chain exercises with band. Stationary bike to pain free tolerance without walking boot.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Phase III for Early Motion and Rehabilitation: Weeks 12-24 Goals: Full weight bearing at 12 weeks Normal ankle/foot ROM Normal gait mechanics without walking boot Intervention: Initiation of gait training in parallel bars Progressive resistive strengthening of ankle musculature with band Proprioceptive weight bearing activities for balance Gait training on treadmill with progression to incline surface Single leg support activities Fast walking with progression to jogging for patient specific activities

Selected References: Crim J. Talus Fractures.July 13, 2004.http://www.emedicine.com/radio/topic672.htm#target24. Low CK, Chong CK , Wong HP, Low YP. Operative treatment of displaced talar neck fractures. Ann Acad Med Singapore. 1998;27:763-766. Cronier P, Talha A, Massin P. Central talar fractures therapeutic considerations. Int J Care Injured. 2004; 35:S-B10 S-B22. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G. Surgical treatment of talus fractures. a retrospective study of 80 cases followed for 1-15 years. Acta Orthop Scand. 2002;73:344-351.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Syndesmosis Ankle Sprains


ICD 9 code: 719.47 Pain in joint involving ankle and foot Description: The mechanism of injury for syndesmotic ankle sprains can be difficult to isolate as there are different anatomic structures involved, depending upon the mechanism of injury. The manner in which these structures can be injured may involve 3 planes of motion. There are 3 proposed mechanisms on injury for the syndesmotic ankle sprain. These include external rotation of the foot, eversion of the talus within the ankle mortise, and excessive dorsiflexion. These mechanisms of injury vary significantly from the typical lateral ankle sprain, in which the ankle and foot are plantarflexed and inverted. Forceful external rotation of the foot results in widening of the ankle mortise. Additionally, elevated forces with eversion of the talus can widen the mortise. Finally, forceful dorsiflexion may widen the ankle mortise with the wider anterior aspect of the talar dome entering the joint space. With all the above scenarios, the distal fibula is forced laterally away from its articulation with the distal tibia. Etiology: The mechanism of injury dictates which structures are involved with the sydesmotic ankle sprain. The three major ligaments involved are the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous ligament. Syndesmotic ankle sprains may coexist with traditional ankle sprains, as well as deltoid ligament injuries, or occur independently. Research has shown that between 1% and 18% of all ankle sprains involve injury to the syndesmosis. Patients with incomplete syndesmotic ankle sprains, on average, require 55 days to recover. This period of time is almost twice the recovery period for patients with third degree lateral ankle sprains. Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition Severe swelling Severe ecchymosis Loss of function and motion (patient may have heel raise gait pattern in order to avoid dorsiflexion at terminal stance) Positive External Rotation Test, Squeeze Test, or Point Test Dorsiflexion may bring on pain and apprehension Tenderness over Anterior Inferior Tibiofibular Ligament, Posterior InferiorTibiofibular Ligament, or Interosseous Ligament Possible lateral and/or anterior shift/displacement of lateral malleolus

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Sub Acute Stage / Moderate Condition Moderate pain and swelling Mild to moderate ecchymosis Some loss of motion and function (patient has pain with weight-bearing and ambulation) Mild to moderate instability Pain with dorsiflexion and/or external rotation of the foot Mild to moderate tenderness with swelling/effusion over the above mentioned ligaments

Settled Stage / Mild Condition Mild tenderness and swelling Slight or no functional loss (patient is able to bear weight and ambulate with minimal pain) No mechanical instability (ER test and squeeze tests are negative Slight to no apprehension when taken into external rotation or dorsiflexion

Intervention Approaches / Strategies Acute Stage / Severe Condition Pain & Edema Control Physical Agents: pain and swelling control; rest, ice compression, and elevation (RICE), electrical stimulation, toe curls, ankle pumps Note: Early Mobilization of joints following ligamentous injury actually stimulates collagen bundle orientation and promotes healing, although full ligamentous strength is not reestabilished for several months. Limiting soft-tissue effusion speeds healing. Temporary stabilization (ie, short leg cast, splint, brace) Non-weight bearing with crutches

Sub Acute Stage / Moderate Condition Partial weight-bearing without pain Low-level balance training:bilateral standing activity or standing on balance pad Lower-level strengthening with Theraband Manual Therapy to restore accessory and physiological mobility deficits

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Settled Stage / Mild Condition Unilateral balance training Progress from double heel raises to single heel raises Treadmill walking with progression to fast walking Therapeutic Exercises Gradual return to sport activities through use of functional progression, such as activity-specific exercise for example: Running in pool, swimming Gradual progression of functional activities Pain free hopping on both legs progressing to single leg Stand on toes and hop on toes Step up / over / forward / sideways on high step pain free Begin stairmaster, treadmill, biking Initiate running when fast pace walking is pain free Figure 8s, cross-over walking Jump rope Ball on wall Weight bearing wobble board Heel raises External Devices (Taping/Splinting/Orthotics) Reinjury is common with ankle sprains; so external bracing is recommended and can include taping, lace-up braces, and air splints

Intervention for High Performance / High Demand Functioning with Workers or Athletes Goals: Return to desired occupational or leisure time activities Prevention of recurring injury Approaches / Strategies listed above Therapeutic Exercises Progress functional activies related to desired sport activity for example: Walk-jog, 50/50 backwards, forwards, patterns, circles Jog-running, backwards, forwards, patterns Jumping rope single limb Figure 8s, cross-over running Improve strength and endurance through use of progressive resistive training Consider early mobilization with the motivated athlete. However, when choosing the specific intervention strategy, consider the patients activity level, age, goals for recovery, degree of injury, previous history of injury, and general motivation.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References Lin CFL, Gross MT, Weinhold P. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther 2006: 36(6):372-384 Alonso A, Khoury L, Adams R. Clinical Tests for ankle syndesmoisis injury: reliability and prediction of return to function. J Orthop Sports Phys Ther. 1998: 27:276-284 Fallat L, Grimm DJ, Saraco JA. Sprained ankle syndrome: prevalence and analysis of 639 injuries. J Foot Ankle Surg. 1998;37:280-285 Gerber JP, Williams GN, Scoville CR, Arciero RA. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19:653-660 Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10:325-330

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Ankle Lateral Ligament Reconstruction and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The main lateral soft tissue stabilizers of the ankle are the ligaments of the lateral ligamentous complex: the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. As the foot goes into plantar flexion the bony talar contribution to overall talocrural stability dissociates thereby causing the ligamentous structures to assume a greater role in providing stability and become more susceptible to injury. Pathogenesis: The anterior talofibular ligament is a small thickening of the tibiotalar capsule. When the foot is in plantar flexion, the ligaments course becomes parallel to the axis of the leg allowing for greater force to be placed upon it. Most sprains occur when the foot is in plantar flexion and inversion thereby injuring the anterior talofibular ligament. Epidemiology: Ankle sprains are the most common sport-related injury accounting for 10-15% of all sport injuries. Approximately 85% of all ankle sprains involve the lateral structures of the ankle: a tear of the anterior talofibular ligament and sometimes the calcaneofibular ligament and anterior inferior tibiofibular ligament. Previous sprain is a predictive factor for lateral ankle sprains although studies have found a decreased risk of re-injury when a brace is worn. Gender, joint laxity, and anatomical foot type does not appear to be a risk factor as was previously thought but the literature remains divided with regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical alignment, muscle strength, muscle-reaction time, and postural sway are risk factors for ankle sprains. Diagnosis: Lateral ankle ligament sprains or general talocrural instability is assessed through a history of the mechanism of injury, a physical examination with special tests, and radiographic evaluation. Previous lateral ankle ligament sprain Foot is usually plantar flexed and inverted during injury Many patients state hearing a snap Immediate pain and swelling usually are localized over the anterior talofibular ligament Positive anterior drawer test (anterior talofibular ligament) or talar tilt test (calcaneofibular ligament) Radiographic analysis to detect fractures

Nonoperative versus Operative Management: Nonoperative management of a lateral ankle sprain includes physical therapy, bracing, activity modification, and steroid injections. Operative management is an option when the above have failed to return the patient to a painfree active lifestyle. A failure occurs when the patient has recurrent giving way of the ankle with activities of daily living or the patients particular activities or sports, abnormal inversion, and

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2 positive anterior drawer stress x-rays. Lateral ligament repair surgery is indicated in patients all ages. However, those older than 40 seldom have surgery secondary to decreased activity levels. Surgical Procedure: Surgery begins with arthroscopy to identify further intraarticular ankle pathology. If intraarticular pathology is identified, it is then addressed and the arthroscopic surgery is completed. Arthroscopic techniques are performed, but an open stabilization gives a reproducible result. There are numerous procedures that use the peroneus brevis tendon to reconstruct the anterior talofibular ligament during open stabilization. More recently other surgical procedures for direct anatomic repair have gained popularity such as direct suturing of the ligament, imbrication, reinsertion to the bone, and in some cases augmentation with surrounding tissues. After the repair is completed the ankle is put through total range of motion to make sure that it has been maintained throughout surgery. Preoperative Rehabilitation: Injury protection with ankle splint or cast Instruction in the use of assistive device to maintain weight-bearing status Instructions/review of postoperative rehabilitation plan

POSTOPERATIVE REHABILITATION

NOTE: The following protocol is taken from Ferkel, Donatelli, and Hall. Refer to their publication for a full explanation of the protocol and for information regarding criteria for advancement to next stage, anticipated impairments and functional limitations, and treatment rationale. Phase I for Lateral Ligament Repair: Postoperative Weeks 4-6 Goals: Decrease pain Control edema Increase range of motion and muscle contraction tolerance Intervention: Isometric exercises Passive and active range of motion: plantar and dorsi flexion Progressive resistance exercises of the hip Soft tissue mobilization and modalities as needed Joint mobilization as indicated Instruct and monitor gait training progressing to full weight bearing ambulation using appropriate device Patient education

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Phase II for Lateral Ligament Repair: Postoperative Weeks 6-8 Goals: Control edema and pain Increase strength and tolerance to single-limb stance and advanced activities Improve proprioception and stability of ankle Minimize gait deviations on level surfaces Intervention: Isometric exercises Active range of motion of ankle for all ranges against gravity Standing bilateral heel raises and squats and lunges Treadmill and stationary bike and pool therapy Elastic tubing and balance board exercises Proprioceptive neuromuscular facilitation

Phase III for Lateral Ligament Repair: Postoperative Weeks 8-10 Goals: Full active and passive range of motion Return ankle strength to 80% of uninvolved side Self-management of edema and pain Intervention: Increase elastic tubing resistance Isotonics and Isokinetics

Phase IV for Lateral Ligament Repair: Postoperative Weeks 11-18 Goals: Prevent reinjury with return to sport Return to sport Discharge to home or gym program Intervention: Ankle brace Advanced exercises: plyometrics, trampoline, box drills, slide board, lateral shuffle, figure eight exercises Increase demand of pivoting and cutting exercises

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Selected References: Baltopoulos P, Tzagarakis GP, Kaseta MA. Midterm results of a modified Evans repair for chronic lateral ankle instability. Clin Orthop Rel Res. 2004;422:180-185. Baumhauer JF, OBrien T. Surgical considerations in the treatment of ankle instability. Journal of Athletic Training. 2002;37:458-462. Burks RT, Morgan J. Anatomy of the lateral ankle ligaments. Am J Sports Med. 1994;22:72-77. DeMaio M, Paine R, Drez D. Chronic lateral ankle instability-inversion sprains: Part I & II. Orthopedics. 1992;15:87-92. Komenda G, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Intern. 1999; 20: 708-14. MacAuley D. Ankle injuries: same joint, different sports. Med Sci Sports Exerc. 1999;31(7 suppl):409-11.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Calcaneal Fracture and Rehabilitation


Surgical Indications and Considerations Anatomic Considerations: The calcaneus articulates with the talus superiorly at the subtalar joint. The three articulating surfaces of the subtalar joint are the: anterior, middle, and posterior facets, with the posterior facet representing the major weight-bearing surface. The subtalar joint is responsible for the majority of foot inversion/eversion (or pronation/supination). The interosseous ligament and medial, lateral, and posterior talocalcaneal ligaments provide additional support for the joint. The tibial artery, nerve, posterior tibial tendon, and flexor hallucis longus tendon are located medially to the calcaneus and are at risk for impingement with a calcaneal fracture, as are the peroneal tendons located on the lateral aspect of the calcaneus. The calcaneus serves three major functions: 1) acts as a foundation and support for the bodys weight, 2) supports the lateral column of the foot and acts as the main articulation for inversion/eversion, and 3) acts as a lever arm for the gastrocnemius muscle complex. Pathogenesis: Fractures of the calcaneal body, anterior process, sustentaculum tali, and superior tuberosity are known as extra-articular fractures and usually occur as a result of blunt force or sudden twisting. Fractures involving any of the three subtalar articulating surfaces are known as intra-articular fractures and are common results of: a fall from a height usually 6 feet or more, a motor vehicle accident (MVA), or an impact on a hard surface while running or jumping. Intra-articular fractures are commonly produced by axial loading; a combination of shearing and compression forces produce both the primary and secondary fracture lines. Shearing forces are created by opposing, parallel forces, which in this case are often the upwardmoving body of the calcaneus against the downward-driving subtalar articulation. Shearing forces often split the calcaneus into medial and lateral halves. The exact position of the hindfoot upon impact is partially responsible for the position of the fracture linea hindfoot in the valgus position tends to move fractures more laterally, whereas a hindfoot in the varus position moves fractures medially. Axial loading also produces a compression fracture line in a characteristic Y pattern, as seen from lateral and oblique radiographic views. The resulting fracture line often splits the middle subtalar facet and creates a superomedial fragment. As described by Essex-Lopresti, the Y pattern can extend more horizontally, as in a tongue-type fracture, or can extend more vertically, as in a joint-depression fracture. Besides the descriptions of Essex-Lopresti, two other classification systems are most widely recognized and utilized in the evaluation of calcaneal fractures. Sanders, utilizing computerized tomography (CT) scanning, divides calcaneal fractures into four categories: Type I - Undisplaced Type II - Two parts (split) Type III - Three parts (or split/depression)
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2 Type IV - Comminuted

Crosby-Fitzgibbons also using CT scans divide calcaneal fractures into three categories: Type I - Small fracture segments which are slightly displaced or undisplaced Type II - Fracture segments which are displaced by 2mm or more Type III - Comminuted fracture Epidemiology: Calcaneal fractures account for 2-3% of all fractures of the body, and 60% of all tarsal fractures. 75% of all calcaneal fractures are intra-articular and involve one or more of the three subtalar articulating facets. Intra-articular fractures have a poorer prognosis than extraarticular fractures. Calcaneal fractures are most often seen in young adult men. Compression fractures of the lumbar vertebrae occur in 10-15% of cases presenting with a calcaneal fracture. Diagnosis: Patients with a fracture of the calcaneus may present with the following symptoms: Pain - Most importantly pressure pain, or pain elicited when providing pressure to the calcaneus by holding the heel of the patients foot and gently squeezing Edema Ecchymosis - A hematoma or pattern of ecchymosis extending distally to the sole of the foot is specific for calcaneal fractures and is known as the Mondor sign Deformity of the heel or plantar arch - Widening or broadening of the heel is seen secondary to the displacement of the lateral calcaneal border outward and accompanying edema Inability to or difficulty weight-bearing on affected side Limited or absent inversion/eversion of the foot Decreased Bohler or tuber-joint angle - In normal anatomical alignment an angle of 25-40 degrees exists between the upper border of the calcaneal tuberosity and a line connecting the anterior and posterior articulating surfaces. With calcaneal fractures, this angle becomes smaller, straighter, and can even reverse. CT scan (both axial and coronal views) to classify the degree of injury to the posterior facet and lateral calcaneal wall X-rays or Radiographs: o Axial - Determines primary fracture line and displays the body, tuberosity, middle and posterior facets o Lateral - Determines Bohler angle o Oblique/Brodens view - Displays the degree of displacement of the primary fracture line

Nonoperative Versus Operative Management: Great debate remains as to what is the best course of treatment following a calcaneal fracture, especially following operative management of displaced or intraarticular fractures. Nonoperative management is preferable when there is no impingement of the peroneal tendons and the fracture segments are not displaced (or are displaced less than 2 mm). Nonoperative care is also recommended when, despite the presence of a fracture, proper weight-bearing alignment has been adequately maintained and articulating surfaces are not disturbed. Extra-articular fractures are generally treated conservatively.

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3 Patients who are over the age of 50 years old or who have pre-existing health conditions, such as diabetes or peripheral vascular disease, are also commonly treated using nonoperative techniques. Patients receiving nonoperative management are 5.5 times more likely to require primary subtalar arthrodesis at some point in the future. Surgical repair is recommended in calcaneal fractures which present with displaced fracture segments, impinged peroneal tendons, or entrapped medial compartments. Patients who are younger, female, have a light or moderate work load involving the foot, or who have a larger remaining Bohler angle have better results with operative care. A 16 percent incidence of wound complication is associated with operative management. Using the classifications of Sanders and Crosby-Fitzgibbons, nonoperative and operative treatment courses are preferred for the following grades of calcaneal fracture: Type I (Sanders), Type I (Crosby-Fitzgibbons) - Nonoperative management of immobilization or early mobilization Type II (Crosby-Fitzgibbons) - Nonoperative management of immobilization or early mobilization, or operative management including closed reduction and fixation Type II/III (Sanders), Type III (Crosby-Fitzgibbons) - Operative management commonly including ORIF Type IV (Sanders) - Nonoperative management for non-salvageable comminuted fractures or operative management consisting of ORIF with primary arthrodesis Surgical Procedure: The goals of operative management of a calcaneal fracture include: 1) restoration of normal heel height and length, 2.) realignment of the posterior facet of the subtalar joint, 3) restoration of the mechanical axis of the hindfoot. Surgical repair is often delayed 3-14 days after the fracture, especially in the presence of significant edema or fracture blister formation, to allow for some reduction of swelling. There are various surgical techniques for the repair of a calcaneal fracture, including the least invasive, closed reduction with percutaneous fixation. Open reductions include the medial, lateral, or combined ORIF approach. The extensive lateral approach is the most popular and allows the surgeon to visualize the entire fracture area. However, this approach requires a fullthickness skin flap for closure. The lateral approach is indicated when: 1) the fracture occurred two to three weeks previous to the surgical repair, 2) the fracture is severely-comminuted, 3) the fracture fragment moves out laterally and positions itself near the talus, 4) a displaced fracture of the calcaneocuboid joint is present, and 5) the fracture is unable to be reduced using the medial approach. A variety of pins, plates and other fixation devices, such as the Gissane spike and Kirschner wires are used for stabilization during surgical repair. Primary fusion, or arthrodesis, can be used for the surgical repair of Type IV (Sanders) or Type III (Crosby-Fitzgibbons) severely comminuted fractures, and is used in combination with an ORIF. Subtalar joint motion is limited after primary fusion and increases the patients risk for development of arthritis secondary to increased rotational forces on the ankle during walking.

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4 Preoperative Rehabilitation: Immediate elevation of involved extremity to decrease swelling Compression including: foot pump, intermittent compression devices, or compression wraps Ice Instruction in use of wheelchair, bedside transfers, or crutches to maintain strict nonweight bearing status Instruction in appropriate nonoperative or postoperative rehabilitation plan

NONOPERATIVE AND POSTOPERATIVE REHABILITATION Note: Both the progression of nonoperative and postoperative management of calcaneal fractures include traditional immobilization and early motion rehabilitation protocols. In fact, the traditional immobilization protocols of nonoperative and postoperative management are similar, and are thereby combined in the progression below. Phases II and III of traditional and early motion rehabilitation protocols after nonoperative or postoperative care are comparable as well and are described together below. Much debate remains on the preferable management of calcaneal fractures after operative management. Bohler, Burdeaux, Palmer, and Parmer recommend traditional immobilization after surgical repair, while Buckley, Essex-Lopresti, Lance, Paley, and Wei advocate early mobilization beginning within 24-72 hours of surgical repair. Debate also exists on the preferable management of calcaneal fractures with nonoperative management. Barnard proposes the use of traditional immobilization in the form of a short leg cast, while Lance, Paley, and Parmer recommend early mobilization with nonoperative management. Phase I for Traditional Immobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 1-4 Goals: Control edema and pain Prevent extension of fracture or loss of surgical stabilization Minimize loss of function and cardiovascular endurance Intervention: Cast with ankle in neutral and sometimes slight eversion, Elevation Ice After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker Instruct in wheelchair use with appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity

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5 Phase I for Early Motion and Rehabilitation following Nonoperative and Postoperative Managment: Weeks 1-4 Goals: Control edema and pain Prevent extension of fracture and loss of surgical stabilization Prevent contracture and loss of motion at ankle/foot joints Minimize loss of function and cardiovascular endurance Intervention: Elevation of involved extremity with ankle maintained at 90 degree angle in relation to the lower leg (or tibia) Ice combined with compression wrap After 24-72 hours, active range-of-motion exercises in small amounts of movement begin at all joints of the foot and ankle, including: tibiotalar, subtalar, midtarsal, and toe joints, and are completed every hour After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker After 14 days, instruct in proper fitting and usage of prescribed surgical shoe or orthosis to prevent contracture Instruct in wheelchair use with appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity

Phase II for Traditional Immobilization/Early Mobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 5-8 Goals: Control remaining or residual edema and pain Prevent re-injury or complication of fracture by progressing weight-bearing safely Prevent contracture and regain motion at ankle/foot joints Minimize loss of function and cardiovascular endurance Intervention: Continued elevation, icing, and compression as needed for involved lower extremity After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker Initiate vigorous exercise and range of motion to regain and maintain motion at all joints: tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts of movement and progressive isometric or resisted exercises Progress and monitor comprehensive upper extremity and cardiovascular program

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KPSoCal Ortho PT Residency

6 Phase III for Traditional Immobilization/Early Mobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 9-12 Goals: Progress weight-bearing status Normal gait on all surfaces Restore full range of motion Restore full strength Allow return to previous work status Intervention: After 9-12 weeks, instruct in normal full-weight bearing ambulation with appropriate assistive device as needed Progress and monitor the subtalar joints ability to adapt for ambulation on all surfaces, including graded and uneven surfaces Joint mobilization to all hypomobile joints including: tibiotalar, subtalar, midtarsal, and to toe joints Soft tissue mobilization to hypomobile tissues of the gastrocnemius complex, plantar fascia, or other appropriate tissues Progressive resisted strengthening of gastrocnemius complex through use of pulleys, weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other plyometric exercise, pool exercises, and other climbing activites Work hardening program or activities to allow return to work between 13- 52 weeks

Selected References: Barnard L and Odegard J. Conservative approach in the treatment of fractures of the calcaneus. J Bone Joint Surg. 1955;37A:1231-1236. Bohler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg. 1931;13:75-89. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, and Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg. 2002;84A:1733-1744. Burdeaux B. The medial approach for calcaneal fractures. Clin Orths. 1993;290:96-107. Carr J. Mechanism and pathoanatomy of the intraarticular calcaneal fracture. Clin Orthos. 1993;290:36-40. Crosby L and Fitzgibbons T. Computerized tomography scanning of acute intra-articular fractures of the calcaneus. J Bone Joint Surg. 1990;72A:852-859. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis.
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7 Br. J Surg. 1951;39:395-419. Hildebrand K, Buckley R, Mohtadi N, and Faris P. Functional outcome measures after displaced intra-articular calcaneal fractures. J Bone Joint Surg. 1996;78-B:119-123. Lance E, Carey E, and Wade P. Fractures of the os calcis: Treatment by early mobilization. Clin Ortho. 1963;30:76-89. Paley D and Hall H. Calcaneal fracture controversiescan we put Humpty Dumpty together again? Clin Ortho. 1989;20:665-677. Palmer I. The mechanism and treatment of fractures of the calcaneus. J Bone Joint Surg. 1948;30A:2-8. Parmar H and Triffitt P. Intra-articular fractures of the calcaneum treated operatively or conservatively. J Bone Joint Surg. 1993;75-B:932-937. Randle J, Kreder H, Stephen D, Williams J, Jaglal S, and Hu R. Should calcaneal fractures be treated surgically? Clin Ortho. 2000;377:217-227. Wei S, Okereke E, Esmail A, Born C, and Delong W. Operatively treated calcaneus fractures: To mobilize or not to mobilize. Univ of Penn Ortho J. 2001;14:71-73. Wilson D. Functional capacity following fractures of the os calcis. Canada Med Ass J. 1966;95:908-911.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Tarsal Tunnel Release


Surgical Indications and Considerations Anatomical Considerations: The tarsal tunnel is a fibro-osseous tunnel created by the tibia anteriorly, posteriorly by the talus, and laterally by the calcaneus. The flexor retinaculum (laciniate ligament) overlays the contents of the tarsal tunnel, which includes the posterior tibialis, flexor digitorum, flexor hallucis longus, posterior artery/vein, and the posterior tibial nerve. The posterior tibial nerve has three main entrapment sites: proximal at the flexor retinaculm, and distally at the medial and lateral plantar nerve (branches from the posterior tibial nerve located at the distal ends of the tarsal tunnel). Pathogenesis: Tarsal tunnel syndrome is an entrapment neuropathy, which occurs as a result of compression of the posterior tibial nerve. In some cases, it is referred to as an ishemic compartment syndrome and exceeding the threshold of tissue pressure at the tunnel can be associated with a reproduction of symptoms and changed in nerve function. Epidemiology: Specific causes of the syndrome can be identified in 60-80% of patients. The most common causes including trauma, varicosities, heel varus, fibrosis, and heel valgus. Tendonitis within the tunnel can cause entrapment of the posterior tibial nerve due to the decreased space, and tethering at the abductor hallicus can cause a stretch injury at the branches tibial nerve within the tunnel. Generally the causes of this syndrome can be placed into three categories: 1) Trauma, 2) Space occupying lesion, and 3) Deformities of the foot. It tends to have a slight female predominance of 56%. Other factors that predispose the patient to a tarsal tunnel syndrome can include rapid weight gain and inflammatory arthopathies such as anklosing spondylitis and rheumatoid arthritis. The inflammatory autoimmune diseases cause an increase in synovium causing synovitis within the tunnel. Along with this syndrome, development of a Double Crush Syndrome can occur. This is when there are multiple sites of nerve entrapment. When pain radiates up the proximal leg, this is called Valleix Phenomenon, and is commonly seen with the Double Crush Syndrome. Diagnosis: History of pain/paresthesia along the posterior tibial nerve and its branches Physical examination includes: inspection of foot deformities, sensory testing, muscle strength testing of the foot intrinsics (especially the flexion of the toes), palpation/percussion (Tinels test) of the posterior tibial nerve, and tibial nerve tension testing Radiographs to determine deformities or bony injury EMG study to determine motor and sensory nerve damage MRI to determine soft tissue damage or deformity, nerve damage, thickening of the flexor retinaculum, and space occupying lesions. Differential Diagnosis: lumbosacral radiculopathy, matatarsalgia, rheumatoid arthritis, plantar fasciitis, peripheral neuritis, diabetic neuropathy, peripheral vascular disease, and morton neuroma.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Nonoperative Versus Operative Management: Nonoperative treatment is most effective when the nerve entrapment/compression is caused by tenosynovitis and flexible foot deformities. Space occupying lesions tend not to respond to conservative treatments. The space occupying lesions can include ganglias, lipomas, chronic thrombophlebitis, and varicosities. Better surgical results are seen in the following: young, short history of symptoms, no history of ankle pathology, early diagnosis prior to motor involvement, and a localized lesion is identified. Failure of the decompression or decreased satisfaction with the surgical release tends to occur with the following factors: older, chronic symptoms with motor involvement, double crush syndrome, valliex phenomenon, systemic disease process, idiopathic causes, inadequate release of the tissue, and pes plantus feet. Surgical Procedure: An incision is made 10 cm to the tip of the medial malleolus and 2 cm posterior to the posterior margin of the tibia. During the proximal release, the flexor retinaculm is released from its proximal extent near the medial malleolus to the sustentaculum tali. The tunnel is followed distally, and release of the fascial arcade around the medial and lateral plantar nerve branches should be followed through to the abductor hallucis. Discussions of surgical complications have been infrequently reported in literature. One case study published an incident of the posterior tibial tendon subluxing following decompression. Follow-up studies on patients who have had decompression have also been infrequent. Currently, the longest follow up study has been an average of 31 months post surgery, with the result of only 44% of the patients receiving significant benefit out of a total of 32 surgical decompressions. Preoperative Rehabilitation: Conservative treatments include as immobilization, orthotics, strengthening and balance exercises, pharmological medications, steroid injections, and inflammatory reducing modalities. In some studies, conservative treatments also included whirlpool therapy and having the patient wear wider shoes. These conservative tools are most effective with tenosynovitis cases and flexible foot deformities. When the co-existence of lumbar nerve root compromise or sciatic nerve entrapments occurs with tibial nerve entrapments, the treatment of both entrapment sites is considered to be essential for a favorable outcome to occur. Once the source of the mechanical nerve entrapments have be addressed, neural gliding techniques may be employed in order to minimize fibrosis at peripheral nerve interfaces. It is very important to understand patient irritability and peripheral nerve healing rates, so as to not increase neurogenic complaints with neural gliding techniques.The ones who are most likely not to respond to these treatments are patients with space occupying lesions, long-term nerve irritation that has produced motor deficits, and a long, chronic history of tarsal tunnel syndrome symptoms.

POSTOPERATIVE REHABILITATION

Note: The research articles only released information for phase one for post-operative procedures. For phase two and three, common rehabilitation protocols for ankle rehabilitation

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3 were taken from: Stephenson K, Saltzman C, Brotzman S. Foot and Ankle Injuries. In Brotzman A, Wilk K., Clinical Orthopaedic Rehabilitation. Philadelphia, 2003, Mosby.

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4 Phase I for Immobilization and Rehabilitation: Weeks 1-3 Goals: Protect joint/nerve Integrity Control inflammation Control pain/edema Intervention: Immobilization with non-weight bearing precautions to protect the nerve and overstretching of the surgical site Passive mobilization to prevent edema and maintain joint integrity post 1-2 weeks per MD request. This may include selective hallux, phalange, and ankle PROM in order to prevent fibrosis of the FHL, FDL, and Posterior Tibialis tendons as they traverse through the tarsal tunnel. Instruct in surgical site protection and infection prevention strategies Elevation and ice to control swelling Educate and monitor non-weight-bearing crutch ambulation

Phase II for Immobilization and Rehabilitation: Weeks 3-6 Goals: Prevent contractions and formation of scar tissue adhesions Maintain soft tissue and joint mobility Intervention: Progress weight bearing as tolerated - starting from non-weight bearing to weight bearing Gentle passive, active-assist, and active ankle stretches out of splint Initiate gentle passive dorsiflexion stretching with towel or strap Initiate tibial nerve gliding techniques, starting with anti-tension techniques of the tibial nerve (foot plantarflexed and inverted), and moving from the hip or knee. As irritability decreases and no evidence of post-treatment latency is eveident, progressing to mobilization of the foot into dorsiflexion and eversion. Initiate gentle, pain free, weight-bearing dorsiflexion stretches Gait training wearing protective splint, to tolerance Pool therapy under buoyancy conditions walk or run

Phase III for Immobilization and Rehabilitation: Weeks 6-12 to 24 Goals: Normal gait mechanics for walking and running on level surfaces Symmetric ankle mobility and single-leg proprioception Ability to perform repeated single leg heel raises pain free Initiate sport-specific or job-specific skill development exercises

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Intervention: Gait training out of walking splint to pain free tolerance Pain free resistive ankle exercises using elastic tubing or band Continue intervention strategies listed in Phase II as indicated by remaining impairments Progress stretching exercises to initiate body weight stretching over incline or wedge Progress resistive exercises to body weight exercises o Partial to full weight bearing Progression o Evaluate compensations and muscular weakness determine specific therapeutic exercises Progress proprioceptive and balance training from single to multi-planar unstable conditions (such as a BAPS board, BOSU ball, roller, foam surfaces) or advanced single-leg balance activities With no pain with over pressure or during walking, patient may begin pain walk/run progression and/or sport-specific or job-specific skill development Cardiovascular conditioning on stationary bicycle to pain free tolerance Resistive exercises for weakened muscle groups Initiation of low level plyometric activities for sport specific activities

Selected References: Cimino W. Tarsal tunnel syndrome: review of the literature. Foot Ankle. 1990;11:47-52. Gondring W, Shields B, Wenger S. An outcome analysis of surgical treatment of tarsal tunnel syndrome. Foot Ankle Internat. 2003; 24:545-550. Langan P, Weiss C. Subluxation of the tibialis posterior, a complication of the tarsal tunnel decompression: a case report. Clin.Orthop.1980;146: 226-227. Lau J, Daniels T. Tarsal tunnel syndrome: a review of the literature. Foot Ankle. 1999;20:201-209. Pfeiffer W, Cracchiolo A. Clinical results after tarsal tunnel decompression. J Bone Joint Surg. 1994;76A:1222-1230. Saal JA, et al. The psuedoradicular syndrome: lower extremity peripheral nerve entrapment masquerading as lumbar radiculopathy. Spine. 1988;13 (8):926-930. Sammarco G, Chang L. Outcome of surgical treatment of tarsal tunnel syndrome. Foot Ankle Internat. 2003; 24:125-131. Shacklock MO. Clinical application of neurodynamics, from: Moving in on Pain, ButterworthHeinemann. 1995; 123-131. Stephenson K, Saltzman C, Brotzman S. Foot and Ankle Injuries. In Brotzman A, Wilk K., Clinical Orthopaedic Rehabilitation. Philadelphia, 2003, Mosby. Trepman, E, Kadel N, Chisholm K, Razzano N. Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle. 1999; 20:721-726.

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Posterior Tibialis Tendon Dysfunction & Repair


Surgical Indications and Considerations Anatomical Considerations: The posterior tibialis muscle arises from the interosseous membrane and the adjacent tibia and fibula in the proximal 1/3 of the leg. The tendon runs within its sheath, posterior to the medial malleolus, beneath the flexor retinaculum. The tendon also runs posterior to the axis of the ankle joint and medial to the subtalar joint. It inserts in a fan-like manner into the navicular, the three cuneiforms, and the plantar surfaces of the base of the second, third, and fourth metatarsals. The posterior tibialis muscle is a plantar flexor and invertor of the foot. At the midtarsal joint, it is an adductor of the forefoot opposing the action of the fibularis brevis. This muscle functions mainly in the stance phase of gait. After heel contact, the muscle acts as a shock absorber for the subtalar joint limiting hindfoot eversion through eccentric contraction. In midstance, contraction of the posterior tibialis muscle causes subtalar inversion thereby causing the calcaneocuboid and talonavicular joints to lock. This locking creates a right lever for forward propulsion of the foot over the metatarsal heads. During the swing phase, the tibialis posterior functions to accelerate subtalar joint supination and assists in heel lift. If there is an existing dysfunction in the posterior tibialis muscle, there is a decrease in tibial deceleration and greater hindfoot eversion. This then leads to increased tension and stretching in the ligaments during contact phase. This also results in a lack of a rigid lever for push-off and decreased tarsometatarsal joint stability and hindfoot inversion. The gastrocnemius and soleus muscles begin to act at the midfoot rather than at the metatarsal heads, which starts creating excessive midfoot stress allowing increased midfoot abduction. All these add to a dysfunction in gait resulting in progressive midfoot collapse, forefoot abduction, and excessive hindfoot valgus. From an anatomical and biomechanical view, the posterior tibialis tendon hugs the undersurface of the medial malleolus and takes on a shaper curve compared with all the other tendons passing along the medial aspect of the ankle. The tendon is also under an increased amount of tension in the area posterior and distal to the medial malleolus, especially during dorsiflexion and eversion of the foot. There is a zone of hypovascularity present in the mid-portion of the posterior tibial tendon. This zone starts approximately forty millimeters from the medial tubercle of the navicular and runs proximally for about fourteen millimeters. Pathogenesis: Studies have shown that a healthy tendon will not tear with acute stress. Instead the muscle, insertion, origin, or musculotendinous junction will fail first. On the other hand, a diseased tendon will rupture secondary to the application of a sudden force. Rupture of the posterior tibial tendon may be related to both local and systemic vascular impairments. Age, hypertension, diabetes, obesity, previous foot or ankle trauma/surgery, traumatic disruption of local blood supply, and the administration of corticosteroids may lead to vascular compromise and subsequent tendon rupture.

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2 Epidemiology: Posterior tibialis tendon ruptures occur predominantly in the late middle-aged population (average age 57 years). For posterior tibialis dysfunction, the patient is typically a female over the age of 40 who exhibits ligamentous laxity in multiple joints and has an occupation that requires extended periods of standing. They usually do not recall any acute traumatic event. There is another subset of the populations in which posterior tibial tendon insufficiency occurs and that consists of the 20- to 40-year old athletes. They usually recall a traumatic event, usually a direct blow to the medial malleolus. Or, they present with years of involvement in athletics with a pronated foot. Diagnosis Swelling along the medial aspect of the foot and ankle Progressive loss of longitudinal arch pes planus and heel valgus Too many toes sign secondary to an increase in forefoot abduction and heel eversion Positive first metatarsal rise sign Palpable pain between medial malleolus and navicular Positive single heel rise (painful but normal rise; rise without inversion of the hindfoot; no elevation of the heel possible) Radiographic studies taken with patient weight bearing along with the contralateral foot to evaluate for pathologic changes secondary to the dysfunction

Classification of Posterior Tibial Tendon Dysfunction Author Stage I Stage II Johnson and Strom Peritendinitis with Elongation of tendon, mild weakness and moderate pain, pain weakness of tendon, mobile valgus rearfoot

Stage III Fixed valgus position of rearfoot with subtalar joint arthrosis, medial and lateral rearfoot pain **Myerson also describes an additional stage, Stage IV: rigid hindfoot, valgus angulation of the talus with ankle joint degeneration. Nonoperative Versus Operative Management: The patients age, weight, and activity level, and the severity of the deformity influence treatment. As with many other pathologies, conservative treatment should be attempted before any surgical interventions are considered. As the severity of the pes planus increases, the treatment options become more and more limited. Once the deformity reaches stage IV, arthrodesis is the only option. Conservative treatment can be broken down into two sections, those with an acute onset and those with a chronic condition. For the patient with an acute onset, rest and oral antiinflammatory medication is given initially. In 2 to 3 months, if the symptoms do not resolve, the treatment progresses to include a lower extremity casting. This cast is left on for 4 to 6 weeks, which provides a longitudinal arch support and guarantees rest to the posterior tibialis muscle. With this cast, the patient is allowed to bear weight as tolerated and uses pain level as a guide. If after the cast is removed and the patient remains to have symptoms but still does not opt for surgical intervention, the patient is fitted for orthotics and their shoe is modified permanently.

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3 During rehab, using ice after exercise and an air stirrup brace or lace-up ankle support can be beneficial. Strengthening and lightweight stretching should also be started after the tenderness has resolved. Orthotic control of excessive pronation and strengthening/movement re-education of the tibialis posterior, peroneous longus, and gastrocnemius-soleus has proven to be effective. The combination of these interventions has been shown to significantly reduce the magnitude of rearfoot pronation more than orthotics alone. This is important to realize for both conservative and post-operative management. For the patients with a chronic condition, the goal of treatment is to relieve their symptoms and to slow the pes planus progression. A molded ankle foot orthosis, or patellar tendon bearing foot ankle orthosis, which redistribute forces proximally, thereby reducing stress in the foot and ankle region can be helpful. Surgical Procedure: If constant attempts at conservative intervention fail, the next progression is operative treatment. There are several options when surgery is the treatment of choice. The decision on which type of procedure should be completed takes into account the severity of the rupture and the mobility of the hindfoot. Surgery types may include the following: primary repair, synovectomy, tendon transfer, calcaneal osteotomy, and arthrodesis. Primary repair Completed for an acute rupture or laceration. If no sign of degeneration is present and the tear or laceration is complete, repair consists of primary end-to-end suturing. Synovectomy Indicated by tenosynovitis or tendinitis of the intact tendon that continues despite efforts of conservative management. Debridement of the tendon and opening of the tendon sheath often results in resolution of symptoms. Failing to complete this operation may allow the tendon to degenerate and rupture eventually. Tendon Transfer May be completed if foot is mobile and supple without evidence of a fixed hindfoot or forefoot deformity. Contraindications of this procedure include obesity, large build, sedentary lifestyle, older than 70 years, and a hypermobile foot. The tendon that is transferred is the flexor digitorum longus. Calcaneal Osteotomy Those who have a flexible valgus deformity of the hindfoot may have this procedure completed. The calcaneus is shifted medially to place the hindfoot in a varus position. This redirects the gastrocnemius-soleus pull medial to the subtalar joint. Arthrodesis Indications include fixed deformities of the forefoot or hindfoot. Arthrodesis should be completed on as few joints as possible required to stabilize the foot, reduce pain, and establish a plantigrade position. This is due to the fact that the more joints subjected to arthrodesis, the more stable the foot becomes, yet it comes at the cost of lesser flexibility of the foot. Preoperative Rehabilitation: Orthotics to prevent further hindfoot valgus Patient education on post-operative care Patient education on use of crutches secondary to non weight bearing post-operation

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POSTOPERATIVE REHABILITATION For tendon transfer procedure Phase I for Immobilization and Rehabilitation: Weeks 1-4 Goals: Control edema and pain Minimize deconditioning Intervention: Patient has short leg cast with foot in plantar flexion and inversion Instruction on crutch ambulation with non-weight-bearing status on all surfaces Initiate cardiovascular program Ice (if possible) and elevate extremity

Phase II for Mobilization and Rehabilitation: Weeks 5-9 Goals: Continue to control edema and pain Prevent cardiovascular deconditioning Encourage full weight bearing during gait cycle Out of cast approximately week 9 Intervention: Patient has short leg walking cast with foot in neutral Weight bearing as tolerated with appropriate assistive devices Gross strengthening and cardiovascular activities Phase III for Mobilization and Rehabilitation: Weeks 9-23 Goals: Normalization of gait cycle Obtain full ankle range of motion Improve strength Return to prior level of function Intervention: Soft tissue mobilization to prevent scar adhesions Strengthening all foot musculature with focus on posterior tibialis muscle and intrinsic muscles of the foot Increasing ankle proprioception Gait training Balance activities Functional task specific training

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Phase IV for Mobilization and Rehabilitation: Week 24 Goals: Return to sports activities Intervention: Sport specific tasks **Progression is dependent on status of repaired tendon and per physicians orders Selected References: Churchill R, Sferra J. Posterior tibial tendon insufficiency. Its diagnosis, management, and treatment. Am J Orthop. 1998;27:339-347. Fleischli J, Fleischli J, Laughlin T. Treatment of posterior tibial tendon dysfunction with tendon procedures from the posterior muscle group. Clin Podiatr Med Surg. 1999;16:453-470. Frey C, Shereff M, Greenidge N. Vascularity of the posterior tibial tendon. J Bone Joint Surg Am. 1990;72:884-888. Holmes G, Mann R. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle. 1992;13:70-79. Janis L, Wagner J, Kravitz R, Greenberg J. Posterior tibial tendon rupture: classification, modified surgical repair, and retrospective study. J Foot Ankle Surg. 1993;32:2-13. Johnson K, Strom D. Tibialis posterior tendon dysfunction. Clin Orthop. 1989;239:196-206. Mosier S, Pomeroy G, Manoli A. Pathoanatomy and etiology of posterior tibial tendon dysfunction. Clin Orthop. 1999;365:12-22. Weimer KM, Reischl SF, Requejo SM, Burnfield JM, Kulig K. Nonoperative treatment of posterior tibialis tendon dysfunction: a randomized clinical trial. Published abstract from APTA Combined Section Meeting, 2005. Feltner ME, et al. Strength training effects on rearfoot motion in running. Med & Science in Sport & Exerc. 1994:1021-1027.

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Tarsometatarsal Joint Sprain


ICD-9: 845.11 sprain of tarsometatarsal joint Description: The tarsometatarsal (TMT) joint, or the Lisfranc joint complex, involves the articulations of the forefoot and the midfoot. The first through third metatarsals articulate with corresponding cuneiforms. The fourth and fifth metatarsals articulate with the cuboid. Transverse ligaments join each metatarsal head, however, there is no transverse ligament between base of the 1st and 2nd metatarsal. Etiology: A Lisfranc injury indicates an injury to the normal alignment of the cuneiforms and metatarsal joints with loss of their normal spatial relationships. The most common injury to the Lisfranc joint occurs at the joint involving the 1st and 2nd metatarsals and the medial cuneiform. In athletes, injury typically is due to an axial load sustained with foot plantarflexed and slightly rotated. If the ligaments between the medial and mid cuneiforms are disrupted, or between the 1st, 2nd metatarsals and the medial cuneiform, then the bones separate and the normal alignment of the joints is lost. When recognized, this injury may be treated surgically and has a much better prognosis then when it is not diagnosed. True Lisfranc sprains (with disruption of Lisfrancs ligament), are most often due to high-energy trauma ( e.g.,motor vehicle accidents) rather than from sporting events. Lisfranc joint injury should be suspected when the mechanism of injury is consistent is as described above and soft tissue edema or pain in the foot persists five or more days after the initial injury Physical Examinations Findings (Key Impairments) Acute Stage / Severe Condition Pain with functional movements and activities Inability to bear weight while standing on tiptoe Inability to squat due to joint instability Decreased range of motion Pain and swelling in the midfoot (typically in the dorsum) with tenderness along Lisfrancs joint Tenderness with passive abduction and pronation of forefoot with fixed hindfoot Dorsalis pedis pulse may be diminished or absent Gross subluxation or lateral deviation of the forefoot is rare but muscle guarding and weakness is common Always consider and assess, if appropriate, for compartment syndrome of the foot

Sub Acute Stage / Moderate Condition As above with the following differences Moderate pain and swelling The symptoms and functional range of motion will improve as the stability of the joint and closure of the diastasis is resolved.
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Settled Stage / Mild Condition As above with the following differences Even greater range of motion and ability to squat Improved segmental stability is commonly associated with improving symptomatology Important to resolve normal joint movement in the surrounding joints

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Intervention Approaches / Strategies

Acute Stage / Severe Condition Sprains of this joint complex must be adequately protected & immobilized until soft tissue healing is complete. Usually 6 weeks in a non-weight bearing straight leg cast to ensure complete healing is recommended. If a weight bearing anterior-posterior x-ray shows any diastasis at the 2nd metatarsal/medial cuneiform articulation, a closed reduction and percutaneous screw fixation is usually indicated. Nonoperative Treatment Mild or moderate sprain weightbearing radiograph and bone scintigrams show no diastasis Immobilization: short leg walking cast, a removable short-leg orthotic or a non weight bearing cast is continued for four to six weeks or until symptoms have resolved. The potential for disability following a Lisfranc joint injury justifies the use of a non-weight bearing cast. After immobilization: ambulation and rehabilitation exercises can be progresses if the symptoms persist up to 2 weeks after rehabilitation has begun, a repeat weight bearing radiograph must be obtained to evaluate the joint articulation for instability and evidence of delayed separation (i.e., disarticulation worsened after weight bearing) Nonoperative vs. Operative Treatment The treatment of Lisfranc joint complex fracture/dislocations remains controversial. Some investigators believe that nonoperative management of fractures and fracture-dislocations is ineffective, because the reduction and alignment that occur with casting are lost when soft tissue swelling decreases. Some investigators suggest a displacement of more than 2mm requires open reduction and internal fixation to avoid a poor outcome, especially in athletes. Others report no correlation between the degree of diastasis and the eventual outcome. All studies indicate that timely diagnosis facilitates treatment and decreases long-term disability. Goal: Restore joint stability and soft tissue healing Limit effusion Reduce pain and protect from further injury Physical Agents Electrical stimulation, Ultrasound, Cryotherapy / Ice to provide pain relief, decrease swelling, promote circulation, promote wound healing, and reduce muscle guarding Manual Therapy Soft tissue mobilization. Joint mobilization. Note: Early mobilization of jointson their midranges following ligamentous injury

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4 can stimulates collagen bundle orientation and promote healing, although full ligamentous strength is not reestablished for several months. Limiting soft tissue effusion speeds healing. External Devices (Taping/Splinting/Orthotics) Immobilization using a short leg walking cast a removable short-leg orthotic or a non weight bearing cast is continued for four to six weeks or until symptoms have resolved. The potential for disability following a Lisfranc joint injury justifies the use of a non-weight bearing cast. Re-injury Prevention Instruction Instruct patient of proper application of non-weight bearing orthotic Crutch training if necessary to facilitate non-weight bearing ambulation

Sub Acute Stage / Moderate Condition Goals: Decrease and eliminate pain Increase pain free range of motion Limit loss of strength and proprioception Approaches / Strategies listed above plus Manual Therapy Joint mobilization of adjacent hypomobile carpal articulation being careful to not strain the involved, potentially unstable and healing tarsometatarsal articulations External Devices (Taping/Splinting/Orthotics) Midfoot taping and orthotics can be used for support with weight bearing activities Therapeutic Exercises Stretching foot, ankle, and lower extremities primarily calf musculature Progress from passive range of motion to active range of motion exercises in dorsiflexion, plantarflexion, inversion, eversion in pain free ranges-add resistance as tolerated Initiate proprioceptive exercises, such as weight bearing on effected foot, seated BAPS board.

Settled Stage / Mild Condition Goals: Regain full pain-free motion Regain normal strength Regain normal proprioception Approaches and strategies listed above plus

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Therapeutic Exercises Gradual return to sport or occupational activities through use of functional progression, such as activity-specific exercise. For example: Running in pool or de-loaded on a treadmill Swimming Gradual progression of functional activities Standing on toes Pushing off on toes Pain free hopping on both legs progressing to single leg Step up on box or stairs Begin Stairmaster, treadmill, biking Initiate running when fast pace walking is pain free Jump rope Squats

Selected References Arntz CT, Hansen ST Jr. Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clin North Am. 1987;18:105-14. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J. Sports Med. 2001;29:100111. Brown DD, Gumbs RV. Lisfrancs fracture-dislocations: report of two cases. J Natl Med Assoc. 1991;83:366-9. Brunet JA, Wiley JJ. The late results of tarsometatarsal joint injuries. J Bone Joint Surg [Br]. 1987;69:437-40. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med. 1993;21:497-502. Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med. 1995;26:229-33. Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Surg [Am]. 1990;72:1519-22. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al: Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg. 1982;64B:349-356. Heckman JD. Fractures and dislocations of the foot. In: Rockwood CA, Green DP, Bucholz

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6 RD, eds. Rockwood and Greens Fractures in adults. Vol 2. 3d ed. Philadelphia: Lippincott, 1991:2140-51. Kraeger DR. Foot injuries. In: Lillegard WA, Rucker KS, eds. Handbook of sports medicine: a symptom-oriented approach. Boston: Andover Medical, 1993:159-71. Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82-A(11):1609-18. Lawson JP, Ogden JA, Sella E, Barwick KW. The painful accessory navicular. Skeletal Radiology. 1984;12(4):250-62. Mantas JP, Burks RT. Lisfranc injuries in the athlete. Clin Sports Med. 1994;13:719-30. Markowitz HD, Chase M, Whitelaw GP. Isolated injury of the second tarsometatarsal joint. A case report. Clin Orthop. 1989;(248):210-12. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20:655-64. Nunley JA, Vertullo CJ. Classification, investigation and management of midfoot sprains:Lisfranc injuries in athletes. Am J Sports Med. 2002;30:871-878. Requejo SM, Kulig K, Thordarson DB. Management of foot pain associated with accessory bones of the foot: two clinical case reports. J Orthop Sports Physical Ther. 200;30(10):580-9. Trevino SG, Kodros S, Controversies in tarsometatarsal injuries. Orthop Clin North Am. 1995;26:229-38. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. 1993;35:40-5. Wiley JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg [Br]. 1971;53:474-82.

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Osteomyelitis in the Diabetic Foot First and Second Ray Amputation


Surgical Indications and Considerations Anatomical Considerations: Osteomyelitis is an infection which involves the bone marrow, surrounding cortical bone, and the periosteum. It results in delayed healing of wounds, more extensive tissue damage, an increased length of stay in the hospital, and higher mortality rates. In the diabetic/neuropathic foot, the most frequent location of a plantar ulcer is the head of metatarsal I, with the interphalangeal joint of the first toe and the head of metatarsal II occurring almost as frequently. Bacteria can also invade through interdigital cracks, fissures, paronychias, and ingrown toenails. The size of the ulcer does not indicate the extent of necrosis. Osteomyelitis is likely if the ulcer is greater than two centimeters in diameter, greater than three millimeters deep, or probes to bone. Ray resections are more durable and functional that transmetatarsal amputations, and are especially indicated in the patient with diabetes, whose other foot is at risk. No more than two ray resections are recommended to preserve the maximum foot stability. The bases of the metatarsals should be preserved if possible, to avoid instability of the Lisfranc (tarsometatarsal) joint. Pathogenesis: Ulcers in the neuropathic foot usually occur because of trauma, including pressure from weight bearing, poorly fitting shoes, burns, and puncture wounds, due to loss of protective sensation. Injuries incurred with trimming of toenails and calluses can precipitate infection. Combined with an impaired immune response, and poor perfusion, nutrition, and glycemic control, patients with diabetes are at high risk for pathogens to enter a wound and extend to the bone. Autonomic neuropathy contributes to decrease in skin hydration and formation of skin fissures, providing a portal for bacteria. The infection may cause the formation of avascular tissue, which forms an area for persistent infection. The local infection can lead to gangrene, necrotizing fasciitis, and sepsis. It is usually polymicrobial, with gram-positive cocci being the most common, reportedly 50-70%. Gram-negative bacilli are increasing, up to 50%. Epidemiology: Approximately 25% (16 million) of Americans with diabetes will have foot problems. 90% will have no infection with early intervention. 15% will have amputations, 5% of which will be major amputations. 85% of lower extremity amputations are preceded by foot ulcers. 68% of diabetic ulcers lead to osteomyelitis, many of which are asymptomatic. Of the hospital admissions for diabetes, 20% are for osteomyelitis in the foot. Drug resistant organisms (MRSA, VRSA) have increased the incidence, with long-term sequelae and morbidity. Ray amputations are the second most common amputation of the foot, next to toe amputations. Diagnosis Clinical suspicion Chronic wound must have careful history and thorough physical exam the wound may not have the normal signs and symptoms of infection Patient can have: pain (rarely), edema, erythema, induration, tenderness, draining

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2 sinus tract, venous insufficiency, impaired range of motion, loss of sensory perception Any exposed joint capsule or bone should be assessed for osteomyelitis Sausage toe with pain and swelling only is a clinical sign with sensitivity and specificity Fetid foot foul smelling wound drainage probably anaerobic Any ulcer that probes to bone is 100% predictive as osteomyelitis Ulcer diameter greater than two centimeters: 94% predictive Ulcer inflammation: 77% predictive

Lab tests Gold standard is aerobic, anaerobic, fungal, and Acid Fast Bacillus bone culture of biopsy under direct vision during surgery Percutaneous needle biopsy under ultrasound or radiologic guidance culture multiple specimens Swab culture of the sinus tract usually is not accurate Blood cultures positive only 50-80% of cases, only in acute stages, rarely in adults WBC elevated only in early stages Erythrocyte sedimentation greater 70 mm/hour with noninflammed ulcer: 100% predictive Check for hyperglycemia people with diabetes may have normal temperature and blood studies Imaging studies Plain films will show soft tissue swelling and bone erosion in about two weeks, with periosteal reaction about four weeks later Three phase bone scan, radionuclide skeletal imaging, is gold standard; wide availability, documented sensitivity; detects early stage of disease and identifies multiple areas; specificity is low MR is equally sensitive, more specific; T1 has decreased signal intensity of bone marrow, T2 is increased, as is STIR(short tau inversion recovery); MR has good differentiation from bone tumor and infarction; useful in planning surgery CT can be helpful Often pathologic fractures with people with diabetes with osteomyelitis, especially the distal first or proximal second toe phalanges, with no history of trauma. Differential diagnosis Charcot requires clinical observations and lab tests Must have wound to allow bacteria to penetrate to infect the bone Recalcification is not present on radiograph RSD Simple fractures Diabetic osteopathy no wound, pointed distal metatarsal peppermint stick sign on radiograph - no surgery needed; if only clinical findings, then need biopsy

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Nonoperative Versus Operative Management: In the acute or initial stages of osteomyelitis in the diabetic foot, IV antibiotics are mandatory and it is precluded that coverage is in effect before any advanced wound management is initiated by the physical therapist. This plan often can be effective, at least in postponing surgical intervention. Irrigation and debridement with pulsatile lavage with suction (PLWS), sharp debridement, topical antimicrobials for short term (about two weeks) for surface bacteriostasis, advanced wound dressings (including living skin equivalents) to provide a moist wound healing environment, negative pressure wound therapy (NPWT), and off-loading are strategies for wound management. Infection control measures are of paramount importance, employing standard precautions, including hand washing and proper Personal Protective Equipment (PPE), especially with the spread of drug resistant organisms. Systemic hyperbaric oxygen therapy (HBO) has a lethal effect on strict anaerobic and some aerobic organisms, and has been shown to stimulate granulation, as has electrical stimulation (ES). They are somewhat controversial, as it is important not to close off any tracts. Whirlpool is contraindicated for neuropathic feet, as is any type of heat, to avoid burns, maceration, and further infection. Cytotoxic agents should not be used. Physical therapy also includes exercises for range of motion (ROM), strength, and circulation. Glycemic control and optimization of nutritional status must be gained. If ischemia is present operative intervention is necessary for revascularization of the lower extremity to improve large vessel perfusion. Systemic antibiotics, IV and oral, are necessary for six weeks to six months, until the wound cultures are negative. In acute osteomyelitis sequential, high dose IV antibiotics can decrease the role of surgery. Response can be evaluated by monitoring the C-reactive protein level, often decreasing the duration to three to four weeks. The choice of antibiotics is determined by specimen cultures or stains, obtained by aspiration, needle biopsy, or swab. Also taken into consideration is the age and health status of the patient, the site of the infection, local sensitivity patterns, systemic toxicity, drug allergies, and any previous antimicrobial therapy. Initial coverage is broad spectrum, with specific antibiotics when the organism(s) is identified. With fluoroquinolones, photosensitivity is produced, and the risk is present of tendinopathy, especially of the Achilles, with possible rupture. Surgical Procedure: If osteomyelitis spreads to a joint, it is considered an orthopedic emergency. Articular cartilage can be damaged in just hours. Surgical debridement includes removing all overlying callous, sinus tracts, infected granulation tissue, dead tendon, exposed cartilage, bursal tissue, and all soft bone to bleeding cancellous and firm cortical bone. All purulent exudate should be drained, and the wound left open for delayed primary closure, to allow for inspection and further debridement if needed. If osteomyelitis involves the entire toe, the ray should be resected: the digit plus the head and shaft of the corresponding metatarsal (MT). Removal of the first ray is devastating to both stance and gait, as an intact medial column is essential to proper forward progression. It is valuable to try to save most of the MT shaft, especially the proximal portion to minimize pronation abnormalities. If the entire MT has to be amputated and the tibialis anterior tendon is not damaged, it should be reattached to the medial cuneiform. Loss of the anterior tibialis will

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4 result not only in pronation of the foot, but will transfer excessive pressure to the MT II head, which will lead to breakdown. If the second toe is involved, it is wise to remove MT II at its proximal metaphysic along with the toe, to preserve cosmesis and function (avoid valgus). The distal toes should be filleted to create additional soft tissue for closure. The wound should be closed on the dorsum of the foot, preserving the plantar skin. Sutures should remain intact for three-four weeks due to delayed healing in patients with diabetes, due to impaired nutrition and oxygen delivery at the surgical site, plus tissue ischemia. The inflammatory phase of healing is limited due to abnormal phagocytosis, contributing to edema. Protein metabolism is also abnormal, impairing fibroblastic proliferation, collagen synthesis, and new capillary formation. Future split thickness skin grafts are often necessary for complete wound closure. Preoperative Rehabilitation Physical therapy wound management: PLWS, sharp debridement, possible NPWT, advanced wound dressings Pressure ulcer prevention Off-loading, non-weight bearing (NWB) on affected lower extremity; wheel chair or walker, monitoring for carpal tunnel syndrome, 11% more likely with patients with diabetes. Crutches not advised due to neuropathy. Monitor and protect integumentary integrity of opposite lower extremity Education re: post surgery: gait, diabetic foot inspection, footwear/orthotics, opposite lower extremity inspection and protection, nutrition, glucose control, no smoking If no sepsis, ROM and strengthening exercises; watch for antibiotic reactions, including hypersensitivity; nausea, vomiting, diarrhea (may need to alter time of PT treatment) Ultraviolet (UV) sensitivity, with need to establish an accurate minimal erythemal dose if utilizing UV radiation Social/family support Psychology consult

POSTOPERATIVE REHABILITATION

Note: There is a lack of evidence-based studies to support the rehabilitation interventions of patients with ray amputations, especially those with diabetes following surgery due to osteomyelitis. Research should and must be done with the explosion of new diagnoses of diabetes in the population.

Phase I: Weeks 1-4 Goals: Control edema Accelerate wound healing process

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Eliminate pressure Prevent contractures and loss of strength Eliminate infection Control pain Intervention: Elevation of foot on one pillow if low ABI PLWS, sharp debridement, advanced wound dressings NWB with walker or wheelchair Suspend heel in bed or sitting; therapeutic positioning in bed Active, active assistive, and passive ROM exercises for adjacent joints Achilles tendon stretching; may require surgical lengthening in the future Rest, antibiotics, infection control measures with wound management Pain medications

Phase II: Weeks 4-8 (up to 27: wound closure) Goals: Wound closure Continue to eliminate pressure Increase strength Eliminate infection Intervention: PLWS, sharp debridement, NPWT/advanced wound dressings, ES, growth factors, skin substitutes NWB with walker, wheelchair, or total contact cast (TCC) if infection clears Avoid high intensity exercise to avoid increase in blood pressure, which could cause further damage to retinas and kidneys. Avoid putting head below the waist to prevent further retinal damage Antibiotics Infection control measures with wound management

Phase III: Weeks 8 (or at wound closure) - lifetime Goals: Protect and accommodate remaining portion of foot Equalize weight bearing to protect remaining MT heads from increased pressure (as medial arch can collapse) Minimize drifting of remaining toes Improve gait Restore functional capacity

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Intervention: Consult orthotist, pedorthist, shoemaker patient should never take an unprotected step. Use adaptive and supportive footwear. Soft, moldable upper to protect and accommodate remaining foot Sandals for shower, night trips to bathroom Custom molded shoe or total contact insert with strong medial counter to support the medial arch Roller or rocker bottom shoe with flare and external extended steel shank or internal rigid carbon footplate to protect remaining MT heads and for improved gait by enhancing the loss of toe-off and adding stability to anteroposterior plane. High top shoes may be necessary to prevent the heel from slipping out of the heel counter Heel raise added to shoe to prevent dorsiflexion of the forefoot, with the same raise used on the contralateral shoe Provide shoe filler for amputated portion of foot, including toe fillers No high heels to avoid increased forefoot pressures Expanded toe boxes to accommodate claw toe deformities caused by intrinsic imbalance in remaining toes Exercises to strengthen remaining plantar flexors to increase power in push-off insertions of plantar fascia and flexor hallucis are lost Gait training for ascending/descending stairs

Selected References: Attinger C, Venturi M, Kim K, Ribiero C. Maximizing length and optimizing biomechanics in foot amputations by avoiding cookbook recipes for amputation. Seminars in Vascular Surgery. 2003; 16:44-66. Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. Journal of Diabetes and Its Complications. 1999; 13:254-263. Karchmer AW, Gibbons GW. Foot infection in diabetes: evaluation and management. Current Clinical Topics in Infectious Diseases. 1994; 14:1-22. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clinical Infectious Diseases. 1997; 25:1318-26.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Nehler MR, Whitehill TA, Bowers SO, Jones DN, et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg. 1999; 30:509-17. Paluska SA. Osteomyelitis. Clinics in Family Practice. 2004; 6:127-149. Philbin TM, Leyes M, Sferra JJ, Donley BG. Orthotic and prosthetic devices in partial foot amputations. Foot and Ankle Clinics. 2001; 6:215-228. Snyder RJ, Cohen MM, Sun C, Livingston J. Osteomyelitis in the diabetic patient: diagnosis and treatment. part 2: medical, surgical, and alternative treatments. OstomyWound Management. 2001; 47(3):24-43.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Bunionectomy
Surgical Indications and Considerations Anatomical Considerations: Normal biplanar flexion and extension of the metatarsophalangeal joint is maintained by counterbalance between muscles acting on the first metatarsophalangeal joint. The action of the long and short toe extensors is normally counteracted by the long and short toe flexors, and the abductor hallucis is counterbalanced by the adductor hallucis. Also, no muscle inserts into the metatarsal head. Therefore, once the hallux becomes destabilized and begins to sublux laterally, the muscles, which previously acted to stabilize the joint, become a deforming force since their pull is lateral to the long axis of the metatarsophalangeal joint. Pathogenesis: Bunion is associated with imbalance of the soft tissues and abnormal bony configuration of the first cuneiform/metatarsophalangeal joint complex. As the proximal phalanx moves laterally on the metatarsal head, it exerts pressure against the metatarsal head, pushing it medially. As this occurs, there is progressive attenuation of the medial joint capsule, as well as a progressive contracture of the lateral joint capsule. While this deformity is occurring, the sesamoid sling, which is anchored laterally by the insertion of the adductor hallucis muscle and transverse metatarsal ligament, remains in place, creating pressure on the medial joint capsule. As a result, the abductor hallucis muscle gradually slides beneath the medially deviating metatarsal head. Once the abductor hallucis slides underneath the metatarsal head, two events occur. First, the intrinsic muscles no longer act to stabilize the metatarsophalangeal joint but actually help to enhance the deformity. Second, as the abductor hallucis rotates beneath the metatarsal head, because it is connected to the proximal phalanx, it will spin the proximal phalanx around on its long axis, giving rise to varying degrees of pronation. Hallux valgus occurs due to hereditary and environmental factors. Tends to occur in families with a genetic predisposition for laxity of the ligaments and excessive pronation of the foot (flat feet). What generally causes the problems of pain and deformity result due to improper fitting footwear. Wearing shoes with a narrow toe box (the part of the shoe that surrounds the front part of the foot) squeezes the toes and cause the crowding of the big toe into the other toes. The problem is also caused by wearing high heels that force the body weight forward onto to the toes. Epidemiology: Adult acquired hallux valgus is found most often in women and is commonly associated with long-term wearing of fashionable, narrow box, pointed-toe shoes. According to the study of Lam Sim-Fook and Hodgson, 33% of shod individuals had some degree of hallux valgus, compared with 1.9% of unshod persons. Other associated findings, which may be implicated in the biomechanical cause of hallux valgus, include contracture of the Achilles tendon complex, hypermobility of the first metatarsal-medial cuneiform joint, and pes planus. The static foot posture of pes palnus, however, has not been found to contribute directly to hallux valgus formation. In contrast, the observation of dynamic forefoot pronation has been found to be present in as many as 84% of cases with hallux valgus. Pronation contributes to midtarsal joint (calcaneal-cuboid joint oblique axis) instability, and as a result, midfoot horizontal abduction at terminal stance. This occurance creates insufficient first ray plantarflexion and an inefficient length-tension relationship for proper peroneous longus function in stabilizing the first metatarsal.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Bunions are relatively unknown in non shoe wearing populations. It is suggested that between 30 to 50% of the people in show wearing populations have some degree of hallux valgus. According to the American Orthopedic Foot and Ankle Society, bunions are nine times more likely to be seen in women than men. This is probably due to ill fitting shoes with a narrow toe box and high heels. Feet naturally widen as we age so bunions do not generally become a problem until middle age. Diagnosis: A diagnosis of hallux valgus can usually be made based upon appearance of the big toe. The symptoms can include; Red, calloused skin at the base of the big toe A bursa or bony bump at the base of the first metatarsal Pain at the MTP joint aggravated by pressure from shoes Big toe turned toward the other toes.

Associated findings can include; Second digit hammertoe Callous on the bottom of the foot Pronated foot Ingrown toenail Radiographic findings include; Medial prominence of the first metatarsal head + or joint space abnormality increased HVA increased IMA lateral displacement of the sesamoids Differential diagnosis includes; Hallux rigidus which presents a distinguishing distal osteophyte on radiograph Hallux arthrosis which presents with loss of the entire joint space on radiograph Gout presents as an acute condition with laboratory tests indicating elevated uric acid and sodium urate crystals.

Diagnosis is further determined by severity. Severity is based upon the HVA and IMA and joint deviation. Stage 1 or mild hallux valgus indicates a HVA < 25 degrees, IMA of < 12 degrees Stage 2 or moderate hallux valgus indicates a HVA of > 25 degrees, IMA of < 16 degrees Stage 3 or severe hallux valgus indicates a HVA of > 35 degrees, IMA of > 16 degrees

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Nonoperative Versus Operative Management: Most bunions do not require surgery. Those that do end with surgical interventions produce debilitating pain or deformity that is not relieved with conservative measures. Because most pain is produced during gait, patients limit their activity which can lead to secondary problems of general deconditioning. Conservative measures usually begin with patient education regarding appropriate footwear. Wide, low heeled shoes such as athletic shoe, soft leather shoes or sandals are recommended. Protect the bunion with moleskin or gel filled pads. Over the counter or prescribed nonsteroidal anti-inflammatory medications may relieve the inflammation and subsequent pain. Semi soft orthotics can be inserted into the shoe to help position the foot properly. Night splints can hold the toe straight. Physical therapy can also be recommended with exercise instruction, stretching, taping, application of modalities as well as education as to prevention. If these conservative measures are not successful the patient should seek medical consultation for surgical bunionectomy. Surgical Procedure: There are over 100 surgical procedures for bunionectomy or osteotomy and the procedure is determined based upon the severity of the hallux valgus as well as the patients age, health, and activity level. The goals of surgery are to remove the bump. realign the joint, relieve the pain and restore normal function particularly during gait. The goal is not to fit the patient into stylish shoes with a narrow toe box. In fact the surgery is not for cosmetic reasons. Usually bunionectomy is performed as an outpatient procedure. However as the procedure becomes more complicated, hospital stay may involve 1 to 3 days. Simple surgical removal of the medial eminence can be performed if the primary complaint is a prominent medial eminence, the deformity is mild, and rapid recovery is desirable. Distal metatarsal osteotomy such as a chevron osteotomy is performed for mild-to-moderate deformity in a young person with no degenerative joint disease. This procedure affords limited realignment by lateral displacement of the head of the first metatarsal, removal of the medial prominence, and plication of the medial capsule. For a more extensive deformity, the distal soft tissue procedure, which is a modification of the procedure originally described by McBride, is performed. Its major components are: 1) release of lateral metatarsophalangeal joint capsule, adductor hallucis tendon, and contractures about the lateral sesamoid. 2) removal of medial eminence of the metatarsal head and realignment of the sesamoid sling. 3) Osteotomy at the base of the first metatarsal. Arthrodesis or resection arthroplasty is a choice of procedure if there is severe degenerative joint disease. The Cochrane Library review of evidence from clinical trials showed that about one third of all patients were dissatisfied with the result of surgery even if pain and toe alignment were improved. This may be due to unrealistic expectations of surgery, poor post surgical rehab or a lack of a suitable way to measure patient satisfaction. Also the survey found little evidence to support whether conservative or surgical intervention worked best. Results from a 2001 randomized controlled trial of 209 patients performed by Torkki et al found that pain intensity, number of painful days, cosmetic disturbance and foot wear problems were the least following surgery as compared with the use of orthoses or watchful waiting. Functional status and satisfaction with treatment were also the best in the surgical group. As of 2003, it is estimated that 209,000 people in the United States undergo some type of bunion surgery each year making it one of the most common orthopedic surgeries in western industrialized countries.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Preoperative Rehabilitation Evaluation and recommendation of proper footwear specifically width of toe box. Foot exercises including toe spread, eat the towel, marble pick up, toe raises and toe curls. Stretching of Achilles tendon if indicated Shoe inserts or orthotics Night splints Bunion pads or moleskin Pain relieving modalities such as ice packs, whirlpool, ultrasound and massage. Post op rehab plan instruction in the use of assistive devices if limited or non weight bearing. Post op rehab plan instruction in donning and doffing brace if indicated.

POSTOPERATIVE REAHBILITATION The rehabilitation following surgical intervention is based upon the procedure itself and the physicians determination. Below are some of the procedures and the post op rehab for that procedure. Chevron Osteotomy a gauze and compression dressing is applied in the operating room (OR), changed weekly for a duration of six weeks Kirschner wire is removed three to four weeks post op PROM exercises begun when wires are removed Gait training allowed with weight on the heel and lateral aspect of the foot At 4 weeks plantigrade walking wearing a wooden-soled postoperative shoe. McBride Procedure a gauze and tape compression dressing is applied in the OR and changed weekly for eight weeks Gait training WBAT wearing a postoperative wooden-soled shoe P and AROM exercises allowed six weeks after the surgery Triple Distal Osteotomies Gauze and tape compression dressing Gait training with walker or crutches for NWB below the knee cast. At four weeks, cast changed to allow weight bearing Cast removed in six to eight weeks dependent upon radiographic confirmation of healing ROM exercise initiated when cast is removed Mitchell or Wilson Osteotomy Gauze and tape compression dressing applied in OR

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Gait training NWB with assistive device, cast applied one week after the operation. NWB maintained for 4 weeks. Weight bearing cast applied at 4 weeks Rom begun when cast is removed usually 6 to 8 weeks post op

Keller Excisional arthroplasty Gauze and tape compression dressing, changed weekly for 6 weeks Gait training WBAT with the patient wearing a wooden soled shoe. Kirschner wires removed at 4 weeks then ROM and plantarflexion exercises are begun.

Phase I: Weeks 1-6/8 Goals: Control edema and pain Protect incision site Intervention: Dressing (Ambulation in a postoperative shoe as tolerated if patient had arthrodesis)

Phase II: Week 6/8-12 Goals: Increase range of motion Continue edema control Progressive weight-bearing status Intervention: Passive and active range of motion Contrast bath and manual lymph drainage techniques Grade I joint mobilization Metatarsophalangeal stretch Gastrocsoleus stretch Ambulation as tolerated in postoperative shoe or soft, wide shoe

Phase III: Weeks 12-16 Goals: Full range of motion Normal gait Intervention:

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Strengthening exercises for foot and lower quarter muscular power/control deficits Grade II-IV joint mobilizations performed at end range, as symptoms allow Gait training Orthotics, as needed, to address overproantion and/or intrinsic foot deformities, which may contribute to impaired healing and/or reocurance of hallux valgus.

Selected References: Ayub A, Yale S, Bibbo C. Common Foot disorders. Clinical Medicine and Research. 2005;Vol.3No2:116-119. Brotzman S, Wilk K Clinical Orthopedic Rehabilitation, Philadelphia, Mosby Second edition, 2003, p. 424. Clinical Practice Guideline First Metatarsophalangela Joint Disorders Panel. Diagnosis and treatmnet of first metatarsophalangels joint disorders. J Foot Ankle Surg. 2003 mayJune;42(3):112-54. Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. St. Louis, Mosby, 1999. Coughlin MJ: Roger A Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995;16:682. Donatelli RA. The Biomechanics of the Foot and Ankle. 2nd ed. Philadelphia, F.A.Davis Company, 1996. Donnery J, Dibacco RD. Postsurgical rehabilitation exercises for hallux abducto valgus repair. J Am Podiatr Med Assoc. 1990;80:410-413. Eustace S, Byrne JO, Beausang O, et al: Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch a radiological correlation. Skeletal Radiol. 1994;23:191. Fink B, Mizel M. Whats New in Foot and Ankle Surgery. The Journal of Bone and Joint Surgery. 2002;84(3):504-509. Radl R, Kastner N, Aigner C, Portugaller H, Schreyer H, Windhager R. Venous Thrombosis After Hallux Valgus Surgery. The Journal of Bone and Joint Surgery. 2003;85:1204-1208. Sargas NP, Becker PJ: Comparitive radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int. 1995; 16:139. Smith A. Easy Exercises for Preventing Bunions. Medical Update 2001;Vol27 Issue 5. Torkki M, Malmivaara A, Seitsalo S, Hoikka V, Laippala P, Paavolainen P. JAMA. 2001;285:2474-2480.

Joe Godges PT, Robert Klingman PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Red Flags for Potential Serious Conditions in Patients with Elbow, Wrist, or Hand Problems
Red Flags for the Elbow, Wrist, and Hand Region Red Flag Red Flag Data obtained during Data obtained during Interview/History Physical Exam
History of trauma, surgery or extreme unaccustomed activity Persistent forearm pain and tightness Tingling, burning, or numbness Recent cut, scrap, or puncture wound, such as a human or animal bite Typical symptoms of infection and inflammation Laceration in area of tendon Forceful flexor contraction History or fall on hand or strain Generalized wrist pain History of fall on outstretched hand Prevalent in males aged 15-30 and females with osteoporosis Fall onto outstretched arm with forceful wrist extension Young male or older female History of fall on outstretched hand Palpable tenderness and tension of involved compartment Pain intensified with stretch to involved muscles Paresthesia, paresis, and sensory deficits Diminished pulse and prolonged capillary refill Kanavel cardinal signs: 1) flexed posture of the digit, 2) uniform swelling of the digit, 3) tenderness over the length of the involved tendon sheath, and 4) severe pain on attempted hyperextension of the digit Loss of isolated DIP or PIP active flexion Possible palpable defect in involved muscle Pain at end ranges of wrist extension Decreased grip strength/pain with grasping objects Swelling, bruising around wrist Tenderness over anatomical snuff box/scaphoid tubercle Increased pain with gripping Wrist swelling Wrist held in neutral resting position Movements into wrist extension are painful Elbow joint effusion - arm held in loose packed position Restricted/painful supination & pronation AROM Tenderness over radial head kin pallor, cyanosis, and/or hyperemic erythema of the Positive family history fingers Women on estrogen therapy Taking medication promoting vasoconstriction such as BCold exposure/frostbite injury blockers, amphetamines, decongestants, and caffeine Underlying collagen vascular disease History of trauma or surgery Area swollen (pitting edema), warm, and erythmatous Severe burning/boring/aching pain out Temperature difference between involved and uninvolved of proportion to the inciting event extremity, hot or cold Pain not responsive to typical analgesics Secondary hyperalgesia/hypersensitivity History of cancer Asymmetric or irregular shape lesion Female < 40 years of age Borders are notched, scalloped or vaguely defined Male >40 years of age Color uneven distributed or defined Fair skin, history of sunburns Diameter >6mm

Condition
Compartment Syndrome1,2

Space Infection of the Hand3

Long Flexor Tendon Rupture4 Lunate Fracture or Dislocation4 Scaphoid Fracture5,6

Distal Radius (Colles) Fracture Radial Head Fracture7

Raynauds Phenomenon8
Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)9,10 Melanoma11

References: 1. Harvey C. Compartment syndrome: when it is least expected. Orthop Nurs. 2001;20(3):15-23. 2. Jawed S, Jawad AS, Padhiar N, Perry JD. Chronic exertional compartment syndrome of the forearms secondary to weight training. Rheumatology 2001;40:344-345. 3. Weinzweig N, Gonzalez M. Surgical infections of the hand and upper extremity: a county hospital experience. Ann Plast Surg. 2002 49;621-7. 4. Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby,. 2002. 5. Phillips TG, Reibach AM, Slomiany WP, Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70:879-884. 6. Bhowal B, Dias JJ, Wildin CJ. The incidence of simultaneous fractures of the scaphoid and radial head. J Hand Surg. 2001;26B:25-27. 7. Major N, Crawford S. Elbow effusion in trauma in adults and children: is there an occult fracture? Am J Radiology. 2002;178:413-418. 8. Bloack J, Sequeira W. Raynauds phenomenon. Lancet. 2001;357:9237. 9. Ciccone DS, Bandilla EB, WU. Psychological dysfunction in patients with RSD. Pain. 1997;71:323-33. 10. Veldman HJM, Reynen HM, Arnitz IE, Goris RJA. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993;343:1012-1016. 11. American Cancer Society, What are the key statistics for melanoma? Revised 04-2004. http://www.cancer.org/docroot/CRI2-4-1X

Joe Godges DPT

KP So Cal Ortho PT Residency

ELBOW, WRIST, HAND SCREENING QUESTIONNAIRE


NAME: ________________________________________ Medical Record #: _________________________ Yes 1. Have you recently had a trauma, such as a fall unto your hand? 2. Have you recently had a surgery for your neck, shoulder or arm? 3. Do you have numbness or tingling in your hands? 4. Has a doctor ever told you that you have osteoporosis (brittle bones)? 5. Have you recently had a sore, cut, scrape, or puncture wound, such as a human or animal bite? 6. Have you recently had an infection? 7. Have you recently or do you now have a fever? 8. Have you noticed an inability to move your wrist or elbow normally? 9. Do your easily hands or feet turn white or become painful when cold? 10. Have you noticed any newly formed or irregular moles on your body? 11. When you have pain, does it respond to pain medication? No DATE: _____________

Joe Godges DPT

KP So Cal Ortho PT Residency

Elbow Mobility Deficits ICD-9-CM code: ICF codes: 812.40 Ulnohumeral Capsulitis

Activities and Participation codes: d4300 Lifting, d4452 Reaching Body Structure code: s73001 Elbow joint Body Functions code: b7101 Mobility of a several joints

Common Historical Findings: Trauma (e.g., fracture) Stiffness following immobilization and healing Pain at end ranges of flexion and/or extension Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restriction: Limited elbow flexion and/or extension ROM (usually more limited in flexion) Pain at end ranges Limited ulnohumeral accessory motions

Physical Examination Procedures:

Elbow Accessory Movement Test Ulnar Distraction

Elbow Accessory Movement Test Ulnar Distraction

Performance Cues: Stabilize humerus at humeral shaft; or at lateral epicondyle Distract ulna from humerus using finger pads; or use hypothenar and thenar eminence with a flexed wrist

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Elbow Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies


The below description is consistent with descriptions of clinical patterns associated with the vernacular term Ulnohumeral Capsulitis

Description: Pain and stiffness in the elbow. The pain is most noticeable at the end ranges of flexion or extension movements, such as carrying a heavy object with the arm hanging or while attempting to dress, groom, or eat. Etiology: Inflammation of the ulnohumeral capsule leads to increased fibrinogenesis of the collagen tissue that forms the capsule eventually leading to capsular adhesions if the capsule is immobilized, such as following a trauma (e.g., fracture ) and subsequent casting and/or splinting.

Acute Stage / Severe Condition: Physical Examination Findings (Key Impairments) ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints Limited elbow flexion and extension ROM usually flexion limitation of motion is greater than the extension motion limitation Pain at end ranges of active and passive movements Limited ulnohumeral accessory motions Restricted myofascia especially the one-joint elbow flexors and extensors (brachialis and short head of the triceps) Pain with palpation of the ulnohumeral joint

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints As above, except: Resisted tests reveal strength deficits especially if the elbow has been immobilized for an extended period of time

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints As above, except: Mild pain at end ranges of flexion and/or extension

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention Approaches / Strategies

Acute Stage / Severe Condition Goals: Reduce pain with elbow flexion and extension Increase elbow range of motion Increase elbow function Physical Agents Ice packs Utrasound Therapeutic Exercises Gentle passive range of motion stretching Re-injury Prevention Instruction Rest/relaxation to reduce pain

Sub Acute Stage / Moderate Condition Goals: Improve flexibility of the involved extremity Improve strength of the involved extremity Approaches / Strategies listed above Manual Therapy Soft tissue mobilization to the restricted myofascia (e.g., the brachialis myofascia) Joint mobilization to the restricted ulnohumeral accessory movements including mobilization with movement Therapeutic Exercises Gentle, prolonged PROM and AROM stretching Initiate strengthening program to the tolerance of the patient External Devices (Taping/Splinting/Orthotics) Apply preventive brace in elbow if reinjury a potential fear.

Settled Stage / Mild Condition Goals: Restore normal flexibility of the involved extremity Restore normal strength of the involved extremity Improve tolerance with participating in function activities of involved extremity
Cuong Pho DPT, Joe Godges DPT Loma Linda U DPT Program KPSoCal Ortho PT Residency

Approaches / Strategies listed above

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: As above Return to optimum level of patient function Approaches / Strategies listed above

Selected References Bonutti PM et al. Static progressive stretch to reestablish elbow rang of motion. Clinical Orthop. 1994;303:128-34. Bruce G et al. Elbow pain. Primary Care 1988 Dec:15 (4):725-35 Byl NN et al, et al. Effects of phonophoresis with corticosteroids: A controlled pilot study. J of Orthop Sports Phys Ther 1993 Nov: 8(5):590-600 Chumbley EM et al. Evaluation of overuse elbow injuries. American Family Physician 2000 Feb:61(3):691 Davila SA et al. Managing the Stiff Elbow: Operative, Nonoperative, and Postoperative Techniques. J Hand Ther 2006;19:268-81. Kaltsas DS. Comparative study of the properties of the shoulder joint capsule with those of other joint capsules. Clin Orthop Mar 1983: 173:20-6 King GJ, Faber KJ. Posttraumatic elbow stiffness. Orthop Clin North Am 2000 Jan;31(1):129-43 Klaiman MD, et al. Phonophoresis vs ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exer 1998 Sep:30(9):1349-55 Leo KC et al. Effect of TENS characteristics on clinical pain. Phys Ther 1986 Feb 66(2):200-5 Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Phys Ther. 1984;64:330-333. Marti RK. Progressive surgical release of a post traumatic stiff elbow. Acta Irthop Scand 2002 73(2):144-50 Nielsen KK, Olsen BS, No stabilizing effect of the elbow joint capsule; Acta Orthop Scand 1999; 70 (1):6-8

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983;64:29-33. Wing GJ, Faber KJ. Posttraumatic elbow stiffness. Orthop Clin of North Am, 2000 Jan 31(1):129-43

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Limited and Painful Elbow Flexion

Elbow Flexion MWM Cues: Position patient sitting on the edge of a raised treatment table Stabilize the lateral side of the distal humerus with one hand Laterally glide the ulna (and radius) using the thenar eminence or 2nd metacarpal head of the other hand Use a pad to limit ulnar nerve discomfort Sustain the lateral glide as the patient actively flexes his/her elbow Alter the amplitude and direction of the lateral glide to achieve painfree active flexion If indicated, the patient can use his/her uninvolved hand to apply passive overpressure at the end range of available active flexion The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 85-87, 1995

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Limited Elbow Extension or Flexion Limited Ulnar Distraction (at the humeroulnar joint)

Ulnar Distraction Cues: Stabilize the humerus via thenar eminence pressure on the lateral epicondyle use distal thigh to help stabilize the forearm Contact the ulna with the volar surface of a flexed wrist and provide the ulnar distraction Counter the distraction with equal and opposite pressure on the lateral epicondyle To improve extension - apply the distraction near the end of available extension ROM To improve flexion - apply the distraction near the end of available flexion ROM Generate the stabilizing and mobilizing forces using trunk rotation

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Limited and Painful Elbow Extension

Elbow Extension MWM Cues: Position patient lying supine Stabilize the humerus Laterally glide the ulna using a belt Sustain the lateral glide while the patient actively extends his/her elbow Make sure that the belt is long enough to allow for the therapists forearms to provide a stabilization/lateral glide force at nearly perpendicular to the humerus and ulna Due to the elbows carrying angle, the direction of lateral glide will likely need to be altered as the elbow extends Provide passive overpressure, if indicated, at the end of available active extension The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 85-87, 1995

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

ICD-9-CM code: ICF codes:

813.00

Proximal Radioulnar Capsulitis

Activities and Participation codes: d4453 Turning or twisting the hands or arms Body Structure code: s73001 Elbow joint Body Functions code: b7101 Mobility of a several joints

Common Historical Findings: Trauma (e.g., contusion, dislocation) Stiffness following immobilization, and healing Pain at end range of supination and/or pronation Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Limited forearm supination and/or pronation Pain at end range(s) of limited motion(s) Limited radioulnar accessory movements Physical Examination Procedures:

Radioulnar Accessory Movement Test Radial Posterior Glide

Radioulnar Accessory Movement Test Radial Anterior Glide

Performance Cues: Stabilize ulna, mobilize radius Modify the procedures to adapt to the patient who has co-occurring elbow extension ROM deficits Determine amount of accessory motion and symptom response - compare with uninvolved side

Radioulnar Accessory Movement Test Radial Distraction Performance Cues: Stabilize humerus - which stabilizes ulna via the olecranon fossa - pull radius, in line with the shaft of the radius - away from the humerus
Cuong Pho DPT, Joe Godges DPT Loma Linda U DPT Program KPSoCal Ortho PT Residency

10

Use a golfers grip on the radius This procedure also assesses accessory movement at the radiohumeral joint Determine availability of motion and symptom response - compare with uninvolved side

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11

Elbow Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies


The below description is consistent with descriptions of clinical patterns associated with the vernacular term Radiohumeral Capsulitis

Description: Pain at end range of forearm supination and/or pronation that limits function. Etiology: Trauma (e.g., contusion, dislocation ) and the resultant inflammation, immobilization, and tissue healing commonly lead to elbow and forearm stiffness Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints Swelling around the proximal radioulnar joint may be present Limited forearm supination and/or pronation active and passive mobility Pain at end range of limited motion Limited radioulnar accessory movements Tenderness to palpation of the proximal radioulnar joint

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints As above, except: Resisted testing reveals weakness of the forearm supinators and pronators

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints As above, except: Mild pain at end range of with overpressure of supination and/or pronation motions

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Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain in forearm supination and pronation Decreased swelling Increased range of motion and functional ability Physical Agents Cool packs Iontophoresis Ultrasound Manual Therapy Joint mobilization of the proximal radioulnar joint (radial posterior and anterior glides) Therapeutic Exercises Gentle (painfree) supination and pronation mobility/stretching exercises

Sub Acute Stage / Moderate Condition Goals: Achieve normal range of motion Restore normal strength and extensibility of involved extremity Manual Therapy Progress intensity of the joint mobilization procedures including mobilizations with movements Soft tissue mobilization to myofascial restrictions of the elbow and forearm region Therapeutic Exercises Progress intensity of stretching procedures Provide strengthening exercises for weak elbow and forearm muscles

Settled Stage / Mild Condition Goal: Return to unlimited performance of functional activities of involved extremity Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises

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Intervention for High Performance /High Demand Functioning in Workers or Athletes Goals: Return to optimal performance of desired activities Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises including exercises/activities that challenge the patient with work related or sport specific demands regarding strength, flexibility, and endurance.

Selected References Davila SA et al. Managing the Stiff Elbow: Operative, Nonoperative, and Postoperative Techniques. J Hand Ther 2006;19:268-81. Kaltenborn F. Manual Mobilization of the Extremity Joints. 1989, 4th edition, p31, 91-93. Kisner C, Colby L. Therapeutic Exercise Foundation and Techniques. 1996;p211,237-39. Wilks K, Arrigo C, Andrews J. Rehabilitation of the elbow in the throwing athlete. J Orthop Sports Phys Ther. 1993; vol 17, no 6, p305-316. Wong K, Elbow Rehabilitation. In Godges J, Deyle G, eds. Upper Quadrant: Evidence-Based Description of Clinical Practice. Orthopaedic Physical Therapy Clinics of North America, Vol. 8(1). March 1999.

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Impairment:

Limited and/or Painful Forearm Pronation

Forearm Pronation MWM Cues: Stabilize the distal radius Anteriorly or posteriorly glide the distal ulna (which ever is painless) Sustain the glide while the patient actively pronates his/her wrist Alter the amplitude and direction of the glide to achieve painfree active pronation Apply overpressure, if indicated, at the end of active pronation The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 84-84, 1995

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Impairment:

Limited Forearm Pronation Limited Radial Posterior Glide (at the superior radioulnar joint)

Radial Posterior Glide Cues: With the patient supine, stabilize (and pad) the ulna against the table Glide the radius posteriorly Use folded towels as a bolster at the wrist if the patient also has limited elbow extension The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 93, 1989

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Impairment:

Limited Forearm Supination Limited Radial Anterior Glide (at the superior radioulnar joint)

Radial Anterior Glide Cues: Position the patient prone with the involved forearm just off the edge of the table Stabilize (and pad) the humerus and ulna against the edge of the table Glide the proximal radius anteriorly - using a dummy thumb over the region of the radial head and under a thenar eminence

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Loma Linda U DPT Program

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1 Elbow Muscle Power Deficits ICD-9-CM code: ICF codes: 726.32 Lateral epicondylitis

Activities and Participation code: d4300 Lifting, d4452 Reaching, d4401 Grasping Body Structure code: s73012 Muscles of forearm Body Functions code: b7300 Power of isolated muscles and muscle groups

Common Historical Findings: Unaccustomed repetitive occupational or recreational activity involving gripping objects (e.g., tennis) Lateral elbow and forearm pain with resumption of activity Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Extensor carpi radialis brevis (ECRB) or extensor carpi radialis longus (ECRL): weak and painful Tenderness and reproduction of symptoms with palpation/provocation of ECRB or ECRL (slightly superior to lateral epicondyle) Physical Examination Procedures:

Manual Resistive Test Extensor Carpi Radialis Brevis

Manual Resistive Test Extensor Carpi Radialis Longus

Performance Cues: ECRB inserts into third metacarpal, ECRL inserts onto 2nd metacarpal Isolate ECRB by 1) full flexion of elbow (make ECRL insufficient), 2) ulnarly deviate wrist, and 3) resist 3rd metacarpal

Palpation/Provocation of Extensor Tendons

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Performance Cues:

1 = Lateral epicondyle 2 = ECRB 3 = ECRL

Elbow Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Tennis Elbow

Description: Inflammation of the tendon attaching the common wrist extensors to the lateral epicondyle of the humerus. The pathology most commonly occurs in the extensor carpi radialis brevis musculo-tendinous junction. Etiology: More prevalent in men than women between the age of 40-50 years old. Repetitive wrist and finger extension during occupational and recreational activities constantly stretches the extensor tendon, causing microscopic tears. Thus, the physiological healing process is triggered. Normally, with adequate rest, the initial inflammatory stage subsides rather quickly and tissue repair follows. However, when the normal healing process is repeatedly interrupted by overloading the tissue too early, the tendon remains chronically inflamed and unrepaired. Consequently, the tendon is weakened and becomes vulnerable to more severe tears. Eventually the tendon becomes fibrotic and ruptures due to the lack of extensibility to the tensile force. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power Swelling in the lateral epicondyle region Increased temperature in the lateral epicondyle region Active wrist extension limited by pain Pain with passive wrist flexion, finger flexion, forearm pronation and elbow extension Pain and weakness with resisted wrist extension and 3rd MCP joint extension Tender (symptoms reproduced) with provocatory palpation of the superior-lateral portion of the lateral epicondyle

Settled Stage/ Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.1 MILD impairments of muscle power Mild to no pain with palpation of the lateral epicondyle Full and pain free active wrist extension although mild discomfort may occur at end range Painfree or mild discomfort with full passive wrist flexion, forearm pronation, and finger flexion Mild pain with resisted wrist extension combined with ulna deviation and forearm supination strength is near normal

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3 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain Decrease swelling Restore normal elbow, wrist, and forearm active range of motion Physical Agents Ice packs or ice massage Manual Therapy Soft tissue and joint mobilization to co-existing impairments contributing to the symptoms, such as radial nerve entrapments near the elbow, superior radioulnar joint dysfunction, or C5-C6 segmental motion restrictions Friction massage to soft tissue restrictions in the lateral epicondyle area Therapeutic Exercise Passive and active movements of the the elbow, forearm, wrist and fingers into alternating flexion, extension, supination, pronation, ulnar and radial deviation to gradually regain normal muscle length without triggering overstress to healing tissues External Devices (Taping/Splinting/Orthotics) Consider using a joint counterforce brace to remove the tensile force from the healing tissue and prevent premature overstress Re-injury Prevention Instruction Educate patient to avoid activities that aggravates the elbow pain

Sub Acute / Moderate Condition Goals: Restore normal muscle flexibility in the involved extremity Restore normal strength in the involved extremity Regain prior level of function with minimal discomfort Approaches / Strategies listed above Manual Therapy Friction massage to soft tissue restrictions in the lateral epicondyle area Soft tissue mobilization and manual stretching to shortened forearm myofascia Therapeutic Exercise Passive and active movements of the the elbow, forearm, wrist and fingers into alternating flexion, extension, supination, pronation, ulnar and radial deviation to

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4 gradually regain normal muscle length without triggering overstress to healing tissues Gradual progression of resistive exercises for weak forearm and wrist myofascia Modify exercise difficulty according to patients tolerance using pain as a guide to gage resistance progression. Re-injury Prevention Instruction Avoid long duration of aggressive activities to prevent re-injury. Incorporate regular stretching and rest periods during the days activity Apply ice if the pain returns with activity

Settled Stage / Mild Condition Approaches / Strategies listed above

Intervention for Higher Performance / High Demand Function in Workers or Athletes Goals: Return patient to optimal level of occupational and recreational performance Avoid re-injury Therapeutic Exercise Simulate the similar movement patterns required by the patients job or sports with appropriate number of repetition and resistance to help patient become independent in recognizing the appropriate activity dose for preventing future injuries Emphasize on eccentric and plyometrics exercises, commonly involved in daily activities, to return muscles to its optimal level of performance Ergonomic Instruction Assess patients work environment to decrease risks of re-injury

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References Fedorczyk JM. Tennis Elbow: Blending Basic Science with Clinical Practice. J Hand Ther 2006;19:146-53. Kamien, M. A Rational Management of Tennis Elbow. Sports Medicine 1990;9(3): 173-191. Lundeberg T, Abrahamsson P, Haker E. A comparative Study of continuous Ultrasound, placebo Ultrasound, and rest in epicondylalgia. Scand J Rehab Med 1998;20:99-101. Ollivierre C, Nirschl R. Tennis elbow. Current concepts of treatment and rehabilitation. Sports Medicine 1996 Aug;22(2):133-9. Stanish W, Rubinovich R, Curwin S. Eccetnric Exercise in Chronic Tendinitis. Clin Orthop 1986;208:65-8 van der Windt D, van der Heijden G, van den Berg S, et al. Ultrasound therapy for musculoskeletal disorders: a systemic review Pain 1999;81:257-271. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996;68:6974.

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1 Elbow Movement Coordination Deficits ICD-9-CM code: ICF codes: 841.1 Ulnar collateral ligament sprain

Activities and Participation code: d4401 Grasping, d4451 Pushing, d4452 Reaching, d4454 Throwing Body Structure code: s73013 Ligaments and fasciae of forearm Body Functions code: b7601 Control of complex voluntary movements

Common Historical Findings: Medial elbow pain Blunt trauma or strain to the medial elbow Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Symptoms reproduced with: 1. Valgus stress test 2. Ulna collateral ligament palpation Physical Examination Procedures:

Elbow Valgus Stress Test Performance Cues: Fully supinate forearm Firmly stabilize humerus into internal rotation Determine symptom response and mobility - compare with uninvolved elbow

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2 Elbow Movement Coordination Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Pitchers Elbow

Description: Progressive medial elbow pain, edema, and lost of functional activities. Etiology: The ulnar collateral ligament (UCL) is the major stabilizing factor against valgus stress, especially in 90o of elbow flexion. This structure is vital in helping generate enough varus torque to resist excessive medial elbow tension, lateral joint compression, and posteromedial impingement. With the exception of trauma, UCL injuries are usually associated with the throwing athlete as a consequence of repetitive valgus overload on the elbow joint. Avulsion fracture of the sublime tubercle of the ulna is a potential cause of chronic medial elbow pain in the throwing athlete. Diagnosis of UCL injury has been based on clinical findings of medial joint pain and valgus instability. Pain is localized to the medial side of the elbow, especially during the late cocking or acceleration phases of the throwing motion. The history typically is further characterized by one of three scenarios: (1) an acute pop or sharp pain on the medial aspect of the elbow with the inability to continue to throw; (2) the gradual onset of medial elbow pain over time with throwing; or (3) pain following an episode of throwing with the inability on successive attempts to throw above 50 to75 percent of full function. Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition: Physical Examination Findings (Key Impairments) ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination of complex voluntary movements Complaints of medial elbow pain during throwing can be reproduced by palpation over the anterior band of UCL Complaints of medial elbow pain during throwing can also be reproduced by a valgus stress to elbow with the elbow in 30o of flexion General weakness of the muscles about the elbow secondary to pain this includes the muscles attaching to the medial epicondyle of the elbow the wrist flexor group Patient are unable to throw in this stage Inflammation involving the UCL can secondarily affect the ulnar nerve as it crosses the elbow. Ulnar nerve compression can result from entrapment by thickened or inflamed tissue in the cubital tunnel and by hypertrophied musculature in the brachium and forearm. Symptoms of ulnar nerve irritation are present in over 40 percent of patients with UCL insufficiency

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.2 MODERATE impairment of motor control/coordination of complex voluntary movements As above, except:

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3 Resisted wrist and elbow motions are less painful Possible pain at the lateral elbow due to the compensation of lateral ligament secondary to the UCL laxity The patient may report associated recurrent pain or paresthesia radiating into the ulnar aspect of the forearm, the hand, and the forth and fifth fingers, especially with throwing At this state patients are unable to throw over 50% capacity because of the pain

Settled Stage / Mild Condition: Physical Examinations Finding (Key Impairments) ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of complex voluntary movements As above, except: Pain with resisted motions are minimal Excessive valgus stress can also lead to posteromdial olecranon impingement on the olecranon fossa producing pain, osteophyte and loose body formation. Patients may have symptoms of ulnar never irritation, medial epicondylitis, or symptoms of loose bodies At this state patients are unable to throw over 75% capacity because of the pain

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4 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Reduce inflammation and pain Promote tissue healing Physical Agents Ice packs or ice massage Ultrasound Phonophoresis (with an anti-inflammatory drug such as dexamethasone) Iontophoresis (with an anti-inflammatory drug such as dexamethasone) Therapeutic Exercises Painfree active mobility exercises for wrist and elbow extension and flexion; forearm supination and pronation. Motions that do not create a valgus force at the elbow, such as midrange upper body ergometry, may be indicated if they can be performed without pain Re-injury Prevention Instruction: Rest the joint with avoiding painful movements (e.g., gripping)

Sub Acute Stage / Moderate Condition Goals: Improve flexibility Increase muscular strength and endurance Increase tolerance to perform functional activities Approaches / Strategies listed above Therapeutic Exercises Stretching exercises for muscles with flexibility deficits Strengthening exercises for muscles with strength deficits include wrist, elbow, and shoulder exercise (where deficiencies are noted) Re-injury Prevention Instruction: Initiate gradual return to stressful activities Gradually reintroduce previously painful movements

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Settled Stage / Mild Condition Goals: Improve muscular strength and endurance Maintain and enhance flexibility Gradually return patient to sport or high-level activities Approaches / Strategies listed above Therapeutic Exercises Progress strengthening exercises (emphasize eccentric and concentric exercises) Re-injury Prevention Instruction: Initiate gradual return to sport activity Recommend equipment modifications (e.g., grip size, string tension, playing surface) Emphasize maintenance program Modification of work activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to optimum level of patient function with occupation or sport Approaches / Strategies listed above External Devices (Taping/Splinting/Orthotics) Taping procedures may be used to reduce stress on the UCL during strenuous activities (or to remind the patient to avoid end range stresses) Re-injury Prevention Instruction: Slowly return to 75-100% capacity with sport or occupational activities Modification of work and sport activities as needed

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Loma Linda U DPT Program

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Selected References Andrews JR, Jelsma RD, Joyce ME, Timmerman LA: Open Surgical Procedures for Injuries to the Elbow in Throwers. Operative Techniques in Sport Medicine 4(2): 109-113, 1996 Badia A, Stennett C: Sports-related Injuries of the Elbow. J Hand Ther 2006;19:206-27. Joneston J, Plancher KD, Hawkins RJ: Elbow Injuries to the Throwing Athletes. Clinics in Sports Medicine 15(2): 320-329 Potter HG: Imaging of Posttraumatic and Soft Tissue Dysfunction of the Elbow. Clinical Orthopaedics and Related Research Jan (307): 9-18,2000 Field LD, Savoie FH, Department of Orthopaedic Surgery: Common elbow injuries in sport. Sports Medicine 1998 Sep 26(3): 193-205 Martin SD, Barmgarten TE: Elbow Injuries in the Throwing Athlete: Diagnosis and Arthroscopic Treatment. Operative Techniques in Sports Medicine 4(2): 1000-108, 1996 Mirowitz SA: Ulnar Collateral Ligament injury in baseball pitchers: MR imaging evaluation. Radiology 1992 Nov; 185(2): 573-6 Frank W. Jobe and Neal S. Elattrache: The Elbow and Its Disorders. Morey 2000, pg. 549-555 Conway, J.E., Jobe, F.W., Glousman, R.E., and Pink, M.: Medial instability of the elbow in throwing athletes: Surgical treatment by ulnar collateral ligament repair or reconstruction. J. Bone Joint Surg. 74A: 67, 1992 Freddie H. FU; Marc R. Safran: The Orthopedic Clinics of North America: Elbow problems in the athlete. Sport Medicine (26)3 1995 Wilk KE, Arrigo CA, Andrews JR: J Orthop Sports Phys Ther 17:305, 1993

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Elbow and Forearm Radiating Pain


ICD-9-CM code: 354.1 354.3 354.2 Other lesion of median nerve Lesion of radial nerve Lesion of ulnar nerve

ICF codes:

Activities and Participation Domain code: d4301 Carrying in the hands, d4400 Picking up, d4401 Grasping, d4402 Manipulating Body Structure codes: s73018 Neural structures of forearm Body Functions code: b2804 Radiating pain in a segment or region

Common Historical Findings: Medial elbow and forearm pain: Medial elbow pain Forearm and hand paresthesias Unaccustomed repetitive occupational or recreational activity involving flexion and pronation(e.g., golfing) Lateral elbow and forearm pain: Lateral elbow and forearm pain Paresthesias in forearm and hand Unaccustomed repetitive activity involving gripping or manipulating objects Medial elbow pain: Medial elbow pain Paresthesias in ulnar distribution of forearm and hand Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Medial elbow and forearm pain: Symptoms reproduced with: 1. Median nerve stretch test 2. Palpation/provocation of median nerve entrapment in pronator teres 3. Repeated pronator teres resisted movement tests Lateral elbow and forearm pain: Symptoms reproduced with: 1. Radial nerve stretch test 2. Palpation/provocation of posterior interosseous branch of radial nerve in supinator muscle 3. Repeated supinator resisted movement tests Medial elbow pain: Symptoms reproduced with: 1. Ulnar nerve stretch test 2. Palpation/provocation of ulnar nerve in cubital tunnel area including the arcade of Struthers which is proximal to the elbow

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Loma Linda U DPT Program

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Elbow and Forearm Radiating Pain Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Pronator Teres Syndrome

Description: Vague, aching pain in the volar aspect of the elbow and forearm with accompanying paresthesias and decreased sensation in the thumb, index finger and middle finger, and may exhibit weakness of grip and palpable tenderness of the pronator teres muscle. These symptoms are exacerbated with repetitive use of the elbow flexors and wrist pronators,. Such motions are typified by weight lifting, writing, doing needlepoint, gripping and swinging a golf club, tennis racket, or hammer or repetitive use of a tool, such as turning a screwdriver. Etiology: Unaccustomed repetitive occupational or recreational activity involving flexion and pronation may create an overuse type of tendonitis for the insertion of the pronator teres muscle. Compression or entrapment of the median nerve can occur at the supracondylar process and ligament of Struthers, the aponeurosis of the biceps brachii muscle (lacertus fibrosus), the pronator teres muscle or the flexor digitorum superficialis muscle. Typically the median nerve or its anterior interosseous branch becomes compressed within the cubital fossa or between the superficial and deep heads of the pronator teres muscle. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.3 SEVERE radiating pain in a segment or region A dull aching forearm pain that is provoked with gripping, lifting, and repeated wrist and forearm movements Median nerve stretch test bias of the upper limb tension test reproduces the reported symptoms Passive stretch into wrist and finger extension with the combination, and elbow extension aggravates the patients symptoms Symptoms are provoked with repeated pronator teres resisted movement tests. Exacerbation of pain with resisted forearm pronation followed by elbow extension indicates entrapment at the pronator teres muscle, the most common site of compression Reproduction of pain with resistance to forearm supination with elbow flexed beyond 120 degrees implicates entrapment at the bicipital aponeurosis Pain with resisted middle-finger flexion localizes entrapment to the flexor digitorum superficialis muscle Decreased static two-point and vibratory discrimination in the involved hand, compared with the contralateral hand especially over the thenar eminence Positive Tinels sign may be present at the antecubital fossa.

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Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.2 MODERATE radiating pain in a segment or region As above, except symptoms are less for example, the patient experiences less aching and requires less time for symptom resolution. Symptom reproduction requires a stronger palpatory provocation or more repetitions with repeated resisted tests.

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.1 MILD radiating pain in a segment or region As above, except symptoms are only noted following extensive repetitive activities that use pronator teres contractions or increase compression of the median nerve.

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Restore normal, pain-free use of the involved extremity for non-strenuous activities Immobilization The elbow may be immobilized in 90 degrees of flexion, the forearm in neutral to slight pronation, and the wrist in neutral to slight volar flexion. Physical Agents Ice Electric stimulation Manual Therapy Soft tissue mobilization/stretching to the myofascial restrictions in the pronator teres near the entrapment site of the median nerve Therapeutic Exercises Median nerve mobility exercises in pain-free ranges Re-injury Prevention Instruction / Patient Education Modification of daily activities to reduce compression

NSAIDS may be prescribed for symptomatic relief but have not been shown to alter the course of the impairment. Injection of corticosteroids into the area of the median nerve may be considered as a last non-operative resort with extreme caution to avoid intraneural injection. Pain and weakness that are refractory to two to three months of non-operative therapy should be referred to a hand or orthopedic surgeon for further evaluation, in which case surgery to decompress the median nerve may be required.

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Loma Linda U DPT Program

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4 Sub Acute Stage / Moderate Condition Goal: To restore normal strength and extensibility of the pronator teres Approaches / Strategies listed above Therapeutic Exercises Stretching exercises for tight muscles in the elbow, forearm and wrist Strengthening exercises for weak muscles in the elbow, forearm and wrist (e.g., progressive resistive exercises for the wrist extensors and pronators, grip strengthening exercises Ergonomic Instruction Provide instruction in optimal shoulder and cervical positioning for household and work activities as well as pacing and sufficient breaks in activity where possible.

Settled Stage / Mild Condition Goal: Ability to use arm without symptoms Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises for the elbow, forearm and wrist

Intervention for High Performance /High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or recreational activities Approaches / Strategies listed above Therapeutic Exercises Progress stretching and strengthening exercises for the elbow, forearm and wrist to include sport/job specific training Re-injury Prevention Instruction Adjust the grip size of sport equipment or hand tools Keep wrist at neutral

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Loma Linda U DPT Program

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Selected References Ashworth NL, Marshall SC, Classen, DA. Anterior Interosseous Nerve Syndrome Presenting with Pronator Teres Weakness: A Case Report. Muscle Nerve. 1997;20(12):1591-4 Berlemann U, Al-Momani Z, Hertel R. Exercise-Induced Compartment Syndrome in the FlexorPronator Muscle Group. Am J Phys Med. 1998;26(3):439-441. Gross PT, Tolomeo EA. Proximal Median Neuropathies. Neurol Clin. 1999;17(3):425-45. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders(1996). Chapter 10, The Elbow and Forearm. Izzi J, Dennison D, Noerdlinger M, Dasilva M, Akelman E. Nerve Injuriees of the Elbow, Wrist, and Hand in Athletes. Clin Sports Med. 2001:20(1);203-17 Kuo MH, Leong CP, Cheng YF, Chang HW. Static Wrist Position Associated with Least Median Nerve Compression: sonographic evaluation. Am J Phys Med Rehab. 2001;16(2):13047. Mazurek MT, Shin AY. Upper Extremity Peripheral Nerve Anatomy: Current Concepts and Applications. Clin Orthop. 2001;(383):7-20. Mysiew WJ, Colachis SC. The Pronator Syndrome. Am J Phys Med Rehabil. 1991;70:274-277. Rehak DC. Pronator Syndrome. Clin Sports Med. 2001; 20(3):531-40. Shafshak TS, El-Hinaway YM. The Anterior Interosseous Nerve Latency in the Diagnosis of Severe Carpal Tunnel Syndrome With Unobtainable Median Nerve Distal Conduction. Arch Phys Med Rehabil. 1995;76:471-475. Shah MA, Sotereanos DG. Recognizing and managing compression neuropathies of the elbow. J Musculoskel Med. 1999;16:116-132. Stal M, Hagert CG, Moritz U. Upper Extremity Nerve Inolvement in Swedish Female Machine Milkers. Am J Ind Med. 1998;33(6):551-9. Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorder(1994). Chapter 5, The Elbow. Wong K, Elbow Rehabilitation. In Godges J, Deyle G, eds. Upper Quadrant: Evidence-Based Description of Clinical Practice. Orthopaedic Physical Therapy Clinics of North America, Vol. 8(1). March 1999.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Elbow and Forearm Radiating Pain Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Supinator Syndrome

Description: Lateral elbow and forearm pain with accompaning forearm and hand paresthesias. There may or may not be accompanying wrist extensor or supinator weakness. These symptoms are exaccerbated with repetitive use of the wrist extensors and wrist supinators, such as with gripping objects or swinging a tennis racket or repetitive use of a tool, such turning a screwdriver. Etiology: Unaccustomed repetitive occupational or recreational activity involving gripping or manipulating objects may create an overuse type tendinitis for the insertion of the supinator muscle or the development of trigger points in the supinator muscle. Also, perhaps more common, is that repeated contraction of the supinator produces an irritation of the posterior interosseous branch of the radial nerve as it courses through the supinator. There is also evidence that a prolonged or heavily loaded pronated posture can increase the amount of pressure being placed upon the radial nerve as it travels through the supinator.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.3 SEVERE radiating pain in a segment or region Symptom reproduction with radial nerve upper limb tension test Symptom reproduction with palpation of radial tunnel Limited forearm pronation Limited elbow extension End range pain with pronation with elbow extension Symptoms reproduced with repeated resisted supination Limited radial head posterior glide at the superior radioulnar joint

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.2 MODERATE radiating pain in a segment or region As above, except: Symptoms more difficult to reproduce reproduced with radial nerve upper limb tension tests and repeated supinator resisted movement tests (i.e., require further end range stresses or more repetitions with resisted movements)

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.1 MILD radiating pain in a segment or region

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As above, except: Only mild lateral elbow and forearm pain with repeated supinator resisted movements tests

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain with active forearm movement Improve strength of supinators Physical Agents Iontophoresis with corticosteroid Ultrasound: 0.5 w/cm2 at 3 MHz pulsed at 5:1x 5-7 min TENS for pain control Manual Therapy Soft tissue mobilization to restricted supinator and extensor carpi radialis brevis myofascia, predominantly the myofascia near the radial head and posterior interosseous nerve Therapeutic Exercises Pain free nerve mobility exercises for the radial and posterior interossei nerve Re-injury Prevention Instruction Rest/relaxation to reduce pain Avoid aggravating postures and activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of supinators Improve strength of supinators Approaches / Strategies listed above Manual Therapy Joint mobilization to restore radial anterior glide at the proximal radioulnar joint Therapeutic Exercises Pain free nerve mobility exercises for the radial and posterior interossei nerve Slowly begin progressive resistive exercises for arm and forearm muscles

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Settled Stage / Mild Condition Goal: Maintain or return to optimum level of patient function Approaches / Strategies listed above Re-injury Prevention Instruction Modification of work activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to opimum level of patient function Approaches / Strategies listed above

Selected References Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Phys Ther. 2002;82:1077-1086. Dickerman RD, Stevens QEJ, Cohen AJ, Jaikumar S. Radial tunnel syndrome in an elite power athlete: a case of direct compressive neuropathy. Journal of the Peripheral Nervous System 2002 7:229-232. Drechsler WI, Knarr JF, Snyder-Mackler L. A Comparison of Two Treatment Regimens for Lateral Epicondylitis: A Randomized Trial of Clinical Interventions. Journal of Sport Rehabilitation 1997, 6, 226-234 Kleinrensink GJ, Stockart R, Mulder PG, et al. Upper limb tension tests in the diagnosis of nerve and plexus lesions: anatomical and biomechanical aspects. Clin Biomech (Bristol, Avon). 2001;33:36-41. Lutz FR. Radial Tunnel Syndrome: An etiology of Chronic Lateral Elbow Pain. Journal of Orthopaedic & Sports Physical Therapy. 1991;14(1):14-17. Spinner M. The arcade of Frohse and its relationship to posterior interosseous paralysis. Journal of Bone and Joint Surgery. 1968; 50B:809-812

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9 Cervical Spine and Related Upper Extremity Radiating Pain Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Cubital Tunnel Syndrome

Description: A peripheral compression neuropathy at the cubital tunnel (the posterior medial aspect of the elbow). This syndrome is related to repetitive activities of the elbow. Common symptoms are medial elbow or proximal forearm pain, numbness or tingling in the ring and little finger, loss of dexterity, fatigue, and possible loss of strength. Etiology: Symptoms may arise without any obvious compression areas. Cubital tunnel syndrome may occur due to nerve enlargement or the narrowing of the space that the nerve runs through. Certain occupations that require repetitive elbow flexion and extension, prolonged elbow flexion, or direct compression of the ulnar nerve while leaning on the medial elbow against a hard surface may be at higher risk for the condition. The ulnar nerve may be compressed by muscle hypertrophy, compression by the aponeurosis of flexor carpi ulnaris, adhesions in the cubital tunnel or trauma to the elbow. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.3 SEVERE radiating pain in a segment or region Impaired fuctioning of the ulnar nerve as evidence by one or more of the following findings: Muscle atrophy in hypothenar region Clawing of the ring and little fingers Weak ulnar intrinsic muscles (e.g., 1st dorsal interossei, positive Froments sign) Weak flexor carpi ulnaris and ulnar portion of flexor digitorum profundus muscles Decreased pinch and grip strength Impaired sensation of dorsoulnar portion of the hand Pain primarily in region of elbow that may radiate proximally or distally with active movements Ulnar bias upper limb nerve tension test reproduce the patients symptoms Positive Tinels sign Anterior subluxation of the ulnar nerve at the elbow with elbow flexion Symptom reproduction with palpatory provocation of the cubital tunnel or the arcade of Struthers entrapment site

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b2804.2 MODERATE radiating pain in a segment or region As above the severity of the ulnar nerve entrapment signs may resolve as the inflammation around the cubital tunnel diminishes Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10 ICF Body Functions codes: b2804.1 MILD radiating pain in a segment or region

As above except less severe symptoms are exhibited

Intervention Approaches / Strategies Acute Stage / Severe Condition: Goals: Alleviate pain in medial elbow and forearm Reduce ulnar nerve symptomology Re-injury Prevention Instruction Avoid any aggravating activities or postures, such as repetitive elbow flexion activities and prolonged elbow flexion postures Therapeutic Exercises Nerve mobility exercises for the ulnar nerve at the elbow in the painfree/symptom free ranges. Strengthening exercises for the ulnar nerve muscles found to be weak Note: Caution not to strain or irritate the ulnar nerve during performance of the mobility or strengthening exercises External Devices (Taping/Splinting/Orthotics) A splint to limit elbow flexion and/or wrist extension can be considered if symptoms are severe Elbow pad worn over the posterior medial elbow may be useful in some patients

Sub Acute Stage / Moderate Condition Goal: Restore normal strength and extensibility of involved extremity Approaches / Strategies listed above Manual Therapy Soft tissue mobilization to the myofascial and fascial tissues that may be contributing to the nerve entrapment Therapeutic Exercises Stretching exercises that increase flexibility of forearm muscles, wrist and finger flexors are introduced slowly as tolerated. These exercises can be used as needed as long as symptoms are not increased. Gradually increase the performance of functional activities as tolerated

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11

External Devices (Taping/Splinting/Orthotics) As symptoms subside, splints can be worn only at night Soft elbow pads can be worn during the day to protect the ulnar nerve from direct pressure or trauma and remind patient to maintain an extended elbow and to keep from putting pressure on elbow Ergonomic Instruction Modify relevant work activity (e.g., keyboard operators should type with elbows relatively extended and arms adducted to avoid increased pressure on ulnar the nerve.) Modify jobs that require forceful extension (e.g., hammering, modify activity by starting action from more extended position, decrease number of repetitions, more frequent rest periods, etc.)

Settled Stage / Mild Condition Goal: Restore normal, painfree movements of the involved upper extremity Approaches / Strategies listed above Therapeutic Exercises Instruct in exercises to address the patients specific muscle strength deficits

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: To return to desired occupation or leisure time activities Approaches / Strategies listed above Therapeutic Exercises Encourage participation in regular activities with emphasis on modification of work areas, use of splint and elbow pad as needed to provide relief and protection of ulnar nerve.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

12

Selected References Dellon AL, Hament W, Gittelshon A. Nonoperative management of cubital tunnel syndrome: an 8 year prospective study. Neurology. 1993;43:1673-1677. Idler RS. General principles of patient evaluation and nonoperative management of cubital syndrome. Hand Clin. 1996;12:397-403. McPherson SA, Meals RA. Cubital tunnel syndrome. Orthopedic Clinics of North America. 1992;23:111-123. Sailer SM. The role of splinting and rehabilitation in the treatment of carpal and cubital tunnel syndromes. Hand Clin. 1996;12:223-41. Tetro AM, Pichora DR. Cubital tunnel syndrome and the painful upper extremity. Hand Clin. 1996;12:665-77. Tomberlin JP, Saunders HD. Evaluation, Treatment and Prevention of Musculoskeletal Disorders, 3rd ed. The Saunders Group. 1994.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

SUMMARY OF ELBOW DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES


IMPAIRMENT PATTERN Elbow Mobility Deficits
s/p Fracture of distal humerus Ulnohumeral Capsulitis s/p Fracture of proximal radius and ulna Proximal Radioulnar Capsulitis

HISTORY Trauma (e.g., fracture) Stiff following immobilization Pain w/ end range flexion and/or extension movements with ulnohumeral disorders Pain w/ end range supination and/or pronation movements with radioulnar disorders Lateral elbow and forearm pain Precipitated by unaccustomed activities involving gripping of objects Medial elbow pain with throwing activities or repetitive gripping Blunt trauma or strain to the medial elbow Medial elbow and forearm pain Forearm and hand paresthesias Precipitated by unaccustomed activities involving flexion and pronation Lateral elbow and forearm pain Forearm and hand paresthesias Precipitated by unaccustomed activities involving gripping or manipulating objects Medial elbow pain Paresthesias in ulnar distribution of the forearm and hand Sxs worse with prolonged bent elbow positions

PHYSICAL EXAM Elbow flexion > extension ROM deficits with ulnohumeral involvement Supination/pronation ROM deficits with radioulnar involvement Pain at end of ranges Hypomobile ulnohumeral and/or radioulnar accessory movement tests Symptoms reproduced with: Isometric contraction of ECRB or ECRL Provocation of proximal ECRB or ECRL tendon attachments Symptoms reproduced with: Valgus stress test Ulna collateral ligament palpation/provocation

PT MANAGEMENT Soft Tissue Mobilization (STM) and Joint mobilization Ther Exs (Gentle, prolonged PROM & AROM stretching)

Elbow Muscle Power Deficits


Lateral Epicondylitis Tennis Elbow

Elbow Movement Coordination Deficits


Ulnar collateral ligament sprain Pitchers elbow

Elbow & Forearm Radiating Pain Lesion of median nerve Pronator Teres Syndrome Elbow & Forearm Radiating Pain Lesion of radial nerve Supinator Syndrome

Symptoms reproduced with: Median nerve bias ULTT Provocation of pronator teres entrapment site Repeated pronator teres resisted mvt. tests Symptoms reproduced with: Radial nerve bias ULTT Provocation of supinator entrapment site Repeated supinator resisted movement tests Symptoms reproduced with: Ulnar nerve bias ULTT Provocation of cubital tunnel and/of arcade of Struthers entrapment site

Reduce aggravating activity Physical agents (Ice, US, Phono, Ionto) STM, friction massage, stretching Wrist extensor strengthening P.R.I.C.E. instructions Physical agents (Ice, US, Ionto) Friction massage Wrist flexors and forearm pronator strengthening Reduce aggravating activities STM in area of nerve entrapment Passive and active mobilization for median nerve Reduce aggravating activities STM in area of nerve entrapment Passive and active mobilization for radial nerve Reduce aggravating activities STM in area of nerve entrapment Passive and active mobilization for ulnar nerve

Elbow & Forearm Radiating Pain Lesion of ulnar nerve "Cubital Tunnel Syndrome

Cuong Pho DPT, Joe Godges DPT

KPSoCal Ortho PT Residency

Lateral Epicondylitis Surgical Treatment and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Lateral epicondylitis primarily involves the origin of the extensor carpi radialis brevis, occasionally, the anterior edges of the extensor communis and the underside of the extensor carpi radialis longus and, rarely, the origin of the extensor carpi ulnaris. The extensor carpi radialis brevis muscle lies deep to the longus muscle and superficial to the joint capsule. The annular and collateral ligaments are located beneath and just distal to the origin of the ECRB muscle. Pathogenesis: Lateral epicondylitis, also known as tennis elbow, represents a pathologic condition of the common extensor muscles at their origin on the lateral humeral epicondyle and is characterized by pain in this area. Lateral epicondylitis is directly related to activities that increase the tension and stress of the wrist extensor and supinator group. Repetitive eccentric muscle overload is thought to be a large contributing factor to the development of this condition. It is theorized that repetitive micro trauma leads to a micro tear which repairs itself, through this process also produces fibrosis and granulation tissue. With repetitive micro trauma, the tendon experiences mucoid degeneration and leads to a failure of the tendon over time. The wrist extensor group falls in to the category of tendons that are vulnerable to injury. The tendons have poor vascular supply, wrap around a convex surface, cross more than one joint and are subjected to repetitive stress. In tendons, collagen fibers and primary tendon bundles run parallel courses. In normal tendons, nerves and blood vessels extend through the major connective tissue septa but do not invade the fascicles. On gross examination, the tendon appears firm, taut and tan or beige. In tendonitis, the abnormal tissue can be easily identified from the normal tissue. Examination usually reveals grey, shiny and edematous immatureappearing tissue. This tissue closely resembles scar tissue. Microscopically, the normal tendon fibers are disrupted by fibroblasts and vascular granulation like tissue. This appearance has been described as an angiofibroblastic hyperplasia. Upon surgical or microscopic examination there is usually no evidence of inflammation associated with tennis elbow. The term tendonitis is rapidly changing to tendinosis, to denote the difference between acute inflammatory changes verse a degenerating pathologic process. Epidemiology: Tendonitis of the elbow is the most prevalent elbow injury, with an incidence of 1-3% in the general population and between 30% and 50% in tennis players. The characteristic age of onset is between 35 and 50 years, with a median of 41 years. Lateral epicondylitis is most common in participants of racket sports or in the industrial worker with jobs, which require repetitive and forceful use of the wrists and elbow. It is more common in white males and usually on their dominant side.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Diagnosis: Pain at the lateral elbow Point tenderness in the area of the ECRB tendon, slightly distal to the lateral elbow Pain with forceful gripping Pain with resisted wrist extension with elbow extended Pain with passive wrist flexion, pronation and ulnar deviation with the elbow extended X-Ray: to rule out radiocapitellar arthritis MRI: MR images correlate well with surgical and histological findings of neovascularization and mucoid degeneration

Differential Diagnosis: Neuropathic Radial tunnel syndrome Entrapment of posterior interosseous nerve Entrapment of musculocutaneous nerve Entrapment of median nerve Ulnar entrapment syndrome Inflammatory Radiocapitellar arthritis Synovitis Gouty arthritis Infection Trauma Radial neck fracture Distal humerus fracture Referred pain Cervical radiculopathy Shoulder arthritis Carpal tunnel syndrome Other Medial Epicondylitis Tumor Bone cyst Nonoperative Verse Operative Management: Surgical intervention is usually indicated for patients who have undergone conservative care but still have pain 6 months to a year after initial symptoms. Conservative care consists of activity modification, NSAIDs, counterforce bracing, physical therapy or cortisone injections. Surgery is usually considered for patients who have had 3 or more cortisone injections with minimal success or for patients who present with pain that alters routine daily function. Nonoperative treatment is successful in between 75 to 90% of cases.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 According to the Cochrane Review, presently, there are no published controlled trials of surgery for lateral elbow pain. Without a control group, it is not possible to draw conclusions about the value of this modality of treatment. Surgical Procedure: There are several surgical procedures for the treatment of lateral epicondylitis; including the open procedure, arthroscopic, and percutaneous release. This guideline will focus on the open procedure described by Nirschl and Pettrone, as this is still considered the gold standard procedure. An oblique incision is made just proximal to the lateral epicondyle distally toward the radial head. The extensor aponeurosis is identified and a longitudinal incision is made to visualize the extensor group. The extensor carpi radialis longus is then retracted back to visualize the brevis tendon. The pathologic tissue usually includes the origin of the extensor carpi radialis brevis and less frequently the anterior extensor aponeurosis or extensor longus. The pathologic tissue is then excised. Often osteotome decortication of the exposed lateral epicondyle is performed to enhance blood flow and postoperative healing but recent evidence suggests no benefit to this aspect of the procedure. Preoperative Rehabilitation: Patients are instructed to stay in their immobilizer for the majority of the time for 48 hours after surgery Supine sleeping is encouraged, with pillows to support the elbow Shoulder motions 3-5 times per day On day one, gently finger and wrist motions are allowed for 2-3 minutes 3 times per day

POSTOPERATIVE REHABILITATION

Note: The following guideline is a summary of the guidelines provided by Nirschl, Baker, and Galloway.

Phase I: Days 1-7 Movement of the wrist and fingers for 2 minutes, 3-5x/day Ice and NSAIDs are utilized for pain control The patient is also educated on the signs of wound infection; including excessive swelling, redness, excessive heat, oozing from the incision, a dramatic increase in pain or a fever greater than 100 for more than one day Day 3: Showering is allowed, with bandages off, and gentle pain-free elbow, wrist and shoulder ROM is started. At this point the immobilizer is optional.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase I: Days 7-17 More aggressive ROM is encouraged in and out of the shower Goals for day 17 are 80% of normal elbow ROM The arm can be used for light activity only Ultrasound High Volt Galvanic Stimulation

Phase I: Days 18-21 Sub maximal Isometrics are started The patient begins antigravity wrist flexion, extension, supination and pronation without pain If painful the patient is instructed to utilize a counterforce brace during exercising Once the patient can perform 30 repetitions, without pain, they can progress to a 1-pound weight or light resistance band. All exercises are performed with the elbow bent to 90 and resting on a table or the lower extremity

Phase II: Weeks 3 6 Goals: Pain level less than pre-surgery level Full ROM. Therapeutic exercises: Rotator cuff, elbow and scapular stabilization training with light resistance Aerobic conditioning on a stationary bike or treadmill Light stretching is encouraged at this stage with emphasis on end range and passive overpressure Progressive resistive exercises strengthening wrist flexion, extension, supination/pronation, ulnar and radial deviation. Progress the patient from a flexed and elbow supported elbow to a fully extended and unsupported elbow Pain free grip strengthening with putty or ball Utilize counterforce brace during exercise if pain continues Gentle soft tissue mobilization/massage along and against fiber orientation Consider use of ice after exercise.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Phase III: Weeks 8 12 Begin task specific functional activities Return to sport activities Continue counterforce bracing if needed Continue wrist, elbow, shoulder and scapular strengthening Patient is allowed to return to athletics once their grip strength is normal.

Selected References:

Baker C, Murphy K, Gottlob, C, Curd D. Arthroscopic classification and treatment of lateral epicondylitis: Two-year clinical results. Shoulder and Elbow Surg. 2000;9(6):475-482. Brotzman B, Wilk K. Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby; 2003. Buchbinder R, Green S, Bell S, Barnsley L, Smidt N, Assendelft WJJ. Surgery for Lateral Elbow Pain. Cochrane Database of Systematic Reviews. 2004; Issue2: CD003525. Kraushaar BS, Nirschl RP. Tendonosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical and electron microscopy studies. JBJS Am. 1999,81:259-278. Morrey B, The Elbow and its Disorders. In Nirschl R, Muscle and Tendon Trauma: Tennis Elbow. Philadelphia, PA: WB Saunders; 1993. Smidt N, Assendelft W, Arola H, Malmivaara A, Green S, Buchbinder R, Van der Windt D, Bouter L. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med. 2003; 35 51-62.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Biceps Brachii Tendon Distal Rupture


Surgical Indications and Considerations Anatomical Considerations: The two heads of the biceps merge to form the biceps tendon, which rotates through an arc of approximately 90 degrees to insert on the tuberosity of the radius. Contraction of the biceps brachii muscle produces both flexion and supination of the radius. Pathogenesis: Possible predisposing mechanical, degenerative and vascular factors for distal rupture of the biceps tendon exist. The space available for the biceps tendon between the radial tuberosity and the ulna is significantly decreased in pronation and may squeeze and injure the tendon with forearm rotation. There is a possibility for degeneration in the form of hypertrophic lipping of the radial tuberosity that can be a possible mechanism for shearing of the tendon at its insertion site, which may also predispose it to rupture. There has been identified an area of hypovascularity near the insertion site of the biceps tendon which may limit the natural tendon repair mechanisms. Aside from all of the predisposing factors for biceps tendon repair, the usual cause is as a result of a sudden acute episode. Epidemiology: Complete rupture of the tendon origin of the long head of the biceps is seen much more frequently than distal rupture (96% versus 3%). Rupture is felt to occur as a result of high-energy rapid eccentric overload. Distal biceps tendon rupture is typically seen in males between the age of 40 and 60 years old who are participating in manual labor, athletic endeavors or weight lifting, with the dominant arm being more commonly affected. This age group is susceptible to tendon ruptures because age is correlated with tendon rupture in that tensile properties of connective tissue decrease as age increases. It has been reported that between 30% and 70% of distal biceps tendon ruptures occur in patients during work related accidents and a vast majority of the ruptures are as a result of an extended arm being overstretched by and outside force such as eccentric tension. Diagnosis: There is generally a report of a sudden and unexpected forceful extension against a flexed elbow, or a pop is felt during heavy lifting Flexion and supination of the elbow are reported to be painful and strength is noticed to be decreased in the affected extremity Flexion may be decreased mildly when compared to the unaffected side; however supination power is usually markedly decreased Magnetic resonance imaging (MRI) is not necessary for a complete tendon rupture, but may be a helpful diagnostic tool for the diagnosis of a partial tendon rupture

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Partial Tendon Ruptures: Partial ruptures are not commonly diagnosed clinically and therefore, are rarely treated surgically. Incomplete ruptures or sprains to the biceps tendon that are clinically diagnosed are typically treated with three weeks of immobilization, three weeks of flexion, assisted brace, and activity modification for an additional three weeks. If nonoperative treatment fails, anatomic reattachment to the radial tuberosity through surgery is necessary to regain function. Nonoperative management: Nonoperative management of the distal tendon has been shown to result in approximately a 50% decrease in supination endurance and strength and a 20% to 30% loss in flexion strength. Conservative treatment of distal biceps tendon ruptures results in decreased functional recovery. Surgical Procedure: If surgical intervention is indicated for a patient with a distal biceps tendon rupture, surgical reattachment is most easily performed within the first 2 weeks after injury. Beyond two weeks, scarring and retraction of the biceps tendon may make the procedure much more difficult. The surgical repair involves direct reattachment of the tendon to the radial tuberosity, which is the anatomic insertion point for the biceps tendon. Reattachment of the tendon may be accomplished through a single anterior incision or by a two-incision method with tendon retrieval by way of the anterior incision and reattachment through the posterior incision. Overall the two-incision method is the most widely used for surgical exposure of the radial tuberosity; however the single incision approach is being seen more frequently. Suture anchors are becoming the popular method for attachment of the tendon to the cortical bone of the radial tuberosity. Postoperative Rehabilitation: A near normal return of supination and flexion power and endurance has been noted in patients who have undergone tendon repair using a two-incision technique. Postoperative activities are dictated by the strength of the initial repair and tendon to bone healing. Results post-surgery are typically excellent, with near full recovery of both strength and function to the patient POSTOPERATIVE REHABILITATION Phase I; Weeks 1-3 Goals: Protect the surgical reattachment Control pain Intervention: After surgery, the arm is generally placed in an adjustable hinged brace that is immobilized at 90 degrees of elbow flexion with the forearm in neutral pronationsupination for 2-3 weeks. Two to three weeks after surgery passive range of motion is started over a full arc of flexion to 90 degrees and is advanced by 10-15 degrees a week. At this point in time, active elbow extension is begun with the elbow being returned to flexion passively by the patient or therapist. Passive pronation and supination range of motion are begun at 3 weeks as well and is advanced by 5-10 degrees per week.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Phase II: Weeks 4-6 Goals: Maintain protection of the reattachment Gradually restore passive range of motion of the affected joints Maintain range of motion in the joints above and below the affected elbow Limit scar tissue adhesions Intervention: At 4 weeks passive wrist and shoulder exercises are begun taking caution not to place stress across the repaired tissue Light scar tissue mobilization taking care not to disrupt the surgical repair

Phase III: Weeks 6-8 Goals: Increase active range of motion in the affected elbow Increase strength Maintain optimal scar and tissue mobility Intervention: Active flexion and supination are avoided until a point 6 weeks after the reattachment, at which point the patient is progressed to sub maximal isotonic exercised for elbow flexion and extension as well as pronation and supination. From 8 weeks following surgery onward, the patient is allowed to progress strengthening exercises as tolerated Scar and soft tissue mobilization to maintain proper mobility in tissues surrounding the surgical site

Phase IV: 3-6 Months Goals: Return to presurgical level of strength and range of motion Begin sport or activity specific training Intervention: Aggressive strengthening and high level plyometrics are advised to be avoided until 3-6 months after surgery Return to jogging for cardiovascular exercise is allowed at 3 to 4 months with return to contact sports or other unrestricted upper extremity activities being limited to 6 months or longer

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Selected References: Bourne MH, Morrey BF. Partial rupture of the distal biceps tendon. Clin Orthop. 1991;271:143148. Curl L. Return to sport following elbow surgery. Clin Sports Med. 2004;23(3):353-66. DArco P, Sitler M, Kelly J, Moyer R, Marchetto P, Kimura I, Ryan J. Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med. 1998;26:254-61. Haupt H. Overuse injuries in the upper extremity: upper extremity injuries associated with strength training. Clin Sports Med. 2001;20(3):481-90. Pearl M, Bessos K, Wong K. Strength deficits related to distal biceps tendon rupture and repair: a case report. Am J Sports Med. 1998;26:295-96. Strauch R. Elbow trauma and reconstruction: biceps and triceps injuries of the elbow. Orthop Clin North Am. 1999;30(1)95-107.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Elbow Ulnohumeral Dislocation and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Elbow dislocations uncommon. Posterior dislocations are the most common; they comprise over 90% of all elbow dislocations. Anterior, divergent, and radial head subluxations in children comprise the other 10%. Pathogenesis: Posterior dislocations are by far the most common and occur from a fall on an outstretched hand (FOOSH). This type of elbow dislocation occurs from hyperextension in which the trochlea is levered over the coronoid process. Anterior dislocations occur as a direct blow to a flexed elbow. This usually results in an olecranon fracture thus dislocating the ulna. Less rare is a divergent dislocation which is usually associated with a high-energy force in which the ulna and radius dislocate in opposite directions. Radial head subluxations occur in young children when they are being picked up by their arms. Epidemiology: Elbow dislocations are more common in males than females. About 90% of elbow dislocations are posterior from FOOSH. Anterior dislocations occur from a direct blow on the flexed elbow usually fracturing the olecranon. Radial head subluxations occur when the arm is pulled. (The arm is usually pronated, flexed, and abducted against the body.) Diagnosis Swelling and obvious deformity Obvious mechanism of injury Severe pain and guarding Limited ROM Posterior dislocations often have a prominent olecranon Radiographs confirm the diagnosis

Nonoperative Versus Operative Management: Surgical reduction is typically recommended for patients that have this condition. It consists of reduction of the ulna back into its anatomical position. This has to occur paying special attention to the ulnar nerve and median nerves. Motor function of the ulnar and median nerves is assessed by testing the opposibility of the thumb (median), and abduction/adduction strength of the digits (ulnar). Sensation of the median nerve is evaluated by testing the distal palmar aspect of the first through fifth digits. Sensation of the ulnar nerve is evaluated by testing of the fourth and the fifth digits. It is also important to assess vascular responses because the brachial artery may be compromised. Surgical Procedure: There have been several methods for reducing a posterior dislocation. Adequate analgesia and sedation is necessary for patient comfort. If the patient has a posterior dislocation, the patient is put in a prone position having their elbow flexed at 90 degrees. Downward traction is applied to the forearm while pressure is applied to the olecranon in a downward direction to facilitate reduction. The second method has the patient laying supine

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 with the arm in flexion. Traction is applied to the humerus and another individual applies traction to the forearm, which is slightly supinated. Anterior dislocations are reduced by holding the humerus with two hands to apply counter traction. An assistant needs to apply traction to the forearm. Radial head subluxations in children are reduced by placing pressure to the radial head. Supination, flexion, and traction need to occur to reduce the dysfunction. There is little evidence that the surgical repair of ligaments is advantageous to the patient. Preoperative Rehabilitation: There is no preoperative rehabilitation. The elbow needs to be reduced. Pre-hospital care should include splinting the limb in the position found. Secondary to neurovascular injury, reduction in the field is not recommended.

POSTOPERATIVE REHABILITATION

Note: There is currently no rehabilitation program developed specifically for elbow dislocations. The following rehabilitation protocol was developed from numerous sources of literature. Individual cases will vary dependent upon age, pain tolerance, and complications with the reductions. In most articles prognosis is excellent if the patient has full ROM within 3 weeks.

Phase I: Weeks 1-4 Goals: Control edema and pain Early full ROM Protect injured tissues Minimize deconditioning Intervention: Continue to assess for neurovascular compromise Elevation and ice Gentle PROM - working to get full extension Splinting as needed General cardiovascular and muscular conditioning program Strengthen through ROM Soft tissue mobilization if indicated especially assess the brachialis myofascia

Phase II: Weeks 5-8 Goals: Control any residual symptoms of edema and pain Full ROM Minimize deconditioning

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Intervention: Active range of motion (AROM) exercises, isometric exercises, progressing to resisted exercises using tubing or manual resistance or weights Incorporate sport specific exercises if indicated Joint mobilization, soft tissue mobilization, or passive stretching if indicated Continue to assess for neurovascular compromise Nerve mobility exercises if indicated Modify/progress cardiovascular and muscular conditioning program

Phase III: Weeks 9-16 Goals: Full range of motion and normal strength Return to preinjury functional activities Intervention: Interventions as above Modify/progress cardiovascular and muscular conditioning Progress sport specific or job specific training

Selected References: Cohen MS, Hasting H. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998;6:15-23. Halstead M. Elbow Dislocation. emedicine. 2001 July 26 1-11 Kaminski. Differential assessment of elbow injuries. Athletic Therapy Today. 2000;5(3): 6-11 Nirschl R, Kraushaar B. Assessment and Treatment Guidelines for Elbow Injuries. Phys Sportsmed. 1996;24(5):43-60. Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone Joint Surg Am 1998;80:566-580. Ross G, Chronister R, McDevitt. Treatment of simple elbow dislocation utilizing an immediate motion protocol. Am J Sports Med. 1999:27:308-311. Ross G. Acute elbow dislocation: on site treatment. Phys Sportsmed. 1999; 27(2):121. Uhl T. Uncomplicated elbow dislocation rehabilitation. Athletic Therapy Today. 2000 5(3):3135. Villiarin LA Jr, Belk KE, Freid R. Emergency department evaluation and treatment of elbow forearm injuries. Emerg Med Clin North Am 1999;17:843-858

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Radial Head Fracture Repair and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The elbow is a complex joint due to its intricate functional anatomy. The ulna, radius and humerus articulate in such a way as to form four distinctive joints. Surrounding the osseous structures are the ulnar collateral ligament complex, the lateral collateral ligament complex and the joint capsule. Four main muscle groups provide movement: the elbow flexors, the elbow extensors, the flexor-pronator group, and the extensor-supinator groups. Different types of radial head fractures can occur each of which has separate surgical indications and considerations. Fractures of the proximal one-third of the radius normally occur in the head region in adults and in neck region in children. The most recognized and used standard for assessing radial head fractures is the 4-part Mason classification system. It is used for both treatment and prognosis. Classification: Type I fracture A fissure or marginal fracture without displacement. Type II fracture Marginal fractures with displacement involving greater than 2 mm displacement. Type III fracture Comminuted fractures of the whole radial head. Type IV fracture (variation) A comminuted fracture, with an associated dislocation, ligament injury, coronoid fracture, or Monteggia lesion.

Pathogenesis: Severe comminuted fractures or fracture dislocations of the head of the radius often occur as the result of a fall on an outstretched arm with the distal forearm angled laterally, or a valgus stress on the elbow. Fractures can also occur from a direct blow or force to the elbow (e.g. MVA). Chronic synovitis and mild deterioration of the articular surfaces associated with arthritis (e.g. rheumatoid arthritis, osteoarthritis) of the humeroradial and proximal radioulnar joints resulting in bone deterioration may cause fractures as well.

Epidemiology: Radial head fractures are relatively uncommon. These fractures occur in all ages.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Diagnosis Reported fall on outstretched arm Guarding with elbow flexed Pain on the lateral side of the elbow Swelling/effusion at lateral elbow Difficulty with flexion or extension of the elbow, decreased ROM Difficulty with pronation and supination of the forearm, decreased ROM Tenderness with palpation near the radial head Fat pad sign with radiograph examination, CT scan also used

Non-operative treatment: Conservative treatment usually coincides with Type I radial head fractures. An undisplaced fracture does not need manipulation. Fractures in adults with slight displacement < 2 mm, an attempt is always made to reduce the fracture with manipulation. In children closed reduction alone is often successful. After reduction, sling immobilization with active motion is a welldocumented treatment of choice. The addition of a posterior splint for a few days may add comfort for the patient. Initial pain control includes cryotherapy, NSAIDS, and pain medication. Protection of the radial head from accidental bumping can be accomplished by elastic wrapping or loosely taping molded thermoplast over the lateral elbow.

Operative treatment: This type of treatment is indicated for radial head fractures Type II-IV. This type of treatment is an option when closed manipulation has failed. There are two types of operative treatment: radial head resection and open reduction internal fixation. Open reduction internal fixation has shown to have better results. With an ORIF the fractures are internally fixed with the use of low-profile mini-plates and or Herbert screws. The radial head facture is accessed through a similar approach as in resection, which is a lateral or posterolateral approach. The fracture is reduced by small forceps, tenacular clamps, or fixed with 1.0-mm Kirschner wires. Ligaments are sutured back into place using number-1 nonabsorbable braided sutures. The elbow is then fitted with a long arm cylinder cast and the elbow at 90 degrees of flexion. The cast is to be worn for 2 weeks after which it is changed to a hinged brace to allow elbow movement in the following 4 weeks.

NONOPERATIVE AND POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Kisner and Colby, Gutierrez, and Teperman. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 REHABILITATION FOR NON-OPERATIVE RADIAL HEAD FRACTURES

Early Passive Motion: (2-7 days post fracture) Goals: Control pain and edema Protect fracture site Minimize deconditioning Maintain range in joints around the effected region (shoulder, wrist, fingers) Prevent contractures Intervention: Modalities, such as TENS and ice, for pain control Splint/Sling as direct by MD Monitor use and weight bearing instructions per MD Cardiovascular conditioning Gentle range of motion exercises of the shoulder, wrist, and fingers Passive flexion/extension of the elbow Passive pronation/supination of the elbow

Phase I maximum protection phase: (3-6 weeks post fracture) Goals: Continue to control pain and edema as needed Minimize deconditioning Regain range of motion within pain limits Prevent muscle atrophy Intervention: Active assistive flexion/extension of the elbow Active assistive pronation/supination of the elbow Isometrics: flexion, extension, and pronation, supination Active assistive hyper extension of elbow (at 6 weeks) Gripping exercises

Phase II moderate protection phase: (6-8 weeks post fracture) Goals: Regain full range of motion Actively work within newly gained range of motion Increase strength

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Intervention: Active flexion/extension of the elbow Active pronation/supination of the elbow Active flexion/extension in standing with wand Pulleys with eccentric control of the elbow with flexion/extension

Phase III minimum protection phase: (8 weeks post fracture) Goals: Educate patient on proper joint protection and therapeutic exercises Gain adequate strength in the forearm flexors and extensors to increase stability at the elbow Strengthen the elbow flexors and extensors to gain full range of motion Intervention: Resistive exercises: standing with weights, theraband resisted (flexion, extension, pronation, supination) exercises Self-stretching: flexion/extension, pronation/supination, shoulder flexion/extension, and wrist flexion/extension, ulnar deviation/ radial deviation Advance elbow extension with radial deviation and elbow flexion with ulnar deviation

REHABILITATION FOR OPERATIVE RADIAL HEAD FRACTURES

Preoperative Rehabilitation Injury is protected with immobilization through casting, splinting and/or placed in a sling Patient is instructed of post-operative rehabilitation goals and plan

Immobilization: (3-5 days post op) Goals: Control pain and edema Protect fracture site with posterior splint or compression bandage Minimize cardiovascular deconditioning Maintain range in joints around the effected region (shoulder, wrist, and fingers) Prevent contractures Patient can don/doff sling independently with elbow at 90 degrees flexion with forearm in neutral

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Intervention: Modalities, such as TENS and ice, for pain control Splint/Sling as direct by MD Monitor use and weight bearing instructions per MD Cardiovascular conditioning Gentle range of motion exercises of the shoulder, wrist, and fingers Passive flexion/extension of the elbow Passive pronation/supination of the elbow

Phase I maximum protection phase: (7 days - 3 weeks post op) Goals: Continue to control pain and edema as needed Minimize deconditioning Regain range of motion within pain limits Prevent muscle atrophy Intervention: Active assistive flexion/extension with stick or pulleys Active assistive pronation/supination with stick or pulleys Cardiovascular conditioning Increase mobility to tolerance, prevent stiffness CPM

Phase II moderate protection phase: (4-6 weeks post op) Goals: Regain full range of motion Actively work within newly gained range of motion Increase strength Intervention: Active flexion/extension of the elbow Active pronation/supination of the elbow Active: flexion, extension, pronation, supination with a wand or pulleys Pulleys with eccentric control during flexion/extension Isometrics: flexion, extension, pronation, supination Gentle stretching using inhibition/elongation techniques or joint mobilization to increase range of motion

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Phase III minimum protection phase: (12 weeks post op) Goals: Increase strength (especially at end ranges) Educate patient on proper joint protection and therapeutic exercises Gain adequate strength in the forearm flexors and extensors to increase stability at the elbow Strengthen the elbow flexors and extensors to gain full range of motion Increase speed and control of limb movement

Intervention: Resistive exercises: standing with weights, theraband resisted (flexion, extension, pronation, supination) exercises Self-stretching: flexion/extension, pronation/supination, shoulder flexion/extension, and wrist flexion/extension, ulnar deviation / radial deviation Advance elbow extension with radial deviation and elbow flexion with ulnar deviation Higher speed and high intensity isotonic flexion/extension, pronation/supination while standing or performing ADLs Incorporate open and closed-chain exercises

Selected References: Ashwood N, Bain G, Unni R. Management of Mason Type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg. 2004;86:274-80. Gutierrez G. Management of radial head fracture. Am Fam Physician. 1997;55:2213-16. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. J Bone Joint Surg. 2005;87:76-84. Teperman L. Active functional restoration and work hardening program returns patient with 2 1/2-year old elbow fracture-dislocation to work after 6 months: a case report. J Can Chiropr Assoc. 2002;46:22-30.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Elbow Open Reduction Internal Fixation

Surgical Indications and Considerations Anatomical Considerations: The elbow is composed of 3 articulations; humeroulnar, humeroradial, and the proximal radioulnar joint. The distal radioulnar joint is thought to be a part of the elbow complex due to the fact that its function is directly related to the proximal radio ulnar joint. The two major collateral ligaments and the joint capsule along with the surrounding muscles provide the strength and support to the joint. The radial head is more susceptible to fractures because of the 15 angle between the neck and the shaft of the radius. Pathogenesis: Elbow fractures are classified as distal humeral fractures, proximal radial fractures, and proximal ulnar fractures. Most elbow fractures are a result of direct trauma or a fall onto an outstretched hand. (FOOSH) With the forearm in pronation and the elbow extended, the valgus (lateral) stress causes the elbow joint to be a vulnerable position. Approximately 60% of the body weight is forced onto the elbow joint during a fall, and especially to the radial head. Other medical factors such as arthritis, puts the patient at a higher risk to fracture the elbow joint. The Mason classification system is most commonly used to classify and to treat the fractures. Class I Non-displaced ~ generally small, hairline fractures (easily missed) ~ may not be visible on X-rays (visible if X-ray is taken 3 weeks post injury) ~ can displace if too much movement occurs. Class II Marginal head fracture ~ splinting for 1 2 weeks ~ slightly displaced and involves a larger portion of the bone ~ may need surgical removal of small fragments ~ if fragments are larger, surgical procedures with pins and screws. ~ for geriatric patients, the surgeon generally removes the broken piece or entire even the entire radial head. Class III - Comminuted ~ more than 3 fragments of bone ~ significant damage to joint and ligaments ~ surgery is required to remove fragments and repair soft-tissue damage ~ prosthesis can be used to prevent deformity Class IV With elbow dislocation ~ the dislocations are treated first, then the fracture ~ usually other complications involved such as ligament tear or other elbow fractures.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Epidemiology: Elbow fractures are not as common as other fractures of the body, accounting for 7% of all elbow trauma. The most common fractures of the elbow vary with the mechanism of injury and patient's age. Supracondylar fractures are more common in children and radial head fractures are most common in adults, occurring more frequently in women then men.

Diagnosis ~ Patient will report of a fall on outstretched arm (FOOSH) or a direct trauma to the elbow ~ Joint effusion and ecchymosis near the elbow may be present ~ Point tenderness at the radial head ~ Pain with ROM, especially with pronation and supination of the forearm

Non-operative Versus Operative Management: Class I and some Class II fractures (non-displaced and non-comminuted fractures) are typically treated conservatively with immobilization. Open reduction and internal fixation is indicated for displaced fractures like Class II(displaced), Class III, and Class IV fractures. Ring et al. suggest that fractures involving the whole radial head should be treated with radial head arthroplasty rather then open reduction internal fixation. Open reduction and internal fixation is best reserved for minimally comminuted fractures with three or less articular fragments (Mason Type II fractures). Surgical Procedures: The surgical approach depends on the structures that are involved. If the ulna or medial side of the elbow needs to be accessed, a posterior approach is used for the incision. If the radial head alone needs to be accessed, a lateral incision is made. Exposure of the radial head varies according to the approaches used, however will involve the anconeus, extensor carpi ulnaris, and the supinator muscles. Miniature screws of different depths, a Herbert screw (headless screw), small Kirschner wires, and/or bioabsorbable pins may be used if the fracture does not involve the radial neck. However if the radial neck is involved, then a small plate is indicated. An autogenous bone graft is applied taken either from the lateral epicondyle or the olecranon if necessary. When applying the screws, the angle of placement is taken into consideration not to obstruct the radioulnar articulation for movement of pronation and supination. Any other damage (i.e. ligament tear) is then surgically repaired and the incision is sutured. Preoperative Rehabilitation ~ Further injury protection using a splint or cast ~ Go over post-operative rehabilitation plan with the patient

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

POSTOPERATIVE REHABILITATION

Protection: Day 1-7 Immobilized in a splint* (90 flexion, neutral rotation) - about 3 days *(Splint is removed for exercise but put back on after exercise and worn at night for several weeks) Elevation prevent or minimize edema

Phase I: Weeks 1 - 4 Goals: Pain and edema control Protect surgical repair site PROM progress to AROM Independent home exercise program Intervention: Modalities for pain control Gentle active and active-assisted range-of-motion exercises Teach patient self ROM exercises and HEP

Phase II: Weeks 5 8 Goals: Increase upper extremity strength Increase/progress range of motion Implement function Intervention: Modalities for pain control Gentle mod stretching Active: Flexion, Extension, Pronation, Supination exercises Mobilization to increase range of motion (Grades I II)

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Phase III: Weeks 9 12 Goals: Normal functional use for ADLs Limit scar tissue adhesions Full ROM Improve strength of elbow muscles Improve cardiovascular and muscular endurance Intervention: Progressive resistance exercises to all weak elbow musculature Soft tissue mobilization to hypomobile tissue near surgery site Joint mobilization (Grades III IV) Functional use for light ADLs

References: Frankle MA, Koval KJ, Sanders RW, Zuckerman JD. Radial head fractures associated with elbow dislocations treated by immediate stabilization and early motion. J Shoulder Elbow Surg. 1999;8(4):355-60. Keppler P, Salem K, Schwarting B, Kinzl L. The Effectiveness of Physiotherapy After Operative Treatment of Supracondylar Humeral Fractures in Children. J Pediatr Orthop. 2005;25(3):314-6. Kisner C, Colby LA. The Elbow and Forearm Complex. In: Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques(4th Edition.) Philadelphia, PA: F.A. Davis; 2002. Morrey BF. Anatomy of the elbow joint. In: Morrey BF, ed., The Elbow and its disorders(3rd Edition.) Philadelphia, PA: W.B. Saunders; 2000. Ozturk K, Esenyel CZ, Orhun E, Ortak O, Durmaz H. [The results of open reduction and internal fixation of radial head fractures] Acta Orthop Traumatol Turc. 2004;38(1):42-9. Turkish. Ring D. Open reduction and internal fixation of fractures of the radial head. Hand Clin. 2004;20(4):415-27. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84-A(10):1811-5.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Heterotopic Ossification About The Elbow: Repair And Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The complex anatomy of the elbow joint and its relation to the hand, forearm, and shoulder underlie the functional deficits associated with heterotopic ossificans (HO). Despite much study and newly gained insights into its development, treatment of HO of the elbow remains largely based upon the more widely studied HO of the hip joint. The elbow differs from the hip in a number of different ways, one of which being that the crosssectional area of the elbow in comparison with the upper limb is relatively much larger than that of the hip in relation to the lower limb; thus, involvement of neighboring nerves and vasculature by HO is much more likely at the elbow. Pathogenesis: Acquired HO is a recognized complication of various traumatic etiologies such as spinal cord injury, traumatic brain injury, burns, surgical resection and joint arthroplasty. However, while many theories have been put forth to explain HO of the elbow, the true mechanism of how ectopic bone forms around a joint, possibly causing severe functional limitations, and even total joint ankylosis, remains uncertain. The transformation of primitive mesenchymal cells in connective tissue into osteoblastic tissue and osteoid involve diverse and poorly understood biological triggers, ranging from bone morphogenic proteins, human skeletal growth factors, to genetic, neurological and traumatic factors. The presence of limb spasticity, fracture, infection, and pressure sores are generally believed to increase the likelihood of HO development. Epidemiology: The incidence of clinically significant HO in the common settings of elbow injury (trauma, brain injury, spinal cord injury) has been reported to be as high as 10% to 20%. In addition, the elbow is the most frequent site of HO in burn patients, of whom 1% to 3% may be affected, although estimates as high as 35% have been given in the literature. Other risk factors include the following: male gender, trauma, full-thickness burns, spinal cord injury, deep local infection, overzealous joint manipulation, microtrauma to the musculotendinous apparatus with resultant hemorrhage, circulatory stasis, postoperative immobilization with limitation of joint movement, bone demineralization from prolonged bedrest or assisted ventilation. Diagnosis: HO characteristically begins approximately two weeks after injury, however, diagnosis is often delayed. Common signs and symptoms include decreased range of motion, pain, swelling, and erythema. These non-specific clinical signs may not appear until eight to ten weeks after the initial injury. Positive radiological findings may not appear for four weeks. An acute rise in serum alkaline phosphatase and a transient depression in serum calcium may occur within the first two weeks. However, these are non-specific laboratory findings and may not be helpful in early diagnosis. The determining characteristics of HO include a radiologically verification of a periarticular location, an intact cortex, a lucent zone between cortex and ossification (string sign), peripheral density of calcification, and contraction of the ossification zone with maturity. Finally, while plain films are used for delineating the precise extent of HO at the elbow, bone scans remain the gold standard for diagnosis.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Surgery plays a prominent role in many treatment plans, particularly when orthopedic trauma is the initiating injury and if certain prerequisites are met. As a rule, if the elbow is able to span an arc of 30 to 110 (range of motion as described here assumes that complete extension represents an arc of 145 measured at the elbow joint), the elbow is not considered functionally impaired. In addition, there should be no evidence of acute inflammation in the periarticular tissues. The skin overlying the proposed surgical site should be completely healed. It must not, however, be assumed that surgery is always required for the treatment of HO of the elbow. One recent report of established HO noted decreased pain and improved range of motion after radiation therapy to the elbow joint, even without excision of the heterotopic bone. Similarly, neuropathic pain may respond better to anticonvulsants (e.g., gabapentin) or tricyclics (e.g., amitriptyline) than to operative intervention. One surgeon even observed that range of motion is maximized when gradual physical therapy, rather than surgical excision, is used to release muscle contractures. The fundamental prerequisite for surgical intervention then, is not the mere presence of HO, but peripheral nerve compromise, pain, or an impaired range of motion affecting daily activities that would not be manageable by more conservative medical or physical therapy intervention. Surgical Procedure: Surgery is usually performed once the lesion has stabilized radiographically. And in the case of brain-injured patients, the key principle is that surgery should follow, not precede, neurological recovery (persistent loss of neurological function is the setting in which HO gains a foothold, and if excised, tends to recur). Surgical approach depends on the location of the heterotopic bone and its relation to normal structures. A posterior approach is recommended to avoid traumatizing previously damaged skin. Access to the anterior capsule can be accomplished by removing the radial head. Once the capsule has been entered, the ulnar nerve should be transposed so heterotopic bone and ossified periarticular ligaments in surrounding soft tissue can be removed. The entire bridge of bone and its bony attachments must be removed. A posterolateral approach is recommended when the elbow ankylosis in extreme flexion. In this setting, heterotopic impingement on the olecranon may be present. Here, the olecranon should be excised and the fibrofatty tissue within the fossa left in, because adipose tissue tends to prevent recurrence of heterotopic bone that has already formed. An incision is then made proximal to the mass on the posterolateral arm across the olecranon. The triceps aponeurosis is exposed, incised, and retracted medially to expose the subperiosteal heterotopic bone joining the lateral condyle of the humerus to the posterolateral olecranon. If the proximal forearm is involved, with compromise of supination and pronation, the incision is extended distally. An osteotome is used to remove the heterotopic bone, whereas the fat pad in the fossa is left in place. The elbow is passively flexed to facilitate removal of the bone from its attachments to the olecranon and humerus. A medial approach is used if the posteriorly situated heterotopic bone extends medially, if its presence near the ulnar collateral ligament compromises range of motion, or if the ulnar nerve is to be transposed anteriorly. If bone encircles the ulnar nerve, it must be removed so that the ulnar nerve can be released before complete resection proceeds. If heterotopic bone follows the brachialis muscle in the direction of the coronoid process or follows the path of the biceps

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 tendon, anterior synostosis of the forearm may occur. In this setting, an anterolateral approach allows the brachialis and brachioradialis muscles to be identified and retracted from the radioulnar joint. The radial nerve is retracted laterally with the brachioradialis muscle. Heterotopic bone is then dissected subperiosteally, and the central bridge of bone is resected, with anterior capsule left intact. Postoperative hematomas are common in this setting. Preoperative Rehabilitation Activity as tolerated (continue to assess function/lack of function) Infection control/integument healing In brain injury patients, continue with neurological recovery Pain management Instructions/review post-operative rehabilitation plan

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Calandruccio, Akin, Griffith, Andrews, Hurd, and Wilk. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Phase I for Early Motion and Rehabilitation: Week 1 Goals: Prevent infection Decrease stress on surgical site Decrease pain Control and decrease edema Protect surgical site Elbow PROM to within 80% available limits structurally Maintain ROM of joints proximal and distal to surgical site Intervention: Monitoring of surgical site Instruction of patient in activity modification Continuous passive motion (some MDs place CPM immediately post-op on the patient) AROM: exercises for hand, shoulder, elbow (within patients tolerance)

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase II for Early Motion and Rehabilitation: Weeks 2-8 Goals: Reduce pain Manage edema Encourage limited activity of daily living performances Promote scar mobility and proper remodeling Promote full elbow PROM Encourage quality muscle contraction Intervention: Continuation of edema and pain management techniques as in Phase 1 Soft tissue mobilization myofascial restrictions are present Retrograde or lymphatic massage if tissue edema is present Scar desensitization/mobilization after sutures are removed and incision is closed AROM: Elbow flexion/extension/pronation/supination PROM: Elbow flexion/extension/pronation/supination Isometrics: wrist and shoulder, sub-maximal

Phase III for Early Motion and Rehabilitation: Weeks 9-24 Goals: Self-manage pain Prevent flare-up with progression of functional activities Improve strength: Grip strength to 75% of uninvolved side Wrist strength to within 80% Improve ROM if it still limited Return to previous activity level Intervention: Continue pain and edema management as indicated Patient education regarding activity modification and performance of activities with good mechanics Progressive resistance exercises for shoulder, elbow, and wrist Putty exercises-finger pinch and grip Work simulator (at 16-20 weeks)

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Selected References: Calandruccio J, Akin K, Griffith KL, Andrews J, Hurd WJ, Wilk KE. Elbow Conditions. In Maxey L, Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2001. Chua K, Kong KH. Acquired heterotopic ossification in the settings of cerebral anoxia and alternative therapy: two cases. Brain Injury. 2003;17:535-544. Ellerin B, Helfet D, Parikh S, Hotchkiss R, Levin N, Nisce L, Nori D, Moni J. Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil. 1999;78:259-271. Gaur A, Sinclair M, Caruso E, Peretti G, Zaleske D. Heterotopic ossification around the elbow following burns in children: results after excision. J Bone Joint Surg Am. 2003;85-A:1538-1543. Karapinar H, Yagdi S. A Case of myositis ossificans as a complication of tetanus treated by surgical excision. Acta Orthopaedica Belgica. 2003;69:285-288. Lane J, Dean R, Foukles G, Chandler P. Idiopathic heterotopic ossification in the intensive care setting. Postgraduate Med. 2002;78:494-495. Reeves SU. Burn-Related Complications: Heterotopic Ossification. In Pedretti LW, Early MB, eds., Occupational Therapy: Practice Skills for Physical Dysfunction. St. Louis, MO: Mosby; 2001. Ring D, Jupiter J. Operative release of ankylosis of the elbow due to heterotopic ossification: surgical technique. J Bone Joint Surg Am. 2004; 86-A Supplement 1:2-10. Ring D, Jupiter J. Operative release of complete ankylosis of the elbow due to heterotopic bone in patients without severe injury of the central nervous system. J Bone Joint Surg Am 2003;85A:849-857. Taly AB, Nair KP, Jayakumar PN, Ravishankar D, Indiradevi B, Murali T. Neurogenic heterotopic ossification: a diagnostic and therapeutic challenge in neurorehabilitation. Neurology India. 2001;49:37-40. Wilk KE, Andrews JR. Heterotopic Ossification. In Brotzman SB, Wilk KE, eds., Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby; 2003.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Median Nerve Compression at Pronator Teres


Surgical Indications and Considerations Anatomical Considerations: The median nerve and brachial artery travel together down the arm. Therefore, one must be very careful not to interfere with either the median nerve or the brachial artery, especially when conducting surgical procedures. In the area of the pronator teres, there are many tendons as well. It is important to identify, as much as possible, the correct site of compression. Pathogenesis: The median nerve can get entrapped or compressed by several structures in the arm. The pronator teres muscle is the most common. Others entrapment sites include the flexor digitorum superficialis arch, the lacertus fibrosis (bicipital aponeurosis), and ligament of Struthers (frequency occurs in that order). For compression of the median nerve at the pronator teres and flexor digitorum superficialis, the cause is almost always due to hypertrophy of the respected muscle. This hypertrophy is from quick, forceful and repeated movements to the involved muscle. Examples include a carpenter or a baseball batter. As the muscle hypertrophies, the signal from the median nerve is diminished resulting in paresthesias in the median nerve distribution (lateral arm and hand) distal to the site of compression. Pain in the volar part of the forearm, often aggravated by repetitive supination and pronation, is a common symptom of pronator involvement. Another indicator is forearm pain with the compression of muscle such as pain in the volar part of the forearm implicating pronator teres. Onset is typically insidious and diagnosis is usually delayed 9 months to 2 years. Epidemiology: Pronator teres syndrome is the second most common cause of median nerve compression behind carpal tunnel syndrome. It tends to occur in athletics (especially those with rapid, exertional supination and pronation) and in occupations where the forearm may be hypertrophied. In addition, anomalies involving the ligament of Struthers and the course of the median nerve may contribute to median nerve entrapment. Diagnosis Aching discomfort and easy fatigability of the muscle of the forearm Numbness and paresthesia in median nerve distribution and palmer cutaneous branch in hand Absence of nocturnal symptoms Direct compression of the pronator teres muscle resulting in symptom reproduction Electromyographic studies of muscles innervated by the median nerve are considered mildly reliable (confirms diagnosis of AIN syndrome in 80-90% of cases) Can occur with a sudden increase in use of pronation or supination muscles.

Nonoperative Versus Operative Management: Conservative management is almost always attempted prior to surgery and can often result in positive results. With conservative treatment, 50% of patients report recovery within 4 months. Other reports say improvement can be seen

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 from 18 months to 2.5 years after conservative treatment. Conservative treatment involves rest and casting early, modalities and nerve gliding next, followed by return to modified duties and full work/recreation. Cortisone injections could be attempted after conservative treatment is deemed not successful. Surgery is the next option when both of the previous attempts were not able to improve the patients symptoms. Some literature says the decision to have surgery may be determined as early as 8 weeks or as long as 6 months after initiating conservative treatment. In general, median nerve decompression has an 85 to 90% good to excellent outcome. Surgical Procedure: Decompression is performed with an anterior approach and uses a longitudinal incision along the arm. If it is determined the patient has a supracondylar process (ligament of Struthers) and requires decompression, the incision will start several centimeters above this site. Otherwise, the incision is made just above or at the elbow crease. It is then carried to the midforearm. Due to difficulty in differentiation, the surgery involves decompressing all possible sites along the course of the nerve. This can include several sites that may not be entrapping the nerve and may result in longer recovery and rehabilitation due to several sites of injury. In instances such as high-level athletes, careful identification of the site of entrapment is performed and only that site is decompressed. As stated earlier, median nerve decompression has an 85 to 90% good to excellent outcome. Conservative Rehabilitation (Preoperative Rehabilitation): Phase I: Weeks 1-2 Goals: Control edema Pain reduction Intervention: Protect elbow from further entrapments with use of splinting the elbow at 90 degrees flexion and neutral supination/pronation Gentle passive range of motion activities Elevation, ice and compression Modalities and medications for inflammation, pain, and swelling Gentle median nerve gliding Soft tissue mobilization and massage Maintain physical fitness and conditioning

Phase II: Weeks 3-4 Goals: Improve Flexibility Strengthening (Caution is exhibited in this phase to prevent recurrence of overuse syndrome)

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Intervention: Modalities may be used to help reduce inflammatory and pain Wrist flexion and extension exercises are initiated. Once this is tolerated well, the patient may begin with elbow flexion and extension exercises and gentle supination and pronation. Soft tissue mobilization/massage to forearm may be used to areas when entrapment is suspected Begin to address work or sport related activities Progress with physical fitness and conditioning Provide nerve mobility gliding exercises to address nerve mobility impairments and prevent recurrence

Phase III: Weeks 5-8 Goals: Progress to independent home program Return to occupational, recreational, or sport activities Prevent recurrence of injury For non-dominant arm, progress patient to 90% strength of opposite arm. For dominant arm, progress patient to 100% strength Intervention: Education to patient regarding prevention and management Nerve gliding to prevent recurrence Strengthening and flexibility is large component for the athlete to return to sports Focus on tasks the simulate the patients sport or work or both

POSTOPERATIVE REHABILITATION Phase I: Days 1-21 Goals: Control edema and pain Prevent infection of would site Maintain AROM of surrounding joints Decrease sensitivity at incision site and increase scar mobility Intervention: Instruct on surgical site protection and monitor drainage Rest, ice, and elevate arm Elbow splinted for 7 to 10 days in slight flexion Active finger, wrist, and shoulder movement later in Phase I include elbow and forearm

Cuong Pho DPT, Joe Godges DPT

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4 motions Painfree, gentle nerve mobility exercises Iontophoresis and modalities as needed to reduce inflammation and control pain Gentle soft tissue mobilization and massage to decrease swelling and maintain tissue mobility

Phase II: Weeks 4-6 Goals: Grip and elbow strength 30-50% of uninvolved hand Increase forearm and elbow AROM to greater than 50% of normal. Continue to prevent scar adhesions and sensitivity Independence with activities of daily living Assess ergonomics at work or sport activity Intervention: Passive stretches to elbow, forearm, wrist and shoulder Patient education regarding prevention of recurrence Isotonic exercises for elbow, wrist, forearm, and shoulder Begin work and sport simulated exercises

Phase III: Weeks 6-12 Goals: Adequate strength to return to full work duties or sport activities Self-management of symptoms Intervention: Work or sport simulated activities Progress upper extremity exercises emphasizing endurance for return to work or sport Continue exercises and stretches from Phase I and II as indicated

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References: Hartz C, Linscheid R, Gramse R, Daube J. The pronator teres syndrome: Compressive neuropathy of the median nerve. J Bone Joint Surg. 1981;63:885-890. Hershman B, Lorei M. Peripheral nerve injuries in athletes. treatment and prevention. Sports Medicine. 1993;16:130-147. Keefe D, Lintner D. Nerve injuries in the throwing elbow. Clinical Sports Medicine. 2004; 23:723-742. Lee M, LeStayo P. Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome. J Orthop Sports Phys Ther. 2004;34:601-609. Maser B, Clark C, Girard D. Carpal Tunnel Syndrome: Postoperative Management. In Maxey L, Magnusson J. eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2001. Posner M. Compressive neuropathies of the median and radial nerve at the elbow. Clin Sports Med. 1990;9:343-363.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Radial/Posterior Interosseous Nerve Decompression


Surgical Indications and Considerations Anatomical Considerations: The close proximity of the radial/posterior interosseous nerve to bony, muscular, tendinous, and arterial structures puts it at risk for entrapment. There are several regions where compression of the radial/posterior interosseous nerve occurs in the axillary/proximal region, at the elbow, and very rarely at the wrist. Pathogenesis: Nerve compression of the radial/posterior interossesous nerve is caused by both intrinsic and extrinsic factors. In addition to the factors listed below, compression can be caused from tumors, septic arthritis in the elbow, synovitis secondary to rheumatoid arthritis, lipomas, hemangiomas, ganglion cysts, and other masses. Also, a tardy palsy may occur secondary to compression by a callus in a healing fracture at any of the locations. High radial nerve (upper arm to elbow) compression sites and syndromes: Close proximity of the radial nerve to the radial groove of the humerus puts the nerve at risk for compression against the bone, being severed secondary to a fracture, or compressed by either orthopedic plates to repair a fracture or by a callus during bone healing Close proximity of the radial nerve to the medial and lateral head of the triceps, or a fibrous origin of the lateral head of the triceps leading to injury during strenuous activity Compression secondary to axillary crutches Secondary to windmill pitching in competitive softball Saturday Night Palsy arm draped over a chair or hard surface as patient is asleep or intoxicated, Honeymooners Palsy- caused by one honeymooner resting on the others arm External compression and trauma most common cause of problems in this region At the elbow Entrapment by fibrous bands around the anterior margin of the radial head Entrapment by the Leash of Henry- vessels from the radial recurrent artery Entrapment by the tendinous edge of Extensor Carpi Radialis Brevis Entrapment at the Arcade of Frohse (proximal entrance of the posterior interosseous nerve into the supinator muscle)-this structure is soft in childhood and can become fibrous in adulthood with fibrous occurrence ranging from 30-50% in cadaver studies but present in 80% of patients who undergo radial nerve decompression at the elbow Entrapment at the distal entrance of the posterior interosseous nerve from the supinator muscle Compression secondary to elbow synovitis in patients with rheumatoid arthritis Compression secondary to Monteggia fracture (fracture of proximal ulna in combination with posterior dislocation of the radial head) Frisbee flinging

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2 Lipoma, elbow ganglion (tumor should be considered when there is dense paralysis) At the wrist 4th extensor compartment Epidemiology: The radial nerve is involved less frequently than the ulnar or median nerve in entrapment syndromes, however the radial nerve is the most frequently traumatically injured nerve in the arm, usually secondary to fractures. The dominant arm is involved twice as much as the nondominant arm, and men are affected twice as often as women. Injuries involving the elbow are thought to be related to activities that involve repeated supination and pronation such as tennis, racquetball sports, swimming, violin playing, orchestra conducting, and manual labor. Radial nerve compression often coexists with compression syndromes of other nerves or with other conditions such as lateral epicondylitis. Diagnosis: Radial nerve compression is difficult to diagnose due to its wide spectrum of presentation, which often coexist or are confused with nonneurologic syndromes. EMG studies generally not reliable for diagnosis, but can be used to rule out radiculopathies from C7. If compression is suspected to be secondary to fracture or due to pressure from a mass, the use of radiographs, MRI, CT scan, and sonography can be useful in diagnosis. More evidence for the use of sonography in diagnosing radial compression is becoming apparent. High Radial Nerve Proximal to the radial groove Involves weakness in elbow extension, wrist, thumb and finger extension Sensory loss over the posterior arm and forearm and of the posterior lateral hand and thumb Rule out C7 radiculopathy History of use of crutches with compression in the axillary region Mechanisms of injury consistent with Saturday Night Palsy or Honeymooners Palsy At the radial groove Involves weakness in wrist extension, thumb and finger extension Possible sensory loss over posterior lateral hand and thumb with sensation of posterior arm and forearm intact At the elbow Radial tunnel (distal to the lateral intermuscular septum and proximal to the supinator muscle) **Note there is a discrepancy in the literature of what the radial tunnel refers to with several authors including the supinator muscle in the tunnel with the tunnel ending distal to the supinator. Weak thumb and finger extensors, varying degrees of wrist extension weakness (may or may not be present), may affect grip strength Possible sensory loss over posterior lateral hand and thumb with sensation of posterior arm and forearm intact Controversy over using a lidocaine injection to diagnose this syndrome

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3 Aching in lateral humerus, lateral elbow, and extensor mass (most common point of pain is at radial neck where as for lateral epicondylitis it is most common at the radial head or on the lateral epicondyle) Night pain common according to some literature Elbow popping with passive pronation (may occur in some) Resisted supination with elbow in extension reproducing pain a common test used for diagnosis (however also positive with lateral epicondylitis) Middle finger test with resistance to elevation of middle finger with wrist in neutral and elbow extended reproducing pain is a test used for diagnosis but many authors have the opinion that it provides no diagnostic reliability Rule out lateral epicondylitis (many times occurs along with radial nerve compression with decompression sometimes reliving symptoms of both and other times not) Possible history of strenuous use of forearm Posterior Interosseous Nerve Weakness in wrist extension with ulnar deviation, thumb and finger extension (metacarpophalangeal joints), may cause grip weakness, may have thumb abduction weakness Normal sensation May be a history of strenuous or repetitive effort involving supination and pronation Rule out tendon rupture (tenodesis is present with posterior interosseous nerve syndrome, not present in tendon rupture) Pain in deep proximal forearm or elbow which may precede weakness According to one recent study most consistent symptoms were deep aching pain in the forearm, pain radiation to the neck and shoulder, and a heavy sensation of the affected arm. The most common physical findings were tenderness over the radial nerve at the supinator muscle level, pain on resisted supination, and the presence of Tinel sign over the radial forearm. Terminal Branch of Posterior Interosseous Nerve involvement Dorsal wrist pain (may be following a resection of a dorsal wrist ganglion) described as a deep dull ache Pain provoked by wrist flexion, extension, and pressure on the 4th compartment with wrist flexed Pain relieved by a local anesthetic block

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Nonoperative Versus Operative Management: High radial nerve injuries are generally neuropraxic in origin and resolve spontaneously. Treatment is conservative and guided by EMG, which should show evidence of recovery within 4 months, with surgical exploration recommended if no recovery by this time. When conservative measures for radial tunnel and posterior interosseous nerve syndrome fail to relieve symptoms within three months, surgical intervention is pursued. The same time frame is used for involvement with the terminal branch of the posterior interosseous nerve at the wrist. Favorable responses to nonoperative management have been reported to be infrequent, probably less than 10%. According to several authors it is not clear what candidates will have a successful decompression surgery and several complications are common such as keloid scar formation, recurrence of symptoms, and hematomas. Surgical outcome for radial tunnel syndrome is variable with success rates varying from 39% excellent or good outcome to 95%. Surgeries for posterior interosseous nerve syndrome have been reported to have a positive outcome with one study reporting a 97% good to excellent outcome and another reporting increase in strength, with most patients in the 4-5/5 range. The involvement of a patient in a workers compensation suit as a determining factor in outcome, is controversial. The definition of excellent results does not seem to correlate well with subjective patient report or return to work rates. Therefore, the best method for evaluating patients, initially and on follow-up, the most appropriate surgical techniques or alternative therapies for treatment is open to debate, despite detailed anatomical studies. A call for randomized controlled studies has been made, but as of yet has not been conducted. Surgical Procedure: General surgical approaches include the anterior, posterior, transmuscular brachioradialis-splitting, and brachioradialis-extensor carpi radialis longus interval approach. For more details on the approaches see Hornbach and Culp. Most approaches involve proximal to distal dissection as this allows for less likelihood of injury to the radial nerve and it branches. Rinker et al. describe a different approach involving the use of intravenous corticosteriods before decompression with the idea that it reduces swelling and inflammation postoperatively. They also use a distal to proximal approach and a unique approach to bandaging, with no post-surgical immobilization cast or splint. A recent report of the use of arthroscopy to relieve radial tunnel syndrome by cyst decompression has also been reported. Intraoperative recordings of nerve action potentials were used in one study to make a decision for or against resection of the nerve. Preoperative Rehabilitation General preoperative care includes rest, non-steroidal anti-inflammatory medications, oral corticosteriods (in one study), refraining from repetitive supination/pronation activities (for compression or involvement at the elbow), various types of splinting with the use of buddy taping at times (taping a weaker finger to a stronger finger), and physical therapy using heat, ultrasound and massage. Steroid injections are controversial. Various time frames for conservative treatment are given from 1 month to 6 months unless there is motor weakness, clear trauma, or a suspected mass. Extensor tenodesis splint has been recommended for posterior interosseous nerve syndrome (Eaton) In radial tunnel syndrome, wrist extension splints are recommended with the elbow flexed and supinated to provide maximum relief (Levine) General Conservative treatment according to Alba
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Acute Phase (Continues until patient reports decreased pain level at rest and during activities) Goal: Reduce patients pain and inflammation Interventions: Rest via splinting Avoidance of exacerbating postures Pain and edema control through non-steroidal anti-inflammatories and modalities (ultrasound, phonophoresis, electrical stimulation, and cryotherapy) Range of motion exercises-Active, active-assistive and gentle passive range of motion Modify ADLs Rehabilitation Phase (May last in addition to acute phase for a total of 3-6 months) Goal: Reintroduce dynamic forces across the forearm in a gentle, controlled manner to build endurance, strength, and postural awareness Interventions: Progressive strengthening Modified work-simulated tasks Continued modalities POSTOPERATIVE REHABILITATION Note: Protocols vary and in many cases are not detailed in the literature with no research found on efficacy. General Protocols: Postoperatively active, but not strenuous motion is encouraged (Eaton) Patient should be immobilized in a long arm posterior splint for 7-10 days with range of motion at the hand and shoulder encouraged immediately postoperatively. Gentle range of motion of the elbow is started when the dressings are removed at 7-10 days. (Levine, Spinner) Following surgery for posterior interosseous nerve syndrome, patients should receive physical therapy that includes range of motion exercises. Many also benefited from a dynamic extension splint with outrigger, rubber bands and finger pads to maintain flexibility and mobility of all finger and thumb joints. (Cravens, Spinner) Postsurgical protocol according to Rinker et al: Phase I -Day 1 to 10 Simple soft dressing is applied, without elbow immobilization Rest for 24 hours and maintain strict, continuous elevation of the limb for 48 hours Finger, thumb and shoulder exercises begun on day 2

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6 Phase II Day 10-12 to 2 months Sutures removed post-op days 10-12 and scar taped longitudinally with 1-inch paper tape for a minimum of 2 months General postoperative rehabilitation according to Alba Phase I-Day 1 to 7 Goal: Rest Treatment: No formal therapy until after 1st week Immobilization in a splint Postsurgical dressings usually removed by end of this 1st week Phase II-Day 8-21 Range of motion exercises Wrist extension splint may be worn to promote healing and patient comfort Modalities for pain and edema management (TENS, cryotherapy, pulsed ultrasound, high frequency electrical stimulation) Scar management, including desensitization as tolerated, once wound completely closes Radial nerve glides (only to point just before feeling of tension) Phase III-5 to 6 weeks post-op to end of rehab. Resistance exercises begun at 5-6 weeks post-op (begin with concentric and isometric, progress to eccentric as tolerated) Work simulated tasks integrated as above progresses

Selected References: Alba CD. Therapists Management of Radial Tunnel Syndrome. In Mackin E, Callahan A, Skirven T et al. eds., Rehabilitation of the Hand and Upper Extremity (5th Edition). Philadelphia, PA: Mosby; 2002. Arle JE, Zager EL. Surgical treatment of common entrapment neuropathies in the upper limbs. Muscle Nerve. 2000;23:1160-74. Atroshi I, Johnsson R. Ornstein E. Radial tunnel release. Unpredictable outcome in 37 consecutive cases with a 1-5 year follow-up. Acta Orthop Scand. 1995;66:255-7. Carlson N, Logigian. Radial neuropathy. Neurol Clin. 1999;17:499-523. Chien AJ, Jamadar DA, Jacobson JA, Hayes CW, Louis DS. Sonography and MR imaging of posterior interosseous nerve syndrome with surgical correlation. Am J Roentgenol. 2003;181:219-21. Cravens G, Kline D. Posterior interosseous nerve palsies. Neurosurgery. 1990;27:397-402.

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7 Eaton CJ, Lister GD. Radial nerve compression. Hand Clin. 1992;8:345-57. Hornbach EE, Culp RW. Radial Tunnel Syndrome. In Mackin E, Callahan A, Skirven T et al. eds., Rehabilitation of the Hand and Upper Extremity(5th Edition). Philadelphia, PA: Mosby; 2002. Kato H, Iwasaki N, Minami A, Kamishima T. Acute posterior interosseous nerve palsy caused by septic arthritis of the elbow: a case report. J Hand Surg [Am]. 2003;28:44-7. Konjengbam M, Elangbam J. Radial nerve in the radial tunnel: anatomic sites of entrapment neuropathy. Clin Anat. 2004;17:21-5. Levine BP, Jones JA, Burton RI. Nerve entrapments of the upper extremity; a surgical perspective. Neurol Clin. 1999;17:549-65. Martinoli C, Bianchi S, Pugliese F, Pugliese F, Bacigalupo L, Gauglio C, Valle M, Derchi LE. Sonography of entrapment neuropathies in the upper limb (wrist excluded). J Clin Ultrasound. 2004;32:438-50. Mileti J, Largacha M, ODriscoll SW. Radial tunnel syndrome caused by ganglion cyst: treatment by arthroscopic cyst decompression. Arthroscopy. 2004;20:e39-44. Moss S, Switzer H. Radial tunnel syndrome: a spectrum of clinical presentations. J Hand Surg. 1983;8:414-20. Riffaud L, Morandi X, Godey B, Brassier G, Guegan Y, Darnault P, Scarabin JM. Anatomic bases for the compression and neurolysis of the deep branch of the radial nerve in the radial tunnel. Surg Radiol Anat. 1999;21:229-233. Rinker B, Effron C, Beasley R. Proximal Radial Compression Neuropathy. Ann Plast Surg. 2004;52:174-80. Rosenbaum R. Letters to the editor on surgical treatment. J Hand Surg [Am]. 1999;24:1345-6. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, Westaemper JG. Results of surgical treatment for radial tunnel syndrome. J Hand Surg [Am]. 1999;24:566-70. Spinner M, Spinner RJ. Nerve Decompression. In Morrey B, ed., Master Techniques in Orthopedic Surgery-The Elbow (2nd Edition). Philadelphia, PA: Lippincott Williams and Wilkins; 2002.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Ulnar Nerve Transposition


Surgical Indications and Considerations Anatomical Considerations: The ulnar nerve runs just posterior to the medial epicondyle in the cubital tunnel (ulnar groove). This key depression helps protect the ulnar nerve and is the most frequent site for ulnar nerve injury. Posner defined 5 areas of potential compression around the elbow as follows:

Under the heading intermuscular septum. Posner lists the arcade of Struthers (a musculofascial band about 8 cm proximal to the medial epicondyle), the medial intermuscular septum (which the nerve pierces to reach the olecranon groove), and the medial head of the triceps muscle (which can be hypertrophied or can chronically snap over the medial epicondyle, causing a neuritis). The area of the medial epicondyle is a valgus deformity caused by malunion of a condylar fracture, nonunion of a condylar fracture, or an epiphyseal injury to the lateral side of the elbow. These may cause tardy ulnar palsy secondary to chronic stretching of the ulnar nerve. The olecranon or epicondylar groove is a fibroosseous tunnel holding the ulnar nerve and its vascular accompaniment. A congenitally shallow groove or a torn fibrous roof can allow the nerve to chronically sublux or dislocate, causing neuritis and palsy. The cubital tunnel is the passage between the 2 heads of the flexor carpi ulnaris, which are connected by a continuation of the fibroaponeurotic covering of the epicondylar groove (Osborne ligament). During elbow flexion, the tunnel flattens as the ligament stretches, causing pressure on the ulnar nerve. Flexor-pronator aponeurosis is the fifth area. As the nerve exits the flexor carpi ulnaris, it perforates a fascial layer between the flexor digitorum superficialis and the flexor digitorum profundus. Entrapment can occur here also.

Pathogenesis: With the anatomic positioning of the ulnar nerve, it is subject to entrapment and injury by a wide variety of causes. The most common sites of entrapment around the elbow are the olecranon groove and the cubital tunnel. With its superficial position at the elbow, it is often injured by excessive pressure in this area (leaning on the elbow during work, while driving a car, using elbows to lift the body from bed, and resting elbows on car windows while driving, epicondylar fracture). Fracture fragments and arthritic spurs in or around the groove impinging on the nerve can also cause entrapment and subsequent neuritis. Traumatic hemorrhage, soft tissue tumors, ganglia, infections, osteochondromas, and synovitis secondary to rheumatoid diseases may also cause entrapment and nerve dysfunction. Epidemiology: Ulnar nerve entrapment is the second most frequent entrapment neuropathy in the upper extremity (the first being the median nerve and its branches). Because of the anatomic arrangement of structures, the area around the elbow is the most common area for entrapment. The ulnar nerve can also be compressed at Guyons canal.

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2 Diagnosis: Presenting symptoms can vary from mild transient parasthesias in the ring and small fingers to clawing of these digits and severe intrinsic muscle atrophy. The patient may report severe pain at the elbow or wrist with radiation into the hand or up into the shoulder and neck. Patients may report difficulty in opening jars or turning doorknobs. Early fatigue or weakness may be noticed if work requires repetitive hand motions. If the patient rests on the elbows at work, increasing numbness and parasthesias may be noticed throughout the day. Tenderness to palpation along the course of the nerve is probable. Flexor carpi ulnaris and flexor digitorum profundus strength may be weak. Weakness of thumb pinch may be elicited by the Froment sign. Numbness usually precedes motor loss. Muscle wasting and clawing of the ring and small digits are indicative of a chronic compressive syndrome. Ulnar nerve compression will either occur at the cubital tunnel or Guyons canal. The dorsal cutaneous branch of the ulnar nerve comes off proximal to Guyon canal. Therefore, dorsal sensory involvement of the 4th and 5th digits would indicate a problem proximal to the wrist. Thus by assessing whether the numbness involves both volar and dorsal or just dorsal aspects of digits you can diagnosis compression site. Radiographs of the elbow reveal abnormal anatomy, such as a valgus deformity, bone spurs or bone fragments, a shallow olecranon groove, osteochondromas, and destructive lesions (e.g., tumors, infections, abnormal calcifications). Electromyography tests and nerve conduction studies are indicated to confirm the area of entrapment, document the extent of the pathology, and detect or rule out the possibility of double crush syndrome. Nonoperative versus Operative Management: Conservative treatment of ulnar nerve compression is most successful when parasthesias are transient and caused by malposition of the elbow or blunt trauma. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting elbows on car windows while driving all are causes of parasthesia that can be corrected without surgical treatment. Patient education, anterior elbow extension splinting (if necessary), nerve mobilization techniques, soft tissue mobilization, ultrasound, strengthening exercises, stretching and correction of ergonomics at work should correct these transient palsies. Nonsteroidal anti-inflammatory medications also are useful adjuncts to relieve nerve irritation. Oral vitamin B-6 supplements may be helpful for mild symptoms. This treatment should be carried out for 6-12 weeks, depending on patient response. Indications for surgery are the following: 1) no improvement in presenting symptoms after 6-12 weeks of conservative treatment, 2) progressive palsy or paralysis, 3) clinical evidence of a long-standing lesion (e.g., muscle wasting, clawing of the fourth and fifth digits.) Dellons investigation noted that ulnar nerve transposition was associated with an 88% rate of good to excellent results. Fitzgerald noted that the average duration of limited work capacity (full military active duty work status) was 4.8 months (range 3-7 months).

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3 Surgical Procedure: Decompression with anterior transposition usually is the operation of choice for ulnar nerve compression at the elbow because it removes the nerve from its compressive bed and puts it in one that is more suitable. By transferring the nerve anteriorly, it effectively lengthens the nerve, decreasing tension on it in flexion. It is the most commonly used method of transposition because it is easy to perform and results are good. An incision begins 8 cm above the medial epicondyle and continues downward to a point midway between the medial epicondyle and the olecranon groove. It then continues for about 6 cm distally over the flexor carpi ulnaris. Once the nerve has been visualized the distal portion of the medial intermuscular septum, the fibroaponeurotic roof of the epicondylar groove, the Osborne ligament, and the fascia of flexor carpi ulnaris are incised, freeing the ulnar nerve. The nerve is positioned beneath the subcutaneous tissue and held to the muscle fascia with a few sutures through the epineurium. Postoperatively, the elbow is immobilized in a cast or splint at 45 degrees of flexion for 2 weeks.

Preoperative Rehabilitation Further injury protection using a splint with the elbow in about 90 degrees of flexion for 2 weeks Instructions/review post-operative rehabilitation plan

POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Andrews, Hurd and Wilk. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales. Phase I for Immobilization and Rehabilitation: Weeks 1-3 Goals: Control edema and pain Protect surgical site Minimize deconditioning of upper extremity Manage edema Increase elbow ROM Intervention: Posterior splint with elbow at 90 degrees of flexion At 2 weeks, place elbow in hinged elbow brace set a -30 extension and 100 flexion At 3 weeks progress brace ROM to -15 extension and 110 flexion Cryotherapy Submaximal isometrics for shoulder and wrist Active wrist flexion and extension

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4 Phase II for Immobilization and Rehabilitation: Weeks 4-8 Goals: Elbow active range of motion 0-145 Continue to protect repair and from unprotected valgus force Increase upper quarter strength Improve tolerance to active range of motion Intervention: Brace set at -10 extension and 120 flexion. May increase 5 extension and 10 flexion per week Isotonic exercise (1-2 lbs) Wrist flexion/extension, forearm pronation/supination, elbow flexion/extension, and rotator cuff exercises avoiding internal rotation After 6 weeks, brace set at 0-130, add shoulder internal rotation exercises and progress all exercises as indicated

Phase III for Rehabilitation: Weeks 9-13 Goals: Increase strength of upper extremity Increase muscular control of upper extremity Full range of motion (ROM) Allow patient to become pain free or self-manage with gradual return to activities Strengthen upper extremity with sport-specific activities Intervention: Progress with plyometric exercises Isotonic exercises Progress wrist, elbow and shoulder Initiate eccentric elbow flexion and extension exercises Proprioceptive neuromuscular facilitation (PNF) patterns Light sporting activities such as golf or swimming

Phase IV for Rehabilitation: Weeks 14-26 Goals: Symmetric upper extremity strength Gradual return to unrestricted sport activity Intervention: Continue intervention strategies listed in Phase III as indicated by remaining impairments Return to competitive sports between 22 and 28 weeks

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Selected References: Andrews J, Hurd WJ, Wilk KE. Reconstruction of the Ulnar Collateral Ligament with Ulnar Nerve Transposition. In Maxey L, Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2001. Dellon AL, Coert JH. Results of the musculofascial lengthening technique for submuscular transposition of the ulnar nerve at the elbow. J Bone Joint Surg. 2004;86-A Suppl 1(Pt 2):16979. Fitzgerald BT, Dao KD, Shin AY. Functional outcomes in young, active duty, military personnel after submuscular ulnar nerve transposition. J Hand Surg. 2004;29(4):619-24. Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Phys Ther. 2002;82:1077-1086. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. 1998;6(5):282-8.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Ulnar Collateral Ligament Reconstruction


Surgical Indications and Considerations Anatomical Considerations: The ulnar collateral ligament complex consists of three ligaments including the anterior oblique, posterior oblique, and transverse ligament. The anterior oblique originates at the medial epicondyle and inserts into the medial coronoid process. The anterior oblique ligament is considered the primary stabilizer of the elbow to valgus stress during the throwing motion and is the most commonly injured portion. Pathogenesis: The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus force stress during the late cocking and acceleration phases of throwing. During these phases the tensile force placed on the anterior bundle exceeds its restraining capabilities. Repeated valgus stress results in a degenerative process of the ulnar collateral ligament with eventual increased laxity and medial instability. In this sense, overuse is the primary cause of ulnar collateral ligament injury. Often a single episode during the throwing motion will cause the final insult or tear. However, an underlying degenerative process is the primary pathology. Laxity of the ulnar collateral ligament results in overuse injuries of the dynamic stabilizers of the elbow secondary to compensatory mechanisms. These injuries include pronator and flexor mass tendinopathy. The instability of the ulnar collateral ligament will cause abnormal force and subsequent symptoms to other elbow structures including the radiocapitellar compartment, posteriomedial olecranon, medial epicondyle, and ulnar nerve. Epidemiology: Ulnar collateral ligament injuries occur primarily in overhead athletes such as baseball players, javelin throwers, quarterbacks, tennis players, and water polo players. These athletes are subjected to valgus force at the medial elbow during the throwing motion, which is the primary cause of ulnar collateral ligament injuries. Other athletes subjected to medial valgus stress include wrestlers, gymnasts, and hockey players. Diagnosis Differential diagnosis is usually difficult due to the fact that ulnar collateral ligament injuries have an underlying degenerative process that predispose the patient to concomitant symptoms of flexor and pronator mass tendinopathy, ulnar neuritis, and symptoms consistent with loose bodies in the elbow Most pain is felt during the acceleration phase of throwing and at the point of ball release Some patients will describe a giving way feeling after a throwing motion and will be unable to continue throwing thereafter (considered the final insult to a degenerative process) Point tenderness two centimeters distal to the medial epicondyle Pain and instability with a valgus stress test (humerus stabilized with elbow at thirty degrees flexion). This test may also produce numbness and tingling in the ulnar nerve distribution because the excess medial gapping at the elbow will stretch the ulnar nerve

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2 Several types of valgus stress tests are described in the current literature with different positions of the humerus. Note that compensatory humeral torsion deformities are believed to occur with throwing athletes which may alter the examiners view of relative glenohumeral range of motion Imaging studies and arthroscopy have proven helpful with diagnosis of ulnar collateral ligament injuries. However, due to variability of ulnar collateral ligament laxity associated with symptomatic versus asymptomatic elbow pain, physical examination and patient history remain as the primary means of diagnosis.

Nonoperative Versus Operative Management: Nonoperative management has yielded acceptable results in the non-throwing athletic population. Nonoperative rehabilitation starts with a period of active rest, which consists of cessation of throwing while focusing on strengthening of the rotator cuff and shoulder girdle. Once elbow pain resolves, a strengthening program of the pronator and flexor musculature is initiated. If elbow pain remains controlled and shoulder mechanics are satisfactory, an interval-throwing program is employed. Surgical reconstruction versus repair is recommended for any patient wishing to return to throwing activities. Both non-surgical rehabilitation and postoperative repairs have shown a high incidence of valgus laxity in follow-up studies when compared to reconstruction procedures. Ulnar collateral reconstruction has proven effective in several patient populations including high level throwing athletes. Surgical Procedure: The most current and accepted procedure is a modification of the original technique described by Jobe et al. This current method elevates the flexor-pronator muscle mass from the elbow without detachment and utilizes subcutaneous rather than sub muscular ulnar nerve transposition. Several types of tendon grafts have been used to reconstruct the ulnar collateral ligament including the gracilis, plantaris, and toe extensor tendons. Currently the palmaris longus is the graft of choice and the most commonly used tendon for reconstruction. The graft is woven in a figure eight fashion through bone tunnels at the medial ulna and humerus. The elbow is then placed in ninety degrees of flexion and splinted for one week after surgery for soft tissue healing. Preoperative Rehabilitation Cessation of throwing program Focus towards controlling symptoms at the elbow Initiate a shoulder girdle strength and stabilization program including rotator cuff strengthening Flexor and pronator mass strengthening initiated if elbow pain is controlled Educate and familiarize patient to post-operative rehabilitation

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Andrews, Hurd, and Wilk. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales. Phase I for Immobilization and Rehabilitation: Weeks 1-3 Goals: Protect surgical site Improve tolerance to elbow range of motion Control pain and edema Improve upper extremity strength and muscle contraction Improve active wrist range of motion Intervention: Posterior splint with 90 degrees elbow flexion for 1-2 weeks replaced by hinged brace at 30 to 100 degrees At 3 weeks progress brace to 15 to 115 degrees Rest, ice, compression, and elevation Submaximal shoulder isometrics At 2 weeks begin wrist flexion and extension

Phase II for Mobilization and Rehabilitation: Weeks 4-8 Goals: Elbow active range of motion 0-145 degrees Protect elbow from valgus force Increase functional strength of upper extremity Improve tolerance to active range of motion Intervention: Elbow brace set at 10-120 degrees and increased by 5 degrees extension and 10 degrees flexion per week Isotonic exercise (1-2 pounds) for wrist flexion/extension, forearm pronation/supination, elbow flexion/extension, and rotator cuff exercises except internal rotation At 6 weeks: brace set at 0-130 degrees and add shoulder internal rotation exercises

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase III for Mobilization and Rehabilitation: Weeks 9-13 Goals: Increase muscular control of upper extremity Prepare for return to previous activities Allow patient to self manage symptoms and gradually return to activities Sport specific training Intervention: Continue exercises in phase I and phase II Begin plyometric exercises in throwing position Initiate eccentric elbow flexion/extension exercises Proprioceptive neuromuscular facilitation patterns Light sporting activities (golf and swimming) Rotator cuff, shoulder girdle stabilization, and shoulder active range of motion isotonics Elbow flexion/extension exercises Forearm pronation/supination exercises Wrist flexion/extension exercises

Phase IV for Mobilization and Rehabilitation: Weeks 14-26 Goals: Symmetric upper extremity strength Gradual return to unrestricted sport and throwing Intervention: Interval warm up throwing program at 60 to180 feet with two sessions of 25 throws at each distance with a 10-minute rest between each session Fastball only throwing program starting at 15 throws off a mound at 50% and increasing the number of throws by 15 until reaching 60 throws Fastball only throwing program with the above progression at 75% Fastball progression as above with initiation of breaking pitches at 50% Work up to simulated game progression and limit breaking pitches to 25% of total throws Return to competitive level at 22 to 28 weeks

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Selected References: Azar F, Andrews J, Wilk K, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28:16-23. Andrews J, Hurd W, Wilk K. Reconstruction of the Ulnar Collateral Ligament with Ulnar Nerve Transposition. In Maxey L, Magnusson J, eds., Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2001. Cain E, Dugas J, Wolf R, Andrews J. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003; 31:621-634. Safran M. Injury to the ulnar collateral ligament: diagnosis and treatment. Sports Med Arthrosc. 2003;11:15-24. Rettig C, Colin S, Snead S, Mendler C, Mieling P. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med. 2001;29:15-17. Timmerman L, Andrews J. Histology and arthroscopic anatomy of the ulnar collateral ligament of the elbow. Am J Sports Med. 1994;22:667-673.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Total Elbow Arthroplasty and Rehabilitation

Surgical Indications and Considerations Anatomical Considerations: There are three bones and four joint articulations that have a high degree of congruence in the elbow. Also, the ulnar nerve runs directly through the ulnar groove of the humerus and travels down the medial forearm. With joint replacement, careful consideration must be taken to limit ulnar nerve entrapment. The ulnar nerve is subject to transient (10%) or, occasionally, partial dysfunction. Routine anterior translocation has been beneficial, but there is considerable variation in technique in this regard. Triceps insufficiency can be virtually eliminated with the Kocher lateral-to-medial or the Bryan lateral-to-medial triceps-sparing approach. Pathogenesis: In elbow arthritis the joint surface is destroyed by wear and tear, inflammation, injury, or previous surgery. This joint destruction makes the elbow stiff, painful, and unable to carry out its normal functions. Rheumatoid arthritis (RA) usually affects the elbow in the first five years of onset. Individuals with RA of the elbow usually notice pain, stiffness, and loss of the ability to use the elbow for their usual activities. Commonly, they have difficulty sleeping on the affected arm and notice a limited range of motion in the elbow. Some people with arthritis notice a grinding feeling when the elbow is moved. Rheumatoid arthritis of the elbow usually gets worse over time, but the rate of this progression varies widely. Distal humerus fractures typically occur during high energy situations (such as motor vehicle accidents) or during low energy situations (such as a fall). Epidemiology: Total elbow arthroplasties are most commonly performed on elbows with severe rheumatoid arthritis and elbows with distal humerus fractures. Elbow fractures comprise approximately 4.3% of all fractures. These fractures typically occur in young boys ages 5-10. In contrast, total elbow arthroplasty is also considered to be a viable treatment for women over the age of 65 with distal humerus fractures. Diagnosis Intractable pain Joint Instability Failed synovectomy Decreased elbow ROM Severe RA Ulnohumeral ankylosis Non-operative Vs Operative Management: Non surgical interventions such as casting can be recommended for distal humerus fractures. Although, surgical intervention can become necessary for distal humerus fractures when fracture type, soft tissue involvement, joint stability and bone integrity are assessed. Surgical intervention is normally recommended for elbow joints with severe rheumatoid arthritis. The goal of elbow replacement arthroplasty is to restore functional mechanics to the joint by removing scar tissue, balancing muscles, and inserting a joint replacement in the place of the destroyed elbow.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Post Surgical Considerations Risk of infection Joint dislocation Prosthetic loosening Surgical Procedure: There are many different surgical approaches and implants for total elbow arthroplasties. The Coonrad-Morrey implant has been found to prevent dislocation without increasing the risk of loosening (Little, 2005). This implant is semiconstrained (unlinked prosthesis) which requires the preservation of bone stock and the ability to achieve stability of the collateral ligaments. Elbow joint replacement surgery is a highly technical procedure; each step plays a critical role in the outcome. The Bryan-Morrey approach is often used for this procedure. A straight 15cm incision centered lateral to the medial epicondyle and medial to the tip of the olecranon. The ulnar nerve is located and translocated to protect it from damage. After the anesthetic has been administered and the elbow has been prepared, an incision is made along the medial aspect of the proximal ulna, from three inches above the elbow to three inches below it. This incision allows access to the joint without damaging the important muscles that are responsible for the elbow's motion. The medial aspect of the triceps along with the anconeus is reflected laterally. The radial and ulnar collateral ligaments are also released from the anconeus. This is done to avoid fracturing the medial column by the ligament when the forearm is manipulated. The ulnar nerve is also isolated to protect it during the procedure; as a result, the little finger is sometimes numb for a period of time after this surgery. The muscles and other tissues near the elbow are mobilized by removing any scar tissue that may restrict their motion. The capsule is released in front of and behind the elbow joint. The distal end of the humerus and the proximal of the ulna are fit to receive their respective implants. The components are stabilized by cementing their stems inside the bones using polymethylmethacrylate (bone cement). Once the implants are securely fixed, they are linked together using a hinge pin. At the conclusion of the procedure, the deep tissues and skin are closed and a protective dressing is applied. PREOPERATIVE & POST OPERATIVE REHABILITATION Note: The following rehabilitation protocol is taken from Protocol for Rehabilitation from Seacoast Orthopedics and Sports Medicine (sosmed.org). Refer to the previously noted website for further information regarding this progression. General Rehabilitation Guidelines Program for Total Elbow Arthroplasty Rehabilitation Considerations: Hematoma formation follow elbow arthroplasty can lead to pain and loss of motion in the early phases after surgery. Attempts to reduce and mobilize edema are critical in the early phases. Hematoma also increases the risk of infection which occurs in 2-3 percent of elective cases and up to 7% of cases performed for trauma.

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Full flexion and extension can usually be obtained on the table but stiffness may ensue rapidly. Continuous passive motion is almost always employed when possible but patients must be encouraged to perform daily stretching exercises to preserve motion. Because the extensor mechanism must heal back to the ulna, active elbow extension, such as using the arm to assist in rising from a chair, is not permitted for 8 weeks. Adjacent joint therapy may be particularly important for patients with rheumatoid arthritis who may have concomitant disease of the shoulder and wrist. Pre-rehabilitation: Instruct in application of ice and encourage use as much as tolerated within a 24 hour period for first week. If using ice packs, encourage to ice 20-30 minutes every 3-4 hours while awake. Instruct in home program of elbow flexion, extension, pronation and supination. Instruct in basic progression of rehabilitation program and expectations for time course to recovery Arrange follow-up physical therapy appointment on 7th-10th day post-op to correspond with physicians post-operative evaluation Inpatient: (0-4 days) Arm is generally splinted in extension with hemo-vac drain in place for 1st 36 hours to prevent swelling and reduce chance of a hematoma. Arm is generally elevated in a sling on a pole. Evening of the first postoperative day, the splint is removed and patients are started on CPM set to provide full flexion and extension. Arm should be removed every 1-2 hours to prevent compressive neuropathy Cryotherapy in between sessions ROM Instruct in home program, and begin, active assisted elbow and wrist flexion, extension, pronation and supination Instruct in home program, and begin, self-assisted forward elevation and external rotation of the shoulder to prevent adjacent joint stiffness Finger ROM but no aggressive grip strengthening so that muscular attachments heal Other Instruct to don and doff sling Methods of edema control Instruct in precautions of no active elbow extension and avoid direct pressure on posterior aspect of elbow Instruct on proper use of ice or cryocuff 20-30 minutes at a time, several times per day, especially after exercises Arrange for outpatient physical therapy follow-up to begin on day of office follow-up

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Wound Instructions Dry gauze to wound q day until dressing totally dry, then cover prn May shower at 7 days but no bath or hot tub for 3 weeks Outpatient Phase 1: (Hospital Discharge to Week 4) ROM Continue program active elbow and wrist flexion, pronation and supination and active assisted elbow flexion. Continue shoulder flexibility exercises Strength Can start gentle grip strengthening but no active elbow or wrist strengthening exercises until Phase II Sling Sling should only be used when patients are out in busy or crowded locations but not around the house and not to bed Other Incision mobilization and desensitization Modalities for pain, inflammation and edema control (no e-stim) Cryotherapy as needed Ulnar nerve desensitization Outpatient Phase 2: (Weeks 5-8) ROM Continue shoulder elbow and wrist ROM At 6 weeks can add active extension (anti-gravity only but no resistance) Night time extension splinting if flexion contracture developing Strength May begin gentle isometric and isotonic wrist flexion/extension and elbow flexion strengthening Biceps strengthening should be done with elbow supported No elbow extension strengthening Sling Sling should be fully discontinued at this point Other Continue scar massage Outpatient Phase 3: (Weeks 9 -12) ROM Active range of motion in all planes

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Continue night time extension splinting if necessary Dynasplint if flexion contracture >30o

Strength Continue isotonic strengthening May add anti-gravity active extension but no resistance May add UBE at very low resistance for conditioning May add exercises for shoulder to promote generally upper extremity conditioning Outpatient Phase 4: Weeks 12 - 16) ROM Continue maintenance flexibility program Strength Progressive isotonic resistance including elbow extension Progress to functional use

Selected References: Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A Comparison of Open Reduction and Internal Fixation and Primary Total Elbow Arthroplasty in the Treatment of Intraarticular Distal Humerus Fractures in Women Older Than Age 65. J of Orthop Trauma. 2003(8);17(7):473-480. Little CP, Graham AJ, Karatzas G, Woods DA, Carr AJ. Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants. J Bone Joint Surg Am. 2005;87:2439-2448. Mansat P, Morrey BF. Semiconstrained Total Elbow Arthroplasty for Ankylosed and Stiff Elbows. J Bone Joint Surg Am. 2000; 82:1260. Morrey BF, Bryan RS. Complications of Total Elbow arthroplasty. Clinical Orthop Relat Res. 1982;170:204-12. Morrey BF. The Elbow and its Disorders 2nd ed. Philadelphia, PA: W.B. Saunders Co.; 1993: 648-765. Shafer BL, Fehringer EV, Boorman RS, Churchill RS, Matsen FA. Ulnar Component Fracture After Revision Total Elbow Arthroplasty with Proximal Ulnar Bone Loss: A Report of 2 Cases. J Shoulder Elbow Surg. 2003; 12:297-30.1

Cuong Pho DPT, Joe Godges DPT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems Medical Screening for the Knee, Leg, Ankle or Foot Region
Condition Fractures1-4 Red Flag Data obtained during Physical Exam Joint effusion and hemarthorsis Bruising, swelling, throbbing pain, and point tenderness over involved tissues Unwillingness to bear weight on involved leg Unilaterally cool extremity (may be bilateral if aorta is site of occlusion) Prolonged capillary refill time (>2 sec) Decreased pulses in arteries below the level of the occlusion Prolonged vascular filling time Ankle Brachial index < 0.90 Calf pain, edema, tenderness, warmth Calf pain that is intensified with standing or walking and relieved by rest and elevation Possible pallor and loss of dorsalis pedis pulse History of blunt trauma, crush Severe, persistent leg pain that is intensified with injury - or stretch applied to involved muscles Recent participation in a rigorous, Swelling, exquisite tenderness and palpable unaccustomed exercise or tension/hardness of involved compartment training activity Paresthesia, paresis, and pulselessness History of recent infection, surgery, Constant aching and/or throbbing pain, joint or injection swelling, tenderness, warmth Coexisting immunosuppressive May have an elevated body temperature disorder History of recent skin ulceration or Pain, skin swelling, warmth and an advancing, abrasion, venous insufficiency, irregular margin of erythema/reddish streaks CHF, or cirrhosis Fever, chills, malaise and weakness History of diabetes mellitus Red Flag Data obtained during Interview/History History of recent trauma: crush injury, MVA, falls from heights, or sports injuries Osteoporosis in the elderly Age > 55 years old History of type II diabetes History of ischemic heart disease Smoking history Sedentary lifestyle Co-occurring intermittent claudication Recent surgery, malignancy, pregnancy, trauma, or leg immobilization

Peripheral Arterial Occlusive Disease5-9

Deep Vein Thrombosis10,11

Compartment Syndrome12-14

Septic Arthritis15

Cellulitis16

References: 1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-794. 2. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2002;68:2413-2418. 3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman. J of Bone Joint Surg. 2003;85:820-824. 4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments. Injury. 2004;35:443-461. 5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. Journal of Clinical Epidemiology. 1997;50:659-668. 6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158:1357-1364. 7. Halperin, JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303-11. 8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182. 9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ. 1996;313:1440-79. 10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in outpatients. Amer J Med. 2003;115:436-440. 1. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome. Pain Res Manag. 2001;6:200-203. 2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-104. 3. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup. Postgraduate Medicine. 1999:105. 4. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder. Orthop Trauma. 2002;16:572-577. 5. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 6. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections. Am Fam Physician. 2002; 66:119-124.

Joe Godges DPT

KP SoCal Ortho PT Residency

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE


NAME: ________________________________________ Medical Record #: _________________________ DATE: _____________

Yes 1. Have you recently experienced a trauma, such as a vehicle accident, a fall from a height, or a sports injury? 2. Have you recently had a fever? 3. Have you recently taken antibiotics or other medicines for an infection? 4. Have you had a recent surgery? 5. Have you had a recent injection to one or more of your joints? 6. Have you recently had a cut, scrape, or open wound? 7. Do you have diabetes? 8. Have you been diagnosed as having an immunosuppressive disorder? 9. Do you have a history of heart trouble? 10. Do you have a history of cancer? 11. Have you recently taken a long car ride, bus trip, or plane flight? 12. Have you recently been bedridden for any reason? 13. Have you recently begun a vigorous physical training program? 14. Do you have groin, hip, thigh or calf aching or pain that increases with physical activity, such as walking or running? 15. Have you recently sustained a blow to your shin or any other trauma to either of your legs?

No

Joe Godges DPT

KP SoCal Ortho PT Residency

Knee Capsular Disorder "Knee Capsulitis" ICD-9-CM: 719.56 Stiffness in joint of lower leg, not elsewhere classified

Diagnostic Criteria History: Stiffness Aching with prolonged weight bearing ROM loss - more loss of flexion than extension Pain at end ranges

Physical Exam:

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Knee Capsulitis
ICD-9: 719.56 stiffness in joint of lower leg, not elsewhere classified Description: This disorder is particularly disabling because of it results in difficulty with rising from a chair, climbing stairs, kneeling, and walking. The primary complains are pain, stiffness, instability, and loss of function and sometimes with impaired muscle function. Etiology: It is considered a sequela of traumatic and age-dependent changes which result in a loss of cartilage and impairment of function. Capsulitis has been essentially classified as primary (idiopathic) or secondary, that is a process related to infection, trauma, inflammation, metabolism, or aging. The portion of the capsule that becomes extended on joint sliding or rolling may thicken and act to restrict motion in that direction. This capsular thickening subsequent to synovitis accompanies the destruction of the articular cartilage, and thus the joint mechanism becomes gradually impaired.

Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition Restricted knee motion Pain worse with end-range stretch positions Tibiofemoral accessory movements and joint play movements are considerable limited. Patellofemoral accessory and joint play movements may also be limited Quadriceps femoris muscles may be weak and painful due to the tension transmitted to an inflamed joint capsule by the contracting musculotendinous units that attach to the capsule Palpable tenderness around the joint capsule

Sub Acute Stage / Moderate Condition As above with the following differences Resisted tests of the quadriceps femoris are strong and relatively painless when the tibio-femoral joint positioned in slight flexion (thus lessening tension on the capsule)

Now (when less acute) examine the patient for common coexisting lower quadrant impairments. For example: Lumbar, hip and ankle movement abnormalities Muscle flexibility deficits especially of the hamstrings, tensor fascia lata, iliotibial band and sartorius Nerve mobility deficits especially tibial and common peroneal nerves in the knee area
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

3 Weak quadriceps femoris commonly vastus medialis Restricted knee extension

Settled Stage / Mild Condition As above with the following differences Pain with repetitive activities of the knee especially at end range Passive movements are painful only with overpressures at end range

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Prevent movement induced inflammatory reactions. Avoid muscle guarding Pain free with daily activities that use knee with low range and amplitude of movements Pain free sleep Physical Agents Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding Elevation/compression of knee to assist in reducing inflammation External Devices (Taping/Splinting/Orthotics) Fit patient with knee support if pain relief requires temporary use of an external device Use of assistive device for unloading tissue Therapeutic Exercises Pain free active mobility exercises Pain free walking Pain free walking and swimming in a pool Re-injury Prevention Instruction Temporarily limit end range of flexion or stretches or activities that aggravate the patients condition.

Sub Acute Stage / Moderate Condition Goals: Improve tibiofemoral and patellofemoral mobility Prevent re-injury to the joint capsule Restore strength of the muscles around knee Physical agents May use ultrasound to the joint capsule prior to active or passive stretching procedures/exercises. Manual Therapy Soft tissue mobilization to adaptive shortened myofascia around the knee Joint mobilization to restricted accessory and joint play motions of the tibiofemoral and patellofemoral articulations

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Therapeutic Exercises Provide stretching exercises to enhance carryover of manual stretching procedures Provide strengthening exercises to weak knee and hip muscles Neuromuscular Reeducation Provide proprioception exercises to facilitate correct knee position Therapeutic Exercise Initiate lumbar stabilization exercises (i.e., trunk flexor and extensor strengthening to maintain the lumbar spine in its neutral positions during performance of daily activities Initiate stretching exercises to myofascia with flexibility deficits (e.g., hamstrings) Initiate nerve mobility exercises the nerve with mobility limitations (e.g., sciatic nerve) Promote daily performance of low-stress aerobic activity (e.g., walking)

Settled Stage / Mild Condition Goals: Normalize tibiofemoral and patellofemoral mobility Normalize lower quadrant muscle flexibility and muscle strength Progress activity tolerance Approaches / Strategies listed above Manual Therapy Increase intensity and duration of soft tissue mobilization and myofascial stretching to the maximal tolerable Increase intensity and duration of joint mobilization procedures to the maximal tolerable Therapeutic Exercises Progresses intensity and duration of the stretching exercises as tolerated. Maximize muscle performance of the relevant lower quadrant (hip, knee, ankle and lumbar) muscles required to perform the desired occupational or recreational activities Ergonomic Instruction Provide job/sport specific training

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities. Approaches / Strategies listed above

Selected References Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. Ann Int Med. 2000;132:173181. Puett DW, Griffin MR. Published trials of non medicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Int Med. 1994;121:133-140. Rogind H, Bibow-Nielsen B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil. 1998;79:1421-1427.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Impairment: Limited and Painful Knee Flexion

Knee Flexion MWM Cues: Position the patient supine with the involved knee flexed and a strap around the patients ankle (approximately 80 degrees of knee flexion is required for this procedure) Place one palm on the anterior aspect of the distal femur and the other on the anterior aspect of the proximal tibia Posteriorly glide the tibia Sustain the posterior glide while the patient actively flexes his/her knee and assists the active flexion with a pull on the strap This procedure uses long levers so instruct the patient to apply the force cautiously The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 101-103, 1995

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Limited Knee Extension Limited Tibial Anterior Glide

Tibial Anterior Glide Cues: Position patient with his/her involved thigh supported on the treatment table with the patella just distal to the end of the table a strap securing the proximal femur and/or pelvis to the table adds to the stabilization A belt holding the involved knee in flexion instead of hanging off the edge of the table is a nice courtesy Use a Chuck Berry stance - hug the limb like a guitar and generate the force with a trunk weight shift and a slight knee bend Stand on the lateral side of the involved limb to do an anterior glide of the medial condyle stand on the medial side of the involved limb to do an anterior glide of the lateral condyle The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 169, 1989

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee Muscle Power Deficits Patellofemoral Pain Syndrome ICD-9-CM: 719.46 Pain in joint - lower leg

Diagnostic Criteria History: Anterior knee pain Precipitated by trauma (subluxation), unaccustomed weight bearing activities, or prolonged sitting Worsens with bent knee sitting and activities especially squatting, climbing stairs, or running Limited medial patellar glide and/or excessive lateral patellar glide with pain at end range of one or both of these glides (may need to vary the amount of knee flexion to elicit symptoms) Biomechanical abnormalities (such as pronatory disorders, patella malalignment, VMO/quadriceps weakness, tight lateral retinaculum and myofascia excessive lateral tracking excessive Q angle, hip muscle length and strength imbalances

Physical Exam:

Patella Lateral Glide Cues

Patella Medial Glide

Assess glides at varying degrees of knee flexion - up to about 30 Determine motion availability Determine symptom responses at end range - be sure to use a strong force if mildmoderate forces are asymptomatic

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

"Patellar Tendinitis" ICD-9-CM: 726.64 Patellar tendinitis

Diagnostic Criteria History: Anterior knee pain. Pain associated with repetitive use of extensor mechanism (e.g., jumping, kicking) Symptoms reproduced with palpation to inferior pole of patella, or patella tendon insertion at the tibial tuberosity

Physical Exam:

Patellar Tendon Palpation/Provocation Cues: P= Patella 1= Inferior Pole 2= Superior Pole 3= Tibial Tuberosity

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Iliotibial Band "ITB Friction Syndrome" ICD-9-CM: 726.60 Enthesopathy of knee, unspecified Diagnostic Criteria History: Lateral knee pain Pain precipitated by unaccustomed weight bearing activities - such as stair climbing or running on unlevel surfaces Symptom reproduction with palpation and provocation of (1) Gurdy's tubercle, or (2) lateral femoral condyle with the knee slightly flexed

Physical Exam:

Iliotibial Band Palpation Cues: May need to utilize aggressive palpation to reproduce mild symptoms which develop after extensive repetitive movement. 1 = Gurdy's Tubercle (insertion of ITB) 2 = Lateral femoral condyle (common site of friction with ITB)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

"Pes Anserinus Bursitis" ICD-9-CM: 726.61 Diagnostic Criteria History: Symptom precipitated by recent repetitive activity (e.g., long distance running) usually in the presence of some biomechanical abnormality (e.g., abnormal pronation) Medial knee pain Symptoms reproduced with palpation of pes anserine bursa Pes anserinus bursitis

Physical Exam:

Pes Anserine Palpation Cues: Bursa is located on the medial tibia flare adjacent to the insertion of the semitendinosis (follow tendon distally to locate bursa) 3 = Pes Anserine Bursa

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Patellofemoral Pain Syndrome


ICD-9: 719.46 pain in joint - lower leg Description: Patellofemoral pain syndrome (PFPS) is described as anterior knee pain during squatting, kneeling, stairs, walking and sitting (especially prolonged sitting) with the knee flexed. It is typically caused by poor mechanics of the patella as it travels in the femoral groove during flexion and extension of the knee. This poor tracking which typically causes the patella to deviate laterally, resulting in excessive stress on the medial patello-femoral compartment due to stretching and irritation, as well as increased lateral compartment compression. Etiology: The specific causes of this disorder can vary in individuals and typically lacks a mechanism of injury. Tight lateral structures including the iliotibial band and the lateral retinaculum are thought to be the primary causes. There are several biomechanical factors that contribute to poor tracking of the patella. These include excessive femoral anteversion and increased midfoot pronation with resultant tibial lateral rotation. **The depth, of the femoral trochlear groove also has direct bearing on the tracking of the patella. Another factor is the motor control/strength of the hip abductors and external rotators during weight loading activities. Intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking the patella medially during extension causing the patient to experience PFPS. This disorder is common in adolescent females due to the biomechanical changes occurring as their bodies develop, though is not limited to this population.

Physical Examinations Findings (Key Impairments) Acute Stage / Severe Condition The patients reported symptoms are elicited typically with compressive forces about the involved knee during activities such as squatting and sitting for long periods of time The patella typically has limited medial gliding of the patella secondary to taut peripatellar structures The patient may present with any or all of the following biomechanical abnormalities: an increased Q-angle, femoral anteversion, lateral tibial torsion, and increased midfoot pronation, limited external rotation of the hip, limited tibiofemoral extension, decreased strength in the supinators of the foot during gait, and medial quadriceps weakness.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Sub Acute Stage / Moderate Condition As Above except: The patients reported symptoms are elicited intermittently with the activities noted above.

Settled Stage / Mild Condition Pain may be elicited only in certain positions of excessive patellofemoral compression maintained over prolonged periods of time such as sitting, sustained stair climbing, running or biking with seat too low.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease inflammation Decrease pain Physical Agents Ice Ultrasound (in conjunction with mobilization/manipulation) Acupuncture, acupressure or electroacupuncture for pain control Manual Therapy Soft tissue mobilization to tight lateral peripatellar structures Joint mobilization to the patella medial patellar glides, sustained stretch and high velocity low amplitude manipulation Joint mobilization to the tibiofemoral joint restoring normal knee extension Sacroiliac evaluation and manipulation External Devices (Taping/Splinting/Orthotics) Patellar taping procedures in conjunction with biofeedback and exercise program to promote proper patellar tracking Foot orthotics to correct excessive pronation if present Resistive brace (such as Protonics) to improve hamstring use and restore proper biomechanics Neuromuscular Reeducation Facilitory techniques to improve the contraction of the hip abductors and lateral rotators, foot supinators, and, the quadriceps muscle group, focusing, if possible, on the oblique fibers of the vastus medialis muscle Therapeutic Exercises Stretching exercises for the iliotibial band and hamstrings Initial exercises should be largely closed kinetic chain activities in the pain-free range only Re-injury Prevention/Instruction: Temporarily limit any deep squatting, heavy lifting, or through-range resistive training of the quadriceps

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Sub Acute Stage / Moderate Condition Goals: Normalize lower extremity flexibility muscle strength, motor control, and patellofemoral tracking Approaches / Strategies listed above Therapeutic Exercises Progress exercises to include training for return to a specific work, recreational, or sport activity Assess the biomechanics of aggravating activity (e.g. cycling with a seat too low can increase pain and cause pressure) Promote painfree, low resistance, repetitive exercises (e.g., cycling) that provide non-injurious compressive loads to the patellofemoral cartilage

Settled Stage / Mild Condition Goal: Return to desired activities Approaches / Strategies listed above Therapeutic Exercises Progress stretching, strengthening and coordination exercises which includes training for return to a specific work, recreational, or sport activity

Intervention for High Performance /High Demand Functioning in Workers or Athletes


Goal: Return to desired occupation or sport Approaches / Strategies listed above Further biomechanical assessment during aggravating activity

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33(1):4-19. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993;73(2):62-8. Fulkerson JP. The etiology of patellofemoral pain in young, active patients: a prospective study. Clin Orthop. 1983;179:129-33. Lohman E, Harp T. A critical review of patellofemoral pain syndrome in rehabilitation. Crit Review in Phys Rehab Med. 2002;14(3&4):197-222. Powers CM. Patellar kinematics, part ii: the influence of the depth of the trochlear groove in subjects with and without patellofemoral pain. Phys Ther. 2000;80(10):965-78. Powers CM, Maffucci R, Hampton S. rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther.1995;22(4):155-60. Salsich GB, Brechter JH, Farwell D, Powers CM. The effects of patellar taping on knee kinetics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. J Orthop Phys Ther. 2002; 32(1): 3-10.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10

Patellar Tendinitis
ICD-9: 726.64 patellar tendinitis Description: Repetitive strain injury affecting the patellar tendon, resulting in anterior knee pain. Etiology: This condition is believed to be the result of repetitive mechanical stresses and is most commonly found in athletes whose sport involves repetitive, sudden, ballistic movements of the knee such as jumping. Intratendinous changes can begin as microtears, which lead to collagen degeneration, and subsequent fibrosis. The result is usually pain well localized to a small area of the anterior knee region with specific tenderness at the inferior pole of the patella. Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition Severe local tenderness on palpation at either the proximal or distal insertion of the patellar tendon Accessory movement deficits of patella medial/lateral/superior/inferior glide Pain with maximum stretching of the quadriceps Weak and painful quadriceps muscle when tested isometrically against resistance Symptoms can be reproduced 1) using the decline squat test, 2)with eccentric knee contractions, 3) with deep squats, or 4) with jumping/ sports activities Biomechanical abnormalities of the lower quarter may be present such as excessive foot pronation; patella alta; femoral anteversion; flexibility deficits in the quadriceps, hamstrings, and calf muscles, as well as in the iliotibial band; strength deficits of the gluteal, lower abdominal, quadriceps, and calf muscles

Sub Acute Stage / Moderate Condition As Above except: The patient tolerates more repetitions during functional strength tests before onset of pain (pain may hinder sport performance, but usually does not limit activities of daily living) Patellar tendon palpation is less tender

Settled Stage / Mild Condition As Above except: Symptoms may be difficult to illicit unless repeated strenuous movements are performed Mild local tenderness with patellar palpation note that mild patellar tenderness with palpation may be a normal finding in active athletes

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain Reduce aggravating and predisposing factors Physical Agents Ice Phonophoresis Iontophoresis External Devices (Taping/Splinting/Orthotics) Patellar taping procedures may assist with promoting proper patellar tracking Foot orthotics may be useful to correct excessive pronation Taping or bracing to unload patellar tendon Manual Therapy Joint mobilization at the patella if hypomobility exists Therapeutic Exercise Initiate non-aggravating, stretching exercises for relevant muscles or fascial tissue typically the muscles with trigger points Initiate non-aggravating, strengthening exercises for relevant weak musculature Re-injury Prevention/Instruction: Temporarily limit any deep squatting, heavy lifting, or resistive training of the quadriceps

Subacute Stage / Moderate Condition Goals: Restore function Prevent future re-injury Approaches / Strategies listed above Manual Therapy Friction massage to the patellar tendon Therapeutic Exercise Progress stretching and strengthening to the relevant myofascia and connective tissue Begin sport specific training as tolerated, although still avoiding maximal concentric and eccentric loads

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

12 Settled Stage / Mild Condition Goals: As above Progress activity tolerance Ability to resume sports activity and daily activities without pain Approaches / Strategies listed above Therapeutic Exercise Progress stretching exercises provide a comprehensive lower quarter stretching program with emphasis on patient independence and carryover Progress strengthening exercises with an with eccentric emphasis (e.g., light jumping activities, progressive resistive exercises, sport specific training) Begin sport specific training as tolerated, although still avoiding maximal concentric and eccentric loads

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Full return to sport activity or occupation Approaches / Strategies listed above Therapeutic Exercise Review and correct biomechanics of desired activity, especially landing pattern of jumps, ankle/foot biomechanics, and hip/pelvic balance and stability Agility training specific to sports activity High-velocity ballistic training that is sport specific Single-leg exercises Progress with combinations of load (weight), speed, and jumping height

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

13

Selected References Bellemans J, Witvrouw, et al. Intrinsic risk factors for the development of patellar tendonitis in an athletic population. A two-year prospective study. Am J Sports Med. 2001;29:190-5. Benjamin HJ, Briner WW. Volleyball Injuries. Phys Sportsmed. 1999;27:48-58. Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 1: A New Paradigm for a Difficult Clinical Problem. Phys Sportsmed. 2000;28:38-48. Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 2: Applying the New Approach to Patellar Tendinopathy. Phys Sportsmed. 2000; 28:31-46. Panni AS. Patellar Tendinopathy in Athletes. Am J Sports Med. 2000;28:392-397.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

14

Patellar Bursitis
ICD-9: 726.65 prepatellar bursitis Description: Inflammation and swelling of bursae over the patella. Etiology: Cause is typically trauma, either due to repetitive extremity movement or to acute trauma to patella. In active persons, bursitis can be induced by work activity, as seen by carpet layers, gardeners, and/or roofers. In athletes, patellar bursitis has been reported in football players, wrestlers, basketball players and dart throwers. Direct injury to the bursae comes from repetitive contact with the artificial turf, wrestling mat, hardwood floor, or exercise mat.

Physical Therapy Findings (Key Impairments) Acute Stage / Severe Condition Enlarged bursa, commonly the bordering the patellar surfaces The involved bursa are tender, may be slightly warm, and reproduce the reported symptoms with provocatory palpation Resisted knee extension also reproduce the reported symptoms Decreased range of motion of knee pain with passive knee flexion at end range

Sub Acute Stage / Moderate Condition As Above except: Bursa not as tender to palpation swelling and warmth are also decreased The pain is not as intense with active movement of knee Improved passive range of motion of knee due to decreased swelling and pain

Settled Stage / Mild Condition As Above except: Full active and passive range of motion is available with slight pain at end ranges Muscles around knee may test to be weak, especially the quadriceps

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

15 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease swelling and pain Physical Agents Ice Ultrasound/phonophoresis Patient Education/Re-injury Prevention Avoid activities that aggravate the symptoms Therapeutic Exercises Gentle mobility within painfree ranges

Sub Acute Stage / Moderate Condition Goals: Restore normal knee and patellar and patellar mobility Return to moderate activity Approaches / Strategies listed above Patient Education/Re-injury Prevention Add padding over bursa during kneeling activities Therapeutic Exercises Encourage painfree, low resistance activities such as bicycling or walking

Settled Stage / Mild Condition Goal: Return to pain free daily activity Approaches / Strategies listed above Therapeutic Exercises Provide strengthening to weak lower extremity musculature

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

16 Intervention for High Performance /High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure activities. Approaches / Strategies listed above Therapeutic Exercises Encourage participation in regular low stress aerobic activities to improve fitness, and strength.

Selected References McFarland EG, Mamanee P, Queale WS, Cosgarea AJ. Olecranon and Prepatellar Bursitis: Treating Acute, Chronic, and Inflamed. Phys Sportsmed. 2000; 68(3). Butcher, JD, Salzman, KL, Lillegard WA. Lower Extremity Bursitis. Am Fam Physician. 1996;53:2317-24. Almekinders, LC, Temple, JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998;30:1183-90.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

17

Iliotibial Band Friction Syndrome


ICD-9: 726.60 enthesopathy of knee, unspecified Description: The iliotibial band is a thickened strip of fascia lata that extends from the iliac crest to the lateral tibial tubercle. It serves as a ligament between the lateral femoral condyle and lateral tibia, stabilizing the knee joint. Iliotibial Band Friction Syndrome (ITBFS) is an overuse syndrome resulting from friction between the iliotibial band and the lateral knee. It occurs primarily in runners but is also prominent in cyclists. Characteristic symptoms are sharp pain or burning on the lateral aspect of the knee proximal to the joint line during exercise. For runners, the pain is often most intense during the deceleration phase of gait. Walking with the knee fully extended may lessen the symptoms. Activities start out pain free but symptoms develop after a reproducible time or distance. Pain subsides shortly after the activity but return with the next bout of running or cycling. Etiology: Classified as an over-use injury, Iliotibial Band Friction Syndrome occurs after continuous, steady long distance runs or cycling. It can also occur after unaccustomed change in training programs, i.e. cycling or running over hilly terrain, sprint training, increased training distances, or running on sloped surface (e.g., on the crown of the road always running in the same direction, such as against traffic). The main symptom is lateral knee pain proximal to the joint line during exercise. Other predisposing factors are sudden increase in training distances, cavus foot, genu varum, tibial varum, rearfoot and/or forefoot varus, and leg length discrepancy. There is also evidence that weak hip abductor musculature is a contributing factor.

Physical Examinations findings (Key Impairments) Acute Stage / Severe Condition Antalgic gait Stiff legged walking in order to reduce knee flexion Aggravation of symptoms upon climbing or descending stairs or running downhill Pain elicited upon thumb pressure over lateral femoral condyle while active flexionextension of the knee is performed, with maximum pain at 300 flexion Positive Obers test suggesting a Tight tensor fascia lata Soft tissue restriction along the iliotibial band Provocation of pain with palpation over Gurdys tubercle

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

18

Sub Acute Stage / Moderate Condition As above with the following differences Reduced antalgic gait. Increased knee flexion during walking Reduced aggravation of symptoms upon climbing or descending stairs or running downhill Decreased pain upon thumb pressure over lateral femoral condyle while active flexion-extension of the knee is performed, with maximum pain at 30o flexion Reduced pain after start of activity (running, cycling)

Settled stage / Mild Condition As above with the following differences Mild pain after start of activity (running, cycling)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

19

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Control pain and inflammation Correct poor training habits or any other structural abnormalities Physical Agents Ice packs, ice massage Ultrasound Phonophoresis Electrical stimulation Re-injury Prevention Instruction Temporarily limit any activity that aggravate symptoms

Sub Acute Stage / Moderate Condition Goals: Avoid continued irritation Prevent Re-injury Approaches / Strategies listed above Manual Therapy Soft tissue mobilization and manual stretching to the fascial adhesions to the ITB

Therapeutic Exercises Stretching intended to elongate the iliotibial band, such as Half-kneeling diagonal stretch, Ober stretch, modified Ober stretch, Crossover toe touch, Lateral hip drop stretch The most tension on the ITB is created by having the patient standing and extending and adducting the leg to be stretched across and behind the other leg. The patient than sidebends the trunk away from the involved hip/thigh hands clasped overhead Re-injury Prevention Instruction Instruction in proper footwear (including bicycle toe clip options) and orthotics may be helpful (a lateral sole wedge may be of help)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

20

Settled Stage / Mild Condition Goals: As Above Prevent recurrence of resolved symptoms. Approaches / Strategies listed above Therapeutic Exercises Provide stretching exercises to elongate shortened myofascial (e.g., hip flexors, calf muscles) and strengthening exercises to improve the motor performance in weak muscles (e.g., gluteus medius and gluteus maximus) Re-injury Prevention Instruction Instruction in proper footwear and orthotics may be necessary

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: To return to optimum level of function at work or sports. Approaches / Strategies listed above Therapeutic Exercises Continuation of gradual increase in distance and frequency of activities

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

21

Selected References Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med. 1992;14:144-148. Drogset JO, Rossvoll I, Grontvedt T. Surgical treatment of iliobitial band friction syndrome: A retrospective study of 45 patients. Scand J Med Sci Sports. 1999;9:296-298. Fredericson M, Guillet M, DeBenedictis L. Quick solutions for iliotibial band syndrome. Phys Sports Med. 2000;28. Fredericson M, White JJ, MacMohon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83:589-92. Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band friction syndrome in cyclist. Am J Sports Med. 1993;21:419-424. Martens M, Libbrecht P, Burssens A. Surgical treatment of the iliotibial band friction syndrome. Am J Sports Med 1989;17:651-654. Noble CA. Iliotibial band friction syndrome in runners. Am J of Sports Med. 1980;8:232-234. Noble HB, Hajek RM, Porter M. Diagnosis and treatment of iliotibial band tightness in runners. Phys Sports Med. 1982; 10:67-74.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

22

Pes Anserine Bursitis


ICD-9: 727.9 unspecified disorder of synovium, tendon, and bursa Description: An inflammatory condition of the medial knee especially common in certain patient populations and often coexisting with other knee disorders. The term pes anserinus refers to the conjoined tendons of the sartorius, semitendinosus, and gracilis muscles as they cross the proximal aspect of the tibia to insert along its medial surface. The term originates from the Latin pes for foot and anserinus for goose and derives from the anatomic observation that the tendons form a structure reminiscent of a gooses webbed foot. Etiology: Inflammation of the pes anserine bursa. This bursa is located 2 inferior to joint line at the medial tibial flare. Inflammation to this bursa is often a sequela to local trauma, exostosis and tendon tightness, pes planus (predisposes the patient to problems affecting the medial knee) or DJD affecting the knee especially in overweight middle-aged to elderly women . A female patient who is overweight can also experience referred pain to the knee from broad pelvic area with the resultant angulation at the knee joint putting more stress on the bursa.

Physical Examinations Findings (Key Impairments) Tenderness over proximal medial tibia May have localized swelling at the insertion of medial hamstring muscles Negative valgus stress at 30 flexion lessens likelihood of medial collateral ligament strain Negative McMurrays and painfree knee flexion overpressures lessens the likelihood of meniscal involvement Positive resisted knee flexion in prone position

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

23

Intervention Approaches / Strategies Goal: Decrease swelling and pain. Physical Agents Iontophoresis with dexamethasone Ultrasound/ phonophoresis Electrical stimulation Ice Therapeutic Exercises Gentle stretching in pain free ranges of: sartorius (hip IR in hip and knee extension) gracilis (supine hook lying, gently spread knees apart) hamstrings (long sit, foot turned slightly in, loop towel or sheet around foot and pull gently while maintaining lumbar lordosis) triceps surae (standing one with knee extended and one leg flexed) Quadriceps, hamstring and calf strengthening External Devices (Taping/Splinting/Orthotics) Orthotics, where indicated, to correct pes planus Re-injury Prevention Instruction Instruct patient in appropriate exercises, stretches, application of ice and instruct in the use of orthotics Patient education for weight management

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

24 Selected References Abeles M. Anserine bursitis. Arthritis Rheum. 1986;29:812-3. Brookler MI, Mongan ES. Anserina bursitis: a treatable cause of knee pain in patients with degenerative arthritis. California Medicine. 1973;119:8-10. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996;53:2317-2324. Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part II: Differential Diagnosis. American Family Physician. 2003;68:917. Forbes JR, Helms CA, Janzen DL.Acute Pes Anserine Bursitis: MR Imaging. Radiology. 1995; 194:525-527 Handy JR. Anserine bursitis: a brief review. South Med J. 1997; 90:376-7. Hemler DE, Ward WK, Karstetter KW, Bryant, PM. Saphenous Nerve Entrapment caused by Pes Anserine Bursitis mimicking Stress Fracture of Tibia. ArchPhys Med Rehabil. 1991;72:3367. Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arth Rheum 1985;28:1062-5. Magee, D. Orthopedic Physical Assessment 3rd ed. WB Saunders Co., Philadelphia, PA, 1997 Stuttle FL: The no-name and no-fame bursa. Clin Orthop. 1959;15:197-99. White, T. Pes anserine (knee) bursitis rehabilitation exercises. Sports Medicine Adviser 2002.1. http://www.med.umich.edu/1libr/sma/sma_pesanser_rex.htm

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Knee Movement Coordination Deficits Anterior Cruciate Ligament ACL Tear ICD-9-CM: 844.2 Sprain of cruciate ligament of knee

ACL Insufficiency ICD-9-CM: 717.83 Old disruption of anterior cruciate ligament

Medial Collateral Ligament MCL Tear ICD-9-CM: 844.1 Sprain of medial collateral ligament of knee

Diagnostic Criteria History: ACL Tear: Trauma or strain - often accompanied by an audible snap or pop, followed by rapid onset of a large effusion/hemarthrosis ACL Insufficiency: Episodic giving way, effusion and pain with specific (usually pivoting) activities MCL Tear: Trauma involving a valgus stress (e.g., from a fall or a blow to the lateral knee) ACL Tear and Insufficiency: Excessive anterior tibial translation with Lachmans Test MCL Tear: Pain - and possibly laxity - with valgus stress test at 30 degrees of knee flexion

Physical Exam:

Lachmans Test Cues: Stabilize femur, pull tibia anteriorly in a line parallel to the tibial plateau - determine the amount of tibial anterior translation (0-2 mm is normal) Other tests (e.g., anterior drawer, pivot shift, KT 2000) may also be used to assess ACL integrity Involuntary, protective muscle guarding by the patient lowers sensitivity of these tests

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Valgus Stress Test Cues: Stand facing patient Allow thigh to rest on table, flex tibia off table Performing test at 30 degrees of knee flexion is more selective for MCL involvement Prevent rotational motion of femur and tibia when applying the valgus stress

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Medial Collateral Ligament Sprain of the Knee


ICD-9: 844.1 sprain of medial collateral ligament of knee Description: Tension injury to the medial collateral ligament of the knee commonly from a sudden application of valgus force to the knee. The MCL tenses to the point of micro or macroscopic injury to its structure. Etiology: The medial collateral ligament can be injured as the result of contact with a direct blow to the lateral aspect of the thigh/leg or noncontact with the sudden application of a valgus torque to the knee. The classic example is a direct blow to the lateral aspect of the athletes knee while the foot is planted to the ground. Physical Examination Findings (Key Impairments) Acute Stage/ Severe Condition May have the inability to walk or bear weight without pain in more severe cases Minimal to moderate effusion and warmth with an isolated MCL injuries; larger amounts of effusion are associated with ACL and PCL tears which must be ruled out Palpation of the MCL produces tenderness Knee extension and flexion may be limited due to joint effusion and pain. Abnormal laxity and the reproduction of symptoms are identified with valgus stress testing at 30 degrees of knee flexion. May have weakness and pain with knee extension and flexion manual muscle testing due to the close anatomical proximity of the MCL to vastus medialis, semitendinosis, and semimembranosis. In a contact injury, lateral structures such as vastus lateralis and biceps femoris may also be affected.

Sub Acute Stage / Moderate Condition As above with the following differences Able to walk with minimal pain and without a significant limp Strong and painful knee extension and flexion with manual muscle testing Minimal to no effusion at the knee

Settled Stage/ Mild Condition As above with the following differences Knee motion may be limited by stiffness with non-painful spongy end feel or motion may not be limited at all May have difficulty with deep squatting, cutting (Zigzags), and sprinting
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

4 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain, swelling, and inflammation at the knee Maintain knee mobility Restore strength to hamstrings and quadriceps Encourage weight bearing of involved leg Maintain general conditioning Physical Agents: Ice with compressive wrap or Cryo/Cuff applied to injured knee with elevation Ultrasound Electrical stimulation Manual Therapy Friction massage External Devices (Taping/Splinting/Orthotics) May use crutches as required to limit pain May consider a Neoprene sleeve or minimally restrictive lateral hinge brace Therapeutic Exercises Range of motion exercises of the knee (passiveactive assistedactive) Quadriceps setting and straight leg raise exercises (isometric) Upper body ergometer or swimming to maintain general fitness level while MCL is healing Patient Education/Re-injury Prevention Avoiding activities that may stress the MCL

Subacute Stage/ Moderate Condition Goals: Walk unassisted without a limp Achieve 90o of knee flexion Increase knee strength Maintain general conditioning Approaches / Strategies listed above Therapeutic Exercises Begin isotonic progressive resistive for quadriceps and hamstrings Begin isokinetic exercise if available Begin closed-chain exercises Bicycle ergometer, stair climber Exercises to increase knee flexion to 90o

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Settled Stage/ Mild Condition Goals: Achieve full knee ROM Begin running and functional exercise program Continue with general conditioning Therapeutic Exercise Full active knee motion exercises Improve muscle performance required to participate in desired occupational or recreational activities. For example: Fast speed walking to gentle straight-line jogging Jumping Sprints Zig-zags

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goals: Return to desired occupational or recreational activities Approaches / Strategies listed above Therapeutic Exercise Maximize muscle performance to relevant leg muscles required to perform the desired occupational or recreational activities Progress job/sports specific training to increase mechanical demand. Examples of activities for athletes: Sprinting up to full-speed Zig-zags up to full-speed Jogging greater than one mile Figure-eights Noncontact drills to full-contact drills Acceleration/deceleration speed play External Devices (Taping/Splinting/Orthotics) May utilize standard MCL taping as needed prior to athletic participation Brace application may be used as needed may provide psychological benefit

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References Dersheid GL, Garrick JG. Medial collateral ligament injuries in football: nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9:365-368. Holden DL, Eggert AW, Butler JE. The nonoperative treatment of grade I and II medial collateral ligament injuries to the knee. Am J Sports Med. 1983;11:340-4. Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996; 21:147-56. Reider B, Sathy MR, Talkington J. Treatment of isolated medical collateral ligament injuries in athletes with early functional rehabilitation: a five-year follow-up study. Am J Sports Med. 1994; 22: 470-477.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Anterior Cruciate Ligament Sprain/Insufficiency


ICD 9: 844.2 sprain of the cruciate ligament of knee - or 717.83 old disruption of anterior cruciate ligament Description: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee. The ACL extends from the anterior aspect of the tibia to the inner aspect of the lateral femoral condyle and it helps stabilize the knee in the anterior-posterior and rotational planes. The main blood supply is provided by the synovial membrane and the ACL is innervated by the tibial nerve. Etiology: ACL sprains are caused by sudden decelerations, abrupt changes in direction, hyperextensions, cutting maneuvers on a planted foot, internal tibial rotation, and valgus stresses. Physical Examinations Finding (Key Impairments) Acute Stage / Severe Condition Pain Swelling Decreased range of motion Decreased strength Abnormal laxity produced with Lachmans and anterior drawer tests Decreased weight bearing on involved lower extremity

Sub Acute Stage/ Moderate Condition As above with the following differences: Minimal to no effusion at the knee Minimal limitations in ROM Strength testing of knee extension and flexion in mid range are relatively strong and pain free Able to walk with minimal pain and without a significant gait deviations Decreased proprioception

Settled Stage / Mild Condition As above with the following differences: Full ROM Minimal to no gait deviations Difficulty with sport specific activities (i.e., fast change in directions)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Intervention Approaches / Strategies Acute Stage/ Severe Condition Goals: Decrease pain, swelling, and inflammation at the knee Maintain knee mobility Restore strength to hamstrings and quadriceps Encourage weight bearing of involved leg Maintain general conditioning Physical Agents Ice with compression and elevation Electrical Stimulation Ultrasound External Devices (Taping/Splinting/Orthotics) Assistive device as needed to limit pain Bracing to provide stability and limit anterior tibial torsion Therapeutic Exercise* Range of motion exercises of the knee (passiveactive assistedactive) Isometric exercises for quadriceps and hamstrings

*Caution: Open chain terminal knee extension exercises (from 60 degrees to 0) with resistance applied to the distal leg, and closed-chain squatting between 60 and 90 degrees may cause increased anterior translation of the tibia and excessive stress to the ACL. Patient Education Activity modification, especially avoiding positions that lead to giving way, pain, and effusion.

Sub Acute Stage/ Moderate Condition Goals: Walk independently without gait deviations Increase knee strength Increase proprioception Physical Agents: Same as those listed above External Devices Functional bracing to increase knee stability Therapeutic Exercise Isotonic progressive resistive for quadriceps and hamstrings Isokinetic exercise if available Closed-chain exercises

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9 Stationary bicycle Running on treadmill Proprioceptive training Perturbation exercises Settled Stage / Mild Condition Goals: As above Return to desired recreational activity or sport Therapeutic Exercises Improve muscle performance required to participate in desired occupational or recreational activities. For example: Fast speed walking to gentle straight-line jogging Jumping Sprints Zig-zags Perturbation training Plyometric and agility training

Selected References Bagger J, Ravn J, Lavard P, Blyme P, Sorensen C. Effects of functional bracing, quadriceps and hamstrings on anterior tibial translation in anterior cruciate ligament insufficiency: A preliminary study. J Rehabil Res Dev. 1992;29(1):9-12. Colby S, Hintermeister RA, Torry MR, Steadman JR. Lower Limb Stability with ACL Impairment. J Ortho Sport Phys Ther. 1999;25(8):444-454. Cooperman JM, Riddle DL, Rothstein JM. Reliability and Validity of Judgments of the Integrity of the Anterior Cruciate Ligament of the Knee Using the Lachmans Test. Phys Ther. 1990;70(4):225-232. Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc. 1999;31(2):210-215. Fitzgerald K, Axe MJ, Snyder-Mackler L. Proposed Practice Guidelines for Nonoperative Anterior Cruciate Ligament Rehabilitation of Physically Active Individuals. J Ortho Sport Phys Ther. 2000;30(4)194-203. Fitzgerald K, Axe MJ, Snyder-Mackler L. The Efficacy of Perturbation Training in Nonoperative Anterior Cruciate Ligament Rehabilitation Programs for Physically Active Individuals. Phys Ther. 2000;80(2):128-139. Roberts D, et al. Proprioception in People with Anterior Cruciate Ligament Deficient Knees: Comparison of Symptomatic and Asymptomatic Patients. J Ortho Sport Phys Ther. 1999;29(10):587-594.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee Pain "Medical Meniscus Tear" or "Lateral Meniscus Tear" ICD-9-CM: 717.3 717.40 Unspecified derangement of medial meniscus Derangement of lateral meniscus, unspecified

Diagnostic Criteria History: Joint line or posterior knee pain Joint locking Inability to fully bend or straighten the knee Precipitating twisting/pivoting, hyperflexion, or hyperextension mechanism Joint line tenderness (symptoms reproduced) Guarding, clicking, or pain with hyperflexion, hyperextension or McMurrays Test

Physical Exam:

Hyperflexion Test

Hyperextension Test

McMurray's Test Cues: Begin tests slowly and gently - increase the amount of overpressure force if gentle forces are easily tolerated Add tibial rotations and varus/valgus forces in an attempt to elicit symptoms

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Meniscal Tears of the Knee


ICD-9: 717.3 unspecified derangement of medial meniscus ICD-9: 717.40 derangement of lateral meniscus, unspecified Description: Meniscal tears are very common sports injuries. Typical symptoms include pain, catching, and buckling. Etiology: The mechanism of injury often describes a twisting injury to the knee, or full flexion of the knee (as in kneeling) that leads to pain or locking. The twisting can lead to meniscal tearing through shear forces, whereas loading the knee in full flexion can overload the posterior horn leading to a meniscal tear. Physical Examinations Findings (Key Impairments) Acute Stage / Severe Condition Effusion usually accompanies a medial meniscus tear, but not always a lateral tear Weight bearing flexion-extension (i.e., squatting) is painful and difficult to perform If the knee is locked, a springy- rebound end feel will be noted moving into extension McMurrays test may not able to be performed if considerable effusion restricts flexion, because it is applicable only from full flexion to 90 degrees. If flexion is possible, a painful click may elicited on combined external rotation and extension if a tear exists in the posterior portion of medial meniscus, or on combined internal rotation and extension if posterior lateral meniscus lesion exists Tenderness is present at the joint line where a sprain to the peripheral attachment has occurred

Sub Acute Stage / Moderate Condition As Above except: Passive overpressure reveals a muscle-guarding end feel at the extremes of flexion and extension.

Settled Stage / Mild Condition As Above-except Passive overpressures are reproductive of symptoms only with end range in either combined external rotation and extension or combined internal rotation and extension Rotation opposite the side of the lesion may be painful, especially during Apleys test with compression applied. Distraction with rotation should relieve the pain. This movement should be relatively normal unless a ligamentous injury also exists

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Restore painfree active knee movement Physical Agents Ice Electrical stimulation Therapeutic Exercises Submaximal, controlled, quadriceps and hamstring setting exercises through available painfree ranges External Devices (Taping/Splinting/Orthotics) May use crutches as required to limit pain

Sub Acute Stage / Moderate Condition Goal: Restore normal, painfree response to overpressure at end ranges flexion or extension. Approaches / Strategies listed above Manual Therapy May attempt manual traction and manual resistance using PNF patterns with an emphasis on the distraction portion of the facilitation. Therapeutic Exercises Progress knee mobility and strengthening exercises if tolerated Include exercises that focus on maintaining strength in hip musculature

Settled Stage / Mild Condition Goals: Restore normal, painfree response to overpressure to both flexion and extension and combined movements of external rotation and extension and / or internal rotation and extension. Normalize status on weight bearing Increase strength dynamic control, and endurance of the involved lower extremity Approaches / Strategies listed above Therapeutic Exercises Instruct in stretching exercises to address the patients specific muscle flexibility deficits

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Progress strengthening exercises to address the patients specific muscle strength deficits

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational on leisure time activities. Approaches / Strategies listed above Therapeutic Exercises Progress strengthening with isokinetic exercises using velocity spectrum rehabilitation Continue to improve general endurance and conditioning with aerobic activities such as bicycling, swimming and walking Progress strengthening, stabilization, and balance activities in functional position with marching, lunges, step-up and step-down exercises, and plyometric training or slide board and balance board exercises

Selected References Bernstein J. Meniscal Tears of the Knee. Diagnosis and Individualized Treatment. Phys Sportsmed. 2000;28:83-90. McCarty E. Meniscal Tears in the Athlete: Operative and Non operative Management. Phys Med Rehabil Clin N Am. 2000;11:867-879.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee and Leg Radiating Pain "Peroneal Nerve Entrapment" ICD-9CM: 355.3 Lesion of lateral popliteal nerve

Diagnostic Criteria History: Line of pain on lateral side of knee and calf Paresthesias, potential numbness and weakness Onset precipitated by trauma or pressure to lateral knee, constrictive garment, brace, or cast around upper calf Symptoms reproduced with peroneal nerve tension test Symptoms reproduced with palpation/provocation of common peroneal nerve

Physical Exam:

Peroneal Nerve Tension Test

Cues: Perform a SLR to the point of first resistance, then plantarflex and invert the ankle and foot - inquire regarding symptoms with hip extension and flexion while maintaining plantar flexion and inversion

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Common Peroneal Nerve Palpation Cues: 5 = Fibular head/proximal tibiofibular joint Nerve is located posterior and medial to the superior tibiofibular joint Assess symptom response to palpation

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Peroneal Nerve Entrapment


ICD-9: 355.3 lesion of the lateral popliteal nerve Description: Defined as a state of altered transmission in a peripheral nerve because of mechanical irritation from related anatomical structures. Entrapment neuropathy of the common peroneal nerve across the knee can occur in different regions. It can occur as the nerve passes beneath the biceps femoris tendon in the popliteal fossa or over the bony prominence of the fibular head and in the fibular tunnel formed by the origin of the peroneus longus muscle and the inter-muscular septum. The updated name for the peroneal nerve is the fibular nerve. Etiology: Peroneal nerve entrapment usually is attributed to excessively thick fibrous arch and narrowing of the tunnel through which the nerve passes. The suspected causes of this disorder vary, but all causes relate to space occupying disorders of the peroneal nerve as it courses through the posteriolateral region of the knee and superiolateral region of the leg. Suspected causes of peroneal nerve entrapment are: trauma or injury to the knee; fracture of the fibula; use of a tight plaster cast (or other long-term constriction) of the lower leg; habitual leg crossing; wearing of high boots; pressure to the knee from positions during deep sleep or coma; or injury during knee surgery. Risk factors for developing this condition are the following: being extremely thin or emaciated, having diabetes, or having polyarteritis. The diagnosis is confirmed by a nerve conduction velocity - short segment stimulation technique.

Physical Examinations Findings (Key Impairments) Acute Stage / Severe condition Positive Tinel's sign at the neck of the fibula Decreased sensations, numbness or tingling on the dorsum of the foot Weakness of the ankles or feet Pain with provocation of the entrapment site Gait abnormalities - such as: "Slapping" gait, foot drop (unable to hold foot horizontal), or toe drag during swing phases

Sub Acute Stage / Moderate Condition In this stage you will see symptoms similar to the acute stage except the symptoms might ease up and will be to a lesser extent.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Intervention Approaches / Strategies Acute Stage / Severe condition Goals: Remove or decrease structures causing entrapment Keep edema or pooling of blood to a minimum Increase movement of nerve in between tissue Maintain strength, endurance, and sensations in unaffected sites. Manual Therapy Soft tissue mobilization to restricted fascia or myofascia near entrapment site Joint mobilization to restricted accessory motions in the superior tibiofibular, patellofemoral or tibiofemoral joint Physical Agents Electrical stimulation to maintain muscle functioning if a paresis is present Ultrasound for inflammation reduction Therapeutic Exercises Nerve mobility exercises External Devices (Taping/Splinting/Orthotics) An ankle-foot orthosis for the severely impaired with drop foot until return of function of ankle dorsiflexors Sub Acute Stage / Moderate Condition Goal: Remove entrapment structures and increase movement of peroneal nerve through entrapment sites. Approaches / Strategies listed above

Note that surgery to decompression of peroneal nerve entrapment site may be required in severe cases or when symptoms persist or recovery remains incomplete for three to four months

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Selected References 1. Kanakamedala RV, Hong CZ. Peroneal nerve entrapment at the knee localized by short segment stimulation. Am J Phys Med Rehabil. 1989;68:116-122. 2. Fabre T, Piton C, Andre D, Lasseur E, Eurandeal A. Peroneal Nerve Entrapment. J Bone Joint Surg. 1998;1:47-53 3. Vastamaki M. Decompression for peroneal nerve entrapment. Acta Erthop. Scand. 1986;57:551-554 4. Sridhara CR, Izzo KL. Terminal sensory branches of the superficial peroneal nerve: an entrapment syndrome. Arch Phys Med Rehabil. 1985;66:789-791 5. MEDLINE Plus Medical Encyclopedia Common peroneal nerve dysfunction http://www.nlm.nih.gov/medlineplus/ency/article/000791.htm

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Manual Therapy for Peroneal Nerve Entrapment


Examination: Superior Tibiofibular Accessory Movements Treatment: Joint Mobilization: Posterior-Medial Glide (supine w/ wedge) Anterior-Lateral Glide (tibia on chair - use pisiform) Soft Tissue Mobilization: Lateral Popliteal or Calf area (p. 57) Nerve Mobilization: AROM and PROM progression

Impairment:

Limited Superior Tibiofibular Posterior/Medial Glide

Fibular Posterior/Medial Glide Cues: Position the patient with slight knee flexion under a mobilization wedge - with the heel just off the edge of the table Stabilize the tibia into internal rotation The treatment plane runs posterior -medially, thus, the mobilization force is directed medially, or, it is directed straight posteriorly if the tibia is internally rotated Use a soft thenar eminence as the mobilization contract

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Impairment:

Superior Tibiofibular Anterior/Lateral Glide

Fibular Anterior/Lateral Glide Cues: Position the patient with the involved knee flexed and with the tibia resting on a low table or a chair (Provide a stationary table or chair for the patient to hold on to for balance) Stabilize the tibia with one hand Mobilize the fibula anterio-laterally with the hypothenar eminence of the other hand using a trunk lean Catch a large portion of the lateral gastrocnemius to cushion the pressure careful not to compress the common peroneal nerve The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 159, 1989

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

SUMMARY OF KNEE (TIBIOFEMORAL) DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER


Knee Mobility Deficit Knee Capsulitis Knee Muscle Power Deficit Iliotibial Band Friction Syndrome

HISTORY
Aching worse with wt. bearing Stiffness Lateral knee pain Overuse MOI precipitated by unaccustomed wt. bearing e.g., stair climbing or running on unlevel surfaces Medial knee pain Overuse MOI such as long distance running in the presence of a LE biomechanical abnormality (e.g., abnormal pronation) Trauma Swelling (often acute hemarthrosis) Giving way Trauma involving a valgus stress Swelling

PHYSICAL EXAM
ROM deficits esp. loss of flexion Pain at end ranges SR w/ provocation of Gurdys tubercle or Lateral Femoral Condyle

PT MANAGEMENT
PROM/Joint Mobs Ther Exs Reduce overuse Physical agents (Ice, US) STM, C/R, FM, to ITB and Lat thigh PF Taping Rx LE biomechanical impairments Reduce overuse and LE biomechanical impairments Physical agents (US/Phono) Gentle FM Physical agents if acute P.R.I.C.E. instructions Proprioceptive and functional strength training Physical agents if acute (Ice, US) P.R.I.C.E. instructions Proprioceptive and functional strength training Friction massage Painfree Ther Exs

Knee Muscle Power Deficit Pes Anserinus Bursitis

SR w/ palpation or provocation of the pes anserine bursa

Knee Movement Coordination Deficit Anterior Cruciate Ligament Sprain/Insufficiency Knee Movement Coordination Deficit Medial Collateral Ligament Sprain

Excessive anterior tibial translation with Lachmans Test

Pain and possibly laxity with valgus stress test at 30o of flexion

Knee Pain Medial or Lateral Meniscal Tear Knee and Leg Radiating Pain Peroneal Nerve Entrapment

Twisting/pivoting MOI Joint line pain Locking Cannot fully bend or straighten knee Line of pain on Lat side of knee/calf Paresthesias, sensory & motor deficits Onset MOI trauma or pressure to lateral side of knee (e.g., brace)

SR w/: Joint line palpation or provocation Hyperflexion, hyperextension, or McMurrays maneuvers SR w/: Peroneal Nerve bias LLTT Palpation/provocation of the Peroneal Nerve

Rx entrapment (STM/JM to Sup. Tib-Fib area) Peroneal Nerve Mob (PROM and AROM Exs)

Joe Godges DPT

KPSoCal Ortho PT Residency

SUMMARY OF PATELLOFEMORAL DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES

DISORDER Muscle Power Deficits Patellofemoral Pain Syndrome

HISTORY Anterior Knee pain Onset related to overuse or trauma Sxs worsen with bent knee/sitting positions Anterior knee pain Onset associated with repetitive use of Quads i.e., jumping Recent blunt trauma to the anterior knee Repetitive weight bearing onto knee i.e., kneeling

PHYSICAL EXAM Lateral patella orientation Limited medial patellar glide SR w/end range of patella glide Biomechanical abnormalities of the LE are common

Muscle Power Deficits Patellar Tendinitis

Muscle Power Deficits Patellar Bursitis

SR w/: Resisted extension Palpation/provocation of the patellar tendon at the superior pole, inferior pole, or insertion on the tibial tuberosity Patellar effusion SR w/provocation of the suprapatellar, prepatellar, or infrapatellar bursa

PT MANAGEMENT Reduce overuse STM and stretching of the lateral PF/thigh structures Patellar joint mobs (medial glides) PF taping Normalize LE impairments related to PF symptomatology Reduce overuse Physical agents (Ice, US, Ionto) Friction massage Taping Progressive reloading/sports training Reduce weight bearing stress allow healing Physical agents (Ice, US, Phono)

Joe Godges DPT

KPSoCal Ortho PT Residency

Patellar Dislocation Conservative and Operative Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Patellar stability is dependent upon two components: bony (trochlear groove) and soft tissue structures. There are multiple soft tissue layers that surround the patellofemoral joint. Medially, the superficial layer is consists of the fascia over the sartorius muscle, the second layer contains the medial patellofemoral ligament (MPFL) and the retinaculum, and the third layer contains the medial collateral ligament and joint capsule. The MPFL provides 50-80% of total restraining force medially. Fascial interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps comprise the lateral retinaculum. Pathogenesis: Patellar instability can be correlated with one or more of the following anatomical risk factors: tightness of lateral structures, patella alta, patella or femoral dysplasia, increased Q-angle, increased sulcus angle, generalized laxity, increased femoral anteversion, increased external tibial torsion, lateral position of the tibial tuberosity, abnormal foot pronation, and a vertical vastus medialis oblique (VMO) insertion. Patella dislocation can occur from indirect, twisting or rapid change of direction with the foot planted, or direct trauma to patella. Epidemiology: A higher incidence of patellar dislocations occur in females ages 10 to 17 years of age and the athletically active, with less incidence over age 30. Lateral dislocations are very common and will be the topic of discussion in this guideline. Medially dislocations are typically rare and result from direct trauma, an excessive lateral release or overcorrection of a realignment procedure. Redislocations occur more frequently in patients younger than 20 and tend to decrease with advancing age. Diagnosis History of dislocation with giving way Effusion Positive apprehension test (Fairbank sign) Medial retinacular tenderness Other clinical findings may include: Patellar mobility (Sage test for lateral retinacular tightness positive if medial patellar excursion is less than of greatest patellar width) Patellar maltracking Abnormal Q angle (normal = males 8-10 degrees, females 10-20 degrees) Abnormal sulcus angle (normal = <150 degrees) Imaging studies help confirm the diagnosis

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Conservative treatment includes bracing and taping to restore proper patellar alignment and physical therapy to regain strength and range of motion. Conservative treatment is most often attempted first, especially with a first-time dislocation. Operative treatment is recommended in the presence of anatomical abnormalities or osteochondral fractures. It is more effective in preventing recurrence of dislocations and is often only considered after conservative treatment has been unsuccessful. Surgical Procedure: Many different procedures are performed to correct patellar instability. Proximal realignment procedures include lateral release, medial reefing, advancement of the vastus medialis oblique (VMO), and Galleazzis procedure. Lateral release involves an incision of the lateral retinaculum. Medial reefing involves tightening the medial structures and is often done in conjunction with a lateral release. VMO realignment involves reattaching the VMO insertion more distally and laterally on the patella. The Galeazzi procedure is seldom performed however involves attaching the semitendinosus tendon to the medial side of the patella. Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial collateral ligament. Evidence has shown that lateral release is more effective when combined with another procedure (i.e. proximal or distal realignment) and for many investigators would only be used it there was a residual patellar tilt after repair/reconstruction of the medial retinacular structures.

CONSERVATIVE REHABILITATION (Acute)

Note: The following rehabilitation progression after a first-time acute lateral patellar dislocation is a summary of the guidelines provided by DAmato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk.

Phase I Goals: Decrease pain and swelling Limit range of motion and weight-bearing to protect healing tissues Return muscle function Avoid overaggressive therapy that may lead the patient into a patellofemoral pain syndrome Intervention: Bracing: set at 0 degrees initially with ambulation, lateral buttress pad in brace Ice McConnell taping; light compressive bandage Instruction in partial weight-bearing with crutches Electrical stimulation for activation of the VMO

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Supine straight leg raise (SLR) with minimal to no pain Ankle pumps if edema is present Isometric hamstrings

Phase II Criteria: no significant joint effusion, no quadriceps extension lag, minimal to no pain with activities of daily living Goals: Full ROM pain-free Improve quadriceps strength Low-level functional activities Initiate conditioning Avoid patellofemoral symptoms or instability Intervention: Continue patellar bracing or taping Weight-bearing as tolerated; discard crutches when extension lag is no longer present Continue electrical stimulation and modalities as needed Continue supine SLR and add adduction and abduction SLRs Toe raises with equal weight bearing Closed kinetic chain exercises Low-level endurance and pool exercises

Phase III Criteria: full active ROM, good to normal quadriceps strength, full weight-bearing with normal gait pattern Goals: Improve function Gradual return to high-level activities Intervention: Bracing: wean from bracing and taping as quadriceps function improves Four-way hip exercises Pool therapy walking with progression to running Sport and skill-specific training Proprioceptive training Patient education

Criteria for Return to Full Activity (8-12 weeks)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Equal ROM between lower extremities No pain or edema 85% strength compared with uninvolved limb Satisfactory 1-minute single leg hop test, two-legged hop test Patellar stability with clinical tests

Preoperative Rehabilitation: Acute Phase: PRICE - protection, rest, ice, compression, elevation (if acute) Maintain quadriceps strength and flexibility of the hamstrings Patellar bracing and taping to restore proper alignment

POSTOPERATIVE REHABILITATION Distal and/or Proximal Realignment Procedures

Note: The following rehabilitation progression is a summary of the guidelines after a distal and/or proximal realignment procedure provided by DAmato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk. The same rehabilitation protocol is used for both distal and proximal realignment procedures, with a few exceptions noted below. For a combined distal and proximal realignment, the protocol for distal realignment is used.

Phase I for Immediate Postoperative Weeks 1-6 Goals: Control inflammation Protect fixation Activation of quadriceps and VMO Full knee extension and minimize adverse effects of immobilization Intervention: ROM: 0-2 wks 0-30 degrees of flexion, 2-4 wks 0-60 degrees, 4-6 wks 0-90 degrees Brace: 0-4 wks locked in full extension 24 hours 7 days a week except for therapeutic exercises and continuous passive motion use, 4-6 wks unlocked for sleeping, locked for ambulation Weight-bearing: Proximal realignment as tolerated with two crutches, Distal realignment 50% with two crutches Quadriceps sets and isometric adduction with electrical stimulation for VMO (* no electrical stimulation for 6 wks with proximal realignment procedure)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Heel slides 0-60 degrees (proximal), 0-90 degrees (distal) Non-weight bearing gastrocnemius/soleus, hamstring stretches 4-way SLR with brace locked in full extension Resisted ankle ROM Patellar mobilization (when tolerable) Aquatic therapy at 3-4 wk gait training

Phase II Weeks 6-8 Criteria for progression: Good quadriceps set, ~90 degrees of flexion, no signs of active inflammation Goals: Increase flexion Avoid overstressing fixation Control of quadriceps and VMO for proper patellar tracking Intervention: Brace: discontinue use for sleeping, unlock for ambulation as per physician's orders Weight bearing: As tolerated with crutches Progress to weight-bearing gastrocnemius/soleus stretching, full flexion with heel slides Aquatic therapy Balance exercises Stationary bike low-resistance, high seat Wall slides 0-45 degrees of flexion progress to mini squats

Phase III Week 8-4 months Criteria for progression: No quadriceps extensor lag with SLR, nonantalgic gait, no evidence of lateral patellar tracking or instability Intervention: Discontinue crutches when: no extensor lag with SLR, full extension, nonantalgic gait pattern Step-ups - 2 inches progress to 8 inches Stationary bike moderate resistance Endurance swimming, Stairmaster Gait training 4-way hip exercise Leg press 0-45 degrees of flexion Toe raises, hamstring curls Continue balance activities
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

6 Hamstrings, gastrocnemius/soleus, add quadriceps and iliotibial band stretches

Phase IV 4-6 months Criteria for progression: Good to normal quadriceps strength, no soft tissue complaints, no evidence of patellar instability, clearance from physician to progress closed-chain exercises and resume full or partial activity. Intervention: Progression of closed-kinetic chain exercises Jogging/running in pool with resistance Functional progression, sport-specific training

Selected References: Aglietti P, Buzzi R, De Biase P, Giron F. Surgical treatment of recurrent dislocation of the patella. Clin Orthop. 1994;308:8-17. Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. Philadelphia, 2003. Mosby, Inc. pp 327-342. Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121. Garth WP, Pomphrey M, Merrill K. Functional treatment of patellar dislocation in an athletic population. Am J Sports Med. 1996;24:785-791. Maenpaa H, Lehto MUK. Surgery in acute patellar dislocation evaluation of the effect of injury mechanism and family occurrence on the outcome of treatment. Br J Sports Med. 1995;29:239-241. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-579. Scuderi G. Surgical treatment for patellar stability. Orthop Clin N Am. 1992;23:619-630. Vainionpaa S, Laasonen E, Silvennoinen T, Vasenius J, Rokkanen P. Acute Dislocation of the patella. J Bone Joint Surg. 1990;72:366-9.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Lateral Retinacular Release of the Patella and its relation with proximal and distal realignment procedures
Surgical Indications and Considerations Anatomical Considerations: Two components of knee extensor mechanism primarily affect the limits of medial and lateral patellar displacement: bony constraints and ligamentous tethers. Fulkerson and Gossling described the lateral retinacular structures from superficial to deep as: the fibrous expansion of the vastus lateralis muscle, the superficial oblique retinaculum (iliotibial band to lateral border of the patella and patellar tendon), the deep transverse retinaculum (from iliotibial band to lateral patellar border) bordered superiorly by the epicondylopatellar ligament and inferiorly by the patellotibial ligament, and the capsulosynovial layer. Fascial interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps comprise the lateral retinaculum. The medial retinacular structures from superficial to deep are the fascia over the sartorius muscle, the medial patellofemoral ligament (MPFL), the vastus medialis oblique muscle (VMO) and the retinaculum, and the medial collateral ligament and joint capsule. The primary restraint to lateral displacement is the medial patellofemoral ligament (MPFL). Slips of the vastus medialis oblique muscle insert into the MPFL. Contraction of the VMO tensions the MPFL providing (approximately) a 60% contribution of this ligament force limiting lateral patellar dislocation. Pathogenesis: The most common reasons for anterior knee pain are: overuse, patellofemoral malalignment, and trauma. Malalignment leads to instabilities (dislocations and subluxations), and overload of the retinaculum and subchondral bone. Patellar dislocations and subluxations can be categorized by chronicity (acute vs chronic), direction (medial vs lateral) and cause (traumatic vs non traumatic). Patellar instability can be predisposed by certain anatomic factors: patella alta, tightness of lateral structures, increased Q-angle (lateralization of the tibial tubercle), increased sulcus angle, excessive femoral anteversion, external tibial rotation, genu valgum, pes planus, hypoplastic lateral trochlear ridge, generalized laxity, weak or hypotrophic vastus medialis oblique, and hypertrophic vastus lateralis. Another factor is the altered motor control/strength of the hip abductors and external rotators during weight loading activities. Also, intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking the patella medially during extension predisposing the patient to experience patellofemoral pain. Chain of events in lateral instability: Patellar tilt resulting from a tight lateral retinaculum can exert over time lateral retinacular strain and increased pressure on the lateral facet of the patella leading to lateral patellar compression syndrome or even excessive lateral pressure syndrome, heralded by arthrosis of the lateral patellofemoral joint. The syndrome is then primarily the result of chronic lateral tilt, with subsequent lateral retinacular shortening and tightening. This continues the lateral facet overload, and articular cartilage degeneration results in osteoarthritis (chronic imbalance of facet loads). In addition, studies have demonstrated MPFL tears at the adductor tubercle in patients with lateral patellar dislocation.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Epidemiology: Historically, it has been considered a primarily female disorder, however some studies clearly show a male preponderance. Based on the research done, it cannot be said what the relative risk of patellar dislocation is among males and females. Subluxation and dislocation occur most frequently laterally, though medial instability can occur as a result of trauma or overaggressive surgical treatment. There is a higher incidence of acute instability in young active patients between the ages of 13-20, with less incidence over age 30, reoccurrence is higher in patients who dislocate at younger than 15. A recurrent rate up to 44% in non-operatively managed patients has been reported. Fourteen to forty-nine (14%-49%) percent of patients who sustain a primary acute dislocation will experience recurrent dislocation. Acute dislocation is seen predominantly in football and basketball players. Diagnosis History of dislocation with giving way Anterior knee pain with prolonged knee flexion, ascending or descending stairs. Peripatellar retinaculum tenderness Effusion Crepitus Postitive apprehension test (Fairbank sign) Positive quadriceps pull test Other clinical findings may include: o Patella alta: most consistent physical examination feature associated with patellar instability o Patellar hypomobility (positive on glide if medial patellar excursion is less than of greatest patellar width, positive on tilt if decreased) o Increased Q angle (10 5 for men and 15 5 for women) o Increased Sulcus angle (normal = <150 degrees) Imaging studies that help confirm the diagnosis: o X-rays: Axial view (tilt, patellofemoral incongruence), lateral view (rotational malalignment, trochlear dysplasia) o CT: Patellar tilt angles are taken from three midpatellar transverse tomographic images at 15, 20, 40, and 60 degrees of flexion o MRI Arthroscopy also has a role in confirming the preoperative diagnosis of patellofemoral malalignment

The diagnosis is best made on the basis of the history, physical examination and radiographic examination (X-rays, CT scan). Nonoperative Versus Operative Management: Consists of weight reduction, medial quadriceps and hip external rotator muscles strengthening, hamstrings and quadriceps stretching, mobilization of the tight lateral retinaculum, kinetic chain balancing, orthotic devices, correction of foot pronation, low impact loading exercises, taping and bracing and oral anti-inflammatory medication. It has been reported that 80% of symptomatic patellofemoral disorders respond to non-operative treatment.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Surgical Procedures: Arthroscopic lateral release is primarily indicated for patients with persistent anterior knee pain despite of supervised physical therapy with a tight lateral retinaculum clinically and radiographically documented by lateral patellar tilt, a tender lateral retinaculum, a medial glide of two or less quadrants, a normal Q-angle, and minimal or nonexistent patellofemoral chondrosis. The superomedial portal is established 3-6 cm proximal to the superior pole of the patella in line with the medial edge. Excessive superior extension should be avoided so as not to damage the vastus lateralis muscle. The entire retinaculum is released, paralleling the lateral edge of the patella. At the superior aspect of the patella, the release should stay posterior. The patella should be able to tilt 70 to 90 degrees. Goal: Allow the patella to seek a central position and prevent lateralization of the patella. Complications: Hemarthrosis, infection, medial patellar subluxation if excessive lateral release. An isolated lateral release has poor prognosis in patients with patella alta, an abnormal q-angle or a hypoplastic trochlea. Some studies reported better results when this release was combined with another procedure on the medial retinaculum. Many investigators suggest performing a lateral release if there is a residual patellar tilt after repair/reconstruction or reefing (tightening the medial structures) of the medial retinacular structures. Other proximal realignment procedures include reefing (mentioned above, open or via arthroscopy) and the advancement of the vastus medialis oblique (VMO), which involves reattaching the VMO insertion more distally and laterally on the patella. Goal: Restore patellofemoral alignment in recurrent subluxation or dislocation and to centralize the patella after a lateral retinacular release. Complication: Reflex sympathetic dystrophy (possible entrapment of the saphenous nerve). The lateral retinacular release and the other proximal realignment procedures do not address bone malalignment. Studies have reported a 86% return to previous level of activity within 3-4 months for individuals having a proximal realignment procedure. Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial collateral ligament. Osteotomy involves reorienting the tibial tubercle medially or anteromedially to reduce the Q-angle. Goal: correct patellar tracking on the skeletally mature patient with recurrent subluxation/dislocation, or an increased Q-angle, and unload damaged articular surfaces. Indications for surgical procedures are: failure of nonoperative care, osteochondral injury, patella instability, disruption of MPFL-VMO, high level athletic demands and risk factors. Surgical Outcomes: 79% obtain good to excellent functional outcome after lateral release with a combined VMO advancement and tibial tubercle transfer (Palmer 2004). Preoperative Rehabilitation: Control pain and inflammation: protection, rest, ice, compression, elevation (if acute) Maintain or improve strength and flexibility of the quadriceps and the hamstrings Improve general lower extremity alignment Patellar bracing and taping to prevent more damage

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 POSTOPERATIVE REHABILITATION Lateral Retinacular Release The following is a general guideline for the rehabilitation after lateral retinacular release. Advancement of the patient to the next phase should be considered on an individual basis taking also into consideration the surgeons directives. The overall goal of rehabilitation is to reestablish appropriate extensor mechanism function and reduce patellofemoral contact forces. Phase I: Immediate Postoperative Weeks 1-2 Goals: Control postoperative pain and swelling Protect tissues in the process of healing limiting range of motion Improve muscle function of the lower extremity, specially quadriceps and VMO Improve range of motion: 0- 115 knee flexion and full knee extension Full weight bearing if extension ROM is controlled by muscle Independent ambulation Intervention: Pain, inflammation and hemarthrosis management: Cryotherapy, compression bandage, elevation and ankle pumps ROM: Early range of motion is needed to ensure that the lateral structures are maintained in an opened or released position. * Knee flexion: 0-1 week: 0- 90 flexion, 75 by day 3, 110-115 by week 2. * Knee extension: full. Brace: 0-2/4 wks locked in full extension, removed for rehabilitation * Some do not recommend the use of immobilizers Weight bearing: immediate post-operative ambulation with crutches, weight bearing as tolerated (WBAT). Full by 2 weeks Therapeutic Exercise: Quadriceps sets at full extension progressing to multi angle isometrics Electrical stimulation for VMO Hip external rotators strengthening Heel slides and wall slides Non-weight bearing gastrocnemius/soleus, hamstring, ITB, hip flexors stretching 4-way SLR with brace locked in full extension. * Begin abduction at approximately 3 weeks to minimize lateral pulling of this muscle group on the patella. Patellar mobilization (when tolerable) Aquatic therapy at 2 wks (when wound is healed) with emphasis on gait training Stationary bike for ROM when sufficient knee flexion is achieved Phase II Weeks 3-5 Criteria for progression: Well-controlled swelling and pain Good quadriceps strength and control
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

5 ROM: 90 of active knee flexion and full active knee extension Full weight bearing Goals: Increase lower extremity strength and flexibility: 70% muscle reconditioning Control of quadriceps and VMO for proper patellar tracking Exercise swelling controlled Improve gait pattern, balance and proprioception. Establish home exercise program Independent activities of daily living Intervention: Brace: if brace is used, discontinue use for sleeping, brace at 0-60 when ambulating Weight bearing: WBAT without crutches if: * Full active knee extension, active 90- 100 knee flexion, non-antalgic gait pattern, and no extension lag with SLR. * Patient can progress from two to one crutches, and then ambulate without them. ROM: Knee flexion: Week 2: 100-115 Week 3: 115-125 Knee extension: 60-0 Therapeutic Exercise: 45 flexion with heel slides Complete lower extremity flexibility: Quadriceps, ITB and hip flexors stretching and progress to weight-bearing gastrocnemius/soleus stretching Calf raises 4 way hip exercises Wall slides progression (0-45) to mini squats Closed chain kinetic terminal knee extension with resistive tubing or weight machine, and open chain reconditioning. Balance and proprioceptive activities Stationary bike Treadmill walking with emphasis on normalization of gait pattern Aquatic therapy Aerobic reconditioning Phase III Week 6 weeks return to activity Criteria for progression: Good to Normal quadriceps strength Non-antalgic gait No evidence of lateral patellar tracking or instability Pain is controlled and associated with activity only Clearance from physician to progress closed-chain exercises and resume full or partial activity Necessary joint range of motion, muscle strength, and endurance to safely return to athletic participation Knee extension: 70% of contralateral side.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Goals: Restore any residual loss of ROM Improve functional strength and proprioception Return to appropriate activity level Maintenance program development Intervention: Brace: for activity only Therapeutic Exercise: Endurance swimming, stairmaster Complete lower extremity flexibility Continue balance activities and gait training Progression of closed-kinetic chain exercises and proprioception exercises Step-ups - 2 inches progress to 8 inches: forward and lateral Stationary bike moderate resistance Leg press 0-45 degrees of flexion 0-70 wall squats Knee extension 90-0 Toe raises, hamstring curls Jogging/running in pool with resistance * Walk/jog progression, Jogging in pool with progression to land * Forward and backward running, cutting, figure 8s Slide Board Plyometrics Emphasis on sport/work -specific activity development Return to sports when the knee is pain free, near full ROM has been obtained, and they have achieved at least 80% strength as compared with the opposite leg. Most patients are able to go back to sports by four to six months (Arendt, Fithian and Cohen 2002). POSTOPERATIVE REHABILITATION Proximal Realignment Procedures After a combined proximal and distal realignment, the protocol for distal realignment is suggested. Phase I: for Immediate Postoperative Weeks 1-4 Goals: Control pain and inflammation Activation of quadriceps and VMO Full knee extension and reestablish 0-110 knee flexion 75% weight bearing progression Reestablish patellar normal glide Note with VMO advancement: Early flexion may stretch the advancement Delay quad strengthening for tissue healing

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention: Pain and swelling management ROM: 0-1 wk: 0-30of flexion, 2 wks:0-60, 3 wks: 0-90, 4 wks:0-110 (others recommend no more than 90 for 4 weeks) Brace: 0-4 wks locked in full extension and by 6 weeks unlocked for ambulation * Other studies: in full extension for 1 week then unlocked and by 3 weeks discontinued. * Some do not recommend brace locked, but brace as ROM limiting only Weight-bearing: with two crutches, from toe touch to 75% WB by end of phase Therapeutic Exercise: Muscle reeducation: initiate multi-angle exercises Heel slides 0-60 Non-weight bearing gastrocnemius/soleus, hamstring and ITB stretches 4-way SLR with brace locked in full extension Patellar mobilization (when tolerable) Aquatic therapy at 3-4 wk gait training Phase II: Weeks 4-10 Criteria for progression: Minimal pain No signs of active inflammation 0- 110 of flexion Muscle control of extension to 0 75% weight bearing

Goals: Improve ROM and muscle strength (70% of contralateral side) Avoid overstressing fixation Exercise swelling controlled Improve function to full activities of daily living Intervention: Weight bearing: As tolerated with crutches Therapeutic Exercise: Complete lower extremity flexibility and progress to weight-bearing gastrocnemius/soleus stretching, Balance exercises and gait training Aquatic therapy Stationary bike low-resistance, high seat Wall slides 0-45 of flexion progress to mini squats Late phase: close chain/open chain reconditioning Patella mobilization Aerobic reconditioning after 6 weeks Phase III: Week 11 - 4 months

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Criteria for progression: Full ROM achieved 70% of contralateral side Pain is associated with activity only Criteria for activity return must be met

Goals: Resume activity Maintain program development Intervention: Therapeutic Exercise: Discontinue crutches when: no extensor lag with SLR, full knee extension, nonantalgic gait pattern Step-ups - 2 inches progress to 8 inches Stationary bike moderate resistance Endurance swimming Jogging/running in pool Gait training Progression of closed-kinetic chain exercises Continue balance activities Complete lower extremity flexibility: hamstrings, gastrocnemius/soleus, quadriceps and iliotibial band stretches Emphasis on sport specific strength Develop home exercise program Some studies considered the phase between 4 and 6 months the returning to activity level phase Phase IV: 4-6 months Goals: Return to appropriate activity level Improve functional strength and proprioception Intervention: Progress close kinetic chain activities, jogging and running, sport specific activities. POSTOPERATIVE REHABILITATION Distal Realignment Procedures Phase I: 1-2 weeks Goals: Protect fixation Control pain and inflammatory process, and minimize effects of immobilization Re-gain quad and VMO control ROM: 0-90/110 flexion and full knee extension TTWB, two crutches (50% by end of phase) Good skin integrity Independent ambulation

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Intervention: Pain, swelling and hemarthrosis management ROM: 0-90/110 Brace: 0-30 0-4/6 weeks; for ambulation only * Brace only days 1-4 Weight Bearing: 0-4 weeks: crutches progressing to 50% weight bearing Therapeutic Exercise: Multi angle Quad sets with isometric adduction for VMO recruitment Full passive knee extension Passive and active-assisted ROM Calf, hamstring stretches (non-weight bearing) 4 way SLR (locked brace if extensor lag) Patellar mobilization Muscle reeducation, use EMS Begin aquatic therapy with emphasis on gait at 3-4 weeks Phase II: 3-4 wks Criteria for progression: 70% of contralateral side WB: 50% (X-ray verification of osteometry site healing) Approximately 90 flexion ROM No active inflammation Pain controlled Muscle control of extension

Goals: Increase flexion ROM: 0-110 Avoid overstressing fixation Muscle control of extension Control inflammation and pain Wound closure complete Minimal gait deviation Intervention: Pain and inflammation management Brace: for ambulation only Discontinue brace at 4 weeks ROM: 0-75 (3rd week), 90/110 4th week Passive and A/A ROM Discontinue CPM Mobilize patella Weight bearing: 4-6 weeks: wean from crutches Therapeutic Exercise: Emphasis on extension exercises Flexibility: hamstrings and gastrocnemius Muscle reeducation utilizing EMS

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10 SLR and multi angle submaximal isometrics knee extension Gait and balance training Phase III: 4 weeks - 8 weeks Criteria for progression: Approximately 110 flexion ROM 75% WB with 2-1 crutch Pain control with WB and ROM Independent in ADLs

Goals: Increase flexion ROM: 0-135 Muscle control throughout ROM Control pain and inflammation One crutch to none (week 6) Intervention: Continue modalities for pain and swelling Weight Bearing: 1 to no crutch, by 6 weeks full WB. Therapeutic Exercise: Continue Phase I exercise, progress to full flexion with heel slides Muscle reeducation using close chain program with 0-30 restriction Active extension with SLR Balance exercises and gait training Stationary bike - week 6 to 8 Pool program Phase IV: 9 weeks Criteria for progression: Swelling controlled Full range of motion achieved Normal gait pattern Good dynamic patellar control with out evidence of lateral tracking or instability Criteria for specific activity must be met

Goals: Resume activity Maintain program development Intervention: Pain is controlled and may be associated with activity only Brace: for activity Weight Bearing: full weight bearing Therapeutic Exercise: Step-ups, begin at 2 inches and progress to 8 inches Stationary bike with moderate resistance

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11 Squats, leg press, forward and lateral lunges Closed kinetic chain terminal knee extension with resistance Toe raises Hamstring curls Sports specific activity development Continue proprioceptive exercises Develop and assess home exercise program Some recommend a Phase V Phase V: 4 months - 6 months Goals: Continue improvements in quadriceps strength, improve functional strength and proprioception Intervention: Progression of closed chain activities, Jogging in pool with progression to land, functional progression, sport/work specific training Late Phase Exercises for Postoperative Patellofemoral Conditions (Mangine et al proposed late phase exercises for postoperative patellofemoral conditions.) Criteria for progression: No effusion, painless ROM, joint stability, Patient performs ADLs and can complete previous protocol ROM: minimum of 0-135, minimal bilateral difference in muscle tone

Goals: Increase function to full activity level Return to previous activity level Establish maintenance program Intervention: Warm up: jump rope, stretch, push-ups, sit ups. Lifting: leg curls, squats, lunges, toe rises, triceps, bench press Agility: plyoball sit-ups, dots, chest bands. Selected References Ahmad CS, Lee FY. An all-arthroscopic soft-tissue balancing technique for lateral patellar instability. Arthroscopy. 2001;17:555-557. Ahmad CS, Stein BE, Matuz D, Henry JH. Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. A review of eight cases. Am J Sports Med. 2000;28:804-10. Arendt EA, Fithian DC, Cohen E. Current concepts of patella dislocation. Clin Sports Med. 2002;499-519.
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

12

Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Ed. Philadelphia, Mosby, Inc.; 2003. Fithian DC, Meier SW. The case for advancement and repair of the medial patello femoral ligament in patients with recurrent patellar instability. JOTSM. 1999;7:81-89. Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121. Fu FH, Maday MG. Atthorscopic lateral release and the lateral patellar compression syndrome. Orthop Clin North Am. 1992;24:601-612. Fulkerson JP, Gossling HR: Anatomy of the knee joint lateral retinaculum. Clin Orthop. 1980;153:183-188. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med. 2002;30:447-456. Halbrecht JL. Arthroscopic patella realignment: an all-inside technique. Arthroscopy. 2001;17:940-945. Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am. 2003;34:385-96. Irwin LR, Bagga TK. Quadriceps pull test: an outcome predictor for lateral retinacular release in recurrent patellar dislocation. J R Coll Surg Edinb. 1998;43:40-42. Mangine RE, Eifert-Mangine M, Burch D, Becker BL, Farag L. Postoperative management of the patellofemoral patient. J Orthop Sports Phys Ther. 1998;28:323-335. Marumoto Jm, Jordan C, Akins R. A biomechanical comparison of lateral retinacular releases. Am J of Sports Med. 1995;23:151-155. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-579. Nam EK, Karzel RP. Mini open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation. a medium-term follow-up. Am J Sports Med [on line publication].December 2004; volume 32. Palmer SH, Servant CT, Maguire J, Machan S, Parish EN, Cross MJ. Surgical reconstruction of severe patellofemoral maltracking. Clin Orthop. 2004;419:144-148.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Distal Osteotomy For Patellar Realignment And Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Patellar tracking and stability rely on two restraining mechanisms: a transverse group and a longitudinal group. The longitudinal group consists of the quadriceps superiorly and the patellar ligament inferiorly. Transversely are the medial and lateral retinacula from the vastus medialis and vastus lateralis, which include retinacular thickenings acting as medial and lateral patellofemoral ligaments. Pathogenesis: Patellofemoral pain, patellar subluxation or dislocation can occur when abnormal tracking secondary to malalignment of the patella occurs. The origin of malalignment may be a result of obliquity in the pull of the quadriceps, unilateral tightness, unilateral weakness, trauma to any of the stabilizing structures, or structural abnormalities, i.e. increased Q-angle. Epidemiology: There is a higher incidence of acute instability in young active patients between the ages of 13-20; reoccurrence is higher in patients who dislocate at younger than 15. Female athletes are at a greater risk for recurrent instability than males, possibly due to anatomic differences (greater Q-angle). Subluxation and dislocation occur most frequently laterally, though medial instability can occur as a result of trauma or overaggressive surgical treatment. The following guidelines discuss lateral instabilities. Diagnosis: Patellofemoral instability is mainly a clinical diagnosis based on history and clinical examination. Diagnostic imaging can be utilized to rule out other pathologies. MRI may detect a disruption in the medial retinaculum, chondral lesions, and determine the angle of congruence. Non-operative Versus Operative Management: Conservative treatment is generally done initially which includes physical therapy, taping, and bracing. Surgical intervention is indicated when conservative treatment fails and recurrent instability and/or pain persists. Distal bony realignment procedures are indicated for the skeletally mature patient. Surgical Procedure: Distal realignment involves osteotomy reorienting the tibial tubercle medially to reduce the Q-angle. Distal osteotomy may be accompanied with proximal soft tissue procedures including lateral release, reconstruction of the medial patellofemoral ligament, or advancement of the vastus medialis. Currently, the most frequently used operations include a flat osteotomy cut with straight medialization of the tibial tubercle (Elmslie-Trillat procedure) or an oblique cut which uses anteriorization in addition to medialization of the tibial tubercle (Fulkersons procedure). Medialization is recommended for isolated instability, while anteromedialization is preferred with accompanying patellofemoral pain or chondral lesions to reduce compressive forces on the patellofemoral joint.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Preoperative Rehabilitation: Control pain and inflammation Utilize bracing to prevent further subluxation or dislocation Maintain ROM and strength without promoting further instability

POSTOPERATIVE REHABILITATION

Note. The following rehabilitation guidelines are compiled from multiple sources (see references). A comprehensive plan of care should be individualized based on each patients presentation and depending on the operative procedure(s) used. Many surgeons have specific protocols for use in post-op rehabilitation.

Phase I: Post-op - 6 weeks Goals Protect fixation Control inflammatory process Re-gain quad and VMO control Minimize effects of immobilization Full knee extension Intervention: ROM: 0-90 Brace: 0-4 weeks; locked in extension except for therapy and CPM use 4-6 weeks; unlocked brace for sleeping Weight Bearing: 0-4 weeks; crutches with weight bearing as tolerated 4-6 weeks; wean from crutches, maintain locked brace Therapeutic Exercise: Quad sets with isometric adduction for VMO recruitment Heel-slides 0-90 Calf, hamstring stretches (non-weight bearing) 4 way SLR (locked brace if extensor lag) Resisted ankle ROM (non-weight-bearing) Patellar mobilization Begin aquatic therapy with emphasis on gait at 3-4 weeks

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Phase II: 6weeks - 8 weeks Criteria for advancement to Phase II: Good quad set Approximately 90 flexion ROM No active inflammation Goals: Increase flexion ROM Avoid overstressing fixation Increase quadriceps and VMO control Intervention: Brace: Discontinue for sleeping, unlock with ambulation Weight Bearing: as tolerated, no crutches Therapeutic Exercise: Continue phase I exercise, progress to full flexion with heel slides Calf stretch in weight bearing Discontinue CPM Balance exercises Stationary bike: low resistance/high seat Short arc quadriceps extension in pain free ranges Wall slides 0-45 of flexion Phase III: 8 weeks - 4 months Criteria for advancement to Phase III: Good quadriceps tone without extensor lag with SLR Non-antalgic gait pattern Good dynamic patellar control with out evidence of lateral tracking or instability

Goals: Quad strength good to normal No patellar instability with exercise Normalize gait pattern Intervention: Brace: may discontinue Weight Bearing: full weight bearing Therapeutic Exercise: Step-ups, begin at 2 inches and progress to 8 inches Stationary bike with moderate resistance 4-way hip for flexion, extension, adduction, abduction Leg press 0-45 Closed kinetic chain terminal knee extension with resistance Toe raises Hamstring curls

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Treadmill walking Continue proprioceptive exercises Phase IV: 4 months - 6 months Criteria for advancement to Phase IV: good to normal quad strength no evidence of patellar instability no soft-tissue complaints normal gait pattern physician clearance for more concentrated closed chain exercises and resume full or partial activity Goals: Continue improvements in quad strength Improve functional strength and proprioception Return to appropriate activity level Intervention: Therapeutic Exercise: Progression of closed chain activities Jogging in pool with progression to land Functional progression, sport/work specific Selected References: Cosgarea AJ, Browne JA, Kim TK, McFarland EG. Evaluation and management of the unstable patella. Phys Sportsmee. 2002;30:1-11. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med. 2002;30:447-456. Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. Philadelphia, 1996, F.A. Davis Company. Klimkiewicz JJ. Proximal/distal patellar realignment rehabilitation guidelines. Georgetown University Hospital Orthopedic Protocols. 2003. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-587. Palmer SH, Servant C, Maguire J, Machan S, Parish E, Cross M. Surgical reconstruction of severe patellofemoral maltracking. Clin Orthop Relat Res. 2004;419:144-8. Shelbourne KD, Porter DA. Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle. Am J Sports Med. 1994;22:318-323.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Patellar Tendon Rupture and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Rupture of the patellar tendon most often takes place at the osteotendinous (tibial tubercle) junction. Rupture of the tendon in this area causes complete derangement of the extensor mechanism of the knee. Destruction of the extensor mechanism may lead to an inability to actively obtain and maintain knee extension. Pathogenesis: Patellar tendon ruptures tend to occur during resisted knee flexion with violent quadriceps contraction (when landing from a jump). A force greater than 17.5 times body weight has been reported as the estimated force required to rupture the patellar tendon. The patellar tendon sustains greater stress than the quadriceps tendon during knee flexion. Since there is more tensile load on the tendon at its insertion sites than in the middle portion, the tendon tends to rupture just distal to its attachment to the patella. Etiology: Intrinsic factors that can lead to rupture of the patellar tendon include repetitive microtrauma, systemic inflammatory disease, diabetes mellitus, and chronic renal failure. Extrinsic factors include ruptures that may occur as a result of a corticosteroid injection near the inferior poll of the patella, sudden eccentric contraction of the quadriceps with the foot planted and the knee flexed while the person falls (most prevalent mechanism). Surgery to the knee can also cause rupture of the patellar tendon, these include total knee replacement, using the central third of the patellar tendon as an autograft (ACL repair) and excision of patellar tendonitis. Diagnosis: Rupture of the patellar tendon is usually associated with a pop or tearing sensation with immediate pain, immediate swelling, and an inability to rise and weight-bear will also be noted. Upon physical exam the patient will present with tenderness along the anterior knee and retinacula, patella alta and ecchymosis will also be observed. Lab values may be taken to rule out systemic disease. Plain film radiographs (AP, axial and lateral views), and/or MRI provide the confirmation. Nonoperative versus Operative Management: The type of treatment given to a patient with a rupture depends on the severity of the rupture. A patellar tendon rupture can be treated nonoperatively, but only in the case of a partial tear were the patient is able to maintain active full extension and has normal patellar height. In this case the patient would be immobilized until the tendon has fully healed and strengthening exercises should be delayed for at least 3 months. Operative management is typically the approach of choice, especially with a complete rupture. Surgical intervention is typically initiated as soon as possible to limit the amount of quadriceps contracture and atrophy. Surgical Procedure: Surgical repair of a ruptured tendon is usually delayed 4-7 days to allow a decrease in inflammation and decrease the risk of wound complications. For a patient with an acutely ruptured tendon the general surgical procedure would include suturing the torn tendon through bone tunnels in either the patella or tibial tubercle. The location of suturing depends on the location of the rupture. Debridement of viable tissue may also be performed along the patellar tendon, tibial tubercle and patella. In patients with chronic patellar tendon ruptures or

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 patients where repair may be impossible the surgeon may choose to do surgery in stages. This decision depends on the need to replace the patellar tendon with and autograft or allograft, the degree of patella alta, whether the repair requires augmentation or whether there is peripatellar scaring. Preoperative Intervention: Discuss with the importance of postoperative rehabilitation Identify appropriate patellar height for patient (Surgeon responsibility) Identify possible injuries to associated structures: medial/lateral retinacula, menisci, ACL, PCL, MCL, LCL POSTOPERATIVE REHABILITATION Phase I for Immobilization and Rehabilitation: 4-13 days Goals: Control pain and inflammation Maintain patellar mobility Maintain hamstring strength of the ipsilateral leg and lower extremity strength of the contralateral leg Active knee flexion to 45o and passive knee extension to 0o Intervention: Crutch training with toe-touch weight-bearing Ice and elevation Isometric ipsilateral hamstring exercise, contralateral LE strengthening Gentle medial/lateral patellar mobilization (~25%) AROM, AAROM and PROM Hinged knee brace locked in extension Phase II for Immobilization and Rehabilitation: 2-4 weeks Goals: Control pain and inflammation Begin weight-bearing Maintain patellar mobility Active flexion to 90o and passive knee extension to 0o Maintain ipsilateral hamstring and contralateral LE strength Begin ipsilateral quadriceps retraining Intervention: Crutch training with partial weight-bearing (25-50%) Ice and elevation Isometric ipsilateral hamstring exercise, contralateral LE strengthening Gentle medial/lateral patellar mobilization (~25%) AROM, AAROM and PROM Hinged knee brace locked in extension

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Ipsilateral quadriceps sets (NO straight leg raises)

Phase III for Immobilization and Rehabilitation: 4-6 weeks Goals: Control pain and inflammation Progress weight-bearing (possibly discontinue crutch use) Active flexion progressed as tolerated and passive extension to 0o Maintain patellar mobility Maintain ipsilateral hamstring and contralateral LE strength Continue ipsilateral quadriceps retraining Intervention: Progress to weight-bearing as tolerated, may discontinue crutch use if good quadriceps control is acquired Gait training Ice and elevation Isometric ipsilateral hamstring exercise, contralateral LE strengthening Gentle medial/lateral patellar mobilization (~25%) AROM, AAROM and PROM Hinged knee brace locked in extension Ipsilateral quadriceps sets (NO straight leg raises) Phase IV for Immobilization and Rehabilitation: 6-12 weeks Goals: Control pain and inflammation Progress to full active ROM Maintain patellar mobility Maintain ipsilateral hamstring and contralateral LE strength Continue ipsilateral quadriceps retraining Intervention: Weight-bearing as tolerated Gait training Hinged knee brace locked in extension until good quadriceps control and normal gait are obtained Ice and elevation Isometric ipsilateral hamstring exercise, contralateral LE strengthening Gentle medial/lateral patellar mobilization (~50%) AROM Ipsilateral quadriceps strengthening (straight leg raises without resistance and stationary cycling at 8 weeks)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase V for Rehabilitation: 12-16 weeks Goals: Complete weight-bearing Progress ipsilateral quadriceps strength Begin neuromuscular retraining Intervention: Gait Training No immobilization Ipsilateral quadriceps strengthening Proprioception and balance activities (including single leg support) Phase VI for Rehabilitation: 16-24 weeks Goals: Begin running Sport/Job specific training Intervention: Progress program as listed for Phase IV, with sport or job specific training Phase VII for Rehabilitation: >6 months May begin jumping and contact sports when ipsilateral strength is 85-90% of contralateral extremity

Selected References: Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation. Am J Sports Med. 1999;27:304-307. Casey MT, Tietjens BR. Neglected ruptures of the patellar tendon. a case series of four patients. Am J Sports Med. 2001;29:457-460. Enad JG, Loomis LL. Patellar tendon repair: postoperative treatment. Arch Phys Med Rehabil. 2000;81:786-788. Matsumoto K, Hukuda S, Ishizawa M, Kawasaki T, Okabe H. Partial rupture of the quadriceps tendon (jumper's knee) in a ten-year-old boy: a case report. Am J Sports Med. 1999;27: 521-525.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Patella Open Reduction and Internal Fixation


Surgical Indications and Considerations Anatomical Considerations: The patella is a sesamoid bone that is embedded in the quadriceps tendon. Tensile forces are transmitted from the quadriceps to the tibia via the patella. The patella is also subjected to compressive forces at the articulation with the femur. At 45 the patella is under the most force (approximately between 2 and 10 newtons per millimeter squared). During development the patella most often originates from a single ossification center. In approximately 23% of patients two to three separate ossification centers exist. Two percent of the time these centers do not completely merge, the condition is called bipartite patella. Of these individuals approximately 2% develop symptoms secondary to trauma or chronic stress on the patella. Traumatic patellar fractures are identified as transverse, vertical, marginal or osteochondral. Transverse fractures occur horizontally across the patella. Vertical fractures run from the inferior pole to the superior pole. Marginal fractures occur at the perimeter of the patella and most often include small fragments. Osteochondral fractures are cracks or discontinuities of the covering of the patella. Pathogenesis: Fractures of the patella occur in when the force applied to the patella is stronger than the bone that constitutes the patella. This can happen when the patella receives a direct blow or as a result of indirect forces. If the patella is osteoporotic, much less force is required to fracture the patella. The patella can also be fractured during ACL reconstruction surgery when autogenous patellar tendon is used. The patella can be fractured while the proximal bone plug is being removed. Transverse fractures most often occur with indirect force (for example a forceful quadriceps contraction). Transverse fractures are the most common fracture to result from a traumatic patellar dislocation. Vertical and osteochondral fractures are rare and can occur with either direct or indirect force. Marginal fractures are usually due to a direct force to the side of the patella. Epidemiology: Patellar fractures make up approximately 1% of skeletal injuries. Males are more likely to have bipartite than females, but traumatic patellar fractures do not occur more commonly in men or women. Osteochondral fractures are more common in children than in adults. Diagnosis: History of a direct blow to the patella There may be a palpable ridge in the patella if the break is complete Persistent patellar tenderness Decreased function of the extensor mechanism (inability to extend the knee against resistance) Radiographs confirm injury to the bone MRI can be helpful to identify or rule out associated ligamentous injuries to the knee

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Fractures with 2mm or less separation are indicated for nonoperative treatment. This includes 4-6 weeks of immobilization in a splint or cast on the conservative side and as little as 2 weeks of immobilization on the aggressive side. Aggressive nonoperative treatment may include weight bearing as tolerated as early as 1-week post fracture. Surgical repair is typically recommended for all patellar fractures that demonstrate 3mm or more separation of fragments or a step off of 2mm or more. In the case of comminuted fractures or fractures of severely osteoporotic bone a synthetic patellar prosthesis can be used. Surgical Procedure: Surgical techniques include placing two or three wires or canulated screws perpendicular to the fracture line. In addition, wire can be used around the circumference of the patella. New procedures include arthroscopic techniques also using screws perpendicular to the fracture line as well as circumferential wiring. Fixation screws and wiring are not removed post operatively unless there are complications. Small fragments and loose bodies are removed if found. Preoperative Rehabilitation: Goals include gait with the appropriate assistive device, control of swelling/inflammation, maintaining maximum range of motion, strengthening of surrounding stabilizing musculature, and patient education. Physical therapy interventions include gait training, joint mobilizations, strengthening, and modalities.

POSTOPERATIVE REHABILITATION

Phase I: Weeks 1-4 Goals: Pain and edema control Improvement in muscle contraction PROM: 0-30 Avoid excessive stress on the extensor mechanism Independent home program Intervention: Cryotherapy Electrical stimulation for muscle stimulation (remember to not stress extensor mechanism) Patellar mobilization PROM: heel slides Isometrics: Quadriceps sets at 20-30, hamstring sets Straight leg raises Immobilization for gait with WBAT (begin WBAT around week 4) Weight shifting

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3 Phase II: Weeks 5-8 Goals: Pain management Normalize gait pattern Increase lower extremity strength PROM: 0-90 Intervention: Modalities for pain control Progress PROM AAROM: therapist assisted and stationary bike AROM when cleared by physician (6-8weeks) Isometrics continue progress from Phase I Open chain hip and ankle strengthening Gait training (progress weight bearing)

Phase III: Post Week 8 Goals: Self management of symptoms Increased ambulation distance Good sitting and standing tolerance Good patellar stability and tracking Intervention: AROM: 0-120 Progress lower extremity strengthening: closed chain (squats, steps), continue hip and ankle strengthening, focus on stability, proprioception, balance, and extensor strengthening

Phase I for Aggressive Rehabilitation: Weeks 1-2 Goals: Pain and edema control Improvement in muscle contraction PROM: 0-30 Avoid excessive stress on the extensor mechanism Independent home program

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4 Intervention Week1: Cryotherapy Electrical stimulation for muscle stimulation Patellar mobilization PROM: heel slides in hinged splint set at 0-30 to be work constantly except for bathing. Isometrics: Quadriceps sets at 20, hamstring sets NWB gait with crutches Relative immobilization with hinged splint set at 0-30 Open chain hip strengthening: abduction, adduction, extension

Intervention Week 2: Continue interventions from Week 1 AAROM in hinged splint set at 0-30 Begin WBAT gait with splint and crutches

Phase II for Aggressive Rehabilitation: Weeks 3-4 Goals: Pain management Increase weight bearing with gait Increase lower extremity strength ROM: 0-90 Intervention: Modalities for pain control AAROM: therapist assisted and stationary bike 0-90 AROM: heel slides, short arc quad extension, begin closed chain strengthening Isometrics: continue progress from Phase I Closed chain hip and ankle strengthening Gait training: WBAT with hinged splint and crutches

Phase III for Aggressive Rehabilitation: Weeks 5-6 Goals: Pain management Normalize gait pattern Increase lower extremity strength ROM: 0-120

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Intervention: Modalities for pain control Patellar and tibial/femoral mobilization AROM Closed chain strengthening: wall squats, supine leg press, stationary bike Proprioceptive and balance training Gait training: FWB with hinged splint

Phase IV for Aggressive Rehabilitation: Weeks 7-12 Goals: Self management of symptoms Increased gait distance and speed Good sitting and standing tolerance Good patellar stability and tracking 5/5 hip, knee and ankle strength Intervention: AROM: 0-120 Progress lower extremity strengthening: closed chain (squats, steps, increase speed and force), continue hip and ankle strengthening, focus on stability, proprioception, balance, and quadriceps strengthening.

Selected References: Binder AJ. Spoken interview July 28th, 2004. Diagnosis Patella ORIF. Medical University of South Carolina, Department of Physical Therapy. Online. www.muschealth.com/pt May 3, 2004. Donatelli R. Wooden M. Orthopaedic Physical Therapy. 3rd ed, Churchill Livingstone. 2001:471-473. Lamoureux C. Patella Fractures. eMedicine Online. http://www.emedicine.com/radio/topic528.htm May 3, 2004. Neumann, D. Kinesiology of the Musculoskeletal System. Mosby, Inc. 2002:456-461. Shabat S, Stern Y, Berner D, Morgenstern D, Mann G, Nyska M. Functional results after patellar fractures in elderly patients. Arch Gerentol Geriatr. 2003;37:93-98.

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Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Anterior Cruciate Ligament Reconstruction


Surgical Indications and Considerations Anatomical Considerations: The anterior cruciate ligament (ACL) lies in the middle of the knee. It arises from the anterior intercondylar area of the tibia and extends superiorly, posteriorly, and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur. The ligament is intra-articular but extrasynovial. The ACL is described as being composed of 3 main bundles. These bundles include the anteromedial, posterolateral, and intermediate. The ACL really functions as a continuum, with a portion being tight through all ranges of knee flexion. It acts as the primary restraint to anterior tibial translation and guides the screw-home mechanism associated with knee extension. The ACL acts secondarily to prevent varus and valgus, particularly in the extended knee. Injury leads to abnormal kinematics of the knee. Subluxation episodes occur, creating abnormal shear forces on the meniscus and articular cartilage. Subsequent meniscal injury, therefore, is increased significantly. The major blood supply for the ACL comes from the synovium and fat pads. The vessels involved are middle geniculate and terminal branches of the inferior medial and lateral geniculate vessels. Sensory receptors and nerve fibers have been identified in the ligament, which suggests some sensory role and possible proprioceptive function. Pathogenesis: Ligaments tear when the mechanical load exceeds the physiological capacity of the tissue. ACL tears are most commonly due to extrinsic mechanical forces. It may be due to contact injuries where there is a blow to the side of the knee, such as may occur during a football tackle. Alternatively, non-contact ACL injuries can occur by coming to a quick stop combined with a direction change while running, pivoting, landing from a jump, or hyperextension of the knee joint. ACL injuries are often associated with other injuries. The unhappy triad is a classic example, in which the ACL is torn at the same time as the MCL and the medial meniscus. Basketball, football, soccer and skiing injuries are common causes of ACL tears. Epidemiology: Injury of the ACL is the most common ligamentous injury of the knee and accounts for about 30 injuries per 100,000 of the population, with greater than 100,000 new ACL injuries occurring each year. Women are more likely to suffer an ACL tear than men are. Females are at higher risk of ACL injury when considering sports participation numbers. This is believed to be related to both intrinsic factors (increased Q angle, decreased notch width, increased joint laxity, hormonal influences) and extrinsic factors (less muscle strength, different muscle activation patterns, altered cutting and landing patterns). Adults who tear their ACL usually do so in the middle of the ligament or pull the ligament off the femur bone. These injuries do not heal by themselves. Children are more likely to pull off their ACL with a piece of bone still attached, these may heal on their own, or may require the bone to be fixed.

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2 Diagnosis Mechanism of injury Most patients describe a pop sound at the time of injury Immediate pain and swelling in knee Knee joint instability once swelling and pain resolves Limited ROM Joint line tenderness Positive Lachman Test /or Anterior Drawer Test Pivot-Shift or Jerk Tests (to assess rotational instability) Radiographs to exclude fracture, tumor, and osteoarthrosis Arthroscopy CT scan for associated fractures or avulsions of the cruciate MRI can be helpful in determining the presence, location, and severity of the tear(s) and to evaluate other injuries to the knee with 98% accuracy

Nonoperative Versus Operative Management: Surgical repair depends on the extent of instability and level of activity. It is typically recommended for patients who expect to return to relatively high functional activities required of recreational athletics. In chronic cases, the major indication for surgical reconstruction is recurrent instability. Indications for nonoperative management include patients with active infection, soft-tissue abrasion, and reluctance to participate in the complex rehabilitation required. Conservative care includes a comprehensive rehabilitation program, a functional brace for sports, and activity modification. Relative contraindications are common and include the following: patient is less than 2 weeks from injury, low activity levels, preexisting osteoarthrosis, skeletal immaturity, and inflammatory arthropathy. Some people are able to live and function normally with a torn ACL. However, most people complain that their knee is unstable and may "give out" with attempted physical activity. Unrepaired ACL tears may also lead to early arthritis in the affected knee. Surgical Procedure: There are several surgical procedures available including mini-arthrotomy open technique, two-incision arthroscopically assisted techniques, and one incision endoscopic technique. Currently, ACL reconstruction is most often performed using an arthroscopically assisted technique. The most frequently used graft types for ACL reconstruction are the patellar tendon (PT) and the combined semitendinosis and gracilis tendons (HT). For the past two decades, the gold standard in ACL reconstructions has been the patellar tendon graft from the middle third of the tendon, but increasingly the hamstring tendon graft has been used. The shift in popularity is due to several reasons, including, concerns about damaging the knee extensor apparatus using the PT and the potential for subsequent anterior knee pain, patella fracture, ligament rupture, and infrapatella contraction. The HT techniques also have potential complications including tunnel widening and fixation and concerns of the affects on the muscle function.

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3 Preoperative Rehabilitation Patient education on expectation and likely outcomes of rehab Patient education on joint protection, to avoid deep squats and low chairs for 12 weeks Instructions on post-operative exercises Documentation of pre-operative strength and ROM Correction on any deficits in flexibility and soft tissue compliance

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Bollen, Risberg, Shelbourne. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Phase I of Rehabilitation: Weeks 0-2 Note: Contact MD immediately if increasing pain, signs of infection, or signs of DVT. Goals: Control edema and pain Achieve full extension and 90 of flexion Weight bearing as tolerated Begin regaining muscle strength Quad activation Intervention: Local treatment of swelling with cryotherapy and elevation Soft tissue mobilization to hypomobile tissue in superficial fascia near surgery site Passive knee extension (heel propped up on pillows and let knee sag) Exercise for 5 minutes/hour to stimulate graft ligamentization Maintain flexibility with heel slides or prone hamstring curls Closed Kinetic chain exercises: hamstrings and quads strengthening, half squats (20-70 degree), cycling with seat high to avoid too much flexion Neuromuscular electrical stimulation (NMES), quad activation exercises Tibiofemoral mobilization with rotation, patellar mobilizations Begin introducing proprioception training with eyes closed Crutch training for the first few days

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Phase II of Rehabilitation: Weeks 2-6 Goals: Control any residual symptoms of edema and pain Full knee extension ROM to almost full flexion Progress strength training Normal gait Progressive weight-bearing Return to normal ADL Intervention: Increase load to knee with squats and dips Cycling, step machine, leg press 0-90 degrees Theraband work to improve knee control and proprioception Increase hip adductor and abductor strengthening Gait training

Phase III of Rehabilitation: Weeks 6-12 Goals: Full range of motion Increasing functional activity level Improve proprioception Intervention: Proprioception training on unstable surfaces Wobble board work Progressive resistive exercises Begin open kinetic chain exercises, beginning range at 40-90 of flexion Introduce jogging when muscle strength and control allows Progress to jogging in and out of cones from about 10 weeks, changes in directions should be smooth vs. sudden

Phase IV of Rehabilitation: Weeks 12-26 Goals: Return to pre-injury level sport/occupation at 6 months Normal strength and speed Normal agility Patient fully educated about the future of the knee Intervention:

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5 Progressive sport specific program Sport/work specific strength training Progressive sport specific agility and speed work (no sudden twisting/turning until 4 months) Plyometrics, quality not quantity

Selected References: Bollen SR. BASK Instructional lecture 3: Rehabilitation after ACL reconstruction. Knee. 2001;8:75-77. Bonamo JJ, Fay C, Firestone T. The conservative treatment of the anterior cruciate deficient knee. Am J Sports Med. 1990;18:618-623. Chmielewski TL, Stackhouse S, Axe MJ, Synder-Mackler L. A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925-30 . Herrington L, Wrapson C, Matthews M, Matthews H. Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery. Knee. 2005; 12:41-50. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Physical Therapy Sport. 2004;5:125-145. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18:292-299.

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Posterior Cruciate Ligament Reconstruction and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: Many authors describe the posterior cruciate ligament (PCL) as the primary stabilizer of the knee. It is about twice as strong as the anterior cruciate ligament. It is approximately 38 mm in length and 13mm wide. It runs from the medial femoral condyle to the posterior tibia. The PCL consists of two bands, the anterolateral and posterolateral. The anterolateral band is two times as large and is 1.5 times stronger. The anterolateral band is the band that gets tight on knee flexion, while the posterolateral band is the band that tightens with knee extension. The PCL as a whole gives the knee 95% restraint to posterior tibial torsion and is a secondary control to lateral rotation, varus stresses and hyperextension. Pathogenesis: Tears to the PCL by itself are uncommon. The cause of injury most often is when some force is applied to the anterior portion of the tibia while the knee is flexed, e.g., the anterior aspect of the flexed knee striking a dashboard. A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, causing a posterior force to the proximal tibia, may also result in injury to the PCL. Injury may also occur with forced hyperextension while the foot is planted in dorsiflexion. A force applied to the anteromedial aspect of the knee, as during a football tackle, results in a posteriorly directed force and a varus hyperextension force, may lead to PCL and posterolateral capsular ruptures. When the PCL is ruptured there is increased posterior translation and this translation increases as knee flexion increases and has maximum translation between 70-90 degrees, when the anterior cruciate ligament is fully relaxed. Epidemiology: Of all the patients seen in the emergency room for ligamentous injuries 37% are patients with severe knee injuries. Of that 37%, one third are related to sports injuries. The other two thirds are attributed to other types of injury such as falls and motor vehicle accidents. PCL injuries account for as many as 20% of all knee ligament injuries. Chronic PCL weakness can cause or predispose patients to the following pathologies: (1) medial compartmental osteoarthritis of the knee, (2) meniscal injury, and (3) patellofemoral arthritis. Diagnosis: The clinical examinations commonly used to assess for PCL instability are the posterior drawer test, Godfrey or posterior sag test, and the dynamic posterior shift test. Positive Posterior Drawer Test with knee at 90 is 90% sensitive and 99% specific. The posterior drawer test with the knee at 90 is the most sensitive test for detecting PCL injury. Decreased range of motion may be observed, but may only lack 10-20 of flexion. Grading the injury upon examination is usually performed by using the following scale: Grade I injury, step off present but minimal (i.e., 0-5 mm); Grade II injury, 5-10 mm of posterior translation; and Grade III injury, greater than 10 mm of posterior translation. Positive Godfrey or posterior sag test. 58% sensitive, 97% specificity. Positive Dynamic Posterior Shift Test. 95% specific, but only 26% sensitive. Imaging such as MRI has high sensitivity and specificity in the diagnosis of PCL injury. MRI is found to be 99% sensitive and specific in the diagnosis of complete PCL tears. Arthroscopy can
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2 be performed for further diagnoses of tears in the PCL. Operative vs. Non-operative Management: The decision to perform surgery or not is primarily based on the severity of the injury. It is common for non-operative rehabilitation to take place if the Grade is less than II. The key is to control the swelling, instability, and pain. If the patient, however, continues to experience pain and instability regardless of rehabilitation and bracing, a PCL reconstruction may be needed and performed. There are numerous factors that contribute to which route of treatment will be pursued. It depends on severity of the injury, whether the injury is to the PCL itself or if it is combined with other injuries to the ligaments or menisci, the activity level and goals of the patient, and the preference of the physician. Below is outlined the non-operative and the operative methods of rehabilitation. Note: the below rehabilitation protocols are derived from guidelines provided by McNeal, Lintner, Agesen, Ertl, Bhatti, and Kischner. Please refer to their publications for further information regarding progressions, limitations, expectations, and goals. Non-operative Rehabilitation: Day 1 to Week 2 Goals: Control the initial inflammation Regain ROM with muscle function as quickly as possible Intervention: Rest, ice, compression, and elevation (RICE) several times a day, in addition to other modalities such as electrical stimulation, ice baths. Assisted weight bearing. Patients with grade I and grade II injuries can bear as much weight as they can tolerate immediately. Some may need crutches initially. Crutches and a long leg brace are recommended only with severe grade III injuries with no other associated ligamentous laxity or intra-articular damage. Electrical stimulation (ES) may be used to stimulate the quadriceps muscle, if the patient is having difficulty performing quadriceps contractions. Exercises for quadriceps and hip strengthening. All open kinetic chain (OKC) hamstring exercises should be avoided since they promote posterior tibial translation at the knee. Non-operative Rehabilitation: Weeks 2-12 Intervention: Bracing - Only patients with grade III injuries should still be wearing a brace (0-60) until at least the third week of therapy. Then, the patient may be fitted for a functional knee brace. Assistive Devices - Crutches can be discontinued and weight bearing as tolerated can be progressed Exercises At 2-3 weeks, exercises should be progressed with light resistance as tolerated. The stationary bike may be used for improving ROM. Aquatic exercises can be used for improving ROM and strengthening. At weeks 3-6, the exercises may be increased to include closed kinetic chain exercises (CKC) including: leg press, mini squats, stair stepper, step-ups. Resistance may be increased on the bicycle as tolerated. At 8-12 weeks, strengthening exercises should be progressed and a light jogging program

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3 may be initiated. Non-operative Rehabilitation: 3 9 months Exercises Strengthening and proprioception exercises are progressed as tolerated. Plyometrics and sport-specific training should also be initiated and accelerated as tolerated. A running program is developed, and agility drills are integrated. An isokinetic test and a KT-2000 test should be performed at 3-month, 6-month, 9month, and 12-month follow-up visits. The athlete may return to sporting activities when isokinetic and functional tests are satisfactory according to the PT and the MD. The patient should not return to competitive sports until full quadriceps strength has been reestablished. POSTOPERATIVE REHABILITATION There are a number of different techniques used to reconstruct the PCL, so the treatment protocol is determined by the physician, the PT, and the type of graft used in surgery. The types of grafts used are the patellar tendon, quadriceps tendon, hamstring tendons, and the medial head of gastrocnemius. Phase I: Day 1 to Week 2 Goals: Protect the new graft no active knee flexion. Gain full knee extension so patient can ambulate with normal gait. Improve quadriceps control Intervention: Bracing The patient will be in a post-op brace that is locked at 0 degrees. The brace is to be worn at all times. The brace will be progressed slowly to 30 depending on how stiff the patient may be getting. The patient needs to be educated that activities such as walking down a ramp/hill/incline, sudden deceleration, and squatting activate the hamstrings and should be avoided and that any weight-bearing exercises should be performed in brace. The patient can usually weight bear as tolerated on the affected limb with the use of crutches and a long leg brace. Neuromuscular re-education Improve muscular quadriceps control consider using biofeedback or electrical stimulation on the quadriceps including on vastus medialis oblique. Mobility Exercises: Passive only 0-30 Seated heel slides using towel Hamstring stretch Gastrocnemius/soleus stretch Strengthening exercise Quad sets - if possible 1million/day, straight leg raises, short arc quads Manual Therapy Manual patella mobs especially superior/inferior. Patellar mobility is also very important, and the patient should be instructed in self-mobilization exercises

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4 for the patella, scars, and soft tissues around the knee to prevent fibrosis. Physical Agents Ice can be used following exercise and initially every hour for 20 minutes

Phase II: Week 2 to Week 6 Goals: Protect the graft (note that it is at its weakest point in the healing process) Ambulate with normal gait Good quad control Improve strength and ROM Minimal to no swelling Able to ascend/descend stairs Intervention: Exercises:

Brace:

Heel slides seated and/or supine Continue quad sets until swelling is gone and quad tone is good Straight leg raises - add ankle weights when ready Active knee flexion PRONE 0-30/40 Shuttle/Total gym 0-60 - bilateral and unilateral; focus on weight distribution more on heel than toes to avoid overload on patella tendon Closed chain terminal knee extension Leg Press Step-ups forward Step-overs Wall squats 0-30 Calf raises Cycle when 110 of flexion is reached Continue with HS and calf stretching Balance/proprioceptive training - weight shifting - med/lat, single leg stance - even and uneven surface - focus on knee flexion, plyoball tossing Aquatic resistance training may be initiated during the later part of this phase. Continue to wear brace unlocked to 90 at week 4

Phase III: Week 6 to Week 12 Goal: Perform everyday ADLs without difficulty Full knee ROM Intervention: Bracing - Post-op brace will is often discontinued at 6 weeks patient may then be fitted for functional brace

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5 Exercises: Continue with above exercises, increasing intensity as tolerated. Active knee flexion prone 0-90 Knee extensions 0-90 Step-ups forward and lateral; add dumbbells to increase intensity; focus on slow, controlled movement during the ascent and descent Squats - standing (at week 8) Lunges forward and reverse; add dumbbells or medicine ball Theraband hip flexion Single leg squats Single leg wall squats Cycle increase intensity; single leg cycle maintaining 80 RPM Balance/proprioceptive exercise - Plyoball tossing even and uneven surfaces, squats on balance board/foam roll, Cycle increase intensity

Phase IV: Week 12 to one year Goal: Perform everyday ADLs without difficulty Full knee ROM Increase strength, power, and endurance. Prepares the athlete for return to competition Intervention: Exercises: Strengthening should continue with focus on high intensity and low repetitions (6-10) for increased strength. Hamstring and calf stretches should also continue Quad stretch should be implemented. Week 12: Light resisted hamstring work can be initiated Initiate lateral movements and sports cord exercises: lunges, forward, backward, or side-step with sports cord, lat step-ups with sports cord, step over hurdles. Jogging/Plyometrics: When cleared by the physician, the patient can begin light plyos and jogging at a slow to normal pace. Patient should be focusing on achieving normal stride length and frequency. Initiate jogging for 2 minutes, walking for 1 until this is comfortable for the patient and then progress the time as able. Jogging should first be performed on even surfaces such as a treadmill or track. Then it can be progressed to mild uneven surfaces such as grass and then asphalt or concrete. It is normal for the patient to have increased swelling as well as some soreness, but this should not persist beyond one day or the patient did too much. Jump rope and line jumps can be initiated when the patient is cleared to jog.

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6 Jogging and plyos should be performed with brace on. Advanced Plyos can include squat jumps, tuck jumps, box jumps, depth jumps, 180 jumps, cone jumps, broad jumps, scissor hops. Leg circuit: squats, lunges, scissor jumps on step, squat jumps. Power skipping Bounding in place and for distance Quick feet on step forward and side-to-side use sports cord Progress lateral movements shuffles with sports cord; slide board Ladder drills Swimming all styles Focus should be on quality, NOT quantity Landing from jumps is critical knees should flex to 30 and should be aligned over second toe. Controlling valgus stress and movements, will be a challenge at first, and unilateral hops should not be performed until this is achieved. Gradually initiate sprints and cutting drills. Progression: Straight line, figure 8, circles, 45 turns, 90 cuts and sports specific drills

Selected References: Agesen T, Ertl J; Kovacs G. Posterior Cruciate Ligament Injury. E-medicine. http://www.emedicine.com/sports/topic105.htm. Jan. 12, 05. Bhatti J; Kischner S; Sarmini M. Posterior Cruciate Ligament Injury. E-medicine. 12/19/03. http://www.emedicine.com/pmr/topic102.htm. McNeal M; Lintner D. PCL Protocol. http://www.drlintner.com/PCLrehab.htm Stapelton T. The Posterior Cruciate Ligament. Hughston Health Alert. 1996 http://www.hughston.com/hha/a.pcl.htm. Sekiya J, Kurtz C, Carr D. Transtibial and tibial inlay double-bundle posterior cruciate ligament reconstruction: Surgical technique using a bifid bone-patellar tendon-bone allograft. Arthroscopy. 2004;1095-1100. Wind W, Bergfeld J, Parker R. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med. 2004;32:1765-1775.

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Medial/Lateral Meniscectomy and Rehabilitation


Anatomical considerations: The meniscus is an important load-bearing structure that supports 70% of the load transmitted through the lateral compartment and 50% medially, thus decreasing contact pressures on the articular cartilage. It is also an important secondary stabilizer of the knee, resisting anterior translation. The meniscus has nutritive as well as lubricating properties in the knee joint as well. The medial meniscus is C shaped and thicker posteriorly. It occupies 50% of the articular contact area of the medial compartment. The lateral meniscus is O shaped and of equal thickness throughout. It covers 70% of the lateral tibial plateau. The red zone or fibrous outer portion of the meniscus is vascular and therefore tears there will often heal. The inner 2/3rds or white cartilaginous zone of the meniscus does not have a good blood supply and therefore, tears are less likely to heal in this area. The lateral meniscus is not as firmly attached to the tibia as the medial meniscus and therefore is less prone to injury. Pathogenesis: The meniscus is most commonly injured by a compressive or weight bearing force, combined with tibiofemoral rotation in the transverse plane as the knee moves from flexion to extension. A tear may therefore occur during activities that require rapid cutting or pivoting. Epidemiology: The posterior medial meniscus is the most commonly injured portion of the menisci, secondary to it being less mobile and therefore, greater stresses occurring in this area. Athletes and younger individuals most often obtain meniscus tears via non-contact activities like rapid cutting, pivoting or deceleration movements. With increasing age, tears can often occur with trivial injury due to degeneration of the meniscus. Diagnosis Injury followed by pain in area of medial or lateral joint lines Most patients describe pain especially when the knee is straightened. Following an injury, the knee may click, lock or feel weak Positive McMurrays or Apleys tests MRI may help to confirm the diagnosis

Nonoperative vs. operative management: The overall treatment goal is to preserve as much meniscal tissue as possible while addressing the clinical symptoms caused by the meniscal tear. Nonoperative treatment which consists of anti-inflammatory medications and careful strengthening exercises may allow for the menisci to heal, especially if the tear lies in the outer third of the structure. This treatment may take 6-8 weeks in order for meniscal healing to occur. If the patient continues to complain of symptoms following 6 weeks, arthroscopic meniscectomy may be considered. Non-operative treatment is usually more appropriate for patients who are less active or sedentary. Meniscal tears that extend beyond the outer third or vascular zone will not heal and therefore a partial meniscectomy is recommended. A complete meniscectomy may be performed especially with significant degenerative tears to the meniscus.

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2 Both complete and partial meniscectomies result in a significant increase in the load across the joint and on the articular cartilage and reduce the shock absorption capacity of the knee. A partial meniscectomy leaves a rim of tissue in place, which maintains some stress protection for the articular cartilage, in contrast to a total meniscectomy, which (in the absence of regeneration) is associated with increased cartilage degeneration, joint narrowing, alterations in bone geometry, and osteophyte formation. Due to these factors, many surgeons choose to preserve the meniscus with a meniscal repair or in some cases reconstruction with an allograft. In addition to the location of the tear, the pattern of the tear may also indicate if surgery may be required. Longitudinal tears have a favorable healing potential except for a bucket-handle tear (a variant of a longitudinal tear) in which circumferential fibers are involved. Radial or flap meniscus tears also involve the circumferential fibers. These tears are more easily managed with debridement/ meniscectomy. Degenerative tears also respond better to meniscectomy than repair. Surgical procedure: Although meniscectomy was originally performed by open arthrotomy, the procedure is almost universally done today by arthroscopic means. Partial meniscectomy is indicated in unstable tears that are not repairable due to location or configuration and serves to preserve as much of the normal meniscus as possible. In this procedure, the surgeon removes only the damaged or unstable portion of the meniscus, and balances the residual meniscal rim. The procedure for a total meniscectomy, the entire meniscus may be removed. Preoperative rehabilitation: Pre operative rehab for a meniscal injury that is to undergo a meniscectomy may involve: (1) Swelling and pain control, (2) range of motion exercises, (3) quadriceps strengthening and (4) aquatic therapy for strengthening if pain is preventing strengthening with normal weight bearing

POSTOPERATIVE REHABILITATION

Rehab following a partial medial or lateral meniscectomy can usually progress as tolerated, with no contraindications or limitations due to the fact that there is no anatomic structure that must be protected. Goals are early control of pain and edema, immediate weight bearing, obtaining and maintaining full ROM and regaining proper quadriceps strength. The following is a rehab progression provided by S. Brent Brotzman and Kevin E. Wilk. Phase 1: Acute phase Goals: Diminish inflammation and swelling Restore ROM Reestablish quadriceps muscle activity

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3 Intervention: Days 1-3 Cryotherapy Light compression wrap Electrical muscle stimulation to quadriceps Strengthening Exercises: Straight leg raises, hip adduction and abduction, and/or squats Active assisted ROM stretching, emphasizing full knee extension (flexion to tolerance) Weight bearing as tolerated (use of axillary crutches as needed) Days 4-7 Cryotherapy and continued use of compression wrap Electric muscle stimulation to quadriceps Strengthening Exercises: Straight leg raises, quadriceps sets, hip adduction and abduction, knee extension 90-40 degrees, and/or squats Balance/proprioceptive drills Active assisted, passive ROM, and stretching exercises (hamstrings, gastrocsoleus, quadriceps) Weight bearing as tolerated Days 7-10 Continue all exercises and add: Leg press (light weight), toe raises, and hamstring curls Bicycle (when ROM 0-105 degrees with no swelling)

Phase 2: Internal Phase Goals: Restore and improve muscular strength and endurance Reestablish full nonpainful ROM Gradual return to functional activities Intervention: Days 10-17 Bicycle, Stairmaster and/or elliptical trainer for motion and endurance Strengthening and coordination exercises: Lateral lunges, front lunges, squats, leg press, lateral step ups, knee extension (90-40 degrees), hamstring curls, hip adduction and abduction, hip flexion and extension, toe raises Proprioceptive and balance training Stretching exercises Day 17-Week 4 Continue all exercises Pool program (deep water running and leg exercises)

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4 Compression brace may be used during activities

Criteria for progression to Phase 3: Satisfactory clinical examination (minimal effusion) Full/nonpainful ROM No pain or tenderness Satisfactory isokinetic test

Phase 3: Advanced Activity Phase Weeks 4-7 Goals: Enhance muscular strength and endurance Maintain full ROM Return to sport/functional activities Intervention: Therapeutic exercises:Continue to emphasize closed-kinetic chain exercises May begin plyometrics Begin running program and agility drills

Selected References: Brindle T, Nyland J, Johnson D. The meniscus: review of basic principles with application to surgery and rehabilitation. J Athl Train. 2001;36:160-169. DAmato M, Bach B. Knee Injuries. In Brotzman B, Wilk K, eds., Clinical Orthopedic Rehabilitation. Philadelphia, Mosby,2003. Poole R, Blackburn T. Dysfunction, Evaluation, and Treatment of the Knee. In Donatelli R, Wooden M, eds., Orthopedic Physical Therapy. New York,Edinburgh, London, Melbourne, Tokyo, Churchill Livingstone, 1994. Rath E, Richmond J. The menisci: basic science and advances in treatment. Br J Sports Med. 2000;34:252-257. Weinstein S. Arthritis of the Knee. In Weinstein S, Buckwalter J, eds., Tureks Orthopedics, Principles and their Applications. Philadelphia, J.B. Lippincott Co., 1994.

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Meniscal Repair
Surgical Indications and Considerations Anatomical Considerations: The meniscus is a half moon shaped piece of cartilage that acts as force transmitter between the femur and the tibia. The meniscus has nutritive as well as lubricating properties in the knee joint as well. In a normal knee, there are two menisci, which sit on the tibia itself; the lateral and medial menisci. The meniscus itself is largely avascular, and therefore, cannot repair itself if the tear is in an avascular portion of the meniscus. The only time a meniscus will repair itself is if the injury is located in the periphery of the meniscus, where it has a vascular supply. A short (<1cm) stable tear that is limited to the outer 20% of the meniscus could heal itself with a period of immobilization. Descriptively, the anterior third of the meniscus is known as the anterior horn, the posterior third as the posterior horn, and the middle as the body. The complete removal of the meniscus can result in progressive knee arthritis. Pathogenesis: Traumatic tears are the result of a sudden load being applied to the meniscal tissue that is severe enough to cause the cartilage to fail. This trauma is usually the result of a twisting injury on a semi-flexed knee or a blow to the side of the knee that causes the meniscus to be compressed or levered against. Common examples of this injury are a fall backwards onto the heel with rotation of the lower leg or a football clipping injury. Degenerative tears are a result of the failure of the meniscus over time. There is a natural drying out of the center of the meniscus which progresses with age. Therefore, often the mechanism of injury is nothing out of the ordinary for the patient. An example of a possible mechanism would be a squat to pick an item up off of the floor. However, other times, there are no memorable injury that caused the tear. Epidemiology: A meniscus tear can be located in any location, and in any conceivable pattern. However, tears that are confined to the anterior horn are unusual. Tears typically begin in the posterior horn and progress anteriorly. Patients with sports injuries have a mean age of 33 years, and account for approximately 32% of cases. Patients with non-sporting injuries have a mean age of 41 years, and account for approximately 39% of cases. Patients with an indefinable injury have a mean age of 43 years, and account for about 29% of cases. There is a 4:1 male to female ratio in these tears, and approximately 2/3 of all cases occur in the medial meniscus. It should also be noted that associated ACL tears were found in 47% of the patients in sports injuries and in 13% of the non-sporting injuries. In the no-injury group, there were no ACL tears. Diagnosis Pain on the side of the knee at the level of the joint line between femur and tibia May observe swelling, but generally low grade, associated with stiffness and limping Patient may report a locking of the knee in a bent position, associated with pain Twisting, squatting or impacting activities cause pain Positive McMurrays, Apleys grinding test and/or Bounce home test Radiographs rule out bony injury MRI is helpful in determining the presence, size, location and severity of the tear

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2 Nonoperative Versus Operative Management: Surgical repair is typically recommended for patients who are experiencing pain and/or locking of the joint. Arthroscopic surgery is the method of choice to treat a tear, as there are currently no medications, braces or physical therapy treatments that have been shown to promote healing in avascular tears. Arthroscopic surgery is performed on an outpatient basis, with the surgeon evaluating the tear. Upon this evaluation, the decision is made to either remove or repair the tear based on the location and size of the tear. If there is a vertical tear at the rim near the meniscal blood supply, it is desirable to repair the meniscus by approximating the torn edges of the meniscus to allow for healing and preventing these edges getting caught in the joint. Note that if the tear is located in an avascular portion of the joint, a meniscectomy will most likely need to be performed. The main surgical risk is wound infection and breakdown. Surgical Procedure: One arthroscopic technique is known as the inside-out method. It uses cannulas to direct a pair of long needles into the meniscus and out through a small incision in the back of the knee. The suture ends are then tied together on the outside of the knee capsule to firmly approximate the tear. This procedure does require a 1 incision to access the area where the sutures are tied together. Other arthroscopic methods can avoid incisions completely. Some of these include bioabsorbable arrows and dissolving meniscal staples. T-Fix sutures are another option that provide a good repair. These sutures have an anchor that acts like a wall anchor and is deployed after placing the suture through the meniscus, the tear, and the peripheral rim. The sutures are then tied together from the inside using a knot pusher instrument that secures the meniscus to the rim.

POSTOPERATIVE REHABILITATION

Phase I: Weeks 1-4 Goals: Decrease swelling and pain Protect Repair Increase range of motion and strength Intervention: Physical Agents Electrical Muscle Stimulation Cryotherapy Therapeutic Exercises Isometric quadriceps, straight leg raises, active knee extension Non-weight bearing gait training (weeks 1-2) Toe touch weight bearing body weight gait training (weeks 3-4) Progressive Strengthening Exercises (hamstrings, quadriceps, gastroc-soleus, iliotibial band) Closed Chain activities (gait, toe raises, wall squats, mini squats) in weeks 3 and 4 UBE for conditioning (weeks 1-2)

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3 Stationary bike < 15 minutes (weeks 3-4) External Devices Post-operative bracing (immobilizer) Axillary Crutches Passive Range of Motion/Manual Therapy Goal of achieving 0-90 degrees in weeks 1-2; 0-120 degrees in weeks 3-4 Patellar mobilizations

Phase II: Weeks 5-8 Goals: Restore normal, pain free full range of motion Ability to walk with full weight bearing by weeks 7 and 8, while wearing immobilizing brace Intervention: Physical Agents Electrical Muscle Stimulation (stops after week 6) Cryotherapy Passive Range of Motion/Manual Therapy Goal of achieving 0-135 degrees Patellar and peri-patellar soft tissue and joint mobilizations Therapeutic Exercises Knee flexion (hamstring curls to 90o) Knee extension (quad sets 0-30o) 4 way hip exercises Leg press (70-10o) Step-Downs Proprioceptive/balance training (weight shifting, mini trampoline, BAPS board, KAT board, plyometrics) Conditioning with stationary bike Weeks 7/8 and on stationary bike, aquatic therapy, swimming, walking, stair climber, elliptical machine, straight running External Devices Axillary Crutches and immobilizing brace as indicated

Phase III: Weeks 9-12 Goal: Allow patient to return to most normal activities including community ambulation, unlevel surfaces and stairs without pain - and without brace

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4 Intervention: Approaches / strategies listed above Functional training: Introduce running without brace, multi-plane single leg activities, cutting and full sport activities

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to unrestricted sport or work activity Therapeutic exercises Review desired activity and progress to ballistic activity specific exercises Patient education/ergonomics instruction Educate patient to recognize knee injuries Instruct in home/gym exercise and stretching program to prevent recurrence.

Selected References Asik M, Sen C, Taser OF, Sozen YV, Alturfan AK. Arthroscopic meniscal repair with the use of conventional suturing materials. Acta OrthopedicTraumatol Turc. 2002. Abstract (article is in Turkish) Cincinnati Sports Medicine and Orthopaedic Center. Rehabilitation Protocol Summary for Meniscus Repairs. www.cincinnatisportsmed.com, accessed 7/6/2004 Drosos GI, Pozo JL. The causes and mechanisms of meniscal injuries in the sporting and nonsporting environment in an unselected population. Knee. 2004;4:143-149. Greis PE, Bardana DD, Holmstrom MC, Burks RT. Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg. 2002;10:168-76. Magee, D. Orthopedic Physical Assessment 4th ed. WB Saunders Co., Philadelphia, PA, 2002 Nevsimal L, Skotak M, Mika P, Behounek J. Clinical examination of menisci in the era of arthroscopy. Acta Orthopedic Traumatol Cech. 2002. Abstract only as article is in Czech. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees. Am J of Sports Med. 2004;32:675-680.

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Knee - Articular Cartilage Procedures


Surgical Indications and Considerations Anatomical Considerations: Articular cartilage covers the articular surfaces of synovial joints and provides a nearly frictionless surface for kinematics. It lacks blood supply and lymphatic supply, receiving its nutrients secondary to movement and stresses to the proteoglycans and collagen. Articular cartilage is composed of type II hyaline cartilage, which does not spontaneously reproduce and is naturally replaced with fibrocartilage following pathology. Fibrocartilage lacks the shock absorption and smooth characteristic of hyaline cartilage. Mechanical motion and loading have been found to increase chondrocyte activity and improve cartilage generation. Pathogenesis: Research suggest that it may stem from a variety of causes including: post traumatic avascular necrosis, idiopathic avascular necrosis, overuse and repeated impact, blockage of a small artery, unrecognized injury, tiny fracture leading to cartilage damage, genetic predisposition (if multiple joints involved or family history), abnormal ossification, and acute trauma or shear force. Osteochondral defects are divided into five stages. Stage 0 - normal, Stage 1 - softening and/or superficial fissures, Stage 2 - injury extending to less than 50% of cartilage depth, Stage 3 - injury through 50% of cartilage depth and to subchondral bone, Stage 4 - Subchondral bone exposed, injury to subchondral bone or through to trabecular bone. Epidemiology: Osteochondral defect is a common disorder of unclear etiology. Predisposing factors include high impact athletic activities, muscular weakness and instability, malalignment, and endocrine imbalance. The pathology is historically more common in males (thought to be secondary to activity level) with prevalence increasing in females, ages 10-40 years, and is known to occur in the knee, dome of the talus, capitellum, femoral head, and trochlea. Occurrence is greater in the weight bearing joints and may occur in the upper extremities with falling onto an outstretched arm. Diagnosis: Patients present with varying pain levels from no complaints to non-relieving pain following trauma, sudden onset (loose body), gradual onset, or intermittent pain Pain is primary complaint, dull ache, poorly localized, rest alleviates, increases with activity. Swelling is often intermittent, increases with activity Grating in the joint Decreased range of motion, stiffness. Inconsistent range of motion could be indicative of a loose body Locking in the joint and giving way Plain film radiographs confirm lesion. MRI, CT, and US are used to diagnose stage of lesion. Arthroscopy is gold standard evaluation tool

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Nonoperative Versus Operative Management: Treatment of osteochondral lesions depends on the size, location, stability of the fragment, and skeletal maturity (epiphyseal plates). Research and history has shown that articular cartilage will not spontaneously heal. Stage 1 and 2 lesions are often treated conservatively because the surgery is invasive and reliability of techniques is indifferent. Surgical intervention is recommended for stage 3 and 4 lesions and occasional stage 2 lesions depending on level of activity of patient and physician's choice. Surgical Procedures: Several surgical intervention options are available and chosen depending upon the condition of the lesion and goals of the patient. Arthroscopic debridement consists of removal of loose bodies, spurs, loose cartilage, and the cartilage surface is made smooth. Arthroscopic abrasion is utilized following debridement to expose bleeding surface of bone in order to stimulate cartilage healing however, healing occurs with a less than optimal fibrocartilage layer. Arthroscopic micro fracture or drilling consists of drilling holes into the subchondral bone with the intention of stimulating articular cartilage formation from the subchondral bone. Drilling can be done either retrograde (does not touch the remaining cartilage) or antegrade (through the remaining cartilage). More invasive options include osteochondral autograft transfer (OAT) procedure that involves removing a graft and bone plug from a non weight bearing surface of the knee, usually the patella groove of the medial condyle. Holes are drilled into the osteochondral lesion and the plugs are then placed in the lesion. The articular surface is then hyaline cartilage from the plugs, but the space between the plugs is filled with fibrocartilage. The latest option is Autologous Chondrocyte Transplantation/Implantation (ACI) that requires a biopsy of healthy articular cartilage from a non weight bearing surface to be gathered and sent to the lab to culture hyaline cartilage. Cartilage is sent back to the physician. A periosteal graft is then taken from the tibia and inserted into the lesion with the new cartilage cells injected below it. The graft is sutured in place with flat sutures. Preoperative Rehabilitation: Conservative treatment to return patient to highest level of function. If conservative fails to meet the desired outcomes and/or expectations, then surgery is implicated Lower extremity strengthening and arm bike to maintain cardiovascular strength Patient education in use of crutches and weight bearing status as appropriate A controlled motion brace may be appropriate with symptoms of instability Instructions and review post-operative plan and educate on long recovery period

POSTOPERATIVE REHABILITATION Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Fitzgerald and Irrgang and published in Clinical Orthopaedic Rehabilitation by Brotzman and Wilk. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan.

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3 ARTHROSCOPIC DEBRIDEMENT

Phase I: Early post-operative protection phase: 0-6 weeks Goals: Protection of healing tissue from shear forces Restoration of full passive knee extension Gradual improvement of full knee flexion Re-establish voluntary quadriceps control Adhere to weight bearing status Intervention: Full extension at 1 wk Full flexion at 3 wks Initiate isometric exercises Open chain resisted exercises as tolerated Closed chain exercise as tolerated in accordance to weight bearing status Weight bearing as tolerated crutch training Initiate walking program: 3-6 weeks Stationary bike: 3-6 weeks Swimming program: 3-6 weeks Elevate and ice

Phase II: Intermediate Phase: 6-12 weeks Goals: Full active range of motion should be achieved by this time Return to full activities. Intervention: Exercises to maintain full active range of motion Progress to open and closed chain resisted exercises as tolerated Agility and sport specific skill training at 50% effort is initiated, progress to full effort as tolerated Initiate return to full activity as these activities do not induce pain or effusion Elevate and ice as needed

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4 OSTEOCHONDRAL AUTOGRAFT PROCEDURE Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan. Phase I: Protection Phase: 0-6 weeks Goals: Protection of healing tissue from shear forces Restoration of full passive knee extension Gradual improvement of knee flexion Re-establishment of voluntary quadriceps control Intervention: Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks Weight bearing- toe touch for 2 weeks, 25% body weight 3-4 weeks, 50-75% 5-6 weeks Immediate motion Patellar mobilization Full passive knee extension Passive knee flexion, active assisted range of motion: 0-90o week 1 0-100o week 2 0-110o week 3 0-115o week 4 0-125o week 6 Isometric quadriceps sets Straight leg raises Isometrics in multiple angles for quads Electrical muscle stimulator to quads if poor recruitment Bicycle as range of motion permits Active knee extensions: Week 3 Mini squats 0-50 degrees: Week 3 Leg press: Week 3 Gradual return to daily activities as tolerated, reduce if symptoms occur

Phase II: Transition Phase: 6-12 weeks Goals: Gradual increase range of motion Gradually improve lower extremity strength and endurance Gradually increase functional activities Intervention:

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Full weight bearing: Weeks 6-8 Knee range of motion: 0-125o Progress resistive exercises Initiate closed chain exercises including step ups and wall squats to 70 degrees Stationary bike Balance and proprioception drills Pool program Initiate isotonic strengthening program: Weeks 6-8 Gradual increase in walking and standing, as swelling and pain allows

Phase III: Maturation Phase: 12-20 weeks Goals: Improve muscular strength and endurance Increase functional activities Intervention: Leg press 0-90o Bilateral squats 0-60o Unilateral step ups and step downs, 2-8 Forward lunges Walking program Stationary bike Balance and proprioceptive drills Pool program Stairmaster Initiate light running program DETERMINED BY PHYSICIAN

Phase IV: Return to Activity Phase: 20-26 weeks Goals: Gradual return to full unrestricted functional activities Intervention: Progress exercise program Squats 0-65o Leg press 0-90o Step ups, step downs Front lunges Bike Gradual increase to running and agility drills Low impact sports 4 months Moderate impact sports 5 months

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6 High impact sports 6-7 months

AUTOLOGOUS CHONDROCYTE IMPLANTATION Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan. Phase I: Protection Phase: 0-6 weeks Goals: Protection of healing tissue from load and shear forces Restoration of full passive knee extension Gradual improvement of knee flexion Regain quad control Intervention: Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks. Weight bearing: non weight bearing for 2 weeks, toe touch 3-4 weeks, 25% 5 weeks Immediate motion CPM first 4-12 hours: 0-40o for 2-3 weeks, increase as tolerated 5-10 degrees per day Patellar mobilization Full passive knee extension Passive knee flexion 0-90o at 2 weeks, 0-105o at 4 weeks, 0-120o at 6 weeks Stretch hamstrings, calf, quads Theraband resisted ankle pumps Isometrics for quads Active knee extension 90-40 degrees, no resistance Straight leg raises Stationary bike Biofeedback as needed Isometric leg press at week 4 Gradual return to daily activities Elevation and ice

Phase II: Transition Phase: 6-12 Weeks Goals: Gradual increase in range of motion Gradually improve quad strength and endurance Gradual increase in functional activities Intervention: Discontinue brace at 4-6 weeks

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7 Progress knee flexion to 125o Patella mobilization and soft tissue work Continue stretching Mini-squats 0-45o Closed chain exercises, leg press Calf raises Open chain resistance, 1#/week Stationary bike Balance Front and lateral step ups Increase functional activity as pain and swelling allow Walking program

Phase III: Maturation Phase: 12-26 weeks Goals: Improve muscular strength and endurance Increase functional activities Intervention: Range of motion to 0-125/135 Leg press 0-90o Squats 0-60o Unilateral step ups 2-8 Forward lunges Walking program Open chain extension 0-90o Bike Stairmaster Swimming Nordic track Light running at end of phase

Phase IV: Functional Activity Phase: 26-52 weeks Goals: Gradual return to full unrestricted activities Intervention: Progress resistance as tolerated Progress agility and balance drills Impact and loading program to build to patients requirements

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8 Progress sport programs as necessary Low impact sports at 6 months Moderate impact sports at 8-9 months High impact sports at 12 months

Selected References: Barber FA, Chow JCY. New frontiers in articular cartilage injury. Arthroscopy. 2003;19:142146. Bentley G, Biant LC, Carrington RWJ. A prospective, randomized comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg. Br.2003;85:223-230. Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia, Mosby Inc.,. 2003: 350-355. DLima DD, Hashimoto S. Osteoarthritis and cartilage. Journal of the OsteoArthritis Research Society International. 2001;9:712-719. Ellenbecker T. Knee Ligament Rehabilitation: New Techniques for Cartilage Repair and Replacement. Churchill Livingston; 2nd edition. 2000. Mendicino RW, Catanzariti AR. Mosaicplasty for the treatment of osteochondral defects of the ankle joint. Clin Podiatr Med Surg. 2001;18:495-511. Milbrandt T, Berthoux L, Christenson V. Tracing transduced cells in osteochondral defects. J Pediatr Orthop. 2003;23:430-436. Nakagawa Y, Matsusue Y. Osteochondral grafting for cartilage defects in the patellar grooves of bilateral knee joints. Arthroscopy. 2004;20 Suppl 2:32-38. Wilk K. Surgical treatment options for articular cartilage defects. Northeast Seminars. Los Angeles 2003.

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Total Knee Arthroplasty Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The knee is composed of the distal end of the femur, proximal portion of the tibia, and the patella. It has a medial and lateral meniscus in between the femur and tibia to cushion the joint, absorb and transmit weigh-bearing forces. Four ligaments, the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL) provide anterior-posterior and medial-lateral support. The knee is an unstable joint, relying on ligaments, menisci, and balanced muscles on all sides of the joint, particularly the hamstrings and quadriceps, for cushioning and stability. It is more than a simple hinge joint, as the bone surfaces roll, glide, and rotate on each other. Pathogenesis: Wear and tear of the knee joint is part of the normal aging process, however, osteoarthritis (OA) accelerates the degenerative wear of the meniscus. This form of arthritis usually results from some predisposing factor, such as an injury or deformity. Whether of unknown origin or secondary to trauma or disease, poor alignment of the leg bones may cause unequal weight distribution. This leads to excessive wear on one side of the joint surface versus another, and any irregularity of the knee joint results in wear and tear of the menisci. Over time, the menisci no longer function as an effective shock absorber/transmitter for the knee. Excessive localized pressure and damage to the joint result, possibly leading to bone-on-bone contact, causing symptoms of increased knee stiffness and pain. Remodeling of bone may also occur due to bone-on-bone contact, causing bony spurs. These spurs contribute to increased pressures within the joint, leading to pain and decreased function. Rheumatoid arthritis is an inflammatory joint disease that is destructive to articular cartilage lining the surfaces of the knee joint. The inflammatory process can cause joint instability and deformity, muscle atrophy and weakness, swelling, stiffness, and pain. Epidemiology: Total knee arthroplasty (TKA) is one of the most common orthopedic procedures: 171,335 primary total knee replacements occurred in 2001. Nearly 90% of patients who elected to have TKA had OA of the knee, 2/3 were female, and 1/3 were considered obese. Although patients as young as late-40s and as old as mid-90s have received total knee replacements, the ideal knee replacement candidate is between the ages of 65-75, as patients are healthy enough to recover well from surgery, yet old enough so replacement most likely lasts the rest of their lives (15-20 years). Obesity is the most modifiable risk factor, but prior knee injuries/trauma, and extreme physical or repetitive activity can also contribute to increased incidence of knee OA. Other causes of knee dysfunction leading to TKA include rheumatoid arthritis, trauma, congenital/acquired joint deformity, and tumors.

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2 Diagnosis/Indications For Surgery Severe joint pain with weight bearing or motion that compromises functional activities (severity of pain correlates poorly with radiographic and structural changes in the joint) Extensive destruction of articular cartilage of the knee secondary to advanced arthritis Gross instability or limitation of motion Marked deformity of the knee such as genu varum or valgum Knee pain that does not respond to conservative therapy (medication, injections, physical therapy > six months) Previous failed surgical procedure Nonoperative Versus Operative Management: There are typically four major groups of nonsurgical treatments: 1) Health and behavior modification, including weight loss and patient education about behavior changes to reduce impact of disease, physical therapy and exercise to stretch, strengthen muscles surrounding the knee. Deyle et al concluded that a combination of manual physical therapy and supervised exercise is more effective than no treatment in improving walking distance and decreasing pain, dysfunction, and stiffness in patients with OA of the knee, possibly deferring or decreasing the need for surgical intervention. Vad et al proposed a progressive five-stage rehabilitation program for managing knee OA that ranges from protected mobilization to exercises to improve neuromuscular coordination, timing, and joint protection. Taping and bracing to support and protect the knee joint, foot orthoses to correct imbalances contributing to unequal weight bearing forces across the knee joint, and use of TENS for pain control are also included under this category. 2) Drug treatments, including simple pain relievers, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, opiates, and glucosamine and/or chondroitin sulfate are several types of drugs used to treat knee OA. 3) Intra-articular treatments involve one or more injections into the knee joint. Corticosteroid injections, limited to four or less per year, are helpful for significant swelling causing moderate to severe pain. Typically corticosteroid injections are not helpful if arthritis affects joint mechanics. Viscosupplementation with hyaluronic acid, a molecule that is found in joints of the body, is a way of adding fluid to lubricate the joint and make it easier to move. It can be helpful for people whose arthritis does not respond to behavior modification or basic drug treatments. Three to five weekly shots are needed to reduce the pain, but relief is not permanent. 4) Alternative therapies include the use of acupuncture and magnetic pulse therapy. Acupuncture is adapted from a Chinese medical practice. It uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Because the body produces electrical signals, proponents think that magnetic pulse therapy may stimulate the production of new cartilage. Many forms
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3 of therapy are unproven but reasonable to try provided they are through a qualified practitioner and the primary physician is informed of the patients decision to try these therapies. Elective total knee replacement is, more often than not, the last effort in managing joint pain and dysfunction caused by arthritis when non-operative treatment of knee pain is not effective. When erosion of articular joint surfaces becomes severe, TKA is the surgical procedure of choice to decrease pain, correct deformity, and improve functional movement. Surgical Procedure: An incision is made down the front of the leg from mid-thigh to several inches below the knee. The quadriceps muscles are either split down the middle or shifted, along with the patella, to the side of the thigh. The distal end of the femur and proximal end of the tibia are sawed off; the menisci and ACL are excised as well. The PCL may also be cut; the pros and cons of sparing the PCL is currently of debate in knee replacement surgery. The knee replacement consists of three components that help the surgeon tailor the device to the patient. A curved femoral component is usually made of shiny chrome alloy; it is attached to the femur and replaces the femoral condyles. The metal tibial component has a flat top with a spike that goes into a 2 hole that the surgeon drills into the tibia. A disc, made of polyethylene, is cemented to the top of the tibial component. Depending on its condition, the patella is either left intact or the inside resurfaced- the patella is never totally replaced. If the patella is resurfaced, polyethylene is also used to cover the inside. Total knee arthroplasty components are either held in place with bone cement (cemented fixation), utilize bone ingrowth via a porous prosthesis (uncemented fixation), or combine cemented fixation of the tibial component and uncemented fixation of the femoral component (hybrid). Uncemented fixation has been used primarily for the active patient in whom the risk of prosthetic loosening over time is most likely, however, the ultimate decision rests with the attending surgeon. Preoperative Rehabilitation Ensure adequate strength of trunk and upper extremities for support during use of assistive devices Instruction in use of walker/crutches/or cane to maintain desired postoperative weight bearing status (touchdown weight bearing for uncemented or hybrid replacements, weight bearing as tolerated for cemented replacements) Review of post-operative exercises, bed mobility and transfers, use of continuous passive motion (CPM) machine as indicated per physician General strengthening, flexibility, and aerobic conditioning While it seems reasonable to believe patients undergoing TKA would benefit from preoperative strengthening exercises, there is no evidence to support this assumption, either in improving functional outcome or shortening hospital stay (DLima et al., Rodgers et al.). However, a study by Jones et al showed that patients who have greater preoperative dysfunction may require more intensive physical therapy intervention after surgery because they are less likely to achieve similar functional outcomes to those of patients who have less preoperative
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4 dysfunction. POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Kisner and Colby. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, and goals. *Use of a CPM device is often initiated by the first day after surgery, per physician protocol. It has been suggested that CPM decreases postoperative pain, promotes wound healing, decreases incidence of deep venous thrombosis (DVT), and enables the patient to regain knee flexion more rapidly during early postoperative days. However, Kumar et al conducted a randomized prospective study that found no statistically significant difference in range of motion gains using a CPM device versus active movement. Continuous passive motion units may be recommended as an adjunct to, not a replacement for, a supervised postoperative rehabilitation program.

Phase I: Maximum Protection: Weeks 1-2 Goals: Control postoperative swelling Minimize pain Knee ROM 0-90 Muscle strength 3/5-4/5 Ambulation with or without use of an assistive device Establish home exercise program Intervention: Passive range of motion (PROM)-CPM as indicated per physician Ankle pumps to decrease risk of DVT Bed mobility and transfers usually initiated 24-48 hours post-surgery, depending on surgical procedure and co-morbidities Heel slides in supine or sitting to increase knee flexion Muscle-setting exercises of the quadriceps, hamstrings, and hip adductors, possibly coupled with neuromuscular electrical stimulation Assisted progressing to active straight-leg raises in supine, prone, and sidelying positions Gravity-assisted knee extension in supine by periodically placing a towel roll under the ankle and leaving the knee unsupported Gentle inferior and superior patellar glides Neuromuscular inhibition techniques such as agonist-contraction techniques to decrease muscle guarding, particularly in the quadriceps, and increase knee flexion Gentle stretches for the hamstrings, calf, and iliotibial band Pain modulation modalities Compressive wrap to control effusion

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Gait training

Phase II: Moderate-Minimum Protection: Weeks 3-6 Goals: Diminish swelling and inflammation Increase ROM 0-115 or more Increased dynamic joint stability/full weight bearing per implant status Muscle strength 4/5-5/5 Return to functional activities Adhere to home exercise program Intervention: Interventions listed in Phase I Patellar mobilizations Tibiofemoral joint mobilization if appropriate and needed Soft tissue mobilization to quadriceps or hamstrings myofascia Incision mobilization after suture removal, when incision is clean and dry Progressive passive stretches to hamstrings, gastrocnemius, soleus, quadriceps within a pain-free range Stationary bike or peddler without resistance to increase flexion ROM Pain-free progressive resisted exercises using ankle weights, theraband/tubing Proprioceptive training such as weight shifting, tandem walking, lateral stepping over/around objects, obstacle courses, lower extremity proprioceptive neuromuscular facilitation (PNF), front and lateral step-ups, closed-kinetic chain activities Closed-kinetic chain strengthening, such as squats, front lunges Gait training as needed to decrease limp, wean off assistive device Protected, progressive aerobic exercise, such as cycling without resistance, walking, or swimming

Phase III: Return to Activity: Week 6 and beyond Goals: Progress ROM 0-115 as able, to a functional range for the patient Enhance strength and endurance and motor control of the involved limb Increase cardiovascular fitness Develop a maintenance program and educate patient on the importance of adherence, including methods of joint protection Intervention: Continue interventions of previous phases; advance as appropriate Implement exercises specific to functional tasks, such as transferring from sit-to-stand, lifting, carrying, push/pulling, squat/crouching, return to work tasks, return to sport tasks Improve cardiorespiratory and muscle endurance with activities such as bicycling, walking, or aquatic programs

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Selected References: Avramidis K, Strike P, Taylor P, Swain I. Effects of electrical stimulation of the vastus medialis muscles in the rehabilitation of patients after total knee arthroplasty. Arch Phys Med Rehab. 2003;84:1850-1853. DLima D, Colwell C, Morris B, Hardwick M, Kozin F. The effect of preoperative exercise on total knee replacement outcomes. Clin Orthop. 1996;1(326):174-182. Deyle G, Henderson N, Matekel R, Ryder M, Garber M, Allison S. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A randomized controlled trial. Ann Intern Med. 2000;132:173-181. Fitzgerald G, Oatis C. Role of physical therapy in management of knee osteoarthritis. Curr Opin Rheumatol. 2004;16:143-147. Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia, W.B. Saunders Company, 1998. Jones C, Voaklander DC, Suarez-Almazor ME. Determinants of function after total knee arthroplasty. Phys Ther. 2003;83:696-706. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. Philadelphia, F.A. Davis Company, 2002. Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop. 2003;1(410):225-234. Kumar PJ, McPherson EJ, Dorr L, Wan Z, Baldwin K. Rehabilitation after total knee arthroplasty: A comparison of 2 rehabilitation techniques. Clin Orthop. 1996;1(331):93-101. Moore K, Dalley A. Clinically Oriented Anatomy, 4th ed. Baltimore, Lippincott Williams and Wilkins, 1999. Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol. What makes the difference? J Arthroplasty. 2003;18(3):27-30. Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J, Bedard J. Preoperative physical therapy in primary total knee arthroplasty. J Arthroplasty. 1998;13:414-421. Vad V, Hong HM, Zazzali M, Agi N, Basrai D. Exercise recommendations in athletes with early osteoarthritis of the knee. Sports Med. 2002;32(11):729-739.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Red Flags for Potential Serious Conditions in Patients with Neck and Shoulder Problems

Red Flags for the Neck and Shoulder Region


Condition Cervical Fractures or Ligamentous Instabilities1-6 Red Flag Data obtained during Interview/History Major trauma such as a motor vehicle accident or a fall from a height with associated immediate onset of neck pain Rheumatoid arthritis or Downs syndrome Older age History of a trauma (esp. MVA or fall) Incontinence Red Flag Data obtained during Physical Exam Midline cervical spine tenderness Positive ligamentous integrity tests: Sharp-Purser test Alar ligament integrity test Apprehension with or inability to actively rotate head < 45o Gait disturbances due to hyperreflexic lower extremities Upper extremity (especially hand) sensory and motor deficits, and atrophy
Wheezing with auscultation when tumor obstructs bronchus May have Horners syndrome Ptosis (drooping eyelid) Constricted pupil Sweating disturbances

Cervical Central Cord Lesion7-9

Pancoast tumor10-12

Men over 50 with a history of cigarette smoking. Nagging type pain in the shoulder and along the vertebral border of the scapula often progressing to burning pain down the arm into the ulnar nerve distribution. Insidious onset of chest pain localized in the S-C joint History of IV drug use, diabetes, trauma, infection (especially of central venous access)

Septic Arthritis (A-C Joint)13

Tender S-C joint Limited shoulder movement Swelling over S-C joint Fever

References: 1. Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54. 2. Panjabi M. (1992) in Swinkels R, Beeton K, Alltree J. Pathogenesis of upper cervical instability. Manual Therapy. 1996; 1:127-132. 3. Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.[erratum appears in N Engl J Med 2001 Feb 8;344(6):464]. N Engl J Med. 2003;343:94-99. 4. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-Spine Rule versus the Nexus Low Risk Criteria in patients with trauma. N Engl J Med. 2003; 349:2510-2518.Niere KR, Torney SK. Clinicians perception of minor cervical instability. Manual Therapy. 2004;9:144-150.Delfini R, Dorizzi A, Facchinetti G, et al. Delayed post-traumatic cervical instability. Surg Neurol. 1999; 51:588-95. 7. Newey MI, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone Joint Surg Br. 2000;82:851-855. 8. Tow AM, Kong KH. Central cord syndrome: functional outcome after rehabilitation. Spinal Cord. 1998; 36:156-160. 9. Waters RL, Adkins RH, Sie IH, Yakura JS. Motor recovery following spinal cord injury associated with cervical spondylosis: a collaborative study. Spinal Cord. 1996;34:711-715. 10. Spengler D, Kirsh M, Kaufer H. Orthopaedic aspects and early diagnosis of superior sulcus lung tumor. J Bone Joint Surg. 1973;55:1645-1650. 11. Jett J. Superior sulcus tumors and Pancoasts syndrome. Lung Cancer. 2000;42:S17-S21. 12. Robinson D, Halperin N, Agar G, et al. Shoulder girdle neoplasms mimicking frozen shoulder syndrome. J Shoulder Elbow Surg. 2003; 12:451-5. 13. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine. 2004;83:139-148.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

NECK AND SHOULDER SCREENING QUESTIONNAIRE


NAME: __________________________________________ Medical Record #: _________________________ DATE: _____________

Yes 1. Have you recently experienced a blow to the head or a whiplash injury? 2. Do you have rheumatoid arthritis? 3. Are you currently taking steroids or have you been on prolonged steroid therapy? 4. Have you noticed any recent weakness, tingling, or numbness in you arms or legs? 5. Have you noticed a recent onset of difficulty with retaining your urine? 6. Do you now smoke or have you been a smoker in the past? 7. Do you administer medicine or drugs to yourself for which you need to inject using a needle?

No

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Shoulder Mobility Deficits ICD-9-CM codes: ICF codes: 726.0 Adhesive capsulitis of the shoulder

Activities and Participation Domain codes: d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) Body Structure code: s7201 Joints of shoulder region Body Functions code: b7100 Mobility of a single joint

Common Historical Findings Lateral shoulder pain - worsens with positions or activities which put stretch on the glenohumeral joint Progresses to stiffness Gradual, usually insidious, onset of symptoms Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: ROM limitations - external rotation and abduction are most limited, flexion and internal rotation are least limited Pain at end ranges--some motions are more painful than others (external rotation with abduction is typically the most painful) Limited glenohumeral accessory movements Physical Examination Procedures:

Glenohumeral External Rotation ROM Measurement Performance Cues: Remember that glenohumeral ROM is different than shoulder ROM (shoulder ROM is the sum of glenohumeral and scapular ROM) Stand in patients axillary region Stabilize scapula with forearm Be precise with stabilization of humeral abduction (to 90 degrees if possible) and horizontal abduction (maintain 0 degrees)

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

If glenohumeral external rotation ROM is greater at 90 degrees of abduction than at 45 degrees of abduction, suspect a muscle flexibility deficit of the subscapularis Normal glenohumeral external rotation ROM is 90 degrees

Glenohumeral Internal Rotation ROM Measurement Performance Cues: Stand above the patient Stabilize scapula in neutral - use forearm to prevent protraction Be precise with humeral abduction (90 degrees if possible) and horizontal abduction (maintain 0 degrees) Normal is 60 degrees of isolated glenohumeral internal rotation ROM

Glenohumeral Flexion ROM Measurement Performance Cues: Stabilize scapula - maintain lateral scapular border in a position that is parallel to the tabletop Normal is 120 degrees of isolated glenohumeral flexion

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Glenohumeral Abduction ROM Measurement Performance Cues: Glenohumumeral (GH) abduction is difficult to assess in patients with adhesive capsulitis because GH abduction requires GH external rotation Externally rotate humerus to the maximum of pain free motion - then abduct to limitation. (Notate both: e.g., 70o of GH abduction with GH E/R at 30o) Stabilize scapular to prevent compensatory scapular elevation Normal is 120 degrees of isolated GH abduction (at 90 degrees of GH E/R)

Shoulder Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies


The below description is consistent with descriptions of clinical patterns associated with shoulder Adhesive Capsulitis the vernacular term Frozen Shoulder

Description: Insidious onset of progressive stiffness and pain of the shoulder Etiology: The cause of this disorder is presumed to be due to repeated inflammatory reactions in the glenohumeral capsule and synovium, which lead to a thickened, fibrotic and inextensible glenohumeral joint capsule. The altered scapular and glenohumeral joint mechanics due to the glenohumeral capsular restrictions often lead to abnormal stress and subsequent inflammation of the rotator cuff tendons and subacromial bursa Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7100.3 SEVERE impairments of mobility of a single joint Excessive scapular protraction Excessive scapulothoracic joint motion a common characteristic is excessive scapular elevation with the scapular upward rotation that normally accompanies overhead activities Restricted active ROM lateral rotation and abduction are commonly the most limited if overhead reaching is the reported functional limitation. Medial rotation is commonly limited if hand behind back movements are the reported functional limitation.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Isolated glenohumeral motions are considerably limited typically about 50% of normal (Normal glenohumeral PROM is 120o of flexion, 120o of abduction, 90o of lateral rotation and 70o of medial rotation when measured at 90o of glenohumeral abduction) Glenohumeral accessory movements and joint play movements are also considerable limited especially humeral inferior, posterior and anterior glides Symptoms are worst with end-range positions that stretch the capsule Rotator cuff muscles may weak and painful due to the tension transmitted to an inflamed joint capsule by contracting musculotendinous units that attach to the capsule Pain around joint capsule (near axilla)

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7100.2 MODERATE impairments of mobility of a single joint As above with the following differences: Resisted Tests are strong and relatively painless when the glenohumeral joint positioned in midrange (thus lessening tension on the capsule)

Now (when less acute) examine the patient for common coexisting upper quadrant impairments. For example: Segmental movement abnormalities cervical and upper thoracic spine Limited glenohumeral physiologic and accessory movements Muscle flexibility deficits especially subscapularis, infraspinatus, pectoralis minor, pectoralis major, latissimus dorsi, and teres major myofascia Nerve mobility deficits especially median, radial, and ulnar nerves in the common thoracic outlet entrapment areas Weak scapular upward rotator muscles commonly lower trapezius, middle trapezius, and serratus anterior Excessive scapular elevation, abduction, downward rotation or winging with overhead reaching

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7100.1 MILD impairments of mobility of a single joint As above with the following differences: Pain with repetitive activities of the shoulder especially at end range Painful only with overpressures at end ranges

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Prevent movement induced inflammatory reactions Avoid muscle guarding Painfree with daily activities that use shoulder within available range Painfree sleep Physical Agents: Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding External Devices (Taping/Splinting/Orthotics) Fit patient with a sling if pain relief requires temporary use of an external device Therapeutic Exercises Painfree AROM or passive ROM exercises Pendulum (Codmans) exercises Re-injury Prevention Instruction Temporarily limit end range motions or stretches, overhead or behind the back activities that aggravate the patients condition

Sub Acute Stage / Moderate Condition Goals: Improve glenohumeral ROM Improve scapulohumeral rhythm Prevent re-injury to the joint capsule Restore strength of the muscles around shoulder and scapula Physical Agents: May use ultrasound to the joint capsule prior to active or passive stretching procedures/exercises Manual Therapy Soft tissue mobilization to adaptive shortened myofascia Joint mobilization to restricted accessory and joint play motions Therapeutic Exercises Stretching exercises to enhance carryover of manual stretching procedures Strengthening exercises to weak scapular depressors, scapular upward rotators, and rotator cuff motions

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Neuromuscular Reeducation Facilitate neutral thoracic cage, scapular position, and shoulder proprioception Ergonomic Instruction: Promote efficient, painfree, motor control of the trunk, scapulae and arm with overhead activities. Modify activities to prevent overuse and re-injury

Settled Stage / Mild Condition Goals: Normalize glenohumeral ROM Normalize upper quarter posture, muscle flexibility and muscle strength Progress activity tolerance Approaches/ Strategies listed above Manual Therapy Increase intensity and duration of soft tissue mobilization and myofascial stretching to the maximal tolerable level Increase intensity and duration of joint mobilization procedures to the maximal tolerable Therapeutic Exercises Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion and shoulder girdle muscles required to perform the desired occupational or recreational activities.

Ergonomic Instruction: as above Add job or sport specific training

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to desired occupational or sport activities Therapeutic Exercises Progress exercises focusing on job/sport specific training program based on individual needs of patient.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Selected References Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Hannifan JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clinical Orthop Rel Res. 2000; 372:95-109. Loyd JA. Adhesive capsulitis of the shoulder, diagnosis and treatment. South Medical Journal. 1993;76:879-883. Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin of North Am. 1980;11:327-333. Nicholson GG. The effects of passive joint mobilization on pain and hypomobility associated with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. 1985; 6(4): 238-246. Placzek J, Roubal P, Freeman C, et al. Long term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop and Rel Res. 1998;356:181-191. Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983;64:29-33. Roubal PJ, Dobitt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996;24:66-77. Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, 3rd ed., Vol. 2, (Extremities). Educational Opportunities, 1994. Vermeulen HM, Oberman WR, et. al. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple subject case report. Phys Ther. 2000;80:1204-1213. Wadsworth T. Frozen shoulder. Phys Ther. 1986;66:1878-83.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

SHOULDER MANUAL INTERVENTIONS

Patient Problem: LIMITED HUMERAL INTERNAL ROTATION ST MOB: JNT MOB: Infraspinatus/Teres Minor/Posterior Deltoid Posterior Glide (loose packed position) Posterior Glide (combined movements) Distraction Extension/Adduction/Internal Rotation PNF pattern (emphasize traction + rotation) Contract/Relax to glenohumeral external rotators Hand-Behind Back Maneuvers

RE-ED:

MWM:

Patient Problem: LIMITED HUMERAL EXTERNAL ROTATION ST MOB: Pectoralis Minor Subscapularis Inferior Glide Posterior Glide Anterior Glide Contract/Relax of Extension/Adduction/Internal Rotation PNF pattern (emphasize spiral/ diagonal) Flexion/Abduction/External Rotation PNF pattern (facilitate movement/traction) Arm Overhead Maneuvers

JNT MOB:

RE-ED:

MWM:

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Infraspinatus Soft Tissue Mobilization

Subscapularis Soft Tissue Mobilization

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Impairment:

Limited Shoulder Hand Behind Back Motions Limited Glenohumeral Internal Rotation Limited Humeral Posterior Glide

Humeral Posterior Glide Cues: Position the patient supine with a wedge under the spine of the scapula (not under the glenohumeral joint) A strap is handy to fixate the upper thorax and scapula - especially if you plan to add the combined movement of humeral distraction Hug the arm Use a flat hand and padding (folded sheet) to prevent irritation of the anterior humeral/bicipital groove area Consider adding combined movements of humeral distraction, abduction, and internal rotation as well as cervical sidebending prior to the posterior glide The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 114, 1989

Joe Godges, DPT, MA, OCS

10

KP So Cal Ortho PT Residency

Impairment:

Limited and Painful Shoulder Elevation

Shoulder Elevation MWM Cues: Position patient seated at the end of a raised treatment table Stand to the side of the uninvolved shoulder Stabilize scapula with one hand Glide the humeral head posteriorly - parallel to the glenoid treatment plane Sustain the glide as the patient actively elevates his humerus Alter the amplitude and direction of the glide to achieve painfree active elevation Repeat several times (sets of 10) Progress the re-education with 1) lifting a weight during the MWM, or 2) overpressure at end of available active range one option is illustrated below The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 88-91, 1995

Shoulder Elevation MWM (with overpressure)

Joe Godges, DPT, MA, OCS

11

KP So Cal Ortho PT Residency

Impairment:

Limited Shoulder Elevation Limited Glenohumeral External Rotation Limited Humeral Anterior Glide

Humeral Anterior Glide Cues: Position the patient prone with the involved humerus off the side of the table place a towel pad under the coracoid process and clavicle A strap can be used to assist in stabilizing the scapula (especially when adding combined movements) Hug the distal humerus into your thigh with one hand Apply an anterior glide to the proximal humerus with the other hand Use a soft flat hand Generate the anterior glide with a trunk lean or slight bend of the knees Consider adding combined movements of humeral distraction, abduction, horizontal abduction, or external rotation prior to the anterior glide (an adjustable, rolling stool can be used to provide the external rotation) The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 112, 1989

Joe Godges, DPT, MA, OCS

12

KP So Cal Ortho PT Residency

Ext/Add/IR Contract-Relax

FLEX/ABD/ER facilitation

Joe Godges, DPT, MA, OCS

13

KP So Cal Ortho PT Residency

Shoulder Muscle Power Deficits ICD-9-CM codes: 840.6 726.12 Supraspinatus strain Bicipital tenosynovitis

ICF codes: Activities and Participation Domain codes: d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table.) Body Structure code: s7202 Muscles of shoulder region Body Functions code: b7300 Power of isolated muscles and muscle groups Common Historical Findings Shoulder abductors/external rotators musculotendinous involvement: Pain in posterior-lateral shoulder Pain with overhead activities Midrange (about 90 degrees) catching sensation Symptoms developed from, or worsen with, repetitive overhead activities or from an acute strain such as a fall onto the shoulder Shoulder flexors musculotendinous involvement: Pain in anterior-lateral shoulder Pain with shoulder flexion and lifting activities Painful arc Symptoms developed from, or worsen with, repetitive flexion and lifting activities Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Shoulder abductors/external rotators musculotendinous involvement: Painful arc with active elevation Supraspinatus manual resistive test: weak and painful (moderately painful) Infraspinatus manual resistive test: weak and painful (mildly painful) Palpable posteriolateral rotator cuff tenderness Shoulder girdle muscle flexibility, strength, and coordination deficits Shoulder flexors musculotendinous involvement: Painful arc with shoulder flexion Biceps brachii manual resistive test: weak and painful Palpable tenderness in bicipital groove Shoulder girdle muscle flexibility, strength, and coordination deficits

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Physical Examination Procedures:

Normal Arm Elevation

Painful Arc and Associated Motor Control Deficits

Performance Cues: Common muscle flexibility deficits include short pectoralis minor, levator scapulae, teres major, and latissimus dorsi Common muscle strength deficits include weak supraspinatus, infraspinatus, lower trapezius, and serratus anterior Common motor coordination deficits include excessive 1) thoracic spine flexion, 2) contralateral weight shift of thorax, 3) scapular protraction and downward rotation, 4) scapular abduction during overhead activities

Supraspinatus Manual Resistive Test Performance Cues: Elevate arm about 40 degrees in scapular plane Thumb down to internally rotate humerus Contact only dorsal surface of distal forearm Stabilize thorax - contact contralateral shoulder Remember - slow build-up of resistance, sustain peak, slow release of resistance If there is a grade III (complete) tear of the rotator cuff the patient will be unable to hold the arm in this position (positive Drop Arm Test)

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Infraspinatus Manual Resistive Test Performance Cues: Contact only dorsal surface of distal wrist Stabilize ipsilateral elbow May test at differing degrees of humeral flexion and abduction

Biceps Manual Resistive Test

Supraspinatus and Infraspinatus Tendon (Rotator Cuff) Palpation

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Performance Cue: Placing the humerus in a position of internal rotation, extension, and adduction assists in gaining easier access to the tendons

Palpation of the Bicipital Groove

Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Rotator Cuff Tendinitis

Description: Repetitive strain injury to the deep tendons of the shoulder most commonly the tendons of the supraspinatus of infraspinatus muscles. Etiology: The suspected cause of this disorder is the abnormal impingement of the tendons of the rotator cuff between the humeral head and the acromial arch due to deficits in the ability of the humeral head depressors (the rotator cuff muscles) or the scapular upward rotator muscles to function in a coordinated manner during overhead activities.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power Accentuated thoracic kyphosis, scapular protraction, scapular abduction, and/or scapular downward tilt Excessive scapular elevation, abduction, downward rotation or winging with overhead reaching Midrange arc of pain with overhead movements (e.g., pain during 130o to 160o of shoulder flexion) Weak and painful supraspinatus and/or infraspinatus during manual muscle tests Palpation of involved rotator cuff tendons reproduce the patients reported pain complaint

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power As above, except: Strong and painful supraspinatus and/or infraspinatus

Now (when less acute) assess thoracic and scapular malalignments, and muscle flexibility and strength deficits for example: Shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia Weak scapular upward rotator muscles commonly lower trapezius, middle trapezius, and serratus anterior

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.1 MILD impairments of muscle power As above, except: Strong and painful supraspinatus and/or infraspinatus muscles only with repeated contractions Midrange arc of pain only with repeated overhead movements Overpressure, or passively forcing end range shoulder flexion (e.g., impingement tests) reproduce the patients reported pain complaints

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain with active arm elevation Restore strength to supraspinatus and infraspinatus muscles Physical Agents Ultrasound, iontophoresis, and/or ice applied to the rotator cuff tendons Manual Therapy Soft tissue mobilization to shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia Neuromuscular Reeducation Facilitate neutral thoracic cage and scapular posture with overhead activities

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Therapeutic Exercises Strengthening exercises for the supraspinatus and/or infraspinatus External Devices (Taping/Splinting/Orthotics) Taping procedures to promote scapular alignment and to facilitate contraction of the lower trapezius, middle trapezius, and/or serratus anterior May consider a sling if necessary to temporarily limit painful active movements Re-injury Prevention Instruction Temporarily limit overhead activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the rotator cuff Improve strength of supraspinatus and infraspinatus Alleviate upper quarter malalignments and muscle flexibility and strength deficits contributing to the mechanical impingement of the rotator cuff Approaches / Strategies listed above Manual Therapy If a localized area of tendon thickening is palpable transverse friction massage may be indicated Neuromuscular Reeducation Normalize scapulohumeral and scapulothoracic rhythm using verbal, manual, or biofeedback training Therapeutic Exercises Stretching exercises for shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia Strengthening exercises for weak lower trapezius, middle trapezius, and serratus anterior muscles Ergonomic Instruction Promote efficient, pain free, motor control of the trunk, scapulae and arm with overhead activities Modify activities to prevent overuse and re-injury

Settled Stage / Mild Condition Goals: As above Progress activity to improve tolerance with overhead arm use

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Approaches / Strategies listed above Therapeutic Exercises Provide muscularendurance exercises to improve muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities Ergonomic Instruction Add job/sport specific training

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities Therapeutic Exercises Provide exercises to maximize muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities Ergonomic Instruction Progress job/sport specific training to increase more mechanically demanding activities

Selected References Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment approaches for impingement syndrome of the shoulder: supervised exercise versus supervised exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000;30: Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718. Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther. 1995;75:803-812. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-38.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Bicipital Tendinitis

Description: An inflammatory process involving both the tendon and its sheath within the intertubercular groove caused by repetitive strain injury to the long head of the biceps brachii tendon typically producing anterior shoulder pain. Etiology: The suspected cause of this disorder is abnormal friction or strain of biceps tendon against the medial wall of the bicipital (intertubercular) groove. The structure of the anatomy leaves the tendon relatively unprotected. It is very important to recall that the bicipital groove acts as a trochlea, causing the tendon and its overlying sheath to be susceptible to wear and injury in this region. Eventually, fraying and narrowing of the tendon may occur with dense adhesions if the repetitive activities precipitating the condition are not ceased. It is important to differentiate between primary and secondary bicipital tendonitis. With primary bicipital tendonitis, the tendonitis is specific to the intertubercular groove without associated shoulder pathology. When the condition occurs in association with other pathologic conditions, such as impingement syndrome or rotator cuff disease, it is termed secondary bicipital tendonitis.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.3 SEVERE impairments of muscle power Excessive scapular protraction Pain with lifting objects Pain with reaching and overhead activities Pain with shoulder flexion, lateral rotation or extension Weak and painful biceps brachii Tenderness to palpation over bicipital groove

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.2 MODERATE impairments of muscle power As above with the following differences: Strong and painful biceps brachii contraction e.g., pain with resisted shoulder flexion with the elbow fully extended Pain with resisted shoulder horizontal adduction with the shoulder in 90o of glenohumeral lateral rotation

In conjunction with the above findings, it is appropriate to examine the patient for common coexisting upper quadrant impairments in this stage. Posterior glenohumeral capsular tightness Coexisting upper thoracic or cervical disorders

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Upper limb nerve tension Scapular malalignment Muscle flexibility and strength deficits, e.g., shortened pectoralis major, coracobrachialis, biceps brachii and weak middle and lower trapezius musculature

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7300.1 MILD impairments of muscle power As above with the following differences: Strong and painful biceps brachii only with repeated contractions Pain with repetitive activities, such as lifting It is important to rule out any rotator cuff disorders since these groups of muscles play a critical role in anterior shoulder stability. One of the most vulnerable positions for the shoulder complex is during extreme abduction and external rotation, as seen in the late cocking phase of pitching or throwing. Studies have shown that the glenohumeral joint (shoulder complex) can withstand higher and higher external rotational forces (torque) as the long head of the biceps muscle force is increased. In other words, the shoulder becomes torsionally stiffer with increasing biceps force. The greater the shoulders torsional stiffness or rigidity, the more force that would be required to externally rotate it to a state of dislocation. In one of the studies, it was discovered that while the shoulder was being stressed in the vulnerable abducted and externally rotated position with 100% predicted biceps force, the long head of the biceps muscle was able to increase the torsional rigidity of the glenohumeral joint by 32%. Further studies have provided evidence to support an additional significant stabilizing effect of the tendon of the long head of the biceps brachii against superior translation of the humeral head during abduction of the shoulder, contributing to a reduction in impingement. Other reasons as to why it is important to rule out pathologies of the shoulder lie in the possibility of pre-existing lesions or tears in the glenohumeral region, which may impair stability. In the case of a superior labral lesion, this can lead to disruption of the superior labrums firm attachment to the glenoid as well as a disruption of the origin of the long head of the biceps tendon, impairing shoulder stability.

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Alleviate pain with active arm flexion Physical Agents Ultrasound, phonophoresis, iontophoresis or ice applied to the biceps tendon for pain relief and to decrease inflammation

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Manual Therapy Soft tissue mobilization and manual stretching to normalize the length of pectoralis major and coracobrachialis Friction Massage to the long head of the biceps brachii may be used to reduce adhesions of the retinaculum and tenosynovitic tissues in the intertubercular groove External Devices (Taping/Splinting/Orthotics) May consider a sling if necessary to temporarily limit painful active movements Taping to reposition the scapula in order to promote normal scapulohumeral rhythm when raising the arm. Neuromuscular Reeducation Facilitate neutral thoracic cage, scapular posture, and shoulder proprioception exercises Taping may also be used to train the patient to use weak, elongated muscles (e.g., lower trapezius) to function in a normal position Therapeutic Exercises Normalize the strength of the muscles commonly found to be weak, namely lower trapezius, serratus anterior, and perhaps the biceps brachii and brachialis Re-injury Prevention Instruction Temporarily limit shoulder flexion, lateral rotation, and overhead activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the biceps tendon Normal length and strength of the shoulder girdle musculature Approaches / Strategies listed above Therapeutic Exercises Manual stretching procedures and home/gym stretching exercises to the trunk and shoulder girdle muscles that have flexibility deficits Progressive resistive exercises to trunk and shoulder girdle muscles that have strength deficits. (Depending on the patients strength deficits, this may include instructing the patient in isometric, isotonic (e.g., tubing or free weights), and/or glenohumeral/scapular stabilization exercises (e.g., seated press-ups, progressive push-ups, Swiss ball exercises) Neuromuscular Reeducation Progression of strengthening exercises to regain normal coordination of rotator cuff and shoulder girdle musculature during functional activities. (Depending on the patients strength deficits, this may include instructing the patient in isometric,

Joe Godges, DPT, MA, OCS

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KP So Cal Ortho PT Residency

isotonic exercises. For example, use of tubing or free weights for shoulder elevation, rows, scaption, curls and/or glenohumeral/scapular stabilization exercises such as seated press-ups, progressive push-ups, Swiss ball exercises) Ergonomic Instruction Modification of jobsite or other environmental factors as well as ergonomic cuing (movement training) to promote efficient, painfree, motor control of the trunk, scapulae and arm with lifting, reaching and overhead activities Modify activities to prevent overuse and re-injury

Settled Stage / Mild Condition Goals: As above Approaches / Strategies listed above Therapeutic Exercises Progress activities to tolerance Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion and shoulder girdle muscles required to perform the desired occupational or recreational activities

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities Approaches/ Strategies listed above Ergonomic Instruction Progress job/sport specific training depending on the needs and desires and (impairments) of the worker or athlete

Joe Godges, DPT, MA, OCS

11

KP So Cal Ortho PT Residency

Selected References Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment approaches for impingement syndrome of the shoulder: supervised exercise versus supervised exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000; 30 Bonafede RP, Bennett RM. Shoulder Pain Guidelines to diagnosis and management. Postgraduate Medicine. 1987 July; 82 (1): 185 193. Bang MD. Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop & Sports Phys Ther. 2000;30:126-137.

13a: Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718. Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Physical Therapy. 1995; 75:803-812. Post M, Benca P. Primary Tendonitis of the Long Head of the Biceps. Clinical Orthopedics and Related Research. 1989 September; 246: 117 125. Rodosky MW, Harner CD, Fu FH. The Role of the Long Head of the Biceps Muscle and Superior Glenoid Labrum in Anterior Stability of the Shoulder. The American Journal of Sports Medicine. 1994; 22 (1): 121 130. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999; 29:31-38. Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, 3rd ed.,Vol. 2, (Extremities). Educational Opportunities, 1994. Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Williams & Wilkins, 1988. Warner JP, McMahon PJ. The Role of the Long Head of the Biceps Brachii in Superior Stability of the Glenohumeral Joint. The Journal of Bone and Joint Surgery. 1995 March; 77-A (3): 366 371.

Joe Godges, DPT, MA, OCS

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KP So Cal Ortho PT Residency

Shoulder Movement Coordination Deficits ICD-9-CM codes: 840.2 840.0 Shoulder ligament sprain Acromioclavicular joint sprain

ICF codes:

Activities and Participation Domain codes: d4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground.) d4451 Pushing (Using fingers, hands and arms to move something from oneself, or to move it from place to place, such as when pushing an animal away.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Throwing (Using fingers, hands and arms to lift something and propel it with some force through the air, such as when tossing a ball.) d4550 Crawling (Moving the whole body in a prone position from one place to another on hands, or hands and arms, and knees.) d4551 Climbing (Moving the whole body upwards or downwards, over surfaces of objects, such as climbing steps, rocks, ladders of stairs, curbs or other objects.) Body Structure code: s7203 Ligaments and fasciae of shoulder region Body Functions code: b7601 Control of complex voluntary movements

Common Historical Findings Glenohumeral ligaments and fasciae involvement: Shoulder pain during activity - aching afterwards Recurrent subluxations or dislocations with certain movements, positions, and activities Apprehension Acromioclavicular ligaments and fasciae involvement: Trauma--a fall on the tip of the shoulder or a fall onto an outstretched arm Pain with reaching across body, with overhead activities and with weight bearing on elbows or sleeping on the injured shoulder Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Glenohumeral ligaments and fasciae involvement: Excessive glenohumeral accessory motion Apprehension at end range elevation, horizontal abduction, and external rotation (if anterior instability)

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Acromioclavicular ligaments and fasciae involvement: If Grade II or III sprain - palpable and observable displacement between the clavicular and acromial articular surfaces Pain with accessory movement tests Pain with palpation/provocation of acromioclavicular ligament Physical Examination Procedures:

Glenohumeral Accessory Movement Test Humeral Posterior Glide Performance Cues: Patient sits on end of table Ensure loose packed position Do not elevate scapula Allow the patients wrist to rest on your elbow Stabilize spine of scapula with palm Glide humerus (and thus, humeral head) posteriolaterally - in a direction parallel to the plane of the glenoid fossa OK to use weight shift of thorax to produce glide

Glenohumeral Accessory Movement Test Humeral Anterior Glide

Glenohumeral Accessory Movement Test Humeral Anterior Glide

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Performance Cues: Glide humeral head anteriomedially - in line with the treatment plane Stabilize the clavicle with fingers or palm Normal is an excursion that is less than one half of the width of the humeral head

A/C Joint Accessory Movement Test Clavicular Anterior Glide

A/C Joint Accessory Movement Test Clavicular Posterior Glide

Performance Cues: Stand behind patient Stabilize posteriorly via the spine of the scapula with you thumb and anteriorly via the glenoid fossa (hugging the humeral head into the fossa) Grab the distal portion of the clavicle (it is OK to be somewhat medial to the A/C joint line - which may be tender), glide the clavicle anteriorly and posteriorly Determine the amount of accessory motion and the patients response to this movement provocation

Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies


The below description is consistent with descriptions of clinical patterns associated with the vernacular term Glenohumeral Instability

Description: This condition is the excessive mobility in the glenohumeral joint in one direction or more, where the humeral head slips out of the glenoid cavity or the patient feels that it is about to dislocate. Etiology: The cause of glenohumeral instability could be due to traumatic or atraumatic (e.g., idiopathic glenohumeral ligament laxity or RA) causes that lead to dislocation of shoulder. The coracohumeral ligament is the primary restraint to inferior translation in adduction. The middle glenohumeral ligament is the primary restraint to anterior instability at 45o of abduction. The inferior glenohumeral ligament is the primary restraint to anterior instability from 45-90 o of abduction and secondary to posterior instability. The superior ligament prevents inferior dislocation and stabilizes the shoulder during dependent positions. Instabilities are labeled anterior, posterior, inferior, and superior depending on the direction of laxity. In addition,

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

dynamic stability is provided by the muscular action of the supraspinatus, infraspinatus, subscapularis, and deltoid muscles along with the tendon of the longhead of the biceps. Classification of Glenohumeral Instability is derived from four factors: 1. Frequency (acute, recurrent, chronic) 2. Causes (traumatic, atraumatic including voluntary, repeated micro trauma) 3. Direction (anterior, posterior, inferior, multidirectional) 4. Degree (subluxation, dislocation) Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination of complex voluntary movements Patients with a recent ligament injury typically try to support the arm with opposite extremity and avoid using the injured arm Active shoulder movements are restricted and painful Passive and accessory movement testing reveals hypermobility of the glenohumeral joint Note: The direction of laxity typically corresponds to the label given to the instability (e.g., excessive anterior glide corresponds with an anterior instability) Positive apprehension (Crank) test Supraspinatus and infraspinatus weakness is common Palpatory abnormalities may be present (e.g., with an anterior instability the humeral head may palpable anteriorly and shows a hallow beneath the acromion posteriorly. Axillary nerve injury is most commonly associated with an anterior shoulder dislocation leading to altered sensation in an area of the lateral shoulder

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.2 MODERATE impairment of motor control/coordination of complex voluntary movements As above with the following differences: Weakness is common to the dynamic stabilizers such as scapular upward rotators (trapezius, serratus anterior, rhomboids, and levator scapulae), and rotator cuff musculature (supraspinatus, infraspinatus, teres minor, and subscapularis) with contractions at end range of movement Now (when less acute) examine patient for co-existing upper quadrant impairments, such as upper thoracic and cervical pathologies, disorders of the acromioclavicular and sternoclavicular joints, muscle flexibility deficits such as tight pectoralis minor, pectoralis major, and/or serratus anterior and muscle strength deficits especially of the rotator cuff muscles and scapular upward rotators

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of complex voluntary movements

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

As above with the following differences: Shoulder symptoms are reproduced with repeated movements at end range Intervention Approaches / Strategies Acute Stage / Severe Condition: Goals: Prevent further tissue damage Re-establish non-painful mid-range mobility and avoid unstable positions with the involved shoulder Retard muscle atrophy Decrease pain and inflammation Physical Agents Ice pack or ice massage Electrical stimulation External Devices (Taping/Splinting/Orthotics) Application of a shoulder sling may reduce pain, protect the joint from futher injury and prevent excessive muscle guarding following a glenohumeral ligament injury Therapeutic Exercises Pendulum and wand exercises in painfree, mid ranges Isometric rotator cuff exercises in painfree, mid ranges Re-injury Prevention Instruction: Temporarily limit abduction, flexion, lateral rotation and overhead activities or behind back activities that aggravate patient's symptoms.

Sub Acute Stage / Moderate Condition Goals: As above Regain and improve muscular strength and endurance Regain and improve proprioception and neuromuscular control Therapeutic Exercises Strengthening exercises for the dynamic stabilizers such as rotator cuff and scapular muscles in order to increase stability with pain free active movements at mid as well as end ranges Upper body endurance can improved through use of mid range aerobic exercises such as rowing machines or upper body ergometers External Devices (Taping/Splinting/Orthotics)
KP So Cal Ortho PT Residency

Joe Godges, DPT, MA, OCS

Taping procedures may be used to 1) assist stabilization, 2) aid proprioception, and 3) promote scapular alignment Neuromuscular reeducation Proprioceptive neuromuscular facilitation (PNF) patterns be used to facilitate neutral thoracic cage position, scapular posture, and shoulder proprioception Closed chain shoulder stabilization exercises can be used to facilitate coordination with rest of the shoulder girdle Ergonomic Instruction Promote efficient, pain free, motor control of the trunk, scapulae and arm with overhead activities Modify activities to prevent repetitive strains or re-injury

Settled Stage / Mild Condition Goals: As above Increase power (Reaching 90% strength in the injured shoulder) Progress activity tolerance and endurance Increase neuromuscular control Prepare individual for functional activities Normalize upper quadrant posture, muscle flexibility, and muscle strength Pain free AROM with increased stability with repeated active movements at end range Approaches / Strategies listed above Therapeutic Exercises Stretching exercises for muscles that may have flexibility deficits, such pectoralis major, pectoralis minor, and latissimus dorsi Strengthening exercises as above with using increased resistance Utilitize muscular endurance exercises to maximize muscle performance of the relevant trunk, scapulae, shoulder girdle muscles required to perform the desired occupational or recreational activities Manual Therapy Soft tissue mobilization for myofascia that may exhibit flexibility deficits, such pectoralis major, pectoralis minor, and latissimus dorsi Neuromuscular Reeducation PNF techniques to increase shoulder control and stability with repeated movements at the end range

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Approaches / Strategies listed above

Selected References Rockwood C., Masten III F., Fredrick A, The Shoulder 2nd ed. WBSaunders:Philadelphia, 1998. Donatelli R., Physical Therapy of the Shoulder 3ed ed. Churchill Livingston, London. 1997. Iannotti J, Williams G., Disorders of the Shoulder Diagnosis and Management, Lippincott: Philadelphia, 1999. Kessel L., Clinical Disorders of the Shoulder, Churchill Livingston, London. 1982. Kibler WB, McMullen J, Uhl T: Shoulder rehabilitation strategies, guidelines, and practice. Orthopedic Clinics of North America 2001;32:527-538. Rubin BD, Kibler WB: Fundamental principles of shoulder rehabilitation: Conservative to postoperative management. J Arthroscopic Related Surgery 2002:Suppl 2;18: 29-39. Burkhead WZ, Rockwood CA: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg. 1992; 74-A: 890-896. Kibler WB: The role of the scapula in athletic shoulder function. Am J Sports Med 1998;26:325-37. Jobe Fw, Bradley JP: The diagnosis and nonoperative treatment of shoulder injuries in athletes. Clinics in Sports Medicine 1989 Jul; 8 (3): 419-437. Dines DM, Levinson M: The conservative management of the unstable shoulder including rehabilitation. Clinics in Sports Medicine 1995;14:797-814. Moseley JB, Jobe FW, Pink M, Perry J: EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med 1992;20:128-134. NevasierRJ, Nevasier TJ, Nevasier JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clinical Orthopaedic and Related Research 1993; 291:103-106. Hovelius L et al.: Recurrences after initial dislocation of the shoulder. J Bone Joint Surg. 1983;65A: 343-348. Gamulin A, Pizzolato G, Stern R: Anterior shoulder instability: histomorphometric study of the subscapularis and deltoid muscles. Clinical Orthopaedics 2002;398:121-126. Tibone JF, Lee TQ, Csintalan RP, Dettling J: Quantitative assessment of glenohumeral translation. Clinical Orthopaedics 2002;400: 93-97.

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Shoulder Stability Deficits: Description, Etiology, Stages, and Intervention Strategies


The below description is consistent with descriptions of clinical patterns associated with the vernacular term Acromioclavicular Instability

Description: Disruption of the ligamentous integrity of the acromioclavicular (also called A/C) joint. The acromioclavicular ligament may be damaged with excessive posteriorly directed translatory or rotatory force. The coracoclavicular ligaments (conoid and trapezoid) may be damaged with excessive superiorly or anteriorly directed forces. Etiology: The cause of this injury is generally a traumatic incident such as a fall directly on the shoulder with the arm adducted or a fall on an outstretched hand. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7150.3 SEVERE impairments of stability of a single joint Protective posturing (e.g., cradling the arm and stabilizing it against the body) Variable elevation of the distal clavicle relative to the acromion Pain limited active shoulder flexion Pain with reaching across the body (horizontal abduction) Weak and painful with resisted shoulder flexion and shoulder abducton Tenderness to palpation over the acromioclavicular joint Symptoms reproduced with palpation or provocation of the A/C ligament Localized swelling around the joint Positive A/C compression or shear tests

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7150.3 MODERATE impairments of stability of a single joint As above with the following differences: Pain with overhead activities Resisted shoulder flexion and abduction are now strong and painful

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b7150.3 MILD impairments of stability of a single joint As above with the following differences: Resisted tests are now strong and painful only with repeated shoulder flexion and abduction Pain with repetitive activities of the shoulder especially at end range Pain with sustained end ranges stresses to the A/C, such as with prone-on-elbows positions

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Avoid movements that increase inflammatory reactions Decrease pain with daily activities Physical Agents Ice External Devices (Taping/Splinting/Orthotics) Taping may be used to assist in stabilization and to reduce pain A sling may be used especially if splint immobilization aids pain relief and limits aggravation of the injury Type II A/C sprains may benefit from a Kenny- Howard splint Therapeutic Exercises Active or passive shoulder abduction to 90 degrees and external rotation to 30 degrees are initiated at 2 weeks if no internal fixation has been used Sub-maximal isometric exercises to maintain scapular and glenohumeral strength Re-injury Prevention Instruction Temporarily limit end range ROM stretches, avoid vigorous work, avoid overhead activities

Sub Acute Stage / Moderate Condition Goals: Prevent re-injury of the AC joint Restore full pain-free active and passive range of motion of the shoulder girdle Restore strength of the muscles around scapula and glenohumeral joint Therapeutic Exercises Progress mobility exercises to regain full pain free range of motion Progress strengthening exercises (e.g., Rotator cuff strengthening, closed chain exercises, progressive resistive exercises below 90 degree of flexion) Manual Therapy Joint mobilization of glenohumeral joint to prevent restrictions

Settled Stage / Mild Condition Goals: As above Approaches / Strategies listed above

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Re-injury Prevention Instruction Progress activities to tolerance

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to desired occupational or sport activities Therapeutic Exercises Progress exercises focusing on job/sport specific training program based on individual needs of patient.

Selected References Fukuda K, Craig KE, Kai-nan AN, Cofield RH Chao EYS. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg. 1986; 68A:434-9. Urist MR, Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatment with an analysis of 41 cases. J Bone Joint Surg. 1946;28:813-37. Donatelli R, Wooden MJ. Orthopedic Physical Therapy. 2nd ed. 1994. Churchill Livingston Inc. Hulstyn MJ, Fadale PD. Shoulder Injuries in the athlete. Clinical Sports Medicine. 1997;16:663-679. Dias JJ, Gregg PJ. Acromioclavicular joint injuries in sport. Sports Medicine. 1991;11: 125-32. Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. J Bone Joint Surg. 1989;71B:848-50. Larsen E, Bierg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. J Bone Joint Surg. 1986;68(4):552-5. Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Medicine. 1998;26:137-44. Turnbull JR. Acromioclavicular joint disorders. Med Sci Sports Exercise. 1998;30(4 suppl.):526-32. Shamus JL, Shamus EC. A taping technique for the treatment of acromioclavicular joint sprains: a case study. J Orthop Sports Phys Ther. 1997;25:390-4. Kisner C, Colby LA. Therapeutic Exercises Foundations and Techniques. Third Edition. 1996 F.A. Davis Company. Philadelphia, PA.

Joe Godges, DPT, MA, OCS

10

KP So Cal Ortho PT Residency

Shoulder Pain ICD-9-CM code: ICF codes: 726.19 Subacromial bursitis

Activities and Participation Domain codes: d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table.) d4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground.) d4451 Pushing (Using fingers, hands and arms to move something from oneself, or to move it from place to place, such as when pushing an animal away.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Throwing (Using fingers, hands and arms to lift something and propel it with some force through the air, such as when tossing a ball.) d4550 Crawling (Moving the whole body in a prone position from one place to another on hands, or hands and arms, and knees.) d4551 Climbing (Moving the whole body upwards or downwards, over surfaces of objects, such as climbing steps, rocks, ladders of stairs, curbs or other objects.) Body Structure code: s7201 Joints of shoulder region Body Functions code: b28016 Pain in joints

Common Historical Findings: Diffuse shoulder pain Pain at rest Recent unaccustomed repetitive use of upper extremity

Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Pain with all shoulder movements Symptoms are reproduced/increased with palpation of subacromial bursa

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Physical Examination Procedures:

Subacromial Bursa Palpation/Provocation Performance Cue: Slightly extend and internally rotate the humerus to improve access to the bursa

Shoulder Pain: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with Subacromial Bursitis. Description: An inflammatory condition of the sub-deltoid bursa which develops due to recent unaccustomed overuse causing diffuse shoulder pain. A discriminating characteristic of acute subacromial bursitis is pain/aching at rest, which is aggravated by most all shoulder movements. Etiology: The subacromial bursa is a synovial-lined sac separating the superior surface of the supraspinatus tendon from coracoacromial arch and deep surface of deltoid muscle. The floor of the bursa is the supraspinatus tendon and the roof is the acromium. Inflammation of this bursa is most commonly the result of repetitive strain, or overuse, injury to other structures like the rotator cuff. Subacromial bursitis rarely occurs alone and is usually associated with supraspinatus tendonitis, or tenosynovitis of the rotator cuff, bicipital muscles, or glenohumeral arthritis. A detailed history is important to distinguish the bursa from a supraspinatus strain or involvement of other rotator cuff structures. Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28016.3 SEVERE pain in joints Protection of the shoulder and avoidance of use of the injured arm Unable to flex or abduct the shoulder or reach during overhead activities secondary to pain Apprehension with all shoulder movements Symptoms are reproduced or increased with palpation of the subacromial bursa

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28016.2 MODERATE pain in joints As above with the following differences: Symptoms are provoked at end range of active abduction Pain with resisted abduction/ flexion of the shoulder Painful arc of ROM for subacromial bursitis is 70-110 of abduction Resisted tests may be weak and painful due to the compression of an inflamed subacromial bursa by a contracting deltoid muscle and involvement of rotator cuff muscles Impingement sign may help distinguish between bicipital tendonitis and bursitis. Lateral subacromial tenderness suggests bursitis or supraspinatus tendonitis, anterior subacromial tenderness suggests bicipital tendonitis Arthritis may cause osteophyte/calcium projections into the bursa (calcific bursitis) Limitations in functional activities include difficulty in sleeping, grooming, dressing, work and sports activities

Now (when less acute) examine the patient for common coexisting upper quadrant impairments. For example: Cervical and upper thoracic segmental movement abnormalities Limited glenohumeral physiologic and accessory movements Muscle flexibility deficits especially subscapularis, infraspinatus, pectoralis minor, pectoralis major, latissimus dorsi, and teres major myofascia Nerve mobility deficits especially median, radial, and ulnar nerves in the common thoracic outlet entrapment areas Weak scapular upward rotator muscles commonly lower trapezius, middle trapezius, and serratus anterior Excessive scapular elevation, abduction, downward rotation or winging with overhead reaching Chronic Stage radiographic findings show narrowing of acromiohumeral gap, superior subluxation of the humeral head, erosive changes at the inferior aspect of the acromium

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28016.1 MILD pain in joints As above with the following differences: Pain with repetitive activities of flexion/abduction such as overhead activities Overpressure, or passively forcing end range shoulder flexion (e.g., impingement tests) reproduces the patients reported pain complaint Painfree resisted tests when performed in midrange shoulder positions Pain only with repeated flexion and abduction contractions

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Painfree at rest Physical Agents Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation (A random, controlled, double blind study suggests there is no evidence to support ultrasound having an important therapeutic effect over treatment with just ROM and non-steroidal anti-inflammatory drugs (NSAIDs) Ice and/or TENS for relief of acute pain as well as to decrease muscle guarding External Devices (Taping/Splinting/Orthotics) May consider a sling if necessary to temporarily limit painful active movements Therapeutic Exercises Pendulum (Codmans) exercises Painfree passive ROM, active assisted AROM, or AROM exercises once or twice a day Re-injury Prevention Instruction Temporarily limit flexion, abduction, and, overhead activities

Sub Acute Stage / Moderate Condition Goal: Painfree with active movements Approaches / Strategies listed above Therapeutic Exercises Progress AROM exercises to painfree tolerance AROM exercises progress to weighted, supine and sitting shoulder flexion, abduction and rotation strengthening program Manual Therapy Soft tissue mobilization to shortened subscapularis, infraspinatus, pectoralis minor, pectoralis major, latissimus dorsi, and teres major myofascia Joint mobilization in an attempt to normalize the accessory mobility or physiologic motion deficits believed to be associated with the patients complaints Neuromuscular reeducation in an attempt to normalize the strength and coordination deficits believed to be associated with the patients complaints

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Ergonomic Instruction Promote efficient, painfree, motor control of the trunk, scapulae and arm with overhead activities Modify functional activities to prevent overuse and re-injury Patient education for prevention strategies

Settled Stage / Mild Condition Goal: Painfree with repeated active movements Approaches / Strategies listed above Therapeutic Exercises Attempt to normalize the strength and endurance deficits believed to be associated with the patients complaints Maximize muscle performance of the relevant trunk, scapulae, and shoulder girdle muscles required to perform the desired occupational or recreational activities Ergonomic Instruction Add job/sport specific training

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities Approaches / Strategies listed above

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Selected References Bonafede PR, Bennett RM. Shoulder pain: guidelines to diagnosis and management. Postgrad Med. 1987; 82:185-193 Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115. Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis: a double blind trial. Phys Ther. 1986;66:194-199 Gorkiewicz R. Ultrasound for subacromial bursitis: a case report. Phys Ther. 1984;64:46-47 Gross J, Fetto J, Rosen E. Musculoskeletal Examination. Blackwell Science, 1996. Reveille JD. Soft-tissue rheumatism: diagnosis and treatment. Am J Med. 1997;102 (suppl 1A):1A-25S Salzman KL, Lilligard WA, Butcher JD. Upper extremity bursitis. American Family Physician. 1997;56(7) www.aafp.org Steinfeld R MD, Rock M MD, Younge D MD, Cofield R MD. Massive subacromial bursitis with rice bodies: report of three cases, one of which was bilateral. Clin Orthop. 1994;301:185-190 Tomberlin J, Saunders D. Evaluation, Treatment, and Prevention of Musculoskeletal Disorders, Vol. 2. 3rd ed. (Extremities). Minneapolis MN. Educational Opportunities, 1994. Wadsworth C. Manual Examination and Treatment of the Spine and Extremities. Philadelphia. Williams & Wilkins, 1988.

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Shoulder and Related Upper Extremity Radiating Pain ICD-9-CM codes: ICF codes: 723.3 Cervical brachial syndrome

Activities and Participation Domain codes: d4301 Carrying in the hands (Taking or transporting an object from one place to another using the hands, such as when carrying a drinking glass or a suitcase.) d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) Body Structure code: s7208 Structure of shoulder region, other specified s7308 Structure of upper extremity, other specified Body Functions code: b28014 Pain in upper limb b2804 Radiating pain in a segment or region

Common Historical Findings Paresthesias, pain, and numbness in upper extremity Symptoms aggravated by postures or activities that put stretch on neurovascular bundle (e.g., reaching tasks, sleeping with arms overhead) Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Symptoms reproduced with nerve tension test Symptoms reproduced with provocation of the peripheral entrapment site (e.g., scalenes, clavipectoral fascia, pectoralis minor) Physical Examination Procedures:

Nerve Tension Test Median Nerve Stretch Test Performance Cues: Position patient with shoulder off edge of table and with the trunk and lower extremities diagonally on the table

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Establish baseline level of symptoms and determine the change in symptoms as the following components are moved toward end range: Scapular depression Elbow extension Humeral external rotation Forearm supination Wrist, fingers, thumb extension Humeral abduction Attempt to alter symptoms by moving a component two segments proximally or distally (e.g., alter elbow pain with cervical side bending; alter shoulder pain with wrist flexion and extension)

Nerve Tension Test Radial Nerve Stretch Test Performance Cues: Components: Scapular depression Elbow extension Humeral internal rotation Forearm pronation Wrist, finger, thumb flexion Humeral abduction

Nerve Tension Test Ulnar Stretch Test

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Performance Cues: Components: Scapular depression Elbow flexion (to 90 degrees) Humeral external rotation Forearm pronation Wrist, finger extension Elbow flexion (to available and range) Humeral abduction

Shoulder and Related Upper Extremity Radiating Pain: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term Thoracic Outlet Syndrome

Description: Thoracic outlet syndrome (TOS) is a complex of signs and symptoms caused by compression or stretching of the nerves and vessels (portions of the brachial plexus, subclavian artery, and subclavian vein) to the upper limb where they pass through the interval between the scalene muscles, over the first rib, and down into the axilla. Patient complains of numbness, tingling, weakness of hands and arms and pain in the upper chest, back and neck. The location of paresthesias, pain, numbness, and muscle weakness in the shoulder, arm, and hand depend on what nerve is vulnerable to compression. The patient with TOS may also report vascular symptoms such as swelling of the fingers and hands, heaviness of the upper extremities, clumsiness and coldness of hands, and tiredness, heaviness on elevation of arms. TOS symptoms are worst with postures and ADLs that stress the neurovascular bundle, such as combing hair, driving, or carrying bags with strap on sore shoulder. TOS symptoms are also reproduced with activities such as lifting heavy objects, looking up (neck extension), arm overstretched or reaching and overhead activities for extended periods of time. Etiology: The cause of this disorder may be due to tight muscles, ligaments, fibrous bands or bony abnormalities in the thoracic outlet area. The two common precipitating factors of TOS are trauma (such as auto accidents that cause whiplash) and excessive strains from repetitive activities. Other conditions that can lead to TOS are paradoxical breathing patterns, poor posture, an extra cervical rib from the neck at birth, and tumors (such as upper lobe lung cancer).

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28014 SEVERE pain in upper limb Accentuated upper thoracic kyphosis and forward head posture leading to tightness around shoulder and neck musculature Excessive scapular abduction and medial rotation Weak cervical flexors, upper thoracic extensors, and scapular depressors/retractors Symptoms are reproduced with upper limb nerve tension testing

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Symptoms are reproduced with palpatory provocation of peripheral entrapment site (e.g., scalene muscles palpation will cause tingling down the arm) Sensory and motor deficits may be present

Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28014 MODERATE pain in upper limb As above, except: Now (when less acute) examine patient for co-existing upper quadrant impairments such as cervical pathologies (extra cervical rib), assess scapular, thoracic malalignments and muscle flexibility and strength deficits For example: Shortened anterior chest musculature such as pectoralis, serratus anterior Shortened scalene muscles, and costoclavicular approximation Tight muscles that are pressed against the nerves causing compression such as subclavian artery or suprascapular nerve maybe affected. Paradoxical breathing patterns in which the scalenes and pectorals are used as the initiators of each breath, rather than assisting the diaphragm and lower intercostals during a deep inspiration

Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes: b28014 MILD pain in upper limb As above, except: Pain with repetitive activities such as arm elevation, hyperextension of neck or with overhead activities

Intervention Approaches / Strategies Acute Stage / Severe Condition Goal: Reduce neurological and vascular symptoms Re-injury Prevention Instruction Limit any activity that aggravates the symptoms e.g., avoid sleeping on stomach with arms overhead Manual Therapy Soft tissue mobilization to restricted myofascia or fascia adjacent to relevant nerve and vascular entrapment sites e.g., scalene myofascia, clavipectoral fascia, subclavius myofascia

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Joint mobilization to restricted joints adjacent to relevant nerve and vascular entrapment sites e.g., cervical articulations adjacent to lateral foramina, 1st rib adjacent to C8 nerve root Soft tissue mobilization and manual stretching to address shortened musculature such as pectoralis minor, serratus anterior, scalene, levator scapulae Therapeutic Exercises Painfree, and symptom-free nerve mobility exercises

Sub Acute Stage / Moderate Condition Goals: As above Improve strength of weak upper quarter musculature Approaches / Strategies listed above Therapeutic Exercises Stretching exercises for shortened myofascia causing symptoms, such as pectoralis minor, or anterior scalenes Strengthening exercises for upper thoracic extensors, scapular adductors and depressors, and neck flexors Diaphragmatic and lateral costal breathing exercises to decrease paradoxical breathing patterns Neuromuscular Reeducation Facilitate neutral thoracic cage and neutral scapular posture. Ergonomic Instruction Promote efficient, painfree, motor control of the trunk, scapulae and arm with overhead activities Modify activities to prevent re-injury Teach proper body mechanics and modify work-setting area as required to prevent symptoms

Settled Stage / Mild Condition Goals: As above Progress activity tolerance Lessen predisposition to symptoms during active repeated movements Approaches / Strategies listed above Therapeutic Exercises

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Muscular endurance exercises to maximize muscle performance of the relevant trunk, scapulae, shoulder girdle muscles required to perform the desired occupational or recreational activities Aerobic conditioning exercises such as progressive walking program with emphasizing correct breathing techniques and posture Ergonomic Instruction As above Add job/sport specific training

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities Approaches / Strategies listed above

Selected References Colby L, Kisner C. Foundations and Techniques of Therapeutic Exercise, 2nd ed. F. A. Davis Company, Philadelphia, PA 494-495, 1990 Daskalakis M. Thoracic outlet compression syndrome: current concepts and surgical experience. Int Surg. 68:337-344, 1983 Donatelli R. Orthopedic Physical Therapy. Churchill Livingstone Inc., Georgia, 1994 Donatelli R. Physical Therapy of the Shoulder, 3rd edition, pp. 153-178. New York: Churchill Livingstone, 1997 Kelly M, Clark W. Orthopedic Therapy of the Shoulder, pp. 144-148. Philadelphia: J.B. Lippincott Company, 1995 Kenny R, Traynor G, Withington D, Keegan D. Thoracic outlet syndrome: a useful exercise treatment option. Am J Surg. Feb 165:282-4, 1993 Lindgren K, Leino E, Hakola M, Hamberg J. Cervical spine rotation and lateral flexion combined motion in examination of the thoracic outlet. Arch Phys Med Rehabil 71:343-344, 1989 Lindgren K, Leino E, Manninen H. Cervical rotation lateral flexion test in brachialgia. Arch Phys Med Rehabil 73:735-7, 1992

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Lindgren K. Conservative treatment of thoracic outlet syndrome: a 2-year follow up. Arch Phys Med Rehabil Vol 78, April 1997 Magee D. Orthopedic Physical Assessment. W. B. Saunders Company, Philadelphia, PA. 90142, 1992 Novak CB, Mackinnon SE. Thoracic outlet syndrome. Orthopedic Clinics of North America 1996 Oct; 27(4): 747-762 Rockwood C, Matsen F. The Shoulder, 2nd edition, volume 2, pp. 984. Philadelphia: WB Saunders Company, 1998 Saidoff D, McDonough A. Critical Pathways in Therapeutic Intervention: Extremities and Spine, pp. 189-202. Mosby, Missouri, 1998

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

Cervical and Shoulder Examination Algorithm #1

Suspect 1) Fracture or Loss of Connective Tissue Integrity Due to Trauma or Disease, and/or 2) Abnormal/Hypermobile Cervical Segmental Mobility

Yes

Stabilization Procedures

No

Consultation with Appropriate Healthcare Provider

Yes

Screen for Potentially Serious Non-Musculoskeletal Pathology

If Negative

Medical Clearance and Negative Imaging

If Negative

Cervical Examination Algorithm #2

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Cervical Examination and Intervention Algorithm #2


Cervical and Upper Thoracic Single Plane Active Mobility Examination

Pain During Movement or Pain Limits Motion in Available Ranges or Movement Produces Peripheral Symptoms If Positive for Upper Motor Neuron

Pain Does Not Limit Motion in Available Ranges and/or Pain at End of Range Does Not Produce Peripheral Symptoms

Consultation with Other Healthcare Providers

Lesions

Neurological Status Examination

Produces Peripheral Symptoms

Cervical Spine Side Bending, and/or Combined Side Bending/Rotation /Extension Over Pressures Does Not Produce Peripheral Symptoms

Produces Vertebro-

Basilar Insufficiency
Signs

Vertebrobasilar Insufficiency Exam

If Safe to Proceed

Mobility Examination of Upper Quarter Neural Elements Peripheral Nerve Entrapment Sites
If Symptoms Unresolved If Positive If Negative

If Segmental Instability

Mobility Examination of: Upper Thoracic and Cervical Spine Upper Quarter Neural Elements

If Negative

Pain Limited Nerve Mobility

Pain Limited Cervical Mobility

Resistance Limited Nerve Mobility

Resistance Limited Cervical Mobility

Nerve Entrapment Reduction Procedures

Cervical Stabilization Procedures

Mobilization of Upper Quarter Neural Elements

Mobilization of Cervical and Thoracic Spinal Segments

If Symptoms Resolve to the Point Where Pain Does Not Limit Motion in Available Range, Return to Single Plane Active Mobility Examination

To Algorithm #3 Shoulder Examination

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Shoulder Examination and Intervention


Active ROM Tests: 1) Elevation 2) 90/90 or Neutral External Rotation 3) Hand Behind Back

Algorithm #3a

Passive ROM Tests: 1) Elevation with Over Pressure 2) Isolated Glenohumeral External Rotation\ 3) Isolated Glenohumeral Internal Rotation

1) 2) 3) 4)

Passive Accessory Motion Tests: Posterior Humeral Translation Anterior Humeral Translation Inferior Humeral Translation (sulcus sign) Acromioclavicular Accessory Movements

Resisted Tests: 1) External Rotation 2) Abduction Active Compression 3) Flexion Test

Palpatory Examination of Suspected Enthesopathy

To Algorithm #3b

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

First Time Traumatic Dislocation Age 25 Years Old

Algorithm #3b

Dislocation Over 40 Years of Age Shoulder Elevation <90 degrees after 6 weeks

or

Night Pain Weak External Rotators Over 65 Years of Age

Medical/Surgical Consultation in Addition to PT Intervention

Suspect Glenohumeral Capsuloligamentous Labral Tear

Suspect Rotator Cuff Tear

Medical/Surgical Consultation in Addition to PT Intervention

Pain Limits Active and Passive Movements in Mid Ranges

Normal or Excessive Active and Passive Range of Motion Painful and/or Excessive Humeral Accessory Motions Positive Active Compression Tests

Pain with Active Motions Pain with Passive Over Pressure Weak and/or Painful Resisted Tests

Limited Active and Passive Range of Motion Limited Humeral Accessory Motions

Pain Limited Shoulder Mobility

Instability

continuum

Impingement

Resistance Limited Shoulder Mobility

Physical Agents and Ergonomic Counseling

Shoulder Strengthening Therapeutic Exercises

Shoulder Strengthening Therapeutic Exercises

Shoulder Mobilization Procedures

If Symptoms Resolve, and Pain No Longer Limits Active and Passive Movements in Mid Ranges, Return to Start of Algorithm #3 If Symptoms Unresolved

Associated Upper Quarter Impairment Examination Algorithm #4

Consultation with Other Healthcare Providers

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Associated Upper Quarter Impairment Examination Algorithm #4 Shoulder Stabilization Procedures and Therapeutic Exercises

Physical Agents and Ergonomic Instructions Nerve Entrapment Reduction Procedures

Shoulder Strengthening Therapeutic Exercises

Shoulder Mobilization Procedures

Mobilization of Upper Quarter Neural Elements

Cervical Stabilization Procedures

Mobilization of Cervical and Thoracic Spinal Segments

Deep Neck Flexors

Strength/Motor Control/Endurance Deficits Lower Trapezius Middle Trapezius

Serratus Anterior

Levator Scapulae Upper Trapezius Suboccipital Myofascia

Flexibility Deficits Pectoralis Major Latissimus Dorsi Teres Major

Pectoralis Minor Subscapularis Sternocleidomastoid

Excessive Capital Extension

Postural Deficits Protracted Scapulae

Excessive Thoracic Kyphosis

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Selected References Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ. 1996;313:1291-6. Antonaci F, Ghirmai S, Bono G, Sandrini G, Nappi G. Cervicogenic headache: evaluation of the original diagnostic criteria. Cephalalgia. 2001;21:57383. Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine. 1990;15:458-61. Aspinall W. Clinical testing for the craniovertebral hypermobility syndrome. J Orthop Sports Phys Ther. 1990;12:47-54. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-37. Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC. Glenohumeral stability. biomechanical properties of passive and active stabilizers. Clin Orthop Rel Res. 1996;330:13-30. Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Rel Res. 1993;294:103-10. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine. 2001;26:788-97. Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43:353-60. Burkehead WZ, Rockwood CA. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg. 1992;74A:890-6. Calis M, Akgun K, Birtane M, Karacan I, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000;59:44-7. Chesworth BM, MacDermid JC, Roth JH. Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients with shoulder pathology. Phys Ther. 1998;78:593-601. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain. 1993;52:259-85. Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28:3-14. Dall'Alba PT, Sterling MM, Treleaven JM, Edwards SL, Jull GA. Cervical range of motion discriminates between asymptomatic persons and those with whiplash. Spine. 2001;26:2090-4. Davidson RI, Dunn EJ, Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine. 1981;6:441-6. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Therapy. 1999;79:50-65. Donatelli R, Greenfield B. Rehabilitation of a stiff and painful shoulder: a biomechanical approach. J Orthop Sports Phys Ther. 1987;9:118-26. Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine. 1994:1125-31. Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint pain patterns. a study in normal volunteers. Spine. 1994;19:807-11. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine. 1990;15:453-7. Farmer JC, Wisneski RJ. Cervical spine nerve root compression. an analysis of neuroforaminal pressures with varying head and arm positions. Spine. 1994;19:1850-5. Feinstein B, Langton JNK, Jameson RM, Schiller F. Experiments on pain referred from deep structures. J Bone Joint Surg. 1954;36A:981-97. Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y, Yuda Y. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996;68:79-83. Fukui S, Ohseto K, Shiotani M. Patterns of pain induced by distending the thoracic zygapophyseal joints. Regional Anesthesia. 1997;22:332-6. Gifford LS, Butler DS. The integration of pain sciences into clinical practice. J Hand Therapy. 1997;10:86-95. Glousman RE. Instability versus impingement syndrome in the throwing athlete. Orthop Clin North Am. 1993;24:89-99. Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718.
Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency

Grad A, Baloh RW. Vertigo of vascular origin. clinical and electronystagmographic features in 84 cases. Arch Neurology. 1989;46:281-4.

Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ. 1998;316:354-60.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine. 1999;24:785-94. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR. 2000;174:713-7. Hawkins RJ, Abrams JS. Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2). Orthop Clin North Am. 1987;18:373-82. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med.1980;8:151-8. Heald SL, Riddle DL, Lamb RL. The shoulder pain and disability index: the construct validity and responsiveness of a region-specific disability measure. Phys Ther. 1997;77:1079-89. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. [erratum appears in N Engl J Med 2001;344:464]. N Engl J Medicine. 2000;343:94-9. Hoving JL, Gross AR, Gasner D, Kay T, Kennedy C, Hondras MA, Haines T, Bouter LM. A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain. Spine. 2001;26:196-205. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Barr JS. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine. 1996;21:1746-60. Ide M, Ide J, Yamaga M, Takagi K. Symptoms and signs of irritation of the brachial plexus in whiplash injuries. J Bone Joint Surg. 2001;83:226-9. Johnson EG, Godges JJ, Lohman EB, Stephens JA, Zimmerman GJ. Disability self-assessment and upper quarter muscle balance between female dental hygienists and non-dental hygienists. J Dent Hyg. 2003;77:217-23. Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. a prospective, single-blinded, randomized clinical trial. Spine. 1998;23:311-8 Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27:1835-43. Kasch H, Stengaard-Pedersen , Arendt-Nielsen L, Staehelin Jensen T. Headache, neck pain, and neck mobility after acute whiplash injury: a prospective study. Spine. 2001;26:1246-51. Katayama Y, Fukaya C, Yamamoto T. Poststroke pain control by chronic motor cortex stimulation: neurological characteristics predicting a favorable response. J Neurosurgery. 1998;89:585-91. Keating L, Lubke C, Powell V, Young T, Souvlis T, Jull G. Mid-thoracic tenderness: a comparison of pressure pain threshold between spinal regions, in asymptomatic subjects. Manual Therapy. 2001;6:34-9. Kellgren JH. Observation on referred pain arising from muscle. Clin Sci. 1938;3:175-190. Kellgren JH. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin Sci. 1939;4:35-46. Kopell H, Thompson W. Peripheral Entrapment Neuropathies. Florida, Robert I. Krieger Pub. Co., 1976, pp. 146-153,156,167. Larson E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. J Bone Joint Surg. 1986;68A:552-5. Levy AS, Lintner S, Kenter K, Speer KP. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med. 1999;27:460-3. Lorei M, Hershman E. Peripheral nerve injuries in athletes. Sports Medicine. 1993;16:130-147. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9:299-301. Mahadevan S, Mower WR, Hoffman JR, Peeples N, Goldberg W, Sonner R. Interrater reliability of cervical spine injury criteria in patients with blunt trauma. Ann Emerg Med. 1998;31:197-201. McFarland EG, Campbell G, McDowell J. Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med. 1996;24:468-71. McFarland EG, Kim TK, Savino RM. Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med. 2002;30:810-5.

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Moseley JB, Jobe FW, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med. 1992;20:128-34. Muhle C, Bischoff L, Weinert D, Lindner V, Falliner A, Maier C, Ahn JM, Heller M, Resnick D. Exacerbated pain in cervical radiculopathy at axial rotation, flexion, extension, and coupled motions of the cervical spine: evaluation by kinematic magnetic resonance imaging. Investigative Radiology. 1998;33:279-88. Muhle C, Resnick D, Ahn JM, Sudmeyer M, Heller M. In vivo changes in the neuroforaminal size at flexion-extension and axial rotation of the cervical spine in healthy persons examined using kinematic magnetic resonance imaging. Spine. 2001;26:E287-93. O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610-3. Panjabi MM. The stabilizing system of the spine. Part I. function, dysfunction, adaptation, and enhancement. J Spinal Disorders. 1992;5:383-9. Panjabi MM. The stabilizing system of the spine. Part II. neutral zone and instability hypothesis. J Spinal Disorders. 1992;5:390-7. Panjabi MM, Lydon C, Vasavada A, Grob D, Crisco JJ, Dvorak J. On the understanding of clinical instability. Spine. 1994;19:2642-50. Peeters GG, Verhagen AP, de Bie RA, Oostendorp RA. The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials. Spine. 2001;26:E64-73. Petersen CM, Hayes KW. Construct validity of Cyriax's selective tension examination: association of end-feels with pain at the knee and shoulder. J Orthop Sports Phys Ther. 2000;30:512-21; discussion 522-7. Pevny T, Hunter RE, Freeman JR. Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy. 1998;14:289-94. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Phys Ther. 2001;81:1701-17. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Phys Ther. 2001;81:1719-30. Pho C, Godges JJ. Management of whiplash-associated disorders addressing thoracic spine impairments: a case report. J Ortho Sports Phys Ther. 2004;34:511-523. Pope DP, Croft PR, Pritchard CM, Macfarlane GJ, Silman AJ. The frequency of restricted range of movement in individuals with self-reported shoulder pain: results from a population-based survey. British Journal of Rheumatology. 1996;35:1137-41. Rheault W, Albright B, Byers C. Intertester reliability of the cervical range of motion device. J Orthop Sports Phys Ther. 1992;15:147-150. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina, AG, Iannotti JP, Mow VC, Sidles JA, Zuckerman JD. A standardized method for the assessment of shoulder function. J Shoulder and Elbow Surg, 1994;3:347-52. Riddle DL, Stratford PW. Use of generic versus region-specific functional status measures on patients with cervical spine disorders. Phys Ther. 1998;78:951-63. Robinson CM, Kelly M, Wakefield AE. Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: risk factors and results of treatment. J Bone Joint Surg. 2002;84-A:1552-9. Rowe CR. Recurrent anterior transient subluxation of the shoulder. the "dead arm" syndrome. Orthop Clin North Am. 1988;19:767-72. Sarhadi NS, Korday SN, Bainbridge LC. Radial tunnel syndrome: diagnosis and management. J Hand Surgery - British Volume.1998;23:617-9. Schmitt L, Snyder-Mackler L, Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Ortho Sports Phys Ther. 1999;29:31-8. Schoensee SK. Jensen G. Nicholson G. Gossman M. Katholi C. The effect of mobilization on cervical headaches. J Ortho Sports Phys Ther. 1995;21:18496. Sonnabend DH. Treatment of primary anterior shoulder dislocation in patients older than 40 years of age. conservative versus operative. Clin Orthopaedics Rel Res. 1994;304:74-7. Speer KP, Hannafin JA, Altchek D, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med. 1994;22:177-83. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on WhiplashAssociated Disorders: redefining "whiplash" and its management.[erratum appears in Spine 1995 Nov 1;20:2372]. Spine. 1995;20(8 Suppl):1S-73S. Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002;82:1098-107.

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain. 2003;104:509-17. Sterling M, Jull G, Carlsson Y, Crommert L. Are cervical physical outcome measures influenced by the presence of symptomatology?. Physiotherapy Research International. 2002;7:113-21. Tanaka N, Fujimoto Y, An HS, Ikuta Y, Yasuda M. The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine. 2000;25:286-91. Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med. 1997;25:306-11. Thomas D, Williams RA, Smith DS. The frozen shoulder: a review of manipulative treatment. Rheumat Rehabil. 1980;19:173-9. Tibone JE, Fechter J, Kao JT. Evaluation of a proprioception pathway in patients with stable and unstable shoulders with somatosensory cortical evoked potentials. J Shoulder Elbow Surg.1997;6:440-3. Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial instability using the Sharp-Purser test. Arthritis Rheumatism. 1988;31:918-22. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359-62. van der Heide B, Allison GT, Zusman M. Pain and muscular responses to a neural tissue provocation test in the upper limb. Manual Therapy. 2001;6:15462. van der Heijden GJ, Van der Windt DA, De Winter AF. Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomized clinical trials. BMJ. 1997;31:25-30. van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. British Journal of General Practice. 1996;46:519-23. van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54:959-64. van der Windt DA, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317:1292-6. Vermeulen HM, Oberman WR, Burger BJ, Kok GJ, Rozing PM. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple-subject case report. Phys Ther. 2000;80:1204-1213. Vicenzino B, Neal R, Collins D, Wright A. The displacement, velocity and frequency profile of the frontal plane motion produced by the cervical lateral glide treatment technique. Clinical Biomechanics. 1999;14:515-21. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient selfreport measures for cervical radiculopathy. Spine. 2003;28:52-62. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. Am J Sports Med. 1990;18:366-75. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome. a study using Moire topographic analysis. Clin Orthop Rel Res. 1992;285:191-9. Williams JW, Holleman DR, Simel DL. Measuring shoulder function with the Shoulder Pain and Disability Index. J Rheumatology. 1995;22:727-32. Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: a review of diagnosis and treatment. J Ortho Sports Phys Ther. 2000;30:755-66. Yamaguchi K, Sher JS, Andersen WK, Garretson R, Uribe JW, Hechtman K, Neviaser RJ. Glenohumeral motion in patients with rotator cuff tears: a comparison of asymptomatic and symptomatic shoulders. J Shoulder Elbow Surg. 2000;9:6-11. Yoo JU, Zou D, Edwards WT, Bayley J,Yuan HA. Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine. Spine. 1992;17:1131-6. Youdas JW, Carey JR, Garrett TR, Reliability of measurements of cervical spine range of motion-comparison of three methods. Phys Ther. 1991;71:98106.

Emmanuel Yung PT, MA, OCS

Skulpan Asavasopon MPT, OCS

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

SUMMARY OF SHOULDER DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER


Supraspinatus Tendinitis
840.6 onov* = 4 or less mnov** = 12

HISTORY
Post-Lat pain Pain w/overhead ADL Midrange catch Sxs worse w/repetitive OH ADL or strains Ant-Lat pain Pain w/flexion and lifting ADL Sxs worse w/repetitive activities Diffuse pain Pain at rest Recent unaccustomed use Lat pain Sxs worse w/end range stretch positions Gradual prog. of stiffness Recurrent subluxations or dislocations Apprehension Fall on tip of shld or onto outstretched arm Pain w/reaching across body, overhead, or weight bearing on elbows UE paresthesias, pain, and numbness -- Sxs worse w/postures or ADLs which stress NV bundle Persistent neck & shld girdle aching Sxs worse w/repeated, inefficient muscle use

PHYSICAL EXAM
Painful arc Weak and painful Supraspinitus MMT Post-Lat rotator cuff tenderness Shoulder girdle muscle flexibility, strength, and coordination deficits Painful arc Weak and painful Biceps Brachii MMT Bicipital groove tenderness Shoulder girdle muscle flexibility, strength, and coordination deficits SR w/palpation or provocation of the subacromial bursa Glenohumeral ROM deficits ER and ABD are the most limited Pain at end of range Limited accessory movements Excessive GH accessory motion Apprehension w/passive end range movements Observable displacement of A/C joint Pain w/accessory movements SR w/palpation or provocation of A/C ligament

PT MANAGEMENT
Reduce aggravating activities Physical agents (Ice, US) Address deficits in shoulder girdle strength, flexibility, and coordination Reduce aggravating activities Physical agents (Ice, US) Address deficits in shoulder girdle strength, flexibility, and coordination Rest (i.e. sling) Physical agents (Ice, E.Stim.) Patient ed. (Prevent recurrence) Patient education (Avoid aggravating positions/movements) Rx myofascial & joint ROM deficits (STM, JM, MWM, C/R, Ther Ex) Patient education (Avoid unstable positions) Shld girdle & GH strengthening Patient education (Avoid positions of strain) Normalize ROM and strength deficits of the scapulothoracic, GH and S/C articulations Reduce entrapment neuropathy with applicable STM, Joint mob, Nerve mob, ergonomic cues, Ther Ex, Rx of Up muscle flexibility and strength deficits Rx trigger points (Inhibit, elongate, prevent) Rx muscle imbalances Provide ergonomic cuing

Bicipital Tendinitis
726.12 onov = 4 or less mnov = 12

Subacromial Bursitis
726.19 onov = 4 or less mnov = 8 onov = 8 or less mnov = 16

Adhesive Capsulitis
726.0

Glenohumeral Instability
840.2 onov = 4 or less mnov = 12

Acromioclavicular Joint Sprain


840.0 onov = 4 or less mnov = 8

Thoracic Outlet Syndrome


723.3 onov = 8 or less mnov = 16

SR: w/ULTT Provocation of peripheral entrapment site SR w/provocation of trigger points Muscle flexibility and strength imbalances Ergonomic deficiencies

Myofascial Pain Syndrome


726.2 onov = 8 or less mnov = 12

onov = optimal number of visits mnov = maximal number of visits SR = Symptom reproduction

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Acromioclavicular Joint Stabilization


Surgical Indications and Considerations: Anatomical Considerations: The acromioclavicular (AC) joint is a diarthroidal joint formed by the distal end of the clavicle and the medial facet of the acromion. A capsule consisting of anterior, posterior, superior, and inferior AC ligaments supports the joint. The posterior and superior ligaments are the strongest and are invested by the deltotrapezial fascia. The primary functions of the AC joint are to transmit force from the appendicular skeleton to the axial skeleton and to suspend the upper extremity. The coracoclavicular ligaments are extra-capsular and consist of two components: the medial conoid ligament, and the lateral trapezoid ligament. The AC joint is inherently unstable and relies heavily on these ligaments to maintain its integrity. So strong are the ligaments of the AC joint and the sternoclavicular (SC) joint, that the more frequent result of impact to the area is a fractured clavicle as opposed to rupturing of any ligaments. Pathogenesis: Injury to the AC joint is typically brought on by a force applied to the acromion with the arm adducted. A moderate force will injure the AC ligaments, and a more severe force will tear the coracoclavicular ligaments. A major trauma will involve all ligaments listed above as well as injury to the deltotrapezial fascia. Epidemiology: AC injuries are most common among athletes in contact sports, throwing sports, or people whose occupation requires a lot of overhead activities. Other possible mechanisms include falls and strength training. Males significantly outnumber females with this type of injury. Diagnosis: Anterior and superior shoulder pain Visible and palpable deformity at the AC joint Limitations in strength and range of motion, especially in abduction and flexion Radiographs to rule out fracture and classify the injury (see below for scale) MRI may be helpful in distinguishing extent of soft tissue damage Classification is typically done using the Rockwood classification scale for acromioclavicular injuries, a scale with six levels of injury classification: I. Mild injury of the AC ligaments II. AC ligaments disrupted, coracoclavicular ligaments are intact. III. AC and coracoclavicular ligaments disrupted. IV. Ligaments disrupted, posterior displacement of clavicle through trapezius. V. AC joint dislocation with extreme superior elevation of clavicle. VI. Clavicle displaced inferior to the acromion and coracoid processes.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

Nonoperative Versus Operative Management: Patients who sustained Grade I or II AC injuries typically undergo conservative, nonoperative treatment. Most patients would rather deal with the cosmetic issue of a deformed AC joint than go under general anesthesia and surgery to repair their injury. Grades IV, V, and VI are all treated surgically for reduction and fixation of the dislocated AC joint. Grade III injuries are highly controversial regarding course of treatment. In the past, most Grade III injuries were treated surgically, but multiple recent studies have shown no benefit to from nonoperative management focusing on immobilization for a period of time followed by rehabilitation ro regain full strength, range of motion, and functional status. Several studies concluded that using a good splint, such as the Kenny-Howard splint, to immobilize the shoulder for several weeks was just as effective as surgical intervention at achieving restabilization. The number of complications associated with surgery are well documented. Infection and hardware malfunction were the primary concerns, and hardware has been known to migrate to the great vessels, heart and lungs. Surgical Procedure: Surgery typically occurs shortly after injury, one to two weeks at most. However, for Grade III injuries, sometimes surgery is put off to try nonoperative rehabilitation first. Several different surgical procedures have been described, including fixation across the AC joint using Kirschner wire or hook plate, dynamic muscle transfer, coracoclavicular fixation using Bosworth screw or synthetic augmentation, reconstruction of ligaments, and excision of the distal clavicle. Lemos prefers to do reconstruction using synthetic loop augmentation. Holes are drilled in the coracoid and clavicle, and synthetic fiber is used to tie the augmentation piece between the two. POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Lemos. Refer to his publication for further information regarding criteria to progress from one phase to the next.

Phase I: Weeks 1-6 Goals: Control pain and swelling Protect the repair Intervention: Sling for 4-6 weeks in with the shoulder in adduction and internal rotation Patient permitted to use arm for activities of daily living Restrict active elevation or abduction, and pushing, pulling, or carrying over 5 lbs.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

3 Phase II: Weeks 6-12 Goal: Regain full active range of motion and strength Intervention: Discontinue use of sling Progressive range of motion exercises Progressive strengthening regimen

Phase III: Weeks 12-24 Goal: Return to activities at prior level of function Intervention: Continue to progress strengthening, incorporating functional activities into treatment plan Once patient has equal range of motion and strength bilaterally, he/she can return to preinjury activities, including contact sports at 24 weeks

Selected References: Clarke H, McCann P. Acromioclavicular joint injuries. Orthop Clin North Am. 2000;31:177-187. Deerhake R, Olix M. Stabilization in acromioclavicular disruption. J Sports Med. 1976;3:218227. Lemos M. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998;26:137-144. Neviaser R. Injuries to the clavicle and acromioclavicular joint. Orthop Clin North Am. 1987;18:433-438. Taft T, Wilson F, Oglesby J. Dislocation of the acromioclavicular joint. J Bone Joint Surg. 1987;69-A:1045-1051.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

Acromioplasty
Surgical Indications and Considerations Anatomical Considerations: Any abnormality that disrupts the intricate relationship within the subacromial space may lead to impingement. Both intrinsic (intratendinous) and extrinsic (extratendinous) factors have been implicated as etiologies of the impingement process. The unique anatomy of the shoulder joint sandwiches the soft tissue structures of the subacromial space (rotator cuff tendons, coracoacromial ligament, long head of biceps, bursa) between the overlying anterior acromion, acromioclavicular joint, coracoid process, underlying greater tuberosity of the humeral head and the superior glenoid rim. Pathogenesis: When subacromial impingement is suspected it is necessary to differentiate primary from secondary impingement. This is essential for successful treatment. Primary subacromial impingement is the result of an abnormal mechanical relationship between the rotator cuff and the coracoacromial arch. Secondary impingement is a clinical phenomenon that results in relative narrowing of the subacomial space. This often results from glenohumeral or scapulothoracic joint instability. The loss of the stabilizing function of the rotator cuff also leads to an abnormal superior translation of the humeral head (decreased depression of the humeral head during overhead activity and less clearance) and mechanical impingement of the rotator cuff on the coracoacromial arch. In patients who have scapular instability, impingement results from improper positioning of the scapula with relation to the humerus. The instability leads to the insufficient retraction of the scapula, which allows for earlier contact of the coracoacromial arch on the underlying rotator cuff. Epidemiology: Patients with primary impingement are usually older than 40 years, complain of anterior shoulder and lateral upper arm pain, with an inability to sleep on the affected side. They have complaints of shoulder weakness, and difficulty performing overhead activities. Patients with secondary impingement are usually younger and often participate in overhead sporting activities such as baseball, swimming, volleyball, or tennis. They complain of pain and weakness with overhead motions and may even describe a feeling of the arm going dead. Diagnosis History and physical examination are crucial in diagnosing subacromial impingement syndrome because findings may be subtle and symptoms may overlap with various differential diagnoses Physical examination focuses on shoulder and cervical spine. Cervical spine must be cleared to rule out cervical radiculopathy, degenerative joint disease, and other disorders of the neck contributing to referred pain in the shoulder. Primary impingement: o (+) Hawkins sign o (+) Neer impingement sign o Possible associated AC joint arthritis (tenderness to palpation and increased pain with horizontal adduction)
Joe Godges DPT, MA, OCS

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

2 Secondary impingement: look for associated pathology o GH instability: (+) apprehension and relocation test, load and shift o Abnormal scapular function: scapular winging, scapular dyskinesia o Posterior capsule tightness: leads to an obligatory translation of the humeral head and rotator cuff in an anterior and superior direction, which contributes to impingement problem. Radiographs are helpful in demonstrating acromial anatomy types, hypertrophic coracoacromial ligament spurring, acromioclavicular joint osteoarthritis, and calcific tendonitis. MRI can be helpful in revealing relationships in impingement syndrome, especially if rotator cuff tear and other internal derangement pathologies are suspected.

Nonoperative Versus Operative Management: Nonoperative treatment is very successful and the comprehensive rehabilitative protocols for primary and secondary impingement syndrome are similar and follow the postoperative rehabilitation plan for patients who have had a subacromial decompression with a normal rotator cuff. Initial goals of the rehabilitation process are to obtain pain relief and regain range of motion. Various modalities, oral medications and corticosteroid subacromial injections are helpful in the early stages to decrease the inflammatory process allowing for more successful advances in motion and strengthening. Strengthening exercises begin by avoiding impingement positions while performing the exercises. The focus is on closed kinetic chain exercises initially with open chain exercises to follow without aggravating shoulder discomfort. These exercises help to restore the ability of the rotator cuff to dynamically depress and stabilize the humeral head, resulting in a gradual relative increase in the subacromial space. Nonoperative treatment should be considered unsuccessful if the patient shows no improvement after 3 months of a comprehensive and coordinated medical and rehabilitative program. In addition, after 6 months of appropriate treatment, most patients have achieved maximal improvement from the nonoperative treatment program. The success of operative treatment is determined by the choice of an appropriate operative procedure and the skills of the surgeon. It is imperative to determine whether the patient has a primary or secondary impingement. For primary impingement the procedure of choice presently is arthroscopic subacromial decompression, although comparable long-term results can be obtained with a traditional open acromioplasty. Arthroscopic subacromial decompression has many advantages including the ability to evaluate the glenohumeral joint for associated labral, rotator cuff, and biceps pathology, as well as assessment of the acromioclavicular joint. Second, this technique produces less postoperative morbidity and is relatively noninvasive, minimizing deltoid muscle fiber detachment. However, arthroscopic subacromial decompression is a technically demanding procedure and the surgeon must be very skilled. When glenohumeral joint instability is the reason for secondary impingement, surgical treatment is a stabilization procedure. Surgical Procedure: Many different arthroscopic techniques have been described, but one that is often recommended is the modified technique initially described by Caspari and Thaw. Using standard posterior portal, the surgeon inserts the arthroscope into the glenohumeral joint and evaluates for pathology including biceps tendon, labrum and rotator cuff. Any incidental pathology can be addressed arthroscopically at this time prior to subacromial space arthroscopy being performed. Starting from the posterior portal and using an aggressive synovial resector with the inflow in the anterior portal, the surgeon uses the lateral portal to perform a bursectomy

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

3 and debride the soft tissues of the subacromial space. This is done in a sequential manner, working from the lateral bursal area to the anterior and medial acromioclavicular regions. After the subacromial bursectomy and denudement of the undersurface of the acromion, the superior rotator cuff can be visualized along the acromioclavicular joint and anterior acromial anatomy is more easily defined. The surgeon must be careful not to disturb the coracoacromial ligament during the initial bursectomy procedure. Next the surgeon performs sequential acromioplasty with an acromionizer instrument with the therapeutic goal of a flat type I acromion and removal of the coracoacromial ligament from its bony attachment. In addition, the acromioclavicular joint may be assessed at this point and minimal inferior osteophytes may be excised. Lastly, dependent on preoperative evaluation the surgeon may choose to perform a distal clavicle excision (usually 1.5-2.0 cm). Surgical outcomes for arthroscopic subacromial decompression, partial acromioplasties, and distal clavical excisions have been favorable. Most surgical failures are associated with incomplete bone resection and not addressing acromioclavicular joint arthropathy.

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Phillips and Tippet. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Postoperative rehabilitation can be divided into three phases: 1. Phase one emphasizes a return of range of motion 2. Phase two stresses regaining muscle strength 3. Phase three stresses endurance and functional progression

Phase I: Return of range of motion: Weeks 0-3 Goals: Days: 1-10 Control normal postoperative inflammation and pain Prevent infection Protect healing soft tissues Minimize effects of immobilization and activity restriction Days: 11-14 Flexion PROM to 150 External/internal rotation PROM to functional levels Supine AROM flexion to 120

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

4 Intervention: Phase I a & b (first 10 days post op) Cryotherapy Grip strengthing exercises Passive range of motion as indicated Isometrics (Submaximal to maximal internal and external rotation) Active range of motion (scapular retraction/protraction) Joint mobilizations (sternoclavicular and acromioclavicular joints as indicated) Phase I c (11-21 days post op) Active range of motion: o External rotation (at 60-90 abduction) o Supine flexion, scapular protraction o Sidelying external rotation o Prone scapular retraction Cardiovascular exercise, pool therapy Return to limited work duties (depending on job tasks)

Phase II: Regaining muscle strength: Weeks 3-8 Goals: Control any residual symptoms of inflammation and pain Full PROM in all ranges Symmetric flexion AROM AROM flexion in standing to shoulder height without substitution Emphasis on muscle strengthening with continued work on rotator cuff musculature and scapula stabilizer strengthening Continue range of motion efforts if limited capsular extensibility detrimentally affects physiologic motion Restoration of normal arm strength ratios (involved/uninvolved) Return to previous levels of activities/sport Prevention of poor throwing mechanics Intervention: Progressive resistance exercises for rotator cuff musculature and scapular stabilizers Joint mobilizations as indicated Proprioceptive neuromuscular retraining Towards end of phase 2 begin progressive throwing program and gentle plyometrics

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

Phase III: Endurance and Functional Progression: Weeks 9-12 Goals: Unrestricted overhead work and sporting activity Focus on enhancing kinesthesia and joint position sense Muscular endurance Performing work-specific and sport-specific tasks Intervention: Exercises to improve both passive detection of shoulder movement and active joint repositioning for enhanced kinethesia and joint positioning sense Decreased weight with increased repetitions during strengthening exercises of rotator cuff and scapular stabilizers. Emphasis on timing of muscle contraction and movement without substitution (proprioceptive neuromuscular facilitation) Functional progression program involving a series of sport or work-specific basic movement patterns graduated according to the difficulty of the skill and the patients tolerance.

Selected References: Caspari R: A technique for arthroscopic S.A.D., Arthroscopy. 1992;8:23. Gartsman GM et al: Arthroscopic subacromial decompression. an anatomical study, Am J Sports Med. 1988;16:48. Jobe FW: Impingement problems in the athlete. In Nicholas JA, Hershamann EB, eds. The Upper Extremity in Sports Medicine. St Louis, Mosby, 1990. Jobe FW, Jobe CM: Painful athletic injuries of the shoulder. Clin orthop., 1989; 173:117-124. Paulos LE, Franklin JC: Arthroscopic S.A.D. Development and application: a 5 year experience. Am J Sports Med. 1990; 18:235. Phillips P, Tippett S. Acromioplasty. In Maxey L, Magnusson J, eds, Rehabilitation for the Postsurgical Orthopedic Patient. St. Louis, Mosby, 2001. Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002; 30:136-151. Wilk KE: The shoulder. In Malone TR, McPoil T, Nitz AJ, editors: Orthopaedic and sports physical therapy, ed 3, St Louis, Mosby, 1997.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

Arthroscopic Shoulder Stabilization and Rehabilitation


Surgical Indications and Considerations Anatomical Considerations: The concave surface of the glenoid is relatively less concave, and only 1/3 the size of the articulating surface of the much larger, more convex humeral head. However, the glenoid labrum accounts for the difference in concavity. In conjunction with the static and dynamic stabilizers of the shoulder, the labrum enables proper articulation to be possible in the non-pathologic shoulder, making up the difference between concavity/convexity of the glenoid and humeral head. However, when the stabilizing mechanisms of the joint are not sufficient, anatomic fit is compromised, causing excessive wear and tear on the joint, often resulting in pain with activity. Pathogenesis: While a certain amount of tissue laxity is required for proper articulation, a breakdown at any level: labral, static and/or dynamic stabilization, can result in excessive/pathologic laxity, termed instability. Breakdown at any level, static or dynamic, will place undue stress on the other, and lend itself toward more global effects. Resultant instability is often symptomatic by shoulder pain/discomfort with motions that cause excessive accessory joint motion. Epidemiology: While most common in overhead athletes and swimmers, glenohumeral capsular instability is not widely common/problematic among the general public. Among those affected, most are male. 86% male vs. 14% female. Diagnosis/Indications for Surgery Recurrent shoulder subluxation/dislocation Acute traumatic dislocation Pain or symptom associated with the above conditions.

Nonoperative Versus Operative Management: Conservative management of shoulder instability consists of strengthening for the dynamic stabilizers of the shoulder in effort to compensate for laxity in the static stabilizers. Dynamic stabilization of the rotator cuff and scapular stabilizers can sufficiently achieve glenohumeral stability for everyday activities in most patients. In those who participate in a high level of overhead activity, however (throwers, swimmers, etc.) surgical intervention may be required for future return to sport. However, from the physical therapists perspective, rehabilitation is quite similar for operative vs. nonoperative patients. Furthermore, there is no urgent need for surgical intervention to be immediate. In fact, most patient cases are those of chronic instability to begin with. Therefore, conservative management is often tried first, before resorting to surgical intervention when the instability is not related to rotator cuff or labral tears. Surgical Procedure: Among the newest and increasingly more common ways to increase shoulder stability is thermal-assisted capsular shrinkage. This is a process by which laser or
Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS

2 radio-frequency sound waves are used to heat collagen tissues to temperatures above 60C at which the collagen helix begins to unwind and cause resultant tissue shrinkage. This is a simple, yet very precise procedure in the sense that if the tissue is heated too rapidly, or too far, the desired effect is lost and tissue necrosis results instead. Due to the repetitive nature of the injuries that cause patients to require such a procedure, the majority of them (90%) have other reparative surgical procedures simultaneously with capsullorhaphy. Most commonly these include surgical repair and/or debridement of the labrum and/or rotator cuff as well as capsular suture repair in addition to laser. Even with that being the case, 87% of overhead athletes who undergo this procedure successfully return to competitive sport. Preoperative Rehabilitation None required May include dynamic stabilization in attempt to manage nonoperatively.

POSTOPERATIVE REHABILITATION

The greatest factor in post-operative rehabilitation is whether the patients shoulder instability is an acquired condition, or a congenital state of laxity, possibly worsened by lifestyle or activity. Those born inherently loose are most prone to capsular creep and thus eventual failure of the procedure, so their rehabilitation must be much more conservative so as to avoid any stretching to the capsular structures, especially during the critical early stages after surgery when the collagen is most susceptible to stretch. Patients whose laxity is an acquired condition may be advanced more quickly. Acquired or congenital instability can be determined by examination of the uninvolved shoulder. Other considerations: Individuals prone to scar tissue deposition must be advanced through their rehabilitation more aggressively to prevent development of excessive capsular scarring and subsequent loss of range of motion (ie: frozen shoulder). For this reason, tissue end feel should be re-assessed on a weekly basis for all individuals post-surgery. Stretchy end feels indicate conservative treatment. Stiffer end feels indicate the need for more aggressive rehabilitation with stretching to maintain/gain range of motion as required. Note: The following rehabilitation progression is a synopsis of the guidelines provided by Wilk, Reinold, Dugas, and Andrews. Refer to their publication for details regarding how to apply the progression effectively to individual patients. Phase I for individuals with Acquired Laxity: Weeks 1-6 (Protection Phase) Goals: Tissue healing Minimize pain and inflammation Initiate protected motion Retard muscular atrophy

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

3 Weeks 0-2: Sling use for 14 days Wrist, elbow, and cervical ROM exercises Passive and active-assisted shoulder ROM (no aggressive stretching) Shoulder isometrics and rhythmic stabilization (7 days) Weeks 3-4: Begin AROM at week 3, add 1 pound at week 4. Emphasize strength of ER and scapular stabilization. Weeks 5-6: Progress ROM to: o Elevation to 160o o ER at 90o ABD (75-80o) o IR at 90o ABD (60-65o) Initiate Throwers Ten strengthening program Phase II for individuals with Acquired Laxity: Weeks 7-12 (Intermediate Phase) Goals: Restore full ROM (week 8) Restore functional ROM (weeks 10-11) Normalize arthrokinematics Improve dynamic stability, muscular strength Weeks 7-8: Progress ROM o Elevation 180o o ER 90-100o o IR 60-65o May be more aggressive with ROM progression and stretching May perform joint mobilization Continue strengthening as above (Throwers Ten, dynamic stab, rhythmic stab) Initiate plyometrics (2-handed drills) Weeks 9-12: Progress ROM to specific athletic demand o ER 110-115o Generalized stretching Strengthening o Continue as above, with progressive resistance o Push-ups o Bench press (do not allow arm below body) o Single handed plyometric throwing o Plyoball wall drills

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

Phase III for individuals with Acquired Laxity: Weeks 12-20 (Advanced Activity and Strengthening Phase) Goals: Improve strength, power, and endurance Enhance neuromuscular control Functional activities Weeks 12-16: Continue stretching/strengthening as above Weeks 16-22 May resume normal training program

Phase IV for individuals with Acquired Laxity: Weeks 26 (Return to Activity Phase) Goals: Gradual return to unrestricted activities Maintain static and dynamic stability of shoulder joint Criteria: Full functional ROM No pain or tenderness Satisfactory muscular strength Satisfactory clinical exam

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

5 Phase I for individuals with Congenital Instability: Weeks 0-8 (Protection Phase) Goals: Allow healing of tightened capsule Begin early protected motion of elbow, wrist and hand Decrease pain and inflammation Gradual increase in ROM after week 3 Weeks 0-2 Active abduction after 10 days, but not to exceed 70o Sleep in slign x 2 weeks No overhead activity for 12 weeks Weeks 2-4 Pulley exercises (to 90o) Isometric strengthening Rhythmic stabilization Weeks 4-6 ROM exercises with cane o Flexion to 125o o ER to 25o o IR to 45o Continue strengthening as above o Add theratubing at week 5 Gentle mobilization to reestablish normal arthrokinematics

Phase II for individuals with Congenital Instability: Weeks 6-12 (Intermediate Phase) Goals: Full nonpainful ROM at weeks 10-12 Normalize arthrokinematics Increase strength Improve neuromuscular control Weeks 6-12