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Biomedical Physio & Kines
BPK 241
Donald Hedges

The foot Plantar Fasciitis Inflammation of plantar fascia - Not traumatic - Biomechanical issue - Pain worse in the morning (feeling of walking on broken glass), due to lack of shock absorption in pes cavus. - Often sore to touch on heel - Small tears can occur along length of planatar fascia causing pains Tests: - Check arches while standing. (either pes planus, or pes cavus can lead to PF) - AROM/PROM in WB. 1/3 squat - Twist test (check differences between injured and uninjured side in pronation/supination while standing) - Muscle length testing. (FHL-plantar flexion, G/S (check dorsi, then bend knee and check dorsi again, if more length, then G/S was limiting dorsi)) check for tightness. NWB - Muscle strength. Weakness into inversion, weakness of big toe flexor - Palpation pain over medial calcaneal tubercle, pain over length of plantar fascia Treatment - Rest (cut down on WB activities) - Ice (avoid too much compression) - Stretch – G,S,FHL - Check footwear/correct training errors - Night splint - Tape: Low Dye/FHL Stretch Fat Pat Syndrome Irritation of fat tissue in the rearfoot - Can be acute from fall on heel - Can chronically develop from excessive heel strike with poor heel cushioning Tests: - TOP (tender on palpation) over central heel and possibly sides of hind foot. Treatment - Rest - Heel cup, and supportive footwear - Fat pad tape job - Ice - Ultrasound Heel Spurs Excess bone growth usually emanating from medial calcaneal tubercle - Usually caused by increased traction at insertion of plantar fascia - Frequently present in asymptomatic population (10-30%) - Present in up to 75% of athletes with plantar fasciitis - May contribute to pain similar to that of plantar fasciitis Test: - Send athlete for xray, when conservative treatment fails - TOP may be observed in area of spur Treatment - Similar to plantar fasciitis - Patient needs xray/bone scan to confirm - Surgical removal may be performed (rare, low success rate) Posterior lower leg Achilles Tendon Rupture A complete tear of the Achilles tendon - Easy to misdiagnose because athlete will be convinced they were kicked from behind - It can occur due to forceful plantar flexion - When ankle is forced into DF while G/S contract - In chronic conditions evidence of pre-existing microtrauma or microtear can be found - Physical defend in tendon or lump in back of leg where tendon has rolled up - Inability to single leg raise - Swelling and bruising around malleoli - Excessive passive DF Tests - Thompson Test (patient lies prone, squeeze calf, should produce PF of foot) - ROM - Strength test DF, PF, EV & INV (all should be strong except PF) - Palpation (look for lump from rolled up tendon) Treatment - RICE - Surgical repair - Foot put in boot after surgery in PF via heel lifts - Tendons regain full strength around 12 weeks - Recovery time for sport return is 9-12 months - Once out of boot, exercise therapy (AROM/PROM, balance, strengthening, gradual tendon loading, Deep Tissue Friction Massage) Achilles Tendinopathy Irritation of, or microtears to the Achilles tendon - Can be due to training errors - Foor dysfuncion (previous sprains, pes cavus or planus) - Improper footwear - Usually tender 2-6 cm above calcaneus - Pain with WBPF - Night pain is often common in chronic cases - Boggy feel on tendon palpation Tests - AROM & PROM (slight pain with Passive DF) - Strength tests: PF (painful) & DF Treatment - Eccentric only loading exercises (if left injured, tiptoe on right, switch to tiptoe on left, drop down on left. Pain should disappear in exercise after 2 days, if not, stop. Eventually move to negative exercises- on stair so as to go lower than ground) - RICE for first 2 weeks - Tape job – reduce pull on Achilles with DF - Balance exercises, calf stretches Calf Strain Tear of G or S - Vulnerable to strain during forceful PF of ankle (direction change, jump, propelling in sprint) - Athlete will complain of pain in calf with push off phase of gait - Improper warmup - Symptoms similar to rupture of Achilles, differentiate with Thompson test - TOP - Possible swelling - Weakness and pain with PF muscle test Tests - Arom/prom in WB and NWB - Test G with straight knees - Test S with bent knees - Strength test (pain+weak with PF) - Palpation Treatment - RICE - Possible heel lift - Do not do moderate-heavy stretching post ANY muscle injury - AROM - Microstretch - Balance exercises - Strengthening exercises (concentric involving PF progressing to eccentric) - Achillies tendon tapejob to decrease DF Anterior Lower Leg Anterior compartment syndrome Compression of deep peroneal nerve and anterior tibial artery supplying the muscles of the anterior compartment - Altered sensation in lower leg anteriorly (numbness) - Muscle weakness - Feeling of tightness in anterior lower leg with exercise - Possible foot drop Tests - Arom (inability or difficulty with DF) - Prom (passively PF foot may elicit pain in anterior compartment - Strength tests (weakness with resisted DF) - Pulse (test dorsal pedal pulse. Top of foot) - Palpation (firm to touch especially post exercise) Treatment - RIE (no compression) - G/S stretches - Refer to compartmental pressure testing, xray to rule out other possibilities - Correct possible training errors or intrinsic factors such as malalignment - As last resort, may need surgical release of compartment - No tape job Medial Tibial Stress Syndrome (Shin Splints) Inflammation of tibia and/or surrounding periosteum Inflammation of tendon to tibialis posterior - Develops over time – repeated pounding of legs - Common in court sports, long distance runners, aerobics - Possible contributing factors: o New to sport o Dramatically increased mileage within weeks of injury o Change of training surfaces o Inappropriate footwear o Poor running mechanics o Muscle tightness and imbalance o Poor conditioning o Overweight o Lower limb structural abnormalities - TOP medial aspect of tibia, usually distal 1/3 - Increased pain with exercise, lingers after exercise is finished Tests - Arom and prom (possible pain with PF/EV) - Muscle tests (possible pain and/or weakness with resisted inversion) - Palpation(pain along medial aspect of tibia, often 2-3 cm sore spot) Treatment - Rest ~2 weeks - Ice cups and ice massage - Suggest alternative cardio workouts that reduce pounding through legs - Send for xrays, bone scan to rule out stress fracture - Correct faulty biomechanics/training erors - Strengthening exercises ( tibialis posterior, towel scrunches) - Tape job (low dye to correct pronation or shin splint tape job) Stress Fracture of Tibia Hairline fracture of tibia, usually in distal half of bone - Develops over time from repeated pounding of legs during activity - Common in distance running - Pain is worse following activity especially with hill training - More of a deep seated pain or ache - TOP over fracture site - Increased pain with increased training Tests - Can use a tuning fork - TOP over fracture site - Weakness or pain with resisted tests - ROM should be ok Treatment - Rest at least 2 weeks initially - Ice cups/ice massage - Xrays,bone scan - Change footwear - Check any imbalance or malalignment problems - Gradual reintroduction to full WB exercise - Workout on softer surfaces - No tape job unless low dye for arch support The Knee Anterior Cruciate Ligament Sprain Complete or partial tear of ACL (helps keep tibia anterioir to femur, it is most taut in full knee extension) - With rupture, athlete will often report hearing popping sound - Athlete may be able to continue, but will complain of knee “give way” with rotational or quick movements - Several possible mechanisms of injury - Often significant swelling post rupture - Feeling of instability with rotational movements Tests - Arom/prom (may be painful at end range of knee flexion/extension) - Strength test (possible weakness in knee flexion/extension- sitting over the edge of table; foot PF) - Ligament tests: o Lackman test (put roll under knee, hold down femur, pull up on tibia, ACL should stop the tibia from moving too far) o Anterior Drawer test (knee at 90 degrees, sit on foot, put both hands on tibia, pull forward) Treatment - Rice - Mri asap - ROM exercises, balance exercises, Hamstring strengthening exercises - Potential bracing - Likely to get surgery if acl was ruptured Posterior Cruciate Ligament Sprain PCL prevents hyperextension, most taut in full flexion of knee. - Knee is flexed to 90 degrees and athlete falls on knee, or suffers a direct trauma to anterior knee - Forceful or sudden rotation of the knee with or without lateral or anterior trauma Tests - Sag test (supine athlete, both knees at 90 degrees, and compare tibial tuberosity, if one is shifted posteriorly- looks indented or shifted, it is a sign of PCL strain) - Arom and prom, likely pain at end ranges of knee flexion/extension - Strength, possible weakness in knee flexion/extension and foot PF - Ligaments: o Posterior Drawer Test (knee still at 90, stabilize femur, push on tibia with other hand) Treatment - As per ACL except, strength work should focus on quads - PCL surgery has lower success rate than ACL, therefore not as readily performed Medial Collateral Ligament Sprain Provides medial stability to the knee. MCL contains both deep and superficial fibers - Knee flexed with a direct trauma or force applied to the joint - Foot can be planted or in the air - Valgus force Tests - ROM and strength tests - Ligaments: o Valgus stress test-moves laterally (supine, hold foot against you between hip and elbow, giving you two free hands)  Deep fibers (stabilize femur, and rotate back and out-medial pressure)  Superficial fibers (bend knee at 30, stabilize femur, and rotate back and out) o Looking for increase in joint play. With or without pain Treatment - Avoid valgus force through knee with ADL’s - Regain AROM, strengthen surrounding muscles - RICE - Deep tissue friction massage after 2 weeks to promote realignment of ligament - Use brace or tape to increase support Lateral Collateral Ligament Sprain Provides lateral stability - Foot planted, knee is flexed, and a blow or trauma medially - Varus force- lateral pressure - Not very common Tests - ROM and strength tests similar to ACL/PCL/MCL - Ligaments o Varus stress test (supine athlete, knee extension, rest leg on hip, stabilize, and apply lateral force, repeat at 30 degrees. o Looking for increase in joint play. With or without pain Treatment - Avoid varus force through knee - surgery done more readily for LCL than MCL - similar treatment to MCL Terrible Triad Tear of ACL, MCL, Medial Meniscus, and Joint capsule - foot planted, knee slightly flexed, and lateral trauma to leg TREAT INDIVIDUALLY Meniscus Tear - can be torn longitudinally, transversely, or horizontally - can be torn: o bucket handle o parrot beak o peripheral - often athlete feels pop or tear - isolated or repetitive rotational stresses, often cause with ERand flexion - increased swelling usually observed and difficulty with extension and flexion - hyperextension - maybe repeated popping - maybe swelling - maybe localized pain at joint line - may get locking, catching, giving way, pain on rotary motion Tests - usual strength and ROM tests for knee - McMurray’s test (supine, hip at 90, fully flex knee, turn tibia-NOT THE HIP, into external or internal rotation, start to extend the knee and bring it down while applying valgus force. Repeat with the other rotation, then repeat again and this time provide varus force, so do a total of 4 times) Look for pain) - Appley’s Test (prone, knee at 90 degrees flexion, grab a little about the ankle with both hands, and push down, then rotate out and rotate in, looking for pain. Repeat at 70 degrees, and 110 degrees) - Palpation (sit on edge of table, palpate around the knee joint at meniscus) Treatment - RICE, AROM, and STRENGTH exercises - Knee locking requires immediate medical attention
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