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Prep, Knee Anatomy, Knee Assessment Course, Hip DIFF Course (Clinical…
Prep
Methods of reviewing
CPG's
Chat GPT
PhysioU
Go-To PT
Chris Johnson Materials
Running Rewired Jay Dicharry
Hand's on Work with Char
Special Tests
Hip
Knee
Ankle
Joint Mobs
DF (open back 10 deg PF, bend knee to take out calf)
Joe Norton's Instagram and BLog
R2P's Run Analysis
Youtube
Clinical Physio
Physio Network
PhysioU
Chris Johnson Materials
Concepts
Tapgin
Return to Run Progressions
Level 0
Run in place
Level 1
Jog 1 min, walk 4 min
Level 2
Jog 1:30, Walk 1:30 (Rich Willy)
Cadence
Regional Interdependence
Red FLAGS
Frozen shoulder vs RTC
Froz
Biggest Issue is Stiffness
Fibrosis of joint capsule and surr structures
Painfull ->
stiffness
stage "lost movement in shoulder"
50% loss in ER on painful to unpainful side
Equal restriction AROM and PROM
RTC Tendonopathy
Pain and irritability - part with loading of shoulder - Resisted tests
Tendons overloaded
Not much stiffness
Pt's able to reach ATLEAST 140 deg, passive can reach those levels
Treating the runner
Common injuries
ITBS
DX: No ober
PFP
Causes
Treatments
Hip Pain (SEE Other)
Phyisionetwork videos on hip
Testing:
FABER
Can be lumosacral pain
FADIR
Resisted IR and ER - Strength of Glutes
FAI
Sporty, younger, deep groin pain - clicking, giving way
OA; older, stiffness < 60 min, socks = flexion with rotation
Achilles
Plantar Fasciitis aka fasciopathy or plantar heel pain
DX
1st steps in the morning, heel pain, pain gets better while walk. Prolonged standing and running
Medial calc tubercle, Pos windlass, NEG Tarsal tunnel test tinel, NEG tibial nerve SLR.
Risks: High BMI, Lack of DF, excessive Pes cavus (high arch)
TX
Calf - Soft tissue to Calf and stretching can help
short term
12-13 Months most cases
Fear avoidance factors
Taping Reverse 6
Motor control ex:
Short foot exercise:
Doming
Arch control with squat with band
E3 Rehab
Plantar fascia stretch - after prolonged standing or sleeping
optional ex: toe curls, toe yoga
Long term: SL Heel raise: step with towel under toe
optional inch worm or elephant walks
Myths: don't roll out bottom.
BSI
Tibial
Femoral head
Navicular
Fifth Met
Nathan Carlson Slides
Hamstring Strain
Physio Network
Gluteal Tendinopathy
DX
Single Leg Stand Test (pain around greater troch)
Women, overload, pain in greater trochanter
Hip Flexor Strain
Baker's Cyst
Bursa between semimembranosus and head of gastroc medial
centrally palpable bump, 35-70. Aggravated by Knee extension
Can be delayed after injury
Steroid inj.
Eval Flow
use R2P's Run analysis
Subjective:
Daily Step Count?
Working Narrative
Exercise Schedule
Objective
Functional Testing
SL Calf raise Test (30 CJ, 60 bpm, 90)
Success: younger than 50 = > 25 reps, 50-60 > 20, 60's = 15-20
watch for: Forward lean, rolling to outside of foot. Perform on 10 deg incline -> greater compressive loads at Achilles
SL Stance:
30 sec: looking at compr and contractile load of pelvis
Flex this side up. Look for pelvic shift. What is back doing? L sided lateral hip band? Look for leaning to compensate to offset control deficit. Lateral hip pain strength deficit low back compensatory pattern.
The practitioner should monitor for toe gripping, holding one’s
breath, excessive trunk lean, and poor control of the pelvis in the
horizontal and transverse plane
Lateral Stepdown
Assessing: tolerance to SL eccentric contractions, Lateral hip strength, Lumbopelvic control, ankle DF, tolerance to comp at PFJ, ITB, Achilles. Imitates ROM of stance phase. Look for Knee or Hip strategy.
7-8 inch step, hands on hips, heel tap down. 30 BPM during test. 10-20 reps
Unilat Bridge + SLR
Hold for 30 sec w/o breaking form,
posterior chain strength, endurance
and lumbopelvic hip control (targeting glute max, hams, AND glute medius
Sideplannk stand + plank hip ABD
20 sec each side top leg lifted, Pass 1 min standard STAGGERED
Adductor Plank
Good for FAI, adductor strain, BSI to prox femur or pevlis
Pass 20 seconds - Long Lever
Pogo Jumps
Tests: Tolerate energy storage and release?
Good for testing: calf strain, achilles tendinopathy, Plantar fasciopathy, BSI's
1 min 150 bpm - pass short GCT's.
Consider dropping to 100 bpm, also Anterior to posterior, medial lateral,
SL Hopping
30 sec 150 bpm
Quick taps
1 min round
Summary and Plan doc
Narrative, education, Primary exercises, Exericse Schedule, Running considerations, footwear considerations, gait retraining, lifestyle factors, Next aapt
Tools to Review
Physio U
Anatomy Tour
Gastrocnemius
Medial head Bigger than lateral head
attaches to lateral and medial femoral condyle. Runs down to posterior calf in achilles tendon.
Weaker role in knee flexion
Tibial nerve (S1 S2)
Strain
When foot everted - medial strain.
Medial head more likely to strain ( Slightly longer and larger - contract over longer surface- - more force)
Sciatica
Weakness in the calves
Outcome Measures
Modified Wilk Classification system
1 Pain upon exertion
2 Pain with ADLs
3 Pain at rest
4 Pain managed with meds
5 Severe Disabling Pain
Knee Anatomy
Gastrocnemius - 2 heads
Quads - knee ext, rectus fem - > weak hip flexor
Hamstrings - Role of knee flexion and hip extension.
Sartorius - weak knee flexor and hip flexion.
Gracillius
Pes anserine: superomedial aspect of tibia (SGT) -> tendons irritated
Popliteus: -orig lat fem cond to medial and prox surface of tibia
Knee Assessment Course
Observation
Alignment - valgus varus, wasting of quads, patella should be forward. Side - flexion deformity, popliteal fossa (cysts, wasting of calves hamstrings)
Gait: 4 phases heel strike, stance, toe off, swing
antalgic gait: Reduced stance phase of R (limping)
Hyperextension Extension gait (Weakness of quads forces into quadriceps)
Supine: Wasting, scars, portals, redness, swelling
Palpation: Done in extension AND flexion.
Joint line opens in flexion
palpate: extension: tibial tub -> patellar tendon -> go around medial patella, lateral border -> superior pole to quad tendon. See tenderness. THEN flex knee -> opens joint line -> start tibial tub-> then inferior pole of patella -> medial joint line all around to back -> posterior horn of meniscus tear -> THEN lateral joint line -> go back -> arteries, cysts, popliteal fossa.
Posterior horn of Meniscus tear meidal more common -> MORE fixed - twisting can't get out of way.
FLEXED knee -> Feel for condyles-> AVN, osteocondryle defects, Spont osteonecrosis of knee. EXPOSED HERE in flexion.
Palpate MCL, LCL (inserts head of fibula)
Tests
Sweep test: up medial down lateral. Sweep fluid away from medial. Grading 0-3 (0 no wave, trace).
HIP
Groin pain -> obturator nerve radiates down to knee
Obj: Flex hip PROM,
Test for ABD, ADD - Put leg over opp site to fix pelvis. Abduct and add hip. Flex knee up and test for rotation. Any pain radiating down to knee.
Ankle:
1 hand lock talus, other hand move to df.
ROM: Active flexion and extension:
EXT: DF ankle and push knee onto table. Shouldn't get fingers under the knee.
Flexion: bring heel up towards bottom. Feel for crepitus during PROM.
Functional Tests:
Squat: apprehension, alignment, lunge, kinesiophobia
Lunge: apprehension, kinesiophobia
Hip DIFF Course (Clinical Physio)
Joint Specific
OsteoArthritis
Older > 45, pain in groin mostly- buttock possible. Can refer to the hip as well. referred pain goes down obturator pain. Any pain from HIP going further then knee -> not from hip.
Walking, Flexion and rotation (shoes, twisting, getting in an dout of car) CANT CUT TOENAILS. pain on exercise ->
degen issue not inflammatory issue
pain in morning no more than 30 minutes from morning stiffness.
Objective: ROM A and P - IR deficit. Leg may be shortened and externally rotated
Tests
FABERS: Repro with pain at hip
FADDIR: Repro pain at hip
Hip Quadrant Test (SCOUR) - scooping from FABER to FADDIr and back
Fitzgeralds: Anterior: FABER -> FADDIR -> Scoop into extension, Posterior opposite
Rheumatoid Arthrits
Family hx, multiple joint pain, shoulder elbow knee ankle AND hip pain
Objective: IR hip deficits, restr A and P ROM
Differentiating factors: MORE than 30 minutes of early morning stiffness, Worse after rest, Better with exercise, BETTER with Nsaids. Joint feels better with inflammatory conditions.
RA: Osteopenic bone, subluxations, Ankylosis (Fusing of bones)
Labral Tears
Most tears secondary to OA and FAI, Hip dysplagia, Hip dislocations, hyperligamentous laxity
If genuine cause of pain - Younger, Trauma, Pain gradual onset - twisting injury and deep flexion activity. Pain exacb walking, running twisting, prolonged sitting.
Location - anterior - groin, deep. Post: lateral hip or deep butt, pain may go to knee. MAY rep stiffness at the hip after sitting. Clicking, clunking or locking in hip on movement DX of exclusion.
MRI - often incidental finding
Avascular Necrosis
Femoral Head.
Risk factors: STARS - Steroids, Lupus, Trauma, Alcohol, Radiation, RA, Sickle Cell Disease, Males, mean age is 58, can be bilat
Slow onset of anterior hip or groind pain vauge diffuse, worse WB, worse stairs, stiffness feeling
Early Stage vs Late: As progresses may present morel ike OA with pain and joint stiffness. IR deficits, arom and prom limited.
Joint Related
FAI
Motion related disorder of the hip. symptomatic contact between femur and acetabulum.
Types Pincer and CAM
Can give rise to Labral Tears. PAin deep sitting, prolonged sitting. insidious onset.
Ruling out: no pain with FADDIR, no ROM restric during FABER Ruling in: Prone Hip IR at 90 knee flx and PAIN
Femoral neck Stress FX
Risk: Overloading of repeated activity (runners military) athletic fit women, low BMI, Altered bone health, poor nutrition.
2 Types: Compression: (Inferomedial side of neck) - non op Tension: Superolateral part of neck (Operatively) -fixation op
Extreme ROM painful, WB can be painful. Pinpoint pain around the groin. Hop test - positive for pain. may not have rom limitations.
Joint Specific Peeds
Perthes - AVN in fem head of femur, ages 3-12. Leg length discrepancy late finding.
Hip Dysplagia
Excessive movement.Shallow acetabulum, prone to sublux, dislocation
Extracapsular
Greater troch pain syndrome:
Compression of glute med and min tendons from ITB - during hip ADD - insertional tendonopathy. PAIN during hip addduction.
Subj - story of overloading with grad worsening, worse with adduction. Ex - SL activities move into adduction. NIGHT pain - lying on that side - pelvis sinks in -> adduction can be other side though.
Obj: Palpation painful around GT (rule out) . Single Leg Stand Test (Rule in), FADER Test: Flexion ad er -> RESIST rule in.
Not the hip
Lumbar spine
Subj: Does pt have back pain, neuro symptoms running down and PAST the knee -> if yes its low back. ASK bending and picking things up, static postures, leaning backwards.
Obj: Palpation painful of lumbar? lumbar spine ROM,
Case Studies
Knee pain 60 yo female
2 weeks severe pain, constant, immed on WBing. Night pain, can't find comfortable pos. Xray - early OA.
Objective: Antalgic gait, TTP medial femoral condyle and medial joint line, AROM: flexion limited to 70. Ext full ROM with pain at end range. PROM same as AROM.
Xrays neg, MRI though - meniscus tear, cartilage injury.
Subchondral insufficiency fracture of the knee. Form of a stress fracture.
Hip pain
40 yo R side anterior groin pain. 3 weeks ago end of long run - training for marathon. physio dx hip flexor tightness. Dull aching anterior thigh pain when walking worse when running. Gradually worsens more she runs. Getting worse past 3 weeks. Low BMI, Early menopause.
Objective
Antalgic gait, don't like loading in stance phase. Lumbar spine fine. R hip reduced flexion to 100 and IR at 10 due to pain. Strength 4 globally. SL Hop on R leg pain ++,, SL stand minor pain on R. FADDIR:
BSI femoral neck on R - refer for imaging. Hip flexor issues - heavily overdiagnosed. Running doesn't use hip flexors as much.
47 yo heel pain, gradual, worse in morning, works as a chef
Obj: pes planus bilat, medial heel pain, good ROM, lumbar spine fine. Tightness in calf limited by gastroc. Windlass test pos.
Taping everyday Lowdye taping in short term
Morrissey et all 2021 best practice guide 3 core treatments.
PF stretching hands on toes 30 sec x3 through the day
Education - reducing time on their feet, don't aggravate. Reduce BMI, comfortable foot wear.