7/2/2008

1

Strengthening your musculoskeletal Strengthening your musculoskeletal assessment ofassessment of common common

complications of the Lumbosacral complications of the Lumbosacral spine and lower extremityspine and lower extremity

L i M D i MSL i M D i MSLouise McDevitt MSLouise McDevitt MSFNPFNP--BC, ANPBC, ANP--BC, ACNPBC, ACNP--BCBC

Lumbosacral SpineLumbosacral Spine

55thth most common reason for o.v.most common reason for o.v.Common: musculoskeletal, degenerative Common: musculoskeletal, degenerative changes, herniated disc, spinal stenosis, scoliosischanges, herniated disc, spinal stenosis, scoliosisL A S i i f iL A S i i f iLess common: A.S., metastasis, infection, Less common: A.S., metastasis, infection, visceralvisceralRed flagsRed flags

Hx of serious disease: CAHx of serious disease: CANeurologic changes Neurologic changes

Normal vertebrae & Compression fx Normal vertebrae & Compression fx

7/2/2008

2

HistoryHistory

See presentation #1 of c spine, upper extremity for See presentation #1 of c spine, upper extremity for pertinent historypertinent historyP.E.P.E.

General appearance, VSGeneral appearance, VSPPPosturePostureGait: both directionsGait: both directionsSitting positionSitting positionObservation of spineObservation of spinePalpationPalpation

Vertebrae and musclesVertebrae and musclesROM ROM

Lumbar ROMLumbar ROM

FlexionFlexion 6060--9090°°Difficult with paraspinal spasmDifficult with paraspinal spasm

ExtensionExtension 2020--3535°°Pain with SpondylolisthesisPain with SpondylolisthesisPain with SpondylolisthesisPain with Spondylolisthesis

RotationRotation 3030°°Stabilize pelvisStabilize pelvis

Lateral Lateral bendingbending

3535°°Limited by surrounding ligamentsLimited by surrounding ligaments

Lumbosacral examinationLumbosacral examination

Neurologic examinationNeurologic examinationMuscles: size, symmetry, strengthMuscles: size, symmetry, strengthDTRDTRS n rS n rSensorySensory

SLRSLR+ if pain at 30+ if pain at 30--6060°°

Pseudoclaudication: bilateral, nonvascularPseudoclaudication: bilateral, nonvascular

7/2/2008

3

Age RelatedChanges

SynovitisHypomobility Dysfunction

HerniationContinuing

Circumferential Tears

Radial Tears

Facet Joints Intervertebral Disc

Chronic Degenerative Cascade of Chronic Degenerative Cascade of Lumbar Spinal StenosisLumbar Spinal Stenosis

Instability

Lateral NerveEntrapment

Stenosis

gDegeneration

Capsular Laxity

Subluxation

Poor Quality Of Life

Enlargement ofArticular Processes

Internal Disruption

Disc Resorption

Osteophytes

Physical signs and differential dxPhysical signs and differential dx

Lumbar strain, Lumbar strain, sprain, myofascialsprain, myofascial

Muscle spasmMuscle spasm Pain ↑ activity, tender Pain ↑ activity, tender palpation, ↓ flexionpalpation, ↓ flexion

Disc herniationDisc herniation Sharp, burningSharp, burning Pain ↑ compression; Pain ↑ compression; sitting, SLR neuropathysitting, SLR neuropathy

OsteoarthritisOsteoarthritis AchingAching Pain ↑ activity, ↓ROMPain ↑ activity, ↓ROM

Spinal stenosisSpinal stenosis AchingAching Pseudoclaudication Pseudoclaudication Flexion ↓ pain Flexion ↓ pain Extension ↑ pain Extension ↑ pain

SpondylolisthesisSpondylolisthesis Aching, sharp Aching, sharp ↑ lumbar curve↑ lumbar curveExtension↑ pain Extension↑ pain

Physical signs and differential dxPhysical signs and differential dxAnkylosing Ankylosing spondylitisspondylitis

AchingAching SI joint, Bamboo spine SI joint, Bamboo spine HLAB27HLAB27

Infection: abscess, Infection: abscess, diskitis, diskitis, osteomyelitisosteomyelitis

SharpSharp Localized pain, feverLocalized pain, fever

MalignancyMalignancy DullDull Constant pain, night pain, ↓ wtConstant pain, night pain, ↓ wt

NephrolithiasisNephrolithiasis ColicColic ↑ Flank pain, radiation to groin ↑ Flank pain, radiation to groin u/a +RBCu/a +RBC

PyelonephritisPyelonephritis DullDull ↑temp,CVA tenderness, pyuria↑temp,CVA tenderness, pyuria

AAAAAA SharpSharp Pulsating abd massPulsating abd massPelvic/GIPelvic/GI A,C,D,SA,C,D,S Referred, see HXReferred, see HX

7/2/2008

4

ScoliosisScoliosis

Radiograph & CT scanRadiograph & CT scan

Spondylolisthesis Degenerative Disc Disease

Lumbosacral strainLumbosacral strain

7/2/2008

5

Lumbosacral strainLumbosacral strain

Mechanical back pain of days to weeks from twisting or Mechanical back pain of days to weeks from twisting or liftinglifting

Tendons, muscles, joint capsulesTendons, muscles, joint capsules

Pt Hx: Pt Hx: Often young adultsOften young adultsPain radiates to both buttocks or along paraspinal musclesPain radiates to both buttocks or along paraspinal musclesDiscomfort standingDiscomfort standingRisk factors: sedentary job, poor conditioning, poor work Risk factors: sedentary job, poor conditioning, poor work conditions, smoking conditions, smoking

Lumbosacral strainLumbosacral strain

Physical examinationPhysical examinationVSS stable, poss. increased pulse to painVSS stable, poss. increased pulse to painDiffuse paraspinal tendernessDiffuse paraspinal tendernessS.I. tendernessS.I. tendernessROM esp. flexion produces painROM esp. flexion produces painSLR=bilateral LSLR=bilateral L--S painS painppNormal neuro examination Normal neuro examination

Radiograph?Radiograph?Trauma, atypical symptoms (night or resting pain)Trauma, atypical symptoms (night or resting pain)

ConcernsConcernsFunctional impairmentFunctional impairmentSocial concerns: longer work loss less likely to returnSocial concerns: longer work loss less likely to return

90% better in 90 days90% better in 90 days

Lumbosacral strainLumbosacral strain

TreatmentTreatmentNew guidelines ACP and APS, Annals Internal Med 2007New guidelines ACP and APS, Annals Internal Med 2007Nonspecific pain, do not obtain imagesNonspecific pain, do not obtain imagesOrder testing if severe pain, progressive neuro deficits, underlying med. Order testing if severe pain, progressive neuro deficits, underlying med. ConditionsConditionsMRI if pt’s are sx candidate or epidural steroidMRI if pt’s are sx candidate or epidural steroidMRI if pt s are sx candidate or epidural steroidMRI if pt s are sx candidate or epidural steroidMaintain activity, improvement in 1 mo.Maintain activity, improvement in 1 mo.11stst line meds: NSAID’s or acetaminophenline meds: NSAID’s or acetaminophenSelf care failure: acute pain, spinal manipulationSelf care failure: acute pain, spinal manipulation

Chronic: interdisciplinary rehabChronic: interdisciplinary rehabWeight loss, conditioning, core strengtheningWeight loss, conditioning, core strengthening

Remember atypical, persistent pain, or worsening expand differential to Remember atypical, persistent pain, or worsening expand differential to include red flags include red flags

7/2/2008

6

Lumbar radiculopathyLumbar radiculopathy

“Sciatica”: usually results compression from disc “Sciatica”: usually results compression from disc or chemical irritation of 5or chemical irritation of 5thth lumbar or 1lumbar or 1stst sacral sacral nerve rootnerve rootPt HxPt HxPt HxPt Hx

Hx of previous back “problems”, with abrupt onset Hx of previous back “problems”, with abrupt onset of severe pain buttocks to post/postlateral legof severe pain buttocks to post/postlateral leg--ankle, ↑ with intrathecal pressureankle, ↑ with intrathecal pressureRestless position of comfort varies depending on Restless position of comfort varies depending on defect .i.e. spinal flexiondefect .i.e. spinal flexion

Lumbar radiculopathyLumbar radiculopathy

Physical examinationPhysical examinationPosture: listing, away from affected nervePosture: listing, away from affected nerveSitting: spinal extensionSitting: spinal extensionSLR: Pain < 45SLR: Pain < 45°°Hip flexion: + pain= L3Hip flexion: + pain= L3

L4L4--5=L5 nerve root=67% radiculopathies5=L5 nerve root=67% radiculopathiesWeak great extensor great toe, hallicus longusWeak great extensor great toe, hallicus longusNumbness top of foot, post/lat thigh calf Numbness top of foot, post/lat thigh calf No associated DTR No associated DTR

HipHip

14% adults 14% adults Deep ball and socket, fixed by pelvic girdleDeep ball and socket, fixed by pelvic girdle

Therefore immobility refers pain to back or knee Therefore immobility refers pain to back or knee and vise versa and vise versa

Greater trochanter: attachment of the abductors Greater trochanter: attachment of the abductors glut med/minimus and ext rotatorsglut med/minimus and ext rotatorsHip extensors: glut medius & hamstringsHip extensors: glut medius & hamstringsHip flexor: iliopsoasHip flexor: iliopsoas18 bursa: trochanteric bursitis18 bursa: trochanteric bursitis

7/2/2008

7

Osteoarthritis of hipOsteoarthritis of hip

Pt HxPt HxGradual onset varying Gradual onset varying degrees of anterior hip degrees of anterior hip painpainP i ↑ i iP i ↑ i i ↓↓ ↑↑

Tony’s Pizza

Pain ↑ activity, Pain ↑ activity, ↓ rest, ↓ rest, ↑ ↑ timetimeA.M. stiffness < 60 min.A.M. stiffness < 60 min.ObesityObesity> 40 y.o.> 40 y.o.

Osteoarthritis of hipOsteoarthritis of hip

Physical examinationPhysical examinationGait: lurching/lateral Gait: lurching/lateral shifting=intrashifting=intra--articular articular problemsproblemsA i hi i iA i hi i i

Measure leg lengthMeasure leg lengthuneven iliac crestsuneven iliac crests

Patrick’s maneuver: Patrick’s maneuver: Faber Faber

Anterior hip, groin pain, Anterior hip, groin pain, crepitus on ROMcrepitus on ROMSevere Restriction: Severe Restriction: Internal rotation<15 Internal rotation<15 °°, , flexion<115flexion<115°°

Note end point stiffnessNote end point stiffness

Pt flex hip, ext rotation, Pt flex hip, ext rotation, affected heel, to knee, affected heel, to knee, compress knee laterallycompress knee laterally

Note:+ pain in hip or S.I. Note:+ pain in hip or S.I. joint joint

7/2/2008

8

P.E. & TxP.E. & Tx

Treatment: xTreatment: x--ray or empiricray or empiricWeight lossWeight lossBone DensityBone DensityMinimiz t b rinMinimiz t b rinMinimize wt bearingMinimize wt bearingPassive stretchingPassive stretching

NSAIDS 7NSAIDS 7--10 days10 days

Hip bursitis Hip bursitis

Inflammation of trochanteric bursaInflammation of trochanteric bursaResults from ↑ movement of glut medius over femurResults from ↑ movement of glut medius over femur

Pt HxPt HxLateral hip pain, difficult to sleep on affected sideLateral hip pain, difficult to sleep on affected sidep p , pp p , pGait abnormalities ↑ bursitisGait abnormalities ↑ bursitis

↓ ROM L↓ ROM L--S spineS spineUneven legsUneven legs

Up/down headUp/down headOsteoarthritis kneeOsteoarthritis kneeSprained ankleSprained ankle

7/2/2008

9

Hip bursitisHip bursitis

Physical examinationPhysical examinationObservation of pt Observation of pt climbing onto exam table climbing onto exam table demonstrates:demonstrates:

Hi fl iHi fl i

Identifying the bursaIdentifying the bursaFlex hip to 90 degrees, Flex hip to 90 degrees, sitting or lat. decubitussitting or lat. decubitusIdentify superior aspect Identify superior aspect of trochanteric process of trochanteric process Hip flexionHip flexion

Quad and iliopsoas Quad and iliopsoas musclesmusclesNl LNl L--S nervesS nerves

Obese patientsObese patientsFind iliac crestFind iliac crest8 8 “ under top of pelvis“ under top of pelvis

ppPoint tenderness Point tenderness prominent part femur, prominent part femur, over bursaover bursa11" " posterior/superior to posterior/superior to gr trochantergr trochanter

Nl ROM, pain abductionNl ROM, pain abduction

Hip bursitisHip bursitis

TreatmentTreatmentRadiographRadiograph

Acute pain: r/o fxAcute pain: r/o fxModerate to severe chronic painModerate to severe chronic painNl articular width 4Nl articular width 4--5mm 5mm

MRI: osteonecrosis, infection, tumor, fxMRI: osteonecrosis, infection, tumor, fxLocal anesthetic block, Local anesthetic block, ↓pain=+ dx↓pain=+ dxSteroid injection: procedure manualsSteroid injection: procedure manualsOrthotics Orthotics

Aseptic necrosisAseptic necrosis

Osteonecrosis from vascular compromise leading to Osteonecrosis from vascular compromise leading to bone death of femoral head within 3bone death of femoral head within 3--5 yrs5 yrsPt HxPt Hx

3030--60 y.o. male to female 4:1 60 y.o. male to female 4:1 TraumaTrauma

http://www.emedicine.com/orthoped/TOPIC430.HTM

Atraumatic: Etoh (>400ml/wk), corticosteroid use, Atraumatic: Etoh (>400ml/wk), corticosteroid use, idiopathic, Lupus, pancreatitis, sickle cellidiopathic, Lupus, pancreatitis, sickle cell

Physical examinationPhysical examinationGroin, buttock, femur pain with wt bearing & restGroin, buttock, femur pain with wt bearing & rest1/3 night pain, 50% bilateral involvement1/3 night pain, 50% bilateral involvement

Dx: 3Dx: 3--5 yrs for radiograph changes, may be too late 5 yrs for radiograph changes, may be too late think MRI, bone scanthink MRI, bone scan

7/2/2008

10

Osteonecrosis of the hipOsteonecrosis of the hip

http://www.emedicine.com/orthoped/TOPIC430.HTM

Treatment: Modification of risk factors, staging and surgery

Knee Knee

ThinkThinkLigament/meniscusLigament/meniscusPatella malalignmentPatella malalignmentSeptic, inflammatory, or Septic, inflammatory, or osteoarthritisosteoarthritisBursitisBursitisTendonitisTendonitisSynovitisSynovitisReferred: Hip, spine,Referred: Hip, spine,

7/2/2008

11

Patellofemoral syndromePatellofemoral syndrome

Chondromalacia patellaChondromalacia patella#1 cause knee pain < 45 y.o. #1 cause knee pain < 45 y.o. active, female>maleactive, female>maleCauses Causes

Lateral subluxation of patella, Lateral subluxation of patella, pparthritis, trauma, patella alta arthritis, trauma, patella alta

Uneven trackingUneven trackingPt HxPt Hx

Anterior knee painAnterior knee painPain rising from sitting to Pain rising from sitting to standing standing Pain in flexion, clickingPain in flexion, clicking

Patellofemoral syndrome Patellofemoral syndrome

Physical examinationPhysical examinationFemales wide Q angleFemales wide Q anglePain to compression of Pain to compression of patella against femurpatella against femurCrepitus with flexionCrepitus with flexionTight hamstringsTight hamstrings+ Apprehension test+ Apprehension test

Laterally displace medial Laterally displace medial patellapatellaTighten quadricepsTighten quadriceps

Iliotibial band syndromeIliotibial band syndromeRunners kneeRunners knee

Hip or knee painHip or knee painThick connective tissue, fascia of tensor fascia lata & Thick connective tissue, fascia of tensor fascia lata & vastus lateralisvastus lateralisCrosses lateral femoral epicondyle or prox lateral tibial Crosses lateral femoral epicondyle or prox lateral tibial C osses ate a e o a ep co dy e o p o ate a t b aC osses ate a e o a ep co dy e o p o ate a t b a=friction=frictionPt HxPt Hx

Runners often increased training on sloped surfacesRunners often increased training on sloped surfacesPoor stretchingPoor stretchingUneven leg lengthUneven leg length

Pain lateral hip or femoral epicondyle Pain lateral hip or femoral epicondyle

7/2/2008

12

Iliotibial band syndrome Iliotibial band syndrome

Physical examinationPhysical examinationLocal tenderness lateral femoral epicondyle or Local tenderness lateral femoral epicondyle or anterior to origin of the LCLanterior to origin of the LCLPain increases with flexion and extension Pain increases with flexion and extension Foot pronationFoot pronation

TreatmentTreatmentAvoid side hill running or downhillAvoid side hill running or downhillIce, stretchingIce, stretchingOrthoticsOrthotics

Knee effusionsKnee effusions

Multiple intraarticular causes: trauma, infection, Multiple intraarticular causes: trauma, infection, gout, osteoarthritisgout, osteoarthritisHx: consistent with each differentialHx: consistent with each differential

K i hK i hKnee tightnessKnee tightnessPhysical examination: Extend knee, milk tissue Physical examination: Extend knee, milk tissue inferiorly from distal quad , + fluid wave medial inferiorly from distal quad , + fluid wave medial patellapatella

Diminished flexionDiminished flexion

7/2/2008

13

Evaluation of synovial fluid Evaluation of synovial fluid

NoninflammatoryNoninflammatory

2000wbc/mcl2000wbc/mcl

InflammatoryInflammatory

22--75,000 75,000 wbc/mclwbc/mcl

PurulentPurulent

>100,000 WBC>100,000 WBC

RBCRBC MicroscopicMicroscopic

DJDDJD R.A.R.A.GoutGout

InfectionInfectionBacterialBacterial

TraumaTraumaACLACL

Monosodium Monosodium UrateUrateGoutGout

Ank Ank SpondSpondT.B.T.B.

Bacterial Bacterial culturescultures

ACL ACL Meniscus Meniscus MCLMCLTibial Tibial plateau fxplateau fx

Anterior cruciate ligament sprainAnterior cruciate ligament sprain

Uncommon unless traumaUncommon unless traumaCutting, deceleration, “pop”Cutting, deceleration, “pop”

Grade 1: Microscopic tear, tenderness, decreased Grade 1: Microscopic tear, tenderness, decreased ROM l t thROM l t thROM, nl strengthROM, nl strengthGrade 2: Laxity with end pointGrade 2: Laxity with end pointGrade 3: No end point of laxityGrade 3: No end point of laxity

ACL ACL

Pt Hx: Pt Hx: Acute: swelling after Acute: swelling after injury p 2injury p 2--4 hrs4 hrs“My knee gives out.”“My knee gives out.”

Physical examinationPhysical examination+ Lachman sign+ Lachman sign+Anterior drawer sign+Anterior drawer signHemarthrosisHemarthrosisPoss. Meniscus, mcl tearPoss. Meniscus, mcl tear

7/2/2008

14

ACL specialty testsACL specialty tests

Lachman test Lachman test Pt is supine with affected knee 20 flexionPt is supine with affected knee 20 flexionGrasp femur with one hand, tibia with the otherGrasp femur with one hand, tibia with the otherApply anterior displacement, note laxity, compareApply anterior displacement, note laxity, compare

Anterior Drawer testAnterior Drawer test90 flexion of knee, 45 flexion of hip90 flexion of knee, 45 flexion of hip“Sit” on pt’s foot “Sit” on pt’s foot Grasp posterior tibia with both hands, use index/long fingers to relax Grasp posterior tibia with both hands, use index/long fingers to relax hamstringshamstringsCompareCompare

P.T. Quad strengthening P.T. Quad strengthening Refer for arthroscopy or MRI Refer for arthroscopy or MRI

Post surgical muscle atrophyPost surgical muscle atrophy

Grading muscle testsGrading muscle tests

Grade 5Grade 5 NormalNormal No resistance & full ROM No resistance & full ROM against gravityagainst gravity

Grade 4Grade 4 GoodGood Some resistance full ROM Some resistance full ROM against gravityagainst gravityg g yg g y

Grade 3Grade 3 FairFair Can hold muscle against Can hold muscle against gravity gravity -- resistanceresistance

Grade 2Grade 2 PoorPoor Full ROM with no gravityFull ROM with no gravity

Grade1Grade1 TraceTrace Slight contractility no ROMSlight contractility no ROM

Grade 0Grade 0 ZeroZero No contractilityNo contractility

7/2/2008

15

uadweakness.mo

Medial meniscus injuryMedial meniscus injury

Cartilage: semi lunar spacers between femur and tibia, stabilizersCartilage: semi lunar spacers between femur and tibia, stabilizersCollision Sports injury striking lateral aspect, often with MCL Collision Sports injury striking lateral aspect, often with MCL Physical examinationPhysical examination

Pain of medial joint line often with hyperflexion/extention, external Pain of medial joint line often with hyperflexion/extention, external rotation rotation Palpate joint lines while internally/externally rotating knee, note pain or Palpate joint lines while internally/externally rotating knee, note pain or clickclickApley’s test: pt is prone, knee at 90 degrees, externally rotate with Apley’s test: pt is prone, knee at 90 degrees, externally rotate with compression of foot translating pressure to medial meniscuscompression of foot translating pressure to medial meniscusMcMurray: Pt is supine. Flexion of hip and knee, heel near buttock. With McMurray: Pt is supine. Flexion of hip and knee, heel near buttock. With hand on medial joint line and external rotation of the foot, extends leg. hand on medial joint line and external rotation of the foot, extends leg. These tests have low sensitivity and specificity. MRI or arthroscopy These tests have low sensitivity and specificity. MRI or arthroscopy

7/2/2008

16

Osgood Schlatter’s DiseaseOsgood Schlatter’s Disease

Traction of patella Traction of patella tendon on the tibial tendon on the tibial tuberosity=periostial tuberosity=periostial inflammationinflammationAdolescent males 10Adolescent males 10 1616

Physical examinationPhysical examinationPain, resisted extensionPain, resisted extension+/+/-- swelling t.t.swelling t.t.Bony prominenceBony prominence

Adolescent males 10Adolescent males 10--16 16 y.o., jumping sports y.o., jumping sports Pt HxPt Hx

Insidious, low grade pain Insidious, low grade pain of tibial tuberosity after of tibial tuberosity after exertion, acceleration & exertion, acceleration & deceleration deceleration

Osgood SchlatterOsgood Schlatter

TreatmentTreatment22--3 weeks of avoidance3 weeks of avoidance

Occ. longerOcc. longer

Substitute exerciseSubstitute exercise

Pes Anserine BursitisPes Anserine Bursitis

“Duck or goose foot”“Duck or goose foot”--gracilis, sartorius, gracilis, sartorius, semitendinosis muscles meet, semitendinosis muscles meet, 5 cm below medial joint line5 cm below medial joint line

Causes: tight medial Causes: tight medial

Pt HxPt HxPain with stair ascensionPain with stair ascensionPoint tenderness of bursaPoint tenderness of bursaSwellingSwelling

Physical examinationPhysical examinationgghamstrings, knee or heel hamstrings, knee or heel valgus, tibial tortionvalgus, tibial tortionOverweight female wide Q Overweight female wide Q angle, 50angle, 50--80 y.o. 80 y.o.

Degenerative joint diseaseDegenerative joint disease

Physical examinationPhysical examinationTender localized areaTender localized areaPain on resisted medial Pain on resisted medial hamstring testhamstring testPain resisted flexion/extension Pain resisted flexion/extension with internal rotation of tibiawith internal rotation of tibia

Treatment: Biomechanical, Treatment: Biomechanical, weight lossweight loss

7/2/2008

17

Sprain of the Anterior Talofibular Ligament

ATF sprainATF sprain

85% of ankle sprains=lateral instability85% of ankle sprains=lateral instability72% pt’s report symptoms 672% pt’s report symptoms 6--18 mo later18 mo later

?Advice?AdvicePt HxPt Hx

Flexion, inversion injury, rolling in, off the curbFlexion, inversion injury, rolling in, off the curbPain increases with activity, swelling, decreased Pain increases with activity, swelling, decreased proprioception proprioception

RadiographsRadiographs

Ottawa rules: when to xOttawa rules: when to x--ray ankleray ankleInability to walk 4 stepsInability to walk 4 stepsPoint tenderness tip of lateral or medial malleolusPoint tenderness tip of lateral or medial malleolusP in n i l r r b 5P in n i l r r b 5thth m t t r lm t t r lPain navicular or base 5Pain navicular or base 5thth metatarsalmetatarsal

Order AP, Lateral, Mortise, medial oblique of Order AP, Lateral, Mortise, medial oblique of footfoot

7/2/2008

18

ATFATF

Always test achillesAlways test achillesThompson test: pt kneels on a chair, squeeze calf, expect Thompson test: pt kneels on a chair, squeeze calf, expect plantar flexion in normal examination plantar flexion in normal examination

TreatmentTreatmentIceIceAircastAircastPhysical therapyPhysical therapyROM: active, alphabet T.I.D. passive, towel stretchROM: active, alphabet T.I.D. passive, towel stretchStrengthening: Graduate to toe raise, single leg standsStrengthening: Graduate to toe raise, single leg stands

Pes CavusPes Cavus

CongenitalCongenitalPrefer heelsPrefer heelsInflexible, tight gastrocs, Inflexible, tight gastrocs, abnormal overload, abnormal overload, pressure pointspressure pointspressure pointspressure pointsPhysical examinationPhysical examination

Foot inflexible, no Foot inflexible, no dorsiflexion over neutraldorsiflexion over neutralHammer toesHammer toesCallusesCalluses

Pes CavusPes Cavus

StretchingStretchingBoard at 35 degreesBoard at 35 degrees

Paring callusesParing callusesOrthoticsOrthoticsOrthoticsOrthotics

7/2/2008

19

Plantar fasciitisPlantar fasciitis

Plantar fasciitisPlantar fasciitis

Nonathletic or athletic populationNonathletic or athletic populationRunnersRunnersObesity, prolonged standingObesity, prolonged standing

Pinpoint, knifelike pain medial plantar aspect of heel Pinpoint, knifelike pain medial plantar aspect of heel ddpadpadWorse in the a.m. or starting exerciseWorse in the a.m. or starting exercise

Causes: Causes: Tight achilles, pulls on gastrocnemius and weak attachment: Tight achilles, pulls on gastrocnemius and weak attachment: the fasciathe fasciaExcessive pronation or supinationExcessive pronation or supination

7/2/2008

20

Morton NeuromaMorton Neuroma

Interdigital entrapment of the nerve base of the Interdigital entrapment of the nerve base of the 3, 43, 4thth toestoes

Females 8:1, high heels result in foot compression Females 8:1, high heels result in foot compression and forward weightand forward weightand forward weightand forward weight

Physical examination Physical examination Neuropathy with compression of nerve at base of 3, Neuropathy with compression of nerve at base of 3, 44thth metatarsals metatarsals