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MSK Notes
MSK Notes
MSK Notes
Mobility:
Stretching = thought to increase ROM about a given joint
- attributed to changes in the stretch re ex (traditionally)
- Protective mechanism -> muscle contracts in response to being stretched €“
- Ruled out as a 'potential mechanism' - mechanisms include changes in:
1. ability to tolerate stretch
2. Viscoelastic properties of muscle
Techniques:
- Dynamic (ballistic) = repetitive bouncing (oldest)
- Static = stretch to point of discomfort & hold for an extended time (3-4 x 15-30s) - PNF =
alternating contractions, relaxations +stretches - 10s push +10s relax
- Neural tissue = stretching of nerve tissue or surrounding tissue impeding nerve.
'No clear evidence about which technique is most e ective for improving ROM'
Static + PNF = clinically & Ballistic = healthy athletes
Alternative Techniques:
1. Pilates: develop self-image via increased posture + coordination + exibility.
- Concentrates on body alignment + muscle lengthening endurance + strength without stress on
the lungs and heart.
- Basic principles =
1- increase awareness of bodies as single integrated units
2- increase body alignment & breathing e ciency of movement.
3- increase e ciency of movement
2. Yoga: reduce stress - combined mental + physical approaches
- uniting body + mind
- Caution = needed - positions can be dangerous (for inexperienced individuals)
- Slow + deep + diaphragmatic breathing = important to calm body & produce endorphins
Triggers: Used to relieve soft tissue from the abnormal grip of tight fascia
Fascia = CT surrounds muscles + tendons + nerves + bones + organs.
- Composed: collagen + elastic bres.
- During mvt = must stretch + move freely.
- Damaged/in amed fascia impairs movement
- can soften & release with gentle pressure (over a long period of time).
Acute cases = resolve in just a few treatments. Occasionally single treatment
Longer cases = take longer to resolve.
- Typical treatment is 3 x /wk - done manually using a foam roller/ball.
Injury:
When structure = damaged - normal function is compromised
- Adaptive/compensatory changes occur, changing force distribution + movement
- Leads = tissue overload, decreases performance & predictable injury patterns
-E.g. di erent force distribution, activation patterns, length changes etc
OKC Knee Extension: foot is not xed or not in contact with a surface
- allows lower leg move independently - creates shear + compression on joint.
- Modifying exercise reduces these forces + manage pain while still targeting quadriceps
strength.
Incorporating additional external resistance (Thera bands):
- placing resistance bands, you alter forces acting on joint and alleviate pain.
- if shear force causes discomfort, add an extra thera band to reduce shear force by changing
direction or magnitude of resistance.
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CKC Knee Extension: foot is xed or in contact with a surface
- Terminal knee extension exercise in a CKC provides bene ts:
- as you extend your knee
- involves hip extension + activates hamstrings along with the quadriceps.
- This co-contraction of the quads and hams enhances joint stability at knee & hip
- Engaging hams = counterbalance anterior pull on tibia caused by the quads.
- Bene cial for reducing shear forces + minimising discomfort in knee joint.
- Additionally adding trunk exion, you can activate posterior chain, including the hamstrings,
which can assist in maintaining an upright posture and engaging more muscle groups.
Step ups: Lateral, forward & backward step-ups = widely used CKC exercises
- Lateral step-ups = used more clinically
- Step height can be adjusted to patient capabilities (up to 20cm)
- > 20 cm create a large exion moment at knee, increasing anterior shear force and lowering
hams cocontraction.
- can produce increased join tshear forces compared to stepping exercise.
- Hams contraction appears to be insu cient to neutralise shear force produced by quads.
Surgical Tubing:
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- Have created a means of safely strengthening terminal knee extension
- NB:OKC shear greatest between 0-30 degrees exion
- Ant. resistance at femur produces ant. shear of femur & eliminates ant. tibial translation
- Performed in 0-30 degrees also lowers knee exion moment, further lowering ant. tibial shear
- Rubber tubing produces an eccentric quad contraction when moving to knee exion
- Weightbearing terminal knee ext. with tubing increase the quads EMG activity
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WEEK 6: Hip
Adductor-Related Groin Strains:
- Pain on palpation of tendons/insertion
- Groin pain during resisted adduction
1st deg: pain but minimal loss of strength and
minimal restriction of motion
2nd Deg: tissue damage that compromises the
strength of the muscle, but not including complete loss
of strength and function
3rd Deg: complete disruption of tendon (complete loss of function of muscle)
- Incidence = known - Athletes play --> minor groin pain.
- common = ice-hockey + soccer (often adductor/iliopsoas)
Signs/Symptoms:
- Gait = Antalgic (€˜against pain€™) gait + Uneven stride cadence/length
- Muscle spasm + tenderness + swelling
- Stress to muscle = determines which muscle is injured
Pain responses in one of the following movements:
1. hip ex. + knee ext. (iliopsoas)
2. hip ex. + knee ex. (rectus femoris)
3. hip ex. + lateral rot. + abd. + resisted knee ex. (sartorius)
4. hip add (adductors)
Potential Mechanisms:
- Extended beyond limit OR rapid forceful contraction
- Falls, direct blow to muscle, overstretching OR overuse
Risk Factors:
1. Muscle => tightness/weakness/imbalances/prior injury/poor WU/workload spike.
2. Association btw strength, exibility & MSK strains
- low abd ROM among injured soccer players
- low add muscle strength
'Adductor : Abductor' strength ratio in NHL players
- 95% = asymptomatic
- 78% = symptomatic
Assessment:
ROM:
- Flex/Ext
- Add/Abd
- IR/ER
Strength (HHD):
- Hip Abd =
- Squeeze Test = sphygmomanometer cu placed b/e knees and squeeze hard
- highest pressure displayed and site of pain experienced was recorded
- IR/ER = assessed in supine position - dynamometer placed on medial malleous
HHD Considerations:
1. Long vs Short Lever:
- lever positioned = 5 cm proximal to joint center for knee/ankle joint assessments
- placement helps that force exerted by subject is captured by the HHD.
2. Learning E ect:
- No. of trials required before reaching a plateau varies among individuals.
- Some achieve consistently within a few trials - others require more practice.
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- Speci c no. of trials needed reach a plateau depend son factors such as:
- complexity of the task
- subject's familiarity with HHD + their motor skill level.
3. Subject Stabilisation:
- minimise extraneous movements that a ects accuracy of the measurements. - some
require to stabilise themselves (holding a bench),
- others require external stabilisation provided by the tester.
- choice of subject stabilisation method depends speci c protocol being used.
4. Intra-inter tester reliability:
Intra-tester reliability = Single tester should be able to obtain consistent values.
Inter-tester reliability = Di erent testers should be able to obtain consistent values
5. HHD Reliability
in uenced by various factors:
- technique
- calibration
- subject cooperation
- positioning of HHD relative to the joint being assessed.
To have reliable measurements = protocols, training, calibration should be followed.
Rehab: -> Steps = in ammation/Pain -> ROM -> Stability -> Functional Training
Type I etiology:
- caused during high speed running/mvts such as kicking/twisting/jumping/hurdling
- common = long head of biceps femoris at proximal junction
- Swing phase (sprinting) - hamstrings eccentrically decelerate tibia before foot strike
Type II etiology:
- Generally caused during stretch related movements and ballistic limb actions
- Commonly seen in dancing and gymnastics
- Cause of injury is often an excessive stretch into hip exion
- Proximal free tendon of semimembranosus (near the ischial tuberosity)
Prognosis:
Time (days) to jog pain free is the greatest predictor of time to return to play (RTP) post HSI:
- 1-2 days -> <2 weeks to RTP
- 3-5 days -> >2 weeks to RTP
- >5 days -> >4 weeks to RTP
- More proximal the injury in type I HSI = > time to return to pre-injury level
- Length of the hamstring tear correlates with time to RTP
Rehab:
Phase I acute =
First 48 hours
1. Minimising scar tissue formation (may reduce changes of re-injury
2. Simple analgesics
3. Light, frequent pain-free muscle contractions (prior to RICE)
4. RICE
Before moving into sub-acute phase:
1) Pain free walking
2) Adequate force with resisted muscle contraction
Phase II sub-acute/conditioning =
- Stretching surrounding structures
- Soft tissue treatment
- Myofascial release
- Neural mobilisation (hamstring stretch position w/knee exed + gentle cervical
ex)
Phase RTP =
- Completion of progressive running program
- Full ROM L = R: PROM + AROM straight leg raises
- Pain free maximal iso contraction
- 90-95% of ecc strength of contralateral limb
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WEEK 7: Knee
ACL Rupture:
- Mechanism = hyperext., valgus, ant. tibial translation, rot.
- Clinical = Lachman, pivot shift
- Conservative Tx for older pop. with low demands who do not have instability
- Surgery: allograft, autograft (patellar tendon, hamstrings)
- Traditional vs. accelerated protocol
- Outcomes: very good short-term, knee OA in long-term
PCL Rupture:
- Dx = Posterior draw of up to 25mm, €˜sag€™ sign
- Lax capsule posterior + collateral ligaments ‰ provide posterior displacement resistance
- Mechanism = blow to ant. tibia (dashboard injury) or hyper ex.
- Other ligaments commonly torn
- If isolated injury €“ conservative tx
- Surgical repair technically di cult
Collateral Ligaments:
- MCL: strong at band from medial epicondyle of femur -> medial condyle of tibia and medial
side of tibial shaft
- LCL: rounded cord from lateral epicondyle of femur to lateral head of bula
- MCL tear: valgus stress
- Conservative treatment
- 98% return to sport
- May have instability afterwards
- LCL tear: v.rare
Meniscus:
- Mechanism = loading + rotation
- Types = bucket-handle, posterior horn, anterior horn, horizontal (degenerative)
- Medial tears = common than lateral
- Lat. = common with ACL tears as the lat. tibia plateau subluxates anteriorly
Goal: preserve as much of the healthy meniscus as possible
- Vascular regions may heal themselves
- Surgery:
- Arthroscopic meniscectomy
- Repair
- Transplantation
Considerations:
1. Mechanism of injury
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2. Structures damaged
3. Client€™s physical activity prior to injury
4. Stairs in home?
5. Return to work/sport
6. Co-morbidities
7. Long-term outcomes/goals
- Incidence of graft failure 3-6%
- Re-injury most likely within 12 months post surgery
- Risk of ACL tear ipsilateral or contralateral knee 5-10x higher than uninjured
- Post ACL-recon kinematics of gait ‰ˆ ruptured ACL than intact ACL
Results:
- Right knee full ACL rupture, MCL Grade 2 tear and bucket handle tear of meniscus
- GP => referral for orthopaedic surgeon
- Orthopaedic surgeon orders MRI for left knee => Full ACL rupture (old injury)
- 2 weeks o work to reduce swelling, minimal use of motorcycle as transport
Prehab + ExRx:
- Surgical outcomes are improved with the knee in as good condition as possible.
- Goal: similar strength and ROM as uninjured leg
- Recovery time is reduced
- Exercise prescription similar to that of rehabilitation
ExRx:
1. Increasing ROM
2. Increasing Strength
Prehabilitation:
- Aims: minimise swelling, increase ROM/ exibility, increase strength & balance
Initial exercises:
- Heel slides
- Isometric quad contractions
- Single leg raise - supine
Progression:
- Single leg raise standing with then w/out support
- Mini squats
- Heel raises
- Hamstring stretches
Surgery:
- Options:
1. No surgery, just rehabilitation exercise
2. Partial meniscectomy
3. ACL reconstruction and meniscectomy
- Client chose meniscectomy
- Home based exercises is all that is necessary, no requirement for physio treatment.
Conservative Rehab:
- Goals: Restore full ROM/strength & Control in ammation
Week 1:
- Isometric quads, hamstring and calf muscles
- SLR
- Heel slides
Week 2:
- SLR all planes
- CKC up to 90°
- Start resisted lower extremity ex
- Balance and proprioception supported progress to unsupported bilateral
- Cycling no tension increase time gradually
- Once full weight bearing start treadmill
- Flexibility/stretching ex€™s
Week 3:
- Flexibility/stretching (avoid crouch and full squats)
- Weight bearing CKC
- Lower extremity resisted ex€™s
- Mini squats up to 90° exion
- Balance txn bilateral progress to unilateral
- Stairs
Avoid: running, jumping, twisting , if swimming no breaststroke
Week 4:
- Continue strength, functional proprioceptive and endurance txn
- Start jumping, light running
Rehab:
Post-ACL Surgery Rehab:
- 2x recovery time
- If ACL = repaired using hamstring tendon - avoid hamstring curls/stretches 2 wks
- If patella tendon = used in ACL reconstruction then consider knee pain during exercises up to
6-12mths postop when kneeling or in full knee ex.
Week 6-9:
- Full pain free ROM
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- Gait training
- Lower limb Strength
- Proprioception
- CV
Week 9-12:
- Continue ROM
- Lower limb Strength
- Commence ecc hamstring exercise
- Progress glutes and calves
- Progress exercises focus on dynamic strength and eccentric quad control
- Proprioception progress to dynamic
- CV
- progress bike time and distance
- Treadmill incline walking (avoid jogging)
- Commence jogging in pool -> by end week 12 post-op light jogging on land
Post-ACL Reconstruction:
- Return to sport
- Single leg hop for distance
- Co-contraction
- Carioca
- Shuttle run
Preventative Measures:
Control of the limb in pivoting and landing and reducing functional valgus
- Increase exion of knee and hip
- Eccentric knee control
Balance of power + recruitment of quads&hamstrings crucial for knee stability
- Hamstring activation to dynamically stabilise jknee and prevent ant. tibial displacement
- Balance training
- Prevention programs demonstrated an ovrall +ve e ect in reduced ACL injuries
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WEEK 9: Ankle
Ankle Stability:
Ankle laxity dependant on joint position
- DF position has the least ankle joint laxity
- Talar geometry
- Show a strong degree of symmetry when comparing limbs but they have been shown to have up
to 7.5% di erence in surface area and volume
Talar positioning €“ how to palpate for the talus?
What e ect maytalar positioning have on ligaments of the ankle?
Ankle Injuries:
Lateral Ankle Injury (Inversion Sprain): most common during sport
- Mechanism: athlete's COG = shifted over the lat. border of weight-bearing leg, causing the ankle
to roll inward at a high velocity
- Dx: mechanism of injury, oedema, site of pain/discomfort
- Anterior talo bular ligament most likely involved
- Being the primary stabiliser, contributes to ongoing instability
Management =
Acute:
- gait support = use of an Aircast ankle brace for Tx lat. ligament ankle sprains
- produces signi cant improvement in ankle joint function at both 10 days
- and 1 month compared with standard management with elastic support bandage
Rehab Progression: AROM, stretching, strengthening and proprioception/balance
Pott€™s Fracture:
- Mechanism: Foot forcibly moved laterally - violent abduction mvt
- Fracture of lateral malleolus OR/AND medial malleolus
- Lateral talus knocks against lateral malleolus
- Inferior tibio bular ligaments ruptured
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- Deltoid ligament sprain -> talus rotate about long axis -> potential for fracturing posterior
margin of tibia
- Reduction if bones are not aligned, pins/plate and screws
- Plaster cast 8-12 weeks
- If bony and soft tissue damage excessive -> fusion of joint
Management =
Tendinopathy
- Eccentric Ex: 3x 15 reps 2xdaily 12 weeks
- Decreased pain
- Improved function
- E ects last up to 1yr
- Stretching
- Rupture
- Surgery
- Post physio tx -> same treatment as for tendinopathy
- Residual problems persist for decades - 72% of unable to return to previous level of activity
- Fear of ankle giving way - been reported to worsen over time rather than improve
- Likely development of impairment + activity limitation is independent of severity of initial injury
- Not con ned to injured limb - problems reported in contralateral ankle of 85% of people who
develop CAI after unilateral sprain.
Gait:
- More inverted before during and immediately after initial contact
- Decreased toe clearance during terminal swing phase
- Poor dorsi exion ROM in gait among individuals with CAI = risk factor for sprains
Innovation:
- Unstable ankles associated with:
1. Lower inversion proprioception
2. Higher concentric plantar exion strength at faster speeds
3. Lower eccentric eversion strength at slower speeds
- Muscle actions important for protection against ankle sprains
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