Lower Extremity
A 17-Year-old female soccer player presents to the clinic with localized anterior hip pain that becomes more symptomatic with flexion and internal rotation. She specifies feeling Joint stiffness and worsening symptoms with prolonged hip flexion when seated in class.
What could be the probable differential diagnosis? What special test could you perform to rule in or rule out?
Femoral acetabular impingement and FADIR
What are the 5 salter-Harris fracture classification types?
SALTER (straight, above, lower, through, erased)
I- Physis
II- Physis + Metaphysis
III- Physis + Epiphysis
IV- Physis + Metaphysis + Epiphysis
V- Crush Fracture
A 15-Year-old male presents with tenderness and bruising at the anterior superior lateral aspect of his pelvis. He suggests this may have been caused by a "hard hit" from his football game 2 days prior. He presents with all normal MMT, AROM, PROM for all hip movements and is only symptomatic with direct touch to the affected area.
What is the possible diagnosis?
Hip Pointer - iliac crest contusion
What special test could you use to rule in or rule out a TFCC tear? What S/S may you see with TFCC tears?
TFCC grind
S/S: Tenderness at ulnar styloid and pain with full passive supination
What are common causes for PFPS?
- Muscle imbalances (Quadricep group)
-Wide Q Angle
- Weak Glute medius or Excessive foot pronation
- Ostechndromalacia (all can eventually lead to this)
What are the most common avulsion fractures in the adolescent population?
Hip- ASIS, Lesser Trochanter, AIIS
Knee- Tibial tuberosity (not as common)
Ankle/Foot - 5th metatarsal (pseudo-jones fracture)
What is the beighton-Horan index?
Congenital ligament laxity assessment
1. Hyperextension of knees >10 degrees
2. Hyperextension of elbows >10 degrees
3. Passive flexion of thumbs to forearm
4. Passive extension of 5th digit >90 degrees
5. Forward trunk flexion + palms resting on the floor
What would be the best treatment intervention for a snapping hip syndrome diagnosis?
Eccentric loading for tendinous remodeling to properly lengthen and model collagen fibers (becomes stronger)
What makes up the terrible triad at the elbow?
1.) Fracture of radial head
2.) Radial head dislocation
3.) Coronoid process fracture
What treatment interventions can be used for PFPS?
- VMO biofeedback
- McConell Patella taping (4 week intervention)
- Patellar joint Mobs + Stretching lateral structures
What are the 3 major rules that make up the Ottawa Ankle rules?
1.) Inability to bear weight immediately after injury and in the ED (can't take 4 steps)
2.) Bone tenderness at tip of medial/lateral malleoulus or posterior tip of tibia/fibula
3.) Bone tenderness at navicular or proximal 5th metatarsal
A 10-year-old male baseball player presents with proximal shoulder pain that is tender to the touch along the lateral superior portion of the arm. His father mentioned that the pain was very minimal when he first started pitching and after a few months it has now progressed to severe pain and is unable to finish practice sessions.
What is a possible diagnosis? Would you treat, treat and refer, or refer out exclusively?
Little league shoulder- widening and eventual fracture of the proximal humeral growth plate.
REFER OUT!
Make sure child stops activity until further notice and is placing ice on shoulder.
16-year-old Female patient presents with a ACL tear diagnosis after having participated in a after school volleyball tournament with a couple of friends. MOI consists of landing forcefully with a rotational force after having jumped up to return a serve during the match. She is most likely going to perform prehab to have a more improved prognosis.
What are the 3 major goals for ACL prehab?
1.) Full terminal knee extension (TKE)
2.) Little to no extensor lag
3.) Little to no effusion
What structures are commonly involved with Internal impingements?
All rotator cuff muscle
Portion underneath the tendon will rub on the glenoid rim and progressively irritate tendon.
What is the difference between Sinding-Larsen and osgood shlatter?
Osgood Schlatter's is characterized by traction at the tibial tubercle via the patellar tendon
Sinding-Larsen is characterized by osteochondrosis of the patellar tendon at the inferior patellar pole
What joint and particular motion is greatly affected with someone who has a tarsal coalition diagnosis?
Subtalar joint (STJ) ability to perform pronation and supination due to fusion
17-year-old male lacrosse player presents to you with superior arm numbness and is very hesitant to perform any movement. Individual is held in an internally rotated and adducted position. Pt describes his arm as feeling like "dead weight".
What special test could you perform to rule in or rule out a diagnosis? What other possible signs/symptoms may also be present?
Sulcus sign (MDI) -used to access for a possible GH dislocation
Apprehension test (anterior capsular laxity)
Numbness may be possibly related to axillary nerve involvement. Perform dermatomal testing.
S/S= muscular spasms
What is the tanner staging system?
Method used to access growth remaining in long bones
What structures are commonly involved in external impingements?
1. Supraspinatus
2. Infraspinatus
3. Coracoacromial ligament
All can become trapped in subacromial space
What are the 6 P's of compartment syndrome?
Compartment syndrome: excessive pressure build up at a muscle causing decreased blood flow/oxygen
1. Pain
2. Poikilothermia (Cold limbs)
3. Paresthesia (pins and needles)
4. Paralysis (loss of voluntary muscle function)
5. Pulselessness
6. Pallor (pale/white appearance)
What is the common MOI for a high ankle sprain? (syndesmotic ligament injury)
Full dorsiflexion + Tibial External rotation + Eversion
What is the difference between a FOOSH injury compared to Gymnast wrist?
What about S/S? What about positioning for Radiographic imaging?
FOOSH- common cause of a SCAPHOID fracture.
S/S: Snuffbox tenderness and pain with radial deviation + thumb axial loading
x-ray: A-P view in ulnar deviation
Gymnast wrist- progressive overloading to distal radius growth plate
S/S: diffused wrist pain + physeal tenderness
x-ray: NONE
A 19-year-old male rugby player presents to the clinic with post operative ACL reconstruction and medial meniscal meniscectomy. What are most likely his weight bearing precautions?
ACL- Weight bearing as tolerated
but due to the meniscal repair, this individual will be NON-WEIGHT BEARING for 6 weeks to avoid compressive forces and allow healing time.
What is commonly also seen with a bankart lesion with anterior capsular laxity at the shoulder?
Hill Sachs Fracture due to the rebound effect from the subluxation of the humeral head back into the glenoid rim.
14-year-old patient present with ankle pain, increased effusion, tenderness, and pain with gait but is able to weight bear. Pt describes "rolling his ankle" in an inward manner. He has decreased ROM for eversion and dorsiflexion. After performing an Anterior draw and taler tilt he becomes very symptomatic but has no excessive ligamentous laxity.
What possible grade of sprain could he be classified under?
What particular joint mobilization could you perform to increase ROM?
Grade 2- ATFL + CFL sprain
Joint Mobs
1. posterior talar glide (dorsiflexion)
2. subtalar lateral glide (Eversion)