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Introduction
1. Cardiopulmonary system
2. Pulmonary system
3. Neuromuscular system
4. Pediatrics
5. Musculoskeletal system
5.1 Anatomy of musculoskeletal system
5.2 Foundation content of musculoskeletal system
5.3 Anatomy and special tests of upper extremity
5.4 Differential diagnosis with interventions of upper extremity
5.5 Anatomy and special tests of lower extremity
5.6 Differential diagnosis with interventions of lower extremity
5.7 Anatomy and specie tests of spine, pelvis, and temporomandibular joint
5.8 Differential diagnosis with intervention of spine, pelvis, and TMJ
5.9 Other MSK conditions
5.10 Gait
5.11 Prosthetics and orthotics
5.12 Medications, imaging, and fractures
5.13 Surgical protocols
6. Other system
7. Non-systems
Wrapping up
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5.6 Differential diagnosis with interventions of lower extremity
Achievable NPTE-PTA
5. Musculoskeletal system

Differential diagnosis with interventions of lower extremity

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Hip conditions

  • Avascular necrosis
    • Etiologies that result in impaired or loss of blood supply to femoral head
  • Symptoms
    • Loss of range of motion in hip flexion, internal rotation, and abduction
    • Pain in groin and/or thigh
    • Tenderness with palpation at hip joint
    • Antalgic gait
  • Diagnosis
    • Clinical presentation
    • X-ray
    • Bone scans
    • CT or MRI imaging
  • Medical management
    • Surgical intervention for revascularization
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management
    • Joint protection
    • Functional mobility training
    • Improve joint mechanics and mobility
    • Improve strength/coordination
  • Trochanteric bursitis
    • Inflammation of deep trochanteric bursa due to direct injury, irritation by iliotibial band, or repetitive microtrauma
      • Can be associated with rheumatoid arthritis
  • Symptoms
    • Sharp or dull ache on the outside of the hip
    • Pain that radiates down the upper thigh
    • Pain that worsens with activities that involve the hip, such as walking, running, or climbing stairs
    • Tenderness at lateral hip
  • Diagnosis
    • Clinical presentation
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Management of rheumatoid arthritis as indicated
  • Physical therapy management
    • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Iliotibial band tightness
    • Tight iliotibial band, abnormal gait pattern
      • Can lead to trochanteric bursitis
  • Symptoms
    • Pain that worsens with activity, especially running, cycling, or going up and down stairs
    • Severe pain when bending your knee
    • Swelling on the outside of the knee
    • Tenderness to the touch on the outside of the knee
  • Diagnosis
    • Clinical presentation
      • Special tests- Ober’s and Noble’s tests
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Treatment of trochanteric bursitis as appropriate
  • Physical therapy management
    • Gait training- appropriate running shoes, orthotics may be prescribed
    • Reduction of pain/inflammation
    • Soft tissue and manual techniques
    • Joint mobility and functional training
  • Coxa vara and coxa valga
    • Caused by defect in ossification (formation) of femoral head; can also be a result of avascular necrosis due to septic arthritis
      • Coxa vara- angle of femoral neck <115 degrees
      • Coxa valga- angle of femoral neck >125 degrees
  • Symptoms
    • Coxa vara
      • Leg length discrepancy
      • Pain in the hip and/or leg
      • Stiffness with abduction
      • Prominent greater trochanter
      • Limited hip mobility
    • Coxa valga
      • Increased anterior pelvic tilt
  • Diagnosis
    • Clinical presentation
    • X-ray
  • Medical management
    • Surgery if angle is >60 degrees from normal value
    • Assistive devices as indicated
  • Physical therapy management
    • Improve joint mobility and mechanics
    • Use of orthotics for leg length discrepancy
    • Use of muscle energy techniques to correct pelvis tilt

Image #56

alt_text

https://upload.wikimedia.org/wikipedia/commons/3/34/FemurAngles.jpg

  • Piriformis syndrome
    • Tightness or spasm of piriformis can result in compression of sciatic nerve
      • Tightness can be a result of repetitive movement of piriformis or overuse
      • Compression of sciatic nerve can cause radiation of pain down leg
  • Symptoms
    • Restriction in internal rotation
    • Pain with palpation of piriformis muscle
    • Referred pain to down posterior leg
    • Weakness of external rotation
  • Diagnosis
    • Clinical presentation
      • Special test- piriformis test
      • Rule out lumbar spine involvement
    • Electrodiagnostics of sciatic nerve
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management
    • Pain management and reduction of pain from posterior leg to only piriformis (centralization of pain)
    • Muscle mobility and strengthening
    • Muscle balance restoration
    • Correction of biomechanical faults with orthoses

Image #57

alt_text

https://upload.wikimedia.org/wikipedia/commons/a/ac/Fibrovascular_entrapment_of_the_sciatic_nerve_undefined_distribution.jpg

Knee conditions

  • Ligament sprains
    • Can involve one (single plane) or multiple (rotary instability) ligaments of the knee
      • Anterior cruciate ligament
      • Posterior cruciate ligament
      • Medial collateral ligament
      • Lateral collateral ligament
    • Classification of sprains
      • First degree: minimal instability of knee joint; ligament stretched but not torn
      • Second degree: minimal- moderate instability of knee joint; ligament is partially torn
      • Third degree: extreme instability; ligament is completely torn and ruptured
  • Symptoms
    • First degree: minimal pain and swelling
    • Second degree: moderate pain, swelling, tenderness to joint, and joint laxity noted with certain movements
    • Third degree: significant pain, swelling, and instability due to complete tear
  • Diagnosis
    • Clinical presentation
      • Special tests based on ligament injury
        • Anterior cruciate ligament - Lachman, anterior drawer
        • Posterior cruciate ligament- posterior drawer test
          • Medial collateral ligament- valgus knee test
          • Lateral collateral ligament - varus knee test
      • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Surgery indicated if functional instability present- can be for grade two or three sprains
  • Physical therapy management
    • If surgery performed, interventions will be based on protocols post-surgery
    • Reduction of pain and inflammation
    • Functional training
    • Joint mobility
  • Meniscus injuries
    • Combination of flexion, compression, and rotary forces on knee casing abnormal stress to knee
  • Symptoms
    • Pain increases with twisting or weight-bearing activities.
    • A sensation of the knee giving way or locking up, especially when squatting, standing up, or turning.
    • A feeling that the knee is not stable or may give out.
  • Diagnosis
    • Clinical presentation
      • Special tests- McMurray, Apley, Thessaly
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Surgery may be indicated
  • Physical therapy management
    • Reduction of pain and inflammation
    • Functional training
    • Joint mobility
  • Patellafemoral pain syndrome
    • Dysfunction of knee due to trauma, muscle imbalance/tightness, improper loading of joints
  • Symptoms
    • Pain in the front of the knee, around or behind the kneecap
    • Pain when going up or down stairs
    • Pain when squatting or kneeling
    • Pain after prolonged sitting with bent knees
    • A grinding or catching sensation in the knee
  • Diagnosis
    • Clinical presentation- description of pain when increased load to patellar such as stair climbing or squatting
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management
    • Reduction of pain and inflammation
    • Taping, mobilization of patellar
    • Functional training
    • Biofeedback for vastus medialis
    • Prescription of orthotics as appropriate
  • Patellar tendinopathy
    • Degeneration of patellar tendon due to overload and/or jumping related activities
      • Can be related to patellofemoral pain syndrome
  • Symptoms
    • Pain that’s worse with activity, such as running, jumping, or walking
    • Pain that’s worse when going downhill or descending stairs
    • Pain that’s worse when bending or straightening your leg
    • Pain that’s worse when sitting for long periods or using stairs
    • Tenderness on the front of the knee
    • Tenderness behind the lower part of the kneecap
  • Diagnosis
    • Clinical presentation
      • Abnormal patella position
        • Patella alta- patella tracks superiorly
        • Patella baja- patella tracks inferiorly
      • X-ray
  • Medical management
    • Re-alignment of patella if subluxation has occurred
  • Physical therapy management
    • Improve lower extremity strength- specifically quadriceps and hamstrings
    • Functional training
    • Joint mobility
    • Patella taping or bracing

Conditions of lower leg

  • Acute compartment syndrome
    • Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas)
      • Commonly caused by direct trauma or fracture
  • Symptoms (six P’s)
    • Pain to lower leg
    • Palpable tenderness to lower leg
    • Paresthesia to lower leg - specifically to deep peroneal nerve
    • Paresis to lower leg- specifically to deep peroneal nerve
    • Pallor to lower leg
    • Pulselessness to dorsal pedal artery
  • Diagnosis
    • Clinical presentation
  • Medical management
    • Medial emergency- immediate fasciotomy is indicated to relieve pressure and decrease the likelihood of prolonged neurovascular compromise
  • Physical therapy management
    • Post-operatively physical therapy to ensure return to normal function

Image #58

alt_text

https://upload.wikimedia.org/wikipedia/commons/c/c4/Leg_compartments.jpg

  • Chronic exertional compartment syndrome
    • Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas) causing a restriction in blood flow
      • Develops gradually over a period of time due to repetitive movements and exertional activities
      • Typically occurring in only one compartment of lower leg
  • Symptoms
    • Pain
    • Numbness and tingling
    • Weakness
    • Swelling
    • Tightness
    • Foot drop
  • Diagnosis
    • Clinical presentation
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management
    • Functional training, proprioceptive training
    • Decrease exacerbating activity
    • May require use of orthoses
  • Stress fractures
    • Microfractures to the tibia or fibula due to overuse (repetitive micro-traumas to the tibia or fibula)
      • Commonly due to poor alignment of lower extremity when performing activity, deconditioning, or improper training
  • Symptoms
    • Dull, aching pain that gradually worsens with activity
    • Mild swelling may occur around the fracture site
    • Affected area may feel weak or unstable
    • Difficult to put weight on the injured area
    • Pain may be more severe at night or when resting
  • Diagnosis
    • Clinical presentation
    • X-ray
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Physical therapy management
    • Initially decreased exacerbating activity
    • Correction of malalignment and biomechanical issues
    • Strengthening and coordination activities

Ankle and foot conditions

  • Ligament sprains
    • Classification of sprains
      • Grade 1
        • A mild sprain where the ligament is stretched or slightly torn
        • Symptoms include minor swelling, tenderness, and bruising
        • Recovery time is usually 1–3 weeks
      • Grade 2
        • A moderate sprain where the ligament is partially torn
  • Symptoms include swelling, bruising, pain, and difficulty walking
  • Recovery time is usually 3–6 weeks * Grade 3
  • A severe sprain where the ligament is completely torn
  • Symptoms include severe pain, swelling, bruising, and instability
  • Recovery time can be several months
  • Symptoms
    • See specific grade for symptoms associated
  • Diagnosis
    • Clinical presentation
      • Special tests: Anterior drawer, talar tilt
    • X-ray
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Grade 2- immobilization device may be recommended
    • Grade 3 sprains typically will need surgical intervention
  • Physical therapy management
    • Grade 1- conservative management of rest, ice, compression, and elevation acutely; then functional mobility training
    • Grade 2 and 3:
      • Functional mobility training
      • Biomechanical fault re-alignment
      • Joint protection and mobility
      • Post-surgical protocols if surgery indicated
  • Achilles tendinopathy
    • Chronic inflammation of the Achilles tendon due to overuse, age, rheumatoid arthritis, or gout
  • Symptoms
    • Pain, typically located in the back of the heel or just above it
    • Tenderness and stiffness in the Achilles tendon
    • Swelling and redness around the tendon
    • Pain that worsens with activity and improves with rest
  • Diagnosis
    • Clinical presentation
      • Special tests- Thompson’s test
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Corticosteroids
    • Management of rheumatoid arthritis or gout
  • Physical therapy management
    • Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing
  • Tarsal tunnel syndrome
    • Entrapment of posterior tibial nerve within tarsal tunnel
      • Overuse injury due to tendonitis of posterior tibialis
  • Symptoms
    • Numbness and tingling in the sole of the foot, arch, or toes.
    • Burning or shooting pain may radiate from the ankle to the foot or calf
    • Foot drop
    • Swelling or redness
    • Pain that improves with rest
  • Diagnosis
    • Clinical presentation
      • Special test- Tinel’s sign
    • Electrodiagnositic testing
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Surgical intervention if conservative management not effective
  • Physical therapy management
    • Joint mobility
    • Functional exercise training
    • Orthoses
    • Neurotension stretching
  • Foot deformities
    • Pes cavus- hollow or flat foot
      • Due to genetics or biomechanical faults
    • Equinus- plantarflexed foot
      • Can be due to genetics, bone deformity, neurological conditions
  • Symptoms
    • Observation of foot as noted above
  • Diagnosis
    • Clinical presentation and observation
  • Medical management
    • Management of underlying causes as appropriate
  • Physical therapy management
    • Improved biomechanical alignment
    • Orthoses as appropriate
    • Joint mobility
    • Patient education
  • Charcot- Marie tooth disease
    • Progressive disorder causing peroneal muscular atrophy and peroneal nerves- causing motor and sensory deficits
      • Genetic disorder
      • Begins in lower legs but can progress to forearm and hands
    • Symptoms
      • Foot and leg weakness
      • Foot abnormalities: High arches, hammertoes, and flat feet
      • Numbness, tingling, and burning sensations in lower leg
      • Muscle atrophy in the feet and legs
      • Clumsiness and difficulty with fine motor skills
  • Diagnosis
    • Clinical presentation
    • Electrodiagnostic exam
    • Genetic testing
  • Medical management
    • Acetaminophen or non-steroidal inflammatory (NSAIDs)
    • Surgical correction of joint abnormalities as deemed appropriate
  • Physical therapy management
    • Progressive disorder with no cure so physical therapy interventions are centered around patient education, skin assessments for possible development of wounds, contraction prevention/management, and functional mobility assessment/training
  • Foot deformities
    • Rearfoot varus
      • inversion of calcaneus when subtalar joint in neutral
    • Rearfoot valgus
      • ** eversion of calcaneus when subtalar joint in neutral**
    • Forefoot varus
      • inversion of forefoot when subtalar in neutral
    • Forefoot valgus
      • eversion of forefoot when subtalar in neutral
  • Diagnosis of foot deformities
    • Clinical presentation and observation
  • Symptoms
    • Abnormalities in gait due to uneven levers
  • Medical management
    • None indicated
  • Physical therapy management
    • Improving foot alignment
    • Orthoses as appropriate
    • Strengthening as appropriate

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