Sacroiliac joint structure

Compression of the joint = pain

● Nutation = Anterior tilt of sacrum = done by piriformis

● Counter-nutation = posterior tilt of sacrum = done by Gmax
 ● ASIS and PSIS are at the same level anteriorly and posteriorly.
● Left and right sides are at the same level.
● ASIS corresponds to a vertebra.
● AIIS corresponds to a vertebra.
● Anterior pelvic tilt = counter-nutation = long leg discrepancy
● posterior r pelvic tilt = nutation = short leg discrepancy

Anterior pelvic Posterior pelvic Pelvic upslip Pelvic down slip

tilt tilt

Tight muscles Rectus femoris, Gluteus Quadratus Gluteus medius

sartorius, iliacus, maximus, hams, lumborum
erector spinae rectus
abdominis

Weak muscles

Note = In the question of pelvic tilt, think about the movement, which muscles are doing which
movement and where the pelvic bone goes while strengthening those muscles. Depending
upon that, the answer can be isometric strengthening. We want the origin to go towards
insertion in this case.

Anterior SI ligament:
The ligament is stretched in External rotation = pain

Posterior SI ligament:
The ligament is stretched in Internal rotation = pain
Pelvic ligaments
1. Iliofemoral ligament:
Superolateral = limits hip adduction and external rotation / stretched in this position
Inferomedial = limits hip extension / stretched in this position

2. Pubofemoral ligament:
Limits Abduction - Extension - External rotation

3. Ischiofemoral ligament:
Limits internal rotation

4. Ligamentum teres:
Limits Adduction - Flexion - External rotation
 Pelvic tilt

Anterior pelvic tilt

● Tight structures = tight hip flexors and back extensors
● Weak structures = Gluteus medius and piriformis
● Associated lower extremity compensations including internal rotation of the femur,
genu valgum, lateral tibial torsion, pes planus, and hallux valgus

Posterior pelvic tilt

Tight structures = tight hip extensors and back flexors
Pelvic drop / Trendelenburg gait
Treatment:
● Add heel raise on the dropped side.
● Affected gluteus medius closed-chain exercises.
● Open-chain exercises are not recommended in standing because the opposite leg will be
dropped further, which we don't want, can do open-chain side-lying.

Limb length discrepancy

It can be of two types:
1. True = actual bone length is short and it can be measured from 3 landmarks:
a. Iliac crest to greater trochanter
b.
2. Apparent = due to muscle imbalance or postural deformity
 Coxa vara and coxa valga

● Unilateral coxa vara leads to a relatively shorter leg with associated genu valgum
 Anteversion and retroversion

(Anteversion often results in genu valgum and pes planus.)

Total Hip Arthroplasty

Assessment:
● Which approach is used?
● Which muscles are affected?
● Any signs of post-op complications?

Complications:
● Malposition of a prosthetic limb
● Femoral fracture
● Pneumonia
● Chest pain due to embolism
● Delayed wound healing
 ● Infection at the wound site
● Disruption of bone graft
● Persistent limb length discrepancy

Signs of failure of fixation:

● Severe and persistent pain with movement or weight bearing
● Progressive limb length inequality
● Persistent external rotation of the operated limb
● Positive Trendelenburg sign does not go with strengthening

Movements to avoid:
● Posterior/posterolateral approach = flexion > 90, adduction and IR beyond neutral
● Anterior/anterolateral / lateral = flexion > 90, extension, adduction and ER beyond
neutral
● Transgluteal approach / trochanteric osteotomy = active hip abduction, adduction
beyond neutral because gluteus medius is cut.
● Do not cross your legs for all the approaches
● Don't seat on a low chair
PT management:
● Exercise from day 1
● Max protection phase = Ankle pump and muscle setting exercises, Stairs with an
assistive device (ascend = unaffected leg first, descend = affected leg first), always use
rails
● Intermediate phase = exercise with light resistance
● Min protection phase = every exercise

Note = Always use a cane on the good side.

To achieve knee extension To achieve knee flexion

Stretch hams Stretch quads

Cephalad patellar mobilization Caudal patellar mobilization

Tibial distraction with external rotation Tibial distraction with

internal rotation

Gait training -

Low load, long-duration stretching weight-bearing stretches

Serial casting Manipulation under anesthesia

Trochanteric bursitis

Cause = Genu valgum, Gluteus medius weakness, TFL and IT band tightness
Pain during active or passive hip abduction

Patellofemoral pain syndrome

Patella should move in the center during knee flexion extension but if it's tracked laterally, it
will rub on the lateral condyle of the femur which causes pain.

Who moves the patella laterally? = IT band tightness in genu valgum.

After some time, the cartilage is completely worn out, called chondromalacia patella.
Symptoms = pain during descending stairs
Rx = strengthening of VMO, do the last degree of knee extension
 IT band friction syndrome

IT band = Gluteus maximus + Tensor fascia latte

IT band syndrome = IT band tightness
Cause = Genu valgum (Gluteus medius is weak)
Symptoms = pain at 30 degrees of flexion.
Diagnosis = Noble compression test / Ober test

Slipped capital femoral epiphysis (SCFE)

Slipped capital femoral epiphysis (SCFE) is a hip disorder that typically affects adolescents
during periods of rapid growth. In SCFE, the ball at the top of the thigh bone (femur) slips off
the neck of the bone through the growth plate, which is a weak area in the bone where growth
occurs. This displacement can lead to pain, stiffness, and limping, and it may cause the affected
leg to turn outward. SCFE requires prompt medical attention to prevent further complications,
such as damage to the blood supply to the hip joint. Treatment often involves surgery to
stabilize the femur and prevent further slippage. Early diagnosis and treatment are crucial for a
successful outcome in SCFE.

SCFE patients show decreased ROM, particularly of internal rotation, abduction, and flexion.

Sinding Larson vs Osgood Sclatter

Sinding Larson = Pain at the apex of the patella (happens mainly in kids)
Osgood Schlatters = Pain at the tibial tubercle, prominent bone (happens mainly in kids)
Patellar tendonitis = same things happen in adults
Cause = trauma, excessive flexion

Piriformis syndrome

Cause = piriformis hypertrophy / genu valgum / hip flexion contracture / SI or gluteal region
trauma
Effect = Sciatic nerve compression

Myositis ossificans

Bone formation within the muscle

Cause = closed-injury on muscle (mudh maar)
Rx = AROM
Precautions = No PROM, No stretching because it will break muscle, No ultrasound, No massage

Knee joint ligaments

 ACL PCL MCL LCL

● Excessive ● Excessive ● Valgus force ● Varus force

knee knee flexion + ● Excessive tibia ● Excessive tibia
extension + IR ER IR
ER ● Falling on
● Valgus force bend knees
● Strong ● Dashboard
popping injury
sound ● Popping
● Supported by sound but not
hams loud as ACL
● Supported by
quads
ACL Rehab
 Meniscal injury

Symptoms:
● Immediate swelling
 ● Locking and catching
● Joint line tenderness
● Clicking sensation during walking
● Locking of the knee in a flexed position
● Pain with maximal knee flexion/extension

Diagnosis:
● Macmurray’s test = Fully flexed knee medially rotates tibia then fully extends the knee,
laterally rotate tibia then fully extends knee, pain or locking suggest a positive test.
● Apley’s compression test = prone with knee 90 flexed, compress the knee and rotate it,
pain shows positive test.

Intervention for meniscus repair:

Immobilization:
● Knees in full extension in immobilizer and then in knee-brace after rigid dressing is
removed
● Knees are locked in full extension range-liming brace set about 0 to 90 degrees flexion,
each week flexion range is increased 10 degree
● Brace is 2 weeks for peripheral repair and 6 weeks for central zone repair

Weight bearing:
● Partial weight bearing with crutches - knee in full extension immediate post-operatively.
● Full weight bearing around 4 weeks in peripheral repair and 6 weeks in central repair.

Max protection Moderate protection Functional phase

(1 to 4 weeks) (4 to 12 weeks) (after 12 weeks)

● PRICE ● Low-load stretching ● Aerobic conditioning

● CPM ● Cycling against
● Gravity assisted resistance
flexion ● Hip and ankle
● 1 and 2 patellar glides strengthening
● Quads and hams ● Closed-chain activities
 setting ex ● Balance activities -
● Active full knee stairs
extension should be ● Lower extremity
achieved strength should be 60
● Active 120 flexion to 80% of
should be achieved contralateral side
Total Knee Arthroplasty
 Ankle sprain

Phase Intervention

1 PRICE protocol, temporary immobilization - splint or cast, no

weight bearing with crutches

2 - reduce pain and swelling Partial weight bearing, balance training, treadmill walking

3 - no pain Full weight bearing, unilateral balance training

4 - heel raised in unilateral Jogging, running, sports training, sensorimotor training,

stance plyometric training, ankle destabilization devices

Plantar fasciitis
 ● Attached from the anteromedial calcaneus to the base of the phalanx
● It's like a ligament, so stretching is a problem.
● Causes = flat foot, evertors tightness, sudden weight gain (pregnancy), genu valgum,
coxa vara, anterior pelvic tilt, Gmed weakness, IT band tightness
● Clinical features = pain on prolonged standing, morning pain for a short time, heel pain,
pain during the push-off part of the walk, calf cramps

Diagnosis:
● Windlass test

PT management:
● Taping to shorten fascia
● Correction of flatfoot
● Night splint
● Foot orthosis (anti-pronation device)
● Stretching of plantar flexors and plantar fascia
● Strengthening of intrinsic muscles to prevent flattening of the foot
● Extracorporeal shock wave therapy

Anterior compartment syndrome

● Increase pressure in the compartment leads to the ischemic condition of the leg
● Pain is continuous
● Causes = trauma, fracture, muscle hypertrophy
● Signs = intense cramping pain, pulselessness, pallor skin, tingling or numbness,
paresthesia, paralysis, loss of two-point discrimination
● Test = passive stretch and active movement both painful
● Rx = medical emergency, call 911, surgical fasciotomy

Tarsal tunnel syndrome

● Compression of the posterior tibial nerve

● Causes = excessive eversion, everything which causes flat foot, poor shoe
● signs = pain, numbness, paraesthesia at medial side and plantar surface, motor and
sensory deficiency in mid and forefoot
● Rx = stretch evertors, strengthen invertors
 Achilles tendon pathology

Achilles tendonitis Achilles strain/rupture

Chronic Acute

Inflammation and pain Pain present or not

Palpation test Thompson test

Stretching of the calf and eccentric ex Surgery

Retrocalcaneal bursitis

● Repetitive trauma to the bursa due to running and jumping, excessive loading on the
heel
● Cause = Overuse of Achilles' muscle, wearing high heels, exercising without a warmup,
overweight

Anterior and posterior shin splint

Tibialis anterior fibers rips Tibialis posterior fibers rips

Cause - tight PF and evertors Cause - tight DF and evertors

Pain location - anterior lateral 2/3 Pain location - posterior medial 1/3

Active DF and inversion / passive PF and Active PF and eversion / passive DF and
eversion painful inversion painful

Flexor hallucis tendinopathy

● Flexor hallucis tendon inflammation

● Seen in a Ballet dancer
● Pain location = Lower medial 1/3
● Pain with active PF
● Great toe extension (differentiate it from posterior shin split)

Sever’s disease

● Traction apophysitis of calcaneus due to the sudden strong contraction of the

gastrocnemius
● Seen in kids because their tendons are stronger than bones
● Rx = keep gastrocnemius in shortened position (active insufficiency), stretch them after
becoming asymptomatic, walk only with heel wedges, strengthen of dorsiflexors and
intrinsic muscles

Toe deformities

Lis franc injury

is a dorsum of foot problem due to tear of ligament between tarsometatarsal joint.

Osteochondritis dissecans

● Happens generally in the knee and elbow

● Fissures in cartilage and bones due to vascular deprivation
● Fragmentation of cartilage and bone causing pain
● Avoid weight bearing exercises which involved fragmented bone

Osteogenesis imperfecta

● Affect how body makes collagen - congenital defect

● Hundreds of fractures without cause
● Weight-bearing activities to strengthen bones
 Charcot Marie tooth

● Genetic disorder
● Peroneal atrophy - “inverted champagne bottle” appearance - foot deformity -
sensorimotor problems - numbness and burning sensation in the foot and hands -
slapping while walking - loss of balance - difficulty in grasping objects

Gait
 Right foot - stance phase

Heel strike Flat foot Midstance Heel off Toe off

Ankle Neutral, going 5-10 degree PF 5 degree PF 10 degree DF 20 degree PF

toward PF

Muscles DF - DF - PF - PF - PF -
eccentrically eccentrically eccentrically concentrically concentrically

Heel strike Flat foot Midstance Heel off Toe off

Knee 5-degree flexion 20-degree Neutral Neutral to 40-degree

flexion flexion flexion

Muscles Quads - Quads - Quads - Quads - Quads -

eccentrically eccentrically concentrically eccentrically eccentrically
Gastrocnemius -
concentrically

Heel strike Flat foot Midstance Heel off Toe off

Hip 25-30 degree 20-degree Neutral 15-20 degree 10-degree

flexion flexion extension extension

Muscles Gmax Gmax Gmax Iliopsoas Iliopsoas

eccentrically concentrically concentrically eccentrically concentrically
Right foot - swing phase

Acceleration Midswing Deceleration

Ankle 5 degree PF Neutral Neutral

Muscles DF - concentrically DF - concentrically DF - eccentrically

Acceleration Midswing Deceleration

Knee 40-50 degree flexion 25-degree flexion 5-degree flexion

Muscles Hams - concentrically Hams - eccentrically Quads -

concentrically

Acceleration Mid Swing Deceleration

Hip 15-degree flexion 25-degree flexion 20-degree flexion

Muscles Iliopsoas Iliopsoas Iliopsoas eccentrically

concentrically concentrically
A heel spur is a calcium deposit causing a bony protrusion on the underside of the heel bone,
causing heel pain - a shorter stance phase