msk

1. Musculoskeletal disorders of
the Lower limb

2. KINETIC CHAIN
• Model of human motion that
analyzes and treats dysfunction
along connected anatomic
regions, rather than focusing on a
single location of pain.
• (Braddom, 5th
edition)

3. The Hip joint

4. Hip joint
• Ball-and-socket joint
• Promote stability but limits ROM
• 3 degrees of freedom

5. Muscles

9. II-A. Hip MSK Conditions
Hamstring strain
• AKA pulled hamstrings
• MC strained muscle group
• Balistic activities
• Occurs during eccentric phase of
muscle contraction and at the
myotendinous junction
Clinical Presentation
• (+) pain on hamstring after
forceful contraction or knee
extension (Origin)
• (+) tenderness
• (+/-) LOM
• (+/-) Echhymosis

10. Hamstring strain
Diagnostics
• Generally not needed
• MSK Ultrasound
• Xrays to R/O fractures
• MRI – determine severity
Imaging
Treatment
• NSAIDs, RICE
• Rehab
• Modalities
• ROMEs
• Stretching
• Progress to strengthening
• Core stabilization
Protocol
• 1st-3rd week – GPS, PREs
• 3weeks - 6 months depends on
severity à return to sport

11. Adductor Strains
• MC cause of groin discomfort among
athletes
• MOI - Forced external rotation of an
abducted leg
• Clinical Presentation
• Pain on stretch
• Tenderness over pubic rami
• LOM sec to pain

12. Adductor
strain
• Diagnostics
• Imaging
• Generally not needed
• MSK Ultrasound
• Xrays to R/O fractures
Treatment
• NSAIDs, RICE
• Rehab
• Modalities
• ROMEs
• Stretching
• Progress to
strengthening
• Core stabilization
Protocol
• 1st-3rd week – GPS,
PREs
• 3weeks - 6 months
depends on severity
à return to sport

13. Piriformis Syndrome
- Ext hip rotator
MOI
• Stressed by poor body
mechanics in a chronic condition
• Forceful hip internal rotation in
an acute injury
Clinical Presentation
• (+) pain – Lat. gluteals, post hip
and proximal thigh
• Excacerbated by walking up
stairs
• (+) tenderness on muscle belly
(sacrum – GT)

14. Piriformis Syndrome
• Diagnostic
• Provocative test – FAIR test
• Imaging
• Xrays LS AP/L to R/O other
conditions
• Treatment
• NSAIDs
• Rest, ice
Rehab
• Modalities – HMP, TENS, Utz
• Stretching
• Strengthening
• Postural education

15. Hip dislocations
• Posterior – MC 90%
• Vehicular accident
• “Dashboard injury”
• Clinical Presentation
Posterior - Flexed, adducted and
Int. rotated
• Anterior – Abducted, Externally
rotated, Slightly flexed
• (+) Pain, Tenderness
• LOM

16. Hip dislocation
Diagnostics
• Xrays
• CT scan
• MRI
• Treatment
• Orthopaedic emergency
• Reduction
• Pain medications
Rehab post op
• Modalities (Cryo, TENS)
• ROMEs
• BUE Strengthening
• Strengthening (Isometrics) 0-4 weeks
• CCK exercises at > 6 wks
Precautions:
• No excessive hip ER/IRs and adduction past midline at
0-6 weeks
• Hip flexion until 0-75deg for 1-4 weeks à 0-90deg at 6
weeks
• 3-4 weeks protected wt bearing
• Return to sports 12-20wks

17. Hip Fractures
• Fall, Trauma, osteoporosis
• Non modifiable RF
• Age = >75 years of age
• F > M
• Modifiable risk factors
• Alcohol and caffeine consumption
• Smoking
• Medications (steroids,
benzodiazepines)
Clinical presentation
• Hip pain
• Externally rotated
• Slightly shorter
• LOM

18. Hip Fractures
• Types

20. STABLE
fractures
UNSTABLE
fractures
• Nondisplaced
• No deformity
• Impacted in a valgus position
• May not be detectable on plain radiographs
• MRI scanning may be required
• Leg is externally rotated and shortened
• Degree of rotation and shortening varies
with the degree of displacement

21. Hip fractures
• Diagnostics
• Radiographs
• CT
• MRI
Treatment
• Pain medications
• Surgery
• Grade I and II Garden
– Pins or screws
- Partial or FWB
• Gr III and IV Garden
- PHA/ THA
• Post op Rehab
• THA cemented – FWB
• THA uncemented – NWB/ Partial
WB
• Precautions – until 6 weeks
• Posterior approach – avoid hip
FLEXION over 90deg, ADD past
midline and extreme IR
• Anterior approach – avoid hip
EXTENSION , ER
• Monitor wound healing and signs
for DVT and PE

22. Load
TRANSFER/
BEARING
• Transfer load from one bony part to
another, usually the epiphysis of a long
bone or the surface of a joint
• Entire load is carried by the device
• Used for: comminuted fractures, defect
fractures
• Example: plates

23. Load
SHARING
• Implant may carry all the load BUT shares
the load with the bone
• May carry all the load for an unstable
fracture in the area of instability, but shares
the load where it is attached to the bone
• Used for: fractures with adequate bony
buttressing at the fracture site
• Cannot be used for: defect / comminuted
fractures
• Example: intramedullary nails

24. Hip Fractures
Rehab PT
• Modalities
• Home modification (railings, bed
height, organize things)
Phases
• 0-3 wks (AROMEs, CCK, ambu w/
assistive device)
• 4-6 wks (ambu w/o assistive
device, uneven surface
ambulation)
• 7-12 wks ( Return to work,
functional activities)
• > 12 wks – return to sports
OT
• ADL retraining
• Environmental assessment and
modifications
Psychology
• Screening for anxiety and depression
• Caregiver counseling

25. Hip Arthroplasty Home Instructions

26. The Knee joint

27. I-B. Knee
joint
Q angle

28. Screw Home mechanism
Femur rotates medially to lock
Tibia rotates laterally to lock

29. II-A. Knee MSK Conditions
Hamstring strain (Distal)
• AKA pulled hamstrings
• MC strained muscle group
• Occurs during eccentric phase of
muscle contraction and at the
myotendinous junction
Clinical Presentation
• (+) pain on hamstring after
forceful contraction or knee
extension (Insertion)
• (+) tenderness
• (+/-) LOM
• (+/-) Echhymosis

30. Hamstring strain
• Diagnostics
• Imaging
• Generally not needed
• MSK Ultrasound
• Xrays to R/O fractures
• MRI – determine severity
Treatment
• NSAIDs, RICE
• Rehab
• Modalities
• ROMEs
• Stretching
• Progress to strengthening
• Core stabilization
Protocol
• 1st-3rd week – GPS, PREs
• 3weeks - 6 months depends on
severity à return to sport

31. Prepatellar Bursitis
• Housemaid’s knee
• Inflammation of the bursa in
front of patella
• bursa becomes irritated and
produces too much fluid,
Clinical presentation
• Swelling
• Pain
• Tenderness
• LOM

32. Prepatellar bursitis
• Diagnostics
• Imaging
• MSK Ultrasound
• Xrays
Treatment
• NSAIDs, RICE
• Rehab
• Modalities (Cryo)
• ROMEs
• Progress to strengthening once
swelling decreases

33. Baker’s cyst
Popliteal cyst
MC mass of popliteal fossa
Fluid-filled cyst that causes a bulge and a
feeling of tightness behind your knee.
Secondary to trauma or arthritis
Clinical Presentation
• Swelling
• Knee pain
• Stiffness
• LOM

34. • Diagnostics
• Imaging
• MSK Ultrasound
• Xrays
Treatment
• NSAIDs, RICE
• Steroids injection
• Joint aspiration
• Surgery
• Rehab
• Modalities (Cryo)
• ROMEs
• Progress to strengthening

35. Meniscal injuries
• MOI
• Tibial rotation while knee is
partially flexed during wt bearing
(CCK)
• Clinical Presentation
• Sharp pain on wt bearing
• Gradual swelling
• Audible “clicking”
• Symptom of “catching or locking”
• Mild effusion
• Joint line tenderness – Hallmark
• LOM

36. Special test for Menisci
McMurray’s test
• Flex and extend with varus&valgus and
internal and external rotation
• • (+) ireproduction of pain
Apley’s compression test
• Prone with knee flexed, axial load and
rotation

37. Meniscal tears
Diagnostics
• Xrays – Rule out fractures
• MRI – imaging of choice
Therapeutic
• NSAIDs
• RICE – Knee immobilizer
• Surgery
• Rehab
Physical Therapy
• Modalities
Post op Phases
• 0-3 wks (Muscle sets, ROMEs, core
strengthening)
• 4-12 wks (CCK, PREs)
• > 12 wks – Sports specific
progressive training

38. ACL tears
• most frequent completely
disrupted ligament in the knee
MOI
• Rotation on a planted foot with
knee in flexion and quads
activating strongly à (+) Pop
Clinical Presentation
• Pain
• Effusion
• Feeling of instability
• LOM
• (+) Special Tests – Lachmans, Ant
drawer test, Pivot shift

39. ACL tears
Diagnostics
• MRI
• Xrays
Segond Fracture
or avulsion fracture of the lateral proximal
tibia, is pathognomonic of an anterior
cruciate ligament tear 70-100%.
Unhappy triad
1. ACL
2. MCL
3. Medial meniscus

40. ACL tears
Treatment
• NSAIDs
• Initial Treatment - RICE
• May need immobilization with
crutch walking for pain relief
• Definitive Treatment
• Surgery – ACL reconstruction
• 2-3 weeks post injury
• Post op Rehab
• Phase I (0-3 wks)
• Muscle sets, ankle pumps
• ambulation
• Phase II (4-12 wks)
• CCK
• PREs, core strengthening
• Phase III (>12 wks)
• Progressive agility drills
• Plyometrics
• Phase IV (16-20 wks)
• Can return to sports if with clearance
from ortho

41. Collateral Ligament Injuries
MOI
• Injuries to the medial collateral
ligament are usually caused by contact
on the lateral side of the knee
• MCL > LCL
Clinical Presentation
• Pain
• Point tenderness
• Valgus stress test at 30 degrees
knee flexion

42. MCL Injury
• Graded I-III
• I opening < 5mm
• II 5-10mm
• III > 10mm

43. Diagnosis Treatment
• PE
• Imaging
• Xrays
• MRI
• Surgery
• NSAIDs
• RICE
• Rehab Ex
• Same as ACL program
• Return to sports
• 3-4 weeks ( low grade)
• 6-12 weeks ( High-grade)

44. Patellofemoral Disorders
• MC cause of anterior knee pain
• Runner’s knee
• Overuse injury repeated
microtrauma
• Pain aggravated upon sitting,
excessive use, or climbing and
descending stairs
Clinical Presentation
• Anterior knee pain
• Tenderness anterior-posterior
patellar compression
• LOM
• (+) Patella compression test or
patella grind test.

45. Causes of PFS
• Increased pressure on the
patellofemoral joint.
• Increased levels of physical activity
• Malalignment of the patella as it
moves through the femoral groove
• Quadriceps muscle imbalance
(VMOs)
• Tight anatomical structures, e.g.
retinaculum or iliotibial band.

46. Chondromalacia patellae
• Arthroscopic diagnosis
• Cartilage degeneration
• Chronic patellofemoral overload
and tracking dysfuctions

47. Patellofemoral Disorders
• Diagnostics
• Xrays
• CT – useful for growth plate injuries
• MRI – chondromalacia
• Treatment
NSAIDs
RICE
Rehab
• Modalities (Cryo, TENS)
• Activity modification ( decrease
phase)
• Strengthening the quads with
short-arc (0-15 degrees) or straight
leg raise
• CCK - VMOs
• Patellar taping
• Surgery is considered if
conservative measures fail after 4-
6 months

48. Iliotibial band syndrome
• Common condition in runners
and cyclists
MOI
• ITB slides over lat. Femoral
condyle with knee flexion/
extension
Clinical Presentation
• Complain of sharp burning pain
at the lateral aspect of the knee
(lat femoral condyle or Gerdys
tubercle)
• (+) tenderness
• (+) Ober/ITB test

49. Diagnosis Treatment
• Imaging
• MSK Utz
• Xrays
NSAIDs
RICE
Rehab
• Modalities
• Stretching ITBs, gluts max and hip
flexors
• Strengthening (Gluts, TFL)
• Shoe modifications (increase
medial arch)

50. Patellar Tendon Rupture
• Often related to deceleration
injury
• Semiflexed knee, strong
contraction of quads, planted or
obstructed foot/leg
• Clinical Presentation
• Popping or tearing sensation
• Triad
• Pain
• Inability to actively extend knee
• Infrapatellar gap on palpation
• Hemarthrosis may make this
difficult

51. Diagnosis
• Imaging
• MSK Utz
• Xrays
• MRI
Treatment
Surgery
NSAIDs
RICE - Immobilizer
Rehab
• Modalities
• Post op protocol
• Phase I (0-2 wks) – Immobilize c dial
lock brace muscle sets, BUE
strengthening, crutch ambulation
• Phase II (2-6 wks) – continue brace,
0-90 knee flexion at 3wks, ROMEs,
patellar mobilizations
• Phase III (6-12 wks) – ROMEs upto
0-110 knee flexion CCK, Core
strengthening
• Phase IV (>12 wks) – sports specific
training

52. I-C. Lower leg Anatomy

53. Calf (gastroc-soleus) strain
• Occurs during eccentric phase of
muscle contraction and at the
myotendinous junction
• Repetitive activities of LE (Running)
Clinical Presentation
• (+) pain
• (+) tenderness
• (+/-) LOM
• (+/-) Echhymosis

54. Adductor strain
• Diagnostics
• Imaging
• Generally not needed
• MSK Ultrasound
• Xrays to R/O fractures
Treatment
• NSAIDs, RICE
• Rehab
• Modalities
• ROMEs
• Stretching
• Progress to strengthening
• Core stabilization
Protocol
• 1st-3rd week – GPS, PREs
• 3weeks - 6 months depends on
severity à return to sport

55. Compartment syndrome
• Osseofascial compartment
pressure rises to a level that
decreases perfusion may lead to
irreversible muscle and nerve
damage (Acute or Chronic)
• Etiology (trauma, tight casts,
dressings, or external wrappings
postischemic swelling, bleeding
disorders, arterial injury)
• 5 Ps
1. Pain w/ passive stretch ***
2. Paresthesias
3. Paralysis
4. Palpable swelling
5. Peripheral pulses absent

56. Compartment syndrome
Diagnostics
• Intramuscular compartment
pressure testing (Manometer)
• (+) if diastolic pressure minus the
intracompartmental pressure is
>/= 20mmHg
• MRI
Treatment
• Acute – ER Fasciotomy
• NSAIDs, RICE
• Rehab
• Modalities (Cryo, TENS)
• ROMEs
• Stretching
• Progress to strengthening

57. Medial tibial stress syndrome, (MTSS)
AKA “Shin Splint”
Overuse injury that results from chronic traction
on periosteum at periosteal – fascial junction
Periosteum detaches
Clinical presentation
Presents with gradual onset of pain along the
posteromedial border of the tibia
Pain worsens after activity can last a day
(+) Tenderness • Repetitive running

58. Diagnosis Treatment
• Imaging
• MSK Utz
• Xrays usually normal
• MRI – R/O stress fractures
NSAIDs
RICE
Rehab
• Modalities (Cryo, TENS)
• Stretching
• Pain free ROMEs
• Gradual resumption of activities
• 50% of pre injury level (distance /
intensity), soft level surfaces
• Orthotics – for overpronation

59. Stress fractures
• MC Tibia
• Repetitive loading causes
irreversible bone deformation à
Microfractures à overuse à
symptomatic stress fracture
• Commonly seen in running
sports
Causes
• Muscle imbalances, LLD
• Overpronation (genu valgum)
• Poor nutrition
• Vices
Clinical Presentation
• Pain worsens during activity
• Localized
• (+) Tenderness

60. Tibial stress fractures
• Diagnostics
• Xrays
• CT
• MRI
Treatment
NSAIDs
RICE – NWB 7-10 days
Splinting – short leg splint
Rehab
• Modalities (Cryo)
• Stretching
• Strengthening (Non impact activities –
cycling, swimming)
• Progress to impact activities after 1-2
weeks of pain free normal ambulation
• Orthotics
• Softer running surfaces
Appears 2-3 weeks after symptoms appear
Periosteal thickening 1st (lucency)

61. Ankle and Foot

62. I-D Ankle Foot Anatomy
Subtalar joint

63. Medial
Longitudinal Arch

64. Plantar Fascia as tie rod Weakened plantar fascia

65. Ankle Sprain
• Ankle sprains are responsible for
25% of all sports injuries in LE
• ATFL – MC ligament injured
• Lateral > Medial, Syndesmotic
• MOI: Inversion of plantar flexed
foot places foot in most
vulnerable to cause ligamentous
injury
Clinical Presentation
• Pain on weight bearing and
movement
• Swelling
• (+) tenderness
• (+/- ecchymosis)

66. Lateral Medial Syndesmotic

67. Special Tests

68. Ankle sprain Grading
• Grade I
• stretching and partial tear of ATFL with
only minimal swelling and pain.
• No instability
• Grade II (Moderate)
• Complete tear of ATFL with partial tear of
CFL.
• Diffuse pain, swelling and ecchymosis over
the lateral ankle.
• (+) Anterior Drawer
• Grade III (Severe)
• Complete tear of ATFL and the CFL
• (+) Anterior Drawer, (+) Talar tilt
• will not be able to bear weight on the
injured limb due to discomfort

69. Diagnostics
• Xrays
• APOL views
• Stress views
Treatment of Ankle Sprain
• Gr 1 and 2 Sprain
• Acute - NSAIDs, RICE, immobilize
• Early mob
• Rehab – modalities, AROMEs,
strengthening, proprioceptive ex,
taping, bracing, Dynamic
strengthening
• Gr 3 Sprain
• Conservative vs Surgery
• 6 months trial of rehab, 3 mos if
athlete
• Surgery if no improvements
(tenodesis)
• Treatment of High ankle sprain
• Conservative
• Surgical – Screw fixation

70. Ankle Fractures
• Injury patterns
• isolated medial malleolus fracture
• isolated lateral malleolus fracture
• bimalleolar and bimalleolar-
equivalent fractures
• posterior malleolus fractures
• Bosworth fracture-dislocations
• open ankle fractures
• associated syndesmotic injuries
Clinical presentation
• Severe pain
• Swelling
• LOM
• Inability to weight bear

71. Diagnostics
• Xrays
• APOL views
• Stress views
Treatment of Ankle Sprain
• RICE – Casting
• Surgery (ORIF, Ex Fix)
• Pain medications (NSAIDs,
Opioids)
Rehab post op
Phase I (0-6 weeks)
• Modalities
• ROMEs, stretching
• Crutch ambulation
Phase II (6-8wks)
• Strengthening
• FWB as tolerated
Phase III (>8 wks post op)
• Return to work, sports

72. Achilles Tendinopathy
• Repetitive eccentric overload causing
inflammation and microtears of
tendon
• Thickening and inflammation of the
peritendinous tissue
• Risk Factors:
• Increased activity (distance, speed, terrain)
• Reduced recovery time
• Change in recent footwear
• Flat feet
• Tight gastrocsoleus complex
• Muscle imbalance
Clinical feature
• Stiffening in morning
• Post ankle pain, swelling
• Tenderness

73. Achilles Tendinopathy
Diagnostic
• MSK Utz
• Xrays – R/O fractures
• MRI – reveal severity
Treatment:
• NSAIDs, RICE – Short immobilization (splinting)
~ 2-3 weeks
• Rehab
• Modalities – Cryo, Utz,
• Stretching (hamstrings, gastroc)
• Strengthening - theraband
• Orthotics
• Heel lift ¼ inch
M Childress, A Beutler. Management of Chronic Tendon Injuries. Am Fam Physician. 2013 Apr 1;87(7):486-490.

74. Achilles Tendon Rupture
• Repetitive microtrauma in a
relatively hypovascular area.
• Reparative process unable to keep
up
Clinical Presentation
• Sudden “audible snap” with
immediate swelling, ecchymosis,
weakness

75. Achilles Tendinopathy
Diagnostic
•MSK Utz
•MRI
Treatment:
• NSAIDs
• Conservative RICE – Immobilization in
brace, plantar flexed position for 8-12
weeks. Gradual ROMEs DF
• Surgical – Tendon repair, cast for 2
weeks à plantar flexion dial lock for
4-6 wks, slowly brought to neutral
• Rehab
• Modalities – Cryo
• Stretching
• Strengthening
• Orthotics
• Heel lift

76. Plantar Fasciitis
Inflammation of plantar fascia à
medial plantar heel pain
MOI
- Increased tension on plantar fascia à
chronic inflammation,
- Disorders causing tension:
- Poor biomechanics (pes cavus, pes
planus)
- Tight Achilles tendon and bone spurs
Clinical Presentation
• Pain worse in the morning at
start of wt bearing
• Pain upon hyperextension of
great toe with palpation of
plantar fascia
• (+) Tenderness

77. Plantar Fasciitis
Diagnosis:
- History and Physical
- Xray – R/O heel spurs
Treatment:
• NSAIDs, Steroids injections
• Rehab
• Modalities
• Calf/Achilles stretching (towel)
• Activation of Tibialis posterior
• Foot Strengthening
• Pick up pencils or marbles with toes
• Arch supports
• Weight loss
• Avoidance of unsupportive shoes, barefoot walking

78. References
• Braddom’s Physical Medicine and Rehabilitation 5th edition
• Delisa’s Physical Medicine and Rehabilitation 5th edition
• Physical Medicine and Rehabilitation Board Review 3rd edition
• University of Winsconsin Sports Rehabilitation Medicine Protocol -
https://www.uwhealth.org/files/uwhealth/docs/sportsmed/Adult_Rehab.pd