Dx & Rx ENG (JFE)€¦ · MTSS (shin splints) 2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch,...
Transcript of Dx & Rx ENG (JFE)€¦ · MTSS (shin splints) 2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch,...
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Dx & Rx of running injuries:
Practical aspects
Twitter: @JFEsculier
Jean-Francois Esculier PT, PhD
Postdoctoral fellow, University of British Columbia
Vice-President, Director R&D, The Running Clinic
PT, Allan McGavin Sports Medicine Clinic (UBC)
Plan
• Practice and discussion
• Practice and discussion!
• Practice and discussion!!
• Practice and discussion!!!
No stats, no strong science, no manual
and not so much theory...
Protectionvs
Adaptation
@JFEsculier
ITBSITBS
Stress Fx (distal)Stress Fx (distal)
PFPPFP
Plantar FasciapathyPlantar Fasciapathy
LBPLBP
MTSS (Shin Splints)MTSS (Shin Splints)
Tendinopathy (A, P, ...)Tendinopathy (A, P, ...)
Stress Fx (proximal)Stress Fx (proximal)
Tendinopathy (IP)Tendinopathy (IP)
Muscle StrainMuscle Strain
Range Repetition
Load
Pes AnserinusPes Anserinus
Injury typesdepending on the stress applied …increase load on
Maximalist running shoes
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…decrease load on
Maximalist running shoes
KISS
90%
5%
3%
2%
DxTx
Therapeutic relationship
Voltaire
The art of medicine
consists in amusing the
patient while nature cures
the disease.
Scanning the Lower Extremity
• Flexions: Squat test
• Extensions: Long strike on step
• Rotations: Body torque
Assess quality and quantity of movement at
each lower extremity joint:
Lower back-hip, Knee, Ankle-foot-hallux
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Functional ROM
• Flexion: Squat test
Functional ROM
• Extension: Long strike on step
Functional ROM
• Rotations: Body torque
Hip
Trochanteric bursitis
Dx:
- Lateral hip pain.
- Pain on palpation and swelling just
proximal to greater trochanter.
- Manual compression test +.
DDx : Femur, ilium, sacrum, lumbar, Coxo-femoral, sacro-iliac,
labrum, TFL-BIT, gluteus medius/minimus, gluteus maximus,
hamstrings, adductors, quadriceps, hip flexors, Lx radiculopathy,
lateral cutaneous nerve.
Proximal ITB syndrome
Dx:
- Lateral hip pain.
- Painful repeated movements.
- Pain on palpation proximal ITB (?).
- Compression stress test + (friction with
repeated hip flex/ext while in adduction,
weight bearing).
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Insertional ITB fasciapathy
Dx:
- Pain localized specifically at iliac tubercle
provoked by repeated pelvic drop
movements.
- Pain on palpation of iliac tubercle.
- Painful stretch of ITB in standing (weight
bearing hip adduction).
Gluteus medius tendinopathy
Dx:
- Pain superior to greater trochanter.
- Painful resisted hip abduction (stress at
different angles)
- Pain on palpation, superior to greater
trochanter.
Hip flexors tendinopathy
Dx:
- Pain in groin / anterior hip.
- Painful resisted hip flexion (test at different
angles). Differentiate from abdominal
muscles.
- Painful palpation anterior aspect of hip
(ASIS, AIIS, fascia).
Sacro-iliac joint Robinson 2007 Laslett 2003, 2008
Dx:
- Posterior pain, localized around PSIS (?)
- Pain provocation tests: FABER,
Compression, Distraction, Prone internal
rotation (ipsi or contralateral), Thigh thrust
(Minimum 3/5 positive tests and no centralization or directional preference)
Femoro-acetabular
impingementDx:
- Deep groin pain
- FADIR test + (anatomical?)
- Compensatory toeing-out
Femoro-acetabular
impingementDx:
- Deep groin pain
- FADIR test + (anatomical?)
- Compensatory toeing-out
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Labral tearSR 2008, Leibold
Dx:
- Deep groin pain.
- Perceived "clunk" (?)
- If FADIR, FABER, Fitzgerald and Thigh
thrust negative, labral tear is excluded
Currently, research has produced no tests with sufficient specificity to help confidently rule in a
diagnosis of hip labral lesion. Current best evidence indicates that a negative finding for the flexion-
adduction-internal rotation test, the flexion-internal rotation test, the impingement provocation test, the
flexion-adduction-axial compression test, the Fitzgerald test, or a combination of these tests provides
the clinician with the greatest evidence-based confidence that a hip labral lesion is absent.
Coxo-femoral capsular
patternDx:
- Restricted ROM and pain at end-range (?)
Femoral neck stress fracture
Dx:
- Deep pain, not localized on palpation
- Inconsistency in pain location during
resisted hip movements (pain not
suggestive of muscle involvement)
- Fulcrum test + (sitting at edge of table)
Proximal hamstrings
tendinopathyDx:
- Pain localized at ischial tuberosity (inferior
buttock pain).
- Painful activities: bending forward,
squatting, upstairs, prolonged sitting.
- Painful resisted movements, worse in
stretched/compression positions.
- Painful stretch/compression (SLR).
- Painful palpation.
Meralgia Paresthetica
Dx:
- Neural-type pain antero-lateral aspect of
the thigh (tingling, pins and needles,
burning).
- Decreased sensitivity to light touch.
- Neural tension tests + (PKB / HADD).
- Tinel's sign + (?)
T : � speed, avoid uphill and plyometrics
P : “doughnut” cushion for sitting (avoid compression)
E : Eccentric strengthening for hamstrings,
stretching (PRN)
MSQ… 180, minimalist
Proximal hamstring tendinopathy
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Kn
ee
Ottawa knee rules
Bone tenderness patella Bone tenderness fubular head
Inability to bear weight both immediately after the injury and in the emergency department
Inability to flex the knee more than 900
Patellofemoral pain2013-Lankhorst, 2013-Osorio, 2013-Toumi, 2012-Dolak, 2012-Jessee, 2009(SR)-Fagan, 2005-Aminaka, 2003-D’hondt
Dx:
- Anterior knee pain, pain with squatting.
- 3 painful activities among: running,
walking, kneeling, upstairs/downstairs,
prolonged sitting
- Clark compression test + (?).
- Painful resisted knee extension 20-45°.DDx : tibial plateau, tibial tuberosity, patella, femoral condyles,
bursae, hoffa fat pad, synovial plica, menisci, patellar tendon,
quadriceps tendon, VMO, tibialis anterior, lateral retinaculum,
saphenous nerv (infra-patellar branch), lateral/medial/intermediate
cutaneous nerves of thigh
Prepatellar bursitis
Dx:
- Pain localized just proximal to patella with
edema (not always apparent).
- Painful palpation.
- Painful passive end-range knee flexion.
- Cutaneous tension/release test +.
Fat pad syndrome (Hoffa)
Dx:
- Infra-patellar pain.
- Painful palpation medial and/or lateral to
patellar tendon.
- Painful end-range passive extension
- Hoffa test +.
Patellar tendinopathy
Dx:
- Infrapatellar pain, localized on patellar
tendon.
- Painful activities: deep squats, kneeling.
- Painful palpation of patellar apex.
- Painful resisted knee extension 90-120°.
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Quadriceps tendinopathy
Dx:
- Suprapatellar pain.
- Pain on squatting.
- Painful palpation of quadriceps
attachment on patella (superior).
- Painful resisted knee extension 90-120°.
Pediatric apophysitis
Osgood Schlatter
Sinding-Larsen-Johansson
Lateral retinaculatis
Dx:
- Pain on lateral aspect of patella during
flexion/extension movements at the knee.
- Pain on palpation lateral border of patella.
- Pseudo-Ober test + (selective tension of
lateral retinaculum by flexing knee on
Ext/Add hip)
Pes anserinus tendinopathy
Dx:
- Pain localized at pes anserinus (bursitis more
than tendinitis? Extension of intra-articular edema?).
- Painful repeated movements.
- Resisted movements rarely painful
(gracilis, sartorius, semitendinosus).
- Painful palpation, edema.
Iliotibial band syndrome2013-Louw, 2012-Meardon, 2005-Hoch, 1979-Noble
Dx:
- Non-traumatic lateral knee pain.
- Painful repeated flex/ext (running).
- Painful palpation of lateral femoral
epicondyle.
- Noble test + (friction around 30° flexion).
Superior tibiofibular joint
Dx:
- Lateral knee pain.
- Painful palpation of superior tibiofibular
joint.
- Painful passive joint mobilisation (90° of
knee flexion with relaxed biceps femoris).
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Biceps femoris tendinopathy
Dx:
- Pain at posterolateral aspect of knee
during activities involving knee flexion.
- Pain on palpation of tendon (squeeze).
- Painful resisted knee flexion + external
rotation while at 90° of flexion.
- Straight Leg Raise (SLR) stretch.
Tendinopathy of popliteus
Dx:
- Lateral knee pain.
- Painful palpation of lateral tibiofemoral
joint line.
- Garrick test + (resisted knee flexion + IR
while at 20° of knee flexion).
Common fibular neuropathy
Dx:
- Neural-type lateral knee pain (tingling,
numbness, burning).
- Painful palpation along path of common
fibular nerve.
- Decreased nerve conductivity?
- Neural tension test + (SLR, ankle
inversion + plantarflexion).
Sciatica?
Dx:
- Posterior knee pain
- SLR / Slump test +.
Baker's cyst Patellofemoral pain2015-van der Heijden(CR), 2015-Lack(SR), 2015-Santos(SR), 2015-Alba(SR), 2013-Lankhorst, 2013-Osorio, 2013-
Toumi, 2012-Dolak, 2012-Jessee, 2009(SR)-Fagan, 2005-Aminaka, 2003-D’hondt
T: � volume, speed, avoid downhill
gait retraining
P: Neuro-proprioceptive taping2015-Chang (SR), 2015-Leibbrandt (SR), 2014-Barton (SR)
E: Hip strengthening, Quadriceps
strengthening, Core strengthening,
Lower limb control
MSQ… 180, minimalist
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Patellofemoral pain2016-Crossley
Patellofemoral pain
Weeks
1-2
Weeks 3
-4
Patellofemoral painExercises
@JFEsculier
Weeks
5-6
Weeks 7
-8Patellofemoral pain
Exercises
@JFEsculier
T: � volume, avoid downhill, maintain
intensity, 1’walk, avoid straight line
P: Neuro-proprioceptive taping, massage ,
NSAID (per os, gel, corticosteroids)
E: Hip strengthening (Abductors)
Step down (increase demand on control / increase loading)
Iliotibial band syndrome2013-Louw, 2012-Meardon, 2005-Hoch, 1979-Noble
MSQ… 180, minimalist
T: � intensity, volume, avoid downhill
P: “Levy” strap
E: Isometric knee extension at 45°of
knee flexion; Concentric/Eccentric;
Eccentric strengthening of quadriceps
Patellar Tendinopathy
MSQ… 180, minimalist
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Fo
ot
Ottawa ankle rules
Bone tenderness at posterior edge (distal 6 cm) or tip of lateral malleolus
Bone tenderness at posterior edge (distal 6 cm) or tip of medial malleolus
Inability to bear weight both immediately after the injury and in the emergency department
Bone tenderness at base of fifth metatarsal
Bone tenderness at navicular bone
MTSS (shin splints)2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker
Dx:
- Pain at posteromedial tibial crest.
- Painful palpation of medial tibial diaphysis
(large zone).
MTSS (stress fracture) 2013-Liem, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker
Dx:
- Pain at posteromedial tibial crest.
- Local edema.
- Painful localized palpation of the medial
tibial crest.
- Fulcrum test +.
MTSS (stress fracture) 2014-Warden
Compartment syndrome
• Pain during activity.
• Increases in intracompartmentalpressure can potentially cause neural or vascularsymptoms.
Increases in muscle volume (+25%) during activity is
greater than the compartment's capacity.
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T: � speed, avoid hills and plyometrics
P: Taping (circular or butterfly)
Desensitization (myofascial release)
US for stress fracture (0.05w/cm2, 20’, 4x/week)
E: Calf stretch (PRN)
Heel drop program (adaptation)
MTSS & Stress fracture2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker
MSQ… 180, minimalist
Chronic exertional
compartment syndrome2013-Waterman
Dx:
- Pain of potentially severe intensity at the
anterior part of the leg (lateral of tibia)
after several minutes of exercise.
- Painful activity: running with a significant
rearfoot strike.
- No clinical signs aside from pain during
effort.
T: Avoid downhill
P: 180, forefoot, low drop shoes
E: Skipping
Ant. compartment syndrome2015-Helmhout, 2013-Waterman, 2012-Diebal
180, minimalist
Achilles tendinopathy
Dx:
- Pain located at Achilles tendon.
- Pain during hopping, jumping, running.
- Royal London Hospital test +
- Squeeze test palpation.*Differentiation between mid-portion and insertional
tendinopathy will help focusing treatment aproach.
Retrocalcaneal bursitis
Dx:
- Pain located anterior to Achilles tendon.
- Pain during walking with increased ankle
dorsiflexion (uphill).
- Negative Royal London Hospital test.
- Painful palpation just proximal to
calcaneus.
- Potential edema.
Haglund's syndrome
Bony exostosis caused by repeated traction of Achilles on calcaneus. Treat just like persistent insertional Achilles tendinopathy.
*Avoid tendon compression component during early stages of rehab*
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Calcification
Tendon condition sometimes associated withpersistent tendinopathy. Treat like persistent Achilles tendinopathy. Shock wave therapycould be indicated if longstandingsymptoms.
Pediatric apophysitis
Sever's disease
Appropriate load management to allowrecovery and decreased symptoms / improved function.
T: � speed, avoid uphill
P: Neuro-proprioceptive taping (?)
Desensitization (calf massage)
E: Isometric program with plantarflexed
ankle; Heel drop program (adaptation)
Calf stretch (PRN; avoid if insertional tendinopathy!!!)
Achilles Tendinopathy
MSQ… 180
T: � speed, avoid hills
P: Neuro-proprioceptive taping (?)
Plantar orthoses
E: Heel drops with elastic pulling medially (adaptation)
Strengthening foot intrinsics (dynamic support)
Calf stretch (PRN)
Tib post Tendinopathy
MSQ… 180, minimalist
Plantar fasciapathy2008-Neufeld, 2003-DiGiovanni
Dx:
- Pain located anteromedial to calcaneus
- Morning stiffness.
- Pain with toe walking, jumping, hopping,
running.
- Painful palpation at proximal insertion of
plantar fascia, best without tension in
plantar fascia by flexing hallux.
Heel spur
• Bony exostosis at proximal insertion of plantar fascia secondary to repeatedtractions.
Found in 10 - 30 % of
asymptomatic people;
Represents 50 - 75 % of heel pain.
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Fat pad syndrome (foot)
2012-Dragoo
Dx:
- Pain inferior to calcaneus (central or
sides).
- Pain during heel walking.
- Painful palpation central and inferior of
calcaneus.
(periostitis inferior of calcaneus?)
T: � speed, avoid uphill and plyometrics
P: Neuro-proprioceptive taping
Orthoses (?)
Desensitization (massage)
E: Strengthening foot intrinsics (dynamic support)
Heel drop program (adaptation)
Calf stretch (PRN)
Plantar Fasciapathy2015-Rathleff, 2008-Neufeld, 2003-DiGiovanni
MSQ… 180
T: � downhill
P: 180, forefoot,
Taping, gel pad (?), plantar orthoses
Shoes with lower drop
E: Heel drop program (adaptation)
Fat pad syndrome (heel)
2012-Dragoo
MSQ… 180
Metatarsalgia
Dx:
- Pain located on the plantar aspect of
metatarsal heads.
- Pain during toe walking, jumping, hopping.
- Painful palpation of plantar aspect of
metatarsal heads.
T: � speed, avoid uphill and plyometrics
P: Metatarsal support, cushioned insole,
plantar orthoses
E: Strengthening foot intrinsics
Metatarsalgia
MSQ… 180
Metatarsal stress fracture
Dx:
- Pain located on dorsal aspect of foot.
- Local edema.
- Sharp pain on palpation of metatarsal
diaphysis.
- Fulcrum test +.
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T: � speed, avoid uphill and plyometrics
P: Taping, rigid sole, high drop shoes
E: Strengthening foot intrinsics
Metatarsal stress fracture
MSQ
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