Lower Extremity Musculoskeletal Exam Techniques ...1 Lower Extremity Musculoskeletal Exam Techniques: Evidence-Based Treatment Anthony Beutler, MD, FAAFP ACTIVITY DISCLAIMER The material

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Lower Extremity Musculoskeletal Exam Techniques:

Evidence-Based Treatment

Anthony Beutler, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Anthony Beutler, MD, FAAFPProfessor, Department of Family Medicine/Program Director, National Capital Consortium (NCC) Primary Care Sports Medicine Fellowship/Medical Director, Injury Prevention Research Laboratory, Uniformed Services University (USU) of the Health Sciences, Bethesda, Maryland

Dr. Beutler practices family medicine and comprehensive primary care sports medicine for the U.S. Air Force, caring for active-duty service members, retirees, and their families in the Washington, DC, area. He is an award-winning educator and teacher, and he and his team recently developed and implemented a new musculoskeletal curriculum for USU's medical school. The author of numerous articles and a textbook, Dr. Beutler has lectured throughout the world. One of his favorite activities is helping family physicians make their musculoskeletal practices more rewarding and profitable.

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Learning Objectives1. Distinguish musculoskeletal conditions that result from overuse/repetitive motion

injuries in the lower extremities, with particular attention to those that occur in pediatric patients.

2. Assess an injured patient’s range of motion, stability, bone alignment, soft tissue swelling, palpable warmth or mass(es), pain or tenderness and crepitation in the lower extremities.

3. Apply appropriate treatment strategies for patients with musculoskeletal injuries in the lower extremities that include pain management, application of the RICE strategy, casting, splinting, joint injection/ aspiration, dislocation reduction and/or emergency stabilization.

4. Identify red flags from the physical examination of lower extremity injuries that warrant referral to a sub-specialist (e.g. surgery, physical therapy) or for diagnostic imaging.

Audience Engagement SystemStep 1 Step 2 Step 3

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Associated Session

• (PBL) Upper & Lower Extremity Musculoskeletal Exam Techniques: Evidence-Based Treatment

Overview• Facts and Philosophy• 3 Common Conditions

– Victims and Culprits– Myths, Legends & Mystical Truths– Evidence-Based Treatment

• Coding Minute• Annoying Editorial Comments

Better Diagnose, Treat, and Code for Musculoskeletal Medicine

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AES Question #1

Tell me about you...Who are you?

1. Family Medicine Resident

2. Family Medicine Staff or Family Med Trained

3. Peds

4. Other

AES Question #2

Have You Previously Attended an MSK Session That I Have Taught?

1. Yes, at this AAFP conference.

2. Yes, at a previous AAFP or other conference.

3. No. And why is your nose so big?

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AES Question #3

How Comfortable Are You Diagnosing & Treating Common MSK Problems?

1. Not at all comfortable

2. Comfortable with the basics

3. Fairly comfortable with MSK

4. Confidently diagnose & treat MSK

Facts and Philosophy

Editorial CommentHow much Musculoskeletal Medicine (MSK) do

you See?

• 22-34% of outpt visits (civilian) for MSK complaints

• How much Musculoskeletal Medicine will you Know?

• MSK = 2% of Med School Curriculum (US & Canada)

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Two Areas of Difficulty

• Proper History and Physical leading to correct Diagnosis

• Proven-Effective Treatments for the Correct Diagnosis

• 32 yo male with R heel pain

• Recently “started running to get fit”

• Hurts to run, but he can run through pain

• No PMHx– no previous h/o pain

– no previous h/o running

• Hurts worst with 1st step in AM

3 Common Culprits & Victims

Case #1

Exam:

Normal appearance

TTP medial calcaneal tubercle

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AES Question #4

What is most likely the correct diagnosis?

A. Plantar fasciitis

B. Calcaneal stress fracture

C. Achilles tendinopathy

D. Tarsal tunnel syndrome

• NOT an inflammatory condition (not an “–itis”)

• Microtears of the plantar fascia

• Subsequent collagen degeneration

Plantar Fasciitis

Pathoanatomy

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Clues to Diagnosis• Pain worst with first steps

• Classic TTP medial tubercle of calcaneus

• Dull “toothache” daytime pain

Plantar Fasciitis

Diagnosis

Like Real Estate: Location, Location, Location….

Achilles Tendinopathy

Plantar Fasciitis

Differential Diagnosis

Tarsal Tunnel

Plantar Fasciitis

InsertionalAchilles

Pain

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Take Your Right Shoe Off

• Identifying The VICTIM– That’s easy

• Identifying The CULPRIT– Most common error:

Not Identifying/Treating the Culprit

Plantar Fasciitis

Victims & Culprits

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AES Question #5

What is the Best Initial Treatment for Plantar Fasciitis?

1. Steroid Injection

2. NSAIDs & Heel Cups

3. Stretching & Strengthening Ex.

4. New Running Shoes/Orthotics

Victim– Plantar Fascia

Culprits– Tight Heel Chord

(70%)

Plantar Fasciitis

Victims & Culprits

15 deg Dorsiflexion!

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Heel Strike Mid Foot Stance Supination Pronation

Re-Supination Heel Off Blah, Blah Blah….

15 degDorsiflexion

X X XHeel Off

Plantar Fasciitis

Biomechanics of Walking 101


Culprits– Tight Heel Chord (70%)– Training Error– Muscular Weakness– Overpronation– Shoes

Plantar Fasciitis

Victims & Culprits

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Culprits– Tight Heel Chord (70%)– Training Error– Muscular Weakness– Overpronation– Shoes

Treatments NSAIDs

Heel Pads/Cups

Steroid Injection

Ionto/phonophoresis

Plantar Fasciitis

Treatments for Victims & Culprits


Culprits– Tight Heel Cord (70%)– Training Error– Muscular Weakness– Overpronation– Shoes

Treatments NSAIDs Heel Pads/Cups Steroid Injection Ionto/phonophoresis

Heel Cord Stretching Increase 10% per wkTowel Drag ExercisesOrthoticswww.aapsm.org

Plantar Fasciitis


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Plantar Fasciitis

TreatmentFirst Line• Stretching of Achilles/PF

– a MUST for prolonged relief• Strengthening

– calf & foot intrinsics– strong muscles absorb shock that

would otherwise injure fascia• Ice• Activity Modification

– Decrease running to 50% pre-injury level

– If pain changes gait, d/c running

Berbrayer D, PM R, 2014Covey CJ, J Fam Pract, 2013

Altman JR, Br J Sports Med, 2015

Plantar Fasciitis - TreatmentSecond Line

• Orthotics– first line for those with significant pes planus/cavus– “off-the-shelf” for 1st time PF

• Night Splints– most helpful for chronic PF pain (w/ stretching)– excellent for 1st step AM pain

• Steroid Injection– effective for short-term pain control– use proper injection technique

• Referral Therapies – 3rd Line Treatments– Platelet Rich Plasma (PRP) Injection– Extra-Corporal Shock Wave Therapy

• Surgery– Recommend 12 months of conservative tx first

Berbrayer D, PM R, 2014Covey CJ, J Fam Pract, 2013Hsiao MY, Rheumatology, 2015Gollwitzer H, J Bone Joint Surg Am, 2015

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Plantar Fasciitis

Patient Speak

But Doctor, what about my heel spurs?

Stretch & Strengthen!

Plantar Fasciitis

Patient Speak

But Doctor, what about my ibuprofen?

“Ice, Ice, Baby!!!”

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Welcome to the GRAMP-C’s

“Great Research; And Maybe Practice-Changing”

Fantastic Reviews Awards“Updates on Evidence-Based Treatments for Plantar Fasciopathy”

&

“Plantar Fasciitis: How Best to Treat?”

Both Well-Done Reviews of Primary Care Treatment of Plantar Fasciitis

- Recommended Reading!!

Conclusions:

#1 – Stretching and orthotics still work well for Plantar Fasciitis.

#2 – Stretching works even better if a Big Hunk Trainer helps you do it!

Berbrayer D, Fredericson M. Update on evidence-based treatments for plantar fasciopathy. PM R. 2014 Feb;6(2):159-69. doi: 10.1016/j.pmrj.2013.08.609. Epub 2013 Dec 21. Review. PubMed PMID: 24365781.

Covey CJ, Mulder MD. Plantar fasciitis: How best to treat? J Fam Pract. 2013, Sep;62(9):466-71. PubMed PMID: 24080555

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2014-2015 – Masochistic 3rd Line TherapiesLots of Studies about Steroid Injections

vs Platelet Rich Plasma Injections

vs Organic Bear Snot Injections

vs Etc.What does it all mean?

Summary:#1 – What can you do in your office?#2 – Steroid injections ARE effective for pain relief, probably 3-6 weeks.#3 – PRP might be more effective… but not much!#4 – Ultrasound-guided injection might be more effective than palpation guided… but not much!

Li Z, Corticosteroid versus placebo injection for plantar fasciitis: A meta-analysis. Exp Ther Med. 2015Hsiao MY, Comparative effectiveness of aut blood-derived products, shock-wave therapy, CSI, Rheumatology (Oxford). 2015

Franceschi F, Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review. Br Med Bull. 2014Li Z, Ultrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis. PLoS One. 2014

What’s the Deal with Shock Wave Therapy?

“Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study”

Good study (246 patients!), definitively proves:

• Shock Wave Therapy is PAINFUL!!!!

• Shock Wave better than placebo for people with 6 months or more of pain

– 69% shock wave vs 35% placebo group at 12 weeks

– Less difference (but still significant) at 1 year

My Conclusion:

• Before having surgery, patients should consider shock wave

“Shock wave therapy works better if patients continue their plantar fascia stretching program!!”

Gollwitzer H. Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis. J Bone Joint Surg Am. 2015 May 6;97(9):701-8

Rompe JD. Radial shock wave treatment alone is less efficient than radial shock wave treatment combined with tissue-specific plantar fascia-stretching in patients with chronic plantar heel pain. Int J Surg. 2015

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Culprits– Tight Heel Cord (70%)– Training Error– Muscular Weakness– Overpronation– Shoes

Treatments

NSAIDs Heel Pads/Cups Steroid Injection Ionto/phonophoresis

Heel Cord/PF Stretching Increase 10% per wk Towel Drag Exercises Orthoticswww.aapsm.org

Plantar Fasciitis


#1- Stretch, Strengthen, #2 – Orthotics, #3 – Steroid Injection

Overview• Overview of Musculoskeletal Exam• 3 Common Conditions

– Victims and Culprits– Evidence-Based Treatment


Case 1 – Plantar FasciitisCase 2 –Case 3 –

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• 38 yo male with L ankle pain

• Was playing tennis yesterday afternoon and…

• He is limping, but can bear weight

• PMHx “weak ankles,” no surgeries

Common Culprits & Victims

Case #2

• Swollen, esp lateral, echy

• No TTP over shaded areas

• Very TTP antero-distal to lateral malleolus

• Xrays – tech on vacation to Ottawa…

5 Common Culprits & Victims

Case #2Exam:

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• Why the Anterior Talo-Fibular Ligament (ATFL)?– Biomechanics 101– The “buckle point”

• Why do I care?

Medial Sprains are scary!

Differential Diagnosis:• Ankle Fracture

• Foot Injury

Lateral Ankle Sprain

Differential Diagnosis

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Differential Diagnosis:• Ankle Fracture

• Foot Injury

• Other Sprains:– Medial Ankle Sprain

– Tibialis posterior or peroneal tendons

– Syndesmotic (High Ankle) Sprain


Differential DiagnosisLateral

Medial

Victim– ATFL

Culprits– The Tennis Court? – Loss of Motion– Loss of Strength– Loss of Balance

(Proprioception)


Victims & Culprits

For Re-Injury

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AES Question #6After a Grade I-II Ankle Sprain, How Long Should You Wear an Ankle Brace?

A. Not at allB. 6-8 daysC. 6-8 weeksD. 6-8 monthsE. Indefinitely

Victim– ATFL

Culprits

Treatments RICE

NSAIDs

Brace



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Victim– ATFL

Culprits– Loss of Motion

– Loss of Strength

– Loss of Proprioception

Treatments RICE NSAIDs Bracing

ABC Exercises

Towel Drag Exercises

Balance Drills



For Re-Injury

Medial Ankle Sprain– Be skeptical & cautious

It’s a sprain, but patient can’t walk…– Need a brace?– Need crutches?


Thinking Points

Medial

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Medial Ankle SprainIt’s a sprain, but patient can’t

walk…What brace do I use and for

how long?– Who is your patient?– Decrease re-injury rates for 6-8

monthsWhen should pt come back if

not better?– 6 weeks


Thinking Points



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Best Ankle Sprain Reviews of 2012 & 2017 (and Probably All Time!)

“How can we minimize recurrent ankle sprains”

• #1 - Wear Ankle Braces (SOR: A)– Lace-up, semi-rigid braces prevent primary and secondary injury

– Bigger effect in secondary prevention, but still significant in primary

– NNT – 22 (combined 1º and 2º)

• #2 - Do Balance Training (SOR: A)– Effective for primary prevention: NNT = 22

– VERY effective for secondary prevention: NNT = 9Hemphill B, J Fam Pract, 2011 Dec 60(12): 759-60

- Doherty C, et al. Br J Sports Med 2017;51:113–125

So Which is Better?Bracing, Balance Training, or Combination

“Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomized controlled trial”

• 3 Arm RCT (n=384!) looking at re-sprain rate after 1 year1. Balance training for 8 weeks

2. Semi-rigid brace with sport activity for 12 months

3. Combination (balance x 8 wks; brace w/ sport x 8 wks)

Jandsen KW, Br J Sports Med, 2014 & Am J Sports Med 2014

= 27% recurrence

= 15% recurrence

= 19% recurrence

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So Which is Better?Bracing, Balance Training, or Combination

“Bracing superior to neuromuscular training for the prevention of self-reported recurrent ankle sprains: a three-arm randomised controlled trial”

• 3 Arm RCT (n=384!) looking at re-sprain rate after 1 year1. Balance training for 8 weeks

2. Semi-rigid brace with sport activity for 12 months

3. Combination (balance x 8wks; brace w/ sport x 8 wks)

• Bracing also results in significant cost savings!

• Speaking of Cost – Home PT = Referral PT efficacy for ankle sprain– And Home PT much LESS Cost Jandsen KW, Br J Sports Med, 2014 & Am J Sports Med 2014

- Brison RJ, The BMJ, 2016 Nov 16; 355: i5650

= 27% recurrence

= 15% recurrence

= 19% recurrence

Patient Speak:But Doctor, I Can’t Jump in Braces!

“Effects of prophylactic ankle bracing on dynamic reach distance and obstacle course performance in military cadets”

• 37 Healthy military cadets • Did obstacle course and functional measures with & without bracesFindings:#1 – Small difference in range of motion when braced#2 – NO DIFFERENCES in agility, run-times, or other performance

measures

Your Answer: “Suck It Up and Wear Your Brace!”Newman T, Mil Med, 2012 May 177(5):567-72

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Victim– ATFL

Culprits– Loss of Motion

– Loss of Strength

– Loss of Proprioception

Treatments RICE NSAIDs Bracing

ABC Exercises

Towel Drag Exercises

Balance Drills



For Re-Injury

#1- Triple Therapy Rehab, #2 – Brace x 8-12 mo, #3 – Re-eval after 6 wks




Case 1 – Plantar FasciitisCase 2 – Lateral Ankle SprainCase 3 –

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• 28 yo female with bilateral knee pain for 6 weeks

• No trauma, PSHx

• No swelling, locking, or giving way

• Started an exercise program (on your advice) 8 weeks ago

• Hurts worst going up and especially down stairs


Case #3

AES Question #7

What is your most likely diagnosis?A. Meniscus Injury

B. ACL Tear

C. Patellofemoral Pain

D. Iliotibial Band Pain Syndrome

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• Pain syndrome – accounts for ~ 90% of knee pain to military primary care clinics

• Unclear link with osteoarthritis

• Natural Selection vs Military Recruitment

Synonyms• Patellofemoral Synd• PFPS• PFCS• Anterior Knee Pain

Patellofemoral Pain

Epidemiology

Keeping Train on Tracks• Biomechanical imbalance → pain in

peri-patellar structures• Many possible pain generators

Diagnostic Clues• Bilateral• Vague, no discrete injury• Pain with stairs, esp. down• Theatre sign• “Effusion” very uncommon

Patellofemoral Pain

Pathoanatomy & Diagnosis

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AES Question #8What is the best treatment for patellofemoral pain?

A. 21-day course of NSAID at anti-inflammatory dosage range

B. Rest, Ice, Compression and slow return to activity

C. Kinesio tape or patellar bracingD. Quadriceps & core strengthening exercises

Patellofemoral Pain

Best Treatment

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CSI Musculoskeletal

3 Prevalent MythsWool, Cashmere, and NSAIDs

Patellofemoral Pain

The Dirty Truth About NSAIDs

• “There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS.”

–Cochrane Review 2007

Heintjes E, Berger MY, Bierma-Zeinstra SMA, Bernsen RMD, Verhaar JAN, Koes BW. Pharmacotherapy for patellofemoral pain syndrome (Cochrane Review). In: The Cochrane Library, Issue 1, 2007.

Chichester, UK: John Wiley and Sons, Ltd.

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Victim– Patellofemoral Joint

Culprits– Muscle Tightness

• Quads, Hams, Gastroc– Muscle Weakness

• Quad, Glut Medius– Mal-alignment

• Pes planus, patellar tilt

Patellofemoral Pain

Victims & CulpritsTreatments

RICE – Acute 4 Chronic

NSAIDs – Acute 4 Chronic

Brace – Works well 4 few

Hamstrings Popliteal Angle

Normal: Women ~0°

Men < 30°

Patellofemoral Pain

Assess for Muscular TightnessPopliteal Angle

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Quadriceps & Hip Flexor Modified Thomas Test

Patellofemoral Pain

Assess for Muscular Tightness

Tight Hip Flexor

Tight Quadriceps


Quadriceps & Hip Flexor Modified Thomas Test

Gastrocnemius You already know 15° dorsiflexion

Patellofemoral Pain

Assess for Muscular Tightness

15° Dorsiflexion!

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Quadriceps Listen

LOOK

Single Leg Squat

Patellofemoral Pain

Assess for Muscular Strength

Quadriceps Listen LOOK Single Leg Squat

Gluteus Medius Single-leg stance Single-leg squat Step-down

Patellofemoral Pain


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Patellofemoral Pain




Patellofemoral Pain


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Pes Planus

Patellofemoral Pain

Assess Anatomic AlignmentWhether the problem is the track or the train….Derailment is BAD!






Patellofemoral Pain





Popliteal Angle, Thomas Test, 15° dorsi

Single Leg Squats & Single Leg Step-Downs

Orthotics (OTC vs Custom)

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Feel Like You’re Drowning?

Annoying Editorial Comment• How to Find a Good Physical Therapist

– Fingers do the walking– Phone a friend

– Refer patellofemoral pain• If patient returns with stretching, strengthening =Good Therapist!• If patient gets lots of ice, heat, and fancy gels =Don’t waste your time….

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Welcome to the GRAMP-C’s“Great Research; And Maybe Practice-Changing”

Best Patellofemoral Articles

3 Incredible Reviews of Effective Therapy for Patellofemoral Pain

What Do They All Say?

1. Muscle strengthening exercise therapy is best treatment for PFP

2. Exercise therapy works better if a big hunk trainer helps you do it!

- van der Heijden RA. Cochrane Database Syst Rev. 2015

- Covey CJ. J Fam Pract. 2014

- Crossley KM, BJSM, 2016

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Best Patellofemoral ArticlesA Closer Look

Cochrane Review:

“… consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery.”

Rixe et al:

“The most effective… treatment modality for patients with PFPS is… strength training of the quadriceps and hip abductors and stretching of the quadriceps muscle group.”

“Adjunctive therapies, including taping, biofeedback devices, and prefabricated orthotic inserts, may provide limited additive benefits in select populations.”

Back to Cochrane:

“hip plus knee exercises may be more effective in reducing pain than knee exercise alone.”

- van der Heijden RA. Cochrane Database Syst Rev. 2015

- Rixe JA. Phys Sportsmed. 2013

Maybe You DO Need to Look For Risk Factors!

Additional Effects of an Individualized Risk Factor-Based Approach on Pain and the Function of Patients With Patellofemoral Pain

Syndrome: A Randomized Controlled Trial

53 patients with PFPS randomized to standard or tailored rehab• Findings:Both groups improved But TAILORED rehab group showed greater pain relief

- Halabchi F, Clin J Sports Med, 2015

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Patellofemoral Pain





Popliteal Angle, Thomas Test, 15° dorsi

Single Leg Squats & Single Leg Step-Downs

Orthotics

#1- Strengthen Quads/Hip/Core, #2 – Supervised/Expert Rehab, #3 –Orthotics/Brace




Case 1 – Plantar FasciitisCase 2 – Lateral Ankle SprainCase 3 – Patellofemoral Pain

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Coding MinuteTake Credit for What you Do

• Military Disclaimer

Coding MinuteTaking Credit for What you Do

5 Dos and Don’ts of Coding

1. Do capture time required for:– Exercise Teaching (E&M or CPT 97110)

– Crutch Training (E&M or CPT 97116)

– Brace Fitting and Care Coordination (E&M)

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1. Do capture time required

2. Don’t forget to code injections– Most injections - CPT 20610



1. Do capture time required

2. Don’t forget to code injections

3. Do use a 25 or 29 modifier– Diagnosis and treatment in same visit requires

the modifier in many states

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5 Dos and Don’ts of Coding1. Do capture time required2. Don’t forget to code injections3. Do use a 29 modifier4. Don’t forget to bill Durable Medical

Equipment– Ankle braces, crutches, etc…


5 Dos and Don’ts of Coding1. Do capture time required2. Don’t forget to code injections3. Do use a 29 modifier4. Don’t forget to bill DME5. Do phone a friend

– Orthopedic coder– Ortho P.A.– Ortho R.N.

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Case 1 – Plantar FasciitisCase 2 – Lateral Ankle SprainCase 3 – Patellofemoral Pain

Practice Recommendations• Plantar Fasciitis:

1st Line: Stretching and Strengthening Exercises (See handouts)

2nd Line: Orthotics (Start with over the counter)

3rd Line: Steroid Injection (For pain causing limp or recalcitrant symptoms)

• Ankle Sprain:1st Line: ROM, Strength, and Balance (See handout)

2nd Line: Brace for 8-12 months!

3rd Line: Re-evaluate if still painful after 6 weeks

• Patellofemoral Pain:1st Line: Strengthen Hips/Quad/Core

2nd Line: Supervised Strengthening (Find a good PT or Athletic Trainer)

3rd Line: Orthotics/Bracing

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Questions

Contact Information

Anthony Beutler, MDColonel, USAF, MC

Professor, Dept Family Medicine

Uniformed Services University

[email protected]

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• 56 yo female with L hip pain for a week

• No trauma, may have banged it into a door a few weeks ago

• Pain runs down outside of thigh down to knee

• Hurts to get out of a chair and to lay on L side

• Getting so bad she can hardly walk


Hip Case

• Hip Pain & Leave Paperwork– Hip-Joint– Hip-Groin – Hip-SI– Hip-Lspine– Lateral Hip– Hip-Pelvis– Hip-Abdomen

• Press on the Troch Bursa before the triplicate


Hip Case

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Trochanteric Bursitis

DiagnosisClues to Diagnosis• Any lateral hip pain• Pain running down toward knee• Wide spectrum of pain• No matter the history, always press

on the troch bursa

Differential Diagnosis• Anything….


Treating Victims & Culprits

Victim:– Troch Bursa

Culprits:

Treatments RICE

NSAIDs

Phonophoresis

Steroid Injection

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Pathoanatomy• Gluteus Medius is Key

– Keeps hips level


Treating the Culprits• Gluteus Medius

Strengthening– Single-leg step downs– Lateral leg lifts– Hula Girl exercises

• Iliotibial Band Stretching– A good idea in theory– Mixed practical results

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Inject First, Ask Questions Later…..• Steroid Injections vs NSAIDs

– No head-to-head studies

– Retrospective study:• Patients receiving injection 3X more likely to be pain free

after 3 months

• If pain recurs or patient is young/athletic:Find & Treat the Culprit


Treatment

-Lievense A et al Br J Gen Pract 2005

-Shbeeb MI, J Rheum, 1996



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Most Ostentatious Troch Bursa Article – 2012

“Management of the greater trochanteric pain syndrome: a systematic review”

• Reviewed all clinical trials EVER• 14 papers using conservative vs surgical treatments

Findings:• Repeated Shock Wave Therapy or Home PT Exercises

– Both = 80% relief at 15 months• All other treatments “Need More Study”

-Del Buono A, Br Med Bull, 2012 Jun; 102

They’ve Changed the Name, but Treatment the Same?

“Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care”

• Open label, multicenter randomized clinical trial• 120 patients visiting Dutch GP’s received:

– Steroid injection (60)– Usual care (home PT, NSAIDs, n=60)

Findings:• At 3 months:

– 34% usual care, 55% steroid inject “recovered”– Significantly less pain in steroid injection group

• At 12 months: No Difference between groups

- Brinks A, Ann Fam Med. 2011 May-Jun;9(3):226-34

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Treating Victims & CulpritsVictim:

– Troch Bursa

Culprits:– Weak Gluteals– Tight Iliotibial Band– Training Error– Anatomic Alignment

Treatments RICE

NSAIDs

Phonophoresis

Steroid Injection

Strengthening

Stretching

Correct regimen / level

Orthotics, Braces

#1- Strengthen Hip/Core, #2 – Steroid Injection, #3 – Supervised PT vs SWT

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Walk 5 min.Run 1. (Repeatfor a total of 17min.) Walk 5.Walk 5 min.Run 3. (Repeatfor a total of 21min.) Walk 5.Walk 6 min.Run 4. (Repeatfor a total of 26min.) Walk 5.Walk 3 min.Run 2. (Repeatfor a total of 30min.) Walk 5.Walk 5 min.Run 5. (Repeatfor a total of 35min.) Walk 5.Walk 4 min.Run 6. (Repeattwice.) Walk 5.

Walk 4 min.Run 6. (Repeattwice.) Walk 5.

Walk 2 min.Run 1. (Repeat 9times.) Walk 5.

Walk 1 min. Run30 sec. (Repeat20 times.)Walk 5.Walk 15 min.

Walk 15 min.

Walk 15 min.

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Rest!

Walk 15 min.Vary your pace.Try not to stop.

Walk 15 min.Run 1. Walk 2.




Walk 30 min.







Walk 5 min.Run 1. (Repeatfor a total of 17min.) Walk 5.Walk 5 min.Run 3. (Repeat for a total of 21min.) Walk 5.Walk 6 min.Run 4. (Repeatfor a total of 26min.) Walk 5.Walk 3 min.Run 2. (Repeatfor a total of 30min.) Walk 5.Walk 5 min.Run 5. (Repeatfor a total of 35min.) Walk 5.Walk 4 min.Run 6. (Repeattwice.) Walk 5.



Walk 1 min. Run30 sec. (Repeat20 times. )Walk 5.Walk 15 min.

Walk 15 min.

Walk 15 min.






Walk 30 min.



Walk 5 min. Run20. Walk 5.




Walk 5 min. Run 1. (Repeatfor a total of 17min.) Walk 5.Walk 5 min.Run 3. (Repeat for a total of 21min.) Walk 5.Walk 6 min. Run4. (Repeat for atotal of 26 min.)Walk 5.Walk 3 min. Run2. (Repeat for atotal of 30 min.)Walk 5.Walk 5 min. Run5. (Repeat for atotal of 35 min.)Walk 5.Walk 4 min.Run 6. (Repeattwice.) Walk 5.



Walk 1 min. Run30 sec. (Repeat20 times.)Walk 5.Walk 15 min.

Walk 15 min.

Walk 15 min.

DAY SIX DAY SEVENDAY FIVEDAY FOURDAY THREEDAY ONE DAY TWO






Walk 30 min.

Walk 30 min.

Walk 30 min.

Walk 30 min.




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Easy 12-Week Walk/Run Program!

√ Check with your doctor when starting torun. This is especially important if you or yourfamily have any heart problems, high bloodpressure, high cholesterol, breathing problems,diabetes, or if you are overweight or smoke.

√ Get well-fitting, well-cushioned running orcross-training shoes. If you run less than 10miles a week and don't have a history ofsports injuries, most entry-level running shoeswill work for you. A specialty shoe store withknowledgeable salespeople can help you find ashoe made for your needs. Or send a self-addressed, stamped envelope to AmericanRunning to get our Running Shoe DatabaseQuestionnaire.

√ Wear comfortable, loose-fitting clothes. Ifthe temperature is cool, dress in layers tostrip down as you warm up.

√ Ask a friend to join you. When gettingstarted, it sometimes helps to find a friend towork out with. You'll motivate each other.

√ Schedule time for your workouts — mark iton your calendar. If you set aside a definitetime to exercise, you'll be more likely to keepthe commitment.

√ Keep a log. You'll be surprised and proud ofhow much you are doing. It also makes iteasier to track your progress.

It's easy. Here's how...

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RUN!Your Way to

FitnessDo you want to improve your health and

get fit? Try running! People who are active

not only feel better and have more energy

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more likely to be healthier.

Running reduces your risk of developing

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mon cold. It improves your cardiorespiratory

health, making it easier to do everyday

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with an active child. And if it's weight you're

worried about, running can burn that excess

body fat and create a leaner you!

Warm up for five to 10 minutes beforeexercising by doing light activity (sothat your heart beats faster, yourbreathing gets heavier, and you begin toget sweaty).

Many athletes stretch their musclesafter warming up. For walking or running,stretch the front of your thighs(quadriceps), back of your thighs(hamstrings), and back of your lowerlegs (calves). It may feel good to alsostretch your back and hips. Hold eachstretch, with no bouncing, for about 20to 30 seconds.

Cool down slowly after your workout.Your heart should beat slower whileyour breathing gets easier. It isimportant to stretch the muscles youused in running after exercise toprevent your muscles from tighteningup.

Don't become dehydrated. Drink six toeight glasses of fluids (water, sportsdrinks with a 6% to 7% carbohydrateconcentration, or diluted fruit juices)throughout the day. About 15 to 30minutes before exercise, drink four toeight ounces of fluid. During exercise,drink four to eight ounces of fluid at 15minute intervals. After exercise, drinkat least eight to 16 ounces of fluid. Tofind out if you're drinking enough, checkyour urine. It should be clearthroughout most of the day.

Listen to your body. If you are sore,skip an exercise session. If you are stillsore after resting, call AmericanRunning for advice or for the name of asports medicine professional in yourneighborhood.

The Role of Eccentric Exercise in Treating Tendinosis Background Alfredson first reported success using heavy-load eccentric training to treat chronic Achilles tendinosis in 1998. From 1998 to 2002 only five articles appeared in the scientific literature regarding eccentric training. But this past year (2006), thirteen articles were published describing eccentric exercise treatment for varied types of tendinosis. As of July 1, at least 23 such articles had been published in 2007. Given this information explosion, what do we know about eccentric exercise and its role in the treatment of chronic tendinopathies? What is Eccentric Exercise? The term eccentric exercise refers to muscular activation during muscle lengthening (e.g. the biceps is activated eccentrically when a dumbbell is slowly lowered from the shoulder to the waist). For decades conventional wisdom held that tendinosis patients should scrupulously avoid eccentric exercise for fear of rupturing the diseased tendon. However, as proven by Alfredson and others from 1985 to 2004, eccentric exercise seems to result in normalization of peritendinous blood flow, improvement in tendon histology and morphology, and most importantly, in decreased clinical tendinosis symptoms. Mechanism of Therapeutic Action The exact mechanisms by which eccentric exercise exerts its beneficial effects are incompletely understood. Tendinosis is a non-inflamatory, degenerative tendon condition. Eccentric exercise appears to decrease the characteristic neovascularization found in degenerative tendons. It is not known whether eccentric exercise reduces neovascularization directly by mechanically destroying neovessels or indirectly through alterations in vascular growth factors. It is also possible that eccentric exercise may directly stimulate collagen synthesis pathways. What does the Evidence show?

Many questions still exist regarding optimal frequency, duration, and loading of eccentric exercise. Also unclear is the question of whether athletes can continue to train and compete while undergoing eccentric rehabilitation for symptomatic tendinosis. But what we do know is that strong clinical evidence shows that eccentric exercise treatment is highly effective for Achilles tendinosis and patellar tendinosis (jumper’s knee). Moderate evidence supports its efficacy in tendinosis at the elbow (tennis elbow) and smaller studies show benefit in other wrist tendinopathies.

Decline eccentric squats for patellar tendinopathy A patient education handout demonstrating eccentric exercise for Achilles tendinosis is attached.

Heel Drop Exercises for Achilles Tendinopathy

Exercise 1: 1. Stand on the edge of a step, in good shoes with heels off the edge of the step as shown. 2. Using both legs, push up onto your toes (Figure A). 3. Lift your left foot up so that you standing on the toes of your right foot only. Keep your right knee straight. 4. Using only your right leg, slowly lower your heel towards the ground (Figure B). Lower yourself in a controlled fashion. 5. Replace your left foot onto the step. Push up with both legs to return to starting position (Figure A). Perform 15 repetitions with the right leg. 6. Repeat the above using the left leg. In all you should perform 2 sets of 15 repetitions for both the right and left legs. Exercise 2: 1. Stand on the step again in shoes, up on your toes (Figure A), and lift your left foot up. 2. Lower your heel to the ground slowly using only your right leg, but this time keeping your right knee bent (Figure C) 3. Perform 15 repetitions with the right leg, then repeat for the left leg. Again you should perform 2 sets of 15 repetitions for both right and legs. Tips: - Maintain good alignment, keeping knees, hips, and ankles in alignment. Avoid excessive trunk flexion (Figure D). - Your legs will be sore. This is actually good and part of the healing process. In a couple of weeks you will notice that your legs are not sore anymore after the exercises. When this happens, you’ll want to increase the resistance (perform on a weight sled in the gym, put weights in a backpack, etc) to make your legs sore again. - During the first 4-6 weeks of exercises, you should not be running or playing sports. During the last 4-6 weeks your doctor may allow you to return to some of these activities. Any questions or concerns, please call: _______________________

X

REHABILITATION FOR ANKLE SPRAIN

STEP 1: IMPROVING RANGE OF MOTION - TOE ALPHABET

While sitting in a chair, “write” each letter of the alphabet from A to Z on the floor with your toes. Move only your ankle--Try not to move your knee and hip. The letters will start out large and

sloppy, but will get smaller and neater as your ankle improves. You can start these exercises immediately after being diagnosed with an ankle sprain. STEP 2: REGAINING STRENGTH - TOWEL DRAG EXERCISES Towel drag exercises are decidedly low-tech, but very effective for strengthening ankle and foot muscles. Start these exercises as soon as you can move your ankle from side to side with only minor discomfort.

1. Start with towel spread to maximum length, but folded to 4-6” wide. 2. Place towel medial to bare foot on wood, tile, or other smooth surface. 3. Keeping heel on the ground, drag towel from medial to lateral, until entire towel is

bunched lateral to foot (See Fig. 1 above). 4. Re-fold towel and place lateral to foot. 5. Keep heel on the ground while using toes to drag towel lateral to medial, until entire

towel is bunched medial to foot. 6. Re-fold towel and place anterior to foot. 7. Lift heel off the ground and use toes to curl towel back towards heel, until entire

towel bunched under arch of foot (See Fig. 2 above) 8. Perform same 3 towel drags with opposite foot. 9. Repeat each set of drags 10 times with each foot, once or twice daily. 10. A can of soup can be placed on top of the towel and dragged with the towel for added

resistance. 11. Continue exercises until you can do 3 sets of 10 with 1 or 2 soup cans.

Fig. 1 Towel Drag (Side to Side) Fig. 2 Towel Crunch (Front to Back)

STEP 3: RE-TRAINING BALANCE – SINGLE LEG BALANCE When your ankle is injured, it looses the ability to sense its position in space. Regaining this sense of position or “proprioception” is essential to preventing re-injury. Begin these exercises as soon as you can stand on one leg with minimal discomfort.

1. Practice standing on one leg, barefoot on a hard floor. Do several repetitions at least twice per day on each foot. Some patients find the best time to do this is while they are brushing their teeth.

2. After you can stand on one foot and feel somewhat balanced, try standing on one

foot with your eyes closed. Make sure you have something or someone to grab on to. It’s harder than it looks!

3. When you can stand for ~20 seconds on your injured ankle with your eyes closed,

make the task harder. Examples: a. Try brushing your teeth while standing on one foot, eyes closed. b. Stand on a pillow instead of the hard ground. c. Stand on one leg and play catch with someone. Have your partner throw

the ball so that you have to bend to catch it. 4. Continue the balancing exercises until you could play catch with a young child

while standing one your injured ankle. OTHER NOTES:

Remember that simply resting your ankle will not help it get strong again. Your ankle needs gentle exercise and activity to help it heal. Most ankle sprains take 4-6 weeks to feel better. If your ankle is still hurting after 6 weeks of treatment, please make a return appointment to see your doctor. If you were given a brace, make sure and ask your doctor or therapist how long you should wear the brace and for what specific activities.

HEEL CORD STRETCHING Stretching the gastrocnemius and soleus is a therapeutic key in the treatment of many types of heel pain. The following box illustrates the recommended routine. Stretching the heel cord involves stretching two separate muscles: the gastrocnemius and the soleus. Both muscles should be stretched individually for best results.

Knee S

traigh

t

Knee

Bent

GastrocnemiusGastrocnemius SoleusSoleus

Knee S

traigh

t

Knee

Bent

Knee S

traigh

t

Knee

Bent

Knee S

traigh

t

Knee

Bent

GastrocnemiusGastrocnemius SoleusSoleus

1. Place leg to be stretched behind the other and lean forward onto wall, keeping back knee straight.

2. Continue to lean forward keeping knee straight and heel on the ground until pull is felt in upper calf (gastrocnemius)

3. Hold for 30 seconds (That’s a full commercial! That’s a LONG time!) Muscle begins to lengthen after 20 seconds of stretching, so final 10 seconds are the most essential.

4. Next lean forward again, but bend knee on back leg, still keeping heel on the ground. Often helpful to visualize trying to “kneel while keeping your heel on the ground.”

5. Continue to kneel and lean until pull felt in lower calf (soleus) 6. Hold for 30 seconds 7. Repeat on opposite leg 8. Stretch each leg 3 times in one stretching session 9. To improve heel cord flexibility, recommend 3 stretching sessions per day. To

maintain flexibility, one session per day is adequate.

Plantar Fascia Stretch – Hold stretch for 30 seconds Stretch each foot, 3 times Perform Stretch 2-3 times/day

TOWEL DRAG EXERCISES Towel drag exercises are decidedly low-tech, but very effective for strengthening ankle and foot muscles.

1. Start with towel spread to maximum length, but folded to 4-6” wide. 2. Place towel medial to bare foot on wood, tile, or other smooth surface. 3. Keeping heel on the ground, drag towel from medial to lateral, until entire

towel is bunched lateral to foot (See Fig. 1 above). 4. Re-fold towel and place lateral to foot. 5. Keep heel on the ground while using toes to drag towel lateral to medial, until

entire towel is bunched medial to foot. 6. Re-fold towel and place anterior to foot. 7. Lift heel off the ground and use toes to curl towel back towards heel, until

entire towel bunched under arch of foot (See Fig. 2 above) 8. Perform same 3 towel drags with opposite foot. 9. Repeat each set of drags 10 times with each foot, once or twice daily. 10. A can of soup can be placed on top of the towel and dragged with the towel

for added resistance.

Fig. 1 Towel Drag (Side to Side) Fig. 2 Towel Crunch (Front to Back)

Documents

Lower Extremity Musculoskeletal Exam Techniques ...1 Lower Extremity Musculoskeletal Exam Techniques: Evidence-Based Treatment Anthony Beutler, MD, FAAFP ACTIVITY DISCLAIMER The material