Gait Deviations  Wide walking base / Abd.

Gait/ Walking
base greater than the Normal Range of 5-
Causes:
10cm / 2-4 inches
 Excessive knee flexion or abrupt/early knee
flexion 1. Hip Abductors: Socket
2. Abd: Socket
All are excessive: 3. Lat. Wall : Low
1. Foot DF 4. Med. Wall: High
2. Posterior displacement of foot in rel. to 5. Prosthesis: Long
med. Socket 6. Leg: Long
3. Stiff/Hard : Heel, wedge, PF bumper 7. Shank: Invalgus
4. Soft: DF bumper
5. Anterior displacement of heel  Circumduction Gait- anything that would
6. Knee Flexion Contracture produce longer leg

Rule: 1. Excessive PF
Foot: I/L 2. Abd Contructure
3. Socket: too small
Socket and Heel: C/L 4. Insufficient: Knee extension
5. Manual: Knee lock
 Excessive knee extension / Genu
6. Excessive Knee Friction
recurvatum/ Deleyed, limited, absent knee
7. Tight: Tight Extension Aid
flexion/ “Heel Climbing” Sensation

All are excessive:  Vaulting – raising the body by early and

excessive PF of the sound foot during swing
1. Foot PF
of the prosthesis
2. Ant. displacement of foot rel. to socket
- Anything that would produce a longer
3. Stiff/Hard: DF bumper
leg
4. Soft : Heel, wedge, PF bumper
1. Excessive PF
7. Posterior displacement of knee
2. Socket: Too small
5. Knee extension contracture
3. Insufficient: Knee flexion
4. Manual: Knee lock
 Lateral Trunk Bending- Leaning toward the
5. Excessive: Knee friction
prosthesis side when the prosthesis is in
6. Tight: Tight Extension aid
stance phase
 Whips at swing phase:
- Medial Whip: Heel travels med on initial
1. Hip Abductors: weak or contracted
flexion at the beginning of swing phase
2. Abducted: Socket
- Lateral Whip: Heel travels lat on initial
3. Socket: Large
flexion at the beginning of swing phase
4. Lat. Wall: Low
 Foot Rot at heel stike:
5. Med. Wall: High
1. Heel cushion / Pf bumper too hand
6. Prosthesis: Short
2. Excessive toe out
7. Leg: Short
3. Loose socket sit
8. Pain: Distal and Lat. Femur
4. Post socket tightness
 Foot slap: PF bumper on heel cushion Congenital
 Heel Rise
 Amelia – absence of limbs
- Excessive:
 Ectromelia – partial absence
1. Insufficient friction
 Phocomelia – “Fliplike”(-)humerus , F.A.
2. Insufficient tension of the ext. aid
 Acheira – absence of hand
3. Forceful hip flexion
 Apodia – absence of foot
- Insufficient:
 Adactylia- absence of phalanges
1. Excessive friction
 Hemimelia – (-) radius
2. Too tight ext aid
 Triphalagism- 3 phalanx of thumb
3. Manual Knee Lock
 Terminal Swing Impact
Classification of amputation levels
- Prosthesis comes into a sudden stop
Below Elbow Classification
with visible and audible impact as the
0% Elbow disarticulation
knee reaches full ext.
1-35 % Very short
1. Insufficient friction at terminal unit
36-55 % Short
2. Too tight extension aid
56- 90 % Long
3. Fear of Buckling 91-100 % Wrist disarticulation
4. Absent ext bumper in the Knee Above Elbow
Knee Friciton Heel Rise TSwing Impact 0% Sh disarticulation
Inc Dec Dec 1-30 % Humeral Neck
Dec Inc Inc 31-50 % Short
Extension Aid 51- 90 % Standard/ Long
Haut Dec Inc 91-100 % Elbow disarticualtion
/Lax Inc Dec Below Knee
 Uneven Step Length: < 20 % Short transtibial
- Shorter stance phase on prosthetic side 20-50 % Transtibial
> 50 % Long transtibial
1. Insufficient friction at the knee
Above Knee
2. Hip Flexion Contracture
> 35% Short transfemoral
 Excessive Trunk Extension/ Exaggerated
35-60 % Transfemoral
Lordosis
> 60% Long Transfemoral
1. Hip Flexion Contracture
2. Insufficient socket flexion and
support from ant. brim Stump Measurement Reference Point
Level Proximal Distal
BK Med Tibial Distal End of Stump
6 Plateau
TRAUMA AK Med. Distal End of Stump
Inguinal Line
Etiology: AE Tip of Distal End of Stump
acromion
Acquired BE Med. Distal End of Stump
 Vascular Epicondyle
 Truma Stump Measurement – Length of amputated
 Tumors limb (*) Normal Limb
Types of Amputation - Advantages:
 Long Lever arm
 Upper Extrimity
 Inc. stability in pt.’s prosthesis
1. Forequarter – (-) UE and partial clavicle
 BKA (Partial Leg Amputation)
2. Sh Disarticulation – GH
 Very short
3. AEA
 Short
4. Elbow Articultion
 Medium
5. BEA
 Long
6. Wrist Disarticulation
 ANKLE
7. Phalangeal Amputation
- Syme/ Ankle Disarticulation
8. Interphalangeal Disarticualtion
 BOYD – removal of all tarsal bone
 Transradial Amputation
except calcaneus
- Most preferred
 Piragoft- vertical dissection of calcaneus
- Allows highest functional recovery
 Chopart/ Surgeons/ Midtarsal jt.
 Short – limit elbow flexion
* talonavicular jt, calcaneocuboid jt.
 Medium – Cosmesis and Good Function
*lisfarc – transometatarsal jt.
Optimum ext. powered prosthesis
 Partial foot / Ray Resection – removal of
 Long – for physically demanding work
phalanges
Optimum Body Powered Prosthesis
 Toe Disarticulation – (-) Toe
 HIP
 Myodesis –suture of m to bone
 Hip Disarticulation
Most effective and strong
- The act made through the hip
 Myoplasty –suture of mm to
jt./acetabulofemoral jt.
periosteum
- Complete thigh removal
 Hip Hemipelvectomy (AKA Hindquarter)
 POTENTIAL COMPLICATIONS
- (-) Hip + LE
o Neuroma – ballooning of nn = pain
- To prevent metastasis (CA)
o Phantom limb sensation
- GMAX spared for flap
o Phantom limb pain
 Hemicorporectomy
o Stum pain
- (-) Pelvis & (-) LE , cut is L4-L5
 Phantom limb
- (-) Amus
Pain = after 110k post-op
- (-) Genitals
Pain in the missing part of the limb
 AKA (Partial Thigh Amputaion)
Tx SAME :
- Short AKA
Sensation – Painless
- Middle AKA
Sensation that the missing limb is still
Supracondylar amp
attached to the body
 KNEE
Tx: Desensitization techniques
- Knee Disarticulation = COMPLETE leg
- Massage, TENS, Icing
removal
- Easily fitting of Prosthesis
- Gritti- Strokes = patella is intact
 Stump Pain – pain arising on the residual
- Kirk- Calendar = removal of patella
part of the body
 Knee Disarticulation
6 P etio:
- Most often used on children and young
1. Prosthogenic
adults
2. Neurogenic
- Avoided in elderly
 3. Arthogenic  Severe wrap with tape; don’t use clips
4. Symphathetic for they are unsafe
5. Reffered  Use 3 to 4 inch wrap for transtibial
6. AbN stump tissues  Use 6 inch wrap for tranfemoral
amputation
 IDEAL STUMP  Rewrap frequently to maintain
 NO “Dog Ears” – due to bandage too loose adequate Presuure
 Intact sensation
 No tenderness RIGID DRESSING
 Less phatom pain - ADVANTAGES
 No open wound  Allows early ambulation
 No LOM  Promotes circulation and
 No contractures healing
 Good to N MMT  Stimulates proprioception
 Ideal shape and flaps  Provides protection
 SHAPE  Limits Edema
 AKA = CONICAL - DISADVANTAGES
 BKA = Cylindrical  Immediate wound inspection is
not possible
Types of Post-Operative Dressing
 Doesn’t allow daily dressing
o Rigid (POP) – no daily check-up change
o Semirigid – UNA paste, air splint  Pressure sensitive areas
o SOFT- Ave wrap, shinker  BK – Fibular head, Antero-distal
end of stump, tibial crest and
FLAPS:
tubercle
o Burges – post flap  AK- Disto-lat. femur, Pubic
o Fishmouth- same length ant = post Symphysis, Perianal Area
o Gullotine = use of flaming sword  Pressure tolerance areas
 Distal end of stump
 Wrapping Guidelines  I.T.
 Elastic warp should have no wrinkle  Lat side of stump
 Diagonal and angular pattern should be  Glutels
used  BK- Patellar Tendon, Tibiofibular
 Don’t wrap in circular pattern shaft, med tibial crest, distal end of
 Provide Pressure distally to enhance stamp
stamping  STAGES OF AMPUTEE REHABILITION
 Anchor warp above the knee for PROGRAM
transtibial amputation 1. Pre amputation counseling
 Anchor warp around the peilvic for 2. Amputation Surgery
tranfemoral amp 3. Acute post amputation period
 Promote full knee ext. for transtibial 4. Pre prosthetic training
amputation 5. Preparatory prosthetic training
 Promote full hip ext. for tranfemoral 6. Prosthetic fitting and training
amp 7. Reintegration into the community
 8. Long-term follow up SC Ant
AC Sup
 Grieving Process (death ) GH Ant
S schock ELBOW Post
A anguish/ awareness WRIST Volar
M mourning HIP Post
R resolution of loss Knee and patella Lat
I dealization of loss person ANKLE Post

 5 stages of grief  Sh D/L

D denial Ant Sh D/L – 95%
A anger MOI: ABER
B bargaining Nn affectation: axilliary NN
D depression Post SH D/L- 5%
A acceptance MOI: ADIR
 POSITIONING  Glenoid Labrum
AKA – Hip ext. Barkart’s Lesion – Ant
BKA – Knee ext. SLAP Lesion
 ENERGY EXPENDITURE – The higher the Bennet’s Lesion- Post.
amputation, the higher the energy  AC jt. D/L
expenditure. MOI: Fall Sideways
Transtibial unilat 10- 40 %  Elbow: post
Transtibial B/L 41%  Wrist and Hand:
U/L transfemoral 65% Scaphoid / Navicular
U/L transfemoral, U/L 75% m/c fx : tenderness , 2nd m/c disloc
transtib Lunate/ Semilunar
B/L transfemoral 110% m/c D/L

 SPEED OF WALKING ASSISTIVE DEVICES

NORMAL – 3 miles / hr FXNs:
BKA – 2-2.5 mpH  promote balance
AKA – 1.5 mpH  Widen BOS
 Support weak or paralyzed mm to
 PROBLEMS improve stability
 Skin infections  Reduce wt. bearing
 Contact dermatitis INDICATIONS:
 Choke syndrome – lack of total  Dec. strength
contact on prosthesis  Pain on LE or wt bearing
 Bone problem  Impaired tolerance or altered
 Neuronal stability
 Phantom limb/pain  Absence of LE
 Contractures FACTORS TO CONSIDER:
 DISLOCATIONS  Age
JOINT DIRECTION  Desired amnt of wt bearing
 Balance
  Physical Endurance  Standard – most stable, not
 MM strength portable
 Coordination  Folding
 Mental status  Roling
 Nature of pt’s disability  Stair climbing
 ROM UE and LE  Reciprocal
 Sensory perception  Hemi-walker
MAIN DETERMINANTS OF GAIT PATTERN  Crutches
 Desired amnt of wt bearing - Mod. Stab
 Balance - Use to inc. BOS
 Physical endurance - Provide relief WB on LE
 Mm strength  Measurements:
 Coordination  Hand Grip: 20 to 30 ˚ elbow Flex
 Nature of pt’s disability  Rubber Tip: 6”, 2” antero-Lat from
LEVELS OF WT BEARING foot
 Non wt bearing  (+) wing nuts (DRAWING)
 Toe touch wt bearing  2 types:
 PWB
 Axilliary:
 Wt bearing as tolerated
1. Triceps
PREPATION FOR AMBULATION
2. Ortho
 Review pt. med record
 Non- Axilliary:
 Determine the appropriate
1. Platform – for RA pts.
equipment of gait pattern based on
2. F.A. crutch
the medical record
3. Cuff – prox 3rd of arm or 1.5
 Prepare the pt for ambulation
below olecranon P ˚
 Maintain safe environment for amb
 Canes
 Apply gait belt to the pt
- Provide stab
 Use the gait belt to the pt’s sh or
- Widen BOS to improve BAL
trunk as point of control when
- Unlocks forces on involved Extremity by
guiding the pt
aprox 30%
 Maintain proper body mechanics
- 2 landmarks:
for yourself and the pt
- Measurement: SAME
 TYPES:
 Standard
 Walkers
 J-sharp/Offset
- Can be used in any type of wt bearing
 Quadcane
- Has significant BOS and offers good
 Parallel Bars
stability
- For bal gait training
- (+) ant and lat stability
- Most stable
- 20-30 ˚ Flexion of elbow
- HAND: 6” ant
- 4-6 ant to greater troch
- Distance from HIP: 2” each
- (-) reciprocal arm swing
 TILT TABLE
PD: Post. Rolling walker with a stop
 TYPES:
 - May Benefit person who need to  Seat Width: + 2” on widest area of
physiologically acclimate to an upright buttock
position  Backheight: Buttobk to axilla – 4”
- Prolonged recumbence  Arm rest height: 90 ˚ elbow flexion
- Disturbance of Bal. +1“
- Dec. proprioception or kinesthesia
- Gen Weakness LCPD (Legg-Calve-Perthes Disease)
- Avascular necrosis of femoral head
- Lat. epicondyle of Med. Femoral
BASIC GAIT PATTERN
Circumflex Artery
4 Point. Gait
Cane – Crutch - B/L AD - - m/c cause: Unknown
Stable/ slow – safest – - Manifestation:
low energy extremity –  Lalake
for max stab  Children
 Pito/Payat/Pandak
2 Point Gait  Di- nagtatagal
Cane- crutch – faster – - STAGES:
coordination – relative I. Necrosis
stable – B/L AD II. Fragmentation (+) Head
Flattening
3 Point Gait III. Remodelling
Walker – Cain, crutch – IV. Revascularization
less stable – Inc. energy
V. Healed Stage
of extremity – require
- X-ray Findings:
good strength
 CRESENT SIGN : (-) blood supply of
femoral head
 Wheelcahir  SAGGING ROPE SIGN: sclerotic line
-inadvasability of amb. running through fem. Neck
-impossibility of amb horizontally
-Additional means of locomotion  Cage/Gage sign: calcification of lat.
-promotion of performance in ADLs, sports epi
and recreational activities - m/c manifestation:
 C/I  limp (psoatic limp) and pain
 P ˚sore  LOM: Abd and IR
 Surgical or post-op conditions of pelvs  Post capsule thickening
 Vertebral fx  Shortened leg
 Disc or nn root compression
 Certain type of LBP MX:
 Weak transmusculature  Traction: to avoid compression
 Standard w/c measurement  Orthosis: Toronto, Scottish Rith , Trilateral
 Seat height: popliteal fossa to lat  Surgery: Osteotomy – poor prognosis,
heel + 2” elderly
 Seat Depth: Buttock to popliteal –
2”  Congenital hip dysplasia:
- Dev. Malalignment of Hip
 - Mani: LIMP - Fem head projects medially to ilioischial
- LOM: ABIR line
- TX: HMP+TENS  C/M: - LOM: AB and Rot
- ORTHOSIS: Von Rossen, Il felt, - Pain and discomfort
Paulik Harness = ABER, m/c post. - Ankylosis
 Mx:
- Tx for several wks
Coxa VARA Coxa VALGA
- Use of crutches
Ant. pelvic tilt Post. pelvic tilt
- THA
Shortened Lengthened
Med. Femoral Lat. SNAPPING HIP SYNDROME
Torsion AKA: Coxa Saltan/ Dancer’s Hip
 M/C: ITB: greater troch (Ext. SHS) with
ANTEROVERSION RETROVERSION ant. fiber of Gmax
Intoing Outoing  Cause: Iliopsoas – ASIS (Int. SHS)
IR ER  ST: Ober’s Test
Int. Tibial Torsion Ext. Tibial Torsion Snapping Bottom
Squinting patella Grosshoper Patella - Long head of biceps fem
ST: Craigs/ Rayder’s Snapping Sh
method N: 15 ˚ - Deltoids – Greater Tubercle

SCFE (Slipped capital femoral epiphysis) HIP BURSITIS

 AGE: 12/15
 M/c slippage: inferiorly
 LOM: ABIR assoc with coxa vara
 MX: - gradual tx in mild ABD and IR
- Skeletal or splint russel skin tx
- Gentle manipulation under anesthesia
- Crutches are recommended to limit wt
bearing forces
- Osteotomy
 M/c affected: Obese and Tall
CHONDROLYSIS
- Rapidly progressive disruption or
articular cartilage
 Clinical Manifestation : (+) Pain
- Hip flexion, add contracture
- X-Ray: dec. jt space
- Severe : fibrous ankyloses
 MX: - Immob. Of Hip
- Crutches
- Gentle active ex
- Salicylate, anti-inflam drugs
- Surgical intervention
- Arthodesis
INTRAPELVIC PROTRUSION OF ACETABULUM
Ischial Bursitis, Weaver’s bottom, Taylor’s
bottom, boatman bottom
Trochanteric Bursitis
- Superficial TB
- Deep TB
- Pain on the Lat. Hip
Iliopectal or Iliopsoas Bursitis
ITB Friction Syndrome
- m/c cause of lat knee pain
- d/t : ITB – Gerdy’s Tubercle
- usually assoc w/ runners
- ST: Noble Compression Test
Contusion/ Hip Pointer Injury
- Severe contusion ; to Iliac Crest; ASIS
- GRADE:
I. mild stretch – no tear
II. Partial Tear
III. Full Tear
Piriformis Syndrome
- (+) spasm of piriformis
- c/c: shooting pain @ buttock up to Hip
- Tx: HMP+TENS, GPS, active ex
Meralgia Parasthetica 5. Isomets
- m/c c/c: tingling, numbeness on outer
thigh Adductor Strain
- m/c cause: Pregnancy, Tight clothing - C/M: (+) Pain and pop upon injury on
- nn affected: lat fem cutaneous nn (L2- med. Thigh
L3) - (+) LOM
- tx: desensitization, avoid tight clothing - Mm guarding
- Mx :
THR  Rhizotomy
- method of fixation  Most superficial
 Cemented: Elderly, severe cases  Same w/ Hams
 Uncemented: - m/c adductor:
- Approacher: 1st adductor longus
 P-Lat 2nd add magnus
 m/c
 Gmax and ERots – Ectopic Bone Formation
exercise - (+) bone outside skeletal system
 Pressure GMed  MO (MYOSITIS OSSIFICANS)
 Direct Lat o MO progression =AD\
 TFL, GMed, Vastus Lat o MO traumatics = 2 to trauma
 Ant-Lat  M/C :
 Gmed, TFL, Iliopsoas,  UE: Brachialis
Rectus Femoris, Vastus  LE: Quads
Lateralis  HO (HETEROTOPIC OSSIFICATION)
- ExAbEr = for stab position o 2˚ to immob
o SCI = Hip – Knee – Sh – Elbow
Quadriceps Contusion o TBI= Sh - Hip
- Causes: Tightness or weakness of o BURN=Post elbow- Hip- Sh
quads, tight hams, lack of warm-up, o CVA= Sh
previous injury w/o rehab, over training - Stages:
- CHARLEY HORSE – severe contusion of  Warmth and erythema , (-)
Quads XRAY
- Grading:  Ossification (+) X-Ray F
 Mild: > 90 ˚  Complete bone ossification
 Mod: 45-90 ˚ - Tx: REST
 Severe : < 45 ˚ - Diagnostic Tool:
- m/c strained: rectus fem in quads o GOID STANDARD – Bone Scan
- m/c strain : Hams- short head (+) alkaline phosphatase
- Hams Strain - MEDS: Disodium Ethdronate
- C/M: 1. Pain on prox thigh KNEE: ligamentous injury
2. Pop upon injury ACL: MOI:
3. Palpable mass  blow to the lat. side of knee creating
4. (+) ecchymoses valgus force (contact)
5. Tenderness  ER on PF
- Mx: 1. Rest & immob  HyperExtension
2. ICF  Tendon graft: Semitendinosus and
3. NSAIDs Gracilis
4. GPS PCL : MOI:
  Dashboard 3. Ulceration – (+) crab meat
 Fall on Flexed knee w/ PF appearance
 Hyperflexion 4. Cartilage Distraction
* Tendon Graft = Achilles tendon - Tx: *Quad setting
*Terminal Knee Extension
Segond Fx *Rest/immob
- Assoc with ACL injury Bursitis
- Anterolateral margin of lat. tbial plateau - Prepatellar Bursitis/ Housemaid knee
- Triad of (TERRIBKE TRAID) : - Deep infrapatellar bursitis / Nun’s Knee
 ER w/ - Superficial infrapatellar bursitis/ Clergy
 Valgus force w/ Man / Vicar’s
 Flexed Leg - Popliteal Bursitis/ baker’s cyst
Swimmer’s Knee - Pes anserinus; m/c in soccer players
- m/c affected: MCL 2˚ to valgus stress
Swimmer’s Sh KNEE DEFORMITY
- Supraspinatous
Pellegrini Steida 0-2 Varum
- Ossification of MCL 2-3 Straight
- Age: 25-40 3-4 Valgum
- Gender: M>F 4-6 Straight
Osgood Schaltter Disease >6 Valgum
- Avulsion fx of tibial tubercle (T.T.)
- Age: 10-14 y/o Genu Valgum/ Knock Knee – often assoc
- Gender: Male with R.A.
- CM: * pain on T.T. upon ext. of knee Genu Varum/ Bow Leg - often assoc with
*tender & enlargement of T.T. O.A.
- Mx: * Restriction of act Recurvatum – Hyperextensive
*Rest - 2˚ to weakness of quads
*Braces - Tx: *PF stop
Sinding-larsen-johansson syndrome *DF assist
- Inf pole of patella
- CM: * pain on T.T. upon ext. of knee Osteochondritis dissecans
*tender & enlargement of T.T. - Crack on Osteocartilage
Patellar Tendinitis/ Jumper’s Knee - m/c affected: Infero-lat. portion of med.
- CM: Pain upon knee ext. femoral condyle
- ST: Clarks Test - Stages:
- MX: * Restriction of act  Flattening of epiphyseal plate
*Rest  A. Subcondral cyst
*Braces B. Inc Separation of
*NSAIDs osteochondral fragment(+)AVN
*Splints  Jt. Effusion
Chondromalacia Patella/ Runner’s Knee  Complete Separation and with
- “ANEMA or THEATRE SIGN” loose bodies
- Pain upon rising from siting position
- ST: Waldron’s Tibia Vara/ Blount’s Disease
- Stage: 1. Swelling - Prox. Tibial physis abN growth
2. Fissuring - Gender: Male
- Affectation: U/L
 2nd Distal Tibia and Fibula
Hoffa’s Syndrome ANKLE SPRAIN
- Impingement of fat pad - m/c injury in the foot
- MOI: forcefull knee extension - MOI: PF and Inv.
- ST: Talar-Tilt ant.
Plica Syndrome ANKLE FX
- Enlarged plica d/t irritation or inflam - Hawkin’s classification of Talar Neck Fx
- m/c affected: med. plica  Type 1: non-displaced fx
PATELLA  Type 2: talar neck fx, displaced
Alta High mild, subluxation of subtalar jt
Baja Low  Type 3: talar neck fx, displaced
Magna Double mod, subluxation of subtalar jt
Parva Small Patella + ankle jt
Grosshopper Lat  Type 4: talar neck fx, displaced
Squinting Med severe, subluxation of subtalar
jt + ankle jt+ talonavicular jt
 Leg Length Measurement: 71.6 cm - Weber’s classification of Ankle Fx:
 TLL Landmark: ASIS – Med. Malleolus  A = Talar Dome Below
 B = Talar Dome at the Level
 Landmark (w/ Imbal; quad mm ) :
 C = Talar Dome Above
ASIS – Lat Malleolus ;
Pilon’s Fx
used with bony problem
- Distal Tibia
 Apparent Leg Length :
 m/c fx = Calcaneus
Navel/Umbilicus – Med. Malleolus;
for positional problems
Accessory Bones
(+) mm imbal : Xiphoid – med. malleolus
Os Trigonum Talus
Compartment Syndrome Os Naviculare T. Post
- Inc P˚ inside mm Os Vesaliarum Pedis 5th MT
- Inc 30-40 mmHg (necrosis) Os Peroneum Peroneus Longus
Os Interphalangeus FHL
Stress Fx
- m/c causes : repeated mechanical stress Deformities:
- m/c affected: 4 cardinal deformities:
1st Tibia 1. Pes Equinus
2nd Fibula 2. Pes Calcaneus
3rd Metatarsal 3. Pes Varus
4th Femur 4. Pes Valgus
Medial Tibial Syndrome/ Shin Splints Talipes Equinovarus
- m/c mm involed: Tibialis Post - Aka: Club Foot
- ST: Resisted PF and Inv. - Foot position : AdIP ( Add, Inv, PF)
Ant Tibial Syndrome - Gender: Male
- m/c mm involed: Tibialis Post Talipes Calcaneovalgus
Postero- Medial Tibial Syndrome - 2nd m/c
- m/c mm involed: Soleus, FDL - Foot position : AbED ( Abd, Ev, DF)
Osteochondroma - Tx: Dennis Brown Splint
- m/c benign bone tumor Pes Planus
- m/c site: 1st Distal fem and prox tibia - Foot flat
Pes Cavus
- Claw foot/ pes arcuatus/ hollow foot
- Assoc with Charcot Marie Tooth’s dse
Hallux Valgus
- 15˚ EGYPTIAN 1>2>3>4>5
- M/c cause: in fitting shoes foot
- Assoc with OA
Claw Toes
- Flexed PIP and DIP
Mallet Toes
- Flexed DIP and Extend PIP
Hammer Toes ROMAN’S 1=2>3>4>5
- Flexed PIP and Extend DIP FOOT
Bunion
- 1st MTP
- (+) callus formation
- bursitis
Bunionitis foot/ Taylor’s bunion
- 5th MTP GERMANIC 1>2=3,4,5
Turf Toe FOOT
- Ballerina
- MOI: Hyperextension pf 1st MTP, soft
sole
- M/c: Affected FHL
Metatarsus atavicus CELTIC 1>2>3>4=5
- Short 1st MTP FOOT
Hallux Rigidus
- (+) bony spur = blocked extension
Splay Foot
- Assoc with flat foot
- Weakness in intrinsic mm

Jogger’s Foot
- Local entrapment of med. plantar nn at
abd. hallucis
Heel Pain
 Plantar Fascitis – over pronation
 Calcaneal apophysitis/ Sever’s Dse –
Mortons Neuroma inflammation of growth plate of heel
- Impingement of interdigital nn
 Haglund’s Deformity/ “pump bump” –
- m/c webspace: 3-4 webspace
enlargement at the back of the hip
- morton’s test :
 Retrocalcaneal Burstis – bet. Calcaneus
S: squeeze metatarsal heas
and triceps surae
R: (+) pain
Metatarsalgia
-
- Pain o metatarsal head d/t abN
MORTONS/ 2>1>3>4>5
distribution of wt.
GREEK’s
- M/c cause: high heeled shoes
toe/ foot
 *leg length discrepancy
Common MT conditions:
 2nd MT Head : Freiberg’s Common Spinal Problem
 2nd MT shaft : March Fx 1. Lordosis : Ant convex Post Concave
 5th MT Base: Jones Fx - Exaggeration of the N curves of cervical
 5th MT Base apophysitis: Iselin Dse and lumbar
- Ant. curvature of spine
POSTURE - Causes: Lower Crossed Syndrome
Correct Posture: min. stress on body
Faulty Posture: max. stress
m/c cause: mm imbal
2 curves:
Primary Secondary
Present @ birth Develop as the baby
learn to lift head, sit,
stand and walk
Thoracis, Sacral Cervical , Lumbar

COG
Adult: slightly ant to S2
Child: T12 - Postural and functional deformity
Genu varum: 18 mons. - Lax mm
Genu valgum: 3 y/o - Heavy Abdominal
Straight: 6 y/o - Congenital Problems (B/L disloc of hip)
- Fashion ( High Heels)
Foot Flat / Pes Planus - Pathologic Changes assoc with Lordosis
- (+) med. fat pad covers MLA  Body Segment Alignment
 Ant Pelvic Tilt
Hormonal influences  Knees are Hyperextended
Puberty: Female : 8-14 /o last 3 yrs  Ankle PF
Male: 9 ½ - 16 y/o last for 5 yrs  Mm that are
 Elongated and weak
PLUMBLINE TEST  Ant abdominal
- To assess posture  Multifidus and rotatores
1. Ant. to ext. auditory meatud  Lower and Mid Traps
2. Through the cervical vertebra  Upper Erector Spinae
3. Ant to thoracic Vertebra (Cevical and Thoracis)
4. Through the Lumbar vertebra  Shortened and tight
5. Post to Hip  Lumbar ES
6. Ant to Knee (Post to Patella)  Hip Flexors
7. Ant to Ankle  Hams are weak but become
tight
Causes of Postural Deviations - Pelvic Angles: * N= 30 ˚
1. Postural/ Positional * Lordosis: 40 ˚
2. Structural- Ex:  Sway Back/ relaxed Pattern
* scheuman’s dse (m/c T10-T12)  Ant Shifting of pelvis
*thin vent end plate  Post shifting of thoracic
  Inc in pelvic angle of 40 ˚ HO Terminal Stance
 Kyphotic posture on TO Pre-Swing
thoracolumbar spine Swing Phase
2. Kyphosis Acc Initial Swing
- Exaggeration of thoracic spinal curve Midswing Midswing
- Roundback Decce Terminal Swing
- Flat Back
- Hump back/ Gibbus Double Support
- Dowager’s hump - There are two periods of double
3. Scoliosis support and one period of single leg
- Lateral curvature of the spine stance during gait
- Mm most commonly weak and - B leg on the ground
elongated mm on convexity - 25% of gait (22%)
- Tight and shortened mm on concavity - No double support in running
- Hip abd on concavity ¦ HS to TO HS to TO & TO to HS
- Hip add on convexity ¦ FF to Acc constitute the double
¦ MS to MS Support
BODY TYPES: ¦ HO to Decce
 ECTOMORPH – thin, arthenic (no Force) ¦ TO to HS
 MESOMORPH– muscular and sturdy, ¦ Ace to FF
athletic ¦ MS to MS
 ENDOMORPH–fat body, pyknic ¦ Dec to HO

GAIT
- Human Locomotion  Clinical Significance:
- Translatory progression of a body as a COG - lowest on double support
whole, produced by rotatory movement - Highest in Mid Swing
of the body segments -lower COG greater STABILITY
STANCE: WB, close kinematic chain, 60 % Walking - 25%(20-22%)Double Support
SWING: NWB, OKC, 40 % Running -(+) Floating Phase /
Gait Cycle Double Unsupported Phase
- Time interval or sequence of motions
occurring bet 2 consecutive initial  PARAMETERS OF GAIT
contact of the same foot  Step Width
 3 main tasks:  Step Length
 Wt acceptance HS / FF  Stride Length
 Single limb support MS/HO  Lat Pelvic Shift
 Swing limb advancement  Vertical Pelvic Shift
Acc/ Midswing/ Decce  Pelvic Rot
Walking Speed =  COG
o Gait Speed = 3.0 mpH / 1.4 mpS  Cadence
 Degree of Toe out
Traditional Term Ranchos Los Amigos
Stance Phase STEP WIDTH/ BASE WIDTH
HS Intial contact - 2-4”
FF Loading Response - BOS
MS Midstance - Small on CP due to Add Spacticity
 o CLINICAL SIGNIFICANCE - 90-120 steps/min
1. Poor Balance – Wide BOS - Fast gait = > 120
2. Loss of Sensation – Tabes Dorsalis - Slow agit = <90
3. Musculoskeletal Problem – ex: CP - Average: 113 steps/ min
scissoring gait - Dec. with age
STEP LENGTH - Shorter step length will result to dec. in
- Gait Length cadence at any given velocity
- 15” N Leg - Women has more cadence than men
- Affected by : Degree of toe out
Leg Length and Height = Tall - 7˚
Age = Old - Dec when Inc speed in walking
Gender = Male - And and 2nd toe
o CLINICAL SIGNIFICANCE Standing Walking Running
1. R hip Flexion Contracture 15 ˚ 7˚ Dec or Absent
= Dec L step length Energy cost of walking
2. R Iliopsoas Weakness - Ave. O2 for comfortable walking
=Dec R Step Length = 12 mL/ kg x min
3. R quads weakness - Metabolic cost of walking averages
=Dec R Step Length =5.5 Kcal/min on level surface
4. R knee flexion contracture  Gait Parameters are Sig. Dec in women are
=Dec R Step Length compared to men
5. R Calf Weakness  Velocity
=Dec L Step Length  Stride and Step Length
Stance Time  Sagittal hip motion
- Ex. Injured L foot  Knee flexion in initial swing
- Dec. stance time on Left and Inc stance  BOS
time on Right  Vertical Head Excussion
Stride Length  Lat Head Excursion
- Distance between two consecutive  Sh Sagittal Motion
same foot  Elbow motion
- Normal : 30”  Gait Variations in Elderly
- Equal to 1 gait cycle  Slower speed
Lat. Pelvic Shift  Shorter but wider steps
- Side to side movement of pelvis during  Dec arm swing
walking  Dec LE excursion during swing
- N : 1-2”  Less pelvic rot
Vertical Pelvic Shift  Inc toe out
- Keeps COG from moving up and down  Inc time in stance
- 2” Stance Phase
Pelvic Rotation Jt HS FF Mst HO TO
- Necessary to lessen the angle of the HIP Flex Ext Ext Ext Ext
femur on the floor 20-40 Slight 0˚ 10-20 0˚
- It lengthens the femur Gmax Gmax Gmax Iliopsoas Iliopsoas
- 8 ˚ = 4 ˚ ant / 4 ˚post. Ecc Con Noact Ecc Con
- To maintain balalance, the thorax KNEE Ext Flex Flex Flex Flex
rotates on opp direction Full 20 5-15 4 30
Cadence
Quads Quads Quads Quads Quads
- No. of steps / min
 Con Ecc To no To no Ecc flexion heel rise on affected legs occur
act act earlier
ANKLE DF PF PF PF PF 4. Equinus Gait (PLANTAR)
0-neutral 15 5-10 0 20 - Toe walking
Pretibials Pretibials Calf Calf Calf - Seen in clubfoot pt. (talipes
Isometric Ecc Con Con equinovarus)
HO and TO calf = Push off/ Roll over 5. Plantar Flexion Gait
- Loss of PF
 Important notes: - Dec or absent Push off
1. Max Hip Flexion = 30 ˚ - Dec stance phase
- Seen in HS and entire swing phase - Shorter step length on unaffected side
- Steppage: excessive hip and knee 6. Psoatic Limp
flexion - Seen in LCPD
- Use to compensate for toe drag - Difficulty in swing through
2. Knee is fully extended only in HS and - Accompanied by exaggerated trunk and
flexed during the remaining stance and pelvic movement
entire swing
3. GMax (Inf Gluteal nn – S1) PARALYTIC GAIT PATTERN
- Max act -HS- eccentric 1. Gmax Lurch
- If weak- backward lurching in STANCE = - Extensor lurch
HONEYMOON’S GAIT - Honeymoon gait
4. Quads- max act – HS - Backward trunk lurch in early stance
- Early stance to FF 2. Iliopsoas Weakness
- Paralysis = forward lurching on STANCE - Backward trunk lurch in early swing
3. Quads
PATHOLOGIC GAITS - Back Knee Gait
1. ANTALGIC GAIT (painful gait) - “Pushing the thigh backward” =
- Stance phase of the affected leg is Buckling
shorter than the non-affected leg. - Forward trunk lurch in early stance
- Dec swing phase of uninvolved leg 4. Gastrocsoleus Weakness
- Dec step length of uninvolved leg - NO rollover/ Push off
- Dec walking velocity - Lack of push off in late stance
- Dec Cadence 5. DF
2. ANTROGENIC GAIT - STANCE: Foot Slap,
- Stiff hip or knee gait Toe Drag (late stance)
- PF on unaffected side to circumduct - SWING: Foot Drop,
affected leg Toe Drag(early swing)
3. CONTRACTURED GAIT 6. G. Med
- Hip flexion contracture result in lumbar - U/L = Trendelenburg
lordosis and ext. trunk - B/L = Waddling, Wobbling, Ghorus G.
- Knee flexion contracture result in GAIT DEVIATIONS AT HIP
excessive DF from late swing to early 1. Weak hip extensors
stance on uninvolved leg/ early heel rise - backward trunk lean in stance
on involved leg on terminal stance. 2. Weak Hip Abd
- PF contracture: knee hyperextension - Lat trunk lean on stance side
forward bending of trunk with hip - Pelvic drop on opp side
3. Hip flexion Contracture
- Excessive lumbar lordosis
 - Forward bending during mid and GROUP D/O
terminal stance Seronegative Ankylosing spondylitis
4. Hip Flexion Weakness (Spondyloarthro- Psoriatic Arthritis
- Trunk lurch backward during HO to paties) Inflam. Bowel dse
midswing Reactive Arthritis
- PPT Inflam. Crystal- Gout Metabolic Arthritis
- Hip Circumduction induced dse. (MSUC)
GAIT DEVIATIONS AT KNEE Pseudo Gout = CPPD
1. Rapid ext of knee during IC Calcium Pyrophosphate
- Spastic Quads Deposition Dse
2. Knee remains extended during LR Inflam. Induced by Syphilitic A. ,Bacterial A,
- Weak Quads infectious agents Fungi A. , Tuberculosis
3. Genu Recurvatum Inflam Connective jt RA, JRA, Polymyalgia,
- Weak Quads dse Rheumatica, SLE,
4. Reduced or Absent knee flexion Sjogrens, PM-DM,
- Spastic knee extensor Fibromyalgia, PAN
5. Flexed position of knee during stance
and lack of knee ext in Terminal Swing
- Knee Flexion COntructure PHARMACOLOGY
- Hams Overactivity - Study of drugs and the harmful effects
GAIT DEVIATIONS AT ANKLE of drugs
1. Foot Slap – “FOOT FLAT”  DRUGS- any chemical agents that
2. IC w/ ground made by the forefoot FF affects the process of living
by heel region = WEAK DF  Pharmacodynamics- effects of drugs in
3. IC w. the ground made by the forefoot the body
but the heel region never makes  Pharmacokinetics- body on the drugs
contact with the ground during stance=  Pharmacy- process of dispensing drugs
HEEL PAIN/PF CONTRACTURE  Toxicology- study of toxins and harmful
ARTHRITIS effects
- Inflammation of jt DRUG NAMING
- Affects the jt and other connective o Chemical Name – specific
tissue compound drugs
- Affecting synovial jt o Generic name – non- proprietary
 INFLAM = m/c RA name
 NON-INFLAM=m/c OA o Brand name – trade name
 m/c arthritis= OA –proprietary name
ARTHROSIS Rout
- Limitation of jts w/o inflammation  Drug Administration
1. Enteral – GIT/ Alimentary Canal
a. Oral – m/c form, easiest from,
 SIGNS AND SYMPTOMS: first pass effects = LIVER
 Impaired mobility b. Sublingual- fastest enteral
 Impaired mm performance c. Rectal – via anal canal
 Impaired bal - for unconscious, vomiting,
 Activity Limitation and participation hemorrhoids, suppositories
restriction (fever,constipated)
2. Parenteral – non- alimentary
INFLAMMATORY ARTHRITIS a. Inhalation – ex. Nebulizer
 b. Injection
Types of injection
i. IM = m/c gmax and deltoid
ii. IA=
iii. IU=
iv. Subcutaneous= insulin (under the skin)
v. Intrathecal = sheath of SC
3. Topical
4. Transdermal
– Iontophoresis
– phonophoresis
Bioavailability - % of drugs that us present
and active in the bloodstream
Drug Storage  Skeletal mm relaxant / Antispacticity drugs
1. Adipose Tissue – 1st storage 1. Centrally acting
2. Bone ¦ CP- Benzidiazepine (D & V)
3. MM SE: mm weakness
4. Organs (Liver and Kidney) ¦ MS & SCI- baclofen has no mm
Drug Excretion weaknesss SE: SEDATION
KIDNEY - 1 ˚ site of drug secretion 2. Peripherally / Direct-acting
¦ BOTOX – for spasmodic torticollis,
 Sedative Hypnotic drug dystonia, blepharospasm
- Use to calm and pacify pt. ¦ DANTROLENE- Sodium (DANTRIUM)
- Promote sleeping and relaxation SE: Gen mm weakness
- SE: Sedation and GI distress  NSAIDS aka: COX (cyclooxygenase)
1. Barbiturates ( Phenobarbital) inhibitory
- Tranquilizer SE: Gastric irritation/ upset, bleeding
2. Benzodiazepine 1. Anti-Inflam
- Diazepam / vallium 2. Anti-coagulant
 Anti-Depressant drugs 3. Anti-Pyretic
- TCA: tricyclic acid 4. Analgesia – M/c : ASPIRIN
- SE: sedation SE in child: REYE SYNDROME
 Anti- Psychotic Drugs/ Neuroleptic Drugs = GI Bleeding, high fever, vomiting
- For psychotic pt.  Acetaminophen
- Most feared SE: - Not considered as NSAIDs
Jardive Dyskinesia= invol. Fragmented - For antipyretics and analgesia only
movement of the face , mouth and jaw - Not assoc with GI bleeding and reye
producing lip smocking sound syndrome
 Anti-Epileptic Drugs/ Anti-Seizure/ Anti-
Convulsant
1. Barbiturates – SE: Sedation
2. Benzodiazepne – SE: Sedation
3. Carboxylix Acid (Valproic Acid)
4. Hydantoins (Dilantin)
 PD

 PGs- covering of stomach

 - TPA: Tissue Plasminogen Activator
- SE: Hemorrhage

OSTEOPOROSIS:
- Significant dec. in bone density
- Bone Density: (t-score)
 N = -1.0 or higher
 Osteopenia= -1.0 to -2.5
 Osteoporosis= <2.5
RA - Clinical Union: formation of callus from
Goals of drugs: fx site
1. Dec inflammation - Bone Remodeling
NSAIDs and Corticosteroids 1. Activation
2. To halt progression of dse 2. Resorption
DMARDs 3. Reversal
a. Anti-malarial drugs : 4. Formation
SE: retinal damage 5. Quiescence
b. Azathioprine: - Pathogenesis:
SE; Renal Damage  Dysequilibrium bet resorption
c. Gold Compounds and formation favoring
OA resorption w/c result to bone
Best tx: wt loss loss
MEDS: NSAIDs – pain management  Inc osteoclast
Heart  Dec Osteobalct
- Anti-Htn drugs  Peak of one mass – 20-30
1. Diuretics – m/c anti-Htn - Classification (CAUSES)
-cheapest Hereditary:
-1st line in tx o Congenital-
-SE: Fluid and electrolyte depletion and ¦ Osteogenesis Imperfecta/
imbal ; Hyponatremia; Hypokalemia Brittle bone
2. Beta Blockers/ Beta Adrenergic Agonist ¦ Neurologic Disturbance
- Dec HR and BP ¦ Growth of litthe known dse
-inhibit adrenergic (epi and Nore) *Osteopetrosis (MARBLE BONE)
3. Vasodilators / Albergs – Shoerbergs
4. Ca++ channel blockers – reduce *Osteopoikilosis –Spotted bone
contractility of heart o Acquired
5. ACE inhibitors – “pril” ¦ Primary
SE: dry hacking cough  Idiopathic
6. Anti-coagulant  Post-menopausal
- Target is building up of clotting factor  Age-related
- Affect the synthesis of clotting factor
7. Anti-Thrombotic ¦ Secondary
- Target the platelets  Nutrition
- Inhibit production of platelet  Sedentary lifestylr
- Aspirin – SE: Reye Syndrome  Drug intake -
8. Thrombolytic Drugs biphospahte
- Breakdown of thrombus  Malignancy
- Ex. Streptokinase  Endocrine d/o
 Osteoporosis is typically a “Silent dse” until ¦ Until 5 y/o – every 15-18 mons/
fx occurs annually
 CM: ¦ 5-12 y/o – every 18 mons / every 2
- Back pain yrs
- Dowager’s hump ¦ 12y/o to adulthood
- Multiple fx - Every 2 yrs : 12-21 y/o
- Height loss
- Every 3-4 yrs : >21 y/o
 Fx Sites:
¦ Lifespan of UE &LE prosthesis = 3yrs
1. Spine
2. Femur TERMINAL DEVICES
3. Mid Thirax
4. Distal forearm – Colles Fx  Classifications
5. Upper Lumbar 1. Mitt (Heart )– sports/ energy absorption
 Prevention (Primary) /release
- Adequate Calcium intake 2. Hand – 3 jaw check/ prehensile grasp
¦ Elderly/pregnant – 3. Hook – lat. prehension
1200mg/day  Types of Terminal Devices
¦ Young & children – 1. Passive Terminal Devices – no fxnal use,
800mg/day
for cosmesis, lightest
(Secondary)
2. Body Powered Terminal Devices
- Medication - Postural awareness
- Bal exe - Prevention of fall a. Voluntary opening terminal devices
- m/c type; Dorrance
-5-10 lbs
PROSTHESIS -lighter than voluntary closing TD
b. Voluntary Closing T.D
UE Prosthesis
-more physiologic in fxn
- Gen Timing: 3-9 mons -most commonly used and most
- Terminal Device: 1 ½ - 2yrs functional terminal device is :
- Elbow unit: 3-4 yrs VOLUNTARY OPENING HOOK
 Best time to fit a child with an initial upper -provide sensory feedback
limb prosthesis = 5 mons -20-25 lb.
 When the child can incorporate the 3. Externally Powered T.D.
prosthesis to body image a. Myoelectric – Controlled T.D.
- more motivation needed
LE Prosthesis
-use of AP
- Gen Timing: 3-4 y/o -(+) electron
- Terminal Device: 3<4 y/o b. Microswitch-controlled TD
- Elbow unit: 4.5 y/o Fxn: for easy use
1.Optimal Liner thickens – 3-9 mm UPPER EXTRIMITY
2.Replacement period for body powered  Prosthetic wrist unit
prosthesis : 1 ½ - 3 y/o Prosupination
3. Replacement period for myoelectric - Promotes pronation and supination
prosthesis : 2-4 yrs 1. Friction wrist- easily position – not
 Prosthetic Replacement Check Up recommended for heavy lifting
2. Quick disconnect/ locking wrist
 ¦ Best prosthetic unit for blue colar jib
¦ For heavy lifting – locking unit
¦ Easy usedue ro quick disconnect
3. Spring- assisted- pronation and sup
for bilat
- Flexion-wrist flexion = more for b/l
amputees to promote midline
consciousness
Below-Elbow Prosthesis Socket
- Split Socket – for very short transradial
amputation = <35% of elbow
- Merenster Socket/Self Suspended
Socket
¦ For STA= 35-55%
¦ 30 degree elbow flexion position
¦ (+) figure of 9 harness
¦ Socket encloses the olecranon and
epicondyle of harness
Below-Elbow Prosthesis Elbow Hinges
- Flexible
Recommended for :
 Wrist disarticulation
 Long transradial amputee = 55-90%
Note: active pron-sup
- Rigid
 For short transradial amp = 35-55%
 Note: (-) active pron and sup
- Step-up Hinge
 For very short transradial
 Note: enhances elbow flexion
- Prosthetic elbow
a. Flexion – for flexion
b. Rot. turn table – as compensation
for sh IR
Transradial Harness Suspension
- Figure-8 (O-ring Harness)
 (+) reaction of pt: all force is applied
on opp/ unaffected side
 m/c use
 give the widest range of activation
and least body restriction
- Figure 9
 Basically the same but offers
greater ROM
Chest- strap with sh straddle saddle harness
- If pt. can’t tolerate axilla loop
- 3 notes:
1. Very comfortable to girls
2. Primary Recommended
= forequarter amputation
=(-) harness , some clavicle and scap
3. Recommended for heavy lifting
Above Elbow Prosthesis
- Tanshumeral/above elbow sockets
 Lat. socket wall – acromion process
 Med socket wall- below axilla
Elbow units
- Internal Elbow jt- 4cm on prox from
epicondyle
- Ext. elbow jt ->4cm prox from
epicondyle
Control-Cable Sys.
- Single/Bowden Control Cable System
¦ Transradial amputee
¦ Only operates the terminal device
¦ Motion: sh abd, scap, protraction and
elbow flexion
- Dual Control Cable System
¦ Operates the elbow unit and terminal
device
¦ Unlocked elbow unit : Sh Flexion, scap
protraction
¦ Locked elbow unit: Sh ext, scap
retraction, scap depression
LOWER EXTRIMITY
Syme’s Amputation/ ankle disartculation
- Socket Design
¦ Posterior Opening
– cut down to level of malleoli
¦ Medial Opening
– cut out to allow malleoli to pass
¦ Stove pipe Design
– no flaps/windows are cut
– has a cylindrical socket
Foot-ankle asssembly
- Single Axis Foot
¦ all motion is around one axis (PF&DF)
 ¦ contains a PF Bumper (15˚) and DF stop  Less life-like, more durable
(<5˚) Below Knee Socket
¦ prescribed for: prox amputess - Patellar Tendon Bearing Socket
- Multi-Axis Foot ¦ Trim lines extend ant (midpatellar level)
¦ Controlled mov’t in amp direction and medio-lat post (fem condyle)
¦ For athletic activities/ uneven terrain ¦ Helps prevent edema and recurvation
Rigid Keed - Supracondykar cuff susoension socket
- Solid Ankle Cushion Heel (SACH) ¦ Trim Lines extend medially (sup edge of
¦ m/c used prosthetic foor patella) and laterally
¦ lightest ¦ m/c below knee socket
¦ allow simulation N walking - Rubber/ Neoprene Slum
¦ offers mediolateral stab ¦ Difficult to do
Flexible Keel ¦ Inc Perspiration
- stationary ankle flexible ¦ Provides min to no stability only
endoskeleton(SAFE) foot advantage : retains Heat
¦ Accomodates uneven surfaces but - Hydrostatic Socekt
heavy, costly and not cosmetic ¦ Designed to elongate the tissues
¦ Permits; Both PF and DF - Thigh corset
¦ Doesn’t allow : Ev and Inv ¦ Main advantage: Dec. WB of residual
- Otto back dynamic foot limb– 40-60
¦ Same with SAFE but ¦ Provides mediolateral stability and
¦ Permits: PF only sensory feedback
¦ Doesn’t allow: DF, Inv and Ev ¦ Disadvantages (4)
Energy – Storing / Fynamic Foot - Bulky - atrophy quads
- For jogging and ge. Sports - Pistoning -edema aggravation
1. Stored Energy (STEN) foot – more  Borrelia Burgdorferi
exoensive - Lyme’s dse
2. Seattle foot - Knee affectation
3. Carbon Copy II Below knee Scoket
4. Quantum - Pressure tolerant areas (+redness)
5. Flex- Foot 1. Popliteal fossa
6. Flex- Walk- most energy storing , 2. Patellar tendon
lowest inertia 3. Tibial Tuberosity
 A type of energy storing with Derlin Kell- 4. Mid Tibial Flare
Seathe 5. Prox medial tibia
 Force- Absorbing foot and not an energy 6. Lat Shafts of fibula
storing foot – Safe II 7. Pretibial mm
SHANKS 8. Gastrosoleus mm
- Connects the ankle foot assembly to the 9. Med and Lat residual limb
socket - Pressure sensitive areas
- Types: 1. Fibular head
¦ Exoskeletal/Crustacean 2. Fibular neck
 Life-like appearance , lighter 3. Peroneal nn
¦ Endoskeletal/Modular 4. Ant. tibia
 5. Tibial crest - Lat sides of residual limbs
6. Ant distal tibia and fibula Pressure sensitive (-) redness
7. Hams tendon - Sacrum -peningeal area
Above Knee Socket - Med. thigh -distal lat femur
- Total Contact Quadrilat. Socket - Patella
¦ Narrow anteroposteriorly and relatively  Knee Units
wide mediolaterally - Conventional Single Axis
¦ Provide relief to several mm and bony ¦ Flexion and extension occur around a
landmark single axis
¦ For pt with bulging over scarpa’s ¦ Primary indic. For pediatric pts.
triangle ¦ Disadvantages:
¦ However, it lacks stab;  In swing phase/ diff knee flex
¦ (+) tenderness and walking probs  early sw/ excessive heel rise
¦ Lurdrines or grad. socket  late sw/ terminal sw impact
CHARCOT jts - Manual Locking Knee
Syryngomyelia = SH ¦ Last resort
Tabes Dorsalis= Knee ¦ Offers max stability in stance phase esp.
DM = Ankle ; M/C in elderly and during transfers but stiff
Relief mm of TCQS knee gait
Gmax - Stance control Knee
Hams ¦ For amputees with weak hip extensors
Add Longus and for geriatrics pt.
Rectus Femoris ¦ Disadvantages
Greater Troch 1. Produces a single cadence
- Ischial containment/ Narrow shape N 2. Not recommended for active
alignment (NSWA) walkers
¦ Narrow medio-lat than 3. Not recommended for b/l amp
anteroposteriorly measurement - Fair- bar Polycentric
¦ For younger and more active patients ¦ For pts with very long residual limbs
¦ Wt. bearing – ischium ¦ Dis/A include greater wt , high cost,
- Recommended for : more maintenance, & late stance prob.
1. Mild abductor weakness - Hip Disarticulation / Hemipelvectomy
2. Short above knee amputee ¦ For amputees with <5cm of residual
 Sunction Suspension femur
- Most secure suspension method ¦ Canadian hip disarticulation prosthesis
- Advantages: ¦ Standard prosthetic used
1. Provide greatest prosthetic control 1. Ant Prosthetic wall is – Flexible
2. For amputees who have well- 2. What type of shank– endoskeleton
shaped fairly strong residual limbs 3. What type of foot – ankle assembly
3. For young active pts. (AXIS: SINGLE)
- Main disadvantage: 4. What type of foot – ankle assembly
1. Above knee sockets: (KEEL: SACH)
Pressure tolerant areas (+ redness)
- Gluteals, -Ischial Tub
OSTEOARTHRITIS ¦ Tenderness
¦ Palpable osteophyte
- Non inflammation d/o of movable jts
¦ Boggy synovitis
characterized by deterioration of
¦ Crepitation
articular cartilage and formation of new
¦ LOM :
bone at jt surfaces and margins
 HIP – Flex, Abd, IR, ER
- Bone eburnation – new bone formation
 Knee- Flexion
on articular cartilage
 Ankle- loss of df
- Aka. Degenerative jt dse
 LAB abN
 Patho Findings:
- ESR: N d/t no inflammation
- Early deterioration on disruption of
- CBC : N
articular cartilage
- RF : (-)
- Complete loss of articular cartilage
- Serum Calcium Alkaline (Paget’s, HO) (-)
eburnation of bone
“NO LAB Abnormalities”
- Cyst on subarticular bone
 Dse that may lead to OA:
 Subchondral cyst- Synovial
- Acute/ Chronic trauma
enters the bone articular
- Alcapturia – urine turn block when
cartilage/eburnation
exposed
- New bone formation found at base of
- Wilson’s Dse – copper deposit
articular cartilage
- Hematochromatosis
 Important Etio:
- Acromegaly
- Obesity
- Hyperarathyroidism
- Genetic and heredity forms
- Intra-articular corticosteroid therapy
- Occupation
- DM
- Multiple endocrine dse (ex. Pseudogaut
- Syryngomelia
or gaut)
- Frost Brite
- Multiple Metabolic dse (Acromegaly)
- Hemophilia
 Epidemiology:
Primary OA – Iodized or Generalized
- Age: 40 y/o
AKA: Kellgren Syndrome
- M=F
Secondary OA -(+) underlying dse
 OSTEOPHYTE – bone “outgrowth”
 OA of SH
– main characteristic of OA
¦ AC jt – most limited motion : IR –
 AbN in radiograph
*in RA- GH
- Cartilage erosion
 Heberden’s Node – bony enlargement
- Bone eburnation
 Bouchard’s Node – in PIP
- Subchondral cyst
 Mucinous Cyst – PIP, DIP
- Osteophyte
– mucinous fibrous tissue
- Bony Collapse
¦ M/C affected:
- Loose bodies
1st Cervical
- Deformity and malalignment
2nd Lumbar
 Symptoms: Cardinal Sx
3rd Knee and Hip
¦ Pain during wt bearing and relieved
4th DIP
with rest or NWB
5th Thumb
¦ Stiffness from awakening in the
 OA of the trapeziometacarpal articulation
morning; after periods of inactivity

 Degenerative Arthritis of wrist jt
- Kienback’s dse
- Trauma
- Non-union of scaphoid
- Gout
- CPPD/Pseudogout
- Carpal instab from ligamentous
disruption and scapulolunate lig.
 Bunion- Combi of deg jt dse at 1st MTP jt
and valgus angulation
Sx:
- Progressive Swelling
- Pain
- Difficulty wearing shoes/ walking
- Inflam of bursa or the med aspect
OA of spine
- Narrowing of IV disc
- Subluxation of one vertebral body esp
in lumbar spine
- Facet jt with osteophyte formation may
cause narrowing of foraminal space
which may cause nn root irritation
Erosive OA
- Involves PIP and DIP
- Hereditary
- Severe inflam leads to jt deformation
and ankyloses
- Post-menopausal women are most
severely affected
- Severe bone erosion and subchondral
bony sclerosis as seen in radiograph
- (+) Gun Wing Sign
SLAC – Scapulolunate Advance Collapse
– m/c arthritis of the wrist
STT – Scaphotrapeziotrapeziodal arthosis
– 2nd m/c arthritis of wrist
*HCTT –STT *FTLS –SLAC
DISH (Diffuse Idiopathic Skeletal Hyperostosis)
- “Foresties Dse”
 Principles of mngt : OA
- Pts educ
- Pain mx – NSAIDs
- Assistive and Supportive device
- Resistance exe – multiple angle
isometric on pain free
- Stretching and jt mob – Grade 1 & 2
- Balance Act- tai Chi
- Aerobic Conditioning – walking, biking,
swimming
- C/I – running jogging and jumping
RHEUMATOIDARTHRITIS
- Autoimmune, chronic, inflam, systemic
dse of unknown etio affecting synovial
lining of jt and other connective tissue
 CHARACTERISTICS OF RA:
- Symmetric erosive synovitis with period
of exacerbation (flare) and remission
- Inflam changes
- Intra-articular pathological changes
 Rheumatiod nodules
 Atrophy
 Fibrosis
 Mm weakness
 Fatigue
 Mild cardiac dse
- Progessive deterioration and decline in
fxnal level of individual
- RF:
 Immunoglobulins
 Found in serum of RA pts but
not a pathognomonic of RA
 Criteris for dx of RA:
1. Morning stiffness of at least 1 hr
2. Symmetry / B/L arthritis
 3. Arthritis of Hands - Nalebuff’s Catery – Duck bill , hitch
4. Arthritis of 3 or more jts hiker’s
5. RF - Mutilan’s deformity/ opera glass hand –
6. Rheumatoid nodules inc skin fold on the thumb resembling a
7. Radiographic changes folded telescope
1-3 present for at least 6 wks HIP
5-7 chronic dse - Prosthesia acetabuli – thin acetabulum
S/SX: KNEES
- Synovial inflammation - m/c affected due to large synovium
- Onset is usually in small jts of hands and Common foot abN in RA
feet (MC, PIP Jt)  Forefoot
- Jts maybe deformed ; ankylosed/ - Widening of metatarsal area/ splay foot
sublaxed (inflammation weakened the lig)
- Low grade fever - Flattening of medial arch
- Loss of appetite and wt - Matatarsalgia
- Malaise and fatigue - Hammer Toes
M/c extra-articular sx: - Claw toe
- Nodules - Hallux Valgus
- Dry eyes - Bunion
- Dry mouth  Midfoot
- CTS - Dec MLA- spring lig laxity
Xray Hallmark of RA - Post Tibial Tendon (PTT) –tendinitis (2˚
- Soft tissue swelling support)
- Juxta-artocular osteoporosis  Hindfoot
Cervical Spine – C1 –C@ - Pronation of subtalar jt
- Atlantoaxial jt – aa d/l - PTT tendinitis
- Midcervical region - Ligamentous laxity
TMJ  Associated medical condition and
- Inability to open mouth fully corpobidity
Hangs and fingers  Rheumatoid Vasculitis
 Swan Neck Def – FDS  Pericarditis
 Boutonniere def – EDC – central slip  Pulmunary dse
 Mallet def –EDC – lat slip  Felty’s Syndrome
 Zigzag effect o Splenomegaly
 Bouchards Def –PIP o Lymphadenopathy
 Vaugh Jackson syndrome – EDC- 4th,5th o Arthritis
 Mannerfelt Syndrome – destructive process o Anemia
initiated by synovitis of DRU jt o Neutrocytopenia
 m/c sublax : ECU o Thrombocytopenia
Wrist  Sjogren’s syndrome
- Stenosing tenosynovitis / De quervains  Classification of RA
- Volar subluxation of carpal bones Class 1: Indep in self-care, vocational,
- De quervains Dse avocational
Thumb Class 2: Indep in self-care, voc, dep in avoc
 Class 3: Indep in self-care, dep in voc & avoc JUVENILLE RHEUMATOIDARTHRITIS
Class 4: Dep on all
- Chronic jt inflammation
 STAGES OF RA
- Persistent arthritis lasting for at least 6
1 2 3 4
wks in one or more jts in a child
Osteopo Osteopor Osteopor Osteopor
rois ois + ois + ois + younger than 16 y/o
SubQ SubQ SubQ - Systemic JRA- still’s dse
nodules, nodules, nodules, - Oligoarthritis – Pauciarticular – 4 or less
LOM, mm LOM, mm LOM, mm jts
atrophy, atrophy, atrophy, - Polyarticluar – 5 or more jts
tenosyno tenosyno tenosyno  Systemic JRA
vitis vitis + vitis + - Characterized by spiking fever
Extensive Extensive - Evanescent rash – linear rash found on
mm mm trunk and extremity
atrophy, atrophy, - Arthralgia
jt def jt def+ - Jt swelling
Bony or
 Pauciarticular
fibrous
- Arthritis affecting four or fever jts
ankylosis
- Typically larger jts (Knees, ankle, wrist)
Management:  Polyarticular
- Affcets at least 5 jts
 Px educ
- Energy conservation technique - Both larger and small jts often in
- Avoid potential dif stresses during act symmetric bilateral distribution
- Sever LOM
and exercise
 Joint protection - Weakness and dec physical fxn
 Jt mobilization Etio of JRA – IDIOPATHIC
 Exercise: ROM but not stretching if ROM is S/s
not possible perform PROM - morning stiffness
 4 maj Pharmacological Tx - school hx of absence and inability to
- Narcotic analgesic participate in PE classes
- NSAIDs & Corticosteriod to dec inflam - Gait dev: Limping
- DMARDs – to halt the progression of - Acute or chronic uveitis
dse - Hx of travel : tick bites
 Ex. Antimalarial drugs : SE: blind - GI sx
 Methotrexate:SE:Renal Damage Juveniel Arthritis Functional Assessment
 Gold Compound Scale – the only instrument that measures
the child’s actual performance
OA RAA
Age >40 15-40 MX
Progression gradual Abrupt - ROM and stretching
Manipulation Off space systemic  Acute- PROM/AROM
narrowing  SubA/chronic – AROM
Jt involve WB, assy Symme,hand - Strengthening
Jt s/s 30 min > 1 hr  Acute- Isomets
Systemic s/s (-) (+)  SubA/chronic –Concentric
- Endurance Ex – Swimming
 - Jt protection strategies
(pajamas/electric)
- Mobility assistive devices
- Posture and positioning
- Modalities to control pain
 Polymyalgia Rheumatica
- An inflam d/o that causes mm pain and
stiffness
- Elderly (affecting prox area, neck, sh,
pelvis, upper arm)
Meds – Corticosteriods
– calcium & Vit D supplement
– Anti-inflam tx
– Anti- convulsant tx
–Anti-biotics
Assoc w/ Giant cell arteritis/ temporal
Arteritis
S/s
¦ Difficulty getting out of the bed, standing
from a chair, getting out of car, personal
hygiene
¦ Aching and stiffness develop quickly in PMR
¦ m/c in sh area, upper arm
¦ sx worse in the morning
¦ sx respond promptly to low doses of
corticosteroids but may as the dose is
lowered
¦ KEY SX:
- Fever - painful and tender jts
- Chest pain - Migratory jt pain
- Heart murmur - fatigue
- Small painless nodules beneath the skin
- Flat or slightly raised, painless rash w/
ragged edge (erythema margination)
- Jerky uncontrollable body mov’t
- Outburst of unusual behavior
Rheumatic fever – inflammation dse that
can occur as a complication of inadequate
treated throat and scarlet fever
– m/c 5-15 y/o
– permanently damage the aortic and mitral
valve
FIBROMYALGIA
- Chronic condition characterized by
widespread pain that covers half of the
body (R & L half / upper or lower half) plus
axial skeleton that lasted for more than 3
mons
- Aka: WIDESPREAD PAIN SYNDROME
Epi: F, 40 y/o
Etio: stress, noise, anxiety, pollution,
weather disturbance
Contributing factors: Environmetal,
physical and emotional stress
Characteristics of FM
- 1st sx can occur at any age, usually bet
early to middle adulthood
- Sx usually from physical trauma
- Pain that is muscular in origin
- Indiv with FM have a higher incidence
of tendonitis, h/a, irritable bowel, TMJ
dysfunction, restless leg syndrome,
mitral valve prolapse, anxiety,
depression and memory problems
FIBROMYALGIA
- Chronic regional pain sx
- Hallmark :
*Trigger pts
*Taut band – shortened mm
–electrically silent
*Twitch response – localized
Management:
- Correct contributing factor to chronic
overload of a mm
- Eliminate trigger points
 Contract relax passive stretch
 Contract relax active stretch
 Trigger point release
 Spray and stretch
 Modalities
 Dry needling or injection
- Strengthening the mm
 Similarities of FM and MPS
- Pain in mm
- Dec ROM
- Postural Stress
  Difference  Pseudogaut
FM MPS - CPPD
Fatigue & Body Malaise + - - Commonly affects elderly
Reffered Pain - + - Affects older pts
Tender Points + - - Affects prox jts
Trigger pts - + - (+) birefringent crystal
Tight Band - + SX:
Crystalline Arthropaties - Acute onset jt tenderness
GOUT: Metabolic Artritis - Warm, erythematous jt
- Monosodium urate arthropathy Assoc condition:
- Purines: Beer, nuts and beans, - Hemochromatosis
mushrooms, aspagarus, sardines, int. - Hyperparathyroidism
organs - SLE
- Inc URIC ACID in blood - Gout
- AKA: erosis tophaceous Arthritis - RA
Causes: - Wilson’s dse
- Obesity - Alcoholism - Hemophilia
- Water pills (diuretics) - Long-term dialysis
- Meat, Seafoods, Int organs that are high - Chondrocalcinosis
in purines MX : - NSAIDs, colchicine
M/C signs: Clinical Features of acute gaut and
- Nighttime attack of swelling, Pseudogaut
tenderness, and sharp pain on big toe - Abrupt onset
- Foot and Ankle : Podagra - Jts are painful , swollen , warm and
- Knee : Gonagra tenderness
- Hand: Cheiagra - Pain may awaked the pt (from sleep)
Pathognomonic of Gout – TOPHI - May resemble a bacterial cellulitis
TOPHI – nodular mass of uric acid crystals - Mild attack (1-2 days)
– common in fingers , tips of elbow , big toe - Severe untreated attacks (7-10 days)
– ears patella bursa, Achilles tendon - Systemic signs :
Assoc condition: * FEVER *Leukocytosis * Inc ESR
– Renal Strokes/ Nephrolith  M/c affected jt in GOUT – 1st MTP
–Septic Arthritis  M/c affected jt in PSEUDOGOUT – knees
MANAGEMENT:  Tx choice for acute crystalline induced
- Indomethacin and Colchicine (first line) Arthritis – indomethacine
for acid
- Allopurinol – chronic Sjogren’s Syndrome
- Corticosteriods – jt aspiration - Autoimmune d/o primarily
 Postive Birefringent characterized by lymphatic infiltrates in
- Pseudogaut the exocrine gland
- Rhomboidal in shape - Sicca symptoms
 Negative Birefringent - AKA:
- Gaut o Mickulicz Syndrome
- (+) neddle like crystals o Gougerot Dse
o Autoimmune Exocrinopathy
 o Sicca Syndrome RA Spondyloart
 Sicca Symptoms hropathy
o Dry eyes – Xeropthamia Peripheral Art Symmetric Assym
o Dry mouth – Xerostomia Sacroilitis (-) (+)
o Dryness of vagina- Dyspareunia Spondylitis (-) (+)
 Primary Sjogrens (+) Sicca sx only Enthesopathy (-) (+)
 Secondary Sjogrensp- plus underlying dse RF (+) (-)
Other sx: Subq Nodules (+) (-)
- Jt pain swelling and stiffness HLA B27 (-) (+)
- Swollen salivary glands
- Skin rashes / dry skin Ankylosing Spondylitis
- Vaginal dryness - AKA: Marie Stampell Dse/ Von
- Persistent dry cough Bechetereu M. Dse
- Prolonged fatigue - > 3 hrs stiffness in morning
Complications : Characteristics:
- Dental cavities - Onset of 40 y/o
- Yeast infection - Insidious onset
- Visual probs – corneal ulcers - Prolonges morning stiffness
Confirmatory test : - Improvement of sx w/ exe
- Eyes : - Acute uveitis = m/c extraarticular sx of
* schirmos test AS
*Lissa mine green test ST : Wright Schoeber’s Test
*Rose Bengal test - S2 – 10 above , 5 below
- Saliva: SIALOGRAM Management:
- NSAIDs
Seronegative Spondyloarthropathies - Pt educ : * Posture
- Grp of rheumatic dse that share *ROM stretching prog bid
common clinical, genetic and radiologic o Back Extensor Exercises
features * strengthening of sh, hip, spinal
- Ex: extensor
 B/L: AS *sports (Archery, tennis, badminton)
 U/L: Psoariatic Arthritis *C/I = Golf, bicycling, bowling, crocket
 Reiter’s syndrome
 IBP Psoriatic Arthritis
- HLA – B27 Entheritis (SI jt affectation) Clinical Features
Common features : - Psoriasis
- Predilection of inflammatory lesions of - Asymmetric arthritis w/ frequent
axila skeleton (sacroillitis/ sponaylytic) involvement of DIP jt
- Oligoarticular peripheral jt arthritis - (-) RH factor
- Enthesis - Sausage digits
- Extraarticular inflammation of eye, - Spondylitis
heart, and skin and mucus membrane - Sacroilitis
- Affect young adults (m/c men) Pathognomonic
- Strong association with HLA-B27 - Pencil in a cup deformity
- (-) RF Arthritis Mutilans - Onycholysis
 Management: and sores in the innermost lining of large
- NSAIDs intestine and rectum
- Corticosteroid’s Chron’s disease – inflammation of entire
- Dse modifiers digestive tract; most affected part ileum
- Hydroxychloloquines Symptoms
- Gold - Diarrhea -Fever
- Methotrexate - Fatigue -Blood in the stool
- Wt loss - Reduce appetite
Reiter’s Syndrome
- Abdominal pain & cramping
- Aka: Reactive Arthritis
- Acute non-purulent arthritis Whipples Dse
complicating an inflammation in the - Bacterial infection that affects the GI
body tract
- Triggered ff intrinsic or urogenital - Interfers Normal digestion by impairing
infection food breakdown
Triad of reiter’s - Trophyrema Whipphei–Bacteria Causing
 Polyarthritis Complication: Nutritional Deficiency
 Urethritis
Lofgren’s Syndrome
 Conjunctivitis
- A benign, self-limited, acute
Musculoskeletal Manifestation
arthropathy that occurs in pt w/
- Asymmetric oligoarthritis of LE
sarcoidosis
- Sausage digits
- Hilar lymphadenopathy
- Enthesitis
- Erythema nodosum
- Spondylitis/ Sacroilitis
- Symmetric migratory polyarthritis
 Lover’s Heel – Enthesitis of Achilles Tendon
Mucocutaneous Features Lyme Disease
- Keratoderma Bleramhagierum- - Tick bone inflammation disorder caused
palm,sole by spirochete borrelia burgdorferi
- Circinate Balanitis – penile shaft - Char . : erythema chronicum migran/
- Oral Ulceration bulls eye rash
- Nail changes - Erythema migrans (m/c in groins &
axilla)
AS PA IBD Reiter’s
Other Sx:
Sacroillitis BI UNI UNI UNI
- Fever - Body ache
Eye Invol- Iritis Conjunc- Iritis Conjunc-
vement tivitis tivitis - H/a -Fatigue
- Stiffneck -Arthritis
Inflammatory Bowel Disease  m/c affected jt : Knee
- Chronic inflammation of all parts of  neurologic involvement :
digestive tarct - memory loss -meningitis
 Ulcerative colitis - mood changes -cog. dysfxn
 Chron’s dse - bell’s palsy -h/a
- (+) Diarrhea , Pain, Fatigue, wt loss  Cardiac involvement
Ulcertaive cholitis – an inflammation bowel Stages: 1-rash 2-neurologic 3-arthritis
dse that cause long lastive inflammation o Stage 1 – 1-30 days after bite
¦ Erythema migrans
 o Stage 3
¦ Mons to yrs after bite
¦ Disproportionate swelling
¦ Acrodermatitis chronica
atrophicans (ACA)
 Dorsum of hand
 Cigarette papu skin
Septic Arthritis
- A bacterial infection in the synovium
and jt space w/c cause an intense
inflammatory reaction w/ migration of
polymorphonuclear leukocytes and
subsequent release of proteolytic
enzymes
Polymorphonuclear – granular / PMN – NEB
 m/c jt : 1st Knee 2nd Hip 3rd sh
4thelbow 5th wrist 6th ankle
 m/c sites in pedia - knee>hip
 m/c bacteria children w/ septic
arthritis – Hemophillus Influenzae
 common bacteria found in non
gonococcal jt infection –
Psedomonas Aeruginosa
Major Predisposing Conditions for Septic
Arthritis
- Trauma - jt infection
- RA -Parental drug abuse
- DM -Malignancy
- Underlying chronic dse
- Steroid Administration
- Immunosuppressive drugs
- Injection / aspiration
- Vascular insufficiency
Clinical Features:
- Pain - Limping gait
- Fever - Jt effusion
- Loss of ROM 2˚ to pain
- Can be mono/polyarticular
Most accurate dx tool – jt aspiration
Mx : Anti-biotics given IV
Tuberculosis Arthritis
- Mycobacterium tuberculosis
- m/c affected: Hip & Knee
Phenister’s Triad
 juxtaarticular osteoporosis
 marginal erosion
 jt space narrowing
Syphilitic Arthritis
- aka: Infectious arthritis
Clutton’s Jt- symmetric swelling seein in pt
with congenital syphilis
 m/c : KNEE
PM:DM
Diagnostic Criteria :
- Symmetrical mm weakness
- EMG w/ myopathic pattern
- Elevated CPK
- Mm biopsy with inflam of mm
- Dermatologic feat. (dermatomyositis)
TYPES:
1. Polymyositis/ PM adult
2. DM adult
3. PM-DM malignancy/ neoplasm
4. PM DM vasculitis in children
5. Collagen Vascular dse
6. Inclusion body myositis
Pathognomonic:
¦ Heliotrope rash – dusky lilac eyelids
¦ Gottrons papules – rushes on knuckles
¦ V-sign rash – Neck
¦ Shawl Sign – Sh
¦ Mechanic Hands- dry & cracked palms
Mx: Isomets, aerobic training, stretching
Systemic Lupus Erythematosus Si lupe ay baluga
- Belongs to the family of autoimmune
rheumatic dse
- Chronic, systemic, inflammatory dse,
characterized by injury to the skin, jts,
redness, heart and blood forming
organs, nervous system, mucuous
membrane
Primary forms of lupus
- Discoid lupus – only skin
- Systemic Lupus – in organs
Factors that may trigger SLE
 - Infection, Antibiotics, Exposure of UVR,  En coup de sabre -ant forehead
extreme physical and emotional stress  Honey comb lung – lung
* Common in women *Common in A-A *15 to 40 y/o  Tbacco pounch lips- lips
Pulmonary involvement
- Anemia - Alopecia Neuropathy Arthropathy
CNS involvement - AKA: charcot jt
- seizure - h/a - Progressive degeneration of WB jt
- CVA -Organic brain d/o marked by bony destruction, resorption
- peripheral neuropathy and eventual deformity
- cranial neuropathy - Any condition resulting in dec.
- psychosis sensation proprioception and fine
mouth, nose, vaginal ulcer motor control
 CRITERIA : 4/11 (+) Classically: Tabes Dorsalis
1. Serositis MC: Diabetic Neuropathy
2. Hematologic d/o UE: Syringomyelia
3. Immunologic d/o FRACTURE
4. Neurologic d/o - Break in the continuity of the bone
5. Renal d/o – m/c cause of death - Caused by force that exceeds the bone
6. Oral ulcer strength
7. Arthritis (Jaccoud’s A) non-erosive A - Bone Strenght: 10-20 x the body wt
8. Discoid rash- circular rash on L dorsum of hand Gen classification:
9. Malar/Butterfly Rash  Avulsion:
10. ANA – lab hallmark - An injury to the bone where a tendon
11. Photosensitivity or ligament pulls off a piece of the bone
Scleroderma - Ex. Osgood schlates dse, haglands/
- Progressive Systemic Sclerosis (PSS) swerse/ calcaneal
- Inflammation and fibrosis of many parts  Comminuted
of the body (Skin, blood vessels, - 2 or more fragments of the bone have
synovium, skeletal mm, kidneys, lungs, been broken
heart and GI tract ) - Highly unstable type of bone
2 major form: - Ex: *Essex-Loprestir fx – comminuted fx
o Limited cutaneous scleroderma of radial head
o Diffuse cutaneous scleroderma *stellate patella – tx: kirsehner wires
Hallmarks:  Complete fx
o Skin tightening - A fx in w/c the bone has been
o Raynauds phenomenon completely fx through its own width
Crest Syndrome:  Complex
o Calcinosis - Type of fx bone that severely damages
o Raynauds Phenomenon the soft tissue that surrounds the bone
o Esophageal dysmotility  Compression Fx
o Scleroductyly - Occurs when the bone is compressed
o Telangiectasia beyond its limit of tolerance m/c in
 Calcinosis cutis- fingertips osteoporosis
 Morphea – ant trunk
- Ex: Calcaneal fx – landing from high  Ventral : Dorsal
jump *m/c fx in tarsal bone  Diaphysis:Metaphysis:Epiphysis
 Epiphyseal fx  Position : Displaced : Undisplaced
- Fx of epiphysis and epiphyseal growth Gustillo-Anderson – open fx
plate ¦ Grade 1: <1cm wound
- Salter harris classification ¦ Grade 2: >1cm wound (1-10cm)
 Greenstick fx ¦ Grade 3: adequate tissue covering bony
- Inc fx in w/c only one side of the bone exposure ;circulatory damage
has been broken E. Tscherne – close fx
- “BENT” only broken at the outside of ¦ Grade 0: min soft tissue damage
the bend ¦ Grade 1: sup. abrasion
- Considered stable fx due to the fact that ¦ Grade 2: deep abrasion
the whole bone is not broken ¦ Grade 3: crush injury or severe
 Hairline fx contusion
- Fissure fx ͏ REGIONAL FX
- Inc bone fx  Clavicle – m/c fx bone ; MOI: FOOSH
- No sig. bone displacement o Lat 3rd – traumatic fx
- Stable fx o Med 3rd –pathologic fx
- Ex: March fx – 2nd MTP; soldier fx  Humerus fx –
 Impaction o Malgaigne fx –supracondylar fx
- Occurs when one fragment is driven o Holstein- Lewis fx – spiral fx distal
into another 3rd of humerus
- Common in tibial plateau fx  Radius & Ulna (Proximally) “MURG”
 Transverse fx o Monteggia fx – fx of ulna w/ d/Loc
- Cause by simple angulation force prox radius
 Oblique fx o Galeazzi fx – fx of necessity/
- A fx that goes at an angle to the axis of predmont fx ; fx of radius w/ d/loc
the bone of ulna distally“Reverse monteggia”
 Spiral fx o Nightstick fx – blocker’s fx;fx of ulna
- Results from torsion / twisting type  Hume fx – fx of olecranon w/ ant. d/loc of
motion radial head ; children
 Communication:  Radius (DISTAL)
- Open : (+) skin penetration o Borton’s fx – intraarticular fx of
- Closed: (-) penetration distal radius w/ d/l of radiocarpal jt
 Completeness : o Colles fx – “dinner/silver def”
- Compete: –MOI: FOOSH on palmar
- Incomplete: –D/L: post/dorsal
 Greenstick fx – distraction & o Smith Fx – “reverse colles, garden
compressed sparde” ; on dorsum of hand
 Torus fx – aka: Buckle fx – d/l : ant/ ventral
–m/c : children Smith’s (Modified Thomas) classification
–bulging on the cortex ¦ Grade 1: extraarticular
 Location: ¦ Grade 2: crosses the dorsal articular
 Distal : Prox surfaces
 ¦ Grade 3: enters radio-carpal jt o Teardrop fx – fx of odontoid process
 Hand of C2
o Boxer’ fx/ streetfrighters fx – fx of Fx Healing
5th MCP neck 1. Impact
o Bennet’s fx – fx of 1st CMC base 2. Inflammation
–m/c fx of thumb 3. Soft callus formation
o Rolando’s fx – fx of 1st CMC base 4. Hard Callus formation
–intraarticular fx of the base of the 5. Remodelling
thumb a. Clinical union =
–comminution fx i. (+) callus formation
 Hip & Pelvis ii. (-) pain
o Malgaine Fx – vertical shear of iii. (-) mov’t of bone
pelvis iv. (-) tenderness
o Duverney’s fx – iliac wing b. Radiographic union = Normal
o Intratrrochanteric fx – m/c in males i. (+) callus union
o Subtrochanteric fx – m/c in female  To terminate ORIF = (+) clinical union
 Knee Healing time
o Segond fx – avulsion of antero-Lat o Children – 4-6 wks.
margin of lat tibial plateau ; o Adolescent – 6-8 wks.
secondary to lig. injury o Adults – 10-12 wks.
o Reverse Segond fx – medial tibial  2 wks – blood vessel
plateaus  3-4 – nn
–assoc w/ excessive varus force w/  5-6 – tendon & lig
IR applied to the lower body  2-5 wks fx (hand)
–assoc w/ ACL tear (75 to 100%) & Fx Anomalies
injuries to medial and lat. meniscus 1. Delayed Union – heals > the
 Ankle & Foot expected time
o Cotton fx / trimalleolar fx – medial 2. Malunion – fx heals in
and lat malleolus and distal aspect unsatisfactory pos’t = def.
of tibia 3. Non-union – fx fails to unite
o March fx – m/c in soldiers Complications:
– 2nd MT>3rd MT - Infection -fat embolism
o Jones fx – base of 5th MTP - Nn damage -hemorrhage
o Pseudo – Jones fx – base of 5th MT; - Volkman’s ischemic contracture
extending in to the jt Treatment :
– m/c in dancers - Reduction
 Back and Spine  Manual reduction – m/c
o Jefferson’s fx : C1 fx  Closed fx: CAST
o Hangman’s fx : C2 fx  Open fx : ORIF
o Clayshoveler’s fx : fx of spinous - Maintenance
process ¦ Skin traction
o Chance fx : seatbelt fx/ lapbelt fx  Buck’s – fem LE; m/c in fem fx
o Compression: fx of vertebral body
of thoracic
  Bryant’s – m/c in children; fem Sh EXADIR Knee ext
fx, congenital anomalies; limb Elbow Flexion Ankle PF
suspended in air FA pronation
 Russel- LE is supported in a sling FLEXOR BIAS EXT BIAS
¦ Skeletal traction Attitudinal or postural reflexes:
¦ Internal fixators 1. Tonic neck and Labyrinthine Reflexes
Preservations: - Magnu’s and de Kleijris Reflexes
- Bed turning -ROM 2. Tonic Lumbar Reflexes
- Modalities -exercise - Flexe on unrotated side, Ext on rotated
Associated Reaction:
- Automatic activities
BRUNNSTROM - Either vountaty effort or reflex
- Mov’t therapy stimulation
- Use of reflexes to elicit mov’t when - For either flaccid or spastic
none exists 1. Homolateral limb synkinesis
- Use of proprioceptive and exteroceptive S: active mov’t of affected UE
stimuli to elicit desired move or tonal R: mov’t on affected LE
changes 2. Raimistes Phenomenon/coordination
Basic limb synergists - “organic” hemiplegia
͏ UE - Coordination synkinesis
¦ FLEXORS: scap retraction, sh ER & abd, - Abd and add phenomena
elbow flexion , fa sup, wrist and finger S: resistance on unaffected UR
flexion R:mov’t of the opp UE
¦ EXTENSORS: scap prot and depression, - Abd>Add
sh ExAdIR, elbow extension, fa 3. Proprioceptive Traction Response/ PTR
pronation, wrist and finger extension - 3 stimulus:
¦ Strongest flexor synergist Stretch to any flexor mm of the UE
1. Elbow flexion – most powerfull Tonic neck reflex (ATNR)
2. Scap retraction Body-righting reflex
¦ Strongest extensor synergist - Response: mass flexion of UE
1. Sh ExADIR 4. True Grasp Reflex
2. Fa pron S: distally pressure on reflexogenic zone
͏ LE (ant surface of wrist, hand & fingers
¦ FLEXORS: hip FABER, knee flexion, ankle except ulnar border 1st-3rd digit)
DF, Inv R: closing of the hand
¦ EXTENSORS: hip EXADIR, knee extensor, - Gestation – 9 wks
ankle PF and INV - 2 phases
¦ Strongest flexor synergist  Catching phase
1. Hip flexor and ankle DF  holding phase
¦ Strongest extensor synergist 5. Instinctive Grasp Reaction
2. Knee extensor – most powerful S: stationary contact on reflex zone
Note: no EVERSION R: closing of the hand
Interaction of synergy  for CVA pt
UE LE 6. Instinctive avoiding reaction
Scap ret Hip EXAD
 - Seen in parietal lobe lesion FA sup Knee ext
S: *elevation of arm Elbow ext Ankle DF
*stroking on palmar surface Wrist ext Great toe Abd
R: extension of the wrist and fingers Thumb abd
7. Souques Finger Phenomenon TRUNK:
S: elev of arm (sh flexion, fa pron) - c/l rot of sh in relation to pelvis
R: finger ext
8. Imitation synkinesis - Wt bearing on affected side in sitting
S: active mov’t on unaffected and standing
R: mov’t of affected - Sit (-) stand (BAD leg forward – to
Note: no resistance receive wt ; Prog: Higher chair: lower)
9. Tonic Thumb Reflex - Walking
S: arm elev w/ fa sup - prone
R: thumb ext
10. Bechterewis/marie-Foix reflex
S: passive toe PF
R: massive flexion of the LE
Note: post. Supine w/ hip and knees
slightly flexed
Associated mov’t
- Same stimulus w/ AR
- For spastic > flaccid

BOBATH
- Sensorimotor approach
Bobath concept (1990)
- NDT
- The pt must be active
- Key pts of control and reflex-inhibiting
patterns (RIP)
- m/c use tx approach in neurodev rehab
AbN postural reflex act
- Assoc reaction
- ATNR
- Positive supporting reaction
Key points of control
- Most important are the prox key pts
o Head
o Sh
o Pelvis – most important
Reflex- Inhibiting Pattern (RIP)
- Opp of typical synergy

UE LE
Sh ER Hip ExAbER