Melting pot kinésithérapie

http://titan.medhyg.ch/mh/formation/print.php3?sid=23158

Les lésions articulaires varient en fonction de l’âge du patient. Cet article présente quelques aspects typiques en imagerie de lésions dégénératives des ménisques, du cartilage et de l’os sous-chondral du genou.

Les lésions dégénératives des ménisques typiquement sont horizontales, parfois avec des fragments déplacés. La rupture radiaire du ménisque interne est une lésion moins fréquente, mais facilement méconnue.

La perte de cartilage est évaluée par la mesure de l’interligne articulaire. Cependant, cette mesure n’est valable que pour autant que les surfaces correspondantes soient en contact intime (en charge). L’aspect particulier éburné de l’os sous-chondral permet parfois de reconnaître des lésions sévères, qui auraient pu être méconnues sur une radiographie non adéquate.

Finalement, une lésion de l’os sous-chondral typiquement survient chez des personnes âgées : l’ostéonécrose spontanée du condyle fémoral interne, qui est probablement consécutive à une fracture sous-chondrale par insuffisance. Son diagnostic précoce est difficile, même par IRM, et nécessite un examen très attentif des anomalies de l’os et la moelle sous-chondrale.

From "Donatelli - The Biomechanics of the foot and ankle - 2nd ed. CPR"

Vocabulary:

Calcaneus:

inversion = varus; eversion = valgus

Subtalar joint (Calcaneus - Talus):

Axis: Antero-medially, through talus neck to postero-lateral aspect of calcaneus

Pronation (eversion) = dorsiflexion + abduction + eversion (pronation)

Supination (inversion) = plantar flexion + adduction + inversion (supination)

Forefoot (Tarso - MT joint = Lisfranc):

Varus (supination) = clockwise rotation of 1st metatarsal round 5th metatarsal

Valgus (pronation) = COUNTER clockwise rotation of 1st metatarsal round 5th metatarsal

Gait

At heel strike, pronation (absorption compressive force, adjust to uneven ground, maintain equilibrium)

Eccentric action of Tibialis anterior + Toes extensors -> to control plantar flexion

At forefoot contact,

Eccentric action of supinators (Tibialis posterior, flexor hallucis longus and digitorum longus, soleus) -> to control pronation

During midstance,

Same muscles control eccentrically forward toppling of tibia on talus

Subtalar joint in neutral position

At push-off,

Supination (from mid-stance to toe off) -> to establish a rigid lever for extrinsic foot muscles (plantar flexors)

Windlass mechanism = Tension of plantar fascia (aponeurosis)

Plantar fascia

From postero-medial calcaneal tuberosity to proximal phalanges

Tension during push-off because of phalangeal flexion

Medial origin -> tension -> Inversion of calcaneus + Supination of subtalat joint

Standing position

High medial arch (Pes cavus) = external rotation of tibia + supination at subtalar and talar joint + pronation of forefoot

Low medial arch (Flat foot) = internal rotation of tibia + pronation at subtalar and talar joint + supination of forefoot

Concurrent motions:

- Internal rotation of tibia + pronation subtalar joint

- External rotation of tibia + supination subtalar joint

Orthotics

Rearfoot posting -> modify subtalar joint position from heel strike to flat foot

Brings calcaneus back to neutral position:

- Varus (Inversion) = lateral posting to correct inversion

- Valgus (eversion) = medial positng to correct eversion

As well, forefoot posting brings the ground to the metatarsals, reducing need for rearfoot compensation

- Medial wedge = forefoot varus = No need for rearfoot pronation to compensate

- Lateral wedge = forefoot valgus = No need for rearfoot inversion to compensate

Videos des principaux transferts, patients neurologiques.

Couché - Assis:
http://www.wat.tv/video/transfert-couche-assis-1vclm_2iqoj_.html

Couché - Debout:
http://www.wat.tv/video/transfert-couche-debout-1vclg_2iqoj_.html

Assis - Assis:
http://www.wat.tv/video/transfert-assis-lit-assis-1vcl6_2iqoj_.html

Fauteil roulant - chaise:
http://www.wat.tv/video/transfert-fr-siege-1vclu_2iqoj_.html

Transfert paraplégique:
http://www.wat.tv/video/transfert-paraplegique-1vclx_2iqoj_.html

Videos des chaines de Kabat

Membre supérieur:
http://www.wat.tv/video/kabat-b-1yny9_2iqoj_.html
http://www.wat.tv/video/kabat-mi-c-1vb2w_2iqoj_.html

Membre inférieur:
http://www.wat.tv/video/kabat-membre-superieur-2rkib_2iqoj_.html

Snapping Hip (iliotibial band)

The most common cause of a snapping hip is the iliotibial band snapping over the greater trochanter.
http://emedicine.medscape.com/article/87659-treatment

Class of October 2010
Non-exhaustive notes, just a reminder of a few interesting topics

Knee Joint = Patello-Femoral Joint + Tibio-Femoral Joint + Proximal Tibio-Fibular Joint

Specific questions for Knee joint

1. Pain when ascending or descending stairs ?

Pressure lower on Patello-Femoral Joint when ascending stairs
Because of greater activation of hamstrings and subconsequent reduced action of quadriceps
In closed chain, hamstrings act as knee extensors
On the contrary descending stairs puts the highest stress (pressure) on Patello-Femoral Joint

> Retro patellar pain when descending: Patello-Femoral Joint
> Pain only when ascending stairs: will orientate PT more toward Tibio-Femoral Joint

2. Does the knee lock?

Positive answer is a strong indication for Meniscus tear

3. Age of patient

+50: primary arthrosis
-50: secondary arthrosis caused by: Traumatic event (meniscus lesion, ligament rupture...), weight, Excessive valgum/varum,...

Patellar position

Height: apex of patella at level of joint line
Orientation: no rotation, patellar vertical axis must be in line with tibial tuberosity

Patellar subluxation

Almost always lateral
Often connected with Vastus Medialis weakness (not necessarily cause of luxation)
Often connected with non-congruence of femur trochlea and retro patellar surface
Can be solved by operation: medial shift of tibial tuberosity

Tibio-Fibular Joints

1. Proximal: joint play = lateral + ventral <> medial + dorsal
2. Distal: joint play = ventral <> dorsal

Ankle sprain: lateral ligament (inverted position)
> first fibula pulled downward
> then fibula pulled upward and POSTERIORLY by Biceps Femoris

After ankle sprain: it might be necessary to replace fibula on both tibio-fibular joints
> anteriorly (laterally) for proximal (because displaced posteriorly)
> posteriorly for distal (because displaced anteriorly)

Joint play movements

> Patella - Femur

First lift patella with fingers
1. cranial - caudal: hand and forearm in line with femur or tibia (avoid pressure on patella)
Use thenar or hypothenar. In practice patella always to high (cranial glide not really important)
2. lateral - medial: generally, more movement medially

> Tibia - Femur

Both arms must be as close to the joint line as possible

1. Posterior glide of tibia

Small cushion under femur (LPP).
Fixation: femur with one hand (pressure can be applied on patella)
Moving part: tibia grabbed with other hand (index to thumb) equally distributed over tibial tuberosity
> Press downward (move knee to flexion)

2. Posterior glide of femur on tibia (= anterior movement of tibia)

Small cushion under tibia (LPP).
Fixation: tibia with one hand
Moving part: femur grabbed with other hand under patella (no pressure applied on patella)
> Press downward (move knee to extension)

Class of October 2010

Hypothesis

Active stabilizers (muscles) are responsible for joint stability; passive stabilizers are loaded only when active structures fail in their function.
Yet, pathologies of passives structures (lesions of ligaments, capsule...) can lead to a disturbed proprioception (erroneous afferent signals), which induces in turn wrong efferent signals (incorrect pattern of muscular contractions).
A disturbed senso-motorical process is responsible for instability.

http://books.google.com/books?id=yT25tBsZbbYC&pg=PA199&lpg=PA199&dq=muscular+contraction+joint+stability&source=bl&ots=PkdiN1T4P6&sig=7uXboQDqX8_138m_3HOYjhUwyQs&hl=fr&ei=VY61TJXHGY3sOa6j-ZUG&sa=X&oi=book_result&ct=result&resnum=5&ved=0CCwQ6AEwBA#v=onepage&q=muscular%20contraction%20joint%20stability&f=false

Neurology

Improvement of stability = improvement of muscle control (not of strength)
Control is based upon slow twitch fibres (small motor units > finer movements)
Strength is based upon fast twitch fibres
Slow twitch fibres depolarization threshold lower than fast twitch threshold.

?Older people are more unstable because nerves get thinner and thus speed of conduction decreases (the higher the diameter, the faster the conduction)?

Testing of global stability of knee joint

Dynamic:
Walk forward, walk backward, run, jump using both legs (no adjustment step allowed), jump using 1 leg (1 adjustment step allowed)

Static:
> Stand on one leg, stand on one leg and perform short flexion movements
> Push patient backward: expected response: 1st contraction of tibialis anterior, 2nd contraction of quadriceps
> Push patient forward: expected response: 1st contraction of calves, 2nd contraction of hamstrings

Observation:
Standing: quadriceps must be relaxed > patella mobile, patella centred (no squinting or frog eyes), apex of patella at the altitude of joint space, contraction of quadriceps (must rise patella)

Proprioception

With eyes closed:
> PT moves healthy leg, patient performs simultaneously identical movement with unstable leg
> PT moves healthy leg to a given position, patient moves unstable leg to identical position (if necessary PT corrects error)
> Patient moves both legs in opposite directions with a precise timing, one leg must reach 90° of flexion when the other reach full extension (the slower the more difficult)

Testing of passive structures with related instability

MEDIAL instability = Medial Collateral Ligament (MCL)
> Valgus (ABD) test at 0° (locked) and at 30° (unlocked)

LATERAL instability = Lateral Collateral Ligament (LCL)
> Varus (ADD) test at 0° (locked) and at 30° (unlocked)

ANTERIOR instability = ACL
> Lachman test (or modifications) (ACL + POL)
http://www.youtube.com/watch?v=dH_jnTy1rNk&feature=related
> Anterior Drawer sign (ACL + Post. Capsule)
http://www.youtube.com/watch?v=yQdBrr3Mmj0

POSTERIOR instability = PCL
> Posterior Drawer sign (PCL + Arcuate-politeus complex)
> Posterior sag sign (Drawer gravity) (PCL + Arcuate-politeus complex)

ANTERIOR + MEDIAL instability = MCL + ACL
> Slocum test (= Drawer) with tibia in LATERAL rotation (MCL + ACL)
http://www.youtube.com/watch?v=d5Thc-o6Q3Y

ANTERIOR + LATERAL instability = ACL
> Slocum test (= Drawer) with tibia in MEDIAL rotation (ACL + Post. Lat. Capsule)
> Lateral Pivot shift (ACL + Post. Lat. Capsule)
Based upon action of iliotibial band: extensor when knee extended, flexor when knee flexed from 30°
Knee in extension and medial rotation > flexion by examiner reduces subluxation by action of iliotibial band
http://www.youtube.com/watch?v=ZWEGB0ToXZo

POSTERIOR + MEDIAL instability= PCL
> Hughston's postero-medial drawer sign (PCL + POL)
= Drawer with knee medially rotated

POSTERIOR + LATERAL instability= PCL
> Hughston's postero-lateral drawer sign (PCL + popliteus-arcuate complex)
= Drawer with knee laterally rotated

As a reminder about MENISCUS:
> Bounce home test = ventral part
> Apley's test = middle part (most frequently injured)
> Mac Murray's test = dorsal part

> Généralités sur l'arthrose (simple et didactique).
http://www.rhumatopratique.com/public/biblioth/arthrose.html

> Extrait d' un article de rhumatologie :

L'arthrose est une maladie articulaire chronique caractérisée par une détérioration structurale du cartilage articulaire.
Du point de vue anatomique, les lésions du cartilage articulaire peuvent être classées en 4 stades :
- stade I : ramollissement (chondromalacie)
- stade II : fibrillation, fissures superficielles
- stade III : fissures profondes avec aspect en chair de crabe ou détachement d'un clapet cartilagineux
- stade IV : ulcération avec mise à nu de l'os sous-chondral.

La réaction osseuse comporte :
- en périphérie à la jonction capsulo-synoviale des ostéophytes
- au niveau de la zone de charge, condensation osseuse sous-chondrale avec épaississement des travées et parfois développement de kystes intra-osseux à contenu liquidien fibreux ou nécrotique.
La synoviale est normale ou fibreuse, sauf lors des poussées congestives d'arthrose où il existe une réaction inflammatoire aux débris cartilagineux libérés dans l'articulation.

Du point de vue histologique, fragmentation des fibres de collagène constituant l'armature du cartilage, déperdition en protéoglycanes (acide hyaluronique, chondroitine sulfate, kératane sulfate). Les chondrocytes sont hyperactifs, avec prolifération de clones chondrocytaires, mais aboutissant à une nécrose cellulaire. Il existe une dérégulation des activités d'anabolisme et de catabolisme des chondrocytes, au profit du catabolisme, avec libération d'enzymes dégradant les protéoglycanes et le collagène (métalloprotéases), l'ensemble du processus étant activé par des cytokines (interleukine 1, tumor necrosis factor).

Vidéo présentée par l'Université Victor Segalen de Bordeaux

Rééducation des épaules opérées et non opérées suite à un diagnostic d'instabilité:
- rétablissement de la balance musculaire
- rééducation proprioceptive
- ré-apprentissage des gestes sportifs

http://www.canal-u.tv/producteurs/universite_victor_segalen_bordeaux_2_dcam/dossier_programmes/sciences_de_la_sante_et_du_sport/medecine/reeducation_des_instabilites_d_epaule

Videos of knee assessment

> Mc Murray's test (tibia internally rotated = test of external meniscus, tibia externally rotated = test of internal meniscus):
http://www.youtube.com/watch?v=fkt1TOn1UfI&feature=related

> Meniscal palpation and bounce home test:
http://www.youtube.com/watch?v=52reQsXQAZk&feature=related

> Apley's test:
http://www.youtube.com/watch?v=At0FdkHaCGo&feature=related