Lower Extremity Workshop

1. Lower Extremity Workshop Adam Lucassian, AT, ATCGraduate Assistant Athletic Trainer (Women’s Soccer)

2. About Me • From Michigan (Near Detroit) • Graduated from Central Michigan University • Intern: • Saint Joseph’s University, Philadelphia, PA (Women’s Soccer) • Florida Gulf Coast University, Ft. Myers, FL (Men’s Soccer, Men/Women Tennis) • Research: • Kinesio Tape • Laser v. Foam Rolling v. Grasten on Performance

3. What are we going to do? • Go over Lower Extremity Assessment • Quick Facts • Case Studies • SOAP Approach • Questions

4. Quick Facts • Diagnostic Testing vs. Clinical Evaluation • Hardy et. Al (2012) • Study comparing diagnostic testing vs. clinical evaluation • Lateral/Medial Meniscus • Findings: Clinical Evaluation comparable to diagnostic testing • Antero Lateral Ligament (ALL) • Newly discovered ligament

5. Case Study #1

6. Set the Scene • You are in the Athletic Training Room of a local High School • A high school basketball player reports to the athletic training room complaining of discomfort in the anterior thigh for the past week. • GO

7. Subjective • What did you do? • NOW: Bumped in R though • PRIOR: Kneed in the R thigh ~1 week ago (didn’t report) • Management: Ibuprofen from home • Sounds/Sensations • No Sounds or sensations • Prior Medical History: None • Pain • Discomfort after initial injury, but ok • Increased pain after current hit • 7/10 “deep achy pain • Worse is with Hip flex and extension • Ambulation • Can’t continue with practice • Pain with walking

8. Differential Diagnosis

9. Objective- Inspection/Palpation Inspection • Partial weight bearing on R leg • Unable to fully extend during walking • Redness over mid thigh (impact site) • Girth Measurement • 3cm larger than left Palpation • Deformity • Not Detected • +Palpable muscle spasms • Point Tenderness • 8/10 “sharp” pn over impact site • Skin Temperature • Warm to the touch

10. Differential Diagnosis

11. Objective- Range of Motion • AROM • Knee Flexion 0-25 • Unable to perform AROM knee extension without pn (7/10 “sharp”) • Unable to Hip flexion without pain (7/10 “sharp”) • PROM • Knee Flexion 0-30 • Unable to perform hip extension without pain (7/10 “sharp”) • RROM • Do not perform due to pain • The Key to Strains* • Example: Hamstring • AROM: Pn with Hip Ext • PROM: Pn with Hip Flex

12. Objective- Special TestsWhat are we looking for?

13. Objective- Special Tests • Compression Test- Negative • Bump Test- Negative • Femur Traction/Axial Load- Negative**** • Tuning Fork- Positive when placed over impact site***

14. Assessment

15. Quadriceps Contusion (Possible Myositis Ossificans) • MOI? • Direct Impact • Myositis Ossificans • Treatment

16. Case Study #2

17. Set the Scene You are a Hockey Athletic Trainer During a faceoff, your player gets checked from behind, lands on his right knee, and stays down You go out to the player, perform quick assessment, and get the player back to the locker room GO

18. Subjective • Pain • Immediate: 8/10 “sharp” pn • Now: 5/10 “dull” pn • Location: Inside the Knee • Sounds/Sensations • Knee feels “loose and unstable” • Felt/heard a “pop” • Prior Medical History: None • Ambulation • Getting Off Ice: Needs some support but able to partially weight bear • Now: Able to walk with an antalgic gait (limp) • Medication • Ibuprofen • When: 2 hours prior

19. Differential Diagnosis • ACL • MCL • LCL • PCL • Medial Meniscus • Lateral Meniscus • Unhappy Triad • Patellar Subluxation • Knee Dislocation • Fracture • Bone Bruise • Muscle Strain/Tear

20. Objective- Inspection/Palpation Inspection • Swelling • Moderate Swelling over whole knee • Discoloration • Negative • Deformity • Negative Palpation • Point Tenderness • Back of the knee (6/10 “sharp” • Feel “Pressure” as palpating over the knee • **NO PAIN ANYWHERE ELSE** • Skin Temperature • Warm to the touch • Pulse • Swelling impedes popliteal • Dorsal Pedis/Post. Tib?

21. Differential Diagnosis • ACL • MCL • LCL • PCL • Medial Meniscus • Lateral Meniscus • Unhappy Triad • Patellar Subluxation • Knee Dislocation • Fracture • Bone Bruise • Muscle Strain/Tear

22. Objective- Range of Motion • AROM • Pain and restricted Flex/Ext • PROM • Pain with flexion as approaching 90 degrees • NOT SHARP • Feel “Pressure” • RROM • Do not perform due to pain • The Key to Strains* • Example: Hamstring • AROM: Pn with Hip Ext • PROM: Pn with Hip Flex

23. Objective- Special TestsWhat are we looking for? • Anterior Drawer • Posterior Drawer • Lachman’s • Varus Stress Test • Valgus Stress Test • Ober’s Test • Nobel’s • McMurray’s • Apley’s Compression/Distraction • Thessaly Test • Sag Test • Quadricep Active Test • Slocum Drawer Test • Pivot Shift*

24. Objective- Special Tests • Anterior Drawer- Positive* • Posterior Drawer- Positive • Lachman’s- Negative • Varus Stress Test- Negative • Valgus Stress Test- Negative • Ober’s Test • Nobel’s • McMurray’s- Negative • Apley’s Compression/Distraction- Negative • Thessaly Test • Godfrey’s Test- Positive • Quadricep Active Test- Positive • Slocum Drawer Test • Pivot Shift*

25. Assessment • ACL • MCL • LCL • PCL • Medial Meniscus • Lateral Meniscus • Unhappy Triad • Patellar Subluxation • Knee Dislocation • Fracture • Bone Bruise • Muscle Strain/Tear

26. PCL Tear • RARE • MOI? • Posterior Displacement of the tibia on the femur • Surgery Uncommon • Why? • Show and Tell