Hip OA
- moderate anterior or lateral hip pain during weight bearing
- morning stiffness less than 1 hour
- hip IR less than 24*
OR IR and flexion 15* less than non painful side
AND OR increased pain with passive IR
Meniscal Pathology
- reported catching or locking
- joint line tenderness
- pain with forced hyperextension
- pain with maximal passive knee flexion
- Pain or audible click with McMurray test
- delayed effusion
- discomfort or locking/catching during Thessaly test
- twisting injury
- tearing sensation at time of injury
3+ positive findings: specificity 90.2%
Lumbar Spinal Stenosis
- age over 48
- bilateral symptoms
- leg pain > back pain
- pain during walking/standing
- pain relief upon sitting
Vertebral Fractures
- Age over 70
- female gender
- Significant trauma
- Prolonged use of corticosteroids
Spinal Malignancy
- age over 50
- previous hx of cancer
- unexplained weight loss
- failure to improve after 1 month
Likely to respond from stabilization exercises
- instability catch or aberrant movement during lumbar flex/ext
- positive prone instability test
- greater general flexibility (postpartum or avg SLR >90*
- younger age (<40 yrs)
Ottawa Knee Rules
ANY of the following:
- Age 55 years or older
- Isolated tenderness of patella
- Tenderness at head of fibula
- Inability to flex to 90*
- Inability to bear weight immediately and in the ER for 4 steps regardless of limping
Pittsburgh Knee Rule
MOI: fall or blunt trauma
- no —> no radiography
- yes —> age <12 or >50
- yes —> radiography
- no —> inability to walk 4 weight bearing steps
- yes —> radiography
- no —> no radiography
Lumbar Manipulation
- symptom onset less than 16 days
- no symptoms distal to the knee
- at least one hypomobile lumbar segment
- at least one hip with IR >35*
- FABQ work subscale <19 points
3/5 = 68%
4/5 = 98%
Cauda Equina
- bowel/bladder changes
- saddle anesthesia
- sensory or motor deficits in the L4-S1 regions
All needed to develop around the same time as the back pain
Knee Ligament Sprain CPG Revision 2017: A level evidence (3)
- weight bearing/NWB concentric or eccentric exercises should be implemented within 4 to 6 weeks, 2-3x/wk for 6 to 10 months, to increase thigh muscle strength and functional performance after ACL reconstruction
- NMES should be used for 6-8 weeks after ACL reconstruction to increase quadriceps muscle strength
- neuromuscular re-ed should be incorporated with muscle strengthening in patients with knee stability and movement coordination impairments
Knee Ligament Sprain CPG Revision 2017: B level evidence (3)
- immediate mobilization within 1 week after ACL reconstruction
- cryotherapy should be used immediately after ACL reconstruction
- supervised rehab programs following ACL reconstruction should include exercise and a HEP with education to ensure independence
Knee Ligament Sprain CPG Revision 2017: C level evidence (3)
- functional knee bracing in patients with ACL deficiency
- CPM in the immediate post-operative period to decrease pain after ACL reconstruction
- early WBAT may be implemented within 1 week after ACL reconstruction
Knee Ligament Sprain CPG Revision 2017: Patient reported outcome measures - B level evidence
Knee symptoms and function:
- IKDC 2000
- KOOS
- Lysholm
Activity level:
- Tegner scale
- Marx
Psychological factors:
- ACL-RSI
Patellofemoral Pain CPG 2019: A level evidence (10)
- clinicians should use reproduction of retro or peri patellar pain during squatting as a diagnostic test.
- performance of other functional activities that load the patellofemoral joint in a flexed position such as stair climbing or descent as diagnostic tests
- clinicians should use the anterior knee pain scale (AKPS), the patellofemoral pain and osteoarthritis subscale of the KOOS or the VAS for activity
- clinicians should use the Eng and Pierrynowski Questionnaire (EPQ) to measure pain and function
- use VAS for worst and usual pain or NPRS to measure pain
- include exercise therapy with combined hip and knee targeted exercises. Target posterolateral hip musculature. Knee-targeted exercise should include weight bearing (resisted squats) or NWB (resisted knee extension) exercise. The combination of hip and knee is preferred.
- clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only up to 6 weeks. If prescribed combined with an exercise program. There is no evidence to recommend custom over prefabricated
- do not use dry needling to treat PFP
- do not use manual therapy in isolation
- combine other interventions such as foot orthoses, patellar taping, patellar mobilizations and lower limb stretching with exercise therapy as the critical component
Patellofemoral Pain CPG 2019: B level evidence (7)
- diagnosis PFP from the following criteria: presence of retro or peri patellar pain, reproduction with squatting, stair climbing, prolonged sitting or other functional activities loading the PFJ in a flexed position, exclusion of all other conditions that may cause anterior knee pain
- clinicians should administer appropriate clinical or field tests that reproduce pain and assess lower-limb movement coordination such as squatting, step-downs, and single leg squats
- patellar taping in combination with exercise therapy to assist in immediate pain reduction and to enhance outcomes of exercise therapy in the short term (4wks). Taping applied with the aim of enhancing muscle function is not recommended
- do not prescribe patellofemoral knee orthoses
- do not use electromyography-based biofeedback on medial vastii activity to augment quadriceps exercise therapy for treatment
- do not use visual biofeedback on lower extremity alignment during exercise therapy
- do not use biophysical agents including ultrasound, cryotherapy, phonophoresis, ionto, e-stim and therapeutic laser
Patellofemoral Pain CPG 2019: C level evidence (4)
- clinicians may use the patellar tilt test with the presence of hypomobility to support the dx of PFP
- gait retraining consisting of multiple sessions of cuing to adopt a forefoot strike pattern (for rear foot strike runners), cuing to increase running cadence or cuing to reduce peak hip adduction while running for runners with PFP
- clinicians may use acupuncture to reduce pain however caution should be exercised because the superiority over placebo or sham is unknown
- measure of patellar provocation, patellar mobility, foot position, hip and thigh muscle strength and muscle length
Patellofemoral Pain CPG 2019: F level evidence (3)
- BFR plus high repetition knee exercise therapy for those with limiting painful resisted knee extension
- PFP Impairment/Function-Based Classification Subcategories:
Overuse/overload
Muscle performance deficits
Movement coordination deficits
Mobility impairments: foot hyper mobility and or flexibility deficits of 1 or more of the following… HS, quad, gastroc, soleus, lateral retinaculum, ITB
- patient education
Knee Ligament Sprain CPG Revision 2017: D level evidence
- elicit patient preferences in the decision to use functional bracing after ACL reconstruction, as evidence exists for and against its use
Articular cartilage
- acute trauma with hemarthrosis (0-2 hours)
- insidious onset aggravated by repetitive impact
- intermittent pain and swelling
- history of catching or locking
- joint line tenderness
Stroke test
0 - no wave on lateral downstroke
Trace - small wave on medial side with downstroke
1+ - larger bulge on medial side with downstroke
2+ effusion spontaneously returns to medial side after upstroke (no downstroke needed)
3+ - not possible to move the effusion out of the medial aspect with upstroke
Ankle Stability and Movement Coordination Impairments 2021 Revision CPG: Outcome Measures
A Level
- Foot and Ankle Ability Measure
- LEFS
- Patient-Reported Outcomes Measurement Information System function and pain interference scales
Ankle Stability and Movement Coordination Impairments 2021 Revision CPG: Examination
A Level Evidence:
- ankle swelling
- ROM
- talar translation and inversion
- SLS
- weight bearing lunge test for DF
- SLS firm surface with eyes closed
- Star Excursion Balance Test
C Level Evidence:
- hip abduction, extension and ER strength for CAI
Ankle Stability and Movement Coordination Impairments 2021 Revision CPG: Intervention
A Level Evidence:
- primary prevention: recommend the use of prophylactic bracing to reduce risk of a first time LAS, particularly those with risk factors
- secondary prevention of recurrent LAS after initial: prophylactic bracing and proprioceptive and balance focused therapeutic exercise training programs
- acute/postacute LAS protection and optimal loading: use external supports and progressively bear weight on the affected limb
- severe injuries: immobilization ranging from semi rigid bracing to below knee casting may be indicated for up to 10 days
- acute/post acute LAS
