The NeuromusculoskeletalMedicine

The disorders of Hip, Knee, leg,ankle and foot

Jun Xu, M.D., L. Ac

Piriformis Syndrome

• Original: Pelvicsurface of sacrum

• Insertion: Uppergreater trachantergreater trachanterthrough greatersciatic foramen.

• A painful muscleinjury with forceful hipinternal rotation.

Piriformis SyndromeTreatment: Acupuncture

• GB 30 + Arshi

points.

• Moxa + electricalstimulation.stimulation.

• Steroid injection.

• Deep massage.

• Stretch exercise.

Iliopsoas Bursitis and TendonitisIliopsoas Snapping-Tendon Syndrome

• Hip snapping: due tothe iliotibial bandsnapping over thegreater trochanter orthe iliopsoas tendonthe iliopsoas tendonsubluxating over thepectineal eminence ofthe pelvis.

Iliopsoas Bursitis and TendonitisIliopsoas Snapping-Tendon Syndrome

• Clinical: Hip snapping may occur withflexion and may cause pain.

• The pain and tenderness is over theiliopsoas muscle.iliopsoas muscle.

• Provocative test: pain on hip flexion.

• Treatment: Ice, stretching andstrengthening, steroid injection.

• Acupuncture: Archi points with electricalstimulation and Moxa.

Hamstring Strain

• Predisposing factors:inadequate warm up,poor flexibility, exercisefatigue, poor conditioning,and muscle imbalance.and muscle imbalance.

• Grade 1: Strain

• Grade 2: partial Tear

• Grade 3: complete Tear

• Strength ratio of H/Q: 3/5

• Track and Gym injuries

Hamstring Strain

• Treatment:

-Ice pad for acuteinjury

-Acupuncture for-Acupuncture forArchi, and WeiZhong,if chronic pain, Moza.

-Weight bearingreduction, gentlestretch

Hip Adductor Strain-Groin Strain

• A common injury insports due to resistedforceful abduction ofhip.

• Ice, gentle stretch,Archi points plusmoxa if becomechronic.

Greater Trochanter Bursitis

• Inflammation of the bursalocated over the greaterTrochanter and deep tothe gluteus medius andgluteus minimus andtensor fasciae latae.tensor fasciae latae.

• Night pain and are unableto lie on the affected side.

• Provocative test: painover the bursa duringmovement from fullextension to flexion.

Greater Trochanter BursitisTreatment

• Iliotibial bandstretching, Nsaid andcane.

• Acupuncture, Arshi• Acupuncture, Arshipoints, electricalstimulation, Moxa

• Local steroidinjection.

Hip Osteoarthritis

• OA of the hip ischaracterized by loss ofarticular cartilage of thehip joint, whether fromtrauma, infection, heredityof for idopathic reasons.

• Gradual onset of pain in• Gradual onset of pain inthe groin, buttock or thelateral aspect of the thigh.The pain is related withactivity. Night pain isassociated with severearthritis. With limitedmotion and limp.

Hip Osteoarthritis

• X-Ray:

– Joint space narrowing.

– Osteophytes

– Cyst formation

– Subchondral sclerosis

Tx:

Acupuncture, Arshi,Moxa, electricalstimulation.

Heating pad, ROM, etc.

Avascular Necrosis of the FemoralHead

• Death of thefemoral headwithout sepsis.

• Interruption of the• Interruption of thevascular supply.

• Most commoncauses: steroiduse and alcoholabuse.

Avascular Necrosis of the FemoralHead

• Pain in the groin, anteriorthigh, or even the knee

• Symptoms are ofinsidious onset.

• Short swing and stance• Short swing and stancephase on the affectedside.

• Loss of external andinternal rotation of Hip.

• Pain elicited on RPM.

Avascular Necrosis of the FemoralHead--Treatment

• Acupuncture: help to reduce pain. Arshi,moxa, and electrical stimulation.

• Chinese herbs: Improving blood circulationat the femoral head.at the femoral head.

• Help to maintain the femoral head withinthe acetabulum while healing andremodeling.

• Last resort: total hip replacement.

Knee Disorders - Meniscal Injuries

• Medial meniscus injuries:cutting injuries, tibialrotation while the knee ispartially flexed duringweight bearing (football,weight bearing (football,soccer)

• Lateral meniscus injuries:during squatting, fullflexion with rotation(wresting)

Knee Disorders - Meniscal Injuries

• Acute tears are often associated with apop sound.

• May cause true locking.

• Effusion may occur within 24 hours.• Effusion may occur within 24 hours.

• Patients frequently C/O knee stiffness.

• Degenerative tears often involve minimaltrauma. Patients’ age > 40 yo.

• Impingement episodes may be minimal.

Knee Disorders - Meniscal Injuries

• PE

• Range of Motion is decreaed

• Effusion will limit flexion

• Menical fragment impingement will limit• Menical fragment impingement will limitextension

• Tenderness of the medical joint line for medialmeniscus damage, lateral joint line tendernessindicates the lateral menicus damage.

• Apley and McMurray tests./

Knee Disorders - Meniscal Injuries

• MRI is gold standard.

• The inner two thirds ofthe meniscus is not wellvascularized, oftenrequires surgical removalrequires surgical removalof the damaged tissue.

• Non weight bearing for 4-6 weeks. If surgicalremoval, weight bearingwithin 1-2 days.

• Acupuncture arshi points.

ACL INJURIES

• Cutting, decelerationand hyperextension ofthe knee.

• Seeing in the athletics

• >50% of ACL tears• >50% of ACL tearsoccur with meniscaltears.

• O’Donoghue’s Triad:ACL, MCL and medialmeniscus.

ACL INJURIES

• Clinical: sudden popand anterior kneepain.

• Instability of the knee

• Tx: partial wt bearing

• Ice and compression

• Arthroscopy surgicalreconstruction.• Instability of the knee

• Early swelling

• Anterior draw sign +

• MRI 85 to 90% +

• Arthroscopy close to100% +

reconstruction.

• Early range of motion.

• Closed chain kinetics

• Acupuncture for painrelief.

• Complete rehab 1 yr.

ACL INJURIES

• Normal ACL • Complete ACL tear

PCL INJURIES

• Normal PCL • PCL tear

PCL INJURIES

• Dashboard injury

• May not have pop

• Injury with KneeHyperextension

• Effusion

• Popliteal tenderness

• Posterior drawer andSag tests +Hyperextension

• Less common thanACL injury

• Minimal swelling atearly stage,increasing over 24 hr.

Sag tests +

• Arthroscopic repair.

• Quadricepsstrengthening

• Arshi points.

Lateral & Medial Collateral Lig.Tears

Lateral and Medial Collateral Lig.Tears

• Isolated LCL tears arerare.

• Tx: conservative, ice,brace, Acupuncture,strengthening and

• MCL tears arecommon in footballand skiing after lateralblow to the knee anda pop. strengthening and

stability.

• Triad of MCL tear,ACL tear and medialmeniscal tear(O’Donghue’s Triad)needs evaluation.

a pop.

• Medial knee pain andswelling are oftenimmediately present.

• LCL tears usually arethe result of kneedislocations.

Ilial Tibial Band Syndrome(ITB Syndrome)

• The ITB slides overthe lateral femoralcondyle with the kneein flexion andextension.extension.

• The pain is worsewith running andwalking.

• Evaluated by theOber test.

Ilial Tibial Band Syndrome(ITB Syndrome)

• Stretching the ITB, hipflexors and gluteusmaximus.

• Acupuncture, archi pointsand mexa. Electricaland mexa. Electricalstimu.

• Orhtotics and footoverpronation must becorrected.

• Injection at the lateralfemoral condyle.

RECURRENT PATELLARSUBLUXATION

• The patella may bedisplaced medially orlaterally in the acutephase.

• The knee tends to• The knee tends tobuckle after asubluxation.

• Pain at theperipatellar region.

• Effusion.

RECURRENT PATELLARSUBLUXATION

• R:Patellar subluxation

• L: Patellar tilt

• Wasting of the vastusmedialis.

• Impaired fullextensionextension

• The patella will oftenreset at 25-30 degreeof flexion.

• Tx: see below

Patellofemoral Pain and OverloadSyndrome (Runner’s or Biker’s Knee)

• The most commonanterior knee painsyndrome.

• Overuse injury caused byrepeated microtraumarepeated microtraumaleading to peripatellarsynovitis.

• Recurrent patellarsubluxation predisposesthe syndrome.

Patellofemoral Pain and OverloadSyndrome (Runner’s or Biker’s Knee)

• Tx: Non Surgical-most cases aresuccessful

– Controlling symptoms: Decreasing pain,increasing strength, increasing range ofincreasing strength, increasing range ofmotion.

– Activity modification: Reduce the pace ofclimbing, jumping, squatting.

– Ice 15 min before and after activities.

– Nonsteroidal anti-inflammatory medications.

Patellofemoral Pain and OverloadSyndrome (Runner’s or Biker’s Knee)

• Therapeutic exercise

– Quadriceps, especiallyVMO.

– Straight leg raising.

– Stretching of thehamstrings, ITB,adductors, and VL.

– swim slowly.

Chondromalacia Patella

• Normal View • Chondromalacia View

Chondromalacia Patella

• Softening of the patellar articular cartilage.

• Culmination of cartilage degeneration.

• Essentially an arthroscopic diagnosis.

• Roughened orfibrillated cartilage on• Roughened orfibrillated cartilage onarthroscopy.

• Often seen with chronic patellofemoraloverload and tracking dysfunction.

• Treatment: the same as above.

Plica

• A redundant fold of thesynovial lining of theknee.

• Susceptible to tearing asit pass over the condyles.

• Occur in the the• Occur in the themedialpatellar,infrapatellar orsuprapatellar region.

• The symptom and Txsimilar to the kneeoverload syndrom.

• May indicate surgery.

Jumper’s Knee

• Patellar tendinitis.

• Micro-tears of the tendon.

• Involving pole of the patella.

• Most common site: inferiorpole of the patella.pole of the patella.

• Sometimes superior pole ofthe patella or the insertionover the tibial tubercle.

• Pain on activity.

• Tx: the same.

Osteochondritis Dissecans

Osteochondritis Dissecans

• Localized area of avascular necrosis.

• Formation of dead subchondral bonecovered with articular hyaline cartilage.

• The entire piece may detach, enter the• The entire piece may detach, enter thejoint space as a loose body.

• Locking, irritation, buckling.

• Rest, non wt bearing, surgery.

Pes Anserine Bursitis

Bursa Around Knee

• Repetitive activitiesmay cause differentbursitis.

• Location, Location!

• Acupuncture, archi• Acupuncture, archipoints.

• Moxa, electricalstimulation, if acute,use ice.

• Steroid injection.

Shin Splints(Medial Tibial Stress Syndrome)

• Exercise induced chronictraction on the periosteumat the poeriosteal-fascialjunction.

• Gradual onset of pain along• Gradual onset of pain alongthe anterior medial borderof tibia or the lower medialankle.

• Hx of repetitive running onhard surfaces andinappropriate warm-up.

• Recently changed footwear.

Shin Splints(Medial Tibial Stress Syndrome)

• Bone scan or MRI ruleout stress fracture.

• Rest is the best and first.

• Ice and stretch orwalking with crutch.walking with crutch.

• Acupuncture pointsstimulation, no heat.

• Orthotics to correct over-pronation.

• Fasciotomy.

Stress Fractures

• Most common inrunning sports.

• 25% incidence inathletes with lower legpain.pain.

• Low bone mineraldensity imposes ahigher risk.

• Over-pronation placeshigher stress on thefibula and tibia.

Lateral Ankle Sprain

Lateral Ankle Sprain

• Mechanism: inversionon a plantarflexedfoot.

• Anterior draw tests for• Anterior draw tests forthe integrity of theATFL.

• Talar tilt tests for theintegrity of ATFL andCFL.

Lateral Ankle Sprain

• Grade I (mild): Partialtear of ATFL.

• Grade II (Mordrate):Complete tear of theComplete tear of theATFL, partial tear ofthe CFL.

• Grade III (Severe):Complete tear ofATFL and CFL.

Lateral Ankle Sprain

• Grade I and II: Ice, rest, compression,elevation , NSAIDs, analgesics,immobilization. Acupuncture, archi, etc.

• Grade III: controversial : conservative vs.• Grade III: controversial : conservative vs.surgical.

• Acupuncture only can treat for Grade I.

Medial Ankle Sprain

• Rare ankle injury, 5%occurrence rate.

• Pure eversion injury.

• Grade I: Stretch• Grade I: Stretch

• Grade II: Stretchpartial tear.

• Grade III: Full tear.

• Tx: The same aslateral ankle sprain.

Achilles Tendon Disorders

• Tendonitis: Posteriorankle pain, swelling,pain elicited on push-off.

• Rupture: Suddenaudible snap withimmediate swelling,ecchymosis andweakness in plantarflexion.

Achilles Tendon Disorders

• Positive Thompsontest on right legindicates rupturedachilles tendon bysqueezing the calf.squeezing the calf.

• Negative Thompsontest on left legindicates intactachilles tendon.

Achilles Tendon DisordersTreatment

• Achilles tendonitis: relative rest, ice, anti-inflammatory medications, acupuncture,arshi points. Moxa in chronic phase.

• Rupture:• Rupture:– Conservative: Bracing in a plantar-flexed

position for a period of 8 – 12 weeks

– Surgical, cast for 2 weeks. Then plantarflexion dial lock brace for 4 to 6 weeks.Acupuncture may help for stiffness of theankle postsurgically.

Plantar Fasciitis

• Medial plantar heelpain, which mayevolve from heel spuror plantar fascia.

• Tension on theplantar fascia leadingto chronicinflammation mostcommonly at itsorigin.

Plantar Fasciitis

• Tenderness over themedial aspect of theheel and the entireplantar fascia.

• Increased onawakening anddecreased with activity.

• Tight Achilles tendonfrequently associated.

Plantar Fasciitis

• Heel pads, cushion andtaping.

• Acupuncture, archi,capping, moxa, verycapping, moxa, veryuseful.

• Achilles and plantarfascia stretching.

• Night splints, NSAIDsand modalities.

Morton’s Neuroma• A painful mass near the

area of the metatarsalheads. The mass issecdondary to the nervefibrosing. More women.

• Sharp shooting forefoot• Sharp shooting forefootpain.

• Tx: Shoes with soft soleand wide toe box with pad.

• Acupuncture: archi withelectrical stim, moxa,cupping.