Key Takeaways
- Rotator cuff tears are most common in the supraspinatus tendon; rehabilitation progresses from PROM to isometrics to dynamic strengthening
- ACL reconstruction rehabilitation follows a criterion-based progression: protect graft, restore ROM, progressive strengthening, return to sport at 6-12 months
- Low back pain treatment emphasizes active approaches: McKenzie directional preference, core stabilization, and graded exposure to activity
- Total knee arthroplasty (TKA) goals: 0-90 degrees ROM by 2 weeks, 0-120 degrees by 6 weeks, with emphasis on quadriceps activation and gait training
- Total hip arthroplasty (THA) precautions depend on surgical approach: posterior (no flexion >90, adduction, or IR) vs. anterior (less restrictive)
- Adhesive capsulitis (frozen shoulder) follows three stages: freezing (painful), frozen (stiff), thawing (recovery), total duration 1-3 years
- Lateral epicondylitis (tennis elbow) affects the common extensor origin; treated with eccentric wrist extension exercises
- Fracture healing stages: inflammation (1-7 days), soft callus (2-3 weeks), hard callus (3-12 weeks), remodeling (months to years)
Common Musculoskeletal Conditions & Management
The NPTE tests your ability to identify, evaluate, and treat common orthopedic conditions encountered in physical therapy practice. This section covers the highest-yield conditions for the exam.
Rotator Cuff Pathology
Anatomy and Pathology
The rotator cuff consists of four muscles that stabilize the glenohumeral joint:
| Muscle | Action | Nerve |
|---|---|---|
| Supraspinatus | Initiates abduction (first 15-30 degrees) | Suprascapular nerve (C5, C6) |
| Infraspinatus | External rotation | Suprascapular nerve (C5, C6) |
| Teres Minor | External rotation | Axillary nerve (C5, C6) |
| Subscapularis | Internal rotation | Subscapular nerves (C5, C6) |
Memory Aid: SITS (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
The supraspinatus is the most commonly torn rotator cuff muscle, particularly in the region of relative avascularity near its insertion on the greater tuberosity.
Rehabilitation Progression (Post-Repair)
| Phase | Timeline | Goals | Interventions |
|---|---|---|---|
| Phase I: Protection | 0-6 weeks | Protect repair, minimize pain, maintain PROM | Sling use, pendulum exercises, PROM within limits |
| Phase II: Active Motion | 6-12 weeks | Restore AROM, begin isometrics | AAROM to AROM, isometric rotator cuff exercises |
| Phase III: Strengthening | 12-16 weeks | Progressive strengthening | Isotonic RC exercises, scapular stabilization |
| Phase IV: Return to Activity | 16-24+ weeks | Full functional return | Sport/work-specific training, plyometrics |
ACL Reconstruction Rehabilitation
ACL reconstruction (most commonly using bone-patellar tendon-bone or hamstring autograft) follows a criterion-based progression:
| Phase | Goals | Key Criteria to Progress |
|---|---|---|
| Acute (0-2 weeks) | Reduce swelling, restore extension, protect graft | Full passive extension, quad activation |
| Early Rehab (2-6 weeks) | Restore full extension, begin CKC exercises | 0 degrees extension, minimal effusion |
| Mid Rehab (6-12 weeks) | Progressive strengthening, begin running program | 90% quad strength symmetry, no effusion |
| Late Rehab (3-6 months) | Sport-specific training, agility | Functional hop tests >90% of uninvolved |
| Return to Sport (6-12 months) | Full return to sport | Pass all functional tests, psychological readiness |
Key Principle: Full knee extension must be achieved early — failure to restore extension leads to long-term dysfunction.
Total Hip Arthroplasty (THA) Precautions
THA precautions vary by surgical approach:
Posterior (Posterolateral) Approach — MOST COMMON
Avoid (to prevent posterior dislocation):
- Hip flexion beyond 90 degrees
- Hip adduction past midline (no crossing legs)
- Hip internal rotation
Anterior (Direct Anterior) Approach
Avoid (to prevent anterior dislocation):
- Hip extension beyond neutral
- Hip external rotation
- Combined extension and external rotation
Note: Anterior approach precautions are generally less restrictive, and many surgeons allow more freedom of movement earlier.
Low Back Pain (LBP)
Low back pain is one of the most common conditions treated by physical therapists. The NPTE focuses on evidence-based management:
McKenzie Classification (Mechanical Diagnosis and Therapy)
| Classification | Description | Treatment |
|---|---|---|
| Derangement | Symptoms change with repeated motions (centralization/peripheralization) | Directional preference exercises (most common: extension) |
| Dysfunction | Pain at end range only, no change with repeated motions | Stretching at end range in direction that produces pain |
| Postural | Pain only with sustained postures, no pain with movement | Postural correction, education |
Centralization (symptoms moving from distal to proximal) is a positive prognostic sign and indicates the correct direction of treatment.
Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis progresses through three stages:
| Stage | Duration | Characteristics | Treatment Focus |
|---|---|---|---|
| Freezing (Painful) | 2-9 months | Gradual onset of diffuse shoulder pain, progressive loss of motion | Pain management, gentle PROM within tolerance |
| Frozen (Stiff) | 4-12 months | Pain diminishes, significant ROM restriction in capsular pattern | Joint mobilization (grades III-IV), stretching |
| Thawing (Recovery) | 5-24 months | Gradual return of ROM | Progressive stretching, strengthening, functional training |
Capsular Pattern of the Shoulder: External rotation most limited > abduction > internal rotation
A patient is 2 days post-posterior approach total hip arthroplasty. Which of the following positions should be AVOIDED?
Which rotator cuff muscle is MOST commonly torn?
In McKenzie classification for low back pain, centralization of symptoms indicates:
What is the capsular pattern of the glenohumeral joint?
Which of the following are precautions after a POSTERIOR approach total hip arthroplasty? (Select all that apply)
Select all that apply