2022 OCS
Risk factors for abdmonal aortic aneurysm (include liklihood ratios)
1. Back, abdominal, or groin pain, 2. presence of perifpheral vascular disease or coronary artery disease and associated risk factors (age over 50, smoker, HTN, DM), 3. smoking history (Odds Ratio: *** ) 4. family history (Odds Ratio: *** ), 5. age over 70 (Odds Ratio: *** ), 6. Non-caucasin (Odds Ratio: *** ), 7. female (Odds Ratio: *** ), 8. symptoms not related to movement stresses associated with somatic low back pain, 9. abdominal girth, 10. Presence of a bruit in the central epigastric area upon auscultation, 11. palation of abnormal aortic pulse, 12. Aortic pulse 4 cm or greater, 13. Aortic pulse 5cm or greater.
How would you test the integrity of the C5-7 Rami and the C5 Rami?
C5-7 - Test Serratus Anterior, C5 - test rhomboids
Indications for TENS
Knee OA
Peripheral Neuropathy CPR
abscence of achilles reflex, decreased vibration sensation, decreased position sense of the toe. looking for 2 or more of these predictors.
What does behavioral education include?
activity pacing, attention diversion, cognitive restructuring, goal setting, graded exposure, motivational enhancement therapy, maintenance strategies, problem solving strategies.
Clinical Prediction Rule
algorithmic decision tools desinged to aid clinicians in determining a diagnosis, prognosis, or likely repsonse to an intervention. Guide clinician to accurately and efficiently subgroup patiens while reducing bias.
Axonotmesis
axonal injury involving wallerian degernation distal to the injry site. Axonal sprouting (nerves constantly send out sprouts --> when they hit innervated tissue, they retract. When they hit denervated tissue they latch on) occurs, VERY GOOD prognosis.
Monofilament Testing Sites for Peripheral Neuropathy
big toe*, 3rd toe, 5th toe, 1st met head *, 3rd met head *, 5th met head *, middle midfoot, lateral midfoot, calcaneus, 1st and 2nd midspace
Indication for ultrasound
calcific tendinitis, RA, tissue heating
When psychological factors are identified, what should the rehabiliation approach be modified to include?
emphasize active rehabilitation, graded exercise programs, positive reinforcement of functional accomplishments, and/or graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform.
Gout
insidious onset, typically at 1st MTP, sx's resolve in 7-10 days, causes include excessive ETOH consumption, surgery, immobilization, and trauma. mobilize in painfree ROM.
Neuropraxia
local conduction block due to segmental demyelination. No axonal abnormality. Excellent prognosis.
What is the distinguishing movement/pain characteristic for chronic low back pain with radiating pain?
pain occurs with sustained end-range movements or positions. INTERVENTIONS: movements that increase movement tolerances in the end ranges of motion.
What was proven to be more meaningful than MRI identified disc abnormalities in predicting low back pain related medical consultation?
physical job characteristics and psychological aspects of work.
indications for iontophoresis
plantar heel pain
Indications for NMES
post op Quads, 1st 4 weeks s/p ACL, functional estim (shoulder subluxation)
Myofascial Pain Syndrome
regional disorder (not global), trigger points - active versus latent, trigger points can elicit pain, tingling, or numbness. clinical presentation - diffuse pain on a specific body region, (+) trigger points, sleep disorders, morning stiffness, and fatigue. Intervention - dry needling
Type 2 Error
"Missing a winner." Results falsely conclude that no statistically difference occurred between groups when there actually was a difference. Typically due to small sample sizes
Type 1 Error
"backing a loser." results falsely conclude that a statistically significant difference occurred when there is actually no difference.
Clinical Findings of Entrapped: SCIATIC NERVE L4/5/S1/2/3
(+) SLR, Posterior thigh pain, Hamstring weakness, Trigger points - piriformis, Restricted piriformis and hamstring muscles, Reflexes Achilles tendon
CPR Cervical spine Radiculopathy
(+) Spurlings, pain relieve with distraction, (+) Upper Limb Tension Test A, (+) ipsilateral cervical spine rotation less than 60 degs
TMJ Group 1: Muscle Disorders
(+) Tenderness to Palpation of masseter or temporalis, (+) pain with minimal opening (assisted or unassisted, pain in temporalis or massetter). If opening is greater than 40 mm - myofascial pain, if less than 40 mmg - myofascial pain with limited opening
Lumbar Stabilization CPR
(+) aberrant movements, (+) prone instability test. If both are present do a stabilization program
TMJ Group 2: Disc Displacement
(+) click with opening and closing, + excursive movements (lateral, protrusive), Just those = disc displacement with reduction, those + locking up of the jaw = disc displacment without reduction
Identify Exercise-Based Knee Injury Prevention Programs that are Effective for Specific Subgroups of Athletes
(A) Implement exercise-based knee injury prevention programs PRIOR to practice or games in female athletes, especially < 18, to reduce risk of ACL injuries. (A) Soccer players, especially women, should use exercise based knee injury prevention programs to reduce risk of serious knee injury. (B) Male and female handball players (15-17 years).
when should a clinician initiate the referral out process according to the low back pain CPG?
1. The patient's clinical findings are suggestive of a serious medical or psychological pathology. 2. activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of these guidelines, 3. symptoms are not resolving.
Acute Low Back Pain with Related (referral) lower Extremity Pain: Primary Intervention Strategies
1. Therapeutic exercises, manual therapy, or traction procedures that promote centralization and improve lumbar extension mobility. 2. patient education in positions that promote centralization. 3. progress to interventions consistent with the subacute or chronic low back pain with movement coordination impairments intervention strategies.
What are some factors that increase risk of having low back pain?
1. Women tend to have a higher prevalence of low back pain than men. 2. increased age, 3. lower educational status, 4. longer episode duration, 5. high physical demand in daily activities.
What is the clinical prediction rule for a stabilization focused exercise program?
1. age less than 40 years old, 2. + prone instability test, 3. prescence of aberrant movements with motion testing, 4. straight leg raise greater than 91 degrees. positive = at least 3 findings, (LR = 4.0) negative = fewer than 2 clinical findings (LR = 0.20)
What are the findings for diagonsis/classification of Intra-articular Injury (labral tear, osteochondral lesion, loose bodies, and ligamentum teres tears)?
1. anterior groin or genoralized hip joint pain. 2. pain with FADIR or FABER test. 3. Mechanical symptoms popping, locking, or snapping. 4. reports instability (ligamentum teres) and instability with squatting. 5. Imaging findings for labral tear.
What are the findings for diagnosis/classification of Structural Instability?
1. anterior groin, lateral hip, or generalized hip joint pain. 2. pain with FADIR or FABER. 3. hip apprehension sign positive. 4. Hip IR < 30 degrees with hip in 90 degrees of flex. 5. mechanical symptoms popping, loacking, or snapping. 6. Radiographic findings of increased acetabular inclination, decreased femoral head coverage, Tonnis angle > 10 deg.
What are the findings for diagnosis/classification of FAI?
1. anterior hip/groin pain and/or lateral hip/trochanteric pain. 2. pain described as aching or sharp. 3. aggravated by sitting. 4. pain with FADIR test. 5. hip IR < 20 degrees with hip in 90 degrees flex. 6. limitation in hip flexion and abduction. 7. mechanical symptoms of popping, locking, snapping. 8. Radiographic findings of Cam or Pincher impingment.
What objective measurements are the most meaningful for patients presenting with hip pain?
1. flexion, abduction, and external rotation (FABER) test and PROM hip motion (will be limited), hip muscle strength. Inc all motions of the hip.
What are the three main approaches for patient education strategies?
1. general education and advice in acute and subacute populations, 2. behavioral education, including cognitive-behavioral theory, graded activity, and graded exposure, in a variety of populations; 3. education of patients on the physiology of pain
What are the components of MENISCAL PATHOLOGY COMPOSITE SCORE?
1. history of catching/locking. 2. pain with forced hyper extension. 3. pain with maximum pasive knee flexion. 4. joint line tenderness. 5. pain/click with McMurrays. Greater than 5 (sensitivity 11.2% & specificity 99%), greater than 3 (sensitivity 30.8% & specificity 90.2%).
What are the Risk Factors for Acute Lateral Ankle Sprain?
1. history of previous ankle sprain. 2. do not use an external support. 3. do not properly warm up with static stretching and dynamic movements. 4. do not have normal ankle dorsiflexion ROM. 5. do not participate in balance/proprioceptive prevention program with a history of previous injury.
What are the prognostic factors for developing of recurrent low back pain?
1. history of previous episodes, 2. excessive spine mobility, 3. excessive mobility of other joints
What is the American College of Physicians stance on imaging?
1. imaging is only indicated for severe progressive neurological deficits or when red flags are suspected, 2. routine imaging does not result in clinical benefit and may lead to harm.
What are the Risk Factors for Ankle Instability?
1. increased talar curvature. 2. not using external support. 3. not performing balance/proprioception exercises following acute lateral ankle sprain.
Rule IN Criteria for: Shoulder Stability and movement coordination impairments/Dislocation of shoulder joint, or sprain and strain of shoulder Joint
1. less than 40 years old. 2. history of dislocation, 3. excessive GHJ motion in multiple directions, 4. Apprehension at end ranges of flexion, horizontal abduction, and/or ER.
What clinical findings are useful for diagnosis/classification of acute lateral ankle sprain?
1. ligamentous laxity. 2. hemorrhaging. 3. point tenderness. 4. total ankle motion. 5. swelling. 6. pain.
What are the recommendations in regards to Risk Factors associated with heel pain and plantar fasciitis?
1. limited ankle DF ROM. 2. high BMI (nonathletic population). 3. running. 4. work-related WB activities particularly under conditions with poor shock absorption.
Acute Low Back Pain with Related (referral) lower Extremity Pain: Impairments of Body Function
1. low back and lower extremity pain that can be centralized and diminished with specific postures and/or repeated movements. 2. reduced lumbar lordosis, 3. limited lumbar extension mobility, 4. lateral trunk shift may be present. 5. Clinical findings consistent with subacute or chronic low back pain with movement coordination impairments classification criteria.
What is the summary regarding clinical course for midportion achilles tendinopathy?
Althetes; missed participation is brief, however can reduce performance in older athletes. Most patients will improve with mixed levels of recovery.
17. A 28 year old female presents to your clinic with the following finger deformity: DIP hyperextended, PIP flexed. What is the name of this deformity and its most probably intervention? a. Boutonniere deformity & splinting/exercise b. Boutonniere deformity & surgical intervention c. Swan-neck deformity & splinting/exercise d. Swan-neck deformity & surgical intervention
Boutinniere deformity & splinting/exercise
11. A 21 year old male college student presents to your clinic complaining of a two week history of dorsal hand pain over the area of the 4th metacarpal. The patient reports he inadvertently punched his dorm room door two weeks ago when he lost his key and couldn't get in his room and has had pain since. The patient has decreased AROM extension at the 4th PIP and MCP. Grip strength is also diminished and painful. When the patient makes a fist, you observe the head of the 4th metacarpal is more proximal than the 3rd and 5th metacarpal heads. The patient is tender to palpation over the distal shaft of the 4th metacarpal. Based on this information, what is the most likely diagnosis for this patient? a. Base of 4th proximal phalanx fracture b. Boxer's fracture c. Distal MCP contusion d. Distal MCP dislocation
Boxer's fracture
Path: TIBIAL NERVE L4/5/S1/2/3
Branches off Sciatic nerve at popliteal fossa deep to soleus, Crosses knee joint, Descends between superficial and deep compartments, Crosses posterior to medial malleolus, Divides into lateral and medial plantar nerves
Path: SAPHENOUS NERVE L3/4
Branches off femoral nerve inferiorly to inguinal ligament, adductor canal, Pierces fascia at Sartorius, Travels with saphenous vein subcutaneously to supply medial leg and medial arch of the foot
Clinical Findings of Entrapped: SAPHENOUS NERVE L3/4
Burning, ache, pain at medial knee/medial leg and foot, May be present at night or during sleep at medial knee with knee flexion and hip adduction, Painful to palpation at distal Sartorius.
What is the typical presentation of patients with NECK PAIN WITH HEADACHE (Cervicogenic)
COMMON SYMPTOMS; Noncontinuous, unilateral neck pain and associated headache, headache is precipitated or aggravated by neck movements or sustained postures. EXAM FINDINGS; positive cervical flexion-rotation test, headache reproduced with involved upper cervical segments, limited cervical ROM, restricted upper cervical segmental mobility, strength/endurance/coordination deficits of neck muscles.
Centralization versus Directional preference
Centralization - change in symptom location to a more proximal/centralized location. Directional preference - reduction in pain intensity from repeated motions. Centralization should accompany a directional preference, but a directional preference will not necessarily coincide with a change in symptom location
4. A 55 year old male complains of left-sided neck pain for the past 3 months. He cannot recall a mechanism of injury. Based on this data, you elect to treat him with which of the following? a. Cervical and thoracic mobilizations/manipulations b. Gentle AROM cervical spine within pain tolerance c. Mechanical traction d. Postural education
Cervical and thoracic mobilizations/manipulation. This is a matched intervention for the "mobility" classification. The patient's age, symptom duration and lack of peripheralizing symptoms match him to this classification.
What must data show to be clinically significant?
Change on a measure that has value to the patient, change of a magnitude that will make an actual difference in the patient's life.
17. You are evaluating a 36 year old male with a 4 month history of proximal right sided plantar fasciitis. You provide Achilles tendon and plantar fascia stretches. You decide to provide one of four available shoe inserts. Based on the evidence, which of the following is the WORST choice for this pat A. Custom orthotic B. Felt insert C. Rubber insert D. Silicone insert
Custom orthotic
23. Which of the following are "cons" about using confidence intervals in a study? a. Dependent on the power of the study b. Does not indicate clinical significance c. Usually set a priori d. Yes/No dichotomy - results are either significant or not
Dependent on the power of the study
What are the recommendations for interventions - education and weight loss counseling for heel pain and plantar fasciitis?
Experimental evidence. May provide education on exercise strategies to gain or maintain optimal lean body mass. May referr to appropriate provider to address nutrition issues.
Randomized Controlled Trial
Experimental study in which an experimental treatemtn is compared to a control treatment. Subjects are randomized into groups
26. Double-blind research designs can help to eliminate which of the following types of bias a. Experimenter b. Recall c. Systematic d. Sampling
Experimenter
What are the manual therapy recommendations for nonarthritic hip pain?
Expert opinion. Abscence of contraindications (structual instability or abnormalities) joint mobilization proceedures to address capsular restrictions and soft tissue mobilizations to address mayofascial impairments.
What are the recommended interventions - taping for midportion achilles tendinopathy?
Expert opinion. Clinicians may use rigid tape to decrease strain on achilles tendon/alter foot posture. Clinicians should NOT use elastic tape.
What are the recommended interventions - dry needling for midportion achilles tendinopathy?
Expert opinion. Combined therapy of dry needling with injection under ultrasound guidance and eccentric exercise to decrease pain in individuals with symptoms > 3 months and increased tendon thickness.
What are the recommended interventions - manual therapy for midportion achilles tendinopathy?
Expert opinion. Consider using joint and soft tissue mobilization to increase ROM.
What are the recommendations for interventions - therapeutic exercise and neuromuscular re-education for heel pain and plantar fasciitis?
Expert opinion. May prescribe strength exercises and movement training for muscles that control pronoation and attenuate forces during WB activities.
What are the therapeutic exercise and activity recommendations for nonarthritic hip pain?
Expert opinion. May use therex and theract to address joint mobility, flexibility (iliopsoas, recus femoris, hamstrings, TFL/ITB), strength (abductors and rotators) and power deficits, deconditioning, and metabolic disorders.
What are the nueromuscular re-education recommendations for nonarthritic hip pain?
Expert opinion. May utilize neruomuscular re-ed to diminish movement coodination impairments.
What are the patient education recommendations for nonarthritic hip pain?
Expert opinion. Modifying aggravating factors and managing pain.
What are the recommended interventions - neuromuscular re-education for midportion achilles tendinopathy?
Expert opinion. Neuromuscular re-ed targeting LE impairments leading to abnormal kinetics/kinematics specifically eccentric overloard of achilles tendon during WB activities.
What is the recommendation for bracing for hip pain/mobility deficits?
Expert opinion. Should NOT use bracing as first line of treatment. May use after failure of exercise therapy to improve participation in activities that require turning/pivoting with mild to moderate OA.
What are the recommendations for interventions - Dry needling for heel pain and plantar fasciitis?
Expert opinion. Use of dry needling cannot be recommened.
8. Compression of the nerve within the cubital tunnel will most likely affect which muscle? a. Abductor Pollicus Brevis b. Extensor Digiti Minimi c. First Dorsal Interrosei d. Opponens Pollicus
First Dorsal Interrosei
Nerve Entrapment Sites: SURAL NERVE S1/2
Gastrocnemius-soleus complex at distal third of leg
Clinical Findings of Entrapped: SURAL NERVE S1/2
Gastrocnemius-soleus complex at distal third of leg; CLINICAL FINDINGS: Mimics Achilles tendinopathy, Pain/paresthesia posterior/lateral leg
Chronic LBP with Radiating Pain Suggested Matched Interventions
General Exercise Training and Neural Tissue Mobilization Exercises, Thrust or Non-Thrust Joint Mobilization, Soft Tissue Mobilization, and Massage, Active Education to Pursue an Active Lifestyle
Acute LBP with Radiating Pain Suggested Matched Interventions
General Exercise Training and Neural Tissue Mobilization, Thrust or Non-Thrust Joint Mobilization, Soft Tissue Mobilization, and Massage, Education on the Favorable Natural History of Acute Low Back Pain and Self-Management Techniques
25. A Likelihood Ratio of 0.2 would be interpreted using which of the following definitions? a. Alters post-test probability to a small, and rarely important, degree b. Generate a small, but sometimes important, shift in post-test probability c. Generate a moderate shift in post-test probability d. Generate a large and often conclusive shift in probability
Generate a moderate shift in post-test probability
According to Battie et al, what factors were determined to contribute to degenerative changes of the spine?
Genetics, body build, and early environmental influences.
2. A 22 year old female patient presents 28 days s/p MVA with initial NDI score of 53% and VAS pain score of 7/10. Based on this data you elect to initially treat her with which of the following? a. Cervical and thoracic mobilizations/manipulations b. Gentle AROM cervical spine within pain tolerance c. Mechanical traction d. Postural education
Gentle Active Range of Motion within pain tolerance. "pain control Classification."
20. Which muscle has trigger points whose typical symptom referral pattern can most closely resemble the symptom distribution of sciatica? A. Gluteus Maximus B. Gluteus Medius C. Gluteus Minimus D. Piriformis
Gluteus Minimus
11. A 19 year old right-handed male collegiate baseball pitcher presents to your clinic complaining of right shoulder pain. His pain has increased gradually over the past two weeks. He reports that he has had right shoulder pain since his junior year in high school that typically occurs during mid-season, but that is resolved by cessation of throwing activities at the end of each season. His pain began approximately 2 weeks ago and he is currently in the middle of baseball season. The patient only has pain with throwing a baseball. He is able to sleep on his affected side without pain. You decide to perform an Anterior Load/Shift test on this patient and note a feeling of the humeral head overriding the glenoid rim, but spontaneously reducing. Based on this information, how would you grade the amount of anterior glenohumeral translation? a. Normal b. Grade 1 c. Grade 2 d. Grade 3
Grade 2
4. A 17 year old highschool cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain, abduction 4+ /5 with pain, external rotators 4/5 with pain. Obers and FABER's tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter. What would be the most likely diagnosis? a. Greater Trochanteric bursitis b. Iliopectineal bursitis c. SI Joint dysfunction d. Slipped Captial Femoral Epiphysis
Greater Trochanter Bursitis. This is an overuse injury. Symptoms are elicited with tests and positions that place stress on the lateral hip structures (FABER's, Ober's) and MMT of posterior hip muscles that insert on the Greater Trochanter would be weak with pain. Note, the patient reports the condition has worsened and the pain is now continuous. This is suggestive of a more advanced stage of the inflammation.
10. Which is the most likely anatomical rationale for shoulder impingement? a. Greater tubercle and associated rotator cuff tendons compress against the coracoacromial ligament during shoulder elevation and internal rotation b. Lesser tubercle and associated rotator cuff tendons compress against the coracoacromial ligament during shoulder elevation and internal rotation c. Greater tubercle and associated rotator cuff tendons compress against the coracoclavicular ligament during shoulder elevation and internal rotation d. Lesser tubercle and associated rotator cuff tendons compress against the coracoclavicular ligament during shoulder elevation and internal rotation
Greater tubercle and associated rotator cuff tendons compress against the coracoacromial ligament during shoulder elevation and internal rotation
Clinical Findings of Entrapped: OBTURATOR NERVE L2/3/4
Groin/inner thigh pain, Exercise induced medial knee pain/numbness, Adductor weakness, Painful passive abduction, Restricted adductors
According to the CCR, what things are considered high risk? Low risk?
HIGH RISK; (1) > 65 years, (2) dangerous MOI, (3) paresthesias in extremities. These individuals should undergo CT (preferred) or cervical radiograph. LOW RISK (indicating safe cervical ROM assessment can be done); (1) able to sit in emergency department, (2) had a simple rear-end MVC, (3) ambulatory at anytime, (4) has delayed onset of neck pain or (5) does not have midline cervical spine tenderness. Lastly if able to rotate the head in 45 degrees in each direction, patient is classified as low risk (imaging not required at this stage).
1. A 34 year old male complains of LBP for the past 27 days that has caused him to miss several days of work. He has pain in the right lower lumbar region and paresthesias into the right proximal third of his posterior thigh. He also complains of intermittent pain in the lower thoracic region. He has an Oswestry score of 41%, VAS of 5.8 and FABQ work subscale 17 and physical activity subscale 18. Physical examination demonstrates painful and limited lumbar flexion with aberrant motion upon returning to neutral, right rotation and right sidebending. PROM hip IR 38 deg left, 27 deg right. He demonstrates positive lumbar spring testing at L3-L5 over the spinous processes. Based on this data, what would be the best intervention? a. Extension exercises b. HVLA to the SI Joints c. Mechanical lumbar traction & Extension exercises d. Stabilization exercises to the lumbar spine
HVLA to Sacroiliac Joints
10. A patient with numbness & paresthesias along the radial/palmar portion of the forearm would, in the absence of other physical findings, most likely have involvement of which of the following nerves? a. Anterior Interosseus nerve b. Dorsal Ulnar Cutaneus Nerve c. Lateral Antebrachial Cutaneus Nerve d. Superficial Sensory Branch of the Radial Nerve
Lateral Antebrachial Cutaneus Nerve
Path: SURAL NERVE S1/2
Lateral branch arises from common peroneal, Medial branch from Tibial nerve, Travels distally on top of gastrocnemius, Joins at distal third of gastrocnemius/soleus to form common sural nerve
17. Which of the following is a common factor for ACL injuries in female athletes? A. Ankle dominance B. Leg dominance C. Hamstring dominance D. Pelvic dominance
Leg Dominance
Dix-Hallpike
Long Sitting, arms crossed over chest. 1. rotate head 45 degrees and extend 30 deg, 2. Rapidly move pnt to supine, 3. hold head off table x 30s, 4. look for nystagmus
What is the summary regarding the clinical course of heel pain and plantar fasciitis?
Long term follow up data suggestes positive outcomes with 80% of patients reporting resolution of symptoms within 12 months. However typically presents as a chronic condition with symptom duration > 1 year prior to seeking treatment, mean duration of symptoms ranged from 13.3-14.1 months.
How do you determine the effectiveness of an intervention in a meta analysis?
Look at the charts, find the diamond, does the diamond touch the line? If not --> to the left of the line is good. The closer the diamond is to the line the worse the effect is. If touching the line --> no effect.
9. You are evaluating a patient with right lower back and buttock pain. Your physical examination revealed a positive Gillet (Stork) and Standing Forward Flexion tests and a negative Seated Forward Flexion test. Based on this data you make which of the following decisions? A. Low Back Pain without involvement of the SIJ B. Sciatica C. SIJ Dysfunction D. SIJ Pain
Low Back Pain without involvement of the SIJ
Movement Control Category - Treatment Based Classification
Low/moderate pain/disability, affecting Activities Of Daily Living, pain stable and not irritable, Active Range of Motion often full sometimes with aberrant movements, exam: (+) impaired flexbility, muscle activation, motor control deficits, treatment - improve movement quality by Mobilizations, manipulations, motor control, flexibility, balance
18. According to the Orthopedic Section's Clinical Practice Guidelines, which of the following low back pain interventions has the worst evidence supporting its use? A. Centralization and directional preference exercises and procedures B. Progressive endurance exercise and fitness activities C. Lower quarter nerve mobilization procedures D. Patient education and counseling
Lower quarter nerve mobilization procedures
5. A 27 year old female postal worker tore her right rotator cuff. The patient elected to have surgery for her right shoulder. What type of repair would allow for the fastest post-operative rehabilitation? a. Arthroscopic b. Open c. Mini-open
Mini-open
11. Which of the following physical therapy interventions has the best evidence supporting the treatment of lateral epicondylalgia? A. Mobilization with Movement B. Transverse friction massage across the ECRB tendon C. Taping D. Ulnohumeral joint manipulation
Mobilization with Movement
What is the recommendation on education for adhesive capsulitis?
Moderate evidence. 1. Describe the natural course of the disease. 2. promotes activity modification to encourage functional pain-free ROM. 3. matches the intensity of stretching to the patient's current level of irritability.
What are the recommended interventions - patient education for midportion achilles tendinopathy?
Moderate evidence. Advise patients that complete rest is NOT indicated, cointinue with activity within pain tolerance.
What are the recommendations regarding postural changes in PGP?
Moderate evidence. Clinicians should NOT consider postural changes as indicated of development or intensity of PGP.
What are the recommended interventions - modalities for midportion achilles tendinopathy?
Moderate evidence. Clinicians should use iontophoresis with dexamethasone to decrease pain and improve function in acute midportion tendinopathy. Conflicting evidence for low-level laser.
What are the recommendations for intervention - acute/protected motion phase: manual therapy?
Moderate evidence. Manual procedures include lymphatic drainage, active/passive soft tissue and joint mobilizations, AP talar mobs.
What are the recommendations for interventions-orthoses in CTS?
Moderate evidence. Neutral-position wrist orthosis worn at night for short term relief. Weak evidence. Adjust wear time to include daytime, symptomatic, or full-time use when night only use is ineffective in mild to moderate CTS. May also add MCPJ immobilization/modify wrist position. Pt education on pathology, risk, symptom management, and postures/activities that aggravate. Weak evidence. Should recommend orthosis for women experience CTS during pregnancy with postpartum follow to insure resolution of symptoms
What is the recommendation for modalities for hip pain/mobility deficits?
Moderate evidence. Ultrasound (1MHz; 1 W/cm2 for 5 minutes each to ant/lat/post hip for a total of 10 treatments over a 2 week period) in addition to exercise and hot packs for short term pain management and activity limitations.
22. A study reports that the diagnostic accuracy of a cluster of tests for shoulder impingement has a positive likelihood ratio of 7.4. This alters the pre-test probability to which of the following? a. Large and often conclusive shift in probability b. Moderate shift in probability c. Small but sometimes important shift in probability d. Small and rarely important degree
Moderate shift in probability
What are other physical impairment measures recommend for Mensical and Articular Cartilage lesions?
Modified stroke test for effusion, AROM, max voluntary isometric or isokinetic quadriceps strength testing, and palpation of joint line tenderness.
Benign Paroxysmal Positional Vertigo
Most common cause of vertigo, pnt with c/o sudden sensation of spinning, typically when moving their head. Calcium breaks free and flots in the semicanals. This send aberrant positional information to the brain
Function: FEMORAL NERVE L2/3/4
Motor - quads, pectineus, Sartorius, Sensory - anterior medial thigh
Function: LATERAL PLANTAR NERVE S1/2
Motor and sensory for lateral side of the foot and 4th/5th toes, deep muscles
Function: SCIATIC NERVE L4/5/S1/2/3
Motor and sensory to posterior thigh
Function: MEDIAL PLANTAR NERVE L4/5
Motor for short toe flexors, Sensory for medial half of the plantar foot
Function: DORSAL SCAPULAR NERVE C5
Motor to Levator scapula and rhomboids
Function: AXILLARY NERVE C5/6
Motor: Deltoid, teres minor and lateral head of triceps, Sensory: upper lateral arm via superior lateral cutaneous nerve
Function: ULNAR NERVE C8/T1
Motor: FCU, FDP, hypothenar muscles, 3rd and 4th lumbricals, interossei, Adductor Pollicis, FPB and palmaris brevis, Sensory: sensation to half of 4th and 5th fingers
Function: MEDIAN NERVE (C5/6, C8-T1)
Motor: all flexors except FCU and lateral half of FDP (4th and 5th), 1st and 2nd lumbricals, and thenar eminence, Sensory: volar forearm, and palmar surface thumb, 2nd, 3rd, half of 4th digits
Function: TIBIAL NERVE L4/5/S1/2/3
Motor: plantarflexors and invertors and long flexors of toes
Function: SUPRASCAPULAR NERVE C5/6
Motor: supraspinatus, infraspinatus, Sensory: AC joint, GH joint
Contraindications to OMT interventions
Multi-level nerve root pathology, worsening neurological function, unremitting night pain - prevents patient from falling asleep, relevant recent trauma, upper motor neuron lesions, spinal cord damage
Interventions for fibromyalgia
Multiple strategies, EDUCATION, medications (not NSAIDs), Exercise (aquatic, low impact aerobic, low load and low rep strength training, do not exceed pain limits
What are the characteristics of fibromyalgia?
Muscle Endurance Disorder, diffuse musculoskeletal aches and pain, stiffness, general fatigue, disturbed sleep, at least 11 of the 18 known tenderoints, absence of labs and XRs indicating other rheumatologic disorders. May present with excessive fatigue, chronic tension/migraine headaches, bowel or bladder irritability, raynaud's, chest pains, anxiety, depression, and swelling and numbness in extremities.
9. Fibromyalgia is most appropriately defined as a a. Muscle endurance disorder b. Myofascial pain disorder c. Sleep disorder d. Psychosomatic disorder
Muscle endurance disorder
What are the recommendations for examination and physical impairment measures in the neck pain CPG?
NECK PAIN WITH MOBILITY DEFICITS; Cervical AROM, Cervical flexion-rotation test, cervical and thoracic segmental mobility tests. NECK PAIN WITH HEADACHE; Cervical AROM, cervical flexion-rotation test, upper cervical segmental mobility testing. NECK PAIN WITH RADIATING PAIN; neurodynamic testing, Spurling's test, distraction test, and the Valsalva test. NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENTS; cranial cervical flexion and neck flexor muscle endurance tests. Generally clinicians should include algometric assessment of pressure pain threshold for classifying pain.
What are the current reccommendations for imaging and neck pain? Think about each subgroup.
NECK PAIN WITH MOBILITY DEFICITS; in absence of red flags, no imaging is indicated, NECK PAIN WITH RADIATING PAIN; patients with normal radiographs and have neurologic signs should undergo cervical MRI including cranial cervical junction and upper thoracic region (CT myelography w/ multiplanar reconstruction if MRI contraindicated). MRI indicated for patients with nonresolving radiculopathy/myelopathy. Traumatic myelopathy CT for bony injury or MRI for problem solving/operative planning. NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENT; Conflicting evidence. Imaging often fails to identify pathology related to symptoms. MRI does identy changes in muscle morphology (fatty infiltrate) however more research is needed to identy influence on recovery. Generally in absence of neurological signs, patients with normal radiographs or evidence of sponylosis do not need imaging.
How do you differentiate a sensory nerve injury?
NERVE ROOT: transient, proximal to distal symptoms. PERIPHERAL: distal to proximal, except in carpal tunnel syndrome (goes both ways)
Spinal Stenosis
Narrowing of the lumbar spinal canal, nerve root canals, and/or intervertebral formamina that may encorach on the nerve roots of the lumbar spine. Exam - decreased Side Bending, extension Range of Motion, decrease gait tolerance, decreased sensation, Muscle Strength in at least 1 LE, decreased hip Range of Motion, weak hips. Treatment - thrust, non-thrust to spine and LEs, manual stretching, strengthening, flexion exercises, supported walking
12. Which palpable structure would be the main point of reference for this test? a. 1st Cuneiform b. Cuboid tuberosity c. Head of talus d. Navicular tuberosity e. Sustentaculum tali
Navicular tuberosity
What are the recommendations for outcome measures in the neck pain CPG?
Neck Disability Index; MCID: Mechanical Neck Pain (7.5 Young et al, 19% Cleland et al), Cervical Radic (8.5 Young el al, 7.0 Cleland et al), Non-Specific Neck Pain (3.5 Pool et al, Jorristsma et al), Cervical Spine Fusion (7.5 Carreon et al). OTHER; PSFS, SF-36, VAS.
Path: BRACHIAL PLEXUS C5/6/7/8/T1
Nerve roots converge and run through scalene triangle, thoracic outlet (between 1st rib and clavicle), posterior to pec minor
18. CASE STUDY: A 30 year old left-hand dominant female sustained a compression injury to her left arm approximately 2cm proximal to the medial epicondyle. The injury occurred three weeks prior and is beginning to show signs of improvement. Physical examination revealed decreased pinch and grip strength, compromised thumb stability with manual resistance, and flexion contractures or "clawing" of the 4th and 5th fingers. What is the most likely classification of her nerve injury? a. Axonotmesis b. Neurapraxia c. Neurotmesis d. Wallerian Degeneration
Neurapraxia
What are risk factors present in individuals with neck pain?
New Onset Neck Pain; Female, older age, prior history of neck or lower back pain, high job demands, low social/work support, smoking history. Chronic Neck Pain; Age > 40, history of neck pain, cyclist,, loss of hand strength, worrisome attitude, poor quality of life/less vitality.
10. CASE STUDY: A 48 year old homemaker presents to your clinic with a four month history of bilateral neck and shoulder pain of insidious onset. She complains of poor sleep, lack of endurance, and an onset of symptoms with using her upper extremities for greater than 15 minutes. Her pain is severely impacting her quality of life. Upon physical examination, you discover tenderness to palpation at the bilateral Suboccipital muscles, bilateral upper Trapezius, the medial portion of the supraspinatus muscles bilaterally, and the intertransverse spaces of C6-7 bilaterally. You also discover tenderness along her right elbow at the lateral epicondyle and at her bilateral paraspinals of L4/5. When palpating, you are careful to use only enough pressure to cause the nailbed of your finger to blanche. You have performed special tests that have ruled out all other cervical and shoulder pathology. Based solely on the above information, would you diagnosis this patient with Fibromyalgia? a. Yes b. No
No
Nerve Entrapment Sites: MEDIAL PLANTAR NERVE L4/5
Occurs at the flexor digitorum and hallucis longus tendons at the medial foot
Nerve Entrapment Sites: LATERAL PLANTAR NERVE S1/2
Occurs between the abductor hallucis muscle and quadratus plantae muscle
Acute or Subacute low back pain with related cognitive of affective tendencies: Impairments of Body Function
One or more of the following: 1. two positive responses to primary care evaluation of mental disorders screen and affect consistent with an individual who is depressed. 2. high scores on the fear-avoidance beliefs questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear. 3. High scores on the pain catastrophizing scale and cognitive process consistent with rumination, pessimism, or helplessness.
Chronic low back pain with related generalized pain: Impairments of Body Function
One or more of the following: 1. two positive responses to primary care evaluation of mental disorders screen and affect consistent with an individual who is depressed. 2. high scores on the fear-avoidance beliefs questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear. 3. High scores on the pain catastrophizing scale and cognitive process consistent with rumination, pessimism, or helplessness.
19. Why would tight hamstrings predispose a person to develop patellofemoral pain? A. Reciprocal inhibition: Tightness of the hamstrings would cause the gluteus maximus to do more work to support the posterior chain. This would in-turn cause reciprocal inhibition of the hip flexors, to include the rectus femoris. Rectus femoris inhibition will cause a decrease in patellofemoral joint control and the aberrant patella tracking will lead to pain. B. Instability: Hamstring tightness will prevent the hamstrings from providing maximum force production, thus requiring more work from the quadriceps. This additional work will place an overload thru the quadriceps and/or patella tendon which can lead to an overuse injury. C. Slacking: Tightness of the hamstrings will cause a posterior glide at the tibia on the femur, which will result in decreased tension across the patellofemoral joint. This will lead to aberrant motions and pain. D. Open Kinetic Chain at 0-40 degrees. The quadriceps should be electrically silent during swing phase with the hamstrings eccentrically contracting to decelerate the tibia. Tight hamstrings cause the quadriceps to initiate action early, extending the knee during end-range thus promoting breakdown of the joint surfaces.
Open Kinetic Chain at 0-40 degrees. The quadriceps should be electrically silent during swing phase with the hamstrings eccentrically contracting to decelerate the tibia. Tight hamstrings cause the quadriceps to initiate action early, extending the knee during end-range thus promoting breakdown of the joint surfaces
28. "Pain" is an example of which of the following levels of measurement? a. Interval b. Nominal c. Ordinal d. Ratio
Ordinal
6. A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings Based on your findings, what is the likely diagnosis? a. Chondromalacia b. Osgood Schlater's Disease c. Patella Femoral Syndrome d. Seaver's Disease
Osgood Schlatter's Disease
What are the risk factors for development of nonarthritic hip pain?
Osseous abnormalities, local or global ligamentous laxity, connective tissue disorders, nature of activity and participation.
10. A 51 year old male presents with right hip pain for the past 6 months. AROM right hip IR 10 deg and flexion 103 deg. He complains of stiffness in the right hip upon awakening each morning and this pain persists for approximately 30-40 minutes. Based on this data alone you have a high suspicion of which diagnosis? a. Avascular necrosis b. Labral tear c. Osteoarthritis d. Slipped Capital Femoral Epiphysis
Osteoarthritis
14. A 42 year old male presents to your clinic with >1 year history of left knee pain. He complains of knee pain and crepitus with AROM and has morning stiffness that lasts for more than 30 minutes each day. He also complains of pain and paresthesias at the left hip. PROM left knee flexion is 113 degrees with pain at endrange. Based on the above data what is the most likely diagnsosis for this patient a. Medial plica syndrome b. OA at the hip c. OA at the knee d. Recurrent patella instability
Osteoarthritis
11. A 51 year old patient presents to your clinic complaining of left anterior hip/thigh pain. He has a negative FABER and hip AROM is normal. Based on this data, you feel confident in ruling out which of the following? a. Femoral neck stress fracture b. Iliopsoas bursitis c. Osteoarthritis at the hip d. Slipped Capital Femoral Epiphysis
Osteoarthritis at the hip
8. A 45 year old male has had a 2 week history of insidious knee pain. Physical exam reveals nothing significant other then a hot swollen joint that is painful with movement. The patient does have a past medical history of a R tibial bone infection from a trauma several years ago. Based on this information, what condition must you be prepared to rule out? a. Lymes' Disease b. Osteomalacia c. Osteomyelitis d. Reiter's Syndrome
Osteomyelitis
What self-report questionnaires should clinicians use? What are the respective minimally important change values?
Oswestry Disability Index (MDC = 10 points or 30%), Roland-Morris Disability Questionnaire (MDC = 5 points or 30%)
Clinical Findings of Entrapped: MEDIAL PLANTAR NERVE L4/5
Overpronation and calcaneal eversion, Arch supports can also cause compression
List some validated knee injury prevention programs.
PEP, Sportsmetrics, Knakontroll, HarmoKnee, Olsen et al and Peterson et al.
What is the definition of pelvic girdle pain (PGP) based on European guidelines?
PGP arises in relation to pregnancy, trauma, arthritis and OA. Pain is experinced bewteeen posterior iliac crest and gluteal folds, particularly in vicinity of SIJ. Pain may radiate to the posterior thigh and can occur in conjuction w/ or separately in the symphysis.
Clinical Findings of Entrapped: RADIAL NERVE (C5/6/7/8/T1)
PIN Syndrome: Finger/Wrist drop and radial deviation on wrist extension with compression at the Radial Tunnel/Arcade of Frohse (a fibrous band between the two heads of the supinator muscle). Can mimic Tennis elbow, Wartenberg's Syndrome: compression of radial superficial nerve at brachioradialis. Common with deQuervain's
1. What are the most common locations associated with Rheumatoid Arthritis? a. DIP's, hips, knees, feet b. DIP's, wrists, hips, feet c. PIP's, wrists, knees, feet d. Shoulders, PIP's, hips, knees
PIP's, wrists, knees, feet
Common attachments of muscles on the: ULNA - SHAFT
PROXIMAL: Abductor pollicis longus (posterior surface), extensor pollicis longus (posterior surface), extensor indicis (posterior surface), Flexor carpi ulnaris (posterior border), Extensor Carpi Ulnaris (posterior border), Flexor digitorum profundus (medial surface), flexor digitorum profundus (anterior surface); pronator quadratus (anterior surface); DISTAL: anconeus (posterior surface)
Common attachments of muscles on the: CARPALS - CAPITATE
PROXIMAL: Adductor pollicis
Common attachments of muscles on the: SCAPULA - SUPRAGLENOID TUBERCLE
PROXIMAL: Biceps brachii (long head)
Common attachments of muscles on the: SCAPULA - CORACOID PROCESS
PROXIMAL: Biceps brachii (short head), coracobrachialis, DISTAL: Pectoralis minor
Common attachments of muscles on the: HUMERUS - SHAFT
PROXIMAL: Brachialis (anterior surface), Triceps Brachii (lateral and medial head); DISTAL: Coracobrachialis
Common attachments of muscles on the: HUMERUS - LATERAL SUPRACONDYLAR RIDGE
PROXIMAL: Brachioradialis, extensor carpi radialis longus
Common attachments of muscles on the: FIBULA - HEAD
PROXIMAL: Fibularis longus, soleus, DISTAL: biceps femoris
Common attachments of muscles on the: CARPALS - HAMATE
PROXIMAL: Flexor digiti minimi brevis, opponens digiti minimi; DISTAL: flexor carpi ulnaris
Common attachments of muscles on the: INTERMUSCULAR SEPTA
PROXIMAL: Flexor digitorum brevis, abductor digiti minimi.
Common attachments of muscles on the: INTEROSSEOUS MEMBRANE
PROXIMAL: Flexor digitorum profundus, flexor pollicis longus, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis
Common attachments of muscles on the: ULNAR COLLATERAL LIGAMENT
PROXIMAL: Flexor digitorum superficialis
Common attachments of muscles on the: FEMUR - POPLITEAL SURFACE
PROXIMAL: Gastrocnemius (medial head)
Common attachments of muscles on the: COCCYX
PROXIMAL: Gluteus maximus
Common attachments of muscles on the: SACROTUBEROUS LIGAMENT
PROXIMAL: Gluteus maximus, piriformis.
Common attachments of muscles on the: ILIUM - EXTERNAL SURFACE
PROXIMAL: Gluteus maximus/medius/minimis
Common attachments of muscles on the: FOOT - FIRST METATARSAL?
PROXIMAL: Interossei (dorsal only), DISTAL: tibialis anterior, fibularis longus
Common attachments of muscles on the: RIBS
PROXIMAL: Latissimus dorsi, pectoralis major/minor, subclavius, serratus anterior
Common attachments of muscles on the: OBTURATOR MEMBRANE
PROXIMAL: Obturator internus, obturator externus
Common attachments of muscles on the: STERNUM
PROXIMAL: Pectoralis Major
Common attachments of muscles on the: SCAPULA - INFRAGLENOID TUBERCLE
PROXIMAL: Triceps Brachii (long head)
Common attachments of muscles on the: FEMUR - BODY
PROXIMAL: Vastus intermedius
Common attachments of muscles on the: FEMUR - GREATER TROCHANTER
PROXIMAL: Vastus lateralis, DISTAL: gluteus medius, gluteus minimus, piriformis, obturator internus, gemelli superior and inferior
Common attachments of muscles on the: CARPALS - PISIFORM
PROXIMAL: abductor digiti minimi; DISTAL: flexor carpi ulnaris
Common attachments of muscles on the: FLEXOR RETINACULUM (FOOT)
PROXIMAL: abductor hallucis
Common attachments of muscles on the: PLANTAR APONEUROSIS
PROXIMAL: abductor hallucis, flexor digitorum brevis, abductor digiti minimi
Common attachments of muscles on the: CARPALS - SCAPHOID
PROXIMAL: abductor pollicis brevis, flexor pollicis brevis, opponens pollicis
Common attachments of muscles on the: CARPALS - TRAPEZIUM
PROXIMAL: abductor pollicis brevis, flexor pollicis brevis, opponens pollicis
Common attachments of muscles on the: PUBIS - INFERIOR RAMUS
PROXIMAL: adductor brevis, adductor magnus (adductor part), gracilis
Common attachments of muscles on the: FOOT - SECOND METATARSAL?
PROXIMAL: adductor hallucis (oblique head), interossei (dorsal only), DISTAL: tibialis posterior
Common attachments of muscles on the: FOOT - FOURTH METATARSAL?
PROXIMAL: adductor hallucis (oblique head), interossei, DISTAL: tibialis posterior
Common attachments of muscles on the: FOOT - THIRD METATARSAL?
PROXIMAL: adductor hallucis (oblique head), interossei, DISTAL: tibialis posterior
Common attachments of muscles on the: PLANTAR LIGAMENTS OF MTP JOINTS
PROXIMAL: adductor hallucis (transverse head)
Common attachments of muscles on the: PUBIS - BODY
PROXIMAL: adductor longus, adductor brevis, gracilis
Common attachments of muscles on the: ISCHIUM - RAMUS
PROXIMAL: adductor magnus (adductor part)
Common attachments of muscles on the: HAND - THIRD METACARPAL
PROXIMAL: adductor pollicis, interossei, DISTAL: extensor carpi radialis brevis.
Common attachments of muscles on the: HAND - SECOND METACARPAL
PROXIMAL: adductor pollicis, interossei, DISTAL: flexor carpi radialis, extensor carpi radialis longus.
Common attachments of muscles on the: HUMERUS - LATERAL EPICONDYLE
PROXIMAL: anconeus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, supinator.
Common attachments of muscles on the: FEMUR - LATERAL SUPRACONDYLAR LINE
PROXIMAL: biceps femoris (short head), plantaris
Common attachments of muscles on the: FEMUR - LINEA ASPERA
PROXIMAL: biceps femoris (short head), vastus lateralis, vastus medialis; DISTAL: adductor longus, adductor brevis, adductor magnus (adductor part)
Common attachments of muscles on the: CLAVICLE
PROXIMAL: deltoid, pectoralis major; DISTAL: Subclavius, trapezius
Common attachments of muscles on the: SCAPULA - ACROMION
PROXIMAL: deltoid; DISTAL: trapezius
Common attachments of muscles on the: SCAPULA - SPINE
PROXIMAL: deltoid; DISTAL: trapezius
Common attachments of muscles on the: INFERIOR EXTENSOR RETINACULUM
PROXIMAL: extensor digitorum brevis, extensor hallucis brevis
Common attachments of muscles on the: INTEROSSEOUS TALOCALCANEAL LIGAMENT
PROXIMAL: extensor digitorum brevis, extensor hallucis brevis
Common attachments of muscles on the: TARSALS - CALCANEUS
PROXIMAL: extensor digitorum brevis, extensor hallucis brevis, abductor hallucis, flexor digitorum brevis, abductor digiti minimi, quadratus plantae, DISTAL: gastrocnemius, soleus, plantaris, tibialis posterior.
Common attachments of muscles on the: ULNA - OLECRANON
PROXIMAL: flexor carpi ulnaris; DISTAL: triceps Brachii, anconeus
Common attachments of muscles on the: FOOT - FIFTH METATARSAL?
PROXIMAL: flexor digiti minimi brevis, interossei, DISTAL: fibularis tertius, fibularis brevis
Common attachments of muscles on the: TARSALS - CUBOID
PROXIMAL: flexor hallucis brevis, DISTAL: tibialis posterior
Common attachments of muscles on the: TARSALS - LATERAL CUNEIFORM
PROXIMAL: flexor hallucis brevis, DISTAL: tibialis posterior
Common attachments of muscles on the: FEMUR - LATERAL CONDYLE
PROXIMAL: gastrocnemius (lateral head), popliteus
Common attachments of muscles on the: ISCHIUM - ISCHIAL TUBEROSITY
PROXIMAL: gemelli inferior, quadratus femoris, semitendinosus, semimembranosus, biceps femoris (long head), adductor magnus (hamstrings part)
Common attachments of muscles on the: ISCHIUM - ISCHIAL SPINE
PROXIMAL: gemelli superior
Common attachments of muscles on the: SACRUM
PROXIMAL: gluteus maximus, piriformis, iliacus
Common attachments of muscles on the: ANTERIOR SACROILIAC LIGAMENTS
PROXIMAL: iliacus
Common attachments of muscles on the: ILIUM - ILIAC FOSSA
PROXIMAL: iliacus
Common attachments of muscles on the: SCAPULA - INFRASPINOUS FOSSA
PROXIMAL: infraspinatus
Common attachments of muscles on the: HAND - FOURTH METACARPAL
PROXIMAL: interossei
Common attachments of muscles on the: HAND - FIRST METACARPAL
PROXIMAL: interossei (Dorsal Only), DISTAL: abductor pollicis longus, opponens pollicis
Common attachments of muscles on the: HAND - FIFTH METACARPAL
PROXIMAL: interossei, DISTAL: Flexor carpi ulnaris, extensors carpi ulnaris, opponens digiti minimi.
Common attachments of muscles on the: THORACOLUMBAR FASCIA
PROXIMAL: latissimus dorsi
Common attachments of muscles on the: FLEXOR DIGITORUM PROFUNDUS TENDONS
PROXIMAL: lumbricals
Common attachments of muscles on the: TENDONS OF FLEXOR DIGITORUM LONGUS
PROXIMAL: lumbricals, DISTAL: quadratus plantae
Common attachments of muscles on the: FLEXOR RETINACULUM (WRIST)
PROXIMAL: palmaris longus, abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, flexor digiti minimi brevis, opponens digiti minimi
Common attachments of muscles on the: PUBIS - SUPERIOR RAMUS
PROXIMAL: pectineus
Common attachments of muscles on the: APONEUROSIS OF EXTERNAL ABDOMINAL OBLIQUE
PROXIMAL: pectoralis Major
Common attachments of muscles on the: OBLIQUE POPLITEAL LIGAMENT
PROXIMAL: plantaris
Common attachments of muscles on the: LATERAL MENISCUS
PROXIMAL: popliteus
Common attachments of muscles on the: HUMERUS - MEDIAL EPICONDYLE
PROXIMAL: pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis.
Common attachments of muscles on the: ULNA - CORONOID PROCESS
PROXIMAL: pronator teres, flexor digitorum superficialis; DISTAL: brachialis
Common attachments of muscles on the: ILIUM - AIIS
PROXIMAL: rectus femoris
Common attachments of muscles on the: ILIUM - SUPERIOR TO ACETABULUM
PROXIMAL: rectus femoris
Common attachments of muscles on the: ILIUM - NOTCH INFERIOR OF ASIS
PROXIMAL: sartorius
Common attachments of muscles on the: SCAPULA - SUBSCAPULAR FOSSA
PROXIMAL: subscapularis
Common attachments of muscles on the: ANNULAR LIGAMENT
PROXIMAL: supinator
Common attachments of muscles on the: RADIAL COLLATERAL LIGAMENT
PROXIMAL: supinator
Common attachments of muscles on the: SUPINATOR CREST
PROXIMAL: supinator
Common attachments of muscles on the: SUPINATOR FOSSA
PROXIMAL: supinator
Common attachments of muscles on the: SCAPULA - SUPRASPINOUS FOSSA
PROXIMAL: supraspinatus
Common attachments of muscles on the: ILIUM - ASIS
PROXIMAL: tensor fascia lata, sartorius
Common attachments of muscles on the: SCAPULA - LATERAL BORDER
PROXIMAL: teres major, teres minor
Common attachments of muscles on the: TIBIA - LATERAL CONDYLE
PROXIMAL: tibialis anterior, extensor digitorum longus
Common attachments of muscles on the: INTEROSSEOUS MEMBRANE
PROXIMAL: tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis tertius, flexor hallucis longus, tibialis posterior.
Common attachments of muscles on the: OCCIPITAL BONE
PROXIMAL: trapezius
Common attachments of muscles on the: LIGAMENTUM NUCHAE
PROXIMAL: trapezius, rhomboid minor
Common attachments of muscles on the: FEMUR - INTERTROCHANTERIC LINE
PROXIMAL: vastus medialis
Clinical Findings of Entrapped: GREATER AURICULAR NERVE (C2/3)
Pain and paresthesia to SCM, mastoid area and ear, jaw, parotid gland area. Symptom reproduction with cervical quadrants. Restricted SCM, scalenes, trapezii, and levator scapulae
Clinical Findings of Entrapped: TRANSVERSE CERVICAL NERVE (C2/3)
Pain and paresthesia to the anterior lateral neck
Clinical Findings of Entrapped: LATERAL FEMORAL CUTANEOUS L2/3
Pain at ASIS, Paresthesia anterior lateral thigh, Distal crossed syndrome at pelvis
What are the Ottawa Ankle Rules (negative LR 1.4%, specificity low to modest) criteria that indicate the need for radiographs?
Pain in the malleolar zone and any of the following; 1. tenderness along the tip of the posterior edge of the distal 6 cm of the lateral malleolus. 2. tenderness along the medial malleolus. 3. inability to bear weight for 4 steps. Pain the midfoot area and any of the following; 1. tenderness at the base of the 5th metatarsal. 2. tenderness over the navicular. 3. inability to bear weight for 4 steps.
What is the distinguishing movement/pain characteristic for subacute low back pain with mobility deficits?
Pain occurs with mid to end ranges. INTERVENTIONS: movements that increase movement tolerances in the mid to end ranges of motions.
What is the distinguishing movement/pain characteristic for subacute low back pain with movement coordination impairment?
Pain occurs with mid to end ranges. INTERVENTIONS: movements that increase movement tolerances in the mid to end ranges of motions.
What is the distinguishing movement/pain characteristic for subacute low back pain with radiating pain?
Pain occurs with mid to end ranges. INTERVENTIONS: movements that increase movement tolerances in the mid to end ranges of motions.
What are "Odd" Pain Behaviors?
Pain that is boring, deep aching, *** pain that is unrelated to activity ***, Pain that is not rlieved in any position and may be worsened by rest, pain that is worse at night
Clinical Findings of Entrapped: BRACHIAL PLEXUS C5/6/7/8/T1
Paresthesia UE to wrist/hand, = Adson's, + ULTT testing, Symptoms reproduction with hyper abduction, ER, reflexes, TTP at scalenes, pec minor, and 1st rib, Proximal crossed syndrome
Clinical Findings of Entrapped: SUPRACLAVICULAR NERVE (C3/4)
Paresthesia and pain at lateral mid cervical spine, posterior aspect of mid SCM, and anterior/middle/posterior shoulder, Symptom reproduction with cervical quadrants. Restricted SCM, scalenes, trapezii and levator scapulae
Clinical Findings of Entrapped: LATERAL PLANTAR NERVE S1/2
Paresthesia lateral foot, 4th and 5th toe weakness
Path: SUPERIOR CLUNEAL NERVE T10/11/12/L1/L2
Passes through psoas, posterior to quadratus lumborum, Courses distally to iliac crest via fibrous tunnel 7cm lateral to midline
Path: SCIATIC NERVE L4/5/S1/2/3
Passes through sciatic foramen underneath piriformis, ischial tuberosity, distally underneath hamstrings. Divides into common peroneal and tibial nerve at popliteal fossa
What other impairment measures should be examined in individuals with PFP?
Patellar provocation, patellar mobility, foot position, hip and thigh muscle strength, and muslce length.
What is the distinguishing movement/pain characteristic for acute low back pain with mobility deficits?
Patient demonstrates restricted spinal range of motion and segmental mobility, reproduced with provocation of the involved segments. INTERVENTION: reduce pain and improve mobility of the involved spinal segments.
Acute or Subacute low back pain with related cognitive of affective tendencies: Primary Intervention Strategies
Patient education and couseling to address specific classification exhibited by the patient (ie: depression, fear-avoidance, pain catastrophizing)
9. A 28-year-old mechanic presents to your clinic with right ulnar sided wrist pain. He reports he was competing in a martial arts competition 4 weeks ago when an opponent grabbed his wrist and pulled him into a position of radial deviation. Since then he has had ulnar sided wrist pain with using a screwdriver, a wrench, and when hand-tightening a screw or bolt. This has caused him to miss at least 2 days from work a week. The patient he can produce pain and a click by flexing and extending his wrist while it is in a position of ulnar deviation. He demonstrates this for you. Physical examination reveals tenderness along the distal ulna/proximal carpals and a no symptoms with manual compression and shearing of the lunate and triquetrium. Resisted ulnar deviation is strong with pain and the patient demonstrates a (+) Press Test. Which is the proper technique for performing the Press Test? a. Patient places their palms together and maximally presses them together. Ulnar sided wrist pain is a positive sign b. Examiner passively positions the patient into supination and ulnar deviation and then has the patient resist radial deviation. Ulnar sided wrist pain and visible/palpable subluxation is a positive sign c. Patient sits in a chair and grasps the sides of the seat with each hand and pushes themselves up off the chair. Ulnar sided wrist pain is a positive sign d. Patient performs AROM wrist radial & ulnar deviation. A clunk and pain at a point just beyond neutral as the wrist moves into ulna deviation is a positive sign.
Patient sits in a chair and grasps the sides of the seat with each hand and pushes themselves up off the chair. Ulnar sided wrist pain is a positive sign
What is the Clinical Presentation of PFP?
Characterized by insidous onset of anterior retropatellar and/or peripatellar region. Onset can be slow or accute, typically pain worsenswith loading such as squatting, prolonged sitting, stairs, jumping, running (hills). Pathoanatomical tissues poorly associated with symptoms and thus diagnosis is made with a cluster of signs and symptoms as well as ruling out other pathoanatomical diagnoses.
What are the recommendations for interventions - physical agents for heel pain and plantar fasciitis?
Conflicting evidence for electrotherapy with combination of manual therapy, stretching and foot orthoses. Conflicting evidence for use of iontophoresis with dexamethasone or acetic acid. Weak evidence for low-level laser, phonophoresis with ketoprofen. Weak evidence to NOT use ultrasound.
What are the recommended interventions - orthoses for midportion achilles tendinopathy?
Conflicting evidence for heel lifts and orthoses. Weak evidence to NOT use night splints.
What are the recommendations regarding intervention-support belts in PGP?
Conflicting evidence. May consider however evidence was variable regarding intervention/control groups, duration of application, follow up times.
What are the recommendations regarding intervention-exercise in PGP?
Conflicting evidence. Should consider use of exercise. American College of Obstetrics and Gynecologists and Canadian Practice Guidelines have recommended exercise for health benefits for antepartum population. However evidence were nonspecific in application of exercise to groups of pregnancy LBP and PGP. More research is required.
What is the summary of the clinical course with and without surgical intervention for CTS?
Conflicting evidence. Some individuals managed nonsurgically have positive outcomes (even curative). In contrast evidence for failure and progression to surgery is reported 23-84%. CIinicians should assess symptom duration, positive Phalen test, thenar muscle waisting, and prior nonsurgical intervention as these factors may influence outcomes.
When should a clinician consider translational manipulation?
Consider manipulation under anesthesia when patients are not responding to conservative treatment.
Nerve Distribution - Motor: MEDIAL PECTORAL NERVE - C8/T1
Pectoralis major, pectoralis minor
3. A 75 year old female presents to your clinic with a 3 week history of left knee pain of an insidious onset. She reports her pain is increased with activity and decreased with rest, primarily seated in a recliner or lying in bed. Her pain is steadily getting worse without sign of improvement. Radiographs of her left knee, taken at her physician's office, are without sign of pathology. Prior medical history is significant for osteoporosis and diabetes. She also reports she is a cancer survivor. She reports she increased her daily walking regimen one month ago from 20 minutes a day to 60 minutes a day at the request of her cardiologist. She is taking medication for hypertension, diabetes, osteoporosis, and depression. She states her husband died 5 months ago and she has been severely depressed, however, her medications are improving her mood. She also moved into an assisted-living facility last week at the request of her daughters because she was too depressed to cook and clean for one and is eating more consistently as a result. Your physical examination of the left knee reveals no deficits in range of motion or strength. Special tests for ligamentous and meniscal pathology are also negative. Gait assessment reveals an antalgic gait on the left. Her ability to balance in left single leg stance is also significantly diminished due to pain. Based on this information, what would the most appropriate next course of action? a. Perform an evaluation of her left foot and ankle b. Perform an evaluation of her left hip c. Perform an evaluation of her lumbar spine d. Refer her back to her physician for an MRI of her knee
Perform an evaluation. The hip is a major source of pain referral to the knee. Often, in cases of avascular necrosis, a complaint of same-sided knee pain is the first sign of pathology at the hip. Also, her primary complaint of symptoms is with weightbearing - typical in the referral of pain from the hip to the knee.
What is the Silbernagel Protocol for Achilles Tendinopathy?
Phase 1: weeks 1-2, pain and difficulty with all exercise, <10 SL heel raises, starting to exercise, understand injury, and monitor pain with exercise, perform exercises every day. Phase 2: weeks 2-5, pian with exercise, morning stiffness, pain when performing toe raises, begin strengthening, perform exercises every day; Phase 3: Weeks 3-12, no pain distally in tendon, continued morning stiffness, heavier strength training increase or start running/jumping, perform exercises every day and with heavier loads 2-3x/week; Phase 4: Weeks 12-24, minimal symptoms, morning stiffness occasionally, can participate in sports without difficulty, maintanence exericse, no symptoms, exercise 2-3/week
Nerve Entrapment Sites: SCIATIC NERVE L4/5/S1/2/3
Piriformis, Ischial tuberosity at biceps femoris origin
What is the summary regarding the prevalence of heel pain and plantar fasciitis?
Plantar fasciitis is the most common foot condition treated by healthcare providers. Can be present in nonathletic and athletic populations.
What are the ranges of likelihood ratio?
Positive - > 10 = large, 5-10 = moderate, 2-5 = small. Negative - <0.1 = large, 0.1-0.2 = moderate, 0.2-0.5 = small
31. Which two items from the patient's history have the best +LR and -LR for accurately assessing patients with cancer causing LBP? a. Age >=50 & unexplained weight loss b. Failure to improve with 1 month of conservative care and insidious onset c. Pain duration >1 month and lack of radicular symptoms d. Prior medical history of cancer and no relief with bedrest
Prior medical history of cancer and no relief with bedrest
What are the pro's/con's of the SF 36?
Pro: more comprehensive in capturing pain, back-specific function, work disability, generic health status, and patient satisfaction. Con: lacking region specificity and sensitivity to change in specific patient populations.
P-Value
Probability that differences between groups did not occur by chance. Significanlty affected by data set. Can change the impact by reusing the same data set to increase the sample size.
Chronic LBP with Movement Coordination Impairments Suggested Matched Interventions
Specific Trunk Activation and Movement Control Training, Trunk Muscle Strengthening and Endurance Exercises, Thrust or Non-Thrust Joint Mobilization, Soft Tissue Mobilization, and Massage, Active Education to Pursue an Active Lifestyle
27. Which of the following types of bias can lead to an over-estimation of the sensitivity and specificity of a test? a. Incorporation bias b. Review bias c. Spectrum bias d. Work-up bias
Spectrum bias
What are the recommendations for intervention - progressive loading/sensorimotor training phase: manual therapy?
Strong evidence. Graded joint mobilizations, manipulations, and non-WB/WB mobilizations with movement to improve ankle dorsiflexion, proprioception, and WB tolerance recovering from lateral ankle sprain.
What are the recommendations for intervention - acute/protected motion phase: therapeutic exercises?
Strong evidence. Implement rehab programs including therex with severe lateral ankle sprains.
What are the recommendations for interventions - manual therapy for heel pain and plantar fasciitis?
Strong evidence. Joint and soft tissue mobilization to treat relevant LE mobility and calf flexibility deficits.
What are the recommended interventions - exercise for midportion achilles tendinopathy?
Strong evidence. Mechanical loading in form of eccentric or heavy-load slow speed (concentric/eccentric) exercise program. Expert opinion. Patients should exercise 2x per week within pain tolerance.
What are the recommendations for interventions - night splints for heel pain and plantar fasciitis?
Strong evidence. Should prescribe 1-3 month program of night splints for individuals who consistently have pain with first step in morning.
What are the recommendations for interventions - taping for heel pain and plantar fasciitis?
Strong evidence. Should use antipronation taping for immediate (up to 3 weeks) pain reduction. Also may use elastic tape applied to gastrocnemius and plantar fascia for short term (1 week) pain reduction.
What are the recommendations for interventions - foot orthoses for heel pain and plantar fasciitis?
Strong evidence. Should use foot orthoses, prefab or custom, to support medial longitudinal arch and cushion heel to reduce pain and increase function for short (2 weeks) to long term (1 year), especially in those who respond positively to antipronation taping techniques.
What are the recommendations for interventions - stretching for heel pain and plantar fasciitis?
Strong evidence. Should use plantar fascia specific and gastroc/soleus stretching to provide shoft term (1 week-4 months) pain relief. Heel pads may be used to increase benefits of stretching.
What is the recommendation for flexibility, strengthening and endurance exercises for hip pain/mobility deficits?
Strong evidence. Should use tailored flexbility, strength, and endurance exercises based on specific ROM, muscle strength and flexbility deficits. Dosage and duration range from 1-5 x per week, 6-12 weeks for mild to moderate hip OA.
What are the recommendations for intervention - acute/protected motion phase: early WB with support?
Strong evidence. Use of external supports to progressively bear weight. Type of support/assisted device based on severity of injury, phase of tissue healing, level of protection needed, extent of pain, and patient preference.
What is the recommendation for manual therapy and hip pain/mobility deficits?
Strong evidence. use with mild to moderate hip OP. Use thrust and non thrust mobilizations, as well as soft tissue release. 1-3 times a week, for 6-12 weeks. Increase exercises when hip motion improves. *Soft tissue areas of restriction, like iliacus, hip ERs, posterior g.medius, quadratus femoris and g.max.
What are the recommendations regarding clinical course in PGP?
Strong to moderate evidence. Consider treating patients with early onset, multiple pain locations, a high number of positive pelvic pain provocation tests (PPPTs), work dissatisfaction, and a lack of belief of improvement.
What is the summary regarding Occupational Risk Factors for CTS?
Strongest association is forceful hand exertions. Weaker associations; high psychologic demand at work paired with low decision authority, vibration, prolonged off neutral wrist positioning and repetitive work. Computer users do NOT have increased risk of CTS when compared to gen pop or industrial workers however odds slightly increased when long duration is compared to short duration computer use.
What is the summary regarding Intrinsic Risk Factors for CTS?
Strongest link to CTS include obesity (BMI > 30), age (>50), and female sex. Other intrinsic factors include Diabetes Mellitus, Osteoarthritis, previous musculoskeletal disorders, estrogen replacement therapy, cardiovascular disease, hypothyroidism, family history of CTS, lack of physical activity, wrist ration > .70, wrist-palm ratio >.39, a short/wide hand and short stature. Conflicting evidence for RA, smoking, alcohol abuse, oral contraceptive use, menopause, parity, hysterectomy, and oophorectomy.
Clinical Findings of Entrapped: AXILLARY NERVE C5/6
Weakness in elbow extension, Paresthesia to axilla and lateral deltoid area, Teres Minor weakness, Deltoid weakness
Clinical Findings of Entrapped: SUPRASCAPULAR NERVE C5/6
Weakness of RTC, Pain at posterior shoulder/scapula, AC, GH joint, Protracted scapula, Proximal Crossed Syndrome
Nerve Distribution - Motor: LATERAL PLANTAR - TIBIAL NERVE DERIVATIVE
abductor digiti minimi, quadratus plantae, lumbricals - lateral 3, adductor hallucis, flexor digiti minimi brevis, interossei
Nerve Distribution - Motor: MEDIAL PLANTAR - TIBIAL NERVE DERIVATIVE
abductor hallucis, flexor digitorum brevis, lumbrical - medial 1, flexor hallucis brevis.
16. Which of the following muscles are both innervated by the median nerve? a. Abductor Pollicus Brevis & 1st Lumbrical b. Adductor Pollicus & 2nd lumbricals c. Flexor Pollicus Brevis & 1st dorsal interossei d. Opponens Pollicus & 2nd dorsal interossei
abductor pollicis brevis & 1st Lumbrical
What are the wrist RADIAL DEVIATORS?
abductor pollicis longus, flexor carpi radialis, extensor carpi radialis longus/brevis, extensor pollicis brevis/longus
What education points should a clinician cover with a patient with hip pain?
activity modification, exercise, supporting weight reduction when overweight, and methods of UNLOADING arthritic joints.
2. A 21 year old male runner complains of a three month history of anterior-lateral shin pain after reaching a certain threshold of activity. Having being treated with rest, stretching, NSAIDS, and extrinsic strengthening for suspected shin splints, the patient fails to demonstrate improvement. As the patient returns to his running endeavors, the pain readily returns, and this time is associated with decreased sensation in area of the first web space. The dorsalis pedis and anterior tibial pulses are present. What may be the likely etiology for this patient? a. acute exercise induced compartment syndrome b. knee plical syndrome c. lumbar nerve root compression d. stress fracture
acute exercise induced compartment syndrome
What functional activities will the patient have difficulty with?
pain during sleeping, pain and difficulty with grooming and dressing activities. Pain and difficulty with reaching activities: to the shoulder level, behind the back, and overhead.
What 3 factors have been consistently found to determine recovery in patients with low back pain?
pain intensity, coping styles, and work parameters, like overall satisfaction with work (higher satisfaction = better outcome.
What is the distinguishing movement/pain characteristic for acute low back pain with related (referred) lower extremity pain?
pain is HIGHLY irritable. INTERVENTIONS: centralizing/abolishing the patient's symptoms.
What is the distinguishing movement/pain characteristic for acute low back pain with movement coordination impairments?
pain occurs with initial to mid ranges of active/passive motions. INTERVENTIONS: movements that limit pain or increase the pain-free movement in the mid ranges.
What is the distinguishing movement/pain characteristic for acute low back pain with radiating pain?
pain occurs with initial to mid ranges of active/passive motions. INTERVENTIONS: movements that limit pain or increase the pain-free movement in the mid ranges.
What is the distinguishing movement/pain characteristic for chronic low back pain with movement coordination impairments?
pain occurs with sustained end-range movements or positions. INTERVENTIONS: movements that increase movement tolerances in the end ranges of motion.
Nerve Distribution - Motor: FEMORAL NERVE - L2/3/4
pectineus, sartorius, iliacus, rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
Nerve Distribution - Motor: LATERAL PECTORAL NERVE - C5/6/7
pectoralis major
What are the shoulder FLEXORS?
pectoralis major (clavicular head), deltoid (anterior), coracobrachialis, biceps brachii
What are the shoulder ADDUCTORS?
pectoralis major, latissimus dorsi, teres major, coracobrachialis, triceps brachii (long head)
Nerve Distribution - Motor: VENTRAL RAMI OF S1/S2
piriformis
1. What is the only proximal carpal that has a tendon attachment? a. Lunate b. Pisiform c. Scaphoid d. Triquetrial
pisiform
Pregnancy and Low Back Pain Risk Factors and Treatment
previous Low Back Pain hx, prior pregnancy related Low Back Pain, trauma to pelvis, strenuous work; treatment - Soft Tissue Release and manipulation, exercise, and education
What are the forearm PRONATION?
pronator quadratus, pronator teres
Nerve Distribution - Motor: CRANIAL NERVE XI - SPINAL ACCESSORY
trapezius
What are the elbow EXTENSORS?
triceps brachii, anconeus
Herner's Syndrome
unilateral constricted pupil, ptosis, loss of facial sweating, hx of smoking without trauma or neurological disease
What are the scapular ELEVATORS?
upper trapezius, levator scapulae
What is the recommendation for lower quarter nerve mobilization procedures in the LBP CPG?
utilize lower-quarter nerve mobilzation procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain.
What functional interventions should clinicians utilize for hip pain?
weak evidence to support gait training with proper assistive devices. Should base all other interventions on the patient's values, daily life participation, and functional activity needs.
Acute LBP with Radiating Pain
• Acute LBP with associated radiating (narrow band of lancinating) pain in the involved lower extremity • Lower extremity paresthesias, numbness, and weakness may be reported Rule-in if: • Symptoms are reproduced or aggravated with mid-range and worsen with end-range spinal mobility, lower limb tension/ straight leg raising, and/or slump tests • Signs of nerve root involvement (sensory, strength, or reflex deficits) may be present Rule-out if: • Lower limb tension tests (eg, straight leg raising) or slump testing do not reproduce reported low back or leg pain It is common for the symptoms and impairments of body function in patients who have Acute LBP with Radiating Pain to also be present in patients who have Acute LBP with Related (Referred) Lower Extremity Pain
Acute LBP with Movement Coordination Impairments
• Acute exacerbation of recurring LBP that is commonly associated with referred lower extremity pain • Symptoms often include numerous episodes of low back and/or low back-related lower extremity pain in recent years Rule-in if: • Symptoms reproduced with (1) mid-range motions that worsen with end-range movements or positions, and (2) provocation of the involved lumbar segment(s) • Observable movement coordination impairments of the lumbopelvic region with flexion and extension movements or while performing daily physical activities • Diminished trunk or pelvic region muscle strength and endurance • Mobility deficits of the thorax and hips regions may be present • Signs of lumbar segmental or sacroiliac hypermobility may be present Rule-out if: • Presence of adequate left and right passive straight leg raise (80o) and thorax rotation (80o) mobility • Presence of normal trunk flexor (eg, double-leg lowering test), trunk extensors (Sorensen test), lateral abdominals and hip abductors (eg, side plank/side bridge tests) and hip and thigh muscle performance (star excursion balance tests)
What outcome measures are supported for the examination of PFP?
1. Anterior Knee Pain Scale (AKPS). 2. Knee injury and Osteoarthritis Outcome Score (KOOS-patellofemoral subscale. 3. VAS.
What is the 2018 summary for Diagnosis Meniscal Lesions?
Knee pain, history of twisting knee MOI, history of "catching" or "locking", delayed onset of effusion, & Meniscal Composite Score > 3 points.
13. You are treating a patient with an anterior cruciate ligament reconstruction (hamstring graft), with a meniscus repair. When would ROM beyond 90 degrees flexion be allowed? a. Immediately b. 2 weeks post-op c. 6 weeks post-op d. 10 weeks post-op
10 weeks post op
What is the summary regarding Diagnosis of PFP?
(A) Reproduction of retropatellar or peripatellar pain during squatting as well as other activities that load the PFJ in a flexed position such as stair climbing/descent. (B) criteria 1. presence of retropatellar or peripatella pain, 2. reproduction of retropatellar peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities that load the PFJ in flexed position, 3. exclusionof all other conditions that may cause anterior knee pain. (C) patellar tilt test with pressence of hypopmobility.
What are the Components of knee injury prevention program?
(A) incorporate multiple compenents, proximal control exercises, and a combination of strength and plyometric exercises. (A) Programs should be implemented in all young althetes (12-25) regardless of being screened for high risk for ACL.
What are the recommendations for dosage and delivery of knee injury prevention programs.
(A)Programs should involve training multiple times per week, training sessions last > 20 minutes, and volumes are > 30 minutes per week. (A) Programs should start in the preseason and continue through regular season. Clinicians/coaches/parents need to ensure compliance especially in females.
Low Back Pain Decision Tree
* Understand the Patient's LBP Experience ( assess for pain related psychological distress, collect baseline outcome assessment information, form initial impression of subgroup classification, perform examination) * Intervention Selection and Implementation (consider the patient perspective, patient and PT collaborate to determine treatment plan, incorporate Practice Guideline Intervention recommendation * Reassess and Respond to Emerging data ( pain related psychological distress, patient outcomes, patient and clinician collaborate to modify treatment plan, initial impressions, classifications, and exam data)
Low Back Pain Symptom Modulation Category - Treatment Based Classifcation
* recent pain, significant symptoms, avoids certain postures, ACTIVE RANGE OF MOTION limited/painful, (+) hypersensitivity. Treatment - manua therapy + exercise, traction, directional preferences, modalities, education, meds.
According to Flynn et al what five variables were determined to be predictors of rapid treatment success from general lumbopelvic thrust manipulation with 50% reduction in ODI scores in 2 visits?
***1. Duration of symptoms of less than 16 days, ***2. No symptoms distal to the knee, 3. Lumbar hypomobility, 4. At least 1 hip with greater than 35 degrees of internal rotation, 5. FABQ-W score less than 19.
Risk factors for Cauda equina (include liklihood ratios)
***1. Urine retention (+LR: 18.0 , -LR: 0.11), 2. fecal incontinence, 3. saddle anesthesia, 4. sensory or motor deficits in the feet (L4/5, S1 areas)
Risk factors for compression fracture (include liklihood ratios)
***1. history of major trauma, such as vehicular accident, fall from a height, or direct blow to the spine. (+LR: 12.8 , -LR: 0.37 ) 2. Age of 50. (+LR: 2.2 , -LR: 0.34 ) 3. Age of 75 (+LR: 3.7 , -LR: 0.49 ), 4. Prolonged use of corticosteroids, 5. point tenderness over site of fracture, 6. increased pain with weight bearing.
30. According to Deyo & Diehl's 1988 article, what is the combined specificity for erythrocyte sedimentation rate (lab) and radiographs for identifying cases of occult neoplasms in the lumbar spine? a. 0.85 b. 0.90 c. 0.95 d. 1
1
19. According to the APTA's Orthopedic Section's Clinical Guidelines on the treatment of plantar fasciitis, a patient with what duration of symptoms would be contraindicated for orthotics? A. 6 months B. 12 months C. 18 months D. 24 months
12 months
In a systematic review completed by Henschke et al, what are the 5 factors most helpful in identifying spinal fractures?
1. Age greater than 50 (+LR: 2.2 , -LR: 3.4 ), 2. female gender (+LR: 2.3 , -LR: 0.67), 3. history of major trauma (+LR: 12.8, -LR: 0.37), 4. pain and tenderness (+LR: 6.7 , -LR: 0.44), 5. co-occurring, distracting/painful injury (+LR: 1.7, -LR: 0.78). FOLLOW UP STUDY: to improve diagnositc accuracy, they added older than 70 years old, and prolonged use of corticosteroids.
What are the questions suggested that PTs use to screen for depression?
1. "during the past month, have you often been bothered by feeling down, depressed, or hopeless?" 2. "during the past month, have you often been bothered by little interest or pleasure in doing things. Answering yest to 1 or both of these questions should raise suspcion of depressive symptoms.
Based on a survey completed by orthopedic certified specialists, what patient education strategies were ranked the highest? Give an example of how we do this in clinic.
1. "educate patient in home care treatment"; 2. "recommends strategies to prevent recurrent problems, 3. "functional movement training/re-education, 4. For example, this commonly involves identifying movemetns that are associated with LBP, then providing cueing and education on movement options that enable the activity to be performed with fewer, or no, symptoms.
What interventions are supported in PFP?
1. (A) EXERCISE THERAPY with combined hip and knee targeted exercises. Hip targeted should focus on posterolateral hip musculature. Knee targeted include WB (resisted squats) and NWB (resisted knee extension). Preference given to hip in early sttages of treatment. Combination is preferred over soley knee targeted exercises. 2. (B) PATELLAR TAPING in combination with exercise therapy to assist in immediate pain reduction and enhance short term outcomes (4weeks), not indicated long term or when applied with aim of enhancing muscle performance. 3. (A) FOOT ORTHOSES, prefabricated for foot orthoses for patients with greater than normal pronation in short term (6 weeks). Used in conjuction with exercise therapy. Insufficient evidence to recommend custom over prefab orthoses. 4. (C) RUNNING GAIT RETRAINING consisting of cuing to adopt forefoot-strik pattern (for heel strikers), increase cadence, and to reduce peak hip adduction while running. 5. (F) BFR with HIGH REPETITIVE KNEE EXERCISE. 6. (F) PT ED regarding load management, body weight management, adherence with exercise therapy and biomechanics, evidence for various treatment options, and kinesiophobia.
What interventions are NOT suppoted in PFP?
1. (B) BRACING. 2. (B) BIOFEEDBACK. 3. (A) DRY NEEDLING/ACUPUNCTURE. 4. (A) MANUAL THERAPY as stand alone treatment. 5. (B) BIOPHYSICAL AGENTS including ultrasound, crotherapy, phonophoresis, iontophoresis, Stim, and laser.
How is MODERATE irritability classified in the Shoulder Pain and Mobility Deficits CPG?
1. 4-6/10, 2. intermittent night or resting pain, 3. moderate levels of reported disability on standardized self-report outcome tools. 4. pain occurs at END ranges of AROM or PROM. 5. AROM similar to passive PROM.
Rule IN Criteria for: Shoulder Pain and Mobility deficits/Adhesive Capsulitis
1. 40-65 years old, 2. gradual onset and progressive worsening of pain and stiffness. 3. Pain and stiffness limit sleeping, grooming, dressing, and reaching activities, 4. GHJ PROM limited in multiple directions with ER the most limited. 5. GHJ ER or IR ROM decreases as the humerus is abducted from 45 to 90. 6. PROM at end range reproduces pain. 7. Joint glides are restricted in all directions
How is HIGH irritability classified in the Shoulder Pain and Mobility Deficits CPG?
1. <7/10 pain, 2. consistent nigh or resting pain, 3. high levels of reported disability on self-report outcome tools. 4. pain occurs before end ranges of active or passive movements, 5. Active ROM is significantly less than passive ROM due to pain
How is LOW irritability classified in the Shoulder Pain and Mobility Deficits CPG?
1. >3/10, 2. no night/resting pain. 3. minimal levels of reported disability on standardized self-report outcome tools. 4. pain occurs with overpressures into end ranges of PROM. 5. Active ROM same as PROM.
What is the criteria for classifying adults with hip pain and mobility deficits/hip OA?
1. >50 years old. 2. moderate anterior or lateral hip pain during WB activities, 3. morning stiffness less than 1 hour in duration after wakening, hip IR <24 degrees OR hip IR/flexion 15 degrees less than contralateral side, 4. increased hip pain associated with passive hip IR.
What are the impairment based classifications for low back pain?
1. Acute or subacute low back pain with mobility deficits, 2. acute, subacute, or chronic low back pain with movement coordination impairments, 3. Acute low back pain with related (referred) lower extremity pain, 4. Acute, subacute, or chronic low back pain with radiating pain, 5. Acute or subacute low back pain with related cognitive or affective tendencies, 6. Chronic low back pain with related generalized pain.
What is the recommendation regarding diagnosis/classification of midportion achilles tendinopathy?
1. Arc sign (a palpable tendon nodule that moves during plantar- and dorsiflexion of the foot). 2. Royal London Hospital test (reduction of pain on palpation when the foot is dorsiflexed). 3. pain localized 2-6 cm proximal to insertion, gradual onset, and tender to palpation.
What are the limitations of all statistics?
1. Biased study design, 2. Data is no normally distributed, 3. SD's are very wide
What interventions are recommended for knee ligament injuries?
1. CPM; (C) CPM immediately post op ACL. 2. EARLY WB; within 1 week post ACL. 3. BRACING; (C) functional knee bracing in ACL deficiency or (F) for patients with acute PCL, severe MCL, or PLC injuries. 4. IMMEDIATE MOBILIZATIONS (B) within 1 week post ACL. 5. CRYOTHERAPY (B) post op. 6. SUPERVISED REHAB; exercisse as part of in-clinic program post ACL with progressive HEP/educate for compliance. 7. THERAPEUTIC EXERCISES; (A) WB and NWB concentric/eccentric exercises within 4-6 weeks 2-3x per week for 6-10 months to increase thigh muscle strength and functional performance. 8. NMES (A) post up for 6-8 weeks for quad strengthening, neuromuscular re-ed incorporated with strengthening exercises.
Risk factors for back related tumors (include liklihood ratios)
1. Constant pain not affected by position or activity; worse with weight bearing, worse at night. 2. Age over 50 (+LR: 2.2, -LR: 0.34), *3. History of Cancer (+LR: 23.7, -LR: 0.25), 4. Failure of conservative intervention (+LR: 3.0 , -LR: 0.79) 5. Unexplained weight loss (+LR: 3.0 , -LR: 0.87 ), 6. no relief with bedrest (+LR: 1.7 , -LR: 0.22)
What is the 2018 summary of the Risk Factors of meniscular and articular cartilage lesions?
1. Cutting and pivoting sports. 2. increased age and delayed ACL reconstruction. 3. Female, older age, higher BMI, lower physical activity and delayed ACL are risk factors for medial meniscus tears. 4. Female, older age, higher BMI, longer symptom duration, previous procedures/surgies, and lower self reported function are associated with failures of articular cartilage repair.
What are the pathoanatomical features of Structural Instability?
1. Defined as extraphysiologic hip motion causing pain with or without joint unsteadiness. 2. Traumatic, autramatic, or secondary to bony/soft tissue abnormality. 3. Related to shallow acetabulum and excessive femoral anteversion as well as excessive anteversion/retroversion, inferior acetabular insufficiency, and neck shaft angle > 140 degrees (normal 120-125). 3. Insufficient acetabular coverage of femoral head may result in repetitive shear stress leading instability and labral lesions. 4. Seen with hip dysplasia.
What are the pathoanatomical features of Femoroacetabular Impingement?
1. Describe as abnormal contact between femoral head/neck and acetabular margin associated with labral and chondral damage (Slipped Capital Femoral Epiphysis or SCFE also associated with FAI). 2. Repetive motions into impingement position (flexion/IR) results in excessive labral shear and compressive forces. 3. Three Categories; Cam Impingement: asphericity of femoral head or protrusion of head/neck junction, Pincer Impingement: acetabular abnormalities including general and localized anterosuperior overcoverage of femur. Combination Cam/Pincer: most common presentation. Retroversion/anterversion of femur or acetabulum may make impingement more pronounced.
What is the summary for pathoanatomical features of CTS?
1. Elevated carpal tunnel pressure. 2. Disruption in intraneural blood flow contributing to edema and fibrosis. 3. Englargement of flexor tendon synovial sheaths (fibrous synovial hypertrophy).
What interventions have weak evidence for low back pain treatment?
1. FLEXION EXERCISES - flexion exercises, combined with other interventions with older patients with chronic low back pain with radiating pain. 2. LOWER QUARTER NERVE MOBILIZATION PROCEDURES - with subacute and chronic low back pain and radiating pain.
Clinical Predictors for Cervical spine Myelopathy
1. Gait deviation, 2. (+) Hoffman's, 3. Inverted supinator Sign, 4. (+) Babinski, 5. Age less than 45
What are the pathoanatomical features of Acetabular Labral Tears?
1. Labrum functions to deepen socket, buffer forces transmitted to articular cartilage, stabilizes joint with negative intra-articular pressure, and may play role in proprioception. 2. Traumatic MOI; rapid twisting, pivoting or falling motions (forceful rotation in hyperextened position). Insidious onset; compination of anatomical variants with repetitive forces. 3. Four Classifications; Radial Flap (most common): free margin is disrupted, Radial Fibrillated: free margin fraying, Longitudinal Peripheral (least common): tear along acetabular-labral junction, and Abnormally Mobile: partially detached.
Acute Low Back pain with Movement Coordination Impairments: Impairments of Body Function
1. Low back and/or low back-related lower extremity pain at rest or produced with INITIAL to MID range spinal movements. 2. low back and/or low back-related lower extremity pain reproduced with provocation of the involved lumbar segments, 3. movement coordination impairments of the lumbopelvic region with low back flexion and extension movements.
Acute low back pain with radiating pain: Impairments of Body Function
1. Lower extremity radicular symptoms that are present at rest or produced with INITIAL to MID range spinal mobility, lower-limb tension tests/straight leg raising, and/or slump tests. 2. Signs of nerve root involvement may be present. *** it is common for the symptoms and impairments of body function in paitents who have acute low back pain with radiating pain to also be present in patients who have acute low back pain with related (referred) lower extremity pain.
What interventions have strong evidence for low back pain treatment?
1. MANUAL THERAPY - thrust manipulative procedures to reduce pain and disability in patients with mobility deficits AND acute low back pain and back related buttock or thigh pain. Thrust or non-thrust mobilization to improve spine and hip mobility and reduce pain with subacute and chronic low back and back related lower extremity pain. 2. TRUNK COORDINATION, STRENGTHENING, AND ENDURANCE EXERCISES - for subacute and chronic low back pain with movement coordination impairments OR post microdiscectomy. 3. CENTRALIZATION AND DIRECTIONAL PREFERENCE EXERCISE AND PROCEDURES - repeated movements, exercises, or produce to promote centralization for acute low back pain with related (referred) lower extremity pain. Repeated exercises in a specific direction for acute, subacute, and chronic low back pain with mobility deficits. 4. PROGRESSIVE ENDURANCE EXERCISE AND FITNESS ACTIVITIES - moderate to high intensity for patient with chronic low back pain without generalized pain AND use progressive, low intensity submaximal fitness and endurance activities with chronic low back pain with generalized pain.
Chronic low back pain with radiating pain: Primary Intervention Strategies
1. Manual therapy and therapeutic exercises to address thoracolumbar and lower-quarter nerve mobility deficits. 2. Patient education pain management strategies.
Subacute low back pain with radiating pain: Primary Intervention Strategies
1. Manual therapy to mobilize the articulations and soft tissues adjacent to the involved nerve root(s) or nerve that exhibit mobility deficits. 2. Manual or mechanical traction. 3. Nerve mobility and slump exercises in the MID to END ranges to improve the mobility of central (dural) and peripheral neural elements.
What are the pathoanatomical features of Chondral Lesions?
1. May be associated with dysplasia, anterior joint laxity, and FAI. 2. May correlate with labral lesions and loss of ROM in hip OA. 3. Found in younger, more active population following traumatic injury involving acute overloading after impact sustained to trochanteric region.
What are the pathoanatomical features of Ruptured Ligament Teres?
1. May function as strong instrinsic stabilizer of hip, particularly with ER in Flex or IR in Ext. 2. High association between labral tears/cartilage injury and ligamentum teres tears, however isolated tears are rare.
What physical impairment measures are useful for the examination of heel pain and plantar fasciitis?
1. Measures of pain with initial steps after a period of immobility. 2. Pain with palpation of the proximal insertion of the plantar fascia. 3. Active and passive ankle DF ROM. 4. BMI in nonathletic population.
Subacute low back pain with radiating pain: Impairments of Body Function
1. Mid back, low back, and back related radiating pain or paresthesia that are reproduced with MID range and worsen with end range: a) lower limb tension testing/straight leg raising tests, and/or... b) slump tests. 2. May have lower extremity sensory, strength, or reflex deficits associated with the involved nerve(s).
Chronic low back pain with radiating pain: Impairments of Body Function
1. Mid-back, low back, or lower extremity pain or paresthesias that are reproduced with sustained end-range lower-lim tension tests and/or slump tests. 2. Signs or nerve root involvement may be present
What is the summary of prevalence in regards to disorders of achilles tendon?
1. Most frequent overuse injury reported in literature. 2. Majority are active individuals/athletes, runners most common subgroup but found in variety of sports. 3. Mean age 30-50 years. 4. May be more prevalent in males versus females.
What are the pathoanatomical features of Loose Bodies?
1. Multiple mechanisms; ossified and nonossified present in joint disrupt function. may be present with dislocation (single bodies), osteochondritis dissecans (single), synovial chondromatosis (multiple).
Acute Low Back pain with Movement Coordination Impairments: Primary Intervention Strategies
1. Neuromuscular re-education to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in les symptomatic, MID range positions. 2. Consider the use of temporary external devices to provide passive restraint to maintain the involved lumbosacral structures in less sypmtomatic, MID range positions. 3. Self-care/home management training pertaining to a) postures and motions that maintain the involved spinal sturctures in neutral, symptom-alleviating positions, and b) recommendations to pursue or maintain an active lifestyle.
Rule OUT Criteria for: Shoulder Stability and movement coordination impairments/Dislocation of shoulder joint, or sprain and strain of shoulder Joint
1. No history of dislocation, 2. presence of global GHJ motion limitations. 3. No apprehension with end-range shoulder active or passive motions.
TMJ Muscles
1. Opening - Lateral pterygoid muscle, suprahyoid muscle group 2. Closing - Masseter, medial pterygoid, temporalis 3. Protrusion - lateral pterygoid ***, medial pterygoid, masseter 4. Retraction - Temporalis, suprahyoid 5. Lateral Deviation - Contralateral medial and lateral pterygoid***, Ipsilateral masseter and temporalis
What are the 4 subcatagories of classification of PFP acording to the ICF?
1. PFP with OVERUSE/OVERLAD; classified without other impairment and reports history suggesting increase in magnitude and/or frequency of PFJ loading surpassing ability to recover. 2. PFP with MUSCLE PERFORMANCE DEFICITS; individuals with lower extremity muscle performance deficits on the hip and quadriceps (may respond favorably to resistance exercise). 3. PFP with MOVEMENT COORDINATION DEFICITS; individuals who present with ecessive or porrly controlled knee valgus during dynamic task but not necessarily due to weakness (may respond favorablly to gait retraining and movement re-education). 4. PFP with MOBILITY IMPAIRMENTS; individuals who present with higher than normal foot mobility and/or flexbility deficits of 1 or more of the following: hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or ITB.
What are the recommended Interventions for Meniscal and Articular Cartilage lesions?
1. PROGRESSIVE MOTION (B) PROM/AROM following surgery. 2. PROGRESSIVE WB (C) early progressive WB following meniscal repairs. (B) stepwise WB progression to full by 6-8 weeks after Matrix ACI. 3. PROGRESSIVE RETURN TO ACTIVITY (C) early progressive return to activity following meniscal repair. (E) may delay return depending on type of surgery. 4. SUPERVISED REHAB (B) exercises as part of in-clinic program following meniscectomy with progressive HEP, educate importance of compliance. 5. (B) THERAPEUTIC EXERCISES (B) progressive ROM, strengthening of knee and hip, and nueromuscular training. 6. NMES (B) following meniscus procedures to increase quad strength, performance, and function.
Rule OUT Criteria for: Shoulder Pain and Mobility deficits/Adhesive Capsulitis
1. PROM Normal. 2. GHJ arthritis on radiographs, 3. Passive GHJ ER or IR ROM increases as humerus is abducted. 4. Pain reproduced with palpation of subscapularis myofasica, 5. + ULTT, 6. + peripheral nerve entrapment.
Cervical spine Treatment Based Classification Scheme
1. Pain Control - < less than than 30 days onset, trauma --> gentle Range of Motion and activity 2. Centralization - radiculopathy signs and symptoms, symptoms distal to the elbow. Treatment- activities to promote centralization 3. Headaches - primary complaint of cervicogenic Headaches. Treatment - OMT, deep neck flexor traingin, PREs for scapula 4. Exercise and Conditioning - no radiculopathy signs and symptoms, age > greater than 60, chronic. Treatment - strengthening and conditioning exercises 5. Mobility - recent onset of symptoms, No radiculopathy signs and symptoms. Treatment - manual therapy + exercise
Chronic low back pain with related generalized pain: Primary Intervention Strategies
1. Patient education and couseling to address specific classification exhibited by the patient (ie: depression, fear-avoidance, pain catastrophizing). 2. Low intensity, prolonged (aerobic) exercise activities.
Acute low back pain with radiating pain: Primary Intervention Strategies
1. Patient education in positions that reduce strain or compression to the invovled nerve root(s) or nerves. 2. Manual or mechanical traction. 3. Manual therapy to mobilize the articulations and soft tissues adjacent to the involved nerve root(s) or nerves that exhibit mobility deficits. 4. Nerve mobility exercises in the pain free, non-symptom-producing ranges to improve the mobility of central (dural) and peripheral neural elements.
What clinical findings are useful for diagnosis/classification of heel pain and plantar fasciitis?
1. Plantar medial heel pain (most noticeable with initial steps after inactivity but also worse following prolonged WB). 2. Heel pain precipitated by incresae WB activity. 3. Pain with palpation of proximal inservion of plantar fascia. 4. Positive Windlass test. 5. Negative Tarsal Tunnel tests. 6. Limited active and passive talocrural joint DF ROM. 7. Abnormal Foot Posture Index score. 8. High BMI in nonathletic individuals.
Risk factors for back infection (include liklihood ratios)
1. Recent infection (eg: urinary tract or skin), IV drug user/abuse; 2. Concurrent immunosuppressive disorder, 3. deep constant pain, increases with weight bearing, 4. fever, malaise, and swelling, 5. spine rigidity; accessory mobility may be limited. ***6. Fever: tuberculosis osteomyelitis (+LR: 13.5 , -LR: 0.75 ), ***7. Fever: pyogenic osteomyelitis (+LR: 25.0 , -LR: 0.51 ), ***8. Fever: spinal epidural abscess (+LR: 41.5 , -LR: 0.17)
Rule OUT Criteria for: Shoulder pain and muscle power deficits/ RTC Syndrome
1. Resistive tests are PAIN FREE. 2. Supraspinatus, infraspinatus, and biceps brachii have normal strength, 3. Significant loss of PROM.
What are the physical impairment measures utilized for PGP?
1. SLR (sensitivity 44% & specificity 83%); positive result if pain noted with first attempt, reduced with compression of pelvis in second attempt. 2. Compression/Separation test (sensitivity 4-59% & specificity 50-100%). 3. Distraction/Compression test (sensitivity 13-70% & specificity 67-100%). 4. Gaenslen Test (sensitivity 47% & specificity 100%). 5. FABER (sensitivity 40-70% & specificity 99%). 6. Hip PROM. 7. Lunge (sensitivity 44% & specificity 83%). 8. Menells Test (sensitivity 0-70% & specificity 100%). 9. Palpation of Pubic Symphisis. 10. Palpation of SIJ. 11. Posterior Pelvic Pain Test/Thigh Thrust Test (sensitivity 17-93% & specificity 67-98%). 12. Trendelenburg Test (sensitivity 18-62% & specificity 99%).
Rule IN Criteria for: Shoulder pain and muscle power deficits/ RTC Syndrome
1. Symptoms developed from, or worsen with, repetitive overhead activities or from an acute sprain such as a fall onto the shoulder. 2. Midrange (about 90 degrees) catching sensation/arc of pain with active elevation.. 3. Manual resistive tests to the RTC, performed in midranges of shoulder flexion and abduction, reproduce the patient's reported shoulder pain. 4. RTC muscle weakness.
What is the difference between the ICF classification system and the treatment based classification system?
1. Terminology - uses low back pain with mobility deficits, movement coordination impairments, related lower extremity pain, radiating pain, and generalized pain. 2. classification with patients with pain who, in addition to movement related impairments of body function, have impairments of mental functioning and impairments of sensory function, 3. patient's level of acuity.
Sub-Acute Low Back pain with Movement Coordination Impairments: Impairments of Body Function
1. lumbosacral pain with MID range motions that worsens with END range movements or positions. 2. low back and low back-related lower extremity pain reproduced with provocation of the involved lumbar segments. 3. lumbar hypermobility with segmental mobility assessment may be present. 4. mobility deficits of the thorax and/or lumbopelvic/hip regions. 5. diminished trunk or pelvic-region muscle strength and endurance. 6. movement coordination impairments while performing self-care/home management activities.
What is the recommendation regarding clinical findings which can help with low back diagnosis according to the LBP CPG ?
1. mobility impairment in the thoracic, lumbar, or sacroiliac regions 2. referred or radiating pain into a lower extremity 3. generalized pain.
Chronic Low Back pain with Movement Coordination Impairments: Primary Intervention Strategies
1. neuromuscular re-education to provide dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, MID range positions during household, occupational, or recreational activities. 2. Manual therapy procedures and therapeutic exercises to address identified thoracic spine, ribs, lumbopelvic, or hip mobility deficits, 3. Therapeutic exercises to address trunk and pelvic region muscle strength and endurance deficits. 4. Community/work reintegration training in pain management strategies while returning to community/work activities.
Sub-Acute Low Back pain with Movement Coordination Impairments: Primary Intervention Strategies
1. neuromuscular re-education to provide dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, MID range positions during self-care related functional activities. 2. Manual therapy procedures and therapeutic exercises to address identified thoracic spine, ribs, lumbopelvic, or hip mobility deficits, 3. Therapeutic exercises to address trunk and pelvic region muscle strength and endurance deficits. 4. Self-care/home management training in maintaining the involved structures in MID range, less symptom-producing positions. 5. Initiate community/work reintegration training in pain management strategies while returning to community/work activities.
What are the important pathoanatomical features regarding midportion achilles tendinopathy?
1. pain is preceded by excessive mechanical stressor such as tensile loading/shearing initiating pathological tendon changes (tenocyte proliferation with tendon thickening, neovascularity, collagen fibril thinning and disorganization, increased noncollagenic and fibrocarticalge matrix, fat deposition, and altered fluid movement). 2. Tendon changes decrease tendon stiffness/strength, cause innefective force transfer, and affect CNS motor control. 3. Severity of tendon abnormalities are NOT consistent with clinical presentation. 4. Plantaris tendon and associated peritendinous nerve may contribute to pain.
The CPG for low back pain will describe diagnostic classification categories using what general principles?
1. patient's level of acuity (acute, subacute, and chronic), 2. the relation of the patient's reported pain to active movements or to passive movements that the clinician utilizes during the physical examination, 3. the recurring nature of low back pain requires clinicians to expand beyond the times frames traditionally used for acute, subacute, and chronic low back pain, 5. Focuses on more movement/pain relations rather than solely using time.
What are should clinicians recognize as risk factors for adhesive capsulitis?
1. patients with DM and thyroid disease are at risk for developing adhesive capsulitis. 2. more prevalent in individuals who are 40-65 years of age, female, and have had a previous episode of AC in the contralateral side.
What subgroup of patients benefited from traction according to Fritz et al?
1. prescence of sciatica, 2. nerve root compression, 3. patients who experienced peripheralization of symptoms with extension movement, 4. had a positive crossed straight leg raise test.
What are the prognostic factors for development of chronic low back pain?
1. presence of pain below the knee, 2. psychological distress or depression, 3.fear of pain, movement, and reinjury or low expectations of recovery, 4. pain of high intensity, 5. passive coping style.
What are the general findings for adolescents and low back pain?
1. prevalence rates as high of 70-80% by 20 years old. 2. females have almost 3 times more risk. 3. Anthropometrics do NOT appear to be strongly associated, 4. lifestyle factors most contributory - physical activity, sedentary activities, and mechanical load.
What are the risk factors associated with antepartum pelvic girdle pain (PGP)?
1. prior history of pregnancy. 2. orthopedic dysfunctions. 3. increased BMI. 4. smoking. 5. work dissatisfaction. 6. lack of believe of improvement in progrnosis of PGP.
What education points should you avoid with low back pain?
1. promote extended bed-rest. 2. provide in-depth, pathoanatomical explanations for the specific cause of the patient's low back pain.
Subacute Low Back Pain with Mobility Deficits: Impairments of Body Function
1. symptoms reproduced with END range spinal motions, 2. symptoms reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments, 3. Prescence of 1 or more of the following: restricted thoracic range of motion and associated segmental mobility, restricted lumbar rane of motion and associated segmental mobility, restricted lumbopelvic or hip rang eof motion and associated accessory mobility.
What education strategies should you use with low back pain?
1. the promotion of understanding of the anatomical/structural strength inherent in the spine, 2. the neuroscience that explains pain perception, 3. the overall favorable prognosis of low back pain, 4. the use of active pain coping strategies that decrease fear and catastrophizing, 5. early resumption of normal or vocational activities, even when still experiencing pain, 6. the importance of improvement in activity levels, not just pain relief.
15. You perform the Ankle-Brachial Index (ABI) test on this patient. Which of the following ranges is considered "normal"? A. 1.10 - 1.11 B. 1.00 - 1.10 C. 0.94 - 0.95 D. 0.80 - 0.81
1.00 - 1.10
16. The Ottawa Ankle Rules can be applied to adults and children alike as long as the child is at least how old? A. 10 B. 12 C. 14 D. 16
16
3. What is the most common location associated with Gout? a. 1st MCP joint b. Patellofemoral joint c. 5th TMT joint d. 1st MTP joint
1st MTP joint
What are the current recurrence rates of low back pain?
20-35% over a period of 6-22 months, with 45% over 3 years.
2. What percentage of maximal grip strength can be produced with the wrist in full flexion? a. 15% b. 25% c. 40% d. 55%
25%
What is the median age of onset for Fibromyalgia?
29-37 onset of sx's, 34-53 for actual diagnosis.
20. According to the Podiatrist's Clinical Practice Guideline for the treatment of plantar heel pain, at which Tier of the "treatment ladder" does a referral to physical therapy occur? A. Initial tier B. 2nd tier C. 3rd tier D. 4th tier
2nd tier
20. You are screening a patient for the possibility of a proximal DVT at the right leg. You document the following findings: Patient was recently bedridden for 2 days due to lower back pain, pitting edema of similar magnitude at right and left lower extremities, right calf swelling 2cm compared to the left (measured 10cm below the tibial tuberosity), and varicose veins. Based on these findings, what is the posttest probability that the patient has a proximal DVT? A. 3% B. 17% C. 46% D. 68%
3%
Tension Type Headache Signs and symptoms
30 minutes to 7 days, BILATERAL, activation of myofascial trigger points, No more than 1: photo or phonophobia. No Nause/vomitting is seen
Cervicogenic Headache signs and symptoms
4-72 hours, unilateral + or - a side shift, Aggravating activities - neck movements, no other symptoms
Migraine Signs and symptoms
4-72 hours, unilateral, Aggravating activities - routine physical activity, at least 1: (+) nausea, vomitting, phono/photophobia
What are some possible differential diagnoses for adhesive capsulitis?
AC is a gradual progression of pain and loss of active AND passive shoulder motion in both elevation and rotation. Other diagnoses: RTC Tendinopathy, arthrosis, bursitis,
CPR for HVLA
5 Clinical Predictors - 1. Pain less than 16 days, no symptoms distal to the knee, FABQ less than 19, Passive Range of Motion Hip Internal Rotation greater than 35 °, (+) Lumbar spirng test (hypomobile + pain), (-) gaenslen's. Want greater than 3 out of 5.
What outcome measures should a clinician utilize in regards to activity limitations with hip pain?
6 minute walk test, 30 second chair stand, stair measure, timed up and go test, self-paced walk, timed single leg stance, 4 square step test and step test. *** want to make sure to assess balance and activities that would increase the risk of falls. Can utilize the berg balance scale in addition to the aforementioned ones.
Common attachments of muscles on the: FEMUR - QUADRATE TUBERCLE
DISTAL: quadratus femoris
6. When is it safe to D/C the sling for this patient? a. 7-10 days b. 2 weeks c. 3 weeks d. 4 weeks
7-10 days
1. A patient is referred to your clinic from the ER for neck pain sustained due to whiplash in an MVA 24 hours prior. Initial intake data demonstrates a Neck Disability Index score of 16% and a Tampa Scale for Kinesiophobia score of 42. Based on this information, your concern for the possibility of chronic disability with this patient is approximately: a. 36% b. 54% c. 68% d. 83%
83%. Pre-test probability for a patient with whiplash to develop chronic disability is 33%. NDI score of >15 raises that suspicion to 54%. A TSK score of >41 further raises the post-test probability to 83% (Nederhand, 2004)
17. You are rehabilitating a 21 year old female that is 2 weeks status-post arthroscopic anterior capsulolabral repair. The surgeon's prescription stated to progress her PROM "as indicated". Repeated attempts to contact the surgeon for more specific guidance have not met with success. Your patient has a follow-up with her surgeon next week (3 weeks post-op). How much PROM forward elevation should she have when she returns to her surgeon next week? A. 85 degrees B. 90 degrees C. 95 degrees D. 110 degrees
90 degrees
12. A 43 year old male presents to your clinic with a five month history of left lateral elbow pain consistent with lateral epicondylalgia. He is able to perform pain-free grip strength on the left of 28# and pain-free grip strength on the right of 79#. Based on this information, what is the likelihood that he will have success with a Mobilization with Movement intervention? A. 79% B. 87% C. 93% D. 100%
93%
7. How large is a "small" tear of the rotator cuff? a. <1cm b. 1.5-2cm c. 2-3cm d. 5cm
<1cm
What clinical findings indicate a sprain of the ACL?
Acceleration/decellation MOI with noncontact valgus load at/or near full knee extension, hearing/feeling a "pop", Hemarthrosis within 0-12 hours, history of giving way, positive Lachman test (sensitivity 85% & specificity 94%), positive Pivot Shift (sensitivity 24% & specificity 98%). Movement coordination impairments; 6m SL timed hop test < 80% uninvolved limb, max voluntary isometric quad strength < 80%, reported history of giving-way with 2 or more ADLs.
What are the components of the Ottawa Knee Rule (sensitivity 99% & specificity 49%) in regards of imaging?
A knee radiograph is required following an acute knee injury if patients prevent with any of the following criteria; older than 55, isolated tenderness to patella, tenderness of fibular head, inability to flex knee to 90 degrees, inability to bear weight immediately and in the ER for 4 steps regardless of limping.
29. You are reading an abstract in JOSPT on a systematic review of neural mobilization techniques for carpal tunnel syndrome. The authors report there is "weak evidence" supporting this intervention and assign it a grade of "C". Based on this information, what type of studies were available to assess the effectiveness of neural mobilizations for CTS? a. A single high quality RCT or a preponderance of Level II studies support the recommendation b. A single Level II study or a preponderance of Level III & IV studies including statements of consensus by content experts support the recommendation c. Higher quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies. d. A preponderance of evidence from animal or cadaver studies, from conceptual models/principles, or from basic sciences/bench research support this conclusion
A single Level II study or a preponderance of Level III & IV studies including statements of consensus by content experts support the recommendation
16. According to the Ottawa Knee Rules, which of the following findings would indicate x-rays following knee trauma. A. AROM extension >10 degrees from 0 with hard, painful endfeel B. AROM flexion <60 degrees C. Age >55 years D. Isolated tenderness to the fibula head (no other bony tenderness)
Age > greater than 55 years old
3. Which two flexor pulleys are the most important for the mechanical function of the finger? a. A1 & A2 b. A2 & A4 c. C1 & C2 d. C1 & A1
A2&A4
Common attachments of muscles on the: TIBIA - TUBEROSITY
DISTAL: rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
What are the recommendations for interventions for the NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENTS subgroup in the neck pain CPG?
ACUTE; (B) patient eduction return to normal/non-provocative activities ASAP, minimize use of cervical collar, postural and mobility exercises to decrease pain/increase ROM, reassurance recovery is expected to occur within 2-3 months. Manual mobilization techniques plus exercise (strengthening, endurance, flexbility, postural, coordination, aerobic, and functional exercises) for patients expected to experience moderate to slow recovery/persistent symptoms. (C) Patients perceived to be low risk of progressing towards chronicity may benefit from 1 session of education and exercise instruction, comprehsenive exercise program including strength/endurance w/wo coordination exercises, TENS. (F) Monitor recovery status to identity individuals who may need more intensive rehab/early pain education. CHRONIC; (C) patient education focus on reasurance, encouragement, prognosis, and pain management. Mobilization combined with individualized/progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination using principles of cognitive behavioral therapy. TENS.
What are the recommendations for interventions for the NECK PAIN WITH HEADACHES subgroup in the neck pain CPG?
ACUTE; (B) supervised active mobility exercise. (C) C1-2 self-SNAG. SUBACUTE; (B) cervical manipulation and mobilization. (C) C1-2 self-SNAG. CHRONIC; (B) cervicothoracic manipulation or mobilization combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.
What are the recommendations for interventions for the NECK PAIN WITH MOBILITY DEFICITS subgroup in the neck pain CPG?
ACUTE; (B) thoracic manipuation, program of neck ROM exercises, and scapulothoracic/upper extremity stretching and strengthening exercises. (C) cervical manipulation and/or mobilization. SUBACUTE; (B) neck and shoulder girdle endurance exercises. (C) thoracic manipulation and cervical manipulation/mobilization. CHRONIC; (B) multimodal approach including thoracic manipulation, cervical mobiliation/manipulation, mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (coordination, propioception, and postural training), strethcing, strengthening, endurance, aerobic conditioning, and cognitive affective elements. Modalities include dry needling, laser, or intermittent traction. (C) Endurance exercise for neck, shoulder girdle, trunk. Patient education promoting active lifestyle and address cognitive and affective factors.
What are the recommendations for interventions for the NECK PAIN WITH RADIATING PAIN subgroup in the neck pain CPG?
ACUTE; (C) mobilization and stabilization exercises, laser, and short-term cervical collar. CHRONIC; (B) mechanical intermittent cervical traction, combined with interventions of stretching/strengthening exercise and cervical and thoracic mobilization/manipulation. Patient education encouraging participation in occupational and exercise activities.
How are the stages of the condition of neck pain classified?
ACUTE; highly irritable, pain experienced at rest or with initial to mid-range spinal movements prior to tissue resistance. SUBACUTE; moderate irritability, pain experienced with mid-range motions that worsen at end-range with tissue resistance. CHRONIC; low irritability (pain that worsens with sustained end-range spinal movements/positions, overpressure into tissue resistance. There are cases where irritability and duration of symptoms do not match, in such cases clinician should make best judgements when applying time based intervention.
Nerve Distribution - Motor: OBTURATOR NERVE - L2/3/4
ANTERIOR BRANCH: adductor longus, adductor brevis, gracilis; POSTERIOR BRANCH: adductor magnus (adductor part), obturator externus
Common attachments of muscles on the: FIBULA - SHAFT
ANTERIOR SURFACE: PROXIMAL: Extensor digitorum longus, extensor hallucis longus, fibularis tertius; LATERAL SURFACE: PROXIMAL: fibularis longus, fibularis brevis; POSTERIOR SURFACE: PROXIMAL: soleus, flexor hallucis longus, tibialis posterior, flexor digitorum longus.
2. CASE STUDY: A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg's Sign, and (+) Froment's sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. What does Wartenberg's sign assess? a. Ability to adduct the 5th digit b. Abductor Pollicus weakness c. Ulnar nerve regeneration distal to the Cubital Tunnel of the elbow d. Pinch deformity at IP of thumb and DIP of index finger
Ability to adduct the 5th digit
8. A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, "it felt like someone kicked me in the back of my leg". His calf is obviously deformed, and he is unable to actively plantar flex his foot. Based on these findings, what is the most likely diagnosis. a. Achilles tendon rupture b. Flexor hallicus longus strain c. Peroneus longus strain d. Posterior tibialis rupture
Achilles tendon rupture
Path: ILIO-INGUINAL AND ILIOHYPOGASTRIC NERVES L1
Across quadratus lumborum and psoas, inguinal ligament
What were the three trajectories of neck pain in Sterling et al's work?
Acute Traumatic Conditions typically follow 3 trajectories; (1) Mild problems with rapid recovery (40-45% of cases), (2) Moderate problems with incomplete recovery (39-43%), (3) Severe problems without recovery (16-17%).
Acute LBP with Mobility Deficits
Acute low back, buttock, or thigh pain (≤6 weeks), Onset of symptoms is often linked to a recent, unguarded/awkward movement or position Rule-in if: • Lower thoracic or lumbar range of motion limitations • Low back and low back-related lower extremity reproduced with (1) end-range spinal motions, and (2) provocation of the involved lower thoracic or lumbar segments Rule-out if: • Combined end-range spinal motions (eg, end-range lumbar extension combined with end-range lumbar sidebending) with clinician-provided overpressure into the combined motion is pain free • Unable to produce reported low back or low back-related lower extremity pain with provocation (eg, end-range unilateral posterior-to-anterior pressures) of the lower thoracic or lumbar segments
3. CASE STUDY: A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg's Sign, and (+) Froment's sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. What does Froment's sign assess? a. Ability to adduct the 5th digit b. Adductor Pollicus weakness c. Ulnar nerve regeneration distal to the Cubital Tunnel of the elbow d. Pinch deformity at IP of thumb and DIP of index finger
Adductor Pollicus weakness
4. A patient with chronic LBP and evidence of HNP at L5/S1 asks your opinion on getting a spinal fusion. Based on the evidence, you: a. Agree with surgery, citing a 75% success rate b. Agree with surgery, citing a 65% success rate c. Advise against surgery, citing a 75% failure rate d. Advise against surgery, citing a 65% failure rate
Advise against surgery, citing a 75% failure rate
What factors were not supported for establishing a prognosis for neck pain (WAD)?
Angular deformity of neck (scoliosis/flattened lordosis), impact direction, seating position, awareness of impending collision, having a headrest, stationary vs. moving when hit, older age.
What physical impairment measures are useful for the examination of achilles tendinopathy?
Ankle DF ROM, subtalar joint ROM, PF strength and endurance, static arch height, forefoot alignment, and pain with palpation.
ABI
Ankle/brachial index. Used with peripheral artery disease, Normal - 1-1.1; Abnormal - outside range, less than 1 at rest, 0.25 and below - significant PAD present
4. CASE STUDY: A 22 year old sedentary male presents to your clinic with an insidious onset of low back pain for three weeks. The patient reports his pain is increased with rest and decreased with activity. The pain is localized to his lower lumbar and upper SIJ region. Radiographs have not been taken and NSAID's have helped reduce the pain. Based on the above information, the patient's signs and symptoms are most closely associated with: a. Ankylosing Spondylitis b. Herniated Nucleus Pulposus c. Mechanical low back pain d. Spondylolisthesis
Ankylosing Spondylitis
Common attachments of muscles on the: TIBIA - MEDIAL CONDYLE
DISTAL: semimembranosus
Common attachments of muscles on the: HUMERUS - LESSER TUBERCLE
DISTAL: subscapularis
What are the 18 Tenderpoints for fibromyalgia?
Bilateral neck between C5 and C7, Bilateral subocciptals, Bilateral Trapezius, Bilateral supraspinatus, Bilateral lateral humeral epicondyle, bilateral gluteal, bilateral knees - medial, bilateral greater trochanter, second rib at costochondral junctions.
6. A patient has been clinically diagnosed with lumbar spinal stenosis. According to the literature, the best results can be obtained with which type of walking program? a. Aquatic walking b. Body weight supported on a treadmill c. Home exercise program PRN d. Inclined treadmill walking
Body weight supported on a treadmill
6. A 36 year old male presents to your clinic with right sided groin pain associated with a popping sensation. The patient cannot recall any specific mechanism of injury. He reports he is unable to sit "Indian-style" on the floor while playing with his children. Physical examination reveals negative Femoral Grind test. Placing the patient's right hip in a position of flexion, external rotation, and abduction and then rapidly moving it into extension, internal rotation, and adduction produces a sharp pain "deep" in the groin area. Based on this information, what is the most likely diagnosis? a. Anterior Acetabular labral tear b. DJD Hip c. Iliopectineal Bursitis d. Legg-Calves-Perthes disease
Anterior Acetabular Labral Tear. Acetabular tears are caused by a slipping or twisting injury. The patient will typically not be able to pinpoint an exact mechanism of injury. Pain associated with popping or snapping "deep" within the hip is a common complaint. Limited range of motion into rotation is common (this patient could not sit "Indian-style" on the floor). The special test described above is specific for Anterior Acetabular tears.
10. A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a "pop", which was associated with immediate swelling. Physical findings include AROM between -10 degrees extension, and - 20 degrees flexion versus the uninvolved side. You note a positive Lachman's test and a positive anterior drawer test. Given your clinical examination findings, what do you suspect is the likely diagnosis? a. Anterior cruciate ligament injury b. Medial collateral ligament injury c. Medial meniscus injury d. Posterior cruciate ligament injury
Anterior Cruciate Ligament Injury
12. A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a "pop", which was associated with immediate swelling. Physical findings include AROM between -10 degrees extension, and - 20 degrees flexion versus the uninvolved side. You note a positive Lachman's test and a positive anterior drawer test. What structures would be involved if this patient was determined to have a Terrible (Unhappy) Triad of O' Donoghue? a. Anterior cruciate, medial meniscus, lateral collateral ligament b. Anterior cruciate, medial meniscus, medial collateral ligament c. Posterior cruciate, medial meniscus, lateral collateral ligament d. Posterior cruciate, medial meniscus, medial collateral ligament
Anterior Cruciate Ligament, Medial Meniscus, Medial Collateral Ligament
7. A 34 year old female presents to your clinic with a prescription from her family practice physician to evaluate and treat a hypomobile right TMJ. The patient reports she has been having pain in her TMJ for the past 6 months without relief. Physical examination reveals the following data: • S-curve with jaw opening • 25mm of jaw opening • Auditory and palpable "click" with opening and closing the jaw • Pain is decreased by having the patient bite down with a cotton roll between their molars What is the most likely cause of this patient's TMJ disorder? a. Anterior dislocation of the disc with relocation b. Capsular (TMJ) restriction c. Muscle imbalance d. Posterior subluxation of the TMJ
Anterior Dislocation of the disc with relocation
1. A 24 year old male presents to your clinic following a traumatic injury that occurred to his right shoulder 2 days prior while playing basketball. The patient stated that an opposing player struck his right forearm while he was attempting to catch a pass. He immediately felt pain and a "pop" at the time of injury. After further questioning, you determine his arm was in a position of approximately 100° abduction, 90° of external rotation, and slight extension at the time of injury and that the opposing player's force was directed from anterior to posterior. The patient is very hesitant to move his arm and presents with his arm in glenohumeral neutral and slight adduction. Based upon the information above, you suspect the patient most likely has what type of injury? a. Anterior glenohumeral instability b. Acromioclavicular sprain c. Posterior glenohumeral instability d. SLAP lesion
Anterior glenohumeral instability
Function: OBTURATOR NERVE L2/3/4
Anterior: Motor - adductor longus/brevis, gracilis, pectineus; Sensory - medial thigh, Posterior - Motor - adductor magnus, Sensory: medial knee
What are the pathoanatomical features of Femoral Version?
Anteversion: increased femoral IR ROM and limitation in femoral ER ROM. Retroversion: increased femoral ER ROM and limitation in femoral IR ROM. Excessive anteversion/retroversion associated with increased risk for labral injury and development of hip OA.
What pathoanatomical structures can cause low back pain according to the literature?
Any innervated structure in the lumbar spine can cause low back pain, like muscles, ligaments, dura mater and nerve roots, zygapophyseal joints, annulus fibrosis, thoracolumbar fascia and vertebrae.
Path: ULNAR NERVE C8/T1
Arise from the medial cord of the brachial plexus, Travels distally posteromedial arm, Enters Cubital Tunnel, Passes underneath the aponeurosis of the FCU, Runs alongside the ulna and enters the wrist/hand via Guyon's Canal
Path: COMMON PERONEAL NERVE L4/5/S1/2
Arises from Sciatic Nerve at popliteal fossa, distal and lateral to biceps femoris, lateral to lateral head of gastrocnemius, around fibular head deep and superficial branches
Path: MEDIAN NERVE (C5/6, C8-T1)
Arises from the medial and lateral cord of the brachial plexus in the axilla, Courses down the medial arm alongside the brachial artery between the biceps and brachialis, though the cubital fossa, pronator teres. Continues between FDS and FDP. Gives off Anterior Interosseous Nerve Branch, Emerges at FPL and enters into Carpal Tunnel, Divides into the recurrent branch and Digital Cutaneous Branch
Common attachments of muscles on the: TARSALS - MEDIAL CUNEIFORM
DISTAL: tibialis anterior, fibularis longus, tibialis posterior
Path: RADIAL NERVE (C5/6/7/8/T1)
Arises from the posterior cord of the brachial plexus, Courses through the triangular interval, Continues posteriorly medial to lateral, Gives branches to triceps, Travels deep to triceps and emerges at radial groove at the lateral epicondyle, Branches into 1. Radial Sensory Nerve (Superficial Branch), which runs deep to brachioradialis and supplies sensory to dorsum of wrist and hand and web space between 1st and 2nd finger and 2. Deep Branch which pieces supinator, wraps around radial head and pierces supinator again as the posterior interosseous nerve and ends at EPB and extensor retinaculum
Path: DORSAL SCAPULAR NERVE C5
Arises off Brachial Plexus, Pierces middle scalene, Runs deep to levator Scapula, Terminates at Rhomboids
Path: SUPRASCAPULAR NERVE C5/6
Arises off Upper Trunk of Brachial Plexus, Passes through posterior triangle of neck and parallel to trapezii, Runs along superior border of scapula, Enters suprascapular notch/fossa, spine of scapula and into infraspinous fossa
Path: AXILLARY NERVE C5/6
Arises off posterior cord of brachial plexus at axilla, Enters into the quadrangular space bound above subscapularis, below by teres major and medially by lateral head of the triceps, Divides into 3 branches: anterior, posterior, motor branches
6. What is the "classic triad" associated with Reiter's Syndrome? a. Arthritis, laryngitis, ptosis b. Arthritis, conjunctivitis, laryngitis c. Arthritis, ptosis, urethritis d. Arthritis, conjunctivitis, urethritis
Arthritis, conjunctivitis, urethritis
Nerve Entrapment Sites: SAPHENOUS NERVE L3/4
At knee joint where nerve pierces fascia at adductor canal, Sartorius just superior to the knee
24. Which is the best definition of Intention to Treat Analysis? a. Attributing all patients to the group which they were randomized rather than the treatment that they actually received. b. Ensuring each patient whose data goes into the statistical analyses signed an informed consent document. c. Measuring the error of patients receiving the incorrect intervention in double-blind studies d. Statistical method requiring all patient to complete the study regardless of outcome
Attributing all patients to the group which they were randomized rather than the treatment that they actually received.
14. A 42-year old male complains of insidious onset of vague, difficult to isolate left hip and groin pain that has been progressively worsening since it occurred two months ago. He was referred by his family physician (which he saw two weeks ago). He states he typically wouldn't have gone to the doctor for this, but he was being seen for his sickle cell anemia and mentioned to his physician while he was there. His physician ordered x-rays which were unremarkable and provided a referral to physical therapy. His prior medical history is significant for gout to the right great toe as a complication from a 1st metatarsal fracture 7 years ago. He is currently taking Zoloft for chronic depression. His Zoloft is assisting him to cope with his alcoholism but reports the medication often makes him feel fatigued, this has impaired his ability to begin a cardiovascular program. He is currently very sedentary. He has no pain with bowel movements and valsalva testing is negative. Physical examination revealed bilateral and ipsilateral squats caused a reproduction of his symptoms and an increase in left hip IR and knee valgus was noted. Hip and knee AROM WNL and only with mild pain at end ranges. MMT at the hip and knee is 4/5 bilaterally without reproduction of his symptoms. No tenderness to palpation is noted. Based on this information, what is the most likely diagnosis? A. Avascular Necrosis B. Hernia C. Ilioinguinal nerve entrapment D. Stress fracture
Avascular Necrosis. This typically occurs in the 4th decade of life and has fairly benign physical findings. AROM is typically WNL unless advanced and x-rays often will not demonstrate any pathology until at least 3 months. The key to this diagnosis is knowledge of predisposing factors, which are present in 80% of the cases. Predisposing factors include: Sickle Cell Anemia, Gout, Alcoholism, steroid usage, renal disease, radiation, and previous trauma to the hip.
Nerve Entrapment Sites: RADIAL NERVE (C5/6/7/8/T1)
Axilla due to crutches, Mid humerus due to fractures, Radial head fractures, Supinator/Arcade of Frohse, ECRB tendon
Common attachments of muscles on the: TARSALS - NAVICULAR
DISTAL: tibialis posterior
4. A fifteen year old female soccer player presents to your clinic 1 week after traumatic anterior dislocation of her right shoulder. She states her athletic trainer had to reduce her injury on the sideline. Since the time of injury, she has been treated in her training room with ice and TENS and has been wearing a sling. Upon physical examination, you find the following: Positive Anterior Apprehension/Relocation test, negative Feagin's sign, and negative sulcus sign. Radiographs reveal no fractures of the Humerus or Glenoid When assessing this patient on the field, her athletic trainer would want to assess for possible injury to what nerve? a. Axillary b. Dorsal Scapular c. Radial d. Suprascapular
Axillary
19. Which of the following tissues has the ability to regenerate itself instead of repairing with scar tissue? a. Bone b. Ligament c. Muscle d. Tendon
Bone
Abdominal Aneurysm
Back, abdominal, or groin pain • Presence of peripheral vascular disease or coronary artery disease and associated risk factors (age over 50, smoker, hypertension, diabetes mellitus) Increase index of suspicion if: • Symptoms not related to movement stresses associated with somatic LBP • Abdominal girth <100 cm (40 in)
2. What is the "telltale" radiographic sign of Ankylosing Spondylitis? a. Bamboo Spine b. Degenerative Disc Disease c. Schmoral's nodes d. Scotty Dog
Bamboo Spine
4. A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg's Sign, and (+) Froment's sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. Which muscle assists the Supinator in all activities requiring rapid forearm supination? a. Biceps Brachii b. Brachialis c. Brachioradialis d. Extensor Carpi Radialis Brevis
Biceps Brachii
Common attachments of muscles on the: ANTEBRACHIAL FASCIA
DISTAL: triceps brachii
What is the typical presentation of patients with NECK PAIN WITH MOBILITY DEFICITS?
COMMON SYMPTOMS; central and/or unilateral neck pain, limitatin in neck motion that consistent reproduces symptoms, associated referred shoulder girdle or upper extremity pain may be present. EXAM FINDINGS; limited cervical ROM, neck pain at end active/passive ranges, restricted cervicothoracic segmental mobility, pain reproduced with segmental mobility assessment or cervical musculature, decreased cervicoscapulothoracic strengthen and motor control.
What is the typical presentation of patients with NECK PAIN WITH MOVEMENT COORDINATION IMPAIRMENTS (WAD)
COMMON SYMPTOMS; mechanism of onset linked to trauma or whiplash, associated shoulder girdle or UE pain, associated caried nonspecific concussive signs, dizziness/nausea, headache, concentration/memory difficulties, confusion, hypersensitivity to mechanics/thermal/acoustic/odor/light stimuli, heightened affective distress. EXAM FINDINGS; positive cranial flexion and neck flexor muscle endurance tests, strength and endurance deficits of neck muscles, pain with mid-range motion/worsens with end-ranges, point tenderness may include TrP, sensorimotor impairment may include altered muscle activation patterns/proprioception deficit/postural control, pain reproduced by provocation of involved cervical segments.
What is the typical presentation of patients with NECK PAIN WITH RADIATING PAIN (Radicular)
COMMON SYMPTOMS; neck pain with radiating (narrow band of lancinating) pain in the involved extremity, upper extremity dermatomal paresthesias or numbnesss, myotomal muscle weakness. EXAM FINDINGS; neck and neck-related radiating pain reproduced or relieved with radiculopathy testing (positive test cluter includes ULTT, Spurling's test, cervical distraction, & cervical ROM. May have upper extremtiy sensory, strength, or reflex deficits associated with the involvedd nerve roots.
5. A 27 year old sales clerk slipped on the ice and fractured her scaphoid. It was repaired via open reduction/internal fixation. Fracture union must be verified by which diagnostic test prior to initiating active-assistive and active exercises? a. CT scan b. MRI c. Ultrasound d. X-Ray
CT Scan
8. One of your PT technicians comes to work Monday morning complaining of excruciating right shoulder pain. She tells you that the pain came about Saturday morning and was of insidious onset and that she had not performed any strenuous activity Friday. The pain is in her lateral upper arm that has not been relieved by rest or changes in position and that forward flexion exacerbates the pain. She also reports she has tenderness along the distal acromion near the middle deltoid insertion. Based on this information alone, which of the following diagnoses is most likely correct? a. AC joint sprain b. Calcific tendonitis c. Deltoid tendonitis d. Impingement syndrome
Calcific tendonitis
8. A 34 year old female presents to your clinic with a prescription from her family practice physician to evaluate and treat a hypomobile right TMJ. The patient reports she has been having pain in her TMJ for the past 6 months without relief. Physical examination reveals the following data: • S-curve with jaw opening • 25mm of jaw opening • Auditory and palpable "click" with opening and closing the jaw • Pain is decreased by having the patient bite down with a cotton roll between their molars Assume instead that this patient had a straight-line deviation to the left with jaw opening (instead of an S-curve) that occurred late during the jaw opening phase. The patient had no clicking associated with opening or closing the jaw and biting on the cotton roll increased her symptoms. What would her diagnosis most likely be? a. Anterior dislocation of the disc without relocation b. Capsular (TMJ) restriction c. Muscle imbalance d. Posterior subluxation of the TMJ
Capsular (TMJ) Restriction
13. A 50 year old female data entry specialist presents to your clinic with a 2 month history of pain in the palmar aspect of her right hand and the 2nd and 3rd fingers. In addition, she complains of numbness and tingling at night. She finds relief by "shaking" or massaging her hand. She reports that her husband sustained a spinal cord injury at C6/7 and came home from the hospital 3 months ago. She is his sole caregiver. Her employer allowed her to work at home, and bought her a notebook computer for home use so she wouldn't have to make room for her desktop model computer at home. The patient has no history of diabetes, hypothyroidism, and does not drink alcohol. You note the following on physical examination. Cervical AROM left sidebending WNL and right rotation 70 deg, both produce pain at the right cervical region. Symptom Severity Score is 2.2 and her wrist ratio index is 0.71. She has diminished sensation to sharp/dull at her DIP of the 2nd digit compared to her thenar eminence. Spurling's test is negative. Roos test is negative. Tinel's and Phalen's tests are negative at bilateral wrists. Upper limb tension test (median nerve bias) is negative. Cervical distraction is negative. Based on this information, what is the most probable diagnosis? a. Carpal tunnel syndrome b. Cervical radiculopathy c. Radial tunnel syndrome d. Thoracic outlet syndrome
Carpal Tunnel Syndrome
Clinical Findings of Entrapped: TIBIAL NERVE L4/5/S1/2/3
Chronic heel pain, Paresthesia of plantar surface of foot, Aching calf, Weak plantarflexors and inverters, Burning of toes and plantar aspect of the foot, Overpronation, Pain with walking
20. Which of the following is an example of the pathology attributed to Rheumatoid Arthritis? a. Chronic thickening and edema of the synovial lining b. Thinning and breakdown of hyaline cartilage c. Inability to weightbear on the MTP's of the feet d. Inability to flex the DIP's of the hand
Chronic thickening and edema of the synovial lining
Clinical Prediction Rule for DVT
Clinical Findings - 1. active cancer, 2. paralysis or recently casted, 3. recently bedridden > 3 days, 4. localized tenderness, 5. entire LE swelling, 6. Calf swelling > 3 cm, 7. Pitting edema, 8. collateral superficial veins, 9. no alterantive diagosis. 3 or higher --> high probability
What is known regarding clinical course of neck pain?
Clinical course is widely variable. Acute Traumatic Conditions typically follow 3 trajectories; (1) Mild problems with rapid recovery, (2) Moderate problems with incomplete recovery, (3) Severe problems without recovery (15% of cases). Acute Non-Traumatic (less known); Most recovery expected by the 6-12 week mark and slows considerably beyond this point. Chronic Neck Pain; Stable or Fluctuating, most cases recurrent. Acute Cervical Radiculopathy; Clinical course favorable resolution within weeks to months.
In regards to the high prevalence of recurrent/chronic low back pain, how should clinicians prioritize interventions?
Clinicians should place high priority on interventions that prevent 1) recurrences and 2) the transition to chronic low back pain.
What are the recommendations for diagnosis and classification in the neck pain CPG?
Clinicians should use motion limitations in cervical and upper thoracic regions, pressence of cervicogenic headace, history of trauma, and referred/radiating pain as usefull findings for classifying patients with neck pain into following categories; (1) NECK PAIN WITH MOBILITY DEFICITS, (2) NECK PAIN WITH MOVEMENT COODINATION IMPAIRMENTS (including WAD), (3) NECK PAIN WITH HEADACHES (cervicogenic headache), (4) NECK PAIN WITH RADIATING PAIN (radicular).
Function: COMMON PERONEAL NERVE L4/5/S1/2
Common: sensory at popliteal fossa, Superficial: Motor - peroneals, extensor digitorum tertius, Sensory - anterior/lateral leg and dorsum of foot except between 1st and 2nd toes. Deep: Motor - anterior tibialis, extensors, Sensory - between 1st and 2nd Toes
15. You are evaluating a 35 year old male who is 1 week status post right ACL reconstruction with a hamstring autograft. The patient complains of significant pain and swelling in the posterior thigh and leg. He has tenderness to firm palpation along the center of the right posterior calf, popliteal space, and anterior medial thigh extending proximal to the groin region. The diameter of his right calf (measured 10cm distal from the tibial tuberosity) is 4.5cm larger than his left calf. His distal pulses are intact and equal bilaterally. The area is warm to the touch. The patient denies any recent fever. Your differential diagnosis includes proximal deep vein thrombosis. Based on this data, what is your next best course of action? A. Contact referring physician, recommend compressive ultrasound study B. Contact referring physician, recommend D-Dimer lab C. Contact referring physician, express concern for infection D. Contact referring physician, express concern for hemarthrosis
Contact referring physician, recommend D-Dimer lab
12. CASE STUDY: A 68 year old retired metal worker is 9 weeks status post right TKA. The patient has been on a fishing vacation for the past two weeks. When he returns for physical therapy, you notice he has a flexion contracture at his right knee that is preventing him from attaining the last 15 degrees of knee extension. He was able to attain terminal knee extension prior to leaving for vacation. He reports that he was not adherent to his home exercises while on vacation and that he is beginning to develop some low back pain. Which of the following interventions would you choose to perform in the clinic in order to restore this patient's range of motion as rapidly as possible? a. Contract/Relax stretches to his hamstrings b. Static stretch to his hamstrings c. Ultrasound to his distal hamstrings followed by Contract/Relax stretches to his hamstrings d. Ultrasound to his distal hamstrings followed by static stretch to his hamstrings
Contract/Relax stretches to his hamstrings
11. The 2008 Clinical Practice Guidelines for Neck Pain from the APTA's Orthopedic Section report "strong evidence" for which of the following interventions for neck pain? A. Centralization procedures and exercises B. Coordination, strengthening, and endurance training C. Stretching exercises D. Thoracic mobilizations/manipulations
Coordination, strengthening, and endurance training
2. Why would an anterior cruciate injury be more apt to swell immediately following injury versus a meniscus injury, which could take from 24 to 48 hours to swell? a. Cruciates are extrasynovial and extracapsular, menisci are intrasynovial b. Cruciates are extrasynovial and intracapsular, menisci are intrasynovial c. Cruciates are intrasynovial and extracapsular, menisci are extrasynovial d. Cruciates are intrasynovial and intracapsular, menisci are extrasynovial
Cruciates are extrasynovial and intracapsular, menisci are intrasynovial
Clinical Findings of Entrapped: ULNAR NERVE C8/T1
Cubital Tunnel Syndrome: Claw hand due to hyperextension of MCP's at 4th and 5th and flexion at IP's, weakness in flexion at wrist, Sensory: loss at 4th and 5th digits both palmar and dorsal. Guyon Canal: loss of flexion at 4th and 5th digits, claw hand, Sensory: loss at 4th and 5th palmar side only
Nerve Entrapment Sites: ULNAR NERVE C8/T1
Cubital Tunnel, Guyon's Canal, FCU Origin
What clinical findings are useful for diagnosis/classification of ankle instability?
Cumberland Ankle Instability Tool.
10. Which of the following lumbar stabilization exercises produces the greatest recruitment of the Transverse Abdominis & Internal Oblique Abdominis? Look at other page. A B C D
D. correct
What functional outcomes measures should be used with Adhesive Capsulitis?
DASH, ASES, or the SPADI.
Common attachments of muscles on the: ULNA - TUBEROSITY
DISTAL: Brachialis
Common attachments of muscles on the: HUMERUS - DELTOID TUBEROSITY
DISTAL: Deltoid
Common attachments of muscles on the: SCAPULA - MEDIAL BORDER
DISTAL: Levator Scapulae, rhomboid minor, rhomboid major, serratus anterior.
Common attachments of muscles on the: FOOT - FIFTH PHALANX?
DISTAL: PROXIMAL PHALANX: abductor digiti minimi, flexor digiti minimi brevis, interossei (plantar only), MIDDLE PHALANX: extensor digitorum longus, flexor digitorum brevis, DISTAL PHALANX: extensor digitorum longus, flexor digitorum longus.
Common attachments of muscles on the: FOOT - FIRST PHALANX?
DISTAL: PROXIMAL PHALANX: extensor hallucis brevis, abductor hallucis, flexor hallucis brevis, adductor hallucis; DISTAL PHALANX: extensor hallucis longus, flexor hallucis longus.
Common attachments of muscles on the: HAND - FIRST PHALANX
DISTAL: PROXIMAL PHALANX: extensor pollicis brevis, abductor pollicis brevis, flexor pollicis brevis, adductor pollicis; DISTAL PHALANX: flexor pollicis longus, extensor pollicis longus
Common attachments of muscles on the: FOOT - SECOND PHALANX?
DISTAL: PROXIMAL PHALANX: interossei (dorsal only), MIDDLE PHALANX: extensor digitorum longus, flexor digitorum brevis, DISTAL PHALANX: extensor digitorum longus, flexor digitorum longus.
Common attachments of muscles on the: FOOT - FOURTH PHALANX?
DISTAL: PROXIMAL PHALANX: interossei, MIDDLE PHALANX: extensor digitorum longus, flexor digitorum brevis, DISTAL PHALANX: extensor digitorum longus, flexor digitorum longus.
Common attachments of muscles on the: FOOT - THIRD PHALANX?
DISTAL: PROXIMAL PHALANX: interossei, MIDDLE PHALANX: extensor digitorum longus, flexor digitorum brevis, DISTAL PHALANX: extensor digitorum longus, flexor digitorum longus.
Common attachments of muscles on the: PATELLA
DISTAL: Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
Common attachments of muscles on the: HUMERUS - GREATER TUBERCLE
DISTAL: Supraspinatus, infraspinatus, teres minor
Common attachments of muscles on the: TARSALS - INTERMEDIATE CUNEIFORM
DISTAL: Tibialis posterior
Common attachments of muscles on the: HAND - FIFTH PHALANX
DISTAL: abductor digiti minimi, flexor digiti minimi brevis, interossei (palmar only); flexor digitorum superficialis (middle phalanx), flexor digitorum profundus (distal phalanx)
Common attachments of muscles on the: FEMUR - MEDIAL SUPRACONDYLAR LINE
DISTAL: adductor magnus (adductor part)
Common attachments of muscles on the: FEMUR - ADDUCTOR TUBERCLE
DISTAL: adductor magnus (hamstrings part)
Common attachments of muscles on the: BICIPITAL APONEUROSIS
DISTAL: biceps brachii
Common attachments of muscles on the: RADIUS - TUBEROSITY
DISTAL: biceps brachii
Common attachments of muscles on the: EXTENSOR EXPANSIONS (HAND)
DISTAL: extensor digitorum (digits 2-5), extensor digiti minimi (5th digit), extensor indicis (2nd digit), lumbricals (digits 2-5), interossei.
Common attachments of muscles on the: TENDONS OF EXTENSOR DIGITORUM LONGUS
DISTAL: extensor digitorum brevis
Common attachments of muscles on the: FEMUR - GLUTEAL TUBEROSITY
DISTAL: gluteus maximus, adductor magnus (adductor part)
Common attachments of muscles on the: ILIOTIBIAL TRACT
DISTAL: gluteus maximus, tensor of fascia latae
Common attachments of muscles on the: HAND - FOURTH PHALANX
DISTAL: interossei (proximal phalanx); flexor digitorum superficialis (middle phalanx), flexor digitorum profundus (distal phalanx)
Common attachments of muscles on the: HAND - SECOND PHALANX
DISTAL: interossei (proximal phalanx); flexor digitorum superficialis (middle phalanx), flexor digitorum profundus (distal phalanx)
Common attachments of muscles on the: HAND - THIRD PHALANX
DISTAL: interossei DORSAL ONLY (proximal phalanx); flexor digitorum superficialis (middle phalanx), flexor digitorum profundus (distal phalanx)
Common attachments of muscles on the: EXTENSOR EXPANSION (FOOT)
DISTAL: lumbricals (digits 2-5)
Common attachments of muscles on the: FEMUR - TROCHANTERIC FOSSA
DISTAL: obturator externus
Common attachments of muscles on the: PALMAR APONEUROSIS
DISTAL: palmaris longus
Common attachments of muscles on the: FEMUR - PECTINEAL LINE
DISTAL: pectineus, adductor brevis
Common attachments of muscles on the: HUMERUS - INTERTUBERCULAR GROOVE
DISTAL: pectoralis major, latissimus dorsi, teres major (a lady between 2 majors)
Common attachments of muscles on the: PUBIS - ILIOPUBIC EMINENCE
DISTAL: psoas minor
Common attachments of muscles on the: PUBIS - PECTEN PUBIS
DISTAL: psoas minor
Common attachments of muscles on the: FEMUR - LESSER TROCHANTERIC
DISTAL: psoas minor, iliacus
7. You are discussing physical therapy referrals with a family physician at your hospital and she states that she always waits 6 weeks prior to referring a patient with acute LBP to physical therapy because of the "naturally favorable course of low back pain." You point out to her that patients with acute LBP that are delayed entry into physical therapy by 6 weeks are 31% more likely to develop: a. Chronic LBP b. Depression c. Missed time from work d. Neurological symptoms
Depression
What are the recommendations for differential diagnosis in the neck pain CPG?
Direct pathoanatomical causes of mechanical neck pain are rarely identifiable. Clinicians should test/inquire for clinical findings/red flags to determine presence of serious pathology (infection, cancer, cardiac, arterial insufficiency, cranial nerve dysfunction, and fracture).
12. A 21 year old male college student presents to your clinic complaining of a two week history of dorsal hand pain over the area of the 4th metacarpal. The patient reports he inadvertently punched his dorm room door two weeks ago when he lost his key and couldn't get in his room and has had pain since. The patient has decreased AROM extension at the 4th PIP and MCP. Grip strength is also diminished and painful. When the patient makes a fist, you observe the head of the 4th metacarpal is more proximal than the 3rd and 5th metacarpal heads. The patient is tender to palpation over the distal shaft of the 4th metacarpal. Further examination with the patient making a fist reveals a rotational misalignment of the injury. What was your most likely observation when you made this conclusion? a. Distal aspect of the digit was pointed toward the scaphoid b. Distal aspect of the digit was pointed away from the scaphoid c. Distal aspect of the digit (DIP) was unable to completely extend d. Distal aspect of the digit (DIP) was hyperextended
Distal aspect of the digit was pointed away from the scaphoid
Clinical Findings of Entrapped: FEMORAL NERVE L2/3/4
Distal crossed syndrome, Paresthesia anterior medial thigh, Weak quads, Knee buckling, Reflexes at patellar tendon L3
Nerve Entrapment Sites: LATERAL FEMORAL CUTANEOUS L2/3
Distal psoas, TFL, inguinal ligament
Patient that would benefit from Flexion Oriented Treatment Approach
Distal symptoms, improvement with flexion activities, worsens with extension, likely diagnosis - spinal stenosis
Sacroiliac Joint pain provocation Test Clusters
Distraction, compression, thigh thrust, Gaenslen's, sacral thrust, FABER. Need at least 3 to be (+), better if no centralization with repeated motion testing
Function: SAPHENOUS NERVE L3/4
Sensory - medial lower leg and medial foot/arch
8. After evaluating a patient with subacute right-sided low back and buttock pain you determine they meet the clinical prediction rule for success as described by Flynn. You decide to perform an HVLA gapping technique directed at the right SIJ. You perform the technique but cavitation does not occur. Upon reassessment you determine that the patient's asterix signs have improved but you are troubled that the joint failed to "pop". Based on the current evidence, what is the next best course of action? a. Do not perform another HVLA that session b. Perform a 2nd HVLA at the right SIJ c. Perform a HVLA at the left (opposite) SIJ d. Use a contract-relax technique due to joint stiffness
Do not perform another HVLA that session
18. Which of the following is a Colles' Fracture? See Additional page. A. Dorsal angulation, dorsal displacement, extra-articular B. This is a Smith's (reverse Colles') fracture - note the volar angulation/displacement. It is also extra-articular. C. This is a Barton's fracture. It is intra-articular and can be either volarly or dorsally displaced.
Dorsal angulation, dorsal displacement, extra-articular
Best Recruitment of Transverse Abdominis - looking for exercises
Draw in Manuever, Quadruped Opposite Upper Extremity/Lower Extremity Lift (bird dog)
21. CASE STUDY: A patient presents with 12 week history of right Achilles tendon pain that is cyclic in nature. He has inconsistent pain with running in his current state. However, when the symptoms began 3 months ago he had pain with running that progressed to pain with walking. He stopped running 4 weeks after symptom onset. What is the best treatment option for this patient? a. Combined ice and stretching x 20 minutes BID x 4 weeks b. Eccentric calf raises 3x15 BID into painful threshold x 12 weeks c. Isotonic calf raises 3 sets, repetitions to painfree tolerance x 4-6 weeks d. Pulsed ultrasound, 3.3Mhz, 1.0 w/cm2 TIW x 3 weeks
Eccentric calf raises 3x15 BID into painful threshold x 12 weeks
13. A 41 year old female with an 18 week history of right lateral epicondylalgia presents to your clinic. She has failed conservative therapy in the past that consisted ultrasound and TENS. Her history is significant for repetitive work activities that exacerbate her condition and she is unable to take time off of work. You decide to attempt to reduce the strain at the proximal ECRB tendon. Based on the best evidence, you elect to use which of the following? A. Elbow sleeve orthosis at proximal forearm B. Elbow strap orthosis at midpoint of the forearm C. Tape applied in a diamond pattern around the lateral epicondyle D. Wrist Cock-up splint placing the wrist in 15 degrees of extension
Elbow sleeve orthosis at proximal forearm
Path: SUPRACLAVICULAR NERVE (C3/4)
Emerges via posterior border of the SCM, Descends in the posterior triangle , At clavicle divides into 3 branches - medial, intermediate, and lateral
1. Postero-medial shin splints are more likely correlated with a. excessive forefoot supination b. excessive forefoot pronation c. excessive forefoot rigidity d. excessive internal tibial torsion
Excessive foot pronation
2. A 39 year old female complains of low back pain and left lower extremity pain for 60 days. Oswestry is 37%, VAS 5, FABQ work subscale 14, physical activity subscale 15. The patient demonstrates painful AROM flexion that increases her left lower extremity symptoms and aberrant movements upon return to neutral. The patient reports relief of symptoms with walking. Based on this data, what would be the best intervention? a. Extension exercises b. HVLA to the SI Joints c. Mechanical lumbar traction & Extension exercises d. Stabilization exercises to the lumbar spine
Extension exercises
5. CASE STUDY: A 22 year old sedentary male presents to your clinic with an insidious onset of low back pain for threeweeks. The patient reports his pain is increased with rest and decreased with activity. The pain is localized to his lower lumbar and upper SIJ region. Radiographs have not been taken and NSAID's have helped reduce the pain. This patient would most likely benefit from which of the following physical therapy interventions? a. Bedrest for 48 hours and education about staying as active as possible and continuing to take his NSAID's b. Flexion exercises and education about sleeping with a pillow under his knees c. Extension exercises and education about discontinuing usage of a pillow under his head while sleeping d. Mechanical lumbar traction
Extension exercises and education about discontinuing usage of a pillow under his head while sleeping
4. Dorsal ganglion cysts commonly compress into which soft-tissues at the wrist? a. Abductor Pollicus Longus, Extensor Pollicus Brevis b. Extensor Carpi Ulnaris, Extensor Digiti Minimi c. Extensor Digit Minimi, Extensor Digitorum d. Extensor Pollicus Longus, Extensor Digitorum
Extensor Pollicis Longus, Extensor Digitorum
10. What is the proper classification of a Colles' fracture? a. Extra-articular distal radius fracture with dorsal angulation, displacement, and shortening of the fracture b. Extra-articular distal radius fracture with volar displacement and angulation of the fracture. c. Intra-articular shear fracture of the distal radius with dorsal displacement of the fracture d. Intra-articular shear fracture of the distal radius with volar displacement of the fracture
Extra-articular distal radius fracture with dorsal angulation, displacement, and shortening of the fracture
What outcome measures are recommended for examination of heel pain and plantar fasciitis?
FAAM, Foot Health Status Questionnaire (FHSQ), or Foot Function Index (FFI). LEFS
What are the cutoff values for the Fear Avoidance Behavior Questionnaire?
FABQ - W: greater than 29 for working population and greater than 22 for non-working populations. FABQ-PA: greater than 14. FABQW was a better predictor of self-reported disability at 6 months in comparison to the FABQ-PA.
15. Decrease in key chuck pinch can be attributed to an injury to which muscle & nerve? a. First dorsal interossei (ulnar) b. First lumbricals (median) c. Flexor Policus Longus (anterior interosseus nerve) d. Flexor digitorum profundus (median)
First Dorsal Interossei
5. You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a "pop". X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive "sag sign". During your exam, you note laxity present with a Lachman's test. Does this confirm the patient has a torn anterior cruciate ligament injury? a. True b. False
False
Nerve Entrapment Sites: OBTURATOR NERVE L2/3/4
Fascia at adductor brevis
11. What would be a good objective test to measure for a pes planus deformity? a. Buerger's Test b. Duchenne's Test c. Feiss Line Test d. Morton's Test
Feiss Line Test
What are the risks factors and common findings for PFP?
Female > male. Sports specialization in younger population (Female). Reduced isometric knee extension strength. Decreased hip force production (Abd, ER, & Ext) however not shown to be cause but rather a result of PFP. Altered biomechanics/increased Frontal Plan Projection Angle (FPPA) with SL squat and hop landing tests. No correlation with anthropometrics and conflicting evidence for altered foot mechanics. Psycosocial impact; individuals with longer duration of symptoms, higher baseline pain severity and poorer function were more likely to have unfavorable recovery.
Nerve Entrapment Sites: COMMON PERONEAL NERVE L4/5/S1/2
Fibular head due to braces or casts, Repetitive exercise, Trauma to lateral leg, Prolonged squatting (gardner's syndrome)
10. A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, "it felt like someone kicked me in the back of my leg". His calf is obviously deformed, and he is unable to actively plantar flex his foot. Based on your findings, this patient was referred to orthopedics and a surgical repair of the involved tissue was done within 24 hours. At would point in his post-operative rehab would you consider isotonic strength training and proprioception for the repaired area? a. Three weeks b. Five weeks c. Seven weeks d. Nine weeks
Five weeks
Example of a Knee Injury Prevention Program.
Flexbility (dynamic stretches); quads, hamstrings, adductors, hip flexors, calf. Running; forward running, backwards running, zigzag, bounding. Strength; double leg squat, single leg squat, lunges, nordic hamstring. Core; planks, bridges. Plyometrics; SL hopping (anterior/posterior), "ice skaters", jump to header or catch ball overhead (sport dependent).
12. You are evaluating a patient with "deep" hip pain. You do not suspect acetabular labral pathology but decide to rule the condition out so you can confidently continue with your plan of care. Which of the following tests is best suited to rule out an acetabular labral tear? A. FABER Test B. Flexion-Adduction-Internal Rotation Test C. Flexion-Internal Rotation Test D. Fitzgerald Test
Flexion- Internal Rotation Test
6. CASE STUDY: A 56 year old male right-hand dominant carpenter presents to your clinic with a 3 week history of proximal right anterior forearm pain and paresthesias in his 1st -3rd digits. These symptoms are exacerbated by activity. Examination reveals weakness with 1st-3rd digit flexion and wrist flexion. He exhibits tenderness to palpation along the proximal anterior forearm. Manual muscle tests of biceps brachii and of 3rd digit PIP flexion are both strong but with a reproduction of his paresthesias. Resisted pronation with the Why would this patient have a reproduction of symptoms (paresthesias in 1st -3rd digits with resisted 3rd digit PIP flexion?elbow flexed to 90° is weak with pain. However, resisted pronation with the elbow extended is strong and without pain. Why would this patient have a reproduction of symptoms (paresthesias in 1st-3rd digits with resisted 3rd digit PIP flexion? Why would this patient have a reproduction of symptoms (paresthesias in 1st-3rd digits with resisted 3rd digit PIP flexion? a. Flexor Carpi Ulnaris compresses the posterior interosseous nerve b. Flexor Digitorum Profundus compresses the anterior interosseous nerve c. Flexor Digitorum Superficialis compresses the median nerve d. Palmaris Longus compresses the radial nerve
Flexor Digitorum Superficialis compresses the median nerve
9. What are the contents of the carpal tunnel? a. Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Flexor CarpiRadialis tendons, Median nerve b. Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Flexor CarpiUlnaris tendons, Median nerve c. Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Flexor PolicusLongus tendons, Median nerve d. Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Palmaris LongusLongus tendons, Median nerve
Flexor Digitorum Superficialis, Flexor Digitorum Profundus, Flexor PolicusLongus tendons, Median nerve
7. Which of the following groups of muscles are innervated by the Anterior Interosseous nerve? a. Flexor Pollicus Longus, Pronator Quadratus, Flexor Digitorum Profundus (lateral half) b. Flexor Carpi Ulnaris, Pronator Quadratus, Flexor Digitorum Profundus (lateral half) c. Pronator Teres, Pronator Quadratus, Flexor Digitorum Profundus (lateral half) d. Pronator Teres, lateral two lumbricals, Flexor Digitorum Profundus (lateral half)
Flexor Pollicus Longus, Pronator Quadratus, Flexor Digitorum Profundus (lateral half)
What are the Bernese Ankle Rules (sensitivity 100% & specificity 91%) criteria that indicate the need for radiographs?
Following low-energy malleolar and/or midfoot trauma. 1. indirect fibular stress applied 10 cm proximal to fibular tip. 2. direct medial malleolar stress. 3. simultaneous compression of midfoot and hindfoot.
What outcome measures are recommended for ankle ligament sprains?
Foot and Ankle Ability Measure and LEFS.
Clinical Findings of Entrapped: COMMON PERONEAL NERVE L4/5/S1/2
Foot slap, Pain at fibular head or popliteal fossa, Pain/numbness anterior lateral leg and in between 1st two toes.
Path: OBTURATOR NERVE L2/3/4
Forms in Psoas, Passed through obturator foramen, Divides into anterior and posterior branches to medial thigh
Path: FEMORAL NERVE L2/3/4
Forms in psoas, Descends between psoas and iliacus, deep to inguinal ligament, femoral triangle, Terminates in quadriceps and becomes the saphenous nerve
Function: SURAL NERVE S1/2
Sensory for posterior-lateral leg and lateral heel/lateral foot along 5th ray
5. A 39 year old male with 5 week history of left lower cervical pain presents to your clinic. His Neck Disability Index score is 30%, FABQ physical activity subscale is 10. AROM cervical flexion is painful and limited. Right rotation is 58 degrees with mild pain, left rotation is 45 degrees with moderate pain. Bilateral sidebending is slightly limited with mild pain. PA mobilizations (centrally) at C4-6 reproduce his pain. Based on this data what is the best intervention for this patient? a. HVLA mid/lower cervical spine and AROM neck exercises. b. HVLA upper and middle thoracic spine (gapping technique) c. PA mobilizations to lower cervical and upper thoracic spine over the spinous processes d. PA mobilizations to the upper and middle thoracic spine over the left transverse processes
HVLA upper and middle thoracic spine (gapping technique).
18. "Quadriceps dominance" is a factor that can predispose a female athlete to an ACL injury when landing from a jump. Which of the following rationales supports the use of the hamstring muscles to counter a quadriceps dominance and thus decrease the likelihood of ACL injury? A. Hamstring insert on either side of the tibia and offer better transverse plane support to the knee B. Hamstrings are an ACL synergist C. Hamstrings allow for more hip extension which places the center of mass more anteriorly thus easier to control D. Hamstrings allow for more stability since they cross both the knee and hip
Hamstrings are an Anterior Cruciate Ligament synergist
Clinical Findings of Entrapped OCCIPITAL NERVE (C2)
Headache, Painful cervical motion, especially rotation, Hypertonic trapezius and levator scapula, Proximal crossed syndrome;
Treatment of TMJ Disorders
High evidence - Cervical spine Mobilizations - upper; moderate evidence - myofascial release, O1/2 HVLA, Low evidence - massage, C7/T1 HVLA
what factors were determined to have high to moderate confidence for developing persistent neck pain (WAD)?
High pain intensity, high NDI, high post traumatic stress symptoms, strong catastrophic beliefs, & cold hyperalgesia.
What are the recommend outcome measures for nonarthitic hip pain?
Hip Outcome Score (HOS), Copenhagen Hip and Groin Outcome Score (HAGOS), Internation Hip Outcome Tool (iHOT-33).
What physical impairment measures should be evaluated for nonarthritic hip pain?
Hip pain, mobility, muscle power and movement coordination.
7. A 47 year old male presents to your clinic with right wrist pain x 2 weeks. He reports he made a bad golf swing in which his club struck the ground and he has had pain ever since. His pain is exacerbated with attempting to ride his bicycle and while driving his car (primarily using his right hand to turn the wheel to the left). His primary care physician ordered AP and lateral x-rays that revealed no pathology at the wrist and hand. Physical examination reveals tenderness to palpation approximately 1-2cm distal and radial to the pisiform. He also has pain with resisted 4th and 5th DIP flexion and ulnar deviation. Why were the x-rays negative for wrist and hand pathology in this particular case? a. Ganglion cysts are unlikely to show up on AP and lateral radiographs b. Hook of Hamate fractures are unlikely to show up on AP and lateral radiographs c. Trapezium fractures are unlikely to show up on AP and lateral radiographs d. Ligamentous injuries do not show up on radiographs
Hook of Hamate fractures are unlikely to show up on AP and Lateral Radiographs
What is the 2018 summary for Diagnosis Articular Cartilage Lesions?
Intermittent knee pain, history of acute trauma, catching/locking, effusion, joint line tenderness.
6. A 47 year old male presents to your clinic with right wrist pain x 2 weeks. He reports he made a bad golf swing in which his club struck the ground and he has had pain ever since. His pain is exacerbated with attempting to ride his bicycle and while driving his car (primarily using his right hand to turn the wheel to the left). His primary care physician ordered AP and lateral x-rays that revealed no pathology at the wrist and hand. Physical examination reveals tenderness to palpation approximately 1-2cm distal and radial to the pisiform. He also has pain with resisted 4th and 5th DIP flexion and ulnar deviation. What is the most likely diagnosis? a. Ganglion cyst b. Hook of Hamate fracture c. Trapezium fracture d. 5th CMC sprain
Hook of the hamate fracture
Acute or Subacute low back pain with related cognitive of affective tendencies: Symptoms, ICD 10
ICD: Low back pain, disorder of central nervous system, specified as central nervous system sensitivity to pain; Symptoms: 1. Acute or subacute low back and/or low back related lower extremity pain.
Acute Low Back Pain with Related (referral) lower Extremity Pain: Symptoms, ICD 10
ICD: flatback syndrome, lumbago due to displacement of intervertebral disc ; Symptoms: 1. acute low back pain that is commonly associated with referred buttock, thigh, or leg pain. 2. symptoms are often worsened with flexion activities, and sitting.
Chronic low back pain with related generalized pain: Symptoms, ICD 10
ICD: low back pain, disorder of central nervous system, persistent somatoform pain disorder; Symptoms: 1. low back and/or low back-related lower extremity pain with symptom duration for longer than 3 months. 2. generalized pain not consistent with other impairment-based classification criteria presented in theses clinical guidelines.
Subacute low back pain with radiating pain: Symptoms, ICD 10
ICD: lumbago with sciatica ; Symptoms: 1. Subacute, recurring mid-back and/or low back pain with associated radiating pain in the involved lower extremity. 2. lower extremity paresthesias, numbness, and weakness may be reported.
Acute low back pain with radiating pain: Symptoms, ICD 10
ICD: lumbago with sciatica ; Symptoms: 1. acute low back pain with associated radiating (narrow band of lancinating) pain in the involved lower extremity. 2. lower extremity paresthesias, numbness, and weakness may be reported.
Chronic low back pain with radiating pain: Symptoms, ICD 10
ICD: lumbago with sciatica; Symptoms: 1. Chronic, recurring, mid-and/or low back pain with associated radiating pain in the involved lower extremity. 2. Lower extremity paresthesias, numbness, and weakness may be reported.
Acute Low Back pain with Mobility deficits: Symptoms, ICD 10
ICD: lumbosacral segmental/somatic dysfunction ; Symptoms: acute low back, buttock, or thigh pain (duration 1 month or less), unilateral pain, onset of symptoms is often linked to a recent unguarded/awkward movement or position
Subacute Low Back Pain with Mobility Deficits: Symptoms, ICD 10
ICD: lumbosacral segmental/somatic dysfunction ; Symptoms: subacute, unilateral low back, buttock, or thigh pain, may reprots sensation of back stiffness
Chronic Low Back pain with Movement Coordination Impairments: Symptoms, ICD 10
ICD: spinal instabilities ; Symptoms: Chronic, recurring low back pain and associated (referred) lower extremity pain.
Acute Low Back pain with Movement Coordination Impairments: Symptoms, ICD 10
ICD: spinal instabilities ; Symptoms: acute exacerbation of recurring low back pain that is commonly associated with referred lower extremity pain. Symptoms often include numerous episodes of low back and/or low back-related lower extremity pain in recent years.
Sub-Acute Low Back pain with Movement Coordination Impairments: Symptoms, ICD 10
ICD: spinal instabilities; Symptoms: 1. subacute, recurring low back pain that is commonly associated with referred lower extremity pain. 2. symptoms often include numerous episdoes of low back and/or low back-related lower extremity pain in recent years.
What outcome measures are recommended for knee ligament injuries?
IKDC 2000, KOOS, Lysholm scale. Tegner activity scale and Marx Activity Rating Scale to assess activity level before and after interventions. ACL-Return to Sport after Injury to assess psychologic factors hindering return to sports.
7. You are performing the Supine-to-Longsit test on a patient with suspected leg length discrepancy. When the patient is supine you note the right leg to be longer than the left. When the patient moves into Longsit, the right leg becomes shorter than the left. What do these findings most likely indicate? a. Right anterior innominate rotation b. Left posterior innominate rotation c. Anatomical leg length dysfunction d. Iliosacral dysfunction
Iliosacral dysfunction. A positive Supine-to-Longsit test rules out a sacroiliac dysfunction and rules in an iliosacral dysfunction (example: innominate rotation)
What is the 2017 summary for the INCIDENCE for Knee Ligament Sprains?
Incidence for ACL and MCL injuries are high in active individuals. ACL rate higher in young female athletes compared to males, most of which are non-contact injuries. Rate of second ACL injury rises progressively from surgery and young female athletes who return to sport are vulnerable. Incidence of PCL injuries range from .65% to 44% with most common causes being MVA and athletics. LCL injuries are least common (7.9%). MCL/ACL and PLC/ACL or PCL are the two most common multiligamentous injuries.
What is the summary regarding the pathoanatomical features of heel pain and plantar fasciitis?
Increased plantar fascia thickness is associated with symptoms and altered compressive properties of the fat pad in those with heel pain.
What is a Likelihood Ratio?
Indicators of how much a test result will raise or lower the pretest probability of the target disorder. Positive - increased the probability that target disorder present. Negative - decreased the probability that the target disorder is present. Best statistics for summarizing the usefulness of a diagnostic test
2. A 24 year old male presents to your clinic following a traumatic injury that occurred to his right shoulder 2 days prior while playing basketball. The patient stated that an opposing player struck his right forearm while he was attempting to catch a pass. He immediately felt pain and a "pop" at the time of injury. After further questioning, you determine his arm was in a position of approximately 100° abduction, 90° of external rotation, and slight extension at the time of injury and that the opposing player's force was directed from anterior to posterior. The patient is very hesitant to move his arm and presents with his arm in glenohumeral neutral and slight adduction. Based on the mechanism of injury, what structures are most likely to be compromised? a. Inferior Glenohumeral Ligament Complex & Biceps Brachii b. Coracoclavicular ligament c. Posterior Glenohumeral capsule d. Anterior labrum and long head of the Biceps tendon
Inferior Glenohumeral Ligament Complex & Biceps Brachii
Nerve Entrapment Sites: FEMORAL NERVE L2/3/4
Inguinal ligament with hip extension, Psoas
What is the most reliable indicator of a brachial plexus injury?
Integrity of the sensory nerves. Superior Trunk - lateral antebrachial cutaneous; Inferior Trunk - median nerve to D1/D2; Medial Antebrachial Cutaneous
Function: LATERAL FEMORAL CUTANEOUS L2/3
Sensory to anterior lateral thigh
16. A 32 year old male presents to your clinic with insidious onset of right shoulder pain. The pain is "deep" in the shoulder and is exacerbated with activities that place his arm at or above shoulder height or when reaching across his body. He has no prior medical history of right shoulder pain, neck or thoracic pain. His referring physician ordered plain films that did not demonstrate any pathology. Which special test would give you the best data for determining whether this patient's impairment was Rotator Cuff, ExtraArticular, or Intra-Articular in nature? A. Drop Arm Test B. External Rotation Lift-Off Sign (ERLS) C. Internal Rotation Resisted Strength Test (IRRST) D. O'Brians
Internal Rotation Resisted Strength Test (IRRST)
Clinical Findings of Entrapped: DORSAL SCAPULAR NERVE C5
Internal scapula pain, Levator scapula pain, Weakness at rhomboids and levator scapula, Dysfunctional scapulohumeral rhythm, Protracted scapula
What are the recommended outcome measures for knee specific outcomes?
Internation Knee Documentation Committe Subjective Knee Evaluation Form (IKDC 200) or KOOS.
3. A 38 year old male patient presents to your clinic with a 6 week history of neck pain and right shoulder and arm pain that extends just distal to the elbow. VAS at the neck is 4/10 and the Neck Disability Index score is 47%. A neurologic scan addressing sharp/dull touch, DTR's C5-C7 and MMT C4-T1 do not demonstrate any deficits. Based on this information alone, you elect to initially treat him with which of the following? a. Cervical and thoracic mobilizations/manipulations b. Gentle AROM cervical spine within pain tolerance c. Interventions to promote centralization d. Postural education
Interventions to promote centralization. This is a matched intervention for the "centralization" classification. While the patient does not have signs of nerve root compromise he does have symptoms distal to the elbow and symptoms >30 days duration - two key elements to this classification.
What conditions are considered for nonarthritic hip pain?
Intra-articular lesions, femoracetabular impingement, structual instability, labral tears, chondral lesions, and ligamentous teres tears. Septic conditions may also be present.
What is the summary regarding risk factors for midportion achilles tendinopathy?
Intrinsic Factors; abnormal ankle DF ROM, abnormal subtalar ROM, decreased PF strength, increased foot pronation, abnormal tendon structure. Medical conditions; obesity, HTN, hyperlipidemia, and diabetes. Extrinsic factors; training errors, environmental factors, faulty equipment.
14. CASE STUDY: A 27 year old female presents to physical therapy to reduce scar-tissue adhesions to her right forearm 3 months after a radial shaft fracture was surgically repaired with open reduction/internal fixation. You elect to combine iontophoresis and transverse friction massage in order to break up the scar tissue. What agent will you "push" with the iontophoresis? a. Acetic acid b. Dexamethasone c. Dexamethasone combined with Lidocaine d. Iodine
Iodine
Common attachments of muscles on the: RADIUS - SHAFT
LATERAL SURFACE - PROXIMAL: Pronator Teres; DISTAL: brachioradialis, supinator; ANTERIOR BORDER: PROXIMAL: flexor digitorum superficialis; ANTERIOR SURFACE: PROXIMAL: Flexor pollicis longus, DISTAL: pronator quadratus, supinator, POSTERIOR SURFACE: PROXIMAL: abductor pollicis longus, extensor pollicis brevis, DISTAL: supinator.
9. Based on this patient's straight-line deviation to the left with jaw opening (occurring late in the opening phase), what is the most likely impairment at the TMJ(s)? a. Bilateral TMJ hypermobility b. Bilateral TMJ hypomobility c. Left TMJ hypermobile, right TMJ hypomobile d. Left TMJ hypomobile, right TMJ hypermobile
LEFT TMJ hypomobile, RIGHT TMJ hypermobile
What is the summary regarding Classification of CTS?
Lack of consensus. Some evidence to suggest staging of mild, moderate and severe. Mild; demonstrating intermittent symtpoms, Moderate; demonstrating more constant symptoms, Severe; thenar muscle atrophy.
Function: SUPRACLAVICULAR NERVE (C3/4)
Sensory to anterior, middle, and posterior shoulder, lateral aspect to cervical spine
17. Using the case study in #16, you follow up with this patient one week after her initial eval and treatment. Her ODI score is 32%. Based on the your initial treatment, you would expect improved thickness/activation of which muscle(s). A. External obliques B. Internal obliques C. Lumbar multifidus D. Transverse abdominus
Lumbar multifidus
8. A series of chronic relapses of Reiter's Syndrome typically causes which of the following? a. Pain at the PIP's and DIP's of the hands and a decrease in depth perception b. Upper cervical spine hypermobility and kidney infection c. Lumbar/SIJ deformity and chronic Plantar Fasciitis and Achilles tendonitis d. Pannus formation at the wrist and PIP's of the hand
Lumbar/SIJ deformity and chronic Plantar Fasciitis and Achilles tendonitis
Pancoast Tumor
Lung tumor that can invade the roots of the brachial plexus as they enlarge. Often present with C8/T1 pain pattern, wasting of the thenar and hypothenar muscles
Common attachments of muscles on the: TIBIA - SHAFT
MEDIAL SURFACE: DISTAL: semitendinosus, sartorius, gracilis; MEDIAL BORDER: PROXIMAL: soleus; LATERAL SURFACE: PROXIMAL: tibialis anterior; SOLEAL LINE: PROXIMAL: soleus; POSTERIOR SURFACE: PROXIMAL: flexor digitorum longus, DISTAL: popliteus
What is the 2018 summary of the incidence of meniscal and articular cartilage lesions?
MENISCAL lesions account for approximately 25% of all knee injuries. More common amongst females in high school athletes. Older individuals have a higher rate compared to younger. Lateral tears more likely in younger athletes and medial teras more likely in older people. High prevalence in individuals undergoing ACL reconstruction or revision. Older than 45 more likely to have meniscectomy, younger than 35 more likely to have repair and meniscus procedures have increased substantially over last decade. ARTICULAR CARTILAGE prevalence in athletes ranges from 17-59% some of those are asymptomatic. Incidence rate is high after partial meniscectomy or second ACL surgery.
What is the 2018 summary of the Clinical Course of meniscal and articular cartilage lesions?
MENISCUS LESIONS: satisfactory regardless of management with or without surgery but may report lower knee function than healthy population. Non-operative mangement have similar to better outcomes in terms of strength and function in short and intermediate term. Impairments in proprioception and muscle strength noted acutely and short term following APM, most resolve within 2 years. Return to sport influenced by demographics, tear location, function levels and physical impairments. Athletes younger than 30 likely to return < 2 months, older athletes return by 3 months. SURGICAL IMPLICATIONS: Athletes with Osteoarticular Transfer (OAT) procedure have higher self reported knee function, return to sport and maintenance of activity compared to Autologus Chondrocyte Implantation (ACI) or microfracture. ACI return to sport rate is high but delayed and fairlure rates/complications are high. Microfracture procedure best for small articular cartilage lesions and those returning to low demand sport.
What interventions should be utilized for those patients in a HIGHLY IRRITABLE state?
MODALITIES: heat/TENS for pain modulation; SELF-CARE/HOME MANAGEMENT TECHNIQUES: education on positions of comfort and activity modifications; MANUAL THERAPY: low-intensity joint mobilization procedures in the pain-free accessory ranges and GHJ positions; MOBILITY EXERCISES: pain free PROM/AAROM
What interventions should be utilized for those patients in a MODERATELY IRRITABLE state?
MODALITIES: heat/TENS for pain modulation; SELF-CARE/HOME MANAGEMENT TECHNIQUES: education on progressing activities to gain motion and function without producing tissue inflammation and pain; MANUAL THERAPY: moderate-intensity joint mobilization procedures, progressing amplitude and duration of procedures into tissue resistance without producing post treatment tissue inflammation and associated pain. STRETCHING EXERCISES: gentle to moderate stretching exercises, progressing the intensity and duration of the stretches into tissue resistance without producing post tx tissue inflammation and associated pain. NEUROMUSCULAR RE-EDUCATION: procedures to integrates gains in mobility into normal scapulohumeral movement while performing reaching activities.
11. A 19 year old female injured her R knee x 2 days ago after a fall while skiing. She recalls twisting her knee and feeling a "pop", which was associated with immediate swelling. Physical findings include AROM between -10 degrees extension, and - 20 degrees flexion versus the uninvolved side. You note a positive Lachman's test and a positive anterior drawer test. What diagnostic test would be most appropriate to confirm your clinical findings? a. Computed tomography test (CT) b. Magnetic Resonance Arthrogram (MRA) c. Magnetic Resonance Imaging (MRI) d. X-ray
MRI
15. CASE STUDY: Your clinic performed a research study to determine the efficacy of lumbar manipulation in patients with acute low back pain. Ten subjects were included in the study and were equally divided into two groups. The experimental group received lumbar manipulation twice a week for two weeks. The control group received moist heat and TENS for twenty minutes, twice a week for two weeks. The outcome measure was the Oswestry Disability Index which patients were asked to complete before their initial treatment and after their last treatment. A two-tailed t-test was performed with a significance set at p<0.05. Based on the above information, what was the independent variable of this study? a. Manipulation b. Moist heat and TENS c. Oswestry Disability Index d. T-test
Manipulation
16. CASE STUDY: You have evaluated a 47-year old patient with pain in her right-sided lower lumbar region that extends into her right upper buttocks. She reports no other area of symptoms. Her ODI is 42% and NPRS is 5/10 with FABQ(work) of 17 and FABQ(PA) of 11. She has painful and limited PA glides at L3 and L5 centrally and to the right. Remainder of lumbar PA's are normal. Left hip IR is 37 degrees, right hip IR is 32 degrees. She has a positive Gaenslan's test on the right, positive SIJ compression test, positive Lumbar Extension load test, positive Passive Lumbar Extension test, and positive PITS test. She has negative thigh thrust, sacral thrust, SIJ gapping tests, and no aberrant motions with AROM testing of the lumbar spine. How do you classify this patient based on the Treatment-Based Classification Algorithm? A. Manipulation and exercise B. Pilates exercises C. Stabilization exercises D. Traction and extension oriented exercises
Manipulation and exercise
9. What muscles comprise the lower scapular force couple? a. Rhomboids, Middle Trapezius, Lower Trapezius b. Rhomboids, Lower Trapezius, Serratus Anterior c. Levator Scapula, Middle Trapezius, Lower Trapezius d. Middle Trapezius, Lower Trapezius, Serratus Anterior
Middle Trapezius, Lower Trapezius, Serratus Anterior
13. You are evaluating a 38 year old female with right-sided neck pain. She reports insidious onset of pain 5 weeks prior. She has a NDI of 19, NPRS of 5, Fear Avoidance Belief Questionnaire (work) 13, (physical activity) 11, and a Tampa Scale of Kinesiophobia score of 25. She has no symptoms distal to the shoulder and no prior history of neck pain. The symptoms are aggravated by computer use, driving, and turning her head to the right. AROM cervical spine flexion and extension are normal and without pain. Right rotation is 62 degrees and left rotation is 75 degrees. She has painful and limited PA glides at C3 and C4. She also presents with a slight forward head posture. Spurling's, distraction, and upper limb tension tests for Median nerve are negative. Based on this data, what would the best initial intervention be? A. Manipulation and exercise to the cervical spine B. Manipulation to the upper thoracic spine and painfree ROM to the cervical spine C. Mobilizations and exercise to the cervical spine D. Mobilizations to the cervical spine and manipulation to the upper/middle thoracic spine
Manipulation and exercise to the cervical spine
15. A 42 year old male presents to your clinic with >1 year history of left knee pain. He complains of knee pain and crepitus with AROM and has morning stiffness that lasts for more than 30 minutes each day. He also complains of pain and paresthesias at the left hip. PROM left knee flexion is 113 degrees with pain at endrange. What is the best treatment for this patient a. Bracing & VMO exercises b. Manual therapy directed at the hip c. Manual therapy directed at the hip and knee d. NSAIDs and ice
Manual Therapy directed at the hip and knee
13. According to the APTA's clinical practice guidelines for plantar heel pain, which of the following interventions has the least evidence advocating its use? a. Iontophoresis using dexamethasone or acetic acid b. Stretching c. Taping d. Manual therapy
Manual therapy
Subacute Low Back Pain with Mobility Deficits: Primary Intervention Strategies
Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility; therapeutic exercises to improve or maintain spinal and hip mobility; Focus on preventing reccuring low back pain episodes throught the use of 1. therapeutic exercises that address coexisting coordination impairments, strength deficits, and endurance deficits, and 2. education that encourages the patient to pursue or maintain an active lifestyle.
Acute LBP with Related (Referred) Lower Extremity Pain Suggested Matched Interventions
Mechanical Diagnosis and Therapy interventions, Progress to Acute LBP with Movement Coordination, Impairments intervention strategies
3. A 40 year old male presents to your clinic with a prescription from his family physician requesting you eval and treat for right-sided"sciatica". The patient has an Oswestry score of 41%, FABQ work subscale of 10, physical activity subscale of 15. The patient has painful AROM lumbar extension with reproduction of right LE symptoms into posterior thigh and calf. The patient has a positive left SLR at 43 degrees. Based on this data, what would be the best intervention? a. Extension exercises b. HVLA to the SI Joints c. Mechanical lumbar traction & Extension exercises d. Stabilization exercises to the lumbar spine
Mechanical lumbar traction & Extension exercises
What are the exam findings used for Diagnosis/Classification of knee ligament sprains?
Mechanism of injury, passive knee laxity, joint pain, joint effusion, and movement coordination impairments.
9. What structure is most likely injured during a lateral patella subluxation? a. Lateral patellar retinaculum b. Medial patellar retinaculum c. Patellar tendon d. Vastus medialis obliques
Medial Patellar Retinaculum
Nerve Entrapment Sites: MEDIAN NERVE (C5/6, C8-T1)
Median: Fibrous arch of FDS, Pronator Teres, Carpal Tunnel, AIN: pronator teres, FDP and FPL, FDS, FCR. Fractures, surgeries, casting, counter-force braces
14.A 50 year old female data entry specialist presents to your clinic with a 2 month history of pain in the palmar aspect of her right hand and the 2nd and 3rd fingers. In addition, she complains of numbness and tingling at night. She finds relief by "shaking" or massaging her hand. She reports that her husband sustained a spinal cord injury at C6/7 and came home from the hospital 3 months ago. She is his sole caregiver. Her employer allowed her to work at home, and bought her a notebook computer for home use so she wouldn't have to make room for her desktop model computer at home. The patient has no history of diabetes, hypothyroidism, and does not drink alcohol. You note the following on physical examination. Cervical AROM left sidebending WNL and right rotation 70 deg, both produce pain at the right cervical region. Symptom Severity Score is 2.2 and her wrist ratio index is 0.71. She has diminished sensation to sharp/dull at her DIP of the 2nd digit compared to her thenar eminence. Spurling's test is negative. Roos test is negative. Tinel's and Phalen's tests are negative at bilateral wrists. Upper limb tension test (median nerve bias) is negative. Cervical distraction is negative. Would you request an EMG study to confirm your diagnosis? a. Yes b. No
No
2. A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a "diet" might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds. Assume this patient was overweight when he saw his physician 7 months ago. Based on your knowledge of the biomechanics at the hip, was this patient's physician correct in his advice that if he lost weight his pain would resolve? a. Yes b. No
No. This patient only complained of pain with static stance. The forces at the hip during static stance is only 0.3 times the body weight. Given this perspective, it is highly unlikely that this patient's weight was exacerbating his symptoms.
Indications for Traction
None as a single modality, preliminary evidence as part of multi-modal approach to neck/back pain.
13. To prevent recurrence, a patient with an acute anterior shoulder dislocation (without concomitant fracture or labral pathology) should be immobilized for how long? A. 4 weeks B. 5 weeks C. 6 weeks D. None of the above. Length of immobilization does not alter the chance of recurrence.
None of the above. Length of immobilization does not alter the chance of recurrence.
What are the MCIDs for common outcome measures?
ODI: 6%, NDI: 5-7%, 100mm VAS - 9-11mm, NPRS (Numeric pain Rating Scale) - greater than or equal to 3, PSFS (Patient Specific Functional Scale) - > 2, GROC (Global Rating of Change) - > 5-10, FABQ - > 20, LEFS - 9 points, DASH - 12.8, Quick DASH - 14.
13. Which X-Ray views are most diagnostic for spondylolisthesis? A. AP B. Flexion & Extension C. Lateral D. Oblique
Oblique
Nerve Entrapment Sites: OCCIPITAL NERVE (C2)
Occipital triangle, oblique capitis,
12. You are evaluating a patient with right-sided low back and buttock pain. Bilateral SLR and Slump tests are negative and repeated movements do not centralize his symptoms. Which of the following cluster of SIJ tests would lead you to believe this patient had pain originating from his SIJ? A. Positive distraction, thigh thrust, Gaenslans, Negative compression, sacral thrust, FABER, resisted hip abduction B. Positive FABER, resisted hip abduction, posterior shear, sacral sulcus, Negative sacral thrust, compression, Gaenslans, thigh thrust C. Positive compression, sacral thrust, resisted hip abduction, Negative distraction, FABER, posterior shear D. Positive sacral sulcus, posterior shear, FABER, distraction, Negative sacral thrust, compression, Gaenslans, thigh thrust
Positive distraction, thigh thrust, Gaenslans, Negative compression, sacral thrust, FABER, resisted hip abduction
3. You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a "pop". X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive "sag sign". Given this presentation, what injury do you suspect that she has sustained? a. Anterior Cruciate Ligament Injury b. Medial Collateral Ligament Injury c. Meniscus Injury d. Posterior Cruciate Ligament Injury
Posterior Cruciate Ligament Injury
4. You are evaluating a patient referred to you from the emergency room. She is a 17 year old female who was struck from behind during an MVA x 1 week ago. She indicated that her R knee struck the dashboard and she felt a "pop". X-rays in the emergency room were negative for fracture. She notes that her R leg has buckled since on a couple of occasions. During your examination, you observe that she has a positive "sag sign". What would be an appropriate special test to check the integrity of this structure? a. Anterior Drawer Test b. Pivot Shift Test c. Posterior Drawer Test d. Valgus Stress Test
Posterior Drawer Test
What clinical findings indicate a sprain of the PCL?
Posterior directed force on the proximal tibia (MVA dashboard blow injury, fall on flexed knee, or violent hyperextension), localized posterior knee pain with kneeling or decelerating, positive Posterior Drawer (sensitivity 90% & specificity 99%), positive Posterior Sag Sign (sensitivity 79% & specificity 100%).
14. What radiographs are indicated pre-reduction and post-reduction for anterior glenohumeral subluxation? A. Pre: AP with slight internal rotation, AP with slight external rotation, Post: AP with slight internal rotation, AP with slight external rotation B. PA with slight internal rotation, PA with slight external rotation, Post: PA with slight internal rotation, PA with slight external rotation C. Pre: AP with slight internal rotation, Post: Scapular AP, West Point Modified Axillary View, Stryker Notch View D. Pre: PA with slight internal rotation, Post: Scapular PA, West Point Modified Axillary View, Stryker Notch View
Pre: AP with slight internal rotation, Post: Scapular AP, West Point Modified Axillary View, Stryker Notch View
What is the difference between pre and post ganglionic lesions
Pre: sensory is ok, motor impaired. EMG is normal. Post: sensory and motor compromised. Myelinopathy - slows down nerve conduction. Axonopathy - decreased amplitudes to total denervation.
Chronic Low Back pain with Movement Coordination Impairments: Impairments of Body Function
Presence of 1 or more of the following: 1. low back and/or low back-related lower extremity pain that worsens with sustained END range movements or positions. 2. Lumbar hypermobility with segmental motion assessment. 3. Mobility deficits of the thorax and lumbopelvic/hip regions. 4. diminished trunk or pelvic-region muscle strength and endurance. 5. Movement coordination impairments while performing community/work-related recreational or occupational activities.
What are the findings in regards to Prevalence and Incidence of Patellofemoral Pain (PFP)?
Prevalence ranges vary, 1.5% to 7.3% of all patients seeking medical care. Can across a lifetime however commonly seen in 12-19 but may be dependent on activity level and environmental context. Females more likely than males. High recurrence rate, reported more than 50% report recurrent issues or unfavorable outcomes.
Function: GREATER AURICULAR NERVE (C2/3)
Sensory to jaw, ear, and mastoid
Acute LBP with Related Cognitive or Affective Tendencies Suggested Matched Interventions
Prognostic Risk Stratification to Prioritize Interventions to Address Biopsychosocial Contributors to Pain, Pain Neuroscience Education, General Exercise Training, Aerobic Exercises, and Active Education and Advice
Chronic LBP with Generalized Pain Suggested Matched Interventions
Prognostic Risk Stratification to Prioritize Interventions to Address Biopsychosocial Contributors to Pain, Pain Neuroscience Education, General Exercise Training, Aerobic Exercises, and Active Education and Advice, Cognitive Functional Therapy to Address Multiple Components Associated with LBP
Clinical Findings of Entrapped: MEDIAN NERVE (C5/6, C8-T1)
Pronator Teres Syndrome: Numbness and pain in volar forearm and thenar eminence, AIN Syndrome: Muscle weakness volar forearm, 1st and 2nd finger pincer dysfunction (weak FDP and FPL), Carpal Tunnel Syndrome: wrist pain, paresthesia 1st through 3rd fingers and half of 4th, thenar eminence atrophy
5. CASE STUDY: A 56 year old male right-hand dominant carpenter presents to your clinic with a 3 week history of proximal right anterior forearm pain and paresthesias in his 1st -3rd digits. These symptoms are exacerbated by activity. Examination reveals weakness with 1st -3rd digit flexion and wrist flexion. He exhibits tenderness to palpation along the proximal anterior forearm. Manual muscle tests of biceps brachii and of 3rd digit PIP flexion are both strong but with a reproduction of his paresthesias. Resisted pronation with the elbow flexed to 90° is weak with pain. However, resisted pronation with the elbow extended is strong and without pain. Based on this information, what is the most likely diagnosis? a. Anterior Interosseous nerve entrapment b. Bicepital tendonitis c. Posterior Interosseous nerve entrapment d. Pronator Teres syndrome
Pronator Teres syndrome
Nerve Distribution - Motor: MEDIAN NERVE - C6/7/8/T1
Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis; ANTERIOR INTEROSSEOUS: flexor digitorum profundus (digits 2-3), flexor pollicis longus, pronator quadratus; RECURRENT BRANCH: abductor pollicis brevis, flexor pollicis brevis, opponens pollicis; LATERAL/MEDIAL BRANCHES: lumbricals 1-2
Confidence Intervals
Provide the reliability of an estimate. Tell us how accurately the mean represents the population. The narrower the interval the better. If the interval crosses zero, then the results cannot be considered statistically significant.
1. A 55 year old male hospital volunteer presents to your clinic with an 8 month history of right anterior hip pain. The patient reports his symptoms have increased significantly over the past 2 months. He reports no symptoms with walking, however, his symptoms are exacerbated with static stance. Further questioning reveals the patient began working for Wal-Mart 10 weeks ago as a greeter. He will stand for 1-2 hours without a break during a typical workday. The patient originally saw his family physician for this condition 7 months ago. His physician suggested that he was overweight, and that going on a "diet" might help. The patient reports he has lost approximately 45 pounds in the last 7 months. The patient is 72 inches tall and weights approximately 210 pounds. A physical examination reveals the following data. (+) Trendelenberg sign, (+) Ober's test, (+) FABER test for pain, (-) Thomas test, (-) Femoral Grind test, MMT Gluteus Medius/Minimus 4/5 with reproduction of symptoms, Gluteus Maximus 4-/5, hip flexors and knee extensors/flexors 5/5. What is the most likely diagnosis? a. Avascular necrosis of the femoral head b. Gluteus Medius/Minimus strain c. Pubofemoral ligament & Y-Ligament sprain d. Trendelenberg gait
Pubofemoral ligament & Y-Ligament sprain - During Static stance, stability a the hips is provided entirely by its ligaments and capsule. The key element of this patient's subjective history was when he reported anterior hip pain with static stance, not walking. Moreover, his symptoms coincide with beginning employment with Wal-Mart as a greeter. The weakness observed at the Gluteal muscles is most likely from a stretch reflex at the anterior hip capsule and ligaments. The Pubofemoral ligament checks extension and abduction while the Y-Ligament checks hyperextension of the hip. If these structures are injured, an inhibitory interneuron is often activated that synapses with the posterior muscles of the hip. By inhibiting these muscles, increased stretch (and further injury) can be avoided at these ligaments. The FABER sign was positive because this test placed a passive stretch on these ligaments. Ober's sign was positive because it involves placing the patient in hip abduction and extension during the initial phase of the test.
Function: OCCIPITAL NERVE (C2)
Sensory to posterior head
Function: TRANSVERSE CERVICAL NERVE (C2/3)
Sensory to the anterior lateral neck
Function: ILIO-INGUINAL AND ILIOHYPOGASTRIC NERVES L1
Sensory: inguinal region and genitals
Function: SUPERIOR CLUNEAL NERVE T10/11/12/L1/L2
Sensory: lower lumbar and iliac crest
7. A 13 year old male is brought to your clinic by his mother. He has a three-month history of knee pain that is worse with running, jumping, and ascending or descending stairs. His mother notes that he has had a growth spurt of about 2-3 inches over the last year. Your examination findings reveal a tender palpable bump in the area of the tibial tubercle. It is also moderately warm to touch. His ROM appears fine and he has good strength with some mild pain with resisted quadriceps action. He also has moderate tightness of his quadriceps and hamstrings. What would be the most appropriate treatment for this patient? a. Open chain quadriceps strengthening exercises b. Knee sleeve with donut cutout c. Phonophoresis, 1.2 watts/cm2 x 6 minutes, 3 x week d. Quadricep stretching and counterforce brace
Quadriceps stretching and counterforce brace
Nerve Entrapment Sites: AXILLARY NERVE C5/6
Quadrilateral space compression, axillary compression, anterior/inferior GH dislocation, forced hyperabduction and External Rotation of UE.
Function: RADIAL NERVE (C5/6/7/8/T1)
Radial Nerve: Triceps, ECRL, Brachioradialis, Deep Branch: ECRB, supinator, PIN: extensor muscle groups of fingers and thumb
What are some red flags that should be ruled out prior to the beginning of treatment for neck pain?
Red flags/serious pathology (infection, cancer, cardiac, arterial insufficiency, cranial nerve dysfunction, and fracture)
Clinical Findings of Entrapped: SUPERIOR CLUNEAL NERVE T10/11/12/L1/L2
Restricted thoracolumbar junction quadratus lumborum, Psoas, Distal crossed syndrome, TTP with trigger point 7cm lateral to midline at inferior iliac crest
Clinical Findings of Entrapped: ILIO-INGUINAL AND ILIOHYPOGASTRIC NERVES L1
Restricted thoracolumbar junction, quadratus lumborum, Psoas restricted hip flexors, Distal crossed syndrome, Pain inguinal region, genitals, tenderness to palpation medial to ASIS
What are the recommendations regarding outcome measures for PGP?
Strong evidence. Disability Rating Index (DRI), Oswestry Disability Index (ODI), Pelvic Girdle Questionnaire (PGQ), Fear-Avoidance Beliefs Questionnaire (FABQ), and Pain Catastrophizing Scale (PCS).
8. A 23 year old male presents to your clinic complaining of right thigh and testicular pain that is exacerbated with standing and walking. He reports this pain came on insidiously 3 days ago. Relieving factors include laying supine with the hips and knees flexed. The patient is not taking any medication except Tylenol prn because of a low-grade fever. Physical examination findings include tenderness to palpation at McBurney's Point, negative Femoral Grind test, and reproduction of symptoms with SI compression test. There is no tenderness to palpation at the right thigh and MMT at the right hip are without noted deficit. Based on this information, what is the most likely diagnosis a. Hernia b. Iliopsoas strain c. Retrocecal appendicitis d. SI Joint dysfunction
Retrocecal Appendicits. Retrocecal appendicitis refers pain to the right thigh and testicle. Appendicitis is associated with insidious onset, low-grade fevers, and patients often find relief by bringing their knees to their chest (as this patient reported). Tenderness to McBurney's Point is a key finding: it is located between the right ASIS and the umbilicus (over the appendix). The SI Compression test was most likely positive due to the fact that you have to press in the area of McBurney's Point to perform the test.
What is the cancer algorithm?
Ruling in - history of CA (+LR 14.7), AND >50 yo OR weight loss OR failure to improve with conservative treatment (Hx + one other +LR 67), THEN ESR > 50, then Advanced imaging. RULING OUT: No relief with bedrest, pain at night (-0.11)
Path: LATERAL FEMORAL CUTANEOUS L2/3
Runs across iliacus towards ASIS, Emerges distal lateral aspect psoas, inguinal ligament. Pierces TFL, Terminates in lateral thigh
Path: OCCIPITAL NERVE (C2)
Runs underneath oblique capitis, Pierces upper trapezius, Innervates posterior scalp
Nerve Entrapment Sites: GREATER AURICULAR NERVE (C2/3)
SCM and platysma
Nerve Entrapment Sites: TRANSVERSE CERVICAL NERVE (C2/3)
SCM and platysma
Nerve Entrapment Sites: SUPRACLAVICULAR NERVE (C3/4)
SCM posteriorly, platysma muscle, Clavicle,
What interventions should be utilized for those patients in a LOWLY IRRITABLE state?
SELF-CARE TRAINING: education on progression to performing high-demand functional and/or recreational activities. MANUAL THERAPY: end-range joint mobilization procedures into tissue resistance. STRETCHING: stretching exercises, progressing the duration of the stretches into tissue resistance without producing post tx tissue inflammation and pain. NEUROMUSCULAR RE-EDUCATION: procedures to integrate gains in mobility into normal scapulohumeral movement during performance of the activities performed by the patient during his/her functional and/or recreational activities.
What physical performance measures are recommended for Mensical and Articular Cartilage lesions?
SL hop test (distance, cross-over hop for distance, tripple hop for distance, 6m timed hop) that can identify baseline status relative to pain, function, and disability, detect side to side asymmetries, global knee function, readiness to return to normal activities.
What physical performance measures are indicated for knee ligament injuries?
SL hop tests (distance, crossover, triple hop, and 6m for time).
What examination findings are helpful in assessing activity limitations/participation restrictions in ankle ligament sprains?
SL hop tests.
What is the 2017 summary for the CLINICAL COURSE for Knee Ligament Sprains?
Satisfactory, no differences noted between graft type or timing of surgery. Rates of return to any sport are good but there are substantially lower rates for return to preinjury levels or competitive sports. Other important factors found to influence outcomes include psychologic responses including fear of movement/reinjury, athletic confidence, self-efficacy, and emotions.
Nerve Entrapment Sites: BRACHIAL PLEXUS C5/6/7/8/T1
Scalenes, 1st rib, pec minor
Nerve Entrapment Sites: DORSAL SCAPULAR NERVE C5
Scalenes, levator scapula, repetitive overhead ADL's, trauma
12. A 25 year old female presents to your clinic as a direct access referral 3 days after being involved in a simple motor vehicle accident in which her car was struck from behind in a parking lot. VAS pain is 4/10 and her Neck Disability Index score is 32%. She is able to rotate her neck 35 degrees to the right and 60 degrees to the left. She has 25 degrees of cervical extension that does not aggravate her symptoms. Her thoracic kyphosis is diminished. She has no tenderness to the midline of the cervical spine and reports a delayed onset of pain (24 hours after the accident). She has no numbness or paresthesias in her upper extremities. Her pain is primarily midline at the C/T junction. Based on this information, what would your next course of action be? A. Manipulate upper thoracic spine, patient meets clinical prediction rule for thoracic HVLA for treatment of neck pain B. Send to the ER for xrays of her cervical spine C. Strengthen her deep neck flexors D. Treat with pain modalities and gentle range of motion exercises until her symptoms calm down
Send to the ER for xrays of her cervical spine
17. CASE STUDY: A 33 year old male recreational tennis player reports that he heard a "pop" and felt immediate pain when performing a serve three days ago. His shoulder hurts when he attempts to elevate his arm greater than 90°. You suspect a labral injury. You immediately perform the anterior apprehension test (for SLAP lesions) as described by Mimori. The test is negative. You feel confident that the patient does not have a SLAP lesion because the test has a reported high degree of: a. Power b. Precision c. Sensitivity d. Specificity
Sensitivity
Inflammatory Arthritis
Severe morning stiffness, lasting greater than 1 hour; symptoms improvement with activity, worsened with rest, symptoms greater than 3 months, decreased motions in all plances, fever, fatigue, weight loss
What are the RISK FACTORS for Knee Ligament Sprains?
Shoe-surface interaction, increased BMI, increased joint laxity, narrow femoral notch, preovulatory phase, combined loading pattern, and strong quadriceps activation durring eccentric contractions. Majority of PCL, collateral and multi-ligament injuries are contact injuries. 2017 summary; Dry weather/artificial turf surface, female sex, lesser concavity of medial tibial plateau, prior ACL recon, family history.
12. A patient diagnosed with a frozen shoulder with a VAS pain rating of 4/10 and pain at the end of the range of motion during motion testing would be best treated with which of the following? A. Grade 1 Maitland mobilizations B. Grade 3 Maitland mobilizations with sustained hold C. PROM with overpressure of increased duration D. Short duration (5-15 second) Passive Range of Motion
Short duration (5-15 second) Passive Range of Motion
What is the 2017 summary on the prevalence of neck pain?
Significant variation exists in the definition of neck pain which limits concensus however general view is that neck pain is common and increasing worldwide in general population and specific subgroups.
11. Which of the following imaging studies has the highest diagnostic accuracy for spondylolisthesis in the lumbar spine? A. Bone Scan B. MRI C. Single Photon Emission Cat Scan D. X-Ray
Single Photon Emission Cat Scan
Sliding/Flossing a nerve versus Tensioning a Nerve
Sliding - one side is on tension, and the other is slacked, tensioning a nerve - both sides are tensioned/at max.
13. An 11-year old male complains of 4 months of right hip and groin pain of insidious onset. He is referred by his family practice physician. His mother reports that X-Rays were recommended, but she declined because she did not want radiation near his pelvic region. Prior medical history is significant for Legg-Calve-Perthes disease when he was 4 years old. This resolved within 2 years with the assistance of physical therapy. He has a mild limp but has no pain with motion testing of the right hip. Right hip flexion is slightly limited and right hip IR is progressively limited as hip flexion increases. MMT demonstrate right hip abductors 4/5, remainder of right hip and knee MMT 5/5 without pain. Based on the above information, what is the most likely diagnosis? A. Iliopsoas bursitis B. Legg-Calve-Perthes disease C. Slipped Capital Femoral Epiphysis D. Obturator nerve entrapment
Slipped Capital Femoral Epiphysis
Sensitivity vs Specificity
SpIN versus SnOUT: High specificity = positive test --> rule diagnosis in, High Sensitivity= negative test --> rule diagnosis out.
Acute LBP with Movement Coordination Impairments Suggested Matched Interventions
Specific Trunk Activation Training, Trunk Muscle Strengthening and Endurance Exercises, Thrust or Non-Thrust Joint Mobilization, Soft Tissue Mobilization, and Massage, Active Education and Advice to pursue an active lifestyle, Education on the Favorable Natural History of Acute LBP and Self-Management Techniques
What examination should be administered to test activity limitations and physical performance measures in PFP?
Squatting, step downs, SL squat.
16 CASE STUDY: Your clinic performed a research study to determine the efficacy of lumbar manipulation in patients with acute low back pain. Ten subjects were included in the study and were equally divided into two groups. The experimental group received lumbar manipulation twice a week for two weeks. The control group received moist heat and TENS for twenty minutes, twice a week for two weeks. The outcome measure was the Oswestry Disability Index which patients were asked to complete before their initial treatment and after their last treatment. A two-tailed t-test was performed with a significance set at p<0.05. The researchers involved in this study were particularly worried about a Type 2 Error occurring when they performed their statistical tests. A Type 2 Error is: a. Stating there is a difference between two treatments when there is not one b. Stating there is no difference between two treatments when there is one c. The generalization from the sample being studied to the population d. The probability of reaching a correct decision
Stating there is no difference between two treatments when there is one
15. According to the 2013 Clinical Practice Guidelines published by the Orthopedic Section of the APTA, which of the following interventions is best for the treatment of adhesive capsulitis? A. Joint mobilizations B. Modalities such as diathermay, ultrasound or e-stim C. Stretching exercises D. Translational manipulation
Stretching exercises
What is the recommendation for corticosteroid injections and adhesive capsulitis?
Strong Evidence. Intra-articular corticosteroid injections combined with shoulder mobility and stretching exercises are more effective in providing SHORT-TERM (4-6 weeks) pain relief and improved function compared to shoulder mobility and stretching exercises alone.
What is the recommendation for Diagnosis of Carpal Tunnel Syndrome (CTS)?
Strong evidence for Semmes-Weinstein monofilament testing on the middle finger. Moderate to severe concerns should use any radial finger. Moderate evidence for Katz hand diagram, Phalen test, Tinel sign, and carpal compression test. 3 or more of the following findings have shown acceptable diagnostic accuracy; age > 45, whether shaking hands relieves symptoms, sensory loss in thumb, wrist ratio index > .67, and scores from the Boston Carpal Tunnel Questionnaire-symptom severity scale (CTQ-SSS) > 1.9.
What physical impairment measures are recommended for assessing strength in CTS?
Strong evidence. Clinicians should NOT use lateral pinch strength. Moderate evidence. Clinicians should NOT use grip strength when assessing short term (< 3 mo) change following CTR. Weak evidence. Clinicians may assess grip strength and 3 point or tip pinch strength in patients presenting with signs and symptoms of CTS.
What are the recommendations for intervention - acute/protected motion phase: physical agents?
Strong evidence. Cryotherapy; repeated intermittent applications of ice to reduce pain, decrease need for meds, and improve WB. Ultrasound; clinicians should NOT use ultrasound for management of acute ankle sprains. Weak evidence. Diathermy; utilze pulsating shortwave diathermy for reducing edema and gait deviations with acute ankle sprains. Conflicting evidence. Electrotherapy and Low-level laser.
5. What would be the best treatment choice for a patient with a Morton's neuroma? a. Achilles and hamstring stretching b. Joint mobilizations to the metatarsals to promote improved mobility c. Neural tension stretching d. Supporting the transverse metatarsal arch with an appliance
Supporting the transverse metatarsal arch with an appliance
Nerve Entrapment Sites: SUPRASCAPULAR NERVE C5/6
Suprascapular notch, trapezii (possibly), repetitive overhead ADL's, trauma, forced horizontal ABDUCTION
18. Long-term (12 months) improvement for a patient with Hallux Valgus is best achieved by which of the following interventions? A. Orthotics using a biomechanical approach B. Surgical intervention (Chevron procedure) C. rest, ice, nsaids
Surgical intervention (Chevron procedure)
What physical impairment measures are helping in assessing ankle ligamnet sprains?
Swelling, ROM, talar translation and inversion, and SL balance.
8. A 28-year-old mechanic presents to your clinic with right ulnar sided wrist pain. He reports he was competing in a martial arts competition 4 weeks ago when an opponent grabbed his wrist and pulled him into a position of radial deviation. Since then he has had ulnar sided wrist pain with using a screwdriver, a wrench, and when hand-tightening a screw or bolt. This has caused him to miss at least 2 days from work a week. The patient he can produce pain and a click by flexing and extending his wrist while it is in a position of ulnar deviation. He demonstrates this for you. Physical examination reveals tenderness along the distal ulna/proximal carpals and a no symptoms with manual compression and shearing of the lunate and triquetrium. Resisted ulnar deviation is strong with pain and the patient demonstrates a (+) Press Test. Based on this information, what is the most likely diagnosis? a. Extensor Carpi Ulnaris tendon subluxation b. Lunotriquetrial pathology c. Scaphoid instability d. Triangular Fibrocartilage Complex (TFCC) tear
TFCC tear
What examination findings are useful for assessing activity limitations/physical performance measures in CTS?
Weak evidence. Purdue Pegboard or Dellon-modified Moberg pick-up test (DMPUT) to quantify dexterity. Clinicians may use DMPUT to assess change following CTR surgery but should NOT use PPB, Jebsen Taylor Hand Function Test, or Nine-Hold Peg test.
6. A 23 year old female presents to your clinic with an 8 week history of occipital headaches of an insidious onset. Her physician has referred her to physical therapy for treatment of cervical strain/sprain. The patient's medical history is significant for left shoulder surgery 6 years prior (Bankart repair) and she currently complains of tinnitus and impacted wisdom teeth on the right. Physical examination reveals active range of motion WNL. Spurling's test is negative and there is no reproduction of headache with PROM or isometric muscle testing. AP, PA, and lateral joint mobilizations are without deficit or pain provocation and the patient has negative cervical distraction and compression tests. There is no tenderness to palpation along the cervical spine, suboccipital muscles, or scalenes. Based on your lack of physical findings, you determine the patient is experiencing referred pain. Which is the most likely source of this patient's symptoms? a. Tectorial membrane b. Levator Scapulae c. TMJ d. Wisdom teeth
TMJ
3. A fifteen year old female soccer player presents to your clinic 1 week after traumatic anterior dislocation of her right shoulder. She states her athletic trainer had to reduce her injury on the sideline. Since the time of injury, she has been treated in her training room with ice and TENS and has been wearing a sling. Upon physical examination, you find the following: Positive Anterior Apprehension/Relocation test, negative Feagin's sign, and negative sulcus sign. Radiographs reveal no fractures of the Humerus or Glenoid Based on the above information, this patient would most likely fit into which surgical diagnostic category? a. AMBRI b. Inferior Instability c. SLAP Type 1 d. TUBS
TUBS
4. A 42 year old female complains of a six month history of medial heel and medial longitudinal arch pain primarily with walking and at night. Visual inspection reveals increased forefoot pronation. Symptoms are elicited with palpation just posterior to the medial malleolus. What is likely diagnosis? a. Achilles Tendonitis b. Metatarsalgia c. Plantar Fasciitis d. Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome
Nerve Entrapment Sites: TIBIAL NERVE L4/5/S1/2/3
Tarsal tunnel, Origin of soleus muscle at popliteal fossa
14. According to the Ottawa Ankle Rules, which of the following findings would indicate x-rays be taken of the acute injured ankle? A. Positive syndesmosis stress test B. Tenderness to palpation distal fibula at the Anterior Talofibular Ligament's proximal insertion C. Tenderness to palpation Fibular just proximal to the lateral malleolus D. Tenderness to palpation middle 1/3 of the fibula
Tenderness to palpation Fibular just proximal to the lateral malleolus
19. According to the Orthopedic Section's Clinical Practice Guidelines, which is the best counseling strategy to use when educating patients about their lower back pain? A. Avoidance of recreational and vocational activities when still experiencing pain B. Promote extended bed rest C. Provide in-depth, pathoanatomical explanations for the cause of the patient's LBP D. The neuroscience that explains pain perception
The neuroscience that explains pain perception
1. A 42-year old male complains of insidious onset of vague, difficult to isolate left hip and groin pain that has been progressively worsening since it occurred two months ago. He was referred by his family physician (which he saw two weeks ago). He states he typically wouldn't have gone to the doctor for this, but he was being seen for his sickle cell anemia and mentioned to his physician while he was there. His physician ordered x-rays which were unremarkable and provided a referral to physical therapy. His prior medical history is significant for gout to the right great toe as a complication from a 1st metatarsal fracture 7 years ago. He is currently taking Zoloft for chronic depression. His Zoloft is assisting him to cope with his alcoholism but reports the medication often makes him feel fatigued, this has impaired his ability to begin a cardiovascular program. He is currently very sedentary. He has no pain with bowel movements and valsalva testing is negative. Physical examination revealed bilateral and ipsilateral squats caused a reproduction of his symptoms and an increase in left hip IR and knee valgus was noted. Hip and knee AROM WNL and only with mild pain at end ranges. MMT at the hip and knee is 4/5 bilaterally without reproduction of his symptoms. No tenderness to palpation is noted. Based on this information, what is the most likely diagnosis? a. The patient's findings are consistent with osteoarthritis b. The patient may have a meniscus tear c. The patient may have strained his bicep's femoris d. The patient may have subluxed his patella
The patient may have a meniscus tear
What is the recommendation for traction in the LBP CPG?
There is CONFLICTING evidence for the efficacy of intermittent lumbar traction for patients with LBP. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. MODERATE evidence supporting NOT USING TRACTION for patients with acute or subacute, nonradicular low back pain or in paitents with chronic low back pain.
9. A 38 year old male was playing basketball with friends next door to your clinic. It just so happens your were having a free walk-in Saturday morning clinic to expand your sports-medicine and orthopedic expertise to the community. His friends carry him in and laid him on a plinth as he was unable to bear weight. He reported that while running, "it felt like someone kicked me in the back of my leg". His calf is obviously deformed, and he is unable to actively plantar flex his foot. Which special test would best test the integrity of this structure a. Anterior drawer test b. Hoffa's test c. Homans' sign d. Thompson's test
Thompson's test
Nerve Entrapment Sites: SUPERIOR CLUNEAL NERVE T10/11/12/L1/L2
Thoracolumbar junction, Osteofibrous tunnel inferior to iliac crest
Acute LBP with Mobility Deficits Suggested Matched Interventions
Thrust or Non-Thrust Joint Mobilization, Soft Tissue Mobilization, and Massage, General Exercise Training, Active Education and Advice to Pursue an Active Lifestyle, Education on the Favorable Natural History of Acute Low Back Pain and Self-Management Techniques
Path: MEDIAL PLANTAR NERVE L4/5
Tibial Nerve divides into medial and lateral plantar nerves at the medial malleolus, Medial plantar runs to the base of the metatarsals, deep to transverse ligament. Divides into interdigital nerves
Path: LATERAL PLANTAR NERVE S1/2
Tibial nerve divides into medial and lateral plantar nerves at the medial malleolus, Runs laterally to the 5th ray, Divides into superficial and deep branches
13. CASE STUDY: A 43 year old male recreational basketball player presents to your clinic with acute patella tendonitis. You decide to utilize iontophoresis using dexamethasone to treat the inflammation and ask a technician to set-up the treatment. Once the patient is ready, you stop by to ensure the parameters are correct before beginning the iontophoresis treatment. The technician comments that there was only 1.25cc of dexamethasone left in the medicine dispenser and that he used a 1.5cc pad. You check to ensure that no dexamethasone has leaked from under the pad. It hasn't. You notice that the technician has placed the dispersive pad on the patient's distal quadriceps. The active pad is placed over the patella tendon with pre-wrap covering the pad along the edges to keep it in place. The negative electrode is attached to the active pad. The generator is set to 40mA-min. Based on this information, what is most likely to cause a burn during this treatment? a. Intensity: 40mA-min is too high of a setting for dexamethasone b. Pre-wrap covering the active pad c. Too little medication on the active pad d. Wrong polarity: dexamethasone should be pushed from the positive electrode
Too little medication on the active pad
5. You decide to treat a patient with LBP and right lower extremity numbness/tingling with lumbar traction. Based on EBM, which parameters do you choose? a. Traction BIW x15 minutes at 30-35% of their body weight b. Traction QIW x 12 minutes at 40-60% of their body weight c. Traction TIW x 10 minutes at 25-30% of their body weight d. Traction QIW x 8 minutes at 20-25% of their body weight
Traction QIW x 12 minutes at 40-60% of their body weight
what clinical findings indicate a sprain of the MCL?
Trauma applied to lateral aspect of LE, rotation trauma, medial knee pain with Valgus Stress Test (sensitivity 78% & specificity 67%), increased laxity with Valgus Stress Test at 30 degrees of flexion (sensitivity 91% & specificity 49%), tenderness over the MCL and attachments.
Nerve Distribution - Motor: RADIAL NERVE - C5/6/7/8/T1
Triceps Brachii, Anconeus, Brachioradialis, Extensor Carpi Radialis Longus; DEEP BRANCH: Extensor Carpi Radialis Brevis, Extensor Digitorum, Extensor Digiti Minimi, Extensor Carpi Ulnaris, Supinator; POSTERIOR INTEROSSEOUS NERVE - abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis
10. The TMJ is innervated by branches of which cranial nerve? a. Facial b. Glossopharyngeal c. Hypoglossal d. Trigeminal
Trigeminal
What are the effect size guidelines?
Trivial - < 0.1, Small: 0.2-0.4, Moderate: 0.5 - 0.7, Large: 0.8-2.0.
What are the important pathophysiological factors regarding stabilization of the pelvis during load transfers?
Two Mechanisms; Form Closure: achieved by wedge-shaped sacrum fits tightly between ilia & Force Closure: muscle, fascia, and ligaments that provide joint stability. Changes in ability to manage load transfers due to joint laxity may account for development of PGP. Some evidence suggests increased laxity and movement in the pelvic joints of pregnant females PGP. Pubic symphasis widening (average 7mm) at full term (begins 8-10 weeks gestation). Pain symptoms more likely if widening is > 10mm horizontal & 5mm vertical.
Function: BRACHIAL PLEXUS C5/6/7/8/T1
UE Motor and Sensory
Common attachments of muscles on the: ILIUM - ILIAC CREST
UPPER EXTREMITY: PROXIMAL: Latissimus Dorsi; LOWER EXTREMITY: PROXIMAL: Tensor Fascia Lata, iliacus
Common attachments of muscles on the: VERTEBRAE
UPPER EXTREMITY: PROXIMAL: trapezius, latissimus dorsi, levator scapulae, rhomboid minor, rhomboid major; LOWER EXTREMITY: PROXIMAL: Psoas Major, Minor
1. CASE STUDY: A 34 year old female presents to your clinic complaining of elbow pain and numbness and paresthesias in the fingers of her left upper extremity. She could not recall which fingers specifically. The patient has (+) Wartenberg's Sign, and (+) Froment's sign. Resisted thumb flexion, and forearm supination and pronation are strong and without pain. No deformities are noted at the IP joints. Based on this information, which peripheral nerve is most likely injured? a. Anterior Interosseous Nerve b. Posterior Interosseous Nerve c. Radial Nerve d. Ulnar Nerve
Ulnar Nerve
Positive Results for Dix Hallpike
Upbeating - posterior canalisthiasis ipsi side, downbeating - anterior canalithiasis contra side
11. CASE STUDY: A 17 year old female soccer player presents to your clinic 24 hours after sustaining a Grade 2 contusion to her right quadriceps. She is leaving for a soccer road trip that very afternoon and asks your advice as to whether put heat or ice on her leg while traveling on the team bus. She states that she has been icing for the past 24 hours, however, she has heard conflicting advice regarding the use of ice or heat after the first 24 hours of the injury. You instruct her to do which of the following? a. Use ice b. Use heat c. Use ice for the next 24 hours, then switch to heat d. Neither. If she is OK to play soccer this weekend, she doesn't need to worry about the bruise.
Use ice
what clinical findings indicate a sprain of the LCL?
Varus trauma, localized swelling over LCL, tenderness over LCL and attachments, Lateral knee pain with Varus Stress Test at 0 and 30 degrees knee flexion, laxity with vaus stress test at 0 and 30 degrees knee flexion.
What are the recommended interventions - stretching for midportion achilles tendinopathy?
Weak evidence. Stretching of ankle plantarflexors with knee flexed and extended.
What is the recommendation for modalities and adhesive capsulitis?
Weak evidence. shortwave diathermy, ultrasound, or electrical stimulation combined with mobility and stretching exercises to reduce pain and improve shoulder ROM in patients with adhesive capsulitis.
14. A 65 year old male presents to your clinic with a diagnosis of lumbar radiculopathy. He reports prior medical history of right tibia fracture 10 years ago treated with ORIF and high cholesterol. He complains of a "tight aching" pain in his right foot, calf, and thigh that occurs after ½ mile of walking. He tries to "push through" the pain and can typically walk an additional ¼ mile before the pain makes his stop. His symptoms are relieved by rest. SLR produces similar symptoms in the right thigh at 65 degrees. Deep tendon reflexes are +1 bilateral Achilles tendons. Babinski and ankle clonus are negative bilaterally. Current medications include Zocor for high cholesterol, naproxyn for his pain, and Levitra for erectile dysfunction. Based on this information, what is his most likely diagnosis? A. Neurogenic claudication B. Osteomyelitis from previous tibial fracture C. S1 Radiculopathy D. Vascular Claudication
Vascular Claudication
7. Reiter's Syndrome has two forms, each associated with a different pathology. These two pathologies are: a. Flu & Meningitis b. Malaria & Ringworm c. Typhoid & Yellow Fever d. Venereal Disease & Dysentery. 1st MTP joint
Venereal Disease & Dysentery. 1st MTP joint
What are the recommended outcome measures for achilles tendinopathy?
Victorian Institute of Sport Assessment-Achilles (VISA-A), Foot and Ankle Ability Measure (FAAM) or LEFS.
What self report measures should a clinician use to assess activity limitation and participation regarding hip pain?
WOMAC physical functional subscale, the hip disability and osteoarthritis outcome score (HOOS), LEFS, and Harris Hip Score (HHS).
9. Which of the following is the most efficient method for strengthening the right hip abductors in a 200 pound male? a. Left sidelying, right straight leg raises into abduction with 10 pound ankle weight b. Standing right hip hikes on a raised platform with a 10 pound weight in the left hand c. Squats with a 10 pound weight in the right hand d. Walking with a 10 pound weight in the left hand
Walking with a 10 pound weight in the LEFT hand. Placing the weight on the ipsilateral side would serve to decrease the load on the hip abductors
What are the recommendations regarding intervention-manual therapy in PGP?
Weak Evidence. May or may not utilze techniques including HVLA manipulations for pregnancy LBP and PGP.
What are the recommendations for interventions-biophysical agents in CTS?
Weak evidence for superficial heat, microwave or shortwave diathermy, IFC/electical modalities, phonophoresis. Moderate evidence to NOT use low-level laser, NOT use iontophoresis, NOT use magnets. Weak evidence to NOT use theram ultrasound.
What is the recommendation for joint mobilizations and adhesive capsulitis?
Weak evidence to promote using GHJ mobs to reduce pain and increase motion.
What are the recommendations for interventions-assistive technologies in CTS?
Weak evidence. Clinicians may educate patients regarding effects of mouse use, alternative strategies including use of arrow keys, touch screens, alternating mouse hand. May recommend keyboards with reduced strike force.
What are the recommendations for interventions-manual therapy in CTS?
Weak evidence. Clinicians may perform manual therapy directed to cervical spine and UE for mild to moderate CTS. Conflicting evidence for neurodynamic mobilizations.
What physical impairment measures are recommended for assessing sensory and provication in CTS?
Weak evidence. Clinicians should NOT use threshold or vibration testing to assess change with CTS undergoing nonsurgical management.
What is the recommendation for weight loss for hip pain/mobility deficits?
Weak evidence. Collaboration with physicians, nutritionists, or dietitians to support weight loss with hip OA and are obese/overweigth.
What are the recommendations for interventions-therapeutic exercise in CTS?
Weak evidence. Combined orthotic/stretching program with mild to moderate CTS, normal 2-point discrimination, and do NOT have thenar atrophy.
What are the recommendations for intervention - progressive loading/sensorimotor training phase: sport-related activity training?
Weak evidence. Implement balance and sport related activity training to reduce the risk for recurring ankle sprains in athletes.
What are the recommendations for intervention - progressive loading/sensorimotor training phase: therapeutic exercise and activities?
Weak evidence. Include exercises such as WB function exercises, SL balance using unstable surfaces to improve mobility, strength, coordination, and postural control in postacute ankle sprains.
What are the recommendations for interventions - footwear for heel pain and plantar fasciitis?
Weak evidence. Prescribe (1) a rocker-bottom shoe in conjection with foot orthosis and (2) shoe rotation during the work week for those who stand for long periods.
5. A 17 year old high school cross country track runner who averages 35 miles a week reports a 6 month history of right lateral hip pain. Initially, the pain occurred only after running, but is now hurting her continuously throughout the course of the day. She reports pain with right sidelying. Past medical history is significant for left proximal Tibial fracture that was surgically repaired with open reduction internal fixation when she was 12 years old. Physical examination reveals asymmetry at the pelvic landmarks (patient standing) with the left ASIS superior compared to the right. MMT of hip flexors, internal rotators, and extensors is 5/5 without pain, abduction 4+ /5 with pain, external rotators 4/5 with pain. Obers and FABER's tests are positive. Femoral Grind test is negative. Patient demonstrates moderate ITB tightness and tenderness to palpation along the right greater trochanter. Based on her pelvic asymmetries and her prior medical history of a tibial fracture, you decide to assess her leg length in supine. Prior to assessing her leg length, you perform which of the following techniques to align her pelvis? a. Watson's Test b. Weber Test c. Weber-Barstow Maneuver d. Wright's Maneuver
Weber-Barstow maneuver.
What self report measures should a clinician use to assess hip pain?
Western Ontario and McMaster Universities Osteoarthritis Outcome Score (WOMAC) pain subscale, Brief Pain Inventory (BPI), pressure pain threshold (PPT), and pain visual analog scale.
Path: GREATER AURICULAR NERVE (C2/3)
Winds around posterior border of SCM, Pierces fascia, Runs anteriorly underneath platysma to the mastoid and ear, parotid gland
Path: TRANSVERSE CERVICAL NERVE (C2/3)
Winds around the posterior border of SCM, Pierces the cervical fascia, Runs anteriorly and obliquely beneath the platysma to the anterior neck
What are the hip ADDUCTORS?
adductor longus, adductor brevis, adductor magnus, gracilis, pectineus
3. A 21 year old male runner complains of a three month history of anterior-lateral shin pain after reaching a certain threshold of activity. Having being treated with rest, stretching, NSAIDS, and extrinsic strengthening for suspected shin splints, the patient fails to demonstrate improvement. As the patient returns to his running endeavors, the pain readily returns, and this time is associated with decreased sensation in area of the first web space. The dorsalis pedis and anterior tibial pulses are present. What would be the best treatment decision for this patient? a. request that the patient's physician consider an x-ray to rule out bony pathology b. advising the patient to seek emergent care to possibly include wick catheter measurements c. consider lumbar traction to help decrease any suspected radicular findings d. advising the patient to request a bone scan from family physician as the x-ray may not fully demonstrate a fracture
advising the patient to seek emergent care to possibly include wick catheter measurements
7. The most commonly injured ligament in the ankle is the: a. anterior talofibular ligament b. anterior tibiofibular ligament c. calcaneofibular ligament d. deltoid ligament
anterior talofibular ligament
When a patient presents with shoulder pain and mobility deficits, what is the most significant finding that can be used to guide treatment planning?
assess impairments in capsuloligamentous complex and musculotendinous structures. The loss of passive motion in multiple planes, particularly external rotation with the arm at the side and in varying degrees of shoulder abduction is the most significant.
Nerve Distribution - Motor: MUSCULOCUTANEOUS NERVE - C5/6/7
biceps brachii, brachialis, coracobrachialis
Nerve Distribution - Motor: COMMON FIBULAR DIVISION OF SCIATIC NERVE - L4/5/S1/2
biceps femoris (short head)
What are the knee FLEXORS?
biceps femoris, semitendinosus, semimembranosus, sartorius, gracilis, gastrocnemius, popliteus
What are the elbow FLEXORS?
brachialis, biceps brachii, brachioradialis, pronator teres
6. The most common mechanism for an ankle sprain is: a. calcaneal eversion, plantar flexion, and forefoot adduction b. calcaneal eversion, plantar flexion, and forefoot abduction c. calcaneal inversion, plantar flexion, and forefoot adduction d. calcaneal inversion, plantar flexion, and forefoot abduction
calcaneal inversion, plantar flexion, and forefoot adduction
What is the recommendation for flexion exercises in the Low Back Pain CPG?
consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain, and disability in OLDER patients with chronic low back pain with radiating pain.
What is the recommendation for risk factors in the Low Back Pain CPG?
current literature does not support a definitive cause for initial episodes of low back pain. They are multifactorial, population specific, and only weakly associated with the development of low back pain.
What are the shoulder ABDUCTORS?
deltoid (middle), supraspinatus
What are the shoulder EXTENSORS?
deltoid (posterior), teres major, latissimus dorsi, pectoralis major (sternocostal head), triceps brachii (long head)
Nerve Distribution - Motor: AXILLARY NERVE - C5/6
deltoid, teres minor
What is the recommendation for clinical course in the Low Back Pain CPG?
described as acute, subacute, recurrent, or chronic; due to high prevalence of recurrent and chronic cases, clinicians should prioritize interventions to prevent recurrences and the transition to chronic low back pain.
What is the 2017 summary on differential diagnosis for neck pain?
direct pathoantamocial causes of mechangical neck pain are rarely identifiable. Want to especially look for infections, cancer, cardiac involvement, arterial insufficiency, upper cervical ligamentous insufficiency, unexplained cranial nerve dysfunction and fracture.
What are the wrist EXTENSORS?
extensor carpi radialis longus/brevis, extensor carpi ulnaris, abductor pollicis longus, assistance from extensors of the fingers and thumb
What are the wrist ULNAR DEVIATORS?
extensor carpi ulnaris, flexor carpi ulnaris
Nerve Distribution - Motor: SUPERFICIAL FIBULAR NERVE
fibularis longus, fibularis brevis
What are the ankle EVERTORS?
fibularis longus, fibularis brevis, fibularis tertius.
What are the wrist FLEXORS?
flexor carpi radialis, flexor carpi ulnaris, palmaris longus, assistance from flexors of the fingers and thumbs
Nerve Distribution - Motor: ULNAR NERVE - C7/8/T1
flexor carpi ulnaris, flexor digitorum profundus (digits 4-5), DEEP BRANCH: flexor pollicis brevis, adductor pollicis, abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi, lumbricals (3-4), dorsal interossei (4), palmar interossei (3).
Nerve Distribution - Motor: TIBIAL NERVE
gastrocnemius, soleus, plantaris, popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior
What are the ankle PLANTARFLEXORS?
gastrocnemius, soleus, plantaris, popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior, fibularis longus, fibularis brevis
Nerve Distribution - Motor: INFERIOR GLUTEAL NERVE - L5/S1/2
gluteus maximus
Nerve Distribution - Motor: SUPERIOR GLUTEAL NERVE - L4/5/S1
gluteus medius, gluteus minimus, tensor of fascia lata
What are the hip MEDIAL/INTERNAL ROTATION?
gluteus medius, gluteus minimus, tensor of fascia lata, pectineus, semimembranosus, semitendinosus
What are the hip ABDUCTORS?
gluteus medius, gluteus minimus, tensor of fascia lata, sartorius, piriformis (when hip flexed), obturator internus (when hip flexed), gemelli (when hip flexed)
What are the hip EXTENSORS?
hamstrings (semitendinosus, semimembranosus, biceps femoris (long head), adductor magnus (hamstring part), gluteus maximus.
Best Recruitment of Transverse Abdominis and internal oblique - looking for exercises
horizontal side support (side planks), abdominal crunch
What are the hip FLEXORS?
iliopsoas, sartorius, tensor of fascia lata, rectus femoris, pectineus, adductor longus, adductor brevis, gracilis (when knee extended)
What are the shoulder LATERAL/EXTERNAL ROTATORS?
infraspinatus, teres minor, deltoid (posterior)
What is the primary utilizaton of imaging?
interventional and/or surgical planning or in determining the presence of serious medical conditions.
What other physical impairment measures should be assesed for knee ligament injuries?
knee laxity/stability, lower limb movement coordination, thigh muscle strength, knee effusion, knee ROM.
Laminectomy versus discectomy
laminectomy - used with stenosis symptoms, discectomy used with Lower Extremity nerve symptoms
Nerve Distribution - Motor: THORACODORSAL NERVE - C6/7/8
latissimus dorsi
Nerve Distribution - Motor: DORSAL SCAPULAR NERVE - C4/5
levator scapulae, rhomboid major, rhomboid minor
What are the scapular DOWNWARD ROTATORS?
levator scapulae, rhomboid major, rhomboid minor
What is the distinguishing movement/pain characteristic for acute low back pain with related cognitive and affective tendencies?
low back pain does NOT follow the initial, mid, and end range movement/pain relationship. INTERVENTIONS: address the relevant cognitive and affective tendencies and pain behaviors with patient education and counseling.
What is the distinguishing movement/pain characteristic for chronic low back pain with generalized pain?
low back pain does NOT follow the initial, mid, and end range movement/pain relationship. INTERVENTIONS: address the relevant cognitive and affective tendencies and pain behaviors with patient education and counseling.
What is the distinguishing movement/pain characteristic for subacute low back pain with related cognitive and affective tendencies?
low back pain does NOT follow the initial, mid, and end range movement/pain relationship. INTERVENTIONS: address the relevant cognitive and affective tendencies and pain behaviors with patient education and counseling.
What are the scapular DEPRESSORS?
lower trapezius, subclavius, pectoralis minor.
Acute Low Back pain with Mobility deficits: Impairments of body function
lumbar range of motion limitations, restricted lower thoracic and lumbar segemental moibility, low back and low back-related lower extremity symptoms are reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments
Acute Low Back pain with Mobility deficits: Primary Intervention Strategies
manual - thrust manipulation and other nonthrust mobilizations - to diminish pain and improve segmental spinal or lumbopelvic motion, therapeutic exercises to improve or maintain spinal mobility, patient education that encourages the patient to return to or pursue an active lifestyle.
What are the scapular RETRACTORS?
middle trapezius, rhomboid major, rhomboid minor
When using the treatment based classification system what are the four treatment subgroups?
mobilization, specific exercise, immobilization, and traction.
What are some examples of trunk coordination, strengthening, and endurance exercises?
motor control exercises, transversus abdominis training, lumbar multifidus training, and dynamic lumbar stabilization exercises.
Indication for Cryotherapy
muscle spasm, inflammation
Number needed to Treat
number of patients you need to treat t prevent one additional bad outcome.
What are the hip LATERAL/EXTERNAL ROTATION?
obturator externus, obturator internus (when hip extended), gemelli (when hip extended), piriformis (when hip extended), quadratus femoris, gluteus maximus, sartorius, biceps femoris
Nerve Distribution - Motor: NERVE TO OBTURATOR INTERNUS - L5/S1/2
obturator internus, gemellus superior
Nerve Distribution - Motor: VENTRAL RAMI OF L1/2/3
psoas major
Nerve Distribution - Motor: VENTRAL RAMI OF L1/2
psoas minor
Nerve Distribution - Motor: NERVE TO QUADRATUS FEMORIS - L4/5/S1
quadratus femoris, inferior gemellus
Nerve Entrapment Sites: ILIO-INGUINAL AND ILIOHYPOGASTRIC NERVES L1
quadratus lumborum, psoas, inguinal canal, hernia
What are the knee EXTENSORS?
rectus femoris, vastus lateralis, vastus medial, vastus intermedius.
Why can excessively exercising lead to increased symptoms?
releases proinflammatory cytokines, bluntd increased in muscular vascularity leading to widespread muscular ischemia, and inefficiencies in the endogenous opoid and adrenergic pain inhibitory mechanism.
What are the knee LATERAL/EXTERNAL ROTATORS?
rotation is possible in the loose-packed position of the knee. Movement of tibia on femur, unless specified. Biceps femoris, popliteus - unlocks extended knee, tibia unfixed - rotates tibia medially, tibia fixed - rotates femur laterally.
What are the knee MEDIAL/INTERNAL ROTATION?
rotation is possible in the loose-packed position of the knee. Movement of tibia on femur, unless specified. Semimembranosus, semitendinosus, sartorius, gracilis.
What is the recommendation for activity limitation and participation restrictions measures in the Low Back Pain CPG?
routinely assess activity limitation and participation restriction through validated performance based measures. Changes in the patients' level of activity limittion and participatin restriction should be monitored with the same measures.
What general psychological catergories should be looked at in regards to low back pain?
screening for depressive symptoms, measurement of fear avoidance beliefs and pain catastrophizing, and screeening for psychological distress
Nerve Distribution - Motor: TIBIAL DIVISION OF SCIATIC NERVE - L4/5/S1/2/3
semitendinosus, semimembranosus, biceps femoris (long head), adductor magnus (hamstring part)
Nerve Distribution - Motor: LONG THORACIC NERVE - C5/6/7
serratus anterior
What are the scapular PROTRACTORS?
serratus anterior
What are the scapular UPWARD ROTATORS?
serratus anterior, upper and lower trapezius
What is the clinical course of adhesive capsulitis?
staged progression of pain and mobility deficits for 12-18 months. After which, mild to moderate mobility deficits and pain may persist, but many patients report minimal to no disability.
Nerve Distribution - Motor: NERVE TO SUBCLAVIUS - C4/5/6
subclavius
Nerve Distribution - Motor: UPPER SUBSCAPULAR NERVE - C5/6
subscapularis
What are the shoulder MEDIAL/INTERNAL ROTATORS?
subscapularis, pectoralis major, deltoid (anterior), latissimus dorsi, teres major.
What are the forearm SUPINATION?
supinator, biceps brachii
Nerve Distribution - Motor: SUPRASCAPULAR NERVE - C4/5/6
supraspinatus, infraspinatus
Nerve Distribution - Motor: LOWER SUBSCAPULAR NERVE - C5/6
teres major, subscapularis
What are the ankle DORSIFLEXORS?
tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis tertius
Nerve Distribution - Motor: DEEP FIBULAR NERVE
tibialis anterior, extensor digitorum, extensor hallucis longus, fibularis tertius, extensor digitorum brevis, extensor hallucis brevis.
What are the ankle INVERTORS?
tibialis anterior, tibialis posterior
Neurotmesis
transection of the nerve. Prognosis is extremely poor.
Acute LBP with Related Cognitive or Affective Tendencies
• Acute or subacute low back and/or low back-related lower extremity pain Rule-in if: • Clinical presentation suggesting the presence of fear-avoidance, pain catastrophizing, or depression, such as: o High scores on the psychosocial subscale of the STarT Back Screening tool, assessing for bothersome, fear, catastrophizing, anxiety, and depressive tendencies o High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear o High scores on the Pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness o High scores on the Patient Health Questionnaire-2 or PHQ-9 or Beck Depression Inventory and affect consistent with an individual who is depressed Rule-out if: • Scores on the psychosocial subscale of the STarT Back Screening tool total to be 0
Chronic LBP with Movement Coordination Impairments
• Chronic, recurring LBP that is commonly associated with referred lower extremity pain Rule-in if: • Low back and/or low back-related lower extremity pain that worsens with sustained end-range movements or positions • Observable movement coordination impairments of the lumbopelvic region with flexion and extension movements or while performing daily, occupational, or recreational activities • Diminished trunk or pelvic region muscle strength and endurance • Mobility deficits of the thorax and hips may be present • Signs of lumbar segmental or sacroiliac hypermobility may be present Rule-out if: • Presence of adequate left and right passive straight leg raise (80o) and thorax rotation (80o) mobility • Presence of normal trunk flexor (eg, double-leg lowering test), trunk extensors (Sorensen test), lateral abdominals and hip abductors (eg, side plank/side bridge tests) and hip and thigh muscle performance (star excursion balance tests)
Chronic LBP with Radiating Pain
• Chronic, recurring, mid-back and/or LBP with associated radiating pain and potential sensory, strength, or reflex deficits in the involved lower extremity • Lower extremity paresthesias, numbness, and weakness may be reported Rule-in if: • Symptoms are reproduced or aggravated with sustained end-range lower-limb nerve tension/straight leg raise and/ or slump tests Rule-out if: • Lower limb tension tests (eg, straight leg raising) or slump testing do not reproduce reported low back or leg pain
Back Related Tumor
• Constant pain not affected by position or activity, worse at night • Age over 50, History of cancer, Failure of conservative intervention • Unexplained weight loss • No relief with bed-rest Increase index of suspicion if: • Constant pain not affected by movement, but worse with weight bearing • Pain not responsive to therapy (failure to improve within 30 days) Reduce index of suspicion if: • Clinical findings are consistent with one or more of the ICF-based LBP subgroups • Symptoms are resolving with subgroup matched interventions
Spinal Compression Fracture
• History of major trauma, such as vehicular accident, fall from a height, or direct blow to the spine • History of minor trauma for osteoporotic or elderly individuals, such as falls or heavy lifts • Age over 75 • Prolonged use of corticosteroids Increase index of suspicion if: • Increased pain with weight bearing • Point tenderness over site of fracture Reduce index of suspicion if: • Age of 50 years or less • Symptoms are not aggravated with weight loading or thoracolumbar flexion movements • Clinical findings are consistent with one or more of the ICF-based LBP subgroups
Acute LBP with Related (Referred) Lower Extremity Pain
• LBP commonly associated with referred buttock, thigh, or leg pain, that worsens with flexion activities and sitting • Reports numerous low back-related lower extremity pain episodes Rule-in if: • Low back and lower extremity pain that can be centralized and diminished with positioning, manual procedures, and/ or repeated movements • Lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility, and clinical findings associated with the acute or chronic low back pain with movement coordination impairments category are commonly present Rule-out if: • Baseline assessments of pain location and pain levels are not altered with prolonged positioning, manual procedures (eg, lateral shift correction), or repeated movements (eg, prone press-ups)
Chronic LBP with Generalized Pain
• Low back and/or low back-related lower extremity pain with symptom duration for longer than 3 months • Generalized pain not consistent with other impairment-based classification criteria • Cognitive processes or affective behaviors exhibited that suggest the presence of fear avoidance beliefs, pain catastrophizing, and/or depression Rule-in if: • Clinical presentation suggesting the presence of fear-avoidance, pain catastrophizing, or depression, such as: o High scores on the psychosocial subscale of the STarT Back Screening tool, assessing for bothersome, fear, catastrophizing, anxiety, and depressive tendencies o High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear o High scores on the Pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness o High scores on the Patient Health Questionnaire-2 or PHQ-9 or Beck Depression Inventory and affect consistent with an individual who is depressed Rule-out if: • Scores on the psychosocial subscale of the STarT Back Screening tool total to be 0
Back-related Infection
• Recent infection (eg, urinary tract or skin) • Intravenous drug user/abuser • Concurrent immunosuppressive disorder • Reports of fever, malaise, and swelling Increase index of suspicion if: • Fever, malaise, and swelling • Spine rigidity, accessory mobility may be limited • Elevated body temperature, increasing suspicion of: - tuberculosis osteomyelitis - pyogenic osteomyelitis - spinal epidural abscess Reduce index of suspicion if: • Body temperature is normal • Clinical findings are consistent with one or more of theICF-based LBP subgroups
Cauda Equina syndrome
• Urine retention or incontinence, Fecal incontinence • Saddle anesthesia • Global or progressive weakness in the lower extremities Increase index of suspicion if: • Saddle anesthesia • Sensory or motor deficits in the feet (L4, L5, S1 areas) Reduce index of suspicion if: • Lower extremity sensation is normal or improving • Lower extremity muscle performance is normal or Improving
