omm step 2

Rib 1-12 - muscle attachments

1: anterior & middle scalenes (use to tx rib 1 dysfcn) 2: posterior scalenes (use to tx rib 2 dysfcn) 3-5: pectoralis minor (use to tx rib 3-5 dysfcn) 6-9: serratus anterior (use to tx rib 6-8 dysfcn) 10-11: latissimus dorsi (use to tx rib 9-10 dysfcn) 12: quadratus lumborum (use to tx rib 11-12 dysfcn)

chap: heart

2nd intercostal space, near the sternum

chap: lungs

3rd/4th intercostal spaces, near the sternum

subluxation of the radial head at the elbow joint

AKA radial head dislocation, aka nursemaid's elbow. common in young kids pulled up vertically too hard by the hand, e.g. to prevent a fall. Leads to dislocation of the radial head. MC injury to the UE in kids. Annular ligament has straight sides in kids, becomes more funnel shaped with age, and that prevents the head from being pulled inferiorly. Pts usu hold arm in slight flexion at the elbow & close to torso (position with least stress). Tx= manual reduction of the joint. Usu a palpable or audible click confirms successful reduction. 2 common methods: Supination technique= elbow in 90 deg with pressure on radial head, then supinate forearm & fully flex the elbow while maintaing radial head pressure. Hyperpronation technique= elbow flexed to 90def with forceful pronation of the wrist.

chap: bladder

Anterior: periumbilical region

difference between pseudogout (calcium pryophosphate dihydrate, CPPD) & urate gout

CPPD = positively birefringent crystals Urate gout = negatively birefringent crystals

what happens to the AP and transverse diameter during cranial flexion and extension phases

Cranial Flexion = The SBS moves cephalad, midline bones in flexion & paired bones in external rotation. Decreases the AP diameter & increases the transverse diameter (FLEXED HEAD = FAT & FLAT HEAD) Cranial Extension = The SBS moves caudad, midline bones in extension & paired bones in internal rotation. Increases the AP diameter & decreases the transverse diameter (EXTENDED HEAD = ALIEN HEAD)

When the PROXIMAL fibular head is ANTERIOR the foot is in

DORSIFLEXION (DAP)

Posterior radial head

During pronation the radial head moves posterior. If you fall forward onto an outstretched pronated hand, the head gets stuck in this position - posterior & pronated. Will have restricted supination.

Anterior radial Head

During supination the radial head moves anterior. If you fall backwards onto a supinated hand, the head gets stuck in this position - anterior & supinated. Will have restricted pronation.

exs of direct & passive techniques

HVLA

in post-isometric relaxation muscle energy (direct tx) what position is the pt placed in & in what direction does the pt provide counter force to the

In direct treatments you put pt into their barrier (opposite their dx) & you push the pt further into their barrier while they push against you in the direction of freedom (or towards their original dx). Operator's force is matched by the pt's force, resulting in increased muscle tension without change in approximation of muscle origin & insertion. isometric means no shortening or lengthening of the muscle. Tension causes activation of the golgi tendon organs, during relaxation they relax.

supraspinatous impairment

Mc rotator cuff tendon to be injured or torn. MRI of the shoulder without contrast can help confirm dx. Or do empty can/Jobe's test.

flexion & extension phases of cranial movement

Named after position of midline cranial bones (the sacral position is opposite the cranial position) FLEXION (short & fat): SBS cephalad, midline bones flexed, paired bones externally rotate, sacral base moves posterior into extension/counternutation EXTENSION (extra tall & thin): SBS caudal, midline bones extended, paired bones internally rotate, sacral base moves anterior into flexion/nutation

where does cranial mvt occur & what are the paired & midline cranial bones?

Occurs at articulation between sphenoid & occipital bones, called sphenobasilar synchondrosis (SBS). Midline bones: sphenoid, occiput, ethmoid, vomer Paired bones: frontal, temporal, parietal

When the PROXIMAL fibular head is POSTERIOR the foot is in

PLANTARFLEXION (PPP)

R vs L thoracic duct

R drains = R side of head & neck, R UE, heart & lungs. The rest drains into the L thoracic duct.

ottawa ankle fracture rules

Should get an xray if: inability to ambulate initially after injury & on exam in ED/urgent care, tenderness/pain at medial & lateral malleoli, pain over the navicular or at the base of the 5th metatarsal. If none of those then no xray, start early ROM exercises & PT. (If it were higher grade then you could immobilize jt with a fracture boot/CAM walker)

rule of 3s thoracic

T1-T3= spinous process at level of corresponding vertebral body & transverse process T4-T6= spinout process half a level below the corresponding vertebral body & transverse process T7-T9= spinous process one level below the corresponding vertebral body & spinous process T10= same as T7-T9 T11= same as T4-T6 T12= same as T1-T3

spinal cord levels associated with sympathetic innervation to: head & neck

T1-T4

spinal cord levels associated with sympathetic innervation to: heart

T1-T5

spinal cord levels associated with sympathetic innervation to: middle GI tract

T10-T11 includes portion of duodenum, jejunum, ilium, ascending colon, proximal 2/3 of transverse colon, adrenals, kidneys, upper ureters, ovaries, testes

what sympathetic levels associated with reflex innervation of the lower extremities?

T11-L2

spinal cord levels associated with sympathetic innervation to: lower GI tract & pelvic organs

T12-L2 (includes distal 1/3 of transverse colon, descending colon, sigmoid colon, rectum)

spinal cord levels associated with sympathetic innervation to: Lungs

T2-T7

spinal cord levels associated with sympathetic innervation to: upper GI tract

T5-T9 spleen stomach gallbladder liver, pancreas, portion of duodenum

What happens to sacrum when cranium in flexion/extension phases?

When cranium in flexion phase, sacral base moves posterior into extension/counternutation. When cranium in extension phase, sacral base moves anterior into flexion/nutation. Nutation/Counternutation occurs around a superior transverse axis of the sacrum in a sagittal plane of motion.

migraine headaches

abnormal strain pattern at sphenobasilar synchondrosis (SBS). also assoc with cervical or upper thoracic spine dysfcn. may have decreased CRI (sign of stress & may be trigger).

disc herniation L5-S1

affects s1 nerve root- diminished achilles reflex & problems walking on toes. also pain in posterolateral thigh, leg, to heel.

what test do you do before taking an ABG sample

allens test

Movement of the sacrum along an oblique axis

anterior or posterior torsion of the sacrum

Chap: kidneys

anterior: 1 inch superior & 1 inch lateral to the umbilicus posterior: between spinous & transverse processes of T12 & L1

Chap: adrenals

anterior: 2 inches superior & 1 inch lateral to umbilicus Posterior: between spinous & transverse processes of T11 & T12

chap: prostate

anterior: myofacial tissue along the posterior margin of the iliotibial band

Chap: appendix

anterior: tip of R 12th rib posterior: tip of transverse process T11

pes anserine bursitis

anteromedial aspect of tibia, 3 tendons insert at the pes anserine (sartorius, gracillis, semitendinosis). usu pain with lateral mvts/sports. PT = main therapy, focus on stretching hamstrings, steroid injection in certain cases

phrenic nerve

arises from neck c3-c5. innervates diaphragm

CN 12 (hypoglossal)

arises in medulla exits cranium via hypoglossal canal Dysfunction of this nerve occurs more frequently with somatic dysfn at the occipital condyles, especially in infants after vaginal birth, causes suckling disorders

CN 3 (oculomotor)

arises in midbrain exits cranium via superior orbital fissure

CN 7 (facial)

arises in pons enters internal acoustic meatus exits cranium via stylomastoid foramen

Rib raising

articulatory technique to normalize hypersympathetic activity via the thoracic chain ganglia that lie directly anterior to the rib heads. Initially stimulates sympathetic outflow, but ultimately inhibits it. It enhances expectoration by thinning mucous secretions. It also increases rib excursion & makes the work of respiration easier. It improves breathing in asthmatics or pts with viral PNA.

axillary nerve injury

associated with fracture of surgical neck of humerus associated with dislocated shoulder Causes deltoid paralysis

bennett fracture

base of the 1st metacarpal into intra-articular space

forearm supination

biceps brachii innervated by the musculocutaneous nerve

fracture of 4th/5th metacarpal bones

boxers fracture - closed fist strike

thompson test

calf squeeze test for achilles tendon rupture. absence of plantar flexion with squeezing gastroscnemius muscle belly is pos

anatomical leg length discrepancies

can be from unilateral total hip replacement. PE: sacral base unleveling-lower on short leg side anterior innominate on short leg side posterior innominate on long leg side lumbar dysfcn type 1 with sidebend away & rotation toward short leg side can also measure femoral heads on postural xrays

v spread technique of OM suture

can perform at any suture within the cranium to open it from impaction or restriction of its normal ROM. The occipital-mastoid (OM) suture between occipital & temporal bones, affects any of the nerves that exit the cranium via the jugular foramen. Including CN 9 (glossopharyngeal),10(vagus),11(spinal accessory). The vagus nerve (which originates in the medulla) can have dysfunction in parasympathetic innervation of organs, including the heart. stimulation of the vagus can aid in stabilizing heart rate.

Erb's palsy

causes about 50% of brachial plexus injuries in the newborn. mmc from dystocia, a difficult childbirth, where infants head & neck is pulled & stretches the brachial plexus. Usu C5 & C6 are injured, and sometimes C7 also. Causes deltoid & intraspinatous weakness and classic "waiter's tip". Distal muscles preserved so can still grasp objects with fingers.

ulnar nerve damage d/t medial epicondyle fracture

causes claw hand: flexion of the PIP & DIP jts of the 4th & 5th digits & extension of the MCP jts of the 4th & 5th digits. Lose innervation to the lumbricals in 4th/5th digits so extensor muscles unopposed. Ulnar nerve from c8-t1, responsible for finger adduction & abduction. Also innervates the adductor pollicis muscle that adducts thumb (this is the only muscle in the thenar eminence innervated by the ulnar nerve & the only thumb movement by the ulnar, the rest are innervated by the median nerve).

Radial nerve palsy

causes weakness of supinators & extensors of forearm. can have wrist drop.

acromioclavicular joint injury

common in athletes from falls or direct impact to the shoulder, e.g. contact sports. Pain commonly elicited with cross body adduction & neer's testing. AC separation graded by severity of disarticulation of clavicle from acromion. Low grade injuries (1,2,most 3)= manage conservatively. Higher grade injuries (some 3,4,5,6)= usu need surgery d/t instability & pain.

posterior tibia or anterior talus dysfcn

common in ppl who have prolonged plantar flexion like dancers or wearing high heels. Restricted dorsiflexion at ankle bc talus is anterior. Plantar flexion causes distal talus to move anteriorly and tibia moves posteriorly. HVLA by putting into dorsiflexion by applying traction to ankle with pt supine, then force in an arcing motion posteriorly & towards the floor.

nerve injury that causes foot drop

common peroneal/fibular (L4-S2). supplies sensory to anterior lower leg. supplies motor to dorsiflexors of foot. can be caused by impingement at fibular head, e.g. posterior fibular head somatic dysfcn or by fibular fx

scaphoid fracture

commonly injured with fall onto outstretched hand, dx is frequently missed. pain with palpation of the anatomical snuff box & limitations in wrist ROM are signs. Watson test is helpful to confirm dx also.

greater trochanter bursitis

commonly involves friction of the overlying iliotibial band. presents with pain during palpation of the greater trochanter.

vault hold (STMO 2345)

commonly used to eval CRI. index finger: greater wing of sphenoid Middle finger: preauricular part of temporal bone ring finger: mastoid process pinky: squamous part of occiput (STMO)

meralgia paresthetica

compression of the lateral femoral cutaneous nerve (L2-3) between the ilium & the inguinal ligament at its attachment near the ASIS. mc in pts that sit for long time with seat belt on, overwt and/or wear tight clothing. Also see from seatbelt compression in MVAs. Causes hypoesthesia & paresthesias of lateral thigh

effort thrombosis (paget-schroetter synd)

compression of vasculature at pectoral girdle can cause venous thrombosis. presents with shoulder pain & swelling. Usu in throwing athletes, swimmers, wt lifters ( and occupations/ hobbies with similar types of repetitive mvts)

interspinous ligament

connects adjacent vertebral bodies, from root to apex of each section. Connect the ligamentum flavum anteriorly with the supraspinous ligament posteriorly.

ligamentum flavum

connects the laminae of adjacent vertebrae from c2-s1

frontal & parietal bones

coronal suture

exs of indirect & passive techniques

counterstrain, vailitated positional release balanced ligamentous tension.

cervical disc herniation at C7-C8

dec sens 5th digit dec finger extension

cervical disc herniation at C6-C7

dec sensation in 3rd finger dec triceps strength

cervical disc herniation at C5-C6

dec sensation in thumb & index finger dec biceps fcn

cervical disc herniation at C4-C5

dec sensation over outer arm dec deltoid fcn

cervical disc herniation at C8-T1

dec sensation over ulnar forearm dec fcn of intrinsic muscles of the hand

spinal stenosis

degen changes (eg loss of intervertebral disc ht, hypertrophy of the zygapophyseal jts, calcium deposits in ligamentum flavum & posterior longitudinal ligament) that cause narrowing of spinal canal or intervertebral foramina causing pressure on nerve roots or the cord itself. Sxs: usu LBP/ache that radiates to legs as shooting or paresthesias in one or both legs. sx's usu worse with extension, standing, walking, lying supine. tx: activity modification, PT, analgesics as needed, epidural steroid injections, or surgical laminectomy w decompression.

how do you name somatic dysfunctions

direction of freedom = direction it is stuck in or likes to go to or the direction that causes mechanics to become MORE symmetrical.

female athlete triad

disordered eating, amenorrhea, low bone density. Usu underlying problem is with perceived body image - primary tx goal is to address this underlying cause.

T12-L2 sympathetics

distal 1/3 of transverse colon, descending colon, sigmoid, rectum, lower ureters, bladder, pelvic organs (except testes, ovaries, prostate)

pronation of the ankle

dorsiflexion, eversion, abduction

Lateral meniscus tear

dz with mcmurrays test or MRI. mc after notable trauma or injury to knee

tx for anatomical leg discrepancies

elderly/fragile pts: initial heel lift 1.5mm (1/16''), use increments of 1/16'' every 2 wks until 100% level younger/flexible pts: initial heel lift 3.2mm (1/8''), use increments of 1/8'' until 1/2-3/4 of discrepancy fixed.

conus medullaris syndrome (CMS)

enlarged distal termination of the spinal cord superior to the cauda equina, causes cms when compressed. Will have UMS like spasticity & hyperactive reflexes as well as LMS like muscle flaccidity & loss of reflexes. progressly quickly and is bilateral (Note: can appear similarly to cauda equina synd, but CES presents slowly and is unilateral and doesn't have UMN sxs).

entrapment tendinitis

entraped tendons within first dorsal wrist compartment

dequervains tenosynovitis

entraped tendons within first dorsal wrist compartment. apl & epb involved (abductor pollicis longus & extensor pollicis brevis). finkelstein test

snapping over ulnar styloid

extensor carpi radialis

tendon around lister's tubercle

extensor pollicis longus in 3rd wrist compartment

nerve injury that causes decreased knee jerk reflex

femoral nerve (L4) innervates quadriceps supplies sensory to medial & middle thigh & medial lower leg

apleys scratch test

for ROM of the shoulder. reach behind head to opp shoulder : abduction & external rotation reach in front of head to opp shoulder or reach behind back to opp scapula: adduction & internal rotation

Yergason Test

for bicipital tendonitis. Pt elbow in 90 deg flexion & full pronation, resist pt's attempt to supinate forearm & externally rotate humerus. Pos if pain reproduced in the bicipital groove. May have pain with palpation of bicipital tendon over the groove also.

Thomas Test

for iliopsoas muscle tightness. pt supine at end of exam table with both knees fully flexed against chest, then lowers 1 leg until fully relaxes or until there is either an anterior pelvic tilt or an increase in lumbar lordosis. A pos test is when there is lack of hip extension with knee flexion greater than 45 deg. If there is full hip extension with knee flexion less than 45 deg- it may be rectus femoris tightness. If there is lack of hip extension with knee flexion less than 45 deg- it may be tightness of iliopsoas & rectus femoris. Also, hip external rotation during the test may indicate a tight IT band.

McMurray's test

for meniscal injury, often false negatives. Usu present with gradual development of joint effusions, locking, instability.

spurlings test

for narrowing of cervical foramina that can cause cervical radiculopathy & referred pain. Extend head & sidebend cpine to side being tested, apply compression. this narrows the intervertebral foramina more & compresses the nerve root to try & elicit sx's.

Adson's maneuver

for thoracic outlet synd caused by compression of subclavian artery by scalene muscles. Palpate radial artery while pt's arm is externally rotated & extended then pt extends & rotates neck toward the arm tested & takes a deep breath. Pos if radial pulse diminishes or disappears. Has a high false positive rate (>50%)

dorsal scapular nerve

from c5 of brachial plexus, innervates rhomboids & levator scapula. Damage causes problems with elevating the scapula & pulling it to midline, so may sit lower & more lateral than unaffected side but no winging.

tibial nerve & plantar branches

from nerve roots L4-S3. gives rise to medial & lateral plantar nerves. Together they innervate muscles of the posterior leg & provide sensation to the lateral posterior leg. tibial nerve dysfcn causes decreased ankle jerk reflex.

sciatic nerve injury

from roots L4-S3. It gives rise to the tibial & common fibular (peroneal) nerves & supplies muscles of the posterior thigh. Injury causes sciatic neuritis aka sciatica. sx's = pain with or without paresthesias radiating down back of thigh to knee. usu does not cause sx's below the knee. Can be injured by hypertonic piriformis muscle also as it is in close proximity

median nerve injury

from roots c6,c7, c8,t1, sometimes c5 too branch of medial & lateral cords of brachial plexus high nerve palsy from lesions at elbow & forearm low nerve palsy from lesions at wrist

Systemic lymphatic congestion treatment (e.g. for CHF)

general approach is central to peripheral (use indirect myofascial release or balanced ligamentous tension in acute/fragile pt setting). first tx thoracic inlet, then release abdominal diaphragm, etc, and lymphatic pump (good for pulmonary & LE edema) should be last. Note: tx's should be conservative in CHF so as to not overload the heart, but once the pt is stable (eg no SOB) it is not contraindicated.

bakers cyst

get ultrasound to confirm

sciatic nerve & piriformis

in 85% the nerve runs inferior to piriformis & muscle spasm can contribute to sciatica. In 15% the nerve is split by the piriformis & pts more likely to have sx's from this anatomic abnormality.

disc herniation and affected nerve root

in general, the nerve number that is affected by herniation, corresponds to the lower vertebra number of the 2 adjacent vertebrae. Cervical nerve roots exit above their corresponding vertebra except for C8, which is between C7 and T1, then starting with the T1 nerve root & everything below (thoracic, lumbar, sacral) - each nerve roots exits below its corresponding vertebra.

goblet cell production in lungs & ANS

increased by sympathetics, decreased by parasympathetics

venous sinus technique

increases venous flow through venous sinuses so blood can exit cranium via jugular foramen.

ex of indirect & active techniques

indirect myofascial release with respiratory assist

osteitis pubis

inflammation & degeneration of the symphysis pubis. Usu have vague lower abdominal pain, adductor or groin sx's that don't localize.

rhomboid major

innervated by dorsal scapular nerve attaches to medial border of scapula paralysis causes weak scapula adduction

levator scapula

innervated by dorsal scapular nerve. attaches to medial border of scapula paralysis causes weak scapula elevation

serratus anterior

innervated by long thoracic nerve (c5-c7) paralysis causes winged scapula

trapezius muscle

innervated by spinal accessory nerve (CN11) paralysis causes lateral winging of scapula nerve injury usu from radical neck surgery for head & neck cancers.

latissimus dorsi

innervated by thoracodorsal nerve. attaches to inferior angle of the scapula. anchors scapula to chest wall during shoulder motion use to tx dysfcns of ribs 9&10 originates from spinous processes T7-L5, thoracolumbar fascia, iliac crest, sacrum, lower ribs. inserts on medial lip of bicipital groove of humerus. Adducts, extends & internally rotates humerus

carcinoid syndrome

intermittent diarrhea, flushing, wheezing, R sided cardiac abnormalities - all secondary to secretion of serotonins, kinins, and other biogenic amines from fcnl secretory neuroendocrine tumors. Dx: measure urinary 5-hydroxyindoleacetic acid (5 HIAA) levels. Tx= octreotide &/or surgical removal of tumor.

Q angles

intersection of 2 lines from ASIS through middle of patella & tibial tuberosity through middle of patella. Normal is 14-17 degrees Genu Valgum = >17 (knock knees) Genu Varum = <14 (bowleggedness)

measuring cobb angles for scoliosis

intersection of lines drawn parallel from the endplates of the most superior & inferior vertebrae of the curve. Dx of scoliosis if angle >10 degrees. Get AP & lateral xrays from occiput to sacrum. Lateral to look for sponylolysis or spondylolisthesis. Treat by severity: <20deg = conservative (OMT, exercises, PT) = mild 20-40deg = spinal bracing = mod >50deg = surgery = pulmonary compromise >75 = cardiac compromise

the dura matar attaches where & why important

intracranial & intraspinal membranes attaches to foramen magnum, C2, C3 & the posterior superior portion of S2. When SBS moves cephalad the dura moves cephalad also & visa versa. This allows for movement of the cranium with CSF fluctuation.

common fibular nerve (peroneal nerve) injury

it is innervated by L4-S2 and supplies sensory innervation to the anterior lateral leg & motor innervation to the anterior lower leg- specifically muscles that cause dorsiflexion in the foot and dysfcn can cause foot drop (can be caused by impingement at fibular head that isn't resolved).

pterion

junction of temporal parietal sphenoid frontal bones. weakest point in the skull anterior division of middle meningeal artery along the inside & can rupture with trauma to the temple, causing epidural hematoma.

quadriceps muscles

knee extension innervated by femoral nerve (L2-L4)

lateral pectoral nerve

lateral cord of brachial plexus c5,c6. innervates pectoralis major. damage causes problems with flexing, adducting & medially rotating humerus

musculocutaneous nerve

lateral cord of brachial plexus, c5-c7. innervates multiple muscles in anterior compartment of arm. becaomes lateral cutaneous nerve of forearm. injury rare, causes weakness in elbow flexion & forearm supination

lateral collateral ligament

lateral knee stabilizer, femur to fibula, can tear after trauma or injury to jt, dx with MRI

Cranial motion around a vertical axis

lateral strain at the SBS

Chap: colon

lateral thigh along IT band. Proximal R: terminal ileum & cecum Mid R: ascending colon Distal R: hepatic flexure & R transverse colon Distal L: L transverse colon & splenic flexure Mid L: descending colon Proximal L: sigmoid?

chap: pancreas

lateral to costal cartilage between ribs 7 & 8 on R side

chap: rectum

lesser trochanter on medial thigh

leg length measurement

line from ASIS to medial malleolus in same extremity (medial more accurate than lateral malleolus).

how to tx inion tenderpoint

marked flexion

rheumatoid arthritis

mc chronic inflammatory arthritis, multiple joints, usu symmetric, atraumatic swollen jts, finger deformities or weakness early in dz, chronically develop ulnar deviation of phalanges, ocular issues (keratoconjunctivitis), foot deformities, spine involvement.

cervical myelopathy

mc spinal cord compression disorder >55yo. usu from spinal stenosis. sxs: heaving feeling in legs, slow gait, shooting pains into arms & legs. Neck flexion may reproduce sxs - called Lhermitte's sign.

essential HTN

mc type of HTN, defined as BP > 140/90 on repeated measurements without another cause. usu asymptomatic, tx with lifestyle change & meds if fails.

winged scapula

mcc is injury to long thoracic causing paralysis of serratus anterior (which attaches to ribs 1-9 and the ventral surface of the scapula), & dysfcn in rotation of scapula. d/t acute or recurring trauma in sports. dx based on hx & PE, EMG useful to eval nerve damage. Sx include shoulder pain & weak scapula in forward elevation (arm flexion?). have pt push against wall & abduct arms over head. most atraumatic lesions resolve itself. can brace scapula to rib cage to alleviate pain & stabilize shoulder to prevent overstretching of serratus. Must avoid heavy liftin during recovery. Surgical stabilization if no resolution & pain & weakness are causing instability.

MEN 1,2a,2b PPP, PPM, PMM(M)

men1: parathyroid hyperplasia, pancreatic tumors, pituitary adenoma men2a: parathyroid hyperplasia, pheochromocytoma, medullary thyroid carcinoma (MTC) men2b: mucosal neuromas, pheochromocytoma, medullary thyroid carcinoma (MTC) (also marfanoid body habitus)

apleys compression test

meniscus & ligamentous knee structures

2 frontal bones

metopic suture (allows frontal to act like a paired cranial bone even though it usually is closed by 6yo)

Lachman's test

most specific test for ACL integrity. ACL tears m/c in female athletes, usu from planting foot to stop/change directions. Also from direct trauma to knee, forcing tibia anteriorly in relation to the femur. Usu have immediate pain & sound/sensation of pop in knee then instability & problems with wt bearing & gait. Definitive tx=surgery, but many pts choose just PT.

spinal accessory nerve (CN11) injury

motor innervation to SCM & trapezius SCM sidebends & rotates head trapezius adducts scapula & elevates shoulders trapezius paralysis causes lateral winging of scapula

carpal tunnel syndrome

numbness & tingling of the first 3 digits of the hand in distribution of medial nerve & wasting of the thenar eminence, may have wrist pain. Do Phalens test & tinel's test. D/t repetitive use of flexor tendons, eg keyboardin other tests = prayer & provocation

nerve injury that causes weak hip adduction

obturator nerve (L2-4) supplies hip adductor muscles supplies sensory to small circle of skin on medial thigh

lambdoidal suture

occipital & parietal bones

occipital-mastoid suture

occipital and temporal bones

sphenobasilar synchondrosis

occiput and sphenoid bones

quadratus lumborum

originates from iliac crest & iliolumbar ligament. inserts onto 12th rib & transverse process of lumbar vertebraa. MOA is to laterally flex lumbar spine to ipsilateral side

pectoralis minor

originates near costal cartilage ribs 3-5, inserts on coracoid process of scapula. primarily draws scapula inferiorly & anteriorly against thoracic cage for stabilization.

sacroiliitis

pain & inflammation at the sacroiliac jts. Sx's include pain in lower back & buttocks either localized or with radiation down the legs.

lateral epicondylitis (Tennis elbow)

pain over lateral elbow d/t strain of the extensor muscle tendons that attach to the lateral epicondyle. Overuse injury from repeated extension & forearm supination. also grasping with hand & twisting at elbow like racquet sports or screwdriving. espec the extensor carpi radialis brevis is affected. pain reproduced with resisted wrist extension. tx is conservative.

medial epicondylitis (Golfer's elbow)

pain over medial elbow d/t strain of the flexor muscle tendons that attach to the medial epicondyle. Overuse injury from repeated flexion & forearm pronation

sphenopalatine ganglion

parasympathetic ganglia in pterygopalatine fossa. Tx to this area reduces mucus flow & thins nasal mucus as sx relief. Best for pts with nasal congestion, sinusitis, TMJ.

supination of the ankle

plantarflexion, inversion, adduction

nerve injury that causes loss of sensation to posterior thigh

posterior femoral cutaneous nerve (s1-3)

quadratus femoris

posterior portion of the hip jt thigh adduction stabilization of the femoral head in the acetabulum

posterior & anterior longitudinal ligaments

posterior: runs along posterior surfaces of vertebral bodies within the vertebral canal. Anterior: runs along anterior surface of vertebral bodies

Genu recurvatum

postural hyperextension of a joint, e.g. normal range of motion of knee is 0-135 degrees. This is any extension beyond zero, normal if extra extension <10 degrees. mc in females, also seen in the elbow

spondylolisthesis

presents similarly to spondylolysis and commonly occurs together. On lateral xray will see anterior displacement of vertebra over adjacent inferior vertebra and may be able to feel a "step off" on palpation of spinous processes. will see collar on scottie dog from spondylolysis if present on oblique xray also. neuro deficits rare. either in old people due to degenerative disc dz (usu L4-L5) or in young ppl that do sports with repetitive flexion/extension may have localized pain in lower back esp with extension. most ppl can be tx'd conservatively. home exercise & PT strengthen abdominal muscles , decrease lumbar extension. High grade with slip >50% or neurologic / radiculopathy signs may need surgery. grade 1 & 2 is <50% slippage & conservative tx usu fine. grade 1 <25%, grade 2 25-50%, grade 3 50-75%, grade 4 75-100%

forearm pronation

pronator teres & pronator quadratus, both innervated by the median nerve

anterior fibular head SD

proximal fibular head anterior, resists posterior spring distal fibular head posterior, resists anterior spring talus externally rotated, ankle pronated (dorsiflexed, everted, abducted)

posterior fibular head SD

proximal fibular head posterior, resists anterior spring distal fibular head anterior, resists posterior spring talus internally rotated, ankle supinated (plantarflexed, inverted, adducted)

spondylosis

radiologic term for ankylosing or adjacent vertebral bodies (fusion of bones/joint) & degenerative chances within an injured vertebral disc.

acute intermittent porphyria

rare autosomal dominant disorder of partial deficiency in porphobilinogen deaminase (PBGD), an enzyme required for heme biosynthesis. Results in accumulation of porphyrin precursors, porphobilinogen (PBG), and delta-aminolevulinic acid (ALA). Most pts asymptomatic, when symptomatic may have neuropathic pain in abdomen, extremities, back, chest, tachycardia, htn, N/V, constipation, peripheral motor neuropathy. Red-brown urine d/t inc urinary excretion of heme pathway intermediates. Dx: urinary prophobilinogen (PBG), quantitative measurement of urinary PBGs, urinary total porphyrins, & serum PBG.

pheochromocytoma

rare catecholamine secreting tumor of adrenal medulla. mc tumor of the adrenal medulla in adults. pts usu present w episodic htn, h/a, diaphoresis, palpitations, tremor, panic attacks, pallor. rule of 10s: 10% malignant, 10% bilateral, 10% extra-adrenal, 10% calcify, 10% occur in kids, 10% are familial. Classically associated with 3 syndromes: von hippel-lindau (VHL) synd, MEN 2A & 2B, neurofibromatosis type 1 (NF1). best initial diagnostic test: plasma free metanephrine level, then confirm with 24 hr urine collection for metanephrines. (this is more sensitive than a urine vanillylmandelic acid level). Tx: phenoxybenzamine (alpha blocker). If sx's aren't controlled then use calcium channel blocker. surgically remove tumor.

cauda equina syndrome (CES)

rare emergency that requires neurosurgical intervention. collection of terminal lumbar & sacral nerve roots inferior to the end of the spinal cord at L2. compression of nerve roots cause neurologic & urogenital sxs including bladder & bowel dysfcn (usu starts as urinary retention & constipation followed by loss of sphincter control), variable LE motor & sensory nerve impairment, perineal sensory loss "saddle anesthesia". Can be caused by a large lumbar disc herniation. Cannot be caused by disc bulge though, because the annulus fibrosus is intact & disc material is not extruded into the spinal canal so bladder changes & saddle anesthesia very unlikely. Note: similar to conus medullaris syndrome but that presents fast & is b/l & has UMN signs also. this presents unilaterally and slowly & doesn't have UMN signs, just LMN signs. Should request immediate neurosurgical consult & immobilize SUMMARY: distinguishing signs= isolated LMN signs, perineal paresthesia, bowel & bladder incontinence, presents slowly & unilaterally.

contraindication to pedal pump

recent abdominal surgery- can augment thoracoabdominal pressure, also in pts with DVT, fractures of lower extremities.

HVLA contraindications

recent ligamentous injury.

scheuermann kyphosis

rigid curvature in spine not corrected by changes in position. See anterior wedging of at least 3 adjacent vertebral bodies, endplate abnormalities. Schmorl's nodes = small protrustion of intervertebral discs into adjacent vertebral bodies. etiology unknown, usu seen in adolescent boys during rapid growth.

c5, c6, c7, c8 nerve roots

roots emerge above corresponding vertebrae, so herniation of a disc impinges nerve root below it (eg herniating disc 4 between vertebra 4 & 5 will impinge c5. C5: biceps dtr, motor to biceps & deltoid, sensation to upper arm c6: brachioradialis dtr, motor to biceps & wrist extensors, sensory to lateral forearm & first 2 digits. c7: triceps dtr, motor to wrist flexors via median nerve, motor to wrist extensors & triceps via radial nerve, sensory to 3rd digit. c8: no dtr, motor to finger flexors, sensory to 5th digit & medial forearm.

short leg syndrome

sacral base lower on side of short leg, innominate rotated anteriorly on side of short leg, lumbar sidebent away & rotated towards short leg side. Heel lifts should be used if femoral head difference >5mm & can be used up to 10-12mm. if larger need to use shoe lift. surgery only considered if difference >5cm. In an acute leg discrepancy, e.g. total hip replacement, hip fracture or acute injury - should correct the full discrepancy with 3mm to start & increasing by this every 2 wks. In chronic leg discrepancy & old people start with 1.5ishmm & increase by this every 2 wks but only up until 1/2 to 3/4 of the difference is corrected.

2 parietal bones

sagittal suture

watsons test

scaphoid subluxation or reduction indicates carpal ligament injury

4 rules of sacral torsions

seated flexion test must be positive for dx of torsion seated flexion test is pos on opposite side of the axis L5 sidebends to the side of the axis L5 rotates in the opposite direction of the sacrum In forward sacrum (L on L, R on R), L5 is type 1 In backward sacrum (R on L, L on R), L5 is type 2 Forward sacrum has a negative lumbar spring test Backward sacrum has a positive lumbar spring test

loss of wrist extension (wrist drop)

seen in radial nerve damage from midshaft humerus fracture

hamstring muscles

semitendinosus semimembranosus biceps femoris (2 origins for long & short head) origin: ischial tuberosity insert: fibular head, medial tibia Powerful knee flexors & hip extensors short head of biceps innervated by common peroneal branch of sciatic nerve (L5-S2) rest innervated by tibial branch of sciatic nerve (L5-S3) very active in gait cycle, commonly injured in runners

spencer technique

series of muscle energy technique to increase shoulder ROM in adhesive capsulitis. This is the order: extension, flexion, circumduction with compression, circumduction with traction, abduction, internal rotation, pump E,F,CC,CT,A,I,P (every foolish child tries aspirating in pools)

erector spinae

set of 3 paraspinal muscles that run longitudinally parallel to vertebral column. From lateral to medial: iliocostalis, longissimus, spinalis.

loss of arm abduction beyond 90 deg

shoulder dislocations, axillary nerve injury of supraspinatous tears

Hawkins test

shoulder impingement or rotator cuff tendinosus. flex shoulder forward, elevate to 90 deg, then forcibly internally rotate & bring the greater tuberosity of the humeral head toward acromion.

chapmans points

smooth, discree nodules approc 2-3 mm in diameter that lie within fascial tissue & along bone periosteum. They are somatic findings of visceral dysfunction. Anterior points are used for dx & posterior points are used for tx.

frontal & sphenoid bones

sphenofrontal suture

sphenoid & parietal bones

sphenoparietal jcn

sphenoid & temporal bones

sphenosquamosal jcn. common area of restriction & dysfcn.

temporal & parietal bones

squamosal suture

lachmans test

stability of acl - more accurate than anterior drawer test

chap: stomach & liver & gallbladder

stomach: 5th/6th intercostal spaces on L side liver: 5th/6th intercostal spaces on R side gallbladder: 6th intercostal space on R side

jones fracture

stress fracture of base or proximal third of the 5th metatarsal

spondylolysis

stress fracture of the pars interarticularis (between sup & inf articular processes of the zygapophyseal joint) without displacement of affected vertebra on adjacent inferior vertebra. common cause of lower back pain in athletes that throw, dance, gymnyst. pain also in butt or posterior thigh ache. elicited with extension, single leg hop, usu no neuro deficits. may have b/l tight hamstrings, waddling gait, short stride. image: oblique lumbar xrays & lumbar CT can help confirm dx- may show collar on the scottie dog. mc in L4-L5. Tx=conservative, good prognosis

supraspinous ligament

strong fibrous cord, connects apices of spinous processes from c7 to sacrum

suprascapular nerve

supoerior trunk of brachial plexus, c5-c6. innervates suprasinatus & infraspinatus of rotator cuff. damage causes problems with abduction & external rotation of humerus.

common peroneal/fibular nerve entrapment causes

supplies sensory innervation to anterior lateral leg. nerve directly posterior to proximal fibular head. A posterior fibular head somatic dysfcn or fractured fibula can cause dysfcn of the nerve. Also, can be seen in pts that sit crossed legged for prolonged time. (it is not usu entrapped in the popliteal fossa, where it comes off the tibial nerve, bc it contains mostly fat)

SITS muscles

supraspinatus: arm abduction intraspinatus & teres minor: external rotation subscapularis: internal rotation

complete rupture of distal biceps tendon

swollen elbow, pop while doing biceps curls, immediate pain & loss of strength with arm flexion, arm looks cartoonish, abnormal hook test, diminished strength with resisted supination. confirm dx with MRI of elbow.

athletic pubalgia

tendinopathy of the pelvic stabilizers at confluence of rectus abdominus insertion, adductor origin, and pelvic floor at the pubic ramus.

Wright maneuver

test for thoracic outlet synd. passively hyperabduct & extend/ externally rotate pt's arm. Head & neck in neutral position. If reproduces sx's or decreased radial pulse then positive. can be d/t compression of neurovasc bundle under pec minor at coracoid process. sxs can mimic carpal tunnel synd, but usu b/l and alternate sides.

sensory & motor innervation provided by the common fibular nerve (peroneal nerve) & it's branches

the peroneal/common fibular nerve branches off the tibial nerve in the popliteal fossa. It supplies sensation to the anterolateral leg & motor innervation to the anterior lower leg. It bifurcates in the proximal-lateral compartment into the deep & superficial fibular nerves. The superficial fibular stays in the lateral compartment & supplies motor innervation to the fibularis longus & brevis & sensory to the medial/intermediate dorsal cutaneous nerves. The deep fibular nerve goes through the anterior intermuscular septum & descends into the extensor compartment, it supplies the tibialis anterior, extensor digitorum longus/brevis, extensor hallucis longus/brevis & fibularis tertius.

c2-c7 are unusual because

they are type 2 like because side bend & rotate in same direction, but can be flexed, extended, or neutral because cervical vertebrae don't follow typical fryette laws (only applied to thoracic & lumbar)

gracillis

thigh adduction

sartorius, gluteus & tensor fascia lata muscles

thigh/hip abduction

nerve injury that causes decreased ankle jerk reflex

tibial nerve (L4-S3) supplies muscles of posterior leg supplies sensory to lateral posterior leg

obers test

tightness in tensor fascia lata & iliotibial band

u/s of the shoulder

to determine causes for shoulder pain, e.g. rotator cuff tendinopathies/tears, proximal biceps tendinopathy, acromioclavicular degenerative joint dz

u/s of wrist

to determine causes for wrist pain, hand atrophy or hand weakness, e.g. carpal tunnel syndrome.

Well straight leg raise test

to eval for vertebral disc damage. Pt supine & both knees & hips extended, passively flex the pts uninvolved LE. Pos test if radicular sx's are reproduced down the symptomatic leg (the one not being lifted). Back pain or hamstring discomfort is not a positive test, it must be radicular sx's. This test is more specific for intervertebral disc pathology than the Lasegue test.

Lasegue Test (unilateral straight leg raise test)

to evaluate for dural involvement from herniated nucleus pulposus or neural foraminal stenosis. Pt supine w both knees & hips extended. Slowly raise pt's symptomatic leg until reproduces pain then lower leg until pain resolves then dorsiflex ankle & ask pt to flex their neck. If the pain is reproduced again then is a true positive test for reproduction of radicular sx's. If there is no pain with ankle dorsiflexion then the original pain is probably d/t hamstring tightness or lower back dysfunction especially if the pain was localized there.

MRI arthrogram of shoulder

to evaluate labral pathology in the shoulder

galbreath technique

to tx acute otitis media. simple mandibular manipulation. Eustachian tube opened & closed in a pumping action that allows the ear to drain accumulated fluid more effectively. Place one hand on chin with thumb & forefinger resting along lower jawbone. Other hand on forehand to hold head in place. As pt opens mouth, move lower jaw to the side opposite of the infection & hold for 3-5 seconds before releasing jaw. Repeat 3x.

Cranial motion around an AP axis

torsion strain at the SBS

anterior & middle scalenes

transverse processes c3-c5, inserts on first rib. Elevates first rib & rotates head & neck to contralateral side.

posterior scalene

transverse processes c4-c6, inserts on second rib. elevates second rib & sidebends head & neck to ipsilateral side.

sphenoid rocking

tx for pituitary & sinus problems

complex regional pain syndrome

type 1 no confirmed nerve lesion, type 2 has confirmed nerve lesion. sx's = allodynia, joint stiffness, localized edema, increased hair growth, vasospasm, continued pain out of proportion to injury

ankle sprain type 1,2,3

type 1: ATF Lig (anterior talofibular) type 2: ATF + (calcaneofibular) type 3: ATF + CF + PTF (posterior talofibular)

psoas syndrome or tendonitis

typical in athletes with repeated hip flexion like runners, dancers & gymnasts, or desk jobs Other causes of spasm: salpingitis, ureteral calculi/dysfcn, metastatic prostate ca, appendicitis, sigmoid colon dysfcn. sxs: pain, stiffness in hip & thigh, may start as lbp that radiates to groin, increased w walking or standing, snaping feeling frequent, caused by iliopsoas tendon catching on pelvic bone when hip flexed. tender point medial to ipsilateral asis, postiive pelvic shift to contralateral side, sacral dysfunction on oblique axis, positive thomas test, spasm of contralateral piriformis muscle. powerful hip flexor & external rotator, so may have LE of affected side in external rotation & trunk bent forward with flexed type 2 dysfcn in the upper lumbar segments (L1 or L2). Tx= ice, idirect omm, stretching after acute phase.

cubital tunnel syndrome

ulnar nerve compression at the elbow, paresthesias in distribution of ulnar nerve.

Jobe's test / empty can test

unable to abduct arm against resistance downward force with arm at 90deg, flexed forward 30 deg, internally rotate pointing thumb toward floor. Isolates the supraspinatus, positive if provokes pain.

compartment syndrome

usu after trauma/crush injury. 6P's: pain out of proportion to what is expected, paresthesias, pallor, paralysis, pulselessness, poikilothermia (failure to themoregulate). surgical emergency that requires fasciotomy.

guillain-barre syndrome (GBS)

usu follows viral illness. presents with stocking/glove peripheral neuropathy that progresses from distal to proximal.

ankylosing spondylitis

usu presents in 3rd/4th decade, chronic inflammation of spine & SI jts. back pain, dec rom in spine, morning stiffness, pain/inflamm in other jts hips knees ankles. PE: pain with back flexion, dec ROM, pos schober test, pos FABER test. Dx = blood work for HLA-B27, xray, MRI. Tx= antirheumatologic drugs, tnf blockers, nsaids, steroids, PT.

renal artery stenosis

usu presents with accelerated and/or difficult to control HTN. D/T atherosclerotic dz or fibromuscular dysplasia of the renal arteries. Worsening kidney fcn especially after starting therapy with an ACE inhibitor or ARB, and recurrent flash pulmonary edema = common sx's. Dx = imaging.

sympathetics L1-L2

uterus, cervix, bladder, prostate, erectile tissue of penis

parasympathetics to ovaries & testes

vagus nerve (not s2-s4 like the other pelvic organs

olecranon subluxation

very uncommon bc jt very stable. Assoc with severe trauma, usu with epicondylar fractures.

s2-s4 parasympathetics

via pelvic splanchinic nerves - lower GI tract, pelvic organs except for testes & ovaries.

patellofemoral syndrome

weakness of the vastus medialis obliquus. (sometimes called chrondromalacia- but this dx cannot be confirmed without a tissue sample). Common cause of anterior subpatellar knee pain, usu worse after long periods of sitting and when ascending & descending stairs, usu improves with walking. Usually caused by altered biomechanics from trauma, muscular imbalances, effusions, and/or meniscal tears. PE may find patellar maltracking, muscular atrophy, crepitus, locking and/or instability. Xrays usu normal. Tx= address underlying biomechanical imbalances via physical therapy. Weakness of the vastus medialis obliquus (or VMO, the most distal part of the muscle that attaches the the medial aspect of the patella) allows the vastus lateralis to dominate & pull the patella laterally. (Note: weak vastus lateralis can cause medial tracking, but this is much less common)

superior orbital fissure

within sphenoid bone. CN 3,4,V1,6 exits cranium through this. dysfcn can lead to diplopia, esotropia, ptosis, accomodation problems.

stylomastoid foramen

within temporal bone. CN 7 (facial) exits the cranium through this. Dysfcn of CN7 or the foramen can cause Bell's palsy.

foramen magnum

within the occipital bone. Brainstem forms spinal cord & exits cranium through this. The spinal accessory nerve (CN11) originates at C1-C6 spinal nerves and enters the cranium via this, and exits the cranium via the jugular foramen.

foramen ovale

within the sphenoid bone. CN V3 (trigeminal 3rd division) goes through it.

Reciprocal inhibition muscle energy

you put pt into their barrier like post-isometric, but instead of you pushing them into their barrier, the pt pushes further into their barrier. This is used in acute situations or when the pt is in too much pain to tolerate post-isometric relaxation. This does not utilize the muscle that is injured & allows the pt to control how far their are going towards their restriction.

colles fracture

...

rib motion

1-5 = pump handle (axis of motion more transverse, dysfcn more apparent anteriorly). 6-10 = bucket handle (axis of motion more AP, dysfcn more apparent laterally) 11-12 = caliper (ant & med during exhale, post & lat during inhale)