Quiz #4 C-C-C-C-Combo breaaakkkerrr
How much rotation occurs at the SI joint?
0-5 degrees
Coxa vara is more likely in ___________individuals
Heavy
What are surgical treatment options for the hip?
Hemiarthroplasty, resurfacing arthroplasty, total joint arthroplasty
Traction is not as effective when large _______________ fill spinal canal
Herniations
When in doubt, someone w/ chronic hip pain would probably benefit from strengthening of what?
Hip ABD, ERs
Weakness of what muscles are common in the hip?
Hip ABD, gluteals
MOI for labral tears
Hip extension and ER
If the pelvic innominate is anteriorly rotated, what muscle do we have to rotate it back posteriorly?
Hip extensors
Resisted isometrics: (and what muscle they focus on) L1-L2: L3-L4: L4-L5: L5: S1: S2:
Hip flexion (iliopsoas) Knee extension (quadriceps) Ankle DF (tibialis anterior) Great toe extension (EHL) Ankle PF (gastroc/soleus) (also hip extension and knee flexion) Hip extensors, knee flexors
If the pelvic innominate is posteriorly rotated, what muscles do we have to rotate it back anteriorly?
Hip flexors
Use of traction dates back to ___.
Hippocrates
Types of meniscal tears
Horizontal, radial (transverse), longitudinal (vertical), oblique, degenerative lesions
Non-operative treatment
Medication (analgesics, NSAIDS), epidural/facet joint steroid injections (usually max 3), modified activity, bracing, PT
What type of cartilage covers the sacral surface? How thick is it?
Hyaline (articular) 1.5 to 3 times thicker than the ilium
What type of cartilage covers the ilium?
Hyaline and fibrocartilage
Sacral surface
Hyaline cartilage (1.5-3x thicker than the ilium)
Other less invasive options
Hyaluronic acid or cortisone injections, Uni Spacer implant, unicompartmental athroplasty
The nucleus pulposus has more ground substance. Is it hydrophilic or hydrophobic?
Hydrophilic (loves water)
You need at least _____% of patient's BW to distract the lumbar facet joints
50
_______% of cases (piriformis syndrome) are due to macrotrauma of the buttocks, leading to soft tissue inflammation and muscle spasms, with resulting nerve compression
50
You need at least ___% of the patient's body weight to distract the lumbar facet joints.
50%
____% of patient's body weight is indicated for separation of facet joints and an increase in foraminal space.
50-60%
During a step up, there is up to ____x the person's BW through the hip
6
Recommendation for conservative care (time frame)
6 months
After THA through a posterolateral approach, how long are hip precautions continued for?
6 weeks (but may vary depending on surgeon)
_______ lbs of force during lumbar traction can reduce a disc prolapse, retracting the herniated disc material.
60-120 (this is also effective in the C-spine; about 30-40 lbs)
The nucleus pulposus is ___% water in adults and ___% water in children.
70% 90%
Grade 4 Spondylolithesis
75-100%
The lifetime prevalence of at least 1 episode of LBP is as high as _______%
80
Total costs associated w/ arthritis are over $____billion/year (including hospital and drug costs, rehabilitation costs, and lost productivity and work)
82
Bony lesions have been reported in _____-____% of ACL injuries
84-98 (often either lateral femoral condyle, lateral tibial plateau, or both due to compressive forces)
Specificity for clicking w/ labral tears
85%
Up to ____% of patients can't be given a precise pathoanatomical diagnosis
90
Stabilization CPR: Criteria (for a positive finding) of patient's age?
< than 40 years old
Interspinous decompression spacers are not indicated for what level of stenosis?
>2 (they will do other decompressive type procedures for these patients)
How common is combined FAI?
>80% of cases according to some reports
What is the difference between mobilization and manipulation?
A mobilization is a LOW velocity skilled movement done at a velocity that a patient CAN resist A manipulation is a HIGH velocity skilled movement done at a velocity that a patient CANNOT resist
Patient specific HQRL questionnaires are good for what population?
A particular individual (what is important to them?)
Nonspecific LBP is not a homogeneous group, but instead consists of subtypes of patients who can be identified based on specific signs and symptoms. This classification category does not describe a pathoanatomical condition such as a HNP. Instead, it is intended to direct the clinician to what?
A specific type of management
What is a resurfacing arthroplasty?
A surface replacement preserves the head and neck of the femur and only removes the diseased portion, preserved portion is sculpted to accept a metal cap w/ a short stem, acetabulum is replaced by the same procedure in a THA
Children w/ CP have a lot of tone in their hip_______________
Adductors
Requirements of proper posture
Adequate ROM, muscle length, muscle strength and endurance
Use of test
Administer at initial evaluation, as needed, and at discharge; establish a goal for change; document changes in chart
Evidence that low-stress ___________exercise may be effective in treatment for acute or chronic LBP
Aerobic
What all goes through the greater sciatic foramen?
I PIN SPIN Inferior gluteal N Pudendal N Inferior gluteal vessels N to quadratus femoris Sciatic N Posterior cutaneous N of the thigh Inferior pudendal vessels N to obturator internus
Management of trochanteric bursitis
Ice, NSAIDS, activity mod, taping, e-stim, and possibly corticosteroid injection are used acutely to dec. pain, soft tissue and TP techniques to muscles attaching to GT, GM, and TFL, stretch hip flexors, ADD, IRs, strengthen hip ABD and ER, address leg length discrepancy
Interventions for grade I strains (mild)
Ice, being active, keeping moving
What does ICF stand for?
International Classification of Function
Classification system uses information gathered from __________ and ___________exam to guide the management
Interview; physical
After the disc heals, which way do you stretch the patient with derangement syndrome?
Into the direction of limitation *Also patient education
Nucleus moves through torn ________ ________
Annular rings
Genu valgus
Knock knees, women tend to have a natural valgus
What are stenosis signs and symptoms?
LBP (localized or radiating) Pain and paresthesia in LEs Limited lumbar extension which may bring on distal symptoms Possible B&B changes, especially with central stenosis Posture - flexed in standing and walking (think little old lady) (also patients who like to sit all the time) Much more common in older adults
Signs and symptoms of stenosis
LBP, pain and paresthesia in LEs, limited lumbar extension which may bring on distal symptoms, possible B&B changes (esp. central stenosis), posture (flexed in standing and walking), more common in older adults
Interventions for stenosis
LS bracing to avoid extension and support extensors, traction (mechanical or manual), low grade mobs, soft tissue mobs, patient education (position of relief, no heavy lifting or extending), position in flexion to relieve symptoms (flexion, SB away, rotate toward)
CAM results in impingement, wearing away of articular cartilage, and possible __________ tears over time
Labral
Surgical options
Lateral retinacular release, proximal realignment (VMO advancement - slide it more distally), distal realignment (Fulkerson - move attachment of patella ligament medially)
Where is Gerdy's tubercle located? What attaches there?
Lateral tibia, insertion of IT band
What is a Segond fracture?
Lateral tibial plateau fracture
Describe the trochlear groove
Lies superior to the medial and lateral condyles, articulation site for patella, lateral surface has an inc. height to prevent excessive lateral patella slide during active extension
Slow loading
Ligament deformation
Hypomobility screen findings
Limited mobility in one or more planes of motion, limited mobility in one or more segments, may be hypermobile at others, may be hypomobile in other regions such as hips
Posture syndrome
Mechanical deformation of soft tissue results in postural stress; intermittent pain brought on by certain postures; symptoms are relieved w/ change in posture
The GRF falls __________ to the joint during a cutting maneuver
Medial
Explain intermittent traction.
Brief intervals; "on/off" cycles Distraction, mobilization, stretching
The fear of possible complications with manipulations keeps PTs from doing them. What are some of these complications?
Cauda equina syndrome (1 in 100 million) Cervical brain stem lesions, vertebral artery injury (3-6 in 10 million) Risk with death with spinal surgery (300 times greater)
Tibial plateau fractures
Cause my varus or valgus forces w/ axial loading, lateral tibial plateau fractures (Segond fracture) are most common
History of SIJ dysfunction
Cause?, trauma? (fall, lifting injury, MVA), unknown etiology?, symptoms (LBP or buttock pain), muscle spasms (LB, gluteals), sensory changes (not normally, but could irritate nerve root)
Patient hx of disc problems
Many small bouts of LBP over many years, usually resolves on its own w/ rest, each time it gets a little worse, LBP, worse w/ sitting and bending, begins in 20s, eventually pain goes from back to back and buttock and down LE
Static traction
May result in depression of monosynaptic response through prolonged stretch; higher forces; soft tissue stretching
Documentation applicable to goal setting
Measurable, functional, time elements
Etiology of iliopsoas bursitis
Caused by RA, acute trauma, overuse, multiple mini-traumas caused by vigorous hip flexion and ext, when hip suddenly goes from flexion to hyperextension, there is tension that stretched the iliopsoas and the bursa, over time this can inflame the bursa
Primary piriformis syndrome
Caused by anatomical variation, <15% of all cases
____________evidence as to whether obese patients have lower functional gains and higher complication rates
Conflicting
Grades of Recommendation - D
Conflicting evidence, high level studies disagree
Causes of central stenosis
Congenital narrowing, thickening of ligamentum flavum, bone spurs, central disc bulge, growth within central canal (tumor)
How are degenerative meniscal tears most treated?
Conservative treatment
Neuromuscular control
Injury to system, which can occur with traumatic spinal injury can result in diminished proprioceptive input and lead to further damage of passive restraint structures, diminished spinal stability
Nerve roots are highly ______________ - react to compression
Innervated
Outer 1/3 of annular is ____________
Innervated
Nucleus and inner annulus has no ____________
Innervation
Annulus tears from the ___________ _________
Inside out
McKenzie principles: Annulus tears from inside out or outside in?
Inside out
What are exercises used for hypermobile patients?
Core strengthening utilizing a posterior pelvic tilt position Strengthening abdominals and gluteals Proprioception exercises Core stabilization exercises Spine neutral exercises Short range exercises (strengthening and endurance)
How do you know if treatment is successful?
Correction of alignment, symmetry of motion, relief of pain
Elaborate on passive mobility testing in hypomobility patients.
Diminished PA glides (put a pillow under the patient to take them out of closed pack position) Diminished PIVMS (passive intervertebral motion testing) May have especially tight erector spine, hamstrings, iliopsoas, rectus femoris Often an globally tight muscled, tight jointed individual
Acute LBP w/ mobility deficits
Diminished ROM, pain worse w/ provocation of involved segments
What is the gold standard for HNP surgery?
Discectomy (often done w/ laminectomy or laminotomy)
Coxa valga - increased risk of hip____________
Disclocation (femoral head is not well covered by acetabulum), worse w/ adductor spasticity
The Sickness Impact Profile is a generic HQRL questionnaire. Describe it.
136 items 30 min to complete Looks at physical tasks, psychosocial and emotional aspects
Normal antiversion is ________degrees
15 (anything less is retroversion)
Coxa Valgus
170 degrees
Posterior interbody fusion surgical procedure
1st a laminectomy is performed, next the posterior 2/3 of the disc is removed and an interbody graft is placed into the evacuated disc space, most surgeons use pedicle screws to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis
Ongoing impairments and functional deficits can be seen for as long as ____ years post THA
2
The presence of ___ or fewer findings was almost associated with failure to experience dramatic improvement
2
The presence of ___ findings were almost associated with a failure to experience dramatic improvement.
2 or fewer
What should frequency and duration be?
2-3 times per week for 6 to 8 weeks depending on diagnosis
What is a precursor to hip OA?
If left untreated FAI will progress to labral tear, labral tear can lead to arthritis and DJD
Interventions for acute LBP, radicular
Education to reduce nerve root symptoms, manual, traction, nerve root mobilization
Where do most injuries happen?
End range
Effects of faulty posture
Energy insufficient, prolonged end range stresses, prolonged uneven loading of the IV discs, poor articular cartilage and disc nutrition, excessive lengthened or shortened muscles
Male and female children have _______motion
Equal
What are your main spine extensors?
Erector spinae Transversospinalis Quadratus lumborum (also stabilizes spine and elevates pelvis)
What is between the posterior and middle layer of TL fascia? What is between the middle and anterior layer of TL fascia?
Erector spinae and transversospinalis (as you go lower, you will get multifidus too) Quadratus lumborum
Rotation is a complex movement that requires co-contraction of several muscle groups, including:
Erector spinae, transversospinalis, and obliques
What causes lateral stenosis?
Facet joint arthritis Loss of disc height Postereolateral bulge of IV disc or a growth within the IV foramen
What is tight when there is lumbar spine hypomobility?
Facets/joint capsule, ligaments, muscles
What are indications for surgery?
Failure of conservative treatment (4 weeks to 6 months) Unbearable pain Significant or increasing neurologic deficit Cauda equina syndrome (absolute indication)
Indications for surgery
Failure of conservative treatment (4 weeks-6 months), unbearable pain, significant or increasing neurologic deficit, cauda equina syndrome (absolute indication)
Indications for TKA
Failure of conservative treatment (NSAIDS, activity modification, PT, bracing and orthotics), intractable pain w/ loss of function
Correlation b/t medical imaging and LBP
False positive - 20-76% on subjects w/ no symptoms, 47% who had symptoms had positive findings (just b/c there is a positive finding does not necessarily mean the findings matches the patients complaints
Fat pad syndrome
Fat pad around patella tendon is inflamed
End plate
Fibrocartilage, serves as growth plate in child, transition point b/t body and disc, nutrition for disc from vertebral body
What are the menisci made of?
Fibrocartilaginous discs
*When you rotate right, what happens to the following: Vertebral body? Spinous process? *Which muscles are used: Erector spinae? Transversospinalis? External oblique? Internal oblique?
Goes right Goes left Right erectors Left transversospinalis Left external oblique Right interal oblique
Generic
Good for anyone w/ any disability or condition
How to correct a lateral shift?
Grab pelvis, should into rib cage, and shift to opposite side, ask about leg symptoms, patient can perform by themselves using a wall; if it hurts more in their back, but makes their leg symptoms better - this is GOOD
Soft tissue stretching results in...
Inc. spinal ROM/joint mobility, dec. pressure on facet joints, discs, and nerve roots, inc. proprioceptive input
What are the benefits of using an operating microscope?
Increased magnification and illumination Limits the amount of tissue damage by working through a small exposure Minimizes blood loss, risk for infection Decreased length of stay in the hospital
Rapid loading
Increased stiffness
Derangement dysfunction
Mechanical deformation caused by internal derangement (disc); constant or intermittent pain; certain motions cause either centralization or peripheralization of pain
Clinical presentation of external snapping hip syndrome
Gradual onset of snapping or pain laterally over the greater trochanter, usually not associated w/ a major traumatic event, observable and audible snap as patient flexes and extends the hip, may describe a sense that the hip is dislocating, may have coxa vara or a prominent greater trochanter
Mobile TKA
Polyethylene insert can rotate slightly, which gives the knee implant a more natural interface b/t the surface of the femoral component and polyethylene insert, both gliding and rotating motion can be done, since PE can rotate, contact w/ FC is more even, less stresses and wear
The tibial N splits from the sciatic N and runs through the ____. It sends a branch to the ____ N. Then it continues down and runs behind the medial malleolus can becomes ___.
Popliteal fossa Sural N Medial and lateral plantar Ns
____________must unlock knee when knee is in full extension when moving into flexion
Popliteus
Exercise routines involving repeated movements into end-range spinal motion have been _____________ over the years
Popularized
Posterior sag test/Godfrey sign
Position passively patient at 90 degrees of knee flexion (table top position), compare both sides, positive side you will see a sag at the tibial plateau
Stabilization CPR: Criteria (for a positive finding) for prone instability test?
Positive test
The nucleus sits more anterior or posterior within the annulus?
Posterior
When you apply the harness, the loops should maintain a ____ pull.
Posterior
____ pelvic tilt will lessen the LS angle.
Posterior
During counternutation: Sacral tilt: Iliac (pelvic) tilt: Lumbar:
Posterior Anterior Extension
What direction does the PCL run?
Posterior lateral on tibial plateau to anterior medial on lateral side of medial condyle
PCL is primary restraint to ________________ and secondary restrain to ________________
Posterior tibial translation; hyperextension and tibial rotation
If a patient has diminished reflexes and nothing else in the LQS is positive, what does it mean?
Probably nothing
What is the KT100 arthrometer?
Provides an objective measurement of anterior tibial translation, can be useful when pain and guarding preclude evaluation, can be used as part of the follow up exam after ACL reconstruction
Describe the proximal tibia
Proximally flared into two plateaus (condyles) that articulate with the femoral condyles, separated by intracondylar eminences (tibial spines), attachment of the cruciate ligaments and the menisci, both plateaus densely covered w/ articular cartilage
Positional traction
Pt is placed in a position which causes gaping of a facet joint, intervertebral foramen, or reduces pressure on a nerve root, most common position is SL on non-involved side w/ towel roll or bolster under to create opening on contralateral side
If the forefoot is more abducted =
Pronator
In order for muscles to control within the neutral zone, what is key?
Proprioception
Complete meniscal tear
Tear runs through both the superior and inferior surfaces
Unicompartmental arthroplasty
Replaces only damaged or arthritic parts in either compartments
Goals of treatment
Restore mobility and function, decrease pain, avoid surgery, lack of literature on manual therapy and FAI
Weeks 3-8 following Lumbar Microdiscectomy
Return to work and ADLs, adhere to surgeon guidelines for lifting and activity/sports, pt able to walk on level surfaces w/o restrictions, advance TA exercises, advance glute/bridging exercises, advance hip strengthening (esp. hip abductors), initiate nonimpact LE involved cardiovascular exercise (pool workouts, treadmill, elliptical, stationary bike)
Weeks 8-12 following Lumbar Microdiscectomy
Return to work without restrictions, objective measures improve, release to activity base on achievement of goals and MD clearance
Surfaces are covered w/ interlocking ___________and_______________
Ridges; depression (smaller in children and females, larger in males and post menopausal females)
What provides the most of the extensor force needed for lifting?
The large lumbar erector spinae
S&Ss of quad strains
Same as HS strains, pain and weakness w/ resisted knee flexion, thomas test (kendal's test - modified thomas test that adds knee flexion)
What anchors the meniscus to bone?
Sharpey's fibers
What are you palpating through to get to the SIJ?
Skin, fat, thoracolumbar fascia, thick tendon of erector spinae, multifidus, thoracolumbar fascia, lumbosacral ligament, joint space
Always go into extension __________
Slowly (need to give them time to adjust to new position)
Why are women at more risk for ACL injuries?
Smaller intercondylar notch, wider pelvis, greater Q angle, neuromuscular factors, hormonal variations may alter laxity of ligaments, females take longer for ADDs and ERs to fire
How can an X-ray tell you if there is shearing of the SIJ?
Stand on one leg, take the X-ray - stand on the other leg, take the X-ray; compare the two and look for a shearing effect
Grades of Recommendation - E
Theoretical/foundational evidence animal or cadaver studies, conceptual models, base science
Genu recavatum
Standing with knees hyperextended
Elaborate on the observation portion of the LQS.
Starts when the patient walks in the door Look at posture (lumbar spine, pelvis, LEs) - entire kinetic chain Atrophy Hypertrophy Asymmetries *Shirts off for this
Manual traction can be ___ or ___.
Static or intermittent
As the posterior longitudinal ligament descends, does it get thinner or thicker? Why is this important?
Thinner Because if you have a bulging disc and the PLL is wimpy, the disc can go right through centrally which puts pressure on the cauda equina
McKenzie principles: How does the nucleus move?
Through torn annular rings
Medial plantar N is a branch of what N?
Tibial N
If butt raises off the table during Ely's test, what does this indicate?
Tight hip flexors
High compliance groups have greater improvements in what?
Strength, walking speed, functional outcome scores, recommend HEP 3x/week
Intervention for dysfunction syndrome
Stretch into direction of limitation, avoid bad postures, patient education
What is the initial intervention for derangement syndrome?
Stretch into direction that causes centralization (opposite of the direction that peripheralized symptoms) Avoid direction of peripheralization
What are interventions for dysfunction syndrome?
Stretching Avoid bad postures Patient education
Manual therapy techniques include...
Stretching of muscles of the hip joint, traction of the hip, traction manipulation of the hip
What are the proposed mechanisms for discal realignment? (Ideas as to why traction helps with disc herniation)
Suction due to decreased intra-discal pressure Pulling displaced disc pieces back to the center (pulls the disc more anterior if it's a posterior herniation) Tensing the PLL, pushing any posteriorly displaced material anteriorly toward original position Could cause lumbar musculature to relax
The proposed mechanisms for disc realignment include...
Suction due to decreased intra-discal pressure, pulling displaced disc pieces back to center, tensing PLL pushing any posteriorly displaced material anteriorly towards original position
Common mechanisms of quad strains
Sudden deceleration of leg (kicking), violent contraction of quad (sprinting), rapid deceleration of an overstretched ms (by quick change in direction)
What is a common symptoms of hamstring strains?
Sudden onset of pain in posterior thigh, may have an audible "pop"
Patient selection for artificial disc replacement
Suffer from DDD, single level disease, failed conservative treatment
What portions of the capsule form the suprapatellar pouch?
Superior and anterior
What nerve can be damaged w/ a hip pointer?
Superior cluneal nerve (folds over the top of iliac crest, you would lose sensation to the upper buttock region)
Ears of "scotty dog"
Superior facets
Grade 1 Spondylolithesis
Superior vertebrae migrates anteriorly 0-25% over the inferior vertebra
______________(such as Gore-Tex) are also used for ACL reconstruction
Synthetics
T/F Patient education has been shown to reduce the use of narcotics and hospital length stay
T
T/F: Symptoms of degenerative meniscus are the same as traumatic meniscus
T
Scoring for ODI
Min-disability: 0-20, patient education Mod disability: 20-40, problems w/ sitting, lifting, usually do well with conservative care Severe disability: 40-60, pain effects travel, personal care, sex, and sleep Crippling: 60-80, back pain effects all aspects of life 80-100 - bed bound or may be severely exaggerating symptoms
Traditionally, ___________assessments and _________tests have been used to classify a patient as needing manual therapy
Mobility; special
What are the four basic categories used for patients with acute LBP?
Mobilization/manipulation Stabilization Specific exercise (flexion, extension, lateral shift patterns) Traction
PT interventions for stenosis
Modalities (especially E-stim) LS bracing to avoid extension and support extensors Traction (mechanical, manual - see if manual is successful first before moving to mechanical) Positioning the patient in flexion to relieve symptoms - prone or side-lying with/without pillows (stretch into flexion, SB away, rotate toward) Patient education (position for relief, no heavy lifting or extending) Soft tissue mobilization (erectors) Low grade joint mobilization
What can facilitate a deeper stretch prior to interventions for hypomobility?
Modalities - warm tissues stretch better (i.e. hot pack)
What interventions are used for hypomobile patients?
Modalities as needed - warm tissue stretches better (hot pack, warm-up exercises) Joint mobilization/manipulation (start low, when appropriate do 3s and 4s and end back with 1s and 2s) Muscle stretching Strengthening muscle into new range
Interventions
Modalities to calm inflammation of SIJ capsule and ligaments, local muscle attachments, attempt to correct pelvic asymmetry, correct asymmetry of position of sacrum b/t iliums, SIJ support belts (good for hypermobile individuals)
PT management for GTPS
Modify activities (avoid lying/sleeping on affected area, no sitting w/ legs crossed), use of crutches if really painful, ice/heat, US, shock wave therapy, low evidence for iontophoresis, phonophoresis, TENS, soft tissue mobs/massage, TP therapy, foam roller to TFL, ITB, gluteals, vastus lateralis, stretching piriformis, qauds, TFL, strengthening hip ABD, ER, and knee ext, gait mechanics and pelvic stability
Is the lateral femoral cutaneous N a branch of the femoral N?
NO; it comes directly off of the plexus
Does the pudendal N run through the greater sciatic foramen?
NO; it's the only one that runs through the lesser sciatic foramen
Medical management of piriformis syndrome
NSAIDs, muscle relaxants and neuropathic pain medication, Ultrasound guided injections of anesthetics, steroids, and botulinum can serve both diagnostic and therapeutic purposes , Indications for surgical management include abscess, neoplasms, hematoma, and compression of the gluteal arteries, Surgical release of the piriformis tendon
How do you name a lateral shift?
Name it by which direction they are shifting towards (look @ shoulders)
Females have a more ___________condylar notch
Narrow
Lateral stenosis
Narrowing of the intervertebral foramen affecting a nerve root
Foraminotomy
Narrowing of the intervertebral foramen leads to stenosis, goal is to take pressure off nerve roots, bone is cut or shaved away to open the foramen, may be done w/ removal of disc or lamina
Central stenosis
Narrowing of the spinal canal effecting the spinal cord or cauda equina
Who is Robin McKenzie?
New Zealand PT, developed theory due to mistake by patient, developed theory based on patients' responses then wrote a book, no early research
Distraction
Nice to follow after a (+) scour test, 30 degrees of flexion and ABDuction w/ slight ER, if distraction relieves symptoms it helps confirm the hypothesis of hip OA, if test is painful, a capsular or ligamentous injury is possible
Does the RMQ look at psychological or social aspects?
No
Explain bed traction.
No longer used Very low-load (9-10 lbs), prolonged stretch (hours to days) Costly for hospitals to have patient lie in bed - causes secondary complications
Manipulation CPR: Criteria (for a positive finding) of the distribution symptoms?
No symptoms distal to the knee
Is acuity strictly based on the total length of time the patient has had symptoms? If not, what is it based on?
No; it's based on the severity of symptoms, the goals for rehab, and the natural history of the condition
Facet injections
Non-operative alternative; analgesic effect; may last for several days, weeks, or months; also done @ epidural space to treat pain caused by nerve root irritation from HNP
What test has a high level of diagnostic accuracy for a hip labrum tear?
None
In patients >60, labral tears are so common that it is a _________part of aging
Normal
*Resisted isometrics results: Strong and pain free: Strong and painful: Weak and painful: Weak and painless:
Normal Contractile unit Severe inflammation of contractile unit or partial tear N or N root involvement or complete tear
Non-specific LBP
Not a homogeneous group, but consists of subtypes of patients who can be identified based on specific S&Ss
How long should you work with cauda equina syndrome patients, huge disc bulge patients, etc., before you send them to the doctor?
Not much time at all (1-2 sessions); there's not much chance that you're going to help them and you can cause N damage
How long should the duration of traction treatment be?
Not supported by evidence 5-10 minutes initially Relief of symptoms - same treatment time Partial relief - increase duration and/or intensity
Nerve root compression results in...
Numbness/tingling, motor weakness, decreased deep tendon reflexes, decreased blood flow to nerve
Clinical presentations of ACL injuries
Occurs after either a cutting maneuver, landing, or jumping, may be a audible pop, feeling of initial instability which may be masked later by extensive swelling, episodes of "giving way" especially on pivoting or twisting motions, initially injury is extremely painful, swelling may be immediate and extensive, but can be minimal or delayed, restricted movement, especially inability to fully extend
MOI for LCL
Occurs w/ varus stress, usually w/ contact, much less common than MCL injuries, usually respond well to conservative treatment
Paget's disease is more common in what population?
Older adults
What are predictors of overall satisfaction?
Older age, not living alone, worse pre op hip scale score, shorter LOS
Management of iliopsoas bursitis
PRICE, NSAIDs, corticosteroid, or lidacaine injections, hip flexor stretching, hip rotator strengthening, bursectomy
Describe external snapping hip syndrome (most common)
TFL or glute maximus tendon as it inserts into IT band snaps over greater trochanter
Xenograft
Taken from animals, bovine xenogratfs have been associated w/ high complication rate
Allograft
Taken from cadavers, slight risk for injection
Autograft
Taken from the patient's own body and include portions of the patellar tendon, IT band, semitendinosus tendon, gracilis tendon
What shape is the patella?
Triangular, frontal plane (wider proximal base and a distal apex), transverse plane (broader anteriorly and posterior apex)
T/F All manual therapy effects are short term.
True
T/F Often what you learn is not what tissue is at fault, but what activity or position is at fault. From there we might speculate what tissue is injured based on the grouping of signs and symptoms but necessary to know to begin treatment.
True
T/F Other types of traction include over the door traction units and gravity assisted or inversion traction.
True
T/F The fibers of the annulus fibrosis alternate in a crossing pattern. There is clear differentiation between it and the nucleus when we are young.
True
How much more mobility can you have before you have symptoms? Too much motion of not enough control?
Unanswerable question; think gymnasts - they can control excessive mobility and it's not a problem
Drehmann's sign
Unavoidable passive ER while performing hip flexion
What is meralgia paresthetica?
Underwear is too tight and compressed the lateral femoral cutaneous nerve
What are the types of patella fractures?
Undisplaced, transverse, lower or upper pole, comminuted undisplaced, comminuted displaced, vertical, osteochondral
Gravity assisted or inversion traction
Units available to general public
Osteoarthrosis will usually produce a ______________limited ROM
Universal
FADIR test
Used to assess FAI, esp. anterior/superior labrum, passively move the hip into flexion, ADD, and IR, (+) test = hip or groin pain, Sn = 0.95
Anterior interbody fusion
Uses same principles of disc excision and interbody bone grafting
Describe intra-articular snapping hip syndrome (least common)
Usually due to tear of cartilage and/or loose body within the hip joint, may cause the hip to "lock up"
Is high impact aerobics and jogging recommended following THA?
Usually not
Individuals who do not weight bear stay in coxa ____________
Valga
You have more coxa ___________ when you are born
Valga (changes as we WB)
You are born w/ coxa _________
Valga (~170 degrees)
Can load the ACL in a more _______position
Valgus
When does the MCL become taut?
Valgus force, extension and looser in flexion
Special test for MCL injury
Valgus stress at 20-30 degrees of flexion
Medial meniscus injury is associated w/ a ______________force and lateral meniscus injury is associated w/ a ____________force
Valgus; varus
Describe the vascularization of the menisci
Vascularization along the periphery via capsular attachments, inner borders are avascular; red zone (best), red/white, white (no blood supply)
Anterior displacement occurs due to...
Vertebra no longer attached posteriorly, sacral angle created anterior sheer, supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to "slide" anteriorly on the one below (creep)
Most of the time a traumatic lesion is a _____ or a _________tear of meniscus
Vertical; longitudinal
FABs of HC providers
Very similar to that of patients, low expectations for patients, recommend avoidance of activities that "might" bring on symptoms, recommend limiting activity levels
Methods before McKenzie
Williams flexion exercises (1930s); open the IV foramen to relieve nerve root compression - lordosis was bad; promote flattened lordosis postures; brace into flexion; bed rest; disc dynamics were no understood esp. nucleus within annulus;
Laminotomy
Window is made into lamina
43. The superficial fibular nerve provides sensory where?
a. Anterior lateral lower leg and dorsum of the foot
15. What are the 2 states that have it illegal for PTs to manipulate their patients?
a. Arkansas and Washington
Clinical presentation of labral tears of hip
"C" sign, deep ache w/ prolonged sitting or standing and hip flexion type movements
21. What are the nerve roots for the lateral femoral cutaneous nerve?
a. L2 and L3
2. A low velocity skilled movement done at a velocity that a patient CAN resist is called a?
a. Mobilization
16. What are the clinical prediction rules of manipulation?
a. Onset less than 16 days (rarely occurs b/c pts usually wait) b. No symptoms below the knee c. Lumbar stiffness d. Hip IR less than 35 degrees (hypomobile)
15. The posterior thoracolumbar fascia attaches to where on the spine?
a. Spinous process
14. The thoracolumbar fascia most laterally becomes?
a. The lateral raphae
30. Explain the pathway of the posterior femoral cutaneous nerve
a. The nerve comes off the sacral plexus, goes through the greater sciatic foramen and then the piriformis.
2. PLL is thicker or thinner in the lumbar vertebrae compared to cervical?
a. Thinner
5. A thickening of the ligamentum flavum occurs as you age, why might this be important and what do we need to ask, as therapists with patients in this population?
a. This is important because it can narrow the spinal cord canal. b. Ask the patient if they have had bilateral symptoms of weakness, pain or paresthesia. Also any changes in bowel and bladder or saddle numbness.
2. Vascular symptoms will generally be described as?
a. Throbbing b. Pounding c. Pulsating
49. The sural nerve receives innervation contributions from what nerves?
a. Tibial and COMMON fibular nerve
Grade 3 Spondylolithesis
50-75%
Femoral stem insertion
Press fit, cemented
What is the #1 predictor of an injury?
Previous injury
Up to _____% of those who do recover are prone to reoccurrence
60
Longitudinal tears are often ____, full thickness tears
Complete
MOI for disc
Often flexion or flexion w/ rotation
How do you assess outcome measures?
Patient questionnaires
T/F Lateral stenosis occurs with DDD (degenerative disc disease) and DJD (degenerative joint disease).
True
Effective separation of the lumbar spine occur at ___ lbs.
60-200 lbs
TKAs are most performed on people ____-____ years old
60-80
ODI: What is the score for the crippled classification? What are the patient's problems?
60-80 Back pain affects all aspects of life
Effective separation is reported at _____-______ lbs
65-200
Ratio of piriformis syndrome female to male
6:1
Interventions for hypermobility
Braces or corsets, patient education (keep out of end range postures and activities), strengthening and endurance, proprioception exercises, spine and neutral exercises
What comes off and/or attaches to the medial epicondyle?
Insertion of adductor magnus at adductor tubercle, MCL
What motion does the LCL, MCL, ACL, and PCL limit?
LCL - varus, MCL - valgus, ACL - anterior shear of tibia, PCL - posterior shear of tibia
Medial femoral condyle is ________AP
Smaller
6. What is the position for maximal closure of the lumbar facets?
a. Extension, rotation and side bending toward.
9. T/F: Referred pain cannot refer from internal organs
a. False
8. The IV disks are made up of what types of collagen allowing for what to occur?
a. Type 1 and Type 2 b. Type 1: Restricts motion c. Type 2: Shock absorption
7. What are some non-musculoskeletal warning signs?
a. Unable to find a comfortable position b. Pain is unaltered by position c. Pain is worse at night (partially indicative, pain can be worse at night due to high activity which causes a gating effect for pain which would stop at night) d. Feelings of fatigue
The concentric rings of the annulus fibrosis are more and thicker anteriorly or posteriorly?
Anterior
Low early dislocation rate can be achieved using a __________________approach w/o restrictions
Anterolateral
Pincer can be due to increased acetabular ______________
Antiversion
What are causes of central stenosis?
Congenital narrowing Thickening of ligamentum flavum Bone spurs Central disc bulge (not as common as lateral) Growth within central canal (tumor)
What muscle works to keep your pelvis more stable?
Latissimus dorsi
Side bend right - nucleus moves __________
Left
Chief complaints of meniscal tears
Pain w/ WB, locking and catching, episodes of giving way
What direction does the PCL resist?
Posterior shear of tibia on femur or anterior shear of femur on tibia, rotational shear in both directions, ER
Where does the posterior sacroiliac ligament run? Describe it.
Posterior side of the sacrum to the posterior side of the iliac crest Thick, multidirectional, very stable
What are the desired effects of spine traction?
Distraction and separation of vertebral bodies Distraction and gliding of facet joints Tensing of ligaments and joint capsule Widening of the intervertebral foramen Stretching of the spine musculature
Where does the sacrospinous ligament?
From sacrum to spine of ischium
Over the door traction units
Generally not used anymore
3 categories of HRQL Questionnaires
Generic, Condition specific, Patient specific
The SF-36 is a generic HQRL questionnaire. Describe it.
Gives a physical and mental components score Subgroups - general health, physical functioning, role functioning, bodily pain, mental health, emotional functioning, vitality, social functioning (They basically looked at the Sickness Impact Profile and narrowed it down)
Condition specific
Good for patients w/ a specific condition
Femoral head is removed but not _______________ _____________
Greater trochanter
What structures in the posterolateral corner of the knee can affect rotatory stability?
IT band, biceps femoris tendon, lateral gastrocnemius, arcuate ligament, LCL, politeus tendon, popliteofibular ligament
Segmental lumbar musculature
In individuals w/o LBP, the TA and MF contracts prior to extremity movement to stabilize spine in preparation of movement, however in patients w/ LBP there is a delay in the onset of these muscles
Post op complications
Infections (<5%), DVT, loosening of the prosthesis components, component misalignment and breakdown, nerve damage
If you are always in a flexed posture, what will be working overtime? What does this lead to?
Lumbar and thoracic extensors to eccentrically keep you upright; leads to trigger points which can lead to LBP/radicular symptoms
Pain past 70 degrees is most likely what?
Lumbar spine or SIJ, could be hip joint or articular in nature
Most patients are given a meaningless diagnosis such as ____________ ___________ or ___________ _____________
Lumbar strain; lumbar pain
CAM occurs more in whom?
Males (ave. age 32)
__________therapy should not be considered a first-choice treatment
Manual
_____________ ___________techniques have been shown to inc. hip ROM and dec. pain in patients w/ hip OA
Manual therapy
Interventions for LBP
Manual therapy (thrust vs. non thrust), exercise (strength, endurance, stabilization), flexion exercises, extension exercises, nerve mobilization, traction, patient education, fitness exercises
The neutral zone is at ___.
Midrange
Symptoms of an isolated PCL injury
Minimal pain, swelling, instability, and full ROM, may also have near-normal gait pattern
Is there any conclusive evidence to support on type of traction being superior than the other?
No
Does the nucleus and the annulus have innervation?
No, with the exception of the outer 1/3 of the annulus
Interventions for hypomobility
Joint mobilization/manipulation, stretching, strengthening into a new range (elastic zone)
Where are TPs on glute max often located?
Just below and lateral to PSIS
Which is more common: lateral or central stenosis?
Lateral stenosis
What does the lateral condyle have to stabilize the position of the patella?
Lateral superior flair
___________meniscus moves more than the _____________meniscus
Lateral, medial
Repair of meniscus
Lesion in vascular outer third, tear extending in central, relatively avascular third of meniscus of a young (<40-50 years) or physically active older adult (>50), restrictions on WB status (don't want to put compressive forces through the knee
Where does the interosseous ligament run?
Lies inside the joint (has synovial fluid and lining)
What are the two harnesses used for traction?
Pelvic belt and rib belt
A major part of pre op education should be dedicated to what?
Prevention of dislocation
Other variables important for predicting the outcome of stabilization treatment were a hx of _________________________ and _____________detected during segmental mobility testing
Previous episodes of LBP; hypermobility
Newer machines allows a ____ increase in the traction force after initiation.
Progressive
Newer machines allow a ____________increase in traction force after initiation
Progressive (can select the number of steps to achieve the full force and can also have regressive steps)
Sheer
Pt in supine, PT flexes and abducts the hip, PT then compresses downward along the line of the femur attempting to create a shear force alone the SIJ
Posterior glide test
Pt is in prone, palpate PSIS, grab ASIS in front and lift up, this creates a shearing force
Strengthening treatment
SL hip ABD, clamshells, prone/quadruped hip extension, bridge variations, squats, lunges, front/side step-ups
Discs heal w/ ______ __________, making tissues less flexible
Scar tissue
Why is it important to note that the sciatic N runs beneath the piriformis?
Scarring of the piriformis or hypertrophy of the piriformis can cause sciatica
Reg flags S&Ss
Sensory changes in the rectal, genital region; changes in bowel and bladder
What is the purpose of overpressures?
To stress tissues at end range (joint capsule and muscle) Assess the end feel
Action of proximal tibia
Transfer weight across knee to ankle
What are your main spine rotators?
Transversospinalis Abdominals
ACL/PCL has a _________orientation in extension and a more ____________orientation in flexion
Vertical; horizontal
You always want know _____ status from the surgeon
WB
Rehabilitation
WB status, hip strengthening (hip extension, ABD, knee ext), balance, ADLs, beware of orthostatic hypotension
What is the #1 activity recommended by surgeons and PTs following lumvar surgery?
Walking (to prevent blood clots)
What are signs of infection?
Warmness, redness, low grade fever
Grades of Recommendation - C
Weak evidence, a single level II study or support from level III or IV studies
Timing of TJR failure (later >5 years post op)
Wear of articular bearing surface, osteolysis, mechanical loosening, peri-prosthetic fracture
Deep fibular N is sensory to: Motor to:
Web space between 1st and 2nd toes Tibialis anterior, EHL, EDL, fibularis tertius
Suitable sports and activity recommendations
Cycling, swimming, low-resistance rowing, walking, hiking, low-resistance weight lifting, ballroom dancing, square dancing
Upper extremity
DASH
Lateral stenosis occurs with ___________ and DJD
DDD
Clinical force _______ ________equal functional forces
DO NOT
Post op complications
DVT (swelling, change in temperature, pedal pulses, gold standard - Doppler), leg length discrepancy, infection, nerve palsy, dislocation
When do patients start to ambulate after surgery?
Day of surgery or post op day 1, usually WBAT
What is the role of pre-op education?
Dec post op pain, medication use, LOS, and fear/anxiety
Gait observations
Dec. stance phase on involved side, dec. hip extension, Trendelenburg or lateral lurch
Vascular claudication is caused by _____. What does this result in?
Decreased circulation Antalgic gait (painful/difficult) Paresthesia Cramping of the muscles in one or both LE with activities such as walking
Pre op education leads to what?
Decreased post op pain, medication use, LOS, and fear/anxiety
What part of the MCL typically gets damaged first?
Deep part of ligament, which may lead to medial meniscal or ACL damage
Misinformed avoiders
Discouraged, pain indicated harm and spine is vulnerable, hyper vigilant but will to try limited painful activates, mild to moderate disability, PTs need to challenge beliefs about importance of pain and restore confidence in spine
Learned pain avoiders
Discouraged, pain is benign, spine is sound but pain may be avoided, value of pain, must be avoided, mild to moderate disability, PTs need to utilize exercise and modalities to desensitize for pain
Timing of TJR failure (early <10%)
Dislocation, infection, implant failure
Colles fracture (dinner fork deformity)
Distal fragment goes dorsally
Smith's fracture
Distal fragment goes palmarly
What are the desired effects of spine traction?
Distraction and separation of vertebral bodies, distraction and gliding of facet joints, tensing of ligaments and joint capsule, widening of the intervertebral foramen, stretching of the spine musculature
Why should you do static tests in standing and sitting both?
Doing the leg length in sitting will take away a leg length discrepancy that would throw off the height of ASISs, PSISs, iliac crests, etc.
Most of the time, the _______ side of pelvis sits lower
Dominant
L5 deramtome
Dorsum of the foot
Suitable but more risky
Downhill skiing, ice-skating, hunting, low-impact aerobics, volleyball, basketball, soccer, baseball
Slocum test for anteromedial rotary instability
Drawer test with tibia in ER
You want to strengthen the ________stabilizers when you have weakness of the static stabilizers
Dynamic
*What muscles attach into the abdominal fascia?
External oblique Internal oblique Transverse abdominis
Order the abdominal muscles from superficial to deep.
External oblique (coat pocket fiber direction) Internal oblique Transverse abdominis
What are the 3 types of snapping hip syndrome?
External, internal, or intra-articular
What is a plica?
Extra fold in the joint capsule
Cruciate ligaments are _____-synovial but ______-articular
Extra; intra (between joint surfaces but not in the capsule)
With hypomobility, what could be tight?
Facets/joint capsule Ligaments (most people are hypomobile at L5, S1 because of the three hip ligaments: iliofemoral, ischiofemoral, pubofemoral) Muscles
Therapeutic Neuroscience Education
Focuses on the neurophysiology and the processing/representation of pain
Sports to avoid after TKA
Football, hockey, high-impact aerobics, jogging, parachuting, power lifting
Patient specific
For a particular individual, patient is asked to select 5 main activates effected by back pain, rate ability 0-10 scale, 15 min
Acute LBP
For some individuals can be greatly heightened following an episode of acute, severe LBP; avoidance behaviors may persist long after the acute injury has resolved
What is myositis ossificans?
Formation of ectopic bone as a result of bleeding due to blunt trauma, x-rays show a calcium deposit 2-6 weeks post injury, pain, weakness, swelling, point tenderness, and dec. ROM
Popliteal (Baker's) cyst
Forms when a bursa swells w/ synovial fluid, results from chronic effusion and intra-articular lesions
During extension the menisci move _______________via attachments to the retinaculum
Forward (effect of quads)
What is spondylolisthesis?
Forward displacement of one vertebral body over another
Spondylolithesis
Forward displacement of one vertebral body over another, most common is L5, S1 (second most common is L4, L5), occurs due to spondylolysis (pars fracture) or elongated pars interarticularis
Dengenerative meniscal tears occur most often in what decade of life?
Fourth and fifth decade
THA Indications
Fracture (due to fall), OA, RA, significant loss of function, failure of conservative treatment
Spondylolysis
Fracture of pars interarticularis, often begins w/ stress fracture, often caused by hyperextension trauma
What is the importance of knowing if the patient has a history of osteoporosis?
Fractures are common in these patients (think sitting down to hard in their chair)
Exercises should focus on _______________tasks such as lifting
Functional
The goals for management for patients in stage II are more focused on improving more _______________abilities and avoiding ____________of symptoms
Functional; re-occurrence
What is removed during a THA?
Head and neck of femur (loss of labrum), but not greater and lesser trochanter due to muscular attachment
What areas of the body should you examine when observing posture?
Head and neck, thoracic spine, shoulder girdle, lumbar spine, pelvis, knees, foot and ankle complex
Order of infant progression
Head control, prone on elbows, sitting, pull to stand, standing
What are some of the pathologies possibly requiring surgery?
Herniated nucleus pulposus Spinal stenosis Segmental instability Degenerative disease
Pathologies possibly requiring surgery
Herniated nucleus pulposus, spinal stenosis, segmental instability, degenerative disease
Levels of Evidence - 1
High quality diagnostic studies, prospective studies, or randomized control studies
Explain static/sustained traction.
Higher forces Soft tissue stretching
What is the mechanism of injury of spondylolysis?
Hyperextension of the lumbar spine resulting in a repetitive loading of the facet joints and pars interarticularis Pars interarticularis may be congenitally thinner or not completely formed
SIJ support belts are good for what population?
Hypermobile patients who tend to slide right back out of place (place it just below ASISs and tighten it up)
Changes in discs can lead to facet ______________
Hypertrophy; results in redirection of compressive loads to the posterior elements
Most common to be_______________in the lower lumbar spine
Hypomobile
*Most likely to benefit from manipulation?
Hypomobile joints Those who did not respond to low velocity techniques No radicular symptoms
What does Gillet test test for?
Hypomobility of SIJ
Pros/cons of ceramic ball w/ ceramic liner
Incredibly low wear rate, very hard and strong, a wide range of sizing to meet patient specific needs, wear rate - 0.0001 mm/year
General criteria for home discharge include:
Independent ambulation farther than 150 ft on level indoor surfaces, adherence to hip precautions, achieving basic functional ADLs using adaptive equipment
What happens once it is really bad?
Individual is stuck in flexion and/or lateral shift, radicular symptoms
Front feet of "scotty dog"
Inferior facets
What direction does the oblique popliteus ligament run?
Inferior medial to superior lateral
What direction does the popliteus run?
Inferior medial to superior lateral
What causes compression of the N root?
Inflammation Disc protrusion (typically posterior or posterior lateral) Bone spurs Narrowed foramen
What is nerve root compression caused by?
Inflammation, disc protrusion (typically posterior or posterolateral), bone spurs, narrowed foramen
Why is a posterior tilt important?
It will lessen LS angle (don't want them in extension)
Stability of the posterolateral corner of the knee is provided by what?
LCL, popliteus, and posterolateral capsule
If knee is unstable in full extension, it is suggestive of what?
LCL/PCL injury
Patients fitting a traction classification will most likely have symptoms that extend into the ____________, often distal to the knee
LE
PF assessments
LQS, alignment, patella tracking (eyeball test), patella mobility (apprehension test), ballotment test (joint effusion), patella grinding/compression, quad strength, Q angle, VMO, foot alignment (standing), strength of hip ABD and ER (resisted clamshells), patella atla vs baja, McConnell test, Craig's test
Grade I Sprain
Ligament fibers are stretched but there is no tear, little tenderness and swelling, knee does not feel unstable or give out during activity, no increased laxity and there is a firm end feel
How is knee stability maintained?
Ligaments, muscles, menisci, bony contours
What causes a diminished diameter of the central canal?
Ligamentum flavum hypertrophy, facet hypertrophy, disc degeneration
What will the "scotty dog" look like if there is a pars fracture?
Like the dog has a collar on
LQS findings
Limited and painful extension (radicular), possible painful flexion, SB toward (radicular), dermatomes, myotomes, reflexes
In the LQS, what should you look for?
Limited and painful extension - radicular symptoms (these are more than likely your stenosis patients; if they have limited and painful flexion, these are more than likely your bulging disc patients) Possible painful flexion SB toward - radicular
4. What are the normal end feels?
a. Bone on bone b. Normal capsule c. Tissue approximation d. Normal muscle
5. What are the abnormal end feels?
a. Bone on bone - bony block b. Meniscus block c. Tight capsule d. Tight muscle e. Empty
13. When a maximal effort is needed for the spinal musculature, do the superficial or deep muscles contract?
a. Both!
11. What is the lumbar segment that is the common site for a disc hernation and what resisted isometric can do you for it?
a. L4-5, and you'd test both ankle dorsiflexion and great toe extension.
60. The lateral plantar nerve supplies sensory where?
a. Lateral plantar surface of the foot (except heel) and plantar surface to half of the 4th toe and 5th toe.
41. What sensory innervation does the common fibular nerve provide?
a. Lateral, superior lower leg (around the neck of the fibula)
14. Manipulations by PTs is supported by the?
a. Orthopedic section of the APTA and the American Association of Orthopedic Manual Physical Therapists
20. The risk of cervical manipulation goes up greatly when there is a ______ component of manipulation
a. Rotational component
15. The calcaneal tendon reflex tests what nerve root?
a. S1
47. The sural nerve is supplied by what nerve roots?
a. S1 and S2
29. What are the nerve roots involved wth the posterior femoral cutaneous nerve?
a. S1, S2 and S3
51. Pudendal nerve is supplied by what nerve roots?
a. S2, S3, S4
33. The sciatic nerves come out through ________ beneath the piriformis.
a. Sciatic notch
57. The ilioinguinal nerve supplies:
a. Sensory of the skin of the upper medial thigh and anterior scrotum and labia majora
What 3 things do you evaluate when looking at feet?
1) Arch - high, low, or middle 2) In WB, how do they hold their calcaneus 3) How do they hold their forefoot
What are the 3 syndromes in the McKenzie classification system?
1) Postural 2) Dysfunction 3)Derangement
Nearly ____ will suffer from re-injury within the 1st year following a return to sport w/ subsequent injuries often being more severe that original ones (hamstring strains)
1/3
Prevalence of FAI
10-15% of population
Coxa Vara
100 degrees
Sensitivity for clicking w/ labral tears
100%
Normal hip angle
125 degrees
Sickness Impact Profile (Generic)
136 items, 30 min to complete, physical tasks, psychosocial, emotional
Normal rotation
15-25 degrees
Manual traction is typically applied between ____ seconds.
15-60
Q angle for females
17 degrees +/- 3
What % of people over the age of 70 suffer from hip OA?
20-30
What is a normal sacral angle?
20-30 degrees
ODI: What is the score for moderate disability? What are the patient's problems? What is the intervention?
20-40 Problems with sitting, lifting Usually do well with conservative care
Hip pain from FAI is more common in what age group?
20-40 years old
>______________discectomies are performed i the US per year
200,000
The Roland-Morris Questionnaire (RMQ) is a condition specific HQRL questionnaire. Describe it.
24 questions related to pain and function 5 min to complete, 1 min to score 0-24 (0 = no pain and no functional limitations, 24 = maximal pain and limitations) Minimal detectable change - variable (5-9) Patient checks statement that applies to them (i.e., "because of my back pain... Short, simple, easy to understand
What is indicative for separation of facet joints and to increase foraminal space?
50-60% of patient's BW
Frequency of spondylolysis?
6% of adult population with LB pain *47% of adolescent population with LB pain (really common) 2X more common in males than in females
Standard incision length
8-12 inches
What is the typical length of stay after a THA?
<5 days
Pars interarticularis ("scotty dog")
A bony isthmus b/t the superior and inferior facet joints of the spine
Describe process of acetabular reaming
Acetabular cup is reamed into a hemisphere, cartilage is removed
What are the parts of THA implants?
Acetabular cups, polyethylene liner, femoral head, neck, stem
The classification system is intended for use in patients w/ _________LBP, however acuity is not strictly based on the total length of time the patient has had symptoms (based on severity of symptoms, goals, natural hx of condition)
Acute
Labral tears can be ________ or__________
Acute or chronic
What are the 2 types of trochanteric bursitis?
Acute, chronic
Which approach is more technically demanding?
Anterior
Superficial fibular N is sensory to: Motor to:
Anterior lateral lower leg, dorsum of foot Fibularis longus and brevis
What direction does the ACL run?
Anterior medial on tibial plateau intercondylar eminence to posterior lateral on medial side of lateral condyle
What motion does the ACL resist?
Anterior shear of tibia on femur or posterior shear of femur on tibia , rotational shear in both directions
Neutral zone (mid-range)
Area in range of motion segment where there is little resistance to motion; muscle function limits and stabilize motion segments in this area
What is the elastic zone?
Area of range in which there is substantial resistance to motion
Elastic zone (end-range)
Area of range in which there is substantial resistance to motion; provided by ligaments and tight musculature, facet joint capsule, disc
Pars fracture can be unilateral or bilateral. If there is displacement, is it usually unilateral or bilateral?
Bilateral
AVN is fairly common in _______________
Childhood
Where does the lower cluneal nerve come off?
Comes off the posterior femoral cutaneous nerve and goes up
Cementless fixation
Liner consists of porous material compatible for bone growth, bone grows and secures liner in place, younger - less potential for cement to crack, more active, protected WB for 6-12 weeks, better for long-term fixation, longer recovery
Acrylic cemented fixation
Liner is permanently attached to the pelvis, >65 years old, low activity demand, tolerates small deviations from the operation, the bed cut for the prosthetic doesn't need to be very exact because the bone cement filler w/ level out all incongruities, can WB immediately after operation, later loosening
Clinical findings of FAI
Loss of IR out of proportion w/ loss of movement at other positions (flexion and IR may be restricted when combined)
Examination of Spondylolithesis
Lower quarter screen, palpation for step deformity, PA glides
What is GTPS provoked by?
Lying on affected side but can also hurt lying on unaffected side, standing for a long time, sitting w/ legs crossed, climbing stairs, running or other high impact, repetitive activities
_______provides the most sensitive view for dx hamstring strain
MRI
Medial plantar N does sensory to: Motor to:
Medial plantar surface of foot (except heel) and plantar surface of toes 1, 2, 3 and half of 4 Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, first lumbrical
Where does the semimembranosus insert?
Medial posterior tibia
What is patellar tilt?
Medial retinaculum is overstretched and lateral retinaculum is too tight
Where is the pes anserine located? What attaches there?
Medial tibia, gracilis, sartorius, semitendinosus
Meniscal tears occur more often in men or women?
Men
Stenosis is most commonly seen in what population?
Middle aged and up
In hypermobile individuals, you either have too much ________ or not enough _____________
Mobility; control
Femoral neck fracture
Must repair or replace right away
What are normal/abnormal end feels?
Normal: Bone on bone, normal capsule, tissue approximation, normal muscle Abnormal: Bone on bone - bony block, meniscus block, tight capsule, tight muscle, empty (torn ACL/PCL)
Examination of MCL injury
Normally isolated swelling is seen on medial side of knee (may be minimal), palpation along the joint line may be tender, feel/hears "pop" or "snap", knee "stiffens up" within hours of injury, walking may be significantly limited, muscle guarding
What are some structures that could become problematic and would receive benefits from joint distraction?
OA Menisci Osteochondral fragments Portion of the capsule that "catch" or impinge joints
Who is most likely to have capsular component w/ FABER test?
OA (distraction can be very effective)
What attaches to the lateral meniscus?
PCL, popliteus, and posterior thickenings of the capsule
If the cauda equina is affected, there will be ____ signs and possible ____ signs.
PNS Bowel and bladder
If the cauda equina is affected, there will be _____________ signs and possibly ______&________signs
PNS; bowel and bladder
Management of quad contusion
PRICE, NSAIDS and analgesics, crutches if necessary, taping and wrapping, aspiration of hematoma, ROM exercises, knee flexion is typically last to return
Management of snapping hip syndrome
PRICE, NSAIDS, corticosteroids, lidocaine injections, stretching or TP release of iliopsoas or TFL, address hip muscle weakness, esp hip abductors, surgical lengthening of involved tendon
If sacrum is pushed to the left, it can put tension on _______________
Piriformis (can create symptoms that are radicular in nature)
Sciatica - always check the __________
Piriformis (could also be the superior and inferior gemellus)
Forward flexion test
Place thumbs on PSISs and have pt flex forward and look for movement of PSISs (can also perform in sitting)
If an individual spends long periods of time at end range, then the ligaments engaged in the elastic zone with have what kind of response?
Plastic response
Lesser trochanter faces _______________, when muscle shortens it allows you to ______________
Posteriorly; ER
When in decreased lumbar lordosis, the pelvis is ___________ tilted and the ____________ and ______________are tight
Posteriorly; gluteals and abdominals
What three syndromes make up the McKenzie classification system?
Postural Dysfunction Derangement
What muscle group would you want to strengthen to prevent posterior translation?
Quads
Pros of minimally-invasive THA
Quicker recovery, cosmetic appearance, less perceived invasion of the body, patients are asking for MITHA
*What are precautions of traction?
RA (unstable C1-C2) Down syndrome (joint instability) Cognitive impairment Claustrophobia Tumor Osteoporosis Can't tolerate supine or prone Pregnancy Dentures/TMJ dysfunction Hernia Systemic corticosteroid use
Patients with chronic symptoms are less focused on pain and more focused on what?
Reducing anxiety and returning to participation in work, home, or athletic activities
Patients who have acute symptoms are directed toward what in rehabilitation?
Reducing pain and decreasing impairments
What is GTPS?
Refers to chronic pain caused by a number of structures including trochanteric bursa, gluteus medius and minimus tendons and IT band, previously trochanteric bursitis was seen as main source of pain, but research now shows bursitis to be to be only component
Hamstrings are often re-injured due to inadequate __________ and _____________return to activity
Rehab; premature
What are some possible causes of cavitations?
Release of nitrogen gas within the joint Breaking of adhesions within the joint capsule Cavitation is not necessary to attain improved movement
Evidence based for outcome measures
Reliable and valid measurement tools, based on the opinion of effectiveness from the patient prospective
Goals of joint replacement surgery
Relieve pain, restore function and mobility
What is a laminectomy? What is a laminotomy?
Removal of both lamina Removal of a portion of the lamina (window)
Controversy of SIJ
SIJ does not move, SIJ has such a small amt of motion that it does not cause pain, pain only results from severe trauma, pain is caused by strain of SIJ ligaments, pain is caused by hyper or hypomobility, pain is caused by joint that subluxes
How can you test the endurance of S1 and L4-L5?
S1: walk on toes L4-L5: walk on heels (Do this at the end because you wouldn't be able to tell if the patient has a mild weakness with just your hand)
Pudendal N roots? Motor to:
S2, S3, S4 External genitals, sphincters of bladder and retum, pelvic floor muscles, erection (can be damaged with cycling and child birth)
Precautions for traction
RA (unstable C1-C2), Down Syndrome, cognitive impairment, claustrophobia, tumor, osteoporosis, can not tolerate supine or prone, pregnancy, dentures/TMJ dysfunction, hernia, systemic steroid use
Traction is effective to reduce __________ symptoms in the C-spine
Radicular
With SIJ issues, it is not common to find ____ symptoms. It is common to find ____ symptoms.
Radicular Referred
Who is most likely to benefit from traction?
Radicular symptoms from lateral stenosis
Coordination impairment signs + symptoms
Radicular weakness and lumbar spine stays stiff
Grade III strain (severe)
Ranges from >50% to complete rupture, both the ms belly and tendon may be involved, causes massive swelling and pain, significant weakness and loss of function
ACL injuries _______occur in isolation
Rarely
Failure to regain strength of the important trunk stabilizers may increase risk of _________________
Re-occurrence
What muscle is between the layers of the abdominal fascia?
Rectus abdominis
Explain the grading system for the sacral angle displacement: Grade 1: Grade 2: Grade 3: Grade 4:
Superior vertebra migrates anteriorly 0-25% over the inferior vertebra 25-50% 50-75% 75-100% (major instability)
*Explain what happens in the spine during flexion. To the vertebra? To the facets? IV foramen? Ligaments?
Superior vertebra tips and glides anteriorly on the inferior vertebra Inferior facet of the superior vertebra slides superior and anterior on superior facet of the inferior vertebra IV foramen opens ALL slack; PLL, interspinous, supraspinous, and ligamentum flavum are all taut
T/F Facet injections have an anesthetic effect that may last for several days, weeks, or months.
True
T/F Headaches, muscle soreness, and fatigue are possible risks with cervical manipulations.
True
T/F How you choose to position the patient on the table is related to being able to centralize or decrease symptoms.
True
T/F In cauda equina syndrome, N roots may become chronically inflamed or scarred and adhere together.
True
T/F In physical therapy, manipulations bring tissue into the plastic range of stress-strain curve, but not so forceful to cause failure.
True
T/F In the absence of cauda equina syndrome or significant neurologic deficits, conservative care is advocated before recommending surgery.
True
T/F Injections can also be done in the epidural space to treat pain caused by N root irritation from HNP (herniated nucleus pulposus).
True
T/F There is less morbidity and an earlier hospital discharge in arthroscopic microdiscectomies compared with the standard discectomy.
True
T/F When you go from the PSISs in, you will be over the top of the SIJ. However, there are a lot of tissues over the top of the joint, so when you think you're feeling movement at the joint, you're probably deceiving yourself.
True
T/F With derangement syndrome, there will be constant or intermittent pain depending on the patient. Certain motions will cause either centralization or peripheralization of pain.
True
T/F Children (both male and female) have equal motion at the SIJ.
True
T/F Injury to system, which can occur with traumatic spinal injury, can result in diminished proprioceptive input and lead to further damage of passive restraint structures.
True
True McKenzie believes that LB pain is generally self-limiting. He also believes that patients with severe pain and neuro deficits that are not relieved with changes in position are not manual therapy candidates.
True
T/F Individuals with lumbar injury show more postural sway and slower reaction times. They have diminished spinal stability.
True (in order to maintain balance, you need musculature input; the sway gives you proprioceptive input for this)
T/F Every time that you treat the SIJ, you're treating lumbar spine.
True (the two go hand in hand)
What type of collagen makes up the annulus fibrosis?
Type 1
What type of collagen makes up the IV discs?
Type 1 AND type 2
What type of collagen makes up the nucleus pulposus?
Type 1 and 2
Nucleus pulposus
Type 1 and 2 collagen; more ground substance, hydrophilic (70% in adult, 90% in child), sits more posterior within annulus
What is the annulus fibrosis made of?
Type 1 collagen - resists tensile forces w/ alternating crossing pattern
Secondary pirformis syndrome
The result of macrotrauma (fall or microtrauma from repetitive overuse)
What is the purpose of manipulations?
To increase ROM Hypomobility due to joint capsule restriction Joint is blocked due to mechanical restriction (meniscus, disc) Reflex inhibition of muscle spasm
What is the goal of the LQS?
To rule in or rule out spine or peripheral joint involvement
What is the purpose of interspinous decompression spacers?
To separate the SP to relieve pressure
Men tend to have _________ligaments than females
Tighter
Why do physical therapists use manipulations?
To break adhesions in the folds of the joint capsule and restore normal joint mobility Restore normal arthrokinematics Nutrition of articular cartilage
Degrees of translation and rotation at joint
Translation - 0-4 mm Rotation - 0-5 degrees
T/F Chiropractors believe that an adjustment or repositioning of subluxed vertebra will release the N and rehabilitate affected organs. They also believe an adjustment restores normal physiological motion to the joints.
True
T/F Classification system uses information gathered from interview and physical exam to guide the management. The clinician must also take into account screening for medical red flags and psychosocial yellow flags in order to determine suitability.
True
T/F Creep leads to elongation which increases the size of the elastic zone, leading to instability unless a sufficient amount of muscle control is attained.
True
T/F Deformity of vertebra leads to central or lateral stenosis or both.
True
T/F Evidence for traction has inconsistent outcomes among studies.
True
Re-occurrence of LBP
Very common, not predictable as to how often or severity of next occurrence, more common w/ hx of re-occurrence excessive spine mobility, more likely to become chronic w/ symptoms BK, depression, fear of reinjuries, high pain levels
How does the transverse abdominis attach to the spine?
Via the TL fascia; this makes it a HUGE spine stabilizer
Intervention for spondylolithesis
W/ fracture: often brace in neutral, avoid end ranges especially extension and rotation Once healed: trunk strengthening, endurance, proprioception exercises
If the patient has had past treatment to the same body part, what should you ask them?
Was it the same problem? What was done? (PT, chiropractor, surgery, medications, injections) Was the treatment successful? If not then why do the same thing?
What should you look for in the screening process?
What brings on or relieves symptoms Hypermobility/hypomobility Willingness to move Sensation Strength
Questions typically asked on HRQL Questionnaires
What can they do or not do? How often can they do them? Level of difficulty perform them?
What do HQRL questionnaires ask?
What can they do or not do? How often can they do them? Level of difficulty performing them?
After completing the screen, what questions should you ask?
What did you learn? Review what was positive and what was negative Is there a pattern? Does it make you want to examine another area more carefully?
7. What are the purposes for manipulating a patient?
a. Increase ROM in hypomobile patients b. Hypomobility due to a joint capsule restriction c. When the joint is blocked due to a mechanical restriction (meniscus, disc) d. To provide a reflex inhibition of muscle spasm (almost instantaneous)
1. What is the common mechanism of injury for the lumbar spine?
a. Flexion or flexion with rotation
2. What is the common mechanism of injury for the Thoracic spine?
a. Flexion, especially with sustained flexion
7. What is the position for maximal opening of the lumbar facets?
a. Flexion, side bending and rotating away
58. The medial plantar nerve provides sensory where?
a. In the medial planar surface of foot (except heel) and plantar surface of toes 1,2,3 and half of 4.
31. What sensory pattern does the posterior femoral cutaneous nerve innervate?
a. Inferior buttock (inferior clunial nerve), posterior thigh and perineum.
28. What are the muscles that insert into the thoracolumbar fascia?
a. Internal oblique b. Trasnverse abdominus c. Lastissium dorsi
11. Chiropractors believe the vertebrae can become subluxed which causes what?
a. It effects the nerve and blood vessels at the IV foramen which can lead to nerve dysfunction leading to disease. Therefore an adjustment or repositioning of subluxed vertebra will release nerve and rehabilitate effected organs.
. 56. The ilioinguinal nerve is supplied by what nerve roots?
a. L1
54. What nerve roots supply the genitofemoral nerve?
a. L1 and L2
What all should you include when you document traction?
Patient position Traction method Type of traction Magnitude of force Duration of traction Duration of hold/release periods Patient's symptoms before, during, and after
CPR for stabilization
Patient's age >40 years old, average straight leg raise ROM >90 degrees, positie prone instability test, aberrant motions present in sagittal plane AROM
Goals of rehabilitation
Patients w/ acute symptoms are directions towards reducing pain and decreasing impairments; patients w/ chronic symptoms are less focused on pain and more focused on reducing anxiety and returning to participation in work, home, or athletic activities
What are the common approaches to THA?
Posterior, lateral, posterior-lateral (incision is lateral and slightly anterior to trochanter), anterior (preserves musculature - b/t fibers of sartorius and TFL)
Lateral shift
Posterolateral bulge blocks extension and side bending toward - causing patient to shift away or towards side of bulge (most of the time they will shift away)
Reasons for traumatic PF disease
Posttraumatic OA, quad tendon rupture, patella tendon rupture, avulsion of tibial tubercle, contusion
What should you look for in your observation?
Posture, atrophy, hypertrophy, gait, skin folds, body type, leg length difference
The spine is most restricted in what? By what?
Rotation Facets *Especially in extension (closed pack position); some rotation is available when the spine is in flexion
Femoral antiversion
Rotation medially in shaft of bone (~15 degrees)
Control of the lumbar spine is best provided by what muscles?
Rotatores Multifidus All abdominals especially TRANSVERSE ABDOMINIS Abdominals, spine extensors, diaphragm and pelvic floor muscles make a semi-rigid cylinder and tighten TL fascia and abdominal fascia
Control is best provided by...
Rotatories, multifidus, all abdominals (esp. TA)
Centralizing
Doing better
FABER test
Flex, ABD, ER
Knee
KOOS, knee osteoarthritis outcome scor
What motion does the interspinous decompression spacer limit?
Extension
The deep fibular N travels under what?
Extensor retinaculum
Distraction
Pt is supine, PT presses the ASISs toward the midline
Is the N root innervated?
HIGHLY - reacts to compression
What is a complication of a resurfacing anthroplasty?
Neck fracture
Possible reasons for hip hypomobility
Tight joint capsule, hip adductors, hip flexors
Describe spondylolisthesis surgery.
"The big fix"; screws are anchored into the bone and compress them together to stabilize
What population is most likely to have a herniated disc?
"Younger" people
Describe the artificial disc surgery.
(Discectomy and implantation) Removal of the damaged disc Determination of correct implant size Verify size, correct placement and alignment by AP and lateral fluoroscopy and x-rays Insertion of endplates in the disc space followed by insertion of sliding core Final verification of the position of the implant
Implant and fixation choices for standard TKA
-Cemented, uncemented, or hybrid fixation -Metal-backed tibia or all-polyethylene tibia -Patella resurfacing or patella retaining -PCL or bi-cruciate substituting, PCL retaining, or mobile-bearing surfaces
ODI: What is the score for minimal disability? What is the intervention?
0-20 Patient education
How much translation occurs at the SI joint?
0-4 mm
Normal hip extension
20 degrees
Separation of the lumbar spine occurs with ___% body weight.
25
Hybrid fixation
Acetabular cup (press fit, fixation screws), femoral stem (cemented)
Extension - nucleus moves _____________
Anterior
You want pt to maintain position for _______ after treatment
Awhile
AVN of hip is due to injury of what arteries?
Circumflex
Aquatic therapy
Benefits are pain control, ROM, stabilization
Depth of sacral sulcus
Divot that is medial to PSIS
What is spondylolysis?
Fracture of the pars interarticularis
What is the most common injury in soccer?
Hamstring strain
Quadriceps active test
Have patient actively fire quads and see degree of tibial movement
Evidence for traction
Inconsistent outcomes among studies
Healing scar is __________and must be mobilized to regain mobility
Inelastic
Stiffness/rigidity after TKA
Initially felt in morning, gradually increased to affect all activities
Modalities
Most heat, Estim
Post op complaints
Over or underuse, pain, stiffness/rigidity
Everter =
Pronator
Femoral nerve innervates the ______________
Quads
LBP is generally_________
Self-limiting
Thessaly (meniscus)
Stand on one foot and rotate
Research says that _________tests are unreliable
Static
Anti-inflammatory meds
Steroids, NSAIDS
Studies have reported that up to ___% of patients can't be given a precise pathoanatomical diagnosis.
90%
T/F Low pressure with traction does not produce the same effects as manual or self-traction.
True
When should SLRs be allowed?
When partial or full WB is permitted
How do you rotate pelvis back anteriorly?
Work hip flexors
Degrees of nutation and counternutation of sacrum
~0.5 degrees
Inverter =
Supinator
Force of ____% of patients BW is sufficient enough to increase the length of the lumbar spine
25
Some individuals recover w/o intervention or recovery can be _______________
Delayed
What should the focus of any post op program be on?
Early activation of hip extensors, ABD, and knee extensors
Actions of TFL
Flexes, ABD, IR
What is a stabilization procedure done for lumbar HNP?
Fusion
Problems following THA
Hip ABD weakness, muscle contracture, limb length difference, mal-alignment
Examination of GTPS
In addition to pain along the posterior, lateral portion of the GT and pain w/ resisted hip ABD and/or ER, Trendelenburg test, FABER test, Ober's test, MRI can be effective to determine whether a patient is suitable for surgery
Where is the sacral sulcus?
Just medial to the PSISs
Surgery
Laminectomy, foramenectomy
Primary and secondary restraint of LCL
Primary - varus force Secondary - anterior and posterior stress
What can a radiograph differentiate a hamstring strain from?
Stress fx
Validity
Testing what you think you are testing
Can PVD have some of the same types of symptoms as claudication?
Yes
42. The common fibular nerve divides into what 2 nerves?
a. Superficial and deep fibular nerves
Why should you ask the patient if their pain is aggravated by a cough or sneeze?
Because when we cough/sneeze we increase our intra-abdominal pressure, we also do this in flexion (tell the patient to stand up straight when coughing/sneezing)
You often find TPs _______the PSIS
Below
Femoral retroversion
Anything less than the 15% of normal antiversion
Open chain - screw home mechanism
As knee extends tibia rotates laterally in the last 30 degrees of motion; due to shape of joint surfaces, pull of quads and PCL
Patient education
Avoid forward flexion and sitting, maintain lumbar lordosis, avoid activities that peripheralize symptoms, may benefit from brace to maintain extended posture
Chronic LBP
Avoidance behaviors may become even more related to fear of continued pain and disability even after pain has become under control; can influence performance of functional tasks and can be a predictor of long term work disability
DD of hamstring straings
Avulsion fx of ischial tuberosity, adductor strain, referred lumbosacral pain, piriformis syndrome, SI dysfunction, sciatica, hamstring tendinitis, ischial bursitis
How are TKAs different these days?
Admitted morning of surgery, mobilize day of surgery or 1 day post op, usually WBAT, LOS <1-2 days
How does the IV disc restrict motion?
The fibers of the annulus fibrosis will tighten and act as a ligament during motion
The most important characteristic of patients likely to respond from specific exercise routines appears to be the presence of __________________
Centralization
How do you choose what position to place pt in?
Choice is related to being able to centralize or decrease symptoms
Etiology of trochanteric bursitis
Females> males (have wider pelvis), overweight, trauma, overuse of the muscles around the bursa, tight hip ADD, glute med tendinopathy, hip OA, rapidly increased running mileage, poorly cushioned shoes, excessive pronation, leg length differences (causes you to go into more adduction), ITBS, bacterial infection, RA, hip prosthesis
Prevalence of LBP (Level I evidence)
Females>males, inc. w/ aging, lower educational status, and jobs w/ higher physical demand
TKA components
Femoral component (strong polished metal - cobalt chrome), tibial component (proximal tibia is covered w/ metal tray, topped w/ a disk-shaped polyethylene insert, may be fixed, may rotate around a platform), patellar component (places posterior surface of the patella)
What would be some red flags that you notice during the interview?
Fever Chills Sudden/unwanted weight loss
FABER
Flexion, abduction, ER
Tibial portion of the sciatic nerve innervates the knee ____________ and ___________
Flexors and rotators
Adductors are __________when the hip is extended and _________when the hip is flexed
Flexors; extensors
Why should individuals who are hypomobile stretch?
For pain (rocking rhythmic), to warm tissue, to increase mobility, to increase strength, endurance, and stability into a new range, to maintain improvements over time
Motion detection tests
Forward flexion test, Gillet (Stork) test, long sitting test, posterior glide test
What is the most common MOI of the cervical spine?
Forward head with lift or twist or trauma; especially in forward head posture
Effects of long-term poor posture
Forward head, protracted scapula, increased lordosis, decreased lordosis, increased kyphosis, cox valgus or varus
What direction does the arcuate ligament run?
From fibular head it runs superior and medial
Where does the sacrotuberous ligament run?
From sacrum to ischial tuberosity
Where does the iliolumbar ligament run?
From the crest of the ilium to the tp of L4-L5
ACL is taut in _______ ________________
Full extension
Strong evidence exists that an inactive person will show ______ wear than in an active person with a THA, but exercise will decrease fall risk, ___________ bone density, and prosthesis fixation
Less, increase
Cervical
Neck Disability Index
What is the most common application of traction?
Nerve root compression
Who reported greater reductions in pain after surgery?
Older patients, females, and patients w/o revisions
SIJ tests w/ the highest level of reliability
Pain
W/ a more central bulge, the patient tend shift _________side of bulge
Towards
35. How might the sciatic nerve become impinged?
a. Hypertrophy of the piriformis or the external rotators causing a decrease in space for the nerve to exit out of.
23. What individuals are most likely to benefit from manipulation?
a. Hypomobile joints b. Pts who did not respond to low velocity techniques c. Pts with no radicular symptoms
6. The iliolumbar ligament O/I/A?
a. Iliac crest to TP of L4-5 b. Limits flexibility in the lower lumbar region. Mostly limits flexion.
9. What is the rule of the artery?
a. It is the idea of early osteopaths that every disease was caused by a reduction in blood flow which could be fixed with relief of pressure on the blood supply.
17. What common complaint has the best evidence for manipulation?
a. LB pain that is not radicular
26. What is the sensory component for the obturator nerve?
a. Medial middle thigh (small oval)
45. The deep fibular nerve provides sensory where?
a. Web space between 1st and 2nd ties
The hip angle normalizes w/ aging and weight _____________
Bearing
Lachman's test
Slightly flex knee to 30 degrees, top hand on femur, bottom hand on tibia, quick pull w/ bottom hand, try to get an anterior pull with tibia; (+) test = do you feel laxity, does patient feel a difference from side to side
What is a posterolateral approach associated with?
Slightly higher risk of dislocation
Individuals w/ lumbar injury show more postural sway and have ___________reaction times
Slower
What position is the patient in during facet injections?
Some type of flexion (side-lying/prone with flexion) - this opens up the joint
What population is the most common target of application of traction?
Someone who has pain and paresthesia; radicular symptoms from lateral stenosis most likely
How long does recovery from a hamstring strain typically take?
Sometimes weeks to a full year
What is the hip labrum made of? What is its purpose?
Specialized fibrocartilage; lines the acetabulum to increase its surface area, inc. joint stability, contributes to proprioceptive feedback, decreases the forces b/t the femoral head and acetabulum
What prevents backward migration of the interspinous decompression spacer?
Supraspinous ligament
What is the collagen fiber orientation of the menisci?
Surface layers - random orientation, inferior layers - circumferentially "hoop strength", tie fibers - radially oriented
Symptoms of hamstring strain
Swelling and ecchymosis, pain w/ palpation, when there is a palpable defect - more severe injury, dec. AROM and PROM (SLR, 90-90 degree SLR, tripod sign)
Symptoms of a PCL injury combined w/ other ligamentous injuries
Swelling, bruising, anterior and posterior knee pain, a feeling of instability, limited ROM, difficulty walking
What is the purpose of the IV discs?
They absorb shock and restrict motion
Why do patients who have stenosis tend to be more flexed in posture?
They are trying to open up the central/lateral foramen to take pressure off of the disc
Why should you ask the patient if they have had any recent kidney or bladder infections?
They can cause low back pain
How do muscle energy techniques work?
They use the bodies of muscles to reposition bones
As the anterior longitudinal ligament descends, does it get thinner or thicker?
Thicker
Annular rings are _____________anteriorly and _______________posteriorly
Thicker; thinner
The medial plateau is ____shaped and the lateral plateau is ____ shaped
C; O
Combined FAI
CAM and Pincer can occur together
If the spinal cord is affected, there will be ___________signs
CNS
If the spinal cord is affected, where will be ____ signs.
CNS
Provocation tests
Compression, distraction, knee to opp. shoulder, sheer, approximation, sacral compression, FABER, anterior and posterior rotation
Partial meniscal tear
Compromises 1 surface
What are fear avoidance beliefs?
Concerns and fears about potential for physical activities to produce pain and further injury to the spine; result in heightened anxiety, an obstacle for recovery and potential disability
What patient typically goes to in-patient rehab after a THA?
Those who are able to tolerate at least 3 hours of therapy a day and have a good chance of returning home, typically older patients w/o family support and patients w/ comorbid medical conditions
What patient typically goes to a SNF after THA?
Those who cannot tolerate 3 hours of therapy a day and are not at risk for medical instability
Most susceptible athletes to pars fracture
Those who do frequent end range lumbar spine hyperextension: linemen in football, gymnasts, swimming and diving, wrestling, volleyball, cheerleaders, weightlifters
Lateral plantar N is a branch of what N?
Tibial N
Functions of the knee
Transmit loads, allows lengthening and shortening of LE, provides stability for WB, provides mobility for functional movement
The menisci are attached anteriorly via the _______________ligament
Transverse
Before movement ever even occurs, what contracts?
Transverse abdominis and multifidus (i.e., when you are thinking about bending over to pick up your socks)
Layers of the cervical region (superficial to deep)
Trapezius, splenius, erector spinae transversospinalis, subocciptals
Weak hip ABDuctors results, results in a ________________gait
Trendelenburg
T/F >200,000 discectomies are performed in the US each year.
True
PCL is most taut in ____________
Flexion
T/F Centralization was originally described by McKenzie as occurring during lumbar movement testing when the patient reports the pain moves from an area more distal or lateral to location more central or near midline position.
True
S&Ss of Spondylolithesis
Grade 1+2: LBP and/or buttock and leg referred pain, feeling of instability w/ sudden movements, jarring movements, spine "give out", legs may buckle Grade 3+4: LBP, may be radicular signs into LE related to traction on lumbosacral nerve roots, pain paresthesia, numbness, muscle weakness, radicular signs may be unilateral or bilateral
T/F Once you complete your interview, you should make a list of all signs and symptoms and what causes them, makes them better or worse, and when they occur. You should then have a good idea on what the problem is and why. Use the physical exam to support or refute what you think the problem is from the interview.
True
T/F When doing manual traction, monitor the patient's reaction. You can't control the force exactly.
True
T/F Patients should maintain the position for a period of time after treatment.
True (think orthostatic hypotension)
Arthroscopic microdiscectomy
Very common, less morbidity and an earlier hospital discharge compared w/ standard discectomy
Adult Posture
Very dependent on body type and function
*What are contraindications of traction?
Where motion is contraindicated (fractures, hypermobility, dislocated joints) Uncontrolled HTN if using inversion table If traction peripheralizes symptoms (it's meant to centralize them) Immediately post-surgery of the spine Positive vertebral artery test
Contraindications to traction
Where motion is contraindicated (fx, hypermobility, dislocated joint), uncontrolled HTN if using inversion table, if traction peripheralizes symptoms, immediately post-surgery of spine, (+) vertebral artery sign
How do you diagnosis spondylolysis?
X-ray (often diagnosed with an oblique view x-ray) MRI CT Bone scan
Diagnosis of pars fracture
X-ray (often oblique view, sometimes does not show), MRI, CT, bone scan
Meniscal allograft
Young/active patient who previously underwent total meniscectomy and now is symptomatic because of early osteoarthritic changes
What population is a resurfacing arthroplasty good for?
Younger patient w/ better bone stock
19. What is the sensory component of the femoral nerve?
a. Anterior and anterior medial thigh and (saphenous nerve) anterior medial lower leg to about the medial malleolus.
21. Never manipulation C ____ to C _____. Always start at C_____
a. C1-2 b. C3
14. The patella tendon reflex tests what nerve root?
a. L4
40. The common fibular nerve is supplied by what nerve roots?
a. L4, L5
32. What nerve roots does the sciatic nerve come off of?
a. L4, L5, S1, S2, S3
36. The tibial nerve comes off what nerve roots?
a. L4, L5, S1, S2, S3
29. The muscles that create the hydraulic effect causing stability of the trunk include:
a. Muscles between layers of thoracolumbar fascia: Erector spinae, transversospinalis, quadratus lumborum b. Muscles between layers of abdominal fascia: Rectus abdominis c. Diaphragm d. Pelvic floor
48. What motor component does the sural nerve provide?
a. NOTHING
24. What populations of pts should NOT be manipulation?
a. Near unhealed fractures b. RA c. Pregnancy including breastfeeding females due to hormone release d. Osteoporosis e. Hypermobility of affect joints f. Unstable joints g. Unknown cause of symptoms h. Long term corticosteroid use i. Down syndrome (laxity in upper c-spine and OP of dens)
13. What are the biggest reasons for concern with non-musculoskeletal pain?
a. No history of injury b. No change in symptoms with changes in position or with activities c. Fever/chills/night sweats/etc d. Unable to reproduce symptoms with a physical examination
25. Obturator nerve travels through what to get to the obturator canal?
a. Obturator foramen
1. What are some characteristics of pain that might be indicative that the patient is dealing with something that is beyond our scope of practice?
a. Onset: Did it come on slowly (indicative of cancer) b. Did the pain start suddenly without a mechanical event? (Vascular) c. Does the pain not change with position or activity? d. Is it a true constant pain (does not vary with position or activity)
8. Who are the individuals who perform manipulation?
a. Osteopaths b. Chiropractors c. Physical Therapists
13. If you have diminished reflexes, what is it indicative of?
a. PNS issue or nothing.
3. What are the S&S of radicular pain?
a. Pain b. Paresthesia c. Muscle weakness d. And/or diminished reflexes
2. What are some common patient complaints that may exist with lumbar hypomobility?
a. Pain and stiffness b. Dull ache c. LE referred signs d. Past history of trauma e. Often unknown etiology f. Often sedentary g. Worsens with aging
1. What is referred pain?
a. Pain from a lesion In one location that is experienced by the patient in another location. b. Often from musculoskeletal structures are dull and achy.
20. What is the motor component of the femoral nerve?
a. Pectineus, Sartorius and quadriceps.
7. To determine if a person has diminished PA glides or PIVMs in the lumbar spine, what should you do?
a. Place a pillow under the hips to get the lumbar spine out of closed pack (end range extension)
38. What muscles are innervated by the tibial nerve?
a. Popliteus, gastrocnemius, soleus, plantaris, tibialis posterior, FHL, FDL
50. The sural nerve provides sensory where?
a. Posterior lateral lower leg and foot.
18. What muscles are between the middle and anterior layers of the TCF?
a. Quadratus lumborum.
61. The lateral plantar nerve provides motor innervation where?
a. Quadratus plantae, abductor digiti minimi, plantar and dorsal interossei and lumbricals 2, 3, and 4.
22. Where is the sensory component for the lateral femoral cutaneous nerve?
a. Sensory only to lateral anterior thigh.
28. Can you still adduct your lower extremity without obturator nerve?
a. Yes! Adductor magnus has a tibial portion of the sciatic nerve, medial hamstrings and part of pectineus would allow adduction to occur.
The menisci are attached to the tibia via ___________ligaments
Coronary
Interventions
Correct lateral shift, posture, modalities, exercise, mobilization, traction, brace w/ extension
What causes local lumbar spasms? (a symptom of claudication)
If the patient stands flexed to give more space for N roots - tends to over stress lumbar extensors which causes the spasms
Reason for symptoms
If the patient stands flexed to give more space for nerve roots- tends to over stress lumbar extensors which causes local lumbar spasm, if the patient stands in an extended position- tends to close IV foramen and impinge nerve roots, causing distal symptoms
What causes distal symptoms? (symptoms of claudication)
If the patient stands in an extended position - tends to close IV foramen and impinge N roots, causing distal symptoms
Why are foraminotomies performed?
If you have narrowing of the intervertebral foramen it will lead to stenosis causing pressure on the N root
Explain the dysfunction syndrome.
Mechanical deformation of soft tissue affected by adaptive shortening
Where should you start with treatment?
Movements or positions that cause or worsen symptoms should be avoided Movements or positions that relieve or lessen symptoms are to be encouraging and used to begin treatment
Risk factors for TKA
Multiple compartments are damaged due to arthritic changes, articular cartilage is damaged and is no longer able to absorb shock, previous injury, menisectomy, RA, fractures and congenital factors
Studies have indicated that endurance, balance, and neuromuscular control may be more important than max ______strength for both prevention and rehabilitation
Muscle
What limits and stabilizes motion segments in the neutral zone?
Muscle function
Examples of soft tissue mobilizations
Muscle relaxation, massage, trigger point techniques (high volt estim through sound head), deep pressures, myofascial release
Compression of the N root results in:
Numbness/tingling Motor weakness Decreased DTRs (deep tendon reflexes) Decreased blood flow to the N (ischemia)
Craig's test
Patient is prone, bend knee, feel GT and feel for when it is most prominent
Ely's test for tight quad
Patient is prone, flex knee
Documentation of traction
Patient position, traction method, types of traction, magnitude of force, duration of traction, duration of hold/release periods, patient's symptoms before, during, after
Does the nucleus pulposus sit more anteriorly or posteriorly within the annulus?
Posteriorly
During flexion the menisci move ____________ via the semimembranosis and lateral meniscus via popliteus
Posteriorly
Many of the concentric ring of the annulus fibrosis are incomplete, especially those anteriorly or posteriorly?
Posteriorly
Approximation
Pt is side-lying, PT compresses into the subject towards the exam table
Gillet (stork) test
Pt is standing, one thumb on PSIS (on side you lift) and one thumb on sacrum around S2, PSIS should rotate backwards on side you lift
Sign of the buttock
Restriction of SLR concurrently with limited hip flexion and a non-capsular pattern of restriction of hip joint ROM
Clinical presentation of intra-articular snapping hip syndrome
Results from a sudden onset of snapping or clicking from a traumatic even to the hip capsule, sources of the snapping can come from intracapsular lesions, loose bodies in the acetabulum, a torn labrum, or idiopathic recurrent subluxation
Spinal stabilization
Retraining appropriate activation of the TA and/or multifidus
Long right leg
SB to the right, rotated to the left (if it is more than 1/2 an inch, you probably need to adjust the shoe, not something in the shoe)
What are some of the controversies regarding the SI joint?
SIJ doesn't move (no) SIJ has such a small amount of motion that it does not cause pain (no) Pain only results from severe trauma (no) Pain is caused by a strain of SIJ ligaments (maybe) Pain is caused by hypomobility (maybe; you start out hyper and most too much causing SIJ to shift into a new position and end up hypo) Pain is caused by joint that subluxes (maybe)
There is some evidence supporting manual therapy techniques directed toward the lumbar spine and SIJ as an effect _______-term intervention
Short
McConnell test
Short squat, take thumb and push on outside of patella in medial direction, can also do taping technique
The RMQ is designed to measure short or long term changes?
Short term changes
Mobility/manipulation classification: Traditionally, mobility assessments and special tests have been used to classify a patient as needing a manual therapy. There is some evidence supporting manual therapy techniques directed toward the lumbar spine or sacroiliac joint as an effective short or long term intervention?
Short-term
Should you have both knees done at the same time?
Short-term and long-term outcomes were equal by 12 weeks, except quad strength (equal by 52 weeks)
Coxa Varus
Shortening of abductors
Minimally invasive TKA
Shorter incision, quad sparing, early, limited results: better ROM, less blood loss, shorter LOS
Shoulder
Shoulder pain and disability index
DD of piriformis syndrome
Si dysfunction, HNP, tumor, cyst (hematoma), FAI, tabeal tear, hip OA, spinal stenosis
Traumatic chondromalacia (formerly patellofemoral syndrome)
Sick cartilage, degenerative changes in cartilage on posterior side of the patella
Where does the piriformis attach?
Sacrum anteriorly to GT
Neurological symptoms w/ patellofemoral disorders
Saphenous nerve neuralgia, CRPS
What can a positive FABERs test indicate?
Tight hip flexors, adductors, joint capsule
If your patient is overall hypomobile, what should you look for?
Tight muscled, tight jointed individual May stand in flattened lumbar lordosis May sit in spine flexion Feet more likely supinated May have overall limited mobility in most joints
What causes a sports hernia?
Weakening of the abdominal wall
What is the shape of the menisci?
Wedge shaped to improve joint congruency, improve joint stability, and maintain joint space
How do you rotate pelvis back posteriorly?
Works glutes and hamstrings
Explain the centralization peripheralization phenomena.
Worse w/ flexion (peripheralize radicualr symptoms), better w/ extension (centralize peripheral radicular symptoms)
Examination findings
Worse w/ flexion and/or SB, worse w/ repeated flexion, better w/ extension or repeated extension, motions must be slow or you risk pinching bulging disc, nucleus moves like a very thick fluid
Which direction does the acetabulum face?
Anterior, inferior, lateral
Classification of instabilities - straight
Anterior, posterior, medial lateral
What are the 2 bundles of the PCL?
Anterior-lateral, posterior-medial
What are the 2 bundles of the ACL?
Anterior-medial, posterior-lateral
What are possible dysfunctions of the SIJ?
Anterior/posterior rotation Up/down slip In/out flair Sacral tip Sacral obliquity (when the inferior angle of the sacrum is off to the side)
When in increased lumbar lordosis, the pelvis is ____________tilted and the __________ and __________ are tight
Anteriorly; hip flexors and spine extenders
Classification of instabilities - rotatory
Anteromedial, anterolateral, posterolateral, posteromedial
2 bands of the ACL
Anteromedial, posterolateral
What are non-PT interventions for stenosis?
Anti-inflammatory medication (because of the chemical irritation to the N) - steriods, NSAIDs Surgery (laminectomy, foramemectomy)
General HQRL questionnaires are good for what population?
Anyone with any disability or condition
Neurogenic claudication
Compression of nerve roots results in: Antalgic gait, paresthesia, cramping of muscles in one or both LE with activities such as walking; tend to be in a more flexed position (open packed)
Where does the biceps femoris tendon insert?
Fibular head
How do you palpate the TFL?
Find ASIS and palpate just below it, attaches to IT band
How do you palpate the rectus femoris?
Find ASIS and slide ~ 1 inch distal and have patient extend knee
Describe a posterior interbody fusion surgical procedure.
First a laminectomy is performed Next, the posterior 2/3 of the disc is removed and an interbody graft is placed into the evacuated disc space Most surgeons use pedicle screws to immobilize the vertebrae rigidly while preserving the normal lumbar lordosis
Describe the posterior drawer test
Flex hip to 45 degrees, knees to 90 degrees, push knee posteriorly
Decreased lumbar lordosis, lumbar spine is __________________
Flexed
Gait - OA
Flexed hips, extended lumbar spine, shorter stride
Increased Q angle
Increased valgus, more likely to have an ACL, medial meniscus injury
Scarring from hamstring strains ____________risk of re occurrence
Increases
Risk factors for hamstring strains
Increases age (collagen is less elastic, mallard effect), hip flexor tightness (can cause inhibition of glute max), poor lumbopelvic control (anterior pelvic tilt), muscle fatigue, previous injury, overuse
Is central or lateral stenosis more common?
Lateral
Most of the time, the bulge is __________to the nerve root
Lateral
Common accessory motion testing at hip
Lateral glide, lateral distraction, lateral distraction w/ combined movements, anterior glide, posterior glide
LCL is not connect w/ the _________
Lateral meniscus
Lateral plantar N does sensory to: Motor to:
Lateral plantar surface of foot (except heel) and plantar surface of half of the 4th toe and 5th toe Quadratus plantae, abductor digiti minimi, plantar and dorsal interossei and lumbricals 2, 3, and 4
Pregnant females have more or less motion at the SI joint than those who are not pregnant?
More
Coxa Valgus long-term effects
More likely to dislocate hips
What is stenosis?
Narrowing of the spinal canal or IV foramen
What % of people have recurring episodes of dislocation?
30-50%
_____-_______ lbs during lumbar traction can reduce a disc prolapse, retracting the herniated discal material
60-120
Ligaments of the SIJ
Posterior and anterior SI, interosseus, sacrotuberous, sacrospinous
How does the trochanteric bursa sit?
Posterior and inferior to trochanter
Diastasis Recti
Abdominal separation
Jefferson fracture
C1 vertebra
Describe the lateral meniscus
Circular or "O" shaped, less extensively attached to joint capsule, no attachment to LCL
The elastic zone is at ___.
End range
Ilium surface
Hyaline and fibrocartialge
Anteromedial rotary instability
Posterior horn of medial meniscus, oblique popliteal ligament, ACL, MCL
Where does the plantaris muscle originate from?
Posterior lateral femoral condyle
Symptoms for a ___________meniscal lesion are produced by instability of the torn fragment
Traumatic
Closed chain - screw home mechanism
As knee extends femoral condyles rotate medially on fixed tibia; no muscle action necessary due to shape of joint
If a disc bulges in the lumbar region, which way does it typically go? Why?
Posterior laterally because of PLL
Ligaments of the SI joint
Posterior sacroiliac Anterior sacroiliac Interosseous Sacrotuberous Sacrospinous
Neck of "scotty dog"
Pars
Flexion - nucleus moves ___________
Posterior
ODI: What is the score for severely disabled? What are the patient's problems?
40-60 Pain affects travel, personal care, sex, and sleep
Stabilization CPR: Criteria (for a positive finding) for quality of sagittal plane AROM?
Aberrant motions present
How is the dysfunction named?
According to the direction of the loss of range (i.e., if you're stuck in flexion, you've lost extension - extension dysfunction)
Describe inserting the acetabular component
Acetabular shell is inserted (porous coated or cemented), a hard smooth plastic liner is inserted into the metal shell
The classification system is intended for use in patients with acute or chronic LBP?
Acute
Etiology of quad strains
Acute - single event Chronic - result of repetitive micro trauma
What are CNS signs?
Bilateral LE numbness, tingling, and weakness Leg pain/cramping when standing for long periods of time or when you walk (think sciatica and/or claudication)
Pressure on the cauda equina can cause what symptoms?
Bilateral pain, paresthesia, motor weakness, bowel and bladder changes, saddle numbness (changes in sensory in the rectal/genital area)
Hydrogel implants
Biocompatible, can be synthesized w/ a wide variety of mechanical and structural properties, characteristics similar to meniscus, proven durable in small animals
What do they do in a foraminotomy?
Bone is cut or shaved away to open the foramen (may be done with removal of disc or lamina)
What causes FAI?
Bone overgrowth (spurs)
Clinical presentation of BOTH hip OA and FAI
Both present w/ + tests for FABER and FADIR, both present w/ dec. hip flexion and IR, patients w/ hip OA often develop osteophytes and bony overgrowth of the acetabular rim and femoral head
What surrounds the iliopsoas bursa?
Bounded by iliopsoas muscle/tendon anteriorly and the joint capsule posteriorly
Genu varus
Bow legged, rare to see a true varus at the knee
What are interventions for hypermobile patients?
Braces or corsets Patient education (keep out of end range postures and activities) Strengthening and endurance exercises Proprioception exercises Spine neutral exercises
ACL is most taut in full ________
Extension
Disc patients feel better in____________
Extension
What does the ALL restrict? Does it get thinner or thicker as it goes down the spine?
Extension Thicker
3 different movements are typically found to centralize symptoms: what are these?
Extension, flexion, side bending (lateral shift)
When is the LCL taut? Loose?
Extension; flexion
Total meniscectomy
Extensive damage to major portion of meniscus and it is determined to be unsalvageable
Recurrent subluxation is associated w/ what?
Extensor mechanism imbalance, dysplastic femoral trochlea, patellar tilt, LE malaligment
Typical ACL injury occurs with the tibia ___________rotated and in 10-30 degrees of flexion w/ the knee in a __________position
Externally; valgus
What test would you perform for a suspected anterior femoroacetabular impingement?
FADIR test
What is the most common MOI of the thoracic spine?
Flexion; especially sustained flexion
When is the PCl most taut? Most loose?
Flexion; extension
In the lumbar spine, most of the time you have a ___ dysfunction.
Flexion; stretch these people into extension
Why should hypomobile patients exercise?
For pain - rocking rhythmic movements To warm tissue To increase mobility To increase strength, endurance, and stability into a new range To maintain improvements over time
Exercise based on what may be more effective than traditional exercise programs?
Functional activities
Proprioception treatment
Gait training (stride/step length, trunk rotation, arm swing), lumbopelvis stability, sit to stand correction, Trendelenburg correction, body supported gait training, aquatic therapy
What are outcome measures designed to do?
Gauge treatment effectiveness and efficacy; looks at biopsycosocial effect of treatment; patient generated questionnaires
Prevalence of LBP (Level II evidence)
Genetic component, inc. w/ leisure activities, smoking (don't heal very well, don't fight pain well), obesity, fear pain level, adolescence vs. adult same, most at risk - very active and sedentary
What neurovascular structures are moved out of the way in an anterior fusion surgery?
Genitofemoral N Psoas muscle Aorta and vena cava Sympathetic chain Iliac vessels
Arthritis affects over ____ million people in the US
32
Pincer occurs more often in whom?
3x more in females (ave. age 40)
Elongation of annular fibers by more than _____% will cause permanent damage to annular rings
4
The presence of ____out of 5 findings was strongly predictive of a dramatic response to the manipulation interventions
4
The presence of at least __ out of 5 of these findings was strongly predictive of a dramatic response to the manipulation intervention.
4
What should you suspect if a patient has increased reflexes? Diminished reflexes?
CNS PNS or nothing
Why should you ask your patient about caffeine?
Caffeine is a stimulant and it can potentially mask pain
Causes of lateral stenosis
Can be congenital, facet joint arthosis, loss of disc height, posterolateral bulge of IV disc or a growth within the IV foramen
Is a pars fracture unilateral or bilateral?
Can be either
How does separation of the pubic symphysis occur?
Can occur with trauma, repetitive stress, or post-partum *Can also cause a pubic fracture
Flexion exercises
SKC, DKC, sitting flexion, posterior pelvic tilts, spine neutral, rocking rhythmic exercises
18. What are the best results achieve by for low back pain?
a. A combination of manipulation and exercise
24. What are all of the spine flexors?
a. Abdominals, iliopsoas
Roland-Morris Questionnaire
24 questions related to pain and function, 5 min to complete, 1 min to score, 0-24 (0 no pain and no functional limitations, 24 max pain and limitations), minimal detectable change (variable - 5 to 9), patient checks statement that applies to them, "because of my back pain...", designed to measure short term changes, short, simple, easy to understand, does not look at psychological or social, may be more sensitive in patients w/ lesser disability
Force of ___% of patient's body weight is sufficient to increase the length of the lumbar spine.
25%
Separation occurs w/ ______ of BW
25%
What should you start w/ at initial treatment?
25% of BW
Grade 2 Spondylolithesis
25-50%
Long-term risk of dislocation
4.8%, highest risk is 1st year after surgery
What is the pars interarticularis?
A bony isthmus between the superior and inferior facet joints of the spine
Pubofemoral ligament is taut w/ ____________ and __________
ABD and ER
You can easily dislocate a newborn baby's hip - What positions are most stable and what should be avoided?
ABD and ER are most stable, you should not extend hips
During single leg support, your hip ______are firing
ABDuctors
Anterolateral rotary instability
ACL, LCL, posterolateral capsule, and arcuate complex
Associated procedures w/ meniscal tears
ACL, PCL, articular cartilage repairs
Ischiofemoral ligaments is taut w/ ____________ and __________
ADD and IR
Where can you palpate the rectus femoris?
AIIS
Where does the rectus femoris attach?
AIIS to tibial tubersoity via quad tenson
Standard ________ or__________view will not give you a great view of the hip
AP or lateral
How can you clear the lumbar spine?
AROM, PROM w/ overpressures, quadrant positions, PA spring testing to lumbar spine, LLTT
How do you measure the Q angle?
ASIS to mid patella, mid patella to tibial tubercle
What are your main spine flexors?
Abdominals Iliopsoas
During nutation: Sacral tilt: Iliac (pelvic) tilt: Lumbar:
Anterior Posterior Flexion
What is the preferred approach to THA today?
Anterior due to much smaller incision 3-4 inches
Possible dysfunctions of SIJ
Anterior or posterior rotation, up slip or down slip, in flair, out flair, sacral tip (nutation or counternutation_, sacral obliquity
What surface of the patella is highly vascularized?
Anterior surface
What is the neutral zone?
Area in a ROM segment where there is little resistance to motion
Manipulations are illegal for PTs in what two states?
Arkansas Washington
Odd facet (or flexion facet)
Articulates only in full flexion (more medial)
Non-constrained knee replacement
Artificial components inserted into the knee are not linked to each other, rely exclusively on the body's muscles, ligaments, and tendons to keep kneecap in place, no stability built into system, most common type of knee replacement; used when the knee is highly unstable and the person's ligaments will not be able to support the other type of replacement (severely damaged knee), 2 pieces are connected w/ a hinge-like device that keeps the joint inline and helps support the patella's proper alignment
Elaborate on the AROM portion of the LQS.
Ask for full motion ("I want you to move as far as you feel that you can") and ask: "Does this change your symptoms? If so, describe them." Look at willingness to move (Did they selectively decide NOT to go into certain directions because of pain?) Approximate ROM - estimate, don't measure
Posterolateral corner injury
Associated w/ rupture of one or both cruciate ligaments, failure to address instability of these corner structures increased the forces at the ACL and PCL graft sites and may predispose to failure of cruciate ligament reconstruction
When do you administer questionnaires?
At initial evaluation, as needed, and at discharge
Manipulation CPR: Criteria (for a positive finding) of hip IR ROM?
At least 1 hip with less than 35 degrees of motion
Manipulation CPR: Criteria (for a positive finding) of lumbar segment mobility?
At least 1 hypomobile segment
The presence of ____ positive factors indicates a greater likelihood of responding to stabilization intervention.
At least 3
__________ make of 15% of reported cases and sports that involve repetitive end range hyperextension or hyperflexion w/ ABD and/or rotation - they are at risk for ___________tears
Athletes; labral
ACL neuromuscular prevention programs include what?
Balance training, jump training (landing w/ inc. flexion at the knee and hip), strengthening (emphasize proximal hip control through hip ABD, ER, and hamstrings), skill training (controlling body motions, esp. deceleration and pivoting maneuvers), movement education, agility training
S&Ss of recurrent subluxation
C/O of pain (difficult to localize), giving way (could also be meniscus or ligamentous injury), feeling of instability, pseudo locking, "something jumps in my knee", "something feels out of place"
Cemented vs. Cementless THA
Cemented technique: 98% survivorship @ 10 years, 93% survivorship @ 25 years Cementless technique: similar to above #'s for femoral component, and better w/ acetabular component at 15 year mark (now preferred method, especially in younger patients)
What are the two types of stenosis?
Central and lateral stenosis
McKenzie also came up w/ the ________________phenomena
Centralization
The most important characteristic of patients likely to respond from specific exercise routines appears to be the presence of ____.
Centralization
The goal of treatment is to _________patient's symptoms and permit the patient to progress into another classification, most often a specific exercise or stabilization classification
Centralize
Static tests
Compare relative positions of: ASISs, PSISs, iliac crests, pubic rami, depth of sacral sulcus, inferior angle of sacrum
How can you tell if traction is working?
Compare the patient's signs and symptoms before and after treatment and see if they get better
What all is common in a hypomobile patient history?
Complains of pain and stiffness Dull ache May have LE referred signs (most of the time they won't have radicular symptoms unless something else is going on) May have h/o trauma Often unknown etiology Often sedentary Worsens with aging
What do patients typically complain of when they have lumbar spine hypomobility?
Complains of pain and stiffness, dull ache, may have LE referred signs, may have past h/o trauma, often unknown etiology, often sedentary, worsens with aging
Clinical findings for labral tear
Complaints of pain locking, catching, instability, giving way, and/or stiffness, anterior groin pain in 96-100% of cases, hip locking in 58% of cases, predisposing factor: coxa valga 87% of cases, c/o of clicking in the hip w/ (+) LR
Rotation - nucleus is ____________
Compressed
Neurogenic claudication is caused by _____. What does this result in?
Compression of N roots Antalgic gait (painful/difficult) Paresthesia Cramping of the muscles in one or both LE with activities such as walking
Cauda Equina Syndrome
Compression of inflammation of the cauda equina results in paresthesia, anesthesia, paresis or paralysis, and possible B&B or genital dysfunction; nerve roots become chronically inflamed and adhere together
What is cauda equina syndrome?
Compression or inflammation of the cauda equina (so after T12-L1) results in paresthesia or anesthesia (lack of sensation), paresis, or paralysis, and possible B&B or genital dysfunction
How do you prepare for mechanical traction?
Description of traction to patient Patient expectations Donn harness Position patient Explain/provide "kill" switch and bell Set parameters Initiate treatment
What should you do in preparation for traction?
Description of traction to patient, patient expectations, donn harness, position patient, explain/provide "kill" switch, set parameters, initiate treatment
What is the purpose of outcome measures?
Designed to gauge treatment effectiveness and efficacy Looks at bio-psyco-social effect of treatment
Global patellar pressure syndrome
Develops secondary to localized trauma or immbolization, fibrosis of surrounding retinaculum, hypomobility of the patella medially, laterally, and superiorly, may result in patella baja
What are some other special questions you should ask your patient?
Did the symptoms start gradually or suddenly? Leg cramps with walking? Do symptoms change with time of menstrual cycle? Any feelings of instability of the spine especially with lifting, twisting, bending, stairs? Smoking, drinking, drugs?
Slocum test for anterolateral rotary instability
Drawer test with tibia in IR
CAM FAI
Excessive "bump" in the superior-anterior femoral head-neck that results in an abnormal junction w/ the superior-anterior acetabular rim
What can cause an increased Q angle?
Excessive femoral antiversion, external tibial torsion, genu valgus, excessive pronation
Sponge effect
Exercise and loadbearing diffuses supply of nutrients and removes metabolic wastes
Levels of Evidence - 5
Expert opinion
Grades of Recommendation - F
Expert opinion, clinical experience
Adductor magnus helps __________the hip
Extend
If patient cannot _______then nucleus has moved through rings and blocks motion
Extend
For the quadrant tests, how do you maximally close the IV foramen? Maximally open?
Extend, SB ipsilaterally, rotate ipsilaterally ("take you hand and run it down the back of your leg") Flex, SB contralaterally, rotate ipsilaterally ("bring your L hand to your R knee")
New born/infant posture
Flexed posture in all regions of the spine, postural control goes cephalocaudal and proximal-distal, not yet developed cervical lordosis or lumbar lordosis, cervical lordosis comes first with child lifting head and gaining head control, lumbar lordosis comes with going prone on elbows, infant must establish proximal control before distal movements
W/ meniscal tears, symptoms are frequently worsened by _______ and loading the knee
Flexing (squatting and kneeling are poorly tolerated)
The standard nucleus pushing through the annulus will peripheralize with what motion?
Flexion
What does the PLL restrict? Does it get thinner or thicker as it goes down the spine?
Flexion Thinner
What action does the psoas do regarding the spine?
Flexion (think doing sit ups)
The spine is most free in ___ and ___. The spine is less free in ___.
Flexion and extension SB
What is the most common MOI of the lumbar spine?
Flexion or flexion with rotation
Infant hips are most stable in what position?
Flexion, abduction, and ER
Specific exercise
Flexion, extension, lateral shift patterns
What is the most frequently strained muscle in the body?
Hamstring
Tight ____ will limit anterior tilt of the pelvis.
Hamstrings
Tightness of what muscles are common at the hip?
Hamstrings, hip flexors
PT management of piriformis syndrome
If symptoms are due to a shortened, hypertonic piriformis, change the tone and increase mobility, Soft tissue techniques. PNF patterns, contract/hold relax techniques If the symptoms are due to a weak or inhibited piriformis, focus on strength (ABD and ER), Nerve glides - put patient in slumped position and have them do knee ext, or in supine (could add DF and ADD), McKenzie exercises. Lower trunk rotations - if really irritable at first, Bridge variations, Clamshells, Seated resisted ER, Quadruped fire hydrants, Theraband squats , Side steps, monster walks with theraband, Forward and lateral lunges
Functions of the meniscus
Improves articular congruency, distributes load during movement, reduces friction b/t femur and tibia, shock absorption, nutrition of articular cartilage, secondary restraint to tibial rotation
The disc between the pubic symphysis is similar to the lumbar disc. What is different?
It doesn't have a nucleus
*What are the relative contraindications to exercise?
L main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities (i.e., hypokalemia or hypomagnesemia) Severe arterial HTN (i.e., systolic blood pressure [SBP] of >200 mm Hg and/or a diastolic BP [DBP] of >110 mm Hg) at rest Tachydysrhythmia or bradydysrhythmia Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise High-degree atrioventricular block Ventricular aneurysm Uncontrolled metabolic disease (i.e., diabetes, thyrotoxicosis, or myxedema) Chronic infectious disease (i.e., HIV) Mental or physical impairment leading to inability to exercise adequately
Ilioinguinal N root? Sensory to:
L1 Skin of upper medial thigh and anterior scrotum and labia majora
Genitofemoral N roots? Sensory to:
L1, L2 Upper anterior thigh and anterior scrotum or mons pubis and labia majora
Lateral femoral cutaneous N root? Sensory to: Motor to:
L2, L3 Sensory ONLY to the lateral anterior thigh
Femoral N roots? Sensory to: Motor to:
L2, L3, L4 Anterior medial thigh (saphenous N), anterior medial lower leg to about medial malleolus Pectineus, sartorius, quadriceps (a lot of your hip flexors)
Obturator N roots? Sensory to: Motor to:
L2, L3, L4 Medial middle thigh (small oval) Obturator externus, adductor longus, brevis, and magnus (magnus also gets tibial N), pectineus (inconsistent and with femoral N)
Dermatomes of the knee
L3-S2
Common fibular N roots? Sensory to:
L4, L5 Lateral, superior lower leg
Tibial N roots? Sensory to: Motor to:
L4, L5, S1, S2, S3 Plantar surface of the heel Popliteus, gastroc, soleus, plantaris, tibialis posterior, FHL, FDL
Sciatic N roots? Runs through the ___ and under the ___.
L4, L5, S1, S2, S3 Through the sciatic notch and under the piriformis (lies on top of the deep ER)
Where is the most common site for fusion in the lumbar spine?
L4-L5 (the most mobility is here, so it has the most degeneration)
90% of lumbar herniations occur where?
L4-L5 and L5-S1
Install-salvati ration
Length of patella tendon (ligament) should be the same as the length of the patella top to bottom, if tendon is too long - patella alta, if too short - patella baja
Manipulation CPR: Criteria (for a positive finding) of the duration of current symptoms?
Less than 16 days
Manipulation CPR: Criteria (for a positive finding) of the Fear Avoidance Beliefs Questionnaire - work subscale?
Less than 19 points
The RMQ may be more sensitive (better for) patients with lesser or more severe disability?
Lesser disabled people
Soft tissue treatment
Look for TPs, stretch what is tight (hip flexors, quadriceps, gluteals, TFL, piriformis, hip rotators
Dysfunction syndrome results in:
Loss of movement Pain with stress on shortened structures Intermittent pain Decreased ROM
_______pressure does not produce the same effects (i.e. manual, self traction)
Low
What are signs and symptoms of grades 1 and 2 sacral displacement?
Low back pain and/or buttock and leg referred pain Feeling of instability with sudden movements, jarring movements Spine "gives out", legs may buckle
Focus should be on ____load, ____ hold
Low, tonic
Signs and symptoms of pars fracture
Lower lumbosacral back pain and spasm, may have associated referred pain in buttock or LE, often increased lordosis, tender w/ PA pressure to spinous processes
When the ACL is disrupted, the _______ provides most of the anterior stability
MCL
Clinical presentation of GTPS
Main symptom is pain and tenderness along the lateral thigh, pain may radiate down the thigh and buttocks, but rarely goes to the posterior thigh or distal to the knee, often described as aching but can be intense w/ strenuous activity, aggravated by passive, active and resisted hip ABD and ER
What is infant hip dysplasia?
Malformation of the hip, can be either congenital or acquired, at risk for dislocation
Manual techniques
Manual therapy, energy muscle technique, trust techniques (hard to focus on SI joint)
Interventions for acute LPB w/ mobility deficits
Manual therapy, exercise, patient education
Interventions for subacute LBP w/ mobility deficits
Manual therapy, exercise, patient education (focus on prevention and maintaining lifestyle)
Interventions for acute LBP, referred
Manual, exercise, exercise, traction, patient education, all to centralize symptoms
Interventions for chronic LBP, radicular
Manual, pain management
Interventions for subacute LBP, radicular
Manual, traction, nerve root mobilization
Adult females have more or less motion at the SI joint than males?
More (adult males SI joints are more stable)
Adult females have more __________ than males
Motion
What are wind-swept hips (common in CP)?
One hip is abducted and ER, one hip is adducted and IR
Step Deformity (EXAM)
One spinous process may appear to be anteriorly displaced over one below
*Explain the step deformity. How do you treat it?
One spinous process may appear to be anteriorly displaced over the one below For example, if the L5 vertebral body is anterior on S1 then L4 MAY FEEL more anterior (but the problem is at L5) As the L5 vertebral body slides anteriorly, the posterior arch and spinous process stays attached to S1 L4 feels deep because L4 has migrated anteriorly with L5 vertebral body (to find the, do the LQS, palpate for the deformity, proceed with PA glides)
Significant long-term impairment and disability (including pain) can continue for how long post TKA?
One year or more
What is a hemi-arthroplasty?
Only femoral side is replaced, but may not be efficient in pain relief
Clinical presentation of FAI
Onset of hip pain usually b/t ages 20-40 years; typically unilateral; typically aware of limited hip mobility long before pain begins
Ober's test
Originally designed for abductor muscle contracture, pain production or reduced ROM may be indicative, tight TFL will push into trochanter, make sure to stabilize pelvis, bring them into circumduction, then bring patient into ADD and extension
What hip pathology is more common in older age?
Osteoarthritic changes
PT management of hamstring strain
PRICE, modalities, taping, instrument assisted soft tissue mobs, dry needling, restore quad/hamstring strength ratio (focus on eccentrics once soreness is eliminated), BW hangs (eccentrically lowering), nordic HS curls, bridge variations, deadlift, kettlebell swing, flexibility, manually resisted hip ext or knee flex in prone, standing theraband flutter kicks, 2 or 1 leg stool scoots, forward or sideways 2 or 1 leg hops, 2 or 1 landing from a box
Post op PT implications following TKA
PRICE, pain control, compression garments, elevation, scar management once staples come out, patella mobility - glides, gentle rocking rhythmics
FABER test
Passively position the hip in flexion, ABD, and ER, (+) test = pain, this test doesn't tell you where the problem is, it tells you where to look next (hip joint, labrum, SI joint)
What is the largest sesamoid bone in the human body?
Patella
Where is articular cartilage thickest in the body (4-5 mm)
Patella articulating surfaces
Reflexes: L4: S1:
Patella tendon Calcaneal tendon
Trendelenburg
Pelvis drops on the non-stance side (most everyone drops a few degrees, females more than males)
Occurs when the pt reports the movement of pain from an area more proximal in the lumbar spine to an area more distal or lateral
Peripheralization
Surgical procedure for discectomy
Pre-op x-rays to identify appropriate level, 2-3 cm incision is made lateral to the SP on symptomatic side over the disc space, dissection is through erector spinae and transversospinalis groups (supraspinous, interspinous ligaments, and joint capsules are preserved), small metal tube is inserted under x-ray guidance, tube serves as a passage for the surgical tools so muscles aren't cut (in contrast to open discectomy), herniated disc is found w/ a tiny camera, ligamentum flavum may be removed or sparred, nerve root is retracted to expose the HNP, herniated nuclear material is then cleaned out w/ rongeurs (forceps)
Describe the discectomy surgical procedure.
Preoperative x-ray identifies the appropriate level involved A 2 to 3 cm incision is made lateral to the SP on the symptomatic side over the disc space Dissection through the erector spinae and transversospinalis groups is made (supraspinous, interspinous ligs, and jt capsules are preserved) A small metal tube is inserted under x-ray guidance The herniated disc is found with a tiny camera (endoscope) looking through the tube The ligamentum flavum may be removed or sparred The N root is retracted to expose the HNP The herniated nuclear material is then cleaned out with rongeurs (forceps type instrument)
Advantages of Unicompartmental arthroplasty
Preservation of ACL, smaller incision, less blood loss, lower morbidity, shorter recovery time, lesser bone removed
Primary and secondary restrain for MCL
Primary - valgus force Secondary - Anterior knee stability
Biomechanics of the PCL
Primary restrain for posterior tibial translation at 30 and 90 degrees of flexion
Motions at the SI joint diminish at what age in males? What about with women?
Puberty (because of the ridges and depressions getting deeper and thicker) Postmenopausal (same reason)
Positive SLR for piriformis syndrome will most likely be between 35-70 degrees, why?
Putting tension on the dura, which would most likely be lumbar spine (HNP)
Clinicians must take into account screening for medical ____flags and psychosocial ______flags in order to determine suitability for therapy
Red; yellow
The initial goal of an acute episode is to ________pain and disability and progress the patient into stage II of treatment
Reduce
What does joint distraction do?
Reduces compression on the joint surfaces and widens the IV foramen
What are some flexion exercises for stenosis?
SKC DKC Sitting flexion Posterior pelvic tilts Spine neutral Rocking rhythmic exercises
Sural N roots? Sensory to: Motor to:
S1, S2 Sensory ONLY to posterior lateral lower leg and foot
Posterior femoral cutaneous N roots? Sensory to: Motor to:
S1, S2, S3 Sensory ONLY to the inferior buttock (inferior clunial N), posterior thigh, and perineum
In absence of primary restraint, ___________structures are put under larger tension to restrain the same force
Secondary
Contraction of the diaphragm and pelvic floor make the trunk a _____.
Semirigid cylinder
What are red flag signs and symptoms of sacral displacement?
Sensory changes in the rectal, genital region Changes in bowel and bladder control
Interspinous decompression spaces
Separates the SP to relieve pressure, not indicated for stenosis > 2 levels, supraspinous ligament prevents backward migration, spacer only limits extension
What is the most common position for positional traction?
Side-lying on the non-involved side with a towel roll or bolster under to create opening of the contralateral side (put the patient in this position and leave them there)
What are indications for a lumbar fusion?
Significant trauma Degenerative disc or joint disease (usually in combination) Hypermobility (spondylolisthesis) - once both pars have fractures (grade 3s and 4s), conservative treatment probably won't work Severe, disabling back and/or leg
Oswestry LBP Disability Index
Specific to LBP, measure patients perceived level of disability, takes 5 min, 10 questions w/ 6 answers per question, each answer assigned a value (0-5), x 2 for percentage score, may be more sensitive in patients w/ severe disability
If the forefoot is more adducted they are a....
Supinator
It is recommended that exercises be started with the patient in ____________
Supine
What position should you place patient in?
Supine, prone, some table allow SB, increased hip flexion (to 90 degrees) causes greater separation of posterior structures
Describe the meniscus blood supply
Supplied by medial and lateral geniculate arteries, only 10% to 30% of peripheral medial meniscus and 10% to 25% of lateral meniscus receive direct blood supply, remaining portion receives nourishment from synovial fluid via diffusion
Inspection of meniscal tears
Swelling, stands w/ knee partially flexion, quad atrophy (chronic), joint line tenderness, terminal extension may be blocked, end feel - springy if knee is locked, limb girth measurement (reduced quad girth), balance and proprioception testing
BW support treadmills may be more effective at restoring what?
Symmetrical gait
Partial meniscectomy
Symptomatic displaced tear in older inactive individual, tear in central avascular third
*What is radicular pain?
Symptoms caused by a N root lesion irritation; symptoms are perceived along the distribution of the N root; "more of a dermatome type pattern"
Injections treat ___________, not the __________
Symptoms; cause
What is the #1 sign of a pars fracture?
Tender w/ PA pressures to spinous processes
Clinical presentation of trochanteric bursitis
Tender w/ palpation to superior/posterior greater trochanter, symptoms may radiate laterally or posteriorly down the thigh, resisted isometrics may be strong and painful or weak and painful (hip ABD, ER), walking, running, esp. stairs are painful, difficulty laying on the affected side, sleep may be affected
Etiology of GTPS
Tendons of the gluteus minimus, medius and maximus and TFL attach directly or indirectly to the greater trochanter, the vastus lateralis increases the tension on the ITB because of its attachment to the greater trochanter, with hip flexion, the TFL pulls the ITB forward over the GT and with hip extension, the gluteus maximus pulls the ITB backwards over the GT, eventually the gluteus medius will tear from the repetitive friction, tightness of the ITB compresses and inflames the gluteal bursa; overuse and tightness of muscles that attach to the GT, contact sport or traumas
What is traction?
Tensile force applied manually, with a machine, or using a patient's own body weight and the force of gravity
What is traction?
Tensile force is applied manually, with a machine, or using patient's own BW and the force of gravity
Surgical fusion procedure
The basic lumbar fusion is posterolateral, incision is made over the operative levels, and the paraspinals are separated off the SP, lamina, and TP, retractors hold back muscles to expose the bone for fusion, a high-speed burr removes the TP and facets in preparation for bone graft, pedicle screws and interbody cage are inserted
What is a cavitation?
The cracking sound during a manipulation
What are the two most important factors for predicting success with manipulation?
The duration of symptoms and the lack of symptoms distal to the knee
Mobility of the spine is determined by what?
The facets
Overall spine stability is provided by what?
The tightening of all muscles into the TL and abdominal fascia Contraction of the muscles between the layers of fascia (hydraulic effect) Contraction of the diaphragm and pelvic floor
What is the purpose of a myotome scan?
To see if the patient can generate a good contraction (are they weak or strong) Is there pain? If so, where?
What is the goal of a foraminotomy?
To take pressure off of the N root
What is the purpose of the dermatome scan?
To test for sensation of specific N roots and/or peripheral Ns
Causes of TJA failure
Wear of articular bearing surface, aseptic/mechanical loosening, osteolysis, infection, instability, per-prosthetic fracture, implant failure
What do patients want to know?
What is going on, how long will recovery take, how can they help themselves, what will the clinician do for them
Explain the stabilization classification.
Without any muscle activity, the lumbar spine is a highly unstable structure even under low loading Muscle force, including timing and balance of muscle activity, is therefore very important for maintaining stability Spinal stability and instability have more recently been proposed as etiologic mechanisms for patients with LBP Recent studies have focused on muscle performance instead of maximal force output These studies have indicated that endurance, balance, and neuromuscular control may be more important than maximum muscle strength for both prevention and rehabilitation
When in side lying, what direction do men and women side bend toward?
Women SB toward the opposite side they are lying on (curvature to same side) due to wider hips, men SB toward the same side they are lying on (curvature to opposite side) because they have wider shoulders
Diagnosis of Spondylolithesis
X-ray, MRI, Bone scan, increase symptoms w/ hyperextension (sometimes flexion as well), pain w/ pressure on spinous processes, Step Deformity
Examination of lumbar stenosis
X-ray, MRI, CT scan, bone scan, EMG, NCV
How is sacral displacement diagnosed?
X-ray, MRI, bone scan Increase in symptoms with hyperextension Pain with pressure on spinous processes Step deformity
Diagnostic imaging for labral tears
X-rays and MRI are often inconclusive for detecting intra-articular pathologies; gold standard - MRA
13. PTs used manipulation to...
a. Break adhesions in the folds of the joint capsule and restore normal joint mobility b. Bring tissue into the plastic range c. Restore normal arthrokinematics d. Nutrition of articular cartilage
3. Neurological symptoms will generally be described as?
a. Burning b. Stabbing c. Itching d. Shooting e. Tingling f. Numbing g. Electrical
12. If you have an increased reflex, what is it indicative of?
a. CNS (clonus or hyperrigidity)
53. The pudendal nerve can be damaged by what?
a. Cycling and child birth
8. Referred pain is most often ____ or _____
a. Dull or achy
90% of lumbar herniations occur @ ___-___ and ___-____
L4-L5, L5-S1
Laminectomy
Removal of lamina
What is the ligamentum flavum located between?
Lamina
Sequestration
Nuclear material came completely through
When can patients resume sexual relations?
Standard is 1-3 months
When should you refer to a surgeon?
The patient fails to respond to PT, joint injection does not provide relief, MRA
Can lateral stenosis be congenital?
Yes
Normal translation during flexion/extension
3-4.5 mm or 9-15% of vertebral body width
Q angle for males
14 degrees +/- 3
PCL is ____x as thick as the ACL (which is why it results in less injuries)
2
Describe the distal femur
2 WB condyles that are covered w/ articular cartilage, separated by the intercondylar notch (provides area for cruciate ligament to pass), trochlear groove (articulating surface w/ patella)
Rectus femoris is a _________ joint muscle and has a high % of type ____ fibers
2; II
The presence of at least ___ positive factors indicates a greater likelihood of responding to a stabilization intervention
3
Women are ____x more likely to have an ACL injury compared to men
3
Posterior surface of patella articulates w/ trochlear groove through facets ______,______, and ______
3, 5, 7
Minimally invasive incision length
3-4 inches
Minimal Detectable Change for ODI
4-6 points, 10-15 points
Acute trochanteric bursitis
Due to trauma (fall or blow to lateral hip), pain, swelling, and warmth w/ palpation, motion may be limited
Etiology of snapping hip syndrome
5% of the population (higher prevalence b/t 15-40 years old), occurs more in females, typically an overuse injury, occurs in activities that involve repetitive hip flexion and extension (such as dance, soccer, gymnastics, and running)
Normal hip drop
5-10 degrees
>_______ of all ACL ruptures have associated meniscal injuries
50
Frequency of spondylolysis
6% of adult population w/ LB pain, 47% of adolescent population w/ LB pain, 2x more common in males than females, pars interarticularis may not reach bony maturity until age 25
Often pain from musculoskeletal structures are described as what?
Dull and achy
Posterolateral rotary instability
A direct blow to the anteromedial knee with the tibia in external rotation, Often occurs with concomitant ligamentous injuries making it difficult to detect/diagnose, Joint line tenderness with swelling in the posterolateral corner, Common fibular nerve injuries occur up to 30% of the time, Episodes of knee buckling during the stance phase of gate or with pivoting movements, Some patients present with unpredictable giving way without provocation or simply when just standing
What is diastasis recti?
A gap between the two sides of the rectus abdominis (occurs after child birth; abdominal instability after childbirth)
Explain a grade 5 manipulation.
A high velocity, short amplitude force applied at end range
What are other variables important for predicting the outcome of stabilization treatment?
A history of previous episodes of LBP and hypermobility detected during segmental mobility testing
Explain a grade 4 mobilization.
A low velocity force (sustained or small amplitude) applied at end range
According to the Guide to PT Practice, what is a mobilization/manipulation?
A manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small amplitude, high velocity therapeutic movement
What is the largest bursa in the body? What is its purpose?
Iliopsoas bursa; reduces friction b/t anterior hip capsule and iliopsoas
*What are the absolute contraindications to exercise?
A recent significant change in the resting electrocardiogram (ECG) suggesting significant ischemia, recent myocardial infarction (within 2 days), or other acute cardiac event Unstable angina Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Suspected or known dissecting aneurysm Acute systemic infections, accompanied by fever, body aches, or swollen lymph glands
Care immediately after surgery
A suction drain may be used for 1-2 days after surgery, intravenous fluids & antibiotics, pain medication, compression stockings and blood thinners, hip precautions based on type of approach (may be kept for 6-8 weeks or longer, some surgeons leave precautions indefinitely)
The 2 most important factors for predicting success w/ manipulation are the _______ of symptoms and the lack of symptoms _____to the knee
Duration; distal
What is positional traction?
Patient is placed in a position which causes gaping of a facet joint, intervertebral foramen, or reduces pressure on a N root
Scour test
Move hip through ROM flexion/ADD and extension/ABD while adding compression, (+) test = reproduction of clicking or popping, if it hurts, then distraction should make it better
Why might the ligamentum flavum be removed or sparred?
Because it lies right behind the lamina and if the lamina is removed they may not be able to keep it
Peripheralizing
Not doing better
Why are endoscopic decompressive laminectomies performed?
Because of diminished diameter of the central canal
How will shoulder extension help support the TL fascia?
Because of the latissimus dorsi attaching to it
Why do they take the smallest amount of disc possible (microdiscectomy)?
Because the more of the disc you take away, the more the body mechanics change
Why is the nucleus more likely to push through the annular rings in flexion?
Because the rings are as thick posteriorly and this is the direction the nucleus moves during flexion
You can use an anterior approach for the interbody fusion. Why is this approach becoming more and more common?
Because there's less stuff in the way
Why should you ask the patient if their spine pain is relieved with bowel movements?
Because this would lead to you believe the issue is gastrointestinal in nature; you can't do much with this - refer out
ODI: If the patient's score is 80-100, what are their symptoms?
Bed bound or may be severely exaggerating symptoms
What should the frequency be during a traction treatment?
Not supported by evidence Some authors report daily
Frequency
Not supported by evidence, some authors report daily
Extension protocol
Begin in position of comfort (the way they came in the door but now supported in prone), slowly progress to extension w/ passive positioning (leave in positions for 5-10 minutes), progress to prone on elbows and prone press ups (slow), must do often at home and avoid all forms of flexion
Duration
Not supported by evidence, start w/ brief bout (5-10 minutes), relief of symptoms (leave same treatment time), partial relief (increased duration and/or frequency)
Examination of iliopsoas bursitis
Iliopsoas bursitis is often under diagnosed due to its unspecific symptoms, tenderness in femoral triangle, positive thomas test, active resistance of the iliopsoas is weak and/or painful
Describe internal snapping hip syndrome
Iliopsoas tendon snaps over the head of the femur, iliopectineal eminence or lesser trohanter
What might the individual feel or hear after a MCL injury?
Immediate pain or feel/hear "pop"
Classification category does not describe a _________________condition such as HNP
Pathoanatomical
All 4 ligaments of the knee are somewhat taut in what position?
All positions
What is the #1 intervention for poor proper?
Patient education
Subgroups
Acute LB pain with related referred symptoms Acute LB pain with radicular symptoms Subacute LB pain with referred symptoms Subacute LB pain with radicular symptoms Chronic LB pain with referred symptoms Chronic LB pain with radicular symptoms
McKenzie principles: Healing of a disc after injury results in ____.
Adaptive shortening (because it will heal with scar tissue, making the disc less flexible)
Prevalence of GTPS
Affects 10 to 25 % of the general population Higher prevalence in runners, women, and between ages 40 - 60
Par interarticularis may not reach bony maturity until when?
Age 25
Signs of cancer
Age >50, unexplained weight loss, previous hx of cancer, no relief w/ treatment in last month
Degenerative tears are due to _______ as well as activity levels (long-term ________ forces)
Age; compressive
Disc function
Aide in mobility, restricts mobility, annulus acts as ligament, provide space b/t vertebra, keeps IV foramen open, acts as shock absorber, normally - even distribution of forces throughout disc
Cognitive Behavioral Therapy (CBT)
Aims to address fears related to movement, pathology, and function
For most people snapping hip syndrome is simple an _________________, however it may result in pain and weakness
Annoyance
ACl is a primary restraint to what action? Secondary restraint to what action?
Anterior tibial subluxation; rotation in both directions
Where does the anterior sacroiliac ligament run?
Anterior side of the sacrum to the anterior side of the iliac crest Thick, multidirectional, stable (just not as much as the posterior SI ligament)
Where does the vastus lateralis come off of?
Anterior surface of GT
Reasons for PF pain w/o malalignment
Atraumatic PF OA, patella tendonitis, quadriceps tendonitis, IT band syndrome, prepatella bursitis, apophysitis (tendon attachment @ growth plate), bipartite patella (patella is split), oswood schlater's disease
What are the 2 most common types of ACL reconstruction?
Autografts (patella bone and hamstring) and allografts (no consensus on which provides the most stability)
Stabilization CPR: Criteria (for a positive finding) for straight leg raise ROM?
Average ROM > 90
Precautions at 1-3 weeks
Avoid deep trunk flexion, high-velocity movements, valsalva, prolonged sitting
For grades 1 and 2 step deformities, you should educate your patient to:
Avoid hyperextension Limit end range flexion especially with heavy loads Proper lifting, bending, sitting Often LS brace until healed
How can you rule out a stress fracture int he pelvis?
Patient is supine, SLR, then bend knee and flex more, sign of the buttock
Why is ligamentum flavum yellow?
Because it has more elastin in it (it gives more than other ligaments)
Sensory innervation of joint capsule of the knee
Branches of femoral, saphenous, tibial, obturator, and fibular
Risk factors for hip dysplasia
Breach birth, infant held in hip adduction and extension
McMurray's test (meniscus)
Bring patient into full end range knee flexion, ER - medial, IR - lateral and drop them down into extesion
Describe the MCL
Broadest structure of the medial aspect of knee, runs from adductor tubercle 3-4 cm below the crest of the tibial plateau, supercial + deep portions (deep portions have extensive attachment to meniscus and capsule, most taut w/ valgus force
Longitudinal (vertical) meniscal tears
Bucket handle tears (most likely to cause some type of catching or inability to get full knee extension or flexion), posterior horn or anterior horn tear
Clinical presentation of piriformis syndrome
Buttock pain that radiates to the posterior thigh and proximal lower leg . aggravated with prolonged sitting or walking, squatting, and positions that increase tension on the piriformis (hip adduction and IR) , pain decreases when lying down, bending the knee or when walking, knee flexion takes some tension off the nerve (not all patients can tolerate), isn't characterized by dermatome changes, myotome weakness, or diminished deep tendon reflexes, the patient may present with a limp when walking , knee flexed or when piriformis contracts it hurts , the patient may keep their leg in a shortened and externally rotated position while supine (splayfoot)
How does creep occur?
By spending a long time just hanging on ligaments
*What are signs and symptoms of spondylolysis?
Lower lumbosacral back pain and spasm May have associated referred pain into buttock or lower extremity Often increased lordosis (pain with extension) Tender with PA pressures to spinous processes
Grades of Recommendation - B
Moderate evidence, a single strong evidence study or level II study support
Apley's test (meniscus)
Can be most painful, so do it last! patient is prone, compression and IR/ER of lower leg
Progression of degeneration
Can begin in teens (breakdown of innermost annular rings), fissures b/t annular rings, fissures across annular rings, nucleus bulging through fissures, outer rings bulge, nucleus protrudes through (radicular symptoms if on nerve root), sequestration of nuclear material
Diagnostic procedures - MRI
Can diagnose ligamentous injuries w/ an accuracy of 95% or better, will also reveal any associated meniscal tears, chondral injuries, or bone bruises
Symptoms of meniscal tears
Can result in locking of the joint (especially "bucket-handle tears"), "popping and locking" occur when torn part of meniscus moves under the femoral condyle, medial or lateral line joint pain may occur due to abnormal increase in tension on the joint capsule
Levels of Evidence - 3
Case controlled studies or retrospective studies
Levels of Evidence - 4
Case studies
Ref flag conditions
Cauda Equina Syndrome, infection, spinal compression fractures, abdominal aneurysm
In the absence of ________ __________syndrome or significant neurological deficits, conservative care is advocated before recommending surgery
Cauda equina
Chronic trochanteric bursitis (more common)
Caused by overuse (esp. cycling, running, swimming), results from repetitive compression and friction
Most common type of TKA
Cemented fixation- ambulating day 1 or 2, Cobalt-chromium alloy femur articulating with polyethylene tibial surface, All-polyethylene patella, Posterior cruciate substitution (Not enough evidence to say whether keeping or removing PCL is best)
What are some other questionnaires used?
Cervical - neck disability index Upper extremity - DASH (disability arm, shoulder, and hand) Knee - KOOS (knee osteoarthritis outcome score) Shoulder - shoulder pain and disability index Foot and ankle - FAOS - foot and ankle outcome score
Effects of forward head posture
Cervical spine flexed, head on neck extended, all muscles of the subocciptal region are tight
What are interventions for postural syndrome?
Change posture Patient education
Intervention for posture syndrome
Change posture, patient education
Why do facets need injections?
Changes in the disc can lead to hypertrophy (as we age, discs get thinner and lose height, shock absorbing forces are transferred to the facets) Results in redirection of compressive loads to the posterior elements (Facet injections are a non-operative alternative)
What is snapping hip syndrome?
Characterized by a snapping sensation and/or audible "snap" or "click" in or around the hip when it is in motion
Pincer FAI
Characterized by bony growth on the superior-anterior aspect of the acetabulum, labrum is pinched b/t the prominent rim of the acetabulum and the superior-anterior head and/or neck of the femur
What is piriformis syndrome?
Characterized by buttock or hip pain , Neuritis of the sciatic nerve
MRA
More sensitive test for labral lesions than the standard MRI and would help rule out intra-articular injury prior to the more invasive arthroscopy
Nerve root can be ___________ irritated when in contact w/ nuclear material
Chemically
The articular surfaces of the sacroiliac joint are covered with interlocking ridges and depressions. The ridges and depression are smaller in what populations? They are larger and what populations?
Children and females (therefore there is more motion at the joint) Males and post menopausal females
What is the main cause of GTPS?
Chronic friction of the glute medius tendon over GT (glute min and TFL can also be affected - friction of these tendons leads to a secondary inflammation of the bursa)
As a child, hip joint relies heavily on the artery to the femoral head; Adults rely more on _______________ arteries
Circumflex
The annulus fibrosis has a ___________differentiation w/ nucleus when young
Clear
Patients w/ labral tears typically complain of what?
Clicking, locking, or catching
Pros/cons of metal ball w/ metal liner
Cobalt chromium alloy, more sizing options, allows for larger ball (more like natural joint, inc. ROM), fairly low wear rate, particles from wearing may cause inflammation, may perform better over long term, wear rate - 0.01 mm/year
Disability
Impact on daily life, activity might cause pain and therefore harm, results in no activity, disuse atrophy, diminished strength and endurance, depression, injury result in pain experience, pain catastrophizing, pain perceive as threat, anxiety over pain and threat of pain, need to avoid pain, disability due to fear of pain
What joint has the largest synovial capsule in the body?
Knee
LCL injuries may occur w/....?
Knee dislocation, distal IT band injury, popliteus rupture, posterolateral capsule injury, fibular nerve injury
According to the TN PT Practice Act, what are manual therapy techniques?
Consists of a broad group of passive interventions in which physical therapists use their hands to administer skilled movements designed to modulate pain, increase joint ROM; reduce or eliminate soft tissue swelling, inflammation or restriction; induce relaxation; improve contractile and noncontractile tissue extensibility; and improve pulmonary function; these interventions involve a variety of techniques, such as the application of graded forces
Red flags w/ LBP
Constant pain not affected by positions or activity, over 50, h/o CA, failure of conservative intervention over 30 days, unexplained weight loss, no relief w/ rest
MOI for anterolateral rotary instability
Contact/Non-Contact , hyperextension with varus and IR stress, IR of tibia or ER of femur
MOI for anteromedial rotary instability
Contact/Non-Contact, flexed knee and valgus stress, ER of tibia or IR of femur
Exercises for Spondylolithesis
Core strengthening w/ proper posterior tilt, strengthen abdominals and gluteals, tighter hamstrings will limit anterior tilt of pelvis (maybe not stretch?), proprioception exercises, fine control pelvic tilts, pelvic clocks, spine neutrals, short range exercises, isometrics
Anterior drawer test
Knee is flexed, foot is flat on table; (+) test = tibia excessively translated anteriorly, mushy, empty end feel
What is the most common place for spondylolisthesis to occur? Second most common?
L5, S1 L4, L5
What is the most common level for spondylolysis? More common in males or females?
L5, more common in males
The Oswestry Low Back Pain Disability Index (ODI) is specific to what?
LBP
What comes off the lateral epicondyle?
LCL, lateral head of gastroc
What structures work together to stabilize the knee by restraining varus forces, tibial external rotation and posterior rotation?
LCL, popliteus tendon, popliteofibular ligament
Children who never properly WB are much more likely to __________hips (CP)
Dislocate
What hip pathology is more common middle age?
Labral tear
Over time, FAI can result in what?
Labral tears and articular cartilage breakdown
Precautions for posterior approach
Do not flex hip greater than 90 degrees, do not IR the hip beyond neutral, do not ADD past neutral
In a pincer FAI, what is the first structure to be effected?
Labrum (repetitive impact results in degeneration of labrum w/ bone spur formation on acetabular rim)
Precautions for anterior approach
Don't extend hip past neutral, no lying prone, do not ER or extend hip, do not perform bridging
When are patients admitted to hospital before THA?
Morning of surgery
Pain after TKA
Most common complaint and mostly felt in whole knee, also behind patella, may affect sleep
Acute MOI for labral tear
Most commonly from a slipping or twisting injury w/ catching-type groin pain
Do most people tend to have tibial antiversion or retroversion?
Most have retroversion because femur is rotated in (tibia is rotated out)
Contraindication for surgery
Lack of clear diagnosis, anatomic level of lesion or radiographic evidence; no attempt at non-operative treatment, medication contraindications (major comorbidities, unfavorable survival)
What are contraindications for surgery?
Lack of clear diagnosis, anatomic level of lesion, or radiographic evidence No attempt at non-operative treatment Medical contraindications (i.e., major comorbidities, unfavorable survival)
Discectomies are often done with what other surgeries?
Laminectomy or laminotomy (they see lots of things going on and really try to decompress that area)
General toddler posture
Large lumbar lordosis, stand and ambulate with wide BOS, hold furniture, initially frequent falls, foot arches flat, genu varum
Describe the lumbar vertebra: Small or large vertebral body? Size of spinal canal and why? Size of spinous processes?
Large vertebral body Narrower spinal canal for cauda equina Short, stout sp
Dislocation is _________99% of the time
Lateral
Interventions for Grades 3 and 4 Spondylolithesis
Spinal orthosis, often require surgery (if radicualr symptoms are present), realignment and fusion
What can cause lateral patellar compression syndrome?
Lateral tilted patella, hypomobility of patella, loss of patella mobility, excessive tightness of lateral retinaculum including distal attachment of IT band, atrophy of VMO (reflex inhibition)
Squat/sit-to-stand observations
Deep squat has evidence of validity in FAI, decreased WB on involved side
What are the key stability muscles of the spine?
Deep transversospinalis (multifidus and rotatores) Abdominals; especially transverse abdominis, quadratus lumborum
What is a directional preference?
Defined as a situation when movements in one direction improve pain and the limitation of ROM but may not centralize symptoms
The Roland-Morris Questionnaire is specific to what part of the body?
Spine
If an individual spends long periods of time at end range then the ligaments engaged in the elastic zone will have a plastic response - what is this called?
Creep
Typical MOI for ACL injury is what time of movement?
Cut-and-plant movement or a sudden change in speed w/ the foot firmly planted
Paget's disease (osteitis deformans)
Deformation of bone due to re-absorption and formation of bone leading to a cycle of softening and thickening, deformity of vertebra leads to central or lateral stenosis or both, most common in older adults, congenital condition
Where does each layer of the TL fascia attach? Posterior: Middle: Anterior:
Spinous processes Transverse processes Transverse processes
Paget's disease is caused by osteitis deformans. What is osteitis deformans?
Deformation of the mother freaking bone due to reabsorption and formation of bone leading to a bitch ass cycle of softening and thickening
A traumatic meniscal tear is more likely to require surgery than a _________tear
Degenerative
McKenzie principles: Increase or decrease in lumbar ROM further influences poor posture?
Decrease
What is the primary objective of an education session?
Decrease unnecessary fear
Vascular claudication
Decreased circulation results in: antalgic gait, paresthesia, cramping of muscles in one or both LE w/ activities such as walking; might get referred to a Doppler; more common in older adults
________portions of the MCL have extensive attachment to the meniscus and capsule
Deep
What is the clinical prediction rule (CPR)?
Designed to assist in the classification process and improve decision making by using evidence to determine treatment strategies most likely to benefit patient w/ particular characteristics; multiple factors from a hx and exam to predict a priori which patients will most likely benefit from manipulation
What is the purpose of a clinical prediction rule (CPR)?
Designed to assist in the classification process and improve decision making by using evidence to determine treatment strategies most likely to benefit patient with particular characteristics
Motions w/ males ______________@ puberty
Diminish
Both genders have __________motion w/ age
Diminished
Elderly
Diminished strength of spine extensors, degenerative disc and joint disease, posture becomes more flexed, forward head, increased thoracic kyphosis, flattened lumbar lordosis, may ambulate with flexed hips and knees, wider BOS, less energy efficient
MOI for PCL
Direct blow to front of tibia w/ knee flexed (most common), also forced hyperextension, can result from car accident in which posterior force is applied to tibia when the flexed knee hits dashboard
What is a hip pointer?
Direct blow to the hip, lateral femoral cutaneous nerve (sensation to anterior lateral thigh), is compressed and could cause transient sensory changes
MOI of action for ACL injuries
Direct contact - 30% of cases Indirection contact - 70% of cases
MOI of quad contusion
Direct impact to muscle
What is a hip pointer?
Direct trauma to iliac crest
Some patients will not centralize symptoms w/ movement, but do display a ________________preference
Directional
Posture w/ bulging disc
Disc occupies space and blocks extension, causing patient to flex
Which decompression surgery is the gold standard for HNP?
Discectomy
What are the different types of decompression surgeries for lumbar HNP?
Discectomy Laminotomy Laminectomy Foraminotomy (you're trying to take the pressure off of the disc with these)
Types of decompression surgeries
Discectomy, laminotomy, laminectomy, foraminotomy
Posterior lumbar laminectomy
Due to diminished diameter of central canal cause by ligamentum flavum hypertrophy, facet hypertrophy, disc degeneration
How does a quad strain occur?
Due to eccentric contraction or repetitive overloading during activity
MOI for MCL
Mostly occur after an impact on the outside of knee; w/ foot fixated to the ground, combined movement of flexion/valgus/tibial ER will place excessive tension on MCL
Pregnant females have more _________than other females
Motion
High-speed activities (such as cutting or landing maneuvers) require ___________muscle action of the quads to resist further flexion
Eccentric
Desired effects of traction on soft tissue
Elongation of spine increases the distance between vertebral bodies and facet joint surfaces to increase the length of soft tissue/ligaments, stretch occurs slowly
Fear Avoidance Beliefs (FAB) are derived from...
Emotionally based fears of pain and injury, information based beliefs about soundness of the spine, cause of spine degeneration, importance of pain
Levels of Evidence - 2
Lesser quality diagnostic studies, prospective studies, or randomized control studies (weaker diagnostic criteria, reference standards, improper randomization)
What musculature is tight with hypomobile individuals?
Erector spinae, hamstrings, iliopsoas, rectus femoris
Disadvantages of Unicompartmental arthroplasty
Error in proper placement of components, loosening, prosthetic wear, secondary degeneration of opposite compartment
From inferior to superior, if the muscle goes into the spinous processes, what will it do?
Extend, SB toward, rotate away
From inferior to superior, if the muscle goes into the transverse processes, what will it do?
Extend, SB toward, rotate toward
Increased lumbar lordosis, lumbar spine is ___________________
Extended
What is FAI?
Extra bone causes abnormal contact and prevents the joints from moving smoothly during activity
Adolescents w/ anterior groin pain and (+) impingement tests have a 50% chance of ________
FAI
Foot and ankle
FAOS, foot and ankle outcome score
Clinical presentation of internal snapping hip syndrome
Gradual onset, usually not associated w/ a traumatic event, may describe a painful sensation coming from deep within the anterior groin as the leg moves from flexion into extension or ER, snapping movement can produce an auditory clunk or click
ALIF alone can't withstand the forces across the ______, so many collapse or don't fuse
Grafts (protected w/ posterior instrumentation)
Where does the iliopsoas attach to?
Lesser trochanter
Spondylolisthesis occurs due to what?
Spondylolysis (pars fracture) or elongated pars interarticularis
Affective avoiders
Fearful and highly distressed, distorted significance of pain and condition of spine, will not attempt activities that might trigger pain, severely disabled, PTs need to address dysfunctional thinking, gradual exposure to fear activities
*The risk with cervical manipulation goes up greatly when what is part of the manipulation? Especially in what region of the spine?
Rotation Upper cervical
An increase in the neutral zone requires what?
Greater muscle performance (strength, endurance, proprioception)
The posterior femoral cutaneous N comes off of the sacral plexus, through the ____, and under the ____.
Greater sciatic foramen Piriformis
When positioning patient on the table, increased flexion (to 90 degrees) causes what?
Greater separation of posterior structures
CAM leads to _________between the 2 surfaces
Grinding
For anterior labral tear, pain can occur where?
Groin (92%), anterior thigh (52%), labral hip (59%), buttock (38%)
Dermatome scan: L1: L2: L3: L4: L5: S1: S2: S3-S5:
Groin, inguinal ligament Mid-anterior thigh Medial knee Lateral knee to the medial malleolus Lateral lower leg to dorsum of the foot Lateral heel, lateral calf, and lateral posterior thigh Medial calf and medial posterior thigh Perianal area
Adolescent
Growing into their body, gain more control, improve balance and efficiency of movements, maturing of connective tissue
What muscle group would you want to strengthen to prevent an ACL tear?
Hamstrings (prevent anterior translation)
The elastic zone is provided by what?
Hanging on ligaments and tight musculature, facet joint capsules, disc
Pros/cons of ceramic ball w/ polyethylene liner
Harder than metal, don't scratch very much, less wear means less inflammations/bone loss, more expensive, in past ceramics were brittle and cracked, wear rate - 0.05 mm/year
Outcome measure for THA
Harris hip score, FIM, Oxford hip score, WOMAC, SF-12, 12-item hip questionnaire, VAS, overall satisfaction
Secondary restraint
Has some significant function in resisting displacement but isn't the major restraint, ex: MCL - primary restraint to valgus force, but secondary restraint if you take it far enough
How can you tell the difference between neurogenic and vascular claudication?
Have patient ride a bike, sit up nice and straight, then ride bike again in a flexed forward position (if it is better flexed forward, it is probably neurogenic) - can also perform on a treadmill (walk on incline)
What is a test you can do to determine whether the claudication is neurogenic or vascular?
Have patient ride a bike, sit up straight, time how long they last till they have leg symptoms, take a break, do it again but flexed forward this time, time it again - it should take longer for the symptoms to appear when flexed if it's neurogenic claudication; with vascular claudication, the symptoms will occur just as fast as they did before (can also perform this test on a treadmill - start them on an incline and patient will naturally flex)
What are questions you should ask about the patient's past medical history?
Have you ever had these symptoms before? Any past history of significant illness, injury, surgery? Cancer, DM, heart disease? Injury? Where? When? Any to the same body part? Surgery? What was done? When?
Slipped capital femoral epiphysis
Head separates from the neck, usually seen in obese adolescent males
Mensci lose _____ and _____over time
Height, water
Acute management of quad strain
If knee is left in ext the healing process will be slower and more painful b/c the quad will start to heal in a shortened position; knee should be flexed to avoid potential ms spasms, reduce hemorrhage, and minimize the risk of developing myositis ossificans
Facet orientation
Helps protect disc from excessive rotary forces; more rotation available when spine is in flexion
Is taping beneficial? How do you perform taping?
Helps stimulate afferents; put ms in a slightly stretched position, origin to insertion (tends to come off in 24-48 hours)
What does a lateral approach alter?
Hip ABD, which can result in weakness and may result in prolonged limping
What is known to predispose someone to labral tears?
Hip dysplasia (coxa valgus)
What can cause LE malaligment?
Hip excessive antiversion, excessive tibial torsion, excessive foot pronation (flat feet causing tibia to rotate medially)
All hip ligaments are taut w/ _____________
Hip extension
Lateral pivot shift test
Hip flexed to 90, IR lower leg, drop patient down into extension
Telescoping hip
Hip is flexed to 90 degrees, PT grasps lower leg and pulls hip anteriorly, feeling for excessive movement
DD of trochanteric bursitis
Hip pointer, ITBS, snapping hip syndrome, gluteus medius tendinopathy, meralgia paraesthetica
3 most common fractures in those w/ osteoporosis
Hip, colles, vertebral body
The use of traction dates back to _____________
Hippocrates
Ortolani's sign and Barlow's test
Hips flexed, abducted and externaly rotated, you feel a click
McKenzie Method
History, examination, classification into syndromes, interventions based on syndrome, emphasized self treatment, therapists job is to guide treatment, patient education is emphasized, minimal hands-on treatment
The interbody cage (interbody graft) is made of what?
Hollow cylinders made of titanium, carbon, or bone and filled with autogenous bone graft or a bone graft substitute and inserted between the bodies
Interbody cage
Hollow cylinders made of titanium, carbon, or bone filled w/ autogenous bone graft or a bone graft substitute and inserted b/t the bodies
Abdominals, spine extensors, diaphragm and pelvis floor muscles make the trunk a semi-rigid cylinder and tighten the TL fascia and abdominal fascia - what is this effect called?
Hydraulic effect
Mechanism of injury of pars fracture
Hyperextension of the lumbar spine resulting in a repetitive loading of the facet joint and pars interarticularis; pars interarticularis may be congenitally thinner or not completely formed
As you age, your collagen tends to bind together and you become _____________; you lose ______, tissues become more brittle
Hypomobile; GAGS
Grade II strain (moderate)
Identified by a sudden "pop", about 50% of fibers torn, symptoms are acute pain, swelling, and a mild loss of function, gait will be impaired, pain w/ palpation or resisted knee flexion, could feel a breach in tendon
Example of Step Deformity (EXAM)
If L5 vertebral body is anterior on S1, then L4 may feel more anterior (as L5 vertebral body slides anteriorly, the posterior arch and spinous process stays attached to S1), L4 feels deep b/c L4 has migrated anteriorly w/ L5 vertebral body (if L4 feels deep, then L5 is the problem)
What are signs and symptoms of grades 3 and 4 sacral displacement?
In addition to low back pain, there may be radicular signs into lower extremity related to traction on lumbosacral N roots Pain, paresthesia, numbness, muscle weakness Radicular signs may be unilateral or bilateral (Much more serious)
Grade III Sprain
Ligament fibers are completely torn, there is pain during initial injury but then it subsides, tenderness may be present, lots of swelling, hemarthrosis may occur within 1-2 hour, feels unstable or gives out at certain times, rotational instability, end feel is empty
Explain TA and MF contraction prior to movement regarding patients with and without LBP.
In people without LBP, transverse abdominis and multifidus contract prior to extremity movement to stabilize the spine in preparation of movement; however, in patients with LBP, there is a delay in the onset of these muscles
Slump test
In sitting, bring their leg out and hold it there, have them slump down
Etiology of hamstring strain
In the late swing phase, hamstrings are at their greatest length at this moment and generate max tension (contract eccentrically to decelerate flexion of the hip and ext of lower leg), strong hamstring contraction and quad relaxation is needed (lack of coordination results in hamstring tear)
Grade II Sprain
Ligament fibers are partially torn w/ hemorrhaging, little tenderness and moderate swelling, joint may feel unstable or give out during activity, increased joint laxity yet there is still firm end point
What are some causes of patellofemoral pain w/ malalignment?
Inc. Q angle, lateral patellar compression syndrome, inadequate medial stabilizers, patella alta (too high), patella baja (too low), dysplastic femoral trochlea (if it is more shallow it can jump out of the groove)
How do cardiovascular exercises work?
Inc. blood flow and oxygenation, memory improves, focus and concentration improves, mood if affected, deeper breathing engages diaphragm and dec. accessory muscle activation
Use of an operating microscope
Inc. magnification and illumination, limits amt of tissue damage by working through a small exposure, minimizes blood loss and risk for infection, dec. length of stay in the hospital
Weeks 1-3 following Lumbar Microdiscectomy
Inc. walking tolerance to 30 min w/o pain, no symptoms in LE, wound protection and complete closure, pain management PRN
The basic lumbar fusion is posterolateral. Describe this procedure.
Incision is made over the operative level(s) and the paraspinals are separated off the SP, lamina, and TP Retractors hold back the muscles to expose the bone for fusion A high-speed burr removes the TP and facets in preparation for the bone graft Pedicle screws and interbody cage are inserted
Pre op exercise?
Inconclusive studies, improvement w/ pre-op function but not in immediate post op recovery, decrease LOS, or complications
Prevalence of LBP and costs of treatment and lost work productivity continues to ___________
Increase
Cons of minimally-invasive THA
Increased complications, smaller visual field/surgeon learning curve, skin integrity (greater risk for skin tears, infection), why fix what isn't broken?
What are the benefits of soft tissue stretching?
Increased spinal ROM/joint mobility Decreased pressure on facet joints, discs, and N roots Increased proprioceptive input
Stretching should be slow and progressive. If rapid loading occurs, what happens? If too slow loading occurs, what happens?
Increased stiffness (you will activate muscle spindles, thus increasing tone which causes stiffness) Ligament deformation
Days 1-6 following Lumbar Microdiscectomy
Initiate walking 1-3x per day as tolerated, become independent w/ bed mobility (sit to stand and toileting day 2), discharge from hospital 12-48 hours post op, protection of wound, limit bending and lifting, pain management, walking progression 5-10 minutes on level surface w/ minimal AD
What are possible screen findings in hypomobile patients?
Limited mobility one or more planes of motion Limited mobility one or more segments May be hypermobile at others Most common to be hypomobile in lower lumbar May be hypomobile in other regions such as hips
What are the different types of traction?
Intermittent Static/sustained Bed traction Manual Positional
*What muscles attach into the the TL fascia?
Internal oblique Transverse abdominis Latissimus dorsi
*What direction should you stretch the patient with a dysfunction?
Into the direction of the limitation
DD of snapping hip syndrome
Intra-articular hip disorders, trochanteric bursitis, iliopsoas bursitis, IT band syndrome
Describe reaming of the femoral canal
Intramedullary reaming (manually, robotically) rasp (sands down rough edges, used to size femur to accept the stem)
Pre-op for lumbar microdiscectomy
Introduction of neutral spine positioning and TA contractions, education on nature of surgical procedure, expected outcomes/timelines, precautions/contraindications, bending/lifting strategies, neutral spine/pelvic
How do you know if the treatment was successful?
Is the alignment corrected? Is there symmetry of motion? Relief of pain? If there is any relief, why did you get relief?
Accessory motion testing through the hip
It can be difficult to replicate accessory motions in the hip manually, common to use a mobilization belt when performing lateral glide
McKenzie principles: If the patient can't extend, then what has happened with the nucleus?
It has moved through rings and blocked motion (this is why the patient comes in flexed)
What does it mean if you extend the patients back and the local back pain goes away?
It is already centralized
What is the purpose of the small metal tube insertion?
It serves as a passage for the surgical tools so muscles aren't cut, in contrast to an open discectomy
What makes a classification system effective?
It should improve clinical decision making and ultimately result in outcomes superior to the one-fits-all approach (Delitto and colleagues were the first to propose a treatment-based classification)
Patients with neurogenic claudication tend to stand in a flexed position. Why?
It takes pressure off of the N root; leads to overworking erectors eccentrically
What would happen if your disc started to pancake? What causes the pancake?
It would decrease the diameter of the IV foramen or spinal canal; if the height of the IV foramen shortens, the facet joints can hypertrophy and cause shortening back to front Not as much water, the disc gets flatter, bulges all the way around if it pancakes (this is what happened in the older adult)
Injections treat the symptoms, not the cause. Explain.
Just because the pain is gone, the cause isn't; patients still need to change their lifestyle
List some knee outcome measures
KOOS (knee disability and OA outcome scor), LE functional scale (FEFS), 6 minute walk test, TUG, VAS
Hamstring strains commonly occur w/ what action?
Kicking or running
Bone contusions (microtrabecular fractures)
May occur due to pressure on the knee w/ trauma, unlikely to significantly reduce function
How does static traction cause muscle relaxation?
May result in depression of monosynaptic response through prolonged stretch
Centralization was originally described by _______________ as occurring during lumbar movement testing when the patient reports the pain moves from an area more distal or lateral to a location more central or near midline position
McKenzie
Documentation should be applicable to goal setting. What three things should the goals have?
Measureable Functional Time element
The Oswestry Low Back Pain Disability Index (ODI) is a condition specific questionnaire. Describe it.
Measures patients perceived level of disability Takes 5 min 10 questions with 6 answers per each question Each answer is assigned a value (0-5) and you multiply each value by 2 for a percentage score
Explain the derangement syndrome.
Mechanical deformation caused by internal derangement (disc)
Dysfunction syndrome
Mechanical deformation of soft tissue affect by adaptive shortening; results in loss of movement; pain w/ stress on shortened structures; intermittent pain; dec. ROM; name for the DIRECTION OF THE LOSS OF RANGE (typically extension)
Explain the postural syndrome.
Mechanical deformation of soft tissue results in postural stress (take on finger, bend it back a little bit - no big deal, bend it back until it hurts, would you like to hold it here for hours? probably not; this is what's happening when you sit with bad posture - you're going to hurt after a while) Intermittent pain brought on by certain postures Symptoms are relieved with change in posture (when you brought your finger back, didn't it stop hurting?)
Nerve root signs
Mechanical pressure of disc compressing nerve root, chemical irritation of nuclear material on nerve root
____________compartment of the knee is more likely to get osteoarthritic problems
Medial
_______femoral condyle goes down farther distally, therefore it wears out sooner
Medial
If you fracture the femoral neck, what could be damaged?
Medial and lateral circumflex arteries, obturator artery
Where does the medial and lateral head of the gastroc originate?
Medial and lateral femoral condyles
Medial or lateral meniscus injury is more common?
Medial because it is attached to the MCL and is less mobile
The ______compartment is more likely to wear out, why?
Medial, less meniscus coverage over the tibia
What are non-operative treatments?
Medications (analgesics, NSAIDs) Epidural/facet steroid injections (usually 3 max) Modified activity (don't ask the patient to stop, change their mechanics first) Bracing (for the acute patient, short term) Physical therapy
Who indicated the least satisfaction after surgery?
Men and those requiring revision
Etiology of meniscal tears
Meniscal tears are either due to an excessive force applied to a 'normal' meniscus or a normal force acting on a degenerative meniscus, most common MOI is a twisting motion on a semi-flexed knee in weight bearing, may also be associated with other ligamentous injuries, typically the ACL and the MCL
What are the 4 basic categories used for patients w/ acute LBP?
Mobilizaation/manipulation, stabilization, specific exercise, traction
What interventions can be used for SIJ issues?
Modalities to calm inflammation of SIJ capsule and ligaments, local muscle attachments Attempt to correct pelvic asymmetry Correct asymmetry of position of sacrum between iliums Manual techniques: manual therapy of pelvic innominate, muscle energy techniques to effect pelvic innominate position, thrust techniques
Differential diagnosis for FAI and labral tears
Muscle strain, contusion/hip pointer, dislocation or subluxation, osteitis pubis, trochanteric bursitis, stress fracture, infection, AVN, referred lumbosacral pain, cancer
Quad strains typically occur where?
Muscle-tendon junction (distally to proximally and sometimes muscle belly itself)
W/o any ____________activity the lumbar spine is a highly unstable structure even under low loading
Muscular
Is the posterior femoral cutaneous N a branch from the femoral N?
NO
What is stenosis?
Narrowing of the spinal canal or intervertebral foramen
*Who SHOULD NOT be manipulated?
Near unhealed fractures RA Pregnancy Osteoporosis Hypermobility of affected joints Unstable joints Unknown cause of symptoms Women who are breastfeeding (because they are still secreting the hormone that makes their ligaments lax) Long term corticosteroid use Down syndrome (they patients have ligament laxity in the C spine and can sometimes have early unknown osteoporosis of the dens)
FABs of patients and health care providers have a ____________influence on LBP outcomes
Negative
What are the two types of claudication?
Neurogenic and vascular
Interventions for acute LBP w/ coordination deficits
Neuromuscular reeducation exercises, possible external supports to prevent end ranges, patient education (posture control, maintain lifestyle)
Interventions for subacute LBP w/ coordination exercises
Neuromuscular reeducation, Manual , Exercise strength & endurance, Self acre training in mid range, Pain management
Is lumbar traction as effective when large herniations fill the spinal canal?
No (think central herniations)
Is intermittent or static traction better?
No conclusive evidence to support one method being superior
Bed traction
No longer use, very low-load (9-10 lbs), prolonged stretch (hours to days), costly for hospitals to have patient lie in bed (secondary complications)
Does touching your toes tell you if you have tight hamstrings?
No; look at the patient's sacrum when they flex
Quad strains are typically a ____-contact injury
Non
Patient w/ severe pain and neuro deficits that are not relieved w/ changes in position are ________manual therapy candidates
Not
How long do non-constrained knee replacements last?
Not as long as other knee replacements
A combination of ACL, medial meniscus, and MCL is called what?
O'Donohue's or Terrible Triad
Interventions for Grades 1 and 2 Spondylolithesis
Patient education to avoid hyperextension, limit end range flexion (esp. w/ heavy loads), proper lifting, bending, sitting, often LS brace
Chondral injury
Occurs at the time of impact, chondral degradation is common years after an ACL injury
What are some components of a post-op treatment program for the lumbar spine?
Patient education, exercise (spinal stabilization, strength, ROM, aquatic therapy, and cardiovascular), walking program, manual therapy, neural tissue mobilization, modalities
Examination of snapping hip syndrome
Patient hx - location of snap, timing of snap, duration of inset, pain and disability w/ activities Palpation - greater trochanter and the lateral border of glute max Observation - gait abnormalities, have pt demonstrate the snap Tests - ROM, MMT, muscle length Screen - lumbar spine and knee
Single episode of patellofemoral subluxation/dislocation
Often associated w/ trauma, described as "pop" w/ dislocation and a second "pop" w/ relocation (w/ ext), high incidence of underlying misalignment
What is the intervention for spondylolisthesis with the fracture? What about once it's healed?
Often brace in neutral, avoid end ranges especially in extension and rotation Trunk strengthening, endurance, proprioception exercises
LQS findings
Often stands w/ reduced lumbar lordosis (more flexion), observe for atrophy or hypertrophy, limited AROM, overpressure only if no peripheral symptoms w/ AROM, perform dermatome and myotome scan, reflexes, gait (you will shorten stride on affected side due to tensioning on nerve), heel walking, toe walking, squat test, may or may not have a lumbar muscle spasm
Who does manipulations?
Osteopaths (and a few MDs) Chiropractors PTs
What are key contraindications for an artificial disc replacement?
Osteoporosis or osteopenia Scoliosis (disc won't stay in place - these patients will do better with a fusion) Instability
Contraindications for artificial disc replacement
Osteoporosis or osteopenia, scoliosis, instabilty
Examination of the low back
Outcome measures, measurements of lumbar ROM, centralization and peripheralization of symptoms, instability tests, straight leg test, slump test, trunk strengthening and endurance tests, fear avoidance questionnaire, pain assessment questionnaire
Total joint replacement is one of the most commonly performed and successful operations in orthopedics as defined by clinical_______________ and ____________survivorship
Outcomes; implant
Describe the medial meniscus
Oval or "C" shaped, wider posteriorly, attach to deep portion of the MCL, semimembranosis attaches to posterior horn
What can cause inadequate medial stabilization?
Overstretched retinaculum, under functioning VMO
In a patient specific questionnaire you can make up your own. Give an example.
Patient is asked to select 5 main activities affected by back pain Rate the ability 0-10 scale 15 minutes (Good if patients do something unusual)
What are some examples of passive mobility testing?
PA glides, PIVMs
Examples of joint mobs to lumbar spine
PA glides, side bending, rotation, combination of all 3
If you are suspecting a ligamentous injury, what do you always want to check first?
PCL
Management of quad strains
PRICE, taping for pain, proprioception, maybe swelling, gentle soft tissue mobs, IASTM, dry needling, quad setting, terminal knee ext in supine or standing, concentric/eccentric, manual, or theraband knee ext, standing hip flexion flutters w/ theraband, isometric wall sits, closed chain exercises, squats (2 or 1 leg), lunges, set ups, step downs (eccentric)
A highly irritable patient is ___ dominate. A moderately irritable patient is ___ dominate. A stiffness irritable patient is ___ dominate.
Pain Combination of pain and stiffness Stiffness
*What is referred pain?
Pain from a lesion in one location that is experienced by the patient in another location
Rehab
Pain management, control of joint effusion, knee ROM, normalize gait mechanics, flexibility of LE mm, foot alignment (orthotics or proper exercises), hip ABD and ER strength/control
Acute LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ initial or mid range of active or passive movements
Subacute LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ mid range or end range active or passive movements
Chronic LBP w/ movement coordination impairments and acute LBP w/ radiating pain
Pain occurs w/ sustained end range movements
Typical S&Ss of an adolescent athlete w/ a pars fracture
Pain w/ extension and palpation - need to have imaging performed
S&Ss of quad contusion
Pain, loss of function, decreased ROM, decreased strength, effusion
Clinical presentation of iliopsoas bursitis
Pain/tenderness is felt anteromedial aspect of the thigh, may have snapping sensation form front of hip, pain when passively going from extremes of flexion to extension and vice versa, pain worse w/ activity (esp walking or crossing legs), rest can relieve pain
Clinical findings for a posterior impingement
Painful ER in full extension w/ leg hanging off the end of table and uninvolved leg flexed
What is trochanteric bursitis?
Painful and inflamed trochanteric bursa (in b/t greater trochanter and tendon of TFL), component of greater trochanteric pain syndrome, commonly results from friction of overlying IT band
Examination of LCL injury
Palpation could reveal tenderness over the posterolateral knee, no significant joint effusion (unless there is also a cruciate ligament or meniscal injury), varus stress test at 30 degrees of flexion
Examination of trochanteric bursitis
Palpation is the most provocative clinical test, Ober's test, MRI provides the most sensitive image
What attaches to the tibial tuberosity?
Patellar tendon
Excessive antiversion
Patellas are facing medially, compensate w/ hip deep ERs (piriformis syndrome), risk for femoral acetabular impingement, associated w/ ACL injuries
Elaborate on the correlation between acute or chronic LBP in patients who have difficulty performing ADLs and patients who are able to perform ADLs.
Patients who have difficulty with basic ADLs and have increased levels of self-reported pain and disability may be considered acute (it doesn't matter if their symptoms have been present for weeks, months, or even years) Patients who are able to perform ADLs and have lower levels of pain and disability, but experience difficulties with more demanding activities such as sports or occupational duties may be considered to have chronic LBP
Condition specific HQRL questionnaires are good for what population?
Patients with a specific condition (i.e., LBP)
Outcome measures are an attempt to measure a person's Health Related Quality of Life (HQRL). What categories fall under HQRL?
Physical Emotional Psychological Social
SF-36 (Generic)
Physical and mental components score, subgroups - general health, physical functioning, role functioning, bodily pain, mental health, emotional functioning, vitality, social functioning
FABs result in...
Physical inactivity, reduced mental well being, assumption of sick roll, deterioration of family dynamics, dependence on medications, excessive utilization of medical services
Health Related Quality of Life (HRQL)
Physical, emotional, psychological, social
What type of patient education should be performed prior to surgery?
Post op pain management, position restrictions, ambulation, rehabilitation progression
Buttock pain is associated w/ ____________labral tears and lumbar spine problems
Posterior
Which way does the nucleus move during each motion? Flexion: Extension: SB: Rotation:
Posterior Anterior Opposite side Every other annular ring tightens and compresses nucleus
Biomechanics of the ACL
Primary restraint for anterior tibial translation, orientation of fibers also plays a role in high rate of injury
Interventions for weeks 1-3
Prone press-ups to tolerance from slight flexion to neutral, prolonged prone ext 30 seconds to 2 minutes w/ pillow/cushion under stomach, treadmill w/ an initial goal of 5 minutes (progression to 30 minutes), aquatic therapy (once cleared by MD), cryotherapy post-therapy and prn for pain, review bed mobility, sit to sand, utilization of UE, LE nerve glides, TA activations, gluteal/hip strengthening
__________________ is key in order for muscles to control within this range (neutral zone)
Proprioception
Long sitting test
Pt is lying in supine, check leg length, check ASISs, have patient sit up and check leg length again; if ASIS is down, acetabulum would be down and leg could appear longer, leg length should correct itself when patient sits up
Sacral compression
Pt is prone, PT applies a downward pressure to the superior portion of the sacrum and then the inferior portion of the sacrum
Anterior and posterior rotation
Pt is side lying, PT grasps the subjects ASIS w/ one hand and ischial tuberosity w/ the other and applies an anterior and posterior rotatory force
Knee to opposite shoulder
Pt is supine, PT brings one knee towards the subjects opposite shoulder
Compression
Pt is supine, PT crossed their arms and pushes the ASISs away from the midline
What is the patella held in place by?
Quadriceps mechanism (patella tendon and ligament)
Discectomy and implantation of artificial disc
Removal of damaged disc, determination of correct implant size, verify size, correct placement and alignment by AP and lateral fluoroscopy and x-rays, insertion of endplates in the disc space followed by insertion of sliding core, final verification of the position of the implant
What are the goals and advantages of artificial disc replacements?
Replicate normal disc and joint biomechanics Reduce the forces transmitted to adjacent segments Improve disc height while maintaining structural integrity
Goals and advantages of artificial disc replacement
Replicate normal disc and joint biomechanics, reduce the forces transmitted to adjacent segments, improve disc height while maintaining structural integrity
What are the goals of osteopaths when manipulating?
Restoring normal range and quality of movement Break mechanical adhesions Stimulate proprioceptors to restore afferent and efferent balance Move synovial fluid - restore viscosity Improve local circulation and drainage Psychological - firm confident therapeutic touch
Etiology of secondary piriformis syndrome
Results from macrotrauma, microtrauma, muscle spasms, and ischemic mass effect (hematoma), microtrauma may result from overuse during running or sports with repetitive hip rotation, i.e. tennis, SI joint pathology, "Wallet neuritis", Excessive hip adduction and internal rotation occurs during weight-bearing due to a weak gluteus maximus and/or gluteus medius (eccentrically contracting), this shifts a greater eccentric load to the piriformis muscle, perpetual loading of the piriformis through overlengthening and eccentric demand results in sciatic nerve compression or irritation
Benefits of good posture
Results in minimized abnormal forces on the body and energy efficiency of static and dynamic activities
If your left hip ABDuctors are weak, you will drop to the ___________side
Right
Describe the LCL
Round cord like tissue, runs from lateral epicondyle area just above the groove for the popliteal tendon distally to attach on fibular head b/t tendons of biceps femoris, does NOT attach to meniscus or capsule, most taut w/ varus force
Examination of piriformis syndrome
Rule out lumbar spine, tender to palpation deep to gluteus maximus , pain and/or weakness with resisted hip abduction and external rotation, symptoms with the piriformis in a stretch position, Lasèque sign/Straight Leg Raise Test, positive for SLR will most likely be between 35-70 degrees, repetitive clamshells could cause symptoms
ROM exercises/stretches
SKC, DKC, piriformis stretch, lower trunk rotations, hip flexor stretches, pelvic tilts
What are some example of hip ABD exercises?
SL hip ABD, SL wall slides, SL hip lifts, side plank variations, step outs w/ or w/o theraband, hip hikes on stool, runner's pivot
It is important to ask the patient about bowel and bladder changes. Where should you look for pain and/or numbness regarding this?
Saddle numbness, rectal, genital region (think cauda equina syndrome)
What is joint distraction?
Separation of 2 articular surfaces, reduces compression on the joint surfaces and widens the intervertebral foramen
What are the desired effects of joint distraction?
Separation of joint surfaces Increased joint mobility Increased proprioception may contribute to pain modulation (Gate theory) Nourish articular cartilage
What are the desired effects of joint distraction?
Separation of joint surfaces (OA, menisci, osteochondral fragments, portions of capsule that "catch" or impinge joints), increase joint mobility, increase proprioception (may contribute to pain modulation), nourish articular cartilage
Diastasis Pubic Symphasis
Separation of pubic symphysis, can occur w/ trauma, repetitive stress or postpartum
What is diastasis of the pubic symphysis?
Separation of the pubic symphysis
What is joint distraction?
Separation to two articular surfaces
The ODI is more sensitive (better) for which patients?
Severely disabled patients
What is the acetabular component made of?
Shell is made of metal, plastic liner (load bearing, fits snugly inside shell)
Lateral lurch
Shifts weight toward the weak or painful side
Indications for lumbar fusion
Significant trauma, degenerative disc or joint disease, hypermobility (spondylolithesis), severe, disabling back and/or leg
Primary restraint
Signifies the structure that is the major restraint to movement, ex: ACL - primary restraint to anterior translation of tibia
Best results based on ________and not anatomical structures, as it is impossible to be sure what anatomical structures are causing pain
Signs and symptoms
Outcomes of artificial disc replacement
Similar to lumbar fusion w/ respect to functional outcomes and pain relief, further research needed to determine if disc replacement reduces rate of adjacent segment disease compared with fusions, disc replacement products are being developed for lateral or posterior approaches
What are artificial disc replacement outcomes?
Similar to those of a lumbar fusion with respect to functional outcomes and pain relief Further research is needed to determine if the disc replacement reduces rate of adjacent segment disease compared with fusions (Disc replacement products are being developed for lateral or posterior approaches)
Patella baja
Sits low and is associated w/ diminished ROM esp. flexion and OA of PF joint
Patella alta
Sits too high and is associated w/ subluxation/dislocation, OA of PF joint, and patella ligament ruptures
McKenzie Principles
Sitting causes lumbar spine to flex, stressing ligaments, and increasing disc pressure; dec. in lumbar ROM further influences poor posture; healing of a disc after injury results in adaptive shortening
Order the tissues from superficial to deep when feeling for tp in the lumbar region:
Skin Fat TL fascia Erector spinae (very tendinous here) Multifidus TL fascia (other side) Transverse process
Try to figure out what tissue caused the symptoms. What tissues cause symptoms?
Skin, fat, bone, ligament, tendon, disc, muscle, nerve, blood vessels (Can each of these tissues be individually assessed? Palpated or tensioned?)
Grade I strain (mild)
Small % (<20) of fibers are damaged, rarely influences the muscle's power and endurance, pain and sensitivity usually happen the day after the injury, C/O stiffness and minimal swelling on the back of leg, ROM minimally impaired and gait may be normal
Classification category is intended to direct clinician to a ________ ______ of management
Specific type
Central stenosis involves narrowing of what? Lateral stenosis involves narrowing of what?
Spinal canal IV foramen
What is the intervention for grades 3 and 4 step deformities?
Spinal orthosis (patients need to be in this) Often require surgery, especially those with radicular signs Realignment and fusion
What positions put the most pressure on the discs?
Standing flexion w/ weights and sitting in forward flexion
Apply harness in ___________ or lying. Loops should maintain a __________pull
Standing; posterior
What are the types of clinical tests used for assessing SIJ?
Static tests Motion detection tests Provocation tests *see lab notes
What makes of the femoral components?
Stem (made of metal - usually titanium), head (made of either cobalt chrome or ceramic)
_________and________ are the the most prevalent early complaints
Stiffness & pain
How does intermittent traction cause muscle relaxation?
Stimulation of mechanoreceptors through oscillations - stimulates the GTO which leads to muscle relaxation and spasm reduction Gate control theory of pain modulation
Intermittent traction
Stimulation of mechanoreceptors through oscillations - stimulates the GTO which leads to muscle relaxation and spasm reductions (Gate Control Theory); brief intervals; "on/off" cycles; distraction, mobilization, stretching
Tests for sciatic nerve
Straight leg test, sciatic LLTT, slump test, stealth slump test
Explain the two schools of thought (straights and mixers) with chiropractors.
Straights (old schools) believe that all disease can be treated with manipulation. Most everyone can and should have regular manipulation treatments to maintain normal health. Mixers use manipulations to treat musculoskeletal pain due to hypomobility, muscle spasm, correct alignment, and to relieve pressures on nerves.
Spondylolysis often begins as what? Often caused by what?
Stress fracture Hyperextension trauma
Derangement dysfunction intervention
Stretch into direction that causes centralization, avoid direction of peripheralization, after disc healing stretch into the direction of limitation, patient education
Grades of Recommendation - A
Strong evidence, supported by level I studies
Inc. in technology (MRI, bone scans, US, etc) have allowed for precise _____________ assessment
Structural
Support for the McKenzie Method
Studies by Nachemson and Anderson showed changes in pressure w/ the IV disc w/ changes in posture; numerous studies have looked at reliability of method and others at effectiveness; effective for acute discs (not so much for degenerative discs)
Describe an overview of the anterior fusion surgical procedure.
Subcutaneous tissue and rectus abdominis are retracted Done with a retroperitoneal approach An anterior discectomy and bone graft are done The external oblique, internal oblique, and transverse abdominis are divided
Anterior interbody fusion procedure
Subcutaneous tissue and rectus abdominis are retracted, done w/ retroperitoneal approach, an anterior discectomy and bone graft are done, EO, IO, and TrA are divided, neurovascular and visceral structures are moved out of the way (genitofemoral nerve, psoas muscle, aorta and vena cava, sympathetic chain, iliac vessels)
*Explain what happens in the spine during extension. To the vertebra? To the facets? IV foramen? Ligaments?
Superior vertebra tips and glides posteriorly on the inferior vertebra Inferior facet of superior vertebra slides inferior and posterior on superior facet of the inferior vertebra IV foramen closes ALL taut; PLL, interspinous, supraspinous, and ligamentum flavum all slack
CPR for manipulation
Symptoms less than 16 days; at least 1 hypomobile segment; at least 1 hip w/ less than 35 degrees of motion; no symptoms distal to the knee; less than 19 points on FABQ
T/F: In degenerative meniscal tears, the patient may not have a "click" upon examination since tears are often multiple frays rather than large tears
T
What 2 muscles attach to IT band?
TFL and glute max
Arthroscopic debridement
Tear of the labrum is only part of the pathology, labrum may be a source of the pain, debridement of the labrum w/o addressing the reason for impingement will lead to poor surgical outcome
Galeazzi sign
Test for infant hip dislocation, infant is supine w/ feet together on flat surface, femur will appear short on side of dislocation (femoral head is posterior to acetabulum)
Thomas test
Tests for tightness of hip flexors
*Explain the difference between the anterior and posterior annular rings.
The annular rings aren't thicker anteriorly; they are thinner and less complete posteriorly
Prevalence in lumbar pain
The lifetime prevalence of at least 1 episode of LBP is as high as 80% Some individuals recover without intervention or recovery can be delayed Up to 60% of those who do recover are prone to recurrence Increases in technology (i.e., MRI, bone scans, ultrasound, etc.) have allowed for precise structural assessment Despite these advances, the prevalence of LBP and costs of treatment and lost work productivity continues to increase
The lateral femoral cutaneous N can become impinged under what?
The inguinal ligament (called meralgia paresthetica); this can occur from wearing really tight underwear - causes a loss of sensory to the lateral side of the leg because the underwear is compressing the N
Global lumbar musculature
The large lumbar erector spinae provide most of extensor force needed for lifting; rotation is a complex movement that requires co-contraction of several ms groups (erector spinae, transversospinalis, obliques); ms groups do not have a direct attachment to the lumbar spine and can't control the motion of individual segments
The common fibular N travels along the lateral popliteal fossa and wraps around what? What does it divide into?
The neck of the fibula Superficial and deep fibular Ns
What questions should you ask patients regarding their posture?
What does their job require? Do they sit most of the day? Do they stand most of the day? Do they walk most of the day? What leisure activities do they do? Does it require lifting, bending, and twisting? How often do they change their posture? How often do they reverse their posture?
What are things you should ask the patient concerning their history?
What is the chief complaint? Signs and symptoms Pain - where? (back, neck, LE, UE) What kind of pain? (sharp, dull, shooting) Paresthesia? Where?
What is the #1 most important piece of information to know about patient after hip surgery?
What is their WB status
Are you better off with a vertical or transverse patella fracture?
Vertical b/c quad contracts and holds it together
*What are symptoms of radicular pain?
The patient may experience pain, paresthesia, muscle weakness, and/or diminished reflexes (can have combinations)
What are proprioception exercises important? What are some exercises?
The patient needs to learn the feel of where the limits are on their movements and be able to limit them during sports activities Fine control pelvic tilts Pelvic clocks
To stabilize the interbody fusion, where do the screws go through?
The pedicles
Osteopaths initially believed in the Rule of the Artery. What is this?
The philosophy that relief will occurs after a manipulation due to release of pressure on blood supply to N roots
Before the McKenzie method, there were the Williams flexion exercises in the 1930s. Explain.
The purpose was to open the foramen to relieve N root compression Lordosis was bad Promote flattened lordosis postures Brace into flexion Bed rest
Chiropractors believe in the Law of the Nerve. Explain.
The relationship between nerves, muscles, joint, and general health; if the vertebra is subluxed (partial dislocation), it can affect N and blood vessels at the IV foramen - impaired N function leads to disease
What are the two key questions to ask your patient?
What makes your symptoms better? What makes your symptoms worse? (Think activities or positions; gives you the best idea on where to start)
Explain why the spinal canal gets smaller as it goes down.
The spinal cord ends around T12-L1 so all that is in the canal at this point is the cauda equina
In central stenosis, narrowing of the spinal canal effects what?
The spinal cords or cauda equina
What is the reason for the anterior displacement in spondylolisthesis?
The vertebra are no longer attached posteriorly The sacral angle creates an anterior shear Supporting ligaments and the annular rings will slowly stretch out and allow one vertebral body to "slide" anteriorly on the one below (creep)
Who are the most susceptible athletes to spondylolysis?
Those who do frequent end range lumbar spine hyperextension: Linemen in football (at impact, their neck is in extension) Gymnasts Swimming and diving Wrestling Volleyball (going for a spike and they crank back with neck) Cheerleaders Weightlifters (overhead movements with weight can overload the facets)
What type of patients are good candidates for artificial disc replacement?
Those who suffer from degenerative disc disease Those with single level disease Those who have had failed conservative treatment
The obturator N travels through what and into what?
Through the obturator foramen and into the obturator canal
The sural N has contributions from what two Ns?
Tibial and common fibular N
Above the popliteal region, the sciatic N splits into what two Ns?
Tibial and common fibular Ns (happens around the popliteal fossa)
Condylar TKA
Tibial component is topped w/ a flat metal piece that securely holds the polyethylene insert, when knee is in motion, the femoral component glides over the polyethylene, natural shape of condyle is not a perfect circle
What are your supinator muscles of the foot (inverters)?
Tibialis anterior and posterior
What 2 joints make up the knee?
Tibiofemoral joint and patellofemoral joint
A hypomobile individual typically presents with the following:
Tight muscles, tight joints, flattened lumbar lordosis, spine flexion, feet more supinated, overall limited mobility in most joints
What is the first goal with stenosis patients? Then what?
To get them out of the acute phase; then make this less likely to happen in the future (patient education; if you ever get a twinge of symptoms down the leg again, that's a sign that you need to start doing exercises again: i.e., hold pelvic tilt while walking)
What is normal mobility of the lumbar spine?
Translation during flexion and extension 3-4.5 mm or 9-15% of vertebral body width sliding on the vertebral body below (just know there is a fairly small amount of translation) Rotation 15-25 degrees
Medical management of GTPS
Trochanteric bursectomy, IT band release, reduction-osteotomy of GT, glute med tendon repair, corticosteroid injections, platelet rich plasma injections
McKenzie principles: T/F Healing scar is inelastic and must be mobilized early to regain mobility.
True
T/F An experienced therapist will have a very good idea of what the problem is from the interview. They will then use the physical exam to either support or refute their diagnosis.
True
T/F An increase in the neutral zone requires greater muscle performance (strength, endurance, proprioception).
True
T/F Anterior interbody fusion (ALIF) uses the same principles of disc excision and interbody bone grafting. ALIF alone can't withstand the forces across the grafts, so many collapse or don't fuse. ALIF is protected with posterior instrumentation.
True
T/F Both genders have diminished motion at the SI joint as they age.
True
T/F Exercise routines involving repeated into end-range spinal motion have been popularized over the year. There is emerging evidence to support the classification of some patients as likely to respond to these specific exercise routines.
True
T/F Flynn et al developed a CPR consisting of multiple factors from a history and exam to predict ahead of time which patients will most likely benefit from manipulation. The results of their study identified a set of 5 criteria that accurately identified patients most likely to benefit from manipulation.
True
T/F Foraminotomies allow for more room laterally for the interforaminal space.
True
T/F It is possible that a patient with chronic low back pain hasn't healed yet because they aren't stabilizing themselves properly due to lack of contraction/strength/endurance of transverse abdominis and multifidus.
True
T/F Most patients with LBP are given a meaningless diagnosis such as lumbar strain or lumbar pain. These patients are often viewed as a homogenous group, equally likely to respond to any particular treatment.
True
T/F Most techniques used at any joints as grade 4 can be converted to grade 5.
True
T/F Outcome measures are based on the opinion of effectiveness from the patient perspective.
True
T/F PTs traditionally measure impairment (anatomical abnormality or loss) like ROM, strength, etc. This may not relate to the patient's disability (lack of ability to perform a task). This is why it's important to look at the patient's perspective.
True
T/F Questionnaires can be used to establish a goal for change. You should document these changes in the chart.
True
T/F Risks with other treatments include NSAIDS and vigorous exercise.
True
T/F Sitting causes the lumbar spine to flex, stressing ligaments, and increasing disc pressure.
True
T/F Some feel that the risk may be close to zero if there is no rotation and the manipulation is not done in upper cervical.
True
T/F The McKenzie method emphasizes self-treatment/exercises. It is the therapist's job to guide the treatment. Patient education should be emphasized. There is minimal hands on treatment.
True
T/F The N root can become chemically irritated when in contact with nuclear material.
True
T/F The best results occur with the combination of manipulation/mobilization and exercise.
True
T/F The superficial muscles are best for general movement. The deep muscles are best for stability. Both superficial and deep will be involved when maximal effort is needed.
True
Manual traction
Typically applied b/t 15-60 seconds, can be static or intermittent, monitor patient's reaction, can't control force exactly
Muscle energy techniques
Use bodies muscles to reposition bones; if pelvic innominate is posteriorly rotated what muscle do we have to rotate it back anteriorly?, if anterior, what muscle to rotate back posteriorly?
Uni space implant
Used for isolated medial tibiofemoral OA, metallic spacer that distracts the medial compartment and transfers load to lateral side, meant to replicate shape of medial meniscus, doesn't require bone cuts or component fixation, results in good relief of pain, minimally invasive, higher rate of implant failure due to medial overhang
Elongation of the spine increased the distance between what?
Vertebral bodies and facet joint surfaces to increase the length of soft tissue/ligaments
What should you look at regarding the patient's history when working with SIJ patient?
What what the cause? Trauma? (fall, lifting injury, MVA) Unknown etiology ? Symptoms in LB and/or buttock pain Muscle spasm in LB and/or gluteals Sensory changes - not common
When you do typically get central LBP?
When the outer rings bulge because they are innervated
Explain how to tell if patient's hamstrings are tight by looking at the sacrum.
When the patient bends foward, look at the sacrum to see if it flattens out; if it does, hamstring flexibility is fine, if it doesn't and it stays more vertical, their hammys are tight (the sacrum and the pelvis move together, which is why you look at the hamstrings; the hamstrings attach to the pelvis via the ischial tuberosity)
What is a discectomy?
When they take out a portion of the disc
What are things you should ask the patient regarding the MOI?
When? How? (lifting, twisting, falling) Unknown How has symptoms changed over time? Peripheralized or centralized? Under what circumstances? (i.e., when they are tying their shoe, picking up their child from the ground, etc., it causes symptoms)
Can you have stenosis at more than one level?
Yes
Can US diagnose a hamstring strain?
Yes, relatively cheap and has the ability to image muscles dynamically
If you had no obturator N, could you still adduct your hip?
Yes, your medial hamstring and part of your pectineus would do it, however, it would be weak
What happens if a disc bulges through the PLL?
You will get bilateral symptoms (cauda equina)
Disc herniations are most commonly seen in what population?
Young adults
5. Musculoskeletal symptoms will generally be described as?
a. Aching b. Dull c. Sore d. Stabbing (esp when acute) e. Sharp (esp when acute)
4. If a person is found to overall be hypomobile in the lumbar region, the individual may stand in a increased or decreased lumbar lordosis?
a. Decreased
27. What are the muscles involved with stability of the spine?
a. Deep transversospinalis (multifidus and rotatories) b. Abdominal, especially transverse abdominus and quadratus lumborum
8. A pt with lumbar spine hypomobility may have especially tight musculature where?
a. Erector spinae b. Hamstrings c. Iliopsoas d. Rectus Femoris
17. What muscles are between the posterior and middle layer of the thoracolumbar fascia?
a. Erector spinae and transversospinalis (in lumbar = multifidus)
9. What happens with the annular rings and nucleus during rotation?
a. Every other annular ring tightens up and compresses the nucleus.
23. What are all of the spine extensions?
a. Exerector spinae, transversospinalis, quadratus lumbroum
21. If a muscle inserts into a spinous process, what movement does it do?
a. Extension, rotate away, side bend towards
22. If a muscle inserts into a transverse process, what movement does it do?
a. Extension, rotate toward, side bend toward.
20. What muscles attach to the abdominal fascia?
a. External, internal obliques and transverse abdominis.
1. What structures are generally found to be tight with lumbar spine hypomobility?
a. Facets/joint capsules b. Ligaments c. Muscles
19. What are some common reasons for manipulations being underutilized by PTs?
a. Fear of possible complications including i. cauda equine syndrome (1-100 million) ii. cervical brain stem lesions iii. Vertebral artery injury (3-6 per 10 million) iv. Risk of death with spinal surgery (300x greater w/ very high risk for infection)
6. Non-musculoskeletal signs and symptoms can include?
a. Fever, chills, night sweats, nausea, vomiting, unexplained weight loss, bilateral symptoms of paresthesia, shortness of breath, excessive sweating, visual changes, skin lesions, GI changes, B&B (bowel and bladder) changes, menstrual cycle changes
44. The superficial fibular nerve provides motor where?
a. Fibularis longus and fibularis brevis
10. Why is exercising for lumbar hypomobility is important?
a. For pain: Rocking rhythmic movements b. To warm tissue c. To increase mobility d. To increase strength, endurance and stability into a new range e. To maintain improvements over time
3. What is the common mechanism of injury for the Cervical spine?
a. Forward head with tilt or twist or trauma, especially while in that forward head posture position.
12. The lumbar region pain can be referred from?
a. GI b. Kidneys c. Bladder d. Uterus/ovaries e. Prostate/testicles
12. Superficial spinal muscles are best for _________ while deep muscles are best for ______.
a. General movement b. Stability
16. How do you test the posterior right quadrant?
a. Have the pt reach back and try to slide their hand down the back of their leg.
22. What are the other risks with cervical manipulation?
a. Headaches b. Muscle soreness c. Fatigue
11. Thoracic spine and rib pain can be referred from?
a. Heart b. Stomach c. Kidney d. Gall bladder e. Appendix
1. A High velocity thrust or manipulation involves a _____ velocity and _____ amplitude.
a. High velocity, low amplitude
6. A grade 5 manipulation is a ______ velocity force with a ______ amplitude applied at ______ (mid/end) range.
a. High velocity, short amplitude, end range
4. What are some individuals that you do not want to apply a manipulation to?
a. Hypermobile individuals
10. Explain the lower extremity resisted isometrics to test each of the spinal segments.
a. L1-2: Hip flexion (iliopsoas) b. L3-4: Knee extension (quads) c. L4-5: Ankle dorsiflexion (tibialis anterior) d. L5: Great toe extension (EHL) e. S1: Ankle plantar flexion (gastric/soleus, also hip extension and knee flexion) f. S2: Hip extensions, knee flexors g. Walk on toes (S1), walk on heels (L4-5)
17. Explain the lower extremity dermatome scan for each of the spinal segments
a. L1: Groin, inguinal ligament b. L2: Mid-anterior thigh c. L3: Medial knee d. L4: Lateral knee to medial malleolus e. L5: Lateral lower leg to dorsum of foot f. S1: Lateral heel, lateral calf and lateral posterior thigh g. S2: Medial calf and medial posterior thigh h. S3-5: Perianal area
24. What are the nerve roots for the obturator nerve?
a. L2, L3 and L4
18. Femoral nerve branches off what nerve roots?
a. L2/L3/L4
3. Lumbar hypomobility screening findings may include
a. Limited mobility to one or more planes of motion b. Limited mobility with one or more segments c. Hypermobility at other segments d. Most commonly found to be hypomobile in lower lumbar e. May be hypomobile in regions such as the hips
5. A grade 4 manipulation is a ______ velocity force with a ______ amplitude applied at ______ (mid/end) range.
a. Low velocity, sustained/small amplitude, end range
10. Cervical pain can refer from?
a. Lung b. Liver c. Heart (usually into the left shoulder/jaw)
3. A high velocity skilled movement done at a velocity hat a patient cannot resist is called a?
a. Manipulation
39. When the tibial nerve runs posterior to the medial malleolus, it becomes what nerves?
a. Medial and lateral plantar nerves
23. What is it called when the lateral femoral cutaneous nerve becomes impinged under the inguinal ligament?
a. Meralgia paraesthetica
9. What are some interventions to do with patients who have lumbar spine hypomobility?
a. Modalities as needed (warm tissue stretches are better) b. Joint mobilization/manipulation c. Muscle stretching d. Strengthen muscles into the new range
27. What are the muscles innervated by the obturator nerve?
a. Obturator externus, adductor longus, adductor brevis, adductor magnus (& tibal nerve), pectineus (along with femoral nerve)
8. If you have a weak and painful result from a patient during a resisted isometric test, what might be going on?
a. Severe inflammation of the contractile unit or partial tear.
4. If trying to feel a lumbar TP, what tissues do you have to feel from superficial to deep?
a. Skin, fat, thoracolumbar fascia, erector spinae, a very thick multifidus, otherside of thoracolumbar fascia and then finally, the transverse process.
12. What are the 2 schools of thoughts for chiropractors and what do they entail?
a. Straights: i. All disease can be treated with manipulation. Most everyone can and should have regular manipulation treatments to maintain normal health b. Mixers: i. Used to treat ms pain due to hypomobility, muscle spasm, correct alignment and relieve pressure on the nerves
11. Explain the spine biomechanics that occur during flexion.
a. Superior vertebra tips forward and glides anteriorly on the inferior vertebra b. Inferior facet of superior vertebra slides superior and anterior on superior facet of inferior vertebra c. IV foramen opens d. ALL slacks e. PLL, interpsinous, supraspinous and ligamentum flavum all become taut
37. The tibial nerve sends a branch to the _______ nerve which provides sensory where?
a. Sural nerve which provides sensory to the plantar surface of the heel
2. What is radicular pain?
a. Symptoms that are caused by nerve root lesion irritation (dermatome type pattern) or symptoms that are perceived along the distribution of the nerve root.
3. The actual spinal cord ends at what spinal levels and then turns into the cauda equine?
a. T12 or L1
59. The motor component of medial plantar nerve innervates what muscles?
a. The abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, first lumbrical
9. If a patient has a strong and painful resisted isometric test, what structures are involved?
a. The contractile units.
52. What does the pudendal nerve innervate?
a. The external genitals, sphincters of bladder and rectum, pelvic floor muscles and erection
7. Lumbar spine biomechanics allow what movements to occur? What do the facets mainly restrict?
a. The facets allow for most free motion to occur in flexion and extension. Less free in side bending. b. Most restricted: Rotation, especially in extension (closed pack). Some rotation occurs while spine is in flexion.
10. Chiropractors believe in the law of the nerve which is what?
a. The relationship between nerves, muscles, joints and general health
6. How might a persons feet look who has lumbar hypomobility?
a. They are likely supinated.
5. How might a person who is hypomobile in the lumbar segments sit?
a. They may sit in spine flexion
1. ALL is thicker or thinner in the lumbar vertebrae compared to cervical?
a. Thicker
10. Annular rings are _______ (thicker/thinner) anteriorly and ________ (thicker/thinner) posteriorly.
a. Thicker anteriorly, thinner or less complete posteriorly.
34. Above the popliteal region, the sciatic nerve is divided into what nerves?
a. Tibial and common fibular
46. The deep fibular nerve provides motor where?
a. Tibialis anterior, EHL, EDL, fibularis tertius
4. Emotional symptoms will generally be described as?
a. Tiring b. Agonizing c. Dreadful d. Unbearable
19. Transversospinalis go from where on the spine to where?
a. Transverse process up to the spinous process.
16. The anterior and middle thoracolumbar fascia insertions attach where on the spine?
a. Transverse process.
25. What are the spine rotators?
a. Transversospinalis and abdominals
55. The genitofemoral nerve supplies sensory where?
a. Upper anterior thigh and anterior scrotum or mons pubis and labia majora
26. If you were to rotate the spine to the right, explain what muscles would be working and what the vertebral body and spinous process are doing.
a. Vertebral body goes right b. Spinous process goes left c. Right erector spinae, left transversospinalis, left external oblique, right internal oblique.
