Study Guide MSK Exam 2
How can you rule in hip OA with a physical exam when looking at pain stiffness?
+ Hip pain - physical exam Pain on IR Morning stifness <60 *Age >50 years
How can you rule in hip OA with a physical exam?
+ Hip pain - physical exam, measured in PROM Hip IR < 15 degrees Hip flexion < 115 degrees
Red flags to watch for in pregnancy:
- DVT/ blood clot (increased risk due to changes in blood flow) - blood glucose crisis - fracture (rare, transient osteoporosis )- preterm labor symptoms
Cam
- Femur impingement (Men) - Gets pinched or compressed during Flexion or IRsome patients have both
What is the treatment and gold standard for diagnosing athletic pubalgia?
- Imaging - MRI - relative rest - PT - surgery - 2-6 months recovery
According to a 2013 Cochrane Review, does exercise help pregnant women?
- exercise tailored to the individual significantly reduced pain but a generic exercise program did not - a multimodal intervention program including MT + exercise seems effective in relieving pain and improving function
What are the characteristics of transient osteoporosis of the hip and osteonecrosis of the femoral head?
- extreme waddling gait - pain is deep in groin - pain is not position dependent - extreme loss of AROM - treating hip pain for several weeks and no improvement
What is the two-stage treadmill test?
- have pt who has LSS to walk on a level treadmill at a self selected pace - ask them when their symptoms come on - start your stop watch and see how long it takes them to recover - then you make them do the incline
Resting joint position
- maximum joint play - evaluation and treatment position utilized with hypomobile joints
Factors favoring manipulation:
- more recent onset of symptoms (< 16 days) - hypomobility with spring test - LBP only (no symptoms below the knee)- low FABQw scores < 19
iliopsoas
- most important hip flexor - only flexor that flexes past 90 degrees
transient osteoporosis of the hip
- occurs during the 3rd trimester - pain and limitation of ROM of the hip accompanied by radiographi signs of unilateral or bilateral osteoporosis of the hip with preservation of joint space - continued unprotected weight bearing can result in a fracture of the femoral neck
What is the bicycle test?
- patient pedals with the spine in extension - cycle until buttock pain , thigh pain, or tingling - patient instructed to continue pedaling while leaning forward into lumbar flexion
What is a "+" test?
- pts have earlier onset of symptoms and prolonged recovery while walking on level treadmill - + test longer walking time with incline (very specific for lumbar spinal stenosis as well as neurogenic claudication)
If pain radiates down the leg into the foot and radiculopathy is suspected, what should also be seen?
- strength loss in a myotomal pattern - sensation loss in a dermatomal pattern - decrease or absence of associated DTR (deep tendon reflex/ muscle stretch reflex)
Factors against manipulation:
- symptoms below the knee - increasing episode frequency - peripheralization with motion testing - no pain with spring testing
Loose-packed position
-articulating surfaces are maximally separated - joints exhibit greatest amount of joint play - position used for both traction and joint mobilization
What are some symptoms associated with a patient having a back-related spinal infection
1. LBP, flank or pelvic pain 2. local tenderness over spinal process with percussion (tapping or pressing on spinous process) 3. concurrent infection or drug use 4. fever
What are the four most useful clinical features of a spinal compression fracture?
1. major trauma 2. pain and tenderness 3. age > 50 4. female
What are some symptoms associated with a patient having a spinal compression fracture? (the first 4 are the most useful)
1. major trauma (fall, MVA, etc.) 2. > 50 years old 3. female 4. a lot of pain and tenderness in region of fracture 5. prolonged use of corticosteroids6. increased pain with weight bearing
What are some clinical presentations for a patient with abdominal aortic aneurysm (AAA)?
1. midline lower thoracic/lumbar pain (can be asymptomatic) 2. palpable pulsating abdominal mass 3. pain = throbbing/pulsating or ripping/tearing sensation in back 4. unable to find comfortable position 5. history of smoking 6. positive family history 7. history of AAA or other vascular atherosclerotic disorders
What are some clinical presentations associated with ankylosing spondylitis?
1. morning stiffness > 30 minutes 2. stiffness can be improved with exercise 3. nigh pain during second half of the night ONLY 4. alternating buttock pain
What are the 2 rare, but serious, potential diagnoses of a pregnant woman with hip pain?
1. transient osteoporosis of the hip 2. osteonecrosis of the femoral head
What are some symptoms associated with a patient presenting cauda equina syndrome?
1. urinary retention (really good for ruling out) 2. saddle anesthesia 3. neurologic deficits from L4-S1 (motor/sensory deficits)
What is the average angle of inclination?
126 degrees
What is normal femur neck anteversion?
15 degrees
How long should anticoagulations be taken after surgery?
28-35 days
What percentage of the 1st and 2nd layers of the pelvic floor are slow twitch?
30%
What percentage of the 1st and 2nd layers of the pelvic floor are fast twitch?
70%
What % of LBP is unknown? Why is this? What did this make Waddel come up with?
85% - LBP is an illness influenced by multiple factors - Biopsychosocial model
According to research by Childs, which of the following has been shown to be most effective in decreasing a patient's ODQ score? A. manipulation when positive on rule B. manipulation when negative on rule C. exercise when positive on rule D. exercise when negative on rule
A
Which is correct? A. All centralizers have a directional preference B. All directional preferencers have centralization
A
Which of the following symptoms does not suggest a GI system disorder? A. pain relieved by repeated lumbar extension B. difficulty walking C. abdominal disttension D. heart burn and indigestion
A.pain relieved by repeatd lumbar extension
What is the average angle of torsion for adults and infants?
Adults: 10-20 degrees Infants: 40 degrees
According to Vibe's research, which is more effective at decreasing ODQ scores and pain intensity over the period of a week? A. current best manual therapy and home exercise program B. cognitive behavior therapy aimed at changing lifestyle behaviors maladaptive to the patient's disorder
B
What is the potential referral region for gallbaldder disease/ cholecytitis? A. left lower abdomen and left low back B. right upper abdomen and right mid back C. L5 dermatomal pattern D. central coccygeal region
B
Cauda Equina Syndrome is considered a lesion or injury of which system? A. UMN B. LMN C. cervicogenic neuronal system D. lumbar neuronal system
B.Lower Motor Neuron
What are insufficiency fractures?
Breaks in abnormal bone under normal force
You are examining a 28-year-old female with hip pain and activity limitations. When examining the hip region in the frontal plane, which best describes the change from childhood to adulthood. A Increasing retroversion as we age B Increasing angle of inclination as we age C. Decreasing angle of inclination as we age D. None of the above
C. Decreasing angle of inclination as we age
You are examining a 13 y/o male with gradual onset of right hip pain after baseball practice. He is moderately obese and has decreased stance time on the right secondary to pain. Hip ROM shows limited hip IR and abduction. What is the most likely diagnosis?Multiple Choice A. Avascular necrosis (AVN) B. Rheumatoid Arthritis C. Slipped Capital Femoral Epiphysis (SCFE) D. All of the above are equally likely
C. Slipped Capital Femoral Epiphysis (SCFE)
You are examining an older adult with low back and leg pain that increases with walking and improves with sitting. You believe this is due to lumbar spinal stenosis. What term describes this type of leg pain in this population? A Vascular claudication B Deep Vein Thrombosis C. Neurogenic claudication D None of the above
C.Neurogenic claudication
pulmonary embolism
Clot travels through venous system and then lodges into one of the arterials in the lung Causes 15% of deaths after hip fracture surgery
In an individual with acute LBP each of the following factors is predictive of a positive response to lumbar spine manipulation except: A. pain less than 16 days B. lumbar spine stiffness C. low fear avoidance beliefs about work D. pain below the knee
D
Which of the following is considered an inflammatory arthritic condition? A. spinal cord tumor B. radiculopathy C. osteomyelitis D. ankylosing spondylitis
D
You have a patient with a 3-year history of low back pain and you are concerned about depression. Which of the below questions if answered yes would most suggest major depression?Multiple Choice A. During the past month I have not been bothered by feeling down, depressed or hopeless? B. During the past month have you often been bothered by little interest or pleasure in doing things? C. Is this feeling something with which you would like help? D. Answers B & C together
D. Answers B & C together
Which of the following factor(s) influence spinal stability and mobility? A. thickness, elasticity and compressibility on the IVD B. shape and orientation of the facet/ zygapophyseal joints C. resistance of back muscles and ligaments D. all of the above
D. all of the above
You are examining a 32 y/o female with chronic hip pain. Which of the following structures is considered an intra-articular hip tissue? Multiple Choice A Posterior iliotibial band B Iliofemoral ligament C Iliopsoas bursae D. Acetabular labrum
D.Acetabular labrum
You are managing a 73 y/o female who is 6 weeks post operative of a left hip replacement. She has been progressing well. Today she arrives complaining of increasing pain in the hip region that radiates down her leg and general malaise. What physical examination item would be most appropriate to do next? A. Hip Scour B. FABER C. Straight Leg Raise D. Temperature Check
D.Temperature Check
What are pts with hip fractures at high risk for, what can you do to lower this?
DVT - Routine use of antithrombic agents after surgery
Hip Osteoarthritis
Degenerative arthritis characterized by wearing away of the cartilage in the hip joint
You are treating a 44-year old male patient complaining of right sided sciatica.
Diabetes melatitis
How does someone present with an athletic pubalgia?
Disabling lower ab and inguinal pain, pain with sit=ups, hip adduction or valsalva aggrvated by ballistic movements
What happens if you have a femoral neck intracapsular fracture?
Disruption of blood supply to the femoral head, high incidence of healing complications
Which is more effective in reducing leg pain intensity in patients with moderate- severe sciatica of varying duration? A. Pregabalin B. Placebo C. equally effective
Equally Effective
developed for the assessment of the results of hip surgery, and is intended to evaluate various hip disabilities
Harris hip survey (HHS)
What is 2nd leading cause hospitalization in older pts?
Hip fracture
myositis ossificans
Iregular bone growth
Performed a sham PT and regular PT and concluded that the differences were not statistically significant between the two questioning PT
Jama trial
In adults, what level does cauda equina start?
L2
What does a larger angle mean?
Larger angle = less stability, increase likelihood of anterior dislocation of the head of the femur
Showed Manual therapy was important to OA as well as showing that it was cost effective
MOA trial
What are the average angles of acetabular anteversion in males and females?
Male: 18.5 degrees Female: 21.5 degrees
Effectiveness of epidural injections varies based on which of the following? A.injection technique B. corticosteroids C. dosage D. comparator E. all of the above F. none of the above
None of the above
lumbosacral angle
Obtuse angle formed by the junction of the lumbar and pelvic curvesSteeper curve for females
ORIF
Open reduction and internal fixation - Used pins to stabilize the femoral neck
What is the red flag to the hip we should be aware of which involves bone death
OsteonecrosisBone death or osteonecrosis to the femoral head Not rare Risk factors - Steroids, smoking, blood clotting disorders, high cholesterol, caissons disease, sickle cell, and radiation Pain - Bone pain, deep aching pain Gold standard - MRI for diagnosis
What the 2 types of FAI?
Pincer and Cam
somatic
Poorly localized, aching pain
Vascular Claudication
Predictably reproducible pattern with relief always at rest. Commonly caused by arteriosclerosis or Beurger's disease
Hoaxman trial
RCT = Manual therapy and exercise Pts over 70 Duration of symptoms - majority of pts had symptoms greater than one year - Showed that manual therapy really helped pts who had severe OA, improved ROM which is releated to arthritis - Shaped PTS views on pts Hip progres
What is the best sensitive and specific test for Glut med and minimus?
Single-leg stance when performing a pain provacation tests
If someone had symptoms of trochanteric bursitis > 6 months, what could happen and what is the outcome?
Surgical IT band release or debridement results in a good outcome
True/False: There is discrimination, stereotyping, and prejudice for people who are older
TRUE
Gilmore's groin
Tears in the external oblique aponeurosis and conjoint tendon
What is false about the Femoral fracture? 2nd leading cause of hospitalizations in older patients Increased incidence with age Woman over age 50- 15% lifetime risk hip fracture 1/5 people will die after a year of hip fracture 3/10 go to a skilled nursing facility after their hip fractures
That hip fractures are the 2nd leading cause of hospitilzations in older patients
What is the hip capsular pattern limitations?
The capsular pattern of the hip is when there are limitations in medial (internal) rotation, flexion, abduction
True/False: Pelvic floor contractions should feel more like a lifting sensation
True
neurogenic claudication
Unpredicatable pattern with a relief that is position related, like seated with flexion. Commonly caused by DJD or spinal stenosis
spondylosis
a degenerative process affecting the vertebral disc and facet join that gradually develop with age - degeneration - flattening of the disc
claudication
a term referring to impairments in walking, pain, discomfort, or tiredness in the legs that occur during walking and is relieved by rest
Pincer
acetabuluar impingement (Woman) - Excess acetabular coverage, creating a deeper socket - Less room for movement
Graded ___________ in the short term is slightly more effective than minimal care, but no more effective than other forms of exercise.
activity
Soft tissue injuries
affect more AROM and be more painful
intra-articular joint injury
affect their PROM more than active ROM, have pain with PROM
avascular necrosis
an area of bone tissue death caused by insufficient blood flow
spondylolisthesis
anterior sliding of one vertebrae over another
Where is the hip joint capsule strongest?
anterosuperior
Accessory motion = _____ motion
arthrokinematic
impairments thought to contribute to the patient's condition
asterisk signs
pubic symphysis
attachment of rectus, adductors, internal oblique, transverse abdominis and levator anidoes not move except in the case of child birth
Legg-Calve-Perthes Disease
avascular necrosis of the femoral head in a growing child
How can you have stenosis?
both centrally and laterally central = spinal canal lateral = vertebral canal
What are fatigue fractures?
breaks in normal bone abnormal stress
Stimulation of the L4 & L5 ZGPJ can lead to what pain?
buttock or trochanteric region
How can chemical pain be reduced?
by movement my mechanoreceptor modulation, but does not remain reduced
How can mechanical pain be reduced and/ or abolished?
by repeated motion or sustained positioning in the correct direction
What type of pain cannot be abolished by repeated motion or sustained positioning?
chemical pain
directional preference
clinical phenomenon where a specific direction of repeated movement and/ or sustained position results in a clinically relevant improvement in either symptoms and/ or mechanics, though not always the centralization of the symptoms; essential feature of derangement syndrome
What causes radiculopathys?
compression of nerve root
urogenital triangle
contains the urethral and vaginal orifices in females and the base of the penis and scrotum in males
What is retroversion?
decrease in angle of torsion to < 0 degrees
Spondylolsis
defect in pars interarticularis, maybe a fracture in the pars interarticulars
2 written screening questions for depression plus the addition of a question inquiring " if help is needed"
depression screen
centralization
describes the phenomenon by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
Before beginning a rehabilitation program for a pregnant woman, it is crucial to:
determine whether the patient has had an uncomplicated pregnancy thus far
- dual entrapment of a nerve - usually one proximal and one distal site - most of the time during pregnancy one is a true entrapment (scar tissue from an old ankle injury, fibular head immobility from an old sprain, etc.) and the other is from an irritation from excess movement of the sacrum and pelvis
double crush syndrome
What does it mean when someone has a vascular claudication?
exercising muscle is not getting the right balance of O2/Co2 - problem with the cardiopulmonary system
What movement tightens the ligaments of the hip?
extension
What are the different types of snapping hip syndrome/Coxa Saltans?
external and internal articular
What is the general rule for joint mobilizations?
extremes of joint motion are close-packed midrange positions are loose-packed
True/False: A central stenosis would more often present unilaterally than bilaterally
false
True/False: It took great experimenter force to elicit pain in the facet joints, but once it did it easily radiated down the lower limb
false
FAI
femoracetabular impingement Young patients with hip pain Reduced ROM in flexion & IR
What nerve innervates the iliopsoas?
femoral nerve (L2-L3)
What nerve innervates the sartorius?
femoral nerve (L2-L3)
What nerve innervates the rectus femoris?
femoral nerve (L2-L4)
sacrococcygeal joint
fibrocartilaginous joint that moves with defecation, breathing, child birth and positional changes (sit --> stand)
graded activity
focuses on functional activities and progresses in a time-contingent manner regardless of pain
What plane is Coxa valga and vara observed in?
frontal
coxa valga causes
genu valga and bowlegs
coxa vara causes
genu valgum and knock knees
consequences of excessive femoral anteversion
get a toe in perspective
LBP and SI joint pain occurs in up to half of all pregnant women and is twice as common in women who had LBP prior to pregnancy Why is this so common?
gravid uterus (posterior posture) causes the weight of the uterus to be carried posterior to the normal CoG, creating a tremendous mechanical strain on the LB; relaxin also causes ligamentous laxity in the spine and pelvic joints
coxa valga angle of inclination
greater than 150 degrees
Stimulation of the L2 & L5 ZGPJ can lead to what pain?
groin pain
What are the first two screening questions good for?
have good sensitivity and lack diagnostic specificity, GOOD FOR RULING OUT
When looking at a body chart what should we compare?
how does the patient's story correlate with how their describing their symptoms
What is internal extra-articular coxa saltans?
iliopsoas tendon snapping iliofemoral ligament snapping hamstring syndrome iliopsoas bursal/capsular thickening
What is anteversion? What is it commonly seen with?
increase in angle of torsion > 30 degrees or 60 degrees in kids with hip dysplasia - commonly seen with coxa valga
if symptoms improve during the bicycle test
increased likelihood of neurogenic claudication
if symptoms worsen during the bicycle test
increased likelihood of vascular claudication
As the pain centralizes, it often significantly (increases/ decreases).
increases
osteitis pubis
inflammation around the pubic symphysis, common among athletes and pregnant women - MOI: overuse injury secondary to repetitive shear and the pubic symphysis
What are the clinical features of septic arthritis?
irritable infant Hip held in open packed position Fever, sweating, chills tachycardia, loss of appetite
What happens with the acetabulum concavity with age?
it decreases
typically presents as a burning pain along the skin innervated by the lateral femoral cutaneous nerves- caused by compression- can be unilateral or bilateral
lateral femoral cutaneous
Coxa vara - angle of inclination is ________
less
coxa vara angle of inclination of femur?
less than 125 degrees
congenital LSS
lumbar spinal stenosis that has occurred since birth
What type of pain can become constant with internal derangement?
mechanical pain
- can be unilateral or bilateral - typically presents as a burning pain along the skin innervated by the lateral femoral cutaneous nerves - caused by compression of the lateral femoral cutaneous nerves - usually resolves spontaneously with delivery
meralgia paresthetica
Coxa valga - angle of inclination is ______
more
What are grades III and IV used for?
motion
Which of the following is considered a non-mechanical spinal injury
multiple myeloma
What can contusions lead to?
myositis ossificans
How is mechanical pain produced?
nociceptors become actiated by force, stress, deformity and damage
How is chemical pain produced?
nociceptors become activated by damage, causing a high concentration of irritating chemicals
contusions
occur through a direct blow
Strains
occur through indirect trama
Physiologic motion = _____ motion
osteokinematic
consequences of anteversion
out-toe persoeptive
What are grades I and II used for?
pain
the region between the superior and inferior articular processes- in the transverse plane, it lies between the lamina and pedicle
pars interarticularis
During bilateral weight bearing:
pelvic drop only
maximum joint play
position in which joint capsule and ligaments are most relaxed
Centralization is a (negative/ positive) prognostic indicator.
positive
slipped capital femoral epiphysis (SCFE)
post and inferior displacement of the femoral head relative to the neck
What is external extra-articular coxa saltans?
posterior ITBanterior glut maxtrochanteric bursitis MOST COMMON
anorectal triangle
posterior part of the perineum containing the anal canal
What factors might increase the lumbosacral angle?
pregnancy obesity postural habits abrupt change in facet orientation
What nerve supplies the pelvic floor?
pudendal nerve branches, S2-4
radiculopathy
radiating paresthesia numbness in a dermatome, weakness, or combo of these
What appears with a central canal stenosis?
radiculopathy (bilateral nerve root presentation) claudication forward flexion in patients
What does a tight ITB lead to?
reduced hip ADD with hip extended
consistency overtime with the same measure
reliability
maximum joint play occurs in
resting position
What does not having a fever rule out for? What kind of test is this?
rule out infection - sensitive tests (Spin)
What does having a fever rule in for? What kind of test is this?
rules in infection - specific tests (Snout)
What plane is anteversion and retroversion observed in?
sagittal
When is the Cam Type FAI seen?
see after a pediatric hip condition SCFELegg calves perthes disease
radicular pain
sharp, shooting, superficial or deep pain into the leg in a defined band (<4cm) wide
anterior sliding of one vertebrae over another, which can compress spinal canal- progression of spondylolysis
spondylolisthesis
posterior elements of vertebrae can be injured
spondylolysis
degenerative changes of the lumbar vertebra
spondylosis
What do the 1st and 2nd layers of the pelvic floor provide?
squeeze for continence and release for sexual penetration and elimination
What nerve innervates the TFL?
superior gluteal nerve (L5-S1)
carpal tunnel syndrome
swelling in the carpal tunnel due to the body's tendency to retain fluid during pregnancy swelling in the carpal tunnel due to the body's tendency to retain fluid during pregnancy
Explain why you might use the SLR test as opposed to the X-SLR test.
the SLR test has a high sensitivity, thus if a patient has a negative test, we can be confident in ruling out radiculopathy
vascular claudication
the constellation consists of symptoms that are relieved with standing alone and located below the knees
neurogenic claudication
the constellation consists of symptoms that are triggered with standing, relieved with sitting and located above the knees and that have a positive shopping cart sign (+LR = 13)
Femoracetabular Impingement (FAI)
the dysfunctional abutment of the proximal femur & the acetabulum causes pain & can lead to progressive degenerative changes in the hip joint, specially the labrum
When are you at highest risk of Hip dislocation post surgery?
the first year - hip precautions should be adhered for 3 months
Decartes model of pain
there is a linear relationship of pain to tissue/ muscle/ ligamentous damage
How will an increased lumbosacral angle affect shear forces at this joint?
they will be increased along with an increase in lumbar lordosis; the facet apposition counterbalances shear forces
What is the function of the 3rd layer of the pelvic floor?
to provide lift to help control intraabdominal pressure and to suspend the organs
goal of spinal fusion
to stabilize a segment of the spine that has weakened and eliminate motion at that segment, should ideally reduce the pain associated with that vertebral movement
True/False: 1/3 of patients who had spinal surgery received surgery and had better prognostic indicators after doing it
true
True/False: Lateral femoral cutaneous usually resolves spontaneously with delivery
true
True/False: Mechanical prophylaxis are better than nothing
true
True/False: Pain can be the result of actual or perceived tissue damage
true
True/False: Patients with LSS responded very well to aerobic exercise conditioning
true
True/False: Stenosis and aging can lead to spondylolisthesis
true
True/False: The higher someone's kinesiophobia, the lower their QOL
true
True/False: There is a difference between normal older aging adults and frail old people
true
True/False: Treating pregnant woman should follow the same course as treating anyone else with some exceptions
true
Means that it measures what we intend to measure
validity
When is radicular pain elicited?
when a previously damaged nerve root is compressed
intracapsular joint fracture
within the joint capsule; absence of secondary blood supply to the head increases the risk of avascular necrosis
Glut medius and minimus conditions are more common in who?
woman
graded exposure
working from least fearful activity to most fearful
