Musculoskeletal Spine and TMJ Test 2

What are False Ribs?

"Falsely" articulate with the sternum; Ribs 8-10

What are differential diagnosis' of TMJ dysfunction?

-trigeminal neuralgia -migraine headaches -herpes zoster -parotid gland tumor -temporal arteritis -tooth abscess -acoustic neuroma

Which ribs are considered "atypical" or ribs that only articulate with their own vertebrae?

1, 10, 11, 12

Common Treatment of TMJ

1. Elimination of spasms and pain 2. Counseling or biofeedback/relaxation training 3. Correcting the way the teeth fit together 4. Surgery 5. PT

An S-curve usually indicates a muscular imbalance. Muscle re-education may include:

1. relaxation of facial muscles: make a "clicking" sound with the tongue on the roof of the mouth; when doing so, the jaw drops open quickly and returns with the teeth slightly apart; this is the resting position of the jaw and the first step of relaxation exercises 2. relaxation of facial muscles: fill cheeks with air (mouth closed), then let the air out in a puff tongue proprioception: place the tip of tongue on the hard palate behind the front teeth and draw little circles 3. control of jaw muscles: teach recognition of the resting position of the jaw (lips closed, teeth slightly apart, tongue resting lightly on the hard palate behind the front teeth); the patient should breathe in and our slowly through the nose, using diaphragmatic breathing 4. mirror use for symmetry of movements 5. active motions progressing to gentle resistance

C&S Curves: 1.) Usually indicates a capsular pattern 2.) Indicates a muscular imbalance A.) C-Curve B.) S-Curve

1.) A 2.) B

Special Tests for Thoracic Outlet Syndrome

1.) Adson's Test 2.) Roos Test 3.) Costoclavicular Assessment 4.) Pec Minor Assessment 5.) Anterior Capsule Assessment

The cause of Scheuermann's kyphosis has not been discovered, but there are several theories. What are they?

1.) Avascular necrosis of the cartilage ring of the vertebral body 2.) Most researchers think some sort of damage to the growth area of the vertebrae starts the process

Scoliosis Curves: 1.) <25 degrees 2.) 25-45 degrees 3.) >45 degrees A.) Moderate B.) Severe C.) Mild

1.) C 2.) A 3.) B

Sites of Compression for Thoracic Outlet Syndrome

1.) Interscalene triangle 2.) Costoclavicular space 3.) Subpectoral tunnel 4.) Anterior humeral head 5.) Median nerve roots 6.) Axilla

Thoracic Kyphosis occurs because of?

1.) Less anterior vertebral body height 2.) The wedge shape of the thoracic discs

Structural Causes of Thoracic Outlet Syndrome

1.) Scalene muscle alterations 2.) Prominent C7 TP 3.) First rib malformation 4.) Cervical rib presence 5.)Callus formation on the clavicle or ribs

Treatment Options for Thoracic Outlet Syndrome

1.) Strengthen and Stretch Shoulder Girdle Muscles 2.) Cervical Exercises and Mobilization 3.) Modification of movement patterns at work and home 4.) Bracing

Exercises for Ankylosing Spondylitis

1.) Stretching of the posterior and anterior spinal muscle chains in standing, sitting, and supine (3-4 minutes of each stretch) 2.) Neural mobilization of the median nerve 3.) Eccentric work of the erector spine muscles 4.) Respiratory Exercises

Cervical Rib, T/F 1.) Originates from costal process 2.) Fuses with transverse process by age 12 3.) Only 10% of peopole with cervical rib become symptomatic 4.) Most commonly at C6 5.) Can compress neurological and vascular structures

1.) True 2.) False, age 10 3.) True 4.) False, C7 5.) True

Scheuermann's Kyphosis, T:F, 1.) Symptoms generally develop in early teens around puberty 2.) The onset of kyphosis is generally fast 3.) In most cases, patients with Scheuermanns also has scoliosis 4.) About 5% of the population suffers from Scheuermann's Kyphosis 5.) These patients are not neurologically normal 6.) Lung and cardiac functions may be decreased

1.) True 2.) False, slow 3.) True 4.) True 5.) False, they are generally neurologically normal 6.) True

What is the normal amount of "free space" between the upper and lower teeth?

1.5-5.0 mm of "free space" between upper and lower teeth. Maintenance of this space helps decrease intra-articular pressure in the TMJ

Which Ribs are Floating Ribs?

11 and 12

Each typical thoracic vertebrae has how many articulations?

12: 4 zygpophyseal 2 costotransverse 4 costovertebral 1 body/IV disc

What is the ratio between IV disc height to vertebral body height in the thoracic spine?

1:5

The typical ribs articulate with what?

2 adjacent vertebrae, the disc, and TPs

Treatment of idiopathic scoliosis is indicated for patients with curves greater than _____ degrees

20

The angulation of the thoracic facets from the frontal plane is approximately?

20 degrees

If the kyphosis is due to Scheuermann's disease, the x-ray will show __ or more adjacent vertebra that are wedged together at least ___ degrees each

3 or more adjacent vertebrae 5 degrees

Bracing should be initiated immediately for curves greater than?

30 degrees

Bracing is generally considered with curves between?

30-40 degrees

Surgical treatment is indicated in patients with curvatures greater than _____ degrees, especially those with severe rotational abnormalities.

45

With Ankylosing Spondylitis, the male-to-female ration is 2:1 or 3:1, and the increased risk of mortality is about ____ (related to several organ systems, and often a result of circulatory, malignant, or infectious diseases).

50%

The angulation of the thoracic facets from the transverse plan is approximately?

60 degrees

Scheuermann's Kyphosis: Surgery is usually reserved for kyphosis exceeding ___ degrees as measured on x-rays.

75

_______% of individuals over 60 have signs of some OA and TMJ

80-90%

The axis of rib motion is represented by?

A line drawn through the costotransverse joint and the costovertebral joint through the neck of the rib

-Most common form of dwarfism -Foramen magnum stenosis and sleep apnea in the infant -Spinal stenosis in the adult

Achondroplasia

is a chronic rheumatic disorder affecting the axial skeleton that progressively inhibits spinal mobility.

Ankylosing Spondylitis

Reciprocal Click: -When the click occurs early in the opening phase, and late in the closing phase, the amount of ______ displacement is relatively limited. -The later the click during opening, and the earlier the click during closing, the more severe the _______.

Anterior Dislocation

-In some patients, the meniscus remains anteriorly displaced at full mouth opening. -This causes an inability to fully open the mouth. -There is sometimes a tear or perforation of the meniscus. -Grinding noises in the joint are often present.

Anterior Displacement WITHOUT Reduction

The displaced posterior band will often return to its normal position when the condyle reaches a certain point. When the meniscus reduces, the patient often feels a pop or click in the joint.

Anterior Displacement with Reduction

The space between the mandibular condyle and fossa is occupied by collagenous fibrous tissue called the

Articular Disk, the disk allows the mandibular condyle to glide across the mandibular fossa

-Likely a capsular problem -Ice/heat -E-stim -US -ST release -Joint mobilization if range permits -Self-stretching exercises

Close Lock

the ends of each vertebra in the curve are determined and a line is drawn along the endplate of each of them, making a connected perpendicular/vertical line. This line makes up the angle of the curve, which can be measured in degrees.

Cobb Angle

Most adolescents receive what kind of care?

Conservative, including bracing and exercise therapy, which have been show to be effective

The TMJ is formed by a _____ mandibular condyle and a _____ mandibular fossa:

Convex Concave

Scoliosis is named for the side of?

Convexity

Bony rib emerges into the cartilaginous attachment of the sternum

Costochondral Joint

Is present at T1-T10. At T1-T6, the rib portion is convex on a concave TP articulation. At T7-10, the joint is planar

Costotransverse Joint

Costotransverse Joints are reinforced by what ligaments?

Costotransverse Ligaments

The joint between the vertebral body and ribs. Its capsule attaches to each vertebrae and the IV disc

Costovertebral Joint

If a rib stops moving relative to the others on inhalation, it is called a? If it stops moving relative to the other on exhalation, it is called an?

Depressed Rib Elevated Rib

Depressed ribs are are usually the (highest/lowest) restricted rib while elevated ribs are usually the (highest/lowest) restricted ribs

Depressed Ribs: Highest Elevated Ribs: Lowest

What are the muscles of Depression?

Digastric, Lateral Pterygoid, and Suprahyoid group

-Incidence: 1 in 700 live births -Upper cervical spine defects -Symptomatic instability as low as 2.6% -A silent killer -Flexion/Extension films suggested for this population

Down Syndrome

What is one of the most important prognostic factors for Ankylosing Spondylitis?

Early limitation of spinal mobility

-Muscle relaxants or other medications -Massaging the muscles -Eating soft, non-chewy foods -Bite plate or occlusal (bite) splints can also be made

Elimination of Spasms and Pain

Flexion of the thoracic spine occurs during (inhalation/exhalation)?

Exhalation

Positional Dysfunction: upper two thoracic spine segments restrict the ability to?

Extend fully, results in a flexed, kyphotic posture

Positional Dysfunction: T8-T12: often restrict the ability to?

Extend, results in a flexed, kyphotic posture

T/F, scoliosis that surpasses about 30 degrees at the end stage of growth, the risk of problems in adulthood (i.e. disability, cosmetic deformity, functional limitations, and pulmonary problems) decreases significantly.

False, increases

Positional Dysfunction: T3-T7: often restrict the ability to?

Flex, results in an extended (flat) posture

Torsional rib dysfunctions are the result of thoracic vertebral dysfunction in the form of?

Hyper/Hypo mobility

-Usually shortening of SCM -Plagiocephaly (skull and facial asymmetry) may be present -Possibly due to birth trauma -There may be an underlying osseous problem. -Conservative management is 97% successful

Infantile Torticollis

The contralateral ribs during sidebending causes an ______ glide of the rib facet at the costotransverse joint as vertebrae continues to move. ______ Rotation of ribs 1-6 also occurs

Inferior Glide Posterior Rotation

Posterior rotation of ribs 1-6 occurs with an associated?

Inferior glide of the costotransverse rib facet

Extension occurs with backward bending, elevation of both arms, and during (inspiration/expiration)?

Inspiration

is present when the posterior band of the meniscus is anteriorly displaced in front of the condyle. As the meniscus translates anteriorly, the posterior band remains in front of the condyle and the bilaminar zone becomes abnormally stretched and attenuated.

Internal Derangement of TMJ

With sidebending, (ipsilateral/contralateral) ribs will approximate before the motion is complete?

Ipsilateral

Structural dysfunction of the ribs are the result of?

Joint subluxation or Dislocation

-No neck appearance; head appears to rest on thorax Fusion of the cervical spine, partial or total, unilateral or bilateral -Abnormally low hair line with a short neck -May be asymptomatic until adulthood until they develop instability or spondylosis

Kippel-Feil Syndrome

-Deviation to the right: right condyle spinning, and left condyle translating/gliding forward -The rotation occurs around an anterior-posterior axis. In other words, the spin occurs in the frontal plane. The opposite condyle depresses in addition to translating/gliding forward. -This motion is used bilaterally for chewing.

Lateral Deviation

The higher the child's Risser sign at diagnosis, the (more/less) chance there is of progression.

Less (Double S curves are more likely to progress)

Sagittal plane orientation of rib articulation with TP and vertebra; bucket handle motion; apex (or lateral) portion of the rib moves cranial-caudal

Lower Ribs

What are the muscles of Protrusion?

Masseter, Medial and Lateral Pterygoids

What are the muscles of Mastication?

Masseter, medial and lateral pterygoid, and temporalis muscles

thought to work by taking pressure off the front half of the vertebra, allowing the growth of the bone in the front to catch up with the growth in the back. Is the most common form of treatment for Scheuermann's Kyphosis

Milwaukee Brace

15-20 degree range, the doctor will likely choose monitoring the curve rather than bracing. With monitoring, the patient will have x-rays taken every year, or every four months in rapid growth years

Monitoring

What is the Resting Position of the TMJ?

Mouth slightly open, lips together, and teeth not in contact.

-The inability to close the mouth when the condyle is locked in an open position -This usually happens after wide openings from yawning or a dental procedure. -The most likely cause is overstretching of the lateral pterygoid or a posteriorly displaced disk.

Open Lock

Pec Minor OIA

Origin: Anterior aspect Ribs 3-5 Insertion: Coracoid Process Action: Scapular Protraction

Middle Trap OIA

Origin: C7-T3 spinous processes Insertion: Acromion, Lateral Scapular Spine Action: Retract Scapula

Serratus Anterior OIA

Origin: Ribs 1-9 Insertion: Medial Border of Scapula Action: Holds Medial Scapula against Thoracic Cage

External Oblique OIA

Origin: Ribs 5-12 Insertion: Iliac Crest, Pubic Tubercle, Linea Alba Action: Contralateral Rotation of the Trunk

Lower Trap OIA

Origin: T3-T12 vertebrae Insertion: Medial Scapular Spine Action: Retractor and Depressor of Scapula

Lats OIA

Origin: T7-L5 spinous processes and lower ribs Insertion: Bicipital Groove of Humerus Action: Adduct, Extend, IR arm

What are the muscles of Retrusion?

Posterior Fibers of Temporalis

Muscles of Lateral Deviation?

Pterygoids pull into protrusion on the contralateral side; posterior fibers of the temporalis pull posteriorly (similar to retrusion) ipsilaterally

Costovertebral Joints are reinforced by what ligaments?

Radiate

-An anteriorly dislocated disk will have an audible click upon opening and closing of the mouth. -With opening, the condyle slips under the disk, causing a click. -Once the condyle is in a proper relationship to the disk, motion is normal. -When closing, the condyle again slips out from under the disk, resulting in another click.

Reciprocal Click

Splint to Correct the Teeth: generally used to recapture anteriorly displaced disk and/or manage disk/condyle discoordination; should be worn continuously throughout the day and night except for oral cleaning

Repositioning Splint

Splint to Correct Teeth: preferred when relaxation or balancing of soft tissues is desired; worn during the day or only at night to offset soft tissue reaction from nocturnal clenching/bruxing

Resting Splint

The Adam's Test is used to diagnose what?

Rib Hump

What are True Ribs?

Ribs that directly attach to the sternum; Ribs 1-7

Uses ossification of iliac epiphysis to grade remaining skeletal growth (degree of skeletal maturity). Ossification starts laterally and runs medially

Risser Classification

Upon opening (depression), the mandibular condyle rolls (anterior/posterior) and slides (anterior/posterior)

Rolls Posterior Slides Anterior

-Wedging of the vertebrae causes this condition. -This disease develops in adolescents while the bones are still growing. -Males are 2X as likely to develop this type of kyphosis than females. -Schmorl's nodes may develop

Scheuermann's Kyphosis

Small herniations of the disc in the endplates of the vertebrae

Schmorl's Nodules

A three-dimensional deformity of the spine. It can be secondary to other pathologies, but 70-80% of the cases are idiopathic.

Scoliosis

Vertebral motion may continue after rib motion stops during sidebending, creating a _______ glide of the rib facet and ________ rotation of ribs 1-6?

Superior Glide Anterior Rotation

Facet Joints Kinematics: Flexion

Superior articular facets glide up and forward on the inferior vertebrae with INTERNAL ROTATION of the ribs

How do the superior and inferior articular facets of T11-T12 face?

Superior: Medially Inferior: Laterally

How do the superior and inferior articular facets of T1 face?

Superior: Superiorly and Posteriorly Inferior: Inferiorly and Anteriorly

How do the superior and inferior articular facets of T2-T10 face?

Superior: Superiorly, Posteriorly, Laterally Inferior: Inferiorly, Anteriorly, Medially

What does the Rule of Threes state?

T1-T3: spinous processes project posteriorly nearly to the same level as their TPs T4-T6: spinous processes project down to about halfway between their own TPs and those of the inferior segment T7-9: spinous processes project down to the level of the inferior vertebrae T10: Similar to T7-T9 T11: Similar to T4-T6 T12: Similar to T1-T3

Where is the apex of the thoracic curve?

T7/T8

is a ginglymodiarthrodial joint, capable of hinge-type and gliding movements, with its bony components enclosed and connected by a fibrous capsule.

TMJ

What muscles attach to the anterior portion of the articular disk?

Temporalis, Masseter, Lateral Pterygoid

What are the muscles of Elevation?

Temporalis, Masseter, Medial Pterygoid

T2-T9 have a DEMIFACET on the posterolateral corner of the vertebral body for articulation with?

The rib head

Respiratory rib dysfunctions are the result of hypomobility between?

The ribs or costovertebral/costotransverse joints

T/F, Curves < 20 degrees generally do not require a brace, especially with Risser types 3-5.

True

T/F, Curves < 30 degrees that progress 5 degrees or more over 12 months should be braced.

True

T/F, Factors related to the teeth and bite are also believed to be common causes of TMJ disorders.

True

T/F, For Scheuermann's Kyphosis, surgery involves fusion of the abnormal vertebrae. The spine is fused anteriorly and posteriorly with surgical implants (Harrington rods).

True

T/F, Scoliosis and Rib Hump usually are on the same side

True

T/F, the side of the convexity, rib hump, and thoracic rotation is also the side of subsequently decreased intrathoracic space

True

T/F, there is an intimate connection between the cervical spine and TMJ. The cervical spine is interposed between proximal and distal attachments of some muscles controlling the TMJ.

True

T/F, the thoracic spine is more stiff and less mobile than the rest of the spine?

True, due to rib cage articulation and facet joint orientation

Ossification of lateral 25% iliac epiphysis

Type 1 Risser's

Ossification of lateral 50% iliac epiphysis

Type 2 Risser's

Ossification of lateral 75% iliac epiphysis

Type 3 Risser's

Complete fusion of iliac epiphysis

Type 4 Risser's

Fusion to ilium

Type 5 Risser's

Relatively frontal plane orientation of rib articulation with TP and vertebra; pump handle motion; anterior portion of rib moves cranial-caudal

Upper Ribs

What muscles attach to the posterior portion of the articular disk?

a mass of soft tissue called retrodiscal tissue, composed of two laminae of connective tissue and loose connective tissue