Back and Lower Extremities - Pitcher Flashcards
What type of synovial joint is the knee joint?
Condylar
What type of joint is the foot?
Hinge
Two main areas of lumbar spine inspection during exam?
Posture and gait
The iliac crest is located at what spinous process level?
L4
Three main areas of lumbar spine neurologic exam?
Reflexes, sensation and strength
Muscle strength testing scale (again)?
0 = no movement 1 = muscle twitch without joint movement 2 = movement only with gravity eliminated *3 = movement against gravity only 4 = movement against gravity + some resistance 5 = movement against gravity + full resistance
***Lumbar neuro exam, sensory deficits:
***Sensory area changes:
L4 is lateral strip ankle to large toe
L5 mid top of foot and most of plantar surface
S1 lateral strip of foot
Viscero-somatic reflexes (brief understanding)?
If there is disease or pathology in organs, they can reflect a somatic dysfunction in these segments of the spine giving clues to the diagnosis.
Where is the most common area of injury or source of pain from the lumbar spine?
L5-S1
Ankylosing spondylitis triad of symptoms?
Sacroilitis (SI pain), Uveitis (photophobia and eye pain), and arthritis (generalized) (Reiter’s syndrome?)
Ankylosing spondylitis details?
Hereditary, chronic inflammatory disease (HLA-B27) Pronounced lumbar lordosis Sacroiliac tenderness (sacroilitis) often the source of their “back pain” Other body systems affected as well: uveitis (photophobia,pain), general synovial arthritis (hip/shoulder most common) enthesopathathies (inflammation at tendon insertion)
What do you think about in regards to osteoarthritis?
Deterioration (common at L5-S1 level of spine)
What do you think about in regards to osteoporosis?
Thinning of bone…compression fractures are the source of back pain here
Requirement for sciatica dx?
Pain must radiate below the level of the knee
Main test for sciatica?
Straight leg raise (sciatica vs. hamstrings)
Description of the hip joint?
“stabilizer”
What type of joint is the hip?
Spheroidal synovial
With hx of hip dislocation, what do we need to worry about?
Femoral head necrosis
What are the most sensitive exam indicators of true hip (hip joint) pathology?
Internal and external rotation (***true hip pain is deep inguinal, not lateral)
Location of pain with trochanteric bursitis?
Lateral (duh)
How do you inspect/palpate the inguinal ligament?
Place the pt supine, then place heel on opposite knee, palpate ASIS to pubic tubercle
NAVEL (lateral to medial = nerve, artery, vein, empty space, lymph nodes)
Trendelenburg test?
Evaluates gluteus medius (hip stabilizer during ambulation) muscle
Ober test?
Evaluates iliotibial tract tightness/ITB syndrome
abnormal test = leg remains in abducted position, ITB tight
Thomas test?
Flexion contractors of the hip due to tight psoas (iliopsoas)
flex leg to abdomen, positive would be when other leg comes off of table
FABER testing
flexion, abduction and external rotation
looking to reproduce their pain
Leg length discrepancy?
measure distance from ASIS to medial malleoli
Knee is a ________ joint
condylar (synovial hinge joint)
Bursas of the knee?
Prepatellar, pes anserine, suprapatellar pouch
Pain, symptoms, hx, signs with pre patellar bursitis?
Anterior pain, dome swelling over patella with tenderness, usually from excessive kneeling, “housemaid’s knee”
Anserine bursitis signs?
Medial pain, excessive running is a common cause, can also be from valgus knee deformity and arthritis, difficult to differentiate from a pes anserinus tendonitis
Baker’s cyst signs (extra-capsular)?
Posterior pain, cyst found in popliteal fossa, can extend medially, check for fullness and tenderness posteriorly when knee is in full extension
Sign of tendonitis?
tenderness with active ROM (muscle engages and pulls on tendon)
Sign of bursitis (vs. tendonitis)?
Pain is equal with active or passive ROM
What is a balloon sign?
Suggests a large effusion
Bulge sign?
Suggests a minor effusion in suprapatellar pouch
What is balloting?
Compress suprapatellar pouch, use other hand to sharply press patella to feel for fluid returning to suprapateallar pouch…also for large effusions
Patellofemoral grind test?
extend leg, place pressure over patella, ask patient to contract quads… reveals chondromalacia or patellofemoral syndrome
Apprehension testing?
tests for dislocation or subluxation of patella… attempt to manually is locate patella laterally…observe patient’s facial expressions
Anterior drawer sign?
flex knee to 90 degrees, pull tibia forward to check for movement anteriorly…positive test = ACL tear
Lachman test?
Only good for ACL (knee flexed at 15 degrees, move femur and tibia in opposite directions)
***always test both knees, asymmetric findings most important
Posterior drawer testing?
Tests for PCL laxity/tearing (push tibia posteriorly when knee flexed at 90 degrees)
McMurray test?
Pt supine, fully flex knee, grasp heel and point to the direction of the meniscus getting tested (external rotation for medial meniscus and IR for lateral meniscus)
***not a very specific test
Apley’s compression test?
Pt prone with knee flexed at 90 degrees, stabilize thigh with one hand while leaning onto heel compressing medial and lateral menisci…rotate heel during compression noting any pain
Key features of patient presentation for a meniscal tear?
Locking or giving out: sensation of or actual occurrence
Not feeling they can trust the knee when walking or stepping off a curb
A catching sensation or true catching of the knee: sudden pain stops ROM, ie, suddenly cannot extend the leg fully
Thessaly test?
Standing, rotatory motion on one leg at 5-10 deg, and again at 20 degrees
***More sensitive and specific for mensical injury or tear than McMurray, bent knee position best
Homan’s sign?
Evaluates for DVT (deep venous thrombosis)
Dorsiflex patient’s ankle with leg extended at knee…pain in calf is a positive sign
Thompson test?
Patient prone, leg bent 90 deg, squeeze calf and observe for normal passive plantar flexion
Best to determine achilles rupture if done w/in 48 hrs of injury
(Thomas testing is for psoas!)
What type of joint is the ankle?
Hinge, formed from articulating surface of the tibia, fibula and talus
Principal joints of the hinge are:
Tibiotalar joint
Subtalar (Talocalcaneal) joint
Most commonly injured ligaments during a sprain of the ankle?
Anterior talofibular and calcaneofibular (lateral ankle)
Ottawa Rules (Age > 18yr):
Inability to bear weight after 4 steps or tenderness over posterior aspect of either malleolus
***Always be suspicious of fracture
Ottawa Rules (details):
Developed to avoid unnecessary radiography in ankle injury:
Perform an xray expecting to find a fracture if:
Pain around the malleolus and tenderness in posterior malleolar area or tip of fibula
OR
Pain around the malleolus and unable to weight bear immediately and more than 4 steps in ED
OR
Pain in mid-foot and either
1. Tenderness at base of 5th metatarsal or navicular, OR
2. Unability to weight bear immediately OR more than 4 steps in ED
How to you distinguish if pain snot in the hip joint itself?
Lack of pain with rotation!
When should you order a MRI of the spine?
When surgical signs/symptoms are present… atrophy, weakness or intractable pain.
