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MSK 3 Fall 2024 > Common Conditions and Anatomy Lumbopelvic Unit 1 > Flashcards

Common Conditions and Anatomy Lumbopelvic Unit 1 Flashcards

1
Q

Spinal Stenosis

A
  • narrowing of : central canal and or intervertebral foramen

Associated with:
- age
spondylosis
- congenital variants- trefoil canal
- trauma or degeneration induced structural changes/listhes

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2
Q

Foraminal Stenosis

A
  • Secondary stenosis its acquired
    advancing age
  • gradual onset
  • neurogenic claudication of one or both legs
  • symptoms increased with prolonged walking and standing
  • Better sitting and eased with leaning forward
  • consistent aggravating factors
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3
Q

Foraminal Stenosis Special Tests

A

Bike test
2- stage treadmill (+)

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4
Q

Foraminal Stenosis Findings

A
  • Global ROM decreased
  • Pronounced decrease in Lumbar extension
  • Observed decrease lordosis and often increased kyphosis
    Segmental mobility is usually hypomobile

REPETITIVE MOTION EXTENSION WORSENS AND FLEXION IMPROVES (usually)

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5
Q

What is the Cluster/CPR for Lumbar Stenosis

A
  1. Bilateral Symptoms
  2. Leg pain more than back pain
  3. Pain during walking/standing
  4. Pain relief upon sitting
  5. Age >48
    1 of 5 Sn= 96 Sp= 20 LR+=1.2 LR-=.19

4 of 5 Sn=6 Sp=98 LR+= 4.6 LR-= .95

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6
Q

What are some interventions for Foraminal Stenosis

A
  • Posture
  • DP: flexion, contralateral lateral flexion
  • Anterior/posterior balance and quadriceps
  • traction- positional distraction
  • Manual: mobilization (opening), soft tissue psoas release
  • bodyweight supported treadmill or bike
  • education
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7
Q

Central Stenosis with cord compression Etiology

A

Congenitally narrowed canal, broad based protrusions, neoplasm osteophytes and listhesis

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8
Q

Central Stenosis with Cord Compression Findings

A
  • Diffuse sensory loss
  • Non- dermatomal stocking pattern
  • Hyperreflexia
    • babinski
    • Hoffman
  • ataxia and abnormal romberg
  • wide base gait ( Sn = 0.43/ Sp= 0.97)
  • Lower extremity buckling
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9
Q

Discogenic Pathology/ Nomenclature

A

DDD= desiccation, end plate sclerosis, decreased height, decreased signal on T2MR

Disc Bulge= >50% (180 degrees) may be asymmetrical

Herniation= localized : disc protrusion intact annulus: disc extrusion outer annulus torn

Fissure= deflect

High Intensity Zone= increased signal on T2 image at outer annulus

Internal Disc Disruption= internal fissuring (radial, T, Transverse)

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10
Q

Discogenic Pathology History

A
  • gradual or sudden onset
  • somatic or radicular
  • Variable pain pattern
  • AM worse
  • Symptoms increase with coughing and sneezing
  • Worse with slouched sitting, bending, and lifting
  • trouble rising from sitting
  • improved standing and walking
  • Walk off pain
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11
Q

Discogenic pathology is most common cause of________

A

Radiculopathy

  • age 2-0-55 most common
  • Herniations 50% post/lat, 25% central, 10% lateral
  • 95% at L4-5 or L5-S1
  • Site of pathology reflects pain location
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12
Q

What are some things you might find during a discogenic pathology examination?

A

Static Positioning:
- flexion = worsens
- extension= improves

Neurological signs:
- hyporeflexia
- motor loss > sensory
- UMN if cord impingement

  • MRI used most often GOLD STANDARD IS DISCOGRAPHY
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13
Q

What special tests would you do for discogenic pathology?

A

SLUMP
SLR with nerve root involvement

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14
Q

Discogenic Pathology Tests and Measures

A
  • Posture may have an acute deformity/kyphosis or shift/list
  • AROM limited in all planes with obstruction toward herniation
  • repetitive motion - internal bulge/ protrusions
  • Repetitive motion extrusion, sequestration or large protrusion
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15
Q

Discogenic Pathology Interventions

A
  • Posture: Anterior pelvic tilt, lordosis, avoidance of A.M. flexion
  • DP- extension and or lateral group most often
  • Impairments: flexibility and muscle performance
  • Traction if no DP: monitor annular competence
  • Mobilization- as required for complete reduction
  • neural mobilization PRN
  • medical= micro lumbar discectomy, fusion, disc replacement, IDET
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16
Q

Facet Joint Dysfunction (zygapophyseal joint) Anatomy

A
  • Synovial joint with capsule and fat pad
  • Capsule attached to ligamentum flavum anterior and multifidus posterior
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17
Q

Facet Joint Dysfunction (zygapophyseal joint) Disorders Inflammatory or Mechanical

A
  1. Joint Inflammation= synovitis or hemarthrosis (trauma)
  2. Impingement = articular fat-synovitis capsular folds - fibrillated/detached cartilage
  3. DJD (if pronounced may lead to stenosis )= with degenerative change; decreased disc height leads to increased weight bearing load on facet
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18
Q

Mechanical Facet Joint Disorders: Dysfunction leads to

A

Leads to impaired joint mobility and or theoretical malpositioning

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19
Q

Mechanical Facet Joint Disorders: What are the Facet mobility patterns?

A
  • Facet joint guide movement of the spine
  • In the lumbar spine the facet joints:
    -OPEN with FLEXION
    -CLOSE with EXTENSION
  • OPEN on CONTRALATERAL side of LATERAL FLEXION
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20
Q

Mechanical Facet Joint Disorders: Facet Coupling when standing in neutral

A

L1-L5
- Right lateral flexion couples with left rotation (EXECEPT AT L5-S1
- Opens on ipsilateral side of rotation (EXCEPT AT L5-S1

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21
Q

Facet Joint Dysfunction : History

A
  • Sudden/gradual onset
  • Reports of “stiffness” or “feeling stuck”
  • Unilateral pain in the lumbar, gluteal and thigh region
  • No symptoms increase with sit to stand
  • Often will meet CPR for thrust manipulation
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22
Q

Facet Joint Dysfunction: Tests and Measures

A
  • AROM: facet opening or closing pattern - movement obstruction or restriction
  • Repetitive Motion: will not see centralization/peripheralization no directional preference
  • Hypomobile segmental testing
  • Palpation: tenderness and guarding in region of affected joint
  • Absence of neurological findings
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23
Q

Facet Joint Dysfunction: Intervention

A
  • restore mobility/correct dysfunction
  • mobilize/manipulation
  • supportive intervention for impairments
  • medical Interventions: corticosteroid injection/percutaneous radiofrequency neurotomy/ facetectomy or joint replacement
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24
Q

Lumbar Segmental Instability (LSI): Radiological Instability

A
  • End range Instability
  • Based on >3mm translation on stress films (non-invasive gold standard)
  • May require surgical stabilization
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25
Q

Lumbar Segmental Instability (LSI): Clinical Instability

A
  • thought to be excessive motion in a segments neural zone
  • decrease capacity of the stabilizing system to maintain neutral zone within physiological limits
  • Clinical dx only can’t see on films
  • Requires clinical rx
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26
Q

Lumbar Segmental Instability (LSI):

A
  • Loss of motion stiffness in segments neutral zone
  • Decrease capacity of stabilizing system
  • Clinical Instability: loss of system control
  • Radiological instability: failure of passive system : trauma/neoplasm/degeneration/hyperlaxity/ iatogenic
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27
Q

Lumbar Segmental Instability (LSI): History

A
  • static positioning Increases pain
  • symptom improve with bracing/support
  • Self manipulates/ often seeks/requests
    -radiological: found 10-20% asymptomatic
  • prior episodes often with minimal perturbation
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28
Q

Lumbar Segmental Instability (LSI): Symptoms

A
  • Consistent clicking or clunking noises
  • protracted pain (with full ROM)
  • Excessive active ROM
  • Inability to recover normally from full ROM/commonly flexion
  • Compression symptoms (vertebrobasilar/spinal cord) which are not associated with a history of an IVD herniation or stenosis
  • Minor arching for a few days after a sensation of giving way
  • repeated episodes of feeling unstable or giving way/ following minor provocation
  • Back pain that most commonly described as recurrent, constant, catching, locking
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29
Q

Lumbar Segmental Instability (LSI): Tests and Measures

A
  • Observation: self supports spine or s observed to be restless

AROM
- Isolated lumbar flexion >53 degrees (+LR 4.8)
- Spasms at end range of mobility and worsening with repetitive motion
- Aberrant movement : painful arc, catching, Gower sign, reversal of lumbopelvic rhythm

Segmental Mobility Testing PA Glide
- Lack of hypomobility (+LR 9.0) or Hypomobility (+LR 2.4)

Special testing
- generalized ligamentous laxity testing : Beighton score >2 (+LR 2.5)
- prone Instability test (+)/ passive lumbar extension test (+)

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30
Q

Lumbar Segmental Instability (LSI): Intervention

A
  • Determine position of comfort and “maintain”
  • Stabilization in position of comfort
  • orthosis in acute stage due to trauma
  • Ok to mobilize neighboring hypomobile levels ( high failure rate to manipulate at unstable levels)
  • Educate: avoid prolonged positioning
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31
Q

SIJ and Pelvic Girdle Disorder

A
  • Rarely below knee
  • Absence of Lumbar pain
  • may refer distally to the buttock, groin, and post thigh
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32
Q

SIJ and Pelvic Girdle Disorder: Exam Findings

A
  • pain with sit to stand
  • no centralization /peripheralization
  • 3 or more pain provocation tests
    (+) sacral thrust
    (+) gaenslen’s
    (+) distraction/compression
    (+) thigh thrust
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33
Q

SIJ and Pelvic Girdle Disorder: Interventions

A
  • If hypomobile /mobilize
  • if hypermobile stabilize
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34
Q

Peripherally Mediated Pelvic Girdle Pain Disorder : general

A
  • Well defined, localized SIJ pain
  • May be associated with CT or myofascial structures
  • Usually unilateral and intermittent
  • MOI= repeated activity or trauma (fall onto butt or landing hard on one leg)
35
Q

Peripherally Mediated Pelvic Girdle Pain Disorder : Specific to reduced Force Closure

A
  • Insufficient compressive force
  • Excess strain due to ligament laxity and motor control deficits
  • Postpartum PGP
36
Q

Reduced Force Closure Exam Findings

A
  • Reduced TrA, multifidus, iliopsoas, glutes
  • Overactive QL, ES, EO, RA,OI
  • Swayback posture, slump sitting, asymmetrical standing
  • No L spine pain, centralization or peripheralization
    (+) ASLR
37
Q

Reduced Force Closure Interventions

A
  • Stabilization
  • SIJ belt
  • Posture co-contraction strategies
  • Relax overactive mm
38
Q

Excessive Force Closure

A
  • Excessive compressive forces or sustained loading at SIJ
  • Overactivation of pelvic local motor system
  • Hypomobility due to trauma or fusion
  • Localized to SIJ
39
Q

Excessive Force Closure Exam Findings

A

(+) Pain provocation Test
(-) ASLR
- high level of mm co-contraction in local and global

40
Q

Excessive Force Closure Interventions

A
  • Mobilization/Manipulation
    (CPR= pain not extending below knee symmetrical PSIS is seated/ (+) seated flexion test/(+) prone knee bend test)
  • Alternating submax isometric hip abd/add
  • butt gripping strategy: PPT, L-spine in flexion, LE’s ER
  • Cardiovascular exercise
  • Stretching
  • STM
  • MET
  • Diaphragmatic breathing
41
Q

Spondylosis

A
  • Fx at the par interarticularis
  • Loaded rotational movements or extension loading can lead to damage
  • Common in young males
42
Q

Spondylolysis Exam Findings

A
  • Scotty dog sign - utilize oblique view
43
Q

Spondylolysis Interventions

A
  • Correct mm imbalances
  • Increase trunk mm strength
  • Surgery if failed conservative management
44
Q

Spondylolisthesis

A
  • 4x more common in woman
  • Commonly @L4-L5
  • No association with LBP
  • Forward slippage of one vertebrae on another
  • Can be attributed to degenerative changes or defects at vertebrae
  • Chronic mechanical midline pain
  • Exacerbated by repetitive extension and torsional activities
45
Q

Spondylolisthesis Exam Findings

A
  • may complain of leg pain manifesting as neurogenic claudication
  • Bilateral thigh/leg fatigue
  • Normal lumbar flexion
  • Increased lumbar and hamstring mm tone due to compensation
  • May have palpable/visible step off
  • Utilize lateral view
46
Q

Spondylolisthesis Interventions

A
  • Pelvic positioning
  • Active lumbar stabilization
  • Stretching rectus femoris and iliopsoas to decrease anterior tilt
47
Q

Ankylosing Spondylitis

A
  • Chronic Progressive rheumatoid disorder
  • Inflammatory spondyloarthropathy
  • Insidious
  • Age <40
    Male>female
48
Q

Ankylosing Spondylitis Exam Findings

A
  • Ligament ossification with bamboo spine appearance
  • Pain > 3 months
  • Limited chest expansion

Cluster (3/4)
- pain improved with exercise not relieved with rest
- Awakening due to LBP in the second half of the night
- AM stiffness >30 minutes
- Buttock pain

49
Q

Ankylosing Spondylitis Interventions

A

Treat body impairments

50
Q

Cauda Equina Syndrome

A
  • Urine retention
  • fecal incontinence
  • Sensory or motor deficits in feet L4,L5,S1
  • Saddle anesthesia
  • EMERGENCY
51
Q

What are poor prognostic factors of LBP

A
  • Hx of LBP
  • Low education
  • Poor status
  • Peripheralization
  • Can’t modify at work
  • Depression/fear avoidance
52
Q

Where does LBP frequently originate from?

A
  • Skin
  • Postero/lateral annulus
  • Compressed nerve root
  • PLL
  • vertebral end plate
53
Q

What does the Waddell Screen Help Identify?
What comprises the screen ?

A
  • Yellow falgs
  • overreaction to exam like wincing, verbalizing, muscle tension, sweating
  • Stimulation- movements like axial loading produce pain
  • Distraction- (SLR)
  • Tenderness
  • ## Regional disturbances
54
Q

What muscles Make up the intermediate layer of the posterior trunk?

A
  • Serratus posterior superior and inferior
  • Helps with rib elevation/depression
55
Q

What are the 3 groups of muscles making up the deep musculature of the posterior trunk?
Superficial
Intermediate
Deep

A
  1. Superficial= Erector spinae (longissimus, spinalis, iliocostalis)
  2. Intermediate= transversospinal (semispinalis, multifidus, rotatores)
  3. Deep= Short segmental = Interspinalis/intertransveraris
56
Q
  1. the right external oblique rotates you what direction?
  2. The left oblique rotates you what direction?
A
  1. Left
  2. Right
57
Q

What would you stretch and strengthen to help foraminal lumbar stenosis

A

Stretch
- ES
- Iliopsoas
- rectus femoris

Strengthen
- ABs
- Hammies
- Glutes

58
Q

T/F Spinal flexion is worse for disc problems but better for opening IV foramen like with stenosis

A

true

59
Q

What Makes up the pelvic ring?

A
  • SIJ
  • Pubic Symphysis
  • Coxae Bones
60
Q

When is intradiscal pressure highest?

A

When sitting and bending over holding a weight

Second highest when standing bending over holding a weight

61
Q

What is the effect of Females having a CoG more posterior than males?

A

Increases rotational forces in female pelvis
Increases need for stabilization

62
Q

Why is the SIJ like no other joint in the body

A

No muscles perform active movements of the joint
Its a stress relieving joint

63
Q

What is the most stable position of the sacrum

A

A little bit of nutation

64
Q

What are the extrinsic ligaments of the SIJ ?

A
  • Superior/Inferior Iliolumbar & sacrotuberous = resist nutation and ER
  • Sacrotuberous connects with biceps femoris/resists nutation
65
Q

What is the most Important ligament of the SI ligaments?

A

Interosseous
- joints lateral sacrum to PSIS
- nutation torque stretches the interosseous and sacrotuberous ligament which compresses and stabilizes the SIJ

66
Q

What is inflare?

A

IR of ilium

67
Q

Is hip extension or flexion associated with counternutation

A
  • Hip extension
68
Q

Is lumbar extension or flexion associated with nutation

A

Lumbar extension

69
Q

What tests would be positive with lumbar disc herniation?

A

-SLR
-SLUMP
-Hyporeflexic
-Repeated flexion increases pain and peripheralization
- Pseudo-Gower Sign (using hands on knees to stand)

70
Q

How is -listhesis different from -lysis ?

A
  • lithesis = slippage
  • Lysis= fracture
71
Q

Which x-ray angle is good to view the facets and thus visualize spondylolysis?

A

Oblique

72
Q

What type of tilt do you want to avoid with spondylolysis?

A

Anterior

73
Q

What radiograph view allows us to see the intervertebral foramina well?

A

Lateral

74
Q

What is one of the first things you see on an x-ray with ankylosing spond?

A

Blurring of the arcuate lines on the sacrum

75
Q

What is the gold standard for abdominal or pelvic pain/trauma for imaging?

A

CT with contrast

76
Q

What is directional prefernce?

A

A favorable response to repeated movements (centralized, reduced pain, increased mobility without peripheralization)

77
Q

For Passive SLR list the nerve associated with each ankle movement

A
  1. Tibial Nerve= DF with eversion and great toe extension
  2. Sural Nerve= Dorsiflexion with inversion (posterolateral leg sensation)
  3. Saphenous Nerve= PF with eversion (posteromedial leg sensation)
  4. Common fibular nerve=PF with inversion
78
Q

Which pain provocation test of the SIJ stresses the sacrotuberous ligament?

A

Thigh trust

79
Q

What is the proper hip extension firing pattern?

A
  1. hammies
  2. glute max
  3. Contralater QL
    - Ipsilateral QL
80
Q

How can you differentiate between SIJ, hip problems and lumbar problems

A
  • (+) provication tests like thigh thrust and gaenslan + posterior pelvic palpation

-SIJ sign of the buttock, hip scour, FADIR, Trendelenburg, hop test, fulcrum test

  • Hip- spring test, SLR/Crosses SLR, femoral nerve tension test, bilateral sx, leg pain >back pain, pain with walking and relieved when sitting –> lumbar stenosis
81
Q

What is the diagnostic gold standard used for chronic LBP when MRI doesn’t show anything?

A

Discography

82
Q

What are the 4 lumbar special tests ?

A
  1. Lumbar Quadrant test
  2. Prone instability
  3. Passive Lumbar Extension
  4. Crossed SLR sign
83
Q

Name 5 pain provocation tests for SIJ

A
  1. Distraction and compression
  2. Gaenslen’s
  3. FABER
  4. Sacral Thrust
  5. Thigh Trust

MSK 3 Fall 2024 (8 decks)

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