Counterstrain - Extremity & Diabetes screening

Question 1

Counterstrain Steps (7)

Answer 1

1. Find most significant Tenderpoint.
2. Physician establish a tenderness scale.
3. Monitor Tenderpoint throughout.
4. Place patient in “Position of Ease” of at least 70% improvement.
5. Hold 90 seconds.
6. Slowly return to neutral.
7. Recheck tenderness and associated TART findings.

Question 2

Supraspinatus: counterstrain positioning/treatment

Answer 2

F Abd ER patient’s arm is flexed 45 degrees, abducted 45 degrees, and externally rotated

Question 3

Levator Scapulae: counterstrain positioning/treatment

Answer 3

IR Abd traction IR pt’s shoulder, add mild-mod traction with minimal abduction

Question 4

Subscapularis: counterstrain positioning/treatment

Answer 4

E IR pt’s shoulder extended and internal rotated, traction can help

Question 5

Biceps Brachii (Long Head): counterstrain positioning/treatment

Answer 5

F Abd ir elbow and shoulder flexed, arm is minimally abducted and internally rotated

Question 6

Biceps Brachii (Short Head)Coracobrachialis: counterstrain positioning/treatment

Answer 6

F Add ir elbow and shoulder flexed, arm is minimally adducted and internally rotated

Question 7

Radial Head–Lateral (Supinator): counterstrain positioning/treatment

Answer 7

E SUP Val pt’s elbow in full Extension, forearm markedly supinated, fine tune with vaLgus force

Question 8

Medial Epicondyle (Pronator Teres): counterstrain positioning/treatment

Answer 8

F PRO Add pt’s elbow Flexed, marked pronation, forearm slightly aDducted

Question 9

Dorsal Wrist (Extensor Carpi Radialis): counterstrain positioning/treatment

Answer 9

E Abd/rd pt’s wrist passively Extended and aBducted

Question 10

Dorsal Wrist (Extensor Carpi Ulnaris): counterstrain positioning/treatment

Answer 10

E ADD pt’s wrist passively Extended and aDducted

Question 11

Palmar Wrist (Flexor Carpi Radialis): counterstrain positioning/treatment

Answer 11

F Abd pt’s wrist passively Flexed and aBducted

Question 12

Palmar Wrist (Flexor Carpi Ulnaris): counterstrain positioning/treatment

Answer 12

F Add

pt’s wrist passively Flexed and aDducted

Question 13

First CMP (Abductor Pollicis Brevis): counterstrain positioning/treatment

Answer 13

F (wrist) Abd (thumb) pt’s wrist passively Flexed, thumb is aBducted

Question 14

Lateral Trochanter (Tensor Fasciae Latae): counterstrain positioning/treatment

Answer 14

patient’s knee is aBducted and slightly flexed •May require slight internal rotation of the hip

Question 15

Iliotibial band: counterstrain positioning/treatment

Answer 15

f ABD patient’s hip/thigh is abducted and slightly flexed until the tenderness is ≥70% reduction •May require slight internal or external rotation of the hip

Question 16

Lateral hamstring tender point: counterstrain positioning/treatment

Answer 16

F ER ABd patient’s knee is flexed and the tibia is externally rotated with slight abduction; compression on the calcaneus is added to plantar flex the ankle

Question 17

Medial hamstring: counterstrain positioning/treatment

Answer 17

F IR Add patient’s knee is flexed and the tibia is Internally rotated with slight aDduction; compression on the calcaneus is added to plantar flex the ankle

Question 18

Lateral Meniscus: Lateral (Fibular) Collateral Ligament counterstrain positioning/treatment

Answer 18

pt’s thigh abducted so leg is off table, flex knee~35-40 degrees, tibia is abducted and externally or internally rotated until the tenderness is ≥70% reduction •May require ankle dorsiflexion and eversion of the ankle

Question 19

Medial Meniscus: Medial (Tibial) Collateral Ligament counterstrain positioning/treatment

Answer 19

pt’s thigh abducted so leg is off table, flex knee~35-40 degrees, tibia is adducted and internally rotated until the tenderness is ≥70% reduction •May require plantar flexion and inversion of the ankle

Question 20

Anterior Cruciate: counterstrain positioning/treatment

Answer 20

towel roll or pillow under distal femur for fulcrum, apply force to proximal tibia to translate tibia posteriorly on distal femur until the tenderness is ≥70% reduction

Question 21

Posterior Cruciate: counterstrain positioning/treatment

Answer 21

towel roll or pillow under proximal tibia for fulcrum, apply force to distal femur to translate femur posteriorly on proximal tibia until the tenderness is ≥70% reduction

Question 22

Popliteus: counterstrain positioning/treatment

Answer 22

pt’s knee flexed and tibia is internally rotated until the tenderness is ≥70% reduction

Question 23

Extension Ankle (Gastrocnemius): counterstrain positioning/treatment

Answer 23

pt’s knee flexed and dorsum of foot on doc’s thigh, add compressive force through calcaneus until the tenderness is ≥70% reduction

Question 24

Medial Ankle (Tibialis Anterior): counterstrain positioning/treatment

Answer 24

Inversion apply inversion force to foot and ankle with slight internal rotation until the tenderness is ≥70% reduction

Question 25

Lateral Ankle Fibularis (Peroneus)Longus, Brevis, Tertius: counterstrain positioning/treatment

Answer 25

Eversion apply eversion force to foot and ankle with slight external rotation until the tenderness is ≥70% reduction

Question 26

Flexion Calcaneus (Quadratus Plantae): counterstrain positioning/treatment

Answer 26

patient’s knee is flexed, dorsum of foot on doc’s thigh, marked flexion while translating calcaneus toward the forefoot until the tenderness is ≥70% reduction

Question 27

Navicular: counterstrain positioning/treatment

Answer 27

F patient’s knee is flexed, dorsum of foot on doc’s thigh, plantar flexion of subtalar joint, supination of forefoot until the tenderness is ≥70% reduction

Question 28

Why do we examine diabetic feet?

Answer 28

Elevated levels of blood sugar cause damage to nerves and smaller blood vessels ◦Loss of sensation ◦Decreased blood flow

Question 29

Lack of sensation puts (diabetes) patients at risk for:

Answer 29

◦Repetitive trauma ◦Unnoticed injuries ◦Structural deformities

Question 30

◦Decreased blood flow puts (diabetes) patients at risk for:

Answer 30

◦Infection ◦Insufficient wound healing ◦Tissue breakdown (gangrene)

Question 31

Steps for diabetic foot exam (6)

Answer 31

Steps 1.Inspection 2.Palpation 3.Vascular evaluation 4.Reflexes 5.Monofilament Testing 6.Sensation testing

Question 32

Most commonly missed foot inspection site?

Answer 32

Toe web spaces

Question 33

Monofilament Exam - how?

Answer 33

◦Patient supine or seated with eyes closed and plantar surface exposed

◦Provide patient with reference sensation

◦Instruct patient to inform you when they feel the monofilament

◦Apply monofilament perpendicularly to skin at testing sites with enough pressure to buckle the filament for 1 second

◦Testing sites should be assessed in random order so patients cannot anticipate it