Exam 2 Flashcards
Capsular patterns
pattern of movement restriction in more than one direction with interarticular effusions, swelling, and fibrosis of the joint capsule
non capsular patterns
not a problem with the joint
hip capsular pattern
limited flexion, abduction, and medial rotation in that order
glenohumeral capsular pattern
limited ER, abduction, and IR in that order
knee capsular pattern
limited flexion more than extension
likely cause of pain in every motion
referred pain (originating from an outside area)
how to test for referred pain?
fortin finger test
what does positive fortin finger test point to?
S1 joint problems
what does it mean if AROM and PROM do not recreate symptoms?
likely not a muscle problem
could be dermatome, myotome, sclerotome
how to assess dermatomes
use light touch
evaluation: assess upper and lower extremity and trunk
how to test for muscle function?
myotomes
irritation/weakness on only one side could mean
chronic irritation of nerve
central lesion
pushing towards back and normally on one side
Symptoms of L5 nerve being indicated
inability to extend great toe w/ 3/5 strength
inability to walk on heels, foot drop
inability to resist prone knee flexion or prone hip extension, 3/5 strength
only on one side
what other nerves have similar symptoms to L5?
L4 or S1
areas of the body to look for pain and weakness and sensation for L5
Butt, hamstring, shin, toes
sclerotomes
deep somatic tissues innervated by the same vertebral segmental nerve
will musculoskeletal injury cross the midline?
no
will a neurological injury cross the midline?
yes
superficial injury is more likely
referred pain
deeper injury travels?
in one direction, less likely to travel
muscle injury pain travels
along length of the muscle but doesn’t go through many joints
groin pain is a sign of
deep labral tear
what can organ problems cause
back pain
when to look elsewhere for cause/ injury
cannot reproduce symptoms or relieve pain with AROM, PROM, joint play, or resisted isometric motions
patient red flags
unexplained weight loss
malaise
pain and symptoms that dont change with MS tests
MS problem not responding to usual treatment
symptoms out of proportion to injury
night pain, sweats, fever
Cancer warning signs
change in bowel/ bladder habits
a sore that doesnt heal in 6 weeks
unusual bleeding or discharge
thickening/ lump in breast or elsewhere
indigestion or difficulty swallowing
obvious changes in wart/ mole
nagging cough or hoarseness
strongest ligament in body
iliofemoral ligament
ischiofemoral ligameent
limits flexion and extension
superior fibers limit abduction
closed pack of hip joint
full extension (20 degrees)
ligaments tightened
not boney congruency
open pack of hip joint
flexion, abduction and ER
iliofemoral ligament limits
hip extension
psoas major action
flexion and lateral rotation of the hip
psoas minor action
trunk flexion
iliacus action
flexion and ER of femur
rectus femoris action
hip flexion
knee extension
lumbar origin nerves
L2-L4
local nerve
femoral nerve
what does major weakness of glute max look like?
leaning back
what does major weakness of glute med look like?
hip drop w/ Trendelenburg test
hip flexion ROM
120
hip extension ROM
20
hip abduction ROM
45
hip adduction ROM
15
hip internal rotation ROM
45
hip external rotation ROM
45
coxa vara
angle of femoral head is less than 125 degrees
results of coxa vara
distal leg shifted medially into adduction
femur adducted
genu valgum (knock knees)
coxa valga
angle of femoral head is greater than 140
results of coxa valga
distal leg shifted laterally into abduction
femur abducted
genu varum (bow leg)
normal femur angle in hip
126-139
coxa valga and leg length
coxa valga on one side creates longer leg length
causes genu varum
smaller moment arm
less torque from glutes
coxa varum and leg length
coxa varum on one side creates shorter leg length
causes genu valgum
longer moment arm –> mechanical advantage
more susceptible to femoral neck fractures
angle of torsion
angle of femoral neck
larger angle of torsion
femoral antiversion
head in front of where it should be
internal rotation
knees IR
smaller angle of torsion
femoral retroversion
head is behind where it should be
external rotation
results of femoral anteversion
greater risk of anterior dislocation
causes pes caves foot if uncompensated
pes plants foot if compensated
results of femoral retroversion
increased posterior dislocation risk
causes pes plants foot if uncompensated
pes caves if compensated
intracapsular fracture
femoral neck
extra capsular fracture
intertrochanteric
femoral shaft
causes of femoral shaft fractures
trauma
sports collision
MVA
workplace injury
open reduction internal fixation
IM nail
IM rod
single fixation
double fixation
plate and screws fixation
exercise post femoral shaft fracture
start with open chain b/c short lever arm
muscles spastic and inhibited
improve mobility
acute treatment phase femoral shaft fracture
PROM and AAROM to engagee
isometric exercises will be uncomfy
carry over from opposite side
crutch training
stairs
subacute treatment phase femoral shaft fracture
50% WB for a couple of weeks
work up to WBAT
progress to AROM
extend against gravity
open chain then work towards closed chain
surgical treatment for intertrochanteric fracture
ORIF
compression screw- WB sooner
dynamic compression screw
PT for intertrochanteric fracture
similar
want OP notes
NWB to PWB to FWB
femoral neck fracture surgery
hemi arthroplasty to replace bone that has died
blood supply at risk (circumflex femoral a. and obturator artery)
hemiarthroplasty process
femoral half fits into acetabular socket
cemented or uncemented
cut off head and neck that has necrosis and ream it in
how long does a hemiarthroplasty last?
15-20 years
options to hold a hemiathroplasty in place
boney ingrowth or cementing
bipolar endoprothesis
lower rate of acetabular erosion
atmospheric pressure and muscle and capsules hold it in place
considerations with bipolar endoprothesis
tissues need to head and get muscles strong
more likely to dislocate
total hip arthroplasty
acetabulum is cut and replaced with a socket
femoral head fits in plastic liner within acetabular component
when to do total hip arthroplasty
acetabulum is not healthy enough to keep
arthritis of the hip
wearing down of articular surfaces (cartilage) and uneven weight on surfaces that becomes painful
boney overgrowth around joints and bone spurs
what can develop on surface of bone with arthritis
cysts, pits, groves, atrophy
symptoms of arthritis of hip
irritation of bone, atrophy, sclerotic, inflammation, synovium hypertrophies, capsule thickening, shortening and thickening in capsular pattern, spastic muscles, increased vascularity, fibrosis of capsules
impacts of hip arthritis
painful
development of adaptations that wear down the rest of the kinetic chain
PT interventions for arthritis
patient education
realistic activities with rest
assistive devices as needed
thermal modalities
joint mobilizations
meds
function and treatment of arthritis
is functioning okay, then leave it
hip osteoarthritis symptoms
groin pain
referred knee pain
stiffness
antalgic gait (glute med)
limited hip extension, IR, flexion
muscle weakness (quads, glute med, glute max)
functional limitations of hip OA
sit to stand
walking
stairs
squatting
in and out of car
dressing
PT treatment for arthritis
ROM: joint mob, stretching, ROM exercises
muscle strength
independence (ADLs, progressing)
posterior approach total hip
glute max is divided
ERs released and repaired
posterior capsule released and repaired
most common approach
no damage to abductors
anterior approach total hip
no muscles cut
access between TFL and RF
more difficult, newer
posterior approach hip dislocation precautions
no IR
no adduction
no Flexion >90
avoid crossing legs
avoid sitting in low chairs
avoid pivoting on and towards operative leeg
avoid sleeping without abd pillow
avoid donning shoes and socks normally
anterior approach hip dislocations precautions
no ER
no extension
no flexion >90
avoid combo flex, abduction, ER
avoid crossing leegs
avoid large steps with ambulation
do step to gait
avoid pivoting on and away from operative leg
acute care THA
hospitalization 2-5days
PT day of or day afteer
abduction pillow in supine
no pillow under knee/thigh
early movement
WBAT or PWB
education
acute care exercises THA
ankle pumps
deep breathing
bed mobility and transfers
submax isometrics (quads, ext., abduction)
resistance for intact UE and LE
ambulation with assistive device
AAROM of hip
AROM of knee
clamshells
standing hip flex/ext of operative leg
weight shifting
heel raises
meds THA
NSAIDs
COX 1 and 2 inhibitors (aspirin, Motrin, Advil)
Tylenol
discharge criteria THA
achieve independent functional mobility
bed mobility
sit to stand
transfer
ambulations with assistive devices
stairs with assistive devices
what do special tests tell you in general
ligament tests and grading
sensitivity
specificity
clinical predication values
ligament stress test grade I
0-5mm
ligament stress test grade II
6-10mm
ligament stress test grade III
11-15mm
ligament stress test grade IV
15mm +
what to look for during ligament stress test with valgus and varus
gaping
valgus knee stress test restraints
MCL is primary restraint
Medial capsule is secondary restraint
when are capsule and MCL tight
0 degrees extension
when is MCL most tight
30 degrees knee flexion
Valgus knee stress test in acute stage
not very valid because of inflammation and muscle guarding
primary restraint is typically?
a ligament or group of ligaments
secondary restraint is typically?
the joint capsular ligaments or capsule itself
passive test for ligament stress testing
no muscle guarding
what to do when there is joint stiffness?
joint mobilization (grade 3 sustained or grade 3 or 4 oscillating )
positioning for 2 joint muscles
put on slack to get more ROM
what muscles will be affecting by gravity?
weak muscles
PT intervention for joint dysfunction
mobility and stability first
progress to adding load to improve strength
painful joints and ROM
will not want to move in passive
end feel is empty
how to identify irritated nerve?
neural tension tests
treatment intervention for irritated nerve?
neural mobilization
move joints to allow nerve to go proximal and vital and mobilize the area
how to identify soft tissue restrictions
palpation
how to identify tight muscles
ROM affected by proximal or distal joint positioning
how to identify intra articular adhesions
ROM not affected by joint positioning
treatment for tight muscles
stretch
treatment for soft tissue restrictions
soft tissue mobilization
special tests are used to
assess the integrity of the joint, surrounding structures, and musculature as stabilizers and the patient’s level of anxiety during the injury and the trust of their PT
Specificity rule
High specificity, rule in
ordering of special tests
start with high sensitivity to rule things out and then move on to highly specific tests
highly sensitive tests are good at finding?
patients with a condition
likely to test positive on someone who has the condition
sensitivity rule
if a high sensitivity test is negative
rule out
high specificity is good at picking up?
for one certain condition
benefits of sensitive tests
good to rule things out
easy clinical tests
specific tests of high value examples
x-ray, MRI
PPV
positive predictive value
what does PPV show us?
probability that a person with positive results actually has the condition
NPV
negative predictive value
what does NPV show us?
probability that a person with negative results will likely show they do not have the condition
why are predictive values useful?
to assess feasibility
save time, resources on testing
likelihood ratios assess
assess the potential utility of a particular diagnostic test
assess the likelihood that a patient has a disease or condition
likelihood ratio
ratio of the probability that a test result is correct to the probability that the test result is incorrect
does LR rely on symptoms?
no
it is a stand alone calculation
high LR means
large and significant increase in the probability of a disease given a positive test
do nerves elicit pain with light stimulation?
no
what happens with compression or stretching of irritated nerves?
sharp and shooting pain
Slump test
gives tension to nerve and DF increases
sciatic nerve tests
slump test, SLR, Bowstring
Bowstring test
bend knee and press it into back of knee to reproduce pain
SLR sensitivity and specificity
91% sensitive- if negative, rule out
26% specificity- if positive, could be due to other reasons
what can SLR indicate if ankle DF or cervical flexion increases symptoms?
L5-S1 nerve entrapment
Positive SLR could be
tight hamstrings, weak muscles, nerve damage, posterior joint capsule of hip
Tinel’s sign
thumping on nerve and having pain at 30 degrees of SLR
nerve and vascular compression test groupings
carpal tunnel and tinel’s
carpal tunnel and phalen’s
radial and ulnar artery sufficiency, Allen’s
