Exam 2: Immob, pain, LLAF Flashcards
What do you attend to during observation?
- alignment
- atrophy
- edema/effusion
- color
- callus patterns
- shape
- signs of CRPS/RSD
- abnormal skin lesions/moles
What joint does “pronation/supination twist” occur at?
-tarsometatarsal
3 mechanisms that maintain arches in foot.
1) wedging of the interlocking tarsal and metatarsal bones
2) tightening of the ligaments on the plantar aspect of the foot
3) the intrinsic and extrinsic muscles of the foot and their tendons.
Ottawa Rules with Buffalo Modifications
1) tenderness over lateral malleolus to 6cm proximally
2) tenderness over medial malleolus to 6cm proximally
3) tenderness over navicular
4) tenderness over base of fifth metatarsal
Effects of immobilization on bone
- bone loss
- resorption > formation
- seen w/in 2 weeks
- drops 55-60% by week 12. after 12wk = permanent changes
-dec elastic resistance (more brittle)
Effects of immobilization on articular cartilage
- softening
- dec thickness
- adhesions
- dec proteoglycan synthesis
- pressure necrosis
- > 30 day immobilization = OA
Effects of immobilization on periarticular connective tissue
- dec GAG and water content
- dec lubrication
- abnormal cross linkage
- excessive fatty fiber deposition -> scar tissue
- clinical: ankylosis, jt stiffness, or joint contracture
Effects of immobilization on ligaments
- makes weaker
- dec fiber size and density = dec CSA
- dec GAG level
- haphazard arrangement of collagen fibers
- dec collagen synthesis
- inc osteoclastic activity at bone-ligament junction
Effects of immobilization on muscle
- dec size and mass
- dec strength
- inc or dec length depending on position of immobilization
- dec endurance
- dec recruitment
- slower contractions
- slow twitch > fast twitch
Effects of immobilization on nervous system
Dysponetic signaling = the misuse of energy in functional disorders. Reversible.
First oder pain stuff
- A delta, C fibers, (A beta) dorsal horn (SG)
2nd order pain stuff
- T (transmission) cells. Spinal cord to thalamus
lateral ST = a delta
anterospinothalamic = C fibers
periaquaductal gray = opiate
3rd order pain stuff
from thalamus to CNS higher centers
How does inflammation affect nerve endings?
- activates nociceptive receptors at nerve endings.
- increases threshold of firing, inc firing rate
= primary hyperalgesia - silent nociceptors activated (respond to inflammation in area) -> inc firing rate
- second messenger system activated = greater permeability and excitability
- catecholamines released as stress response = inc firing rate.
Peripheral nerve sensitization
- pain along nerve or distribution
- pain w/ palpation
- trigger points
- burning
- pain linked with stress
- off-loading nerve = relief
Central nervous sensitization
- not in neat boundaries
- spread
- multiple areas linked
- similar pain on contralateral side
- “chasing pain”
- temporal summation
- significant BPS factors
Sympathetic nervous system is regulated by what?
- brain and hypothalamus
- arousal, fear, and readiness. Part of upregulation in central sensitization
Cortical “smudging”
- decreased clarity of motor/sensory representation
- thought to explain why pain spreads.
Pain neuromatrix
Inputs: cognitive, sensory, emotion
Output: pain perception, action, stress-regulation
“neurotag”
- central sensitization
- pain “program”/memory/matrix
- recursive process between parts of brain related to a pain experience
A typical pain neurotag: 9 steps
1) pre-motor/motor
2) cingulate cortex
3) pre-frontal cortex
4) amygdala
5) sensory Cortex
6) hypothalamus/thalamus
7) Cerebellum
8) hippocampus
9) Spinal cord
Premotor/motor (neuro tag fx)
- organize and prepare movement
Cingulate cortex (neuro tag fx)
- concentration, focusing
Prefrontal Cortex (neuro tag fx)
- problem solving, memory
Amygdala (neuro tag fx)
- fear, fear conditioning, addiction
Sensory cortex (neuro tag fx)
- sensory distribution
Hypothalamus/thalamus (neuro tag fx)
- stress response, autonomic regulation, motivation
Cerebellum (neuro tag fx)
- movement and cognition
Hippocampus (neuro tag fx)
- memory, spatial recognition, fear conditioning
Spinal cord (neuro tag fx)
- gating from periphery
Cartesian pain model
- old theory. intensity of pain is directly related to the amount of associated tissue injury.
- not true.
L2-S2 myotomes
- L2 = hip flexors
- L3 = knee extensors
- L4 = ankle dorsiflexors
- L5 = big top extensors
- S1 = ankle plantar flexors
- S2 = hamstrings.
knee extensor reflex
- L3 level
DTR of achilles
- S1 level
Observation: Helbing’s sign
- bowing
- looking for achilles tendon alignment
Observation: Haglund’s deformity
- “pump bumps”/calcaneus exostosis
Observation: Feiss line
- “draw” line from medial malleolus to plantar 1st MTP
- in weight bearing position
- normal, 1 degree (1/3), 2 degree (2/3), and 3rd degree (3/3 - flat?)
Observation: navicular drop test
- check height of navicular in neutral
- check height while relaxed standing
- < 1 cm = normal
Observation: Medial longitudinal arch
- pec cavus (high arch) / planus (flat foot)
- feel for rigid vs supple
Observation: abductor hallicus
look for hypertrophy associated with overpronation
Observation: Fick angle
- toe out
- not specific to where motion comes from, only quantifies
- normal 5-18 degrees unilateral, adults = 12-18 degrees
Observation: Hallux valgus
- MTP bunion, callus formation
- normal 8-20 degrees, >15 degrees = “HV”
Observation: Morton’s/Greek toe
- the 2nd toe is longer than great toe
Observation: claw vs hammer toe
- Claw = Ext, Flex, Flex
- Hammer = ext, flex, ext.
Observation: transverse arch
- need to palpate STJ neutral. could appear normal with supinated foot and overpronating
Observation: Toe nails
- color, quality, etc
Shoe: Last
- either straight or inflare. Look at bottom of shoe
Shoe: Slipper vs board vs combo lasted
- Slipper = stitch down middle and glued. Is less stable
- Board = stitched around border. More stable
- Combo = stitched down middle and around.
Shoe: look for wear pattern
- inside shoe and outside. Will tell posture and gait stuff. correlates with callus formations
Shoe: creases
- will tell if first toe is rigid. Straight across or diagonal.
Shoe: flexibility
test with one finger to see if it is too stiff, etc.
Shoe: orthotics. look at them
- see if they are still effective and doing what they are supposed to be doing
Flexibility: hamstring 90/90
- it is passive. more reliable
- males norm = -20 degrees
- females norm = -10 degrees
Flexibility: thomas test. what are you looking for
- “J” sign indicates tight/short abductors
- look for short hip flexors
- IR or leg indicates tight/short TFL
Flexibility: Ober test
- do with knee flexed.
- looking for IT band tightness.
- make sure to stabilize pelvis
- norm = 20 degrees
Flexibility: piriformis
- hip flexion/adduction with maintained ER.
- quantify in 3 planes
Common finding of superior tib-fib
= hypermobility as a compensation for distal hypo-mobility
Circumferential rings for measurements
- measure a landmark that can be easily repeated
Ankle figure 8 for edema
- start at tib ant tendon
- medially over navicular
- under foot
- just prox to 5th styloid
- back to start
- around malleoli
Overuse syndromes: Consensus Intrinsic risk factors (know these!!)
- lack of running experience
- competitive running
- excessive weekly miles
- poor physical condition
- previous injury
Overuse syndromes: other intrinsic factors
- older/younger age
- female
- overweight
- smoking
Overuse syndromes: proposed extrinsic risk factors
- type of sport
- hard running surfaces
- uneven terrain
- time of day
- shoes
- orthoses
- running on same side of road (banked track examples)
- climate/weather
Common structural deformities: Rearfoot varus
- calcaneus on inversion bias
- will see: compensatory STJ overpronation, hip IR to get foot flat
- predisposes pt to inv ankle sprains, stress fractures
Common structural deformities: Forefoot varus (forefoot supination)
- common compensations: STJ overpronation, plantar flex 1st ray, hip IR
- common to find callus under metatarsal heads 1-3
