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PTH 507: ORTHO > Exam 2: Immob, pain, LLAF > Flashcards

Exam 2: Immob, pain, LLAF Flashcards

1
Q

What do you attend to during observation?

A
  • alignment
  • atrophy
  • edema/effusion
  • color
  • callus patterns
  • shape
  • signs of CRPS/RSD
  • abnormal skin lesions/moles
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2
Q

What joint does “pronation/supination twist” occur at?

A

-tarsometatarsal

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3
Q

3 mechanisms that maintain arches in foot.

A

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.

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4
Q

Ottawa Rules with Buffalo Modifications

A

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

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5
Q

Effects of immobilization on bone

A
  • bone loss
    - resorption > formation
    - seen w/in 2 weeks
    - drops 55-60% by week 12. after 12wk = permanent changes

-dec elastic resistance (more brittle)

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6
Q

Effects of immobilization on articular cartilage

A
  • softening
  • dec thickness
  • adhesions
  • dec proteoglycan synthesis
  • pressure necrosis
  • > 30 day immobilization = OA
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7
Q

Effects of immobilization on periarticular connective tissue

A
  • dec GAG and water content
  • dec lubrication
  • abnormal cross linkage
  • excessive fatty fiber deposition -> scar tissue
  • clinical: ankylosis, jt stiffness, or joint contracture
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8
Q

Effects of immobilization on ligaments

A
  • 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
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9
Q

Effects of immobilization on muscle

A
  • 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
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10
Q

Effects of immobilization on nervous system

A

Dysponetic signaling = the misuse of energy in functional disorders. Reversible.

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11
Q

First oder pain stuff

A
  • A delta, C fibers, (A beta) dorsal horn (SG)
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12
Q

2nd order pain stuff

A
  • T (transmission) cells. Spinal cord to thalamus

lateral ST = a delta
anterospinothalamic = C fibers
periaquaductal gray = opiate

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13
Q

3rd order pain stuff

A

from thalamus to CNS higher centers

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14
Q

How does inflammation affect nerve endings?

A
  • 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.
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15
Q

Peripheral nerve sensitization

A
  • pain along nerve or distribution
  • pain w/ palpation
  • trigger points
  • burning
  • pain linked with stress
  • off-loading nerve = relief
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16
Q

Central nervous sensitization

A
  • not in neat boundaries
  • spread
  • multiple areas linked
  • similar pain on contralateral side
  • “chasing pain”
  • temporal summation
  • significant BPS factors
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17
Q

Sympathetic nervous system is regulated by what?

A
  • brain and hypothalamus

- arousal, fear, and readiness. Part of upregulation in central sensitization

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18
Q

Cortical “smudging”

A
  • decreased clarity of motor/sensory representation

- thought to explain why pain spreads.

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19
Q

Pain neuromatrix

A

Inputs: cognitive, sensory, emotion

Output: pain perception, action, stress-regulation

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20
Q

“neurotag”

A
  • central sensitization
  • pain “program”/memory/matrix
  • recursive process between parts of brain related to a pain experience
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21
Q

A typical pain neurotag: 9 steps

A

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

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22
Q

Premotor/motor (neuro tag fx)

A
  • organize and prepare movement
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23
Q

Cingulate cortex (neuro tag fx)

A
  • concentration, focusing
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24
Q

Prefrontal Cortex (neuro tag fx)

A
  • problem solving, memory
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25
Q

Amygdala (neuro tag fx)

A
  • fear, fear conditioning, addiction
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26
Q

Sensory cortex (neuro tag fx)

A
  • sensory distribution
27
Q

Hypothalamus/thalamus (neuro tag fx)

A
  • stress response, autonomic regulation, motivation
28
Q

Cerebellum (neuro tag fx)

A
  • movement and cognition
29
Q

Hippocampus (neuro tag fx)

A
  • memory, spatial recognition, fear conditioning
30
Q

Spinal cord (neuro tag fx)

A
  • gating from periphery
31
Q

Cartesian pain model

A
  • old theory. intensity of pain is directly related to the amount of associated tissue injury.
  • not true.
32
Q

L2-S2 myotomes

A
  • L2 = hip flexors
  • L3 = knee extensors
  • L4 = ankle dorsiflexors
  • L5 = big top extensors
  • S1 = ankle plantar flexors
  • S2 = hamstrings.
33
Q

knee extensor reflex

A
  • L3 level
34
Q

DTR of achilles

A
  • S1 level
35
Q

Observation: Helbing’s sign

A
  • bowing

- looking for achilles tendon alignment

36
Q

Observation: Haglund’s deformity

A
  • “pump bumps”/calcaneus exostosis
37
Q

Observation: Feiss line

A
  • “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?)
38
Q

Observation: navicular drop test

A
  • check height of navicular in neutral
  • check height while relaxed standing
  • < 1 cm = normal
39
Q

Observation: Medial longitudinal arch

A
  • pec cavus (high arch) / planus (flat foot)

- feel for rigid vs supple

40
Q

Observation: abductor hallicus

A

look for hypertrophy associated with overpronation

41
Q

Observation: Fick angle

A
  • toe out
  • not specific to where motion comes from, only quantifies
  • normal 5-18 degrees unilateral, adults = 12-18 degrees
42
Q

Observation: Hallux valgus

A
  • MTP bunion, callus formation

- normal 8-20 degrees, >15 degrees = “HV”

43
Q

Observation: Morton’s/Greek toe

A
  • the 2nd toe is longer than great toe
44
Q

Observation: claw vs hammer toe

A
  • Claw = Ext, Flex, Flex

- Hammer = ext, flex, ext.

45
Q

Observation: transverse arch

A
  • need to palpate STJ neutral. could appear normal with supinated foot and overpronating
46
Q

Observation: Toe nails

A
  • color, quality, etc
47
Q

Shoe: Last

A
  • either straight or inflare. Look at bottom of shoe
48
Q

Shoe: Slipper vs board vs combo lasted

A
  • Slipper = stitch down middle and glued. Is less stable
  • Board = stitched around border. More stable
  • Combo = stitched down middle and around.
49
Q

Shoe: look for wear pattern

A
  • inside shoe and outside. Will tell posture and gait stuff. correlates with callus formations
50
Q

Shoe: creases

A
  • will tell if first toe is rigid. Straight across or diagonal.
51
Q

Shoe: flexibility

A

test with one finger to see if it is too stiff, etc.

52
Q

Shoe: orthotics. look at them

A
  • see if they are still effective and doing what they are supposed to be doing
53
Q

Flexibility: hamstring 90/90

A
  • it is passive. more reliable
  • males norm = -20 degrees
  • females norm = -10 degrees
54
Q

Flexibility: thomas test. what are you looking for

A
  • “J” sign indicates tight/short abductors
  • look for short hip flexors
  • IR or leg indicates tight/short TFL
55
Q

Flexibility: Ober test

A
  • do with knee flexed.
  • looking for IT band tightness.
  • make sure to stabilize pelvis
  • norm = 20 degrees
56
Q

Flexibility: piriformis

A
  • hip flexion/adduction with maintained ER.

- quantify in 3 planes

57
Q

Common finding of superior tib-fib

A

= hypermobility as a compensation for distal hypo-mobility

58
Q

Circumferential rings for measurements

A
  • measure a landmark that can be easily repeated
59
Q

Ankle figure 8 for edema

A
  • start at tib ant tendon
  • medially over navicular
  • under foot
  • just prox to 5th styloid
  • back to start
  • around malleoli
60
Q

Overuse syndromes: Consensus Intrinsic risk factors (know these!!)

A
  • lack of running experience
  • competitive running
  • excessive weekly miles
  • poor physical condition
  • previous injury
61
Q

Overuse syndromes: other intrinsic factors

A
  • older/younger age
  • female
  • overweight
  • smoking
62
Q

Overuse syndromes: proposed extrinsic risk factors

A
  • type of sport
  • hard running surfaces
  • uneven terrain
  • time of day
  • shoes
  • orthoses
  • running on same side of road (banked track examples)
  • climate/weather
63
Q

Common structural deformities: Rearfoot varus

A
  • calcaneus on inversion bias
  • will see: compensatory STJ overpronation, hip IR to get foot flat
  • predisposes pt to inv ankle sprains, stress fractures
64
Q

Common structural deformities: Forefoot varus (forefoot supination)

A
  • common compensations: STJ overpronation, plantar flex 1st ray, hip IR
  • common to find callus under metatarsal heads 1-3

PTH 507: ORTHO (4 decks)

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