Exam 3: Thoracic, Lumbar, SI, Hip, & Knee Flashcards
What is the orientation of the spinous processes in the thoracic spine?
T2-T6: project one level caudally
T7-T8: project two levels caudally
T11-T12: project one level caudally
What is the orientation of the facets in the thoracic spine?
superior facets face mostly posteriorly and slightly lateral; inferior facets face mostly anteriorly and slightly medial
Describe the shape of the rib cage during rotation
during rotation, the posterior aspect of the rib cage to the side ipsilateral to the rotation becomes more convex and the anterior portion flattens, the opposite occurs on the contralateral side
What are the relevant dermatomes of the thoracic spine?
T1: medial upper arm
T2: axilla
T5-6: nipple line
T10: umbilicus
What are the relevant dermatomes of the thoracic spine?
T1: medial upper arm
T2: axilla
T5-6: nipple line
T10: umbilicus
What are the three locations for potential impingement of the brachial plexus (i.e. thoracic outlet syndrome)?
between anterior and middle scalene, between the clavicle and the first rib, & under the tendon of pectoralis minor as it inserts on the coracoid process
Gibbus Deformity
anterior wedging of bodies of two or more vertebrae, resulting in a sharp angulation of the spine
Ankylosing Spondylitis
inflammatory arthritis that begins as synovitis of the facet joints and then begins to affect the ligaments, connective tissue, & disc; annulus ossifies and fuses with vertebrae; initially SI, upper leg pain (uni- or bi-), and progresses to costovertebral and costotransverse joints, and eventually affects the shoulders and hips in 30% of pts; associated with enthesitis; hallmarks are stiffness and motion loss
What is the plan of care for ankylosing spondylitis?
- coordination with other professionals
- decrease pain with TENS and cold packs
- improve mobility
- improve aerobic endurance
- improve function
- prevention/slowing the progression (bracing)
- compensation
Scheuerman’s Disease
growth deformity resulting from wedging of anterior aspects of bodies of at least three vertebrae (acquired gibbus deformity); usually diagnosed in adolescence and does not usually progress past growth spurt; not inflammatory in and of itself
What is the plan of care for Scheuerman’s disease?
surgery is usually rare unless the kyphotic angle is >75˚; braces can also be used during the growth spurt, especially if the kyphotic angle is >50˚
Scholiosis
curvature >10˚: thoracic curve may be structural, lumbar or cervical curves may be compensatory and more mobile; idiopathic = 70-80%
How is scoliosis designated?
by the apex of the curve; right thoracic is most common, but right thoracolumbar, right lumbar, left thoracic right lumbar, and cervicothoracic can also occur
Cobb Angle
lines through most angulated vertebrae of curve; >40˚ = more assertive approach to treatment; progression of 5˚ per year in children is a red flag for more assertive intervention
Adam’s Forward Bend Test
Sn = .92; Sp = .60; compared with the gold standard of Cobb angle = >20˚ on a radiograph
What are treatment options for scoliosis?
- pain
- mobility
- stability
- breathing
- education
- exercises
- prevention of progression
Surgery for Scholiosis
goal is to straighten and stabilize the curve, rods and screws to straighten and hold, associated with a risk of instability; fusion stimulated by flaking bone during surgery (rod may eventually be removed)
Osteoporosis
- 25% of all older women; 40% >80 yrs
- older men almost as high
- 15% mortality rate after fall
What is the plan of care after fracture?
- stabilization
- thoracolumbosacral brace for 6 weeks
- kyphoplasty (balloon inserted to decompress the fx, then acrylic material is injected into balloon
- vertebroplasty (medical cement is injected into the spine of the fracture)
What are the common causes of Thoracic Outlet Syndrome?
- cervical rib
- abnormal first thoracic rib (wide, elevated, malformed)
- hypertrophied scalene
- pec minor
Costochondritis
inflammatory process of costochondral or chondrosternal joints; usually self-limiting within one year, but are often recurrent
The spinal cord occupies about __% of the canal in the thoracic spine, but about __% in the lumbar and cervical regions (smaller thoracic canal)
40%; 25%; tumors have more of an impact
What are the effects of aging in the thoracic spine?
- costal cartilages ossify
- joints ossify
osteoporosis of ribs - increased kyphosis
- diaphragm less domed
In regards to pathoanatomical origins of LBP, only __% have identified causes, while __% are unidentified
15%; 85%
What are the identified pathoanatomical causes of LBP?
- disc herniation w/ nerve root compression
- stenosis
- spondylolysis/spondylolisthesis
- fracture
- malignancy
- infection/inflammation
Factors that Increase Suspicion of Sinister Pathology in LBP
- trauma >50 YO
- age >70
- history of cancer
- unexplained weight loss
- signs of systemic illness
- pain rest > activity
- pain worse at night
- unexplained fever
- corticosteroid use
- IV drug use
- immunosuppression
- failure to improve w/ conservative care for 1 month
Visceral/Vascular Origins
- abdominal aortic aneurysm (AAA)
- prostatitis
- renal disease
- gynecologic disorders
- numerous others
Ankylosing Spondylitis Pain Characteristics
- usually dull in character
- poorly localized and often deep gluteal area
- sometimes intermittent and alternating sides
- often becomes bilateral
Indicators or Inflammatory LBP
- morning stiffness >30 minutes duration
- improved with exercise/activity
- not better with rest
- awakening because of LBP in 2nd half of night only
- alternating buttock pain
- pain duration > 3 mos
Suspicion of Ankylosing Spondylitis
age onset <40 YO and unusual after 45; mean age of onset 25; positive family history; traumatic improvement with NSAIDs
What is the clinical presentation of ankylosing spondylitis?
- loss of lordosis
- loss of motion - fixed kyphosis
- forward bending all hip flexion
- may have diminished chest expansion
- may be unable to face forward
- likely with marked functional limitations
Fibromyalgia
widespread musculoskeletal aches with multiple tender point areas in all four quadrants; complaints of stiffness; pts may present w/ area of primary complaint; often with fatigue and lack of restorative sleep
Exam Findings of Fibromyalgia
- joints without effusion or edema
- neurological exam normal
- cervical and lumbar motion modestly limited
- global tender point areas
- may accompany other MSK or rheumatologic disorders
Signs and Sx. of Cauda Equina Syndrome
- saddle anesthesia
- changes in bowel or bladder
- gait disturbances
Fractures
usually associated with trauma or osteoporosis and usually demonstrable on rads, CT, MRI; flexion and wt. bearing activities usually irritating; thoracolumbar junction is more common than lower lumbar
Clinical Presentation of Fractures
- possible deformity
- motion loss, flexion usually more painful
- usually no neurological signs if stable
- debilitating pain for two weeks
Exam Findings of Mechanical LBP
- no radiculopathy, but may have distal symptoms
- pattern of motion loss
- may/may not have deformity
- negative neuro exam
- loss of PIVM
Biomechanical Effects
- realignment/reducing subluxation
- breaking adhesions
- reduction of capsular/ligamentous hypomobility
- increased fluid exchange
- cavitation
Neurophysiological Effects
- change in central pain processing
- change in muscle recruitment
- reduced temporal summation
- biochemical changes
Psychological Effects
- placebo effect
- perception of benefit
- patient expectations & beliefs
Acute Sprain/Strain
usually traumatic onset that involves multiple tissues; nay position maintained and every motion provocative; inflammatory initial stage, then evolves into mechanical syndrome
Facet Joint Syndrome
mechanics compressing/loading of facet, onset related to extension; generalized loss of capsular mobility; often with prior disc pathology (older) and hyperlordotic posture (younger); standing/walking is more painful than sitting
Facet Joint Syndrome Exam Findings
- pain usually low back and buttock, occasionally thigh, but not typically distal to knee
- extension provocation
- no neurological signs or sx
- reduces PIVM
- often dramatic reduction with manual therapy
Spondylolysis/Spondylolisthesis
- often adolescent athletes (female > male)
- onset often related to extension activities
- suspect fx until ruled out radiologically
- hypertonus in hamstrings/short hip flexors
- hx of repreated extension activity in adolescents
- if severe, may have radicular symptoms
Spondylolisthesis Grading
- Grade I: 25% or less
- Grade II: 26-50%
- Grade III: 51-75%
- Grade IV: 76-100% (spondyloptosis = slipping off)
Disc Prolapse
displacement of nuclear or annular material from normal; often in central canal or IV foramen; may/may not compress nerve root; occurs as often in those with as without pain; gradually resorbs; usually posterior, lateral, or posterolateral; most common age circa 40, atypical >age 60; 90% at levels L4-L5 or L5-S1; may effect nerve root, typically one exiting below (potential for >level)
Disc Prolapse Exam Findings
- motion loss
- sx sitting/flexion > standing/walking
- may have radiculopathy
- SLR
- may have lateral shift or kyphotic deformity
Stenosis
narrowing of central spinal canal, lateral recess or foramen due to advancing degenerative change; familial tendency; age 50 or later for onset; usually confirmed radiologically; slowly progressive disorder
According to Dr. Hazle, what are the two conditions where the patient’s complaints of pain are particularly noteworthy?
thoracic outlet syndrome and stenosis
Stenosis Exam Findings
- c/o LE weakness, fatigue, ache (not pain)
- sx: walking > standing > sitting
- flexion often reductive
- flat lordosis; restriction of lumbar extension
- may walk in flexed posture
- neurological exam negative initially, but may progress; bilateral pattern
Instability Exam Findings
- increased PIVM
- exam similar to nonspecific mechanical dys
- sometimes prior hx of LBP
- often a cluster of findings, including prone instability test, generally more mobile, younger age
- inconsistent hypomobility
- radiculopathy, if severe
Piriformis Syndrome Exam Findings
- loss of hip internal rotation
- sx increase with ER isometric contraction 90/90 from IR
- rule out lumbar/SI primary and hip joint pathology
SI Joint Dysfunction Sx Behavior
- increased with walking, stair climbing, turning in bed
- decreased with non-weight bearing, sitting
- sitting and lying sometimes variable (position dependent)
What are the four categories of tests used in diagnosis of pelvic girdle syndromes?
- pain provocation tests
- positional tests
- kinetic tests
- passive movement
What is the CPR for manipulation for LBP?
- sx < 16 days
- no sx distal to knee
- score < 19 on FABQ work subscale
- at least one hypomobile lumbar segment
- at least one hip w/ >35˚ internal rotation
What are the major themes regarding intervention principles for the lumbar spine?
- address mobility
- facilitate function of supporting muscles
- self-care
Interventions for Mobility Deficits
- manual therapy
- self-mobilization
- exercise for spinal supporting musculature
- patient education
Interventions for Movement Coordination Impairments
- neuromuscular re-reducation/stabilization
- patient education
- external support
Interventions for Referred Lower Extremity Pain
- exercises and mechanical treatment to centralize sx
- direction preference emphasis
- neuromuscular re-education
- patient education
Interventions for Radiating Pain
- traction
- cautious application of manual treatment
- exercise of supporting musculature
- neural mobilization
- patient education
Interventions for Cognitive, Affective Involvement or Generalized Pain
- may include prior elements
- low level exercise
- emphasis on behavioral aspects & encouragement toward activity
- patient education
Dickectomy
incision of offending portion of the disc affecting the nerve root; no repair of the disc involved
Laminectomy
decompressive procedure typically employed for pts with stenosis; lamina is removed to create more space for lumbar nerve roots
Fusion
salvage operation; usually with hardware to immobilize the segment(s) involved; benefit is usually modest
Disc Replacement
indications evolving; value is that motion within the involved segment is preserved to some degree, thus there is a greater preservation toward normal biomechanics; typically long-standing back pain for many years and has developed a number of complicated issues
What ligaments comprise the hip capsule and what do each of them prevent?
- iliofemoral ligament: prevents hyperextension
- pubofemoral ligament: prevents abduction
- ischiofemoral ligament: limits flexion, adduction, and IR
What is the capsular pattern of the hip?
flexion, abduction, and IR in no particular order
What is the loose packed position of the hip?
30 degrees flexion, 30 degrees abduction, and slight ER
What is the structure of the femoral triangle?
sartorius comprises the lateral border, adductor longus forms the medial border, and the inguinal ligament forms the superior border, while the iliacus and pectineus form the floor; contents include the femoral nerve, femoral artery, and femoral vein, as well as lymphatics
What are the categories for mechanism of injury at the hip?
- congenital (coxa vara vs. coxa valga)
- trauma (falls, MVAs, slipped capital femoral epiphysis)
- degeneration (OA, RA)
- overuse (trochanteric bursitis, tendinitis, labral tear)
- stress fracture (repetitive microtrauma)
What is the clinically significant difference for the LEFS?
9
What symptoms should lead you to hip impairment?
- decreased IR
- groin pain
- pain w/ weight bearing
- limp or pain with gait
Craig’s Test
proposed test for femoral anteversion/retroversion; normal is 8-15 degrees; anteversion will result in a larger angle and retroversion will result in a smaller angle
Ortolani test and Barlow test
tests for pediatric hip pathology
What are clinical findings associated with hip OA?
- limited active hip flexion with lateral pain
- active hip extension is painful
- less than 25 degrees passive IR
- limited/painful squat
- scour test with hip adduction yields lateral or groin pain
What are clinical findings associated with a hip labral tear?
- positive scour test for pain and clicking
- passive rotation of the hip in supine clicking
- positive impingement test
- positive FABER test for pain/limited motion
What are clinical findings associated with congenital hip location?
- short leg
- Barlow and/or Ortolani signs
- decreased abduction
- more common in females and parents usually first to notice
*could cause asymmetry in gait if not caught early; may lead to acetabular dysplasia, femoral anteversion, elongated capsule, posterior dislocation, and contracture
What is the mechanism of congenital hip location?
genetic joint laxity and breech presentation with extended legs
What are clinical findings associated with Legg-Perthes disease?
- ages 3-10; boys > girls
- 4 phase process which can span 2-8 years
- pain referred to knee is possible
- decreased ROM
- atrophy of LE
- radiograph helps with diagnosis
What are the four phases of Legg-Perthes disease?
- early phase of necrosis: ossific nucleus in epiphysis ceases to grow, articular cartilage keeps growing, no deformity
- phases of revascularization: revascularization of epiphysis, ossification of pre-osseous cartilage, new bone laid, no subchondral fracture, pathological fracture in subchondral bone at site of greatest stress on ant/sup femoral head
- phase of bone healing: bone resorption stops, bone deposition continues until new bone replaces fibrous and granulation tissue
- phase of residual deformity: articular cartilage remains unchanged so joint operates well, any bony deformity remains, gradual degeneration results in DJD later
Interventions for Legg-Perthes Disease
- traction in loose packed
- NWB
- walking abduction braces
- prevent deformity through containment in acetabulum
- some may do nothing
ACL
prevents anterior tibial translation, tibial rotation, and hyperextension; also aids in screw home mechanism
two bundles: anteromedial is taut in flexion and extension, and posterolateral is taut in extension
PCL
prevents posterior tibial translation and provides rotational stability; tightens with full extension and aids in screw home mechanism
What is the muscular support to the ligaments during dynamic movements?
- ACL: knee flexors
- PCL: knee extensors
- MCL: knee flexors and adductors
- LCL: knee flexors and extensors
Patellar Articular Facets
- inferior: most contact at 20 degrees flexion
- medial: most contact at 20, 45, 90 degrees flexion
- superior: most contact at 90 degrees flexion
- lateral: contact throughout ROM
- odd: most contact at 135 degrees
Stress to PF Joint
- walking = 50% body weight
- ascending stairs = 3.3 x body weight
- deep squatting = 7.8 x body weight
What structures are taut during various positions of the valgus stress test?
- 20-30 degrees of flexion: MCL, POL, PCL
- 0 degrees of flexion: MCL, POL, PCL, ACL, Capsule, VMO, and semimembranosus extensibility
What structures are taut during various positions of the varus stress test?
- 20-30 degrees of flexion: LCL, capsule, arcuate popliteus complex, ITB, Biceps femoris tendon
- 0 degrees of flexion: all of the above, plus PCL, ACL, lateral gastroc
What structures are taut during various positions of the Lachman’s test?
- 20-30 degrees of flexion: ACL, POL, arcuate popliteus complex
- 90 degrees of flexion: ACL, capsule, MCL, ITB, POL, arcuate popliteus complex
What structures are taut during the posterior drawer test and posterior sag?
- PCL, POL, ACL, arcuate popliteus complex
What structures are taut during the posterior drawer test and posterior sag?
- PCL, POL, ACL, arcuate popliteus complex
What are the four special tests for the meniscus (from highest to lowest psychometrics)?
- Joint Line Tenderness test
- Thessaly test (20 degrees flexion)
- Apley’s test
- McMurray’s test
What are the three special tests for patellofemoral pain?
- McConnell test
- Apprehension test
- Patellar Tilt test
MCL Sprain
MOI = valgus force to knee in extension or flexed < 90 degrees with foot planted on the ground
frequently with medial meniscus tear, medial joint capsule, ACL (terrible triad); pain with palpation to MCL, pain with weight bearing; pain with full extension; + valgus stress test; limited ROM and gait
differential diagnoses include contusion, tear of medial meniscus, ACL, medial joint capsule, avulsion fracture
Interventions for MCL Sprain
if no meniscus involvement, usually managed conservatively; protective bracing; pain management (ice, e-stim), swelling management, AROM (pain-free), strengthening (hip and knee)
ACL Tear
MOI: can be either contact (valgus and tibial ER on planted foot, excessive tibial IR, tibial IR and hyperextension) or non-contact (deceleration or deceleration and rotation)
Exam Findings of ACL Tear
- “pop”
- swelling
- positive Lachman’s
- pain with weight bearing
- limited ROM
- limited gait
- instability
Interventions for ACL Tear (non-operative)
situations when pt. has minimal tibial translation (< 5mm), stability brace, and lifestyle modifications
Interventions for ACL Tear (operative)
situations when pt. has meniscus tear, increased tibial translation, and lifestyle activities require surgery
Weeks 1-4: protective bracing, cryotherapy, PROM/AROM (with meniscal repair limited to 90 degrees), quad strength, WBAT, gait training, proprioception, and bike
Weeks 4-8: protective bracing, full ROM, normal gait, closed chain quad and HS exercises, proprioception
Weeks 8-12: agility ladder drills, jumping drills, treadmill running
Weeks 12-16: running, jumping drills, proprioception, functional testing
Weeks 16-24: cutting/pivoting/reaction time, sport specific training, ACL prevention programs
How much ROM is available in the thoracic spine?
Extension = 25 degrees
Flexion = 45 degrees
Lateral flexion = 20 degrees
Rotation = 35 degrees
What are the tissue changes over the lifespan?
Structures of spine and SI joint change continuously and progressively over lifespan
Degenerative changes inevitable
Discs lose water content and stiffen
Osteophytes form at margin of disc/bodies
Z-joint cartilage thins and osteophytes form
Ligaments/JT capsules become less extensible
