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Pathomechanics > Exam 3: Thoracic, Lumbar, SI, Hip, & Knee > Flashcards

Exam 3: Thoracic, Lumbar, SI, Hip, & Knee Flashcards

1
Q

What is the orientation of the spinous processes in the thoracic spine?

A

T2-T6: project one level caudally
T7-T8: project two levels caudally
T11-T12: project one level caudally

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2
Q

What is the orientation of the facets in the thoracic spine?

A

superior facets face mostly posteriorly and slightly lateral; inferior facets face mostly anteriorly and slightly medial

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3
Q

Describe the shape of the rib cage during rotation

A

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

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4
Q

What are the relevant dermatomes of the thoracic spine?

A

T1: medial upper arm
T2: axilla
T5-6: nipple line
T10: umbilicus

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5
Q

What are the relevant dermatomes of the thoracic spine?

A

T1: medial upper arm
T2: axilla
T5-6: nipple line
T10: umbilicus

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6
Q

What are the three locations for potential impingement of the brachial plexus (i.e. thoracic outlet syndrome)?

A

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

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7
Q

Gibbus Deformity

A

anterior wedging of bodies of two or more vertebrae, resulting in a sharp angulation of the spine

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8
Q

Ankylosing Spondylitis

A

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

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9
Q

What is the plan of care for ankylosing spondylitis?

A
  • coordination with other professionals
  • decrease pain with TENS and cold packs
  • improve mobility
  • improve aerobic endurance
  • improve function
  • prevention/slowing the progression (bracing)
  • compensation
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10
Q

Scheuerman’s Disease

A

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

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11
Q

What is the plan of care for Scheuerman’s disease?

A

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˚

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12
Q

Scholiosis

A

curvature >10˚: thoracic curve may be structural, lumbar or cervical curves may be compensatory and more mobile; idiopathic = 70-80%

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13
Q

How is scoliosis designated?

A

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

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14
Q

Cobb Angle

A

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

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15
Q

Adam’s Forward Bend Test

A

Sn = .92; Sp = .60; compared with the gold standard of Cobb angle = >20˚ on a radiograph

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16
Q

What are treatment options for scoliosis?

A
  • pain
  • mobility
  • stability
  • breathing
  • education
  • exercises
  • prevention of progression
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17
Q

Surgery for Scholiosis

A

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)

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18
Q

Osteoporosis

A
  • 25% of all older women; 40% >80 yrs
  • older men almost as high
  • 15% mortality rate after fall
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19
Q

What is the plan of care after fracture?

A
  • 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)
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20
Q

What are the common causes of Thoracic Outlet Syndrome?

A
  • cervical rib
  • abnormal first thoracic rib (wide, elevated, malformed)
  • hypertrophied scalene
  • pec minor
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21
Q

Costochondritis

A

inflammatory process of costochondral or chondrosternal joints; usually self-limiting within one year, but are often recurrent

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22
Q

The spinal cord occupies about __% of the canal in the thoracic spine, but about __% in the lumbar and cervical regions (smaller thoracic canal)

A

40%; 25%; tumors have more of an impact

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23
Q

What are the effects of aging in the thoracic spine?

A
  • costal cartilages ossify
  • joints ossify
    osteoporosis of ribs
  • increased kyphosis
  • diaphragm less domed
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24
Q

In regards to pathoanatomical origins of LBP, only __% have identified causes, while __% are unidentified

A

15%; 85%

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25
Q

What are the identified pathoanatomical causes of LBP?

A
  • disc herniation w/ nerve root compression
  • stenosis
  • spondylolysis/spondylolisthesis
  • fracture
  • malignancy
  • infection/inflammation
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26
Q

Factors that Increase Suspicion of Sinister Pathology in LBP

A
  • 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
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27
Q

Visceral/Vascular Origins

A
  • abdominal aortic aneurysm (AAA)
  • prostatitis
  • renal disease
  • gynecologic disorders
  • numerous others
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28
Q

Ankylosing Spondylitis Pain Characteristics

A
  • usually dull in character
  • poorly localized and often deep gluteal area
  • sometimes intermittent and alternating sides
  • often becomes bilateral
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29
Q

Indicators or Inflammatory LBP

A
  • 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
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30
Q

Suspicion of Ankylosing Spondylitis

A

age onset <40 YO and unusual after 45; mean age of onset 25; positive family history; traumatic improvement with NSAIDs

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31
Q

What is the clinical presentation of ankylosing spondylitis?

A
  • 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
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32
Q

Fibromyalgia

A

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

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33
Q

Exam Findings of Fibromyalgia

A
  • 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
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34
Q

Signs and Sx. of Cauda Equina Syndrome

A
  • saddle anesthesia
  • changes in bowel or bladder
  • gait disturbances
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35
Q

Fractures

A

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

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36
Q

Clinical Presentation of Fractures

A
  • possible deformity
  • motion loss, flexion usually more painful
  • usually no neurological signs if stable
  • debilitating pain for two weeks
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37
Q

Exam Findings of Mechanical LBP

A
  • no radiculopathy, but may have distal symptoms
  • pattern of motion loss
  • may/may not have deformity
  • negative neuro exam
  • loss of PIVM
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38
Q

Biomechanical Effects

A
  • realignment/reducing subluxation
  • breaking adhesions
  • reduction of capsular/ligamentous hypomobility
  • increased fluid exchange
  • cavitation
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39
Q

Neurophysiological Effects

A
  • change in central pain processing
  • change in muscle recruitment
  • reduced temporal summation
  • biochemical changes
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40
Q

Psychological Effects

A
  • placebo effect
  • perception of benefit
  • patient expectations & beliefs
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41
Q

Acute Sprain/Strain

A

usually traumatic onset that involves multiple tissues; nay position maintained and every motion provocative; inflammatory initial stage, then evolves into mechanical syndrome

42
Q

Facet Joint Syndrome

A

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

43
Q

Facet Joint Syndrome Exam Findings

A
  • 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
44
Q

Spondylolysis/Spondylolisthesis

A
  • 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
45
Q

Spondylolisthesis Grading

A
  • Grade I: 25% or less
  • Grade II: 26-50%
  • Grade III: 51-75%
  • Grade IV: 76-100% (spondyloptosis = slipping off)
46
Q

Disc Prolapse

A

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)

47
Q

Disc Prolapse Exam Findings

A
  • motion loss
  • sx sitting/flexion > standing/walking
  • may have radiculopathy
    • SLR
  • may have lateral shift or kyphotic deformity
48
Q

Stenosis

A

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

49
Q

According to Dr. Hazle, what are the two conditions where the patient’s complaints of pain are particularly noteworthy?

A

thoracic outlet syndrome and stenosis

50
Q

Stenosis Exam Findings

A
  • 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
51
Q

Instability Exam Findings

A
  • 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
52
Q

Piriformis Syndrome Exam Findings

A
  • loss of hip internal rotation
  • sx increase with ER isometric contraction 90/90 from IR
  • rule out lumbar/SI primary and hip joint pathology
53
Q

SI Joint Dysfunction Sx Behavior

A
  • increased with walking, stair climbing, turning in bed
  • decreased with non-weight bearing, sitting
  • sitting and lying sometimes variable (position dependent)
54
Q

What are the four categories of tests used in diagnosis of pelvic girdle syndromes?

A
  • pain provocation tests
  • positional tests
  • kinetic tests
  • passive movement
55
Q

What is the CPR for manipulation for LBP?

A
  • 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
56
Q

What are the major themes regarding intervention principles for the lumbar spine?

A
  • address mobility
  • facilitate function of supporting muscles
  • self-care
57
Q

Interventions for Mobility Deficits

A
  • manual therapy
  • self-mobilization
  • exercise for spinal supporting musculature
  • patient education
58
Q

Interventions for Movement Coordination Impairments

A
  • neuromuscular re-reducation/stabilization
  • patient education
  • external support
59
Q

Interventions for Referred Lower Extremity Pain

A
  • exercises and mechanical treatment to centralize sx
  • direction preference emphasis
  • neuromuscular re-education
  • patient education
60
Q

Interventions for Radiating Pain

A
  • traction
  • cautious application of manual treatment
  • exercise of supporting musculature
  • neural mobilization
  • patient education
61
Q

Interventions for Cognitive, Affective Involvement or Generalized Pain

A
  • may include prior elements
  • low level exercise
  • emphasis on behavioral aspects & encouragement toward activity
  • patient education
62
Q

Dickectomy

A

incision of offending portion of the disc affecting the nerve root; no repair of the disc involved

63
Q

Laminectomy

A

decompressive procedure typically employed for pts with stenosis; lamina is removed to create more space for lumbar nerve roots

64
Q

Fusion

A

salvage operation; usually with hardware to immobilize the segment(s) involved; benefit is usually modest

65
Q

Disc Replacement

A

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

66
Q

What ligaments comprise the hip capsule and what do each of them prevent?

A
  • iliofemoral ligament: prevents hyperextension
  • pubofemoral ligament: prevents abduction
  • ischiofemoral ligament: limits flexion, adduction, and IR
67
Q

What is the capsular pattern of the hip?

A

flexion, abduction, and IR in no particular order

68
Q

What is the loose packed position of the hip?

A

30 degrees flexion, 30 degrees abduction, and slight ER

69
Q

What is the structure of the femoral triangle?

A

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

70
Q

What are the categories for mechanism of injury at the hip?

A
  • 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)
71
Q

What is the clinically significant difference for the LEFS?

A

9

72
Q

What symptoms should lead you to hip impairment?

A
  • decreased IR
  • groin pain
  • pain w/ weight bearing
  • limp or pain with gait
73
Q

Craig’s Test

A

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

74
Q

Ortolani test and Barlow test

A

tests for pediatric hip pathology

75
Q

What are clinical findings associated with hip OA?

A
  • 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
76
Q

What are clinical findings associated with a hip labral tear?

A
  • 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
77
Q

What are clinical findings associated with congenital hip location?

A
  • 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

78
Q

What is the mechanism of congenital hip location?

A

genetic joint laxity and breech presentation with extended legs

79
Q

What are clinical findings associated with Legg-Perthes disease?

A
  • 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
80
Q

What are the four phases of Legg-Perthes disease?

A
  • 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
81
Q

Interventions for Legg-Perthes Disease

A
  • traction in loose packed
  • NWB
  • walking abduction braces
  • prevent deformity through containment in acetabulum
  • some may do nothing
82
Q

ACL

A

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

83
Q

PCL

A

prevents posterior tibial translation and provides rotational stability; tightens with full extension and aids in screw home mechanism

84
Q

What is the muscular support to the ligaments during dynamic movements?

A
  • ACL: knee flexors
  • PCL: knee extensors
  • MCL: knee flexors and adductors
  • LCL: knee flexors and extensors
85
Q

Patellar Articular Facets

A
  • 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
86
Q

Stress to PF Joint

A
  • walking = 50% body weight
  • ascending stairs = 3.3 x body weight
  • deep squatting = 7.8 x body weight
87
Q

What structures are taut during various positions of the valgus stress test?

A
  • 20-30 degrees of flexion: MCL, POL, PCL

- 0 degrees of flexion: MCL, POL, PCL, ACL, Capsule, VMO, and semimembranosus extensibility

88
Q

What structures are taut during various positions of the varus stress test?

A
  • 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
89
Q

What structures are taut during various positions of the Lachman’s test?

A
  • 20-30 degrees of flexion: ACL, POL, arcuate popliteus complex
  • 90 degrees of flexion: ACL, capsule, MCL, ITB, POL, arcuate popliteus complex
90
Q

What structures are taut during the posterior drawer test and posterior sag?

A
  • PCL, POL, ACL, arcuate popliteus complex
91
Q

What structures are taut during the posterior drawer test and posterior sag?

A
  • PCL, POL, ACL, arcuate popliteus complex
92
Q

What are the four special tests for the meniscus (from highest to lowest psychometrics)?

A
  • Joint Line Tenderness test
  • Thessaly test (20 degrees flexion)
  • Apley’s test
  • McMurray’s test
93
Q

What are the three special tests for patellofemoral pain?

A
  • McConnell test
  • Apprehension test
  • Patellar Tilt test
94
Q

MCL Sprain

A

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

95
Q

Interventions for MCL Sprain

A

if no meniscus involvement, usually managed conservatively; protective bracing; pain management (ice, e-stim), swelling management, AROM (pain-free), strengthening (hip and knee)

96
Q

ACL Tear

A

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)

97
Q

Exam Findings of ACL Tear

A
  • “pop”
  • swelling
  • positive Lachman’s
  • pain with weight bearing
  • limited ROM
  • limited gait
  • instability
98
Q

Interventions for ACL Tear (non-operative)

A

situations when pt. has minimal tibial translation (< 5mm), stability brace, and lifestyle modifications

99
Q

Interventions for ACL Tear (operative)

A

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

100
Q

How much ROM is available in the thoracic spine?

A

Extension = 25 degrees
Flexion = 45 degrees
Lateral flexion = 20 degrees
Rotation = 35 degrees

101
Q

What are the tissue changes over the lifespan?

A

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

Pathomechanics (4 decks)

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