Methods 5-Final Flashcards
Motions of the rib cage
-Pump handle
-Bucket Handle
-Caliper
-Torsion
Thoracic movements
-Flexion/Extension (Mostly)
-Lateral Bending
-Axial Rotation
Scheuermann’s Disease
-D/t growth plate trauma during adolescence
-Schmorl’s Nodes=Evidence of nuclear disc extrustions
-Wedging of >5* in three consecutive segments
-Midthoracic (75% of the time)/Thoracolumbar (25%)
Scheurmann’s disease typically affects:
Young male (13-17yo) & female gymnasts
Scheurmann’s Disease will typically structurally involve:
-Exaggerated cervical/lumbar lordosis
-Hyperkyphotic thoracic spine
Scheuremann’s Disease: Management
-Soft tissue/gentle mobilization
-Address during adolescence/brace (>60) sometime
-Address functional overuse
-Surgery: May be considered at >70 w/ pain
-Kyphosis <60* will most likely resolve in adulthood
Costochondritis: Observation
Antalgia, shallow breathing, anterior rib
pain at the costosternal articulation (usually ribs 2-5)
Costochondritis:ROM
-Bucket and/or pump handle restriction
-Arm abduction limited d/t pain
What ortho can you use for costochondritis?
Schepelmann’s
Costochondritis: Active Treatment
-Light stretching
-Avoid exacerbating activity
-Focused breathing
Costochondritis: Home Care
-Bromelain: 500mg 3x/day
-Curcumin
-Heat
Costochondritis: Referral
-Massage therapy
-Anesthetic or corticosteroid
Costochondritis: Passive Treatment
-Chiropractic adjustments
-Muscle work
-Moist heat
-Laser
Causes of intercostal neuritis
*Herpes Zoster
-Tumors
-Ruptured discs/bone spurs
-Diabetes
-Rib motion dysfunction
Ortho for Intercostal neuritis
Schepelmann’s sign produces pain on the concave
side
During intercostal neuritis, what should you do if herpes zoster is suspected?
Wear gloves
Intercostal neuritis: Supplements
-B1, B2, B6, B12 & pantothenic acid given together
-Zinc
Intercostal neuritis: Active treatment
-Thoracic and core stability
-Posture
-Breathing exercises
Intercostal Neuritis: Passive Treatment
-Adjust (be careful of shingles lesions)
-US, EMS, Laser
Intercostal Neuritis: Co-Management
-Injections: Anesthetic (Xylocaine or Lidocaine)
-Analgesics, NSAIDS
-Acupuncture & Acupressure
(NO proven cures)
Idiopathic Scoliosis is influenced by:
-Family History
-Female patients w/ curves >30*
Idiopathic scoliosis can be corrected to some degree with:
Lateral flexion
How does Idiopathic scoliosis affect ROM?
Decrease in ROM of trunk and pelvis
Idiopathic scoliosis: Ortho
Adam’s Position
Are there any neuro findings with idiopathic scoliosis?
No
Congenital Scoliosis includes:
Club foot/foot deformities
Spina bifida includes:
Patches of hair along the spine
Neurofibromatosis includes:
Cafe au lait spots or patches
Idiopathic Scoliosis: PARTS
-Pain in areas of the rib
-Asymmetry both globally as well as joint level
A cobb angle of _____ is considered scoliosis
> 10 degrees
Active treatment of Idiopathic Scoliosis: Strengthen muscles of _______/Stretch muscles of ____
Convexity; Concavity
With idiopathic scoliosis is contraindicated to adjust into a ________
Concavity
TOS: Cause/Risk
-Repetitive activity, Poor posture, pregnancy
Most cases of TOS are:
Neurogenic
TOS involves what musculature
Scalene, 1st rib, pectoralis
TOS: Presentation
-Pain/numbness tingling into 4th/5th digit that worsens with activity
-Neck/shoulder pain
-Thenar atrophy
-Diminished grip strength
-Hand/arm swelling
-Pallor or dislocation of the hand
In TOS, imaging is used to rule out:
Cervical Rib
TOS Treatment: Active
-Stretch Scalenes, pectoralis
-Radial and ulnar nerve flossing
TOS: Home Care
Bruegger’s relief*, heat, avoid sleep posture with elevated arm, postural awareness
TOS responds well to:
Chiropractic care
Adhesive Capsulitis: Phases
-Acute: Moderate to severe pain that limits ROM
-Middle: Less pain but lifting arm & internal/external rotation is severely restricted
-Final: Slowly increased ROM
Adhesive capsulitis often resolves in:
2-3 years
Adhesive Capsulitis: Stages
-Freezing
-Frozen Stage
-Thaw
Cause of adhesive capsulitis
-Unknown
-Slight increase if diabetic, hyperthyroid, COPD
-Inflammation leads to fibrosis
Adhesive Capsulitis: Risk Factors
-Age: 45 to 60 years old
-Gender: Women (70%)
-Prolonged immobility, previous injury, surgery
-Diabetes mellitus, hypothyroid
Adhesive capsulitis: Diagnosis
-Loss of Shoulder ROM: External and Abduction
-Orthopedic Tests: Mazion shoulder
Adhesive Capsulitis: Treatment (Phase 1)
Phase 1: Avoid aggressive adjustments;Focus on mobilization/pain relief & laser. Exercises: Isometric or Codman’s exercises
Adhesive Capsulitis: Treatment (Phases 2/3)
-Adjust and mobilize shoulder
-Codman’s and isometric exercises
Impingement Syndrome:Causes
-Narrowing of the space between the acromion process and head of the humerus
-Examples: Subacromial spurs, osteoarthritic spurs, variations in shape of the acromion
Variations in acromion process
-Type 1: Flat (normal)
-Type 2: Gently curved
-Type 3: Hooked (will lead to more issues)
Impingement Syndrome: Signs/Symptoms
-Pain, weakness at night sleeping on affected shoulder
-ROM limited by pain
-Painful arc during forward elevation (60-120*)
-Passive movement appears painful with downward force @ the acromion
Impingement Syndrome: Active Care
Isometric to Isotonic exercises, beginning with shoulder slightly abducted
What adjustments are best for impingement syndrome?
S-I adjustments of the glenohumeral joint
-I-S adjustments of the sternoclavicular joint
What disorders of the hand/wrist/elbow are most prominently seen in clinic?
Lateral Epicondylitis & Carpal Tunnel Syndrome
Lateral Epicondylitis: M99 Codes
M77.11(Right elbow), M77.12 (Left elbow)
Lateral Epicondylitis: Causes/Risk Factors
-Overuse injury
-Age: Late 30s-Early 60s
-Desk Work
Lateral Epicondylitis: Signs/Symptoms
-Tenderness along the lateral border of the elbow
-Pain when picking up objects while pronated
-Reduced grip strength
-Provoke pain when palpating the lateral elbow
-Hypertonicity of the forearm
-Radiating pain into the forearm
Lateral Epicondylitis: MSR would show
Motor strength weakness w/ wrist extension and grip
Lateral Epicondylitis: PARTS
-Tenderness over tendons of extensor carpi radialis brevis
-Asymmetry/diminished mobility of the radial head
-Hypertonic forearm muscles
Orthos for Lateral Epicondylitis
Kaplan’s, Mills, Cozens
Lateral Epicondylitis: Home Treatment
-Avoid excessive/repetitive twisting at the wrist
-Ice Pack: Outside of the Elbow
-Brace
Lateral Epicondylitis: Passive Treatment
-Soft tissue release/IASTM
-Laser
-Manipulation
Lateral Epicondylitis: Complications
-Recurrence of the injury with overuse
-Rupture of the tendon with repeated steroid injections
What kind of adjustments should be used for lateral epicondylitis?
P-A glide of the radial head
Cubital Tunnel Syndrome: ICD Code
G56.30-Lesion of the ulnar nerve, unspecified upper limb
Cubital tunnel Syndrome is influenced by which movements?
Shoulder abduction, elbow flexion, and wrist extension
Cubital Tunnel Syndrome: Signs/Symptoms
Wartenburg Sign: Pinky finger abducts, difficulty with opposition
Cubital tunnel syndrome: Diagnosis
-History: Recurrent elbow flexion or pressure
-Observation: Wartenburg Sign
-ROM: Limited by elbow flexion
Cubital Tunnel Syndrome: Exam
Parts: Pain over the posterior and medial elbow
-MSR: Weak flexor digitorum profundus, paresthesia along the ulnar distribution of the hand
Cubital Tunnel Syndrome: Orthopedic Tests
Froment’s Test, Tinels sign of the elbow, elbow flexion test
Cubital Tunnel Syndrome: Grade I
Mild lesions with paresthesia (ulnar nerve), feeling of clumsiness in the affected hand. NO WASTING OR WEAKNESS of the intrinsic muscles
Cubital Tunnel Syndrome: Grade II
Intermediate lesions with WEAK INTEROSSEI and MUSCLE WASTING
Cubital Tunnel Syndrome: Grade III
Severe lesions with paralysis of the interossei and a MARKED WEAKNESS OF THE HAND
Cubital Tunnel Syndrome: Special Tests
-EMG
-NCS
-Asymptomatic: Medical subluxation of the ulnar nerve
Cubital Tunnel Syndrome: Treatment
-Passive: ST mobilization, adjustments
-Active: Progressively strengthen flexors
-Home: Reduce elbow flexion
-Medical comanagement: PT, surgical placement of nerve
Adjustments for Cubital Tunnel
-P-A glide of the ulna into extension
-A-P glide of the ulna
M-L glide of the elbow in supine position
Carpal Tunnel Syndrome: ICD Codes
-ICD-9354.0
-IDC-10G56.0
Carpal Tunnel Syndrome: Signs/Symptoms
-Pain, tingling, numbness in the hand and forearm (median nerve distribution)
-Weakness with wrist and finger flexion
• Frequently dropping things
• Prolonged or repetitive wrist flexion
CTS: Exam
• MSR
• PINCH AND GRIP STRENGTH WEAK OR DIMINISHED, PARESTHESIA ALONG THE MEDIAN NERVE, REFLEX – N/A
• PARTS
• PAIN NOTED OVER THE CARPAL TUNNEL REGION
• ASYMMETRY OF THE TRAPEZIUM, TRAPEZOID AND CAPITATE
• LOSS OF A-P OR P-A SEGMENTAL MOTION
• TONE – HYPOTONICITY OF OPPONENS POLLICIS BREVIS, FLEXOR POLLICUS BREVIS AND ABDUCTOR POLLICUS BREVIS
• SPECIAL TESTS
• X-RAY
• ELECTROMYOGRAM
• NERVE CONDUCTION STUDY
CTS: Orthopedic Tests
Tinels sign (Wrist), Phalen’s Test, Reverse Phalens Test
Carpal Tunnel: Adjustments
LAD of intercarpal joint
-P-A/A-P of the intercarpal joint
-A-P/P-A of distal radioulnar joint
-A-P/P-A of carpals
Dequervains Tenosynovitis: ROM
ROM
• LOSS OF FLEXION, EXTENSION OR RADIAL DEVIATION AT THE WRIST
• LOSS OF THUMB FLEXION/EXTENSION, ABDUCTION/ADDUCTION AND OPPOSITIO
Dequervains: Ortho
Finkelsteins
Dequervains: MSR
• WEAKNESS AND REPRODUCTION OF PAIN WITH RESISTED THUMB EXTENSION
• POSSIBLE PARESTHESIA
• DIMINISHED BRACHIORADIALIS REFLEX
DeQuervains: PARTS
• PALPATORY TENDERNESS NOTED OVER THE BASE OF THE THUMB
• ASYMMETRY/Loss of segmental motion OF THE SCAPHOID, TRAPEZIUM OR FIRST CARPAL
• OVERLY FIRM/HARD DORSAL COMPARTMENT
When would you use X-Ray with potential Dequervains Case
Rule out OA or RA
Dequervains: Treatment
Passive: IASTM, mobilization of the wrist
-Active: Gentle wrist stretches, ROM
-Home: Ice, Nsaids
Dequervains: Adjustments
LAD of the metacarpalphalangeal joints
Legg-Calve Perthes Disease: Causes/Risk
• Sometimes trauma?
• Subcapital fx
• Posterior hip dislocation
• Boys age 4-9
• Not genetic
Legg-Calve Perthes: Signs/Symptoms
• Painless limp or waddling gait
• Mild pain in the affected hip
• Limited hip ROM
• Hip stiffness that restricts movement
• Ipsilateral Knee pain
• Persistent thigh or groin pain
• Wasting of muscles in the upper thigh
• Apparent shortening of the leg, or legs of unequal length
Stages of LCP
1) Initial- loss of blood supply
2) Fragmentation/resorptive phase
3) Re-ossification
4) Healed
LCP: Examination
History (rule out)
• Compression fractures
• Infection
• Endocrine disorders
• Clotting disorders
Observation
• Limping, muscle atrophy, leg length
LCP: ROM
Range of Motion
• Limited internal rotation and abduction
LCP: Orthopedic Tests
Leg Length Measurement, Trendelenburg Sign
LCP: PARTS
PARTS
– Palpatory tenderness over the femur head
– Asymmetry and leg length discrepancy
– Loss of segmental ROM at the hip
– Hypotonicity or atrophy of the quadriceps
• Special Tests
– X-ray or MRI
– Labs
LCP: MSR
MSR
– Sensory is equal and WNL
– Reflexes equal and WNL
- Weak hip muscles especially internal rotators and ABductors.
LCP: DDx
Unilateral: Inflammatory
• Septic arthritis, Toxic synovitis, Juvenile RA
Bilateral: Dysplasia
• Spondyloepiphyseal dysplasia, Metaphyseal dysplasia
Systems: Endocrine
• Hypothyroidism
LCP: Treatment (Active)
Active
– Balance training, Gait training, ROM exercises ,Strength training
Home
– Minimize weight bearing, restrict aggravating activities, Traction (PM), Ice/Heat
Co management
• Bracing to keep the femoral head abducted
and internally rotated & Pain medications
What kind of cast can you use with LCP
Petrie Cast
Subtrochanteric Bursitis: Orthos
– Ober’s
– Patrick’s
– Leg length
Subtrochanteric Bursitis Ddx: MSR
– Internal and external rotation weak due to pain
– Sensory - equal bilateral light touch
– Lower extremity reflexes - 2/2
Subtrochanteric Bursitis DDx: PARTS
– Pain over the greater trochanter and bursa
– Asymmetry R vs L femur
– Loss of internal rotation and external rotation
– Hypertonic IT band
Subtrochanteric Bursitis: Special Tests
– X-ray rule out bone spurs, arthritis
– MRI
Subtrochanteric Bursitis: Active Tx
– Stretching the IT and hip abductors
– Isometric glute strengthening
Subtrochanteric Bursitis: Passive Tx
– Adjust the hip, ilium, sacrum dependent on leg length.
– Adjust above and below: pelvis, knees, ankles, feet – Avoid side posture (Bergmann figure 6-155)
– Ultrasound (Pulsed ultrasound if chronic)
– EMS
Osteitis Pubis: ICD
ICD-10 M85.30 UNSPECIFIED
Osteitis Pubis is common in:
• Athletes- runners or kicking activities
• Exercise intensity
• Direct compressive or distractive injury
• Often from a sudden forced adduction injury
• Repetitive side-foot kicking
Osteitis Pubis: Signs/Symptoms
• Adductor pain
• Lower abdominal pain
• Clicking sensation
• Pain walking, running, kicking, etc
Osteitis Pubis: Observation
– Limping gait, difficulty rising from a chair/car
– ROM: Weak hip aDDuctors and flexors
– Local pain with resisted adduction
Osteitis Pubis: Orthopedics
– Compression ASIS joints toward one another
– Spring test: apply direct pressure over the pubic rami approximately 3cm from midline
Osteitis Pubis: PARTS
– Pain with palpation over the pubic symphysis
– Asymmetry of pubic rami
– Loss of PA motion
– Spasm of the piriformis, adductors
Osteitis Pubis: MSR
– Motor weakness due to pain
– Sensory & Reflexes WNL
Osteitis Pubis: Special Tests
– Gait evaluation
– X-ray, MRI, CT
Osteitis Pubis: Active Tx
-Strengthening of the hip flexors, adductors, abdominal muscles, hamstring and quadriceps
-Dynamic muscular stabilization technique
Osteitis Pubis: Home
– Avoidance of side-foot kicking and bilateral adduction maneuvers until pain and inflammation is reduced. A slow return to activity is recommended
– Heat or ice
Osteitis Pubis: Passive Tx
– Adjust the pelvis and pubic symphysis.
Osgood Schlatter: Presentation
• Young athlete (Runners, jumpers, etc)
• More common in male athletes
• Worse with activity
• Pain/swelling and tenderness at tibial tuberosity
• Due to repetitive stress on the tibial apophysis by the patellar tendon
• RARE to have avulsion of the apophysis
Sinding-Larsen-Johansson Syndrome
• Involving the patellar tendon and the lower margin of the patella
• Also called Juvenile Osteochondrosis of the patella
Osgood-Schlatter Disease Diagnosis
• OBSERVATION – PAINFUL, RED LUMP INFERIOR TO THE PATELLA
• ROM – PAIN INFERIOR TO THE PATELLA WITH RESISTED EXTENSION
• MSR: WEAKNESS DURING RESISTED KNEE EXTENSION D/T PAIN
• PATELLAR REFLEX INTACT BUT SITE MAY BE PAINFUL
Osgood-Schlatter Disease: PARTS
• PALPATORY PAIN AT THE POINT OF INSERTION
• ASYMMETRY OF PATELLA, FIBULA AND TIBIA ASSESSED. PALPATORY BUMP OVER THE TIBIAL TUBEROSITY
• PATELLAR TRACKING, FIBULA AND TIBIA
• HYPERTONICITY OF THE QUADRICEPS, SCAR TISSUE OF THE TENDON
X-Ray would be used with suspected Osgood-Schlatter if a ______ is suspected
Avulsion Fracture
Osgood-Schlatter Disease: Active Tx
• STRETCH THE QUADRICEPS AND HAMSTRING
Osgood-Schlatter Disease: Passive Tx
• PER THE PARTS EXAM FINDINGS
• AVOID ADJUSTING OVER THE ACUTE AREA AS IT IS CONSIDERED A POTENTIAL AVULSION FRACTURE (SCOPE OF PRACTICE)
• LASER
Prepatellar Bursitis: Causes/Risk Factors
Housemaid’s Knee
Pre-patellar Bursitis DDx
HISTORY
• ACTIVITIES/OCCUPATION
• SIGNIFICANT PAIN WHEN KNEELING
• STIFFNESS AND PAIN WITH WALKING
OBSERVATION: RUBOR, CALOR, EDEMA
ROM – GENERALLY PRESERVED
• ORTHOPEDIC TEST: PATELLAR GRINDING TEST – PAIN ON TOP
Prepatellar Bursitis Diagnosis: MSR
• MOTOR – PAINFUL 5/5
• SENSORY – NAF
• REFLEXES – WNL (2/4) MAY BE PAINFUL
Prepatellar Bursitis Ddx: PARTS
• PALPATORY DOLOR (PAIN) NOTED
• ASYMMETRY BETWEEN RIGHT AND LEFT PATELLA
• PATELLAR TRACKING PROBLEM D/T TUMOR (SWELLING)
• EDEMA AND BOGGINESS OVER THE SWOLLEN AREA
Prepatellar Bursitis: Tx
• THE TREATMENT OF ANY BURSITIS DEPENDS ON WHETHER OR NOT IT INVOLVES INFECTION
ASEPTIC PREPATELLAR BURSITIS
• ICE COMPRESSES, REST, AND ANTI-INFLAMMATORY AND PAIN MEDICATIONS.
• OCCASIONALLY, IT REQUIRES ASPIRATION OF THE BURSA FLUID.
• CBC - ASPIRATED TO IDENTIFY THE MICROBES
• ANTIBIOTIC THERAPY
Prepatellar Bursitis: Passive Care (Acute)
• ASSESS & ADJUST ABOVE/BELOW
• ADJUST THE KNEE: IF there is Patellar tracking disorder
• TAPE THE KNEE FOR COMPRESSION AND/OR LYMPHATIC DRAINAGE
Prepatellar Bursitis: Chronic (Active Care)
ACTIVE CARE (ONCE PAIN AND SWELLING HAS REDUCED)
• ISOMETRIC CONTRACT OF HAMSTRINGS/ QUADS
• LEG EXTENSION AND LEG CURLS
• FUNCTIONAL EXERCISES– SQUATS, ETC.
• HOME – ANTI INFLAMMATORY DIET, HEAT/ICE PUMP
Prepatellar Bursitis: Passive Care (Chronic)
• PULSED ULTRASOUND
• GENTLE MANIPULATION OF THE PATELLA
Meniscus Tear: History
HISTORY OF TRAUMA (YOUNGER) OR DEGENERATION(AGE RELATED)
• PAIN
• STIFFNESS
• SWELLING OFTEN MAIN COMPLAINT
• CATCHING OR LOCKING OF THE KNEE
• SENSATION OF KNEE INSTABILITY
• ROTATIONAL INJURY OF KNEE (PLANT AND TWIST)
• LIMITED ROM
Meniscus Tear: Observation
• NOT A LOT OF BRUISING FROM PURE MENISCUS TEARS DUE TO LACK OF BLOOD SUPPLY (ALSO SPEAKS TO HEALING). HOWEVER, CAN HAVE SWELLING DUE TO SYNOVIAL FLUID REACTION
• LIMPING GAIT
Meniscus Tear: Examination
• ROM: LIMITED FLEXION AND EXTENSION
• PARTS: PAIN ALONG THE JOINT LINE, IF LOCKED - LIMITED ROM AND CLICKING NOTED, SWELLING
• MSR: NO ABNORMAL FINDINGS
• MRI: CORRELATE WITH CLINICAL FINDINGS; FALSE POSITIVES – ASYMPTOMATIC TEAR WITH OTHER PATHOLOGY CAUSING SYMPTOMS
Meniscus Tear: Orthopedic Tests
McMurrays, Apley’s Compression Test, Bounce Home
Meniscus Tear Treatment
• ACTIVE: FOCUS ON ROM, GAIT, PROPRIOCEPTION, MUSCLE STRENGTH
• HOME CARE: AVOID AGGRAVATING ACTIVITY, HYALURONIC ACID
• CO-MANAGEMENT: PT, NSAIDS, SURGERY
Meniscus Tear Treatment: Passive
• STABLE TEARS WITH LESS THAN 1CM DAMAGE
• ADJUST TO PATIENT’S TOLERANCE: INDUCE LAD OR GAPPING
