OMM Flashcards
5 elements of joint PE
inspection/palpation, ROM, strength, stability, special test
4 fxnal joints of shoulder
SC, AC, glenohumeral, scapulothoracic
rotator cuff muscles
supraspinatus, infraspinatus, teres minor, subscapularis
orthopedic vs osteopathic clinical data
gross ROM, symmetry of motion, quality of motion vs gliding motion
glenohumeral joint motion
ball and socket joint –> rotation, translation/gliding, rolling (combo of rotation and translation)
what does abnl scapular motion look like?
scapular winging, rhomboids weakness, posterior instability, rib/thoracic somatic dysfxn
strength test for shoulder girdle and rotator cuff muscles: Speed’s test vs supraspinatus vs infraspinatus/teres minor vs subscapularis
find bicipital groove –> pt arm straight out and resist your downward force; if pain –> biceps tendinitis vs full/empty can –> arms out in scaption (45 degree) –> pt abducts to resist you vs pt externally rotates to resist you vs pt internally rotates to resist you
what are the 2 static stabilizers?
glenoid (convex, thin socket –> ball/hinge movement) and glenoid labrum (mobile superior portion, immobile inferior portion)
what are the 5 dynamic stabilizers?
rotator cuff muscles + long head of biceps tendon (NOT a RC muscle)
stability tests: load & shift test vs anterior release test/apprehension test vs axillary nerve eval
pt = supine, dr stabilize pt shoulder, “load and shift” humeral head ant and post in glenoid vs pt = supine, dr stabilize pt shoulder, abduct pt while externally rotating vs scratch deltoid (if no sensation –> anterior dislocation)
superior AC ligament vs conoid and trapezoid ligament of AC joint
horizontal stability vs CORACOCLAVICULAR LIGAMENT = most impt ligament for stabilizing AC joint! constrains forward/anterior and backward/posterior rotation of distal clavicle respectively; trapezoid ligament also prevents compression of distal clavicle on acromion
AC joint. What 2 motions does it do?
plane, synovial joint; small cartilage plate/meniscus b/w acromion and clavicle. Abduction (clavicle goes up)/adduction (clavicle goes down), rotation; lateral clavicle = reference point for motion
tests for AC joint: crossed arm adduction test vs chuck norris test
arm and elbow flexed at 90 degrees –> pt grabs opposite shoulder, dr moves shoulder more into forward flexion, if pain at AC –> pos test vs arm and elbow flexed at 90 degrees –> pt abducts to resist you, if pain at AC –> pos test
labrum tests: O’Briens test
shoulder FF 90 degrees w/ 15 degree adduction –> pt externally rotates to resist you w/ thumb down then again palm up, if pain thumb down and no pain thumb up –> pos test –> labral tear
thoracic outlet syndrome
compression of subclavian vessels and brachial plexus, commonly against 1st rib
how to dx thoracic outlet syndrome?
Adson’s test: dec radial pulse w/ arm abducted and externally rotated while pt looks toward affected side; pain at 1st rib; trunk rotation symmetry; arteriogram and EMG
lumbar pain = low back pain
pain occurring posteriorly in region b/w lower rib and prox thigh, accompanied by referred pain
referred pain
pain that’s perceived in wider area than origin site (pelvis, legs, abd, groin)
sciatica
pain radiating down posterior or lateral leg beyond knee
if LBP = recurrent and sxs worsens over time, think of it as…
chronic dz –> early intervention, diag testing
when taking pt’s h/o pain, remember to differentiate…?
differentiate onset/duration, severity, modifying factors of primary location pain and radiating pain (quality of primary pain can be diff from that of radiating pain)
red flags in hx for LBP
h/o malignancy, unexplained wt loss/loss of appetite, recent infxn, trauma, fx risk, cauda spina sxs (urinary retention or fecal incontinence)
red flags in PE for LBP
fever, neuro deficit, peritoneal signs on GI/GU exam
red flags in pmhx for LBP
trauma, surgery, chronic illness, skel anomalies
red flags in fhx for LBP
congenital anomalies of hip/foot, scoliosis, arthritis, genetic d/o
red flags in social hx for LBP
tobacco (inc risk of osteoporosis, lumbar disc dz, impaired bone/wound healing and O2 delivery)
red flags in meds for LBP
statins, erectile dysfxn drugs, bp meds, ocp, alendronate
ddx for LBP in adolescents/teens
somatic dysfxn, postural imbalance; spondylosis/listhesis, spinal apophysitis; scoliosis, Scheuermnn dz; herniated disc. vertebral fx, infxn, congenital dz
ddx for LBP in adults
sprains, muscle imbalance; disc degen, herniated disc; skel irregularities; trauma. infxn/tumor, cauda equina; kidney stones; osteoporosis, fibromyalgia
referred pain: dermatomal vs radicular vs myelopathic pain
sxs following dermatome (pain, rash) that may indicate pathology involving that nerve root vs pain radiating in specific dermatome suggesting nerve trauma at lvl of vertebral foramen –> peripheral; NOT synonymous to radiculopathy (mult sxs vs single sx (ie. pain)) vs tissue of spinal cord = compressed –> dysfxn; bilateral and central
scleratome vs dermatome
each somite give rise to bone or skeletal tissue; ventral and mesial parts of somite prolif mesenchyme and migrate about notochord to make axial skel and ribs; deep somatic track innervated by same single spinal nerve vs area of skin supplied by sensory neurons risssing from SINGLE spinal nerve ganglion
radiculopathy
whole complex of sxs arising from nerve root including par/hypo/anesthesia, motor loss and pain
referred pain: sclertomal referred vs myotomal referred
skel, arthrodial, ligamentous pain vs muscle pain –> crampy, stiff, “grabbing” them in particular motion; sxs can be located away from actual lesion
key LBP principles
LBP = biopsychosocial problem (biophysical, psych, social factors), LBP = sx not a dz, typical LBP presents w/ multifactorial contributors; LBP more in women than men, peak prevalence in midlife
LBP prevention
be active, pt pain education, graded exer therapy, spinal manipulation, cog behavioral therapy; acupuncture, yoga, meds (NSAIDs, SNRIs)
radiating pain = NOT radicular/dermotomal –>
think myotomal and sclerotomal
malingering tests have 2 types: they’re looking for…?
poor or inconsistent effort (more reliable), or pain provocation that does not seem appropriate (less reliable)
standard orthopedic MSK exam in 1995
- observation
- palpation
- ROM
- special tests
- segmental dx
PE: standing vs sitting vs supine vs prone
postural exam, gait, standing flexion, standing Kemp’s vs neuro test (strength test, sensation test, reflexes), pulses, seated Kemp’s, tissue texture screen of spine and ribs vs straight leg raise (Braggard’s test, Brudzinki’s sign, Lasegue’s test), Bonnet’s test, Hoover’s test, hip exam vs palpate lumbar and pelvic muscles, tissue texture screen, Pheasant’s
trendelenburg test
hip and pelvic test, single leg stance and hold; screens for weakness in ipsilateral gluteus medius (pos if plane of contralateral iliac crest drops) and weakness in fxnal hip & core stability (pos if plane of contralateral iliac crest elevates/rotates); named after stanced glut med w/ opposite pelvis drop
stork test aka single legged hyperextension test
dr stands behind pt w/ hand on shoulder on side pt standing on –> pt stands on 1 leg –> dr passively extends spine, rotates, sidebends ipsilateral to standing leg. if early pain –> possible stenosis, lumbar disc; if late pain –> pars fx, facet syndrome
standing Kemp’s
dr grabs testing shoulder and stabilizes opposite iliac crest –> passively extend, rotate, sidebend spine until sxs = reproduced. early pain –> disc, late pain –> facet
what do nerve tension root tests look for?
tingling/numb, muscle weakness, inc sensitivity, back/neck/limb pain in question
supine straight leg test
passively flex straight leg; pos if radiating sxs along leg, not back. if pain <30degrees –> somatic dysfxn, mechanical pain, malingering pt; if pain 30-70degrees –> lumbar disc herniation, chemical nerve irritation
Lasegue’s test vs Bragard’s test vs Brudzinkski’s test vs Sicard test
same w/ SLR but w/ flexed knee vs SLR w/ ankle dorsiflexion vs SLR w/ flexed neck vs SLR w/ great toe extension
Bonnet’s test
for piriformis syndrome, mimicker of discogenic pain. do SLR –> if pos then lower leg to relieve sxs and forcefully internally rotate hip –> pos if same sx in ipsilateral leg
Pheasant’s test
light compression on lumbar spine and flex knee to buttock –> hold for 60s for stenosis pain; immediate pain –> mech soft tissue, discogenic, facet; pos if reproduced leg pain
Yeoman’s test
test for SI joint movement; pt prone –> dr slowly extends hip w/ bent knee while monitoring LS joint; pain in thigh –> hip musculature or tightness, pain in SI region –> SI joint pathology, pain in lumbar region –> posterior element pathology (facet, pedicle, disc), radiating pain anterior –> radicular (L1-3), myotomal, sclerotomal (hip, SIJ), radiating pain posterior –> myotomal or sclerotomal (facet, SIJT)
Hoover test
hands on b/l heels, pt activly lifts 1 leg w/ knee extended –> dr should feel downward force thru opposite heel; pos if no downward force. relies on synergistic ctx principle
CT vs CT myelogram vs provocative surgery vs MRI vs bone scan
provide superior bone detail, higher radiation than XR, not useful for soft tissue pathology compared to MRI vs contrasted spinal canal CT, for pts who can’t have MRI vs for pts who can’t have MRI and ONLY for surgery vs use for radicular LBP, cauda equina syndrome (bil leg weakness, urinary retention, saddle anesthesia, neurogenic claudication), spinal stenosis vs use w/ Tc-99m methylene diphosphonate (MDP), if uptake –> bone mineralization; detects tumor, infxn, occult vertebral fx
spondylosis vs spondylolysis vs spondylolisthesis
lumbar OA, osteophyte formation in vertebral bodies, unrelated to sciatic sxs vs defect of pars interarticularis, check Scottie dog, congenital or acquired (children/adolescents, hyperextension injuries), most common in L5 vs slippage of lumbar vertebral body (anterolisthesis/anterior or retrolisthesis/posterior), congenital or acquired (spondylolysis); grades 1-4 based on length of vertebral body, high grade –> tingling/numb, weakness in 1 or both legs d/t pressure in nerve roots
how to tx spond–?
be active, OMM, PT, meds (NSAIDs, steroids, muscle relaxers, pain meds), CAM, injections, surgery consult
3 primary oss centers vs 5 secondary oss centers (7-9 apophyses) during vertebral development
1 in endochondral centrum –> vertebral body, 1 in each neural process –> pedicles; starts at TL jxn and spreads out in cranial and caudal directions; fuse 3-6yo vs tip of spinous process and both transverse processes, superior & inferior surfaces of vertebral body; appear in puberty
when does vertebral oss start vs end?
8wks vs 25yo
vertebrae characteristics
large vertebral bodies, spinous process (short, thick, perpendicular from body), triangular vertebral foramen, articular facets (superior ones directed posteromedially and medially)
what’s special about L5?
atypical, largest body and transverse processes, anterior aspect has more height than posterior aspect –> lumbrosacral angle b/w lumbar and sacrum
lumbar vertebrae characteristics
support entire upper body (inc wt bearing and stability); flexion, greatest extension of vertebral column, lateral flexion, no rotation; attachment for intertransversari muscles and multifi
know trends on lec 8, slide 8
yep
lumbarization vs sacralization vs lumbosacral transition vertebra
nonfusion of 1st and 2nd segments of sacrum vs transverse process of L5 fuses to sacrum on one side or both, to ilium, or to both vs usually asx, but can cause Bertolotti’s syndrome –> LBP
intrinsic vs extrinsic muscles of lumbar spine
develop in back; superficial (movement and posture), middle (extend vertebrae, posture), deep layers (posture) vs develop from upper limb; superficial (moves scapula, inc load capacity from lower to upper body and head), intermediate layers (movement and stabilization of vertebrae & thorax, assist aspiration)
5 posterior abd wall muscles
illiacus, psoas minor & major, quadratus lumborum, thoracoabdominal diaphragm
posterior abd wall = formed by?
formed by lumbar vertebra, pelvic girdle, posterior abd wall muscles, associated fascia
Spurling’s maneuver
For disc pathology, brachial plexus, radiculopathy; dr passively hyperextends and laterally flexes pt’s neck to affected side and compresses; pos test if axial loading by dr reproduces sxs radiating down arm
Describe scapulothoracic and glenohumeral motion
For straight up arm movement, first 30-45 degrees humeral abduction involves little scapula movement; after that, for q 15 degree abduction -> 10 degree at glenohumeral joint and 5 degree at scapulothoracic joint; glenohumeral to scapulothoracic motion ratio = 2:1
C5/C6 vs C6/C7 chk which reflexes?
Biceps tendon reflex and brachioradialis tendon reflex vs triceps tendon reflex
Describe scapulothoracic joint
Scapula and muscles cover posterior chest wall; scapula = mobile platform from which upper limb operates —> scapula can glide in any direction and rotate over poster o lateral chest cage
Scapular movements include:
Medial/lateral, elevation (d/t upper trapezius & levator scapulae)/depression (d/t lower trapezius & rhomboid major), abduction/protraction (serratus anterior, pec minor), abduction/retraction (middle trapezius & rhomboids); rotation (low serratus anterior, upper & lower trapezius)
What is the labrum?
Ring of fibrocartilage surrounding and deepening glenoid fossa
SC joint. What 3 motions does it do?
Saddle shaped synovial joint. Allows humerus to achieve 180 degree abduction; anterior/posterior glide, superior/inferior glide, rotation anteriorly/posterior lay
Tests for SC joint: ab/duction of clavicle vs horizontal flexion/extension
Pt = supine and dr at pt’s head —> dr places fingertips on superior edges of medial clavicles —> pt shrugs shoulders to go into abduction —> medial clavicles SHOULD move inferiorly, if not => adduction somatic dysfxn —> tx: palpate superior border of SC joint —> hold pt’s extended wrist and point their thumb down —> pt adducts to resist you vs pt = supine and dr at pt’s head —> dr places fingertips on anterior edges of medial clavicles —> pt reaches toward ceiling —> medial clavicles SHOULD move posteriorly, if not => horizontal extension in somatic dysfxn —> tx: dr has thenar on sternal end of affected clavicle and other hand on pt’s posterior shoulder —> pt extends elbow to reach dr and rest their hand on dr’s neck —> dr stands more erect while pt resists
Dorsal lobe vs ulnar lobe of triquetrum
On dorsal wrist distal to ulnar head vs in ulnar snuffbox distal to ulnar head/styloid process
Dorsal vs palmar surface of trapezium
In distal aspect of anatomic snuffbox vs distal to scaphoid tubercle
Dorsal vs ulnar surface of hamate
Distal to triquetrum vs the hook on palmar side of hand
Degrees of motion for wrist flexion vs extension vs radial deviation vs ulnar deviation
90 degrees vs 70 degrees vs 20 degrees vs 30 degrees
Strength testing of wrist: grip vs wrist extension vs finger abduction
Tests finger flexors and intrinsic muscles (median nerve) vs stabilize wrist and extend wrist against resistance (radial nerve) vs spread fingers apart (branch of ulnar nerve)
tinel’s test
Tap ulnar nerve in groove b/w medial epicondyle and olecranon or tap median nerve on palmar hand; pos if pain or tingling
phalen’s/reverse phalen’s test checks for?
Carpal tunnel syndrome –> median nerve neuropathy
Finkelstein looks for?
De Quervain’s tendonitis test: Thumb under fingers —> passive ulnar deviation of wrist; pos if pain over 1st extensor
CMC grind test
Axial compression of 1st CMC joint in mortar and pestle motion; dr takes pt’s 1st metacarpal w/ one hand and distal radius in the other —> apply longitudinal compression and rotary motion along 1st metacarpal compressing 1st CMC joint => grinding motion; pos if pain at 1st CMC joint –> degen arthritis at that joint
Describe elbow
Links forearm and upper arm in concert w/ shoulder; uni-axial hinge joint
3 joints in elbow: humeroulnar vs humeroradial vs proximal radioulnar
True elbow joint, modified hinge joint for fl/ex vs combined hinge and pivot joint, some fl/ex and more rotation of radial head on capitulum of elbow vs rotation for supination and pronation
2 ligaments of elbow: medial/ulnar and lateral/radial
Resists and prevents excessive ab/dduction; does not impede supination/pronation
Interosseous membrane b/w radius and ulna characteristics
Fibrous membrane actively transferring force from radius to ulna; go in oblique direction from prox radius in caudad direction towards ulna; can have strain after injury to radius or ulna
what are the growth plates of elbow?
CRITOE/CRMTOL: Capitulum, radial head, internal/medial epicondyle, trochlea, olecranon, external/lateral epicondyle
Carrying angle. Cubitus valgus vs varus
Nmlly 15 degrees; female > male. >15 degrees d/t forearm deviating outwards vs <15 degrees d/t forearm deviating inwards
Median vs radial vs ulnar nerve
Crosses elbow medically; passes thru 2 heads of pronation teres vs descends arms laterally and divides into superficial (sensory) branch and deep (motor or posterior osseous) branch, deep branch passes thru Arcade of Frohse —> most susceptible to injury vs descends arm medially and posterior to medial epicondyle thru cubital tunnel
Test for lateral epicondylitis: resisted 3rd digit extension test
Pt’s hands on table and fingers spread out —> dr places finger on pt’s 3rd digit —> pt lifts 3rd digit to resist you; pos if pain at lateral epicondyle
Tests for medial/ulnar and lateral/radial collateral ligaments: valgus/varus test
Ulnar and hand deviation test thingy; pos if lax
Milking maneuver/test
Elbow flexed to >55 degrees, hand supinated, pt pulls down on thumb —> pos if pain —> valgus stress
describe lumbrosacral jxn motion
opposite directions: lumbar flexion –> sacral extension and vice versa
Know Fryette’s principles and nomenclature
Type I vs II. lvl of dysfxn, neutral or fl/ex, SR or RS; based on superior vertebra over inferior vertebra
T6-T9 vs T10-L1 vs T8-L2 vs T10-L2 vs T11-L2 vs L1-L2 innervate which organs?
pancreas vs kidney/adrenals/ureter, ovaries/testes vs colon vs ut vs appendix vs rectum/anus, bladder, prostate
do plexuses have valves?
no –> allow blood flow superiorly and inferiorly depending on pressure gradients
lumbar spine gets blood supply from subcostal and lumbar arteries. these arteries branch out into…?
periosteal and equatorial arteries —> branch into ant/posterior canal branches
openings of diaphragm –> pass thru b/ thorax and abd: vena cava vs esophagus vs aortic hiatus
pass thru diaphragm at T8 vs T10 vs T12
RC ctx pulls what?
pulls humerus down into lower/wider portion of glenoid cavity
vert LV and LN characteristics?
Vert LV meet w/ periphery sensory and sympathetic ganglia. Vert LN = aortic LN b/w abd diaphragm and pelvis
Which type of lumbar motion = coupled vs not coupled?
S/R, can be same or opposite side vs F/E
Medial vs lateral lumbocostal arch covers which muscle?
Psoas major vs Quadratus lumborum
How do superior facets of lumbar spine face?
BUM (posteromedially and medially)
