OMM 2 Flashcards
red flags of LBP
age, major trauma, malig, unexplained wt loss/loss of appetite, cauda equina (incontinence, saddle anesthesia, neuro sxs), constitutional sxs (fever, chills, infxn, immunosuppression, IVDU)
components of body system exam
observe, ROM, palpate, segmental dx of somatic dysfxn, special tests
how to observe for body system exam?
inspect skel and extremities (gross deformity, postural alignment, muscle imbal, gait), inspect muscles (size, symmetry, tone, temp)
how to chk ROM in body system exam?
single plane motions –> mult plane motions –> AROM w/ observation only –> AROM w/ stabilizing pelvis
how to do palpation in body system exam?
tissue texture changes (acute vs chronic), tender/swelling, fluctuation/effusion, crepitus, resistance to pressure
how to chk PNS vs CNS vs gait neuro exam?
motor = muscle strength, sensory = light touch eval in each dermatome, peripheral nerve distribution, DTR vs r/o upper motor neuron lesions, CNS balance vs yep
Spinal nerve roots w/ muscle: L2-4 vs L4-L5/S1 vs L4-L5/S1-2 vs S1. L4-S3?
psoas, medial muscles (hip adductors, pectineus, gracilis, obturator ex), quads, TA vs glut min & med vs hamstrings (biceps fem, semis) vs glut max, gas/sol. sup/inf gemellus, quadratus femoris
Motor strength = 0 to 5 criteria
o 0 = no movement at all
o 1 = flicker of movement, unable to move joint
o 2 = can move parallel but not against gravity
o 3 = can move against but not resistance
o 4 = weak resistance
o 5 = nml
how to find tone vs bulk
have pt relax and move limb –> inc/dec, nml, rigid, spastic vs atrophy, hypertrophy
muscles to look for hip extension firing pattern. hip extensors vs hip flexors
hamstring, gluteus, contra/ipsilateral quadratus lumborum. hamstrings, glut max, adductor magnus vs iliopsoas, rectus femoris
why use special tests vs pain provocation tests vs fxnal tests
uncover specific pathology or dysfxn to further delineate the problem vs for pain patterning and anatomical structures, finding local or radiating pain vs to find nml structural fxn during dynamic motion
what’s the hip drop test? how to do it?
screens ability for lumbar to sidebend away from side of hip drop –> hip that drops the least = pos side. dr on iliac crest, pt bends one knee w/o lifting heel off floor –> bends other knee –> dr finds which hip drops more
FABER/Patrick’s/Figure 4 test vs FADIR
flex, abduct, externally rotate leg –> pain before SI joint –> acetabulum/femoral joint; pain after SI joint –> SI joint pain vs flex, adduct, internally rotate –> pain –> femoroacetabular impingement
how to do standing eval?
observe gait; posture (kyphosis, lordosis, scoliosis, sidebent, fl/exed); asymm/spasm/wasting of extremities and back; trunk A/PROM, standing flexion test
how to do seated eval?
muscle strength of LE, sensory exam of LE and back; straight leg test, DTR; vasculature/chk arteries; trunk A/PROM; seated flexion test
how to do supine eval?
hip: ROM, leg lengths; pel: ASIS, umblicus, pubic ramus, iliopsoas, tenderpoints and hypertonicity
how to do prone eval?
lumbar TART changes; pel/sacrum: PSIS, sacral base, ILAs; hypertonicity of quadratus lumborum
sequencing tx approach methods
bottom to top, top to bottom, start w/ foundation, area of greatest restriction or tissue texture change, start nonpainful to painful tx
sequencing tx if present:
true dislocations (upslip/downslip, pubic shears, ribs) –> long restrictors (psoas, QL, iliacus, lat, trap) –> T-L jxn & lumbar spine –> sacrum & innominates
what is USPSTF?
indep, volunteer panel of nat’l experts in prevention and evidence-based medicine; includes IM, FM, peds, OB/GYN, behavioral health, nursing, preventive medicine; does recs for screenings, counseling, preventive meds
goal of USPSTF?
provide evidence-based recs about using clinical preventive services in asx ppl; determine rec grades but don’t consider the costs, only apply to asx ppl, addressed only in primary care setting
What does USPSTF consider to make recs?
assess benefits > risks, determine age and risk factors
A vs B vs C vs D vs I
USPSTF recommends service –> offer vs recommends service, mod to high certainty there is net benefit –> offer vs mod certainty there is small benefit –> selectively offer service depending on situation vs mod to high certainty no net benefit –> recommends against service vs evidence = insufficient –> if service = offered, pt needs to be aware of uncertainty, benefits, and risks
stats on women vs men for osteoporosis. osteoporotic fx can lead to? (4)
1 in 2 PMP women vs 1 in 5 older men. chronic pain/disability, loss of indep, dec QOL, inc mortality
who to screen per USPSTF for osteoporosis? how to screen for osteoporosis?
older adults in US pop who don’t have h/o osteoporotic fx, osteoporosis 2ndary to other condition, no specific indications for bone measurement testing; they didn’t define upper age limit for screening in women. DEXA –> T and Z score
uncontrollable vs controllable risk factors per National Osteoporosis Foundation
> 50yo, female, menopause, fhx, thin frame, fx, height loss, race (Cauc/Asians) vs not enough calc & vit D/fruits/veggies, too much protein/alc/sodium/caffeine, inactive, losing weight, smoking; steroids, anticoag/epileptic, proton pump inhibitors, lithium, long term bisphosphonates
what’s the leading cause of injury in adults >65yo?
falls
which tests to measure fall risk? (4)
gait and balance performance testing, fxnal reach test, timed get up and go test, presence of environmental hazards
types of fall prevention
PT, OT; no benefit from vit D –> D rec; comprehensive multifactorial assessment (provides risk factors and social care to address those factors) but timing consuming –> not appropriate for all pts –> small benefit –> C rec
what’s the most sig risk factor for progression of scoliosis?
skel maturity
USPSTF screening tests for scoliosis: Adam’s test vs scoliometer vs Moire topography vs radiography
visual inspection of spine for asymm of shoulders and scapulae during active trunk flex vs measure the curve vs using a grid, screen, light source and camera to assess symmetry vs used to confirm idiopathic scoliosis
USPSTF recommendation grade for scoliosis screen? why? what happens if children have mild to mod curvature?
I. no direct evidence of effective screen for adolescent idiopathic scoliosis –> don’t screen asx children. brace dec curve progression
evidence of calc and vit D on bone health
adeq evidence daily low dose 400mg vit D and 1000mg Ca2+ –> no effect on incidence of fx in PMP women; inadeq evidence of higher doses of calc and vit D in men and PMP women
what’s the goal dose of vit D? 2 types of vit D: D2 vs D3
> 35ng/mL. ergocalciferol from irradiation of yeast and plant sterol ergosterol vs cholecalciferol from oily fish and skin synthesis from sun
low vs high serum vit D = linked to?
inc fx risk, fxnal limitations, CVD, ca, depression and dec cognitive fxn vs hypercal, kidney stones
evidence of motor vehicle restraints
good evidence of community and public health interventions in improving use of car seats, booster seats, seatbelts
what is the 2nd leading cause of death from injury of all ages?
MVA (kill more children and young adults)
what to look for joint sxs characteristics?
uni/bil, stiffness/locking, ROM, change in size or contour, constant pain or pain w/ motion
what to look for muscle sxs characteristics?
ROM, weak, fatigue, wasting; tremor/tic/spasm/clumsy, paralysis
what to look for skel sxs characteristics?
difficulty gait/limp, pressure sensation, pain w/ movement, crepitus, skel deformity or change in contour
what to look for neuro sxs characteristics?
uni/bil, numb/tingling/weakness, visual disturbances, progressive neuro deficits
elements of pmhx
acute/chronic illness, injuries/accidents, congenital dz, screening tests (mammo, prostate DRE, pap, colonscopy), birth hx for infants and children
elements of surghx
surgery, year, hospital, dx, complications
elements of fhx
relationship, dz, age, cause of death
elements of meds
rx and OTC, herb, vit
elements of MSK hip/pel PE (think of pt encounter)
inspection (scars, ecchymosis, erythema, deformities); palpation (bony pain, muscle defects, TART changes); ROM (symm and restriction); muscle strength test, neuro/vasc test (DTR, sensation), special tests
special considerations for infants/children vs preg vs elderly
fine/gross motor development, overwt/obese, growth spurt, competitive sports vs previous surg before preg (ut tightening, N/V, fever/malaise), wks gestation vs minor injury, fx, meds
6 cardinal ROM vs minor motions
fl/ex, in/external rotation, ab/duct vs anterior glide w/ ext rotation, posterior glide w/ int rotation
knee characteristics. how many bones? any stability?
largest joint in body; hinge joint; 3 articulations: tibiofemoral, tibibofibular, patellofemoral. 4 bones (patella, femur, tibia, fibula). no inherent stability –> relies on lig –> highly susceptible to injury
what are menisci?
medial and lateral semilunar fibrocartilaginous discs that add cuplike surface to flat tibial plateau –> limit extreme fl/ex
what do menisci do at full flex vs full ex?
posterior horns of meniscus drive posteriorly –> block further flex vs Anterior rim of meniscus driven anteriorly –> block further extension
ACL vs PCL vs MCL vs LCL w/ attachments
prevents extreme ant glide/ant motion of tibia on femur; attaches from post medial femoral condyle thru knee to intercondylar space vs prevents extreme post glide/post motion of tibia on femur; attaches to intercondylar space and medial femoral condyle vs prevents valgus stress, aka tibial collateral lig vs prevents varus stress, aka fibular collateral lig
knee pain can be mimicked by:
somatosomatic –> upper lumbar radiculopathy, pelv/hip/sacrum (SCFE); or viscersomatic –> lg intest, prostate/broad lig
special considerations for infants/children vs preg vs elderly FOR KNEE PAIN
unfused growth plates, XR bil vs inc laxity, ligmentous tissue vs prior injury/overuse, OA
in ROS for knee pain, what’s the diff b/w arthralgia vs polyarthralgia vs myalgia?
1 joint –> trauma, bursitis, tendonitis, OA vs mult joints –> rheum fever, gono arth vs muscle strain, systematic illness
in ROS for knee pain, how to find articular pain vs nonarticular pain
loss of A/PROM vs loss of AROM but not PROM
when to use diag img for knee pain: US vs XR vs MRI vs joint aspiration vs bone scan
tendinopathy, cysts vs standing AP, lat, Merchant (knee flexed and look underneath patellofemoral joint space); arth, fx, growth plate injury, loose body, joint effusion, alignment vs bone marrow and soft tissues, confirm dx vs inflammtory arthropathies vs occult fx, tumor, insertional tendonitis, inflamm conditions
Q angle (per Ryan)
when ASIS > patella, tibial tuberosity; >12 –> genu valgus, <10 –> genu varus
what do inc vs dec temp changes mean for knee pain?
infxn, inc blood flow after trauma/injury, acute inflamm vs swelling which impairs circulation, dmg circ system w/ fx/dislocation/blood clots
why chk patellar tracking?
patellar tilt, inverted J sign, patellofemoral syndrome
what can you palpate on for ant vs post vs medial vs lateral knee?
quads tendon/prox patella, patellar tendon/distal patella, patella, tibial tuberosity vs Baker’s cyst, hamstring tendons, gastrocnemius tendons vs medial fem condyle, medial tibial plateau, adductor tubercle, MCL vs lateral fem condyle, lateral tibial plateau, LCL
what’s the dx if patella tenderness at superior pole vs inferior pole vs long med/lat facets/retinaculum?
quadriceps tendinopathy vs patellar tendinopathy, Sinding Larsen Johansson syndrome vs patellofemoral pain syndrome, Plica syndrome
what’s the dx if pain at tibial tuberosity?
osgood schlatter, skel immature
pulses in LE
Popliteal a, dorsalis pedis a, posterior tibial a
screw home mechanism
med condyle = long b/c tibial ER w/ full ex –> goes posteriorly on tibial plateau, popliteal unlocks w/ flex and tibial IR, femur IR
how to tx tibial fl/ant glide vs ex/post glide dysfxn?
take tibia to restricted barrier –> spring posteriorly vs anteriorly –> RECHECK
how to tx tibial ER vs IR dysfxn?
bring tibia to IR barrier –> muscle energy or springing technique vs bring tibia to ER barrier –> muscle energy or springing technique
fibular motion
prox –> synovial joint, distal –> syndesmosis, fibular head glides: anterolat –> ankle eversion, posteromed –> ankle inversion
fib head dysfxn: anterior vs posterior fib head
hold mid/hindfoot –> invert and plantarflex foot –> apply posteromed force on prox fib, anterolat force on distal fib –> pt pronates to resist –> engage new barrier, do 3-5x –> RECHK vs hold mid/hindfoot –> evert and dorsiflex foot –> apply anterolat force on prox fib, posteromed force on distal fib –> pt supinates to resist –> engage new barrier, do 3-5x –> RECHK
indications vs contraindications of inteross mem myofascial release. how to do it?
restricted leg fascial rotation from leg/ankle pain, gait abnlity vs acute sprain/fx, DVT. pt supine –> dr hand on tibi tuberosity/fib head and other hand on med/lat malleoli –> rotate hands in opposite directions to find restriction –> indirect or direct technique –> RECHK
what to do for foot/ankle injury PE
gen appearance, vitals, gait/FXNAL ARCH, inspection, palpation, ROM, strength, stability, special tests, OMM exam, neurovasc
med longitudinal arch vs lat longitudinal arch vs prox transverse arch vs distal transverse arch/metatarsal arch
calcaneus, talus, navic, cuneiforms, 1st 3 metatarsals; major shock absorbing arch; if MC dysfxn –> anteromed talus on calcaneus –> moves navicular inferiorly vs calcaneus, cuboid, 4/5th metatarsals; inferior cuboid dysfxn > talocalcaneal dysfxn (talus = anterior and calcaneus = inferior) vs navicular, cuboid, cuneiforms; rigid arch –> maintains osseus foot architecture vs articulations of metatarsal heads w/ phalanges; no muscle attachments –> foot can adjust to uneven ground; arch flattens w/ wt bearing
components of tarsals vs metatarsals vs phalanges
calcaneus talus, navic, cuboid, cuneiforms vs 5th metatarsal base vs MTP/IP joints
ex of syndesmotic lig. what happens if there’s an injury to them?
ant/post tibiofibular lig maintain the mortise joint. high ankle sprain
how to chk ROM for foot/ankle
test both A/PROM, knees together, foot/ankle exposed. dorsi/plantar flex, in/eversion, MTP/PIP/DIP joint stability medially/laterally and plantar/dorsally. goniometer
which muscles = used when checking dorsi vs plantarflex? inversion vs eversion?
TA/P, EH/DL vs TP, gastroc, soleus, peroneus longus/brevis, FH/DL. TA/P vs peroneal group (LBT), EDL
triplanar movements: sup vs pron
inversion, forefoot adduct, flex vs eversion, forefoot abduct, ex
which part of foot = impt for gait push off?
MTP
how to do muscle testing for TP vs Fibularis longus and brevis vs TA vs gastroc/soleus
test inversion strength in plantarflexion and inversion vs patient plantarflexes and everts, resisting examiner’s inversion force vs patient hold foot in dorsiflexion and resist examiner’s plantar force vs toe-walking
OA vs inflamm conditions
both have gradual onset, morning symptoms, worsening with activity, and stiffness. dec A/PROM on internal rotation and extension vs abnormal blood tests (increased ESR), WBC in the joint fluid, other joint involvement, skin or bowel symptoms
fem stress fx vs fem/acetab impingement
overuse. insidious vague pain. antalgic gait, Hops+, pain ant thigh and extreme ROM vs blank. click/catch/stiff/dec ROM. cam/pincer/combo, FADIR+, AP/lat/frog leg/Dunn views
snapping hip vs hip labrum tear
blank. internal/external. palpate –> fl/ex –> snap vs running, hip hyperex, trauma. deep sharp ant hip pain, deep clicking, rpt flex/pivot/LS dysfxn. FADIR+, Scrub/Scour+
hernia vs sportsman hernia PE/dx
localized pain hard to pinpoint; weak adductors and abd muscles vs PE findings subtle –> imaging
psoas syndrome
shortened muscle, organic (AAA, abscess, appendicitis, prostatitis, diverticulitis, hernia, kidney stones). LBP radiating to hip, groin, contralat glut; sl flexed posture. Thomas+, leg length+, LS dysfxn
osteitis pubis vs delayed onset of muscle soreness
rpt trauma or exertional stress on fascia or joint. insidious pain on groin, hip, testes, pubic area; adductor pain or low abd pain. XR, MRI vs bil sore muscles. rhabdo, immobilized, acute dehydration w/ overuse. high CK for rhabdo; muscle pain on PE
purpose of arthrocentesis. contraindic?
reduce effusion (since it restricts flex and causes pain) and analyze synovial fluid; must have consent before and must reassess ROM after. prosthetic/replaced joint, cellulitis, open growth plates
ant: superficial vs deep thigh muscles. post: superficial vs deep thigh muscles. horizontal muscles vs medial muscles
quads (RF, vastus med/inter/lat, sart) vs iliopsoas, tendons inserting to lesser troch. hamstrings (biceps femoris, semis) vs gluts, tens fasc lata, piri. obturator in/externus vs obturator ex, adductors, gracilis, pectineus
sciatic n originates from? can be compressed by? passes thru?
L4-S3. piriformis. sciatic notch
ant thigh n: lat fem cut n vs fem n vs obturator n
L2-3; sensory to anterolateral hip and thigh; compressed under inguinal ligament vs L2-4; anterior hip, thigh, knee; injured during surgery or trauma vs L2-4; medial hip, thigh, knee; entrapped in obturator foramen or adductor fascia
describe SI joint. thoracolumbar fascia?
parallel flat joint surface; form closure; force closure –> 2 surfaces of joint provide frxn –> enhances stability (seg stiffness, position, compression force, torsion ctrl). transfers load b/w lat’s and opposite gluts
in what conditions is muscle energy most useful?
subacute to chronic conditions, where muscle shortening & fibrosis may be present
hip abductors vs adductors
glut min/med, piri, tens fasc lata vs medial muscles (4 = main; pect/gracilis + glut max = minor)
primary vs secondary indic of ME. relative vs absolute contraindic of ME
stretch/improve elasticity of fibrotic muscle, reduce hypertonic muscle, mobilize restricted joints vs improve circ and resp, inc tone, balance neuromusculature. osteoporosis, severe illness, mod to severe muscle strain vs pt refusal, fx/dislocation, mod to severe joint instability
what type of dysfxn does pt have if they have tight/short iliopsoas vs tight/short hamstrings vs tight/short quads? KNOW HOW TO TX EACH and in/external rotation somatic dysfxn
flexion somatic dysfxn, hip extension restriction vs extension somatic dysfxn, hip flexion restriction vs extension somatic dysfxn, knee flexion restriction
how to tx tight ITB or tens fasc lata?
myofascial release. can also do kneading movement for tens fasc lata (pt prone –> flex knee 90 –> pull ITB towards you and foot away from you –> knead)
how to tx ant vs post talus dysfxn?
flex knee, dorsiflex to barrier, pt plantarflexes to resist you vs extend knee, plantarflex to barrier, pt dorsiflexes to resist you
reasons for navic dysfxn? how to tx it?
TP inserts on navic –> medial arch collapse; calcaneonavicular/spring ligament insufficiency; acute inversion ankle sprain –> peroneus longus tendon inserts on medial cuneiform and 1st MTP. hold calcan in one hand and forefoot w/ other –> evert and dorsiflex pt –> pt inverts and plantarflexes to resist you
reasons for cuboid dysfxn?
fibularis inserts on cuboid –> lateral arch collapse; calcaneocuboid ligament insufficiency; more prominent cuboid in lat arch and plantar surface, more sup when standing
how to tx dropped navic vs cuboid?
push navic superior and medial vs push cuboid superior and lateral
marfan’s syndrome physical findings
- tall and thin
– Long extremities
– Arachnodactyly
– Pectus excavatum
– Hypermobility of joints
– High arched palate - worry about cardio
what’s Sever’s dz?
achilles tendon insertion into vertical calcaneal apophysis
AHA screening questions for pmhx vs fhx vs PE
chest pain, bp, heart murmur, syncope, extreme fatigue from exer vs disability from heart dz in relative <50yo, premature death, specific heart conditions (marfan’s, long QT syndrome, arrhythmia, cardiomyopathy) vs brachial a bp, heart murmur, physical appearance for Marfan, fem pulse to exclude aortic coarctuation
how to chk for intra vs extra articular knee swelling?
bulge test (min effusion), ballottement test (lg effusion) vs mild local swelling –> contusion, bug bites, local infxn; massive general swelling –> fx, major internal derangement, infxn, blood clot, ruptured Baker’s/popliteal cyst
lumbar fl/ex vs sidebending vs rotation can be created by hip…?
hip fl/ex vs hip rotation vs hip ab/adduct
stability testing: grade 1 vs 2 vs 3
sprain vs partial tear w/ laxity vs complete tear w/ no endpoint
