Week 4-8 Flashcards
What MFTP mimics C8?
Latissimus dorsi, serratus, pectoralis major
What MFTP mimics C6?
Infraspinatus, subclavius, supraspinous, scalenes
What are the x-ray indications?
Trauma with Ottawa rules, red flags for disease, significant deficits, nerve damage
What are the Ottawa rules?
Trauma+ over 70, limited rotation (less than 45 total), rust sign, spinal percussion
What are the red flags for disease?
Fever, fatigue, malaise, weight loss, loss of appetite
What are the indications for MRI?
Profound muscle weakness, neurological deficits, progressive muscle weakness, signs of cord involvement
What rules out facet syndrome?
Lack of tenderness on the facet and inability to recreating the pain with extension and rotation
What motions induce LB extension?
Sitting, overhead work, Superman’s, extension, prone extension, passive DSLR (prone)
What motions induce flexion?
Knees to chest, bending forward, standing with one leg on a stool, using a shopping cart to walk, squatting
What is the B list for spinal disorders?
SOL, infections, fractures, facet syndrome, sprain strain, NR adhesions, instability
What is the only helpful thing to rule out stenosis?
If flexion does not improve symptoms or ability to walk (shopping cart sign) .5 LR
What are the top 3 Rule in signs with stenosis?
Wide gait, sitting is relieving, burning sensation in buttock
What is the difference between radiographic stenosis and clinical stenosis?
Radiographic stenosis can be asymptomatic and is made by measurement
Clinical stenosis has symptoms into the extremity and may not meet the diagnostic criteria based on the radiograph
What are indicators of stenosis?
Leg symptoms made worse by walking, extension increases leg symptoms (especially arms overhead), flexion relieves symptoms, SMR deficits (50%), balance/ proprioception disturbances
Why do you not get a + SLR in stenosis?
Because the inflammation is local and less severe than in herniations
What is the role of age in diagnosing neuropathic leg pain?
It changes what is most likely.
Younger than 40: herniations
Over 60: stenosis
Between 40 and 60: 15% will have stenosis, but it could also be a herniation. There are also B list causes
What are the causes of peripheral neuropathic pain?
Diabetes, neuropathy (specific nerve), piriformis syndrome, entrapments
What B list causes will have red flags? What red flags?
Tumors: weight loss/ appetite loss, anemia, ESR/CRP, no comfortable position
Infections: fever, fatigue
Which A list disorder will valsalva more likely be positive?
Herniations
Which A list disorder will dejerine’s triad more likely be negative?
Stenosis
What A list disorder will sitting likely improve symptoms?
Stenosis
What A list disorder will flexion likely increase symptoms?
Herniations
What A list disorder will extension aggravate the leg symptoms?
Stenosis
What A list disorder will sustained loading centralize symptoms?
Herniations
Which A list disorder will usually have a positive SLR?
Herniations
Which A list disorder will more likely have neuro deficits?
Herniations (both are possible)
Which A list disorder will more likely have ataxia?
Stenosis
Where does Psoas refer to?
Anterior thigh and iliac crest
What is the pain pattern for Maigne’s syndrome?
Upper buttock, iliac crest, trochanter, and groin
What is the referral pattern for QL?
Trochanter, iliac crest, ischial tuberosity
What is the referral pattern for the glut med?
Sacrum, glut, trochanter, lateral leg
How do you tell if a spondy is unstable?
Passive extension, excessive motion, prone instability test, painful arc, reversed lumbopelvic rhythm
Who will respond well to a core stabilization program?
A >40 yo, with greater than 90 SLR BL, positive prone instability test, and aberrant motion with lumbar flexion
What are examples of aberrant motion with lumbar flexion?
Minors sign, reversal of lumbopelvic rhythm, or instability catch
What indicates poor motor control?
Segmental abnormal movement, painful arc abolished with bracing, trunk forward lean,
difficulty learning pelvic clocking or abdominal hollowing,
bad form in hip extension or single leg stands
What are history clues that suggest instability?
Episodic nature, progressive, popping/locking/catching/feeling of giving way, immediate pain with sitting relieved by standing, temporary response to treatment which is decreasing
What is the difference between structural and functional instability?
Structural is an issue with the bones/ tissues such that they can no longer support normal movement
Functional is a neurological issue where the muscles are not being given the signals to react in the appropriate time within the neutral zone causing other tissues to pick up the slack.
What is the measurement for radiographic stenosis?
12mm
What is the measurement for absolute stenosis?
10mm
What is the measurement for radiographic hyper mobility?
Greater than 3mm sagittally
What is the gold standard imaging choice for spondys?
Radiographs, flexion extension and MRI
When is spondylolethisis likely to be a candidate for DDx in a 40+ yo?
When there is a history of symptoms before 30 yo.
What is phalanx Dickson sign?
Flexed knees and hips
What physical exam finding suggest spondylolethisis?
Functional scoliosis, hamstring spasm, tenderness to deep palpation at the SP above the slip, step off defect, positive passive leg extension, and segmental hyper mobility
Who is more likely to have a step off defect?
Young athletics with spondylolethisis
What is a positive passive leg extension test?
Heaviness in the legs with lifting and traction that decreases when the legs are lowered
What does a positive passive leg extension test more likely indicate?
Unstable spondy
How long should an athlete with a spondy be removed from sport?
3 or more months
What 3 things can you do for a stenosis patient?
Flexion distraction, neuromobilization and stabilization program
What are the 5 options for neuropathic symptoms?
Nerve root, peripheral neuropathy, extremity lesion, referred pain, cord lesion
What are the causes of nerve root damage?
Herniation, SOL, osteophytic compression, NR adhesion, instability, infection, fracture
What are the signs and symptoms of NR osteophytic compression (lumbar)?
NO CES, unilateral SMR/ sensation/ pain distribution, positive kemps, pure flexion and extension loads are not sensitive or as sensitive
What are the signs and symptoms of tumor/cyst?
Pt >50, SMR deficits, cord signs, spinal percussion, leg pain w/out back pain, classic red flags, increased ESR/CRP, ALP, hypercalcemia
What are the classic red flags?
Prior history of cancer, unexplained weight loss, increased pain laying supine, unremitting pain unaffected by position
What are the signs and symptoms of spinal infections?
Pt >50, prior history of infection (any), immunocompromised, fever, spinal percussion, high ESR, positive tension tests, neuro deficits, disc destroyed and end plates damaged
What is the difference between infection and cancer on imaging?
Cancers spare the disc while infection destroy. Discs and end plates
How to differentiate PAD from stenosis?
Location of pain, effect of walking on pain, what helps, what hurts, and pulses
When will muscles be weaker after walking stenosis or PAD?
Stenosis
What will help stenosis?
Bending over, sitting
What will help PAD?
Sitting, stopping (walking or changing position)
What will increase stenosis symptoms?
Walking downhill, extension
What will increase PAD symptoms?
Walking uphill, increased metabolic demand
What will have diminished lower limb pulses?
PAD
When will the pain come on with walking for PAD?
Commonly 30 min
Where is the pain for stenosis and PAD in the lower extremity?
Stenosis- thighs
PAD- calves/ lower leg
What is the difference between DVT and PAD?
DVT- swelling, tender nodules, increased temperature, pain at rest
PAD- reduced temperature, tissue loss, muscle wasting, hair loss, bruits/ dismissed pulses
What are the tests you might add for stenosis?
Single leg stand (Romberg sign), sustained extension, lower extremity pulses
What are the ancillary studies for PAD?
MRA, ABI, and Doppler ultrasound
What is the conservative management for PAD?
A walking program (near the pain threshold), toe raises to pain +5
What 3 things together indicates the hip itself rather than the spine?
A limp, groin pain and limited internal rotation
What is the most common location for hip pain?
Localized to the groin
What muscles commonly go into spasm with hip problems?
Adductors
How far can hip problems radiate?
To the foot
What are the top ddxs for lateral hip pain?
Glut med tendinopathy, ITB tendinopathy, trochanteric bursitis, external snapping hip
What is snapping hip?
When a tendon is tight and snapping over the acetabulum
What rules in glut med tendinopathy?
Lateral hip pain with single leg stand and resisted FADER test
What rules out glut med tendinopathy?
Lack of tenderness with palpation of insertion
What are the DDxs for anterior hip pain?
Hair osteoarthritis, famoroacetablular impingement, labral tear, AVN, stress fracture, adductor tear, internal snapping hip
What is the DDx for posterior hip pain?
Femoracetabular pathology (OA, labrum, AVN) SI, Hamstring, Piriformis, lumbar referral
How much of the SI accounts for chronic low back pain?
20%
What 5 tests should you always do check the SI?
Thigh thrust, sacral thrust, SI compression, SI distraction, gaenslens
What are causes of sacroiliitis?
RA, AS, reactive arthritis, psoriatic arthritis, enteric arthritis
What is lower cross?
Weak abdominals, weak glut max, weak glut med, overactive psoas, overactive erectors, overactive rec fem, overactive TFL, overactive QL
What is SI muscle imbalance?
Ipsilateral glut max inhibited, contra glut med inhibited, ipsilateral psoas tight, ipsilateral piriformis tight
What is upper cross?
Overactive SCM, overactive Trap, Overactive Pec, overactive suboccipitals, overactive levator scalp, inhibited deep neck flexors, inhibited rhomboids, inhibited lower trap, inhibited serratus
How to progress through a stabilization program (3 stages)?
1- dead bug, quadruped, side bridge, bracing, hip hinge
2-lunge track, squat track
3- functionally mimic ADLs
What orthos will be positive in a sprain?
Anything passive (knees to chest, passive extension, pROM)
What orthos will be painful in a strain?
Anything resisted (rROM, prone extension with over pressure)
What is the single best clue for disc?
Centralization/ directional preference
What travels in the posterior column?
Proprioception, vibration, touch, 2 point discrimination
What travels in the lateral spinothalamic track?
Pain and temperature
What will effect the posterior column?
UMNL or spinal cord compression
What is the difference between the three piriformis diagnoses?
Piriformis syndrome-nerve involvement
Piriformis MFTP- radiation
Piriformis spasm- no leg pain
