E1 Flashcards
(168 cards)
1
Q
Where is the true hip joint located?
**board question
A
In inguinal fold, lateral to femoral artery and just lateral to femoral nerve
2
Q
Why is the location of the true hip joint important?
A
Arthrocentesis
3
Q
Where do you insert the needle for hip arthrocentesis?
**board question
A
Palpate the arterial pulse, cover the nerve with your finger, and insert needle just lateral to that
4
Q
How much pressure is transmitted through the femoral head?
A
3 pounds of pressure for every pound of body weight
5
Q
Which hand is the cane held in?
A
Contralateral hand (to the injury/dysfunction)
6
Q
Psoas innervation
A
L1-L3
7
Q
Actions of the psoas
A
Flexes thigh
Externally rotates femur
Balances trunk in seated position
8
Q
How does the psoas flex the trunk?
A
Only with knees locked in extension in the recumbent position (Straight Leg Sit Up)
9
Q
Why can the psoas muscle cause diffuse pain patterns?
A
Nerve roots L1-L4 pierce the muscle–pain can follow dermatomal, myotomal, sclerotomal patterns
10
Q
What is in contact with the anterior surface of the psoas?
A
Ureter
11
Q
Psoas spasm without known injury can result from…
A
Ureter problems (ureteric calculus, ureteritis)
12
Q
What lies on the medial aspect of the psoas?
A
Sympathetic chain
13
Q
What lies across the front of both psoas muscles?
A
Transverse colon
14
Q
Hip osteoarthritis Femoral bursitis Piriformis hypertonicity Diverticulitis Prostatitis Colon cancer Salpingitis
A
Causes of psoas spasm
15
Q
Etiology of psoas muscle strain
A
Sudden hyperextension/external rotation of hip joint and lumbar spine
Prolonged sitting
Sudden standing after sitting for a long period of time
16
Q
What is the Hugh Owens Thomas Test?
**board question
A
Normal:
Supine patient has increased lumbar lordosis
Flexion of one or both hips allows the lordosis to flatten out –> indicating psoas contracture
17
Q
What would constitute an abnormal Hugh Owens Thomas Test?
A
Flexing one hip/leg causes the other to lift off the table
18
Q
What is a frequent cause of hamstring hypertonicity?
A
Psoas shortening
19
Q
What is often the triggering event for Psoas Syndrome?
A
Non-neutral dysfunction at L1-L3, establishing a somato-somatic reflex, triggering psoas hypertonicity.
20
Q
What condition is commonly associated with osteoarthritis of the hip?
A
Femoral bursitis
21
Q
What condition is often caused by tuberculosis of the spine?
A
Psoas abscess (infection in the spine at the thoracolumbar junction spreads in psoas fascia)
22
Q
Positive (buttock pain) Straight Leg Raising Test
Positive (buttock pain) Patrick’s FABERE Test
A
Ishiogluteal bursitis
23
Q
Ischial avulsion fracture can result from…
A
Forceful contraction of the hamstrings
24
Q
Piriformis innervation
A
S1/S2 via superior and inferior gluteal nerves
25
What shares innervation with the piriformis?
SI joint
26
Actions of the piriformis
Externally rotates the neutral thigh
Abducts the flexed thigh
Works in conjunction with the other GOGOQ muscles
27
Common injury causing piriformis syndrome
Lift and internally rotate the hip on a fixed leg
28
People who drive a lot can suffer from what condition?
Piriformis syndrome (right hip externally rotated resulting in shortening of the piriformis)
29
Piriformis spasm causes...
Anterior sacral torsion on contralateral oblique axis
30
What nerves are compressed in piriformis syndrome?
Superior and inferior gluteal nerves, sciatic nerve
31
Fascia lata problems refer to....
The iliotibial tract
32
Fascia lata action
Lateral support for the hip joint and knee
33
```
L4/L5 dysfunctions
Sacroiliac and iliosacral dysfunctions
Inominate dysfunctions
Tibial dysfunctions at the knee
Fibular dysfunctions at the knee
```
Alter the function of the IT band
34
Which dysfunctions are produced by shortening of the IT band?
Inominate (inferior vertical shear, outflare inominate)
| Anterior fibular head
35
Condition caused by increased tension in the IT band
Trochanteric bursitis
36
Fascia Lata Syndrome presentation
Tenderness along IT band
Trochanteric bursitis
Fibular nerve compression (foot drop, posterior/lateral calf pain)
37
Ely Test
With patient prone, flex leg at knee
| If this causes the pelvis to lift up and the leg abducts at the hip, there is flexion contracture of the rectus femoris
38
Boring pain in the joint
Stiffness after periods of rest
Walking is curtailed
Symptoms of osteoarthritis of the hip
39
Physical finding for osteoarthritis of the hip
```
Limp
Globally decreased ROM
Pain with Patrick's FABERE Test
Palpable joint effusion
Palpable and auscultable joint crepitance
```
40
Patient cannot walk
| LE appears shortened and externally rotated
Hip fracture outside hip capsule
41
Which condition presents with pain out of proportion to physical findings?
Avascular necrosis of the hip
42
Etiologies of avascular necrosis of the hip
Increased intracapsular pressure
Intravascular coagulopathy
Fat embolism
Arteriolosclerosis
43
Corticosteroids can cause...
Avascular necrosis of the hip
44
Which nerve is involved in meralgia parethetica?
Entrapment of the lateral femoral cutaneous nerve
45
Burning, tingling paresthesia with standing, sitting, walking
Point tenderness below inguinal ligament just medial to ASIS
Numbness over lateral thigh
Meralgia parethetica
46
Meralgia parethetica etiologies
```
Somatic dysfunction (anterior inominate rotation, inominate outflare, inferior inominate shear)
Tight belts
Tight jeans
Tool belts
Herniorrhaphy scar
```
47
What condition typically follows a trauma to the soft tissues?
Myositis ossificans traumatica
48
Most common locations of myositis ossificans traumatica
Hip and elbow
49
Where does the piriformis exit the pelvis?
Greater sciatic foramen
50
Psoas hypertonicity will cause sciatica on ipsilateral/contralateral side
Contralateral
51
There are ____ axes of sacral motion
Seven:
Three transverse (superior, middle, inferior)
Two oblique (left, right)
One vertical
One AP
52
Where is the sacral middle transverse axis located?
Anteriorly at the level of S2, near the junction of the long and short arms of the SI joint
53
What is the axis on which the sacrum flexes and extends in response to truncal motion?
Middle transverse
54
Once the lumbar lordosis begins to reverse with further flexion of the trunk, the sacrum moves into ______.
Extension
55
What is the axis the sacrum moves upon with ventilation?
Superior transverse: extension with inhalation, flexion with exhalation
56
Which sacral axis is located in the posterior superior sacroiliac ligaments?
Superior transverse
57
Which sacral axis is involved with the cranial rhythmic impulse cycle?
Superior transverse
58
With cranial base extension, the sacrum moves into _____
Flexion
59
Which sacral axis is located at the level of the ILAs?
Inferior transverse
60
On which axis does the inominate rotate during the gait cycle?
Inferior transverse
61
Which axis is not a true sacral axis?
Vertical --> actually an axis of pelvic rotation during the gait cycle
62
How do you know you have a unilateral sacral dysfunction?
1. Motion testing (seated flexion, lumbar spring, and sphinx tests)
2. Know the relative positions of the sacral sulci and ILAs
63
Where is the restriction in a positive seated flexion test?
On the side of the higher PSIS
64
Patient position for seated flexion test
Seated on a low stool with knees higher than hips, or seated on the edge of a low table with feet on the floor
65
Positive lumbar spring test results
Stiffness --> posteriorly going dysfunction (extension or posterior torsion)
Softness --> anteriorly going dysfunction (flexion or anterior torsion)
66
What is a torsion?
Two parts of the spine rotating in opposite directions about a single axis
67
When L5 is dysfunctional and rotates with the sacrum rather than the ilia, it is called ______
Non-compensated L5
68
What determines direction of rotation of the sacrum?
Motion of the anterior most point on the sacral promontory
69
What causes anterior sacral torsion?
1. Truncal sidebending and rotational forces in extension coming down from the lumbar spine
2. Gait cycle
70
Symptoms of anterior sacral torsion
Back pain, buttock pain
71
What causes posterior sacral torsion?
Truncal sidebending and rotational forces in flexion coming down from the lumbar spine
72
T/F: Gait cycle causes posterior sacral torsion
False. Only anterior.
73
Symptoms of posterior sacral torsion
Intense low back and hip pain, piriformis pain, walking with a limp
74
Unilateral flexed sacral dysfunction is also called....
Sacral shear
75
Positive sacral rock test indicates....
Bilateral dysfunction
76
Really, really shallow sacral sulci
ILAs so far anterior that you feel like you will be going internal before you find them
Flattening of the lumbar lordosis
Bilaterally extended sacrum
77
Where are the SI joints?
Where the LE ends and the spine begins
78
During the gait cycle, as the leg comes forward, the inominate rotates _______
Posteriorly
79
What serves as a universal joint in the gait cycle?
Pubic symphysis
80
How much motion is available in the SI joint?
About 5 degrees each for sacral flexion and extension.
81
Dysfunction introduced from the LE and causing restriction of motion between the ilium and sacrum
Iliosacral / inominate dysfunction
82
Dysfunction introduced from the spine and causing restriction of motion between the sacrum and the ilium
Sacroiliac / sacral dysfunction
83
A pubic symphysis dysfunction is an iliosacral or sacroiliac dysfunction?
Iliosacral
84
How are pelvic dysfunctions named?
For the site of greatest motion restriction and apparent assymetry
85
SI joint innervation
S1-S5
86
Where is the site of greatest ligamentous stress in the pelvis?
The site from which somato-somatic and somato-visceral reflexes will emanate
87
False positives for standing flexion test
Asymmetric hamstring or gluteal tension
Sacral dysfunction
Severe L4 or L5 dysfunction
88
What do you do after a negative standing flexion test?
This means inominates are normal, so screen the sacrum next
89
Posterior inominate landmarks
PSIS
Sacral sulci
Ischial tuberosities
Sacrotuberous ligament tension
90
Anterior inominate landmarks
ASIS
Pubic tubercles
Pubic symphysis
91
What are the inominate axis dysfunctions?
Anterior/posterior rotation
| Superior/inferior pubic shear
92
What is the most common pelvic dysfunction?
Posterior inominate rotation
93
Symptoms of posterior inominate rotation
Pain located at the ipsilateral PSIS
94
Which muscle is targeted in treatment for posteriorly rotated inominate?
Rectus femoris
95
Symptoms of anterior inominate rotation
Diffuse low back pain radiating around the abdominal wall attachments to the iliac crest and following the inguinal ligament into the groin
96
Asymmetries in anterior vs. posterior inominate rotation
Anterior: PSIS cephalad, sacral sulcus shallow
Posterior: PSIS caudad, sacral sulcus deep
97
Which muscle is targeted in treatment for anteriorly rotated inominate?
Gluteus maximus
98
What are the symptoms of superior inominate shear?
Pain overlying the posterior sacroiliac ligaments
99
PSIS cephalad
Ischial tuberosity cephalad
Sacrotuberous ligament lax
Superior inominate shear
100
Respiratory assistance (muscle energy) is used to treat what condition?
Superior / inferior inominate shear
101
What are the symptoms of inferior inominate shear?
Often very painful. Pain overlying posterior sacroiliac ligaments. More intense pain in the buttock overlying the sacrotuberous and sacrospinous ligaments.
102
PSIS caudad
Ischial tuberosity caudad
Exquisitely tender over sacrotuberous ligament
Taut sacrotuberous ligament
Inferior inominate shear
103
Symptoms of inflare inominate
Pain medial to PSIS
104
Principal asymmetry in inflare inominate
ASIS closer to midline
105
Which musculature is targeted in treatment of inflare inominate?
Hip adductors
106
Symptoms of outflare inominate
Pain along the ipsilateral inguinal ligament
107
Principal asymmetry in outflare inominate
ASIS farther from midline
108
Which muscles are targeted in treatment of outflare inominate?
Tensor fascia lata, gluteus minimus, piriformis
109
Most common in women, especially ages 25-35, and during third trimester of pregnancy, as well as in immediate post-partum period
Pubic symphysis dysfunctions
110
Tenderness at pubic symphysis
Pain in anterior and medial thigh inferior to the inguinal ligament
Pain may radiate into labium or testicle
Superior symphyseal shear
111
Primary asymmetry in superior symphyseal shear
Pubic tubercle cephalad
112
HVLA is ill advised for which pelvic dysfunction?
Symphyseal shear, pubic symphysis gapping
113
Which musculature is targeted in muscle energy tx of superior symphyseal shear?
Hip adductors
114
Which is more common, superior or inferior symphyseal shear?
Inferior
115
Lower abdominal pain, just superior to inguinal ligament
| May be mistaken for intra-abdominal pathology
Inferior symphyseal shear
116
Primary asymmetry in inferior symphyseal shear
Pubic tubercle caudad
117
Pain at pubic symphysis
| Urinary urgency, frequency, dysuria (with sterile urine)
Pubic symphysis gapping
118
Symptoms of pubic symphysis compression
Pain at pubic symphysis (no urinary symptoms)
119
Because degenerative disease of the spine may be asymptomatic, how do you determine the appropriate course of action?
Imaging, combined with history and physical
120
Symptoms of spinal osteoarthritis
```
Local and/or radicular pain of insidious onset
Mild to moderate intensity (1-6)
Pain worse with use, better with rest
Weather sensitivity
Stiffness after periods of rest
Crepitance with motion
Joint enlargement
Weakness
```
121
Most cases of spinal osteoarthritis appear after what age?
40
122
Radiographic findings of spinal osteoarthritis
```
Osteophyte formation (bone spurs)
Asymmetric joint space narrowing
Subchondral sclerosis
Subchondral cyst formation
Chondrocalcinosis
```
123
MRI findings of spinal osteoarthritis
Neural entrapment
| Intervertebral disc dessication, internal disruption, or protrusion
124
What is The Challenge in treating spinal osteoarthritis?
Discover the pain generator
125
What is the innervation of facet joints?
Posterior primary ramus of nerve root of both that segment and the segment below
126
What is the innervation of discs?
1. Recurrent meningeal nerve innervates the posterior longitudinal ligament and outer 1/3 of the annulus fibrosus posteriorly
2. Visceral afferents from the SNS make up the sensory supply for the anterior longitudinal ligament and the outer 1/3 of the annulus fibrosus anterolaterally
127
What type of joints are the spinal facet joints?
Synovial
128
What is first in the sequence of events leading to osteoarthritis of a synovial joint?
Articular somatic dysfunction (compression and adherence of the joint surfaces impairs the flow of synovial fluid across the joint surface, a major contributor to cartilage nutrition)
129
What leads to thinning of the hyaline cartilage surface of the joint?
Immobility. This is believed to be due to reduced nutritional support from decreased blood flow.
130
What does "luxation" mean?
Full joint dislocation
131
What is Wolff's Law?
Bone will remodel in accordance with the stresses placed on it
132
What forms as a result of degenerative disease in the joint?
Bone spurs (osteophytes)
133
What is the difference between radicular pain, radiculitis, radiculopathy?
Pain: pain that follows a nerve distribution
Itis: nerve root distribution pain without identifiable neurologic deficits
Opathy: nerve not functioning properly (compressed)
134
First step in sequence of events of disc degeneratiion
Disc is weakened by circumferential microtears in the annulus fibrosus
135
Sequence of events of disc degeneration
1. Disc weakened by microtears
2. Radial tear formation
3. Focal disc bulging
4a. Disc herniation
or
4b. Circumferential bulging
5. Disc narrowing
6. Osteophyte formation
7. Vertebral body enlargement
136
Where does the pain originate from in a radial tear of the disc?
Believed to be related to the leakage of nucleus pulposus into this pain sensitive area of the disc
137
T/F: the nucleus itself and the inner 2/3 of the annulus fibrosus contain no free nerve endings
True
138
What does the psoas test provoke?
Discogenic pain in the spine
139
Disc herniation is usually accompanied by....
Radiculopathy
140
What are the three stages of spinal degeneration?
1. Dysfunction
2. Instability
3. Restabilization and Stenosis
141
Therapy for stage I of spinal osteoarthritis
Exercise and OMT
142
Therapy for stage II of spinal osteoarthritis
```
Exercise
OMT
Bracing
Prolotherapy
Pain mangement
Rhizotomy
Fusion surgery
```
143
Therapy for stage III of spinal osteoarthritis
Exercise
OMT
Pain management
Surgical decompression
144
Disc narrowing leads to what nerve root symptomatology?
Narrowing of the neural foramen
145
What two conditions yield posterior joint syndrome?
Facet synovitis and circumferential annular tears
146
How do you differentiate between facet syndrome and facet subluxation?
Imaging. Subluxation imaging reveals misalignment of facet joint surfaces
147
Facet subluxation therapy
OMT
Exercise
Bracing
Prolotherapy
148
Neurologic evaluation of the extremities if typically normal
Pain increases in seated position
Pain in L spine increases with voluntary contraction of the psoas
Pain in L spine increases with truncal rotation
Pain in C spine increases with attempts at rotation or sidebending
Disc bulging
149
When is imaging performed for potential disc bulging?
After six weeks
150
What are McKenzie exercises used for?
Disc bulging
151
Entrapment of the nerve root in the area of the lateral recess caused by facet subluxation and disc narrowing
Dynamic lateral stenosis
152
Excruciating nerve pain relieved by position
Worst positions are extension and rotation
Much easier to walk uphill or push a shopping cart
Increased pain walking downhill and reaching overhead
Neurogenic claudication
Dynamic lateral stenosis
153
Use flexion exercise series
| Avoid McKenzie exercises
Dynamic lateral stenosis
154
Gold standard imaging for fixed lateral stenosis
CT scan with myelogram
155
Patchy neurologic exam calling card of which condition?
Central canal stenosis
156
CT scan is better than MRI at showing what feature in the spine?
Bone detail
157
Williams ____ Exercises
| McKenzie _____ Exercises
Flexion --> Dynamic lateral stenosis
| Extension --> Disc bulging
158
Which condition can cause neurogenic claudication?
Fixed lateral stenosis
159
How many degrees of motion in the SI joint?
5 each in flexion and extension --> 10 total
160
PSIS caudad
| Sacral sulcus deep
Posterior inominatre rotation
161
PSIS caudad
Ischial tuberosity caudad
Salcral sulci even
Inferior inominate shear
162
PSIS cephalad
| Sacral sulci shallow
Anterior rotation
163
PSIS cephalad
Ischial tuberosity cephalad
Sacral sulci even
Lax sacrotuberous ligament
Superior inominate shear
164
ASIS lateral
Outflare
165
ASIS medial
Inflare
166
Pubic tubercle cephalad
Superior pubic shear
167
Pubic tubercle caudad
Inferior pubic shear
168
What happens to the sacral sulcus when the pelvis rotates posteriorly?
Becomes deeper
