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1

What are the 3 joint complexes that make up the pelvis?

1)sacroiliac (diathrosis, true synovial joint with joint cavity, synovial fluid and joint capsule). 2) Pubic Symphsis- fibrocartilagonous joint, amphiathrosis.

2

What is the SI joint shape morphology?

L-shape: upper half articulates at level of S1 and lower half articulates at the level of S2-3

3

Sacral Segment is lined with what type of cartilage?

Hyaline Cartilage

4

What surface is thicker?

Sacral Surface is thicker than the iliac surface

5

Describe the general shape of the sacrum

central groove that gives in a concave shape, it is wedge shaped superior to inferior and S shaped anterior to posterior

6

Describe the iliac surface

PSIS to PIIS, it is made of fibrocartilage (yellow colour) with a central convex ridge and has rough bony surfaces posteriorly and superiorly for ligamentous attachements.

7

Describe the pelvis at birth

joints are underdeveloped, smooth, flat and can glide in any direction. stability is provided by ligaments and it begins to develop during walking

8

Describe the pelvis during teen years

roughened surfaces, development of grooves/ridges. more pronounced in males than females. track bound movement developes (tram and rail)

9

Describe the pelvis in 3rd and 4th decades of life

articular change in the surface anatomy are well established, joint surfaces become more irregular, enlargement of iliac tuberosity/depression, beginning of joint surface erosions and possible DJD on the iliac surface which is more common in males.

10

Describe the pelvis in the 5th/6th decade of life

Joint surfaces become more irregular, each individual joint is unique in its topography to varying degrees (more pronounced in males), possible DJD develops on the sacral surface and continuing on iliac surface (more in males) possible development of joint adhesions, osteophytes and fusion (esp in males)

11

Describe the pelvis in the 7th decade and beyond

interarticular adhesions, high prevalence of bony anklylosis, Gender dependant (more in males) and age dependance in males (more in males over 80 years old. Fusion occurs mainly in the superior part of the joint

12

What are the Intrinsic SI ligaments?

Intrinsic SI ligaments bind sacrum to ilium.

13

Define the Anterior and posterior SI ligaments

1)Posterior SI ligaments include the interosseous (major stablizer) and dorsal ligaments (smaller, non-critical, limits nutation, runs from PSIS to iliac tuberosity)
2)Anterior SI ligaments: thin, thickening of the anterior joint capsule and it is weaker than the dorsal SI ligaments
3) Joint capsule is well developed anteriorly not posteriorly

14

What are the two Extrinsic ligaments

Sacrotuberous: Sacrum to Isch. Tube and limits posterior movement of sacral apex
Sacrospinous: Sacrum to Coccyx to Isch Spine, limits posterior moment of the sacral apex

15

What is the Symphysis Pubis

Amphiarthrosis joint with an interpubic fibrocartilaginous disc

16

Do muscles directly cross the SI joint

NO

17

What muscles load the SI joint?

Erector Spinae, QL, PSOAS, ILLIACUS, Piriformis, Gluteals.

18

What are some key static features of the pelvis?

1) Keystone effect: sacrum forms the keystone of the arch, inferior displacement is resister by this shape ligaments prevent AP displacement
2) Self locking mechanism: promotes stability and form closure due to wedging and form closure is aided by the thoracolumbar fascia and ligaments

19

Why is the SI a good shock absorber

it transmits forces between lower and axial skeleton. it glides/pivots during locomotion and decreases stress to the lumbar spine and opposing SI joint.

20

Describe SI kinematics

Unclear, amount of movement is debated and generally thought to be very small. Movability decreases with age, range is greater in females. Predominent ROM is around X-axis

21

What is thought to be the axis of rotation for the SI joint

posterior to the iliac tuberosity with some coupled motions with joint seperation

22

What is the most influencial model of locomotion

Illi's: reciprocal motion between ilium and sacrum. flexion of hip and ilium is accompanied by ipsilateral anterior inferior movement of the sacral base and likewise extension of the hip and ilium is accompanied by ipsilateral posterior superior movement of the sacral base.
Motion is gyroscopic (oblique and horizontal figure 8)
Correlation to Gillet's test!

23

Sacral base nutation (AI movement) creates what

LS extension and SI Flexion

24

Sacral counter nutation (PS movement) creates what

LS extension and SI Extension

25

SI movement is based on what the ____ does

Ilium

26

Pubic symphysis kinematics

gliding/shearing compression and seperation, rotation in the saggital plane with flexion/extension of the SI joint and it may play a role in the SI dysfunctions

27

What is the pideau's test

PSIS and sacral apex should seperate when flexion happens. Can be done seated/standing

28

What is gillet's test

evaluate the upper /lower portion of the joint, knee bent, raise up flexion, contacts move together, extention contacts move apart.

29

Define allydonia

pain produced by normal painless stimuli

30

Leg length evaluations can describe inequalities that are

anatomical or functional.

31

If you bend the knees to 90 degrees it does what

1) isolate the tibia/fibula length 2) if discrepency persists-->tib/fib inequality 3) if inequality is gone then its functional LLI or femoral inequality

32

Side posture: Lumbar segmental motion palpation can be done for flextion/extention, lateral flexion and rotation. What are they

flexion/extension: heel of hand/SP contact
rotation: hypothenar-mamillary resisted, spinous pull resisted, spinous push pull counter-resisted
LF: icshial push and double leg lift (long lever)

33

Side posture: SI joint motion palpation can be done by _________

one or two handed contacts for flexion and extension

34

Sitting: lumbar motion palpation can be done by

PA scan checking for pain/stiffness, Sectional/Segmental motion palpation and end play.

35

Sitting: SI motion palpation:

PA glide-->if motion is induced it is most likely extension
Sacral Shear/Illiac Shear
Sacral Push==> lean back and the sacrum should counternutate
Leg flare: PSIS movement M to L
Piedau's test: SI joint extends and the sacrum counternutates.

36

What are some supine evaluations for the SI joint

leg length: same as prone,
allis test (knee bent, checking for femoral or tib/fib inequalities or LLI).
sit up test: most helpful. if leg length remains the same -->anatomical LLI if lengths change: functional LLI...remember that the short leg becomes long on the PI side!!!!!

37

What are the two ways to evaluate the low back

Neurological testing and orthopedic testing

38

What are the components of neurological testing,

1) nerve root compression/irritation a)sensory (pin prick), b) motor (muscle testing) c) reflex (DTR, superficial reflexes) d) radicular pain (pain from nerve root compression or irritation, sharp shooting pain)
2) Sclerotogenous pain: referred pain from deep somatic structures, deep, dull achy, hard to localize, diffuse, differently refferal areas than radicular

39

What is the straight leg raise?

patient raises their leg when supine (on their own). this stretches their sciatic nerve and spinal nerve roots primarily L5,S1,S2.

40

What are the degrees that indicate particular types of pain when doing the SLR

If symptoms shown between 0-35 degrees: extradural sciatic involvement. if between 35-70: radicular pain into extremities, in this range the sciatic nerve root tenses over the intervertebral disc causing futher irritation to a sensitve nerve root. IVD lesion/ nerve root compression
75-90: pain in the lumbars. lumbar pain suspected,
dull posterior thigh pain indicates tight hamstrings.

41

What is the Braggards test

patient is supine, raises leg to point of SLP and DR dorsiflexes the foot passively which increases sciatic nerve tension and is used as a confirmatory test for SLR. Radicular pain in the 35-70 degree range indicates IVD lesion, nerve root compression

42

What is the Bowstring test

patient is supine, bend leg and tuck between forearm and body, apply pressure on the popliteal fossa, increasing tension on the sciatic nerve. used as a confirmation test for the SLR. Lumbar or radicular pain and nerve root compression suspected

43

What is the Gaenslen's test

knee flexed, thigh of unaffected side down and hanging off the side. flexing unaffected leg stablizies lumbar spine. pain on affected side indicates SI lesions

44

Sacroiliac stretch test

patient supine, dr crosses arms and puts lateral pressure on the ASIS's, stretching the SI joint, pain indicates SI lesion

45

What is the SI compression test

pt lies on side, dr presses down on ilium and compresses the SI joint more posteriorly. Pain in SI indicates SI lesions

46

Sacral thurst

good test! PA thrust on sacral base on level of S2-3. NOT HVLA. pain suggest pathology or dysfunction

47

Hibbs test

patient is prone and the dr flexes patient knee towards the butt and moves leg outward causing internal rotation of the hip. this causes distraction of the SI

48

Yeoman's

patien is prone, dr flexes knee, lifts it to extend SI joint

49

What are the qualifications for taking xrays of pelvis

dont take them to check for malpositions only use them to check for pathologies. If already done use them to check for positioning but do not over interpret the xrays

50

Spinographic methods: Femoral head line

a horizontal line is compared to that drawn connecting the two femoral heads, if discrepency it suggests leg length issue

51

Spinographic methods: Scanogram

three seperate exposures on the same film of hip, knee and ankle joint. limits distortion and gives the most accurate respresentation of actual leg length

52

Spinographic methods: intercrestal line

a line drawn across the most superior margins of the iliac crests and it should be parallel to the femoral head line.

53

Spinographic methods: sacral base line

a line formed by connecting two dots placed btwn junctions of the sacral ala and the superior sacral articulating facets. also should be paralel to the femoral head line

54

Ilium misalignments- describe what happens during flextion/extension when compared to neutral

flexion: PI ilum, appears larger than normal
extension: AS ilium, appears smaller than normal

55

Illium: what happens during internal and external malpositions

internal: psis roles in and ilium appears wider
external: psis roles out and ilium appears narrow.

56

How are sacral misalignments measured

The sacrum is evaluated for rotational misalignments by measuring the distance from the second sacral tubercle to the most lateral margin of the sacral ala. The wider side is the apprarent posterior rotation.

57

How is lateral flexion evaluated

evaluated with the aid of the sarcal base line which converges with the femoral head line on the side of the lateral flexion.

58

Is there a gold standard test for assessing SI syndrome?

NO

59

what are the three theories that can explain SI joint dysfunction

Joint subluxation (based on misalignment)
Joint dysfunction (abnormal mobility)
Inflammation of joint (chronic low grade, can be detected with bone scans and stress tests)

60

The SIJ is more vulnerable to ____ and ____ over the lumbar

axial compression faliure and axial torsion overloading

61

Axial compression and torsion can be a result of

1) Acute Trauma: Forward bending, twisting, lifting, falling on your butt, unexpected step, return from flexed posture
2) Repetivitve stress injury (MOST COMMON)
3)Static overstrain (bad posture)
4)Post traumatic complications of sprains and strains (myofiborsis, perarticular fibrosis)
5) Osteoarthrosis ( doesn't ness. correlate with symptom or dysfxn)
6)Gender (more DJD in women, pregnancy, childbirth)

62

What is the prevelance of SI dysfunction

estimates say 50-70%, mireau study: 23% LBP, 28% hypomobility of SI joint and most abnormalities found in 12-17 years old group)

63

What are some general characteristics of SI syndrome?

Unilateral deep achy pain over SI region. Episodes of sharp pain and referred sclerotogenous pain to butt, post thigh and groin and occasional to lateral calf and ankle and dorsum of the foot.

64

How does SI pain differ from lumbar pain?

lumbar pain is often bilateral, and is reffered (sclerotogenous) only to knee and above-->facet syndrome
lumbar pain with radicular pain into butt, leg and calf is a disc herniation.

65

What are sensory changes associated with SI syndrome

hypersthesia and paresthesia are not consistent with this condition but hypersthesia may be found in the butt/leg

66

What can aggrevate SI syndome? what can alleviate pain?

aggravate: increasing weight in joint, activities that involve extreme SI motion and sustained postures
alleviate: mild wlaking, rest, direct pressure (massage), stretching, ice, heat, anti-inflammatory drugs

67

Describe the posture/gait/GROM for si syndrome

posture: normal to antalgic, unleveling of the crests/psis, gluteal folds and associated lumbar scoliosis
gait: normal to protective, decreasing stance to affected side
gROM: normal to painful to restricted, altered lumbopelvic rhythm.

68

What is associated with a PI ilium

inferior and prominent PSIS, relatively deep sacarl base, medial knee pain, functionally short leg

69

What is associated with AS ilium

superior and less prominent PSIS, lateral knee pain and functionally long leg.

70

What are some tests to check SI syndrome

SI strech test, hibbs, iliac compression test, thigh thurst, sacral thrust

71

What are some treatment options for SI syndrome?

Hypomobolity: manipulate, mobilize, excercise, LLI, orthotics
Hypermobility: Belts, Excercise, Proliferant injections, Fusion (surgery)
Inflammation: Ice, anti-inflamm drugs, PT modalities, and rest

72

What is a SI strain

strain of the support musculature PROM is painless except for some muscle stretching pain. AROM is painful (ie. Gillets) Provocative and neurological testing is negative. Pain free adjustment

73

What is a SI strain

injury to ligaments or joint capsule. both AROM and PROM are painful. provocative tests are painful and neurological testing is negative.

74

What is facet syndrome (wrt lumbar spine)

Irritation of the facet joints, patient has LBP with scleretogenous radiating pain into groin, hip and butt and above knee. Area is tender to pressure, can have joint restrictions, pain mimics SI syndrome, provocative test increasing lordosis increases pain, lumbar flexion decreases pain, Kemp's test, negative neurological test.

75

What is maigne's syndrome

facet syndrome in TL spine. most common after 40 years old. close proximity to cluneal nerves, can cause inflammation.
findings: t12-L1 painful SP's TL extension restriction, painful skill rolling, hypersthesia to pin and may cause sclerotogenous pain to post iliac crest region and butt

76

What is Gluteal Trigger point syndrome

commonly associated with SI syndrome
findings: nodule in muscle, referal myotomal pain, local twitch response, reproduction of patients pain syndromes

77

What is piriformis syndrome

inflammation or irriation of the sciatic nerve. myofascial trigger point syndrome. 15-20% have entrapment syndrome where the nerve seperate the muscle into two.

78

What is ankylosing spondolytis

chronic inflammatory poly arthritis characterized by progressive bony akylosis of the SI and spinal joints. SI's fuse first and progress cephalad

79

What is Reiter's

Conjunctivitis, Urethritis, Polyarthritis. STD/STI. reaction to an infection. diagnosis made with lab tests

80

What are some other (conterversial) disorders associated with pelvic adjustments

GI: ulcers, colic, constipation, IBC
Gyne: dsynmenorrhea, PMS
Urinary: bed wetting

81

When the injury is acute do you want to adjust in the direction of pain?

no

82

when do you want to start adjusting the injury

when it is in the reparative, remodeling states

83

true or false: unstable joints generally dont benefit from asjusting, particularly in their planes of instability

true

84

true or false: hypermobile joints dont become restricted in which case adjusting can be beneficial

false

85

for lumbar disc herniations, when is adjusting contraindicated

when there is progressive neurological deficit

86

Are SI adjustive complications common?

no

87

What is meralgia parethetica

entrapment of the lateral femoral cutaneous nerve as it passes under the inguinal ligament medial to the ASIS causeing dysesthesia and pain along the lateral thigh. sensory impairment only, no atrophy, motor or reflex changes, commonly confused with L2-3 nerve root compression. Initiated by obesity, pressure from belt or genu ilium adjustment.

88

true or false: one adjustment may clear multiple directions of restrictions at a single joint

true

89

true or false: LS joints may be affected more when trying to adjust an SI

true

90

What adjustments gap joint surfaces?

SI flexion (sacral base contact)
SI extension (PSIS contact with a ML vector)
SI extention (kick start and sacral apex contact)

91

What adjustments shouldn't create cavitations

SI extenstions (cavitation is prob due to LS rotation in setup)

92

What do extension (flexion) adjustive procedures provide for the joint?

extension (flexion) and distraction of the joint

93

What are some adjustments for extending the SI joint

Side posture:
1)contact ilum with hypothenar or forearm, kick start (caudad, cephalad). stances: genu-pincer or thigh to thigh (vector: PA, ML, IS)
2)contact sacrum (AI sacrum) with hypothenar or forearm. (vector: PA, LM, SI scoop)
Prone: -->opposite side contact!
1) two handed: PSIS and S. apex. PSIS vector: PA IS. Apex vector: PA, SI
2) one handed is PSIS contact only
3) Genu ilium: PSIS contact and knee. vector: PA, ML

94

What are some adjustments for flexing the SI joint?

Side:
1) Ischium contact (AS ilium): palm or forearm contact. legs: low fencer, straddle thihg, double thigh to shin, split leg (knee to pop fossa), vector: PA scoop
2) Sacrum contact (PS sacrum):
-dysfunctional side up: hip flexed less than 90, cupped hand. for flexion restriction hip is flexed above 90.
-dysfunctional side down: PS sacrum -- rolled over less and more. vector PA
Prone:
1) two handed contact Ischium and S. base. vectors: Ischium: PA, SI and base: PA, IS.
2) one handed S. base contact only. same vector

95

How do you decide between a sacral contact and ilium contact?

1) dr. pref 2) mechanical advantage 3) patient comfort 4) possible LS dysfucntion 5) Trial/error

96

What is pelvic blocking? why is it good

developed as a part of SOT placing blocks under patient to induce movement., makes biomech. sense, patients can do it at home, can be used with other modalities/manipulatons

97

For flex/ext where do you place blocks/

Extension:
prone: isch tube on side where extension wanted. ASIS on other side
supe: PSIS on side extension wanted, isch tube on other side
Flexion:
prone: ASIS where flexion wanted, isch tube other side.
supe: Isch tube where flexion wanted and PSIS on other side.

98

When is pubic symphysis dysfunction suspected?

patient complains of pain in the pubic region, and treating the SI joints isn't helping.

99

What are some possible findings for pubic symphysis dysfunctoin?

Static palpation: pain, vertical displacement and can be seen on xray, vertical displacement is MOST COMMON. can be anteriorly displaced but this is uncommon, can be seperated (laterally) but this is less common and may be related to childbirth/preg and can be seen on xrays

100

What is the motion of the pubic symphysis

usually around the x axis, small tranlational movements forward, backward and up and down.

101

What are some adjustive setups to fix the pubic symphysis

Palm thigh- superior displaces pubes
Hypothenar/thenar pubes: anterior (AP vector) or superior pubes (SI vector)
Palm ilium- ischium: inferior pubes
Pubic distracion: distract the pubes apart.

102

When do we suspect coccygeal dysfuction

1)local pain with traumatic history (fall on butt)- anterior displacement into flexion
childbirth- posterior displacement into extension
2) rectal complaints.
3)external palaptions indicating displacement
4) xrays showing displacement

103

What are some adjustive setups of coccyx?

external: thumb on coccyx base, vector IS
internal: digit-anterior coccyx, calcaneal posterior superior sacrum

104

Are coccyx adjustments affective?

mildly effect due to recent evidence. (maigne et al)

105

What are absolute contraindacations for adjusting

vertebrobasilar insufficiency, aneurysm, fracture, bone tumor, diabetic neuropathy

106

What are relative contraindications for adjusting (based on stage and degree)

Arthrosclerosis, clotting disorder, advanced osteoarthrisits, Uncoarthritis, Severe sprains, Osteopenia (osteoporosis), Space occupying lesion, malingering, hysteria, hypochondriasis, Alzheimer's disease.