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MSK Pathology Flashcards

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1
Q 
Degenerative joint disease (DJD)
Degenerative osteoarthritis (OA)
A

Degeneration of articular cartilage with hypertrophy of subchondral bone and joint capsule of weight-bearing joints

Meds: corticosteroids, NSAIDs, glucocorticoid injections, acetaminophen (mild pain)

Diagnostic tests: plain film (diminished joint space, decreased height of articular cartilage, osteophytes) and lab tests (rule out RA)

PT GOALS:
joint protection strategies

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2
Q

Ankylosing spondylitis

Marie-Strumpell disease, Bechterew’s disease, rheumatoid spondylitis

A

Progressive inflammatory disorder that initially affects the axial skeleton
Initial onset before 4th decade; men 3x more
First sx = mild and low back pain, morning stiffness and sacroilitis (3+ months duration)
Leads to kyphotic deformity of CS/TS and decreased lumbar lordosis
Degeneration of peripheral and costovertebral joints in advanced stages

Meds: NSAIDs, corticosteroids, cytotoxic drugs, tumor necrosis factor inhibitors

Diagnostic tests: HLA-B27 antigen

PT GOALS:
flexibility exercises
relaxation activities–breathing strategies

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3
Q

Gout

A

Genetic disorder of purine metabolism –> elevated serum uric acid (hyperuricemia) which forms crystals that deposit in peripheral joints (knee/great toe) and other tissues (kidneys)

Meds: NSAIDs, COX-2 inhibitors, colchicine, corticosteroids, ACTH, allopurinol, probenecid and sulfinpyrazone

Diagnostic tests: lab tests identify monosodium rate crystals in synovial fluid and/or connective tissue samples

PT GOALS:
pt education for injury prevention

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4
Q

Psoriatic arthritis

A

Chronic, erosive inflammatory disorder (digits and axial skeleton) associated with psoriasis

Meds: acetaminophen, NSAIDs, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), biological response modifiers (BRMs)–Enbrel

Diagnostic tests: lab tests rule out RA

PT GOALS:
joint protection strategies

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5
Q

Rheumatoid Arthritis (RA)

A

Chronic systemic disorder in a symmetrical pattern of dysfunction in synovial tissues and articular cartilage of hands, wrists, elbows, shoulders, knees, ankle and feet
Women 2x more than men
**MCP/PIP: panes formation (inflamm granulation tissue covering joint surface), ulnar drift, volar subluxation of MCP
**swan neck and boutonniere deformity, Bouchard’s nodes (excess bone formation on dorsal PIP)

JRA: onset

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6
Q

Osteoporosis

A

Metabolic disease that depletes bone mineral density/mass predisposing individual to fracture
Women 10x > men
Common fracture sites: TS/LS, femoral neck, proximal humerus/tibia, pelvis, distal radius
Primary = decreased estrogen production
Senile = decreased bone cell activity due to genetics or acquired abnormalities

Meds: calcium, vitamin D, estrogen, calcitonin, and biophosphonates

Diagnostic tests: CT, single and dual photon absorptiometry

PT GOALS:
joint/bone protection strategies

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7
Q

Osteomalacia

A

Decalcification of bones due to vitamin D deficiency
Sx: severe pain, fractures, weakness, deformities

Meds: calcium, vitamin D, vitamin D injections (calciferol–vitamin D2)

Diagnostic tests: plain film, lab tests, bone scan, bone biopsy

PT GOALS:
joint/bone protection strategies

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8
Q

Osteomyelitis

A

Inflammatory response within bone caused by infection (staphylococcus aureus)
Children and immunosuppressed adults (male)

Meds: antibiotics, proper nutrition, surgery if spreads to joints

Diagnostic tests: lab tests (infection), bone biopsy

PT GOALS:
joint/bone protection strategies and cast care

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9
Q

Arthrogryposis multiplex congenita

A

Congenital deformity of skeleton and soft tissues limiting joint motion and “sausage-like” appearance of limbs; normal intelligence

Diagnostic tests: plain films

PT GOALS:
joint/bone protection strategies
pt education regarding adaptive devices
flexibility exercises

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10
Q

Osteogenesis imperfecta

A 
Inherited disorder (autosomal dominant) leading to abnormal collagen synthesis creating imbalance between bone deposition and reabsorption
Cortical and cancellous bone become thin leading to fractures/deformity of WB bones

Meds: calcium, vitamin D, estrogen, calcitonin and biophosphonates

Diagnostic tests: bone scan and plain film, serological testing

PT GOALS:
joint/bone protection strategies

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11
Q

Osteochondritis dissecans

A

Separation of articular cartilage from underlying bone (osteochondral fracture) usually medial femoral condyle near intercondylar notch or humeral capitellum
Surgery indicated if displaced

Diagnostic test: pain film or CT scan

PT GOALS:
joint/bone protection strategies
flexibility exercises

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12
Q

Myofascial pain syndrome

A

“Trigger point”: focal point of irritability within a muscle; taut, palpable band within muscle
Active = tender, referral pattern of pain when provoked
Latent = palpable taut bands, not tender, can become active
Onset: sudden overload, overstitching and/or repetitive/sustained muscle activities

Medical intervention: dry needling, injection of analgesic, corticosteroid

PT GOALS:
flexibility exercises
manual therapy: soft tissue, jt mobs, “spray and stretch” technique, dry needling, modalities and manual pressure
strength, power and endurance exercises

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13
Q

Tendonosis/Tendonopathy

A

Common tendon dysfunction (supraspinatus, common extensor tendon of elbow, patella, Achille’s tendon)
Histological charac: hypercellularity, hypervascularity, no inflammatory infiltrates, poor organization/loosening of collagen fibrils

Meds: acetaminophen, NSAIDs, and/or steroid injection

Diagnostic tests: possibly MRI

PT GOALS:
flexibility exercises
manual therapy: soft tissue and joint mobs
endurance and strengthening (ECCENTRIC)
modalities
pt education for IADLs
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14
Q

Bursitis

A

Inflammation of bursa due to overuse, trauma, gout or infection
S/S: pain with rest, limited motion due to pain (non-capsular pattern)

Meds: acetaminophen, NSAIDs, and/or steroid injection

PT GOALS:
flexibility exercises
manual therapy: soft tissue and joint mobs
modalities
pt education for IADLs
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15
Q

Muscle strains

A

Inflammatory response within muscle due to micro tearing of musculotendinous fibers
Pain and tenderness within muscle

Meds: acetaminophen and/or NSAIDs

Diagnostic tests: MRI if necessary

PT GOALS:
flexibility exercises
manual therapy: soft tissue and joint mobs
modalities
pt education for IADLs
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16
Q

Myositis ossificans

A

Painful condition of abnormal calcification within muscle belly (quadriceps, brachial and biceps brachii) due to direct trauma leading to a hematoma and calcification
**Can be induced by early mobilization and stretching

Meds: acetaminophen and/or NSAIDs

Surgery: if nonhereditary and after maturation of the lesion (6-24 months) when lesions interfere with joint movement or impinge on nerves

Diagnostic tests: plain films, CT scan or MRI

PT GOALS:
flexibility exercises
manual therapy: soft tissue and joint mobs
NOTE: avoid aggressive soft tissue/massage techniques which may worsen condition

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17
Q

Complex regional pain syndrome (CRPS)

A

Dysfunction of SNS: pain, circulation and vasomotor disturbances
CRPS I: frequently triggered by tissue injury; its with above sx but no underlying nerve injury
CRPS II: same sx but clearly associated with a nerve injury

Medical intervention: sympathetic nerve block, surgical sympathectomy, spinal cord stimulation, intrathecal drug pumps

Meds: topical analgesics, anti seizure drugs, antidepressants, corticosteroids and opioids

Long term changes: muscle wasting, trophic skin changes, decreased bone density, decreased proprioception, loss of muscle strength from disuse and joint contractors

PT GOALS:
pt education for injury prevention/reduction
desensitization activiies 
flexibility exercises
TENS for pain relief
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18
Q

Paget’s disease

osteitis deformans

A

Metabolic bone disease involving abnormal osteoclastic and osteoblastic activity leading to spinal stenosis, facet arthropathy and possible spinal fracture
Unknown etiology: possibly viral infection and/or environmental

Meds: acetaminophen, calcitonin and etidronate disodium (limit osteoclastic activity)

Diagnostic test: plain film, lab tests (increased serum alkaline phosphatase and urinary hydroxyporline)

PT GOALS:
joint/bone protection strategies

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19
Q

Idiopathic scoliosis

A

Structural: irreversible lateral curvature of spine with a rotational component
Nonstructural: reversible lateral curvature of spine without rotational component and straightening as individual flexes spine

Intervention (structural): bracing and possible surgery (Harrington rods placement)
45 deg: surgery

Diagnostic test: plain film (full-length Cobb’s method), CT scan and/or MRI to rule out associated conditions

PT GOALS:
flexibility exercises
application/pt education with orthoses

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20
Q

Torticollis

A

Spasm and/or tightness of sternocleidomastoid
SB toward and rotation away from affected SCM

Meds: acetaminophen, muscle relaxants and/or NSAIDs

PT GOALS:
flexibility exercises
manual therapy: soft tissue, joint mobs

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21
Q

Glenohumeral Subluxation and Dislocation

A

95% in anterior-inferior direction: when abducted UE is forcefully ER causing tearing of the inferior GH ligament, anterior capsule and occasionally glenoid labrum
Posterior dislocation: horizontal add and IR

Complications:
Hill-Sachs lesion: compression fracture of posterior humeral head
SLAP lesion: tearing of superior glenoid labrum from anterior to posterior
Bankart’s lesion: avulsion of anteroinferior capsule and ligaments associated with glenoid rim
Bruising of axillary nerve

Following surgical repair: AVOID apprehension position (flexion>90, horiz abd>90, ER to 80)

Diagnostic tests: plain film, CT scan, MRI

Meds: acetaminophen, NSAIDs

PT GOALS:
joint mobs
exercise focused on regaining scapulothoracic, GH stabilization and muscular re-ed

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22
Q

Instability (Shoulder)

A

Traumatic: young throwing athletes
Atraumatic: congenitally loose connective tissue around shoulder

Popping/clicking and repeated dislocation/subluxation of shoulder
Unstable injuries require surgery

Meds: acetaminophen, NSAIDs

PT GOALS:
return of function without pain

POST SURGERY:
Sling 3-4 wks
After 6 wks: sports-specific training
Full fitness: 3-4 months

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23
Q

Labral Tears

A

Superior: toward the top of glenoid socket
Inferior: toward bottom of glenoid socket
SLAP: tear of rim above middle of socket that may also involve biceps tendon
Bankart’s lesion: tear of rim below middle of glenoid socket

S/S:  
Pain cannot be localized
Pn incr with OH activities or arm behind back
Weakness
Instability
Pn on resisted flexion of biceps
Tenderness over front of shoulder

Diagnostic tests: MRI arthrogram, “gold” standard: arthroscopic surgery

Meds: acetaminophen, NSAIDs

POST SURGERY:
Sling 3-4 wks
After 6 wks: sports-specific training
Full fitness: 3-4 months

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24
Q

Thoracic Outlet Syndrome (TOS)

A

Compression of neuromuscular bundle (brachial plexus, subclavian A/V, vagus and phrenic nerves and sympathetic trunk)

Common areas of compression:
Superior thoracic outlet
Scalene triangle
Between clavicle and first rib
Between p. minor and thoracic wall

Surgery: remove cervical rib or release anterior and/or middle scalene

Diagnostic tests: plain film, MRI, EMG

Special tests: Adson’s, Roo’s, Wright, Costoclavicular

Meds: acetaminophen, NSAIDs

PT GOALS:
Postural re-ed
Manipulations (first rib)

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25
Acromioclavicular and Sternoclavicular joint disorders
MOI: fall onto shoulder with UE add OR collision with another individual in a sporting event Acute phase: UE pos. in neutral in a sling; AVOID shoulder elevation Diagnostic tests: plain film Special tests: Shear test Meds: acetaminophen, NSAIDs PT GOALS: manual therapy: soft tissue, joint mobs
26
Subacromial and Subdeltoid Bursitis
Subacromial and sub deltoid bursae (may be continuous) have close relationship to RC tendons--susceptible to overuse Impinged under acromial arch Meds: acetaminophen, NSAIDs
27
Rotator Cuff Tendonosis/Tendonopathy
Relatively poor blood supply near insertion of muscles makes them more susceptible Mechanical impingement of distal attachment of rotator cuff on anterior acromion and/or coracoacromial ligament with repetitive overhead activities Diagnostic test: MRI Special tests: Supraspinatus tet, Neer's impingement test Meds: Acetaminophen, NSAIDs
28
Impingement Syndrome
Soft tissue inflammation of shoulder from impingement against acromion with repetitive overhead AROM Diagnostic tests: arthrogram or MRI Special tests: Neer's impingement test Supraspinatus test Drop arm test Surgical repair: AVOID shoulder elevation >90 Meds: acetaminophen, NSAIDs PT GOALS: restoration of posture joint mobs
29
Internal (Posterior) Impingement
Irritation between the RC and greater tuberosity or posterior glenoid and labrum Overhead athletes Pain in posterior shoulder Special test: Posterior internal impingement test Meds: acetaminophen, NSAIDs PT GOALS: joint mobs
30
Bicipital Tendonosis/Tendonopathy
Inflammation of long head of biceps Mechanical impingement of proximal tendon between anterior acromion and bicipital groove of humerus Diagnostic test: MRI Special test: Speed's test Meds: acetaminophen, NSAIDs
31
Proximal humeral fractures
Fall onto an outstretched UE among older osteoporotic women Diagnostic test: plain film Meds: acetaminophen, NSAIDs PT GOALS: joint mobs early PROM to prevent capsular adhesions
32
Adhesive capsulitis | Frozen shoulder
Restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule due to disuse or repetitive microtrauma *Capsular pattern: ER > abd & flex > IR Common with diabetes mellitus Meds: acetaminophen, NSAIDs PT GOALS: joint mobs
33
Elbow Contractures
Loss of motion in capsular pattern (flex>ext) Loss of motion in non capsular pattern: loose body, ligamentous sprain and/or CRPS Meds: acetaminophen, NSAIDs PT GOALS: joint mobs soft tissue techniques splinting (for capsular restrictions)
34
Lateral Epicondylosis/Epicondylopathy
Chronic degenerative condition of ECRB at its proximal attachment on lateral epicondyle Onset is gradual with repetitive wrist extension or strong grip with wrist extended RULE OUT involvement/relationship to cervical spine condition Special test: Lateral epicondylitis test Meds: acetaminophen, NSAIDs ``` PT GOALS: ECCENTRIC exercise joint mobs education regarding prevention modalities counterforce bracing to reduce forces on ECRB ```
35
Medial Epicondylosis/Epicondylopathy
Degenerative condition of the pronator teres and flexor carpi radials tendons at their attachment to the medial epicondyle of the humerus Overuse with strong hand grip and excessive pronation of the forearm Special test: medial epicondylitis test ``` PT GOALS: ECCENTRIC exercise joint mobs education regarding prevention modalities ```
36
Distal Humeral Fractures
Complications: loss of motion, myositis ossificans, malalignment, neuromuscular compromise, ligamentous injury, CRPS Supracondylar fractures: examine quickly for neuromuscular status (radial nerve involvement) may lead to Volkmann's ischemia; youth: growth plate; high incidence of malunion Lateral epicondyle fractures: young people, require ORIF to ensure alignment Diagnostic test: plain film Meds: acetaminophen, NSAIDs PT GOALS: pain reduction, reduce inflammation flexibility exercises
37
Osteochondrosis of humeral capitellum
Osteochondritis dissecans: central and/or lateral aspect of capitellum or radial head - Osteochondral bone fragment becomes detached from articular surface forming a loose body in the joint - Repetitive compressive forces between radial head and humeral capitellum - 12-15 years old Panner's disease: localized avascular necrosis of capitellum leading to loss of subchondral bone with fissuring and softening of articular surfaces -
38
Ulnar collateral ligament injuries
Repetitive valgus stresses to medial elbow with overhead throwing S/S: pn along medial elbow at distal insertion of lig paresthesias in ulnar nerve distribution Diagnostic test: MRI Special test: medial ligament instability test, Tinel's sign Meds: acetaminophen and NSAIDs PT GOALS: initial: rest and pain management later: strength elbow flexors, taping
39
Ulnar nerve entrapment
Direct trauma at cubital tunnel Traction due to laxity at medial elbow Compression due to thickened retinaculum Hypertrophy of flexor carpi ulnaris muscle Recurrent subluxation or dislocation DJD affecting cubital tunnel S/S: medial elbow pain, paresthesias in ulnar distribution Diagnostic test: EMG Special Test: Tinel's sign Meds: acetaminophen, NSAIDs, Neurontin PT GOALS: early: rest, avoiding activities, modalities, soft tissue neurodynamic mobilization protective padding and night splints
40
Median nerve entrapment
Pronator teres muscle and under superficial head of flexor digitorum superficial with repetitive gripping activities S/S: aching pain with weakness of forearm muscles Diagnostic test: EMG Special Test: Tinel's sign with paresthesias in median nerve distribution Meds: acetaminophen, NSAIDs, Neurontin PT GOALS: early: rest, avoiding activities, modalities, soft tissue neurodynamic mobilization protective padding and night splints
41
Radial nerve entrapment
Distal branches (posterior interosseous nerve) within radial tunnel (radial tunnel syndrome) due to overhead activities and throwing S/S: lateral elbow pain that can be confused with lat epicondylitis pain over supinator muscle paresthesias in radial nerve distribution Diagnostic test: EMG Special Test: Possible Tinel's sign Meds: acetaminophen, NSAIDs, Neurontin PT GOALS: early: rest, avoiding activities, modalities, soft tissue neurodynamic mobilization protective padding and night splints
42
Elbow dislocations
Posterior: position of olecranon relative to humerus; cause avulsion fractures of medial epicondyle due to pull of MCL Posterolateral: most common due to elbow hyperextension from a FOOSH Anterior/radial head: 1-2% Complete dislocation: UCL will rupture, possible rupture of anterior capsule, LCL, brachialis muscle, and/or wrist flex/ext mm S/S: rapid swelling, severe elbow pain and deformity with olecranon pushed posterior Diagnostic tests: plain film Meds: acetaminophen and NSAIDs PT GOALS: initial: reduction of dislocation if stable: initial phase of immobilization if not stable: surgery
43
Carpal tunnel syndrome | Repetitive stress syndrome
Compression of median nerve at carpal tunnel of wrist due to inflammation of flexor tendons and/or median nerve Occurs with repetitive wrist motions or gripping, pregnancy, diabetes and RA *RULE OUT cervial spine dysfunction, TOS or peripheral nerve entrapments Diagnostic test: EMG S/S: exacerbation of burning, tingling, pins/needles numbness in median nerve distribution at night Long term: atrophy/weakness of thenar mm and lateral 2 lumbricals Special test: Tinel's sign, Phalen's test Meds: acetaminophen and NSAIDs PT GOALS: joint mobs soft tissue
44
DeQuervain's tenosynovitis
Inflammation of extensor policies brevis and abductor policies longus tendons at first dorsal compartment due to microtrauma or swelling during pregnancy Diagnostic test: MRI S/S: pain at anatomical snuffbox swelling decreased grip and pinch strength Special test: Finkelstein's test Meds: acetaminophen and NSAIDs PT GOALS: joint mobs soft tissue
45
Colles' fracture
Most common, due to a FOOSH Immobilized 5-8 wks Complication of median nerve compression with excessive edema "Dinner fork" deformity: dorsal or posterior displacement of radius, with a radial shift of wrist and hand Diagnostic test: plain film Complications: decreased motion, grip strength, CRPS, carpal tunnel syndrome Meds: acetaminophen, NSAIDs PT GOALS: early: normalizing flexibility joint mobs soft tissue
46
Smith's fracture
Distal fragment of radius dislocates in a volar direction causing a "garden spade" deformity Diagnostic test: plain film Meds: acetaminophen and NSAIDs PT GOALS: early: normalizing flexibility joint mobs soft tissue
47
Scaphoid fracture
Most commonly fracture carpal bone; FOOSH in a younger person Diagnostic test: plain film Complications: avascular necrosis of proximal fragment of scaphoid due to poor vascular supply Immobilized 4-8 weeks Meds: acetaminophen and NSAIDs PT GOALS: early: maintenance of flexibility in distal/proximal joints while UE is casted later: strength, stretching, soft tissue/joint mobs
48
Dupuytren's contracture
Banding on palm and digit flexion contractors due to contracture of plamar fascia that adheres to skin Men > women Contractures: MCP and PIP of 4th/5th digits (nondiabetics) MCP and PIP of 3rd/4th digits (diabetics) Meds: acetaminophen and NSAIDs PT GOALS: flexibility and splints post-surgery: wound management, edema control and progression of exercise
49
Boutonniere deformity
Rupture of central tendinous slip of extensor hood following trauma or with RA MCP extension DIP extension PIP flexion Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility splinting or taping
50
Swan neck deformity
Contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons following trauma or with RA MCP flexion DIP flexion PIP extension Diagnostic test: plain film Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility splinting or taping
51
Ape hand deformity
Thenar much wasting with 1st digit moving dorsally until it is in line with second digit due to median nerve dysfunction Diagnostic test: EMG Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility splinting or taping
52
Mallet finger
Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digits due to trauma forcing distal phalanx into flexion DIP flexion Diagnostic test: MRI Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility splinting or taping
53
Gamekeeper's thumb
Sprain/rupture of UCL of MCP joint of 1st digit leading to medial instability of thumb due to a fall while skiing when increasing forces are placed on thumb through ski pole Immobilized 6 weeks Diagnostic test: MRI Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility splinting or taping
54
Boxer's fracture
Fracture of neck of 5th metacarpal due to a fight or punching a wall in anger/frustration Casted 2-4 weeks Diagnostic test: plain film Meds: acetaminophen and NSAIDs PT GOALS: edema management flexibility
55
``` Avascular necrosis (AVN) of the hip Osteonecrosis ```
Impaired blood supply to femoral head Hip ROM decreased in flexion, IR, abd Diagnostic test: plain film, bone scans, CT and/or MRI S/S: pain in groin/thigh tenderness with palpation at hip joint coxalgic gait Meds: acetaminophen and NSAIDs **corticosteroids are contraindicated PT GOALS: joint/bone protection post-surgery: flexibility, strength, gait training
56
Legg-Calve-Perthes disease | Osteochondrosis
2-13 years old (avg age = 6 years) Males 4x > females Psoatic limp due to weakness of psoas major: affected LE moves into ER, flex, add Gradual onset of "aching" at hip, thigh, knee AROM limited: abd and ext Diagnostic test: MRI (positive bony crescent sign--collapse of subchondral bone at femoral neck/head) Meds: acetaminophen and NSAIDs PT GOALS: joint/bone protection post-surgery: flexibility, strength, gait training
57
Slipped capital femoral epiphysis
Males: 10-17 y/o (avg age = 13) Females: 8-15 y/o (avg age = 11) Males 2x > females AROM limited in abd, flex and IR Vague pain at knee, thigh, hip Chronic: Trendelenburg sign Diagnostic test: plain film (positive displacement of upper femoral epiphysis) Meds: acetaminophen and NSAIDs PT GOALS: joint/bone protection post-surgery: flexibility, strength, gait training
58
Femoral anteversion
25-30 deg or more anteversion leads to squinting patellae and toeing-in
59
Coxa Vara and Coxa Valga
Coxa vara: 125 deg Both can result from necrosis of femoral had with septic arthritis Diagnostic test: plain film
60
Trochanteric bursitis
Inflammation of deep trochanteric bursa from a direct blow, irritation by ITB and biomechanical or gait abnormalities causing repetitive microtrauma Common with RA AROM vs PROM and resistive tests Meds: acetaminophen and NSAIDs
61
Iliotibial band tightness/friction disorder
Tight ITB, abnormal gait pattern leads to inflammation of trochanteric bursa Special test: Noble compression test, Ober's test Meds: acetaminophen and NSAIDs ``` PT GOALS: reduce pain/inflammation with modalities correct muscle imbalances joint mobs gait training/patient education ```
62
Piriformis syndrome
ER of hip can become overworked with excessive pronation of foot causing abnormal femoral IR Tightness/spasm can compress sciatic nerve or lead to SIJ dysfunction Diagnostic test: possible EMG ``` S/S: restriction in IR pain with palpation of piriformis referral of pain to posterior thigh weakness in ER, + piriformis test uneven sacral base **RULE OUT lumbar spine and/or SIJ ``` Meds: acetaminophen, NSAIDs and Neurontin ``` PT GOALS: pain reduction with modalities correct muscle imbalances patient education orthotic device for feet ```
63
ACL laxity leads to...
anterior instability
64
PCL laxity leads to...
posterior instability
65
ACL and MCL laxity leads to...
anteromedial rotary instability
66
ACL and LCL laxity leads to..
anterolateral rotary instability
67
PCL and MCL laxity leads to...
posteromedial rotary instability
68
PCL and LCL laxity leads to..
posterolateral rotary instability
69
Classification of ligament injury
First degree: little or no instability Second degree: minimal to moderate instability Third degree: extreme instability
70
"Unhappy triad"
Injury to MCL, ACL and medial meniscus Results from a combination of valgum, flexion and ER forces applied to knee when foot is planted
71
Knee Ligament Injury
Diagnostic test: MRI Special tests: Lachman's, anterior drawer, collateral ligament instability tests, pivot shift, posterior sag test, posterior drawer test, reverse Lachman Meds: acetaminophen and NSAIDs PT GOALS: reduce pain/inflammation with modalities correct muscle imbalances joint mobs
72
Mensical Injuries
Combination of forces: TF joint flexion, compression and rotation placing abnormal shear stress on meniscus ``` S/S: lateral and/or medial joint pain effusion joint popping knee giving way during walking limitation of knee joint joint locking ``` Diagnostic test: MRI Special tests: McMurray, Apley Meds: acetaminophen and NSAIDs PT GOALS: reduce pain/inflammation with modalities correct muscle imbalances
73
Patella alta
Patella tracks superiorly in femoral intercondylar notch, may lead to chronic patellar subluxation Positive camel back sign: 2 bumps over anterior knee instead of one Diagnostic test: plain film including "sunrise" view ``` PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping ```
74
Patella baja
Patella tracks inferiorly in femoral intercondylar notch, leads to restricted nee extension with abnormal cartilaginous wearing--> DJD Diagnostic test: plain film including "sunrise" view ``` PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping ```
75
Lateral patellar tracking
Could result if increased "Q-angle" with tendency for lateral subluxation or dislocation Diagnostic test: plain film including "sunrise" view ``` PT GOALS: functional strength (VMO) flexibility of ITB and hamstrings orthoses patella bracing/taping ```
76
Patellofemoral pain syndrome (PFPS)
Abnormal patellofemoral tracking ends to abnormal patellofemoral stress May be related to chorndromalacia patellae and/or patella tendonitis Diagnostic test: MRI Meds: acetaminophen and NSAIDs ``` PT GOALS: patellofemoral taping patella mobilization correct muscle imbalances DO NOT USE: quad sets, single-leg raise flexion, isolated quads exercises ```
77
Patellar tendonosis/tendonopathy | "Jumpers knee"
Degenerative condition of patellar tendon (deep aspect) Related to overload and/or jumping activity and interrelated to patellofemoral dysfunction Meds: acetaminophen, NSAIDs, corticosteroid
78
Pes anserine bursitis
Due to overuse or contusion *Differentiate from tendonitis AROM vs PROM and resistive tests Meds: acetaminophen, NSAIDS and corticosteroids
79
Osgood Schlatter disease
Mechanical dysfunction leading to traction apophysitis of tibial tubercle at patellar tendon insertion Diagnostic test: plain film (irregularities at epiphyseal line) Meds: acetaminophen and NSAIDs early flexibility is important in prevention PT GOALS: modify activities to decrease excessive stress
80
Genu varum and valgum
NORMAL tibiofemoral shaft angle: 6 deg valgum Genu varum: excess medial tibial torsion "bow legs"; excess medial patellar positioning and pigeon-toed orientation of feet Genu valgum: excess lateral tibial torsion "knock knees"; excess lateral patellar positioning Diagnostic test: plain film PT GOALS: decreased loading at knee
81
Femoral condyle fracture
Medial femoral most often involved Trauma, shearing, impacting, avulsion forces MOI: fall with knee subjected to shearing force Diagnostic test: plain film unless complex fracture (CT) Meds: acetaminophen and NSAIDs PT GOALS: return to function without pain
82
Tibial plateau fracture
MOI: valgum and compression forces when knee is in a flexed position Often occurs with MCL injury Diagnostic test: plain film unless complex fracture (CT) Meds: acetaminophen and NSAIDs PT GOALS: return to function without pain
83
Epiphyseal plate fracture
MOI: weight bearing torsional stress More frequent in adolescents Diagnostic test: plain film unless complex fracture (CT) Meds: acetaminophen and NSAIDs PT GOALS: return to function without pain
84
Patella fracture
MOI: direct blow to patella due to fall Diagnostic test: plain film unless complex fracture (CT) Meds: acetaminophen and NSAIDs PT GOALS: return to function without pain
85
Anterior compartment syndrome (ACS)
Increased compartmental pressure resulting in a local ischemic condition due to direct trauma, fracture, overuse and/or muscle hypertrophy Sx (chronic or exertion): produced by exercise or exertion = deep, cramping feeling Sx (acute): produced by sudden trauma causing swelling within compartment **Acute ACS = medical emergency and requires immediate surgical intervention with fasciotomy
86
Anterior tibial periostitis | Shin splints
Musculotendinous overuse condition 3 common etiologies: abnormal biomechanical alignment poor conditioning improper training methods Muscles involved: anterior tibialis and extensor hallucis longus Pain elicited with palpation of lateral tibia and anterior compartment Meds: acetaminophen and NSAIDs PT GOALS: correct muscle imbalances flexibility
87
Medial tibial stress syndrome
Overuse injury of posterior tibias and/or medial soles resulting in periosteal inflammation at the muscular attachment due to excess pronation Pain elicited with palpation of distal posteromedial border of tibia Meds: acetaminophen and NSAIDs PT GOALS: correct muscle imbalances flexibility
88
Stress fracture
Overuse injury resulting in microfracture of the tibia (49%) or fibula (10%) 3 common etiologies: abnormal biomechanical alignment poor conditioning improper training Diagnostic test: plain film and bone scan Meds: acetaminophen and NSAIDs PT GOALS: correct muscle imbalances flexibility
89
Ankle ligament sprains (lateral)
95% of sprains: foot is plantarflexed and inverted Grade I: no loss of function, minimal tearing of ATFL Grade II: some loss of function, partial disruption of ATFL and calcaneofibular ligg Grade III: complete loss of function, complete tearing of ATFL and calcaneofibular ligg with partial tear of posterior talofibular lig Diagnostic test: MRI Special test: anterior drawer and talar tilt Meds: acetaminophen and NSAIDs PT GOALS: reduce pain/inflammation with modalities correct muscle imbalances joint mobs
90
Achilles' tendonosis/tendonopathy
Degenerative condition of Achille's tendon Special test: Thompson's test Meds: acetaminophen, NSAIDs and corticosteroids
91
Fractures of foot and ankle
Unimalleolar: medial or lateral malleolus Bimalleolar: medial and lateral malleoli Trimalleolar: medial and lateral malleoli and posterior tubercle of distal tibia Diagnostic test: plain film * *Growth plate fractures are a concern since bone growth can be affected - Types III and IV fractures and Salter Harris classification are of most concern with high complication rate Meds: acetaminophen and NSAIDs PT GOALS: return of function without pain correct muscle imbalances early PROM to prevent capsular adhesions
92
Tarsal tunnel syndrome
Entrapment of posterior tibial nerve or one of its branches within the tarsal tunnel due to over/excess pronation, overuse problems (tendonitis of long flexor and post tib) and trauma S/S: pain, numbness, paresthesias along medial ankle to plantar surface of foot Diagnostic test: EMG Special tests: Tinel's sign at tarsal tunnel Meds: acetaminophen, NSAIDs and Neurontin PT GOALS: foot orthoses neurodynamic mobilization
93
Flexor hallucis tendonopathy
Acute stage: tendonitis Can be chronic tendonosis Common in ballet dancers Meds: acetaminophen, NSAIDs and corticosteroids
94
Pes cavus | Hollow foot
Genetic predisposition, neurological disorders resulting in muscle imbalances and contracture of soft tissues leading to decreased ability to absorb forces through foot ``` Deformity: Increased height of longitudinal arches Dropping of anterior arch Metatarsal heads lower than hind foot PF and splaying of forefoot Claw toes ``` PT GOALS: patient education: limit high impact sports, proper footwear, orthosis fitting
95
Pes planus | Flat foot
Genetic predisposition, muscle weakness, ligamentous laxity, paralysis, excessive pronation, trauma or disease (RA) leading to decreased rigid level for push-off *Normal in infant/toddler feet Deformity: reduction in height of medial longitudinal arch PT GOALS: pt education: proper footwear and orthotic fitting
96
Talipes equinovarus | Clubfoot
Postural: intrauterine malpositioning Talipes equinovarus: abnormal development of head and neck of talus due to heredity or neuromuscular disorders (spina bifida) Postural deformity: foot is in.... plantarflexion inversion adduction Talipes equinovarus deformity: 3 components (1) plantarflexion at talocrural joint (2) inversion at subtler, talocalcaneal, talonavicular and calacaneocuboit joints (3) supination at midtarsal joints PT GOALS: manipulation followed by casting/splinting talipes equinovarus requires surgery to correct deformity followed by casting/splinting
97
Equinus
Congenital bone deformity, neurological disorders (CP), contracture of gastrocnemius and/or soleus, trauma or inflammatory disease DEFORMITY: plantarflexed foot Compensation secondary to limited dorsiflexion includes subtalar or midtarsal pronation PT GOALS: flexibility exercises joint mobs
98
Hallux valgus
Biomehcanical malalignment (excess pronation), ligamentous laxity, heredity, weak muscles, tight footwear DEFORMITY: metatarsal and base of proximal 1st phalanx move medially; distal phalanx moves laterally NORMAL metatarsophalangeal angle: 8-20 deg PT GOALS: early orthotic fitting and patient education later: surgery
99
Metatarsalgia
Mechanical=tight triceps surae group and/or Achille's tendon, collapse of transverse arch, short first ray, pronation of forefoot Structural=changes in transverse arch leading to vascular and/or neural compromise of forefoot tissues Pain at 1st/2nd metatarsal heads after long periods of weight bearing Meds: acetaminophen, NSAIDs, and neurontin ``` PT GOALS: correction of biomechanical abnormalities modalities to decrease pain orthotics pt education on footwear ```
100
Metatarsus adductus
Congenital, muscle imbalance or neuromuscular disease (polio) DEFORMITY OBSERVED: Rigid=medial subluxation of tarsometatarsal joints; hind foot valgus with navicular lateral to head of talus Flexible=adduction of all 5 metatarsals at the tarsometatarsal joints PT GOALS: strengthening regaining proper alignment (orthotics)
101
Charcot-Marie-Tooth Disease
Peroneal muscular atrophy that affects motor and sensory nerves Initially lower leg and foot, progresses to hands and forearm Diagnostic test: electrodiagnostic Meds: acetaminophen, NSAIDs, neurontin PT GOALS: prevent contractures/skin breakdown pt education regarding braces/assistive devices
102
Plantar fascitis
Chronic irritation of plantar fascia from excess pronation, Limited ROM of 1st MTP and talocrural joint, Tight triceps surae, Acute injury from excessive loading of foot, Rigid cavus foot Differentiate from tarsal tunnel syndrome by a negative Tinel's sign Meds: acetaminophen, NSAIDs, corticosteroid ``` PT GOALS: proper mechanical alignment modalities to reduce pain/inflammation flexibility of plantar fascia for pes caves foot flexibility exercises for triceps surae joint mobilization night splints strengthen invertors pt education regarding footwear/orthotics ```
103
Rearfoot varus
Abnormal mechanical alignment of tibia, shortened rearfoot soft tissues or malunion of calcaneus DEFORMITY: rigid inversion of calcaneus while subtalar joint is in neutral PT GOALS: proper mechanical alignment improve flexibility orthotic fitting and pt education (footwear/orthotics)
104
Rearfoot valgus
Abnormal mechanical alignment of knee (genu valgum) or tibial valgus DEFORMITY: eversion of calcaneus with neutral subtalar joint *Increase mobility of hind foot, fewer MSK problems develop than with rearfoot virus ``` PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics) ```
105
Forefoot varus
Congenital abnormal deviation of head and neck of talus DEFORMITY: inversion of forefoot when subtalar joint is neutral ``` PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics) ```
106
Forefoot valgus
Congenital abnormal development of head and neck of talus DEFORMITY: eversion of forefoot when subtalar joint is neutral ``` PT GOALS: regain proper alignment improve flexibility orthotic fitting pt education (footwear/orthotics) ```
107
Spondylolysis | Spondylolisthesis
Congenitally defective pars interarticularis SPONDYLOLYSIS: fracture of pars interarticularis with positive "Scotty dog" sign on oblique x-ray of spine SPONDYLOLISTHESIS: ant or post slippage of one vertebra on another following B fracture of pars interarticularis Diagnostic test: plain film (oblique and lateral views) Special tests: Stork tests Meds: acetaminophen, NSAIDs, corticosteroids, muscle relaxants, trigger point injections ``` PT GOALS: joint mobilization dynamic stabilization (abdominals) AVOID extension and other postures that add stress pt education braces ```
108
Spinal or intervertebral stenosis
Congenital narrow spinal canal or IV foramen, coupled with hypertrophy of spinal lamina and ligamentum flavum or facets due to age-related degenerative process leading to vascular and/or neural compromise ``` S/S: B pain/paresthesia in back, buttocks, thighs, calves and feet Pain dear in flexion, Incr in ext Pain incr with walking Pain relieved with prolonged rest ``` Diagnostic test: plain film, MRI, CT scan, myelography Meds: acetaminophen, NSAIDs, corticosteroids, muscle relaxants, trigger point injections ``` PT GOALS: joint mobs flexion based exercise AVOID extension Manual therapy: traction ```
109
Internal disc disruption
Internal structure of disc annulus is disrupted; external structures remain normal (most common in LS) S/S: constant deep achy pain increased with movement referred pain to LE Diagnostic test: CT discogram or MRI Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids PT GOALS: joint mobs pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc. **spinal manipulation may be CONTRAINDICATED**
110
Posterolateral bulge/herniation
Most common disc disorder of LS because: (1) post disc narrower in height than ant (2) post long leg not a s strong in LS (3) post lamellae of annulus is thinner Overstitching and/or tearing of annular rings, vertebral endplate and/or ligg from high compressive forces or repetitive microtrauma leads to loss of strength, radicular pain, paresthesia and inability to perform ADLs Diagnostic test: MRI Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids PT GOALS: promote dynamic stability positional gapping x 10 min pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc. manual and/or mechanical traction **spinal manipulation may be CONTRAINDICATED
111
Central posterior bulge/herniation
More common in CS than LS Overstitching and/or tearing of annular rings, vertebral endplate and/or ligamentous structures (PLL) from high compressive forces and/or long-term postural malalignment leads to loss of strength, radicular pain, paresthesias, inability to perform ADL, compression of spinal cord Diagnostic test: MRI Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids PT GOALS: promote dynamic stability positional gapping x 10 min pt education: body mechanics, positions to avoid, limit repetitive bend/twist, etc. manual and/or mechanical traction **spinal manipulation may be CONTRAINDICATED
112
Degenerative joint disease (DJD)
Normal aging process due to WB properties of facets and IV joints leads to bone hypertrophy, capsular fibrosis, hypermobility or hypomobility of joint and proliferation of synovium S/S: reduction in mobility of spine pain, loss of strength and paresthesias possible impingement of assoc. nerve root Diagnostic test: plain film Special test: LS quadrant test Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids PT GOALS: promote dynamic stability joint mobs spinal manipulation
113
Facet entrapment | acute locked back
Abnormal movement of fibroadipose meniscoid in facet during extension (from flexion) Meniscoidal does not properly re-enter joint cavity and bunches up becoming a space-occupying lesion which distends capsule and causes pain **Flexion is most comfortable and extension increases pain** Special tests: LS quadrant test Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids PT GOALS: positional facet joint gapping and/or manipulation
114
Acceleration/deceleration injuries of cervical spine | "Whiplash"
Excess shear and tensile forces are exerted on cervical structures (facets/articular processes, facet jt capsules, ligg, disc, ant/post mm, fx to odontoid/spinous processes, TMJ, sympathetic chain ganglia and spinal/cranial nn) S/S: EARLY=H/A, neck pn, decr flexibility, reversal of LCS lordosis and decr in UCS kyphosis, vertigo, change in vision/hearing, irritability to noise/light, dysesthesias of face/BUE, nausea, diff swallow, emotional lability LATE=chronic head/neck pain, limited flexibility, TMJ dysfunction, limited ADL too, disequilibrium, anxiety, depression Clinical findings: postural changes, excess mm guarding with soft tissue fibrosis, segmental hyper mobility, gradual development of restricted segmental motion cranial to caudal Diagnostic test: plain film, CT and/or MRI Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids ``` PT GAOLS: spinal manipulation correct muscle imbalance joint mobs manual and/or mechanical traction (CS at 15 deg flexion) ```
115
Hypermobile spinal segments
Abnormal increase in ROM at a joint due to insufficient soft tissue control Diagnostic test: plain film (flex/ext views) Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, sclerosing agents, corticosteroids ``` PT GOALS: pain reduction modalities passive ROM passive stabilization (corsets, splints, casts, tape and collars) correct muscle imbalance pt education ```
116
Sacroiliac joint (SIJ) conditions
Need to closely examine BOTH LS and SIJ Diagnostic test: plain film and possible MRI, occasionally double blind injections Special tests: Gillet's test, IPSI anterior rotation test, Gaenslen's test, Long-sitting (supine to sit) test, Goldthwait's test Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections and corticosteroids ``` PT GOALS: spinal manipulation (SIJ gapping) correct muscle imbalances joint mobs pt education SIJ belts ```
117
Repetitive/cumulative trauma to back
Disorders of nerves, soft tissues and bones precipitated/aggravated b repeated exertions or movements of back Vocational factors: physically heavy static work postures, lifting, frequent bending/twisting, repetitive work and vibration PT GOALS: focus on prevention pt education
118
Bone tumors
Primary: multiple myeloma, Ewing's sarcoma, malignant lymphoma, cohondrosarcoma, osteosarcoma and chondromas Metastatic: primary sites in lung, prostate, breast, kidney and thyroid S/S: pain unvarying and progressive, not relieved with rest or analgesics more pronounced at night Diagnostic test: plain film, CT and/or MRI, lab tests
119
Visceral tumors leading to LBP
Esophageal cancer: radiating pain to back, pain with swallowing, dysphagia, weight loss Pancreatic cancer: deep, gnawing pain that may radiate from chest to back Diagnostic test: plain film, CT and/or MRI and lab tests
120
Gastrointestinal conditions leading to LBP
Acute pancreatitis: mid-epigastric pain radiating through to back Cholecystitis: abrupt, severe abdominal pain and RUQ tenderness, N/V, fever Diagnostic test: plain film, CT and/or MRI and lab tests
121
Cardiovascular and pulmonary conditions leading to LBP
Heart and lung: chest, back, neck, jaw and UE Abdominal aortic aneurysm (AAA): nonspecific lumbar pain Diagnostic test: plain film, CT and/or MRI and lab tests
122
Urological and gynecological conditions leading to LBP
Kidney, bladder, ovary and uterus reer to trunk, pelvis and thighs Diagnostic test: plain film, CT and/or MRI and lab tests
123
Temperomandibular joint conditions
``` S/S: joint noise (click, pop, crepitation) joint locking, limited flexibility lateral deviation of mandible during depr/elev decreased strength/endurance of mm tinnitus, H/A, forward head posture pain with mandible movement **CS must be thoroughly examined** ``` 3 diagnostic categories (1) DJD (OA or RA in TMJ) (2) myofascial pain: most common, discomfort or pain in mm controlling jaw/neck/shoulder (3) internal derangement of joint: dislocated jaw, displaced articular disc or injury to condyle - -Causes: trauma, congenital, abnormal fun Diagnostic test: plain film and/or MRI Meds: acetaminophen, NSAIDs, muscle relaxants, trigger point injections, corticosteroids ``` PT GOALS: postural re-ed modalities biofeedback joint mobs pt education night splints ```

NPTE (16 decks)

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