Musculoskeletal System Flashcards

Question

**What is the convex-concave rule or arthrokinematics for 1st IP (thumb) extension?**

Answer 1

***Concave on convex.*** The concave surface of the base of the distal phalanx rolls and glides in the dorsal direction.

Answer 2

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and glide in the palmar direction.

Answer 3

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and glide in the dorsal direction.

Answer 4

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and slide in the radial direction.

Answer 5

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and slide in the ulnar (medial) direction.

Answer 6

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and slide in the ulnar direction.

Answer 7

***Concave on convex.*** The concave surfaces of the bases of the proximal phalanges roll and slide in the radial direction.

Answer 8

***Concave on convex.*** The concave bases of the middle phalanges (for the PIP joints) or the distal phalanges (for the DIP joints) roll and slide in a palmar direction.

Answer 9

***Concave on convex.*** The concave bases of the middle phalanges (for the PIP joints) or the distal phalanges (for the DIP joints) roll and slide in a dorsal direction.

Answer 10

**_Atlanto-occipital joint:_** ***Convex on concave.*** The convex occipital condyles roll anteriorly while simultaneously sliding slightly posteriorly. **_Atlanto-axial joint complex:_** The atlas tilts anteriorly. **_Intracervical joints (C2-C7):_** ***Slide.*** The inferior articular facets of superior vertebrae slide superiorly and anteriorly, relative to the superior articular facets of the inferior vertebrae.

Answer 11

**_Atlanto-occipital joint:_** ***Convex on concave.*** The convex occipital condyles roll posteriorly while simultaneously sliding slightly anteriorly. **_Atlanto-axial joint complex:_** The atlas tilts posteriorly. **_Intracervical joints (C2-C7):_** ***Slide.*** The inferior articular facets of superior vertebrae slide inferiorly and posteriorly, relative to the superior articular facets of the inferior vertebrae.

Answer 12

**_Atlanto-occipital joint:_** ***Convex on concave*** * _Right lateral flexion:_ The convex occipital condyles roll laterally to the right while simultaneously sliding slightly to the left. * _Left lateral flexion:_ The convex occipital condyles roll laterally to the left while simultaneously sliding slightly to the right. **_Intracervical joints (C2-C7):_** ***Slide*** * _Right lateral flexion:_ The inferior articular facets of the superior vertebrae slide inferiorly and posteriorly on the right side, and superiorly and anteriorly on the left side. * _Left lateral flexion:_ The inferior articular facets of the superior vertebrae slide inferiorly and posteriorly on the left side, and superiorly and anteriorly on the right side.

Answer 13

**_Atlanto-axial joint complex:_** The ring-shaped atlas and attached transverse ligament “twist” about the dens as the generally flat inferior articular facets of the atlas slide in a curved path across the broad “shoulders” of the superior articular facets of the axis. **_Intracervical joints (C2-C7):_** ***Slide*** * _Right rotation:_ The inferior facets of the superior vertebrae slide posteriorly and inferiorly on the right side, and anteriorly and superiorly on the left side. * _Left rotation:_ The inferior facets of the superior vertebrae slide posteriorly and inferiorly on the left side, and anteriorly and superiorly on the right side.

Answer 14

**_Intrathoracic and intralumbar joints:_** ***Slide*.** The inferior articular facets of superior vertebrae slide superiorly and anteriorly, relative to the superior articular facets of the inferior vertebrae

Answer 15

**_Intrathoracic and intralumbar joints:_** ***Slide.*** The inferior articular facets of superior vertebrae slide inferiorly and posteriorly, relative to the superior articular facets of the inferior vertebrae.

Answer 16

**_Intrathoracic and intralumbar joints_** * _Right lateral flexion:_ ***Slide*.** The inferior articular facets of the superior vertebrae slide inferiorly and slightly posteriorly on the right side, and slide superiorly and slightly anteriorly on the left side. * _Left lateral flexion:_ ***Slide*.** The inferior articular facets of the superior vertebrae slide inferiorly and slightly posteriorly on the left side, and slide superiorly and slightly anteriorly on the right side.

Answer 17

**_Intrathoracic and intralumbar joints_** * _Right rotation:_ ***Slide*.** The inferior facets of the superior vertebrae slide posteriorly and slightly inferiorly on the right side, and anteriorly and slightly superiorly on the left side. * _Left rotation:_ ***Slide*.** The inferior facets of the superior vertebrae slide posteriorly and slightly inferiorly on the left side, and anteriorly and superiorly on the right side.

Answer 18

***Spin***. The femoral head spins within the acetabulum. * For joint mobilization purposes, the movement at the hip joint is considered to be ***convex on concave***. During hip flexion, the convex femoral head is thought to roll anteriorly while a posterior glide simultaneously occurs.

Answer 19

***Spin***. The femoral head spins within the acetabulum. * For joint mobilization purposes, the movement at the hip joint is considered to be ***convex on concave***. During hip extension, the convex femoral head is thought to roll posteriorly while an anterior glide simultaneously occurs.

Answer 20

***Convex on concave.*** The femoral head rolls superiorly while simultaneously sliding inferiorly.

Answer 21

***Convex on concave.*** The femoral head rolls inferiorly while simultaneously sliding superiorly.

Answer 22

***Convex on concave.*** The femoral head rolls anteriorly while simultaneously sliding posteriorly.

Answer 23

***Convex on concave.*** The femoral head rolls posteriorly while simultaneously sliding anteriorly.

Answer 24

**_Femoral-on-tibial flexion (e.g., lowering into a deep squat from standing):_** ***Convex on concave.*** The convex femoral condyles roll posteriorly while simultaneously sliding anteriorly. **_Tibial-on-femoral flexion (e.g., sitting knee flexion):_** ***Concave on convex.*** The concave tibial plateau rolls and slides posteriorly. \*_Note:_ For a knee that is fully extended to be unlocked to complete knee flexion, the tibia must first internally rotate slightly to undo the screw-home mechanism.

Answer 25

**_Femoral-on-tibial extension (e.g., standing up from a deep squat):_ *Convex on concave*.** The convex femoral condyles roll anteriorly while simultaneously sliding posteriorly. **_Tibial-on-femoral extension (e.g., sitting knee extension):_ *Concave on convex*.** The concave tibial plateau rolls and slides anteriorly. \*_Note:_ During knee extension, the tibia externally rotates in order to lock the knee in full extension (screw-home mechanism).

Answer 26

***Spin.*** With the knee flexed (i.e., unlocked), a spin occurs between the menisci and the articular surfaces of the tibia and femur.

Answer 27

***Convex on concave.*** In an unloaded foot, the convex trochlea of the talus rolls anteriorly while simultaneously sliding posteriorly.

Answer 28

***Convex on concave.*** In an unloaded foot, the convex trochlea of the talus rolls posteriorly while simultaneously sliding anteriorly.

Answer 29

***Convex on concave.*** In an unloaded foot, the convex calcaneal component rolls medially while simultaneously sliding laterally.

Answer 30

***Convex on concave.*** In an unloaded foot, the convex calcaneal component rolls laterally while simultaneously sliding medially.

Answer 31

***Spin.*** In an unloaded foot, the convex calcaneal component spins laterally (for ABduction) or medially (for ADduction) within the concave talus component.

Answer 32

***Spin.*** In an unloaded foot at the talonavicular joint, the concave proximal surface of the navicular bone spins around the convex head of the talus. The calcaneocuboid joint remains relatively rigid during the movement. \*_Note:_ The arthrokinematics of the transverse tarsal joint contributes to all movements at the ankle and foot: plantarflexion, dorsiflexion, inversion, eversion, ABduction, and ADduction.

Answer 33

Eversion, ABduction, and dorsiflexion

Answer 34

Inversion, ADduction, and plantarflexion

Answer 35

# **_Fill in the blanks:_** In general, the joint motions at the foot follow a **concave-on-convex** movement. * Flexion of the MTP and IP joints produces **roll and glide** in the **plantar** direction * Extension produces **roll and glide** in the **dorsal** direction. * ABduction of the 1st MTP joint (great toe) produces **roll and glide** in the **medial** direction. * ADduction of the 1st MTP joint (great toe) produces **roll and glide** in the **lateral** direction. * ABduction of the 3rd-5th MTP joints produces **roll and glide** in the **lateral** direction. * ADduction of the 3rd-5th MTP joints produces **roll and glide** in the **medial** direction.

Answer 36

**_Grade I:_** Small-amplitude rhythmic oscillations performed at the beginning of the resistance-free range of joint play; usually are rapid oscillations, like manual vibrations **_Grade II:_** Large-amplitude rhythmic oscillations performed within the resistance-free range of joint play up to but not past tissue resistance (R1) **_Grade III:_** Large-amplitude rhythmic oscillations performed past tissue resistance (R1) and up to the anatomical limit of the available motion (R2) **_Grade IV:_** Small-amplitude rhythmic oscillations performed at the anatomical limit of the available motion (R2); usually are rapid oscillations, like manual vibrations

Answer 37

**Grade I (loosen):** Small-amplitude distraction within the beginning of the resistance-free range of joint play * Equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint **Grade II (tighten or “taking up the slack”):** Moderate-amplitude distraction up to but not past tissue resistance (R1) * Tightens the tissues around the joint **Grade III (stretch):** Large-amplitude distraction or glide is applied past tissue resistance (R1) and up to the anatomical limit of the available motion (R2) * Places a stretch on the joint capsule and surrounding periarticular structures

Answer 38

**Pain is greater than stiffness:** * Oscillatory grades I and II * Sustained grades I and II **Stiffness is greater than pain:** * Oscillatory grades III and IV * Sustained grade III **Pain is equal to stiffness:** Treat pain first, and then see what effect the treatment has on stiffness.

Answer 39

1. _What:_ A **capsular pattern** refers to a “characteristic pattern of restriction in ***passive range of motion*** when a joint impairment affects the entire joint.” It has been proposed that each joint demonstrates a specific pattern of restriction, in which the proportional limitation in one motion is greater than one or more other motions. 2. _Why:_ Determining the presence of capsular patterns is helpful in diagnosing articular lesions because the presence of a capsular pattern would indicate that the diagnosis is one in which the entire joint capsule is involved, suggesting that mobilization/manipulation interventions in all directions would be indicated. 3. _Examples of causes:_ Osteoarthritis and conditions involving trauma to the entire joint capsule

Answer 40

Limitation in mouth opening

Answer 41

**Shoulder capsular pattern:** Lateral rotation is more limited than ABduction, which is more limited than medial (internal) rotation

Answer 42

**Humeroulnar and humeroradial joints:** Flexion is more limited than extension. **Proximal and distal radioulnar joints:** Pain at the end of the range of motion for pronation or supination or both

Answer 43

**Radiocarpal and midcarpal joints:** Flexion and extension are equally limited.

Answer 44

**1st CMC joint (thumb):** Limitation in ABduction and extension, and no limitation in flexion **MCP and IP joints:** Flexion is more limited than extension.

Answer 45

Lateral flexion and rotation are equally limited; extension is more limited than flexion

Answer 46

Flexion, ABduction, and medial (internal) rotation are grossly limited; extension is slightly limited

Answer 47

Gross limitations in flexion accompanied by slight limitations in extension

Answer 48

**Talocrural joint:** If the calf muscles are not short or stiff (i.e., “tight”), plantarflexion is more limited than dorsiflexion, whereas if the calf muscles are short or stiff, the capsular pattern is simply limitation into plantarflexion. **Subtalar joint (aka, talocalcaneal joint):** Limitations in inversion **Transverse tarsal joint (aka, midtarsal joint):** Limitations in dorsiflexion, plantarflexion, ADduction, and inversion **Metatarsophalangeal (MTP) joints** * **1^st MTP joint (great toe):** Marked limitation in extension and slight limitation in flexion * **2^nd-5^th MTP joints:** Variable, but flexion is generally more limited than extension *\*No capsular pattern described for the interphalangeal (IP) joints of the foot*

Answer 49

**S**upraspinatus **I**nfraspinatus **T**eres Minor **S**ubscapularis

Answer 50

**_Origin:_** Medial 2/3 of supraspinous fossa of the scapula **_Insertions:_** * Superior facet of greater tubercule of the humerus * Glenohumeral joint capsule **_Innervations:_** * _Peripheral:_ Suprascapular nerve * _Segmental:_ C4, C5, and C6 spinal nerve roots **_Actions:_** * Shoulder ABduction * Stabilizes head of the humerus in glenoid cavity during movements * May assist with shoulder lateral (external) rotation from neutral to full lateral rotation

Answer 51

**_Origin:_** Medial 2/3 of infraspinous fossa of scapula **_Insertions:_** * Middle facet of greater tubercle of the humerus * Glenohumeral joint capsule **_Innervations:_** * _Peripheral:_ Suprascapular nerve * _Segmental:_ C4, C5, and C6 spinal nerve roots **_Actions:_** * Shoulder lateral (external) rotation * Stabilizes head of the humerus in glenoid cavity during movements * Scapular internal rotation

Answer 52

**_Origins:_** Upper 2/3 and dorsal surface of lateral border of scapula **_Insertions:_** * Inferior facet of greater tubercle of the humerus * Glenohumeral joint capsule **_Innervations:_** * _Peripheral:_ Axillary nerve * _Segmental:_ C5 and C6 spinal nerve roots **_Actions:_** * Shoulder lateral (external) rotation * Stabilizes head of the humerus in glenoid cavity during movements * Scapular internal rotation

Answer 53

**_Origin:_** Subscapular fossa of scapula **_Insertions:_** * Lesser tubercle of the humerus * Glenohumeral joint capsule **_Innervations:_** * _Peripheral:_ Upper and lower subscapular nerves * _Segmental:_ C5, C6, and C7 spinal nerve roots **_Actions:_** * Shoulder internal (medial) rotation * Stabilizes head of the humerus in glenoid cavity during movements. * Prevents anterior glide of the humeral head

Answer 54

**_Origins:_** * _Short head:_ Apex of coracoid process of scapula * _Long head:_ Supraglenoid tubercle of scapula **_Insertions:_** * Radial tuberosity * Aponeurosis of biceps brachii **_Innervations:_** * _Peripheral:_ Musculocutaneous nerve * _Segmental:_ C5 and C6 spinal nerve roots **_Actions:_** * Shoulder flexion * _With origin fixed:_ * Elbow flexion, moving the forearm toward the humerus * Forearm supination * _With insertion fixed:_ * Elbow flexion, moving the humerus toward the forearm * May contribute to scapular anterior tilt

Answer 55

***Adhesive capsulitis*** (aka, *idiopathic frozen shoulder*, *periarthritis*) refers to inflammation and fibrosis of the glenohumeral joint capsule that causes severe pain and a progressive loss of shoulder mobility.

Answer 56

* **_Gender:_** Female * **_Age:_** 40-65 years old * **_Past medical history:_** * Diabetes mellitus * Hyperglycemia is linked to pathological joint inflammation. * Thyroid disease (i.e., hyperthyroidism, hypothyroidism) * Autoimmune disruptions that characterize thyroid disease is linked to pathological inflammation throughout the body. * Previous episode of adhesive capsulitis in the contralateral arm * Chronic inflammation in the glenohumeral joint capsule or in the tendons of the rotator cuff muscles or biceps brachii (long head)

Answer 57

**_Mechanism of injury:_** * Usually insidious onset with no known cause (***primary frozen shoulder***) * If a cause is known (***secondary frozen shoulder***), the cause is usually trauma, immobilization, or certain joint diseases such as rheumatoid arthritis or osteoarthritis.

Answer 58

**_Stage 1:_** Characterized by a gradual onset of pain that increases with movement and is present at night. Loss of external rotation motion with intact rotator cuff strength is common. The duration of this stage is usually less than 3 months. **_Stage 2 (“Freezing” Stage):_** Characterized by persistent and more intense pain even at rest. Motion is limited in all directions and cannot be fully restored with an intra-articular injection. This stage is typically between 3 and 9 months after onset. **_Stage 3 (“Frozen” Stage):_** Characterized by pain only with movement, significant adhesions, and limited glenohumeral joint motions. Excessive scapulothoracic movement is a typical compensation. Atrophy of the deltoid, rotator cuff, biceps brachii, and triceps brachii muscles may be noted. This stage occurs between 9 and 15 months after onset. **_Stage 4 (“Thawing” Stage):_** Characterized by minimal pain and no synovitis but significant capsular restrictions from adhesions. Motion may gradually improve during this stage. This stage lasts from 15 to 24 months after onset, although some patients never regain normal ROM.

Answer 59

* Progressive loss of both active and passive range of motion (loss of AROM = loss of PROM) * In the beginning stages, will present with intact rotator cuff muscle strength (fair+ [3+] to good [4]). As the disease progresses, there may appear to be muscle weakness, but the presented muscle weakness is due to an increase in pain. * Observation of a shoulder capsular pattern: Shoulder lateral rotation will be more limited than ABduction, which will be more limited than medial rotation (\*see image) * The glenohumeral joint play of patients with adhesive capsulitis is often be limited in all directions. * In the later stages, pain gradually improves, but shoulder ROM remains limited.

Answer 60

On average, spontaneous recovery can occur 2 years from onset. However, there is the possibility that there will be long-term limitations without spontaneous recovery.

Answer 61

None. There is no special test specifically for adhesive capsulitis.

Answer 62

* ***In combination with shoulder mobility and stretching exercises, corticosteroid (i.e., glucocorticoid) injections*** to dampen the inflammatory response, reduce pain, and improve shoulder range of motion (ROM) * ***Patient education*** that (1) describes the natural course of the disease; (2) promotes activity modification to encourage functional, pain-free ROM; and (3) matches the intensity of stretching to the patient’s current level of irritability (i.e., encourage completing exercises without significant pain) * ***Therapeutic modalities*** (e.g., short-wave diathermy, ultrasound, or electrical stimulation) to alleviate pain associated with adhesive capsulitis * ***Joint mobilizations*** to reduce pain and improve shoulder ROM

Answer 63

Treatment management should follow a progression from acute (i.e., maximum protection and focus on pain management during stages 1 and 2), subacute (controlled motion during stage 3), and chronic (return to function during stage 4).

Answer 64

* **Rotator cuff pathology** * Resisted muscle tests result in weakness or pain, especially with shoulder ABduction and lateral rotation * _Special tests:_ Positive for drop-arm test and empty-can test * Pain at night (especially indicative of full-thickness tears)

Answer 65

The **open-packed joint position** (aka, resting position, loose-packed or maximum loose-packed joint position) is the joint position in which there is minimal congruency between the articular surfaces and the joint capsule, with the ligaments being in the position of greatest laxity, and passive separation of the joint surfaces being at the greatest. * The open-packed joint position allows for the arthrokinematic movements of spin, slide, and roll to occur. Therefore, the open-packed joint position is the most common position used for treatment using joint play mobilizations. The **close-packed position** is the joint position in which two joint surfaces fit together precisely—that is, they are fully congruent. The joint surfaces are tightly compressed; the ligaments and capsule of the joint are maximally taut; and the joint surfaces cannot be separated by distractive forces. * The close-packed position is the position of maximum joint stability. In the close packed position, there is minimal to no accessory movement. Thus, this position is commonly used during treatment to stabilize the joint if an adjacent joint is being treated.

Answer 66

_Open-packed position:_ Mouth slightly open _Close-packed position:_ Mouth closed

Answer 67

_Open-packed position:_ 40° to 55° ABduction, 30° horizontal ADduction (scapular plane), slight lateral rotation _Close-packed position:_ Full elevation (i.e., full ABduction and lateral rotation)

Answer 68

**_Humeroulnar joint_** * _Open-packed position:_ 70° flexion, 10° supination * _Close-packed position:_ Full extension and supination **_Humeroradial joint_** * _Open-packed position:_ Full extension and supination * _Close-packed position:_ 90° flexion, 5° supination **_Proximal radioulnar joint_** * _Open-packed position:_ 70° flexion, 35° supination * _Close-packed position:_ Full supination or full pronation **_Distal radioulnar joint_** * _Open-packed position:_ 10° supination * _Close-packed position:_ Full supination or full pronation

Answer 69

**_Radiocarpal and midcarpal joints_** * _Open-packed position:_ Slight flexion and ulnar deviation * _Close-packed position:_ Full extension

Answer 70

**_1st carpometacarpal (CMC) joint (thumb)_** * _Open-packed position:_ Midway between ABduction-ADduction and flexion-extension * _Close-packed position:_ Full opposition **_Metacarpophalangeal (MCP) joint_** * _Open-packed positions_ * _1st MCP joint (thumb):_ Slight flexion * _2nd-5th MCP joints:_ Slight flexion and slight ulnar deviation * _Close-packed positions_ * _1st MCP joint (thumb):_ Full extension * _2nd-5th MCP joints:_ Full flexion **_Interphalangeal (IP) joints_** * _Open-packed position:_ Slight flexion * _Close-packed position:_ Full extension

Answer 71

_Open-packed position:_ 30° flexion, 30° ABduction, and slight external (lateral) rotation _Close-packed position:_ Full extension, ABduction, and internal (medial) rotation

Answer 72

_Open-packed position:_ 25° to 40° of flexion _Close-packed position:_ Full extension

Answer 73

**Talocrural joint** * _Open-packed position:_ 10° plantar flexion and midway between inversion and eversion * _Close-packed position:_ Full dorsiflexion **Subtalar joint (aka, talocalcaneal joint)** * _Open-packed position:_ 10° plantar flexion and midway between inversion and eversion * _Close-packed position:_ Full inversion (supination) **Transverse tarsal joint (aka, midtarsal joint)** * _Open-packed position:_ 10° plantar flexion and midway between inversion and eversion * _Close-packed position:_ Full inversion (supination) **Metatarsophalangeal (MTP) joints** * _Open-packed position:_ 10° extension * _Close-packed position_ * _1st MTP joint (great toe):_ Full extension * _2nd-5th MTP joints:_ Full flexion **Interphalangeal (IP) joints** * _Open-packed position:_ Slight flexion * _Close-packed position:_ Full extension

Answer 74

Wrist—20-30° of extension with slight ulnar deviation Fingers—35-45° of metacarpophalangeal (MCP) joint flexion; 15-30° of proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint flexion Thumb—35- 45° of carpometacarpal (CMC) joint ABduction \*_Note:_ The individual alignments of the finger and thumb joints in the position of function are based on the open (loose) packed positions of these joints. The exception to this is the alignment of the wrist joint. The wrist is positioned in wrist extension in order to maintain optimal length of the finger flexor muscles and preserve the tenodesis action of the finger flexors.

Answer 75

* Expression is used clinically to establish a baseline or reference position for casting a foot orthotic. * Defined as the position in which the calcaneus inverts twice as many degrees as it everts (i.e., the subtalar joint is in a position in which it is one-third the distance from full eversion and two-thirds the distance from full inversion) * Subtalar joint neutral can be found by placing the subject's calcaneus in a position that allows both the lateral and medial sides of the trochlea (dome) of the talus to be equally exposed for palpation within the mortise formed by the distal ends of the tibia and fibula.

Answer 76

***Osteoarthritis (OA)*** (aka, *degenerative joint disease*) is a slowly evolving articular disorder that affects the entire synovial joint organ and involves inflammation of the articular cartilage and underlying bone (i.e., subchondral bone).

Answer 77

* **_Gender:_** Most common in men before age 45 years; more common in women after age 45 years * **_Age:_** Usually begins at age 40 years; affects a majority of adults older than age 65 years * Older age is a risk factor because the incidence of OA increases with age. * **_Past medical history:_** * Family history of OA (i.e., genetic predisposition) * Tobacco smoking * Tobacco potentially contributes to cartilage degeneration. * Obesity * Synovial joint injury (e.g., anterior cruciate ligament injury, femoroacetabular impingement, labral tears) or surgery (e.g., meniscectomy) * Participation in sports (e.g., football, soccer, hockey, baseball pitchers) that involve high-intensity, acute, direct joint impact from contact with other players, especially when repetitive joint impact and twisting are combined * Occupational activities such as kneeling, squatting, heavy lifting, and repetitive use of heavy machinery * Generalized ligamentous laxity of joints (e.g., hypermobility joint syndrome, which is characterized by loose and unstable joints) * Postmenopausal women are at an increased risk for developing hypermobility joint syndrome and OA. This may be related to the presence of estrogen receptors on ligaments and chondrocytes. * Muscle weakness (especially of the quadriceps femoris muscle group) secondary to prolonged immobilization, multiple sclerosis, or any of the myopathies (e.g., polymyositis) * Muscles are normally the major shock-absorbing mechanism of joints (especially the knee) through eccentric muscle contraction. * Because of its lack of vascular supply, articular cartilage depends on repetitive mechanical loading and unloading of the synovial joints for diffusion of nutrients and cellular waste products.

Answer 78

**_Mechanism of injury:_** * **_Primary OA:_** Insidious onset with no known cause (idiopathic) * **_Secondary OA:_** Cause is known (e.g., trauma, infection, hemarthrosis, osteonecrosis, etc.)

Answer 79

* Progressive loss of articular cartilage and narrowing of the joint space results in an increase in friction between the articular surfaces of the bones and subsequently inflammation of the articular cartilage and underlying bone. In addition, progressive loss of articular cartilage results in an increase in mechanical loading through the synovial joint. * In response to the excessive mechanical load, sclerosis of the subchondral bone occurs as new bone is formed (bone remodeling). The formation of new bone contributes to the creation of osteophytes at the margins of the joints. Fissuring and eburnation of the cartilage (i.e., thinning and loss of the articular cartilage resulting in exposure of the subchondral bone, which becomes denser with the surface becoming worn and polished) also occur. * As OA progresses, other degenerative processes occur at the joint, including inflammation of the synovial membrane (i.e., synovitis) due to the accumulation of fragments of cartilage in the synovial fluid, and degenerative changes in periarticular structures such as menisci, ligaments, and tendons (e.g., ligamentous laxity, progressive muscle weakness and atrophy). * Osteoarthritis ultimately results in chronic joint pain, joint deformities and malalignment, and loss of joint function.

Answer 80

* Usually begins in the synovial joints on one side of the body * Primarily affects the weight-bearing synovial joints: hip, knee, shoulder, cervical and lumbar spine, hands (i.e., 1st CMC & MCP joints, 2nd-5th PIP & DIP joints), and feet (i.e., 1st metatarsophalangeal [MTP] joint [great toe]) * Brief morning stiffness (i.e., lasting 5-10 minutes after awakening) that decreases with movement and physical activity * Limited range of motion at affected synovial joints * Pain is often described as a deep ache that is worse with activity and better after rest * Crepitus (i.e., audible crackling or grating sensation produced when roughened articular or extraarticular surfaces rub together during movement) * Joint deformities such as enlarged joint surfaces due to osteophyte (bone spur) formation (e.g., Heberden nodes at the DIP joints of the hand, Bouchard nodes at the PIP joints of the hand)

Answer 81

* Poor correlation between radiographic evidence of OA (e.g., joint space narrowing, osteophyte formation) and the presence of symptoms * Physical therapists should rely primarily on the clinical examination findings for direction regarding the development of prognosis (including plan of care) and intervention.

Answer 82

None. There are no special tests for osteoarthritis.

Answer 83

***Flexibility (stretching), strengthening, and endurance exercises*** to improve general mobility as well as improve the ability of muscles to absorb mechanical stress through the synovial joints * Muscle strength and endurance exercises: Low-intensity and controlled movements that are within the tolerance of the affected joints * Aerobic conditioning: Activities that have low impact on joints (e.g., walking, biking, swimming). Avoid activities that cause repetitive and intensive loading of the joints (e.g., jogging, jumping). Aerobic exercises can also help to reduce pain. * Aquatic therapy for flexibility, strengthening, and endurance: Decrease in mechanical stress through joints due to buoyancy of water ***Manual therapy*** to provide short-term pain relief and improve identified restrictions in joint mobility * Soft-tissue mobilizations of areas with soft-tissue restrictions * Joint mobilizations and manipulations * Avoid manipulations and forceful (end-range) mobilizations in the presence of inflammation. Instead, provide gentle oscillating or distraction motions with a focus on addressing pain associated with inflammation. ***Therapeutic modalities*** (e.g., hot packs, ultrasound) for management of short-term pain and activity limitation ***Patient education*** in combination with exercise or manual therapy * HEP for muscle strength, endurance, and ROM * Joint unloading strategies (e.g., movement and activity modifications, assistive devices or orthoses) * Disease progression and symptom management * Supporting weight reduction when patient is overweight ***Impairment-based functional, gait, and balance training*** * Due to impaired joint proprioception * Aquatic therapy for gait and balance training: Decrease in mechanical stress through joints due to buoyancy of water

Answer 84

_Outcome measures for determining outcomes following arthroplasties to treat OA:_ * Western Ontario and McMaster University Osteoarthritis Index (WOMAC) * Knee Injury and Osteoarthritis Outcome Score (KOOS) * Lequesne (“Luh-ken”) Index _Clinical practice guidelines to diagnose hip OA:_ * Moderate anterior or lateral hip pain during weight-bearing activities * Morning stiffness less than 1 hour in duration after awakening * Decrease in hip internal (medial) rotation, flexion * Increased hip pain with passive hip internal (medial) rotation

Answer 85

**_Adult rheumatoid arthritis_** * Can develop as early as age 25 years * Insidious onset with intermittent periods of exacerbation (active joint inflammation) and remission (absence of joint inflammation) * Affects women 3 times as often as compared with men * Occurs in synovial joints on both sides of the body at the same time * Can affect any synovial joint in the body but often affects the synovial joints in the upper extremities (especially the joints at the wrist and fingers) * Characterized by synovial joint swelling (i.e., synovitis) that is red, warm, and painful * Prolonged morning stiffness lasting 1 hour or more * Systemic signs and symptoms (e.g., fatigue, malaise, weight loss, fever) * Presence of elevated levels of rheumatoid factor and C-reactive protein

Answer 86

Rectus femoris Vastus medialis Vastus lateralis Vastus intermedius

Answer 87

**_Origins_** * _Straight head:_ Anterior inferior iliac spine (AIIS) * _Reflected head:_ Groove above the rim of the acetabulum of the inominate bone **_Insertions_** * Proximal border of the patella * Tibial tuberosity through the patellar ligament **_Innervations_** * _Peripheral:_ Femoral nerve * _Segmental:_ L2, L3, and L4 spinal nerve roots **_Actions_** * Knee extension * Assists the iliopsoas with hip flexion *\*For review of bony landmarks on the femur, see Netter Plate 476.*

Answer 88

**_Origins_** * Anterior and proximal surface of the femur: Distal half of the intertrochanteric line * Posterior and proximal surface of the femur: Medial lip of the linea aspera * Posterior and distal surface of the femur: Proximal part of the medial supracondylar line * Tendons of the ADductor longus and ADductor magnus * Medial intermuscular septum **_Insertions_** * Proximal border of the patella * Tibial tuberosity throught the patellar ligament **_Innervations_** * _Peripheral:_ Femoral nerve * _Segmental:_ L2, L3, and L4 spinal nerve roots **_Action_** * Knee extension * \*For review of bony landmarks on the femur, see Netter Plate 476.*

Answer 89

**_Origins_** * Anterior and proximal surface of the femur: * Proximal part of the intertrochanteric line * Anterior and inferior borders of the greater trochanter * Posterior and proximal surface of the femur: * Proximal half of the lateral lip of the linea aspera * Lateral lip of the gluteal tuberosity * Lateral intermuscular septum **_Insertions_** * Proximal border of the patella * Tibial tuberosity throught the patellar ligament **_Innervations_** * _Peripheral:_ Femoral nerve * _Segmental:_ L2, L3, and L4 spinal nerve roots **_Action_** * Knee extension * \*For review of bony landmarks on the femur, see Netter Plate 476.*

Answer 90

**_Origins_** * Anterior surface of the femur: Proximal 2/3 of the anterior and lateral surfaces of the body of the femur * Posterior surface of the femur: Distal half of the linea aspera * Lateral intermuscular septum **_Insertions_** * Proximal border of the patella * Tibial tuberosity throught the patellar ligament **_Innervations_** * _Peripheral:_ Femoral nerve * _Segmental:_ L2, L3, and L4 spinal nerve roots **_Action_** * Knee extension * \*For review of bony landmarks on the femur, see Netter Plate 476.*

Answer 91

***End feel*** refers to the sensation that the examiner “feels” in the joint as it reaches the end of the ROM during assessment of passive range of motion (PROM) at a joint. **_Physiologic (normal) end feels:_** * _Hard (aka, bone-to-bone):_ A hard, unyielding sensation as during knee extension * _Soft (aka, soft tissue approximation):_ A yielding compression (i.e., mushy feel) that stops further movement as during knee flexion * _Firm (i.e., stretch of the muscles, capsules, or ligaments):_ A feeling of springy or elastic resistance with a slight give as during ankle dorisflexion when the Achilles (calcaneal) tendon is stretched **_Pathological (abnormal) end feels:_** * _Muscle spasm (aka, rubbery):_ A sudden and hard sensation ("vibrant twang") as passive movement is abruptly ended * _Hard (aka, bony block):_ A hard, unyielding sensation before the end of ROM would normally occur or where a bone-to-bone end feel would not be expected (e.g., due to osteophyte formation) * _Soft (aka, mushy):_ A yielding compression (i.e., mushy feel) when the primary restraints to movement are impaired (e.g., ligament or capsule injury) and other structures are stopping the movement * _Firm (aka, springy block):_ A rebound sensation with a thick stretching feel (e.g., as with a torn meniscus at the knee when the knee is locked or unable to go into full extension) * _Hard capsular:_ A springy sensation with a thicker feel to it in the presence of restricted range of motion (e.g., due to capsular patterns as with adhesive capsulitis) * _Soft capsular (aka, boggy):_ A springy sensation in the presence of restricted range of motion (e.g., due to synovitis, soft-tissue edema, hemarthrosis) * _Empty:_ No real mechanical resistance is felt due to premature termination of passive movement as a result of pain (e.g., due to acute subacromial bursitits, tumor) *_References:_ Magee (6th ed.), pp.35-36; see also Table 1-17*

Answer 92

**The Ottawa knee rules** are a set of clincial decision guidelines to help determine the need for diagnostic imaging of acute knee injuries. According to the Ottawa knee rules, radiographs (aka, X-rays) are only required for patients with acute knee injuries who meet one or more of these criteria: * 55 years of age or older * Patellar tenderness * Fibular head tenderness * Inability to flex knee to 90° * Inability to bear weight and walk four steps when examined at time of injury *_References:_* * *Magee (6th ed.), p. 859* * *The Ottawa Knee Rule, http://www.theottawarules.ca/knee\_rules*

Answer 93

Scapulothoracic protraction = scapulothoracic ABduction Scapulothoracic retraction = scapulothoracic ADduction

Answer 94

After about 30° of shoulder ABduction, the scapulohumeral rhythm occurs at a ratio of 2:1, meaning that for every 3° of shoulder abduction, 2° occurs by glenohumeral joint ABduction and 1° occurs by scapulothoracic joint upward rotation. Based on a generalized 2:1 scapulohumeral rhythm, a full arc of nearly 180° of shoulder abduction is the result of a simultaneous 120° of glenohumeral joint abduction and 60° of scapulothoracic upward rotation.

Answer 95

***Rotator cuff pathology*** (aka, *rotator cuff disease*) refers to a continuum of conditions related to the rotator cuff (SITS) muscle group. These conditions include: * Tendinitis (inflammation of one or more tendons of the rotator cuff muscle group) * Bursitis (inflammation of the subacromial bursa adjacent to the tendons of the rotator cuff muscle group) * Partial-thickness tears of one or more rotator cuff tendons (\*see image below) * Partial-thickness tears are incomplete disruptions of the tendon that do NOT extend all the way through the tendon. * Full-thickness tears in one or more of the rotator cuff tendons (\*see image below) * A full-thickness tear is characterized by a complete disruption or rupture of the tendon that extends ALL the way through the tendon. \*_Note:_ The tendon that is generally involved in rotator cuff pathology is the supraspinatus tendon. Tendinitis or tears usually occur at the insertion of the supraspinatus tendon (i.e., the greater tubercle of the humerus; glenohumeral capsule), and because of the relatively poor blood supply at the insertion site, injury at this location is unlikely to heal well (\*adapted from Kisner and Colby [7th ed.], "Insidious [Atraumatic] Onset," p.569). *_References:_* * *Medscape: Rotator Cuff Pathology--Pathophysiology (https://emedicine.medscape.com/article/1262849-overview#a3)* * *Coach K's Lecture Materials --\> Rotator Cuff Tears* * *Johns Hopkins Medicine: Partial Rotator Cuff Tear (https://www.hopkinsmedicine.org/health/conditions-and-diseases/partial-rotator-cuff-tear)* * *Kisner and Colby (7th ed.), pp.566-569*

Answer 96

* **_Age:_** 30-50 years * Rotator cuff tears are observed more often among individuals older than 40 years of age (\*adapted from Kisner and Colby [7th ed], "Intrinsic Impingement: Rotator Cuff Disease," p.568). * **_Past medical history:_** Pain and weakness after eccentric load (e.g., attempting to control the descent of a falling beer keg) *_References:_* * *Magee (6th ed.), pp.257-258, Table BLE 5-2* * *Coach K's Lecture Materials --\> Rotator Cuff Tears*

Answer 97

* Overuse injuries from repeated contact of the rotator cuff muscle tendons and subacromial bursa with the undersurface of the acromion process of the scapula (i.e., subacromial impingement) during overhead activities such as repetitive lifting, pushing, pulling, or throwing * Traumatic tear of the tendon after a fall, accident, or chronic subacromial impingement * It has been observed that most cases of rotator cuff tears are preceded by chronic subacromial impingement (\*adapted from Kisner and Colby [7th ed.], "Insidious [Atraumatic] Onset," p.569). * Degeneration of the tendon over time (e.g., osteophyte or bone spur formation around the acromion process that contributes to degeneration of the supraspinatus tendon) *_References:_* * *Medscape: Rotator Cuff Pathology--Pathophysiology (https://emedicine.medscape.com/article/1262849-overview#a3)* * *Coach K's Lecture Materials --\> Rotator Cuff Tears*

Answer 98

* **_General:_** * Pain at night * Due to laying on affected shoulder * Night pain is especially indicative of full-thickness tears. * If supraspinatus tendon is involved, pain referral pattern that radiates into the lateral elbow * Protective shoulder hike may be observed in conjunction with shoulder stiffness due to muscle guarding and reduced use of the affected arm. * Tender to palpation over the rotator cuff muscles or tendons * **_Subacromial impingement and partial-thickness tears_** * PROM of the affected shoulder can be painful if impingement of the tendon occurs (e.g., during shoulder ABduction [frontal plane]) or when the shoulder is moved into a position that stretches the partially torn tendon and muscle (e.g., into shoulder ADduction [frontal plane]) * Reduced shoulder ABduction (frontal plane) or rotation AROM that is painful * Painful arc sign may be present if subacromial impingement is the primary issue. * Resisted isometric movements result in pain and weakness (i.e., MMT grade of fair or 3), especially during shoulder ABduction (frontal plane) and lateral (external) rotation * Usually occurs when partial-thickness tear is the primary issue * **_Full-thickness tears_** * PROM is painless and full * Reduced AROM that is painless * Resisted isometric movements is painless but severely weak, especially during shoulder ABduction (frontal plane) and lateral (external) rotation *_References:_* * *Coach K's Lecture Materials --\> Rotator Cuff Tears* * *Magee (6th ed.): Table BLE 5-2, pp.257, 258; Table BLE 5-3, p.258*

Answer 99

The following special tests can be positive in the presence of rotator cuff pathology: * Painful Arc * Supraspinatus ("Empty-Can" or Jobe's) Test * Drop-Arm Test *_References:_* * *Coach K's Lecture Materials --\> Rotator Cuff Tears* * *Magee (6th ed.), pp.257-258, Table BLE 5-2* * *File Explorer --\> JYOUNG Passport --\> WUSTL DPT’19 --\> Classroom Files --\> Year 2 --\> Fall 2017 --\> DMMC II --\> Lecture Materials --\> Shoulder Unit --\> Intro to Shldr Exam & Special Tests --\> "Special Tests for Source of Shlder Sxs" Word doc*

Answer 100

**_Acute: Protection and pain management_** * ***Therapeutic modalities*** (e.g., ultrasound, e-stim, cold pack) for pain management and \*facilitation of tissue healing (\*see rationale below) * ***Low-intensity cross-friction massage*** to promote tissue healing by increasing blood flow to the injured tissues (i.e., inducing local inflammation to promote repair and regeneration of the tissues) * ***Arm sling*** to support and rest the affected arm * ***Isometric (aka, muscle-setting) exercises*** to stimulate the stabilizing function and maintain the muscle performance of the rotator cuff and scapulothoracic muscles * Avoid the impingement positions (e.g., midrange of ABduction with internal rotation; end-range position when the involved muscle is on a stretch such as putting the hand behind the back). * Scapulothoracic muscles to focus on strengthening include the serratus anterior, middle and lower trapezius, and rhomboids (\*from Kisner and Colby [7th ed.], p.572). * ***Pendulum exercises without weights*** to maintain glenohumeral joint mobility and reduce pain through grade II joint distraction and oscillation motions **_Subacute: Controlled motion_** * ***Joint mobilizations*** (e.g., inferior glides for shoulder ABduction) to improve glenohumeral joint mobility and faciliate normal motion at the shoulder * ***Muscle stretching*** of the pectoralis minor, levator scapulae, and the shoulder internal (medial) rotators (i.e., pectoralis major, latissimus dorsi, teres major, and subscapularis). * Common postural dysfunctions associated with rotator cuff pathology include increased thoracic kyphosis, forward head (i.e., excessive cervical extension), and ABducted and anteriorly-tilted scapulae. As a result, the pectoralis minor, levator scapulae, and shoulder internal rotators may become short and stiff (\*adapted from Kisner and Colby (7th ed.), p.569). * ***Progressive strengthening*** of the rotator cuff and scapulothoracic muscles **_Chronic: Return to function_** * ***Functional mobility training*** *_References:_* * *Kisner and Colby (7th ed.), pp.571-573*

Answer 101

If the supraspinatus tendon is torn, magnetic resonsance imaging (MRI) of the affected shoulder will show a superior displacement of the humeral head. *_Reference:_* * *For MRIs of rotator cuff tears--Magee (6th ed.), pp. 371-372, Figs. 5-200 & 5-202*

Answer 102

**_Adhesive capsulitis:_** * Progressive loss of both active and passive range of motion (loss of AROM = loss of PROM) * In the beginning stages, will present with intact rotator cuff muscle strength (fair+ [3+] to good [4]). As the disease progresses, there may appear to be muscle weakness, but the presented muscle weakness is due to an increase in pain. * Observation of a shoulder capsular pattern: Shoulder lateral rotation will be more limited than ABduction, which will be more limited than medial rotation * Special tests for rotator cuff pathology may be negative or inconclusive. If the patient is in stage 2-4 of adhesive capsulitis, patient may not be able to position affected shoulder into the test positions due to pain or limited shoulder mobility.

Answer 103

**_Test procedure:_** * Examiner places the patient's arm in 90° of shoulder ABduction with neutral (no) rotation, and examiner provides manual resistance against shoulder ABduction. * The shoulder is then medially rotated and angled forward 30° (“empty-can” position) so that the patient's thumbs point toward the floor in the plane of the scapula. Resistance against shoulder ABduction is again given. **_Positive result:_** Weakness or pain in the "empty-can" position **_Interpretation of positive result:_** Tear of the supraspinatus tendon or muscle, or neuropathy of the suprascapular nerve *_Reference:_* * *Magee (6th ed.), p.341 (\*see also Figure 5-143)*

Answer 104

**_Test procedure:_** Examiner places the patient's shoulder in 90° of ABduction and then asks the patient to slowly lower the arm to the side in the same arc of movement **_Positive result:_** Patient is unable to return the arm to the side slowly or has severe pain when attempting to do so. **_Interpretation of positive result:_** Tear of the rotator cuff tendon *_Reference:_* * *Magee (6th ed.), Figure 5-127, p.334; p.332*

Answer 105

**_Test procedure:_** Examiner instructs the patient to perform active shoulder ABduction in the patient’s preferred manner. **_Positive result:_** Shoulder ABduction is painful throughout a range of 60-120°. Pain may be present during the raising motion into shoulder ABduction or the lowering motion into shoulder ADduction. **_Interpretation of positive result:_** Mechanical impingement of structures underneath the acromion process (aka, subacromial impingement). Involved structures include the subacromial bursa or the rotator cuff tendon insertions (especially the supraspinatus). *_References:_* * *Magee (6th ed.), pp.272-274 (\*see also Figure 5-29)* * *TherapyEd Review Study Guide, p.29*

Answer 106

Biceps femoris--long head Biceps femoris--short head Semitendinosis Semimembranosis

Answer 107

**_Origin:_** * Ischial tuberosity (proximal and lateral to the origins of the semitendinosus and biceps femoris [long head]) **_Insertion:_** * Posteromedial aspect of the medial condyle of the tibia **_Innervations_** * _Peripheral:_ Tibial nerve * _Segmental:_ L4, L5, S1, and S2 spinal nerve roots **_Actions:_** * Knee flexion * Knee internal (medial) rotation * Hip extension * Assists with hip internal (medial) rotation

Answer 108

**_Origin:_** * Ischial tuberosity via the tendon common with the biceps femoris (long head) **_Insertions_** * Proximal part of the anteromedial surface of the body of the tibia * Deep fascia of the lower leg **_Innervations_** * _Peripheral:_ Tibial nerve * _Segmental:_ L4, L5, S1, and S2 spinal nerve roots **_Actions:_** * Knee flexion * Knee internal (medial) rotation * Hip extension * Assists with hip internal (medial) rotation

Answer 109

**_Origins:_** * Posterior part of the ischial tuberosity * Distal part of the sacrotuberous ligament **_Insertions:_** * Lateral side of the head of the fibula * Lateral condyle of the tibia * Deep fascia of the lateral side of the lower leg **_Innervations_** * _Peripheral:_ Tibial nerve * _Segmental:_ L5, S1, S2, and S3 spinal nerve roots **_Actions:_** * Knee flexion * Knee lateral (external) rotation * Hip extension * Assists with hip lateral (external) rotation

Answer 110

**_Origin:_** * Lateral lip of the linea aspera * Proximal 2/3 of the lateral supracondylar line * Lateral intermuscular septum **_Insertions:_** * Lateral side of the head of the fibula * Lateral condyle of the tibia * Deep fascia of the lateral side of the lower leg **_Innervations_** * _Peripheral:_ Common fibular nerve * _Segmental:_ L5, S1, and S2 spinal nerve roots **_Actions:_** * Knee flexion * Knee lateral (external) rotation *\*For review of bony landmarks on the femur, see Netter Plate 476.*

Answer 111

***Rheumatoid arthritis (RA)*** is a chronic and systemic autoimmune disorder that is characterized by inflammation and destruction of the synovial joint capsule (i.e., articular manifestations) (especially the synovium) and elsewhere throughout the body (i.e., extraarticular manifestations--e.g., eye lesions, osteoporosis, cardiopulmonary impairments). Juvenile idiopathic arthritis is included under rheumatoid arthritis. ***Juvenile idiopathic arthritis (JIA)*** (aka, *juvenile rheumatoid arthritis, or JRA*) is an umbrella term for a heterogeneous group of disorders among children that develop and present similarly to RA. Juvenile idiopathic arthritis usually begins before 16 years of age and is characterized by complete remission in 75% of children. *_References:_* * *Goodman & Fuller (4th ed.), pp.192 ("Rheumatoid Arthritis"), 1317-1318 ("Overview;" "Pathogenesis"), 1328 ("Overview and Incidence")* * *TherapyEd Review Study Guide, p. 53*

Answer 112

**_Age_** * _RA:_ Initial onset of 25-50 years, peak onset of 30-60 years * _JIA:_ Children younger than 16 years **_Gender_** * _RA:_ Affects women 3 times as often compared with men * _JIA:_ Affects girls more often than boys *_Reference:_* * *Goodman and Fuller (4th ed), p.1317 ("Incidence and Risk Factors"), p.1330 ("Etiologic and Risk Factors and Pathogenesis")*

Answer 113

The cause of RA and JIA is unknown and poorly understood, but it is most likely from a combination of genetic and environmental factors. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1317 ("Incidence and Risk Factors"), p.1330 ("Etiologic and Risk Factors and Pathogenesis")*

Answer 114

* Insidious onset with intermittent periods of exacerbation (active joint inflammation) and remission (absence of joint inflammation) * Occurs in synovial joints on both sides of the body at the same time * Can affect any synovial joint in the body but often affects the synovial joints in the upper extremities (especially the joints at the wrist and fingers) * Characterized by synovial joint swelling (i.e., synovitis) that is red, warm, and painful * Prolonged morning stiffness lasting 1 hour or more * Systemic signs and symptoms (e.g., fatigue, malaise, weight loss, fever) * Presence of elevated rheumatoid factor and C-reactive protein *_References:_* * *Goodman & Fuller (4th ed.), p.1317 (Table 27-2), p.1318 ("Pathogenesis"), p.1319 (Box 27-8), pp.1318-1321 ("Clinical Manifestations"), 1326 ("Remission")*

Answer 115

**_Active inflammatory period_** * ***Gentle joint mobilizations*** to reduce pain (e.g., grade I and II distraction and oscillation techniques) * ***PROM or AAROM*** to maintain available joint motion * ***Isometric (aka, muscle-setting) exercises*** to minimize muscle atrophy and maintain the ability of muscles to absorb mechanical stress through the synovial joints (\*see OA flashcards) **_Remission period_** * ***Aquatic therapy*** for flexibility, strengthening, and endurance * Decrease in mechanical stress through joints due to buoyancy of water *_References:_* * *Kisner & Colby (7th ed.), pp.337-341* * *Goodman & Fuller (4th ed.), p.1328 ("Aquatic Therapy")*

Answer 116

* ***Do not perform stretching techniques across swollen joints.*** When there is effusion, limited motion is the result of excessive fluid in the joint space. Forcing motion on the distended capsule overstretches it, leading to subsequent hypermobility (or subluxation) when the swelling abates. It may also increase the irritability of the joint and prolong the joint reaction. * ***Avoid exercises that cause excessive stress to bone or joints*** (e.g., jogging, jumping). Patients with RA or JIA may have osteoporosis and ligamentous laxity due to use of steroidal medications to treat the condition. * ***Avoid vigorous stretching or high-velocity thrust manipulative techniques of affected joints.*** The joint capsule, ligaments, and tendons may be structurally weakened by the rheumatic process or secondary to steroidal use, and forceful (end-range) techniques can result in muscle guarding, pain, and greater tissue damage. *_Reference:_* * *Kisner & Colby (7th ed.), pp.339-341*

Answer 117

***Fibromyalgia*** (aka, *fibromyalgia syndrome*, or *FMS*) is a chronic muscle pain syndrome characterized by widespread muscle pain with allodynia or hyperalgesia to pressure pain. In particular, fibromyalgia is a disorder of pain processing (i.e., abnormal pain modulation with hypersensitivity to painful stimuli and reduced pain inhibition). *_Reference:_* * *Goodman & Fuller (4th ed.), p.310 ("Definition and Overview")*

Answer 118

* Muscle pain (aka, myalgia) that is described as aching or burning * Diffuse pain or tender points on both sides of the body * Fatigue and exhaustion due to sleep distrubances secondary to muscle pain * Visual problems (e.g., blurring, double vision, bouncing images) possibly due to hypersensitivity to visual stimuli *_References:_* * *Goodman & Fuller (4th ed.), Table 7-6, p.314; p.312 ("Clinical Manifestations")* * *Medscape: Fibromyalgia--Patients Hypersensitive to Nonpain Sensations (https://www.medscape.com/viewarticle/831831)*

Answer 119

* ***Aerobic fitness and strength training*** to reduce muscle pain and other symptoms * _Example:_ Aquatic therapy due to reduced joint loading secondary to buoyancy of water (\*see OA flashcards) * ***Slow and gentle soft-tissue techniques*** to reduce muscle pain and intensity of tender points * Avoid cross-friction massage. * ***Therapeutic modalities*** (e.g., ultrasound, interferential current) to reduce muscle pain. *_References:_* * *Goodman & Fuller (4th ed.), p.316 ("Modalities and Fibromyalgia), 316-317 ("Exercise and Firbomyalgia")* * *Kisner & Colby (7th ed.), pp.345-346*

Answer 120

***Osteoporosis*** is a chronic, progressive disease characterized by low bone mass, impaired bone quality, decreased bone strength, and enhanced risk of fractures. *_Reference:_* * *Goodman & Fuller (4th ed.), p.1211 ("Definition and Overview")*

Answer 121

* ***Strengthening exercises***, ***weight-bearing exercises*** (e.g., walking, jogging, climbing stairs, jumping, standing partial squats) * Muscle contraction (e.g., during strengthening exercises and resistance training) and mechanical loading (i.e., e.g., during weight-bearing activities) deform bone. This deformation stimulates osteoblastic activity and improves bone mineral density. * Physical activity has been shown to have a positive effect on bone remodeling. In children and adolescents, this activity may increase the peak bone mass. In adults, it has been shown to maintain or increase bone density; in the elderly, it has been shown to reduce the effects of age-related or disuse-related bone loss. *_Reference:_* * *Kisner and Colby (7th ed.), pp.348-349*

Answer 122

* ***Avoid spinal flexion activities and exercise*** (e.g., supine curl-ups and sit-ups) ***as well as the use of sitting abdominal machines.*** Osteoporosis changes the shape of the vertebral bodies (i.e., they become more wedge shaped), leading to kyphosis. Stress into spinal flexion increases the risk of a vertebral compression fracture. * ***Avoid combining spinal flexion and rotation*** to reduce stress on the vertebrae and the intervertebral discs. * ***Avoid high-intensity resistance exercises*** that go beyond the structural capacity of the affected bones. *_Reference:_* * *Kisner and Colby (7th ed.), p.349 ("Precautions and Contraindications")* * *"Reasons for Spinal Compression Fractures" YouTube video (https://www.youtube.com/watch?v=LILgFAEMAbg&feature=emb\_title)* * *NCBI-StatsPearl BookShelf: "Vertebral Compression Fractures" (https://www.ncbi.nlm.nih.gov/books/NBK448171/)*

Answer 123

***Scoliosis*** is an abnormal lateral curvature of the spine. Curves are designated as right or left, depending on the convexity (e.g., right thoracic scoliosis describes a curve in the thoracic spine with convexity to the right). In the thoracic spine, rotational deformity on the convex side (i.e., rotation of the vertebral bodies toward the convex side) is observed as a rib hump sometimes seen in the upright position, but always apparent in the forward bend position. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1164 ("Definition"), p.1166 ("Clinical Manifestations")* * *Kisner and Colby (7th ed.), p.432*

Answer 124

***Functional (postural) scoliosis*** is NOT due to vertebral involvement. Functional scoliosis is therefore also called non-structural scoliosis. The abnormal lateral curves in functional scoliosis disappear when the underlying cause is addressed. Examples of these causes include: * Leg-length discrepancy * Poor posture * Pain or muscle spasm ***Structural scoliosis*** IS due to vertebral involvement--in particular, deformity of the vertebral bodies. Most cases of structural scoliosis are idiopathic. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1165 ("Etiologic Factors")*

Answer 125

***Ankylosing spondylitis*** (aka, *Marie-Strümpell disease*) is a chronic systemic and inflammatory disorder that primarily affects the joints of the axial skeleton and the sacroiliac (SI) joint. Ankylosing spondylitis is also characterized by extraarticular complications (e.g., eye, cardiopulmonary) and can be associated with asymmetrical involvement of the large peripheral joints, including the hip, knee, and shoulder. *_References:_* * *Goodman and Fuller (4th ed.), p.1332 ("Overview and Incidence"), 1334* * *Kisner and Colby (7th ed.), p.473*

Answer 126

**_Gender:_** Male **_Age:_** 15-30 years **_Past medical history:_** Genetic predisposition with family history of anklyosing spondylitis *_Reference:_* * *Goodman and Fuller (4th ed.), p.1333 ("Overview and Incidence," "Eiologic and Risk Factors")*

Answer 127

Anklyosing spondylitis is marked by chronic inflammation at the area where the ligaments attach to the vertebrae (an area called the *enthesis*), initially in the lumbar spine and then in the sacroiliac joint. Disruption of this ligamentous–osseous junction results, and reactive bone formation occurs as part of the repair process. The replacement of inflamed cartilaginous structures by bone contributes to progressive ossification with bony growth between the vertebrae, leading to a fused, rigid, or bamboo spine that is characteristic of end-stage disease (\*see image below). *_References:_* * *Goodman and Fuller (4th ed.), p.1333 ("Pathogenesis")*

Answer 128

* Insidious onset of low back or buttock pain and stiffness lasting for at least 3 months * Significant morning stiffness lasting more than 1 hour * Flexion posture characterized by thoracic kyphosis, hip flexion contractures, and loss of lumbar extension * Rigid gait due to loss of spinal extension and rotation * Systemic signs and symptoms (e.g., fever, fatigue, loss of appetite, weight loss) *_Reference:_* * *Goodman and Fuller (4th ed.), pp.1333-1334 ("Clinical Manifestations")*

Answer 129

* ***Patient education*** on how to faciliate a functional thoracic kyphotic posture before the entire spine becomes fused (i.e., maintaining exaggerated lumbar extension by sleeping in the prone position; using a towel roll or pillow behind the lumbar spine when sitting) * ***Strengthening exercises*** focused on the muscles at the trunk (e.g., back extensors) and scapulae in order to improve the stability of the spine and facilitate the functional posture position * ***Stretching exercises*** focused on reducing hip flexion contractures * ***Aerobic exercise*** (e.g., aquatic therapy) that are low intensity and emphasize spinal extension and rotational components to maintain joint mobility at the spine * ***Gentle joint mobilizations*** (i.e., grades I and II oscillatory and sustained techniques) for pain mangement at segments unaffected by ankylosing spondylitis *_References:_* * *Kisner and Colby (7th ed.), p.473* * *Goodman and Fuller (4th ed.), p.1337 ("Exercise Prescription")*

Answer 130

* ***Avoid high-impact and flexion exercises*** due to increased risk for vertebral fractures secondary to the associated thoracic kyphotic posture and the development of the stiff and osteoporotic spinal column *_References:_* * *Goodman and Fuller (4th ed.), p.1334 ("Complications"), 1337 ("Exercise Prescription")* * *"Reasons for Spinal Compression Fractures" YouTube video (https://www.youtube.com/watch?v=LILgFAEMAbg&feature=emb\_title)* *NCBI-StatsPearl BookShelf: "Vertebral Compression Fractures" (https://www.ncbi.nlm.nih.gov/books/NBK448171/)*

Answer 131

***Gout*** is a metabolic disorder that is also described as a crystalopathy (aka, crystal-induced arthritis). Gout is characterized by elevated levels of uric acid in the blood and subsequent deposition of monosodium urate crystals in the joints, soft tissues, and kidneys. *_Reference:_* * *Goodman and Fuller (4th ed.), pp.1344-1345 ("Overview," "Pathogenesis")*

Answer 132

**_Gender:_** Male **_Age:_** Older than 30 years of age * Predominantly associated with middle-aged men around 50 years of age **_Past medical history_** * Heavy alcohol consumption (especially beer) * Obesity * Diet rich in: * Purines, or nitrogen-containing com-pounds found in foods such as shellfish, trout, sardines, anchovies, meat (especially organ meats), asparagus, beans, peas, spinach * Fructose-sweetened foods and beverages *_Reference:_* * *Goodman and Fuller (4th ed.), p.1345 ("Incidence," "Etiologic and Risk Factors")*

Answer 133

Uric acid is a substance that normally forms when the body breaks down cellular waste products called purines. In healthy people, uric acid dissolves in the blood, passes through the kidneys, and is then excreted through the urine. If the body produces more uric acid than the kidneys can process or if the kidneys are unable to handle normal levels of uric acid, then the acid level in the blood rises. When the uric acid in the blood reaches high levels, it may precipitate out and accumulate in body tissues (e.g., joints and kidneys), forming supersaturated body fluids that develop into monosodium urate crystals. The crystals trigger an inflammatory response, resulting in local tissue necrosis and a proliferation of fibrous tissue secondary to an inflammatory foreign-body reaction. *_References:_* * *Goodman and Fuller (4th ed.), p.1345 ("Pathogenesis")* * *Medscape: Gout and Pseudogout--Pathophysiology (https://emedicine.medscape.com/article/329958-overview#a3)*

Answer 134

* Severe joint pain (e.g., at the 1st metatarsophalangeal joint [great toe]) occuring suddenly at night * Erythema, warmth, extreme tenderness, and hypersensitivity at the affected joints * Chills, fever, and tachycardia

Answer 135

**_Acute: Protection and Pain Management Phase_** * ***Orthosis or bracing*** to support and protect the affected joint (e.g., orthotic shoe insert and well-constructed shoes for gout of the 1st MTP joint [great toe]) * ***Gentle joint mobilizations*** to reduce joint pain (e.g., grade I and II oscillatory and distraction techniques) * ***PROM, AAROM, and AROM*** as tolerated to maintain joint mobility * ***Gentle isometric (aka, muscle-setting) exercises*** to reduce muscle atrophy and maintain muscle performance in the area around the affected joint * ***Aquatic therapy*** for low-impact, buoynacy-assisted exercises to maintain joint mobility and muscle strength **_Subacute and Chronic: Controlled Motion and Return to Functional Mobility_** * ***Joint mobilization and stretching exercises*** to improve joint mobility *_Reference:_* * *Kisner and Colby (7th ed.), pp.856-858*

Answer 136

***Torticollis*** (aka, *congenital muscular torticollis [CMT]; wry neck*) means "twisted neck" and is characterized by a contracted state of the sternocleidomastoid muscle (SCM), producing head tilt (i.e., cervical lateral flexion) to the affected side with rotation of the chin to the opposite side (\*see image below). Torticollis is designated as right or left depending on side the head tilt is directed toward (e.g., right cervical lateral flexion = right torticollis). *_Reference:_* * *Goodman and Fuller (4th ed.), p.1199*

Answer 137

* Lateral flexion to the affected side with rotation to the opposite side * Firm, nontender, palpable enlargement of the sternocleidomastoid (SCM) muscle * Craniofacial asymmetry (i.e., plagiocephaly, or flat head syndrome) characterized by flattening of the infant's face, ear, and head from resting on the affected side

Answer 138

* ***Passive stretching exercises*** for the shortened sternocleidomastoid (SMC) muscle to improve cervical spine movement as well as improve muscle length of the affected SCM * Be sure to stabilize the proximal attachment of the SCM and trapezius during passive stretching exercises. *_References:_* * *Goodman and Fuller (4th ed.), p.1200 ("Clinical Manifestations--Treatment")* * *TherapyEd Review Study Guide, p.56*

Answer 139

**_Origins:_** * Sternal head: Manubrium of the sternum * Clavicular head: Medial 1/3 of the clavicle **_Insertion:_** * Lateral surface of the mastoid process of the temporal bone * Lateral 1/2 of the superior nuchal line of the occipital bone **_Innervations_** * _Peripheral:_ Spinal accessory nerve (CN XI) * _Segmental:_ Anterior primary rami of the C1 and C2 spinal nerve roots **_Actions:_** * Unilaterally: Cervical rotation to the opposite side, and lateral cervical flexion to same side * Bilaterally: Flexion of the lower cervical spine (C3 - C7) with anterior translation of the cervical vertebrae and no sagittal rotation; extension of the upper cervical spine (occiput, atlas, axis) (i.e., capital extension, or head-on-neck extension)

Answer 140

***Lateral elbow tendinosis*** (aka, "tennis elbow") is an overuse injury characterized by degeneration and weakening of the superficial extensor muscle tendons (i.e., extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) at their shared origin attachment via the common extensor tendon to the lateral epicondyle of the distal humerus. Lateral elbow tendinosis is also called lateral elbow tendinopathy, lateral epicondylitis, lateral epicondylalgia, or lateral epicondylosis. \*_Note #1:_ The primary muscle involved in lateral elbow tendinosis is the extensor carpi radialis brevis muscle. In about 50% of patient cases, the extensor digitorum is involved as well. \*_Note #2:_ The extensor carpi radialis brevis and extensor carpi ulnaris contribute to wrist extension only. The extensor digitorum and extensory digiti minimi contribute to both wrist and finger extension (\*see Neumann [3rd ed.], p.235 ["Wrist Extensor Muscles" Box]). *_References:_* * *Kisner and Colby (7th ed.), p.641 ("Overuse Syndromes: Repetitive Trauma Syndromes," "Related Pathologies--Lateral Elbow Tendinopathy")* * *Moore et al. (8th ed.), p.222, p.235 ("Clinical Box: Forearm--Elbow Tendinitis")*

Answer 141

Repetitive loading of the superficial extensor muscle tendons during: * Activities requiring repetitive or forceful grasp, such as hammering or playing tennis * The main function of the wrist extensors is to position and stabilize the wrist during activities involving active flexion of the digits. For example, when making a fist, the wrist extensor muscles counterbalance the significant wrist flexion torque produced by the finger flexor muscles and place the wrist in an extended position, optimizing the length-tension relationship of the extrinsic finger flexors and thereby facilitating maximal grip strength (\*adapted from Neumann [3rd ed.], p.236; see also Figure 7.25). * Prolonged positioning of the wrist in extension, such as when typing on a computer keyboard *_References:_* * *Kisner and Colby (7th ed.), p.641 ("Lateral Elbow Tendinopathy")* * *Neumann (3rd ed.), p.236* * *Sahrmann (2011), p.299 ("Symptoms and History")*

Answer 142

* Complaints of lateral elbow pain during gripping activities such as lifting or pouring a gallon of milk * Pain may radiate distally along the posterior aspect of the forearm * The following tests for source will be positive. * Palpation tenderness on or near the lateral epicondyle * Pain at the lateral epicondyle during: * Resisted wrist extension performed with the elbow flexed, forearm pronated, and wrist in slight extension * Resisted middle finger extension (aka, Maudsley's test) * If pain is instead over the medial border of the extensor carpi radialis brevis, positive for radial nerve compression (aka, radial tunnel syndrome). * Pain with passive wrist flexion with the elbow extended and forearm pronated (aka, Mill's test) * Due to stretch of the superficial extensor muscles of the forearm *_Reference:_* * *Kisner and Colby (7th ed.), p.641* * *Sahrmann (2011), p.288 ("Test for Radial Nerve Compression in the Forearm"), 290 ("Test for Wrist Extension with Forearm Pronation"), 299 ("Symptoms and History")* * *Magee (6th ed.), p.408 ("Mill's Test," "Maudsley's Test")*

Answer 143

***Medial elbow tendinosis*** (aka, "golfer's elbow") is an overuse injury characterized by degeneration and weakening of the superficial pronator and flexor muscle tendons (i.e., pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris) at their shared origin attachment via the common flexor tendon to the medial epicondyle of the distal humerus. Medial elbow tendinosis is also called medial elbow tendinopathy, medial epicondylitis, medial epicondylalgia, or medial epicondylosis. **\*_Note:_** The flexor carpi radialis, flexor carpi ulnaris, and palmaris longus contribute to wrist flexion only (\*see Neumann [3rd ed.], p.239 ["Wrist Flexor Muscles" Box]). The pronator teres contributes to forearm pronation. *_References:_* * *Kisner and Colby (7th ed.), p.641 ("Overuse Syndromes: Repetitive Trauma Syndromes," "Related Pathologies--Medial Elbow Tendinopathy")* * *Moore et al. (8th ed.), p.217*

Answer 144

Repetitive loading of the superficial pronator and flexor muscle tendons during: * Repetitive movements into wrist flexion, such as swinging a golf club or pitching a ball *_References:_* * *Kisner and Colby (7th ed.), p.642 ("Medial Elbow Tendinopathy")*

Answer 145

* Complaints of medial elbow pain with wrist flexion * Pain may radiate distally along the anterior aspect of the forearm. * The following tests for source will be positive. * Palpation tenderness on or near the medial epicondyle * Pain at the medial epicondyle during: * Resisted wrist flexion * Passive wrist extension performed with the elbow extended and forearm supinated (aka, "golfer's elbow" test) * Due to stretch of the superficial pronator and flexor muscles *_References:_* * *Magee (6th ed.), p.408 ("Medial Epicondylitis [Golfer's Elbow] Test"), 426 (Table 6-5)* * *Medscape: Medial Epicondylitis Clinical Presentation (https://emedicine.medscape.com/article/97217-clinical)*

Answer 146

***Osgood-Schlatter's disease*** is a traction phenomenon in which the fibers of the patellar tendon pull small bits of immature bone from the tibial tuberosity. Inflammation of the patellar ligament (i.e., tendinitis) is also associated with Osgood-Schlatter's disease. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1369 ("Overview")* * *Medscape: Osgood-Schlatter's Disease (https://emedicine.medscape.com/article/1993268-overview)*

Answer 147

**_Gender:_** Male **_Age:_** 10-15 years **_Personal medical history:_** * Actively involved in sports * Abnormal alignments of the lower extremities such as genu valgum (aka, knock-knees) or pes planus (aka, flat-foot) that create large Q-angles (\*see image below) * Large Q-angles place more tension on the tibial tuberosity. * High-riding patella (aka, patella alta) *_Reference:_* * *Goodman and Fuller (4th ed.), p.1369 ("Etiologic Factors and Pathogenesis")*

Answer 148

* Indirect trauma (i.e., a force produced by the sudden, powerful contraction of the quadriceps femoris muscle group during an activity such as running and jumping) * Repetitive stress (e.g., repeated knee flexion against a short or stiff quadriceps femoris muscle group) * Longstanding tension on the patella and patellar ligament during rapid growth spurts *_Reference:_* * *Goodman and Fuller (4th ed.), p.1369 ("Etiologic Factors and Pathogenesis")*

Answer 149

* Complaints of constant and localized aching and pain at the site of the tibial tuberosity * Swelling over the tibial tuberosity that is warm and tender (\*see image below) * Pain with activities involving forceful contraction of the patellar ligament against the tibial tuberosity (e.g., active knee extension, resisted knee flexion, ascending or descending stairs, running, jumping, biking, hiking, kneeling, squatting) * Significant shortness and stiffness of the hamstrings muscle group, quadriceps femoris muscle group, iliotibial band, or triceps surae muscle group. * Shortness and stiffness in these structures can potentially increase the knee flexion internal moment and subsequently the stresses at the tibial tuberosity. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1369 ("Clinical Manifestations")*

Answer 150

***Patellofemoral syndrome*** (aka, *patellofemoral pain syndrome*) refers to a collection of signs and symptoms associated with the patellofemoral joint that is characterized by a general description of anterior knee pain. \*_Note:_ The patellofemoral joint refers to the articulation between the articular side of the patella and the trochlear groove of the femur (\*from Neumann [3rd ed.], p.556). *_References:_* * *Kisner and Colby (7th ed.), p.792 ("Related Patellofemoral Pathologies and Etiology of Symptoms")* * *Medscape: Patellofemoral Syndrome (https://emedicine.medscape.com/article/308471-overview)*

Answer 151

**_Gender:_** Female *_Reference:_* * *Kisner and Colby (7th ed.), p.793 ("Focus on the Evidence")*

Answer 152

Examples of causes include: * Direct trauma to (i.e., overloading of) the patellofemoral joint * Overuse of the patellofemoral joint * Faulty patellar tracking during knee movements * Patellofemoral joint degeneration * Soft tissue length and strength imbalances in the hip, knee, or ankle and foot *_References:_* * *Kisner and Colby (7th ed.), p.792 ("Related Patellofemoral Pathologies and Etiology of Symptoms")* * *Medscape: Patellofemoral Syndrome Clinical Presentation--Causes (https://emedicine.medscape.com/article/308471-clinical#b5)*

Answer 153

* Pain that is located behind the patella (i.e., retropatellar) * Increased pain during activities that increase patellofemoral joint compressive forces through repetitive knee flexion (e.g., running, biking) or large amounts of knee flexion (e.g., squatting, prolonged sitting with flexed knees, and ascending and descending stairs) * Pain during prolonged sitting with the knee flexed is called the "theater sign" or "movie-goer's knee." * Altered lower extremity alignment: Increased hip ADduction, internal (medial) rotation, and dynamic genu valgum that occurs during weight-bearing activities (e.g., ascending and descending stairs, squatting, landing after a jump) *_References:_* * *Kisner and Colby (7th ed.), p.792 ("Related Patellofemoral Pathologies and Etiology of Symptoms"), 794 ("Common Impairments")* * *Medscape: Patellofemoral Syndrome--Practice Essentials (https://emedicine.medscape.com/article/308471-overview#a1)* * *Medscape: Patellofemoral Syndrome--Presentation History (https://emedicine.medscape.com/article/308471-clinical)* * *Physiopedia:* Patellofemoral Joint--Kinetics (https://physio-pedia.com/Patellofemoral\_Joint?utm\_source=physiopedia&utm\_medium=search&utm\_campaign=ongoing\_internal)

Answer 154

***Legg-Calvé-Perthes disease*** (aka, *coxa plana*, or "flat hip;" *osteochondritis deformans juvenilis*) refers to avascular necrosis of the proximal end of the femur at the femoral head (aka, capital femoral epiphysis of the immature femur) (\*see image below). *_Reference:_* * *Goodman and Fuller (4th ed.), p.1365 ("Definition and Overview")* * *Palisano et al. (5th ed.), p.319 ("Legg-Calvé-Perthes Disease)*

Answer 155

**_Gender:_** Male **_Age:_** 3-12 years **_Ethnicity:_** White *_Reference:_* * *Goodman and Fuller (4th ed.), p.1365 ("Definition and Overview")*

Answer 156

The cause of the avascular necrosis that is characteristic of Legg-Calvé-Perthes disease is unknown. *_Reference:_* * *Goodman and Fuller (4th ed.), p.1366 ("Etiologic Factors")*

Answer 157

* Complaints of insidious onset of hip pain that is described as sore or aching * Pain may also be present in the groin and along the path of the obturator nerve (i.e., the proximal anteromedial surface of the thigh). Pain may also be referred to the knee. * Pain is aggravated by activity and fatigue and relieved somewhat by rest. * Palpation over the hip capsule produces pinpoint tenderness. * Limping presentation on the involved side * Pathological gait patterns of compensatory Trendelenberg gait, antalgic gait, or psoatic limp may be present. * Short stature as a result of epiphyseal dysplasia * ROM limitations in the directions of hip ABduction and internal (medial) rotation *_References:_* * *Goodman and Fuller (4th ed.), p.1367 ("Clinical Manifestations")* * *Obturator Nerve - Cutaneous Innervation: Moore et al. (8th ed.), p.697 (Figure 7.17); Netter Plate 526*

Answer 158

The process of Legg-Calvé-Perthes disease lasts from 2-5 years and typically ends with resolution of the disease and return to normal functioning of the hip joint. As a result, a non-surgical treatment approach with physical therapy is typically recommended. *_References:_* * *Goodman and Fuller (4th ed.), p.1366 ("Pathogenesis," Table 27-4), 1368* * *Osmosis: "Legg-Calve-Perthes disease" video (https://www.youtube.com/watch?v=ylhiGkrQ8A8--1:59 to 2:23)*

Answer 159

* ***Aquatic therapy and gait training*** to maintain involvement in weight-bearing activities as tolerated so as to facilitate the bone remodeing process (\*see "Osteoporosis" flashcards) * Weight-bearing activities should be completed in hip ABduction in order to contain the capital femoral epiphysis (aka, femoral head) within the depths of the acetabulum. * Containment prevents deformities of the diseased epiphysis from occuring, equalizes the pressure on the femoral head, and allows the molding action of the acetabulum to occur to ensure a perfectly smooth interface between the femoral head and acetabulum. * With aquatic therapy, the buoyancy of the water decreases joint loading and subsequently makes it easier to perform weight-bearing exercises. * ***Hip mobility exercises*** to restore and prevent loss of ROM at the hip joint (especially hip ABduction and internal [medial] rotation) * The buoyancy of water associated with aquatic therapy also facilitates hip mobility exercises. *_References:_* * *Palisano et al. (5th ed.), p.320 ("ROM is limited in the directions of..."), 321 ("Containment is an important principle of...")* * *Goodman and Fuller (4th ed.), p.1368 ("Special Implications for the Therapist")*

Answer 160

***Slipped capital femoral epiphysis*** refers to the displacement of the femoral head (aka, capital femoral epiphysis) relative to the femoral neck and shaft. The displacement or "slippage" occurs at the proximal epiphyseal plate (aka, growth plate) (\*see image below). *_References:_* * *Palisano et al. (5th ed.), p.323* * *Medscape: Slipped Capital Femoral Epiphysis--Funtional Anatomy (https://emedicine.medscape.com/article/91596-overview#a7)*

Answer 161

**_Gender:_** Male **_Age:_** 10-16 years; average of 14 years **_Past medical history:_** * Metabolic disorders such as obesity * Obesity creates a higher mechanical load across the proximal epiphyseal plate (aka, growth plate). *_Reference:_* * *Palisano et al. (5th ed.), p.323 ("The presence in boys [13.35 per 100,000] is higher than...;" "The presence of these symptoms when presenting...")*

Answer 162

* Abnormally widened and weakened proximal epiphyseal plate (aka, growth plate) * May or may not be caused by trauma (e.g., fall or twist) * Due to increased mechanical shear forces through the proximal epiphyseal plate (aka, growth plate) as a result of trauma or an abnormally shaped proximal femur * Abnormalities at the proximal femur that increase mechanical shear forces across the epiphyseal plate include: (1) Femoral retrotorsion (aka, "femoral retroversion"), (2) a decreased femoral neck-shaft angle (i.e., angle of inclination) called coxa vara, or (3) a deeper acetabulum. * _Rationale:_ Femoral retrotorsion positions the proximal femur close to the medial-lateral axis through the femoral condyles, and coxa vara positions the epiphyseal plate more vertically (\*see image below). A deeper acetabulum is associated with the femoral head being anchored more completely within the acetabulum, making the proxmial epiphyseal plate more vulnerable to mechanical shear forces at the extremes of hip motion. *_References:_* * *Palisano et al. (5th ed.), p.323 ("The eitology of SCFE is multifactorial...")* * *Medscape: Slipped Capital Femoral Epiphysis--Functional Anatomy (https://emedicine.medscape.com/article/91596-overview#a7)* * *For more about femoral torsion, version, and angle of inclination: Neumann (3rd ed.), pp.484-485 ("Shape of the Proximal Femur"); KINES II --\> Developmental Kinesiology --\> Lecture Notes --\> Lecture #9b\_Developmental Biomechanics (pp.11-14); DMNMC II --\> Lecture Materials --\> Exam #1 --\> Cerebral Palsy (p.4)*

Answer 163

**_Acute (i.e., due to trauma; symptoms present for less than 3 weeks)_** * Severe, fracture-like pain in the groin, thigh, or knee * Unable to bear weight on the affected lower extremity * Position of comfort is hip lateral (external) rotation of the affected hip * Observable shortening of the affected lower extremity **_Chronic (i.e., symptoms present for several months)_** * Vague and intermittent pain in the groin and upper or lower thigh * Increased pain with running or sport activities * Tender to palpation over the anterior hip joint * Hip capsular pattern: Limitations in flexion, ABduction, and internal (medial) rotation * Limping presentation on the involved side * Pathological gait patterns of compensatory Trendelenberg gait, antalgic gait, or backward trunk lean (due to gluteus maximus weakness) may be present. * Affected lower extremity is held in a position of hip lateral (external) rotation * Muscle atrophy of the affected thigh * Observable shortening of the affected lower extremity *_References:_* * *Palisano et al. (5th ed), p.323 ("SCFE may be classified by the onset of...")* * *Coach's K Lecture Materials --\> SCFE vs. LCPD (slide 12)*

Answer 164

Older children generally have more severe slips or displacements of the proximal epiphyseal plates. Therefore, they have a poorer prognosis than younger children. In general, emergent surgery is required to prevent the progression of SCFE. *_References:_* * *Palisano et al. (5th ed.), p.323 ("Also of note is that older children generally..."), 324 ("Options for surgical management include...")* * *Medscape: Slipped Capital Femoral Epiphysis--Treatment & Management (https://emedicine.medscape.com/article/91596-treatment)*

Answer 165

When a child is suspected to have SCFE, immediate referral with radiology testing is recommended. Once the diagnosis has been confirmed, absolutely no weight bearing is recommended because this can lead to osteonecrosis. The child is then treated with emergent surgery to prevent the progression of SCFE. *_References:_* * *Palisano et al. (5th ed.), p.324* * *Medscape: Slipped Capital Femoral Epiphysis--Treatment & Management (https://emedicine.medscape.com/article/91596-treatment)*

Answer 166

***Duchenne muscular dystrophy*** is a genetic disorder that is characterized by progressive degeneration of skeletal and cardiac muscle fibers and subsequent weakening of the muscles. *_References:_* * *Vander's (15th ed.), p.283 ("Muscular Dystrophy")* * *Palisano et al. (5th ed.), pp. 242-265*

Answer 167

**_Gender:_** Male **_Past medical history:_** * Family history of DMD (genetic predisposition) *_Reference:_* * *Goodman and Fuller (4th ed.), p.1182 ("Incidence and Etiologic Factors")*

Answer 168

Genetic cause--DMD is a a sex-linked recessive disorder caused by a mutation in a gene on the X chromosome that codes for the protein dystrophin. The defective gene can result in either a nonfunctional or missing dystrophin protein. \*_Note:_ Dystrophin is an extremely large protein that normally forms a link between the contractile filament actin and proteins embedded in the overlying sarcolemma (i.e., plasma membrane of a muscle fiber) (\*see also Goodman and Fuller [4th ed.], p.1184, Figure 23-17). Lack of normal dystrophin makes the sarcolemma susceptible to damage during muscle contraction–relaxation cycles. Disruption of the sarcolemma and muscle fiber necrosis are initiated by muscle contraction, especially eccentric contraction. *_References:_* * *Vander's (15th ed.), p.284 ("Muscular Dystrophy")* * *Goodman and Fuller (4th ed.), p.1185 ("Duchenne and Becker Muscular Dystrophies")*

Answer 169

* Psudohypertrophy and contracture of the posterior calf muscles due to connective tissue and fat deposits * Difficulty getting up off the floor (i.e., Gowers sign) due to weakening of the hip and trunk muscles * In Gowers sign, the patient places the hands on the thighs and walks up the legs with the hands until the weight of the trunk can be placed posterior to the hip joint (\*see image below). This sign is characteristic of weakness of the lumbar and gluteal muscles. * Lumbar lordosis (which may present also as a protuberant or bulging abdomen) that places the line of gravity behind the hip joint to compensate for shoulder girdle, abdominal, and hip extensor weakness * Pathological gait patterns: Waddling gait due to proximal muscle weakness, compensatory Trendelenberg gait due to hip ABductor weakness, toe walking due to posterior calf muscle contractures and anterior lower leg muscle weakness * Progressive restrictive respiratory impairment secondary to weakness and contracture of the respiratory muscles * Frequent falls * Difficulty climbing stairs *_Reference:_* * *Goodman and Fuller (4th ed.), p.1182 ("Definition and Overview"), 1188-1189 ("Duchenne Muscular Dystrophy")*

Answer 170

Duchenne muscular dystrophy is rapidly progressive, with a loss of walking ability by 9-10 years; death around 20 years. *_References:_* * *Vander's (15th ed.), p.284 ("Muscular Dystrophy")* * *Goodman and Fuller (4th ed.), p.1184 (Table 23-5)*

Answer 171

* ***Aquatic therapy*** to improve muscle endurance * Because of the benefit of reduced joint and muscle loading with aquatic therapy, exercise is best done in the pool, where exercise is concentric. Any exercise program should produce only minimal fatigue with no post-exercise soreness, because the amount of damage to the sarcolemma with exercise is related directly to the magnitude of the stress placed on it during contraction. * ***Diaphragmatic or deep-breathing exercises or airway clearance techniques*** to address respiratory impairments * ***Splinting and night positioning as well as AROM and PROM*** exercises to reduce the extent of muscle contractures and maintain joint mobility * ***Adaptive equipment training*** (e.g., grab bars, power wheelchairs) to maintain functional mobility and independence as disease progresses *_Reference:_* * *Goodman and Fuller (4th ed.), pp.1193-1194*

Answer 172

* Avoid low-repetition maximum weightlifting, especially eccentric strengthening. * Strenuous exercise may facilitate the breakdown of muscle fibers. * Because of respiratory involvement, careful monitoring of breathing techniques, respiratory movements, and oxygen saturation levels is required. *_Reference:_* * *Goodman and Fuller (4th ed.), pp.1193-1194*

Musculoskeletal System Flashcards

(196 cards)