1
Q
True/False: The Costal Cage provides the bony framework for protection of organs and vessels.
Ribs provide the structural integrity for respiration, but multiple rib fractures can lead to loss of rib function.
A
True
*paradoxical movement during lung inflation and deflation
2
Q
Expansion of the costal cage during inhalation leads to _____ pressure within the thorax. This pulls in air, lymph, and venous drainage into the thoracic cavity and enhances flow.
A
Negative pressure
*sympathetic chain ganglia run along costovertebral joints – stimulated by motion
3
Q
- True ribs are ribs ______. THey articulate directly to the sternum via the costal cartilage.
- False ribs are ribs _____. They articulate indirectly via the cartilage of the superior rib. They share costal cartilage.
- Floating ribs _____. have no connection to the sternum.
A
- True ribs
- -synovial (except R1) - False ribs
- -synovial joint - Floating ribs
4
Q
The Costovertebral joint is formed by the head of the rib. The head has two articular facets:
- Superior costal facet which articulates with ______
- Inferior facet which articulates with
A
- Superior costal
- -articulates with vertebrae above - Inferior facet
- -articulates with numerically corresponding vertebrae
5
Q
- The ______ make up the most prominent posterior portion of the rib
- The ____ is not located on the 1st or 12th rib. It is short on the 2nd and shallow on the 11th.
A
- rib angles
- Costal groove
* vein, artery, nerve
6
Q
Atypical ribs are
A
1, 2, 10, 11, 12
7
Q
Typical ribs have a head (w/ 2 articular facets), neck, tubercle, angle and shaft. List the typical ribs
A
All but 1, 2, 10, 11, 12
8
Q
The shortest rib. It has a site for attachment of the anterior and middle scalenes. It is atypical because it only articulates with T1 and lacks an angle or a groove
A
Rib 1
9
Q
Is a small atypical rib that has attachment sites for Serratus and Posterior scalene.
It has a large tuberosity on the shaft for the serratus anterior, but no non-articular tuburcle
A
Rib 2
10
Q
________ is caused by Cervical Rib/Spasm of scalenus anterior muscle that compresses the subclavian artery and brachial plexus leading to ischemia and nerve pressure symptoms of the upper limb
A
Thoracic Outlet Syndrome
11
Q
- Rib 10 articulates only with _____
- Rib 11 has a single articular facet, but no ____ and no ____
- Rib 12 has a single articular facet with no neck, no tubercle, no angle, and no costal groove. It is tapered.
A
- T10
2. no neck, no tubercle
12
Q
True/False: The ribs protect the organs, provide attachment sites for respiratory muscles, and support postural mechanics.
They are connected to the upper extremity by the clavicle
A
True
13
Q
Most commonly caused by trauma (e.g. motor vehicle accidents, assault, sports, CPR, etc.)
Clinical presentation includes focal tenderness, crepitus and ecchymosis.
A
Rib fracture
*cancer, stress fractures
Complications:
–pneumothorax, flail chest, pneumonia, etc.
NOTE: start w/ X-ray; CT is gold standard
14
Q
Inhalation involves the External Intercostals, Interchondral intercostals, and what accessory muscles?
A
- sternocleidomastoid
- -elevates sternum - Scalenes
- -elevate upper ribs
*diaphragm: descends; elevates lower ribs
Pec minor
Serratus ant.
Latissimus dorsi
15
Q
Exhalation occurs by passive recoil. However, forced expiration occurs by what muscles?
A
extrachondral internal intercostals and abdominals
16
Q
The Diaphragm is the musculotendinous boundary between the negative pressure thoracic cavity and the positive pressure abdominal cavity.
It is innervated and supplied by
A
Phrenic nerve (C3-C5) Phrenic artery
*attaches to lower 6 ribs
17
Q
Principle muscles of inhalation They originate on ribs 1-11 but insert on ribs 2-12.
They are responsible for elevation of the ribs and bending them open (expanding transverse dimensions of the thoracic cavity).
A
External Intercostals (elevate ribs; enlarge rib cage) and Intercatilaginous portion of Internal Intercostals (elevate ribs)
18
Q
The diaphragm is divided intoperipheral andcentral attachments.
There are 3 Peripheral Attachments:
- Lumbar vertebrae and arcuate ligaments.
- ______ of ribs 7-12.
- _____ of the sternum.
A
- Costal cartilages of ribs 7-12
3. Xiphoid process
19
Q
The Central attachments of the diaphragm are the R and L crura which arise from L1-L3 and their IVD’s.
The muscle fibers of the diaphragm combine to form a ______
A
central tendon
20
Q
Accessory muscles involved in inhalation include the Scalenes and Sternocleidomastoid.
The Scalenes originate from C2-7 and insert on ribs ______.
The SCM originates on the manubrium and medial clavicle. It inserts onto the mastoid process and aids in ____
A
Scalenes: Ribs 1 and 2
SCM:
–insert: mastoid process
–lifts/elevates sternum
in addition to head sidebending towards/rotating away
21
Q
Accessory muscles involved in inhalation include the Pectoralis Minor and Serratus Anterior
- The Pec minor originates on ribs ______ and inserts on the coracoid process. It acts to stabilize the scapula and rases ribs in inspiration.
- The serratus anterior originates on ribs ____. It inserts on the ant. medial border of the scapula. It functions to pull the scapula forward as well as lift ribs (when the shoulder girdle is fixed)
A
Pec minor: ribs 3-5
- -stabilize scapula
- -raises ribs in inspiration
Serratus anterior: ribs 1-9
- -pull scapula forward
- -lift ribs (girdle is fixed)
22
Q
This is an accessory muscle to inhalation.
It originates at T7-L5, the Iliac crest and on Ribs 8-12.
It inserts on the floor of bicipital groove of humerus after spiraling around teres major
It functions in: extension, adduction and medial rotation of the arm, but its Costal attachment helps with deep inspiration.
A
Latissimus dorsi
23
Q
True/False: Exhalation is usually quiet and passive. However, in active (forced exhalation) it involves the extrachondral internal intercostals and abdominal muscles.
A
True
24
Q
During inhalation, the diameter increases in both the AP and transverse plane.
Anteriorly, there is upward motion of the _____ and _____. Posteriorly, there is caudal motion of the _____, and Laterally, there is upward and lateral motion of the ribs.
A
- Anterior
- -upward motion of ribs and sternum - POsterior
- -caudal motion of ribs - Laterally:
- -upward and lateral rib motion
- extension of spine
- external rotation of extremities
25
During exhalation, there is decreased diameter of the AP and transverse plane.
Anteriorly, there is _____ motion of the sternum and ribs. Posteriorly, there is ____ motion of the ribs. Laterally, there is downard and medial motion of the ribs.
1. Anterior
- -downward motion
2. Posterior
- -upward motion
3. Lateral
- -downward and medial
* Flexion of spine
* Internal rotation of extremities
26
Pump Motion ribs are associated with _____ motion. They increase the A-P diameter and are dominant in the ____ ribs.
Anterior motion
* dominant in upper ribs 1-5
* palpated on ant. chest wall
27
Bucket motion ribs are associated with ____ motion. They increase transverse dimension and are dominant in _____ ribs.
Lateral motion
* lower ribs 6-10
* palpate on lateral chest wall
28
Ribs 11-12 are referred to as Caliper ribs. They have unique motion along a horizontal plane.
They are involved in _____ articulation only because they are single faceted with no tubercle, angle or groove
Costovertebral articulation only
29
When diagnosis Ribs, take into account
a. sources of chest pain (cardiac, GI)
b. review musculoskeletal syndromes
c. check vitals, history, physical
d. fix thoracics first
Answer: all of the above
30
Musculoskeletal chest pain is insidious, persistent and exacerbated by breathing and motion. It is NOT associated with systemic signs.
True/False: Attempting to reproduce the patients pain will be informative regarding diagnosis.
True
| **Table Slide 36
Costal Cage Mechanics
31
Screening ribs steps:
1. General inhalation/exhalation motion
2. Check for tissue texture changes and tenderness
3. Assess statically and dynamically
4. Compare sides and look for asymmetry
- -----Anterior, superior, inferior, lateral
5. Segmentally test each rib while they take deep breaths – Try to assess which ribs are not moving fully into inhalation or exhalation.
Finger placement:
1. Rib 1
- --Fingers placed supraclavicular fossa
- --May need to move traps out of way
2. Ribs 2-5 - pump
- --Mid clavicular line
- --Along superior anterior aspect of rib
3. Ribs 6-10 - bucket
- --Mid axillary line
- --Along lateral aspect of rib.
4. Ribs 11-12 – caliper
- --Patient prone
32
An_______ rib is caught in inhaled position (stuck up). It looks higher (anterior/lateral/cephalad) than the other side.
As the patient inhales, the rib may move superiorly, laterally or anteriorly, but as they exhale the rib will not go down as well.
Inhaled rib
* may be predominately pump rib (anterior) or bucket rib
* not spring as easily
Name: Side that is inhaled and Rib #'s
(e.g. Ribs 1-4 inhaled on Left)
33
The key rib for Inhalation dysfunctions is the ______ rib. The interspace below will be wider. The key rib must be treated first
*common to find group inhalation on the left
Bottom RIb
*BITE
(Bottom, Inhaled)
DX: Trace ribs down until find rib w/ normal exhalation. The rib just above that is the key rib
34
An ______ rib is caught in exhaled position (down; caudad, medial and posterior).
The rib will enter easily into exhalation, but will not move into inhalation.
Exhaled rib
* spring easily
* pump or bucket
Name: Side that cannot come into full inhalation; Exhaled dysfunction (e.g. Ribs 3-6 exhaled on the right)
35
Indications for Cervical Manipulation include:
```
a. pain & stiffness in neck
torticollis
b. tension headache
c. pseudomigraine
d. dizziness/vertigo symptoms
e. symptoms in upper extremity
flexion/extension injury (whiplash)
f. Viscerosomatic reflexes from chronic head, neck, nose, sinuses or throat inflammation
```
Answer: All of the above
36
Typical Cervical Vertebrae are C3-C7.
Which of the following are features of typical cervical vertebrae?
a. No typical transverse processes (ant/post. tubercles)
b. transverse foramen for vertebral artery (C2-C6)
c. grooving of transverse process for cervical nerves
Answer: all of the above
* articular pillars b/t superior and inferior articular facets
* bifid spinous process
37
C2-7 articulations include:
a. synovial joints
b. articular pillars
c. superior articular facets that face up and back
d. 45 degree orientation (to transverse plane)
e. lack transverse processes
Answer: A-D
38
______ joints are found in the cervical region (posterior/lateral) corner of the vertebral body.
They act as guide rails for flexion-extension, and limit lateral translatory motion.
Uncovertebral joints (Luschka)
- Uncal processes elevate in childhood
- Joint develops secondarily (age 8-10)
- Initially functional advantage preventing disk herniation
- Later may be site for degeneration
39
Typical Cervical Mechanics Follow Type _____ Mechanics: non-neutral.
*Use lateral translation
Type II
* flexion/extension
* sidebending and rotation = same side
C2-C4: rotation
C5-C7: sidebending
40
Flexed Cervical Dysfunction:
Name the dysfunction for what it WILL do.
If it cannot extend or translate to the right, but CAN flex and translate to the left, then what is the dysfunction?
FSrRr
Tx: What it won't do (Sidebend Left; Rotate Left)
41
For cervicals (C2-7), translation to the Left induces _____ sidebending. Translation to the right induces _____ sidebending.
Left translation: Right sidebending
| Right translation: Left sidebending
42
Desribe screening of Cervical Spine
1. Screen for restriction (via translation) in neutral at each segment by palpating the articular pillars
2. Semi flex the patient's neck and screen
3. Repeat with the neck extended
4. Give positional diagnosis
Ex: If dec. Left translation in Flexion, then it is Extended, SLRL (because it can translate to the right; Extension)
43
Describe Tx of the Cervicals
1. Flex or Extend the head until the motion is felt at the segment
2. Sidebend and rotate in the same direction to the barrier (patient pushes against hand)
3. Repeat 3-5 times
4. Re-check
*Do not lift patients head off the table (let chin drop to chest)
44
An extended dysfunction of the Cervicals means that the patient does not like to go into ______.
Treatment will involve what it won't do.
Flexion
*prefers to stay in extension
45
When screening cervicals, How would you diagnose and treat a patient who fails to go into flexion and has difficulty translating to the right?
DX: ESRr
*they translate to the Left with ease, so SRr
Tx: FSRl
46
Atypical cervicals include
1. C1 (atlas) - ring like, kidney shaped bone lacking a spinous process or body
2. C2 (axis) - odontoid process (dens) that projects superiorly from the body.
The Atlanto-axial (AA) joint refers to 4 articulations between C1 and C2. What are these articulations?
- 2 lateral AA joints
- 2 median AA joints
- Inferior atlas facets are convex
- superior articular facets of axis are slightly convex
47
AA motion is primarily ______. Rotation and sidebending occur in the ______ directions.
50-60% of neck rotation occurs at the AA. Atlas rotates on the axis with pivot around the dens.
Primarily Rotation
Rotation and Sidebending occur in Opposite directions
NOTE: movement other than rotation is limited by anteriorly located odontoid process (dens) of axis
48
Describe Evaluation of the AA joint
1. Flex cervical spine to 45 degrees
2. Rotate head to left and right
3. Assess Range of Motion and freedom or resistance
(compare degree of restriction)
4. Name by the direction it WILL go
(e. g. If it WILL rotate right, but NOTE Left: AA Rotated Right)
49
Describe Treatment of AA joint
1. Restrict motion of C2-7 by flexing patient's neck at least 45 degrees
2. Rotate patient's head to the barrier
3. Perform ME by having the patient rotate their head back to the midline (3-5 times)
50
Atlanto-axial subluxation: Caution must be taken for HVLA with patient suffering from what ailments?
Rheumatoid arthritis or Down's syndrome
*weakness of AA ligaments
51
The Occipito-atlantal joint (OA) joint articulates between the superior articular facets of the atlas and the 2 occipital condyles. THe joint is spherical, gliding on articular surfaces of the atlas.
Describe movment of the condyles to the facets
condyles: convex, diverge posterior
| articular facets: concave
52
Primary motion of the OA joint is ______. It involves occipital motion on the atlas that is limited by muscular and ligamentous attachments.
Small amounts of sidebending and rotation may occur. This happens in ____ directions.
Primary motion: Nodding (flexion/extension)
Limited motion: 20-25 degrees (flexion/extension); 8 degrees lateral bending/side bending
Sidebending and rotation: OPPOSITE directions (Type I)
53
Evaluation of the OA involves palpation of cervical tissue over the OA in the suboccipital region (looking for TART).
Describe OA evaluation.
Remember: TYPE I MECHANICS (sidebending and rotation are OPPOSITE)
1. Lie patient supine, physician forearms resting on table
2. Screen for restriction w/ OA in neutral. Cradle head in hands (palms at base of occiput)
3. Translate the OA in neutral
4. Semi-flex patient's neck and test w/ translation
5. Repeat w/ extension
6. Give positional diagnosis
(e. g. If OA does NOT translate Left, and is worse in Flexion -- It translates Right and is thus: ESLRr)
NOTE: slide fingers downward from the Inion to suboccipital region, then laterally to sulcus
54
If the OA does NOT translate Left and is WORSE in FLEXION, what is the DX?
Extended, Sidebent L, Rotate R
*TYPE I
TX: Flexed, Sidebent R, Rotate L
55
Describe Tx of the OA joint if the Patient is Dx: OA FSrRl
Tx: ESlRr
1. Position the patients head at the restrictive barrier
(localize motion to the segment being treated)
2. Apply a counterforce with opposite hand to create gentle isometric contraction
3. After 1-2 seconds relaxation, take up the slack in all 3 directions
4. Perform muscle energy 3-5 times
5. Re-check
56
OA motion:
1. Flexion of the occiput on the atlas results in _____ glide of occiput on atlantal facets.
2. Extension of the occiput on the atlas results in _____ glide of the occiput on the atlantal facets
3. Rotation/Sidebending results in the Left occipital condyle sliding _____ and the right occipital condyle sliding ____
1. anterior glide of occiput on atlantal facets
2. posterior glide of occiput on atlantal facets
3. Left occipital condyle slide uphill (superior/posteriorly)
4. Right occipital condyle slides downhill (inferiorly/anteriorly)
57
The complex of the OA and AA is known as the suboccipital articulation.
THe range of motion makes it function as a universal ____ joint. It is considered the final compensator of the spine by which the body adjusts to dysfunctions below.
Swivel joint
*NOTE: articulation of C3-C3 common area of chronic dysfunction due to tremendous stress being below final compensator and above remainder of spine
58
________ test involves compression of the head in neutral, extension w/ sidebending towards, and extension with sidebending away.
Positive test reproduced patients symptoms (pain in neck and arm along the nerve root)
Spurling's test
*indicateds nerve root compression (cervical radiculopathy)
59
True/False: The Cervical Spine is the Most mobile region of the Spine. Combined ROM is:
Flexion/Extension: 145 degrees
Axial rotation: 180
Lateral flexion: 90
It has lower intrinsic stability and is vulnerable to excessive dynamic loading (injuries). Restriction often results in compensatory mobility elsewhere.
True
NOTE: vertebral artery especially vulnerable w/ neck rotation and extension
60
“Impairment of a central nerve root, usually causing radiating pain, numbness, tingling, or muscle weakness that corresponds with a specific nerve root”
Includes:
1. Lumbar herniated discs
2. Lumbar spinal stenosis
3. Lumbar neuroforaminal impingement
Lumbar radiculopathy
61
“Pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle.”
Sciatica
62
Common postural Problems: True/False
1. Anterior pelvic tilt is associated with a number of conditions including: pelvic cross syndrome (tight hip flexors), weak hip extensors and hamstrings and sacroiliac disfunction.
2. Exaggerated posterior pelvic tilt w/ buttocks tucked in is associated w/ spondylolisthesis.
True
63
_______ is a lumbar radiculopathy characterized by weakening of the fibrous outer wall of the disc. The nucleus pulposes pushes outward, but does NOT rupture through.
It generally does not protrude far enough to compress on a nerve, but can progress to a herniated disc.
Bulging disc
> 90 deg of the total circumfrence of the disc and does not extend beyond the boundaries of the annulus fibrosus
64
A herniated disc is a lumbar radiculopathy characterized by rupture of disc material beyond the annulus fibrosus.
It can be subdivided into two types:
1. ________: rupture of disc material in which the base is broader than the dome. Generally does NOT extend above or below disc spaces.
2. _______: rupture of a disc where the dome is wider than the base "dumbell". This can extend above or below the disc space.
* nerve root compression can occur
1. Protrusion
2. Extrusion
*NOTE: can produce a "free fragment" that can migrate out of the disc space
65
_______ describes herniation of the nucleus pulposes through cartilaginous and boney end plant on the body of adjacent vertebrae
Shmorl's nodes
*lumbar
66
________ is a that can refer to one or more of the following:
1. Narrowing of intraspinal (central) canal
2. Narrowing of lateral recess
3. Narrowing of the neural foramen
It can lead to lumbar radiculopathy (causing mechanical compression, inflammation, or ishemia of the nerve roots)
Lumbar spinal stenosis
* can be congenital or acquired
* usually age 60 or older
67
The following clinical presentation best describes what disorder?
1. Neurogenic (or psuedo) claudication
2. Symptoms (usually pain) exacerbated with walking, standing and/or maintaining certain postures, and relieved by sitting or lying
3. Symptomatic when active
4. Look for a patient with discomfort, sensory loss, and/or weakness in the legs that reflects the involvement of the spine nerve roots (see previous slides on this)
Lumbar spinal stenosis
Neurogenic (pseudo) claudication (Hallmark of lumbar spinal stenosis)
68
Arthritis of the spine. It is seen radiographically as disc space narrowing and arthritic changes of the facet joint
Spondylosis
69
“A fracture of the pars interarticularis where the vertebral body and the posterior elements protecting the nerves are joined.”
This fracture looks like a "scotty dog" with a broken neck.
Spondylolysis
- unilateral or bilateral defect
- “fatigue fracture” or acute overload on the joint and vertebrae
*athletes/overuse injuries
****Almost always at the 5th lumbar vertebrae (85 – 95% of the time)
70
There are different types of spondylolisthesis:
1. ______: anterior displacement of a vertebral body relative to the one below.
2. _____: posterior displacement of the vertebral body relative to the one below
3. ______: anteriorlisthesis secondary to spondylolysis
1. Anteriolisthesis
2. Retrolisthesis
3. Spondylolisthesis
71
Dysplastic type of spondylolisthesis (1 - 25% anterior slippage)
It is often due to congenital rounding of S1 vertebrae.
The more rounded, the greater the risk of slippage.
Type I spondylolisthesis
72
Isthmic type of spondylolisthesis (26 - 50% anterior slippage) . This is the MOST COMMON TYPE seen in athletes .
1. Type II A: usually from that a stress fracture causing bilateral spondylolysis and with the anterior slippage.
2. Type II B: repetitive fracture – healing causes the pars interarticularis to be elongated and then pretty much the same as above for II A
Rarely, rarely acute trauma can lead to this too
Type II spondylolisthesis
Type IIA: stress fracture; bilateral sponyloslysis w/ ant. slip
Type IIB: repetitive fracture; elongated pars articularis; ant. slip
73
Degenerative type of spondylolisthesis (51 – 75% anterior slippage).
It is NOT necessarily due to a fracture or insufficiency of the pars interarticularis. It is typically a segmental instability (usually L4 -5) that leads to such a fracture and significant anterior slippage
Classic patient for this is a female > 40 yo with super bad arthritis
Type III spondylolisthesis
*segmental instability leading to fracture and ant. slip
NOTE: Arthritis will destroy the contour of the facet joint leading to poor motion of the spine and chronic breakdown of the ligamentum flavum
*surgery sometimes
74
Traumatic type of Spondylolisthesis (76 – 100% slippage).
This is normally caused by high impact trauma, and leads to injury and fracture to way more than just the pars interarticularis.
Type IV spondylolisthesis
Lots of bony and ligamentous structures injured with this
This one is almost always surgical
75
Grading of spondylolisthesis is based on the Myerding classification. This categorizes spondylolisthesis lesions according to what percentage of the cephalad vertebral body extends beyond the anterior border of the caudal vertebra.
Explain grades 1-4.
Grade I: 1-25% slip
Grade II: 26-50% slip
Grade III: 51-75% slip
Grade IV: 76-100% slip
76
This is due to autoimmunity and the inflammatory process (HLA-B27 problem).
It is commonly diagnosed in men under 40 yo who present with back pain, morning stiffness that improves with exercise and pain at night.
These patients have terrible spinal mobility = Bamboo spine (vertebral fusion)
Ankylosing spondylitis
Problems may occur w/ the skeletal system, or others (Ex. Uveitis, inflammatory bowel problems, cardiovascular and pulmonary issues) and the long term issues associated with these
77
________ occurs from massive nerve compression due to herniation of multiple (Sometimes just one) intervertebral discs and spinal cord compression
Clinical presentation includes:
1. Pain 1st, then motor and sensory problems
“Saddle anesthesia”
2. Bilateral leg weakness in multiple root distributions (L3 – S1 typically)
3. Bowel, bladder, and/or erectile dysfunction (S2 – 4 typically)
Cauda Equina Syndrome
*NEUROLOGICAL EMERGENCY
The earlier this is diagnosed and treated, the better the long term outcome from this
78
1. _______ curve refers to the outward curve of the thoracic spine (at ribs)
2. _____ curve refers to the inward curve of the lumbar spine (above butt)
3. _____ curve refers to sideways curve of the spine and is always abnormal
1. Kyphosis (excessive: sherumann's)
2. Lordosis (excessive: Swayback)
3. Scoliosis
79
Types of Neural tube defects:
1. _______: completely open brain and spinal cord
2. ______: Open brain, lack of skull vault
3. _____: herniation of mennges and brain
4. _____: occipital skull and spine defects w/ extreme retroflexion of head
1. cranioraschischis
2. anencephaly
3. encepalocele
4. iniencephaly
80
Types of neural tube defects:
1. _____: closed asymptomatic NTD in which some of the vertebrae are not completely closed
2. ____: deficiency of at least 2 vertebral arches; covered with lipoma
3. _____: Protrusion of meninges (filled w/ CSF) through a defect in the skull of spine
4. _____: open spinal cord w/ meningeal cyst
1. Spina bifida occulta
2. Closed spinal dysraphism
3. Meningocele
4. Myelomeningocele
81
______ is a birth defect in which a baby's spine doesn't form normally. Babies with this defect have an opening in their back. The spinal cord and covering around the spinal cord stick out of the opening, forming a sac.
*open , myelomeningocele
Spina bifida
82
True/False: Sacral dimples are th emost common cutaneous sign of spinal dysraphism (incomplete closure of the neural tube during early embryogenesis). Atypical normally located above the gluteal cleft.
True
NOTE: hemangiomas are also signs of dysraphism
83
Functions of the Lymph system include which of the following?
a. Removes proteins, fluids, and particulates from extracellular spaces
b. Removes inflammatory mediators and fluid from areas of inflammation in timely manner
c. Conserves plasma protein (maintains osmotic balance)
10% of intravascular protein and fluid volume “leaks” into interstitium and then into lymphatics; lymphatic vessels return it to venous circulation
d. Defense against disease—recirculation of lymphocytes estimated 40X/day for “immune surveillance”
Anwer: all of the above
84
Lymphatic circulation occurs via lymph channels. What are the contents of these channels?
a. Capillaries
b. Pre-collector vessels (superficial & deep)
c. Collecting vessels
d. Lymph nodes and spleen
e. Right lymphatic duct
f. Thoracic duct into venous circulation
NOTE: No tight junctions between cells, but endothelial cells overlap so substances can't go backwards
Answer: all of the above
The lymphatic-blood-interstitium cycle can occur up to 40x/day!
NOTE: lymphatic fluid forced out of arterial part of capillary bed when net hydrostatic pressure > than osmotic pressure
--fluid enters venous side (reabsorption)
85
True/False: Valves of lymphatic vessels ensure unidirectional flow
True
*lymphangions (lymph hearts) b/t valves cyclically contract to pump lymph
86
True/False: Lymph nodes strain out particulates and pathogens and undego Ag processing. Macrophages and lymphocytes are involved.
All lymph passes thorugh at least one node before joining circulation.
True
*gets concentrated
87
Deep diaphragmatic breathing facilitates movement of the lymph through the bloodstream. Lymphatics in the diaphragm form a specialized system that drain fluid from the peritoneal cavity and returns it to the vascular system.
What does it pass through?
parasternal lymph
*thoracic duct and cisternal chyli
**FINISH
88
THe _____ is drained by the right lymphatic duct, while the rest is drained by the thoracic duct.
RUQ (right lymphatic duct)
| Rest (thoracic duct)
89
Superficial lymph channels pierce the _____ tissue to enter deep channels. Lymph nodes present along this course.
Pierce the myofascial tissue
90
Deep lymph drainage occurs when lymph is channeled to reach the junction of what veins?
Jugular and Subclavian
*fascial planes can restrict flow
91
Lymph movement influences:
a. Fascia
b. Interstitial fluid volume
Interstitial pressure
c. External compression
d. Organ/tissue motion
e. Intrathoracic/intra-abdominal pressure
All of the above
a. Fascia—lymph vessels are thin walled so external compression from fascia can impact lymphatic movement
b. Interstitial fluid volume
Interstitial pressure
c. External compression—peripheral muscle contraction increases lymphatic fluid 15-20x
d. Organ/tissue motion—peristalsis, arterial pulses, organ motion
e. Intrathoracic/intra-abdominal pressure
92
This disorder may be primary or secondary:
1. Primary: occurs from congenital malformations of the lymphatic system
2. Secondary: from damage to lymphatic system with decreased reabsorption +/- lymphatic fluid transport (ex: from lymph node resection in cancer surgery or fluid overload in CHF)
It results in Pedal edema. Edema is pitting in early stages (tissue fails to rebound), then can become non-pitting as more fibrosis develops
Lymphedema
*Secondary: lymphatic vessels compressed
93
This disorder occurs either from hereditary disorder of lipid metabolism (abnormal deposits of adipose cells) or as a secondary disorder that may develop from lymphedema (compression of lymphatic vessels from superficial fascia)
No pedal edema is seen. Edema is non-pitting
Allodynia (hypersensitivity to light touch)
Lipidema
*columnar legs
94
Structural anatomic consideration of the thoracic inlet associated with lymph:
1. Clavicle (SC and AC)
2. Manubrium and Sternum
3. Rib 1
4. T1-2
5. Myofascial structures of thoracic inlet (Sibson's fascia)
NO idea what I need to know for this
95
Infections or increased fluids in tissues constitute situations where lymphatic techniques may be helpful.
How would lymphatic techniques help in these cases?
INfections: Improve circulation and presentation of Ag - faster recovery
Edema and INflammation: improved removal of proteins, cytokines, fluid
Post-Injury, Post-op: improved circulation
96
List absolute contraindications to lymphatic techniques
aneuresis (end stage renal disease), necrotizing fasciitis, and lack of consent
97
List relative contraindications to lymphatic techniques
- CHF in patients who can't tolerate inc. preload
- severe, unstable COPD
- -acute unstable asthma
- -unstable cardiac conditions
- -chronic infection at risk of reactivation
- -venous Thromboembolisms
- -fractures
- -cancer
98
How do you get rid of edema/impediment to flow?
1. is it fascial, muscular or bony?
- -overdistension of lymph vessels, but dec. lymphangion contraction?
2. Maximize motion of diaphragm (stagnation problem)
(thoracic inlet diaphragm, pelvic diaphragm)
3. Increase pressure differentials (stagnation problem)
- -get lymph moving into capillaries
use: thoracic pump, pedal pump
- -pedal pump at 2x HR inc. shear stress; inc. NO
4. Mobilize target tissue (drainage stagnation; volume problems)
- -effleurage, galbreath, petrissage
99
List the order in which you treat lymphatics
Central to Peripheral:
- thoracic inlet
- ribs
- abdominal diaphragm
- pelvic d...
- muscles and fascia constricting flow in extremities
100
Example of treatment structure for sinus congestion:
1. thoracic inlet
2. cervical soft tissue
3. OA decompression
4. Sinus tapotement, efluerage
101
Describe the Technique for Thoracic Inlet Release (Lymphatics)
1. Patient may be seated or Supine
2. Gently place honds on patient's shoulders close to the cervicothoracic juntion (thumbs behind neck, fingers on sternum)
3. Apply enough pressure to engage the skin and underlying fascia
a. inferiorly and superiorly
b. laterally and medially
c. clockwise and counterclockwise
4. Stack the three restriction motions into the barrier with the most bind and hold for 30-60 sec until feel relese
5. Re-check
*page 95 manual
102
Describe Rib Walking (Lymphatics)
page 95 manual
*Practice this technique
1. Stand at head of table w/ patient supine
2. Make sure the patient is relaxed and breathing normally
3. Place hands laterally on their chest so that heels are parallel to each other
4. Apply firm, direct pressure posteriorly and caudally to groups 2-4 ribs
5. "Walk" and and down the chest 2-4 times alternating pressure
103
Rib raising is useful to increase the range of motion of the costal cage and increase lymphatic drainage.
List the steps in rib raising/Practice this technique
*page 96 manual
1. patient may be supine or sitting up
2. Place finger pads medial to rib angle
3. Apply rhythmic upward motion to rib age
***LOOK AT MANUAL
104
Mandibular drainiage is used for lymphatic congestion or infection of the ears, nose or throat. It should not be used w/ people who suffer from TMJ.
List the steps in Mandibular drainage
Page. 97 manual **PRACTICE
1. place finger pads below ear, and along body of mandible
2. jaw should be relaxed and slightly open
3. stabilize forehead (turn head towards you)
4. apply pressure
105
The thoracic pump may be used in cases of lymphatic congestion, fever or infection.
List the steps in the THoracic Pump
*Page 98 Manual/Practice
Practice this
106
Practice the Pedal Pump (Page 99 Manual)
used for lymphatic congestion
107
What are the components in obtaining a good patient history?
- Why (Why are you Here?)
- What (what is pain like?
- Where? (where is it? localized or referred)
- When (did it begin; duration)
- Do any motions make pain better or worse?
108
Types of Pain
1. Cramping, dull, ache = ____
2. sharp shooting = _____
3. deep, nagging, dull = ____
4. sharp, severe = ____
5. throbbing, diffuse = ____
1. muscle
2. nerve root
3. bone
4. fracture
5. vascular/visceral
109
What specifics do you need to know for a musculoskeletal complaint?
a. loss of motion (stiffness)
b. swelling
c. localized warmth
d. redness
e. abnormal sensations (crepitance, popping, instability)
Answer: all of the above
110
Definitions:
1. ________: joint pain
2. ________: inflammation of a joint
3. _______: inflammation involving the complex sleeve-like ligamentous structure surrounding a joint (made up of ligaments, tendon expansions, and tendon attachments)
4. ______: palpable or audible crunching or grinding noise made when moving a joint or tendon
1. Arthralgia
2. Arthritis
3. Capsulitis
4. Crepitus
111
Definitions:
1. _______: inflammation of a tendon
2. _______: inflammation of a tendon sheath
3. _______: inflammation of a bursa, which is a potential sac cushioning a bony or tendonous prominence and the skin
4. _______: inflammation of an epicondyle
1. Tendonitis
2. Tenosynovitis
3. Bursitis
4. Epicondylitis
112
Definitions:
1. ______: ligamentous injury with overstretching or tearing
2. _____: injury or overuse of individual muscles or muscle groups
3. _____: pathological increase in the mobility of a joint
4. _______: normal variant of joint laxity
1. Sprain
2. Strain
3. Instability
4. Hypermobility
113
Definitions:
1. _______: congenital or traumatic joint disruption (hip, shoulder, radial head, patella)
2. _______: partial dislocation of a joint, partial loss of joint surface contact
1. Dislocation
| 2. Subluxation
114
Principles of a Physical Exam (of the Shoulder)
1. Check vitals
2. Evaluate ____ side first.
3. Active movements first
4. Painful movements last
- -warn of exacerbation of symptoms
5. Isometric movements = in neutral
6. Sports medicine axiom (check joints above and below sore joint
* common to have
2. Evaluate Normal side first
6. Sports medicine axiom:
- -common to have referred pain
- -slipped capital femoral epiphysis (notorious for referring pain to knee when problem is in Hip)
115
True/False: When treating shoulder problems, make sure to first rule out cervical involvement
True
116
List the shouldert tests based on their descriptions:
1. Gross motion, Apleys
2. Glenohumeral instability
3. Glenohumeral dislocation/subluxation
4. AC arthritis, shoulder impingement
5. Rotator cuff tear
6. bicipital tendonitis
7. bicipital tendon suluxation
8. long thoracic nerve injury
1. General motion test
2. Apprehension test
3. Sulcus sign
4. Hawkins test
5. Drop arm and Empty can test
6. Speeds test
7. Yergason
8. Scapular winging sign
117
Normal range of motion of the knee includes flexion and extension.
Special maneuvers can be performed to test for injuries or tears to the knee. These include:
1. McMurray's
2. Varus stress
3. Valgus stress
4. Lachman's/Anterior drawer testing
5. Posterior drawer testing
6. Patella apprehension
Explain these
1. McMurray’s test: meniscal tear
2. Varus stress: LCL instability
3. Valgus stress: MCL instability
4. Lachman’s/Anterior drawer testing: ACL tears
5. Posterior drawer: PCL tears
6. Patella apprehension: patellar instability
118
The most common ankle sprains involve in version of the foot with respect to the ankle.
Key ligaments involved are the anterior talofibular (most common) and calcaneoufibular.
How are sprains graded?
Sprains are graded I, II, and III
I: slight stretching of ligaments
II: partial tearing of ligaments
III: complete tear of ligaments
119
Ankle Motions:
1. Plantarflexion
2. Dorsiflexion
3. Internal rotation
4. External rotation (foot is parallel to ground)
5. Inversion (roughly equivalent to supination)
6. Eversion (roughly equivalent to pronation)
What are special maneuvers associated with the ankle?
1. Anterior drawer sign
(diruption of ligaments)
2. Talar tilt test
(disruption of ligaments)
3. Thompson test
(Achilles tendon rupture)
120
When can you use OMM for Joint problems?
- soft tissue sprain or minor injury
| * Do not use if fracture, infection or cancer
121
The shoulder is part of the appendicular skeleton.
The appendicular skeleton contains 4 articular surfaces. List them
1. Sternoclavicular
2. Acromioclavicular
3. Glenohumeral
4. Scapulothoracic
*Glenohumeral joint = principal articulation
NOTE: subacromial space (impingement and bursitis)
122
True/False: The shoulder girdle is composed of 3 bones:
1. Clavicle
2. Scapula
3. Proximal humerus
True
123
Articular cartilage covers the head of the humerus and face of the glenoid fossa.
1. The ______ joint is loosely constrained within a thin capsule bounded by surrounding muscles and ligaments.
2. The______, a ring of fibrous tissue, surrounds the glenoid fossa assisting in stabilization.
1. Glenohumeral joint
2. Labrum
NOTE: The shoulder's great mobility is due to the shallow depth of the glenoid and the limited contact between the glenoid and the humeral head.
124
Motion of shoulder is:
- 2/3 glenohumeral
- 1/3 scapulothoracic
```
180˚ flexion
60 ˚ extension,
180 ˚ abduction
50 ˚ adduction
90 ˚ internal and external rotation
```
What is the most common somatic dysfunction?
Most common somatic dysfunction of the shoulder: limited internal and external rotation
SIDE NOTE: remember to consider cervicals, ribs, and thoracic spine when dealing with shoulder pain
125
Which of the following is a muscle of the shoulder?
a. Trapezius
b. Deltoid
c. Infraspinatus and Suprapinatus
d. Teres Minor and Teres major
Answer: B-D
also: subscapularis, Triceps brachii (long head) and Omohyoid
126
Muscles of the Rotator Cuff are:
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis
All are innervated by C5-C6. Describe the function of the Supraspinatus.
- -abduction (w/ deltoid)
- -stabilize glenohumeral
- -supraspinous fossa to greater tubercle of humerus
*most commonly torn
127
Muscles of the Rotator Cuff are:
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis
All are innervated by C5-C6.
The infraspinatus is responsible for what movement?
External rotation
(with teres minor)
---infraspinatus process to greater tubercle of humerus
128
Muscles of the Rotator Cuff are:
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis
All are innervated by C5-C6.
Teres Minor muscle works with the Infraspinatus muscle to perform what action?
External rotation
-lat. border of scapula to greater tubercle of humerus
129
Muscles of the Rotator Cuff are:
1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. Subscapularis
(TISS)
All are innervated by C5-C6.
The subscapularis muscle is responsible for what motion?
Internal rotation and adduction
*subscapular fossa to lesser tubercle of humerus and GH capsule
130
Additional Muscles that aid in movement of the upper extremity are the Teres Major and the Latissimus Dorsi.
The Teres major muscle originates from the inferior angle of the scapula. It inserts onto the medial lip of the intertubercular sulcus of the humerus. What is its action?
Extend, internally rotate, adduct
131
Additional Muscles that aid in movement of the upper extremity are the Teres Major and the Latissimus Dorsi.
THe Lats originate on the spinous processes of the lower thoracic vertebrae and ribs, crest of ilium, inferior angle of scapula. They insert into the intertubercular groove of the humerus. What is their action?
Internal rotation and adduction of humerus
*intertubercular groove
132
Additional muscles that aid in movement of the arm are the pectoralis minor and Serratus anterior.
The Pec minor originates on ribs 3-5 and inserts into the coracoid process.
What is its function?
stabilizes scapula and raises ribs (inspiration)
133
Additional muscles that aid in movement of the arm are the pectoralis minor and Serratus anterior.
The serratus anterior originates on ribs 1-9. It inserts onto the medial border of the scapula.
What is the function of the Serratus anterior?
- -pull scapular forward
- -lift ribs (when shoulder girdle is fixed)
Innervation: LOng thoracic nerve (C5-C7)
If damaged: Winged scapula
134
True/False: The upper limb is innervated by ventral rami originating from spinal nerve levels C5–T1. These rami form a network of nerves referred to as the brachial plexus, which extends from the neck into the axilla providing motor and sensory innervation to the upper limb
True
NOTE: motor innervation: Musculocutaneous, Ulnar, Median and Radial nerves
135
Sensory innervation of the upper limb is characterized in two ways:
1. Dermatomes
2. Cutaneous fields
A _______ is a region of skin that is innervated by one spinal nerve level.
In contrast, a _______ provides sensory innervation from a region of skin and may consist of sensory neurons from more than one spinal nerve level.
1. Dermatome
2. Cutaneous field/nerve
The brachial plexus provides the pathways for sensory neurons from the skin of the upper limb to the spinal cord.
136
Red Flags during Screening of Upper extremity
1. Persistent nighttime pain - cancer
2. Weight loss, fatigue, night sweats, fevers - cancer
3. Discolored painful distal extremities – vascular compromise
4. Associated cardiovascular symptoms like shortness of breath, chest heaviness, lightheadedness - MI
5. Problems with coordination/balance – stroke
6. Systemic symptoms such as fever, redness, swelling - infection
6. e.g. Septic joint
- -red, hot swollen and painful
* ROM severely limited by pain
* acute infection
* surgical emergency
137
Review Upper Extremity Tests and Positive Signs
*Slide 29-30 Upper Ex. 1
Review it
138
Intrinsic Pathologies of the Upper Extremity
1. Glenohumeral
- osteoarthritis
- impingement
- rotator cuff tear
- labral tear
- dislocation/subluxation
- adhesive capsulitis
2. Extraglenohumeral
List the Extraglenohumeral
Biceps tendonitis, AC joint pathology, Scapulothoracic bursitis
139
An uncommon cause of shoulder complaint. It occurs from wear and tear leading to degenerative changes as well as joint space narrowing.
* increasing pain and stiffness
* remote history of trauma
Glenohumeral osteoarthritis
* females
* crepitus and loss of ROM
* Treat w/ OMM, PT, NSAID, injection
140
A common syndrome of the upper extremity involving impingement and compression of structures around the glenohumeral joint.
Compression of tendons and/or bursa may cause pain, and friction rub may occur. This pain is most often worse at night, but is persistent and affects daily activity.
Impingement Syndrome
*repeated activity can increase risk
(painting, lifting, swimming, tennis; bone and joint abnormalities)
*can lead to tendinitis, calcific tendinitis, labral tears, etc.
NOTE: patient has normal strength
141
This test may be performed to confirm impingement syndrome of the upper extremity.
The patient actively elevates the arm in the scapular plane. It is a positive test when pain occurs at 60-120 degrees abduction.
Subacromial is diminished, pinching structures under the acromion and coracoacromial ligament.
Painful arc
*passive movement will appear painfrul when downward force applied at acromion
142
What is the 1st test to order for impingement syndrome?
X-ray
*Tx: NSAIDS, PT, etc.
Athletes may return to play once pain has resolved enough for normal ROM and near normal strength
143
This test may be performed to confirm impingement syndrome of the upper extremity.
While elbow is extended, internally rotate arm so that thumb is facing posterior
Flex shoulder 180 degrees
If positive = pain
Neers
144
This test may be performed to confirm impingement syndrome of the upper extremity.
1. Flex shoulder to 90 degrees and flex elbow.
2. Internally rotate arm 90 degrees
+ test = pain especially towards end of internal rotation
May be more specific for supraspinous tendon impingement
Hawkins Kennedy test
145
Rotator cuff tears are very similar to Impingement however patients tend to be older and there is weakness.
They normally involve a partial or complete tear of one of SITS tendons.
Which is the most commonly torn tendon?
NOTE: presentation will be similar to impingement w/ anterolateral should pain exacerbated by overhead activities.
Most common: supraspinatus
- pain worse at night when sleeping on that side
- shoulder weakness, loss of active ROM
NOTE: chronic tears: long standing tendinopathy
146
Physcial examination of a rotator cuff tear will not pain and weakness on external rotation test, which may have loss of active ROM.
Passive motion may be full, but crepitance may be noted w/ tenderness on greater tubercle.
What are special shoulder tests? Risk factors? Diagnostics?
Tests: Drop arm, Empty can
Diagnosis: X-ray (proximal migration of humeral head); MRI or ultrasound
Tx: individualized
Risk factors: age, degeneration w/ chronic impingement
147
A special test that can be used to confirm rotator cuff injury:
WIth this test, abduct the arm 90 degrees and adduct 15 degrees. Turn the arm so that the thumb is facing the floor. Instruct the patient to resist as an inferior force is applied.
Empty Can test
positive = pain
--injury to supraspinatus
148
A test to confirm rotator cuff injuty.
1. Abduct to 90 degrees and have patient slowly lower.
Any FULL tear of the rotator cuff tendons will cause “drops” as patient lowers arm.
Drop Arm test
149
A special test that may be used to confirm rotator cuff injury:
The patient touches superior and inferior aspects of the opposite scapula
+ = decreased ROM
Indicates rotator cuff dysfunction (may or may not have tear)
Apley Scratch test
150
These usually occur secondary to trauma (traction, compression, direct blow).
The patient complains of pain with overhead activities and decreased function. It is associated with popping, clicking or catching.
Labral tears
*similar to rotator cuff tears
Special tests: not very specific -- O'brien's
DX: Image w/ MRI
Tx: surgery
151
Testing for Labral Injury:
1. Flex shoulder to 90 degrees
2. Adduct 10 degrees
Internally rotate so that thumb is facing down
3. Have patient resist against inferior force
+ test = pain and indicates labral tear
Externally rotate so that thumb is facing up
Have patient resist against inferior force
+ test = pain is reduced compared to previous position
O'Brien's
152
This injury causes Glenohumeral instability
symptomatic abnormal translation of the humeral head on the glenoid
May be:
- anterior
- posterior
- multi-directional
It is often associated with trauma acutely (anterior), or repetitive microtrauma with laxity (multidirectional with swimmers).
SHoulder instability and dislocation
- pain, weakness, recurrent dislocations
- Special tests: Apprehension, Sulcus sign
153
A special test for shoulder instability:
1. The elbow is flexed and the arm abducted to 90 degrees.
2. Apply slight anterior pressure and slowly externally rotate the shoulder
+ test = apprehension
Apprehension test
154
A special test for shoulder instability:
1. Traction applied to arm in inferior direction
+ = presence of a sulcus lateral to acromion
Sulcus sign
155
A disorder of the upper extremity characterized by pain and gradual loss of BOTH active and passive ROM.
It is usually idiopathic, however, mor ecommon in women and diabetics. It may also follow immobilization or prolonged inflammation.
Adhesive capsulitis
Dx: X-rays will be negative. MRI maybe
Tx: OMM, persistence, home exercises
156
True/False: In a normal AC joint, the bottom of the acromion should align with the bottom of the distal
True
157
Arthritis of this joint presents with breakdown of cartilage but no trauma. Abnormal bony growths (osteophytes) or bone spurs may develop.
The patient will have difficulty reaching their arm across the body (e.g. swing golf club or seat belt).
Acromioclavicular joint
Tests: Crossover test
158
This is caused by falling onto the abducted arm with point tenderness over the AC.
There are 6 grades: sprain to complete rupture of both the Ac and CC ligaments.
Exam in a seated position may note swelling and tenderness over the AC joint
AC separation
-palpable "stepped" deformity b/t acromion and clavicle = severe injury (dislocation)
(AP view of shoulder confirms)
Special test: Crossover test
159
AC joint pathology may be determined by the crossover test.
In this test, Crossover test the patient forward flexes the affected arm to 90 degrees.
This is followed by ______ across the chest, forcing the acromion into the distal end of the clavicle
+ test = pain
adduction across the chest
160
This disorder is caused by isolated inflammation of the proximal biceps tendon.
Risk factors include age and overuse activities, but NOT trauma.
The patient will present with pain over the anterior aspect of the shoulder which radiates down the biceps.
Bicept tendonitis
Special tests: Speeds and Yergasons
DX:
-Xrays = often normal
Tx: start w/ NSAIDs, OMM, and ROM exercises. Steroid injections can be considered.
Athlete may return to play once pain has resolved enough for near normal ROM and strength.
161
Special test for Biceps tendonitis.
1. Extend elbow
2. Have patient flex elbow against resistance while monitoring at bicipital grove
+ test = snap or pain under thumb near biceps tendon and indicates biceps tendonitis
Speed test
162
Special Test for Biceps Tendonitis
1. Flex elbow to 90 degrees
2. Have patient supinate arm against resistance while monitoring at bicipital grove.
+ test = snap or pain under thumb near biceps tendon and indicates biceps tendonitis
Yergason's test
163
Syndrome seen in patients that are thin with rolled shoulders, kyphotic, and have poor posture.
It is due to mechanical friction and pressure between the scapula and 2nd and 3rd ribs.
It is aggravated by repetitive motion (ironing), and exhibits pain near scapula
Scapulothoracic bursitis
(snapping scapula syndrome)
*Crepitus when shoulder is shrugged.
164
True/False: Neurologic shoulder pain can be due to multiple etiologies such as:
1. stingers (stretch nerve root)
2. disc herniation
3. nerve impingement
Patients may complain of pain radiating into the arm, but may have no history of shoulder trauma, and no loss of ROM.
True
normal X-rays
Special Test: Spurling's
165
Clinical features of cervical herniation:
1. C5
2. C6
3. C&
4. C8
Slide 57 upper ext. 1
1. C5 - deltoid (weak/absent reflex)
2. C6 -- biceps brachii
(weak/absent reflex)
--loss of sensation in thumb
3. C7 -- triceps brachii
(weak/absent reflex)
--loss of sensation in digits 2,3
4. C8 -- Interossei (Horner's syndrome)
- -loss of sensation in digits 4, 5
166
The elbow joint is composed of the humerus, radius and ulna.
In X-ray it has a coronoid process, anterior fat pad, and bare area of the proximal unla. Whate are these?
coronoid process:
Fat pad: important in capitulum fractures
(radial head to lateral distal humerus)
Bare area: divides olecranon and coronoid
167
The elbow joint works in conjunction wiht the shoulder to put the hand in space. It is a hinge joint with flexion/extension
Flexion is accomplished by:
Extension is accomplished by:
Flexion: biceps brachii, brachialis, brachioradialis
Extension:
- passive: gravity
- active: triceps brachii
168
The carrying angle of the elbow joint is formed by the intersection of two lines:
1. long. axis of the humerus
2. line through radial-ulnar joint (proximal and distal)
What is the normal? What are issues?
NOrmal:
males: 5-10 degrees
females: 10-15
1. cubitus valgus: inc. anlge
2. cubitus varus: dec. angle
169
True/False: A parralelogram effect causes the wrist to compensate for what ulnar deviation occurs. Injuries such as fractures can alter the carrying angle
True
170
1. Supination of the Arm occurs when the radial head is ________
2. Pronation of the Arm occurs when the radial head is ______
1. Supination: anterior
| 2. Pronation: posterior
171
If an arm does not supinate well, how is it Dx?
Pronation:
Posterior radial head
172
With the elbow joint, Supination/pronation are rotations about a longitudinal axis.
Motion occurs at both proximal and distal radioulnar articulations.
How is motion of the radial head best observed?
Elbow flexed at 90 degrees
**taut in supinationon (more powerful)
173
Golfer's elbow is known as _______
Tennis elbow is known as ______
Golfer: medial epicondylitis
Tennis: lateral epicondylitis
174
Thought to be an inflammatory response to overuse of the extensor muscle groups attached to the lateral epicondyle of the humerus but could be due to a degenerative tendinosis or ischemic phenomenon.
*common radial head dysfunction
Lateral epicondylitis
* pain at lat. epicondyle and radiate up into brachioradialis OR down into forearm extensor group
* worsenes with resistive extension of wrist or shaking hands
175
Lateral epicondylitis involves what muscle groups?
FOrearm extensor bundle
*extensors (top of arm)
176
This muscle is usually the damaged muscle in Tennis elbow. It acts to stabilize the wrist when arm is straightened.
When it is overused, microscopic tears weaken the attachment at the lateral epicondyle.
Extensor Carpi Radialis Brevis (ECRB)
*muscle rubs over bone ridges -- and wears down muscle
177
Commonly known as “Golfer’s Elbow”
Involves irritation of the muscles of the forearm flexor bundle which make the palm flex toward the wrist
This isn't thought to be due to inflammation, but rather, overuse.
Medial epicondylitis
*inc. fibroblast production = scar tissue
**Tendinosis
**Flexor muscles
*travels inner forearm
178
Most common somatic dysfunction at the elbow is radial head and it mimics
Tennis elbow
*extensor
179
Caused by cubital tunnel syndrome and olecranon bursitis
Extra-articular elbow pain
Cubital tunnel (elbow):
- -ulnar nerve in ulnar groove
* digits 4 and 5
* benediction hand
180
Occurs because of trauma or repetitive pressure over the bursa (resting on elbow)
Olecranon bursitis
*ROM not affected (outside joint)
181
____ is a general maneuver for reproducing pain by tapping over an inflamed or impinged nerve
Tinel's sign
*ROM not affected
182
Strain of the _______ membrane of the elbow joint can occur at the time of injury but may persist long after the initial problem has healed
Interosseous
Tx: myofascial
183
Which describves the function of the interoseous membrane?
a. symmetry and stability of radio-ulnar motion
b. past injuries may persist in the tension and tenderness of membrane
c. Treat with fascial release
all of the above
184
_______ syndrome is a compression of the median nerve at the level of the elbow. It occurs more often in females and presents similar to carpal tunnel syndrome.
Pronator terest syndrome
*numness in palm, thumb, forefinger, middle finger
185
The true wrist involves radio-carpal articulations.
It involves what structures?
proximal carpals, scaphoid, lunate, triquetrum + articular disc and distal radius
*flex, extend, abduct, adduct
186
Somatic dysfunction of the wrist affects glide between ____ and ___
carpals and the radius
187
______ involves compression of the median nerve by the flexor retinaculum.
It presents as pain and parasthesia in the thumb, index and long finger.
Carpal Tunnel
*Tinel's and Phalen's tests
188
______ involves flexing the wrist to 90 degrees for 1 minute (with dorsums of hands facing one another). Pain or numbness indicates median nerve issues
Phalen's
*reverse phalens = "prayer hands"
189
True/False: OMM on the wrist is helpful by decompressing the entrapment of the distal branches of the median nerve at the wrist and improving the circulation and decrease endotunnel and endoneural edema.
True
190
The tunnel of Guyon (ulnar tunnel) is the other tunnel in the wrist and houses the _____. It is formed by the ligament connecting the hook of the hamate and the pisiform bones.
Lateral compression (cyclist's palsy) may occur, outside of the flexor retinaculum.
ulnar artery and ulnar nerve
*ulnar neuritis (compression of intercarpals)
191
_____________ At elbow or wrist- progression of symptoms from numbness, to weakness, to muscle atrophy and contractures
Ulnar Nerve Entrapment
*Tinel's test
192
There are six dorsal wrist compartments
Compartment 1 houses a commonly inflamed tendon complex (DeQuervain’s tenosynovitis). This occurs from repetitive movement of the thumb leading to inflammation of the tendon sheath.
Which muscles are affected?
Extensor policis brevis
Abductor pollicis longus
* pain in dorsolateral wrist
* video gamers
*Finkelstein's test
193
There are six dorsal wrist compartments
Compartment 1 houses a commonly inflamed tendon complex (DeQuervain’s tenosynovitis). This occurs from repetitive movement of the thumb leading to inflammation of the tendon sheath.
Which muscles are affected?
Extensor policis brevis
Abductor pollicis longus
* pain in dorsolateral wrist, thumb
* video gamers
* Finkelstein's test
194
Finkelstein test: Flex the thumb and place the wrist in ulnar deviation, which exacerbates the pain. When is this used?
DeQuervain's Tenyosynovitis
195
Dysfunction of the A-1 pulley system locks the finger in extension or flexion.
Trigger finger
196
Thickening and gradual shortening of the Flexor tendons in the hand that. Though to have genetic inheritance. Treated with injections or surgery
Dupyterent's contracture
